Schedule of Medical Fees

December 1, 2005

Kansas Department of Labor
Workers Compensation

KANSAS DEPARTMENT OF LABOR
DIVISION OF WORKERS COMPENSATION
Schedule of Medical Fees
COPYRIGHT© 2005, 2003, 2001, 1999 State of Kansas, Department of Labor
Division of Workers Compensation
The Kansas Workers Compensation Schedule of Medical Fees incorporates portions of the
following documents:
1. The Current Procedural Terminology, Fourth Edition, copyright 2004 (a.k.a. CPT 2005) by
the American Medical Association
2. The Current Dental Terminology, CDT-2005, copyright 2004, published by the American
Dental Association
3. The Relative Values for Dentists 2005, copyright 2004, published by Relative Value
Studies, Inc. of Broomfield, Colorado
4. The 2005 Relative Value Guide, copyright 2004, developed by the American Society of
Anesthesiologists
5. The 2005 Essential RBRVS, A comprehensive listing of RBRVS values for CPT and
HCPCS Codes, copyright 2004 Ingenix, Inc.
6. The 2005 HCPCS allowances that were obtained from Cigna HealthCare who is under
contract with CMS as the Durable Medical Equipment Regional Carrier (DMERC)
Some of the most important revisions that have been incorporated within this Schedule of Medical
Fees are as follows:
1. Incorporation of the RBRVS concept for improvement in the statistical validity is used for
the unit values employed to determine maximum allowable fees.
2. Expansion and refinement of the DRG based reimbursement system for hospital inpatient
care has been updated to coincide with the most recent data available at the time of this
publication.
3. Medical Nutrition Therapy has been added as a new section within the fee schedule. A
Conversion Factor of $41.19 has been established.
4. Acupuncture has been added as a new section within the fee schedule. A Conversion
Factor of $41.19 has been established.
5. The Conversion Factor for the various sections of the fee schedule (except for Anesthesia)
has been changed as follows to reflect the incorporation of the RBRVS system.
Surgery: Conversion Factor changed from $110.00 to $67.95
Radiology: Conversion Factor changed from $110.00 to $63.15
Pathology: Conversion Factor changed from $110.00 to $75.10
Medicine: Conversion Factor changed from $82.50 to $52.42
Physical Medicine: Conversion Factor changed from $50.00 to $43.80
Osteopathic Manipulative Treatment: Conversion Factor changed from $60.00 to
$54.43
Chiropractic Manipulative Treatment: Conversion Factor changed from $53.50 to
$50.75
Special Services and Reports: Conversion Factor changed from $30.00 to $42.35
Evaluation and Management: Conversion Factor changed from $25.00 to $46.33

6. The Conversion Factor for Anesthesia has been changed from $45.00 to $48.75.
7. A new payment schedule for nurse anesthesists has been introduced; i.e., payment will be
limited to 85% of the maximum allowable fee associated with the CPT code used for billing.
8. A new payment schedule for physician assistants or advanced practice nurses has been
introduced; i.e., payment will be limited to 85% of the maximum allowable fee associated
with the particular CPT code used for billing.
9. The Ground Rule within the Surgery Section that related to Starred Procedures has been
deleted to correspond with the changes made by AMA in conjunction with CPT 2004.
10. A new column identified as “FUD” has been added in the Maximum Allowable pages of the
Surgery Section to specify the amount of follow-up days that pertain to a particular type of
surgical procedure and/or service.
11. A new rule pertaining to Conscious Sedation has been included in the Surgery Section of
the fee schedule.
12. A new column identified as “PC/TC” has been added in the Maximum Allowable pages of
the Radiology Section to specify the percentage amount or split for the Professional
Component and the Technical Component with respect to each of the CPT codes.
13. The special exception for CPT code 97534 found within the Physical Medicine Section has
been deleted from the fee schedule.
14. The Dentistry Section of the fee schedule has been changed to reflect that dental services
will no longer be subject to any discount/reduction as it relates to Bilateral or Multiple
Procedures. Modifiers -50 and -51 that were used to report any bilateral/multiple services
are no longer a part of the dental fee schedule. Also, the Conversion Factor has been
changed from $33.00 to $35.75.
15. The Hospital/Ambulatory Surgical Center of the fee schedule has been changed whereby
Ambulatory Surgery Centers within Peer Groups 1 and 2 are now specifically being listed.
16. The Medical Equipment and Supplies Section has been amended to now include the
maximum allowance for any prosthetic and/or orthotic devices. The maximum payments as
listed have been computed by using the 2005 HCPCS rates obtained from Cigna
HealthCare, who is under contract with CMS as the Durable Medical Equipment Regional
Carrier (DMERC) and increasing those rates by 25%.
17. The maximum allowances for Vocational Rehabilitation Services have been increased by
10%.
All rights reserved. No part of this publication may be reproduced or transmitted, stored or
retrieved in any form or by any means, except as allowed by law, without the express written
permission of the publisher.
First Edition Printed - November 1993
First Revision - May 1996
Second Revision - September 1997
Third Revision - October 1999
Fourth Revision - December 2001
Fifth Revision - December 2003
Sixth Revision - December 2005
This Schedule of Medical Fees, planned for implementation December 1, 2005, was approved by
the Workers Compensation Director on July 27, 2005.
The most recent contract agreement between the American Medical Association (AMA) and the
Kansas Department of Labor prohibits the fee schedule inclusion of individual CPT code
descriptions. This is a new policy decision by the AMA and will similarly apply to other jurisdictions
that publish medical fee schedules for Workers Compensation. For the applicable CPT 2005 Code

descriptions, refer to the Current Procedural Terminology, copyright 2004 (a.k.a. CPT 2005),
available through the American Medical Association.
Although the American Dental Association contract agreement does not prohibit the inclusion of
CDT code descriptions, those descriptions will not be included within the fee schedule, so as to
maintain a uniform presentation format for all codes employed to obtain reimbursement for
services provided. For the applicable CDT code descriptions, refer to the Current Dental
Terminology, CDT-2005, available through the American Dental Association.

TABLE OF CONTENTS
INTRODUCTION ................................................................................................................................................. 1
GENERAL INSTRUCTIONS ............................................................................................................................... 4
ANESTHESIA SECTION .................................................................................................................................... 6
SURGERY SECTION........................................................................................................................................ 11
RADIOLOGY SECTION (Including Nuclear Medicine and Diagnostic Ultrasound) .................................. 50
PATHOLOGY AND LABORATORY SECTION ............................................................................................... 57
MEDICINE SECTION ........................................................................................................................................ 67
PHYSICAL MEDICINE AND REHABILITATION SECTION ............................................................................ 75
MEDICAL NUTRITION THERAPY SECTION .................................................................................................. 79
ACUPUNCTURE............................................................................................................................................... 81
OSTEOPATHIC MANIPULATIVE TREATMENT SECTION ............................................................................ 83
CHIROPRACTIC MANIPULATIVE TREATMENT SECTION .......................................................................... 85
SPECIAL SERVICES AND REPORTS SECTION ........................................................................................... 87
EVALUATION AND MANAGEMENT SERVICES SECTION........................................................................... 88
HOME HEALTH PROCEDURES / SERVICES SECTION ............................................................................... 91
HOME INFUSION PROCEDURES / SERVICES SECTION............................................................................. 93
DENTISTRY SECTION ..................................................................................................................................... 95
HOSPITAL/AMBULATORY SURGICAL CENTER SECTION....................................................................... 101
MEDICAL EQUIPMENT AND SUPPLIES SECTION ..................................................................................... 109
PRESCRIPTION SERVICES SECTION ......................................................................................................... 116
VOCATIONAL REHABILITATION SERVICES SECTION............................................................................. 117
DEPOSITIONS, TESTIMONY, AND MEDICAL RECORDS REPRODUCTION SECTION........................... 119
AMBULANCE AND AIRCRAFT SERVICES SECTION................................................................................. 122
NURSING HOMES / INTERMEDIATE CARE FACILITIES SECTION .......................................................... 123
APPENDIX A - MODIFIERS ........................................................................................................................... 124
APPENDIX B - QUICK REFERENCE TABLE ............................................................................................... 129

INTRODUCTION
In accordance with the provisions of Substitute for HOUSE BILL No. 3069 that was enacted by the 1990 Kansas
Legislature, and through the assistance of the advisory panel that was created by law to assist the Director in the
establishment of a Schedule of Medical Fees, this fee schedule has been adopted and is to be used as the basis for
the billing or payment of medical, surgical, hospital, dental, nursing, vocational rehabilitation, or any other treatment
or services that are provided to injured workers under the Workers Compensation Law of the State of Kansas.
This Schedule of Medical Fees governs the medical services provided to injured workers by health care providers
including the medical services provided by registered physical and occupational therapists, and the medical services
of a hospital or other health care facility; it also governs facilities and agencies providing vocational rehabilitation
services. The maximum allowable fees and unit values contained within this schedule, which vary by the specific
type of service, take into consideration the difficulty in performing a certain type of service that is based upon the
risk, time, ability, and skill involved. Note specifically the code designation by type of service being provided. These
codes have been adopted by various medical societies and associations (e.g., American Medical Association,
American Dental Association) and are to be used in the respective billing or payment of medical services involving
injured workers. Note: The maximum allowable payment to a physician is to be limited to the

maximum allowable payment contained within the appropriate sections of this fee schedule,
regardless of who either bills for the service or where the service(s) was/were provided. Billing
for all physician services, whether provided in a physician’s office, hospital, or any other setting,
must be submitted using the CMS 1500 form or an equivalent form containing the same
information. Additionally, and to assure that Cost Containment is achieved, nothing in this fee
schedule shall preclude an employer (or insurance carrier) from entering into payment
agreements to promote the continuity of care and reduction of health care costs. Such payment
agreements, if less, will supersede the limitation amounts specified herein. Please refer to K.S.A.
44-510i(e) for further clarification, if necessary.
The maximum allowable payment for physician assistants or advanced practice nurses is limited to eighty-five
percent (85%) of the maximum allowable fee associated with the CPT code submitted.
The unit values for the respective CPT codes listed within this Schedule of Medical Fees expresses the relativity,
based on comparative magnitude, between various procedures and services. Thus, the maximum fee schedule
amount for a particular procedure or service is determined by multiplying the listed unit value by the applicable
conversion factor for the section in which the service or procedure is located. See the “Conversion Factors” at the
end of this Introduction Section for the applicable conversion factors.
With regard to Anesthesia, the Basic Unit Values contained within the Anesthesia Section of this Schedule of
Medical Fees were obtained from the 2005 Relative Value Guide developed by the American Society of
Anesthesiologists (ASA), which is recognized as an appropriate assessment of current relative values for specific
procedures related to anesthesiology.
The accompanying General Instructions, and Ground Rules that are applicable to each section, explain the
application of the CPT codes and unit values. It is important to remember that this fee schedule has been
developed anticipating that it can be used by all health care providers. Note, however, that appropriate surgical
codes are not confined to use by surgeons, nor are the Medicine or Evaluation and Management Sections confined
to use by specialists, internists, etc.
Since this fee schedule is applicable to the entire state of Kansas, the maximum allowable fees, unit values, and
conversion factors contained herein do not necessarily reflect the charges or services of any specific type of health
care provider, nor are they to reflect the current usual and customary fee for any specific area in the state of Kansas.
All the maximum allowable fees or unit values (with the use of a conversion factor) listed herein represent the
maximum payment to be reimbursed for the treatment or service provided. It is important to remember that

reimbursement for any needed services is to be limited to the schedule of charges hereby being
adopted or the health care provider's usual and customary charge, whichever is less. All bills
submitted for payment must include the actual charges plus the categorization of the charges as
per the codes contained in this Schedule of Medical Fees. There is a provision, however, for allowing a
greater fee if it can be clearly established that extraordinary services were required in a particular case. In such a
case, this fee is subject to approval by the Director of Workers Compensation.
Medical treatment provided by Out-of-State Providers: For any service (emergency or non-emergency) that is
provided by an out-of-state provider, and if a claim is filed under the Kansas Workers Compensation Law,
reimbursement for such service is to be limited to the maximum allowable payment contained within the appropriate
1

INTRODUCTION
sections of this fee schedule. Thus, any out-of-state provider who willingly provides medical service to an injured
worker who is seeking benefits under the Kansas Workers Compensation Law, must realize that said service is to
be limited to this fee schedule and should take the necessary steps to receive authorization from the insurance
company, employer, or payer prior to providing said service. Prior authorization for such services should be
obtained to assure that the processing of a Workers Compensation claim will not be denied. Additionally, absent
any pre-approval by the insurance company, employer, or payer, balance billing the injured worker, or any other
party, for the services provided is prohibited.
Any service or charge that is not contained within this fee schedule is to be determined by referring to the
"Procedures/Services Listed Without Specified Maximum Allowance" rule found within the General Instructions
Section. See also the "Procedures Listed Without Specified Maximum Allowance" rule found within each individual
section.

STANDARDIZED BILLING FORM: Health care providers, including ambulatory surgical centers, pharmacists,
and suppliers of medical equipment and supplies shall use the CMS 1500 form or an equivalent form containing the
same information for the billing of their services, drugs, or supplies. Dental offices shall use the ADA-94 form or an
equivalent form containing the same information. Hospitals shall use Form UB-92.* (See Footnote.)
Any insurance company, employer, or other payer who reduces or denies charges from a provider according to the
general instructions, ground rules, unit values, or maximum fees contained within this fee schedule must show the
specific basis of the reduction or denial by use of an "Explanation of Benefits" form. The specific general
instruction, specific ground rule, specific unit value or specific maximum fee that was used for the reduction or
denial must be indicated or identified. When payment is reduced or denied on some other basis, the "Explanation
of Benefits" form must contain a complete explanation as to why, for example, the service was unreasonable, the
service was more appropriately defined by another procedure code, or the service was not related to a compensable
injury. When any such reduction or denial occurs, the "Explanation of Benefits" form shall also include: 1) the
identity of the person or entity that made the decision for the reduction or denial; 2) the identity of the person or
entity that is ultimately responsible for payment; and 3) the telephone number of such person or entity where further
explanation of the reduction or denial can be obtained. In the event a controversy arises between the

provider and the payer, an attempt should be made by the involved parties to resolve said
issue(s). Issues which cannot satisfactorily be resolved should then be referred to the Director of
Workers Compensation for review.
As a further attempt to avoid controversy arising between the provider and the payer for failure to make timely
payment for any medical services provided, it is recommended that the insurance company or self-insured employer
make payment for any medical services that were provided either: 1) within 30 days of receiving the bill submitted
and any necessary documentation required by the fee schedule, or; 2) within 30 days of it being determined that the
medical service provided is the result of an injury that is compensable under the Workers Compensation Law.
Where the word "physician" appears within this fee schedule it shall mean, where appropriate, a "health care
provider" as defined by the Kansas Workers Compensation Law.

SPECIAL NOTE: The five-digit codes included in this Schedule of Medical Fees (with the exception of the
Dentistry Section and the Medical Equipment and Supplies Section) are obtained from Current Procedural
Terminology (CPT®), copyright 2004 by the American Medical Association (AMA). CPT is developed by the AMA
as a listing of descriptive terms and five-digit codes and modifiers for reporting medical services and procedures
performed by physicians.
The responsibility for the content of the Schedule of Medical Fees is with the state of Kansas Division of Workers
Compensation and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility
for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained
in the Schedule of Medical Fees. No fee schedules, basic unit values, relative value guides, conversion factors or
scales are included in any part of CPT. Any use of CPT outside of Workers Compensation Schedule of Medical
Fees should refer to the most current Current Procedural Terminology which contains the complete and most
current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.
Relative value units for anesthesia services have been excerpted from the 2005 Relative Value Guide, copyright
2004 by permission of American Society of Anesthesiologists.

2

INTRODUCTION
The five-digit codes included in the Dentistry Section of this Schedule of Medical Fees are obtained from the
publication of the American Dental Association titled Current Dental Terminology, CDT-2005. The following is
therefore applicable: Current Dental Terminology copyright 2002, 2004 American Dental Association. All rights
reserved.

ADDITIONAL SPECIAL NOTE: The Kansas Workers Compensation Law specifically prescribes that an injured
employee shall not be liable for any charges above the amount contained within this fee schedule. The respective
section of the Kansas Workers Compensation Law (K.S.A. 44-510j) that prohibits an injured employee for being
liable for any charges above the amount contained within this fee schedule reads as follows:
Any health care provider, nurse, physical therapist, any entity providing medical, physical or vocational
rehabilitation services or providing reeducation or training pursuant to K.S.A. 44-510g and amendments
thereto, medical supply establishment, surgical supply establishment, ambulance service or hospital
which accept the terms of the workers compensation act by providing services or material thereunder shall
be bound by the fees approved by the director and no injured employee or dependent of a deceased
employee shall be liable for any charges above the amounts approved by the director.
Interpreter Services: If the services of an interpreter are required for the provision of medical care to a hearing
impaired, speech impaired, or other person whose primary language is other than English, the following will apply:

Maximum allowable payment for the first hour or less is limited to $35.00.

Each additional quarter hour increment of time is to be paid at $8.75 per quarter hour increment.

Any reimbursement for necessary travel mileage (including any tolls and parking fees actually incurred) is to
be at the rate prescribed for compensation of state officers and employees pursuant to K.S.A. 75-3203a.

CONVERSION FACTORS
Any reimbursement for necessary travel mileage (including any tolls and parking fees actually incurred) is to be at
the rate prescribed for compensation of state officers and employees pursuant to K.S.A. 75-32The conversion
factors applicable to this fee schedule are as follows:
Anesthesia ............................................................................ $48.75
Surgery ................................................................................. $67.95
Radiology .............................................................................. $63.15
Pathology and Laboratory..................................................... $75.10
Medicine................................................................................ $52.42
Physical Medicine and Rehabilitation ................................... $43.80
Medical Nutrition Therapy..................................................... $41.19
Acupuncture.......................................................................... $41.19
Osteopathic Manipulative Treatment.................................... $54.43
Chiropractic Manipulative Treatment .................................... $50.75
Special Services and Reports............................................... $42.35
Evaluation and Management Services ................................. $46.33
Home Health Procedures / Services .................................... $25.00
Home Infusion Procedures / Services .................................. $25.00
Dentistry................................................................................ $35.75
Hospital / Ambulatory Surgical Center....................................... N/A
Medical Equipment and Supplies .............................................. N/A
Prescription Services ................................................................. N/A
Vocational Rehabilitation Services ............................................ N/A
Depositions, Testimony, and Medical Records Reproduction... N/A
Ambulance and Aircraft Services............................................... N/A
Nursing Homes / Intermediate Care Facilities ........................... N/A
To determine the maximum fee schedule amount for a procedure, it is necessary to multiply the unit value of the
procedure by the dollar conversion factor applicable to the particular section in effect on the date the service was
provided. Formula: unit value multiplied by conversion factor = maximum fee schedule amount.
* Form UB-92 is to gradually be replaced by Form UB-04, beginning March 1, 2007. Either form (UB-04 or
UB-92) may be used until May 22, 2007. Starting May 23, 2007, the UB-92 will no longer be accepted.
3

GENERAL INSTRUCTIONS
FOR USING THE SCHEDULE
FORMAT
Twenty-two major sections comprise this Fee Schedule: Anesthesia; Surgery; Radiology (including Nuclear
Medicine and Diagnostic Ultrasound); Pathology and Laboratory; Medicine; Physical Medicine and Rehabilitation;
Medical Nutrition Therapy; Acupuncture; Osteopathic Manipulative Treatment; Chiropractic Manipulative Treatment;
Special Services and Reports; Evaluation and Management; Home Health; Home Infusion; Dentistry;
Hospital/Ambulatory Surgical Center; Medical Equipment and Supplies; Prescription Services; Vocational
Rehabilitation Services; Depositions, Testimony, and Medical Records Reproduction; Ambulance and Aircraft
Services; and, Nursing Homes/Intermediate Care Facilities. This Fee Schedule is divided into these sections for
structural purposes only. Providers of medical services and/or suppliers are to use the section(s) which contain the
procedures they perform, or the services they render.
Also included in this Fee Schedule is a separate section identified as Appendix B - Quick Reference Table, which
is to be considered only as a supplement to this Fee Schedule. This appendix is provided for use in determining the
maximum fee that is associated with a particular procedure code. Note specifically that each maximum fee found
therein is calculated by multiplying the respective conversion factor of this Fee Schedule by the unit value of the
procedure code.
GROUND RULES
Introductory material, known as Ground Rules, precedes the separate sections of this Fee Schedule and contains
the necessary general information, instructions, and general rules with which the user needs to become acquainted
before undertaking the use of this Fee Schedule. Familiarity with these general rules, which may include definitions,
references, prohibitions, and directions for their proper employment, is necessary for all who use this Fee Schedule.
It cannot be emphasized too strongly that these rules need to be read before this schedule is used.
PROCEDURES/SERVICES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE
Some procedures/services are not accompanied by allowable fees. Procedures/services denoted "by report" (BR)
in the unit value column are too unusual or variable in the nature of their performance, too new, or too infrequently
performed to permit the assignment of a unit value. Fees for such procedures/services need to be justified "by
report." The report should contain sufficient supportive information to permit proper identification. Pertinent
information should be furnished concerning the nature, extent, and need for the procedure or service, the time, the
skill, and equipment necessary, etc. For any procedure/service where the unit value is "BR," the health care
provider shall establish a charge that is consistent with other unit values shown in the Schedule. The insurance
carrier or self-insured employer should review all submitted "BR" amounts to assure that an excessive charge for
services provided is not occurring. Note also that for any procedures/services not listed within this Fee
Schedule, the associated charge(s) will need to be substantiated "by report" (BR).
DEFINITIONS
New Patient: One who has not received any professional services from the physician or another physician of the
same specialty who belongs to the same group practice, within the past three years.
Established Patient: One who has received professional services from the physician or another physician of the
same specialty who belongs to the same group practice, within the past three years. In the instance where a
physician is on call for or covering for another physician, the patient's encounter will be classified as it would have
been by the physician who is not available.
Note that no distinction is made between new and established patients in the emergency department. E / M
services in the emergency department category may be reported for any new or established patient who presents
for treatment in the emergency department.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

4

GENERAL INSTRUCTIONS
Modifiers: A modifier (located in Appendix A) provides the means by which the reporting physician can indicate
that a service or procedure, that has been performed, has been altered by some specific circumstance but not
changed in its definition or code. Only one modifier should be added to any single five-digit code submitted by an
individual health care provider. The judicious application of modifiers obviates the necessity for separate procedure
listings that may describe the modifying circumstance. Modifiers may be used to indicate to the recipient of a report
that:
# A service or procedure has both a professional and technical component.
# A service or procedure was performed by more than one physician or in more than one location.
# A service or procedure has been increased or reduced.
# Only part of a service was performed.
# An adjunctive service was performed.
# A bilateral procedure was performed.
# A service or procedure was provided more than once.
# Unusual events occurred.
MODIFIER EXAMPLES
1:

A physician providing diagnostic or therapeutic radiology services, ultrasound, or nuclear medicine services
in a hospital would use modifier -26 to report the professional component, as follows:
73090-26 =

2:

Professional component only for an x-ray of the forearm

Two surgeons, usually with different skills, may be required to manage a specific surgical problem. The
modifier -62 would be applicable. Modifier -62 would be appropriate only when both surgeons are reporting
the same code number and descriptor. For instance, a neurological surgeon and an otolaryngologist are
working as co-surgeons in performing transsphenoidal excision of a pituitary neoplasm. The first surgeon
would report:
61548-62 =

Hypophysectomy or excision of pituitary tumor,
transnasal
or
transseptal
approach,
nonstereotactic + two surgeons modifier

AND the second surgeon would report:
61548-62 =

Hypophysectomy or excision of pituitary tumor,
transnasal
or
transseptal
approach,
nonstereotactic + two surgeons modifier

A listing of modifiers pertinent to ANESTHESIA, SURGERY, RADIOLOGY, PATHOLOGY AND LABORATORY,
MEDICINE, and EVALUATION AND MANAGEMENT are located in Appendix A - Modifiers.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

5

ANESTHESIA GROUND RULES
1.

GENERAL: All anesthesia values are determined by taking the BASIC UNIT VALUE, which is related to
the complexity of the service, and adding MODIFYING UNITS (if any), and TIME UNITS. The fee for a
particular procedure or service in this section is determined by multiplying the listed "Basic Unit Value" by
the conversion factor that is applicable to this section. See page 8 to obtain the conversion factor.
The values contained within this section apply when the anesthesia care is provided by or under the
medical supervision of qualified physician. This anesthesia care may include but is not limited to general,
regional, monitored anesthesia care, supplementation of local anesthesia, or other supportive services in
order to afford the patient the anesthesia care deemed optimal. For anesthesia care provided by nurse
anesthetists, billing for independent unsupervised services, payment will be limited to 85% of the maximum
allowable fee associated with the CPT code submitted.

2.

BASIC UNIT VALUE: A Basic Unit Value is listed for anesthetic management of most surgical procedures.
This includes the value of all usual anesthesia services except the time actually spent in anesthesia care
and any modifiers. The usual anesthesia services included in the Basic Unit Value include usual preoperative and post-operative visits, the administration of fluids and/ or blood products incident to the
anesthesia care and interpretation of non-invasive monitoring (ECG, temperature, blood pressure,
oximetry, capnography, and mass spectrometry). Placement of arterial, central venous and pulmonary
artery catheters and use of transesophageal echocardiography (TEE) are not included in the basic unit
value.
A service that is rarely provided, unusual, variable, or new may require a special report in determining
medical appropriateness of the service.
When multiple surgical procedures are performed during a single anesthetic administration, only the
anesthesia code with the highest basic unit value is reported. (The time reported is the combined total for
all procedures.) Add-on codes are an exception to this policy. They are listed in addition to the code for
the primary procedure.
When it is necessary to have a second attending anesthesiologist assist with the preparation and conduct
of the anesthesia, these circumstances should be substantiated "By Special Report." Such services shall
have a Basic Unit Value of 5.0 Units plus Time Units.
Any procedure around the head, neck, or shoulder girdle, requiring field avoidance, or any procedure
requiring a position other than supine or lithotomy, has a minimum Basic Unit Value of 5.0 regardless of
any lesser Basic Unit Value assigned to such procedure in the body of the Relative Value Guide.

3.

ANESTHESIA MODIFIERS: All anesthesia services are reported by use of the anesthesia five-digit
procedure code plus the addition of a physical status modifier. These modifying units may be added to the
basic unit value. The use of other optional modifiers may also be appropriate.
Physical Status Modifiers
Physical status modifiers are represented by the initial letter P followed by a single digit from 1 to 6 as
defined below:
Unit
Value
P1 - A normal healthy patient .................................................................................................... 0
P2 -

A patient with mild systemic disease ................................................................................. 0

P3 - A patient with severe systemic disease............................................................................... 1
P4 - A patient with severe systemic disease that is a constant threat to life .............................. 2
P5 -

A moribund patient who is not expected to survive without the operation......................... 3

P6 -

A declared brain-dead patient whose organs are being removed for donor
purposes ............................................................................................................................ 0

CPT only copyright 2004 American Medical Association. All Rights Reserved.

6

ANESTHESIA GROUND RULES
The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient
physical status. Physical status is included in CPT to distinguish between various levels of complexity of
the anesthesia service provided.
Other Modifiers (Optional)
Under certain circumstances, medical service and procedure codes need to be further modified. For other
modifiers that may need to be used for Anesthesia, refer to Appendix A - Modifiers.
4.

TIME UNITS (TM): TIME UNITS WILL BE ADDED TO THE BASIC UNIT VALUE AND MODIFYING UNITS
AS IS CUSTOMARY IN THE LOCAL AREA. Anesthesia time begins when the anesthesiologist begins to
prepare the patient for anesthesia care in the operating room or in an equivalent area, and ends when the
anesthesiologist is no longer in personal attendance, that is, when the patient may be safely placed under
other post-anesthesia supervision.
The time units are calculated by allowing one unit for each 15 minutes or significant fraction thereof (7.5
minutes or more) of anesthesia time. If anesthesia time extends beyond three hours, 1.0 unit for each 10
minutes or significant fraction thereof (5 minutes or more) is allowed after the first three hours.
Documentation of actual anesthesia time may be required, such as a copy of the anesthesia record in the
hospital file.

5.

UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the values
used should be substantiated "By Special Report." For an unlisted service or procedure, the health care
provider or anesthetist shall establish a unit value consistent with other unit values listed in the schedule.

6.

MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the health
care provider or anesthetist (e.g., sterile trays, drugs) over and above those usually included with the office
visit or other services rendered may be listed separately. The statement of charges will need to reflect any
drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s)
to the health care provider plus 25%, or the cost of the item(s) plus $15.00 per item, whichever is less.
Use procedure code 99070.

7.

SUPPLEMENTAL SKILLS: When warranted by the necessity of supplemental skills, values for the
services of two or more health care providers and/or anesthetists will be allowed. Substantiate by report.

8.

MONITORING SERVICES: When an anesthesiologist or anesthetist is required to participate in and be
responsible for monitoring the general care of the patient during a surgical procedure but does not
administer anesthesia, these services are charged on the basis of the extent of the services rendered.
Payment is to be made on the basis of the time units the anesthesiologist or anesthetist is in constant
attendance for the sole purpose of the monitoring services; therefore, basic unit values are not to be
added.

9.

ANESTHESIA ADMINISTERED, OTHER THAN BY AN ANESTHESIOLOGIST OR ANESTHETIST:
Anesthesia fees are not payable when local infiltration, digital block, or topical anesthesia is administered
by the operating surgeon or surgical assistants. Such services are included in the Unit Value for the
surgical procedure.

10.

OTHER FEES: The Unit Values for surgery, x-rays, laboratory procedures, consultation and other medical
services, and office and hospital visits are listed in the following sections: Surgery, Radiology, Pathology
and Laboratory, Medicine, Physical Medicine and Rehabilitation, and Evaluation and Management. A
consultation fee is not payable to an anesthesiologist examining the patient prior to administering
anesthesia to that patient. No additional charge is to be made for routine follow-up care and observation.

11.

QUALIFYING CIRCUMSTANCES (more than one may be reported): Many anesthesia services are
provided under particularly difficult circumstances depending on factors such as the extraordinary condition
of the patient, notable operative conditions, unusual risk factors. This section includes a list of important
qualifying circumstances that significantly impact on the character of the anesthetic service provided.
These procedures would not be reported alone but would be reported as additional procedure numbers
qualifying an anesthesia procedure or service. These modifying units may be added to the basic unit
values.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

7

ANESTHESIA GROUND RULES
CPT Code

Unit Values

99100

Anesthesia for a patient of extreme age, under one year or over
seventy (List separately in addition to code for primary anesthesia
procedure)............................................................................................................. 1

99116

Anesthesia complicated by utilization of total body hypothermia (List
separately in addition to code for primary anesthesia procedure ......................... 5

99135

Anesthesia complicated by utilization of controlled hypotension (List
separately in addition to code for primary anesthesia procedure ......................... 5

99140

Anesthesia complicated by emergency* conditions (specify) (List
separately in addition to code for primary anesthesia procedure ......................... 2
* An emergency is defined as existing when delay in treatment of the patient
would lead to a significant increase in the threat to life or body part.

12.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care costs.
Such payment agreements, if less, will supersede the limitation amounts specified herein. Please refer to
K.S.A 44-510i(e) for further clarification, if necessary.

CALCULATION EXAMPLES:
1:

In a procedure with a Basic Unit Value of 3.0 requiring one hour and forty-five minutes of
anesthesia time, the total value should be determined as follows:
Basic Unit Value
105 minutes÷15 minutes
Total value

2:

= 3.0 units
= 7.0 units
= 10.0 units

In a procedure with a Basic Unit Value of 10.0 requiring four hours and twenty minutes of
anesthesia time, the total value should be determined as follows:
Basic Unit Value
First three hours
Subsequent 80 minutes
Total value

= 10.0 units
= 12.0 units
= 8.0 units
= 30.0 units

In both cases, the Maximum Allowable Fee is determined by multiplying the total value units by the
Conversion Factor. In billing, list the Basic Unit Value (showing the procedure code and all
modifiers) and Time Units separately, as in the following:
Procedure code + Modifier(s)
Anesthesia Time
Total value

= Basic Unit Value
= Time Units
= Total units

Total units x Conversion Factor = Maximum Allowable Fee

The relative value units for the anesthesia services were excerpted from the 2005 Relative Value Guide,
copyright 2004) with permission by the American Society of Anesthesiologists.

CONVERSION FACTOR = $48.75

CPT only copyright 2004 American Medical Association. All Rights Reserved.

8

ANESTHESIA
(CONVERSION FACTOR = $48.75)
BASIC
CODE UNIT VALUE
00100
5+TM
00102
6+TM
00103
5+TM
00104
4+TM
00120
5+TM
00124
4+TM
00126
4+TM
00140
5+TM
00142
6+TM
00144
6+TM
00145
6+TM
00147
6+TM
00148
4+TM
00160
5+TM
00162
7+TM
00164
4+TM
00170
5+TM
00172
6+TM
00174
6+TM
00176
7+TM
00190
5+TM
00192
7+TM
00210
11+TM
00212
5+TM
00214
9+TM
00215
9+TM
00216
15+TM
00218
13+TM
00220
10+TM
00222
6+TM
00300
5+TM
00320
6+TM
00322
3+TM
00326
8+TM
00350
10+TM
00352
5+TM
00400
3+TM
00402
5+TM
00404
5+TM
00406
13+TM
00410
4+TM
00450
5+TM
00452
6+TM
00454
3+TM
00470
6+TM
00472
10+TM
00474
13+TM
00500
15+TM
00520
6+TM
00522
4+TM
00524
4+TM

BASIC
CODE UNIT VALUE
00528
8+TM
00529
11+TM
00530
4+TM
00532
4+TM
00534
7+TM
00537
10+TM
00539
18+TM
00540
12+TM
00541
15+TM
00542
15+TM
00546
15+TM
00548
17+TM
00550
10+TM
00560
15+TM
00561
25+TM
00562
20+TM
00563
25+TM
00566
25+TM
00580
20+TM
00600
10+TM
00604
13+TM
00620
10+TM
00622
13+TM
00630
8+TM
00632
7+TM
00634
10+TM
00635
4+TM
00640
3+TM
00670
13+TM
00700
4+TM
00702
4+TM
00730
5+TM
00740
5+TM
00750
4+TM
00752
6+TM
00754
7+TM
00756
7+TM
00770
15+TM
00790
7+TM
00792
13+TM
00794
8+TM
00796
30+TM
00797
10+TM
00800
4+TM
00802
5+TM
00810
5+TM
00820
5+TM
00830
4+TM
00832
6+TM
00834
5+TM
00836
6+TM

CPT only copyright 2004 American Medical Association. All Rights Reserved.

9

BASIC
CODE UNIT VALUE
00840
6+TM
00842
4+TM
00844
7+TM
00846
8+TM
00848
8+TM
00851
6+TM
00860
6+TM
00862
7+TM
00864
8+TM
00865
7+TM
00866
10+TM
00868
10+TM
00870
5+TM
00872
7+TM
00873
5+TM
00880
15+TM
00882
10+TM
00902
5+TM
00904
7+TM
00906
4+TM
00908
6+TM
00910
3+TM
00912
5+TM
00914
5+TM
00916
5+TM
00918
5+TM
00920
3+TM
00921
3+TM
00922
6+TM
00924
4+TM
00926
4+TM
00928
6+TM
00930
4+TM
00932
4+TM
00934
6+TM
00936
8+TM
00938
4+TM
00940
3+TM
00942
4+TM
00944
6+TM
00948
4+TM
00950
5+TM
00952
4+TM
01112
5+TM
01120
6+TM
01130
3+TM
01140
15+TM
01150
10+TM
01160
4+TM
01170
8+TM
01173
12+TM

ANESTHESIA
(CONVERSION FACTOR = $48.75)
BASIC
CODE UNIT VALUE
01180
3+TM
01190
4+TM
01200
4+TM
01202
4+TM
01210
6+TM
01212
10+TM
01214
8+TM
01215
10+TM
01220
4+TM
01230
6+TM
01232
5+TM
01234
8+TM
01250
4+TM
01260
3+TM
01270
8+TM
01272
4+TM
01274
6+TM
01320
4+TM
01340
4+TM
01360
5+TM
01380
3+TM
01382
3+TM
01390
3+TM
01392
4+TM
01400
4+TM
01402
7+TM
01404
5+TM
01420
3+TM
01430
3+TM
01432
6+TM
01440
8+TM
01442
8+TM
01444
8+TM
01462
3+TM
01464
3+TM
01470
3+TM
01472
5+TM
01474
5+TM
01480
3+TM
01482
4+TM
01484
4+TM
01486
7+TM
01490
3+TM
01500
8+TM
01502
6+TM
01520
3+TM
01522
5+TM
01610
5+TM
01620
4+TM
01622
4+TM
01630
5+TM

BASIC
CODE UNIT VALUE
01632
6+TM
01634
9+TM
01636
15+TM
01638
10+TM
01650
6+TM
01652
10+TM
01654
8+TM
01656
10+TM
01670
4+TM
01680
3+TM
01682
4+TM
01710
3+TM
01712
5+TM
01714
5+TM
01716
5+TM
01730
3+TM
01732
3+TM
01740
4+TM
01742
5+TM
01744
5+TM
01756
6+TM
01758
5+TM
01760
7+TM
01770
6+TM
01772
6+TM
01780
3+TM
01782
4+TM
01810
3+TM
01820
3+TM
01829
3+TM
01830
3+TM
01832
6+TM
01840
6+TM
01842
6+TM
01844
6+TM
01850
3+TM
01852
4+TM
01860
3+TM
01905
5+TM
01916
5+TM
01920
7+TM
01922
7+TM
01924
6+TM
01925
8+TM
01926
10+TM
01930
5+TM
01931
7+TM
01932
7+TM
01933
8+TM
01951
3+TM
01952
5+TM

BASIC
CODE UNIT VALUE
01953
1
01958
5+TM
01960
5+TM
01961
7+TM
01962
8+TM
01963
10+TM
01964
4+TM
01967
5+TM
01968
3+TM
01969
5+TM
01990
7+TM
01991
3+TM
01992
5+TM
01995
5
01996
3
01999
I.C.*
* Individual Consideration

CPT only copyright 2004 American Medical Association. All Rights Reserved.

10

SURGERY GROUND RULES
1.

PACKAGE OR GLOBAL FEE CONCEPT: Listed surgical procedures include the surgery itself, local
anesthesia, metacarpal/digital block, or topical anesthesia when used, and normal, uncomplicated follow-up
care. The Unit Values for all procedures in this section applies to this "package" or "global" service for
surgical procedures. To report a postoperative follow-up for documentation purposes only, use 99024 (see
Special Services and Reports Section). For preoperative visits, see Ground Rules 3 and 4 below; see the
respective Anesthesia Ground Rule pertaining to anesthesia administered by other than an anesthesiologist
or anesthetist.

2.

OPERATIVE REPORT AND BILLING: A bill for an operative procedure shall be deemed properly submitted
only if an operative report or an informative description of the surgery performed is received by the payer. If
surgery was performed in a hospital or an ambulatory surgery center, a copy of the hospital's or ambulatory
surgery center's operative report will suffice. If surgery was performed at some other site and classified as
minor surgery, such as at a physician's office, identify the (geographic) location and submit an informative
description of the surgery performed.

3.

IMMEDIATE PREOPERATIVE VISITS AND OTHER SERVICES BY THE SURGEON: Under most
circumstances, including ordinary referrals, the immediate preoperative visit in the hospital or elsewhere that
is necessary to examine the patient, or to initiate the treatment program, is included in the Unit Value listed
for the surgical procedure.

4.

SEPARATE PREOPERATIVE CHARGES: Charges for separate preoperative procedures are sometimes
warranted and may be billed under the following circumstances:
a)

when the preoperative visit is the initial visit (e.g., an emergency) and prolonged detention or
evaluation is required to prepare the patient, or to establish the need for and type of surgical
procedure.

b)

when the preoperative visit is an initial consultation, as defined in the Medicine Section of this
manual.

c)

when procedures not usually part of the basic surgical procedure (e.g., myelography prior to
laminectomy, bronchoscopy prior to chest surgery) are provided during the immediate
preoperative visit.

5.

FOLLOW-UP CARE FOR DIAGNOSTIC PROCEDURES: Follow-up care for diagnostic procedures (e.g.,
endoscopy, injection procedures for radiography) includes only that care related to recovery from the
diagnostic procedure itself. Care of the condition for which the diagnostic procedure was performed or of
other concomitant conditions is not included and may be billed separately.

6.

MULTIPLE OR BILATERAL PROCEDURES: Multiple related procedures shall not warrant an additional fee
except in those subsections of the listings where separate codes are given. When more than one identifiable
surgical procedure or service is rendered, an additional fee may be warranted. Identify each procedure and
bill at full value for the major procedure and at 50% for the lesser procedure, up to a total maximum of twice
the greater fee (e.g., unsuccessful closed reduction of a fracture followed on a different day by open
reduction).
When multiple procedures, unrelated to the major procedure and adding significant time or complexity are
provided at the same operative session, payment is for the procedure with the highest allowance, plus half of
the lesser procedure up to a total maximum allowance of twice the highest fee.
When bilateral procedures are performed that require preparation of separate operative sites (e.g., bilateral
carpal tunnel), payment for the second (or bilateral) procedure is to be reimbursed at 75% of the primary
procedure.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

11

SURGERY GROUND RULES
MULTIPLE/BILATERAL EXAMPLES:
Related Procedures.
a)

Open reduction of a fracture: the excision of a previous scar, the incision of fascia
and muscle, the identification and retraction of nerves, muscles, and area structures,
and the closure of the wound (irrespective of type of closure) are all related to the
principal procedure of the bone repair and merit no additional fee.

b)

Repair of a tendon: the skin incision and linear closure, as well as the identification,
incision and retraction of adjacent or overlying structures are related to the principal
procedure and merit no additional fee.

Unrelated Procedures.
a) Multiple lacerations of an area such as the face: an additional fee may be warranted
when such lacerations are not continuous.
b)

Closure of an incision or laceration incidental to the repair of deeper structures such
as nerves, tendons, etc., does not merit an additional fee irrespective of the method
of closure.

7.

ADD-ON CODES: Certain codes, by the nature of their description and the unit values assigned, have
already been reduced, as they are not to be billed as primary procedures. For a complete list of the codes
which are considered to be add-on codes, refer to the appropriate appendix found within the most recent
publication of the AMA Current Procedural Terminology (CPT).

8.

CODES THAT ARE NOT CLASSIFIED AS ADD-ON CODES BUT ARE EXEMPT FROM THE MULTIPLE
PROCEDURE RULE / MODIFIER -51: For a complete list of the codes which fall into this category, refer to
the appropriate appendix found within the most recent publication of the AMA Current Procedural
Terminology (CPT).

9.

CODES WHICH INCLUDE CONSCIOUS SEDATION: Certain codes include conscious sedation as an
inherent part of providing the procedure. For a complete list of codes that include conscious sedation, refer
to the appropriate appendix that is found within the most recent publication of the AMA Current Procedural
Terminology (CPT).

10. FOLLOW-UP OR AFTERCARE: Follow-up care for therapeutic surgical procedures includes all normal
postoperative care, that care which is usually a part of the surgical service. Complications, exacerbations,
recurrence of the condition, or the presence of other diseases or injuries requiring additional services
concurrent with the procedure may warrant additional charges. If such separate charges are made, explain
by report with an adequate description. When an additional surgical procedure is performed during any
follow-up care and is related to the previously performed procedure but is not an intrinsic part of the latter,
the additional procedure will be paid at one-half the maximum allowable payment.
The column headed “FUD” reflects the amount of days that would be applicable for the particular type of
surgical procedure and/or service provided. Note that some procedures show the “FUD” as being XXX,
YYY, or ZZZ. The following definitions, which correspond with the Medicare Fee Schedule, are incorporated
within this fee schedule:
XXX = Reflects that the global surgery concept does not apply to these codes.
YYY = Reflects that the global period (FUD’s) are to be set by the carrier.
ZZZ = Reflects that the codes are an add-on service and are to be treated in the global
period (FUD’s) of the other procedures that are billed in conjunction with the ZZZ
code.
CPT only copyright 2004 American Medical Association. All Rights Reserved.

12

SURGERY GROUND RULES
11. SEPARATE PROCEDURE: Some of the procedures or services listed are commonly carried out as an
integral component of a total service or procedure and are identified by the inclusion of the term “separate
procedure.” The codes designated as “separate procedure” should not be reported in addition to the code
for the total procedure or service of which it is considered an integral component.
However, when a procedure or service that is designated as a “separate procedure” is carried out
independently or considered to be unrelated or distinct from other procedures/services provided at that time,
it may be reported by itself, or in addition to other procedures/services by appending modifier -59 to the
specific “separate procedure” code to indicate that the procedure is not considered to be a component of
another procedure, but is a distinct, independent procedure. This may represent a different session or
patient encounter, different procedure or surgery, different site or organ system, separate incision/excision,
separate lesion, or separate injury (or area of injury in extensive injuries).
12. PRIMARY, SECONDARY, OR DELAYED PROCEDURES: A primary procedure is one that is attempted or
performed for the first time, irrespective of the relationship to the date of injury or the onset of the condition
being treated. Secondary refers to a procedure performed when a condition has been previously treated.
For example, where a tendon is lacerated and it is elected to close the laceration without suturing the tendon,
the first direct repair of the tendon would constitute a delayed but primary repair. In this example, if the first
repair is unsuccessful, any subsequent repair of the tendon would be a secondary procedure. Secondary
procedures lie within the content of service. Delayed procedures have the same Maximum Allowable Fee as
the primary procedures.
13. PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in the Unit Value column
indicates that the amount charged for this service is to be determined "by report" because the service is too
unusual or variable to be assigned a Unit Value. Pertinent information should be furnished concerning the
nature, extent, and need for the procedure or service, the skill and equipment necessary, etc., using any of
the following as indicated:
• Diagnosis (postoperative), pertinent history, and physical findings
• Size, location, and number of lesions or procedures where appropriate
• Major surgical procedure accompanied by an additional procedure
• The closest similar procedure by code number and the associated Unit Value, if possible
• Operative time
14. UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the
procedure should be identified and the amount charged substantiated "by report" (BR). Unlisted service or
procedure codes usually end in "99."
15. CONCURRENT SERVICES BY MORE THAN ONE HEALTH CARE PROVIDER: Charges for concurrent
services of two or more health care providers may be warranted under the following circumstances:
a) Identifiable medical services: Services provided prior to or during the surgical procedure or in the
postoperative period are to be charged by the health care provider rendering the service,
identified by the appropriate code. Payable fees under this category are unrelated to the
surgeon's fee.
b) Assistant surgeon: Identify the surgery performed by using the respective code number along
with the appropriate modifier (-80, -81, or -82) and bill at 25% of the code fee. The code number
must coincide with that of the primary surgeon. Assistant surgeon fees are not payable when the
hospital provides an intern or a resident staff to assist at surgery.
c) Two surgeons: Under certain circumstances, the skills of two surgeons (usually with different
skills) may be required in the management of a specific surgical procedure. Identify the surgery
performed by using the respective code number along with modifier -62. The total allowable fee
may be increased by 25% in lieu of an assistant surgeon’s fee. If the physicians have
agreed upon a payment distribution and that agreement is documented and explained in
conjunction with the bill, payment is to be made in accordance with the percentage agreed upon.
CPT only copyright 2004 American Medical Association. All Rights Reserved.

13

SURGERY GROUND RULES
In the absence of a prior agreement, the total allowable fee will be divided equally between the
two surgeons.
d) Surgical team: Under some circumstances, highly complex procedures (e.g., open heart or
organ transplant surgery) may require the concurrent services of several health care providers,
often of different specializations and using various types of complex equipment. These types of
services vary widely and a single unit value cannot be assigned. The amount charged should be
supported by a narrative report to include itemization of the health care provider, paramedical
personnel, and equipment involved. Modifier -66 should be used in this type of situation.

16. SURGERY AND FOLLOW-UP CARE PROVIDED BY DIFFERENT HEALTH CARE PROVIDERS: When
one health care provider performs the surgical procedure and another provides the follow-up care, the value
may be apportioned between them by agreement. Whether the amount charged is for the procedure, or the
follow-up care should be clearly indicated. The "global fee" is not to be increased, but prorated between the
health care providers.
17. REPEAT PROCEDURE BY ANOTHER HEALTH CARE PROVIDER: A basic procedure performed by one
health care provider may have to be repeated by another. Identify and submit an explanatory note. (See
modifier -77.)
18. PRORATION OF SCHEDULED FEE: When the schedule specifies a unit value for a definite treatment and
the patient is transferred from one health care provider to another, the applicable Unit Value is to be
apportioned between the health care providers. The providers involved shall agree upon the amount of the
proration, and shall render separate bills accordingly with an explanatory note.
19. MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the health
care provider (e.g., sterile trays, drugs) over and above those included with the office visit or other services
rendered may be listed separately. The statement of charges will need to reflect any drugs, trays, supplies,
and materials provided. Payment shall not exceed the cost of the item(s) to the health care provider plus
25%, or the cost of the item(s) plus $15.00 per item, whichever is less. Use procedure code 99070.
20. SURGICAL IMPLANTABLES: Reimbursement for any single surgical implantable item (e.g. rods, pins,
screws, plates, prosthetic joint replacements) and which is made of plastic, metallic, or of autogenous/nonautogenous graft material that reflects a charge of $250.00 or more, is to be determined by cost to the
provider plus a 50% markup above the invoice cost. A copy of the invoice (date of purchase within twelve
months of implantation) must be submitted with the bill.
21. SURGICAL ASSISTANT: Non-physician surgical assistants such as physician assistants or registered
nurses, who are either certified or licensed by the Kansas State Board of Healing Arts, the Kansas State
Board of Nursing, or some other comparable State licensing agency, may bill at 10% of the code fee. The
code(s) must coincide with those of the primary surgeon who must be identified as the responsible physician.
Such services are to be identified by adding modifier -NP to the procedure code. (See modifier -NP).
Additionally, bills for any surgical services provided by non-physicians such as physician assistants or
registered nurses must be submitted on the CMS 1500 or an equivalent form containing the same
information. The form must also clearly identify the responsible physician.
22. OTHER FEES: The Unit Values for anesthesia, x-rays, laboratory procedures, consultation and other
medical services, and office and hospital visits are listed in the following sections: Anesthesia, Radiology,
Pathology and Laboratory, Medicine, Physical Medicine and Rehabilitation, and Evaluation and
Management.
23. MEASUREMENTS: When listed with a described procedure, measurements pertain to the original wounds
or defects before any treatment is effected. The allowable charge includes creation of any additional defect.
The necessary preparations for repair do not merit an additional charge. The depth of a wound is not a
factor in the measurements when the described procedure is stated in terms of length or area.
CPT only copyright 2004 American Medical Association. All Rights Reserved.

14

SURGERY GROUND RULES
24. PROFESSIONAL/TECHNICAL COMPONENTS: When the professional and technical components are
furnished by different providers (inclusive of hospitals and ambulatory surgical centers), the professional
component and the technical component shall be identified by adding either modifier -26 or modifier -TC to
the usual procedure number. For surgical procedures, the unit value for the professional component is 60%
of the total unit value, and the unit value for the technical component is 40% of the total unit value for the
procedure code submitted. See Appendix A - Modifiers for the listing of the modifiers.
Additionally, and except for outpatient services, hospitals and ambulatory surgical centers will continue to be
reimbursed at their usual and customary charge less the specified discount as contained within the
Hospital/Ambulatory Surgical Center Section of the fee schedule. However, hospitals and ambulatory
surgical centers need to amend their billing process to specify, by use of modifiers, when only the technical
component or the professional component was provided.
25. MODIFIERS:
Procedure codes for surgery may be modified under certain circumstances.
The
circumstances are to be identified by the addition of a hyphen and the appropriate two-digit modifier code.
Refer to Appendix A - Modifiers for a list of modifiers that may be used.
26. COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care costs.
Such payment agreements, if less, will supersede the limitation amounts specified herein. Please refer to
K.S.A. 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $67.95

CPT only copyright 2004 American Medical Association. All Rights Reserved.

15

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
10021
10022
10040
10060
10061
10080
10081
10120
10121
10140
10160
10180
11000
11001
11004
11005
11006
11008
11010
11011
11012
11040
11041
11042
11043
11044
11055
11056
11057
11100
11101
11200
11201
11300
11301
11302
11303
11305
11306
11307
11308
11310
11311
11312
11313
11400
11401
11402
11403
11404
11406
11420
11421

FUD
XXX
XXX
10
10
10
10
10
10
10
10
10
10
00
ZZZ
00
00
00
ZZZ
10
00
00
00
00
00
10
10
00
00
00
00
ZZZ
10
ZZZ
00
00
00
00
00
00
00
00
00
00
00
00
10
10
10
10
10
10
10
10

UNIT VALUE
3.52
3.89
2.25
2.50
4.48
4.38
6.77
3.51
6.52
3.49
2.94
5.56
1.25
0.56
14.88
20.27
18.74
7.63
11.66
13.80
20.09
1.08
1.58
2.22
6.05
7.91
1.04
1.32
1.63
2.10
0.76
1.86
0.47
1.53
2.01
2.40
2.89
1.59
2.17
2.51
2.99
1.89
2.34
2.68
3.52
2.91
3.38
3.86
4.35
4.97
6.14
2.84
3.61

CODE
11422
11423
11424
11426
11440
11441
11442
11443
11444
11446
11450
11451
11462
11463
11470
11471
11600
11601
11602
11603
11604
11606
11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
11719
11720
11721
11730
11732
11740
11750
11752
11755
11760
11762
11765
11770
11771
11772
11900
11901
11920
11921

FUD
10
10
10
10
10
10
10
10
10
10
42
42
42
42
42
42
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
00
00
00
00
ZZZ
00
10
10
00
10
10
10
10
42
42
00
00
00
00

UNIT VALUE
4.03
4.79
5.48
7.67
3.34
3.94
4.41
5.41
6.90
8.94
8.10
11.05
7.92
11.27
8.70
11.65
4.04
4.62
4.90
5.42
5.97
7.84
3.88
4.58
5.19
6.14
7.07
9.36
4.10
5.34
6.18
7.15
9.07
12.29
0.44
0.70
1.05
2.30
1.08
0.96
4.24
6.01
3.03
4.40
6.13
2.55
6.40
12.10
15.35
1.20
1.49
5.54
6.17

CPT only copyright 2004 American Medical Association. All Rights Reserved.

16

CODE
11922
11950
11951
11952
11954
11960
11970
11971
11975
11976
11977
11980
11981
11982
11983
12001
12002
12004
12005
12006
12007
12011
12013
12014
12015
12016
12017
12018
12020
12021
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
12052
12053
12054
12055
12056
12057
13100
13101
13102
13120

FUD
ZZZ
00
00
00
00
42
42
42
XXX
00
XXX
00
XXX
XXX
XXX
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
ZZZ
10

UNIT VALUE
1.70
2.04
2.79
3.70
4.53
20.74
14.21
11.54
3.07
3.71
5.94
2.69
3.30
3.89
5.82
3.84
4.08
4.78
5.96
7.43
8.37
4.06
4.45
5.26
6.62
7.85
7.08
8.38
6.74
3.89
4.61
6.48
6.37
8.99
10.11
11.37
5.11
6.19
6.64
9.29
11.25
11.54
5.94
6.18
6.60
7.31
9.35
12.55
12.62
7.44
8.85
2.54
7.72

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
13121
13122
13131
13132
13133
13150
13151
13152
13153
13160
14000
14001
14020
14021
14040
14041
14060
14061
14300
14350
15000
15001
15050
15100
15101
15120
15121
15200
15201
15220
15221
15240
15241
15260
15261
15342
15343
15350
15351
15400
15401
15570
15572
15574
15576
15600
15610
15620
15630
15650
15732
15734
15736

FUD
10
ZZZ
10
10
ZZZ
10
10
10
ZZZ
42
42
42
42
42
42
42
42
42
42
42
00
ZZZ
42
42
ZZZ
42
ZZZ
42
ZZZ
42
ZZZ
42
ZZZ
42
ZZZ
10
ZZZ
42
ZZZ
42
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
9.46
3.10
8.42
12.19
4.03
9.01
9.56
12.77
4.56
19.11
14.32
18.70
15.83
20.85
17.31
22.82
17.95
24.64
24.03
18.06
8.26
2.49
11.76
22.87
5.69
21.69
7.52
18.39
4.06
17.87
3.67
20.17
4.52
20.96
5.13
2.96
0.37
10.94
1.50
8.46
3.03
21.77
19.93
21.73
19.30
9.77
7.45
11.07
10.64
11.52
37.82
38.41
36.86

CODE
15738
15740
15750
15756
15757
15758
15760
15770
15775
15776
15780
15781
15782
15783
15786
15787
15788
15789
15792
15793
15810
15811
15819
15820
15821
15822
15823
15824
15825
15826
15828
15829
15831
15832
15833
15834
15835
15836
15837
15838
15839
15840
15841
15842
15845
15850
15851
15852
15860
15876
15877
15878
15879

FUD
42
42
42
42
42
42
42
42
00
00
42
42
42
42
10
ZZZ
42
42
42
42
42
42
42
42
42
42
42
00
00
00
00
00
42
42
42
42
42
42
42
42
42
42
42
42
42
XXX
00
00
00
00
00
00
00

UNIT VALUE
38.47
21.04
21.83
60.30
60.68
60.84
19.60
15.22
8.70
11.60
19.47
12.09
14.50
11.43
5.51
1.46
8.93
13.21
9.08
10.22
9.12
11.67
17.52
12.52
13.51
10.63
15.39
20.45
23.38
20.45
54.04
59.88
22.25
21.55
20.25
20.12
20.78
17.43
18.15
13.78
19.37
24.54
40.78
65.70
22.65
2.39
2.60
2.79
3.03
BR
BR
BR
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

17

CODE
15920
15922
15931
15933
15934
15935
15936
15937
15940
15941
15944
15945
15946
15950
15951
15952
15953
15956
15958
15999
16000
16010
16015
16020
16025
16030
16035
16036
17000
17003
17004
17106
17107
17108
17110
17111
17250
17260
17261
17262
17263
17264
17266
17270
17271
17272
17273
17274
17276
17280
17281
17282
17283

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
00
00
00
00
00
00
42
ZZZ
10
ZZZ
10
42
42
42
10
10
00
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10
10

UNIT VALUE
14.52
18.50
16.14
20.17
22.47
26.92
22.31
26.03
16.79
22.50
21.67
24.10
39.01
13.95
20.01
20.71
23.38
28.43
28.71
BR
1.83
1.62
3.81
2.17
3.80
4.49
5.77
2.30
1.60
0.27
5.22
9.53
17.01
23.26
2.32
2.64
1.77
2.23
2.83
3.53
3.92
4.24
4.96
3.08
3.32
3.84
4.34
5.27
6.32
2.83
3.69
4.28
5.30

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
17284
17286
17304
17305
17306
17307
17310
17340
17360
17380
17999
19000
19001
19020
19030
19100
19101
19102
19103
19110
19112
19120
19125
19126
19140
19160
19162
19180
19182
19200
19220
19240
19260
19271
19272
19290
19291
19295
19296
19297
19298
19316
19318
19324
19325
19328
19330
19340
19342
19350
19355
19357
19361

FUD
10
10
00
00
00
00
ZZZ
10
10
00
YYY
00
ZZZ
42
00
00
10
00
00
42
42
42
42
ZZZ
42
42
42
42
42
42
42
42
42
42
42
00
ZZZ
ZZZ
00
ZZZ
00
42
42
42
42
42
42
ZZZ
42
42
42
42
42

UNIT VALUE
6.28
8.36
16.15
6.86
6.88
6.53
2.60
1.18
2.93
1.99
BR
2.90
0.71
10.33
4.48
3.51
8.06
5.97
15.48
10.64
10.20
10.81
11.62
4.31
12.97
10.19
21.61
14.99
13.51
25.32
25.95
26.28
28.64
39.41
43.42
4.20
1.88
2.70
129.38
2.53
48.59
19.78
29.63
11.57
16.26
11.59
14.82
10.47
21.89
24.14
18.73
36.60
34.52

CODE
19364
19366
19367
19368
19369
19370
19371
19380
19396
19499
20000
20005
20100
20101
20102
20103
20150
20200
20205
20206
20220
20225
20240
20245
20250
20251
20500
20501
20520
20525
20526
20550
20551
20552
20553
20600
20605
20610
20612
20615
20650
20660
20661
20662
20663
20664
20665
20670
20680
20690
20692
20693
20694

FUD
42
42
42
42
42
42
42
42
00
YYY
10
10
10
10
10
10
42
00
00
00
00
00
10
10
10
10
10
00
10
10
00
00
00
00
00
00
00
00
00
10
10
00
42
42
42
42
10
10
42
42
42
42
42

UNIT VALUE
70.61
36.03
46.33
56.77
52.62
16.21
18.75
18.25
3.55
BR
5.05
7.34
15.76
9.56
11.88
14.58
22.71
4.70
6.56
7.56
5.92
26.54
6.20
15.57
9.50
10.81
3.61
3.71
4.97
13.12
2.03
1.54
1.51
1.43
1.62
1.39
1.52
1.84
1.50
5.99
4.90
6.11
10.90
12.14
11.18
16.77
3.64
13.55
12.66
6.60
11.20
12.27
11.98

CPT only copyright 2004 American Medical Association. All Rights Reserved.

18

CODE
20802
20805
20808
20816
20822
20824
20827
20838
20900
20902
20910
20912
20920
20922
20924
20926
20930
20931
20936
20937
20938
20950
20955
20956
20957
20962
20969
20970
20972
20973
20974
20975
20979
20982
20999
21010
21015
21025
21026
21029
21030
21031
21032
21034
21040
21044
21045
21046
21047
21048
21049
21050
21060

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
XXX
ZZZ
XXX
ZZZ
ZZZ
00
42
42
42
42
42
42
42
42
00
00
00
00
YYY
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
65.82
89.04
110.59
73.17
63.69
72.00
66.47
64.74
14.92
15.70
11.14
12.84
10.15
14.85
13.37
11.08
2.60
3.16
2.74
4.78
5.20
8.29
68.23
70.76
66.53
71.89
75.34
74.93
68.82
76.41
1.41
4.81
1.51
117.50
BR
18.26
10.97
23.59
13.30
18.01
11.33
8.88
9.04
33.76
11.41
22.35
30.03
26.71
34.26
27.36
32.56
21.60
20.20

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
21070
21076
21077
21079
21080
21081
21082
21083
21084
21085
21086
21087
21088
21089
21100
21110
21116
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
21198
21199

FUD
42
10
42
42
42
42
42
42
42
10
42
42
42
42
42
42
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
16.55
27.71
69.54
46.86
53.19
48.33
43.26
40.91
47.15
18.49
52.30
51.58
BR
BR
16.09
15.41
5.20
16.10
18.26
18.20
23.34
66.59
55.42
18.86
23.42
26.83
34.05
33.97
35.51
36.62
39.07
38.62
44.49
53.49
56.05
64.90
79.53
77.93
45.02
55.70
39.12
43.98
18.67
54.08
60.53
65.77
42.97
31.97
35.56
33.65
36.63
28.28
26.51

CODE
21206
21208
21209
21210
21215
21230
21235
21240
21242
21243
21244
21245
21246
21247
21248
21249
21255
21256
21260
21261
21263
21267
21268
21270
21275
21280
21282
21295
21296
21299
21300
21310
21315
21320
21325
21330
21335
21336
21337
21338
21339
21340
21343
21344
21345
21346
21347
21348
21355
21356
21360
21365
21366

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
00
00
10
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
10
42
42
42

UNIT VALUE
28.03
33.63
18.39
36.35
54.15
20.07
17.16
28.31
26.21
41.37
25.20
27.43
22.83
42.75
25.13
36.67
35.19
29.63
30.23
59.06
50.06
40.32
48.27
22.58
20.66
12.36
8.22
4.22
9.49
BR
3.20
2.92
5.88
5.94
12.69
15.65
18.96
15.88
9.10
21.26
22.93
20.29
29.89
38.53
18.91
23.98
30.31
30.24
10.33
11.72
13.10
27.43
31.55

CPT only copyright 2004 American Medical Association. All Rights Reserved.

19

CODE
21385
21386
21387
21390
21395
21400
21401
21406
21407
21408
21421
21422
21423
21431
21432
21433
21435
21436
21440
21445
21450
21451
21452
21453
21454
21461
21462
21465
21470
21480
21485
21490
21493
21494
21495
21497
21499
21501
21502
21510
21550
21555
21556
21557
21600
21610
21615
21616
21620
21627
21630
21632
21685

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
42
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
18.39
17.20
19.70
18.83
23.14
4.15
11.63
13.80
16.41
22.67
15.15
17.38
20.94
17.26
17.47
44.46
31.88
49.28
10.17
15.88
10.66
14.81
15.27
17.00
13.52
33.51
38.64
23.19
29.28
2.44
12.70
23.47
1.94
10.38
14.56
12.80
BR
10.66
13.72
12.16
5.81
10.39
10.32
15.30
13.57
26.21
17.98
21.89
13.71
14.09
31.71
31.78
24.01

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
21700
21705
21720
21725
21740
21742
21743
21750
21800
21805
21810
21820
21825
21899
21920
21925
21930
21935
22100
22101
22102
22103
22110
22112
22114
22116
22210
22212
22214
22216
22220
22222
22224
22226
22305
22310
22315
22318
22319
22325
22326
22327
22328
22505
22520
22521
22522
22532
22533
22534
22548
22554
22556

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
10
42
42
42
42
42
42
ZZZ
42
42
42
ZZZ
42
42
42
ZZZ
42
42
42
ZZZ
42
42
42
42
42
42
42
42
ZZZ
10
10
10
ZZZ
42
42
ZZZ
42
42
42

UNIT VALUE
11.07
16.60
9.01
13.62
27.35
24.87
32.74
18.41
2.39
6.33
12.76
3.25
14.86
BR
5.49
10.24
11.34
29.94
19.32
19.24
19.59
3.96
24.58
24.50
24.53
3.96
44.54
36.39
37.05
10.44
39.98
36.05
39.75
10.35
4.71
5.89
20.30
39.99
44.60
34.10
36.51
35.41
7.79
3.11
71.98
65.63
6.67
42.85
39.61
10.20
47.12
35.26
42.22

CODE
22558
22585
22590
22595
22600
22610
22612
22614
22630
22632
22800
22802
22804
22808
22810
22812
22818
22819
22830
22840
22841
22842
22843
22844
22845
22846
22847
22848
22849
22850
22851
22852
22855
22899
22900
22999
23000
23020
23030
23031
23035
23040
23044
23065
23066
23075
23076
23077
23100
23101
23105
23106
23107

FUD
42
ZZZ
42
42
42
42
42
ZZZ
42
ZZZ
42
42
42
42
42
42
42
42
42
ZZZ
XXX
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
42
42
ZZZ
42
42
YYY
42
YYY
42
42
10
10
42
42
42
10
42
10
42
42
42
42
42
42
42

UNIT VALUE
38.47
9.49
38.43
36.46
30.94
30.84
39.53
11.14
39.00
9.02
34.64
56.50
65.82
47.31
53.35
57.96
56.94
64.03
21.03
21.72
6.41
21.71
22.83
28.30
20.77
21.60
23.76
10.31
34.01
18.50
11.52
17.64
28.17
BR
9.76
BR
13.53
18.00
11.34
11.04
18.31
18.61
14.74
4.95
12.43
6.37
14.27
28.56
12.70
11.84
16.74
12.62
17.47

CPT only copyright 2004 American Medical Association. All Rights Reserved.

20

CODE
23120
23125
23130
23140
23145
23146
23150
23155
23156
23170
23172
23174
23180
23182
23184
23190
23195
23200
23210
23220
23221
23222
23330
23331
23332
23350
23395
23397
23400
23405
23406
23410
23412
23415
23420
23430
23440
23450
23455
23460
23462
23465
23466
23470
23472
23480
23485
23490
23491
23500
23505
23515
23520

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
42
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
14.77
18.53
15.96
13.14
18.01
16.28
16.66
20.44
17.54
13.92
14.18
19.49
18.95
18.00
20.27
14.57
19.21
22.56
23.43
27.79
32.46
43.57
5.76
15.40
22.89
4.52
32.48
30.13
25.86
16.70
20.93
23.94
25.44
19.65
26.39
19.77
20.51
25.51
27.24
29.35
28.60
29.72
27.99
32.29
39.07
21.85
25.60
21.99
27.35
5.24
8.68
15.22
5.33

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
23525
23530
23532
23540
23545
23550
23552
23570
23575
23585
23600
23605
23615
23616
23620
23625
23630
23650
23655
23660
23665
23670
23675
23680
23700
23800
23802
23900
23920
23921
23929
23930
23931
23935
24000
24006
24065
24066
24075
24076
24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
42
42
42
42
YYY
10
10
42
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
8.57
14.43
16.35
5.36
7.78
14.82
17.21
5.59
9.49
18.12
7.94
11.81
19.77
39.01
6.39
9.48
15.22
7.45
9.38
15.13
10.48
16.06
13.83
19.85
5.12
26.79
29.43
34.51
26.86
11.33
BR
9.67
7.96
13.01
12.17
18.53
5.46
14.89
11.80
12.07
21.13
10.22
13.08
16.16
8.59
15.28
18.49
22.89
13.65
15.10
16.48
13.29
20.19

CODE
24136
24138
24140
24145
24147
24149
24150
24151
24152
24153
24155
24160
24164
24200
24201
24220
24300
24301
24305
24310
24320
24330
24331
24332
24340
24341
24342
24343
24344
24345
24346
24350
24351
24352
24354
24356
24360
24361
24362
24363
24365
24366
24400
24410
24420
24430
24435
24470
24495
24498
24500
24505
24515

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
16.58
17.14
19.77
16.86
17.40
28.10
25.49
29.65
19.25
17.83
22.01
15.98
13.01
5.36
15.02
5.03
10.07
19.94
15.28
12.49
19.79
19.05
21.06
15.44
16.19
17.14
20.90
18.19
27.83
18.05
27.63
11.68
12.82
13.70
13.69
14.07
23.80
26.80
27.59
35.13
16.99
18.17
21.75
27.66
26.11
24.70
26.25
17.93
18.01
23.18
8.54
12.61
22.99

CPT only copyright 2004 American Medical Association. All Rights Reserved.

21

CODE
24516
24530
24535
24538
24545
24546
24560
24565
24566
24575
24576
24577
24579
24582
24586
24587
24600
24605
24615
24620
24635
24640
24650
24655
24665
24666
24670
24675
24685
24800
24802
24900
24920
24925
24930
24931
24935
24940
24999
25000
25001
25020
25023
25024
25025
25028
25031
25035
25040
25065
25066
25075
25076

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
42
42
42
42
42
42
42
42
42
42
10
42
42
42

UNIT VALUE
22.73
9.24
15.85
19.69
20.68
29.66
7.69
13.06
17.23
20.86
8.06
13.65
22.39
19.12
29.00
28.66
9.55
11.64
18.81
14.25
29.47
3.16
6.27
11.02
17.02
19.14
7.04
11.48
17.81
21.54
26.31
18.14
18.05
14.28
19.09
20.30
25.68
27.92
BR
10.77
8.12
16.40
29.84
18.27
28.21
14.17
12.65
22.14
15.60
5.37
11.80
10.13
15.18

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
25077
25085
25100
25101
25105
25107
25110
25111
25112
25115
25116
25118
25119
25120
25125
25126
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25246
25248
25250
25251
25259
25260
25263
25265
25270
25272
25274
25275
25280
25290
25295
25300
25301
25310
25312
25315
25316
25320
25332
25335
25337
25350

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
23.19
13.44
9.74
11.32
14.05
15.74
11.57
8.60
10.47
24.14
21.34
10.78
14.56
19.15
21.37
21.82
12.47
15.38
13.58
19.42
16.44
21.28
27.91
13.60
17.82
12.14
12.91
4.98
14.34
13.67
18.73
10.06
22.27
22.21
25.65
18.95
20.91
23.70
17.38
20.90
21.08
19.69
18.50
17.72
22.37
24.91
26.14
30.26
23.72
22.37
26.35
22.81
24.17

CODE
25355
25360
25365
25370
25375
25390
25391
25392
25393
25394
25400
25405
25415
25420
25425
25426
25430
25431
25440
25441
25442
25443
25444
25445
25446
25447
25449
25450
25455
25490
25491
25492
25500
25505
25515
25520
25525
25526
25530
25535
25545
25560
25565
25574
25575
25600
25605
25611
25620
25622
25624
25628
25630

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
26.48
23.69
30.15
31.68
31.68
26.59
32.38
31.98
36.16
20.02
27.88
33.91
31.98
37.17
36.38
34.87
17.84
20.71
21.42
24.89
21.24
20.50
21.85
19.21
30.90
20.59
27.31
19.40
21.29
24.69
25.99
29.73
6.35
12.55
18.18
14.13
24.21
28.59
6.17
11.98
18.04
6.46
13.21
15.40
21.70
7.12
13.98
18.04
17.21
7.27
11.55
17.60
7.49

CPT only copyright 2004 American Medical Association. All Rights Reserved.

22

CODE
25635
25645
25650
25651
25652
25660
25670
25671
25675
25676
25680
25685
25690
25695
25800
25805
25810
25820
25825
25830
25900
25905
25907
25909
25915
25920
25922
25924
25927
25929
25931
25999
26010
26011
26020
26025
26030
26034
26035
26037
26040
26045
26055
26060
26070
26075
26080
26100
26105
26110
26115
26116
26117

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
11.03
15.06
7.79
11.65
15.79
10.03
16.16
13.12
10.89
16.66
11.46
19.13
11.85
16.74
20.38
23.29
22.09
16.50
19.89
25.99
22.84
22.78
20.65
22.60
38.84
17.86
15.58
17.86
21.73
14.59
20.41
BR
7.27
11.32
10.73
10.68
12.55
13.54
18.79
14.68
7.91
12.11
17.47
6.76
7.50
8.07
9.72
8.29
8.51
8.09
17.52
12.35
16.84

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
26121
26123
26125
26130
26135
26140
26145
26160
26170
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26255
26260
26261
26262
26320
26340
26350
26352
26356
26357
26358
26370
26372
26373
26390
26392
26410
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437
26440
26442
26445
26449
26450
26455

FUD
42
42
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
15.65
19.55
7.74
11.69
14.47
13.11
13.32
16.00
10.40
11.36
12.06
11.70
15.77
11.33
14.37
13.22
12.93
11.42
15.04
23.44
14.18
16.38
11.87
8.86
7.76
21.50
24.15
27.63
25.52
27.14
23.31
26.67
25.42
23.85
28.48
17.27
20.53
21.08
24.74
17.20
21.45
20.23
22.14
14.89
16.05
18.55
18.27
19.18
25.27
18.08
23.81
11.57
11.48

CODE
26460
26471
26474
26476
26477
26478
26479
26480
26483
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26504
26508
26510
26516
26517
26518
26520
26525
26530
26531
26535
26536
26540
26541
26542
26545
26546
26548
26550
26551
26553
26554
26555
26556
26560
26561
26562
26565
26567
26568
26580
26587
26590

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
11.13
17.83
17.45
16.87
17.00
18.52
18.20
22.73
25.04
24.18
22.79
22.42
24.61
22.71
24.25
24.52
32.23
23.35
18.28
20.27
21.28
18.64
17.55
20.45
23.72
23.71
19.97
20.09
13.85
16.19
9.68
16.95
19.27
23.27
19.82
20.08
25.37
22.05
41.22
86.87
71.28
101.76
37.25
83.06
16.01
24.69
34.34
19.73
19.79
25.99
34.06
24.76
34.61

CPT only copyright 2004 American Medical Association. All Rights Reserved.

23

CODE
26591
26593
26596
26600
26605
26607
26608
26615
26641
26645
26650
26665
26670
26675
26676
26685
26686
26700
26705
26706
26715
26720
26725
26727
26735
26740
26742
26746
26750
26755
26756
26765
26770
26775
26776
26785
26820
26841
26842
26843
26844
26850
26852
26860
26861
26862
26863
26910
26951
26952
26989
26990
26991

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
ZZZ
42
42
42
YYY
42
42

UNIT VALUE
13.34
17.21
19.14
5.86
7.86
12.47
12.47
11.47
8.90
10.20
13.33
15.08
8.32
10.85
13.08
14.18
16.06
7.79
10.12
10.98
12.15
4.66
8.59
12.28
12.45
5.36
9.39
12.26
4.39
7.92
10.80
9.18
6.73
9.41
11.55
9.38
22.76
21.52
22.92
21.10
23.40
20.21
22.55
16.59
2.93
20.79
6.56
19.96
15.43
18.89
BR
15.85
18.91

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
26992
27000
27001
27003
27005
27006
27025
27030
27033
27035
27036
27040
27041
27047
27048
27049
27050
27052
27054
27060
27062
27065
27066
27067
27070
27071
27075
27076
27077
27078
27079
27080
27086
27087
27090
27091
27093
27095
27096
27097
27098
27100
27105
27110
27111
27120
27122
27125
27130
27132
27134
27137
27138

FUD
42
42
42
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
25.51
11.85
14.24
14.91
19.13
19.32
21.48
24.85
25.58
29.99
25.07
8.37
17.82
15.55
11.94
24.05
9.37
13.15
17.33
10.58
11.47
12.28
20.48
26.29
21.54
23.45
59.65
40.19
68.67
25.56
25.16
12.13
6.65
16.49
21.82
39.88
5.88
7.36
5.85
16.75
16.79
21.50
22.61
24.43
23.18
32.79
28.56
27.79
36.84
42.89
51.15
38.70
40.32

CODE
27140
27146
27147
27151
27156
27158
27161
27165
27170
27175
27176
27177
27178
27179
27181
27185
27187
27193
27194
27200
27202
27215
27216
27217
27218
27220
27222
27226
27227
27228
27230
27232
27235
27236
27238
27240
27244
27245
27246
27248
27250
27252
27253
27254
27256
27257
27258
27259
27265
27266
27275
27280
27282

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
10
42
42
42
42
10
42
42

UNIT VALUE
23.68
32.48
37.34
34.31
44.76
33.81
31.65
33.86
30.11
16.58
23.24
28.55
22.45
25.18
26.42
19.06
26.18
11.57
18.91
4.32
24.95
19.04
27.42
26.58
34.97
12.93
24.75
25.15
42.79
49.35
11.90
19.51
23.67
29.29
11.52
24.01
29.94
37.49
9.96
20.42
12.17
19.40
24.88
33.34
8.07
8.70
28.87
39.35
10.44
15.09
4.75
26.01
21.17

CPT only copyright 2004 American Medical Association. All Rights Reserved.

24

CODE
27284
27286
27290
27295
27299
27301
27303
27305
27306
27307
27310
27315
27320
27323
27324
27327
27328
27329
27330
27331
27332
27333
27334
27335
27340
27345
27347
27350
27355
27356
27357
27358
27360
27365
27370
27372
27380
27381
27385
27386
27390
27391
27392
27393
27394
27395
27396
27397
27400
27403
27405
27407
27409

FUD
42
42
42
42
YYY
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
42.06
42.29
40.63
32.81
BR
17.55
16.65
12.07
10.16
12.20
18.42
13.00
12.57
6.03
9.80
11.07
10.76
25.23
10.35
12.39
16.80
15.22
17.59
19.93
9.44
12.52
12.16
16.80
15.72
18.92
21.13
8.07
21.78
30.66
4.76
15.90
15.66
21.17
16.72
21.86
11.34
14.95
18.34
13.27
17.16
23.05
16.17
22.11
17.57
16.93
17.62
20.29
25.05

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
27412
27415
27418
27420
27422
27424
27425
27427
27428
27429
27430
27435
27437
27438
27440
27441
27442
27443
27445
27446
27447
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
27475
27477
27479
27485
27486
27487
27488
27495
27496
27497
27498
27499
27500
27501
27502
27503
27506
27507
27508
27509
27510
27511

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
42.36
35.37
21.60
19.60
19.57
19.57
11.63
18.73
27.60
30.58
19.32
19.63
17.17
21.68
18.20
19.35
22.85
21.50
33.05
29.85
39.79
21.54
26.92
33.08
24.90
25.67
26.52
30.88
34.56
30.58
33.39
17.20
19.28
25.17
17.75
36.05
46.11
30.12
29.60
12.67
13.73
15.17
17.27
12.99
12.71
20.39
20.65
33.15
26.17
13.23
16.99
17.94
27.15

CODE
27513
27514
27516
27517
27519
27520
27524
27530
27532
27535
27536
27538
27540
27550
27552
27556
27557
27558
27560
27562
27566
27570
27580
27590
27591
27592
27594
27596
27598
27599
27600
27601
27602
27603
27604
27605
27606
27607
27610
27612
27613
27614
27615
27618
27619
27620
27625
27626
27630
27635
27637
27638
27640

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
42
YYY
42
42
42
42
42
10
10
42
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
34.84
33.57
12.49
17.43
29.12
7.85
19.93
9.70
15.89
23.56
29.92
11.80
24.81
12.48
16.17
28.50
32.75
33.78
9.05
11.47
23.63
3.81
37.41
20.40
23.25
17.61
13.09
18.94
19.14
BR
11.01
11.28
13.55
13.13
11.22
10.96
8.17
15.42
16.70
14.53
5.61
13.55
23.70
11.78
19.13
12.38
16.03
17.29
13.08
15.80
19.77
20.63
23.50

CPT only copyright 2004 American Medical Association. All Rights Reserved.

25

CODE
27641
27645
27646
27647
27648
27650
27652
27654
27656
27658
27659
27664
27665
27675
27676
27680
27681
27685
27686
27687
27690
27691
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707
27709
27712
27715
27720
27722
27724
27725
27727
27730
27732
27734
27740
27742
27745
27750
27752
27756
27758
27759
27760
27762

FUD
42
42
42
42
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
19.02
28.55
25.68
21.57
4.56
18.76
20.02
18.70
13.73
10.31
13.52
9.88
11.24
14.01
16.53
11.77
13.86
14.75
15.18
12.54
16.37
19.34
3.12
13.41
15.97
17.76
16.27
26.46
29.80
14.46
20.27
10.04
19.76
27.42
27.58
23.18
22.93
33.65
30.10
26.74
15.52
11.01
16.10
18.88
17.61
19.92
8.46
13.46
14.38
22.83
26.40
8.14
12.38

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
27766
27780
27781
27784
27786
27788
27792
27808
27810
27814
27816
27818
27822
27823
27824
27825
27826
27827
27828
27829
27830
27831
27832
27840
27842
27846
27848
27860
27870
27871
27880
27881
27882
27884
27886
27888
27889
27892
27893
27894
27899
28001
28002
28003
28005
28008
28010
28011
28020
28022
28024
28030
28035

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42
YYY
10
10
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
16.99
7.23
10.59
14.78
7.73
10.79
15.91
8.08
12.16
21.04
7.68
12.65
23.50
26.66
7.38
13.78
18.81
29.19
32.90
13.20
8.69
9.74
13.62
8.78
12.29
19.34
22.77
4.70
26.75
18.30
20.69
23.11
16.69
15.15
17.20
18.66
17.88
14.05
13.89
19.85
BR
6.05
10.22
15.76
15.88
9.57
5.58
8.02
11.73
10.48
10.15
10.55
11.63

CODE
28043
28045
28046
28050
28052
28054
28060
28062
28070
28072
28080
28086
28088
28090
28092
28100
28102
28103
28104
28106
28107
28108
28110
28111
28112
28113
28114
28116
28118
28119
28120
28122
28124
28126
28130
28140
28150
28153
28160
28171
28173
28175
28190
28192
28193
28200
28202
28208
28210
28220
28222
28225
28226

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
7.80
10.71
20.27
9.73
9.37
8.62
11.39
13.86
11.03
10.76
9.15
13.50
10.20
10.13
9.33
14.41
14.81
12.01
11.29
12.55
12.81
9.27
9.82
11.95
10.90
11.46
22.83
15.57
13.03
11.50
13.44
15.09
10.39
8.17
16.06
15.04
9.44
8.43
8.78
16.34
17.51
12.48
5.57
10.69
12.04
10.29
14.95
9.75
13.37
9.76
11.54
8.40
9.89

CPT only copyright 2004 American Medical Association. All Rights Reserved.

26

CODE
28230
28232
28234
28238
28240
28250
28260
28261
28262
28264
28270
28272
28280
28285
28286
28288
28289
28290
28292
28293
28294
28296
28297
28298
28299
28300
28302
28304
28305
28306
28307
28308
28309
28310
28312
28313
28315
28320
28322
28340
28341
28344
28345
28360
28400
28405
28406
28415
28420
28430
28435
28436
28445

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
9.46
8.35
8.47
16.02
9.56
12.36
15.41
21.89
31.93
19.60
10.26
8.44
12.15
10.04
9.92
11.31
16.03
12.72
15.41
21.02
17.08
18.52
19.43
16.19
20.70
18.09
17.84
18.36
18.47
13.52
18.25
11.72
22.73
11.86
10.60
11.00
10.37
17.30
18.76
14.26
16.38
10.51
12.91
26.08
6.12
10.11
14.18
31.86
32.28
5.78
7.80
11.39
29.18

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
28450
28455
28456
28465
28470
28475
28476
28485
28490
28495
28496
28505
28510
28515
28525
28530
28531
28540
28545
28546
28555
28570
28575
28576
28585
28600
28605
28606
28615
28630
28635
28636
28645
28660
28665
28666
28675
28705
28715
28725
28730
28735
28737
28740
28750
28755
28760
28800
28805
28810
28820
28825
28899

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
10
10
42
10
10
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY

UNIT VALUE
5.29
6.94
7.27
14.39
5.40
6.73
8.89
11.97
3.24
3.95
10.94
12.45
2.75
3.53
11.30
2.64
9.95
4.69
5.16
10.63
17.23
4.30
7.59
9.02
16.53
4.97
6.23
10.40
17.09
3.46
4.19
7.07
9.74
2.62
3.60
8.97
10.51
34.25
24.97
21.68
20.90
20.32
17.89
20.09
20.31
11.48
16.77
15.14
15.19
11.53
12.56
11.07
BR

CODE
29000
29010
29015
29020
29025
29035
29040
29044
29046
29049
29055
29058
29065
29075
29085
29086
29105
29125
29126
29130
29131
29200
29220
29240
29260
29280
29305
29325
29345
29355
29358
29365
29405
29425
29435
29440
29445
29450
29505
29515
29520
29530
29540
29550
29580
29590
29700
29705
29710
29715
29720
29730
29740

FUD
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00

UNIT VALUE
5.61
5.79
5.67
5.57
5.98
5.66
5.04
6.44
6.05
2.31
5.04
3.03
2.34
2.15
2.28
1.65
2.22
1.68
2.04
1.03
1.33
1.41
1.40
1.61
1.34
1.34
5.70
6.23
3.39
3.48
3.73
3.04
2.22
2.39
2.94
1.34
3.84
3.82
1.94
1.69
1.42
1.40
0.99
0.95
1.29
1.36
1.53
1.70
3.06
2.21
1.95
1.68
2.44

CPT only copyright 2004 American Medical Association. All Rights Reserved.

27

CODE
29750
29799
29800
29804
29805
29806
29807
29819
29820
29821
29822
29823
29824
29825
29826
29827
29830
29834
29835
29836
29837
29838
29840
29843
29844
29845
29846
29847
29848
29850
29851
29855
29856
29860
29861
29862
29863
29866
29867
29868
29870
29871
29873
29874
29875
29876
29877
29879
29880
29881
29882
29883
29884

FUD
00
YYY
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
2.52
BR
14.37
17.13
12.55
27.96
27.23
15.69
14.48
15.81
15.38
16.77
17.18
15.66
18.05
29.50
12.05
13.16
13.46
15.54
14.17
15.86
11.68
12.54
13.22
14.97
13.85
14.34
11.90
14.39
25.19
21.18
27.17
16.34
18.03
20.06
19.82
27.61
32.98
44.71
10.78
13.53
13.59
14.18
13.23
16.29
15.34
16.53
17.31
16.04
17.36
21.98
15.28

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
29885
29886
29887
29888
29889
29891
29892
29893
29894
29895
29897
29898
29899
29900
29901
29902
29999
30000
30020
30100
30110
30115
30117
30118
30120
30124
30125
30130
30140
30150
30160
30200
30210
30220
30300
30310
30320
30400
30410
30420
30430
30435
30450
30460
30462
30465
30520
30540
30545
30560
30580
30600
30620

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
10
10
00
10
42
42
42
42
42
42
42
42
42
42
42
10
10
10
10
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
42
42

UNIT VALUE
18.61
15.67
18.51
26.46
31.14
17.28
18.14
12.14
13.81
13.55
14.22
15.77
26.79
12.20
13.44
14.35
BR
5.62
4.82
2.98
5.01
10.51
16.56
19.69
12.27
6.96
16.12
9.28
9.97
21.04
20.69
2.46
3.27
5.90
5.75
5.23
11.94
26.34
32.74
35.23
23.98
32.23
42.44
20.92
42.29
24.64
12.82
17.69
24.94
6.13
15.34
14.21
15.36

CODE
30630
30801
30802
30901
30903
30905
30906
30915
30920
30930
30999
31000
31002
31020
31030
31032
31040
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
31200
31201
31205
31225
31230
31231
31233
31235
31237
31238
31239
31240
31254
31255
31256
31267
31276
31287
31288
31290
31291
31292
31293
31294
31299

FUD
42
10
10
00
00
00
00
42
42
10
YYY
10
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00
00
00
00
00
10
00
00
00
00
00
00
00
00
10
10
10
10
10
YYY

UNIT VALUE
15.67
5.31
6.81
2.68
4.38
5.65
6.54
14.47
19.59
3.00
BR
4.08
5.31
11.76
17.99
14.39
20.08
12.15
15.98
10.60
19.68
26.08
29.17
28.24
29.82
27.21
27.10
23.00
14.47
18.35
22.78
38.71
43.08
4.57
6.68
7.81
8.45
8.76
17.31
4.58
7.94
11.79
5.74
9.29
14.87
6.75
7.84
30.75
32.30
26.56
28.88
33.42
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

28

CODE
31300
31320
31360
31365
31367
31368
31370
31375
31380
31382
31390
31395
31400
31420
31500
31502
31505
31510
31511
31512
31513
31515
31520
31525
31526
31527
31528
31529
31530
31531
31535
31536
31540
31541
31545
31546
31560
31561
31570
31571
31575
31576
31577
31578
31579
31580
31582
31584
31585
31586
31587
31588
31590

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
42
42
42
42
42
42
42
42

UNIT VALUE
30.43
16.01
35.17
46.50
45.53
54.77
45.42
42.17
42.47
43.81
54.22
61.86
24.91
20.58
3.07
1.01
2.11
5.38
5.47
5.45
3.73
5.48
4.32
6.48
4.50
5.40
4.03
4.61
5.62
6.14
5.41
6.09
7.00
7.67
10.14
15.48
9.03
9.84
9.84
7.20
3.09
5.78
6.44
7.35
6.23
29.29
49.13
39.46
11.69
19.54
22.26
27.76
23.29

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
31595
31599
31600
31601
31603
31605
31610
31611
31612
31613
31614
31615
31620
31622
31623
31624
31625
31628
31629
31630
31631
31632
31633
31635
31636
31637
31638
31640
31641
31643
31645
31646
31656
31700
31708
31710
31715
31717
31720
31725
31730
31750
31755
31760
31766
31770
31775
31780
31781
31785
31786
31800
31805

FUD
42
YYY
00
00
00
00
42
42
00
42
42
00
ZZZ
00
00
00
00
00
00
00
00
ZZZ
ZZZ
00
00
ZZZ
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
19.57
BR
11.16
7.24
6.29
5.14
17.81
13.16
2.09
11.01
16.44
4.85
7.15
8.63
9.46
8.81
9.37
11.01
18.51
5.87
6.48
2.03
2.41
10.04
6.37
2.27
7.07
7.46
7.28
4.92
8.49
7.74
9.62
3.59
3.51
1.84
1.52
10.51
1.46
2.76
5.27
31.67
41.74
35.81
48.52
35.52
38.27
30.39
37.82
28.97
40.29
17.44
22.13

CODE
31820
31825
31830
31899
32000
32002
32005
32019
32020
32035
32036
32095
32100
32110
32120
32124
32140
32141
32150
32151
32160
32200
32201
32215
32220
32225
32310
32320
32400
32402
32405
32420
32440
32442
32445
32480
32482
32484
32486
32488
32491
32500
32501
32520
32522
32525
32540
32601
32602
32603
32604
32605
32606

FUD
42
42
42
YYY
00
00
00
00
00
42
42
42
42
42
42
42
42
42
42
42
42
42
00
42
42
42
42
42
00
42
00
00
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
00
00
00
00
00
00

UNIT VALUE
10.53
15.02
10.69
BR
4.68
5.54
8.86
24.55
5.74
15.73
17.48
14.88
25.20
36.83
20.20
21.76
23.54
23.51
23.69
24.11
15.80
25.81
24.93
19.77
40.32
23.56
22.73
39.50
3.98
13.70
2.71
3.00
41.41
44.77
42.73
39.15
41.40
34.98
40.60
43.11
36.78
37.46
6.87
36.00
39.56
42.98
26.29
8.58
9.31
11.94
13.45
10.79
12.92

CPT only copyright 2004 American Medical Association. All Rights Reserved.

29

CODE
32650
32651
32652
32653
32654
32655
32656
32657
32658
32659
32660
32661
32662
32663
32664
32665
32800
32810
32815
32820
32850
32851
32852
32853
32854
32855
32856
32900
32905
32906
32940
32960
32997
32999
33010
33011
33015
33020
33025
33030
33031
33050
33120
33130
33140
33141
33200
33201
33206
33207
33208
33210
33211

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
XXX
42
42
42
42
XXX
XXX
42
42
42
42
00
00
YYY
00
00
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
42
00
00

UNIT VALUE
18.99
21.94
31.37
21.61
21.57
22.14
22.65
23.25
20.58
20.63
28.94
22.84
27.40
31.86
24.14
25.78
22.94
22.42
37.32
36.12
BR
71.58
80.86
86.34
92.79
BR
BR
33.01
33.88
42.61
31.62
3.73
8.44
BR
3.17
3.22
12.38
21.11
20.14
30.93
34.89
24.26
39.67
34.34
33.66
7.10
20.97
18.08
11.64
13.30
13.48
4.74
4.93

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
33212
33213
33214
33215
33216
33217
33218
33220
33222
33223
33224
33225
33226
33233
33234
33235
33236
33237
33238
33240
33241
33243
33244
33245
33246
33249
33250
33251
33253
33261
33282
33284
33300
33305
33310
33315
33320
33321
33322
33330
33332
33335
33400
33401
33403
33404
33405
33406
33410
33411
33412
33413
33414

FUD
42
42
42
42
42
42
42
42
42
42
00
ZZZ
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
9.33
10.56
13.21
8.30
10.37
10.38
10.12
10.17
9.66
11.49
13.61
12.06
13.11
6.79
13.30
16.95
21.67
23.03
25.35
12.65
6.41
36.17
23.63
24.16
33.55
23.40
35.90
39.99
49.28
39.99
8.43
6.18
29.68
35.09
30.62
36.45
27.01
32.82
33.75
34.39
37.42
47.48
48.16
40.90
42.66
47.33
58.33
61.94
53.60
60.23
68.63
70.70
48.88

CODE
33415
33416
33417
33420
33422
33425
33426
33427
33430
33460
33463
33464
33465
33468
33470
33471
33472
33474
33475
33476
33478
33496
33500
33501
33502
33503
33504
33505
33506
33508
33510
33511
33512
33513
33514
33516
33517
33518
33519
33521
33522
33523
33530
33533
33534
33535
33536
33542
33545
33572
33600
33602
33606

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
42
42
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
42
42
42
42
42
42
ZZZ
42
42
42

UNIT VALUE
42.93
48.26
46.15
34.05
43.31
43.92
54.85
65.12
55.59
38.25
42.20
44.77
45.89
47.75
32.50
35.32
37.60
37.07
53.08
40.08
43.60
43.96
40.63
27.87
35.04
33.34
39.75
41.87
54.63
0.45
49.48
51.39
53.94
54.36
55.43
58.77
3.78
7.12
10.46
13.81
17.15
20.52
8.61
50.75
54.39
57.52
61.00
45.98
57.47
6.53
46.36
44.72
48.73

CPT only copyright 2004 American Medical Association. All Rights Reserved.

30

CODE
33608
33610
33611
33612
33615
33617
33619
33641
33645
33647
33660
33665
33670
33681
33684
33688
33690
33692
33694
33697
33702
33710
33720
33722
33730
33732
33735
33736
33737
33750
33755
33762
33764
33766
33767
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33786
33788
33800
33802
33803
33813
33814
33820

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
49.83
48.68
52.41
55.33
51.35
58.52
72.12
34.03
40.18
45.68
47.89
46.35
52.73
49.63
46.69
45.73
31.62
49.17
53.38
54.87
42.70
48.01
42.56
43.52
53.28
45.14
32.20
38.38
35.87
32.75
33.78
35.01
34.95
38.07
39.97
57.29
52.61
50.34
52.08
54.81
54.46
62.96
54.42
64.41
55.65
61.31
42.53
26.76
29.09
32.50
34.62
42.17
27.01

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
33822
33824
33840
33845
33851
33852
33853
33860
33861
33863
33870
33875
33877
33910
33915
33916
33917
33918
33919
33920
33922
33924
33930
33933
33935
33940
33944
33945
33960
33961
33967
33968
33970
33971
33973
33974
33975
33976
33977
33978
33979
33980
33999
34001
34051
34101
34111
34151
34201
34203
34401
34421
34451

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
XXX
XXX
42
XXX
XXX
42
00
ZZZ
00
00
00
42
00
42
XXX
XXX
42
42
XXX
42
YYY
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
28.90
32.33
33.03
36.62
35.06
37.16
50.91
59.92
65.72
70.09
68.59
51.83
64.62
39.60
32.28
40.77
40.30
42.60
63.35
50.07
37.44
8.15
BR
BR
98.59
BR
BR
69.51
26.84
15.42
7.03
0.94
9.84
16.89
14.28
23.95
30.24
33.72
33.10
36.65
67.65
89.76
BR
21.37
25.15
16.72
16.69
38.83
16.84
26.85
38.56
19.81
42.10

CODE
34471
34490
34501
34502
34510
34520
34530
34800
34802
34803
34804
34805
34808
34812
34813
34820
34825
34826
34830
34831
34832
34833
34834
34900
35001
35002
35005
35011
35013
35021
35022
35045
35081
35082
35091
35092
35102
35103
35111
35112
35121
35122
35131
35132
35141
35142
35151
35152
35180
35182
35184
35188
35189

FUD
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
00
ZZZ
00
42
ZZZ
42
42
42
00
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
16.60
16.60
26.66
42.77
30.60
28.55
26.94
32.18
35.00
36.20
35.00
33.48
6.02
10.12
7.00
14.38
19.38
5.92
50.75
51.61
54.60
18.04
8.28
25.84
31.89
33.66
28.68
28.43
34.68
31.79
36.13
27.45
43.34
59.05
53.95
68.78
47.45
61.97
38.78
45.96
46.53
53.44
39.40
46.60
31.70
36.91
35.77
40.50
21.54
47.06
28.75
24.02
43.83

CPT only copyright 2004 American Medical Association. All Rights Reserved.

31

CODE
35190
35201
35206
35207
35211
35216
35221
35226
35231
35236
35241
35246
35251
35256
35261
35266
35271
35276
35281
35286
35301
35311
35321
35331
35341
35351
35355
35361
35363
35371
35372
35381
35390
35400
35450
35452
35454
35456
35458
35459
35460
35470
35471
35472
35473
35474
35475
35476
35480
35481
35482
35483
35484

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
ZZZ
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00

UNIT VALUE
20.96
26.37
21.62
18.92
35.85
30.30
37.55
23.89
32.51
27.36
37.67
41.52
45.99
29.27
28.32
23.94
35.72
38.77
43.55
26.49
29.78
42.08
25.58
41.11
39.64
35.86
29.18
43.82
47.00
23.73
28.60
25.78
4.70
4.53
14.85
10.40
9.18
11.11
14.18
12.96
9.12
98.20
111.02
71.85
66.39
95.67
66.23
51.15
16.38
11.57
10.09
12.22
15.47

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
35485
35490
35491
35492
35493
35494
35495
35500
35501
35506
35507
35508
35509
35510
35511
35512
35515
35516
35518
35521
35522
35525
35526
35531
35533
35536
35541
35546
35548
35549
35551
35556
35558
35560
35563
35565
35566
35571
35572
35583
35585
35587
35600
35601
35606
35612
35616
35621
35623
35626
35631
35636
35641

FUD
00
00
00
00
00
00
00
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
ZZZ
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
14.32
16.52
11.63
10.31
12.47
15.60
14.58
9.36
30.33
31.88
31.89
30.89
29.41
35.24
33.32
34.57
30.64
25.42
33.09
35.03
33.58
32.07
46.00
55.64
43.38
49.04
40.57
39.97
33.90
36.94
41.66
34.49
33.63
49.92
38.08
36.54
42.04
38.25
10.03
35.62
44.53
39.62
7.28
28.61
30.32
25.65
25.91
31.50
37.88
43.62
52.64
45.81
39.04

CODE
35642
35645
35646
35647
35650
35651
35654
35656
35661
35663
35665
35666
35671
35681
35682
35683
35685
35686
35691
35693
35694
35695
35697
35700
35701
35721
35741
35761
35800
35820
35840
35860
35870
35875
35876
35879
35881
35901
35903
35905
35907
36000
36002
36005
36010
36011
36012
36013
36014
36015
36100
36120
36140

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
42
42
42
42
ZZZ
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
XXX
00
00
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX

UNIT VALUE
28.88
28.18
48.40
43.64
29.99
38.94
39.09
30.83
30.55
35.00
33.37
35.91
31.38
2.35
10.59
12.51
5.97
4.94
29.02
25.26
30.40
30.39
4.43
4.53
14.75
12.62
13.74
10.11
12.61
21.92
16.35
10.34
34.82
16.67
26.84
25.93
29.16
14.62
16.82
48.75
53.95
0.76
4.99
8.66
21.92
31.24
22.70
24.11
23.33
27.39
15.36
12.86
14.94

CPT only copyright 2004 American Medical Association. All Rights Reserved.

32

CODE
36145
36160
36200
36215
36216
36217
36218
36245
36246
36247
36248
36260
36261
36262
36299
36400
36405
36406
36410
36415
36416
36420
36425
36430
36440
36450
36455
36460
36468
36469
36470
36471
36475
36476
36478
36479
36481
36500
36510
36511
36512
36513
36514
36515
36516
36522
36540
36550
36555
36556
36557
36558
36560

FUD
XXX
XXX
XXX
XXX
XXX
XXX
ZZZ
XXX
XXX
XXX
ZZZ
42
42
42
YYY
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
00
00
10
10
00
ZZZ
00
ZZZ
00
00
00
00
00
00
00
00
00
00
XXX
XXX
00
00
10
10
10

UNIT VALUE
14.69
16.25
19.78
32.02
34.72
62.19
6.18
37.09
35.62
56.28
5.13
15.86
9.80
7.28
BR
0.69
0.60
0.47
0.48
0.08
0.10
1.42
1.04
1.07
1.42
3.15
3.60
9.61
BR
BR
3.89
4.83
58.48
11.44
53.86
11.55
13.25
5.11
5.08
2.55
2.56
2.64
18.79
68.12
85.35
34.17
0.75
0.76
8.55
8.31
26.80
26.40
36.48

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
36561
36563
36565
36566
36568
36569
36570
36571
36575
36576
36578
36580
36581
36582
36583
36584
36585
36589
36590
36595
36596
36597
36600
36620
36625
36640
36660
36680
36800
36810
36815
36818
36819
36820
36821
36822
36823
36825
36830
36831
36832
36833
36834
36835
36838
36860
36861
36870
37140
37145
37160
37180
37181

FUD
10
10
10
10
00
00
10
10
00
10
10
00
10
10
10
00
10
10
10
00
00
00
XXX
00
00
00
00
00
00
00
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00
00
42
42
42
42
42
42

UNIT VALUE
36.14
33.76
31.26
32.56
9.57
9.35
39.05
39.10
4.93
10.33
14.82
8.44
23.12
31.40
31.47
8.36
32.81
4.75
7.10
21.08
4.49
3.69
0.83
1.46
2.89
3.35
1.98
1.80
4.47
6.08
4.13
19.43
22.27
22.28
14.78
10.53
33.16
16.21
18.85
13.01
16.63
18.77
16.07
12.44
32.97
3.92
4.27
58.51
36.03
38.65
33.60
38.17
41.01

CODE
37182
37183
37195
37200
37201
37202
37203
37204
37205
37206
37207
37208
37209
37215
37216
37250
37251
37500
37501
37565
37600
37605
37606
37607
37609
37615
37616
37617
37618
37620
37650
37660
37700
37720
37730
37735
37760
37765
37766
37780
37785
37788
37790
37799
38100
38101
38102
38115
38120
38129
38200
38204
38205

FUD
00
00
XXX
00
00
00
00
00
00
ZZZ
00
ZZZ
00
42
42
ZZZ
ZZZ
42
YYY
42
42
42
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
42
42
ZZZ
42
42
YYY
00
XXX
00

UNIT VALUE
24.03
11.48
6.99
6.32
7.89
9.16
38.24
25.52
12.63
5.87
12.56
6.07
3.17
28.89
27.83
3.06
2.34
19.36
BR
17.81
19.27
21.93
12.06
10.54
7.87
10.53
26.84
34.13
9.10
17.18
13.45
32.48
7.03
10.13
12.59
17.49
17.18
12.44
15.09
7.21
9.53
33.29
13.29
BR
22.53
23.77
7.05
24.44
26.56
BR
3.70
BR
2.24

CPT only copyright 2004 American Medical Association. All Rights Reserved.

33

CODE
38206
38207
38208
38209
38210
38211
38212
38213
38214
38215
38220
38221
38230
38240
38241
38242
38300
38305
38308
38380
38381
38382
38500
38505
38510
38520
38525
38530
38542
38550
38555
38562
38564
38570
38571
38572
38589
38700
38720
38724
38740
38745
38746
38747
38760
38765
38770
38780
38790
38792
38794
38999
39000

FUD
00
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
10
XXX
XXX
00
10
42
42
42
42
42
10
00
10
42
42
42
42
42
42
42
42
10
10
10
YYY
42
42
42
42
42
ZZZ
ZZZ
42
42
42
42
00
00
42
YYY
42

UNIT VALUE
2.24
1.65
1.80
1.58
1.72
1.72
1.72
1.72
1.44
1.72
4.86
5.37
8.22
3.39
3.42
2.59
6.53
11.28
11.03
13.93
21.57
17.18
7.91
3.28
12.70
11.55
10.15
13.46
11.00
11.69
24.43
17.45
17.37
14.34
21.46
25.53
BR
15.22
24.19
25.66
16.26
20.86
7.19
7.18
20.73
31.21
20.36
26.64
8.77
1.02
8.20
BR
11.59

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
39010
39200
39220
39400
39499
39501
39502
39503
39520
39530
39531
39540
39541
39545
39560
39561
39599
40490
40500
40510
40520
40525
40527
40530
40650
40652
40654
40700
40701
40702
40720
40761
40799
40800
40801
40804
40805
40806
40808
40810
40812
40814
40816
40818
40819
40820
40830
40831
40840
40842
40843
40844
40845

FUD
42
42
42
10
YYY
42
42
42
42
42
42
42
42
42
42
42
YYY
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
10
10
10
10
00
10
10
10
42
42
42
42
10
10
10
42
42
42
42
42

UNIT VALUE
20.98
23.04
29.13
11.25
BR
21.35
25.59
139.10
26.32
24.60
25.97
21.27
22.87
22.70
19.81
29.16
BR
2.91
11.55
11.78
12.72
14.69
17.46
13.75
10.80
12.49
14.50
22.79
28.80
22.51
25.20
26.88
BR
4.25
6.86
4.74
7.48
2.18
3.71
4.32
6.31
8.76
9.24
7.79
6.76
5.32
5.67
7.41
19.55
19.86
25.41
33.72
37.60

CODE
40899
41000
41005
41006
41007
41008
41009
41010
41015
41016
41017
41018
41100
41105
41108
41110
41112
41113
41114
41115
41116
41120
41130
41135
41140
41145
41150
41153
41155
41250
41251
41252
41500
41510
41520
41599
41800
41805
41806
41820
41821
41822
41823
41825
41826
41827
41828
41830
41850
41870
41872
41874
41899

FUD
YYY
10
10
42
42
42
42
10
42
42
42
42
10
10
10
10
42
42
42
10
42
42
42
42
42
42
42
42
42
10
10
10
42
42
42
YYY
10
10
10
00
00
10
42
10
10
42
10
10
00
00
42
42
YYY

UNIT VALUE
BR
3.73
4.71
8.38
8.55
8.46
9.01
4.56
9.81
10.19
10.22
11.88
4.20
3.85
3.22
4.62
7.49
8.27
16.48
5.21
7.02
25.90
28.29
48.25
54.37
63.13
49.73
50.82
56.90
4.84
5.76
7.15
11.45
11.54
7.62
BR
3.88
4.04
6.63
5.92
1.34
6.51
9.32
4.52
5.04
9.27
7.33
8.74
2.96
7.40
7.91
8.37
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

34

CODE
42000
42100
42104
42106
42107
42120
42140
42145
42160
42180
42182
42200
42205
42210
42215
42220
42225
42226
42227
42235
42260
42280
42281
42299
42300
42305
42310
42320
42325
42326
42330
42335
42340
42400
42405
42408
42409
42410
42415
42420
42425
42426
42440
42450
42500
42505
42507
42508
42509
42510
42550
42600
42650

FUD
10
10
10
10
42
42
42
42
10
10
10
42
42
42
42
42
42
42
42
42
42
10
10
YYY
10
42
10
10
42
42
10
42
42
00
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00

UNIT VALUE
3.91
3.52
4.34
5.57
10.59
18.47
5.47
16.18
6.22
5.78
8.09
23.46
24.90
28.08
19.18
14.51
27.48
25.70
26.03
20.44
21.23
3.69
4.73
BR
4.91
11.31
3.95
5.83
7.62
9.96
5.54
8.51
11.06
2.49
7.57
10.89
7.60
16.46
29.18
33.60
22.74
36.09
12.35
10.93
10.38
13.85
13.12
18.47
22.64
16.59
4.53
11.82
1.94

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
42660
42665
42699
42700
42720
42725
42800
42802
42804
42806
42808
42809
42810
42815
42820
42821
42825
42826
42830
42831
42835
42836
42842
42844
42845
42860
42870
42890
42892
42894
42900
42950
42953
42955
42960
42961
42962
42970
42971
42972
42999
43020
43030
43045
43100
43101
43107
43108
43112
43113
43116
43117
43118

FUD
00
42
YYY
10
10
42
10
10
10
10
10
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
42
42
10
42
42
42
42
42
YYY
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
2.57
6.93
BR
4.40
10.71
19.88
3.68
6.43
5.08
5.78
5.58
4.30
9.26
14.09
7.50
8.13
6.83
6.68
5.33
5.77
4.97
6.40
20.46
31.71
49.49
4.80
14.40
28.16
34.33
46.78
9.43
20.68
27.18
18.85
4.49
11.00
13.63
9.99
11.83
13.51
BR
14.37
13.87
33.35
16.32
26.33
63.22
52.29
68.45
54.71
50.88
62.28
51.00

CODE
43121
43122
43123
43124
43130
43135
43200
43201
43202
43204
43205
43215
43216
43217
43219
43220
43226
43227
43228
43231
43232
43234
43235
43236
43237
43238
43239
43240
43241
43242
43243
43244
43245
43246
43247
43248
43249
43250
43251
43255
43256
43257
43258
43259
43260
43261
43262
43263
43264
43265
43267
43268
43269

FUD
42
42
42
42
42
42
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00

UNIT VALUE
46.68
62.58
51.41
44.03
20.47
26.44
5.85
6.88
7.59
5.58
5.58
4.03
3.66
10.11
4.39
3.24
3.56
5.32
5.65
4.74
6.62
7.51
7.75
9.54
6.01
7.42
8.80
10.01
3.90
10.56
6.70
7.37
4.74
6.35
5.02
4.70
4.33
4.77
5.46
7.05
6.39
8.06
6.66
7.54
8.67
9.11
10.70
10.58
12.85
14.42
10.71
10.80
11.88

CPT only copyright 2004 American Medical Association. All Rights Reserved.

35

CODE
43271
43272
43280
43289
43300
43305
43310
43312
43313
43314
43320
43324
43325
43326
43330
43331
43340
43341
43350
43351
43352
43360
43361
43400
43401
43405
43410
43415
43420
43425
43450
43453
43456
43458
43460
43496
43499
43500
43501
43502
43510
43520
43600
43605
43610
43611
43620
43621
43622
43631
43632
43633
43634

FUD
00
00
42
YYY
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00
00
00
00
00
42
YYY
42
42
42
42
42
00
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
10.70
10.71
26.74
BR
16.57
29.63
39.80
44.23
69.42
75.95
31.63
32.02
31.40
31.78
30.85
32.71
30.99
33.71
25.61
30.55
25.59
55.55
61.75
32.51
34.55
32.32
22.83
40.09
23.17
33.89
4.12
7.68
16.51
9.95
5.60
BR
BR
17.41
30.93
35.61
21.10
16.55
2.71
18.81
22.62
27.69
45.69
46.65
49.31
34.65
34.65
35.41
38.46

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
43635
43638
43639
43640
43641
43644
43645
43651
43652
43653
43659
43750
43752
43760
43761
43800
43810
43820
43825
43830
43831
43832
43840
43842
43843
43845
43846
43847
43848
43850
43855
43860
43865
43870
43880
43999
44005
44010
44015
44020
44021
44025
44050
44055
44100
44110
44111
44120
44121
44125
44126
44127
44128

FUD
ZZZ
42
42
42
42
42
42
42
42
42
YYY
10
00
00
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
42
42
ZZZ
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
ZZZ

UNIT VALUE
3.03
44.59
45.14
26.46
26.78
42.17
45.48
16.22
19.42
12.90
BR
7.10
1.11
3.27
3.32
21.34
22.71
23.75
29.72
15.56
13.33
24.35
24.32
28.65
28.81
49.41
37.16
41.28
44.99
37.67
39.87
38.17
40.42
15.42
37.68
BR
25.00
19.54
3.84
21.69
21.81
22.07
21.77
33.50
2.89
18.52
22.20
26.23
6.53
26.99
54.22
62.35
6.58

CODE
44130
44132
44133
44135
44136
44137
44139
44140
44141
44143
44144
44145
44146
44147
44150
44151
44152
44153
44155
44156
44160
44200
44201
44202
44203
44204
44205
44206
44207
44208
44210
44211
44212
44238
44239
44300
44310
44312
44314
44316
44320
44322
44340
44345
44346
44360
44361
44363
44364
44365
44366
44369
44370

FUD
42
XXX
XXX
XXX
XXX
XXX
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
42
42
42
42
YYY
YYY
42
42
42
42
42
42
42
42
42
42
00
00
00
00
00
00
00
00

UNIT VALUE
22.52
BR
BR
BR
BR
BR
3.27
32.28
32.01
36.59
33.88
40.42
43.72
31.87
38.93
43.67
42.85
48.43
44.36
49.71
28.66
22.46
15.70
33.74
6.51
38.06
33.75
41.62
45.07
48.92
43.22
53.76
49.79
BR
BR
19.13
24.57
12.93
23.31
31.96
27.49
22.06
12.95
24.23
26.43
3.88
4.28
5.14
5.49
4.91
6.45
6.57
7.13

CPT only copyright 2004 American Medical Association. All Rights Reserved.

36

CODE
44372
44373
44376
44377
44378
44379
44380
44382
44383
44385
44386
44388
44389
44390
44391
44392
44393
44394
44397
44500
44602
44603
44604
44605
44615
44620
44625
44626
44640
44650
44660
44661
44680
44700
44701
44715
44720
44721
44799
44800
44820
44850
44899
44900
44901
44950
44955
44960
44970
44979
45000
45005
45020

FUD
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
XXX
XXX
XXX
YYY
42
42
42
YYY
42
00
42
ZZZ
42
42
YYY
42
10
42

UNIT VALUE
6.48
5.18
7.70
8.05
10.34
10.99
1.68
2.02
4.43
5.32
8.95
8.16
10.02
11.25
13.37
10.73
12.15
12.61
6.88
0.68
24.45
28.28
24.50
30.37
24.59
19.01
23.16
38.35
32.91
34.26
31.79
37.11
23.71
24.55
4.53
BR
7.08
10.36
BR
18.01
19.08
17.09
BR
16.10
31.49
15.60
2.26
19.26
13.90
BR
7.98
6.28
8.52

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
45100
45108
45110
45111
45112
45113
45114
45116
45119
45120
45121
45123
45126
45130
45135
45136
45150
45160
45170
45190
45300
45303
45305
45307
45308
45309
45315
45317
45320
45321
45327
45330
45331
45332
45333
45334
45335
45337
45338
45339
45340
45341
45342
45345
45355
45378
45379
45380
45381
45382
45383
45384
45385

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00

UNIT VALUE
6.45
8.10
43.67
25.66
45.63
46.49
41.46
37.47
46.55
37.54
41.31
25.36
68.56
24.94
30.00
42.48
9.21
23.60
18.04
15.44
1.95
19.17
3.75
4.08
2.91
5.04
4.41
4.08
4.65
1.86
2.50
3.31
4.31
6.95
6.81
4.08
4.78
3.57
7.74
6.86
8.21
3.87
5.89
4.31
5.24
10.13
12.73
11.97
11.62
16.05
14.26
11.87
13.52

CODE
45386
45387
45391
45392
45500
45505
45520
45540
45541
45550
45560
45562
45563
45800
45805
45820
45825
45900
45905
45910
45915
45999
46020
46030
46040
46045
46050
46060
46070
46080
46083
46200
46210
46211
46220
46221
46230
46250
46255
46257
46258
46260
46261
46262
46270
46275
46280
46285
46288
46320
46500
46600
46604

FUD
00
00
00
00
42
42
42
42
42
42
42
42
42
42
42
42
42
10
10
10
10
YYY
10
10
42
42
10
42
42
10
10
42
42
42
10
10
10
42
42
42
42
42
42
42
42
42
42
42
42
10
10
00
00

UNIT VALUE
17.36
8.71
7.48
9.44
11.54
12.27
2.24
24.86
20.87
34.76
16.74
24.15
36.98
26.99
32.31
27.66
33.32
4.41
4.00
4.75
7.76
BR
5.54
2.71
11.04
7.73
3.86
9.58
4.89
5.15
4.07
7.64
8.09
10.11
4.02
4.90
5.93
9.65
10.98
8.89
9.67
10.29
11.46
12.04
9.16
9.70
9.88
8.27
11.58
3.91
3.88
2.11
10.55

CPT only copyright 2004 American Medical Association. All Rights Reserved.

37

CODE
46606
46608
46610
46611
46612
46614
46615
46700
46705
46706
46715
46716
46730
46735
46740
46742
46744
46746
46748
46750
46751
46753
46754
46760
46761
46762
46900
46910
46916
46917
46922
46924
46934
46935
46936
46937
46938
46940
46942
46945
46946
46947
46999
47000
47001
47010
47011
47015
47100
47120
47122
47125
47130

FUD
00
00
00
00
00
00
00
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42
10
42
42
42
10
10
10
10
10
10
42
10
42
10
42
10
10
42
42
42
YYY
00
ZZZ
42
42
42
42
42
42
42
42

UNIT VALUE
4.68
6.07
5.50
5.33
7.79
4.53
5.48
14.25
11.47
3.91
11.68
24.59
41.18
48.84
45.58
56.30
79.99
90.89
91.08
16.37
15.11
13.06
5.98
23.05
21.23
19.43
4.66
4.94
5.12
11.19
5.34
11.70
8.88
6.12
8.89
5.60
9.22
4.53
4.06
5.29
6.56
8.66
BR
5.09
2.79
26.15
5.12
24.36
19.18
55.13
83.59
74.79
80.99

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
47133
47135
47136
47140
47141
47142
47143
47144
47145
47146
47147
47300
47350
47360
47361
47362
47370
47371
47379
47380
47381
47382
47399
47400
47420
47425
47460
47480
47490
47500
47505
47510
47511
47525
47530
47550
47552
47553
47554
47555
47556
47560
47561
47562
47563
47564
47570
47579
47600
47605
47610
47612
47620

FUD
XXX
42
42
42
42
42
XXX
42
42
XXX
XXX
42
42
42
42
42
42
42
YYY
42
42
10
YYY
42
42
42
42
42
42
00
00
42
42
10
42
ZZZ
00
00
00
00
00
00
00
42
42
42
42
YYY
42
42
42
42
42

UNIT VALUE
BR
122.55
103.87
82.32
99.43
109.48
BR
BR
BR
8.88
10.36
24.20
30.90
41.76
71.35
29.58
30.25
30.38
BR
35.10
35.63
22.21
BR
48.98
31.19
31.17
28.47
18.09
13.22
2.72
1.06
13.31
16.19
20.96
39.99
4.43
8.83
8.80
13.35
10.46
11.84
7.19
7.72
17.49
18.77
22.01
19.55
BR
21.45
23.08
29.16
29.08
31.82

CODE
47630
47700
47701
47711
47712
47715
47716
47720
47721
47740
47741
47760
47765
47780
47785
47800
47801
47802
47900
47999
48000
48001
48005
48020
48100
48102
48120
48140
48145
48146
48148
48150
48152
48153
48154
48155
48160
48180
48400
48500
48510
48511
48520
48540
48545
48547
48550
48551
48552
48554
48556
48999
49000

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
42
42
42
42
42
10
42
42
42
42
42
42
42
42
42
42
XXX
42
ZZZ
42
42
00
42
42
42
42
XXX
XXX
XXX
42
42
YYY
42

UNIT VALUE
14.63
25.02
42.88
35.92
46.46
29.64
26.35
25.43
30.12
29.16
33.39
40.01
38.86
41.08
48.01
36.29
24.45
33.99
31.35
BR
42.89
53.86
64.10
25.07
19.35
12.91
24.73
35.40
36.94
41.78
27.12
73.64
67.63
73.60
68.01
39.45
68.87
38.04
2.74
24.58
23.50
25.12
24.28
30.32
28.44
39.59
BR
BR
6.07
56.50
25.75
BR
18.51

CPT only copyright 2004 American Medical Association. All Rights Reserved.

38

CODE
49002
49010
49020
49021
49040
49041
49060
49061
49062
49080
49081
49085
49180
49200
49201
49215
49220
49250
49255
49320
49321
49322
49323
49329
49400
49419
49420
49421
49422
49423
49424
49425
49426
49427
49428
49429
49491
49492
49495
49496
49500
49501
49505
49507
49520
49521
49525
49540
49550
49553
49555
49557
49560

FUD
42
42
42
00
42
00
42
00
42
00
00
42
00
42
42
42
42
42
42
10
10
10
42
YYY
00
42
00
42
10
00
00
42
42
00
10
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
16.82
19.66
35.74
24.62
21.56
23.74
25.01
23.53
18.16
5.42
3.93
19.16
4.94
16.45
23.61
51.73
23.36
13.67
18.12
8.35
8.72
9.39
15.14
BR
5.10
11.00
3.52
9.38
9.92
15.62
4.52
18.44
15.63
1.26
10.77
11.81
17.56
21.89
9.56
14.12
9.29
14.15
12.34
15.26
15.32
18.74
13.74
16.47
13.87
15.07
14.46
17.57
18.19

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
49561
49565
49566
49568
49570
49572
49580
49582
49585
49587
49590
49600
49605
49606
49610
49611
49650
49651
49659
49900
49904
49905
49906
49999
50010
50020
50021
50040
50045
50060
50065
50070
50075
50080
50081
50100
50120
50125
50130
50135
50200
50205
50220
50225
50230
50234
50236
50240
50280
50290
50300
50320
50323

FUD
42
42
42
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
42
42
ZZZ
42
YYY
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
XXX
42
XXX

UNIT VALUE
22.13
18.27
22.37
7.19
9.58
11.06
7.19
10.98
10.32
12.26
13.72
17.58
113.68
28.67
16.74
16.66
10.37
13.40
BR
20.03
37.81
9.60
BR
BR
17.11
23.66
25.22
22.79
23.29
28.45
28.41
29.93
36.99
22.00
32.06
25.87
23.87
24.89
25.64
28.29
4.08
17.60
25.73
29.84
32.20
32.80
36.81
32.56
23.52
22.55
BR
35.19
BR

CODE
50325
50327
50328
50329
50340
50360
50365
50370
50380
50390
50391
50392
50393
50394
50395
50396
50398
50400
50405
50500
50520
50525
50526
50540
50541
50542
50543
50544
50545
50546
50547
50548
50549
50551
50553
50555
50557
50561
50562
50570
50572
50574
50575
50576
50580
50590
50600
50605
50610
50620
50630
50650
50660

FUD
XXX
XXX
XXX
XXX
42
42
42
42
42
00
00
00
00
00
00
00
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
00
00
00
00
00
42
00
00
00
00
00
00
42
42
42
42
42
42
42
42

UNIT VALUE
BR
5.64
4.94
4.72
20.26
50.73
59.33
22.49
35.16
2.72
3.68
5.10
6.18
3.49
5.08
3.30
17.86
28.74
34.67
29.92
26.11
33.05
35.78
29.57
23.61
29.49
37.49
32.46
34.88
30.37
39.30
35.27
BR
10.14
10.73
11.79
11.66
13.20
15.97
13.42
14.67
15.53
19.59
15.41
16.68
22.12
23.69
23.63
24.24
22.56
22.30
25.86
28.90

CPT only copyright 2004 American Medical Association. All Rights Reserved.

39

CODE
50684
50686
50688
50690
50700
50715
50722
50725
50727
50728
50740
50750
50760
50770
50780
50782
50783
50785
50800
50810
50815
50820
50825
50830
50840
50845
50860
50900
50920
50930
50940
50945
50947
50948
50949
50951
50953
50955
50957
50961
50970
50972
50974
50976
50980
51000
51005
51010
51020
51030
51040
51045
51050

FUD
00
00
10
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
YYY
00
00
00
00
00
00
00
00
00
00
00
00
10
42
42
42
42
42

UNIT VALUE
5.78
5.06
2.30
3.05
23.58
29.71
26.01
28.01
13.06
18.56
28.08
28.84
27.64
28.93
27.44
29.85
30.70
30.34
22.16
31.40
29.94
32.37
41.34
45.73
29.90
31.28
23.25
20.90
21.88
27.93
22.14
25.36
36.28
32.84
BR
10.54
11.07
13.63
11.83
10.81
10.11
9.84
12.90
12.74
9.71
2.78
5.82
9.40
11.04
11.31
7.47
11.23
11.04

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
51060
51065
51080
51500
51520
51525
51530
51535
51550
51555
51565
51570
51575
51580
51585
51590
51595
51596
51597
51600
51605
51610
51700
51701
51702
51703
51705
51710
51715
51720
51725
51726
51736
51741
51772
51784
51785
51792
51795
51797
51798
51800
51820
51840
51841
51845
51860
51865
51880
51900
51920
51925
51940

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00
00
00
00
00
00
00
10
10
00
00
00
00
00
00
00
00
00
00
00
00
XXX
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
13.95
13.83
9.93
16.15
14.64
21.08
19.16
19.86
23.70
31.57
32.20
35.77
44.58
45.73
51.35
47.53
53.82
57.46
55.94
5.99
6.73
3.40
2.55
2.12
2.62
4.31
3.36
4.93
7.92
3.84
7.26
9.39
1.25
2.04
7.38
5.67
6.12
7.29
9.04
7.55
0.42
26.30
27.87
17.32
20.64
15.26
18.91
22.95
12.32
20.22
18.60
26.19
42.58

CODE
51960
51980
51990
51992
52000
52001
52005
52007
52010
52204
52214
52224
52234
52235
52240
52250
52260
52265
52270
52275
52276
52277
52281
52282
52283
52285
52290
52300
52301
52305
52310
52315
52317
52318
52320
52325
52327
52330
52332
52334
52341
52342
52343
52344
52345
52346
52351
52352
52353
52354
52355
52400
52402

FUD
42
42
42
42
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
42
00

UNIT VALUE
34.26
17.57
20.02
21.59
5.45
10.90
8.10
19.68
13.99
17.05
42.06
39.81
6.61
7.76
13.70
6.46
5.61
16.50
14.63
20.57
7.12
8.82
10.09
9.09
7.93
7.87
6.55
7.58
7.94
7.53
7.70
14.23
36.13
12.92
6.66
8.70
37.37
44.21
8.78
6.89
8.63
9.29
10.29
11.03
11.72
13.17
8.41
9.86
11.38
10.52
12.58
14.09
7.37

CPT only copyright 2004 American Medical Association. All Rights Reserved.

40

CODE
52450
52500
52510
52601
52606
52612
52614
52620
52630
52640
52647
52648
52700
53000
53010
53020
53025
53040
53060
53080
53085
53200
53210
53215
53220
53230
53235
53240
53250
53260
53265
53270
53275
53400
53405
53410
53415
53420
53425
53430
53431
53440
53442
53444
53445
53446
53447
53448
53449
53450
53460
53500
53502

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
00
00
42
10
42
42
00
42
42
42
42
42
42
42
10
10
10
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
11.84
12.98
10.30
18.32
12.25
12.27
10.65
10.05
10.95
10.04
85.01
16.77
10.45
3.98
6.79
4.90
4.94
10.29
4.98
12.75
18.56
4.12
19.31
23.29
11.23
15.01
15.75
10.49
9.66
5.48
6.07
5.59
7.10
19.77
21.86
24.66
28.09
21.35
23.97
24.51
29.36
20.54
17.81
20.19
22.12
16.15
20.84
31.68
15.10
9.85
11.32
19.30
12.23

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
53505
53510
53515
53520
53600
53601
53605
53620
53621
53660
53661
53665
53850
53852
53853
53899
54000
54001
54015
54050
54055
54056
54057
54060
54065
54100
54105
54110
54111
54112
54115
54120
54125
54130
54135
54150
54152
54160
54161
54162
54163
54164
54200
54205
54220
54230
54231
54235
54240
54250
54300
54304
54308

FUD
42
42
42
42
00
00
00
00
00
00
00
00
42
42
42
YYY
10
10
10
10
10
10
10
10
10
00
10
42
42
42
42
42
42
42
42
10
10
10
10
10
10
10
10
42
00
00
00
00
00
00
42
42
42

UNIT VALUE
12.02
16.02
20.26
13.77
2.44
2.32
1.78
3.73
3.52
2.07
2.07
1.07
104.17
99.34
60.94
BR
4.56
5.53
8.24
2.98
2.87
2.99
3.54
5.17
5.19
4.81
8.02
15.60
20.28
23.75
10.96
15.31
20.31
29.79
38.34
6.32
3.70
6.81
5.07
7.87
5.22
4.52
2.93
13.16
6.44
2.51
3.57
2.24
2.50
3.31
16.71
19.66
18.60

CODE
54312
54316
54318
54322
54324
54326
54328
54332
54336
54340
54344
54348
54352
54360
54380
54385
54390
54400
54401
54405
54406
54408
54410
54411
54415
54416
54417
54420
54430
54435
54440
54450
54500
54505
54512
54520
54522
54530
54535
54550
54560
54600
54620
54640
54650
54660
54670
54680
54690
54692
54699
54700
54800

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00
00
10
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
42
YYY
10
00

UNIT VALUE
21.76
25.94
18.40
20.36
25.37
24.58
23.84
25.97
32.48
14.56
25.19
26.69
38.09
18.78
20.69
24.48
32.52
13.96
16.71
20.27
18.35
19.36
23.19
24.13
12.96
16.98
21.33
17.76
15.95
10.16
15.25
2.15
2.01
5.63
13.37
8.50
15.24
13.46
18.65
12.16
17.16
11.06
7.69
11.25
17.97
8.53
10.39
19.93
16.88
19.58
BR
5.63
3.50

CPT only copyright 2004 American Medical Association. All Rights Reserved.

41

CODE
54820
54830
54840
54860
54861
54900
54901
55000
55040
55041
55060
55100
55110
55120
55150
55175
55180
55200
55250
55300
55400
55450
55500
55520
55530
55535
55540
55550
55559
55600
55605
55650
55680
55700
55705
55720
55725
55801
55810
55812
55815
55821
55831
55840
55842
55845
55859
55860
55862
55865
55866
55870
55873

FUD
42
42
42
42
42
42
42
00
42
42
42
10
42
42
42
42
42
42
42
00
42
10
42
42
42
42
42
42
YYY
42
42
42
42
00
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00
42

UNIT VALUE
8.46
8.79
8.34
10.06
13.82
19.89
27.23
3.60
8.67
12.29
9.04
5.97
9.24
8.41
11.61
8.62
16.95
16.86
15.02
5.06
13.17
11.39
9.22
10.00
9.10
10.43
12.39
10.42
BR
10.32
12.87
18.00
8.61
5.87
7.18
12.38
13.85
26.71
33.06
40.46
44.44
21.43
23.35
33.53
35.86
41.44
19.20
21.84
27.67
33.69
44.54
4.27
29.74

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
55899
55970
55980
56405
56420
56440
56441
56501
56515
56605
56606
56620
56625
56630
56631
56632
56633
56634
56637
56640
56700
56720
56740
56800
56805
56810
56820
56821
57000
57010
57020
57022
57023
57061
57065
57100
57105
57106
57107
57109
57110
57111
57112
57120
57130
57135
57150
57155
57160
57170
57180
57200
57210

FUD
YYY
XXX
XXX
10
10
10
10
10
10
00
ZZZ
42
42
42
42
42
42
42
42
42
10
00
10
10
42
10
00
00
10
42
00
10
10
10
10
00
10
42
42
42
42
42
42
42
10
10
00
42
00
00
10
42
42

UNIT VALUE
BR
BR
BR
2.94
3.82
4.89
3.98
3.48
5.62
2.30
1.11
13.14
14.70
20.64
26.90
32.10
26.97
29.41
35.54
35.55
4.65
1.27
7.66
6.51
30.37
6.89
2.99
4.04
5.00
10.50
2.61
4.31
7.86
3.05
5.21
2.42
3.68
11.26
36.08
41.34
23.23
42.73
44.09
12.87
4.87
5.24
1.71
11.25
2.00
2.50
3.92
7.27
9.20

CODE
57220
57230
57240
57250
57260
57265
57267
57268
57270
57280
57282
57283
57284
57287
57288
57289
57291
57292
57300
57305
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57420
57421
57425
57452
57454
57455
57456
57460
57461
57500
57505
57510
57511
57513
57520
57522
57530
57531
57540
57545
57550
57555
57556

FUD
42
42
42
42
42
42
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00
00
10
00
00
42
00
00
00
00
00
00
00
10
10
10
10
42
42
42
42
42
42
42
42
42

UNIT VALUE
7.90
9.58
10.49
9.74
14.06
18.67
7.49
11.72
19.74
24.04
12.38
17.77
21.23
17.07
20.02
18.80
13.79
21.56
12.74
21.70
24.82
16.15
11.14
12.73
13.04
19.09
29.61
3.63
3.93
3.83
3.13
4.30
24.10
2.95
4.25
3.95
3.72
9.01
9.94
3.62
2.73
3.68
3.94
3.85
8.44
6.90
8.74
44.43
19.91
21.19
10.00
15.09
14.14

CPT only copyright 2004 American Medical Association. All Rights Reserved.

42

CODE
57700
57720
57800
57820
58100
58120
58140
58145
58146
58150
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275
58280
58285
58290
58291
58292
58293
58294
58300
58301
58321
58322
58323
58340
58345
58346
58350
58353
58356
58400
58410
58520
58540
58545
58546
58550
58552
58553
58554
58555
58558
58559
58560

FUD
42
42
00
10
00
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
XXX
00
00
00
00
00
10
42
10
10
10
42
42
42
42
42
42
42
42
42
42
00
00
00
00

UNIT VALUE
7.05
7.70
1.62
3.34
3.03
5.96
23.46
13.78
30.24
24.51
32.83
24.36
34.04
45.30
60.09
21.20
23.90
25.84
27.42
23.00
25.37
27.22
34.85
30.37
33.11
35.08
36.43
32.12
2.55
2.74
2.17
2.43
0.79
4.13
7.49
11.24
2.62
39.63
14.02
11.02
20.59
19.40
23.33
23.52
30.16
23.16
25.69
30.17
34.60
5.92
7.48
9.62
10.90

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
58561
58562
58563
58565
58578
58579
58600
58605
58611
58615
58660
58661
58662
58670
58671
58672
58673
58679
58700
58720
58740
58750
58752
58760
58770
58800
58805
58820
58822
58823
58825
58900
58920
58925
58940
58943
58950
58951
58952
58953
58954
58956
58960
58970
58974
58976
58999
59000
59001
59012
59015
59020
59025

FUD
00
00
00
42
YYY
YYY
42
42
ZZZ
10
42
10
42
42
42
42
42
YYY
42
42
42
42
42
42
42
42
42
42
42
00
42
42
42
42
42
42
42
42
42
42
42
42
42
00
00
00
YYY
00
00
00
00
00
00

UNIT VALUE
15.46
8.17
63.09
57.77
BR
BR
9.57
8.69
2.19
7.06
17.90
17.48
18.97
9.53
9.53
20.62
21.95
BR
19.51
18.48
22.78
24.01
23.54
21.60
22.57
8.19
10.03
8.02
16.47
24.94
18.07
10.23
18.32
18.41
12.27
29.24
27.31
35.38
39.68
50.24
54.76
35.07
23.74
6.25
3.75
6.97
BR
3.68
5.12
5.79
4.27
1.70
1.11

CODE
59030
59050
59051
59070
59072
59074
59076
59100
59120
59121
59130
59135
59136
59140
59150
59151
59160
59200
59300
59320
59325
59350
59400
59409
59410
59412
59414
59425
59426
59430
59510
59514
59515
59525
59610
59612
59614
59618
59620
59622
59812
59820
59821
59830
59840
59841
59850
59851
59852
59855
59856
59857
59866

FUD
00
XXX
XXX
00
00
00
00
42
42
42
42
42
42
42
42
42
10
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
00
ZZZ
00
00
00
00
00
00
42
42
42
42
10
10
42
42
42
42
42
42
00

UNIT VALUE
3.23
1.45
1.20
10.67
12.27
10.09
12.27
21.69
20.37
20.72
22.34
24.35
22.87
8.95
20.39
20.23
6.64
2.17
5.15
4.30
6.83
7.98
43.78
21.96
24.54
2.92
2.63
10.13
17.76
3.86
49.62
25.92
29.26
13.76
46.24
24.64
27.10
52.51
28.39
31.99
7.48
9.36
9.78
11.52
5.84
9.95
10.43
10.94
15.06
11.09
13.29
15.99
6.75

CPT only copyright 2004 American Medical Association. All Rights Reserved.

43

CODE
59870
59871
59897
59898
59899
60000
60001
60100
60200
60210
60212
60220
60225
60240
60252
60254
60260
60270
60271
60280
60281
60500
60502
60505
60512
60520
60521
60522
60540
60545
60600
60605
60650
60659
60699
61000
61001
61020
61026
61050
61055
61070
61105
61107
61108
61120
61140
61150
61151
61154
61156
61210
61215

FUD
42
42
YYY
YYY
YYY
10
00
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
42
42
42
42
YYY
YYY
00
00
00
00
00
00
00
42
00
42
42
42
42
42
42
42
00
42

UNIT VALUE
11.90
4.37
BR
BR
BR
3.82
2.45
3.06
16.53
17.72
25.60
19.35
23.20
25.47
32.94
43.72
28.02
32.97
27.17
11.06
15.08
25.61
32.18
35.00
6.60
27.22
31.13
37.54
26.34
30.47
31.05
34.92
30.22
BR
BR
2.66
2.71
3.14
3.36
2.89
3.68
2.05
10.34
8.75
19.84
16.65
29.79
32.19
23.18
28.52
30.18
10.19
10.08

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
61250
61253
61304
61305
61312
61313
61314
61315
61316
61320
61321
61322
61323
61330
61332
61333
61334
61340
61343
61345
61440
61450
61458
61460
61470
61480
61490
61500
61501
61510
61512
61514
61516
61517
61518
61519
61520
61521
61522
61524
61526
61530
61531
61533
61534
61535
61536
61537
61538
61539
61540
61541
61542

FUD
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
19.98
22.65
39.95
47.66
45.71
45.95
43.34
50.56
2.33
46.57
51.50
52.38
54.84
39.35
47.44
47.29
30.60
34.34
53.93
49.23
47.62
45.92
49.48
50.64
45.70
48.40
46.79
32.62
27.03
52.19
63.47
45.91
45.02
2.36
67.65
74.07
95.80
79.14
53.25
50.14
88.39
74.84
27.44
36.13
38.35
21.95
63.93
46.45
48.83
58.01
55.42
51.54
56.74

CODE
61543
61544
61545
61546
61548
61550
61552
61556
61557
61558
61559
61563
61564
61566
61567
61570
61571
61575
61576
61580
61581
61582
61583
61584
61585
61586
61590
61591
61592
61595
61596
61597
61598
61600
61601
61605
61606
61607
61608
61609
61610
61611
61612
61613
61615
61616
61618
61619
61623
61624
61626
61680
61682

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
ZZZ
ZZZ
ZZZ
42
42
42
42
42
00
00
00
42
42

UNIT VALUE
53.05
45.20
77.86
56.21
37.62
22.54
29.70
38.19
41.71
41.08
60.45
47.14
60.73
55.47
62.61
43.79
48.21
59.04
92.59
59.21
61.86
65.82
69.59
66.81
72.00
51.96
75.52
78.61
75.39
55.74
63.38
69.20
62.12
49.20
54.68
54.06
72.49
66.69
78.55
17.26
50.37
13.10
45.43
75.40
59.39
79.81
31.02
36.81
15.08
28.93
23.35
55.69
109.19

CPT only copyright 2004 American Medical Association. All Rights Reserved.

44

CODE
61684
61686
61690
61692
61697
61698
61700
61702
61703
61705
61708
61710
61711
61720
61735
61750
61751
61760
61770
61790
61791
61793
61795
61850
61860
61863
61864
61867
61868
61870
61875
61880
61885
61886
61888
62000
62005
62010
62100
62115
62116
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
62148
62160

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
ZZZ
42
ZZZ
42
42
42
42
42
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
ZZZ

UNIT VALUE
71.95
115.26
52.86
92.55
90.89
87.11
90.83
84.69
31.84
64.16
52.89
47.74
65.24
29.43
35.25
33.28
32.80
36.02
37.17
19.43
26.57
31.57
6.83
23.22
37.80
35.95
11.98
54.52
17.13
28.45
26.53
12.43
12.56
16.26
9.96
19.06
28.68
36.29
39.49
38.73
42.96
46.41
44.75
41.08
25.03
27.42
20.31
24.25
33.98
29.25
34.81
3.33
5.28

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
62161
62162
62163
62164
62165
62180
62190
62192
62194
62200
62201
62220
62223
62225
62230
62252
62256
62258
62263
62264
62268
62269
62270
62272
62273
62280
62281
62282
62284
62287
62290
62291
62292
62294
62310
62311
62318
62319
62350
62351
62355
62360
62361
62362
62365
62367
62368
63001
63003
63005
63011
63012
63015

FUD
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
XXX
42
42
10
10
00
00
00
00
00
10
10
10
00
42
00
00
42
42
00
00
00
00
42
42
42
42
42
42
42
XXX
XXX
42
42
42
42
42
42

UNIT VALUE
37.08
45.91
29.37
47.72
38.30
38.08
20.89
22.78
8.34
33.62
27.69
24.02
24.11
10.82
19.54
2.41
12.93
26.79
19.24
12.42
16.69
20.08
4.20
5.13
5.00
9.87
8.49
10.88
6.63
14.26
10.38
9.10
13.13
18.62
6.84
6.56
7.89
6.97
11.78
19.28
9.34
5.66
10.10
12.54
9.82
0.64
1.00
28.96
29.42
28.14
26.08
28.91
35.83

CODE
63016
63017
63020
63030
63035
63040
63042
63043
63044
63045
63046
63047
63048
63050
63051
63055
63056
63057
63064
63066
63075
63076
63077
63078
63081
63082
63085
63086
63087
63088
63090
63091
63101
63102
63103
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
63250
63251
63252

FUD
42
42
42
42
ZZZ
42
42
ZZZ
ZZZ
42
42
42
ZZZ
42
42
42
42
ZZZ
42
ZZZ
42
ZZZ
42
ZZZ
42
ZZZ
42
ZZZ
42
ZZZ
42
ZZZ
42
42
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
35.40
29.87
28.06
23.31
5.51
34.77
32.86
14.41
13.69
30.72
29.43
27.63
5.63
37.23
42.36
40.22
37.46
9.06
44.44
5.59
35.95
7.02
37.90
5.55
43.37
7.58
46.53
5.33
60.62
7.27
48.21
4.96
56.67
56.67
7.99
36.47
32.64
40.40
33.14
36.67
25.77
30.76
34.27
34.10
34.68
41.37
38.61
40.17
43.28
35.17
69.55
73.64
73.43

CPT only copyright 2004 American Medical Association. All Rights Reserved.

45

CODE
63265
63266
63267
63268
63270
63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290
63295
63300
63301
63302
63303
63304
63305
63306
63307
63308
63600
63610
63615
63650
63655
63660
63685
63688
63700
63702
63704
63706
63707
63709
63710
63740
63741
63744
63746
64400
64402
64405
64408

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
42
42
42
42
ZZZ
42
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
00
00
00
00

UNIT VALUE
39.57
40.81
33.25
32.46
48.78
48.91
46.00
44.27
43.01
42.68
38.17
37.31
51.62
51.07
48.07
45.83
64.86
64.34
65.86
66.64
8.42
44.24
48.01
48.83
51.84
53.90
55.68
58.22
52.81
9.10
20.88
69.26
28.16
10.44
19.49
10.55
12.19
9.78
30.23
33.57
38.60
43.82
21.35
26.71
26.42
21.36
14.58
15.10
11.68
3.09
2.95
2.86
3.09

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
64410
64412
64413
64415
64416
64417
64418
64420
64421
64425
64430
64435
64445
64446
64447
64448
64449
64450
64470
64472
64475
64476
64479
64480
64483
64484
64505
64508
64510
64517
64520
64530
64550
64553
64555
64560
64561
64565
64573
64575
64577
64580
64581
64585
64590
64595
64600
64605
64610
64612
64613
64614
64620

FUD
00
00
00
00
10
00
00
00
00
00
00
00
00
10
00
10
10
00
00
ZZZ
00
ZZZ
00
ZZZ
00
ZZZ
00
00
00
00
00
00
00
10
10
10
10
10
42
42
42
42
42
10
10
10
10
10
10
10
10
10
10

UNIT VALUE
4.03
3.91
3.33
4.38
4.59
4.58
4.02
5.15
7.88
3.54
4.08
4.12
4.25
4.49
2.03
4.02
4.12
2.64
9.21
3.71
8.40
3.17
9.84
4.50
9.91
4.70
2.70
4.51
4.74
5.03
6.57
6.13
0.47
5.33
5.57
5.20
37.29
5.17
14.26
7.60
8.93
8.02
19.90
13.54
9.75
12.31
13.12
15.92
17.49
4.56
5.00
5.53
8.10

CODE
64622
64623
64626
64627
64630
64640
64680
64681
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64722
64726
64727
64732
64734
64736
64738
64740
64742
64744
64746
64752
64755
64760
64761
64763
64766
64771
64772
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64792
64795
64802
64804
64809
64818

FUD
10
ZZZ
10
ZZZ
10
10
10
10
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
ZZZ
42
42
ZZZ
42
42
42
42
42
42
42
42

UNIT VALUE
10.97
4.02
11.28
5.77
5.96
7.22
9.51
13.11
8.69
8.48
11.91
13.69
18.59
15.70
12.92
13.01
10.13
10.36
8.25
7.51
5.07
8.84
9.84
9.13
11.40
11.39
11.64
10.09
11.24
12.25
20.94
11.18
10.45
13.05
14.96
14.11
13.41
9.74
9.52
5.06
10.86
6.05
17.82
27.80
6.99
8.74
20.48
26.08
5.07
15.55
23.87
20.91
16.88

CPT only copyright 2004 American Medical Association. All Rights Reserved.

46

CODE
64820
64821
64822
64823
64831
64832
64834
64835
64836
64837
64840
64856
64857
64858
64859
64861
64862
64864
64865
64866
64868
64870
64872
64874
64876
64885
64886
64890
64891
64892
64893
64895
64896
64897
64898
64901
64902
64905
64907
64999
65091
65093
65101
65103
65105
65110
65112
65114
65125
65130
65135
65140
65150

FUD
42
42
42
42
42
ZZZ
42
42
42
ZZZ
42
42
42
42
ZZZ
42
42
42
42
42
42
42
ZZZ
ZZZ
ZZZ
42
42
42
42
42
42
42
42
42
42
ZZZ
ZZZ
42
42
YYY
42
42
42
42
42
42
42
42
42
42
42
42
42

UNIT VALUE
18.95
17.32
17.24
20.03
17.89
9.42
18.78
20.28
20.24
10.44
22.61
25.04
26.32
30.54
7.11
35.03
35.62
22.59
30.29
30.91
26.88
25.99
3.36
4.93
5.58
30.77
36.36
27.40
25.32
25.94
28.04
31.42
34.57
31.42
34.00
16.83
19.31
24.47
34.45
BR
15.12
15.93
16.91
17.67
19.37
28.44
33.87
34.86
12.10
16.65
17.01
18.31
14.55

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
65155
65175
65205
65210
65220
65222
65235
65260
65265
65270
65272
65273
65275
65280
65285
65286
65290
65400
65410
65420
65426
65430
65435
65436
65450
65600
65710
65730
65750
65755
65760
65765
65767
65770
65771
65772
65775
65780
65781
65782
65800
65805
65810
65815
65820
65850
65855
65860
65865
65870
65875
65880
65900

FUD
42
42
00
00
00
00
42
42
42
10
42
42
42
42
42
42
42
42
00
42
42
00
00
42
42
42
42
42
42
42
XXX
XXX
XXX
42
XXX
42
42
42
42
42
00
00
42
42
42
42
10
42
42
42
42
42
42

UNIT VALUE
19.63
15.09
1.39
1.69
1.40
1.87
14.69
21.16
23.82
7.22
11.72
8.15
11.93
14.26
22.73
16.91
10.46
14.68
3.65
13.22
15.67
2.83
1.97
8.48
7.50
8.57
24.13
26.95
27.69
27.49
32.51
37.70
35.11
31.59
19.11
10.02
12.01
20.96
31.75
27.41
3.79
4.17
9.80
15.29
17.57
19.46
8.34
7.76
11.49
12.98
13.64
14.46
21.73

CODE
65920
65930
66020
66030
66130
66150
66155
66160
66165
66170
66172
66180
66185
66220
66225
66250
66500
66505
66600
66605
66625
66630
66635
66680
66682
66700
66710
66711
66720
66740
66761
66762
66770
66820
66821
66825
66830
66840
66850
66852
66920
66930
66940
66982
66983
66984
66985
66986
66990
66999
67005
67010
67015

FUD
42
42
10
10
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
YYY
42
42
42

UNIT VALUE
16.97
14.63
4.79
4.27
17.68
18.15
18.04
20.84
17.64
24.95
30.96
26.00
15.91
15.28
20.30
17.96
8.52
9.26
17.33
23.56
10.10
12.16
12.29
10.97
13.12
10.25
10.17
13.37
10.82
10.09
9.85
10.45
11.51
9.88
6.55
17.68
15.52
15.14
17.18
18.55
16.59
18.78
16.95
23.95
15.31
18.05
16.21
22.02
2.28
BR
10.83
12.61
13.70

CPT only copyright 2004 American Medical Association. All Rights Reserved.

47

CODE
67025
67027
67028
67030
67031
67036
67038
67039
67040
67101
67105
67107
67108
67110
67112
67115
67120
67121
67141
67145
67208
67210
67218
67220
67221
67225
67227
67228
67250
67255
67299
67311
67312
67314
67316
67318
67320
67331
67332
67334
67335
67340
67343
67345
67350
67399
67400
67405
67412
67413
67414
67415
67420

FUD
42
42
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
ZZZ
42
42
42
42
YYY
42
42
42
42
42
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
ZZZ
42
10
00
YYY
42
42
42
42
42
42
42

UNIT VALUE
16.39
19.37
5.34
10.92
8.44
21.57
37.74
27.39
31.73
17.01
15.85
26.85
36.23
19.47
29.47
10.31
14.85
19.71
11.30
11.35
13.14
15.82
31.57
24.18
8.53
0.74
13.48
24.83
18.29
19.22
BR
13.03
15.71
14.45
17.64
15.18
6.50
6.09
6.74
5.96
3.74
7.37
14.22
5.71
4.90
BR
21.58
18.15
20.95
21.30
23.81
2.62
38.64

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
67430
67440
67445
67450
67500
67505
67515
67550
67560
67570
67599
67700
67710
67715
67800
67801
67805
67808
67810
67820
67825
67830
67835
67840
67850
67875
67880
67882
67900
67901
67902
67903
67904
67906
67908
67909
67911
67912
67914
67915
67916
67917
67921
67922
67923
67924
67930
67935
67938
67950
67961
67966
67971

FUD
42
42
42
42
00
00
00
42
42
42
YYY
10
10
10
10
10
10
42
00
00
10
10
42
10
10
00
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
42
10
42
10
42
42
42
42

UNIT VALUE
29.17
28.10
29.24
28.91
1.52
1.56
1.23
22.20
22.54
27.93
BR
7.44
6.44
6.65
3.07
3.93
4.85
7.77
4.88
1.53
3.18
7.32
10.46
7.61
5.14
4.73
10.60
12.96
15.57
12.87
12.93
16.39
16.29
12.61
12.04
13.73
10.35
24.88
10.22
9.33
13.65
14.83
9.76
9.12
14.31
15.02
9.52
15.12
6.78
14.80
14.69
16.06
17.59

CODE
67973
67974
67975
67999
68020
68040
68100
68110
68115
68130
68135
68200
68320
68325
68326
68328
68330
68335
68340
68360
68362
68371
68399
68400
68420
68440
68500
68505
68510
68520
68525
68530
68540
68550
68700
68705
68720
68745
68750
68760
68761
68770
68801
68810
68811
68815
68840
68850
68899
69000
69005
69020
69090

FUD
42
42
42
YYY
10
00
00
10
10
42
10
00
42
42
42
42
42
42
42
42
42
10
YYY
10
10
10
42
42
00
42
00
10
42
42
42
10
42
42
42
10
10
42
10
10
10
10
10
00
YYY
10
10
10
XXX

UNIT VALUE
22.91
22.80
16.57
BR
2.85
1.60
4.67
5.96
8.44
13.88
3.74
1.05
16.92
14.33
13.93
16.00
14.48
13.92
13.24
12.62
14.09
10.06
BR
7.68
8.61
3.07
21.28
22.14
12.17
15.33
6.67
12.02
20.58
25.38
12.92
6.33
17.30
16.99
17.39
5.36
3.70
10.54
2.93
5.67
4.90
11.62
2.91
1.72
BR
4.45
5.22
5.59
0.77

CPT only copyright 2004 American Medical Association. All Rights Reserved.

48

CODE
69100
69105
69110
69120
69140
69145
69150
69155
69200
69205
69210
69220
69222
69300
69310
69320
69399
69400
69401
69405
69410
69420
69421
69424
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
69550
69552
69554
69601
69602
69603
69604
69605
69610
69620
69631
69632
69633
69635
69636
69637
69641
69642

FUD
00
00
42
42
42
42
42
42
00
10
00
00
10
YYY
42
42
YYY
00
00
10
00
10
10
00
10
10
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
42
42
10
42
42
42
42
42
42
42
42
42

UNIT VALUE
2.56
3.26
10.47
10.60
21.91
8.62
28.06
42.29
3.21
2.66
1.29
3.26
5.37
11.29
27.91
40.17
BR
3.06
1.92
6.35
2.46
4.59
4.04
3.10
4.74
4.44
16.94
13.04
18.83
24.95
31.24
32.06
42.31
70.91
5.04
26.73
41.67
66.33
26.94
27.89
33.51
28.81
40.90
10.33
17.47
21.85
27.24
26.11
31.14
35.74
35.54
26.51
34.46

SURGERY
(CONVERSION FACTOR = $67.95)
CODE
69643
69644
69645
69646
69650
69660
69661
69662
69666
69667
69670
69676
69700
69710
69711
69714
69715
69717
69718
69720
69725
69740
69745
69799
69801
69802
69805
69806
69820
69840
69905
69910
69915
69930
69949
69950
69955
69960
69970
69979
69990

FUD
42
42
42
42
42
42
42
42
42
42
42
42
42
XXX
42
42
42
42
42
42
42
42
42
YYY
42
42
42
42
42
42
42
42
42
42
YYY
42
42
42
42
YYY
ZZZ

UNIT VALUE
31.36
38.71
37.71
40.18
20.34
24.02
31.69
30.42
20.50
20.52
24.12
21.06
18.13
BR
22.04
27.77
34.72
30.33
36.95
30.06
47.89
30.62
32.77
BR
18.70
26.46
26.80
24.38
22.44
24.20
23.45
26.59
39.33
32.89
BR
46.76
50.84
49.20
55.85
BR
6.08

CPT only copyright 2004 American Medical Association. All Rights Reserved.

49

RADIOLOGY GROUND RULES
(Including Nuclear Medicine and Diagnostic Ultrasound)

1.

DUPLICATION OF X-RAYS: Every attempt should be made to minimize the number of x-rays taken. The
attending health care provider or any other person or institution having possession of x-rays, which pertain to
the patient and are deemed to be needed for diagnostic or treatment purposes, should make those x-rays
available upon request. No payments shall be made for additional x-rays when recent x-rays are available,
except when the charge is supported by adequate information regarding the need to perform another x-ray.

2.

PHOTOGRAPHIC MEDIA: The use of photographic media or imaging is not reported separately but is
considered to be a component of the basic procedure and shall not merit any additional payment.

3.

XERORADIOGRAPHY: Imaging performed by this process shall have the same Maximum Allowable Fees
as those listed for conventional x-ray procedures of the same anatomical area and views.

4.

UNIT VALUES: The Unit Values contained within this fee schedule include both the "professional
component” and the "technical component”. Identification of a service or procedure by its five digit code,
without pertinent modifiers, indicates that the services provided includes both the professional and technical
components.
The professional component includes the examination of the patient when indicated, performance or
supervision of the procedure, interpretation and written report of the examination including procedure results
(e.g., x-ray images), and consultation with the referring health care provider. To identify a charge for the
professional component only, see Appendix A - Modifiers for modifier -26. The percentage is shown in the
“PC/TC” column of this fee schedule.
The technical component includes the charges for personnel, materials and other supplies, and space,
equipment, and other facilities, but excludes the cost of radioisotopes. To identify a charge for the technical
component only, see Appendix A - Modifiers for modifier -TC. The percentage is shown in the “PC/TC”
column of this fee schedule.
Hospital outpatient facilities and ambulatory surgical centers must specify, by use of modifiers, when only the
technical component or the professional component is provided.

5.

SERVICES PROVIDED BY A HOSPITAL OUTPATIENT FACILITY AND/OR AMBULATORY SURGICAL
CENTER: For any radiology service(s) provided by a hospital outpatient facility and/or ambulatory surgical
center, reimbursement for said service is to be limited to the maximum allowable payment contained within
this section of the Fee Schedule.

6.

NECESSITY OF SERVICES OR PROCEDURES: When a patient is referred to radiologists or other health
care providers for services covered in the Radiology Section, the provider(s) shall evaluate the patient's
problem and determine the services or procedures medically necessary. Such evaluations or necessary
consultations with the referring health care providers are an integral part of the professional component and
do not merit any additional charges. No payment shall be made for excessive or inappropriate x-rays
taken on initial or subsequent visits.

7.

MULTIPLE PROCEDURES: It is appropriate to designate multiple procedures that are rendered on the
same day by separate entries. Use modifier -51 to reflect multiple procedures except for the Add-On Codes.

8.

SEPARATE PROCEDURE: Some of the procedures or services listed are commonly carried out as an
integral component of a total service or procedure and are identified by the inclusion of the term “separate
procedure.” The codes designated as “separate procedure” should not be reported in addition to the code
for the total procedure or service of which it is considered an integral component.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

50

RADIOLOGY GROUND RULES
(Including Nuclear Medicine and Diagnostic Ultrasound)
However, when a procedure or service that is designated as a “separate procedure” is carried out
independently or considered to be unrelated or distinct from other procedures/services provided at that time,
it may be reported by itself, or in addition to other procedures/services by appending modifier -59 to the
specific “separate procedure” code to indicate that the procedure is not considered to be a component of
another procedure, but is a distinct, independent procedure. This may represent a different session or
patient encounter, different procedure or surgery, different site or organ system, separate incision/excision,
separate lesion, or separate injury (or area of injury in extensive injuries).
9.

ADD-ON CODES: Certain codes, by the nature of their description and the unit values assigned, have
already been reduced, as they are not to be billed as primary procedures. For a complete list of the codes
which are considered to be add-on codes, refer to the appropriate appendix found within the most recent
publication of the AMA Current Procedural Terminology (CPT).

10. MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the health
care provider (e.g., sterile trays, drugs) over and above those usually included with the office visit or other
services rendered may be listed separately. The statement of charges will need to reflect any drugs, trays,
supplies, and materials that were provided. Payment shall not exceed the cost of the item(s) to the health
care provider plus 25% of the cost or the cost of the item(s) plus $15.00 per item, whichever is less. Use
procedure code 99070.
The Unit Values in this section do not include radiopharmaceutical or other radionuclide material costs. List
the name and dosage of radiopharmaceutical material and cost.
11. INJECTION PROCEDURES: Charges for injection procedures are to include all usual pre- and postinjection care specifically related to the injection procedure, necessary local anesthesia, placement of needle
or catheter, and injection of contrast media. Vascular injection procedures are listed under the
Cardiovascular Subsection of the Surgery Section, procedure codes 36000-36299. Other injection
procedures are listed in pertinent sections.
12. PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in the unit value column
indicates that the amount charged for this service is to be determined "by report" because the service is too
unusual, or variable to be assigned a Unit Value. Pertinent information should be furnished concerning the
nature, extent, and need for the procedure or service, the time, skill, and equipment necessary, etc.
Additional items which may be helpful might include: complexity of symptoms, final diagnosis, pertinent
physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care.
13. UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the
procedure should be identified and the amount charged substantiated "by report" (BR). Unlisted service or
procedure codes usually end in "99."
14. MODIFIERS: Procedure codes for radiology services may be modified under certain circumstances. The
circumstances are to be identified by the addition of a hyphen and the appropriate two digit modifier code.
Refer to Appendix A - Modifiers for a list of modifiers that may be used.
15. COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care costs.
Such payment agreements, if less, will supersede the limitation amounts specified herein. Please refer to
K.S.A. 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $63.15
CPT only copyright 2004 American Medical Association. All Rights Reserved.

51

RADIOLOGY
(CONVERSION FACTOR = $63.15)
CODE
70010
70015
70030
70100
70110
70120
70130
70134
70140
70150
70160
70170
70190
70200
70210
70220
70240
70250
70260
70300
70310
70320
70328
70330
70332
70336
70350
70355
70360
70370
70371
70373
70380
70390
70450
70460
70470
70480
70481
70482
70486
70487
70488
70490
70491
70492
70496
70498
70540
70542
70543
70544

PC/TC UNIT VALUE
40/60
6.19
40/60
3.09
40/60
0.68
40/60
0.79
40/60
1.00
40/60
0.91
40/60
1.30
40/60
1.25
40/60
0.92
40/60
1.18
40/60
0.78
40/60
1.42
40/60
0.95
40/60
1.21
40/60
0.90
40/60
1.17
40/60
0.70
40/60
0.99
40/60
1.42
40/60
0.44
40/60
0.69
40/60
1.14
40/60
0.76
40/60
1.22
40/60
2.99
20/80
13.83
40/60
0.65
40/60
0.89
40/60
0.68
40/60
1.81
40/60
3.38
40/60
2.49
40/60
0.95
40/60
2.41
20/80
6.14
20/80
7.51
20/80
9.19
20/80
6.73
20/80
7.85
20/80
9.43
20/80
6.53
20/80
7.75
20/80
9.38
20/80
6.73
20/80
7.85
20/80
9.42
20/80
13.58
20/80
13.58
20/80
13.44
20/80
16.13
20/80
28.68
20/80
13.44

CODE
70545
70546
70547
70548
70549
70551
70552
70553
70557
70558
70559
71010
71015
71020
71021
71022
71023
71030
71034
71035
71040
71060
71090
71100
71101
71110
71111
71120
71130
71250
71260
71270
71275
71550
71551
71552
71555
72010
72020
72040
72050
72052
72069
72070
72072
72074
72080
72090
72100
72110
72114
72120

PC/TC UNIT VALUE
20/80
13.43
20/80
25.47
20/80
13.43
20/80
13.43
20/80
25.47
20/80
13.83
20/80
16.59
20/80
29.44
20/80
20.55
20/80
22.70
20/80
22.80
40/60
0.74
40/60
0.83
40/60
0.96
40/60
1.15
40/60
1.20
40/60
1.36
40/60
1.25
40/60
2.16
40/60
0.79
40/60
2.34
40/60
3.35
40/60
2.56
40/60
0.91
40/60
1.08
40/60
1.20
40/60
1.38
40/60
0.97
40/60
1.05
20/80
7.81
20/80
9.15
20/80
11.20
20/80
15.41
20/80
13.65
20/80
16.34
20/80
28.66
20/80
14.28
40/60
1.70
40/60
0.65
40/60
0.94
40/60
1.37
40/60
1.69
40/60
0.82
40/60
0.99
40/60
1.08
40/60
1.27
40/60
1.01
40/60
1.09
40/60
1.01
40/60
1.39
40/60
1.75
40/60
1.25

CPT only copyright 2004 American Medical Association. All Rights Reserved.

52

CODE
72125
72126
72127
72128
72129
72130
72131
72132
72133
72141
72142
72146
72147
72148
72149
72156
72157
72158
72159
72170
72190
72191
72192
72193
72194
72195
72196
72197
72198
72200
72202
72220
72240
72255
72265
72270
72275
72285
72295
73000
73010
73020
73030
73040
73050
73060
73070
73080
73085
73090
73092
73100

PC/TC UNIT VALUE
20/80
7.81
20/80
9.11
20/80
11.06
20/80
7.81
20/80
9.12
20/80
11.06
20/80
7.81
20/80
9.11
20/80
11.06
20/80
13.99
20/80
16.79
20/80
15.28
20/80
16.78
20/80
15.12
20/80
16.60
20/80
29.73
20/80
29.71
20/80
29.44
20/80
15.46
40/60
0.78
40/60
1.00
20/80
14.91
20/80
7.72
20/80
8.79
20/80
10.59
20/80
13.66
20/80
16.34
20/80
28.90
20/80
14.26
40/60
0.78
40/60
0.92
40/60
0.85
40/60
6.24
40/60
5.77
40/60
5.41
40/60
8.24
40/60
3.32
40/60
10.40
40/60
9.42
40/60
0.76
40/60
0.78
40/60
0.70
40/60
0.86
40/60
2.96
40/60
0.99
40/60
0.85
40/60
0.75
40/60
0.85
40/60
2.98
40/60
0.76
40/60
0.73
40/60
0.73

RADIOLOGY
(CONVERSION FACTOR = $63.15)
CODE
73110
73115
73120
73130
73140
73200
73201
73202
73206
73218
73219
73220
73221
73222
73223
73225
73500
73510
73520
73525
73530
73540
73542
73550
73560
73562
73564
73565
73580
73590
73592
73600
73610
73615
73620
73630
73650
73660
73700
73701
73702
73706
73718
73719
73720
73721
73722
73723
73725
74000
74010
74020

PC/TC UNIT VALUE
40/60
0.79
40/60
2.43
40/60
0.73
40/60
0.79
40/60
0.62
20/80
6.71
20/80
7.81
20/80
9.49
20/80
13.83
20/80
13.44
20/80
16.14
20/80
28.68
20/80
13.44
20/80
16.13
20/80
28.68
20/80
14.10
40/60
0.73
40/60
0.90
40/60
1.07
40/60
2.97
40/60
0.94
40/60
0.89
40/60
3.01
40/60
0.85
40/60
0.78
40/60
0.86
40/60
0.96
40/60
0.75
40/60
3.50
40/60
0.78
40/60
0.73
40/60
0.73
40/60
0.79
40/60
2.97
40/60
0.73
40/60
0.79
40/60
0.71
40/60
0.62
20/80
6.71
20/80
7.81
20/80
9.48
20/80
13.96
20/80
13.44
20/80
16.13
20/80
28.67
20/80
13.44
20/80
16.13
20/80
28.68
20/80
14.29
40/60
0.79
40/60
0.93
40/60
1.03

CODE
74022
74150
74160
74170
74175
74181
74182
74183
74185
74190
74210
74220
74230
74235
74240
74241
74245
74246
74247
74249
74250
74251
74260
74270
74280
74283
74290
74291
74300
74301
74305
74320
74327
74328
74329
74330
74340
74350
74355
74360
74363
74400
74410
74415
74420
74425
74430
74440
74445
74450
74455
74470

PC/TC UNIT VALUE
40/60
1.21
20/80
7.59
20/80
8.95
20/80
10.84
20/80
15.02
20/80
13.65
20/80
16.34
20/80
28.90
20/80
14.26
40/60
2.04
40/60
1.75
40/60
1.88
40/60
2.10
40/60
4.40
40/60
2.49
40/60
2.52
40/60
3.76
40/60
2.69
40/60
2.74
40/60
3.96
40/60
2.02
40/60
2.33
40/60
2.25
40/60
2.76
40/60
3.71
40/60
5.47
40/60
1.21
40/60
0.72
40/60
1.43
40/60
0.83
40/60
1.41
40/60
4.06
40/60
2.83
40/60
4.28
40/60
4.28
40/60
4.55
40/60
3.50
40/60
4.36
40/60
3.80
40/60
4.08
40/60
7.64
40/60
2.46
40/60
2.73
40/60
2.91
40/60
3.26
40/60
1.88
40/60
1.55
40/60
1.71
40/60
2.77
40/60
2.00
40/60
2.14
40/60
2.06

CPT only copyright 2004 American Medical Association. All Rights Reserved.

53

CODE
74475
74480
74485
74710
74740
74742
74775
75552
75553
75554
75555
75556
75600
75605
75625
75630
75635
75650
75658
75660
75662
75665
75671
75676
75680
75685
75705
75710
75716
75722
75724
75726
75731
75733
75736
75741
75743
75746
75756
75774
75790
75801
75803
75805
75807
75809
75810
75820
75822
75825
75827
75831

PC/TC UNIT VALUE
40/60
5.03
40/60
5.03
40/60
4.06
40/60
1.58
40/60
1.91
40/60
4.16
40/60
2.40
20/80
13.99
20/80
14.51
20/80
14.33
20/80
14.24
20/80
BR
40/60
13.95
40/60
14.84
40/60
14.83
40/60
16.33
20/80
19.60
40/60
15.31
40/60
15.10
40/60
15.08
40/60
15.58
40/60
15.09
40/60
15.55
40/60
15.09
40/60
15.55
40/60
15.06
40/60
16.29
40/60
14.85
40/60
15.06
40/60
14.85
40/60
15.36
40/60
14.81
40/60
14.82
40/60
15.06
40/60
14.83
40/60
15.05
40/60
15.52
40/60
14.82
40/60
14.88
40/60
13.75
40/60
3.97
40/60
6.85
40/60
7.30
40/60
7.56
40/60
8.03
40/60
1.47
40/60
14.81
40/60
1.98
40/60
3.02
40/60
14.83
40/60
14.82
40/60
14.83

RADIOLOGY
(CONVERSION FACTOR = $63.15)
CODE
75833
75840
75842
75860
75870
75872
75880
75885
75887
75889
75891
75893
75894
75896
75898
75900
75901
75902
75940
75945
75946
75952
75953
75954
75960
75961
75962
75964
75966
75968
75970
75978
75980
75982
75984
75989
75992
75993
75994
75995
75996
75998
76000
76001
76003
76005
76006
76010
76012
76013
76020
76040

PC/TC UNIT VALUE
40/60
15.32
40/60
14.84
40/60
15.29
40/60
14.83
40/60
14.83
40/60
14.89
40/60
1.97
40/60
15.23
40/60
15.22
40/60
14.81
40/60
14.81
40/60
14.00
40/60
27.22
40/60
23.92
40/60
3.39
40/60
22.76
40/60
2.81
40/60
2.68
40/60
14.01
40/60
5.38
40/60
3.01
40/60
64.20
40/60
19.40
40/60
31.80
40/60
16.82
40/60
16.90
40/60
17.33
40/60
9.33
40/60
18.41
40/60
9.33
40/60
13.29
40/60
17.32
40/60
7.67
40/60
8.40
40/60
3.04
40/60
4.95
40/60
17.33
40/60
9.33
40/60
18.41
40/60
18.40
40/60
9.32
40/60
1.93
40/60
1.61
40/60
3.70
40/60
2.12
40/60
2.17
40/60
0.65
40/60
0.79
40/60
5.37
40/60
9.70
40/60
0.80
40/60
1.20

CODE
76061
76062
76065
76066
76070
76071
76075
76076
76077
76078
76080
76082
76083
76086
76088
76090
76091
76092
76093
76094
76095
76096
76098
76100
76101
76102
76120
76125
76140
76150
76350
76355
76360
76362
76370
76375
76380
76390
76393
76394
76400
76496
76497
76498
76499
76506
76510
76511
76512
76513
76514
76516

PC/TC UNIT VALUE
40/60
1.68
40/60
2.26
40/60
1.74
40/60
1.60
20/80
3.45
20/80
3.30
40/60
3.67
40/60
1.11
40/60
1.04
40/60
1.08
40/60
1.85
40/60
0.52
40/60
0.52
40/60
3.26
40/60
4.47
40/60
2.07
40/60
2.57
40/60
2.26
20/80
20.77
20/80
27.38
40/60
9.73
40/60
2.15
40/60
0.66
40/60
2.12
40/60
2.30
40/60
2.64
40/60
1.64
40/60
1.20
40/60
BR
40/60
0.44
40/60
1.04
20/80
10.35
20/80
10.27
20/80
15.20
20/80
4.28
40/60
3.94
20/80
5.02
20/80
13.54
20/80
13.84
20/80
18.62
20/80
13.98
40/60
BR
20/80
BR
20/80
BR
40/60
BR
40/60
2.42
40/60
4.51
40/60
3.47
40/60
3.29
40/60
2.59
40/60
0.32
40/60
2.08

CPT only copyright 2004 American Medical Association. All Rights Reserved.

54

CODE
76519
76529
76536
76604
76645
76700
76705
76770
76775
76778
76800
76801
76802
76805
76810
76811
76812
76815
76816
76817
76818
76819
76820
76821
76825
76826
76827
76828
76830
76831
76856
76857
76870
76872
76873
76880
76885
76886
76930
76932
76936
76937
76940
76941
76942
76945
76946
76948
76950
76965
76970
76975

PC/TC UNIT VALUE
40/60
2.17
40/60
2.04
40/60
2.27
40/60
2.13
40/60
1.85
40/60
3.20
40/60
2.31
40/60
3.09
40/60
2.30
40/60
3.09
40/60
3.02
40/60
3.59
40/60
2.33
40/60
3.59
40/60
2.63
40/60
6.66
40/60
3.98
40/60
2.41
40/60
2.38
40/60
2.62
40/60
3.20
40/60
2.79
40/60
2.45
40/60
2.73
40/60
4.42
40/60
1.91
40/60
2.66
40/60
2.00
40/60
2.57
40/60
2.62
40/60
2.57
40/60
2.29
40/60
2.50
40/60
3.07
40/60
4.40
40/60
2.31
40/60
2.63
40/60
2.35
40/60
2.56
40/60
2.56
40/60
9.41
40/60
0.91
40/60
4.75
40/60
3.49
40/60
3.83
40/60
2.54
40/60
2.16
40/60
2.15
40/60
2.18
40/60
7.71
40/60
1.66
40/60
2.75

RADIOLOGY
(CONVERSION FACTOR = $63.15)
CODE
76977
76986
76999
77261
77262
77263
77280
77285
77290
77295
77299
77300
77301
77305
77310
77315
77321
77326
77327
77328
77331
77332
77333
77334
77336
77370
77399
77401
77402
77403
77404
77406
77407
77408
77409
77411
77412
77413
77414
77416
77417
77418
77427
77431
77432
77470
77499
77520
77522
77523
77525
77600

PC/TC UNIT VALUE
40/60
0.95
40/60
4.48
40/60
BR
40/60
1.97
40/60
2.97
40/60
4.41
40/60
4.61
40/60
7.31
40/60
9.00
40/60
35.67
40/60
BR
40/60
2.26
40/60
40.36
40/60
2.94
40/60
3.90
40/60
4.94
40/60
5.55
40/60
3.77
40/60
5.55
40/60
8.08
40/60
1.71
40/60
2.15
40/60
3.15
40/60
5.12
40/60
3.14
40/60
3.67
40/60
BR
40/60
1.88
40/60
1.88
40/60
1.88
40/60
1.88
40/60
1.88
40/60
2.21
40/60
2.21
40/60
2.21
40/60
2.21
40/60
2.46
40/60
2.46
40/60
2.46
40/60
2.46
40/60
0.63
40/60
18.11
40/60
4.54
40/60
2.58
40/60
11.23
40/60
14.61
40/60
BR
40/60
BR
40/60
BR
40/60
BR
40/60
BR
40/60
5.35

CODE
77605
77610
77615
77620
77750
77761
77762
77763
77776
77777
77778
77781
77782
77783
77784
77789
77790
77799
78000
78001
78003
78006
78007
78010
78011
78015
78016
78018
78020
78070
78075
78099
78102
78103
78104
78110
78111
78120
78121
78122
78130
78135
78140
78160
78162
78170
78172
78185
78190
78191
78195
78199

PC/TC UNIT VALUE
40/60
7.19
40/60
5.36
40/60
7.14
40/60
5.49
40/60
8.13
40/60
7.72
40/60
11.64
40/60
16.47
40/60
8.34
40/60
14.70
40/60
20.71
40/60
23.63
40/60
24.78
40/60
26.46
40/60
29.04
40/60
2.01
40/60
1.96
40/60
BR
40/60
1.29
40/60
1.74
40/60
1.48
40/60
3.18
40/60
3.40
40/60
2.47
40/60
3.16
40/60
3.64
40/60
4.80
40/60
6.91
40/60
2.28
40/60
5.52
40/60
6.74
40/60
BR
40/60
2.92
40/60
4.38
40/60
5.39
40/60
1.28
40/60
3.02
40/60
2.16
40/60
3.49
40/60
5.47
40/60
3.84
40/60
6.01
40/60
4.98
40/60
4.34
40/60
4.03
40/60
6.16
40/60
2.88
40/60
3.05
40/60
7.57
40/60
8.55
40/60
5.96
40/60
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

55

CODE
78201
78202
78205
78206
78215
78216
78220
78223
78230
78231
78232
78258
78261
78262
78264
78267
78268
78270
78271
78272
78278
78282
78290
78291
78299
78300
78305
78306
78315
78320
78350
78351
78399
78414
78428
78445
78455
78456
78457
78458
78459
78460
78461
78464
78465
78466
78468
78469
78472
78473
78478
78480

PC/TC UNIT VALUE
40/60
3.10
40/60
3.72
40/60
7.20
40/60
7.35
40/60
3.75
40/60
4.44
40/60
4.58
40/60
5.01
40/60
2.93
40/60
4.06
40/60
4.37
40/60
4.04
40/60
5.28
40/60
5.41
40/60
5.42
40/60
0.29
40/60
2.48
40/60
1.93
40/60
2.02
40/60
2.82
40/60
6.48
40/60
2.12
40/60
4.15
40/60
4.44
40/60
BR
40/60
3.48
40/60
5.00
40/60
5.68
40/60
6.43
40/60
7.66
40/60
1.10
40/60
2.03
40/60
BR
40/60
2.10
40/60
3.48
40/60
2.65
40/60
5.20
40/60
5.65
40/60
3.87
40/60
5.49
40/60
7.07
40/60
3.68
40/60
6.68
40/60
8.95
40/60
14.45
40/60
3.72
40/60
4.95
40/60
6.76
40/60
7.17
40/60
10.72
40/60
2.53
40/60
2.52

RADIOLOGY
(CONVERSION FACTOR = $63.15)
CODE
78481
78483
78491
78492
78494
78496
78499
78580
78584
78585
78586
78587
78588
78591
78593
78594
78596
78599
78600
78601
78605
78606
78607
78608
78609
78610
78615
78630
78635
78645
78647
78650
78660
78699
78700
78701
78704
78707
78708
78709
78710
78715
78725
78730
78740
78760
78761
78799
78800
78801
78802
78803

PC/TC UNIT VALUE
40/60
6.88
40/60
10.34
40/60
7.17
40/60
8.93
40/60
9.03
40/60
8.07
40/60
BR
40/60
4.63
40/60
4.73
40/60
7.44
40/60
3.28
40/60
3.62
40/60
4.88
40/60
3.54
40/60
4.30
40/60
5.96
40/60
9.18
40/60
BR
40/60
3.63
40/60
4.28
40/60
4.31
40/60
4.96
40/60
8.61
40/60
BR
40/60
BR
40/60
2.10
40/60
4.65
40/60
6.25
40/60
3.54
40/60
4.39
40/60
7.47
40/60
5.73
40/60
2.97
40/60
BR
40/60
3.83
40/60
4.41
40/60
5.18
40/60
6.02
40/60
6.37
40/60
6.64
40/60
7.13
40/60
2.10
40/60
2.42
40/60
2.04
40/60
3.03
40/60
3.73
40/60
4.35
40/60
BR
40/60
4.50
40/60
5.55
40/60
7.02
40/60
8.42

CODE
78804
78805
78806
78807
78811
78812
78813
78814
78815
78816
78890
78891
78999
79005
79101
79200
79300
79403
79440
79445
79999

PC/TC UNIT VALUE
40/60
12.84
40/60
4.59
40/60
7.97
40/60
8.42
40/60
6.60
40/60
8.16
40/60
8.44
40/60
9.24
40/60
10.20
40/60
10.44
40/60
1.45
40/60
2.90
40/60
BR
40/60
5.24
40/60
5.47
40/60
5.53
40/60
3.82
40/60
7.65
40/60
5.55
40/60
6.12
40/60
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

56

PATHOLOGY AND LABORATORY
GROUND RULES
1.

SEROLOGY: All serological procedures must be performed by registered pathologists or laboratories.

2.

MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and material provided by the health
care provider (e.g., sterile trays, drugs) over and above those usually included with the office visit or other
services rendered may be listed separately. The statement of charges will need to list individually any
drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s)
to the health care provider plus 25%, or the cost of the item(s) plus $15.00 per item, whichever is less.
Use procedure code 99070.

3.

UNIT VALUES: The Unit Values specified herein apply to laboratories owned or operated by a health
care provider, hospital laboratories, and commercial laboratories, but only when the services or
procedures are performed by or under the responsible supervision of a health care provider. When a
health care provider is hospital based and is not salaried or otherwise compensated for the services listed
in this section, a separate bill can be rendered for the particular service. The charge is to be 60% of the
Unit Value.
The Unit Values specified herein include both the "professional" component and the "technical"
component. Identification of a service or procedure by its five-digit code, without pertinent modifiers,
indicates that the charge includes both the professional and technical components.
The professional component includes the examination of the patient when indicated, performance or
supervision of the procedure, interpretation and written report of the examination including procedure
results (e.g., x-ray images), and consultation with the referring health care provider. To identify a charge
for the professional component only, see Appendix A - Modifiers for modifier -26. Unless otherwise

specified in the Schedule, the maximum allowable charge for the professional
component is 60% of the listed Unit Value.
The technical component includes the charges for personnel, materials and other supplies, and space,
equipment, and other facilities, but excludes the cost of radioisotopes. To identify a charge for the
technical component only, see Appendix A - Modifiers for modifier -TC. Unless otherwise

specified in the Schedule, the maximum allowable charge for the technical
component is 40% of the listed Unit Value.
Hospital outpatient facilities and ambulatory surgical centers must specify, by use of modifiers, when only
the technical component or the professional component is provided.
4.

SERVICES PROVIDED BY HOSPITAL OUTPATIENT FACILITIES AND/OR AMBULATORY
SURGICAL CENTERS: For any pathology and laboratory service(s) provided by a hospital outpatient
facility and/or ambulatory surgical center, reimbursement for said service is to be limited to the maximum
allowable payment contained within this section of the Fee Schedule.

5.

ANATOMIC AND SURGICAL PATHOLOGY: The sections of Anatomic Pathology and Surgical
Pathology are exempt from the 60/40 split. Instead, the professional component of the procedures listed
in those sections will be reimbursed at 80% of the listed unit value, and the technical component will be
reimbursed at 20% of the listed unit value.

6.

MULTIPLE PROCEDURES: It is appropriate to designate multiple procedures that are rendered on the
same day by separate entries. Use modifier -51 to reflect multiple procedures except for the Add-On
Codes.

7.

ADD-ON CODES: Certain codes, by the nature of their description and the unit value assigned, have
already been reduced, as they are not to be billed as primary procedures. For a complete list of the

CPT only copyright 2004 American Medical Association. All Rights Reserved.

57

PATHOLOGY AND LABORATORY
GROUND RULES
codes which are considered to be add-on codes, refer to the appropriate appendix found within the most
recent publication of the AMA Current Procedural Terminology (CPT).
8.

REPORTS: No statement of charges for services or procedures included in this section shall be
considered properly rendered unless it is accompanied by a report that includes both the findings and an
interpretation of such findings.

9.

PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in the Unit Value
column indicates that the charge for this service is to be determined "by report" because the service is too
unusual or variable to be assigned a Unit Value. Pertinent information should be furnished concerning
the nature, extent, and need for the procedure or service, the time, skill, and equipment necessary, etc.

10.

INDICES OR RATIOS: Tests which produce an index or ratio based on mathematical calculations from
two or more other results may not be billed as separate independent tests (e.g., A/G ratio, free thyroxin
index).

11.

UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the
procedure should be identified and the amount charged substantiated "by report" (BR). Unlisted service
or procedure codes usually end in "99."

12.

DENIAL OF PAYMENT: Payment may be denied for procedures or services determined to be excessive
or unnecessary for the management of the work-related injury or disease.

13.

MODIFIERS: Procedure codes for pathology and laboratory services may be modified under certain
circumstances. The circumstances are to be identified by the addition of a hyphen and the appropriate
two-digit modifier code. Refer to Appendix A - Modifiers for a list of modifiers that may be used.

14.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A. 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $75.10
CPT only copyright 2004 American Medical Association. All Rights Reserved.

58

PATHOLOGY AND LABORATORY
(CONVERSION FACTOR = $75.10)
CODE
80048
80050
80051
80053
80055
80061
80069
80074
80076
80100
80101
80102
80103
80150
80152
80154
80156
80157
80158
80160
80162
80164
80166
80168
80170
80172
80173
80174
80176
80178
80182
80184
80185
80186
80188
80190
80192
80194
80196
80197
80198
80200
80201
80202
80299
80400
80402
80406
80408
80410
80412
80414

UNIT VALUE
0.31
1.14
0.26
0.39
1.31
0.80
0.32
1.96
0.30
0.54
0.51
0.49
0.52
0.56
0.66
0.68
0.54
0.49
0.67
0.63
0.49
0.50
0.57
0.60
0.60
0.60
0.54
0.63
0.54
0.24
0.50
0.42
0.49
0.51
0.61
0.62
0.62
0.54
0.26
0.51
0.52
0.59
0.44
0.50
0.50
1.96
3.60
3.35
4.49
4.01
9.98
1.48

CODE
80415
80416
80417
80418
80420
80422
80424
80426
80428
80430
80432
80434
80435
80436
80438
80439
80440
80500
80502
81000
81001
81002
81003
81005
81007
81015
81020
81025
81050
81099
82000
82003
82009
82010
82013
82016
82017
82024
82030
82040
82042
82043
82044
82045
82055
82075
82085
82088
82101
82103
82104
82105

UNIT VALUE
1.48
4.66
2.00
27.81
3.54
2.20
2.14
5.20
2.60
3.16
5.64
3.74
3.97
3.66
1.75
2.18
2.14
0.59
1.93
0.12
0.12
0.09
0.08
0.08
0.09
0.11
0.14
0.23
0.11
BR
0.46
0.75
0.17
0.30
0.41
0.51
0.62
1.42
0.95
0.18
0.19
0.21
0.17
1.25
0.40
0.44
0.36
1.50
1.11
0.50
0.53
0.62

CPT only copyright 2004 American Medical Association. All Rights Reserved.

59

CODE
82106
82108
82120
82127
82128
82131
82135
82136
82139
82140
82143
82145
82150
82154
82157
82160
82163
82164
82172
82175
82180
82190
82205
82232
82239
82240
82247
82248
82252
82261
82270
82273
82274
82286
82300
82306
82307
82308
82310
82330
82331
82340
82355
82360
82365
82370
82373
82374
82375
82376
82378
82379

UNIT VALUE
0.62
0.94
0.14
0.51
0.51
0.62
0.61
0.62
0.62
0.54
0.25
0.57
0.24
1.06
1.08
0.92
0.76
0.54
0.57
0.70
0.36
0.55
0.42
0.60
0.63
0.98
0.19
0.19
0.17
0.62
0.12
0.12
0.59
0.25
0.85
1.09
1.19
0.99
0.19
0.50
0.19
0.22
0.43
0.47
0.48
0.46
0.67
0.18
0.45
0.22
0.70
0.62

PATHOLOGY AND LABORATORY
(CONVERSION FACTOR = $75.10)
CODE
82380
82382
82383
82384
82387
82390
82397
82415
82435
82436
82438
82441
82465
82480
82482
82485
82486
82487
82488
82489
82491
82492
82495
82507
82520
82523
82525
82528
82530
82533
82540
82541
82542
82543
82544
82550
82552
82553
82554
82565
82570
82575
82585
82595
82600
82607
82608
82615
82626
82627
82633
82634

UNIT VALUE
0.34
0.63
0.92
0.93
0.77
0.40
0.52
0.47
0.17
0.19
0.18
0.22
0.16
0.29
0.28
0.76
0.67
0.59
0.79
0.68
0.67
0.67
0.75
1.03
0.56
0.69
0.46
0.83
0.62
0.60
0.17
0.67
0.67
0.67
0.67
0.24
0.49
0.43
0.44
0.19
0.19
0.35
0.32
0.24
0.72
0.56
0.53
0.30
0.93
0.82
1.14
1.08

CODE
82638
82646
82649
82651
82652
82654
82656
82657
82658
82664
82666
82668
82670
82671
82672
82677
82679
82690
82693
82696
82705
82710
82715
82725
82726
82728
82731
82735
82742
82746
82747
82757
82759
82760
82775
82776
82784
82785
82787
82800
82803
82805
82810
82820
82926
82928
82938
82941
82943
82945
82946
82947

UNIT VALUE
0.45
0.76
0.95
0.95
1.42
0.51
0.43
0.67
0.67
1.27
0.79
0.69
1.03
1.19
0.80
0.89
0.92
0.64
0.55
0.87
0.19
0.62
0.63
0.49
0.67
0.50
2.37
0.68
0.73
0.54
0.64
0.64
0.79
0.41
0.78
0.31
0.34
0.61
0.30
0.31
0.71
1.05
0.32
0.37
0.20
0.24
0.65
0.65
0.53
0.14
0.56
0.14

CPT only copyright 2004 American Medical Association. All Rights Reserved.

60

CODE
82948
82950
82951
82952
82953
82955
82960
82962
82963
82965
82975
82977
82978
82979
82980
82985
83001
83002
83003
83008
83009
83010
83012
83013
83014
83015
83018
83020
83021
83026
83030
83033
83036
83045
83050
83051
83055
83060
83065
83068
83069
83070
83071
83080
83088
83090
83150
83491
83497
83498
83499
83500

UNIT VALUE
0.12
0.18
0.47
0.14
0.56
0.36
0.22
0.09
0.79
0.29
0.58
0.27
0.53
0.25
0.68
0.56
0.69
0.68
0.61
0.62
2.48
0.46
0.63
2.48
0.29
0.69
0.81
1.00
0.67
0.09
0.31
0.22
0.36
0.18
0.27
0.27
0.18
0.31
0.25
0.31
0.15
0.18
0.25
0.62
1.09
0.62
0.71
0.65
0.48
1.00
0.93
0.84

PATHOLOGY AND LABORATORY
(CONVERSION FACTOR = $75.10)
CODE
83505
83516
83518
83519
83520
83525
83527
83528
83540
83550
83570
83582
83586
83593
83605
83615
83625
83630
83632
83633
83634
83655
83661
83662
83663
83664
83670
83690
83715
83716
83718
83719
83721
83727
83735
83775
83785
83788
83789
83805
83825
83835
83840
83857
83858
83864
83866
83872
83873
83874
83880
83883

UNIT VALUE
0.90
0.43
0.31
0.50
0.48
0.42
0.48
0.59
0.24
0.32
0.33
0.52
0.47
0.97
0.39
0.22
0.47
0.43
0.75
0.20
0.42
0.45
0.81
0.70
0.70
0.70
0.34
0.25
0.42
0.92
0.30
0.43
0.35
0.63
0.25
0.27
0.91
0.67
0.67
0.65
0.60
0.62
0.60
0.40
0.55
0.73
0.36
0.22
0.63
0.48
1.25
0.50

CODE
83885
83887
83890
83891
83892
83893
83894
83896
83897
83898
83901
83902
83903
83904
83905
83906
83912
83915
83916
83918
83919
83921
83925
83930
83935
83937
83945
83950
83970
83986
83992
84022
84030
84035
84060
84061
84066
84075
84078
84080
84081
84085
84087
84100
84105
84106
84110
84119
84120
84126
84127
84132

UNIT VALUE
0.90
0.87
0.15
0.15
0.15
0.15
0.15
0.15
0.15
0.62
0.62
0.52
0.62
0.62
0.62
0.62
0.65
0.41
0.74
0.61
0.61
0.61
0.72
0.24
0.25
1.10
0.47
2.37
1.52
0.13
0.54
0.57
0.20
0.13
0.27
0.29
0.36
0.19
0.27
0.55
0.61
0.25
0.38
0.17
0.19
0.16
0.31
0.32
0.54
0.94
0.43
0.17

CPT only copyright 2004 American Medical Association. All Rights Reserved.

61

CODE
84133
84134
84135
84138
84140
84143
84144
84146
84150
84152
84153
84154
84155
84156
84157
84160
84163
84165
84166
84181
84182
84202
84203
84206
84207
84210
84220
84228
84233
84234
84235
84238
84244
84252
84255
84260
84270
84275
84285
84295
84300
84302
84305
84307
84311
84315
84375
84376
84377
84378
84379
84392

UNIT VALUE
0.16
0.54
0.71
0.70
0.76
0.84
0.77
0.71
0.92
0.68
0.68
0.68
0.14
0.14
0.14
0.19
0.55
0.92
1.18
1.15
1.21
0.53
0.32
0.66
1.04
0.40
0.35
0.43
2.37
2.39
1.93
1.35
0.81
0.75
0.94
1.14
0.80
0.50
0.87
0.18
0.18
0.18
0.78
0.67
0.26
0.09
0.72
0.20
0.20
0.42
0.42
0.18

PATHOLOGY AND LABORATORY
(CONVERSION FACTOR = $75.10)
CODE
84402
84403
84425
84430
84432
84436
84437
84439
84442
84443
84445
84446
84449
84450
84460
84466
84478
84479
84480
84481
84482
84484
84485
84488
84490
84510
84512
84520
84525
84540
84545
84550
84560
84577
84578
84580
84583
84585
84586
84588
84590
84591
84597
84600
84620
84630
84681
84702
84703
84830
84999
85002

UNIT VALUE
0.94
0.95
0.78
0.43
0.59
0.25
0.24
0.33
0.55
0.62
1.87
0.52
0.66
0.19
0.20
0.47
0.21
0.24
0.52
0.62
0.58
0.36
0.28
0.27
0.28
0.38
0.28
0.15
0.14
0.18
0.24
0.17
0.18
0.46
0.12
0.26
0.19
0.57
1.30
1.25
0.43
0.43
0.51
0.59
0.44
0.42
0.77
0.55
0.28
0.37
BR
0.17

CODE
85004
85007
85008
85009
85013
85014
85018
85025
85027
85032
85041
85044
85045
85046
85048
85049
85055
85060
85097
85130
85170
85175
85210
85220
85230
85240
85244
85245
85246
85247
85250
85260
85270
85280
85290
85291
85292
85293
85300
85301
85302
85303
85305
85306
85307
85335
85337
85345
85347
85348
85360
85362

UNIT VALUE
0.24
0.13
0.13
0.14
0.09
0.09
0.09
0.29
0.24
0.16
0.11
0.16
0.15
0.21
0.09
0.16
0.99
0.65
2.89
0.44
0.13
0.17
0.48
0.65
0.66
0.66
0.75
0.85
0.85
0.85
0.70
0.66
0.66
0.71
0.60
0.33
0.70
0.70
0.44
0.40
0.44
0.51
0.43
0.56
0.56
0.47
0.38
0.16
0.16
0.14
0.31
0.25

CPT only copyright 2004 American Medical Association. All Rights Reserved.

62

CODE
85366
85370
85378
85379
85380
85384
85385
85390
85396
85400
85410
85415
85420
85421
85441
85445
85460
85461
85475
85520
85525
85530
85536
85540
85547
85549
85555
85557
85576
85597
85610
85611
85612
85613
85635
85651
85652
85660
85670
85675
85705
85730
85732
85810
85999
86000
86001
86003
86005
86021
86022
86023

UNIT VALUE
0.32
0.42
0.26
0.38
0.38
0.31
0.31
0.70
0.57
0.33
0.28
0.63
0.24
0.38
0.16
0.25
0.29
0.24
0.33
0.48
0.44
0.52
0.24
0.32
0.32
0.69
0.25
0.49
1.33
0.66
0.14
0.15
0.35
0.35
0.36
0.13
0.10
0.20
0.21
0.25
0.35
0.22
0.24
0.43
BR
0.26
0.19
0.19
0.29
0.55
0.68
0.46

PATHOLOGY AND LABORATORY
(CONVERSION FACTOR = $75.10)
CODE
86038
86039
86060
86063
86064
86077
86078
86079
86140
86141
86146
86147
86148
86155
86156
86157
86160
86161
86162
86171
86185
86215
86225
86226
86235
86243
86255
86256
86277
86280
86294
86300
86301
86304
86308
86309
86310
86316
86317
86318
86320
86325
86327
86329
86331
86332
86334
86335
86336
86337
86340
86341

UNIT VALUE
0.45
0.41
0.27
0.21
1.39
1.37
1.44
1.42
0.19
0.48
0.94
0.94
0.59
0.59
0.25
0.30
0.44
0.44
0.75
0.37
0.33
0.49
0.51
0.45
0.66
0.76
0.97
0.97
0.58
0.30
0.72
0.77
0.77
0.77
0.19
0.24
0.27
0.77
0.55
0.48
1.36
1.33
1.46
0.52
0.44
0.90
1.35
1.60
0.57
0.79
0.56
0.73

CODE
86343
86344
86353
86359
86360
86361
86376
86378
86379
86382
86384
86403
86406
86430
86431
86485
86490
86510
86580
86585
86586
86587
86590
86592
86593
86602
86603
86606
86609
86611
86612
86615
86617
86618
86619
86622
86625
86628
86631
86632
86635
86638
86641
86644
86645
86648
86651
86652
86653
86654
86658
86663

UNIT VALUE
0.46
0.29
1.81
1.39
1.73
0.99
0.54
0.73
1.39
0.62
0.42
0.38
0.39
0.21
0.21
0.35
0.31
0.34
0.27
0.21
0.35
1.39
0.41
0.16
0.16
0.38
0.47
0.55
0.48
0.38
0.48
0.49
0.57
0.63
0.49
0.33
0.48
0.44
0.44
0.47
0.42
0.45
0.53
0.53
0.62
0.56
0.49
0.49
0.49
0.49
0.48
0.48

CPT only copyright 2004 American Medical Association. All Rights Reserved.

63

CODE
86664
86665
86666
86668
86671
86674
86677
86682
86684
86687
86688
86689
86692
86694
86695
86696
86698
86701
86702
86703
86704
86705
86706
86707
86708
86709
86710
86713
86717
86720
86723
86727
86729
86732
86735
86738
86741
86744
86747
86750
86753
86756
86757
86759
86762
86765
86768
86771
86774
86777
86778
86781

UNIT VALUE
0.56
0.67
0.38
0.38
0.45
0.54
0.54
0.48
0.58
0.31
0.52
0.71
0.63
0.53
0.49
0.71
0.46
0.33
0.50
0.51
0.44
0.43
0.40
0.43
0.46
0.42
0.50
0.56
0.45
0.49
0.49
0.47
0.44
0.49
0.48
0.49
0.49
0.49
0.55
0.49
0.46
0.48
0.71
0.49
0.53
0.48
0.49
0.49
0.55
0.53
0.53
0.49

PATHOLOGY AND LABORATORY
(CONVERSION FACTOR = $75.10)
CODE
86784
86787
86790
86793
86800
86803
86804
86805
86806
86807
86808
86812
86813
86816
86817
86821
86822
86849
86850
86860
86870
86880
86885
86886
86890
86891
86900
86901
86903
86904
86905
86906
86910
86911
86920
86921
86922
86927
86930
86931
86932
86940
86941
86945
86950
86965
86970
86971
86972
86975
86976
86977

UNIT VALUE
0.46
0.48
0.48
0.49
0.59
0.53
0.57
1.93
1.75
1.46
1.09
0.95
2.14
1.03
2.37
2.08
1.35
BR
0.46
0.46
0.81
0.20
0.21
0.19
1.84
2.88
0.11
0.23
0.35
0.35
0.14
0.29
0.51
0.39
0.51
0.46
0.28
0.25
2.30
2.53
2.76
0.30
0.45
0.69
1.27
0.32
0.37
0.37
0.35
0.23
0.18
0.23

CODE
86978
86985
86999
87001
87003
87015
87040
87045
87046
87070
87071
87073
87075
87076
87077
87081
87084
87086
87088
87101
87102
87103
87106
87107
87109
87110
87116
87118
87140
87143
87147
87149
87152
87158
87164
87166
87168
87169
87172
87176
87177
87181
87184
87185
87186
87187
87188
87190
87197
87205
87206
87207

UNIT VALUE
0.51
0.48
BR
0.49
0.62
0.25
0.38
0.35
0.35
0.32
0.35
0.35
0.35
0.30
0.30
0.24
0.32
0.30
0.30
0.28
0.31
0.33
0.38
0.38
0.57
0.72
0.40
0.40
0.21
0.46
0.19
0.74
0.19
0.19
0.90
0.42
0.16
0.16
0.16
0.22
0.33
0.18
0.25
0.18
0.32
0.38
0.24
0.21
0.55
0.16
0.20
0.76

CPT only copyright 2004 American Medical Association. All Rights Reserved.

64

CODE
87210
87220
87230
87250
87252
87253
87254
87255
87260
87265
87267
87269
87270
87271
87272
87273
87274
87275
87276
87277
87278
87279
87280
87281
87283
87285
87290
87299
87300
87301
87320
87324
87327
87328
87329
87332
87335
87336
87337
87338
87339
87340
87341
87350
87380
87385
87390
87391
87400
87420
87425
87427

UNIT VALUE
0.16
0.16
0.73
0.72
0.96
0.74
0.72
1.25
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.53
0.44
0.38
0.38
0.42
0.61
0.44
0.65
0.65
0.44
0.44
0.44
0.44

PATHOLOGY AND LABORATORY
(CONVERSION FACTOR = $75.10)
CODE
87430
87449
87450
87451
87470
87471
87472
87475
87476
87477
87480
87481
87482
87485
87486
87487
87490
87491
87492
87495
87496
87497
87510
87511
87512
87515
87516
87517
87520
87521
87522
87525
87526
87527
87528
87529
87530
87531
87532
87533
87534
87535
87536
87537
87538
87539
87540
87541
87542
87550
87551
87552

UNIT VALUE
0.44
0.44
0.35
0.35
0.74
1.29
1.58
0.74
1.29
1.58
0.74
1.29
1.54
0.74
1.29
1.58
0.74
1.29
1.29
0.74
1.29
1.58
0.74
1.29
1.54
0.74
1.29
1.58
0.74
1.29
1.58
0.74
1.29
1.54
0.74
1.29
1.58
0.74
1.29
1.54
0.74
1.29
3.14
0.74
1.29
1.58
0.74
1.29
1.54
0.74
1.29
1.58

CODE
87555
87556
87557
87560
87561
87562
87580
87581
87582
87590
87591
87592
87620
87621
87622
87650
87651
87652
87660
87797
87798
87799
87800
87801
87802
87803
87804
87807
87810
87850
87880
87899
87901
87902
87903
87904
87999
88000
88005
88007
88012
88014
88016
88020
88025
88027
88028
88029
88036
88037
88040
88045

UNIT VALUE
0.74
1.29
1.58
0.74
1.29
1.58
0.74
1.29
1.54
0.74
1.29
1.58
0.74
1.29
1.54
0.74
1.29
1.54
0.74
0.74
1.29
1.58
1.48
2.59
0.44
0.44
0.44
0.44
0.44
0.44
0.44
0.44
9.49
9.49
18.01
4.81
BR
5.95
6.61
7.27
5.48
5.48
6.66
8.54
9.20
9.86
5.48
5.48
3.54
2.60
14.16
1.18

CPT only copyright 2004 American Medical Association. All Rights Reserved.

65

CODE
88099
88104
88106
88107
88108
88112
88125
88130
88140
88141
88142
88143
88147
88148
88150
88152
88153
88154
88155
88160
88161
88162
88164
88165
88166
88167
88172
88173
88174
88175
88182
88184
88185
88187
88188
88189
88199
88230
88233
88235
88237
88239
88240
88241
88245
88248
88249
88261
88262
88263
88264
88267

UNIT VALUE
BR
1.45
1.95
2.35
1.81
3.19
0.53
0.55
0.29
0.59
0.75
0.75
0.42
0.56
0.39
0.39
0.39
0.39
0.22
1.37
1.48
1.83
0.39
0.39
0.39
0.39
1.37
3.60
0.79
0.98
2.82
1.34
0.66
1.82
2.27
2.99
BR
4.30
5.19
5.43
4.66
5.44
0.37
0.37
5.49
6.38
6.38
6.52
4.60
5.54
4.60
6.63

PATHOLOGY AND LABORATORY
(CONVERSION FACTOR = $75.10)
CODE
88269
88271
88272
88273
88274
88275
88280
88283
88285
88289
88291
88299
88300
88302
88304
88305
88307
88309
88311
88312
88313
88314
88318
88319
88321
88323
88325
88329
88331
88332
88342
88346
88347
88348
88349
88355
88356
88358
88360
88361
88362
88365
88367
88368
88371
88372
88380
88399
88400
89050
89051
89055

UNIT VALUE
6.13
0.79
0.99
1.18
1.28
1.48
0.93
2.53
0.70
1.27
0.71
BR
0.55
1.19
1.57
2.73
4.86
6.81
0.49
2.09
1.51
2.55
2.10
3.98
2.14
3.20
5.24
1.35
2.37
1.09
2.36
2.48
2.17
10.99
4.41
10.75
7.39
1.97
2.91
4.38
7.02
3.38
5.53
5.02
1.33
1.38
BR
BR
0.19
0.17
0.20
0.16

CODE
89060
89100
89105
89125
89130
89132
89135
89136
89140
89141
89160
89190
89220
89225
89230
89235
89240
89250
89251
89253
89254
89255
89257
89258
89259
89260
89261
89264
89268
89272
89280
89281
89290
89291
89300
89310
89320
89321
89325
89329
89330
89335
89342
89343
89344
89346
89352
89353
89354
89356

UNIT VALUE
0.80
2.46
2.74
0.16
2.21
1.75
2.72
1.95
3.06
3.67
0.14
0.18
0.41
0.12
0.13
0.20
BR
27.46
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
0.33
0.32
0.44
0.44
0.39
0.77
0.36
BR
BR
BR
BR
BR
BR
BR
BR
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

66

MEDICINE GROUND RULES
1.

GENERAL: Visits, examinations, consultations and similar services listed in this section reflect the
variation in time and skills required in the diagnosis and treatment of illness or injury. The stipulated Unit
Value applies only when the services are performed by or under the responsibility and direct supervision
of a health care provider, unless otherwise stated.

2.

UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the
procedure should be identified and the amount charged substantiated "by report" (BR). Unlisted service
or procedure codes usually end in "99."

3.

PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in the Unit Value
column indicates that the amount charged for this service is to be determined "by report" because the
service is too unusual or variable to be assigned a Unit Value. Pertinent information should be furnished
concerning the nature, extent, and need for the procedure or service, the time, skill, and equipment
necessary, etc.

4.

MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the
health care provider (e.g., sterile trays, drugs) over and above those usually included with the office visit
or other services rendered may be listed separately. The statement of charges will need to reflect any
drugs, trays, supplies, and materials that were provided. Payment shall not exceed the cost of the item(s)
to the health care provider plus 25%, or the cost of the item(s) plus $15.00 per item, whichever is less.
Use procedure code 99070.

5.

SEPARATE PROCEDURES: Some of the procedures or services listed are commonly carried out as an
integral part of a total service and identified by the inclusion of the term “separate procedure.” The codes
designated as “separate procedure” should not be reported in addition to the code for the total procedure
or service of which it is considered an integral component.
However, when a procedure or service that is designated as a “separate procedure” is carried out
independently or considered to be unrelated or distinct from other procedures/services at that time, it may
be reported by itself, or in addition to other procedures/services by appending modifier -59 to the specific
“separate procedure” code to indicate that the procedure is not considered to be a component of another
procedure, but is a distinct, independent procedure. This may represent a different session or patient
encounter, different procedure or surgery, different site or organ system, separate incision/excision,
separate lesion, or separate injury (or area of injury in extensive injuries).

6.

MULTIPLE PROCEDURES: It is appropriate to designate multiple procedures that are rendered on the
same day by separate entries. Use modifier -51 to reflect multiple procedures except for the Add-On
Codes.

7.

ADD-ON CODES: Certain codes, by the nature of their description and the unit values assigned, have
already been reduced, as they are not to be billed as primary procedures. For a complete list of the
codes which are considered to be add-on codes, refer to the appropriate appendix found within the most
recent publication of the AMA Current Procedural Terminology (CPT).

8.

CODES THAT ARE NOT CLASSIFIED AS ADD-ON CODES BUT ARE EXEMPT FROM THE
MULTIPLE PROCEDURE RULE / MODIFIER -51: For a complete list of the codes which fall within this
category, refer to the appropriate appendix found within the most recent publication of the AMA Current
Procedural Terminology (CPT).

9.

CONCURRENT CARE: When the condition of the patient requires the skills of two or more health care
providers to treat different conditions, payment is due each health care provider who plays an active role
in the treatment program. The services rendered by each health care provider shall be distinct,
identifiable, and adequately documented in the records and reports.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

67

MEDICINE GROUND RULES
10.

ALTERNATING HEALTH CARE PROVIDERS: When health care providers of similar skills alternate in
the care of a patient (e.g., partners, groups of same facility, covering providers on weekends or vacation
periods), each health care provider shall charge individually for the services personally rendered and
such charges shall be in accordance with this Fee Schedule.

11.

PRORATION OF SCHEDULED FEE: Where the schedule specifies a unit value for a definite treatment,
and the patient is transferred from one health care provider to another, the unit value multiplied by the
conversion factor or the usual and customary charge, whichever is less, should be apportioned between
or among the providers. The providers involved shall agree upon the amount of proration, and shall
render separate bills accordingly, with an explanatory note.

12.

MISCELLANEOUS: The Unit Values for other diagnostic therapeutics, anesthesia, surgery, x-rays, and
laboratory procedures are listed in the following sections: Anesthesia, Surgery, Radiology, Pathology and
Laboratory, Medicine, and Evaluation and Management.

13.

CONSULTATIONS AND REFERRALS: A consultation is a service rendered by a specialist at the
request of the attending health care provider or other appropriate source seeking further evaluation or an
opinion on how to proceed in the management of a patient's illness. Consultations always require a
narrative report from the consultant to the attending health care provider requesting the opinion. The fee
payable should correspond appropriately to the level of service. When the consulting specialist assumes
responsibility for the continuing care of the patient, any service rendered subsequent to the consultation
will be reimbursed according to the actual level of service rendered, as listed under the appropriate
subsection headings (e.g., office or hospital visits).
A referral is the transfer of a patient to a specialist for diagnosis, and where necessary, treatment of a
specific illness or injury, rather than for advice. A referral will be reimbursed according to the actual level
of services rendered, as listed under the appropriate subsection headings (e.g., office or hospital visits).

14.

LIMITATIONS ON PATIENT VISITS FOR PSYCHOTHERAPY OR PSYCHOLOGICAL COUNSELING:
Psychotherapy or Psychological counseling, for work-related conditions requiring either more than 21
visits or continuing for more than 3 months after initiation of therapy, whichever comes first, requires prior
authorization from the employer, insurance carrier, the Workers Compensation Fund, or the Kansas
Division of Workers Compensation, unless such authorization was previously received for a greater
number of visits.

15.

PROFESSIONAL/TECHNICAL COMPONENTS: When the professional and technical components are
furnished by different providers (inclusive of hospitals and ambulatory surgical centers), the
professional component and the technical component shall be identified by adding either modifier -26 or
modifier -TC to the usual procedure number. If any of the medical procedures in this section become
subject to either the professional or technical component, the unit value for the professional component is
60% of the total unit value, and the unit value for the technical component is 40% of the total unit value for
the procedure code submitted. See Appendix A- Modifiers for a listing of the modifiers.
Additionally, and with the exception of Pathology and Laboratory, hospitals and ambulatory surgical
centers will continue to be reimbursed at their usual and customary charge less the specified discount as
contained within the Hospital/Ambulatory Surgical Center Section of the fee schedule. However,
hospitals and ambulatory surgical centers need to amend their billing process to specify, by use of
modifiers, when only the technical component or the professional component was provided.

16.

FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT: In the event a patient fails to keep
a scheduled appointment, the health care provider is not to bill for any services that would have been
provided by said appointment nor shall there be any reimbursement for such scheduled services (i.e.,
reimbursement for a "no show" appointment is not allowed). This rule does not apply with regard to a
deposition, testimony, or IME.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

68

MEDICINE GROUND RULES
17.

MODIFIERS: Procedure codes for medicine services may be modified under certain circumstances. The
circumstances are to be identified by the addition of a hyphen and the appropriate two-digit modifier code.
Refer to Appendix A - Modifiers for a list of modifiers that may be used.

18.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A. 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $52.42
CPT only copyright 2004 American Medical Association. All Rights Reserved.

69

MEDICINE
(CONVERSION FACTOR = $52.42)
CODE
90281
90283
90287
90288
90291
90296
90371
90375
90376
90378
90379
90384
90385
90386
90389
90393
90396
90399
90465
90466
90467
90468
90471
90472
90473
90474
90476
90477
90581
90585
90586
90632
90633
90634
90636
90645
90646
90647
90648
90655
90656
90657
90658
90660
90665
90669
90675
90676
90680
90690
90691
90692

UNIT VALUE
BR
BR
BR
BR
BR
BR
BR
3.35
2.80
BR
BR
2.43
1.47
BR
3.28
BR
BR
BR
0.49
0.29
0.51
0.51
0.49
0.29
0.44
0.44
BR
BR
2.84
4.58
4.79
1.81
0.84
0.84
2.00
0.75
BR
0.67
0.68
0.32
0.32
0.23
0.23
BR
BR
1.57
4.13
BR
BR
0.87
1.21
BR

CODE
90693
90698
90700
90701
90702
90703
90704
90705
90706
90707
90708
90710
90712
90713
90715
90716
90717
90718
90719
90720
90721
90723
90725
90727
90732
90733
90734
90735
90740
90743
90744
90746
90747
90748
90749
90780
90781
90782
90783
90784
90788
90799
90801
90802
90804
90805
90806
90807
90808
90809
90810
90811

UNIT VALUE
BR
BR
0.60
BR
0.28
0.31
0.50
0.41
0.44
0.98
BR
BR
BR
0.78
BR
1.82
1.85
0.28
BR
1.06
1.39
1.78
BR
BR
0.38
2.04
BR
2.02
5.67
0.80
0.80
1.81
5.67
1.46
BR
2.39
0.67
0.50
0.50
1.01
0.44
BR
4.04
4.29
1.73
1.90
2.61
2.77
3.89
4.03
1.87
2.09

CPT only copyright 2004 American Medical Association. All Rights Reserved.

70

CODE
90812
90813
90814
90815
90816
90817
90818
90819
90821
90822
90823
90824
90826
90827
90828
90829
90845
90846
90847
90849
90853
90857
90862
90865
90870
90871
90875
90876
90880
90882
90885
90887
90889
90899
90901
90911
90918
90919
90920
90921
90922
90923
90924
90925
90935
90937
90939
90940
90945
90947
90989
90993

UNIT VALUE
2.81
2.95
4.07
4.19
1.74
1.91
2.63
2.75
3.91
4.02
1.87
2.05
2.78
2.89
4.07
4.16
2.41
2.53
3.08
0.88
0.86
0.94
1.37
4.31
3.86
3.86
2.14
3.11
3.29
2.35
1.36
2.34
2.03
BR
1.08
2.50
17.63
12.82
11.24
7.04
0.59
0.42
0.37
0.24
1.93
3.15
2.14
2.14
2.01
3.22
13.94
2.35

MEDICINE
(CONVERSION FACTOR = $52.42)
CODE
90997
90999
91000
91010
91011
91012
91020
91030
91034
91035
91037
91038
91040
91052
91055
91060
91065
91100
91105
91110
91120
91122
91123
91132
91133
91299
92002
92004
92012
92014
92015
92018
92019
92020
92060
92065
92070
92081
92082
92083
92100
92120
92130
92135
92136
92140
92225
92226
92230
92235
92240
92250

UNIT VALUE
2.56
BR
1.10
5.78
6.86
7.35
6.09
3.40
6.33
12.51
4.02
3.44
12.22
3.30
3.95
2.46
1.69
3.94
2.50
25.98
12.06
7.07
BR
1.12
1.41
BR
1.87
3.41
1.72
2.54
1.88
3.64
1.90
0.72
1.45
0.92
1.79
1.32
1.69
1.95
2.29
1.90
2.11
1.16
2.27
1.50
0.61
0.55
2.15
3.50
7.29
1.99

CODE
92260
92265
92270
92275
92283
92284
92285
92286
92287
92310
92311
92312
92313
92314
92315
92316
92317
92325
92326
92330
92335
92340
92341
92342
92352
92353
92354
92355
92358
92370
92371
92390
92391
92392
92393
92395
92396
92499
92502
92504
92506
92507
92508
92510
92511
92512
92516
92520
92526
92531
92532
92533

UNIT VALUE
0.47
2.36
2.39
3.00
1.03
2.14
1.21
3.75
3.21
2.33
2.20
2.37
2.00
1.64
1.31
1.61
1.40
0.41
1.69
2.10
1.36
1.08
1.22
1.30
1.06
1.25
8.96
4.34
1.02
0.89
0.64
BR
BR
3.81
12.33
1.38
2.23
BR
2.67
0.69
3.48
1.65
0.78
3.65
4.18
1.71
1.64
1.30
2.21
0.62
0.72
1.14

CPT only copyright 2004 American Medical Association. All Rights Reserved.

71

CODE
92534
92541
92542
92543
92544
92545
92546
92547
92548
92551
92552
92553
92555
92556
92557
92559
92560
92561
92562
92563
92564
92565
92567
92568
92569
92571
92572
92573
92575
92576
92577
92579
92582
92583
92584
92585
92586
92587
92588
92590
92591
92592
92593
92594
92595
92596
92597
92601
92602
92603
92604
92605

UNIT VALUE
0.50
1.47
1.50
0.69
1.19
1.06
2.30
0.14
2.90
0.29
0.48
0.72
0.42
0.63
1.31
0.94
0.55
0.78
0.45
0.42
0.52
0.44
0.58
0.42
0.45
0.43
0.10
0.39
0.32
0.49
0.79
0.79
0.79
0.97
2.68
2.73
1.99
1.62
2.13
1.12
1.68
0.49
0.74
0.54
0.81
0.65
2.58
3.57
2.45
2.21
1.42
BR

MEDICINE
(CONVERSION FACTOR = $52.42)
CODE
92606
92607
92608
92609
92610
92611
92612
92613
92614
92615
92616
92617
92620
92621
92625
92700
92950
92953
92960
92961
92970
92971
92973
92974
92975
92977
92978
92979
92980
92981
92982
92984
92986
92987
92990
92992
92993
92995
92996
92997
92998
93000
93005
93010
93012
93014
93015
93016
93017
93018
93024
93025

UNIT VALUE
BR
3.13
0.60
1.63
3.51
3.51
4.05
1.16
3.81
1.03
5.33
1.28
1.20
0.31
1.18
BR
8.25
0.32
8.64
6.96
4.76
2.68
4.80
4.39
10.28
8.51
7.37
4.48
21.35
5.92
15.84
4.22
34.30
35.60
27.89
31.02
21.74
17.42
4.63
17.26
8.47
0.71
0.47
0.24
6.19
0.73
2.85
0.64
1.79
0.42
2.87
8.48

CODE
93040
93041
93042
93224
93225
93226
93227
93230
93231
93232
93233
93235
93236
93237
93268
93270
93271
93272
93278
93303
93304
93307
93308
93312
93313
93314
93315
93316
93317
93318
93320
93321
93325
93350
93501
93503
93505
93508
93510
93511
93514
93524
93526
93527
93528
93529
93530
93531
93532
93533
93539
93540

UNIT VALUE
0.38
0.16
0.22
4.37
1.32
2.32
0.73
4.67
1.63
2.31
0.73
3.39
2.76
0.63
8.24
1.32
6.19
0.73
1.62
5.91
3.13
5.39
2.82
7.14
1.22
5.84
8.67
1.24
6.45
6.27
2.37
1.41
3.22
3.99
22.33
3.79
8.51
19.70
46.04
46.01
48.85
60.52
60.51
61.01
63.57
57.32
24.39
63.81
64.86
59.87
0.57
0.61

CPT only copyright 2004 American Medical Association. All Rights Reserved.

72

CODE
93541
93542
93543
93544
93545
93555
93556
93561
93562
93571
93572
93580
93581
93600
93602
93603
93609
93610
93612
93613
93615
93616
93618
93619
93620
93621
93622
93623
93624
93631
93640
93641
93642
93650
93651
93652
93660
93662
93668
93701
93720
93721
93722
93724
93727
93731
93732
93733
93734
93735
93736
93740

UNIT VALUE
0.41
0.41
0.41
0.36
0.57
7.77
11.58
1.27
0.58
7.34
4.41
26.60
35.47
5.19
4.29
4.90
10.18
5.88
6.15
10.23
1.63
2.35
10.26
18.90
30.53
5.44
8.02
7.37
9.25
18.00
12.58
16.02
14.84
15.65
23.67
25.75
4.39
7.27
1.40
1.17
1.00
0.77
0.23
11.15
0.74
1.17
1.85
1.04
0.91
1.53
0.91
0.37

MEDICINE
(CONVERSION FACTOR = $52.42)
CODE
93741
93742
93743
93744
93745
93760
93762
93770
93784
93786
93788
93790
93797
93798
93799
93875
93880
93882
93886
93888
93890
93892
93893
93922
93923
93924
93925
93926
93930
93931
93965
93970
93971
93975
93976
93978
93979
93980
93981
93990
94010
94014
94015
94016
94060
94070
94150
94200
94240
94250
94260
94350

UNIT VALUE
1.85
2.01
2.24
2.39
BR
1.66
2.44
0.26
1.96
0.92
0.52
0.52
0.49
0.75
BR
2.67
6.54
4.16
8.13
5.18
6.35
6.76
6.63
3.08
4.74
5.59
7.75
4.71
6.22
4.06
3.28
6.38
4.34
9.99
5.90
5.59
3.92
4.52
3.64
4.50
0.87
1.31
0.60
0.71
1.45
1.55
0.56
0.58
0.98
0.77
0.76
1.07

CODE
94360
94370
94375
94400
94450
94452
94453
94620
94621
94640
94642
94656
94657
94660
94662
94664
94667
94668
94680
94681
94690
94720
94725
94750
94760
94761
94762
94770
94772
94799
95004
95010
95015
95024
95027
95028
95044
95052
95056
95060
95065
95070
95071
95075
95078
95115
95117
95120
95125
95130
95131
95132

UNIT VALUE
1.03
1.01
0.94
1.33
1.29
1.37
1.95
3.26
3.78
0.32
1.58
2.45
1.85
1.45
1.02
0.35
0.57
0.47
2.19
2.85
2.11
1.33
3.30
1.62
0.06
0.13
0.57
0.98
BR
BR
0.11
0.48
0.30
0.16
0.16
0.24
0.21
0.26
0.18
0.37
0.21
2.30
2.94
1.80
0.27
0.41
0.52
0.51
0.63
0.88
1.12
1.35

CPT only copyright 2004 American Medical Association. All Rights Reserved.

73

CODE
95133
95134
95144
95145
95146
95147
95148
95149
95165
95170
95180
95199
95250
95805
95806
95807
95808
95810
95811
95812
95813
95816
95819
95822
95824
95827
95829
95830
95831
95832
95833
95834
95851
95852
95857
95858
95860
95861
95863
95864
95867
95868
95869
95870
95872
95875
95900
95903
95904
95920
95921
95922

UNIT VALUE
1.63
1.95
0.26
0.39
0.51
0.49
0.65
0.87
0.26
0.20
4.09
BR
4.11
19.57
5.37
14.01
16.39
21.60
23.59
5.28
6.96
4.95
4.22
5.87
2.72
3.97
37.70
5.10
0.75
0.64
1.07
1.26
0.53
0.38
1.15
2.75
2.45
3.09
3.76
4.86
1.79
2.50
0.78
0.78
2.86
2.66
1.72
1.84
1.47
4.58
1.67
1.81

MEDICINE
(CONVERSION FACTOR = $52.42)
CODE
95923
95925
95926
95927
95928
95929
95930
95933
95934
95936
95937
95950
95951
95953
95954
95955
95956
95957
95958
95961
95962
95965
95966
95967
95970
95971
95972
95973
95974
95975
95978
95979
95990
95991
95999
96000
96001
96002
96003
96004
96100
96105
96110
96111
96115
96117
96150
96151
96152
96153
96154
96155

UNIT VALUE
2.91
1.77
1.77
1.79
4.61
4.80
2.62
1.71
0.98
1.05
1.35
5.95
22.18
11.30
6.86
3.56
19.08
4.76
8.09
6.14
6.30
59.30
29.45
24.10
1.33
1.53
2.85
1.61
4.87
2.71
5.61
2.59
1.56
2.29
BR
2.44
2.91
0.58
0.51
3.19
1.94
1.94
0.36
3.83
1.94
1.94
0.69
0.67
0.64
0.15
0.63
0.64

CODE
96400
96405
96406
96408
96410
96412
96414
96420
96422
96423
96425
96440
96445
96450
96520
96530
96542
96545
96549
96567
96570
96571
96900
96902
96910
96912
96913
96920
96921
96922
96999

UNIT VALUE
1.30
2.85
3.84
3.14
4.41
0.98
5.47
2.90
5.08
2.07
4.72
10.46
10.37
8.92
4.03
2.91
5.72
BR
BR
1.00
1.58
0.77
0.46
0.60
1.03
1.31
1.78
3.71
3.80
5.63
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

74

PHYSICAL MEDICINE AND REHABILITATION
GROUND RULES
1.

AUTHORIZED PROVIDERS: Services applicable to this section are payable at the level of the Unit Value (or
the usual and customary charge, whichever is less) when provided by: a health care provider as defined by
K.S.A. 44-508; a Registered Physical Therapist; a Registered Occupational Therapist; a Certified Physical
Therapist Assistant or a Certified Occupational Therapist Assistant when the service is performed under the
direct supervision of a Registered Physical Therapist or Registered Occupational Therapist; an Exercise
Physiologist; and any type of an Assistant when the service is performed under the direct supervision of a
health care provider, Registered Physical Therapist, or a Registered Occupational Therapist.

2.

CONCURRENT EVALUATION AND MANAGEMENT SERVICES: When evaluation and management
services have also been provided, it is acceptable to charge separately for these services only if the patient’s
condition required an evaluation or examination that is beyond the usual preservice and postservice work
associated with physical medicine and rehabilitation services. Such additional services, however, shall be
reported separately using modifier -25. These services must also be performed or supervised by a health
care provider as defined by K.S.A. 44-508, a Registered Physical Therapist, or a Registered Occupational
Therapist. Charges for any evaluations or examinations after the initial visit must be documented and
included with the bill.

3.

DOCUMENTATION OF TREATMENT REQUIRED: Documentation of treatment shall include evaluation,
diagnosis, progress notes, prognosis, treatment plan, and need for further therapy. This documentation will
be made part of the patient's record and be made available upon request. This documentation does not
warrant a separate fee.

4.

WRITTEN REFERRAL: A written referral by a health care provider, as defined by K.S.A. 44-508, is required
for services to be provided by a physical or occupational therapist, exercise physiologist, or their assistants.

5.

SEPARATE BILLING: Employed physical or occupational therapists may not bill separately for services
provided. This does not apply to physical or occupational therapists who are self-employed.

6.

DISPUTE RESOLUTION: In the event a controversy arises between the provider and the payer about the
number of modalities or therapeutic procedures that were provided at each visit, an attempt should be made
by the involved parties to resolve said issue(s). Issues which cannot satisfactorily be resolved should then be
referred to the Kansas Division of Workers Compensation for review.

7.

MAXIMUM NUMBER OF VISITS: Treatment beyond 21 visits must be authorized by the employer, the
insurance carrier, the Workers Compensation Fund, or the Kansas Division of Workers Compensation, unless
prior authorization was received for a greater number of visits.

8.

FOLLOW-UP OR AFTERCARE: Fees for any follow-up or aftercare for fractures, dislocations, or
postoperative procedures provided by physical or occupational therapists shall be in addition to those payable
to the referring health care provider.

9.

HOME SERVICES: When an authorized provider renders treatment in a patient's home, the Unit Value may
be increased by 50%. An explanation substantiating the need for home therapy shall be submitted along with
the bill.

10. UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the
procedure should be identified and the amount charged substantiated "by report" (BR). Unlisted service or
procedure codes usually end in "99."

CPT only copyright 2004 American Medical Association. All Rights Reserved.

75

PHYSICAL MEDICINE AND REHABILITATION
GROUND RULES
11. PROCEDURES LISTED WITHOUT A SPECIFIED UNIT VALUE: "BR" in the Unit Value column indicates
that the amount charged for this service is to be determined "by report" because the service is too unusual or
variable to be assigned a Unit Value. Pertinent information should be furnished concerning the nature,
extent, and need for the procedure or service, the time, skill, and equipment necessary, etc.
12. SEPARATE PROCEDURES: Some procedures are commonly carried out as an integral part of a total
service, and do not warrant a separate identification. When such a procedure is performed independently of
other services to which the procedure is not immediately related, the Unit Value for the "separate procedure"
listing, where identified as such in the Schedule, is applicable (i.e., when a procedure which is ordinarily a
component of a larger procedure is performed alone for a specific purpose, the component procedure may be
considered to be a separate procedure).
13. CONCURRENT CARE: When the condition of the patient requires the skills of two or more health care
providers to treat different conditions, payment is due each health care provider who plays an active role in
the treatment program. The services rendered by each health care provider shall be distinct, identifiable, and
adequately documented in the records and reports.
14. ALTERNATING HEALTH CARE PROVIDERS: When health care providers of similar skills alternate in the
care of a patient (e.g., partners, groups of same facility, covering providers on weekends or vacation periods),
each health care provider shall charge individually for the services personally rendered and such charges
shall be in accordance with this Fee Schedule.
15. PRORATION OF UNIT VALUE: Where the schedule specifies a unit value for a definite treatment, and the
patient is transferred from one health care provider to another, the Unit Value stated in the Schedule or the
usual and customary charge, whichever is less, should be apportioned between or among the providers. The
providers involved shall agree upon the amount of proration, and shall render separate bills accordingly, with
an explanatory note.
16. ADD-ON CODES: Certain codes, by the nature of their description and the unit values assigned, have
already been reduced, as they are not to be billed as primary procedures. For a complete list of the codes
which are considered to be add-on codes, refer to the appropriate appendix found within the most recent
publication of the AMA Current Procedural Terminology (CPT).
17. MISCELLANEOUS: The Unit Values for other diagnostic therapeutics, anesthesia, surgery, x-rays, and
laboratory procedures are listed in the following sections: Anesthesia, Surgery, Radiology, Pathology and
Laboratory, Medicine, and Evaluation and Management. Physical or occupational therapists may utilize these
other sections for billing if the coding is more appropriate, and the service provided was medically necessary
and prescribed by a physician.
18. CONSULTATIONS AND REFERRALS: A consultation is a service rendered by a specialist at the request
of the attending health care provider or other appropriate source seeking further evaluation or an opinion on
how to proceed in the management of a patient's illness. Consultations always require a narrative report from
the consultant to the attending health care provider requesting the opinion. The fee payable should
correspond appropriately to the level of service. When the consulting specialist assumes responsibility for the
continuing care of the patient, any service rendered subsequent to the consultation will be reimbursed
according to the actual level of service rendered, as listed under the appropriate subsection headings (e.g.,
office or hospital visits).
A referral is the transfer of a patient to a specialist for diagnosis, and where necessary, treatment of a
specific illness or injury, rather than for advice. A referral will be reimbursed according to the actual level of
services rendered, as listed under the appropriate subsection headings (e.g., office or hospital visits).

CPT only copyright 2004 American Medical Association. All Rights Reserved.

76

PHYSICAL MEDICINE AND REHABILITATION
GROUND RULES
19. FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT: In the event a patient fails to keep a
scheduled appointment, the health care provider is not to bill for any services that would have been provided
by said appointment nor shall there be any reimbursement for such scheduled services (i.e., reimbursement
for a “no show” appointment is not allowed). This rule does not apply with regard to a deposition, testimony,
or IME.
20. MODIFIERS: Appendix A - Modifiers of this Schedule includes all of the modifiers applicable to the current
CPT codes.
21. COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care costs.
Such payment agreements, if less, will supersede the limitation amounts specified herein. Please refer to
K.S.A 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $43.80
CPT only copyright 2004 American Medical Association. All Rights Reserved.

77

PHYSICAL MEDICINE AND
REHABILITATION
(CONVERSION FACTOR = $43.80)
CODE
97001
97002
97003
97004
97005
97006
97010
97012
97014
97016
97018
97020
97022
97024
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97139
97140
97150
97504
97520
97530
97532
97533
97535
97537
97542
97545
97546
97597
97598
97602
97605
97606
97703
97750
97755
97799

UNIT VALUE
2.00
1.06
2.14
1.29
1.62
0.81
0.12
0.39
0.38
0.37
0.17
0.13
0.39
0.14
0.13
0.16
0.42
0.54
0.37
0.32
0.61
0.31
0.74
0.78
0.85
0.65
0.59
0.42
0.70
0.46
0.81
0.74
0.78
0.65
0.69
0.79
0.72
0.74
3.22
1.29
1.29
1.64
0.47
BR
BR
0.68
0.79
0.92
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

78

MEDICAL NUTRITION THERAPY
GROUND RULES
1.

GENERAL: Medical Nutrition Therapy includes services ordered by, or under the direct supervision of a
designated health care provider.

2.

CONCURRENT EVALUATION AND MANAGEMENT SERVICES: When evaluation and management
services have concurrently been provided in association with medical nutrition therapy, it is acceptable to
charge separately for these services only if the patient's condition required an evaluation or examination
that is beyond the usual preservice and postservice work associated with any medical nutrition therapy.
Such additional services, however, shall be reported separately using modifier -25. Charges for
any evaluations and examinations after the initial visit must be documented and included with the bill.

3.

EXTENSION OF OTHER SECTIONS OF THE FEE SCHEDULE: Since medical nutrition therapy is
incorporated within the broad category of the Medicine and Physical Medicine Guidelines, the Ground
Rules found within the Medicine and the Physical Medicine and Rehabilitation Section of the fee
schedule shall be similarly applied.

4.

FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT: In the event a patient fails to keep a
scheduled appointment, the health care provider is not to bill for any services that would have been
provided by said appointment nor shall there be any reimbursement for such scheduled services (i.e.,
reimbursement for a “no show” appointment is not allowed). This rule does not apply with regard to a
deposition, testimony, or IME.

5.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A. 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $41.19
CPT only copyright 2004 American Medical Association. All Rights Reserved.

79

MEDICAL NUTRITION THERAPY
(CONVERSION FACTOR = $41.19)

CODE
97802
97803
97804

UNIT VALUE
0.48
0.48
0.19

CPT only copyright 2004 American Medical Association. All Rights Reserved.

80

ACUPUNCTURE
GROUND RULES
1.

GENERAL: Acupuncture includes services ordered by, or under the direct supervision of a designated
health care provider.

2.

CONCURRENT EVALUATION AND MANAGEMENT SERVICES: When evaluation and management
services have concurrently been provided in association with acupuncture services, it is acceptable to
charge separately for these services only if the patient's condition required an evaluation or examination
that is beyond the usual preservice and postservice work associated with any acupuncture services.
Such additional services, however, shall be reported separately using modifier -25. Charges for
any evaluations and examinations after the initial visit must be documented and included with the bill.

3.

EXTENSION OF OTHER SECTIONS OF THE FEE SCHEDULE: Since acupuncture services are
incorporated within the broad category of the Medicine and Physical Medicine Guidelines, the Ground
Rules found within the Medicine and the Physical Medicine and Rehabilitation Section of the fee schedule
shall be similarly applied.

4.

FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT: In the event a patient fails to keep a
scheduled appointment, the health care provider is not to bill for any services that would have been
provided by said appointment nor shall there be any reimbursement for such scheduled services (i.e.,
reimbursement for a “no show” appointment is not allowed). This rule does not apply with regard to a
deposition, testimony, or IME.

5.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A. 44- 510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $41.19

CPT only copyright 2004 American Medical Association. All Rights Reserved.

81

ACUPUNCTURE
(CONVERSION FACTOR = $41.19)

CODE
97810
97811
97813
97814

UNIT VALUE
0.63
0.53
0.68
0.58

CPT only copyright 2004 American Medical Association. All Rights Reserved.

82

OSTEOPATHIC MANIPULATIVE TREATMENT
GROUND RULES
1.

GENERAL: Osteopathic manipulative treatment is a form of manual treatment applied by a physician to
eliminate or alleviate somatic dysfunction and related disorders, and may be accomplished by a variety of
techniques.

2.

CONCURRENT EVALUATION AND MANAGEMENT SERVICES: When evaluation and management
services have concurrently been provided in association with osteopathic manipulative treatment, it is
acceptable to charge separately for these services only if the patient's condition required an evaluation or
examination that is beyond the usual preservice and postservice work associated with osteopathic
manipulative treatment. Such additional services, however, shall be reported separately using
modifier -25. Charges for any evaluations and examinations after the initial visit must be documented
and included with the bill.

3.

EXTENSION OF OTHER SECTIONS OF THE FEE SCHEDULE: Since osteopathic manipulative
treatment is similar to treatments and services contained within the Physical Medicine and Rehabilitation
Section, the Ground Rules applicable to the Physical Medicine and Rehabilitation Section shall be
similarly applied.

4.

BODY REGIONS: Body regions commonly involved in osteopathic manipulative treatment are: head
region; cervical region; thoracic region; lumbar region; sacral region; pelvic region; lower extremities;
upper extremities; rib cage region; and abdominal and visceral region.

5.

FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT: In the event a patient fails to keep a
scheduled appointment, the health care provider is not to bill for any services that would have been
provided by said appointment nor shall there be any reimbursement for such scheduled services (i.e.,
reimbursement for a “no show” appointment is not allowed). This rule does not apply with regard to a
deposition, testimony, or IME.

6.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $54.43
CPT only copyright 2004 American Medical Association. All Rights Reserved.

83

OSTEOPATHIC MANIPULATIVE TREATMENT
(CONVERSION FACTOR = $54.43)

CODE
98925
98926
98927
98928
98929

UNIT VALUE
0.79
1.09
1.40
1.66
1.91

CPT only copyright 2004 American Medical Association. All Rights Reserved.

84

CHIROPRACTIC MANIPULATIVE TREATMENT
GROUND RULES
1.

GENERAL: Chiropractic manipulative treatment is a form of manual treatment applied by a physician to
influence joint and neurophysiological function, and may be accomplished by a variety of techniques.

2.

CONCURRENT EVALUATION AND MANAGEMENT SERVICES: When evaluation and management
services have concurrently been provided in association with chiropractic manipulative treatment, it is
acceptable to charge for these services only if the patient's condition required a significant separately
identifiable evaluation or examination that is beyond the usual preservice and postservice work
associated with chiropractic manipulative treatment. Such additional services, however, shall be
reported separately using modifier -25. Charges for any evaluations and examinations after the initial
visit must be documented and included with the bill.

3.

EXTENSION OF OTHER SECTIONS OF THE FEE SCHEDULE: Since chiropractic manipulative
treatment is similar to treatments and services contained within the Physical Medicine and Rehabilitation
Section, the Ground Rules applicable to the Physical Medicine and Rehabilitation Section shall be
similarly applied.

4.

BODY REGIONS: Body regions commonly involved in chiropractic manipulative treatment are: cervical
region (includes atlanto-occipital joint); thoracic region (includes costo-vertebral and costotransverse
joints); lumbar region; sacral region; and pelvic (sacro-iliac joint) region. The five extraspinal regions
referred to are:
head (including temporomandibular joint, excluding atlanto-occipital) region; lower
extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints) and
abdomen.

5.

FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT: In the event a patient fails to keep a
scheduled appointment, the health care provider is not to bill for any services that would have been
provided by said appointment nor shall there be any reimbursement for such scheduled services (i.e.,
reimbursement for a “no show” appointment is not allowed). This rule does not apply with regard to a
deposition, testimony, or IME.

6.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A. 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $50.75

CPT only copyright 2004 American Medical Association. All Rights Reserved.

85

CHIROPRACTIC MANIPULATIVE TREATMENT
(CONVERSION FACTOR = $50.75)

CODE
98940
98941
98942
98943

UNIT VALUE
0.69
0.97
1.25
0.65

CPT only copyright 2004 American Medical Association. All Rights Reserved.

86

SPECIAL SERVICES AND REPORTS
(CONVERSION FACTOR = $42.35)

CODE
99000
99001
99002
99024
99026
99027
99050
99052
99054
99056
99058
99070
99071
99075
99078
99080
99082
99090
99091

UNIT VALUE
0.18
0.20
0.28
BR
BR
BR
0.53
0.53
0.53
0.70
0.72
BR
*
**
BR
BR
BR
BR
BR

CODE
99100
99116
99135
99140
99141
99142
99170
99172
99173
99175
99183
99185
99186
99190
99191
99192
99195
99199

UNIT VALUE
#
#
#
#
2.72
1.59
3.59
0.65
0.31
1.49
5.74
0.68
2.23
14.18
10.63
7.09
0.46
BR

* The maximum fee for this code (99071) is to be determined "by report" (BR); however, when the
charge for any item exceeds $7.00, documentation of cost to the provider for such an item must
be attached to the bill when submitted for payment. Payment shall not exceed the cost of the
item to the health care provider plus 25%.
** For this code (99075), see separate section referenced "Depositions, Testimony, and Medical
Records Reproduction Section."
# See the Anesthesia Section for an explanation of the services contemplated by these codes
(99100, 99116, 99135, and 99140) as well as the Unit Values associated therewith. Note also
that these codes are considered Add-On codes and are not to be billed as primary procedures.
Thus, the services for these codes are to be reimbursed at the listed Unit Value when billed with
other procedures and are exempt from the Multiple Procedure Rule.
Special note in regard to Codes 99141 and 99142: The services for these codes are to be reimbursed
at the listed unit value when billed with other procedures, if applicable, and are exempt from the
Multiple Procedure Rule.

Special Note in regard to Cost Containment: Nothing in this section shall preclude an
employer (or insurance carrier) from entering into payment agreements to promote the
continuity of care and the reduction of health care costs. Such payment agreements, if
less, will supersede the limitation amounts specified herein. Please refer to K.S.A.
44-510i(e) for further clarification, if necessary.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

87

EVALUATION AND MANAGEMENT (E/M)
SERVICES GROUND RULES
1. CLASSIFICATION OF EVALUATION AND MANAGEMENT (E/M) SERVICES: This section is divided into
broad categories such as office visits, hospital visits, and consultations. Most of the categories are further
divided into two or more subcategories of E/M services. For example, there are two subcategories of office
visits (new patient and established patient), and there are two subcategories of hospital visits (initial and
subsequent). The subcategories of E/M services are further classified into levels of E/M services that are
identified by specific codes. This classification is important because the nature of physician work varies by
type of service, place of service, and the patient's status.
The basic format of the levels of E/M services is the same for most categories. First, a unique code number is
listed. Second, the place and/or type of service is specified (e.g., office consultation). Third, the content of
the service is defined (e.g., comprehensive history and comprehensive examination). Fourth, the nature of
the presenting problem(s) usually associated with a given level of service is described. Fifth, the time
typically required to provide the service is specified.
2. UNLISTED SERVICE: An E/M service may be provided that is not listed in this section. When reporting such
a service, the appropriate "Unlisted" code may be used to indicate the service, identifying it by "Special
Report" as discussed in item 3. The "Unlisted Services" and accompanying codes for the E/M section are as
follows:
99429 Unlisted preventive medicine service
99499 Unlisted evaluation and management service
3. SPECIAL REPORT: An unlisted service or one that is unusual, variable, or new may require a special report
demonstrating the medical appropriateness of the service. Pertinent information should include an adequate
definition or description of the nature, extent, and need for the procedure; and the time, effort and equipment
necessary to provide the service. Additional items which may be included are complexity of symptoms, final
diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and
follow-up care.
4. MULTIPLE PROCEDURES: It is appropriate to designate multiple procedures that are rendered on the same
day by separate entries. Use modifier -51 to reflect multiple procedures except for the Add-On Codes.
5. ADD-ON CODES: Certain codes, by the nature of their description and the Unit Values assigned, have
already been reduced, as they are not to be billed as primary procedures. For a complete list of the codes
which are considered to be add-on codes, refer to the appropriate appendix found within the most recent
publication of the AMA Current Procedural Terminology (CPT).
6. MODIFIERS: Listed services may be modified under certain circumstances. When applicable, the modifying
circumstance against general guidelines should be identified by the addition of the appropriate modifier code
by a two digit number placed after the usual procedure number from which it is separated by a hyphen. Refer
to Appendix A- Modifiers for the modifiers that are available for E/M:
7. INSTRUCTIONS FOR SELECTING A LEVEL OF E/M SERVICE: Refer specifically to the Evaluation and
Management (E/M) Services Guidelines of the most recent publication of the AMA Current Procedural
Terminology (CPT).
8. BILLS SUBMITTED BY NON-PHYSICIAN PROVIDERS: Bills for E/M services provided by non-physicians
such as physician assistants or advanced practice nurses must be submitted on the CMS 1500 form or an
equivalent form containing the same information. Payment for these services will be limited to 85% of the
maximum allowable fee associated with the CPT code submitted. This form must also clearly identify the
responsible physician.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

88

EVALUATION AND MANAGEMENT (E/M)
SERVICES GROUND RULES
9. FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT: In the event a patient fails to keep a
scheduled appointment, the health care provider is not to bill for any services that would have been provided
by said appointment nor shall there be any reimbursement for such scheduled services (i.e., reimbursement
for a "no show" appointment is not allowed). This rule does not apply with regard to a deposition, testimony,
or IME.
10. COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care costs.
Such payment agreements, if less, will supersede the limitation amounts specified herein. Please refer to
K.S.A 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $46.33

CPT only copyright 2004 American Medical Association. All Rights Reserved.

89

EVALUATION AND MANAGEMENT
(CONVERSION FACTOR = $46.33)
CODE
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99261
99262
99263
99271
99272
99273
99274
99275
99281

UNIT VALUE
0.97
1.72
2.56
3.62
4.58
0.57
1.02
1.39
2.18
3.17
1.87
1.78
2.96
4.16
1.80
2.98
4.15
0.90
1.47
2.09
3.58
4.72
5.89
1.87
2.55
1.33
2.43
3.24
4.56
5.90
0.95
1.91
2.61
3.75
5.17
0.59
1.20
1.78
1.03
1.73
2.40
3.22
4.10
0.44

CODE
99282
99283
99284
99285
99288
99289
99290
99291
99292
99293
99294
99295
99296
99298
99299
99301
99302
99303
99311
99312
99313
99315
99316
99321
99322
99323
99331
99332
99333
99341
99342
99343
99344
99345
99347
99348
99349
99350
99354
99355
99356
99357
99358
99359

UNIT VALUE
0.73
1.64
2.56
4.01
BR
6.48
3.33
6.77
3.00
21.82
10.84
24.98
10.85
3.84
3.52
1.75
2.32
2.86
0.90
1.49
2.10
1.63
2.16
1.08
1.52
1.88
0.95
1.21
1.50
1.54
2.27
3.31
4.34
5.37
1.20
1.90
2.94
4.34
2.62
2.59
2.40
2.42
3.75
1.88

CODE
99360
99361
99362
99371
99372
99373
99374
99375
99377
99378
99379
99380
99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
99401
99402
99403
99404
99411
99412
99420
99429
99431
99432
99433
99435
99436
99440
99450
99455
99456
99499

UNIT VALUE
2.55
2.15
3.75
0.34
0.85
1.71
1.85
3.35
1.85
3.74
1.84
2.78
2.74
2.95
2.89
3.14
3.14
3.69
4.00
2.08
2.33
2.30
2.54
2.57
2.84
3.13
1.11
1.87
2.59
3.32
0.34
0.51
BR
BR
1.60
2.26
0.84
2.15
2.03
3.98
BR
**
**
BR

** No maximum fee has been assigned. The maximum fee for these codes
(99455 and 99456) is to be determined in the same manner as that which
pertains to an IME and other Special Examinations and/or Reports. Refer to item 2
of the Depositions/Testimony & Reproduction of Medical Records Section of this
fee schedule as it relates to an IME and other Special Examinations and/or Reports.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

90

HOME HEALTH PROCEDURES / SERVICES
GROUND RULES
The codes contained within this section were introduced by the American Medical Association in conjunction with
CPT 2002. Said codes are to be used by non-physician health care professionals for services provided in a
patient’s residence (including assisted living apartments, group homes, non-traditional private homes, custodial
care facilities, or schools) and can be submitted as part of the normal procedure when applicable.
No Unit Values have been established at the state, regional, or national level as determined from available data
resources. All Unit Values are listed as BR; thus, a report must accompany all bills utilizing these codes.

CONVERSION FACTOR = $25.00

CPT only copyright 2004 American Medical Association. All Rights Reserved.

91

HOME HEALTH PROCEDURES / SERVICES
(CONVERSION FACTOR =$25.00 )

CODE
99500
99501
99502
99503
99504
99505
99506
99507
99509
99510
99511
99512
99600

UNIT VALUE
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

92

HOME INFUSION PROCEDURES / SERVICES
GROUND RULES
The codes for Home Infusion Procedures and/or Services are to be used by non-physician health care
professionals. Physicians are to use the home visit codes 99341 – 99350 found within the Evaluation and
Management Section.
No Unit Values have been established at the state, regional, or national level as determined from available data
resources. All Unit Values are listed as BR; thus, a report must accompany all bills utilizing these codes.

CONVERSION FACTOR = $25.00

CPT only copyright 2004 American Medical Association. All Rights Reserved.

93

HOME INFUSION PROCEDURES / SERVICES
(CONVERSION FACTOR =$25.00)

CODE
99601
99602

UNIT VALUE
BR
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

94

DENTISTRY GROUND RULES
1.

GENERAL: The allowable fee for any dental service or procedure is the provider’s usual and customary
charge or the maximum fee schedule allowance, whichever is less. The maximum fee schedule
allowance for a particular service or procedure is determined by multiplying the listed Unit Value by the
current dollar Conversion Factor applicable to dentistry. The Unit Values and Conversion Factor for
dentistry are not applicable to any other section of the fee schedule.

2.

UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the
procedure should be identified and the amount charged substantiated " by report" (BR).

3.

PROCEDURES LISTED WITHOUT A SPECIFIED UNIT VALUE: "BR" in the Unit Value column
indicates that the amount charged for this service shall be determined "by report" because the service is
too unusual or variable to be assigned a Unit Value. Pertinent information should be furnished
concerning the nature, extent, and need for the procedure or service, the time, skill, and equipment
necessary, etc.

4.

MATERIAL SUPPLIED BY A DENTIST: Supplies and materials provided by a dentist (e.g., sterile trays,
supplies, drugs) over and above those usually included with the office visits or other services rendered
may be listed separately. Statement of charges will need to reflect any drugs, trays, supplies, and
materials that were provided. Payment shall not exceed the cost of the item(s) to the dentist plus 25% of
the cost or the cost of the item(s) plus $15.00 per item, whichever is less.

5.

CONCURRENT CARE: When the condition of the patient requires the skills of two or more dentists or
health care providers to treat different conditions, payment is due each dentist or health care provider
who plays an active role in the treatment program. The services rendered by each dentist or health care
provider shall be distinct, identifiable, and adequately documented in the records and reports.

6.

ALTERNATING DENTISTS AND/OR HEALTH CARE PROVIDERS: When dentists or health care
providers of similar skills alternate in the care of a patient (e.g., partners, groups of same facility, covering
providers on weekends or vacation periods), each dentist and health care provider shall charge
individually for the services personally rendered; such charges shall be in accordance with this Fee
Schedule.

7.

PRORATION OF SCHEDULED FEE: When the schedule specifies a Unit Value for a definite treatment,
and the patient is transferred from one dentist or health care provider to another, the applicable Unit
Value is to be apportioned between the health care providers. The providers involved shall agree upon
the amount of proration, and shall render separate bills accordingly with an explanatory note.

8.

MODIFIERS: Procedure codes for dentistry may be modified under the circumstances described below.
The circumstances are to be identified by the addition of a hyphen and the appropriate two-digit modifier
code. The modifiers that may be used are as follows:
-22

Unusual Services: A report is required.

-52

Reduced Values: Under certain circumstances, the listed value for a procedure is
reduced or eliminated because of common practice, or at the dentist’s election.

-53

Primary Emergency Services: When a dental procedure is carried out by a
dentist who will not be providing the follow-up care, the value shall be 70% of the
listed value.

-54

Surgical Procedure Only: When one dentist performs the surgical procedure itself
and another provides the follow-up care, the fee may be apportioned between
them. Identify the dentist performing the surgery with this modifier. The “global
fee” is not to be increased, but prorated between the dentists.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

95

DENTISTRY GROUND RULES
-55

Follow-Up Care Only: When one dentist performs the main procedure itself and
another provides the follow-up care, the value may be apportioned between
them. Identify the dentist providing the follow-up care with this modifier. The
“global fee” is not to be increased, but prorated between the dentists.

-56

Pre-Operative Care Only: When one dentist performs the care up until surgery
and another dentist then takes over the care, the value may be apportioned
between them. Identify the dentist providing the pre-operative care with this
modifier. The “global fee” is not to be increased, but prorated between the
dentists.

-99

Multiple Modifiers: By Report

9.

FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT: In the event a patient fails to keep a
scheduled appointment, the health care provider is not to bill for any services that would have been
provided by said appointment nor shall there be any reimbursement for such scheduled services (i.e.,
reimbursement for a “no show” appointment is not allowed). This rule does not apply with regard to a
deposition, testimony, or IME.

10.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A. 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $35.75

CPT only copyright 2004 American Medical Association. All Rights Reserved.

96

DENTISTRY
(CONVERSION FACTOR = $35.75)
CODE
D0120
D0140
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0274
D0277
D0290
D0310
D0320
D0321
D0322
D0330
D0340
D0350
D0415
D0416
D0421
D0425
D0431
D0460
D0470
D0472
D0473
D0474
D0475
D0476
D0477
D0478
D0479
D0480
D0481
D0482
D0483
D0484
D0485
D0502
D0999
D1110
D1120
D1201
D1203
D1204

UNIT VALUE
0.76
0.98
1.10
1.45
BR
BR
2.24
0.43
0.35
0.60
1.00
0.50
0.43
0.70
1.00
BR
BR
BR
BR
BR
BR
1.91
2.00
BR
BR
BR
BR
BR
BR
0.73
1.52
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
1.50
1.07
1.33
0.64
0.69

CODE
D1205
D1310
D1320
D1330
D1351
D1510
D1515
D1520
D1525
D1550
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2410
D2420
D2430
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2712
D2720
D2721
D2722
D2740
D2750
D2751

UNIT VALUE
1.67
BR
0.30
0.67
0.83
5.26
7.41
4.00
6.00
0.93
1.96
2.48
3.01
3.60
2.41
3.06
3.75
4.46
BR
BR
BR
BR
BR
BR
BR
BR
12.53
14.33
BR
BR
17.07
16.67
14.30
15.95
17.00
17.35
18.21
18.50
12.40
14.17
17.00
13.00
15.77
17.00
11.90
BR
17.37
BR
BR
19.67
19.17
17.22

CODE
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2794
D2799
D2910
D2915
D2920
D2930
D2931
D2932
D2933
D2934
D2940
D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2960
D2961
D2962
D2971
D2975
D2980
D2999
D3110
D3120
D3220
D3221
D3230
D3240
D3310
D3320
D3330
D3331
D3332
D3333
D3346
D3347
D3348
D3351
D3352
D3353
D3410

Current Dental Terminology copyright 2002, 2004 American Dental Association. All rights reserved.

97

UNIT VALUE
17.98
BR
BR
BR
BR
18.39
13.83
14.54
BR
BR
1.30
BR
1.55
4.39
5.31
BR
BR
BR
1.61
4.34
0.53
6.34
BR
5.00
BR
BR
8.65
BR
16.81
BR
BR
BR
BR
1.36
1.29
2.77
BR
3.12
3.19
10.83
12.93
16.06
BR
BR
BR
BR
BR
BR
BR
BR
BR
9.37

DENTISTRY
(CONVERSION FACTOR = $35.75)
CODE
D3421
D3425
D3426
D3430
D3450
D3460
D3470
D3910
D3920
D3950
D3999
D4210
D4211
D4240
D4241
D4245
D4249
D4260
D4261
D4263
D4264
D4265
D4266
D4267
D4268
D4270
D4271
D4273
D4274
D4275
D4276
D4320
D4321
D4341
D4342
D4355
D4381
D4910
D4920
D4999
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5225
D5226
D5281
D5410

UNIT VALUE
BR
BR
BR
BR
8.51
BR
BR
BR
BR
BR
BR
8.99
3.07
6.00
BR
BR
BR
15.27
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
5.73
4.49
BR
BR
BR
2.13
BR
BR
27.04
26.98
28.27
28.28
19.27
19.33
29.09
29.04
BR
BR
14.18
1.06

CODE
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5670
D5671
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5810
D5811
D5820
D5821
D5850
D5851
D5860
D5861
D5862
D5867
D5875
D5899
D5911
D5912
D5913
D5914
D5915
D5916
D5919
D5922
D5923
D5924
D5925
D5926
D5927
D5928
D5929

UNIT VALUE
1.06
1.06
1.06
3.23
2.71
3.19
4.75
4.38
2.73
3.50
4.54
BR
BR
9.60
10.00
8.00
8.00
5.42
5.42
5.17
5.17
8.24
8.26
7.37
7.37
10.83
10.83
10.00
10.00
2.00
2.00
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

CODE
D5931
D5932
D5933
D5934
D5935
D5936
D5937
D5951
D5952
D5953
D5954
D5955
D5958
D5959
D5960
D5982
D5983
D5984
D5985
D5986
D5987
D5988
D5999
D6010
D6040
D6050
D6053
D6054
D6055
D6056
D6057
D6058
D6059
D6060
D6061
D6062
D6063
D6064
D6065
D6066
D6067
D6068
D6069
D6070
D6071
D6072
D6073
D6074
D6075
D6076
D6077
D6078

Current Dental Terminology copyright 2002, 2004 American Dental Association. All rights reserved.

98

UNIT VALUE
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
25.00
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

DENTISTRY
(CONVERSION FACTOR = $35.75)
CODE
D6079
D6080
D6090
D6094
D6095
D6100
D6190
D6194
D6199
D6205
D6210
D6211
D6212
D6214
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6253
D6545
D6548
D6600
D6601
D6602
D6603
D6604
D6605
D6606
D6607
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6624
D6634
D6710
D6720
D6721
D6722
D6740
D6750
D6751
D6752
D6780
D6781

UNIT VALUE
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
19.66
14.00
16.00
BR
19.17
17.33
15.99
BR
BR
BR
BR
BR
12.78
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
18.43
BR
BR
BR
19.23
17.35
15.60
18.33
BR

CODE
D6782
D6783
D6790
D6791
D6792
D6793
D6794
D6920
D6930
D6940
D6950
D6970
D6971
D6972
D6973
D6975
D6976
D6977
D6980
D6985
D6999
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7260
D7261
D7270
D7272
D7280
D7282
D7283
D7285
D7286
D7287
D7288
D7290
D7291
D7310
D7320
D7321
D7340
D7350
D7410
D7411
D7412
D7413
D7414

UNIT VALUE
BR
BR
18.50
13.83
14.54
BR
BR
BR
2.32
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
4.32
5.00
6.19
7.51
8.83
4.55
12.00
BR
5.00
BR
6.00
BR
BR
4.68
4.68
BR
BR
12.00
0.92
3.84
5.08
BR
BR
BR
5.16
BR
BR
BR
BR

CODE
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7465
D7471
D7472
D7473
D7485
D7490
D7510
D7511
D7520
D7521
D7530
D7540
D7550
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
D7830
D7840
D7850
D7852
D7854
D7856
D7858
D7860
D7865
D7870
D7871

Current Dental Terminology copyright 2002, 2004 American Dental Association. All rights reserved.

99

UNIT VALUE
BR
BR
BR
10.00
16.00
10.00
16.00
BR
BR
BR
BR
BR
BR
4.00
BR
5.58
BR
1.21
2.62
BR
BR
40.00
35.00
45.00
40.00
BR
BR
14.87
BR
BR
50.00
44.00
55.76
45.00
BR
BR
26.00
BR
68.84
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

DENTISTRY
(CONVERSION FACTOR = $35.75)
CODE
D7872
D7873
D7874
D7875
D7876
D7877
D7880
D7899
D7910
D7911
D7912
D7920
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7953
D7955
D7960
D7963
D7970
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D7995
D7996
D7997
D7999
D8010
D8020
D8030
D8040
D8050
D8060
D8070
D8080
D8090
D8210
D8220
D8660
D8670

UNIT VALUE
BR
BR
BR
BR
BR
BR
14.19
BR
3.36
6.26
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
5.56
BR
6.10
6.00
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
6.00
7.00
BR
BR

CODE
D8680
D8690
D8691
D8692
D8999
D9110
D9210
D9211
D9212
D9215
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
D9440
D9450
D9610
D9630
D9910
D9911
D9920
D9930
D9940
D9941
D9942
D9950
D9951
D9952
D9970
D9971
D9972
D9973
D9974
D9999

UNIT VALUE
BR
BR
BR
BR
BR
1.83
0.83
0.37
BR
0.30
BR
BR
0.92
BR
BR
BR
3.00
2.78
2.97
1.07
2.00
BR
BR
0.66
0.83
BR
BR
BR
7.91
2.38
BR
BR
2.61
8.33
BR
BR
BR
BR
BR
BR

Current Dental Terminology copyright 2002, 2004 American Dental Association. All rights reserved.

100

HOSPITAL/AMBULATORY SURGICAL CENTER
GROUND RULES AND FEES
1.

GENERAL: With regard to the DRG classifications listed below and for the hospitals in Peer Group 1,
reimbursement for inpatient hospital services provided on or after October 1, 1999, and updated to remain
current, is to be determined in accordance with the DRG classification and methodology that was developed
by the Center for Medicare & Medicaid Services (CMS) for the Medicare program.
DRG No.

DRG DESCRIPTION

032
209
210
211
217

Concussion, age > 17 w/o cc
Major joint and limb reattachment procedures of lower extremity
Hip and femur procedures except major joint, age > 17 w cc
Hip and femur procedures except major joint, age > 17 w/o cc
Wound debridement and skin graft except hand, for musculoskeletal and connective
tissue disorder
Lower extremity and humerus procedures except hip, foot, femur, age > 17 w cc
Lower extremity and humerus procedures except hip, foot, femur, age > 17 w/o cc
Major shoulder / elbow procedure, or other upper extremity procedure w cc
Shoulder, elbow or forearm procedure except major joint procedure, w/o cc
Foot procedures
Soft tissue procedures, w/o cc
Fractures of hip and pelvis
Medical back problems
Fracture, sprain, strain and dislocation of upper arm, lower leg except foot, age > 17
w/o cc
Cellulitis, age > 17 w/o cc
Trauma to the skin, subcutaneous tissue and breast, age > 17 w/o cc
Operating room procedure for infectious and parasitic diseases
Wound debridements for injuries
Hand procedures for injuries
Traumatic injury age > 17 w/o cc
Other multiple significant trauma
Combined anterior/posterior spinal fusion
Spinal fusion w cc
Spinal fusion w/o cc
Back and neck procedures except spinal fusion w cc
Back and neck procedures except spinal fusion w/o cc
Full thickness burn with skin graft or inhal inj w/o cc or sig trauma
Non-extensive burns w/o cc or significant trauma
Cervical spinal fusion w/o cc
Local excision and removal of internal fixation device except hip and femur w cc
Local excision and removal of internal fixation device except hip and femur w/o cc

218
219
223
224
225
227
236
243
254
278
281
415
440
441
445
487
496
497
498
499
500
507
511
520
537
538

For any hospitals or ambulatory surgical centers in Peer Groups 2 and 3, and for all other DRG
classifications not listed above, reimbursement is to be at a variable discount rate. The variable discount
rate for Peer Groups 1, 2, and 3 is 15.0%, 12.5%, and 10.0% respectively which is to be applied to the
facility’s usual and customary charge. Ambulatory surgical centers are to be similarly grouped in
association with the nearest proximate hospital, and are to be reimbursed in accordance with the
variable discount rate. Unless otherwise specified in this section of the fee schedule (Pathology and
Laboratory charges, for example), outpatient services are also subject to the variable discount rate.
Limited data available for hospital Peer Groups 2 and 3, dictates that the DRG reimbursement system be
introduced in phases beginning, with Peer Group 1. When sufficient data are available, the DRG
reimbursement system may be expanded for use in the smaller hospitals.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

101

HOSPITAL/AMBULATORY SURGICAL CENTER
GROUND RULES AND FEES
PEER GROUP 1 (15.0% Discount)
Derby ..............................................Derby Ambulatory Surgery Center
Kansas City.....................................Heart of America Surgery Center
Kansas City.....................................Providence Medical Center-Providence Health
Kansas City.....................................University of Kansas Hospital
Lawrence ........................................Lawrence Memorial Hospital
Lawrence ........................................Lawrence Surgery Center
Leawood .........................................Discover Vision Surgery and Laser Center
Leawood .........................................Skin and Mohs Surgery Center
Leawood .........................................Surgery Center of Leawood
Leawood .........................................The Headache and Pain Center
Leawood .........................................Kansas City Otrhopaedic Institute
Leawood .........................................Doctors Specialty Hospital LLC
Olathe .............................................Olathe Surgical Associates
Olathe .............................................Olathe Medical Center, Inc.
Overland Park .................................ADS Ambulatory Surgery Center
Overland Park .................................College Park Family Care Center, PA
Overland Park .................................Comprehensive Health Planned Parenthood
Overland Park .................................Endoscopic Imaging Center, LLC
Overland Park .................................Novamed Eye Surg. Center
Overland Park .................................Park Place Surgery Center, Inc.
Overland Park .................................South KC Surgical Center, LLC
Overland Park .................................Surgicenter of Johnson County
Overland Park .................................Heartland Surgical Specialty Hospital
Overland Park .................................Children’s Mercy South
Overland Park .................................Menorah Medical Center
Overland Park .................................Mid-America Rehabilitation Hospital
Overland Park .................................Specialty Hospital of Mid-America
Overland Park .................................Saint Luke’s South Hospital
Overland Park .................................Overland Park RMC
Overland Park .................................Select Specialty Hospital – Kansas City
Prairie Village..................................Physicians Surgery Center
Shawnee .........................................KU Medwest Ambulatory Surgery
Shawnee .........................................The Westglen Endoscopy Center
Shawnee Mission............................Ambulatory Surgery Center of KC, Inc.
Shawnee Mission............................Shawnee Mission Surgery Center
Shawnee Mission............................Shawnee Mission Medical Center
Topeka ............................................Cotton-O’Neil Clinic Endo. Ctr.
Topeka ............................................Endoscopy and Surgery Center of Topeka
Topeka ............................................Tallgrass Surgical Center
Topeka ............................................Topeka Single Day Surgery
Topeka ............................................Washburn Surgery Center, LLC
Topeka ............................................St. Francis Health Center
Topeka ............................................Select Specialty Hospital of Topeka
Topeka ............................................Stormont-Vail Health Care
Topeka ............................................Stormont-Vail West
Topeka ............................................Kansas Rehabilitation Hospital
Wichita ............................................Associated Eye Surgical Center
Wichita ............................................Cypress Surgery Center
Wichita ............................................Endoscopic Services, PA
Wichita ............................................Galichia Heart Hospital, LLC
Wichita ............................................Kansas Endoscopy, LLC
Wichita ............................................Kansas Hearth Hospital
Wichita ............................................Kansas Spine Hospital, LLC

CPT only copyright 2004 American Medical Association. All Rights Reserved.

102

HOSPITAL/AMBULATORY SURGICAL CENTER
GROUND RULES AND FEES
PEER GROUP 1 (15.0% Discount) (continued)
Wichita ............................................Mid West Surgery Center LLC
Wichita ............................................Plastic Surgery Center
Wichita ............................................Surgery Center of Kansas
Wichita ............................................Surgicare of Wichita, Inc.
Wichita ............................................Team Vision Surgery Center East
Wichita ............................................Team Vision Surgery Center West
Wichita ............................................The Center For Same Day Surgery
Wichita ............................................Wichita Clinic Day Surgery
Wichita ............................................Kansas Surgery and Recovery Center
Wichita ............................................Select Specialty Hospital of Wichita
Wichita ............................................Via Christi RMC
Wichita ............................................Via Christi Rehab Ctr. - Our Lady of Lourdes Campus
Wichita ............................................Via Christi Riverside Medical Center
Wichita ............................................Wesley Medical Center
Wichita ............................................Wichita Specialty Hospital
Wichita ............................................Wesley Rehabilitation Hospital
PEER GROUP 2 (12.5% Discount)
Chanute ..........................................Neosho Memorial Hospital
Coffeyville .......................................Coffeyville Regional Medical Center
Dodge City ......................................Surgery Center of Dodge City, LLC
Dodge City ......................................Western Plains Medical Complex
El Dorado ........................................Susan B. Allen Memorial Hospital
Emporia...........................................Emporia Ambulatory Surgery Center
Emporia...........................................Newman Regional Health
Emporia...........................................Emporia Surgical Hospital LLC
Fort Scott ........................................Quinlan Eye Surgery and Laser Center
Fort Scott ........................................Mercy Health Center
Garden City.....................................Fry Eye Surgery Center
Garden City.....................................Surgery Center of SW Kansas, LLC
Garden City.....................................Saint Catherine Hospital
Great Bend......................................Central Kansas Medical Center
Great Bend......................................Surgical & Diagnostic Center of Great Bend
Hays ................................................NW Kansas Surgery Center
Hays ................................................Hays Medical Center
Hutchinson ......................................Hutchinson Ambulatory Surgery
Hutchinson ......................................Hutchinson Clinic, ASA
Hutchinson ......................................Surgery Center of South Central Kansas
Hutchinson ......................................Hutchinson Hospital
Junction City ...................................Geary Community Hospital
Leavenworth ...................................Cushing Memorial Hospital
Leavenworth ...................................Saint John Hospital
Manhattan .......................................Mercy Regional Health Center, Inc.
Manhattan .......................................Manhattan Surgical Center, LLC
Newton............................................Newton Surgery Centre
Newton............................................Newton Medical Center
Newton............................................Prairie View, Inc.
Paola ...............................................Miami County Medical Center, Inc.
Parsons...........................................Labette County Medical Center
Pittsburg..........................................Century Surgical Associates, Inc.
Pittsburg..........................................Mt. Carmel Regional Medical Center

CPT only copyright 2004 American Medical Association. All Rights Reserved.

103

HOSPITAL/AMBULATORY SURGICAL CENTER
GROUND RULES AND FEES
PEER GROUP 2 (12.5% Discount) (continued)
Salina ..............................................Laser Center
Salina ..............................................Salina Regional Health Center
Salina ..............................................Saint Francis at Salina
Salina ..............................................Salina Surgical Hospital
Winchester ......................................Jefferson County Memorial Hospital, Inc.
and Geriatric Center
PEER GROUP 3 (10.0% Discount)
All other hospitals are to be reimbursed at their usual and customary charge, less 10%. This is to include
the following state institutions:
Rainbow Mental Health Facility at Kansas City, Kansas
Larned State Hospital at Larned, Kansas
Osawatomie State Hospital at Osawatomie, Kansas
Parsons State Hospital & Training Center at Parsons, Kansas
Kansas Neurological Institute at Topeka, Kansas
Out-of-state hospitals are subject to a 15% discount. Additionally, for any hospital that is paid using the
variable discount method, regardless of peer group classification, and when the total charges for an
inpatient hospitalization exceed $40,000, an additional 5.0% discount is to be applied to all the charges in
excess of $40,000.
2.

DETERMINING PAYMENT FOR INPATIENT HOSPITAL CLAIMS: Each and every claim for inpatient
hospital services (regardless of whether the hospital is located in Peer Group 1, 2, or 3 and may be
subject to the variable discount rate) is to be assigned a DRG classification. This is achieved by means
of a DRG grouper. The grouper uses vital information from the claim, such as diagnosis and charge
information, to determine which DRG classification best describes the inpatient stay. Only a CMS-DRG
grouper (current with the care provided and employing the ICD-9 codes in effect at the time the services
were provided) may be used to classify Workers Compensation claims for payment. Once a DRG is
assigned to the claim, payment can be determined.
A hospital is to assign a DRG classification to the claim prior to submitting it for payment. The DRG is to be
listed in form locator (field) 78 on the UB-92 claim form. Upon receipt of the claim, the reviewer/payer is to
process the claim to verify the DRG classification assigned by the hospital. If the reviewer/payer processes
a claim and arrives at a DRG classification other than the one assigned by the hospital, the reviewer/payer
should contact the hospital to agree on the correct DRG classification that is necessary to process the
claim.
After the claim has been assigned a DRG classification, payment is then determined in accordance with the
methodology referenced below. Note that all inpatient claims will not be paid at the DRG rate. The only
claims to be paid at the DRG rate will be those claims having been assigned a DRG classification that
corresponds with those listed in this section of the fee schedule and for which the inpatient hospital services
were provided by a hospital located in Peer Group 1. The Workers Compensation DRG payment system
takes into account that within any given DRG classification there will be claims with actual total charges that
are unusually high or unusually low. Payment for these unusual claims are not to be made at the DRG rate,
but are to be paid according to the methodologies described later.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

104

HOSPITAL/AMBULATORY SURGICAL CENTER
GROUND RULES AND FEES
3.

DRG
032
209
210
211
217
218
219
223
224
225
227
236
243
254
278
281
415
440
441
445
487
496
497
498
499
500
507
511
520
537
538

4.

DRG CLASSIFICATIONS AND RATES (including low and high trimpoints):

DRG DESCRIPTION
Concussion, age > 17 w/o cc
Major joint and limb reattachment procedure of lower extremity
Hip and femur procedures except major joint, age > 17 w cc
Hip and femur procedures except major joint, age > 17 w/o cc
Wound debridement and skin graft except hand, for
musculoskeletal and connective tissue disorder
Lower extremity and humerus procedure except hip, foot,
femur, age > 17 w/cc
Lower extremity and humerus procedure except hip, foot,
femur, age > 17 w/o cc
Major shoulder / elbow procedure, or other upper extremity
procedure, w cc
Shoulder, elbow or forearm procedure except major joint
procedure, w/o cc
Foot procedures
Soft tissue procedures w/o cc
Fractures of hip and pelvis
Medical back problems
Fracture, sprain, strain and dislocation of upper arm, lower leg,
except foot age > 17 w/o cc
Cellulitis, age > 17 w/o cc
Trauma to the skin, subcutaneous tissue and breast,
age > 17 w/o cc
Operating room procedure for infectious and parasitic diseases
Wound debridements for injuries
Hand procedures for injuries
Traumatic injury age > 17 w/o cc
Other multiple significant trauma
Combined anterior/posterior spinal fusion
Spinal fusion w/cc
Spinal fusion w/o cc
Back and neck procedure except spinal fusion w/cc
Back and neck procedure except spinal fusion w/o cc
Full thickness burn with skin graft or inhal inj w/o cc or sig trauma
Non-extensive burns w/o cc or significant trauma
Cervical spinal fusion w/o cc
Local excision and removal of internal fixation device except
hip and femur w cc
Local excision and removal of internal fixation device except
hip and femur w/o cc

TRIMPOINTS
LOW
HIGH
3,138
34,287
14,127
50,480
7,731
71,027
5,563
52,941
7,665
95,232

DRG
RATE

5,806

51,540

23,222

3,989

33,914

15,954

5,359

61,011

21,438

4,554

23,644

11,984

5,383
4,106
2,112
1,651
1,657

26,219
41,225
19,362
17,598
16,884

13,431
16,423
8,448
6,602
6,627

1,308
2,275

13,183
23,667

5,232
9,099

4,826
6,214
4,894
2,485
4,903
29,125
12,824
6,489
6,526
6,359
4,660
3,778
13,617
8,261

57,294
66,670
60,937
32,474
50,058
108,113
78,573
56,313
37,567
24,701
53,011
51,485
33,052
90,297

19,305
24,858
19,575
9,940
19,612
58,326
38,844
25,955
18,739
13,200
18,640
15,114
19,834
33,046

3,469

24,583

13,874

12,551
27,458
30,924
22,252
30,659

DETERMINING PAYMENT: As reflected above, each of the specific DRGs has a designated DRG rate as
well as a low trim point and a high trim point. Trim points have been set at statistically defined intervals and,
as the name applies, serve to exclude outlier claims with actual total charges that are unusually low or high.
The DRG payment rate is applied to those claims when the actual total charge falls between the low and the
high trim points.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

105

HOSPITAL/AMBULATORY SURGICAL CENTER
GROUND RULES AND FEES
Example:

DRG 500: Back & neck procedures except spinal fusion w/o cc
Low Trim: $6,359

High Trim: $24,701

DRG Rate: $13,200

Actual Total Charge = $23,000
Because the actual total charge is between the low trim amount and the high
trim amount, payment will be made at the DRG rate of $13,200
Note: Any claim in DRG classification 500 whose actual total charge is not
lower than $6,359 or higher than $24,701, such claim is to be paid at the DRG
rate of $13,200.
A claim whose actual total charge is less than the low trim amount is considered a low-lier claim and one
whose actual total charge exceeds the high trim amount is considered a high-lier claim. Low-lier and highlier claims are not paid at the DRG rate.
5.

DETERMINING PAYMENT FOR A LOW-LIER CLAIM: A low-lier claim is any claim when the actual total
charge is less than the low trim amount for its assigned DRG classification. Such a type of claim is not to be
paid at the DRG rate. Payment is determined by multiplying the actual total charge by .85 to achieve a
15.0% discount.
Example:

DRG 500: Back & neck procedures except spinal fusion w/o cc
Low Trim: $6,359

High Trim: $24,701

DRG Rate: $13,200

Actual Total Charge = $6,000
Because the actual total charge is lower than the low trim amount, payment is
determined by applying the low-lier calculation: $6,000 x .85 = $5,100.
Note: Payment for any claim in DRG classification 500 whose actual total
charge is lower than $6,359 will be calculated according to this methodology.
6.

DETERMINING PAYMENT FOR A HIGH-LIER CLAIM: A high-lier claim is any claim when the actual total
charge is greater than the high trim point for its assigned DRG classification. Such a type of claim is not
paid at the DRG rate. Payment is determined by multiplying the actual total charge by .85 to achieve a
15.0% discount. Reimbursement for Pathology or Laboratory charges, and Surgical Implantables is
defined as any other Non-DRG Hospital charges.
Example:

DRG 500: Back & neck procedures except spinal fusion w/o cc
Low Trim: $6,359

High Trim: $24,701

DRG Rate: $13,200

Actual Total Charge = $25,000
Because the actual total charge is greater than the high trim amount, payment
is determined by applying the high-lier calculation: $25,000 x .85 = $21,250.
Note: Payment for any claim in DRG classification 500 whose actual total
charge is higher than $24,701 will be calculated according to this methodology.
7.

DRGs AND PATIENT TRANSFER TO ANOTHER HOSPITAL: When a hospital is unable to provide the
level of care and service necessary for the management of a complex medical or surgical problem, transfer
of the patient to another hospital facility may become necessary. In that event, charges incurred by the

CPT only copyright 2004 American Medical Association. All Rights Reserved.

106

HOSPITAL/AMBULATORY SURGICAL CENTER
GROUND RULES AND FEES
transferring hospital are to be paid in accordance with that hospital’s peer group assignment and the
associated variable discount rate. The receiving hospital is to be paid in accordance with the entire DRG
classification assignment for that admission.
8.

PRE-ADMISSION HOSPITAL CHARGES: Any hospital charges incurred up to 72 hours prior to admission
at the same hospital under the DRG payment system, are to be billed as part of that admission and not to
be billed separately.

9.

PHYSICAL MEDICINE AND REHABILITATION: Except for any inpatient hospital services that would be
grouped within a DRG classification, reimbursement for any services provided by physical/occupational
therapists is to be in accordance with the variable discount rate. However, for any hospitals having one or
more affiliate clinics providing services on an outpatient basis, only one such clinic is allowed to submit
billings using the hospital’s Federal Tax ID number. The services for all other clinics affiliated with the same
hospital are limited to the Maximum Allowable Fee for the respective CPT code that is contained within the
Physical Medicine and Rehabilitation Section of this Fee Schedule.

10.

RADIOLOGY CHARGES: Except for any inpatient hospital radiology services that would be grouped within
a DRG classification for payment purposes, all other inpatient hospital radiology services are to be
reimbursed according to the variable discount rate. Reimbursement for any outpatient radiology services
provided by hospitals or ambulatory surgical centers are subject to the Maximum Allowable Fee for the
respective CPT code that is contained within the Radiology Section of this Fee Schedule.

11.

PATHOLOGY OR LABORATORY CHARGES: Except for any inpatient hospital services that would be
grouped within a DRG classification for payment purposes, reimbursement for any other pathology and
laboratory services provided by hospitals or ambulatory surgical centers are subject to the Maximum
Allowable Fee for the respective CPT code that is contained within the Pathology and Laboratory Section of
this Fee Schedule.

12.

INPATIENT CARE: Charges for inpatient hospital care of more than one day shall be subject to review in
cases where the patient is ambulatory. The attending health care provider will be required to submit
sufficient information to substantiate why inpatient care was necessary. Once the patient's condition
becomes such that further inpatient care is only a matter of personal convenience, the executive officer or
administrator of the hospital or ambulatory surgical center should notify the employer (or insurance carrier)
at once. Such notification should also be provided to the Director of Workers Compensation.

13.

DETERMINING PAYMENT FOR AMBULATORY SURGICAL CENTERS INVOLVING MULTIPLE OR
BILATERAL PROCEDURES: The Surgery Ground Rules for multiple or bilateral procedures are similarly
applied to individual billed charges submitted by ambulatory surgical centers. Please refer to the Surgery
Section of this fee schedule for details and examples. Note that the variable discount will still apply to any
multiple or bilateral procedures.

14.

FACILITY FEES: Ambulatory Surgical Centers must indicate that services provided and identified by a
CPT code, reflect a facility fee, rather than the maximum amount related to the CPT code and its Unit Value
defined for an individual provider.
Outpatient facility fees are only reimbursed if the facility is credentialed at the appropriate level for the
services provided. Such credentials include:
A.
B.
C.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO); or
Kansas Department of Health and Environment (KDHE) licensure as an ambulatory
surgical center; or
The facility level of safety, monitoring and quality of care as the JCAHO or KDHE licensure
requires and has documented use showing the processes and procedures are in practice.
In all other cases, a facility fee is not reimbursable without prior agreement from the payer,
regardless of location of service.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

107

HOSPITAL/AMBULATORY SURGICAL CENTER
GROUND RULES AND FEES
15.

PHYSICIAN CHARGES: A hospital or ambulatory surgical center shall bill for services provided by a
physician only if that service involves: both professional and technical components; and, the physician is a
contract employee of said facility. Both of these conditions must be satisfied for the hospital to bill.
Services of this type would most frequently be in the physician specialty areas of radiology, pathology, or
emergency room.
Billing for any physician service is to be submitted using the CMS 1500 form (or an equivalent form)
containing the appropriate information as well as identifying the specific CPT code that was involved. Note
also that the maximum allowable payment to a physician providing services in a hospital or ambulatory
surgical center is to be limited to the maximum allowable payment that is contained within this Fee
Schedule, which applies to the particular CPT code(s) being submitted.

16.

PROFESSIONAL AND TECHNICAL COMPONENTS: Hospitals and ambulatory surgical centers must
recognize that a difference may exist between the professional and technical components of services
provided. It is, therefore, necessary to amend the billing process to specify, by use of modifiers, when only
the professional component or the technical component was provided.

17.

ROOM: Charges for other than semiprivate or ward service shall be subject to review, and must be
accompanied by a statement identifying the source of authorization and necessity for other types of
accommodations.

18.

SURGICAL IMPLANTABLES: Reimbursement for any single surgical implantable item (e.g., rods, pins,
screws, plates, prosthetic joint replacements) and which is made of plastic, metallic, or of autogenous/nonautogenous graft material that reflects a charge of $250.00 or more, is to be determined by cost to the
hospital or ambulatory surgical center plus a 50% markup above the invoice cost. A copy of the invoice
(date of purchase within twelve months of implantation) must be submitted with the bill.
This payment determination is not applicable when the total bill, including charges for surgical implantables,
falls within the low and high trim points of any DRG specifically listed within this fee schedule.

19.

DURABLE MEDICAL EQUIPMENT: Items such as wheelchairs, crutches, etc. when supplied by a hospital
or ambulatory surgical center for the care of an inpatient or outpatient and billed with a charge of $250.00 or
more will be reimbursed at invoice cost plus a 50% markup. Verification of such cost must be attached to
the bill when it is submitted for payment.
In accordance with Kansas Law, the Kansas Department of Revenue does not collect sales tax on Durable
Medical Equipment, if purchased with a prescription or written order from the physician ordering the item
classified as Durable Medical Equipment.

20.

TRANSFUSIONS: Charges for any blood transfusions shall be subject to review, to determine if the patient
made any arrangements to obtain replacement units on his or her own.

21.

REVIEWS AND AUDITS: The employer (or insurance carrier) has the right to conduct, or make
arrangements for a bill audit of inpatient services to determine that such services were directly related to the
compensable injury. The hospital or ambulatory surgical center should not make any additional charges on
a given case under review during the course of the bill audit, unless it is for service which would not be
covered under the Workers Compensation Act.

22.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements with hospitals or ambulatory surgical centers in their community to
promote the continuity of care and the reduction of health care costs. Such payment agreements, if less,
will supersede the limitation amounts specified herein. Please refer to K.S.A. 44-510i(e) for further
clarification, if necessary.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

108

MEDICAL EQUIPMENT AND SUPPLIES
GROUND RULES AND FEES
1.

GENERAL: Reimbursement for certain medically necessary equipment, devices, or supplies (except for
Prosthetic and/or Orthotic devices) that are appropriate and medically necessary as a result of a
compensable injury shall be limited to the supplier's cost plus 50%. If the charge for a single item
(equipment, device, or supply) or the charge for a line item total is more than $100.00, verification of the
supplier's costs must be attached to the provider's bill.
Reimbursement for any prosthetic and/or orthotic devices (excluding prosthetic surgical implants),
regardless of the charge, shall be limited to the 2005 Medicare Fee Schedule, plus an additional 25%,
as reflected by the L Code System of the 2005 Healthcare Common Procedure Coding System (HCPCS).
Additionally, any charges for any prosthetic and/or orthotic devices shall be billed using the L Code
System of the Healthcare Common Procedure Coding System (HCPCS), and submitted using the CMS
(formerly HCFA) 1500 form or an equivalent form containing the same information.
Included herein are the Prosthetic and Orthotic Fee Schedule Allowances. The 2005 HCPCS allowances
were obtained from Cigna HealthCare who is under contract with CMS as the Durable Medical Equipment
Regional Carrier (DMERC). DMERC provides claims administration for Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS). The maximum payments, as listed, include an
additional 25% which has been added to the 2005 HCPCS L Codes.
Note carefully the -KM and -KN modifiers applicable to facial prostheses (codes L8040 through L8047):
-KM
-KN

Replacement of facial prosthesis including new impression/moulage.
Replacement of facial prosthesis using previous master model.

Be advised further that the rates contained within this section for the various L Codes will remain
in effect until the next revision of the Kansas Workers Compensation Schedule of Medical Fees.
Any equipment or supplies, including prosthetic and/or orthotic devices, not specifically recommended or
prescribed by a health care provider shall not be reimbursed. In the event, however, a health care
provider recommends and/or prescribes the use of any medical equipment or supplies (e.g., special size
of gauze) that can be purchased over-the-counter, and the injured employee pays for said medical supply
directly, the injured employee is entitled to be reimbursed for the purchase of such equipment or supplies.
The injured employee must submit copies of any receipts and/or proofs of purchase to the employer (or
insurance carrier) for proper reimbursement. However, a pharmacy may bill the insurer directly for
payment, at the usual and customary price for the pharmacy, for items recommended by a health care
provider.
2.

PRIOR AUTHORIZATION: Prior authorization, by the employer (or insurance carrier), is required on
whether to rent or purchase an item. The decision to rent or purchase shall be made by the employer, an
authorized representative, or the insurance carrier, based on a cost comparison of the monthly rental fee,
the prescribing health care provider's estimate of how long the item will be needed, and the purchase
price.

3.

FORMS: Items which are prescribed for work-related injuries should be billed using the CMS 1500 form.

4.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into a contract with a qualified supplier for the renting or purchasing of items that are medically
necessary. Such contract, if less, will supersede the limitation amounts specified herein. Please refer to
K.S.A. 44-510i(e) for further clarification, if necessary.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

109

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L0100
L0110
L0112
L0120
L0130
L0140
L0150
L0160
L0170
L0172
L0174
L0180
L0190
L0200
L0210
L0220
L0430
L0450
L0452
L0454
L0456
L0458
L0460
L0462
L0464
L0466
L0468
L0470
L0472
L0480
L0482
L0484
L0486
L0488
L0490
L0700
L0710
L0810
L0820
L0830
L0860
L0861
L0960
L0970
L0972
L0974
L0976
L0978
L0980
L0982
L0984

MAXIMUM
FEE
$703.10
$174.09
$1,401.54
$33.29
$153.51
$80.31
$134.85
$163.86
$618.41
$120.79
$273.61
$351.23
$493.76
$592.80
$42.26
$128.41
$1,313.95
$184.11
BR
$347.31
$995.95
$893.06
$1,005.20
$1,250.31
$1,488.45
$367.24
$466.41
$643.25
$405.34
$1,735.26
$1,624.01
$1,691.40
$1,774.10
$1,005.20
$283.26
$2,536.41
$2,104.45
$2,589.55
$2,070.60
$3,048.75
$1,146.29
$215.81
$67.43
$107.54
$98.48
$179.49
$167.63
$240.11
$16.43
$17.59
$65.58

HCPCS
CODE
L0999
L1000
L1005
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L1120
L1200
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
L1300
L1310
L1499
L1500
L1510
L1520
L1600
L1610
L1620
L1630
L1640
L1650
L1652
L1660
L1680
L1685
L1686
L1690
L1700
L1710
L1720
L1730
L1750
L1755

MAXIMUM
FEE
BR
$1,998.04
$3,205.04
$70.48
$81.33
$117.34
$59.86
$74.20
$78.34
$92.58
$84.66
$52.08
$144.84
$87.13
$164.58
$302.76
$37.38
$1,707.53
$246.21
$215.81
$534.89
$73.06
$67.98
$71.19
$72.90
$81.18
$73.96
$1,692.36
$1,803.88
BR
$2,231.20
$1,297.08
$2,618.39
$121.25
$48.64
$130.10
$174.56
$490.10
$229.45
$356.98
$161.03
$1,396.21
$1,119.24
$858.33
$1,936.39
$1,572.64
$1,682.08
$1,456.38
$1,170.50
$185.13
$1,524.38

CPT only copyright 2004 American Medical Association. All Rights Reserved.

110

HCPCS
CODE
L1800
L1810
L1815
L1820
L1825
L1830
L1831
L1832
L1834
L1836
L1840
L1843
L1844
L1845
L1846
L1847
L1850
L1855
L1858
L1860
L1870
L1880
L1900
L1901
L1902
L1904
L1906
L1907
L1910
L1920
L1930
L1932
L1940
L1945
L1950
L1951
L1960
L1970
L1971
L1980
L1990
L2000
L2005
L2010
L2020
L2030
L2035
L2036
L2037
L2038
L2039

MAXIMUM
FEE
$67.33
$94.19
$111.98
$124.91
$51.74
$85.75
$294.73
$572.06
$788.83
$133.63
$886.40
$898.51
$1,893.38
$769.09
$999.00
$575.95
$280.73
$1,033.99
$1,127.49
$1,282.89
$1,062.58
$720.64
$264.34
$17.71
$79.26
$444.79
$113.16
$563.44
$251.63
$328.95
$260.15
$893.59
$509.60
$871.03
$732.43
$840.99
$521.55
$800.29
$469.36
$383.08
$484.15
$954.39
$3,604.61
$874.69
$1,098.70
$1,015.18
$173.45
$1,745.76
$1,567.24
$1,345.30
$2,225.45

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L2040
L2050
L2060
L2070
L2080
L2090
L2106
L2108
L2112
L2114
L2116
L2126
L2128
L2132
L2134
L2136
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2232
L2240
L2250
L2260
L2265
L2270
L2275
L2280
L2300
L2310
L2320
L2330
L2335
L2340
L2350
L2360
L2370
L2375
L2380
L2385
L2390
L2395
L2397
L2405

MAXIMUM
FEE
$167.06
$448.24
$565.63
$131.01
$367.79
$457.03
$639.76
$1,005.36
$439.00
$576.98
$709.11
$1,126.74
$1,613.46
$759.04
$910.06
$1,123.51
$111.03
$103.46
$116.56
$146.95
$281.80
$86.85
$425.03
$44.74
$63.25
$79.00
$74.34
BR
$82.91
$393.91
$188.63
$113.09
$50.54
$150.05
$426.08
$263.06
$115.75
$207.00
$391.58
$285.01
$423.23
$917.26
$52.09
$322.06
$114.68
$140.04
$128.15
$103.00
$154.86
$126.78
$87.29

HCPCS
CODE
L2415
L2425
L2430
L2492
L2500
L2510
L2520
L2525
L2526
L2530
L2540
L2550
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2627
L2628
L2630
L2640
L2650
L2660
L2670
L2680
L2750
L2755
L2760
L2768
L2770
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
L2860
L2999
L3031
L3160
L3201
L3202
L3203
L3204
L3206
L3207

MAXIMUM
FEE
$121.64
$143.53
$143.53
$95.95
$297.55
$739.53
$433.48
$1,256.58
$644.50
$243.01
$397.81
$270.24
$515.61
$436.70
$193.25
$228.51
$317.65
$303.38
$367.54
$1,613.05
$1,576.45
$233.00
$316.21
$139.39
$175.38
$163.11
$165.00
$86.86
$130.85
$57.16
$130.50
$58.10
$63.68
$31.83
$79.95
$100.36
$73.49
$81.71
$88.40
$42.54
$77.69
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

111

HCPCS
CODE
L3208
L3209
L3211
L3212
L3213
L3214
L3215
L3216
L3217
L3219
L3221
L3222
L3224
L3225
L3230
L3250
L3251
L3252
L3253
L3254
L3255
L3257
L3260
L3265
L3320
L3485
L3649
L3650
L3651
L3652
L3660
L3670
L3675
L3677
L3700
L3701
L3710
L3720
L3730
L3740
L3760
L3762
L3800
L3805
L3807
L3810
L3815
L3820
L3825
L3830
L3835

MAXIMUM
FEE
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$67.63
$78.66
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$64.81
$60.01
$180.86
$118.51
$138.83
$159.91
BR
$79.26
$18.59
$113.83
$630.55
$988.40
$1,045.46
$455.75
$98.00
$202.10
$319.98
$227.88
$66.38
$55.74
$122.25
$60.55
$94.53
$106.00

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L3840
L3845
L3850
L3855
L3860
L3890
L3900
L3901
L3904
L3906
L3907
L3908
L3909
L3910
L3911
L3912
L3914
L3916
L3917
L3918
L3920
L3922
L3923
L3924
L3926
L3928
L3930
L3932
L3934
L3936
L3938
L3940
L3942
L3944
L3946
L3948
L3950
L3952
L3954
L3956
L3960
L3962
L3963
L3980
L3982
L3984
L3985
L3986
L3995
L3999
L4000

MAXIMUM
FEE
$68.85
$74.75
$124.55
$142.04
$189.25
BR
$1,490.46
$1,727.11
$2,696.40
$368.05
$467.73
$56.06
$12.90
$430.85
$22.60
$108.03
$104.11
$134.90
$96.25
$81.73
$106.35
$107.44
$35.48
$120.21
$110.63
$68.46
$72.81
$57.70
$58.40
$97.46
$100.73
$121.83
$78.10
$120.58
$108.80
$58.93
$181.34
$180.43
$102.53
BR
$741.69
$771.10
$1,536.13
$338.99
$358.13
$381.44
$538.16
$546.36
$30.11
BR
$1,334.49

HCPCS
CODE
L4002
L4010
L4020
L4030
L4040
L4045
L4050
L4055
L4060
L4070
L4080
L4090
L4100
L4110
L4130
L4205
L4210
L4350
L4360
L4370
L4380
L4386
L4392
L4394
L4396
L4398
L5000
L5010
L5020
L5050
L5060
L5100
L5105
L5150
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5301
L5311
L5321
L5331
L5341
L5400
L5410
L5420
L5430

MAXIMUM
FEE
BR
$707.43
$911.13
$490.26
$404.88
$332.34
$438.46
$268.95
$307.96
$301.14
$115.28
$108.96
$103.50
$84.78
$514.66
BR
BR
$84.11
$260.54
$177.64
$101.06
$158.78
$22.74
$16.56
$162.08
$74.61
$529.11
$1,413.19
$1,986.63
$2,319.14
$3,055.60
$2,640.38
$3,730.51
$4,109.24
$4,366.66
$3,535.83
$2,611.18
$3,056.81
$4,069.51
$5,845.73
$6,123.48
$6,010.25
$2,608.01
$3,925.33
$3,294.79
$5,569.59
$5,692.90
$1,356.96
$504.40
$1,828.18
$598.80

CPT only copyright 2004 American Medical Association. All Rights Reserved.

112

HCPCS
CODE
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570
L5580
L5585
L5590
L5595
L5600
L5610
L5611
L5613
L5614
L5616
L5617
L5618
L5620
L5622
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
L5643
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
L5654

MAXIMUM
FEE
$493.43
$647.20
$1,686.56
$1,974.39
$1,732.25
$1,759.51
$1,844.14
$2,041.00
$2,263.26
$2,176.90
$2,407.86
$2,613.75
$2,787.33
$2,816.11
$4,036.41
$4,498.53
$2,767.31
$1,851.50
$2,991.00
$1,693.09
$1,594.11
$560.79
$298.15
$283.74
$365.58
$364.45
$488.79
$507.31
$318.59
$577.89
$440.46
$252.43
$327.89
$258.58
$289.60
$487.86
$1,123.94
$670.29
$636.41
$1,560.28
$647.23
$799.85
$549.26
$1,063.23
$722.21
$1,908.63
$489.39
$1,203.88
$437.05
$675.36
$355.34

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L5655
L5656
L5658
L5661
L5665
L5666
L5668
L5670
L5671
L5672
L5673
L5676
L5677
L5678
L5679
L5680
L5681
L5682
L5683
L5684
L5685
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
L5700
L5701
L5702
L5704
L5705
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5781
L5782

MAXIMUM
FEE
$265.90
$421.38
$438.84
$684.31
$676.35
$74.81
$102.46
$272.01
$664.84
$309.06
$750.94
$363.26
$531.69
$44.79
$625.76
$334.85
$1,319.76
$674.29
$1,319.76
$53.41
BR
$55.20
$71.11
$99.96
$159.74
$181.86
$163.49
$197.99
$80.48
$116.25
$186.91
$3,378.34
$3,974.83
$5,787.01
$623.25
$1,023.19
$1,014.11
$1,441.56
$408.65
$573.93
$435.40
$477.76
$820.18
$1,217.61
$1,081.89
$1,835.25
$2,032.15
$2,538.86
$1,530.30
$4,014.50
$4,232.21

HCPCS
CODE
L5785
L5790
L5795
L5810
L5811
L5812
L5814
L5816
L5818
L5822
L5824
L5826
L5828
L5830
L5840
L5845
L5848
L5850
L5855
L5856
L5857
L5910
L5920
L5925
L5930
L5940
L5950
L5960
L5962
L5964
L5966
L5968
L5970
L5972
L5974
L5975
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
L5987
L5988
L5990
L5995
L5999
L6000

MAXIMUM
FEE
$520.83
$740.61
$1,076.34
$488.06
$768.58
$608.11
$3,726.24
$852.54
$1,136.13
$1,707.09
$1,594.48
$3,133.33
$3,143.78
$2,081.73
$4,125.13
$1,798.34
$1,078.90
$128.24
$412.79
$24,080.26
$8,541.01
$363.06
$531.89
$445.73
$3,373.69
$666.93
$837.86
$1,071.61
$785.65
$1,153.10
$1,494.94
$3,646.03
$210.20
$391.05
$254.43
$465.13
$632.36
$390.06
$3,049.83
$4,136.69
$3,347.78
$675.36
$669.19
$283.03
$716.13
$7,217.73
$2,004.34
$1,820.24
BR
BR
$1,726.74

CPT only copyright 2004 American Medical Association. All Rights Reserved.

113

HCPCS
CODE
L6010
L6020
L6025
L6050
L6055
L6100
L6110
L6120
L6130
L6200
L6205
L6250
L6300
L6310
L6320
L6350
L6360
L6370
L6380
L6382
L6384
L6386
L6388
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
L6586
L6588
L6590
L6600
L6605
L6610
L6615
L6616
L6620
L6623
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6638
L6640
L6641

MAXIMUM
FEE
$1,928.26
$1,842.63
$8,029.01
$2,283.56
$2,794.11
$2,360.71
$2,556.18
$2,844.39
$2,973.13
$3,274.40
$3,750.00
$3,171.91
$4,205.48
$3,710.14
$2,284.19
$4,727.81
$3,220.83
$2,259.56
$1,283.33
$1,508.06
$1,911.30
$457.70
$474.28
$2,521.71
$3,491.13
$3,769.15
$4,110.80
$4,475.99
$1,686.19
$1,433.63
$2,080.50
$1,925.90
$3,049.84
$2,691.18
$189.21
$185.66
$185.45
$191.14
$65.03
$380.46
$728.08
$533.16
$589.66
$151.23
$216.05
$71.84
$198.33
$390.30
$2,509.08
$288.23
$195.59

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L6642
L6645
L6646
L6647
L6648
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6680
L6682
L6684
L6686
L6687
L6688
L6689
L6690
L6691
L6692
L6693
L6694
L6695
L6696
L6697
L6698
L6700
L6705
L6710
L6715
L6720
L6725
L6730
L6735
L6740
L6745
L6750
L6755
L6765
L6770
L6775
L6780
L6790
L6795
L6800
L6805
L6806
L6807

MAXIMUM
FEE
$267.81
$339.16
$3,164.46
$520.96
$3,263.71
$339.33
$90.13
$114.49
$46.18
$58.03
$169.14
$120.39
$130.48
$241.54
$261.00
$349.43
$591.81
$578.23
$558.54
$697.14
$730.86
$411.69
$567.28
$2,848.46
BR
BR
BR
BR
BR
$565.24
$364.21
$403.31
$399.48
$889.90
$502.71
$742.91
$378.10
$499.51
$447.74
$416.34
$413.13
$466.96
$443.63
$487.03
$520.54
$476.39
$1,607.21
$1,161.31
$436.38
$1,622.70
$1,630.86

HCPCS
CODE
L6808
L6809
L6810
L6825
L6830
L6835
L6840
L6845
L6850
L6855
L6860
L6865
L6867
L6868
L6870
L6872
L6873
L6875
L6880
L6881
L6882
L6890
L6895
L6900
L6905
L6910
L6915
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7010
L7015
L7020
L7025
L7030
L7035
L7040
L7045
L7170
L7180
L7181
L7185

MAXIMUM
FEE
$1,268.78
$374.08
$204.06
$1,263.40
$1,521.59
$1,331.00
$897.10
$892.54
$790.60
$914.95
$810.33
$339.75
$1,122.50
$262.71
$260.75
$1,100.06
$494.40
$941.36
$601.18
$4,101.85
$3,111.45
$227.34
$641.15
$1,980.45
$1,572.74
$1,911.81
$830.18
$7,526.83
$8,280.63
$7,467.01
$8,443.36
$8,816.49
$10,232.33
$9,997.11
$11,972.91
$12,429.70
$14,399.20
$15,134.16
$17,063.03
$3,661.34
$5,818.14
$3,411.29
$3,442.49
$5,456.73
$3,525.51
$2,900.40
$1,620.31
$5,877.94
$36,225.78
BR
$5,952.20

CPT only copyright 2004 American Medical Association. All Rights Reserved.

114

HCPCS
CODE
L7186
L7190
L7191
L7260
L7261
L7266
L7272
L7274
L7360
L7362
L7364
L7366
L7367
L7368
L7499
L7500
L7510
L7520
L7900
L8000
L8001
L8002
L8010
L8015
L8020
L8030
L8035
L8039
L8040
L8040-KM
L8040-KN
L8041
L8041-KM
L8041-KN
L8042
L8042-KM
L8042-KN
L8043
L8043-KM
L8043-KN
L8044
L8044-KM
L8044-KN
L8045
L8045-KM
L8045-KN
L8046
L8046-KM
L8046-KN
L8047
L8047-KM

MAXIMUM
FEE
$10,920.18
$7,640.38
$10,631.40
$2,252.85
$4,061.84
$992.51
$2,078.09
$6,441.46
$228.90
$251.16
$472.21
$591.33
$390.61
$506.36
BR
BR
BR
BR
$532.88
$40.55
$125.84
$165.56
BR
$60.13
$238.80
$357.48
$3,675.83
BR
$2,303.04
$2,187.88
$921.21
$2,775.94
$2,637.13
$1,110.36
$3,119.03
$2,963.06
$1,247.60
$3,493.31
$3,318.65
$1,397.33
$3,867.58
$3,674.21
$1,547.04
$2,465.15
$2,341.90
$986.06
$2,495.21
$2,370.45
$998.09
$1,278.80
$1,214.85

MEDICAL EQUIPMENT AND SUPPLIES
HCPCS
CODE
L8047-KN
L8048
L8049
L8100
L8130
L8140
L8150
L8160
L8170
L8180
L8190
L8195
L8200
L8210
L8220
L8230
L8239
L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8417
L8420
L8430
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8499
L8500
L8501
L8505
L8507
L8509
L8510
L8511
L8512
L8513
L8514
L8515
L8600
L8603
L8606
L8610
L8612

MAXIMUM
FEE
$511.53
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$112.75
$170.74
$53.59
$49.49
$18.36
$21.23
$24.38
$75.45
$21.59
$24.49
$23.34
$42.03
$66.81
$48.90
$6.69
$9.23
$14.70
BR
$752.31
$121.10
BR
$42.05
$109.56
$253.55
$73.00
$2.16
$5.21
$94.63
$63.34
$625.99
$438.96
$219.99
$586.75
$609.54

HCPCS
CODE
L8613
L8614
L8615
L8616
L8617
L8618
L8619
L8620
L8621
L8622
L8630
L8631
L8641
L8642
L8658
L8659
L8670
L8699
L9900

MAXIMUM
FEE
$272.16
$19,019.69
$452.51
$105.39
$92.05
$26.33
$8,165.01
$64.93
$0.63
$0.33
$337.74
$2,178.11
$350.90
$379.50
$305.95
$1,936.13
$558.01
BR
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

115

PRESCRIPTION SERVICES
GROUND RULES AND FEES
1.

GENERAL: Reimbursement for prescription drugs shall be limited to the amount established by the
following formulas or by the pharmacist's or health care provider's usual and customary charge,
whichever is less, AND, whenever possible, it is required that a generic equivalent be substituted
for a more expensive brand-name drug.

AWP less 10% + $5.00 for generic drugs
AWP less 10% + $4.00 for brand name drugs
2.

DETERMINING AWP: The average wholesale price (AWP) for brand name and generic drugs shall be
determined by using the publications of any recognized company, such as the PriceAlert of Medi-Span,
which makes this information available. AWP shall be based upon the date the prescription was
dispensed.

3.

AUTHORIZED PRESCRIPTION NECESSARY: Any medication, drugs, or medical supplies not
specifically prescribed by a health care provider shall not be reimbursed. In the event, however, a health
care provider recommends and/or prescribes any medication, drugs, or medical supplies that can be
purchased over-the-counter (without a prescription), and the injured employee pays for said medication,
drugs, or medical supplies directly, the injured employee is entitled to be reimbursed. The injured
employee, however, must submit copies of any receipts and/or proofs of purchase to the employer (or
insurance carrier) for proper reimbursement. Additionally, and as opposed to the injured employee
paying for said medication, drugs, or medical supplies, the pharmacy can bill the insurer directly, for
payment at the usual retail rate for said pharmacy.

4.

PRIOR AUTHORIZATION FOR MORE THAN 30-DAY SUPPLIES: Prior authorization by the employer
(or insurance carrier) is required for the dispensing of more than a 100 unit dose or 30-day supply of
medication. Any refilling of this medication will also require prior authorization.

5.

ITEMIZATION: Any bills for medication shall be itemized for proper reimbursement, except for drugs
furnished by a hospital or other health care facility which include the associated charges in the inpatient
hospital service charges.

6.

FORMS: The pharmacist or health care provider shall use the CMS 1500 form (or an equivalent form)
containing the same information. When using such a form, the pharmacist or health care provider shall
include the metric quantity and National Drug Code (NDC) number of the drug being dispensed. Items
which are prescribed for a work-related injury and do not have an NDC code shall be specifically
identified as being a supply.

7.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into a contract with pharmacists or health care providers in their community to promote the
continuity of care and the reduction of pharmacy costs. Such a contract shall supersede any limitation
specified herein, as long as any charges are less than or equal to the formulas reflected above to
determine reimbursement for prescription drugs. Please refer to K.S.A. 44-510i(e) for further clarification,
if necessary.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

116

VOCATIONAL REHABILITATION SERVICES
GROUND RULES
1.

VENDOR ADMINISTRATIVE AND CLERICAL COSTS: The cost of administrative and clerical services
shall be covered by, and be included in, the rates charged by the vendor for professional and
nonprofessional services (specified under Items A and B in the Schedule), up to the approved Maximum
Fees and limits.

2.

EXCEEDING TOTAL CASE COST LIMITS SPECIFIED BY THE SCHEDULE: The nonprofessional and
total case cost caps may be increased by the Workers Compensation Rehabilitation Administrator upon
submission of the required request documentation by the vendor.

3.

DEFINITIONS AND EXAMPLES:
Nonprofessional services:
those activities which are performed by a qualified rehabilitation
professional but which are not professional in nature, which do not directly and in themselves result in a
benefit to the parties; these include travel and waiting time.
Miscellaneous expenses: these include long distance phone charges, mileage, tolls, food and lodging,
parking, and special mailing costs (such as overnight or certified return receipt delivery).

4.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A. 44-510i(e) for further clarification, if necessary.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

117

VOCATIONAL REHABILITATION SERVICES
Maximum Fee/Limit
A. Professional services rendered by a qualified rehabilitation professional .............................................. $77.00/hr
B. Nonprofessional services rendered by a qualified rehabilitation professional........................................ $77.00/hr
subject to a case cap of...................................................................................................................$1,540.00
C. Miscellaneous Expenses: ............................................................................................................ Actual expenses
(not to exceed the
amount incurred)
D. Total of all fees and expenses in any one claim: (A + B + C above).....................................................$4,400.00

CPT only copyright 2004 American Medical Association. All Rights Reserved.

118

DEPOSITIONS, TESTIMONY, AND
MEDICAL RECORDS REPRODUCTION
GROUND RULES AND FEES
1.

DEPOSITIONS AND TESTIMONY: In determining fees for medically related depositions or testimony
rendered on behalf of employees receiving benefits under the Kansas Workers Compensation Act, the
following guideline shall be used:
A health care provider's time for giving a deposition or testimony shall be billed using CPT Code
99075. Reimbursement is to be at the health care provider's usual and customary charge, not to
exceed the following:


$300.00 for the first hour
Plus an allowance of $75.00 for each additional 15-minute increment
Travel time may also be reimbursed, but is limited to one-half the prescribed
hourly rate for a deposition or testimony

Anticipating that a health care provider may require time to prepare for a deposition and/or
testimony, charges for the review of previously reviewed records in preparation for said
deposition or court appearance are subject to the following maximum allowable fees:


2.

$75.00 for a review of medical records for the first 50 pages
$37.50 for each additional 50 pages or part thereof

INDEPENDENT MEDICAL EXAMINATIONS (IMEs) AND OTHER SPECIAL EXAMINATIONS AND/OR
REPORTS: In determining the fee for any necessary IMEs and other special examinations or reports
rendered on behalf of employees receiving benefits under the Kansas Workers Compensation Act, the
following guideline shall be used:
A health care provider's time for performing an IME or other special type of examination or report,
shall be reimbursed at the health care provider's usual and customary charge, not to exceed the
following:


$300.00 for the first hour
Plus an allowance of $75.00 for each additional 15-minute increment.
Travel time may also be reimbursed, but is limited to one-half the prescribed
hourly rate for an IME or other special type of examination or report.

Charges for any related review of medical records for, or in association with an IME, or other
special type of examination or report, are subject to the following maximum allowable fees:

$100.00 for all or part of the first 50 pages
$75.00 for each additional 50 pages or part thereof

Payments to health care providers for performing an IME and any related review of medical
records, or other special type of examination or report, are to be made in compliance with
guidelines of this fee schedule and are not subject to any form of discount (other than those
individually negotiated) which might be imposed. For example, it is not allowed that a health care
provider will be reimbursed at a discounted rate because a Workers Compensation claim had
been settled for an amount less than originally contemplated.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

119

DEPOSITIONS, TESTIMONY, AND
MEDICAL RECORDS REPRODUCTION
GROUND RULES AND FEES
Reimbursement for performing an IME, other special type of report, or examination shall
include that written documentation of such service(s), be provided to the insurance
carrier, and the person or agency requesting such service(s). There will be no charge to the
Kansas Division of Workers Compensation if a copy of such service documentation is requested.
However, further additional copies, if necessary, shall initially be requested of the insurance
carrier. In the event that requested copies are not obtainable from the carrier, prepayment will be
required to obtain additional copies from the physician or other health care provider. The
charges for providing additional copies is not to exceed the usual and customary charges of said
provider, or those as outlined in the Workers Compensation Schedule of Medical Fees,
whichever is less.
3.

REPRODUCTION OF MEDICAL RECORDS: Note: Medical records related to Workers Compensation
are not included in the medical records copying charges contained in Senate Bill 119 (2002) codified as
K.S.A. 65-4971. Reimbursement for the reproduction of an employee’s medical records (inclusive of any
ancillary expenses such as postage and sales tax, which are not to be charged as separate items) should
be at the health care provider’s usual and customary charge, not to exceed the following:
Up to 10 pages: ............ $16.00
11-50 pages:................. $28.00 ($16.00 for the 1st 10 pages
plus $12.00 for 11-50 pages)
Above 50 pages:........... $28.00, plus $0.35 per page above 50
The maximum allowable payment for the copying of medical records is applicable to any health care
provider, business, or other entity providing any forms of copying services. Any additional charges
submitted by/for copying services are prohibited. Any payments made in advance for copying medical
records that exceed the allowable payments of this fee schedule, must be refunded.
A health care provider has the responsibility to submit supporting information or documentation (except
for routine office notes) when seeking timely payment and reimbursement for the services provided. If
the payer has not received all the necessary information to process payment and thus, sends a request to
the health care provider for said information, such information should be provided at no charge, in order
to expedite payment of the service. However, in the event the payer routinely requests an entire medical
record (including all related documentation) of the services provided in order to process the claim, it is
acceptable for the health care provider to submit a bill to the payer in accordance with the above
guidelines as it relates to the reimbursement for the reproduction of medical records.
An “access fee” or “administrative fee” for providing specific and limited information is inappropriate as an
additional charge. However, when records are stored off-site, any expense involved in the retrieval of
such records will be reimbursed upon receipt of the necessary documentation substantiating the expense
incurred for retrieving said medical records.
Reimbursement for the reproduction of medical records also applies to copies of microfiche or any other
types of storage systems such as electronic media, etc. Health care providers may also charge up to
$5.00 a film for the copying of x-rays.

4.

REIMBURSEMENT FOR MILEAGE AND TRAVEL TIME ASSOCIATED WITH DEPOSITIONS,
TESTIMONY, OR INDEPENDENT MEDICAL EXAMINATIONS: Mileage (including any tolls and parking
fees actually incurred) to and from the place of a deposition, testimony, or independent medical
examination is to be reimbursed at the rate prescribed for compensation of state officers and employees
pursuant to K.S.A. 75-3203a.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

120

DEPOSITIONS, TESTIMONY, AND
MEDICAL RECORDS REPRODUCTION
GROUND RULES AND FEES
5.

CANCELLATION AND/OR RESCHEDULING OF A DEPOSITION, TESTIMONY, OR IME: If notice of
cancellation or a request to reschedule a deposition, testimony, or IME is less than two working days, a
maximum charge of $150.00 is allowable. Note: Any payment exceeding $150.00 that a health care
provider received in advance is to be refunded, as no actual deposition, testimony or IME was
provided.

6.

FAILURE OF PATIENT TO KEEP A SCHEDULED APPOINTMENT FOR AN IME: With regard
specifically to an IME, and in the event a patient fails to keep a scheduled appointment for an IME, the
health care provider is allowed to make a maximum charge of $150.00 for the services that would have
been provided by said appointment (i.e., a maximum charge of $150.00 for a “no show” appointment is
allowed). Additionally, if a review of medical records was required to prepare for an IME, charges for
such record reviews may be added to the charge of $150.00 for the services that would have been
provided by said appointment.

7.

ITEMIZATION OF CHARGES: All bills submitted for payment shall be itemized and shall include the
following CPT code(s) as appropriate, for proper reimbursement:
99075 Medical testimony (including depositions)
99199 Unlisted special service or report

8.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A. 44-510i(e) for further clarification, if necessary.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

121

AMBULANCE AND AIRCRAFT SERVICES
GROUND RULES AND FEES
1.

GENERAL: Reimbursement for ambulance services (both ground and air transportation) will be limited
to the emergency medical service's usual and customary charge, less 10%.

2.

BILLING DOCUMENTATION: When bills are submitted for reimbursement, they must include
documentation of the distance traveled, the number of passengers (patients) transported, and the specific
services required.

3.

SPECIAL SERVICES: Billings for any additional required services, such as specialized life support care,
extra attendants, or administration of medications, may be submitted with substantiation that such
additional services were warranted. Reimbursement for these additional services is also limited to the
usual and customary charge, less 10%.

4.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care
costs. Such payment agreements, if less, will supersede the limitation amounts specified herein. Please
refer to K.S.A. 44-510i(e) for further clarification, if necessary.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

122

NURSING HOMES / INTERMEDIATE CARE
FACILITIES
GROUND RULES AND FEES
1.

GENERAL: Reimbursement for nursing homes or intermediate care facilities will be limited to their usual
and customary charge, less 10%. Workers Compensation patients should not be charged a fee that is
higher than that of privately insured patients.

2.

PRIOR AUTHORIZATION: Prior Authorization from the employer (or insurance carrier) is required before
admission to a nursing home or intermediate care facility.

3.

PHYSICIAN CHARGES: All physician charges, regardless of the setting or location in which the services
were provided, are subject to the limits of this fee schedule. All physician billings must be submitted on
the CMS 1500 form (or an equivalent form) containing the same information.

4.

COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements with nursing homes or intermediate care facilities to promote the
continuity of care and the reduction of health care costs. Such payment agreements, if less, will
supersede the limitation amounts specified herein. Please refer to K.S.A. 44-510i(e) for further
clarification, if necessary.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

123

APPENDIX A - MODIFIERS
MODIFIERS: Procedure codes may be modified under the circumstances described below. The
circumstances are to be identified by the addition of a hyphen and the appropriate two-digit modifier code.
Only one modifier should be added to any single five-digit CPT code, submitted by an individual health care
provider. The modifiers that may be used are as follows:
-21 Prolonged Evaluation and Management Services: When the face-to-face or floor/unit
service(s) provided is prolonged or otherwise greater than that usually required for the
highest level of evaluation and management service within a given category, it may be
identified by adding modifier -21 to the evaluation and management code number. A report
may also be appropriate.
-22 Unusual Procedural Services: When the service(s) provided is greater than that usually
required for the listed procedure, it may be identified by adding modifier -22 to the usual
procedure code. A report may also be appropriate.
-23 Unusual Anesthesia: Occasionally, a procedure, which usually requires either no
anesthesia or local anesthesia, because of unusual circumstances must be done under
general anesthesia. This circumstance may be reported by adding modifier -23 to the
procedure code of the basic service.
-24 Unrelated Evaluation and Management Service by the Same Physician During a
Postoperative Period: The physician may need to indicate that an evaluation and
management service was performed during a postoperative period for a reason(s)
unrelated to the original procedure. This circumstance may be reported by adding modifier
-24 to the appropriate level of E/M service.
-25 Significant, Separately Identifiable Evaluation and Management Service by the Same
Physician on the Same Day of the Procedure or Other Service: The physician may
need to indicate that on the day a procedure or service identified by a CPT code was
performed, the patient’s condition required a significant, separately identifiable E/M service
above and beyond the other service provided or beyond the usual preoperative and
postoperative care associated with the procedure that was performed. The E/M service
may be prompted by the symptom or condition for which the procedure and/or service was
provided. As such, different diagnoses are not required for reporting the E/M services on
the same date. This circumstance may be reported by adding modifier -25 to the
appropriate level of E/M service. Note: This modifier is not used to report an E/M service
that resulted in a decision to perform surgery. See modifier -57. Note that this modifier
has also been approved for Ambulatory Surgery Center (ASC) and Hospital
Outpatient Use.
-26 Professional Component:
Certain procedures are a combination of a physician
component and a technical component. When the physician component is reported
separately, the service may be identified by adding modifier -26 to the usual procedure
code.
-TC Technical Component: When the professional component is reported separately, the
technical component must be reported separately. The technical component will be the
total value less the value for the professional component. Identify by adding modifier -TC to
the usual procedure code.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

124

APPENDIX A - MODIFIERS
-27 Multiple Outpatient Hospital E/M Encounters on the Same Date: For hospital outpatient
reporting purposes, utilization of hospital resources related to separate and distinct E/M
encounters performed in multiple outpatient hospital settings on the same date may be
reported by adding modifier -27 to each appropriate level outpatient and/or emergency
department E/M codes(s). This modifier provides a means of reporting circumstances
involving evaluation and management services provided by physician(s) in more than one
(multiple) outpatient hospital setting(s) (e.g., hospital emergency department, clinic). Note:
This modifier is not to be used for physician reporting of multiple E/M services performed by
the same physician on the same date. For physician reporting of all outpatient evaluation
and management services provided by the same physician on the same date and
performed in multiple outpatient setting(s) (e.g., hospital emergency department, clinic), see
Evaluation and Management Emergency Department Services, or Preventive
Medicine Services codes. Note that this modifier has also been approved for
Ambulatory Surgery Center (ASC) and Hospital Outpatient Use.
-32 Mandated Services: Services related to mandated consultation and/or related services
(e.g., PRO, third party payer, governmental, legislative or regulatory requirement) may be
identified by adding modifier -32 to the basic procedure.
-47 Anesthesia by Surgeon: Regional or general anesthesia provided by the surgeon may be
reported by adding modifier -47 to the basic service. (This does not include local
anesthesia.) Note: Modifier -47 would not be used as a modifier for the anesthesia
procedures.
-50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that
are performed at the same operative session should be identified by adding modifier -50 to
the appropriate five-digit code. Note that this modifier has also been approved for
Ambulatory Surgery Center (ASC) and Hospital Outpatient Use.
-51 Multiple Procedures: When multiple procedures, other than E/M services, are performed
at the same session by the same provider, the primary procedure or service may be
reported as listed. The additional procedure(s) or service(s) may be identified by
appending modifier -51 to the additional procedure or service code(s). Note: This modifier
should not be appended to designated "add-on" codes.
-52 Reduced Services: Under certain circumstances, a service or procedure may be partially
reduced or eliminated at the physician's discretion. Under these circumstances, the service
provided can be identified by its usual procedure code and the addition of modifier -52,
signifying that the service is reduced. This provides a means of reporting reduced services
without disturbing the identification of the basic service. Note that this modifier has also
been approved for Ambulatory Surgery Center (ASC) and Hospital Outpatient Use.
-53 Discontinued Procedure: Under certain circumstances, the physician may elect to
terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those
that threaten the well being of the patient, it may be necessary to indicate that a surgical or
diagnostic procedure was started but discontinued. This circumstance may be reported by
adding modifier -53 to the code for the discontinued procedure. Note: This modifier is not
used to report the elective cancellation of a procedure prior to the patient's anesthesia
induction and/or surgical preparation in the operating suite.
-54 Surgical Care Only: When one physician performs a surgical procedure and another
provides preoperative and/or postoperative management, surgical services may be
identified by adding modifier -54 to the usual procedure code.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

125

APPENDIX A - MODIFIERS
-55 Postoperative Management Only: When one physician performed the postoperative
management and another physician performed the surgical procedure, the postoperative
component may be identified by adding modifier -55 to the usual procedure code.
-56 Preoperative Management Only: When one physician performed the preoperative care
and evaluation and another physician performed the surgical procedure, the preoperative
component may be identified by adding modifier -56 to the usual procedure code.
-57 Decision for Surgery: An evaluation and management service that resulted in the initial
decision to perform the surgery may be identified by adding modifier -57 to the appropriate
level of E/M service.
-58 Staged or Related Procedure or Service by the Same Physician During the
Postoperative Period: The physician may need to indicate that the performance of a
procedure or service during the postoperative period was: a) planned prospectively at the
time of the original procedure (staged); b) more extensive than the original procedure; or c)
for therapy following a diagnostic surgical procedure. This circumstance may be reported
by adding modifier -58 to the staged or related procedure. Note: This modifier is not used
to report the treatment of a problem that requires a return to the operating room. See
modifier -78. Note that this modifier has also been approved for Ambulatory Surgery
Center (ASC) and Hospital Outpatient Use.
-59 Distinct Procedural Service: Under certain circumstances, the physician may need to
indicate that a procedure or service was distinct or independent from other services
performed on the same day. Modifier -59 is used to identify procedures/services that are
not normally reported together, but are appropriate under the circumstances. This may
represent a different session or patient encounter, different procedure or surgery, different
site or organ system, separate incision/excision, separate lesion, or separate injury (or area
of injury in extensive injuries) not ordinarily encountered or performed on the same day by
the same physician. However, when another already established modifier is appropriate, it
should be used rather than modifier -59. Only if no more descriptive modifier is available,
and the use of modifier -59 best explains the circumstances, should modifier -59 be used.
Note that this modifier has also been approved for Ambulatory Surgery Center (ASC)
and Hospital Outpatient Use.
-62 Two Surgeons: When two surgeons work together as primary surgeons performing distinct
part(s) of a procedure, each surgeon should report his/her distinct operative work by adding
modifier -62 to the procedure code and any associated add-on code(s) for that procedure
as long as both surgeons continue to work together as primary surgeons. Each surgeon
should report the co-surgery once using the same procedure code. If additional
procedure(s) (including add-on procedure(s)) are performed during the same surgical
session, separate code(s) may be reported without modifier -62 added. Note: If a cosurgeon acts as an assistant in the performance of additional procedure(s) during the same
surgical session, those services may be reported using separate procedure code(s) with
the modifier -80 or modifier -82 added, as appropriate.
-66 Surgical Team: Under some circumstances, highly complex procedures (requiring the
concomitant services of several physicians, often of different specialties, plus other highly
skilled, specially trained personnel and various types of complex equipment) are carried out
under the "surgical team" concept. Such circumstances may be identified by each
participating physician with the addition of modifier -66 to the basic procedure code used for
reporting services.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

126

APPENDIX A - MODIFIERS
-73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior
to the Administration of Anesthesia: Due to extenuating circumstances or those that
threaten the well being of the patient, the physician may cancel a surgical or diagnostic
procedure subsequent to the patient’s surgical preparation (including sedation when
provided, and being taken to the room where the procedure is to be performed) but prior to
the administration of anesthesia (local, regional block(s) or general). Under these
circumstances, the intended service that is prepared for but canceled can be reported by its
usual procedure code and the addition of modifier -73. Note: The elective cancellation of a
service prior to the administration of anesthesia and/or surgical preparation of the patient
should not be reported. For physician reporting of a discontinued procedure, see modifier 53.
-74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After
Administration of Anesthesia: Due to extenuating circumstances or those that threaten
the well being of the patient, the physician may terminate a surgical or diagnostic procedure
after the administration of anesthesia (local, regional block(s), general) or after the
procedure was started (incision made, intubation started, scope inserted, etc. Under these
circumstances, the procedure started but terminated can be reported by its usual procedure
number and the addition of modifier -74. Note: The elective cancellation of a service prior
to the administration of anesthesia and/or surgical preparation of the patient should not be
reported. For physician reporting of a discontinued procedure, see modifier -53.
-76 Repeat Procedure by Same Physician: The physician may need to indicate that a
procedure or service was repeated subsequent to the original procedure or service. This
circumstance may be reported by adding modifier -76 to the repeated procedure/service.
Note that this modifier has also been approved for Ambulatory Surgery Center (ASC)
and Hospital Outpatient Use.
-77 Repeat Procedure by Another Physician: The physician may need to indicate that a
basic procedure or service performed by another physician had to be repeated. This
situation may be reported by adding modifier -77 to the repeated procedure/service. Note
that this modifier has also been approved for Ambulatory Surgery Center (ASC) and
Hospital Outpatient Use.
-78 Return to the Operating Room for a Related Procedure During the Postoperative
Period: The physician may need to indicate that another procedure was performed during
the postoperative period of the initial procedure. When this subsequent procedure is
related to the first, and requires the use of the operating room, it may be reported by adding
modifier -78 to the related procedure. (For repeat procedures on the same day, see
modifier -76.) Note that this modifier has also been approved for Ambulatory Surgery
Center (ASC) and Hospital Outpatient Use.
-79 Unrelated Procedure or Service by the Same Physician During the Postoperative
Period: The physician may need to indicate that the performance of a procedure or service
during the postoperative period was unrelated to the original procedure. This circumstance
may be reported by using modifier -79. (For repeat procedures on the same day, see
modifier -76.) Note that this modifier has also been approved for Ambulatory Surgery
Center (ASC) and Hospital Outpatient Use.
-80 Assistant Surgeon: Surgical assistant services may be identified by adding modifier -80
to the usual procedure numbers(s).

CPT only copyright 2004 American Medical Association. All Rights Reserved.

127

APPENDIX A - MODIFIERS
-81 Minimum Assistant Surgeon: Minimum surgical assistant services are identified by
adding modifier -81 to the usual procedure code.
-82 Assistant Surgeon (when qualified resident surgeon not available): The unavailability
of a qualified resident surgeon is a prerequisite for use of modifier -82 appended to the
usual procedure code number(s).
-NP Non-Physician Assistant: A non-physician such as a physician assistant or registered
nurse who assists during surgery is to be identified by adding modifier -NP to the usual
procedure number.
-90 Reference (Outside) Laboratory: When laboratory procedures are performed by a party
other than the treating or reporting physician, the procedure may be identified by adding
modifier -90 to the usual procedure code.
-91 Repeat Clinical Diagnostic Laboratory Test: In the course of treatment of the patient, it
may be necessary to repeat the same laboratory test on the same day to obtain subsequent
(multiple) test results. Under these circumstances, the laboratory test performed can be
identified by its usual procedure number and the addition of modifier -91. Note: This
modifier may not be used when tests are rerun to confirm initial results; due to testing
problems with specimens or equipment; or for any other reason when a normal, one-time,
reportable result is all that is required. This modifier may not be used when other code(s)
describe a series of test results (e.g., glucose tolerance tests, evocative/suppression
testing). This modifier may only be used for laboratory test(s) performed more than once
on the same day on the same patient. Note that this modifier has also been approved
for Ambulatory Surgery Center (ASC) and Hospital Outpatient Use.
-99 Multiple Modifiers: Under certain circumstances, two or more modifiers may be
necessary to completely delineate a service. In such situations, modifier -99 should be
added to the basic procedure, and other applicable modifiers shall be listed as part of the
description of the service.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

128

APPENDIX B
QUICK REFERENCE TABLE
This appendix is provided as a supplement to this schedule of medical fees and is to provide a rapid
determination of the dollar amount associated with the particular Procedure Code. The dollar amount specified
herein was calculated by multiplying the respective conversion factor of the fee schedule section by the Unit
Value of the Procedure Code that was used for billing purposes.
The Anesthesia section was not included in this quick reference table, as the determination of the maximum
allowable payment incorporates the variable of time required for the provision of each service. Please refer to
Anesthesia section of this fee schedule for the maximum allowable payment.
RADIOLOGY CHARGES: Radiology services provided by hospitals or ambulatory surgical care facilities on an
outpatient basis are exempt from the variable discount, and are therefore subject to the Maximum Fees in the
Radiology Section.
PATHOLOGY AND LABORATORY CHARGES: Pathology and Laboratory services provided by hospitals or
ambulatory surgical care facilities are exempt from the variable discount, and are therefore subject to the
Maximum Fees in the Pathology and Laboratory Section.

Section Numbers and Their Sequences:

Surgery ................................................................. 10021 to 69990
Radiology.............................................................. 70010 to 79999
Pathology and Laboratory .................................... 80048 to 89356
Medicine ............................................................... 90281 to 99199
Evaluation and Management................................ 99201 to 99499
Home Health Procedures/Services ...................... 99500 to 99600
Home Infusion Procedures/Services.................... 99601 to 99602
Dentistry ......................................................ADA D0120 to D9999

CPT only copyright 2004 American Medical Association. All Rights Reserved.

129

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
10021
10022
10040
10060
10061
10080
10081
10120
10121
10140
10160
10180
11000
11001
11004
11005
11006
11008
11010
11011
11012
11040
11041
11042
11043
11044
11055
11056
11057
11100
11101
11200
11201
11300
11301
11302
11303
11305
11306
11307
11308
11310
11311
11312
11313
11400
11401
11402
11403
11404
11406

MAXIMUM
FEE
$239.18
$264.33
$152.89
$169.88
$304.42
$297.62
$460.02
$238.50
$443.03
$237.15
$199.77
$377.80
$84.94
$38.05
$1,011.10
$1,377.35
$1,273.38
$518.46
$792.30
$937.71
$1,365.12
$73.39
$107.36
$150.85
$411.10
$537.48
$70.67
$89.69
$110.76
$142.70
$51.64
$126.39
$31.94
$103.96
$136.58
$163.08
$196.38
$108.04
$147.45
$170.55
$203.17
$128.43
$159.00
$182.11
$239.18
$197.73
$229.67
$262.29
$295.58
$337.71
$417.21

CPT
CODE
11420
11421
11422
11423
11424
11426
11440
11441
11442
11443
11444
11446
11450
11451
11462
11463
11470
11471
11600
11601
11602
11603
11604
11606
11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
11719
11720
11721
11730
11732
11740
11750
11752
11755
11760
11762
11765
11770
11771
11772

MAXIMUM
FEE
$192.98
$245.30
$273.84
$325.48
$372.37
$521.18
$226.95
$267.72
$299.66
$367.61
$468.86
$607.47
$550.40
$750.85
$538.16
$765.80
$591.17
$791.62
$274.52
$313.93
$332.96
$368.29
$405.66
$532.73
$263.65
$311.21
$352.66
$417.21
$480.41
$636.01
$278.60
$362.85
$419.93
$485.84
$616.31
$835.11
$29.90
$47.57
$71.35
$156.29
$73.39
$65.23
$288.11
$408.38
$205.89
$298.98
$416.53
$173.27
$434.88
$822.20
$1,043.03

CPT
CODE
11900
11901
11920
11921
11922
11950
11951
11952
11954
11960
11970
11971
11975
11976
11977
11980
11981
11982
11983
12001
12002
12004
12005
12006
12007
12011
12013
12014
12015
12016
12017
12018
12020
12021
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
12052
12053
12054
12055
130

MAXIMUM
FEE
$81.54
$101.25
$376.44
$419.25
$115.52
$138.62
$189.58
$251.42
$307.81
$1,409.28
$965.57
$784.14
$208.61
$252.09
$403.62
$182.79
$224.24
$264.33
$395.47
$260.93
$277.24
$324.80
$404.98
$504.87
$568.74
$275.88
$302.38
$357.42
$449.83
$533.41
$481.09
$569.42
$457.98
$264.33
$313.25
$440.32
$432.84
$610.87
$686.97
$772.59
$347.22
$420.61
$451.19
$631.26
$764.44
$784.14
$403.62
$419.93
$448.47
$496.71
$635.33

CPT
CODE
12056
12057
13100
13101
13102
13120
13121
13122
13131
13132
13133
13150
13151
13152
13153
13160
14000
14001
14020
14021
14040
14041
14060
14061
14300
14350
15000
15001
15050
15100
15101
15120
15121
15200
15201
15220
15221
15240
15241
15260
15261
15342
15343
15350
15351
15400
15401
15570
15572
15574
15576

MAXIMUM
FEE
$852.77
$857.53
$505.55
$601.36
$172.59
$524.57
$642.81
$210.65
$572.14
$828.31
$273.84
$612.23
$649.60
$867.72
$309.85
$1,298.52
$973.04
$1,270.67
$1,075.65
$1,416.76
$1,176.21
$1,550.62
$1,219.70
$1,674.29
$1,632.84
$1,227.18
$561.27
$169.20
$799.09
$1,554.02
$386.64
$1,473.84
$510.98
$1,249.60
$275.88
$1,214.27
$249.38
$1,370.55
$307.13
$1,424.23
$348.58
$201.13
$25.14
$743.37
$101.93
$574.86
$205.89
$1,479.27
$1,354.24
$1,476.55
$1,311.44

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
15600
15610
15620
15630
15650
15732
15734
15736
15738
15740
15750
15756
15757
15758
15760
15770
15775
15776
15780
15781
15782
15783
15786
15787
15788
15789
15792
15793
15810
15811
15819
15820
15821
15822
15823
15824
15825
15826
15828
15829
15831
15832
15833
15834
15835
15836
15837
15838
15839
15840
15841

MAXIMUM
FEE
$663.87
$506.23
$752.21
$722.99
$782.78
$2,569.87
$2,609.96
$2,504.64
$2,614.04
$1,429.67
$1,483.35
$4,097.39
$4,123.21
$4,134.08
$1,331.82
$1,034.20
$591.17
$788.22
$1,322.99
$821.52
$985.28
$776.67
$374.40
$99.21
$606.79
$897.62
$616.99
$694.45
$619.70
$792.98
$1,190.48
$850.73
$918.00
$722.31
$1,045.75
$1,389.58
$1,588.67
$1,389.58
$3,672.02
$4,068.85
$1,511.89
$1,464.32
$1,375.99
$1,367.15
$1,412.00
$1,184.37
$1,233.29
$936.35
$1,316.19
$1,667.49
$2,771.00

CPT
CODE
15842
15845
15850
15851
15852
15860
15876
15877
15878
15879
15920
15922
15931
15933
15934
15935
15936
15937
15940
15941
15944
15945
15946
15950
15951
15952
15953
15956
15958
15999
16000
16010
16015
16020
16025
16030
16035
16036
17000
17003
17004
17106
17107
17108
17110
17111
17250
17260
17261
17262
17263

MAXIMUM
FEE
$4,464.32
$1,539.07
$162.40
$176.67
$189.58
$205.89
BR
BR
BR
BR
$986.63
$1,257.08
$1,096.71
$1,370.55
$1,526.84
$1,829.21
$1,515.96
$1,768.74
$1,140.88
$1,528.88
$1,472.48
$1,637.60
$2,650.73
$947.90
$1,359.68
$1,407.24
$1,588.67
$1,931.82
$1,950.84
BR
$124.35
$110.08
$258.89
$147.45
$258.21
$305.10
$392.07
$156.29
$108.72
$18.35
$354.70
$647.56
$1,155.83
$1,580.52
$157.64
$179.39
$120.27
$151.53
$192.30
$239.86
$266.36

CPT
CODE
17264
17266
17270
17271
17272
17273
17274
17276
17280
17281
17282
17283
17284
17286
17304
17305
17306
17307
17310
17340
17360
17380
17999
19000
19001
19020
19030
19100
19101
19102
19103
19110
19112
19120
19125
19126
19140
19160
19162
19180
19182
19200
19220
19240
19260
19271
19272
19290
19291
19295
19296
131

MAXIMUM
FEE
$288.11
$337.03
$209.29
$225.59
$260.93
$294.90
$358.10
$429.44
$192.30
$250.74
$290.83
$360.14
$426.73
$568.06
$1,097.39
$466.14
$467.50
$443.71
$176.67
$80.18
$199.09
$135.22
BR
$197.06
$48.24
$701.92
$304.42
$238.50
$547.68
$405.66
$1,051.87
$722.99
$693.09
$734.54
$789.58
$292.86
$881.31
$692.41
$1,468.40
$1,018.57
$918.00
$1,720.49
$1,763.30
$1,785.73
$1,946.09
$2,677.91
$2,950.39
$285.39
$127.75
$183.47
$8,791.37

CPT
CODE
19297
19298
19316
19318
19324
19325
19328
19330
19340
19342
19350
19355
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
19396
19499
20000
20005
20100
20101
20102
20103
20150
20200
20205
20206
20220
20225
20240
20245
20250
20251
20500
20501
20520
20525
20526
20550
20551
20552
20553
20600
20605

MAXIMUM
FEE
$171.91
$3,301.69
$1,344.05
$2,013.36
$786.18
$1,104.87
$787.54
$1,007.02
$711.44
$1,487.43
$1,640.31
$1,272.70
$2,486.97
$2,345.63
$4,797.95
$2,448.24
$3,148.12
$3,857.52
$3,575.53
$1,101.47
$1,274.06
$1,240.09
$241.22
BR
$343.15
$498.75
$1,070.89
$649.60
$807.25
$990.71
$1,543.14
$319.37
$445.75
$513.70
$402.26
$1,803.39
$421.29
$1,057.98
$645.53
$734.54
$245.30
$252.09
$337.71
$891.50
$137.94
$104.64
$102.60
$97.17
$110.08
$94.45
$103.28

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
20610
20612
20615
20650
20660
20661
20662
20663
20664
20665
20670
20680
20690
20692
20693
20694
20802
20805
20808
20816
20822
20824
20827
20838
20900
20902
20910
20912
20920
20922
20924
20926
20930
20931
20936
20937
20938
20950
20955
20956
20957
20962
20969
20970
20972
20973
20974
20975
20979
20982
20999

MAXIMUM
FEE
$125.03
$101.93
$407.02
$332.96
$415.17
$740.66
$824.91
$759.68
$1,139.52
$247.34
$920.72
$860.25
$448.47
$761.04
$833.75
$814.04
$4,472.47
$6,050.27
$7,514.59
$4,971.90
$4,327.74
$4,892.40
$4,516.64
$4,399.08
$1,013.81
$1,066.82
$756.96
$872.48
$689.69
$1,009.06
$908.49
$752.89
$176.67
$214.72
$186.18
$324.80
$353.34
$563.31
$4,636.23
$4,808.14
$4,520.71
$4,884.93
$5,119.35
$5,091.49
$4,676.32
$5,192.06
$95.81
$326.84
$102.60
$7,984.13
BR

CPT
CODE
21010
21015
21025
21026
21029
21030
21031
21032
21034
21040
21044
21045
21046
21047
21048
21049
21050
21060
21070
21076
21077
21079
21080
21081
21082
21083
21084
21085
21086
21087
21088
21089
21100
21110
21116
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150

MAXIMUM
FEE
$1,240.77
$745.41
$1,602.94
$903.74
$1,223.78
$769.87
$603.40
$614.27
$2,293.99
$775.31
$1,518.68
$2,040.54
$1,814.94
$2,327.97
$1,859.11
$2,212.45
$1,467.72
$1,372.59
$1,124.57
$1,882.89
$4,725.24
$3,184.14
$3,614.26
$3,284.02
$2,939.52
$2,779.83
$3,203.84
$1,256.40
$3,553.79
$3,504.86
BR
BR
$1,093.32
$1,047.11
$353.34
$1,094.00
$1,240.77
$1,236.69
$1,585.95
$4,524.79
$3,765.79
$1,281.54
$1,591.39
$1,823.10
$2,313.70
$2,308.26
$2,412.90
$2,488.33
$2,654.81
$2,624.23
$3,023.10

CPT
CODE
21151
21154
21155
21159
21160
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
21198
21199
21206
21208
21209
21210
21215
21230
21235
21240
21242
21243
21244
21245
21246
21247
21248
21249
21255
21256
21260
21261
21263
21267
21268
21270
21275
21280
21282
21295
21296
21299
21300
132

MAXIMUM
FEE
$3,634.65
$3,808.60
$4,409.96
$5,404.06
$5,295.34
$3,059.11
$3,784.82
$2,658.20
$2,988.44
$1,268.63
$3,674.74
$4,113.01
$4,469.07
$2,919.81
$2,172.36
$2,416.30
$2,286.52
$2,489.01
$1,921.63
$1,801.35
$1,904.64
$2,285.16
$1,249.60
$2,469.98
$3,679.49
$1,363.76
$1,166.02
$1,923.66
$1,780.97
$2,811.09
$1,712.34
$1,863.87
$1,551.30
$2,904.86
$1,707.58
$2,491.73
$2,391.16
$2,013.36
$2,054.13
$4,013.13
$3,401.58
$2,739.74
$3,279.95
$1,534.31
$1,403.85
$839.86
$558.55
$286.75
$644.85
BR
$217.44

CPT
CODE
21310
21315
21320
21325
21330
21335
21336
21337
21338
21339
21340
21343
21344
21345
21346
21347
21348
21355
21356
21360
21365
21366
21385
21386
21387
21390
21395
21400
21401
21406
21407
21408
21421
21422
21423
21431
21432
21433
21435
21436
21440
21445
21450
21451
21452
21453
21454
21461
21462
21465
21470

MAXIMUM
FEE
$198.41
$399.55
$403.62
$862.29
$1,063.42
$1,288.33
$1,079.05
$618.35
$1,444.62
$1,558.09
$1,378.71
$2,031.03
$2,618.11
$1,284.93
$1,629.44
$2,059.56
$2,054.81
$701.92
$796.37
$890.15
$1,863.87
$2,143.82
$1,249.60
$1,168.74
$1,338.62
$1,279.50
$1,572.36
$281.99
$790.26
$937.71
$1,115.06
$1,540.43
$1,029.44
$1,180.97
$1,422.87
$1,172.82
$1,187.09
$3,021.06
$2,166.25
$3,348.58
$691.05
$1,079.05
$724.35
$1,006.34
$1,037.60
$1,155.15
$918.68
$2,277.00
$2,625.59
$1,575.76
$1,989.58

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
21480
21485
21490
21493
21494
21495
21497
21499
21501
21502
21510
21550
21555
21556
21557
21600
21610
21615
21616
21620
21627
21630
21632
21685
21700
21705
21720
21725
21740
21742
21743
21750
21800
21805
21810
21820
21825
21899
21920
21925
21930
21935
22100
22101
22102
22103
22110
22112
22114
22116
22210

MAXIMUM
FEE
$165.80
$862.97
$1,594.79
$131.82
$705.32
$989.35
$869.76
BR
$724.35
$932.27
$826.27
$394.79
$706.00
$701.24
$1,039.64
$922.08
$1,780.97
$1,221.74
$1,487.43
$931.59
$957.42
$2,154.69
$2,159.45
$1,631.48
$752.21
$1,127.97
$612.23
$925.48
$1,858.43
$1,689.92
$2,224.68
$1,250.96
$162.40
$430.12
$867.04
$220.84
$1,009.74
BR
$373.05
$695.81
$770.55
$2,034.42
$1,312.79
$1,307.36
$1,331.14
$269.08
$1,670.21
$1,664.78
$1,666.81
$269.08
$3,026.49

CPT
CODE
22212
22214
22216
22220
22222
22224
22226
22305
22310
22315
22318
22319
22325
22326
22327
22328
22505
22520
22521
22522
22532
22533
22534
22548
22554
22556
22558
22585
22590
22595
22600
22610
22612
22614
22630
22632
22800
22802
22804
22808
22810
22812
22818
22819
22830
22840
22841
22842
22843
22844
22845

MAXIMUM
FEE
$2,472.70
$2,517.55
$709.40
$2,716.64
$2,449.60
$2,701.01
$703.28
$320.04
$400.23
$1,379.39
$2,717.32
$3,030.57
$2,317.10
$2,480.85
$2,406.11
$529.33
$211.32
$4,891.04
$4,459.56
$453.23
$2,911.66
$2,691.50
$693.09
$3,201.80
$2,395.92
$2,868.85
$2,614.04
$644.85
$2,611.32
$2,477.46
$2,102.37
$2,095.58
$2,686.06
$756.96
$2,650.05
$612.91
$2,353.79
$3,839.18
$4,472.47
$3,214.71
$3,625.13
$3,938.38
$3,869.07
$4,350.84
$1,428.99
$1,475.87
$435.56
$1,475.19
$1,551.30
$1,922.99
$1,411.32

CPT
CODE
22846
22847
22848
22849
22850
22851
22852
22855
22899
22900
22999
23000
23020
23030
23031
23035
23040
23044
23065
23066
23075
23076
23077
23100
23101
23105
23106
23107
23120
23125
23130
23140
23145
23146
23150
23155
23156
23170
23172
23174
23180
23182
23184
23190
23195
23200
23210
23220
23221
23222
23330
133

MAXIMUM
FEE
$1,467.72
$1,614.49
$700.56
$2,310.98
$1,257.08
$782.78
$1,198.64
$1,914.15
BR
$663.19
BR
$919.36
$1,223.10
$770.55
$750.17
$1,244.16
$1,264.55
$1,001.58
$336.35
$844.62
$432.84
$969.65
$1,940.65
$862.97
$804.53
$1,137.48
$857.53
$1,187.09
$1,003.62
$1,259.11
$1,084.48
$892.86
$1,223.78
$1,106.23
$1,132.05
$1,388.90
$1,191.84
$945.86
$963.53
$1,324.35
$1,287.65
$1,223.10
$1,377.35
$990.03
$1,305.32
$1,532.95
$1,592.07
$1,888.33
$2,205.66
$2,960.58
$391.39

CPT
CODE
23331
23332
23350
23395
23397
23400
23405
23406
23410
23412
23415
23420
23430
23440
23450
23455
23460
23462
23465
23466
23470
23472
23480
23485
23490
23491
23500
23505
23515
23520
23525
23530
23532
23540
23545
23550
23552
23570
23575
23585
23600
23605
23615
23616
23620
23625
23630
23650
23655
23660
23665

MAXIMUM
FEE
$1,046.43
$1,555.38
$307.13
$2,207.02
$2,047.33
$1,757.19
$1,134.77
$1,422.19
$1,626.72
$1,728.65
$1,335.22
$1,793.20
$1,343.37
$1,393.65
$1,733.40
$1,850.96
$1,994.33
$1,943.37
$2,019.47
$1,901.92
$2,194.11
$2,654.81
$1,484.71
$1,739.52
$1,494.22
$1,858.43
$356.06
$589.81
$1,034.20
$362.17
$582.33
$980.52
$1,110.98
$364.21
$528.65
$1,007.02
$1,169.42
$379.84
$644.85
$1,231.25
$539.52
$802.49
$1,343.37
$2,650.73
$434.20
$644.17
$1,034.20
$506.23
$637.37
$1,028.08
$712.12

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
23670
23675
23680
23700
23800
23802
23900
23920
23921
23929
23930
23931
23935
24000
24006
24065
24066
24075
24076
24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
24136
24138
24140
24145
24147
24149
24150
24151
24152
24153
24155
24160
24164
24200
24201
24220
24300
24301
24305

MAXIMUM
FEE
$1,091.28
$939.75
$1,348.81
$347.90
$1,820.38
$1,999.77
$2,344.95
$1,825.14
$769.87
BR
$657.08
$540.88
$884.03
$826.95
$1,259.11
$371.01
$1,011.78
$801.81
$820.16
$1,435.78
$694.45
$888.79
$1,098.07
$583.69
$1,038.28
$1,256.40
$1,555.38
$927.52
$1,026.05
$1,119.82
$903.06
$1,371.91
$1,126.61
$1,164.66
$1,343.37
$1,145.64
$1,182.33
$1,909.40
$1,732.05
$2,014.72
$1,308.04
$1,211.55
$1,495.58
$1,085.84
$884.03
$364.21
$1,020.61
$341.79
$684.26
$1,354.92
$1,038.28

CPT
CODE
24310
24320
24330
24331
24332
24340
24341
24342
24343
24344
24345
24346
24350
24351
24352
24354
24356
24360
24361
24362
24363
24365
24366
24400
24410
24420
24430
24435
24470
24495
24498
24500
24505
24515
24516
24530
24535
24538
24545
24546
24560
24565
24566
24575
24576
24577
24579
24582
24586
24587
24600

MAXIMUM
FEE
$848.70
$1,344.73
$1,294.45
$1,431.03
$1,049.15
$1,100.11
$1,164.66
$1,420.16
$1,236.01
$1,891.05
$1,226.50
$1,877.46
$793.66
$871.12
$930.92
$930.24
$956.06
$1,617.21
$1,821.06
$1,874.74
$2,387.08
$1,154.47
$1,234.65
$1,477.91
$1,879.50
$1,774.17
$1,678.37
$1,783.69
$1,218.34
$1,223.78
$1,575.08
$580.29
$856.85
$1,562.17
$1,544.50
$627.86
$1,077.01
$1,337.94
$1,405.21
$2,015.40
$522.54
$887.43
$1,170.78
$1,417.44
$547.68
$927.52
$1,521.40
$1,299.20
$1,970.55
$1,947.45
$648.92

CPT
CODE
24605
24615
24620
24635
24640
24650
24655
24665
24666
24670
24675
24685
24800
24802
24900
24920
24925
24930
24931
24935
24940
24999
25000
25001
25020
25023
25024
25025
25028
25031
25035
25040
25065
25066
25075
25076
25077
25085
25100
25101
25105
25107
25110
25111
25112
25115
25116
25118
25119
25120
25125
134

MAXIMUM
FEE
$790.94
$1,278.14
$968.29
$2,002.49
$214.72
$426.05
$748.81
$1,156.51
$1,300.56
$478.37
$780.07
$1,210.19
$1,463.64
$1,787.76
$1,232.61
$1,226.50
$970.33
$1,297.17
$1,379.39
$1,744.96
$1,897.16
BR
$731.82
$551.75
$1,114.38
$2,027.63
$1,241.45
$1,916.87
$962.85
$859.57
$1,504.41
$1,060.02
$364.89
$801.81
$688.33
$1,031.48
$1,575.76
$913.25
$661.83
$769.19
$954.70
$1,069.53
$786.18
$584.37
$711.44
$1,640.31
$1,450.05
$732.50
$989.35
$1,301.24
$1,452.09

CPT
CODE
25126
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25246
25248
25250
25251
25259
25260
25263
25265
25270
25272
25274
25275
25280
25290
25295
25300
25301
25310
25312
25315
25316
25320
25332
25335
25337
25350
25355
25360
25365
25370
25375
25390
25391
25392
25393
25394
25400
25405
25415

MAXIMUM
FEE
$1,482.67
$847.34
$1,045.07
$922.76
$1,319.59
$1,117.10
$1,445.98
$1,896.48
$924.12
$1,210.87
$824.91
$877.23
$338.39
$974.40
$928.88
$1,272.70
$683.58
$1,513.25
$1,509.17
$1,742.92
$1,287.65
$1,420.83
$1,610.42
$1,180.97
$1,420.16
$1,432.39
$1,337.94
$1,257.08
$1,204.07
$1,520.04
$1,692.63
$1,776.21
$2,056.17
$1,611.77
$1,520.04
$1,790.48
$1,549.94
$1,642.35
$1,799.32
$1,609.74
$2,048.69
$2,152.66
$2,152.66
$1,806.79
$2,200.22
$2,173.04
$2,457.07
$1,360.36
$1,894.45
$2,304.18
$2,173.04

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
25420
25425
25426
25430
25431
25440
25441
25442
25443
25444
25445
25446
25447
25449
25450
25455
25490
25491
25492
25500
25505
25515
25520
25525
25526
25530
25535
25545
25560
25565
25574
25575
25600
25605
25611
25620
25622
25624
25628
25630
25635
25645
25650
25651
25652
25660
25670
25671
25675
25676
25680

MAXIMUM
FEE
$2,525.70
$2,472.02
$2,369.42
$1,212.23
$1,407.24
$1,455.49
$1,691.28
$1,443.26
$1,392.98
$1,484.71
$1,305.32
$2,099.66
$1,399.09
$1,855.71
$1,318.23
$1,446.66
$1,677.69
$1,766.02
$2,020.15
$431.48
$852.77
$1,235.33
$960.13
$1,645.07
$1,942.69
$419.25
$814.04
$1,225.82
$438.96
$897.62
$1,046.43
$1,474.52
$483.80
$949.94
$1,225.82
$1,169.42
$494.00
$784.82
$1,195.92
$508.95
$749.49
$1,023.33
$529.33
$791.62
$1,072.93
$681.54
$1,098.07
$891.50
$739.98
$1,132.05
$778.71

CPT
CODE
25685
25690
25695
25800
25805
25810
25820
25825
25830
25900
25905
25907
25909
25915
25920
25922
25924
25927
25929
25931
25999
26010
26011
26020
26025
26030
26034
26035
26037
26040
26045
26055
26060
26070
26075
26080
26100
26105
26110
26115
26116
26117
26121
26123
26125
26130
26135
26140
26145
26160
26170

MAXIMUM
FEE
$1,299.88
$805.21
$1,137.48
$1,384.82
$1,582.56
$1,501.02
$1,121.18
$1,351.53
$1,766.02
$1,551.98
$1,547.90
$1,403.17
$1,535.67
$2,639.18
$1,213.59
$1,058.66
$1,213.59
$1,476.55
$991.39
$1,386.86
BR
$494.00
$769.19
$729.10
$725.71
$852.77
$920.04
$1,276.78
$997.51
$537.48
$822.87
$1,187.09
$459.34
$509.63
$548.36
$660.47
$563.31
$578.25
$549.72
$1,190.48
$839.18
$1,144.28
$1,063.42
$1,328.42
$525.93
$794.34
$983.24
$890.82
$905.09
$1,087.20
$706.68

CPT
CODE
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26255
26260
26261
26262
26320
26340
26350
26352
26356
26357
26358
26370
26372
26373
26390
26392
26410
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437
26440
26442
26445
26449
26450
26455
26460
26471
26474
26476
26477
26478
26479
135

MAXIMUM
FEE
$771.91
$819.48
$795.02
$1,071.57
$769.87
$976.44
$898.30
$878.59
$775.99
$1,021.97
$1,592.75
$963.53
$1,113.02
$806.57
$602.04
$527.29
$1,460.93
$1,640.99
$1,877.46
$1,734.08
$1,844.16
$1,583.91
$1,812.23
$1,727.29
$1,620.61
$1,935.22
$1,173.50
$1,395.01
$1,432.39
$1,681.08
$1,168.74
$1,457.53
$1,374.63
$1,504.41
$1,011.78
$1,090.60
$1,260.47
$1,241.45
$1,303.28
$1,717.10
$1,228.54
$1,617.89
$786.18
$780.07
$756.28
$1,211.55
$1,185.73
$1,146.32
$1,155.15
$1,258.43
$1,236.69

CPT
CODE
26480
26483
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26504
26508
26510
26516
26517
26518
26520
26525
26530
26531
26535
26536
26540
26541
26542
26545
26546
26548
26550
26551
26553
26554
26555
26556
26560
26561
26562
26565
26567
26568
26580
26587
26590
26591
26593
26596
26600
26605

MAXIMUM
FEE
$1,544.50
$1,701.47
$1,643.03
$1,548.58
$1,523.44
$1,672.25
$1,543.14
$1,647.79
$1,666.13
$2,190.03
$1,586.63
$1,242.13
$1,377.35
$1,445.98
$1,266.59
$1,192.52
$1,389.58
$1,611.77
$1,611.09
$1,356.96
$1,365.12
$941.11
$1,100.11
$657.76
$1,151.75
$1,309.40
$1,581.20
$1,346.77
$1,364.44
$1,723.89
$1,498.30
$2,800.90
$5,902.82
$4,843.48
$6,914.59
$2,531.14
$5,643.93
$1,087.88
$1,677.69
$2,333.40
$1,340.65
$1,344.73
$1,766.02
$2,314.38
$1,682.44
$2,351.75
$906.45
$1,169.42
$1,300.56
$398.19
$534.09

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
26607
26608
26615
26641
26645
26650
26665
26670
26675
26676
26685
26686
26700
26705
26706
26715
26720
26725
26727
26735
26740
26742
26746
26750
26755
26756
26765
26770
26775
26776
26785
26820
26841
26842
26843
26844
26850
26852
26860
26861
26862
26863
26910
26951
26952
26989
26990
26991
26992
27000
27001

MAXIMUM
FEE
$847.34
$847.34
$779.39
$604.76
$693.09
$905.77
$1,024.69
$565.34
$737.26
$888.79
$963.53
$1,091.28
$529.33
$687.65
$746.09
$825.59
$316.65
$583.69
$834.43
$845.98
$364.21
$638.05
$833.07
$298.30
$538.16
$733.86
$623.78
$457.30
$639.41
$784.82
$637.37
$1,546.54
$1,462.28
$1,557.41
$1,433.75
$1,590.03
$1,373.27
$1,532.27
$1,127.29
$199.09
$1,412.68
$445.75
$1,356.28
$1,048.47
$1,283.58
BR
$1,077.01
$1,284.93
$1,733.40
$805.21
$967.61

CPT
CODE
27003
27005
27006
27025
27030
27033
27035
27036
27040
27041
27047
27048
27049
27050
27052
27054
27060
27062
27065
27066
27067
27070
27071
27075
27076
27077
27078
27079
27080
27086
27087
27090
27091
27093
27095
27096
27097
27098
27100
27105
27110
27111
27120
27122
27125
27130
27132
27134
27137
27138
27140

MAXIMUM
FEE
$1,013.13
$1,299.88
$1,312.79
$1,459.57
$1,688.56
$1,738.16
$2,037.82
$1,703.51
$568.74
$1,210.87
$1,056.62
$811.32
$1,634.20
$636.69
$893.54
$1,177.57
$718.91
$779.39
$834.43
$1,391.62
$1,786.41
$1,463.64
$1,593.43
$4,053.22
$2,730.91
$4,666.13
$1,736.80
$1,709.62
$824.23
$451.87
$1,120.50
$1,482.67
$2,709.85
$399.55
$500.11
$397.51
$1,138.16
$1,140.88
$1,460.93
$1,536.35
$1,660.02
$1,575.08
$2,228.08
$1,940.65
$1,888.33
$2,503.28
$2,914.38
$3,475.64
$2,629.67
$2,739.74
$1,609.06

CPT
CODE
27146
27147
27151
27156
27158
27161
27165
27170
27175
27176
27177
27178
27179
27181
27185
27187
27193
27194
27200
27202
27215
27216
27217
27218
27220
27222
27226
27227
27228
27230
27232
27235
27236
27238
27240
27244
27245
27246
27248
27250
27252
27253
27254
27256
27257
27258
27259
27265
27266
27275
27280
136

MAXIMUM
FEE
$2,207.02
$2,537.25
$2,331.36
$3,041.44
$2,297.39
$2,150.62
$2,300.79
$2,045.97
$1,126.61
$1,579.16
$1,939.97
$1,525.48
$1,710.98
$1,795.24
$1,295.13
$1,778.93
$786.18
$1,284.93
$293.54
$1,695.35
$1,293.77
$1,863.19
$1,806.11
$2,376.21
$878.59
$1,681.76
$1,708.94
$2,907.58
$3,353.33
$808.61
$1,325.70
$1,608.38
$1,990.26
$782.78
$1,631.48
$2,034.42
$2,547.45
$676.78
$1,387.54
$826.95
$1,318.23
$1,690.60
$2,265.45
$548.36
$591.17
$1,961.72
$2,673.83
$709.40
$1,025.37
$322.76
$1,767.38

CPT
CODE
27282
27284
27286
27290
27295
27299
27301
27303
27305
27306
27307
27310
27315
27320
27323
27324
27327
27328
27329
27330
27331
27332
27333
27334
27335
27340
27345
27347
27350
27355
27356
27357
27358
27360
27365
27370
27372
27380
27381
27385
27386
27390
27391
27392
27393
27394
27395
27396
27397
27400
27403

MAXIMUM
FEE
$1,438.50
$2,857.98
$2,873.61
$2,760.81
$2,229.44
BR
$1,192.52
$1,131.37
$820.16
$690.37
$828.99
$1,251.64
$883.35
$854.13
$409.74
$665.91
$752.21
$731.14
$1,714.38
$703.28
$841.90
$1,141.56
$1,034.20
$1,195.24
$1,354.24
$641.45
$850.73
$826.27
$1,141.56
$1,068.17
$1,285.61
$1,435.78
$548.36
$1,479.95
$2,083.35
$323.44
$1,080.41
$1,064.10
$1,438.50
$1,136.12
$1,485.39
$770.55
$1,015.85
$1,246.20
$901.70
$1,166.02
$1,566.25
$1,098.75
$1,502.37
$1,193.88
$1,150.39

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
27405
27407
27409
27412
27415
27418
27420
27422
27424
27425
27427
27428
27429
27430
27435
27437
27438
27440
27441
27442
27443
27445
27446
27447
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
27475
27477
27479
27485
27486
27487
27488
27495
27496
27497
27498
27499
27500
27501
27502
27503
27506

MAXIMUM
FEE
$1,197.28
$1,378.71
$1,702.15
$2,878.36
$2,403.39
$1,467.72
$1,331.82
$1,329.78
$1,329.78
$790.26
$1,272.70
$1,875.42
$2,077.91
$1,312.79
$1,333.86
$1,166.70
$1,473.16
$1,236.69
$1,314.83
$1,552.66
$1,460.93
$2,245.75
$2,028.31
$2,703.73
$1,463.64
$1,829.21
$2,247.79
$1,691.96
$1,744.28
$1,802.03
$2,098.30
$2,348.35
$2,077.91
$2,268.85
$1,168.74
$1,310.08
$1,710.30
$1,206.11
$2,449.60
$3,133.17
$2,046.65
$2,011.32
$860.93
$932.95
$1,030.80
$1,173.50
$882.67
$863.64
$1,385.50
$1,403.17
$2,252.54

CPT
CODE
27507
27508
27509
27510
27511
27513
27514
27516
27517
27519
27520
27524
27530
27532
27535
27536
27538
27540
27550
27552
27556
27557
27558
27560
27562
27566
27570
27580
27590
27591
27592
27594
27596
27598
27599
27600
27601
27602
27603
27604
27605
27606
27607
27610
27612
27613
27614
27615
27618
27619
27620

MAXIMUM
FEE
$1,778.25
$898.98
$1,154.47
$1,219.02
$1,844.84
$2,367.38
$2,281.08
$848.70
$1,184.37
$1,978.70
$533.41
$1,354.24
$659.12
$1,079.73
$1,600.90
$2,033.06
$801.81
$1,685.84
$848.02
$1,098.75
$1,936.58
$2,225.36
$2,295.35
$614.95
$779.39
$1,605.66
$258.89
$2,542.01
$1,386.18
$1,579.84
$1,196.60
$889.47
$1,286.97
$1,300.56
BR
$748.13
$766.48
$920.72
$892.18
$762.40
$744.73
$555.15
$1,047.79
$1,134.77
$987.31
$381.20
$920.72
$1,610.42
$800.45
$1,299.88
$841.22

CPT
CODE
27625
27626
27630
27635
27637
27638
27640
27641
27645
27646
27647
27648
27650
27652
27654
27656
27658
27659
27664
27665
27675
27676
27680
27681
27685
27686
27687
27690
27691
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707
27709
27712
27715
27720
27722
27724
27725
27727
27730
27732
27734
27740
137

MAXIMUM
FEE
$1,089.24
$1,174.86
$888.79
$1,073.61
$1,343.37
$1,401.81
$1,596.83
$1,292.41
$1,939.97
$1,744.96
$1,465.68
$309.85
$1,274.74
$1,360.36
$1,270.67
$932.95
$700.56
$918.68
$671.35
$763.76
$951.98
$1,123.21
$799.77
$941.79
$1,002.26
$1,031.48
$852.09
$1,112.34
$1,314.15
$212.00
$911.21
$1,085.16
$1,206.79
$1,105.55
$1,797.96
$2,024.91
$982.56
$1,377.35
$682.22
$1,342.69
$1,863.19
$1,874.06
$1,575.08
$1,558.09
$2,286.52
$2,045.30
$1,816.98
$1,054.58
$748.13
$1,094.00
$1,282.90

CPT
CODE
27742
27745
27750
27752
27756
27758
27759
27760
27762
27766
27780
27781
27784
27786
27788
27792
27808
27810
27814
27816
27818
27822
27823
27824
27825
27826
27827
27828
27829
27830
27831
27832
27840
27842
27846
27848
27860
27870
27871
27880
27881
27882
27884
27886
27888
27889
27892
27893
27894
27899
28001

MAXIMUM
FEE
$1,196.60
$1,353.56
$574.86
$914.61
$977.12
$1,551.30
$1,793.88
$553.11
$841.22
$1,154.47
$491.28
$719.59
$1,004.30
$525.25
$733.18
$1,081.08
$549.04
$826.27
$1,429.67
$521.86
$859.57
$1,596.83
$1,811.55
$501.47
$936.35
$1,278.14
$1,983.46
$2,235.56
$896.94
$590.49
$661.83
$925.48
$596.60
$835.11
$1,314.15
$1,547.22
$319.37
$1,817.66
$1,243.49
$1,405.89
$1,570.32
$1,134.09
$1,029.44
$1,168.74
$1,267.95
$1,214.95
$954.70
$943.83
$1,348.81
BR
$411.10

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
28002
28003
28005
28008
28010
28011
28020
28022
28024
28030
28035
28043
28045
28046
28050
28052
28054
28060
28062
28070
28072
28080
28086
28088
28090
28092
28100
28102
28103
28104
28106
28107
28108
28110
28111
28112
28113
28114
28116
28118
28119
28120
28122
28124
28126
28130
28140
28150
28153
28160
28171

MAXIMUM
FEE
$694.45
$1,070.89
$1,079.05
$650.28
$379.16
$544.96
$797.05
$712.12
$689.69
$716.87
$790.26
$530.01
$727.74
$1,377.35
$661.15
$636.69
$585.73
$773.95
$941.79
$749.49
$731.14
$621.74
$917.33
$693.09
$688.33
$633.97
$979.16
$1,006.34
$816.08
$767.16
$852.77
$870.44
$629.90
$667.27
$812.00
$740.66
$778.71
$1,551.30
$1,057.98
$885.39
$781.43
$913.25
$1,025.37
$706.00
$555.15
$1,091.28
$1,021.97
$641.45
$572.82
$596.60
$1,110.30

CPT
CODE
28173
28175
28190
28192
28193
28200
28202
28208
28210
28220
28222
28225
28226
28230
28232
28234
28238
28240
28250
28260
28261
28262
28264
28270
28272
28280
28285
28286
28288
28289
28290
28292
28293
28294
28296
28297
28298
28299
28300
28302
28304
28305
28306
28307
28308
28309
28310
28312
28313
28315
28320

MAXIMUM
FEE
$1,189.80
$848.02
$378.48
$726.39
$818.12
$699.21
$1,015.85
$662.51
$908.49
$663.19
$784.14
$570.78
$672.03
$642.81
$567.38
$575.54
$1,088.56
$649.60
$839.86
$1,047.11
$1,487.43
$2,169.64
$1,331.82
$697.17
$573.50
$825.59
$682.22
$674.06
$768.51
$1,089.24
$864.32
$1,047.11
$1,428.31
$1,160.59
$1,258.43
$1,320.27
$1,100.11
$1,406.57
$1,229.22
$1,212.23
$1,247.56
$1,255.04
$918.68
$1,240.09
$796.37
$1,544.50
$805.89
$720.27
$747.45
$704.64
$1,175.54

CPT
CODE
28322
28340
28341
28344
28345
28360
28400
28405
28406
28415
28420
28430
28435
28436
28445
28450
28455
28456
28465
28470
28475
28476
28485
28490
28495
28496
28505
28510
28515
28525
28530
28531
28540
28545
28546
28555
28570
28575
28576
28585
28600
28605
28606
28615
28630
28635
28636
28645
28660
28665
28666
138

MAXIMUM
FEE
$1,274.74
$968.97
$1,113.02
$714.15
$877.23
$1,772.14
$415.85
$686.97
$963.53
$2,164.89
$2,193.43
$392.75
$530.01
$773.95
$1,982.78
$359.46
$471.57
$494.00
$977.80
$366.93
$457.30
$604.08
$813.36
$220.16
$268.40
$743.37
$845.98
$186.86
$239.86
$767.84
$179.39
$676.10
$318.69
$350.62
$722.31
$1,170.78
$292.19
$515.74
$612.91
$1,123.21
$337.71
$423.33
$706.68
$1,161.27
$235.11
$284.71
$480.41
$661.83
$178.03
$244.62
$609.51

CPT
CODE
28675
28705
28715
28725
28730
28735
28737
28740
28750
28755
28760
28800
28805
28810
28820
28825
28899
29000
29010
29015
29020
29025
29035
29040
29044
29046
29049
29055
29058
29065
29075
29085
29086
29105
29125
29126
29130
29131
29200
29220
29240
29260
29280
29305
29325
29345
29355
29358
29365
29405
29425

MAXIMUM
FEE
$714.15
$2,327.29
$1,696.71
$1,473.16
$1,420.16
$1,380.74
$1,215.63
$1,365.12
$1,380.06
$780.07
$1,139.52
$1,028.76
$1,032.16
$783.46
$853.45
$752.21
BR
$381.20
$393.43
$385.28
$378.48
$406.34
$384.60
$342.47
$437.60
$411.10
$156.96
$342.47
$205.89
$159.00
$146.09
$154.93
$112.12
$150.85
$114.16
$138.62
$69.99
$90.37
$95.81
$95.13
$109.40
$91.05
$91.05
$387.32
$423.33
$230.35
$236.47
$253.45
$206.57
$150.85
$162.40

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
29435
29440
29445
29450
29505
29515
29520
29530
29540
29550
29580
29590
29700
29705
29710
29715
29720
29730
29740
29750
29799
29800
29804
29805
29806
29807
29819
29820
29821
29822
29823
29824
29825
29826
29827
29830
29834
29835
29836
29837
29838
29840
29843
29844
29845
29846
29847
29848
29850
29851
29855

MAXIMUM
FEE
$199.77
$91.05
$260.93
$259.57
$131.82
$114.84
$96.49
$95.13
$67.27
$64.55
$87.66
$92.41
$103.96
$115.52
$207.93
$150.17
$132.50
$114.16
$165.80
$171.23
BR
$976.44
$1,163.98
$852.77
$1,899.88
$1,850.28
$1,066.14
$983.92
$1,074.29
$1,045.07
$1,139.52
$1,167.38
$1,064.10
$1,226.50
$2,004.53
$818.80
$894.22
$914.61
$1,055.94
$962.85
$1,077.69
$793.66
$852.09
$898.30
$1,017.21
$941.11
$974.40
$808.61
$977.80
$1,711.66
$1,439.18

CPT
CODE
29856
29860
29861
29862
29863
29866
29867
29868
29870
29871
29873
29874
29875
29876
29877
29879
29880
29881
29882
29883
29884
29885
29886
29887
29888
29889
29891
29892
29893
29894
29895
29897
29898
29899
29900
29901
29902
29999
30000
30020
30100
30110
30115
30117
30118
30120
30124
30125
30130
30140
30150

MAXIMUM
FEE
$1,846.20
$1,110.30
$1,225.14
$1,363.08
$1,346.77
$1,876.10
$2,240.99
$3,038.04
$732.50
$919.36
$923.44
$963.53
$898.98
$1,106.91
$1,042.35
$1,123.21
$1,176.21
$1,089.92
$1,179.61
$1,493.54
$1,038.28
$1,264.55
$1,064.78
$1,257.75
$1,797.96
$2,115.96
$1,174.18
$1,232.61
$824.91
$938.39
$920.72
$966.25
$1,071.57
$1,820.38
$828.99
$913.25
$975.08
BR
$381.88
$327.52
$202.49
$340.43
$714.15
$1,125.25
$1,337.94
$833.75
$472.93
$1,095.35
$630.58
$677.46
$1,429.67

CPT
CODE
30160
30200
30210
30220
30300
30310
30320
30400
30410
30420
30430
30435
30450
30460
30462
30465
30520
30540
30545
30560
30580
30600
30620
30630
30801
30802
30901
30903
30905
30906
30915
30920
30930
30999
31000
31002
31020
31030
31032
31040
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
139

MAXIMUM
FEE
$1,405.89
$167.16
$222.20
$400.91
$390.71
$355.38
$811.32
$1,789.80
$2,224.68
$2,393.88
$1,629.44
$2,190.03
$2,883.80
$1,421.51
$2,873.61
$1,674.29
$871.12
$1,202.04
$1,694.67
$416.53
$1,042.35
$965.57
$1,043.71
$1,064.78
$360.81
$462.74
$182.11
$297.62
$383.92
$444.39
$983.24
$1,331.14
$203.85
BR
$277.24
$360.81
$799.09
$1,222.42
$977.80
$1,364.44
$825.59
$1,085.84
$720.27
$1,337.26
$1,772.14
$1,982.10
$1,918.91
$2,026.27
$1,848.92
$1,841.45
$1,562.85

CPT
CODE
31200
31201
31205
31225
31230
31231
31233
31235
31237
31238
31239
31240
31254
31255
31256
31267
31276
31287
31288
31290
31291
31292
31293
31294
31299
31300
31320
31360
31365
31367
31368
31370
31375
31380
31382
31390
31395
31400
31420
31500
31502
31505
31510
31511
31512
31513
31515
31520
31525
31526
31527

MAXIMUM
FEE
$983.24
$1,246.88
$1,547.90
$2,630.34
$2,927.29
$310.53
$453.91
$530.69
$574.18
$595.24
$1,176.21
$311.21
$539.52
$801.13
$390.03
$631.26
$1,010.42
$458.66
$532.73
$2,089.46
$2,194.79
$1,804.75
$1,962.40
$2,270.89
BR
$2,067.72
$1,087.88
$2,389.80
$3,159.68
$3,093.76
$3,721.62
$3,086.29
$2,865.45
$2,885.84
$2,976.89
$3,684.25
$4,203.39
$1,692.63
$1,398.41
$208.61
$68.63
$143.37
$365.57
$371.69
$370.33
$253.45
$372.37
$293.54
$440.32
$305.78
$366.93

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
31528
31529
31530
31531
31535
31536
31540
31541
31545
31546
31560
31561
31570
31571
31575
31576
31577
31578
31579
31580
31582
31584
31585
31586
31587
31588
31590
31595
31599
31600
31601
31603
31605
31610
31611
31612
31613
31614
31615
31620
31622
31623
31624
31625
31628
31629
31630
31631
31632
31633
31635

MAXIMUM
FEE
$273.84
$313.25
$381.88
$417.21
$367.61
$413.82
$475.65
$521.18
$689.01
$1,051.87
$613.59
$668.63
$668.63
$489.24
$209.97
$392.75
$437.60
$499.43
$423.33
$1,990.26
$3,338.38
$2,681.31
$794.34
$1,327.74
$1,512.57
$1,886.29
$1,582.56
$1,329.78
BR
$758.32
$491.96
$427.41
$349.26
$1,210.19
$894.22
$142.02
$748.13
$1,117.10
$329.56
$485.84
$586.41
$642.81
$598.64
$636.69
$748.13
$1,257.75
$398.87
$440.32
$137.94
$163.76
$682.22

CPT
CODE
31636
31637
31638
31640
31641
31643
31645
31646
31656
31700
31708
31710
31715
31717
31720
31725
31730
31750
31755
31760
31766
31770
31775
31780
31781
31785
31786
31800
31805
31820
31825
31830
31899
32000
32002
32005
32019
32020
32035
32036
32095
32100
32110
32120
32124
32140
32141
32150
32151
32160
32200

MAXIMUM
FEE
$432.84
$154.25
$480.41
$506.91
$494.68
$334.31
$576.90
$525.93
$653.68
$243.94
$238.50
$125.03
$103.28
$714.15
$99.21
$187.54
$358.10
$2,151.98
$2,836.23
$2,433.29
$3,296.93
$2,413.58
$2,600.45
$2,065.00
$2,569.87
$1,968.51
$2,737.71
$1,185.05
$1,503.73
$715.51
$1,020.61
$726.39
BR
$318.01
$376.44
$602.04
$1,668.17
$390.03
$1,068.85
$1,187.77
$1,011.10
$1,712.34
$2,502.60
$1,372.59
$1,478.59
$1,599.54
$1,597.50
$1,609.74
$1,638.27
$1,073.61
$1,753.79

CPT
CODE
32201
32215
32220
32225
32310
32320
32400
32402
32405
32420
32440
32442
32445
32480
32482
32484
32486
32488
32491
32500
32501
32520
32522
32525
32540
32601
32602
32603
32604
32605
32606
32650
32651
32652
32653
32654
32655
32656
32657
32658
32659
32660
32661
32662
32663
32664
32665
32800
32810
32815
32820
140

MAXIMUM
FEE
$1,693.99
$1,343.37
$2,739.74
$1,600.90
$1,544.50
$2,684.03
$270.44
$930.92
$184.14
$203.85
$2,813.81
$3,042.12
$2,903.50
$2,660.24
$2,813.13
$2,376.89
$2,758.77
$2,929.32
$2,499.20
$2,545.41
$466.82
$2,446.20
$2,688.10
$2,920.49
$1,786.41
$583.01
$632.61
$811.32
$913.93
$733.18
$877.91
$1,290.37
$1,490.82
$2,131.59
$1,468.40
$1,465.68
$1,504.41
$1,539.07
$1,579.84
$1,398.41
$1,401.81
$1,966.47
$1,551.98
$1,861.83
$2,164.89
$1,640.31
$1,751.75
$1,558.77
$1,523.44
$2,535.89
$2,454.35

CPT
CODE
32850
32851
32852
32853
32854
32855
32856
32900
32905
32906
32940
32960
32997
32999
33010
33011
33015
33020
33025
33030
33031
33050
33120
33130
33140
33141
33200
33201
33206
33207
33208
33210
33211
33212
33213
33214
33215
33216
33217
33218
33220
33222
33223
33224
33225
33226
33233
33234
33235
33236
33237

MAXIMUM
FEE
BR
$4,863.86
$5,494.44
$5,866.80
$6,305.08
BR
BR
$2,243.03
$2,302.15
$2,895.35
$2,148.58
$253.45
$573.50
BR
$215.40
$218.80
$841.22
$1,434.42
$1,368.51
$2,101.69
$2,370.78
$1,648.47
$2,695.58
$2,333.40
$2,287.20
$482.45
$1,424.91
$1,228.54
$790.94
$903.74
$915.97
$322.08
$334.99
$633.97
$717.55
$897.62
$563.99
$704.64
$705.32
$687.65
$691.05
$656.40
$780.75
$924.80
$819.48
$890.82
$461.38
$903.74
$1,151.75
$1,472.48
$1,564.89

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
33238
33240
33241
33243
33244
33245
33246
33249
33250
33251
33253
33261
33282
33284
33300
33305
33310
33315
33320
33321
33322
33330
33332
33335
33400
33401
33403
33404
33405
33406
33410
33411
33412
33413
33414
33415
33416
33417
33420
33422
33425
33426
33427
33430
33460
33463
33464
33465
33468
33470
33471

MAXIMUM
FEE
$1,722.53
$859.57
$435.56
$2,457.75
$1,605.66
$1,641.67
$2,279.72
$1,590.03
$2,439.41
$2,717.32
$3,348.58
$2,717.32
$572.82
$419.93
$2,016.76
$2,384.37
$2,080.63
$2,476.78
$1,835.33
$2,230.12
$2,293.31
$2,336.80
$2,542.69
$3,226.27
$3,272.47
$2,779.16
$2,898.75
$3,216.07
$3,963.52
$4,208.82
$3,642.12
$4,092.63
$4,663.41
$4,804.07
$3,321.40
$2,917.09
$3,279.27
$3,135.89
$2,313.70
$2,942.91
$2,984.36
$3,727.06
$4,424.90
$3,777.34
$2,599.09
$2,867.49
$3,042.12
$3,118.23
$3,244.61
$2,208.38
$2,399.99

CPT
CODE
33472
33474
33475
33476
33478
33496
33500
33501
33502
33503
33504
33505
33506
33508
33510
33511
33512
33513
33514
33516
33517
33518
33519
33521
33522
33523
33530
33533
33534
33535
33536
33542
33545
33572
33600
33602
33606
33608
33610
33611
33612
33615
33617
33619
33641
33645
33647
33660
33665
33670
33681

MAXIMUM
FEE
$2,554.92
$2,518.91
$3,606.79
$2,723.44
$2,962.62
$2,987.08
$2,760.81
$1,893.77
$2,380.97
$2,265.45
$2,701.01
$2,845.07
$3,712.11
$30.58
$3,362.17
$3,491.95
$3,665.22
$3,693.76
$3,766.47
$3,993.42
$256.85
$483.80
$710.76
$938.39
$1,165.34
$1,394.33
$585.05
$3,448.46
$3,695.80
$3,908.48
$4,144.95
$3,124.34
$3,905.09
$443.71
$3,150.16
$3,038.72
$3,311.20
$3,385.95
$3,307.81
$3,561.26
$3,759.67
$3,489.23
$3,976.43
$4,900.55
$2,312.34
$2,730.23
$3,103.96
$3,254.13
$3,149.48
$3,583.00
$3,372.36

CPT
CODE
33684
33688
33690
33692
33694
33697
33702
33710
33720
33722
33730
33732
33735
33736
33737
33750
33755
33762
33764
33766
33767
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33786
33788
33800
33802
33803
33813
33814
33820
33822
33824
33840
33845
33851
33852
33853
33860
33861
33863
33870
33875
141

MAXIMUM
FEE
$3,172.59
$3,107.35
$2,148.58
$3,341.10
$3,627.17
$3,728.42
$2,901.47
$3,262.28
$2,891.95
$2,957.18
$3,620.38
$3,067.26
$2,187.99
$2,607.92
$2,437.37
$2,225.36
$2,295.35
$2,378.93
$2,374.85
$2,586.86
$2,715.96
$3,892.86
$3,574.85
$3,420.60
$3,538.84
$3,724.34
$3,700.56
$4,278.13
$3,697.84
$4,376.66
$3,781.42
$4,166.01
$2,889.91
$1,818.34
$1,976.67
$2,208.38
$2,352.43
$2,865.45
$1,835.33
$1,963.76
$2,196.82
$2,244.39
$2,488.33
$2,382.33
$2,525.02
$3,459.33
$4,071.56
$4,465.67
$4,762.62
$4,660.69
$3,521.85

CPT
CODE
33877
33910
33915
33916
33917
33918
33919
33920
33922
33924
33930
33933
33935
33940
33944
33945
33960
33961
33967
33968
33970
33971
33973
33974
33975
33976
33977
33978
33979
33980
33999
34001
34051
34101
34111
34151
34201
34203
34401
34421
34451
34471
34490
34501
34502
34510
34520
34530
34800
34802
34803

MAXIMUM
FEE
$4,390.93
$2,690.82
$2,193.43
$2,770.32
$2,738.39
$2,894.67
$4,304.63
$3,402.26
$2,544.05
$553.79
BR
BR
$6,699.19
BR
BR
$4,723.20
$1,823.78
$1,047.79
$477.69
$63.87
$668.63
$1,147.68
$970.33
$1,627.40
$2,054.81
$2,291.27
$2,249.15
$2,490.37
$4,596.82
$6,099.19
BR
$1,452.09
$1,708.94
$1,136.12
$1,134.09
$2,638.50
$1,144.28
$1,824.46
$2,620.15
$1,346.09
$2,860.70
$1,127.97
$1,127.97
$1,811.55
$2,906.22
$2,079.27
$1,939.97
$1,830.57
$2,186.63
$2,378.25
$2,459.79

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
34804
34805
34808
34812
34813
34820
34825
34826
34830
34831
34832
34833
34834
34900
35001
35002
35005
35011
35013
35021
35022
35045
35081
35082
35091
35092
35102
35103
35111
35112
35121
35122
35131
35132
35141
35142
35151
35152
35180
35182
35184
35188
35189
35190
35201
35206
35207
35211
35216
35221
35226

MAXIMUM
FEE
$2,378.25
$2,274.97
$409.06
$687.65
$475.65
$977.12
$1,316.87
$402.26
$3,448.46
$3,506.90
$3,710.07
$1,225.82
$562.63
$1,755.83
$2,166.93
$2,287.20
$1,948.81
$1,931.82
$2,356.51
$2,160.13
$2,455.03
$1,865.23
$2,944.95
$4,012.45
$3,665.90
$4,673.60
$3,224.23
$4,210.86
$2,635.10
$3,122.98
$3,161.71
$3,631.25
$2,677.23
$3,166.47
$2,154.02
$2,508.03
$2,430.57
$2,751.98
$1,463.64
$3,197.73
$1,953.56
$1,632.16
$2,978.25
$1,424.23
$1,791.84
$1,469.08
$1,285.61
$2,436.01
$2,058.89
$2,551.52
$1,623.33

CPT
CODE
35231
35236
35241
35246
35251
35256
35261
35266
35271
35276
35281
35286
35301
35311
35321
35331
35341
35351
35355
35361
35363
35371
35372
35381
35390
35400
35450
35452
35454
35456
35458
35459
35460
35470
35471
35472
35473
35474
35475
35476
35480
35481
35482
35483
35484
35485
35490
35491
35492
35493
35494

MAXIMUM
FEE
$2,209.05
$1,859.11
$2,559.68
$2,821.28
$3,125.02
$1,988.90
$1,924.34
$1,626.72
$2,427.17
$2,634.42
$2,959.22
$1,800.00
$2,023.55
$2,859.34
$1,738.16
$2,793.42
$2,693.54
$2,436.69
$1,982.78
$2,977.57
$3,193.65
$1,612.45
$1,943.37
$1,751.75
$319.37
$307.81
$1,009.06
$706.68
$623.78
$754.92
$963.53
$880.63
$619.70
$6,672.69
$7,543.81
$4,882.21
$4,511.20
$6,500.78
$4,500.33
$3,475.64
$1,113.02
$786.18
$685.62
$830.35
$1,051.19
$973.04
$1,122.53
$790.26
$700.56
$847.34
$1,060.02

CPT
CODE
35495
35500
35501
35506
35507
35508
35509
35510
35511
35512
35515
35516
35518
35521
35522
35525
35526
35531
35533
35536
35541
35546
35548
35549
35551
35556
35558
35560
35563
35565
35566
35571
35572
35583
35585
35587
35600
35601
35606
35612
35616
35621
35623
35626
35631
35636
35641
35642
35645
35646
35647
142

MAXIMUM
FEE
$990.71
$636.01
$2,060.92
$2,166.25
$2,166.93
$2,098.98
$1,998.41
$2,394.56
$2,264.09
$2,349.03
$2,081.99
$1,727.29
$2,248.47
$2,380.29
$2,281.76
$2,179.16
$3,125.70
$3,780.74
$2,947.67
$3,332.27
$2,756.73
$2,715.96
$2,303.51
$2,510.07
$2,830.80
$2,343.60
$2,285.16
$3,392.06
$2,587.54
$2,482.89
$2,856.62
$2,599.09
$681.54
$2,420.38
$3,025.81
$2,692.18
$494.68
$1,944.05
$2,060.24
$1,742.92
$1,760.58
$2,140.43
$2,573.95
$2,963.98
$3,576.89
$3,112.79
$2,652.77
$1,962.40
$1,914.83
$3,288.78
$2,965.34

CPT
CODE
35650
35651
35654
35656
35661
35663
35665
35666
35671
35681
35682
35683
35685
35686
35691
35693
35694
35695
35697
35700
35701
35721
35741
35761
35800
35820
35840
35860
35870
35875
35876
35879
35881
35901
35903
35905
35907
36000
36002
36005
36010
36011
36012
36013
36014
36015
36100
36120
36140
36145
36160

MAXIMUM
FEE
$2,037.82
$2,645.97
$2,656.17
$2,094.90
$2,075.87
$2,378.25
$2,267.49
$2,440.08
$2,132.27
$159.68
$719.59
$850.05
$405.66
$335.67
$1,971.91
$1,716.42
$2,065.68
$2,065.00
$301.02
$307.81
$1,002.26
$857.53
$933.63
$686.97
$856.85
$1,489.46
$1,110.98
$702.60
$2,366.02
$1,132.73
$1,823.78
$1,761.94
$1,981.42
$993.43
$1,142.92
$3,312.56
$3,665.90
$51.64
$339.07
$588.45
$1,489.46
$2,122.76
$1,542.47
$1,638.27
$1,585.27
$1,861.15
$1,043.71
$873.84
$1,015.17
$998.19
$1,104.19

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
36200
36215
36216
36217
36218
36245
36246
36247
36248
36260
36261
36262
36299
36400
36405
36406
36410
36415
36416
36420
36425
36430
36440
36450
36455
36460
36468
36469
36470
36471
36475
36476
36478
36479
36481
36500
36510
36511
36512
36513
36514
36515
36516
36522
36540
36550
36555
36556
36557
36558
36560

MAXIMUM
FEE
$1,344.05
$2,175.76
$2,359.22
$4,225.81
$419.93
$2,520.27
$2,420.38
$3,824.23
$348.58
$1,077.69
$665.91
$494.68
BR
$46.89
$40.77
$31.94
$32.62
$5.44
$6.80
$96.49
$70.67
$72.71
$96.49
$214.04
$244.62
$653.00
BR
BR
$264.33
$328.20
$3,973.72
$777.35
$3,659.79
$784.82
$900.34
$347.22
$345.19
$173.27
$173.95
$179.39
$1,276.78
$4,628.75
$5,799.53
$2,321.85
$50.96
$51.64
$580.97
$564.66
$1,821.06
$1,793.88
$2,478.82

CPT
CODE
36561
36563
36565
36566
36568
36569
36570
36571
36575
36576
36578
36580
36581
36582
36583
36584
36585
36589
36590
36595
36596
36597
36600
36620
36625
36640
36660
36680
36800
36810
36815
36818
36819
36820
36821
36822
36823
36825
36830
36831
36832
36833
36834
36835
36838
36860
36861
36870
37140
37145
37160

MAXIMUM
FEE
$2,455.71
$2,293.99
$2,124.12
$2,212.45
$650.28
$635.33
$2,653.45
$2,656.85
$334.99
$701.92
$1,007.02
$573.50
$1,571.00
$2,133.63
$2,138.39
$568.06
$2,229.44
$322.76
$482.45
$1,432.39
$305.10
$250.74
$56.40
$99.21
$196.38
$227.63
$134.54
$122.31
$303.74
$413.14
$280.63
$1,320.27
$1,513.25
$1,513.93
$1,004.30
$715.51
$2,253.22
$1,101.47
$1,280.86
$884.03
$1,130.01
$1,275.42
$1,091.96
$845.30
$2,240.31
$266.36
$290.15
$3,975.75
$2,448.24
$2,626.27
$2,283.12

CPT
CODE
37180
37181
37182
37183
37195
37200
37201
37202
37203
37204
37205
37206
37207
37208
37209
37215
37216
37250
37251
37500
37501
37565
37600
37605
37606
37607
37609
37615
37616
37617
37618
37620
37650
37660
37700
37720
37730
37735
37760
37765
37766
37780
37785
37788
37790
37799
38100
38101
38102
38115
38120
143

MAXIMUM
FEE
$2,593.65
$2,786.63
$1,632.84
$780.07
$474.97
$429.44
$536.13
$622.42
$2,598.41
$1,734.08
$858.21
$398.87
$853.45
$412.46
$215.40
$1,963.08
$1,891.05
$207.93
$159.00
$1,315.51
BR
$1,210.19
$1,309.40
$1,490.14
$819.48
$716.19
$534.77
$715.51
$1,823.78
$2,319.13
$618.35
$1,167.38
$913.93
$2,207.02
$477.69
$688.33
$855.49
$1,188.45
$1,167.38
$845.30
$1,025.37
$489.92
$647.56
$2,262.06
$903.06
BR
$1,530.91
$1,615.17
$479.05
$1,660.70
$1,804.75

CPT
CODE
38129
38200
38204
38205
38206
38207
38208
38209
38210
38211
38212
38213
38214
38215
38220
38221
38230
38240
38241
38242
38300
38305
38308
38380
38381
38382
38500
38505
38510
38520
38525
38530
38542
38550
38555
38562
38564
38570
38571
38572
38589
38700
38720
38724
38740
38745
38746
38747
38760
38765
38770

MAXIMUM
FEE
BR
$251.42
BR
$152.21
$152.21
$112.12
$122.31
$107.36
$116.87
$116.87
$116.87
$116.87
$97.85
$116.87
$330.24
$364.89
$558.55
$230.35
$232.39
$175.99
$443.71
$766.48
$749.49
$946.54
$1,465.68
$1,167.38
$537.48
$222.88
$862.97
$784.82
$689.69
$914.61
$747.45
$794.34
$1,660.02
$1,185.73
$1,180.29
$974.40
$1,458.21
$1,734.76
BR
$1,034.20
$1,643.71
$1,743.60
$1,104.87
$1,417.44
$488.56
$487.88
$1,408.60
$2,120.72
$1,383.46

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
38780
38790
38792
38794
38999
39000
39010
39200
39220
39400
39499
39501
39502
39503
39520
39530
39531
39540
39541
39545
39560
39561
39599
40490
40500
40510
40520
40525
40527
40530
40650
40652
40654
40700
40701
40702
40720
40761
40799
40800
40801
40804
40805
40806
40808
40810
40812
40814
40816
40818
40819

MAXIMUM
FEE
$1,810.19
$595.92
$69.31
$557.19
BR
$787.54
$1,425.59
$1,565.57
$1,979.38
$764.44
BR
$1,450.73
$1,738.84
$9,451.85
$1,788.44
$1,671.57
$1,764.66
$1,445.30
$1,554.02
$1,542.47
$1,346.09
$1,981.42
BR
$197.73
$784.82
$800.45
$864.32
$998.19
$1,186.41
$934.31
$733.86
$848.70
$985.28
$1,548.58
$1,956.96
$1,529.55
$1,712.34
$1,826.50
BR
$288.79
$466.14
$322.08
$508.27
$148.13
$252.09
$293.54
$428.76
$595.24
$627.86
$529.33
$459.34

CPT
CODE
40820
40830
40831
40840
40842
40843
40844
40845
40899
41000
41005
41006
41007
41008
41009
41010
41015
41016
41017
41018
41100
41105
41108
41110
41112
41113
41114
41115
41116
41120
41130
41135
41140
41145
41150
41153
41155
41250
41251
41252
41500
41510
41520
41599
41800
41805
41806
41820
41821
41822
41823

MAXIMUM
FEE
$361.49
$385.28
$503.51
$1,328.42
$1,349.49
$1,726.61
$2,291.27
$2,554.92
BR
$253.45
$320.04
$569.42
$580.97
$574.86
$612.23
$309.85
$666.59
$692.41
$694.45
$807.25
$285.39
$261.61
$218.80
$313.93
$508.95
$561.95
$1,119.82
$354.02
$477.01
$1,759.91
$1,922.31
$3,278.59
$3,694.44
$4,289.68
$3,379.15
$3,453.22
$3,866.36
$328.88
$391.39
$485.84
$778.03
$784.14
$517.78
BR
$263.65
$274.52
$450.51
$402.26
$91.05
$442.35
$633.29

CPT
CODE
41825
41826
41827
41828
41830
41850
41870
41872
41874
41899
42000
42100
42104
42106
42107
42120
42140
42145
42160
42180
42182
42200
42205
42210
42215
42220
42225
42226
42227
42235
42260
42280
42281
42299
42300
42305
42310
42320
42325
42326
42330
42335
42340
42400
42405
42408
42409
42410
42415
42420
42425
144

MAXIMUM
FEE
$307.13
$342.47
$629.90
$498.07
$593.88
$201.13
$502.83
$537.48
$568.74
BR
$265.68
$239.18
$294.90
$378.48
$719.59
$1,255.04
$371.69
$1,099.43
$422.65
$392.75
$549.72
$1,594.11
$1,691.96
$1,908.04
$1,303.28
$985.95
$1,867.27
$1,746.32
$1,768.74
$1,388.90
$1,442.58
$250.74
$321.40
BR
$333.63
$768.51
$268.40
$396.15
$517.78
$676.78
$376.44
$578.25
$751.53
$169.20
$514.38
$739.98
$516.42
$1,118.46
$1,982.78
$2,283.12
$1,545.18

CPT
CODE
42426
42440
42450
42500
42505
42507
42508
42509
42510
42550
42600
42650
42660
42665
42699
42700
42720
42725
42800
42802
42804
42806
42808
42809
42810
42815
42820
42821
42825
42826
42830
42831
42835
42836
42842
42844
42845
42860
42870
42890
42892
42894
42900
42950
42953
42955
42960
42961
42962
42970
42971

MAXIMUM
FEE
$2,452.32
$839.18
$742.69
$705.32
$941.11
$891.50
$1,255.04
$1,538.39
$1,127.29
$307.81
$803.17
$131.82
$174.63
$470.89
BR
$298.98
$727.74
$1,350.85
$250.06
$436.92
$345.19
$392.75
$379.16
$292.19
$629.22
$957.42
$509.63
$552.43
$464.10
$453.91
$362.17
$392.07
$337.71
$434.88
$1,390.26
$2,154.69
$3,362.85
$326.16
$978.48
$1,913.47
$2,332.72
$3,178.70
$640.77
$1,405.21
$1,846.88
$1,280.86
$305.10
$747.45
$926.16
$678.82
$803.85

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
42972
42999
43020
43030
43045
43100
43101
43107
43108
43112
43113
43116
43117
43118
43121
43122
43123
43124
43130
43135
43200
43201
43202
43204
43205
43215
43216
43217
43219
43220
43226
43227
43228
43231
43232
43234
43235
43236
43237
43238
43239
43240
43241
43242
43243
43244
43245
43246
43247
43248
43249

MAXIMUM
FEE
$918.00
BR
$976.44
$942.47
$2,266.13
$1,108.94
$1,789.12
$4,295.80
$3,553.11
$4,651.18
$3,717.54
$3,457.30
$4,231.93
$3,465.45
$3,171.91
$4,252.31
$3,493.31
$2,991.84
$1,390.94
$1,796.60
$397.51
$467.50
$515.74
$379.16
$379.16
$273.84
$248.70
$686.97
$298.30
$220.16
$241.90
$361.49
$383.92
$322.08
$449.83
$510.30
$526.61
$648.24
$408.38
$504.19
$597.96
$680.18
$265.01
$717.55
$455.27
$500.79
$322.08
$431.48
$341.11
$319.37
$294.22

CPT
CODE
43250
43251
43255
43256
43257
43258
43259
43260
43261
43262
43263
43264
43265
43267
43268
43269
43271
43272
43280
43289
43300
43305
43310
43312
43313
43314
43320
43324
43325
43326
43330
43331
43340
43341
43350
43351
43352
43360
43361
43400
43401
43405
43410
43415
43420
43425
43450
43453
43456
43458
43460

MAXIMUM
FEE
$324.12
$371.01
$479.05
$434.20
$547.68
$452.55
$512.34
$589.13
$619.02
$727.07
$718.91
$873.16
$979.84
$727.74
$733.86
$807.25
$727.07
$727.74
$1,816.98
BR
$1,125.93
$2,013.36
$2,704.41
$3,005.43
$4,717.09
$5,160.80
$2,149.26
$2,175.76
$2,133.63
$2,159.45
$2,096.26
$2,222.64
$2,105.77
$2,290.59
$1,740.20
$2,075.87
$1,738.84
$3,774.62
$4,195.91
$2,209.05
$2,347.67
$2,196.14
$1,551.30
$2,724.12
$1,574.40
$2,302.83
$279.95
$521.86
$1,121.85
$676.10
$380.52

CPT
CODE
43496
43499
43500
43501
43502
43510
43520
43600
43605
43610
43611
43620
43621
43622
43631
43632
43633
43634
43635
43638
43639
43640
43641
43644
43645
43651
43652
43653
43659
43750
43752
43760
43761
43800
43810
43820
43825
43830
43831
43832
43840
43842
43843
43845
43846
43847
43848
43850
43855
43860
43865
145

MAXIMUM
FEE
BR
BR
$1,183.01
$2,101.69
$2,419.70
$1,433.75
$1,124.57
$184.14
$1,278.14
$1,537.03
$1,881.54
$3,104.64
$3,169.87
$3,350.61
$2,354.47
$2,354.47
$2,406.11
$2,613.36
$205.89
$3,029.89
$3,067.26
$1,797.96
$1,819.70
$2,865.45
$3,090.37
$1,102.15
$1,319.59
$876.56
BR
$482.45
$75.42
$222.20
$225.59
$1,450.05
$1,543.14
$1,613.81
$2,019.47
$1,057.30
$905.77
$1,654.58
$1,652.54
$1,946.77
$1,957.64
$3,357.41
$2,525.02
$2,804.98
$3,057.07
$2,559.68
$2,709.17
$2,593.65
$2,746.54

CPT
CODE
43870
43880
43999
44005
44010
44015
44020
44021
44025
44050
44055
44100
44110
44111
44120
44121
44125
44126
44127
44128
44130
44132
44133
44135
44136
44137
44139
44140
44141
44143
44144
44145
44146
44147
44150
44151
44152
44153
44155
44156
44160
44200
44201
44202
44203
44204
44205
44206
44207
44208
44210

MAXIMUM
FEE
$1,047.79
$2,560.36
BR
$1,698.75
$1,327.74
$260.93
$1,473.84
$1,481.99
$1,499.66
$1,479.27
$2,276.33
$196.38
$1,258.43
$1,508.49
$1,782.33
$443.71
$1,833.97
$3,684.25
$4,236.68
$447.11
$1,530.23
BR
BR
BR
BR
BR
$222.20
$2,193.43
$2,175.08
$2,486.29
$2,302.15
$2,746.54
$2,970.77
$2,165.57
$2,645.29
$2,967.38
$2,911.66
$3,290.82
$3,014.26
$3,377.79
$1,947.45
$1,526.16
$1,066.82
$2,292.63
$442.35
$2,586.18
$2,293.31
$2,828.08
$3,062.51
$3,324.11
$2,936.80

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
44211
44212
44238
44239
44300
44310
44312
44314
44316
44320
44322
44340
44345
44346
44360
44361
44363
44364
44365
44366
44369
44370
44372
44373
44376
44377
44378
44379
44380
44382
44383
44385
44386
44388
44389
44390
44391
44392
44393
44394
44397
44500
44602
44603
44604
44605
44615
44620
44625
44626
44640

MAXIMUM
FEE
$3,652.99
$3,383.23
BR
BR
$1,299.88
$1,669.53
$878.59
$1,583.91
$2,171.68
$1,867.95
$1,498.98
$879.95
$1,646.43
$1,795.92
$263.65
$290.83
$349.26
$373.05
$333.63
$438.28
$446.43
$484.48
$440.32
$351.98
$523.22
$547.00
$702.60
$746.77
$114.16
$137.26
$301.02
$361.49
$608.15
$554.47
$680.86
$764.44
$908.49
$729.10
$825.59
$856.85
$467.50
$46.21
$1,661.38
$1,921.63
$1,664.78
$2,063.64
$1,670.89
$1,291.73
$1,573.72
$2,605.88
$2,236.23

CPT
CODE
44650
44660
44661
44680
44700
44701
44715
44720
44721
44799
44800
44820
44850
44899
44900
44901
44950
44955
44960
44970
44979
45000
45005
45020
45100
45108
45110
45111
45112
45113
45114
45116
45119
45120
45121
45123
45126
45130
45135
45136
45150
45160
45170
45190
45300
45303
45305
45307
45308
45309
45315

MAXIMUM
FEE
$2,327.97
$2,160.13
$2,521.62
$1,611.09
$1,668.17
$307.81
BR
$481.09
$703.96
BR
$1,223.78
$1,296.49
$1,161.27
BR
$1,094.00
$2,139.75
$1,060.02
$153.57
$1,308.72
$944.51
BR
$542.24
$426.73
$578.93
$438.28
$550.40
$2,967.38
$1,743.60
$3,100.56
$3,159.00
$2,817.21
$2,546.09
$3,163.07
$2,550.84
$2,807.01
$1,723.21
$4,658.65
$1,694.67
$2,038.50
$2,886.52
$625.82
$1,603.62
$1,225.82
$1,049.15
$132.50
$1,302.60
$254.81
$277.24
$197.73
$342.47
$299.66

CPT
CODE
45317
45320
45321
45327
45330
45331
45332
45333
45334
45335
45337
45338
45339
45340
45341
45342
45345
45355
45378
45379
45380
45381
45382
45383
45384
45385
45386
45387
45391
45392
45500
45505
45520
45540
45541
45550
45560
45562
45563
45800
45805
45820
45825
45900
45905
45910
45915
45999
46020
46030
46040
146

MAXIMUM
FEE
$277.24
$315.97
$126.39
$169.88
$224.91
$292.86
$472.25
$462.74
$277.24
$324.80
$242.58
$525.93
$466.14
$557.87
$262.97
$400.23
$292.86
$356.06
$688.33
$865.00
$813.36
$789.58
$1,090.60
$968.97
$806.57
$918.68
$1,179.61
$591.84
$508.27
$641.45
$784.14
$833.75
$152.21
$1,689.24
$1,418.12
$2,361.94
$1,137.48
$1,640.99
$2,512.79
$1,833.97
$2,195.46
$1,879.50
$2,264.09
$299.66
$271.80
$322.76
$527.29
BR
$376.44
$184.14
$750.17

CPT
CODE
46045
46050
46060
46070
46080
46083
46200
46210
46211
46220
46221
46230
46250
46255
46257
46258
46260
46261
46262
46270
46275
46280
46285
46288
46320
46500
46600
46604
46606
46608
46610
46611
46612
46614
46615
46700
46705
46706
46715
46716
46730
46735
46740
46742
46744
46746
46748
46750
46751
46753
46754

MAXIMUM
FEE
$525.25
$262.29
$650.96
$332.28
$349.94
$276.56
$519.14
$549.72
$686.97
$273.16
$332.96
$402.94
$655.72
$746.09
$604.08
$657.08
$699.21
$778.71
$818.12
$622.42
$659.12
$671.35
$561.95
$786.86
$265.68
$263.65
$143.37
$716.87
$318.01
$412.46
$373.73
$362.17
$529.33
$307.81
$372.37
$968.29
$779.39
$265.68
$793.66
$1,670.89
$2,798.18
$3,318.68
$3,097.16
$3,825.59
$5,435.32
$6,175.98
$6,188.89
$1,112.34
$1,026.72
$887.43
$406.34

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
46760
46761
46762
46900
46910
46916
46917
46922
46924
46934
46935
46936
46937
46938
46940
46942
46945
46946
46947
46999
47000
47001
47010
47011
47015
47100
47120
47122
47125
47130
47133
47135
47136
47140
47141
47142
47143
47144
47145
47146
47147
47300
47350
47360
47361
47362
47370
47371
47379
47380
47381

MAXIMUM
FEE
$1,566.25
$1,442.58
$1,320.27
$316.65
$335.67
$347.90
$760.36
$362.85
$795.02
$603.40
$415.85
$604.08
$380.52
$626.50
$307.81
$275.88
$359.46
$445.75
$588.45
BR
$345.87
$189.58
$1,776.89
$347.90
$1,655.26
$1,303.28
$3,746.08
$5,679.94
$5,081.98
$5,503.27
BR
$8,327.27
$7,057.97
$5,593.64
$6,756.27
$7,439.17
BR
BR
BR
$603.40
$703.96
$1,644.39
$2,099.66
$2,837.59
$4,848.23
$2,009.96
$2,055.49
$2,064.32
BR
$2,385.05
$2,421.06

CPT
CODE
47382
47399
47400
47420
47425
47460
47480
47490
47500
47505
47510
47511
47525
47530
47550
47552
47553
47554
47555
47556
47560
47561
47562
47563
47564
47570
47579
47600
47605
47610
47612
47620
47630
47700
47701
47711
47712
47715
47716
47720
47721
47740
47741
47760
47765
47780
47785
47800
47801
47802
47900

MAXIMUM
FEE
$1,509.17
BR
$3,328.19
$2,119.36
$2,118.00
$1,934.54
$1,229.22
$898.30
$184.82
$72.03
$904.41
$1,100.11
$1,424.23
$2,717.32
$301.02
$600.00
$597.96
$907.13
$710.76
$804.53
$488.56
$524.57
$1,188.45
$1,275.42
$1,495.58
$1,328.42
BR
$1,457.53
$1,568.29
$1,981.42
$1,975.99
$2,162.17
$994.11
$1,700.11
$2,913.70
$2,440.76
$3,156.96
$2,014.04
$1,790.48
$1,727.97
$2,046.65
$1,981.42
$2,268.85
$2,718.68
$2,640.54
$2,791.39
$3,262.28
$2,465.91
$1,661.38
$2,309.62
$2,130.23

CPT
CODE
47999
48000
48001
48005
48020
48100
48102
48120
48140
48145
48146
48148
48150
48152
48153
48154
48155
48160
48180
48400
48500
48510
48511
48520
48540
48545
48547
48550
48551
48552
48554
48556
48999
49000
49002
49010
49020
49021
49040
49041
49060
49061
49062
49080
49081
49085
49180
49200
49201
49215
49220
147

MAXIMUM
FEE
BR
$2,914.38
$3,659.79
$4,355.60
$1,703.51
$1,314.83
$877.23
$1,680.40
$2,405.43
$2,510.07
$2,838.95
$1,842.80
$5,003.84
$4,595.46
$5,001.12
$4,621.28
$2,680.63
$4,679.72
$2,584.82
$186.18
$1,670.21
$1,596.83
$1,706.90
$1,649.83
$2,060.24
$1,932.50
$2,690.14
BR
BR
$412.46
$3,839.18
$1,749.71
BR
$1,257.75
$1,142.92
$1,335.90
$2,428.53
$1,672.93
$1,465.00
$1,613.13
$1,699.43
$1,598.86
$1,233.97
$368.29
$267.04
$1,301.92
$335.67
$1,117.78
$1,604.30
$3,515.05
$1,587.31

CPT
CODE
49250
49255
49320
49321
49322
49323
49329
49400
49419
49420
49421
49422
49423
49424
49425
49426
49427
49428
49429
49491
49492
49495
49496
49500
49501
49505
49507
49520
49521
49525
49540
49550
49553
49555
49557
49560
49561
49565
49566
49568
49570
49572
49580
49582
49585
49587
49590
49600
49605
49606
49610

MAXIMUM
FEE
$928.88
$1,231.25
$567.38
$592.52
$638.05
$1,028.76
BR
$346.55
$747.45
$239.18
$637.37
$674.06
$1,061.38
$307.13
$1,253.00
$1,062.06
$85.62
$731.82
$802.49
$1,193.20
$1,487.43
$649.60
$959.45
$631.26
$961.49
$838.50
$1,036.92
$1,040.99
$1,273.38
$933.63
$1,119.14
$942.47
$1,024.01
$982.56
$1,193.88
$1,236.01
$1,503.73
$1,241.45
$1,520.04
$488.56
$650.96
$751.53
$488.56
$746.09
$701.24
$833.07
$932.27
$1,194.56
$7,724.56
$1,948.13
$1,137.48

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
49611
49650
49651
49659
49900
49904
49905
49906
49999
50010
50020
50021
50040
50045
50060
50065
50070
50075
50080
50081
50100
50120
50125
50130
50135
50200
50205
50220
50225
50230
50234
50236
50240
50280
50290
50300
50320
50323
50325
50327
50328
50329
50340
50360
50365
50370
50380
50390
50391
50392
50393

MAXIMUM
FEE
$1,132.05
$704.64
$910.53
BR
$1,361.04
$2,569.19
$652.32
BR
BR
$1,162.62
$1,607.70
$1,713.70
$1,548.58
$1,582.56
$1,933.18
$1,930.46
$2,033.74
$2,513.47
$1,494.90
$2,178.48
$1,757.87
$1,621.97
$1,691.28
$1,742.24
$1,922.31
$277.24
$1,195.92
$1,748.35
$2,027.63
$2,187.99
$2,228.76
$2,501.24
$2,212.45
$1,598.18
$1,532.27
BR
$2,391.16
BR
BR
$383.24
$335.67
$320.72
$1,376.67
$3,447.10
$4,031.47
$1,528.20
$2,389.12
$184.82
$250.06
$346.55
$419.93

CPT
CODE
50394
50395
50396
50398
50400
50405
50500
50520
50525
50526
50540
50541
50542
50543
50544
50545
50546
50547
50548
50549
50551
50553
50555
50557
50561
50562
50570
50572
50574
50575
50576
50580
50590
50600
50605
50610
50620
50630
50650
50660
50684
50686
50688
50690
50700
50715
50722
50725
50727
50728
50740

MAXIMUM
FEE
$237.15
$345.19
$224.24
$1,213.59
$1,952.88
$2,355.83
$2,033.06
$1,774.17
$2,245.75
$2,431.25
$2,009.28
$1,604.30
$2,003.85
$2,547.45
$2,205.66
$2,370.10
$2,063.64
$2,670.44
$2,396.60
BR
$689.01
$729.10
$801.13
$792.30
$896.94
$1,085.16
$911.89
$996.83
$1,055.26
$1,331.14
$1,047.11
$1,133.41
$1,503.05
$1,609.74
$1,605.66
$1,647.11
$1,532.95
$1,515.29
$1,757.19
$1,963.76
$392.75
$343.83
$156.29
$207.25
$1,602.26
$2,018.79
$1,767.38
$1,903.28
$887.43
$1,261.15
$1,908.04

CPT
CODE
50750
50760
50770
50780
50782
50783
50785
50800
50810
50815
50820
50825
50830
50840
50845
50860
50900
50920
50930
50940
50945
50947
50948
50949
50951
50953
50955
50957
50961
50970
50972
50974
50976
50980
51000
51005
51010
51020
51030
51040
51045
51050
51060
51065
51080
51500
51520
51525
51530
51535
51550
148

MAXIMUM
FEE
$1,959.68
$1,878.14
$1,965.79
$1,864.55
$2,028.31
$2,086.07
$2,061.60
$1,505.77
$2,133.63
$2,034.42
$2,199.54
$2,809.05
$3,107.35
$2,031.71
$2,125.48
$1,579.84
$1,420.16
$1,486.75
$1,897.84
$1,504.41
$1,723.21
$2,465.23
$2,231.48
BR
$716.19
$752.21
$926.16
$803.85
$734.54
$686.97
$668.63
$876.56
$865.68
$659.79
$188.90
$395.47
$638.73
$750.17
$768.51
$507.59
$763.08
$750.17
$947.90
$939.75
$674.74
$1,097.39
$994.79
$1,432.39
$1,301.92
$1,349.49
$1,610.42

CPT
CODE
51555
51565
51570
51575
51580
51585
51590
51595
51596
51597
51600
51605
51610
51700
51701
51702
51703
51705
51710
51715
51720
51725
51726
51736
51741
51772
51784
51785
51792
51795
51797
51798
51800
51820
51840
51841
51845
51860
51865
51880
51900
51920
51925
51940
51960
51980
51990
51992
52000
52001
52005

MAXIMUM
FEE
$2,145.18
$2,187.99
$2,430.57
$3,029.21
$3,107.35
$3,489.23
$3,229.66
$3,657.07
$3,904.41
$3,801.12
$407.02
$457.30
$231.03
$173.27
$144.05
$178.03
$292.86
$228.31
$334.99
$538.16
$260.93
$493.32
$638.05
$84.94
$138.62
$501.47
$385.28
$415.85
$495.36
$614.27
$513.02
$28.54
$1,787.09
$1,893.77
$1,176.89
$1,402.49
$1,036.92
$1,284.93
$1,559.45
$837.14
$1,373.95
$1,263.87
$1,779.61
$2,893.31
$2,327.97
$1,193.88
$1,360.36
$1,467.04
$370.33
$740.66
$550.40

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
52007
52010
52204
52214
52224
52234
52235
52240
52250
52260
52265
52270
52275
52276
52277
52281
52282
52283
52285
52290
52300
52301
52305
52310
52315
52317
52318
52320
52325
52327
52330
52332
52334
52341
52342
52343
52344
52345
52346
52351
52352
52353
52354
52355
52400
52402
52450
52500
52510
52601
52606

MAXIMUM
FEE
$1,337.26
$950.62
$1,158.55
$2,857.98
$2,705.09
$449.15
$527.29
$930.92
$438.96
$381.20
$1,121.18
$994.11
$1,397.73
$483.80
$599.32
$685.62
$617.67
$538.84
$534.77
$445.07
$515.06
$539.52
$511.66
$523.22
$966.93
$2,455.03
$877.91
$452.55
$591.17
$2,539.29
$3,004.07
$596.60
$468.18
$586.41
$631.26
$699.21
$749.49
$796.37
$894.90
$571.46
$669.99
$773.27
$714.83
$854.81
$957.42
$500.79
$804.53
$881.99
$699.89
$1,244.84
$832.39

CPT
CODE
52612
52614
52620
52630
52640
52647
52648
52700
53000
53010
53020
53025
53040
53060
53080
53085
53200
53210
53215
53220
53230
53235
53240
53250
53260
53265
53270
53275
53400
53405
53410
53415
53420
53425
53430
53431
53440
53442
53444
53445
53446
53447
53448
53449
53450
53460
53500
53502
53505
53510
53515

MAXIMUM
FEE
$833.75
$723.67
$682.90
$744.05
$682.22
$5,776.43
$1,139.52
$710.08
$270.44
$461.38
$332.96
$335.67
$699.21
$338.39
$866.36
$1,261.15
$279.95
$1,312.11
$1,582.56
$763.08
$1,019.93
$1,070.21
$712.80
$656.40
$372.37
$412.46
$379.84
$482.45
$1,343.37
$1,485.39
$1,675.65
$1,908.72
$1,450.73
$1,628.76
$1,665.45
$1,995.01
$1,395.69
$1,210.19
$1,371.91
$1,503.05
$1,097.39
$1,416.08
$2,152.66
$1,026.05
$669.31
$769.19
$1,311.44
$831.03
$816.76
$1,088.56
$1,376.67

CPT
CODE
53520
53600
53601
53605
53620
53621
53660
53661
53665
53850
53852
53853
53899
54000
54001
54015
54050
54055
54056
54057
54060
54065
54100
54105
54110
54111
54112
54115
54120
54125
54130
54135
54150
54152
54160
54161
54162
54163
54164
54200
54205
54220
54230
54231
54235
54240
54250
54300
54304
54308
54312
149

MAXIMUM
FEE
$935.67
$165.80
$157.64
$120.95
$253.45
$239.18
$140.66
$140.66
$72.71
$7,078.35
$6,750.15
$4,140.87
BR
$309.85
$375.76
$559.91
$202.49
$195.02
$203.17
$240.54
$351.30
$352.66
$326.84
$544.96
$1,060.02
$1,378.03
$1,613.81
$744.73
$1,040.31
$1,380.06
$2,024.23
$2,605.20
$429.44
$251.42
$462.74
$344.51
$534.77
$354.70
$307.13
$199.09
$894.22
$437.60
$170.55
$242.58
$152.21
$169.88
$224.91
$1,135.44
$1,335.90
$1,263.87
$1,478.59

CPT
CODE
54316
54318
54322
54324
54326
54328
54332
54336
54340
54344
54348
54352
54360
54380
54385
54390
54400
54401
54405
54406
54408
54410
54411
54415
54416
54417
54420
54430
54435
54440
54450
54500
54505
54512
54520
54522
54530
54535
54550
54560
54600
54620
54640
54650
54660
54670
54680
54690
54692
54699
54700

MAXIMUM
FEE
$1,762.62
$1,250.28
$1,383.46
$1,723.89
$1,670.21
$1,619.93
$1,764.66
$2,207.02
$989.35
$1,711.66
$1,813.59
$2,588.22
$1,276.10
$1,405.89
$1,663.42
$2,209.73
$948.58
$1,135.44
$1,377.35
$1,246.88
$1,315.51
$1,575.76
$1,639.63
$880.63
$1,153.79
$1,449.37
$1,206.79
$1,083.80
$690.37
$1,036.24
$146.09
$136.58
$382.56
$908.49
$577.58
$1,035.56
$914.61
$1,267.27
$826.27
$1,166.02
$751.53
$522.54
$764.44
$1,221.06
$579.61
$706.00
$1,354.24
$1,147.00
$1,330.46
BR
$382.56

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
54800
54820
54830
54840
54860
54861
54900
54901
55000
55040
55041
55060
55100
55110
55120
55150
55175
55180
55200
55250
55300
55400
55450
55500
55520
55530
55535
55540
55550
55559
55600
55605
55650
55680
55700
55705
55720
55725
55801
55810
55812
55815
55821
55831
55840
55842
55845
55859
55860
55862
55865

MAXIMUM
FEE
$237.83
$574.86
$597.28
$566.70
$683.58
$939.07
$1,351.53
$1,850.28
$244.62
$589.13
$835.11
$614.27
$405.66
$627.86
$571.46
$788.90
$585.73
$1,151.75
$1,145.64
$1,020.61
$343.83
$894.90
$773.95
$626.50
$679.50
$618.35
$708.72
$841.90
$708.04
BR
$701.24
$874.52
$1,223.10
$585.05
$398.87
$487.88
$841.22
$941.11
$1,814.94
$2,246.43
$2,749.26
$3,019.70
$1,456.17
$1,586.63
$2,278.36
$2,436.69
$2,815.85
$1,304.64
$1,484.03
$1,880.18
$2,289.24

CPT
CODE
55866
55870
55873
55899
55970
55980
56405
56420
56440
56441
56501
56515
56605
56606
56620
56625
56630
56631
56632
56633
56634
56637
56640
56700
56720
56740
56800
56805
56810
56820
56821
57000
57010
57020
57022
57023
57061
57065
57100
57105
57106
57107
57109
57110
57111
57112
57120
57130
57135
57150
57155

MAXIMUM
FEE
$3,026.49
$290.15
$2,020.83
BR
BR
BR
$199.77
$259.57
$332.28
$270.44
$236.47
$381.88
$156.29
$75.42
$892.86
$998.87
$1,402.49
$1,827.86
$2,181.20
$1,832.61
$1,998.41
$2,414.94
$2,415.62
$315.97
$86.30
$520.50
$442.35
$2,063.64
$468.18
$203.17
$274.52
$339.75
$713.48
$177.35
$292.86
$534.09
$207.25
$354.02
$164.44
$250.06
$765.12
$2,451.64
$2,809.05
$1,578.48
$2,903.50
$2,995.92
$874.52
$330.92
$356.06
$116.19
$764.44

CPT
CODE
57160
57170
57180
57200
57210
57220
57230
57240
57250
57260
57265
57267
57268
57270
57280
57282
57283
57284
57287
57288
57289
57291
57292
57300
57305
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57420
57421
57425
57452
57454
57455
57456
57460
57461
57500
57505
57510
57511
57513
57520
57522
150

MAXIMUM
FEE
$135.90
$169.88
$266.36
$494.00
$625.14
$536.81
$650.96
$712.80
$661.83
$955.38
$1,268.63
$508.95
$796.37
$1,341.33
$1,633.52
$841.22
$1,207.47
$1,442.58
$1,159.91
$1,360.36
$1,277.46
$937.03
$1,465.00
$865.68
$1,474.52
$1,686.52
$1,097.39
$756.96
$865.00
$886.07
$1,297.17
$2,012.00
$246.66
$267.04
$260.25
$212.68
$292.19
$1,637.60
$200.45
$288.79
$268.40
$252.77
$612.23
$675.42
$245.98
$185.50
$250.06
$267.72
$261.61
$573.50
$468.86

CPT
CODE
57530
57531
57540
57545
57550
57555
57556
57700
57720
57800
57820
58100
58120
58140
58145
58146
58150
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275
58280
58285
58290
58291
58292
58293
58294
58300
58301
58321
58322
58323
58340
58345
58346
58350
58353
58356
58400
58410
58520
58540
58545

MAXIMUM
FEE
$593.88
$3,019.02
$1,352.88
$1,439.86
$679.50
$1,025.37
$960.81
$479.05
$523.22
$110.08
$226.95
$205.89
$404.98
$1,594.11
$936.35
$2,054.81
$1,665.45
$2,230.80
$1,655.26
$2,313.02
$3,078.14
$4,083.12
$1,440.54
$1,624.01
$1,755.83
$1,863.19
$1,562.85
$1,723.89
$1,849.60
$2,368.06
$2,063.64
$2,249.82
$2,383.69
$2,475.42
$2,182.55
$173.27
$186.18
$147.45
$165.12
$53.68
$280.63
$508.95
$763.76
$178.03
$2,692.86
$952.66
$748.81
$1,399.09
$1,318.23
$1,585.27
$1,598.18

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
58546
58550
58552
58553
58554
58555
58558
58559
58560
58561
58562
58563
58565
58578
58579
58600
58605
58611
58615
58660
58661
58662
58670
58671
58672
58673
58679
58700
58720
58740
58750
58752
58760
58770
58800
58805
58820
58822
58823
58825
58900
58920
58925
58940
58943
58950
58951
58952
58953
58954
58956

MAXIMUM
FEE
$2,049.37
$1,573.72
$1,745.64
$2,050.05
$2,351.07
$402.26
$508.27
$653.68
$740.66
$1,050.51
$555.15
$4,286.97
$3,925.47
BR
BR
$650.28
$590.49
$148.81
$479.73
$1,216.31
$1,187.77
$1,289.01
$647.56
$647.56
$1,401.13
$1,491.50
BR
$1,325.70
$1,255.72
$1,547.90
$1,631.48
$1,599.54
$1,467.72
$1,533.63
$556.51
$681.54
$544.96
$1,119.14
$1,694.67
$1,227.86
$695.13
$1,244.84
$1,250.96
$833.75
$1,986.86
$1,855.71
$2,404.07
$2,696.26
$3,413.81
$3,720.94
$2,383.01

CPT
CODE
58960
58970
58974
58976
58999
59000
59001
59012
59015
59020
59025
59030
59050
59051
59070
59072
59074
59076
59100
59120
59121
59130
59135
59136
59140
59150
59151
59160
59200
59300
59320
59325
59350
59400
59409
59410
59412
59414
59425
59426
59430
59510
59514
59515
59525
59610
59612
59614
59618
59620
59622

MAXIMUM
FEE
$1,613.13
$424.69
$254.81
$473.61
BR
$250.06
$347.90
$393.43
$290.15
$115.52
$75.42
$219.48
$98.53
$81.54
$725.03
$833.75
$685.62
$833.75
$1,473.84
$1,384.14
$1,407.92
$1,518.00
$1,654.58
$1,554.02
$608.15
$1,385.50
$1,374.63
$451.19
$147.45
$349.94
$292.19
$464.10
$542.24
$2,974.85
$1,492.18
$1,667.49
$198.41
$178.71
$688.33
$1,206.79
$262.29
$3,371.68
$1,761.26
$1,988.22
$934.99
$3,142.01
$1,674.29
$1,841.45
$3,568.05
$1,929.10
$2,173.72

CPT
CODE
59812
59820
59821
59830
59840
59841
59850
59851
59852
59855
59856
59857
59866
59870
59871
59897
59898
59899
60000
60001
60100
60200
60210
60212
60220
60225
60240
60252
60254
60260
60270
60271
60280
60281
60500
60502
60505
60512
60520
60521
60522
60540
60545
60600
60605
60650
60659
60699
61000
61001
61020
151

MAXIMUM
FEE
$508.27
$636.01
$664.55
$782.78
$396.83
$676.10
$708.72
$743.37
$1,023.33
$753.57
$903.06
$1,086.52
$458.66
$808.61
$296.94
BR
BR
BR
$259.57
$166.48
$207.93
$1,123.21
$1,204.07
$1,739.52
$1,314.83
$1,576.44
$1,730.69
$2,238.27
$2,970.77
$1,903.96
$2,240.31
$1,846.20
$751.53
$1,024.69
$1,740.20
$2,186.63
$2,378.25
$448.47
$1,849.60
$2,115.28
$2,550.84
$1,789.80
$2,070.44
$2,109.85
$2,372.81
$2,053.45
BR
BR
$180.75
$184.14
$213.36

CPT
CODE
61026
61050
61055
61070
61105
61107
61108
61120
61140
61150
61151
61154
61156
61210
61215
61250
61253
61304
61305
61312
61313
61314
61315
61316
61320
61321
61322
61323
61330
61332
61333
61334
61340
61343
61345
61440
61450
61458
61460
61470
61480
61490
61500
61501
61510
61512
61514
61516
61517
61518
61519

MAXIMUM
FEE
$228.31
$196.38
$250.06
$139.30
$702.60
$594.56
$1,348.13
$1,131.37
$2,024.23
$2,187.31
$1,575.08
$1,937.93
$2,050.73
$692.41
$684.94
$1,357.64
$1,539.07
$2,714.60
$3,238.50
$3,105.99
$3,122.30
$2,944.95
$3,435.55
$158.32
$3,164.43
$3,499.43
$3,559.22
$3,726.38
$2,673.83
$3,223.55
$3,213.36
$2,079.27
$2,333.40
$3,664.54
$3,345.18
$3,235.78
$3,120.26
$3,362.17
$3,440.99
$3,105.32
$3,288.78
$3,179.38
$2,216.53
$1,836.69
$3,546.31
$4,312.79
$3,119.58
$3,059.11
$160.36
$4,596.82
$5,033.06

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
61520
61521
61522
61524
61526
61530
61531
61533
61534
61535
61536
61537
61538
61539
61540
61541
61542
61543
61544
61545
61546
61548
61550
61552
61556
61557
61558
61559
61563
61564
61566
61567
61570
61571
61575
61576
61580
61581
61582
61583
61584
61585
61586
61590
61591
61592
61595
61596
61597
61598
61600

MAXIMUM
FEE
$6,509.61
$5,377.56
$3,618.34
$3,407.01
$6,006.10
$5,085.38
$1,864.55
$2,455.03
$2,605.88
$1,491.50
$4,344.04
$3,156.28
$3,318.00
$3,941.78
$3,765.79
$3,502.14
$3,855.48
$3,604.75
$3,071.34
$5,290.59
$3,819.47
$2,556.28
$1,531.59
$2,018.12
$2,595.01
$2,834.19
$2,791.39
$4,107.58
$3,203.16
$4,126.60
$3,769.19
$4,254.35
$2,975.53
$3,275.87
$4,011.77
$6,291.49
$4,023.32
$4,203.39
$4,472.47
$4,728.64
$4,539.74
$4,892.40
$3,530.68
$5,131.58
$5,341.55
$5,122.75
$3,787.53
$4,306.67
$4,702.14
$4,221.05
$3,343.14

CPT
CODE
61601
61605
61606
61607
61608
61609
61610
61611
61612
61613
61615
61616
61618
61619
61623
61624
61626
61680
61682
61684
61686
61690
61692
61697
61698
61700
61702
61703
61705
61708
61710
61711
61720
61735
61750
61751
61760
61770
61790
61791
61793
61795
61850
61860
61863
61864
61867
61868
61870
61875
61880

MAXIMUM
FEE
$3,715.51
$3,673.38
$4,925.70
$4,531.59
$5,337.47
$1,172.82
$3,422.64
$890.15
$3,086.97
$5,123.43
$4,035.55
$5,423.09
$2,107.81
$2,501.24
$1,024.69
$1,965.79
$1,586.63
$3,784.14
$7,419.46
$4,889.00
$7,831.92
$3,591.84
$6,288.77
$6,175.98
$5,919.12
$6,171.90
$5,754.69
$2,163.53
$4,359.67
$3,593.88
$3,243.93
$4,433.06
$1,999.77
$2,395.24
$2,261.38
$2,228.76
$2,447.56
$2,525.70
$1,320.27
$1,805.43
$2,145.18
$464.10
$1,577.80
$2,568.51
$2,442.80
$814.04
$3,704.63
$1,163.98
$1,933.18
$1,802.71
$844.62

CPT
CODE
61885
61886
61888
62000
62005
62010
62100
62115
62116
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
62148
62160
62161
62162
62163
62164
62165
62180
62190
62192
62194
62200
62201
62220
62223
62225
62230
62252
62256
62258
62263
62264
62268
62269
62270
62272
62273
62280
62281
62282
62284
62287
152

MAXIMUM
FEE
$853.45
$1,104.87
$676.78
$1,295.13
$1,948.81
$2,465.91
$2,683.35
$2,631.70
$2,919.13
$3,153.56
$3,040.76
$2,791.39
$1,700.79
$1,863.19
$1,380.06
$1,647.79
$2,308.94
$1,987.54
$2,365.34
$226.27
$358.78
$2,519.59
$3,119.58
$1,995.69
$3,242.57
$2,602.49
$2,587.54
$1,419.48
$1,547.90
$566.70
$2,284.48
$1,881.54
$1,632.16
$1,638.27
$735.22
$1,327.74
$163.76
$878.59
$1,820.38
$1,307.36
$843.94
$1,134.09
$1,364.44
$285.39
$348.58
$339.75
$670.67
$576.90
$739.30
$450.51
$968.97

CPT
CODE
62290
62291
62292
62294
62310
62311
62318
62319
62350
62351
62355
62360
62361
62362
62365
62367
62368
63001
63003
63005
63011
63012
63015
63016
63017
63020
63030
63035
63040
63042
63043
63044
63045
63046
63047
63048
63050
63051
63055
63056
63057
63064
63066
63075
63076
63077
63078
63081
63082
63085
63086

MAXIMUM
FEE
$705.32
$618.35
$892.18
$1,265.23
$464.78
$445.75
$536.13
$473.61
$800.45
$1,310.08
$634.65
$384.60
$686.30
$852.09
$667.27
$43.49
$67.95
$1,967.83
$1,999.09
$1,912.11
$1,772.14
$1,964.43
$2,434.65
$2,405.43
$2,029.67
$1,906.68
$1,583.91
$374.40
$2,362.62
$2,232.84
$979.16
$930.24
$2,087.42
$1,999.77
$1,877.46
$382.56
$2,529.78
$2,878.36
$2,732.95
$2,545.41
$615.63
$3,019.70
$379.84
$2,442.80
$477.01
$2,575.31
$377.12
$2,946.99
$515.06
$3,161.71
$362.17

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
63087
63088
63090
63091
63101
63102
63103
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
63250
63251
63252
63265
63266
63267
63268
63270
63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290
63295
63300
63301
63302
63303
63304

MAXIMUM
FEE
$4,119.13
$494.00
$3,275.87
$337.03
$3,850.73
$3,850.73
$542.92
$2,478.14
$2,217.89
$2,745.18
$2,251.86
$2,491.73
$1,751.07
$2,090.14
$2,328.65
$2,317.10
$2,356.51
$2,811.09
$2,623.55
$2,729.55
$2,940.88
$2,389.80
$4,725.92
$5,003.84
$4,989.57
$2,688.78
$2,773.04
$2,259.34
$2,205.66
$3,314.60
$3,323.43
$3,125.70
$3,008.15
$2,922.53
$2,900.11
$2,593.65
$2,535.21
$3,507.58
$3,470.21
$3,266.36
$3,114.15
$4,407.24
$4,371.90
$4,475.19
$4,528.19
$572.14
$3,006.11
$3,262.28
$3,318.00
$3,522.53
$3,662.51

CPT
CODE
63305
63306
63307
63308
63600
63610
63615
63650
63655
63660
63685
63688
63700
63702
63704
63706
63707
63709
63710
63740
63741
63744
63746
64400
64402
64405
64408
64410
64412
64413
64415
64416
64417
64418
64420
64421
64425
64430
64435
64445
64446
64447
64448
64449
64450
64470
64472
64475
64476
64479
64480

MAXIMUM
FEE
$3,783.46
$3,956.05
$3,588.44
$618.35
$1,418.80
$4,706.22
$1,913.47
$709.40
$1,324.35
$716.87
$828.31
$664.55
$2,054.13
$2,281.08
$2,622.87
$2,977.57
$1,450.73
$1,814.94
$1,795.24
$1,451.41
$990.71
$1,026.05
$793.66
$209.97
$200.45
$194.34
$209.97
$273.84
$265.68
$226.27
$297.62
$311.89
$311.21
$273.16
$349.94
$535.45
$240.54
$277.24
$279.95
$288.79
$305.10
$137.94
$273.16
$279.95
$179.39
$625.82
$252.09
$570.78
$215.40
$668.63
$305.78

CPT
CODE
64483
64484
64505
64508
64510
64517
64520
64530
64550
64553
64555
64560
64561
64565
64573
64575
64577
64580
64581
64585
64590
64595
64600
64605
64610
64612
64613
64614
64620
64622
64623
64626
64627
64630
64640
64680
64681
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64722
64726
64727
64732
153

MAXIMUM
FEE
$673.38
$319.37
$183.47
$306.45
$322.08
$341.79
$446.43
$416.53
$31.94
$362.17
$378.48
$353.34
$2,533.86
$351.30
$968.97
$516.42
$606.79
$544.96
$1,352.21
$920.04
$662.51
$836.46
$891.50
$1,081.76
$1,188.45
$309.85
$339.75
$375.76
$550.40
$745.41
$273.16
$766.48
$392.07
$404.98
$490.60
$646.20
$890.82
$590.49
$576.22
$809.28
$930.24
$1,263.19
$1,066.82
$877.91
$884.03
$688.33
$703.96
$560.59
$510.30
$344.51
$600.68

CPT
CODE
64734
64736
64738
64740
64742
64744
64746
64752
64755
64760
64761
64763
64766
64771
64772
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64792
64795
64802
64804
64809
64818
64820
64821
64822
64823
64831
64832
64834
64835
64836
64837
64840
64856
64857
64858
64859
64861
64862
64864
64865
64866

MAXIMUM
FEE
$668.63
$620.38
$774.63
$773.95
$790.94
$685.62
$763.76
$832.39
$1,422.87
$759.68
$710.08
$886.75
$1,016.53
$958.77
$911.21
$661.83
$646.88
$343.83
$737.94
$411.10
$1,210.87
$1,889.01
$474.97
$593.88
$1,391.62
$1,772.14
$344.51
$1,056.62
$1,621.97
$1,420.83
$1,147.00
$1,287.65
$1,176.89
$1,171.46
$1,361.04
$1,215.63
$640.09
$1,276.10
$1,378.03
$1,375.31
$709.40
$1,536.35
$1,701.47
$1,788.44
$2,075.19
$483.12
$2,380.29
$2,420.38
$1,534.99
$2,058.21
$2,100.33

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
64868
64870
64872
64874
64876
64885
64886
64890
64891
64892
64893
64895
64896
64897
64898
64901
64902
64905
64907
64999
65091
65093
65101
65103
65105
65110
65112
65114
65125
65130
65135
65140
65150
65155
65175
65205
65210
65220
65222
65235
65260
65265
65270
65272
65273
65275
65280
65285
65286
65290
65400

MAXIMUM
FEE
$1,826.50
$1,766.02
$228.31
$334.99
$379.16
$2,090.82
$2,470.66
$1,861.83
$1,720.49
$1,762.62
$1,905.32
$2,134.99
$2,349.03
$2,134.99
$2,310.30
$1,143.60
$1,312.11
$1,662.74
$2,340.88
BR
$1,027.40
$1,082.44
$1,149.03
$1,200.68
$1,316.19
$1,932.50
$2,301.47
$2,368.74
$822.20
$1,131.37
$1,155.83
$1,244.16
$988.67
$1,333.86
$1,025.37
$94.45
$114.84
$95.13
$127.07
$998.19
$1,437.82
$1,618.57
$490.60
$796.37
$553.79
$810.64
$968.97
$1,544.50
$1,149.03
$710.76
$997.51

CPT
CODE
65410
65420
65426
65430
65435
65436
65450
65600
65710
65730
65750
65755
65760
65765
65767
65770
65771
65772
65775
65780
65781
65782
65800
65805
65810
65815
65820
65850
65855
65860
65865
65870
65875
65880
65900
65920
65930
66020
66030
66130
66150
66155
66160
66165
66170
66172
66180
66185
66220
66225
66250

MAXIMUM
FEE
$248.02
$898.30
$1,064.78
$192.30
$133.86
$576.22
$509.63
$582.33
$1,639.63
$1,831.25
$1,881.54
$1,867.95
$2,209.05
$2,561.72
$2,385.72
$2,146.54
$1,298.52
$680.86
$816.08
$1,424.23
$2,157.41
$1,862.51
$257.53
$283.35
$665.91
$1,038.96
$1,193.88
$1,322.31
$566.70
$527.29
$780.75
$881.99
$926.84
$982.56
$1,476.55
$1,153.11
$994.11
$325.48
$290.15
$1,201.36
$1,233.29
$1,225.82
$1,416.08
$1,198.64
$1,695.35
$2,103.73
$1,766.70
$1,081.08
$1,038.28
$1,379.39
$1,220.38

CPT
CODE
66500
66505
66600
66605
66625
66630
66635
66680
66682
66700
66710
66711
66720
66740
66761
66762
66770
66820
66821
66825
66830
66840
66850
66852
66920
66930
66940
66982
66983
66984
66985
66986
66990
66999
67005
67010
67015
67025
67027
67028
67030
67031
67036
67038
67039
67040
67101
67105
67107
67108
67110
154

MAXIMUM
FEE
$578.93
$629.22
$1,177.57
$1,600.90
$686.30
$826.27
$835.11
$745.41
$891.50
$696.49
$691.05
$908.49
$735.22
$685.62
$669.31
$710.08
$782.10
$671.35
$445.07
$1,201.36
$1,054.58
$1,028.76
$1,167.38
$1,260.47
$1,127.29
$1,276.10
$1,151.75
$1,627.40
$1,040.31
$1,226.50
$1,101.47
$1,496.26
$154.93
BR
$735.90
$856.85
$930.92
$1,113.70
$1,316.19
$362.85
$742.01
$573.50
$1,465.68
$2,564.43
$1,861.15
$2,156.05
$1,155.83
$1,077.01
$1,824.46
$2,461.83
$1,322.99

CPT
CODE
67112
67115
67120
67121
67141
67145
67208
67210
67218
67220
67221
67225
67227
67228
67250
67255
67299
67311
67312
67314
67316
67318
67320
67331
67332
67334
67335
67340
67343
67345
67350
67399
67400
67405
67412
67413
67414
67415
67420
67430
67440
67445
67450
67500
67505
67515
67550
67560
67570
67599
67700

MAXIMUM
FEE
$2,002.49
$700.56
$1,009.06
$1,339.29
$767.84
$771.23
$892.86
$1,074.97
$2,145.18
$1,643.03
$579.61
$50.28
$915.97
$1,687.20
$1,242.81
$1,306.00
BR
$885.39
$1,067.49
$981.88
$1,198.64
$1,031.48
$441.68
$413.82
$457.98
$404.98
$254.13
$500.79
$966.25
$387.99
$332.96
BR
$1,466.36
$1,233.29
$1,423.55
$1,447.34
$1,617.89
$178.03
$2,625.59
$1,982.10
$1,909.40
$1,986.86
$1,964.43
$103.28
$106.00
$83.58
$1,508.49
$1,531.59
$1,897.84
BR
$505.55

QUICK REFERENCE TABLE
SURGERY
CPT
CODE
67710
67715
67800
67801
67805
67808
67810
67820
67825
67830
67835
67840
67850
67875
67880
67882
67900
67901
67902
67903
67904
67906
67908
67909
67911
67912
67914
67915
67916
67917
67921
67922
67923
67924
67930
67935
67938
67950
67961
67966
67971
67973
67974
67975
67999
68020
68040
68100
68110
68115
68130

MAXIMUM
FEE
$437.60
$451.87
$208.61
$267.04
$329.56
$527.97
$331.60
$103.96
$216.08
$497.39
$710.76
$517.10
$349.26
$321.40
$720.27
$880.63
$1,057.98
$874.52
$878.59
$1,113.70
$1,106.91
$856.85
$818.12
$932.95
$703.28
$1,690.60
$694.45
$633.97
$927.52
$1,007.70
$663.19
$619.70
$972.36
$1,020.61
$646.88
$1,027.40
$460.70
$1,005.66
$998.19
$1,091.28
$1,195.24
$1,556.73
$1,549.26
$1,125.93
BR
$193.66
$108.72
$317.33
$404.98
$573.50
$943.15

CPT
CODE
68135
68200
68320
68325
68326
68328
68330
68335
68340
68360
68362
68371
68399
68400
68420
68440
68500
68505
68510
68520
68525
68530
68540
68550
68700
68705
68720
68745
68750
68760
68761
68770
68801
68810
68811
68815
68840
68850
68899
69000
69005
69020
69090
69100
69105
69110
69120
69140
69145
69150
69155

MAXIMUM
FEE
$254.13
$71.35
$1,149.71
$973.72
$946.54
$1,087.20
$983.92
$945.86
$899.66
$857.53
$957.42
$683.58
BR
$521.86
$585.05
$208.61
$1,445.98
$1,504.41
$826.95
$1,041.67
$453.23
$816.76
$1,398.41
$1,724.57
$877.91
$430.12
$1,175.54
$1,154.47
$1,181.65
$364.21
$251.42
$716.19
$199.09
$385.28
$332.96
$789.58
$197.73
$116.87
BR
$302.38
$354.70
$379.84
$52.32
$173.95
$221.52
$711.44
$720.27
$1,488.78
$585.73
$1,906.68
$2,873.61

CPT
CODE
69200
69205
69210
69220
69222
69300
69310
69320
69399
69400
69401
69405
69410
69420
69421
69424
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
69550
69552
69554
69601
69602
69603
69604
69605
69610
69620
69631
69632
69633
69635
69636
69637
69641
69642
69643
69644
69645
69646
69650
69660
155

MAXIMUM
FEE
$218.12
$180.75
$87.66
$221.52
$364.89
$767.16
$1,896.48
$2,729.55
BR
$207.93
$130.46
$431.48
$167.16
$311.89
$274.52
$210.65
$322.08
$301.70
$1,151.07
$886.07
$1,279.50
$1,695.35
$2,122.76
$2,178.48
$2,874.96
$4,818.33
$342.47
$1,816.30
$2,831.48
$4,507.12
$1,830.57
$1,895.13
$2,277.00
$1,957.64
$2,779.16
$701.92
$1,187.09
$1,484.71
$1,850.96
$1,774.17
$2,115.96
$2,428.53
$2,414.94
$1,801.35
$2,341.56
$2,130.91
$2,630.34
$2,562.39
$2,730.23
$1,382.10
$1,632.16

CPT
CODE
69661
69662
69666
69667
69670
69676
69700
69710
69711
69714
69715
69717
69718
69720
69725
69740
69745
69799
69801
69802
69805
69806
69820
69840
69905
69910
69915
69930
69949
69950
69955
69960
69970
69979
69990

MAXIMUM
FEE
$2,153.34
$2,067.04
$1,392.98
$1,394.33
$1,638.95
$1,431.03
$1,231.93
BR
$1,497.62
$1,886.97
$2,359.22
$2,060.92
$2,510.75
$2,042.58
$3,254.13
$2,080.63
$2,226.72
BR
$1,270.67
$1,797.96
$1,821.06
$1,656.62
$1,524.80
$1,644.39
$1,593.43
$1,806.79
$2,672.47
$2,234.88
BR
$3,177.34
$3,454.58
$3,343.14
$3,795.01
BR
$413.14

QUICK REFERENCE TABLE
RADIOLOGY
CPT
CODE
70010
70015
70030
70100
70110
70120
70130
70134
70140
70150
70160
70170
70190
70200
70210
70220
70240
70250
70260
70300
70310
70320
70328
70330
70332
70336
70350
70355
70360
70370
70371
70373
70380
70390
70450
70460
70470
70480
70481
70482
70486
70487
70488
70490
70491
70492
70496
70498
70540
70542
70543

MAXIMUM
FEE
$390.90
$195.13
$42.94
$49.89
$63.15
$57.47
$82.10
$78.94
$58.10
$74.52
$49.26
$89.67
$59.99
$76.41
$56.84
$73.89
$44.21
$62.52
$89.67
$27.79
$43.57
$71.99
$47.99
$77.04
$188.82
$873.36
$41.05
$56.20
$42.94
$114.30
$213.45
$157.24
$59.99
$152.19
$387.74
$474.26
$580.35
$425.00
$495.73
$595.50
$412.37
$489.41
$592.35
$425.00
$495.73
$594.87
$857.58
$857.58
$848.74
$1,018.61
$1,811.14

CPT
CODE
70544
70545
70546
70547
70548
70549
70551
70552
70553
70557
70558
70559
71010
71015
71020
71021
71022
71023
71030
71034
71035
71040
71060
71090
71100
71101
71110
71111
71120
71130
71250
71260
71270
71275
71550
71551
71552
71555
72010
72020
72040
72050
72052
72069
72070
72072
72074
72080
72090
72100
72110

MAXIMUM
FEE
$848.74
$848.10
$1,608.43
$848.10
$848.10
$1,608.43
$873.36
$1,047.66
$1,859.14
$1,297.73
$1,433.51
$1,439.82
$46.73
$52.41
$60.62
$72.62
$75.78
$85.88
$78.94
$136.40
$49.89
$147.77
$211.55
$161.66
$57.47
$68.20
$75.78
$87.15
$61.26
$66.31
$493.20
$577.82
$707.28
$973.14
$862.00
$1,031.87
$1,809.88
$901.78
$107.36
$41.05
$59.36
$86.52
$106.72
$51.78
$62.52
$68.20
$80.20
$63.78
$68.83
$63.78
$87.78

CPT
CODE
72114
72120
72125
72126
72127
72128
72129
72130
72131
72132
72133
72141
72142
72146
72147
72148
72149
72156
72157
72158
72159
72170
72190
72191
72192
72193
72194
72195
72196
72197
72198
72200
72202
72220
72240
72255
72265
72270
72275
72285
72295
73000
73010
73020
73030
73040
73050
73060
73070
73080
73085
156

MAXIMUM
FEE
$110.51
$78.94
$493.20
$575.30
$698.44
$493.20
$575.93
$698.44
$493.20
$575.30
$698.44
$883.47
$1,060.29
$964.93
$1,059.66
$954.83
$1,048.29
$1,877.45
$1,876.19
$1,859.14
$976.30
$49.26
$63.15
$941.57
$487.52
$555.09
$668.76
$862.63
$1,031.87
$1,825.04
$900.52
$49.26
$58.10
$53.68
$394.06
$364.38
$341.64
$520.36
$209.66
$656.76
$594.87
$47.99
$49.26
$44.21
$54.31
$186.92
$62.52
$53.68
$47.36
$53.68
$188.19

CPT
CODE
73090
73092
73100
73110
73115
73120
73130
73140
73200
73201
73202
73206
73218
73219
73220
73221
73222
73223
73225
73500
73510
73520
73525
73530
73540
73542
73550
73560
73562
73564
73565
73580
73590
73592
73600
73610
73615
73620
73630
73650
73660
73700
73701
73702
73706
73718
73719
73720
73721
73722
73723

MAXIMUM
FEE
$47.99
$46.10
$46.10
$49.89
$153.45
$46.10
$49.89
$39.15
$423.74
$493.20
$599.29
$873.36
$848.74
$1,019.24
$1,811.14
$848.74
$1,018.61
$1,811.14
$890.42
$46.10
$56.84
$67.57
$187.56
$59.36
$56.20
$190.08
$53.68
$49.26
$54.31
$60.62
$47.36
$221.03
$49.26
$46.10
$46.10
$49.89
$187.56
$46.10
$49.89
$44.84
$39.15
$423.74
$493.20
$598.66
$881.57
$848.74
$1,018.61
$1,810.51
$848.74
$1,018.61
$1,811.14

QUICK REFERENCE TABLE
RADIOLOGY
CPT
CODE
73725
74000
74010
74020
74022
74150
74160
74170
74175
74181
74182
74183
74185
74190
74210
74220
74230
74235
74240
74241
74245
74246
74247
74249
74250
74251
74260
74270
74280
74283
74290
74291
74300
74301
74305
74320
74327
74328
74329
74330
74340
74350
74355
74360
74363
74400
74410
74415
74420
74425
74430

MAXIMUM
FEE
$902.41
$49.89
$58.73
$65.04
$76.41
$479.31
$565.19
$684.55
$948.51
$862.00
$1,031.87
$1,825.04
$900.52
$128.83
$110.51
$118.72
$132.62
$277.86
$157.24
$159.14
$237.44
$169.87
$173.03
$250.07
$127.56
$147.14
$142.09
$174.29
$234.29
$345.43
$76.41
$45.47
$90.30
$52.41
$89.04
$256.39
$178.71
$270.28
$270.28
$287.33
$221.03
$275.33
$239.97
$257.65
$482.47
$155.35
$172.40
$183.77
$205.87
$118.72
$97.88

CPT
CODE
74440
74445
74450
74455
74470
74475
74480
74485
74710
74740
74742
74775
75552
75553
75554
75555
75556
75600
75605
75625
75630
75635
75650
75658
75660
75662
75665
75671
75676
75680
75685
75705
75710
75716
75722
75724
75726
75731
75733
75736
75741
75743
75746
75756
75774
75790
75801
75803
75805
75807
75809

MAXIMUM
FEE
$107.99
$174.93
$126.30
$135.14
$130.09
$317.64
$317.64
$256.39
$99.78
$120.62
$262.70
$151.56
$883.47
$916.31
$904.94
$899.26
BR
$880.94
$937.15
$936.51
$1,031.24
$1,237.74
$966.83
$953.57
$952.30
$983.88
$952.93
$981.98
$952.93
$981.98
$951.04
$1,028.71
$937.78
$951.04
$937.78
$969.98
$935.25
$935.88
$951.04
$936.51
$950.41
$980.09
$935.88
$939.67
$868.31
$250.71
$432.58
$461.00
$477.41
$507.09
$92.83

CPT
CODE
75810
75820
75822
75825
75827
75831
75833
75840
75842
75860
75870
75872
75880
75885
75887
75889
75891
75893
75894
75896
75898
75900
75901
75902
75940
75945
75946
75952
75953
75954
75960
75961
75962
75964
75966
75968
75970
75978
75980
75982
75984
75989
75992
75993
75994
75995
75996
75998
76000
76001
76003
157

MAXIMUM
FEE
$935.25
$125.04
$190.71
$936.51
$935.88
$936.51
$967.46
$937.15
$965.56
$936.51
$936.51
$940.30
$124.41
$961.77
$961.14
$935.25
$935.25
$884.10
$1,718.94
$1,510.55
$214.08
$1,437.29
$177.45
$169.24
$884.73
$339.75
$190.08
$4,054.23
$1,225.11
$2,008.17
$1,062.18
$1,067.24
$1,094.39
$589.19
$1,162.59
$589.19
$839.26
$1,093.76
$484.36
$530.46
$191.98
$312.59
$1,094.39
$589.19
$1,162.59
$1,161.96
$588.56
$121.88
$101.67
$233.66
$133.88

CPT
CODE
76005
76006
76010
76012
76013
76020
76040
76061
76062
76065
76066
76070
76071
76075
76076
76077
76078
76080
76082
76083
76086
76088
76090
76091
76092
76093
76094
76095
76096
76098
76100
76101
76102
76120
76125
76140
76150
76350
76355
76360
76362
76370
76375
76380
76390
76393
76394
76400
76496
76497
76498

MAXIMUM
FEE
$137.04
$41.05
$49.89
$339.12
$612.56
$50.52
$75.78
$106.09
$142.72
$109.88
$101.04
$217.87
$208.40
$231.76
$70.10
$65.68
$68.20
$116.83
$32.84
$32.84
$205.87
$282.28
$130.72
$162.30
$142.72
$1,311.63
$1,729.05
$614.45
$135.77
$41.68
$133.88
$145.25
$166.72
$103.57
$75.78
BR
$27.79
$65.68
$653.60
$648.55
$959.88
$270.28
$248.81
$317.01
$855.05
$874.00
$1,175.85
$882.84
BR
BR
BR

QUICK REFERENCE TABLE
RADIOLOGY
CPT
CODE
76499
76506
76510
76511
76512
76513
76514
76516
76519
76529
76536
76604
76645
76700
76705
76770
76775
76778
76800
76801
76802
76805
76810
76811
76812
76815
76816
76817
76818
76819
76820
76821
76825
76826
76827
76828
76830
76831
76856
76857
76870
76872
76873
76880
76885
76886
76930
76932
76936
76937
76940

MAXIMUM
FEE
BR
$152.82
$284.81
$219.13
$207.76
$163.56
$20.21
$131.35
$137.04
$128.83
$143.35
$134.51
$116.83
$202.08
$145.88
$195.13
$145.25
$195.13
$190.71
$226.71
$147.14
$226.71
$166.08
$420.58
$251.34
$152.19
$150.30
$165.45
$202.08
$176.19
$154.72
$172.40
$279.12
$120.62
$167.98
$126.30
$162.30
$165.45
$162.30
$144.61
$157.88
$193.87
$277.86
$145.88
$166.08
$148.40
$161.66
$161.66
$594.24
$57.47
$299.96

CPT
CODE
76941
76942
76945
76946
76948
76950
76965
76970
76975
76977
76986
76999
77261
77262
77263
77280
77285
77290
77295
77299
77300
77301
77305
77310
77315
77321
77326
77327
77328
77331
77332
77333
77334
77336
77370
77399
77401
77402
77403
77404
77406
77407
77408
77409
77411
77412
77413
77414
77416
77417
77418

MAXIMUM
FEE
$220.39
$241.86
$160.40
$136.40
$135.77
$137.67
$486.89
$104.83
$173.66
$59.99
$282.91
BR
$124.41
$187.56
$278.49
$291.12
$461.63
$568.35
$2,252.56
BR
$142.72
$2,548.73
$185.66
$246.29
$311.96
$350.48
$238.08
$350.48
$510.25
$107.99
$135.77
$198.92
$323.33
$198.29
$231.76
BR
$118.72
$118.72
$118.72
$118.72
$118.72
$139.56
$139.56
$139.56
$139.56
$155.35
$155.35
$155.35
$155.35
$39.78
$1,143.65

CPT
CODE
77427
77431
77432
77470
77499
77520
77522
77523
77525
77600
77605
77610
77615
77620
77750
77761
77762
77763
77776
77777
77778
77781
77782
77783
77784
77789
77790
77799
78000
78001
78003
78006
78007
78010
78011
78015
78016
78018
78020
78070
78075
78099
78102
78103
78104
78110
78111
78120
78121
78122
78130
158

MAXIMUM
FEE
$286.70
$162.93
$709.17
$922.62
BR
BR
BR
BR
BR
$337.85
$454.05
$338.48
$450.89
$346.69
$513.41
$487.52
$735.07
$1,040.08
$526.67
$928.31
$1,307.84
$1,492.23
$1,564.86
$1,670.95
$1,833.88
$126.93
$123.77
BR
$81.46
$109.88
$93.46
$200.82
$214.71
$155.98
$199.55
$229.87
$303.12
$436.37
$143.98
$348.59
$425.63
BR
$184.40
$276.60
$340.38
$80.83
$190.71
$136.40
$220.39
$345.43
$242.50

CPT
CODE
78135
78140
78160
78162
78170
78172
78185
78190
78191
78195
78199
78201
78202
78205
78206
78215
78216
78220
78223
78230
78231
78232
78258
78261
78262
78264
78267
78268
78270
78271
78272
78278
78282
78290
78291
78299
78300
78305
78306
78315
78320
78350
78351
78399
78414
78428
78445
78455
78456
78457
78458

MAXIMUM
FEE
$379.53
$314.49
$274.07
$254.49
$389.00
$181.87
$192.61
$478.05
$539.93
$376.37
BR
$195.77
$234.92
$454.68
$464.15
$236.81
$280.39
$289.23
$316.38
$185.03
$256.39
$275.97
$255.13
$333.43
$341.64
$342.27
$18.31
$156.61
$121.88
$127.56
$178.08
$409.21
$133.88
$262.07
$280.39
BR
$219.76
$315.75
$358.69
$406.05
$483.73
$69.47
$128.19
BR
$132.62
$219.76
$167.35
$328.38
$356.80
$244.39
$346.69

QUICK REFERENCE TABLE
RADIOLOGY
CPT
CODE
78459
78460
78461
78464
78465
78466
78468
78469
78472
78473
78478
78480
78481
78483
78491
78492
78494
78496
78499
78580
78584
78585
78586
78587
78588
78591
78593
78594
78596
78599
78600
78601
78605
78606
78607
78608
78609
78610
78615
78630
78635
78645
78647
78650
78660
78699
78700
78701
78704
78707
78708

MAXIMUM
FEE
$446.47
$232.39
$421.84
$565.19
$912.52
$234.92
$312.59
$426.89
$452.79
$676.97
$159.77
$159.14
$434.47
$652.97
$452.79
$563.93
$570.24
$509.62
BR
$292.38
$298.70
$469.84
$207.13
$228.60
$308.17
$223.55
$271.55
$376.37
$579.72
BR
$229.23
$270.28
$272.18
$313.22
$543.72
BR
BR
$132.62
$293.65
$394.69
$223.55
$277.23
$471.73
$361.85
$187.56
BR
$241.86
$278.49
$327.12
$380.16
$402.27

CPT
CODE
78709
78710
78715
78725
78730
78740
78760
78761
78799
78800
78801
78802
78803
78804
78805
78806
78807
78811
78812
78813
78814
78815
78816
78890
78891
78999
79005
79101
79200
79300
79400
79403
79440
79999

MAXIMUM
FEE
$419.32
$450.26
$132.62
$152.82
$128.83
$191.34
$235.55
$274.70
BR
$284.18
$350.48
$443.31
$531.72
$810.85
$289.86
$503.31
$531.72
$416.79
$515.30
$532.99
$583.51
$644.13
$659.29
$91.57
$183.14
BR
$330.91
$345.43
$349.22
$241.23
$483.10
$350.48
$386.48
BR

159

QUICK REFERENCE TABLE
PATHOLOGY
CPT
CODE
80048
80050
80051
80053
80055
80061
80069
80074
80076
80100
80101
80102
80103
80150
80152
80154
80156
80157
80158
80160
80162
80164
80166
80168
80170
80172
80173
80174
80176
80178
80182
80184
80185
80186
80188
80190
80192
80194
80196
80197
80198
80200
80201
80202
80299
80400
80402
80406
80408
80410
80412

MAXIMUM
FEE
$23.28
$85.61
$19.53
$29.29
$98.38
$60.08
$24.03
$147.20
$22.53
$40.55
$38.30
$36.80
$39.05
$42.06
$49.57
$51.07
$40.55
$36.80
$50.32
$47.31
$36.80
$37.55
$42.81
$45.06
$45.06
$45.06
$40.55
$47.31
$40.55
$18.02
$37.55
$31.54
$36.80
$38.30
$45.81
$46.56
$46.56
$40.55
$19.53
$38.30
$39.05
$44.31
$33.04
$37.55
$37.55
$147.20
$270.36
$251.59
$337.20
$301.15
$749.50

CPT
CODE
80414
80415
80416
80417
80418
80420
80422
80424
80426
80428
80430
80432
80434
80435
80436
80438
80439
80440
80500
80502
81000
81001
81002
81003
81005
81007
81015
81020
81025
81050
81099
82000
82003
82009
82010
82013
82016
82017
82024
82030
82040
82042
82043
82044
82045
82055
82075
82085
82088
82101
82103

MAXIMUM
FEE
$111.15
$111.15
$349.97
$150.20
$2,088.53
$265.85
$165.22
$160.71
$390.52
$195.26
$237.32
$423.56
$280.87
$298.15
$274.87
$131.43
$163.72
$160.71
$44.31
$144.94
$9.01
$9.01
$6.76
$6.01
$6.01
$6.76
$8.26
$10.51
$17.27
$8.26
BR
$34.55
$56.33
$12.77
$22.53
$30.79
$38.30
$46.56
$106.64
$71.35
$13.52
$14.27
$15.77
$12.77
$93.88
$30.04
$33.04
$27.04
$112.65
$83.36
$37.55

CPT
CODE
82104
82105
82106
82108
82120
82127
82128
82131
82135
82136
82139
82140
82143
82145
82150
82154
82157
82160
82163
82164
82172
82175
82180
82190
82205
82232
82239
82240
82247
82248
82252
82261
82270
82273
82274
82286
82300
82306
82307
82308
82310
82330
82331
82340
82355
82360
82365
82370
82373
82374
82375
160

MAXIMUM
FEE
$39.80
$46.56
$46.56
$70.59
$10.51
$38.30
$38.30
$46.56
$45.81
$46.56
$46.56
$40.55
$18.78
$42.81
$18.02
$79.61
$81.11
$69.09
$57.08
$40.55
$42.81
$52.57
$27.04
$41.31
$31.54
$45.06
$47.31
$73.60
$14.27
$14.27
$12.77
$46.56
$9.01
$9.01
$44.31
$18.78
$63.84
$81.86
$89.37
$74.35
$14.27
$37.55
$14.27
$16.52
$32.29
$35.30
$36.05
$34.55
$50.32
$13.52
$33.80

CPT
CODE
82376
82378
82379
82380
82382
82383
82384
82387
82390
82397
82415
82435
82436
82438
82441
82465
82480
82482
82485
82486
82487
82488
82489
82491
82492
82495
82507
82520
82523
82525
82528
82530
82533
82540
82541
82542
82543
82544
82550
82552
82553
82554
82565
82570
82575
82585
82595
82600
82607
82608
82615

MAXIMUM
FEE
$16.52
$52.57
$46.56
$25.53
$47.31
$69.09
$69.84
$57.83
$30.04
$39.05
$35.30
$12.77
$14.27
$13.52
$16.52
$12.02
$21.78
$21.03
$57.08
$50.32
$44.31
$59.33
$51.07
$50.32
$50.32
$56.33
$77.35
$42.06
$51.82
$34.55
$62.33
$46.56
$45.06
$12.77
$50.32
$50.32
$50.32
$50.32
$18.02
$36.80
$32.29
$33.04
$14.27
$14.27
$26.29
$24.03
$18.02
$54.07
$42.06
$39.80
$22.53

QUICK REFERENCE TABLE
PATHOLOGY
CPT
CODE
82626
82627
82633
82634
82638
82646
82649
82651
82652
82654
82656
82657
82658
82664
82666
82668
82670
82671
82672
82677
82679
82690
82693
82696
82705
82710
82715
82725
82726
82728
82731
82735
82742
82746
82747
82757
82759
82760
82775
82776
82784
82785
82787
82800
82803
82805
82810
82820
82926
82928
82938

MAXIMUM
FEE
$69.84
$61.58
$85.61
$81.11
$33.80
$57.08
$71.35
$71.35
$106.64
$38.30
$32.29
$50.32
$50.32
$95.38
$59.33
$51.82
$77.35
$89.37
$60.08
$66.84
$69.09
$48.06
$41.31
$65.34
$14.27
$46.56
$47.31
$36.80
$50.32
$37.55
$177.99
$51.07
$54.82
$40.55
$48.06
$48.06
$59.33
$30.79
$58.58
$23.28
$25.53
$45.81
$22.53
$23.28
$53.32
$78.86
$24.03
$27.79
$15.02
$18.02
$48.82

CPT
CODE
82941
82943
82945
82946
82947
82948
82950
82951
82952
82953
82955
82960
82962
82963
82965
82975
82977
82978
82979
82980
82985
83001
83002
83003
83008
83009
83010
83012
83013
83014
83015
83018
83020
83021
83026
83030
83033
83036
83045
83050
83051
83055
83060
83065
83068
83069
83070
83071
83080
83088
83090

MAXIMUM
FEE
$48.82
$39.80
$10.51
$42.06
$10.51
$9.01
$13.52
$35.30
$10.51
$42.06
$27.04
$16.52
$6.76
$59.33
$21.78
$43.56
$20.28
$39.80
$18.78
$51.07
$42.06
$51.82
$51.07
$45.81
$46.56
$186.25
$34.55
$47.31
$186.25
$21.78
$51.82
$60.83
$75.10
$50.32
$6.76
$23.28
$16.52
$27.04
$13.52
$20.28
$20.28
$13.52
$23.28
$18.78
$23.28
$11.27
$13.52
$18.78
$46.56
$81.86
$46.56

CPT
CODE
83150
83491
83497
83498
83499
83500
83505
83516
83518
83519
83520
83525
83527
83528
83540
83550
83570
83582
83586
83593
83605
83615
83625
83630
83632
83633
83634
83655
83661
83662
83663
83664
83670
83690
83715
83716
83718
83719
83721
83727
83735
83775
83785
83788
83789
83805
83825
83835
83840
83857
83858
161

MAXIMUM
FEE
$53.32
$48.82
$36.05
$75.10
$69.84
$63.08
$67.59
$32.29
$23.28
$37.55
$36.05
$31.54
$36.05
$44.31
$18.02
$24.03
$24.78
$39.05
$35.30
$72.85
$29.29
$16.52
$35.30
$32.29
$56.33
$15.02
$31.54
$33.80
$60.83
$52.57
$52.57
$52.57
$25.53
$18.78
$31.54
$69.09
$22.53
$32.29
$26.29
$47.31
$18.78
$20.28
$68.34
$50.32
$50.32
$48.82
$45.06
$46.56
$45.06
$30.04
$41.31

CPT
CODE
83864
83866
83872
83873
83874
83880
83883
83885
83887
83890
83891
83892
83893
83894
83896
83897
83898
83901
83902
83903
83904
83905
83906
83912
83915
83916
83918
83919
83921
83925
83930
83935
83937
83945
83950
83970
83986
83992
84022
84030
84035
84060
84061
84066
84075
84078
84080
84081
84085
84087
84100

MAXIMUM
FEE
$54.82
$27.04
$16.52
$47.31
$36.05
$93.88
$37.55
$67.59
$65.34
$11.27
$11.27
$11.27
$11.27
$11.27
$11.27
$11.27
$46.56
$46.56
$39.05
$46.56
$46.56
$46.56
$46.56
$48.82
$30.79
$55.57
$45.81
$45.81
$45.81
$54.07
$18.02
$18.78
$82.61
$35.30
$177.99
$114.15
$9.76
$40.55
$42.81
$15.02
$9.76
$20.28
$21.78
$27.04
$14.27
$20.28
$41.31
$45.81
$18.78
$28.54
$12.77

QUICK REFERENCE TABLE
PATHOLOGY
CPT
CODE
84105
84106
84110
84119
84120
84126
84127
84132
84133
84134
84135
84138
84140
84143
84144
84146
84150
84152
84153
84154
84155
84156
84157
84160
84163
84165
84166
84181
84182
84202
84203
84206
84207
84210
84220
84228
84233
84234
84235
84238
84244
84252
84255
84260
84270
84275
84285
84295
84300
84302
84305

MAXIMUM
FEE
$14.27
$12.02
$23.28
$24.03
$40.55
$70.59
$32.29
$12.77
$12.02
$40.55
$53.32
$52.57
$57.08
$63.08
$57.83
$53.32
$69.09
$51.07
$51.07
$51.07
$10.51
$10.51
$10.51
$14.27
$41.31
$69.09
$88.62
$86.37
$90.87
$39.80
$24.03
$49.57
$78.10
$30.04
$26.29
$32.29
$177.99
$179.49
$144.94
$101.39
$60.83
$56.33
$70.59
$85.61
$60.08
$37.55
$65.34
$13.52
$13.52
$13.52
$58.58

CPT
CODE
84307
84311
84315
84375
84376
84377
84378
84379
84392
84402
84403
84425
84430
84432
84436
84437
84439
84442
84443
84445
84446
84449
84450
84460
84466
84478
84479
84480
84481
84482
84484
84485
84488
84490
84510
84512
84520
84525
84540
84545
84550
84560
84577
84578
84580
84583
84585
84586
84588
84590
84591

MAXIMUM
FEE
$50.32
$19.53
$6.76
$54.07
$15.02
$15.02
$31.54
$31.54
$13.52
$70.59
$71.35
$58.58
$32.29
$44.31
$18.78
$18.02
$24.78
$41.31
$46.56
$140.44
$39.05
$49.57
$14.27
$15.02
$35.30
$15.77
$18.02
$39.05
$46.56
$43.56
$27.04
$21.03
$20.28
$21.03
$28.54
$21.03
$11.27
$10.51
$13.52
$18.02
$12.77
$13.52
$34.55
$9.01
$19.53
$14.27
$42.81
$97.63
$93.88
$32.29
$32.29

CPT
CODE
84597
84600
84620
84630
84681
84702
84703
84830
84999
85002
85004
85007
85008
85009
85013
85014
85018
85025
85027
85032
85041
85044
85045
85046
85048
85049
85055
85060
85097
85130
85170
85175
85210
85220
85230
85240
85244
85245
85246
85247
85250
85260
85270
85280
85290
85291
85292
85293
85300
85301
85302
162

MAXIMUM
FEE
$38.30
$44.31
$33.04
$31.54
$57.83
$41.31
$21.03
$27.79
BR
$12.77
$18.02
$9.76
$9.76
$10.51
$6.76
$6.76
$6.76
$21.78
$18.02
$12.02
$8.26
$12.02
$11.27
$15.77
$6.76
$12.02
$74.35
$48.82
$217.04
$33.04
$9.76
$12.77
$36.05
$48.82
$49.57
$49.57
$56.33
$63.84
$63.84
$63.84
$52.57
$49.57
$49.57
$53.32
$45.06
$24.78
$52.57
$52.57
$33.04
$30.04
$33.04

CPT
CODE
85303
85305
85306
85307
85335
85337
85345
85347
85348
85360
85362
85366
85370
85378
85379
85380
85384
85385
85390
85396
85400
85410
85415
85420
85421
85441
85445
85460
85461
85475
85520
85525
85530
85536
85540
85547
85549
85555
85557
85576
85597
85610
85611
85612
85613
85635
85651
85652
85660
85670
85675

MAXIMUM
FEE
$38.30
$32.29
$42.06
$42.06
$35.30
$28.54
$12.02
$12.02
$10.51
$23.28
$18.78
$24.03
$31.54
$19.53
$28.54
$28.54
$23.28
$23.28
$52.57
$42.81
$24.78
$21.03
$47.31
$18.02
$28.54
$12.02
$18.78
$21.78
$18.02
$24.78
$36.05
$33.04
$39.05
$18.02
$24.03
$24.03
$51.82
$18.78
$36.80
$99.88
$49.57
$10.51
$11.27
$26.29
$26.29
$27.04
$9.76
$7.51
$15.02
$15.77
$18.78

QUICK REFERENCE TABLE
PATHOLOGY
CPT
CODE
85705
85730
85732
85810
85999
86000
86001
86003
86005
86021
86022
86023
86038
86039
86060
86063
86064
86077
86078
86079
86140
86141
86146
86147
86148
86155
86156
86157
86160
86161
86162
86171
86185
86215
86225
86226
86235
86243
86255
86256
86277
86280
86294
86300
86301
86304
86308
86309
86310
86316
86317

MAXIMUM
FEE
$26.29
$16.52
$18.02
$32.29
BR
$19.53
$14.27
$14.27
$21.78
$41.31
$51.07
$34.55
$33.80
$30.79
$20.28
$15.77
$104.39
$102.89
$108.14
$106.64
$14.27
$36.05
$70.59
$70.59
$44.31
$44.31
$18.78
$22.53
$33.04
$33.04
$56.33
$27.79
$24.78
$36.80
$38.30
$33.80
$49.57
$57.08
$72.85
$72.85
$43.56
$22.53
$54.07
$57.83
$57.83
$57.83
$14.27
$18.02
$20.28
$57.83
$41.31

CPT
CODE
86318
86320
86325
86327
86329
86331
86332
86334
86335
86336
86337
86340
86341
86343
86344
86353
86359
86360
86361
86376
86378
86379
86382
86384
86403
86406
86430
86431
86485
86490
86510
86580
86585
86586
86587
86590
86592
86593
86602
86603
86606
86609
86611
86612
86615
86617
86618
86619
86622
86625
86628

MAXIMUM
FEE
$36.05
$102.14
$99.88
$109.65
$39.05
$33.04
$67.59
$101.39
$120.16
$42.81
$59.33
$42.06
$54.82
$34.55
$21.78
$135.93
$104.39
$129.92
$74.35
$40.55
$54.82
$104.39
$46.56
$31.54
$28.54
$29.29
$15.77
$15.77
$26.29
$23.28
$25.53
$20.28
$15.77
$26.29
$104.39
$30.79
$12.02
$12.02
$28.54
$35.30
$41.31
$36.05
$28.54
$36.05
$36.80
$42.81
$47.31
$36.80
$24.78
$36.05
$33.04

CPT
CODE
86631
86632
86635
86638
86641
86644
86645
86648
86651
86652
86653
86654
86658
86663
86664
86665
86666
86668
86671
86674
86677
86682
86684
86687
86688
86689
86692
86694
86695
86696
86698
86701
86702
86703
86704
86705
86706
86707
86708
86709
86710
86713
86717
86720
86723
86727
86729
86732
86735
86738
86741
163

MAXIMUM
FEE
$33.04
$35.30
$31.54
$33.80
$39.80
$39.80
$46.56
$42.06
$36.80
$36.80
$36.80
$36.80
$36.05
$36.05
$42.06
$50.32
$28.54
$28.54
$33.80
$40.55
$40.55
$36.05
$43.56
$23.28
$39.05
$53.32
$47.31
$39.80
$36.80
$53.32
$34.55
$24.78
$37.55
$38.30
$33.04
$32.29
$30.04
$32.29
$34.55
$31.54
$37.55
$42.06
$33.80
$36.80
$36.80
$35.30
$33.04
$36.80
$36.05
$36.80
$36.80

CPT
CODE
86744
86747
86750
86753
86756
86757
86759
86762
86765
86768
86771
86774
86777
86778
86781
86784
86787
86790
86793
86800
86803
86804
86805
86806
86807
86808
86812
86813
86816
86817
86821
86822
86849
86850
86860
86870
86880
86885
86886
86890
86891
86900
86901
86903
86904
86905
86906
86910
86911
86920
86921

MAXIMUM
FEE
$36.80
$41.31
$36.80
$34.55
$36.05
$53.32
$36.80
$39.80
$36.05
$36.80
$36.80
$41.31
$39.80
$39.80
$36.80
$34.55
$36.05
$36.05
$36.80
$44.31
$39.80
$42.81
$144.94
$131.43
$109.65
$81.86
$71.35
$160.71
$77.35
$177.99
$156.21
$101.39
BR
$34.55
$34.55
$60.83
$15.02
$15.77
$14.27
$138.18
$216.29
$8.26
$17.27
$26.29
$26.29
$10.51
$21.78
$38.30
$29.29
$38.30
$34.55

QUICK REFERENCE TABLE
PATHOLOGY
CPT
CODE
86922
86927
86930
86931
86932
86940
86941
86945
86950
86965
86970
86971
86972
86975
86976
86977
86978
86985
86999
87001
87003
87015
87040
87045
87046
87070
87071
87073
87075
87076
87077
87081
87084
87086
87088
87101
87102
87103
87106
87107
87109
87110
87116
87118
87140
87143
87147
87149
87152
87158
87164

MAXIMUM
FEE
$21.03
$18.78
$172.73
$190.00
$207.28
$22.53
$33.80
$51.82
$95.38
$24.03
$27.79
$27.79
$26.29
$17.27
$13.52
$17.27
$38.30
$36.05
BR
$36.80
$46.56
$18.78
$28.54
$26.29
$26.29
$24.03
$26.29
$26.29
$26.29
$22.53
$22.53
$18.02
$24.03
$22.53
$22.53
$21.03
$23.28
$24.78
$28.54
$28.54
$42.81
$54.07
$30.04
$30.04
$15.77
$34.55
$14.27
$55.57
$14.27
$14.27
$67.59

CPT
CODE
87166
87168
87169
87172
87176
87177
87181
87184
87185
87186
87187
87188
87190
87197
87205
87206
87207
87210
87220
87230
87250
87252
87253
87254
87255
87260
87265
87267
87269
87270
87271
87272
87273
87274
87275
87276
87277
87278
87279
87280
87281
87283
87285
87290
87299
87300
87301
87320
87324
87327
87328

MAXIMUM
FEE
$31.54
$12.02
$12.02
$12.02
$16.52
$24.78
$13.52
$18.78
$13.52
$24.03
$28.54
$18.02
$15.77
$41.31
$12.02
$15.02
$57.08
$12.02
$12.02
$54.82
$54.07
$72.10
$55.57
$54.07
$93.88
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04

CPT
CODE
87329
87332
87335
87336
87337
87338
87339
87340
87341
87350
87380
87385
87390
87391
87400
87420
87425
87427
87430
87449
87450
87451
87470
87471
87472
87475
87476
87477
87480
87481
87482
87485
87486
87487
87490
87491
87492
87495
87496
87497
87510
87511
87512
87515
87516
87517
87520
87521
87522
87525
87526
164

MAXIMUM
FEE
$33.04
$33.04
$33.04
$33.04
$33.04
$39.80
$33.04
$28.54
$28.54
$31.54
$45.81
$33.04
$48.82
$48.82
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$26.29
$26.29
$55.57
$96.88
$118.66
$55.57
$96.88
$118.66
$55.57
$96.88
$115.65
$55.57
$96.88
$118.66
$55.57
$96.88
$96.88
$55.57
$96.88
$118.66
$55.57
$96.88
$115.65
$55.57
$96.88
$118.66
$55.57
$96.88
$118.66
$55.57
$96.88

CPT
CODE
87527
87528
87529
87530
87531
87532
87533
87534
87535
87536
87537
87538
87539
87540
87541
87542
87550
87551
87552
87555
87556
87557
87560
87561
87562
87580
87581
87582
87590
87591
87592
87620
87621
87622
87650
87651
87652
87660
87797
87798
87799
87800
87801
87802
87803
87804
87807
87810
87850
87880
87899

MAXIMUM
FEE
$115.65
$55.57
$96.88
$118.66
$55.57
$96.88
$115.65
$55.57
$96.88
$235.81
$55.57
$96.88
$118.66
$55.57
$96.88
$115.65
$55.57
$96.88
$118.66
$55.57
$96.88
$118.66
$55.57
$96.88
$118.66
$55.57
$96.88
$115.65
$55.57
$96.88
$118.66
$55.57
$96.88
$115.65
$55.57
$96.88
$115.65
$55.57
$55.57
$96.88
$118.66
$111.15
$194.51
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04
$33.04

QUICK REFERENCE TABLE
PATHOLOGY
CPT
CODE
87901
87902
87903
87904
87999
88000
88005
88007
88012
88014
88016
88020
88025
88027
88028
88029
88036
88037
88040
88045
88099
88104
88106
88107
88108
88112
88125
88130
88140
88141
88142
88143
88147
88148
88150
88152
88153
88154
88155
88160
88161
88162
88164
88165
88166
88167
88172
88173
88174
88175
88182

MAXIMUM
FEE
$712.70
$712.70
$1,352.55
$361.23
BR
$446.85
$496.41
$545.98
$411.55
$411.55
$500.17
$641.35
$690.92
$740.49
$411.55
$411.55
$265.85
$195.26
$1,063.42
$88.62
BR
$108.90
$146.45
$176.49
$135.93
$239.57
$39.80
$41.31
$21.78
$44.31
$56.33
$56.33
$31.54
$42.06
$29.29
$29.29
$29.29
$29.29
$16.52
$102.89
$111.15
$137.43
$29.29
$29.29
$29.29
$29.29
$102.89
$270.36
$59.33
$73.60
$211.78

CPT
CODE
88184
88185
88187
88188
88189
88199
88230
88233
88235
88237
88239
88240
88241
88245
88248
88249
88261
88262
88263
88264
88267
88269
88271
88272
88273
88274
88275
88280
88283
88285
88289
88291
88299
88300
88302
88304
88305
88307
88309
88311
88312
88313
88314
88318
88319
88321
88323
88325
88329
88331
88332

MAXIMUM
FEE
$100.63
$49.57
$136.68
$170.48
$224.55
BR
$322.93
$389.77
$407.79
$349.97
$408.54
$27.79
$27.79
$412.30
$479.14
$479.14
$489.65
$345.46
$416.05
$345.46
$497.91
$460.36
$59.33
$74.35
$88.62
$96.13
$111.15
$69.84
$190.00
$52.57
$95.38
$53.32
BR
$41.31
$89.37
$117.91
$205.02
$364.99
$511.43
$36.80
$156.96
$113.40
$191.51
$157.71
$298.90
$160.71
$240.32
$393.52
$101.39
$177.99
$81.86

CPT
CODE
88342
88346
88347
88348
88349
88355
88356
88358
88360
88361
88362
88365
88367
88368
88371
88372
88380
88399
88400
89050
89051
89055
89060
89100
89105
89125
89130
89132
89135
89136
89140
89141
89160
89190
89220
89225
89230
89235
89240
89250
89251
89253
89254
89255
89257
89258
89259
89260
89261
89264
89268
165

MAXIMUM
FEE
$177.24
$186.25
$162.97
$825.35
$331.19
$807.33
$554.99
$147.95
$218.54
$328.94
$527.20
$253.84
$415.30
$377.00
$99.88
$103.64
BR
BR
$14.27
$12.77
$15.02
$12.02
$60.08
$184.75
$205.77
$12.02
$165.97
$131.43
$204.27
$146.45
$229.81
$275.62
$10.51
$13.52
$30.79
$9.01
$9.76
$15.02
BR
$2,062.25
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

CPT
CODE
89272
89280
89281
89290
89291
89300
89310
89320
89321
89325
89329
89330
89335
89342
89343
89344
89346
89352
89353
89354
89356

MAXIMUM
FEE
BR
BR
BR
BR
BR
$24.78
$24.03
$33.04
$33.04
$29.29
$57.83
$27.04
BR
BR
BR
BR
BR
BR
BR
BR
BR

QUICK REFERENCE TABLE
MEDICINE
CPT
CODE
90281
90283
90287
90288
90291
90296
90371
90375
90376
90378
90379
90384
90385
90386
90389
90393
90396
90399
90465
90466
90467
90468
90471
90472
90473
90474
90476
90477
90581
90585
90586
90632
90633
90634
90636
90645
90646
90647
90648
90655
90657
90658
90659
90660
90665
90669
90675
90676
90680
90690
90691

MAXIMUM
FEE
BR
BR
BR
BR
BR
BR
BR
$175.61
$146.78
BR
BR
$127.38
$77.06
BR
$171.94
BR
BR
BR
$25.69
$15.20
$26.73
$26.73
$25.69
$15.20
$23.06
$23.06
BR
BR
$148.87
$240.08
$251.09
$94.88
$44.03
$44.03
$104.84
$39.32
BR
$35.12
$35.65
$16.77
$16.77
$12.06
$12.06
BR
BR
$82.30
$216.49
BR
BR
$45.61
$63.43

CPT
CODE
90692
90693
90698
90700
90701
90702
90703
90704
90705
90706
90707
90708
90710
90712
90713
90715
90716
90717
90718
90719
90720
90721
90723
90725
90727
90732
90733
90734
90735
90740
90743
90744
90746
90747
90748
90749
90780
90781
90782
90783
90784
90788
90799
90801
90802
90804
90805
90806
90807
90808
90809

MAXIMUM
FEE
BR
BR
BR
$31.45
BR
$14.68
$16.25
$26.21
$21.49
$23.06
$51.37
BR
BR
BR
$40.89
BR
$95.40
$96.98
$14.68
BR
$55.57
$72.86
$93.31
BR
BR
$19.92
$106.94
BR
$105.89
$297.22
$41.94
$41.94
$94.88
$297.22
$76.53
BR
$125.28
$35.12
$26.21
$26.21
$52.94
$23.06
BR
$211.78
$224.88
$90.69
$99.60
$136.82
$145.20
$203.91
$211.25

CPT
CODE
90810
90811
90812
90813
90814
90815
90816
90817
90818
90819
90821
90822
90823
90824
90826
90827
90828
90829
90845
90846
90847
90849
90853
90857
90862
90865
90870
90871
90875
90876
90880
90882
90885
90887
90889
90899
90901
90911
90918
90919
90920
90921
90922
90923
90924
90925
90935
90937
90939
90940
90945
166

MAXIMUM
FEE
$98.03
$109.56
$147.30
$154.64
$213.35
$219.64
$91.21
$100.12
$137.86
$144.16
$204.96
$210.73
$98.03
$107.46
$145.73
$151.49
$213.35
$218.07
$126.33
$132.62
$161.45
$46.13
$45.08
$49.27
$71.82
$225.93
$202.34
$202.34
$112.18
$163.03
$172.46
$123.19
$71.29
$122.66
$106.41
BR
$56.61
$131.05
$924.16
$672.02
$589.20
$369.04
$30.93
$22.02
$19.40
$12.58
$101.17
$165.12
$112.18
$112.18
$105.36

CPT
CODE
90947
90989
90993
90997
90999
91000
91010
91011
91012
91020
91030
91034
91035
91037
91038
91040
91052
91055
91060
91065
91100
91105
91110
91120
91122
91123
91132
91133
91299
92002
92004
92012
92014
92015
92018
92019
92020
92060
92065
92070
92081
92082
92083
92100
92120
92130
92135
92136
92140
92225
92226

MAXIMUM
FEE
$168.79
$730.73
$123.19
$134.20
BR
$57.66
$302.99
$359.60
$385.29
$319.24
$178.23
$331.82
$655.77
$210.73
$180.32
$640.57
$172.99
$207.06
$128.95
$88.59
$206.53
$131.05
$1,361.87
$632.19
$370.61
BR
$58.71
$73.91
BR
$98.03
$178.75
$90.16
$133.15
$98.55
$190.81
$99.60
$37.74
$76.01
$48.23
$93.83
$69.19
$88.59
$102.22
$120.04
$99.60
$110.61
$60.81
$118.99
$78.63
$31.98
$28.83

QUICK REFERENCE TABLE
MEDICINE
CPT
CODE
92230
92235
92240
92250
92260
92265
92270
92275
92283
92284
92285
92286
92287
92310
92311
92312
92313
92314
92315
92316
92317
92325
92326
92330
92335
92340
92341
92342
92352
92353
92354
92355
92358
92370
92371
92390
92391
92392
92393
92395
92396
92499
92502
92504
92506
92507
92508
92510
92511
92512
92516

MAXIMUM
FEE
$112.70
$183.47
$382.14
$104.32
$24.64
$123.71
$125.28
$157.26
$53.99
$112.18
$63.43
$196.58
$168.27
$122.14
$115.32
$124.24
$104.84
$85.97
$68.67
$84.40
$73.39
$21.49
$88.59
$110.08
$71.29
$56.61
$63.95
$68.15
$55.57
$65.53
$469.68
$227.50
$53.47
$46.65
$33.55
BR
BR
$199.72
$646.34
$72.34
$116.90
BR
$139.96
$36.17
$182.42
$86.49
$40.89
$191.33
$219.12
$89.64
$85.97

CPT
CODE
92520
92526
92531
92532
92533
92534
92541
92542
92543
92544
92545
92546
92547
92548
92551
92552
92553
92555
92556
92557
92559
92560
92561
92562
92563
92564
92565
92567
92568
92569
92571
92572
92573
92575
92576
92577
92579
92582
92583
92584
92585
92586
92587
92588
92590
92591
92592
92593
92594
92595
92596

MAXIMUM
FEE
$68.15
$115.85
$32.50
$37.74
$59.76
$26.21
$77.06
$78.63
$36.17
$62.38
$55.57
$120.57
$7.34
$152.02
$15.20
$25.16
$37.74
$22.02
$33.02
$68.67
$49.27
$28.83
$40.89
$23.59
$22.02
$27.26
$23.06
$30.40
$22.02
$23.59
$22.54
$5.24
$20.44
$16.77
$25.69
$41.41
$41.41
$41.41
$50.85
$140.49
$143.11
$104.32
$84.92
$111.65
$58.71
$88.07
$25.69
$38.79
$28.31
$42.46
$34.07

CPT
CODE
92597
92601
92602
92603
92604
92605
92606
92607
92608
92609
92610
92611
92612
92613
92614
92615
92616
92617
92620
92621
92625
92700
92950
92953
92960
92961
92970
92971
92973
92974
92975
92977
92978
92979
92980
92981
92982
92984
92986
92987
92990
92992
92993
92995
92996
92997
92998
93000
93005
93010
93012
167

MAXIMUM
FEE
$135.24
$187.14
$128.43
$115.85
$74.44
BR
BR
$164.07
$31.45
$85.44
$183.99
$183.99
$212.30
$60.81
$199.72
$53.99
$279.40
$67.10
$62.90
$16.25
$61.86
BR
$432.47
$16.77
$452.91
$364.84
$249.52
$140.49
$251.62
$230.12
$538.88
$446.09
$386.34
$234.84
$1,119.17
$310.33
$830.33
$221.21
$1,798.01
$1,866.15
$1,461.99
$1,626.07
$1,139.61
$913.16
$242.70
$904.77
$444.00
$37.22
$24.64
$12.58
$324.48

CPT
CODE
93014
93015
93016
93017
93018
93024
93025
93040
93041
93042
93224
93225
93226
93227
93230
93231
93232
93233
93235
93236
93237
93268
93270
93271
93272
93278
93303
93304
93307
93308
93312
93313
93314
93315
93316
93317
93318
93320
93321
93325
93350
93501
93503
93505
93508
93510
93511
93514
93524
93526
93527

MAXIMUM
FEE
$38.27
$149.40
$33.55
$93.83
$22.02
$150.45
$444.52
$19.92
$8.39
$11.53
$229.08
$69.19
$121.61
$38.27
$244.80
$85.44
$121.09
$38.27
$177.70
$144.68
$33.02
$431.94
$69.19
$324.48
$38.27
$84.92
$309.80
$164.07
$282.54
$147.82
$374.28
$63.95
$306.13
$454.48
$65.00
$338.11
$328.67
$124.24
$73.91
$168.79
$209.16
$1,170.54
$198.67
$446.09
$1,032.67
$2,413.42
$2,411.84
$2,560.72
$3,172.46
$3,171.93
$3,198.14

QUICK REFERENCE TABLE
MEDICINE
CPT
CODE
93528
93529
93530
93531
93532
93533
93539
93540
93541
93542
93543
93544
93545
93555
93556
93561
93562
93571
93572
93580
93581
93600
93602
93603
93609
93610
93612
93613
93615
93616
93618
93619
93620
93621
93622
93623
93624
93631
93640
93641
93642
93650
93651
93652
93660
93662
93668
93701
93720
93721
93722

MAXIMUM
FEE
$3,332.34
$3,004.71
$1,278.52
$3,344.92
$3,399.96
$3,138.39
$29.88
$31.98
$21.49
$21.49
$21.49
$18.87
$29.88
$407.30
$607.02
$66.57
$30.40
$384.76
$231.17
$1,394.37
$1,859.34
$272.06
$224.88
$256.86
$533.64
$308.23
$322.38
$536.26
$85.44
$123.19
$537.83
$990.74
$1,600.38
$285.16
$420.41
$386.34
$484.89
$943.56
$659.44
$839.77
$777.91
$820.37
$1,240.78
$1,349.82
$230.12
$381.09
$73.39
$61.33
$52.42
$40.36
$12.06

CPT
CODE
93724
93727
93731
93732
93733
93734
93735
93736
93740
93741
93742
93743
93744
93745
93760
93762
93770
93784
93786
93788
93790
93797
93798
93799
93875
93880
93882
93886
93888
93890
93892
93893
93922
93923
93924
93925
93926
93930
93931
93965
93970
93971
93975
93976
93978
93979
93980
93981
93990
94010
94014

MAXIMUM
FEE
$584.48
$38.79
$61.33
$96.98
$54.52
$47.70
$80.20
$47.70
$19.40
$96.98
$105.36
$117.42
$125.28
BR
$87.02
$127.90
$13.63
$102.74
$48.23
$27.26
$27.26
$25.69
$39.32
BR
$139.96
$342.83
$218.07
$426.17
$271.54
$332.87
$354.36
$347.54
$161.45
$248.47
$293.03
$406.26
$246.90
$326.05
$212.83
$171.94
$334.44
$227.50
$523.68
$309.28
$293.03
$205.49
$236.94
$190.81
$235.89
$45.61
$68.67

CPT
CODE
94015
94016
94060
94070
94150
94200
94240
94250
94260
94350
94360
94370
94375
94400
94450
94452
94453
94620
94621
94640
94642
94656
94657
94660
94662
94664
94667
94668
94680
94681
94690
94720
94725
94750
94760
94761
94762
94770
94772
94799
95004
95010
95015
95024
95027
95028
95044
95052
95056
95060
95065
168

MAXIMUM
FEE
$31.45
$37.22
$76.01
$81.25
$29.36
$30.40
$51.37
$40.36
$39.84
$56.09
$53.99
$52.94
$49.27
$69.72
$67.62
$71.82
$102.22
$170.89
$198.15
$16.77
$82.82
$128.43
$96.98
$76.01
$53.47
$18.35
$29.88
$24.64
$114.80
$149.40
$110.61
$69.72
$172.99
$84.92
$3.15
$6.81
$29.88
$51.37
BR
BR
$5.77
$25.16
$15.73
$8.39
$8.39
$12.58
$11.01
$13.63
$9.44
$19.40
$11.01

CPT
CODE
95070
95071
95075
95078
95115
95117
95120
95125
95130
95131
95132
95133
95134
95144
95145
95146
95147
95148
95149
95165
95170
95180
95199
95250
95805
95806
95807
95808
95810
95811
95812
95813
95816
95819
95822
95824
95827
95829
95830
95831
95832
95833
95834
95851
95852
95857
95858
95860
95861
95863
95864

MAXIMUM
FEE
$120.57
$154.11
$94.36
$14.15
$21.49
$27.26
$26.73
$33.02
$46.13
$58.71
$70.77
$85.44
$102.22
$13.63
$20.44
$26.73
$25.69
$34.07
$45.61
$13.63
$10.48
$214.40
BR
$215.45
$1,025.86
$281.50
$734.40
$859.16
$1,132.27
$1,236.59
$276.78
$364.84
$259.48
$221.21
$307.71
$142.58
$208.11
$1,976.23
$267.34
$39.32
$33.55
$56.09
$66.05
$27.78
$19.92
$60.28
$144.16
$128.43
$161.98
$197.10
$254.76

QUICK REFERENCE TABLE
MEDICINE
CPT
CODE
95867
95868
95869
95870
95872
95875
95900
95903
95904
95920
95921
95922
95923
95925
95926
95927
95928
95929
95930
95933
95934
95936
95937
95950
95951
95953
95954
95955
95956
95957
95958
95961
95962
95965
95966
95967
95970
95971
95972
95973
95974
95975
95978
95979
95990
95991
95999
96000
96001
96002
96003

MAXIMUM
FEE
$93.83
$131.05
$40.89
$40.89
$149.92
$139.44
$90.16
$96.45
$77.06
$240.08
$87.54
$94.88
$152.54
$92.78
$92.78
$93.83
$241.66
$251.62
$137.34
$89.64
$51.37
$55.04
$70.77
$311.90
$1,162.68
$592.35
$359.60
$186.62
$1,000.17
$249.52
$424.08
$321.86
$330.25
$3,108.51
$1,543.77
$1,263.32
$69.72
$80.20
$149.40
$84.40
$255.29
$142.06
$294.08
$135.77
$81.78
$120.04
BR
$127.90
$152.54
$30.40
$26.73

CPT
CODE
96004
96100
96105
96110
96111
96115
96117
96150
96151
96152
96153
96154
96155
96400
96405
96406
96408
96410
96412
96414
96420
96422
96423
96425
96440
96445
96450
96520
96530
96542
96545
96549
96567
96570
96571
96900
96902
96910
96912
96913
96920
96921
96922
96999

MAXIMUM
FEE
$167.22
$101.69
$101.69
$18.87
$200.77
$101.69
$101.69
$36.17
$35.12
$33.55
$7.86
$33.02
$33.55
$68.15
$149.40
$201.29
$164.60
$231.17
$51.37
$286.74
$152.02
$266.29
$108.51
$247.42
$548.31
$543.60
$467.59
$211.25
$152.54
$299.84
BR
BR
$52.42
$82.82
$40.36
$24.11
$31.45
$53.99
$68.67
$93.31
$194.48
$199.20
$295.12
BR

169

QUICK REFERENCE TABLE
PHYSICAL MEDICINE
CPT
CODE
97001
97002
97003
97004
97005
97006
97010
97012
97014
97016
97018
97020
97022

MAXIMUM
FEE
$87.60
$46.43
$93.73
$56.50
$70.96
$35.48
$5.26
$17.08
$16.64
$16.21
$7.45
$5.69
$17.08

CPT
CODE
97024
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116

MAXIMUM
FEE
$6.13
$5.69
$7.01
$18.40
$23.65
$16.21
$14.02
$26.72
$13.58
$32.41
$34.16
$37.23
$28.47

CPT
CODE
97124
97139
97140
97150
97504
97520
97530
97532
97533
97535
97537
97542
97545

MAXIMUM
FEE
$25.84
$18.40
$30.66
$20.15
$35.48
$32.41
$34.16
$28.47
$30.22
$34.60
$31.54
$32.41
$141.04

CPT
CODE
97546
97597
97598
97602
97605
97606
97703
97750
97755
97799

MEDICAL NUTRITION THERAPY
CPT
CODE
97802
97803
97804

MAXIMUM
FEE
$19.77
$19.77
$7.83

ACUPUNCTURE
CPT
CODE
97810
97811
97813
97814

MAXIMUM
FEE
$25.95
$21.83
$28.00
$23.89

OSTEOPATHIC MANIPULATIVE TREATMENT
CPT
CODE
98925
98926
98927
98928
98929

MAXIMUM
FEE
$43.00
$59.33
$76.20
$90.35
$103.96

170

MAXIMUM
FEE
$56.50
$56.50
$71.83
$20.59
BR
BR
$29.78
$34.60
$40.30
BR

QUICK REFERENCE TABLE
CHIROPRACTIC MANIPULATIVE TREATMENT
CPT
CODE
98940
98941
98942
98943

MAXIMUM
FEE
$35.02
$49.23
$63.44
$32.99

SPECIAL SERVICES AND REPORTS
CPT
CODE
99000
99001
99002
99024
99026
99027
99050
99052
99054
99056

MAXIMUM
FEE
$7.62
$8.47
$11.86
BR
BR
BR
$22.45
$22.45
$22.45
$29.65

CPT
CODE
99058
99070
99071
99075
99078
99080
99082
99090
99091
99100

MAXIMUM
FEE
$30.49
BR
*
**
BR
BR
BR
BR
BR
#

CPT
CODE
99116
99135
99140
99141
99142
99170
99172
99173
99175
99183

MAXIMUM
FEE
#
#
#
$115.19
$67.34
$152.04
$27.53
$13.13
$63.10
$243.09

CPT
CODE
99185
99186
99190
99191
99192
99195
99199

MAXIMUM
FEE
$28.80
$94.44
$600.52
$450.18
$300.26
$19.48
BR

*

The maximum fee for this code (99071) is to be determined "by report" (BR); however, when the
charge for any item exceeds $7.00, documentation of cost to the provider for such item must be
attached to the bill when submitted for payment. Payment shall not exceed the cost of the item
to the health care provider plus 25%.

**

See Depositions, Testimony and Medical Records Reproduction Section

#

See Anesthesia Section

171

QUICK REFERENCE TABLE
EVALUATION AND MANAGEMENT
CPT
CODE
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
##

MAXIMUM
FEE
$44.94
$79.69
$118.60
$167.71
$212.19
$26.41
$47.26
$64.40
$101.00
$146.87
$86.64
$82.47
$137.14
$192.73
$83.39
$138.06
$192.27
$41.70
$68.11
$96.83
$165.86
$218.68
$272.88
$86.64
$118.14
$61.62
$112.58
$150.11
$211.26
$273.35
$44.01
$88.49
$120.92

CPT
CODE
99254
99255
99261
99262
99263
99271
99272
99273
99274
99275
99281
99282
99283
99284
99285
99288
99289
99290
99291
99292
99293
99294
99295
99296
99297
99298
99301
99302
99303
99311
99312
99313
99315

MAXIMUM
FEE
$173.74
$239.53
$27.33
$55.60
$82.47
$47.72
$80.15
$111.19
$149.18
$189.95
$20.39
$33.82
$75.98
$118.60
$185.78
BR
$300.22
$154.28
$313.65
$138.99
$1,010.92
$502.22
$1,157.32
$502.68
$177.91
$163.08
$81.08
$107.49
$132.50
$41.70
$69.03
$97.29
$75.52

CPT
CODE
99316
99321
99322
99323
99331
99332
99333
99341
99342
99343
99344
99345
99347
99348
99349
99350
99354
99355
99356
99357
99358
99359
99360
99361
99362
99371
99372
99373
99374
99375
99377
99378
99379

MAXIMUM
FEE
$100.07
$50.04
$70.42
$87.10
$44.01
$56.06
$69.50
$71.35
$105.17
$153.35
$201.07
$248.79
$55.60
$88.03
$136.21
$201.07
$121.38
$119.99
$111.19
$112.12
$173.74
$87.10
$118.14
$99.61
$173.74
$15.75
$39.38
$79.22
$85.71
$155.21
$85.71
$173.27
$85.25

CPT
CODE
99380
99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
99401
99402
99403
99404
99411
99412
99420
99429
99431
99432
99433
99435
99436
99440
99450
99455
99456
99499

MAXIMUM
FEE
$128.80
$126.94
$136.67
$133.89
$145.48
$145.48
$170.96
$185.32
$96.37
$107.95
$106.56
$117.68
$119.07
$131.58
$145.01
$51.43
$86.64
$119.99
$153.82
$15.75
$23.63
BR
BR
$74.13
$104.71
$38.92
$99.61
$94.05
$184.39
BR
##
##
BR

Refer to item 2 of the Deposition/Testimony & Reproduction of Medical Records Section of this fee
schedule as it relates to an IME or other Special Examination and/or Report.

172

QUICK REFERENCE TABLE
HOME HEALTH PROCEDURES / SERVICES
CPT
CODE
99500
99501
99502
99503
99504
99505
99506
99507
99509
99510
99511
99512
99600

MAXIMUM
FEE
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

HOME INFUSION PROCEDURES
CPT
CODE
99601
99602

MAXIMUM
FEE
BR
BR

173

QUICK REFERENCE TABLE
DENTISTRY
ADA
CODE
D0120
D0140
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0274
D0277
D0290
D0310
D0320
D0321
D0322
D0330
D0340
D0350
D0415
D0416
D0421
D0425
D0431
D0460
D0470
D0472
D0473
D0474
D0475
D0476
D0477
D0478
D0479
D0480
D0481
D0482
D0483
D0484
D0485
D0502
D0999
D1110
D1120
D1201
D1203

MAXIMUM
FEE
$27.17
$35.04
$39.33
$51.84
BR
BR
$80.08
$15.37
$12.51
$21.45
$35.75
$17.88
$15.37
$25.03
$35.75
BR
BR
BR
BR
BR
BR
$68.28
$71.50
BR
BR
BR
BR
BR
BR
$26.10
$54.34
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$53.63
$38.25
$47.55
$22.88

ADA
CODE
D1204
D1205
D1310
D1320
D1330
D1351
D1510
D1515
D1520
D1525
D1550
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2410
D2420
D2430
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2712
D2720
D2721
D2722
D2740

MAXIMUM
FEE
$24.67
$59.70
BR
$10.73
$23.95
$29.67
$188.05
$264.91
$143.00
$214.50
$33.25
$70.07
$88.66
$107.61
$128.70
$86.16
$109.40
$134.06
$159.45
BR
BR
BR
BR
BR
BR
BR
BR
$447.95
$512.30
BR
BR
$610.25
$595.95
$511.23
$570.21
$607.75
$620.26
$651.01
$661.38
$443.30
$506.58
$607.75
$464.75
$563.78
$607.75
$425.43
BR
$620.98
BR
BR
$703.20

ADA
CODE
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2794
D2799
D2910
D2915
D2920
D2930
D2931
D2932
D2933
D2934
D2940
D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2960
D2961
D2962
D2971
D2975
D2980
D2999
D3110
D3120
D3220
D3221
D3230
D3240
D3310
D3320
D3330
D3331
D3332
D3333
D3346
D3347
D3348
D3351
174

MAXIMUM
FEE
$685.33
$615.62
$642.79
BR
BR
BR
BR
$657.44
$494.42
$519.81
BR
BR
$46.48
BR
$55.41
$156.94
$189.83
BR
BR
BR
$57.56
$155.16
$18.95
$226.66
BR
$178.75
BR
BR
$309.24
BR
$600.96
BR
BR
BR
BR
$48.62
$46.12
$99.03
BR
$111.54
$114.04
$387.17
$462.25
$574.15
BR
BR
BR
BR
BR
BR
BR

ADA
CODE
D3352
D3353
D3410
D3421
D3425
D3426
D3430
D3450
D3460
D3470
D3910
D3920
D3950
D3999
D4210
D4211
D4240
D4241
D4245
D4249
D4260
D4261
D4263
D4264
D4265
D4266
D4267
D4268
D4270
D4271
D4273
D4274
D4275
D4276
D4320
D4321
D4341
D4342
D4355
D4381
D4910
D4920
D4999
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214

MAXIMUM
FEE
BR
BR
$334.98
BR
BR
BR
BR
$304.23
BR
BR
BR
BR
BR
BR
$321.39
$109.75
$214.50
BR
BR
BR
$545.90
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$204.85
$160.52
BR
BR
BR
$76.15
BR
BR
$966.68
$964.54
$1,010.65
$1,011.01
$688.90
$691.05
$1,039.97
$1,038.18

QUICK REFERENCE TABLE
DENTISTRY
ADA
CODE
D5225
D5226
D5281
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5670
D5671
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5810
D5811
D5820
D5821
D5850
D5851
D5860
D5861
D5862
D5867
D5875
D5899
D5911
D5912
D5913
D5914
D5915
D5916
D5919
D5922
D5923
D5924

MAXIMUM
FEE
BR
BR
$506.94
$37.90
$37.90
$37.90
$37.90
$115.47
$96.88
$114.04
$169.81
$156.59
$97.60
$125.13
$162.31
BR
BR
$343.20
$357.50
$286.00
$286.00
$193.77
$193.77
$184.83
$184.83
$294.58
$295.30
$263.48
$263.48
$387.17
$387.17
$357.50
$357.50
$71.50
$71.50
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

ADA
CODE
D5925
D5926
D5927
D5928
D5929
D5931
D5932
D5933
D5934
D5935
D5936
D5937
D5951
D5952
D5953
D5954
D5955
D5958
D5959
D5960
D5982
D5983
D5984
D5985
D5986
D5987
D5988
D5999
D6010
D6040
D6050
D6053
D6054
D6055
D6056
D6057
D6058
D6059
D6060
D6061
D6062
D6063
D6064
D6065
D6066
D6067
D6068
D6069
D6070
D6071
D6072

MAXIMUM
FEE
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$893.75
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

ADA
CODE
D6073
D6074
D6075
D6076
D6077
D6078
D6079
D6080
D6090
D6094
D6095
D6100
D6190
D6199
D6205
D6210
D6211
D6212
D6214
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6253
D6545
D6548
D6600
D6601
D6602
D6603
D6604
D6605
D6606
D6607
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6624
D6634
D6710
D6720
D6721
D6722
175

MAXIMUM
FEE
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$702.85
$500.50
$572.00
BR
$685.33
$619.55
$571.64
BR
BR
BR
BR
BR
$456.89
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$658.87
BR
BR

ADA
CODE
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6793
D6794
D6920
D6930
D6940
D6950
D6970
D6971
D6972
D6973
D6975
D6976
D6977
D6980
D6985
D6999
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7260
D7261
D7270
D7272
D7280
D7282
D7283
D7285
D7286
D7287
D7288
D7290
D7291
D7310
D7320
D7321

MAXIMUM
FEE
BR
$687.47
$620.26
$557.70
$655.30
BR
BR
BR
$661.38
$494.42
$519.81
BR
BR
BR
$82.94
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$154.44
$178.75
$221.29
$268.48
$315.67
$162.66
$429.00
BR
$178.75
BR
$214.50
BR
BR
$167.31
$167.31
BR
BR
$429.00
$32.89
$137.28
$181.61
BR

QUICK REFERENCE TABLE
DENTISTRY
ADA
CODE
D7340
D7350
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7465
D7471
D7472
D7473
D7485
D7490
D7510
D7511
D7520
D7521
D7530
D7540
D7550
D7560
D7610
D7620
D7630
D7640
D7650
D7660
D7670
D7671
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
D7830
D7840
D7850

MAXIMUM
FEE
BR
BR
$184.47
BR
BR
BR
BR
BR
BR
BR
$357.50
$572.00
$357.50
$572.00
BR
BR
BR
BR
BR
BR
$143.00
BR
$199.49
BR
$43.26
$93.67
BR
BR
$1,430.00
$1,251.25
$1,608.75
$1,430.00
BR
BR
$531.60
BR
BR
$1,787.50
$1,573.00
$1,993.42
$1,608.75
BR
BR
$929.50
BR
$2,461.03
BR
BR
BR
BR
BR

ADA
CODE
D7852
D7854
D7856
D7858
D7860
D7865
D7870
D7871
D7872
D7873
D7874
D7875
D7876
D7877
D7880
D7899
D7910
D7911
D7912
D7920
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7953
D7955
D7960
D7963
D7970
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D7995
D7996
D7997
D7999
D8010
D8020
D8030
D8040

MAXIMUM
FEE
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$507.29
BR
$120.12
$223.80
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
$198.77
BR
$218.08
$214.50
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR
BR

ADA
CODE
D8050
D8060
D8070
D8080
D8090
D8210
D8220
D8660
D8670
D8680
D8690
D8691
D8692
D8999
D9110
D9210
D9211
D9212
D9215
D9220
D9221
D9230
D9241
D9242
D9248
D9310
D9410
D9420
D9430
D9440
D9450
D9610
D9630
D9910
D9911
D9920
D9930
D9940
D9941
D9942
D9950
D9951
D9952
D9970
D9971
D9972
D9973
D9974
D9999

176

MAXIMUM
FEE
BR
BR
BR
BR
BR
$214.50
$250.25
BR
BR
BR
BR
BR
BR
BR
$65.42
$29.67
$13.23
BR
$10.73
BR
BR
$32.89
BR
BR
BR
$107.25
$99.39
$106.18
$38.25
$71.50
BR
BR
$23.60
$29.67
BR
BR
BR
$282.78
$85.09
BR
BR
$93.31
$297.80
BR
BR
BR
BR
BR
BR