Code Short Description Modifier Age Range Rate Qualifying ...

Code Short Description Modifier Age Range Rate Qualifying Visit

Count

APM Procedure

Codes

Excluded TechnicalPaymentsfor RHCI's

ExcludedProcedure

Codes

PPS Visit Code

Effective Date**

10004 Fna Bx W/O Img Gdn Ea Addl $29.32 110005 Fna Bx W/Us Gdn 1st Les $72.70 110021 Fna Bx W/O Img Gdn 1st Les $55.47 110040 Acne Surgery $61.61 110060 Drainage Of Skin Abscess $68.15 110061 Drainage Of Skin Abscess $118.27 110080 Drainage Of Pilonidal Cyst $118.66 110081 Drainage Of Pilonidal Cyst $171.75 110120 Remove Foreign Body $85.38 110121 Remove Foreign Body $153.73 110140 Drainage Of Hematoma/Fluid $96.08 110160 Puncture Drainage Of Lesion $73.50 111000 Debride Infected Skin $31.89 111042 Deb Subq Tissue 20 Sq Cm/< $70.72 111055 Trim Skin Lesion $35.26 111056 Trim Skin Lesions 2 To 4 $41.60 111057 Trim Skin Lesions Over 4 $45.76 111102 Tangntl Bx Skin Single Les $56.26 111103 Tangntl Bx Skin Ea Sep/Addl $29.91 111104 Punch Bx Skin Single Lesion $70.72 111105 Punch Bx Skin Ea Sep/Addl $34.07 111106 Incal Bx Skn Single Les $85.58 111107 Incal Bx Skn Ea Sep/Addl $40.41 111200 Removal Of Skin Tags <W/15 $49.92 111201 Remove Skin Tags Add-On $10.50 011300 Shave Skin Lesion 0.5 Cm/< $56.26 111301 Shave Skin Lesion 0.6-1.0 Cm $68.34 111302 Shave Skin Lesion 1.1-2.0 Cm $79.04 111303 Shave Skin Lesion >2.0 Cm $86.97 111305 Shave Skin Lesion 0.5 Cm/< $59.23 111306 Shave Skin Lesion 0.6-1.0 Cm $69.34 111307 Shave Skin Lesion 1.1-2.0 Cm $81.02 111308 Shave Skin Lesion >2.0 Cm $86.57 111310 Shave Skin Lesion 0.5 Cm/< $65.17 111311 Shave Skin Lesion 0.6-1.0 Cm $77.26 111312 Shave Skin Lesion 1.1-2.0 Cm $89.34 111313 Shave Skin Lesion >2.0 Cm $104.40 111400 Exc Tr-Ext B9+Marg 0.5 Cm< $70.72 111401 Exc Tr-Ext B9+Marg 0.6-1 Cm $86.17 1

Michigan Department of Health and Human ServicesRural Health Clinic Reimbursement List

July 2020Suggested MCO Reimbursement Rate: $52.37

Revised: 05/18/2021

* Indicates temporary coverage during COVID-19 Emergency**Effective date will only be populated when the rate begins after the published fee schedule date.

Page 1 of 63


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Effective Date**



Revised: 05/18/2021

11402 Exc Tr-Ext B9+Marg 1.1-2 Cm $95.68 111403 Exc Tr-Ext B9+Marg 2.1-3cm $110.54 111404 Exc Tr-Ext B9+Marg 3.1-4 Cm $125.60 111406 Exc Tr-Ext B9+Marg >4.0 Cm $179.68 111420 Exc H-F-Nk-Sp B9+Marg 0.5/< $71.32 111421 Exc H-F-Nk-Sp B9+Marg 0.6-1 $89.94 111422 Exc H-F-Nk-Sp B9+Marg 1.1-2 $101.23 111423 Exc H-F-Nk-Sp B9+Marg 2.1-3 $115.10 111424 Exc H-F-Nk-Sp B9+Marg 3.1-4 $132.93 111426 Exc H-F-Nk-Sp B9+Marg >4 Cm $190.77 111440 Exc Face-Mm B9+Marg 0.5 Cm/< $78.65 111441 Exc Face-Mm B9+Marg 0.6-1 Cm $96.67 111442 Exc Face-Mm B9+Marg 1.1-2 Cm $107.57 111600 Exc Tr-Ext Mal+Marg 0.5 Cm/< $111.13 111601 Exc Tr-Ext Mal+Marg 0.6-1 Cm $129.16 111602 Exc Tr-Ext Mal+Marg 1.1-2 Cm $139.07 111603 Exc Tr-Ext Mal+Marg 2.1-3 Cm $158.48 111604 Exc Tr-Ext Mal+Marg 3.1-4 Cm $176.90 111606 Exc Tr-Ext Mal+Marg >4 Cm $253.77 111620 Exc H-F-Nk-Sp Mal+Marg 0.5/< $111.73 111621 Exc S/N/H/F/G Mal+Mrg 0.6-1 $129.76 111622 Exc S/N/H/F/G Mal+Mrg 1.1-2 $143.62 111623 Exc S/N/H/F/G Mal+Mrg 2.1-3 $168.78 111640 Exc F/E/E/N/L Mal+Mrg 0.5cm< $114.30 111641 Exc F/E/E/N/L Mal+Mrg 0.6-1 $134.31 111642 Exc F/E/E/N/L Mal+Mrg 1.1-2 $152.34 111720 Debride Nail 1-5 $18.42 111721 Debride Nail 6 Or More $25.55 111730 Removal Of Nail Plate $62.20 111732 Remove Nail Plate Add-On $18.82 011740 Drain Blood From Under Nail $30.11 111750 Removal Of Nail Bed $88.15 111755 Biopsy Nail Unit $68.74 111760 Repair Of Nail Bed $109.95 111765 Excision Of Nail Fold Toe $95.09 111900 Inject Skin Lesions </W 7 $30.90 111901 Inject Skin Lesions >7 $39.03 111976 Remove Contraceptive Capsule $82.21 1 YES11981 Insert Drug Implant Device $58.64 1 YES


Page 2 of 63


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

11982 Remove Drug Implant Device $66.56 1 YES11983 Remove/Insert Drug Implant $82.21 1 YES12001 Rpr S/N/Ax/Gen/Trnk 2.5cm/< $51.11 112002 Rpr S/N/Ax/Gen/Trnk2.6-7.5cm $62.60 112011 Rpr F/E/E/N/L/M 2.5 Cm/< $62.40 112013 Rpr F/E/E/N/L/M 2.6-5.0 Cm $65.17 112031 Intmd Rpr S/A/T/Ext 2.5 Cm/< $142.04 112032 Intmd Rpr S/A/T/Ext 2.6-7.5 $170.17 112041 Intmd Rpr N-Hf/Genit 2.5cm/< $142.43 112042 Intmd Rpr N-Hf/Genit2.6-7.5 $169.18 112051 Intmd Rpr Face/Mm 2.5 Cm/< $153.13 112052 Intmd Rpr Face/Mm 2.6-5.0 Cm $171.75 116000 Initial Treatment Of Burn(S) $41.40 116020 Dress/Debrid P-Thick Burn S $46.55 117000 Destruct Premalg Lesion $36.65 117003 Destruct Premalg Les 2-14 $3.37 017004 Destroy Premal Lesions 15/> $88.75 117110 Destruct B9 Lesion 1-14 $62.80 117111 Destruct Lesion 15 Or More $73.69 117250 Chem Caut Of Granltj Tissue $47.94 017340 Cryotherapy Of Skin $29.72 119000 Drainage Of Breast Lesion $61.61 120526 Ther Injection Carp Tunnel $44.57 120550 Inj Tendon Sheath/Ligament $30.90 120551 Inj Tendon Origin/Insertion $31.70 120552 Inj Trigger Point 1/2 Muscl $31.50 120553 Inject Trigger Points 3/> $36.05 120600 Drain/Inj Joint/Bursa W/O Us $28.53 120604 Drain/Inj Joint/Bursa W/Us $42.99 120605 Drain/Inj Joint/Bursa W/O Us $29.52 120606 Drain/Inj Joint/Bursa W/Us $47.54 120610 Drain/Inj Joint/Bursa W/O Us $35.06 120611 Drain/Inj Joint/Bursa W/Us $53.09 120612 Aspirate/Inj Ganglion Cyst $34.87 123500 Treat Clavicle Fracture $125.20 124640 Treat Elbow Dislocation $57.25 126010 Drainage Of Finger Abscess $170.76 126011 Drainage Of Finger Abscess $247.03 126750 Treat Finger Fracture Each $105.39 1


Page 3 of 63


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APM Procedure

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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

28190 Removal Of Foot Foreign Body $144.02 128510 Treatment Of Toe Fracture $68.74 129700 Removal/Revision Of Cast $35.26 129705 Removal/Revision Of Cast $36.05 130300 Remove Nasal Foreign Body $106.97 130901 Control Of Nosebleed $81.02 130903 Control Of Nosebleed $128.57 130905 Control Of Nosebleed $190.97 130906 Repeat Control Of Nosebleed $198.89 136415 Routine Venipuncture $2.70 036591 Draw Blood Off Venous Device $13.87 041010 Incision Of Tongue Fold $118.27 143762 Rplc Gtube No Revj Trc $127.77 146083 Incise External Hemorrhoid $109.35 146320 Removal Of Hemorrhoid Clot $111.93 151700 Irrigation Of Bladder $42.39 051701 Insert Bladder Catheter $25.36 051702 Insert Temp Bladder Cath $34.47 051705 Change Of Bladder Tube $53.69 051725 Simple Cystometrogram $119.65 051725 Simple Cystometrogram 26 $43.19 051725 Simple Cystometrogram TC $76.47 051736 Urine Flow Measurement $7.73 051736 Urine Flow Measurement 26 $4.75 051736 Urine Flow Measurement TC $2.97 051741 Electro-Uroflowmetry First $8.12 051741 Electro-Uroflowmetry First 26 $4.95 051741 Electro-Uroflowmetry First TC $3.17 051784 Anal/Urinary Muscle Study $38.04 051784 Anal/Urinary Muscle Study 26 $21.79 051784 Anal/Urinary Muscle Study TC $16.24 051798 Us Urine Capacity Measure $5.74 054050 Destruction Penis Lesion(S) $75.87 154056 Cryosurgery Penis Lesion(S) $79.04 054060 Excision Of Penis Lesion(S) $106.38 054065 Destruction Penis Lesion(S) $124.21 054150 Circumcision W/Regionl Block $87.16 054160 Circumcision Neonate $124.60 055250 Removal Of Sperm Duct(S) $204.44 1


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APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

56405 I & D Of Vulva/Perineum $73.10 156420 Drainage Of Gland Abscess $88.55 156441 Lysis Of Labial Lesion(S) $93.50 156501 Destroy Vulva Lesions Sim $92.91 156515 Destroy Vulva Lesion/S Compl $143.62 156605 Biopsy Of Vulva/Perineum $51.51 156606 Biopsy Of Vulva/Perineum $21.99 056820 Exam Of Vulva W/Scope $67.95 1 YES56821 Exam/Biopsy Of Vulva W/Scope $90.53 1 YES57061 Destroy Vag Lesions Simple $80.23 157065 Destroy Vag Lesions Complex $126.19 157100 Biopsy Of Vagina $54.68 157160 Insert Pessary/Other Device $38.83 157170 Fitting Of Diaphragm/Cap $40.02 157420 Exam Of Vagina W/Scope $71.51 1 YES57421 Exam/Biopsy Of Vag W/Scope $96.28 1 YES57452 Exam Of Cervix W/Scope $68.34 1 YES57454 Bx/Curett Of Cervix W/Scope $93.31 1 YES57455 Biopsy Of Cervix W/Scope $87.96 1 YES57456 Endocerv Curettage W/Scope $82.61 1 YES57460 Bx Of Cervix W/Scope Leep $173.93 1 YES57461 Conz Of Cervix W/Scope Leep $195.13 1 YES57500 Biopsy Of Cervix $81.42 157505 Endocervical Curettage $73.10 157510 Cauterization Of Cervix $85.78 157511 Cryocautery Of Cervix $99.05 157520 Conization Of Cervix $189.98 157522 Conization Of Cervix $163.43 157800 Dilation Of Cervical Canal $39.82 158100 Biopsy Of Uterus Lining $55.47 158110 Bx Done W/Colposcopy Add-On $28.92 0 YES58120 Dilation And Curettage $160.06 158300 Insert Intrauterine Device $51.51 1 YES58301 Remove Intrauterine Device $57.65 1 YES58340 Catheter For Hysterography $109.55 158353 Endometr Ablate Thermal $564.78 0 YES58356 Endometrial Cryoablation $1,030.91 0 YES58555 Hysteroscopy Dx Sep Proc $183.44 1 YES58558 Hysteroscopy Biopsy $784.67 1 YES


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

58562 Hysteroscopy Remove Fb $224.05 1 YES58563 Hysteroscopy Ablation $1,101.63 0 YES59000 Amniocentesis Diagnostic $68.74 159020 Fetal Contract Stress Test $39.62 159020 Fetal Contract Stress Test 26 $21.20 159020 Fetal Contract Stress Test TC $18.42 159025 Fetal Non-Stress Test $27.14 159025 Fetal Non-Stress Test 26 $16.64 159025 Fetal Non-Stress Test TC $10.50 159160 D & C After Delivery $137.09 059425 Antepartum Care Only $447.10 659426 Antepartum Care Only $795.20 1259430 Care After Delivery $195.96 1 YES59812 Treatment Of Miscarriage $195.92 059820 Care Of Miscarriage $234.95 064405 Njx Aa&/Strd Gr Ocpl Nrv $41.01 064450 Njx Aa&/Strd Other Pn/Branch $43.19 164455 N Block Inj Plantar Digit $27.34 165205 Remove Foreign Body From Eye $21.00 069000 Drain External Ear Lesion $105.79 169005 Drain External Ear Lesion $122.43 169200 Clear Outer Ear Canal $45.76 169209 Remove Impacted Ear Wax Uni $7.92 169210 Remove Impacted Ear Wax Uni $26.94 169220 Clean Out Mastoid Cavity $44.57 170030 X-Ray Eye For Foreign Body $17.23 0 YES70030 X-Ray Eye For Foreign Body 26 $4.75 0 YES70030 X-Ray Eye For Foreign Body TC $12.48 0 YES70100 X-Ray Exam Of Jaw <4views $20.40 0 YES70100 X-Ray Exam Of Jaw <4views 26 $5.15 0 YES70100 X-Ray Exam Of Jaw <4views TC $15.25 0 YES70110 X-Ray Exam Of Jaw 4/> Views $23.57 0 YES70110 X-Ray Exam Of Jaw 4/> Views 26 $7.13 0 YES70110 X-Ray Exam Of Jaw 4/> Views TC $16.44 0 YES70120 X-Ray Exam Of Mastoids $20.40 0 YES70120 X-Ray Exam Of Mastoids 26 $5.15 0 YES70120 X-Ray Exam Of Mastoids TC $15.25 0 YES70130 X-Ray Exam Of Mastoids $33.28 0 YES70130 X-Ray Exam Of Mastoids 26 $9.71 0 YES


Page 6 of 63


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APM Procedure

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ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

70130 X-Ray Exam Of Mastoids TC $23.57 0 YES70134 X-Ray Exam Of Middle Ear $31.50 0 YES70134 X-Ray Exam Of Middle Ear 26 $9.91 0 YES70134 X-Ray Exam Of Middle Ear TC $21.59 0 YES70140 X-Ray Exam Of Facial Bones $17.43 0 YES70140 X-Ray Exam Of Facial Bones 26 $5.74 0 YES70140 X-Ray Exam Of Facial Bones TC $11.69 0 YES70150 X-Ray Exam Of Facial Bones $25.55 0 YES70150 X-Ray Exam Of Facial Bones 26 $7.53 0 YES70150 X-Ray Exam Of Facial Bones TC $18.03 0 YES70160 X-Ray Exam Of Nasal Bones $20.21 0 YES70160 X-Ray Exam Of Nasal Bones 26 $4.95 0 YES70160 X-Ray Exam Of Nasal Bones TC $15.25 0 YES70190 X-Ray Exam Of Eye Sockets $21.39 0 YES70190 X-Ray Exam Of Eye Sockets 26 $6.34 0 YES70190 X-Ray Exam Of Eye Sockets TC $15.06 0 YES70200 X-Ray Exam Of Eye Sockets $25.95 0 YES70200 X-Ray Exam Of Eye Sockets 26 $7.92 0 YES70200 X-Ray Exam Of Eye Sockets TC $18.03 0 YES70210 X-Ray Exam Of Sinuses $17.23 0 YES70210 X-Ray Exam Of Sinuses 26 $4.95 0 YES70210 X-Ray Exam Of Sinuses TC $12.28 0 YES70220 X-Ray Exam Of Sinuses $20.40 0 YES70220 X-Ray Exam Of Sinuses 26 $6.34 0 YES70220 X-Ray Exam Of Sinuses TC $14.07 0 YES70240 X-Ray Exam Pituitary Saddle $18.62 0 YES70240 X-Ray Exam Pituitary Saddle 26 $5.55 0 YES70240 X-Ray Exam Pituitary Saddle TC $13.07 0 YES70250 X-Ray Exam Of Skull $19.81 0 YES70250 X-Ray Exam Of Skull 26 $5.74 0 YES70250 X-Ray Exam Of Skull TC $14.07 0 YES70260 X-Ray Exam Of Skull $24.56 0 YES70260 X-Ray Exam Of Skull 26 $8.12 0 YES70260 X-Ray Exam Of Skull TC $16.44 0 YES70300 X-Ray Exam Of Teeth $7.73 0 YES70300 X-Ray Exam Of Teeth 26 $3.17 0 YES70300 X-Ray Exam Of Teeth TC $4.56 0 YES70310 X-Ray Exam Of Teeth $21.79 0 YES70310 X-Ray Exam Of Teeth 26 $4.36 0 YES


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

70310 X-Ray Exam Of Teeth TC $17.43 0 YES70320 Full Mouth X-Ray Of Teeth $30.90 0 YES70320 Full Mouth X-Ray Of Teeth 26 $6.54 0 YES70320 Full Mouth X-Ray Of Teeth TC $24.37 0 YES70328 X-Ray Exam Of Jaw Joint $18.62 0 YES70328 X-Ray Exam Of Jaw Joint 26 $5.15 0 YES70328 X-Ray Exam Of Jaw Joint TC $13.47 0 YES70330 X-Ray Exam Of Jaw Joints $28.72 0 YES70330 X-Ray Exam Of Jaw Joints 26 $6.93 0 YES70330 X-Ray Exam Of Jaw Joints TC $21.79 0 YES70355 Panoramic X-Ray Of Jaws $10.70 0 YES70355 Panoramic X-Ray Of Jaws 26 $5.94 0 YES70355 Panoramic X-Ray Of Jaws TC $4.75 0 YES70360 X-Ray Exam Of Neck $17.04 0 YES70360 X-Ray Exam Of Neck 26 $5.15 0 YES70360 X-Ray Exam Of Neck TC $11.89 0 YES70380 X-Ray Exam Of Salivary Gland $20.01 0 YES70380 X-Ray Exam Of Salivary Gland 26 $4.75 0 YES70380 X-Ray Exam Of Salivary Gland TC $15.25 0 YES71045 X-Ray Exam Chest 1 View $14.26 0 YES71045 X-Ray Exam Chest 1 View 26 $5.15 0 YES71045 X-Ray Exam Chest 1 View TC $9.11 0 YES71046 X-Ray Exam Chest 2 Views $18.23 0 YES71046 X-Ray Exam Chest 2 Views 26 $6.14 0 YES71046 X-Ray Exam Chest 2 Views TC $12.08 0 YES71047 X-Ray Exam Chest 3 Views $22.98 0 YES71047 X-Ray Exam Chest 3 Views 26 $7.73 0 YES71047 X-Ray Exam Chest 3 Views TC $15.25 0 YES71048 X-Ray Exam Chest 4+ Views $24.96 0 YES71048 X-Ray Exam Chest 4+ Views 26 $9.11 0 YES71048 X-Ray Exam Chest 4+ Views TC $15.85 0 YES71100 X-Ray Exam Ribs Uni 2 Views $19.81 0 YES71100 X-Ray Exam Ribs Uni 2 Views 26 $6.34 0 YES71100 X-Ray Exam Ribs Uni 2 Views TC $13.47 0 YES71101 X-Ray Exam Unilat Ribs/Chest $22.78 0 YES71101 X-Ray Exam Unilat Ribs/Chest 26 $7.53 0 YES71101 X-Ray Exam Unilat Ribs/Chest TC $15.25 0 YES71110 X-Ray Exam Ribs Bil 3 Views $23.97 0 YES71110 X-Ray Exam Ribs Bil 3 Views 26 $8.32 0 YES


Page 8 of 63


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APM Procedure

Codes


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

71110 X-Ray Exam Ribs Bil 3 Views TC $15.65 0 YES71111 X-Ray Exam Ribs/Chest4/> Vws $28.53 0 YES71111 X-Ray Exam Ribs/Chest4/> Vws 26 $9.11 0 YES71111 X-Ray Exam Ribs/Chest4/> Vws TC $19.41 0 YES71120 X-Ray Exam Breastbone 2/>Vws $18.23 0 YES71120 X-Ray Exam Breastbone 2/>Vws 26 $5.74 0 YES71120 X-Ray Exam Breastbone 2/>Vws TC $12.48 0 YES71130 X-Ray Strenoclavic Jt 3/>Vws $22.19 0 YES71130 X-Ray Strenoclavic Jt 3/>Vws 26 $6.34 0 YES71130 X-Ray Strenoclavic Jt 3/>Vws TC $15.85 0 YES72020 X-Ray Exam Of Spine 1 View $13.47 0 YES72020 X-Ray Exam Of Spine 1 View 26 $4.56 0 YES72020 X-Ray Exam Of Spine 1 View TC $8.91 0 YES72040 X-Ray Exam Neck Spine 2-3 Vw $21.20 0 YES72040 X-Ray Exam Neck Spine 2-3 Vw 26 $6.34 0 YES72040 X-Ray Exam Neck Spine 2-3 Vw TC $14.86 0 YES72050 X-Ray Exam Neck Spine 4/5vws $28.13 0 YES72050 X-Ray Exam Neck Spine 4/5vws 26 $7.73 0 YES72050 X-Ray Exam Neck Spine 4/5vws TC $20.40 0 YES72052 X-Ray Exam Neck Spine 6/>Vws $33.08 0 YES72052 X-Ray Exam Neck Spine 6/>Vws 26 $8.52 0 YES72052 X-Ray Exam Neck Spine 6/>Vws TC $24.56 0 YES72070 X-Ray Exam Thorac Spine 2vws $17.63 0 YES72070 X-Ray Exam Thorac Spine 2vws 26 $5.74 0 YES72070 X-Ray Exam Thorac Spine 2vws TC $11.89 0 YES72072 X-Ray Exam Thorac Spine 3vws $21.39 0 YES72072 X-Ray Exam Thorac Spine 3vws 26 $6.54 0 YES72072 X-Ray Exam Thorac Spine 3vws TC $14.86 0 YES72074 X-Ray Exam Thorac Spine4/>Vw $23.97 0 YES72074 X-Ray Exam Thorac Spine4/>Vw 26 $6.93 0 YES72074 X-Ray Exam Thorac Spine4/>Vw TC $17.04 0 YES72080 X-Ray Exam Thoracolmb 2/> Vw $19.02 0 YES72080 X-Ray Exam Thoracolmb 2/> Vw 26 $6.14 0 YES72080 X-Ray Exam Thoracolmb 2/> Vw TC $12.88 0 YES72081 X-Ray Exam Entire Spi 1 Vw $23.18 0 YES72081 X-Ray Exam Entire Spi 1 Vw 26 $7.53 0 YES72081 X-Ray Exam Entire Spi 1 Vw TC $15.65 0 YES72082 X-Ray Exam Entire Spi 2/3 Vw $37.64 0 YES72082 X-Ray Exam Entire Spi 2/3 Vw 26 $9.11 0 YES


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

72082 X-Ray Exam Entire Spi 2/3 Vw TC $28.53 0 YES72083 X-Ray Exam Entire Spi 4/5 Vw $43.78 0 YES72083 X-Ray Exam Entire Spi 4/5 Vw 26 $10.30 0 YES72083 X-Ray Exam Entire Spi 4/5 Vw TC $33.48 0 YES72084 X-Ray Exam Entire Spi 6/> Vw $51.90 0 YES72084 X-Ray Exam Entire Spi 6/> Vw 26 $11.69 0 YES72084 X-Ray Exam Entire Spi 6/> Vw TC $40.21 0 YES72100 X-Ray Exam L-S Spine 2/3 Vws $21.20 0 YES72100 X-Ray Exam L-S Spine 2/3 Vws 26 $6.34 0 YES72100 X-Ray Exam L-S Spine 2/3 Vws TC $14.86 0 YES72110 X-Ray Exam L-2 Spine 4/>Vws $26.94 0 YES72110 X-Ray Exam L-2 Spine 4/>Vws 26 $7.33 0 YES72110 X-Ray Exam L-2 Spine 4/>Vws TC $19.61 0 YES72114 X-Ray Exam L-S Spine Bending $33.08 0 YES72114 X-Ray Exam L-S Spine Bending 26 $8.52 0 YES72114 X-Ray Exam L-S Spine Bending TC $24.56 0 YES72120 X-Ray Bend Only L-S Spine $21.99 0 YES72120 X-Ray Bend Only L-S Spine 26 $6.34 0 YES72120 X-Ray Bend Only L-S Spine TC $15.65 0 YES72170 X-Ray Exam Of Pelvis $15.85 0 YES72170 X-Ray Exam Of Pelvis 26 $4.95 0 YES72170 X-Ray Exam Of Pelvis TC $10.90 0 YES72190 X-Ray Exam Of Pelvis $22.58 0 YES72190 X-Ray Exam Of Pelvis 26 $7.13 0 YES72190 X-Ray Exam Of Pelvis TC $15.45 0 YES72200 X-Ray Exam Si Joints $17.83 0 YES72200 X-Ray Exam Si Joints 26 $4.95 0 YES72200 X-Ray Exam Si Joints TC $12.88 0 YES72202 X-Ray Exam Si Joints 3/> Vws $21.20 0 YES72202 X-Ray Exam Si Joints 3/> Vws 26 $6.54 0 YES72202 X-Ray Exam Si Joints 3/> Vws TC $14.66 0 YES72220 X-Ray Exam Sacrum Tailbone $17.43 0 YES72220 X-Ray Exam Sacrum Tailbone 26 $4.95 0 YES72220 X-Ray Exam Sacrum Tailbone TC $12.48 0 YES73000 X-Ray Exam Of Collar Bone $17.43 0 YES73000 X-Ray Exam Of Collar Bone 26 $4.75 0 YES73000 X-Ray Exam Of Collar Bone TC $12.68 0 YES73010 X-Ray Exam Of Shoulder Blade $15.45 0 YES73010 X-Ray Exam Of Shoulder Blade 26 $5.15 0 YES


Page 10 of 63


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APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

73010 X-Ray Exam Of Shoulder Blade TC $10.30 0 YES73020 X-Ray Exam Of Shoulder $11.89 0 YES73020 X-Ray Exam Of Shoulder 26 $4.36 0 YES73020 X-Ray Exam Of Shoulder TC $7.53 0 YES73030 X-Ray Exam Of Shoulder $18.42 0 YES73030 X-Ray Exam Of Shoulder 26 $5.35 0 YES73030 X-Ray Exam Of Shoulder TC $13.07 0 YES73050 X-Ray Exam Of Shoulders $17.43 0 YES73050 X-Ray Exam Of Shoulders 26 $5.35 0 YES73050 X-Ray Exam Of Shoulders TC $12.08 0 YES73060 X-Ray Exam Of Humerus $17.43 0 YES73060 X-Ray Exam Of Humerus 26 $4.75 0 YES73060 X-Ray Exam Of Humerus TC $12.68 0 YES73070 X-Ray Exam Of Elbow $15.85 0 YES73070 X-Ray Exam Of Elbow 26 $4.75 0 YES73070 X-Ray Exam Of Elbow TC $11.09 0 YES73080 X-Ray Exam Of Elbow $17.23 0 YES73080 X-Ray Exam Of Elbow 26 $4.95 0 YES73080 X-Ray Exam Of Elbow TC $12.28 0 YES73090 X-Ray Exam Of Forearm $16.05 0 YES73090 X-Ray Exam Of Forearm 26 $4.75 0 YES73090 X-Ray Exam Of Forearm TC $11.29 0 YES73092 X-Ray Exam Of Arm Infant $16.84 0 YES73092 X-Ray Exam Of Arm Infant 26 $4.56 0 YES73092 X-Ray Exam Of Arm Infant TC $12.28 0 YES73100 X-Ray Exam Of Wrist $18.23 0 YES73100 X-Ray Exam Of Wrist 26 $4.75 0 YES73100 X-Ray Exam Of Wrist TC $13.47 0 YES73110 X-Ray Exam Of Wrist $21.59 0 YES73110 X-Ray Exam Of Wrist 26 $4.95 0 YES73110 X-Ray Exam Of Wrist TC $16.64 0 YES73120 X-Ray Exam Of Hand $16.84 0 YES73120 X-Ray Exam Of Hand 26 $4.75 0 YES73120 X-Ray Exam Of Hand TC $12.08 0 YES73130 X-Ray Exam Of Hand $19.41 0 YES73130 X-Ray Exam Of Hand 26 $4.95 0 YES73130 X-Ray Exam Of Hand TC $14.46 0 YES73140 X-Ray Exam Of Finger(S) $19.81 0 YES73140 X-Ray Exam Of Finger(S) 26 $3.96 0 YES


Page 11 of 63


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Codes


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

73140 X-Ray Exam Of Finger(S) TC $15.85 0 YES73501 X-Ray Exam Hip Uni 1 View $17.63 0 YES73501 X-Ray Exam Hip Uni 1 View 26 $5.35 0 YES73501 X-Ray Exam Hip Uni 1 View TC $12.28 0 YES73502 X-Ray Exam Hip Uni 2-3 Views $25.16 0 YES73502 X-Ray Exam Hip Uni 2-3 Views 26 $6.34 0 YES73502 X-Ray Exam Hip Uni 2-3 Views TC $18.82 0 YES73503 X-Ray Exam Hip Uni 4/> Views $31.10 0 YES73503 X-Ray Exam Hip Uni 4/> Views 26 $7.73 0 YES73503 X-Ray Exam Hip Uni 4/> Views TC $23.38 0 YES73521 X-Ray Exam Hips Bi 2 Views $22.19 0 YES73521 X-Ray Exam Hips Bi 2 Views 26 $6.34 0 YES73521 X-Ray Exam Hips Bi 2 Views TC $15.85 0 YES73522 X-Ray Exam Hips Bi 3-4 Views $28.92 0 YES73522 X-Ray Exam Hips Bi 3-4 Views 26 $8.32 0 YES73522 X-Ray Exam Hips Bi 3-4 Views TC $20.60 0 YES73523 X-Ray Exam Hips Bi 5/> Views $32.88 0 YES73523 X-Ray Exam Hips Bi 5/> Views 26 $8.91 0 YES73523 X-Ray Exam Hips Bi 5/> Views TC $23.97 0 YES73551 X-Ray Exam Of Femur 1 $16.24 073551 X-Ray Exam Of Femur 1 26 $4.75 073551 X-Ray Exam Of Femur 1 TC $11.49 073552 X-Ray Exam Of Femur 2/> $19.22 0 YES73552 X-Ray Exam Of Femur 2/> 26 $5.15 0 YES73552 X-Ray Exam Of Femur 2/> TC $14.07 0 YES73560 X-Ray Exam Of Knee 1 Or 2 $18.62 0 YES73560 X-Ray Exam Of Knee 1 Or 2 26 $4.75 0 YES73560 X-Ray Exam Of Knee 1 Or 2 TC $13.87 0 YES73562 X-Ray Exam Of Knee 3 $21.79 0 YES73562 X-Ray Exam Of Knee 3 26 $5.35 0 YES73562 X-Ray Exam Of Knee 3 TC $16.44 0 YES73564 X-Ray Exam Knee 4 Or More $24.37 0 YES73564 X-Ray Exam Knee 4 Or More 26 $6.34 0 YES73564 X-Ray Exam Knee 4 Or More TC $18.03 0 YES73565 X-Ray Exam Of Knees $21.59 0 YES73565 X-Ray Exam Of Knees 26 $4.95 0 YES73565 X-Ray Exam Of Knees TC $16.64 0 YES73590 X-Ray Exam Of Lower Leg $17.04 0 YES73590 X-Ray Exam Of Lower Leg 26 $4.56 0 YES


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Revised: 05/18/2021

73590 X-Ray Exam Of Lower Leg TC $12.48 0 YES73592 X-Ray Exam Of Leg Infant $16.84 0 YES73592 X-Ray Exam Of Leg Infant 26 $4.56 0 YES73592 X-Ray Exam Of Leg Infant TC $12.28 0 YES73600 X-Ray Exam Of Ankle $17.63 0 YES73600 X-Ray Exam Of Ankle 26 $4.75 0 YES73600 X-Ray Exam Of Ankle TC $12.88 0 YES73610 X-Ray Exam Of Ankle $19.41 0 YES73610 X-Ray Exam Of Ankle 26 $4.95 0 YES73610 X-Ray Exam Of Ankle TC $14.46 0 YES73620 X-Ray Exam Of Foot $15.45 0 YES73620 X-Ray Exam Of Foot 26 $4.36 0 YES73620 X-Ray Exam Of Foot TC $11.09 0 YES73630 X-Ray Exam Of Foot $18.23 0 YES73630 X-Ray Exam Of Foot 26 $4.75 0 YES73630 X-Ray Exam Of Foot TC $13.47 0 YES73650 X-Ray Exam Of Heel $15.65 0 YES73650 X-Ray Exam Of Heel 26 $4.56 0 YES73650 X-Ray Exam Of Heel TC $11.09 0 YES73660 X-Ray Exam Of Toe(S) $15.65 0 YES73660 X-Ray Exam Of Toe(S) 26 $3.76 0 YES73660 X-Ray Exam Of Toe(S) TC $11.89 0 YES74018 X-Ray Exam Abdomen 1 View $16.24 0 YES74018 X-Ray Exam Abdomen 1 View 26 $5.15 0 YES74018 X-Ray Exam Abdomen 1 View TC $11.09 0 YES74019 X-Ray Exam Abdomen 2 Views $20.01 0 YES74019 X-Ray Exam Abdomen 2 Views 26 $6.54 0 YES74019 X-Ray Exam Abdomen 2 Views TC $13.47 0 YES74021 X-Ray Exam Abdomen 3+ Views $23.18 0 YES74021 X-Ray Exam Abdomen 3+ Views 26 $7.53 0 YES74021 X-Ray Exam Abdomen 3+ Views TC $15.65 0 YES74022 X-Ray Exam Complete Abdomen $26.94 0 YES74022 X-Ray Exam Complete Abdomen 26 $8.91 0 YES74022 X-Ray Exam Complete Abdomen TC $18.03 0 YES76010 X-Ray Nose To Rectum $16.05 0 YES76010 X-Ray Nose To Rectum 26 $5.15 0 YES76010 X-Ray Nose To Rectum TC $10.90 0 YES76510 Ophth Us B & Quant A $50.71 076510 Ophth Us B & Quant A 26 $26.55 0


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Revised: 05/18/2021

76510 Ophth Us B & Quant A TC $24.17 076511 Ophth Us Quant A Only $34.67 0 YES76511 Ophth Us Quant A Only 26 $20.21 0 YES76511 Ophth Us Quant A Only TC $14.46 0 YES76512 Ophth Us B W/Non-Quant A $29.52 0 YES76512 Ophth Us B W/Non-Quant A 26 $17.63 0 YES76512 Ophth Us B W/Non-Quant A TC $11.89 0 YES76513 Echo Exam Of Eye Water Bath $55.67 0 YES76513 Echo Exam Of Eye Water Bath 26 $20.21 0 YES76513 Echo Exam Of Eye Water Bath TC $35.46 0 YES76514 Echo Exam Of Eye Thickness $6.74 0 YES76514 Echo Exam Of Eye Thickness 26 $4.56 0 YES76514 Echo Exam Of Eye Thickness TC $2.18 0 YES76516 Echo Exam Of Eye $26.94 0 YES76516 Echo Exam Of Eye 26 $12.88 0 YES76516 Echo Exam Of Eye TC $14.07 0 YES76519 Echo Exam Of Eye $37.24 0 YES76519 Echo Exam Of Eye 26 $17.43 0 YES76519 Echo Exam Of Eye TC $19.81 0 YES76529 Echo Exam Of Eye $46.55 0 YES76529 Echo Exam Of Eye 26 $18.42 0 YES76529 Echo Exam Of Eye TC $28.13 0 YES76536 Us Exam Of Head And Neck $64.78 0 YES76536 Us Exam Of Head And Neck 26 $15.85 0 YES76536 Us Exam Of Head And Neck TC $48.93 0 YES76604 Us Exam Chest $44.18 0 YES76604 Us Exam Chest 26 $16.24 0 YES76604 Us Exam Chest TC $27.93 0 YES76641 Ultrasound Breast Complete $59.83 0 YES76641 Ultrasound Breast Complete 26 $20.40 0 YES76641 Ultrasound Breast Complete TC $39.42 0 YES76642 Ultrasound Breast Limited $48.93 0 YES76642 Ultrasound Breast Limited 26 $19.02 0 YES76642 Ultrasound Breast Limited TC $29.91 0 YES76700 Us Exam Abdom Complete $68.74 0 YES76700 Us Exam Abdom Complete 26 $22.98 0 YES76700 Us Exam Abdom Complete TC $45.76 0 YES76705 Echo Exam Of Abdomen $50.91 0 YES76705 Echo Exam Of Abdomen 26 $16.44 0 YES


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Revised: 05/18/2021

76705 Echo Exam Of Abdomen TC $34.47 0 YES76706 Us Abdl Aorta Screen Aaa $63.59 076706 Us Abdl Aorta Screen Aaa 26 $15.45 076706 Us Abdl Aorta Screen Aaa TC $48.14 076770 Us Exam Abdo Back Wall Comp $63.19 0 YES76770 Us Exam Abdo Back Wall Comp 26 $20.60 0 YES76770 Us Exam Abdo Back Wall Comp TC $42.59 0 YES76775 Us Exam Abdo Back Wall Lim $32.88 0 YES76775 Us Exam Abdo Back Wall Lim 26 $16.24 0 YES76775 Us Exam Abdo Back Wall Lim TC $16.64 0 YES76776 Us Exam K Transpl W/Doppler $87.36 076776 Us Exam K Transpl W/Doppler 26 $21.59 076776 Us Exam K Transpl W/Doppler TC $65.77 076800 Us Exam Spinal Canal $80.03 0 YES76800 Us Exam Spinal Canal 26 $32.88 0 YES76800 Us Exam Spinal Canal TC $47.15 0 YES76801 Ob Us < 14 Wks Single Fetus $68.34 0 YES76801 Ob Us < 14 Wks Single Fetus 26 $27.93 0 YES76801 Ob Us < 14 Wks Single Fetus TC $40.41 0 YES76802 Ob Us < 14 Wks Addl Fetus $35.26 0 YES76802 Ob Us < 14 Wks Addl Fetus 26 $23.18 0 YES76802 Ob Us < 14 Wks Addl Fetus TC $12.08 0 YES76805 Ob Us >= 14 Wks Sngl Fetus $78.25 0 YES76805 Ob Us >= 14 Wks Sngl Fetus 26 $27.93 0 YES76805 Ob Us >= 14 Wks Sngl Fetus TC $50.32 0 YES76810 Ob Us >= 14 Wks Addl Fetus $51.31 0 YES76810 Ob Us >= 14 Wks Addl Fetus 26 $27.73 0 YES76810 Ob Us >= 14 Wks Addl Fetus TC $23.57 0 YES76811 Ob Us Detailed Sngl Fetus $99.25 0 YES76811 Ob Us Detailed Sngl Fetus 26 $53.09 0 YES76811 Ob Us Detailed Sngl Fetus TC $46.16 0 YES76812 Ob Us Detailed Addl Fetus $111.13 0 YES76812 Ob Us Detailed Addl Fetus 26 $49.72 0 YES76812 Ob Us Detailed Addl Fetus TC $61.41 0 YES76813 Ob Us Nuchal Meas 1 Gest $67.75 0 YES76813 Ob Us Nuchal Meas 1 Gest 26 $33.08 0 YES76813 Ob Us Nuchal Meas 1 Gest TC $34.67 0 YES76814 Ob Us Nuchal Meas Add-On $43.98 0 YES76814 Ob Us Nuchal Meas Add-On 26 $27.73 0 YES


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Revised: 05/18/2021

76814 Ob Us Nuchal Meas Add-On TC $16.24 0 YES76815 Ob Us Limited Fetus(S) $46.95 0 YES76815 Ob Us Limited Fetus(S) 26 $18.23 0 YES76815 Ob Us Limited Fetus(S) TC $28.72 0 YES76816 Ob Us Follow-Up Per Fetus $63.19 0 YES76816 Ob Us Follow-Up Per Fetus 26 $23.77 0 YES76816 Ob Us Follow-Up Per Fetus TC $39.42 0 YES76817 Transvaginal Us Obstetric $53.49 0 YES76817 Transvaginal Us Obstetric 26 $21.00 0 YES76817 Transvaginal Us Obstetric TC $32.49 0 YES76818 Fetal Biophys Profile W/Nst $65.97 0 YES76818 Fetal Biophys Profile W/Nst 26 $29.32 0 YES76818 Fetal Biophys Profile W/Nst TC $36.65 0 YES76819 Fetal Biophys Profil W/O Nst $48.53 0 YES76819 Fetal Biophys Profil W/O Nst 26 $21.59 0 YES76819 Fetal Biophys Profil W/O Nst TC $26.94 0 YES76820 Umbilical Artery Echo $26.15 0 YES76820 Umbilical Artery Echo 26 $14.07 0 YES76820 Umbilical Artery Echo TC $12.08 0 YES76821 Middle Cerebral Artery Echo $50.52 0 YES76821 Middle Cerebral Artery Echo 26 $19.41 0 YES76821 Middle Cerebral Artery Echo TC $31.10 0 YES76825 Echo Exam Of Fetal Heart $152.74 0 YES76825 Echo Exam Of Fetal Heart 26 $46.16 0 YES76825 Echo Exam Of Fetal Heart TC $106.58 0 YES76826 Echo Exam Of Fetal Heart $90.73 0 YES76826 Echo Exam Of Fetal Heart 26 $22.98 0 YES76826 Echo Exam Of Fetal Heart TC $67.75 0 YES76827 Echo Exam Of Fetal Heart $41.01 0 YES76827 Echo Exam Of Fetal Heart 26 $16.05 0 YES76827 Echo Exam Of Fetal Heart TC $24.96 0 YES76828 Echo Exam Of Fetal Heart $29.12 0 YES76828 Echo Exam Of Fetal Heart 26 $15.65 0 YES76828 Echo Exam Of Fetal Heart TC $13.47 0 YES76830 Transvaginal Us Non-Ob $68.74 0 YES76830 Transvaginal Us Non-Ob 26 $19.41 0 YES76830 Transvaginal Us Non-Ob TC $49.33 0 YES76831 Echo Exam Uterus $66.56 0 YES76831 Echo Exam Uterus 26 $20.21 0 YES


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PPS Visit Code

Effective Date**



Revised: 05/18/2021

76831 Echo Exam Uterus TC $46.36 0 YES76856 Us Exam Pelvic Complete $61.21 0 YES76856 Us Exam Pelvic Complete 26 $19.22 0 YES76856 Us Exam Pelvic Complete TC $42.00 0 YES76857 Us Exam Pelvic Limited $27.14 0 YES76857 Us Exam Pelvic Limited 26 $13.87 0 YES76857 Us Exam Pelvic Limited TC $13.27 0 YES76870 Us Exam Scrotum $58.64 0 YES76870 Us Exam Scrotum 26 $17.83 0 YES76870 Us Exam Scrotum TC $40.81 0 YES76872 Us Transrectal $87.76 0 YES76872 Us Transrectal 26 $18.82 0 YES76872 Us Transrectal TC $68.94 0 YES76873 Echograp Trans R Pros Study $98.26 0 YES76873 Echograp Trans R Pros Study 26 $43.98 0 YES76873 Echograp Trans R Pros Study TC $54.28 0 YES76881 Us Compl Joint R-T W/Img $43.38 0 YES76881 Us Compl Joint R-T W/Img 26 $17.63 0 YES76881 Us Compl Joint R-T W/Img TC $25.75 0 YES76882 Us Lmtd Jt/Nonvasc Xtr Strux $31.89 0 YES76882 Us Lmtd Jt/Nonvasc Xtr Strux 26 $13.67 0 YES76882 Us Lmtd Jt/Nonvasc Xtr Strux TC $18.23 0 YES76885 Us Exam Infant Hips Dynamic $80.23 0 YES76885 Us Exam Infant Hips Dynamic 26 $20.80 0 YES76885 Us Exam Infant Hips Dynamic TC $59.43 0 YES76886 Us Exam Infant Hips Static $58.84 0 YES76886 Us Exam Infant Hips Static 26 $17.43 0 YES76886 Us Exam Infant Hips Static TC $41.40 0 YES76977 Us Bone Density Measure $3.96 0 YES76977 Us Bone Density Measure 26 $1.58 0 YES76977 Us Bone Density Measure TC $2.38 0 YES76978 Us Trgt Dyn Mbubb 1st Les $182.45 076978 Us Trgt Dyn Mbubb 1st Les 26 $45.36 076978 Us Trgt Dyn Mbubb 1st Les TC $137.09 076979 Us Trgt Dyn Mbubb Ea Addl $124.01 076979 Us Trgt Dyn Mbubb Ea Addl 26 $24.17 076979 Us Trgt Dyn Mbubb Ea Addl TC $99.84 077065 Dx Mammo Incl Cad Uni $74.88 077065 Dx Mammo Incl Cad Uni 26 $22.98 0


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

77065 Dx Mammo Incl Cad Uni TC $51.90 077066 Dx Mammo Incl Cad Bi $94.30 077066 Dx Mammo Incl Cad Bi 26 $28.13 077066 Dx Mammo Incl Cad Bi TC $66.17 077067 Scr Mammo Bi Incl Cad $76.47 077067 Scr Mammo Bi Incl Cad 26 $21.59 077067 Scr Mammo Bi Incl Cad TC $54.87 077071 X-Ray Stress View $29.72 077072 X-Rays For Bone Age $14.07 0 YES77072 X-Rays For Bone Age 26 $5.35 0 YES77072 X-Rays For Bone Age TC $8.72 0 YES77073 X-Rays Bone Length Studies $24.56 0 YES77073 X-Rays Bone Length Studies 26 $7.73 0 YES77073 X-Rays Bone Length Studies TC $16.84 0 YES77074 X-Rays Bone Survey Limited $35.26 0 YES77074 X-Rays Bone Survey Limited 26 $12.48 0 YES77074 X-Rays Bone Survey Limited TC $22.78 0 YES77075 X-Rays Bone Survey Complete $53.09 0 YES77075 X-Rays Bone Survey Complete 26 $15.65 0 YES77075 X-Rays Bone Survey Complete TC $37.44 0 YES77076 X-Rays Bone Survey Infant $57.45 0 YES77076 X-Rays Bone Survey Infant 26 $19.61 0 YES77076 X-Rays Bone Survey Infant TC $37.84 0 YES77077 Joint Survey Single View $25.55 0 YES77077 Joint Survey Single View 26 $9.71 0 YES77077 Joint Survey Single View TC $15.85 0 YES77080 Dxa Bone Density Axial $21.99 0 YES77080 Dxa Bone Density Axial 26 $5.55 0 YES77080 Dxa Bone Density Axial TC $16.44 0 YES77081 Dxa Bone Density/Peripheral $18.03 0 YES77081 Dxa Bone Density/Peripheral 26 $5.74 0 YES77081 Dxa Bone Density/Peripheral TC $12.28 0 YES80047 Metabolic Panel Ionized Ca $11.37 080048 Metabolic Panel Total Ca $7.00 080051 Electrolyte Panel $5.81 080053 Comprehen Metabolic Panel $8.74 080055 Obstetric Panel $39.59 080061 Lipid Panel $11.09 080069 Renal Function Panel $7.19 0


Page 18 of 63


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APM Procedure

Codes


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

80074 Acute Hepatitis Panel $39.44 080076 Hepatic Function Panel $6.76 080081 Obstetric Panel $61.98 080145 Drug Assay Adalimumab $31.94 080156 Assay Carbamazepine Total $12.06 080162 Assay Of Digoxin Total $10.99 080163 Assay Of Digoxin Free $10.99 080164 Assay Dipropylacetic Acd Tot $11.21 080165 Dipropylacetic Acid Free $11.21 080170 Assay Of Gentamicin $13.56 080171 Drug Screen Quant Gabapentin $17.94 080175 Drug Screen Quan Lamotrigine $10.98 080176 Assay Of Lidocaine $12.16 080177 Drug Scrn Quan Levetiracetam $10.98 080178 Assay Of Lithium $5.47 080184 Assay Of Phenobarbital $12.67 080185 Assay Of Phenytoin Total $10.98 080186 Assay Of Phenytoin Free $11.39 080187 Drug Assay Posaconazole $22.45 080197 Assay Of Tacrolimus $11.37 080198 Assay Of Theophylline $11.71 080200 Assay Of Tobramycin $13.36 080201 Assay Of Topiramate $9.87 080202 Assay Of Vancomycin $11.21 080230 Drug Assay Infliximab $31.94 080235 Drug Assay Lacosamide $22.45 080280 Drug Assay Vedolizumab $31.94 080285 Drug Assay Voriconazole $22.45 080299 Quantitative Assay Drug $15.44 080305 Drug Test Prsmv Dir Opt Obs $10.43 080306 Drug Test Prsmv Instrmnt $14.20 080307 Drug Test Prsmv Chem Anlyzr $51.46 080500 Lab Pathology Consultation $12.68 080502 Lab Pathology Consultation $41.80 081000 Urinalysis Nonauto W/Scope $3.33 081001 Urinalysis Auto W/Scope $2.62 081002 Urinalysis Nonauto W/O Scope $2.88 081003 Urinalysis Auto W/O Scope $1.87 081005 Urinalysis $1.79 0


Page 19 of 63


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

81015 Microscopic Exam Of Urine $2.53 081025 Urine Pregnancy Test $7.13 081099 Urinalysis Test Procedure M 081479 Unlisted Molecular Pathology M 081520 Onc Breast Mrna 58 Genes $2,078.45 081521 Onc Breast Mrna 70 Genes $3,206.84 081528 Oncology Colorectal Scr $421.34 081539 Oncology Prostate Prob Score $629.28 082009 Test For Acetone/Ketones $3.74 082010 Acetone Assay $6.76 082024 Assay Of Acth $31.98 082040 Assay Of Serum Albumin $4.10 082042 Other Source Albumin Quan Ea $6.44 082043 Ur Albumin Quantitative $4.78 082044 Ur Albumin Semiquantitative $5.16 082085 Assay Of Aldolase $8.04 082088 Assay Of Aldosterone $33.75 082105 Alpha-Fetoprotein Serum $13.88 082120 Amines Vaginal Fluid Qual $4.96 082128 Amino Acids Mult Qual $11.48 082140 Assay Of Ammonia $12.06 082150 Assay Of Amylase $5.36 082157 Assay Of Androstenedione $24.24 082164 Angiotensin I Enzyme Test $12.09 082175 Assay Of Arsenic $15.70 082232 Assay Of Beta-2 Protein $13.40 082239 Bile Acids Total $14.18 082240 Bile Acids Cholylglycine $22.01 082247 Bilirubin Total $4.16 082248 Bilirubin Direct $4.16 082270 Occult Blood Feces $3.62 082271 Occult Blood Other Sources $4.41 082272 Occult Bld Feces 1-3 Tests $3.51 082274 Assay Test For Blood Fecal $13.18 082306 Vitamin D 25 Hydroxy $24.51 082308 Assay Of Calcitonin $22.18 082310 Assay Of Calcium $4.27 082330 Assay Of Calcium $11.33 082340 Assay Of Calcium In Urine $5.00 0


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

82360 Calculus Assay Quant $10.65 082365 Calculus Spectroscopy $10.68 082374 Assay Blood Carbon Dioxide $4.04 082375 Assay Carboxyhb Quant $10.20 082378 Carcinoembryonic Antigen $15.70 082380 Assay Of Carotene $7.64 082384 Assay Three Catecholamines $20.91 082390 Assay Of Ceruloplasmin $8.90 082435 Assay Of Blood Chloride $3.81 082436 Assay Of Urine Chloride $4.77 082465 Assay Bld/Serum Cholesterol $3.61 082525 Assay Of Copper $10.28 082530 Cortisol Free $13.84 082533 Total Cortisol $13.50 082540 Assay Of Creatine $3.85 082550 Assay Of Ck (Cpk) $5.39 082552 Assay Of Cpk In Blood $11.09 082553 Creatine Mb Fraction $9.57 082565 Assay Of Creatinine $4.24 082570 Assay Of Urine Creatinine $4.29 082575 Creatinine Clearance Test $7.83 082595 Assay Of Cryoglobulin $5.35 082607 Vitamin B-12 $12.48 082626 Dehydroepiandrosterone $20.92 082627 Dehydroepiandrosterone $18.41 082652 Vit D 1 25-Dihydroxy $31.88 082668 Assay Of Erythropoietin $15.56 082670 Assay Of Estradiol $23.14 082671 Assay Of Estrogens $26.74 082672 Assay Of Estrogen $17.97 082677 Assay Of Estriol $20.02 082679 Assay Of Estrone $20.66 082693 Assay Of Ethylene Glycol $12.34 082696 Assay Of Etiocholanolone $21.73 082710 Fats/Lipids Feces Quant $13.91 082728 Assay Of Ferritin $11.29 082731 Assay Of Fetal Fibronectin $53.33 082746 Assay Of Folic Acid Serum $12.17 082784 Assay Iga/Igd/Igg/Igm Each $7.70 0


Page 21 of 63


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

82800 Blood Ph $9.11 082803 Blood Gases Any Combination $21.58 082805 Blood Gases W/O2 Saturation $65.22 082810 Blood Gases O2 Sat Only $8.09 082941 Assay Of Gastrin $14.60 082946 Glucagon Tolerance Test $14.71 082947 Assay Glucose Blood Quant $3.26 082948 Reagent Strip/Blood Glucose $4.18 082950 Glucose Test $3.94 082951 Glucose Tolerance Test (Gtt) $10.65 082952 Gtt-Added Samples $3.25 082955 Assay Of G6pd Enzyme $8.03 082960 Test For G6pd Enzyme $5.01 082962 Glucose Blood Test $2.71 082977 Assay Of Ggt $5.96 082985 Assay Of Glycated Protein $13.87 083001 Assay Of Gonadotropin (Fsh) $15.38 083002 Assay Of Gonadotropin (Lh) $15.34 083003 Assay Growth Hormone (Hgh) $13.80 083010 Assay Of Haptoglobin Quant $10.41 083013 H Pylori (C-13) Breath $55.77 083014 H Pylori Drug Admin $6.50 083015 Heavy Metal Qual Any Anal $17.34 083020 Hemoglobin Electrophoresis $10.65 083020 Hemoglobin Electrophoresis 26 $10.50 083021 Hemoglobin Chromotography $14.95 083036 Glycosylated Hemoglobin Test $8.04 083037 Glycosylated Hb Home Device $8.04 083045 Blood Methemoglobin Test $5.37 083050 Blood Methemoglobin Assay $6.79 083090 Assay Of Homocystine $14.84 083497 Assay Of 5-Hiaa $10.68 083498 Assay Of Progesterone 17-D $22.49 083516 Immunoassay Nonantibody $9.55 083525 Assay Of Insulin $9.47 083540 Assay Of Iron $5.35 083550 Iron Binding Test $7.24 083605 Assay Of Lactic Acid $9.58 083615 Lactate (Ld) (Ldh) Enzyme $5.00 0


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

83625 Assay Of Ldh Enzymes $10.59 083633 Test Urine For Lactose $9.32 083655 Assay Of Lead $10.03 083690 Assay Of Lipase $5.70 083695 Assay Of Lipoprotein(A) $11.86 083700 Lipopro Bld Electrophoretic $9.32 083704 Lipoprotein Bld Quan Part $28.31 083718 Assay Of Lipoprotein $6.78 083719 Assay Of Blood Lipoprotein $10.56 083721 Assay Of Blood Lipoprotein $8.69 083735 Assay Of Magnesium $5.55 083825 Assay Of Mercury $13.46 083835 Assay Of Metanephrines $14.03 083861 Microfluid Analy Tears $18.61 083874 Assay Of Myoglobin $10.70 083880 Assay Of Natriuretic Peptide $32.50 083930 Assay Of Blood Osmolality $5.47 083935 Assay Of Urine Osmolality $5.65 083945 Assay Of Oxalate $11.97 083970 Assay Of Parathormone $34.18 083986 Assay Ph Body Fluid Nos $2.96 083987 Exhaled Breath Condensate $2.96 084075 Assay Alkaline Phosphatase $4.29 084080 Assay Alkaline Phosphatases $12.24 084100 Assay Of Phosphorus $3.93 084105 Assay Of Urine Phosphorus $4.78 084132 Assay Of Serum Potassium $3.94 084133 Assay Of Urine Potassium $3.92 084134 Assay Of Prealbumin $12.08 084140 Assay Of Pregnenolone $17.11 084144 Assay Of Progesterone $17.27 084145 Procalcitonin (Pct) $22.54 084146 Assay Of Prolactin $16.04 084153 Assay Of Psa Total $15.23 084154 Assay Of Psa Free $15.23 084155 Assay Of Protein Serum $3.04 084165 Protein E-Phoresis Serum $8.90 084165 Protein E-Phoresis Serum 26 $10.50 084166 Protein E-Phoresis/Urine/Csf $14.77 0


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

84166 Protein E-Phoresis/Urine/Csf 26 $10.50 084181 Western Blot Test $14.10 084181 Western Blot Test 26 $10.50 084182 Protein Western Blot Test $24.19 084182 Protein Western Blot Test 26 $10.50 084238 Assay Nonendocrine Receptor $30.28 084244 Assay Of Renin $18.21 084295 Assay Of Serum Sodium $3.98 084300 Assay Of Urine Sodium $4.19 084305 Assay Of Somatomedin $17.60 084311 Spectrophotometry $6.71 084402 Assay Of Free Testosterone $21.09 084403 Assay Of Total Testosterone $21.37 084410 Testosterone Bioavailable $42.46 084432 Assay Of Thyroglobulin $13.29 084436 Assay Of Total Thyroxine $5.69 084439 Assay Of Free Thyroxine $7.47 084442 Assay Of Thyroid Activity $12.24 084443 Assay Thyroid Stim Hormone $13.91 084445 Assay Of Tsi Globulin $42.11 084450 Transferase (Ast) (Sgot) $4.29 084460 Alanine Amino (Alt) (Sgpt) $4.39 084466 Assay Of Transferrin $10.56 084478 Assay Of Triglycerides $4.76 084479 Assay Of Thyroid (T3 Or T4) $5.35 084480 Assay Triiodothyronine (T3) $11.74 084481 Free Assay (Ft-3) $14.03 084484 Assay Of Troponin Quant $10.32 084520 Assay Of Urea Nitrogen $3.28 084540 Assay Of Urine/Urea-N $4.60 084550 Assay Of Blood/Uric Acid $3.74 084560 Assay Of Urine/Uric Acid $4.20 084585 Assay Of Urine Vma $12.83 084590 Assay Of Vitamin A $9.61 084600 Assay Of Volatiles $14.17 084630 Assay Of Zinc $9.43 084681 Assay Of C-Peptide $17.23 084702 Chorionic Gonadotropin Test $12.47 084703 Chorionic Gonadotropin Assay $6.23 0


Page 24 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

84704 Hcg Free Betachain Test $12.66 084999 Clinical Chemistry Test M 085002 Bleeding Time Test $3.99 085004 Automated Diff Wbc Count $5.35 085007 Bl Smear W/Diff Wbc Count $3.15 085008 Bl Smear W/O Diff Wbc Count $2.84 085013 Spun Microhematocrit $5.80 085014 Hematocrit $1.96 085018 Hemoglobin $1.96 085025 Complete Cbc W/Auto Diff Wbc $6.43 085027 Complete Cbc Automated $5.35 085044 Manual Reticulocyte Count $3.57 085045 Automated Reticulocyte Count $3.30 085046 Reticyte/Hgb Concentrate $4.61 085048 Automated Leukocyte Count $2.11 085049 Automated Platelet Count $3.71 085060 Blood Smear Interpretation $13.87 085097 Bone Marrow Interpretation $39.22 085220 Blooc Clot Factor V Test $14.62 085240 Clot Factor Viii Ahg 1 Stage $14.82 085245 Clot Factor Viii Vw Ristoctn $19.00 085246 Clot Factor Viii Vw Antigen $19.00 085247 Clot Factor Viii Multimetric $19.00 085250 Clot Factor Ix Ptc/Chrstmas $15.77 085300 Antithrombin Iii Activity $9.82 085301 Antithrombin Iii Antigen $8.95 085302 Clot Inhibit Prot C Antigen $9.95 085303 Clot Inhibit Prot C Activity $11.46 085305 Clot Inhibit Prot S Total $9.61 085306 Clot Inhibit Prot S Free $12.69 085345 Coagulation Time Lee & White $3.88 085347 Coagulation Time Activated $3.54 085379 Fibrin Degradation Quant $8.43 085380 Fibrin Degradj D-Dimer $8.43 085384 Fibrinogen Activity $8.05 085390 Fibrinolysins Screen I&R $12.82 085390 Fibrinolysins Screen I&R 26 $21.20 085396 Clotting Assay Whole Blood $11.49 085460 Hemoglobin Fetal $6.40 0


Page 25 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

85461 Hemoglobin Fetal $7.75 085576 Blood Platelet Aggregation $20.63 085576 Blood Platelet Aggregation 26 $10.50 085610 Prothrombin Time $3.55 085611 Prothrombin Test $3.27 085613 Russell Viper Venom Diluted $7.93 085651 Rbc Sed Rate Nonautomated $3.53 085652 Rbc Sed Rate Automated $2.24 085660 Rbc Sickle Cell Test $4.56 085705 Thromboplastin Inhibition $7.98 085730 Thromboplastin Time Partial $4.98 085732 Thromboplastin Time Partial $5.35 085810 Blood Viscosity Examination $9.66 085999 Hematology Procedure M 086003 Allg Spec Ige Crude Xtrc Ea $4.32 086005 Allg Spec Ige Multiallg Scr $6.60 086008 Allg Spec Ige Recomb Ea $14.85 086038 Antinuclear Antibodies $10.01 086060 Antistreptolysin O Titer $6.04 086063 Antistreptolysin O Screen $4.77 086140 C-Reactive Protein $4.29 086141 C-Reactive Protein Hs $10.73 086148 Anti-Phospholipid Antibody $13.30 086153 Cell Enumeration Phys Interp 26 $19.61 086162 Complement Total (Ch50) $16.83 086200 Ccp Antibody $10.73 086215 Deoxyribonuclease Antibody $10.98 086225 Dna Antibody Native $11.38 086235 Nuclear Antigen Antibody $14.85 086255 Fluorescent Antibody Screen $9.98 086255 Fluorescent Antibody Screen 26 $10.50 086256 Fluorescent Antibody Titer $9.98 086256 Fluorescent Antibody Titer 26 $10.50 086300 Immunoassay Tumor Ca 15-3 $17.23 086304 Immunoassay Tumor Ca 125 $17.23 086308 Heterophile Antibody Screen $4.29 086316 Immunoassay Tumor Other $17.23 086318 Ia Infectious Agent Antibody $14.98 086320 Serum Immunoelectrophoresis $24.77 0


Page 26 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

86320 Serum Immunoelectrophoresis 26 $10.50 086325 Other Immunoelectrophoresis $19.15 086325 Other Immunoelectrophoresis 26 $10.50 086328 Ia Nfct Ab Sarscov2 Covid19 $37.45 086334 Immunofix E-Phoresis Serum $18.50 086334 Immunofix E-Phoresis Serum 26 $10.50 086335 Immunfix E-Phorsis/Urine/Csf $24.31 086335 Immunfix E-Phorsis/Urine/Csf 26 $10.50 086337 Insulin Antibodies $17.73 086340 Intrinsic Factor Antibody $12.48 086341 Islet Cell Antibody $19.51 086356 Mononuclear Cell Antigen $22.17 086386 Nuclear Matrix Protein 22 $18.03 086403 Particle Agglut Antbdy Scrn $9.56 086408 Sars-Cov-2 Neutralizing Antibody Screen $34.88 0 Rate Effective: 08/10/202086409 Sars-Cov-2 Neutralizing Antibody Titer $87.21 0 Rate Effective: 08/10/202086413 Sars-Cov-2 Antb Quantitative $34.88 0 Rate Effective: 09/08/202086430 Rheumatoid Factor Test Qual $5.09 086431 Rheumatoid Factor Quant $4.69 086480 Tb Test Cell Immun Measure $51.32 086481 Tb Ag Response T-Cell Susp $82.80 086485 Skin Test Candida $6.56 086510 Histoplasmosis Skin Test $3.76 086580 Tb Intradermal Test $5.15 086592 Syphilis Test Non-Trep Qual $3.53 086593 Syphilis Test Non-Trep Quant $3.64 086618 Lyme Disease Antibody $14.10 086631 Chlamydia Antibody $9.79 086632 Chlamydia Igm Antibody $10.50 086663 Epstein-Barr Antibody $10.87 086664 Epstein-Barr Nuclear Antigen $12.66 086665 Epstein-Barr Capsid Vca $15.02 086677 Helicobacter Pylori Antibody $13.96 086689 Htlv/Hiv Confirmj Antibody $16.03 086694 Herpes Simplex Nes Antbdy $11.91 086695 Herpes Simplex Type 1 Test $10.92 086696 Herpes Simplex Type 2 Test $16.03 086701 Hiv-1antibody $7.36 086702 Hiv-2 Antibody $11.20 0


Page 27 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

86703 Hiv-1/Hiv-2 1 Result Antbdy $11.35 086704 Hep B Core Antibody Total $9.98 086705 Hep B Core Antibody Igm $9.74 086706 Hep B Surface Antibody $8.90 086707 Hepatitis Be Antibody $9.58 086708 Hepatitis A Antibody $10.26 086709 Hepatitis A Igm Antibody $9.32 086710 Influenza Virus Antibody $11.22 086735 Mumps Antibody $10.81 086762 Rubella Antibody $11.91 086765 Rubeola Antibody $10.66 086769 Sars-Cov-2 Covid-19 Antibody $34.88 086777 Toxoplasma Antibody $11.91 086778 Toxoplasma Antibody Igm $11.93 086780 Treponema Pallidum $10.97 086787 Varicella-Zoster Antibody $10.66 086803 Hepatitis C Ab Test $11.81 086804 Hep C Ab Test Confirm $12.82 086812 Hla Typing A B Or C $21.37 086813 Hla Typing A B Or C $48.02 086849 Immunology Procedure M 086850 Rbc Antibody Screen $8.09 086880 Coombs Test Direct $4.46 086886 Coombs Test Indirect Titer $4.29 086900 Blood Typing Serologic Abo $2.47 086901 Blood Typing Serologic Rh(D) $2.47 086902 Blood Type Antigen Donor Ea $5.26 086905 Blood Typing Rbc Antigens $3.17 086920 Compatibility Test Spin $5.26 086921 Compatibility Test Incubate $5.26 086922 Compatibility Test Antiglob $5.26 086923 Compatibility Test Electric $5.26 087015 Specimen Infect Agnt Concntj $5.53 087040 Blood Culture For Bacteria $8.55 087045 Feces Culture Aerobic Bact $7.82 087046 Stool Cultr Aerobic Bact Ea $7.82 087070 Culture Othr Specimn Aerobic $7.14 087075 Cultr Bacteria Except Blood $7.84 087076 Culture Anaerobe Ident Each $6.69 0


Page 28 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

87077 Culture Aerobic Identify $6.69 087081 Culture Screen Only $5.49 087084 Culture Of Specimen By Kit $22.41 087086 Urine Culture/Colony Count $6.68 087088 Urine Bacteria Culture $6.70 087101 Skin Fungi Culture $6.38 087102 Fungus Isolation Culture $6.96 087103 Blood Fungus Culture $16.94 087106 Fungi Identification Yeast $8.55 087109 Mycoplasma $12.74 087110 Chlamydia Culture $16.23 087116 Mycobacteria Culture $8.94 087140 Culture Type Immunofluoresc $4.61 087147 Culture Type Immunologic $4.29 087150 Dna/Rna Amplified Probe $29.05 087177 Ova And Parasites Smears $7.37 087181 Microbe Susceptible Diffuse $3.94 087184 Microbe Susceptible Disk $6.19 087186 Microbe Susceptible Mic $7.17 087205 Smear Gram Stain $3.53 087206 Smear Fluorescent/Acid Stai $4.46 087207 Smear Special Stain $4.96 087207 Smear Special Stain 26 $10.50 087209 Smear Complex Stain $14.89 087210 Smear Wet Mount Saline/Ink $4.82 087220 Tissue Exam For Fungi $3.53 087252 Virus Inoculation Tissue $21.58 087255 Genet Virus Isolate Hsv $28.03 087270 Chlamydia Trachomatis Ag If $9.92 087272 Cryptosporidium Ag If $9.92 087273 Herpes Simplex 2 Ag If $9.92 087274 Herpes Simplex 1 Ag If $9.92 087275 Influenza B Ag If $10.15 087276 Influenza A Ag If $13.30 087280 Respiratory Syncytial Ag If $11.11 087283 Rubeola Ag If $50.34 087290 Varicella Zoster Ag If $11.11 087299 Antibody Detection Nos If $13.33 087320 Chylmd Trach Ag Ia $12.42 0


Page 29 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

87324 Clostridium Ag Ia $9.92 087328 Cryptosporidium Ag Ia $11.44 087338 Hpylori Stool Ia $11.90 087340 Hepatitis B Surface Ag Ia $8.56 087341 Hepatitis B Surface Ag Ia $8.56 087350 Hepatitis Be Ag Ia $9.55 087380 Hepatitis Delta Ag Ia $15.20 087389 Hiv-1 Ag W/Hiv-1 & Hiv-2 Ab $19.94 087390 Hiv-1 Ag Ia $19.92 087391 Hiv-2 Ag Ia $18.13 087400 Influenza A/B Ag Ia $11.70 087420 Resp Syncytial Ag Ia $11.52 087425 Rotavirus Ag Ia $9.92 087426 Coronavirus Ag Ia $37.45 087430 Strep A Ag Ia $13.92 087449 Ag Detect Nos Ia Mult $9.92 087450 Ag Detect Nos Ia Single $7.94 087480 Candida Dna Dir Probe $16.61 087481 Candida Dna Amp Probe $29.05 087486 Chylmd Pneum Dna Amp Probe $29.05 087490 Chylmd Trach Dna Dir Probe $18.84 087491 Chylmd Trach Dna Amp Probe $29.05 087492 Chylmd Trach Dna Quant $44.27 087501 Influenza Dna Amp Prob 1+ $42.49 087502 Influenza Dna Amp Probe $79.32 087503 Influenza Dna Amp Prob Addl $24.20 087510 Gardner Vag Dna Dir Probe $16.61 087511 Gardner Vag Dna Amp Probe $29.05 087512 Gardner Vag Dna Quant $34.57 087516 Hepatitis B Dna Amp Probe $29.05 087520 Hepatitis C Rna Dir Probe $25.85 087521 Hepatitis C Probe&Rvrs Trnsc $29.05 087528 Hsv Dna Dir Probe $16.61 087529 Hsv Dna Amp Probe $29.05 087530 Hsv Dna Quant $35.48 087534 Hiv-1 Dna Dir Probe $18.15 087535 Hiv-1 Probe&Reverse Trnscrpj $29.05 087536 Hiv-1 Quant&Revrse Trnscrpj $70.46 087537 Hiv-2 Dna Dir Probe $18.15 0


Page 30 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

87538 Hiv-2 Probe&Revrse Trnscripj $29.05 087539 Hiv-2 Quant&Revrse Trnscripj $48.54 087563 M. Genitalium Amp Probe $29.05 087590 N.Gonorrhoeae Dna Dir Prob $22.25 087591 N.Gonorrhoeae Dna Amp Prob $29.05 087592 N.Gonorrhoeae Dna Quant $35.48 087623 Hpv Low-Risk Types $29.05 087624 Hpv High-Risk Types $29.05 087625 Hpv Types 16 & 18 Only $33.58 087631 Resp Virus 3-5 Targets $118.10 087632 Resp Virus 6-11 Targets $180.55 087633 Resp Virus 12-25 Targets $345.09 087634 Rsv Dna/Rna Amp Probe $58.13 087635 Sars-Cov-2 Covid-19 Amp Prb $42.48 087650 Strep A Dna Dir Probe $16.61 087651 Strep A Dna Amp Probe $29.05 087652 Strep A Dna Quant $34.57 087653 Strep B Dna Amp Probe $29.05 087660 Trichomonas Vagin Dir Probe $16.61 087661 Trichomonas Vaginalis Amplif $29.05 087801 Detect Agnt Mult Dna Ampli $58.13 087804 Influenza Assay W/Optic $13.71 087806 Hiv Antigen W/Hiv Antibodies $27.13 087807 Rsv Assay W/Optic $10.85 087808 Trichomonas Assay W/Optic $12.66 087809 Adenovirus Assay W/Optic $18.01 087810 Chylmd Trach Assay W/Optic $29.22 087850 N. Gonorrhoeae Assay W/Optic $20.33 087880 Strep A Assay W/Optic $13.69 087901 Genotype Dna Hiv Reverse T $213.17 087902 Genotype Dna/Rna Hep C $213.17 087905 Sialidase Enzyme Assay $10.12 088104 Cytopath Fl Nongyn Smears $38.23 088104 Cytopath Fl Nongyn Smears 26 $16.05 088104 Cytopath Fl Nongyn Smears TC $22.19 088106 Cytopath Fl Nongyn Filter $36.25 088106 Cytopath Fl Nongyn Filter 26 $11.09 088106 Cytopath Fl Nongyn Filter TC $25.16 088108 Cytopath Concentrate Tech $34.67 0


Page 31 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

88108 Cytopath Concentrate Tech 26 $12.88 088108 Cytopath Concentrate Tech TC $21.79 088112 Cytopath Cell Enhance Tech $37.64 088112 Cytopath Cell Enhance Tech 26 $15.85 088112 Cytopath Cell Enhance Tech TC $21.79 088120 Cytp Urne 3-5 Probes Ea Spec $323.50 088120 Cytp Urne 3-5 Probes Ea Spec 26 $33.08 088120 Cytp Urne 3-5 Probes Ea Spec TC $290.41 088121 Cytp Urine 3-5 Probes Cmptr $247.23 088121 Cytp Urine 3-5 Probes Cmptr 26 $27.93 088121 Cytp Urine 3-5 Probes Cmptr TC $219.30 088141 Cytopath C/V Interpret $14.46 088142 Cytopath C/V Thin Layer $16.77 088143 Cytopath C/V Thin Layer Redo $19.08 088147 Cytopath C/V Automated $41.86 088148 Cytopath C/V Auto Rescreen $13.25 088155 Cytopath C/V Index Add-On $12.13 088160 Cytopath Smear Other Source $39.82 088160 Cytopath Smear Other Source 26 $14.86 088160 Cytopath Smear Other Source TC $24.96 088161 Cytopath Smear Other Source $38.23 088161 Cytopath Smear Other Source 26 $14.46 088161 Cytopath Smear Other Source TC $23.77 088162 Cytopath Smear Other Source $55.47 088162 Cytopath Smear Other Source 26 $21.99 088162 Cytopath Smear Other Source TC $33.48 088164 Cytopath Tbs C/V Manual $12.52 088165 Cytopath Tbs C/V Redo $34.96 088166 Cytopath Tbs C/V Auto Redo $12.52 088167 Cytopath Tbs C/V Select $12.52 088172 Cytp Dx Eval Fna 1st Ea Site $31.30 088172 Cytp Dx Eval Fna 1st Ea Site 26 $20.60 088172 Cytp Dx Eval Fna 1st Ea Site TC $10.70 088173 Cytopath Eval Fna Report $86.37 088173 Cytopath Eval Fna Report 26 $40.61 088173 Cytopath Eval Fna Report TC $45.76 088174 Cytopath C/V Auto In Fluid $21.00 088175 Cytopath C/V Auto Fluid Redo $22.03 088177 Cytp Fna Eval Ea Addl $16.64 0


Page 32 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

88177 Cytp Fna Eval Ea Addl 26 $12.68 088177 Cytp Fna Eval Ea Addl TC $3.96 088182 Cell Marker Study $77.06 088182 Cell Marker Study 26 $22.19 088182 Cell Marker Study TC $54.87 088187 Flowcytometry/Read 2-8 $21.59 088188 Flowcytometry/Read 9-15 $36.25 088189 Flowcytometry/Read 16 & > $48.73 088233 Tissue Culture Skin/Biopsy $116.53 088237 Tissue Culture Bone Marrow $119.03 088262 Chromosome Analysis 15-20 $103.90 088264 Chromosome Analysis 20-25 $119.74 088271 Cytogenetics Dna Probe $17.74 088274 Cytogenetics 25-99 $35.09 088275 Cytogenetics 100-300 $42.38 088291 Cyto/Molecular Report $19.02 088299 Cytogenetic Study M 088300 Surgical Path Gross $8.72 088300 Surgical Path Gross 26 $2.58 088300 Surgical Path Gross TC $6.14 088302 Tissue Exam By Pathologist $17.23 088302 Tissue Exam By Pathologist 26 $3.96 088302 Tissue Exam By Pathologist TC $13.27 088304 Tissue Exam By Pathologist $22.98 088304 Tissue Exam By Pathologist 26 $6.54 088304 Tissue Exam By Pathologist TC $16.44 088305 Tissue Exam By Pathologist $39.22 088305 Tissue Exam By Pathologist 26 $21.59 088305 Tissue Exam By Pathologist TC $17.63 088307 Tissue Exam By Pathologist $154.52 088307 Tissue Exam By Pathologist 26 $47.54 088307 Tissue Exam By Pathologist TC $106.97 088309 Tissue Exam By Pathologist $234.75 088309 Tissue Exam By Pathologist 26 $83.80 088309 Tissue Exam By Pathologist TC $150.95 088311 Decalcify Tissue $12.08 088311 Decalcify Tissue 26 $7.13 088311 Decalcify Tissue TC $4.95 088312 Special Stains Group 1 $58.84 0


Page 33 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

88312 Special Stains Group 1 26 $15.25 088312 Special Stains Group 1 TC $43.58 088313 Special Stains Group 2 $42.39 088313 Special Stains Group 2 26 $6.93 088313 Special Stains Group 2 TC $35.46 088314 Histochemical Stains Add-On $54.08 088314 Histochemical Stains Add-On 26 $12.68 088314 Histochemical Stains Add-On TC $41.40 088319 Enzyme Histochemistry $62.40 088319 Enzyme Histochemistry 26 $15.45 088319 Enzyme Histochemistry TC $46.95 088321 Microslide Consultation $56.26 088323 Microslide Consultation $64.58 088323 Microslide Consultation 26 $49.92 088323 Microslide Consultation TC $14.66 088325 Comprehensive Review Of Data $98.26 088329 Path Consult Introp $29.91 088331 Path Consult Intraop 1 Bloc $55.07 088331 Path Consult Intraop 1 Bloc 26 $35.86 088331 Path Consult Intraop 1 Bloc TC $19.22 088332 Path Consult Intraop Addl $30.51 088332 Path Consult Intraop Addl 26 $17.83 088332 Path Consult Intraop Addl TC $12.68 088333 Intraop Cyto Path Consult 1 $50.52 088333 Intraop Cyto Path Consult 1 26 $35.86 088333 Intraop Cyto Path Consult 1 TC $14.66 088334 Intraop Cyto Path Consult 2 $31.70 088334 Intraop Cyto Path Consult 2 26 $21.79 088334 Intraop Cyto Path Consult 2 TC $9.91 088341 Immunohisto Antb Addl Slide $51.70 088341 Immunohisto Antb Addl Slide 26 $16.24 088341 Immunohisto Antb Addl Slide TC $35.46 088342 Immunohisto Antb 1st Stain $58.84 088342 Immunohisto Antb 1st Stain 26 $20.21 088342 Immunohisto Antb 1st Stain TC $38.63 088344 Immunohisto Antibody Slide $96.28 088344 Immunohisto Antibody Slide 26 $21.99 088344 Immunohisto Antibody Slide TC $74.29 088346 Immunofluor Antb 1st Stain $70.52 0


Page 34 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

88346 Immunofluor Antb 1st Stain 26 $20.60 088346 Immunofluor Antb 1st Stain TC $49.92 088348 Electron Microscopy $216.33 088348 Electron Microscopy 26 $43.78 088348 Electron Microscopy TC $172.55 088350 Immunofluor Antb Addl Stain $51.70 088350 Immunofluor Antb Addl Stain 26 $16.64 088350 Immunofluor Antb Addl Stain TC $35.06 088355 Analysis Skeletal Muscle $76.86 088355 Analysis Skeletal Muscle 26 $47.15 088355 Analysis Skeletal Muscle TC $29.72 088356 Analysis Nerve $131.93 088356 Analysis Nerve 26 $73.50 088356 Analysis Nerve TC $58.44 088358 Analysis Tumor $74.68 088358 Analysis Tumor 26 $28.72 088358 Analysis Tumor TC $45.96 088360 Tumor Immunohistochem/Manual $69.93 088360 Tumor Immunohistochem/Manual 26 $24.17 088360 Tumor Immunohistochem/Manual TC $45.76 088361 Tumor Immunohistochem/Comput $70.92 088361 Tumor Immunohistochem/Comput 26 $25.55 088361 Tumor Immunohistochem/Comput TC $45.36 088363 Xm Archive Tissue Molec Anal $13.27 088364 Insitu Hybridization (Fish) $77.06 088364 Insitu Hybridization (Fish) 26 $19.81 088364 Insitu Hybridization (Fish) TC $57.25 088365 Insitu Hybridization (Fish) $101.03 088365 Insitu Hybridization (Fish) 26 $25.16 088365 Insitu Hybridization (Fish) TC $75.87 088367 Insitu Hybridization Auto $63.19 088367 Insitu Hybridization Auto 26 $19.61 088367 Insitu Hybridization Auto TC $43.58 088368 Insitu Hybridization Manual $73.50 088368 Insitu Hybridization Manual 26 $23.77 088368 Insitu Hybridization Manual TC $49.72 088369 M/Phmtrc Alysishquant/Semiq $63.99 088369 M/Phmtrc Alysishquant/Semiq 26 $18.62 088369 M/Phmtrc Alysishquant/Semiq TC $45.36 0


Page 35 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

88371 Protein Western Blot Tissue $18.41 088371 Protein Western Blot Tissue 26 $11.29 088373 M/Phmtrc Alys Ishquant/Semiq $41.20 088373 M/Phmtrc Alys Ishquant/Semiq 26 $15.25 088373 M/Phmtrc Alys Ishquant/Semiq TC $25.95 088375 Optical Endomicroscpy Interp $28.13 088377 M/Phmtrc Alys Ishquant/Semiq $226.03 088377 M/Phmtrc Alys Ishquant/Semiq 26 $37.04 088377 M/Phmtrc Alys Ishquant/Semiq TC $188.99 088380 Microdissection Laser $75.67 088380 Microdissection Laser 26 $31.70 088380 Microdissection Laser TC $43.98 088381 Microdissection Manual $100.44 088381 Microdissection Manual 26 $14.26 088381 Microdissection Manual TC $86.17 088387 Tiss Exam Molecular Study $19.81 088387 Tiss Exam Molecular Study 26 $15.85 088387 Tiss Exam Molecular Study TC $3.96 088388 Tiss Ex Molecul Study Add-On $20.60 088388 Tiss Ex Molecul Study Add-On 26 $13.67 088388 Tiss Ex Molecul Study Add-On TC $6.93 088399 Surgical Pathology Procedure M 088399 Surgical Pathology Procedure 26 M 088399 Surgical Pathology Procedure TC M 088720 Bilirubin Total Transcut $4.16 088738 Hgb Quant Transcutaneous $4.16 088740 Transcutaneous Carboxyhb $7.76 089049 Chct For Mal Hyperthermia $141.25 089050 Body Fluid Cell Count $3.91 089051 Body Fluid Cell Count $4.64 089055 Leukocyte Assessment Fecal $3.53 089060 Exam Synovial Fluid Crystals $6.07 089060 Exam Synovial Fluid Crystals 26 $10.50 089190 Nasal Smear For Eosinophils $4.79 089220 Sputum Specimen Collection $9.11 089230 Collect Sweat For Test $1.39 089240 Pathology Lab Procedure M 089300 Semen Analysis W/Huhner $8.15 089310 Semen Analysis W/Count $7.13 0


Page 36 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

89320 Semen Anal Vol/Count/Mot $10.19 089322 Semen Anal Strict Criteria $12.83 090281 Human Ig Im M 0 YES90283 Human Ig Iv M 0 YES90296 Diphtheria Antitoxin M 0 YES90371 Hep B Ig Im $115.89 0 YES90375 Rabies Ig Im/Sc $259.55 0 YES90376 Rabies Ig Heat Treated $297.61 0 YES90378 Rsv Mab Im 50mg M 0 YES90384 Rh Ig Full-Dose Im $125.08 0 YES90385 Rh Ig Minidose Im $58.62 0 YES90396 Varicella-Zoster Ig Im M 0 YES90399 Immune Globulin M 0 YES90460 Im Admin 1st/Only Component $7.00 090461 Im Admin Each Addl Component $0.00 090471 Immunization Admin $7.00 090472 Immunization Admin Each Add $7.00 090473 Immune Admin Oral/Nasal $3.00 090474 Immune Admin Oral/Nasal Addl $3.00 090620 Menb-4c Vacc 2 Dose Im 10 to 19 years $0.00 0 YES90620 Menb-4c Vacc 2 Dose Im 19 to 26 years $180.20 0 YES90621 Menb-Fhbp Vacc 2/3 Dose Im 10 to 19 years $0.00 0 YES90621 Menb-Fhbp Vacc 2/3 Dose Im 19 to 26 years $140.84 0 YES90630 Flu Vacc Iiv4 No Preserv Id $20.34 0 YES90632 Hepa Vaccine Adult Im $61.23 0 YES90633 Hepa Vacc Ped/Adol 2 Dose Im $0.00 0 YES90636 Hep A/Hep B Vacc Adult Im $108.65 0 YES90644 Hib-Mency Vacc 6wk-18m0 Im $0.00 0 YES90647 Hib Prp-Omp Vacc 3 Dose Im $0.00 0 YES90648 Hib Prp-T Vaccine 4 Dose Im $0.00 0 YES90651 9vhpv Vaccine 2/3 Dose Im 19 to 46 years $229.34 0 YES90651 9vhpv Vaccine 2/3 Dose Im 9 to 19 years $0.00 0 YES90653 Iiv Adjuvant Vaccine Im $59.53 0 YES90654 Flu Vacc Iiv3 No Preserv Id $18.92 0 YES90655 Iiv3 Vacc No Prsv 0.25 Ml Im $0.00 0 YES90656 Iiv3 Vacc No Prsv 0.5 Ml Im 19 to 124 years $19.77 0 YES90656 Iiv3 Vacc No Prsv 0.5 Ml Im 3 to 19 years $0.00 0 YES90657 Iiv3 Vaccine Splt 0.25 Ml Im $0.00 0 YES90658 Iiv3 Vaccine Splt 0.5 Ml Im 19 to 124 years $17.72 0 YES


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90658 Iiv3 Vaccine Splt 0.5 Ml Im 3 to 19 years $0.00 0 YES90661 Cciiv3 Vac No Prsv 0.5 Ml Im $22.29 0 YES90662 Iiv No Prsv Increased Ag Im $60.98 0 YES Rate Effective: 08/01/202090670 Pcv13 Vaccine Im 19 to 124 years $230.14 0 YES90670 Pcv13 Vaccine Im 42 days to 19 years $0.00 0 YES90672 Laiv4 Vaccine Intranasal 19 to 50 years $26.88 0 YES90672 Laiv4 Vaccine Intranasal 2 to 19 years $0.00 0 YES90673 Riv3 Vaccine No Preserv Im $40.61 0 YES90674 Cciiv4 Vac No Prsv 0.5 Ml Im 19 to 124 years $29.23 0 YES Rate Effective: 08/01/202090674 Cciiv4 Vac No Prsv 0.5 Ml Im 4 to 19 years $0.00 0 YES90675 Rabies Vaccine Im $294.72 0 YES90676 Rabies Vaccine Id M 0 YES90680 Rv5 Vacc 3 Dose Live Oral $0.00 0 YES90681 Rv1 Vacc 2 Dose Live Oral $0.00 0 YES90682 Riv4 Vacc Recombinant Dna Im $60.98 0 YES Rate Effective: 08/01/202090685 Iiv4 Vacc No Prsv 0.25 Ml Im $0.00 0 YES90686 Iiv4 Vacc No Prsv 0.5 Ml Im 19 to 124 years $19.58 0 YES Rate Effective: 08/01/202090686 Iiv4 Vacc No Prsv 0.5 Ml Im 6 months to 19 years $0.00 0 YES90687 Iiv4 Vaccine Splt 0.25 Ml Im $0.00 0 YES90688 Iiv4 Vaccine Splt 0.5 Ml Im 19 to 124 years $19.17 0 YES Rate Effective: 08/01/202090688 Iiv4 Vaccine Splt 0.5 Ml Im 6 months to 19 years $0.00 0 YES90691 Typhoid Vaccine Im $105.11 0 YES90694 Vacc Aiiv4 No Prsrv 0.5ml Im $61.00 0 YES Rate Effective: 08/01/202090696 Dtap-Ipv Vaccine 4-6 Yrs Im $0.00 0 YES90698 Dtap-Ipv/Hib Vaccine Im $0.00 0 YES90700 Dtap Vaccine < 7 Yrs Im $0.00 0 YES90702 Dt Vaccine Under 7 Yrs Im $0.00 0 YES90707 Mmr Vaccine Sc 1 to 19 years $0.00 0 YES90707 Mmr Vaccine Sc 19 to 124 years $77.15 0 YES90710 Mmrv Vaccine Sc $0.00 0 YES90713 Poliovirus Ipv Sc/Im 19 to 124 years $34.74 0 YES90713 Poliovirus Ipv Sc/Im 42 days to 19 years $0.00 0 YES90714 Td Vacc No Presv 7 Yrs+ Im 19 to 124 years $28.94 0 YES90714 Td Vacc No Presv 7 Yrs+ Im 7 to 19 years $0.00 0 YES90715 Tdap Vaccine 7 Yrs/> Im 19 to 124 years $33.44 0 YES90715 Tdap Vaccine 7 Yrs/> Im 7 to 19 years $0.00 0 YES90716 Var Vaccine Live Subq 1 to 19 years $0.00 0 YES90716 Var Vaccine Live Subq 19 to 124 years $136.26 0 YES90717 Yellow Fever Vaccine Subq $149.10 0 YES


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Revised: 05/18/2021

90723 Dtap-Hep B-Ipv Vaccine Im $0.00 0 YES90732 Ppsv23 Vacc 2 Yrs+ Subq/Im 19 to 124 years $119.92 0 YES90732 Ppsv23 Vacc 2 Yrs+ Subq/Im 2 to 19 years $0.00 0 YES90734 Menacwyd/Menacwycrm Vacc Im 19 to 56 years $128.85 0 YES90734 Menacwyd/Menacwycrm Vacc Im 2 months to 19 years $0.00 0 YES90736 Hzv Vaccine Live Subq $236.51 0 YES90739 Hepb Vacc 2 Dose Adult Im $131.10 0 YES90740 Hepb Vacc 3 Dose Immunsup Im 0 to 19 years $0.00 0 YES90740 Hepb Vacc 3 Dose Immunsup Im 19 to 124 years $140.76 0 YES90744 Hepb Vacc 3 Dose Ped/Adol Im 0 to 19 years $0.00 0 YES90744 Hepb Vacc 3 Dose Ped/Adol Im 19 to 20 years $28.21 0 YES90746 Hepb Vaccine 3 Dose Adult Im $69.65 0 YES90747 Hepb Vacc 4 Dose Immunsup Im $140.76 0 YES90749 Vaccine Toxoid M 0 YES90750 Hzv Vacc Recombinant Im $148.40 0 YES90756 Cciiv4 Vacc Abx Free Im 19 to 124 years $27.70 0 YES Rate Effective: 08/01/202090756 Cciiv4 Vacc Abx Free Im 4 to 19 years $0.00 0 YES90785 Psytx Complex Interactive $8.52 090791 Psych Diagnostic Evaluation 0 to 21 years $142.61 190791 Psych Diagnostic Evaluation 21 to 124 years $79.83 090792 Psych Diag Eval W/Med Srvcs 0 to 21 years $157.58 190792 Psych Diag Eval W/Med Srvcs 21 to 124 years $88.35 090832 Psytx W Pt 30 Minutes $39.03 190833 Psytx W Pt W E/M 30 Min $40.02 090834 Psytx W Pt 45 Minutes $51.90 190836 Psytx W Pt W E/M 45 Min $50.71 090837 Psytx W Pt 60 Minutes $77.66 190838 Psytx W Pt W E/M 60 Min $66.56 090839 Psytx Crisis Initial 60 Min $81.02 190840 Psytx Crisis Ea Addl 30 Min $38.83 090847 Family Psytx W/Pt 50 Min $58.84 190853 Group Psychotherapy $15.45 190887 Consultation With Family $49.53 192002 Eye Exam New Patient $46.95 192004 Eye Exam New Patient $83.80 192012 Eye Exam Establish Patient $49.33 192014 Eye Exam&Tx Estab Pt 1/>Vst $70.33 192015 Determine Refractive State $11.29 092020 Special Eye Evaluation $15.45 1


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

92025 Corneal Topography $20.60 092025 Corneal Topography 26 $11.09 092025 Corneal Topography TC $9.51 092065 Orthoptic/Pleoptic Training $29.52 092065 Orthoptic/Pleoptic Training 26 $10.10 092065 Orthoptic/Pleoptic Training TC $19.41 092072 Fit Contac Lens For Managmnt $71.71 192081 Visual Field Examination(S) $18.82 092081 Visual Field Examination(S) 26 $9.11 092081 Visual Field Examination(S) TC $9.71 092082 Visual Field Examination(S) $26.55 092082 Visual Field Examination(S) 26 $12.08 092082 Visual Field Examination(S) TC $14.46 092083 Visual Field Examination(S) $35.26 092083 Visual Field Examination(S) 26 $15.45 092083 Visual Field Examination(S) TC $19.81 092100 Serial Tonometry Exam(S) $46.16 092132 Cmptr Ophth Dx Img Ant Segmt $17.63 092132 Cmptr Ophth Dx Img Ant Segmt 26 $9.31 092132 Cmptr Ophth Dx Img Ant Segmt TC $8.32 092133 Cmptr Ophth Img Optic Nerve $20.80 092133 Cmptr Ophth Img Optic Nerve 26 $12.48 092133 Cmptr Ophth Img Optic Nerve TC $8.32 092134 Cptr Ophth Dx Img Post Segmt $22.78 092134 Cptr Ophth Dx Img Post Segmt 26 $14.26 092134 Cptr Ophth Dx Img Post Segmt TC $8.52 092227 Remote Dx Retinal Imaging $7.53 092228 Remote Retinal Imaging Mgmt $19.02 092228 Remote Retinal Imaging Mgmt 26 $11.69 092228 Remote Retinal Imaging Mgmt TC $7.33 092230 Eye Exam With Photos $43.19 192235 Fluorescein Angrph Uni/Bi $58.04 092235 Fluorescein Angrph Uni/Bi 26 $24.17 092235 Fluorescein Angrph Uni/Bi TC $33.88 092240 Icg Angiography Uni/Bi $112.72 092240 Icg Angiography Uni/Bi 26 $26.55 092240 Icg Angiography Uni/Bi TC $86.17 092242 Fluorescein Icg Angiography $132.93 092242 Fluorescein Icg Angiography 26 $30.51 0


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PPS Visit Code

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Revised: 05/18/2021

92242 Fluorescein Icg Angiography TC $102.42 092250 Eye Exam With Photos $25.16 092250 Eye Exam With Photos 26 $12.08 092250 Eye Exam With Photos TC $13.07 092260 Ophthalmoscopy/Dynamometry $10.90 092265 Eye Muscle Evaluation $48.53 092265 Eye Muscle Evaluation 26 $26.15 092265 Eye Muscle Evaluation TC $22.39 092270 Electro-Oculography $54.08 092270 Electro-Oculography 26 $23.97 092270 Electro-Oculography TC $30.11 092283 Color Vision Examination $29.52 092283 Color Vision Examination 26 $5.15 092283 Color Vision Examination TC $24.37 092284 Dark Adaptation Eye Exam $33.28 092284 Dark Adaptation Eye Exam 26 $7.13 092284 Dark Adaptation Eye Exam TC $26.15 092310 Contact Lens Fitting $56.66 092311 Contact Lens Fitting $58.44 092312 Contact Lens Fitting $67.75 092313 Contact Lens Fitting $54.87 092326 Replacement Of Contact Lens $21.00 092340 Fit Spectacles Monofocal $19.61 092341 Fit Spectacles Bifocal $22.78 092342 Fit Spectacles Multifocal $24.37 092352 Fit Aphakia Spectcl Monofocl $24.56 092353 Fit Aphakia Spectcl Multifoc $28.53 092370 Repair & Adjust Spectacles $17.43 092371 Repair & Adjust Spectacles $6.34 092507 Speech/Hearing Therapy $44.57 192508 Speech/Hearing Therapy $13.47 192511 Nasopharyngoscopy $63.00 192520 Laryngeal Function Studies $45.17 192521 Evaluation Of Speech Fluency $63.59 192522 Evaluate Speech Production $51.90 192523 Speech Sound Lang Comprehen $108.96 192524 Behavral Qualit Analys Voice $50.71 192526 Oral Function Therapy $49.13 192537 Caloric Vstblr Test W/Rec $23.38 1


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Revised: 05/18/2021

92537 Caloric Vstblr Test W/Rec 26 $17.83 192537 Caloric Vstblr Test W/Rec TC $5.55 192538 Caloric Vstblr Test W/Rec $12.68 192538 Caloric Vstblr Test W/Rec 26 $9.11 192538 Caloric Vstblr Test W/Rec TC $3.57 192541 Spontaneous Nystagmus Test $14.26 192541 Spontaneous Nystagmus Test 26 $11.89 192541 Spontaneous Nystagmus Test TC $2.38 192542 Positional Nystagmus Test $16.64 192542 Positional Nystagmus Test 26 $14.26 192542 Positional Nystagmus Test TC $2.38 192544 Optokinetic Nystagmus Test $9.91 192544 Optokinetic Nystagmus Test 26 $8.12 192544 Optokinetic Nystagmus Test TC $1.78 192545 Oscillating Tracking Test $9.31 092545 Oscillating Tracking Test 26 $7.53 092545 Oscillating Tracking Test TC $1.78 092546 Sinusoidal Rotational Test $62.40 192546 Sinusoidal Rotational Test 26 $8.52 192546 Sinusoidal Rotational Test TC $53.88 192547 Supplemental Electrical Test $4.75 092548 Cdp-Sot 6 Cond W/I&R $27.93 192548 Cdp-Sot 6 Cond W/I&R 26 $19.61 192548 Cdp-Sot 6 Cond W/I&R TC $8.32 192549 Cdp-Sot 6 Cond W/I&R Mct&Adt $35.66 192549 Cdp-Sot 6 Cond W/I&R Mct&Adt 26 $25.36 192549 Cdp-Sot 6 Cond W/I&R Mct&Adt TC $10.30 192550 Tympanometry & Reflex Thresh $12.48 192551 Pure Tone Hearing Test Air $6.54 192552 Pure Tone Audiometry Air $17.63 192553 Audiometry Air & Bone $21.39 192555 Speech Threshold Audiometry $13.27 192556 Speech Audiometry Complete $21.20 192557 Comprehensive Hearing Test $21.39 192561 Bekesy Audiometry Diagnosis $21.79 192562 Loudness Balance Test $24.76 192563 Tone Decay Hearing Test $17.04 092564 Sisi Hearing Test $13.27 092565 Stenger Test Pure Tone $8.72 0


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Codes

PPS Visit Code

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Revised: 05/18/2021

92567 Tympanometry $8.91 192568 Acoustic Refl Threshold Tst $8.91 192570 Acoustic Immitance Testing $18.62 192571 Filtered Speech Hearing Test $15.06 092575 Sensorineural Acuity Test $36.45 092576 Synthetic Sentence Test $20.21 092577 Stenger Test Speech $7.73 092579 Visual Audiometry (Vra) $26.15 092582 Conditioning Play Audiometry $41.01 092587 Evoked Auditory Test Limited $12.48 192587 Evoked Auditory Test Limited 26 $10.50 192587 Evoked Auditory Test Limited TC $1.98 192588 Evoked Auditory Tst Complete $19.02 192588 Evoked Auditory Tst Complete 26 $16.44 192588 Evoked Auditory Tst Complete TC $2.58 192590 Hearing Aid Exam One Ear $56.28 092591 Hearing Aid Exam Both Ears $56.28 092594 Electro Hearng Aid Test One $16.30 092595 Electro Hearng Aid Tst Both $32.63 092625 Tinnitus Assessment $39.62 092626 Eval Aud Funcj 1st Hour $50.71 092627 Eval Aud Funcj Ea Addl 15 $12.08 092630 Aud Rehab Pre-Ling Hear Loss $40.85 092633 Aud Rehab Postling Hear Loss $40.85 093000 Electrocardiogram Complete $9.51 093005 Electrocardiogram Tracing $4.75 093010 Electrocardiogram Report $4.75 093015 Cardiovascular Stress Test $39.62 093016 Cardiovascular Stress Test $12.48 093018 Cardiovascular Stress Test $8.32 093040 Rhythm Ecg With Report $7.13 093041 Rhythm Ecg Tracing $3.17 093042 Rhythm Ecg Report $3.96 093224 Ecg Monit/Reprt Up To 48 Hrs $49.33 093225 Ecg Monit/Reprt Up To 48 Hrs $14.26 093226 Ecg Monit/Reprt Up To 48 Hrs $20.21 093227 Ecg Monit/Reprt Up To 48 Hrs $14.86 093228 Remote 30 Day Ecg Rev/Report $15.06 093229 Remote 30 Day Ecg Tech Supp $392.83 0


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Codes

PPS Visit Code

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Revised: 05/18/2021

93268 Ecg Record/Review $111.73 093270 Remote 30 Day Ecg Rev/Report $4.95 093271 Ecg/Monitoring And Analysis $92.51 093272 Ecg/Review Interpret Only $14.26 093278 Ecg/Signal-Averaged $16.84 093278 Ecg/Signal-Averaged 26 $7.13 093278 Ecg/Signal-Averaged TC $9.71 093303 Echo Transthoracic $130.35 093303 Echo Transthoracic 26 $35.86 093303 Echo Transthoracic TC $94.49 093304 Echo Transthoracic $89.54 093304 Echo Transthoracic 26 $20.60 093304 Echo Transthoracic TC $68.94 093306 Tte W/Doppler Complete $116.09 093306 Tte W/Doppler Complete 26 $41.20 093306 Tte W/Doppler Complete TC $74.88 093307 Tte W/O Doppler Complete $79.04 093307 Tte W/O Doppler Complete 26 $25.36 093307 Tte W/O Doppler Complete TC $53.69 093308 Tte F-Up Or Lmtd $55.27 093308 Tte F-Up Or Lmtd 26 $14.46 093308 Tte F-Up Or Lmtd TC $40.81 093320 Doppler Echo Exam Heart $29.91 093320 Doppler Echo Exam Heart 26 $10.30 093320 Doppler Echo Exam Heart TC $19.61 093321 Doppler Echo Exam Heart $14.86 093321 Doppler Echo Exam Heart 26 $4.16 093321 Doppler Echo Exam Heart TC $10.70 093325 Doppler Color Flow Add-On $13.87 093325 Doppler Color Flow Add-On 26 $1.78 093325 Doppler Color Flow Add-On TC $12.08 093350 Stress Tte Only $106.18 093350 Stress Tte Only 26 $40.02 093350 Stress Tte Only TC $66.17 093356 Myocrd Strain Img Spckl Trck $22.39 093880 Extracranial Bilat Study $111.73 093880 Extracranial Bilat Study 26 $22.39 093880 Extracranial Bilat Study TC $89.34 093882 Extracranial Uni/Ltd Study $72.11 0


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Codes

PPS Visit Code

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Revised: 05/18/2021

93882 Extracranial Uni/Ltd Study 26 $14.26 093882 Extracranial Uni/Ltd Study TC $57.85 093922 Upr/L Xtremity Art 2 Levels $47.54 093922 Upr/L Xtremity Art 2 Levels 26 $7.13 093922 Upr/L Xtremity Art 2 Levels TC $40.41 093923 Upr/Lxtr Art Stdy 3+ Lvls $74.09 093923 Upr/Lxtr Art Stdy 3+ Lvls 26 $12.48 093923 Upr/Lxtr Art Stdy 3+ Lvls TC $61.61 093924 Lwr Xtr Vasc Stdy Bilat $91.52 093924 Lwr Xtr Vasc Stdy Bilat 26 $13.87 093924 Lwr Xtr Vasc Stdy Bilat TC $77.66 093925 Lower Extremity Study $142.04 093925 Lower Extremity Study 26 $21.99 093925 Lower Extremity Study TC $120.05 093926 Lower Extremity Study $83.99 093926 Lower Extremity Study 26 $13.67 093926 Lower Extremity Study TC $70.33 093930 Upper Extremity Study $115.49 093930 Upper Extremity Study 26 $22.58 093930 Upper Extremity Study TC $92.91 093931 Upper Extremity Study $72.11 093931 Upper Extremity Study 26 $13.87 093931 Upper Extremity Study TC $58.24 093970 Extremity Study $109.15 093970 Extremity Study 26 $19.41 093970 Extremity Study TC $89.74 093971 Extremity Study $68.15 093971 Extremity Study 26 $12.48 093971 Extremity Study TC $55.67 093975 Vascular Study $155.11 093975 Vascular Study 26 $32.29 093975 Vascular Study TC $122.82 093976 Vascular Study $91.92 093976 Vascular Study 26 $22.39 093976 Vascular Study TC $69.53 093978 Vascular Study $105.39 093978 Vascular Study 26 $22.19 093978 Vascular Study TC $83.20 093979 Vascular Study $67.75 0


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Codes

PPS Visit Code

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Revised: 05/18/2021

93979 Vascular Study 26 $13.87 093979 Vascular Study TC $53.88 093980 Penile Vascular Study $68.54 093980 Penile Vascular Study 26 $34.67 093980 Penile Vascular Study TC $33.88 093981 Penile Vascular Study $41.20 093981 Penile Vascular Study 26 $12.08 093981 Penile Vascular Study TC $29.12 094010 Breathing Capacity Test $19.81 094010 Breathing Capacity Test 26 $4.75 094010 Breathing Capacity Test TC $15.06 094011 Spirometry Up To 2 Yrs Old $48.73 094012 Spirmtry W/Brnchdil Inf-2 Yr $79.44 094013 Meas Lung Vol Thru 2 Yrs $10.90 094060 Evaluation Of Wheezing $33.08 094060 Evaluation Of Wheezing 26 $7.33 094060 Evaluation Of Wheezing TC $25.75 094070 Evaluation Of Wheezing $33.08 094070 Evaluation Of Wheezing 26 $16.05 094070 Evaluation Of Wheezing TC $17.04 094150 Vital Capacity Test $14.07 094150 Vital Capacity Test 26 $2.18 094150 Vital Capacity Test TC $11.89 094200 Lung Function Test (Mbc/Mvv) $12.48 094200 Lung Function Test (Mbc/Mvv) 26 $2.58 094200 Lung Function Test (Mbc/Mvv) TC $9.91 094250 Expired Gas Collection $15.25 094250 Expired Gas Collection 26 $3.17 094250 Expired Gas Collection TC $12.08 094375 Respiratory Flow Volume Loop $21.79 094375 Respiratory Flow Volume Loop 26 $8.32 094375 Respiratory Flow Volume Loop TC $13.47 094400 Co2 Breathing Response Curve $31.50 094400 Co2 Breathing Response Curve 26 $10.90 094400 Co2 Breathing Response Curve TC $20.60 094640 Airway Inhalation Treatment $9.91 095115 Immunotherapy One Injection $5.15 095117 Immunotherapy Injections $5.94 095249 Cont Gluc Mntr Pt Prov Eqp $30.51 0


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

95250 Cont Gluc Mntr Phys/Qhp Eqp $83.80 095251 Cont Gluc Mntr Analysis I&R $20.21 095805 Multiple Sleep Latency Test $231.98 095805 Multiple Sleep Latency Test 26 $33.28 095805 Multiple Sleep Latency Test TC $198.69 095806 Sleep Study Unatt&Resp Efft $65.37 095806 Sleep Study Unatt&Resp Efft 26 $25.36 095806 Sleep Study Unatt&Resp Efft TC $40.02 095807 Sleep Study Attended $227.62 095807 Sleep Study Attended 26 $34.67 095807 Sleep Study Attended TC $192.95 095808 Polysom Any Age 1-3> Param $364.90 095808 Polysom Any Age 1-3> Param 26 $49.33 095808 Polysom Any Age 1-3> Param TC $315.57 095810 Polysom 6/> Yrs 4/> Param $340.93 095810 Polysom 6/> Yrs 4/> Param 26 $68.34 095810 Polysom 6/> Yrs 4/> Param TC $272.59 095811 Polysom 6/>Yrs Cpap 4/> Parm $356.18 095811 Polysom 6/>Yrs Cpap 4/> Parm 26 $70.92 095811 Polysom 6/>Yrs Cpap 4/> Parm TC $285.26 095812 Eeg 41-60 Minutes $184.03 095812 Eeg 41-60 Minutes 26 $32.49 095812 Eeg 41-60 Minutes TC $151.55 095813 Eeg Extnd Mntr 61-119 Min $228.81 095813 Eeg Extnd Mntr 61-119 Min 26 $49.33 095813 Eeg Extnd Mntr 61-119 Min TC $179.48 095816 Eeg Awake And Drowsy $204.04 095816 Eeg Awake And Drowsy 26 $32.49 095816 Eeg Awake And Drowsy TC $171.55 095819 Eeg Awake And Asleep $242.28 095819 Eeg Awake And Asleep 26 $32.69 095819 Eeg Awake And Asleep TC $209.59 095851 Range Of Motion Measurements $12.28 195852 Range Of Motion Measurements $10.70 195857 Cholinesterase Challenge $31.10 095860 Muscle Test One Limb $67.35 095860 Muscle Test One Limb 26 $29.52 095860 Muscle Test One Limb TC $37.84 095861 Muscle Test 2 Limbs $96.47 0


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Codes

PPS Visit Code

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Revised: 05/18/2021

95861 Muscle Test 2 Limbs 26 $46.75 095861 Muscle Test 2 Limbs TC $49.72 095863 Muscle Test 3 Limbs $119.26 095863 Muscle Test 3 Limbs 26 $56.46 095863 Muscle Test 3 Limbs TC $62.80 095864 Muscle Test 4 Limbs $140.06 095864 Muscle Test 4 Limbs 26 $60.22 095864 Muscle Test 4 Limbs TC $79.83 095865 Muscle Test Larynx $85.98 095865 Muscle Test Larynx 26 $47.54 095865 Muscle Test Larynx TC $38.43 095866 Muscle Test Hemidiaphragm $75.87 095866 Muscle Test Hemidiaphragm 26 $37.84 095866 Muscle Test Hemidiaphragm TC $38.04 095867 Muscle Test Cran Nerv Unilat $60.42 095867 Muscle Test Cran Nerv Unilat 26 $24.17 095867 Muscle Test Cran Nerv Unilat TC $36.25 095868 Muscle Test Cran Nerve Bilat $79.24 095868 Muscle Test Cran Nerve Bilat 26 $35.66 095868 Muscle Test Cran Nerve Bilat TC $43.58 095869 Muscle Test Thor Paraspinal $53.69 095869 Muscle Test Thor Paraspinal 26 $11.29 095869 Muscle Test Thor Paraspinal TC $42.39 095870 Muscle Test Nonparaspinal $50.71 095870 Muscle Test Nonparaspinal 26 $11.29 095870 Muscle Test Nonparaspinal TC $39.42 095872 Muscle Test One Fiber $112.12 095872 Muscle Test One Fiber 26 $86.17 095872 Muscle Test One Fiber TC $25.95 095873 Guide Nerv Destr Elec Stim $42.99 095873 Guide Nerv Destr Elec Stim 26 $11.29 095873 Guide Nerv Destr Elec Stim TC $31.70 095874 Guide Nerv Destr Needle Emg $44.18 095874 Guide Nerv Destr Needle Emg 26 $11.09 095874 Guide Nerv Destr Needle Emg TC $33.08 095885 Musc Tst Done W/Nerv Tst Lim $35.06 095885 Musc Tst Done W/Nerv Tst Lim 26 $10.50 095885 Musc Tst Done W/Nerv Tst Lim TC $24.56 095886 Musc Test Done W/N Test Comp $54.48 0


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PPS Visit Code

Effective Date**



Revised: 05/18/2021

95886 Musc Test Done W/N Test Comp 26 $25.95 095886 Musc Test Done W/N Test Comp TC $28.53 095887 Musc Tst Done W/N Tst Nonext $47.54 095887 Musc Tst Done W/N Tst Nonext 26 $21.39 095887 Musc Tst Done W/N Tst Nonext TC $26.15 095907 Nvr Cndj Tst 1-2 Studies $53.69 095907 Nvr Cndj Tst 1-2 Studies 26 $30.51 095907 Nvr Cndj Tst 1-2 Studies TC $23.18 095908 Nrv Cndj Tst 3-4 Studies $68.15 095908 Nrv Cndj Tst 3-4 Studies 26 $38.04 095908 Nrv Cndj Tst 3-4 Studies TC $30.11 095909 Nrv Cndj Tst 5-6 Studies $81.62 095909 Nrv Cndj Tst 5-6 Studies 26 $45.56 095909 Nrv Cndj Tst 5-6 Studies TC $36.05 095910 Nrv Cndj Test 7-8 Studies $107.37 095910 Nrv Cndj Test 7-8 Studies 26 $61.01 095910 Nrv Cndj Test 7-8 Studies TC $46.36 095911 Nrv Cndj Test 9-10 Studies $128.57 095911 Nrv Cndj Test 9-10 Studies 26 $75.48 095911 Nrv Cndj Test 9-10 Studies TC $53.09 095912 Nrv Cndj Test 11-12 Studies $147.19 095912 Nrv Cndj Test 11-12 Studies 26 $89.94 095912 Nrv Cndj Test 11-12 Studies TC $57.25 095913 Nrv Cndj Test 13/> Studies $170.37 095913 Nrv Cndj Test 13/> Studies 26 $106.78 095913 Nrv Cndj Test 13/> Studies TC $63.59 095925 Somatosensory Testing $78.25 095925 Somatosensory Testing 26 $15.85 095925 Somatosensory Testing TC $62.40 095926 Somatosensory Testing $74.49 095926 Somatosensory Testing 26 $15.45 095926 Somatosensory Testing TC $59.03 095927 Somatosensory Testing $74.29 095927 Somatosensory Testing 26 $15.25 095927 Somatosensory Testing TC $59.03 095928 C Motor Evoked Uppr Limbs $126.39 095928 C Motor Evoked Uppr Limbs 26 $45.17 095928 C Motor Evoked Uppr Limbs TC $81.22 095929 C Motor Evoked Lwr Limbs $130.15 0


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

95929 C Motor Evoked Lwr Limbs 26 $45.17 095929 C Motor Evoked Lwr Limbs TC $84.98 095937 Neuromuscular Junction Test $52.69 095937 Neuromuscular Junction Test 26 $19.61 095937 Neuromuscular Junction Test TC $33.08 095981 Io Anal Gast N-Stim Subsq $20.01 095982 Io Ga N-Stim Subsq W/Reprog $31.89 096110 Developmental Screen W/Score $9.20 196112 Devel Tst Phys/Qhp 1st Hr $77.06 196113 Devel Tst Phys/Qhp Ea Addl $34.47 096116 Nubhvl Xm Phys/Qhp 1st Hr $54.68 196121 Nubhvl Xm Phy/Qhp Ea Addl Hr $47.35 096127 Brief Emotional/Behav Assmt $2.77 096130 Psycl Tst Eval Phys/Qhp 1st $66.96 196131 Psycl Tst Eval Phys/Qhp Ea $51.51 096132 Nrpsyc Tst Eval Phys/Qhp 1st $74.88 196133 Nrpsyc Tst Eval Phys/Qhp Ea $56.26 096136 Psycl/Nrpsyc Tst Phy/Qhp 1st $26.35 196137 Psycl/Nrpsyc Tst Phy/Qhp Ea $24.17 096138 Psycl/Nrpsyc Tech 1st $21.20 196139 Psycl/Nrpsyc Tst Tech Ea $21.20 096146 Psycl/Nrpsyc Tst Auto Result $1.19 096156 Hlth Bhv Assmt/Reassessment $41.16 196158 Hlth Bhv Ivntj Indiv 1st 30 $28.09 196159 Hlth Bhv Ivntj Indiv Ea Addl $9.81 096160 Pt-Focused Hlth Risk Assmt $1.39 096161 Caregiver Health Risk Assmt $1.39 096164 Hlth Bhv Ivntj Grp 1st 30 $4.16 196165 Hlth Bhv Ivntj Grp Ea Addl $1.93 096167 Hlth Bhv Ivntj Fam 1st 30 $30.17 196168 Hlth Bhv Ivntj Fam Ea Addl $10.70 096360 Hydration Iv Infusion Init $19.02 096361 Hydrate Iv Infusion Add-On $7.53 096365 Ther/Proph/Diag Iv Inf Init $39.62 096366 Ther/Proph/Diag Iv Inf Addon $12.08 096367 Tx/Proph/Dg Addl Seq Iv Inf $17.23 096368 Ther/Diag Concurrent Inf $11.69 096372 Ther/Proph/Diag Inj Sc/Im $7.92 096374 Ther/Proph/Diag Inj Iv Push $21.99 0


Page 50 of 63


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APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

96375 Tx/Pro/Dx Inj New Drug Addon $9.11 096377 Applicaton On-Body Injector $11.09 097012 Mechanical Traction Therapy $8.52 197014 Electric Stimulation Therapy $8.12 197016 Vasopneumatic Device Therapy $6.93 197018 Paraffin Bath Therapy $3.37 197022 Whirlpool Therapy $10.10 197024 Diathermy Eg Microwave $3.96 197026 Infrared Therapy $3.57 197028 Ultraviolet Therapy $4.56 197032 Electrical Stimulation $8.32 197033 Electric Current Therapy $11.69 197034 Contrast Bath Therapy $8.52 197035 Ultrasound Therapy $8.12 197036 Hydrotherapy $19.81 197039 Physical Therapy Treatment M 197110 Therapeutic Exercises $17.23 197112 Neuromuscular Reeducation $19.81 197116 Gait Training Therapy $17.04 197124 Massage Therapy $16.44 197129 Ther Ivntj 1st 15 Min $13.47 197130 Ther Ivntj Ea Addl 15 Min $12.88 097140 Manual Therapy 1/> Regions $15.85 197161 Pt Eval Low Complex 20 Min $48.14 197162 Pt Eval Mod Complex 30 Min $48.14 197163 Pt Eval High Complex 45 Min $48.14 197164 Pt Re-Eval Est Plan Care $33.08 197165 Ot Eval Low Complex 30 Min $51.11 197166 Ot Eval Mod Complex 45 Min $50.91 197167 Ot Eval High Complex 60 Min $50.91 197168 Ot Re-Eval Est Plan Care $35.26 197530 Therapeutic Activities $22.19 197533 Sensory Integration $29.12 197535 Self Care Mngment Training $19.22 197542 Wheelchair Mngment Training $18.62 197597 Rmvl Devital Tis 20 Cm/< $54.28 097598 Rmvl Devital Tis Addl 20cm/< $25.95 097760 Orthotic Mgmt&Traing 1st Enc $27.73 197761 Prosthetic Traing 1st Enc $23.57 1


Page 51 of 63


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Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

97763 Orthc/Prostc Mgmt Sbsq Enc $29.72 197799 Physical Medicine Procedure M 198925 Osteopath Manj 1-2 Regions $17.63 198926 Osteopath Manj 3-4 Regions $25.55 198927 Osteopath Manj 5-6 Regions $33.28 198928 Osteopath Manj 7-8 Regions $40.61 198929 Osteopath Manj 9-10 Regions $48.53 198940 Chiropract Manj 1-2 Regions $15.85 198941 Chiropract Manj 3-4 Regions $22.78 198942 Chiropractic Manj 5 Regions $29.72 199000* Specimen Handling Office-Lab $12.88 0 YES99001* Specimen Handling Pt-Lab $12.88 0 YES99188 App Topical Fluoride Varnish $6.93 099201 Office/Outpatient Visit New $25.55 199202 Office/Outpatient Visit New $42.39 199203 Office/Outpatient Visit New $60.02 199204 Office/Outpatient Visit New $91.72 199205 Office/Outpatient Visit New $115.89 199211 Office/Outpatient Visit Est $12.88 099212 Office/Outpatient Visit Est $25.36 199213 Office/Outpatient Visit Est $41.80 199214 Office/Outpatient Visit Est $60.62 199215 Office/Outpatient Visit Est $81.42 199241 Office Consultation $26.74 199242 Office Consultation $50.52 199243 Office Consultation $69.14 199244 Office Consultation $103.61 199245 Office Consultation $126.19 199304 Nursing Facility Care Init $50.52 199305 Nursing Facility Care Init $72.31 199306 Nursing Facility Care Init $93.31 199307 Nursing Fac Care Subseq $24.56 199308 Nursing Fac Care Subseq $38.63 199309 Nursing Fac Care Subseq $50.91 199310 Nursing Fac Care Subseq $75.08 199315 Nursing Fac Discharge Day $41.01 199316 Nursing Fac Discharge Day $58.84 199318 Annual Nursing Fac Assessmnt $53.69 199324 Domicil/R-Home Visit New Pat $30.51 1


Page 52 of 63


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Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

99325 Domicil/R-Home Visit New Pat $44.37 199326 Domicil/R-Home Visit New Pat $77.26 199327 Domicil/R-Home Visit New Pat $103.80 199328 Domicil/R-Home Visit New Pat $122.82 199334 Domicil/R-Home Visit Est Pat $33.68 199335 Domicil/R-Home Visit Est Pat $53.29 199336 Domicil/R-Home Visit Est Pat $75.28 199337 Domicil/R-Home Visit Est Pat $108.56 199341 Home Visit New Patient $30.51 199342 Home Visit New Patient $43.78 199343 Home Visit New Patient $71.91 199344 Home Visit New Patient $102.02 199345 Home Visit New Patient $124.21 199347 Home Visit Est Patient $30.51 199348 Home Visit Est Patient $46.95 199349 Home Visit Est Patient $71.91 199350 Home Visit Est Patient $100.24 199354 Prolong E&M/Psyctx Serv O/P $72.50 099355 Prolong E&M/Psyctx Serv O/P $55.07 099381 Init Pm E/M New Pat Infant $86.72 199382 Init Pm E/M New Pat 1-4 Yrs $93.36 199383 Prev Visit New Age 5-11 $91.46 199384 Prev Visit New Age 12-17 $99.37 199385 Prev Visit New Age 18-39 $99.37 199386 Prev Visit New Age 40-64 $117.10 199387 Init Pm E/M New Pat 65+ Yrs $126.92 199391 Per Pm Reeval Est Pat Infant $65.83 199392 Prev Visit Est Age 1-4 $73.74 199393 Prev Visit Est Age 5-11 $72.79 199394 Prev Visit Est Age 12-17 $80.39 199395 Prev Visit Est Age 18-39 $81.34 199396 Prev Visit Est Age 40-64 $89.89 199397 Per Pm Reeval Est Pat 65+ Yr $99.06 199406 Behav Chng Smoking 3-10 Min $8.52 099407 Behav Chng Smoking > 10 Min $16.24 099408 Audit/Dast 15-30 Min $15.16 199409 Audit/Dast Over 30 Min $29.42 199415 Prolong Clincl Staff Svc $5.55 099416 Prolong Clincl Staff Svc Add $2.38 0


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ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

99441* Phone E/M Phys/Qhp 5-10 Min $7.92 099442* Phone E/M Phys/Qhp 11-20 Min $15.45 099443* Phone E/M Phys/Qhp 21-30 Min $22.58 099446 Interprof Phone/Online 5-10 $10.10 099447 Interprof Phone/Online 11-20 $20.40 099448 Interprof Phone/Online 21-30 $30.51 099449 Interprof Phone/Online 31/> $40.61 099451 Ntrprof Ph1/Ntrnet/Ehr 5/> $20.60 099452 Ntrprof Ph1/Ntrnet/Ehr Rfrl $20.60 099453 Rem Mntr Physiol Param Setup $10.30 099454 Rem Mntr Physiol Param Dev $34.27 099457 Rem Physiol Mntr 1st 20 Min $28.33 099458 Rem Physiol Mntr Ea Addl 20 $23.18 099473* Self-Meas Bp Pt Educaj/Train $6.14 099474* Self-Meas Bp 2 Readg Bid 30d $8.32 099483 Assmt & Care Pln Pt Cog Imp $145.60 199495 Trans Care Mgmt 14 Day Disch $103.01 199496 Trans Care Mgmt 7 Day Disch $136.09 199497 Advncd Care Plan 30 Min $47.74 199498 Advncd Care Plan Addl 30 Min $41.80 099605 Mtms By Pharm Np 15 Min $50.00 199606 Mtms By Pharm Est 15 Min $25.00 199607 Mtms By Pharm Addl 15 Min $10.00 0A4266 Diaphragm $18.50 0A4267 Male Condom $0.06 0A4268 Female Condom $0.68 0A4269 Spermicide $4.95 0A4561 Pessary Rubber, Any Type $16.98 0A4562 Pessary, Non Rubber,Any Type $42.18 0D0190 Screening Of A Patient $14.89 0G0008 Admin Influenza Virus Vac $7.00 0G0009 Admin Pneumococcal Vaccine $7.00 0G0010 Admin Hepatitis B Vaccine $7.00 0G0027 Semen Analysis $5.38 0G0101 Ca Screen;Pelvic/Breast Exam $22.39 1G0102 Prostate Ca Screening; Dre $12.68 1G0103 Psa Screening $15.99 0G0117 Glaucoma Scrn Hgh Risk Direc $30.90 1G0118 Glaucoma Scrn Hgh Risk Direc $24.37 1


Page 54 of 63


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APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

G0130 Single Energy X-Ray Study $19.61 0G0130 Single Energy X-Ray Study 26 $6.34 0G0130 Single Energy X-Ray Study TC $13.27 0G0168 Wound Closure By Adhesive $60.02 0G0306 Cbc/Diffwbc W/O Platelet $6.43 0G0307 Cbc Without Platelet $5.35 0G0328 Fecal Blood Scrn Immunoassay $14.95 0G0396 Alcohol/Subs Interv 15-30mn $20.21 1G0397 Alcohol/Subs Interv >30 Min $37.84 1G0432 Eia Hiv-1/Hiv-2 Screen $16.20 0G0433 Elisa Hiv-1/Hiv-2 Screen $15.14 0G0435 Oral Hiv-1/Hiv-2 Screen $9.92 0G0472 Hep C Screen High Risk/Other $38.38 0G0475 Hiv Combination Assay $19.94 0G0476 Hpv Combo Assay Ca Screen $29.05 0G0480 Drug Test Def 1-7 Classes $94.75 0G0481 Drug Test Def 8-14 Classes $129.66 0G0482 Drug Test Def 15-21 Classes $164.56 0G0483 Drug Test Def 22+ Classes $204.45 0G0490 Home Visit Rn, Lpn By Rhc/Fq $80.98 0G0499 Hepb Screen High Risk Indiv $23.40 0G0512 Cocm By Rhc/Fqhc 60 Min Mo $77.85 0 YES Rate Effective: 08/01/2020G0516 Insert Drug Implant,>=4 $147.98 1 YESG0517 Remove Drug Implant $137.48 1 YESG0518 Remove W Insert Drug Implant $293.98 1 YESG2011 Alcohol/Sub Abuse Assess $9.51 1J0121 Inj., Omadacycline, 1 Mg $3.21 0 YESJ0171 Adrenalin Epinephrine Inject $0.91 0 YESJ0291 Inj., Plazomicin, 5 Mg $3.08 0 YESJ0456 Azithromycin $3.42 0 YESJ0520 Bethanechol Chloride Inject M 0 YESJ0558 Peng Benzathine/Procaine Inj $11.68 0 YESJ0561 Penicillin G Benzathine Inj $15.03 0 YESJ0570 Buprenorphine Implant 74.2mg $1,270.19 0 YESJ0583 Bivalirudin $0.74 0 YESJ0588 Incobotulinumtoxin A $5.02 0 YESJ0593 Inj., Lanadelumab-Flyo, 1 Mg M 0 YESJ0600 Edetate Calcium Disodium Inj $5,594.42 0 YESJ0606 Inj, Etelcalcetide, 0.1 Mg $3.47 0 YES


Page 55 of 63


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APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

J0610 Calcium Gluconate Injection $4.19 0 YESJ0620 Calcium Glycer & Lact/10 Ml M 0 YESJ0630 Calcitonin Salmon Injection $2,831.50 0 YESJ0636 Inj Calcitriol Per 0.1 Mcg $0.75 0 YESJ0637 Caspofungin Acetate $6.80 0 YESJ0640 Leucovorin Calcium Injection $3.18 0 YESJ0690 Cefazolin Sodium Injection $0.77 0 YESJ0691 Inj Lefamulin 1 Mg $0.72 0 YESJ0692 Cefepime Hcl For Injection $1.93 0 YESJ0694 Cefoxitin Sodium Injection $6.55 0 YESJ0695 Inj Ceftolozane Tazobactam $6.52 0 YESJ0696 Ceftriaxone Sodium Injection $0.53 0 YESJ0697 Sterile Cefuroxime Injection $2.13 0 YESJ0698 Cefotaxime Sodium Injection $2.33 0 YESJ0702 Betamethasone Acet&Sod Phosp $7.41 0 YESJ0710 Cephapirin Sodium Injection M 0 YESJ0712 Ceftaroline Fosamil Inj $3.33 0 YESJ0713 Inj Ceftazidime Per 500 Mg $1.99 0 YESJ0714 Ceftazidime And Avibactam $91.89 0 YESJ0715 Ceftizoxime Sodium / 500 Mg M 0 YESJ0735 Clonidine Hydrochloride $17.67 0 YESJ0743 Cilastatin Sodium Injection $5.77 0 YESJ0744 Ciprofloxacin Iv $1.13 0 YESJ0780 Prochlorperazine Injection $6.43 0 YESJ0791 Inj Crizanlizumab-Tmca 5mg $122.44 0 YESJ0840 Crotalidae Poly Immune Fab $3,099.37 0 YESJ0875 Injection, Dalbavancin $15.35 0 YESJ0878 Daptomycin Injection $0.14 0 YESJ0881 Darbepoetin Alfa, Non-Esrd $3.79 0 YESJ0882 Darbepoetin Alfa, Esrd Use $3.79 0 YESJ0885 Epoetin Alfa, Non-Esrd $9.70 0 YESJ0887 Epoetin Beta Esrd Use $1.49 0 YESJ0888 Epoetin Beta Non Esrd $1.49 0 YESJ0895 Deferoxamine Mesylate Inj $8.03 0 YESJ1000 Depo-Estradiol Cypionate Inj $23.69 0 YESJ1020 Methylprednisolone 20 Mg Inj $3.61 0 YESJ1030 Methylprednisolone 40 Mg Inj $6.09 0 YESJ1040 Methylprednisolone 80 Mg Inj $11.70 0 YESJ1050 Medroxyprogesterone Acetate $0.56 0 YES


Page 56 of 63


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Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

J1071 Inj Testosterone Cypionate $0.03 0 YESJ1094 Inj Dexamethasone Acetate $0.14 0 YESJ1100 Dexamethasone Sodium Phos $0.12 0 YESJ1130 Inj Diclofenac Sodium 0.5mg M 0 YESJ1170 Hydromorphone Injection $3.11 0 YESJ1200 Diphenhydramine Hcl Injectio $0.72 0 YESJ1201 Inj. Cetirizine Hcl 0.5mg M 0 YESJ1335 Ertapenem Injection $35.33 0 YESJ1364 Erythro Lactobionate /500 Mg $79.08 0 YESJ1380 Estradiol Valerate 10 Mg Inj $7.99 0 YESJ1410 Inj Estrogen Conjugate 25 Mg $322.55 0 YESJ1435 Injection Estrone Per 1 Mg M 0 YESJ1438 Etanercept Injection $411.71 0 YESJ1447 Inj Tbo Filgrastim 1 Microg $0.48 0 YESJ1450 Fluconazole $16.11 0 YESJ1455 Foscarnet Sodium Injection M 0 YESJ1459 Inj Ivig Privigen 500 Mg $41.28 0 YESJ1460 Gamma Globulin 1 Cc Inj $42.69 0 YESJ1555 Inj Cuvitru, 100 Mg $13.92 0 YESJ1556 Inj, Imm Glob Bivigam, 500mg $70.49 0 YESJ1557 Gammaplex Injection $49.16 0 YESJ1559 Hizentra Injection $10.79 0 YESJ1560 Gamma Globulin > 10 Cc Inj $426.93 0 YESJ1561 Gamunex-C/Gammaked $41.69 0 YESJ1562 Vivaglobin, Inj M 0 YESJ1566 Immune Globulin, Powder $66.94 0 YESJ1568 Octagam Injection $38.96 0 YESJ1569 Gammagard Liquid Injection $42.03 0 YESJ1570 Ganciclovir Sodium Injection $9.00 0 YESJ1571 Hepagam B Im Injection $63.67 0 YESJ1572 Flebogamma Injection $37.43 0 YESJ1573 Hepagam B Intravenous, Inj $51.29 0 YESJ1575 Hyqvia 100mg Immuneglobulin $14.07 0 YESJ1580 Garamycin Gentamicin Inj $1.94 0 YESJ1599 Ivig Non-Lyophilized, Nos M 0 YESJ1626 Granisetron Hcl Injection $0.26 0 YESJ1627 Inj, Granisetron, Xr, 0.1 Mg $1.03 0 YESJ1630 Haloperidol Injection $0.99 0 YESJ1631 Haloperidol Decanoate Inj $15.65 0 YES


Page 57 of 63


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Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

J1670 Tetanus Immune Globulin Inj $535.78 0 YESJ1675 Histrelin Acetate M 0 YESJ1700 Hydrocortisone Acetate Inj M 0 YESJ1710 Hydrocortisone Sodium Ph Inj M 0 YESJ1720 Hydrocortisone Sodium Succ I $14.14 0 YESJ1726 Makena, 10 Mg $32.40 0 YESJ1729 Inj Hydroxyprogst Capoat Nos M 0 YESJ1741 Ibuprofen Injection M 0 YESJ1750 Inj Iron Dextran $15.02 0 YESJ1756 Iron Sucrose Injection $0.21 0 YESJ1815 Insulin Injection $0.83 0 YESJ1826 Interferon Beta-1a Inj M 0 YESJ1830 Interferon Beta-1b / .25 Mg M 0 YESJ1833 Injection, Isavuconazonium M 0 YESJ1840 Kanamycin Sulfate 500 Mg Inj $7.69 0 YESJ1850 Kanamycin Sulfate 75 Mg Inj $1.15 0 YESJ1885 Ketorolac Tromethamine Inj $0.58 0 YESJ1890 Cephalothin Sodium Injection M 0 YESJ1940 Furosemide Injection $0.60 0 YESJ1943 Inj., Aristada Initio, 1 Mg $2.76 0 YESJ1944 Aripirazole Lauroxil 1 Mg $2.70 0 YESJ1950 Leuprolide Acetate /3.75 Mg $1,244.34 0 YESJ1956 Levofloxacin Injection $0.40 0 YESJ2010 Lincomycin Injection $11.47 0 YESJ2020 Linezolid Injection $6.46 0 YESJ2062 Loxapine For Inhalation 1 Mg M 0 YESJ2175 Meperidine Hydrochl /100 Mg $7.41 0 YESJ2180 Meperidine/Promethazine Inj M 0 YESJ2182 Injection, Mepolizumab, 1mg $29.05 0 YESJ2185 Meropenem $0.79 0 YESJ2186 Inj., Meropenem, Vaborbactam M 0 YESJ2265 Minocycline Hydrochloride M 0 YESJ2270 Morphine Sulfate Injection $3.72 0 YESJ2280 Inj, Moxifloxacin 100 Mg $8.74 0 YESJ2300 Inj Nalbuphine Hydrochloride $2.37 0 YESJ2310 Inj Naloxone Hydrochloride $14.22 0 YESJ2315 Naltrexone, Depot Form $3.24 0 YESJ2320 Nandrolone Decanoate 50 Mg M 0 YESJ2360 Orphenadrine Injection $6.51 0 YES


Page 58 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

J2405 Ondansetron Hcl Injection $0.10 0 YESJ2410 Oxymorphone Hcl Injection $2.85 0 YESJ2426 Paliperidone Palmitate Inj $12.03 0 YESJ2430 Pamidronate Disodium /30 Mg $12.63 0 YESJ2505 Injection, Pegfilgrastim 6mg $3,807.30 0 YESJ2510 Penicillin G Procaine Inj $30.29 0 YESJ2540 Penicillin G Potassium Inj $1.11 0 YESJ2543 Piperacillin/Tazobactam $1.68 0 YESJ2547 Injection, Peramivir M 0 YESJ2550 Promethazine Hcl Injection $2.23 0 YESJ2650 Prednisolone Acetate Inj M 0 YESJ2675 Inj Progesterone Per 50 Mg $1.69 0 YESJ2680 Fluphenazine Decanoate 25 Mg $11.45 0 YESJ2700 Oxacillin Sodium Injeciton $1.13 0 YESJ2780 Ranitidine Hydrochloride Inj $3.91 0 YESJ2786 Injection, Reslizumab, 1mg $9.78 0 YESJ2788 Rho D Immune Globulin 50 Mcg $25.93 0 YESJ2790 Rho D Immune Globulin Inj $84.90 0 YESJ2791 Rhophylac Injection $4.75 0 YESJ2792 Rho(D) Immune Globulin H, Sd $29.72 0 YESJ2794 Inj Risperdal Consta, 0.5 Mg $10.44 0 YESJ2798 Inj., Perseris, 0.5 Mg $10.19 0 YESJ2840 Inj Sebelipase Alfa 1 Mg M 0 YESJ2860 Injection, Siltuximab $112.93 0 YESJ2916 Na Ferric Gluconate Complex $1.94 0 YESJ2920 Methylprednisolone Injection $4.52 0 YESJ2930 Methylprednisolone Injection $6.72 0 YESJ3000 Streptomycin Injection $38.61 0 YESJ3030 Sumatriptan Succinate / 6 Mg $51.89 0 YESJ3031 Inj., Fremanezumab-Vfrm 1 Mg M 0 YESJ3090 Inj Tedizolid Phosphate $1.59 0 YESJ3111 Inj. Romosozumab-Aqqg 1 Mg $9.05 0 YESJ3250 Trimethobenzamide Hcl Inj $36.82 0 YESJ3260 Tobramycin Sulfate Injection $3.45 0 YESJ3265 Injection Torsemide 10 Mg/Ml M 0 YESJ3300 Triamcinolone A Inj Prs-Free $3.83 0 YESJ3301 Triamcinolone Acet Inj Nos $1.48 0 YESJ3302 Triamcinolone Diacetate Inj M 0 YESJ3303 Triamcinolone Hexacetonl Inj $3.61 0 YES


Page 59 of 63


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APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

J3304 Inj Triamcinolone Ace Xr 1mg $18.31 0 YESJ3305 Inj Trimetrexate Glucoronate M 0 YESJ3310 Perphenazine Injeciton M 0 YESJ3315 Triptorelin Pamoate $282.64 0 YESJ3316 Inj., Triptorelin Xr 3.75 Mg M 0 YESJ3320 Spectinomycn Di-Hcl Inj M 0 YESJ3358 Ustekinumab, Iv Inject, 1 Mg $12.17 0 YESJ3360 Diazepam Injection $6.34 0 YESJ3370 Vancomycin Hcl Injection $2.77 0 YESJ3410 Hydroxyzine Hcl Injection $6.98 0 YESJ3411 Thiamine Hcl 100 Mg $2.76 0 YESJ3415 Pyridoxine Hcl 100 Mg $7.91 0 YESJ3420 Vitamin B12 Injection $1.72 0 YESJ3430 Vitamin K Phytonadione Inj $4.06 0 YESJ3465 Injection, Voriconazole $1.49 0 YESJ3471 Ovine, Up To 999 Usp Units $0.45 0 YESJ3472 Ovine, 1000 Usp Units $137.80 0 YESJ3473 Hyaluronidase Recombinant $0.36 0 YESJ3475 Inj Magnesium Sulfate $0.64 0 YESJ3480 Inj Potassium Chloride $0.18 0 YESJ3485 Zidovudine $1.51 0 YESJ3486 Ziprasidone Mesylate $17.22 0 YESJ3489 Zoledronic Acid 1mg $11.39 0 YESJ3591 Esrd On Dialysi Drug/Bio Noc M 0 YESJ7030 Normal Saline Solution Infus $2.55 0 YESJ7040 Normal Saline Solution Infus $1.28 0 YESJ7042 5% Dextrose/Normal Saline $1.02 0 YESJ7050 Normal Saline Solution Infus $0.64 0 YESJ7060 5% Dextrose/Water $1.78 0 YESJ7070 D5w Infusion $3.51 0 YESJ7100 Dextran 40 Infusion $17.77 0 YESJ7110 Dextran 75 Infusion M 0 YESJ7120 Ringers Lactate Infusion $2.34 0 YESJ7121 5% Dextrose In Lac Ringers M 0 YESJ7296 Kyleena, 19.5 Mg $1,010.72 0 YESJ7297 Liletta, 52 Mg $794.36 0 YESJ7298 Mirena, 52 Mg $1,010.72 0 YESJ7300 Intraut Copper Contraceptive $937.57 0 YESJ7301 Skyla, 13.5 Mg $802.28 0 YES


Page 60 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

J7303 Contraceptive Vaginal Ring $172.38 0 YESJ7304 Contraceptive Hormone Patch $43.15 0 YESJ7307 Etonogestrel Implant System $990.91 0 YESJ7308 Aminolevulinic Acid Hcl Top $394.63 0 YESJ7309 Methyl Aminolevulinate, Top $83.69 0 YESJ7316 Inj, Ocriplasmin, 0.125 Mg $1,046.93 0 YESJ7318 Inj, Durolane 1 Mg M 0 YESJ7320 Genvisc 850, Inj, 1mg $6.25 0 YESJ7321 Hyalgan Or Supartz Inj Dose $75.73 0 YESJ7322 Hymovis Injection 1 Mg M 0 YESJ7323 Euflexxa Inj Per Dose $149.23 0 YESJ7324 Orthovisc Inj Per Dose $133.54 0 YESJ7325 Synvisc Or Synvisc-One $11.19 0 YESJ7326 Gel-One $537.36 0 YESJ7327 Monovisc Inj Per Dose $766.34 0 YESJ7328 Gelsyn-3 Injection 0.1 Mg M 0 YESJ7329 Inj, Trivisc 1 Mg M 0 YESJ7331 Synojoynt, Inj., 1 Mg M 0 YESJ7332 Inj., Triluron, 1 Mg M 0 YESJ7333 Visco-3 Inj Dose M 0 YESJ7336 Capsaicin 8% Patch $3.25 0 YESJ7501 Azathioprine Parenteral $217.30 0 YESJ7504 Lymphocyte Immune Globulin $2,225.62 0 YESJ7511 Antithymocyte Globuln Rabbit $779.00 0 YESJ7516 Cyclosporin Parenteral 250mg $61.70 0 YESJ7525 Tacrolimus Injection $212.17 0 YESJ7999 Compounded Drug, Noc M 0 YESJ9212 Interferon Alfacon-1 Inj M 0 YESJ9213 Interferon Alfa-2a Inj M 0 YESJ9214 Interferon Alfa-2b Inj $34.45 0 YESJ9215 Interferon Alfa-N3 Inj $31.80 0 YESJ9216 Interferon Gamma 1-B Inj M 0 YESJ9217 Leuprolide Acetate Suspnsion $205.89 0 YESJ9219 Leuprolide Acetate Implant M 0 YESJ9225 Vantas Implant $4,350.02 0 YESJ9226 Supprelin La Implant $38,414.97 0 YESJ9246 Inj., Evomela, 1 Mg M 0 YESJ9358 Inj Fam-Trastu Deru-Nxki 1mg $24.19 0 YESL4350 Ankle Control Ortho Pre Ots $73.80 0


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Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

L4360 Pneumat Walking Boot Pre Cst $197.46 0L4361 Pneuma/Vac Walk Boot Pre Ots $176.50 0L4370 Pneum Full Leg Splnt Pre Ots $179.50 0Q0091 Obtaining Screen Pap Smear $23.97 1Q0111 Wet Mounts/ W Preparations $12.52 0Q0112 Potassium Hydroxide Preps $4.83 0Q0113 Pinworm Examinations $3.53 0Q0114 Fern Test $8.07 0Q0138 Ferumoxytol, Non-Esrd $1.06 0 YESQ0139 Ferumoxytol, Esrd Use $1.06 0 YESQ0144 Azithromycin Dihydrate, Oral $15.05 0Q2034 Agriflu Vaccine M 0 YESQ2035 Afluria Vacc, 3 Yrs & >, Im $18.24 0 YESQ2036 Flulaval Vacc, 3 Yrs & >, Im $8.58 0 YESQ2037 Fluvirin Vacc, 3 Yrs & >, Im $17.69 0 YESQ2038 Fluzone Vacc, 3 Yrs & >, Im $12.04 0 YESQ2039 Influenza Virus Vaccine, Nos M 0 YESQ3027 Inj Beta Interferon Im 1 Mcg $54.01 0 YESQ4049 Finger Splint, Static $1.55 0Q4051 Splint Supplies Misc M 0Q4101 Apligraf $30.47 0Q4102 Oasis Wound Matrix $10.79 0Q4106 Dermagraft $32.27 0Q4107 Graftjacket $92.59 0Q4110 Primatrix $43.34 0Q4111 Gammagraft $7.00 0Q4113 Graftjacket Xpress $919.55 0Q4115 Alloskin $13.50 0Q4121 Theraskin $41.24 0Q4132 Grafix Core, Grafixpl Core $115.42 0Q4133 Grafix Stravix Prime Pl Sqcm $136.82 0Q4137 Amnioexcel Biodexcel 1sq Cm $89.13 0Q4145 Epifix, Inj, 1mg $18.43 0Q4151 Amnioband, Guardian 1 Sq Cm $136.54 0Q4154 Biovance 1 Square Cm $111.20 0Q4159 Affinity1 Square Cm $644.48 0Q4160 Nushield 1 Square Cm $100.06 0Q4170 Cygnus, Per Sq Cm $132.78 0Q4186 Epifix 1 Sq Cm $160.50 0


Page 62 of 63


Count

APM Procedure

Codes


ExcludedProcedure

Codes

PPS Visit Code

Effective Date**



Revised: 05/18/2021

Q4187 Epicord 1 Sq Cm M 0Q4195 Puraply 1 Sq Cm $103.10 0Q4196 Puraply Am 1 Sq Cm $109.52 0Q5120 Inj Pegfilgrastim-Bmez 0.5mg $317.28 0 YESQ9991 Buprenorph Xr 100 Mg Or Less $1,744.52 0 YESQ9992 Buprenorphine Xr Over 100 Mg $1,744.52 0 YESS0030 Injection, Metronidazole $0.05 0 YESS0032 Injection, Nafcillin Sodium M 0 YESS0074 Injection, Cefotetan Disodiu M 0 YESS0077 Injection, Clindamycin Phosp $3.30 0 YESS0080 Injection, Pentamidine Iseth M 0 YESS0145 Peg Interferon Alfa-2a/180 M 0 YESS0148 Peg Interferon Alfa-2b/10 M 0 YESS0164 Injection Pantroprazole $5.30 0 YESS0166 Inj Olanzapine 2.5mg $11.37 0 YESS0171 Bumetanide 0.5 Mg M 0 YESS0190 Mifepristone, Oral, 200 Mg M 0 YESS0191 Misoprostol, Oral, 200 Mcg M 0 YESS0199 Med Abortion Inc All Ex Drug M 0S0592 Comp Cont Lens Eval $35.46 1S0620 Routine Ophthalmological Exa $46.95 1S0621 Routine Ophthalmological Exa $49.33 1S2083 Adjustment Gastric Band $34.47 0S9152 Speech Therapy, Re-Eval $36.64 1S9443 Lactation Class $54.91 0T1015 Clinic Service Clinic Specific Rate 0 YESU0001 2019-Ncov Diagnostic P $29.74 0U0002 Covid-19 Lab Test Non-Cdc $42.48 0U0003 Cov-19 Amp Prb Hgh Thruput $82.80 0U0004 Cov-19 Test Non-Cdc Hgh Thru $82.80 0


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Code Short Description Modifier Age Range Rate Qualifying ...

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