Professional Services Fee Schedules Field Keys July 01, 2014 Page 1 Professional Services Fee Schedule Anesthesia Through Local Codes by Specialty Effective for Dates of Service on or After July 1, 2015
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Professional Services Fee SchedulesField Keys
July 01, 2014
Page 1
Professional Services Fee ScheduleAnesthesia Through Local Codes by Specialty
Effective for Dates of Service on or After
July 1, 2015
Professional Services Fee SchedulesField Keys
July 01, 2014
Page 2
Copyright InformationPhysicians’ Current Procedural Terminology (CPT®) five-digit codes, descriptions, and other data only are copyright 2014 American Medical Association. All Rights Reserved. CPT® is a registered trademark of the American Medical Association.No fee schedules, basic units, relative values or related listings are included in CPT.AMA does not directly or indirectly practice medicine or dispense medical services.AMA assumes no liability for data contained or not contained herein.
This document is also on the department’s Internet web site at http://feeschedules.lni.wa.gov/.
Updates to this manual can be found under ‘Updates and Corrections’ tab on the department’s Internet web site at http://feeschedules.lni.wa.gov/
Updates to this manual are also announced on the Medical Provider e-News listserv. Individuals may join the listserv at http://www.lni.wa.gov/Main/Listservs/Provider.asp.
Professional Services Fee SchedulesField Keys
July 01, 2014
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ANESTHESIA SERVICES FEE SCHEDULE FIELD KEY:
Column Title Column Description Column Values Value Definitions
ANES VALUE
Number
Dollar Value Fee schedule dollar value for services paid with the maximum fee method.
By Report Service paid on a “by report” basis.
Not Covered Procedure code is not covered.
Base/Time Service paid with base and time units.
By Report Service paid on a “by report” basis.
Maximum Fee Service paid based on a maximum dollar value.
Not Covered Procedure code is not covered,
BASE SOURCE
CMS Base unit source is the Centers for Medicare and Medicaid Services (CMS).
ASA
N/A Service not paid by base and time unit method
FSI
A Paid using base units
F Flat Fee developed by the department
N No fee or RVUs available, paid By Report
R Fee set by RBRVS RVUs
X Non-covered code
PRIOR AUTH
Y Prior authorization requiredY - UR Prior authorization and UR required
CPTÒ CODE2015 CPT®
anesthesia code. 2015 CPT® anesthesia code.
Indicates the anesthesia base units, maximum dollar value, or
coverage for the anesthesia service.
Anesthesia base units for services paid with the base and time payment method.
PAYMENT METHOD
Indicates the payment method for
the anesthesia service.
Indicates the source of the anesthesia
base units.Base unit source is the American Society of Anesthesiologists’ Relative Value Guide.
Fee Schedule Indicator
This column indicates the
payment status for the procedure code.
Prior authorization indicator
This column indicates whether prior authorization
and utilization review is required.
Professional Services Fee SchedulesField Keys
July 01, 2014
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PRIOR AUTH
Prior authorization indicator
This column indicates whether prior authorization
and utilization review is required.
Professional Services Fee SchedulesField Keys
July 01, 2014
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EVALUATION AND MANAGEMENT THROUGH HCPCS FEESFIELD KEY:
Column Title Column Description Column Values Value Definitions
Dollar Value Maximum dollar amount payable for covered services.Bundled Bundled code, not separately payable.By Report Service paid on a “by report” basis.
Contracted
Facility Only Procedure code for facility outpatient use only.
Not Covered Procedure code is not covered.
Dollar Value Maximum dollar amount payable for covered services.Bundled Bundled code, not separately payable.By Report Service paid on a “by report” basis.
Contracted
Hosp. Only Procedure code for hospital outpatient use only.
Not Covered Procedure code is not covered.
CPTÒ CODE/HCPCS CODE 2015 CPTÒ or HCPCS code 2015 CPTÒ or HCPCS code
ABBREVIATED DESCRIPTION
Abbreviated HCPCS code description. No descriptions are provided for CPTÒ codes.
Abbreviated description for reference purposes only. Refer to a 2015 CPT® or HCPCS code book for complete code descriptions.
DOLLAR VALUE
NON-FACILITY SETTING
This column indicates the:• Maximum dollar amount for covered services provided in a non-facility setting, or• Pricing method for the procedure code, or• Coverage status for the procedure code.
Contracted service. Payable only to department’s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured workers.
DOLLAR VALUE
FACILITY SETTING
This column indicates the:• Maximum dollar amount for covered services provided in a facility setting, or• Pricing method for the procedure code, or• Coverage status for the procedure code.
Contracted service. Payable only to department’s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured workers.
Professional Services Fee SchedulesField Keys
July 01, 2014
Page 6
Column Title Column Description Column Values Value Definitions
FOL UP Follow-up Days for Global Surgery Number
Percent
Percent
Percent
Field Key: Evaluation & Management through HCPCS (continued)
The number of days following surgery during which charges for normal postoperative care are bundled in the global surgery fee.
PRE OP (-56)
Preoperative Percentage(Modifier –56)
The percent of the total global surgery dollar value that is allowed when modifier –56 is billed.
INTRA OP (-54)
Intraoperative Percentage(Modifier –54)
The percent of the total global surgery dollar value that is allowed when modifier -54 is billed.
POST OP (-55)
Postoperative Percentage(Modifier –55)
The percent of the total global surgery dollar value that is allowed when modifier -55 is billed.
Professional Services Fee SchedulesField Keys
July 01, 2014
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Column TitleColumn Description Column Values Value Definitions
0
1
2
3
4
5
6
7 This indicator is not currently in use.
8
9
Field Key: Evaluation & Management through HCPCS (continued)
PCTC(26/TC)
Professional and Technical Component (Modifiers –26 and –TC)This field identifies whether professional and technical component modifiers (-26/-TC) are valid with the procedure code.
Modifiers -26 and -TC are not valid. The procedure is for physician services only; the concept of PC/TC does not apply
Modifiers -26 and -TC are valid. Diagnostic test or radiology service which has both a professional and technical component.
Modifiers -26 and -TC are not valid. Stand alone code for the professional component of a diagnostic test. An associated code describes the technical component of the diagnostic test or the global procedure (professional and technical components).
Modifiers -26 and -TC are not valid. Stand alone code for the technical component of a diagnostic test. An associated code describes the professional component of the diagnostic test or the global procedure (professional and technical components).
Modifiers -26 and -TC are not valid. Stand alone code for the global procedure for a diagnostic test. Associated codes describe the professional and technical components of the diagnostic test.
Modifiers -26 and -TC are not valid. Covered service incident to a physician’s service when provided by auxiliary personnel employed by and working under the direct supervision of the physician. This service not payable when provided to hospital inpatients or outpatients.
Modifier -TC is not valid; modifier -26 may be valid. Clinical laboratory or other service for which separate payment for interpretations by laboratory physicians or other physicians may be made.
Professional component of a clinical laboratory code; payable only if the physician interprets an abnormal smear for a hospital inpatient. No -TC modifier billing is recognized; payment for the underlying clinical laboratory test is made to the hospital. Not payable when furnished to hospital outpatients or non-hospital patients.
Modifiers -26 and -TC are not valid. Concept of a professional/technical component split does not apply.
Professional Services Fee SchedulesField Keys
July 01, 2014
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9
PCTC(26/TC)
Professional and Technical Component (Modifiers –26 and –TC)This field identifies whether professional and technical component modifiers (-26/-TC) are valid with the procedure code.
Modifiers -26 and -TC are not valid. Concept of a professional/technical component split does not apply.
Professional Services Fee SchedulesField Keys
July 01, 2014
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Column Title Column Description Column Values Value Definitions
MSI
0
1 This indicator is not currently in use.
2
3
4 This indicator is not currently in use.5 This indicator is not currently in use.
9
BSI
0
1
2
3
9
Field Key: Evaluation & Management through HCPCS (continued)
Multiple Surgery Indicator(Modifier –51)This field indicates whether multiple surgery payment rules apply to the service.
Modifier -51 is not valid. Payment adjustment rules for multiple surgeries do not apply.
Modifier -51 is valid. Standard multiple surgery payment policy applies (100%, 50%, 50%, 50%, 50%).
Modifier -51 may be valid. Multiple endoscopic procedures payment policy applies if this service is billed with another endoscopy in the same family.
Modifier -51 is not valid. Concept of multiple surgery does not apply.
Bilateral Surgery Indicator(Modifier –50)This field indicates whether the procedure is subject to a payment adjustment for bilateral surgery.
Modifier -50 is not valid. Payment adjustment rule for bilateral surgery does not apply.
Modifier -50 is valid. Payment adjustment for bilateral procedures (150%) applies to this procedure.
Modifier -50 is not valid. Payment adjustment for bilateral procedures does not apply. Procedures in this category include services for which the code descriptor specifically states that the procedure is bilateral; procedures that are usually performed as bilateral procedures; or procedures for which the code descriptor indicates the procedures may be performed either unilaterally or bilaterally.
Modifier -50 is not valid. Payment adjustment for bilateral procedure does not apply. This is a radiology procedure which is not subject to payment rules for bilateral surgeries.
Modifier -50 is not valid. Concept of bilateral surgery does not apply.
Professional Services Fee SchedulesField Keys
July 01, 2014
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Column Title Column Description Column Values Value Definitions
ASI
0
1
2
9
CSI
0
1
2
9
Field Key: Evaluation & Management through HCPCS (continued)
Assistant Surgeon Indicator(Modifiers –80, -81, -82)This field indicates whether or not an assistant surgeon may be paid for the procedure.
Modifiers -80, -81 and -82 are not valid under normal situations. Assistant at surgery is not usually paid for this procedure. Supporting documentation is necessary to establish medical necessity.
Modifiers -80, -81 and -82 are not valid. Assistant at surgery may not be paid for this procedure.
Modifiers -80, -81 and -82 are valid. Assistant at surgery may be paid.
Modifiers -80, -81 and -82 are not valid. Concept does not apply.
Co-surgeons Indicator(Modifier –62)This field indicates whether or not co-surgeons may be paid for the procedure.
Modifier -62 is not valid. Co-surgeons not permitted.
Modifier -62 is not valid under normal situations. Supporting documentation is required to establish medical necessity of two surgeons.
Modifier -62 is valid. Co-surgeons may be paid for this procedure. Supporting documentation is not required if two specialty requirement is met.
Modifier -62 is not valid with this procedure. Concept of co-surgeons does not apply.
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Column Title Column Description Column Values Value Definitions
TSI
0
1
2
9
ENDO BASE Endoscopy Base Code Code number
FSI
B Bundled code, not separately payable.
C
D
F Flat fee developed by the departmentL Clinical lab feeN No fee or RVUs available, code paid by report.O For hospital outpatient use only.R RBRVS feeS State RateT Tracking codeX Non-covered code
Field Key: Evaluation & Management through HCPCS (continued)
Team Surgeons Indicator(Modifier -66)This field indicates whether or not team surgeons may be paid for the procedure.
Modifier -66 is not valid. Team surgeons not permitted.
Modifier -66 is not valid under normal situations. Team surgeons may be payable. Supporting documentation is required to establish medical necessity of a team.
Modifier -66 is valid. Team surgeons permitted.
Modifier -66 is not valid. Concept of team surgery does not apply.
This column contains the endoscopic base code for procedure codes that are part of an endoscopy family. The Multiple Surgery Indicator for procedures in an endoscopy family is 3.
Fee Schedule IndicatorThis column indicates the payment status for the procedure code.
Contracted service. Payable only to department’s contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured workers.
Drug fee based on Average Wholesale Price (AWP) or Average Average Wholesale Price (AAWP).
Professional Services Fee SchedulesField Keys
July 01, 2014
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Column Title Column Description Column Values Value Definitions
Licensure Required
Y
blankNo special professional licensure is required to bill the department.
Y Prior authorization required
Y-UR Prior authorization and UR required
Field Key: Evaluation & Management through HCPCS (continued)
LICREQ
Appropriate professional licensure is required to bill the department for these codes.
PRIOR AUTH
Prior authorization indicator This column indicates whether prior authorization and utilization review is required.
Professional Services Fee SchedulesField Keys
July 01, 2014
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LOCAL CODES FEE SCHEDULEFIELD KEY:
Column Title Column Description Value Definitions
2015 Local Code.
Description Local Code Description Description of the unique service.
Dollar Value Maximum dollar amount payable for covered services.
By Report No fee or RVUs available, code paid By Report
Contracted
State Rate Service paid at state rate for travel or lodging.
Dollar Value Maximum dollar amount payable for covered services.
By Report No fee or RVUs available, code paid By Report
Contracted
State Rate Service paid at state rate for travel or lodging.
Column Values
LOCALCODE
A code assigned by the department to represent a specific service that is unique to injured workers.
Dollar Value Nonfacility
Setting
This column indicates the:
Maximum dollar amount for covered services provided in a non-facility setting, or
Pricing method for the procedure code
Contracted service.
Payable only to department’s contracted vendor for State Fund claims.
Payable to providers treating Self-Insured injured workers.
Dollar Value Facility Setting
This column indicates the:
Maximum dollar amount for covered services provided in a facility setting, or
Pricing method for the procedure code
Contracted service.
Payable only to department’s contracted vendor for State Fund claims.
Payable to providers treating Self-Insured injured workers.
Professional Services Fee SchedulesField Keys
July 01, 2014
Page 14
Column Title Column Description Value Definitions
Reference to payment policies related to the local code.
The local code is used to pay professional services.
The local code is used to pay facility services.
A publication for Independent Medical Examiners
Disability Prevention Evaluation providers
Field Key: Local Codes (continued)Column Values
Payment Policy Reference
The reason for the code or a reference to a page in another document where the reason for the code can be found
To reimburse claimant’s costs
Professional Services
Facility Services
Medical Examiner’s Handbook
For approved DPE providers
only
Professional Services Fee SchedulesField Keys
July 01, 2014
Page 15
LOCAL CODES by SPECIALTY FEE SCHEDULEFIELD KEY:
Column Title Column Description Value Definitions
Specialty Code Code assigned to the specialty
AU AudiologyCM Case ManagementCH Chiropractic CareCL Claimant OnlyDM Durable Medical Equipment & SuppliesEM Employer ReimbursementHM Home ModificationHC Home & Attendant CareHO Hospice CareIM Independent Medical ExamIR Impairment RatingIN Interpretive ServicesJM Job ModificationMS Miscellaneous & Special ServicesPA Pain TreatmentRS Residential ServicesRT RetrainingSR Special ReportsTL Travel, Lodging & MealsUR Utilization Review ServicesVM Vehicle ModificationVR Vocational & Related ServicesWL Weight Loss ServicesWH Work Hardening
Specialty Title Title of the area or specialty to which the local code pertains
Column Values
Professional Services Fee SchedulesField Keys
July 01, 2014
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Column Title Column Description Value Definitions
2015 Local Code.
Description Local Code Description Description of the unique service.
Dollar Value Maximum dollar amount payable for covered services.
By Report No fee or RVUs available, code paid By Report
Contracted
State Rate Service paid at state rate for travel or lodging.
Dollar Value Maximum dollar amount payable for covered services.
By Report No fee or RVUs available, code paid By Report
Contracted
State Rate Service paid at state rate for travel or lodging.
Field Key: Local Codes by Specialty (continued)Column Values
LOCALCODE
A code assigned by the department to represent a specific service that is unique to injured workers.
Dollar Value Nonfacility
Setting
This column indicates the:
Maximum dollar amount for covered services provided in a non-facility setting, or
Pricing method for the procedure code
Contracted service.
Payable only to department’s contracted vendor for State Fund claims.
Payable to providers treating Self-Insured injured workers.
Dollar Value Facility Setting
This column indicates the:
Maximum dollar amount for covered services provided in a facility setting, or
Pricing method for the procedure code
Contracted service.
Payable only to department’s contracted vendor for State Fund claims.
Payable to providers treating Self-Insured injured workers.
Professional Services Fee SchedulesField Keys
July 01, 2014
Page 17
Column Title Column Description Value Definitions
Reference to payment policies related to the local code.
A publication for Independent Medical Examiners
Disability Prevention Evaluation providers
Field Key: Local Codes by Specialty (continued)Column Values
Payment Policy Reference
The reason for the code or a reference to a page in another document where the reason for the code can be found
To reimburse claimant’s costs
Professional Services, Page
nn
The location within the Professional Services of the Medical Aid Rules and Fee Schedule where the code is discussed.
Facility Services, Page
nn
The location within the Facility Services of the Medical Aid Rules and Fee Schedule where the code is discussed.
Medical Examiner’s Handbook
For approved DPE providers
only
Professional Services Fee SchedulesAnesthesia
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 1
Professional Services Fee ScheduleAnesthesia
Professional Services Fee SchedulesAnesthesia
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 2
Anesthesia Fees
BASE SOURCE FSI PRIOR AUTH00100 5 Base/Time CMS A00102 6 Base/Time CMS A00103 5 Base/Time CMS A00104 4 Base/Time CMS A00120 5 Base/Time CMS A00124 4 Base/Time CMS A00126 4 Base/Time CMS A00140 5 Base/Time CMS A00142 4 Base/Time CMS A00144 6 Base/Time CMS A00145 6 Base/Time CMS A00147 4 Base/Time CMS A00148 4 Base/Time CMS A00160 5 Base/Time CMS A00162 7 Base/Time CMS A00164 4 Base/Time CMS A00170 5 Base/Time CMS A00172 6 Base/Time CMS A00174 6 Base/Time CMS A00176 7 Base/Time CMS A00190 5 Base/Time CMS A00192 7 Base/Time CMS A00210 11 Base/Time CMS A00211 10 Base/Time CMS A00212 5 Base/Time CMS A00214 9 Base/Time CMS A00215 9 Base/Time CMS A00216 15 Base/Time CMS A00218 13 Base/Time CMS A00220 10 Base/Time CMS A00222 6 Base/Time CMS A00300 5 Base/Time CMS A00320 6 Base/Time CMS A
CPTÒ CODE
ANES VALUE
PAYMENT METHOD
Professional Services Fee SchedulesAnesthesia
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 3
Anesthesia Fees
BASE SOURCE FSI PRIOR AUTHCPTÒ CODE
ANES VALUE
PAYMENT METHOD
00322 3 Base/Time CMS A
00326 Not Covered Not Covered ASA X
00350 10 Base/Time CMS A00352 5 Base/Time CMS A00400 3 Base/Time CMS A00402 5 Base/Time CMS A00404 5 Base/Time CMS A00406 13 Base/Time CMS A00410 4 Base/Time CMS A00450 5 Base/Time CMS A00454 3 Base/Time CMS A00470 6 Base/Time CMS A00472 10 Base/Time CMS A00474 13 Base/Time CMS A00500 15 Base/Time CMS A00520 6 Base/Time CMS A00522 4 Base/Time CMS A00524 4 Base/Time CMS A00528 8 Base/Time CMS A
00529 Not Covered Not Covered CMS X
00530 4 Base/Time CMS A00532 4 Base/Time CMS A00534 7 Base/Time CMS A00537 10 Base/Time ASA A00539 18 Base/Time CMS A00540 12 Base/Time CMS A00541 15 Base/Time CMS A00542 15 Base/Time CMS A00546 15 Base/Time CMS A00548 17 Base/Time CMS A00550 10 Base/Time CMS A
Professional Services Fee SchedulesAnesthesia
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 4
Anesthesia Fees
BASE SOURCE FSI PRIOR AUTHCPTÒ CODE
ANES VALUE
PAYMENT METHOD
00560 15 Base/Time CMS A
00561 Not Covered Not Covered CMS X
00562 20 Base/Time CMS A00563 25 Base/Time CMS A00566 25 Base/Time CMS A00567 18 Base/Time CMS A00580 20 Base/Time CMS A00600 10 Base/Time CMS A00604 13 Base/Time CMS A00620 10 Base/Time CMS A00625 13 Base/Time CMS A00626 15 Base/Time CMS A00630 8 Base/Time CMS A00632 7 Base/Time CMS A00635 4 Base/Time CMS A00640 3 Base/Time CMS A00670 13 Base/Time CMS A00700 4 Base/Time CMS A00702 4 Base/Time CMS A00730 5 Base/Time CMS A00740 5 Base/Time CMS A00750 4 Base/Time CMS A00752 6 Base/Time CMS A00754 7 Base/Time CMS A00756 7 Base/Time CMS A00770 15 Base/Time CMS A00790 7 Base/Time CMS A00792 13 Base/Time CMS A00794 8 Base/Time CMS A00796 30 Base/Time CMS A
00797 Not Covered Not Covered CMS X
Professional Services Fee SchedulesAnesthesia
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 5
Anesthesia Fees
BASE SOURCE FSI PRIOR AUTHCPTÒ CODE
ANES VALUE
PAYMENT METHOD
00800 4 Base/Time CMS A00802 5 Base/Time CMS A00810 5 Base/Time CMS A00820 5 Base/Time CMS A00830 4 Base/Time CMS A00832 6 Base/Time CMS A
00834 Not Covered Not Covered CMS X
00836 Not Covered Not Covered CMS X
00840 6 Base/Time CMS A00842 4 Base/Time CMS A00844 7 Base/Time CMS A00846 8 Base/Time CMS A00848 8 Base/Time CMS A
00851 Not Covered Not Covered CMS X
00860 6 Base/Time CMS A00862 7 Base/Time CMS A00864 8 Base/Time CMS A00865 7 Base/Time CMS A00866 10 Base/Time CMS A00868 10 Base/Time CMS A00870 5 Base/Time CMS A00872 7 Base/Time CMS A00873 5 Base/Time CMS A00880 15 Base/Time CMS A00882 10 Base/Time CMS A00902 5 Base/Time CMS A00904 7 Base/Time CMS A00906 4 Base/Time CMS A00908 6 Base/Time CMS A00910 3 Base/Time CMS A
Professional Services Fee SchedulesAnesthesia
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 6
Anesthesia Fees
BASE SOURCE FSI PRIOR AUTHCPTÒ CODE
ANES VALUE
PAYMENT METHOD
00912 5 Base/Time CMS A00914 5 Base/Time CMS A00916 5 Base/Time CMS A00918 5 Base/Time CMS A00920 3 Base/Time CMS A00921 3 Base/Time CMS A00922 6 Base/Time CMS A00924 4 Base/Time CMS A00926 4 Base/Time CMS A00928 6 Base/Time CMS A00930 4 Base/Time CMS A00932 4 Base/Time CMS A00934 6 Base/Time CMS A00936 8 Base/Time CMS A00938 4 Base/Time CMS A00940 3 Base/Time CMS A00942 4 Base/Time CMS A00944 6 Base/Time CMS A00948 4 Base/Time CMS A00950 5 Base/Time CMS A00952 4 Base/Time CMS A01112 5 Base/Time CMS A01120 6 Base/Time CMS A01130 3 Base/Time CMS A01140 15 Base/Time CMS A01150 10 Base/Time CMS A01160 4 Base/Time CMS A01170 8 Base/Time CMS A01173 12 Base/Time CMS A01180 3 Base/Time CMS A01190 4 Base/Time CMS A01200 4 Base/Time CMS A01202 4 Base/Time CMS A
Professional Services Fee SchedulesAnesthesia
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 7
Anesthesia Fees
BASE SOURCE FSI PRIOR AUTHCPTÒ CODE
ANES VALUE
PAYMENT METHOD
01210 6 Base/Time CMS A01212 10 Base/Time CMS A01214 8 Base/Time CMS A01215 10 Base/Time CMS A01220 4 Base/Time CMS A01230 6 Base/Time CMS A01232 5 Base/Time CMS A01234 8 Base/Time CMS A01250 4 Base/Time CMS A01260 3 Base/Time CMS A01270 8 Base/Time CMS A01272 4 Base/Time CMS A01274 6 Base/Time CMS A01320 4 Base/Time CMS A01340 4 Base/Time CMS A01360 5 Base/Time CMS A01380 3 Base/Time CMS A01382 3 Base/Time CMS A01390 3 Base/Time CMS A01392 4 Base/Time CMS A01400 4 Base/Time CMS A01402 7 Base/Time CMS A01404 5 Base/Time CMS A01420 3 Base/Time CMS A01430 3 Base/Time CMS A01432 6 Base/Time CMS A01440 8 Base/Time CMS A01442 8 Base/Time CMS A01444 8 Base/Time CMS A01462 3 Base/Time CMS A01464 3 Base/Time CMS A01470 3 Base/Time CMS A01472 5 Base/Time CMS A
Professional Services Fee SchedulesAnesthesia
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 8
Anesthesia Fees
BASE SOURCE FSI PRIOR AUTHCPTÒ CODE
ANES VALUE
PAYMENT METHOD
01474 5 Base/Time CMS A01480 3 Base/Time CMS A01482 4 Base/Time CMS A01484 4 Base/Time CMS A01486 7 Base/Time CMS A01490 3 Base/Time CMS A01500 8 Base/Time CMS A01502 6 Base/Time CMS A01520 3 Base/Time CMS A01522 5 Base/Time CMS A01610 5 Base/Time CMS A01620 4 Base/Time CMS A01622 4 Base/Time CMS A01630 5 Base/Time CMS A01634 9 Base/Time CMS A01636 15 Base/Time CMS A01638 10 Base/Time CMS A01650 6 Base/Time CMS A01652 10 Base/Time CMS A01654 8 Base/Time CMS A01656 10 Base/Time CMS A01670 4 Base/Time CMS A01680 3 Base/Time CMS A01682 4 Base/Time CMS A01710 3 Base/Time CMS A01712 5 Base/Time CMS A01714 5 Base/Time CMS A01716 5 Base/Time CMS A01730 3 Base/Time CMS A01732 3 Base/Time CMS A01740 4 Base/Time CMS A01742 5 Base/Time CMS A01744 5 Base/Time CMS A
Professional Services Fee SchedulesAnesthesia
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 9
Anesthesia Fees
BASE SOURCE FSI PRIOR AUTHCPTÒ CODE
ANES VALUE
PAYMENT METHOD
01756 6 Base/Time CMS A01758 5 Base/Time CMS A01760 7 Base/Time CMS A01770 6 Base/Time CMS A01772 6 Base/Time CMS A01780 3 Base/Time CMS A01782 4 Base/Time CMS A01810 3 Base/Time CMS A01820 3 Base/Time CMS A01829 3 Base/Time CMS A01830 3 Base/Time CMS A01832 6 Base/Time CMS A01840 6 Base/Time CMS A01842 6 Base/Time CMS A01844 6 Base/Time CMS A01850 3 Base/Time CMS A01852 4 Base/Time CMS A01860 3 Base/Time CMS A01916 5 Base/Time CMS A01920 7 Base/Time CMS A01922 7 Base/Time CMS A01924 6 Base/Time ASA A01925 8 Base/Time ASA A01926 10 Base/Time ASA A01930 5 Base/Time CMS A01931 7 Base/Time CMS A01932 7 Base/Time ASA A01933 8 Base/Time ASA A01935 5 Base/Time CMS A01936 5 Base/Time CMS A01951 3 Base/Time CMS A01952 5 Base/Time CMS A01953 $ 50.70 Maximum Fee N/A F
Professional Services Fee SchedulesAnesthesia
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 10
Anesthesia Fees
BASE SOURCE FSI PRIOR AUTHCPTÒ CODE
ANES VALUE
PAYMENT METHOD
01958 5 Base/Time CMS A01960 5 Base/Time CMS A01961 7 Base/Time CMS A01962 8 Base/Time CMS A01963 10 Base/Time ASA A01965 4 Base/Time CMS A01966 4 Base/Time CMS A01967 5 Base/Time CMS A01968 3 Base/Time ASA A01969 5 Base/Time CMS A01990 7 Base/Time CMS A01991 3 Base/Time CMS A01992 5 Base/Time CMS A01996 $ 65.98 Maximum Fee N/A R01999 By Report By Report N/A N
Professional Services Fee SchedulesEvaluation & Management
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 1
Professional Services Fee ScheduleEvaluation and Management
Professional Services Fee SchedulesEvaluation & Management
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 2
Evaluation & Management FeesDOLLAR VALUE MODIFIERS
FSI99201 $ 74.98 $ 44.99 0 0% 0% 0% 0 0 0 0 0 0 R 99202 $ 127.76 $ 83.97 0 0% 0% 0% 0 0 0 0 0 0 R 99203 $ 184.14 $ 128.36 0 0% 0% 0% 0 0 0 0 0 0 R 99204 $ 279.51 $ 217.73 0 0% 0% 0% 0 0 0 0 0 0 R 99205 $ 350.28 $ 283.11 0 0% 0% 0% 0 0 0 0 0 0 R 99211 $ 34.79 $ 15.59 0 0% 0% 0% 0 0 0 0 0 0 R 99212 $ 74.98 $ 42.59 0 0% 0% 0% 0 0 0 0 0 0 R 99213 $ 124.16 $ 85.77 0 0% 0% 0% 0 0 0 0 0 0 R 99214 $ 184.14 $ 131.96 0 0% 0% 0% 0 0 0 0 0 0 R 99215 $ 247.72 $ 187.14 0 0% 0% 0% 0 0 0 0 0 0 R 99217 $ 122.96 $ 122.96 0 0% 0% 0% 0 0 0 0 0 0 R 99218 $ 168.54 $ 168.54 0 0% 0% 0% 0 0 0 0 0 0 R 99219 $ 229.12 $ 229.12 0 0% 0% 0% 0 0 0 0 0 0 R 99220 $ 313.70 $ 313.70 0 0% 0% 0% 0 0 0 0 0 0 R 99221 $ 169.74 $ 169.74 0 0% 0% 0% 0 0 0 0 0 0 R 99222 $ 230.32 $ 230.32 0 0% 0% 0% 0 0 0 0 0 0 R 99223 $ 341.29 $ 341.29 0 0% 0% 0% 0 0 0 0 0 0 R 99224 $ 66.58 $ 66.58 0 0% 0% 0% 0 0 0 0 0 0 R99225 $ 122.96 $ 122.96 0 0% 0% 0% 0 0 0 0 0 0 R99226 $ 177.54 $ 177.54 0 0% 0% 0% 0 0 0 0 0 0 R99231 $ 65.98 $ 65.98 0 0% 0% 0% 0 0 0 0 0 0 R 99232 $ 122.36 $ 122.36 0 0% 0% 0% 0 0 0 0 0 0 R 99233 $ 175.74 $ 175.74 0 0% 0% 0% 0 0 0 0 0 0 R 99234 $ 224.93 $ 224.93 0 0% 0% 0% 0 0 0 0 0 0 R 99235 $ 284.91 $ 284.91 0 0% 0% 0% 0 0 0 0 0 0 R 99236 $ 367.08 $ 367.08 0 0% 0% 0% 0 0 0 0 0 0 R 99238 $ 123.56 $ 123.56 0 0% 0% 0% 0 0 0 0 0 0 R 99239 $ 182.34 $ 182.34 0 0% 0% 0% 0 0 0 0 0 0 R 99241 $ 82.77 $ 55.78 0 0% 0% 0% 9 9 9 9 9 9 R 99242 $ 154.75 $ 116.96 0 0% 0% 0% 9 9 9 9 9 9 R 99243 $ 211.13 $ 163.75 0 0% 0% 0% 9 9 9 9 9 9 R 99244 $ 313.10 $ 260.91 0 0% 0% 0% 9 9 9 9 9 9 R 99245 $ 382.07 $ 323.29 0 0% 0% 0% 9 9 9 9 9 9 R 99251 $ 82.77 $ 82.77 0 0% 0% 0% 9 9 9 9 9 9 R 99252 $ 126.56 $ 126.56 0 0% 0% 0% 9 9 9 9 9 9 R 99253 $ 194.34 $ 194.34 0 0% 0% 0% 9 9 9 9 9 9 R 99254 $ 281.91 $ 281.91 0 0% 0% 0% 9 9 9 9 9 9 R 99255 $ 339.49 $ 339.49 0 0% 0% 0% 9 9 9 9 9 9 R
CPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
Professional Services Fee SchedulesEvaluation & Management
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 3
Evaluation & Management FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
99281 $ 34.79 $ 34.79 0 0% 0% 0% 0 0 0 0 0 0 R 99282 $ 68.38 $ 68.38 0 0% 0% 0% 0 0 0 0 0 0 R 99283 $ 102.57 $ 102.57 0 0% 0% 0% 0 0 0 0 0 0 R 99284 $ 195.53 $ 195.53 0 0% 0% 0% 0 0 0 0 0 0 R 99285 $ 288.50 $ 288.50 0 0% 0% 0% 0 0 0 0 0 0 R 99288 $ 35.99 $ 35.99 0 0% 0% 0% 9 9 9 9 9 9 R 99291 $ 465.44 $ 374.28 0 0% 0% 0% 0 0 0 0 0 0 R 99292 $ 206.33 $ 187.14 0 0% 0% 0% 0 0 0 0 0 0 R 99304 $ 154.75 $ 154.75 0 0% 0% 0% 0 0 0 0 0 0 R 99305 $ 221.33 $ 221.33 0 0% 0% 0% 0 0 0 0 0 0 R 99306 $ 281.91 $ 281.91 0 0% 0% 0% 0 0 0 0 0 0 R 99307 $ 75.57 $ 75.57 0 0% 0% 0% 0 0 0 0 0 0 R 99308 $ 116.96 $ 116.96 0 0% 0% 0% 0 0 0 0 0 0 R 99309 $ 154.75 $ 154.75 0 0% 0% 0% 0 0 0 0 0 0 R 99310 $ 229.72 $ 229.72 0 0% 0% 0% 0 0 0 0 0 0 R 99315 $ 123.56 $ 123.56 0 0% 0% 0% 0 0 0 0 0 0 R 99316 $ 178.14 $ 178.14 0 0% 0% 0% 0 0 0 0 0 0 R 99318 $ 162.55 $ 162.55 0 0% 0% 0% 0 0 0 0 0 0 R 99324 $ 92.97 $ 92.97 0 0% 0% 0% 0 0 0 0 0 0 R 99325 $ 135.55 $ 135.55 0 0% 0% 0% 0 0 0 0 0 0 R 99326 $ 234.52 $ 234.52 0 0% 0% 0% 0 0 0 0 0 0 R 99327 $ 313.70 $ 313.70 0 0% 0% 0% 0 0 0 0 0 0 R 99328 $ 366.48 $ 366.48 0 0% 0% 0% 0 0 0 0 0 0 R 99334 $ 101.97 $ 101.97 0 0% 0% 0% 0 0 0 0 0 0 R 99335 $ 160.75 $ 160.75 0 0% 0% 0% 0 0 0 0 0 0 R 99336 $ 227.32 $ 227.32 0 0% 0% 0% 0 0 0 0 0 0 R 99337 $ 325.09 $ 325.09 0 0% 0% 0% 0 0 0 0 0 0 R 99339 $ 132.56 $ 132.56 0 0% 0% 0% 9 9 9 9 9 9 R 99340 $ 185.34 $ 185.34 0 0% 0% 0% 9 9 9 9 9 9 R 99341 $ 92.37 $ 92.37 0 0% 0% 0% 0 0 0 0 0 0 R 99342 $ 133.76 $ 133.76 0 0% 0% 0% 0 0 0 0 0 0 R 99343 $ 218.33 $ 218.33 0 0% 0% 0% 0 0 0 0 0 0 R 99344 $ 307.10 $ 307.10 0 0% 0% 0% 0 0 0 0 0 0 R 99345 $ 371.88 $ 371.88 0 0% 0% 0% 0 0 0 0 0 0 R 99347 $ 94.17 $ 94.17 0 0% 0% 0% 0 0 0 0 0 0 R 99348 $ 141.55 $ 141.55 0 0% 0% 0% 0 0 0 0 0 0 R 99349 $ 215.93 $ 215.93 0 0% 0% 0% 0 0 0 0 0 0 R 99350 $ 298.70 $ 298.70 0 0% 0% 0% 0 0 0 0 0 0 R
Professional Services Fee SchedulesEvaluation & Management
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 4
Evaluation & Management FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
99354 $ 168.54 $ 155.95 0 0% 0% 0% 0 0 0 0 0 0 R 99355 $ 163.75 $ 150.55 0 0% 0% 0% 0 0 0 0 0 0 R 99356 $ 155.35 $ 155.35 0 0% 0% 0% 0 0 0 0 0 0 R 99357 $ 153.55 $ 153.55 0 0% 0% 0% 0 0 0 0 0 0 R 99358 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99359 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99360 $ 103.77 $ 103.77 0 0% 0% 0% 9 9 9 9 9 9 R 99363 $ 219.53 $ 142.75 0 0% 0% 0% 9 9 9 9 9 9 R 99364 $ 74.38 $ 54.58 0 0% 0% 0% 9 9 9 9 9 9 R 99366 $ 72.58 $ 70.78 0 0% 0% 0% 9 9 9 9 9 9 R 99367 $ 154.75 $ 109.76 0 0% 0% 0% 9 9 9 9 9 9 R 99368 $ 62.38 $ 62.38 0 0% 0% 0% 9 9 9 9 9 9 R 99374 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99375 $ 179.34 $ 149.95 0 0% 0% 0% 9 9 9 9 9 9 R 99377 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99378 $ 179.34 $ 149.95 0 0% 0% 0% 9 9 9 9 9 9 R 99379 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99380 $ 179.34 $ 149.95 0 0% 0% 0% 9 9 9 9 9 9 R 99381 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99382 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99383 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99384 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99385 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99386 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99387 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99391 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99392 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99393 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99394 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99395 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99396 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99397 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99401 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99402 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99403 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99404 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99406 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99407 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
Professional Services Fee SchedulesEvaluation & Management
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 5
Evaluation & Management FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
99408 $ 59.38 $ 56.38 0 0% 0% 0% 9 9 9 9 9 9 R 99409 $ 116.36 $ 112.76 0 0% 0% 0% 9 9 9 9 9 9 R 99411 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99412 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99420 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99429 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99441 $ 23.99 $ 22.19 0 0% 0% 0% 9 9 9 9 9 9 R 99442 $ 45.58 $ 43.19 0 0% 0% 0% 9 9 9 9 9 9 R 99443 $ 67.78 $ 65.38 0 0% 0% 0% 9 9 9 9 9 9 R 99444 $ 45.58 $ 43.19 0 0% 0% 0% 9 9 9 9 9 9 R 99446 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X99447 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X99448 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X99449 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X99450 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99455 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99456 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99460 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99461 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99462 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99463 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99464 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99465 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99466 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99467 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99468 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99469 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99471 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99472 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99475 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99476 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99477 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99478 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99479 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99480 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99485 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X99486 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X99487 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
Professional Services Fee SchedulesEvaluation & Management
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 6
Evaluation & Management FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
99489 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X99490 Not Covered Not Covered 0 0% 0% 0% 0 0 0 9 0 0 X99495 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X99496 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X99497 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X99498 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X99499 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 1
Professional Services Fee ScheduleSurgery
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 2
Surgery FeesDOLLAR VALUE MODIFIERS
FSI10021 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 10022 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 10030 $ 1379.54 $ 263.91 0 0% 0% 0% 9 2 9 0 0 0 R Y10040 $ 172.74 $ 149.95 10 10% 80% 10% 0 2 0 1 0 0 R Y10060 $ 202.13 $ 167.34 10 10% 80% 10% 0 2 0 1 0 0 R 10061 $ 353.28 $ 307.70 10 10% 80% 10% 0 2 0 1 0 0 R 10080 $ 312.50 $ 176.94 10 10% 80% 10% 0 2 0 1 0 0 R Y10081 $ 463.05 $ 288.50 10 10% 80% 10% 0 2 0 1 0 0 R Y10120 $ 265.11 $ 178.74 10 10% 80% 10% 0 2 0 1 0 0 R 10121 $ 469.64 $ 314.90 10 10% 80% 10% 0 2 0 1 0 0 R 10140 $ 281.91 $ 203.33 10 10% 80% 10% 0 2 0 1 0 0 R 10160 $ 224.93 $ 164.35 10 10% 80% 10% 0 2 0 1 0 0 R 10180 $ 419.26 $ 301.10 10 10% 80% 10% 0 2 0 1 0 0 R 11000 $ 94.17 $ 48.58 0 0% 0% 0% 0 2 0 1 0 0 R 11001 $ 35.99 $ 23.99 0 0% 0% 0% 0 0 0 1 0 0 R 11004 $ 959.68 $ 959.68 0 0% 0% 0% 0 2 0 1 0 0 R 11005 $ 1282.97 $ 1282.97 0 0% 0% 0% 0 0 0 0 0 0 R 11006 $ 1160.61 $ 1160.61 0 0% 0% 0% 0 2 0 1 0 0 R 11008 $ 451.05 $ 451.05 0 0% 0% 0% 0 0 0 0 0 0 R 11010 $ 845.72 $ 472.04 10 10% 80% 10% 0 2 2 1 0 0 R 11011 $ 902.70 $ 495.43 0 0% 0% 0% 0 2 2 1 0 0 R 11012 $ 1210.40 $ 707.16 0 0% 0% 0% 0 2 2 1 0 0 R 11042 $ 202.73 $ 104.97 0 0% 0% 0% 0 2 0 1 0 0 R 11043 $ 389.27 $ 261.51 0 0% 0% 0% 0 2 0 1 0 0 R 11044 $ 532.62 $ 388.07 0 0% 0% 0% 0 2 0 1 0 0 R 11045 $ 70.18 $ 43.79 0 0% 0% 0% 0 0 0 0 0 0 R11046 $ 122.36 $ 92.37 0 0% 0% 0% 0 0 0 0 0 0 R11047 $ 206.93 $ 164.35 0 0% 0% 0% 0 0 0 0 0 0 R11055 $ 83.97 $ 27.59 0 0% 0% 0% 0 2 0 1 0 0 R 11056 $ 101.97 $ 38.99 0 0% 0% 0% 0 2 0 1 0 0 R 11057 $ 113.96 $ 50.38 0 0% 0% 0% 0 2 0 1 0 0 R 11100 $ 179.34 $ 82.17 0 0% 0% 0% 0 2 0 1 0 0 R 11101 $ 55.18 $ 41.99 0 0% 0% 0% 0 0 0 1 0 0 R 11200 $ 151.75 $ 126.56 10 10% 80% 10% 0 2 0 1 0 0 R Y11201 $ 31.79 $ 28.19 0 0% 0% 0% 0 0 0 1 0 0 R Y11300 $ 169.74 $ 59.38 0 0% 0% 0% 0 2 9 0 0 0 R 11301 $ 208.13 $ 90.57 0 0% 0% 0% 0 2 9 0 0 0 R 11302 $ 244.12 $ 106.16 0 0% 0% 0% 0 2 9 0 0 0 R
CPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 3
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
11303 $ 269.31 $ 125.36 0 0% 0% 0% 0 2 9 0 0 0 R 11305 $ 171.54 $ 65.98 0 0% 0% 0% 0 2 9 0 0 0 R 11306 $ 211.13 $ 87.57 0 0% 0% 0% 0 2 9 0 0 0 R 11307 $ 248.32 $ 112.16 0 0% 0% 0% 0 2 9 0 0 0 R 11308 $ 260.91 $ 124.76 0 0% 0% 0% 0 2 9 0 0 0 R 11310 $ 197.33 $ 79.77 0 0% 0% 0% 0 2 9 0 0 0 R 11311 $ 190.74 $ 110.96 0 0% 0% 0% 0 2 9 0 0 0 R 11312 $ 277.11 $ 131.96 0 0% 0% 0% 0 2 9 0 0 0 R 11313 $ 318.49 $ 169.14 0 0% 0% 0% 0 2 9 0 0 0 R 11400 $ 215.93 $ 138.55 10 10% 80% 10% 0 2 0 1 0 0 R 11401 $ 256.71 $ 177.54 10 10% 80% 10% 0 2 0 1 0 0 R 11402 $ 284.91 $ 194.94 10 10% 80% 10% 0 2 0 1 0 0 R 11403 $ 327.49 $ 251.32 10 10% 80% 10% 0 2 0 1 0 0 R 11404 $ 370.08 $ 275.31 10 10% 80% 10% 0 2 0 1 0 0 R 11406 $ 528.42 $ 413.86 10 10% 80% 10% 0 2 0 1 0 0 R 11420 $ 212.33 $ 140.35 10 10% 80% 10% 0 2 0 1 0 0 R 11421 $ 270.51 $ 188.34 10 10% 80% 10% 0 2 0 1 0 0 R 11422 $ 301.10 $ 232.12 10 10% 80% 10% 0 2 0 1 0 0 R 11423 $ 345.48 $ 268.71 10 10% 80% 10% 0 2 0 1 0 0 R 11424 $ 397.67 $ 305.90 10 10% 80% 10% 0 2 0 1 0 0 R 11426 $ 561.41 $ 461.85 10 10% 80% 10% 0 2 0 1 0 0 R 11440 $ 233.92 $ 178.74 10 10% 80% 10% 0 2 0 1 0 0 R 11441 $ 289.70 $ 226.12 10 10% 80% 10% 0 2 0 1 0 0 R 11442 $ 322.09 $ 248.92 10 10% 80% 10% 0 2 0 1 0 0 R 11443 $ 382.07 $ 304.10 10 10% 80% 10% 0 2 0 1 0 0 R 11444 $ 478.04 $ 386.27 10 10% 80% 10% 0 2 0 1 0 0 R 11446 $ 661.58 $ 549.42 10 10% 80% 10% 0 2 0 1 0 0 R 11450 $ 654.98 $ 425.26 90 10% 71% 19% 0 2 1 1 0 0 R 11451 $ 825.32 $ 542.82 90 10% 71% 19% 0 2 1 0 0 0 R 11462 $ 635.79 $ 405.46 90 10% 71% 19% 0 2 1 0 0 0 R 11463 $ 842.72 $ 548.22 90 10% 71% 19% 0 2 1 0 0 0 R 11470 $ 701.17 $ 471.44 90 10% 71% 19% 0 2 0 1 0 0 R 11471 $ 866.71 $ 582.41 90 10% 71% 19% 0 2 0 0 0 0 R 11600 $ 331.69 $ 203.93 10 10% 80% 10% 0 2 0 1 0 0 R Y11601 $ 392.87 $ 253.72 10 10% 80% 10% 0 2 0 1 0 0 R Y11602 $ 425.26 $ 278.91 10 10% 80% 10% 0 2 0 1 0 0 R Y11603 $ 484.04 $ 332.29 10 10% 80% 10% 0 2 0 1 0 0 R Y11604 $ 537.42 $ 364.68 10 10% 80% 10% 0 2 0 1 0 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 4
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
11606 $ 764.15 $ 536.22 10 10% 80% 10% 0 2 0 1 0 0 R Y11620 $ 334.69 $ 206.33 10 10% 80% 10% 0 2 0 1 0 0 R Y11621 $ 395.27 $ 256.11 10 10% 80% 10% 0 2 0 1 0 0 R Y11622 $ 439.65 $ 292.70 10 10% 80% 10% 0 2 0 1 0 0 R Y11623 $ 513.43 $ 360.48 10 10% 80% 10% 0 2 0 1 0 0 R Y11624 $ 577.01 $ 406.06 10 10% 80% 10% 0 2 0 1 0 0 R Y11626 $ 692.77 $ 496.03 10 10% 80% 10% 0 2 0 1 0 0 R Y11640 $ 344.89 $ 213.53 10 10% 80% 10% 0 2 0 1 0 0 R Y11641 $ 408.46 $ 266.31 10 10% 80% 10% 0 2 0 1 0 0 R Y11642 $ 464.25 $ 313.70 10 10% 80% 10% 0 2 0 1 0 0 R Y11643 $ 545.22 $ 391.67 10 10% 80% 10% 0 2 0 1 0 0 R Y11644 $ 671.78 $ 481.64 10 10% 80% 10% 0 2 0 1 0 0 R Y11646 $ 873.91 $ 666.98 10 10% 80% 10% 0 2 0 1 0 0 R Y11719 $ 23.99 $ 13.20 0 0% 0% 0% 0 2 0 1 0 0 R 11720 $ 55.78 $ 25.19 0 0% 0% 0% 0 0 0 1 0 0 R 11721 $ 77.37 $ 41.99 0 0% 0% 0% 0 0 0 1 0 0 R 11730 $ 170.94 $ 85.77 0 0% 0% 0% 0 2 0 1 0 0 R 11732 $ 61.78 $ 34.19 0 0% 0% 0% 0 0 0 1 0 0 R 11740 $ 86.37 $ 56.98 0 0% 0% 0% 0 2 0 1 0 0 R 11750 $ 386.27 $ 299.90 10 10% 80% 10% 0 2 0 1 0 0 R 11752 $ 557.81 $ 451.05 10 10% 80% 10% 0 2 0 1 0 0 R 11755 $ 231.52 $ 133.16 0 0% 0% 0% 0 2 0 0 0 0 R 11760 $ 397.67 $ 226.12 10 10% 80% 10% 0 2 0 1 0 0 R 11762 $ 488.24 $ 317.89 10 10% 80% 10% 0 2 0 1 0 0 R 11765 $ 293.30 $ 163.15 10 10% 80% 10% 0 2 0 1 0 0 R 11770 $ 470.24 $ 308.90 10 10% 80% 10% 0 2 0 1 0 0 R Y11771 $ 968.68 $ 723.96 90 10% 71% 19% 0 2 0 1 0 0 R Y11772 $ 1179.21 $ 971.08 90 10% 71% 19% 0 2 0 1 0 0 R Y11900 $ 95.37 $ 52.78 0 0% 0% 0% 0 2 0 1 0 0 R 11901 $ 118.76 $ 81.57 0 0% 0% 0% 0 2 0 1 0 0 R 11920 $ 293.30 $ 193.74 0 0% 0% 0% 0 2 0 0 0 0 R Y11921 $ 338.89 $ 227.92 0 0% 0% 0% 0 2 0 0 0 0 R Y11922 $ 105.56 $ 49.78 0 0% 0% 0% 0 0 0 0 0 0 R Y11950 $ 132.56 $ 89.97 0 0% 0% 0% 0 2 0 0 0 0 R Y11951 $ 179.94 $ 125.36 0 0% 0% 0% 0 2 0 0 0 0 R Y11952 $ 218.33 $ 160.15 0 0% 0% 0% 0 2 0 0 0 0 R Y11954 $ 269.31 $ 193.74 0 0% 0% 0% 0 2 0 0 0 0 R Y11960 $ 1608.66 $ 1608.66 90 10% 71% 19% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 5
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
11970 $ 1032.86 $ 1032.86 90 10% 71% 19% 0 2 1 1 0 0 R 11971 $ 815.73 $ 547.02 90 10% 71% 19% 0 2 1 0 0 0 R 11976 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 11980 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 11981 $ 240.52 $ 137.95 0 0% 0% 0% 0 2 0 0 0 0 R 11982 $ 271.71 $ 167.34 0 0% 0% 0% 0 2 0 0 0 0 R 11983 $ 376.07 $ 292.10 0 0% 0% 0% 0 2 0 0 0 0 R 12001 $ 154.15 $ 74.38 0 0% 0% 0% 0 2 0 1 0 0 R 12002 $ 187.14 $ 97.77 0 0% 0% 0% 0 2 0 1 0 0 R 12004 $ 219.53 $ 121.76 0 0% 0% 0% 0 2 0 1 0 0 R 12005 $ 283.71 $ 164.35 0 0% 0% 0% 0 2 0 1 0 0 R 12006 $ 338.29 $ 199.73 0 0% 0% 0% 0 2 0 1 0 0 R 12007 $ 391.07 $ 247.72 0 0% 0% 0% 0 2 0 1 1 0 R 12011 $ 188.34 $ 91.77 0 0% 0% 0% 0 2 0 1 0 0 R 12013 $ 206.33 $ 103.17 0 0% 0% 0% 0 2 0 1 0 0 R 12014 $ 242.32 $ 130.76 0 0% 0% 0% 0 2 0 1 0 0 R 12015 $ 292.10 $ 163.15 0 0% 0% 0% 0 2 0 1 0 0 R 12016 $ 361.08 $ 220.73 0 0% 0% 0% 0 2 0 1 0 0 R 12017 $ 252.52 $ 252.52 0 0% 0% 0% 0 2 0 0 0 0 R 12018 $ 286.10 $ 286.10 0 0% 0% 0% 0 2 0 2 0 0 R 12020 $ 482.24 $ 320.89 10 10% 80% 10% 0 2 0 1 0 0 R 12021 $ 278.31 $ 236.32 10 10% 80% 10% 0 2 0 1 0 0 R 12031 $ 407.86 $ 261.51 10 10% 80% 10% 0 2 0 1 0 0 R 12032 $ 521.83 $ 334.09 10 10% 80% 10% 0 2 0 1 0 0 R 12034 $ 533.22 $ 351.48 10 10% 80% 10% 0 2 0 1 0 0 R 12035 $ 653.78 $ 406.66 10 10% 80% 10% 0 2 0 1 0 0 R 12036 $ 713.16 $ 467.84 10 10% 80% 10% 0 2 0 1 0 0 R 12037 $ 817.53 $ 551.82 10 10% 80% 10% 0 2 0 0 1 0 R 12041 $ 415.66 $ 268.11 10 10% 80% 10% 0 2 0 1 0 0 R 12042 $ 494.84 $ 341.89 10 10% 80% 10% 0 2 0 1 0 0 R 12044 $ 617.79 $ 366.48 10 10% 80% 10% 0 2 0 1 0 0 R 12045 $ 693.37 $ 463.05 10 10% 80% 10% 0 2 0 1 0 0 R 12046 $ 818.73 $ 519.43 10 10% 80% 10% 0 2 0 0 0 0 R 12047 $ 960.88 $ 641.19 10 10% 80% 10% 0 2 0 2 1 0 R 12051 $ 442.65 $ 293.30 10 10% 80% 10% 0 2 0 1 0 0 R 12052 $ 503.23 $ 347.88 10 10% 80% 10% 0 2 0 1 0 0 R 12053 $ 593.20 $ 370.68 10 10% 80% 10% 0 2 0 1 0 0 R 12054 $ 629.79 $ 385.67 10 10% 80% 10% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 6
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
12055 $ 815.73 $ 511.03 10 10% 80% 10% 0 2 0 1 0 0 R 12056 $ 848.72 $ 588.40 10 10% 80% 10% 0 2 0 0 0 0 R 12057 $ 992.67 $ 635.79 10 10% 80% 10% 0 2 0 2 1 0 R 13100 $ 574.61 $ 350.88 10 10% 80% 10% 0 2 0 1 0 0 R 13101 $ 680.17 $ 431.86 10 10% 80% 10% 0 2 0 1 0 0 R 13102 $ 207.53 $ 124.76 0 0% 0% 0% 0 0 0 1 0 0 R 13120 $ 600.40 $ 403.67 10 10% 80% 10% 0 2 0 1 0 0 R 13121 $ 732.36 $ 454.65 10 10% 80% 10% 0 2 0 1 0 0 R 13122 $ 227.32 $ 143.95 0 0% 0% 0% 0 0 0 1 0 0 R 13131 $ 660.38 $ 425.86 10 10% 80% 10% 0 2 0 1 0 0 R 13132 $ 815.73 $ 533.82 10 10% 80% 10% 0 2 0 1 0 0 R 13133 $ 303.50 $ 221.33 0 0% 0% 0% 0 0 0 1 0 0 R 13151 $ 722.16 $ 487.64 10 10% 80% 10% 0 2 0 1 0 0 R 13152 $ 866.11 $ 590.20 10 10% 80% 10% 0 2 0 1 0 0 R 13153 $ 329.29 $ 238.72 0 0% 0% 0% 0 0 0 1 0 0 R 13160 $ 1357.35 $ 1357.35 90 10% 71% 19% 0 2 0 1 0 0 R 14000 $ 1062.85 $ 855.91 90 10% 71% 19% 0 2 0 1 0 0 R 14001 $ 1359.15 $ 1109.63 90 10% 71% 19% 0 2 0 1 0 0 R 14020 $ 1190.60 $ 971.08 90 10% 71% 19% 0 2 0 1 0 0 R 14021 $ 1485.10 $ 1224.19 90 10% 71% 19% 0 2 0 1 0 0 R 14040 $ 1300.37 $ 1080.24 90 10% 71% 19% 0 2 0 1 0 0 R 14041 $ 1608.06 $ 1325.56 90 10% 71% 19% 0 2 0 1 0 0 R 14060 $ 1323.16 $ 1149.82 90 10% 71% 19% 0 2 0 1 0 0 R 14061 $ 1731.62 $ 1419.73 90 10% 71% 19% 0 2 0 1 0 0 R 14301 $ 1832.39 $ 1497.70 90 10% 71% 19% 0 2 0 2 0 0 R14302 $ 371.28 $ 371.28 0 0% 0% 0% 0 0 0 2 0 0 R14350 $ 1184.01 $ 1184.01 90 10% 71% 19% 0 2 0 0 0 0 R 15002 $ 592.00 $ 381.47 0 0% 0% 0% 0 0 0 0 0 0 R 15003 $ 129.56 $ 76.17 0 0% 0% 0% 0 0 0 0 0 0 R 15004 $ 688.57 $ 460.05 0 0% 0% 0% 0 0 0 0 0 0 R 15005 $ 210.53 $ 151.75 0 0% 0% 0% 0 0 0 0 0 0 R 15040 $ 437.85 $ 213.53 0 0% 0% 0% 0 0 0 1 0 0 R 15050 $ 977.67 $ 767.14 90 10% 71% 19% 0 2 0 1 0 0 R 15100 $ 1455.71 $ 1209.20 90 10% 71% 19% 0 2 0 1 0 0 R 15101 $ 318.49 $ 185.94 0 0% 0% 0% 0 0 0 1 0 0 R 15110 $ 1378.34 $ 1193.00 90 10% 71% 19% 0 2 0 1 0 0 R 15111 $ 190.14 $ 169.74 0 0% 0% 0% 0 0 0 1 0 0 R 15115 $ 1402.93 $ 1217.59 90 10% 71% 19% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 7
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
15116 $ 282.51 $ 256.11 0 0% 0% 0% 0 0 0 1 1 0 R 15120 $ 1446.12 $ 1182.21 90 10% 71% 19% 0 2 0 1 0 0 R 15121 $ 356.28 $ 223.73 0 0% 0% 0% 0 0 0 1 1 0 R 15130 $ 1155.21 $ 963.88 90 10% 71% 19% 0 2 0 1 0 0 R 15131 $ 149.35 $ 135.55 0 0% 0% 0% 0 0 0 1 1 0 R 15135 $ 1435.32 $ 1252.38 90 10% 71% 19% 0 2 0 1 0 0 R 15136 $ 158.95 $ 147.55 0 0% 0% 0% 0 0 0 1 1 0 R 15150 $ 1156.41 $ 1050.85 90 10% 71% 19% 0 2 0 1 0 0 R 15151 $ 196.73 $ 180.54 0 0% 0% 0% 0 0 0 1 0 0 R 15152 $ 242.32 $ 225.52 0 0% 0% 0% 0 0 0 1 0 0 R 15155 $ 1193.00 $ 1097.03 90 10% 71% 19% 0 2 0 1 0 0 R 15156 $ 265.11 $ 248.92 0 0% 0% 0% 0 0 0 1 1 0 R 15157 $ 266.91 $ 247.12 0 0% 0% 0% 0 0 0 1 1 0 R 15200 $ 1412.53 $ 1140.22 90 10% 71% 19% 0 2 0 1 0 0 R 15201 $ 254.32 $ 131.96 0 0% 0% 0% 0 0 0 1 0 0 R 15220 $ 1317.76 $ 1049.05 90 10% 71% 19% 0 2 0 1 0 0 R 15221 $ 235.72 $ 119.96 0 0% 0% 0% 0 0 0 1 0 0 R 15240 $ 1593.07 $ 1368.14 90 10% 71% 19% 0 2 0 1 0 0 R 15241 $ 317.89 $ 187.74 0 0% 0% 0% 0 0 0 1 0 0 R 15260 $ 1729.22 $ 1468.31 90 10% 71% 19% 0 2 0 1 0 0 R 15261 $ 368.28 $ 237.52 0 0% 0% 0% 0 0 0 1 0 0 R 15271 $ 241.72 $ 142.75 0 0% 0% 0% 0 2 0 1 0 0 R15272 $ 46.18 $ 28.79 0 0% 0% 0% 0 0 0 1 0 0 R15273 $ 503.83 $ 338.29 0 0% 0% 0% 0 2 0 1 0 0 R15274 $ 119.96 $ 75.57 0 0% 0% 0% 0 0 0 1 0 0 R15275 $ 256.71 $ 163.75 0 0% 0% 0% 0 2 0 1 0 0 R15276 $ 58.18 $ 41.99 0 0% 0% 0% 0 0 0 1 0 0 R15277 $ 548.22 $ 377.87 0 0% 0% 0% 0 2 0 1 1 0 R15278 $ 143.95 $ 95.37 0 0% 0% 0% 0 0 0 1 1 0 R15570 $ 1551.68 $ 1243.99 90 10% 71% 19% 0 2 0 1 0 0 R 15572 $ 1509.70 $ 1267.38 90 10% 71% 19% 0 2 0 1 0 0 R 15574 $ 1557.08 $ 1305.76 90 10% 71% 19% 0 2 0 1 0 0 R 15576 $ 1376.54 $ 1145.02 90 10% 71% 19% 0 2 0 1 0 0 R 15600 $ 563.81 $ 358.08 90 10% 71% 19% 0 2 0 0 0 0 R 15610 $ 617.79 $ 416.26 90 10% 71% 19% 0 2 0 0 0 0 R 15620 $ 758.15 $ 559.61 90 10% 71% 19% 0 2 0 1 0 0 R 15630 $ 793.54 $ 595.60 90 10% 71% 19% 0 2 0 1 0 0 R 15650 $ 872.71 $ 656.18 90 10% 71% 19% 0 2 0 0 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 8
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
15731 $ 1919.36 $ 1716.63 90 10% 71% 19% 0 2 0 0 0 0 R 15732 $ 2191.67 $ 1906.16 90 10% 71% 19% 0 2 0 1 1 0 R 15734 $ 2522.76 $ 2210.86 90 10% 71% 19% 0 2 0 2 1 0 R 15736 $ 2224.66 $ 1916.96 90 10% 71% 19% 0 2 0 1 1 0 R 15738 $ 2357.81 $ 2068.71 90 10% 71% 19% 0 2 0 2 1 0 R 15740 $ 1740.02 $ 1456.31 90 10% 71% 19% 0 2 0 1 0 0 R 15750 $ 1560.08 $ 1560.08 90 10% 71% 19% 0 2 0 2 0 0 R 15756 $ 3920.89 $ 3920.89 90 10% 71% 19% 0 2 0 2 2 0 R 15757 $ 3892.10 $ 3892.10 90 10% 71% 19% 0 2 0 2 2 0 R 15758 $ 3881.31 $ 3881.31 90 10% 71% 19% 0 2 0 2 2 0 R 15760 $ 1459.91 $ 1211.60 90 10% 71% 19% 0 2 0 1 0 0 R 15770 $ 1140.22 $ 1140.22 90 10% 71% 19% 0 2 0 2 1 0 R 15775 $ 504.43 $ 369.48 0 0% 0% 0% 0 2 0 0 0 0 R 15776 $ 811.53 $ 578.81 0 0% 0% 0% 0 2 0 0 0 0 R 15777 $ 356.28 $ 356.28 0 0% 0% 0% 0 0 1 1 0 0 R15780 $ 1462.31 $ 1092.84 90 10% 71% 19% 0 2 0 0 0 0 R 15781 $ 951.88 $ 740.75 90 10% 71% 19% 0 2 0 1 0 0 R 15782 $ 1112.63 $ 776.74 90 10% 71% 19% 0 2 0 0 0 0 R 15783 $ 836.12 $ 642.99 90 10% 71% 19% 0 2 0 0 0 0 R 15786 $ 421.06 $ 230.32 10 10% 80% 10% 0 2 0 1 0 0 R 15787 $ 85.77 $ 29.39 0 0% 0% 0% 0 0 0 1 0 0 R 15788 Not Covered Not Covered 90 10% 71% 19% 0 2 0 1 0 0 X 15789 Not Covered Not Covered 90 10% 71% 19% 0 2 0 1 0 0 X 15792 Not Covered Not Covered 90 10% 71% 19% 0 2 0 0 0 0 X 15793 Not Covered Not Covered 90 10% 71% 19% 0 2 0 0 0 0 X 15819 Not Covered Not Covered 90 10% 71% 19% 0 2 0 0 0 0 X 15820 $ 992.07 $ 885.30 90 10% 71% 19% 0 2 1 0 0 0 R Y15821 $ 1044.25 $ 934.49 90 10% 71% 19% 0 2 1 0 0 0 R Y15822 $ 769.54 $ 671.78 90 10% 71% 19% 0 2 1 1 0 0 R Y15823 $ 1049.65 $ 938.09 90 10% 71% 19% 0 2 1 1 0 0 R Y15824 $ 1414.55 $ 1414.55 0 0% 0% 0% 0 2 1 0 0 0 F Y15825 $ 1216.28 $ 1216.28 0 0% 0% 0% 0 2 1 0 0 0 F Y15826 $ 1150.17 $ 1150.17 0 0% 0% 0% 0 2 1 0 0 0 F Y15828 $ 3939.63 $ 3939.63 0 0% 0% 0% 0 2 1 0 0 0 F Y15829 By Report By Report 0 0% 0% 0% 0 2 1 0 0 0 N Y15830 $ 1974.54 $ 1974.54 90 10% 71% 19% 0 2 0 2 1 0 R Y15832 $ 1546.28 $ 1546.28 90 10% 71% 19% 0 2 1 2 1 0 R Y15833 $ 1477.31 $ 1477.31 90 10% 71% 19% 0 2 1 0 0 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 9
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
15834 $ 1504.30 $ 1504.30 90 10% 71% 19% 0 2 1 0 0 0 R Y15835 $ 1586.47 $ 1586.47 90 10% 71% 19% 0 2 0 0 0 0 R Y15836 $ 1338.15 $ 1338.15 90 10% 71% 19% 0 2 1 0 0 0 R Y15837 $ 1495.30 $ 1243.39 90 10% 71% 19% 0 2 0 0 0 0 R Y15838 $ 970.48 $ 970.48 90 10% 71% 19% 0 2 0 0 0 0 R Y15839 $ 1498.90 $ 1245.78 90 10% 71% 19% 0 2 0 0 0 0 R Y15840 $ 1706.43 $ 1706.43 90 10% 71% 19% 0 2 0 1 0 0 R 15841 $ 2708.70 $ 2708.70 90 10% 71% 19% 0 2 0 2 1 0 R 15842 $ 4127.22 $ 4127.22 90 10% 71% 19% 0 2 0 2 1 0 R 15845 $ 1726.82 $ 1726.82 90 10% 71% 19% 0 2 0 2 0 0 R 15847 By Report By Report 0 0% 0% 0% 0 0 0 2 1 0 N Y15850 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 15851 $ 172.14 $ 77.37 0 0% 0% 0% 0 2 0 1 0 0 R 15852 $ 78.57 $ 78.57 0 0% 0% 0% 0 2 0 1 0 0 R 15860 $ 185.34 $ 185.34 0 0% 0% 0% 0 2 0 0 0 0 R 15876 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 15877 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 15878 Not Covered Not Covered 0 0% 0% 0% 0 2 1 0 0 0 X 15879 Not Covered Not Covered 0 0% 0% 0% 0 2 1 0 0 0 X 15920 $ 1006.46 $ 1006.46 90 10% 71% 19% 0 2 0 0 0 0 R 15922 $ 1325.56 $ 1325.56 90 10% 71% 19% 0 2 0 2 1 0 R 15931 $ 1142.02 $ 1142.02 90 10% 71% 19% 0 2 0 1 0 0 R 15933 $ 1423.33 $ 1423.33 90 10% 71% 19% 0 2 0 0 0 0 R 15934 $ 1555.88 $ 1555.88 90 10% 71% 19% 0 2 0 1 0 0 R 15935 $ 1844.39 $ 1844.39 90 10% 71% 19% 0 2 0 2 1 0 R 15936 $ 1483.91 $ 1483.91 90 10% 71% 19% 0 2 0 1 1 0 R 15937 $ 1720.83 $ 1720.83 90 10% 71% 19% 0 2 0 1 1 0 R 15940 $ 1168.41 $ 1168.41 90 10% 71% 19% 0 2 0 1 0 0 R 15941 $ 1519.29 $ 1519.29 90 10% 71% 19% 0 2 0 0 0 0 R 15944 $ 1513.90 $ 1513.90 90 10% 71% 19% 0 2 0 0 0 0 R 15945 $ 1651.25 $ 1651.25 90 10% 71% 19% 0 2 0 0 0 0 R 15946 $ 2745.88 $ 2745.88 90 10% 71% 19% 0 2 0 1 1 0 R 15950 $ 989.67 $ 989.67 90 10% 71% 19% 0 2 0 1 0 0 R 15951 $ 1491.70 $ 1491.70 90 10% 71% 19% 0 2 0 0 1 0 R 15952 $ 1530.09 $ 1530.09 90 10% 71% 19% 0 2 0 2 1 0 R 15953 $ 1685.44 $ 1685.44 90 10% 71% 19% 0 2 0 1 1 0 R 15956 $ 1930.76 $ 1930.76 90 10% 71% 19% 0 2 0 1 1 0 R 15958 $ 1978.74 $ 1978.74 90 10% 71% 19% 0 2 0 1 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 10
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
15999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 16000 $ 116.96 $ 77.37 0 0% 0% 0% 0 2 0 1 0 0 R 16020 $ 142.15 $ 92.97 0 0% 0% 0% 0 2 0 1 0 0 R 16025 $ 252.52 $ 188.94 0 0% 0% 0% 0 2 0 1 0 0 R 16030 $ 311.30 $ 222.53 0 0% 0% 0% 0 2 0 1 0 0 R 16035 $ 325.09 $ 325.09 0 0% 0% 0% 0 2 0 1 0 0 R 16036 $ 134.36 $ 134.36 0 0% 0% 0% 0 0 0 1 0 0 R 17000 $ 114.56 $ 91.17 10 10% 80% 10% 0 2 0 1 0 0 R Y17003 $ 9.60 $ 4.20 0 0% 0% 0% 0 0 0 1 0 0 R Y17004 $ 258.51 $ 169.74 10 10% 80% 10% 0 0 0 1 0 0 R Y17106 $ 585.40 $ 470.84 90 10% 71% 19% 0 2 0 1 0 0 R Y17107 $ 737.15 $ 587.20 90 10% 71% 19% 0 2 0 1 0 0 R Y17108 $ 1092.24 $ 894.30 90 10% 71% 19% 0 2 0 0 0 0 R Y17110 $ 193.14 $ 120.56 10 10% 80% 10% 0 2 0 1 0 0 R Y17111 $ 227.92 $ 147.55 10 10% 80% 10% 0 2 0 1 0 0 R Y17250 $ 138.55 $ 62.98 0 0% 0% 0% 0 2 0 1 0 0 R 17260 $ 162.55 $ 119.36 10 10% 80% 10% 0 2 0 1 0 0 R Y17261 $ 247.72 $ 156.55 10 10% 80% 10% 0 2 0 1 0 0 R Y17262 $ 300.50 $ 198.53 10 10% 80% 10% 0 2 0 1 0 0 R Y17263 $ 327.49 $ 219.53 10 10% 80% 10% 0 2 0 1 0 0 R Y17264 $ 352.08 $ 234.52 10 10% 80% 10% 0 2 0 1 0 0 R Y17266 $ 397.67 $ 275.31 10 10% 80% 10% 0 2 0 1 0 0 R Y17270 $ 259.11 $ 170.34 10 10% 80% 10% 0 2 0 1 0 0 R Y17271 $ 280.71 $ 188.94 10 10% 80% 10% 0 2 0 1 0 0 R Y17272 $ 318.49 $ 217.73 10 10% 80% 10% 0 2 0 1 0 0 R Y17273 $ 355.68 $ 245.92 10 10% 80% 10% 0 2 0 1 0 0 R Y17274 $ 418.06 $ 299.30 10 10% 80% 10% 0 2 0 1 0 0 R Y17276 $ 482.24 $ 358.68 10 10% 80% 10% 0 2 0 1 0 0 R Y17280 $ 242.32 $ 155.35 10 10% 80% 10% 0 2 0 1 0 0 R Y17281 $ 304.70 $ 212.33 10 10% 80% 10% 0 2 0 1 0 0 R Y17282 $ 349.08 $ 245.32 10 10% 80% 10% 0 2 0 1 0 0 R Y17283 $ 416.26 $ 305.30 10 10% 80% 10% 0 2 0 1 0 0 R Y17284 $ 475.04 $ 356.88 10 10% 80% 10% 0 2 0 1 0 0 R Y17286 $ 608.80 $ 478.64 10 10% 80% 10% 0 2 0 1 0 0 R Y17311 $ 1133.62 $ 636.99 0 0% 0% 0% 0 2 0 1 0 0 R Y17312 $ 668.78 $ 340.09 0 0% 0% 0% 0 0 0 1 0 0 R Y17313 $ 1062.25 $ 571.61 0 0% 0% 0% 0 2 0 1 0 0 R Y17314 $ 642.39 $ 314.90 0 0% 0% 0% 0 0 0 1 0 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 11
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
17315 $ 136.15 $ 89.37 0 0% 0% 0% 0 0 0 1 0 0 R Y17340 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 17360 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 17380 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 17999 By Report By Report 0 0% 0% 0% 0 2 0 0 1 1 N 19000 $ 197.33 $ 73.78 0 0% 0% 0% 0 2 0 1 0 0 R Y19001 $ 45.58 $ 37.19 0 0% 0% 0% 0 0 0 1 0 0 R Y19020 $ 809.73 $ 512.83 90 10% 71% 19% 0 2 1 1 0 0 R 19030 $ 288.50 $ 133.16 0 0% 0% 0% 0 2 1 1 0 0 R Y19081 $ 1174.41 $ 285.50 0 0% 0% 0% 0 2 1 0 0 0 R Y19082 $ 969.88 $ 142.75 0 0% 0% 0% 0 0 0 0 0 0 R Y19083 $ 1141.42 $ 275.31 0 0% 0% 0% 0 2 1 0 0 0 R Y19084 $ 933.89 $ 134.96 0 0% 0% 0% 0 0 0 0 0 0 R Y19085 $ 1807.20 $ 329.29 0 0% 0% 0% 0 2 1 0 0 0 R Y19086 $ 1461.11 $ 159.55 0 0% 0% 0% 0 0 0 0 0 0 R Y19100 $ 259.11 $ 114.56 0 0% 0% 0% 0 2 1 1 0 0 R Y19101 $ 580.01 $ 368.88 10 10% 80% 10% 0 2 1 1 0 0 R Y19105 Not Covered Not Covered 0 0% 0% 0% 0 2 1 1 0 0 X 19110 $ 825.32 $ 571.01 90 10% 71% 19% 0 2 1 1 0 0 R Y19112 $ 789.94 $ 524.83 90 10% 71% 19% 0 2 1 0 0 0 R Y19120 $ 826.52 $ 686.17 90 10% 71% 19% 0 2 1 1 0 0 R Y19125 $ 916.49 $ 760.55 90 10% 71% 19% 0 2 1 1 1 0 R Y19126 $ 263.91 $ 263.91 0 0% 0% 0% 0 0 0 1 1 0 R Y19260 $ 2001.53 $ 2001.53 90 10% 71% 19% 0 2 0 2 1 0 R Y19271 $ 2727.89 $ 2727.89 90 10% 71% 19% 0 2 0 2 1 0 R Y19272 $ 2987.60 $ 2987.60 90 10% 71% 19% 0 2 0 2 1 0 R Y19281 $ 418.66 $ 173.94 0 0% 0% 0% 0 2 1 0 0 0 R Y19282 $ 294.50 $ 87.57 0 0% 0% 0% 0 0 0 0 0 0 R Y19283 $ 478.64 $ 174.54 0 0% 0% 0% 0 2 1 0 0 0 R Y19284 $ 356.28 $ 88.17 0 0% 0% 0% 0 0 0 0 0 0 R Y19285 $ 791.14 $ 148.75 0 0% 0% 0% 0 2 1 0 0 0 R Y19286 $ 674.78 $ 74.38 0 0% 0% 0% 0 0 0 0 0 0 R Y19287 $ 1543.29 $ 228.52 0 0% 0% 0% 0 2 1 0 0 0 R Y19288 $ 1248.78 $ 113.36 0 0% 0% 0% 0 0 0 0 0 0 R Y19296 Not Covered Not Covered 0 0% 0% 0% 0 2 1 0 0 0 X 19297 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 19298 Not Covered Not Covered 0 0% 0% 0% 0 2 1 0 0 0 X 19300 Not Covered Not Covered 90 10% 71% 19% 0 2 1 1 0 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 12
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
19301 Not Covered Not Covered 90 10% 71% 19% 0 2 1 0 0 0 X 19302 Not Covered Not Covered 90 10% 71% 19% 0 2 1 2 1 0 X 19303 Not Covered Not Covered 90 10% 71% 19% 0 2 1 2 1 0 X 19304 Not Covered Not Covered 90 10% 71% 19% 0 2 1 2 1 0 X 19305 Not Covered Not Covered 90 10% 71% 19% 0 2 1 2 1 0 X 19306 Not Covered Not Covered 90 10% 71% 19% 0 2 1 2 1 0 X 19307 Not Covered Not Covered 90 10% 71% 19% 0 2 1 2 1 0 X 19316 $ 1298.57 $ 1298.57 90 10% 71% 19% 0 2 1 2 1 0 R Y19318 $ 1862.98 $ 1862.98 90 10% 71% 19% 0 2 1 2 1 0 R Y19324 $ 815.73 $ 815.73 90 10% 71% 19% 0 2 1 0 0 0 R Y19325 $ 1091.04 $ 1091.04 90 10% 71% 19% 0 2 1 0 0 0 R Y19328 $ 839.72 $ 839.72 90 10% 71% 19% 0 2 1 1 0 0 R Y19330 $ 1073.64 $ 1073.64 90 10% 71% 19% 0 2 1 1 0 0 R Y19340 $ 1699.23 $ 1699.23 90 10% 71% 19% 0 2 1 1 1 0 R Y19342 $ 1566.08 $ 1566.08 90 10% 71% 19% 0 2 1 0 1 0 R Y19350 $ 1406.53 $ 1142.02 90 10% 71% 19% 0 2 1 1 0 0 R Y19355 Not Covered Not Covered 90 10% 71% 19% 0 2 1 0 0 0 X 19357 $ 2569.54 $ 2569.54 90 10% 71% 19% 0 2 1 2 1 0 R Y19361 $ 2658.31 $ 2658.31 90 10% 71% 19% 0 2 1 2 1 0 R Y19364 $ 4644.25 $ 4644.25 90 10% 71% 19% 0 2 1 2 1 0 R Y19366 $ 2359.01 $ 2359.01 90 10% 71% 19% 0 2 1 2 1 0 R Y19367 $ 3025.99 $ 3025.99 90 10% 71% 19% 0 2 1 2 1 0 R Y19368 $ 3712.16 $ 3712.16 90 10% 71% 19% 0 2 1 2 1 0 R Y19369 $ 3445.85 $ 3445.85 90 10% 71% 19% 0 2 1 2 1 0 R Y19370 $ 1163.61 $ 1163.61 90 10% 71% 19% 0 2 1 1 0 0 R Y19371 $ 1329.76 $ 1329.76 90 10% 71% 19% 0 2 1 1 0 0 R Y19380 $ 1311.16 $ 1311.16 90 10% 71% 19% 0 2 1 1 0 0 R Y19396 $ 506.83 $ 247.12 0 0% 0% 0% 0 2 1 0 0 0 R Y19499 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 20005 $ 526.02 $ 394.67 10 10% 80% 10% 0 2 0 1 0 0 R 20100 $ 1008.86 $ 1008.86 10 10% 80% 10% 0 2 1 2 0 0 R 20101 $ 779.74 $ 346.68 10 10% 80% 10% 0 2 0 1 0 0 R 20102 $ 843.32 $ 424.06 10 10% 80% 10% 0 2 0 1 0 0 R 20103 $ 1002.87 $ 584.81 10 10% 80% 10% 0 2 0 0 0 0 R 20150 $ 1573.28 $ 1573.28 90 10% 69% 21% 0 2 1 2 1 0 R Y20200 $ 357.48 $ 157.75 0 0% 0% 0% 0 2 0 1 0 0 R 20205 $ 493.64 $ 256.71 0 0% 0% 0% 0 2 0 1 0 0 R 20206 $ 419.26 $ 101.97 0 0% 0% 0% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 13
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
20220 $ 295.70 $ 125.36 0 0% 0% 0% 0 2 0 1 0 0 R 20225 $ 934.49 $ 187.74 0 0% 0% 0% 0 2 0 1 0 0 R 20240 $ 368.28 $ 368.28 10 10% 80% 10% 0 2 0 1 0 0 R 20245 $ 1042.45 $ 1042.45 10 10% 80% 10% 0 2 0 1 0 0 R 20250 $ 654.38 $ 654.38 10 10% 80% 10% 0 2 0 1 0 0 R 20251 $ 699.37 $ 699.37 10 10% 80% 10% 0 2 0 2 0 0 R 20500 $ 180.54 $ 146.35 10 10% 80% 10% 0 2 0 1 0 0 R 20501 $ 208.13 $ 65.38 0 0% 0% 0% 0 2 0 1 0 0 R 20520 $ 352.08 $ 251.92 10 10% 80% 10% 0 2 0 1 0 0 R 20525 $ 835.52 $ 422.26 10 10% 80% 10% 0 2 0 1 0 0 R 20526 $ 131.36 $ 97.17 0 0% 0% 0% 0 2 1 1 0 0 R 20527 $ 142.75 $ 112.16 0 0% 0% 0% 0 2 1 1 0 0 R20550 $ 101.37 $ 70.78 0 0% 0% 0% 0 2 1 1 0 0 R 20551 $ 103.77 $ 72.58 0 0% 0% 0% 0 2 0 1 0 0 R 20552 $ 94.77 $ 64.18 0 0% 0% 0% 0 2 0 1 0 0 R Y20553 $ 110.36 $ 73.18 0 0% 0% 0% 0 2 0 1 0 0 R Y20555 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 20600 $ 80.97 $ 60.58 0 0% 0% 0% 0 2 1 1 0 0 R 20604 $ 124.16 $ 77.37 0 0% 0% 0% 0 2 1 1 0 0 R20605 $ 85.17 $ 62.98 0 0% 0% 0% 0 2 1 1 0 0 R 20606 $ 136.75 $ 88.77 0 0% 0% 0% 0 2 1 1 0 0 R20610 $ 102.57 $ 77.37 0 0% 0% 0% 0 2 1 1 0 0 R 20611 $ 157.15 $ 103.77 0 0% 0% 0% 0 2 1 1 0 0 R20612 $ 104.37 $ 70.78 0 0% 0% 0% 0 2 0 1 0 0 R 20615 $ 427.66 $ 282.51 10 10% 80% 10% 0 2 0 1 0 0 R 20650 $ 354.48 $ 266.91 10 10% 80% 10% 0 2 0 1 1 0 R 20660 $ 398.27 $ 398.27 0 0% 0% 0% 0 2 0 1 0 0 R 20661 $ 846.92 $ 846.92 90 10% 69% 21% 0 2 0 1 0 0 R 20662 $ 780.94 $ 780.94 90 10% 69% 21% 0 2 0 0 0 0 R 20663 $ 672.38 $ 672.38 90 10% 69% 21% 0 2 1 0 0 0 R 20664 $ 1441.32 $ 1441.32 90 10% 69% 21% 0 2 0 1 0 0 R 20665 $ 181.14 $ 155.35 10 10% 80% 10% 0 2 0 0 0 0 R 20670 $ 670.58 $ 253.72 10 10% 80% 10% 0 2 0 1 0 0 R 20680 $ 1067.04 $ 718.56 90 10% 69% 21% 0 2 0 0 0 0 R 20690 $ 1001.07 $ 1001.07 90 10% 69% 21% 0 2 0 1 0 0 R 20692 $ 1893.57 $ 1893.57 90 10% 69% 21% 0 2 0 2 1 0 R 20693 $ 761.75 $ 761.75 90 10% 69% 21% 0 2 0 1 0 0 R 20694 $ 729.96 $ 574.61 90 10% 69% 21% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 14
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
20696 $ 2037.52 $ 2037.52 90 10% 69% 21% 0 2 0 2 1 0 R 20697 $ 3802.13 $ 3802.13 0 0% 0% 0% 3 0 0 2 1 0 R 20802 $ 4625.06 $ 4625.06 90 10% 69% 21% 0 2 1 2 1 0 R 20805 $ 5570.94 $ 5570.94 90 10% 69% 21% 0 2 1 2 1 0 R 20808 $ 6738.75 $ 6738.75 90 10% 69% 21% 0 2 1 2 1 0 R 20816 $ 3556.21 $ 3556.21 90 10% 69% 21% 0 2 0 2 1 0 R 20822 $ 3045.78 $ 3045.78 90 10% 69% 21% 0 2 0 2 1 0 R 20824 $ 3435.05 $ 3435.05 90 10% 69% 21% 0 2 1 2 1 0 R 20827 $ 3129.76 $ 3129.76 90 10% 69% 21% 0 2 1 2 1 0 R 20838 $ 3762.55 $ 3762.55 90 10% 69% 21% 0 2 1 2 1 0 R 20900 $ 731.76 $ 320.29 0 0% 0% 0% 0 2 0 2 1 0 R 20902 $ 481.04 $ 481.04 0 0% 0% 0% 0 2 0 2 1 0 R 20910 $ 782.74 $ 782.74 90 10% 69% 21% 0 2 0 0 0 0 R 20912 $ 818.13 $ 818.13 90 10% 69% 21% 0 2 0 0 0 0 R 20920 $ 672.98 $ 672.98 90 10% 69% 21% 0 2 0 1 1 0 R 20922 $ 1020.86 $ 832.52 90 10% 69% 21% 0 2 0 2 1 0 R 20924 $ 861.91 $ 861.91 90 10% 69% 21% 0 2 0 2 1 0 R 20926 $ 728.76 $ 728.76 90 10% 69% 21% 0 2 0 1 0 0 R 20930 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 20931 $ 182.94 $ 182.94 0 0% 0% 0% 0 0 0 1 1 0 R 20936 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 20937 $ 277.71 $ 277.71 0 0% 0% 0% 0 0 0 2 1 0 R 20938 $ 302.90 $ 302.90 0 0% 0% 0% 0 0 0 2 1 0 R 20950 $ 433.66 $ 153.55 0 0% 0% 0% 0 2 0 0 0 0 R 20955 $ 4263.38 $ 4263.38 90 10% 69% 21% 0 2 0 2 1 0 R 20956 $ 4446.32 $ 4446.32 90 10% 69% 21% 0 2 0 2 1 0 R 20957 $ 3614.39 $ 3614.39 90 10% 69% 21% 0 2 0 2 1 0 R 20962 $ 3487.24 $ 3487.24 90 10% 69% 21% 0 2 0 2 1 0 R 20969 $ 4665.24 $ 4665.24 90 10% 69% 21% 0 2 0 2 1 0 R 20970 $ 4809.20 $ 4809.20 90 10% 69% 21% 0 2 0 2 1 0 R 20972 $ 3947.88 $ 3947.88 90 10% 69% 21% 0 2 0 2 0 0 R 20973 $ 4369.54 $ 4369.54 90 10% 69% 21% 0 2 1 2 1 0 R 20974 $ 131.96 $ 85.17 0 0% 0% 0% 0 0 0 1 0 0 R Y20975 $ 298.10 $ 298.10 0 0% 0% 0% 0 0 0 2 1 0 R Y20979 $ 88.77 $ 53.98 0 0% 0% 0% 0 0 0 1 0 0 R Y20982 Not Covered Not Covered 0 0% 0% 0% 0 2 1 1 0 0 X 20983 Not Covered Not Covered 0 0% 0% 0% 0 2 1 1 0 0 X20985 $ 245.92 $ 245.92 0 0% 0% 0% 0 0 0 0 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 15
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
20999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 21010 $ 1293.77 $ 1293.77 90 10% 69% 21% 0 2 1 0 0 0 R Y21011 $ 602.20 $ 443.25 90 10% 69% 21% 0 2 0 2 0 0 R Y21012 $ 571.61 $ 571.61 90 10% 69% 21% 0 2 0 2 0 0 R Y21013 $ 890.70 $ 681.37 90 10% 69% 21% 0 2 0 2 0 0 R Y21014 $ 880.51 $ 880.51 90 10% 69% 21% 0 2 0 2 0 0 R Y21015 $ 1196.60 $ 1196.60 90 10% 69% 21% 0 2 0 1 0 0 R Y21016 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 0 0 X21025 $ 1546.88 $ 1295.57 90 10% 69% 21% 0 2 0 1 0 0 R 21026 $ 1081.44 $ 867.31 90 10% 69% 21% 0 2 0 1 0 0 R 21029 $ 1322.56 $ 1092.84 90 10% 69% 21% 0 2 0 0 0 0 R Y21030 $ 906.90 $ 723.96 90 10% 69% 21% 0 2 1 1 0 0 R Y21031 $ 694.57 $ 513.43 90 10% 69% 21% 0 2 1 1 0 0 R Y21032 $ 704.17 $ 507.43 90 10% 69% 21% 0 2 0 1 0 0 R Y21034 $ 2269.04 $ 1984.14 90 10% 69% 21% 0 2 0 2 1 0 R Y21040 $ 915.29 $ 726.96 90 10% 69% 21% 0 2 0 1 0 0 R Y21044 $ 1504.30 $ 1504.30 90 10% 69% 21% 0 2 0 2 1 0 R Y21045 $ 2092.10 $ 2092.10 90 10% 69% 21% 0 2 0 2 1 0 R Y21046 $ 1933.16 $ 1933.16 90 10% 69% 21% 0 2 0 0 1 0 R Y21047 $ 2254.05 $ 2254.05 90 10% 69% 21% 0 2 0 2 1 0 R Y21048 $ 1984.14 $ 1984.14 90 10% 69% 21% 0 2 0 0 1 0 R Y21049 $ 2063.91 $ 2063.91 90 10% 69% 21% 0 2 0 2 1 0 R Y21050 $ 1437.12 $ 1437.12 90 10% 69% 21% 0 2 1 0 0 0 R Y21060 $ 1389.74 $ 1389.74 90 10% 69% 21% 0 2 1 2 1 0 R Y21070 $ 1053.25 $ 1053.25 90 10% 69% 21% 0 2 1 0 0 0 R Y21073 $ 691.57 $ 436.05 90 10% 69% 21% 0 2 1 0 0 0 R Y21076 $ 1726.82 $ 1431.12 10 10% 80% 10% 0 2 0 0 0 0 R 21077 $ 4335.35 $ 3613.20 90 10% 69% 21% 0 2 1 0 0 0 R 21079 $ 2918.63 $ 2392.60 90 10% 69% 21% 0 2 0 1 0 0 R 21080 $ 3269.51 $ 2655.31 90 10% 69% 21% 0 2 0 1 0 0 R 21081 $ 3025.99 $ 2450.78 90 10% 69% 21% 0 2 0 0 0 0 R 21082 $ 2874.24 $ 2311.03 90 10% 69% 21% 0 2 0 0 0 0 R 21083 $ 2743.49 $ 2146.68 90 10% 69% 21% 0 2 0 0 0 0 R 21084 $ 3135.15 $ 2481.97 90 10% 69% 21% 0 2 0 0 0 0 R 21085 $ 1320.76 $ 971.68 10 10% 80% 10% 0 2 0 0 0 0 R 21086 $ 3223.33 $ 2664.31 90 10% 69% 21% 0 2 1 0 0 0 R 21087 $ 3223.33 $ 2664.31 90 10% 69% 21% 0 2 0 0 0 0 R 21088 By Report By Report 90 10% 69% 21% 0 0 0 0 0 0 N
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 16
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
21089 By Report By Report 90 0% 0% 0% 0 0 0 1 1 1 N 21100 $ 2054.32 $ 907.50 90 10% 69% 21% 0 2 0 0 0 0 R 21110 $ 1428.12 $ 1187.00 90 10% 69% 21% 0 2 0 1 0 0 R 21116 $ 262.11 $ 74.98 0 0% 0% 0% 0 2 1 1 0 0 R 21120 $ 1048.45 $ 830.72 90 10% 69% 21% 0 2 0 1 1 0 R Y21121 $ 1394.54 $ 1152.22 90 10% 69% 21% 0 2 0 2 0 0 R Y21122 $ 1121.03 $ 1121.03 90 10% 69% 21% 0 2 0 2 0 0 R Y21123 $ 1348.35 $ 1348.35 90 10% 69% 21% 0 2 0 2 1 0 R Y21125 $ 5608.73 $ 1246.98 90 10% 69% 21% 0 2 0 2 0 0 R Y21127 $ 7782.41 $ 1512.70 90 10% 69% 21% 0 2 0 2 1 0 R Y21137 $ 1149.22 $ 1149.22 90 10% 69% 21% 0 2 0 2 0 0 R Y21138 $ 1533.69 $ 1533.69 90 10% 69% 21% 0 2 0 2 1 0 R Y21139 $ 1919.96 $ 1919.96 90 10% 69% 21% 0 2 0 2 1 0 R Y21141 $ 2300.23 $ 2300.23 90 10% 69% 21% 0 2 0 2 1 0 R Y21142 $ 2465.78 $ 2465.78 90 10% 69% 21% 0 2 0 2 1 0 R Y21143 $ 2482.57 $ 2482.57 90 10% 69% 21% 0 2 0 2 1 0 R Y21145 $ 2785.47 $ 2785.47 90 10% 69% 21% 0 2 0 2 0 0 R Y21146 $ 2901.83 $ 2901.83 90 10% 69% 21% 0 2 0 2 1 0 R Y21147 $ 3064.98 $ 3064.98 90 10% 69% 21% 0 2 0 2 0 0 R Y21150 $ 2865.84 $ 2865.84 90 10% 69% 21% 0 2 0 2 0 0 R Y21151 $ 3505.23 $ 3505.23 90 10% 69% 21% 0 2 0 2 0 0 R Y21154 $ 3769.74 $ 3769.74 90 10% 69% 21% 0 2 0 2 1 0 R Y21155 $ 4108.03 $ 4108.03 90 10% 69% 21% 0 2 0 2 0 0 R Y21159 $ 4168.01 $ 4168.01 90 10% 69% 21% 0 2 0 2 1 0 R Y21160 $ 4520.09 $ 4520.09 90 10% 69% 21% 0 2 0 2 0 0 R Y21172 $ 3073.38 $ 3073.38 90 10% 69% 21% 0 2 0 2 1 0 R Y21175 $ 3640.19 $ 3640.19 90 10% 69% 21% 0 2 0 2 0 0 R Y21179 $ 2264.84 $ 2264.84 90 10% 69% 21% 0 2 0 2 0 0 R Y21180 $ 2591.14 $ 2591.14 90 10% 69% 21% 0 2 0 2 1 0 R Y21181 $ 1257.78 $ 1257.78 90 10% 69% 21% 0 2 0 0 0 0 R Y21182 $ 3237.72 $ 3237.72 90 10% 69% 21% 0 2 0 2 1 0 R Y21183 $ 3871.11 $ 3871.11 90 10% 69% 21% 0 2 0 2 1 0 R Y21184 $ 4059.45 $ 4059.45 90 10% 69% 21% 0 2 0 2 0 0 R Y21188 $ 2673.31 $ 2673.31 90 10% 69% 21% 0 2 0 2 0 0 R Y21193 $ 2020.73 $ 2020.73 90 10% 69% 21% 0 2 2 2 1 0 R Y21194 $ 2550.95 $ 2550.95 90 10% 69% 21% 0 2 2 2 0 0 R Y21195 $ 2286.44 $ 2286.44 90 10% 69% 21% 0 2 2 2 0 0 R Y21196 $ 2537.75 $ 2537.75 90 10% 69% 21% 0 2 2 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 17
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
21198 $ 2000.33 $ 2000.33 90 10% 69% 21% 0 2 0 2 1 0 R Y21199 $ 1702.83 $ 1702.83 90 10% 69% 21% 0 2 0 2 1 0 R Y21206 $ 2128.69 $ 2128.69 90 10% 69% 21% 0 2 0 2 1 0 R Y21208 $ 3378.67 $ 1447.32 90 10% 69% 21% 0 2 0 0 0 0 R 21209 $ 1410.73 $ 1063.45 90 10% 69% 21% 0 2 0 2 0 0 R 21210 $ 4088.84 $ 1495.30 90 10% 69% 21% 0 2 0 1 0 0 R 21215 $ 7376.34 $ 1551.08 90 10% 69% 21% 0 2 0 1 1 0 R 21230 $ 1292.57 $ 1292.57 90 10% 69% 21% 0 2 0 0 0 0 R 21235 $ 1257.78 $ 973.48 90 10% 69% 21% 0 2 0 1 0 0 R 21240 $ 1916.36 $ 1916.36 90 10% 69% 21% 0 2 1 2 1 0 R Y21242 $ 1756.81 $ 1756.81 90 10% 69% 21% 0 2 1 2 1 0 R Y21243 $ 2908.43 $ 2908.43 90 10% 69% 21% 0 2 1 2 1 0 R Y21244 $ 1838.39 $ 1838.39 90 10% 69% 21% 0 2 0 2 1 0 R 21245 $ 1909.16 $ 1509.10 90 10% 69% 21% 0 2 0 2 0 0 R Y21246 $ 1531.89 $ 1531.89 90 10% 69% 21% 0 2 0 2 0 0 R Y21247 $ 2591.74 $ 2591.74 90 10% 69% 21% 0 2 1 2 1 0 R 21248 $ 1928.96 $ 1558.88 90 10% 69% 21% 0 2 0 1 0 0 R 21249 $ 2636.12 $ 2215.66 90 10% 69% 21% 0 2 0 0 0 0 R 21255 $ 2258.85 $ 2258.85 90 10% 69% 21% 0 2 1 2 1 0 R 21256 $ 2079.51 $ 2079.51 90 10% 69% 21% 0 2 1 2 1 0 R 21260 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 1 0 X 21261 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 1 0 X 21263 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 1 0 X 21267 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 21268 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 21270 $ 1692.04 $ 1258.38 90 10% 69% 21% 0 2 1 2 1 0 R 21275 $ 1420.93 $ 1420.93 90 10% 69% 21% 0 2 0 2 1 0 R 21280 $ 985.47 $ 985.47 90 10% 69% 21% 0 2 1 0 0 0 R 21282 $ 657.38 $ 657.38 90 10% 69% 21% 0 2 1 1 0 0 R 21295 Not Covered Not Covered 90 10% 69% 21% 0 2 1 0 0 0 X 21296 Not Covered Not Covered 90 10% 69% 21% 0 2 1 0 0 0 X 21299 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 21310 $ 233.92 $ 44.99 0 0% 0% 0% 0 2 0 1 0 0 R 21315 $ 490.04 $ 262.71 10 10% 80% 10% 0 2 0 1 0 0 R 21320 $ 449.85 $ 231.52 10 10% 80% 10% 0 2 0 1 0 0 R 21325 $ 833.12 $ 833.12 90 10% 69% 21% 0 2 0 0 0 0 R 21330 $ 993.27 $ 993.27 90 10% 69% 21% 0 2 0 0 0 0 R 21335 $ 1248.78 $ 1248.78 90 10% 69% 21% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 18
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
21336 $ 1118.03 $ 1118.03 90 10% 69% 21% 0 2 0 0 0 0 R 21337 $ 709.56 $ 511.03 90 10% 69% 21% 0 2 0 0 0 0 R 21338 $ 1309.36 $ 1309.36 90 10% 69% 21% 0 2 0 0 0 0 R 21339 $ 1477.31 $ 1477.31 90 10% 69% 21% 0 2 0 2 1 0 R 21340 $ 1392.74 $ 1392.74 90 10% 69% 21% 0 2 0 0 0 0 R 21343 $ 2089.70 $ 2089.70 90 10% 69% 21% 0 2 0 2 1 0 R 21344 $ 2366.81 $ 2366.81 90 10% 69% 21% 0 2 0 2 2 0 R 21345 $ 1347.75 $ 1073.04 90 10% 69% 21% 0 2 0 0 0 0 R 21346 $ 1557.08 $ 1557.08 90 10% 69% 21% 0 2 0 1 1 0 R 21347 $ 1955.95 $ 1955.95 90 10% 69% 21% 0 2 0 2 1 0 R 21348 $ 2048.92 $ 2048.92 90 10% 69% 21% 0 2 0 2 2 0 R 21355 $ 839.72 $ 614.20 10 10% 80% 10% 0 2 1 0 0 0 R 21356 $ 872.71 $ 649.58 10 10% 80% 10% 0 2 1 0 0 0 R 21360 $ 923.09 $ 923.09 90 10% 69% 21% 0 2 1 2 0 0 R 21365 $ 1889.37 $ 1889.37 90 10% 69% 21% 0 2 1 2 1 0 R 21366 $ 1954.15 $ 1954.15 90 10% 69% 21% 0 2 1 2 2 0 R 21385 $ 1167.21 $ 1167.21 90 10% 69% 21% 0 2 1 2 1 0 R 21386 $ 1184.01 $ 1184.01 90 10% 69% 21% 0 2 1 2 0 0 R 21387 $ 1216.39 $ 1216.39 90 10% 69% 21% 0 2 1 2 0 0 R 21390 $ 1359.75 $ 1359.75 90 10% 69% 21% 0 2 1 2 1 0 R 21395 $ 1708.23 $ 1708.23 90 10% 69% 21% 0 2 1 2 1 0 R 21400 $ 338.89 $ 274.11 90 10% 69% 21% 0 2 1 0 0 0 R 21401 $ 862.51 $ 527.22 90 10% 69% 21% 0 2 1 2 0 0 R 21406 $ 977.07 $ 977.07 90 10% 69% 21% 0 2 1 2 1 0 R 21407 $ 1105.43 $ 1105.43 90 10% 69% 21% 0 2 1 2 1 0 R 21408 $ 1526.49 $ 1526.49 90 10% 69% 21% 0 2 1 2 2 0 R 21421 $ 1482.71 $ 1218.19 90 10% 69% 21% 0 2 0 0 0 0 R 21422 $ 1158.81 $ 1158.81 90 10% 69% 21% 0 2 0 2 1 0 R 21423 $ 1349.55 $ 1349.55 90 10% 69% 21% 0 2 0 2 2 0 R 21431 $ 1369.34 $ 1369.34 90 10% 69% 21% 0 2 0 2 0 0 R 21432 $ 1098.83 $ 1098.83 90 10% 69% 21% 0 2 0 2 0 0 R 21433 $ 2943.82 $ 2943.82 90 10% 69% 21% 0 2 0 2 1 0 R 21435 $ 2141.89 $ 2141.89 90 10% 69% 21% 0 2 0 2 0 0 R 21436 $ 3459.65 $ 3459.65 90 10% 69% 21% 0 2 0 2 2 0 R 21440 $ 1026.86 $ 827.72 90 10% 69% 21% 0 2 0 0 0 0 R 21445 $ 1361.55 $ 1098.83 90 10% 69% 21% 0 2 0 2 0 0 R 21450 $ 1110.23 $ 881.11 90 10% 69% 21% 0 2 0 0 0 0 R 21451 $ 1455.71 $ 1190.60 90 10% 69% 21% 0 2 0 0 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 19
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
21452 $ 1029.86 $ 600.40 90 10% 69% 21% 0 2 0 0 0 0 R 21453 $ 1620.06 $ 1380.14 90 10% 69% 21% 0 2 0 0 0 0 R 21454 $ 987.27 $ 987.27 90 10% 69% 21% 0 2 0 0 1 0 R 21461 $ 3818.33 $ 1641.65 90 10% 69% 21% 0 2 0 1 1 0 R 21462 $ 4051.65 $ 1822.79 90 10% 69% 21% 0 2 0 2 1 0 R 21465 $ 1594.87 $ 1594.87 90 10% 69% 21% 0 2 1 2 1 0 R 21470 $ 2062.11 $ 2062.11 90 10% 69% 21% 0 2 0 2 1 0 R 21480 $ 173.94 $ 53.38 0 0% 0% 0% 0 2 1 1 0 0 R 21485 $ 1249.38 $ 1037.65 90 10% 69% 21% 0 2 1 0 0 0 R 21490 $ 1573.88 $ 1573.88 90 10% 69% 21% 0 2 1 2 1 0 R 21495 $ 1128.22 $ 1128.22 90 10% 69% 21% 0 2 0 2 0 0 R 21497 $ 1308.16 $ 1079.04 90 10% 69% 21% 0 2 0 0 0 0 R 21499 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 21501 $ 782.14 $ 544.62 90 10% 69% 21% 0 2 0 1 0 0 R 21502 $ 843.92 $ 843.92 90 10% 69% 21% 0 2 0 2 0 0 R 21510 $ 735.35 $ 735.35 90 10% 69% 21% 0 2 0 0 0 0 R 21550 $ 457.65 $ 270.51 10 10% 80% 10% 0 2 0 1 0 0 R 21552 $ 745.55 $ 745.55 90 10% 69% 21% 0 2 0 2 0 0 R Y21554 $ 1223.59 $ 1223.59 90 10% 69% 21% 0 2 0 2 0 0 R Y21555 $ 713.76 $ 518.23 90 10% 69% 21% 0 2 0 1 0 0 R Y21556 $ 893.10 $ 893.10 90 10% 69% 21% 0 2 0 1 0 0 R Y21557 $ 1607.46 $ 1607.46 90 10% 69% 21% 0 2 0 2 1 0 R Y21558 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 1 0 X21600 $ 943.49 $ 943.49 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR21610 $ 1966.74 $ 1966.74 90 10% 69% 21% 0 2 0 2 0 0 R Y21615 $ 1032.26 $ 1032.26 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR21616 $ 1199.60 $ 1199.60 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR21620 $ 845.72 $ 845.72 90 10% 69% 21% 0 2 0 2 1 0 R 21627 $ 915.29 $ 915.29 90 10% 69% 21% 0 2 0 2 0 0 R 21630 $ 2030.32 $ 2030.32 90 10% 69% 21% 0 2 0 2 1 0 R Y21632 $ 1986.54 $ 1986.54 90 10% 69% 21% 0 2 0 2 1 0 R Y21685 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 21700 $ 603.40 $ 603.40 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR21705 $ 894.90 $ 894.90 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR21720 $ 826.52 $ 826.52 90 10% 69% 21% 0 2 0 2 0 0 R Y21725 $ 914.10 $ 914.10 90 10% 69% 21% 0 2 0 2 1 0 R Y21740 $ 1696.83 $ 1696.83 90 10% 69% 21% 0 2 0 2 1 0 R Y21742 By Report By Report 90 10% 69% 21% 0 2 0 2 1 0 N Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 20
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
21743 By Report By Report 90 10% 69% 21% 0 2 0 2 1 0 N Y21750 $ 1131.22 $ 1131.22 90 10% 69% 21% 0 2 0 2 1 0 R 21805 $ 464.85 $ 464.85 90 10% 69% 21% 0 2 0 0 0 0 R 21811 $ 996.87 $ 996.87 0 0% 0% 0% 0 2 1 2 0 0 R21812 $ 1194.20 $ 1194.20 0 0% 0% 0% 0 2 1 2 0 0 R21813 $ 1626.66 $ 1626.66 0 0% 0% 0% 0 2 1 2 0 0 R21820 $ 245.32 $ 251.32 90 10% 69% 21% 0 2 0 1 0 0 R 21825 $ 905.70 $ 905.70 90 10% 69% 21% 0 2 0 2 1 0 R 21899 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N Y-UR21920 $ 445.65 $ 273.51 10 10% 80% 10% 0 2 0 1 0 0 R 21925 $ 763.55 $ 600.40 90 10% 69% 21% 0 2 0 1 0 0 R 21930 $ 805.53 $ 613.00 90 10% 69% 21% 0 2 0 1 0 0 R 21931 $ 783.34 $ 783.34 90 10% 69% 21% 0 2 0 2 0 0 R Y21932 $ 1102.43 $ 1102.43 90 10% 69% 21% 0 2 0 2 0 0 R21933 $ 1230.79 $ 1230.79 90 10% 69% 21% 0 2 0 2 0 0 R21935 $ 1710.03 $ 1710.03 90 10% 69% 21% 0 2 0 1 1 0 R Y21936 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 1 0 X22010 $ 1585.87 $ 1585.87 90 10% 69% 21% 0 2 0 0 0 0 R 22015 $ 1511.50 $ 1511.50 90 10% 69% 21% 0 2 0 1 0 0 R 22100 $ 1529.49 $ 1529.49 90 10% 69% 21% 0 2 0 2 1 0 R Y22101 $ 1395.13 $ 1395.13 90 10% 69% 21% 0 2 0 2 1 0 R Y22102 $ 1342.35 $ 1342.35 90 10% 69% 21% 0 2 0 2 1 0 R Y22103 $ 231.52 $ 231.52 0 0% 0% 0% 0 0 0 2 1 0 R Y22110 $ 1736.42 $ 1736.42 90 10% 69% 21% 0 2 0 2 1 0 R Y22112 $ 1844.39 $ 1844.39 90 10% 69% 21% 0 2 0 2 1 0 R Y22114 $ 1679.44 $ 1679.44 90 10% 69% 21% 0 2 0 2 1 0 R Y22116 $ 231.52 $ 231.52 0 0% 0% 0% 0 0 0 2 1 0 R Y22206 $ 4037.85 $ 4037.85 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22207 $ 3969.48 $ 3969.48 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22208 $ 952.48 $ 952.48 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR22210 $ 2958.21 $ 2958.21 90 10% 69% 21% 0 2 0 2 1 0 R Y22212 $ 2478.97 $ 2478.97 90 10% 69% 21% 0 2 0 2 1 0 R Y22214 $ 2478.97 $ 2478.97 90 10% 69% 21% 0 2 0 2 1 0 R Y22216 $ 600.40 $ 600.40 0 0% 0% 0% 0 0 0 2 1 0 R Y22220 $ 2653.52 $ 2653.52 90 10% 69% 21% 0 2 0 2 1 0 R Y22222 $ 2633.72 $ 2633.72 90 10% 69% 21% 0 2 0 2 1 0 R Y22224 $ 2645.12 $ 2645.12 90 10% 69% 21% 0 2 0 2 1 0 R Y22226 $ 598.00 $ 598.00 0 0% 0% 0% 0 0 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 21
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
22305 $ 326.89 $ 294.50 90 10% 69% 21% 0 2 0 1 0 0 R Y22310 $ 519.43 $ 475.64 90 10% 69% 21% 0 2 0 1 0 0 R Y22315 $ 1499.50 $ 1296.77 90 10% 69% 21% 0 2 0 1 0 0 R Y22318 $ 2676.31 $ 2676.31 90 10% 69% 21% 0 2 0 2 2 0 R Y22319 $ 2982.21 $ 2982.21 90 10% 69% 21% 0 2 0 2 2 0 R Y22325 $ 2377.61 $ 2377.61 90 10% 69% 21% 0 2 0 2 1 0 R Y22326 $ 2461.58 $ 2461.58 90 10% 69% 21% 0 2 0 2 1 0 R Y22327 $ 2487.97 $ 2487.97 90 10% 69% 21% 0 2 0 2 1 0 R Y22328 $ 462.45 $ 462.45 0 0% 0% 0% 0 0 0 2 1 0 R Y22505 $ 224.33 $ 224.33 10 10% 80% 10% 0 2 0 1 0 0 R Y22510 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X22511 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X22512 Not Covered Not Covered 0 10% 80% 10% 0 0 0 1 0 0 X22513 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X22514 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X22515 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X22526 Not Covered Not Covered 10 10% 80% 10% 9 9 9 9 9 9 X 22527 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 22532 $ 2939.02 $ 2939.02 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22533 $ 2759.08 $ 2759.08 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22534 $ 594.40 $ 594.40 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22548 $ 3207.13 $ 3207.13 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22551 $ 2820.26 $ 2820.26 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22552 $ 652.58 $ 652.58 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22554 $ 2080.71 $ 2080.71 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22556 $ 2765.08 $ 2765.08 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22558 $ 2561.75 $ 2561.75 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22585 $ 542.22 $ 542.22 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22586 $ 3247.92 $ 3247.92 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22590 $ 2594.73 $ 2594.73 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22595 $ 2483.17 $ 2483.17 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22600 $ 2135.29 $ 2135.29 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22610 $ 2099.30 $ 2099.30 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22612 $ 2639.12 $ 2639.12 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22614 $ 644.19 $ 644.19 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22630 $ 2585.14 $ 2585.14 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22632 $ 524.83 $ 524.83 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22633 $ 3064.98 $ 3064.98 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 22
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
22634 $ 815.13 $ 815.13 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22800 $ 2258.25 $ 2258.25 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22802 $ 3499.23 $ 3499.23 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22804 $ 4038.45 $ 4038.45 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22808 $ 3051.78 $ 3051.78 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22810 $ 3346.28 $ 3346.28 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22812 $ 3720.56 $ 3720.56 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22818 $ 3649.18 $ 3649.18 90 11% 76% 13% 0 2 0 2 2 2 R Y-UR22819 $ 4469.11 $ 4469.11 90 11% 76% 13% 0 2 0 2 2 2 R Y-UR22830 $ 1357.35 $ 1357.35 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22840 $ 1250.58 $ 1250.58 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR22841 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y-UR22842 $ 1254.18 $ 1254.18 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22843 $ 1342.35 $ 1342.35 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22844 $ 1632.66 $ 1632.66 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22845 $ 1196.60 $ 1196.60 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22846 $ 1242.79 $ 1242.79 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22847 $ 1341.15 $ 1341.15 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22848 $ 596.20 $ 596.20 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22849 $ 2158.08 $ 2158.08 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22850 $ 1208.00 $ 1208.00 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22851 $ 668.78 $ 668.78 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22852 $ 1160.01 $ 1160.01 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22855 $ 1834.19 $ 1834.19 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR22856 $ 2627.72 $ 2627.72 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22857 $ 2991.80 $ 2991.80 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22858 $ 809.73 $ 809.73 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR22861 $ 3206.53 $ 3206.53 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22862 $ 3040.39 $ 3040.39 90 10% 71% 19% 0 2 0 2 2 2 R Y-UR22864 $ 3384.07 $ 3384.07 90 10% 69% 21% 0 2 0 2 2 0 R Y-UR22865 $ 3447.65 $ 3447.65 90 10% 71% 19% 0 2 0 2 2 2 R Y-UR22899 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N Y-UR22900 $ 939.29 $ 939.29 90 10% 69% 21% 0 2 0 2 1 0 R Y22901 $ 1104.83 $ 1104.83 90 10% 69% 21% 0 2 0 2 1 0 R Y22902 $ 747.95 $ 554.82 90 10% 69% 21% 0 2 0 2 1 0 R Y22903 $ 731.76 $ 731.76 90 10% 69% 21% 0 2 0 2 1 0 R Y22904 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 1 X22905 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 1 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 23
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
22999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N Y23000 $ 1019.66 $ 633.39 90 10% 69% 21% 0 2 1 2 1 0 R Y23020 $ 1164.81 $ 1164.81 90 10% 69% 21% 0 2 1 2 0 0 R Y23030 $ 764.75 $ 431.26 10 10% 80% 10% 0 2 0 1 0 0 R Y23031 $ 747.35 $ 374.28 10 10% 80% 10% 0 2 1 1 0 0 R Y23035 $ 1150.42 $ 1150.42 90 10% 69% 21% 0 2 1 2 0 0 R Y23040 $ 1215.19 $ 1215.19 90 10% 69% 21% 0 2 1 2 1 0 R Y23044 $ 965.68 $ 965.68 90 10% 69% 21% 0 2 1 1 1 0 R Y23065 Not Covered Not Covered 10 10% 80% 10% 0 2 1 1 0 0 X 23066 $ 964.48 $ 605.20 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR23071 $ 701.17 $ 701.17 90 10% 80% 10% 0 2 1 2 0 0 R23073 $ 1160.01 $ 1160.01 90 10% 69% 21% 0 2 1 2 0 0 R23075 $ 804.33 $ 550.02 90 10% 80% 10% 0 2 1 1 0 0 R 23076 $ 905.10 $ 905.10 90 10% 69% 21% 0 2 1 1 0 0 R 23077 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 23078 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X23100 $ 849.32 $ 849.32 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23101 $ 759.95 $ 759.95 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR23105 $ 1077.84 $ 1077.84 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23106 $ 842.72 $ 842.72 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR23107 $ 1115.63 $ 1115.63 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23120 $ 992.07 $ 992.07 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23125 $ 1197.80 $ 1197.80 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23130 $ 1034.06 $ 1034.06 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR23140 $ 889.50 $ 889.50 90 10% 69% 21% 0 2 1 1 0 0 R Y23145 $ 1174.41 $ 1174.41 90 10% 69% 21% 0 2 1 2 1 0 R Y23146 $ 1051.45 $ 1051.45 90 10% 69% 21% 0 2 1 0 0 0 R Y23150 $ 1118.03 $ 1118.03 90 10% 69% 21% 0 2 1 2 1 0 R Y23155 $ 1338.75 $ 1338.75 90 10% 69% 21% 0 2 1 2 1 0 R Y23156 $ 1145.62 $ 1145.62 90 10% 69% 21% 0 2 1 2 0 0 R Y23170 $ 948.88 $ 948.88 90 10% 69% 21% 0 2 1 1 0 0 R Y23172 $ 958.48 $ 958.48 90 10% 69% 21% 0 2 1 2 0 0 R Y23174 $ 1282.37 $ 1282.37 90 10% 69% 21% 0 2 1 2 1 0 R Y23180 $ 1125.82 $ 1125.82 90 10% 69% 21% 0 2 1 1 1 0 R Y23182 $ 1115.03 $ 1115.03 90 10% 69% 21% 0 2 1 2 0 0 R Y23184 $ 1242.79 $ 1242.79 90 10% 69% 21% 0 2 1 2 1 0 R Y23190 $ 966.88 $ 966.88 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23195 $ 1275.77 $ 1275.77 90 10% 69% 21% 0 2 1 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 24
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
23200 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 23210 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 23220 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 23330 $ 416.86 $ 259.71 10 10% 80% 10% 0 2 1 0 0 0 R 23333 $ 771.34 $ 771.34 90 10% 69% 21% 0 2 1 0 0 0 R Y23334 $ 1807.80 $ 1807.80 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR23335 $ 2147.88 $ 2147.88 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR23350 $ 230.32 $ 87.57 0 0% 0% 0% 0 2 1 1 0 0 R 23395 $ 2167.08 $ 2167.08 90 10% 69% 21% 0 2 0 2 1 0 R Y23397 $ 1919.96 $ 1919.96 90 10% 69% 21% 0 2 0 2 1 0 R Y23400 $ 1634.46 $ 1634.46 90 10% 69% 21% 0 2 1 2 1 0 R Y23405 $ 1056.85 $ 1056.85 90 10% 69% 21% 0 2 0 2 1 0 R Y23406 $ 1299.77 $ 1299.77 90 10% 69% 21% 0 2 0 2 0 0 R Y23410 $ 1387.94 $ 1387.94 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23412 $ 1438.32 $ 1438.32 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23415 $ 1179.81 $ 1179.81 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR23420 $ 1635.05 $ 1635.05 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23430 $ 1263.18 $ 1263.18 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23440 $ 1275.17 $ 1275.17 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23450 $ 1596.67 $ 1596.67 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23455 $ 1685.44 $ 1685.44 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23460 $ 1834.19 $ 1834.19 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23462 $ 1788.60 $ 1788.60 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23465 $ 1885.17 $ 1885.17 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23466 $ 1892.37 $ 1892.37 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23470 $ 2024.92 $ 2024.92 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23472 $ 2451.38 $ 2451.38 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23473 $ 2734.49 $ 2734.49 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23474 $ 2955.81 $ 2955.81 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23480 $ 1383.74 $ 1383.74 90 10% 69% 21% 0 2 1 1 1 0 R 23485 $ 1605.06 $ 1605.06 90 10% 69% 21% 0 2 1 2 1 0 R Y23490 $ 1452.72 $ 1452.72 90 10% 69% 21% 0 2 1 2 0 0 R Y23491 $ 1704.03 $ 1704.03 90 10% 69% 21% 0 2 1 2 1 0 R 23500 $ 373.68 $ 379.67 90 10% 69% 21% 0 2 1 1 0 0 R 23505 $ 601.60 $ 565.61 90 10% 69% 21% 0 2 1 1 0 0 R 23515 $ 1217.59 $ 1217.59 90 10% 69% 21% 0 2 1 2 1 0 R 23520 $ 395.87 $ 401.27 90 10% 69% 21% 0 2 1 0 0 0 R 23525 $ 659.18 $ 607.00 90 10% 69% 21% 0 2 1 0 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 25
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
23530 $ 968.68 $ 968.68 90 10% 69% 21% 0 2 1 2 0 0 R 23532 $ 1055.65 $ 1055.65 90 10% 69% 21% 0 2 1 2 0 0 R 23540 $ 385.07 $ 391.67 90 10% 69% 21% 0 2 1 1 0 0 R 23545 $ 584.81 $ 528.42 90 10% 69% 21% 0 2 1 0 0 0 R 23550 $ 960.28 $ 960.28 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23552 $ 1104.83 $ 1104.83 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR23570 $ 396.47 $ 409.06 90 10% 69% 21% 0 2 1 1 0 0 R 23575 $ 684.37 $ 638.79 90 10% 69% 21% 0 2 1 0 0 0 R 23585 $ 1650.65 $ 1650.65 90 10% 69% 21% 0 2 1 2 1 0 R 23600 $ 560.81 $ 526.02 90 10% 69% 21% 0 2 1 1 0 0 R 23605 $ 791.14 $ 720.96 90 10% 69% 21% 0 2 1 1 0 0 R 23615 $ 1493.50 $ 1493.50 90 10% 69% 21% 0 2 1 2 1 0 R 23616 $ 2089.70 $ 2089.70 90 10% 69% 21% 0 2 1 2 2 0 R 23620 $ 463.05 $ 439.65 90 10% 69% 21% 0 2 1 1 0 0 R 23625 $ 648.38 $ 601.60 90 10% 69% 21% 0 2 1 1 0 0 R 23630 $ 1321.36 $ 1321.36 90 10% 69% 21% 0 2 1 2 1 0 R 23650 $ 536.22 $ 489.44 90 10% 69% 21% 0 2 1 1 0 0 R 23655 $ 681.97 $ 681.97 90 10% 69% 21% 0 2 1 1 0 0 R 23660 $ 981.27 $ 981.27 90 10% 69% 21% 0 2 1 2 1 0 R 23665 $ 723.96 $ 671.18 90 10% 69% 21% 0 2 1 1 0 0 R 23670 $ 1480.91 $ 1480.91 90 10% 69% 21% 0 2 1 2 1 0 R 23675 $ 941.09 $ 851.72 90 10% 69% 21% 0 2 1 1 0 0 R 23680 $ 1566.68 $ 1566.68 90 10% 69% 21% 0 2 1 2 1 0 R 23700 $ 333.49 $ 333.49 10 10% 80% 10% 0 2 1 1 0 0 R 23800 $ 1726.82 $ 1726.82 90 10% 69% 21% 0 2 1 2 1 0 R Y23802 $ 2164.68 $ 2164.68 90 10% 69% 21% 0 2 1 2 1 0 R Y23900 $ 2334.42 $ 2334.42 90 10% 69% 21% 0 2 0 2 0 0 R Y23920 $ 1898.97 $ 1898.97 90 10% 69% 21% 0 2 1 2 1 0 R Y23921 $ 786.34 $ 786.34 90 10% 69% 21% 0 2 1 1 0 0 R Y23929 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N Y-UR23930 $ 604.60 $ 361.68 10 10% 80% 10% 0 2 1 1 0 0 R 23931 $ 500.83 $ 274.11 10 10% 80% 10% 0 2 1 1 0 0 R 23935 $ 858.31 $ 858.31 90 10% 69% 21% 0 2 1 0 0 0 R 24000 $ 809.73 $ 809.73 90 10% 69% 21% 0 2 1 0 1 0 R Y-UR24006 $ 1204.40 $ 1204.40 90 10% 69% 21% 0 2 1 2 2 0 R Y-UR24065 $ 443.85 $ 287.30 10 10% 80% 10% 0 2 1 1 0 0 R 24066 $ 1076.04 $ 700.57 90 10% 69% 21% 0 2 1 1 0 0 R 24071 $ 678.37 $ 678.37 90 10% 69% 21% 0 2 1 2 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 26
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
24073 $ 1164.21 $ 1164.21 90 10% 69% 21% 0 2 1 2 0 0 R24075 $ 843.92 $ 555.41 90 10% 69% 21% 0 2 1 1 0 0 R 24076 $ 911.10 $ 911.10 90 10% 69% 21% 0 2 1 1 0 0 R 24077 Not Covered Not Covered 90 10% 69% 21% 0 2 1 1 1 0 X 24079 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X24100 $ 709.56 $ 709.56 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24101 $ 848.72 $ 848.72 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR24102 $ 1040.65 $ 1040.65 90 10% 69% 21% 0 2 1 2 1 0 R 24105 $ 598.60 $ 598.60 90 10% 69% 21% 0 2 1 1 0 0 R 24110 $ 995.07 $ 995.07 90 10% 69% 21% 0 2 1 1 1 0 R 24115 $ 1244.59 $ 1244.59 90 10% 69% 21% 0 2 1 2 1 0 R 24116 $ 1452.12 $ 1452.12 90 10% 69% 21% 0 2 1 2 0 0 R 24120 $ 894.30 $ 894.30 90 10% 69% 21% 0 2 1 0 0 0 R 24125 $ 1049.65 $ 1049.65 90 10% 69% 21% 0 2 1 2 1 0 R 24126 $ 1097.03 $ 1097.03 90 10% 69% 21% 0 2 1 2 0 0 R 24130 $ 859.51 $ 859.51 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR24134 $ 1261.98 $ 1261.98 90 10% 69% 21% 0 2 1 2 0 0 R 24136 $ 961.48 $ 961.48 90 10% 69% 21% 0 2 1 1 0 0 R 24138 $ 1145.62 $ 1145.62 90 10% 69% 21% 0 2 1 2 0 0 R 24140 $ 1188.80 $ 1188.80 90 10% 69% 21% 0 2 1 2 0 0 R 24145 $ 1000.47 $ 1000.47 90 10% 69% 21% 0 2 1 1 1 0 R 24147 $ 1057.45 $ 1057.45 90 10% 69% 21% 0 2 1 1 1 0 R 24149 $ 1986.54 $ 1986.54 90 10% 69% 21% 0 2 1 2 1 0 R 24150 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 24152 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 24155 $ 1437.12 $ 1437.12 90 10% 69% 21% 0 2 1 2 1 0 R 24160 $ 2123.89 $ 2123.89 90 10% 69% 21% 0 2 1 1 1 0 R 24164 $ 1230.19 $ 1230.19 90 10% 69% 21% 0 2 1 1 1 0 R 24200 $ 358.68 $ 239.32 10 10% 80% 10% 0 2 1 0 0 0 R 24201 $ 963.28 $ 619.59 90 10% 69% 21% 0 2 1 1 0 0 R 24220 $ 281.31 $ 117.56 0 0% 0% 0% 0 2 1 0 0 0 R 24300 $ 719.76 $ 719.76 90 10% 69% 21% 0 2 1 1 0 0 R 24301 $ 1262.58 $ 1262.58 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR24305 $ 976.47 $ 976.47 90 10% 69% 21% 0 2 0 0 0 0 R Y-UR24310 $ 803.13 $ 803.13 90 10% 69% 21% 0 2 0 0 0 0 R Y-UR24320 $ 1316.56 $ 1316.56 90 10% 69% 21% 0 2 0 2 1 0 R Y-UR24330 $ 1212.20 $ 1212.20 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR24331 $ 1325.56 $ 1325.56 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 27
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
24332 $ 1037.65 $ 1037.65 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR24340 $ 1035.85 $ 1035.85 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24341 $ 1266.18 $ 1266.18 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24342 $ 1309.96 $ 1309.96 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24343 $ 1197.80 $ 1197.80 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24344 $ 1853.98 $ 1853.98 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24345 $ 1199.60 $ 1199.60 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24346 $ 1853.98 $ 1853.98 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24357 $ 736.55 $ 736.55 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR24358 $ 887.10 $ 887.10 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR24359 $ 1114.43 $ 1114.43 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR24360 $ 1516.29 $ 1516.29 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24361 $ 1693.84 $ 1693.84 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24362 $ 1783.21 $ 1783.21 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR24363 $ 2451.98 $ 2451.98 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR24365 $ 1079.64 $ 1079.64 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24366 $ 1150.42 $ 1150.42 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24370 $ 2613.33 $ 2613.33 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR24371 $ 3009.80 $ 3009.80 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR24400 $ 1380.74 $ 1380.74 90 10% 69% 21% 0 2 1 2 1 0 R 24410 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 24420 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 24430 $ 1781.41 $ 1781.41 90 10% 69% 21% 0 2 1 2 1 0 R 24435 $ 1821.59 $ 1821.59 90 10% 69% 21% 0 2 1 2 1 0 R 24470 $ 1134.82 $ 1134.82 90 10% 69% 21% 0 2 1 2 0 0 R Y24495 $ 885.90 $ 885.90 90 10% 69% 21% 0 2 1 0 0 0 R 24498 $ 1461.71 $ 1461.71 90 10% 69% 21% 0 2 1 2 1 0 R 24500 $ 615.99 $ 557.21 90 10% 69% 21% 0 2 1 1 0 0 R 24505 $ 852.32 $ 766.54 90 10% 69% 21% 0 2 1 1 0 0 R 24515 $ 1479.11 $ 1479.11 90 10% 69% 21% 0 2 1 2 1 0 R 24516 $ 1449.72 $ 1449.72 90 10% 69% 21% 0 2 1 2 2 0 R 24530 $ 651.38 $ 587.20 90 10% 69% 21% 0 2 1 1 0 0 R 24535 $ 1043.05 $ 957.88 90 10% 69% 21% 0 2 1 1 0 0 R 24538 $ 1257.78 $ 1257.78 90 10% 69% 21% 0 2 1 1 0 0 R 24545 $ 1567.88 $ 1567.88 90 10% 69% 21% 0 2 1 2 1 0 R 24546 $ 1751.42 $ 1751.42 90 10% 69% 21% 0 2 1 2 2 0 R 24560 $ 551.22 $ 490.04 90 10% 69% 21% 0 2 1 1 0 0 R 24565 $ 909.30 $ 830.12 90 10% 69% 21% 0 2 1 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 28
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
24566 $ 1215.79 $ 1215.79 90 10% 69% 21% 0 2 1 1 0 0 R 24575 $ 1242.19 $ 1242.19 90 10% 69% 21% 0 2 1 2 1 0 R 24576 $ 587.20 $ 524.23 90 10% 69% 21% 0 2 1 1 0 0 R 24577 $ 936.29 $ 853.52 90 10% 69% 21% 0 2 1 1 0 0 R 24579 $ 1411.93 $ 1411.93 90 10% 69% 21% 0 2 1 2 1 0 R 24582 $ 1371.14 $ 1371.14 90 10% 69% 21% 0 2 1 1 0 0 R 24586 $ 1825.79 $ 1825.79 90 10% 69% 21% 0 2 1 2 1 0 R 24587 $ 1830.59 $ 1830.59 90 10% 69% 21% 0 2 1 2 1 0 R 24600 $ 619.59 $ 563.81 90 10% 69% 21% 0 2 1 1 0 0 R 24605 $ 798.93 $ 798.93 90 10% 69% 21% 0 2 1 1 0 0 R 24615 $ 1199.00 $ 1199.00 90 10% 69% 21% 0 2 1 2 1 0 R 24620 $ 923.09 $ 923.09 90 10% 69% 21% 0 2 1 0 0 0 R 24635 $ 1139.62 $ 1139.62 90 10% 69% 21% 0 2 1 2 1 0 R 24640 Not Covered Not Covered 10 10% 80% 10% 0 2 1 0 0 0 X 24650 $ 449.85 $ 411.46 90 10% 69% 21% 0 2 1 1 0 0 R 24655 $ 743.15 $ 672.98 90 10% 69% 21% 0 2 1 1 0 0 R 24665 $ 1105.43 $ 1105.43 90 10% 69% 21% 0 2 1 2 1 0 R 24666 $ 1240.99 $ 1240.99 90 10% 69% 21% 0 2 1 2 1 0 R 24670 $ 500.83 $ 448.65 90 10% 69% 21% 0 2 1 1 0 0 R 24675 $ 777.94 $ 706.56 90 10% 69% 21% 0 2 1 1 0 0 R 24685 $ 1109.03 $ 1109.03 90 10% 69% 21% 0 2 1 2 1 0 R 24800 $ 1399.33 $ 1399.33 90 10% 69% 21% 0 2 1 2 1 0 R 24802 $ 1686.04 $ 1686.04 90 10% 69% 21% 0 2 1 2 0 0 R 24900 $ 1217.59 $ 1217.59 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24920 $ 1236.19 $ 1236.19 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR24925 $ 855.91 $ 855.91 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR24930 $ 1305.76 $ 1305.76 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR24931 $ 1330.36 $ 1330.36 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR24935 $ 1469.51 $ 1469.51 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR24940 $ 1797.97 $ 1797.97 90 10% 69% 21% 0 2 1 2 0 0 F Y-UR24999 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N Y-UR25000 $ 575.21 $ 575.21 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR25001 $ 587.80 $ 587.80 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR25020 $ 982.47 $ 982.47 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR25023 $ 1869.58 $ 1869.58 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR25024 $ 1311.16 $ 1311.16 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR25025 $ 2063.31 $ 2063.31 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR25028 $ 896.10 $ 896.10 90 10% 69% 21% 0 2 1 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 29
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
25031 $ 619.59 $ 619.59 90 10% 69% 21% 0 2 1 0 0 0 R 25035 $ 986.07 $ 986.07 90 10% 69% 21% 0 2 1 0 0 0 R 25040 $ 952.48 $ 952.48 90 10% 69% 21% 0 2 1 0 0 0 R 25065 $ 442.05 $ 281.31 10 10% 80% 10% 0 2 1 1 0 0 R 25066 $ 611.20 $ 611.20 90 10% 69% 21% 0 2 1 1 0 0 R 25071 $ 713.76 $ 713.76 90 10% 69% 21% 0 2 1 2 0 0 R25073 $ 898.50 $ 898.50 90 10% 69% 21% 0 2 1 2 0 0 R25075 $ 823.53 $ 533.82 90 10% 69% 21% 0 2 1 1 0 0 R 25076 $ 872.71 $ 872.71 90 10% 69% 21% 0 2 1 1 0 0 R 25077 Not Covered Not Covered 90 10% 69% 21% 0 2 1 1 0 0 X 25078 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 0 0 X25085 $ 763.55 $ 763.55 90 10% 69% 21% 0 2 1 2 0 0 R 25100 $ 587.80 $ 587.80 90 10% 69% 21% 0 2 1 0 0 0 R 25101 $ 686.17 $ 686.17 90 10% 69% 21% 0 2 1 0 0 0 R 25105 $ 817.53 $ 817.53 90 10% 69% 21% 0 2 1 0 1 0 R 25107 $ 1048.45 $ 1048.45 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR25109 $ 912.30 $ 912.30 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR25110 $ 578.81 $ 578.81 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR25111 $ 545.82 $ 545.82 90 10% 69% 21% 0 2 1 1 0 0 R 25112 $ 653.78 $ 653.78 90 10% 69% 21% 0 2 1 1 0 0 R 25115 $ 1283.57 $ 1283.57 90 10% 69% 21% 0 2 1 1 0 0 R 25116 $ 1017.86 $ 1017.86 90 10% 69% 21% 0 2 1 0 1 0 R 25118 $ 647.78 $ 647.78 90 10% 69% 21% 0 2 1 1 0 0 R 25119 $ 843.32 $ 843.32 90 10% 69% 21% 0 2 1 2 1 0 R 25120 $ 842.72 $ 842.72 90 10% 69% 21% 0 2 1 0 1 0 R 25125 $ 1013.06 $ 1013.06 90 10% 69% 21% 0 2 1 0 0 0 R 25126 $ 1010.66 $ 1010.66 90 10% 69% 21% 0 2 1 2 0 0 R 25130 $ 758.15 $ 758.15 90 10% 69% 21% 0 2 1 0 0 0 R 25135 $ 945.28 $ 945.28 90 10% 69% 21% 0 2 1 2 1 0 R 25136 $ 835.52 $ 835.52 90 10% 69% 21% 0 2 1 2 1 0 R 25145 $ 875.11 $ 875.11 90 10% 69% 21% 0 2 1 2 0 0 R 25150 $ 959.08 $ 959.08 90 10% 69% 21% 0 2 1 1 1 0 R 25151 $ 992.07 $ 992.07 90 10% 69% 21% 0 2 1 2 1 0 R 25170 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 25210 $ 827.72 $ 827.72 90 10% 69% 21% 0 2 0 0 1 0 R 25215 $ 1046.65 $ 1046.65 90 10% 69% 21% 0 2 1 2 1 0 R 25230 $ 734.76 $ 734.76 90 10% 69% 21% 0 2 1 1 1 0 R 25240 $ 726.96 $ 726.96 90 10% 69% 21% 0 2 1 0 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 30
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
25246 $ 283.71 $ 128.96 0 0% 0% 0% 0 2 1 1 0 0 R 25248 $ 698.77 $ 698.77 90 10% 69% 21% 0 2 1 1 0 0 R 25250 $ 897.30 $ 897.30 90 10% 69% 21% 0 2 1 2 0 0 R 25251 $ 1202.60 $ 1202.60 90 10% 69% 21% 0 2 1 2 0 0 R 25259 $ 716.76 $ 716.76 90 10% 69% 21% 0 2 1 1 0 0 R 25260 $ 1069.44 $ 1069.44 90 10% 69% 21% 0 2 0 1 0 0 R 25263 $ 1061.65 $ 1061.65 90 10% 69% 21% 0 2 0 2 0 0 R 25265 $ 1264.38 $ 1264.38 90 10% 69% 21% 0 2 0 2 0 0 R 25270 $ 831.32 $ 831.32 90 10% 69% 21% 0 2 0 0 0 0 R 25272 $ 936.89 $ 936.89 90 10% 69% 21% 0 2 0 0 0 0 R 25274 $ 1133.62 $ 1133.62 90 10% 69% 21% 0 2 0 0 1 0 R 25275 $ 1135.42 $ 1135.42 90 10% 69% 21% 0 2 1 0 1 0 R 25280 $ 954.28 $ 954.28 90 10% 69% 21% 0 2 0 0 1 0 R 25290 $ 740.15 $ 740.15 90 10% 69% 21% 0 2 0 1 0 0 R 25295 $ 885.30 $ 885.30 90 10% 69% 21% 0 2 0 1 0 0 R 25300 $ 1157.61 $ 1157.61 90 10% 69% 21% 0 2 1 2 0 0 R 25301 $ 1087.44 $ 1087.44 90 10% 69% 21% 0 2 1 2 0 0 R 25310 $ 1049.65 $ 1049.65 90 10% 69% 21% 0 2 0 2 1 0 R 25312 $ 1213.40 $ 1213.40 90 10% 69% 21% 0 2 0 2 1 0 R 25315 $ 1300.37 $ 1300.37 90 10% 69% 21% 0 2 1 2 0 0 R 25316 $ 1537.89 $ 1537.89 90 10% 69% 21% 0 2 1 2 0 0 R 25320 $ 1673.44 $ 1673.44 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR25332 $ 1419.73 $ 1419.73 90 10% 69% 21% 0 2 1 2 0 0 R 25335 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 0 0 X 25337 $ 1505.50 $ 1505.50 90 10% 69% 21% 0 2 1 1 0 0 R 25350 $ 1141.42 $ 1141.42 90 10% 69% 21% 0 2 1 2 0 0 R 25355 $ 1293.17 $ 1293.17 90 10% 69% 21% 0 2 1 2 0 0 R 25360 $ 1106.03 $ 1106.03 90 10% 69% 21% 0 2 1 2 1 0 R 25365 $ 1539.69 $ 1539.69 90 10% 69% 21% 0 2 1 2 0 0 R 25370 $ 1695.03 $ 1695.03 90 10% 69% 21% 0 2 1 2 0 0 R 25375 $ 1603.27 $ 1603.27 90 10% 69% 21% 0 2 1 2 1 0 R 25390 $ 1300.37 $ 1300.37 90 10% 69% 21% 0 2 1 2 1 0 R 25391 $ 1675.24 $ 1675.24 90 10% 69% 21% 0 2 1 2 1 0 R 25392 $ 1714.23 $ 1714.23 90 10% 69% 21% 0 2 1 2 0 0 R 25393 $ 1912.76 $ 1912.76 90 10% 69% 21% 0 2 1 2 0 0 R 25394 $ 1341.15 $ 1341.15 90 10% 69% 21% 0 2 1 2 1 0 R 25400 $ 1354.95 $ 1354.95 90 10% 69% 21% 0 2 1 2 1 0 R 25405 $ 1743.02 $ 1743.02 90 10% 69% 21% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 31
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
25415 $ 1627.86 $ 1627.86 90 10% 69% 21% 0 2 1 2 1 0 R 25420 $ 1964.35 $ 1964.35 90 10% 69% 21% 0 2 1 2 1 0 R 25425 $ 1620.06 $ 1620.06 90 10% 69% 21% 0 2 1 2 1 0 R 25426 $ 1889.37 $ 1889.37 90 10% 69% 21% 0 2 1 2 1 0 R 25430 $ 1236.79 $ 1236.79 90 10% 69% 21% 0 2 1 1 0 0 R 25431 $ 1332.76 $ 1332.76 90 10% 69% 21% 0 2 1 2 1 0 R 25440 $ 1297.97 $ 1297.97 90 10% 69% 21% 0 2 1 2 1 0 R 25441 $ 1582.87 $ 1582.87 90 10% 69% 21% 0 2 1 2 1 0 R 25442 $ 1355.55 $ 1355.55 90 10% 69% 21% 0 2 1 2 1 0 R 25443 $ 1317.76 $ 1317.76 90 10% 69% 21% 0 2 1 2 1 0 R 25444 $ 1392.14 $ 1392.14 90 10% 69% 21% 0 2 1 2 0 0 R 25445 $ 1218.19 $ 1218.19 90 10% 69% 21% 0 2 1 1 1 0 R 25446 $ 1972.14 $ 1972.14 90 10% 69% 21% 0 2 1 2 1 0 R 25447 $ 1400.53 $ 1400.53 90 10% 69% 21% 0 2 1 2 1 0 R 25449 $ 1740.02 $ 1740.02 90 10% 69% 21% 0 2 1 2 1 0 R 25450 $ 863.11 $ 863.11 90 10% 69% 21% 0 2 1 1 0 0 R Y25455 $ 1021.46 $ 1021.46 90 10% 69% 21% 0 2 1 1 0 0 R Y25490 $ 1111.43 $ 1111.43 90 10% 69% 21% 0 2 1 2 0 0 R 25491 $ 1248.18 $ 1248.18 90 10% 69% 21% 0 2 1 2 0 0 R 25492 $ 1522.29 $ 1522.29 90 10% 69% 21% 0 2 1 2 0 0 R 25500 $ 468.44 $ 427.66 90 10% 69% 21% 0 2 1 1 0 0 R 25505 $ 857.71 $ 782.74 90 10% 69% 21% 0 2 1 1 0 0 R 25515 $ 1134.22 $ 1134.22 90 10% 69% 21% 0 2 1 2 1 0 R 25520 $ 965.68 $ 912.90 90 10% 69% 21% 0 2 1 1 0 0 R 25525 $ 1327.36 $ 1327.36 90 10% 69% 21% 0 2 1 2 2 0 R 25526 $ 1612.86 $ 1612.86 90 10% 69% 21% 0 2 1 2 2 0 R 25530 $ 452.25 $ 406.66 90 10% 69% 21% 0 2 1 1 0 0 R 25535 $ 835.52 $ 769.54 90 10% 69% 21% 0 2 1 1 0 0 R 25545 $ 1057.45 $ 1057.45 90 10% 69% 21% 0 2 1 2 1 0 R 25560 $ 477.44 $ 429.46 90 10% 69% 21% 0 2 1 1 0 0 R 25565 $ 885.30 $ 797.13 90 10% 69% 21% 0 2 1 1 0 0 R 25574 $ 1141.42 $ 1141.42 90 10% 69% 21% 0 2 1 2 2 0 R 25575 $ 1519.89 $ 1519.89 90 10% 69% 21% 0 2 1 2 1 0 R 25600 $ 566.21 $ 533.82 90 10% 69% 21% 0 2 1 1 0 0 R 25605 $ 929.69 $ 870.91 90 10% 69% 21% 0 2 1 1 0 0 R 25606 $ 1124.03 $ 1124.03 90 10% 69% 21% 0 2 1 1 0 0 R 25607 $ 1243.99 $ 1243.99 90 10% 69% 21% 0 2 1 2 0 0 R 25608 $ 1393.34 $ 1393.34 90 10% 69% 21% 0 2 1 2 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 32
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
25609 $ 1768.81 $ 1768.81 90 10% 69% 21% 0 2 1 2 0 0 R 25622 $ 522.43 $ 473.24 90 10% 69% 21% 0 2 1 1 0 0 R 25624 $ 819.33 $ 741.95 90 10% 69% 21% 0 2 1 0 0 0 R 25628 $ 1219.39 $ 1219.39 90 10% 69% 21% 0 2 1 2 0 0 R 25630 $ 523.03 $ 478.04 90 10% 69% 21% 0 2 1 1 0 0 R 25635 $ 760.55 $ 672.38 90 10% 69% 21% 0 2 1 0 0 0 R 25645 $ 963.88 $ 963.88 90 10% 69% 21% 0 2 1 2 0 0 R 25650 $ 547.62 $ 512.23 90 10% 69% 21% 0 2 1 1 0 0 R 25651 $ 824.73 $ 824.73 90 10% 69% 21% 0 2 1 0 0 0 R 25652 $ 1055.65 $ 1055.65 90 10% 69% 21% 0 2 1 1 1 0 R 25660 $ 697.57 $ 697.57 90 10% 69% 21% 0 2 1 0 0 0 R 25670 $ 1023.26 $ 1023.26 90 10% 69% 21% 0 2 1 2 1 0 R 25671 $ 899.10 $ 899.10 90 10% 69% 21% 0 2 1 1 0 0 R 25675 $ 746.75 $ 677.17 90 10% 69% 21% 0 2 1 0 0 0 R 25676 $ 1062.25 $ 1062.25 90 10% 69% 21% 0 2 1 2 0 0 R 25680 $ 794.74 $ 794.74 90 10% 69% 21% 0 2 1 0 0 0 R 25685 $ 1241.59 $ 1241.59 90 10% 69% 21% 0 2 1 2 0 0 R 25690 $ 816.93 $ 816.93 90 10% 69% 21% 0 2 1 0 0 0 R 25695 $ 1069.44 $ 1069.44 90 10% 69% 21% 0 2 1 2 1 0 R 25800 $ 1236.79 $ 1236.79 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR25805 $ 1423.93 $ 1423.93 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR25810 $ 1466.51 $ 1466.51 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR25820 $ 1045.45 $ 1045.45 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR25825 $ 1284.77 $ 1284.77 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR25830 $ 1623.06 $ 1623.06 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR25900 $ 1190.60 $ 1190.60 90 10% 69% 21% 0 2 1 0 0 0 R 25905 $ 1183.41 $ 1183.41 90 10% 69% 21% 0 2 1 2 0 0 R 25907 $ 1035.85 $ 1035.85 90 10% 69% 21% 0 2 1 2 0 0 R 25909 $ 1156.41 $ 1156.41 90 10% 69% 21% 0 2 1 2 0 0 R 25915 $ 1680.64 $ 1680.64 90 10% 69% 21% 0 2 1 2 0 0 R 25920 $ 1179.21 $ 1179.21 90 10% 69% 21% 0 2 1 0 0 0 R 25922 $ 1036.45 $ 1036.45 90 10% 69% 21% 0 2 1 2 0 0 R 25924 $ 1151.02 $ 1151.02 90 10% 69% 21% 0 2 1 2 0 0 R 25927 $ 1383.14 $ 1383.14 90 10% 69% 21% 0 2 1 0 0 0 R 25929 $ 908.70 $ 908.70 90 10% 69% 21% 0 2 1 2 0 0 R 25931 $ 1272.78 $ 1272.78 90 10% 69% 21% 0 2 1 1 0 0 R 25999 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 26010 $ 461.85 $ 236.32 10 10% 80% 10% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 33
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
26011 $ 681.37 $ 315.49 10 10% 80% 10% 0 2 0 1 0 0 R 26020 $ 737.75 $ 737.75 90 10% 69% 21% 0 2 0 1 0 0 R 26025 $ 719.16 $ 719.16 90 10% 69% 21% 0 2 1 0 0 0 R 26030 $ 834.92 $ 834.92 90 10% 69% 21% 0 2 1 0 0 0 R 26034 $ 914.10 $ 914.10 90 10% 69% 21% 0 2 0 1 0 0 R 26035 $ 1449.12 $ 1449.12 90 10% 69% 21% 0 2 0 0 0 0 R 26037 $ 955.48 $ 955.48 90 10% 69% 21% 0 2 1 0 0 0 R 26040 $ 531.42 $ 531.42 90 10% 69% 21% 0 2 1 1 0 0 R 26045 $ 793.54 $ 793.54 90 10% 69% 21% 0 2 1 1 0 0 R 26055 $ 975.87 $ 531.42 90 10% 69% 21% 0 2 0 1 0 0 R 26060 $ 448.05 $ 448.05 90 10% 69% 21% 0 2 0 0 0 0 R 26070 $ 538.62 $ 538.62 90 10% 69% 21% 0 2 1 1 0 0 R 26075 $ 568.01 $ 568.01 90 10% 69% 21% 0 2 1 1 0 0 R 26080 $ 663.98 $ 663.98 90 10% 69% 21% 0 2 0 1 0 0 R 26100 $ 570.41 $ 570.41 90 10% 69% 21% 0 2 1 0 0 0 R 26105 $ 574.01 $ 574.01 90 10% 69% 21% 0 2 1 0 0 0 R 26110 $ 547.62 $ 547.62 90 10% 69% 21% 0 2 0 1 0 0 R 26111 $ 708.36 $ 708.36 90 10% 69% 21% 0 2 0 2 0 0 R26113 $ 928.49 $ 928.49 90 10% 69% 21% 0 2 0 2 0 0 R26115 $ 872.71 $ 565.61 90 10% 69% 21% 0 2 0 1 0 0 R 26116 $ 893.10 $ 893.10 90 10% 69% 21% 0 2 0 1 0 0 R 26117 Not Covered Not Covered 90 10% 69% 21% 0 2 0 1 0 0 X 26118 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 0 0 X26121 $ 1011.26 $ 1011.26 90 10% 69% 21% 0 2 1 1 0 0 R 26123 $ 1411.33 $ 1411.33 90 10% 69% 21% 0 2 1 1 0 0 R 26125 $ 458.85 $ 458.85 0 0% 0% 0% 0 0 0 1 0 0 R 26130 $ 784.54 $ 784.54 90 10% 69% 21% 0 2 1 1 0 0 R 26135 $ 930.29 $ 930.29 90 10% 69% 21% 0 2 0 0 0 0 R 26140 $ 854.72 $ 854.72 90 10% 69% 21% 0 2 0 1 0 0 R 26145 $ 867.31 $ 867.31 90 10% 69% 21% 0 2 0 1 0 0 R 26160 $ 1000.47 $ 569.81 90 10% 69% 21% 0 2 0 1 0 0 R 26170 $ 691.57 $ 691.57 90 10% 69% 21% 0 2 0 0 0 0 R 26180 $ 755.15 $ 755.15 90 10% 69% 21% 0 2 0 0 0 0 R 26185 $ 928.49 $ 928.49 90 10% 69% 21% 0 2 1 2 1 0 R 26200 $ 760.55 $ 760.55 90 10% 69% 21% 0 2 0 0 0 0 R 26205 $ 1017.26 $ 1017.26 90 10% 69% 21% 0 2 0 1 0 0 R 26210 $ 750.95 $ 750.95 90 10% 69% 21% 0 2 0 1 0 0 R 26215 $ 952.48 $ 952.48 90 10% 69% 21% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 34
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
26230 $ 846.92 $ 846.92 90 10% 69% 21% 0 2 0 0 0 0 R 26235 $ 836.12 $ 836.12 90 10% 69% 21% 0 2 0 0 0 0 R 26236 $ 746.75 $ 746.75 90 10% 69% 21% 0 2 0 1 0 0 R 26250 $ 1825.79 $ 1825.79 90 10% 69% 21% 0 2 0 0 0 0 R 26260 $ 1355.55 $ 1355.55 90 10% 69% 21% 0 2 0 2 0 0 R 26262 $ 1073.04 $ 1073.04 90 10% 69% 21% 0 2 0 2 0 0 R 26320 $ 589.60 $ 589.60 90 10% 69% 21% 0 2 0 1 0 0 R 26340 $ 575.81 $ 575.81 90 10% 69% 21% 0 2 1 1 0 0 R 26341 $ 170.34 $ 127.76 10 10% 80% 10% 0 2 1 1 0 0 R26350 $ 1211.60 $ 1211.60 90 10% 69% 21% 0 2 0 1 0 0 R 26352 $ 1371.14 $ 1371.14 90 10% 69% 21% 0 2 0 2 1 0 R 26356 $ 1859.38 $ 1859.38 90 10% 69% 21% 0 2 0 1 0 0 R 26357 $ 1476.11 $ 1476.11 90 10% 69% 21% 0 2 0 2 0 0 R 26358 $ 1529.49 $ 1529.49 90 10% 69% 21% 0 2 0 2 0 0 R 26370 $ 1288.37 $ 1288.37 90 10% 69% 21% 0 2 0 0 0 0 R 26372 $ 1499.50 $ 1499.50 90 10% 69% 21% 0 2 0 2 0 0 R 26373 $ 1413.13 $ 1413.13 90 10% 69% 21% 0 2 0 2 0 0 R 26390 $ 1409.53 $ 1409.53 90 10% 69% 21% 0 2 0 2 1 0 R 26392 $ 1646.45 $ 1646.45 90 10% 69% 21% 0 2 0 2 1 0 R 26410 $ 960.88 $ 960.88 90 10% 69% 21% 0 2 0 1 0 0 R 26412 $ 1175.61 $ 1175.61 90 10% 69% 21% 0 2 0 0 0 0 R 26415 $ 1175.61 $ 1175.61 90 10% 69% 21% 0 2 0 0 0 0 R 26416 $ 1497.10 $ 1497.10 90 10% 69% 21% 0 2 0 1 0 0 R 26418 $ 986.67 $ 986.67 90 10% 69% 21% 0 2 0 1 0 0 R 26420 $ 1198.40 $ 1198.40 90 10% 69% 21% 0 2 0 2 0 0 R 26426 $ 848.72 $ 848.72 90 10% 69% 21% 0 2 0 1 0 0 R 26428 $ 1258.38 $ 1258.38 90 10% 69% 21% 0 2 0 0 0 0 R 26432 $ 852.32 $ 852.32 90 10% 69% 21% 0 2 0 1 0 0 R 26433 $ 903.30 $ 903.30 90 10% 69% 21% 0 2 0 1 0 0 R 26434 $ 1097.03 $ 1097.03 90 10% 69% 21% 0 2 0 2 0 0 R 26437 $ 1055.65 $ 1055.65 90 10% 69% 21% 0 2 0 1 0 0 R 26440 $ 1055.05 $ 1055.05 90 10% 69% 21% 0 2 0 1 0 0 R 26442 $ 1633.86 $ 1633.86 90 10% 69% 21% 0 2 0 1 0 0 R 26445 $ 983.07 $ 983.07 90 10% 69% 21% 0 2 0 1 0 0 R 26449 $ 1182.21 $ 1182.21 90 10% 69% 21% 0 2 0 0 0 0 R 26450 $ 690.97 $ 690.97 90 10% 69% 21% 0 2 0 0 0 0 R 26455 $ 686.77 $ 686.77 90 10% 69% 21% 0 2 0 0 0 0 R 26460 $ 666.38 $ 666.38 90 10% 69% 21% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 35
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
26471 $ 1040.65 $ 1040.65 90 10% 69% 21% 0 2 0 0 0 0 R 26474 $ 1022.06 $ 1022.06 90 10% 69% 21% 0 2 0 2 0 0 R 26476 $ 992.07 $ 992.07 90 10% 69% 21% 0 2 0 1 0 0 R 26477 $ 982.47 $ 982.47 90 10% 69% 21% 0 2 0 1 1 0 R 26478 $ 1047.25 $ 1047.25 90 10% 69% 21% 0 2 0 0 0 0 R 26479 $ 1040.65 $ 1040.65 90 10% 69% 21% 0 2 0 2 0 0 R 26480 $ 1278.17 $ 1278.17 90 10% 69% 21% 0 2 0 0 0 0 R 26483 $ 1424.53 $ 1424.53 90 10% 69% 21% 0 2 0 2 1 0 R 26485 $ 1368.14 $ 1368.14 90 10% 69% 21% 0 2 0 2 1 0 R 26489 $ 1582.87 $ 1582.87 90 10% 69% 21% 0 2 0 0 0 0 R 26490 $ 1344.15 $ 1344.15 90 10% 69% 21% 0 2 0 0 0 0 R 26492 $ 1488.10 $ 1488.10 90 10% 69% 21% 0 2 0 2 1 0 R 26494 $ 1317.76 $ 1317.76 90 10% 69% 21% 0 2 0 2 1 0 R 26496 $ 1444.32 $ 1444.32 90 10% 69% 21% 0 2 0 0 0 0 R 26497 $ 1458.71 $ 1458.71 90 10% 69% 21% 0 2 0 2 0 0 R 26498 $ 1931.96 $ 1931.96 90 10% 69% 21% 0 2 0 2 1 0 R 26499 $ 1382.54 $ 1382.54 90 10% 69% 21% 0 2 0 2 1 0 R 26500 $ 1054.45 $ 1054.45 90 10% 69% 21% 0 2 0 0 0 0 R 26502 $ 1200.80 $ 1200.80 90 10% 69% 21% 0 2 0 2 0 0 R 26508 $ 1064.05 $ 1064.05 90 10% 69% 21% 0 2 1 0 0 0 R 26510 $ 1010.06 $ 1010.06 90 10% 69% 21% 0 2 0 0 0 0 R 26516 $ 1182.81 $ 1182.81 90 10% 69% 21% 0 2 1 0 0 0 R 26517 $ 1392.14 $ 1392.14 90 10% 69% 21% 0 2 1 2 0 0 R 26518 $ 1393.34 $ 1393.34 90 10% 69% 21% 0 2 1 2 1 0 R 26520 $ 1108.43 $ 1108.43 90 10% 69% 21% 0 2 0 1 0 0 R 26525 $ 1109.03 $ 1109.03 90 10% 69% 21% 0 2 0 1 1 0 R 26530 $ 910.50 $ 910.50 90 10% 69% 21% 0 2 0 2 0 0 R 26531 $ 1056.25 $ 1056.25 90 10% 69% 21% 0 2 0 2 1 0 R 26535 $ 716.16 $ 716.16 90 10% 69% 21% 0 2 0 1 0 0 R 26536 $ 1209.20 $ 1209.20 90 10% 69% 21% 0 2 0 0 0 0 R 26540 $ 1110.23 $ 1110.23 90 10% 69% 21% 0 2 0 0 1 0 R 26541 $ 1350.15 $ 1350.15 90 10% 69% 21% 0 2 0 2 1 0 R 26542 $ 1148.62 $ 1148.62 90 10% 69% 21% 0 2 0 0 0 0 R 26545 $ 1197.80 $ 1197.80 90 10% 69% 21% 0 2 0 0 0 0 R 26546 $ 1681.84 $ 1681.84 90 10% 69% 21% 0 2 1 2 0 0 R 26548 $ 1281.77 $ 1281.77 90 10% 69% 21% 0 2 0 0 0 0 R 26550 $ 2759.08 $ 2759.08 90 10% 69% 21% 0 2 1 2 0 0 R 26551 $ 5519.96 $ 5519.96 90 10% 69% 21% 0 2 1 2 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 36
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
26553 $ 4667.04 $ 4667.04 90 10% 69% 21% 0 2 1 2 1 0 R 26554 $ 5457.58 $ 5457.58 90 10% 69% 21% 0 2 1 2 1 0 R 26555 $ 2305.03 $ 2305.03 90 10% 69% 21% 0 2 0 2 0 0 R 26556 $ 4637.05 $ 4637.05 90 10% 69% 21% 0 2 0 2 1 0 R 26560 $ 1002.87 $ 1002.87 90 10% 69% 21% 0 2 0 2 0 0 R 26561 $ 1567.88 $ 1567.88 90 10% 69% 21% 0 2 0 2 1 0 R 26562 $ 2241.45 $ 2241.45 90 10% 69% 21% 0 2 0 2 0 0 R 26565 $ 1146.22 $ 1146.22 90 10% 69% 21% 0 2 0 2 0 0 R 26567 $ 1148.02 $ 1148.02 90 10% 69% 21% 0 2 0 0 0 0 R 26568 $ 1524.69 $ 1524.69 90 10% 69% 21% 0 2 0 2 0 0 R 26580 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 0 0 X 26587 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 0 0 X 26590 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 0 0 X 26591 $ 741.95 $ 741.95 90 10% 69% 21% 0 2 0 0 0 0 R 26593 $ 1019.06 $ 1019.06 90 10% 69% 21% 0 2 0 1 0 0 R 26596 $ 1273.38 $ 1273.38 90 10% 69% 21% 0 2 0 2 0 0 R 26600 $ 506.23 $ 475.04 90 10% 69% 21% 0 2 0 1 0 0 R 26605 $ 553.02 $ 500.83 90 10% 69% 21% 0 2 0 1 0 0 R 26607 $ 775.54 $ 775.54 90 10% 69% 21% 0 2 0 0 0 0 R 26608 $ 809.73 $ 809.73 90 10% 69% 21% 0 2 0 0 0 0 R 26615 $ 978.87 $ 978.87 90 10% 69% 21% 0 2 0 1 0 0 R 26641 $ 644.79 $ 583.61 90 10% 69% 21% 0 2 1 0 0 0 R 26645 $ 729.36 $ 665.78 90 10% 69% 21% 0 2 1 0 0 0 R 26650 $ 815.73 $ 815.73 90 10% 69% 21% 0 2 1 1 0 0 R 26665 $ 1067.04 $ 1067.04 90 10% 69% 21% 0 2 1 1 1 0 R 26670 $ 575.21 $ 520.03 90 10% 69% 21% 0 2 0 0 0 0 R 26675 $ 775.54 $ 709.56 90 10% 69% 21% 0 2 0 0 0 0 R 26676 $ 852.32 $ 852.32 90 10% 69% 21% 0 2 0 1 0 0 R 26685 $ 979.47 $ 979.47 90 10% 69% 21% 0 2 0 1 1 0 R 26686 $ 1054.45 $ 1054.45 90 10% 69% 21% 0 2 0 2 0 0 R 26700 $ 547.62 $ 511.63 90 10% 69% 21% 0 2 0 1 0 0 R 26705 $ 708.96 $ 645.98 90 10% 69% 21% 0 2 0 0 0 0 R 26706 $ 744.95 $ 744.95 90 10% 69% 21% 0 2 0 1 0 0 R 26715 $ 972.28 $ 972.28 90 10% 69% 21% 0 2 0 0 0 0 R 26720 $ 341.29 $ 316.09 90 10% 69% 21% 0 2 0 1 0 0 R 26725 $ 575.81 $ 515.83 90 10% 69% 21% 0 2 0 1 0 0 R 26727 $ 797.73 $ 797.73 90 10% 69% 21% 0 2 0 1 0 0 R 26735 $ 1013.06 $ 1013.06 90 10% 69% 21% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 37
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
26740 $ 394.07 $ 368.88 90 10% 69% 21% 0 2 0 1 0 0 R 26742 $ 624.39 $ 562.61 90 10% 69% 21% 0 2 0 1 0 0 R 26746 $ 1254.78 $ 1254.78 90 10% 69% 21% 0 2 0 1 0 0 R 26750 $ 316.09 $ 316.69 90 10% 69% 21% 0 2 0 1 0 0 R 26755 $ 537.42 $ 463.65 90 10% 69% 21% 0 2 0 1 0 0 R 26756 $ 711.36 $ 711.36 90 10% 69% 21% 0 2 0 0 0 0 R 26765 $ 852.92 $ 852.92 90 10% 69% 21% 0 2 0 1 0 0 R 26770 $ 470.24 $ 433.06 90 10% 69% 21% 0 2 0 1 0 0 R 26775 $ 656.18 $ 590.80 90 10% 69% 21% 0 2 0 1 0 0 R 26776 $ 753.35 $ 753.35 90 10% 69% 21% 0 2 0 1 0 0 R 26785 $ 929.09 $ 929.09 90 10% 69% 21% 0 2 0 1 0 0 R 26820 $ 1329.76 $ 1329.76 90 10% 69% 21% 0 2 1 2 1 0 R 26841 $ 1228.39 $ 1228.39 90 10% 69% 21% 0 2 1 0 1 0 R 26842 $ 1322.56 $ 1322.56 90 10% 69% 21% 0 2 1 2 1 0 R 26843 $ 1246.98 $ 1246.98 90 10% 69% 21% 0 2 0 2 1 0 R 26844 $ 1367.54 $ 1367.54 90 10% 69% 21% 0 2 0 2 1 0 R 26850 $ 1168.41 $ 1168.41 90 10% 69% 21% 0 2 0 0 0 0 R 26852 $ 1339.95 $ 1339.95 90 10% 69% 21% 0 2 0 2 1 0 R 26860 $ 960.28 $ 960.28 90 10% 69% 21% 0 2 0 1 0 0 R 26861 $ 173.34 $ 173.34 0 0% 0% 0% 0 0 0 1 0 0 R 26862 $ 1225.99 $ 1225.99 90 10% 69% 21% 0 2 0 2 1 0 R 26863 $ 386.27 $ 386.27 0 0% 0% 0% 0 0 0 2 0 0 R 26910 $ 1206.20 $ 1206.20 90 10% 69% 21% 0 2 0 1 0 0 R 26951 $ 1107.23 $ 1107.23 90 10% 69% 21% 0 2 0 1 0 0 R 26952 $ 1090.44 $ 1090.44 90 10% 69% 21% 0 2 0 1 0 0 R 26989 By Report By Report 90 0% 0% 0% 0 2 0 1 1 1 N 26990 $ 1059.25 $ 1059.25 90 10% 69% 21% 0 2 0 1 0 0 R 26991 $ 1205.60 $ 879.91 90 10% 69% 21% 0 2 0 0 0 0 R 26992 $ 1618.86 $ 1618.86 90 10% 69% 21% 0 2 0 0 0 0 R 27000 $ 705.36 $ 705.36 90 10% 69% 21% 0 2 1 1 1 0 R 27001 $ 912.90 $ 912.90 90 10% 69% 21% 0 2 1 2 1 0 R 27003 $ 1008.26 $ 1008.26 90 10% 69% 21% 0 2 1 2 1 0 R 27005 $ 1224.19 $ 1224.19 90 10% 69% 21% 0 2 1 2 1 0 R 27006 $ 1243.39 $ 1243.39 90 10% 69% 21% 0 2 1 2 1 0 R 27025 $ 1539.69 $ 1539.69 90 10% 69% 21% 0 2 1 0 1 0 R 27027 $ 1495.30 $ 1495.30 90 10% 69% 21% 0 2 1 0 0 0 R 27030 $ 1577.47 $ 1577.47 90 10% 69% 21% 0 2 1 2 1 0 R 27033 $ 1635.05 $ 1635.05 90 10% 69% 21% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 38
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
27035 $ 1856.38 $ 1856.38 90 10% 69% 21% 0 2 1 2 1 0 R Y27036 $ 1706.43 $ 1706.43 90 10% 69% 21% 0 2 1 2 1 0 R 27040 $ 598.00 $ 339.49 10 10% 80% 10% 0 2 1 1 0 0 R 27041 $ 1156.41 $ 1156.41 90 10% 69% 21% 0 2 1 1 0 0 R 27043 $ 782.14 $ 782.14 90 10% 69% 21% 0 2 1 1 0 0 R27045 $ 1254.18 $ 1254.18 90 10% 69% 21% 0 2 1 2 1 0 R27047 $ 800.73 $ 611.20 90 10% 69% 21% 0 2 1 1 0 0 R 27048 $ 1019.06 $ 1019.06 90 10% 69% 21% 0 2 1 2 1 0 R 27049 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 27050 $ 683.77 $ 683.77 90 10% 69% 21% 0 2 1 0 1 0 R 27052 $ 981.87 $ 981.87 90 10% 69% 21% 0 2 1 2 1 0 R 27054 $ 1157.61 $ 1157.61 90 10% 69% 21% 0 2 1 2 1 0 R 27057 $ 1705.23 $ 1705.23 90 10% 69% 21% 0 2 1 0 0 0 R 27059 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X27060 $ 788.14 $ 788.14 90 10% 69% 21% 0 2 1 1 0 0 R 27062 $ 774.34 $ 774.34 90 10% 69% 21% 0 2 1 1 1 0 R 27065 $ 879.91 $ 879.91 90 10% 69% 21% 0 2 1 2 1 0 R 27066 $ 1372.94 $ 1372.94 90 10% 69% 21% 0 2 1 2 1 0 R 27067 $ 1743.02 $ 1743.02 90 10% 69% 21% 0 2 1 2 0 0 R 27070 $ 1433.52 $ 1433.52 90 10% 69% 21% 0 2 1 2 1 0 R 27071 $ 1544.49 $ 1544.49 90 10% 69% 21% 0 2 1 2 1 0 R 27075 $ 3527.42 $ 3527.42 90 10% 69% 21% 0 2 0 2 1 0 R 27076 $ 4265.78 $ 4265.78 90 10% 69% 21% 0 2 0 2 1 0 R 27077 $ 4758.81 $ 4758.81 90 10% 69% 21% 0 2 0 2 1 0 R 27078 $ 3478.84 $ 3478.84 90 10% 69% 21% 0 2 1 2 1 0 R 27080 $ 863.71 $ 863.71 90 10% 69% 21% 0 2 0 2 1 0 R 27086 $ 515.23 $ 287.30 10 10% 80% 10% 0 2 1 0 0 0 R 27087 $ 1053.25 $ 1053.25 90 10% 69% 21% 0 2 1 2 1 0 R 27090 $ 1394.54 $ 1394.54 90 10% 69% 21% 0 2 1 2 1 0 R 27091 $ 2685.30 $ 2685.30 90 10% 69% 21% 0 2 1 2 1 0 R 27093 $ 328.69 $ 119.96 0 0% 0% 0% 0 2 1 1 0 0 R 27095 $ 424.66 $ 140.35 0 0% 0% 0% 0 2 1 1 0 0 R 27096 $ 280.71 $ 145.15 0 0% 0% 0% 0 2 1 1 0 0 R Y-UR27097 $ 1151.62 $ 1151.62 90 10% 69% 21% 0 2 1 2 0 0 R 27098 $ 1173.21 $ 1173.21 90 10% 69% 21% 0 2 1 2 0 0 R 27100 $ 1393.34 $ 1393.34 90 10% 69% 21% 0 2 1 2 1 0 R 27105 $ 1461.11 $ 1461.11 90 10% 69% 21% 0 2 1 2 0 0 R 27110 $ 1631.46 $ 1631.46 90 10% 69% 21% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 39
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
27111 $ 1516.89 $ 1516.89 90 10% 69% 21% 0 2 1 2 1 0 R 27120 $ 2187.47 $ 2187.47 90 10% 69% 21% 0 2 1 2 1 0 R 27122 $ 1849.18 $ 1849.18 90 10% 69% 21% 0 2 1 2 1 0 R 27125 $ 1909.16 $ 1909.16 90 10% 69% 21% 0 2 1 2 1 0 R 27130 $ 2281.64 $ 2281.64 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27132 $ 2817.26 $ 2817.26 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27134 $ 3216.13 $ 3216.13 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27137 $ 2477.17 $ 2477.17 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27138 $ 2571.94 $ 2571.94 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27140 $ 1510.90 $ 1510.90 90 10% 69% 21% 0 2 1 2 1 0 R 27146 $ 2156.28 $ 2156.28 90 10% 69% 21% 0 2 1 2 1 0 R 27147 $ 2472.98 $ 2472.98 90 10% 69% 21% 0 2 1 2 1 0 R 27151 $ 2675.11 $ 2675.11 90 10% 69% 21% 0 2 1 2 1 0 R 27156 $ 2882.64 $ 2882.64 90 10% 69% 21% 0 2 1 2 1 0 R 27158 $ 2358.41 $ 2358.41 90 10% 69% 21% 0 2 2 2 0 0 R 27161 $ 2047.72 $ 2047.72 90 10% 69% 21% 0 2 1 2 1 0 R 27165 $ 2312.23 $ 2312.23 90 10% 69% 21% 0 2 1 2 1 0 R 27170 $ 1981.14 $ 1981.14 90 10% 69% 21% 0 2 1 2 1 0 R 27175 $ 1124.63 $ 1124.63 90 10% 69% 21% 0 2 1 0 0 0 R Y27176 $ 1548.08 $ 1548.08 90 10% 69% 21% 0 2 1 2 1 0 R Y27177 $ 1876.17 $ 1876.17 90 10% 69% 21% 0 2 1 2 1 0 R Y27178 $ 1548.08 $ 1548.08 90 10% 69% 21% 0 2 1 2 1 0 R Y27179 $ 1644.05 $ 1644.05 90 10% 69% 21% 0 2 1 2 0 0 R Y27181 $ 1892.97 $ 1892.97 90 10% 69% 21% 0 2 1 2 0 0 R Y27185 $ 1013.66 $ 1013.66 90 10% 69% 21% 0 2 1 1 1 0 R Y27187 $ 1671.64 $ 1671.64 90 10% 69% 21% 0 2 1 2 1 0 R Y27193 $ 796.53 $ 807.93 90 10% 69% 21% 0 2 0 1 0 0 R 27194 $ 1205.60 $ 1205.60 90 10% 69% 21% 0 2 0 0 2 0 R 27200 $ 309.50 $ 323.89 90 10% 69% 21% 0 2 0 1 0 0 R 27202 $ 899.10 $ 899.10 90 10% 69% 21% 0 2 0 2 0 0 R 27215 $ 1035.85 $ 1035.85 90 10% 69% 21% 9 9 9 9 9 9 R 27216 $ 1534.89 $ 1534.89 90 10% 69% 21% 9 9 9 9 9 9 R 27217 $ 1441.32 $ 1441.32 90 10% 69% 21% 9 9 9 9 9 9 R 27218 $ 1984.14 $ 1984.14 90 10% 69% 21% 9 9 9 9 9 9 R 27220 $ 897.90 $ 889.50 90 10% 69% 21% 0 2 1 1 0 0 R 27222 $ 1647.05 $ 1647.05 90 10% 69% 21% 0 2 1 1 0 0 R 27226 $ 1781.41 $ 1781.41 90 10% 69% 21% 0 2 1 2 2 0 R 27227 $ 2789.67 $ 2789.67 90 10% 69% 21% 0 2 1 2 2 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 40
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
27228 $ 3176.54 $ 3176.54 90 10% 69% 21% 0 2 1 2 2 0 R 27230 $ 806.13 $ 800.13 90 10% 69% 21% 0 2 1 1 0 0 R 27232 $ 1265.58 $ 1265.58 90 10% 69% 21% 0 2 1 1 0 0 R 27235 $ 1531.89 $ 1531.89 90 10% 69% 21% 0 2 1 1 1 0 R 27236 $ 2015.33 $ 2015.33 90 10% 69% 21% 0 2 1 2 1 0 R 27238 $ 780.94 $ 780.94 90 10% 69% 21% 0 2 1 1 0 0 R 27240 $ 1612.26 $ 1612.26 90 10% 69% 21% 0 2 1 1 0 0 R 27244 $ 2073.51 $ 2073.51 90 10% 69% 21% 0 2 1 2 1 0 R 27245 $ 2073.51 $ 2073.51 90 10% 69% 21% 0 2 1 2 2 0 R 27246 $ 652.58 $ 655.58 90 10% 69% 21% 0 2 1 1 0 0 R 27248 $ 1252.98 $ 1252.98 90 10% 69% 21% 0 2 1 2 1 0 R 27250 $ 298.70 $ 298.70 0 0% 0% 0% 0 2 1 1 0 0 R 27252 $ 1279.37 $ 1279.37 90 10% 69% 21% 0 2 1 1 0 0 R 27253 $ 1584.67 $ 1584.67 90 10% 69% 21% 0 2 1 2 1 0 R 27254 $ 2138.29 $ 2138.29 90 10% 69% 21% 0 2 1 2 1 0 R 27256 $ 510.43 $ 392.27 10 10% 80% 10% 0 2 1 0 0 0 R 27257 $ 574.01 $ 574.01 10 10% 80% 10% 0 2 1 0 0 0 R 27258 $ 1868.98 $ 1868.98 90 10% 69% 21% 0 2 1 2 1 0 R 27259 $ 2612.73 $ 2612.73 90 10% 69% 21% 0 2 1 2 0 0 R 27265 $ 676.57 $ 676.57 90 10% 69% 21% 0 2 1 1 0 0 R 27266 $ 983.07 $ 983.07 90 10% 69% 21% 0 2 1 1 0 0 R 27267 $ 734.16 $ 734.16 90 10% 69% 21% 0 2 1 2 1 0 R 27268 $ 910.50 $ 910.50 90 10% 69% 21% 0 2 1 2 1 0 R 27269 $ 2090.90 $ 2090.90 90 10% 69% 21% 0 2 1 2 1 0 R 27275 $ 310.70 $ 310.70 10 10% 80% 10% 0 2 0 1 0 0 R 27279 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X27280 $ 1786.20 $ 1786.20 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27282 $ 1242.19 $ 1242.19 90 10% 69% 21% 0 2 0 2 1 0 R 27284 $ 2545.55 $ 2545.55 90 10% 69% 21% 0 2 1 2 1 0 R 27286 $ 2778.27 $ 2778.27 90 10% 69% 21% 0 2 1 2 1 0 R 27290 $ 2731.49 $ 2731.49 90 10% 69% 21% 0 2 0 2 1 0 R 27295 $ 2103.50 $ 2103.50 90 10% 69% 21% 0 2 1 2 1 0 R 27299 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 27301 $ 1132.42 $ 834.92 90 10% 69% 21% 0 2 1 1 0 0 R 27303 $ 1075.44 $ 1075.44 90 10% 69% 21% 0 2 1 2 1 0 R 27305 $ 818.13 $ 818.13 90 10% 69% 21% 0 2 1 2 1 0 R 27306 $ 615.99 $ 615.99 90 10% 69% 21% 0 2 1 2 0 0 R 27307 $ 813.33 $ 813.33 90 10% 69% 21% 0 2 1 0 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 41
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
27310 $ 1234.99 $ 1234.99 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27323 $ 466.04 $ 302.30 10 10% 80% 10% 0 2 1 1 0 0 R 27324 $ 668.18 $ 668.18 90 10% 69% 21% 0 2 1 1 0 0 R 27325 $ 848.72 $ 848.72 90 10% 69% 21% 0 2 1 2 0 0 R Y27326 $ 870.91 $ 870.91 90 10% 69% 21% 0 2 1 2 1 0 R Y27327 $ 791.14 $ 530.22 90 10% 69% 21% 0 2 1 1 0 0 R 27328 $ 1040.65 $ 1040.65 90 10% 69% 21% 0 2 1 1 0 0 R 27329 $ 1729.82 $ 1729.82 90 10% 69% 21% 0 2 1 2 1 0 R 27330 $ 704.17 $ 704.17 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR27331 $ 806.73 $ 806.73 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27332 $ 1087.44 $ 1087.44 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27333 $ 992.07 $ 992.07 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27334 $ 1157.01 $ 1157.01 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27335 $ 1290.17 $ 1290.17 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27337 $ 698.17 $ 698.17 90 10% 69% 21% 0 2 1 2 0 0 R27339 $ 1260.18 $ 1260.18 90 10% 69% 21% 0 2 1 2 0 0 R27340 $ 632.19 $ 632.19 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR27345 $ 816.33 $ 816.33 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27347 $ 896.70 $ 896.70 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27350 $ 1102.43 $ 1102.43 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27355 $ 1020.86 $ 1020.86 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27356 $ 1246.38 $ 1246.38 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27357 $ 1372.34 $ 1372.34 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27358 $ 466.04 $ 466.04 0 0% 0% 0% 0 0 0 2 0 0 R Y-UR27360 $ 1439.52 $ 1439.52 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27364 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X27365 $ 3468.04 $ 3468.04 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27370 $ 272.31 $ 85.77 0 0% 0% 0% 0 2 1 1 0 0 R 27372 $ 1050.85 $ 685.57 90 10% 69% 21% 0 2 1 0 0 0 R 27380 $ 1007.66 $ 1007.66 90 10% 69% 21% 0 2 1 2 1 0 R 27381 $ 1345.95 $ 1345.95 90 10% 69% 21% 0 2 1 2 1 0 R 27385 $ 978.27 $ 978.27 90 10% 69% 21% 0 2 1 2 1 0 R 27386 $ 1402.33 $ 1402.33 90 10% 69% 21% 0 2 1 2 1 0 R 27390 $ 761.15 $ 761.15 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR27391 $ 976.47 $ 976.47 90 10% 69% 21% 0 2 0 0 1 0 R Y-UR27392 $ 1203.20 $ 1203.20 90 10% 69% 21% 0 2 2 2 1 0 R Y-UR27393 $ 863.11 $ 863.11 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27394 $ 1100.63 $ 1100.63 90 10% 69% 21% 0 2 0 2 0 0 R Y-UR
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 42
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
27395 $ 1480.91 $ 1480.91 90 10% 69% 21% 0 2 2 2 1 0 R Y-UR27396 $ 1041.25 $ 1041.25 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27397 $ 1546.28 $ 1546.28 90 10% 69% 21% 0 2 1 2 0 0 R Y-UR27400 $ 1174.41 $ 1174.41 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27403 $ 1082.64 $ 1082.64 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27405 $ 1144.42 $ 1144.42 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27407 $ 1337.55 $ 1337.55 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27409 $ 1625.46 $ 1625.46 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27412 $ 2782.47 $ 2782.47 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27415 $ 2317.03 $ 2317.03 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27416 $ 1650.05 $ 1650.05 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR27418 $ 1396.93 $ 1396.93 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27420 $ 1249.38 $ 1249.38 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27422 $ 1255.38 $ 1255.38 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27424 $ 1263.78 $ 1263.78 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27425 $ 761.75 $ 761.75 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR27427 $ 1206.20 $ 1206.20 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27428 $ 1880.37 $ 1880.37 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27429 $ 2112.50 $ 2112.50 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27430 $ 1246.98 $ 1246.98 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27435 $ 1364.55 $ 1364.55 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27437 $ 1116.83 $ 1116.83 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR27438 $ 1418.53 $ 1418.53 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27440 $ 1345.95 $ 1345.95 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27441 $ 1390.34 $ 1390.34 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27442 $ 1465.91 $ 1465.91 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27443 $ 1377.14 $ 1377.14 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27445 $ 2107.10 $ 2107.10 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27446 $ 1951.75 $ 1951.75 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27447 $ 2281.04 $ 2281.04 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27448 $ 1297.37 $ 1297.37 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27450 $ 1700.43 $ 1700.43 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27454 $ 2188.07 $ 2188.07 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27455 $ 1588.27 $ 1588.27 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27457 $ 1614.66 $ 1614.66 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27465 $ 2098.10 $ 2098.10 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27466 $ 1993.74 $ 1993.74 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27468 $ 2259.45 $ 2259.45 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 43
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
27470 $ 1981.14 $ 1981.14 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27472 $ 2129.29 $ 2129.29 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27475 Not Covered Not Covered 90 10% 69% 21% 0 2 1 1 1 0 X 27477 Not Covered Not Covered 90 10% 69% 21% 0 2 1 1 1 0 X 27479 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 0 0 X 27485 Not Covered Not Covered 90 10% 69% 21% 0 2 1 1 0 0 X 27486 $ 2368.61 $ 2368.61 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27487 $ 2954.61 $ 2954.61 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27488 $ 2024.33 $ 2024.33 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27495 $ 1898.37 $ 1898.37 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27496 $ 923.09 $ 923.09 90 10% 69% 21% 0 2 1 1 0 0 R 27497 $ 990.87 $ 990.87 90 10% 69% 21% 0 2 1 0 2 0 R 27498 $ 1107.83 $ 1107.83 90 10% 69% 21% 0 2 1 2 2 0 R 27499 $ 1184.01 $ 1184.01 90 10% 69% 21% 0 2 1 2 2 0 R 27500 $ 884.11 $ 813.93 90 10% 69% 21% 0 2 1 1 0 0 R 27501 $ 851.72 $ 843.92 90 10% 69% 21% 0 2 1 0 0 0 R 27502 $ 1290.17 $ 1290.17 90 10% 69% 21% 0 2 1 1 0 0 R 27503 $ 1351.95 $ 1351.95 90 10% 69% 21% 0 2 1 0 0 0 R 27506 $ 2254.05 $ 2254.05 90 10% 69% 21% 0 2 1 2 1 0 R 27507 $ 1636.25 $ 1636.25 90 10% 69% 21% 0 2 1 2 2 0 R 27508 $ 894.30 $ 837.92 90 10% 69% 21% 0 2 1 1 0 0 R 27509 $ 1093.44 $ 1093.44 90 10% 69% 21% 0 2 1 0 0 0 R 27510 $ 1153.42 $ 1153.42 90 10% 69% 21% 0 2 1 1 0 0 R 27511 $ 1675.24 $ 1675.24 90 10% 69% 21% 0 2 1 2 2 0 R 27513 $ 2081.91 $ 2081.91 90 10% 69% 21% 0 2 1 2 2 0 R 27514 $ 1625.46 $ 1625.46 90 10% 69% 21% 0 2 1 2 1 0 R 27516 $ 868.51 $ 812.13 90 10% 69% 21% 0 2 1 1 0 0 R 27517 $ 1160.01 $ 1160.01 90 10% 69% 21% 0 2 1 0 0 0 R 27519 $ 1498.90 $ 1498.90 90 10% 69% 21% 0 2 1 2 1 0 R 27520 $ 556.01 $ 505.03 90 10% 69% 21% 0 2 1 1 0 0 R 27524 $ 1272.78 $ 1272.78 90 10% 69% 21% 0 2 1 2 1 0 R 27530 $ 521.23 $ 481.04 90 10% 69% 21% 0 2 1 1 0 0 R 27532 $ 1047.85 $ 979.47 90 10% 69% 21% 0 2 1 1 0 0 R 27535 $ 1508.50 $ 1508.50 90 10% 69% 21% 0 2 1 2 2 0 R 27536 $ 2005.13 $ 2005.13 90 10% 69% 21% 0 2 1 2 1 0 R 27538 $ 811.53 $ 756.95 90 10% 69% 21% 0 2 1 0 0 0 R 27540 $ 1371.14 $ 1371.14 90 10% 69% 21% 0 2 1 2 1 0 R 27550 $ 857.71 $ 791.74 90 10% 69% 21% 0 2 1 0 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 44
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
27552 $ 1060.45 $ 1060.45 90 10% 69% 21% 0 2 1 0 0 0 R 27556 $ 1473.71 $ 1473.71 90 10% 69% 21% 0 2 1 2 1 0 R 27557 $ 1759.21 $ 1759.21 90 10% 69% 21% 0 2 1 2 1 0 R 27558 $ 2005.13 $ 2005.13 90 10% 69% 21% 0 2 1 2 2 0 R 27560 $ 615.99 $ 565.01 90 10% 69% 21% 0 2 1 1 0 0 R 27562 $ 820.53 $ 820.53 90 10% 69% 21% 0 2 1 0 0 0 R 27566 $ 1504.90 $ 1504.90 90 10% 69% 21% 0 2 1 2 1 0 R 27570 $ 257.91 $ 257.91 10 10% 80% 10% 0 2 1 1 0 0 R 27580 $ 2416.59 $ 2416.59 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27590 $ 1338.75 $ 1338.75 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27591 $ 1627.26 $ 1627.26 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27592 $ 1144.42 $ 1144.42 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27594 $ 851.12 $ 851.12 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR27596 $ 1205.00 $ 1205.00 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR27598 $ 1203.80 $ 1203.80 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR27599 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N Y-UR27600 $ 696.37 $ 696.37 90 10% 69% 21% 0 2 1 1 1 0 R 27601 $ 755.75 $ 755.75 90 10% 69% 21% 0 2 1 1 0 0 R 27602 $ 819.33 $ 819.33 90 10% 69% 21% 0 2 1 2 1 0 R 27603 $ 909.90 $ 656.78 90 10% 69% 21% 0 2 1 1 0 0 R 27604 $ 848.72 $ 584.81 90 10% 69% 21% 0 2 1 0 0 0 R 27605 $ 596.80 $ 316.69 10 10% 80% 10% 0 2 1 0 0 0 R 27606 $ 484.04 $ 484.04 10 10% 80% 10% 0 2 1 1 1 0 R 27607 $ 1034.06 $ 1034.06 90 10% 69% 21% 0 2 1 1 0 0 R 27610 $ 1105.43 $ 1105.43 90 10% 69% 21% 0 2 1 1 0 0 R 27612 $ 964.48 $ 964.48 90 10% 69% 21% 0 2 1 2 1 0 R 27613 $ 436.05 $ 277.71 10 10% 80% 10% 0 2 1 1 0 0 R 27614 $ 990.27 $ 682.57 90 10% 69% 21% 0 2 1 1 0 0 R 27615 Not Covered Not Covered 90 10% 69% 21% 0 2 1 0 1 0 X 27616 Not Covered Not Covered 90 10% 69% 21% 0 2 1 0 1 0 X27618 $ 777.94 $ 520.63 90 10% 69% 21% 0 2 1 1 0 0 R 27619 $ 801.93 $ 801.93 90 10% 69% 21% 0 2 1 1 0 0 R 27620 $ 782.74 $ 782.74 90 10% 69% 21% 0 2 1 2 1 0 R 27625 $ 993.87 $ 993.87 90 10% 69% 21% 0 2 1 2 1 0 R 27626 $ 1049.05 $ 1049.05 90 10% 69% 21% 0 2 1 2 0 0 R 27630 $ 977.07 $ 623.79 90 10% 69% 21% 0 2 1 1 0 0 R 27632 $ 695.77 $ 695.77 90 10% 69% 21% 0 2 1 2 0 0 R27634 $ 1151.62 $ 1151.62 90 10% 69% 21% 0 2 1 2 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 45
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
27635 $ 996.87 $ 996.87 90 10% 69% 21% 0 2 1 1 1 0 R 27637 $ 1291.97 $ 1291.97 90 10% 69% 21% 0 2 1 2 1 0 R 27638 $ 1308.16 $ 1308.16 90 10% 69% 21% 0 2 1 2 1 0 R 27640 $ 1413.13 $ 1413.13 90 10% 69% 21% 0 2 1 1 1 0 R 27641 $ 1133.62 $ 1133.62 90 10% 69% 21% 0 2 1 1 1 0 R 27645 $ 2992.40 $ 2992.40 90 10% 69% 21% 0 2 1 2 1 0 R 27646 $ 2599.53 $ 2599.53 90 10% 69% 21% 0 2 1 2 1 0 R 27647 $ 1759.81 $ 1759.81 90 10% 69% 21% 0 2 1 2 0 0 R 27648 $ 286.10 $ 88.17 0 0% 0% 0% 0 2 1 0 0 0 R 27650 $ 1124.63 $ 1124.63 90 10% 69% 21% 0 2 1 2 1 0 R 27652 $ 1170.21 $ 1170.21 90 10% 69% 21% 0 2 1 1 1 0 R 27654 $ 1208.00 $ 1208.00 90 10% 69% 21% 0 2 1 2 1 0 R 27656 $ 1107.23 $ 674.78 90 10% 69% 21% 0 2 1 2 0 0 R 27658 $ 639.99 $ 639.99 90 10% 69% 21% 0 2 0 2 1 0 R 27659 $ 819.33 $ 819.33 90 10% 69% 21% 0 2 0 2 1 0 R 27664 $ 623.19 $ 623.19 90 10% 69% 21% 0 2 0 0 0 0 R 27665 $ 700.57 $ 700.57 90 10% 69% 21% 0 2 0 2 1 0 R 27675 $ 824.73 $ 824.73 90 10% 69% 21% 0 2 1 2 1 0 R 27676 $ 1008.86 $ 1008.86 90 10% 69% 21% 0 2 1 2 0 0 R 27680 $ 734.16 $ 734.16 90 10% 69% 21% 0 2 0 1 1 0 R 27681 $ 926.09 $ 926.09 90 10% 69% 21% 0 2 1 1 1 0 R 27685 $ 1155.21 $ 793.54 90 10% 69% 21% 0 2 1 2 1 0 R 27686 $ 956.68 $ 956.68 90 10% 69% 21% 0 2 1 1 1 0 R 27687 $ 778.54 $ 778.54 90 10% 69% 21% 0 2 1 2 1 0 R 27690 $ 1076.64 $ 1076.64 90 10% 69% 21% 0 2 1 2 1 0 R 27691 $ 1276.97 $ 1276.97 90 10% 69% 21% 0 2 1 2 1 0 R 27692 $ 174.54 $ 174.54 0 0% 0% 0% 0 0 0 2 1 0 R 27695 $ 814.53 $ 814.53 90 10% 69% 21% 0 2 1 1 1 0 R 27696 $ 941.09 $ 941.09 90 10% 69% 21% 0 2 1 1 1 0 R 27698 $ 1086.84 $ 1086.84 90 10% 69% 21% 0 2 1 2 1 0 R 27700 $ 1009.46 $ 1009.46 90 10% 69% 21% 0 2 1 2 1 0 R 27702 $ 1639.25 $ 1639.25 90 10% 69% 21% 0 2 1 2 1 0 R 27703 $ 1878.57 $ 1878.57 90 10% 69% 21% 0 2 1 2 0 0 R 27704 $ 978.27 $ 978.27 90 10% 69% 21% 0 2 1 1 1 0 R 27705 $ 1272.18 $ 1272.18 90 10% 69% 21% 0 2 1 2 1 0 R 27707 $ 687.97 $ 687.97 90 10% 69% 21% 0 2 1 1 1 0 R 27709 $ 1975.14 $ 1975.14 90 10% 69% 21% 0 2 1 2 1 0 R 27712 $ 1862.98 $ 1862.98 90 10% 69% 21% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 46
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
27715 $ 1764.61 $ 1764.61 90 10% 69% 21% 0 2 1 2 1 0 R 27720 $ 1479.11 $ 1479.11 90 10% 69% 21% 0 2 1 2 1 0 R 27722 $ 1502.50 $ 1502.50 90 10% 69% 21% 0 2 1 2 1 0 R 27724 $ 2129.29 $ 2129.29 90 10% 69% 21% 0 2 1 2 1 0 R 27725 $ 2058.51 $ 2058.51 90 10% 69% 21% 0 2 1 2 1 0 R 27726 $ 1626.66 $ 1626.66 90 10% 69% 21% 0 2 1 1 1 0 R 27727 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X 27730 $ 991.47 $ 991.47 90 10% 69% 21% 0 2 1 1 1 0 R Y27732 $ 759.95 $ 759.95 90 10% 69% 21% 0 2 1 1 0 0 R Y27734 $ 1108.43 $ 1108.43 90 10% 69% 21% 0 2 1 1 0 0 R Y27740 $ 1197.20 $ 1197.20 90 10% 69% 21% 0 2 1 2 0 0 R Y27742 $ 1314.16 $ 1314.16 90 10% 69% 21% 0 2 1 2 1 0 R Y27745 $ 1282.97 $ 1282.97 90 10% 69% 21% 0 2 1 2 1 0 R 27750 $ 595.60 $ 544.02 90 10% 69% 21% 0 2 1 1 0 0 R 27752 $ 914.10 $ 839.12 90 10% 69% 21% 0 2 1 1 0 0 R 27756 $ 979.47 $ 979.47 90 10% 69% 21% 0 2 1 2 1 0 R 27758 $ 1504.90 $ 1504.90 90 10% 69% 21% 0 2 1 2 1 0 R 27759 $ 1682.44 $ 1682.44 90 10% 69% 21% 0 2 1 2 2 0 R 27760 $ 574.61 $ 521.83 90 10% 69% 21% 0 2 1 1 0 0 R 27762 $ 809.73 $ 733.56 90 10% 69% 21% 0 2 1 1 0 0 R 27766 $ 1039.45 $ 1039.45 90 10% 69% 21% 0 2 1 1 1 0 R 27767 $ 485.84 $ 488.24 90 10% 69% 21% 0 2 1 1 0 0 R 27768 $ 749.75 $ 749.75 90 10% 69% 21% 0 2 1 1 0 0 R 27769 $ 1222.39 $ 1222.39 90 10% 69% 21% 0 2 1 1 0 0 R 27780 $ 527.22 $ 476.24 90 10% 69% 21% 0 2 1 1 0 0 R 27781 $ 723.96 $ 668.18 90 10% 69% 21% 0 2 1 1 0 0 R 27784 $ 1213.40 $ 1213.40 90 10% 69% 21% 0 2 1 1 1 0 R 27786 $ 545.82 $ 490.64 90 10% 69% 21% 0 2 1 1 0 0 R 27788 $ 719.76 $ 654.98 90 10% 69% 21% 0 2 1 1 0 0 R 27792 $ 1108.43 $ 1108.43 90 10% 69% 21% 0 2 1 1 1 0 R 27808 $ 576.41 $ 515.83 90 10% 69% 21% 0 2 1 1 0 0 R 27810 $ 798.93 $ 720.96 90 10% 69% 21% 0 2 1 1 0 0 R 27814 $ 1307.56 $ 1307.56 90 10% 69% 21% 0 2 1 2 1 0 R 27816 $ 553.62 $ 493.04 90 10% 69% 21% 0 2 1 1 0 0 R 27818 $ 825.32 $ 735.35 90 10% 69% 21% 0 2 1 1 0 0 R 27822 $ 1425.12 $ 1425.12 90 10% 69% 21% 0 2 1 2 1 0 R 27823 $ 1618.86 $ 1618.86 90 10% 69% 21% 0 2 1 2 1 0 R 27824 $ 535.62 $ 518.83 90 10% 69% 21% 0 2 1 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 47
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
27825 $ 927.29 $ 836.12 90 10% 69% 21% 0 2 1 0 0 0 R 27826 $ 1411.93 $ 1411.93 90 10% 69% 21% 0 2 1 2 2 0 R 27827 $ 1831.19 $ 1831.19 90 10% 69% 21% 0 2 1 2 2 0 R 27828 $ 2188.07 $ 2188.07 90 10% 69% 21% 0 2 1 2 2 0 R 27829 $ 1164.21 $ 1164.21 90 10% 69% 21% 0 2 1 2 2 0 R 27830 $ 647.78 $ 601.00 90 10% 69% 21% 0 2 1 0 0 0 R 27831 $ 680.17 $ 680.17 90 10% 69% 21% 0 2 1 0 0 0 R 27832 $ 1279.37 $ 1279.37 90 10% 69% 21% 0 2 1 2 1 0 R 27840 $ 625.59 $ 625.59 90 10% 69% 21% 0 2 1 1 0 0 R 27842 $ 842.72 $ 842.72 90 10% 69% 21% 0 2 1 1 0 0 R 27846 $ 1240.39 $ 1240.39 90 10% 69% 21% 0 2 1 2 1 0 R 27848 $ 1376.54 $ 1376.54 90 10% 69% 21% 0 2 1 2 1 0 R 27860 $ 295.70 $ 295.70 10 10% 80% 10% 0 2 1 0 0 0 R 27870 $ 1744.82 $ 1744.82 90 10% 69% 21% 0 2 1 2 1 0 R 27871 $ 1161.21 $ 1161.21 90 10% 69% 21% 0 2 1 2 1 0 R 27880 $ 1536.09 $ 1536.09 90 10% 69% 21% 0 2 1 2 1 0 R 27881 $ 1455.11 $ 1455.11 90 10% 69% 21% 0 2 1 2 1 0 R 27882 $ 1005.26 $ 1005.26 90 10% 69% 21% 0 2 1 0 1 0 R 27884 $ 969.88 $ 969.88 90 10% 69% 21% 0 2 1 1 0 0 R 27886 $ 1109.63 $ 1109.63 90 10% 69% 21% 0 2 1 1 1 0 R 27888 $ 1162.41 $ 1162.41 90 10% 69% 21% 0 2 1 2 1 0 R 27889 $ 1079.64 $ 1079.64 90 10% 69% 21% 0 2 1 1 1 0 R 27892 $ 923.69 $ 923.69 90 10% 69% 21% 0 2 1 0 0 0 R 27893 $ 1032.86 $ 1032.86 90 10% 69% 21% 0 2 1 0 0 0 R 27894 $ 1452.72 $ 1452.72 90 10% 69% 21% 0 2 1 2 0 0 R 27899 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 28001 $ 494.24 $ 297.50 10 10% 80% 10% 0 2 0 1 0 0 R 28002 $ 773.14 $ 547.02 10 10% 80% 10% 0 2 0 1 0 0 R 28003 $ 1230.79 $ 971.08 90 10% 69% 21% 0 2 0 1 0 0 R 28005 $ 996.87 $ 996.87 90 10% 69% 21% 0 2 0 1 0 0 R 28008 $ 764.15 $ 508.03 90 10% 69% 21% 0 2 1 1 0 0 R 28010 $ 404.87 $ 364.08 90 10% 69% 21% 0 2 0 1 0 0 R 28011 $ 560.81 $ 497.23 90 10% 69% 21% 0 2 0 1 0 0 R 28020 $ 959.68 $ 625.59 90 10% 69% 21% 0 2 0 1 1 0 R 28022 $ 864.91 $ 562.01 90 10% 69% 21% 0 2 0 1 0 0 R 28024 $ 818.73 $ 529.02 90 10% 69% 21% 0 2 0 1 0 0 R 28035 $ 929.69 $ 611.80 90 10% 69% 21% 0 2 1 1 1 0 R 28039 $ 891.90 $ 599.80 90 10% 69% 21% 0 2 1 2 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 48
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
28041 $ 786.34 $ 786.34 90 10% 69% 21% 0 2 1 0 0 0 R28043 $ 707.16 $ 454.05 90 10% 69% 21% 0 2 1 1 0 0 R 28045 $ 871.51 $ 599.20 90 10% 69% 21% 0 2 1 0 0 0 R 28046 Not Covered Not Covered 90 10% 69% 21% 0 2 1 1 1 0 X 28047 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 1 0 X28050 $ 855.91 $ 539.82 90 10% 69% 21% 0 2 1 1 1 0 R 28052 $ 782.14 $ 484.64 90 10% 69% 21% 0 2 1 1 1 0 R 28054 $ 667.58 $ 410.86 90 10% 69% 21% 0 2 1 0 0 0 R 28055 $ 653.18 $ 653.18 90 10% 69% 21% 0 2 1 0 0 0 R 28060 $ 912.90 $ 614.20 90 10% 69% 21% 0 2 1 1 0 0 R 28062 $ 1026.86 $ 698.77 90 10% 69% 21% 0 2 1 1 1 0 R 28070 $ 931.49 $ 607.60 90 10% 69% 21% 0 2 0 1 0 0 R 28072 $ 909.90 $ 579.41 90 10% 69% 21% 0 2 0 1 0 0 R 28080 $ 933.29 $ 639.99 90 10% 69% 21% 0 2 0 0 0 0 R 28086 $ 971.08 $ 623.19 90 10% 69% 21% 0 2 1 2 1 0 R 28088 $ 780.94 $ 478.64 90 10% 69% 21% 0 2 1 0 0 0 R 28090 $ 833.72 $ 532.62 90 10% 69% 21% 0 2 1 1 0 0 R 28092 $ 750.95 $ 465.44 90 10% 69% 21% 0 2 0 1 0 0 R 28100 $ 1074.84 $ 713.16 90 10% 69% 21% 0 2 1 2 1 0 R 28102 $ 1027.46 $ 1027.46 90 10% 69% 21% 0 2 1 2 0 0 R 28103 $ 676.57 $ 676.57 90 10% 69% 21% 0 2 1 2 0 0 R 28104 $ 938.69 $ 613.00 90 10% 69% 21% 0 2 0 2 1 0 R 28106 $ 741.35 $ 741.35 90 10% 69% 21% 0 2 0 2 1 0 R 28107 $ 913.50 $ 604.00 90 10% 69% 21% 0 2 0 2 0 0 R 28108 $ 785.74 $ 501.43 90 10% 69% 21% 0 2 0 1 0 0 R 28110 $ 822.93 $ 500.83 90 10% 69% 21% 0 2 1 1 1 0 R 28111 $ 872.11 $ 561.41 90 10% 69% 21% 0 2 1 1 1 0 R 28112 $ 869.11 $ 541.62 90 10% 69% 21% 0 2 1 1 1 0 R 28113 $ 1050.25 $ 740.75 90 10% 69% 21% 0 2 1 0 0 0 R 28114 $ 1886.37 $ 1445.52 90 10% 69% 21% 0 2 1 2 1 0 R 28116 $ 1321.96 $ 980.07 90 10% 69% 21% 0 2 1 1 0 0 R 28118 $ 1042.45 $ 708.96 90 10% 69% 21% 0 2 1 2 1 0 R 28119 $ 927.89 $ 622.59 90 10% 69% 21% 0 2 1 1 1 0 R 28120 $ 1184.61 $ 853.52 90 10% 69% 21% 0 2 1 1 1 0 R 28122 $ 1052.65 $ 758.75 90 10% 69% 21% 0 2 1 2 1 0 R 28124 $ 843.92 $ 572.21 90 10% 69% 21% 0 2 1 1 0 0 R 28126 $ 702.37 $ 430.66 90 10% 69% 21% 0 2 0 1 0 0 R 28130 $ 1061.05 $ 1061.05 90 10% 69% 21% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 49
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
28140 $ 1038.85 $ 749.75 90 10% 69% 21% 0 2 0 1 1 0 R 28150 $ 756.35 $ 486.44 90 10% 69% 21% 0 2 0 1 0 0 R 28153 $ 732.36 $ 458.85 90 10% 69% 21% 0 2 0 1 0 0 R 28160 $ 749.15 $ 469.04 90 10% 69% 21% 0 2 0 1 0 0 R 28171 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 0 0 X 28173 Not Covered Not Covered 90 10% 69% 21% 0 2 0 1 1 0 X 28175 Not Covered Not Covered 90 10% 69% 21% 0 2 0 2 1 0 X 28190 $ 457.05 $ 232.12 10 10% 80% 10% 0 2 1 1 0 0 R 28192 $ 830.12 $ 541.62 90 10% 69% 21% 0 2 1 1 0 0 R 28193 $ 941.09 $ 639.39 90 10% 69% 21% 0 2 1 1 0 0 R 28200 $ 864.91 $ 553.62 90 10% 69% 21% 0 2 0 1 1 0 R 28202 $ 1043.65 $ 730.56 90 10% 69% 21% 0 2 0 2 1 0 R 28208 $ 840.32 $ 539.22 90 10% 69% 21% 0 2 0 1 1 0 R 28210 $ 1031.06 $ 715.56 90 10% 69% 21% 0 2 0 2 0 0 R 28220 $ 798.93 $ 523.03 90 10% 69% 21% 0 2 1 1 0 0 R 28222 $ 888.90 $ 599.80 90 10% 69% 21% 0 2 1 1 0 0 R 28225 $ 723.36 $ 447.45 90 10% 69% 21% 0 2 1 1 1 0 R 28226 $ 781.54 $ 507.43 90 10% 69% 21% 0 2 1 1 0 0 R 28230 $ 774.94 $ 492.44 90 10% 69% 21% 0 2 1 1 0 0 R 28232 $ 688.57 $ 422.26 90 10% 69% 21% 0 2 0 1 0 0 R 28234 $ 729.36 $ 459.45 90 10% 69% 21% 0 2 0 1 0 0 R 28238 $ 1187.00 $ 843.32 90 10% 69% 21% 0 2 1 2 1 0 R 28240 $ 780.94 $ 501.43 90 10% 69% 21% 0 2 1 1 0 0 R 28250 $ 1019.66 $ 694.57 90 10% 69% 21% 0 2 1 2 1 0 R 28260 $ 1201.40 $ 876.31 90 10% 69% 21% 0 2 1 2 1 0 R 28261 $ 1737.02 $ 1350.15 90 10% 69% 21% 0 2 1 0 0 0 R 28262 $ 2521.56 $ 1994.34 90 10% 69% 21% 0 2 1 2 1 0 R 28264 $ 1487.50 $ 1118.63 90 10% 69% 21% 0 2 1 2 0 0 R 28270 $ 870.91 $ 577.01 90 10% 69% 21% 0 2 1 1 0 0 R 28272 $ 701.77 $ 443.25 90 10% 69% 21% 0 2 1 1 0 0 R 28280 $ 907.50 $ 599.20 90 10% 69% 21% 0 2 1 0 0 0 R 28285 $ 944.09 $ 652.58 90 10% 69% 21% 0 2 1 1 1 0 R 28286 $ 797.13 $ 517.03 90 10% 69% 21% 0 2 1 1 0 0 R 28288 $ 1064.65 $ 741.95 90 10% 69% 21% 0 2 0 1 0 0 R 28289 $ 1285.37 $ 941.69 90 10% 69% 21% 0 2 1 2 1 0 R 28290 $ 1042.45 $ 683.17 90 10% 69% 21% 0 2 1 1 0 0 R 28292 $ 1390.34 $ 1042.45 90 10% 69% 21% 0 2 1 2 1 0 R 28293 $ 1845.58 $ 1227.79 90 10% 69% 21% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 50
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
28294 $ 1351.95 $ 936.29 90 10% 69% 21% 0 2 1 2 1 0 R 28296 $ 1254.78 $ 900.30 90 10% 69% 21% 0 2 1 2 1 0 R 28297 $ 1419.73 $ 996.27 90 10% 69% 21% 0 2 1 2 1 0 R 28298 $ 1264.38 $ 867.31 90 10% 69% 21% 0 2 1 2 1 0 R 28299 $ 1570.28 $ 1164.81 90 10% 69% 21% 0 2 1 2 1 0 R 28300 $ 1112.03 $ 1112.03 90 10% 69% 21% 0 2 1 2 1 0 R 28302 $ 1209.20 $ 1209.20 90 10% 69% 21% 0 2 1 2 1 0 R 28304 $ 1446.72 $ 1039.45 90 10% 69% 21% 0 2 1 2 1 0 R 28305 $ 1131.82 $ 1131.82 90 10% 69% 21% 0 2 1 2 1 0 R 28306 $ 1080.84 $ 692.77 90 10% 69% 21% 0 2 1 2 1 0 R 28307 $ 1235.59 $ 795.93 90 10% 69% 21% 0 2 1 0 0 0 R 28308 $ 998.07 $ 649.58 90 10% 69% 21% 0 2 1 2 1 0 R 28309 $ 1548.68 $ 1548.68 90 10% 69% 21% 0 2 1 0 0 0 R 28310 $ 968.68 $ 617.79 90 10% 69% 21% 0 2 1 1 1 0 R 28312 $ 917.69 $ 559.01 90 10% 69% 21% 0 2 0 1 1 0 R 28313 $ 932.09 $ 616.59 90 10% 69% 21% 0 2 0 1 0 0 R 28315 $ 853.52 $ 563.21 90 10% 69% 21% 0 2 1 1 1 0 R 28320 $ 1037.05 $ 1037.05 90 10% 69% 21% 0 2 1 2 1 0 R 28322 $ 1377.14 $ 987.27 90 10% 69% 21% 0 2 0 2 1 0 R 28340 Not Covered Not Covered 90 10% 69% 21% 0 2 0 1 0 0 X 28341 Not Covered Not Covered 90 10% 69% 21% 0 2 0 1 0 0 X 28344 Not Covered Not Covered 90 10% 69% 21% 0 2 1 1 1 0 X 28345 Not Covered Not Covered 90 10% 69% 21% 0 2 0 0 0 0 X 28360 Not Covered Not Covered 90 10% 69% 21% 0 2 1 2 0 0 X 28400 $ 432.46 $ 393.47 90 10% 69% 21% 0 2 1 1 0 0 R 28405 $ 684.37 $ 617.79 90 10% 69% 21% 0 2 1 0 0 0 R 28406 $ 900.30 $ 900.30 90 10% 69% 21% 0 2 1 0 0 0 R 28415 $ 1878.57 $ 1878.57 90 10% 69% 21% 0 2 1 2 1 0 R 28420 $ 2119.69 $ 2119.69 90 10% 69% 21% 0 2 1 2 1 0 R 28430 $ 412.06 $ 363.48 90 10% 69% 21% 0 2 1 1 0 0 R 28435 $ 552.42 $ 491.24 90 10% 69% 21% 0 2 1 0 0 0 R 28436 $ 769.54 $ 769.54 90 10% 69% 21% 0 2 1 1 0 0 R 28445 $ 1809.00 $ 1809.00 90 10% 69% 21% 0 2 1 2 1 0 R 28446 $ 2063.91 $ 2063.91 90 10% 69% 21% 0 2 1 2 1 0 R 28450 $ 376.07 $ 333.49 90 10% 69% 21% 0 2 0 1 0 0 R 28455 $ 501.43 $ 448.65 90 10% 69% 21% 0 2 0 0 0 0 R 28456 $ 552.42 $ 552.42 90 10% 69% 21% 0 2 0 1 0 0 R 28465 $ 1055.65 $ 1055.65 90 10% 69% 21% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 51
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
28470 $ 382.07 $ 355.08 90 10% 69% 21% 0 2 0 1 0 0 R 28475 $ 444.45 $ 392.27 90 10% 69% 21% 0 2 0 1 0 0 R 28476 $ 608.20 $ 608.20 90 10% 69% 21% 0 2 0 0 0 0 R 28485 $ 905.70 $ 905.70 90 10% 69% 21% 0 2 0 1 1 0 R 28490 $ 256.11 $ 219.53 90 10% 69% 21% 0 2 1 1 0 0 R 28495 $ 315.49 $ 264.51 90 10% 69% 21% 0 2 1 1 0 0 R 28496 $ 785.14 $ 409.06 90 10% 69% 21% 0 2 1 1 0 0 R 28505 $ 1181.01 $ 867.31 90 10% 69% 21% 0 2 1 1 0 0 R 28510 $ 217.13 $ 211.73 90 10% 69% 21% 0 2 0 1 0 0 R 28515 $ 285.50 $ 250.72 90 10% 69% 21% 0 2 0 1 0 0 R 28525 $ 984.27 $ 678.97 90 10% 69% 21% 0 2 0 0 0 0 R 28530 $ 202.73 $ 179.34 90 10% 69% 21% 0 2 1 0 0 0 R 28531 $ 612.40 $ 318.49 90 10% 69% 21% 0 2 1 1 2 0 R 28540 $ 338.29 $ 304.10 90 10% 69% 21% 0 2 1 0 0 0 R 28545 $ 512.83 $ 450.45 90 10% 69% 21% 0 2 1 0 0 0 R 28546 $ 1022.06 $ 584.81 90 10% 69% 21% 0 2 1 0 0 0 R 28555 $ 1532.49 $ 1142.02 90 10% 69% 21% 0 2 1 2 1 0 R 28570 $ 293.90 $ 251.32 90 10% 69% 21% 0 2 1 0 0 0 R 28575 $ 624.99 $ 562.01 90 10% 69% 21% 0 2 1 0 0 0 R 28576 $ 675.97 $ 675.97 90 10% 69% 21% 0 2 1 0 0 0 R 28585 $ 1489.90 $ 1150.42 90 10% 69% 21% 0 2 1 2 1 0 R 28600 $ 378.47 $ 325.09 90 10% 69% 21% 0 2 0 0 0 0 R 28605 $ 566.81 $ 506.83 90 10% 69% 21% 0 2 0 0 0 0 R 28606 $ 674.18 $ 674.18 90 10% 69% 21% 0 2 0 1 0 0 R 28615 $ 1346.55 $ 1346.55 90 10% 69% 21% 0 2 0 2 1 0 R 28630 $ 271.71 $ 186.54 10 10% 80% 10% 0 2 0 0 0 0 R 28635 $ 300.50 $ 223.73 10 10% 80% 10% 0 2 0 0 0 0 R 28636 $ 612.40 $ 382.07 10 10% 80% 10% 0 2 0 1 2 0 R 28645 $ 1148.62 $ 832.52 90 10% 69% 21% 0 2 0 1 1 0 R 28660 $ 202.73 $ 151.75 10 10% 80% 10% 0 2 0 1 0 0 R 28665 $ 268.71 $ 226.72 10 10% 80% 10% 0 2 0 0 0 0 R 28666 $ 323.89 $ 323.89 10 10% 80% 10% 0 2 0 1 2 0 R 28675 $ 1038.85 $ 716.16 90 10% 69% 21% 0 2 0 1 0 0 R 28705 $ 2129.29 $ 2129.29 90 10% 69% 21% 0 2 1 2 1 0 R 28715 $ 1596.67 $ 1596.67 90 10% 69% 21% 0 2 1 2 1 0 R 28725 $ 1324.96 $ 1324.96 90 10% 69% 21% 0 2 1 2 1 0 R 28730 $ 1248.18 $ 1248.18 90 10% 69% 21% 0 2 1 2 1 0 R 28735 $ 1333.36 $ 1333.36 90 10% 69% 21% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 52
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
28737 $ 1185.20 $ 1185.20 90 10% 69% 21% 0 2 1 2 1 0 R 28740 $ 1479.11 $ 1067.04 90 10% 69% 21% 0 2 0 2 1 0 R 28750 $ 1427.52 $ 1016.06 90 10% 69% 21% 0 2 1 0 0 0 R 28755 $ 897.90 $ 569.21 90 10% 69% 21% 0 2 1 1 1 0 R 28760 $ 1387.34 $ 994.47 90 10% 69% 21% 0 2 1 2 1 0 R 28800 $ 930.89 $ 930.89 90 10% 69% 21% 0 2 1 2 1 0 R 28805 $ 1240.99 $ 1240.99 90 10% 69% 21% 0 2 1 0 0 0 R 28810 $ 733.56 $ 733.56 90 10% 69% 21% 0 2 0 0 0 0 R 28820 $ 993.27 $ 680.77 90 10% 69% 21% 0 2 0 1 0 0 R 28825 $ 950.08 $ 638.79 90 10% 69% 21% 0 2 0 1 0 0 R 28890 Not Covered Not Covered 90 10% 69% 21% 0 2 1 1 1 0 X 28899 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 29000 $ 512.83 $ 302.30 0 0% 0% 0% 0 2 0 0 0 0 R 29010 $ 378.47 $ 234.52 0 0% 0% 0% 0 2 0 0 0 0 R 29015 $ 476.84 $ 296.90 0 0% 0% 0% 0 2 0 0 0 0 R 29035 $ 387.47 $ 225.52 0 0% 0% 0% 0 2 0 0 0 0 R 29040 $ 386.87 $ 245.32 0 0% 0% 0% 0 2 0 0 0 0 R 29044 $ 460.65 $ 277.11 0 0% 0% 0% 0 2 0 0 0 0 R 29046 $ 416.86 $ 265.71 0 0% 0% 0% 0 2 0 0 0 0 R 29049 $ 124.16 $ 95.37 0 0% 0% 0% 0 2 0 0 0 0 R 29055 $ 386.27 $ 236.32 0 0% 0% 0% 0 2 0 0 0 0 R 29058 $ 213.53 $ 160.75 0 0% 0% 0% 0 2 0 0 0 0 R 29065 $ 166.74 $ 116.96 0 0% 0% 0% 0 2 1 1 0 0 R 29075 $ 150.55 $ 106.76 0 0% 0% 0% 0 2 1 1 0 0 R 29085 $ 166.14 $ 115.76 0 0% 0% 0% 0 2 1 1 0 0 R 29086 $ 136.15 $ 87.57 0 0% 0% 0% 0 2 1 1 0 0 R 29105 $ 152.95 $ 101.37 0 0% 0% 0% 0 2 1 1 0 0 R 29125 $ 112.76 $ 67.18 0 0% 0% 0% 0 2 1 1 0 0 R 29126 $ 134.96 $ 83.37 0 0% 0% 0% 0 2 1 1 0 0 R 29130 $ 70.18 $ 47.98 0 0% 0% 0% 0 2 1 1 0 0 R 29131 $ 88.77 $ 56.38 0 0% 0% 0% 0 2 1 1 0 0 R 29200 $ 52.18 $ 31.19 0 0% 0% 0% 0 2 0 1 0 0 R 29240 $ 50.38 $ 31.79 0 0% 0% 0% 0 2 1 1 0 0 R 29260 $ 49.78 $ 32.39 0 0% 0% 0% 0 2 1 1 0 0 R 29280 $ 50.38 $ 33.59 0 0% 0% 0% 0 2 1 1 0 0 R 29305 $ 429.46 $ 272.31 0 0% 0% 0% 0 2 0 0 0 0 R 29325 $ 474.44 $ 304.70 0 0% 0% 0% 0 2 0 0 0 0 R 29345 $ 235.12 $ 171.54 0 0% 0% 0% 0 2 1 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 53
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
29355 $ 241.72 $ 180.54 0 0% 0% 0% 0 2 1 1 0 0 R 29358 $ 278.31 $ 176.34 0 0% 0% 0% 0 2 1 1 0 0 R 29365 $ 212.33 $ 148.75 0 0% 0% 0% 0 2 1 1 0 0 R 29405 $ 142.15 $ 103.17 0 0% 0% 0% 0 2 1 1 0 0 R 29425 $ 136.15 $ 97.77 0 0% 0% 0% 0 2 1 1 0 0 R 29435 $ 203.93 $ 142.15 0 0% 0% 0% 0 2 1 1 0 0 R 29440 $ 76.17 $ 49.78 0 0% 0% 0% 0 2 1 1 0 0 R 29445 $ 233.92 $ 178.74 0 0% 0% 0% 0 2 1 1 0 0 R 29450 Not Covered Not Covered 0 0% 0% 0% 0 2 1 1 0 0 X 29505 $ 145.15 $ 85.17 0 0% 0% 0% 0 2 1 1 0 0 R 29515 $ 124.76 $ 84.57 0 0% 0% 0% 0 2 1 1 0 0 R 29520 $ 53.98 $ 31.79 0 0% 0% 0% 0 2 1 0 0 0 R 29530 $ 48.58 $ 31.19 0 0% 0% 0% 0 2 1 1 0 0 R 29540 $ 44.39 $ 30.59 0 0% 0% 0% 0 2 1 1 0 0 R 29550 $ 32.99 $ 19.79 0 0% 0% 0% 0 2 1 1 0 0 R 29580 $ 90.57 $ 60.58 0 0% 0% 0% 0 2 1 1 0 0 R 29581 $ 110.36 $ 22.19 0 0% 0% 0% 0 2 1 0 0 0 R29582 $ 125.36 $ 27.59 0 0% 0% 0% 0 2 1 0 0 0 R29583 $ 77.97 $ 19.79 0 0% 0% 0% 0 2 1 0 0 0 R29584 $ 125.36 $ 27.59 0 0% 0% 0% 0 2 1 0 0 0 R29700 $ 106.16 $ 55.78 0 0% 0% 0% 0 2 0 1 0 0 R 29705 $ 115.16 $ 79.77 0 0% 0% 0% 0 2 1 1 0 0 R 29710 $ 212.33 $ 140.95 0 0% 0% 0% 0 2 1 0 0 0 R 29720 $ 148.15 $ 74.38 0 0% 0% 0% 0 2 0 1 0 0 R 29730 $ 109.76 $ 74.98 0 0% 0% 0% 0 2 0 1 0 0 R 29740 $ 169.74 $ 117.56 0 0% 0% 0% 0 2 0 1 0 0 R 29750 Not Covered Not Covered 0 0% 0% 0% 0 2 1 0 0 0 X 29799 By Report By Report 0 0% 0% 0% 0 2 0 0 1 1 N 29800 $ 885.90 $ 885.90 90 10% 69% 21% 0 2 1 0 0 0 R Y29804 $ 1094.64 $ 1094.64 90 10% 69% 21% 0 2 1 2 1 0 R Y29805 $ 801.33 $ 801.33 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR29806 $ 1789.20 $ 1789.20 90 10% 69% 21% 0 3 1 1 1 0 29805 R Y-UR29807 $ 1747.82 $ 1747.82 90 10% 69% 21% 0 3 1 1 1 0 29805 R Y-UR29819 $ 993.27 $ 993.27 90 10% 69% 21% 0 3 1 1 1 0 29805 R Y-UR29820 $ 909.90 $ 909.90 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR29821 $ 993.87 $ 993.87 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR29822 $ 966.28 $ 966.28 90 10% 69% 21% 0 3 1 2 0 0 29805 R Y-UR29823 $ 1053.25 $ 1053.25 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 54
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
29824 $ 1137.22 $ 1137.22 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR29825 $ 984.87 $ 984.87 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR29826 $ 293.90 $ 293.90 0 0% 0% 0% 0 0 1 2 1 0 R Y-UR29827 $ 1790.40 $ 1790.40 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR29828 $ 1543.29 $ 1543.29 90 10% 69% 21% 0 3 1 2 1 0 29805 R Y-UR29830 $ 774.34 $ 774.34 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR29834 $ 827.72 $ 827.72 90 10% 69% 21% 0 3 1 2 1 0 29830 R Y-UR29835 $ 852.32 $ 852.32 90 10% 69% 21% 0 3 1 2 1 0 29830 R Y-UR29836 $ 976.47 $ 976.47 90 10% 69% 21% 0 3 1 2 1 0 29830 R Y-UR29837 $ 892.50 $ 892.50 90 10% 69% 21% 0 3 1 2 1 0 29830 R Y-UR29838 $ 996.27 $ 996.27 90 10% 69% 21% 0 3 1 0 0 0 29830 R Y-UR29840 $ 768.34 $ 768.34 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR29843 $ 821.73 $ 821.73 90 10% 69% 21% 0 3 1 2 1 0 29840 R 29844 $ 842.72 $ 842.72 90 10% 69% 21% 0 3 1 2 0 0 29840 R 29845 $ 980.07 $ 980.07 90 10% 69% 21% 0 3 1 2 1 0 29840 R 29846 $ 883.51 $ 883.51 90 10% 69% 21% 0 3 1 0 0 0 29840 R Y-UR29847 $ 920.09 $ 920.09 90 10% 69% 21% 0 3 1 2 0 0 29840 R 29848 $ 867.91 $ 867.91 90 10% 69% 21% 0 2 1 1 0 0 R Y-UR29850 $ 1057.45 $ 1057.45 90 10% 69% 21% 0 2 1 0 2 0 R 29851 $ 1573.28 $ 1573.28 90 10% 69% 21% 0 2 1 2 2 0 R 29855 $ 1328.56 $ 1328.56 90 10% 69% 21% 0 2 1 2 2 0 R 29856 $ 1680.64 $ 1680.64 90 10% 69% 21% 0 2 1 2 2 0 R 29860 $ 1129.42 $ 1129.42 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR29861 $ 1216.99 $ 1216.99 90 10% 69% 21% 0 3 1 2 1 0 29860 R Y-UR29862 $ 1373.54 $ 1373.54 90 10% 69% 21% 0 3 1 2 1 0 29860 R Y-UR29863 $ 1369.94 $ 1369.94 90 10% 69% 21% 0 3 1 2 1 0 29860 R Y-UR29866 $ 1773.61 $ 1773.61 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR29867 $ 2159.28 $ 2159.28 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR29868 $ 2818.46 $ 2818.46 90 10% 69% 21% 0 2 1 0 0 0 R Y-UR29870 $ 1011.86 $ 701.17 90 10% 69% 21% 0 2 1 1 1 0 R Y-UR29871 $ 872.11 $ 872.11 90 10% 69% 21% 0 3 1 1 0 0 29870 R Y-UR29873 $ 894.90 $ 894.90 90 10% 69% 21% 0 3 1 1 1 0 29870 R Y-UR29874 $ 911.10 $ 911.10 90 10% 69% 21% 0 3 1 0 0 0 29870 R Y-UR29875 $ 840.92 $ 840.92 90 10% 69% 21% 0 3 1 0 0 0 29870 R Y-UR29876 $ 1113.83 $ 1113.83 90 10% 69% 21% 0 3 1 1 0 0 29870 R Y-UR29877 $ 1055.05 $ 1055.05 90 10% 69% 21% 0 3 1 2 0 0 29870 R Y-UR29879 $ 1123.43 $ 1123.43 90 10% 69% 21% 0 3 1 0 0 0 29870 R Y-UR29880 $ 955.48 $ 955.48 90 10% 69% 21% 0 3 1 0 1 0 29870 R Y-UR
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 55
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
29881 $ 920.09 $ 920.09 90 10% 69% 21% 0 3 1 2 0 0 29870 R Y-UR29882 $ 1184.61 $ 1184.61 90 10% 69% 21% 0 3 1 1 0 0 29870 R Y-UR29883 $ 1425.12 $ 1425.12 90 10% 69% 21% 0 3 1 0 0 0 29870 R Y-UR29884 $ 1046.05 $ 1046.05 90 10% 69% 21% 0 3 1 2 1 0 29870 R Y-UR29885 $ 1274.58 $ 1274.58 90 10% 69% 21% 0 3 1 2 1 0 29870 R Y-UR29886 $ 1079.64 $ 1079.64 90 10% 69% 21% 0 3 1 1 0 0 29870 R Y-UR29887 $ 1264.98 $ 1264.98 90 10% 69% 21% 0 3 1 2 1 0 29870 R Y-UR29888 $ 1661.45 $ 1661.45 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR29889 $ 2065.71 $ 2065.71 90 10% 69% 21% 0 2 1 2 1 0 R Y-UR29891 $ 1158.21 $ 1158.21 90 10% 69% 21% 0 2 1 2 0 0 R Y29892 $ 1085.04 $ 1085.04 90 10% 69% 21% 0 2 1 2 0 0 R Y29893 $ 1082.64 $ 744.95 90 10% 69% 21% 0 2 1 1 1 0 R Y29894 $ 854.72 $ 854.72 90 10% 69% 21% 0 2 1 2 1 0 R Y29895 $ 825.32 $ 825.32 90 10% 69% 21% 0 2 1 2 1 0 R Y29897 $ 863.71 $ 863.71 90 10% 69% 21% 0 2 1 2 0 0 R Y29898 $ 965.68 $ 965.68 90 10% 69% 21% 0 2 1 2 1 0 R Y29899 $ 1765.81 $ 1765.81 90 10% 69% 21% 0 2 1 2 1 0 R Y29900 $ 730.56 $ 730.56 90 10% 69% 21% 0 2 1 0 0 0 R Y29901 $ 901.50 $ 901.50 90 10% 69% 21% 0 2 1 0 0 0 R Y29902 $ 828.92 $ 828.92 90 10% 69% 21% 0 2 1 0 0 0 R Y29904 $ 1080.84 $ 1080.84 90 10% 69% 21% 0 2 1 2 0 0 R Y29905 $ 1134.82 $ 1134.82 90 10% 69% 21% 0 2 1 2 0 0 R Y29906 $ 1195.40 $ 1195.40 90 10% 69% 21% 0 2 1 2 0 0 R Y29907 $ 1481.51 $ 1481.51 90 10% 69% 21% 0 2 1 2 0 0 R Y29914 Not Covered Not Covered 90 10% 69% 21% 0 3 1 2 1 0 29860 X29915 Not Covered Not Covered 90 10% 69% 21% 0 3 1 2 1 0 29860 X29916 $ 1720.23 $ 1720.23 90 10% 69% 21% 0 3 1 2 1 0 29860 R Y-UR29999 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N Y-UR30000 $ 403.67 $ 202.73 10 10% 80% 10% 0 2 0 0 0 0 R 30020 $ 409.06 $ 205.13 10 10% 80% 10% 0 2 0 1 0 0 R 30100 $ 248.32 $ 118.76 0 0% 0% 0% 0 2 0 1 0 0 R 30110 $ 403.07 $ 223.73 10 10% 80% 10% 0 2 1 1 0 0 R 30115 $ 746.15 $ 746.15 90 10% 76% 14% 0 2 1 1 0 0 R 30117 $ 1558.28 $ 590.20 90 10% 76% 14% 0 2 0 1 0 0 R 30118 $ 1306.96 $ 1306.96 90 10% 76% 14% 0 2 0 1 1 0 R 30120 Not Covered Not Covered 90 10% 76% 14% 0 2 0 1 0 0 X 30124 Not Covered Not Covered 90 10% 76% 14% 0 2 0 1 0 0 X 30125 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 0 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 56
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
30130 $ 661.58 $ 661.58 90 10% 76% 14% 0 2 1 1 0 0 R 30140 $ 767.74 $ 767.74 90 10% 76% 14% 0 2 1 1 0 0 R 30150 $ 1311.76 $ 1311.76 90 10% 76% 14% 0 2 0 1 1 0 R 30160 $ 1318.96 $ 1318.96 90 10% 76% 14% 0 2 0 2 1 0 R 30200 $ 199.13 $ 102.57 0 0% 0% 0% 0 2 0 1 0 0 R 30210 $ 262.71 $ 171.54 10 10% 80% 10% 0 2 0 1 0 0 R 30220 $ 533.82 $ 214.13 10 10% 80% 10% 0 2 0 1 0 0 R 30300 $ 408.46 $ 220.73 10 10% 80% 10% 0 2 0 1 0 0 R 30310 $ 354.48 $ 354.48 10 10% 80% 10% 0 2 0 0 0 0 R 30320 $ 780.34 $ 780.34 90 10% 76% 14% 0 2 0 0 0 0 R 30400 $ 1731.02 $ 1731.02 90 10% 76% 14% 0 2 0 0 0 0 R 30410 $ 2022.53 $ 2022.53 90 10% 76% 14% 0 2 0 2 0 0 R 30420 $ 2346.42 $ 2346.42 90 10% 76% 14% 0 2 0 1 0 0 R 30430 $ 1492.90 $ 1492.90 90 10% 76% 14% 0 2 0 2 0 0 R 30435 $ 2143.69 $ 2143.69 90 10% 76% 14% 0 2 0 2 0 0 R 30450 $ 2547.95 $ 2547.95 90 10% 76% 14% 0 2 0 2 0 0 R 30460 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 2 0 X 30462 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 2 0 X 30465 $ 1674.04 $ 1674.04 90 10% 76% 14% 0 2 0 0 0 0 R 30520 $ 1071.24 $ 1071.24 90 10% 76% 14% 0 2 0 1 0 0 R 30540 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 0 0 X 30545 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 0 0 X 30560 $ 475.04 $ 238.72 10 10% 80% 10% 0 2 0 1 0 0 R 30580 $ 1127.02 $ 871.51 90 10% 76% 14% 0 2 0 1 0 0 R 30600 $ 983.67 $ 726.36 90 10% 76% 14% 0 2 0 0 0 0 R 30620 $ 1079.64 $ 1079.64 90 10% 76% 14% 0 2 0 1 0 0 R 30630 $ 1073.04 $ 1073.04 90 10% 76% 14% 0 2 0 0 0 0 R 30801 $ 404.27 $ 238.72 10 10% 80% 10% 0 2 2 1 0 0 R 30802 $ 508.63 $ 328.69 10 10% 80% 10% 0 2 2 1 0 0 R 30901 $ 163.75 $ 94.77 0 0% 0% 0% 0 2 1 1 0 0 R 30903 $ 359.88 $ 131.96 0 0% 0% 0% 0 2 1 1 0 0 R 30905 $ 449.25 $ 166.14 0 0% 0% 0% 0 2 2 1 0 0 R 30906 $ 487.64 $ 219.53 0 0% 0% 0% 0 2 2 1 0 0 R 30915 $ 982.47 $ 982.47 90 10% 76% 14% 0 2 0 1 0 0 R 30920 $ 1421.53 $ 1421.53 90 10% 76% 14% 0 2 0 1 0 0 R 30930 $ 212.93 $ 212.93 10 10% 80% 10% 0 2 1 1 0 0 R 30999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 31000 $ 322.69 $ 183.54 10 10% 80% 10% 0 2 1 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 57
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
31002 $ 334.69 $ 334.69 10 10% 80% 10% 0 2 1 0 0 0 R 31020 $ 855.91 $ 627.99 90 10% 76% 14% 0 2 1 1 0 0 R 31030 $ 1205.00 $ 910.50 90 10% 76% 14% 0 2 1 1 0 0 R 31032 $ 985.47 $ 985.47 90 10% 76% 14% 0 2 1 1 0 0 R 31040 $ 1312.36 $ 1312.36 90 10% 76% 14% 0 2 1 1 1 0 R 31050 $ 833.12 $ 833.12 90 10% 76% 14% 0 2 1 1 0 0 R 31051 $ 1107.83 $ 1107.83 90 10% 76% 14% 0 2 1 1 0 0 R 31070 $ 758.15 $ 758.15 90 10% 76% 14% 0 2 1 1 0 0 R 31075 $ 1335.75 $ 1335.75 90 10% 76% 14% 0 2 1 2 1 0 R 31080 $ 1760.41 $ 1760.41 90 10% 76% 14% 0 2 1 2 0 0 R 31081 $ 2514.36 $ 2514.36 90 10% 76% 14% 0 2 1 2 1 0 R 31084 $ 1964.35 $ 1964.35 90 10% 76% 14% 0 2 1 2 1 0 R 31085 $ 2535.95 $ 2535.95 90 10% 76% 14% 0 2 1 2 1 0 R 31086 $ 1910.96 $ 1910.96 90 10% 76% 14% 0 2 1 2 0 0 R 31087 $ 1839.59 $ 1839.59 90 10% 76% 14% 0 2 1 2 1 0 R 31090 $ 1760.41 $ 1760.41 90 10% 76% 14% 0 2 1 1 0 0 R 31200 $ 995.07 $ 995.07 90 10% 76% 14% 0 2 1 1 0 0 R 31201 $ 1269.78 $ 1269.78 90 10% 76% 14% 0 2 1 1 0 0 R 31205 $ 1550.48 $ 1550.48 90 10% 76% 14% 0 2 1 2 1 0 R 31225 Not Covered Not Covered 90 10% 76% 14% 0 2 1 2 1 0 X 31230 Not Covered Not Covered 90 10% 76% 14% 0 2 1 2 1 0 X 31231 $ 369.48 $ 110.36 0 0% 0% 0% 0 2 2 1 0 0 R 31233 $ 457.65 $ 232.12 0 0% 0% 0% 0 2 1 0 0 0 R 31235 $ 520.03 $ 274.71 0 0% 0% 0% 0 2 1 0 0 0 R 31237 $ 446.85 $ 273.51 0 0% 0% 0% 0 2 1 1 0 0 R 31238 $ 444.45 $ 286.70 0 0% 0% 0% 0 2 1 0 0 0 R 31239 $ 1052.65 $ 1052.65 10 10% 80% 10% 0 2 1 0 0 0 R 31240 Not Covered Not Covered 0 0% 0% 0% 0 2 1 0 0 0 X 31254 $ 461.85 $ 461.85 0 0% 0% 0% 0 2 1 1 0 0 R 31255 $ 674.78 $ 674.78 0 0% 0% 0% 0 2 1 1 0 0 R 31256 $ 335.89 $ 335.89 0 0% 0% 0% 0 2 1 1 0 0 R 31267 $ 536.82 $ 536.82 0 0% 0% 0% 0 2 1 1 0 0 R 31276 $ 850.52 $ 850.52 0 0% 0% 0% 0 2 1 1 0 0 R 31287 $ 393.47 $ 393.47 0 0% 0% 0% 0 2 1 0 0 0 R 31288 $ 455.25 $ 455.25 0 0% 0% 0% 0 2 1 0 0 0 R 31290 $ 1954.15 $ 1954.15 10 10% 80% 10% 0 2 1 0 0 0 R 31291 $ 2072.31 $ 2072.31 10 10% 80% 10% 0 2 1 0 0 0 R 31292 $ 1692.04 $ 1692.04 10 10% 80% 10% 0 2 1 0 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 58
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
31293 $ 1833.59 $ 1833.59 10 10% 80% 10% 0 2 1 0 0 0 R 31294 $ 2096.90 $ 2096.90 10 10% 80% 10% 0 2 1 0 0 0 R 31295 $ 3678.57 $ 283.71 0 0% 0% 0% 0 2 1 2 0 0 R31296 $ 3726.56 $ 338.29 0 0% 0% 0% 0 2 1 2 0 0 R31297 $ 3663.58 $ 277.71 0 0% 0% 0% 0 2 1 0 0 0 R31299 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 31300 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31320 Not Covered Not Covered 90 10% 76% 14% 0 2 0 0 0 0 X 31360 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31365 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31367 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31368 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31370 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31375 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31380 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31382 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31390 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31395 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31400 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 0 0 X 31420 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31500 $ 184.14 $ 184.14 0 0% 0% 0% 0 0 0 1 0 0 R 31502 $ 58.78 $ 58.78 0 0% 0% 0% 0 2 0 1 0 0 R 31505 $ 145.15 $ 84.57 0 0% 0% 0% 0 2 0 1 0 0 R 31510 $ 368.28 $ 208.73 0 0% 0% 0% 0 3 0 0 0 0 31505 R 31511 $ 365.28 $ 219.53 0 0% 0% 0% 0 3 0 1 0 0 31505 R 31512 $ 358.68 $ 221.93 0 0% 0% 0% 0 3 0 0 0 0 31505 R 31513 $ 225.52 $ 225.52 0 0% 0% 0% 0 3 0 0 0 0 31505 R 31515 $ 361.08 $ 189.54 0 0% 0% 0% 0 2 0 1 0 0 R 31520 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 31525 $ 437.25 $ 272.91 0 0% 0% 0% 0 2 0 1 0 0 R 31526 $ 268.11 $ 268.11 0 0% 0% 0% 0 2 0 1 0 0 R 31527 $ 334.09 $ 334.09 0 0% 0% 0% 0 3 0 0 0 0 31525 R 31528 $ 246.52 $ 246.52 0 0% 0% 0% 0 3 0 0 0 0 31525 R 31529 $ 276.51 $ 276.51 0 0% 0% 0% 0 3 0 0 0 0 31525 R 31530 $ 334.69 $ 334.69 0 0% 0% 0% 0 3 0 1 0 0 31525 R 31531 $ 362.88 $ 362.88 0 0% 0% 0% 0 3 0 0 0 0 31526 R 31535 $ 323.89 $ 323.89 0 0% 0% 0% 0 3 0 1 0 0 31525 R 31536 $ 359.88 $ 359.88 0 0% 0% 0% 0 3 0 1 0 0 31526 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 59
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
31540 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 31525 X 31541 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 31526 X 31545 $ 615.99 $ 615.99 0 0% 0% 0% 0 3 1 1 0 0 31526 R 31546 $ 935.69 $ 935.69 0 0% 0% 0% 0 3 1 1 0 0 31526 R 31560 Not Covered Not Covered 0 0% 0% 0% 0 3 0 0 0 0 31525 X 31561 Not Covered Not Covered 0 0% 0% 0% 0 3 0 0 0 0 31526 X 31570 $ 584.21 $ 390.47 0 0% 0% 0% 0 3 0 1 0 0 31525 R 31571 $ 425.86 $ 425.86 0 0% 0% 0% 0 3 0 1 0 0 31526 R 31575 $ 198.53 $ 131.36 0 0% 0% 0% 0 2 0 1 0 0 R 31576 $ 389.87 $ 211.73 0 0% 0% 0% 0 3 0 1 0 0 31575 R 31577 $ 419.26 $ 256.11 0 0% 0% 0% 0 3 0 0 0 0 31575 R 31578 $ 481.64 $ 292.70 0 0% 0% 0% 0 3 0 0 0 0 31575 R 31579 $ 363.48 $ 240.52 0 0% 0% 0% 0 3 0 1 0 0 31575 R 31580 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31582 Not Covered Not Covered 90 10% 76% 14% 0 2 0 1 1 0 X 31584 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31587 $ 1699.23 $ 1699.23 90 10% 76% 14% 0 2 0 2 1 0 R 31588 $ 1951.15 $ 1951.15 90 10% 76% 14% 0 2 0 2 0 0 R 31590 $ 1550.48 $ 1550.48 90 10% 76% 14% 0 2 0 2 1 0 R 31595 Not Covered Not Covered 90 10% 76% 14% 0 2 1 2 1 0 X 31599 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 31600 $ 660.98 $ 660.98 0 0% 0% 0% 0 2 0 1 0 0 R 31601 Not Covered Not Covered 0 0% 0% 0% 0 2 0 2 1 0 X 31603 $ 372.48 $ 372.48 0 0% 0% 0% 0 2 0 1 0 0 R 31605 $ 304.70 $ 304.70 0 0% 0% 0% 0 2 0 1 0 0 R 31610 $ 1222.39 $ 1222.39 90 10% 76% 14% 0 2 0 1 0 0 R 31611 $ 932.69 $ 932.69 90 10% 76% 14% 0 2 0 2 1 0 R 31612 $ 146.35 $ 82.17 0 0% 0% 0% 0 2 0 0 0 0 R 31613 $ 783.94 $ 783.94 90 10% 76% 14% 0 2 0 1 0 0 R 31614 $ 1303.97 $ 1303.97 90 10% 76% 14% 0 2 0 1 0 0 R 31615 $ 313.70 $ 218.93 0 0% 0% 0% 0 2 0 1 0 0 R 31620 $ 511.03 $ 115.16 0 0% 0% 0% 0 0 0 1 0 0 R 31622 $ 546.42 $ 247.12 0 0% 0% 0% 0 2 0 1 0 0 R 31623 $ 580.61 $ 250.72 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31624 $ 548.82 $ 253.12 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31625 $ 581.21 $ 291.50 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31626 $ 780.34 $ 360.48 0 0% 0% 0% 0 2 0 0 0 0 R31627 $ 2531.16 $ 164.95 0 0% 0% 0% 0 0 0 0 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 60
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
31628 $ 650.18 $ 325.69 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31629 $ 1039.45 $ 350.28 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31630 $ 339.49 $ 339.49 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31631 $ 389.27 $ 389.27 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31632 $ 122.96 $ 83.97 0 0% 0% 0% 0 0 0 1 0 0 R 31633 $ 151.75 $ 108.56 0 0% 0% 0% 0 0 0 1 0 0 R 31634 $ 3363.08 $ 350.88 0 0% 0% 0% 0 3 0 2 0 0 31622 R31635 $ 607.60 $ 320.89 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31636 $ 374.88 $ 374.88 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31637 $ 127.16 $ 127.16 0 0% 0% 0% 0 0 0 1 0 0 R 31638 $ 428.26 $ 428.26 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31640 $ 430.66 $ 430.66 0 0% 0% 0% 0 3 0 1 0 0 31622 R Y31641 $ 437.85 $ 437.85 0 0% 0% 0% 0 3 0 1 0 0 31622 R Y31643 $ 302.30 $ 302.30 0 0% 0% 0% 0 2 0 1 0 0 R Y31645 $ 565.01 $ 275.91 0 0% 0% 0% 0 3 0 1 0 0 31622 R 31646 $ 508.63 $ 239.32 0 0% 0% 0% 0 2 0 1 0 0 R 31647 $ 377.87 $ 377.87 0 0% 0% 0% 0 3 0 1 0 0 31622 R31648 $ 347.88 $ 347.88 0 0% 0% 0% 0 3 0 1 0 0 31622 R31649 $ 116.36 $ 116.36 0 0% 0% 0% 0 0 0 1 0 0 R31651 $ 127.16 $ 127.16 0 0% 0% 0% 0 0 0 1 0 0 R31660 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 31622 X31661 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 31622 X31717 $ 460.05 $ 185.94 0 0% 0% 0% 0 2 0 1 0 0 R 31720 $ 86.97 $ 86.97 0 0% 0% 0% 0 2 0 1 0 0 R 31725 $ 151.15 $ 151.15 0 0% 0% 0% 0 2 0 1 0 0 R 31730 $ 2186.27 $ 246.52 0 0% 0% 0% 0 2 0 1 0 0 R 31750 $ 2366.81 $ 2366.81 90 10% 76% 14% 0 2 0 2 1 0 R 31755 $ 2984.60 $ 2984.60 90 10% 76% 14% 0 2 0 2 1 0 R 31760 $ 2273.24 $ 2273.24 90 10% 76% 14% 0 2 0 2 1 0 R 31766 $ 2932.42 $ 2932.42 90 10% 76% 14% 0 2 0 2 1 0 R 31770 $ 2201.27 $ 2201.27 90 10% 76% 14% 0 2 0 2 1 0 R 31775 $ 2119.69 $ 2119.69 90 10% 76% 14% 0 2 0 2 0 0 R 31780 $ 1985.34 $ 1985.34 90 10% 76% 14% 0 2 0 2 1 0 R 31781 $ 2284.04 $ 2284.04 90 10% 76% 14% 0 2 0 2 1 0 R 31785 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31786 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 31800 $ 1228.39 $ 1228.39 90 10% 76% 14% 0 2 0 0 0 0 R 31805 $ 1355.55 $ 1355.55 90 10% 76% 14% 0 2 0 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 61
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
31820 $ 748.55 $ 557.21 90 10% 76% 14% 0 2 0 0 0 0 R 31825 $ 1037.05 $ 817.53 90 10% 76% 14% 0 2 0 0 0 0 R 31830 $ 762.95 $ 582.41 90 10% 76% 14% 0 2 0 0 0 0 R 31899 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 32035 $ 1206.80 $ 1206.80 90 10% 76% 14% 0 2 1 2 1 0 R 32036 $ 1296.77 $ 1296.77 90 10% 76% 14% 0 2 1 2 1 0 R 32096 $ 1332.16 $ 1332.16 90 10% 76% 14% 0 2 0 2 1 0 R Y32097 $ 1332.76 $ 1332.76 90 10% 76% 14% 0 2 0 2 1 0 R Y32098 $ 1264.98 $ 1264.98 90 10% 76% 14% 0 2 0 2 1 0 R Y32100 $ 1339.95 $ 1339.95 90 10% 76% 14% 0 2 0 2 1 0 R 32110 $ 2417.79 $ 2417.79 90 10% 76% 14% 0 2 0 2 1 0 R 32120 $ 1444.32 $ 1444.32 90 10% 76% 14% 0 2 0 2 1 0 R 32124 $ 1538.49 $ 1538.49 90 10% 76% 14% 0 2 0 2 1 0 R 32140 $ 1649.45 $ 1649.45 90 10% 76% 14% 0 2 0 2 1 0 R 32141 $ 2513.16 $ 2513.16 90 10% 76% 14% 0 2 0 2 1 0 R 32150 $ 1668.04 $ 1668.04 90 10% 76% 14% 0 2 0 2 1 0 R 32151 $ 1673.44 $ 1673.44 90 10% 76% 14% 0 2 0 2 1 0 R 32160 $ 1309.36 $ 1309.36 90 10% 76% 14% 0 2 0 2 1 0 R 32200 $ 1899.57 $ 1899.57 90 10% 76% 14% 0 2 0 2 1 0 R 32215 $ 1327.96 $ 1327.96 90 10% 76% 14% 0 2 1 2 1 0 R Y32220 $ 2624.72 $ 2624.72 90 10% 76% 14% 0 2 1 2 1 0 R Y32225 $ 1646.45 $ 1646.45 90 10% 76% 14% 0 2 1 2 1 0 R Y32310 $ 1503.10 $ 1503.10 90 10% 76% 14% 0 2 0 2 1 0 R Y32320 $ 2645.72 $ 2645.72 90 10% 76% 14% 0 2 0 2 1 0 R Y32400 $ 263.91 $ 149.35 0 0% 0% 0% 0 2 0 1 0 0 R Y32405 $ 799.53 $ 179.34 0 0% 0% 0% 0 2 0 1 0 0 R Y32440 $ 2583.34 $ 2583.34 90 10% 76% 14% 0 2 0 2 1 0 R Y32442 $ 5047.32 $ 5047.32 90 10% 76% 14% 0 2 0 2 1 0 R Y32445 $ 5834.25 $ 5834.25 90 10% 76% 14% 0 2 0 2 1 0 R Y32480 $ 2440.59 $ 2440.59 90 10% 76% 14% 0 2 0 2 1 0 R Y32482 $ 2618.73 $ 2618.73 90 10% 76% 14% 0 2 0 2 1 0 R Y32484 $ 2369.81 $ 2369.81 90 10% 76% 14% 0 2 0 2 1 0 R Y32486 $ 3868.11 $ 3868.11 90 10% 76% 14% 0 2 0 2 1 0 R Y32488 $ 3973.68 $ 3973.68 90 10% 76% 14% 0 2 0 2 1 0 R Y32491 $ 2441.19 $ 2441.19 90 10% 76% 14% 0 2 1 2 1 0 R Y32501 $ 401.27 $ 401.27 0 0% 0% 0% 0 0 0 2 1 0 R Y32503 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X 32504 Not Covered Not Covered 90 10% 76% 14% 0 2 0 2 1 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 62
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
32505 $ 1544.49 $ 1544.49 90 10% 76% 14% 0 2 0 2 1 0 R Y32506 $ 257.31 $ 257.31 0 0% 0% 0% 0 0 0 2 1 0 R Y32507 $ 257.31 $ 257.31 0 0% 0% 0% 0 0 0 2 1 0 R Y32540 $ 2859.85 $ 2859.85 90 10% 76% 14% 0 2 0 2 1 0 R Y32550 $ 1378.94 $ 374.88 0 0% 0% 0% 0 0 0 1 0 0 R 32551 $ 283.71 $ 283.71 0 0% 0% 0% 0 2 1 1 0 0 R 32552 $ 317.29 $ 272.31 10 10% 80% 10% 0 2 0 0 0 0 R32553 Not Covered Not Covered 0 0% 0% 0% 0 2 0 2 0 0 X32554 $ 350.28 $ 151.75 0 0% 0% 0% 0 2 1 1 0 0 R32555 $ 506.83 $ 193.14 0 0% 0% 0% 0 2 1 1 0 0 R32556 $ 981.87 $ 209.33 0 0% 0% 0% 0 2 1 1 0 0 R32557 $ 900.90 $ 263.91 0 0% 0% 0% 0 2 1 1 0 0 R32560 $ 426.46 $ 130.16 0 0% 0% 0% 0 2 0 1 0 0 R 32561 $ 158.95 $ 116.36 0 0% 0% 0% 0 2 0 2 0 0 R32562 $ 142.75 $ 104.37 0 0% 0% 0% 0 2 0 2 0 0 R32601 $ 509.83 $ 509.83 0 0% 0% 0% 0 2 0 0 0 0 R Y32604 $ 794.14 $ 794.14 0 0% 0% 0% 0 2 0 0 0 0 R Y32606 $ 761.15 $ 761.15 0 0% 0% 0% 0 2 0 0 0 0 R Y32607 $ 510.43 $ 510.43 0 0% 0% 0% 0 2 0 0 0 0 R Y32608 $ 624.39 $ 624.39 0 0% 0% 0% 0 2 0 0 0 0 R Y32609 $ 430.06 $ 430.06 0 0% 0% 0% 0 2 0 0 0 0 R Y32650 $ 1107.23 $ 1107.23 90 10% 76% 14% 0 2 1 2 1 0 R Y32651 $ 1814.40 $ 1814.40 90 10% 76% 14% 0 2 1 2 1 0 R Y32652 $ 2741.09 $ 2741.09 90 10% 76% 14% 0 2 1 2 1 0 R Y32653 $ 1752.62 $ 1752.62 90 10% 76% 14% 0 2 0 2 1 0 R Y32654 $ 1909.76 $ 1909.76 90 10% 76% 14% 0 2 1 2 1 0 R Y32655 $ 1582.87 $ 1582.87 90 10% 76% 14% 0 2 1 2 1 0 R Y32656 $ 1332.16 $ 1332.16 90 10% 76% 14% 0 2 1 2 1 0 R Y32658 $ 1188.80 $ 1188.80 90 9% 84% 7% 0 2 0 2 1 0 R Y32659 $ 1218.19 $ 1218.19 90 9% 84% 7% 0 2 0 2 1 0 R Y32661 $ 1327.36 $ 1327.36 90 9% 84% 7% 0 2 0 2 1 0 R Y32662 $ 1482.11 $ 1482.11 90 9% 84% 7% 0 2 0 2 1 0 R Y32663 $ 2312.83 $ 2312.83 90 9% 84% 7% 0 2 0 2 1 0 R Y32664 $ 1408.93 $ 1408.93 90 9% 84% 7% 0 2 1 2 1 0 R Y32665 $ 2042.92 $ 2042.92 90 9% 81% 10% 0 2 0 2 1 0 R Y32666 $ 1445.52 $ 1445.52 90 10% 76% 14% 0 2 0 2 1 0 R Y32667 $ 257.91 $ 257.91 0 0% 0% 0% 0 0 0 2 1 0 R Y32668 $ 257.31 $ 257.31 0 0% 0% 0% 0 0 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 63
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
32669 $ 2221.06 $ 2221.06 90 9% 84% 7% 0 2 0 2 1 0 R Y32670 $ 2647.52 $ 2647.52 90 10% 76% 14% 0 2 0 2 1 0 R Y32671 $ 2937.82 $ 2937.82 90 10% 76% 14% 0 2 0 2 1 0 R Y32672 $ 2510.16 $ 2510.16 90 10% 76% 14% 0 2 0 2 1 0 R Y32673 $ 2015.33 $ 2015.33 90 9% 82% 9% 0 2 0 2 1 0 R Y32674 $ 353.88 $ 353.88 0 0% 0% 0% 0 0 0 2 1 0 R Y32701 $ 353.88 $ 353.88 0 0% 0% 0% 2 0 0 0 1 0 R32800 $ 1582.27 $ 1582.27 90 10% 76% 14% 0 2 0 2 1 0 R Y32810 $ 1500.70 $ 1500.70 90 10% 76% 14% 0 2 0 2 0 0 R Y32815 $ 4622.66 $ 4622.66 90 10% 76% 14% 0 2 0 2 1 0 R Y32820 $ 2332.02 $ 2332.02 90 10% 76% 14% 0 2 0 2 1 0 R Y32850 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y32851 $ 5417.39 $ 5417.39 90 10% 76% 14% 0 2 0 2 1 2 R Y32852 $ 5926.02 $ 5926.02 90 10% 76% 14% 0 2 0 2 1 2 R Y32853 $ 7555.08 $ 7555.08 90 10% 76% 14% 0 2 2 2 1 2 R Y32854 $ 8022.33 $ 8022.33 90 10% 76% 14% 0 2 2 2 1 2 R Y32855 By Report By Report 0 0% 0% 0% 0 2 0 2 1 0 N Y32856 By Report By Report 0 0% 0% 0% 0 2 0 2 1 0 N Y32900 $ 2362.01 $ 2362.01 90 10% 76% 14% 0 2 0 2 1 0 R Y32905 $ 2213.86 $ 2213.86 90 10% 76% 14% 0 2 0 2 1 0 R Y32906 $ 2729.09 $ 2729.09 90 10% 76% 14% 0 2 0 2 1 0 R Y32940 $ 2047.72 $ 2047.72 90 10% 76% 14% 0 2 0 2 1 0 R Y32960 $ 218.33 $ 157.15 0 0% 0% 0% 0 2 0 1 0 0 R Y32997 $ 585.40 $ 585.40 0 0% 0% 0% 0 2 1 1 0 0 R Y32998 $ 5290.24 $ 490.04 0 0% 0% 0% 0 2 1 2 0 0 R Y32999 By Report By Report 90 0% 0% 0% 0 2 0 1 1 1 N Y33010 $ 197.93 $ 197.93 0 0% 0% 0% 0 2 0 1 0 0 R Y33011 $ 198.53 $ 198.53 0 0% 0% 0% 0 2 0 0 0 0 R Y33015 $ 849.92 $ 849.92 90 9% 84% 7% 0 2 0 1 0 0 R Y33020 $ 1460.51 $ 1460.51 90 9% 84% 7% 0 2 0 2 1 0 R Y33025 $ 1321.96 $ 1321.96 90 9% 84% 7% 0 2 0 2 1 0 R Y33030 $ 3301.30 $ 3301.30 90 9% 84% 7% 0 2 0 2 1 0 R Y33031 $ 4061.85 $ 4061.85 90 9% 84% 7% 0 2 0 2 1 0 R Y33050 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33120 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33130 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33140 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X 33141 Not Covered Not Covered 0 0% 0% 0% 0 0 0 2 1 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 64
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
33202 $ 1282.97 $ 1282.97 90 9% 84% 7% 0 2 0 1 0 0 R 33203 $ 1329.76 $ 1329.76 90 9% 84% 7% 0 2 0 1 0 0 R 33206 $ 768.34 $ 768.34 90 9% 84% 7% 0 2 0 1 2 0 R Y33207 $ 815.73 $ 815.73 90 9% 84% 7% 0 2 0 1 2 0 R Y33208 $ 882.31 $ 882.31 90 9% 84% 7% 0 2 0 1 2 0 R Y33210 $ 294.50 $ 294.50 0 0% 0% 0% 0 2 0 1 0 0 R Y33211 $ 299.90 $ 299.90 0 0% 0% 0% 0 2 0 1 0 0 R Y33212 $ 554.22 $ 554.22 90 9% 84% 7% 0 2 0 1 0 0 R Y33213 $ 578.21 $ 578.21 90 9% 84% 7% 0 2 0 1 0 0 R Y33214 $ 812.13 $ 812.13 90 9% 84% 7% 0 2 0 0 2 0 R Y33215 $ 515.23 $ 515.23 90 9% 84% 7% 0 2 0 1 0 0 R Y33216 $ 638.19 $ 638.19 90 9% 84% 7% 0 2 0 1 0 0 R Y33217 $ 624.99 $ 624.99 90 9% 84% 7% 0 2 0 1 0 0 R Y33218 $ 669.38 $ 669.38 90 9% 84% 7% 0 2 0 1 0 0 R Y33220 $ 668.18 $ 668.18 90 9% 84% 7% 0 2 0 1 0 0 R Y33221 $ 620.19 $ 620.19 90 9% 84% 7% 0 2 0 1 0 0 R Y33222 $ 583.61 $ 583.61 90 9% 84% 7% 0 2 0 1 0 0 R Y33223 $ 699.37 $ 699.37 90 9% 84% 7% 0 2 0 0 0 0 R Y33224 $ 848.12 $ 848.12 0 0% 0% 0% 0 2 0 1 0 0 R Y33225 $ 768.94 $ 768.94 0 0% 0% 0% 0 0 0 1 0 0 R Y33226 $ 815.13 $ 815.13 0 0% 0% 0% 0 2 0 1 0 0 R Y33227 $ 583.61 $ 583.61 90 9% 84% 7% 0 2 0 1 0 0 R Y33228 $ 607.60 $ 607.60 90 9% 84% 7% 0 2 0 1 0 0 R Y33229 $ 638.19 $ 638.19 90 9% 84% 7% 0 2 0 1 0 0 R Y33230 $ 654.98 $ 654.98 90 9% 84% 7% 0 2 0 1 0 0 R Y33231 $ 690.97 $ 690.97 90 9% 84% 7% 0 2 0 1 0 0 R Y33233 $ 407.86 $ 407.86 90 9% 84% 7% 0 2 0 1 0 0 R Y33234 $ 825.92 $ 825.92 90 9% 84% 7% 0 2 0 1 0 0 R Y33235 $ 1076.04 $ 1076.04 90 9% 84% 7% 0 2 0 1 0 0 R Y33236 $ 1299.77 $ 1299.77 90 9% 84% 7% 0 2 0 0 2 0 R Y33237 $ 1394.54 $ 1394.54 90 9% 84% 7% 0 2 0 0 2 0 R Y33238 $ 1560.08 $ 1560.08 90 9% 84% 7% 0 2 0 0 2 0 R Y33240 $ 627.39 $ 627.39 90 9% 84% 7% 0 2 0 1 0 0 R Y33241 $ 383.27 $ 383.27 90 9% 84% 7% 0 2 0 1 0 0 R Y33243 $ 2265.44 $ 2265.44 90 9% 84% 7% 0 2 0 2 1 0 R Y33244 $ 1444.32 $ 1444.32 90 9% 84% 7% 0 2 0 1 1 0 R Y33249 $ 1537.29 $ 1537.29 90 9% 84% 7% 0 2 0 1 1 0 R Y33250 $ 2436.99 $ 2436.99 90 9% 84% 7% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 65
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
33251 $ 2670.91 $ 2670.91 90 9% 84% 7% 0 2 0 2 1 0 R Y33254 $ 2246.85 $ 2246.85 90 9% 84% 7% 0 2 0 2 1 0 R Y33255 $ 2700.30 $ 2700.30 90 9% 84% 7% 0 2 0 2 1 0 R Y33256 $ 3208.33 $ 3208.33 90 9% 84% 7% 0 2 0 2 1 0 R Y33257 $ 968.68 $ 968.68 0 0% 0% 0% 0 0 0 2 0 0 R Y33258 $ 1089.84 $ 1089.84 0 0% 0% 0% 0 0 0 2 0 0 R Y33259 $ 1402.33 $ 1402.33 0 0% 0% 0% 0 0 0 2 0 0 R Y33261 $ 2670.91 $ 2670.91 90 9% 84% 7% 0 2 0 2 1 0 R Y33262 $ 639.39 $ 639.39 90 9% 84% 7% 0 2 0 1 0 0 R Y33263 $ 665.18 $ 665.18 90 9% 84% 7% 0 2 0 1 0 0 R Y33264 $ 692.77 $ 692.77 90 9% 84% 7% 0 2 0 1 0 0 R Y33265 $ 2249.25 $ 2249.25 90 9% 84% 7% 0 2 0 2 1 0 R Y33266 $ 3049.98 $ 3049.98 90 9% 84% 7% 0 2 0 2 1 0 R Y33270 $ 983.07 $ 983.07 90 9% 84% 7% 0 2 0 1 0 0 R Y33271 $ 828.92 $ 828.92 90 9% 84% 7% 0 2 0 1 0 0 R Y33272 $ 610.60 $ 610.60 90 9% 84% 7% 0 2 0 1 0 0 R Y33273 $ 666.38 $ 666.38 90 9% 84% 7% 0 2 0 1 0 0 R Y33282 $ 399.47 $ 399.47 90 9% 84% 7% 0 2 0 1 0 0 R Y33284 $ 355.08 $ 355.08 90 9% 84% 7% 0 2 0 1 0 0 R Y33300 $ 4029.46 $ 4029.46 90 9% 84% 7% 0 2 0 2 1 0 R Y33305 $ 6742.35 $ 6742.35 90 9% 84% 7% 0 2 0 2 1 0 R Y33310 $ 1982.94 $ 1982.94 90 9% 84% 7% 0 2 0 2 1 0 R Y33315 $ 3156.15 $ 3156.15 90 9% 84% 7% 0 2 0 2 1 0 R Y33320 $ 1757.41 $ 1757.41 90 9% 84% 7% 0 2 0 2 1 0 R Y33321 $ 1990.74 $ 1990.74 90 9% 84% 7% 0 2 0 2 1 0 R Y33322 $ 2291.24 $ 2291.24 90 9% 84% 7% 0 2 0 2 1 0 R Y33330 $ 2363.21 $ 2363.21 90 9% 84% 7% 0 2 0 2 1 0 R Y33335 $ 3110.56 $ 3110.56 90 9% 84% 7% 0 2 0 2 1 0 R Y33361 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 2 1 X33362 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 2 1 X33363 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 2 1 X33364 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 2 1 X33365 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 2 1 X33366 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 2 1 X33367 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 1 X33368 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 1 X33369 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 1 X33400 $ 3756.55 $ 3756.55 90 9% 84% 7% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 66
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
33401 $ 2391.40 $ 2391.40 90 9% 84% 7% 0 2 0 2 1 0 R Y33403 $ 2450.18 $ 2450.18 90 9% 84% 7% 0 2 0 2 1 0 R Y33404 $ 2926.42 $ 2926.42 90 9% 84% 7% 0 2 0 2 1 0 R Y33405 $ 3740.35 $ 3740.35 90 9% 84% 7% 0 2 0 2 1 0 R Y33406 $ 4732.42 $ 4732.42 90 9% 84% 7% 0 2 0 2 1 0 R Y33410 $ 4186.00 $ 4186.00 90 9% 84% 7% 0 2 0 2 1 0 R Y33411 $ 5522.36 $ 5522.36 90 9% 84% 7% 0 2 0 2 0 0 R Y33412 $ 5209.86 $ 5209.86 90 9% 84% 7% 0 2 0 2 1 0 R Y33413 $ 5382.01 $ 5382.01 90 9% 84% 7% 0 2 0 2 1 0 R Y33414 $ 3524.42 $ 3524.42 90 9% 84% 7% 0 2 0 2 1 0 R Y33415 $ 3355.88 $ 3355.88 90 9% 84% 7% 0 2 0 2 1 0 R Y33416 $ 3351.68 $ 3351.68 90 9% 84% 7% 0 2 0 2 1 0 R Y33417 $ 2739.89 $ 2739.89 90 9% 84% 7% 0 2 0 2 1 0 R Y33418 $ 3084.77 $ 3084.77 90 9% 84% 7% 0 2 0 2 1 0 R Y33419 $ 721.56 $ 721.56 0 0% 0% 0% 0 0 0 2 1 0 R Y33420 $ 2461.58 $ 2461.58 90 9% 84% 7% 0 2 0 1 1 0 R Y33422 $ 2760.28 $ 2760.28 90 9% 84% 7% 0 2 0 2 1 0 R Y33425 $ 4497.30 $ 4497.30 90 9% 84% 7% 0 2 0 2 1 0 R Y33426 $ 3924.49 $ 3924.49 90 9% 84% 7% 0 2 0 2 1 0 R Y33427 $ 4026.46 $ 4026.46 90 9% 84% 7% 0 2 0 2 1 0 R Y33430 $ 4611.26 $ 4611.26 90 9% 84% 7% 0 2 0 2 1 0 R Y33460 $ 4009.06 $ 4009.06 90 9% 84% 7% 0 2 0 2 1 0 R Y33463 $ 5093.50 $ 5093.50 90 9% 84% 7% 0 2 0 2 1 0 R Y33464 $ 4025.86 $ 4025.86 90 9% 84% 7% 0 2 0 2 1 0 R Y33465 $ 4541.09 $ 4541.09 90 9% 84% 7% 0 2 0 2 1 0 R Y33468 $ 4016.86 $ 4016.86 90 9% 84% 7% 0 2 0 2 1 0 R Y33470 $ 2038.12 $ 2038.12 90 9% 84% 7% 0 2 0 2 0 0 R Y33471 $ 2185.67 $ 2185.67 90 9% 84% 7% 0 2 0 2 1 0 R Y33474 $ 3573.61 $ 3573.61 90 9% 84% 7% 0 2 0 2 1 0 R Y33475 $ 3858.51 $ 3858.51 90 9% 84% 7% 0 2 0 2 1 0 R Y33476 $ 2523.36 $ 2523.36 90 9% 84% 7% 0 2 0 2 1 0 R Y33478 $ 2586.94 $ 2586.94 90 9% 84% 7% 0 2 0 2 1 0 R Y33496 $ 2760.88 $ 2760.88 90 9% 84% 7% 0 2 0 2 1 0 R Y33500 $ 2586.94 $ 2586.94 90 9% 84% 7% 0 2 0 2 1 0 R Y33501 $ 1853.98 $ 1853.98 90 9% 84% 7% 0 2 0 2 2 0 R Y33502 $ 2107.70 $ 2107.70 90 9% 84% 7% 0 2 0 2 1 0 R Y33503 $ 2188.67 $ 2188.67 90 9% 84% 7% 0 2 0 0 1 0 R Y33504 $ 2413.00 $ 2413.00 90 9% 84% 7% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 67
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
33505 $ 3376.27 $ 3376.27 90 9% 84% 7% 0 2 0 2 1 0 R Y33506 $ 3570.61 $ 3570.61 90 9% 84% 7% 0 2 0 2 1 0 R Y33507 $ 2826.26 $ 2826.26 90 9% 84% 7% 0 2 0 2 1 0 R 33508 $ 26.39 $ 26.39 0 0% 0% 0% 0 0 0 2 1 0 R Y33510 $ 3186.74 $ 3186.74 90 9% 84% 7% 0 2 0 2 0 0 R Y33511 $ 3502.23 $ 3502.23 90 9% 84% 7% 0 2 0 2 0 0 R Y33512 $ 3979.07 $ 3979.07 90 9% 84% 7% 0 2 0 2 0 0 R Y33513 $ 4092.44 $ 4092.44 90 9% 84% 7% 0 2 0 2 0 0 R Y33514 $ 4320.96 $ 4320.96 90 9% 84% 7% 0 2 0 2 0 0 R Y33516 $ 4515.89 $ 4515.89 90 9% 84% 7% 0 2 0 2 0 0 R Y33517 $ 307.70 $ 307.70 0 0% 0% 0% 0 0 0 2 0 0 R Y33518 $ 675.37 $ 675.37 0 0% 0% 0% 0 0 0 2 0 0 R Y33519 $ 893.10 $ 893.10 0 0% 0% 0% 0 0 0 2 0 0 R Y33521 $ 1070.04 $ 1070.04 0 0% 0% 0% 0 0 0 2 0 0 R Y33522 $ 1202.60 $ 1202.60 0 0% 0% 0% 0 0 0 2 0 0 R Y33523 $ 1368.74 $ 1368.74 0 0% 0% 0% 0 0 0 2 0 0 R Y33530 $ 863.71 $ 863.71 0 0% 0% 0% 0 0 0 2 0 0 R Y33533 $ 3083.57 $ 3083.57 90 9% 82% 9% 0 2 0 2 0 0 R Y33534 $ 3625.79 $ 3625.79 90 9% 82% 9% 0 2 0 2 0 0 R Y33535 $ 4045.05 $ 4045.05 90 9% 82% 9% 0 2 0 2 0 0 R Y33536 $ 4361.15 $ 4361.15 90 9% 82% 9% 0 2 0 2 0 0 R Y33542 $ 4319.76 $ 4319.76 90 9% 84% 7% 0 2 0 2 1 0 R Y33545 $ 5079.71 $ 5079.71 90 9% 84% 7% 0 2 0 2 1 0 R Y33548 $ 4886.57 $ 4886.57 90 9% 84% 7% 0 2 0 2 1 0 R 33572 $ 378.47 $ 378.47 0 0% 0% 0% 0 0 0 2 0 0 R Y33600 $ 2852.65 $ 2852.65 90 9% 84% 7% 0 2 0 2 1 0 R Y33602 $ 2768.68 $ 2768.68 90 9% 84% 7% 0 2 0 2 1 0 R Y33606 $ 2942.02 $ 2942.02 90 9% 84% 7% 0 2 0 2 1 0 R Y33608 $ 2959.41 $ 2959.41 90 9% 84% 7% 0 2 0 2 1 0 R Y33610 $ 2946.82 $ 2946.82 90 9% 84% 7% 0 2 0 2 1 0 R Y33611 $ 3235.32 $ 3235.32 90 9% 84% 7% 0 2 0 2 1 0 R Y33612 $ 3286.90 $ 3286.90 90 9% 84% 7% 0 2 0 2 1 0 R Y33615 $ 3309.10 $ 3309.10 90 9% 84% 7% 0 2 0 2 1 0 R Y33617 $ 3550.82 $ 3550.82 90 9% 84% 7% 0 2 0 2 1 0 R Y33619 $ 4512.30 $ 4512.30 90 9% 84% 7% 0 2 0 2 1 0 R Y33620 $ 2454.98 $ 2454.98 90 9% 84% 7% 0 2 0 2 1 0 R Y33621 $ 1545.08 $ 1545.08 90 9% 84% 7% 0 2 0 2 1 0 R Y33622 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 68
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
33641 $ 2694.90 $ 2694.90 90 9% 84% 7% 0 2 0 2 1 0 R Y33645 $ 2840.65 $ 2840.65 90 9% 84% 7% 0 2 0 2 1 0 R Y33647 $ 2982.21 $ 2982.21 90 9% 84% 7% 0 2 0 2 1 0 R Y33660 $ 2910.83 $ 2910.83 90 9% 84% 7% 0 2 0 2 1 0 R Y33665 $ 3140.55 $ 3140.55 90 9% 84% 7% 0 2 0 2 1 0 R Y33670 $ 3259.31 $ 3259.31 90 9% 84% 7% 0 2 0 2 1 0 R Y33675 $ 3265.31 $ 3265.31 90 9% 84% 7% 0 2 0 2 1 0 R Y33676 $ 3357.08 $ 3357.08 90 9% 84% 7% 0 2 0 2 1 0 R Y33677 $ 3487.24 $ 3487.24 90 9% 84% 7% 0 2 0 2 1 0 R Y33681 $ 3036.79 $ 3036.79 90 9% 84% 7% 0 2 0 2 1 0 R Y33684 $ 3128.56 $ 3128.56 90 9% 84% 7% 0 2 0 2 1 0 R Y33688 $ 3087.77 $ 3087.77 90 9% 84% 7% 0 2 0 2 1 0 R Y33690 $ 1999.73 $ 1999.73 90 9% 84% 7% 0 2 0 2 1 0 R Y33692 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33694 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33697 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33702 $ 2543.15 $ 2543.15 90 9% 84% 7% 0 2 0 2 1 0 R Y33710 $ 3453.65 $ 3453.65 90 9% 84% 7% 0 2 0 2 0 0 R Y33720 $ 2568.34 $ 2568.34 90 9% 84% 7% 0 2 0 2 1 0 R Y33722 $ 2692.50 $ 2692.50 90 9% 84% 7% 0 2 0 2 1 0 R Y33724 $ 2528.76 $ 2528.76 90 9% 84% 7% 0 2 0 2 1 0 R Y33726 $ 3366.08 $ 3366.08 90 9% 84% 7% 0 2 0 2 1 0 R Y33730 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33732 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33735 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X 33736 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33737 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33750 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33755 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33762 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33764 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33766 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33767 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33768 $ 693.37 $ 693.37 0 0% 0% 0% 0 0 0 2 2 0 R 33770 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33771 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33774 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33775 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 69
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
33776 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33777 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X 33778 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33779 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33780 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33781 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X 33782 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X33783 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X33786 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33788 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33800 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 2 0 X 33802 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33803 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33813 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33814 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33820 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X 33822 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33824 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33840 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33845 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33851 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33852 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X 33853 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33860 $ 5284.84 $ 5284.84 90 9% 84% 7% 0 2 0 2 1 0 R Y33863 $ 5181.07 $ 5181.07 90 9% 84% 7% 0 2 0 2 1 0 R Y33864 $ 5307.63 $ 5307.63 90 9% 84% 7% 0 2 0 2 1 0 R Y33870 $ 4151.22 $ 4151.22 90 9% 84% 7% 0 2 0 2 1 0 R Y33875 $ 4518.29 $ 4518.29 90 9% 84% 7% 0 2 0 2 2 0 R Y33877 $ 5984.20 $ 5984.20 90 9% 84% 7% 0 2 0 2 2 0 R Y33880 $ 2986.40 $ 2986.40 90 9% 84% 7% 0 2 2 2 2 0 R 33881 $ 2566.54 $ 2566.54 90 9% 84% 7% 0 2 2 2 2 0 R 33883 $ 1865.38 $ 1865.38 90 9% 84% 7% 0 2 0 2 2 0 R 33884 $ 681.97 $ 681.97 0 0% 0% 0% 0 0 0 2 2 0 R 33886 $ 1607.46 $ 1607.46 90 9% 84% 7% 0 2 0 2 2 0 R 33889 $ 1302.77 $ 1302.77 0 0% 0% 0% 0 2 1 2 2 0 R 33891 $ 1593.67 $ 1593.67 0 0% 0% 0% 0 2 1 2 2 0 R 33910 $ 4342.55 $ 4342.55 90 9% 84% 7% 0 2 0 2 1 0 R Y33915 $ 2091.50 $ 2091.50 90 9% 84% 7% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 70
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
33916 $ 6916.29 $ 6916.29 90 9% 84% 7% 0 2 0 2 1 0 R Y33917 $ 2422.59 $ 2422.59 90 9% 84% 7% 0 2 0 2 1 0 R Y33920 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33922 $ 2285.84 $ 2285.84 90 9% 84% 7% 0 2 0 2 1 0 R Y33924 Not Covered Not Covered 0 0% 0% 0% 0 0 0 2 1 0 X 33925 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33926 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 33930 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 33933 Not Covered Not Covered 0 0% 0% 0% 0 2 0 2 1 0 X 33935 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 2 X 33940 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 33944 Not Covered Not Covered 0 0% 0% 0% 0 2 0 2 1 0 X 33945 $ 7994.13 $ 7994.13 90 9% 84% 7% 0 2 0 2 1 2 R Y33946 $ 513.43 $ 513.43 0 0% 0% 0% 0 0 0 1 0 0 R Y33947 $ 566.81 $ 566.81 0 0% 0% 0% 0 0 0 1 0 0 R Y33948 $ 407.26 $ 407.26 0 0% 0% 0% 0 0 0 1 0 0 R Y33949 $ 396.47 $ 396.47 0 0% 0% 0% 0 0 0 1 0 0 R Y33951 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X33952 $ 705.96 $ 705.96 0 0% 0% 0% 0 2 0 0 0 0 R Y33953 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X33954 $ 788.14 $ 788.14 0 0% 0% 0% 0 2 0 0 0 0 R Y33955 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 1 1 X33956 $ 1380.14 $ 1380.14 0 0% 0% 0% 0 2 0 0 1 1 R Y33957 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X33958 $ 314.90 $ 314.90 0 0% 0% 0% 0 2 0 0 0 0 R Y33959 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X33962 $ 386.27 $ 386.27 0 0% 0% 0% 0 2 0 0 0 0 R Y33963 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 1 1 X33964 $ 843.92 $ 843.92 0 0% 0% 0% 0 2 0 0 1 1 R Y33965 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X33966 $ 389.27 $ 389.27 0 0% 0% 0% 0 2 0 0 0 0 R Y33967 $ 427.06 $ 427.06 0 0% 0% 0% 0 2 0 0 0 0 R Y33968 $ 55.18 $ 55.18 0 0% 0% 0% 0 0 0 1 0 0 R Y33969 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X33970 $ 583.61 $ 583.61 0 0% 0% 0% 0 2 0 2 1 0 R Y33971 $ 1181.01 $ 1181.01 90 9% 84% 7% 0 2 0 1 0 0 R Y33973 $ 849.32 $ 849.32 0 0% 0% 0% 0 2 0 2 1 0 R Y33974 $ 1480.91 $ 1480.91 90 9% 84% 7% 0 2 0 1 0 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 71
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
33975 $ 2153.28 $ 2153.28 0 0% 0% 0% 0 2 0 2 0 0 R Y33976 $ 2613.93 $ 2613.93 0 0% 0% 0% 0 2 2 2 0 0 R Y33977 $ 1864.18 $ 1864.18 0 0% 0% 0% 0 2 0 2 0 0 R Y33978 $ 2202.47 $ 2202.47 0 0% 0% 0% 0 2 2 2 0 0 R Y33979 $ 3205.93 $ 3205.93 0 0% 0% 0% 0 2 0 2 0 0 R Y33980 $ 2932.42 $ 2932.42 0 0% 0% 0% 0 2 0 2 0 0 R Y33981 $ 1368.74 $ 1368.74 0 0% 0% 0% 0 2 0 2 0 0 R Y33982 $ 3217.33 $ 3217.33 0 0% 0% 0% 0 2 0 2 0 0 R Y33983 $ 3806.33 $ 3806.33 0 0% 0% 0% 0 2 0 2 0 0 R Y33984 $ 469.64 $ 469.64 0 0% 0% 0% 0 2 0 0 0 0 R #N/A33985 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 1 1 X33986 $ 855.31 $ 855.31 0 0% 0% 0% 0 2 0 0 1 1 R Y33987 $ 342.49 $ 342.49 0 0% 0% 0% 0 0 0 0 1 1 R Y33988 $ 1275.77 $ 1275.77 0 0% 0% 0% 0 2 0 0 1 1 R Y33989 $ 811.53 $ 811.53 0 0% 0% 0% 0 2 0 0 1 1 R Y33990 $ 722.76 $ 722.76 0 0% 0% 0% 0 2 0 2 0 0 R33991 $ 1043.05 $ 1043.05 0 0% 0% 0% 0 2 0 2 0 0 R33992 $ 350.88 $ 350.88 0 0% 0% 0% 0 2 0 2 0 0 R33993 $ 310.70 $ 310.70 0 0% 0% 0% 0 2 0 2 0 0 R33999 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N Y34001 $ 1648.25 $ 1648.25 90 9% 84% 7% 0 2 1 2 1 0 R Y34051 $ 1482.71 $ 1482.71 90 9% 84% 7% 0 2 1 2 1 0 R Y34101 $ 1007.06 $ 1007.06 90 9% 84% 7% 0 2 1 2 1 0 R Y34111 $ 1001.67 $ 1001.67 90 9% 84% 7% 0 2 1 2 1 0 R Y34151 $ 2338.02 $ 2338.02 90 9% 84% 7% 0 2 1 2 1 0 R Y34201 $ 1720.83 $ 1720.83 90 9% 84% 7% 0 2 1 2 1 0 R Y34203 $ 1591.27 $ 1591.27 90 9% 84% 7% 0 2 1 2 1 0 R Y34401 $ 2432.19 $ 2432.19 90 9% 84% 7% 0 2 1 2 1 0 R Y34421 $ 1217.59 $ 1217.59 90 9% 84% 7% 0 2 1 2 1 0 R Y34451 $ 2756.68 $ 2756.68 90 9% 84% 7% 0 2 1 2 1 0 R Y34471 $ 1792.80 $ 1792.80 90 9% 84% 7% 0 2 1 1 1 0 R Y34490 $ 1022.66 $ 1022.66 90 9% 84% 7% 0 2 1 1 0 0 R Y34501 $ 1490.50 $ 1490.50 90 9% 84% 7% 0 2 1 2 1 0 R Y34502 $ 2556.95 $ 2556.95 90 9% 84% 7% 0 2 0 2 0 0 R Y34510 $ 1984.14 $ 1984.14 90 9% 84% 7% 0 2 1 2 1 0 R Y34520 $ 1645.25 $ 1645.25 90 9% 84% 7% 0 2 1 2 1 0 R Y34530 $ 1848.58 $ 1848.58 90 9% 84% 7% 0 2 1 2 1 0 R Y34800 $ 1881.57 $ 1881.57 90 9% 84% 7% 0 2 0 2 2 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 72
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
34802 $ 2082.51 $ 2082.51 90 9% 84% 7% 0 2 0 2 2 0 R Y34803 $ 2146.68 $ 2146.68 90 9% 84% 7% 0 2 2 2 2 0 R Y34804 $ 2077.71 $ 2077.71 90 9% 84% 7% 0 2 0 2 2 0 R Y34805 $ 1996.13 $ 1996.13 90 9% 84% 7% 0 2 0 2 2 0 R Y34806 $ 164.95 $ 164.95 0 0% 0% 0% 0 0 0 2 2 0 R Y34808 $ 343.69 $ 343.69 0 0% 0% 0% 0 0 0 2 2 0 R Y34812 $ 558.41 $ 558.41 0 0% 0% 0% 0 2 1 2 2 0 R Y34813 $ 391.67 $ 391.67 0 0% 0% 0% 0 0 0 2 2 0 R Y34820 $ 812.13 $ 812.13 0 0% 0% 0% 0 2 1 2 2 0 R Y34825 $ 1166.01 $ 1166.01 90 9% 84% 7% 0 2 0 2 2 0 R Y34826 $ 340.69 $ 340.69 0 0% 0% 0% 0 0 0 2 2 0 R Y34830 $ 2925.22 $ 2925.22 90 9% 84% 7% 0 2 0 2 2 0 R Y34831 $ 3144.15 $ 3144.15 90 9% 84% 7% 0 2 0 2 2 0 R Y34832 $ 3144.15 $ 3144.15 90 9% 84% 7% 0 2 0 2 2 0 R Y34833 $ 1013.06 $ 1013.06 0 0% 0% 0% 0 2 1 2 2 0 R Y34834 $ 452.25 $ 452.25 0 0% 0% 0% 0 2 1 2 2 0 R Y34839 By Report By Report 90 0% 0% 0% 9 0 0 0 0 0 N Y34841 By Report By Report 90 0% 0% 0% 0 2 0 2 2 0 N34842 By Report By Report 90 0% 0% 0% 0 2 0 2 2 0 N34843 By Report By Report 90 0% 0% 0% 0 2 0 2 2 0 N34844 By Report By Report 90 0% 0% 0% 0 2 0 2 2 0 N34845 By Report By Report 90 0% 0% 0% 0 2 0 2 2 0 N34846 By Report By Report 90 0% 0% 0% 0 2 0 2 2 0 N34847 By Report By Report 90 0% 0% 0% 0 2 0 2 2 0 N34848 By Report By Report 90 0% 0% 0% 0 2 0 2 2 0 N34900 $ 1494.70 $ 1494.70 90 9% 84% 7% 0 2 1 2 2 0 R Y35001 $ 1887.57 $ 1887.57 90 9% 84% 7% 0 2 1 2 1 0 R Y35002 $ 1887.57 $ 1887.57 90 9% 84% 7% 0 2 1 2 1 0 R Y35005 $ 1935.55 $ 1935.55 90 9% 84% 7% 0 2 1 2 1 0 R Y35011 $ 1672.24 $ 1672.24 90 9% 84% 7% 0 2 1 2 1 0 R Y35013 $ 2077.71 $ 2077.71 90 9% 84% 7% 0 2 1 2 1 0 R Y35021 $ 2104.70 $ 2104.70 90 9% 84% 7% 0 2 1 2 1 0 R Y35022 $ 2407.00 $ 2407.00 90 9% 84% 7% 0 2 1 2 1 0 R Y35045 $ 1665.04 $ 1665.04 90 9% 84% 7% 0 2 1 2 1 0 R Y35081 $ 2910.83 $ 2910.83 90 9% 84% 7% 0 2 0 2 1 0 R Y35082 $ 3653.98 $ 3653.98 90 9% 84% 7% 0 2 0 2 1 0 R Y35091 $ 2978.01 $ 2978.01 90 9% 84% 7% 0 2 1 2 1 0 R Y35092 $ 4340.15 $ 4340.15 90 9% 84% 7% 0 2 1 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 73
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
35102 $ 3147.75 $ 3147.75 90 9% 84% 7% 0 2 1 2 1 0 R Y35103 $ 3749.95 $ 3749.95 90 9% 84% 7% 0 2 1 2 1 0 R Y35111 $ 2205.46 $ 2205.46 90 9% 84% 7% 0 2 1 2 1 0 R Y35112 $ 3132.16 $ 3132.16 90 9% 84% 7% 0 2 1 2 1 0 R Y35121 $ 2735.69 $ 2735.69 90 9% 84% 7% 0 2 1 2 0 0 R Y35122 $ 3610.20 $ 3610.20 90 9% 84% 7% 0 2 1 2 1 0 R Y35131 $ 2317.63 $ 2317.63 90 9% 84% 7% 0 2 1 2 1 0 R Y35132 $ 2712.90 $ 2712.90 90 9% 84% 7% 0 2 1 2 1 0 R Y35141 $ 1850.98 $ 1850.98 90 9% 84% 7% 0 2 1 2 1 0 R Y35142 $ 2200.67 $ 2200.67 90 9% 84% 7% 0 2 1 2 1 0 R Y35151 $ 2073.51 $ 2073.51 90 9% 84% 7% 0 2 1 2 1 0 R Y35152 $ 2320.63 $ 2320.63 90 9% 84% 7% 0 2 1 2 1 0 R Y35180 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 35182 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 35184 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 35188 $ 1780.81 $ 1780.81 90 9% 84% 7% 0 2 0 2 1 0 R Y35189 $ 2505.96 $ 2505.96 90 9% 84% 7% 0 2 0 2 1 0 R Y35190 $ 1272.78 $ 1272.78 90 9% 84% 7% 0 2 0 2 1 0 R Y35201 $ 1603.87 $ 1603.87 90 9% 84% 7% 0 2 1 2 1 0 R 35206 $ 1296.77 $ 1296.77 90 9% 84% 7% 0 2 1 2 1 0 R 35207 $ 1279.97 $ 1279.97 90 9% 84% 7% 0 2 1 1 1 0 R 35211 $ 2285.84 $ 2285.84 90 9% 84% 7% 0 2 1 2 1 0 R 35216 $ 3395.47 $ 3395.47 90 9% 84% 7% 0 2 1 2 1 0 R 35221 $ 2413.60 $ 2413.60 90 9% 84% 7% 0 2 1 2 1 0 R 35226 $ 1388.54 $ 1388.54 90 9% 84% 7% 0 2 1 2 1 0 R 35231 $ 2077.71 $ 2077.71 90 9% 84% 7% 0 2 1 2 1 0 R 35236 $ 1640.45 $ 1640.45 90 9% 84% 7% 0 2 1 2 1 0 R 35241 $ 2386.00 $ 2386.00 90 9% 84% 7% 0 2 1 2 1 0 R 35246 $ 2614.53 $ 2614.53 90 9% 84% 7% 0 2 1 2 1 0 R 35251 $ 2837.65 $ 2837.65 90 9% 84% 7% 0 2 1 2 1 0 R 35256 $ 1697.43 $ 1697.43 90 9% 84% 7% 0 2 1 2 1 0 R 35261 $ 1793.40 $ 1793.40 90 9% 84% 7% 0 2 1 2 1 0 R 35266 $ 1445.52 $ 1445.52 90 9% 84% 7% 0 2 1 2 1 0 R 35271 $ 2290.04 $ 2290.04 90 9% 84% 7% 0 2 1 2 1 0 R 35276 $ 2433.99 $ 2433.99 90 9% 84% 7% 0 2 1 2 1 0 R 35281 $ 2701.50 $ 2701.50 90 9% 84% 7% 0 2 1 2 1 0 R 35286 $ 1560.08 $ 1560.08 90 9% 84% 7% 0 2 1 2 1 0 R 35301 $ 1889.97 $ 1889.97 90 9% 84% 7% 0 2 1 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 74
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
35302 $ 1880.97 $ 1880.97 90 9% 84% 7% 0 2 1 2 1 0 R Y35303 $ 2072.31 $ 2072.31 90 9% 84% 7% 0 2 1 2 1 0 R Y35304 $ 2141.89 $ 2141.89 90 9% 84% 7% 0 2 1 2 1 0 R Y35305 $ 2038.12 $ 2038.12 90 9% 84% 7% 0 2 1 2 1 0 R Y35306 $ 737.75 $ 737.75 0 0% 0% 0% 0 0 0 2 1 0 R Y35311 $ 2595.93 $ 2595.93 90 9% 84% 7% 0 2 1 2 1 0 R Y35321 $ 1483.91 $ 1483.91 90 9% 84% 7% 0 2 1 2 1 0 R Y35331 $ 2428.59 $ 2428.59 90 9% 84% 7% 0 2 1 2 1 0 R Y35341 $ 2264.25 $ 2264.25 90 9% 84% 7% 0 2 1 2 1 0 R Y35351 $ 2133.49 $ 2133.49 90 9% 84% 7% 0 2 1 2 1 0 R Y35355 $ 1725.62 $ 1725.62 90 9% 84% 7% 0 2 1 2 1 0 R Y35361 $ 2526.96 $ 2526.96 90 9% 84% 7% 0 2 1 2 1 0 R Y35363 $ 2930.02 $ 2930.02 90 9% 84% 7% 0 2 1 2 1 0 R Y35371 $ 1370.54 $ 1370.54 90 9% 84% 7% 0 2 1 2 1 0 R Y35372 $ 1638.65 $ 1638.65 90 9% 84% 7% 0 2 1 2 1 0 R Y35390 $ 265.11 $ 265.11 0 0% 0% 0% 0 0 0 2 1 0 R Y35400 $ 247.12 $ 247.12 0 0% 0% 0% 0 0 0 0 1 0 R Y35450 $ 832.52 $ 832.52 0 0% 0% 0% 0 2 1 2 1 0 R Y35452 $ 564.41 $ 564.41 0 0% 0% 0% 0 2 1 2 1 0 R Y35458 $ 813.93 $ 813.93 0 0% 0% 0% 0 2 1 2 1 0 R Y35460 $ 521.23 $ 521.23 0 0% 0% 0% 0 2 1 1 1 0 R Y35471 $ 4518.29 $ 870.91 0 0% 0% 0% 0 2 1 1 0 0 R Y35472 $ 3308.50 $ 593.80 0 0% 0% 0% 0 2 1 0 1 0 R Y35475 $ 2762.08 $ 566.81 0 0% 0% 0% 0 2 1 1 0 0 R Y35476 $ 2532.36 $ 460.05 0 0% 0% 0% 0 2 1 1 0 0 R Y35500 $ 529.02 $ 529.02 0 0% 0% 0% 0 0 0 2 1 0 R Y35501 $ 2504.76 $ 2504.76 90 9% 84% 7% 0 2 1 2 1 0 R Y35506 $ 2116.69 $ 2116.69 90 9% 84% 7% 0 2 1 2 1 0 R Y35508 $ 2209.66 $ 2209.66 90 9% 84% 7% 0 2 1 2 1 0 R Y35509 $ 2349.42 $ 2349.42 90 9% 84% 7% 0 2 1 2 1 0 R Y35510 $ 2044.12 $ 2044.12 90 9% 84% 7% 0 2 1 2 1 0 R Y35511 $ 1861.78 $ 1861.78 90 9% 84% 7% 0 2 1 2 1 0 R Y35512 $ 2320.63 $ 2320.63 90 9% 84% 7% 0 2 1 2 1 0 R Y35515 $ 2571.34 $ 2571.34 90 9% 84% 7% 0 2 1 2 1 0 R Y35516 $ 2027.32 $ 2027.32 90 9% 84% 7% 0 2 1 2 1 0 R Y35518 $ 1897.77 $ 1897.77 90 9% 84% 7% 0 2 1 2 1 0 R Y35521 $ 2039.32 $ 2039.32 90 9% 84% 7% 0 2 1 2 1 0 R Y35522 $ 2024.92 $ 2024.92 90 9% 84% 7% 0 2 1 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 75
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
35523 $ 2164.08 $ 2164.08 90 9% 84% 7% 0 2 1 2 1 0 R Y35525 $ 1921.76 $ 1921.76 90 9% 84% 7% 0 2 1 2 1 0 R Y35526 $ 2891.04 $ 2891.04 90 9% 84% 7% 0 2 1 2 1 0 R Y35531 $ 3363.68 $ 3363.68 90 9% 84% 7% 0 2 1 2 1 0 R Y35533 $ 2501.17 $ 2501.17 90 9% 84% 7% 0 2 1 2 1 0 R Y35535 $ 3157.95 $ 3157.95 90 9% 84% 7% 0 2 1 2 1 0 R Y35536 $ 2805.26 $ 2805.26 90 9% 84% 7% 0 2 1 2 1 0 R Y35537 $ 3976.67 $ 3976.67 90 9% 84% 7% 0 2 0 2 1 0 R Y35538 $ 3870.51 $ 3870.51 90 9% 84% 7% 0 2 0 2 1 0 R Y35539 $ 3636.59 $ 3636.59 90 9% 84% 7% 0 2 1 2 1 0 R Y35540 $ 4278.37 $ 4278.37 90 9% 84% 7% 0 2 1 1 1 0 R Y35556 $ 2339.82 $ 2339.82 90 9% 84% 7% 0 2 1 2 1 0 R Y35558 $ 2056.71 $ 2056.71 90 9% 84% 7% 0 2 1 2 1 0 R Y35560 $ 2829.26 $ 2829.26 90 9% 84% 7% 0 2 1 2 1 0 R Y35563 $ 2551.55 $ 2551.55 90 9% 84% 7% 0 2 1 2 1 0 R Y35565 $ 2221.06 $ 2221.06 90 9% 84% 7% 0 2 1 2 1 0 R Y35566 $ 2787.27 $ 2787.27 90 9% 84% 7% 0 2 1 2 1 0 R Y35570 $ 2529.96 $ 2529.96 90 9% 84% 7% 0 2 1 2 1 0 R Y35571 $ 2219.86 $ 2219.86 90 9% 84% 7% 0 2 1 2 1 0 R Y35572 $ 572.81 $ 572.81 0 0% 0% 0% 0 0 0 2 0 0 R Y35583 $ 2426.79 $ 2426.79 90 9% 84% 7% 0 2 1 2 1 0 R Y35585 $ 2804.07 $ 2804.07 90 9% 84% 7% 0 2 1 2 1 0 R Y35587 $ 2291.84 $ 2291.84 90 9% 84% 7% 0 2 1 2 1 0 R Y35600 $ 421.06 $ 421.06 0 0% 0% 0% 0 0 0 2 1 0 R Y35601 $ 2339.82 $ 2339.82 90 9% 84% 7% 0 2 1 2 1 0 R Y35606 $ 1966.74 $ 1966.74 90 9% 84% 7% 0 2 1 2 1 0 R Y35612 $ 1737.62 $ 1737.62 90 9% 84% 7% 0 2 1 2 1 0 R Y35616 $ 1831.19 $ 1831.19 90 9% 84% 7% 0 2 1 2 1 0 R Y35621 $ 1838.99 $ 1838.99 90 9% 84% 7% 0 2 1 2 1 0 R Y35623 $ 2182.67 $ 2182.67 90 9% 84% 7% 0 2 1 2 1 0 R Y35626 $ 2624.13 $ 2624.13 90 9% 84% 7% 0 2 1 2 1 0 R Y35631 $ 3084.77 $ 3084.77 90 9% 84% 7% 0 2 1 2 1 0 R Y35632 $ 2999.60 $ 2999.60 90 9% 84% 7% 0 2 1 2 1 0 R Y35633 $ 3352.88 $ 3352.88 90 9% 84% 7% 0 2 1 2 1 0 R Y35634 $ 3051.78 $ 3051.78 90 9% 84% 7% 0 2 1 2 1 0 R Y35636 $ 2647.52 $ 2647.52 90 9% 84% 7% 0 2 1 2 1 0 R Y35637 $ 2904.83 $ 2904.83 90 9% 84% 7% 0 2 0 2 1 0 R Y35638 $ 2946.22 $ 2946.22 90 9% 84% 7% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 76
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
35642 $ 1937.95 $ 1937.95 90 9% 84% 7% 0 2 1 2 1 0 R Y35645 $ 1573.28 $ 1573.28 90 9% 84% 7% 0 2 1 2 1 0 R Y35646 $ 2867.04 $ 2867.04 90 9% 84% 7% 0 2 0 2 1 0 R Y35647 $ 2589.94 $ 2589.94 90 9% 84% 7% 0 2 1 2 1 0 R Y35650 $ 1823.39 $ 1823.39 90 9% 84% 7% 0 2 1 2 1 0 R Y35654 $ 2291.84 $ 2291.84 90 9% 84% 7% 0 2 0 2 1 0 R Y35656 $ 1814.40 $ 1814.40 90 9% 84% 7% 0 2 1 2 1 0 R Y35661 $ 1817.39 $ 1817.39 90 9% 84% 7% 0 2 1 2 1 0 R Y35663 $ 2108.30 $ 2108.30 90 9% 84% 7% 0 2 1 2 1 0 R Y35665 $ 1960.75 $ 1960.75 90 9% 84% 7% 0 2 1 2 1 0 R Y35666 $ 2117.89 $ 2117.89 90 9% 84% 7% 0 2 1 2 1 0 R Y35671 $ 1874.97 $ 1874.97 90 9% 84% 7% 0 2 1 2 1 0 R Y35681 $ 133.16 $ 133.16 0 0% 0% 0% 0 0 0 2 1 0 R Y35682 $ 586.00 $ 586.00 0 0% 0% 0% 0 0 0 0 1 0 R Y35683 $ 677.17 $ 677.17 0 0% 0% 0% 0 0 0 0 1 0 R Y35685 $ 329.29 $ 329.29 0 0% 0% 0% 0 0 0 2 1 0 R Y35686 $ 266.31 $ 266.31 0 0% 0% 0% 0 0 0 2 1 0 R Y35691 $ 1572.08 $ 1572.08 90 9% 84% 7% 0 2 1 2 1 0 R Y35693 $ 1392.74 $ 1392.74 90 9% 84% 7% 0 2 1 2 1 0 R Y35694 $ 1641.65 $ 1641.65 90 9% 84% 7% 0 2 1 2 1 0 R Y35695 $ 1704.03 $ 1704.03 90 9% 84% 7% 0 2 1 2 1 0 R Y35697 $ 244.72 $ 244.72 0 0% 0% 0% 0 0 0 2 2 0 R Y35700 $ 253.12 $ 253.12 0 0% 0% 0% 0 0 0 2 1 0 R Y35701 $ 960.88 $ 960.88 90 9% 84% 7% 0 2 1 2 1 0 R Y35721 $ 768.94 $ 768.94 90 9% 84% 7% 0 2 1 2 1 0 R Y35741 $ 861.91 $ 861.91 90 9% 84% 7% 0 2 1 2 1 0 R Y35761 $ 665.78 $ 665.78 90 9% 84% 7% 0 2 1 2 1 0 R Y35800 $ 1203.80 $ 1203.80 90 9% 84% 7% 0 2 0 2 1 0 R Y35820 $ 3315.69 $ 3315.69 90 9% 84% 7% 0 2 0 2 1 0 R Y35840 $ 1969.74 $ 1969.74 90 9% 84% 7% 0 2 0 2 1 0 R Y35860 $ 1402.33 $ 1402.33 90 9% 84% 7% 0 2 0 2 1 0 R Y35870 $ 2068.11 $ 2068.11 90 9% 84% 7% 0 2 0 2 1 0 R Y35875 $ 996.27 $ 996.27 90 9% 84% 7% 0 2 0 1 1 0 R Y35876 $ 1578.67 $ 1578.67 90 9% 84% 7% 0 2 0 2 1 0 R Y35879 $ 1541.49 $ 1541.49 90 9% 84% 7% 0 2 1 2 1 0 R Y35881 $ 1701.63 $ 1701.63 90 9% 84% 7% 0 2 1 2 1 0 R Y35883 $ 2018.93 $ 2018.93 90 9% 84% 7% 0 2 1 2 1 0 R Y35884 $ 2060.91 $ 2060.91 90 9% 84% 7% 0 2 1 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 77
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
35901 $ 830.12 $ 830.12 90 9% 84% 7% 0 2 0 2 1 0 R Y35903 $ 953.08 $ 953.08 90 9% 84% 7% 0 2 0 2 1 0 R Y35905 $ 2929.42 $ 2929.42 90 9% 84% 7% 0 2 0 2 1 0 R Y35907 $ 3178.94 $ 3178.94 90 9% 84% 7% 0 2 0 2 1 0 R Y36000 $ 44.99 $ 15.59 0 0% 0% 0% 9 9 9 9 9 9 R 36002 $ 280.11 $ 181.74 0 0% 0% 0% 0 2 1 1 0 0 R 36005 $ 574.01 $ 81.57 0 0% 0% 0% 0 2 1 0 0 0 R 36010 $ 883.51 $ 205.73 0 0% 0% 0% 0 2 1 1 0 0 R 36011 $ 1479.71 $ 265.71 0 0% 0% 0% 0 2 1 1 0 0 R 36012 $ 1528.29 $ 294.50 0 0% 0% 0% 0 2 1 1 0 0 R 36013 $ 1389.74 $ 212.33 0 0% 0% 0% 0 2 0 1 0 0 R 36014 $ 1443.72 $ 256.71 0 0% 0% 0% 0 2 1 1 0 0 R 36015 $ 1531.89 $ 291.50 0 0% 0% 0% 0 2 1 1 0 0 R 36100 $ 854.72 $ 253.72 0 0% 0% 0% 0 2 1 1 0 0 R 36120 $ 738.95 $ 167.34 0 0% 0% 0% 0 2 0 1 0 0 R 36140 $ 768.94 $ 170.34 0 0% 0% 0% 0 2 0 1 0 0 R 36147 $ 1477.31 $ 315.49 0 0% 0% 0% 0 2 0 2 0 0 R Y36148 $ 464.85 $ 83.37 0 0% 0% 0% 0 0 0 2 0 0 R Y36160 $ 875.71 $ 211.13 0 0% 0% 0% 0 2 0 1 0 0 R 36200 $ 1097.03 $ 253.72 0 0% 0% 0% 0 2 1 1 0 0 R 36215 $ 1992.54 $ 397.67 0 0% 0% 0% 0 2 0 1 0 0 R 36216 $ 2062.71 $ 455.85 0 0% 0% 0% 0 2 0 1 0 0 R 36217 $ 3355.28 $ 539.82 0 0% 0% 0% 0 2 0 1 0 0 R 36218 $ 323.29 $ 87.57 0 0% 0% 0% 0 0 0 1 0 0 R 36221 $ 1932.56 $ 356.88 0 0% 0% 0% 0 2 2 1 0 0 R36222 $ 2228.26 $ 488.24 0 0% 0% 0% 0 2 1 1 0 0 R36223 $ 2681.71 $ 535.62 0 0% 0% 0% 0 2 1 1 0 0 R36224 $ 3349.28 $ 602.20 0 0% 0% 0% 0 2 1 1 0 0 R36225 $ 2583.94 $ 532.02 0 0% 0% 0% 0 2 1 1 0 0 R36226 $ 3270.71 $ 599.80 0 0% 0% 0% 0 2 1 1 0 0 R36227 $ 449.85 $ 191.34 0 0% 0% 0% 0 0 1 1 0 0 R36228 $ 2227.66 $ 388.67 0 0% 0% 0% 0 0 1 1 0 0 R36245 $ 2424.99 $ 424.06 0 0% 0% 0% 0 2 1 1 0 0 R 36246 $ 1560.08 $ 448.05 0 0% 0% 0% 0 2 1 1 0 0 R 36247 $ 2788.47 $ 533.22 0 0% 0% 0% 0 2 1 1 0 0 R 36248 $ 268.71 $ 83.97 0 0% 0% 0% 0 0 0 1 0 0 R 36251 $ 2514.36 $ 469.04 0 0% 0% 0% 0 2 0 1 0 0 R36252 $ 2715.29 $ 620.19 0 0% 0% 0% 0 2 2 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 78
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
36253 $ 4033.06 $ 642.99 0 0% 0% 0% 0 2 0 1 0 0 R36254 $ 3892.70 $ 720.36 0 0% 0% 0% 0 2 2 1 0 0 R36260 Not Covered Not Covered 90 9% 84% 7% 0 2 0 1 0 0 X 36261 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X 36262 Not Covered Not Covered 90 9% 84% 7% 0 2 0 1 0 0 X 36299 By Report By Report 0 0% 0% 0% 0 2 0 0 1 1 N 36400 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36405 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36406 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36410 $ 29.39 $ 16.19 0 0% 0% 0% 0 2 0 1 0 0 R 36415 $ 4.20 $ 4.20 0 0% 0% 0% 9 9 9 9 9 9 L 36416 $ 4.20 $ 4.20 0 0% 0% 0% 9 9 9 9 9 9 L 36420 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 36425 $ 67.18 $ 67.18 0 0% 0% 0% 0 2 0 1 0 0 R 36430 $ 61.18 $ 61.18 0 0% 0% 0% 5 0 0 1 0 0 R 36440 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 36450 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 36455 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36460 $ 585.40 $ 585.40 0 0% 0% 0% 0 2 0 2 0 0 R Y36468 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 36470 Not Covered Not Covered 10 10% 80% 10% 0 2 1 1 0 0 X 36471 Not Covered Not Covered 10 10% 80% 10% 0 2 1 1 0 0 X 36475 $ 2714.10 $ 467.24 0 0% 0% 0% 0 2 1 1 0 0 R Y36476 $ 509.23 $ 224.33 0 0% 0% 0% 0 0 1 1 0 0 R Y36478 $ 2114.30 $ 466.04 0 0% 0% 0% 0 2 1 1 0 0 R Y36479 $ 531.42 $ 226.72 0 0% 0% 0% 0 0 1 1 0 0 R Y36481 $ 3673.18 $ 605.20 0 0% 0% 0% 0 2 0 1 0 0 R 36500 $ 303.50 $ 303.50 0 0% 0% 0% 0 2 0 1 0 0 R 36510 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 36511 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36512 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36513 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36514 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36515 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36516 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36522 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36555 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X 36556 $ 403.67 $ 203.93 0 0% 0% 0% 0 0 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 79
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
36557 Not Covered Not Covered 10 10% 80% 10% 0 2 1 0 0 0 X 36558 $ 1376.54 $ 473.84 10 10% 80% 10% 0 2 1 0 0 0 R 36560 Not Covered Not Covered 10 10% 80% 10% 0 2 1 0 0 0 X 36561 $ 2069.91 $ 596.80 10 10% 80% 10% 0 2 1 0 0 0 R 36563 $ 2347.62 $ 635.19 10 10% 80% 10% 0 2 0 0 0 0 R 36565 $ 1681.84 $ 578.81 10 10% 80% 10% 0 2 1 0 0 0 R 36566 $ 9918.29 $ 647.78 10 10% 80% 10% 0 2 1 0 0 0 R 36568 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X 36569 $ 440.25 $ 157.15 0 0% 0% 0% 0 0 0 1 0 0 R 36570 Not Covered Not Covered 10 10% 80% 10% 0 2 1 0 0 0 X 36571 $ 2310.43 $ 544.62 10 10% 80% 10% 0 2 1 0 0 0 R 36575 $ 294.50 $ 59.38 0 0% 0% 0% 0 2 0 0 0 0 R 36576 $ 672.38 $ 334.09 10 10% 80% 10% 0 2 0 0 0 0 R 36578 $ 914.10 $ 371.28 10 10% 80% 10% 0 2 0 0 0 0 R 36580 $ 379.07 $ 113.96 0 0% 0% 0% 0 0 0 1 0 0 R 36581 $ 1360.35 $ 336.49 10 10% 80% 10% 0 2 0 0 0 0 R 36582 $ 1934.36 $ 517.03 10 10% 80% 10% 0 2 0 0 0 0 R 36583 $ 2408.80 $ 563.21 10 10% 80% 10% 0 2 0 0 0 0 R 36584 $ 361.68 $ 115.16 0 0% 0% 0% 0 0 0 1 0 0 R 36585 $ 2051.92 $ 482.84 10 10% 80% 10% 0 2 0 0 0 0 R 36589 $ 281.91 $ 235.72 10 10% 80% 10% 0 2 0 0 0 0 R 36590 $ 500.83 $ 346.08 10 10% 80% 10% 0 2 0 0 0 0 R 36591 $ 41.39 $ 41.39 0 0% 0% 0% 3 0 0 0 0 0 R 36592 $ 46.78 $ 46.78 0 0% 0% 0% 3 0 0 0 0 0 R 36593 $ 54.58 $ 54.58 0 0% 0% 0% 3 0 0 0 0 0 R 36595 $ 1031.66 $ 314.90 0 0% 0% 0% 0 2 0 1 0 0 R 36596 $ 235.12 $ 76.77 0 0% 0% 0% 0 2 0 1 0 0 R 36597 $ 223.73 $ 105.56 0 0% 0% 0% 0 2 0 1 0 0 R 36598 $ 194.34 $ 62.98 0 0% 0% 0% 9 2 1 0 0 0 R 36600 $ 55.18 $ 26.39 0 0% 0% 0% 0 2 0 1 0 0 R 36620 $ 86.37 $ 86.37 0 0% 0% 0% 0 0 0 1 0 0 R 36625 $ 171.54 $ 171.54 0 0% 0% 0% 0 0 0 1 0 0 R 36640 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 36660 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 36680 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 36800 $ 207.53 $ 207.53 0 0% 0% 0% 0 2 0 1 0 0 R 36810 $ 359.88 $ 359.88 0 0% 0% 0% 0 2 0 1 0 0 R 36815 $ 226.72 $ 226.72 0 0% 0% 0% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 80
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
36818 $ 1160.01 $ 1160.01 90 9% 84% 7% 0 2 0 2 1 0 R Y36819 $ 1227.79 $ 1227.79 90 9% 84% 7% 0 2 0 2 1 0 R Y36820 $ 1219.99 $ 1219.99 90 9% 84% 7% 0 2 1 2 1 0 R Y36821 $ 1113.23 $ 1113.23 90 9% 84% 7% 0 2 0 2 1 0 R Y36823 Not Covered Not Covered 90 9% 84% 7% 0 2 0 1 0 0 X 36825 $ 1343.55 $ 1343.55 90 9% 84% 7% 0 2 0 2 1 0 R Y36830 $ 1118.63 $ 1118.63 90 9% 84% 7% 0 2 0 2 1 0 R Y36831 $ 1035.85 $ 1035.85 90 9% 84% 7% 0 2 0 2 1 0 R Y36832 $ 1269.78 $ 1269.78 90 9% 84% 7% 0 2 0 2 1 0 R 36833 $ 1357.95 $ 1357.95 90 9% 84% 7% 0 2 0 2 1 0 R Y36835 Not Covered Not Covered 90 9% 84% 7% 0 2 0 1 0 0 X 36838 $ 1907.36 $ 1907.36 90 9% 84% 7% 0 2 1 2 1 0 R Y36860 $ 364.08 $ 190.74 0 0% 0% 0% 0 2 0 1 0 0 R 36861 $ 217.13 $ 217.13 0 0% 0% 0% 0 2 0 1 0 0 R 36870 $ 3267.11 $ 515.83 90 9% 84% 7% 0 2 1 1 2 0 R Y37140 $ 3811.73 $ 3811.73 90 9% 84% 7% 0 2 0 1 1 0 R Y37145 $ 3535.22 $ 3535.22 90 9% 84% 7% 0 2 0 2 0 0 R Y37160 $ 3631.19 $ 3631.19 90 9% 84% 7% 0 2 0 2 1 0 R Y37180 $ 3494.43 $ 3494.43 90 9% 84% 7% 0 2 0 2 1 0 R Y37181 $ 3811.73 $ 3811.73 90 9% 84% 7% 0 2 0 2 1 0 R Y37182 $ 1440.72 $ 1440.72 0 0% 0% 0% 0 2 0 0 0 0 R Y37183 $ 10606.86 $ 680.17 0 0% 0% 0% 0 2 0 0 0 0 R Y37184 $ 4018.66 $ 768.94 0 0% 0% 0% 0 2 1 1 2 0 R 37185 $ 1265.58 $ 277.71 0 0% 0% 0% 0 0 2 1 2 0 R 37186 $ 2440.59 $ 413.86 0 0% 0% 0% 0 0 2 1 2 0 R 37187 $ 3658.78 $ 686.77 0 0% 0% 0% 0 2 1 1 2 0 R 37188 $ 3135.15 $ 497.23 0 0% 0% 0% 0 2 1 1 2 0 R 37191 $ 4715.03 $ 404.87 0 0% 0% 0% 0 2 0 1 0 0 R Y37192 $ 2986.40 $ 647.18 0 0% 0% 0% 0 2 0 1 0 0 R Y37193 $ 2836.45 $ 620.79 0 0% 0% 0% 0 2 0 1 0 0 R Y37195 By Report By Report 0 0% 0% 0% 5 0 0 0 0 0 N Y37197 $ 2693.70 $ 535.02 0 0% 0% 0% 0 2 0 1 0 0 R37200 $ 380.27 $ 380.27 0 0% 0% 0% 0 2 0 1 0 0 R Y37202 $ 496.63 $ 496.63 0 0% 0% 0% 0 2 0 1 0 0 R 37211 $ 670.58 $ 670.58 0 0% 0% 0% 0 2 1 1 0 0 R37212 $ 589.00 $ 589.00 0 0% 0% 0% 0 2 1 1 0 0 R37213 $ 419.26 $ 419.26 0 0% 0% 0% 0 2 0 1 0 0 R37214 $ 230.32 $ 230.32 0 0% 0% 0% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 81
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
37215 $ 1806.60 $ 1806.60 90 9% 84% 7% 0 2 1 0 0 0 R Y37216 By Report By Report 90 9% 84% 7% 9 9 9 9 9 9 N Y37217 $ 1859.38 $ 1859.38 90 9% 84% 7% 0 2 1 0 0 0 R37218 $ 1373.54 $ 1373.54 90 9% 84% 7% 0 2 1 0 0 0 R Y37220 $ 5616.53 $ 690.97 0 0% 0% 0% 0 2 1 1 0 0 R Y37221 $ 8303.63 $ 849.92 0 0% 0% 0% 0 2 1 0 0 0 R Y37222 $ 1560.68 $ 310.10 0 0% 0% 0% 0 0 1 0 0 0 R Y37223 $ 4639.45 $ 356.88 0 0% 0% 0% 0 0 1 0 0 0 R Y37224 $ 6825.72 $ 763.55 0 0% 0% 0% 0 2 1 0 0 0 R Y37225 $ 19768.21 $ 1028.66 0 0% 0% 0% 0 2 1 0 0 0 R Y37226 $ 16251.58 $ 894.30 0 0% 0% 0% 0 2 1 0 0 0 R Y37227 $ 26713.89 $ 1236.19 0 0% 0% 0% 0 2 1 0 0 0 R Y37228 $ 9723.36 $ 929.69 0 0% 0% 0% 0 2 1 0 0 0 R Y37229 $ 19480.90 $ 1200.80 0 0% 0% 0% 0 2 1 0 0 0 R Y37230 $ 14863.04 $ 1184.01 0 0% 0% 0% 0 2 1 0 0 0 R Y37231 $ 23954.81 $ 1287.17 0 0% 0% 0% 0 2 1 0 0 0 R Y37232 $ 2153.88 $ 337.09 0 0% 0% 0% 0 0 1 0 0 0 R Y37233 $ 2588.14 $ 548.22 0 0% 0% 0% 0 0 1 0 0 0 R Y37234 $ 6940.89 $ 473.84 0 0% 0% 0% 0 0 1 0 0 0 R Y37235 $ 7438.12 $ 651.98 0 0% 0% 0% 0 0 1 0 0 0 R Y37236 $ 7401.53 $ 763.55 0 0% 0% 0% 0 2 1 0 0 0 R37237 $ 4442.72 $ 357.48 0 0% 0% 0% 0 0 1 0 0 0 R37238 $ 7361.35 $ 535.02 0 0% 0% 0% 0 2 1 0 0 0 R37239 $ 3630.59 $ 250.12 0 0% 0% 0% 0 0 1 0 0 0 R37241 $ 8220.26 $ 756.95 0 0% 0% 0% 0 2 0 1 0 0 R37242 $ 13892.57 $ 843.32 0 0% 0% 0% 0 2 0 1 0 0 R37243 $ 17542.95 $ 1004.67 0 0% 0% 0% 0 2 0 1 0 0 R37244 $ 12235.92 $ 1172.61 0 0% 0% 0% 0 2 0 1 0 0 R37250 $ 176.94 $ 176.94 0 0% 0% 0% 0 0 0 0 1 0 R 37251 $ 132.56 $ 132.56 0 0% 0% 0% 0 0 0 0 1 0 R 37500 $ 1067.04 $ 1067.04 90 9% 84% 7% 0 2 1 1 1 0 R Y37501 By Report By Report 90 0% 0% 0% 0 2 1 1 1 1 N 37565 $ 1258.38 $ 1258.38 90 9% 84% 7% 0 2 1 0 1 0 R 37600 $ 1203.80 $ 1203.80 90 9% 84% 7% 0 2 0 2 1 0 R 37605 $ 1315.36 $ 1315.36 90 9% 84% 7% 0 2 0 2 1 0 R 37606 $ 803.13 $ 803.13 90 9% 84% 7% 0 2 0 2 0 0 R 37607 $ 633.39 $ 633.39 90 9% 84% 7% 0 2 0 1 1 0 R 37609 $ 534.42 $ 351.48 10 10% 80% 10% 0 2 1 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 82
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
37615 $ 870.31 $ 870.31 90 9% 84% 7% 0 2 0 2 1 0 R 37616 $ 1835.39 $ 1835.39 90 9% 84% 7% 0 2 0 2 1 0 R 37617 $ 2233.06 $ 2233.06 90 9% 84% 7% 0 2 0 2 1 0 R 37618 $ 643.59 $ 643.59 90 9% 84% 7% 0 2 0 2 1 0 R 37619 $ 2703.30 $ 2703.30 90 9% 84% 7% 0 2 0 2 0 0 R Y37650 $ 768.94 $ 768.94 90 9% 84% 7% 0 2 1 1 1 0 R Y37660 $ 2164.68 $ 2164.68 90 9% 84% 7% 0 2 1 2 1 0 R Y37700 $ 422.86 $ 422.86 90 9% 84% 7% 0 2 1 1 0 0 R Y37718 Not Covered Not Covered 90 9% 84% 7% 0 2 1 1 1 0 X 37722 Not Covered Not Covered 90 9% 84% 7% 0 2 1 1 1 0 X 37735 $ 971.08 $ 971.08 90 9% 84% 7% 0 2 1 1 1 0 R Y37760 $ 1025.06 $ 1025.06 90 9% 84% 7% 0 2 1 1 1 0 R Y37761 $ 936.29 $ 936.29 90 9% 84% 7% 0 2 1 2 1 0 R Y37765 $ 1119.83 $ 757.55 90 9% 84% 7% 0 2 1 1 1 0 R Y37766 $ 1324.96 $ 923.69 90 9% 84% 7% 0 2 1 1 1 0 R Y37780 $ 436.05 $ 436.05 90 9% 84% 7% 0 2 1 1 1 0 R Y37785 $ 615.39 $ 448.05 90 9% 84% 7% 0 2 1 1 0 0 R Y37788 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 37790 Not Covered Not Covered 90 8% 83% 9% 0 2 0 0 0 0 X 37799 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 38100 $ 1902.57 $ 1902.57 90 11% 73% 16% 0 2 0 2 1 0 R 38101 $ 1919.36 $ 1919.36 90 11% 73% 16% 0 2 0 2 1 0 R 38102 $ 430.66 $ 430.66 0 0% 0% 0% 0 0 0 2 1 0 R 38115 $ 2108.30 $ 2108.30 90 11% 73% 16% 0 2 0 2 1 0 R 38120 $ 1743.02 $ 1743.02 90 9% 84% 7% 0 2 0 2 1 0 R 38129 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 38200 $ 230.32 $ 230.32 0 0% 0% 0% 0 2 0 0 0 0 R 38204 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 38205 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 38206 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 38207 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 38208 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 38209 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 38210 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 38211 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 38212 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 38213 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 38214 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 83
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
38215 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 38220 $ 287.90 $ 104.37 0 0% 0% 0% 0 2 1 0 0 0 R 38221 $ 294.50 $ 129.56 0 0% 0% 0% 0 2 1 0 0 0 R 38230 $ 335.89 $ 335.89 0 0% 0% 0% 0 2 0 0 0 0 R 38232 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X38240 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 38241 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 38242 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 38243 $ 205.73 $ 205.73 0 0% 0% 0% 0 2 0 0 0 0 R38300 $ 474.44 $ 313.70 10 10% 80% 10% 0 2 0 1 0 0 R 38305 $ 770.74 $ 770.74 90 11% 73% 16% 0 2 0 1 0 0 R 38308 Not Covered Not Covered 90 11% 73% 16% 0 2 0 2 1 0 X 38380 $ 955.48 $ 955.48 90 11% 73% 16% 0 2 0 2 1 0 R Y38381 $ 1329.76 $ 1329.76 90 11% 73% 16% 0 2 0 2 1 0 R Y38382 $ 1125.22 $ 1125.22 90 11% 73% 16% 0 2 0 2 1 0 R Y38500 $ 560.81 $ 424.66 10 10% 80% 10% 0 2 1 1 0 0 R 38505 $ 222.53 $ 123.56 0 0% 0% 0% 0 2 1 1 0 0 R 38510 $ 881.11 $ 704.17 10 10% 80% 10% 0 2 1 1 0 0 R 38520 $ 776.74 $ 776.74 90 11% 73% 16% 0 2 1 1 0 0 R 38525 $ 726.36 $ 726.36 90 11% 73% 16% 0 2 1 1 0 0 R 38530 $ 912.30 $ 912.30 90 11% 73% 16% 0 2 1 2 1 0 R 38542 $ 875.11 $ 875.11 90 11% 73% 16% 0 2 1 2 1 0 R 38550 $ 849.32 $ 849.32 90 11% 73% 16% 0 2 0 0 0 0 R 38555 $ 1668.04 $ 1668.04 90 11% 73% 16% 0 2 0 2 1 0 R 38562 Not Covered Not Covered 90 11% 73% 16% 0 2 2 2 1 0 X 38564 Not Covered Not Covered 90 11% 73% 16% 0 2 0 2 1 0 X 38570 $ 900.90 $ 900.90 10 10% 80% 10% 0 3 0 2 2 0 49320 R Y38571 $ 1348.35 $ 1348.35 10 10% 80% 10% 0 2 2 2 2 0 R Y38572 $ 1638.05 $ 1638.05 10 10% 80% 10% 0 2 2 2 2 0 R Y38589 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 38700 $ 1369.34 $ 1369.34 90 11% 73% 16% 0 2 1 2 1 0 R Y38720 $ 2269.04 $ 2269.04 90 11% 73% 16% 0 2 1 2 1 0 R Y38724 $ 2463.98 $ 2463.98 90 11% 73% 16% 0 2 1 2 1 0 R Y38740 $ 1151.62 $ 1151.62 90 11% 73% 16% 0 2 1 2 1 0 R Y38745 $ 1449.72 $ 1449.72 90 11% 73% 16% 0 2 1 2 1 0 R Y38746 $ 353.28 $ 353.28 0 0% 0% 0% 0 0 0 2 1 0 R Y38747 $ 438.45 $ 438.45 0 0% 0% 0% 0 0 0 2 1 0 R Y38760 $ 1398.13 $ 1398.13 90 11% 73% 16% 0 2 1 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 84
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
38765 $ 2144.29 $ 2144.29 90 11% 73% 16% 0 2 1 2 1 0 R Y38770 $ 1360.35 $ 1360.35 90 11% 73% 16% 0 2 1 2 1 0 R Y38780 $ 1728.02 $ 1728.02 90 11% 73% 16% 0 2 0 2 1 0 R Y38790 $ 141.55 $ 141.55 0 0% 0% 0% 0 2 1 1 0 0 R Y38792 $ 68.38 $ 68.38 0 0% 0% 0% 0 2 1 1 0 0 R Y38794 Not Covered Not Covered 90 11% 73% 16% 0 2 0 0 0 0 X 38900 Not Covered Not Covered 0 0% 0% 0% 0 0 1 2 1 0 X38999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 39000 $ 833.12 $ 833.12 90 9% 84% 7% 0 2 0 2 1 0 R 39010 $ 1308.16 $ 1308.16 90 9% 84% 7% 0 2 0 2 1 0 R 39200 $ 1452.12 $ 1452.12 90 9% 84% 7% 0 2 0 2 1 0 R Y39220 $ 1890.57 $ 1890.57 90 9% 84% 7% 0 2 0 2 1 0 R Y39400 $ 846.92 $ 846.92 10 10% 80% 10% 0 2 0 1 0 0 R Y39499 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 39501 $ 1409.53 $ 1409.53 90 9% 84% 7% 0 2 0 2 1 0 R 39503 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 39540 $ 1434.72 $ 1434.72 90 9% 84% 7% 0 2 0 2 1 0 R 39541 $ 1564.88 $ 1564.88 90 9% 84% 7% 0 2 0 2 1 0 R 39545 $ 1482.11 $ 1482.11 90 9% 84% 7% 0 2 0 2 1 0 R 39560 $ 1322.56 $ 1322.56 90 9% 84% 7% 0 2 0 2 1 0 R 39561 $ 2054.91 $ 2054.91 90 9% 84% 7% 0 2 0 2 1 0 R 39599 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 40490 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 40500 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X 40510 $ 845.12 $ 614.20 90 9% 81% 10% 0 2 0 1 0 0 R Y40520 $ 854.72 $ 618.39 90 9% 81% 10% 0 2 0 1 0 0 R Y40525 $ 944.69 $ 944.69 90 9% 81% 10% 0 2 0 1 0 0 R Y40527 $ 1058.65 $ 1058.65 90 9% 81% 10% 0 2 0 0 0 0 R Y40530 $ 939.29 $ 693.37 90 9% 81% 10% 0 2 0 1 0 0 R Y40650 $ 767.14 $ 515.23 90 9% 81% 10% 0 2 0 0 0 0 R 40652 $ 861.91 $ 614.20 90 9% 81% 10% 0 2 0 0 0 0 R 40654 $ 991.47 $ 732.36 90 9% 81% 10% 0 2 0 1 0 0 R 40700 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 40701 Not Covered Not Covered 90 9% 81% 10% 0 2 2 2 0 0 X 40702 Not Covered Not Covered 90 9% 81% 10% 0 2 2 2 0 0 X 40720 Not Covered Not Covered 90 9% 81% 10% 0 2 1 0 0 0 X 40761 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X 40799 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 85
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
40800 $ 380.87 $ 235.12 10 10% 80% 10% 0 2 0 1 0 0 R 40801 $ 562.61 $ 391.67 10 10% 80% 10% 0 2 0 1 0 0 R 40804 $ 380.87 $ 233.32 10 10% 80% 10% 0 2 0 0 0 0 R 40805 $ 573.41 $ 410.26 10 10% 80% 10% 0 2 0 0 0 0 R 40806 $ 195.53 $ 58.78 0 0% 0% 0% 0 2 0 0 0 0 R 40808 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 40810 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 40812 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 40814 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X 40816 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X 40818 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 40819 $ 559.61 $ 422.26 90 9% 81% 10% 0 2 0 0 0 0 R Y40820 $ 480.44 $ 308.90 10 10% 80% 10% 0 2 0 1 0 0 R 40830 $ 476.24 $ 293.90 10 10% 80% 10% 0 2 0 0 0 0 R 40831 $ 600.40 $ 394.67 10 10% 80% 10% 0 2 0 0 0 0 R 40840 $ 1423.33 $ 1087.44 90 9% 81% 10% 0 2 0 2 0 0 R Y40842 $ 1429.92 $ 1127.62 90 9% 81% 10% 0 2 0 0 0 0 R Y40843 $ 1893.57 $ 1480.91 90 9% 81% 10% 0 2 2 2 0 0 R Y40844 $ 2242.65 $ 1803.00 90 9% 81% 10% 0 2 0 2 0 0 R Y40845 $ 2536.55 $ 2109.50 90 9% 81% 10% 0 2 0 0 0 0 R Y40899 By Report By Report 10 0% 0% 0% 0 2 0 0 1 1 N 41000 $ 289.10 $ 197.93 10 10% 80% 10% 0 2 0 1 0 0 R 41005 $ 407.26 $ 221.33 10 10% 80% 10% 0 2 0 0 0 0 R 41006 $ 680.17 $ 468.44 90 9% 81% 10% 0 2 0 0 0 0 R 41007 $ 669.38 $ 454.65 90 9% 81% 10% 0 2 0 0 0 0 R 41008 $ 673.58 $ 472.04 90 9% 81% 10% 0 2 0 0 0 0 R 41009 $ 713.16 $ 512.83 90 9% 81% 10% 0 2 0 0 0 0 R 41010 $ 363.48 $ 191.34 10 10% 80% 10% 0 2 0 0 0 0 R 41015 $ 803.13 $ 616.59 90 9% 81% 10% 0 2 0 0 0 0 R 41016 $ 779.74 $ 618.39 90 9% 81% 10% 0 2 0 0 0 0 R 41017 $ 791.14 $ 622.59 90 9% 81% 10% 0 2 0 0 0 0 R 41018 $ 890.70 $ 721.56 90 9% 81% 10% 0 2 0 0 0 0 R 41019 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 1 1 X 41100 $ 298.10 $ 188.34 10 10% 80% 10% 0 2 0 1 0 0 R Y41105 $ 302.90 $ 194.94 10 10% 80% 10% 0 2 0 1 0 0 R Y41108 $ 263.91 $ 158.95 10 10% 80% 10% 0 2 0 1 0 0 R Y41110 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 41112 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 86
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
41113 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X 41114 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 41115 $ 440.25 $ 255.51 10 10% 80% 10% 0 2 0 0 0 0 R 41116 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X 41120 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 41130 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 41135 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 41140 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 41145 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 41150 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 41153 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 41155 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 41250 $ 479.84 $ 269.91 10 10% 80% 10% 0 2 0 0 0 0 R 41251 $ 518.23 $ 319.69 10 10% 80% 10% 0 2 0 0 0 0 R 41252 $ 556.01 $ 362.88 10 10% 80% 10% 0 2 0 0 0 0 R 41500 $ 810.93 $ 810.93 90 9% 81% 10% 0 2 0 0 0 0 R 41510 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 41512 $ 1116.23 $ 1116.23 90 10% 76% 14% 0 2 0 0 0 0 R Y41520 $ 630.99 $ 456.45 90 9% 81% 10% 0 2 0 0 0 0 R Y41530 $ 5824.06 $ 728.16 10 10% 80% 10% 0 2 0 0 0 0 R Y41599 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 41800 $ 485.84 $ 260.91 10 10% 80% 10% 0 2 0 1 0 0 R 41805 $ 448.05 $ 307.10 10 10% 80% 10% 0 2 0 0 0 0 R 41806 $ 633.99 $ 461.25 10 10% 80% 10% 0 2 0 0 0 0 R 41820 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 41821 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 41822 Not Covered Not Covered 10 10% 80% 10% 0 2 0 0 0 0 X 41823 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 41825 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 41826 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 41827 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X 41828 Not Covered Not Covered 10 10% 80% 10% 0 2 0 0 0 0 X 41830 Not Covered Not Covered 10 10% 80% 10% 0 2 0 0 0 0 X 41850 $ 66.11 $ 66.11 0 0% 0% 0% 0 2 0 0 0 0 F Y41870 $ 568.48 $ 568.48 0 0% 0% 0% 0 2 0 0 0 0 F Y41872 $ 666.38 $ 460.65 90 9% 81% 10% 0 2 0 0 0 0 R Y41874 $ 672.98 $ 449.85 90 9% 81% 10% 0 2 0 0 0 0 R Y41899 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 87
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
42000 $ 280.11 $ 181.74 10 10% 80% 10% 0 2 0 0 0 0 R 42100 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 42104 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 42106 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 42107 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X 42120 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 42140 $ 450.45 $ 273.51 90 9% 81% 10% 0 2 0 1 0 0 R Y42145 $ 1218.79 $ 1218.79 90 9% 81% 10% 0 2 0 1 0 0 R Y42160 Not Covered Not Covered 10 10% 80% 10% 0 2 0 0 0 0 X 42180 $ 426.46 $ 319.09 10 10% 80% 10% 0 2 0 0 0 0 R 42182 $ 556.61 $ 440.85 10 10% 80% 10% 0 2 0 0 0 0 R 42200 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 0 0 X 42205 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 0 0 X 42210 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 0 0 X 42215 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 0 0 X 42220 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 0 0 X 42225 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 0 0 X 42226 $ 1561.88 $ 1561.88 90 9% 81% 10% 0 2 0 2 0 0 R Y42227 $ 1462.31 $ 1462.31 90 9% 81% 10% 0 2 0 2 0 0 R Y42235 $ 1286.57 $ 1286.57 90 9% 81% 10% 0 2 0 2 0 0 R 42260 $ 1497.70 $ 1239.79 90 9% 81% 10% 0 2 0 2 0 0 R 42280 $ 290.30 $ 192.54 10 10% 80% 10% 0 2 0 0 0 0 R 42281 $ 359.88 $ 263.31 10 10% 80% 10% 0 2 0 0 0 0 R 42299 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 42300 $ 368.28 $ 265.71 10 10% 80% 10% 0 2 0 1 0 0 R 42305 $ 741.35 $ 741.35 90 9% 81% 10% 0 2 0 0 0 0 R 42310 $ 283.71 $ 216.53 10 10% 80% 10% 0 2 0 0 0 0 R 42320 $ 438.45 $ 304.70 10 10% 80% 10% 0 2 0 0 0 0 R 42330 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 42335 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X 42340 Not Covered Not Covered 90 9% 81% 10% 0 2 1 0 0 0 X 42400 $ 188.94 $ 95.97 0 0% 0% 0% 0 2 0 1 0 0 R Y42405 $ 520.63 $ 390.47 10 10% 80% 10% 0 2 0 1 0 0 R Y42408 $ 792.94 $ 562.01 90 9% 81% 10% 0 2 0 0 0 0 R 42409 $ 588.40 $ 386.27 90 9% 81% 10% 0 2 0 2 0 0 R 42410 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X 42415 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X 42420 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 88
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
42425 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X 42426 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X 42440 $ 707.16 $ 707.16 90 9% 81% 10% 0 2 1 2 1 0 R 42450 $ 794.74 $ 623.19 90 9% 81% 10% 0 2 0 0 0 0 R 42500 $ 761.15 $ 595.00 90 9% 81% 10% 0 2 0 0 0 0 R 42505 $ 970.48 $ 783.94 90 9% 81% 10% 0 2 0 1 0 0 R 42507 $ 892.50 $ 892.50 90 9% 81% 10% 0 2 2 2 0 0 R 42509 $ 1458.71 $ 1458.71 90 9% 81% 10% 0 2 2 0 0 0 R 42510 $ 1088.04 $ 1088.04 90 9% 81% 10% 0 2 2 2 1 0 R 42550 $ 238.12 $ 108.56 0 0% 0% 0% 0 2 0 1 0 0 R 42600 $ 839.72 $ 599.80 90 9% 81% 10% 0 2 0 0 0 0 R 42650 $ 147.55 $ 102.57 0 0% 0% 0% 0 2 0 1 0 0 R 42660 $ 218.33 $ 149.95 0 0% 0% 0% 0 2 0 0 0 0 R 42665 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 42699 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 42700 $ 334.69 $ 236.92 10 10% 80% 10% 0 2 0 1 0 0 R 42720 $ 782.14 $ 669.98 10 10% 80% 10% 0 2 0 0 0 0 R 42725 $ 1404.13 $ 1404.13 90 9% 81% 10% 0 2 0 2 1 0 R 42800 $ 279.51 $ 194.94 10 10% 80% 10% 0 2 0 1 0 0 R Y42804 $ 347.28 $ 197.93 10 10% 80% 10% 0 2 0 1 0 0 R Y42806 $ 388.07 $ 229.72 10 10% 80% 10% 0 2 0 1 0 0 R Y42808 $ 396.47 $ 280.11 10 10% 80% 10% 0 2 0 1 0 0 R Y42809 $ 302.90 $ 229.72 10 10% 80% 10% 0 2 0 1 0 0 R 42810 $ 685.57 $ 504.43 90 9% 81% 10% 0 2 1 2 0 0 R Y42815 $ 969.88 $ 969.88 90 9% 81% 10% 0 2 1 2 1 0 R Y42820 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 42821 $ 517.63 $ 517.63 90 9% 81% 10% 0 2 0 0 0 0 R Y42825 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 42826 $ 433.66 $ 433.66 90 9% 81% 10% 0 2 0 1 0 0 R Y42830 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 42831 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 42835 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 42836 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 42842 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 42844 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 42845 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 42860 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 42870 $ 1019.06 $ 1019.06 90 9% 81% 10% 0 2 0 0 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 89
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
42890 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 42892 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 42894 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 42900 $ 580.01 $ 580.01 10 10% 80% 10% 0 2 0 0 0 0 R 42950 $ 1390.34 $ 1390.34 90 9% 81% 10% 0 2 0 2 1 0 R 42953 $ 1675.24 $ 1675.24 90 9% 81% 10% 0 2 0 2 0 0 R 42955 $ 1316.56 $ 1316.56 90 9% 81% 10% 0 2 0 2 0 0 R 42960 $ 294.50 $ 294.50 10 10% 80% 10% 0 2 0 0 0 0 R 42961 $ 731.76 $ 731.76 90 9% 81% 10% 0 2 0 2 0 0 R 42962 $ 894.30 $ 894.30 90 9% 81% 10% 0 2 0 1 0 0 R 42970 $ 714.96 $ 714.96 90 9% 81% 10% 0 2 0 1 0 0 R 42971 $ 787.54 $ 787.54 90 9% 81% 10% 0 2 0 2 0 0 R 42972 $ 879.91 $ 879.91 90 9% 81% 10% 0 2 0 2 0 0 R 42999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 43020 $ 946.48 $ 946.48 90 9% 81% 10% 0 2 0 2 1 0 R 43030 $ 885.90 $ 885.90 90 9% 81% 10% 0 2 0 2 1 0 R 43045 $ 2163.48 $ 2163.48 90 9% 81% 10% 0 2 0 2 1 0 R 43100 $ 1074.24 $ 1074.24 90 9% 81% 10% 0 2 0 2 1 0 R Y43101 $ 1764.01 $ 1764.01 90 9% 81% 10% 0 2 0 2 1 0 R Y43107 $ 4229.19 $ 4229.19 90 9% 81% 10% 0 2 0 2 1 0 R Y43108 $ 7718.83 $ 7718.83 90 9% 81% 10% 0 2 0 2 1 0 R Y43112 $ 4447.52 $ 4447.52 90 9% 81% 10% 0 2 0 2 2 0 R Y43113 $ 7183.20 $ 7183.20 90 9% 81% 10% 0 2 0 2 2 0 R Y43116 $ 8864.44 $ 8864.44 90 9% 81% 10% 0 2 0 2 1 0 R Y43117 $ 4068.44 $ 4068.44 90 9% 81% 10% 0 2 0 2 2 0 R Y43118 $ 6297.30 $ 6297.30 90 9% 81% 10% 0 2 0 2 2 0 R Y43121 $ 4727.62 $ 4727.62 90 9% 81% 10% 0 2 0 2 2 0 R Y43122 $ 4228.59 $ 4228.59 90 9% 81% 10% 0 2 0 2 1 0 R Y43123 $ 7827.99 $ 7827.99 90 9% 81% 10% 0 2 0 2 1 0 R Y43124 $ 6294.30 $ 6294.30 90 9% 81% 10% 0 2 0 2 1 0 R Y43130 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43135 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43180 $ 945.28 $ 945.28 90 9% 81% 10% 0 2 0 1 0 0 R Y43191 $ 262.71 $ 262.71 0 0% 0% 0% 0 2 0 1 0 0 R Y43192 $ 290.90 $ 290.90 0 0% 0% 0% 0 3 0 1 0 0 43191 R43193 $ 290.30 $ 290.30 0 0% 0% 0% 0 3 0 1 0 0 43191 R Y43194 $ 325.09 $ 325.09 0 0% 0% 0% 0 3 0 1 0 0 43191 R43195 $ 317.29 $ 317.29 0 0% 0% 0% 0 3 0 1 0 0 43191 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 90
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
43196 $ 336.49 $ 336.49 0 0% 0% 0% 0 3 0 1 0 0 43191 R43197 $ 329.89 $ 140.35 0 0% 0% 0% 0 2 0 1 0 0 R Y43198 $ 369.48 $ 167.94 0 0% 0% 0% 0 3 0 1 0 0 43197 R Y43200 $ 478.64 $ 160.75 0 0% 0% 0% 0 2 0 1 0 0 R Y43201 $ 487.04 $ 188.94 0 0% 0% 0% 0 3 0 1 0 0 43200 R 43202 $ 644.19 $ 189.54 0 0% 0% 0% 0 3 0 1 0 0 43200 R Y43204 $ 248.32 $ 248.32 0 0% 0% 0% 0 3 0 1 0 0 43200 R Y43205 $ 256.11 $ 256.11 0 0% 0% 0% 0 3 0 1 0 0 43200 R Y43206 $ 580.01 $ 240.52 0 0% 0% 0% 0 3 0 1 0 0 43200 R Y43211 $ 425.26 $ 425.26 0 0% 0% 0% 0 3 0 1 0 0 43200 R43212 $ 335.29 $ 335.29 0 0% 0% 0% 0 3 0 1 0 0 43200 R43213 $ 2202.47 $ 459.45 0 0% 0% 0% 0 3 0 1 0 0 43200 R43214 $ 343.69 $ 343.69 0 0% 0% 0% 0 3 0 1 0 0 43200 R43215 $ 721.56 $ 254.32 0 0% 0% 0% 0 3 0 1 0 0 43200 R 43216 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 43200 X 43217 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 43200 X 43220 $ 2042.32 $ 215.33 0 0% 0% 0% 0 3 0 1 0 0 43200 R 43226 $ 671.78 $ 236.32 0 0% 0% 0% 0 3 0 1 0 0 43200 R 43227 $ 693.37 $ 298.10 0 0% 0% 0% 0 3 0 1 0 0 43200 R 43229 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 43200 X43231 $ 711.36 $ 290.30 0 0% 0% 0% 0 3 0 1 2 0 43200 R 43232 $ 845.12 $ 356.28 0 0% 0% 0% 0 3 0 1 2 0 43200 R 43233 $ 405.46 $ 405.46 0 0% 0% 0% 0 3 0 1 0 0 43235 R43235 $ 552.42 $ 224.33 0 0% 0% 0% 0 2 0 1 0 0 R Y43236 $ 690.37 $ 253.12 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43237 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 43235 X 43238 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 43235 X 43239 $ 707.76 $ 252.52 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y43240 $ 695.77 $ 695.77 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43241 $ 258.51 $ 258.51 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43242 $ 472.04 $ 472.04 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43243 $ 424.66 $ 424.66 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y43244 $ 441.45 $ 441.45 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y43245 $ 1094.64 $ 314.90 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43246 $ 356.28 $ 356.28 0 0% 0% 0% 0 3 0 0 2 0 43235 R 43247 $ 716.16 $ 319.09 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43248 $ 725.76 $ 301.70 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43249 $ 1945.15 $ 278.91 0 0% 0% 0% 0 3 0 1 0 0 43235 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 91
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
43250 $ 806.13 $ 304.70 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43251 $ 885.90 $ 353.28 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43252 $ 645.98 $ 304.70 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y43253 $ 472.04 $ 472.04 0 0% 0% 0% 0 3 0 1 0 0 43235 R43254 $ 483.44 $ 483.44 0 0% 0% 0% 0 3 0 1 0 0 43235 R43255 $ 757.55 $ 362.28 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43257 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 43235 X 43259 $ 407.26 $ 407.26 0 0% 0% 0% 0 3 0 1 0 0 43235 R 43260 $ 575.81 $ 575.81 0 0% 0% 0% 0 2 0 1 0 0 R Y43261 $ 602.80 $ 602.80 0 0% 0% 0% 0 3 0 1 0 0 43260 R Y43262 $ 635.79 $ 635.79 0 0% 0% 0% 0 3 0 1 0 0 43260 R Y43263 $ 636.99 $ 636.99 0 0% 0% 0% 0 3 0 1 0 0 43260 R Y43264 $ 648.38 $ 648.38 0 0% 0% 0% 0 3 0 1 0 0 43260 R Y43265 $ 768.94 $ 768.94 0 0% 0% 0% 0 3 0 1 0 0 43260 R Y43266 $ 404.27 $ 404.27 0 0% 0% 0% 0 3 0 1 0 0 43235 R43270 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 43235 X43273 $ 209.33 $ 209.33 0 0% 0% 0% 0 0 0 0 0 0 R Y43274 $ 819.93 $ 819.93 0 0% 0% 0% 0 3 0 1 0 0 43260 R43275 $ 669.38 $ 669.38 0 0% 0% 0% 0 3 0 1 0 0 43260 R43276 $ 853.52 $ 853.52 0 0% 0% 0% 0 3 0 1 0 0 43260 R43277 $ 672.98 $ 672.98 0 0% 0% 0% 0 3 0 1 0 0 43260 R43278 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 43260 X43279 $ 2132.29 $ 2132.29 90 9% 81% 10% 0 2 0 2 1 0 R Y43280 $ 1786.80 $ 1786.80 90 9% 81% 10% 0 2 0 2 1 0 R Y43281 $ 2544.95 $ 2544.95 90 9% 81% 10% 0 2 0 2 1 0 R Y43282 $ 2859.85 $ 2859.85 90 9% 81% 10% 0 2 0 2 1 0 R Y43283 $ 260.31 $ 260.31 0 0% 0% 0% 0 0 0 2 1 0 R Y43289 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 43300 $ 1055.65 $ 1055.65 90 9% 81% 10% 0 2 0 2 1 0 R Y43305 $ 1859.98 $ 1859.98 90 9% 81% 10% 0 2 0 2 1 0 R Y43310 $ 2432.79 $ 2432.79 90 9% 81% 10% 0 2 0 2 1 0 R Y43312 $ 2634.92 $ 2634.92 90 9% 81% 10% 0 2 0 2 1 0 R Y43313 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43314 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43320 $ 2303.23 $ 2303.23 90 9% 81% 10% 0 2 0 2 1 0 R Y43325 $ 2221.66 $ 2221.66 90 9% 81% 10% 0 2 0 2 1 0 R Y43327 $ 1351.95 $ 1351.95 90 9% 81% 10% 0 2 0 2 1 0 R43328 $ 1869.58 $ 1869.58 90 9% 81% 10% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 92
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
43330 $ 2201.87 $ 2201.87 90 9% 81% 10% 0 2 0 2 1 0 R Y43331 $ 2226.46 $ 2226.46 90 9% 81% 10% 0 2 0 2 1 0 R Y43332 $ 1917.56 $ 1917.56 90 9% 81% 10% 0 2 0 2 1 0 R Y43333 $ 2086.70 $ 2086.70 90 9% 81% 10% 0 2 0 2 1 0 R Y43334 $ 2069.31 $ 2069.31 90 9% 81% 10% 0 2 0 2 1 0 R Y43335 $ 2216.86 $ 2216.86 90 9% 81% 10% 0 2 0 2 1 0 R Y43336 $ 2509.56 $ 2509.56 90 9% 81% 10% 0 2 0 2 1 0 R Y43337 $ 2698.50 $ 2698.50 90 9% 81% 10% 0 2 0 2 1 0 R Y43338 $ 190.14 $ 190.14 0 0% 0% 0% 0 0 0 2 1 0 R Y43340 $ 2273.84 $ 2273.84 90 9% 81% 10% 0 2 0 2 1 0 R Y43341 $ 2451.98 $ 2451.98 90 9% 81% 10% 0 2 0 2 1 0 R Y43351 $ 2312.23 $ 2312.23 90 9% 81% 10% 0 2 0 2 1 0 R Y43352 $ 1777.81 $ 1777.81 90 9% 81% 10% 0 2 0 2 1 0 R Y43360 $ 3930.49 $ 3930.49 90 9% 81% 10% 0 2 0 2 1 0 R Y43361 $ 4215.39 $ 4215.39 90 9% 81% 10% 0 2 0 2 1 0 R Y43400 $ 2508.36 $ 2508.36 90 9% 81% 10% 0 2 0 2 1 0 R Y43401 $ 2588.74 $ 2588.74 90 9% 81% 10% 0 2 0 2 1 0 R Y43405 $ 2553.95 $ 2553.95 90 9% 81% 10% 0 2 0 2 1 0 R Y43410 $ 1750.22 $ 1750.22 90 9% 81% 10% 0 2 0 2 1 0 R 43415 $ 4240.59 $ 4240.59 90 9% 81% 10% 0 2 0 2 1 0 R 43420 $ 1735.82 $ 1735.82 90 9% 81% 10% 0 2 0 0 1 0 R Y43425 $ 2395.60 $ 2395.60 90 9% 81% 10% 0 2 0 2 1 0 R Y43450 $ 376.67 $ 149.95 0 0% 0% 0% 0 2 0 1 0 0 R 43453 $ 1758.01 $ 160.75 0 0% 0% 0% 0 2 0 1 0 0 R 43460 $ 374.28 $ 374.28 0 0% 0% 0% 0 2 0 1 0 0 R Y43496 By Report By Report 90 9% 81% 10% 0 2 0 2 1 0 N Y43499 By Report By Report 90 0% 0% 0% 0 2 0 1 1 1 N 43500 $ 1300.97 $ 1300.97 90 9% 81% 10% 0 2 0 2 1 0 R 43501 $ 2223.46 $ 2223.46 90 9% 81% 10% 0 2 0 2 1 0 R 43502 $ 2513.16 $ 2513.16 90 9% 81% 10% 0 2 0 2 1 0 R 43510 $ 1565.48 $ 1565.48 90 9% 81% 10% 0 2 0 2 1 0 R 43520 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43605 $ 1381.94 $ 1381.94 90 9% 81% 10% 0 2 0 2 1 0 R Y43610 $ 1621.86 $ 1621.86 90 9% 81% 10% 0 2 0 2 1 0 R Y43611 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43620 $ 3240.12 $ 3240.12 90 9% 81% 10% 0 2 0 2 1 0 R Y43621 $ 3733.16 $ 3733.16 90 9% 81% 10% 0 2 0 2 1 0 R Y43622 $ 3803.33 $ 3803.33 90 9% 81% 10% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 93
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
43631 $ 2392.00 $ 2392.00 90 9% 81% 10% 0 2 0 2 1 0 R Y43632 $ 3343.29 $ 3343.29 90 9% 81% 10% 0 2 0 2 1 0 R Y43633 $ 3161.55 $ 3161.55 90 9% 81% 10% 0 2 0 2 1 0 R Y43634 $ 3498.03 $ 3498.03 90 9% 81% 10% 0 2 0 2 1 0 R Y43635 $ 184.74 $ 184.74 0 0% 0% 0% 0 0 0 2 1 0 R Y43640 $ 1945.75 $ 1945.75 90 9% 81% 10% 0 2 0 2 1 0 R Y43641 $ 1984.74 $ 1984.74 90 9% 81% 10% 0 2 0 2 1 0 R Y43644 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43645 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43647 Not Covered Not Covered 90 0% 0% 0% 0 2 0 2 1 0 X 43648 Not Covered Not Covered 90 0% 0% 0% 0 2 0 2 1 0 X 43651 $ 1086.84 $ 1086.84 90 11% 76% 13% 0 2 0 2 1 0 R Y43652 $ 1266.78 $ 1266.78 90 11% 76% 13% 0 2 0 2 1 0 R Y43653 $ 954.88 $ 954.88 90 9% 81% 10% 0 2 0 2 1 0 R Y43659 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 43752 $ 70.18 $ 70.18 0 0% 0% 0% 0 0 0 1 0 0 R 43753 $ 35.99 $ 35.99 0 0% 0% 0% 0 0 0 2 0 0 R43754 $ 232.72 $ 62.98 0 0% 0% 0% 0 0 0 2 0 0 R43755 $ 241.72 $ 103.17 0 0% 0% 0% 0 0 0 2 0 0 R43756 $ 367.08 $ 89.37 0 0% 0% 0% 0 0 0 2 0 0 R43757 $ 523.63 $ 136.15 0 0% 0% 0% 0 0 0 2 0 0 R43760 $ 878.71 $ 79.77 0 0% 0% 0% 0 2 0 1 0 0 R 43761 $ 199.73 $ 176.34 0 0% 0% 0% 0 2 0 1 0 0 R 43770 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43771 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 43772 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43773 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43774 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 1 0 X 43775 Not Covered Not Covered 90 0% 0% 0% 0 2 0 2 1 1 X43800 $ 1535.49 $ 1535.49 90 9% 81% 10% 0 2 0 2 1 0 R Y43810 $ 1680.64 $ 1680.64 90 9% 81% 10% 0 2 0 2 1 0 R Y43820 $ 2212.06 $ 2212.06 90 9% 81% 10% 0 2 0 2 1 0 R Y43825 $ 2159.88 $ 2159.88 90 9% 81% 10% 0 2 0 2 1 0 R Y43830 $ 1163.01 $ 1163.01 90 9% 81% 10% 0 2 0 2 1 0 R 43831 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43832 $ 1722.03 $ 1722.03 90 9% 81% 10% 0 2 0 2 1 0 R 43840 $ 2241.45 $ 2241.45 90 9% 81% 10% 0 2 0 2 1 0 R 43842 Not Covered Not Covered 90 9% 81% 10% 9 9 9 9 9 9 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 94
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
43843 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 2 0 X 43845 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43846 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43847 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43848 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43850 $ 2683.51 $ 2683.51 90 9% 81% 10% 0 2 0 2 1 0 R Y43855 $ 2783.07 $ 2783.07 90 9% 81% 10% 0 2 0 2 1 0 R Y43860 $ 2700.90 $ 2700.90 90 9% 81% 10% 0 2 0 2 1 0 R Y43865 $ 2815.46 $ 2815.46 90 9% 81% 10% 0 2 0 2 1 0 R Y43870 $ 1183.41 $ 1183.41 90 9% 81% 10% 0 2 0 2 1 0 R 43880 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43881 Not Covered Not Covered 90 0% 0% 0% 0 2 0 2 1 0 X 43882 Not Covered Not Covered 90 0% 0% 0% 0 2 0 2 1 0 X 43886 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 43887 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 43888 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 43999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 44005 $ 1807.20 $ 1807.20 90 9% 81% 10% 0 2 0 2 1 0 R 44010 $ 1442.52 $ 1442.52 90 9% 81% 10% 0 2 0 2 1 0 R 44015 $ 233.32 $ 233.32 0 0% 0% 0% 0 0 0 2 1 0 R 44020 $ 1611.06 $ 1611.06 90 9% 81% 10% 0 2 0 2 1 0 R 44021 $ 1615.26 $ 1615.26 90 9% 81% 10% 0 2 0 2 1 0 R 44025 $ 1635.05 $ 1635.05 90 9% 81% 10% 0 2 0 2 1 0 R 44050 $ 1546.28 $ 1546.28 90 9% 81% 10% 0 2 0 2 1 0 R 44055 $ 2457.38 $ 2457.38 90 9% 81% 10% 0 2 0 2 1 0 R 44100 $ 188.34 $ 188.34 0 0% 0% 0% 0 2 0 1 0 0 R Y44110 $ 1412.53 $ 1412.53 90 9% 81% 10% 0 2 0 2 1 0 R Y44111 $ 1629.66 $ 1629.66 90 9% 81% 10% 0 2 0 2 1 0 R Y44120 $ 2018.93 $ 2018.93 90 9% 81% 10% 0 2 0 2 1 0 R Y44121 $ 398.27 $ 398.27 0 0% 0% 0% 0 0 0 2 1 0 R Y44125 $ 1954.75 $ 1954.75 90 9% 81% 10% 0 2 0 2 1 0 R Y44126 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 44127 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 44128 Not Covered Not Covered 0 0% 0% 0% 0 0 0 2 1 0 X 44130 $ 2172.48 $ 2172.48 90 9% 81% 10% 0 2 0 2 1 0 R Y44132 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 44133 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 44135 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 95
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
44136 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 44137 By Report By Report 0 0% 0% 0% 0 2 0 2 1 0 N 44139 $ 199.73 $ 199.73 0 0% 0% 0% 0 0 0 2 1 0 R Y44140 $ 2219.26 $ 2219.26 90 9% 81% 10% 0 2 0 2 1 0 R Y44141 $ 3030.19 $ 3030.19 90 9% 81% 10% 0 2 0 2 1 0 R Y44143 $ 2758.48 $ 2758.48 90 9% 81% 10% 0 2 0 2 1 0 R Y44144 $ 2928.82 $ 2928.82 90 9% 81% 10% 0 2 0 2 1 0 R Y44145 $ 2751.28 $ 2751.28 90 9% 81% 10% 0 2 0 2 1 0 R Y44146 $ 3536.42 $ 3536.42 90 9% 81% 10% 0 2 0 2 1 0 R Y44147 $ 3213.73 $ 3213.73 90 9% 81% 10% 0 2 0 2 1 0 R Y44150 $ 3119.56 $ 3119.56 90 9% 81% 10% 0 2 0 2 1 0 R Y44151 $ 3559.21 $ 3559.21 90 9% 81% 10% 0 2 0 2 1 0 R Y44155 $ 3483.64 $ 3483.64 90 9% 81% 10% 0 2 0 2 1 0 R Y44156 $ 3831.52 $ 3831.52 90 9% 81% 10% 0 2 0 2 1 0 R Y44157 $ 3607.80 $ 3607.80 90 9% 81% 10% 0 2 0 2 1 0 R Y44158 $ 3607.20 $ 3607.20 90 9% 81% 10% 0 2 0 2 1 0 R Y44160 $ 2057.31 $ 2057.31 90 9% 81% 10% 0 2 0 2 1 0 R Y44180 $ 1521.69 $ 1521.69 90 9% 81% 10% 0 2 0 2 1 0 R 44186 $ 1081.44 $ 1081.44 90 9% 84% 7% 0 2 0 2 1 0 R 44187 $ 1860.58 $ 1860.58 90 9% 81% 10% 0 2 0 2 1 0 R 44188 $ 2049.52 $ 2049.52 90 9% 81% 10% 0 2 0 2 1 0 R 44202 $ 2292.44 $ 2292.44 90 9% 81% 10% 0 2 0 2 1 0 R Y44203 $ 400.07 $ 400.07 0 0% 0% 0% 0 0 0 2 1 0 R Y44204 $ 2555.15 $ 2555.15 90 9% 81% 10% 0 2 0 2 1 0 R Y44205 $ 2224.66 $ 2224.66 90 9% 81% 10% 0 2 0 2 1 0 R Y44206 $ 2912.63 $ 2912.63 90 9% 81% 10% 0 2 0 2 1 0 R Y44207 $ 3033.19 $ 3033.19 90 9% 81% 10% 0 2 0 2 1 0 R Y44208 $ 3321.09 $ 3321.09 90 9% 81% 10% 0 2 0 2 1 0 R Y44210 $ 2987.60 $ 2987.60 90 9% 81% 10% 0 2 0 2 1 0 R Y44211 $ 3665.98 $ 3665.98 90 9% 81% 10% 0 2 0 2 1 0 R Y44212 $ 3451.85 $ 3451.85 90 9% 81% 10% 0 2 0 2 1 0 R Y44213 $ 312.50 $ 312.50 0 0% 0% 0% 0 0 0 2 1 0 R 44227 $ 2764.48 $ 2764.48 90 9% 81% 10% 0 2 0 2 1 0 R 44238 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 44300 $ 1392.14 $ 1392.14 90 9% 81% 10% 0 2 0 2 1 0 R 44310 $ 1736.42 $ 1736.42 90 9% 81% 10% 0 2 0 2 1 0 R Y44312 $ 992.67 $ 992.67 90 9% 81% 10% 0 2 0 0 0 0 R Y44314 $ 1680.04 $ 1680.04 90 9% 81% 10% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 96
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
44316 $ 2332.62 $ 2332.62 90 9% 81% 10% 0 2 0 2 1 0 R Y44320 $ 1994.93 $ 1994.93 90 9% 81% 10% 0 2 0 2 1 0 R Y44322 $ 1684.24 $ 1684.24 90 9% 81% 10% 0 2 0 2 1 0 R Y44340 $ 1047.25 $ 1047.25 90 9% 81% 10% 0 2 0 1 1 0 R Y44345 $ 1752.02 $ 1752.02 90 9% 81% 10% 0 2 0 2 1 0 R Y44346 $ 1969.14 $ 1969.14 90 9% 81% 10% 0 2 0 2 1 0 R Y44360 $ 262.11 $ 262.11 0 0% 0% 0% 0 2 0 1 0 0 R Y44361 $ 288.50 $ 288.50 0 0% 0% 0% 0 3 0 1 0 0 44360 R 44363 $ 344.89 $ 344.89 0 0% 0% 0% 0 3 0 0 0 0 44360 R 44364 Not Covered Not Covered 0 0% 0% 0% 0 3 0 0 0 0 44360 X 44365 Not Covered Not Covered 0 0% 0% 0% 0 3 0 0 0 0 44360 X 44366 $ 431.86 $ 431.86 0 0% 0% 0% 0 3 0 1 0 0 44360 R 44369 Not Covered Not Covered 0 0% 0% 0% 0 3 0 0 0 0 44360 X 44370 $ 478.04 $ 478.04 0 0% 0% 0% 0 3 0 0 0 0 44360 R Y44372 $ 428.86 $ 428.86 0 0% 0% 0% 0 3 0 1 0 0 44360 R Y44373 $ 344.29 $ 344.29 0 0% 0% 0% 0 3 0 1 0 0 44360 R Y44376 $ 505.63 $ 505.63 0 0% 0% 0% 0 2 0 0 0 0 R Y44377 $ 534.42 $ 534.42 0 0% 0% 0% 0 3 0 0 0 0 44376 R Y44378 $ 684.37 $ 684.37 0 0% 0% 0% 0 3 0 0 0 0 44376 R Y44379 $ 728.76 $ 728.76 0 0% 0% 0% 0 3 0 0 0 0 44376 R Y44380 $ 115.76 $ 115.76 0 0% 0% 0% 0 2 0 1 0 0 R Y44381 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X44382 $ 137.95 $ 137.95 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y44384 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X44385 $ 466.04 $ 182.34 0 0% 0% 0% 0 2 0 1 0 0 R Y44386 $ 623.19 $ 215.33 0 0% 0% 0% 0 2 0 1 0 0 R 44388 $ 613.00 $ 279.51 0 0% 0% 0% 0 2 0 1 0 0 R Y44389 $ 688.57 $ 310.10 0 0% 0% 0% 0 3 0 1 0 0 44388 R Y44390 $ 807.33 $ 378.47 0 0% 0% 0% 0 3 0 1 0 0 44388 R Y44391 $ 865.51 $ 421.66 0 0% 0% 0% 0 3 0 1 0 0 44388 R Y44392 $ 762.95 $ 367.68 0 0% 0% 0% 0 3 0 1 0 0 44388 R Y44394 $ 860.11 $ 428.86 0 0% 0% 0% 0 3 0 1 0 0 44388 R Y44401 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X44402 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X44403 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X44404 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X44405 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X44406 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 97
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
44407 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X44408 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X44500 $ 41.99 $ 41.99 0 0% 0% 0% 0 0 0 0 0 0 R Y44602 $ 2323.03 $ 2323.03 90 9% 81% 10% 0 2 0 2 1 0 R 44603 $ 2673.91 $ 2673.91 90 9% 81% 10% 0 2 0 2 1 0 R 44604 $ 1749.02 $ 1749.02 90 9% 81% 10% 0 2 0 2 1 0 R 44605 $ 2162.88 $ 2162.88 90 9% 81% 10% 0 2 0 2 1 0 R 44615 $ 1776.61 $ 1776.61 90 9% 81% 10% 0 2 0 2 1 0 R Y44620 $ 1446.12 $ 1446.12 90 9% 81% 10% 0 2 0 2 1 0 R Y44625 $ 1698.63 $ 1698.63 90 9% 81% 10% 0 2 0 2 1 0 R Y44626 $ 2649.92 $ 2649.92 90 9% 81% 10% 0 2 0 2 1 0 R Y44640 $ 2320.03 $ 2320.03 90 9% 81% 10% 0 2 0 2 1 0 R 44650 $ 2402.20 $ 2402.20 90 9% 81% 10% 0 2 0 2 1 0 R 44660 $ 2234.26 $ 2234.26 90 9% 81% 10% 0 2 0 2 1 0 R 44661 $ 2578.54 $ 2578.54 90 9% 81% 10% 0 2 0 2 1 0 R 44680 $ 1765.21 $ 1765.21 90 9% 81% 10% 0 2 0 2 1 0 R Y44700 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 44701 $ 277.71 $ 277.71 0 0% 0% 0% 0 0 0 2 1 0 R 44705 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X44715 By Report By Report 0 0% 0% 0% 0 2 0 2 1 0 N 44720 $ 450.45 $ 450.45 0 0% 0% 0% 0 2 0 2 1 0 R 44721 $ 629.79 $ 629.79 0 0% 0% 0% 0 2 0 2 1 0 R 44799 By Report By Report 0 0% 0% 0% 0 2 0 1 1 1 N 44800 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 44820 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 44850 $ 1246.98 $ 1246.98 90 9% 81% 10% 0 2 0 2 1 0 R 44899 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 44900 $ 1280.57 $ 1280.57 90 9% 81% 10% 0 2 0 2 1 0 R Y44950 $ 1061.05 $ 1061.05 90 9% 81% 10% 0 2 0 2 1 0 R Y44955 Not Covered Not Covered 0 0% 0% 0% 0 0 0 2 1 0 X 44960 $ 1442.52 $ 1442.52 90 9% 81% 10% 0 2 0 2 1 0 R Y44970 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 2 0 X 44979 Not Covered Not Covered 90 0% 0% 0% 0 2 1 2 1 1 X 45000 $ 712.56 $ 712.56 90 9% 81% 10% 0 2 0 1 0 0 R 45005 $ 471.44 $ 272.91 10 10% 80% 10% 0 2 0 1 0 0 R 45020 $ 957.88 $ 957.88 90 9% 81% 10% 0 2 0 1 0 0 R 45100 $ 510.43 $ 510.43 90 9% 81% 10% 0 2 0 1 0 0 R Y45108 $ 617.79 $ 617.79 90 9% 81% 10% 0 2 0 1 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 98
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
45110 $ 3096.77 $ 3096.77 90 9% 81% 10% 0 2 0 2 1 0 R Y45111 $ 1814.99 $ 1814.99 90 9% 81% 10% 0 2 0 2 1 0 R Y45112 $ 3151.35 $ 3151.35 90 9% 81% 10% 0 2 0 2 1 0 R Y45113 $ 3213.13 $ 3213.13 90 9% 81% 10% 0 2 0 2 1 0 R Y45114 $ 2994.80 $ 2994.80 90 9% 81% 10% 0 2 0 2 1 0 R Y45116 $ 2633.12 $ 2633.12 90 9% 81% 10% 0 2 0 2 1 0 R Y45119 $ 3277.31 $ 3277.31 90 9% 81% 10% 0 2 0 2 1 0 R Y45120 $ 2625.92 $ 2625.92 90 9% 81% 10% 0 2 0 2 1 0 R Y45121 $ 2798.67 $ 2798.67 90 9% 81% 10% 0 2 0 2 1 0 R Y45123 $ 1888.77 $ 1888.77 90 9% 81% 10% 0 2 0 2 1 0 R Y45126 $ 4608.86 $ 4608.86 90 12% 74% 14% 0 2 0 2 1 0 R Y45130 $ 1835.39 $ 1835.39 90 9% 81% 10% 0 2 0 2 1 0 R Y45135 $ 2277.44 $ 2277.44 90 9% 81% 10% 0 2 0 2 1 0 R Y45136 $ 3073.98 $ 3073.98 90 9% 81% 10% 0 2 0 2 1 0 R Y45150 $ 615.39 $ 615.39 90 9% 81% 10% 0 2 0 0 0 0 R Y45160 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 45171 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X45172 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X45190 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 1 0 X 45300 $ 217.13 $ 92.37 0 0% 0% 0% 0 2 0 1 0 0 R Y45303 $ 1734.02 $ 155.95 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y45305 $ 342.49 $ 133.76 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y45307 $ 389.87 $ 173.34 0 0% 0% 0% 0 3 0 0 0 0 45300 R Y45308 $ 382.67 $ 148.75 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y45309 $ 389.27 $ 153.55 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y45315 $ 429.46 $ 185.34 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y45317 $ 422.86 $ 199.13 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y45320 $ 424.06 $ 183.54 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y45321 $ 179.94 $ 179.94 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y45327 $ 208.13 $ 208.13 0 0% 0% 0% 0 3 0 1 0 0 45300 R Y45330 $ 239.92 $ 107.96 0 0% 0% 0% 0 2 0 1 0 0 R Y45331 $ 284.91 $ 127.76 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y45332 $ 512.23 $ 186.54 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y45333 $ 521.23 $ 185.94 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y45334 $ 274.71 $ 274.71 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y45335 $ 484.04 $ 155.95 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y45337 $ 239.32 $ 239.32 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y45338 $ 556.61 $ 236.92 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 99
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
45340 $ 862.51 $ 194.94 0 0% 0% 0% 0 3 0 1 0 0 45330 R Y45341 $ 262.11 $ 262.11 0 0% 0% 0% 0 2 0 1 0 0 R Y45342 $ 398.27 $ 398.27 0 0% 0% 0% 0 2 0 1 0 0 R Y45346 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X45347 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X45349 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X45350 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X45378 $ 671.18 $ 362.28 0 0% 0% 0% 0 2 0 1 0 0 R Y45378-53 $ 239.92 $ 107.96 0 0% 0% 0% 0 2 0 1 0 0 R Y45379 $ 864.91 $ 454.65 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y45380 $ 799.53 $ 433.06 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y45381 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 45378 X 45382 $ 1040.65 $ 550.02 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y45384 $ 798.33 $ 452.85 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y45385 $ 900.30 $ 514.03 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y45386 $ 1164.21 $ 444.45 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y45388 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X45389 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X45390 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X45391 $ 494.84 $ 494.84 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y45392 $ 628.59 $ 628.59 0 0% 0% 0% 0 3 0 1 0 0 45378 R Y45393 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X45395 $ 3332.49 $ 3332.49 90 9% 81% 10% 0 2 0 2 1 0 R Y45397 $ 3635.39 $ 3635.39 90 9% 81% 10% 0 2 0 2 1 0 R Y45398 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X45399 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 1 1 X45400 $ 1919.36 $ 1919.36 90 9% 81% 10% 0 2 0 2 1 0 R Y45402 $ 2552.15 $ 2552.15 90 9% 81% 10% 0 2 0 2 1 0 R Y45499 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 45500 $ 901.50 $ 901.50 90 9% 81% 10% 0 2 0 0 0 0 R Y45505 $ 1008.86 $ 1008.86 90 9% 81% 10% 0 2 0 1 0 0 R Y45520 $ 283.71 $ 69.58 0 0% 0% 0% 0 2 0 1 0 0 R Y45540 $ 1780.81 $ 1780.81 90 9% 81% 10% 0 2 0 2 1 0 R Y45541 $ 1573.88 $ 1573.88 90 9% 81% 10% 0 2 0 2 1 0 R Y45550 $ 2454.98 $ 2454.98 90 9% 81% 10% 0 2 0 2 1 0 R Y45560 $ 1173.21 $ 1173.21 90 9% 81% 10% 0 2 0 2 1 0 R Y45562 $ 1897.77 $ 1897.77 90 9% 81% 10% 0 2 0 2 1 0 R Y45563 $ 2730.89 $ 2730.89 90 9% 81% 10% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 100
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
45800 $ 2043.52 $ 2043.52 90 9% 81% 10% 0 2 0 2 1 0 R Y45805 $ 2353.02 $ 2353.02 90 9% 81% 10% 0 2 0 2 1 0 R Y45820 $ 1916.36 $ 1916.36 90 9% 81% 10% 0 2 0 2 1 0 R Y45825 $ 2466.98 $ 2466.98 90 9% 81% 10% 0 2 0 2 1 0 R Y45900 $ 344.29 $ 344.29 10 10% 80% 10% 0 2 0 0 0 0 R Y45905 $ 287.90 $ 287.90 10 10% 80% 10% 0 2 0 1 0 0 R Y45910 $ 331.09 $ 331.09 10 10% 80% 10% 0 2 0 1 0 0 R Y45915 $ 575.21 $ 388.67 10 10% 80% 10% 0 2 0 1 0 0 R Y45990 $ 180.54 $ 180.54 0 0% 0% 0% 0 2 0 0 1 1 R 45999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 46020 $ 474.44 $ 400.07 10 10% 80% 10% 0 2 0 1 0 0 R 46030 $ 241.12 $ 153.55 10 10% 80% 10% 0 2 0 0 0 0 R 46040 $ 918.89 $ 702.37 90 9% 81% 10% 0 2 0 1 0 0 R 46045 $ 734.76 $ 734.76 90 9% 81% 10% 0 2 0 1 0 0 R 46050 $ 353.88 $ 166.74 10 10% 80% 10% 0 2 0 1 0 0 R 46060 $ 809.73 $ 809.73 90 9% 81% 10% 0 2 0 1 0 0 R 46070 Not Covered Not Covered 90 9% 81% 10% 0 2 0 0 0 0 X 46080 $ 424.06 $ 266.31 10 10% 80% 10% 0 2 0 1 0 0 R 46083 $ 305.90 $ 181.74 10 10% 80% 10% 0 2 0 1 0 0 R 46200 $ 777.34 $ 560.81 90 9% 81% 10% 0 2 0 1 0 0 R 46220 $ 358.68 $ 202.13 10 10% 80% 10% 0 2 0 1 0 0 R 46221 $ 470.24 $ 331.09 10 10% 80% 10% 0 2 0 1 0 0 R 46230 $ 471.44 $ 292.70 10 10% 80% 10% 0 2 0 1 0 0 R 46250 $ 799.53 $ 532.62 90 9% 81% 10% 0 2 0 1 0 0 R 46255 $ 873.31 $ 597.40 90 9% 81% 10% 0 2 0 1 0 0 R 46257 $ 713.76 $ 713.76 90 9% 81% 10% 0 2 0 1 0 0 R 46258 $ 779.14 $ 779.14 90 9% 81% 10% 0 2 0 0 0 0 R 46260 $ 803.73 $ 803.73 90 9% 81% 10% 0 2 0 1 0 0 R 46261 $ 882.31 $ 882.31 90 9% 81% 10% 0 2 0 1 0 0 R 46262 $ 938.69 $ 938.69 90 9% 81% 10% 0 2 0 1 0 0 R 46270 $ 874.51 $ 666.38 90 9% 81% 10% 0 2 0 1 0 0 R 46275 $ 930.29 $ 706.56 90 9% 81% 10% 0 2 0 1 0 0 R 46280 $ 800.73 $ 800.73 90 9% 81% 10% 0 2 0 1 0 0 R 46285 $ 922.49 $ 704.77 90 9% 81% 10% 0 2 0 1 0 0 R 46288 $ 935.09 $ 935.09 90 9% 81% 10% 0 2 0 1 0 0 R 46320 $ 317.89 $ 187.74 10 10% 80% 10% 0 2 0 1 0 0 R 46500 $ 419.86 $ 221.93 10 10% 80% 10% 0 2 0 1 0 0 R 46505 $ 488.24 $ 406.66 10 10% 80% 10% 0 2 1 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 101
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
46600 $ 155.95 $ 70.18 0 0% 0% 0% 0 2 0 1 0 0 R 46601 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X46604 $ 1124.03 $ 113.36 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y46606 $ 397.67 $ 129.56 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y46607 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 X46608 $ 415.66 $ 140.35 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y46610 $ 396.47 $ 136.75 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y46611 $ 304.70 $ 137.95 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y46612 $ 481.04 $ 158.35 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y46614 $ 224.93 $ 110.36 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y46615 $ 247.72 $ 156.55 0 0% 0% 0% 0 3 0 1 0 0 46600 R Y46700 $ 1110.83 $ 1110.83 90 9% 81% 10% 0 2 0 1 0 0 R Y46705 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46706 $ 294.50 $ 294.50 10 10% 80% 10% 0 2 0 1 0 0 R 46707 $ 802.53 $ 802.53 90 9% 81% 10% 0 2 0 0 0 0 R46710 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46712 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46715 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 0 0 X 46716 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46730 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46735 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46740 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46742 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46744 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46746 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46748 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46750 $ 1281.17 $ 1281.17 90 9% 81% 10% 0 2 0 2 1 0 R Y46751 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 46753 $ 988.47 $ 988.47 90 9% 81% 10% 0 2 0 1 0 0 R Y46754 $ 521.23 $ 398.87 10 10% 80% 10% 0 2 0 0 0 0 R 46760 $ 1868.98 $ 1868.98 90 9% 81% 10% 0 2 0 2 1 0 R Y46761 $ 1570.88 $ 1570.88 90 9% 81% 10% 0 2 0 2 1 0 R Y46762 $ 1576.87 $ 1576.87 90 9% 81% 10% 0 2 0 2 1 0 R Y46900 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 46910 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 46916 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 46917 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 46922 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 102
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
46924 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 46930 $ 362.28 $ 257.91 90 9% 81% 10% 0 2 0 0 0 0 R 46940 $ 397.07 $ 248.92 10 10% 80% 10% 0 2 0 1 0 0 R 46942 $ 377.27 $ 224.93 10 10% 80% 10% 0 2 0 0 0 0 R 46945 $ 539.82 $ 391.07 90 9% 81% 10% 0 2 0 1 0 0 R 46946 $ 548.22 $ 389.27 90 9% 81% 10% 0 2 0 1 0 0 R 46947 $ 640.59 $ 640.59 90 9% 81% 10% 0 2 0 1 0 0 R 46999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 47000 $ 644.19 $ 178.14 0 0% 0% 0% 0 2 0 1 0 0 R 47001 $ 170.34 $ 170.34 0 0% 0% 0% 0 0 0 1 1 0 R 47010 $ 1997.33 $ 1997.33 90 9% 81% 10% 0 2 0 2 1 0 R 47015 $ 1924.76 $ 1924.76 90 9% 81% 10% 0 2 0 2 1 0 R Y47100 $ 1407.73 $ 1407.73 90 9% 81% 10% 0 2 0 2 1 0 R Y47120 $ 3842.92 $ 3842.92 90 9% 81% 10% 0 2 0 2 1 0 R Y47122 $ 5638.72 $ 5638.72 90 9% 81% 10% 0 2 0 2 1 0 R Y47125 $ 5052.72 $ 5052.72 90 9% 81% 10% 0 2 0 2 1 0 R Y47130 $ 5423.99 $ 5423.99 90 9% 81% 10% 0 2 0 2 1 0 R Y47133 $ 4653.51 $ 4653.51 0 0% 0% 0% 9 9 9 9 9 9 F Y47135 $ 8046.32 $ 8046.32 90 9% 81% 10% 0 2 0 2 1 2 R Y47136 $ 6913.89 $ 6913.89 90 9% 81% 10% 0 2 0 2 1 2 R Y47140 $ 5566.74 $ 5566.74 90 9% 81% 10% 0 2 0 2 1 2 R Y47141 $ 7029.66 $ 7029.66 90 9% 81% 10% 0 2 0 2 1 2 R Y47142 $ 7744.02 $ 7744.02 90 9% 81% 10% 0 2 0 2 1 0 R Y47143 By Report By Report 0 0% 0% 0% 0 2 0 2 1 0 N Y47144 By Report By Report 90 9% 81% 10% 0 2 0 2 1 0 N Y47145 By Report By Report 0 0% 0% 0% 0 2 0 2 1 0 N Y47146 $ 540.42 $ 540.42 0 0% 0% 0% 0 2 0 2 1 0 R Y47147 $ 628.59 $ 628.59 0 0% 0% 0% 0 2 0 2 1 0 R Y47300 $ 1880.37 $ 1880.37 90 9% 81% 10% 0 2 0 2 1 0 R Y47350 $ 2267.84 $ 2267.84 90 9% 81% 10% 0 2 0 2 1 0 R 47360 $ 3079.37 $ 3079.37 90 9% 81% 10% 0 2 0 2 1 0 R 47361 $ 4994.53 $ 4994.53 90 9% 81% 10% 0 2 0 2 1 0 R 47362 $ 2398.00 $ 2398.00 90 9% 81% 10% 0 2 0 2 1 0 R 47370 $ 2057.31 $ 2057.31 90 9% 81% 10% 0 2 0 2 1 0 R Y47371 $ 2072.91 $ 2072.91 90 9% 81% 10% 0 2 0 2 1 0 R Y47379 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 47380 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 47381 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 103
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
47382 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 47383 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X47399 By Report By Report 90 0% 0% 0% 0 2 0 1 1 1 N 47400 $ 3550.82 $ 3550.82 90 9% 81% 10% 0 2 0 2 1 0 R Y47420 $ 2218.06 $ 2218.06 90 9% 81% 10% 0 2 0 2 1 0 R Y47425 $ 2258.25 $ 2258.25 90 9% 81% 10% 0 2 0 2 1 0 R Y47460 $ 2096.90 $ 2096.90 90 9% 81% 10% 0 2 0 2 1 0 R Y47480 $ 1459.31 $ 1459.31 90 9% 81% 10% 0 2 0 2 1 0 R Y47490 $ 579.41 $ 579.41 10 10% 80% 10% 0 2 0 1 0 0 R Y47500 $ 164.95 $ 164.95 0 0% 0% 0% 0 2 0 1 0 0 R 47505 $ 63.58 $ 63.58 0 0% 0% 0% 0 2 0 0 0 0 R 47510 $ 812.73 $ 812.73 90 9% 81% 10% 0 2 0 1 0 0 R 47511 $ 990.27 $ 990.27 90 9% 81% 10% 0 2 1 1 0 0 R 47525 $ 928.49 $ 145.75 0 0% 0% 0% 0 2 1 1 0 0 R 47530 $ 2447.18 $ 607.60 90 9% 81% 10% 0 2 0 1 0 0 R 47550 $ 271.71 $ 271.71 0 0% 0% 0% 0 0 0 2 1 0 R 47552 $ 539.22 $ 539.22 0 0% 0% 0% 0 2 0 1 1 0 R 47553 $ 533.82 $ 533.82 0 0% 0% 0% 0 3 0 1 0 0 47552 R 47554 $ 813.93 $ 813.93 0 0% 0% 0% 0 3 0 1 1 0 47552 R 47555 $ 633.99 $ 633.99 0 0% 0% 0% 0 3 0 1 0 0 47552 R 47556 $ 720.36 $ 720.36 0 0% 0% 0% 0 3 0 1 0 0 47552 R 47560 $ 439.65 $ 439.65 0 0% 0% 0% 0 2 0 0 0 0 R 47561 $ 484.04 $ 484.04 0 0% 0% 0% 0 2 0 0 0 0 R 47562 $ 1089.24 $ 1089.24 90 9% 81% 10% 0 2 0 2 1 0 R 47563 $ 1181.61 $ 1181.61 90 9% 81% 10% 0 2 0 2 1 0 R 47564 $ 1839.59 $ 1839.59 90 9% 81% 10% 0 2 0 2 1 0 R 47570 $ 1281.77 $ 1281.77 90 9% 81% 10% 0 2 0 2 1 0 R 47579 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 47600 $ 1765.21 $ 1765.21 90 9% 81% 10% 0 2 0 2 1 0 R 47605 $ 1855.18 $ 1855.18 90 9% 81% 10% 0 2 0 2 1 0 R 47610 $ 2070.51 $ 2070.51 90 9% 81% 10% 0 2 0 2 1 0 R 47612 $ 2095.10 $ 2095.10 90 9% 81% 10% 0 2 0 2 1 0 R 47620 $ 2272.64 $ 2272.64 90 9% 81% 10% 0 2 0 2 1 0 R 47630 $ 914.10 $ 914.10 90 9% 81% 10% 0 2 0 1 1 0 R 47700 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 47701 $ 2863.45 $ 2863.45 90 9% 81% 10% 0 2 0 0 0 0 R Y47711 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 47712 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 104
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
47715 $ 2199.47 $ 2199.47 90 9% 81% 10% 0 2 0 2 1 0 R Y47720 $ 1911.56 $ 1911.56 90 9% 81% 10% 0 2 0 2 1 0 R Y47721 $ 2239.05 $ 2239.05 90 9% 81% 10% 0 2 0 2 1 0 R Y47740 $ 2171.28 $ 2171.28 90 9% 81% 10% 0 2 0 2 1 0 R Y47741 $ 2438.79 $ 2438.79 90 9% 81% 10% 0 2 0 2 1 0 R Y47760 $ 3718.16 $ 3718.16 90 9% 81% 10% 0 2 0 2 1 0 R Y47765 $ 5001.13 $ 5001.13 90 9% 81% 10% 0 2 0 2 1 0 R Y47780 $ 4067.24 $ 4067.24 90 9% 81% 10% 0 2 0 2 1 0 R Y47785 $ 5340.02 $ 5340.02 90 9% 81% 10% 0 2 0 2 1 0 R Y47800 $ 2609.73 $ 2609.73 90 9% 81% 10% 0 2 0 2 1 0 R Y47801 $ 1701.63 $ 1701.63 90 9% 81% 10% 0 2 0 2 1 0 R Y47802 $ 2522.16 $ 2522.16 90 9% 81% 10% 0 2 0 2 1 0 R Y47900 $ 2271.44 $ 2271.44 90 9% 81% 10% 0 2 0 2 1 0 R Y47999 By Report By Report 90 0% 0% 0% 0 2 0 1 1 1 N 48000 $ 3094.97 $ 3094.97 90 9% 81% 10% 0 2 0 2 1 0 R Y48001 $ 3799.73 $ 3799.73 90 9% 81% 10% 0 2 0 2 1 0 R Y48020 $ 1946.95 $ 1946.95 90 9% 81% 10% 0 2 0 2 1 0 R Y48100 $ 1461.71 $ 1461.71 90 9% 81% 10% 0 2 0 2 1 0 R Y48102 $ 936.89 $ 418.06 10 10% 80% 10% 0 2 0 1 0 0 R Y48105 $ 4689.84 $ 4689.84 90 9% 81% 10% 0 2 0 2 1 0 R Y48120 $ 1828.79 $ 1828.79 90 9% 81% 10% 0 2 0 2 1 0 R Y48140 $ 2576.74 $ 2576.74 90 9% 81% 10% 0 2 0 2 1 0 R Y48145 $ 2693.10 $ 2693.10 90 9% 81% 10% 0 2 0 2 1 0 R Y48146 $ 3106.96 $ 3106.96 90 9% 81% 10% 0 2 0 2 1 0 R Y48148 $ 2062.71 $ 2062.71 90 9% 81% 10% 0 2 0 2 1 0 R Y48150 $ 5122.89 $ 5122.89 90 9% 81% 10% 0 2 0 2 1 0 R Y48152 $ 4757.61 $ 4757.61 90 9% 81% 10% 0 2 0 2 1 0 R Y48153 $ 5096.50 $ 5096.50 90 9% 81% 10% 0 2 0 2 1 0 R Y48154 $ 4778.61 $ 4778.61 90 9% 81% 10% 0 2 0 2 1 0 R Y48155 $ 3001.40 $ 3001.40 90 9% 81% 10% 0 2 0 2 1 0 R Y48160 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y48400 $ 175.74 $ 175.74 0 0% 0% 0% 0 0 0 0 0 0 R Y48500 $ 1907.96 $ 1907.96 90 9% 81% 10% 0 2 0 2 1 0 R Y48510 $ 1820.39 $ 1820.39 90 9% 81% 10% 0 2 0 2 1 0 R Y48520 $ 1810.20 $ 1810.20 90 9% 81% 10% 0 2 0 2 1 0 R Y48540 $ 2161.08 $ 2161.08 90 9% 81% 10% 0 2 0 2 1 0 R Y48545 $ 2220.46 $ 2220.46 90 9% 81% 10% 0 2 0 2 1 0 R 48547 $ 2954.61 $ 2954.61 90 9% 81% 10% 0 2 0 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 105
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
48548 $ 2748.28 $ 2748.28 90 9% 81% 10% 0 2 0 2 1 0 R Y48550 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y48551 By Report By Report 0 0% 0% 0% 0 2 0 2 1 0 N Y48552 $ 387.47 $ 387.47 0 0% 0% 0% 0 2 0 2 1 0 R Y48554 $ 4272.38 $ 4272.38 90 9% 81% 10% 0 2 0 2 2 2 R Y48556 $ 2118.49 $ 2118.49 90 9% 81% 10% 0 2 0 2 2 2 R Y48999 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 49000 $ 1278.17 $ 1278.17 90 9% 81% 10% 0 2 0 2 1 0 R 49002 $ 1730.42 $ 1730.42 90 9% 81% 10% 0 2 0 2 1 0 R 49010 $ 1542.69 $ 1542.69 90 9% 81% 10% 0 2 0 2 1 0 R 49020 $ 2636.12 $ 2636.12 90 9% 81% 10% 0 2 0 2 0 0 R 49040 $ 1657.25 $ 1657.25 90 9% 81% 10% 0 2 0 2 1 0 R 49060 $ 1821.59 $ 1821.59 90 9% 81% 10% 0 2 0 1 1 0 R 49062 $ 1227.79 $ 1227.79 90 9% 81% 10% 0 2 0 2 1 0 R 49082 $ 340.09 $ 128.36 0 0% 0% 0% 0 2 0 1 0 0 R49083 $ 516.43 $ 187.74 0 0% 0% 0% 0 2 0 1 0 0 R49084 $ 179.34 $ 179.34 0 0% 0% 0% 0 2 0 1 0 0 R49180 $ 285.50 $ 147.55 0 0% 0% 0% 0 2 0 1 0 0 R Y49203 $ 1988.34 $ 1988.34 90 9% 81% 10% 0 2 0 2 1 0 R Y49204 $ 2537.75 $ 2537.75 90 9% 81% 10% 0 2 0 2 1 0 R Y49205 $ 2904.23 $ 2904.23 90 9% 81% 10% 0 2 0 2 1 0 R Y49215 $ 3662.98 $ 3662.98 90 9% 81% 10% 0 2 0 2 1 0 R Y49220 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 49250 $ 974.08 $ 974.08 90 9% 81% 10% 0 2 0 1 1 0 R 49255 $ 1316.56 $ 1316.56 90 9% 81% 10% 0 2 0 2 1 0 R 49320 $ 544.02 $ 544.02 10 10% 80% 10% 0 2 0 2 0 0 R 49321 $ 574.61 $ 574.61 10 10% 80% 10% 0 3 0 2 2 0 49320 R Y49322 $ 615.39 $ 615.39 10 10% 80% 10% 0 3 0 2 2 0 49320 R Y49323 $ 1067.64 $ 1067.64 90 10% 80% 10% 0 3 0 2 2 0 49320 R Y49324 $ 647.78 $ 647.78 10 10% 80% 10% 0 3 0 2 2 0 49320 R 49325 $ 689.17 $ 689.17 10 10% 80% 10% 0 3 0 2 2 0 49320 R 49326 $ 310.10 $ 310.10 0 0% 0% 0% 0 0 0 2 1 0 R 49327 Not Covered Not Covered 0 0% 0% 0% 0 0 0 2 1 0 X49329 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 49400 $ 234.52 $ 160.75 0 0% 0% 0% 0 2 0 1 0 0 R 49402 $ 1416.13 $ 1416.13 90 9% 81% 10% 0 2 0 1 1 0 R 49405 $ 1549.88 $ 365.28 0 0% 0% 0% 0 2 0 1 0 0 R49406 $ 1551.68 $ 365.88 0 0% 0% 0% 0 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 106
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
49407 $ 1292.57 $ 388.67 0 0% 0% 0% 0 2 0 1 0 0 R49411 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X49412 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 1 0 X49418 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X49419 Not Covered Not Covered 90 9% 81% 10% 0 2 0 1 0 0 X 49421 $ 378.47 $ 378.47 0 0% 0% 0% 0 2 0 1 0 0 R 49422 $ 629.79 $ 629.79 10 10% 80% 10% 0 2 0 1 0 0 R 49423 $ 980.67 $ 124.16 0 0% 0% 0% 0 2 0 0 0 0 R 49424 $ 259.11 $ 65.98 0 0% 0% 0% 0 2 0 0 0 0 R 49425 $ 1218.19 $ 1218.19 90 9% 81% 10% 0 2 0 2 1 0 R Y49426 $ 1008.26 $ 1008.26 90 9% 81% 10% 0 2 0 1 0 0 R Y49427 $ 77.37 $ 77.37 0 0% 0% 0% 0 2 0 0 0 0 R Y49428 $ 857.71 $ 857.71 10 10% 80% 10% 0 2 0 1 0 0 R Y49429 $ 758.15 $ 758.15 10 10% 80% 10% 0 2 0 1 0 0 R Y49435 $ 196.13 $ 196.13 0 0% 0% 0% 0 0 0 2 1 0 R 49436 $ 312.50 $ 312.50 10 10% 80% 10% 0 2 0 2 1 0 R 49440 $ 1848.58 $ 383.27 10 10% 80% 10% 0 2 0 0 0 0 R 49441 $ 2065.71 $ 437.85 10 10% 80% 10% 0 2 0 0 0 0 R 49442 $ 1720.83 $ 385.07 10 10% 80% 10% 0 2 0 0 0 0 R 49446 $ 1782.61 $ 280.11 0 0% 0% 0% 0 2 0 0 0 0 R 49450 $ 1193.60 $ 115.16 0 0% 0% 0% 0 2 0 0 0 0 R 49451 $ 1299.77 $ 155.95 0 0% 0% 0% 0 2 0 0 0 0 R 49452 $ 1604.47 $ 241.72 0 0% 0% 0% 0 2 0 0 0 0 R 49460 $ 1315.36 $ 82.77 0 0% 0% 0% 0 2 0 0 0 0 R 49465 $ 289.10 $ 53.38 0 0% 0% 0% 0 2 0 0 0 0 R 49491 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X 49492 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X 49495 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X 49496 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X 49500 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X 49501 Not Covered Not Covered 90 9% 81% 10% 0 2 1 2 1 0 X 49505 $ 864.31 $ 864.31 90 9% 81% 10% 0 2 1 2 1 0 R 49507 $ 971.08 $ 971.08 90 9% 81% 10% 0 2 1 2 1 0 R 49520 $ 1046.65 $ 1046.65 90 9% 81% 10% 0 2 1 2 1 0 R 49521 $ 1184.01 $ 1184.01 90 9% 81% 10% 0 2 1 2 1 0 R 49525 $ 950.08 $ 950.08 90 9% 81% 10% 0 2 1 2 1 0 R 49540 $ 1113.83 $ 1113.83 90 9% 81% 10% 0 2 1 2 1 0 R 49550 $ 954.28 $ 954.28 90 9% 81% 10% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 107
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
49553 $ 1046.05 $ 1046.05 90 9% 81% 10% 0 2 1 2 1 0 R 49555 $ 988.47 $ 988.47 90 9% 81% 10% 0 2 1 2 1 0 R 49557 $ 1197.80 $ 1197.80 90 9% 81% 10% 0 2 1 2 1 0 R 49560 $ 1219.99 $ 1219.99 90 9% 81% 10% 0 2 1 2 1 0 R 49561 $ 1536.09 $ 1536.09 90 9% 81% 10% 0 2 1 2 1 0 R 49565 $ 1272.18 $ 1272.18 90 9% 81% 10% 0 2 1 2 1 0 R 49566 $ 1549.88 $ 1549.88 90 9% 81% 10% 0 2 1 2 1 0 R 49568 $ 438.45 $ 438.45 0 0% 0% 0% 0 0 0 2 1 0 R 49570 $ 692.17 $ 692.17 90 9% 81% 10% 0 2 1 2 1 0 R 49572 $ 856.51 $ 856.51 90 9% 81% 10% 0 2 1 2 1 0 R 49580 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 49582 Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X 49585 $ 740.75 $ 740.75 90 9% 81% 10% 0 2 0 2 1 0 R 49587 $ 791.14 $ 791.14 90 9% 81% 10% 0 2 0 2 1 0 R 49590 $ 949.48 $ 949.48 90 9% 81% 10% 0 2 1 2 1 0 R 49600 $ 1144.42 $ 1144.42 90 9% 81% 10% 0 2 0 2 1 0 R Y49605 $ 8098.50 $ 8098.50 90 9% 81% 10% 0 2 0 2 1 0 R Y49606 $ 1865.98 $ 1865.98 90 9% 81% 10% 0 2 0 2 1 0 R Y49610 $ 1137.22 $ 1137.22 90 9% 81% 10% 0 2 0 2 1 0 R Y49611 $ 936.29 $ 936.29 90 9% 81% 10% 0 2 0 2 1 0 R Y49650 $ 712.56 $ 712.56 90 9% 81% 10% 0 2 1 2 1 0 R 49651 $ 925.49 $ 925.49 90 9% 81% 10% 0 2 1 2 1 0 R 49652 $ 1231.99 $ 1231.99 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR49653 $ 1536.69 $ 1536.69 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR49654 $ 1398.13 $ 1398.13 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR49655 $ 1707.63 $ 1707.63 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR49656 $ 1517.49 $ 1517.49 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR49657 $ 2177.87 $ 2177.87 90 9% 81% 10% 0 2 1 2 1 0 R Y-UR49659 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 49900 $ 1359.75 $ 1359.75 90 9% 81% 10% 0 2 0 2 1 0 R 49904 $ 2378.81 $ 2378.81 90 10% 80% 10% 0 2 0 1 1 1 R 49905 $ 583.01 $ 583.01 0 0% 0% 0% 0 0 0 2 2 0 R 49906 By Report By Report 90 9% 81% 10% 0 2 0 1 1 0 N 49999 By Report By Report 90 0% 0% 0% 0 2 0 1 1 1 N 50010 $ 1248.18 $ 1248.18 90 8% 83% 9% 0 2 1 2 1 0 R 50020 $ 1718.43 $ 1718.43 90 8% 83% 9% 0 2 0 1 1 0 R 50040 $ 1572.68 $ 1572.68 90 8% 83% 9% 0 2 1 1 1 0 R 50045 $ 1581.67 $ 1581.67 90 8% 83% 9% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 108
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
50060 Not Covered Not Covered 90 8% 83% 9% 0 2 1 2 1 0 X 50065 Not Covered Not Covered 90 8% 83% 9% 0 2 1 2 0 0 X 50070 Not Covered Not Covered 90 8% 83% 9% 0 2 1 2 1 0 X 50075 Not Covered Not Covered 90 8% 83% 9% 0 2 1 2 1 0 X 50080 $ 1475.51 $ 1475.51 90 8% 83% 9% 0 2 1 1 0 0 R Y50081 $ 2163.48 $ 2163.48 90 8% 83% 9% 0 2 1 2 1 0 R Y50100 Not Covered Not Covered 90 8% 83% 9% 0 2 1 2 1 0 X 50120 $ 1610.46 $ 1610.46 90 8% 83% 9% 0 2 1 2 1 0 R 50125 $ 1667.44 $ 1667.44 90 8% 83% 9% 0 2 1 2 1 0 R 50130 Not Covered Not Covered 90 8% 83% 9% 0 2 1 2 1 0 X 50135 $ 1903.17 $ 1903.17 90 8% 83% 9% 0 2 1 2 1 0 R 50200 $ 1091.04 $ 244.72 0 0% 0% 0% 0 2 1 1 0 0 R Y50205 $ 1248.18 $ 1248.18 90 8% 83% 9% 0 2 1 2 1 0 R Y50220 $ 1763.41 $ 1763.41 90 8% 83% 9% 0 2 1 2 1 0 R 50225 $ 2027.32 $ 2027.32 90 8% 83% 9% 0 2 1 2 1 0 R 50230 $ 2165.88 $ 2165.88 90 8% 83% 9% 0 2 1 2 2 0 R 50234 $ 2200.07 $ 2200.07 90 8% 83% 9% 0 2 1 2 1 0 R 50236 $ 2484.97 $ 2484.97 90 8% 83% 9% 0 2 1 2 1 0 R 50240 $ 2242.05 $ 2242.05 90 8% 83% 9% 0 2 1 2 1 0 R 50250 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 50280 Not Covered Not Covered 90 8% 83% 9% 0 2 1 2 1 0 X 50290 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 50300 $ 3582.67 $ 3582.67 0 0% 0% 0% 9 9 9 9 9 9 F Y50320 $ 2499.97 $ 2499.97 90 8% 83% 9% 0 2 1 2 1 0 R Y50323 By Report By Report 0 0% 0% 0% 0 2 0 2 1 0 N Y50325 By Report By Report 0 0% 0% 0% 0 2 0 2 1 0 N Y50327 $ 356.88 $ 356.88 0 0% 0% 0% 0 2 0 2 1 0 R Y50328 $ 312.50 $ 312.50 0 0% 0% 0% 0 2 0 2 1 0 R Y50329 $ 299.30 $ 299.30 0 0% 0% 0% 0 2 0 2 1 0 R Y50340 $ 1577.47 $ 1577.47 90 8% 83% 9% 0 2 1 2 1 0 R Y50360 $ 4002.47 $ 4002.47 90 8% 83% 9% 0 2 0 2 2 2 R Y50365 $ 4714.43 $ 4714.43 90 8% 83% 9% 0 2 1 2 2 2 R Y50370 $ 1995.53 $ 1995.53 90 8% 83% 9% 0 2 0 2 1 0 R Y50380 $ 3329.49 $ 3329.49 90 8% 83% 9% 0 2 0 2 1 0 R Y50382 $ 2105.30 $ 465.44 0 0% 0% 0% 0 2 1 1 0 0 R 50384 $ 1671.64 $ 421.06 0 0% 0% 0% 0 2 1 1 0 0 R 50385 $ 2028.52 $ 398.27 0 0% 0% 0% 0 2 1 0 0 0 R 50386 $ 1315.96 $ 301.10 0 0% 0% 0% 0 2 1 0 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 109
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
50387 $ 967.48 $ 167.34 0 0% 0% 0% 0 2 1 0 0 0 R 50389 $ 527.82 $ 92.97 0 0% 0% 0% 0 2 1 1 0 0 R 50390 $ 165.54 $ 165.54 0 0% 0% 0% 0 2 1 1 0 0 R Y50391 $ 208.73 $ 167.94 0 0% 0% 0% 0 2 1 1 0 0 R Y50392 $ 307.70 $ 307.70 0 0% 0% 0% 0 2 1 1 0 0 R 50393 $ 373.68 $ 373.68 0 0% 0% 0% 0 2 1 1 0 0 R 50394 $ 182.94 $ 86.37 0 0% 0% 0% 0 2 1 1 0 0 R 50395 $ 307.10 $ 307.10 0 0% 0% 0% 0 2 1 1 0 0 R 50396 $ 204.53 $ 204.53 0 0% 0% 0% 0 2 1 0 0 0 R 50398 $ 891.30 $ 125.36 0 0% 0% 0% 0 2 1 1 0 0 R 50400 $ 1960.15 $ 1960.15 90 8% 83% 9% 0 2 1 2 1 0 R Y50405 $ 2368.01 $ 2368.01 90 8% 83% 9% 0 2 1 2 1 0 R Y50500 $ 1955.35 $ 1955.35 90 8% 83% 9% 0 2 0 2 1 0 R 50520 $ 1757.41 $ 1757.41 90 8% 83% 9% 0 2 0 2 1 0 R Y50525 $ 2610.33 $ 2610.33 90 8% 83% 9% 0 2 0 2 1 0 R Y50526 $ 2454.98 $ 2454.98 90 8% 83% 9% 0 2 0 2 0 0 R Y50540 Not Covered Not Covered 90 8% 83% 9% 0 2 2 2 1 0 X 50541 Not Covered Not Covered 90 8% 83% 9% 0 2 1 2 1 0 X 50542 Not Covered Not Covered 90 8% 83% 9% 0 2 1 2 1 0 X 50543 $ 2520.36 $ 2520.36 90 8% 83% 9% 0 2 1 2 1 0 R 50544 $ 2108.30 $ 2108.30 90 8% 83% 9% 0 2 1 2 1 0 R Y50545 $ 2267.24 $ 2267.24 90 8% 83% 9% 0 2 1 2 1 0 R 50546 $ 2033.92 $ 2033.92 90 8% 83% 9% 0 2 1 2 1 0 R 50547 $ 2674.51 $ 2674.51 90 8% 83% 9% 0 2 1 2 1 0 R Y50548 $ 2279.84 $ 2279.84 90 8% 83% 9% 0 2 1 2 1 0 R Y50549 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 50551 $ 613.60 $ 500.23 0 0% 0% 0% 0 2 1 0 0 0 R 50553 $ 656.78 $ 532.62 0 0% 0% 0% 0 2 1 1 0 0 R 50555 $ 702.97 $ 580.01 0 0% 0% 0% 0 3 1 0 0 0 50551 R 50557 $ 715.56 $ 587.20 0 0% 0% 0% 0 3 1 0 0 0 50551 R 50561 $ 809.13 $ 667.58 0 0% 0% 0% 0 3 1 0 0 0 50551 R 50562 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 50570 $ 831.92 $ 831.92 0 0% 0% 0% 0 2 1 0 0 0 R 50572 $ 899.70 $ 899.70 0 0% 0% 0% 0 3 1 0 0 0 50570 R 50574 $ 956.68 $ 956.68 0 0% 0% 0% 0 3 1 0 0 0 50570 R 50575 $ 1208.00 $ 1208.00 0 0% 0% 0% 0 3 1 1 0 0 50570 R 50576 $ 953.68 $ 953.68 0 0% 0% 0% 0 3 1 0 0 0 50570 R 50580 $ 1028.06 $ 1028.06 0 0% 0% 0% 0 3 1 0 0 0 50570 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 110
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
50590 $ 1233.79 $ 965.68 90 8% 83% 9% 0 2 1 1 0 0 R Y50592 Not Covered Not Covered 10 10% 80% 10% 0 2 1 1 0 0 X 50593 Not Covered Not Covered 10 10% 80% 10% 0 2 1 2 0 0 X 50600 $ 1593.07 $ 1593.07 90 8% 83% 9% 0 2 1 2 1 0 R 50605 $ 1638.65 $ 1638.65 90 8% 83% 9% 0 2 1 2 1 0 R 50610 $ 1603.87 $ 1603.87 90 8% 83% 9% 0 2 1 2 1 0 R Y50620 $ 1534.29 $ 1534.29 90 8% 83% 9% 0 2 1 2 1 0 R Y50630 $ 1515.09 $ 1515.09 90 8% 83% 9% 0 2 1 2 1 0 R Y50650 $ 1754.42 $ 1754.42 90 8% 83% 9% 0 2 1 2 1 0 R Y50660 $ 1937.95 $ 1937.95 90 8% 83% 9% 0 2 0 2 1 0 R Y50684 $ 185.94 $ 86.37 0 0% 0% 0% 0 2 1 1 0 0 R 50686 $ 274.71 $ 161.35 0 0% 0% 0% 0 2 0 0 0 0 R 50688 $ 138.55 $ 138.55 10 10% 80% 10% 0 2 0 1 0 0 R 50690 $ 170.94 $ 122.36 0 0% 0% 0% 0 2 0 1 0 0 R 50700 $ 1571.48 $ 1571.48 90 8% 83% 9% 0 2 1 2 1 0 R 50715 $ 2035.12 $ 2035.12 90 8% 83% 9% 0 2 1 2 1 0 R Y50722 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 50725 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 50727 $ 863.71 $ 863.71 90 8% 83% 9% 0 2 0 2 2 0 R Y50728 $ 1187.00 $ 1187.00 90 8% 83% 9% 0 2 0 2 2 0 R Y50740 $ 2018.33 $ 2018.33 90 8% 83% 9% 0 2 1 2 1 0 R Y50750 $ 1955.35 $ 1955.35 90 8% 83% 9% 0 2 1 2 0 0 R Y50760 $ 1897.17 $ 1897.17 90 8% 83% 9% 0 2 1 2 1 0 R Y50770 $ 1955.35 $ 1955.35 90 8% 83% 9% 0 2 0 2 1 0 R Y50780 $ 1871.38 $ 1871.38 90 8% 83% 9% 0 2 1 2 1 0 R Y50782 $ 1907.96 $ 1907.96 90 8% 83% 9% 0 2 1 2 2 0 R Y50783 $ 1911.56 $ 1911.56 90 8% 83% 9% 0 2 1 2 2 0 R Y50785 $ 2052.52 $ 2052.52 90 8% 83% 9% 0 2 1 2 1 0 R Y50800 $ 1569.68 $ 1569.68 90 8% 83% 9% 0 2 1 2 1 0 R Y50810 $ 2308.03 $ 2308.03 90 8% 83% 9% 0 2 0 2 1 0 R Y50815 $ 2073.51 $ 2073.51 90 8% 83% 9% 0 2 1 2 1 0 R Y50820 $ 2227.06 $ 2227.06 90 8% 83% 9% 0 2 1 2 1 0 R Y50825 $ 2804.66 $ 2804.66 90 8% 83% 9% 0 2 0 2 1 0 R Y50830 $ 3052.38 $ 3052.38 90 8% 83% 9% 0 2 0 2 1 0 R Y50840 $ 2084.31 $ 2084.31 90 8% 83% 9% 0 2 1 2 1 0 R Y50845 $ 2119.09 $ 2119.09 90 8% 83% 9% 0 2 0 2 1 0 R Y50860 $ 1604.47 $ 1604.47 90 8% 83% 9% 0 2 1 2 1 0 R Y50900 $ 1443.72 $ 1443.72 90 8% 83% 9% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
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only are copyright 2014 American Medical Association. All rights reserved. Page 111
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
50920 $ 1495.90 $ 1495.90 90 8% 83% 9% 0 2 0 2 1 0 R Y50930 $ 1868.98 $ 1868.98 90 8% 83% 9% 0 2 0 2 1 0 R Y50940 $ 1506.10 $ 1506.10 90 8% 83% 9% 0 2 1 2 1 0 R 50945 Not Covered Not Covered 90 8% 83% 9% 0 2 1 2 1 0 X 50947 $ 2350.62 $ 2350.62 90 8% 83% 9% 0 2 1 2 1 0 R Y50948 $ 2159.88 $ 2159.88 90 8% 83% 9% 0 2 1 2 1 0 R Y50949 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 50951 $ 641.19 $ 521.23 0 0% 0% 0% 0 2 1 0 0 0 R Y50953 $ 678.97 $ 554.82 0 0% 0% 0% 0 3 1 0 0 0 50951 R Y50955 $ 725.16 $ 598.60 0 0% 0% 0% 0 3 1 0 0 0 50951 R Y50957 $ 732.36 $ 602.20 0 0% 0% 0% 0 3 1 0 0 0 50951 R Y50961 $ 659.78 $ 539.22 0 0% 0% 0% 0 3 1 0 0 0 50951 R Y50970 $ 629.19 $ 629.19 0 0% 0% 0% 0 2 1 0 0 0 R Y50972 $ 608.20 $ 608.20 0 0% 0% 0% 0 2 1 0 0 0 R Y50974 $ 800.73 $ 800.73 0 0% 0% 0% 0 3 1 0 0 0 50970 R Y50976 $ 789.94 $ 789.94 0 0% 0% 0% 0 3 1 0 0 0 50970 R Y50980 $ 605.20 $ 605.20 0 0% 0% 0% 0 2 1 0 0 0 R Y51020 $ 797.73 $ 797.73 90 8% 83% 9% 0 2 0 2 1 0 R 51030 $ 801.33 $ 801.33 90 8% 83% 9% 0 2 0 0 0 0 R Y51040 $ 493.64 $ 493.64 90 8% 83% 9% 0 2 0 2 1 0 R 51045 $ 828.92 $ 828.92 90 8% 83% 9% 0 2 0 2 0 0 R 51050 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 51060 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 51065 Not Covered Not Covered 90 8% 83% 9% 0 2 0 0 0 0 X 51080 $ 695.77 $ 695.77 90 8% 83% 9% 0 2 0 2 1 0 R 51100 $ 106.76 $ 65.98 0 0% 0% 0% 0 2 0 1 0 0 R 51101 $ 217.73 $ 88.17 0 0% 0% 0% 0 2 0 1 0 0 R 51102 $ 391.07 $ 246.52 0 0% 0% 0% 0 2 0 1 0 0 R 51500 $ 1081.44 $ 1081.44 90 8% 83% 9% 0 2 0 2 1 0 R 51520 $ 1010.06 $ 1010.06 90 8% 83% 9% 0 2 0 2 1 0 R Y51525 $ 1457.51 $ 1457.51 90 8% 83% 9% 0 2 0 2 1 0 R Y51530 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 51535 $ 1323.16 $ 1323.16 90 8% 83% 9% 0 2 1 2 1 0 R 51550 $ 1627.86 $ 1627.86 90 8% 83% 9% 0 2 0 2 1 0 R 51555 $ 2142.49 $ 2142.49 90 8% 83% 9% 0 2 0 2 1 0 R 51565 $ 2198.27 $ 2198.27 90 8% 83% 9% 0 2 0 2 1 0 R 51570 $ 2502.97 $ 2502.97 90 8% 83% 9% 0 2 0 2 1 0 R 51575 Not Covered Not Covered 90 8% 83% 9% 0 2 2 2 1 0 X
Professional Services Fee SchedulesSurgery
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only are copyright 2014 American Medical Association. All rights reserved. Page 112
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
51580 $ 3211.33 $ 3211.33 90 8% 83% 9% 0 2 0 2 1 0 R 51585 Not Covered Not Covered 90 8% 83% 9% 0 2 2 2 1 0 X 51590 $ 3269.51 $ 3269.51 90 8% 83% 9% 0 2 0 2 1 0 R 51595 Not Covered Not Covered 90 8% 83% 9% 0 2 2 2 1 0 X 51596 $ 3978.47 $ 3978.47 90 8% 83% 9% 0 2 0 2 1 0 R 51597 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 51600 $ 323.89 $ 76.17 0 0% 0% 0% 0 2 0 1 0 0 R 51605 $ 65.38 $ 65.38 0 0% 0% 0% 0 2 0 1 0 0 R 51610 $ 185.94 $ 110.96 0 0% 0% 0% 0 2 0 1 0 0 R 51700 $ 143.35 $ 75.57 0 0% 0% 0% 0 2 0 1 0 0 R 51701 $ 94.17 $ 46.78 0 0% 0% 0% 0 2 0 1 0 0 R 51702 $ 122.36 $ 51.58 0 0% 0% 0% 0 2 0 1 0 0 R 51703 $ 223.73 $ 138.55 0 0% 0% 0% 0 2 0 1 0 0 R 51705 $ 157.75 $ 88.17 0 0% 0% 0% 0 2 0 1 0 0 R 51710 $ 222.53 $ 136.75 0 0% 0% 0% 0 2 0 1 0 0 R 51715 $ 498.43 $ 339.49 0 0% 0% 0% 0 2 0 0 0 0 R 51720 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 51725 $ 326.89 $ 326.89 0 0% 0% 0% 1 2 0 0 0 0 R 51725-26 $ 130.16 $ 130.16 0 0% 0% 0% 1 2 0 0 0 0 R 51725-TC $ 196.73 $ 196.73 0 0% 0% 0% 1 2 0 0 0 0 R 51726 $ 460.65 $ 460.65 0 0% 0% 0% 1 2 0 1 0 0 R 51726-26 $ 145.75 $ 145.75 0 0% 0% 0% 1 2 0 1 0 0 R 51726-TC $ 314.90 $ 314.90 0 0% 0% 0% 1 2 0 1 0 0 R 51727 $ 544.62 $ 544.62 0 0% 0% 0% 1 2 0 0 0 0 R51727-26 $ 182.34 $ 182.34 0 0% 0% 0% 1 2 0 0 0 0 R51727-TC $ 362.28 $ 362.28 0 0% 0% 0% 1 2 0 0 0 0 R51728 $ 550.02 $ 550.02 0 0% 0% 0% 1 2 0 0 0 0 R51728-26 $ 178.14 $ 178.14 0 0% 0% 0% 1 2 0 0 0 0 R51728-TC $ 371.88 $ 371.88 0 0% 0% 0% 1 2 0 0 0 0 R51729 $ 593.80 $ 593.80 0 0% 0% 0% 1 2 0 0 0 0 R51729-26 $ 215.93 $ 215.93 0 0% 0% 0% 1 2 0 0 0 0 R51729-TC $ 377.87 $ 377.87 0 0% 0% 0% 1 2 0 0 0 0 R51736 $ 26.99 $ 26.99 0 0% 0% 0% 1 2 0 0 0 0 R 51736-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 2 0 0 0 0 R 51736-TC $ 12.60 $ 12.60 0 0% 0% 0% 1 2 0 0 0 0 R 51741 $ 27.59 $ 27.59 0 0% 0% 0% 1 2 0 1 0 0 R 51741-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 2 0 1 0 0 R 51741-TC $ 13.20 $ 13.20 0 0% 0% 0% 1 2 0 1 0 0 R
Professional Services Fee SchedulesSurgery
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only are copyright 2014 American Medical Association. All rights reserved. Page 113
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
51784 $ 335.29 $ 335.29 0 0% 0% 0% 1 2 0 1 0 0 R 51784-26 $ 130.76 $ 130.76 0 0% 0% 0% 1 2 0 1 0 0 R 51784-TC $ 204.53 $ 204.53 0 0% 0% 0% 1 2 0 1 0 0 R 51785 $ 438.45 $ 438.45 0 0% 0% 0% 1 2 0 0 0 0 R 51785-26 $ 139.15 $ 139.15 0 0% 0% 0% 1 2 0 0 0 0 R 51785-TC $ 299.30 $ 299.30 0 0% 0% 0% 1 2 0 0 0 0 R 51792 $ 370.68 $ 370.68 0 0% 0% 0% 1 2 0 0 0 0 R 51792-26 $ 93.57 $ 93.57 0 0% 0% 0% 1 2 0 0 0 0 R 51792-TC $ 277.11 $ 277.11 0 0% 0% 0% 1 2 0 0 0 0 R 51797 $ 195.53 $ 195.53 0 0% 0% 0% 1 0 0 0 0 0 R 51797-26 $ 67.78 $ 67.78 0 0% 0% 0% 1 0 0 0 0 0 R 51797-TC $ 127.76 $ 127.76 0 0% 0% 0% 1 0 0 0 0 0 R 51798 $ 32.99 $ 32.99 0 0% 0% 0% 3 0 0 0 0 0 R 51800 $ 1769.41 $ 1769.41 90 8% 83% 9% 0 2 0 2 1 0 R Y51820 $ 2002.73 $ 2002.73 90 8% 83% 9% 0 2 2 2 1 0 R Y51840 $ 1112.63 $ 1112.63 90 8% 83% 9% 0 2 0 2 1 0 R Y51841 $ 1315.36 $ 1315.36 90 8% 83% 9% 0 2 0 2 1 0 R Y51845 $ 996.27 $ 996.27 90 8% 83% 9% 0 2 0 2 1 0 R Y51860 $ 1255.38 $ 1255.38 90 8% 83% 9% 0 2 0 2 1 0 R 51865 $ 1515.09 $ 1515.09 90 8% 83% 9% 0 2 0 2 1 0 R 51880 $ 793.54 $ 793.54 90 8% 83% 9% 0 2 0 2 1 0 R Y51900 $ 1416.13 $ 1416.13 90 8% 83% 9% 0 2 0 2 1 0 R Y51920 $ 1296.77 $ 1296.77 90 8% 83% 9% 0 2 0 2 1 0 R Y51925 $ 1852.18 $ 1852.18 90 8% 83% 9% 0 2 0 2 1 0 R Y51940 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 51960 $ 2350.62 $ 2350.62 90 8% 83% 9% 0 2 0 2 1 0 R Y51980 $ 1211.00 $ 1211.00 90 8% 83% 9% 0 2 0 2 1 0 R Y51990 $ 1273.98 $ 1273.98 90 8% 83% 9% 0 2 0 2 1 0 R Y51992 $ 1425.12 $ 1425.12 90 8% 83% 9% 0 2 0 2 1 0 R Y51999 By Report By Report 90 0% 0% 0% 0 0 0 0 1 1 N 52000 $ 352.08 $ 214.73 0 0% 0% 0% 0 2 0 1 0 0 R 52001 $ 632.79 $ 487.64 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52005 $ 460.05 $ 226.72 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52007 $ 773.74 $ 281.91 0 0% 0% 0% 0 3 1 1 0 0 52000 R Y52010 $ 636.39 $ 281.31 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52204 $ 642.99 $ 241.12 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52214 $ 1155.81 $ 297.50 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52224 $ 1208.00 $ 344.89 0 0% 0% 0% 0 3 0 1 0 0 52000 R
Professional Services Fee SchedulesSurgery
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only are copyright 2014 American Medical Association. All rights reserved. Page 114
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
52234 $ 417.46 $ 417.46 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52235 $ 490.04 $ 490.04 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52240 $ 665.18 $ 665.18 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52250 Not Covered Not Covered 0 0% 0% 0% 0 3 0 1 0 0 52000 X 52260 $ 358.08 $ 358.08 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52265 $ 635.79 $ 276.51 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52270 $ 615.39 $ 308.90 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52275 $ 828.32 $ 422.26 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52276 $ 449.25 $ 449.25 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52277 $ 548.82 $ 548.82 0 0% 0% 0% 0 3 0 0 0 0 52000 R 52281 $ 469.64 $ 259.11 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52282 $ 571.01 $ 571.01 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52283 $ 472.04 $ 341.89 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52285 $ 477.44 $ 332.89 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52287 $ 536.82 $ 286.70 0 0% 0% 0% 0 3 0 1 0 0 52000 R52290 $ 414.46 $ 414.46 0 0% 0% 0% 0 3 2 1 0 0 52000 R 52300 $ 476.24 $ 476.24 0 0% 0% 0% 0 3 2 0 0 0 52000 R Y52301 $ 493.04 $ 493.04 0 0% 0% 0% 0 3 2 0 0 0 52000 R Y52305 $ 472.64 $ 472.64 0 0% 0% 0% 0 3 0 1 0 0 52000 R Y52310 $ 417.46 $ 257.31 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52315 $ 708.36 $ 466.04 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52317 $ 1395.13 $ 589.00 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52318 $ 801.93 $ 801.93 0 0% 0% 0% 0 3 0 1 0 0 52000 R 52320 $ 418.66 $ 418.66 0 0% 0% 0% 0 3 1 1 0 0 52000 R 52325 $ 544.02 $ 544.02 0 0% 0% 0% 0 3 1 1 0 0 52000 R 52327 $ 443.25 $ 443.25 0 0% 0% 0% 0 3 1 1 0 0 52000 R 52330 $ 851.12 $ 447.45 0 0% 0% 0% 0 3 1 1 0 0 52000 R 52332 $ 854.72 $ 264.51 0 0% 0% 0% 0 3 1 1 0 0 52000 R 52334 $ 434.86 $ 434.86 0 0% 0% 0% 0 3 1 1 0 0 52000 R 52341 $ 481.64 $ 481.64 0 0% 0% 0% 0 3 1 1 0 0 52000 R 52342 $ 524.83 $ 524.83 0 0% 0% 0% 0 3 1 1 0 0 52000 R 52343 $ 584.21 $ 584.21 0 0% 0% 0% 0 3 1 1 0 0 52000 R 52344 $ 626.79 $ 626.79 0 0% 0% 0% 0 3 1 1 0 0 52000 R 52345 $ 668.78 $ 668.78 0 0% 0% 0% 0 3 1 0 0 0 52351 R 52346 $ 757.55 $ 757.55 0 0% 0% 0% 0 3 1 0 0 0 52351 R 52351 $ 514.03 $ 514.03 0 0% 0% 0% 0 2 0 1 0 0 R 52352 $ 601.60 $ 601.60 0 0% 0% 0% 0 3 1 1 0 0 52351 R Y52353 $ 665.18 $ 665.18 0 0% 0% 0% 0 3 1 1 0 0 52351 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
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Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
52354 $ 707.16 $ 707.16 0 0% 0% 0% 0 3 1 1 0 0 52351 R Y52355 Not Covered Not Covered 0 0% 0% 0% 0 3 1 1 0 0 52351 X 52356 $ 704.77 $ 704.77 0 0% 0% 0% 0 3 1 1 0 0 52351 R Y52400 $ 810.93 $ 810.93 90 8% 83% 9% 0 3 0 1 0 0 52000 R Y52402 $ 451.65 $ 451.65 0 0% 0% 0% 0 3 0 1 0 0 52000 R Y52441 $ 2181.47 $ 383.27 0 0% 0% 0% 0 3 0 1 0 0 43235 R Y52442 $ 1683.64 $ 102.57 0 0% 0% 0% 0 0 0 1 0 0 R Y52450 $ 800.13 $ 800.13 90 8% 83% 9% 0 2 0 1 0 0 R 52500 $ 831.32 $ 831.32 90 8% 83% 9% 0 2 0 1 0 0 R 52601 $ 1434.72 $ 1434.72 90 8% 83% 9% 0 2 0 1 0 0 R Y52630 $ 681.37 $ 681.37 90 8% 83% 9% 0 2 0 1 0 0 R Y52640 $ 538.62 $ 538.62 90 8% 83% 9% 0 2 0 1 0 0 R Y52647 $ 3108.16 $ 1100.03 90 8% 83% 9% 0 2 0 1 0 0 R Y52648 $ 3195.73 $ 1172.61 90 8% 83% 9% 0 2 0 1 0 0 R Y52649 $ 1398.13 $ 1398.13 90 8% 83% 9% 0 2 0 0 0 0 R Y52700 $ 749.15 $ 749.15 90 8% 83% 9% 0 2 0 0 0 0 R 53000 $ 253.72 $ 253.72 10 10% 80% 10% 0 2 0 1 0 0 R 53010 $ 504.43 $ 504.43 90 8% 83% 9% 0 2 0 1 0 0 R 53020 $ 164.35 $ 164.35 0 0% 0% 0% 0 2 0 1 0 0 R 53025 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 53040 $ 668.18 $ 668.18 90 8% 83% 9% 0 2 0 0 0 0 R 53060 $ 314.30 $ 281.31 10 10% 80% 10% 0 2 0 1 0 0 R 53080 $ 738.35 $ 738.35 90 8% 83% 9% 0 2 0 1 0 0 R 53085 $ 1103.63 $ 1103.63 90 8% 83% 9% 0 2 0 2 1 0 R 53200 $ 265.11 $ 241.12 0 0% 0% 0% 0 2 0 1 0 0 R Y53210 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 53215 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 53220 Not Covered Not Covered 90 8% 83% 9% 0 2 0 0 0 0 X 53230 $ 1030.46 $ 1030.46 90 8% 83% 9% 0 2 0 2 1 0 R Y53235 $ 1074.84 $ 1074.84 90 8% 83% 9% 0 2 0 2 1 0 R Y53240 $ 722.76 $ 722.76 90 8% 83% 9% 0 2 0 1 0 0 R Y53250 $ 674.18 $ 674.18 90 8% 83% 9% 0 2 0 1 0 0 R Y53260 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 53265 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 53270 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 53275 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 53400 $ 1360.35 $ 1360.35 90 8% 83% 9% 0 2 0 2 1 0 R Y53405 $ 1482.71 $ 1482.71 90 8% 83% 9% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
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only are copyright 2014 American Medical Association. All rights reserved. Page 116
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
53410 $ 1662.05 $ 1662.05 90 8% 83% 9% 0 2 0 2 1 0 R Y53415 $ 1915.76 $ 1915.76 90 8% 83% 9% 0 2 0 2 1 0 R Y53420 $ 1426.32 $ 1426.32 90 8% 83% 9% 0 2 0 1 1 0 R Y53425 $ 1588.27 $ 1588.27 90 8% 83% 9% 0 2 0 2 1 0 R Y53430 $ 1632.66 $ 1632.66 90 8% 83% 9% 0 2 0 2 1 0 R Y53431 $ 1956.55 $ 1956.55 90 8% 83% 9% 0 2 0 2 1 0 R Y53440 $ 1278.77 $ 1278.77 90 8% 83% 9% 0 2 0 2 1 0 R Y53442 $ 1331.56 $ 1331.56 90 8% 83% 9% 0 2 0 2 0 0 R Y53444 $ 1345.95 $ 1345.95 90 8% 83% 9% 0 2 0 2 1 0 R Y53445 $ 1280.57 $ 1280.57 90 8% 83% 9% 0 2 0 2 1 0 R Y53446 $ 1091.64 $ 1091.64 90 8% 83% 9% 0 2 0 2 1 0 R Y53447 $ 1373.54 $ 1373.54 90 8% 83% 9% 0 2 0 2 1 0 R Y53448 $ 2170.08 $ 2170.08 90 8% 83% 9% 0 2 0 2 1 0 R Y53449 $ 1039.45 $ 1039.45 90 8% 83% 9% 0 2 0 2 1 0 R Y53450 $ 696.37 $ 696.37 90 8% 83% 9% 0 2 0 1 0 0 R 53460 $ 778.54 $ 778.54 90 8% 83% 9% 0 2 0 0 0 0 R 53500 $ 1270.98 $ 1270.98 90 12% 74% 14% 0 2 0 2 1 0 R Y53502 $ 827.72 $ 827.72 90 8% 83% 9% 0 2 0 1 0 0 R 53505 $ 826.52 $ 826.52 90 8% 83% 9% 0 2 0 2 0 0 R 53510 $ 1072.44 $ 1072.44 90 8% 83% 9% 0 2 0 2 1 0 R 53515 $ 1350.75 $ 1350.75 90 8% 83% 9% 0 2 0 2 1 0 R 53520 $ 946.48 $ 946.48 90 8% 83% 9% 0 2 0 1 0 0 R Y53600 $ 142.15 $ 107.96 0 0% 0% 0% 0 2 0 1 0 0 R 53601 $ 139.15 $ 91.17 0 0% 0% 0% 0 2 0 1 0 0 R 53605 $ 109.16 $ 109.16 0 0% 0% 0% 0 2 0 1 0 0 R 53620 $ 198.53 $ 148.15 0 0% 0% 0% 0 2 0 1 0 0 R 53621 $ 187.74 $ 122.36 0 0% 0% 0% 0 2 0 1 0 0 R 53660 $ 121.76 $ 70.78 0 0% 0% 0% 0 2 0 1 0 0 R 53661 $ 119.36 $ 68.38 0 0% 0% 0% 0 2 0 1 0 0 R 53665 $ 65.38 $ 65.38 0 0% 0% 0% 0 2 0 1 0 0 R 53850 Not Covered Not Covered 90 8% 83% 9% 0 2 0 1 0 0 X 53852 Not Covered Not Covered 90 8% 83% 9% 0 2 0 1 0 0 X 53855 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X53860 Not Covered Not Covered 90 8% 83% 9% 0 2 0 0 0 0 X53899 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 54000 Not Covered Not Covered 10 10% 80% 10% 0 2 0 0 0 0 X 54001 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 54015 $ 520.63 $ 520.63 10 10% 80% 10% 0 2 0 0 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 117
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
54050 $ 229.12 $ 182.34 10 10% 80% 10% 0 2 0 1 0 0 R Y54055 $ 205.73 $ 159.55 10 10% 80% 10% 0 2 0 1 0 0 R Y54056 $ 245.92 $ 191.94 10 10% 80% 10% 0 2 0 1 0 0 R Y54057 $ 234.52 $ 162.55 10 10% 80% 10% 0 2 0 1 0 0 R Y54060 $ 308.90 $ 222.53 10 10% 80% 10% 0 2 0 1 0 0 R Y54065 $ 374.88 $ 295.70 10 10% 80% 10% 0 2 0 1 0 0 R Y54100 $ 343.09 $ 214.73 0 0% 0% 0% 0 2 0 1 0 0 R Y54105 $ 452.25 $ 363.48 10 10% 80% 10% 0 2 0 1 0 0 R Y54110 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 0 0 X 54111 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54112 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54115 $ 771.34 $ 722.76 90 10% 80% 10% 0 2 0 2 0 0 R 54120 $ 1073.64 $ 1073.64 90 10% 80% 10% 0 2 0 2 1 0 R Y54125 $ 1377.74 $ 1377.74 90 10% 80% 10% 0 2 0 2 1 0 R Y54130 Not Covered Not Covered 90 10% 80% 10% 0 2 2 2 1 0 X 54135 Not Covered Not Covered 90 10% 80% 10% 0 2 2 2 0 0 X 54150 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 54160 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 54161 $ 335.29 $ 335.29 10 10% 80% 10% 0 2 0 1 0 0 R Y54162 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 54163 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 54164 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 54200 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 54205 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 0 0 X 54220 $ 350.88 $ 227.32 0 0% 0% 0% 0 2 0 1 0 0 R 54230 $ 166.14 $ 136.75 0 0% 0% 0% 0 2 0 1 0 0 R 54231 $ 239.92 $ 198.53 0 0% 0% 0% 0 2 0 1 0 0 R 54235 $ 155.35 $ 125.96 0 0% 0% 0% 0 2 0 1 0 0 R 54240 $ 171.54 $ 171.54 0 0% 0% 0% 1 0 0 0 0 0 R 54240-26 $ 109.16 $ 109.16 0 0% 0% 0% 1 0 0 0 0 0 R 54240-TC $ 62.38 $ 62.38 0 0% 0% 0% 1 0 0 0 0 0 R 54250 $ 206.33 $ 206.33 0 0% 0% 0% 1 0 0 0 0 0 R 54250-26 $ 187.14 $ 187.14 0 0% 0% 0% 1 0 0 0 0 0 R 54250-TC $ 19.19 $ 19.19 0 0% 0% 0% 1 0 0 0 0 0 R 54300 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54304 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 0 0 X 54308 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54312 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 118
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
54316 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54318 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54322 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 0 0 X 54324 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54326 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54328 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54332 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54336 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54340 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54344 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54348 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54352 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54360 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54380 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54385 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54390 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 54400 $ 899.70 $ 899.70 90 10% 80% 10% 0 2 0 1 1 0 R Y54401 $ 1119.23 $ 1119.23 90 10% 80% 10% 0 2 0 1 1 0 R Y54405 $ 1371.74 $ 1371.74 90 10% 80% 10% 0 2 0 2 1 0 R Y54406 $ 1240.99 $ 1240.99 90 10% 80% 10% 0 2 0 2 1 0 R Y54408 $ 1342.95 $ 1342.95 90 10% 80% 10% 0 2 0 2 1 0 R Y54410 $ 1459.91 $ 1459.91 90 10% 80% 10% 0 2 0 2 1 0 R Y54411 $ 1742.42 $ 1742.42 90 10% 80% 10% 0 2 0 2 1 0 R Y54415 $ 900.30 $ 900.30 90 10% 80% 10% 0 2 0 2 1 0 R Y54416 $ 1208.00 $ 1208.00 90 10% 80% 10% 0 2 0 2 1 0 R Y54417 $ 1525.89 $ 1525.89 90 10% 80% 10% 0 2 0 2 1 0 R Y54420 $ 1197.20 $ 1197.20 90 10% 80% 10% 0 2 0 2 0 0 R 54430 $ 1088.64 $ 1088.64 90 10% 80% 10% 0 2 2 2 0 0 R 54435 $ 710.16 $ 710.16 90 10% 80% 10% 0 2 0 1 0 0 R 54440 By Report By Report 90 10% 80% 10% 0 2 0 2 1 0 N 54450 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 54500 $ 127.16 $ 127.16 0 0% 0% 0% 0 2 1 0 0 0 R Y54505 $ 357.48 $ 357.48 10 10% 80% 10% 0 2 1 0 0 0 R Y54512 $ 918.29 $ 918.29 90 10% 80% 10% 0 2 1 1 1 0 R 54520 $ 554.82 $ 554.82 90 10% 80% 10% 0 2 1 1 0 0 R 54522 $ 1003.47 $ 1003.47 90 10% 80% 10% 0 2 1 2 1 0 R 54530 $ 858.91 $ 858.91 90 10% 80% 10% 0 2 1 2 1 0 R 54535 $ 1264.38 $ 1264.38 90 10% 80% 10% 0 2 1 2 0 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 119
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
54550 Not Covered Not Covered 90 10% 80% 10% 0 2 1 2 0 0 X 54560 Not Covered Not Covered 90 10% 80% 10% 0 2 1 2 1 0 X 54600 $ 770.74 $ 770.74 90 10% 80% 10% 0 2 1 1 0 0 R 54620 Not Covered Not Covered 10 10% 80% 10% 0 2 1 1 0 0 X 54640 $ 815.13 $ 815.13 90 10% 80% 10% 0 2 1 0 0 0 R Y54650 Not Covered Not Covered 90 10% 80% 10% 0 2 1 2 0 0 X 54660 $ 609.40 $ 609.40 90 10% 80% 10% 0 2 1 0 0 0 R 54670 $ 690.37 $ 690.37 90 10% 80% 10% 0 2 1 0 0 0 R 54680 $ 1336.35 $ 1336.35 90 10% 80% 10% 0 2 2 2 1 0 R 54690 $ 1116.23 $ 1116.23 90 10% 80% 10% 0 2 1 2 1 0 R 54692 Not Covered Not Covered 90 10% 80% 10% 0 2 1 1 0 0 X 54699 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 54700 $ 365.28 $ 365.28 10 10% 80% 10% 0 2 1 1 0 0 R 54800 $ 214.13 $ 214.13 0 0% 0% 0% 0 2 1 0 0 0 R Y54830 $ 634.59 $ 634.59 90 10% 80% 10% 0 2 1 0 0 0 R 54840 $ 547.02 $ 547.02 90 10% 80% 10% 0 2 1 1 0 0 R 54860 $ 713.16 $ 713.16 90 10% 80% 10% 0 2 0 1 0 0 R 54861 $ 962.68 $ 962.68 90 10% 80% 10% 0 2 0 0 0 0 R 54865 $ 611.80 $ 611.80 90 10% 80% 10% 0 2 0 0 0 0 R Y54900 $ 1395.73 $ 1395.73 90 10% 80% 10% 0 2 0 0 0 0 R Y54901 $ 1837.19 $ 1837.19 90 10% 80% 10% 0 2 2 0 0 0 R Y55000 $ 201.53 $ 145.15 0 0% 0% 0% 0 2 1 1 0 0 R Y55040 $ 575.81 $ 575.81 90 10% 80% 10% 0 2 0 1 0 0 R Y55041 $ 867.91 $ 867.91 90 10% 80% 10% 0 2 2 1 0 0 R Y55060 $ 648.38 $ 648.38 90 10% 80% 10% 0 2 1 0 0 0 R Y55100 $ 370.68 $ 284.91 10 10% 80% 10% 0 2 0 1 0 0 R 55110 $ 658.58 $ 658.58 90 10% 80% 10% 0 2 0 1 0 0 R 55120 $ 611.20 $ 611.20 90 10% 80% 10% 0 2 0 0 0 0 R 55150 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 55175 $ 618.39 $ 618.39 90 10% 80% 10% 0 2 0 0 0 0 R 55180 $ 1171.41 $ 1171.41 90 10% 80% 10% 0 2 0 0 0 0 R 55200 Not Covered Not Covered 90 10% 80% 10% 0 2 2 0 0 0 X 55250 Not Covered Not Covered 90 10% 80% 10% 0 2 2 1 0 0 X 55300 Not Covered Not Covered 0 0% 0% 0% 0 2 2 0 0 0 X 55400 Not Covered Not Covered 90 10% 80% 10% 0 2 1 2 1 0 X 55450 Not Covered Not Covered 10 10% 80% 10% 0 2 2 0 0 0 X 55500 $ 669.98 $ 669.98 90 10% 80% 10% 0 2 1 0 0 0 R Y55520 $ 756.35 $ 756.35 90 10% 80% 10% 0 2 1 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 120
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
55530 $ 600.40 $ 600.40 90 10% 80% 10% 0 2 1 1 1 0 R 55535 $ 732.96 $ 732.96 90 10% 80% 10% 0 2 1 2 1 0 R 55540 $ 918.29 $ 918.29 90 10% 80% 10% 0 2 1 1 1 0 R 55550 $ 729.36 $ 729.36 90 10% 80% 10% 0 2 1 2 1 0 R 55559 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 55600 $ 717.96 $ 717.96 90 10% 80% 10% 0 2 1 0 0 0 R Y55605 $ 914.10 $ 914.10 90 10% 80% 10% 0 2 1 0 0 0 R Y55650 $ 1217.59 $ 1217.59 90 10% 80% 10% 0 2 1 2 1 0 R Y55680 Not Covered Not Covered 90 10% 80% 10% 0 2 1 0 0 0 X 55700 $ 374.28 $ 236.92 0 0% 0% 0% 0 2 0 1 0 0 R Y55705 $ 453.45 $ 453.45 10 10% 80% 10% 0 2 0 1 1 0 R Y55706 Not Covered Not Covered 10 10% 80% 10% 0 2 0 2 1 0 X 55720 $ 768.34 $ 768.34 90 10% 80% 10% 0 2 0 2 1 0 R Y55725 $ 1085.64 $ 1085.64 90 10% 80% 10% 0 2 0 2 1 0 R Y55801 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 55810 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 55812 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 55815 Not Covered Not Covered 90 10% 80% 10% 0 2 2 2 1 0 X 55821 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 55831 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 55840 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 55842 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 55845 Not Covered Not Covered 90 10% 80% 10% 0 2 2 2 1 0 X 55860 Not Covered Not Covered 90 10% 80% 10% 0 2 0 1 1 0 X 55862 Not Covered Not Covered 90 10% 80% 10% 0 2 0 2 1 0 X 55865 Not Covered Not Covered 90 10% 80% 10% 0 2 2 2 1 0 X 55866 Not Covered Not Covered 90 8% 83% 9% 0 2 0 2 1 0 X 55870 $ 299.90 $ 241.72 0 0% 0% 0% 0 2 0 1 1 0 R 55873 Not Covered Not Covered 90 8% 83% 9% 0 2 0 1 0 0 X 55875 Not Covered Not Covered 90 10% 80% 10% 0 2 0 0 0 0 X 55876 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 1 1 X 55899 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 55920 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 55970 Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X 55980 Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X 56405 $ 185.94 $ 184.74 10 10% 80% 10% 0 2 0 1 2 0 R Y56420 $ 208.73 $ 154.15 10 10% 80% 10% 0 2 0 1 0 0 R Y56440 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 121
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
56441 Not Covered Not Covered 10 10% 80% 10% 0 2 0 0 0 0 X 56442 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 56501 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 56515 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 56605 $ 139.75 $ 101.37 0 0% 0% 0% 0 2 0 1 2 0 R Y56606 $ 63.58 $ 49.18 0 0% 0% 0% 0 0 0 1 2 0 R Y56620 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 56625 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 56630 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 56631 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 2 0 X 56632 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 2 0 X 56633 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 2 0 X 56634 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 2 0 X 56637 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 2 0 X 56640 Not Covered Not Covered 90 12% 74% 14% 0 2 1 2 1 0 X 56700 Not Covered Not Covered 10 10% 80% 10% 0 2 0 2 1 0 X 56740 Not Covered Not Covered 10 10% 80% 10% 0 2 1 1 0 0 X 56800 $ 406.66 $ 406.66 10 10% 80% 10% 0 2 0 2 1 0 R Y56805 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 56810 $ 437.25 $ 437.25 10 10% 80% 10% 0 2 0 2 2 0 R Y56820 $ 189.54 $ 144.55 0 0% 0% 0% 0 2 0 1 0 0 R Y56821 $ 250.12 $ 193.14 0 0% 0% 0% 0 2 0 1 0 0 R Y57000 $ 311.30 $ 311.30 10 10% 80% 10% 0 2 0 0 0 0 R Y57010 $ 730.56 $ 730.56 90 12% 74% 14% 0 2 0 0 0 0 R Y57020 $ 155.95 $ 134.96 0 0% 0% 0% 0 2 0 0 0 0 R Y57022 $ 283.11 $ 283.11 10 10% 80% 10% 0 2 0 0 0 0 R Y57023 $ 522.43 $ 522.43 10 10% 80% 10% 0 2 0 0 0 0 R Y57061 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 57065 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 57100 $ 151.15 $ 111.56 0 0% 0% 0% 0 2 0 1 0 0 R Y57105 $ 231.52 $ 214.13 10 10% 80% 10% 0 2 0 1 0 0 R Y57106 $ 828.32 $ 828.32 90 12% 74% 14% 0 2 0 2 1 0 R Y57107 $ 2413.60 $ 2413.60 90 12% 74% 14% 0 2 0 2 1 0 R Y57109 $ 2870.64 $ 2870.64 90 12% 74% 14% 0 2 2 2 1 0 R Y57110 $ 1499.50 $ 1499.50 90 12% 74% 14% 0 2 0 2 1 0 R Y57111 $ 2680.51 $ 2680.51 90 12% 74% 14% 0 2 2 2 1 0 R Y57112 $ 3071.58 $ 3071.58 90 12% 74% 14% 0 2 2 2 1 0 R Y57120 $ 857.11 $ 857.11 90 12% 74% 14% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 122
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
57130 Not Covered Not Covered 10 10% 80% 10% 0 2 0 2 1 0 X 57135 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 57150 $ 77.37 $ 48.58 0 0% 0% 0% 0 2 0 1 0 0 R 57155 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 2 0 X 57156 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X57160 $ 131.36 $ 79.17 0 0% 0% 0% 0 2 0 1 0 0 R Y57170 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 57180 $ 241.12 $ 179.34 10 10% 80% 10% 0 2 0 1 0 0 R 57200 $ 509.83 $ 509.83 90 12% 74% 14% 0 2 0 2 1 0 R 57210 $ 619.59 $ 619.59 90 12% 74% 14% 0 2 0 2 1 0 R 57220 $ 538.62 $ 538.62 90 12% 74% 14% 0 2 0 2 1 0 R Y57230 $ 663.98 $ 663.98 90 12% 74% 14% 0 2 0 2 1 0 R Y57240 $ 1128.22 $ 1128.22 90 12% 74% 14% 0 2 0 2 1 0 R Y57250 $ 1136.02 $ 1136.02 90 12% 74% 14% 0 2 0 2 1 0 R Y57260 $ 1398.13 $ 1398.13 90 12% 74% 14% 0 2 0 2 1 0 R Y57265 $ 1530.09 $ 1530.09 90 12% 74% 14% 0 2 0 2 1 0 R Y57267 $ 428.86 $ 428.86 0 0% 0% 0% 0 0 0 2 1 0 R Y57268 $ 814.53 $ 814.53 90 12% 74% 14% 0 2 0 2 1 0 R Y57270 $ 1336.95 $ 1336.95 90 12% 74% 14% 0 2 0 2 1 0 R Y57280 $ 1599.67 $ 1599.67 90 12% 74% 14% 0 2 0 2 1 0 R Y57282 $ 844.52 $ 844.52 90 12% 74% 14% 0 2 0 2 1 0 R Y57283 $ 1157.61 $ 1157.61 90 12% 74% 14% 0 2 0 2 1 0 R Y57284 $ 1368.74 $ 1368.74 90 8% 83% 9% 0 2 0 2 2 0 R Y57285 $ 1129.42 $ 1129.42 90 8% 83% 9% 0 2 0 2 2 0 R Y57287 $ 1149.82 $ 1149.82 90 12% 74% 14% 0 2 0 2 1 0 R Y57288 $ 1206.20 $ 1206.20 90 12% 74% 14% 0 2 0 2 1 0 R Y57289 $ 1238.59 $ 1238.59 90 12% 74% 14% 0 2 0 2 1 0 R Y57291 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 0 0 X 57292 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 57295 $ 804.33 $ 804.33 90 12% 74% 14% 0 2 0 2 1 0 R 57296 $ 1566.08 $ 1566.08 90 12% 74% 14% 0 2 0 2 1 0 R Y57300 $ 950.68 $ 950.68 90 12% 74% 14% 0 2 0 2 1 0 R Y57305 $ 1556.48 $ 1556.48 90 12% 74% 14% 0 2 0 2 1 0 R Y57307 $ 1770.01 $ 1770.01 90 12% 74% 14% 0 2 0 2 1 0 R Y57308 $ 1074.24 $ 1074.24 90 12% 74% 14% 0 2 0 2 1 0 R Y57310 $ 783.94 $ 783.94 90 12% 74% 14% 0 2 0 2 1 0 R Y57311 $ 891.30 $ 891.30 90 12% 74% 14% 0 2 0 2 1 0 R Y57320 $ 896.10 $ 896.10 90 12% 74% 14% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 123
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
57330 $ 1254.78 $ 1254.78 90 12% 74% 14% 0 2 0 2 1 0 R Y57335 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 57400 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 57410 $ 181.74 $ 181.74 0 0% 0% 0% 0 2 0 1 0 0 R Y57415 $ 271.11 $ 271.11 10 10% 80% 10% 0 2 0 0 0 0 R Y57420 $ 199.73 $ 154.15 0 0% 0% 0% 0 2 0 1 0 0 R Y57421 $ 266.31 $ 207.53 0 0% 0% 0% 0 2 0 1 0 0 R Y57423 $ 1530.69 $ 1530.69 90 8% 83% 9% 0 2 0 2 2 0 R Y57425 $ 1625.46 $ 1625.46 90 12% 74% 14% 0 2 0 2 1 0 R Y57426 $ 1418.53 $ 1418.53 90 12% 74% 14% 0 2 0 2 1 0 R Y57452 $ 184.74 $ 155.95 0 0% 0% 0% 0 2 0 1 0 0 R Y57454 $ 258.51 $ 229.12 0 0% 0% 0% 0 3 0 1 0 0 57452 R Y57455 $ 242.92 $ 185.94 0 0% 0% 0% 0 3 0 1 0 0 57452 R Y57456 $ 229.12 $ 173.34 0 0% 0% 0% 0 3 0 1 0 0 57452 R Y57460 $ 486.44 $ 273.51 0 0% 0% 0% 0 3 0 1 0 0 57452 R Y57461 $ 548.22 $ 314.30 0 0% 0% 0% 0 3 0 1 0 0 57452 R Y57500 $ 221.33 $ 128.36 0 0% 0% 0% 0 2 0 1 0 0 R Y57505 $ 173.94 $ 157.15 10 10% 80% 10% 0 2 0 1 0 0 R Y57510 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 57511 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 57513 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 57520 Not Covered Not Covered 90 12% 74% 14% 0 2 0 1 0 0 X 57522 Not Covered Not Covered 90 12% 74% 14% 0 2 0 1 0 0 X 57530 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 57531 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 57540 $ 1352.55 $ 1352.55 90 12% 74% 14% 0 2 0 2 1 0 R Y57545 $ 1377.14 $ 1377.14 90 12% 74% 14% 0 2 0 2 1 0 R Y57550 $ 685.57 $ 685.57 90 12% 74% 14% 0 2 0 2 1 0 R Y57555 $ 1009.46 $ 1009.46 90 12% 74% 14% 0 2 0 2 1 0 R Y57556 $ 954.88 $ 954.88 90 12% 74% 14% 0 2 0 2 1 0 R Y57558 $ 212.33 $ 191.94 10 10% 80% 10% 0 2 0 1 0 0 R Y57700 Not Covered Not Covered 90 12% 74% 14% 0 2 0 0 0 0 X 57720 $ 518.83 $ 518.83 90 12% 74% 14% 0 2 0 2 0 0 R Y57800 $ 103.77 $ 82.77 0 0% 0% 0% 0 2 0 1 0 0 R Y58100 $ 184.74 $ 146.95 0 0% 0% 0% 0 2 0 1 0 0 R Y58110 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 58120 $ 437.25 $ 368.28 10 10% 80% 10% 0 2 0 1 0 0 R Y58140 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 124
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
58145 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 58146 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 58150 $ 1690.24 $ 1690.24 90 12% 74% 14% 0 2 0 2 1 0 R Y58152 $ 2093.30 $ 2093.30 90 12% 74% 14% 0 2 0 2 1 0 R Y58180 $ 1611.06 $ 1611.06 90 12% 74% 14% 0 2 0 2 1 0 R Y58200 $ 2265.44 $ 2265.44 90 12% 74% 14% 0 2 0 2 1 0 R Y58210 $ 3043.39 $ 3043.39 90 12% 74% 14% 0 2 2 2 1 0 R Y58240 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 58260 $ 1385.54 $ 1385.54 90 12% 74% 14% 0 2 0 2 1 0 R Y58262 $ 1545.08 $ 1545.08 90 12% 74% 14% 0 2 0 2 2 0 R Y58263 $ 1656.65 $ 1656.65 90 12% 74% 14% 0 2 0 2 2 0 R Y58267 $ 1765.21 $ 1765.21 90 12% 74% 14% 0 2 0 2 1 0 R Y58270 $ 1476.11 $ 1476.11 90 12% 74% 14% 0 2 0 2 1 0 R Y58275 $ 1651.85 $ 1651.85 90 12% 74% 14% 0 2 0 2 1 0 R Y58280 $ 1759.81 $ 1759.81 90 12% 74% 14% 0 2 0 2 1 0 R Y58285 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 58290 $ 1921.76 $ 1921.76 90 12% 74% 14% 0 2 0 2 1 0 R Y58291 $ 2080.11 $ 2080.11 90 12% 74% 14% 0 2 0 2 2 0 R Y58292 $ 2194.07 $ 2194.07 90 12% 74% 14% 0 2 0 2 2 0 R Y58293 $ 2281.04 $ 2281.04 90 12% 74% 14% 0 2 0 2 1 0 R Y58294 $ 2033.92 $ 2033.92 90 12% 74% 14% 0 2 0 2 1 0 R Y58300 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 58301 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 58321 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 58322 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 58323 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 58340 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 58345 Not Covered Not Covered 10 10% 80% 10% 0 2 1 2 2 0 X 58346 Not Covered Not Covered 90 12% 74% 14% 0 2 0 1 0 0 X 58350 Not Covered Not Covered 10 10% 80% 10% 0 2 1 1 0 0 X 58353 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 2 0 X 58356 Not Covered Not Covered 10 10% 80% 10% 0 2 0 2 2 0 X 58400 $ 738.95 $ 738.95 90 12% 74% 14% 0 2 0 2 1 0 R Y58410 $ 1345.95 $ 1345.95 90 12% 74% 14% 0 2 0 2 1 0 R Y58520 $ 1345.95 $ 1345.95 90 12% 74% 14% 0 2 0 2 1 0 R Y58540 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 0 0 X 58541 $ 1203.20 $ 1203.20 90 12% 74% 14% 0 3 0 2 2 0 49320 R Y58542 $ 1372.34 $ 1372.34 90 12% 74% 14% 0 2 0 2 2 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 125
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
58543 $ 1389.14 $ 1389.14 90 12% 74% 14% 0 2 0 2 2 0 R Y58544 $ 1510.90 $ 1510.90 90 12% 74% 14% 0 2 0 2 2 0 R Y58545 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 2 0 X 58546 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 2 0 X 58548 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 2 0 X 58550 $ 1479.11 $ 1479.11 90 12% 74% 14% 0 3 0 2 2 0 49320 R Y58552 $ 1651.25 $ 1651.25 90 12% 74% 14% 0 2 0 2 2 0 R Y58553 $ 1893.57 $ 1893.57 90 12% 74% 14% 0 2 0 2 2 0 R Y58554 $ 2209.66 $ 2209.66 90 12% 74% 14% 0 2 0 2 2 0 R Y58555 $ 520.03 $ 318.49 0 0% 0% 0% 0 2 0 0 2 0 R Y58558 $ 677.17 $ 446.25 0 0% 0% 0% 0 3 0 1 2 0 58555 R Y58559 $ 570.41 $ 570.41 0 0% 0% 0% 0 3 0 1 2 0 58555 R Y58560 Not Covered Not Covered 0 0% 0% 0% 0 3 0 2 2 0 58555 X 58561 Not Covered Not Covered 0 0% 0% 0% 0 3 0 0 2 0 58555 X 58562 $ 700.57 $ 485.24 0 0% 0% 0% 0 3 0 1 2 0 58555 R Y58563 Not Covered Not Covered 0 0% 0% 0% 0 3 0 0 2 0 58555 X 58565 Not Covered Not Covered 90 12% 74% 14% 0 3 2 1 2 0 58555 X 58570 $ 1305.16 $ 1305.16 90 12% 74% 14% 0 2 0 2 2 0 R Y58571 $ 1490.50 $ 1490.50 90 12% 74% 14% 0 2 0 2 2 0 R Y58572 $ 1700.43 $ 1700.43 90 12% 74% 14% 0 2 0 2 2 0 R Y58573 $ 2013.53 $ 2013.53 90 12% 74% 14% 0 2 0 2 2 0 R Y58578 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 58579 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 58600 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58605 Not Covered Not Covered 90 12% 74% 14% 0 0 2 2 0 0 X 58611 Not Covered Not Covered 0 0% 0% 0% 0 0 0 2 0 0 X 58615 Not Covered Not Covered 10 10% 80% 10% 0 2 0 2 0 0 X 58660 $ 1125.82 $ 1125.82 90 9% 84% 7% 0 3 0 2 2 0 49320 R Y58661 Not Covered Not Covered 10 10% 80% 10% 0 3 1 2 2 0 49320 X 58662 Not Covered Not Covered 90 9% 84% 7% 0 3 0 2 2 0 49320 X 58670 Not Covered Not Covered 90 10% 80% 10% 0 3 0 1 2 0 49320 X 58671 Not Covered Not Covered 90 10% 80% 10% 0 3 0 1 2 0 49320 X 58672 Not Covered Not Covered 90 10% 80% 10% 0 3 1 2 0 0 49320 X 58673 Not Covered Not Covered 90 10% 80% 10% 0 3 1 2 0 0 49320 X 58679 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 58700 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58720 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58740 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 126
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
58750 Not Covered Not Covered 90 12% 74% 14% 0 2 1 2 1 0 X 58752 Not Covered Not Covered 90 12% 74% 14% 0 2 1 2 0 0 X 58760 Not Covered Not Covered 90 12% 74% 14% 0 2 1 2 1 0 X 58770 $ 1426.32 $ 1426.32 90 12% 74% 14% 0 2 1 2 0 0 R Y58800 Not Covered Not Covered 90 12% 74% 14% 0 2 2 1 0 0 X 58805 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58820 Not Covered Not Covered 90 12% 74% 14% 0 2 1 2 0 0 X 58822 Not Covered Not Covered 90 12% 74% 14% 0 2 1 2 1 0 X 58825 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 58900 $ 694.57 $ 694.57 90 12% 74% 14% 0 2 2 2 1 0 R Y58920 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58925 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58940 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58943 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 58950 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58951 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58952 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58953 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58954 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58956 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58957 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58958 Not Covered Not Covered 90 12% 74% 14% 0 2 2 2 1 0 X 58960 Not Covered Not Covered 90 12% 74% 14% 0 2 0 2 1 0 X 58970 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 58974 Not Covered Not Covered 0 0% 0% 0% 0 2 0 2 1 0 X 58976 Not Covered Not Covered 0 0% 0% 0% 0 2 0 2 1 0 X 58999 By Report By Report 90 0% 0% 0% 0 2 0 1 1 1 N 59000 $ 213.53 $ 133.16 0 0% 0% 0% 0 2 0 1 0 0 R Y59001 $ 295.70 $ 295.70 0 0% 0% 0% 0 2 0 1 0 0 R Y59012 $ 332.89 $ 332.89 0 0% 0% 0% 0 2 0 0 0 0 R Y59015 $ 258.51 $ 217.73 0 0% 0% 0% 0 2 0 0 0 0 R Y59020 $ 121.76 $ 121.76 0 0% 0% 0% 1 0 0 0 0 0 R Y59020-26 $ 61.18 $ 61.18 0 0% 0% 0% 1 0 0 0 0 0 R Y59020-TC $ 60.58 $ 60.58 0 0% 0% 0% 1 0 0 0 0 0 R Y59025 $ 81.57 $ 81.57 0 0% 0% 0% 1 0 0 0 0 0 R Y59025-26 $ 48.58 $ 48.58 0 0% 0% 0% 1 0 0 0 0 0 R Y59025-TC $ 32.39 $ 32.39 0 0% 0% 0% 1 0 0 0 0 0 R Y59030 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 127
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
59050 $ 82.77 $ 82.77 0 0% 0% 0% 0 0 0 0 0 0 R Y59051 $ 68.38 $ 68.38 0 0% 0% 0% 0 0 0 0 0 0 R Y59070 $ 685.57 $ 509.83 0 0% 0% 0% 0 2 0 2 0 0 R Y59072 $ 804.33 $ 804.33 0 0% 0% 0% 0 2 0 1 0 0 R Y59074 $ 654.98 $ 510.43 0 0% 0% 0% 0 2 0 2 0 0 R Y59076 $ 804.33 $ 804.33 0 0% 0% 0% 0 2 0 2 0 0 R Y59100 Not Covered Not Covered 90 17% 60% 23% 0 2 0 2 1 0 X 59120 $ 1306.36 $ 1306.36 90 17% 60% 23% 0 2 0 2 1 0 R Y59121 $ 1306.96 $ 1306.96 90 17% 60% 23% 0 2 0 2 1 0 R Y59130 $ 1449.12 $ 1449.12 90 17% 60% 23% 0 2 0 0 0 0 R Y59135 $ 1431.12 $ 1431.12 90 17% 60% 23% 0 2 0 0 0 0 R Y59136 $ 1443.72 $ 1443.72 90 17% 60% 23% 0 2 0 2 0 0 R Y59140 $ 663.38 $ 663.38 90 17% 60% 23% 0 2 0 2 0 0 R Y59150 $ 1266.18 $ 1266.18 90 17% 60% 23% 0 2 0 2 0 0 R Y59151 $ 1228.99 $ 1228.99 90 17% 60% 23% 0 2 0 2 0 0 R Y59160 $ 339.49 $ 285.50 10 10% 80% 10% 0 2 0 0 0 0 R Y59200 $ 121.76 $ 73.78 0 0% 0% 0% 0 2 0 1 0 0 R Y59300 $ 324.49 $ 245.32 0 0% 0% 0% 0 2 0 0 0 0 R Y59320 $ 251.32 $ 251.32 0 0% 0% 0% 0 2 0 0 0 0 R Y59325 $ 398.87 $ 398.87 0 0% 0% 0% 0 2 0 0 0 0 R Y59350 $ 460.05 $ 460.05 0 0% 0% 0% 0 2 0 2 0 0 R Y59400 $ 3463.85 $ 3463.85 45 0% 0% 0% 0 2 0 1 0 0 R Y59409 $ 1337.55 $ 1337.55 0 0% 0% 0% 0 2 0 0 0 0 R Y59410 $ 1708.83 $ 1708.83 45 0% 0% 0% 0 2 0 1 0 0 R Y59412 $ 170.34 $ 170.34 0 0% 0% 0% 0 0 0 0 0 0 R Y59414 $ 149.95 $ 149.95 45 0% 0% 0% 0 2 0 0 0 0 R Y59425 $ 759.95 $ 586.00 0 0% 0% 0% 0 0 0 0 0 0 R Y59426 $ 1365.14 $ 1034.06 0 0% 0% 0% 0 0 0 0 0 0 R Y59430 $ 310.70 $ 229.12 0 0% 0% 0% 0 2 0 1 0 0 R Y59510 $ 3463.85 $ 3463.85 45 0% 0% 0% 0 2 0 1 0 0 R Y59514 $ 1337.55 $ 1337.55 0 0% 0% 0% 0 2 0 2 1 0 R Y59515 $ 1708.83 $ 1708.83 45 0% 0% 0% 0 2 0 1 0 0 R Y59525 $ 792.94 $ 792.94 0 0% 0% 0% 0 0 0 2 1 0 R Y59610 $ 3617.99 $ 3617.99 45 0% 0% 0% 0 2 0 0 0 0 R Y59612 $ 1495.90 $ 1495.90 45 0% 0% 0% 0 2 0 0 0 0 R Y59614 $ 1864.18 $ 1864.18 45 0% 0% 0% 0 2 0 0 0 0 R Y59618 $ 3867.51 $ 3867.51 45 0% 0% 0% 0 2 0 0 0 0 R Y59620 $ 1549.28 $ 1549.28 45 0% 0% 0% 0 2 0 2 0 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 128
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
59622 $ 2120.29 $ 2120.29 45 0% 0% 0% 0 2 0 0 0 0 R Y59812 $ 528.42 $ 489.44 90 17% 60% 23% 0 2 0 1 0 0 R Y59820 $ 634.59 $ 593.20 90 17% 60% 23% 0 2 0 1 0 0 R Y59821 $ 636.99 $ 592.00 90 17% 60% 23% 0 2 0 0 0 0 R Y59830 $ 720.96 $ 720.96 90 17% 60% 23% 0 2 0 0 0 0 R Y59840 $ 361.68 $ 346.08 10 10% 80% 10% 0 2 0 0 0 0 R Y59841 $ 632.19 $ 593.80 10 10% 80% 10% 0 2 0 0 0 0 R Y59850 $ 600.40 $ 600.40 90 17% 60% 23% 0 2 0 0 0 0 R Y59851 $ 658.58 $ 658.58 90 17% 60% 23% 0 2 0 0 0 0 R Y59852 $ 870.91 $ 870.91 90 17% 60% 23% 0 2 0 0 0 0 R Y59855 $ 683.77 $ 683.77 90 17% 60% 23% 0 2 0 0 0 0 R Y59856 $ 801.33 $ 801.33 90 17% 60% 23% 0 2 0 0 0 0 R Y59857 $ 890.70 $ 890.70 90 17% 60% 23% 0 2 0 0 0 0 R Y59866 Not Covered Not Covered 0 0% 0% 0% 0 2 0 2 1 0 X 59870 Not Covered Not Covered 90 17% 60% 23% 0 2 0 2 0 0 X 59871 $ 220.73 $ 220.73 0 0% 0% 0% 0 2 0 0 0 0 R Y59897 By Report By Report 0 0% 0% 0% 0 2 0 1 0 0 N 59898 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 59899 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 60000 Not Covered Not Covered 10 10% 80% 10% 0 2 0 0 0 0 X 60100 $ 194.94 $ 135.55 0 0% 0% 0% 0 2 0 1 0 0 R Y60200 $ 1112.03 $ 1112.03 90 9% 82% 9% 0 2 0 2 1 0 R Y60210 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60212 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60220 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60225 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60240 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60252 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60254 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60260 Not Covered Not Covered 90 9% 82% 9% 0 2 1 2 1 0 X 60270 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60271 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60280 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60281 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60300 $ 208.13 $ 85.17 0 0% 0% 0% 0 2 0 1 0 0 R 60500 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60502 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60505 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 129
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
60512 Not Covered Not Covered 0 0% 0% 0% 0 0 0 2 1 0 X 60520 $ 1733.42 $ 1733.42 90 9% 82% 9% 0 2 0 2 1 0 R Y60521 $ 1859.38 $ 1859.38 90 9% 82% 9% 0 2 0 2 1 0 R Y60522 $ 2249.85 $ 2249.85 90 9% 82% 9% 0 2 0 2 1 0 R Y60540 $ 1765.21 $ 1765.21 90 9% 82% 9% 0 2 1 2 1 0 R Y60545 $ 2025.52 $ 2025.52 90 9% 82% 9% 0 2 1 2 1 0 R Y60600 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60605 Not Covered Not Covered 90 9% 82% 9% 0 2 0 2 1 0 X 60650 $ 1978.14 $ 1978.14 90 9% 84% 7% 0 2 1 2 1 0 R Y60659 By Report By Report 90 0% 0% 0% 0 2 1 2 0 0 N 60699 By Report By Report 90 0% 0% 0% 0 2 0 2 1 1 N 61000 Not Covered Not Covered 0 0% 0% 0% 0 2 2 1 0 0 X 61001 Not Covered Not Covered 0 0% 0% 0% 0 2 2 1 0 0 X 61020 $ 172.14 $ 172.14 0 0% 0% 0% 0 2 0 1 0 0 R 61026 $ 175.14 $ 175.14 0 0% 0% 0% 0 2 0 1 0 0 R 61050 $ 145.75 $ 145.75 0 0% 0% 0% 0 2 0 0 0 0 R 61055 $ 203.93 $ 203.93 0 0% 0% 0% 0 0 0 1 0 0 R 61070 $ 97.17 $ 97.17 0 0% 0% 0% 0 2 0 1 0 0 R 61105 $ 771.94 $ 771.94 90 11% 76% 13% 0 2 0 0 0 0 R 61107 $ 508.03 $ 508.03 0 0% 0% 0% 0 0 0 1 0 0 R 61108 $ 1503.70 $ 1503.70 90 11% 76% 13% 0 2 0 1 0 0 R 61120 $ 1233.19 $ 1233.19 90 11% 76% 13% 0 2 0 0 0 0 R 61140 $ 2067.51 $ 2067.51 90 11% 76% 13% 0 2 0 2 0 0 R 61150 $ 2216.86 $ 2216.86 90 11% 76% 13% 0 2 0 1 1 0 R 61151 $ 1631.46 $ 1631.46 90 11% 76% 13% 0 2 0 1 0 0 R 61154 $ 2084.31 $ 2084.31 90 11% 76% 13% 0 2 1 2 1 0 R 61156 $ 2036.92 $ 2036.92 90 11% 76% 13% 0 2 0 2 1 0 R 61210 $ 596.20 $ 596.20 0 0% 0% 0% 0 2 0 1 0 0 R 61215 $ 838.52 $ 838.52 90 11% 76% 13% 0 2 0 1 1 0 R 61250 $ 1427.52 $ 1427.52 90 11% 76% 13% 0 2 1 2 1 0 R 61253 $ 1498.30 $ 1498.30 90 11% 76% 13% 0 2 2 2 0 0 R 61304 $ 2675.71 $ 2675.71 90 11% 76% 13% 0 2 0 2 1 0 R 61305 $ 3280.31 $ 3280.31 90 11% 76% 13% 0 2 0 2 1 0 R 61312 $ 3384.07 $ 3384.07 90 11% 76% 13% 0 2 0 2 1 0 R 61313 $ 3235.32 $ 3235.32 90 11% 76% 13% 0 2 0 2 1 0 R 61314 $ 2976.81 $ 2976.81 90 11% 76% 13% 0 2 0 2 1 0 R 61315 $ 3369.08 $ 3369.08 90 11% 76% 13% 0 2 0 2 1 0 R 61316 $ 142.15 $ 142.15 0 0% 0% 0% 0 0 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 130
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
61320 $ 3090.17 $ 3090.17 90 11% 76% 13% 0 2 0 2 1 0 R 61321 $ 3474.64 $ 3474.64 90 11% 76% 13% 0 2 0 2 1 0 R 61322 $ 3867.51 $ 3867.51 90 11% 76% 13% 0 2 0 2 1 0 R 61323 $ 3887.90 $ 3887.90 90 11% 76% 13% 0 2 0 1 1 0 R 61330 $ 2675.11 $ 2675.11 90 11% 76% 13% 0 2 1 2 1 0 R 61332 $ 3097.37 $ 3097.37 90 11% 76% 13% 0 2 1 2 1 0 R 61333 $ 3165.14 $ 3165.14 90 11% 76% 13% 0 2 1 2 1 0 R 61340 $ 2366.21 $ 2366.21 90 11% 76% 13% 0 2 1 2 1 0 R 61343 $ 3576.01 $ 3576.01 90 11% 76% 13% 0 2 0 2 1 0 R 61345 $ 3328.89 $ 3328.89 90 11% 76% 13% 0 2 0 2 1 0 R 61450 $ 3136.35 $ 3136.35 90 11% 76% 13% 0 2 0 2 1 0 R 61458 $ 3269.51 $ 3269.51 90 11% 76% 13% 0 2 0 2 1 0 R 61460 $ 3432.06 $ 3432.06 90 11% 76% 13% 0 2 0 2 2 0 R 61480 $ 3162.75 $ 3162.75 90 11% 76% 13% 0 2 0 2 1 0 R 61500 $ 2182.67 $ 2182.67 90 11% 76% 13% 0 2 0 2 1 0 R Y61501 $ 1920.56 $ 1920.56 90 11% 76% 13% 0 2 0 2 1 0 R 61510 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61512 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61514 $ 3108.76 $ 3108.76 90 11% 76% 13% 0 2 0 2 1 0 R 61516 $ 3036.19 $ 3036.19 90 11% 76% 13% 0 2 0 2 1 0 R Y61517 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X 61518 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61519 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61520 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 2 0 X 61521 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61522 $ 3565.81 $ 3565.81 90 11% 76% 13% 0 2 0 2 1 0 R Y61524 $ 3396.07 $ 3396.07 90 11% 76% 13% 0 2 0 2 1 0 R Y61526 Not Covered Not Covered 90 11% 76% 13% 0 2 0 1 2 0 X 61530 Not Covered Not Covered 90 11% 76% 13% 0 2 0 1 2 0 X 61531 $ 2007.53 $ 2007.53 90 11% 76% 13% 0 2 0 2 2 0 R 61533 $ 2481.97 $ 2481.97 90 11% 76% 13% 0 2 0 2 1 0 R 61534 $ 2690.70 $ 2690.70 90 11% 76% 13% 0 2 0 2 1 0 R 61535 $ 1645.25 $ 1645.25 90 11% 76% 13% 0 2 0 2 1 0 R 61536 $ 4198.60 $ 4198.60 90 11% 76% 13% 0 2 0 2 1 0 R 61537 $ 3989.27 $ 3989.27 90 11% 76% 13% 0 2 0 2 1 0 R Y61538 $ 4340.15 $ 4340.15 90 11% 76% 13% 0 2 0 2 1 0 R Y61539 $ 3846.52 $ 3846.52 90 11% 76% 13% 0 2 0 2 1 0 R Y61540 $ 3559.81 $ 3559.81 90 11% 76% 13% 0 2 0 2 1 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 131
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
61541 $ 3504.03 $ 3504.03 90 11% 76% 13% 0 2 0 2 1 0 R Y61543 $ 3541.82 $ 3541.82 90 11% 76% 13% 0 2 0 2 1 0 R Y61544 $ 3101.57 $ 3101.57 90 11% 76% 13% 0 2 0 2 0 0 R Y61545 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61546 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61548 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 2 0 X 61550 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61552 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61556 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 0 0 X 61557 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 0 0 X 61558 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 0 0 X 61559 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61563 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61564 Not Covered Not Covered 90 11% 76% 13% 0 2 1 2 1 0 X 61566 $ 3665.38 $ 3665.38 90 11% 76% 13% 0 2 0 2 1 0 R Y61567 $ 3772.14 $ 3772.14 90 11% 76% 13% 0 2 0 2 1 0 R Y61570 $ 3049.98 $ 3049.98 90 11% 76% 13% 0 2 0 2 1 0 R 61571 $ 3244.92 $ 3244.92 90 11% 76% 13% 0 2 0 2 1 0 R 61575 $ 4079.24 $ 4079.24 90 11% 76% 13% 0 2 0 2 1 0 R Y61576 $ 5825.86 $ 5825.86 90 11% 76% 13% 0 2 0 2 1 0 R Y61580 $ 4208.80 $ 4208.80 90 11% 76% 13% 0 2 1 1 1 2 R Y61581 $ 4521.89 $ 4521.89 90 11% 76% 13% 0 2 1 1 2 2 R Y61582 $ 5001.73 $ 5001.73 90 11% 76% 13% 0 2 0 2 1 2 R Y61583 $ 4758.21 $ 4758.21 90 11% 76% 13% 0 2 0 2 1 2 R Y61584 $ 4694.03 $ 4694.03 90 11% 76% 13% 0 2 1 2 1 2 R Y61585 $ 5283.04 $ 5283.04 90 11% 76% 13% 0 2 1 2 1 2 R Y61586 $ 4025.86 $ 4025.86 90 11% 76% 13% 0 2 0 2 1 2 R Y61590 $ 5134.29 $ 5134.29 90 11% 76% 13% 0 2 1 2 1 2 R Y61591 $ 5214.06 $ 5214.06 90 11% 76% 13% 0 2 1 2 1 2 R Y61592 $ 5230.26 $ 5230.26 90 11% 76% 13% 0 2 1 2 1 2 R Y61595 $ 3970.68 $ 3970.68 90 11% 76% 13% 0 2 1 1 1 2 R Y61596 $ 4169.81 $ 4169.81 90 11% 76% 13% 0 2 1 2 1 2 R Y61597 $ 4693.44 $ 4693.44 90 11% 76% 13% 0 2 1 2 1 2 R Y61598 $ 4679.04 $ 4679.04 90 11% 76% 13% 0 2 0 2 1 2 R Y61600 $ 3594.60 $ 3594.60 90 11% 76% 13% 0 2 0 2 1 2 R Y61601 $ 3979.07 $ 3979.07 90 11% 76% 13% 0 2 0 2 1 2 R Y61605 $ 3704.96 $ 3704.96 90 11% 76% 13% 0 2 0 2 1 2 R Y61606 $ 4954.95 $ 4954.95 90 11% 76% 13% 0 2 0 2 1 2 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 132
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
61607 $ 4479.91 $ 4479.91 90 11% 76% 13% 0 2 0 2 1 2 R Y61608 $ 5340.02 $ 5340.02 90 11% 76% 13% 0 2 0 2 1 2 R Y61610 $ 2992.40 $ 2992.40 0 0% 0% 0% 0 0 0 2 1 2 R Y61611 $ 642.99 $ 642.99 0 0% 0% 0% 0 0 0 2 1 2 R Y61612 $ 2411.20 $ 2411.20 0 0% 0% 0% 0 0 0 2 1 2 R Y61613 $ 5382.01 $ 5382.01 90 11% 76% 13% 0 2 1 2 1 2 R Y61615 $ 4418.73 $ 4418.73 90 11% 76% 13% 0 2 0 2 1 2 R Y61616 $ 5473.18 $ 5473.18 90 11% 76% 13% 0 2 0 2 1 2 R Y61618 $ 2134.09 $ 2134.09 90 11% 76% 13% 0 2 0 2 1 2 R 61619 $ 2393.80 $ 2393.80 90 11% 76% 13% 0 2 0 2 1 2 R 61623 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 61624 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 61626 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 61630 Not Covered Not Covered 0 0% 0% 0% 0 2 0 2 1 0 X 61635 Not Covered Not Covered 0 0% 0% 0% 0 2 0 2 1 0 X 61640 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 61641 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 61642 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 61680 $ 3665.38 $ 3665.38 90 11% 76% 13% 0 2 0 2 1 0 R Y61682 $ 6756.15 $ 6756.15 90 11% 76% 13% 0 2 0 2 1 0 R Y61684 $ 4630.46 $ 4630.46 90 11% 76% 13% 0 2 0 2 1 0 R Y61686 $ 7309.16 $ 7309.16 90 11% 76% 13% 0 2 0 2 1 0 R Y61690 $ 3567.01 $ 3567.01 90 11% 76% 13% 0 2 0 2 1 0 R Y61692 $ 5948.82 $ 5948.82 90 11% 76% 13% 0 2 0 2 1 0 R Y61697 $ 6847.92 $ 6847.92 90 11% 76% 13% 0 2 0 2 1 0 R Y61698 $ 7527.49 $ 7527.49 90 11% 76% 13% 0 2 0 2 1 0 R Y61700 $ 5534.95 $ 5534.95 90 11% 76% 13% 0 2 0 2 1 0 R Y61702 $ 6545.02 $ 6545.02 90 11% 76% 13% 0 2 0 2 1 0 R Y61703 $ 2225.26 $ 2225.26 90 11% 76% 13% 0 2 0 2 1 0 R Y61705 $ 4237.59 $ 4237.59 90 11% 76% 13% 0 2 0 2 1 0 R Y61708 $ 4145.22 $ 4145.22 90 11% 76% 13% 0 2 0 2 0 0 R Y61710 $ 3504.63 $ 3504.63 90 11% 76% 13% 0 2 0 0 0 0 R Y61711 $ 4214.19 $ 4214.19 90 11% 76% 13% 0 2 0 2 1 0 R Y61720 $ 2078.91 $ 2078.91 90 11% 76% 13% 0 2 0 1 0 0 R Y61735 $ 2599.53 $ 2599.53 90 11% 76% 13% 0 2 0 1 1 0 R Y61750 $ 2289.44 $ 2289.44 90 11% 76% 13% 0 2 0 1 1 0 R Y61751 $ 2257.65 $ 2257.65 90 11% 76% 13% 0 2 0 1 1 0 R Y61760 $ 2582.14 $ 2582.14 90 11% 76% 13% 0 2 0 1 2 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 133
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
61770 Not Covered Not Covered 90 11% 76% 13% 0 2 0 1 1 0 X 61781 $ 381.47 $ 381.47 0 0% 0% 0% 0 0 0 0 0 0 R61782 $ 296.90 $ 296.90 0 0% 0% 0% 0 0 0 0 0 0 R61783 $ 379.67 $ 379.67 0 0% 0% 0% 0 0 0 0 0 0 R61790 Not Covered Not Covered 90 11% 76% 13% 0 2 1 1 0 0 X 61791 Not Covered Not Covered 90 11% 76% 13% 0 2 1 0 0 0 X 61796 $ 1661.45 $ 1661.45 90 11% 76% 13% 0 0 0 2 0 0 R Y61797 $ 356.88 $ 356.88 0 0% 0% 0% 0 0 0 2 0 0 R Y61798 $ 2258.85 $ 2258.85 90 11% 76% 13% 0 0 0 2 0 0 R Y61799 $ 491.84 $ 491.84 0 0% 0% 0% 0 0 0 2 0 0 R Y61800 $ 251.92 $ 251.92 0 0% 0% 0% 0 0 0 2 0 0 R Y61850 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 0 0 X 61860 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 0 0 X 61863 Not Covered Not Covered 90 11% 76% 13% 0 2 1 2 1 0 X 61864 Not Covered Not Covered 0 0% 0% 0% 0 0 0 2 1 0 X 61867 Not Covered Not Covered 90 11% 76% 13% 0 2 1 2 1 0 X 61868 Not Covered Not Covered 0 0% 0% 0% 0 0 0 2 1 0 X 61870 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 61880 Not Covered Not Covered 90 11% 76% 13% 0 2 1 2 1 0 X 61885 $ 859.51 $ 859.51 90 11% 76% 13% 0 2 1 0 0 0 R Y-UR61886 $ 1404.73 $ 1404.73 90 11% 76% 13% 0 2 0 0 0 0 R Y-UR61888 $ 648.98 $ 648.98 10 10% 80% 10% 0 2 1 1 0 0 R Y-UR62000 $ 1690.24 $ 1690.24 90 11% 76% 13% 0 2 0 1 0 0 R Y62005 $ 2080.11 $ 2080.11 90 11% 76% 13% 0 2 0 2 1 0 R Y62010 $ 2505.36 $ 2505.36 90 11% 76% 13% 0 2 0 2 1 0 R Y62100 $ 2626.52 $ 2626.52 90 11% 76% 13% 0 2 0 2 1 0 R Y62115 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 62117 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X 62120 $ 2847.85 $ 2847.85 90 11% 76% 13% 0 2 0 2 1 0 R Y62121 $ 2694.90 $ 2694.90 90 11% 76% 13% 0 2 0 2 1 0 R Y62140 $ 1702.83 $ 1702.83 90 11% 76% 13% 0 2 0 2 1 0 R 62141 $ 1877.37 $ 1877.37 90 11% 76% 13% 0 2 0 2 1 0 R 62142 $ 1457.51 $ 1457.51 90 11% 76% 13% 0 2 0 2 0 0 R 62143 $ 1711.23 $ 1711.23 90 11% 76% 13% 0 2 0 2 1 0 R 62145 $ 2309.23 $ 2309.23 90 11% 76% 13% 0 2 0 2 1 0 R 62146 $ 2002.13 $ 2002.13 90 11% 76% 13% 0 2 0 2 1 0 R 62147 $ 2380.61 $ 2380.61 90 11% 76% 13% 0 2 0 2 1 0 R 62148 $ 205.13 $ 205.13 0 0% 0% 0% 0 0 0 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 134
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
62160 $ 307.70 $ 307.70 0 0% 0% 0% 0 0 0 1 0 0 R Y62161 $ 2484.97 $ 2484.97 90 11% 76% 13% 0 2 0 2 1 0 R Y62162 $ 3085.97 $ 3085.97 90 11% 76% 13% 0 2 0 2 1 0 R Y62163 $ 2010.53 $ 2010.53 90 11% 76% 13% 0 2 0 2 1 0 R Y62164 $ 3414.66 $ 3414.66 90 11% 76% 13% 0 2 0 2 1 0 R Y62165 $ 2551.55 $ 2551.55 90 11% 76% 13% 0 2 0 0 1 0 R Y62180 $ 2616.33 $ 2616.33 90 11% 76% 13% 0 2 0 2 0 0 R Y62190 $ 1005.86 $ 1005.86 90 11% 76% 13% 0 2 0 1 1 0 R Y62192 $ 1606.26 $ 1606.26 90 11% 76% 13% 0 2 0 2 1 0 R Y62194 $ 809.13 $ 809.13 10 10% 80% 10% 0 2 0 0 0 0 R Y62200 $ 2250.45 $ 2250.45 90 11% 76% 13% 0 2 0 2 1 0 R Y62201 $ 1976.34 $ 1976.34 90 11% 76% 13% 0 2 0 1 0 0 R Y62220 $ 1681.24 $ 1681.24 90 11% 76% 13% 0 2 0 2 1 0 R Y62223 $ 1727.42 $ 1727.42 90 11% 76% 13% 0 2 0 2 1 0 R Y62225 $ 873.31 $ 873.31 90 11% 76% 13% 0 2 0 1 0 0 R Y62230 $ 1385.54 $ 1385.54 90 11% 76% 13% 0 2 0 2 1 0 R Y62252 $ 144.55 $ 144.55 0 0% 0% 0% 1 0 0 0 0 0 R Y62252-26 $ 74.38 $ 74.38 0 0% 0% 0% 1 0 0 0 0 0 R Y62252-TC $ 70.18 $ 70.18 0 0% 0% 0% 1 0 0 0 0 0 R Y62256 $ 994.47 $ 994.47 90 11% 76% 13% 0 2 0 2 0 0 R Y62258 $ 1839.59 $ 1839.59 90 11% 76% 13% 0 2 0 2 1 0 R Y62263 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 62264 $ 730.56 $ 407.86 10 10% 80% 10% 0 2 0 1 0 0 R Y62267 $ 433.06 $ 275.31 0 0% 0% 0% 0 2 0 0 0 0 R 62268 $ 451.05 $ 451.05 0 0% 0% 0% 0 2 0 1 0 0 R Y62269 $ 463.05 $ 463.05 0 0% 0% 0% 0 2 0 0 0 0 R Y62270 $ 277.71 $ 132.56 0 0% 0% 0% 0 2 0 1 0 0 R 62272 $ 349.68 $ 139.75 0 0% 0% 0% 0 2 0 1 0 0 R Y62273 $ 300.50 $ 194.94 0 0% 0% 0% 0 2 0 1 0 0 R 62280 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X 62281 $ 403.07 $ 260.91 10 10% 80% 10% 0 2 0 1 0 0 R Y62282 $ 515.23 $ 250.72 10 10% 80% 10% 0 2 0 1 0 0 R Y62284 $ 319.69 $ 147.55 0 0% 0% 0% 0 2 0 1 0 0 R Y62287 $ 980.07 $ 980.07 90 11% 76% 13% 0 2 0 1 0 0 R Y-UR62290 $ 584.81 $ 296.30 0 0% 0% 0% 0 2 0 1 0 0 R Y-UR62291 $ 592.00 $ 296.90 0 0% 0% 0% 0 2 0 1 0 0 R Y-UR62292 $ 1010.06 $ 1010.06 90 11% 76% 13% 0 2 0 0 0 0 R Y-UR62294 $ 1365.74 $ 1365.74 90 11% 76% 13% 0 2 0 1 0 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 135
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
62302 $ 424.66 $ 212.93 0 0% 0% 0% 0 2 0 1 0 0 R Y62303 $ 441.45 $ 215.93 0 0% 0% 0% 0 2 0 1 0 0 R Y62304 $ 419.26 $ 209.33 0 0% 0% 0% 0 2 0 1 0 0 R Y62305 $ 458.25 $ 219.53 0 0% 0% 0% 0 2 0 1 0 0 R Y62310 $ 250.72 $ 185.94 0 0% 0% 0% 0 2 0 1 0 0 R Y-UR62311 $ 223.13 $ 158.95 0 0% 0% 0% 0 2 0 1 0 0 R Y-UR62318 $ 237.52 $ 181.14 0 0% 0% 0% 0 2 0 1 0 0 R Y-UR62319 $ 234.52 $ 174.54 0 0% 0% 0% 0 2 0 1 0 0 R Y-UR62350 $ 678.37 $ 678.37 10 10% 80% 10% 0 2 0 1 1 0 R Y-UR62351 $ 1436.52 $ 1436.52 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR62355 $ 458.85 $ 458.85 10 10% 80% 10% 0 2 0 0 0 0 R Y-UR62360 $ 515.83 $ 515.83 10 10% 80% 10% 0 2 0 0 1 0 R Y-UR62361 $ 710.76 $ 710.76 10 10% 80% 10% 0 2 0 0 1 0 R Y-UR62362 $ 651.98 $ 651.98 10 10% 80% 10% 0 2 0 0 1 0 R Y-UR62365 $ 503.23 $ 503.23 10 10% 80% 10% 0 2 0 0 0 0 R Y-UR62367 $ 70.78 $ 42.59 0 0% 0% 0% 0 0 0 1 0 0 R Y-UR62368 $ 97.77 $ 59.98 0 0% 0% 0% 0 0 0 1 0 0 R Y-UR62369 $ 213.53 $ 60.58 0 0% 0% 0% 0 0 0 1 0 0 R Y62370 $ 223.73 $ 79.77 0 0% 0% 0% 0 0 0 1 0 0 R Y63001 $ 2036.92 $ 2036.92 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63003 $ 2036.32 $ 2036.32 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63005 $ 1948.75 $ 1948.75 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63011 $ 1832.39 $ 1832.39 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63012 $ 1964.35 $ 1964.35 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63015 $ 2434.59 $ 2434.59 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63016 $ 2497.57 $ 2497.57 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63017 $ 2062.71 $ 2062.71 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63020 $ 1928.36 $ 1928.36 90 11% 76% 13% 0 2 1 2 2 0 R Y-UR63030 $ 1611.06 $ 1611.06 90 11% 76% 13% 0 2 1 2 2 0 R Y-UR63035 $ 314.90 $ 314.90 0 0% 0% 0% 0 0 1 2 2 0 R Y-UR63040 $ 2300.23 $ 2300.23 90 11% 76% 13% 0 2 1 2 2 0 R Y-UR63042 $ 2153.28 $ 2153.28 90 11% 76% 13% 0 2 1 2 2 0 R Y-UR63043 $ 1151.02 $ 1151.02 0 0% 0% 0% 0 0 1 2 2 0 R Y-UR63044 $ 1076.64 $ 1076.64 0 0% 0% 0% 0 0 1 2 2 0 R Y-UR63045 $ 2095.70 $ 2095.70 90 11% 76% 13% 0 2 2 2 2 0 R Y-UR63046 $ 1997.33 $ 1997.33 90 11% 76% 13% 0 2 2 2 2 0 R Y-UR63047 $ 1831.19 $ 1831.19 90 11% 76% 13% 0 2 2 2 2 0 R Y-UR63048 $ 347.88 $ 347.88 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 136
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
63050 $ 2464.58 $ 2464.58 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63051 $ 2829.86 $ 2829.86 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63055 $ 2670.91 $ 2670.91 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63056 $ 2450.18 $ 2450.18 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63057 $ 525.42 $ 525.42 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR63064 $ 2911.43 $ 2911.43 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63066 $ 334.09 $ 334.09 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR63075 $ 2236.65 $ 2236.65 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63076 $ 403.67 $ 403.67 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR63077 $ 2483.17 $ 2483.17 90 11% 76% 13% 0 2 0 2 2 0 R Y-UR63078 $ 319.09 $ 319.09 0 0% 0% 0% 0 0 0 2 2 0 R Y-UR63081 $ 2898.23 $ 2898.23 90 11% 76% 13% 0 2 0 2 1 2 R Y-UR63082 $ 436.65 $ 436.65 0 0% 0% 0% 0 0 0 2 1 2 R Y-UR63085 $ 3151.35 $ 3151.35 90 11% 76% 13% 0 2 0 2 2 2 R Y-UR63086 $ 312.50 $ 312.50 0 0% 0% 0% 0 0 0 2 2 2 R Y-UR63087 $ 3968.28 $ 3968.28 90 11% 76% 13% 0 2 0 2 2 2 R Y-UR63088 $ 428.86 $ 428.86 0 0% 0% 0% 0 0 0 2 2 2 R Y-UR63090 $ 3258.11 $ 3258.11 90 11% 76% 13% 0 2 0 2 2 2 R Y-UR63091 $ 295.10 $ 295.10 0 0% 0% 0% 0 0 0 2 2 2 R Y-UR63101 $ 3810.53 $ 3810.53 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63102 $ 3760.75 $ 3760.75 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63103 $ 482.84 $ 482.84 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR63170 $ 2606.73 $ 2606.73 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63172 $ 2320.03 $ 2320.03 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63173 $ 2820.86 $ 2820.86 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63180 $ 2434.59 $ 2434.59 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63182 $ 2667.91 $ 2667.91 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63185 $ 1904.37 $ 1904.37 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63190 $ 2110.10 $ 2110.10 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63191 $ 2258.85 $ 2258.85 90 11% 76% 13% 0 2 1 2 1 0 R Y-UR63194 $ 2616.33 $ 2616.33 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63195 $ 2018.33 $ 2018.33 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63196 $ 2345.22 $ 2345.22 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63197 $ 2796.87 $ 2796.87 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63198 $ 2761.48 $ 2761.48 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63199 $ 2897.03 $ 2897.03 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63200 $ 2506.56 $ 2506.56 90 11% 76% 13% 0 2 0 2 0 0 R Y-UR63250 $ 4827.79 $ 4827.79 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 137
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
63251 $ 4938.15 $ 4938.15 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63252 $ 4937.55 $ 4937.55 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63265 $ 2730.89 $ 2730.89 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63266 $ 2814.26 $ 2814.26 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63267 $ 2258.25 $ 2258.25 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63268 $ 2354.22 $ 2354.22 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63270 $ 3386.47 $ 3386.47 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63271 $ 3378.07 $ 3378.07 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63272 $ 3092.57 $ 3092.57 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63273 $ 3046.38 $ 3046.38 90 11% 76% 13% 0 2 0 2 0 0 R Y-UR63275 $ 2946.82 $ 2946.82 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63276 $ 2923.43 $ 2923.43 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63277 $ 2556.35 $ 2556.35 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63278 $ 2600.13 $ 2600.13 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63280 $ 3456.05 $ 3456.05 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63281 $ 3411.66 $ 3411.66 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63282 $ 3217.33 $ 3217.33 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63283 $ 3105.16 $ 3105.16 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63285 $ 4262.18 $ 4262.18 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63286 $ 4214.79 $ 4214.79 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63287 $ 4470.91 $ 4470.91 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63290 $ 4546.48 $ 4546.48 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63295 $ 539.22 $ 539.22 0 0% 0% 0% 0 0 2 2 2 0 R Y-UR63300 $ 3011.60 $ 3011.60 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63301 $ 3500.43 $ 3500.43 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63302 $ 3555.61 $ 3555.61 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63303 $ 3772.14 $ 3772.14 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63304 $ 3832.72 $ 3832.72 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63305 $ 4076.84 $ 4076.84 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63306 $ 3291.70 $ 3291.70 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63307 $ 3689.97 $ 3689.97 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63308 $ 526.62 $ 526.62 0 0% 0% 0% 0 0 0 2 1 0 R Y-UR63600 $ 1566.08 $ 1566.08 90 11% 76% 13% 0 2 0 0 0 0 R Y63610 $ 663.38 $ 663.38 0 0% 0% 0% 0 2 0 0 0 0 R Y63615 $ 1858.18 $ 1858.18 90 11% 76% 13% 0 2 0 1 1 0 R Y63620 $ 1823.39 $ 1823.39 90 11% 76% 13% 0 0 0 2 0 0 R Y63621 $ 409.06 $ 409.06 0 0% 0% 0% 0 0 0 2 0 0 R Y63650 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 138
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
63655 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X Y-UR63661 Not Covered Not Covered 10 10% 80% 10% 0 2 0 2 1 0 X63662 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X63663 Not Covered Not Covered 10 10% 80% 10% 0 2 0 2 1 0 X63664 Not Covered Not Covered 90 11% 76% 13% 0 2 0 2 1 0 X63685 Not Covered Not Covered 10 10% 80% 10% 0 2 0 2 1 0 X Y-UR63688 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X Y63700 $ 1970.34 $ 1970.34 90 11% 76% 13% 0 2 0 2 1 0 R Y63702 $ 2284.04 $ 2284.04 90 11% 76% 13% 0 2 0 2 1 0 R Y63704 $ 2505.36 $ 2505.36 90 11% 76% 13% 0 2 0 2 1 0 R Y63706 $ 2843.65 $ 2843.65 90 11% 76% 13% 0 2 0 2 1 0 R Y63707 $ 1524.69 $ 1524.69 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63709 $ 1823.39 $ 1823.39 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR63710 $ 1795.20 $ 1795.20 90 11% 76% 13% 0 2 0 2 1 0 R Y63740 $ 1568.48 $ 1568.48 90 11% 76% 13% 0 2 0 2 1 0 R Y63741 $ 1125.22 $ 1125.22 90 11% 76% 13% 0 2 0 2 1 0 R Y63744 $ 1119.23 $ 1119.23 90 11% 76% 13% 0 2 0 2 1 0 R Y63746 $ 994.47 $ 994.47 90 11% 76% 13% 0 2 0 0 0 0 R Y64400 $ 219.53 $ 118.76 0 0% 0% 0% 0 2 1 1 0 0 R 64402 $ 221.93 $ 129.56 0 0% 0% 0% 0 2 1 1 0 0 R 64405 $ 173.34 $ 106.16 0 0% 0% 0% 0 2 1 1 0 0 R 64408 $ 201.53 $ 147.55 0 0% 0% 0% 0 2 1 0 0 0 R 64410 $ 208.73 $ 116.96 0 0% 0% 0% 0 2 1 0 0 0 R 64412 $ 247.72 $ 122.36 0 0% 0% 0% 0 2 1 1 0 0 R 64413 $ 221.33 $ 138.55 0 0% 0% 0% 0 2 1 1 0 0 R 64415 $ 203.33 $ 109.16 0 0% 0% 0% 0 2 1 1 0 0 R 64416 $ 133.16 $ 133.16 0 0% 0% 0% 0 2 1 1 0 0 R Y64417 $ 224.33 $ 119.96 0 0% 0% 0% 0 2 1 1 0 0 R 64418 $ 255.51 $ 130.76 0 0% 0% 0% 0 2 1 1 0 0 R 64420 $ 195.53 $ 116.36 0 0% 0% 0% 0 2 0 1 0 0 R 64421 $ 259.71 $ 156.55 0 0% 0% 0% 0 2 1 1 0 0 R 64425 $ 226.12 $ 158.35 0 0% 0% 0% 0 2 1 1 0 0 R 64430 $ 242.32 $ 141.55 0 0% 0% 0% 0 2 1 1 0 0 R 64435 $ 233.32 $ 141.55 0 0% 0% 0% 0 2 1 1 0 0 R 64445 $ 233.32 $ 121.16 0 0% 0% 0% 0 2 1 1 0 0 R 64446 $ 133.76 $ 133.76 0 0% 0% 0% 0 2 1 1 0 0 R Y64447 $ 206.33 $ 111.56 0 0% 0% 0% 0 2 1 1 0 0 R Y64448 $ 119.96 $ 119.96 0 0% 0% 0% 0 2 1 1 0 0 R Y
Professional Services Fee SchedulesSurgery
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CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 139
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
64449 $ 140.95 $ 140.95 0 0% 0% 0% 0 2 1 1 0 0 R Y64450 $ 139.75 $ 78.57 0 0% 0% 0% 0 2 1 1 0 0 R 64455 $ 81.57 $ 58.78 0 0% 0% 0% 0 2 1 0 0 0 R 64479 $ 410.86 $ 227.92 0 0% 0% 0% 0 2 1 1 0 0 R Y-UR64480 $ 196.13 $ 107.96 0 0% 0% 0% 0 0 1 1 0 0 R Y-UR64483 $ 383.27 $ 194.94 0 0% 0% 0% 0 2 1 1 0 0 R Y-UR64484 $ 151.75 $ 89.37 0 0% 0% 0% 0 0 1 1 0 0 R Y-UR64486 $ 216.53 $ 107.36 0 0% 0% 0% 0 2 1 1 0 0 R Y64487 $ 265.11 $ 123.56 0 0% 0% 0% 0 2 1 1 0 0 R Y64488 $ 266.31 $ 134.96 0 0% 0% 0% 0 2 2 1 0 0 R Y64489 $ 371.88 $ 151.15 0 0% 0% 0% 0 2 2 1 0 0 R Y64490 $ 331.69 $ 184.14 0 0% 0% 0% 0 2 1 2 0 0 R Y-UR64491 $ 163.15 $ 103.17 0 0% 0% 0% 0 0 1 2 0 0 R Y-UR64492 $ 163.75 $ 104.97 0 0% 0% 0% 0 0 1 2 0 0 R Y-UR64493 $ 301.10 $ 157.15 0 0% 0% 0% 0 2 1 2 0 0 R Y-UR64494 $ 150.55 $ 88.77 0 0% 0% 0% 0 0 1 2 0 0 R Y-UR64495 $ 151.15 $ 90.57 0 0% 0% 0% 0 0 1 2 0 0 R Y-UR64505 $ 179.94 $ 148.75 0 0% 0% 0% 0 2 1 1 0 0 R Y64508 $ 101.37 $ 121.16 0 0% 0% 0% 0 2 1 0 0 0 R Y64510 $ 222.53 $ 127.16 0 0% 0% 0% 0 2 1 1 0 0 R Y64517 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 64520 $ 326.89 $ 139.75 0 0% 0% 0% 0 2 1 1 0 0 R Y64530 $ 334.09 $ 158.95 0 0% 0% 0% 0 2 0 1 0 0 R Y64550 $ 27.59 $ 15.00 0 0% 0% 0% 0 0 0 1 0 0 R 64553 $ 372.48 $ 278.31 10 10% 80% 10% 0 2 0 0 0 0 R Y-UR64555 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 0 0 X64561 $ 1432.92 $ 514.03 10 10% 80% 10% 0 2 1 1 0 0 R Y64565 $ 329.29 $ 228.52 10 10% 80% 10% 0 2 0 1 0 0 R Y64566 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X64568 $ 1094.04 $ 1094.04 90 11% 76% 13% 0 2 1 0 0 0 R Y-UR64569 $ 1299.17 $ 1299.17 90 11% 76% 13% 0 2 1 0 1 1 R Y-UR64570 $ 1108.43 $ 1108.43 90 11% 76% 13% 0 2 1 0 1 1 R Y-UR64575 Not Covered Not Covered 90 11% 76% 13% 0 2 0 1 0 0 X64580 $ 503.23 $ 503.23 90 11% 76% 13% 0 2 0 2 0 0 R Y64581 $ 1122.83 $ 1122.83 90 11% 76% 13% 0 2 0 1 0 0 R Y64585 $ 427.06 $ 246.52 10 10% 80% 10% 0 2 0 1 0 0 R Y64590 Not Covered Not Covered 10 10% 80% 10% 0 2 0 1 1 0 X64595 $ 429.46 $ 217.13 10 10% 80% 10% 0 2 0 1 0 0 R Y
Professional Services Fee SchedulesSurgery
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CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 140
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
64600 $ 659.78 $ 368.28 10 10% 80% 10% 0 2 2 1 0 0 R Y64605 $ 1007.66 $ 595.60 10 10% 80% 10% 0 2 1 0 0 0 R Y64610 $ 1219.39 $ 793.54 10 10% 80% 10% 0 2 1 1 0 0 R Y64611 $ 195.53 $ 169.74 10 10% 80% 10% 0 2 2 0 0 0 R Y64612 $ 222.53 $ 198.53 10 10% 80% 10% 0 2 1 1 0 0 R Y64615 $ 238.12 $ 202.73 10 10% 80% 10% 0 2 2 1 0 0 R Y64616 $ 204.53 $ 175.74 10 10% 80% 10% 0 2 1 1 0 0 R Y64617 $ 328.09 $ 194.34 10 10% 80% 10% 0 2 1 1 0 0 R Y64620 $ 355.08 $ 297.50 10 10% 80% 10% 0 2 0 1 0 0 R Y64630 $ 397.67 $ 328.09 10 10% 80% 10% 0 2 0 0 0 0 R Y64632 $ 148.15 $ 118.76 10 10% 80% 10% 0 2 1 0 0 0 R Y64633 $ 729.36 $ 392.27 10 10% 80% 10% 0 2 1 1 0 0 R Y-UR64634 $ 328.09 $ 116.96 0 0% 0% 0% 0 0 1 1 0 0 R Y-UR64635 $ 723.36 $ 386.87 10 10% 80% 10% 0 2 1 1 0 0 R Y-UR64636 $ 300.50 $ 103.17 0 0% 0% 0% 0 0 1 1 0 0 R Y-UR64640 $ 233.32 $ 161.95 10 10% 80% 10% 0 2 1 1 0 0 R Y64642 $ 238.12 $ 180.54 0 0% 0% 0% 0 2 0 1 0 0 R Y64643 $ 155.95 $ 121.16 0 0% 0% 0% 0 0 0 1 0 0 R Y64644 $ 274.11 $ 197.33 0 0% 0% 0% 0 2 0 1 0 0 R Y64645 $ 191.34 $ 137.35 0 0% 0% 0% 0 0 0 1 0 0 R Y64646 $ 257.91 $ 195.53 0 0% 0% 0% 0 2 0 1 0 0 R Y64647 $ 298.10 $ 226.12 0 0% 0% 0% 0 2 0 1 0 0 R Y64650 $ 134.36 $ 69.58 0 0% 0% 0% 0 2 0 0 0 0 R Y64653 $ 160.75 $ 87.57 0 0% 0% 0% 0 2 0 0 0 0 R Y64680 $ 548.22 $ 289.70 10 10% 80% 10% 0 2 0 1 0 0 R Y64681 $ 707.76 $ 398.87 10 10% 80% 10% 0 2 0 1 0 0 R Y64702 $ 852.32 $ 852.32 90 11% 76% 13% 0 2 0 1 0 0 R Y64704 $ 544.02 $ 544.02 90 11% 76% 13% 0 2 0 2 1 0 R Y64708 $ 848.12 $ 848.12 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR64712 $ 966.28 $ 966.28 90 11% 76% 13% 0 2 1 2 1 0 R Y64713 $ 1211.60 $ 1211.60 90 11% 76% 13% 0 2 1 2 1 0 R Y-UR64714 $ 1098.83 $ 1098.83 90 11% 76% 13% 0 2 1 2 1 0 R Y64716 $ 914.10 $ 914.10 90 11% 76% 13% 0 2 0 2 1 0 R Y64718 $ 1005.26 $ 1005.26 90 11% 76% 13% 0 2 1 0 0 0 R Y-UR64719 $ 678.97 $ 678.97 90 11% 76% 13% 0 2 1 1 0 0 R Y-UR64721 $ 731.76 $ 725.76 90 11% 76% 13% 0 2 1 1 0 0 R Y-UR64722 $ 629.19 $ 629.19 90 11% 76% 13% 0 2 0 2 1 0 R Y-UR64726 $ 475.04 $ 475.04 90 11% 76% 13% 0 2 0 1 0 0 R Y
Professional Services Fee SchedulesSurgery
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only are copyright 2014 American Medical Association. All rights reserved. Page 141
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
64727 $ 307.10 $ 307.10 0 0% 0% 0% 0 0 0 1 0 0 R Y-UR64732 $ 648.98 $ 648.98 90 11% 76% 13% 0 2 1 2 0 0 R Y64734 $ 831.92 $ 831.92 90 11% 76% 13% 0 2 1 0 0 0 R Y64736 $ 680.77 $ 680.77 90 11% 76% 13% 0 2 1 2 0 0 R Y64738 $ 784.54 $ 784.54 90 11% 76% 13% 0 2 1 2 0 0 R Y64740 $ 781.54 $ 781.54 90 11% 76% 13% 0 2 1 2 0 0 R Y64742 $ 779.14 $ 779.14 90 11% 76% 13% 0 2 1 2 0 0 R Y64744 $ 819.93 $ 819.93 90 11% 76% 13% 0 2 1 0 0 0 R Y64746 $ 719.16 $ 719.16 90 11% 76% 13% 0 2 1 2 1 0 R Y64755 $ 1516.89 $ 1516.89 90 11% 76% 13% 0 2 0 2 1 0 R Y64760 $ 855.31 $ 855.31 90 11% 76% 13% 0 2 0 2 1 0 R Y64763 $ 846.32 $ 846.32 90 11% 76% 13% 0 2 1 2 1 0 R Y64766 $ 967.48 $ 967.48 90 11% 76% 13% 0 2 1 2 0 0 R Y64771 $ 1015.46 $ 1015.46 90 11% 76% 13% 0 2 0 2 0 0 R Y64772 $ 956.08 $ 956.08 90 11% 76% 13% 0 2 0 2 1 0 R Y64774 $ 703.57 $ 703.57 90 11% 76% 13% 0 2 0 1 0 0 R 64776 $ 663.38 $ 663.38 90 11% 76% 13% 0 2 0 0 0 0 R 64778 $ 242.92 $ 242.92 0 0% 0% 0% 0 0 0 1 0 0 R 64782 $ 768.34 $ 768.34 90 11% 76% 13% 0 2 0 1 1 0 R 64783 $ 372.48 $ 372.48 0 0% 0% 0% 0 0 0 1 0 0 R 64784 $ 1233.79 $ 1233.79 90 11% 76% 13% 0 2 0 0 0 0 R 64786 $ 1817.99 $ 1817.99 90 11% 76% 13% 0 2 1 2 0 0 R 64787 $ 413.26 $ 413.26 0 0% 0% 0% 0 0 0 0 0 0 R 64788 $ 689.17 $ 689.17 90 11% 76% 13% 0 2 0 1 0 0 R Y64790 $ 1399.93 $ 1399.93 90 11% 76% 13% 0 2 0 0 1 0 R Y64792 $ 1832.39 $ 1832.39 90 11% 76% 13% 0 2 0 2 1 0 R Y64795 $ 316.69 $ 316.69 0 0% 0% 0% 0 2 0 1 0 0 R Y64802 $ 1155.21 $ 1155.21 90 11% 76% 13% 0 2 1 2 1 0 R Y64804 $ 1541.49 $ 1541.49 90 11% 76% 13% 0 2 1 2 1 0 R Y64809 $ 1780.81 $ 1780.81 90 11% 76% 13% 0 2 1 2 1 0 R Y64818 $ 944.69 $ 944.69 90 11% 76% 13% 0 2 1 2 1 0 R Y64820 $ 1236.19 $ 1236.19 90 11% 76% 13% 0 2 0 1 0 0 R Y64821 $ 1173.21 $ 1173.21 90 11% 76% 13% 0 2 1 1 0 0 R Y64822 $ 1173.21 $ 1173.21 90 11% 76% 13% 0 2 1 1 0 0 R Y64823 $ 1330.36 $ 1330.36 90 11% 76% 13% 0 2 1 1 0 0 R Y64831 $ 1164.21 $ 1164.21 90 11% 76% 13% 0 2 1 1 0 0 R 64832 $ 568.01 $ 568.01 0 0% 0% 0% 0 0 0 0 0 0 R 64834 $ 1249.98 $ 1249.98 90 11% 76% 13% 0 2 1 0 0 0 R
Professional Services Fee SchedulesSurgery
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CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 142
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
64835 $ 1373.54 $ 1373.54 90 11% 76% 13% 0 2 1 2 0 0 R 64836 $ 1392.74 $ 1392.74 90 11% 76% 13% 0 2 1 2 0 0 R 64837 $ 640.59 $ 640.59 0 0% 0% 0% 0 0 0 2 0 0 R 64840 $ 1645.85 $ 1645.85 90 11% 76% 13% 0 2 1 2 0 0 R 64856 $ 1705.83 $ 1705.83 90 11% 76% 13% 0 2 0 1 1 0 R 64857 $ 1769.41 $ 1769.41 90 11% 76% 13% 0 2 0 2 1 0 R 64858 $ 1980.54 $ 1980.54 90 11% 76% 13% 0 2 1 2 1 0 R 64859 $ 427.66 $ 427.66 0 0% 0% 0% 0 0 0 2 1 0 R 64861 $ 2136.49 $ 2136.49 90 11% 76% 13% 0 2 1 2 1 0 R 64862 $ 1987.74 $ 1987.74 90 11% 76% 13% 0 2 1 2 0 0 R 64864 $ 1483.31 $ 1483.31 90 11% 76% 13% 0 2 0 2 1 0 R 64865 $ 1898.97 $ 1898.97 90 11% 76% 13% 0 2 0 2 1 0 R 64866 $ 1967.94 $ 1967.94 90 11% 76% 13% 0 2 0 2 1 0 R 64868 $ 1737.02 $ 1737.02 90 11% 76% 13% 0 2 0 2 1 0 R 64872 $ 196.73 $ 196.73 0 0% 0% 0% 0 0 0 2 1 0 R 64874 $ 277.71 $ 277.71 0 0% 0% 0% 0 0 0 2 1 0 R 64876 $ 292.10 $ 292.10 0 0% 0% 0% 0 0 0 2 1 0 R 64885 $ 1904.96 $ 1904.96 90 11% 76% 13% 0 2 0 2 1 0 R 64886 $ 2205.46 $ 2205.46 90 11% 76% 13% 0 2 0 2 1 0 R 64890 $ 1855.18 $ 1855.18 90 11% 76% 13% 0 2 0 2 0 0 R 64891 $ 1975.74 $ 1975.74 90 11% 76% 13% 0 2 0 2 0 0 R 64892 $ 1767.61 $ 1767.61 90 11% 76% 13% 0 2 0 2 1 0 R 64893 $ 1926.56 $ 1926.56 90 11% 76% 13% 0 2 0 2 0 0 R 64895 $ 2288.84 $ 2288.84 90 11% 76% 13% 0 2 0 2 1 0 R 64896 $ 2588.14 $ 2588.14 90 11% 76% 13% 0 2 0 2 1 0 R 64897 $ 2155.08 $ 2155.08 90 11% 76% 13% 0 2 0 2 0 0 R 64898 $ 2330.82 $ 2330.82 90 11% 76% 13% 0 2 0 2 1 0 R 64901 $ 946.48 $ 946.48 0 0% 0% 0% 0 0 0 2 1 0 R 64902 $ 1096.43 $ 1096.43 0 0% 0% 0% 0 0 0 2 0 0 R 64905 $ 1739.42 $ 1739.42 90 11% 76% 13% 0 2 0 2 1 0 R 64907 $ 2351.22 $ 2351.22 90 11% 76% 13% 0 2 0 2 1 0 R 64910 $ 1400.53 $ 1400.53 90 11% 76% 13% 0 2 0 2 1 0 R 64911 $ 1726.82 $ 1726.82 90 11% 76% 13% 0 2 0 2 1 0 R 64999 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N Y-UR65091 $ 1096.43 $ 1096.43 90 10% 70% 20% 0 2 1 0 1 0 R 65093 $ 1083.84 $ 1083.84 90 10% 70% 20% 0 2 1 1 1 0 R 65101 $ 1275.17 $ 1275.17 90 10% 70% 20% 0 2 1 1 0 0 R 65103 $ 1326.76 $ 1326.76 90 10% 70% 20% 0 2 1 1 1 0 R
Professional Services Fee SchedulesSurgery
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CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 143
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
65105 $ 1465.31 $ 1465.31 90 10% 70% 20% 0 2 1 2 1 0 R 65110 $ 2101.10 $ 2101.10 90 10% 70% 20% 0 2 1 2 1 0 R 65112 $ 2435.19 $ 2435.19 90 10% 70% 20% 0 2 1 2 1 0 R 65114 $ 2552.15 $ 2552.15 90 10% 70% 20% 0 2 1 2 1 0 R 65125 $ 799.53 $ 505.63 90 10% 70% 20% 0 2 1 1 1 0 R 65130 $ 1263.18 $ 1263.18 90 10% 70% 20% 0 2 1 1 1 0 R 65135 $ 1281.17 $ 1281.17 90 10% 70% 20% 0 2 1 1 0 0 R 65140 $ 1393.34 $ 1393.34 90 10% 70% 20% 0 2 1 1 0 0 R 65150 $ 997.47 $ 997.47 90 10% 70% 20% 0 2 1 0 0 0 R 65155 $ 1458.71 $ 1458.71 90 10% 70% 20% 0 2 1 1 0 0 R 65175 $ 1135.42 $ 1135.42 90 10% 70% 20% 0 2 1 1 1 0 R 65205 $ 96.57 $ 75.57 0 0% 0% 0% 0 2 1 1 0 0 R 65210 $ 118.76 $ 91.77 0 0% 0% 0% 0 2 1 1 0 0 R 65220 $ 98.97 $ 70.78 0 0% 0% 0% 0 2 1 1 0 0 R 65222 $ 115.76 $ 89.37 0 0% 0% 0% 0 2 1 1 0 0 R 65235 $ 1226.59 $ 1226.59 90 10% 70% 20% 0 2 1 0 0 0 R 65260 $ 1648.25 $ 1648.25 90 10% 70% 20% 0 2 1 2 0 0 R 65265 $ 1855.18 $ 1855.18 90 10% 70% 20% 0 2 1 2 1 0 R 65270 $ 466.64 $ 242.32 10 10% 80% 10% 0 2 1 0 0 0 R 65272 $ 873.91 $ 604.00 90 10% 70% 20% 0 2 1 1 0 0 R 65273 $ 654.38 $ 654.38 90 10% 70% 20% 0 2 1 1 1 0 R 65275 $ 1001.07 $ 794.74 90 10% 70% 20% 0 2 1 0 0 0 R 65280 $ 1155.81 $ 1155.81 90 10% 70% 20% 0 2 1 0 0 0 R 65285 $ 1904.37 $ 1904.37 90 10% 70% 20% 0 2 1 1 0 0 R 65286 $ 1224.19 $ 853.52 90 10% 70% 20% 0 2 1 1 0 0 R 65290 $ 843.32 $ 843.32 90 10% 70% 20% 0 2 1 1 1 0 R 65400 $ 1176.21 $ 1041.25 90 10% 70% 20% 0 2 1 1 0 0 R 65410 $ 248.32 $ 179.94 0 0% 0% 0% 0 2 1 0 0 0 R Y65420 $ 899.70 $ 652.58 90 10% 70% 20% 0 2 1 1 0 0 R 65426 $ 1134.22 $ 825.92 90 10% 70% 20% 0 2 1 1 0 0 R 65430 $ 197.93 $ 178.14 0 0% 0% 0% 0 2 1 1 0 0 R 65435 $ 137.35 $ 119.96 0 0% 0% 0% 0 2 1 1 0 0 R 65436 $ 668.18 $ 639.99 90 10% 70% 20% 0 2 1 1 0 0 R 65450 $ 563.21 $ 557.21 90 10% 70% 20% 0 2 1 1 0 0 R 65600 $ 683.77 $ 594.40 90 10% 70% 20% 0 2 1 1 0 0 R 65710 $ 1904.37 $ 1904.37 90 10% 70% 20% 0 2 1 2 1 0 R 65730 $ 2110.70 $ 2110.70 90 10% 70% 20% 0 2 1 2 1 0 R 65750 $ 2119.69 $ 2119.69 90 10% 70% 20% 0 2 1 2 1 0 R
Professional Services Fee SchedulesSurgery
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CPT®
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Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
65755 $ 2108.30 $ 2108.30 90 10% 70% 20% 0 2 1 2 1 0 R 65756 $ 2033.32 $ 2033.32 90 10% 70% 20% 0 2 1 2 1 0 R 65757 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 65760 $ 3820.65 $ 3820.65 0 0% 0% 0% 9 9 9 9 9 9 F 65765 $ 4177.55 $ 4177.55 0 0% 0% 0% 9 9 9 9 9 9 F 65767 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 65770 $ 2414.79 $ 2414.79 90 10% 70% 20% 0 2 1 2 0 0 R 65771 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 65772 $ 780.34 $ 701.17 90 10% 70% 20% 0 2 1 1 0 0 R 65775 $ 951.28 $ 951.28 90 10% 70% 20% 0 2 1 1 0 0 R 65778 $ 2461.58 $ 119.96 10 10% 80% 10% 0 2 1 0 0 0 R65779 $ 2170.68 $ 487.04 10 10% 80% 10% 0 2 1 0 0 0 R65780 $ 1535.49 $ 1535.49 90 10% 70% 20% 0 2 1 1 1 0 R 65781 $ 2291.84 $ 2291.84 90 10% 70% 20% 0 2 1 2 1 0 R 65782 $ 1978.74 $ 1978.74 90 10% 70% 20% 0 2 1 1 1 0 R 65800 $ 205.13 $ 156.55 0 0% 0% 0% 0 2 1 1 0 0 R Y65810 $ 802.53 $ 802.53 90 10% 70% 20% 0 2 1 1 0 0 R 65815 $ 1109.03 $ 823.53 90 10% 70% 20% 0 2 1 1 0 0 R 65820 $ 1291.97 $ 1291.97 90 10% 70% 20% 0 2 1 0 0 0 R 65850 $ 1442.52 $ 1442.52 90 10% 70% 20% 0 2 1 1 1 0 R 65855 $ 583.61 $ 511.63 10 10% 80% 10% 0 2 1 1 0 0 R 65860 $ 533.82 $ 434.86 90 10% 70% 20% 0 2 1 0 0 0 R 65865 $ 816.33 $ 816.33 90 10% 70% 20% 0 2 1 1 1 0 R 65870 $ 1019.66 $ 1019.66 90 10% 70% 20% 0 2 1 1 1 0 R 65875 $ 1086.24 $ 1086.24 90 10% 70% 20% 0 2 1 1 1 0 R 65880 $ 1143.22 $ 1143.22 90 10% 70% 20% 0 2 1 1 0 0 R 65900 $ 1659.05 $ 1659.05 90 10% 70% 20% 0 2 1 2 0 0 R 65920 $ 1358.55 $ 1358.55 90 10% 70% 20% 0 2 1 1 1 0 R 65930 $ 1097.63 $ 1097.63 90 10% 70% 20% 0 2 1 1 1 0 R 66020 $ 324.49 $ 227.32 10 10% 80% 10% 0 2 1 1 0 0 R 66030 $ 289.70 $ 191.94 10 10% 80% 10% 0 2 1 1 0 0 R 66130 $ 1203.20 $ 978.27 90 10% 70% 20% 0 2 1 0 0 0 R 66150 $ 1504.30 $ 1504.30 90 10% 70% 20% 0 2 1 1 1 0 R 66155 $ 1512.10 $ 1512.10 90 10% 70% 20% 0 2 1 1 0 0 R 66160 $ 1702.83 $ 1702.83 90 10% 70% 20% 0 2 1 1 1 0 R 66170 $ 2069.91 $ 2069.91 90 10% 70% 20% 0 2 1 2 1 0 R 66172 $ 2610.93 $ 2610.93 90 10% 70% 20% 0 2 1 2 1 0 R 66174 $ 1629.06 $ 1629.06 90 10% 70% 20% 0 2 1 2 1 0 R Y
Professional Services Fee SchedulesSurgery
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CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 145
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
66175 $ 1705.23 $ 1705.23 90 10% 70% 20% 0 2 1 2 1 0 R Y66179 $ 1855.78 $ 1855.78 90 10% 70% 20% 0 2 1 2 0 0 R66180 $ 1957.75 $ 1957.75 90 10% 70% 20% 0 2 1 2 0 0 R 66183 Not Covered Not Covered 90 10% 80% 10% 0 2 1 2 0 0 X66184 $ 1354.35 $ 1354.35 90 10% 70% 20% 0 2 1 2 0 0 R66185 $ 1456.91 $ 1456.91 90 10% 70% 20% 0 2 1 2 0 0 R 66220 $ 1282.37 $ 1282.37 90 10% 70% 20% 0 2 1 2 1 0 R 66225 $ 1601.47 $ 1601.47 90 10% 70% 20% 0 2 1 1 1 0 R 66250 $ 1301.57 $ 960.88 90 10% 70% 20% 0 2 1 1 0 0 R 66500 $ 613.00 $ 613.00 90 10% 70% 20% 0 2 1 1 1 0 R 66505 $ 671.78 $ 671.78 90 10% 70% 20% 0 2 1 1 0 0 R 66600 $ 1435.92 $ 1435.92 90 10% 70% 20% 0 2 1 1 0 0 R 66605 $ 1816.79 $ 1816.79 90 10% 70% 20% 0 2 1 1 0 0 R 66625 $ 740.15 $ 740.15 90 10% 70% 20% 0 2 1 1 0 0 R 66630 $ 981.27 $ 981.27 90 10% 70% 20% 0 2 1 1 0 0 R 66635 $ 990.87 $ 990.87 90 10% 70% 20% 0 2 1 1 0 0 R 66680 $ 893.10 $ 893.10 90 10% 70% 20% 0 2 1 1 1 0 R 66682 $ 1101.83 $ 1101.83 90 10% 70% 20% 0 2 1 1 0 0 R 66700 $ 778.54 $ 677.17 90 10% 70% 20% 0 2 1 0 0 0 R 66710 $ 759.95 $ 677.17 90 10% 70% 20% 0 2 1 1 0 0 R 66711 $ 1107.23 $ 1107.23 90 10% 70% 20% 0 3 1 1 0 0 R 66720 $ 823.53 $ 732.96 90 10% 70% 20% 0 2 1 1 0 0 R 66740 $ 755.15 $ 676.57 90 10% 70% 20% 0 2 1 1 0 0 R 66761 $ 513.43 $ 406.66 10 10% 80% 10% 0 2 1 1 0 0 R 66762 $ 821.13 $ 734.16 90 10% 70% 20% 0 2 1 1 0 0 R 66770 $ 912.90 $ 834.32 90 10% 70% 20% 0 2 1 1 0 0 R 66820 $ 682.57 $ 682.57 90 10% 70% 20% 0 2 1 1 0 0 R 66821 $ 571.61 $ 538.62 90 10% 70% 20% 0 2 1 1 0 0 R 66825 $ 1311.76 $ 1311.76 90 10% 70% 20% 0 2 1 0 0 0 R 66830 $ 1225.39 $ 1225.39 90 10% 70% 20% 0 2 1 1 0 0 R 66840 $ 1199.00 $ 1199.00 90 10% 70% 20% 0 2 1 1 0 0 R 66850 $ 1363.35 $ 1363.35 90 10% 70% 20% 0 2 1 1 0 0 R 66852 $ 1451.52 $ 1451.52 90 10% 70% 20% 0 2 1 0 1 0 R 66920 $ 1296.77 $ 1296.77 90 10% 70% 20% 0 2 1 0 1 0 R 66930 $ 1472.51 $ 1472.51 90 10% 70% 20% 0 2 1 0 0 0 R 66940 $ 1345.35 $ 1345.35 90 10% 70% 20% 0 2 1 0 1 0 R 66982 $ 1365.74 $ 1365.74 90 10% 70% 20% 0 2 1 1 0 0 R 66983 $ 1263.78 $ 1263.78 90 10% 70% 20% 0 2 1 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 146
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
66984 $ 1101.23 $ 1101.23 90 10% 70% 20% 0 2 1 1 0 0 R 66985 $ 1326.16 $ 1326.16 90 10% 70% 20% 0 2 1 1 1 0 R 66986 $ 1561.88 $ 1561.88 90 10% 70% 20% 0 2 1 1 1 0 R 66990 $ 154.75 $ 154.75 0 0% 0% 0% 0 0 0 1 0 0 R 66999 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 67005 $ 815.13 $ 815.13 90 10% 70% 20% 0 2 1 1 1 0 R 67010 $ 935.09 $ 935.09 90 10% 70% 20% 0 2 1 1 1 0 R 67015 $ 1001.67 $ 1001.67 90 10% 70% 20% 0 2 1 1 1 0 R 67025 $ 1256.58 $ 1091.04 90 10% 70% 20% 0 2 1 1 1 0 R 67027 $ 1464.11 $ 1464.11 90 10% 70% 20% 0 2 1 2 1 0 R Y67028 $ 175.14 $ 171.54 0 0% 0% 0% 0 2 1 1 0 0 R 67030 $ 920.69 $ 920.69 90 10% 70% 20% 0 2 1 1 1 0 R 67031 $ 671.18 $ 614.20 90 10% 70% 20% 0 2 1 1 0 0 R 67036 $ 1549.88 $ 1549.88 90 10% 70% 20% 0 2 1 2 1 0 R 67039 $ 1659.65 $ 1659.65 90 10% 70% 20% 0 2 1 2 1 0 R 67040 $ 1792.20 $ 1792.20 90 10% 70% 20% 0 2 1 2 1 0 R 67041 $ 1979.34 $ 1979.34 90 10% 70% 20% 0 2 1 2 1 0 R 67042 $ 1979.34 $ 1979.34 90 10% 70% 20% 0 2 1 2 1 0 R 67043 $ 2087.90 $ 2087.90 90 10% 70% 20% 0 2 1 2 1 0 R 67101 $ 1355.55 $ 1160.61 90 10% 70% 20% 0 2 1 1 0 0 R 67105 $ 1241.59 $ 1109.03 90 10% 70% 20% 0 2 1 1 0 0 R 67107 $ 2087.30 $ 2087.30 90 10% 70% 20% 0 2 1 2 1 0 R 67108 $ 2753.08 $ 2753.08 90 10% 70% 20% 0 2 1 2 1 0 R 67110 $ 1500.70 $ 1332.76 90 10% 70% 20% 0 2 1 1 0 0 R 67112 $ 2275.64 $ 2275.64 90 10% 70% 20% 0 2 1 2 1 0 R 67113 $ 2989.40 $ 2989.40 90 10% 70% 20% 0 2 1 2 1 0 R 67115 $ 862.51 $ 862.51 90 10% 70% 20% 0 2 1 1 0 0 R 67120 $ 1138.42 $ 962.68 90 10% 70% 20% 0 2 1 1 1 0 R 67121 $ 1562.48 $ 1562.48 90 10% 70% 20% 0 2 1 2 1 0 R 67141 $ 905.10 $ 841.52 90 10% 70% 20% 0 2 1 1 0 0 R 67145 $ 909.90 $ 858.31 90 10% 70% 20% 0 2 1 1 0 0 R 67208 $ 1031.66 $ 993.87 90 10% 70% 20% 0 2 1 1 0 0 R 67210 $ 894.30 $ 862.51 90 10% 70% 20% 0 2 1 1 0 0 R 67218 Not Covered Not Covered 90 10% 70% 20% 0 2 1 1 0 0 X 67220 $ 923.69 $ 862.51 90 10% 70% 20% 0 2 1 1 0 0 R Y67221 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 67225 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X 67227 $ 1053.85 $ 983.07 90 10% 70% 20% 0 2 1 1 0 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 147
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
67228 $ 1717.83 $ 1623.06 90 10% 70% 20% 0 2 1 1 0 0 R Y67229 Not Covered Not Covered 90 10% 70% 20% 0 2 1 1 0 0 X 67250 $ 1345.95 $ 1345.95 90 10% 70% 20% 0 2 1 1 1 0 R 67255 $ 1179.21 $ 1179.21 90 10% 70% 20% 0 2 1 2 1 0 R 67299 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 67311 $ 1031.06 $ 1031.06 90 10% 70% 20% 0 2 1 1 0 0 R Y67312 $ 1223.59 $ 1223.59 90 10% 70% 20% 0 2 1 1 1 0 R Y67314 $ 1159.41 $ 1159.41 90 10% 70% 20% 0 2 1 1 0 0 R Y67316 $ 1378.34 $ 1378.34 90 10% 70% 20% 0 2 1 0 0 0 R Y67318 $ 1213.40 $ 1213.40 90 10% 70% 20% 0 2 1 1 1 0 R Y67320 $ 550.62 $ 550.62 0 0% 0% 0% 0 0 0 1 0 0 R Y67331 $ 521.83 $ 521.83 0 0% 0% 0% 0 0 1 1 1 0 R Y67332 $ 566.21 $ 566.21 0 0% 0% 0% 0 0 1 1 1 0 R Y67334 $ 514.63 $ 514.63 0 0% 0% 0% 0 0 1 1 1 0 R Y67335 $ 254.92 $ 254.92 0 0% 0% 0% 0 0 1 1 1 0 R Y67340 $ 611.80 $ 611.80 0 0% 0% 0% 0 0 0 2 0 0 R Y67343 $ 1124.63 $ 1124.63 90 10% 70% 20% 0 2 1 1 1 0 R 67345 $ 413.26 $ 370.68 10 10% 80% 10% 0 2 1 1 0 0 R Y67346 $ 333.49 $ 333.49 0 0% 0% 0% 0 2 1 0 0 0 R Y67399 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N 67400 $ 1603.27 $ 1603.27 90 10% 70% 20% 0 2 1 1 1 0 R 67405 $ 1366.94 $ 1366.94 90 10% 70% 20% 0 2 1 1 0 0 R 67412 $ 1467.11 $ 1467.11 90 10% 70% 20% 0 2 1 1 1 0 R 67413 $ 1473.71 $ 1473.71 90 10% 70% 20% 0 2 1 2 0 0 R 67414 $ 2275.04 $ 2275.04 90 10% 70% 20% 0 2 1 2 1 0 R 67415 Not Covered Not Covered 0 0% 0% 0% 0 2 1 0 0 0 X 67420 $ 2771.68 $ 2771.68 90 10% 70% 20% 0 2 1 2 1 0 R 67430 $ 2149.08 $ 2149.08 90 10% 70% 20% 0 2 1 2 0 0 R 67440 $ 2078.91 $ 2078.91 90 10% 70% 20% 0 2 1 2 1 0 R 67445 $ 2405.20 $ 2405.20 90 10% 70% 20% 0 2 1 2 1 0 R 67450 $ 2156.88 $ 2156.88 90 10% 70% 20% 0 2 1 2 1 0 R 67500 $ 132.56 $ 121.76 0 0% 0% 0% 0 2 1 1 0 0 R 67505 $ 152.95 $ 139.75 0 0% 0% 0% 0 2 1 1 0 0 R 67515 $ 166.14 $ 152.95 0 0% 0% 0% 0 2 1 1 0 0 R 67550 $ 1660.25 $ 1660.25 90 10% 70% 20% 0 2 1 1 1 0 R 67560 $ 1702.23 $ 1702.23 90 10% 70% 20% 0 2 1 0 0 0 R 67570 $ 1970.34 $ 1970.34 90 10% 70% 20% 0 2 1 2 1 0 R 67599 By Report By Report 90 0% 0% 0% 0 2 1 2 1 1 N
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 148
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
67700 $ 470.24 $ 200.93 10 10% 80% 10% 0 2 1 1 0 0 R 67710 $ 392.87 $ 168.54 10 10% 80% 10% 0 2 1 1 0 0 R 67715 $ 417.46 $ 187.14 10 10% 80% 10% 0 2 1 1 0 0 R 67800 $ 220.13 $ 178.14 10 10% 80% 10% 0 2 0 1 0 0 R 67801 $ 280.11 $ 229.72 10 10% 80% 10% 0 2 0 1 0 0 R 67805 $ 348.48 $ 284.31 10 10% 80% 10% 0 2 0 1 0 0 R 67808 $ 634.59 $ 634.59 90 10% 70% 20% 0 2 0 1 0 0 R 67810 $ 298.70 $ 121.16 0 0% 0% 0% 0 2 1 1 0 0 R Y67820 $ 85.77 $ 92.37 0 0% 0% 0% 0 2 1 1 0 0 R 67825 $ 223.13 $ 211.13 10 10% 80% 10% 0 2 1 1 0 0 R 67830 $ 465.44 $ 238.72 10 10% 80% 10% 0 2 1 1 0 0 R 67835 $ 755.75 $ 755.75 90 10% 70% 20% 0 2 1 0 0 0 R 67840 $ 479.84 $ 272.91 10 10% 80% 10% 0 2 1 1 0 0 R 67850 $ 371.88 $ 233.32 10 10% 80% 10% 0 2 1 1 0 0 R 67875 $ 298.10 $ 167.34 0 0% 0% 0% 0 2 1 1 0 0 R 67880 $ 794.74 $ 634.59 90 10% 70% 20% 0 2 1 1 0 0 R 67882 $ 975.27 $ 813.93 90 10% 70% 20% 0 2 1 1 0 0 R 67900 $ 1105.43 $ 873.31 90 10% 70% 20% 0 2 1 1 0 0 R 67901 $ 1309.96 $ 992.67 90 10% 70% 20% 0 2 1 1 0 0 R 67902 $ 1240.99 $ 1240.99 90 10% 70% 20% 0 2 1 1 1 0 R 67903 $ 1023.86 $ 830.12 90 10% 70% 20% 0 2 1 1 1 0 R 67904 $ 1264.98 $ 1026.86 90 10% 70% 20% 0 2 1 1 1 0 R 67906 $ 873.91 $ 873.91 90 10% 70% 20% 0 2 1 1 0 0 R 67908 $ 853.52 $ 731.16 90 10% 70% 20% 0 2 1 1 0 0 R 67909 $ 928.49 $ 755.15 90 10% 70% 20% 0 2 1 1 0 0 R 67911 $ 966.88 $ 966.88 90 10% 70% 20% 0 2 1 1 0 0 R 67912 $ 1536.09 $ 840.32 90 10% 70% 20% 0 2 1 1 0 0 R 67914 $ 819.33 $ 566.21 90 10% 70% 20% 0 2 1 1 0 0 R 67915 $ 510.43 $ 343.09 90 10% 70% 20% 0 2 1 1 0 0 R 67916 $ 1027.46 $ 741.95 90 10% 70% 20% 0 2 1 1 0 0 R 67917 $ 1044.25 $ 788.14 90 10% 70% 20% 0 2 1 1 0 0 R 67921 $ 803.13 $ 536.82 90 10% 70% 20% 0 2 1 1 0 0 R 67922 $ 505.63 $ 341.89 90 10% 70% 20% 0 2 1 1 0 0 R 67923 $ 1026.86 $ 741.95 90 10% 70% 20% 0 2 1 1 0 0 R 67924 $ 1094.04 $ 788.74 90 10% 70% 20% 0 2 1 1 0 0 R 67930 $ 630.99 $ 412.06 10 10% 80% 10% 0 2 1 1 0 0 R 67935 $ 1026.26 $ 756.95 90 10% 70% 20% 0 2 1 1 0 0 R 67938 $ 423.46 $ 199.73 10 10% 80% 10% 0 2 1 1 0 0 R
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 149
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
67950 $ 989.07 $ 796.53 90 10% 70% 20% 0 2 1 1 1 0 R 67961 $ 995.67 $ 783.34 90 10% 70% 20% 0 2 1 0 0 0 R 67966 $ 1324.96 $ 1130.02 90 10% 70% 20% 0 2 1 1 0 0 R 67971 $ 1242.79 $ 1242.79 90 10% 70% 20% 0 2 1 1 1 0 R 67973 $ 1597.27 $ 1597.27 90 10% 70% 20% 0 2 1 2 1 0 R 67974 $ 1594.27 $ 1594.27 90 10% 70% 20% 0 2 1 2 1 0 R 67975 $ 1177.41 $ 1177.41 90 10% 70% 20% 0 2 1 1 0 0 R 67999 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 68020 $ 206.93 $ 190.74 10 10% 80% 10% 0 2 1 1 0 0 R Y68040 Not Covered Not Covered 0 0% 0% 0% 0 2 1 1 0 0 X 68100 $ 295.70 $ 167.34 0 0% 0% 0% 0 2 1 1 0 0 R Y68110 $ 392.27 $ 257.91 10 10% 80% 10% 0 2 1 1 0 0 R 68115 $ 542.22 $ 317.29 10 10% 80% 10% 0 2 1 1 0 0 R 68130 $ 935.09 $ 710.76 90 10% 70% 20% 0 2 1 1 0 0 R 68135 $ 270.51 $ 261.51 10 10% 80% 10% 0 2 1 1 0 0 R 68200 $ 70.78 $ 59.38 0 0% 0% 0% 0 2 1 1 0 0 R 68320 $ 1258.98 $ 930.29 90 10% 70% 20% 0 2 1 1 1 0 R 68325 $ 1134.82 $ 1134.82 90 10% 70% 20% 0 2 1 1 1 0 R 68326 $ 1112.63 $ 1112.63 90 10% 70% 20% 0 2 1 1 0 0 R 68328 $ 1216.39 $ 1216.39 90 10% 70% 20% 0 2 1 0 0 0 R 68330 $ 1048.45 $ 795.33 90 10% 70% 20% 0 2 1 0 0 0 R 68335 $ 1116.23 $ 1116.23 90 10% 70% 20% 0 2 1 1 1 0 R 68340 $ 946.48 $ 688.57 90 10% 70% 20% 0 2 1 0 0 0 R 68360 $ 920.69 $ 709.56 90 10% 70% 20% 0 2 1 1 0 0 R 68362 $ 1131.22 $ 1131.22 90 10% 70% 20% 0 2 1 1 1 0 R 68371 $ 712.56 $ 712.56 10 10% 80% 10% 0 2 1 1 0 0 R 68399 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 68400 $ 498.43 $ 228.52 10 10% 80% 10% 0 2 1 1 0 0 R Y68420 $ 559.61 $ 289.70 10 10% 80% 10% 0 2 1 1 0 0 R Y68440 $ 177.54 $ 172.74 10 10% 80% 10% 0 2 1 1 0 0 R Y68500 $ 1678.84 $ 1678.84 90 10% 70% 20% 0 2 1 1 0 0 R Y68505 $ 1671.04 $ 1671.04 90 10% 70% 20% 0 2 1 1 0 0 R Y68510 $ 773.14 $ 500.83 0 0% 0% 0% 0 2 1 0 0 0 R Y68520 $ 1182.21 $ 1182.21 90 10% 70% 20% 0 2 1 0 0 0 R Y68525 $ 450.45 $ 450.45 0 0% 0% 0% 0 2 1 1 1 0 R Y68530 $ 743.75 $ 441.45 10 10% 80% 10% 0 2 1 1 0 0 R Y68540 Not Covered Not Covered 90 10% 70% 20% 0 2 1 1 1 0 X 68550 Not Covered Not Covered 90 10% 70% 20% 0 2 1 1 0 0 X
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 150
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
68700 $ 1040.05 $ 1040.05 90 10% 70% 20% 0 2 1 1 0 0 R 68705 $ 410.26 $ 287.30 10 10% 80% 10% 0 2 1 1 0 0 R 68720 $ 1299.77 $ 1299.77 90 10% 70% 20% 0 2 1 2 1 0 R 68745 $ 1307.56 $ 1307.56 90 10% 70% 20% 0 2 1 2 1 0 R 68750 $ 1353.15 $ 1353.15 90 10% 70% 20% 0 2 1 2 1 0 R 68760 $ 349.68 $ 253.12 10 10% 80% 10% 0 2 1 1 0 0 R 68761 $ 257.31 $ 206.33 10 10% 80% 10% 0 2 1 0 0 0 R 68770 $ 1083.84 $ 1083.84 90 10% 70% 20% 0 2 1 0 0 0 R 68801 $ 217.73 $ 188.34 10 10% 80% 10% 0 2 1 1 0 0 R 68810 $ 420.46 $ 325.09 10 10% 80% 10% 0 2 1 1 0 0 R 68811 $ 356.28 $ 356.28 10 10% 80% 10% 0 2 1 1 0 0 R 68815 $ 784.54 $ 442.65 10 10% 80% 10% 0 2 1 1 0 0 R 68816 $ 1308.16 $ 431.86 10 10% 80% 10% 0 2 1 1 0 0 R 68840 $ 221.93 $ 202.73 10 10% 80% 10% 0 2 1 1 0 0 R 68850 $ 104.97 $ 95.97 0 0% 0% 0% 0 2 1 1 0 0 R 68899 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 69000 $ 326.29 $ 205.13 10 10% 80% 10% 0 2 1 1 0 0 R 69005 $ 371.28 $ 269.91 10 10% 80% 10% 0 2 1 1 0 0 R 69020 $ 408.46 $ 247.12 10 10% 80% 10% 0 2 1 1 0 0 R 69090 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 69100 $ 175.14 $ 82.77 0 0% 0% 0% 0 2 0 1 0 0 R Y69105 $ 247.72 $ 109.16 0 0% 0% 0% 0 2 1 1 0 0 R Y69110 $ 800.13 $ 559.01 90 7% 79% 14% 0 2 1 1 0 0 R 69120 $ 700.57 $ 700.57 90 7% 79% 14% 0 2 0 1 0 0 R 69140 $ 1533.09 $ 1533.09 90 7% 79% 14% 0 2 1 0 0 0 R 69145 $ 698.17 $ 432.46 90 7% 79% 14% 0 2 1 1 0 0 R 69150 Not Covered Not Covered 90 7% 79% 14% 0 2 0 1 1 0 X 69155 Not Covered Not Covered 90 7% 79% 14% 0 2 0 2 1 0 X 69200 $ 215.93 $ 99.57 0 0% 0% 0% 0 2 1 1 0 0 R 69205 $ 175.74 $ 175.74 10 10% 80% 10% 0 2 1 1 0 0 R 69210 $ 84.57 $ 55.18 0 0% 0% 0% 0 2 2 1 0 0 R 69220 $ 241.72 $ 106.76 0 0% 0% 0% 0 2 1 1 0 0 R 69222 $ 385.67 $ 238.12 10 10% 80% 10% 0 2 1 1 0 0 R 69300 Not Covered Not Covered 10 0% 0% 0% 0 2 1 0 0 0 X 69310 $ 1897.17 $ 1897.17 90 7% 79% 14% 0 2 1 1 0 0 R 69320 Not Covered Not Covered 90 7% 79% 14% 0 2 1 2 0 0 X 69399 By Report By Report 90 0% 0% 0% 0 2 0 0 1 1 N 69420 $ 335.29 $ 209.33 10 10% 80% 10% 0 2 1 1 0 0 R Y
Professional Services Fee SchedulesSurgery
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 151
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
69421 $ 257.91 $ 257.91 10 10% 80% 10% 0 2 1 1 0 0 R Y69424 $ 224.93 $ 106.76 0 0% 0% 0% 0 2 1 1 0 0 R Y69433 $ 353.88 $ 229.12 10 10% 80% 10% 0 2 1 1 0 0 R Y69436 $ 277.11 $ 277.11 10 10% 80% 10% 0 2 1 1 0 0 R Y69440 $ 1194.20 $ 1194.20 90 7% 79% 14% 0 2 1 1 0 0 R 69450 $ 947.68 $ 947.68 90 7% 79% 14% 0 2 1 0 0 0 R 69501 $ 1261.38 $ 1261.38 90 7% 79% 14% 0 2 1 1 0 0 R Y69502 $ 1674.64 $ 1674.64 90 7% 79% 14% 0 2 1 0 0 0 R Y69505 $ 2090.30 $ 2090.30 90 7% 79% 14% 0 2 1 0 0 0 R Y69511 $ 2139.49 $ 2139.49 90 7% 79% 14% 0 2 1 0 0 0 R Y69530 $ 2854.45 $ 2854.45 90 7% 79% 14% 0 2 1 2 0 0 R Y69535 Not Covered Not Covered 90 7% 79% 14% 0 2 1 1 1 0 X 69540 Not Covered Not Covered 10 10% 80% 10% 0 2 1 1 0 0 X 69550 Not Covered Not Covered 90 7% 79% 14% 0 2 1 2 0 0 X 69552 Not Covered Not Covered 90 7% 79% 14% 0 2 1 2 0 0 X 69554 Not Covered Not Covered 90 7% 79% 14% 0 2 1 2 1 0 X 69601 $ 1803.00 $ 1803.00 90 7% 79% 14% 0 2 1 0 0 0 R Y69602 $ 1876.77 $ 1876.77 90 7% 79% 14% 0 2 1 0 0 0 R Y69603 $ 2186.27 $ 2186.27 90 7% 79% 14% 0 2 1 0 0 0 R Y69604 $ 1916.36 $ 1916.36 90 7% 79% 14% 0 2 1 1 0 0 R Y69605 $ 2697.30 $ 2697.30 90 7% 79% 14% 0 2 1 2 0 0 R Y69610 $ 662.18 $ 496.03 10 10% 80% 10% 0 2 1 1 0 0 R 69620 $ 1212.20 $ 843.92 90 7% 79% 14% 0 2 1 1 0 0 R 69631 $ 1533.09 $ 1533.09 90 7% 79% 14% 0 2 1 1 0 0 R 69632 $ 1862.38 $ 1862.38 90 7% 79% 14% 0 2 1 1 0 0 R 69633 $ 1804.20 $ 1804.20 90 7% 79% 14% 0 2 1 1 0 0 R 69635 $ 2138.29 $ 2138.29 90 7% 79% 14% 0 2 1 1 0 0 R 69636 $ 2395.00 $ 2395.00 90 7% 79% 14% 0 2 1 0 0 0 R 69637 $ 2426.19 $ 2426.19 90 7% 79% 14% 0 2 1 0 0 0 R 69641 $ 1797.60 $ 1797.60 90 7% 79% 14% 0 2 1 1 0 0 R Y69642 $ 2305.03 $ 2305.03 90 7% 79% 14% 0 2 1 1 0 0 R Y69643 $ 2110.10 $ 2110.10 90 7% 79% 14% 0 2 1 1 0 0 R Y69644 $ 2565.34 $ 2565.34 90 7% 79% 14% 0 2 1 1 0 0 R Y69645 $ 2520.36 $ 2520.36 90 7% 79% 14% 0 2 1 1 0 0 R Y69646 $ 2670.31 $ 2670.31 90 7% 79% 14% 0 2 1 0 0 0 R Y69650 $ 1387.94 $ 1387.94 90 7% 79% 14% 0 2 1 1 0 0 R 69660 $ 1599.07 $ 1599.07 90 7% 79% 14% 0 2 1 1 0 0 R 69661 $ 2077.11 $ 2077.11 90 7% 79% 14% 0 2 1 0 0 0 R
Professional Services Fee SchedulesSurgery
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CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 152
Surgery FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
69662 $ 1993.74 $ 1993.74 90 7% 79% 14% 0 2 1 1 0 0 R 69666 $ 1399.93 $ 1399.93 90 7% 79% 14% 0 2 1 0 0 0 R 69667 $ 1398.73 $ 1398.73 90 7% 79% 14% 0 2 1 0 0 0 R 69670 $ 1627.86 $ 1627.86 90 7% 79% 14% 0 2 1 2 0 0 R Y69676 $ 1438.92 $ 1438.92 90 7% 79% 14% 0 2 1 1 0 0 R Y69700 $ 1183.41 $ 1183.41 90 7% 79% 14% 0 2 1 1 0 0 R 69710 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y69711 $ 1488.70 $ 1488.70 90 7% 79% 14% 0 2 1 2 0 0 R Y69714 $ 1852.78 $ 1852.78 90 7% 79% 14% 0 2 1 1 0 0 R Y69715 $ 2276.24 $ 2276.24 90 7% 79% 14% 0 2 1 1 0 0 R Y69717 $ 1940.35 $ 1940.35 90 7% 79% 14% 0 2 1 1 0 0 R Y69718 $ 2299.03 $ 2299.03 90 7% 79% 14% 0 2 1 1 0 0 R Y69720 $ 2071.71 $ 2071.71 90 7% 79% 14% 0 2 1 0 1 0 R 69725 $ 3215.53 $ 3215.53 90 7% 79% 14% 0 2 1 2 0 0 R 69740 $ 2002.73 $ 2002.73 90 7% 79% 14% 0 2 1 2 0 0 R 69745 $ 2132.29 $ 2132.29 90 7% 79% 14% 0 2 1 2 0 0 R 69799 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 69801 $ 338.89 $ 214.13 0 0% 0% 0% 0 2 1 0 0 0 R Y69805 $ 1807.80 $ 1807.80 90 7% 79% 14% 0 2 1 2 0 0 R Y69806 $ 1626.06 $ 1626.06 90 7% 79% 14% 0 2 1 1 0 0 R Y69820 $ 1479.11 $ 1479.11 90 7% 79% 14% 0 2 1 2 0 0 R Y69840 $ 1605.66 $ 1605.66 90 7% 79% 14% 0 2 1 2 0 0 R Y69905 $ 1584.07 $ 1584.07 90 7% 79% 14% 0 2 1 1 0 0 R Y69910 $ 1746.02 $ 1746.02 90 7% 79% 14% 0 2 1 0 0 0 R Y69915 $ 2629.52 $ 2629.52 90 7% 79% 14% 0 2 1 2 1 0 R Y69930 $ 2096.90 $ 2096.90 90 7% 79% 14% 0 2 1 0 0 0 R Y-UR69949 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 69950 $ 3039.19 $ 3039.19 90 7% 79% 14% 0 2 1 2 1 0 R Y69955 $ 3382.27 $ 3382.27 90 7% 79% 14% 0 2 1 2 1 0 R 69960 $ 3285.70 $ 3285.70 90 7% 79% 14% 0 2 1 2 1 0 R 69970 Not Covered Not Covered 90 7% 79% 14% 0 2 1 2 1 0 X 69979 By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N 69990 $ 353.28 $ 353.28 0 0% 0% 0% 0 0 0 2 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 1
Professional Services Fee ScheduleRadiology
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 2
Radiology FeesDOLLAR VALUE MODIFIERS
FSI70010 $ 117.56 $ 117.56 0 0% 0% 0% 0 0 0 0 0 0 R 70015 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 70015-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 70015-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 70030 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 3 0 0 0 R 70030-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 3 0 0 0 R 70030-TC $ 32.99 $ 32.99 0 0% 0% 0% 1 0 3 0 0 0 R 70100 $ 56.98 $ 56.98 0 0% 0% 0% 1 0 0 0 0 0 R 70100-26 $ 15.59 $ 15.59 0 0% 0% 0% 1 0 0 0 0 0 R 70100-TC $ 41.39 $ 41.39 0 0% 0% 0% 1 0 0 0 0 0 R 70110 $ 65.98 $ 65.98 0 0% 0% 0% 1 0 0 0 0 0 R 70110-26 $ 21.59 $ 21.59 0 0% 0% 0% 1 0 0 0 0 0 R 70110-TC $ 43.79 $ 43.79 0 0% 0% 0% 1 0 0 0 0 0 R 70120 $ 58.78 $ 58.78 0 0% 0% 0% 1 0 3 0 0 0 R 70120-26 $ 15.59 $ 15.59 0 0% 0% 0% 1 0 3 0 0 0 R 70120-TC $ 43.19 $ 43.19 0 0% 0% 0% 1 0 3 0 0 0 R 70130 $ 94.77 $ 94.77 0 0% 0% 0% 1 0 3 0 0 0 R 70130-26 $ 29.39 $ 29.39 0 0% 0% 0% 1 0 3 0 0 0 R 70130-TC $ 65.38 $ 65.38 0 0% 0% 0% 1 0 3 0 0 0 R 70134 $ 89.37 $ 89.37 0 0% 0% 0% 1 0 0 0 0 0 R 70134-26 $ 30.59 $ 30.59 0 0% 0% 0% 1 0 0 0 0 0 R 70134-TC $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R 70140 $ 51.58 $ 51.58 0 0% 0% 0% 1 0 0 0 0 0 R 70140-26 $ 17.99 $ 17.99 0 0% 0% 0% 1 0 0 0 0 0 R 70140-TC $ 32.99 $ 32.99 0 0% 0% 0% 1 0 0 0 0 0 R 70150 $ 71.98 $ 71.98 0 0% 0% 0% 1 0 0 0 0 0 R 70150-26 $ 22.79 $ 22.79 0 0% 0% 0% 1 0 0 0 0 0 R 70150-TC $ 49.18 $ 49.18 0 0% 0% 0% 1 0 0 0 0 0 R 70160 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 0 0 0 0 R 70160-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 0 0 0 0 R 70160-TC $ 41.39 $ 41.39 0 0% 0% 0% 1 0 0 0 0 0 R 70170 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 70170-26 $ 25.79 $ 25.79 0 0% 0% 0% 1 0 0 0 0 0 R 70170-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 70190 $ 60.58 $ 60.58 0 0% 0% 0% 1 0 3 0 0 0 R 70190-26 $ 19.19 $ 19.19 0 0% 0% 0% 1 0 3 0 0 0 R 70190-TC $ 41.39 $ 41.39 0 0% 0% 0% 1 0 3 0 0 0 R 70200 $ 73.18 $ 73.18 0 0% 0% 0% 1 0 0 0 0 0 R
CPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 3
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
70200-26 $ 23.99 $ 23.99 0 0% 0% 0% 1 0 0 0 0 0 R 70200-TC $ 49.18 $ 49.18 0 0% 0% 0% 1 0 0 0 0 0 R 70210 $ 51.58 $ 51.58 0 0% 0% 0% 1 0 0 0 0 0 R 70210-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 0 0 0 0 R 70210-TC $ 36.59 $ 36.59 0 0% 0% 0% 1 0 0 0 0 0 R 70220 $ 64.78 $ 64.78 0 0% 0% 0% 1 0 0 0 0 0 R 70220-26 $ 21.59 $ 21.59 0 0% 0% 0% 1 0 0 0 0 0 R 70220-TC $ 42.59 $ 42.59 0 0% 0% 0% 1 0 0 0 0 0 R 70240 $ 51.58 $ 51.58 0 0% 0% 0% 1 0 0 0 0 0 R 70240-26 $ 17.39 $ 17.39 0 0% 0% 0% 1 0 0 0 0 0 R 70240-TC $ 34.79 $ 34.79 0 0% 0% 0% 1 0 0 0 0 0 R 70250 $ 61.78 $ 61.78 0 0% 0% 0% 1 0 0 0 0 0 R 70250-26 $ 21.59 $ 21.59 0 0% 0% 0% 1 0 0 0 0 0 R 70250-TC $ 40.19 $ 40.19 0 0% 0% 0% 1 0 0 0 0 0 R 70260 $ 77.97 $ 77.97 0 0% 0% 0% 1 0 0 0 0 0 R 70260-26 $ 29.99 $ 29.99 0 0% 0% 0% 1 0 0 0 0 0 R 70260-TC $ 48.58 $ 48.58 0 0% 0% 0% 1 0 0 0 0 0 R 70300 $ 25.79 $ 25.79 0 0% 0% 0% 1 0 0 0 0 0 R 70300-26 $ 10.20 $ 10.20 0 0% 0% 0% 1 0 0 0 0 0 R 70300-TC $ 15.59 $ 15.59 0 0% 0% 0% 1 0 0 0 0 0 R 70310 $ 67.18 $ 67.18 0 0% 0% 0% 1 0 0 0 0 0 R 70310-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 0 0 0 0 R 70310-TC $ 52.78 $ 52.78 0 0% 0% 0% 1 0 0 0 0 0 R 70320 $ 92.97 $ 92.97 0 0% 0% 0% 1 0 0 0 0 0 R 70320-26 $ 20.99 $ 20.99 0 0% 0% 0% 1 0 0 0 0 0 R 70320-TC $ 71.98 $ 71.98 0 0% 0% 0% 1 0 0 0 0 0 R 70328 $ 53.98 $ 53.98 0 0% 0% 0% 1 0 0 0 0 0 R 70328-26 $ 16.19 $ 16.19 0 0% 0% 0% 1 0 0 0 0 0 R 70328-TC $ 37.79 $ 37.79 0 0% 0% 0% 1 0 0 0 0 0 R 70330 $ 82.17 $ 82.17 0 0% 0% 0% 1 0 2 0 0 0 R 70330-26 $ 22.19 $ 22.19 0 0% 0% 0% 1 0 2 0 0 0 R 70330-TC $ 59.98 $ 59.98 0 0% 0% 0% 1 0 2 0 0 0 R 70332 $ 141.55 $ 141.55 0 0% 0% 0% 1 0 3 0 0 0 R 70332-26 $ 53.98 $ 53.98 0 0% 0% 0% 1 0 3 0 0 0 R 70332-TC $ 87.57 $ 87.57 0 0% 0% 0% 1 0 3 0 0 0 R 70336 $ 561.41 $ 561.41 0 0% 0% 0% 1 4 0 0 0 0 R 70336-26 $ 125.96 $ 125.96 0 0% 0% 0% 1 4 3 0 0 0 R 70336-TC $ 436.05 $ 436.05 0 0% 0% 0% 1 4 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 4
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
70350 $ 33.59 $ 33.59 0 0% 0% 0% 1 0 0 0 0 0 R 70350-26 $ 17.39 $ 17.39 0 0% 0% 0% 1 0 0 0 0 0 R 70350-TC $ 16.19 $ 16.19 0 0% 0% 0% 1 0 0 0 0 0 R 70355 $ 34.79 $ 34.79 0 0% 0% 0% 1 0 0 0 0 0 R 70355-26 $ 19.19 $ 19.19 0 0% 0% 0% 1 0 0 0 0 0 R 70355-TC $ 15.59 $ 15.59 0 0% 0% 0% 1 0 0 0 0 0 R 70360 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R 70360-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 0 0 0 0 R 70360-TC $ 34.19 $ 34.19 0 0% 0% 0% 1 0 0 0 0 0 R 70370 $ 140.95 $ 140.95 0 0% 0% 0% 1 0 0 0 0 0 R 70370-26 $ 26.99 $ 26.99 0 0% 0% 0% 1 0 0 0 0 0 R 70370-TC $ 113.96 $ 113.96 0 0% 0% 0% 1 0 0 0 0 0 R 70371 $ 156.55 $ 156.55 0 0% 0% 0% 1 0 0 0 0 0 R 70371-26 $ 72.58 $ 72.58 0 0% 0% 0% 1 0 0 0 0 0 R 70371-TC $ 83.97 $ 83.97 0 0% 0% 0% 1 0 0 0 0 0 R 70373 $ 133.16 $ 133.16 0 0% 0% 0% 1 0 0 0 0 0 R 70373-26 $ 37.79 $ 37.79 0 0% 0% 0% 1 0 0 0 0 0 R 70373-TC $ 95.37 $ 95.37 0 0% 0% 0% 1 0 0 0 0 0 R 70380 $ 62.38 $ 62.38 0 0% 0% 0% 1 0 0 0 0 0 R 70380-26 $ 16.19 $ 16.19 0 0% 0% 0% 1 0 0 0 0 0 R 70380-TC $ 46.78 $ 46.78 0 0% 0% 0% 1 0 0 0 0 0 R 70390 $ 164.35 $ 164.35 0 0% 0% 0% 1 0 0 0 0 0 R 70390-26 $ 32.39 $ 32.39 0 0% 0% 0% 1 0 0 0 0 0 R 70390-TC $ 131.96 $ 131.96 0 0% 0% 0% 1 0 0 0 0 0 R 70450 $ 201.53 $ 201.53 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70450-26 $ 72.58 $ 72.58 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70450-TC $ 128.96 $ 128.96 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70460 $ 281.91 $ 281.91 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70460-26 $ 96.57 $ 96.57 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70460-TC $ 185.34 $ 185.34 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70470 $ 334.09 $ 334.09 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70470-26 $ 109.16 $ 109.16 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70470-TC $ 225.52 $ 225.52 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70480 $ 407.86 $ 407.86 0 0% 0% 0% 1 4 0 0 0 0 R 70480-26 $ 109.76 $ 109.76 0 0% 0% 0% 1 4 0 0 0 0 R 70480-TC $ 298.10 $ 298.10 0 0% 0% 0% 1 4 0 0 0 0 R 70481 $ 482.84 $ 482.84 0 0% 0% 0% 1 4 0 0 0 0 R 70481-26 $ 117.56 $ 117.56 0 0% 0% 0% 1 4 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 5
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
70481-TC $ 364.68 $ 364.68 0 0% 0% 0% 1 4 0 0 0 0 R 70482 $ 528.42 $ 528.42 0 0% 0% 0% 1 4 0 0 0 0 R 70482-26 $ 124.16 $ 124.16 0 0% 0% 0% 1 4 0 0 0 0 R 70482-TC $ 404.87 $ 404.87 0 0% 0% 0% 1 4 0 0 0 0 R 70486 $ 244.12 $ 244.12 0 0% 0% 0% 1 4 0 0 0 0 R 70486-26 $ 72.58 $ 72.58 0 0% 0% 0% 1 4 0 0 0 0 R 70486-TC $ 171.54 $ 171.54 0 0% 0% 0% 1 4 0 0 0 0 R 70487 $ 293.30 $ 293.30 0 0% 0% 0% 1 4 0 0 0 0 R 70487-26 $ 96.57 $ 96.57 0 0% 0% 0% 1 4 0 0 0 0 R 70487-TC $ 196.73 $ 196.73 0 0% 0% 0% 1 4 0 0 0 0 R 70488 $ 357.48 $ 357.48 0 0% 0% 0% 1 4 0 0 0 0 R 70488-26 $ 108.56 $ 108.56 0 0% 0% 0% 1 4 0 0 0 0 R 70488-TC $ 249.52 $ 249.52 0 0% 0% 0% 1 4 0 0 0 0 R 70490 $ 335.89 $ 335.89 0 0% 0% 0% 1 4 0 0 0 0 R 70490-26 $ 109.76 $ 109.76 0 0% 0% 0% 1 4 0 0 0 0 R 70490-TC $ 226.72 $ 226.72 0 0% 0% 0% 1 4 0 0 0 0 R 70491 $ 411.46 $ 411.46 0 0% 0% 0% 1 4 0 0 0 0 R 70491-26 $ 118.16 $ 118.16 0 0% 0% 0% 1 4 0 0 0 0 R 70491-TC $ 293.30 $ 293.30 0 0% 0% 0% 1 4 0 0 0 0 R 70492 $ 486.44 $ 486.44 0 0% 0% 0% 1 4 0 0 0 0 R 70492-26 $ 124.16 $ 124.16 0 0% 0% 0% 1 4 0 0 0 0 R 70492-TC $ 362.28 $ 362.28 0 0% 0% 0% 1 4 0 0 0 0 R 70496 $ 515.83 $ 515.83 0 0% 0% 0% 1 4 0 0 0 0 R 70496-26 $ 149.95 $ 149.95 0 0% 0% 0% 1 4 0 0 0 0 R 70496-TC $ 365.88 $ 365.88 0 0% 0% 0% 1 4 0 0 0 0 R 70498 $ 512.23 $ 512.23 0 0% 0% 0% 1 4 0 0 0 0 R 70498-26 $ 149.35 $ 149.35 0 0% 0% 0% 1 4 0 0 0 0 R 70498-TC $ 363.48 $ 363.48 0 0% 0% 0% 1 4 0 0 0 0 R 70540 $ 629.19 $ 629.19 0 0% 0% 0% 1 4 0 0 0 0 R 70540-26 $ 114.56 $ 114.56 0 0% 0% 0% 1 4 0 0 0 0 R 70540-TC $ 514.63 $ 514.63 0 0% 0% 0% 1 4 0 0 0 0 R 70542 $ 707.16 $ 707.16 0 0% 0% 0% 1 4 0 0 0 0 R 70542-26 $ 138.55 $ 138.55 0 0% 0% 0% 1 4 0 0 0 0 R 70542-TC $ 568.61 $ 568.61 0 0% 0% 0% 1 4 0 0 0 0 R 70543 $ 863.71 $ 863.71 0 0% 0% 0% 1 4 0 0 0 0 R 70543-26 $ 183.54 $ 183.54 0 0% 0% 0% 1 4 0 0 0 0 R 70543-TC $ 680.17 $ 680.17 0 0% 0% 0% 1 4 0 0 0 0 R 70544 $ 690.97 $ 690.97 0 0% 0% 0% 1 4 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 6
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
70544-26 $ 102.57 $ 102.57 0 0% 0% 0% 1 4 0 0 0 0 R 70544-TC $ 588.40 $ 588.40 0 0% 0% 0% 1 4 0 0 0 0 R 70545 $ 680.17 $ 680.17 0 0% 0% 0% 1 4 0 0 0 0 R 70545-26 $ 101.97 $ 101.97 0 0% 0% 0% 1 4 0 0 0 0 R 70545-TC $ 577.61 $ 577.61 0 0% 0% 0% 1 4 0 0 0 0 R 70546 $ 1056.85 $ 1056.85 0 0% 0% 0% 1 4 0 0 0 0 R 70546-26 $ 154.15 $ 154.15 0 0% 0% 0% 1 4 0 0 0 0 R 70546-TC $ 902.70 $ 902.70 0 0% 0% 0% 1 4 0 0 0 0 R 70547 $ 693.97 $ 693.97 0 0% 0% 0% 1 4 0 0 0 0 R 70547-26 $ 102.57 $ 102.57 0 0% 0% 0% 1 4 0 0 0 0 R 70547-TC $ 591.40 $ 591.40 0 0% 0% 0% 1 4 0 0 0 0 R 70548 $ 728.76 $ 728.76 0 0% 0% 0% 1 4 0 0 0 0 R 70548-26 $ 102.57 $ 102.57 0 0% 0% 0% 1 4 0 0 0 0 R 70548-TC $ 625.59 $ 625.59 0 0% 0% 0% 1 4 0 0 0 0 R 70549 $ 1061.65 $ 1061.65 0 0% 0% 0% 1 4 0 0 0 0 R 70549-26 $ 154.15 $ 154.15 0 0% 0% 0% 1 4 0 0 0 0 R 70549-TC $ 906.90 $ 906.90 0 0% 0% 0% 1 4 0 0 0 0 R 70551 $ 401.27 $ 401.27 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70551-26 $ 126.56 $ 126.56 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70551-TC $ 274.71 $ 274.71 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70552 $ 559.01 $ 559.01 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70552-26 $ 152.95 $ 152.95 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70552-TC $ 406.06 $ 406.06 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70553 $ 659.18 $ 659.18 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70553-26 $ 195.53 $ 195.53 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70553-TC $ 463.65 $ 463.65 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR70554 Not Covered Not Covered 0 0% 0% 0% 1 4 3 0 0 0 X 70554-26 Not Covered Not Covered 0 0% 0% 0% 1 4 3 0 0 0 X 70554-TC Not Covered Not Covered 0 0% 0% 0% 1 4 3 0 0 0 X 70555 Not Covered Not Covered 0 0% 0% 0% 1 0 3 0 0 0 X 70555-26 Not Covered Not Covered 0 0% 0% 0% 1 0 3 0 0 0 X 70555-TC Not Covered Not Covered 0 0% 0% 0% 1 0 3 0 0 0 X 70557 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 70557-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 70557-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 70558 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 70558-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 70558-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 7
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
70559 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 70559-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 70559-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 71010 $ 38.99 $ 38.99 0 0% 0% 0% 1 0 0 0 0 0 R 71010-26 $ 15.59 $ 15.59 0 0% 0% 0% 1 0 0 0 0 0 R 71010-TC $ 23.39 $ 23.39 0 0% 0% 0% 1 0 0 0 0 0 R 71015 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 0 0 0 R 71015-26 $ 18.59 $ 18.59 0 0% 0% 0% 1 0 0 0 0 0 R 71015-TC $ 28.79 $ 28.79 0 0% 0% 0% 1 0 0 0 0 0 R 71020 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R 71020-26 $ 18.59 $ 18.59 0 0% 0% 0% 1 0 0 0 0 0 R 71020-TC $ 29.39 $ 29.39 0 0% 0% 0% 1 0 0 0 0 0 R 71021 $ 58.78 $ 58.78 0 0% 0% 0% 1 0 0 0 0 0 R 71021-26 $ 23.39 $ 23.39 0 0% 0% 0% 1 0 0 0 0 0 R 71021-TC $ 35.39 $ 35.39 0 0% 0% 0% 1 0 0 0 0 0 R 71022 $ 72.58 $ 72.58 0 0% 0% 0% 1 0 0 0 0 0 R 71022-26 $ 28.79 $ 28.79 0 0% 0% 0% 1 0 0 0 0 0 R 71022-TC $ 43.79 $ 43.79 0 0% 0% 0% 1 0 0 0 0 0 R 71023 $ 110.36 $ 110.36 0 0% 0% 0% 1 0 0 0 0 0 R 71023-26 $ 32.99 $ 32.99 0 0% 0% 0% 1 0 0 0 0 0 R 71023-TC $ 77.37 $ 77.37 0 0% 0% 0% 1 0 0 0 0 0 R 71030 $ 71.98 $ 71.98 0 0% 0% 0% 1 0 0 0 0 0 R 71030-26 $ 26.39 $ 26.39 0 0% 0% 0% 1 0 0 0 0 0 R 71030-TC $ 45.58 $ 45.58 0 0% 0% 0% 1 0 0 0 0 0 R 71034 $ 146.95 $ 146.95 0 0% 0% 0% 1 0 0 0 0 0 R 71034-26 $ 39.59 $ 39.59 0 0% 0% 0% 1 0 0 0 0 0 R 71034-TC $ 107.36 $ 107.36 0 0% 0% 0% 1 0 0 0 0 0 R 71035 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 0 0 0 0 R 71035-26 $ 15.59 $ 15.59 0 0% 0% 0% 1 0 0 0 0 0 R 71035-TC $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R 71100 $ 52.78 $ 52.78 0 0% 0% 0% 1 0 0 0 0 0 R 71100-26 $ 19.19 $ 19.19 0 0% 0% 0% 1 0 0 0 0 0 R 71100-TC $ 32.99 $ 32.99 0 0% 0% 0% 1 0 0 0 0 0 R 71101 $ 62.38 $ 62.38 0 0% 0% 0% 1 0 0 0 0 0 R 71101-26 $ 22.79 $ 22.79 0 0% 0% 0% 1 0 0 0 0 0 R 71101-TC $ 39.59 $ 39.59 0 0% 0% 0% 1 0 0 0 0 0 R 71110 $ 64.18 $ 64.18 0 0% 0% 0% 1 0 2 0 0 0 R 71110-26 $ 23.39 $ 23.39 0 0% 0% 0% 1 0 2 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 8
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
71110-TC $ 40.79 $ 40.79 0 0% 0% 0% 1 0 2 0 0 0 R 71111 $ 82.17 $ 82.17 0 0% 0% 0% 1 0 2 0 0 0 R 71111-26 $ 27.59 $ 27.59 0 0% 0% 0% 1 0 2 0 0 0 R 71111-TC $ 53.98 $ 53.98 0 0% 0% 0% 1 0 2 0 0 0 R 71120 $ 50.98 $ 50.98 0 0% 0% 0% 1 0 0 0 0 0 R 71120-26 $ 17.39 $ 17.39 0 0% 0% 0% 1 0 0 0 0 0 R 71120-TC $ 32.99 $ 32.99 0 0% 0% 0% 1 0 0 0 0 0 R 71130 $ 62.38 $ 62.38 0 0% 0% 0% 1 0 0 0 0 0 R 71130-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 0 0 0 R 71130-TC $ 42.59 $ 42.59 0 0% 0% 0% 1 0 0 0 0 0 R 71250 $ 314.30 $ 314.30 0 0% 0% 0% 1 4 0 0 0 0 R 71250-26 $ 86.97 $ 86.97 0 0% 0% 0% 1 4 0 0 0 0 R 71250-TC $ 227.32 $ 227.32 0 0% 0% 0% 1 4 0 0 0 0 R 71260 $ 400.67 $ 400.67 0 0% 0% 0% 1 4 0 0 0 0 R 71260-26 $ 106.76 $ 106.76 0 0% 0% 0% 1 4 0 0 0 0 R 71260-TC $ 294.50 $ 294.50 0 0% 0% 0% 1 4 0 0 0 0 R 71270 $ 481.64 $ 481.64 0 0% 0% 0% 1 4 0 0 0 0 R 71270-26 $ 117.56 $ 117.56 0 0% 0% 0% 1 4 0 0 0 0 R 71270-TC $ 363.48 $ 363.48 0 0% 0% 0% 1 4 0 0 0 0 R 71275 $ 523.63 $ 523.63 0 0% 0% 0% 1 4 0 0 0 0 R 71275-26 $ 155.95 $ 155.95 0 0% 0% 0% 1 4 0 0 0 0 R 71275-TC $ 367.68 $ 367.68 0 0% 0% 0% 1 4 0 0 0 0 R 71550 $ 728.76 $ 728.76 0 0% 0% 0% 1 4 0 0 0 0 R 71550-26 $ 124.76 $ 124.76 0 0% 0% 0% 1 4 0 0 0 0 R 71550-TC $ 604.00 $ 604.00 0 0% 0% 0% 1 4 0 0 0 0 R 71551 $ 803.73 $ 803.73 0 0% 0% 0% 1 4 0 0 0 0 R 71551-26 $ 147.55 $ 147.55 0 0% 0% 0% 1 4 0 0 0 0 R 71551-TC $ 656.18 $ 656.18 0 0% 0% 0% 1 4 0 0 0 0 R 71552 $ 1018.46 $ 1018.46 0 0% 0% 0% 1 4 0 0 0 0 R 71552-26 $ 193.74 $ 193.74 0 0% 0% 0% 1 4 0 0 0 0 R 71552-TC $ 824.73 $ 824.73 0 0% 0% 0% 1 4 0 0 0 0 R 71555 $ 698.17 $ 698.17 0 0% 0% 0% 1 4 0 0 0 0 R 71555-26 $ 153.55 $ 153.55 0 0% 0% 0% 1 4 0 0 0 0 R 71555-TC $ 544.62 $ 544.62 0 0% 0% 0% 1 4 0 0 0 0 R 72010 $ 122.36 $ 122.36 0 0% 0% 0% 1 0 0 0 0 0 R 72010-26 $ 40.19 $ 40.19 0 0% 0% 0% 1 0 0 0 0 0 R 72010-TC $ 82.17 $ 82.17 0 0% 0% 0% 1 0 0 0 0 0 R 72020 $ 37.79 $ 37.79 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 9
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
72020-26 $ 13.20 $ 13.20 0 0% 0% 0% 1 0 0 0 0 0 R 72020-TC $ 24.59 $ 24.59 0 0% 0% 0% 1 0 0 0 0 0 R 72040 $ 56.98 $ 56.98 0 0% 0% 0% 1 0 0 0 0 0 R 72040-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 0 0 0 R 72040-TC $ 37.79 $ 37.79 0 0% 0% 0% 1 0 0 0 0 0 R 72050 $ 77.37 $ 77.37 0 0% 0% 0% 1 0 0 0 0 0 R 72050-26 $ 26.99 $ 26.99 0 0% 0% 0% 1 0 0 0 0 0 R 72050-TC $ 50.38 $ 50.38 0 0% 0% 0% 1 0 0 0 0 0 R 72052 $ 97.17 $ 97.17 0 0% 0% 0% 1 0 0 0 0 0 R 72052-26 $ 31.79 $ 31.79 0 0% 0% 0% 1 0 0 0 0 0 R 72052-TC $ 65.38 $ 65.38 0 0% 0% 0% 1 0 0 0 0 0 R 72069 $ 55.18 $ 55.18 0 0% 0% 0% 1 0 0 0 0 0 R 72069-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 0 0 0 R 72069-TC $ 35.99 $ 35.99 0 0% 0% 0% 1 0 0 0 0 0 R 72070 $ 53.98 $ 53.98 0 0% 0% 0% 1 0 0 0 0 0 R 72070-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 0 0 0 R 72070-TC $ 34.79 $ 34.79 0 0% 0% 0% 1 0 0 0 0 0 R 72072 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R 72072-26 $ 18.59 $ 18.59 0 0% 0% 0% 1 0 0 0 0 0 R 72072-TC $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R 72074 $ 67.78 $ 67.78 0 0% 0% 0% 1 0 0 0 0 0 R 72074-26 $ 18.59 $ 18.59 0 0% 0% 0% 1 0 0 0 0 0 R 72074-TC $ 49.18 $ 49.18 0 0% 0% 0% 1 0 0 0 0 0 R 72080 $ 57.58 $ 57.58 0 0% 0% 0% 1 0 0 0 0 0 R 72080-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 0 0 0 R 72080-TC $ 37.79 $ 37.79 0 0% 0% 0% 1 0 0 0 0 0 R 72090 $ 73.78 $ 73.78 0 0% 0% 0% 1 0 0 0 0 0 R 72090-26 $ 25.79 $ 25.79 0 0% 0% 0% 1 0 0 0 0 0 R 72090-TC $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R 72100 $ 60.58 $ 60.58 0 0% 0% 0% 1 0 0 0 0 0 R 72100-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 0 0 0 R 72100-TC $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R 72110 $ 84.57 $ 84.57 0 0% 0% 0% 1 0 0 0 0 0 R 72110-26 $ 26.99 $ 26.99 0 0% 0% 0% 1 0 0 0 0 0 R 72110-TC $ 57.58 $ 57.58 0 0% 0% 0% 1 0 0 0 0 0 R 72114 $ 108.56 $ 108.56 0 0% 0% 0% 1 0 0 0 0 0 R 72114-26 $ 28.19 $ 28.19 0 0% 0% 0% 1 0 0 0 0 0 R 72114-TC $ 80.37 $ 80.37 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 10
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
72120 $ 69.58 $ 69.58 0 0% 0% 0% 1 0 0 0 0 0 R 72120-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 0 0 0 R 72120-TC $ 49.78 $ 49.78 0 0% 0% 0% 1 0 0 0 0 0 R 72125 $ 322.09 $ 322.09 0 0% 0% 0% 1 4 0 0 0 0 R 72125-26 $ 91.77 $ 91.77 0 0% 0% 0% 1 4 0 0 0 0 R 72125-TC $ 230.32 $ 230.32 0 0% 0% 0% 1 4 0 0 0 0 R 72126 $ 400.67 $ 400.67 0 0% 0% 0% 1 4 0 0 0 0 R 72126-26 $ 104.37 $ 104.37 0 0% 0% 0% 1 4 0 0 0 0 R 72126-TC $ 296.30 $ 296.30 0 0% 0% 0% 1 4 0 0 0 0 R 72127 $ 473.84 $ 473.84 0 0% 0% 0% 1 4 0 0 0 0 R 72127-26 $ 108.56 $ 108.56 0 0% 0% 0% 1 4 0 0 0 0 R 72127-TC $ 365.28 $ 365.28 0 0% 0% 0% 1 4 0 0 0 0 R 72128 $ 314.30 $ 314.30 0 0% 0% 0% 1 4 0 0 0 0 R 72128-26 $ 85.17 $ 85.17 0 0% 0% 0% 1 4 0 0 0 0 R 72128-TC $ 229.12 $ 229.12 0 0% 0% 0% 1 4 0 0 0 0 R 72129 $ 401.27 $ 401.27 0 0% 0% 0% 1 4 0 0 0 0 R 72129-26 $ 103.77 $ 103.77 0 0% 0% 0% 1 4 0 0 0 0 R 72129-TC $ 296.90 $ 296.90 0 0% 0% 0% 1 4 0 0 0 0 R 72130 $ 474.44 $ 474.44 0 0% 0% 0% 1 4 0 0 0 0 R 72130-26 $ 108.56 $ 108.56 0 0% 0% 0% 1 4 0 0 0 0 R 72130-TC $ 365.88 $ 365.88 0 0% 0% 0% 1 4 0 0 0 0 R 72131 $ 312.50 $ 312.50 0 0% 0% 0% 1 4 0 0 0 0 R 72131-26 $ 85.17 $ 85.17 0 0% 0% 0% 1 4 0 0 0 0 R 72131-TC $ 227.32 $ 227.32 0 0% 0% 0% 1 4 0 0 0 0 R 72132 $ 399.47 $ 399.47 0 0% 0% 0% 1 4 0 0 0 0 R 72132-26 $ 104.37 $ 104.37 0 0% 0% 0% 1 4 0 0 0 0 R 72132-TC $ 295.10 $ 295.10 0 0% 0% 0% 1 4 0 0 0 0 R 72133 $ 473.84 $ 473.84 0 0% 0% 0% 1 4 0 0 0 0 R 72133-26 $ 108.56 $ 108.56 0 0% 0% 0% 1 4 0 0 0 0 R 72133-TC $ 365.28 $ 365.28 0 0% 0% 0% 1 4 0 0 0 0 R 72141 $ 389.27 $ 389.27 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72141-26 $ 126.56 $ 126.56 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72141-TC $ 262.71 $ 262.71 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72142 $ 566.21 $ 566.21 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72142-26 $ 152.95 $ 152.95 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72142-TC $ 413.26 $ 413.26 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72146 $ 389.27 $ 389.27 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72146-26 $ 126.56 $ 126.56 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 11
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
72146-TC $ 262.71 $ 262.71 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72147 $ 562.01 $ 562.01 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72147-26 $ 152.95 $ 152.95 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72147-TC $ 409.06 $ 409.06 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72148 $ 387.47 $ 387.47 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72148-26 $ 127.16 $ 127.16 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72148-TC $ 260.31 $ 260.31 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72149 $ 559.01 $ 559.01 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72149-26 $ 152.95 $ 152.95 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72149-TC $ 406.06 $ 406.06 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72156 $ 662.78 $ 662.78 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72156-26 $ 195.53 $ 195.53 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72156-TC $ 467.24 $ 467.24 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72157 $ 663.98 $ 663.98 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72157-26 $ 196.13 $ 196.13 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72157-TC $ 467.84 $ 467.84 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72158 $ 660.38 $ 660.38 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72158-26 $ 196.13 $ 196.13 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72158-TC $ 464.25 $ 464.25 0 0% 0% 0% 1 4 0 0 0 0 R Y-UR72159 $ 732.36 $ 732.36 0 0% 0% 0% 1 4 0 0 0 0 R 72159-26 $ 155.35 $ 155.35 0 0% 0% 0% 1 4 0 0 0 0 R 72159-TC $ 577.01 $ 577.01 0 0% 0% 0% 1 4 0 9 0 0 R 72170 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 0 0 0 R 72170-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 0 0 0 0 R 72170-TC $ 31.79 $ 31.79 0 0% 0% 0% 1 0 0 0 0 0 R 72190 $ 65.98 $ 65.98 0 0% 0% 0% 1 0 0 0 0 0 R 72190-26 $ 19.19 $ 19.19 0 0% 0% 0% 1 0 0 0 0 0 R 72190-TC $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 0 0 0 R 72191 $ 531.42 $ 531.42 0 0% 0% 0% 1 4 0 0 0 0 R 72191-26 $ 154.15 $ 154.15 0 0% 0% 0% 1 4 0 0 0 0 R 72191-TC $ 377.27 $ 377.27 0 0% 0% 0% 1 4 0 0 0 0 R 72192 $ 254.92 $ 254.92 0 0% 0% 0% 1 4 0 0 0 0 R 72192-26 $ 93.57 $ 93.57 0 0% 0% 0% 1 4 0 0 0 0 R 72192-TC $ 161.35 $ 161.35 0 0% 0% 0% 1 4 0 0 0 0 R 72193 $ 394.67 $ 394.67 0 0% 0% 0% 1 4 0 0 0 0 R 72193-26 $ 98.97 $ 98.97 0 0% 0% 0% 1 4 0 0 0 0 R 72193-TC $ 295.70 $ 295.70 0 0% 0% 0% 1 4 0 0 0 0 R 72194 $ 456.45 $ 456.45 0 0% 0% 0% 1 4 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 12
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
72194-26 $ 103.77 $ 103.77 0 0% 0% 0% 1 4 0 0 0 0 R 72194-TC $ 352.08 $ 352.08 0 0% 0% 0% 1 4 0 0 0 0 R 72195 $ 660.38 $ 660.38 0 0% 0% 0% 1 4 0 0 0 0 R 72195-26 $ 125.36 $ 125.36 0 0% 0% 0% 1 4 0 0 0 0 R 72195-TC $ 535.02 $ 535.02 0 0% 0% 0% 1 4 0 0 0 0 R 72196 $ 721.56 $ 721.56 0 0% 0% 0% 1 4 0 0 0 0 R 72196-26 $ 148.75 $ 148.75 0 0% 0% 0% 1 4 0 0 0 0 R 72196-TC $ 572.81 $ 572.81 0 0% 0% 0% 1 4 0 0 0 0 R 72197 $ 887.70 $ 887.70 0 0% 0% 0% 1 4 0 0 0 0 R 72197-26 $ 193.74 $ 193.74 0 0% 0% 0% 1 4 0 0 0 0 R 72197-TC $ 693.37 $ 693.37 0 0% 0% 0% 1 4 0 0 0 0 R 72198 $ 705.36 $ 705.36 0 0% 0% 0% 1 4 0 0 0 0 R 72198-26 $ 152.95 $ 152.95 0 0% 0% 0% 1 4 0 0 0 0 R 72198-TC $ 552.42 $ 552.42 0 0% 0% 0% 1 4 0 0 0 0 R 72200 $ 49.18 $ 49.18 0 0% 0% 0% 1 0 0 0 0 0 R 72200-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 0 0 0 0 R 72200-TC $ 34.19 $ 34.19 0 0% 0% 0% 1 0 0 0 0 0 R 72202 $ 56.98 $ 56.98 0 0% 0% 0% 1 0 0 0 0 0 R 72202-26 $ 16.19 $ 16.19 0 0% 0% 0% 1 0 0 0 0 0 R 72202-TC $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R 72220 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R 72220-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 0 0 0 0 R 72220-TC $ 32.99 $ 32.99 0 0% 0% 0% 1 0 0 0 0 0 R 72240 $ 169.74 $ 169.74 0 0% 0% 0% 1 0 0 0 0 0 R 72240-26 $ 78.57 $ 78.57 0 0% 0% 0% 1 0 0 0 0 0 R 72240-TC $ 91.77 $ 91.77 0 0% 0% 0% 1 0 0 0 0 0 R 72255 $ 169.14 $ 169.14 0 0% 0% 0% 1 0 0 0 0 0 R 72255-26 $ 78.57 $ 78.57 0 0% 0% 0% 1 0 0 0 0 0 R 72255-TC $ 90.57 $ 90.57 0 0% 0% 0% 1 0 0 0 0 0 R 72265 $ 158.95 $ 158.95 0 0% 0% 0% 1 0 0 0 0 0 R 72265-26 $ 71.38 $ 71.38 0 0% 0% 0% 1 0 0 0 0 0 R 72265-TC $ 87.57 $ 87.57 0 0% 0% 0% 1 0 0 0 0 0 R 72270 $ 219.53 $ 219.53 0 0% 0% 0% 1 0 0 0 0 0 R 72270-26 $ 113.96 $ 113.96 0 0% 0% 0% 1 0 0 0 0 0 R 72270-TC $ 105.56 $ 105.56 0 0% 0% 0% 1 0 0 0 0 0 R 72275 $ 201.53 $ 201.53 0 0% 0% 0% 1 9 9 9 9 9 R 72275-26 $ 67.18 $ 67.18 0 0% 0% 0% 1 9 9 9 9 9 R 72275-TC $ 134.36 $ 134.36 0 0% 0% 0% 1 9 9 9 9 9 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 13
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
72285 $ 197.33 $ 197.33 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR72285-26 $ 104.37 $ 104.37 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR72285-TC $ 92.97 $ 92.97 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR72295 $ 170.34 $ 170.34 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR72295-26 $ 73.78 $ 73.78 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR72295-TC $ 96.57 $ 96.57 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR73000 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 3 0 0 0 R 73000-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 3 0 0 0 R 73000-TC $ 32.99 $ 32.99 0 0% 0% 0% 1 0 3 0 0 0 R 73010 $ 51.58 $ 51.58 0 0% 0% 0% 1 0 3 0 0 0 R 73010-26 $ 16.19 $ 16.19 0 0% 0% 0% 1 0 3 0 0 0 R 73010-TC $ 35.99 $ 35.99 0 0% 0% 0% 1 0 3 0 0 0 R 73020 $ 39.59 $ 39.59 0 0% 0% 0% 1 0 3 0 0 0 R 73020-26 $ 13.20 $ 13.20 0 0% 0% 0% 1 0 3 0 0 0 R 73020-TC $ 26.39 $ 26.39 0 0% 0% 0% 1 0 3 0 0 0 R 73030 $ 49.78 $ 49.78 0 0% 0% 0% 1 0 3 0 0 0 R 73030-26 $ 16.79 $ 16.79 0 0% 0% 0% 1 0 3 0 0 0 R 73030-TC $ 32.99 $ 32.99 0 0% 0% 0% 1 0 3 0 0 0 R 73040 $ 175.74 $ 175.74 0 0% 0% 0% 1 0 3 0 0 0 R 73040-26 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 3 0 0 0 R 73040-TC $ 128.36 $ 128.36 0 0% 0% 0% 1 0 3 0 0 0 R 73050 $ 61.78 $ 61.78 0 0% 0% 0% 1 0 2 0 0 0 R 73050-26 $ 18.59 $ 18.59 0 0% 0% 0% 1 0 2 0 0 0 R 73050-TC $ 43.19 $ 43.19 0 0% 0% 0% 1 0 2 0 0 0 R 73060 $ 46.18 $ 46.18 0 0% 0% 0% 1 0 3 0 0 0 R 73060-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 3 0 0 0 R 73060-TC $ 30.59 $ 30.59 0 0% 0% 0% 1 0 3 0 0 0 R 73070 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 3 0 0 0 R 73070-26 $ 13.80 $ 13.80 0 0% 0% 0% 1 0 3 0 0 0 R 73070-TC $ 32.99 $ 32.99 0 0% 0% 0% 1 0 3 0 0 0 R 73080 $ 53.98 $ 53.98 0 0% 0% 0% 1 0 3 0 0 0 R 73080-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 3 0 0 0 R 73080-TC $ 38.99 $ 38.99 0 0% 0% 0% 1 0 3 0 0 0 R 73085 $ 172.14 $ 172.14 0 0% 0% 0% 1 0 3 0 0 0 R 73085-26 $ 48.58 $ 48.58 0 0% 0% 0% 1 0 3 0 0 0 R 73085-TC $ 123.56 $ 123.56 0 0% 0% 0% 1 0 3 0 0 0 R 73090 $ 44.39 $ 44.39 0 0% 0% 0% 1 0 3 0 0 0 R 73090-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 3 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 14
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
73090-TC $ 29.99 $ 29.99 0 0% 0% 0% 1 0 3 0 0 0 R 73092 Not Covered Not Covered 0 0% 0% 0% 1 0 3 0 0 0 X 73092-26 Not Covered Not Covered 0 0% 0% 0% 1 0 3 0 0 0 X 73092-TC Not Covered Not Covered 0 0% 0% 0% 1 0 3 0 0 0 X 73100 $ 50.38 $ 50.38 0 0% 0% 0% 1 0 3 0 0 0 R 73100-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 3 0 0 0 R 73100-TC $ 35.99 $ 35.99 0 0% 0% 0% 1 0 3 0 0 0 R 73110 $ 61.18 $ 61.18 0 0% 0% 0% 1 0 3 0 0 0 R 73110-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 3 0 0 0 R 73110-TC $ 46.18 $ 46.18 0 0% 0% 0% 1 0 3 0 0 0 R 73115 $ 187.14 $ 187.14 0 0% 0% 0% 1 0 3 0 0 0 R 73115-26 $ 48.58 $ 48.58 0 0% 0% 0% 1 0 3 0 0 0 R 73115-TC $ 138.55 $ 138.55 0 0% 0% 0% 1 0 3 0 0 0 R 73120 $ 44.99 $ 44.99 0 0% 0% 0% 1 0 3 0 0 0 R 73120-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 3 0 0 0 R 73120-TC $ 30.59 $ 30.59 0 0% 0% 0% 1 0 3 0 0 0 R 73130 $ 52.78 $ 52.78 0 0% 0% 0% 1 0 3 0 0 0 R 73130-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 3 0 0 0 R 73130-TC $ 37.79 $ 37.79 0 0% 0% 0% 1 0 3 0 0 0 R 73140 $ 53.98 $ 53.98 0 0% 0% 0% 1 0 3 0 0 0 R 73140-26 $ 12.00 $ 12.00 0 0% 0% 0% 1 0 3 0 0 0 R 73140-TC $ 41.99 $ 41.99 0 0% 0% 0% 1 0 3 0 0 0 R 73200 $ 312.50 $ 312.50 0 0% 0% 0% 1 4 3 0 0 0 R 73200-26 $ 85.17 $ 85.17 0 0% 0% 0% 1 4 3 0 0 0 R 73200-TC $ 227.32 $ 227.32 0 0% 0% 0% 1 4 3 0 0 0 R 73201 $ 389.27 $ 389.27 0 0% 0% 0% 1 4 3 0 0 0 R 73201-26 $ 98.97 $ 98.97 0 0% 0% 0% 1 4 3 0 0 0 R 73201-TC $ 290.30 $ 290.30 0 0% 0% 0% 1 4 3 0 0 0 R 73202 $ 487.04 $ 487.04 0 0% 0% 0% 1 4 3 0 0 0 R 73202-26 $ 103.77 $ 103.77 0 0% 0% 0% 1 4 3 0 0 0 R 73202-TC $ 383.27 $ 383.27 0 0% 0% 0% 1 4 3 0 0 0 R 73206 $ 570.41 $ 570.41 0 0% 0% 0% 1 4 0 0 0 0 R 73206-26 $ 153.55 $ 153.55 0 0% 0% 0% 1 4 0 0 0 0 R 73206-TC $ 416.86 $ 416.86 0 0% 0% 0% 1 4 0 0 0 0 R 73218 $ 639.99 $ 639.99 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73218-26 $ 115.16 $ 115.16 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73218-TC $ 524.83 $ 524.83 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73219 $ 708.36 $ 708.36 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 15
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
73219-26 $ 139.15 $ 139.15 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73219-TC $ 569.21 $ 569.21 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73220 $ 876.31 $ 876.31 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73220-26 $ 184.14 $ 184.14 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73220-TC $ 692.17 $ 692.17 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73221 $ 411.46 $ 411.46 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73221-26 $ 116.36 $ 116.36 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73221-TC $ 295.10 $ 295.10 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73222 $ 664.58 $ 664.58 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73222-26 $ 139.15 $ 139.15 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73222-TC $ 525.42 $ 525.42 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73223 $ 822.33 $ 822.33 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73223-26 $ 184.14 $ 184.14 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73223-TC $ 638.19 $ 638.19 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73225 $ 708.36 $ 708.36 0 0% 0% 0% 1 4 0 0 0 0 R 73225-26 $ 145.15 $ 145.15 0 0% 0% 0% 1 4 0 0 0 0 R 73225-TC $ 563.21 $ 563.21 0 0% 0% 0% 1 4 0 9 0 0 R 73500 $ 45.58 $ 45.58 0 0% 0% 0% 1 0 0 0 0 0 R 73500-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 0 0 0 0 R 73500-TC $ 29.99 $ 29.99 0 0% 0% 0% 1 0 0 0 0 0 R 73510 $ 64.18 $ 64.18 0 0% 0% 0% 1 0 0 0 0 0 R 73510-26 $ 19.19 $ 19.19 0 0% 0% 0% 1 0 0 0 0 0 R 73510-TC $ 45.58 $ 45.58 0 0% 0% 0% 1 0 0 0 0 0 R 73520 $ 68.38 $ 68.38 0 0% 0% 0% 1 0 2 0 0 0 R 73520-26 $ 23.39 $ 23.39 0 0% 0% 0% 1 0 2 0 0 0 R 73520-TC $ 44.39 $ 44.39 0 0% 0% 0% 1 0 2 0 0 0 R 73525 $ 177.54 $ 177.54 0 0% 0% 0% 1 0 3 0 0 0 R 73525-26 $ 49.18 $ 49.18 0 0% 0% 0% 1 0 3 0 0 0 R 73525-TC $ 128.36 $ 128.36 0 0% 0% 0% 1 0 3 0 0 0 R 73530 By Report By Report 0 0% 0% 0% 1 0 3 0 0 0 N 73530-26 $ 25.19 $ 25.19 0 0% 0% 0% 1 0 3 0 0 0 R 73530-TC By Report By Report 0 0% 0% 0% 1 0 3 0 0 0 N 73540 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 73540-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 73540-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 73550 $ 46.78 $ 46.78 0 0% 0% 0% 1 0 3 0 0 0 R 73550-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 3 0 0 0 R 73550-TC $ 31.19 $ 31.19 0 0% 0% 0% 1 0 3 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 16
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
73560 $ 50.38 $ 50.38 0 0% 0% 0% 1 0 3 0 0 0 R 73560-26 $ 16.19 $ 16.19 0 0% 0% 0% 1 0 3 0 0 0 R 73560-TC $ 34.79 $ 34.79 0 0% 0% 0% 1 0 3 0 0 0 R 73562 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 3 0 0 0 R 73562-26 $ 16.79 $ 16.79 0 0% 0% 0% 1 0 3 0 0 0 R 73562-TC $ 42.59 $ 42.59 0 0% 0% 0% 1 0 3 0 0 0 R 73564 $ 68.98 $ 68.98 0 0% 0% 0% 1 0 3 0 0 0 R 73564-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 3 0 0 0 R 73564-TC $ 49.18 $ 49.18 0 0% 0% 0% 1 0 3 0 0 0 R 73565 $ 56.98 $ 56.98 0 0% 0% 0% 1 0 2 0 0 0 R 73565-26 $ 16.19 $ 16.19 0 0% 0% 0% 1 0 2 0 0 0 R 73565-TC $ 40.79 $ 40.79 0 0% 0% 0% 1 0 2 0 0 0 R 73580 $ 200.93 $ 200.93 0 0% 0% 0% 1 0 3 0 0 0 R 73580-26 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 3 0 0 0 R 73580-TC $ 152.95 $ 152.95 0 0% 0% 0% 1 0 3 0 0 0 R 73590 $ 45.58 $ 45.58 0 0% 0% 0% 1 0 3 0 0 0 R 73590-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 3 0 0 0 R 73590-TC $ 30.59 $ 30.59 0 0% 0% 0% 1 0 3 0 0 0 R 73592 Not Covered Not Covered 0 0% 0% 0% 1 0 3 0 0 0 X 73592-26 Not Covered Not Covered 0 0% 0% 0% 1 0 3 0 0 0 X 73592-TC Not Covered Not Covered 0 0% 0% 0% 1 0 3 0 0 0 X 73600 $ 46.78 $ 46.78 0 0% 0% 0% 1 0 3 0 0 0 R 73600-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 3 0 0 0 R 73600-TC $ 32.39 $ 32.39 0 0% 0% 0% 1 0 3 0 0 0 R 73610 $ 53.98 $ 53.98 0 0% 0% 0% 1 0 3 0 0 0 R 73610-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 3 0 0 0 R 73610-TC $ 38.99 $ 38.99 0 0% 0% 0% 1 0 3 0 0 0 R 73615 $ 172.14 $ 172.14 0 0% 0% 0% 1 0 3 0 0 0 R 73615-26 $ 49.18 $ 49.18 0 0% 0% 0% 1 0 3 0 0 0 R 73615-TC $ 122.36 $ 122.36 0 0% 0% 0% 1 0 3 0 0 0 R 73620 $ 44.39 $ 44.39 0 0% 0% 0% 1 0 3 0 0 0 R 73620-26 $ 13.20 $ 13.20 0 0% 0% 0% 1 0 3 0 0 0 R 73620-TC $ 31.19 $ 31.19 0 0% 0% 0% 1 0 3 0 0 0 R 73630 $ 50.38 $ 50.38 0 0% 0% 0% 1 0 3 0 0 0 R 73630-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 3 0 0 0 R 73630-TC $ 35.99 $ 35.99 0 0% 0% 0% 1 0 3 0 0 0 R 73650 $ 46.18 $ 46.18 0 0% 0% 0% 1 0 3 0 0 0 R 73650-26 $ 13.80 $ 13.80 0 0% 0% 0% 1 0 3 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 17
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
73650-TC $ 32.39 $ 32.39 0 0% 0% 0% 1 0 3 0 0 0 R 73660 $ 48.58 $ 48.58 0 0% 0% 0% 1 0 3 0 0 0 R 73660-26 $ 11.40 $ 11.40 0 0% 0% 0% 1 0 3 0 0 0 R 73660-TC $ 37.19 $ 37.19 0 0% 0% 0% 1 0 3 0 0 0 R 73700 $ 312.50 $ 312.50 0 0% 0% 0% 1 4 3 0 0 0 R 73700-26 $ 85.17 $ 85.17 0 0% 0% 0% 1 4 3 0 0 0 R 73700-TC $ 227.32 $ 227.32 0 0% 0% 0% 1 4 3 0 0 0 R 73701 $ 394.67 $ 394.67 0 0% 0% 0% 1 4 3 0 0 0 R 73701-26 $ 98.97 $ 98.97 0 0% 0% 0% 1 4 3 0 0 0 R 73701-TC $ 295.70 $ 295.70 0 0% 0% 0% 1 4 3 0 0 0 R 73702 $ 479.24 $ 479.24 0 0% 0% 0% 1 4 3 0 0 0 R 73702-26 $ 103.17 $ 103.17 0 0% 0% 0% 1 4 3 0 0 0 R 73702-TC $ 376.07 $ 376.07 0 0% 0% 0% 1 4 3 0 0 0 R 73706 $ 614.20 $ 614.20 0 0% 0% 0% 1 4 3 0 0 0 R 73706-26 $ 161.35 $ 161.35 0 0% 0% 0% 1 4 3 0 0 0 R 73706-TC $ 453.45 $ 453.45 0 0% 0% 0% 1 4 3 0 0 0 R 73718 $ 641.19 $ 641.19 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73718-26 $ 115.16 $ 115.16 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73718-TC $ 526.02 $ 526.02 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73719 $ 710.16 $ 710.16 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73719-26 $ 138.55 $ 138.55 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73719-TC $ 571.61 $ 571.61 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73720 $ 882.31 $ 882.31 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73720-26 $ 184.14 $ 184.14 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73720-TC $ 698.17 $ 698.17 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73721 $ 410.86 $ 410.86 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73721-26 $ 115.76 $ 115.76 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73721-TC $ 295.10 $ 295.10 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73722 $ 669.98 $ 669.98 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73722-26 $ 139.75 $ 139.75 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73722-TC $ 530.22 $ 530.22 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73723 $ 826.52 $ 826.52 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73723-26 $ 184.14 $ 184.14 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73723-TC $ 642.39 $ 642.39 0 0% 0% 0% 1 4 3 0 0 0 R Y-UR73725 $ 707.16 $ 707.16 0 0% 0% 0% 1 4 3 0 0 0 R 73725-26 $ 154.15 $ 154.15 0 0% 0% 0% 1 4 3 0 0 0 R 73725-TC $ 553.02 $ 553.02 0 0% 0% 0% 1 4 3 0 0 0 R 74000 $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 18
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
74000-26 $ 15.59 $ 15.59 0 0% 0% 0% 1 0 0 0 0 0 R 74000-TC $ 25.19 $ 25.19 0 0% 0% 0% 1 0 0 0 0 0 R 74010 $ 60.58 $ 60.58 0 0% 0% 0% 1 0 0 0 0 0 R 74010-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 0 0 0 R 74010-TC $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R 74020 $ 64.18 $ 64.18 0 0% 0% 0% 1 0 0 0 0 0 R 74020-26 $ 22.79 $ 22.79 0 0% 0% 0% 1 0 0 0 0 0 R 74020-TC $ 41.39 $ 41.39 0 0% 0% 0% 1 0 0 0 0 0 R 74022 $ 76.17 $ 76.17 0 0% 0% 0% 1 0 0 0 0 0 R 74022-26 $ 26.99 $ 26.99 0 0% 0% 0% 1 0 0 0 0 0 R 74022-TC $ 49.18 $ 49.18 0 0% 0% 0% 1 0 0 0 0 0 R 74150 $ 260.31 $ 260.31 0 0% 0% 0% 1 4 0 0 0 0 R 74150-26 $ 101.37 $ 101.37 0 0% 0% 0% 1 4 0 0 0 0 R 74150-TC $ 158.95 $ 158.95 0 0% 0% 0% 1 4 0 0 0 0 R 74160 $ 403.67 $ 403.67 0 0% 0% 0% 1 4 0 0 0 0 R 74160-26 $ 109.16 $ 109.16 0 0% 0% 0% 1 4 0 0 0 0 R 74160-TC $ 294.50 $ 294.50 0 0% 0% 0% 1 4 0 0 0 0 R 74170 $ 458.85 $ 458.85 0 0% 0% 0% 1 4 0 0 0 0 R 74170-26 $ 119.36 $ 119.36 0 0% 0% 0% 1 4 0 0 0 0 R 74170-TC $ 339.49 $ 339.49 0 0% 0% 0% 1 4 0 0 0 0 R 74174 $ 679.57 $ 679.57 0 0% 0% 0% 1 4 0 0 0 0 R74174-26 $ 187.14 $ 187.14 0 0% 0% 0% 1 4 0 0 0 0 R74174-TC $ 491.84 $ 491.84 0 0% 0% 0% 1 4 0 0 0 0 R74175 $ 535.62 $ 535.62 0 0% 0% 0% 1 4 0 0 0 0 R 74175-26 $ 154.75 $ 154.75 0 0% 0% 0% 1 4 0 0 0 0 R 74175-TC $ 380.87 $ 380.87 0 0% 0% 0% 1 4 0 0 0 0 R 74176 $ 347.28 $ 347.28 0 0% 0% 0% 1 4 0 9 0 0 R74176-26 $ 149.35 $ 149.35 0 0% 0% 0% 1 4 0 9 0 0 R74176-TC $ 197.93 $ 197.93 0 0% 0% 0% 1 4 0 9 0 0 R74177 $ 544.62 $ 544.62 0 0% 0% 0% 1 4 0 9 0 0 R74177-26 $ 156.55 $ 156.55 0 0% 0% 0% 1 4 0 9 0 0 R74177-TC $ 388.07 $ 388.07 0 0% 0% 0% 1 4 0 9 0 0 R74178 $ 617.19 $ 617.19 0 0% 0% 0% 1 4 0 9 0 0 R74178-26 $ 172.14 $ 172.14 0 0% 0% 0% 1 4 0 9 0 0 R74178-TC $ 444.45 $ 444.45 0 0% 0% 0% 1 4 0 9 0 0 R74181 $ 583.61 $ 583.61 0 0% 0% 0% 1 4 0 0 0 0 R 74181-26 $ 124.76 $ 124.76 0 0% 0% 0% 1 4 0 0 0 0 R 74181-TC $ 459.45 $ 459.45 0 0% 0% 0% 1 4 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 19
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
74182 $ 798.93 $ 798.93 0 0% 0% 0% 1 4 0 0 0 0 R 74182-26 $ 148.15 $ 148.15 0 0% 0% 0% 1 4 0 0 0 0 R 74182-TC $ 650.78 $ 650.78 0 0% 0% 0% 1 4 0 0 0 0 R 74183 $ 889.50 $ 889.50 0 0% 0% 0% 1 4 0 0 0 0 R 74183-26 $ 193.74 $ 193.74 0 0% 0% 0% 1 4 0 0 0 0 R 74183-TC $ 695.17 $ 695.17 0 0% 0% 0% 1 4 0 0 0 0 R 74185 $ 707.16 $ 707.16 0 0% 0% 0% 1 4 0 0 0 0 R 74185-26 $ 152.95 $ 152.95 0 0% 0% 0% 1 4 0 0 0 0 R 74185-TC $ 554.22 $ 554.22 0 0% 0% 0% 1 4 0 0 0 0 R 74190 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74190-26 $ 40.19 $ 40.19 0 0% 0% 0% 1 0 0 0 0 0 R 74190-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74210 $ 135.55 $ 135.55 0 0% 0% 0% 1 0 0 0 0 0 R 74210-26 $ 30.59 $ 30.59 0 0% 0% 0% 1 0 0 0 0 0 R 74210-TC $ 104.97 $ 104.97 0 0% 0% 0% 1 0 0 0 0 0 R 74220 $ 154.75 $ 154.75 0 0% 0% 0% 1 0 0 0 0 0 R 74220-26 $ 39.59 $ 39.59 0 0% 0% 0% 1 0 0 0 0 0 R 74220-TC $ 115.16 $ 115.16 0 0% 0% 0% 1 0 0 0 0 0 R 74230 $ 225.52 $ 225.52 0 0% 0% 0% 1 0 0 0 0 0 R 74230-26 $ 45.58 $ 45.58 0 0% 0% 0% 1 0 0 0 0 0 R 74230-TC $ 179.94 $ 179.94 0 0% 0% 0% 1 0 0 0 0 0 R 74235 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74235-26 $ 107.96 $ 107.96 0 0% 0% 0% 1 0 0 0 0 0 R 74235-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74240 $ 197.93 $ 197.93 0 0% 0% 0% 1 0 0 0 0 0 R 74240-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R 74240-TC $ 138.55 $ 138.55 0 0% 0% 0% 1 0 0 0 0 0 R 74241 $ 205.13 $ 205.13 0 0% 0% 0% 1 0 0 0 0 0 R 74241-26 $ 58.78 $ 58.78 0 0% 0% 0% 1 0 0 0 0 0 R 74241-TC $ 146.35 $ 146.35 0 0% 0% 0% 1 0 0 0 0 0 R 74245 $ 299.30 $ 299.30 0 0% 0% 0% 1 0 0 0 0 0 R 74245-26 $ 77.97 $ 77.97 0 0% 0% 0% 1 0 0 0 0 0 R 74245-TC $ 221.33 $ 221.33 0 0% 0% 0% 1 0 0 0 0 0 R 74246 $ 223.13 $ 223.13 0 0% 0% 0% 1 0 0 0 0 0 R 74246-26 $ 59.98 $ 59.98 0 0% 0% 0% 1 0 0 0 0 0 R 74246-TC $ 163.15 $ 163.15 0 0% 0% 0% 1 0 0 0 0 0 R 74247 $ 246.52 $ 246.52 0 0% 0% 0% 1 0 0 0 0 0 R 74247-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 20
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
74247-TC $ 187.14 $ 187.14 0 0% 0% 0% 1 0 0 0 0 0 R 74249 $ 320.89 $ 320.89 0 0% 0% 0% 1 0 0 0 0 0 R 74249-26 $ 77.97 $ 77.97 0 0% 0% 0% 1 0 0 0 0 0 R 74249-TC $ 242.92 $ 242.92 0 0% 0% 0% 1 0 0 0 0 0 R 74250 $ 182.34 $ 182.34 0 0% 0% 0% 1 0 0 0 0 0 R 74250-26 $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R 74250-TC $ 141.55 $ 141.55 0 0% 0% 0% 1 0 0 0 0 0 R 74251 $ 740.15 $ 740.15 0 0% 0% 0% 1 0 0 0 0 0 R 74251-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R 74251-TC $ 680.77 $ 680.77 0 0% 0% 0% 1 0 0 0 0 0 R 74260 $ 618.39 $ 618.39 0 0% 0% 0% 1 0 0 0 0 0 R 74260-26 $ 43.19 $ 43.19 0 0% 0% 0% 1 0 0 0 0 0 R 74260-TC $ 575.21 $ 575.21 0 0% 0% 0% 1 0 0 0 0 0 R 74261 $ 851.72 $ 851.72 0 0% 0% 0% 1 4 0 0 0 0 R Y74261-26 $ 206.33 $ 206.33 0 0% 0% 0% 1 4 0 0 0 0 R Y74261-TC $ 645.38 $ 645.38 0 0% 0% 0% 1 4 0 0 0 0 R Y74262 $ 953.08 $ 953.08 0 0% 0% 0% 1 4 0 0 0 0 R Y74262-26 $ 214.73 $ 214.73 0 0% 0% 0% 1 4 0 0 0 0 R Y74262-TC $ 738.35 $ 738.35 0 0% 0% 0% 1 4 0 0 0 0 R Y74263 $ 1331.56 $ 1331.56 0 0% 0% 0% 1 9 9 9 9 9 R Y74263-26 $ 195.53 $ 195.53 0 0% 0% 0% 1 9 9 9 9 9 R Y74263-TC $ 1136.02 $ 1136.02 0 0% 0% 0% 1 9 9 9 9 9 R Y74270 $ 262.71 $ 262.71 0 0% 0% 0% 1 0 0 0 0 0 R 74270-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R 74270-TC $ 203.33 $ 203.33 0 0% 0% 0% 1 0 0 0 0 0 R 74280 $ 371.88 $ 371.88 0 0% 0% 0% 1 0 0 0 0 0 R 74280-26 $ 85.17 $ 85.17 0 0% 0% 0% 1 0 0 0 0 0 R 74280-TC $ 286.70 $ 286.70 0 0% 0% 0% 1 0 0 0 0 0 R 74283 $ 356.28 $ 356.28 0 0% 0% 0% 1 0 0 0 0 0 R 74283-26 $ 176.34 $ 176.34 0 0% 0% 0% 1 0 0 0 0 0 R 74283-TC $ 180.54 $ 180.54 0 0% 0% 0% 1 0 0 0 0 0 R 74290 $ 122.36 $ 122.36 0 0% 0% 0% 1 0 0 0 0 0 R 74290-26 $ 27.59 $ 27.59 0 0% 0% 0% 1 0 0 0 0 0 R 74290-TC $ 94.77 $ 94.77 0 0% 0% 0% 1 0 0 0 0 0 R 74300 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74300-26 $ 31.19 $ 31.19 0 0% 0% 0% 1 0 0 0 0 0 R 74300-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74301 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 21
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
74301-26 $ 17.99 $ 17.99 0 0% 0% 0% 1 0 0 0 0 0 R 74301-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74305 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74305-26 $ 35.39 $ 35.39 0 0% 0% 0% 1 0 0 0 0 0 R 74305-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74320 $ 162.55 $ 162.55 0 0% 0% 0% 1 0 0 0 0 0 R 74320-26 $ 44.99 $ 44.99 0 0% 0% 0% 1 0 0 0 0 0 R 74320-TC $ 117.56 $ 117.56 0 0% 0% 0% 1 0 0 0 0 0 R 74327 $ 235.12 $ 235.12 0 0% 0% 0% 1 0 0 0 0 0 R 74327-26 $ 58.78 $ 58.78 0 0% 0% 0% 1 0 0 0 0 0 R 74327-TC $ 176.34 $ 176.34 0 0% 0% 0% 1 0 0 0 0 0 R 74328 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74328-26 $ 61.78 $ 61.78 0 0% 0% 0% 1 0 0 0 0 0 R 74328-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74329 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74329-26 $ 61.78 $ 61.78 0 0% 0% 0% 1 0 0 0 0 0 R 74329-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74330 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74330-26 $ 78.57 $ 78.57 0 0% 0% 0% 1 0 0 0 0 0 R 74330-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74340 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74340-26 $ 46.18 $ 46.18 0 0% 0% 0% 1 0 0 0 0 0 R 74340-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74355 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74355-26 $ 66.58 $ 66.58 0 0% 0% 0% 1 0 0 0 0 0 R 74355-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74360 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74360-26 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R 74360-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74363 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74363-26 $ 74.38 $ 74.38 0 0% 0% 0% 1 0 0 0 0 0 R 74363-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74400 $ 191.34 $ 191.34 0 0% 0% 0% 1 0 0 0 0 0 R 74400-26 $ 41.39 $ 41.39 0 0% 0% 0% 1 0 0 0 0 0 R 74400-TC $ 149.95 $ 149.95 0 0% 0% 0% 1 0 0 0 0 0 R 74410 $ 186.54 $ 186.54 0 0% 0% 0% 1 0 0 0 0 0 R 74410-26 $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R 74410-TC $ 146.35 $ 146.35 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 22
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
74415 $ 239.92 $ 239.92 0 0% 0% 0% 1 0 0 0 0 0 R 74415-26 $ 41.39 $ 41.39 0 0% 0% 0% 1 0 0 0 0 0 R 74415-TC $ 197.93 $ 197.93 0 0% 0% 0% 1 0 0 0 0 0 R 74420 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74420-26 $ 30.59 $ 30.59 0 0% 0% 0% 1 0 0 0 0 0 R 74420-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74425 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74425-26 $ 29.99 $ 29.99 0 0% 0% 0% 1 0 0 0 0 0 R 74425-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74430 $ 64.18 $ 64.18 0 0% 0% 0% 1 0 0 0 0 0 R 74430-26 $ 26.99 $ 26.99 0 0% 0% 0% 1 0 0 0 0 0 R 74430-TC $ 37.19 $ 37.19 0 0% 0% 0% 1 0 0 0 0 0 R 74440 $ 139.75 $ 139.75 0 0% 0% 0% 1 0 0 0 0 0 R 74440-26 $ 31.79 $ 31.79 0 0% 0% 0% 1 0 0 0 0 0 R 74440-TC $ 107.96 $ 107.96 0 0% 0% 0% 1 0 0 0 0 0 R 74445 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74445-26 $ 97.17 $ 97.17 0 0% 0% 0% 1 0 0 0 0 0 R 74445-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74450 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74450-26 $ 28.19 $ 28.19 0 0% 0% 0% 1 0 0 0 0 0 R 74450-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 74455 $ 142.75 $ 142.75 0 0% 0% 0% 1 0 0 0 0 0 R 74455-26 $ 27.59 $ 27.59 0 0% 0% 0% 1 0 0 0 0 0 R 74455-TC $ 115.16 $ 115.16 0 0% 0% 0% 1 0 0 0 0 0 R 74470 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74470-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74470-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74475 $ 161.35 $ 161.35 0 0% 0% 0% 1 0 0 0 0 0 R 74475-26 $ 44.99 $ 44.99 0 0% 0% 0% 1 0 0 0 0 0 R 74475-TC $ 116.36 $ 116.36 0 0% 0% 0% 1 0 0 0 0 0 R 74480 $ 161.35 $ 161.35 0 0% 0% 0% 1 0 0 0 0 0 R 74480-26 $ 44.99 $ 44.99 0 0% 0% 0% 1 0 0 0 0 0 R 74480-TC $ 116.36 $ 116.36 0 0% 0% 0% 1 0 0 0 0 0 R 74485 $ 160.75 $ 160.75 0 0% 0% 0% 1 0 0 0 0 0 R 74485-26 $ 44.39 $ 44.39 0 0% 0% 0% 1 0 0 0 0 0 R 74485-TC $ 116.36 $ 116.36 0 0% 0% 0% 1 0 0 0 0 0 R 74710 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74710-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 23
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
74710-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74740 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74740-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74740-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74742 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74742-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74742-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 74775 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y74775-26 $ 53.38 $ 53.38 0 0% 0% 0% 1 0 0 0 0 0 R Y74775-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y75557 $ 554.22 $ 554.22 0 0% 0% 0% 1 4 0 0 0 0 R Y75557-26 $ 198.53 $ 198.53 0 0% 0% 0% 1 4 0 0 0 0 R Y75557-TC $ 355.08 $ 355.08 0 0% 0% 0% 1 4 0 0 0 0 R Y75559 $ 757.55 $ 757.55 0 0% 0% 0% 1 4 0 0 0 0 R Y75559-26 $ 244.72 $ 244.72 0 0% 0% 0% 1 4 0 0 0 0 R Y75559-TC $ 512.83 $ 512.83 0 0% 0% 0% 1 4 0 0 0 0 R Y75561 $ 741.35 $ 741.35 0 0% 0% 0% 1 4 0 0 0 0 R Y75561-26 $ 219.53 $ 219.53 0 0% 0% 0% 1 4 0 0 0 0 R Y75561-TC $ 521.83 $ 521.83 0 0% 0% 0% 1 4 0 0 0 0 R Y75563 $ 881.11 $ 881.11 0 0% 0% 0% 1 4 0 0 0 0 R Y75563-26 $ 252.52 $ 252.52 0 0% 0% 0% 1 4 0 0 0 0 R Y75563-TC $ 627.99 $ 627.99 0 0% 0% 0% 1 4 0 0 0 0 R Y75565 $ 96.57 $ 96.57 0 0% 0% 0% 1 0 0 0 0 0 R Y75565-26 $ 20.99 $ 20.99 0 0% 0% 0% 1 0 0 0 0 0 R Y75565-TC $ 75.57 $ 75.57 0 0% 0% 0% 1 0 0 0 0 0 R Y75571 $ 175.74 $ 175.74 0 0% 0% 0% 1 4 0 0 0 0 R Y75571-26 $ 49.18 $ 49.18 0 0% 0% 0% 1 4 0 0 0 0 R Y75571-TC $ 126.56 $ 126.56 0 0% 0% 0% 1 4 0 0 0 0 R Y75572 $ 497.23 $ 497.23 0 0% 0% 0% 1 4 0 0 0 0 R Y75572-26 $ 148.15 $ 148.15 0 0% 0% 0% 1 4 0 0 0 0 R Y75572-TC $ 348.48 $ 348.48 0 0% 0% 0% 1 4 0 0 0 0 R Y75573 Not Covered Not Covered 0 0% 0% 0% 1 4 0 0 0 0 X75574 $ 732.96 $ 732.96 0 0% 0% 0% 1 4 0 0 0 0 R Y75600 $ 350.88 $ 350.88 0 0% 0% 0% 1 6 0 0 0 0 R 75600-26 $ 41.99 $ 41.99 0 0% 0% 0% 1 6 0 0 0 0 R 75600-TC $ 308.90 $ 308.90 0 0% 0% 0% 1 6 0 0 0 0 R 75605 $ 240.52 $ 240.52 0 0% 0% 0% 1 6 0 0 0 0 R 75605-26 $ 94.77 $ 94.77 0 0% 0% 0% 1 6 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 24
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
75605-TC $ 146.35 $ 146.35 0 0% 0% 0% 1 6 0 0 0 0 R 75625 $ 239.32 $ 239.32 0 0% 0% 0% 1 6 0 0 0 0 R 75625-26 $ 93.57 $ 93.57 0 0% 0% 0% 1 6 0 0 0 0 R 75625-TC $ 145.75 $ 145.75 0 0% 0% 0% 1 6 0 0 0 0 R 75630 $ 294.50 $ 294.50 0 0% 0% 0% 1 6 0 0 0 0 R 75630-26 $ 148.75 $ 148.75 0 0% 0% 0% 1 6 0 0 0 0 R 75630-TC $ 145.75 $ 145.75 0 0% 0% 0% 1 6 0 0 0 0 R 75635 $ 662.18 $ 662.18 0 0% 0% 0% 1 4 0 0 0 0 R 75635-26 $ 203.93 $ 203.93 0 0% 0% 0% 1 4 0 0 0 0 R 75635-TC $ 458.85 $ 458.85 0 0% 0% 0% 1 4 0 0 0 0 R 75658 $ 286.10 $ 286.10 0 0% 0% 0% 1 6 0 0 0 0 R 75658-26 $ 107.36 $ 107.36 0 0% 0% 0% 1 6 0 0 0 0 R 75658-TC $ 178.74 $ 178.74 0 0% 0% 0% 1 6 0 0 0 0 R 75705 $ 410.86 $ 410.86 0 0% 0% 0% 1 6 0 0 0 0 R 75705-26 $ 182.94 $ 182.94 0 0% 0% 0% 1 6 0 0 0 0 R 75705-TC $ 227.32 $ 227.32 0 0% 0% 0% 1 6 0 0 0 0 R 75710 $ 280.71 $ 280.71 0 0% 0% 0% 1 6 0 0 0 0 R 75710-26 $ 91.77 $ 91.77 0 0% 0% 0% 1 6 0 0 0 0 R 75710-TC $ 188.94 $ 188.94 0 0% 0% 0% 1 6 0 0 0 0 R 75716 $ 323.29 $ 323.29 0 0% 0% 0% 1 6 2 0 0 0 R 75716-26 $ 107.36 $ 107.36 0 0% 0% 0% 1 6 2 0 0 0 R 75716-TC $ 215.33 $ 215.33 0 0% 0% 0% 1 6 2 0 0 0 R 75726 $ 260.91 $ 260.91 0 0% 0% 0% 1 6 0 0 0 0 R 75726-26 $ 94.77 $ 94.77 0 0% 0% 0% 1 6 0 0 0 0 R 75726-TC $ 165.54 $ 165.54 0 0% 0% 0% 1 6 0 0 0 0 R 75731 $ 298.70 $ 298.70 0 0% 0% 0% 1 6 0 0 0 0 R 75731-26 $ 97.17 $ 97.17 0 0% 0% 0% 1 6 0 0 0 0 R 75731-TC $ 201.53 $ 201.53 0 0% 0% 0% 1 6 0 0 0 0 R 75733 $ 319.69 $ 319.69 0 0% 0% 0% 1 6 2 0 0 0 R 75733-26 $ 109.16 $ 109.16 0 0% 0% 0% 1 6 2 0 0 0 R 75733-TC $ 210.53 $ 210.53 0 0% 0% 0% 1 6 2 0 0 0 R 75736 $ 280.71 $ 280.71 0 0% 0% 0% 1 6 0 0 0 0 R 75736-26 $ 95.97 $ 95.97 0 0% 0% 0% 1 6 0 0 0 0 R 75736-TC $ 185.34 $ 185.34 0 0% 0% 0% 1 6 0 0 0 0 R 75741 $ 263.91 $ 263.91 0 0% 0% 0% 1 6 0 0 0 0 R 75741-26 $ 108.56 $ 108.56 0 0% 0% 0% 1 6 0 0 0 0 R 75741-TC $ 155.35 $ 155.35 0 0% 0% 0% 1 6 0 0 0 0 R 75743 $ 294.50 $ 294.50 0 0% 0% 0% 1 6 2 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 25
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
75743-26 $ 137.35 $ 137.35 0 0% 0% 0% 1 6 2 0 0 0 R 75743-TC $ 157.75 $ 157.75 0 0% 0% 0% 1 6 2 0 0 0 R 75746 $ 268.11 $ 268.11 0 0% 0% 0% 1 6 0 0 0 0 R 75746-26 $ 95.37 $ 95.37 0 0% 0% 0% 1 6 0 0 0 0 R 75746-TC $ 172.74 $ 172.74 0 0% 0% 0% 1 6 0 0 0 0 R 75756 $ 291.50 $ 291.50 0 0% 0% 0% 1 6 0 0 0 0 R 75756-26 $ 95.37 $ 95.37 0 0% 0% 0% 1 6 0 0 0 0 R 75756-TC $ 196.73 $ 196.73 0 0% 0% 0% 1 6 0 0 0 0 R 75774 $ 153.55 $ 153.55 0 0% 0% 0% 1 0 0 0 0 0 R 75774-26 $ 29.99 $ 29.99 0 0% 0% 0% 1 0 0 0 0 0 R 75774-TC $ 124.16 $ 124.16 0 0% 0% 0% 1 0 0 0 0 0 R 75791 $ 560.81 $ 560.81 0 0% 0% 0% 1 6 0 0 0 0 R Y75791-26 $ 139.15 $ 139.15 0 0% 0% 0% 1 6 0 0 0 0 R Y75791-TC $ 421.66 $ 421.66 0 0% 0% 0% 1 6 0 0 0 0 R Y75801 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75801-26 $ 72.58 $ 72.58 0 0% 0% 0% 1 0 0 0 0 0 R 75801-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75803 By Report By Report 0 0% 0% 0% 1 0 2 0 0 0 N 75803-26 $ 101.97 $ 101.97 0 0% 0% 0% 1 0 2 0 0 0 R 75803-TC By Report By Report 0 0% 0% 0% 1 0 2 0 0 0 N 75805 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75805-26 $ 70.18 $ 70.18 0 0% 0% 0% 1 0 0 0 0 0 R 75805-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75807 By Report By Report 0 0% 0% 0% 1 0 2 0 0 0 N 75807-26 $ 101.97 $ 101.97 0 0% 0% 0% 1 0 2 0 0 0 R 75807-TC By Report By Report 0 0% 0% 0% 1 0 2 0 0 0 N 75809 $ 173.94 $ 173.94 0 0% 0% 0% 1 6 0 0 0 0 R 75809-26 $ 40.19 $ 40.19 0 0% 0% 0% 1 6 0 0 0 0 R 75809-TC $ 133.16 $ 133.16 0 0% 0% 0% 1 6 0 0 0 0 R 75810 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75810-26 $ 99.57 $ 99.57 0 0% 0% 0% 1 0 0 0 0 0 R 75810-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75820 $ 200.93 $ 200.93 0 0% 0% 0% 1 6 0 0 0 0 R 75820-26 $ 58.78 $ 58.78 0 0% 0% 0% 1 6 0 0 0 0 R 75820-TC $ 142.15 $ 142.15 0 0% 0% 0% 1 6 0 0 0 0 R 75822 $ 238.72 $ 238.72 0 0% 0% 0% 1 6 2 0 0 0 R 75822-26 $ 88.17 $ 88.17 0 0% 0% 0% 1 6 2 0 0 0 R 75822-TC $ 150.55 $ 150.55 0 0% 0% 0% 1 6 2 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 26
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
75825 $ 236.32 $ 236.32 0 0% 0% 0% 1 6 0 0 0 0 R 75825-26 $ 94.77 $ 94.77 0 0% 0% 0% 1 6 0 0 0 0 R 75825-TC $ 141.55 $ 141.55 0 0% 0% 0% 1 6 0 0 0 0 R 75827 $ 238.72 $ 238.72 0 0% 0% 0% 1 6 0 0 0 0 R 75827-26 $ 93.57 $ 93.57 0 0% 0% 0% 1 6 0 0 0 0 R 75827-TC $ 145.75 $ 145.75 0 0% 0% 0% 1 6 0 0 0 0 R 75831 $ 244.72 $ 244.72 0 0% 0% 0% 1 6 0 0 0 0 R 75831-26 $ 92.37 $ 92.37 0 0% 0% 0% 1 6 0 0 0 0 R 75831-TC $ 152.35 $ 152.35 0 0% 0% 0% 1 6 0 0 0 0 R 75833 $ 285.50 $ 285.50 0 0% 0% 0% 1 6 2 0 0 0 R 75833-26 $ 123.56 $ 123.56 0 0% 0% 0% 1 6 2 0 0 0 R 75833-TC $ 161.95 $ 161.95 0 0% 0% 0% 1 6 2 0 0 0 R 75840 $ 259.71 $ 259.71 0 0% 0% 0% 1 6 0 0 0 0 R 75840-26 $ 98.37 $ 98.37 0 0% 0% 0% 1 6 0 0 0 0 R 75840-TC $ 161.35 $ 161.35 0 0% 0% 0% 1 6 0 0 0 0 R 75842 $ 314.30 $ 314.30 0 0% 0% 0% 1 6 2 0 0 0 R 75842-26 $ 128.36 $ 128.36 0 0% 0% 0% 1 6 2 0 0 0 R 75842-TC $ 185.94 $ 185.94 0 0% 0% 0% 1 6 2 0 0 0 R 75860 $ 250.12 $ 250.12 0 0% 0% 0% 1 6 0 0 0 0 R 75860-26 $ 94.77 $ 94.77 0 0% 0% 0% 1 6 0 0 0 0 R 75860-TC $ 154.75 $ 154.75 0 0% 0% 0% 1 6 0 0 0 0 R 75870 $ 259.11 $ 259.11 0 0% 0% 0% 1 6 0 0 0 0 R 75870-26 $ 98.37 $ 98.37 0 0% 0% 0% 1 6 0 0 0 0 R 75870-TC $ 160.75 $ 160.75 0 0% 0% 0% 1 6 0 0 0 0 R 75872 $ 260.31 $ 260.31 0 0% 0% 0% 1 6 0 0 0 0 R 75872-26 $ 98.37 $ 98.37 0 0% 0% 0% 1 6 0 0 0 0 R 75872-TC $ 161.95 $ 161.95 0 0% 0% 0% 1 6 0 0 0 0 R 75880 $ 256.71 $ 256.71 0 0% 0% 0% 1 6 0 0 0 0 R 75880-26 $ 61.78 $ 61.78 0 0% 0% 0% 1 6 0 0 0 0 R 75880-TC $ 194.94 $ 194.94 0 0% 0% 0% 1 6 0 0 0 0 R 75885 $ 274.11 $ 274.11 0 0% 0% 0% 1 6 0 0 0 0 R 75885-26 $ 117.56 $ 117.56 0 0% 0% 0% 1 6 0 0 0 0 R 75885-TC $ 156.55 $ 156.55 0 0% 0% 0% 1 6 0 0 0 0 R 75887 $ 277.71 $ 277.71 0 0% 0% 0% 1 6 0 0 0 0 R 75887-26 $ 119.96 $ 119.96 0 0% 0% 0% 1 6 0 0 0 0 R 75887-TC $ 158.35 $ 158.35 0 0% 0% 0% 1 6 0 0 0 0 R 75889 $ 251.32 $ 251.32 0 0% 0% 0% 1 6 0 0 0 0 R 75889-26 $ 93.57 $ 93.57 0 0% 0% 0% 1 6 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 27
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
75889-TC $ 157.75 $ 157.75 0 0% 0% 0% 1 6 0 0 0 0 R 75891 $ 254.32 $ 254.32 0 0% 0% 0% 1 6 0 0 0 0 R 75891-26 $ 95.97 $ 95.97 0 0% 0% 0% 1 6 0 0 0 0 R 75891-TC $ 158.95 $ 158.95 0 0% 0% 0% 1 6 0 0 0 0 R 75893 $ 208.73 $ 208.73 0 0% 0% 0% 1 6 0 0 0 0 R 75893-26 $ 46.18 $ 46.18 0 0% 0% 0% 1 6 0 0 0 0 R 75893-TC $ 162.55 $ 162.55 0 0% 0% 0% 1 6 0 0 0 0 R 75894 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75894-26 $ 110.96 $ 110.96 0 0% 0% 0% 1 0 0 0 0 0 R 75894-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75896 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75896-26 $ 113.36 $ 113.36 0 0% 0% 0% 1 0 0 0 0 0 R 75896-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75898 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75898-26 $ 142.15 $ 142.15 0 0% 0% 0% 1 0 0 0 0 0 R 75898-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75901 $ 308.90 $ 308.90 0 0% 0% 0% 1 0 0 0 0 0 R 75901-26 $ 39.59 $ 39.59 0 0% 0% 0% 1 0 0 0 0 0 R 75901-TC $ 269.31 $ 269.31 0 0% 0% 0% 1 0 0 0 0 0 R 75902 $ 124.76 $ 124.76 0 0% 0% 0% 1 0 0 0 0 0 R 75902-26 $ 31.79 $ 31.79 0 0% 0% 0% 1 0 0 0 0 0 R 75902-TC $ 92.97 $ 92.97 0 0% 0% 0% 1 0 0 0 0 0 R 75945 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75945-26 $ 32.99 $ 32.99 0 0% 0% 0% 1 0 0 0 0 0 R 75945-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75946 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75946-26 $ 32.39 $ 32.39 0 0% 0% 0% 1 0 0 0 0 0 R 75946-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75952 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75952-26 $ 370.68 $ 370.68 0 0% 0% 0% 1 0 0 0 0 0 R 75952-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75953 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75953-26 $ 112.16 $ 112.16 0 0% 0% 0% 1 0 0 0 0 0 R 75953-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75954 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75954-26 $ 187.14 $ 187.14 0 0% 0% 0% 1 0 0 0 0 0 R 75954-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75956 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 28
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
75956-26 $ 575.81 $ 575.81 0 0% 0% 0% 1 0 0 0 0 0 R 75956-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75957 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75957-26 $ 493.04 $ 493.04 0 0% 0% 0% 1 0 0 0 0 0 R 75957-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75958 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75958-26 $ 328.69 $ 328.69 0 0% 0% 0% 1 0 0 0 0 0 R 75958-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75959 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75959-26 $ 279.51 $ 279.51 0 0% 0% 0% 1 0 0 0 0 0 R 75959-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75962 $ 243.52 $ 243.52 0 0% 0% 0% 1 0 0 0 0 0 R 75962-26 $ 43.79 $ 43.79 0 0% 0% 0% 1 0 0 0 0 0 R 75962-TC $ 199.73 $ 199.73 0 0% 0% 0% 1 0 0 0 0 0 R 75964 $ 150.55 $ 150.55 0 0% 0% 0% 1 0 0 0 0 0 R 75964-26 $ 28.79 $ 28.79 0 0% 0% 0% 1 0 0 0 0 0 R 75964-TC $ 121.76 $ 121.76 0 0% 0% 0% 1 0 0 0 0 0 R 75966 $ 296.90 $ 296.90 0 0% 0% 0% 1 0 0 0 0 0 R 75966-26 $ 107.36 $ 107.36 0 0% 0% 0% 1 0 0 0 0 0 R 75966-TC $ 189.54 $ 189.54 0 0% 0% 0% 1 0 0 0 0 0 R 75968 $ 155.95 $ 155.95 0 0% 0% 0% 1 0 0 0 0 0 R 75968-26 $ 29.99 $ 29.99 0 0% 0% 0% 1 0 0 0 0 0 R 75968-TC $ 125.96 $ 125.96 0 0% 0% 0% 1 0 0 0 0 0 R 75970 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y75970-26 $ 68.98 $ 68.98 0 0% 0% 0% 1 0 0 0 0 0 R Y75970-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y75978 $ 240.52 $ 240.52 0 0% 0% 0% 1 0 0 0 0 0 R 75978-26 $ 43.79 $ 43.79 0 0% 0% 0% 1 0 0 0 0 0 R 75978-TC $ 197.33 $ 197.33 0 0% 0% 0% 1 0 0 0 0 0 R 75980 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75980-26 $ 122.36 $ 122.36 0 0% 0% 0% 1 0 0 0 0 0 R 75980-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75982 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75982-26 $ 121.16 $ 121.16 0 0% 0% 0% 1 0 0 0 0 0 R 75982-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 75984 $ 185.94 $ 185.94 0 0% 0% 0% 1 0 0 0 0 0 R 75984-26 $ 59.98 $ 59.98 0 0% 0% 0% 1 0 0 0 0 0 R 75984-TC $ 125.96 $ 125.96 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 29
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
75989 $ 209.33 $ 209.33 0 0% 0% 0% 1 0 0 0 0 0 R 75989-26 $ 100.17 $ 100.17 0 0% 0% 0% 1 0 0 0 0 0 R 75989-TC $ 109.16 $ 109.16 0 0% 0% 0% 1 0 0 0 0 0 R 76000 $ 82.17 $ 82.17 0 0% 0% 0% 1 0 0 0 0 0 R 76000-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 0 0 0 0 R 76000-TC $ 67.78 $ 67.78 0 0% 0% 0% 1 0 0 0 0 0 R 76001 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76001-26 $ 60.58 $ 60.58 0 0% 0% 0% 1 0 0 0 0 0 R 76001-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76010 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76010-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76010-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76080 $ 95.37 $ 95.37 0 0% 0% 0% 1 0 0 0 0 0 R 76080-26 $ 44.99 $ 44.99 0 0% 0% 0% 1 0 0 0 0 0 R 76080-TC $ 50.38 $ 50.38 0 0% 0% 0% 1 0 0 0 0 0 R 76098 $ 28.19 $ 28.19 0 0% 0% 0% 1 0 0 0 0 0 R Y76098-26 $ 13.80 $ 13.80 0 0% 0% 0% 1 0 0 0 0 0 R Y76098-TC $ 14.40 $ 14.40 0 0% 0% 0% 1 0 0 0 0 0 R Y76100 $ 161.35 $ 161.35 0 0% 0% 0% 1 0 0 0 0 0 R 76100-26 $ 53.98 $ 53.98 0 0% 0% 0% 1 0 0 0 0 0 R 76100-TC $ 106.76 $ 106.76 0 0% 0% 0% 1 0 0 0 0 0 R 76101 $ 231.52 $ 231.52 0 0% 0% 0% 1 0 0 0 0 0 R Y76101-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R Y76101-TC $ 172.14 $ 172.14 0 0% 0% 0% 1 0 0 0 0 0 R Y76102 $ 305.30 $ 305.30 0 0% 0% 0% 1 0 2 0 0 0 R Y76102-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 2 0 0 0 R Y76102-TC $ 245.92 $ 245.92 0 0% 0% 0% 1 0 2 0 0 0 R Y76120 $ 158.95 $ 158.95 0 0% 0% 0% 1 0 0 0 0 0 R Y76120-26 $ 33.59 $ 33.59 0 0% 0% 0% 1 0 0 0 0 0 R Y76120-TC $ 125.36 $ 125.36 0 0% 0% 0% 1 0 0 0 0 0 R Y76125 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76125-26 $ 24.59 $ 24.59 0 0% 0% 0% 1 0 0 0 0 0 R 76125-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76140 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 76376 $ 39.59 $ 39.59 0 0% 0% 0% 1 0 0 0 0 0 R 76376-26 $ 16.79 $ 16.79 0 0% 0% 0% 1 0 0 0 0 0 R 76376-TC $ 22.19 $ 22.19 0 0% 0% 0% 1 0 0 0 0 0 R 76377 $ 110.36 $ 110.36 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 30
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
76377-26 $ 67.18 $ 67.18 0 0% 0% 0% 1 0 0 0 0 0 R 76377-TC $ 42.59 $ 42.59 0 0% 0% 0% 1 0 0 0 0 0 R 76380 $ 255.51 $ 255.51 0 0% 0% 0% 1 0 0 0 0 0 R 76380-26 $ 83.37 $ 83.37 0 0% 0% 0% 1 0 0 0 0 0 R 76380-TC $ 172.14 $ 172.14 0 0% 0% 0% 1 0 0 0 0 0 R 76390 $ 785.74 $ 785.74 0 0% 0% 0% 1 9 9 9 9 9 R Y76390-26 $ 120.56 $ 120.56 0 0% 0% 0% 1 9 9 9 9 9 R Y76390-TC $ 665.18 $ 665.18 0 0% 0% 0% 1 9 9 9 9 9 R Y76496 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76496-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76496-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76497 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76497-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76497-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76498 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76498-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76498-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76499 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76499-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76499-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76506 $ 208.73 $ 208.73 0 0% 0% 0% 1 0 0 0 0 0 R 76506-26 $ 54.58 $ 54.58 0 0% 0% 0% 1 0 0 0 0 0 R 76506-TC $ 154.15 $ 154.15 0 0% 0% 0% 1 0 0 0 0 0 R 76510 $ 299.30 $ 299.30 0 0% 0% 0% 1 7 3 0 0 0 R 76510-26 $ 154.15 $ 154.15 0 0% 0% 0% 1 7 3 0 0 0 R 76510-TC $ 144.55 $ 144.55 0 0% 0% 0% 1 7 3 0 0 0 R 76511 $ 180.54 $ 180.54 0 0% 0% 0% 1 7 3 0 0 0 R 76511-26 $ 92.37 $ 92.37 0 0% 0% 0% 1 7 3 0 0 0 R 76511-TC $ 87.57 $ 87.57 0 0% 0% 0% 1 7 3 0 0 0 R 76512 $ 162.55 $ 162.55 0 0% 0% 0% 1 7 3 0 0 0 R 76512-26 $ 91.77 $ 91.77 0 0% 0% 0% 1 7 3 0 0 0 R 76512-TC $ 70.78 $ 70.78 0 0% 0% 0% 1 7 3 0 0 0 R 76513 $ 169.14 $ 169.14 0 0% 0% 0% 1 7 3 0 0 0 R 76513-26 $ 62.38 $ 62.38 0 0% 0% 0% 1 7 3 0 0 0 R 76513-TC $ 106.76 $ 106.76 0 0% 0% 0% 1 7 3 0 0 0 R 76514 $ 25.79 $ 25.79 0 0% 0% 0% 1 7 2 0 0 0 R 76514-26 $ 16.79 $ 16.79 0 0% 0% 0% 1 7 2 0 0 0 R 76514-TC $ 9.00 $ 9.00 0 0% 0% 0% 1 7 2 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 31
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
76516 $ 138.55 $ 138.55 0 0% 0% 0% 1 7 2 0 0 0 R 76516-26 $ 53.98 $ 53.98 0 0% 0% 0% 1 7 2 0 0 0 R 76516-TC $ 84.57 $ 84.57 0 0% 0% 0% 1 7 2 0 0 0 R 76519 $ 148.75 $ 148.75 0 0% 0% 0% 1 7 2 0 0 0 R 76519-26 $ 53.98 $ 53.98 0 0% 0% 0% 1 7 3 0 0 0 R 76519-TC $ 94.77 $ 94.77 0 0% 0% 0% 1 7 2 0 0 0 R 76529 $ 140.35 $ 140.35 0 0% 0% 0% 1 0 3 0 0 0 R 76529-26 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 3 0 0 0 R 76529-TC $ 83.97 $ 83.97 0 0% 0% 0% 1 0 3 0 0 0 R 76536 $ 205.13 $ 205.13 0 0% 0% 0% 1 0 0 0 0 0 R 76536-26 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R 76536-TC $ 157.75 $ 157.75 0 0% 0% 0% 1 0 0 0 0 0 R 76604 $ 154.75 $ 154.75 0 0% 0% 0% 1 4 0 0 0 0 R 76604-26 $ 46.78 $ 46.78 0 0% 0% 0% 1 4 0 0 0 0 R 76604-TC $ 107.96 $ 107.96 0 0% 0% 0% 1 4 0 0 0 0 R 76641 $ 189.54 $ 189.54 0 0% 0% 0% 1 0 1 0 0 0 R Y76641-26 $ 62.98 $ 62.98 0 0% 0% 0% 1 0 1 0 0 0 R Y76641-TC $ 127.16 $ 127.16 0 0% 0% 0% 1 0 1 0 0 0 R Y76642 $ 155.95 $ 155.95 0 0% 0% 0% 1 0 1 0 0 0 R Y76642-26 $ 58.18 $ 58.18 0 0% 0% 0% 1 0 1 0 0 0 R Y76642-TC $ 97.17 $ 97.17 0 0% 0% 0% 1 0 1 0 0 0 R Y76700 $ 215.93 $ 215.93 0 0% 0% 0% 1 4 0 0 0 0 R 76700-26 $ 68.98 $ 68.98 0 0% 0% 0% 1 4 0 0 0 0 R 76700-TC $ 146.95 $ 146.95 0 0% 0% 0% 1 4 0 0 0 0 R 76705 $ 161.35 $ 161.35 0 0% 0% 0% 1 4 0 0 0 0 R 76705-26 $ 50.38 $ 50.38 0 0% 0% 0% 1 4 0 0 0 0 R 76705-TC $ 110.36 $ 110.36 0 0% 0% 0% 1 4 0 0 0 0 R 76770 $ 198.53 $ 198.53 0 0% 0% 0% 1 4 0 0 0 0 R 76770-26 $ 62.98 $ 62.98 0 0% 0% 0% 1 4 0 0 0 0 R 76770-TC $ 136.15 $ 136.15 0 0% 0% 0% 1 4 0 0 0 0 R 76775 $ 100.17 $ 100.17 0 0% 0% 0% 1 4 0 0 0 0 R 76775-26 $ 49.18 $ 49.18 0 0% 0% 0% 1 4 0 0 0 0 R 76775-TC $ 50.98 $ 50.98 0 0% 0% 0% 1 4 0 0 0 0 R 76776 $ 276.51 $ 276.51 0 0% 0% 0% 1 4 0 0 0 0 R 76776-26 $ 64.78 $ 64.78 0 0% 0% 0% 1 4 0 0 0 0 R 76776-TC $ 211.13 $ 211.13 0 0% 0% 0% 1 4 0 0 0 0 R 76800 $ 241.72 $ 241.72 0 0% 0% 0% 1 0 0 0 0 0 R 76800-26 $ 97.17 $ 97.17 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 32
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
76800-TC $ 143.95 $ 143.95 0 0% 0% 0% 1 0 0 0 0 0 R 76801 $ 216.53 $ 216.53 0 0% 0% 0% 1 0 0 0 0 0 R 76801-26 $ 86.37 $ 86.37 0 0% 0% 0% 1 0 0 0 0 0 R 76801-TC $ 130.16 $ 130.16 0 0% 0% 0% 1 0 0 0 0 0 R 76802 $ 112.76 $ 112.76 0 0% 0% 0% 1 0 0 0 0 0 R 76802-26 $ 72.58 $ 72.58 0 0% 0% 0% 1 0 0 0 0 0 R 76802-TC $ 40.19 $ 40.19 0 0% 0% 0% 1 0 0 0 0 0 R 76805 $ 249.52 $ 249.52 0 0% 0% 0% 1 0 0 0 0 0 R Y76805-26 $ 86.37 $ 86.37 0 0% 0% 0% 1 0 0 0 0 0 R Y76805-TC $ 163.15 $ 163.15 0 0% 0% 0% 1 0 0 0 0 0 R Y76810 $ 164.35 $ 164.35 0 0% 0% 0% 1 0 0 0 0 0 R 76810-26 $ 85.77 $ 85.77 0 0% 0% 0% 1 0 0 0 0 0 R 76810-TC $ 77.97 $ 77.97 0 0% 0% 0% 1 0 0 0 0 0 R 76811 $ 314.90 $ 314.90 0 0% 0% 0% 1 0 0 0 0 0 R 76811-26 $ 166.74 $ 166.74 0 0% 0% 0% 1 0 0 0 0 0 R 76811-TC $ 148.15 $ 148.15 0 0% 0% 0% 1 0 0 0 0 0 R 76812 $ 359.28 $ 359.28 0 0% 0% 0% 1 0 0 0 0 0 R 76812-26 $ 157.15 $ 157.15 0 0% 0% 0% 1 0 0 0 0 0 R 76812-TC $ 202.73 $ 202.73 0 0% 0% 0% 1 0 0 0 0 0 R 76813 $ 211.13 $ 211.13 0 0% 0% 0% 1 0 0 0 0 0 R 76813-26 $ 103.77 $ 103.77 0 0% 0% 0% 1 0 0 0 0 0 R 76813-TC $ 107.36 $ 107.36 0 0% 0% 0% 1 0 0 0 0 0 R 76814 $ 140.95 $ 140.95 0 0% 0% 0% 1 0 0 0 0 0 R 76814-26 $ 86.97 $ 86.97 0 0% 0% 0% 1 0 0 0 0 0 R 76814-TC $ 53.38 $ 53.38 0 0% 0% 0% 1 0 0 0 0 0 R 76815 $ 148.15 $ 148.15 0 0% 0% 0% 1 0 0 0 0 0 R Y76815-26 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 0 0 0 0 R Y76815-TC $ 91.77 $ 91.77 0 0% 0% 0% 1 0 0 0 0 0 R Y76816 $ 201.53 $ 201.53 0 0% 0% 0% 1 0 0 0 0 0 R Y76816-26 $ 74.38 $ 74.38 0 0% 0% 0% 1 0 0 0 0 0 R Y76816-TC $ 127.16 $ 127.16 0 0% 0% 0% 1 0 0 0 0 0 R Y76817 $ 170.34 $ 170.34 0 0% 0% 0% 1 0 0 0 0 0 R 76817-26 $ 65.38 $ 65.38 0 0% 0% 0% 1 0 0 0 0 0 R 76817-TC $ 104.97 $ 104.97 0 0% 0% 0% 1 0 0 0 0 0 R 76818 $ 211.73 $ 211.73 0 0% 0% 0% 1 0 0 0 0 0 R Y76818-26 $ 92.37 $ 92.37 0 0% 0% 0% 1 0 0 0 0 0 R Y76818-TC $ 119.36 $ 119.36 0 0% 0% 0% 1 0 0 0 0 0 R Y76819 $ 155.35 $ 155.35 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 33
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
76819-26 $ 67.18 $ 67.18 0 0% 0% 0% 1 0 0 0 0 0 R Y76819-TC $ 87.57 $ 87.57 0 0% 0% 0% 1 0 0 0 0 0 R Y76820 $ 81.57 $ 81.57 0 0% 0% 0% 1 0 0 0 0 0 R 76820-26 $ 43.19 $ 43.19 0 0% 0% 0% 1 0 0 0 0 0 R 76820-TC $ 38.39 $ 38.39 0 0% 0% 0% 1 0 0 0 0 0 R 76821 $ 162.55 $ 162.55 0 0% 0% 0% 1 0 0 0 0 0 R 76821-26 $ 61.18 $ 61.18 0 0% 0% 0% 1 0 0 0 0 0 R 76821-TC $ 101.37 $ 101.37 0 0% 0% 0% 1 0 0 0 0 0 R 76825 $ 487.04 $ 487.04 0 0% 0% 0% 1 0 0 0 0 0 R Y76825-26 $ 144.55 $ 144.55 0 0% 0% 0% 1 0 0 0 0 0 R Y76825-TC $ 343.09 $ 343.09 0 0% 0% 0% 1 0 0 0 0 0 R Y76826 $ 289.70 $ 289.70 0 0% 0% 0% 1 0 0 0 0 0 R 76826-26 $ 71.38 $ 71.38 0 0% 0% 0% 1 0 0 0 0 0 R 76826-TC $ 218.33 $ 218.33 0 0% 0% 0% 1 0 0 0 0 0 R 76827 $ 133.76 $ 133.76 0 0% 0% 0% 1 0 0 0 0 0 R 76827-26 $ 49.78 $ 49.78 0 0% 0% 0% 1 0 0 0 0 0 R 76827-TC $ 83.97 $ 83.97 0 0% 0% 0% 1 0 0 0 0 0 R 76828 $ 92.97 $ 92.97 0 0% 0% 0% 1 0 0 0 0 0 R 76828-26 $ 48.58 $ 48.58 0 0% 0% 0% 1 0 0 0 0 0 R 76828-TC $ 44.39 $ 44.39 0 0% 0% 0% 1 0 0 0 0 0 R 76830 $ 215.33 $ 215.33 0 0% 0% 0% 1 0 0 0 0 0 R 76830-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R 76830-TC $ 155.35 $ 155.35 0 0% 0% 0% 1 0 0 0 0 0 R 76831 Not Covered Not Covered 0 0% 0% 0% 1 4 0 0 0 0 X 76831-26 Not Covered Not Covered 0 0% 0% 0% 1 4 0 0 0 0 X 76831-TC Not Covered Not Covered 0 0% 0% 0% 1 4 0 0 0 0 X 76856 $ 193.14 $ 193.14 0 0% 0% 0% 1 4 0 0 0 0 R 76856-26 $ 58.18 $ 58.18 0 0% 0% 0% 1 4 0 0 0 0 R 76856-TC $ 134.96 $ 134.96 0 0% 0% 0% 1 4 0 0 0 0 R 76857 $ 82.17 $ 82.17 0 0% 0% 0% 1 4 0 0 0 0 R 76857-26 $ 41.99 $ 41.99 0 0% 0% 0% 1 4 0 0 0 0 R 76857-TC $ 40.19 $ 40.19 0 0% 0% 0% 1 4 0 0 0 0 R 76870 $ 116.36 $ 116.36 0 0% 0% 0% 1 4 0 0 0 0 R 76870-26 $ 53.98 $ 53.98 0 0% 0% 0% 1 4 0 0 0 0 R 76870-TC $ 62.38 $ 62.38 0 0% 0% 0% 1 4 0 0 0 0 R 76872 $ 164.35 $ 164.35 0 0% 0% 0% 1 0 0 0 0 0 R 76872-26 $ 57.58 $ 57.58 0 0% 0% 0% 1 0 0 0 0 0 R 76872-TC $ 106.76 $ 106.76 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 34
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
76873 Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X 76873-26 Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X 76873-TC Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X 76881 $ 205.13 $ 205.13 0 0% 0% 0% 1 0 0 9 0 0 R76881-26 $ 53.98 $ 53.98 0 0% 0% 0% 1 0 0 9 0 0 R76881-TC $ 151.15 $ 151.15 0 0% 0% 0% 1 0 0 9 0 0 R76882 $ 61.78 $ 61.78 0 0% 0% 0% 1 0 0 9 0 0 R76882-26 $ 41.99 $ 41.99 0 0% 0% 0% 1 0 0 9 0 0 R76882-TC $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 9 0 0 R76885 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76885-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76885-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76886 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76886-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76886-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76930 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76930-26 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 0 0 0 0 R 76930-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76932 By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y76932-26 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 0 0 0 0 R Y76932-TC By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y76936 $ 473.24 $ 473.24 0 0% 0% 0% 1 0 0 0 0 0 R 76936-26 $ 165.54 $ 165.54 0 0% 0% 0% 1 0 0 0 0 0 R 76936-TC $ 308.30 $ 308.30 0 0% 0% 0% 1 0 0 0 0 0 R 76937 $ 55.18 $ 55.18 0 0% 0% 0% 1 0 0 0 0 0 R 76937-26 $ 24.59 $ 24.59 0 0% 0% 0% 1 0 0 0 0 0 R 76937-TC $ 30.59 $ 30.59 0 0% 0% 0% 1 0 0 0 0 0 R 76940 Not Covered Not Covered 90 0% 0% 0% 1 0 0 0 0 0 X 76940-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76940-TC Not Covered Not Covered 90 0% 0% 0% 1 0 0 0 0 0 X 76941 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76941-26 $ 114.56 $ 114.56 0 0% 0% 0% 1 0 0 0 0 0 R 76941-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76942 $ 104.37 $ 104.37 0 0% 0% 0% 1 0 0 0 0 0 R 76942-26 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 0 0 0 0 R 76942-TC $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R 76945 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76945-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 35
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
76945-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76946 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 0 0 0 0 R 76946-26 $ 33.59 $ 33.59 0 0% 0% 0% 1 0 0 0 0 0 R 76946-TC $ 23.39 $ 23.39 0 0% 0% 0% 1 0 0 0 0 0 R 76948 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76948-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76948-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76965 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76965-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76965-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 76970 $ 163.75 $ 163.75 0 0% 0% 0% 1 0 0 0 0 0 R 76970-26 $ 33.59 $ 33.59 0 0% 0% 0% 1 0 0 0 0 0 R 76970-TC $ 129.56 $ 129.56 0 0% 0% 0% 1 0 0 0 0 0 R 76975 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76975-26 $ 73.18 $ 73.18 0 0% 0% 0% 1 0 0 0 0 0 R 76975-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76977 $ 12.00 $ 12.00 0 0% 0% 0% 1 0 0 0 0 0 R 76977-26 $ 4.80 $ 4.80 0 0% 0% 0% 1 0 0 0 0 0 R 76977-TC $ 7.20 $ 7.20 0 0% 0% 0% 1 0 0 0 0 0 R 76998 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76998-26 $ 104.97 $ 104.97 0 0% 0% 0% 1 0 0 0 0 0 R 76998-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 76999 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y76999-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y76999-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77001 $ 122.96 $ 122.96 0 0% 0% 0% 1 0 0 9 0 0 R 77001-26 $ 31.79 $ 31.79 0 0% 0% 0% 1 0 0 9 0 0 R 77001-TC $ 91.17 $ 91.17 0 0% 0% 0% 1 0 0 9 0 0 R 77002 $ 161.35 $ 161.35 0 0% 0% 0% 1 0 0 9 0 0 R 77002-26 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 9 0 0 R 77002-TC $ 113.96 $ 113.96 0 0% 0% 0% 1 0 0 9 0 0 R 77003 $ 148.75 $ 148.75 0 0% 0% 0% 1 9 9 9 9 9 R 77003-26 $ 51.58 $ 51.58 0 0% 0% 0% 1 9 9 9 9 9 R 77003-TC $ 97.17 $ 97.17 0 0% 0% 0% 1 9 9 9 9 9 R 77011 $ 385.67 $ 385.67 0 0% 0% 0% 1 0 0 9 0 0 R Y77011-26 $ 105.56 $ 105.56 0 0% 0% 0% 1 0 0 9 0 0 R 77011-TC $ 280.11 $ 280.11 0 0% 0% 0% 1 0 0 9 0 0 R 77012 $ 215.93 $ 215.93 0 0% 0% 0% 1 0 0 9 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 36
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
77012-26 $ 97.77 $ 97.77 0 0% 0% 0% 1 0 0 9 0 0 R 77012-TC $ 118.16 $ 118.16 0 0% 0% 0% 1 0 0 9 0 0 R 77013 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 77013-26 $ 337.69 $ 337.69 0 0% 0% 0% 1 0 0 9 0 0 R 77013-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 77014 $ 203.93 $ 203.93 0 0% 0% 0% 1 0 0 9 0 0 R Y77014-26 $ 74.38 $ 74.38 0 0% 0% 0% 1 0 0 9 0 0 R Y77014-TC $ 129.56 $ 129.56 0 0% 0% 0% 1 0 0 9 0 0 R Y77021 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77021-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77021-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77022 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 77022-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77022-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 77051 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77051-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77051-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77052 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77052-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77052-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77053 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77053-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77053-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77054 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77054-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77054-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X 77055 $ 155.95 $ 155.95 0 0% 0% 0% 1 0 0 9 0 0 R Y77055-26 $ 59.98 $ 59.98 0 0% 0% 0% 1 0 0 9 0 0 R Y77055-TC $ 95.97 $ 95.97 0 0% 0% 0% 1 0 0 9 0 0 R Y77056 $ 200.93 $ 200.93 0 0% 0% 0% 1 0 0 9 0 0 R Y77056-26 $ 74.38 $ 74.38 0 0% 0% 0% 1 0 0 9 0 0 R Y77056-TC $ 126.56 $ 126.56 0 0% 0% 0% 1 0 0 9 0 0 R Y77057 Not Covered Not Covered 0 0% 0% 0% 1 0 2 9 0 0 X77057-26 Not Covered Not Covered 0 0% 0% 0% 1 0 2 9 0 0 X77057-TC Not Covered Not Covered 0 0% 0% 0% 1 0 2 9 0 0 X77058 $ 953.68 $ 953.68 0 0% 0% 0% 1 4 0 9 0 0 R 77058-26 $ 139.75 $ 139.75 0 0% 0% 0% 1 4 0 9 0 0 R 77058-TC $ 813.93 $ 813.93 0 0% 0% 0% 1 4 0 9 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 37
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
77059 $ 943.49 $ 943.49 0 0% 0% 0% 1 4 2 9 0 0 R Y77059-26 $ 139.75 $ 139.75 0 0% 0% 0% 1 4 2 9 0 0 R Y77059-TC $ 803.73 $ 803.73 0 0% 0% 0% 1 4 2 9 0 0 R Y77061 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X77061-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X77061-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X77062 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X77062-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X77062-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 9 0 0 X77063 Not Covered Not Covered 0 0% 0% 0% 1 0 2 9 0 0 X77063-26 Not Covered Not Covered 0 0% 0% 0% 1 0 2 9 0 0 X77063-TC Not Covered Not Covered 0 0% 0% 0% 1 0 2 9 0 0 X77071 $ 82.77 $ 82.77 0 0% 0% 0% 2 0 2 0 0 0 R 77072 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 77072-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 77072-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 77073 $ 62.38 $ 62.38 0 0% 0% 0% 1 0 0 0 0 0 R 77073-26 $ 24.59 $ 24.59 0 0% 0% 0% 1 0 0 0 0 0 R 77073-TC $ 37.79 $ 37.79 0 0% 0% 0% 1 0 0 0 0 0 R 77074 $ 110.96 $ 110.96 0 0% 0% 0% 1 0 0 0 0 0 R 77074-26 $ 38.39 $ 38.39 0 0% 0% 0% 1 0 0 0 0 0 R 77074-TC $ 72.58 $ 72.58 0 0% 0% 0% 1 0 0 0 0 0 R 77075 $ 151.75 $ 151.75 0 0% 0% 0% 1 0 0 0 0 0 R 77075-26 $ 46.18 $ 46.18 0 0% 0% 0% 1 0 0 0 0 0 R 77075-TC $ 105.56 $ 105.56 0 0% 0% 0% 1 0 0 0 0 0 R 77076 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 77076-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 77076-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 77077 $ 64.78 $ 64.78 0 0% 0% 0% 1 0 0 0 0 0 R 77077-26 $ 28.19 $ 28.19 0 0% 0% 0% 1 0 0 0 0 0 R 77077-TC $ 36.59 $ 36.59 0 0% 0% 0% 1 0 0 0 0 0 R 77078 $ 200.93 $ 200.93 0 0% 0% 0% 1 0 0 0 0 0 R 77078-26 $ 20.99 $ 20.99 0 0% 0% 0% 1 0 0 0 0 0 R 77078-TC $ 179.94 $ 179.94 0 0% 0% 0% 1 0 0 0 0 0 R 77080 $ 71.98 $ 71.98 0 0% 0% 0% 1 0 0 0 0 0 R Y77080-26 $ 17.39 $ 17.39 0 0% 0% 0% 1 0 0 0 0 0 R Y77080-TC $ 54.58 $ 54.58 0 0% 0% 0% 1 0 0 0 0 0 R Y77081 $ 48.58 $ 48.58 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 38
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
77081-26 $ 18.59 $ 18.59 0 0% 0% 0% 1 0 0 0 0 0 R Y77081-TC $ 29.99 $ 29.99 0 0% 0% 0% 1 0 0 0 0 0 R Y77084 $ 686.17 $ 686.17 0 0% 0% 0% 1 0 0 0 0 0 R 77084-26 $ 137.95 $ 137.95 0 0% 0% 0% 1 0 0 0 0 0 R 77084-TC $ 548.22 $ 548.22 0 0% 0% 0% 1 0 0 0 0 0 R 77085 $ 98.37 $ 98.37 0 0% 0% 0% 1 0 0 0 0 0 R77085-26 $ 25.79 $ 25.79 0 0% 0% 0% 1 0 0 0 0 0 R77085-TC $ 72.58 $ 72.58 0 0% 0% 0% 1 0 0 0 0 0 R77086 $ 62.38 $ 62.38 0 0% 0% 0% 1 0 0 0 0 0 R77086-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 0 0 0 0 0 R77086-TC $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 0 0 0 R77261 $ 127.76 $ 127.76 0 0% 0% 0% 2 0 0 0 0 0 R Y77262 $ 189.54 $ 189.54 0 0% 0% 0% 2 0 0 0 0 0 R Y77263 $ 276.51 $ 276.51 0 0% 0% 0% 2 0 0 0 0 0 R Y77280 $ 478.04 $ 478.04 0 0% 0% 0% 1 0 0 0 0 0 R Y77280-26 $ 61.18 $ 61.18 0 0% 0% 0% 1 0 0 0 0 0 R Y77280-TC $ 416.86 $ 416.86 0 0% 0% 0% 1 0 0 0 0 0 R Y77285 $ 753.35 $ 753.35 0 0% 0% 0% 1 0 0 0 0 0 R Y77285-26 $ 91.77 $ 91.77 0 0% 0% 0% 1 0 0 0 0 0 R Y77285-TC $ 661.58 $ 661.58 0 0% 0% 0% 1 0 0 0 0 0 R Y77290 $ 899.10 $ 899.10 0 0% 0% 0% 1 0 0 0 0 0 R Y77290-26 $ 136.15 $ 136.15 0 0% 0% 0% 1 0 0 0 0 0 R Y77290-TC $ 762.95 $ 762.95 0 0% 0% 0% 1 0 0 0 0 0 R Y77293 $ 813.33 $ 813.33 0 0% 0% 0% 1 0 0 0 0 0 R Y77293-26 $ 174.54 $ 174.54 0 0% 0% 0% 1 0 0 0 0 0 R Y77293-TC $ 638.79 $ 638.79 0 0% 0% 0% 1 0 0 0 0 0 R Y77295 $ 845.72 $ 845.72 0 0% 0% 0% 1 0 0 0 0 0 R Y77295-26 $ 374.28 $ 374.28 0 0% 0% 0% 1 0 0 0 0 0 R Y77295-TC $ 471.44 $ 471.44 0 0% 0% 0% 1 0 0 0 0 0 R Y77299 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77299-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77299-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77300 $ 109.16 $ 109.16 0 0% 0% 0% 1 0 0 0 0 0 R Y77300-26 $ 53.98 $ 53.98 0 0% 0% 0% 1 0 0 0 0 0 R Y77300-TC $ 54.58 $ 54.58 0 0% 0% 0% 1 0 0 0 0 0 R Y77301 $ 3396.07 $ 3395.47 0 0% 0% 0% 1 0 0 0 0 0 R Y77301-26 $ 696.97 $ 696.37 0 0% 0% 0% 1 0 0 0 0 0 R Y77301-TC $ 2699.70 $ 2699.70 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 39
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
77306 $ 251.32 $ 251.32 0 0% 0% 0% 1 0 0 0 0 0 R Y77306-26 $ 121.76 $ 121.76 0 0% 0% 0% 1 0 0 0 0 0 R Y77306-TC $ 129.56 $ 129.56 0 0% 0% 0% 1 0 0 0 0 0 R Y77307 $ 490.64 $ 490.64 0 0% 0% 0% 1 0 0 0 0 0 R Y77307-26 $ 253.72 $ 253.72 0 0% 0% 0% 1 0 0 0 0 0 R Y77307-TC $ 237.52 $ 237.52 0 0% 0% 0% 1 0 0 0 0 0 R Y77316 $ 323.89 $ 323.89 0 0% 0% 0% 1 0 0 0 0 0 R Y77316-26 $ 121.76 $ 121.76 0 0% 0% 0% 1 0 0 0 0 0 R Y77316-TC $ 202.13 $ 202.13 0 0% 0% 0% 1 0 0 0 0 0 R Y77317 $ 422.86 $ 422.86 0 0% 0% 0% 1 0 0 0 0 0 R Y77317-26 $ 160.15 $ 160.15 0 0% 0% 0% 1 0 0 0 0 0 R Y77317-TC $ 262.71 $ 262.71 0 0% 0% 0% 1 0 0 0 0 0 R Y77318 $ 610.60 $ 610.60 0 0% 0% 0% 1 0 0 0 0 0 R Y77318-26 $ 253.72 $ 253.72 0 0% 0% 0% 1 0 0 0 0 0 R Y77318-TC $ 356.88 $ 356.88 0 0% 0% 0% 1 0 0 0 0 0 R Y77321 $ 158.95 $ 158.95 0 0% 0% 0% 1 0 0 0 0 0 R Y77321-26 $ 82.77 $ 82.77 0 0% 0% 0% 1 0 0 0 0 0 R Y77321-TC $ 76.17 $ 76.17 0 0% 0% 0% 1 0 0 0 0 0 R Y77331 $ 109.16 $ 109.16 0 0% 0% 0% 1 0 0 0 0 0 R Y77331-26 $ 76.17 $ 76.17 0 0% 0% 0% 1 0 0 0 0 0 R Y77331-TC $ 32.99 $ 32.99 0 0% 0% 0% 1 0 0 0 0 0 R Y77332 $ 143.95 $ 143.95 0 0% 0% 0% 1 0 0 0 0 0 R Y77332-26 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R Y77332-TC $ 95.97 $ 95.97 0 0% 0% 0% 1 0 0 0 0 0 R Y77333 $ 89.37 $ 89.37 0 0% 0% 0% 1 0 0 0 0 0 R Y77333-26 $ 73.78 $ 73.78 0 0% 0% 0% 1 0 0 0 0 0 R Y77333-TC $ 16.19 $ 16.19 0 0% 0% 0% 1 0 0 0 0 0 R Y77334 $ 264.51 $ 264.51 0 0% 0% 0% 1 0 0 0 0 0 R Y77334-26 $ 107.96 $ 107.96 0 0% 0% 0% 1 0 0 0 0 0 R Y77334-TC $ 156.55 $ 156.55 0 0% 0% 0% 1 0 0 0 0 0 R Y77336 $ 135.55 $ 135.55 0 0% 0% 0% 3 0 0 0 0 0 R Y77338 $ 875.71 $ 875.71 0 0% 0% 0% 1 0 0 0 0 0 R Y77338-26 $ 374.28 $ 374.28 0 0% 0% 0% 1 0 0 0 0 0 R Y77338-TC $ 500.83 $ 500.83 0 0% 0% 0% 1 0 0 0 0 0 R Y77370 $ 205.73 $ 205.73 0 0% 0% 0% 3 0 0 0 0 0 R Y77371 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N Y77372 $ 1882.77 $ 1882.77 0 0% 0% 0% 3 0 0 0 0 0 R Y77373 $ 2390.80 $ 2390.80 0 0% 0% 0% 3 0 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 40
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
77385 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X77386 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X77387 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X77399 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77399-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77399-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77401 $ 36.59 $ 36.59 0 0% 0% 0% 3 0 0 0 0 0 R Y77402 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N Y77407 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N Y77412 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N Y77417 $ 18.59 $ 18.59 0 0% 0% 0% 3 0 0 0 0 0 R Y77422 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X 77423 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X 77424 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X77425 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X77427 $ 311.90 $ 311.90 0 0% 0% 0% 2 9 9 9 9 9 R Y77431 $ 170.94 $ 170.94 0 0% 0% 0% 2 0 0 0 0 0 R Y77432 $ 697.57 $ 696.97 0 0% 0% 0% 2 0 0 0 0 0 R Y77435 $ 1053.25 $ 1052.65 0 0% 0% 0% 2 0 0 0 0 0 R Y77469 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X77470 $ 266.31 $ 266.31 0 0% 0% 0% 1 0 0 0 0 0 R Y77470-26 $ 182.34 $ 182.34 0 0% 0% 0% 1 0 0 0 0 0 R Y77470-TC $ 83.37 $ 83.37 0 0% 0% 0% 1 0 0 0 0 0 R Y77499 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77499-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77499-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77520 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N Y77522 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N Y77523 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N Y77525 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N Y77600 $ 707.76 $ 707.76 0 0% 0% 0% 1 0 0 0 0 0 R Y77600-26 $ 136.15 $ 136.15 0 0% 0% 0% 1 0 0 0 0 0 R Y77600-TC $ 571.61 $ 571.61 0 0% 0% 0% 1 0 0 0 0 0 R Y77605 $ 1345.35 $ 1345.35 0 0% 0% 0% 1 0 0 0 0 0 R Y77605-26 $ 181.14 $ 181.14 0 0% 0% 0% 1 0 0 0 0 0 R Y77605-TC $ 1163.61 $ 1163.61 0 0% 0% 0% 1 0 0 0 0 0 R Y77610 $ 1820.39 $ 1820.39 0 0% 0% 0% 1 0 0 0 0 0 R Y77610-26 $ 131.96 $ 131.96 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 41
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
77610-TC $ 1689.04 $ 1689.04 0 0% 0% 0% 1 0 0 0 0 0 R Y77615 $ 1784.41 $ 1784.41 0 0% 0% 0% 1 0 0 0 0 0 R Y77615-26 $ 182.34 $ 182.34 0 0% 0% 0% 1 0 0 0 0 0 R Y77615-TC $ 1602.07 $ 1602.07 0 0% 0% 0% 1 0 0 0 0 0 R Y77620 $ 809.13 $ 809.13 0 0% 0% 0% 1 0 0 0 0 0 R Y77620-26 $ 140.35 $ 140.35 0 0% 0% 0% 1 0 0 0 0 0 R Y77620-TC $ 668.78 $ 668.78 0 0% 0% 0% 1 0 0 0 0 0 R Y77750 $ 634.59 $ 634.59 90 0% 0% 0% 1 0 0 0 0 0 R Y77750-26 $ 436.65 $ 436.65 90 0% 0% 0% 1 0 0 0 0 0 R Y77750-TC $ 197.93 $ 197.93 90 0% 0% 0% 1 0 0 0 0 0 R Y77761 $ 669.98 $ 669.98 90 0% 0% 0% 1 0 0 0 0 0 R Y77761-26 $ 332.29 $ 332.29 90 0% 0% 0% 1 0 0 0 0 0 R Y77761-TC $ 337.69 $ 337.69 90 0% 0% 0% 1 0 0 0 0 0 R Y77762 $ 913.50 $ 913.50 90 0% 0% 0% 1 0 0 0 0 0 R Y77762-26 $ 524.83 $ 524.83 90 0% 0% 0% 1 0 0 0 0 0 R Y77762-TC $ 388.67 $ 388.67 90 0% 0% 0% 1 0 0 0 0 0 R Y77763 $ 1256.58 $ 1255.98 90 0% 0% 0% 1 0 0 0 0 0 R Y77763-26 $ 754.55 $ 753.95 90 0% 0% 0% 1 0 0 0 0 0 R Y77763-TC $ 501.43 $ 501.43 90 0% 0% 0% 1 0 0 0 0 0 R Y77776 $ 808.53 $ 808.53 90 0% 0% 0% 1 0 0 0 0 0 R Y77776-26 $ 403.07 $ 403.07 90 0% 0% 0% 1 0 0 0 2 0 R Y77776-TC $ 405.46 $ 405.46 90 0% 0% 0% 1 0 0 0 0 0 R Y77777 $ 1004.07 $ 1004.07 90 0% 0% 0% 1 0 0 0 0 0 R Y77777-26 $ 657.98 $ 657.98 90 0% 0% 0% 1 0 0 0 2 0 R Y77777-TC $ 346.08 $ 346.08 90 0% 0% 0% 1 0 0 0 0 0 R Y77778 $ 1494.10 $ 1493.50 90 0% 0% 0% 1 0 0 0 0 0 R Y77778-26 $ 984.27 $ 983.67 90 0% 0% 0% 1 0 0 0 2 0 R Y77778-TC $ 509.83 $ 509.83 90 0% 0% 0% 1 0 0 0 0 0 R Y77785 $ 417.46 $ 417.46 0 0% 0% 0% 1 0 0 0 0 0 R Y77785-26 $ 123.56 $ 123.56 0 0% 0% 0% 1 0 0 0 0 0 R Y77785-TC $ 293.90 $ 293.90 0 0% 0% 0% 1 0 0 0 0 0 R Y77786 $ 853.52 $ 853.52 0 0% 0% 0% 1 0 0 0 0 0 R Y77786-26 $ 284.31 $ 284.31 0 0% 0% 0% 1 0 0 0 0 0 R Y77786-TC $ 569.21 $ 569.21 0 0% 0% 0% 1 0 0 0 0 0 R Y77787 $ 1361.55 $ 1361.55 0 0% 0% 0% 1 0 0 0 0 0 R Y77787-26 $ 427.06 $ 427.06 0 0% 0% 0% 1 0 0 0 0 0 R Y77787-TC $ 934.49 $ 934.49 0 0% 0% 0% 1 0 0 0 0 0 R Y77789 $ 206.33 $ 206.33 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 42
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
77789-26 $ 100.17 $ 100.17 0 0% 0% 0% 1 0 0 0 0 0 R Y77789-TC $ 106.16 $ 106.16 0 0% 0% 0% 1 0 0 0 0 0 R Y77790 $ 166.74 $ 166.74 0 0% 0% 0% 1 0 0 0 0 0 R Y77790-26 $ 90.57 $ 90.57 0 0% 0% 0% 1 0 0 0 0 0 R Y77790-TC $ 76.17 $ 76.17 0 0% 0% 0% 1 0 0 0 0 0 R Y77799 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77799-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y77799-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78012 $ 145.15 $ 145.15 0 0% 0% 0% 1 0 0 0 0 0 R Y78012-26 $ 16.19 $ 16.19 0 0% 0% 0% 1 0 0 0 0 0 R Y78012-TC $ 128.36 $ 128.36 0 0% 0% 0% 1 0 0 0 0 0 R Y78013 $ 347.28 $ 347.28 0 0% 0% 0% 1 0 0 0 0 0 R Y78013-26 $ 31.19 $ 31.19 0 0% 0% 0% 1 0 0 0 0 0 R Y78013-TC $ 316.09 $ 316.09 0 0% 0% 0% 1 0 0 0 0 0 R Y78014 $ 440.25 $ 440.25 0 0% 0% 0% 1 0 0 0 0 0 R Y78014-26 $ 41.39 $ 41.39 0 0% 0% 0% 1 0 0 0 0 0 R Y78014-TC $ 398.27 $ 398.27 0 0% 0% 0% 1 0 0 0 0 0 R Y78015 $ 401.27 $ 401.27 0 0% 0% 0% 1 0 0 0 0 0 R Y78015-26 $ 55.78 $ 55.78 0 0% 0% 0% 1 0 0 0 0 0 R Y78015-TC $ 345.48 $ 345.48 0 0% 0% 0% 1 0 0 0 0 0 R Y78016 $ 516.43 $ 516.43 0 0% 0% 0% 1 0 0 0 0 0 R Y78016-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R Y78016-TC $ 457.05 $ 457.05 0 0% 0% 0% 1 0 0 0 0 0 R Y78018 $ 568.61 $ 568.61 0 0% 0% 0% 1 0 0 0 0 0 R Y78018-26 $ 70.78 $ 70.78 0 0% 0% 0% 1 0 0 0 0 0 R Y78018-TC $ 497.83 $ 497.83 0 0% 0% 0% 1 0 0 0 0 0 R Y78020 $ 150.55 $ 150.55 0 0% 0% 0% 1 0 0 0 0 0 R Y78020-26 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 0 0 0 R Y78020-TC $ 102.57 $ 102.57 0 0% 0% 0% 1 0 0 0 0 0 R Y78070 $ 548.22 $ 548.22 0 0% 0% 0% 1 0 0 0 0 0 R Y78070-26 $ 67.18 $ 67.18 0 0% 0% 0% 1 0 0 0 0 0 R Y78070-TC $ 481.04 $ 481.04 0 0% 0% 0% 1 0 0 0 0 0 R Y78071 $ 651.98 $ 651.98 0 0% 0% 0% 1 0 0 0 0 0 R Y78071-26 $ 100.17 $ 100.17 0 0% 0% 0% 1 0 0 0 0 0 R Y78071-TC $ 551.82 $ 551.82 0 0% 0% 0% 1 0 0 0 0 0 R Y78072 $ 745.55 $ 745.55 0 0% 0% 0% 1 0 0 0 0 0 R Y78072-26 $ 130.16 $ 130.16 0 0% 0% 0% 1 0 0 0 0 0 R Y78072-TC $ 614.80 $ 614.80 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 43
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
78075 $ 827.12 $ 827.12 0 0% 0% 0% 1 0 0 0 0 0 R Y78075-26 $ 63.58 $ 63.58 0 0% 0% 0% 1 0 0 0 0 0 R Y78075-TC $ 763.55 $ 763.55 0 0% 0% 0% 1 0 0 0 0 0 R Y78099 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78099-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78099-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78102 $ 308.30 $ 308.30 0 0% 0% 0% 1 0 0 0 0 0 R Y78102-26 $ 45.58 $ 45.58 0 0% 0% 0% 1 0 0 0 0 0 R Y78102-TC $ 263.31 $ 263.31 0 0% 0% 0% 1 0 0 0 0 0 R Y78103 $ 402.47 $ 402.47 0 0% 0% 0% 1 0 0 0 0 0 R Y78103-26 $ 60.58 $ 60.58 0 0% 0% 0% 1 0 0 0 0 0 R Y78103-TC $ 341.29 $ 341.29 0 0% 0% 0% 1 0 0 0 0 0 R Y78104 $ 446.25 $ 446.25 0 0% 0% 0% 1 0 0 0 0 0 R Y78104-26 $ 65.38 $ 65.38 0 0% 0% 0% 1 0 0 0 0 0 R Y78104-TC $ 381.47 $ 381.47 0 0% 0% 0% 1 0 0 0 0 0 R Y78110 $ 187.14 $ 187.14 0 0% 0% 0% 1 0 0 0 0 0 R Y78110-26 $ 16.79 $ 16.79 0 0% 0% 0% 1 0 0 0 0 0 R Y78110-TC $ 170.34 $ 170.34 0 0% 0% 0% 1 0 0 0 0 0 R Y78111 $ 175.14 $ 175.14 0 0% 0% 0% 1 0 0 0 0 0 R Y78111-26 $ 18.59 $ 18.59 0 0% 0% 0% 1 0 0 0 0 0 R Y78111-TC $ 156.55 $ 156.55 0 0% 0% 0% 1 0 0 0 0 0 R Y78120 $ 170.94 $ 170.94 0 0% 0% 0% 1 0 0 0 0 0 R Y78120-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 0 0 0 R Y78120-TC $ 150.55 $ 150.55 0 0% 0% 0% 1 0 0 0 0 0 R Y78121 $ 191.34 $ 191.34 0 0% 0% 0% 1 0 0 0 0 0 R Y78121-26 $ 26.99 $ 26.99 0 0% 0% 0% 1 0 0 0 0 0 R Y78121-TC $ 164.35 $ 164.35 0 0% 0% 0% 1 0 0 0 0 0 R Y78122 $ 173.94 $ 173.94 0 0% 0% 0% 1 0 0 0 0 0 R Y78122-26 $ 35.99 $ 35.99 0 0% 0% 0% 1 0 0 0 0 0 R Y78122-TC $ 137.95 $ 137.95 0 0% 0% 0% 1 0 0 0 0 0 R Y78130 $ 285.50 $ 285.50 0 0% 0% 0% 1 0 0 0 0 0 R Y78130-26 $ 49.78 $ 49.78 0 0% 0% 0% 1 0 0 0 0 0 R Y78130-TC $ 235.72 $ 235.72 0 0% 0% 0% 1 0 0 0 0 0 R Y78135 $ 640.59 $ 640.59 0 0% 0% 0% 1 0 0 0 0 0 R Y78135-26 $ 55.18 $ 55.18 0 0% 0% 0% 1 0 0 0 0 0 R Y78135-TC $ 585.40 $ 585.40 0 0% 0% 0% 1 0 0 0 0 0 R Y78140 $ 245.92 $ 245.92 0 0% 0% 0% 1 0 0 0 0 0 R Y78140-26 $ 51.58 $ 51.58 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 44
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
78140-TC $ 194.34 $ 194.34 0 0% 0% 0% 1 0 0 0 0 0 R Y78185 $ 386.87 $ 386.87 0 0% 0% 0% 1 0 0 0 0 0 R Y78185-26 $ 34.19 $ 34.19 0 0% 0% 0% 1 0 0 0 0 0 R Y78185-TC $ 352.68 $ 352.68 0 0% 0% 0% 1 0 0 0 0 0 R Y78190 $ 716.76 $ 716.76 0 0% 0% 0% 1 0 0 0 0 0 R Y78190-26 $ 93.57 $ 93.57 0 0% 0% 0% 1 0 0 0 0 0 R Y78190-TC $ 623.19 $ 623.19 0 0% 0% 0% 1 0 0 0 0 0 R Y78191 $ 301.70 $ 301.70 0 0% 0% 0% 1 0 0 0 0 0 R Y78191-26 $ 52.78 $ 52.78 0 0% 0% 0% 1 0 0 0 0 0 R Y78191-TC $ 248.92 $ 248.92 0 0% 0% 0% 1 0 0 0 0 0 R Y78195 $ 647.78 $ 647.78 0 0% 0% 0% 1 0 0 0 0 0 R Y78195-26 $ 100.17 $ 100.17 0 0% 0% 0% 1 0 0 0 0 0 R Y78195-TC $ 547.62 $ 547.62 0 0% 0% 0% 1 0 0 0 0 0 R Y78199 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78199-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78199-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78201 $ 343.09 $ 343.09 0 0% 0% 0% 1 0 0 0 0 0 R Y78201-26 $ 36.59 $ 36.59 0 0% 0% 0% 1 0 0 0 0 0 R Y78201-TC $ 306.50 $ 306.50 0 0% 0% 0% 1 0 0 0 0 0 R Y78202 $ 365.88 $ 365.88 0 0% 0% 0% 1 0 0 0 0 0 R Y78202-26 $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R Y78202-TC $ 325.69 $ 325.69 0 0% 0% 0% 1 0 0 0 0 0 R Y78205 $ 382.67 $ 382.67 0 0% 0% 0% 1 0 0 0 0 0 R Y78205-26 $ 57.58 $ 57.58 0 0% 0% 0% 1 0 0 0 0 0 R Y78205-TC $ 325.09 $ 325.09 0 0% 0% 0% 1 0 0 0 0 0 R Y78206 $ 625.59 $ 625.59 0 0% 0% 0% 1 0 0 0 0 0 R Y78206-26 $ 79.77 $ 79.77 0 0% 0% 0% 1 0 0 0 0 0 R Y78206-TC $ 545.82 $ 545.82 0 0% 0% 0% 1 0 0 0 0 0 R Y78215 $ 353.88 $ 353.88 0 0% 0% 0% 1 0 0 0 0 0 R Y78215-26 $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R Y78215-TC $ 312.50 $ 312.50 0 0% 0% 0% 1 0 0 0 0 0 R Y78216 $ 226.72 $ 226.72 0 0% 0% 0% 1 0 0 0 0 0 R Y78216-26 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 0 0 0 R Y78216-TC $ 179.94 $ 179.94 0 0% 0% 0% 1 0 0 0 0 0 R Y78226 $ 605.20 $ 605.20 0 0% 0% 0% 1 0 0 0 0 0 R Y78226-26 $ 62.38 $ 62.38 0 0% 0% 0% 1 0 0 0 0 0 R Y78226-TC $ 542.82 $ 542.82 0 0% 0% 0% 1 0 0 0 0 0 R Y78227 $ 821.13 $ 821.13 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 45
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
78227-26 $ 75.57 $ 75.57 0 0% 0% 0% 1 0 0 0 0 0 R Y78227-TC $ 745.55 $ 745.55 0 0% 0% 0% 1 0 0 0 0 0 R Y78230 $ 315.49 $ 315.49 0 0% 0% 0% 1 0 0 0 0 0 R Y78230-26 $ 38.39 $ 38.39 0 0% 0% 0% 1 0 0 0 0 0 R Y78230-TC $ 277.11 $ 277.11 0 0% 0% 0% 1 0 0 0 0 0 R Y78231 $ 235.12 $ 235.12 0 0% 0% 0% 1 0 0 0 0 0 R Y78231-26 $ 44.39 $ 44.39 0 0% 0% 0% 1 0 0 0 0 0 R Y78231-TC $ 190.14 $ 190.14 0 0% 0% 0% 1 0 0 0 0 0 R Y78232 $ 178.14 $ 178.14 0 0% 0% 0% 1 0 0 0 0 0 R Y78232-26 $ 34.19 $ 34.19 0 0% 0% 0% 1 0 0 0 0 0 R Y78232-TC $ 143.35 $ 143.35 0 0% 0% 0% 1 0 0 0 0 0 R Y78258 $ 400.67 $ 400.67 0 0% 0% 0% 1 0 0 0 0 0 R Y78258-26 $ 62.38 $ 62.38 0 0% 0% 0% 1 0 0 0 0 0 R Y78258-TC $ 338.89 $ 338.89 0 0% 0% 0% 1 0 0 0 0 0 R Y78261 $ 460.65 $ 460.65 0 0% 0% 0% 1 0 0 0 0 0 R Y78261-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R Y78261-TC $ 401.27 $ 401.27 0 0% 0% 0% 1 0 0 0 0 0 R Y78262 $ 444.45 $ 444.45 0 0% 0% 0% 1 0 0 0 0 0 R Y78262-26 $ 56.98 $ 56.98 0 0% 0% 0% 1 0 0 0 0 0 R Y78262-TC $ 387.47 $ 387.47 0 0% 0% 0% 1 0 0 0 0 0 R Y78264 $ 527.82 $ 527.82 0 0% 0% 0% 1 0 0 0 0 0 R Y78264-26 $ 67.18 $ 67.18 0 0% 0% 0% 1 0 0 0 0 0 R Y78264-TC $ 460.65 $ 460.65 0 0% 0% 0% 1 0 0 0 0 0 R Y78267 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 78268 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 78270 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78270-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78270-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78271 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78271-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78271-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78272 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78272-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78272-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78278 $ 636.39 $ 636.39 0 0% 0% 0% 1 0 0 0 0 0 R 78278-26 $ 83.97 $ 83.97 0 0% 0% 0% 1 0 0 0 0 0 R 78278-TC $ 553.02 $ 553.02 0 0% 0% 0% 1 0 0 0 0 0 R 78282 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 46
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
78282-26 $ 32.99 $ 32.99 0 0% 0% 0% 1 0 0 0 0 0 R 78282-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 78290 $ 607.60 $ 607.60 0 0% 0% 0% 1 0 0 0 0 0 R 78290-26 $ 57.58 $ 57.58 0 0% 0% 0% 1 0 0 0 0 0 R 78290-TC $ 550.02 $ 550.02 0 0% 0% 0% 1 0 0 0 0 0 R 78291 $ 452.25 $ 452.25 0 0% 0% 0% 1 0 0 0 0 0 R Y78291-26 $ 71.98 $ 71.98 0 0% 0% 0% 1 0 0 0 0 0 R Y78291-TC $ 380.87 $ 380.87 0 0% 0% 0% 1 0 0 0 0 0 R Y78299 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78299-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78299-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78300 $ 327.49 $ 327.49 0 0% 0% 0% 1 0 0 0 0 0 R 78300-26 $ 53.38 $ 53.38 0 0% 0% 0% 1 0 0 0 0 0 R 78300-TC $ 274.71 $ 274.71 0 0% 0% 0% 1 0 0 0 0 0 R 78305 $ 419.26 $ 419.26 0 0% 0% 0% 1 0 0 0 0 0 R 78305-26 $ 69.58 $ 69.58 0 0% 0% 0% 1 0 0 0 0 0 R 78305-TC $ 349.68 $ 349.68 0 0% 0% 0% 1 0 0 0 0 0 R 78306 $ 458.25 $ 458.25 0 0% 0% 0% 1 2 0 0 0 0 R 78306-26 $ 71.98 $ 71.98 0 0% 0% 0% 1 2 0 0 0 0 R 78306-TC $ 386.27 $ 386.27 0 0% 0% 0% 1 2 0 0 0 0 R 78315 $ 632.79 $ 632.79 0 0% 0% 0% 1 0 0 0 0 0 R 78315-26 $ 85.77 $ 85.77 0 0% 0% 0% 1 0 0 0 0 0 R 78315-TC $ 547.02 $ 547.02 0 0% 0% 0% 1 0 0 0 0 0 R 78320 $ 413.26 $ 413.26 0 0% 0% 0% 1 2 0 0 0 0 R 78320-26 $ 85.77 $ 85.77 0 0% 0% 0% 1 2 0 0 0 0 R 78320-TC $ 327.49 $ 327.49 0 0% 0% 0% 1 2 0 0 0 0 R 78350 $ 57.58 $ 57.58 0 0% 0% 0% 1 9 9 9 9 9 R 78350-26 $ 18.59 $ 18.59 0 0% 0% 0% 1 9 9 9 9 9 R 78350-TC $ 38.99 $ 38.99 0 0% 0% 0% 1 9 9 9 9 9 R 78351 $ 25.79 $ 25.79 0 0% 0% 0% 9 9 9 9 9 9 R 78399 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78399-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78399-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78414 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78414-26 $ 38.39 $ 38.39 0 0% 0% 0% 1 0 0 0 0 0 R Y78414-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78428 $ 328.09 $ 328.09 0 0% 0% 0% 1 6 0 0 0 0 R Y78428-26 $ 64.78 $ 64.78 0 0% 0% 0% 1 6 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 47
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
78428-TC $ 263.31 $ 263.31 0 0% 0% 0% 1 6 0 0 0 0 R Y78445 $ 326.89 $ 326.89 0 0% 0% 0% 1 6 0 0 0 0 R Y78445-26 $ 40.19 $ 40.19 0 0% 0% 0% 1 6 0 0 0 0 R Y78445-TC $ 286.70 $ 286.70 0 0% 0% 0% 1 6 0 0 0 0 R Y78451 $ 620.19 $ 620.19 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78451-26 $ 114.56 $ 114.56 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78451-TC $ 505.63 $ 505.63 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78452 $ 860.71 $ 860.71 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78452-26 $ 134.96 $ 134.96 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78452-TC $ 725.16 $ 725.16 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78453 $ 554.82 $ 554.82 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78453-26 $ 83.97 $ 83.97 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78453-TC $ 470.84 $ 470.84 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78454 $ 794.14 $ 794.14 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78454-26 $ 113.36 $ 113.36 0 0% 0% 0% 1 6 0 0 0 0 R Y78454-TC $ 680.77 $ 680.77 0 0% 0% 0% 1 6 0 0 0 0 R Y78456 $ 584.21 $ 584.21 0 0% 0% 0% 1 6 9 9 9 9 R Y78456-26 $ 83.37 $ 83.37 0 0% 0% 0% 1 6 9 9 9 9 R Y78456-TC $ 500.83 $ 500.83 0 0% 0% 0% 1 6 9 9 9 9 R Y78457 $ 317.89 $ 317.89 0 0% 0% 0% 1 6 0 0 0 0 R Y78457-26 $ 64.18 $ 64.18 0 0% 0% 0% 1 6 0 0 0 0 R Y78457-TC $ 253.72 $ 253.72 0 0% 0% 0% 1 6 0 0 0 0 R Y78458 $ 372.48 $ 372.48 0 0% 0% 0% 1 6 2 0 0 0 R Y78458-26 $ 76.77 $ 76.77 0 0% 0% 0% 1 6 2 0 0 0 R Y78458-TC $ 295.70 $ 295.70 0 0% 0% 0% 1 6 2 0 0 0 R Y78459 $ 2951.50 $ 2951.50 0 0% 0% 0% 1 0 0 0 0 0 F Y-UR78459-26 $ 122.36 $ 122.36 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR78459-TC $ 2768.89 $ 2768.89 0 0% 0% 0% 1 0 0 0 0 0 F Y-UR78466 $ 354.48 $ 354.48 0 0% 0% 0% 1 6 0 0 0 0 R Y78466-26 $ 59.98 $ 59.98 0 0% 0% 0% 1 6 0 0 0 0 R Y78466-TC $ 294.50 $ 294.50 0 0% 0% 0% 1 6 0 0 0 0 R Y78468 $ 350.88 $ 350.88 0 0% 0% 0% 1 6 0 0 0 0 R Y78468-26 $ 66.58 $ 66.58 0 0% 0% 0% 1 6 0 0 0 0 R Y78468-TC $ 284.31 $ 284.31 0 0% 0% 0% 1 6 0 0 0 0 R Y78469 $ 413.86 $ 413.86 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78469-26 $ 77.97 $ 77.97 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78469-TC $ 335.89 $ 335.89 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78472 $ 417.46 $ 417.46 0 0% 0% 0% 1 6 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 48
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
78472-26 $ 82.17 $ 82.17 0 0% 0% 0% 1 6 0 0 0 0 R Y78472-TC $ 335.89 $ 335.89 0 0% 0% 0% 1 6 0 0 0 0 R Y78473 $ 523.63 $ 523.63 0 0% 0% 0% 1 6 0 0 0 0 R Y78473-26 $ 121.16 $ 121.16 0 0% 0% 0% 1 6 0 0 0 0 R Y78473-TC $ 402.47 $ 402.47 0 0% 0% 0% 1 6 0 0 0 0 R Y78481 $ 316.09 $ 316.09 0 0% 0% 0% 1 6 0 0 0 0 R Y78481-26 $ 81.57 $ 81.57 0 0% 0% 0% 1 6 0 0 0 0 R Y78481-TC $ 234.52 $ 234.52 0 0% 0% 0% 1 6 0 0 0 0 R Y78483 $ 430.06 $ 430.06 0 0% 0% 0% 1 6 0 0 0 0 R Y78483-26 $ 121.76 $ 121.76 0 0% 0% 0% 1 6 0 0 0 0 R Y78483-TC $ 308.30 $ 308.30 0 0% 0% 0% 1 6 0 0 0 0 R Y78491 $ 2890.59 $ 2890.59 0 0% 0% 0% 1 0 0 0 0 0 F Y-UR78491-26 $ 122.96 $ 122.96 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR78491-TC $ 2768.89 $ 2768.89 0 0% 0% 0% 1 0 0 0 0 0 F Y-UR78492 $ 2920.44 $ 2920.44 0 0% 0% 0% 1 0 0 0 0 0 F Y-UR78492-26 $ 155.35 $ 155.35 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR78492-TC $ 2768.89 $ 2768.89 0 0% 0% 0% 1 0 0 0 0 0 F Y-UR78494 $ 405.46 $ 405.46 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78494-26 $ 98.97 $ 98.97 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78494-TC $ 306.50 $ 306.50 0 0% 0% 0% 1 6 0 0 0 0 R Y-UR78496 $ 78.57 $ 78.57 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR78496-26 $ 41.39 $ 41.39 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR78496-TC $ 37.19 $ 37.19 0 0% 0% 0% 1 0 0 0 0 0 R Y-UR78499 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78499-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78499-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78579 $ 336.49 $ 336.49 0 0% 0% 0% 1 0 0 0 0 0 R Y78579-26 $ 40.19 $ 40.19 0 0% 0% 0% 1 0 0 0 0 0 R Y78579-TC $ 296.90 $ 296.90 0 0% 0% 0% 1 0 0 0 0 0 R Y78580 $ 434.86 $ 434.86 0 0% 0% 0% 1 0 0 0 0 0 R Y78580-26 $ 62.38 $ 62.38 0 0% 0% 0% 1 0 0 0 0 0 R Y78580-TC $ 372.48 $ 372.48 0 0% 0% 0% 1 0 0 0 0 0 R Y78582 $ 610.60 $ 610.60 0 0% 0% 0% 1 0 0 0 0 0 R Y78582-26 $ 89.97 $ 89.97 0 0% 0% 0% 1 0 0 0 0 0 R Y78582-TC $ 520.03 $ 520.03 0 0% 0% 0% 1 0 0 0 0 0 R Y78597 $ 367.08 $ 367.08 0 0% 0% 0% 1 0 0 0 0 0 R Y78597-26 $ 61.18 $ 61.18 0 0% 0% 0% 1 0 0 0 0 0 R Y78597-TC $ 305.90 $ 305.90 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 49
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
78598 $ 558.41 $ 558.41 0 0% 0% 0% 1 0 0 0 0 0 R Y78598-26 $ 70.78 $ 70.78 0 0% 0% 0% 1 0 0 0 0 0 R Y78598-TC $ 487.64 $ 487.64 0 0% 0% 0% 1 0 0 0 0 0 R Y78599 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78599-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78599-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78600 $ 335.89 $ 335.89 0 0% 0% 0% 1 0 0 0 0 0 R 78600-26 $ 37.79 $ 37.79 0 0% 0% 0% 1 0 0 0 0 0 R 78600-TC $ 298.10 $ 298.10 0 0% 0% 0% 1 0 0 0 0 0 R 78601 $ 391.67 $ 391.67 0 0% 0% 0% 1 0 0 0 0 0 R 78601-26 $ 42.59 $ 42.59 0 0% 0% 0% 1 0 0 0 0 0 R 78601-TC $ 349.08 $ 349.08 0 0% 0% 0% 1 0 0 0 0 0 R 78605 $ 361.68 $ 361.68 0 0% 0% 0% 1 0 0 0 0 0 R 78605-26 $ 45.58 $ 45.58 0 0% 0% 0% 1 0 0 0 0 0 R 78605-TC $ 316.69 $ 316.69 0 0% 0% 0% 1 0 0 0 0 0 R 78606 $ 608.20 $ 608.20 0 0% 0% 0% 1 0 0 0 0 0 R 78606-26 $ 53.98 $ 53.98 0 0% 0% 0% 1 0 0 0 0 0 R 78606-TC $ 554.82 $ 554.82 0 0% 0% 0% 1 0 0 0 0 0 R 78607 $ 641.79 $ 641.79 0 0% 0% 0% 1 0 0 0 0 0 R Y78607-26 $ 101.37 $ 101.37 0 0% 0% 0% 1 0 0 0 0 0 R Y78607-TC $ 540.42 $ 540.42 0 0% 0% 0% 1 0 0 0 0 0 R Y78608 $ 2888.86 $ 2888.86 0 0% 0% 0% 1 0 0 0 0 0 F Y78608-26 $ 124.16 $ 124.16 0 0% 0% 0% 1 0 0 0 0 0 R Y78608-TC $ 2768.89 $ 2768.89 0 0% 0% 0% 1 0 0 0 0 0 F Y78609 $ 2897.47 $ 2897.47 0 0% 0% 0% 1 9 9 9 9 9 F Y78609-26 $ 129.56 $ 129.56 0 0% 0% 0% 1 9 9 9 9 9 R Y78609-TC $ 2768.89 $ 2768.89 0 0% 0% 0% 1 9 9 9 9 9 F Y78610 $ 317.89 $ 317.89 0 0% 0% 0% 1 0 0 0 0 0 R 78610-26 $ 25.19 $ 25.19 0 0% 0% 0% 1 0 0 0 0 0 R 78610-TC $ 292.70 $ 292.70 0 0% 0% 0% 1 0 0 0 0 0 R 78630 $ 620.19 $ 620.19 0 0% 0% 0% 1 0 0 0 0 0 R 78630-26 $ 57.58 $ 57.58 0 0% 0% 0% 1 0 0 0 0 0 R 78630-TC $ 562.61 $ 562.61 0 0% 0% 0% 1 0 0 0 0 0 R 78635 $ 622.59 $ 622.59 0 0% 0% 0% 1 0 0 0 0 0 R 78635-26 $ 52.78 $ 52.78 0 0% 0% 0% 1 0 0 0 0 0 R 78635-TC $ 569.81 $ 569.81 0 0% 0% 0% 1 0 0 0 0 0 R 78645 $ 592.00 $ 592.00 0 0% 0% 0% 1 0 0 0 0 0 R 78645-26 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 50
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
78645-TC $ 544.62 $ 544.62 0 0% 0% 0% 1 0 0 0 0 0 R 78647 $ 641.79 $ 641.79 0 0% 0% 0% 1 0 0 0 0 0 R 78647-26 $ 76.17 $ 76.17 0 0% 0% 0% 1 0 0 0 0 0 R 78647-TC $ 565.61 $ 565.61 0 0% 0% 0% 1 0 0 0 0 0 R 78650 $ 610.60 $ 610.60 0 0% 0% 0% 1 0 0 0 0 0 R 78650-26 $ 51.58 $ 51.58 0 0% 0% 0% 1 0 0 0 0 0 R 78650-TC $ 559.01 $ 559.01 0 0% 0% 0% 1 0 0 0 0 0 R 78660 $ 321.49 $ 321.49 0 0% 0% 0% 1 0 0 0 0 0 R 78660-26 $ 44.39 $ 44.39 0 0% 0% 0% 1 0 0 0 0 0 R 78660-TC $ 277.11 $ 277.11 0 0% 0% 0% 1 0 0 0 0 0 R 78699 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78699-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78699-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78700 $ 312.50 $ 312.50 0 0% 0% 0% 1 0 0 0 0 0 R 78700-26 $ 37.79 $ 37.79 0 0% 0% 0% 1 0 0 0 0 0 R 78700-TC $ 275.31 $ 275.31 0 0% 0% 0% 1 0 0 0 0 0 R 78701 $ 383.27 $ 383.27 0 0% 0% 0% 1 0 0 0 0 0 R 78701-26 $ 40.19 $ 40.19 0 0% 0% 0% 1 0 0 0 0 0 R 78701-TC $ 343.09 $ 343.09 0 0% 0% 0% 1 0 0 0 0 0 R 78707 $ 421.66 $ 421.66 0 0% 0% 0% 1 0 0 0 0 0 R 78707-26 $ 79.77 $ 79.77 0 0% 0% 0% 1 0 0 0 0 0 R 78707-TC $ 341.89 $ 341.89 0 0% 0% 0% 1 0 0 0 0 0 R 78708 $ 312.50 $ 312.50 0 0% 0% 0% 1 0 0 0 0 0 R 78708-26 $ 101.37 $ 101.37 0 0% 0% 0% 1 0 0 0 0 0 R 78708-TC $ 210.53 $ 210.53 0 0% 0% 0% 1 0 0 0 0 0 R 78709 $ 657.38 $ 657.38 0 0% 0% 0% 1 0 0 0 0 0 R 78709-26 $ 115.76 $ 115.76 0 0% 0% 0% 1 0 0 0 0 0 R 78709-TC $ 541.02 $ 541.02 0 0% 0% 0% 1 0 0 0 0 0 R 78710 $ 359.88 $ 359.88 0 0% 0% 0% 1 0 0 0 0 0 R 78710-26 $ 50.98 $ 50.98 0 0% 0% 0% 1 0 0 0 0 0 R 78710-TC $ 308.90 $ 308.90 0 0% 0% 0% 1 0 0 0 0 0 R 78725 $ 196.13 $ 196.13 0 0% 0% 0% 1 0 0 0 0 0 R 78725-26 $ 30.59 $ 30.59 0 0% 0% 0% 1 0 0 0 0 0 R 78725-TC $ 164.95 $ 164.95 0 0% 0% 0% 1 0 0 0 0 0 R 78730 $ 139.75 $ 139.75 0 0% 0% 0% 1 0 0 0 0 0 R 78730-26 $ 13.20 $ 13.20 0 0% 0% 0% 1 0 0 0 0 0 R 78730-TC $ 126.56 $ 126.56 0 0% 0% 0% 1 0 0 0 0 0 R 78740 $ 398.27 $ 398.27 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 51
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
78740-26 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R 78740-TC $ 350.88 $ 350.88 0 0% 0% 0% 1 0 0 0 0 0 R 78761 $ 382.67 $ 382.67 0 0% 0% 0% 1 0 0 0 0 0 R 78761-26 $ 61.18 $ 61.18 0 0% 0% 0% 1 0 0 0 0 0 R 78761-TC $ 321.49 $ 321.49 0 0% 0% 0% 1 0 0 0 0 0 R 78799 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78799-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78799-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78800 $ 346.08 $ 346.08 0 0% 0% 0% 1 0 0 0 0 0 R Y78800-26 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 0 0 0 0 R Y78800-TC $ 289.70 $ 289.70 0 0% 0% 0% 1 0 0 0 0 0 R Y78801 $ 473.84 $ 473.84 0 0% 0% 0% 1 0 0 0 0 0 R Y78801-26 $ 67.78 $ 67.78 0 0% 0% 0% 1 0 0 0 0 0 R Y78801-TC $ 406.06 $ 406.06 0 0% 0% 0% 1 0 0 0 0 0 R Y78802 $ 591.40 $ 591.40 0 0% 0% 0% 1 2 0 0 0 0 R Y78802-26 $ 71.98 $ 71.98 0 0% 0% 0% 1 2 0 0 0 0 R Y78802-TC $ 520.03 $ 520.03 0 0% 0% 0% 1 2 0 0 0 0 R Y78803 $ 620.79 $ 620.79 0 0% 0% 0% 1 2 0 0 0 0 R Y78803-26 $ 88.77 $ 88.77 0 0% 0% 0% 1 2 0 0 0 0 R Y78803-TC $ 532.02 $ 532.02 0 0% 0% 0% 1 2 0 0 0 0 R Y78804 $ 1042.45 $ 1042.45 0 0% 0% 0% 1 0 0 0 0 0 R Y78804-26 $ 88.77 $ 88.77 0 0% 0% 0% 1 0 0 0 0 0 R Y78804-TC $ 953.08 $ 953.08 0 0% 0% 0% 1 0 0 0 0 0 R Y78805 $ 329.89 $ 329.89 0 0% 0% 0% 1 0 0 0 0 0 R 78805-26 $ 61.18 $ 61.18 0 0% 0% 0% 1 0 0 0 0 0 R 78805-TC $ 268.71 $ 268.71 0 0% 0% 0% 1 0 0 0 0 0 R 78806 $ 608.20 $ 608.20 0 0% 0% 0% 1 2 0 0 0 0 R 78806-26 $ 71.38 $ 71.38 0 0% 0% 0% 1 2 0 0 0 0 R 78806-TC $ 536.82 $ 536.82 0 0% 0% 0% 1 2 0 0 0 0 R 78807 $ 621.99 $ 621.99 0 0% 0% 0% 1 2 0 0 0 0 R 78807-26 $ 88.17 $ 88.17 0 0% 0% 0% 1 2 0 0 0 0 R 78807-TC $ 533.82 $ 533.82 0 0% 0% 0% 1 2 0 0 0 0 R 78808 $ 79.17 $ 79.17 0 0% 0% 0% 5 0 0 0 0 0 R Y78811 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78811-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78811-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78812 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78812-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 52
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
78812-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78813 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78813-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78813-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78814 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78814-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78814-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78815 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 78815-26 $ 206.93 $ 206.93 0 0% 0% 0% 1 0 0 0 0 0 R 78815-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 78816 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78816-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78816-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 78999 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78999-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y78999-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y79005 $ 236.92 $ 236.92 0 0% 0% 0% 1 0 0 0 0 0 R Y79005-26 $ 149.35 $ 149.35 0 0% 0% 0% 1 0 0 0 0 0 R Y79005-TC $ 86.97 $ 86.97 0 0% 0% 0% 1 0 0 0 0 0 R Y79101 $ 247.12 $ 247.12 0 0% 0% 0% 1 0 0 0 0 0 R Y79101-26 $ 161.95 $ 161.95 0 0% 0% 0% 1 0 0 0 0 0 R Y79101-TC $ 85.17 $ 85.17 0 0% 0% 0% 1 0 0 0 0 0 R Y79200 $ 235.72 $ 235.72 0 0% 0% 0% 1 0 0 0 0 0 R Y79200-26 $ 143.95 $ 143.95 0 0% 0% 0% 1 0 0 0 0 0 R Y79200-TC $ 91.77 $ 91.77 0 0% 0% 0% 1 0 0 0 0 0 R Y79300 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y79300-26 $ 122.96 $ 122.96 0 0% 0% 0% 1 0 0 0 0 0 R Y79300-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y79403 $ 329.89 $ 329.89 0 0% 0% 0% 1 0 0 0 0 0 R Y79403-26 $ 187.14 $ 187.14 0 0% 0% 0% 1 0 0 0 0 0 R Y79403-TC $ 142.75 $ 142.75 0 0% 0% 0% 1 0 0 0 0 0 R Y79440 $ 221.33 $ 221.33 0 0% 0% 0% 1 0 0 0 0 0 R Y79440-26 $ 149.95 $ 149.95 0 0% 0% 0% 1 0 0 0 0 0 R Y79440-TC $ 71.38 $ 71.38 0 0% 0% 0% 1 0 0 0 0 0 R Y79445 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y79445-26 $ 199.13 $ 199.13 0 0% 0% 0% 1 0 0 0 0 0 R Y79445-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y79999 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
Professional Services Fee SchedulesRadiology
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 53
Radiology FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
79999-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y79999-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 1
Professional Services Fee SchedulePathology & Laboratory
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 2
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSI0006M Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X0007M Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X0008M Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80047 $ 12.17 $ 12.17 0 0% 0% 0% 9 9 9 9 9 9 L 80048 $ 12.17 $ 12.17 0 0% 0% 0% 9 9 9 9 9 9 L 80050 $ 62.96 $ 62.96 0 0% 0% 0% 9 9 9 9 9 9 L 80051 $ 12.17 $ 12.17 0 0% 0% 0% 9 9 9 9 9 9 L 80053 $ 16.25 $ 16.25 0 0% 0% 0% 9 9 9 9 9 9 L 80055 $ 185.57 $ 185.57 0 0% 0% 0% 9 9 9 9 9 9 L 80061 $ 25.51 $ 25.51 0 0% 0% 0% 9 9 9 9 9 9 L Y80069 $ 12.17 $ 12.17 0 0% 0% 0% 9 9 9 9 9 9 L 80074 $ 90.76 $ 90.76 0 0% 0% 0% 9 9 9 9 9 9 L 80076 $ 12.17 $ 12.17 0 0% 0% 0% 9 9 9 9 9 9 L 80150 $ 28.71 $ 28.71 0 0% 0% 0% 9 9 9 9 9 9 L 80155 $ 26.95 $ 26.95 0 0% 0% 0% 9 9 9 9 9 9 L80156 $ 27.75 $ 27.75 0 0% 0% 0% 9 9 9 9 9 9 L 80157 $ 25.26 $ 25.26 0 0% 0% 0% 9 9 9 9 9 9 L 80158 $ 34.40 $ 34.40 0 0% 0% 0% 9 9 9 9 9 9 L 80159 $ 35.24 $ 35.24 0 0% 0% 0% 9 9 9 9 9 9 L80162 $ 25.30 $ 25.30 0 0% 0% 0% 9 9 9 9 9 9 L 80163 $ 25.30 $ 25.30 0 0% 0% 0% 9 9 9 9 9 9 L80164 $ 25.82 $ 25.82 0 0% 0% 0% 9 9 9 9 9 9 L 80165 $ 25.82 $ 25.82 0 0% 0% 0% 9 9 9 9 9 9 L80168 $ 31.14 $ 31.14 0 0% 0% 0% 9 9 9 9 9 9 L 80169 $ 26.17 $ 26.17 0 0% 0% 0% 9 9 9 9 9 9 L80170 $ 31.22 $ 31.22 0 0% 0% 0% 9 9 9 9 9 9 L 80171 $ 25.26 $ 25.26 0 0% 0% 0% 9 9 9 9 9 9 L80173 $ 27.75 $ 27.75 0 0% 0% 0% 9 9 9 9 9 9 L 80175 $ 25.26 $ 25.26 0 0% 0% 0% 9 9 9 9 9 9 L80176 $ 27.99 $ 27.99 0 0% 0% 0% 9 9 9 9 9 9 L 80177 $ 25.26 $ 25.26 0 0% 0% 0% 9 9 9 9 9 9 L80178 $ 12.60 $ 12.60 0 0% 0% 0% 9 9 9 9 9 9 L 80180 $ 34.40 $ 34.40 0 0% 0% 0% 9 9 9 9 9 9 L80183 $ 25.26 $ 25.26 0 0% 0% 0% 9 9 9 9 9 9 L80184 $ 21.81 $ 21.81 0 0% 0% 0% 9 9 9 9 9 9 L 80185 $ 25.26 $ 25.26 0 0% 0% 0% 9 9 9 9 9 9 L 80186 $ 26.22 $ 26.22 0 0% 0% 0% 9 9 9 9 9 9 L 80188 $ 31.61 $ 31.61 0 0% 0% 0% 9 9 9 9 9 9 L
CPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 3
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
80190 $ 31.92 $ 31.92 0 0% 0% 0% 9 9 9 9 9 9 L 80192 $ 31.92 $ 31.92 0 0% 0% 0% 9 9 9 9 9 9 L 80194 $ 27.82 $ 27.82 0 0% 0% 0% 9 9 9 9 9 9 L 80195 $ 26.17 $ 26.17 0 0% 0% 0% 9 9 9 9 9 9 L 80197 $ 26.17 $ 26.17 0 0% 0% 0% 9 9 9 9 9 9 L 80198 $ 26.95 $ 26.95 0 0% 0% 0% 9 9 9 9 9 9 L 80199 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L80200 $ 30.72 $ 30.72 0 0% 0% 0% 9 9 9 9 9 9 L 80201 $ 22.72 $ 22.72 0 0% 0% 0% 9 9 9 9 9 9 L 80202 $ 25.82 $ 25.82 0 0% 0% 0% 9 9 9 9 9 9 L 80203 $ 25.26 $ 25.26 0 0% 0% 0% 9 9 9 9 9 9 L80299 $ 26.10 $ 26.10 0 0% 0% 0% 9 9 9 9 9 9 L 80300 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80301 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80302 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80303 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80304 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80320 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80321 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80322 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80323 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80324 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80325 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80326 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80327 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80328 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80329 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80330 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80331 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80332 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80333 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80334 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80335 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80336 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80337 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80338 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80339 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80340 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 4
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
80341 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80342 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80343 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80344 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80345 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80346 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80347 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80348 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80349 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80350 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80351 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80352 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80353 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80354 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80355 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80356 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80357 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80358 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80359 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80360 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80361 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80362 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80363 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80364 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80365 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80366 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80367 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80368 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80369 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80370 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80371 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80372 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80373 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80374 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80375 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80376 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80377 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X80400 $ 62.15 $ 62.15 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 5
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
80402 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80406 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80408 $ 239.09 $ 239.09 0 0% 0% 0% 9 9 9 9 9 9 L 80410 $ 153.06 $ 153.06 0 0% 0% 0% 9 9 9 9 9 9 L 80412 $ 605.39 $ 605.39 0 0% 0% 0% 9 9 9 9 9 9 L 80414 $ 98.38 $ 98.38 0 0% 0% 0% 9 9 9 9 9 9 L 80415 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80416 $ 251.41 $ 251.41 0 0% 0% 0% 9 9 9 9 9 9 L 80417 $ 83.80 $ 83.80 0 0% 0% 0% 9 9 9 9 9 9 L 80418 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80420 $ 137.26 $ 137.26 0 0% 0% 0% 9 9 9 9 9 9 L 80422 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80424 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80426 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80428 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80430 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80432 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80434 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80435 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80436 $ 139.75 $ 139.75 0 0% 0% 0% 9 9 9 9 9 9 L 80438 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80439 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 80500 $ 39.59 $ 33.59 0 0% 0% 0% 0 0 0 0 0 0 R 80502 $ 124.16 $ 118.16 0 0% 0% 0% 0 0 0 0 0 0 R 81000 $ 6.03 $ 6.03 0 0% 0% 0% 9 9 9 9 9 9 L 81001 $ 6.03 $ 6.03 0 0% 0% 0% 9 9 9 9 9 9 L 81002 $ 4.87 $ 4.87 0 0% 0% 0% 9 9 9 9 9 9 L 81003 $ 4.28 $ 4.28 0 0% 0% 0% 9 9 9 9 9 9 L 81005 $ 4.13 $ 4.13 0 0% 0% 0% 9 9 9 9 9 9 L 81007 $ 4.89 $ 4.89 0 0% 0% 0% 9 9 9 9 9 9 L 81015 $ 5.80 $ 5.80 0 0% 0% 0% 9 9 9 9 9 9 L 81020 $ 7.03 $ 7.03 0 0% 0% 0% 9 9 9 9 9 9 L 81025 $ 7.17 $ 7.17 0 0% 0% 0% 9 9 9 9 9 9 L 81050 $ 5.71 $ 5.71 0 0% 0% 0% 9 9 9 9 9 9 L 81099 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 81161 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81200 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81201 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 6
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
81202 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81203 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81205 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81206 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81207 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81208 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81209 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81210 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81211 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81212 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81213 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81214 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81215 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81216 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81217 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81220 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81221 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81222 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81223 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81224 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81225 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81226 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81227 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81228 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81229 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81235 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81240 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81241 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81242 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81243 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81244 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81245 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81246 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81250 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81251 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81252 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81253 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81254 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 7
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
81255 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81256 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81257 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81260 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81261 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81262 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81263 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81264 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81265 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81266 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81267 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81268 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81270 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81275 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81280 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81281 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81282 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81287 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81288 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81290 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81291 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81292 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81293 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81294 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81295 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81296 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81297 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81298 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81299 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81300 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81301 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81302 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81303 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81304 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81310 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81313 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81315 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81316 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 8
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
81317 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81318 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81319 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81321 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81322 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81323 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81324 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81325 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81326 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81330 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81331 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81332 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81340 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81341 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81342 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81350 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81355 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81370 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81371 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81372 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81373 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81374 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81375 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81376 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81377 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81378 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81379 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81380 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81381 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81382 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81383 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N81400 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81401 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81402 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81403 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81404 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81405 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81406 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 9
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
81407 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81408 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81410 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81411 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81415 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81416 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81417 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81420 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81425 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81426 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81427 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81430 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81431 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81435 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81436 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81440 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81445 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81450 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81455 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81460 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81465 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81470 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81471 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81479 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81500 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81503 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81504 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81506 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81507 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81508 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81509 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81510 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81511 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81512 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81519 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X81599 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X82009 $ 8.61 $ 8.61 0 0% 0% 0% 9 9 9 9 9 9 L 82010 $ 15.57 $ 15.57 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 10
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
82013 $ 21.28 $ 21.28 0 0% 0% 0% 9 9 9 9 9 9 L 82016 $ 26.42 $ 26.42 0 0% 0% 0% 9 9 9 9 9 9 L 82017 $ 10.46 $ 10.46 0 0% 0% 0% 9 9 9 9 9 9 L 82024 $ 69.83 $ 69.83 0 0% 0% 0% 9 9 9 9 9 9 L 82030 $ 49.15 $ 49.15 0 0% 0% 0% 9 9 9 9 9 9 L 82040 $ 9.42 $ 9.42 0 0% 0% 0% 9 9 9 9 9 9 L 82042 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 82043 $ 11.02 $ 11.02 0 0% 0% 0% 9 9 9 9 9 9 L 82044 $ 8.71 $ 8.71 0 0% 0% 0% 9 9 9 9 9 9 L 82045 $ 64.67 $ 64.67 0 0% 0% 0% 9 9 9 9 9 9 L 82075 $ 22.96 $ 22.96 0 0% 0% 0% 9 9 9 9 9 9 L 82085 $ 18.49 $ 18.49 0 0% 0% 0% 9 9 9 9 9 9 L 82088 $ 77.64 $ 77.64 0 0% 0% 0% 9 9 9 9 9 9 L 82103 $ 25.61 $ 25.61 0 0% 0% 0% 9 9 9 9 9 9 L 82104 $ 27.55 $ 27.55 0 0% 0% 0% 9 9 9 9 9 9 L 82105 $ 31.96 $ 31.96 0 0% 0% 0% 9 9 9 9 9 9 L Y82106 $ 31.96 $ 31.96 0 0% 0% 0% 9 9 9 9 9 9 L 82107 $ 122.71 $ 122.71 0 0% 0% 0% 9 9 9 9 9 9 L 82108 $ 48.54 $ 48.54 0 0% 0% 0% 9 9 9 9 9 9 L 82120 $ 3.19 $ 3.19 0 0% 0% 0% 9 9 9 9 9 9 L 82127 $ 26.42 $ 26.42 0 0% 0% 0% 9 9 9 9 9 9 L 82128 $ 26.42 $ 26.42 0 0% 0% 0% 9 9 9 9 9 9 L 82131 $ 32.13 $ 32.13 0 0% 0% 0% 9 9 9 9 9 9 L 82135 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82136 $ 10.46 $ 10.46 0 0% 0% 0% 9 9 9 9 9 9 L 82139 $ 10.46 $ 10.46 0 0% 0% 0% 9 9 9 9 9 9 L 82140 $ 27.76 $ 27.76 0 0% 0% 0% 9 9 9 9 9 9 L 82143 $ 13.09 $ 13.09 0 0% 0% 0% 9 9 9 9 9 9 L 82150 $ 12.35 $ 12.35 0 0% 0% 0% 9 9 9 9 9 9 L 82154 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82157 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82160 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82163 $ 39.10 $ 39.10 0 0% 0% 0% 9 9 9 9 9 9 L 82164 $ 27.82 $ 27.82 0 0% 0% 0% 9 9 9 9 9 9 L 82172 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82175 $ 27.65 $ 27.65 0 0% 0% 0% 9 9 9 9 9 9 L 82180 $ 18.83 $ 18.83 0 0% 0% 0% 9 9 9 9 9 9 L 82190 $ 23.28 $ 23.28 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 11
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
82232 $ 30.83 $ 30.83 0 0% 0% 0% 9 9 9 9 9 9 L 82239 $ 32.63 $ 32.63 0 0% 0% 0% 9 9 9 9 9 9 L 82240 $ 50.64 $ 50.64 0 0% 0% 0% 9 9 9 9 9 9 L 82247 $ 8.78 $ 8.78 0 0% 0% 0% 9 9 9 9 9 9 L 82248 $ 8.78 $ 8.78 0 0% 0% 0% 9 9 9 9 9 9 L 82252 $ 8.67 $ 8.67 0 0% 0% 0% 9 9 9 9 9 9 L 82261 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82270 $ 6.20 $ 6.20 0 0% 0% 0% 9 9 9 9 9 9 L 82271 $ 6.20 $ 6.20 0 0% 0% 0% 9 9 9 9 9 9 L 82272 $ 6.20 $ 6.20 0 0% 0% 0% 9 9 9 9 9 9 L 82274 $ 30.31 $ 30.31 0 0% 0% 0% 9 9 9 9 9 9 L 82286 $ 13.13 $ 13.13 0 0% 0% 0% 9 9 9 9 9 9 L 82300 $ 44.09 $ 44.09 0 0% 0% 0% 9 9 9 9 9 9 L 82306 $ 56.41 $ 56.41 0 0% 0% 0% 9 9 9 9 9 9 L Y82308 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82310 $ 9.83 $ 9.83 0 0% 0% 0% 9 9 9 9 9 9 L 82330 $ 26.04 $ 26.04 0 0% 0% 0% 9 9 9 9 9 9 L 82331 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82340 $ 11.49 $ 11.49 0 0% 0% 0% 9 9 9 9 9 9 L 82355 $ 22.05 $ 22.05 0 0% 0% 0% 9 9 9 9 9 9 L 82360 $ 24.53 $ 24.53 0 0% 0% 0% 9 9 9 9 9 9 L 82365 $ 24.57 $ 24.57 0 0% 0% 0% 9 9 9 9 9 9 L 82370 $ 23.87 $ 23.87 0 0% 0% 0% 9 9 9 9 9 9 L 82373 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82374 $ 9.31 $ 9.31 0 0% 0% 0% 9 9 9 9 9 9 L 82375 $ 23.48 $ 23.48 0 0% 0% 0% 9 9 9 9 9 9 L 82376 $ 11.41 $ 11.41 0 0% 0% 0% 9 9 9 9 9 9 L 82378 $ 36.13 $ 36.13 0 0% 0% 0% 9 9 9 9 9 9 L Y82379 $ 10.46 $ 10.46 0 0% 0% 0% 9 9 9 9 9 9 L 82380 $ 17.57 $ 17.57 0 0% 0% 0% 9 9 9 9 9 9 L 82382 $ 32.76 $ 32.76 0 0% 0% 0% 9 9 9 9 9 9 L 82383 $ 47.74 $ 47.74 0 0% 0% 0% 9 9 9 9 9 9 L 82384 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82387 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82390 $ 20.47 $ 20.47 0 0% 0% 0% 9 9 9 9 9 9 L 82397 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82415 $ 24.14 $ 24.14 0 0% 0% 0% 9 9 9 9 9 9 L 82435 $ 8.76 $ 8.76 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 12
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
82436 $ 9.59 $ 9.59 0 0% 0% 0% 9 9 9 9 9 9 L 82438 $ 7.25 $ 7.25 0 0% 0% 0% 9 9 9 9 9 9 L 82441 $ 11.44 $ 11.44 0 0% 0% 0% 9 9 9 9 9 9 L 82465 $ 8.29 $ 8.29 0 0% 0% 0% 9 9 9 9 9 9 L Y82480 $ 15.01 $ 15.01 0 0% 0% 0% 9 9 9 9 9 9 L 82482 $ 14.63 $ 14.63 0 0% 0% 0% 9 9 9 9 9 9 L 82485 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82486 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82487 $ 30.42 $ 30.42 0 0% 0% 0% 9 9 9 9 9 9 L 82488 $ 40.70 $ 40.70 0 0% 0% 0% 9 9 9 9 9 9 L 82489 $ 35.24 $ 35.24 0 0% 0% 0% 9 9 9 9 9 9 L 82491 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82492 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82495 $ 38.64 $ 38.64 0 0% 0% 0% 9 9 9 9 9 9 L 82507 $ 52.11 $ 52.11 0 0% 0% 0% 9 9 9 9 9 9 L 82523 $ 35.60 $ 35.60 0 0% 0% 0% 9 9 9 9 9 9 L 82525 $ 20.58 $ 20.58 0 0% 0% 0% 9 9 9 9 9 9 L 82528 $ 42.90 $ 42.90 0 0% 0% 0% 9 9 9 9 9 9 L 82530 $ 31.84 $ 31.84 0 0% 0% 0% 9 9 9 9 9 9 L 82533 $ 31.07 $ 31.07 0 0% 0% 0% 9 9 9 9 9 9 L 82540 $ 8.83 $ 8.83 0 0% 0% 0% 9 9 9 9 9 9 L 82541 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82542 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82543 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82544 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82550 $ 12.40 $ 12.40 0 0% 0% 0% 9 9 9 9 9 9 L 82552 $ 25.52 $ 25.52 0 0% 0% 0% 9 9 9 9 9 9 L 82553 $ 22.01 $ 22.01 0 0% 0% 0% 9 9 9 9 9 9 L 82554 $ 22.61 $ 22.61 0 0% 0% 0% 9 9 9 9 9 9 L 82565 $ 9.76 $ 9.76 0 0% 0% 0% 9 9 9 9 9 9 L 82570 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 82575 $ 18.00 $ 18.00 0 0% 0% 0% 9 9 9 9 9 9 L 82585 $ 16.31 $ 16.31 0 0% 0% 0% 9 9 9 9 9 9 L 82595 $ 12.33 $ 12.33 0 0% 0% 0% 9 9 9 9 9 9 L 82600 $ 36.96 $ 36.96 0 0% 0% 0% 9 9 9 9 9 9 L 82607 $ 28.71 $ 28.71 0 0% 0% 0% 9 9 9 9 9 9 L 82608 $ 27.27 $ 27.27 0 0% 0% 0% 9 9 9 9 9 9 L 82610 $ 25.90 $ 25.90 0 0% 0% 0% 9 9 9 9 9 9 L Y
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 13
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
82615 $ 9.38 $ 9.38 0 0% 0% 0% 9 9 9 9 9 9 L 82626 $ 48.15 $ 48.15 0 0% 0% 0% 9 9 9 9 9 9 L 82627 $ 42.36 $ 42.36 0 0% 0% 0% 9 9 9 9 9 9 L 82633 $ 31.56 $ 31.56 0 0% 0% 0% 9 9 9 9 9 9 L 82634 $ 38.81 $ 38.81 0 0% 0% 0% 9 9 9 9 9 9 L 82638 $ 23.32 $ 23.32 0 0% 0% 0% 9 9 9 9 9 9 L 82652 $ 73.35 $ 73.35 0 0% 0% 0% 9 9 9 9 9 9 L 82656 $ 21.98 $ 21.98 0 0% 0% 0% 9 9 9 9 9 9 L 82657 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82658 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82664 $ 31.02 $ 31.02 0 0% 0% 0% 9 9 9 9 9 9 L 82668 $ 35.81 $ 35.81 0 0% 0% 0% 9 9 9 9 9 9 L 82670 $ 53.23 $ 53.23 0 0% 0% 0% 9 9 9 9 9 9 L Y82671 $ 61.54 $ 61.54 0 0% 0% 0% 9 9 9 9 9 9 L Y82672 $ 41.34 $ 41.34 0 0% 0% 0% 9 9 9 9 9 9 L Y82677 $ 46.07 $ 46.07 0 0% 0% 0% 9 9 9 9 9 9 L Y82679 $ 38.36 $ 38.36 0 0% 0% 0% 9 9 9 9 9 9 L Y82693 $ 17.49 $ 17.49 0 0% 0% 0% 9 9 9 9 9 9 L 82696 $ 44.93 $ 44.93 0 0% 0% 0% 9 9 9 9 9 9 L 82705 $ 8.85 $ 8.85 0 0% 0% 0% 9 9 9 9 9 9 L 82710 $ 32.02 $ 32.02 0 0% 0% 0% 9 9 9 9 9 9 L 82715 $ 5.31 $ 5.31 0 0% 0% 0% 9 9 9 9 9 9 L 82725 $ 18.80 $ 18.80 0 0% 0% 0% 9 9 9 9 9 9 L 82726 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 82728 $ 25.96 $ 25.96 0 0% 0% 0% 9 9 9 9 9 9 L 82731 $ 122.71 $ 122.71 0 0% 0% 0% 9 9 9 9 9 9 L 82735 $ 35.32 $ 35.32 0 0% 0% 0% 9 9 9 9 9 9 L 82746 $ 28.01 $ 28.01 0 0% 0% 0% 9 9 9 9 9 9 L 82747 $ 33.00 $ 33.00 0 0% 0% 0% 9 9 9 9 9 9 L 82757 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82759 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82760 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82775 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82776 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82777 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X82784 $ 17.71 $ 17.71 0 0% 0% 0% 9 9 9 9 9 9 L 82785 $ 31.37 $ 31.37 0 0% 0% 0% 9 9 9 9 9 9 L 82787 $ 7.99 $ 7.99 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 14
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
82800 $ 12.43 $ 12.43 0 0% 0% 0% 9 9 9 9 9 9 L 82803 $ 23.21 $ 23.21 0 0% 0% 0% 9 9 9 9 9 9 L 82805 $ 46.37 $ 46.37 0 0% 0% 0% 9 9 9 9 9 9 L 82810 $ 16.63 $ 16.63 0 0% 0% 0% 9 9 9 9 9 9 L 82820 $ 19.03 $ 19.03 0 0% 0% 0% 9 9 9 9 9 9 L 82930 $ 7.42 $ 7.42 0 0% 0% 0% 9 9 9 9 9 9 L82938 $ 33.71 $ 33.71 0 0% 0% 0% 9 9 9 9 9 9 L 82941 $ 33.60 $ 33.60 0 0% 0% 0% 9 9 9 9 9 9 L 82943 $ 27.22 $ 27.22 0 0% 0% 0% 9 9 9 9 9 9 L 82945 $ 7.48 $ 7.48 0 0% 0% 0% 9 9 9 9 9 9 L 82946 $ 28.71 $ 28.71 0 0% 0% 0% 9 9 9 9 9 9 L 82947 $ 7.48 $ 7.48 0 0% 0% 0% 9 9 9 9 9 9 L 82948 $ 6.03 $ 6.03 0 0% 0% 0% 9 9 9 9 9 9 L 82950 $ 9.04 $ 9.04 0 0% 0% 0% 9 9 9 9 9 9 L 82951 $ 24.53 $ 24.53 0 0% 0% 0% 9 9 9 9 9 9 L 82952 $ 7.48 $ 7.48 0 0% 0% 0% 9 9 9 9 9 9 L 82955 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82960 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82962 $ 3.43 $ 3.43 0 0% 0% 0% 9 9 9 9 9 9 L 82963 $ 40.94 $ 40.94 0 0% 0% 0% 9 9 9 9 9 9 L 82965 $ 14.73 $ 14.73 0 0% 0% 0% 9 9 9 9 9 9 L 82977 $ 13.72 $ 13.72 0 0% 0% 0% 9 9 9 9 9 9 L 82978 $ 27.16 $ 27.16 0 0% 0% 0% 9 9 9 9 9 9 L 82979 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 82985 $ 22.36 $ 22.36 0 0% 0% 0% 9 9 9 9 9 9 L 83001 $ 32.62 $ 32.62 0 0% 0% 0% 9 9 9 9 9 9 L Y83002 $ 33.14 $ 33.14 0 0% 0% 0% 9 9 9 9 9 9 L Y83003 $ 31.51 $ 31.51 0 0% 0% 0% 9 9 9 9 9 9 L 83006 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X83009 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83010 $ 23.97 $ 23.97 0 0% 0% 0% 9 9 9 9 9 9 L 83012 $ 32.76 $ 32.76 0 0% 0% 0% 9 9 9 9 9 9 L 83013 $ 128.32 $ 128.32 0 0% 0% 0% 9 9 9 9 9 9 L 83014 $ 14.98 $ 14.98 0 0% 0% 0% 9 9 9 9 9 9 L 83015 $ 35.88 $ 35.88 0 0% 0% 0% 9 9 9 9 9 9 L 83018 $ 15.95 $ 15.95 0 0% 0% 0% 9 9 9 9 9 9 L 83020 $ 19.17 $ 19.17 0 0% 0% 0% 9 9 9 9 9 9 L 83020-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 15
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
83021 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 83026 $ 4.51 $ 4.51 0 0% 0% 0% 9 9 9 9 9 9 L 83030 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83033 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83036 $ 18.49 $ 18.49 0 0% 0% 0% 9 9 9 9 9 9 L 83037 $ 18.49 $ 18.49 0 0% 0% 0% 9 9 9 9 9 9 L Y83045 $ 9.44 $ 9.44 0 0% 0% 0% 9 9 9 9 9 9 L 83050 $ 13.97 $ 13.97 0 0% 0% 0% 9 9 9 9 9 9 L 83051 $ 13.93 $ 13.93 0 0% 0% 0% 9 9 9 9 9 9 L 83060 $ 15.75 $ 15.75 0 0% 0% 0% 9 9 9 9 9 9 L 83065 $ 13.13 $ 13.13 0 0% 0% 0% 9 9 9 9 9 9 L 83068 $ 16.11 $ 16.11 0 0% 0% 0% 9 9 9 9 9 9 L 83069 $ 7.52 $ 7.52 0 0% 0% 0% 9 9 9 9 9 9 L 83070 $ 9.04 $ 9.04 0 0% 0% 0% 9 9 9 9 9 9 L 83080 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83088 $ 56.27 $ 56.27 0 0% 0% 0% 9 9 9 9 9 9 L 83090 $ 32.13 $ 32.13 0 0% 0% 0% 9 9 9 9 9 9 L Y83150 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83491 $ 33.38 $ 33.38 0 0% 0% 0% 9 9 9 9 9 9 L 83497 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83498 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83499 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83500 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83505 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83516 $ 21.98 $ 21.98 0 0% 0% 0% 9 9 9 9 9 9 L 83518 $ 16.14 $ 16.14 0 0% 0% 0% 9 9 9 9 9 9 L 83519 $ 24.19 $ 24.19 0 0% 0% 0% 9 9 9 9 9 9 L 83520 $ 24.67 $ 24.67 0 0% 0% 0% 9 9 9 9 9 9 L 83525 $ 21.77 $ 21.77 0 0% 0% 0% 9 9 9 9 9 9 L 83527 $ 24.67 $ 24.67 0 0% 0% 0% 9 9 9 9 9 9 L 83528 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83540 $ 12.33 $ 12.33 0 0% 0% 0% 9 9 9 9 9 9 L 83550 $ 16.66 $ 16.66 0 0% 0% 0% 9 9 9 9 9 9 L 83570 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83582 $ 26.42 $ 26.42 0 0% 0% 0% 9 9 9 9 9 9 L 83586 $ 24.40 $ 24.40 0 0% 0% 0% 9 9 9 9 9 9 L 83593 $ 50.11 $ 50.11 0 0% 0% 0% 9 9 9 9 9 9 L 83605 $ 20.34 $ 20.34 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 16
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
83615 $ 11.49 $ 11.49 0 0% 0% 0% 9 9 9 9 9 9 L 83625 $ 24.39 $ 24.39 0 0% 0% 0% 9 9 9 9 9 9 L 83630 $ 37.39 $ 37.39 0 0% 0% 0% 9 9 9 9 9 9 L 83631 $ 37.39 $ 37.39 0 0% 0% 0% 9 9 9 9 9 9 L 83632 $ 38.51 $ 38.51 0 0% 0% 0% 9 9 9 9 9 9 L 83633 $ 10.47 $ 10.47 0 0% 0% 0% 9 9 9 9 9 9 L 83655 $ 23.06 $ 23.06 0 0% 0% 0% 9 9 9 9 9 9 L 83661 $ 33.14 $ 33.14 0 0% 0% 0% 9 9 9 9 9 9 L 83662 $ 36.04 $ 36.04 0 0% 0% 0% 9 9 9 9 9 9 L 83663 $ 36.04 $ 36.04 0 0% 0% 0% 9 9 9 9 9 9 L Y83664 $ 36.04 $ 36.04 0 0% 0% 0% 9 9 9 9 9 9 L Y83670 $ 17.46 $ 17.46 0 0% 0% 0% 9 9 9 9 9 9 L 83690 $ 13.13 $ 13.13 0 0% 0% 0% 9 9 9 9 9 9 L 83695 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83698 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83700 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83701 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83704 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83718 $ 15.60 $ 15.60 0 0% 0% 0% 9 9 9 9 9 9 L Y83719 $ 22.18 $ 22.18 0 0% 0% 0% 9 9 9 9 9 9 L Y83721 $ 18.19 $ 18.19 0 0% 0% 0% 9 9 9 9 9 9 L Y83727 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83735 $ 12.75 $ 12.75 0 0% 0% 0% 9 9 9 9 9 9 L 83775 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83785 $ 46.86 $ 46.86 0 0% 0% 0% 9 9 9 9 9 9 L 83788 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 83789 $ 34.41 $ 34.41 0 0% 0% 0% 9 9 9 9 9 9 L 83825 $ 30.97 $ 30.97 0 0% 0% 0% 9 9 9 9 9 9 L 83835 $ 32.27 $ 32.27 0 0% 0% 0% 9 9 9 9 9 9 L 83857 $ 20.47 $ 20.47 0 0% 0% 0% 9 9 9 9 9 9 L 83861 $ 31.47 $ 31.47 0 0% 0% 0% 9 9 9 9 9 9 L83864 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83872 $ 11.17 $ 11.17 0 0% 0% 0% 9 9 9 9 9 9 L 83873 $ 32.77 $ 32.77 0 0% 0% 0% 9 9 9 9 9 9 L 83874 $ 24.61 $ 24.61 0 0% 0% 0% 9 9 9 9 9 9 L 83876 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83880 $ 64.67 $ 64.67 0 0% 0% 0% 9 9 9 9 9 9 L 83883 $ 25.90 $ 25.90 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 17
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
83885 $ 46.68 $ 46.68 0 0% 0% 0% 9 9 9 9 9 9 L 83915 $ 21.25 $ 21.25 0 0% 0% 0% 9 9 9 9 9 9 L Y83916 $ 26.59 $ 26.59 0 0% 0% 0% 9 9 9 9 9 9 L 83918 $ 31.35 $ 31.35 0 0% 0% 0% 9 9 9 9 9 9 L 83919 $ 31.35 $ 31.35 0 0% 0% 0% 9 9 9 9 9 9 L 83921 $ 31.35 $ 31.35 0 0% 0% 0% 9 9 9 9 9 9 L 83930 $ 12.60 $ 12.60 0 0% 0% 0% 9 9 9 9 9 9 L 83935 $ 12.22 $ 12.22 0 0% 0% 0% 9 9 9 9 9 9 L 83937 $ 56.87 $ 56.87 0 0% 0% 0% 9 9 9 9 9 9 L 83945 $ 24.53 $ 24.53 0 0% 0% 0% 9 9 9 9 9 9 L Y83950 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83951 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 83970 $ 78.64 $ 78.64 0 0% 0% 0% 9 9 9 9 9 9 L 83986 $ 5.49 $ 5.49 0 0% 0% 0% 9 9 9 9 9 9 L 83987 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X83992 $ 28.00 $ 28.00 0 0% 0% 0% 9 9 9 9 9 9 L 83993 $ 37.39 $ 37.39 0 0% 0% 0% 9 9 9 9 9 9 L 84030 $ 10.16 $ 10.16 0 0% 0% 0% 9 9 9 9 9 9 L Y84035 $ 4.00 $ 4.00 0 0% 0% 0% 9 9 9 9 9 9 L Y84060 $ 12.59 $ 12.59 0 0% 0% 0% 9 9 9 9 9 9 L 84061 $ 15.06 $ 15.06 0 0% 0% 0% 9 9 9 9 9 9 L 84066 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84075 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 84078 $ 13.92 $ 13.92 0 0% 0% 0% 9 9 9 9 9 9 L 84080 $ 28.17 $ 28.17 0 0% 0% 0% 9 9 9 9 9 9 L 84081 $ 31.47 $ 31.47 0 0% 0% 0% 9 9 9 9 9 9 L 84085 $ 12.85 $ 12.85 0 0% 0% 0% 9 9 9 9 9 9 L 84087 $ 19.67 $ 19.67 0 0% 0% 0% 9 9 9 9 9 9 L 84100 $ 9.03 $ 9.03 0 0% 0% 0% 9 9 9 9 9 9 L 84105 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 84106 $ 8.15 $ 8.15 0 0% 0% 0% 9 9 9 9 9 9 L 84110 $ 15.43 $ 15.43 0 0% 0% 0% 9 9 9 9 9 9 L 84112 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X84119 $ 16.41 $ 16.41 0 0% 0% 0% 9 9 9 9 9 9 L 84120 $ 28.03 $ 28.03 0 0% 0% 0% 9 9 9 9 9 9 L 84126 $ 28.20 $ 28.20 0 0% 0% 0% 9 9 9 9 9 9 L 84132 $ 8.76 $ 8.76 0 0% 0% 0% 9 9 9 9 9 9 L 84133 $ 8.19 $ 8.19 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 18
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
84134 $ 27.78 $ 27.78 0 0% 0% 0% 9 9 9 9 9 9 L 84135 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84138 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84140 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84143 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84144 $ 39.17 $ 39.17 0 0% 0% 0% 9 9 9 9 9 9 L Y84145 $ 51.03 $ 51.03 0 0% 0% 0% 9 9 9 9 9 9 L84146 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84150 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84152 $ 35.04 $ 35.04 0 0% 0% 0% 9 9 9 9 9 9 L Y84153 $ 35.04 $ 35.04 0 0% 0% 0% 9 9 9 9 9 9 L Y84154 $ 35.04 $ 35.04 0 0% 0% 0% 9 9 9 9 9 9 L Y84155 $ 6.99 $ 6.99 0 0% 0% 0% 9 9 9 9 9 9 L 84156 $ 6.99 $ 6.99 0 0% 0% 0% 9 9 9 9 9 9 L 84157 $ 6.99 $ 6.99 0 0% 0% 0% 9 9 9 9 9 9 L 84160 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 84163 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84165 $ 20.45 $ 20.45 0 0% 0% 0% 9 9 9 9 9 9 L 84165-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 84166 $ 33.98 $ 33.98 0 0% 0% 0% 9 9 9 9 9 9 L 84166-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 84181 $ 32.45 $ 32.45 0 0% 0% 0% 9 9 9 9 9 9 L 84181-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 84182 $ 34.29 $ 34.29 0 0% 0% 0% 9 9 9 9 9 9 L 84182-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 84202 $ 27.33 $ 27.33 0 0% 0% 0% 9 9 9 9 9 9 L 84203 $ 16.39 $ 16.39 0 0% 0% 0% 9 9 9 9 9 9 L 84206 $ 33.94 $ 33.94 0 0% 0% 0% 9 9 9 9 9 9 L 84207 $ 32.97 $ 32.97 0 0% 0% 0% 9 9 9 9 9 9 L 84210 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84220 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84228 $ 22.18 $ 22.18 0 0% 0% 0% 9 9 9 9 9 9 L 84233 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84234 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84235 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84238 $ 69.68 $ 69.68 0 0% 0% 0% 9 9 9 9 9 9 L 84244 $ 41.90 $ 41.90 0 0% 0% 0% 9 9 9 9 9 9 L 84252 $ 8.85 $ 8.85 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 19
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
84255 $ 48.64 $ 48.64 0 0% 0% 0% 9 9 9 9 9 9 L 84260 $ 59.02 $ 59.02 0 0% 0% 0% 9 9 9 9 9 9 L 84270 $ 41.41 $ 41.41 0 0% 0% 0% 9 9 9 9 9 9 L Y84275 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84285 $ 44.86 $ 44.86 0 0% 0% 0% 9 9 9 9 9 9 L 84295 $ 9.17 $ 9.17 0 0% 0% 0% 9 9 9 9 9 9 L 84300 $ 9.27 $ 9.27 0 0% 0% 0% 9 9 9 9 9 9 L 84302 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84305 $ 40.50 $ 40.50 0 0% 0% 0% 9 9 9 9 9 9 L Y84307 $ 34.83 $ 34.83 0 0% 0% 0% 9 9 9 9 9 9 L 84311 $ 13.33 $ 13.33 0 0% 0% 0% 9 9 9 9 9 9 L 84315 $ 3.19 $ 3.19 0 0% 0% 0% 9 9 9 9 9 9 L 84375 $ 7.27 $ 7.27 0 0% 0% 0% 9 9 9 9 9 9 L 84376 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84377 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84378 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84379 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84392 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84402 $ 48.51 $ 48.51 0 0% 0% 0% 9 9 9 9 9 9 L Y84403 $ 49.18 $ 49.18 0 0% 0% 0% 9 9 9 9 9 9 L Y84425 $ 40.45 $ 40.45 0 0% 0% 0% 9 9 9 9 9 9 L 84430 $ 20.23 $ 20.23 0 0% 0% 0% 9 9 9 9 9 9 L 84431 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X84432 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84436 $ 13.09 $ 13.09 0 0% 0% 0% 9 9 9 9 9 9 L 84437 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84439 $ 16.66 $ 16.66 0 0% 0% 0% 9 9 9 9 9 9 L 84442 $ 13.33 $ 13.33 0 0% 0% 0% 9 9 9 9 9 9 L 84443 $ 31.89 $ 31.89 0 0% 0% 0% 9 9 9 9 9 9 L 84445 $ 96.88 $ 96.88 0 0% 0% 0% 9 9 9 9 9 9 L 84446 $ 27.01 $ 27.01 0 0% 0% 0% 9 9 9 9 9 9 L 84449 $ 34.29 $ 34.29 0 0% 0% 0% 9 9 9 9 9 9 L 84450 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 84460 $ 10.09 $ 10.09 0 0% 0% 0% 9 9 9 9 9 9 L 84466 $ 24.33 $ 24.33 0 0% 0% 0% 9 9 9 9 9 9 L 84478 $ 10.95 $ 10.95 0 0% 0% 0% 9 9 9 9 9 9 L Y84479 $ 12.33 $ 12.33 0 0% 0% 0% 9 9 9 9 9 9 L 84480 $ 27.01 $ 27.01 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 20
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
84481 $ 13.86 $ 13.86 0 0% 0% 0% 9 9 9 9 9 9 L 84482 $ 30.03 $ 30.03 0 0% 0% 0% 9 9 9 9 9 9 L 84484 $ 18.75 $ 18.75 0 0% 0% 0% 9 9 9 9 9 9 L 84485 $ 14.32 $ 14.32 0 0% 0% 0% 9 9 9 9 9 9 L 84488 $ 13.92 $ 13.92 0 0% 0% 0% 9 9 9 9 9 9 L 84490 $ 14.49 $ 14.49 0 0% 0% 0% 9 9 9 9 9 9 L 84510 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84512 $ 14.67 $ 14.67 0 0% 0% 0% 9 9 9 9 9 9 L 84520 $ 7.52 $ 7.52 0 0% 0% 0% 9 9 9 9 9 9 L 84525 $ 3.19 $ 3.19 0 0% 0% 0% 9 9 9 9 9 9 L 84540 $ 8.85 $ 8.85 0 0% 0% 0% 9 9 9 9 9 9 L 84545 $ 11.87 $ 11.87 0 0% 0% 0% 9 9 9 9 9 9 L 84550 $ 8.61 $ 8.61 0 0% 0% 0% 9 9 9 9 9 9 L 84560 $ 9.04 $ 9.04 0 0% 0% 0% 9 9 9 9 9 9 L 84577 $ 23.77 $ 23.77 0 0% 0% 0% 9 9 9 9 9 9 L 84578 $ 6.20 $ 6.20 0 0% 0% 0% 9 9 9 9 9 9 L 84580 $ 7.84 $ 7.84 0 0% 0% 0% 9 9 9 9 9 9 L 84583 $ 9.59 $ 9.59 0 0% 0% 0% 9 9 9 9 9 9 L 84585 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84586 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84588 $ 64.67 $ 64.67 0 0% 0% 0% 9 9 9 9 9 9 L Y84590 $ 22.11 $ 22.11 0 0% 0% 0% 9 9 9 9 9 9 L 84591 $ 22.11 $ 22.11 0 0% 0% 0% 9 9 9 9 9 9 L 84597 $ 26.12 $ 26.12 0 0% 0% 0% 9 9 9 9 9 9 L 84600 $ 30.63 $ 30.63 0 0% 0% 0% 9 9 9 9 9 9 L 84620 $ 22.57 $ 22.57 0 0% 0% 0% 9 9 9 9 9 9 L 84630 $ 20.16 $ 20.16 0 0% 0% 0% 9 9 9 9 9 9 L 84681 $ 39.65 $ 39.65 0 0% 0% 0% 9 9 9 9 9 9 L 84702 $ 28.69 $ 28.69 0 0% 0% 0% 9 9 9 9 9 9 L 84703 $ 14.32 $ 14.32 0 0% 0% 0% 9 9 9 9 9 9 L 84704 $ 28.69 $ 28.69 0 0% 0% 0% 9 9 9 9 9 9 L 84830 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 84999 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 85002 $ 8.58 $ 8.58 0 0% 0% 0% 9 9 9 9 9 9 L 85004 $ 12.33 $ 12.33 0 0% 0% 0% 9 9 9 9 9 9 L 85007 $ 6.55 $ 6.55 0 0% 0% 0% 9 9 9 9 9 9 L 85008 $ 6.55 $ 6.55 0 0% 0% 0% 9 9 9 9 9 9 L 85009 $ 7.08 $ 7.08 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 21
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
85013 $ 4.52 $ 4.52 0 0% 0% 0% 9 9 9 9 9 9 L 85014 $ 4.52 $ 4.52 0 0% 0% 0% 9 9 9 9 9 9 L 85018 $ 4.52 $ 4.52 0 0% 0% 0% 9 9 9 9 9 9 L 85025 $ 14.81 $ 14.81 0 0% 0% 0% 9 9 9 9 9 9 L 85027 $ 12.33 $ 12.33 0 0% 0% 0% 9 9 9 9 9 9 L 85032 $ 8.19 $ 8.19 0 0% 0% 0% 9 9 9 9 9 9 L 85041 $ 5.75 $ 5.75 0 0% 0% 0% 9 9 9 9 9 9 L 85044 $ 8.19 $ 8.19 0 0% 0% 0% 9 9 9 9 9 9 L 85045 $ 7.62 $ 7.62 0 0% 0% 0% 9 9 9 9 9 9 L 85046 $ 10.63 $ 10.63 0 0% 0% 0% 9 9 9 9 9 9 L 85048 $ 4.84 $ 4.84 0 0% 0% 0% 9 9 9 9 9 9 L 85049 $ 8.53 $ 8.53 0 0% 0% 0% 9 9 9 9 9 9 L 85055 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 85060 $ 42.59 $ 42.59 0 0% 0% 0% 8 0 0 0 0 0 R 85097 $ 154.15 $ 83.97 0 0% 0% 0% 0 0 0 0 0 0 R 85130 $ 22.65 $ 22.65 0 0% 0% 0% 9 9 9 9 9 9 L 85170 $ 5.49 $ 5.49 0 0% 0% 0% 9 9 9 9 9 9 L 85175 $ 8.67 $ 8.67 0 0% 0% 0% 9 9 9 9 9 9 L 85210 $ 11.72 $ 11.72 0 0% 0% 0% 9 9 9 9 9 9 L 85220 $ 31.02 $ 31.02 0 0% 0% 0% 9 9 9 9 9 9 L 85230 $ 26.59 $ 26.59 0 0% 0% 0% 9 9 9 9 9 9 L 85240 $ 34.12 $ 34.12 0 0% 0% 0% 9 9 9 9 9 9 L 85244 $ 38.91 $ 38.91 0 0% 0% 0% 9 9 9 9 9 9 L 85245 $ 43.71 $ 43.71 0 0% 0% 0% 9 9 9 9 9 9 L 85246 $ 43.71 $ 43.71 0 0% 0% 0% 9 9 9 9 9 9 L 85247 $ 43.71 $ 43.71 0 0% 0% 0% 9 9 9 9 9 9 L 85250 $ 31.02 $ 31.02 0 0% 0% 0% 9 9 9 9 9 9 L 85260 $ 34.12 $ 34.12 0 0% 0% 0% 9 9 9 9 9 9 L 85270 $ 31.02 $ 31.02 0 0% 0% 0% 9 9 9 9 9 9 L 85280 $ 36.86 $ 36.86 0 0% 0% 0% 9 9 9 9 9 9 L 85290 $ 31.02 $ 31.02 0 0% 0% 0% 9 9 9 9 9 9 L 85291 $ 16.95 $ 16.95 0 0% 0% 0% 9 9 9 9 9 9 L 85292 $ 36.08 $ 36.08 0 0% 0% 0% 9 9 9 9 9 9 L 85293 $ 36.08 $ 36.08 0 0% 0% 0% 9 9 9 9 9 9 L 85300 $ 22.58 $ 22.58 0 0% 0% 0% 9 9 9 9 9 9 L 85301 $ 20.59 $ 20.59 0 0% 0% 0% 9 9 9 9 9 9 L 85302 $ 22.89 $ 22.89 0 0% 0% 0% 9 9 9 9 9 9 L 85303 $ 26.35 $ 26.35 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 22
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
85305 $ 22.11 $ 22.11 0 0% 0% 0% 9 9 9 9 9 9 L 85306 $ 29.19 $ 29.19 0 0% 0% 0% 9 9 9 9 9 9 L 85307 $ 29.19 $ 29.19 0 0% 0% 0% 9 9 9 9 9 9 L 85335 $ 24.53 $ 24.53 0 0% 0% 0% 9 9 9 9 9 9 L 85337 $ 19.87 $ 19.87 0 0% 0% 0% 9 9 9 9 9 9 L 85345 $ 8.19 $ 8.19 0 0% 0% 0% 9 9 9 9 9 9 L 85347 $ 8.11 $ 8.11 0 0% 0% 0% 9 9 9 9 9 9 L 85348 $ 7.10 $ 7.10 0 0% 0% 0% 9 9 9 9 9 9 L 85360 $ 16.00 $ 16.00 0 0% 0% 0% 9 9 9 9 9 9 L 85362 $ 13.13 $ 13.13 0 0% 0% 0% 9 9 9 9 9 9 L 85366 $ 16.41 $ 16.41 0 0% 0% 0% 9 9 9 9 9 9 L 85370 $ 21.63 $ 21.63 0 0% 0% 0% 9 9 9 9 9 9 L 85378 $ 13.59 $ 13.59 0 0% 0% 0% 9 9 9 9 9 9 L 85379 $ 19.39 $ 19.39 0 0% 0% 0% 9 9 9 9 9 9 L 85380 $ 19.39 $ 19.39 0 0% 0% 0% 9 9 9 9 9 9 L 85384 $ 15.32 $ 15.32 0 0% 0% 0% 9 9 9 9 9 9 L 85385 $ 15.32 $ 15.32 0 0% 0% 0% 9 9 9 9 9 9 L 85390 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 85390-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 85396 $ 34.79 $ 34.79 0 0% 0% 0% 0 0 0 0 0 0 R 85397 $ 43.71 $ 43.71 0 0% 0% 0% 9 9 9 9 9 9 L 85400 $ 16.86 $ 16.86 0 0% 0% 0% 9 9 9 9 9 9 L 85410 $ 14.69 $ 14.69 0 0% 0% 0% 9 9 9 9 9 9 L 85415 $ 21.28 $ 21.28 0 0% 0% 0% 9 9 9 9 9 9 L 85420 $ 12.45 $ 12.45 0 0% 0% 0% 9 9 9 9 9 9 L 85421 $ 19.40 $ 19.40 0 0% 0% 0% 9 9 9 9 9 9 L 85441 $ 8.01 $ 8.01 0 0% 0% 0% 9 9 9 9 9 9 L 85445 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 85460 $ 4.77 $ 4.77 0 0% 0% 0% 9 9 9 9 9 9 L 85461 $ 12.64 $ 12.64 0 0% 0% 0% 9 9 9 9 9 9 L 85475 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 85520 $ 24.95 $ 24.95 0 0% 0% 0% 9 9 9 9 9 9 L 85525 $ 22.57 $ 22.57 0 0% 0% 0% 9 9 9 9 9 9 L 85530 $ 27.01 $ 27.01 0 0% 0% 0% 9 9 9 9 9 9 L 85536 $ 12.33 $ 12.33 0 0% 0% 0% 9 9 9 9 9 9 L 85540 $ 16.39 $ 16.39 0 0% 0% 0% 9 9 9 9 9 9 L Y85547 $ 16.39 $ 16.39 0 0% 0% 0% 9 9 9 9 9 9 L 85549 $ 33.14 $ 33.14 0 0% 0% 0% 9 9 9 9 9 9 L Y
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 23
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
85555 $ 11.07 $ 11.07 0 0% 0% 0% 9 9 9 9 9 9 L 85557 $ 25.45 $ 25.45 0 0% 0% 0% 9 9 9 9 9 9 L 85576 $ 40.94 $ 40.94 0 0% 0% 0% 9 9 9 9 9 9 L 85576-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 85597 $ 34.24 $ 34.24 0 0% 0% 0% 9 9 9 9 9 9 L Y85598 $ 34.24 $ 34.24 0 0% 0% 0% 9 9 9 9 9 9 L Y85610 $ 7.49 $ 7.49 0 0% 0% 0% 9 9 9 9 9 9 L 85611 $ 7.50 $ 7.50 0 0% 0% 0% 9 9 9 9 9 9 L 85612 $ 18.24 $ 18.24 0 0% 0% 0% 9 9 9 9 9 9 L 85613 $ 18.24 $ 18.24 0 0% 0% 0% 9 9 9 9 9 9 L 85635 $ 16.66 $ 16.66 0 0% 0% 0% 9 9 9 9 9 9 L 85651 $ 6.75 $ 6.75 0 0% 0% 0% 9 9 9 9 9 9 L 85652 $ 5.15 $ 5.15 0 0% 0% 0% 9 9 9 9 9 9 L 85660 $ 10.50 $ 10.50 0 0% 0% 0% 9 9 9 9 9 9 L 85670 $ 10.99 $ 10.99 0 0% 0% 0% 9 9 9 9 9 9 L 85675 $ 13.05 $ 13.05 0 0% 0% 0% 9 9 9 9 9 9 L 85705 $ 17.98 $ 17.98 0 0% 0% 0% 9 9 9 9 9 9 L 85730 $ 11.07 $ 11.07 0 0% 0% 0% 9 9 9 9 9 9 L 85732 $ 12.33 $ 12.33 0 0% 0% 0% 9 9 9 9 9 9 L 85810 $ 15.65 $ 15.65 0 0% 0% 0% 9 9 9 9 9 9 L Y85999 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86000 $ 13.30 $ 13.30 0 0% 0% 0% 9 9 9 9 9 9 L 86001 $ 9.94 $ 9.94 0 0% 0% 0% 9 9 9 9 9 9 L 86003 $ 9.94 $ 9.94 0 0% 0% 0% 9 9 9 9 9 9 L 86005 $ 9.46 $ 9.46 0 0% 0% 0% 9 9 9 9 9 9 L 86021 $ 28.69 $ 28.69 0 0% 0% 0% 9 9 9 9 9 9 L 86022 $ 28.60 $ 28.60 0 0% 0% 0% 9 9 9 9 9 9 L 86023 $ 23.73 $ 23.73 0 0% 0% 0% 9 9 9 9 9 9 L 86038 $ 23.03 $ 23.03 0 0% 0% 0% 9 9 9 9 9 9 L 86039 $ 21.27 $ 21.27 0 0% 0% 0% 9 9 9 9 9 9 L 86060 $ 13.92 $ 13.92 0 0% 0% 0% 9 9 9 9 9 9 L Y86063 $ 9.58 $ 9.58 0 0% 0% 0% 9 9 9 9 9 9 L Y86077 $ 95.97 $ 88.77 0 0% 0% 0% 0 0 0 0 0 0 R 86078 $ 94.77 $ 88.17 0 0% 0% 0% 0 0 0 0 0 0 R 86079 $ 92.97 $ 86.97 0 0% 0% 0% 0 0 0 0 0 0 R 86140 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 86141 $ 24.67 $ 24.67 0 0% 0% 0% 9 9 9 9 9 9 L 86146 $ 48.47 $ 48.47 0 0% 0% 0% 9 9 9 9 9 9 L Y
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 24
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
86147 $ 48.47 $ 48.47 0 0% 0% 0% 9 9 9 9 9 9 L 86148 $ 30.62 $ 30.62 0 0% 0% 0% 9 9 9 9 9 9 L Y86152 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X86153-26 Not Covered Not Covered 0 0% 0% 0% 6 0 0 0 0 0 X86155 $ 6.64 $ 6.64 0 0% 0% 0% 9 9 9 9 9 9 L 86156 $ 12.77 $ 12.77 0 0% 0% 0% 9 9 9 9 9 9 L 86157 $ 15.36 $ 15.36 0 0% 0% 0% 9 9 9 9 9 9 L 86160 $ 22.86 $ 22.86 0 0% 0% 0% 9 9 9 9 9 9 L 86161 $ 22.86 $ 22.86 0 0% 0% 0% 9 9 9 9 9 9 L 86162 $ 38.71 $ 38.71 0 0% 0% 0% 9 9 9 9 9 9 L 86171 $ 11.07 $ 11.07 0 0% 0% 0% 9 9 9 9 9 9 L 86185 $ 17.04 $ 17.04 0 0% 0% 0% 9 9 9 9 9 9 L 86200 $ 24.67 $ 24.67 0 0% 0% 0% 9 9 9 9 9 9 L 86215 $ 25.24 $ 25.24 0 0% 0% 0% 9 9 9 9 9 9 L 86225 $ 26.17 $ 26.17 0 0% 0% 0% 9 9 9 9 9 9 L 86226 $ 21.07 $ 21.07 0 0% 0% 0% 9 9 9 9 9 9 L 86235 $ 34.17 $ 34.17 0 0% 0% 0% 9 9 9 9 9 9 L 86243 $ 22.69 $ 22.69 0 0% 0% 0% 9 9 9 9 9 9 L 86255 $ 22.96 $ 22.96 0 0% 0% 0% 9 9 9 9 9 9 L 86255-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 86256 $ 22.96 $ 22.96 0 0% 0% 0% 9 9 9 9 9 9 L 86256-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 86277 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 86280 $ 15.60 $ 15.60 0 0% 0% 0% 9 9 9 9 9 9 L 86294 $ 37.38 $ 37.38 0 0% 0% 0% 9 9 9 9 9 9 L Y86300 $ 39.65 $ 39.65 0 0% 0% 0% 9 9 9 9 9 9 L Y86301 $ 39.65 $ 39.65 0 0% 0% 0% 9 9 9 9 9 9 L Y86304 $ 39.65 $ 39.65 0 0% 0% 0% 9 9 9 9 9 9 L Y86305 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X86308 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 86309 $ 9.38 $ 9.38 0 0% 0% 0% 9 9 9 9 9 9 L 86310 $ 14.04 $ 14.04 0 0% 0% 0% 9 9 9 9 9 9 L 86316 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 86317 $ 25.90 $ 25.90 0 0% 0% 0% 9 9 9 9 9 9 L 86318 $ 24.67 $ 24.67 0 0% 0% 0% 9 9 9 9 9 9 L 86320 $ 42.70 $ 42.70 0 0% 0% 0% 9 9 9 9 9 9 L 86320-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 86325 $ 42.62 $ 42.62 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 25
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
86325-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 86327 $ 43.23 $ 43.23 0 0% 0% 0% 9 9 9 9 9 9 L 86327-26 $ 36.59 $ 36.59 0 0% 0% 0% 6 0 0 0 0 0 R 86329 $ 26.75 $ 26.75 0 0% 0% 0% 9 9 9 9 9 9 L 86331 $ 22.82 $ 22.82 0 0% 0% 0% 9 9 9 9 9 9 L 86332 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 86334 $ 42.57 $ 42.57 0 0% 0% 0% 9 9 9 9 9 9 L 86334-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 86335 $ 55.92 $ 55.92 0 0% 0% 0% 9 9 9 9 9 9 L 86335-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 86336 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 86337 $ 40.78 $ 40.78 0 0% 0% 0% 9 9 9 9 9 9 L 86340 $ 28.71 $ 28.71 0 0% 0% 0% 9 9 9 9 9 9 L 86341 $ 37.69 $ 37.69 0 0% 0% 0% 9 9 9 9 9 9 L 86343 $ 23.74 $ 23.74 0 0% 0% 0% 9 9 9 9 9 9 L 86344 $ 15.22 $ 15.22 0 0% 0% 0% 9 9 9 9 9 9 L 86352 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X86353 $ 93.41 $ 93.41 0 0% 0% 0% 9 9 9 9 9 9 L 86355 $ 71.88 $ 71.88 0 0% 0% 0% 9 9 9 9 9 9 L 86356 $ 34.48 $ 34.48 0 0% 0% 0% 9 9 9 9 9 9 L 86357 $ 71.88 $ 71.88 0 0% 0% 0% 9 9 9 9 9 9 L 86359 $ 71.88 $ 71.88 0 0% 0% 0% 9 9 9 9 9 9 L 86360 $ 89.52 $ 89.52 0 0% 0% 0% 9 9 9 9 9 9 L 86361 $ 34.48 $ 34.48 0 0% 0% 0% 9 9 9 9 9 9 L 86367 $ 71.88 $ 71.88 0 0% 0% 0% 9 9 9 9 9 9 L 86376 $ 27.72 $ 27.72 0 0% 0% 0% 9 9 9 9 9 9 L Y86378 $ 37.52 $ 37.52 0 0% 0% 0% 9 9 9 9 9 9 L 86382 $ 32.21 $ 32.21 0 0% 0% 0% 9 9 9 9 9 9 L 86384 $ 21.70 $ 21.70 0 0% 0% 0% 9 9 9 9 9 9 L 86386 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X86403 $ 19.42 $ 19.42 0 0% 0% 0% 9 9 9 9 9 9 L 86406 $ 20.26 $ 20.26 0 0% 0% 0% 9 9 9 9 9 9 L 86430 $ 10.81 $ 10.81 0 0% 0% 0% 9 9 9 9 9 9 L 86431 $ 10.81 $ 10.81 0 0% 0% 0% 9 9 9 9 9 9 L 86480 $ 118.09 $ 118.09 0 0% 0% 0% 9 9 9 9 9 9 L 86481 $ 142.74 $ 142.74 0 0% 0% 0% 9 9 9 9 9 9 L86485 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N 86486 $ 8.40 $ 8.40 0 0% 0% 0% 3 0 0 0 0 0 R
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 26
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
86490 $ 12.00 $ 12.00 0 0% 0% 0% 3 0 0 0 0 0 R 86510 $ 10.20 $ 10.20 0 0% 0% 0% 3 0 0 0 0 0 R 86580 $ 13.80 $ 13.80 0 0% 0% 0% 3 0 0 0 0 0 R 86590 $ 21.04 $ 21.04 0 0% 0% 0% 9 9 9 9 9 9 L 86592 $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 L 86593 $ 8.39 $ 8.39 0 0% 0% 0% 9 9 9 9 9 9 L 86602 $ 19.39 $ 19.39 0 0% 0% 0% 9 9 9 9 9 9 L 86603 $ 24.51 $ 24.51 0 0% 0% 0% 9 9 9 9 9 9 L 86606 $ 28.69 $ 28.69 0 0% 0% 0% 9 9 9 9 9 9 L 86609 $ 24.54 $ 24.54 0 0% 0% 0% 9 9 9 9 9 9 L 86611 $ 19.39 $ 19.39 0 0% 0% 0% 9 9 9 9 9 9 L 86612 $ 24.58 $ 24.58 0 0% 0% 0% 9 9 9 9 9 9 L 86615 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86617 $ 29.51 $ 29.51 0 0% 0% 0% 9 9 9 9 9 9 L 86618 $ 32.45 $ 32.45 0 0% 0% 0% 9 9 9 9 9 9 L 86619 $ 25.49 $ 25.49 0 0% 0% 0% 9 9 9 9 9 9 L 86622 $ 17.02 $ 17.02 0 0% 0% 0% 9 9 9 9 9 9 L 86625 $ 25.00 $ 25.00 0 0% 0% 0% 9 9 9 9 9 9 L 86628 $ 22.88 $ 22.88 0 0% 0% 0% 9 9 9 9 9 9 L 86631 $ 22.53 $ 22.53 0 0% 0% 0% 9 9 9 9 9 9 L 86632 $ 24.18 $ 24.18 0 0% 0% 0% 9 9 9 9 9 9 L 86635 $ 21.85 $ 21.85 0 0% 0% 0% 9 9 9 9 9 9 L 86638 $ 23.10 $ 23.10 0 0% 0% 0% 9 9 9 9 9 9 L 86641 $ 27.45 $ 27.45 0 0% 0% 0% 9 9 9 9 9 9 L 86644 $ 25.07 $ 25.07 0 0% 0% 0% 9 9 9 9 9 9 L 86645 $ 32.10 $ 32.10 0 0% 0% 0% 9 9 9 9 9 9 L 86648 $ 23.28 $ 23.28 0 0% 0% 0% 9 9 9 9 9 9 L 86651 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86652 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86653 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86654 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86658 $ 24.82 $ 24.82 0 0% 0% 0% 9 9 9 9 9 9 L 86663 $ 25.00 $ 25.00 0 0% 0% 0% 9 9 9 9 9 9 L 86664 $ 29.15 $ 29.15 0 0% 0% 0% 9 9 9 9 9 9 L 86665 $ 34.57 $ 34.57 0 0% 0% 0% 9 9 9 9 9 9 L 86666 $ 19.39 $ 19.39 0 0% 0% 0% 9 9 9 9 9 9 L 86668 $ 19.82 $ 19.82 0 0% 0% 0% 9 9 9 9 9 9 L 86671 $ 14.56 $ 14.56 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 27
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
86674 $ 28.04 $ 28.04 0 0% 0% 0% 9 9 9 9 9 9 L 86677 $ 27.64 $ 27.64 0 0% 0% 0% 9 9 9 9 9 9 L 86682 $ 24.78 $ 24.78 0 0% 0% 0% 9 9 9 9 9 9 L 86684 $ 30.18 $ 30.18 0 0% 0% 0% 9 9 9 9 9 9 L 86687 $ 15.99 $ 15.99 0 0% 0% 0% 9 9 9 9 9 9 L 86688 $ 26.68 $ 26.68 0 0% 0% 0% 9 9 9 9 9 9 L 86689 $ 36.88 $ 36.88 0 0% 0% 0% 9 9 9 9 9 9 L 86692 $ 32.69 $ 32.69 0 0% 0% 0% 9 9 9 9 9 9 L 86694 $ 25.07 $ 25.07 0 0% 0% 0% 9 9 9 9 9 9 L 86695 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86696 $ 36.88 $ 36.88 0 0% 0% 0% 9 9 9 9 9 9 L 86698 $ 23.81 $ 23.81 0 0% 0% 0% 9 9 9 9 9 9 L 86701 $ 16.93 $ 16.93 0 0% 0% 0% 9 9 9 9 9 9 L 86702 $ 25.75 $ 25.75 0 0% 0% 0% 9 9 9 9 9 9 L 86703 $ 26.12 $ 26.12 0 0% 0% 0% 9 9 9 9 9 9 L 86704 $ 22.96 $ 22.96 0 0% 0% 0% 9 9 9 9 9 9 L 86705 $ 22.44 $ 22.44 0 0% 0% 0% 9 9 9 9 9 9 L 86706 $ 20.47 $ 20.47 0 0% 0% 0% 9 9 9 9 9 9 L 86707 $ 22.05 $ 22.05 0 0% 0% 0% 9 9 9 9 9 9 L 86708 $ 23.60 $ 23.60 0 0% 0% 0% 9 9 9 9 9 9 L 86709 $ 21.45 $ 21.45 0 0% 0% 0% 9 9 9 9 9 9 L 86710 $ 25.82 $ 25.82 0 0% 0% 0% 9 9 9 9 9 9 L 86711 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X86713 $ 29.15 $ 29.15 0 0% 0% 0% 9 9 9 9 9 9 L 86717 $ 23.34 $ 23.34 0 0% 0% 0% 9 9 9 9 9 9 L 86720 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86723 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86727 $ 24.51 $ 24.51 0 0% 0% 0% 9 9 9 9 9 9 L 86729 $ 22.76 $ 22.76 0 0% 0% 0% 9 9 9 9 9 9 L 86732 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86735 $ 24.86 $ 24.86 0 0% 0% 0% 9 9 9 9 9 9 L 86738 $ 25.23 $ 25.23 0 0% 0% 0% 9 9 9 9 9 9 L 86741 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86744 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86747 $ 28.64 $ 28.64 0 0% 0% 0% 9 9 9 9 9 9 L 86750 $ 23.28 $ 23.28 0 0% 0% 0% 9 9 9 9 9 9 L 86753 $ 23.60 $ 23.60 0 0% 0% 0% 9 9 9 9 9 9 L 86756 $ 24.56 $ 24.56 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 28
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
86757 $ 36.88 $ 36.88 0 0% 0% 0% 9 9 9 9 9 9 L 86759 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86762 $ 25.07 $ 25.07 0 0% 0% 0% 9 9 9 9 9 9 L 86765 $ 24.54 $ 24.54 0 0% 0% 0% 9 9 9 9 9 9 L 86768 $ 19.63 $ 19.63 0 0% 0% 0% 9 9 9 9 9 9 L 86771 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86774 $ 16.56 $ 16.56 0 0% 0% 0% 9 9 9 9 9 9 L 86777 $ 25.07 $ 25.07 0 0% 0% 0% 9 9 9 9 9 9 L 86778 $ 27.44 $ 27.44 0 0% 0% 0% 9 9 9 9 9 9 L 86780 $ 25.23 $ 25.23 0 0% 0% 0% 9 9 9 9 9 9 L Y86784 $ 23.93 $ 23.93 0 0% 0% 0% 9 9 9 9 9 9 L 86787 $ 24.54 $ 24.54 0 0% 0% 0% 9 9 9 9 9 9 L 86788 $ 32.10 $ 32.10 0 0% 0% 0% 9 9 9 9 9 9 L 86789 $ 25.07 $ 25.07 0 0% 0% 0% 9 9 9 9 9 9 L 86790 $ 24.54 $ 24.54 0 0% 0% 0% 9 9 9 9 9 9 L 86793 $ 25.13 $ 25.13 0 0% 0% 0% 9 9 9 9 9 9 L 86800 $ 30.31 $ 30.31 0 0% 0% 0% 9 9 9 9 9 9 L 86803 $ 27.19 $ 27.19 0 0% 0% 0% 9 9 9 9 9 9 L 86804 $ 29.51 $ 29.51 0 0% 0% 0% 9 9 9 9 9 9 L 86805 $ 41.06 $ 41.06 0 0% 0% 0% 9 9 9 9 9 9 L 86806 $ 33.14 $ 33.14 0 0% 0% 0% 9 9 9 9 9 9 L 86807 $ 39.82 $ 39.82 0 0% 0% 0% 9 9 9 9 9 9 L 86808 $ 25.07 $ 25.07 0 0% 0% 0% 9 9 9 9 9 9 L 86812 $ 49.17 $ 49.17 0 0% 0% 0% 9 9 9 9 9 9 L 86813 $ 110.49 $ 110.49 0 0% 0% 0% 9 9 9 9 9 9 L 86816 $ 53.07 $ 53.07 0 0% 0% 0% 9 9 9 9 9 9 L 86817 $ 122.67 $ 122.67 0 0% 0% 0% 9 9 9 9 9 9 L 86821 $ 107.56 $ 107.56 0 0% 0% 0% 9 9 9 9 9 9 L 86822 $ 69.65 $ 69.65 0 0% 0% 0% 9 9 9 9 9 9 L 86825 $ 103.43 $ 103.43 0 0% 0% 0% 9 9 9 9 9 9 L86826 $ 34.48 $ 34.48 0 0% 0% 0% 9 9 9 9 9 9 L86828 $ 39.82 $ 39.82 0 0% 0% 0% 9 9 9 9 9 9 L86829 $ 25.07 $ 25.07 0 0% 0% 0% 9 9 9 9 9 9 L86830 $ 153.82 $ 153.82 0 0% 0% 0% 9 9 9 9 9 9 L86831 $ 131.85 $ 131.85 0 0% 0% 0% 9 9 9 9 9 9 L86832 $ 241.72 $ 241.72 0 0% 0% 0% 9 9 9 9 9 9 L86833 $ 219.76 $ 219.76 0 0% 0% 0% 9 9 9 9 9 9 L86834 $ 681.23 $ 681.23 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 29
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
86835 $ 615.29 $ 615.29 0 0% 0% 0% 9 9 9 9 9 9 L86849 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86850 $ 106.50 $ 106.50 0 0% 0% 0% 9 9 9 9 9 9 L 86860 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86870 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86880 $ 10.26 $ 10.26 0 0% 0% 0% 9 9 9 9 9 9 L 86885 $ 10.91 $ 10.91 0 0% 0% 0% 9 9 9 9 9 9 L 86886 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 86890 $ 78.92 $ 78.92 0 0% 0% 0% 9 9 9 9 9 9 F 86891 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86900 $ 5.68 $ 5.68 0 0% 0% 0% 9 9 9 9 9 9 L 86901 $ 5.68 $ 5.68 0 0% 0% 0% 9 9 9 9 9 9 L 86902 $ 6.64 $ 6.64 0 0% 0% 0% 9 9 9 9 9 9 L86904 $ 18.12 $ 18.12 0 0% 0% 0% 9 9 9 9 9 9 L 86905 $ 6.64 $ 6.64 0 0% 0% 0% 9 9 9 9 9 9 L 86906 $ 14.15 $ 14.15 0 0% 0% 0% 9 9 9 9 9 9 L 86910 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 86911 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 86920 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86921 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86922 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86923 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86927 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86930 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86931 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86932 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86940 $ 15.62 $ 15.62 0 0% 0% 0% 9 9 9 9 9 9 L 86941 $ 23.07 $ 23.07 0 0% 0% 0% 9 9 9 9 9 9 L 86945 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86950 $ 249.18 $ 249.18 0 0% 0% 0% 9 9 9 9 9 9 F 86960 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86965 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86970 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86971 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86972 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86975 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86976 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86977 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 30
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
86978 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86985 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 86999 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 87003 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 87015 $ 12.73 $ 12.73 0 0% 0% 0% 9 9 9 9 9 9 L 87040 $ 19.67 $ 19.67 0 0% 0% 0% 9 9 9 9 9 9 L 87045 $ 17.99 $ 17.99 0 0% 0% 0% 9 9 9 9 9 9 L 87046 $ 17.99 $ 17.99 0 0% 0% 0% 9 9 9 9 9 9 L 87070 $ 16.41 $ 16.41 0 0% 0% 0% 9 9 9 9 9 9 L 87071 $ 17.99 $ 17.99 0 0% 0% 0% 9 9 9 9 9 9 L 87073 $ 17.99 $ 17.99 0 0% 0% 0% 9 9 9 9 9 9 L 87075 $ 18.03 $ 18.03 0 0% 0% 0% 9 9 9 9 9 9 L 87076 $ 15.40 $ 15.40 0 0% 0% 0% 9 9 9 9 9 9 L 87077 $ 15.40 $ 15.40 0 0% 0% 0% 9 9 9 9 9 9 L 87081 $ 12.63 $ 12.63 0 0% 0% 0% 9 9 9 9 9 9 L 87084 $ 16.41 $ 16.41 0 0% 0% 0% 9 9 9 9 9 9 L 87086 $ 15.39 $ 15.39 0 0% 0% 0% 9 9 9 9 9 9 L 87088 $ 12.22 $ 12.22 0 0% 0% 0% 9 9 9 9 9 9 L 87101 $ 14.69 $ 14.69 0 0% 0% 0% 9 9 9 9 9 9 L 87102 $ 16.00 $ 16.00 0 0% 0% 0% 9 9 9 9 9 9 L 87103 $ 17.18 $ 17.18 0 0% 0% 0% 9 9 9 9 9 9 L 87106 $ 19.67 $ 19.67 0 0% 0% 0% 9 9 9 9 9 9 L 87107 $ 19.67 $ 19.67 0 0% 0% 0% 9 9 9 9 9 9 L 87109 $ 20.58 $ 20.58 0 0% 0% 0% 9 9 9 9 9 9 L 87110 $ 37.32 $ 37.32 0 0% 0% 0% 9 9 9 9 9 9 L 87116 $ 20.58 $ 20.58 0 0% 0% 0% 9 9 9 9 9 9 L 87118 $ 20.86 $ 20.86 0 0% 0% 0% 9 9 9 9 9 9 L 87140 $ 10.63 $ 10.63 0 0% 0% 0% 9 9 9 9 9 9 L 87143 $ 23.87 $ 23.87 0 0% 0% 0% 9 9 9 9 9 9 L 87147 $ 9.86 $ 9.86 0 0% 0% 0% 9 9 9 9 9 9 L 87149 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87150 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L87152 $ 9.97 $ 9.97 0 0% 0% 0% 9 9 9 9 9 9 L 87153 $ 219.77 $ 219.77 0 0% 0% 0% 9 9 9 9 9 9 L87158 $ 9.97 $ 9.97 0 0% 0% 0% 9 9 9 9 9 9 L 87164 $ 20.47 $ 20.47 0 0% 0% 0% 9 9 9 9 9 9 L 87164-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 87166 $ 8.85 $ 8.85 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 31
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
87168 $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 L 87169 $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 L 87172 $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 L 87176 $ 9.94 $ 9.94 0 0% 0% 0% 9 9 9 9 9 9 L 87177 $ 16.95 $ 16.95 0 0% 0% 0% 9 9 9 9 9 9 L 87181 $ 9.04 $ 9.04 0 0% 0% 0% 9 9 9 9 9 9 L 87184 $ 13.15 $ 13.15 0 0% 0% 0% 9 9 9 9 9 9 L 87185 $ 9.04 $ 9.04 0 0% 0% 0% 9 9 9 9 9 9 L 87186 $ 16.48 $ 16.48 0 0% 0% 0% 9 9 9 9 9 9 L 87187 $ 19.74 $ 19.74 0 0% 0% 0% 9 9 9 9 9 9 L 87188 $ 12.66 $ 12.66 0 0% 0% 0% 9 9 9 9 9 9 L 87190 $ 10.77 $ 10.77 0 0% 0% 0% 9 9 9 9 9 9 L 87197 $ 28.63 $ 28.63 0 0% 0% 0% 9 9 9 9 9 9 L 87205 $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 L 87206 $ 10.26 $ 10.26 0 0% 0% 0% 9 9 9 9 9 9 L 87207 $ 11.41 $ 11.41 0 0% 0% 0% 9 9 9 9 9 9 L 87207-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 87209 $ 34.24 $ 34.24 0 0% 0% 0% 9 9 9 9 9 9 L 87210 $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 L 87220 $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 L 87230 $ 37.62 $ 37.62 0 0% 0% 0% 9 9 9 9 9 9 L 87250 $ 36.50 $ 36.50 0 0% 0% 0% 9 9 9 9 9 9 L 87252 $ 49.67 $ 49.67 0 0% 0% 0% 9 9 9 9 9 9 L 87253 $ 38.49 $ 38.49 0 0% 0% 0% 9 9 9 9 9 9 L 87254 $ 36.50 $ 36.50 0 0% 0% 0% 9 9 9 9 9 9 L 87255 $ 64.51 $ 64.51 0 0% 0% 0% 9 9 9 9 9 9 L 87260 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87265 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87267 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87269 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87270 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87271 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87272 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87273 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87274 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87275 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87276 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87277 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 32
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
87278 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87279 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87280 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87281 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87283 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87285 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87290 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87299 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87300 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87301 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87305 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87320 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87324 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87327 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87328 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87329 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87332 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87335 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87336 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87337 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87338 $ 22.86 $ 22.86 0 0% 0% 0% 9 9 9 9 9 9 L 87339 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87340 $ 19.68 $ 19.68 0 0% 0% 0% 9 9 9 9 9 9 L 87341 $ 19.68 $ 19.68 0 0% 0% 0% 9 9 9 9 9 9 L 87350 $ 21.97 $ 21.97 0 0% 0% 0% 9 9 9 9 9 9 L 87380 $ 31.26 $ 31.26 0 0% 0% 0% 9 9 9 9 9 9 L 87385 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87389 $ 45.88 $ 45.88 0 0% 0% 0% 9 9 9 9 9 9 L87390 $ 33.61 $ 33.61 0 0% 0% 0% 9 9 9 9 9 9 L 87391 $ 33.61 $ 33.61 0 0% 0% 0% 9 9 9 9 9 9 L 87400 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87420 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87425 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87427 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87430 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87449 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87450 $ 18.27 $ 18.27 0 0% 0% 0% 9 9 9 9 9 9 L 87451 $ 18.27 $ 18.27 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 33
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
87470 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87471 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87472 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87475 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87476 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87477 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87480 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87481 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87482 $ 79.55 $ 79.55 0 0% 0% 0% 9 9 9 9 9 9 L 87485 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87486 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87487 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87490 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L Y87491 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L Y87492 $ 66.60 $ 66.60 0 0% 0% 0% 9 9 9 9 9 9 L Y87493 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L87495 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87496 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87497 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87498 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87500 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87501 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X87502 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X87503 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X87505 $ 244.41 $ 244.41 0 0% 0% 0% 9 9 9 9 9 9 L87506 $ 406.63 $ 406.63 0 0% 0% 0% 9 9 9 9 9 9 L87507 $ 794.05 $ 794.05 0 0% 0% 0% 9 9 9 9 9 9 L87510 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87511 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87512 $ 79.55 $ 79.55 0 0% 0% 0% 9 9 9 9 9 9 L 87515 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87516 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87517 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87520 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87521 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87522 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L Y87525 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87526 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 34
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
87527 $ 79.55 $ 79.55 0 0% 0% 0% 9 9 9 9 9 9 L 87528 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87529 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87530 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87531 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87532 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87533 $ 79.55 $ 79.55 0 0% 0% 0% 9 9 9 9 9 9 L 87534 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87535 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87536 $ 162.12 $ 162.12 0 0% 0% 0% 9 9 9 9 9 9 L 87537 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87538 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87539 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87540 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87541 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87542 $ 79.55 $ 79.55 0 0% 0% 0% 9 9 9 9 9 9 L 87550 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87551 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87552 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87555 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87556 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87557 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87560 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87561 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87562 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87580 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87581 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87582 $ 79.55 $ 79.55 0 0% 0% 0% 9 9 9 9 9 9 L 87590 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L Y87591 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L Y87592 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L Y87623 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X87624 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X87625 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X87631 $ 244.41 $ 244.41 0 0% 0% 0% 9 9 9 9 9 9 L Y87632 $ 406.63 $ 406.63 0 0% 0% 0% 9 9 9 9 9 9 L Y87633 $ 794.05 $ 794.05 0 0% 0% 0% 9 9 9 9 9 9 L Y87640 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 35
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
87641 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87650 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87651 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87652 $ 79.55 $ 79.55 0 0% 0% 0% 9 9 9 9 9 9 L 87653 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87660 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L Y87661 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X87797 $ 38.21 $ 38.21 0 0% 0% 0% 9 9 9 9 9 9 L 87798 $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 L 87799 $ 81.61 $ 81.61 0 0% 0% 0% 9 9 9 9 9 9 L 87800 $ 76.43 $ 76.43 0 0% 0% 0% 9 9 9 9 9 9 L 87801 $ 133.73 $ 133.73 0 0% 0% 0% 9 9 9 9 9 9 L 87802 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87803 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87804 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87806 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X87807 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87808 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87809 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87810 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L Y87850 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L Y87880 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87899 $ 22.85 $ 22.85 0 0% 0% 0% 9 9 9 9 9 9 L 87900 $ 248.33 $ 248.33 0 0% 0% 0% 9 9 9 9 9 9 L 87901 $ 490.49 $ 490.49 0 0% 0% 0% 9 9 9 9 9 9 L 87902 $ 490.49 $ 490.49 0 0% 0% 0% 9 9 9 9 9 9 L 87903 $ 930.97 $ 930.97 0 0% 0% 0% 9 9 9 9 9 9 L 87904 $ 49.67 $ 49.67 0 0% 0% 0% 9 9 9 9 9 9 L 87905 $ 23.28 $ 23.28 0 0% 0% 0% 9 9 9 9 9 9 L 87906 $ 245.25 $ 245.25 0 0% 0% 0% 9 9 9 9 9 9 L87910 $ 490.49 $ 490.49 0 0% 0% 0% 9 9 9 9 9 9 L87912 $ 490.49 $ 490.49 0 0% 0% 0% 9 9 9 9 9 9 L87999 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88000 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88005 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88007 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88012 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 88014 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 36
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
88016 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 88020 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88025 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88027 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88028 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 88029 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 88036 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88037 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88040 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88045 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88099 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 88104 $ 130.76 $ 130.76 0 0% 0% 0% 1 0 0 0 0 0 R Y88104-26 $ 50.38 $ 50.38 0 0% 0% 0% 1 0 0 0 0 0 R Y88104-TC $ 80.37 $ 80.37 0 0% 0% 0% 1 0 0 0 0 0 R Y88106 $ 154.15 $ 154.15 0 0% 0% 0% 1 0 0 0 0 0 R Y88106-26 $ 34.19 $ 34.19 0 0% 0% 0% 1 0 0 0 0 0 R Y88106-TC $ 119.96 $ 119.96 0 0% 0% 0% 1 0 0 0 0 0 R Y88108 $ 148.15 $ 148.15 0 0% 0% 0% 1 0 0 0 0 0 R Y88108-26 $ 40.19 $ 40.19 0 0% 0% 0% 1 0 0 0 0 0 R Y88108-TC $ 107.96 $ 107.96 0 0% 0% 0% 1 0 0 0 0 0 R Y88112 $ 112.16 $ 112.16 0 0% 0% 0% 1 0 0 0 0 0 R Y88112-26 $ 48.58 $ 48.58 0 0% 0% 0% 1 0 0 0 0 0 R Y88112-TC $ 63.58 $ 63.58 0 0% 0% 0% 1 0 0 0 0 0 R Y88120 $ 1100.03 $ 1100.03 0 0% 0% 0% 1 0 0 0 0 0 R Y88120-26 $ 100.17 $ 100.17 0 0% 0% 0% 1 0 0 0 0 0 R Y88120-TC $ 999.87 $ 999.87 0 0% 0% 0% 1 0 0 0 0 0 R Y88121 $ 978.87 $ 978.87 0 0% 0% 0% 1 0 0 0 0 0 R Y88121-26 $ 87.57 $ 87.57 0 0% 0% 0% 1 0 0 0 0 0 R Y88121-TC $ 891.30 $ 891.30 0 0% 0% 0% 1 0 0 0 0 0 R Y88125 $ 44.99 $ 44.99 0 0% 0% 0% 1 0 0 0 0 0 R Y88125-26 $ 24.59 $ 24.59 0 0% 0% 0% 1 0 0 0 0 0 R Y88125-TC $ 20.39 $ 20.39 0 0% 0% 0% 1 0 0 0 0 0 R Y88130 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 88140 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 88141 $ 55.78 $ 55.78 0 0% 0% 0% 2 0 0 0 0 0 R Y88142 $ 38.60 $ 38.60 0 0% 0% 0% 9 9 9 9 9 9 L Y88143 $ 38.60 $ 38.60 0 0% 0% 0% 9 9 9 9 9 9 L Y88147 $ 21.69 $ 21.69 0 0% 0% 0% 9 9 9 9 9 9 L Y
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 37
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
88148 $ 28.95 $ 28.95 0 0% 0% 0% 9 9 9 9 9 9 L Y88150 $ 20.13 $ 20.13 0 0% 0% 0% 9 9 9 9 9 9 L Y88152 $ 20.13 $ 20.13 0 0% 0% 0% 9 9 9 9 9 9 L Y88153 $ 20.13 $ 20.13 0 0% 0% 0% 9 9 9 9 9 9 L Y88154 $ 20.13 $ 20.13 0 0% 0% 0% 9 9 9 9 9 9 L Y88155 $ 11.41 $ 11.41 0 0% 0% 0% 9 9 9 9 9 9 L Y88160 $ 116.96 $ 116.96 0 0% 0% 0% 1 0 0 0 0 0 R Y88160-26 $ 45.58 $ 45.58 0 0% 0% 0% 1 0 0 0 0 0 R Y88160-TC $ 71.38 $ 71.38 0 0% 0% 0% 1 0 0 0 0 0 R Y88161 $ 105.56 $ 105.56 0 0% 0% 0% 1 0 0 0 0 0 R Y88161-26 $ 43.79 $ 43.79 0 0% 0% 0% 1 0 0 0 0 0 R Y88161-TC $ 61.78 $ 61.78 0 0% 0% 0% 1 0 0 0 0 0 R Y88162 $ 174.54 $ 174.54 0 0% 0% 0% 1 0 0 0 0 0 R Y88162-26 $ 70.18 $ 70.18 0 0% 0% 0% 1 0 0 0 0 0 R Y88162-TC $ 104.37 $ 104.37 0 0% 0% 0% 1 0 0 0 0 0 R Y88164 $ 20.13 $ 20.13 0 0% 0% 0% 9 9 9 9 9 9 L Y88165 $ 20.13 $ 20.13 0 0% 0% 0% 9 9 9 9 9 9 L Y88166 $ 20.13 $ 20.13 0 0% 0% 0% 9 9 9 9 9 9 L Y88167 $ 20.13 $ 20.13 0 0% 0% 0% 9 9 9 9 9 9 L Y88172 $ 98.37 $ 98.37 0 0% 0% 0% 1 0 0 0 0 0 R Y88172-26 $ 63.58 $ 63.58 0 0% 0% 0% 1 0 0 0 0 0 R Y88172-TC $ 34.79 $ 34.79 0 0% 0% 0% 1 0 0 0 0 0 R Y88173 $ 263.91 $ 263.91 0 0% 0% 0% 1 0 0 0 0 0 R Y88173-26 $ 123.56 $ 123.56 0 0% 0% 0% 1 0 0 0 0 0 R Y88173-TC $ 140.35 $ 140.35 0 0% 0% 0% 1 0 0 0 0 0 R Y88174 $ 40.71 $ 40.71 0 0% 0% 0% 9 9 9 9 9 9 L Y88175 $ 50.47 $ 50.47 0 0% 0% 0% 9 9 9 9 9 9 L Y88177 $ 52.78 $ 52.78 0 0% 0% 0% 1 0 0 0 0 0 R Y88177-26 $ 38.99 $ 38.99 0 0% 0% 0% 1 0 0 0 0 0 R Y88177-TC $ 13.80 $ 13.80 0 0% 0% 0% 1 0 0 0 0 0 R Y88182 $ 188.94 $ 188.94 0 0% 0% 0% 1 0 0 0 0 0 R Y88182-26 $ 61.18 $ 61.18 0 0% 0% 0% 1 0 0 0 0 0 R Y88182-TC $ 127.76 $ 127.76 0 0% 0% 0% 1 0 0 0 0 0 R Y88184 $ 166.14 $ 166.14 0 0% 0% 0% 3 0 0 0 0 0 R Y88185 $ 101.37 $ 101.37 0 0% 0% 0% 3 0 0 0 0 0 R Y88187 $ 121.76 $ 121.76 0 0% 0% 0% 2 0 0 0 0 0 R Y88188 $ 154.75 $ 154.75 0 0% 0% 0% 2 0 0 0 0 0 R Y88189 $ 190.74 $ 190.74 0 0% 0% 0% 2 0 0 0 0 0 R Y
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
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Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
88199 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 88199-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 88199-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 88230 $ 221.96 $ 221.96 0 0% 0% 0% 9 9 9 9 9 9 L Y88233 $ 268.11 $ 268.11 0 0% 0% 0% 9 9 9 9 9 9 L Y88235 $ 280.56 $ 280.56 0 0% 0% 0% 9 9 9 9 9 9 L Y88237 $ 240.65 $ 240.65 0 0% 0% 0% 9 9 9 9 9 9 L Y88239 $ 281.05 $ 281.05 0 0% 0% 0% 9 9 9 9 9 9 L Y88240 $ 19.24 $ 19.24 0 0% 0% 0% 9 9 9 9 9 9 L Y88241 $ 19.24 $ 19.24 0 0% 0% 0% 9 9 9 9 9 9 L Y88245 $ 283.61 $ 283.61 0 0% 0% 0% 9 9 9 9 9 9 L Y88248 $ 329.94 $ 329.94 0 0% 0% 0% 9 9 9 9 9 9 L Y88249 $ 329.94 $ 329.94 0 0% 0% 0% 9 9 9 9 9 9 L Y88261 $ 336.71 $ 336.71 0 0% 0% 0% 9 9 9 9 9 9 L Y88262 $ 237.47 $ 237.47 0 0% 0% 0% 9 9 9 9 9 9 L Y88263 $ 286.33 $ 286.33 0 0% 0% 0% 9 9 9 9 9 9 L Y88264 $ 237.47 $ 237.47 0 0% 0% 0% 9 9 9 9 9 9 L Y88267 $ 342.50 $ 342.50 0 0% 0% 0% 9 9 9 9 9 9 L Y88269 $ 316.88 $ 316.88 0 0% 0% 0% 9 9 9 9 9 9 L Y88271 $ 40.80 $ 40.80 0 0% 0% 0% 9 9 9 9 9 9 L Y88272 $ 51.02 $ 51.02 0 0% 0% 0% 9 9 9 9 9 9 L Y88273 $ 61.22 $ 61.22 0 0% 0% 0% 9 9 9 9 9 9 L Y88274 $ 66.32 $ 66.32 0 0% 0% 0% 9 9 9 9 9 9 L Y88275 $ 76.51 $ 76.51 0 0% 0% 0% 9 9 9 9 9 9 L Y88280 $ 47.81 $ 47.81 0 0% 0% 0% 9 9 9 9 9 9 L Y88283 $ 54.17 $ 54.17 0 0% 0% 0% 9 9 9 9 9 9 L Y88285 $ 36.20 $ 36.20 0 0% 0% 0% 9 9 9 9 9 9 L Y88289 $ 65.60 $ 65.60 0 0% 0% 0% 9 9 9 9 9 9 L Y88291 $ 53.98 $ 53.98 0 0% 0% 0% 2 0 0 0 0 0 R Y88299 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 88300 $ 26.39 $ 26.39 0 0% 0% 0% 1 0 0 0 0 0 R 88300-26 $ 7.80 $ 7.80 0 0% 0% 0% 1 0 0 0 0 0 R 88300-TC $ 18.59 $ 18.59 0 0% 0% 0% 1 0 0 0 0 0 R 88302 $ 55.78 $ 55.78 0 0% 0% 0% 1 0 0 0 0 0 R 88302-26 $ 12.00 $ 12.00 0 0% 0% 0% 1 0 0 0 0 0 R 88302-TC $ 43.79 $ 43.79 0 0% 0% 0% 1 0 0 0 0 0 R 88304 $ 79.77 $ 79.77 0 0% 0% 0% 1 0 0 0 0 0 R 88304-26 $ 19.79 $ 19.79 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 39
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
88304-TC $ 59.98 $ 59.98 0 0% 0% 0% 1 0 0 0 0 0 R 88305 $ 126.56 $ 126.56 0 0% 0% 0% 1 0 0 0 0 0 R 88305-26 $ 66.58 $ 66.58 0 0% 0% 0% 1 0 0 0 0 0 R 88305-TC $ 59.98 $ 59.98 0 0% 0% 0% 1 0 0 0 0 0 R 88307 $ 536.82 $ 536.82 0 0% 0% 0% 1 0 0 0 0 0 R 88307-26 $ 146.95 $ 146.95 0 0% 0% 0% 1 0 0 0 0 0 R 88307-TC $ 389.87 $ 389.87 0 0% 0% 0% 1 0 0 0 0 0 R 88309 $ 812.73 $ 812.73 0 0% 0% 0% 1 0 0 0 0 0 R 88309-26 $ 259.11 $ 259.11 0 0% 0% 0% 1 0 0 0 0 0 R 88309-TC $ 554.22 $ 554.22 0 0% 0% 0% 1 0 0 0 0 0 R 88311 $ 35.99 $ 35.99 0 0% 0% 0% 1 0 0 0 0 0 R 88311-26 $ 21.59 $ 21.59 0 0% 0% 0% 1 0 0 0 0 0 R 88311-TC $ 14.40 $ 14.40 0 0% 0% 0% 1 0 0 0 0 0 R 88312 $ 170.94 $ 170.94 0 0% 0% 0% 1 0 0 0 0 0 R 88312-26 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 0 0 0 R 88312-TC $ 123.56 $ 123.56 0 0% 0% 0% 1 0 0 0 0 0 R 88313 $ 119.36 $ 119.36 0 0% 0% 0% 1 0 0 0 0 0 R 88313-26 $ 20.99 $ 20.99 0 0% 0% 0% 1 0 0 0 0 0 R 88313-TC $ 97.77 $ 97.77 0 0% 0% 0% 1 0 0 0 0 0 R 88314 $ 130.76 $ 130.76 0 0% 0% 0% 1 0 0 0 0 0 R 88314-26 $ 38.99 $ 38.99 0 0% 0% 0% 1 0 0 0 0 0 R 88314-TC $ 91.77 $ 91.77 0 0% 0% 0% 1 0 0 0 0 0 R 88319 $ 154.75 $ 154.75 0 0% 0% 0% 1 0 0 0 0 0 R 88319-26 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R 88319-TC $ 106.76 $ 106.76 0 0% 0% 0% 1 0 0 0 0 0 R 88321 $ 163.75 $ 146.35 0 0% 0% 0% 0 0 0 0 0 0 R 88323 $ 263.91 $ 263.91 0 0% 0% 0% 1 0 0 0 0 0 R 88323-26 $ 152.35 $ 152.35 0 0% 0% 0% 1 0 0 0 0 0 R 88323-TC $ 110.96 $ 110.96 0 0% 0% 0% 1 0 0 0 0 0 R 88325 $ 370.68 $ 230.92 0 0% 0% 0% 0 0 0 0 0 0 R 88329 $ 101.37 $ 62.38 0 0% 0% 0% 0 0 0 0 0 0 R 88331 $ 178.74 $ 178.74 0 0% 0% 0% 1 0 0 0 0 0 R 88331-26 $ 110.36 $ 110.36 0 0% 0% 0% 1 0 0 0 0 0 R 88331-TC $ 68.98 $ 68.98 0 0% 0% 0% 1 0 0 0 0 0 R 88332 $ 77.97 $ 77.97 0 0% 0% 0% 1 0 0 0 0 0 R 88332-26 $ 54.58 $ 54.58 0 0% 0% 0% 1 0 0 0 0 0 R 88332-TC $ 23.99 $ 23.99 0 0% 0% 0% 1 0 0 0 0 0 R 88333 $ 188.94 $ 188.94 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 40
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
88333-26 $ 110.36 $ 110.36 0 0% 0% 0% 1 0 0 0 0 0 R 88333-TC $ 77.97 $ 77.97 0 0% 0% 0% 1 0 0 0 0 0 R 88334 $ 115.16 $ 115.16 0 0% 0% 0% 1 0 0 0 0 0 R 88334-26 $ 67.78 $ 67.78 0 0% 0% 0% 1 0 0 0 0 0 R 88334-TC $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R 88341 $ 118.16 $ 118.16 0 0% 0% 0% 1 0 0 0 0 0 R88341-26 $ 37.19 $ 37.19 0 0% 0% 0% 1 0 0 0 0 0 R88341-TC $ 80.97 $ 80.97 0 0% 0% 0% 1 0 0 0 0 0 R88342 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88342-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88342-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88344 $ 204.53 $ 204.53 0 0% 0% 0% 1 0 0 0 0 0 R88344-26 $ 68.38 $ 68.38 0 0% 0% 0% 1 0 0 0 0 0 R88344-TC $ 136.15 $ 136.15 0 0% 0% 0% 1 0 0 0 0 0 R88346 $ 192.54 $ 192.54 0 0% 0% 0% 1 0 0 0 0 0 R 88346-26 $ 74.38 $ 74.38 0 0% 0% 0% 1 0 0 0 0 0 R 88346-TC $ 118.16 $ 118.16 0 0% 0% 0% 1 0 0 0 0 0 R 88347 $ 161.35 $ 161.35 0 0% 0% 0% 1 0 0 0 0 0 R 88347-26 $ 73.18 $ 73.18 0 0% 0% 0% 1 0 0 0 0 0 R 88347-TC $ 88.17 $ 88.17 0 0% 0% 0% 1 0 0 0 0 0 R 88348 $ 608.80 $ 608.80 0 0% 0% 0% 1 0 0 0 0 0 R 88348-26 $ 133.16 $ 133.16 0 0% 0% 0% 1 0 0 0 0 0 R 88348-TC $ 475.64 $ 475.64 0 0% 0% 0% 1 0 0 0 0 0 R 88355 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88355-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88355-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88356 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88356-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88356-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88358 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88358-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88358-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88360 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88360-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88360-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88361 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88361-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88361-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 41
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
88362 $ 512.83 $ 512.83 0 0% 0% 0% 1 0 0 0 0 0 R Y88362-26 $ 189.54 $ 189.54 0 0% 0% 0% 1 0 0 0 0 0 R Y88362-TC $ 323.29 $ 323.29 0 0% 0% 0% 1 0 0 0 0 0 R Y88363 $ 38.99 $ 32.99 0 0% 0% 0% 0 0 0 0 0 0 R Y88364 $ 170.34 $ 170.34 0 0% 0% 0% 1 0 0 0 0 0 R88364-26 $ 46.18 $ 46.18 0 0% 0% 0% 1 0 0 0 0 0 R88364-TC $ 124.16 $ 124.16 0 0% 0% 0% 1 0 0 0 0 0 R88365 $ 274.71 $ 274.71 0 0% 0% 0% 1 0 0 0 0 0 R Y88365-26 $ 76.17 $ 76.17 0 0% 0% 0% 1 0 0 0 0 0 R Y88365-TC $ 197.93 $ 197.93 0 0% 0% 0% 1 0 0 0 0 0 R Y88366 $ 260.91 $ 260.91 0 0% 0% 0% 1 0 0 0 0 0 R88366-26 $ 107.36 $ 107.36 0 0% 0% 0% 1 0 0 0 0 0 R88366-TC $ 152.95 $ 152.95 0 0% 0% 0% 1 0 0 0 0 0 R88367 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88367-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88367-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88368 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88368-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88368-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88369 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88369-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88369-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88371 $ 23.58 $ 23.58 0 0% 0% 0% 9 9 9 9 9 9 L 88371-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 88372 $ 35.36 $ 35.36 0 0% 0% 0% 9 9 9 9 9 9 L 88372-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 88373 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88373-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88373-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88374 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88374-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88374-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88375 $ 80.37 $ 80.37 0 0% 0% 0% 2 0 0 0 0 0 R88377 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88377-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88377-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X88380 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88380-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 42
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
88380-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 88381 $ 218.33 $ 218.33 0 0% 0% 0% 1 0 0 0 0 0 R 88381-26 $ 44.39 $ 44.39 0 0% 0% 0% 1 0 0 0 0 0 R 88381-TC $ 173.94 $ 173.94 0 0% 0% 0% 1 0 0 0 0 0 R 88387 $ 73.78 $ 73.78 0 0% 0% 0% 1 0 0 0 0 0 R88387-26 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 0 0 0 0 R88387-TC $ 17.39 $ 17.39 0 0% 0% 0% 1 0 0 0 0 0 R88388 $ 58.78 $ 58.78 0 0% 0% 0% 1 0 0 0 0 0 R88388-26 $ 41.99 $ 41.99 0 0% 0% 0% 1 0 0 0 0 0 R88388-TC $ 16.79 $ 16.79 0 0% 0% 0% 1 0 0 0 0 0 R88399 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 88399-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 88399-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 88720 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 88738 $ 8.78 $ 8.78 0 0% 0% 0% 9 9 9 9 9 9 L88740 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 88741 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 88749 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y89049 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 89050 $ 9.00 $ 9.00 0 0% 0% 0% 9 9 9 9 9 9 L 89051 $ 10.49 $ 10.49 0 0% 0% 0% 9 9 9 9 9 9 L 89055 $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 L 89060 $ 13.64 $ 13.64 0 0% 0% 0% 9 9 9 9 9 9 L 89060-26 $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 R 89125 $ 8.23 $ 8.23 0 0% 0% 0% 9 9 9 9 9 9 L 89160 $ 4.47 $ 4.47 0 0% 0% 0% 9 9 9 9 9 9 L 89190 $ 9.04 $ 9.04 0 0% 0% 0% 9 9 9 9 9 9 L 89220 $ 27.59 $ 27.59 0 0% 0% 0% 3 0 0 0 0 0 R 89230 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X 89240 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 89250 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89251 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89253 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89254 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89255 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89257 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89258 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89259 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesPathology Laboratory
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 43
Pathology & Laboratory FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
89260 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89261 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89264 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 89268 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89272 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89280 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89281 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89290 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89291 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89300 $ 17.00 $ 17.00 0 0% 0% 0% 9 9 9 9 9 9 L 89310 $ 12.22 $ 12.22 0 0% 0% 0% 9 9 9 9 9 9 L 89320 $ 22.96 $ 22.96 0 0% 0% 0% 9 9 9 9 9 9 L 89321 $ 22.96 $ 22.96 0 0% 0% 0% 9 9 9 9 9 9 L Y89322 $ 29.53 $ 29.53 0 0% 0% 0% 9 9 9 9 9 9 L Y89325 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89329 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89330 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89331 $ 37.32 $ 37.32 0 0% 0% 0% 9 9 9 9 9 9 L Y89335 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89337 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X89342 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89343 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89344 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89346 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89352 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89353 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89354 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89356 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 89398 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 1
Professional Services Fee ScheduleMedicine
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 2
Medicine FeesDOLLAR VALUE MODIFIERS
FSI90281 $ 30.75 $ 30.75 0 0% 0% 0% 9 9 9 9 9 9 D Y90283 $ 684.02 $ 684.02 0 0% 0% 0% 9 9 9 9 9 9 D Y90284 $ 32.62 $ 32.62 0 0% 0% 0% 9 9 9 9 9 9 D Y90287 $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y90288 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90291 $ 26.42 $ 26.42 0 0% 0% 0% 9 9 9 9 9 9 D Y90296 $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y90371 $ 172.85 $ 172.85 0 0% 0% 0% 9 9 9 9 9 9 D 90375 $ 268.96 $ 268.96 0 0% 0% 0% 9 9 9 9 9 9 D 90376 $ 276.40 $ 276.40 0 0% 0% 0% 9 9 9 9 9 9 D 90378 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90384 $ 127.44 $ 127.44 0 0% 0% 0% 9 9 9 9 9 9 D 90385 $ 33.08 $ 33.08 0 0% 0% 0% 9 9 9 9 9 9 D 90386 $ 276.49 $ 276.49 0 0% 0% 0% 9 9 9 9 9 9 D 90389 $ 407.82 $ 407.82 0 0% 0% 0% 9 9 9 9 9 9 D 90393 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90396 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90399 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 90460 $ 44.39 $ 44.39 0 0% 0% 0% 0 0 0 0 0 0 R90461 $ 22.19 $ 22.19 0 0% 0% 0% 0 0 0 0 0 0 R90471 $ 44.39 $ 44.39 0 0% 0% 0% 5 0 0 0 0 0 R 90472 $ 22.19 $ 22.19 0 0% 0% 0% 5 0 0 0 0 0 R 90473 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90474 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90476 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90477 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90581 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90585 $ 156.76 $ 156.76 0 0% 0% 0% 9 9 9 9 9 9 D Y90586 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90630 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90632 $ 67.34 $ 67.34 0 0% 0% 0% 9 9 9 9 9 9 D Y90633 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90634 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90636 $ 95.42 $ 95.42 0 0% 0% 0% 9 9 9 9 9 9 D Y90644 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X90644 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X90645 $ 24.69 $ 24.69 0 0% 0% 0% 9 9 9 9 9 9 D Y90646 $ 23.78 $ 23.78 0 0% 0% 0% 9 9 9 9 9 9 D Y
CPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 3
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
90647 $ 28.87 $ 28.87 0 0% 0% 0% 9 9 9 9 9 9 D Y90648 $ 26.97 $ 26.97 0 0% 0% 0% 9 9 9 9 9 9 D Y90649 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90650 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90651 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X90653 $ 11.07 $ 11.07 0 0% 0% 0% 9 9 9 9 9 9 D Y90654 $ 12.68 $ 12.68 0 0% 0% 0% 9 9 9 9 9 9 D Y90655 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90656 $ 12.68 $ 12.68 0 0% 0% 0% 9 9 9 9 9 9 D Y90657 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90658 $ 14.90 $ 14.90 0 0% 0% 0% 9 9 9 9 9 9 D Y90660 $ 23.71 $ 23.71 0 0% 0% 0% 9 9 9 9 9 9 D Y90661 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90662 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90664 $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y90666 $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y90667 $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y90668 $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y90669 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X90670 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90672 $ 23.71 $ 23.71 0 0% 0% 0% 9 9 9 9 9 9 D Y90673 $ 19.85 $ 19.85 0 0% 0% 0% 9 9 9 9 9 9 D Y90675 $ 275.14 $ 275.14 0 0% 0% 0% 9 9 9 9 9 9 D Y90676 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90680 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90681 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90685 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X90686 $ 16.36 $ 16.36 0 0% 0% 0% 9 9 9 9 9 9 D Y90687 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X90688 $ 15.28 $ 15.28 0 0% 0% 0% 9 9 9 9 9 9 D Y90690 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90691 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90692 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90693 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90696 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90698 $ 82.81 $ 82.81 0 0% 0% 0% 9 9 9 9 9 9 D Y90700 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90702 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 4
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
90703 $ 42.77 $ 42.77 0 0% 0% 0% 9 9 9 9 9 9 D 90704 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90705 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90706 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90707 $ 62.27 $ 62.27 0 0% 0% 0% 9 9 9 9 9 9 D Y90708 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90710 $ 178.71 $ 178.71 0 0% 0% 0% 9 9 9 9 9 9 D Y90712 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90713 $ 30.26 $ 30.26 0 0% 0% 0% 9 9 9 9 9 9 D Y90714 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90715 $ 41.91 $ 41.91 0 0% 0% 0% 9 9 9 9 9 9 D 90716 $ 107.92 $ 107.92 0 0% 0% 0% 9 9 9 9 9 9 D Y90717 $ 127.86 $ 127.86 0 0% 0% 0% 9 9 9 9 9 9 D Y90719 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90720 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90721 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90723 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90725 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90727 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y90732 $ 78.17 $ 78.17 0 0% 0% 0% 9 9 9 9 9 9 D Y90733 $ 132.21 $ 132.21 0 0% 0% 0% 9 9 9 9 9 9 D Y90734 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90735 $ 255.26 $ 255.26 0 0% 0% 0% 9 9 9 9 9 9 D Y90736 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90738 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90739 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X90740 $ 111.78 $ 111.78 0 0% 0% 0% 9 9 9 9 9 9 D Y90743 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90744 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90746 $ 55.89 $ 55.89 0 0% 0% 0% 9 9 9 9 9 9 D 90747 $ 111.78 $ 111.78 0 0% 0% 0% 9 9 9 9 9 9 D 90748 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90748 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 90749 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 90785 $ 23.99 $ 23.99 0 0% 0% 0% 0 0 0 9 0 0 R Y90791 $ 220.13 $ 213.53 0 0% 0% 0% 0 0 0 9 0 0 R Y90792 $ 246.52 $ 239.32 0 0% 0% 0% 0 0 0 9 0 0 R Y90832 $ 107.36 $ 106.16 0 0% 0% 0% 0 0 0 9 0 0 R Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 5
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
90833 $ 110.36 $ 109.16 0 0% 0% 0% 0 0 0 9 0 0 R Y90834 $ 142.15 $ 140.95 0 0% 0% 0% 0 0 0 9 0 0 R Y90836 $ 139.75 $ 139.15 0 0% 0% 0% 0 0 0 9 0 0 R Y90837 $ 213.53 $ 212.33 0 0% 0% 0% 0 0 0 9 0 0 R Y90838 $ 184.74 $ 182.94 0 0% 0% 0% 0 0 0 9 0 0 R Y90839 $ 223.13 $ 221.33 0 0% 0% 0% 0 0 0 0 0 0 R Y90840 $ 106.76 $ 106.16 0 0% 0% 0% 0 0 0 0 0 0 R Y90845 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90846 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90847 $ 179.34 $ 177.54 0 0% 0% 0% 0 0 0 0 0 0 R Y90849 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90853 $ 43.19 $ 42.59 0 0% 0% 0% 0 0 0 0 0 0 R Y90863 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X90865 $ 287.90 $ 215.93 0 0% 0% 0% 0 0 0 0 0 0 R Y90867 By Report By Report 0 0% 0% 0% 0 0 0 1 0 0 N Y90868 By Report By Report 0 0% 0% 0% 0 0 0 1 0 0 N Y90869 By Report By Report 0 0% 0% 0% 0 0 0 1 0 0 N Y90870 $ 305.90 $ 186.54 0 0% 0% 0% 0 0 0 0 0 0 R Y90875 $ 103.77 $ 103.77 0 0% 0% 0% 9 9 9 9 9 9 R Y90876 $ 184.14 $ 164.95 0 0% 0% 0% 9 9 9 9 9 9 R Y90880 $ 170.94 $ 158.35 0 0% 0% 0% 0 0 0 0 0 0 R Y90882 $ 75.18 $ 75.18 0 0% 0% 0% 9 9 9 9 9 9 F Y90885 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 90887 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 90889 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 90899 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y90901 $ 65.98 $ 34.19 0 0% 0% 0% 0 0 0 0 0 0 R 90911 $ 146.35 $ 74.98 0 0% 0% 0% 0 0 0 0 0 0 R 90935 $ 122.36 $ 122.36 0 0% 0% 0% 0 0 0 0 0 0 R 90937 $ 176.34 $ 176.34 0 0% 0% 0% 0 0 0 0 0 0 R 90940 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 90945 $ 145.75 $ 145.75 0 0% 0% 0% 0 0 0 0 0 0 R 90947 $ 209.33 $ 209.33 0 0% 0% 0% 0 0 0 0 0 0 R 90951 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90952 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90953 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90954 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 6
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
90955 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90956 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90957 $ 1091.04 $ 1090.44 0 0% 0% 0% 0 0 0 0 0 0 R 90958 $ 737.15 $ 736.55 0 0% 0% 0% 0 0 0 0 0 0 R 90959 $ 502.03 $ 502.03 0 0% 0% 0% 0 0 0 0 0 0 R 90960 $ 482.24 $ 482.24 0 0% 0% 0% 0 0 0 0 0 0 R 90961 $ 406.06 $ 406.06 0 0% 0% 0% 0 0 0 0 0 0 R 90962 $ 313.70 $ 313.70 0 0% 0% 0% 0 0 0 0 0 0 R 90963 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90964 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 90965 $ 767.74 $ 767.14 0 0% 0% 0% 0 0 0 0 0 0 R 90966 $ 404.87 $ 404.87 0 0% 0% 0% 0 0 0 0 0 0 R 90967 $ 30.59 $ 30.59 0 0% 0% 0% 0 0 0 0 0 0 R 90968 $ 26.39 $ 26.39 0 0% 0% 0% 0 0 0 0 0 0 R 90969 $ 25.79 $ 25.79 0 0% 0% 0% 0 0 0 0 0 0 R 90970 $ 13.20 $ 13.20 0 0% 0% 0% 0 0 0 0 0 0 R 90989 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 90993 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 90997 $ 160.15 $ 160.15 0 0% 0% 0% 0 0 0 0 0 0 R 90999 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 91010 $ 311.90 $ 311.90 0 0% 0% 0% 1 0 0 0 0 0 R Y91010-26 $ 116.36 $ 116.36 0 0% 0% 0% 1 0 0 0 0 0 R Y91010-TC $ 195.53 $ 195.53 0 0% 0% 0% 1 0 0 0 0 0 R Y91013 $ 41.99 $ 41.99 0 0% 0% 0% 1 0 0 0 0 0 R Y91013-26 $ 16.19 $ 16.19 0 0% 0% 0% 1 0 0 0 0 0 R Y91013-TC $ 25.79 $ 25.79 0 0% 0% 0% 1 0 0 0 0 0 R Y91020 $ 413.86 $ 413.86 0 0% 0% 0% 1 0 0 0 0 0 R Y91020-26 $ 129.56 $ 129.56 0 0% 0% 0% 1 0 0 0 0 0 R Y91020-TC $ 283.71 $ 283.71 0 0% 0% 0% 1 0 0 0 0 0 R Y91022 $ 299.30 $ 299.30 0 0% 0% 0% 1 0 0 0 0 0 R 91022-26 $ 130.16 $ 130.16 0 0% 0% 0% 1 0 0 0 0 0 R 91022-TC $ 169.14 $ 169.14 0 0% 0% 0% 1 0 0 0 0 0 R 91030 $ 242.92 $ 242.92 0 0% 0% 0% 1 0 0 0 0 0 R Y91030-26 $ 82.17 $ 82.17 0 0% 0% 0% 1 0 0 0 0 0 R Y91030-TC $ 160.75 $ 160.75 0 0% 0% 0% 1 0 0 0 0 0 R Y91034 $ 332.89 $ 332.89 0 0% 0% 0% 1 0 0 0 0 0 R Y91034-26 $ 86.37 $ 86.37 0 0% 0% 0% 1 0 0 0 0 0 R Y91034-TC $ 246.52 $ 246.52 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 7
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
91035 $ 860.71 $ 860.71 0 0% 0% 0% 1 0 0 0 0 0 R Y91035-26 $ 143.35 $ 143.35 0 0% 0% 0% 1 0 0 0 0 0 R Y91035-TC $ 717.36 $ 717.36 0 0% 0% 0% 1 0 0 0 0 0 R Y91037 $ 284.91 $ 284.91 0 0% 0% 0% 1 0 0 0 0 0 R Y91037-26 $ 87.57 $ 87.57 0 0% 0% 0% 1 0 0 0 0 0 R Y91037-TC $ 197.33 $ 197.33 0 0% 0% 0% 1 0 0 0 0 0 R Y91038 $ 810.33 $ 810.33 0 0% 0% 0% 1 0 0 0 0 0 R Y91038-26 $ 100.17 $ 100.17 0 0% 0% 0% 1 0 0 0 0 0 R Y91038-TC $ 710.16 $ 710.16 0 0% 0% 0% 1 0 0 0 0 0 R Y91040 $ 785.14 $ 785.14 0 0% 0% 0% 1 0 0 0 0 0 R Y91040-26 $ 87.57 $ 87.57 0 0% 0% 0% 1 0 0 0 0 0 R Y91040-TC $ 697.57 $ 697.57 0 0% 0% 0% 1 0 0 0 0 0 R Y91065 $ 144.55 $ 144.55 0 0% 0% 0% 1 0 0 0 0 0 R Y91065-26 $ 17.99 $ 17.99 0 0% 0% 0% 1 0 0 0 0 0 R Y91065-TC $ 126.56 $ 126.56 0 0% 0% 0% 1 0 0 0 0 0 R Y91110 $ 1588.27 $ 1588.27 0 0% 0% 0% 1 0 0 0 0 0 R 91110-26 $ 329.89 $ 329.89 0 0% 0% 0% 1 0 0 0 0 0 R 91110-TC $ 1258.38 $ 1258.38 0 0% 0% 0% 1 0 0 0 0 0 R 91111 $ 1311.76 $ 1311.76 0 0% 0% 0% 1 0 0 0 0 0 R 91111-26 $ 89.97 $ 89.97 0 0% 0% 0% 1 0 0 0 0 0 R 91111-TC $ 1221.19 $ 1221.19 0 0% 0% 0% 1 0 0 0 0 0 R 91112 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X91117 $ 241.72 $ 241.72 0 0% 0% 0% 0 0 0 0 0 0 R91120 $ 767.14 $ 767.14 0 0% 0% 0% 1 0 0 0 0 0 R 91120-26 $ 86.37 $ 86.37 0 0% 0% 0% 1 0 0 0 0 0 R 91120-TC $ 680.77 $ 680.77 0 0% 0% 0% 1 0 0 0 0 0 R 91122 $ 395.27 $ 395.27 0 0% 0% 0% 1 0 0 0 0 0 R 91122-26 $ 152.95 $ 152.95 0 0% 0% 0% 1 0 0 0 0 0 R 91122-TC $ 242.32 $ 242.32 0 0% 0% 0% 1 0 0 0 0 0 R 91132 $ 265.11 $ 265.11 0 0% 0% 0% 1 0 0 0 0 0 R 91132-26 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 0 0 0 R 91132-TC $ 217.73 $ 217.73 0 0% 0% 0% 1 0 0 0 0 0 R 91133 $ 307.10 $ 307.10 0 0% 0% 0% 1 0 0 0 0 0 R 91133-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R 91133-TC $ 247.72 $ 247.72 0 0% 0% 0% 1 0 0 0 0 0 R 91200 $ 62.38 $ 62.38 0 0% 0% 0% 1 0 0 0 0 0 R Y91200-26 $ 24.59 $ 24.59 0 0% 0% 0% 1 0 0 0 0 0 R Y91200-TC $ 37.79 $ 37.79 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 8
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
91299 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 91299-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 91299-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 92002 $ 140.95 $ 82.17 0 0% 0% 0% 0 0 2 0 0 0 R 92004 $ 256.71 $ 170.94 0 0% 0% 0% 0 0 2 0 0 0 R 92012 $ 148.15 $ 89.97 0 0% 0% 0% 0 0 2 0 0 0 R 92014 $ 214.13 $ 136.75 0 0% 0% 0% 0 0 2 0 0 0 R 92015 $ 33.59 $ 32.99 0 0% 0% 0% 9 9 9 9 9 9 R 92018 $ 248.92 $ 248.92 0 0% 0% 0% 0 0 0 0 0 0 R 92019 $ 122.96 $ 122.96 0 0% 0% 0% 0 0 0 0 0 0 R 92020 $ 46.18 $ 35.99 0 0% 0% 0% 0 0 2 0 0 0 R 92025 $ 65.98 $ 65.98 0 0% 0% 0% 1 7 2 0 0 0 R 92025-26 $ 34.79 $ 34.79 0 0% 0% 0% 1 7 2 0 0 0 R 92025-TC $ 31.19 $ 31.19 0 0% 0% 0% 1 7 2 0 0 0 R 92060 $ 113.36 $ 113.36 0 0% 0% 0% 1 7 2 0 0 0 R 92060-26 $ 65.98 $ 65.98 0 0% 0% 0% 1 7 2 0 0 0 R 92060-TC $ 47.38 $ 47.38 0 0% 0% 0% 1 7 2 0 0 0 R 92065 $ 94.17 $ 94.17 0 0% 0% 0% 1 0 2 0 0 0 R Y92065-26 $ 31.19 $ 31.19 0 0% 0% 0% 1 0 2 0 0 0 R Y92065-TC $ 62.98 $ 62.98 0 0% 0% 0% 1 0 2 0 0 0 R Y92071 $ 65.38 $ 57.58 0 0% 0% 0% 0 0 1 0 0 0 R92072 Not Covered Not Covered 0 0% 0% 0% 0 0 2 0 0 0 X92081 $ 59.38 $ 59.38 0 0% 0% 0% 1 7 2 0 0 0 R 92081-26 $ 28.19 $ 28.19 0 0% 0% 0% 1 7 2 0 0 0 R 92081-TC $ 31.19 $ 31.19 0 0% 0% 0% 1 7 2 0 0 0 R 92082 $ 83.97 $ 83.97 0 0% 0% 0% 1 7 2 0 0 0 R 92082-26 $ 37.19 $ 37.19 0 0% 0% 0% 1 7 2 0 0 0 R 92082-TC $ 46.78 $ 46.78 0 0% 0% 0% 1 7 2 0 0 0 R 92083 $ 112.76 $ 112.76 0 0% 0% 0% 1 7 2 0 0 0 R 92083-26 $ 47.98 $ 47.98 0 0% 0% 0% 1 7 2 0 0 0 R 92083-TC $ 64.18 $ 64.18 0 0% 0% 0% 1 7 2 0 0 0 R 92100 $ 140.95 $ 58.18 0 0% 0% 0% 0 0 2 0 0 0 R 92132 $ 60.58 $ 60.58 0 0% 0% 0% 1 7 2 0 0 0 R92132-26 $ 32.99 $ 32.99 0 0% 0% 0% 1 7 2 0 0 0 R92132-TC $ 27.59 $ 27.59 0 0% 0% 0% 1 7 2 0 0 0 R92133 $ 76.17 $ 76.17 0 0% 0% 0% 1 7 2 0 0 0 R92133-26 $ 47.98 $ 47.98 0 0% 0% 0% 1 7 2 0 0 0 R92133-TC $ 28.19 $ 28.19 0 0% 0% 0% 1 7 2 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 9
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
92134 $ 78.57 $ 78.57 0 0% 0% 0% 1 7 2 0 0 0 R92134-26 $ 49.78 $ 49.78 0 0% 0% 0% 1 7 2 0 0 0 R92134-TC $ 28.79 $ 28.79 0 0% 0% 0% 1 7 2 0 0 0 R92136 $ 158.95 $ 158.95 0 0% 0% 0% 1 7 2 0 0 0 R 92136-26 $ 53.98 $ 53.98 0 0% 0% 0% 1 7 3 0 0 0 R 92136-TC $ 104.97 $ 104.97 0 0% 0% 0% 1 7 2 0 0 0 R 92140 $ 109.76 $ 45.58 0 0% 0% 0% 0 0 2 0 0 0 R Y92145 $ 26.99 $ 26.99 0 0% 0% 0% 1 7 2 0 0 0 R Y92145-26 $ 15.00 $ 15.00 0 0% 0% 0% 1 7 2 0 0 0 R Y92145-TC $ 12.00 $ 12.00 0 0% 0% 0% 1 7 2 0 0 0 R Y92225 $ 46.78 $ 36.59 0 0% 0% 0% 0 0 3 0 0 0 R 92226 $ 43.19 $ 32.99 0 0% 0% 0% 0 0 3 0 0 0 R 92227 $ 25.79 $ 25.79 0 0% 0% 0% 3 0 2 0 0 0 R92228 $ 61.78 $ 61.78 0 0% 0% 0% 1 7 2 0 0 0 R92228-26 $ 37.19 $ 37.19 0 0% 0% 0% 1 7 2 0 0 0 R92228-TC $ 24.59 $ 24.59 0 0% 0% 0% 1 7 2 0 0 0 R92230 $ 100.77 $ 56.98 0 0% 0% 0% 0 0 3 0 0 0 R 92235 $ 192.54 $ 192.54 0 0% 0% 0% 1 7 3 0 0 0 R 92235-26 $ 81.57 $ 81.57 0 0% 0% 0% 1 7 3 0 0 0 R 92235-TC $ 110.96 $ 110.96 0 0% 0% 0% 1 7 3 0 0 0 R 92240 $ 450.45 $ 450.45 0 0% 0% 0% 1 7 3 0 0 0 R Y92240-26 $ 110.36 $ 110.36 0 0% 0% 0% 1 7 3 0 0 0 R Y92240-TC $ 340.09 $ 340.09 0 0% 0% 0% 1 7 3 0 0 0 R Y92250 $ 138.55 $ 138.55 0 0% 0% 0% 1 7 2 0 0 0 R 92250-26 $ 41.39 $ 41.39 0 0% 0% 0% 1 7 2 0 0 0 R 92250-TC $ 97.17 $ 97.17 0 0% 0% 0% 1 7 2 0 0 0 R 92260 $ 31.79 $ 18.59 0 0% 0% 0% 0 0 2 0 0 0 R 92265 $ 150.55 $ 150.55 0 0% 0% 0% 1 7 2 0 0 0 R 92265-26 $ 80.97 $ 80.97 0 0% 0% 0% 1 7 2 0 0 0 R 92265-TC $ 69.58 $ 69.58 0 0% 0% 0% 1 7 2 0 0 0 R 92270 $ 160.15 $ 160.15 0 0% 0% 0% 1 7 2 0 0 0 R 92270-26 $ 70.78 $ 70.78 0 0% 0% 0% 1 7 2 0 0 0 R 92270-TC $ 89.97 $ 89.97 0 0% 0% 0% 1 7 2 0 0 0 R 92275 $ 257.91 $ 257.91 0 0% 0% 0% 1 7 2 0 0 0 R 92275-26 $ 92.37 $ 92.37 0 0% 0% 0% 1 7 2 0 0 0 R 92275-TC $ 165.54 $ 165.54 0 0% 0% 0% 1 7 2 0 0 0 R 92283 $ 98.97 $ 98.97 0 0% 0% 0% 1 7 2 0 0 0 R Y92283-26 $ 16.19 $ 16.19 0 0% 0% 0% 1 7 2 0 0 0 R Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 10
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
92283-TC $ 82.77 $ 82.77 0 0% 0% 0% 1 7 2 0 0 0 R Y92284 $ 110.36 $ 110.36 0 0% 0% 0% 1 7 2 0 0 0 R Y92284-26 $ 21.59 $ 21.59 0 0% 0% 0% 1 7 2 0 0 0 R Y92284-TC $ 88.17 $ 88.17 0 0% 0% 0% 1 7 2 0 0 0 R Y92285 $ 35.99 $ 35.99 0 0% 0% 0% 1 7 2 0 0 0 R 92285-26 $ 5.40 $ 5.40 0 0% 0% 0% 1 7 2 0 0 0 R 92285-TC $ 30.59 $ 30.59 0 0% 0% 0% 1 7 2 0 0 0 R 92286 $ 66.58 $ 66.58 0 0% 0% 0% 1 7 2 0 0 0 R 92286-26 $ 38.39 $ 38.39 0 0% 0% 0% 1 7 2 0 0 0 R 92286-TC $ 28.19 $ 28.19 0 0% 0% 0% 1 7 2 0 0 0 R 92287 $ 242.92 $ 242.92 0 0% 0% 0% 1 0 2 0 0 0 R Y92310 $ 165.54 $ 101.37 0 0% 0% 0% 9 9 9 9 9 9 R 92311 $ 175.74 $ 94.77 0 0% 0% 0% 0 0 0 0 0 0 R 92312 $ 204.53 $ 110.36 0 0% 0% 0% 0 0 2 0 0 0 R 92313 $ 169.74 $ 80.97 0 0% 0% 0% 0 0 0 0 0 0 R 92314 $ 139.15 $ 59.38 0 0% 0% 0% 9 9 9 9 9 9 R 92315 $ 128.36 $ 37.19 0 0% 0% 0% 0 0 0 0 0 0 R 92316 $ 160.75 $ 56.38 0 0% 0% 0% 0 0 2 0 0 0 R 92317 $ 133.76 $ 37.79 0 0% 0% 0% 0 0 0 0 0 0 R 92325 $ 74.98 $ 74.98 0 0% 0% 0% 5 0 0 0 0 0 R 92326 $ 62.38 $ 62.38 0 0% 0% 0% 5 0 0 0 0 0 R Y92340 $ 61.78 $ 31.79 0 0% 0% 0% 9 9 9 9 9 9 R 92341 $ 69.58 $ 40.79 0 0% 0% 0% 9 9 9 9 9 9 R 92342 $ 75.57 $ 45.58 0 0% 0% 0% 9 9 9 9 9 9 R 92352 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 92353 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 92354 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 92355 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 92358 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 92370 $ 53.38 $ 27.59 0 0% 0% 0% 9 9 9 9 9 9 R 92371 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 92499 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 92499-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 92499-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 92502 $ 166.74 $ 166.74 0 0% 0% 0% 0 0 0 0 0 0 R 92504 $ 52.78 $ 16.19 0 0% 0% 0% 0 0 0 0 0 0 R 92507 $ 136.15 $ 136.15 0 0% 0% 0% 0 5 0 0 0 0 R 92508 $ 40.79 $ 40.79 0 0% 0% 0% 0 5 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 11
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
92511 $ 241.12 $ 84.57 0 0% 0% 0% 0 0 0 0 0 0 R 92512 $ 106.76 $ 48.58 0 0% 0% 0% 0 0 0 0 0 0 R 92516 $ 124.16 $ 38.39 0 0% 0% 0% 0 0 0 0 0 0 R 92520 $ 130.76 $ 70.18 0 0% 0% 0% 0 0 0 0 0 0 R 92521 $ 185.34 $ 185.34 0 0% 0% 0% 0 5 0 0 0 0 R92522 $ 158.35 $ 158.35 0 0% 0% 0% 0 5 0 0 0 0 R92523 $ 322.09 $ 322.09 0 0% 0% 0% 0 5 0 0 0 0 R92524 $ 152.95 $ 152.95 0 0% 0% 0% 0 5 0 0 0 0 R92526 $ 148.15 $ 148.15 0 0% 0% 0% 0 5 0 0 0 0 R 92531 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 92532 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 92533 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 92534 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 92540 $ 175.74 $ 175.74 0 0% 0% 0% 1 0 0 0 0 0 R92540-26 $ 136.15 $ 136.15 0 0% 0% 0% 1 0 0 0 0 0 R92540-TC $ 39.59 $ 39.59 0 0% 0% 0% 1 0 0 0 0 0 R92541 $ 37.79 $ 37.79 0 0% 0% 0% 1 0 0 0 0 0 R 92541-26 $ 35.99 $ 35.99 0 0% 0% 0% 1 0 0 0 0 0 R 92541-TC $ 2.40 $ 2.40 0 0% 0% 0% 1 0 0 0 0 0 R 92542 $ 44.99 $ 44.99 0 0% 0% 0% 1 0 0 0 0 0 R 92542-26 $ 42.59 $ 42.59 0 0% 0% 0% 1 0 0 0 0 0 R 92542-TC $ 2.40 $ 2.40 0 0% 0% 0% 1 0 0 0 0 0 R 92543 $ 27.59 $ 27.59 0 0% 0% 0% 1 0 0 0 0 0 R 92543-26 $ 9.60 $ 9.60 0 0% 0% 0% 1 0 0 0 0 0 R 92543-TC $ 17.99 $ 17.99 0 0% 0% 0% 1 0 0 0 0 0 R 92544 $ 26.39 $ 26.39 0 0% 0% 0% 1 0 0 0 0 0 R 92544-26 $ 23.99 $ 23.99 0 0% 0% 0% 1 0 0 0 0 0 R 92544-TC $ 2.40 $ 2.40 0 0% 0% 0% 1 0 0 0 0 0 R 92545 $ 24.59 $ 24.59 0 0% 0% 0% 1 0 0 0 0 0 R 92545-26 $ 22.19 $ 22.19 0 0% 0% 0% 1 0 0 0 0 0 R 92545-TC $ 2.40 $ 2.40 0 0% 0% 0% 1 0 0 0 0 0 R 92546 $ 182.34 $ 182.34 0 0% 0% 0% 1 0 0 0 0 0 R 92546-26 $ 25.19 $ 25.19 0 0% 0% 0% 1 0 0 0 0 0 R 92546-TC $ 157.15 $ 157.15 0 0% 0% 0% 1 0 0 0 0 0 R 92547 $ 10.80 $ 10.80 0 0% 0% 0% 3 0 0 0 0 0 R 92548 $ 181.74 $ 181.74 0 0% 0% 0% 1 0 0 0 0 0 R 92548-26 $ 44.99 $ 44.99 0 0% 0% 0% 1 0 0 0 0 0 R 92548-TC $ 137.35 $ 137.35 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 12
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
92550 $ 35.99 $ 35.99 0 0% 0% 0% 0 0 2 0 0 0 R92551 $ 25.06 $ 25.06 0 0% 0% 0% 9 9 9 9 9 9 F 92552 $ 55.18 $ 55.18 0 0% 0% 0% 3 0 2 0 0 0 R 92553 $ 65.38 $ 65.38 0 0% 0% 0% 3 0 2 0 0 0 R 92555 $ 40.79 $ 40.79 0 0% 0% 0% 3 0 2 0 0 0 R 92556 $ 65.98 $ 65.98 0 0% 0% 0% 3 0 2 0 0 0 R 92557 $ 64.18 $ 55.18 0 0% 0% 0% 0 0 2 0 0 0 R 92558 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N92559 $ 125.29 $ 125.29 0 0% 0% 0% 9 9 9 9 9 9 F 92560 $ 50.09 $ 50.09 0 0% 0% 0% 9 9 9 9 9 9 F 92561 $ 66.58 $ 66.58 0 0% 0% 0% 3 0 2 0 0 0 R 92562 $ 82.17 $ 82.17 0 0% 0% 0% 3 0 2 0 0 0 R 92563 $ 54.58 $ 54.58 0 0% 0% 0% 3 0 2 0 0 0 R 92564 $ 50.38 $ 50.38 0 0% 0% 0% 3 0 2 0 0 0 R 92565 $ 27.59 $ 27.59 0 0% 0% 0% 3 0 2 0 0 0 R 92567 $ 25.19 $ 18.59 0 0% 0% 0% 0 0 2 0 0 0 R 92568 $ 26.99 $ 25.79 0 0% 0% 0% 0 0 2 0 0 0 R 92570 $ 54.58 $ 50.98 0 0% 0% 0% 0 0 2 0 0 0 R92571 $ 48.58 $ 48.58 0 0% 0% 0% 3 0 2 0 0 0 R 92572 $ 55.18 $ 55.18 0 0% 0% 0% 3 0 2 0 0 0 R 92575 $ 126.56 $ 126.56 0 0% 0% 0% 3 0 2 0 0 0 R 92576 $ 62.38 $ 62.38 0 0% 0% 0% 3 0 2 0 0 0 R 92577 $ 28.19 $ 28.19 0 0% 0% 0% 3 0 2 0 0 0 R 92579 $ 77.97 $ 65.38 0 0% 0% 0% 0 0 2 0 0 0 R 92582 Not Covered Not Covered 0 0% 0% 0% 3 0 2 0 0 0 X 92583 $ 90.57 $ 90.57 0 0% 0% 0% 3 0 2 0 0 0 R 92584 $ 131.36 $ 131.36 0 0% 0% 0% 3 0 2 0 0 0 R 92585 $ 239.32 $ 239.32 0 0% 0% 0% 1 0 2 0 0 0 R 92585-26 $ 45.58 $ 45.58 0 0% 0% 0% 1 0 2 0 0 0 R 92585-TC $ 193.74 $ 193.74 0 0% 0% 0% 1 0 2 0 0 0 R 92586 $ 148.75 $ 148.75 0 0% 0% 0% 3 0 2 0 0 0 R 92587 $ 37.19 $ 37.19 0 0% 0% 0% 1 0 2 0 0 0 R 92587-26 $ 31.79 $ 31.79 0 0% 0% 0% 1 0 2 0 0 0 R 92587-TC $ 5.40 $ 5.40 0 0% 0% 0% 1 0 2 0 0 0 R 92588 $ 56.38 $ 56.38 0 0% 0% 0% 1 0 2 0 0 0 R 92588-26 $ 49.78 $ 49.78 0 0% 0% 0% 1 0 2 0 0 0 R 92588-TC $ 6.60 $ 6.60 0 0% 0% 0% 1 0 2 0 0 0 R 92590 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 13
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
92591 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 92592 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 92593 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 92594 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 92595 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 92596 $ 74.38 $ 74.38 0 0% 0% 0% 3 0 2 0 0 0 R 92597 $ 122.96 $ 122.96 0 0% 0% 0% 0 5 0 0 0 0 R 92601 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 92602 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 92603 $ 257.31 $ 208.73 0 0% 0% 0% 0 0 0 0 0 0 R Y92604 $ 153.55 $ 115.76 0 0% 0% 0% 0 0 0 0 0 0 R Y92605 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y92606 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y92607 $ 213.53 $ 213.53 0 0% 0% 0% 0 5 0 0 0 0 R Y92608 $ 92.37 $ 92.37 0 0% 0% 0% 0 0 0 0 0 0 R Y92609 $ 191.94 $ 191.94 0 0% 0% 0% 0 5 0 0 0 0 R Y92610 $ 145.75 $ 124.16 0 0% 0% 0% 0 0 0 0 0 0 R Y92611 $ 147.55 $ 147.55 0 0% 0% 0% 0 0 0 0 0 0 R Y92612 $ 303.50 $ 116.36 0 0% 0% 0% 0 0 0 0 0 0 R Y92613 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y92614 $ 251.92 $ 115.16 0 0% 0% 0% 0 0 0 0 0 0 R Y92615 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y92616 $ 358.68 $ 172.14 0 0% 0% 0% 0 0 0 0 0 0 R Y92617 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y92618 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B92620 $ 161.95 $ 141.55 0 0% 0% 0% 9 0 2 0 0 0 R Y92621 $ 38.39 $ 32.99 0 0% 0% 0% 9 0 0 0 0 0 R Y92625 $ 119.96 $ 106.76 0 0% 0% 0% 9 0 2 0 0 0 R Y92626 $ 154.75 $ 130.76 0 0% 0% 0% 9 0 2 0 0 0 R 92627 $ 37.79 $ 30.59 0 0% 0% 0% 9 0 0 0 0 0 R 92630 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 92633 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 92640 Not Covered Not Covered 0 0% 0% 0% 9 0 2 0 0 0 X 92700 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 92920 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X92921 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X92924 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X92925 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 14
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
92928 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X92929 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X92933 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X92934 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X92937 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X92938 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X92941 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X92943 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X92944 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X92950 $ 522.43 $ 314.30 0 0% 0% 0% 0 0 0 0 0 0 R 92953 $ 19.19 $ 19.19 0 0% 0% 0% 0 0 0 0 0 0 R Y92960 $ 358.08 $ 209.33 0 0% 0% 0% 0 0 0 0 0 0 R Y92961 $ 431.26 $ 431.26 0 0% 0% 0% 0 9 9 9 9 9 R Y92970 $ 314.30 $ 314.30 0 0% 0% 0% 0 0 0 0 0 0 R Y92971 $ 166.14 $ 166.14 0 0% 0% 0% 0 0 0 0 0 0 R Y92973 $ 291.50 $ 291.50 0 0% 0% 0% 0 0 0 0 0 0 R Y92974 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 92975 $ 642.99 $ 642.99 0 0% 0% 0% 0 2 0 0 0 0 R Y92977 $ 98.97 $ 98.97 0 0% 0% 0% 5 0 0 0 0 0 R Y92978 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y92978-26 $ 160.15 $ 160.15 0 0% 0% 0% 1 0 0 0 0 0 R Y92978-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y92979 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y92979-26 $ 127.76 $ 127.76 0 0% 0% 0% 1 0 0 0 0 0 R Y92979-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y92986 $ 2202.47 $ 2202.47 90 9% 84% 7% 0 2 0 0 0 0 R Y92987 $ 2276.24 $ 2276.24 90 9% 84% 7% 0 2 0 0 0 0 R Y92990 $ 1797.60 $ 1797.60 90 9% 84% 7% 0 2 0 0 0 0 R Y92992 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X 92993 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X 92997 $ 1087.44 $ 1087.44 0 0% 0% 0% 0 2 0 0 0 0 R Y92998 $ 531.42 $ 531.42 0 0% 0% 0% 0 0 0 0 0 0 R Y93000 $ 29.39 $ 29.39 0 0% 0% 0% 4 6 0 0 0 0 R 93005 $ 15.00 $ 15.00 0 0% 0% 0% 3 6 0 0 0 0 R 93010 $ 14.40 $ 14.40 0 0% 0% 0% 2 0 0 0 0 0 R 93015 $ 132.56 $ 132.56 0 0% 0% 0% 4 6 0 0 0 0 R 93016 $ 37.79 $ 37.79 0 0% 0% 0% 2 0 0 0 0 0 R 93017 $ 70.18 $ 70.18 0 0% 0% 0% 3 6 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 15
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
93018 $ 24.59 $ 24.59 0 0% 0% 0% 2 0 0 0 0 0 R 93024 $ 195.53 $ 195.53 0 0% 0% 0% 1 6 0 0 0 0 R Y93024-26 $ 97.77 $ 97.77 0 0% 0% 0% 1 6 0 0 0 0 R Y93024-TC $ 97.77 $ 97.77 0 0% 0% 0% 1 6 0 0 0 0 R Y93025 $ 288.50 $ 288.50 0 0% 0% 0% 1 6 0 0 0 0 R Y93025-26 $ 63.58 $ 63.58 0 0% 0% 0% 1 6 0 0 0 0 R Y93025-TC $ 225.52 $ 225.52 0 0% 0% 0% 1 6 0 0 0 0 R Y93040 $ 21.59 $ 21.59 0 0% 0% 0% 4 6 0 0 0 0 R 93041 $ 9.60 $ 9.60 0 0% 0% 0% 3 6 0 0 0 0 R 93042 $ 12.00 $ 12.00 0 0% 0% 0% 2 0 0 0 0 0 R 93224 $ 161.35 $ 161.35 0 0% 0% 0% 4 6 0 0 0 0 R 93225 $ 47.98 $ 47.98 0 0% 0% 0% 3 6 0 0 0 0 R 93226 $ 67.78 $ 67.78 0 0% 0% 0% 3 6 0 0 0 0 R 93227 $ 46.18 $ 46.18 0 0% 0% 0% 2 0 0 0 0 0 R 93228 $ 44.39 $ 44.39 0 0% 0% 0% 2 0 0 0 0 0 R 93229 $ 1204.40 $ 1204.40 0 0% 0% 0% 3 6 0 0 0 0 R 93260 $ 115.76 $ 115.76 0 0% 0% 0% 1 6 0 0 0 0 R Y93260-26 $ 76.17 $ 76.17 0 0% 0% 0% 1 6 0 0 0 0 R Y93260-TC $ 39.59 $ 39.59 0 0% 0% 0% 1 6 0 0 0 0 R Y93261 $ 106.16 $ 106.16 0 0% 0% 0% 1 6 0 0 0 0 R Y93261-26 $ 66.58 $ 66.58 0 0% 0% 0% 1 6 0 0 0 0 R Y93261-TC $ 39.59 $ 39.59 0 0% 0% 0% 1 6 0 0 0 0 R Y93268 $ 363.48 $ 363.48 0 0% 0% 0% 4 6 0 0 0 0 R 93270 $ 16.19 $ 16.19 0 0% 0% 0% 3 6 0 0 0 0 R 93271 $ 303.50 $ 303.50 0 0% 0% 0% 3 6 0 0 0 0 R 93272 $ 43.19 $ 43.19 0 0% 0% 0% 2 0 0 0 0 0 R 93278 $ 53.38 $ 53.38 0 0% 0% 0% 1 6 0 0 0 0 R 93278-26 $ 20.99 $ 20.99 0 0% 0% 0% 1 6 0 0 0 0 R 93278-TC $ 31.79 $ 31.79 0 0% 0% 0% 1 6 0 0 0 0 R 93279 $ 85.77 $ 85.77 0 0% 0% 0% 1 6 0 0 0 0 R Y93279-26 $ 55.18 $ 55.18 0 0% 0% 0% 1 6 0 0 0 0 R Y93279-TC $ 30.59 $ 30.59 0 0% 0% 0% 1 6 0 0 0 0 R Y93280 $ 100.77 $ 100.77 0 0% 0% 0% 1 6 0 0 0 0 R Y93280-26 $ 65.98 $ 65.98 0 0% 0% 0% 1 6 0 0 0 0 R Y93280-TC $ 35.39 $ 35.39 0 0% 0% 0% 1 6 0 0 0 0 R Y93281 $ 117.56 $ 117.56 0 0% 0% 0% 1 6 0 0 0 0 R Y93281-26 $ 76.77 $ 76.77 0 0% 0% 0% 1 6 0 0 0 0 R Y93281-TC $ 40.79 $ 40.79 0 0% 0% 0% 1 6 0 0 0 0 R Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 16
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
93282 $ 109.76 $ 109.76 0 0% 0% 0% 1 6 0 0 0 0 R Y93282-26 $ 73.18 $ 73.18 0 0% 0% 0% 1 6 0 0 0 0 R Y93282-TC $ 36.59 $ 36.59 0 0% 0% 0% 1 6 0 0 0 0 R Y93283 $ 140.95 $ 140.95 0 0% 0% 0% 1 6 0 0 0 0 R Y93283-26 $ 98.37 $ 98.37 0 0% 0% 0% 1 6 0 0 0 0 R Y93283-TC $ 41.99 $ 41.99 0 0% 0% 0% 1 6 0 0 0 0 R Y93284 $ 154.75 $ 154.75 0 0% 0% 0% 1 6 0 0 0 0 R Y93284-26 $ 107.36 $ 107.36 0 0% 0% 0% 1 6 0 0 0 0 R Y93284-TC $ 47.98 $ 47.98 0 0% 0% 0% 1 6 0 0 0 0 R Y93285 $ 73.18 $ 73.18 0 0% 0% 0% 1 6 0 0 0 0 R Y93285-26 $ 44.99 $ 44.99 0 0% 0% 0% 1 6 0 0 0 0 R Y93285-TC $ 28.19 $ 28.19 0 0% 0% 0% 1 6 0 0 0 0 R Y93286 $ 47.38 $ 47.38 0 0% 0% 0% 1 6 0 0 0 0 R Y93286-26 $ 25.79 $ 25.79 0 0% 0% 0% 1 6 0 0 0 0 R Y93286-TC $ 20.99 $ 20.99 0 0% 0% 0% 1 6 0 0 0 0 R Y93287 $ 62.38 $ 62.38 0 0% 0% 0% 1 6 0 0 0 0 R Y93287-26 $ 38.99 $ 38.99 0 0% 0% 0% 1 6 0 0 0 0 R Y93287-TC $ 23.39 $ 23.39 0 0% 0% 0% 1 6 0 0 0 0 R Y93288 $ 64.78 $ 64.78 0 0% 0% 0% 1 6 0 0 0 0 R Y93288-26 $ 36.59 $ 36.59 0 0% 0% 0% 1 6 0 0 0 0 R Y93288-TC $ 28.19 $ 28.19 0 0% 0% 0% 1 6 0 0 0 0 R Y93289 $ 112.76 $ 112.76 0 0% 0% 0% 1 6 0 0 0 0 R Y93289-26 $ 77.97 $ 77.97 0 0% 0% 0% 1 6 0 0 0 0 R Y93289-TC $ 34.79 $ 34.79 0 0% 0% 0% 1 6 0 0 0 0 R Y93290 $ 53.38 $ 53.38 0 0% 0% 0% 1 6 0 0 0 0 R Y93290-26 $ 36.59 $ 36.59 0 0% 0% 0% 1 6 0 0 0 0 R Y93290-TC $ 16.79 $ 16.79 0 0% 0% 0% 1 6 0 0 0 0 R Y93291 $ 61.78 $ 61.78 0 0% 0% 0% 1 6 0 0 0 0 R Y93291-26 $ 36.59 $ 36.59 0 0% 0% 0% 1 6 0 0 0 0 R Y93291-TC $ 25.79 $ 25.79 0 0% 0% 0% 1 6 0 0 0 0 R Y93292 $ 55.78 $ 55.78 0 0% 0% 0% 1 6 0 0 0 0 R Y93292-26 $ 36.59 $ 36.59 0 0% 0% 0% 1 6 0 0 0 0 R Y93292-TC $ 19.19 $ 19.19 0 0% 0% 0% 1 6 0 0 0 0 R Y93293 $ 94.17 $ 94.17 0 0% 0% 0% 1 0 0 0 0 0 R Y93293-26 $ 26.39 $ 26.39 0 0% 0% 0% 1 0 0 0 0 0 R Y93293-TC $ 67.78 $ 67.78 0 0% 0% 0% 1 0 0 0 0 0 R Y93294 $ 57.58 $ 57.58 0 0% 0% 0% 2 0 0 0 0 0 R Y93295 $ 113.96 $ 113.96 0 0% 0% 0% 2 0 0 0 0 0 R Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 17
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
93296 $ 46.18 $ 46.18 0 0% 0% 0% 3 0 0 0 0 0 R Y93297 $ 44.99 $ 44.99 0 0% 0% 0% 2 0 0 0 0 0 R Y93298 $ 44.99 $ 44.99 0 0% 0% 0% 2 0 0 0 0 0 R Y93299 $ 0.00 $ 0.00 0 0% 0% 0% 3 0 0 0 0 0 R Y93303 $ 418.06 $ 418.06 0 0% 0% 0% 1 6 0 0 0 0 R Y93303-26 $ 109.16 $ 109.16 0 0% 0% 0% 1 6 0 0 0 0 R Y93303-TC $ 309.50 $ 309.50 0 0% 0% 0% 1 6 0 0 0 0 R Y93304 $ 272.91 $ 272.91 0 0% 0% 0% 1 6 0 0 0 0 R Y93304-26 $ 62.38 $ 62.38 0 0% 0% 0% 1 6 0 0 0 0 R Y93304-TC $ 210.53 $ 210.53 0 0% 0% 0% 1 6 0 0 0 0 R Y93306 $ 400.07 $ 400.07 0 0% 0% 0% 1 6 0 0 0 0 R 93306-26 $ 108.56 $ 108.56 0 0% 0% 0% 1 6 0 0 0 0 R 93306-TC $ 291.50 $ 291.50 0 0% 0% 0% 1 6 0 0 0 0 R 93307 $ 228.52 $ 228.52 0 0% 0% 0% 1 6 0 0 0 0 R 93307-26 $ 77.37 $ 77.37 0 0% 0% 0% 1 6 0 0 0 0 R 93307-TC $ 151.15 $ 151.15 0 0% 0% 0% 1 6 0 0 0 0 R 93308 $ 220.13 $ 220.13 0 0% 0% 0% 1 6 0 0 0 0 R 93308-26 $ 43.79 $ 43.79 0 0% 0% 0% 1 6 0 0 0 0 R 93308-TC $ 175.74 $ 175.74 0 0% 0% 0% 1 6 0 0 0 0 R 93312 $ 534.42 $ 534.42 0 0% 0% 0% 1 6 0 0 0 0 R 93312-26 $ 206.93 $ 206.93 0 0% 0% 0% 1 6 0 0 0 0 R 93312-TC $ 327.49 $ 327.49 0 0% 0% 0% 1 6 0 0 0 0 R 93313 $ 37.79 $ 37.79 0 0% 0% 0% 0 0 0 0 0 0 R 93314 $ 516.43 $ 516.43 0 0% 0% 0% 1 6 0 0 0 0 R 93314-26 $ 170.34 $ 170.34 0 0% 0% 0% 1 6 0 0 0 0 R 93314-TC $ 346.68 $ 346.68 0 0% 0% 0% 1 6 0 0 0 0 R 93315 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93315-26 $ 245.32 $ 245.32 0 0% 0% 0% 1 0 0 0 0 0 R 93315-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93316 $ 64.18 $ 64.18 0 0% 0% 0% 0 0 0 0 0 0 R 93317 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93317-26 $ 180.54 $ 180.54 0 0% 0% 0% 1 0 0 0 0 0 R 93317-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93318 By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N 93318-26 $ 200.33 $ 200.33 0 0% 0% 0% 1 6 0 0 0 0 R 93318-TC By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N 93320 $ 95.97 $ 95.97 0 0% 0% 0% 1 0 0 0 0 0 R 93320-26 $ 31.79 $ 31.79 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 18
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
93320-TC $ 64.18 $ 64.18 0 0% 0% 0% 1 0 0 0 0 0 R 93321 $ 48.58 $ 48.58 0 0% 0% 0% 1 0 0 0 0 0 R 93321-26 $ 12.60 $ 12.60 0 0% 0% 0% 1 0 0 0 0 0 R 93321-TC $ 35.99 $ 35.99 0 0% 0% 0% 1 0 0 0 0 0 R 93325 $ 46.18 $ 46.18 0 0% 0% 0% 1 0 0 0 0 0 R 93325-26 $ 6.00 $ 6.00 0 0% 0% 0% 1 0 0 0 0 0 R 93325-TC $ 40.19 $ 40.19 0 0% 0% 0% 1 0 0 0 0 0 R 93350 $ 422.86 $ 422.86 0 0% 0% 0% 1 6 0 0 0 0 R 93350-26 $ 121.76 $ 121.76 0 0% 0% 0% 1 6 0 0 0 0 R 93350-TC $ 301.10 $ 301.10 0 0% 0% 0% 1 6 0 0 0 0 R 93351 $ 475.04 $ 475.04 0 0% 0% 0% 1 6 0 9 9 9 R 93351-26 $ 146.35 $ 146.35 0 0% 0% 0% 1 6 0 9 9 9 R 93351-TC $ 328.69 $ 328.69 0 0% 0% 0% 1 6 0 9 9 9 R 93352 $ 59.38 $ 59.38 0 0% 0% 0% 0 0 0 0 0 0 R 93355 $ 382.67 $ 382.67 0 0% 0% 0% 0 2 0 0 0 0 R93451 $ 1380.74 $ 1380.74 0 0% 0% 0% 1 2 0 0 0 0 R Y93451-26 $ 238.72 $ 238.72 0 0% 0% 0% 1 2 0 0 0 0 R Y93451-TC $ 1142.02 $ 1142.02 0 0% 0% 0% 1 0 0 0 0 0 R Y93452 $ 1543.89 $ 1543.89 0 0% 0% 0% 1 2 0 0 0 0 R Y93452-26 $ 419.26 $ 419.26 0 0% 0% 0% 1 2 0 0 0 0 R Y93452-TC $ 1124.63 $ 1124.63 0 0% 0% 0% 1 0 0 0 0 0 R Y93453 $ 1985.94 $ 1985.94 0 0% 0% 0% 1 2 0 0 0 0 R Y93453-26 $ 550.62 $ 550.62 0 0% 0% 0% 1 2 0 0 0 0 R Y93453-TC $ 1434.72 $ 1434.72 0 0% 0% 0% 1 0 0 0 0 0 R Y93454 $ 1562.48 $ 1562.48 0 0% 0% 0% 1 2 0 0 0 0 R Y93454-26 $ 421.66 $ 421.66 0 0% 0% 0% 1 2 0 0 0 0 R Y93454-TC $ 1140.22 $ 1140.22 0 0% 0% 0% 1 0 0 0 0 0 R Y93455 $ 1819.19 $ 1819.19 0 0% 0% 0% 1 2 0 0 0 0 R Y93455-26 $ 488.24 $ 488.24 0 0% 0% 0% 1 2 0 0 0 0 R Y93455-TC $ 1331.56 $ 1331.56 0 0% 0% 0% 1 0 0 0 0 0 R Y93456 $ 1953.55 $ 1953.55 0 0% 0% 0% 1 2 0 0 0 0 R Y93456-26 $ 542.22 $ 542.22 0 0% 0% 0% 1 2 0 0 0 0 R Y93456-TC $ 1411.93 $ 1411.93 0 0% 0% 0% 1 0 0 0 0 0 R Y93457 $ 2206.66 $ 2206.66 0 0% 0% 0% 1 2 0 0 0 0 R Y93457-26 $ 606.40 $ 606.40 0 0% 0% 0% 1 2 0 0 0 0 R Y93457-TC $ 1600.27 $ 1600.27 0 0% 0% 0% 1 0 0 0 0 0 R Y93458 $ 1871.98 $ 1871.98 0 0% 0% 0% 1 2 0 0 0 0 R Y93458-26 $ 514.03 $ 514.03 0 0% 0% 0% 1 2 0 0 0 0 R Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 19
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
93458-TC $ 1357.35 $ 1357.35 0 0% 0% 0% 1 0 0 0 0 0 R Y93459 $ 2066.91 $ 2066.91 0 0% 0% 0% 1 2 0 0 0 0 R Y93459-26 $ 580.01 $ 580.01 0 0% 0% 0% 1 2 0 0 0 0 R Y93459-TC $ 1486.90 $ 1486.90 0 0% 0% 0% 1 0 0 0 0 0 R Y93460 $ 2215.66 $ 2215.66 0 0% 0% 0% 1 2 0 0 0 0 R Y93460-26 $ 646.58 $ 646.58 0 0% 0% 0% 1 2 0 0 0 0 R Y93460-TC $ 1569.08 $ 1569.08 0 0% 0% 0% 1 0 0 0 0 0 R Y93461 $ 2535.95 $ 2535.95 0 0% 0% 0% 1 2 0 0 0 0 R Y93461-26 $ 713.16 $ 713.16 0 0% 0% 0% 1 2 0 0 0 0 R Y93461-TC $ 1822.79 $ 1822.79 0 0% 0% 0% 1 0 0 0 0 0 R Y93462 $ 342.49 $ 342.49 0 0% 0% 0% 0 0 0 0 0 0 R Y93463 $ 167.94 $ 167.94 0 0% 0% 0% 0 0 0 0 0 0 R Y93464 $ 484.04 $ 484.04 0 0% 0% 0% 1 0 0 0 0 0 R Y93464-26 $ 149.95 $ 149.95 0 0% 0% 0% 1 0 0 0 0 0 R Y93464-TC $ 334.09 $ 334.09 0 0% 0% 0% 1 0 0 0 0 0 R Y93503 $ 217.13 $ 217.13 0 0% 0% 0% 0 0 0 0 0 0 R 93505 $ 1330.96 $ 1330.96 0 0% 0% 0% 1 2 0 0 0 0 R 93505-26 $ 384.47 $ 384.47 0 0% 0% 0% 1 2 0 0 0 0 R 93505-TC $ 945.88 $ 945.88 0 0% 0% 0% 1 0 0 0 0 0 R 93530 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X 93530-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X 93530-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 93531 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X 93531-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X 93531-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 93532 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X 93532-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X 93532-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 93533 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X 93533-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X 93533-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 93561 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93561-26 $ 41.39 $ 41.39 0 0% 0% 0% 1 0 0 0 0 0 R 93561-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93562 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93562-26 $ 13.80 $ 13.80 0 0% 0% 0% 1 0 0 0 0 0 R 93562-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93563 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 20
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
93564 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X93565 $ 76.77 $ 76.77 0 0% 0% 0% 0 0 0 0 0 0 R93566 $ 298.10 $ 75.57 0 0% 0% 0% 0 0 0 0 0 0 R93567 $ 244.12 $ 85.77 0 0% 0% 0% 0 0 0 0 0 0 R93568 $ 267.51 $ 77.97 0 0% 0% 0% 0 0 0 0 0 0 R93571 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93571-26 $ 160.15 $ 160.15 0 0% 0% 0% 1 0 0 0 0 0 R 93571-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93572 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93572-26 $ 127.76 $ 127.76 0 0% 0% 0% 1 0 0 0 0 0 R 93572-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93580 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 93581 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X 93582 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X93583 $ 1233.79 $ 1233.79 0 0% 0% 0% 0 2 0 0 0 0 R Y93600 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93600-26 $ 197.33 $ 197.33 0 0% 0% 0% 1 0 0 0 0 0 R Y93600-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93602 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93602-26 $ 193.14 $ 193.14 0 0% 0% 0% 1 0 0 0 0 0 R Y93602-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93603 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93603-26 $ 193.14 $ 193.14 0 0% 0% 0% 1 0 0 0 0 0 R Y93603-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93609 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93609-26 $ 463.05 $ 463.05 0 0% 0% 0% 1 0 0 0 0 0 R Y93609-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93610 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93610-26 $ 273.51 $ 273.51 0 0% 0% 0% 1 0 0 0 0 0 R Y93610-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93612 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93612-26 $ 271.71 $ 271.71 0 0% 0% 0% 1 0 0 0 0 0 R Y93612-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93613 $ 652.58 $ 652.58 0 0% 0% 0% 0 0 0 0 0 0 R Y93615 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93615-26 $ 88.77 $ 88.77 0 0% 0% 0% 1 0 0 0 0 0 R Y93615-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93616 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 21
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
93616-26 $ 109.16 $ 109.16 0 0% 0% 0% 1 0 0 0 0 0 R Y93616-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93618 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93618-26 $ 392.87 $ 392.87 0 0% 0% 0% 1 0 0 0 0 0 R Y93618-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93619 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y93619-26 $ 674.18 $ 674.18 0 0% 0% 0% 1 2 0 0 0 0 R Y93619-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93620 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y93620-26 $ 1071.84 $ 1071.24 0 0% 0% 0% 1 2 0 0 0 0 R Y93620-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93621 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93621-26 $ 195.53 $ 195.53 0 0% 0% 0% 1 0 0 0 0 0 R Y93621-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93622 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93622-26 $ 284.91 $ 284.91 0 0% 0% 0% 1 0 0 0 0 0 R Y93622-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93623 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93623-26 $ 266.31 $ 266.31 0 0% 0% 0% 1 0 0 0 0 0 R Y93623-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93624 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y93624-26 $ 425.86 $ 425.86 0 0% 0% 0% 1 2 0 0 0 0 R Y93624-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93631 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93631-26 $ 660.38 $ 660.38 0 0% 0% 0% 1 0 0 0 0 0 R Y93631-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93640 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y93640-26 $ 320.29 $ 320.29 0 0% 0% 0% 1 2 0 0 0 0 R Y93640-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93641 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y93641-26 $ 545.82 $ 545.82 0 0% 0% 0% 1 2 0 0 0 0 R Y93641-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93642 $ 719.16 $ 719.16 0 0% 0% 0% 1 2 0 0 0 0 R Y93642-26 $ 448.65 $ 448.65 0 0% 0% 0% 1 2 0 0 0 0 R Y93642-TC $ 271.11 $ 271.11 0 0% 0% 0% 1 0 0 0 0 0 R Y93644 $ 503.83 $ 503.83 0 0% 0% 0% 1 2 0 0 0 0 R Y93644-26 $ 314.90 $ 314.90 0 0% 0% 0% 1 2 0 0 0 0 R Y93644-TC $ 188.94 $ 188.94 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 22
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
93650 $ 994.47 $ 994.47 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR93653 $ 1395.13 $ 1395.13 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR93654 $ 1856.38 $ 1856.38 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR93655 $ 696.97 $ 696.97 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR93656 $ 1864.78 $ 1864.78 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR93657 $ 696.37 $ 696.37 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR93660 $ 274.11 $ 274.11 0 0% 0% 0% 1 2 0 0 0 0 R Y93660-26 $ 161.35 $ 161.35 0 0% 0% 0% 1 2 0 0 0 0 R Y93660-TC $ 112.76 $ 112.76 0 0% 0% 0% 1 0 0 0 0 0 R Y93662 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93662-26 $ 247.72 $ 247.72 0 0% 0% 0% 1 0 0 0 0 0 R 93662-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93668 $ 34.19 $ 34.19 0 0% 0% 0% 9 9 9 9 9 9 R Y93701 $ 43.19 $ 43.19 0 0% 0% 0% 3 6 0 0 0 0 R Y93702 $ 202.73 $ 202.73 0 0% 0% 0% 3 6 0 0 0 0 R Y93724 $ 468.44 $ 468.44 0 0% 0% 0% 1 6 0 0 0 0 R Y93724-26 $ 418.06 $ 418.06 0 0% 0% 0% 1 6 0 0 0 0 R Y93724-TC $ 50.38 $ 50.38 0 0% 0% 0% 1 6 0 0 0 0 R Y93740 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 93745 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93745-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93745-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y93750 $ 94.17 $ 77.37 0 0% 0% 0% 0 0 0 0 0 0 R Y93770 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 93784 $ 94.17 $ 94.17 0 0% 0% 0% 4 6 0 0 0 0 R 93786 $ 52.78 $ 52.78 0 0% 0% 0% 3 6 0 0 0 0 R 93788 $ 9.00 $ 9.00 0 0% 0% 0% 3 6 0 0 0 0 R 93790 $ 32.39 $ 32.39 0 0% 0% 0% 2 0 0 0 0 0 R 93797 $ 28.19 $ 15.00 0 0% 0% 0% 0 0 0 0 0 0 R Y93798 $ 43.79 $ 23.99 0 0% 0% 0% 0 0 0 0 0 0 R Y93799 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93799-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93799-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 93880 $ 357.48 $ 357.48 0 0% 0% 0% 1 6 2 0 0 0 R 93880-26 $ 67.18 $ 67.18 0 0% 0% 0% 1 6 2 0 0 0 R 93880-TC $ 290.30 $ 290.30 0 0% 0% 0% 1 6 2 0 0 0 R 93882 $ 227.32 $ 227.32 0 0% 0% 0% 1 6 0 0 0 0 R 93882-26 $ 41.39 $ 41.39 0 0% 0% 0% 1 6 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 23
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
93882-TC $ 185.94 $ 185.94 0 0% 0% 0% 1 6 0 0 0 0 R 93886 $ 509.83 $ 509.83 0 0% 0% 0% 1 6 0 0 0 0 R 93886-26 $ 79.77 $ 79.77 0 0% 0% 0% 1 6 0 0 0 0 R 93886-TC $ 430.66 $ 430.66 0 0% 0% 0% 1 6 0 0 0 0 R 93888 $ 264.51 $ 264.51 0 0% 0% 0% 1 6 0 0 0 0 R 93888-26 $ 43.19 $ 43.19 0 0% 0% 0% 1 6 0 0 0 0 R 93888-TC $ 221.33 $ 221.33 0 0% 0% 0% 1 6 0 0 0 0 R 93890 $ 515.83 $ 515.83 0 0% 0% 0% 1 6 0 0 0 0 R 93890-26 $ 86.97 $ 86.97 0 0% 0% 0% 1 6 0 0 0 0 R 93890-TC $ 428.86 $ 428.86 0 0% 0% 0% 1 6 0 0 0 0 R 93892 $ 598.60 $ 598.60 0 0% 0% 0% 1 6 0 0 0 0 R 93892-26 $ 100.77 $ 100.77 0 0% 0% 0% 1 6 0 0 0 0 R 93892-TC $ 497.83 $ 497.83 0 0% 0% 0% 1 6 0 0 0 0 R 93893 $ 614.20 $ 614.20 0 0% 0% 0% 1 6 0 0 0 0 R 93893-26 $ 100.77 $ 100.77 0 0% 0% 0% 1 6 0 0 0 0 R 93893-TC $ 513.43 $ 513.43 0 0% 0% 0% 1 6 0 0 0 0 R 93895 By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N93895-26 By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N93895-TC By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N93922 $ 158.35 $ 158.35 0 0% 0% 0% 1 6 2 0 0 0 R 93922-26 $ 20.99 $ 20.99 0 0% 0% 0% 1 6 2 0 0 0 R 93922-TC $ 137.95 $ 137.95 0 0% 0% 0% 1 6 2 0 0 0 R 93923 $ 245.32 $ 245.32 0 0% 0% 0% 1 6 2 0 0 0 R 93923-26 $ 37.19 $ 37.19 0 0% 0% 0% 1 6 2 0 0 0 R 93923-TC $ 208.13 $ 208.13 0 0% 0% 0% 1 6 2 0 0 0 R 93924 $ 306.50 $ 306.50 0 0% 0% 0% 1 6 2 0 0 0 R 93924-26 $ 41.39 $ 41.39 0 0% 0% 0% 1 6 2 0 0 0 R 93924-TC $ 265.11 $ 265.11 0 0% 0% 0% 1 6 2 0 0 0 R 93925 $ 461.85 $ 461.85 0 0% 0% 0% 1 6 2 0 0 0 R 93925-26 $ 66.58 $ 66.58 0 0% 0% 0% 1 6 2 0 0 0 R 93925-TC $ 395.27 $ 395.27 0 0% 0% 0% 1 6 2 0 0 0 R 93926 $ 271.11 $ 271.11 0 0% 0% 0% 1 6 0 0 0 0 R 93926-26 $ 41.39 $ 41.39 0 0% 0% 0% 1 6 0 0 0 0 R 93926-TC $ 229.72 $ 229.72 0 0% 0% 0% 1 6 0 0 0 0 R 93930 $ 370.08 $ 370.08 0 0% 0% 0% 1 6 2 0 0 0 R 93930-26 $ 66.58 $ 66.58 0 0% 0% 0% 1 6 2 0 0 0 R 93930-TC $ 303.50 $ 303.50 0 0% 0% 0% 1 6 2 0 0 0 R 93931 $ 229.72 $ 229.72 0 0% 0% 0% 1 6 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 24
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
93931-26 $ 41.99 $ 41.99 0 0% 0% 0% 1 6 0 0 0 0 R 93931-TC $ 187.74 $ 187.74 0 0% 0% 0% 1 6 0 0 0 0 R 93965 $ 214.13 $ 214.13 0 0% 0% 0% 1 6 2 0 0 0 R 93965-26 $ 29.39 $ 29.39 0 0% 0% 0% 1 6 2 0 0 0 R 93965-TC $ 184.74 $ 184.74 0 0% 0% 0% 1 6 2 0 0 0 R 93970 $ 349.08 $ 349.08 0 0% 0% 0% 1 6 2 0 0 0 R 93970-26 $ 58.78 $ 58.78 0 0% 0% 0% 1 6 2 0 0 0 R 93970-TC $ 290.30 $ 290.30 0 0% 0% 0% 1 6 2 0 0 0 R 93971 $ 214.13 $ 214.13 0 0% 0% 0% 1 6 0 0 0 0 R 93971-26 $ 37.79 $ 37.79 0 0% 0% 0% 1 6 0 0 0 0 R 93971-TC $ 176.34 $ 176.34 0 0% 0% 0% 1 6 0 0 0 0 R 93975 $ 499.03 $ 499.03 0 0% 0% 0% 1 6 0 0 0 0 R 93975-26 $ 97.17 $ 97.17 0 0% 0% 0% 1 6 0 0 0 0 R 93975-TC $ 401.87 $ 401.87 0 0% 0% 0% 1 6 0 0 0 0 R 93976 $ 288.50 $ 288.50 0 0% 0% 0% 1 6 0 0 0 0 R 93976-26 $ 68.38 $ 68.38 0 0% 0% 0% 1 6 0 0 0 0 R 93976-TC $ 220.13 $ 220.13 0 0% 0% 0% 1 6 0 0 0 0 R 93978 $ 337.09 $ 337.09 0 0% 0% 0% 1 6 0 0 0 0 R 93978-26 $ 65.38 $ 65.38 0 0% 0% 0% 1 6 0 0 0 0 R 93978-TC $ 271.11 $ 271.11 0 0% 0% 0% 1 6 0 0 0 0 R 93979 $ 212.93 $ 212.93 0 0% 0% 0% 1 6 0 0 0 0 R 93979-26 $ 41.39 $ 41.39 0 0% 0% 0% 1 6 0 0 0 0 R 93979-TC $ 171.54 $ 171.54 0 0% 0% 0% 1 6 0 0 0 0 R 93980 $ 209.33 $ 209.33 0 0% 0% 0% 1 6 0 0 0 0 R 93980-26 $ 104.37 $ 104.37 0 0% 0% 0% 1 6 0 0 0 0 R 93980-TC $ 104.97 $ 104.97 0 0% 0% 0% 1 6 0 0 0 0 R 93981 $ 126.56 $ 126.56 0 0% 0% 0% 1 6 0 0 0 0 R 93981-26 $ 35.99 $ 35.99 0 0% 0% 0% 1 6 0 0 0 0 R 93981-TC $ 90.57 $ 90.57 0 0% 0% 0% 1 6 0 0 0 0 R 93982 $ 75.57 $ 75.57 0 0% 0% 0% 0 0 0 0 0 0 R Y93990 $ 284.31 $ 284.31 0 0% 0% 0% 1 6 0 0 0 0 R 93990-26 $ 40.79 $ 40.79 0 0% 0% 0% 1 6 0 0 0 0 R 93990-TC $ 242.92 $ 242.92 0 0% 0% 0% 1 6 0 0 0 0 R 93998 By Report By Report 0 0% 0% 0% 0 0 0 0 1 1 N94002 $ 155.35 $ 155.35 0 0% 0% 0% 0 0 0 0 0 0 R 94003 $ 112.76 $ 112.76 0 0% 0% 0% 0 0 0 0 0 0 R 94004 $ 82.77 $ 82.77 0 0% 0% 0% 0 0 0 0 0 0 R 94005 $ 158.95 $ 158.95 0 0% 0% 0% 9 9 9 9 9 9 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 25
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
94010 $ 63.58 $ 63.58 0 0% 0% 0% 1 0 0 0 0 0 R 94010-26 $ 14.40 $ 14.40 0 0% 0% 0% 1 0 0 0 0 0 R 94010-TC $ 49.18 $ 49.18 0 0% 0% 0% 1 0 0 0 0 0 R 94011 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X94012 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X94013 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X94014 $ 97.77 $ 97.77 0 0% 0% 0% 4 0 0 0 0 0 R 94015 $ 53.98 $ 53.98 0 0% 0% 0% 3 0 0 0 0 0 R 94016 $ 43.19 $ 43.19 0 0% 0% 0% 2 0 0 0 0 0 R 94060 $ 107.36 $ 107.36 0 0% 0% 0% 1 0 0 0 0 0 R 94060-26 $ 22.19 $ 22.19 0 0% 0% 0% 1 0 0 0 0 0 R 94060-TC $ 85.17 $ 85.17 0 0% 0% 0% 1 0 0 0 0 0 R 94070 $ 103.77 $ 103.77 0 0% 0% 0% 1 0 0 0 0 0 R 94070-26 $ 49.18 $ 49.18 0 0% 0% 0% 1 0 0 0 0 0 R 94070-TC $ 54.58 $ 54.58 0 0% 0% 0% 1 0 0 0 0 0 R 94150 Bundled Bundled 0 0% 0% 0% 1 9 9 9 9 9 B 94150-26 Bundled Bundled 0 0% 0% 0% 1 9 9 9 9 9 B 94150-TC Bundled Bundled 0 0% 0% 0% 1 9 9 9 9 9 B 94200 $ 44.39 $ 44.39 0 0% 0% 0% 1 0 0 0 0 0 R 94200-26 $ 9.60 $ 9.60 0 0% 0% 0% 1 0 0 0 0 0 R 94200-TC $ 35.39 $ 35.39 0 0% 0% 0% 1 0 0 0 0 0 R 94250 $ 46.18 $ 46.18 0 0% 0% 0% 1 0 0 0 0 0 R 94250-26 $ 9.00 $ 9.00 0 0% 0% 0% 1 0 0 0 0 0 R 94250-TC $ 37.19 $ 37.19 0 0% 0% 0% 1 0 0 0 0 0 R 94375 $ 68.98 $ 68.98 0 0% 0% 0% 1 0 0 0 0 0 R 94375-26 $ 25.19 $ 25.19 0 0% 0% 0% 1 0 0 0 0 0 R 94375-TC $ 43.19 $ 43.19 0 0% 0% 0% 1 0 0 0 0 0 R 94400 $ 99.57 $ 99.57 0 0% 0% 0% 1 0 0 0 0 0 R 94400-26 $ 33.59 $ 33.59 0 0% 0% 0% 1 0 0 0 0 0 R 94400-TC $ 65.98 $ 65.98 0 0% 0% 0% 1 0 0 0 0 0 R 94450 $ 117.56 $ 117.56 0 0% 0% 0% 1 0 0 0 0 0 R 94450-26 $ 33.59 $ 33.59 0 0% 0% 0% 1 0 0 0 0 0 R 94450-TC $ 83.97 $ 83.97 0 0% 0% 0% 1 0 0 0 0 0 R 94452 $ 101.97 $ 101.97 0 0% 0% 0% 1 0 0 0 0 0 R 94452-26 $ 24.59 $ 24.59 0 0% 0% 0% 1 0 0 0 0 0 R 94452-TC $ 76.77 $ 76.77 0 0% 0% 0% 1 0 0 0 0 0 R 94453 $ 140.95 $ 140.95 0 0% 0% 0% 1 0 0 0 0 0 R 94453-26 $ 32.39 $ 32.39 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 26
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
94453-TC $ 108.56 $ 108.56 0 0% 0% 0% 1 0 0 0 0 0 R 94610 $ 94.77 $ 94.77 0 0% 0% 0% 0 0 0 0 0 0 R 94620 $ 97.17 $ 97.17 0 0% 0% 0% 1 0 0 0 0 0 R 94620-26 $ 52.18 $ 52.18 0 0% 0% 0% 1 0 0 0 0 0 R 94620-TC $ 45.58 $ 45.58 0 0% 0% 0% 1 0 0 0 0 0 R 94621 $ 286.70 $ 286.70 0 0% 0% 0% 1 0 0 0 0 0 R 94621-26 $ 117.56 $ 117.56 0 0% 0% 0% 1 0 0 0 0 0 R 94621-TC $ 169.14 $ 169.14 0 0% 0% 0% 1 0 0 0 0 0 R 94640 $ 32.39 $ 32.39 0 0% 0% 0% 5 0 0 0 0 0 R 94642 By Report By Report 0 0% 0% 0% 5 0 0 0 0 0 N 94644 $ 77.37 $ 77.37 0 0% 0% 0% 5 0 0 0 0 0 R 94645 $ 24.59 $ 24.59 0 0% 0% 0% 5 0 0 0 0 0 R 94660 $ 107.96 $ 63.58 0 0% 0% 0% 0 0 0 0 0 0 R 94662 $ 56.98 $ 56.98 0 0% 0% 0% 0 0 0 0 0 0 R 94664 $ 30.59 $ 30.59 0 0% 0% 0% 5 0 0 0 0 0 R 94667 $ 46.18 $ 46.18 0 0% 0% 0% 5 0 0 0 0 0 R 94668 $ 50.98 $ 50.98 0 0% 0% 0% 5 0 0 0 0 0 R 94669 $ 62.98 $ 62.98 0 0% 0% 0% 5 0 0 0 0 0 R94680 $ 101.37 $ 101.37 0 0% 0% 0% 1 0 0 0 0 0 R 94680-26 $ 21.59 $ 21.59 0 0% 0% 0% 1 0 0 0 0 0 R 94680-TC $ 79.77 $ 79.77 0 0% 0% 0% 1 0 0 0 0 0 R 94681 $ 94.17 $ 94.17 0 0% 0% 0% 1 0 0 0 0 0 R 94681-26 $ 16.79 $ 16.79 0 0% 0% 0% 1 0 0 0 0 0 R 94681-TC $ 77.37 $ 77.37 0 0% 0% 0% 1 0 0 0 0 0 R 94690 $ 87.57 $ 87.57 0 0% 0% 0% 1 0 0 0 0 0 R 94690-26 $ 6.60 $ 6.60 0 0% 0% 0% 1 0 0 0 0 0 R 94690-TC $ 81.57 $ 81.57 0 0% 0% 0% 1 0 0 0 0 0 R 94726 $ 92.97 $ 92.97 0 0% 0% 0% 1 0 0 0 0 0 R94726-26 $ 20.99 $ 20.99 0 0% 0% 0% 1 0 0 0 0 0 R94726-TC $ 71.98 $ 71.98 0 0% 0% 0% 1 0 0 0 0 0 R94727 $ 73.78 $ 73.78 0 0% 0% 0% 1 0 0 0 0 0 R94727-26 $ 20.99 $ 20.99 0 0% 0% 0% 1 0 0 0 0 0 R94727-TC $ 52.78 $ 52.78 0 0% 0% 0% 1 0 0 0 0 0 R94728 $ 68.98 $ 68.98 0 0% 0% 0% 1 0 0 0 0 0 R94728-26 $ 20.99 $ 20.99 0 0% 0% 0% 1 0 0 0 0 0 R94728-TC $ 47.98 $ 47.98 0 0% 0% 0% 1 0 0 0 0 0 R94729 $ 96.57 $ 96.57 0 0% 0% 0% 1 0 0 0 0 0 R94729-26 $ 15.59 $ 15.59 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 27
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
94729-TC $ 80.97 $ 80.97 0 0% 0% 0% 1 0 0 0 0 0 R94750 $ 143.95 $ 143.95 0 0% 0% 0% 1 0 0 0 0 0 R 94750-26 $ 19.19 $ 19.19 0 0% 0% 0% 1 0 0 0 0 0 R 94750-TC $ 124.76 $ 124.76 0 0% 0% 0% 1 0 0 0 0 0 R 94760 Bundled Bundled 0 0% 0% 0% 3 0 0 0 0 0 B 94761 Bundled Bundled 0 0% 0% 0% 3 0 0 0 0 0 B 94762 $ 43.19 $ 43.19 0 0% 0% 0% 3 0 0 0 0 0 R 94770 $ 12.60 $ 12.60 0 0% 0% 0% 0 0 0 0 0 0 R 94772 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 94772-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 94772-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 94774 Not Covered Not Covered 0 0% 0% 0% 4 0 0 0 0 0 X 94775 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X 94776 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X 94777 Not Covered Not Covered 0 0% 0% 0% 2 0 0 0 0 0 X 94780 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X94781 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X94799 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 94799-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 94799-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 95004 $ 10.80 $ 10.80 0 0% 0% 0% 0 0 0 0 0 0 R 95012 $ 34.79 $ 34.79 0 0% 0% 0% 5 0 0 0 0 0 R 95017 $ 13.20 $ 6.00 0 0% 0% 0% 0 0 0 0 0 0 R95018 $ 32.99 $ 12.00 0 0% 0% 0% 0 0 0 0 0 0 R95024 $ 13.80 $ 1.80 0 0% 0% 0% 0 0 0 0 0 0 R 95027 $ 7.80 $ 7.80 0 0% 0% 0% 0 0 0 0 0 0 R 95028 $ 23.99 $ 23.99 0 0% 0% 0% 3 0 0 0 0 0 R 95044 $ 9.60 $ 9.60 0 0% 0% 0% 5 0 0 0 0 0 R 95052 $ 12.00 $ 12.00 0 0% 0% 0% 5 0 0 0 0 0 R 95056 $ 79.17 $ 79.17 0 0% 0% 0% 5 0 0 0 0 0 R 95060 $ 62.38 $ 62.38 0 0% 0% 0% 3 0 0 0 0 0 R 95065 $ 44.39 $ 44.39 0 0% 0% 0% 3 0 0 0 0 0 R 95070 $ 53.38 $ 53.38 0 0% 0% 0% 3 0 0 0 0 0 R 95071 $ 61.78 $ 61.78 0 0% 0% 0% 3 0 0 0 0 0 R 95076 $ 200.93 $ 124.76 0 0% 0% 0% 0 0 0 0 0 0 R95079 $ 142.15 $ 114.56 0 0% 0% 0% 0 0 0 0 0 0 R95115 $ 15.59 $ 15.59 0 0% 0% 0% 5 0 0 0 0 0 R Y95117 $ 17.99 $ 17.99 0 0% 0% 0% 5 0 0 0 0 0 R Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 28
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
95120 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y95125 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y95130 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y95131 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y95132 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y95133 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y95134 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y95144 $ 21.59 $ 5.40 0 0% 0% 0% 0 0 0 0 0 0 R Y95145 $ 38.99 $ 5.40 0 0% 0% 0% 0 0 0 0 0 0 R Y95146 $ 68.98 $ 5.40 0 0% 0% 0% 0 0 0 0 0 0 R Y95147 $ 62.38 $ 5.40 0 0% 0% 0% 0 0 0 0 0 0 R Y95148 $ 93.57 $ 5.40 0 0% 0% 0% 0 0 0 0 0 0 R Y95149 $ 124.76 $ 5.40 0 0% 0% 0% 0 0 0 0 0 0 R Y95165 $ 22.19 $ 5.40 0 0% 0% 0% 0 0 0 0 0 0 R Y95170 $ 16.79 $ 5.40 0 0% 0% 0% 0 0 0 0 0 0 R Y95180 $ 230.92 $ 172.74 0 0% 0% 0% 0 0 0 0 0 0 R Y95199 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 95250 $ 280.71 $ 280.71 0 0% 0% 0% 3 0 0 0 0 0 R Y95251 Not Covered Not Covered 0 0% 0% 0% 2 0 0 0 0 0 X 95782 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X95782-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X95782-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X95783 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X95783-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X95783-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X95800 $ 316.69 $ 316.69 0 0% 0% 0% 1 0 0 0 0 0 R Y95800-26 $ 88.77 $ 88.77 0 0% 0% 0% 1 0 0 0 0 0 R Y95800-TC $ 227.92 $ 227.92 0 0% 0% 0% 1 0 0 0 0 0 R Y95801 $ 159.55 $ 159.55 0 0% 0% 0% 1 0 0 0 0 0 R Y95801-26 $ 84.57 $ 84.57 0 0% 0% 0% 1 0 0 0 0 0 R Y95801-TC $ 74.98 $ 74.98 0 0% 0% 0% 1 0 0 0 0 0 R Y95803 $ 248.92 $ 248.92 0 0% 0% 0% 1 0 0 0 0 0 R Y95803-26 $ 73.78 $ 73.78 0 0% 0% 0% 1 0 0 0 0 0 R Y95803-TC $ 175.14 $ 175.14 0 0% 0% 0% 1 0 0 0 0 0 R Y95805 $ 742.55 $ 742.55 0 0% 0% 0% 1 0 0 0 0 0 R Y95805-26 $ 100.77 $ 100.77 0 0% 0% 0% 1 0 0 0 0 0 R Y95805-TC $ 641.19 $ 641.19 0 0% 0% 0% 1 0 0 0 0 0 R Y95806 $ 295.10 $ 295.10 0 0% 0% 0% 1 0 0 0 0 0 R Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 29
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
95806-26 $ 103.77 $ 103.77 0 0% 0% 0% 1 0 0 0 0 0 R Y95806-TC $ 191.34 $ 191.34 0 0% 0% 0% 1 0 0 0 0 0 R Y95807 $ 829.52 $ 829.52 0 0% 0% 0% 1 0 0 0 0 0 R Y95807-26 $ 105.56 $ 105.56 0 0% 0% 0% 1 0 0 0 0 0 R Y95807-TC $ 723.96 $ 723.96 0 0% 0% 0% 1 0 0 0 0 0 R Y95808 $ 1067.04 $ 1067.04 0 0% 0% 0% 1 0 0 0 0 0 R Y95808-26 $ 148.75 $ 148.75 0 0% 0% 0% 1 0 0 0 0 0 R Y95808-TC $ 918.29 $ 918.29 0 0% 0% 0% 1 0 0 0 0 0 R Y95810 $ 1095.83 $ 1095.83 0 0% 0% 0% 1 0 0 0 0 0 R Y95810-26 $ 207.53 $ 207.53 0 0% 0% 0% 1 0 0 0 0 0 R Y95810-TC $ 888.30 $ 888.30 0 0% 0% 0% 1 0 0 0 0 0 R Y95811 $ 1151.02 $ 1151.02 0 0% 0% 0% 1 0 0 0 0 0 R Y95811-26 $ 215.33 $ 215.33 0 0% 0% 0% 1 0 0 0 0 0 R Y95811-TC $ 935.69 $ 935.69 0 0% 0% 0% 1 0 0 0 0 0 R Y95812 $ 741.35 $ 741.35 0 0% 0% 0% 1 0 0 0 0 0 R 95812-26 $ 98.37 $ 98.37 0 0% 0% 0% 1 0 0 0 0 0 R 95812-TC $ 642.99 $ 642.99 0 0% 0% 0% 1 0 0 0 0 0 R 95813 $ 884.71 $ 884.71 0 0% 0% 0% 1 0 0 0 0 0 R 95813-26 $ 157.75 $ 157.75 0 0% 0% 0% 1 0 0 0 0 0 R 95813-TC $ 726.96 $ 726.96 0 0% 0% 0% 1 0 0 0 0 0 R 95816 $ 635.19 $ 635.19 0 0% 0% 0% 1 0 0 0 0 0 R 95816-26 $ 98.37 $ 98.37 0 0% 0% 0% 1 0 0 0 0 0 R 95816-TC $ 536.82 $ 536.82 0 0% 0% 0% 1 0 0 0 0 0 R 95819 $ 725.16 $ 725.16 0 0% 0% 0% 1 0 0 0 0 0 R 95819-26 $ 98.37 $ 98.37 0 0% 0% 0% 1 0 0 0 0 0 R 95819-TC $ 626.79 $ 626.79 0 0% 0% 0% 1 0 0 0 0 0 R 95822 $ 655.58 $ 655.58 0 0% 0% 0% 1 0 0 0 0 0 R 95822-26 $ 98.37 $ 98.37 0 0% 0% 0% 1 0 0 0 0 0 R 95822-TC $ 556.61 $ 556.61 0 0% 0% 0% 1 0 0 0 0 0 R 95824 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 95824-26 $ 67.78 $ 67.78 0 0% 0% 0% 1 0 0 0 0 0 R 95824-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 95827 $ 1392.74 $ 1392.74 0 0% 0% 0% 1 0 0 0 0 0 R 95827-26 $ 97.77 $ 97.77 0 0% 0% 0% 1 0 0 0 0 0 R 95827-TC $ 1294.97 $ 1294.97 0 0% 0% 0% 1 0 0 0 0 0 R 95829 $ 3335.49 $ 3335.49 0 0% 0% 0% 1 0 0 0 0 0 R 95829-26 $ 565.61 $ 565.61 0 0% 0% 0% 1 0 0 0 0 0 R 95829-TC $ 2769.88 $ 2769.88 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 30
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
95830 $ 430.06 $ 154.75 0 0% 0% 0% 0 0 0 0 0 0 R 95831 $ 53.38 $ 25.19 0 0% 0% 0% 0 0 0 0 0 0 R 95832 $ 52.18 $ 26.99 0 0% 0% 0% 0 0 0 0 0 0 R 95833 $ 65.38 $ 36.59 0 0% 0% 0% 0 0 0 0 0 0 R 95834 $ 87.57 $ 53.38 0 0% 0% 0% 0 0 0 0 0 0 R 95851 $ 32.39 $ 13.20 0 0% 0% 0% 0 0 0 0 0 0 R 95852 $ 28.79 $ 10.20 0 0% 0% 0% 0 0 0 0 0 0 R 95857 $ 93.57 $ 49.78 0 0% 0% 0% 0 0 0 0 0 0 R 95860 $ 215.33 $ 215.33 0 0% 0% 0% 1 0 0 0 0 0 R 95860-26 $ 88.77 $ 88.77 0 0% 0% 0% 1 0 0 0 0 0 R 95860-TC $ 126.56 $ 126.56 0 0% 0% 0% 1 0 0 0 0 0 R 95861 $ 301.70 $ 301.70 0 0% 0% 0% 1 0 0 0 0 0 R 95861-26 $ 140.95 $ 140.95 0 0% 0% 0% 1 0 0 0 0 0 R 95861-TC $ 160.75 $ 160.75 0 0% 0% 0% 1 0 0 0 0 0 R 95863 $ 372.48 $ 372.48 0 0% 0% 0% 1 0 0 0 0 0 R 95863-26 $ 172.14 $ 172.14 0 0% 0% 0% 1 0 0 0 0 0 R 95863-TC $ 199.73 $ 199.73 0 0% 0% 0% 1 0 0 0 0 0 R 95864 $ 424.06 $ 424.06 0 0% 0% 0% 1 0 0 0 0 0 R 95864-26 $ 183.54 $ 183.54 0 0% 0% 0% 1 0 0 0 0 0 R 95864-TC $ 240.52 $ 240.52 0 0% 0% 0% 1 0 0 0 0 0 R 95865 $ 250.12 $ 250.12 0 0% 0% 0% 1 0 2 0 0 0 R 95865-26 $ 143.35 $ 143.35 0 0% 0% 0% 1 0 2 0 0 0 R 95865-TC $ 106.76 $ 106.76 0 0% 0% 0% 1 0 2 0 0 0 R 95866 $ 232.72 $ 232.72 0 0% 0% 0% 1 0 1 0 0 0 R 95866-26 $ 116.36 $ 116.36 0 0% 0% 0% 1 0 1 0 0 0 R 95866-TC $ 116.36 $ 116.36 0 0% 0% 0% 1 0 1 0 0 0 R 95867 $ 163.15 $ 163.15 0 0% 0% 0% 1 0 0 0 0 0 R 95867-26 $ 71.38 $ 71.38 0 0% 0% 0% 1 0 0 0 0 0 R 95867-TC $ 91.77 $ 91.77 0 0% 0% 0% 1 0 0 0 0 0 R 95868 $ 230.32 $ 230.32 0 0% 0% 0% 1 0 2 0 0 0 R 95868-26 $ 107.96 $ 107.96 0 0% 0% 0% 1 0 2 0 0 0 R 95868-TC $ 122.36 $ 122.36 0 0% 0% 0% 1 0 2 0 0 0 R 95869 $ 143.95 $ 143.95 0 0% 0% 0% 1 0 0 0 0 0 R 95869-26 $ 33.59 $ 33.59 0 0% 0% 0% 1 0 0 0 0 0 R 95869-TC $ 109.76 $ 109.76 0 0% 0% 0% 1 0 0 0 0 0 R 95870 $ 155.95 $ 155.95 0 0% 0% 0% 1 0 0 0 0 0 R 95870-26 $ 33.59 $ 33.59 0 0% 0% 0% 1 0 0 0 0 0 R 95870-TC $ 122.36 $ 122.36 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 31
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
95872 $ 340.69 $ 340.69 0 0% 0% 0% 1 0 0 0 0 0 R 95872-26 $ 263.91 $ 263.91 0 0% 0% 0% 1 0 0 0 0 0 R 95872-TC $ 76.77 $ 76.77 0 0% 0% 0% 1 0 0 0 0 0 R 95873 $ 131.96 $ 131.96 0 0% 0% 0% 1 0 0 0 0 0 R 95873-26 $ 35.39 $ 35.39 0 0% 0% 0% 1 0 0 0 0 0 R 95873-TC $ 96.57 $ 96.57 0 0% 0% 0% 1 0 0 0 0 0 R 95874 $ 127.16 $ 127.16 0 0% 0% 0% 1 0 0 0 0 0 R 95874-26 $ 34.19 $ 34.19 0 0% 0% 0% 1 0 0 0 0 0 R 95874-TC $ 92.97 $ 92.97 0 0% 0% 0% 1 0 0 0 0 0 R 95875 $ 211.13 $ 211.13 0 0% 0% 0% 1 0 0 0 0 0 R 95875-26 $ 99.57 $ 99.57 0 0% 0% 0% 1 0 0 0 0 0 R 95875-TC $ 110.96 $ 110.96 0 0% 0% 0% 1 0 0 0 0 0 R 95885 $ 103.17 $ 103.17 0 0% 0% 0% 1 0 3 0 0 0 R95885-26 $ 32.39 $ 32.39 0 0% 0% 0% 1 0 3 0 0 0 R95885-TC $ 70.78 $ 70.78 0 0% 0% 0% 1 0 3 0 0 0 R95886 $ 158.95 $ 158.95 0 0% 0% 0% 1 0 3 0 0 0 R95886-26 $ 78.57 $ 78.57 0 0% 0% 0% 1 0 3 0 0 0 R95886-TC $ 80.37 $ 80.37 0 0% 0% 0% 1 0 3 0 0 0 R95887 $ 142.15 $ 142.15 0 0% 0% 0% 1 0 3 0 0 0 R95887-26 $ 65.38 $ 65.38 0 0% 0% 0% 1 0 3 0 0 0 R95887-TC $ 76.77 $ 76.77 0 0% 0% 0% 1 0 3 0 0 0 R95905 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X95905-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X95905-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X95907 $ 169.14 $ 169.14 0 0% 0% 0% 1 0 0 0 0 0 R95907-26 $ 91.17 $ 91.17 0 0% 0% 0% 1 0 0 0 0 0 R95907-TC $ 77.37 $ 77.37 0 0% 0% 0% 1 0 0 0 0 0 R95908 $ 217.13 $ 217.13 0 0% 0% 0% 1 0 0 0 0 0 R95908-26 $ 115.76 $ 115.76 0 0% 0% 0% 1 0 0 0 0 0 R95908-TC $ 101.97 $ 101.97 0 0% 0% 0% 1 0 0 0 0 0 R95909 $ 257.31 $ 257.31 0 0% 0% 0% 1 0 0 0 0 0 R95909-26 $ 137.95 $ 137.95 0 0% 0% 0% 1 0 0 0 0 0 R95909-TC $ 119.36 $ 119.36 0 0% 0% 0% 1 0 0 0 0 0 R95910 $ 341.89 $ 341.89 0 0% 0% 0% 1 0 0 0 0 0 R95910-26 $ 184.14 $ 184.14 0 0% 0% 0% 1 0 0 0 0 0 R95910-TC $ 157.75 $ 157.75 0 0% 0% 0% 1 0 0 0 0 0 R95911 $ 406.06 $ 406.06 0 0% 0% 0% 1 0 0 0 0 0 R95911-26 $ 229.72 $ 229.72 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 32
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
95911-TC $ 176.34 $ 176.34 0 0% 0% 0% 1 0 0 0 0 0 R95912 $ 452.25 $ 452.25 0 0% 0% 0% 1 0 0 0 0 0 R95912-26 $ 272.31 $ 272.31 0 0% 0% 0% 1 0 0 0 0 0 R95912-TC $ 179.94 $ 179.94 0 0% 0% 0% 1 0 0 0 0 0 R95913 $ 511.63 $ 511.63 0 0% 0% 0% 1 0 0 0 0 0 R95913-26 $ 321.49 $ 321.49 0 0% 0% 0% 1 0 0 0 0 0 R95913-TC $ 190.74 $ 190.74 0 0% 0% 0% 1 0 0 0 0 0 R95921 $ 152.35 $ 152.35 0 0% 0% 0% 1 0 0 0 0 0 R 95921-26 $ 77.97 $ 77.97 0 0% 0% 0% 1 0 0 0 0 0 R 95921-TC $ 74.38 $ 74.38 0 0% 0% 0% 1 0 0 0 0 0 R 95922 $ 175.14 $ 175.14 0 0% 0% 0% 1 0 0 0 0 0 R 95922-26 $ 82.77 $ 82.77 0 0% 0% 0% 1 0 0 0 0 0 R 95922-TC $ 92.37 $ 92.37 0 0% 0% 0% 1 0 0 0 0 0 R 95923 $ 338.29 $ 338.29 0 0% 0% 0% 1 0 0 0 0 0 R 95923-26 $ 78.57 $ 78.57 0 0% 0% 0% 1 0 0 0 0 0 R 95923-TC $ 259.71 $ 259.71 0 0% 0% 0% 1 0 0 0 0 0 R 95924 $ 266.31 $ 266.31 0 0% 0% 0% 1 0 0 0 0 0 R95924-26 $ 151.75 $ 151.75 0 0% 0% 0% 1 0 0 0 0 0 R95924-TC $ 114.56 $ 114.56 0 0% 0% 0% 1 0 0 0 0 0 R95925 $ 277.71 $ 277.71 0 0% 0% 0% 1 0 2 0 0 0 R 95925-26 $ 47.98 $ 47.98 0 0% 0% 0% 1 0 2 0 0 0 R 95925-TC $ 229.72 $ 229.72 0 0% 0% 0% 1 0 2 0 0 0 R 95926 $ 254.32 $ 254.32 0 0% 0% 0% 1 0 2 0 0 0 R 95926-26 $ 46.78 $ 46.78 0 0% 0% 0% 1 0 2 0 0 0 R 95926-TC $ 208.13 $ 208.13 0 0% 0% 0% 1 0 2 0 0 0 R 95927 $ 269.91 $ 269.91 0 0% 0% 0% 1 0 0 0 0 0 R 95927-26 $ 47.38 $ 47.38 0 0% 0% 0% 1 0 0 0 0 0 R 95927-TC $ 222.53 $ 222.53 0 0% 0% 0% 1 0 0 0 0 0 R 95928 $ 455.25 $ 455.25 0 0% 0% 0% 1 0 2 0 0 0 R 95928-26 $ 137.35 $ 137.35 0 0% 0% 0% 1 0 2 0 0 0 R 95928-TC $ 318.49 $ 318.49 0 0% 0% 0% 1 0 2 0 0 0 R 95929 $ 456.45 $ 456.45 0 0% 0% 0% 1 0 2 0 0 0 R 95929-26 $ 135.55 $ 135.55 0 0% 0% 0% 1 0 2 0 0 0 R 95929-TC $ 320.89 $ 320.89 0 0% 0% 0% 1 0 2 0 0 0 R 95930 $ 227.32 $ 227.32 0 0% 0% 0% 1 0 2 0 0 0 R 95930-26 $ 31.79 $ 31.79 0 0% 0% 0% 1 0 2 0 0 0 R 95930-TC $ 196.13 $ 196.13 0 0% 0% 0% 1 0 2 0 0 0 R 95933 $ 146.95 $ 146.95 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 33
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
95933-26 $ 53.38 $ 53.38 0 0% 0% 0% 1 0 0 0 0 0 R 95933-TC $ 93.57 $ 93.57 0 0% 0% 0% 1 0 0 0 0 0 R 95937 $ 145.15 $ 145.15 0 0% 0% 0% 1 0 0 0 0 0 R 95937-26 $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R 95937-TC $ 85.77 $ 85.77 0 0% 0% 0% 1 0 0 0 0 0 R 95938 $ 605.20 $ 605.20 0 0% 0% 0% 1 0 2 0 0 0 R95938-26 $ 77.97 $ 77.97 0 0% 0% 0% 1 0 2 0 0 0 R95938-TC $ 527.22 $ 527.22 0 0% 0% 0% 1 0 2 0 0 0 R95939 $ 885.30 $ 885.30 0 0% 0% 0% 1 0 2 0 0 0 R95939-26 $ 205.73 $ 205.73 0 0% 0% 0% 1 0 2 0 0 0 R95939-TC $ 678.97 $ 678.97 0 0% 0% 0% 1 0 2 0 0 0 R95940 $ 55.18 $ 55.18 0 0% 0% 0% 0 0 0 0 0 0 R95941 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N95943 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N95943-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N95943-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N95950 $ 579.41 $ 579.41 0 0% 0% 0% 1 0 0 0 0 0 R 95950-26 $ 136.15 $ 136.15 0 0% 0% 0% 1 0 0 0 0 0 R 95950-TC $ 443.25 $ 443.25 0 0% 0% 0% 1 0 0 0 0 0 R 95951 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 95951-26 $ 552.42 $ 552.42 0 0% 0% 0% 1 0 0 0 0 0 R 95951-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 95953 $ 732.36 $ 732.36 0 0% 0% 0% 1 0 0 0 0 0 R 95953-26 $ 280.11 $ 280.11 0 0% 0% 0% 1 0 0 0 0 0 R 95953-TC $ 452.85 $ 452.85 0 0% 0% 0% 1 0 0 0 0 0 R 95954 $ 807.93 $ 807.93 0 0% 0% 0% 1 0 0 0 0 0 R 95954-26 $ 212.93 $ 212.93 0 0% 0% 0% 1 0 0 0 0 0 R 95954-TC $ 594.40 $ 594.40 0 0% 0% 0% 1 0 0 0 0 0 R 95955 $ 376.67 $ 376.67 0 0% 0% 0% 1 0 0 0 0 0 R 95955-26 $ 91.77 $ 91.77 0 0% 0% 0% 1 0 0 0 0 0 R 95955-TC $ 284.91 $ 284.91 0 0% 0% 0% 1 0 0 0 0 0 R 95956 $ 2957.61 $ 2957.61 0 0% 0% 0% 1 0 0 0 0 0 R 95956-26 $ 327.49 $ 327.49 0 0% 0% 0% 1 0 0 0 0 0 R 95956-TC $ 2630.12 $ 2630.12 0 0% 0% 0% 1 0 0 0 0 0 R 95957 $ 555.41 $ 555.41 0 0% 0% 0% 1 0 0 0 0 0 R 95957-26 $ 179.94 $ 179.94 0 0% 0% 0% 1 0 0 0 0 0 R 95957-TC $ 375.47 $ 375.47 0 0% 0% 0% 1 0 0 0 0 0 R 95958 $ 1017.26 $ 1017.26 0 0% 0% 0% 1 0 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 34
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
95958-26 $ 382.67 $ 382.67 0 0% 0% 0% 1 0 0 0 0 0 R 95958-TC $ 633.99 $ 633.99 0 0% 0% 0% 1 0 0 0 0 0 R 95961 $ 503.83 $ 503.83 0 0% 0% 0% 1 0 0 0 0 0 R 95961-26 $ 269.31 $ 269.31 0 0% 0% 0% 1 0 0 0 0 0 R 95961-TC $ 235.12 $ 235.12 0 0% 0% 0% 1 0 0 0 0 0 R 95962 $ 445.65 $ 445.65 0 0% 0% 0% 1 0 0 0 0 0 R 95962-26 $ 289.70 $ 289.70 0 0% 0% 0% 1 0 0 0 0 0 R 95962-TC $ 155.35 $ 155.35 0 0% 0% 0% 1 0 0 0 0 0 R 95965 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y95965-26 $ 729.96 $ 729.36 0 0% 0% 0% 1 0 0 0 0 0 R Y95965-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y95966 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y95966-26 $ 368.28 $ 368.28 0 0% 0% 0% 1 0 0 0 0 0 R Y95966-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y95967 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y95967-26 $ 322.09 $ 322.09 0 0% 0% 0% 1 0 0 0 0 0 R Y95967-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y95970 $ 116.96 $ 40.19 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR95971 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 95972 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 95973 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 95974 $ 354.48 $ 277.11 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR95975 $ 190.14 $ 157.15 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR95978 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 95979 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 95980 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 95981 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 95982 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 95990 $ 160.15 $ 160.15 0 0% 0% 0% 5 0 0 0 0 0 R Y-UR95991 $ 212.33 $ 67.18 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR95992 $ 72.58 $ 63.58 0 0% 0% 0% 0 0 0 0 0 0 R Y95999 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 96000 $ 161.95 $ 161.95 0 0% 0% 0% 0 0 2 0 0 0 R 96001 $ 170.34 $ 170.34 0 0% 0% 0% 0 0 2 0 0 0 R 96002 Not Covered Not Covered 0 0% 0% 0% 0 0 2 0 0 0 X 96003 $ 32.99 $ 32.99 0 0% 0% 0% 0 0 2 0 0 0 R Y96004 $ 199.13 $ 199.13 0 0% 0% 0% 2 0 2 0 0 0 R Y96020 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 35
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
96020-26 $ 283.11 $ 283.11 0 0% 0% 0% 1 0 0 0 0 0 R 96020-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 96040 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 96101 $ 134.36 $ 133.16 0 0% 0% 0% 0 0 0 0 0 0 R 96102 $ 110.96 $ 38.99 0 0% 0% 0% 0 0 0 0 0 0 R 96103 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 96105 $ 178.14 $ 178.14 0 0% 0% 0% 0 0 0 0 0 0 R 96110 $ 16.79 $ 16.79 0 0% 0% 0% 9 9 9 9 9 9 R Y96111 $ 217.13 $ 205.13 0 0% 0% 0% 0 0 0 0 0 0 R Y96116 $ 157.15 $ 146.35 0 0% 0% 0% 0 0 0 0 0 0 R 96118 $ 166.14 $ 132.56 0 0% 0% 0% 0 0 0 0 0 0 R 96119 $ 142.15 $ 40.19 0 0% 0% 0% 0 0 0 0 0 0 R 96120 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 96125 $ 200.93 $ 200.93 0 0% 0% 0% 0 5 0 0 0 0 R Y96127 $ 9.00 $ 9.00 0 0% 0% 0% 3 0 0 0 0 0 R96150 $ 36.59 $ 35.99 0 0% 0% 0% 0 0 0 0 0 0 R 96151 $ 34.79 $ 34.19 0 0% 0% 0% 0 0 0 0 0 0 R 96152 $ 32.99 $ 32.39 0 0% 0% 0% 0 0 0 0 0 0 R 96153 $ 7.80 $ 7.20 0 0% 0% 0% 0 0 0 0 0 0 R 96154 $ 32.39 $ 31.79 0 0% 0% 0% 0 0 0 0 0 0 R 96155 $ 38.39 $ 38.39 0 0% 0% 0% 9 9 9 9 9 9 R 96360 $ 101.37 $ 101.37 0 0% 0% 0% 5 0 0 0 0 0 R 96361 $ 26.39 $ 26.39 0 0% 0% 0% 5 0 0 0 0 0 R 96365 $ 122.36 $ 122.36 0 0% 0% 0% 5 0 0 0 0 0 R 96366 $ 32.99 $ 32.99 0 0% 0% 0% 5 0 0 0 0 0 R 96367 $ 52.78 $ 52.78 0 0% 0% 0% 5 0 0 0 0 0 R 96368 $ 35.99 $ 35.99 0 0% 0% 0% 5 0 0 0 0 0 R 96369 $ 345.48 $ 345.48 0 0% 0% 0% 5 0 0 0 0 0 R 96370 $ 26.39 $ 26.39 0 0% 0% 0% 5 0 0 0 0 0 R 96371 $ 160.15 $ 160.15 0 0% 0% 0% 5 0 0 0 0 0 R 96372 $ 44.39 $ 44.39 0 0% 0% 0% 5 0 0 0 0 0 R 96373 $ 34.19 $ 34.19 0 0% 0% 0% 5 0 0 0 0 0 R 96374 $ 100.17 $ 100.17 0 0% 0% 0% 5 0 0 0 0 0 R 96375 $ 39.59 $ 39.59 0 0% 0% 0% 5 0 0 0 0 0 R 96376 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 96379 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 96401 $ 131.36 $ 131.36 0 0% 0% 0% 5 0 0 0 0 0 R 96402 $ 56.98 $ 56.98 0 0% 0% 0% 5 0 0 0 0 0 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 36
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
96405 $ 143.35 $ 50.98 0 0% 0% 0% 0 2 0 1 0 0 R Y96406 $ 208.13 $ 79.17 0 0% 0% 0% 0 2 0 1 0 0 R Y96409 $ 194.34 $ 194.34 0 0% 0% 0% 5 0 0 0 0 0 R 96411 $ 108.56 $ 108.56 0 0% 0% 0% 5 0 0 0 0 0 R 96413 $ 237.52 $ 237.52 0 0% 0% 0% 5 0 0 0 0 0 R 96415 $ 49.18 $ 49.18 0 0% 0% 0% 5 0 0 0 0 0 R 96416 $ 246.52 $ 246.52 0 0% 0% 0% 5 0 0 0 0 0 R 96417 $ 109.76 $ 109.76 0 0% 0% 0% 5 0 0 0 0 0 R 96420 $ 182.34 $ 182.34 0 0% 0% 0% 5 0 0 0 0 0 R Y96422 $ 299.30 $ 299.30 0 0% 0% 0% 5 0 0 0 0 0 R Y96423 $ 138.55 $ 138.55 0 0% 0% 0% 5 0 0 0 0 0 R Y96425 $ 316.69 $ 316.69 0 0% 0% 0% 5 0 0 0 0 0 R Y96440 $ 1509.10 $ 227.92 0 0% 0% 0% 0 0 0 0 0 0 R Y96446 $ 347.88 $ 41.99 0 0% 0% 0% 5 0 0 0 0 0 R Y96450 $ 316.69 $ 136.75 0 0% 0% 0% 0 0 0 0 0 0 R Y96521 $ 242.92 $ 242.92 0 0% 0% 0% 5 0 0 0 0 0 R 96522 Not Covered Not Covered 0 0% 0% 0% 5 0 0 0 0 0 X 96523 $ 43.79 $ 43.79 0 0% 0% 0% 5 0 0 0 0 0 R 96542 $ 209.93 $ 71.38 0 0% 0% 0% 0 0 0 0 0 0 R Y96549 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 96567 Not Covered Not Covered 0 0% 0% 0% 5 0 0 0 0 0 X 96570 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X 96571 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X 96900 $ 36.59 $ 36.59 0 0% 0% 0% 5 0 0 0 0 0 R Y96902 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 96904 Not Covered Not Covered 0 0% 0% 0% 5 0 0 0 0 0 X 96910 $ 127.16 $ 127.16 0 0% 0% 0% 5 0 0 0 0 0 R Y96912 $ 163.15 $ 163.15 0 0% 0% 0% 5 0 0 0 0 0 R Y96913 $ 229.72 $ 229.72 0 0% 0% 0% 5 0 0 0 0 0 R Y96920 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 96921 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 96922 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 96999 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 97001 $ 128.96 $ 128.96 0 0% 0% 0% 0 5 0 0 0 0 R 97002 $ 72.58 $ 72.58 0 0% 0% 0% 0 5 0 0 0 0 R 97003 $ 146.35 $ 146.35 0 0% 0% 0% 0 5 0 0 0 0 R 97004 $ 91.17 $ 91.17 0 0% 0% 0% 0 5 0 0 0 0 R 97005 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 37
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
97006 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 97010 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 97012 $ 27.59 $ 27.59 0 0% 0% 0% 0 5 0 0 0 0 R 97014 $ 27.59 $ 27.59 0 0% 0% 0% 9 9 9 9 9 9 R 97016 $ 33.59 $ 33.59 0 0% 0% 0% 0 5 0 0 0 0 R 97018 $ 19.19 $ 19.19 0 0% 0% 0% 0 5 0 0 0 0 R 97022 $ 40.79 $ 40.79 0 0% 0% 0% 0 5 0 0 0 0 R 97024 $ 10.80 $ 10.80 0 0% 0% 0% 0 5 0 0 0 0 R 97026 $ 10.20 $ 10.20 0 0% 0% 0% 0 5 0 0 0 0 R 97028 $ 12.60 $ 12.60 0 0% 0% 0% 0 5 0 0 0 0 R 97032 $ 32.99 $ 32.99 0 0% 0% 0% 0 5 0 0 0 0 R 97033 Not Covered Not Covered 0 0% 0% 0% 0 5 0 0 0 0 X 97034 $ 31.19 $ 31.19 0 0% 0% 0% 0 5 0 0 0 0 R 97035 $ 21.59 $ 21.59 0 0% 0% 0% 0 5 0 0 0 0 R 97036 $ 58.18 $ 58.18 0 0% 0% 0% 0 5 0 0 0 0 R 97039 $ 18.59 $ 18.59 0 0% 0% 0% 0 0 0 0 0 0 R 97110 $ 55.78 $ 55.78 0 0% 0% 0% 0 5 0 0 0 0 R 97112 $ 58.18 $ 58.18 0 0% 0% 0% 0 5 0 0 0 0 R 97113 $ 74.98 $ 74.98 0 0% 0% 0% 0 5 0 0 0 0 R 97116 $ 49.18 $ 49.18 0 0% 0% 0% 0 5 0 0 0 0 R 97124 $ 45.58 $ 45.58 0 0% 0% 0% 0 5 0 0 0 0 R 97139 $ 25.79 $ 25.79 0 0% 0% 0% 0 0 0 0 0 0 R 97140 $ 51.58 $ 51.58 0 0% 0% 0% 0 5 0 0 0 0 R 97150 $ 29.99 $ 29.99 0 0% 0% 0% 0 5 0 0 0 0 R 97530 $ 60.58 $ 60.58 0 0% 0% 0% 0 5 0 0 0 0 R 97532 $ 46.18 $ 46.18 0 0% 0% 0% 0 0 0 0 0 0 R 97533 $ 50.38 $ 50.38 0 0% 0% 0% 0 5 0 0 0 0 R 97535 $ 60.58 $ 60.58 0 0% 0% 0% 0 5 0 0 0 0 R 97537 $ 52.18 $ 52.18 0 0% 0% 0% 0 5 0 0 0 0 R 97542 $ 52.78 $ 52.78 0 0% 0% 0% 0 5 0 0 0 0 R 97545 $ 145.75 $ 145.75 0 0% 0% 0% 0 0 0 0 0 0 R Y97546 $ 74.38 $ 74.38 0 0% 0% 0% 0 0 0 0 0 0 R Y97597 $ 133.16 $ 40.19 0 0% 0% 0% 0 0 0 0 0 0 R 97598 $ 43.19 $ 19.19 0 0% 0% 0% 0 0 0 0 0 0 R 97602 $ 51.58 $ 51.58 0 0% 0% 0% 9 9 9 9 9 9 R 97605 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y97606 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y97607 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 38
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
97608 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y97610 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X97750 $ 56.98 $ 56.98 0 0% 0% 0% 0 5 0 0 0 0 R 97755 $ 61.78 $ 61.78 0 0% 0% 0% 0 5 0 0 0 0 R 97760 $ 65.98 $ 65.98 0 0% 0% 0% 0 5 0 0 0 0 R 97761 $ 56.98 $ 56.98 0 0% 0% 0% 0 5 0 0 0 0 R 97762 $ 84.57 $ 84.57 0 0% 0% 0% 0 5 0 0 0 0 R 97799 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 97802 $ 59.98 $ 55.78 0 0% 0% 0% 0 0 0 0 0 0 R Y97803 $ 51.58 $ 47.38 0 0% 0% 0% 0 0 0 0 0 0 R Y97804 $ 27.59 $ 26.39 0 0% 0% 0% 0 0 0 0 0 0 R Y97810 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 97811 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 97813 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 97814 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 98925 $ 53.98 $ 40.19 0 0% 0% 0% 0 0 0 0 0 0 R 98926 $ 77.97 $ 61.18 0 0% 0% 0% 0 0 0 0 0 0 R 98927 $ 101.97 $ 80.97 0 0% 0% 0% 0 0 0 0 0 0 R 98928 $ 124.76 $ 101.97 0 0% 0% 0% 0 0 0 0 0 0 R 98929 $ 148.75 $ 122.36 0 0% 0% 0% 0 0 0 0 0 0 R 98940 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 98941 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 98942 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 98943 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 98960 $ 49.18 $ 49.18 0 0% 0% 0% 9 9 9 9 9 9 R 98961 $ 23.99 $ 23.99 0 0% 0% 0% 9 9 9 9 9 9 R 98962 $ 17.39 $ 17.39 0 0% 0% 0% 9 9 9 9 9 9 R 98966 $ 23.99 $ 22.19 0 0% 0% 0% 9 9 9 9 9 9 R 98967 $ 45.58 $ 43.19 0 0% 0% 0% 9 9 9 9 9 9 R 98968 $ 67.78 $ 65.38 0 0% 0% 0% 9 9 9 9 9 9 R 98969 $ 45.58 $ 43.19 0 0% 0% 0% 9 9 9 9 9 9 R 99000 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99001 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99002 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99024 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99026 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99027 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99050 $ 46.78 $ 44.39 0 0% 0% 0% 9 9 9 9 9 9 R
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 39
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
99051 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99053 $ 20.99 $ 20.99 0 0% 0% 0% 9 9 9 9 9 9 R 99056 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y99058 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99060 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 99070 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99071 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99075 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99078 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99080 $ 45.86 $ 45.86 0 0% 0% 0% 9 9 9 9 9 9 F 99082 $ 17.53 $ 17.53 0 0% 0% 0% 0 0 0 0 0 0 F 99090 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99091 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99100 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99116 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99135 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99140 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99143 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99144 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B 99145 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B 99148 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 99149 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 99150 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 99170 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X 99172 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N 99173 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B 99174 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99175 $ 29.99 $ 29.99 0 0% 0% 0% 5 0 0 0 0 0 R 99183 $ 184.74 $ 184.74 0 0% 0% 0% 2 0 0 0 0 0 R Y99184 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X99188 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X99190 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y99191 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y99192 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y99195 $ 177.54 $ 177.54 0 0% 0% 0% 5 0 0 0 0 0 R 99199 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 99500 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99501 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesMedicine
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 40
Medicine FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
99502 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99503 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99504 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99505 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99506 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99507 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99509 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99510 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99511 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99512 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99600 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99601 $ 157.38 $ 157.38 0 0% 0% 0% 9 9 9 9 9 9 F Y99602 $ 66.18 $ 66.18 0 0% 0% 0% 9 9 9 9 9 9 F Y99605 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99606 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 99607 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 1
Professional Services Fee ScheduleCategory II & III
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 2
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSI0001F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0005F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0012F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0014F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0015F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0500F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0501F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0502F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0503F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0505F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0507F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0509F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0513F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0514F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0516F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0517F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0518F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0519F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0520F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0521F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0525F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0526F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0528F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0529F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0535F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0540F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0545F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0550F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0551F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0555F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0556F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0557F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0575F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 0580F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0581F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0582F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0583F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0584F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
CPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 3
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
1000F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1002F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1003F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1004F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1005F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1006F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1007F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1008F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1010F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1011F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1012F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1015F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1018F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1019F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1022F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1026F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1030F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1031F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1032F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1033F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1034F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1035F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1036F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1038F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1039F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1040F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1050F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1052F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1055F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1060F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1061F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1065F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1066F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1070F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1071F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1090F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1091F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1100F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 4
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
1101F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1110F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1111F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1116F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1118F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1119F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1121F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1123F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1124F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1125F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1126F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1127F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1128F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1130F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1134F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1135F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1136F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1137F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1150F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1151F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1152F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1153F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1157F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1158F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1159F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1160F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1170F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1175F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1180F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1181F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1182F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1183F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1200F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1205F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1220F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 1450F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1451F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1460F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 5
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
1461F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1490F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1491F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1493F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1494F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1500F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1501F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1502F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1503F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1504F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T1505F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T2000F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2001F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2002F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2004F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2010F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2014F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2015F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T2016F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T2018F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2019F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2020F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2021F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2022F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2024F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2026F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2027F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2028F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2029F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2030F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2031F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2035F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2040F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2044F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2050F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 2060F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3006F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3008F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 6
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
3011F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3014F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3015F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3016F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3017F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3018F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3019F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3020F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3021F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3022F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3023F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3025F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3027F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3028F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3035F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3037F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3038F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3040F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3042F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3044F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3045F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3046F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3048F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3049F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3050F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3055F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3056F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3060F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3061F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3062F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3066F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3072F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3073F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3074F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3075F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3077F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3078F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3079F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 7
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
3080F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3082F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3083F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3084F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3085F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3088F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3089F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3090F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3091F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3092F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3093F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3095F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3096F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3100F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3110F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3111F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3112F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3115F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3117F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3118F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3119F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3120F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3126F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3130F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3132F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3140F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3141F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3142F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3150F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3155F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3160F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3170F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3200F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3210F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3215F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3216F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3218F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3220F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 8
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
3230F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3250F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3260F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3265F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3266F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3267F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3268F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3269F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3270F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3271F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3272F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3273F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3274F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3278F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3279F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3280F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3281F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3284F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3285F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3288F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3290F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3291F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3292F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3293F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3294F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3300F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3301F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3315F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3316F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3317F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3318F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3319F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3320F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3321F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3322F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3323F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3324F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3325F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 9
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
3328F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3330F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3331F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3340F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3341F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3342F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3343F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3344F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3345F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3350F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3351F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3352F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3353F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3354F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3370F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3372F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3374F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3376F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3378F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3380F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3382F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3384F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3386F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3388F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3390F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3394F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3395F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3450F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3451F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3452F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3455F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3470F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3471F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3472F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3475F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3476F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3490F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3491F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 10
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
3492F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3493F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3494F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3495F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3496F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3497F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3498F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3500F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3502F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3503F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3510F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3511F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3512F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3513F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3514F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3515F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3517F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3520F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3550F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3551F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3552F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3555F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3570F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3572F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3573F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 3650F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3725F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3750F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3751F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3752F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3753F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3754F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3755F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3756F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3757F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3758F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3759F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3760F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 11
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
3761F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3762F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3763F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3775F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T3776F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4000F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4001F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4003F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4004F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4005F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4008F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4010F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4011F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4012F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4013F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4014F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4015F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4016F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4017F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4018F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4019F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4025F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4030F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4033F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4035F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4037F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4040F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4041F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4042F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4043F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4044F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4045F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4046F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4047F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4048F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4049F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4050F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4051F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 12
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
4052F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4053F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4054F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4055F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4056F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4058F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4060F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4062F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4063F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4064F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4065F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4066F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4067F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4069F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4070F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4073F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4075F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4077F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4079F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4084F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4086F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4090F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4095F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4100F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4110F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4115F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4120F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4124F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4130F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4131F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4132F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4133F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4134F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4135F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4136F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4140F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4142F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4144F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 13
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
4145F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4148F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4149F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4150F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4151F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4153F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4155F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4157F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4158F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4159F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4163F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4164F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4165F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4167F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4168F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4169F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4171F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4172F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4174F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4175F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4176F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4177F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4178F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4179F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4180F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4181F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4182F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4185F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4186F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4187F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4188F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4189F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4190F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4191F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4192F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4193F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4194F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4195F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 14
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
4196F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4200F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4201F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4210F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4220F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4221F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4230F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4240F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4242F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4245F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4248F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4250F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4255F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4256F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4260F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4261F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4265F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4266F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4267F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4268F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4269F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4270F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4271F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4274F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4276F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4279F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4280F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4290F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4293F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4300F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4301F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4305F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4306F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4320F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 4322F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4330F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4340F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4350F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 15
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
4450F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4470F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4480F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4481F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4500F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4510F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4525F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4526F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4540F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4541F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4550F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4551F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4552F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4553F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4554F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4555F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4556F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4557F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4558F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4559F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4560F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4561F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4562F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T4563F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T5005F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 5010F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 5015F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 5020F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 5050F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 5060F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 5062F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 5100F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 5200F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T5250F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T5250F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T6005F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 6010F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 6015F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 16
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
6020F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 6030F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 6040F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 6045F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 6070F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T6100F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T6100F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T6101F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T6102F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T6110F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T6150F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T7010F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 7020F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 7025F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T 9001F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T9002F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T9003F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T9004F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T9005F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T9006F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T9007F $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 T0019T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0042T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 0051T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 0052T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 0053T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 0054T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 0055T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 0058T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0071T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0072T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0075T By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 0075T-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 0075T-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 0076T By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 0076T-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 0076T-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N 0085T Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 17
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
0095T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0098T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0099T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0100T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0101T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0102T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0103T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0106T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0107T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0108T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0109T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0110T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0111T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0123T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0126T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0159T Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 0159T-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 0159T-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 0163T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0164T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0165T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0169T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0171T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0172T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0174T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 0175T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N 0178T By Report By Report 0 0% 0% 0% 4 0 0 0 0 0 N 0179T By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N 0180T By Report By Report 0 0% 0% 0% 2 0 0 0 0 0 N 0182T Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X 0184T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0188T Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 0189T Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X 0190T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0191T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X 0195T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y-UR0196T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y-UR0198T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 18
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
0200T Not Covered Not Covered 0 0% 0% 0% 0 0 1 0 0 0 X0201T Not Covered Not Covered 0 0% 0% 0% 0 0 2 0 0 0 X0202T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0205T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N0206T Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X0207T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y0208T By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N0209T By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N0210T By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N0211T By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N0212T By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N0213T By Report By Report 0 0% 0% 0% 0 0 1 0 0 0 N Y-UR0214T By Report By Report 0 0% 0% 0% 0 0 1 0 0 0 N Y-UR0215T By Report By Report 0 0% 0% 0% 0 0 1 0 0 0 N Y-UR0216T By Report By Report 0 0% 0% 0% 0 0 1 0 0 0 N Y-UR0217T By Report By Report 0 0% 0% 0% 0 0 1 0 0 0 N Y-UR0218T By Report By Report 0 0% 0% 0% 0 0 1 0 0 0 N Y-UR0219T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y-UR0220T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y-UR0221T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y-UR0222T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y-UR0223T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0224T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0225T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0228T By Report By Report 0 0% 0% 0% 0 0 1 1 0 0 N Y-UR0229T By Report By Report 0 0% 0% 0% 0 0 1 1 0 0 N Y-UR0230T By Report By Report 0 0% 0% 0% 0 0 1 1 0 0 N Y-UR0231T By Report By Report 0 0% 0% 0% 0 0 1 1 0 0 N Y-UR0232T Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X0233T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0234T By Report By Report 90 0% 0% 0% 0 0 0 0 0 0 N0235T By Report By Report 90 0% 0% 0% 0 0 0 0 0 0 N0236T By Report By Report 90 0% 0% 0% 0 0 0 0 0 0 N0237T By Report By Report 90 0% 0% 0% 0 0 0 0 0 0 N0238T By Report By Report 90 0% 0% 0% 0 0 0 0 0 0 N0240T By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y0240T-26 By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y0240T-TC By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 19
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
0241T By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y0241T-26 By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y0241T-TC By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y0243T Not Covered Not Covered 90 0% 0% 0% 1 0 0 0 0 0 X0243T-26 Not Covered Not Covered 90 0% 0% 0% 1 0 0 0 0 0 X0243T-TC Not Covered Not Covered 90 0% 0% 0% 1 0 0 0 0 0 X0244T Not Covered Not Covered 90 0% 0% 0% 1 0 0 0 0 0 X0244T-26 Not Covered Not Covered 90 0% 0% 0% 1 0 0 0 0 0 X0244T-TC Not Covered Not Covered 90 0% 0% 0% 1 0 0 0 0 0 X0249T By Report By Report 90 0% 0% 0% 0 0 0 0 0 0 N Y0253T Not Covered Not Covered 90 0% 0% 0% 0 0 0 0 0 0 X0254T By Report By Report 90 0% 0% 0% 0 0 0 0 0 0 N Y-UR0255T By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y-UR0255T-26 By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y-UR0255T-TC By Report By Report 90 0% 0% 0% 1 0 0 0 0 0 N Y-UR0262T Not Covered Not Covered 90 0% 0% 0% 0 0 0 0 0 0 X0263T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0264T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0265T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0266T Not Covered Not Covered 90 0% 0% 0% 0 0 0 0 0 0 X0267T Not Covered Not Covered 90 0% 0% 0% 0 0 0 0 0 0 X0268T Not Covered Not Covered 90 0% 0% 0% 0 0 0 0 0 0 X0269T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0270T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0271T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0272T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0273T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0274T Not Covered Not Covered 90 0% 0% 0% 0 0 0 0 0 0 X0275T Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X0278T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0281T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0282T Not Covered Not Covered 0 0% 0% 0% 0 0 1 0 0 0 X0283T Not Covered Not Covered 0 0% 0% 0% 0 0 1 0 0 0 X0284T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0285T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0286T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0287T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0288T By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 20
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
0289T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0290T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0291T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0292T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0293T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0294T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0295T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0296T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0297T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0298T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0299T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0300T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0301T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0302T Not Covered Not Covered 90 0% 0% 0% 0 2 0 1 2 0 X0303T Not Covered Not Covered 90 0% 0% 0% 0 2 0 1 0 0 X0304T Not Covered Not Covered 90 0% 0% 0% 0 2 0 1 0 0 X0305T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0306T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0307T Not Covered Not Covered 90 0% 0% 0% 0 2 0 1 0 0 X0308T Not Covered Not Covered 90 0% 0% 0% 0 2 1 1 0 0 X0309T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0310T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0311T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0312T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0313T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0314T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0315T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0316T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0317T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0329T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0330T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0331T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0332T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0333T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0335T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0336T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0337T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0338T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 21
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
0339T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0340T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0341T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0342T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0345T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0346T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0347T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0348T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0349T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0350T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0351T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0352T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0353T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0354T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0355T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0356T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0357T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0358T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0359T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0360T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0361T Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X0362T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0363T Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X0364T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0365T Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X0366T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0367T Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X0368T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0369T Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X0370T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0371T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0372T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0373T Not Covered Not Covered 90 0% 0% 0% 9 9 9 9 9 9 X0374T Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X0375T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0376T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0377T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0378T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
Professional Services Fee SchedulesCategory II IIIJuly 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 22
Cat II & Cat III FeesDOLLAR VALUE MODIFIERS
FSICPTÒ CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
PRIOR AUTH
0379T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0380T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0381T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0382T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0383T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0384T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0385T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0386T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0387T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0388T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0389T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0390T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X0391T Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 1
Professional Services Fee ScheduleHCPCS Level II
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIA0021 Outside state ambulance serv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A0080 Noninterest escort in non er By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0090 Interest escort in non er By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0100 Nonemergency transport taxi By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0110 Nonemergency transport bus By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0120 Noner transport mini-bus By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0130 Noner transport wheelch van By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0140 Nonemergency transport air By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0160 Noner transport case worker By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0170 Transport parking fees/tolls By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0180 Noner transport lodgng recip By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0190 Noner transport meals recip By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0200 Noner transport lodgng escrt By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0210 Noner transport meals escort By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A0225 Neonatal emergency transport Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A0380 Basic life support mileage Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0382 Basic support routine suppls Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0384 Bls defibrillation supplies Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0390 Advanced life support mileag Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0392 Als defibrillation supplies Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0394 Als iv drug therapy supplies Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0396 Als esophageal intub suppls Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0398 Als routine disposble suppls Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0420 Ambulance waiting 1/2 hr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0422 Ambulance 02 life sustaining Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0424 Extra ambulance attendant Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A0425 Ground mileage $ 13.49 $ 13.49 0 0% 0% 0% 9 9 9 9 9 9 F A0426 Als 1 $ 668.06 $ 668.06 0 0% 0% 0% 9 9 9 9 9 9 F A0427 Als1-emergency $ 693.40 $ 693.40 0 0% 0% 0% 9 9 9 9 9 9 F A0428 Bls $ 364.94 $ 364.94 0 0% 0% 0% 9 9 9 9 9 9 F A0429 Bls-emergency $ 583.92 $ 583.92 0 0% 0% 0% 9 9 9 9 9 9 F A0430 Fixed wing air transport $ 5958.19 $ 5958.19 0 0% 0% 0% 9 9 9 9 9 9 F A0431 Rotary wing air transport $ 6927.25 $ 6927.25 0 0% 0% 0% 9 9 9 9 9 9 F A0432 Pi volunteer ambulance co Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A0433 Als 2 $ 1003.61 $ 1003.61 0 0% 0% 0% 9 9 9 9 9 9 F A0434 Specialty care transport $ 1186.08 $ 1186.08 0 0% 0% 0% 9 9 9 9 9 9 F
HCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 2
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A0435 Fixed wing air mileage $ 33.16 $ 33.16 0 0% 0% 0% 9 9 9 9 9 9 F A0436 Rotary wing air mileage $ 77.05 $ 77.05 0 0% 0% 0% 9 9 9 9 9 9 F A0888 Noncovered ambulance mileage Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A0998 Ambulance response/treatment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A0999 Unlisted ambulance service By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4206 1 cc sterile syringe&needle Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4207 2 cc sterile syringe&needle Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4208 3 cc sterile syringe&needle Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4209 5+ cc sterile syringe&needle Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4210 Nonneedle injection device $ 1804.04 $ 1804.04 0 0% 0% 0% 9 9 9 9 9 9 F YA4211 Supp for self-adm injections Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4212 Non coring needle or stylet Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4213 20+ cc syringe only Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4215 Sterile needle Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4216 Sterile water/saline, 10 ml Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4217 Sterile water/saline, 500 ml Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4218 Sterile saline or water Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4220 Infusion pump refill kit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA4221 Maint drug infus cath per wk $ 24.71 $ 24.71 0 0% 0% 0% 9 9 9 9 9 9 F YA4222 Infusion supplies with pump $ 49.02 $ 49.02 0 0% 0% 0% 9 9 9 9 9 9 F YA4223 Infusion supplies w/o pump By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA4230 Infus insulin pump non needl By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4231 Infusion insulin pump needle By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4232 Syringe w/needle insulin 3cc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4233 Alkalin batt for glucose mon $ 0.58 $ 0.58 0 0% 0% 0% 9 9 9 9 9 9 F A4234 J-cell batt for glucose mon $ 2.50 $ 2.50 0 0% 0% 0% 9 9 9 9 9 9 F A4235 Lithium batt for glucose mon $ 1.06 $ 1.06 0 0% 0% 0% 9 9 9 9 9 9 F A4236 Silvr oxide batt glucose mon $ 1.19 $ 1.19 0 0% 0% 0% 9 9 9 9 9 9 F A4244 Alcohol or peroxide per pint Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4245 Alcohol wipes per box Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4246 Betadine/phisohex solution Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4247 Betadine/iodine swabs/wipes Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4248 Chlorhexidine antisept Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4250 Urine reagent strips/tablets Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4252 Blood ketone test or strip Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4253 Blood glucose/reagent strips Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4255 Glucose monitor platforms $ 4.57 $ 4.57 0 0% 0% 0% 9 9 9 9 9 9 F A4256 Calibrator solution/chips Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4257 Replace lensshield cartridge Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4258 Lancet device each Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 3
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A4259 Lancets per box Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4261 Cervical cap contraceptive Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4262 Temporary tear duct plug Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4263 Permanent tear duct plug Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4264 Intratubal occlusion device Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XA4265 Paraffin Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B YA4266 Diaphragm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4267 Male condom Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4268 Female condom Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4269 Spermicide Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4270 Disposable endoscope sheath Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4280 Brst prsths adhsv attchmnt $ 5.76 $ 5.76 0 0% 0% 0% 9 9 9 9 9 9 F A4281 Replacement breastpump tube Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4282 Replacement breastpump adpt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4283 Replacement breastpump cap Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4284 Replcmnt breast pump shield Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4285 Replcmnt breast pump bottle Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4286 Replcmnt breastpump lok ring Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4290 Sacral nerve stim test lead By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA4300 Cath impl vasc access portal Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4301 Implantable access syst perc Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4305 Drug delivery system >=50 ml Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4306 Drug delivery system <=50 ml Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4310 Insert tray w/o bag/cath Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4311 Catheter w/o bag 2-way latex Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4312 Cath w/o bag 2-way silicone Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4313 Catheter w/bag 3-way Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4314 Cath w/drainage 2-way latex Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4315 Cath w/drainage 2-way silcne Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4316 Cath w/drainage 3-way Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4320 Irrigation tray Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4321 Cath therapeutic irrig agent Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4322 Irrigation syringe Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4326 Male external catheter Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4327 Fem urinary collect dev cup Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4328 Fem urinary collect pouch Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4330 Stool collection pouch Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4331 Extension drainage tubing Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4332 Lube sterile packet Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4333 Urinary cath anchor device Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 4
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A4334 Urinary cath leg strap Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4335 Incontinence supply Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4336 Urethral insert Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 BA4338 Indwelling catheter latex Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4340 Indwelling catheter special Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4344 Cath indw foley 2 way silicn Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4346 Cath indw foley 3 way Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4349 Disposable male external cat Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4351 Straight tip urine catheter Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4352 Coude tip urinary catheter Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4353 Intermittent urinary cath Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4354 Cath insertion tray w/bag Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4355 Bladder irrigation tubing Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4356 Ext ureth clmp or compr dvc Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4357 Bedside drainage bag Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4358 Urinary leg or abdomen bag Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4360 Disposable ext urethral dev Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 BA4361 Ostomy face plate Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4362 Solid skin barrier Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4363 Ostomy clamp, replacement Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4364 Adhesive, liquid or equal Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4366 Ostomy vent Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4367 Ostomy belt Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4368 Ostomy filter Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4369 Skin barrier liquid per oz Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4371 Skin barrier powder per oz Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4372 Skin barrier solid 4x4 equiv Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4373 Skin barrier with flange Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4375 Drainable plastic pch w fcpl Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4376 Drainable rubber pch w fcplt Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4377 Drainable plstic pch w/o fp Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4378 Drainable rubber pch w/o fp Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4379 Urinary plastic pouch w fcpl Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4380 Urinary rubber pouch w fcplt Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4381 Urinary plastic pouch w/o fp Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4382 Urinary hvy plstc pch w/o fp Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4383 Urinary rubber pouch w/o fp Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4384 Ostomy faceplt/silicone ring Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4385 Ost skn barrier sld ext wear Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4387 Ost clsd pouch w att st barr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 5
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A4388 Drainable pch w ex wear barr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4389 Drainable pch w st wear barr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4390 Drainable pch ex wear convex Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4391 Urinary pouch w ex wear barr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4392 Urinary pouch w st wear barr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4393 Urine pch w ex wear bar conv Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4394 Ostomy pouch liq deodorant Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4395 Ostomy pouch solid deodorant Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4396 Peristomal hernia supprt blt Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4397 Irrigation supply sleeve Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4398 Ostomy irrigation bag Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4399 Ostomy irrig cone/cath w brs Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4400 Ostomy irrigation set Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4402 Lubricant per ounce Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4404 Ostomy ring each Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4405 Nonpectin based ostomy paste Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4406 Pectin based ostomy paste Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4407 Ext wear ost skn barr <=4sq" Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4408 Ext wear ost skn barr >4sq" Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4409 Ost skn barr convex <=4 sq i Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4410 Ost skn barr extnd >4 sq Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4411 Ost skn barr extnd =4sq Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4412 Ost pouch drain high output Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4413 2 pc drainable ost pouch Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4414 Ost sknbar w/o conv<=4 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4415 Ost skn barr w/o conv >4 sqi Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4416 Ost pch clsd w barrier/filtr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4417 Ost pch w bar/bltinconv/fltr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4418 Ost pch clsd w/o bar w filtr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4419 Ost pch for bar w flange/flt Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4420 Ost pch clsd for bar w lk fl Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4421 Ostomy supply misc Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4422 Ost pouch absorbent material Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4423 Ost pch for bar w lk fl/fltr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4424 Ost pch drain w bar & filter Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4425 Ost pch drain for barrier fl Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4426 Ost pch drain 2 piece system Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4427 Ost pch drain/barr lk flng/f Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4428 Urine ost pouch w faucet/tap Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4429 Urine ost pouch w bltinconv Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 6
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A4430 Ost urine pch w b/bltin conv Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4431 Ost pch urine w barrier/tapv Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4432 Os pch urine w bar/fange/tap Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4433 Urine ost pch bar w lock fln Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4434 Ost pch urine w lock flng/ft Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4435 1pc ost pch drain hgh output $ 6.41 $ 6.41 0 0% 0% 0% 9 9 9 9 9 9 FA4450 Non-waterproof tape Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4452 Waterproof tape Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4455 Adhesive remover per ounce Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4456 Adhesive remover, wipes Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 BA4458 Reusable enema bag Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4459 Manual pump enema, reusable By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NA4461 Surgicl dress hold non-reuse Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4463 Surgical dress holder reuse Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4465 Non-elastic extremity binder Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4466 Elastic garment/covering Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 BA4470 Gravlee jet washer Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4480 Vabra aspirator Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4481 Tracheostoma filter $ 0.42 $ 0.42 0 0% 0% 0% 9 9 9 9 9 9 F A4483 Moisture exchanger By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4490 Above knee surgical stocking $ 13.95 $ 13.95 0 0% 0% 0% 9 9 9 9 9 9 F A4495 Thigh length surg stocking $ 13.95 $ 13.95 0 0% 0% 0% 9 9 9 9 9 9 F A4500 Below knee surgical stocking $ 10.40 $ 10.40 0 0% 0% 0% 9 9 9 9 9 9 F A4510 Full length surg stocking $ 25.22 $ 25.22 0 0% 0% 0% 9 9 9 9 9 9 F A4520 Incontinence garment anytype Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4550 Surgical trays Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4554 Disposable underpads Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4555 Ca tx e-stim electr/transduc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XA4556 Electrodes, pair Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4557 Lead wires, pair Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4558 Conductive gel or paste Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4559 Coupling gel or paste Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4561 Pessary rubber, any type Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4562 Pessary, non rubber,any type Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4565 Slings $ 8.54 $ 8.54 0 0% 0% 0% 9 9 9 9 9 9 F A4566 Should sling/vest/abrestrain By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NA4570 Splint Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4575 Hyperbaric o2 chamber disps By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4580 Cast supplies (plaster) Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4590 Special casting material Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 7
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A4595 Tens suppl 2 lead per month Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4600 Sleeve, inter limb comp dev By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4601 Lith ion non prosth recharge By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4602 Replace lithium battery 1.5v By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NA4604 Tubing with heating element $ 63.90 $ 63.90 0 0% 0% 0% 9 9 9 9 9 9 F A4605 Trach suction cath close sys $ 18.20 $ 18.20 0 0% 0% 0% 9 9 9 9 9 9 F A4606 Oxygen probe used w oximeter By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA4608 Transtracheal oxygen cath $ 55.63 $ 55.63 0 0% 0% 0% 9 9 9 9 9 9 F A4611 Heavy duty battery $ 479.45 $ 479.45 0 0% 0% 0% 9 9 9 9 9 9 F A4612 Battery cables $ 198.34 $ 198.34 0 0% 0% 0% 9 9 9 9 9 9 F A4613 Battery charger $ 339.37 $ 339.37 0 0% 0% 0% 9 9 9 9 9 9 F A4614 Hand-held pefr meter $ 26.40 $ 26.40 0 0% 0% 0% 9 9 9 9 9 9 F A4615 Cannula nasal $ 0.80 $ 0.80 0 0% 0% 0% 9 9 9 9 9 9 F A4616 Tubing (oxygen) per foot $ 0.07 $ 0.07 0 0% 0% 0% 9 9 9 9 9 9 F A4617 Mouth piece $ 3.44 $ 3.44 0 0% 0% 0% 9 9 9 9 9 9 F A4618 Breathing circuits $ 8.50 $ 8.50 0 0% 0% 0% 9 9 9 9 9 9 F A4619 Face tent $ 2.06 $ 2.06 0 0% 0% 0% 9 9 9 9 9 9 F A4620 Variable concentration mask $ 0.70 $ 0.70 0 0% 0% 0% 9 9 9 9 9 9 F A4623 Tracheostomy inner cannula $ 7.27 $ 7.27 0 0% 0% 0% 9 9 9 9 9 9 F A4624 Tracheal suction tube $ 2.92 $ 2.92 0 0% 0% 0% 9 9 9 9 9 9 F A4625 Trach care kit for new trach $ 7.24 $ 7.24 0 0% 0% 0% 9 9 9 9 9 9 F A4626 Tracheostomy cleaning brush $ 3.54 $ 3.54 0 0% 0% 0% 9 9 9 9 9 9 F A4627 Spacer bag/reservoir $ 48.22 $ 48.22 0 0% 0% 0% 9 9 9 9 9 9 F A4628 Oropharyngeal suction cath $ 4.05 $ 4.05 0 0% 0% 0% 9 9 9 9 9 9 F A4629 Tracheostomy care kit $ 5.13 $ 5.13 0 0% 0% 0% 9 9 9 9 9 9 F A4630 Repl bat t.e.n.s. own by pt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4633 Uvl replacement bulb Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4634 Replacement bulb th lightbox Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4635 Underarm crutch pad $ 5.68 $ 5.68 0 0% 0% 0% 9 9 9 9 9 9 F A4636 Handgrip for cane etc $ 4.03 $ 4.03 0 0% 0% 0% 9 9 9 9 9 9 F A4637 Repl tip cane/crutch/walker $ 1.74 $ 1.74 0 0% 0% 0% 9 9 9 9 9 9 F A4638 Repl batt pulse gen sys Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4639 Infrared ht sys replcmnt pad Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4640 Alternating pressure pad $ 62.90 $ 62.90 0 0% 0% 0% 9 9 9 9 9 9 F A4641 Radiopharm dx agent noc By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A4642 In111 satumomab $ 1599.21 $ 1599.21 0 0% 0% 0% 0 0 0 0 0 0 D YA4648 Implantable tissue marker By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4649 Surgical supplies Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4650 Implant radiation dosimeter By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA4651 Calibrated microcap tube By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 8
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A4652 Microcapillary tube sealant By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4653 Pd catheter anchor belt By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4657 Syringe w/wo needle By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4660 Sphyg/bp app w cuff and stet $ 27.70 $ 27.70 0 0% 0% 0% 9 9 9 9 9 9 F A4663 Dialysis blood pressure cuff $ 53.06 $ 53.06 0 0% 0% 0% 9 9 9 9 9 9 F A4670 Automatic bp monitor, dial Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4671 Disposable cycler set By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4672 Drainage ext line, dialysis By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4673 Ext line w easy lock connect By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4674 Chem/antisept solution, 8oz By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4680 Activated carbon filter, ea $ 137.96 $ 137.96 0 0% 0% 0% 9 9 9 9 9 9 F A4690 Dialyzer, each $ 1367.95 $ 1367.95 0 0% 0% 0% 9 9 9 9 9 9 F YA4706 Bicarbonate conc sol per gal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4707 Bicarbonate conc pow per pac By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4708 Acetate conc sol per gallon By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4709 Acid conc sol per gallon By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4714 Treated water per gallon By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4719 "y set" tubing By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4720 Dialysat sol fld vol > 249cc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4721 Dialysat sol fld vol > 999cc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4722 Dialys sol fld vol > 1999cc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4723 Dialys sol fld vol > 2999cc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4724 Dialys sol fld vol > 3999cc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4725 Dialys sol fld vol > 4999cc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4726 Dialys sol fld vol > 5999cc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4728 Dialysate solution, non-dex By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4730 Fistula cannulation set, ea By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4736 Topical anesthetic, per gram By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4737 Inj anesthetic per 10 ml By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4740 Shunt accessory By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4750 Art or venous blood tubing $ 26.32 $ 26.32 0 0% 0% 0% 9 9 9 9 9 9 F A4755 Comb art/venous blood tubing By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4760 Dialysate sol test kit, each By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4765 Dialysate conc pow per pack By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4766 Dialysate conc sol add 10 ml By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4770 Blood collection tube/vacuum By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4771 Serum clotting time tube By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4772 Blood glucose test strips $ 55.18 $ 55.18 0 0% 0% 0% 9 9 9 9 9 9 F A4773 Occult blood test strips $ 35.00 $ 35.00 0 0% 0% 0% 9 9 9 9 9 9 F A4774 Ammonia test strips By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 9
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A4802 Protamine sulfate per 50 mg $ 9.95 $ 9.95 0 0% 0% 0% 9 9 9 9 9 9 F A4860 Disposable catheter tips By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4870 Plumb/elec wk hm hemo equip By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA4890 Repair/maint cont hemo equip By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N YA4911 Drain bag/bottle By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4913 Misc dialysis supplies noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4918 Venous pressure clamp By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4927 Non-sterile gloves $ 9.82 $ 9.82 0 0% 0% 0% 9 9 9 9 9 9 F A4928 Surgical mask By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A4929 Tourniquet for dialysis, ea $ 0.30 $ 0.30 0 0% 0% 0% 9 9 9 9 9 9 F A4930 Sterile, gloves per pair Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A4931 Reusable oral thermometer Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A4932 Reusable rectal thermometer Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A5051 Pouch clsd w barr attached Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5052 Clsd ostomy pouch w/o barr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5053 Clsd ostomy pouch faceplate Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5054 Clsd ostomy pouch w/flange Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5055 Stoma cap Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5056 1 pc ost pouch w filter Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 BA5057 1 pc ost pou w built-in conv Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 BA5061 Pouch drainable w barrier at Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5062 Drnble ostomy pouch w/o barr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5063 Drain ostomy pouch w/flange Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5071 Urinary pouch w/barrier Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5072 Urinary pouch w/o barrier Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5073 Urinary pouch on barr w/flng Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5081 Stoma plug or seal, any type Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5082 Continent stoma catheter Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5083 Stoma absorptive cover Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5093 Ostomy accessory convex inse Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5102 Bedside drain btl w/wo tube Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5105 Urinary suspensory Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5112 Urinary leg bag Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5113 Latex leg strap Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5114 Foam/fabric leg strap Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5120 Skin barrier, wipe or swab Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5121 Solid skin barrier 6x6 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5122 Solid skin barrier 8x8 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5126 Disk/foam pad +or- adhesive Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A5131 Appliance cleaner Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 10
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A5200 Percutaneous catheter anchor $ 12.53 $ 12.53 0 0% 0% 0% 9 9 9 9 9 9 F A5500 Diab shoe for density insert $ 70.57 $ 70.57 0 0% 0% 0% 9 9 9 9 9 9 F YA5501 Diabetic custom molded shoe $ 211.68 $ 211.68 0 0% 0% 0% 9 9 9 9 9 9 F YA5503 Diabetic shoe w/roller/rockr $ 34.57 $ 34.57 0 0% 0% 0% 9 9 9 9 9 9 F YA5504 Diabetic shoe with wedge $ 34.57 $ 34.57 0 0% 0% 0% 9 9 9 9 9 9 F YA5505 Diab shoe w/metatarsal bar $ 34.57 $ 34.57 0 0% 0% 0% 9 9 9 9 9 9 F YA5506 Diabetic shoe w/off set heel $ 34.57 $ 34.57 0 0% 0% 0% 9 9 9 9 9 9 F YA5507 Modification diabetic shoe $ 34.57 $ 34.57 0 0% 0% 0% 9 9 9 9 9 9 F YA5508 Diabetic deluxe shoe By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA5510 Compression form shoe insert By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA5512 Multi den insert direct form $ 28.79 $ 28.79 0 0% 0% 0% 9 9 9 9 9 9 F YA5513 Multi den insert custom mold $ 42.96 $ 42.96 0 0% 0% 0% 9 9 9 9 9 9 F YA6000 Wound warming wound cover By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA6010 Collagen based wound filler Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6011 Collagen gel/paste wound fil Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6021 Collagen dressing <=16 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6022 Collagen drsg>16<=48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6023 Collagen dressing >48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6024 Collagen dsg wound filler Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6025 Silicone gel sheet, each Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6154 Wound pouch each Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6196 Alginate dressing <=16 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6197 Alginate drsg >16 <=48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6198 Alginate dressing > 48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6199 Alginate drsg wound filler Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6203 Composite drsg <= 16 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6204 Composite drsg >16<=48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6205 Composite drsg > 48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6206 Contact layer <= 16 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6207 Contact layer >16<= 48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6208 Contact layer > 48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6209 Foam drsg <=16 sq in w/o bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6210 Foam drg >16<=48 sq in w/o b Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6211 Foam drg > 48 sq in w/o brdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6212 Foam drg <=16 sq in w/border Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6213 Foam drg >16<=48 sq in w/bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6214 Foam drg > 48 sq in w/border Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6215 Foam dressing wound filler Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6216 Non-sterile gauze<=16 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6217 Non-sterile gauze>16<=48 sq Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 11
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A6218 Non-sterile gauze > 48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6219 Gauze <= 16 sq in w/border Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6220 Gauze >16 <=48 sq in w/bordr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6221 Gauze > 48 sq in w/border Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6222 Gauze <=16 in no w/sal w/o b Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6223 Gauze >16<=48 no w/sal w/o b Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6224 Gauze > 48 in no w/sal w/o b Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6228 Gauze <= 16 sq in water/sal Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6229 Gauze >16<=48 sq in watr/sal Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6230 Gauze > 48 sq in water/salne Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6231 Hydrogel dsg<=16 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6232 Hydrogel dsg>16<=48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6233 Hydrogel dressing >48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6234 Hydrocolld drg <=16 w/o bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6235 Hydrocolld drg >16<=48 w/o b Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6236 Hydrocolld drg > 48 in w/o b Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6237 Hydrocolld drg <=16 in w/bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6238 Hydrocolld drg >16<=48 w/bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6239 Hydrocolld drg > 48 in w/bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6240 Hydrocolld drg filler paste Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6241 Hydrocolloid drg filler dry Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6242 Hydrogel drg <=16 in w/o bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6243 Hydrogel drg >16<=48 w/o bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6244 Hydrogel drg >48 in w/o bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6245 Hydrogel drg <= 16 in w/bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6246 Hydrogel drg >16<=48 in w/b Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6247 Hydrogel drg > 48 sq in w/b Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6248 Hydrogel drsg gel filler Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6250 Skin seal protect moisturizr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6251 Absorpt drg <=16 sq in w/o b Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6252 Absorpt drg >16 <=48 w/o bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6253 Absorpt drg > 48 sq in w/o b Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6254 Absorpt drg <=16 sq in w/bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6255 Absorpt drg >16<=48 in w/bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6256 Absorpt drg > 48 sq in w/bdr Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6257 Transparent film <= 16 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6258 Transparent film >16<=48 in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6259 Transparent film > 48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6260 Wound cleanser any type/size Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6261 Wound filler gel/paste /oz Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 12
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A6262 Wound filler dry form / gram Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6266 Impreg gauze no h20/sal/yard Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6402 Sterile gauze <= 16 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6403 Sterile gauze>16 <= 48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6404 Sterile gauze > 48 sq in Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6407 Packing strips, non-impreg Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6410 Sterile eye pad Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6411 Non-sterile eye pad Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6412 Occlusive eye patch Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6413 Adhesive bandage, first-aid Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6441 Pad band w>=3" <5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6442 Conform band n/s w<3"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6443 Conform band n/s w>=3"<5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6444 Conform band n/s w>=5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6445 Conform band s w <3"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6446 Conform band s w>=3" <5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6447 Conform band s w >=5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6448 Lt compres band <3"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6449 Lt compres band >=3" <5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6450 Lt compres band >=5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
A6451 Mod compres band w>=3"<5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6452 High compres band w>=3"<5"yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6453 Self-adher band w <3"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6454 Self-adher band w>=3" <5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6455 Self-adher band >=5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6456 Zinc paste band w >=3"<5"/yd Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6457 Tubular dressing Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A6501 Compres burngarment bodysuit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6502 Compres burngarment chinstrp By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6503 Compres burngarment facehood By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6504 Cmprsburngarment glove-wrist By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6505 Cmprsburngarment glove-elbow By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6506 Cmprsburngrmnt glove-axilla By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6507 Cmprs burngarment foot-knee By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6508 Cmprs burngarment foot-thigh By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6509 Compres burn garment jacket By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6510 Compres burn garment leotard By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6511 Compres burn garment panty By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6512 Compres burn garment, noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 13
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A6513 Compress burn mask face/neck By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6530 Compression stocking bk18-30 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6531 Compression stocking bk30-40 $ 48.02 $ 48.02 0 0% 0% 0% 9 9 9 9 9 9 F A6532 Compression stocking bk40-50 $ 67.66 $ 67.66 0 0% 0% 0% 9 9 9 9 9 9 F A6533 Gc stocking thighlngth 18-30 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6534 Gc stocking thighlngth 30-40 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6535 Gc stocking thighlngth 40-50 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6536 Gc stocking full lngth 18-30 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6537 Gc stocking full lngth 30-40 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6538 Gc stocking full lngth 40-50 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6539 Gc stocking waistlngth 18-30 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6540 Gc stocking waistlngth 30-40 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6541 Gc stocking waistlngth 40-50 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6544 Gc stocking garter belt By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6545 Grad comp non-elastic bk By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6549 G compression stocking By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A6550 Neg pres wound ther drsg set $ 26.25 $ 26.25 0 0% 0% 0% 9 9 9 9 9 9 F YA7000 Disposable canister for pump $ 9.12 $ 9.12 0 0% 0% 0% 9 9 9 9 9 9 F YA7001 Nondisposable pump canister $ 36.71 $ 36.71 0 0% 0% 0% 9 9 9 9 9 9 F YA7002 Tubing used w suction pump $ 4.25 $ 4.25 0 0% 0% 0% 9 9 9 9 9 9 F A7003 Nebulizer administration set $ 3.05 $ 3.05 0 0% 0% 0% 9 9 9 9 9 9 F A7004 Disposable nebulizer sml vol $ 2.01 $ 2.01 0 0% 0% 0% 9 9 9 9 9 9 F A7005 Nondisposable nebulizer set $ 34.22 $ 34.22 0 0% 0% 0% 9 9 9 9 9 9 F A7006 Filtered nebulizer admin set $ 10.59 $ 10.59 0 0% 0% 0% 9 9 9 9 9 9 F A7007 Lg vol nebulizer disposable $ 5.13 $ 5.13 0 0% 0% 0% 9 9 9 9 9 9 F A7008 Disposable nebulizer prefill $ 12.21 $ 12.21 0 0% 0% 0% 9 9 9 9 9 9 F A7009 Nebulizer reservoir bottle $ 46.67 $ 46.67 0 0% 0% 0% 9 9 9 9 9 9 F A7010 Disposable corrugated tubing $ 26.19 $ 26.19 0 0% 0% 0% 9 9 9 9 9 9 F A7011 Nondispos corrugated tubing $ 58.28 $ 58.28 0 0% 0% 0% 9 9 9 9 9 9 F A7012 Nebulizer water collec devic $ 4.20 $ 4.20 0 0% 0% 0% 9 9 9 9 9 9 F A7013 Disposable compressor filter $ 0.92 $ 0.92 0 0% 0% 0% 9 9 9 9 9 9 F A7014 Compressor nondispos filter $ 4.98 $ 4.98 0 0% 0% 0% 9 9 9 9 9 9 F A7015 Aerosol mask used w nebulize $ 2.09 $ 2.09 0 0% 0% 0% 9 9 9 9 9 9 F A7016 Nebulizer dome & mouthpiece $ 8.04 $ 8.04 0 0% 0% 0% 9 9 9 9 9 9 F A7017 Nebulizer not used w oxygen $ 148.77 $ 148.77 0 0% 0% 0% 9 9 9 9 9 9 F A7018 Water distilled w/nebulizer $ 0.42 $ 0.42 0 0% 0% 0% 9 9 9 9 9 9 F A7020 Interface, cough stim device $ 16.07 $ 16.07 0 0% 0% 0% 9 9 9 9 9 9 FA7025 Replace chest compress vest Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A7026 Replace chst cmprss sys hose Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A7027 Combination oral/nasal mask $ 207.03 $ 207.03 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 14
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A7028 Repl oral cushion combo mask $ 55.00 $ 55.00 0 0% 0% 0% 9 9 9 9 9 9 F A7029 Repl nasal pillow comb mask $ 22.46 $ 22.46 0 0% 0% 0% 9 9 9 9 9 9 F A7030 Cpap full face mask $ 180.47 $ 180.47 0 0% 0% 0% 9 9 9 9 9 9 F A7031 Replacement facemask interfa $ 66.75 $ 66.75 0 0% 0% 0% 9 9 9 9 9 9 F A7032 Replacement nasal cushion $ 38.77 $ 38.77 0 0% 0% 0% 9 9 9 9 9 9 F A7033 Replacement nasal pillows $ 27.18 $ 27.18 0 0% 0% 0% 9 9 9 9 9 9 F A7034 Nasal application device $ 112.53 $ 112.53 0 0% 0% 0% 9 9 9 9 9 9 F A7035 Pos airway press headgear $ 38.01 $ 38.01 0 0% 0% 0% 9 9 9 9 9 9 F A7036 Pos airway press chinstrap $ 17.40 $ 17.40 0 0% 0% 0% 9 9 9 9 9 9 F A7037 Pos airway pressure tubing $ 39.23 $ 39.23 0 0% 0% 0% 9 9 9 9 9 9 F A7038 Pos airway pressure filter $ 5.17 $ 5.17 0 0% 0% 0% 9 9 9 9 9 9 F A7039 Filter, non disposable w pap $ 14.66 $ 14.66 0 0% 0% 0% 9 9 9 9 9 9 F A7040 One way chest drain valve $ 43.82 $ 43.82 0 0% 0% 0% 9 9 9 9 9 9 F A7041 Water seal drain container $ 82.35 $ 82.35 0 0% 0% 0% 9 9 9 9 9 9 F A7044 Pap oral interface $ 115.67 $ 115.67 0 0% 0% 0% 9 9 9 9 9 9 F A7045 Repl exhalation port for pap $ 18.62 $ 18.62 0 0% 0% 0% 9 9 9 9 9 9 F A7046 Repl water chamber, pap dev $ 18.66 $ 18.66 0 0% 0% 0% 9 9 9 9 9 9 F A7047 Resp suction oral interface $ 134.20 $ 134.20 0 0% 0% 0% 9 9 9 9 9 9 FA7048 Vacuum drain bottle/tube kit $ 45.83 $ 45.83 0 0% 0% 0% 9 9 9 9 9 9 FA7501 Tracheostoma valve w diaphra $ 116.57 $ 116.57 0 0% 0% 0% 9 9 9 9 9 9 F A7502 Replacement diaphragm/fplate $ 55.41 $ 55.41 0 0% 0% 0% 9 9 9 9 9 9 F A7503 Hmes filter holder or cap $ 12.59 $ 12.59 0 0% 0% 0% 9 9 9 9 9 9 F A7504 Tracheostoma hmes filter $ 0.75 $ 0.75 0 0% 0% 0% 9 9 9 9 9 9 F A7505 Hmes or trach valve housing $ 5.20 $ 5.20 0 0% 0% 0% 9 9 9 9 9 9 F A7506 Hmes/trachvalve adhesivedisk $ 0.37 $ 0.37 0 0% 0% 0% 9 9 9 9 9 9 F A7507 Integrated filter & holder $ 2.76 $ 2.76 0 0% 0% 0% 9 9 9 9 9 9 F A7508 Housing & integrated adhesiv $ 3.18 $ 3.18 0 0% 0% 0% 9 9 9 9 9 9 F A7509 Heat & moisture exchange sys $ 1.57 $ 1.57 0 0% 0% 0% 9 9 9 9 9 9 F A7520 Trach/laryn tube non-cuffed $ 52.70 $ 52.70 0 0% 0% 0% 9 9 9 9 9 9 F A7521 Trach/laryn tube cuffed $ 52.21 $ 52.21 0 0% 0% 0% 9 9 9 9 9 9 F A7522 Trach/laryn tube stainless $ 50.13 $ 50.13 0 0% 0% 0% 9 9 9 9 9 9 F A7523 Tracheostomy shower protect By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A7524 Tracheostoma stent/stud/bttn $ 85.92 $ 85.92 0 0% 0% 0% 9 9 9 9 9 9 F A7525 Tracheostomy mask $ 2.29 $ 2.29 0 0% 0% 0% 9 9 9 9 9 9 F A7526 Tracheostomy tube collar $ 3.75 $ 3.75 0 0% 0% 0% 9 9 9 9 9 9 F A7527 Trach/laryn tube plug/stop $ 3.98 $ 3.98 0 0% 0% 0% 9 9 9 9 9 9 F A8000 Soft protect helmet prefab $ 170.22 $ 170.22 0 0% 0% 0% 9 9 9 9 9 9 F A8001 Hard protect helmet prefab $ 170.22 $ 170.22 0 0% 0% 0% 9 9 9 9 9 9 F A8002 Soft protect helmet custom By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A8003 Hard protect helmet custom By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 15
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A8004 Repl soft interface, helmet By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A9150 Misc/exper non-prescript dru Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A9152 Single vitamin nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A9153 Multi-vitamin nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A9155 Artificial saliva $ 6.97 $ 6.97 0 0% 0% 0% 9 9 9 9 9 9 D A9180 Lice treatment, topical Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A9270 Non-covered item or service Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A9272 Disp wound suct, drsg/access By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NA9273 Hot/cold h2obot/cap/col/wrap Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 BA9274 Ext amb insulin delivery sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA9275 Disp home glucose monitor By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA9276 Disposable sensor, cgm sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA9277 External transmitter, cgm By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA9278 External receiver, cgm sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA9279 Monitoring feature/devicenoc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA9280 Alert device, noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A9281 Reaching/grabbing device By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A9282 Wig any type Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A9283 Foot press off load supp dev By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A9284 Non-electronic spirometer By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A9300 Exercise equipment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X A9500 Tc99m sestamibi $ 121.70 $ 121.70 0 0% 0% 0% 0 0 0 0 0 0 D A9501 Technetium tc-99m teboroxime By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N YA9502 Tc99m tetrofosmin $ 111.11 $ 111.11 0 0% 0% 0% 0 0 0 0 0 0 D YA9503 Tc99m medronate $ 24.44 $ 24.44 0 0% 0% 0% 0 0 0 0 0 0 D A9504 Tc99m apcitide $ 475.00 $ 475.00 0 0% 0% 0% 0 0 0 0 0 0 D YA9505 Tl201 thallium $ 33.23 $ 33.23 0 0% 0% 0% 0 0 0 0 0 0 D YA9507 In111 capromab $ 3568.78 $ 3568.78 0 0% 0% 0% 0 0 0 0 0 0 D A9508 I131 iodobenguate, dx $ 1325.25 $ 1325.25 0 0% 0% 0% 0 0 0 0 0 0 D A9509 Iodine i-123 sod iodide mil By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9510 Tc99m disofenin $ 54.34 $ 54.34 0 0% 0% 0% 0 0 0 0 0 0 D YA9512 Tc99m pertechnetate $ 13.52 $ 13.52 0 0% 0% 0% 0 0 0 0 0 0 D YA9516 Iodine i-123 sod iodide mic $ 206.17 $ 206.17 0 0% 0% 0% 0 0 0 0 0 0 D A9517 I131 iodide cap, rx By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9520 Tc99 tilmanocept diag 0.5mci $ 270.00 $ 270.00 0 0% 0% 0% 9 9 9 9 9 9 D YA9521 Tc99m exametazime $ 1659.80 $ 1659.80 0 0% 0% 0% 0 0 0 0 0 0 D YA9524 I131 serum albumin, dx $ 308.75 $ 308.75 0 0% 0% 0% 0 0 0 0 0 0 D YA9526 Nitrogen n-13 ammonia By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N YA9527 Iodine i-125 sodium iodide By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9528 Iodine i-131 iodide cap, dx $ 305.58 $ 305.58 0 0% 0% 0% 0 0 0 0 0 0 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 16
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A9529 I131 iodide sol, dx By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9530 I131 iodide sol, rx By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9531 I131 max 100uci By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9532 I125 serum albumin, dx $ 662.36 $ 662.36 0 0% 0% 0% 0 0 0 0 0 0 F A9536 Tc99m depreotide $ 763.80 $ 763.80 0 0% 0% 0% 0 0 0 0 0 0 D YA9537 Tc99m mebrofenin $ 63.06 $ 63.06 0 0% 0% 0% 0 0 0 0 0 0 D YA9538 Tc99m pyrophosphate $ 40.81 $ 40.81 0 0% 0% 0% 0 0 0 0 0 0 D A9539 Tc99m pentetate $ 23.02 $ 23.02 0 0% 0% 0% 0 0 0 0 0 0 D A9540 Tc99m maa $ 22.85 $ 22.85 0 0% 0% 0% 0 0 0 0 0 0 D A9541 Tc99m sulfur colloid By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N YA9542 In111 ibritumomab, dx Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X A9543 Y90 ibritumomab, rx Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X A9544 I131 tositumomab, dx $ 3434.54 $ 3434.54 0 0% 0% 0% 0 0 0 0 0 0 D A9545 I131 tositumomab, rx $ 33129.53 $ 33129.53 0 0% 0% 0% 0 0 0 0 0 0 D A9546 Co57/58 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9547 In111 oxyquinoline $ 2038.46 $ 2038.46 0 0% 0% 0% 0 0 0 0 0 0 D YA9548 In111 pentetate $ 1413.12 $ 1413.12 0 0% 0% 0% 0 0 0 0 0 0 D YA9550 Tc99m gluceptate By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9551 Tc99m succimer $ 683.34 $ 683.34 0 0% 0% 0% 0 0 0 0 0 0 D YA9552 F18 fdg By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9553 Cr51 chromate $ 429.64 $ 429.64 0 0% 0% 0% 0 0 0 0 0 0 D A9554 I125 iothalamate, dx $ 36.27 $ 36.27 0 0% 0% 0% 0 0 0 0 0 0 D YA9555 Rb82 rubidium $ 1751.27 $ 1751.27 0 0% 0% 0% 0 0 0 0 0 0 D A9556 Ga67 gallium $ 320.25 $ 320.25 0 0% 0% 0% 0 0 0 0 0 0 D A9557 Tc99m bicisate $ 426.30 $ 426.30 0 0% 0% 0% 0 0 0 0 0 0 D A9558 Xe133 xenon 10mci $ 88.13 $ 88.13 0 0% 0% 0% 0 0 0 0 0 0 D A9559 Co57 cyano $ 83.94 $ 83.94 0 0% 0% 0% 0 0 0 0 0 0 D A9560 Tc99m labeled rbc $ 106.48 $ 106.48 0 0% 0% 0% 0 0 0 0 0 0 D YA9561 Tc99m oxidronate $ 50.16 $ 50.16 0 0% 0% 0% 0 0 0 0 0 0 D A9562 Tc99m mertiatide $ 588.24 $ 588.24 0 0% 0% 0% 0 0 0 0 0 0 D YA9563 P32 na phosphate $ 1755.21 $ 1755.21 0 0% 0% 0% 0 0 0 0 0 0 D A9564 P32 chromic phosphate $ 332.79 $ 332.79 0 0% 0% 0% 0 0 0 0 0 0 D A9566 Tc99m fanolesomab By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9567 Technetium tc-99m aerosol By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9568 Technetium tc99m arcitumomab $ 1241.18 $ 1241.18 0 0% 0% 0% 0 0 0 0 0 0 D A9569 Technetium tc-99m auto wbc By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9570 Indium in-111 auto wbc $ 4076.93 $ 4076.93 0 0% 0% 0% 0 0 0 0 0 0 D A9571 Indium in-111 auto platelet By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9572 Indium in-111 pentetreotide $ 6470.64 $ 6470.64 0 0% 0% 0% 0 0 0 0 0 0 D A9575 Inj gadoterate meglumi 0.1ml $ 0.59 $ 0.59 0 0% 0% 0% 9 9 9 9 9 9 D Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 17
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
A9576 Inj prohance multipack $ 6.22 $ 6.22 0 0% 0% 0% 9 9 9 9 9 9 D A9577 Inj multihance $ 6.13 $ 6.13 0 0% 0% 0% 9 9 9 9 9 9 D A9578 Inj multihance multipack $ 6.22 $ 6.22 0 0% 0% 0% 9 9 9 9 9 9 D A9579 Gad-base mr contrast nos,1ml By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A9580 Sodium fluoride f-18 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9581 Gadoxetate disodium inj $ 14.74 $ 14.74 0 0% 0% 0% 9 9 9 9 9 9 DA9582 Iodine i-123 iobenguane Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XA9583 Gadofosveset trisodium inj $ 13.13 $ 13.13 0 0% 0% 0% 9 9 9 9 9 9 DA9584 Iodine i-123 ioflupane $ 2566.08 $ 2566.08 0 0% 0% 0% 9 9 9 9 9 9 D YA9585 Gadobutrol injection $ 0.90 $ 0.90 0 0% 0% 0% 9 9 9 9 9 9 DA9585 Gadobutrol injection $ 0.90 $ 0.90 0 0% 0% 0% 9 9 9 9 9 9 DA9586 Florbetapir f18 $ 2808.00 $ 2808.00 90 0% 0% 0% 9 9 9 9 9 9 D YA9599 Radiopha dx beta amyloid pet $ 2808.00 $ 2808.00 0 0% 0% 0% 9 9 9 9 9 9 D YA9600 Sr89 strontium $ 1471.54 $ 1471.54 0 0% 0% 0% 0 0 0 0 0 0 D A9604 Sm 153 lexidronam Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XA9606 Radium ra223 dichloride ther Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XA9698 Non-rad contrast materialnoc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A9699 Radiopharm rx agent noc By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N A9700 Echocardiography contrast By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YA9900 Supply/accessory/service Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B A9901 Delivery/set up/dispensing By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N A9999 Dme supply or accessory, nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N B4034 Enter feed supkit syr by day $ 6.26 $ 6.26 0 0% 0% 0% 9 9 9 9 9 9 F YB4035 Enteral feed supp pump per d $ 11.95 $ 11.95 0 0% 0% 0% 9 9 9 9 9 9 F YB4036 Enteral feed sup kit grav by $ 8.20 $ 8.20 0 0% 0% 0% 9 9 9 9 9 9 F YB4081 Enteral ng tubing w/ stylet $ 22.16 $ 22.16 0 0% 0% 0% 9 9 9 9 9 9 F YB4082 Enteral ng tubing w/o stylet $ 16.47 $ 16.47 0 0% 0% 0% 9 9 9 9 9 9 F YB4083 Enteral stomach tube levine $ 2.53 $ 2.53 0 0% 0% 0% 9 9 9 9 9 9 F YB4087 Gastro/jejuno tube, std $ 36.57 $ 36.57 0 0% 0% 0% 9 9 9 9 9 9 F YB4088 Gastro/jejuno tube, low-pro $ 36.57 $ 36.57 0 0% 0% 0% 9 9 9 9 9 9 F YB4100 Food thickener oral By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YB4102 Ef adult fluids and electro By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YB4103 Ef ped fluid and electrolyte Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X B4104 Additive for enteral formula By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YB4149 Ef blenderized foods $ 1.61 $ 1.61 0 0% 0% 0% 9 9 9 9 9 9 F YB4150 Ef complet w/intact nutrient $ 0.70 $ 0.70 0 0% 0% 0% 9 9 9 9 9 9 F YB4152 Ef calorie dense>/=1.5kcal $ 0.57 $ 0.57 0 0% 0% 0% 9 9 9 9 9 9 F YB4153 Ef hydrolyzed/amino acids $ 1.96 $ 1.96 0 0% 0% 0% 9 9 9 9 9 9 F YB4154 Ef spec metabolic noninherit $ 1.25 $ 1.25 0 0% 0% 0% 9 9 9 9 9 9 F YB4155 Ef incomplete/modular $ 0.97 $ 0.97 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 18
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
B4157 Ef special metabolic inherit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YB4158 Ef ped complete intact nut Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X B4159 Ef ped complete soy based Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X B4160 Ef ped caloric dense>/=0.7kc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X B4161 Ef ped hydrolyzed/amino acid Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X B4162 Ef ped specmetabolic inherit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X B4164 Parenteral 50% dextrose solu $ 19.58 $ 19.58 0 0% 0% 0% 9 9 9 9 9 9 F YB4168 Parenteral sol amino acid 3. $ 28.55 $ 28.55 0 0% 0% 0% 9 9 9 9 9 9 F YB4172 Parenteral sol amino acid 5. $ 111.79 $ 111.79 0 0% 0% 0% 9 9 9 9 9 9 F YB4176 Parenteral sol amino acid 7- $ 55.25 $ 55.25 0 0% 0% 0% 9 9 9 9 9 9 F YB4178 Parenteral sol amino acid > $ 66.32 $ 66.32 0 0% 0% 0% 9 9 9 9 9 9 F YB4180 Parenteral sol carb > 50% $ 28.11 $ 28.11 0 0% 0% 0% 9 9 9 9 9 9 F YB4185 Parenteral sol 10 gm lipids $ 12.95 $ 12.95 0 0% 0% 0% 9 9 9 9 9 9 F YB4189 Parenteral sol amino acid & $ 204.88 $ 204.88 0 0% 0% 0% 9 9 9 9 9 9 F YB4193 Parenteral sol 52-73 gm prot $ 264.73 $ 264.73 0 0% 0% 0% 9 9 9 9 9 9 F YB4197 Parenteral sol 74-100 gm pro $ 322.30 $ 322.30 0 0% 0% 0% 9 9 9 9 9 9 F YB4199 Parenteral sol > 100gm prote $ 368.28 $ 368.28 0 0% 0% 0% 9 9 9 9 9 9 F YB4216 Parenteral nutrition additiv $ 8.90 $ 8.90 0 0% 0% 0% 9 9 9 9 9 9 F YB4220 Parenteral supply kit premix $ 9.23 $ 9.23 0 0% 0% 0% 9 9 9 9 9 9 F YB4222 Parenteral supply kit homemi $ 11.38 $ 11.38 0 0% 0% 0% 9 9 9 9 9 9 F YB4224 Parenteral administration ki $ 28.82 $ 28.82 0 0% 0% 0% 9 9 9 9 9 9 F YB5000 Parenteral sol renal-amirosy $ 13.70 $ 13.70 0 0% 0% 0% 9 9 9 9 9 9 F YB5100 Parenteral sol hepatic-fream $ 5.35 $ 5.35 0 0% 0% 0% 9 9 9 9 9 9 F YB5200 Parenteral sol stres-brnch c By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YB9000-NU Enter infusion pump w/o alrm $ 1256.61 $ 1256.61 0 0% 0% 0% 9 9 9 9 9 9 F YB9000-RR Enter infusion pump w/o alrm $ 115.47 $ 115.47 0 0% 0% 0% 9 9 9 9 9 9 F YB9002-NU Enteral infusion pump w/ ala $ 1256.61 $ 1256.61 0 0% 0% 0% 9 9 9 9 9 9 F YB9002-RR Enteral infusion pump w/ ala $ 121.70 $ 121.70 0 0% 0% 0% 9 9 9 9 9 9 F YB9004-NU Parenteral infus pump portab $ 2908.18 $ 2908.18 0 0% 0% 0% 9 9 9 9 9 9 F YB9004-RR Parenteral infus pump portab $ 460.37 $ 460.37 0 0% 0% 0% 9 9 9 9 9 9 F YB9006-NU Parenteral infus pump statio $ 2908.18 $ 2908.18 0 0% 0% 0% 9 9 9 9 9 9 F YB9006-RR Parenteral infus pump statio $ 460.37 $ 460.37 0 0% 0% 0% 9 9 9 9 9 9 F YB9998 Enteral supp not otherwise c By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YB9999 Parenteral supp not othrws c By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YC1713 Anchor/screw bn/bn,tis/bn Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1714 Cath, trans atherectomy, dir Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1715 Brachytherapy needle Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1716 Brachytx, non-str, gold-198 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C1717 Brachytx, non-str,hdr ir-192 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C1719 Brachytx, ns, non-hdrir-192 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 19
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C1721 Aicd, dual chamber Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1722 Aicd, single chamber Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1724 Cath, trans atherec,rotation Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1725 Cath, translumin non-laser Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1726 Cath, bal dil, non-vascular Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1727 Cath, bal tis dis, non-vas Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1728 Cath, brachytx seed adm Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1729 Cath, drainage Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1730 Cath, ep, 19 or few elect Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1731 Cath, ep, 20 or more elec Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1732 Cath, ep, diag/abl, 3d/vect Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1733 Cath, ep, othr than cool-tip Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1749 Endo, colon, retro imaging Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1750 Cath, hemodialysis,long-term Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1751 Cath, inf, per/cent/midline Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1752 Cath,hemodialysis,short-term Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1753 Cath, intravas ultrasound Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1754 Catheter, intradiscal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1755 Catheter, intraspinal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1756 Cath, pacing, transesoph Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1757 Cath, thrombectomy/embolect Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1758 Catheter, ureteral Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1759 Cath, intra echocardiography Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1760 Closure dev, vasc Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1762 Conn tiss, human(inc fascia) Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1763 Conn tiss, non-human Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1764 Event recorder, cardiac Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1765 Adhesion barrier Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1766 Intro/sheath,strble,non-peel Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1767 Generator, neuro non-recharg Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1768 Graft, vascular Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1769 Guide wire Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1770 Imaging coil, mr, insertable Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1771 Rep dev, urinary, w/sling Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1772 Infusion pump, programmable Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1773 Ret dev, insertable Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1776 Joint device (implantable) Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1777 Lead, aicd, endo single coil Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1778 Lead, neurostimulator Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1779 Lead, pmkr, transvenous vdd Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 20
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C1780 Lens, intraocular (new tech) Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1781 Mesh (implantable) Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1782 Morcellator Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1783 Ocular imp, aqueous drain de Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1784 Ocular dev, intraop, det ret Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1785 Pmkr, dual, rate-resp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1786 Pmkr, single, rate-resp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1787 Patient progr, neurostim Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1788 Port, indwelling, imp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1789 Prosthesis, breast, imp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1813 Prosthesis, penile, inflatab Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1814 Retinal tamp, silicone oil Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1815 Pros, urinary sph, imp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1816 Receiver/transmitter, neuro Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1817 Septal defect imp sys Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1818 Integrated keratoprosthesis Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1819 Tissue localization-excision Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1820 Generator neuro rechg bat sy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C1821 Interspinous implant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C1830 Power bone marrow bx needle Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1840 Telescopic intraocular lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1841 Retinal prosth int/ext comp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1874 Stent, coated/cov w/del sys Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1875 Stent, coated/cov w/o del sy Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1876 Stent, non-coa/non-cov w/del Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1877 Stent, non-coat/cov w/o del Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1878 Matrl for vocal cord Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1880 Vena cava filter Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1881 Dialysis access system Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1882 Aicd, other than sing/dual Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1883 Adapt/ext, pacing/neuro lead Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1884 Embolization protect syst Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1885 Cath, translumin angio laser Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1886 Catheter, ablation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1887 Catheter, guiding Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1888 Endovas non-cardiac abl cath Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1891 Infusion pump,non-prog, perm Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1892 Intro/sheath,fixed,peel-away Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1893 Intro/sheath, fixed,non-peel Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1894 Intro/sheath, non-laser Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 21
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C1895 Lead, aicd, endo dual coil Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1896 Lead, aicd, non sing/dual Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1897 Lead, neurostim test kit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1898 Lead, pmkr, other than trans Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1899 Lead, pmkr/aicd combination Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C1900 Lead, coronary venous Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2614 Probe, perc lumb disc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2615 Sealant, pulmonary, liquid Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2616 Brachytx, non-str,yttrium-90 Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2617 Stent, non-cor, tem w/o del Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2618 Probe/needle, cryo Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2619 Pmkr, dual, non rate-resp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2620 Pmkr, single, non rate-resp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2621 Pmkr, other than sing/dual Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2622 Prosthesis, penile, non-inf Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2623 Cath, translumin, drug-coat Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2624 Wireless pressure sensor Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2625 Stent, non-cor, tem w/del sy Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2626 Infusion pump, non-prog,temp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2627 Cath, suprapubic/cystoscopic Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2628 Catheter, occlusion Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2629 Intro/sheath, laser Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2630 Cath, ep, cool-tip Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2631 Rep dev, urinary, w/o sling Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C2634 Brachytx, non-str, ha, i-125 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2635 Brachytx, non-str, ha, p-103 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2636 Brachy linear, non-str,p-103 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2637 Brachy,non-str,ytterbium-169 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2638 Brachytx, stranded, i-125 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2639 Brachytx, non-stranded,i-125 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2640 Brachytx, stranded, p-103 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2641 Brachytx, non-stranded,p-103 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2642 Brachytx, stranded, c-131 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2643 Brachytx, non-stranded,c-131 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2644 Brachytx cesium-131 chloride Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2698 Brachytx, stranded, nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C2699 Brachytx, non-stranded, nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C5271 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5272 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5273 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 22
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C5274 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5275 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5276 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5277 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5278 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC8900 Mra w/cont, abd Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8901 Mra w/o cont, abd Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8902 Mra w/o fol w/cont, abd Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8903 Mri w/cont, breast, uni Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8904 Mri w/o cont, breast, uni Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8905 Mri w/o fol w/cont, brst, un Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8906 Mri w/cont, breast, bi Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8907 Mri w/o cont, breast, bi Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8908 Mri w/o fol w/cont, breast, Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8909 Mra w/cont, chest Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8910 Mra w/o cont, chest Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8911 Mra w/o fol w/cont, chest Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8912 Mra w/cont, lwr ext Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8913 Mra w/o cont, lwr ext Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8914 Mra w/o fol w/cont, lwr ext Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8918 Mra w/cont, pelvis Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8919 Mra w/o cont, pelvis Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8920 Mra w/o fol w/cont, pelvis Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8921 Tte w or w/o fol w/cont, com Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C8922 Tte w or w/o fol w/cont, f/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C8923 2d tte w or w/o fol w/con,co Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8924 2d tte w or w/o fol w/con,fu Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8925 2d tee w or w/o fol w/con,in Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8926 Tee w or w/o fol w/cont,cong Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C8927 Tee w or w/o fol w/cont, mon Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8928 Tte w or w/o fol w/con,stres Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8929 Tte w or wo fol wcon,doppler Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8930 Tte w or w/o contr, cont ecg Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C8931 Mra, w/dye, spinal canal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8932 Mra, w/o dye, spinal canal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8933 Mra, w/o&w/dye, spinal canal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8934 Mra, w/dye, upper extremity Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8935 Mra, w/o dye, upper extr Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8936 Mra, w/o&w/dye, upper extr Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8957 Prolonged iv inf, req pump Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 23
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C9025 Injection, ramucirumab $ 55.08 $ 55.08 0 0% 0% 0% 9 9 9 9 9 9 DC9026 Injection, vedolizumab $ 17.19 $ 17.19 0 0% 0% 0% 9 9 9 9 9 9 DC9027 Injection, pembrolizumab $ 46.61 $ 46.61 0 0% 0% 0% 9 9 9 9 9 9 D YC9113 Inj pantoprazole sodium, via $ 3.26 $ 3.26 0 0% 0% 0% 9 9 9 9 9 9 D C9121 Injection, argatroban $ 25.53 $ 25.53 0 0% 0% 0% 9 9 9 9 9 9 D C9132 Kcentra, per i.u. $ 2.06 $ 2.06 0 0% 0% 0% 9 9 9 9 9 9 D YC9136 Factor viii (eloctate) $ 2.06 $ 2.06 0 0% 0% 0% 9 9 9 9 9 9 D YC9248 Inj, clevidipine butyrate $ 3.67 $ 3.67 0 0% 0% 0% 9 9 9 9 9 9 D YC9250 Artiss fibrin sealant $ 173.22 $ 173.22 0 0% 0% 0% 9 9 9 9 9 9 DC9254 Injection, lacosamide $ 0.30 $ 0.30 0 0% 0% 0% 9 9 9 9 9 9 DC9257 Bevacizumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9275 Hexaminolevulinate hcl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X YC9285 Patch, lidocaine/tetracaine $ 14.63 $ 14.63 0 0% 0% 0% 9 9 9 9 9 9 DC9290 Inj, bupivacaine liposome $ 1.16 $ 1.16 0 0% 0% 0% 9 9 9 9 9 9 DC9293 Injection, glucarpidase $ 267.89 $ 267.89 0 0% 0% 0% 9 9 9 9 9 9 D YC9349 Fortaderm, fortaderm antimic Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9352 Neuragen nerve guide, per cm Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9353 Neurawrap nerve protector,cm Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9354 Veritas collagen matrix, cm2 Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9355 Neuromatrix nerve cuff, cm Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9356 Tenoglide tendon prot, cm2 Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9358 Surgimend, fetal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9359 Implnt,bon void filler-putty Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9360 Surgimend, neonatal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9361 Neuromend nerve wrap Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9362 Implnt,bon void filler-strip Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9363 Integra meshed bil wound mat Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9364 Porcine implant, permacol Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9399 Unclassified drugs or biolog Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9442 Injection, belinostat $ 32.40 $ 32.40 0 0% 0% 0% 9 9 9 9 9 9 D YC9443 Injection, dalbavancin $ 32.18 $ 32.18 0 0% 0% 0% 9 9 9 9 9 9 DC9444 Injection, oritavancin $ 26.10 $ 26.10 0 0% 0% 0% 9 9 9 9 9 9 DC9445 C-1 esterase, Ruconest Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9446 Inj, tedizolid phosphate $ 1.27 $ 1.27 0 0% 0% 0% 9 9 9 9 9 9 DC9447 Inj, phenylephrine ketorolac Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9448 Oral netupitant palonosetron $ 514.08 $ 514.08 0 0% 0% 0% 9 9 9 9 9 9 DC9449 Inj, blinatumomab $ 98.08 $ 98.08 0 0% 0% 0% 9 9 9 9 9 9 DC9450 Fluocinolone acetonide implt $ 539.78 $ 539.78 0 0% 0% 0% 9 9 9 9 9 9 DC9451 Injection, peramivir $ 1.71 $ 1.71 0 0% 0% 0% 9 9 9 9 9 9 DC9452 Inj, ceftolozane/tazobactam $ 4.48 $ 4.48 0 0% 0% 0% 9 9 9 9 9 9 D
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 24
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C9497 Loxapine, inhalation powder By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YC9600 Perc drug-el cor stent sing Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9601 Perc drug-el cor stent bran Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9602 Perc d-e cor stent ather s Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9603 Perc d-e cor stent ather br Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9604 Perc d-e cor revasc t cabg s Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9605 Perc d-e cor revasc t cabg b Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9606 Perc d-e cor revasc w ami s Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9607 Perc d-e cor revasc chro sin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9608 Perc d-e cor revasc chro add Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9724 Eps stomach plic Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9725 Place endorectal app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C9726 Rxt breast appl place/remov Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C9727 Insert palate implants Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9728 Place device/marker, non pro Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X C9733 Non-ophthalmic fva Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9734 U/s trtmt, not leiomyomata Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9737 Lap esoph augmentation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9739 Cystoscopy prostatic imp 1-3 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9740 Cysto impl 4 or more Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9741 Impl pressure sensor w/angio Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9742 Laryngoscopy with injection Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9800 Dermal filler inj px/suppl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9898 Inpnt stay radiolabeled item Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O C9899 Inpt implant pros dev,no cov Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0120 Periodic oral evaluation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0140 Limit oral eval problm focus $ 68.58 $ 68.58 0 0% 0% 0% 9 9 9 9 9 9 F D0145 Oral evaluation, pt < 3yrs Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0150 Comprehensve oral evaluation $ 80.30 $ 80.30 0 0% 0% 0% 0 0 0 0 0 0 F D0160 Extensv oral eval prob focus $ 142.17 $ 142.17 0 0% 0% 0% 9 9 9 9 9 9 F D0170 Re-eval,est pt,problem focus $ 65.25 $ 65.25 0 0% 0% 0% 9 9 9 9 9 9 F D0171 Re-eval post-op visit $ 68.58 $ 68.58 0 0% 0% 0% 9 9 9 9 9 9 FD0180 Comp periodontal evaluation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0190 Screening of a patient $ 15.89 $ 15.89 0 0% 0% 0% 9 9 9 9 9 9 FD0191 Assessment of a patient $ 15.89 $ 15.89 0 0% 0% 0% 9 9 9 9 9 9 FD0210 Intraor complete film series $ 117.66 $ 117.66 0 0% 0% 0% 9 9 9 9 9 9 F D0220 Intraoral periapical first $ 25.09 $ 25.09 0 0% 0% 0% 9 9 9 9 9 9 F D0230 Intraoral periapical ea add $ 21.76 $ 21.76 0 0% 0% 0% 9 9 9 9 9 9 F D0240 Intraoral occlusal film $ 37.89 $ 37.89 0 0% 0% 0% 0 0 0 0 0 0 F D0250 Extraoral first film $ 59.57 $ 59.57 0 0% 0% 0% 0 0 0 0 0 0 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 25
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D0260 Extraoral ea additional film $ 51.03 $ 51.03 0 0% 0% 0% 0 0 0 0 0 0 F D0270 Dental bitewing single image $ 25.09 $ 25.09 0 0% 0% 0% 0 0 0 0 0 0 F D0272 Dental bitewings two images $ 40.70 $ 40.70 0 0% 0% 0% 0 0 0 0 0 0 F D0273 Bitewings - three images $ 51.03 $ 51.03 0 0% 0% 0% 9 9 9 9 9 9 F D0274 Bitewings four images $ 59.38 $ 59.38 0 0% 0% 0% 0 0 0 0 0 0 F D0277 Vert bitewings 7 to 8 images $ 88.94 $ 88.94 0 0% 0% 0% 9 9 9 9 9 9 F D0290 Skull/facial bone image $ 124.85 $ 124.85 0 0% 0% 0% 9 9 9 9 9 9 F D0310 Dental saliography Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0320 Dental tmj arthrogram incl i $ 523.06 $ 523.06 0 0% 0% 0% 9 9 9 9 9 9 F D0321 Other tmj images by report $ 185.08 $ 185.08 0 0% 0% 0% 9 9 9 9 9 9 F D0322 Dental tomographic survey $ 465.12 $ 465.12 0 0% 0% 0% 9 9 9 9 9 9 F D0330 Panoramic image $ 98.45 $ 98.45 0 0% 0% 0% 9 9 9 9 9 9 F D0340 Cephalometric image $ 109.79 $ 109.79 0 0% 0% 0% 9 9 9 9 9 9 F YD0350 Oral/facial photo images $ 66.09 $ 66.09 0 0% 0% 0% 9 9 9 9 9 9 F D0351 3d photographic image Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XD0364 Cone beam ct capt & interp $ 335.38 $ 335.38 0 0% 0% 0% 9 9 9 9 9 9 FD0365 Cone beam ct interprete man $ 346.80 $ 346.80 0 0% 0% 0% 9 9 9 9 9 9 FD0366 Cone beam ct interprete max $ 328.85 $ 328.85 0 0% 0% 0% 9 9 9 9 9 9 FD0367 Cone beam ct interp both jaw $ 350.06 $ 350.06 0 0% 0% 0% 9 9 9 9 9 9 FD0368 Cone beam ct interprete tmj $ 345.17 $ 345.17 0 0% 0% 0% 9 9 9 9 9 9 FD0369 Max mri capture & interprete $ 372.10 $ 372.10 0 0% 0% 0% 9 9 9 9 9 9 FD0370 Max ultrasound capt & interp $ 370.46 $ 370.46 0 0% 0% 0% 9 9 9 9 9 9 FD0371 Sialoendoscopy capt & interp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XD0380 Cone beam ct capture limited $ 306.00 $ 306.00 0 0% 0% 0% 9 9 9 9 9 9 FD0381 Cone beam ct capt mandible $ 342.72 $ 342.72 0 0% 0% 0% 9 9 9 9 9 9 FD0382 Cone beam ct capt maxilla $ 345.17 $ 345.17 0 0% 0% 0% 9 9 9 9 9 9 FD0383 Cone beam ct both jaws $ 332.93 $ 332.93 0 0% 0% 0% 9 9 9 9 9 9 FD0384 Cone beam ct capture tmj $ 320.69 $ 320.69 0 0% 0% 0% 9 9 9 9 9 9 FD0385 Max mri image capture $ 370.46 $ 370.46 0 0% 0% 0% 9 9 9 9 9 9 FD0386 Max ultrasound image capture $ 363.94 $ 363.94 0 0% 0% 0% 9 9 9 9 9 9 FD0391 Imterprete diagnostic image $ 205.63 $ 205.63 0 0% 0% 0% 9 9 9 9 9 9 FD0393 Trtmnt simulation 3d image By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YD0394 Digital sub 2 or more images $ 230.11 $ 230.11 0 0% 0% 0% 9 9 9 9 9 9 F YD0395 Fusion 2 or more 3d images $ 247.25 $ 247.25 0 0% 0% 0% 9 9 9 9 9 9 F YD0415 Collection of microorganisms Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0416 Viral culture Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0417 Collect & prep saliva sample Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0418 Analysis of saliva sample Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0421 Gen tst suscept oral disease Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0425 Caries susceptibility test Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 26
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D0431 Diag tst detect mucos abnorm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0460 Pulp vitality test $ 51.03 $ 51.03 0 0% 0% 0% 0 0 0 0 0 0 F D0470 Diagnostic casts $ 102.98 $ 102.98 0 0% 0% 0% 9 9 9 9 9 9 F D0472 Gross exam, prep & report Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0473 Micro exam, prep & report Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0474 Micro w exam of surg margins Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0475 Decalcification procedure Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0476 Spec stains for microorganis Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0477 Spec stains not for microorg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0478 Immunohistochemical stains Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0479 Tissue in-situ hybridization Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0480 Cytopath smear prep & report Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0481 Electron microscopy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0482 Direct immunofluorescence Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0483 Indirect immunofluorescence Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0484 Consult slides prep elsewher Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0485 Consult inc prep of slides Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0486 Access of transep cytol samp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D0502 Other oral pathology procedu $ 147.23 $ 147.23 0 0% 0% 0% 0 0 0 0 0 0 F D0601 Caries risk assess low risk $ 54.67 $ 54.67 0 0% 0% 0% 9 9 9 9 9 9 F YD0602 Caries risk assess mod risk $ 53.04 $ 53.04 0 0% 0% 0% 9 9 9 9 9 9 F YD0603 Caries risk assess high risk $ 53.04 $ 53.04 0 0% 0% 0% 9 9 9 9 9 9 F YD0999 Unspecified diagnostic proce By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N YD1110 Dental prophylaxis adult $ 81.98 $ 81.98 0 0% 0% 0% 9 9 9 9 9 9 F D1120 Dental prophylaxis child Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D1206 Topical fluoride varnish Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D1208 Topical app fluorid ex vrnsh Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XD1310 Nutri counsel-control caries Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B D1320 Tobacco counseling Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B D1330 Oral hygiene instruction Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B D1351 Dental sealant per tooth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D1352 Prev resin rest, perm tooth $ 89.51 $ 89.51 0 0% 0% 0% 9 9 9 9 9 9 F YD1353 Sealant repair per tooth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XD1510 Space maintainer fxd unilat $ 285.93 $ 285.93 0 0% 0% 0% 0 0 0 0 0 0 F D1515 Fixed bilat space maintainer $ 385.55 $ 385.55 0 0% 0% 0% 0 0 0 0 0 0 F D1520 Remove unilat space maintain $ 350.25 $ 350.25 0 0% 0% 0% 0 0 0 0 0 0 F D1525 Remove bilat space maintain $ 439.79 $ 439.79 0 0% 0% 0% 0 0 0 0 0 0 F D1550 Recement space maintainer $ 78.63 $ 78.63 0 0% 0% 0% 0 0 0 0 0 0 F D1555 Remove fix space maintainer $ 71.10 $ 71.10 0 0% 0% 0% 9 9 9 9 9 9 F D1999 Unspecified preventive proc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 27
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D2140 Amalgam one surface permanen $ 126.94 $ 126.94 0 0% 0% 0% 9 9 9 9 9 9 F D2150 Amalgam two surfaces permane $ 161.50 $ 161.50 0 0% 0% 0% 9 9 9 9 9 9 F D2160 Amalgam three surfaces perma $ 199.63 $ 199.63 0 0% 0% 0% 9 9 9 9 9 9 F D2161 Amalgam 4 or > surfaces perm $ 233.44 $ 233.44 0 0% 0% 0% 9 9 9 9 9 9 F D2330 Resin one surface-anterior $ 147.23 $ 147.23 0 0% 0% 0% 9 9 9 9 9 9 F D2331 Resin two surfaces-anterior $ 181.69 $ 181.69 0 0% 0% 0% 9 9 9 9 9 9 F D2332 Resin three surfaces-anterio $ 227.49 $ 227.49 0 0% 0% 0% 9 9 9 9 9 9 F D2335 Resin 4/> surf or w incis an $ 282.45 $ 282.45 0 0% 0% 0% 9 9 9 9 9 9 F D2390 Ant resin-based cmpst crown $ 411.77 $ 411.77 0 0% 0% 0% 9 9 9 9 9 9 F D2391 Post 1 srfc resinbased cmpst $ 163.16 $ 163.16 0 0% 0% 0% 9 9 9 9 9 9 F D2392 Post 2 srfc resinbased cmpst $ 211.43 $ 211.43 0 0% 0% 0% 9 9 9 9 9 9 F D2393 Post 3 srfc resinbased cmpst $ 262.09 $ 262.09 0 0% 0% 0% 9 9 9 9 9 9 F D2394 Post >=4srfc resinbase cmpst $ 312.02 $ 312.02 0 0% 0% 0% 9 9 9 9 9 9 F D2410 Dental gold foil one surface Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2420 Dental gold foil two surface Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2430 Dental gold foil three surfa Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2510 Dental inlay metalic 1 surf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2520 Dental inlay metallic 2 surf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2530 Dental inlay metl 3/more sur Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2542 Dental onlay metallic 2 surf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2543 Dental onlay metallic 3 surf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2544 Dental onlay metl 4/more sur Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2610 Inlay porcelain/ceramic 1 su Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2620 Inlay porcelain/ceramic 2 su Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2630 Dental onlay porc 3/more sur Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2642 Dental onlay porcelin 2 surf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2643 Dental onlay porcelin 3 surf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2644 Dental onlay porc 4/more sur Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2650 Inlay composite/resin one su Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2651 Inlay composite/resin two su Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2652 Dental inlay resin 3/mre sur Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2662 Dental onlay resin 2 surface Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2663 Dental onlay resin 3 surface Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2664 Dental onlay resin 4/mre sur Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D2710 Crown resin-based indirect $ 872.61 $ 872.61 0 0% 0% 0% 9 9 9 9 9 9 F YD2712 Crown 3/4 resin-based compos $ 931.79 $ 931.79 0 0% 0% 0% 9 9 9 9 9 9 F YD2720 Crown resin w/ high noble me $ 958.81 $ 958.81 0 0% 0% 0% 9 9 9 9 9 9 F YD2721 Crown resin w/ base metal $ 914.97 $ 914.97 0 0% 0% 0% 9 9 9 9 9 9 F YD2722 Crown resin w/ noble metal $ 930.04 $ 930.04 0 0% 0% 0% 9 9 9 9 9 9 F YD2740 Crown porcelain/ceramic subs $ 1038.53 $ 1038.53 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 28
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D2750 Crown porcelain w/ h noble m $ 1009.96 $ 1009.96 0 0% 0% 0% 9 9 9 9 9 9 F YD2751 Crown porcelain fused base m $ 930.12 $ 930.12 0 0% 0% 0% 9 9 9 9 9 9 F YD2752 Crown porcelain w/ noble met $ 951.28 $ 951.28 0 0% 0% 0% 9 9 9 9 9 9 F YD2780 Crown 3/4 cast hi noble met $ 959.65 $ 959.65 0 0% 0% 0% 9 9 9 9 9 9 F YD2781 Crown 3/4 cast base metal $ 930.12 $ 930.12 0 0% 0% 0% 9 9 9 9 9 9 F YD2782 Crown 3/4 cast noble metal $ 936.98 $ 936.98 0 0% 0% 0% 9 9 9 9 9 9 F YD2783 Crown 3/4 porcelain/ceramic $ 986.87 $ 986.87 0 0% 0% 0% 9 9 9 9 9 9 F YD2790 Crown full cast high noble m $ 1014.69 $ 1014.69 0 0% 0% 0% 9 9 9 9 9 9 F YD2791 Crown full cast base metal $ 930.70 $ 930.70 0 0% 0% 0% 9 9 9 9 9 9 F YD2792 Crown full cast noble metal $ 930.12 $ 930.12 0 0% 0% 0% 9 9 9 9 9 9 F YD2794 Crown-titanium $ 980.99 $ 980.99 0 0% 0% 0% 9 9 9 9 9 9 F YD2799 Provisional crown $ 401.60 $ 401.60 0 0% 0% 0% 9 9 9 9 9 9 F YD2910 Recement inlay onlay or part $ 100.47 $ 100.47 0 0% 0% 0% 9 9 9 9 9 9 F D2915 Recement cast or prefab post $ 104.69 $ 104.69 0 0% 0% 0% 9 9 9 9 9 9 F D2920 Re-cement or re-bond crown $ 97.12 $ 97.12 0 0% 0% 0% 9 9 9 9 9 9 F D2921 Reattach tooth fragment $ 279.89 $ 279.89 0 0% 0% 0% 9 9 9 9 9 9 F YD2929 Prefab porc/ceram crown pri $ 349.25 $ 349.25 0 0% 0% 0% 9 9 9 9 9 9 F YD2930 Prefab stnlss steel crwn pri $ 240.66 $ 240.66 0 0% 0% 0% 9 9 9 9 9 9 F D2931 Prefab stnlss steel crown pe $ 293.45 $ 293.45 0 0% 0% 0% 9 9 9 9 9 9 F D2932 Prefabricated resin crown $ 317.09 $ 317.09 0 0% 0% 0% 9 9 9 9 9 9 F D2933 Prefab stainless steel crown $ 330.59 $ 330.59 0 0% 0% 0% 9 9 9 9 9 9 F D2934 Prefab steel crown primary $ 331.43 $ 331.43 0 0% 0% 0% 9 9 9 9 9 9 F D2940 Protective restoration $ 110.63 $ 110.63 0 0% 0% 0% 9 9 9 9 9 9 F D2941 Int therapeutic restoration Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XD2949 Restorative foundation $ 213.79 $ 213.79 0 0% 0% 0% 9 9 9 9 9 9 F YD2950 Core build-up incl any pins $ 240.66 $ 240.66 0 0% 0% 0% 9 9 9 9 9 9 F D2951 Tooth pin retention $ 67.25 $ 67.25 0 0% 0% 0% 9 9 9 9 9 9 F D2952 Post and core cast + crown $ 377.15 $ 377.15 0 0% 0% 0% 9 9 9 9 9 9 F YD2953 Each addtnl cast post $ 292.62 $ 292.62 0 0% 0% 0% 9 9 9 9 9 9 F YD2954 Prefab post/core + crown $ 301.01 $ 301.01 0 0% 0% 0% 9 9 9 9 9 9 F YD2955 Post removal $ 266.26 $ 266.26 0 0% 0% 0% 9 9 9 9 9 9 F D2957 Each addtnl prefab post $ 188.59 $ 188.59 0 0% 0% 0% 9 9 9 9 9 9 F YD2960 Laminate labial veneer $ 603.08 $ 603.08 0 0% 0% 0% 9 9 9 9 9 9 F YD2961 Lab labial veneer resin $ 909.87 $ 909.87 0 0% 0% 0% 9 9 9 9 9 9 F YD2962 Lab labial veneer porcelain $ 1046.09 $ 1046.09 0 0% 0% 0% 9 9 9 9 9 9 F YD2970 Temp crown (fractured tooth) $ 351.08 $ 351.08 0 0% 0% 0% 9 9 9 9 9 9 F D2971 Add proc construct new crown $ 203.90 $ 203.90 0 0% 0% 0% 9 9 9 9 9 9 F YD2975 Coping $ 543.73 $ 543.73 0 0% 0% 0% 9 9 9 9 9 9 F YD2980 Crown repair $ 268.77 $ 268.77 0 0% 0% 0% 9 9 9 9 9 9 F YD2981 Inlay repair Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 29
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D2982 Onlay repair Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XD2983 Veneer repair $ 290.50 $ 290.50 0 0% 0% 0% 9 9 9 9 9 9 F YD2990 Resin infiltration of lesion $ 174.62 $ 174.62 0 0% 0% 0% 9 9 9 9 9 9 F YD2999 Dental unspec restorative pr By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N YD3110 Pulp cap direct $ 74.45 $ 74.45 0 0% 0% 0% 9 9 9 9 9 9 F D3120 Pulp cap indirect $ 76.12 $ 76.12 0 0% 0% 0% 9 9 9 9 9 9 F D3220 Therapeutic pulpotomy $ 178.30 $ 178.30 0 0% 0% 0% 9 9 9 9 9 9 F D3221 Gross pulpal debridement $ 211.43 $ 211.43 0 0% 0% 0% 9 9 9 9 9 9 F D3222 Part pulp for apexogenesis Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D3230 Pulpal therapy anterior prim Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D3240 Pulpal therapy posterior pri Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D3310 End thxpy, anterior tooth $ 651.26 $ 651.26 0 0% 0% 0% 9 9 9 9 9 9 F D3320 End thxpy, bicuspid tooth $ 755.17 $ 755.17 0 0% 0% 0% 9 9 9 9 9 9 F D3330 End thxpy, molar $ 914.97 $ 914.97 0 0% 0% 0% 9 9 9 9 9 9 F D3331 Non-surg tx root canal obs $ 568.20 $ 568.20 0 0% 0% 0% 9 9 9 9 9 9 F D3332 Incomplete endodontic tx $ 405.00 $ 405.00 0 0% 0% 0% 9 9 9 9 9 9 F D3333 Internal root repair $ 320.42 $ 320.42 0 0% 0% 0% 9 9 9 9 9 9 F D3346 Retreat root canal anterior $ 777.08 $ 777.08 0 0% 0% 0% 9 9 9 9 9 9 F YD3347 Retreat root canal bicuspid $ 876.00 $ 876.00 0 0% 0% 0% 9 9 9 9 9 9 F YD3348 Retreat root canal molar $ 1049.53 $ 1049.53 0 0% 0% 0% 9 9 9 9 9 9 F YD3351 Apexification/recalc initial $ 347.62 $ 347.62 0 0% 0% 0% 9 9 9 9 9 9 F D3352 Apexification/recalc interim $ 240.13 $ 240.13 0 0% 0% 0% 9 9 9 9 9 9 F D3353 Apexification/recalc final $ 494.50 $ 494.50 0 0% 0% 0% 9 9 9 9 9 9 F D3355 Pulpal regeneration initial $ 390.86 $ 390.86 0 0% 0% 0% 9 9 9 9 9 9 F YD3356 Pulpal regeneration interim $ 235.01 $ 235.01 0 0% 0% 0% 9 9 9 9 9 9 F YD3357 Pulpal regeneration complete By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YD3410 Apicoectomy - anterior $ 634.15 $ 634.15 0 0% 0% 0% 9 9 9 9 9 9 F D3421 Root surgery bicuspid $ 705.23 $ 705.23 0 0% 0% 0% 9 9 9 9 9 9 F D3425 Root surgery molar $ 803.22 $ 803.22 0 0% 0% 0% 9 9 9 9 9 9 F D3426 Root surgery ea add root $ 385.55 $ 385.55 0 0% 0% 0% 9 9 9 9 9 9 F D3427 Periradicular surgery $ 663.41 $ 663.41 0 0% 0% 0% 9 9 9 9 9 9 F YD3428 Bone graft peri per tooth $ 533.66 $ 533.66 0 0% 0% 0% 9 9 9 9 9 9 F YD3429 Bone graft peri each addl $ 452.88 $ 452.88 0 0% 0% 0% 9 9 9 9 9 9 F YD3430 Retrograde filling $ 256.98 $ 256.98 0 0% 0% 0% 9 9 9 9 9 9 F D3431 Biological materials $ 465.94 $ 465.94 0 0% 0% 0% 9 9 9 9 9 9 F YD3432 Guided tissue regeneration $ 520.61 $ 520.61 0 0% 0% 0% 9 9 9 9 9 9 F YD3450 Root amputation $ 446.49 $ 446.49 0 0% 0% 0% 9 9 9 9 9 9 F D3460 Endodontic endosseous implan $ 1380.67 $ 1380.67 0 0% 0% 0% 0 0 0 0 0 0 F D3470 Intentional replantation $ 729.65 $ 729.65 0 0% 0% 0% 9 9 9 9 9 9 F D3910 Isolation- tooth w rubb dam Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 30
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D3920 Tooth splitting $ 422.94 $ 422.94 0 0% 0% 0% 9 9 9 9 9 9 F YD3950 Canal prep/fitting of dowel $ 243.55 $ 243.55 0 0% 0% 0% 9 9 9 9 9 9 F D3999 Endodontic procedure By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N YD4210 Gingivectomy/plasty 4 or mor $ 570.71 $ 570.71 0 0% 0% 0% 9 9 9 9 9 9 F YD4211 Gingivectomy/plasty 1 to 3 $ 280.78 $ 280.78 0 0% 0% 0% 9 9 9 9 9 9 F YD4212 Gingivectomy/plasty rest $ 275.81 $ 275.81 0 0% 0% 0% 9 9 9 9 9 9 F YD4230 Ana crown exp 4 or> per quad $ 676.54 $ 676.54 0 0% 0% 0% 9 9 9 9 9 9 F D4231 Ana crown exp 1-3 per quad $ 541.18 $ 541.18 0 0% 0% 0% 9 9 9 9 9 9 F D4240 Gingival flap proc w/ planin $ 676.54 $ 676.54 0 0% 0% 0% 9 9 9 9 9 9 F YD4241 Gngvl flap w rootplan 1-3 th $ 570.71 $ 570.71 0 0% 0% 0% 9 9 9 9 9 9 F YD4245 Apically positioned flap $ 740.93 $ 740.93 0 0% 0% 0% 9 9 9 9 9 9 F YD4249 Crown lengthen hard tissue $ 701.04 $ 701.04 0 0% 0% 0% 9 9 9 9 9 9 F YD4260 Osseous surgery 4 or more $ 1011.34 $ 1011.34 0 0% 0% 0% 0 0 0 0 0 0 F YD4261 Osseous surg 1 to 3 teeth $ 807.66 $ 807.66 0 0% 0% 0% 9 9 9 9 9 9 F YD4263 Bone replce graft first site $ 648.47 $ 648.47 0 0% 0% 0% 0 0 0 0 0 0 F YD4264 Bone replce graft each add $ 515.88 $ 515.88 0 0% 0% 0% 0 0 0 0 0 0 F YD4265 Bio mtrls to aid soft/os reg $ 510.86 $ 510.86 0 0% 0% 0% 9 9 9 9 9 9 F YD4266 Guided tiss regen resorble $ 740.11 $ 740.11 0 0% 0% 0% 9 9 9 9 9 9 F YD4267 Guided tiss regen nonresorb $ 877.66 $ 877.66 0 0% 0% 0% 9 9 9 9 9 9 F YD4268 Surgical revision procedure $ 740.93 $ 740.93 0 0% 0% 0% 9 9 9 9 9 9 F YD4270 Pedicle soft tissue graft pr $ 761.40 $ 761.40 0 0% 0% 0% 0 0 0 0 0 0 F YD4273 Subepithelial tissue graft $ 1018.16 $ 1018.16 0 0% 0% 0% 0 0 0 0 0 0 F YD4274 Distal/proximal wedge proc $ 603.80 $ 603.80 0 0% 0% 0% 9 9 9 9 9 9 F YD4275 Soft tissue allograft $ 911.47 $ 911.47 0 0% 0% 0% 9 9 9 9 9 9 F YD4276 Con tissue w dble ped graft $ 990.85 $ 990.85 0 0% 0% 0% 9 9 9 9 9 9 F YD4277 Soft tissue graft firsttooth $ 832.99 $ 832.99 0 0% 0% 0% 9 9 9 9 9 9 F YD4278 Soft tissue graft addl tooth $ 740.93 $ 740.93 0 0% 0% 0% 9 9 9 9 9 9 F YD4320 Provision splnt intracoronal $ 460.84 $ 460.84 0 0% 0% 0% 9 9 9 9 9 9 F YD4321 Provisional splint extracoro $ 422.94 $ 422.94 0 0% 0% 0% 9 9 9 9 9 9 F YD4341 Periodontal scaling & root Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D4342 Periodontal scaling 1-3teeth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D4355 Full mouth debridement Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X D4381 Localized delivery antimicro Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X D4910 Periodontal maint procedures Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D4920 Unscheduled dressing change $ 92.01 $ 92.01 0 0% 0% 0% 9 9 9 9 9 9 F YD4921 Gingival irrigation per quad $ 90.58 $ 90.58 0 0% 0% 0% 9 9 9 9 9 9 F YD4999 Unspecified periodontal proc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YD5110 Dentures complete maxillary $ 1543.24 $ 1543.24 0 0% 0% 0% 9 9 9 9 9 9 F YD5120 Dentures complete mandible $ 1543.24 $ 1543.24 0 0% 0% 0% 9 9 9 9 9 9 F YD5130 Dentures immediat maxillary $ 1648.80 $ 1648.80 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 31
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D5140 Dentures immediat mandible $ 1649.64 $ 1649.64 0 0% 0% 0% 9 9 9 9 9 9 F YD5211 Dentures maxill part resin $ 1223.64 $ 1223.64 0 0% 0% 0% 9 9 9 9 9 9 F YD5212 Dentures mand part resin $ 1226.15 $ 1226.15 0 0% 0% 0% 9 9 9 9 9 9 F YD5213 Dentures maxill part metal $ 1604.97 $ 1604.97 0 0% 0% 0% 9 9 9 9 9 9 F YD5214 Dentures mandibl part metal $ 1606.68 $ 1606.68 0 0% 0% 0% 9 9 9 9 9 9 F YD5225 Maxillary part denture flex $ 1433.49 $ 1433.49 0 0% 0% 0% 9 9 9 9 9 9 F YD5226 Mandibular part denture flex $ 1406.09 $ 1406.09 0 0% 0% 0% 9 9 9 9 9 9 F YD5281 Removable partial denture $ 896.49 $ 896.49 0 0% 0% 0% 9 9 9 9 9 9 F YD5410 Dentures adjust cmplt maxil $ 80.30 $ 80.30 0 0% 0% 0% 9 9 9 9 9 9 F YD5411 Dentures adjust cmplt mand $ 80.30 $ 80.30 0 0% 0% 0% 9 9 9 9 9 9 F YD5421 Dentures adjust part maxill $ 80.30 $ 80.30 0 0% 0% 0% 9 9 9 9 9 9 F YD5422 Dentures adjust part mandbl $ 80.30 $ 80.30 0 0% 0% 0% 9 9 9 9 9 9 F YD5510 Dentur repr broken compl bas $ 190.14 $ 190.14 0 0% 0% 0% 9 9 9 9 9 9 F YD5520 Replace denture teeth complt $ 169.05 $ 169.05 0 0% 0% 0% 9 9 9 9 9 9 F YD5610 Dentures repair resin base $ 183.41 $ 183.41 0 0% 0% 0% 9 9 9 9 9 9 F YD5620 Rep part denture cast frame $ 257.86 $ 257.86 0 0% 0% 0% 9 9 9 9 9 9 F YD5630 Rep partial denture clasp $ 236.77 $ 236.77 0 0% 0% 0% 9 9 9 9 9 9 F YD5640 Replace part denture teeth $ 172.41 $ 172.41 0 0% 0% 0% 9 9 9 9 9 9 F YD5650 Add tooth to partial denture $ 200.47 $ 200.47 0 0% 0% 0% 9 9 9 9 9 9 F YD5660 Add clasp to partial denture $ 244.39 $ 244.39 0 0% 0% 0% 9 9 9 9 9 9 F YD5670 Replc tth&acrlc on mtl frmwk $ 674.85 $ 674.85 0 0% 0% 0% 9 9 9 9 9 9 F YD5671 Replc tth&acrlc mandibular $ 659.80 $ 659.80 0 0% 0% 0% 9 9 9 9 9 9 F YD5710 Dentures rebase cmplt maxil $ 532.78 $ 532.78 0 0% 0% 0% 9 9 9 9 9 9 F YD5711 Dentures rebase cmplt mand $ 528.58 $ 528.58 0 0% 0% 0% 9 9 9 9 9 9 F YD5720 Dentures rebase part maxill $ 504.96 $ 504.96 0 0% 0% 0% 9 9 9 9 9 9 F YD5721 Dentures rebase part mandbl $ 503.25 $ 503.25 0 0% 0% 0% 9 9 9 9 9 9 F YD5730 Denture reln cmplt maxil ch $ 339.83 $ 339.83 0 0% 0% 0% 9 9 9 9 9 9 F YD5731 Denture reln cmplt mand chr $ 333.93 $ 333.93 0 0% 0% 0% 9 9 9 9 9 9 F YD5740 Denture reln part maxil chr $ 329.75 $ 329.75 0 0% 0% 0% 9 9 9 9 9 9 F YD5741 Denture reln part mand chr $ 333.93 $ 333.93 0 0% 0% 0% 9 9 9 9 9 9 F YD5750 Denture reln cmplt max lab $ 430.55 $ 430.55 0 0% 0% 0% 9 9 9 9 9 9 F YD5751 Denture reln cmplt mand lab $ 430.55 $ 430.55 0 0% 0% 0% 9 9 9 9 9 9 F YD5760 Denture reln part maxil lab $ 422.94 $ 422.94 0 0% 0% 0% 9 9 9 9 9 9 F YD5761 Denture reln part mand lab $ 441.34 $ 441.34 0 0% 0% 0% 9 9 9 9 9 9 F YD5810 Denture interm cmplt maxill $ 790.59 $ 790.59 0 0% 0% 0% 9 9 9 9 9 9 F YD5811 Denture interm cmplt mandbl $ 789.79 $ 789.79 0 0% 0% 0% 9 9 9 9 9 9 F YD5820 Denture interm part maxill $ 634.15 $ 634.15 0 0% 0% 0% 9 9 9 9 9 9 F YD5821 Denture interm part mandbl $ 634.15 $ 634.15 0 0% 0% 0% 9 9 9 9 9 9 F YD5850 Denture tiss conditn maxill $ 189.22 $ 189.22 0 0% 0% 0% 9 9 9 9 9 9 F YD5851 Denture tiss condtin mandbl $ 187.63 $ 187.63 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 32
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D5862 Precision attachment $ 645.92 $ 645.92 0 0% 0% 0% 9 9 9 9 9 9 F YD5863 Overdenture complete max $ 2048.98 $ 2048.98 0 0% 0% 0% 9 9 9 9 9 9 F YD5864 Overdenture partial max $ 2057.14 $ 2057.14 0 0% 0% 0% 9 9 9 9 9 9 F YD5865 Overdenture complete mandib $ 2057.14 $ 2057.14 0 0% 0% 0% 9 9 9 9 9 9 F YD5866 Overdenture partial mandib $ 2161.58 $ 2161.58 0 0% 0% 0% 9 9 9 9 9 9 F YD5867 Replacement of precision att $ 350.25 $ 350.25 0 0% 0% 0% 9 9 9 9 9 9 F YD5875 Prosthesis modification $ 349.41 $ 349.41 0 0% 0% 0% 9 9 9 9 9 9 F YD5899 Removable prosthodontic proc $ 910.66 $ 910.66 0 0% 0% 0% 9 9 9 9 9 9 F YD5911 Facial moulage sectional $ 268.74 $ 268.74 0 0% 0% 0% 0 0 0 0 0 0 F YD5912 Facial moulage complete $ 403.13 $ 403.13 0 0% 0% 0% 0 0 0 0 0 0 F YD5913 Nasal prosthesis $ 4248.91 $ 4248.91 0 0% 0% 0% 9 9 9 9 9 9 F YD5914 Auricular prosthesis $ 4263.60 $ 4263.60 0 0% 0% 0% 9 9 9 9 9 9 F YD5915 Orbital prosthesis $ 9070.05 $ 9070.05 0 0% 0% 0% 9 9 9 9 9 9 F YD5916 Ocular prosthesis $ 9405.98 $ 9405.98 0 0% 0% 0% 9 9 9 9 9 9 F YD5919 Facial prosthesis $ 9405.98 $ 9405.98 0 0% 0% 0% 9 9 9 9 9 9 F YD5922 Nasal septal prosthesis $ 4367.07 $ 4367.07 0 0% 0% 0% 9 9 9 9 9 9 F YD5923 Ocular prosthesis interim $ 5374.84 $ 5374.84 0 0% 0% 0% 9 9 9 9 9 9 F YD5924 Cranial prosthesis $ 5374.84 $ 5374.84 0 0% 0% 0% 9 9 9 9 9 9 F YD5925 Facial augmentation implant $ 5374.84 $ 5374.84 0 0% 0% 0% 9 9 9 9 9 9 F YD5926 Replacement nasal prosthesis $ 3359.26 $ 3359.26 0 0% 0% 0% 9 9 9 9 9 9 F YD5927 Auricular replacement $ 3359.26 $ 3359.26 0 0% 0% 0% 9 9 9 9 9 9 F YD5928 Orbital replacement $ 4535.02 $ 4535.02 0 0% 0% 0% 9 9 9 9 9 9 F YD5929 Facial replacement $ 4535.02 $ 4535.02 0 0% 0% 0% 9 9 9 9 9 9 F YD5931 Surgical obturator $ 2149.94 $ 2149.94 0 0% 0% 0% 9 9 9 9 9 9 F YD5932 Postsurgical obturator $ 5038.91 $ 5038.91 0 0% 0% 0% 9 9 9 9 9 9 F YD5933 Refitting of obturator $ 1007.79 $ 1007.79 0 0% 0% 0% 9 9 9 9 9 9 F YD5934 Mandibular flange prosthesis $ 5038.91 $ 5038.91 0 0% 0% 0% 9 9 9 9 9 9 F YD5935 Mandibular denture prosth $ 5038.91 $ 5038.91 0 0% 0% 0% 9 9 9 9 9 9 F YD5936 Temp obturator prosthesis $ 1847.62 $ 1847.62 0 0% 0% 0% 9 9 9 9 9 9 F YD5937 Trismus appliance $ 640.06 $ 640.06 0 0% 0% 0% 9 9 9 9 9 9 F YD5951 Feeding aid $ 826.22 $ 826.22 0 0% 0% 0% 0 0 0 0 0 0 F YD5952 Pediatric speech aid Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D5953 Adult speech aid $ 2015.56 $ 2015.56 0 0% 0% 0% 9 9 9 9 9 9 F YD5954 Superimposed prosthesis $ 4265.96 $ 4265.96 0 0% 0% 0% 9 9 9 9 9 9 F YD5955 Palatal lift prosthesis $ 4367.07 $ 4367.07 0 0% 0% 0% 9 9 9 9 9 9 F YD5958 Intraoral con def inter plt $ 2553.04 $ 2553.04 0 0% 0% 0% 9 9 9 9 9 9 F YD5959 Intraoral con def mod palat $ 806.32 $ 806.32 0 0% 0% 0% 9 9 9 9 9 9 F YD5960 Modify speech aid prosthesis $ 537.48 $ 537.48 0 0% 0% 0% 9 9 9 9 9 9 F YD5982 Surgical stent $ 410.02 $ 410.02 0 0% 0% 0% 9 9 9 9 9 9 F YD5983 Radiation applicator Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 33
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D5984 Radiation shield Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X D5985 Radiation cone locator Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X D5986 Fluoride applicator Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D5987 Commissure splint $ 812.08 $ 812.08 0 0% 0% 0% 0 0 0 0 0 0 F YD5988 Surgical splint $ 703.55 $ 703.55 0 0% 0% 0% 9 9 9 9 9 9 F YD5991 Vesiculobullous disease carr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D5992 Adjust max prost appliance By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YD5993 Main/clean max prosthesis By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YD5994 Peridontal medicament $ 506.74 $ 506.74 0 0% 0% 0% 9 9 9 9 9 9 F YD5999 Maxillofacial prosthesis By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YD6010 Odontics endosteal implant $ 1804.48 $ 1804.48 0 0% 0% 0% 9 9 9 9 9 9 F YD6011 Second stage implant surgery $ 608.74 $ 608.74 0 0% 0% 0% 9 9 9 9 9 9 F YD6012 Endosteal implant $ 1436.04 $ 1436.04 0 0% 0% 0% 9 9 9 9 9 9 F YD6013 Surgical place mini implant $ 1033.06 $ 1033.06 0 0% 0% 0% 9 9 9 9 9 9 F YD6040 Odontics eposteal implant $ 7138.37 $ 7138.37 0 0% 0% 0% 9 9 9 9 9 9 F YD6050 Odontics transosteal implnt $ 5005.34 $ 5005.34 0 0% 0% 0% 9 9 9 9 9 9 F YD6051 Interim abutment $ 452.88 $ 452.88 0 0% 0% 0% 9 9 9 9 9 9 F YD6052 Semi precision attach abut $ 826.61 $ 826.61 0 0% 0% 0% 9 9 9 9 9 9 F YD6055 Implant connecting bar $ 2692.43 $ 2692.43 0 0% 0% 0% 9 9 9 9 9 9 F YD6056 Prefabricated abutment $ 718.65 $ 718.65 0 0% 0% 0% 9 9 9 9 9 9 F YD6057 Custom abutment $ 864.14 $ 864.14 0 0% 0% 0% 9 9 9 9 9 9 F YD6058 Abutment supported crown $ 1310.73 $ 1310.73 0 0% 0% 0% 9 9 9 9 9 9 F YD6059 Abutment supported mtl crown $ 1318.26 $ 1318.26 0 0% 0% 0% 9 9 9 9 9 9 F YD6060 Abutment supported mtl crown $ 1270.25 $ 1270.25 0 0% 0% 0% 9 9 9 9 9 9 F YD6061 Abutment supported mtl crown $ 1262.38 $ 1262.38 0 0% 0% 0% 9 9 9 9 9 9 F YD6062 Abutment supported mtl crown $ 1310.73 $ 1310.73 0 0% 0% 0% 9 9 9 9 9 9 F YD6063 Abutment supported mtl crown $ 1246.37 $ 1246.37 0 0% 0% 0% 9 9 9 9 9 9 F YD6064 Abutment supported mtl crown $ 1252.25 $ 1252.25 0 0% 0% 0% 9 9 9 9 9 9 F YD6065 Implant supported crown $ 1405.25 $ 1405.25 0 0% 0% 0% 9 9 9 9 9 9 F YD6066 Implant supported mtl crown $ 1404.42 $ 1404.42 0 0% 0% 0% 9 9 9 9 9 9 F YD6067 Implant supported mtl crown $ 1426.80 $ 1426.80 0 0% 0% 0% 9 9 9 9 9 9 F YD6068 Abutment supported retainer $ 1310.73 $ 1310.73 0 0% 0% 0% 9 9 9 9 9 9 F YD6069 Abutment supported retainer $ 1318.26 $ 1318.26 0 0% 0% 0% 9 9 9 9 9 9 F YD6070 Abutment supported retainer $ 1232.06 $ 1232.06 0 0% 0% 0% 9 9 9 9 9 9 F YD6071 Abutment supported retainer $ 1276.64 $ 1276.64 0 0% 0% 0% 9 9 9 9 9 9 F YD6072 Abutment supported retainer $ 1339.06 $ 1339.06 0 0% 0% 0% 9 9 9 9 9 9 F YD6073 Abutment supported retainer $ 1246.37 $ 1246.37 0 0% 0% 0% 9 9 9 9 9 9 F YD6074 Abutment supported retainer $ 1237.87 $ 1237.87 0 0% 0% 0% 9 9 9 9 9 9 F YD6075 Implant supported retainer $ 1396.05 $ 1396.05 0 0% 0% 0% 9 9 9 9 9 9 F YD6076 Implant supported retainer $ 1398.62 $ 1398.62 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 34
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D6077 Implant supported retainer $ 1406.78 $ 1406.78 0 0% 0% 0% 9 9 9 9 9 9 F YD6080 Implant maintenance $ 283.28 $ 283.28 0 0% 0% 0% 9 9 9 9 9 9 F YD6090 Repair implant $ 647.21 $ 647.21 0 0% 0% 0% 9 9 9 9 9 9 F YD6091 Repl semi/precision attach $ 554.65 $ 554.65 0 0% 0% 0% 9 9 9 9 9 9 F YD6092 Recement supp crown $ 142.99 $ 142.99 0 0% 0% 0% 9 9 9 9 9 9 F D6093 Recement supp part denture $ 161.50 $ 161.50 0 0% 0% 0% 9 9 9 9 9 9 F D6094 Abut support crown titanium $ 1164.34 $ 1164.34 0 0% 0% 0% 9 9 9 9 9 9 F YD6095 Odontics repr abutment $ 644.24 $ 644.24 0 0% 0% 0% 9 9 9 9 9 9 F YD6100 Removal of implant $ 684.05 $ 684.05 0 0% 0% 0% 9 9 9 9 9 9 F YD6101 Debridement of a periimplant $ 313.69 $ 313.69 0 0% 0% 0% 9 9 9 9 9 9 F YD6102 Debridement & contouring $ 647.21 $ 647.21 0 0% 0% 0% 9 9 9 9 9 9 F YD6103 Bone graft repair perimplant $ 679.67 $ 679.67 0 0% 0% 0% 9 9 9 9 9 9 F YD6104 Bone graft time of implant $ 679.67 $ 679.67 0 0% 0% 0% 9 9 9 9 9 9 F YD6110 Implnt/abut remov dent max $ 2691.90 $ 2691.90 0 0% 0% 0% 9 9 9 9 9 9 FD6111 Implnt/abut remov dent mand $ 2512.45 $ 2512.45 0 0% 0% 0% 9 9 9 9 9 9 FD6112 Imp/abut rem dent part max $ 2469.17 $ 2469.17 0 0% 0% 0% 9 9 9 9 9 9 FD6113 Imp/abut rem dent part mand $ 2469.17 $ 2469.17 0 0% 0% 0% 9 9 9 9 9 9 FD6114 Implnt/abut fixed dent max $ 5220.00 $ 5220.00 0 0% 0% 0% 9 9 9 9 9 9 FD6115 Implnt/abut fixed dent mand $ 5220.00 $ 5220.00 0 0% 0% 0% 9 9 9 9 9 9 FD6116 Imp/abut fixed dent part max $ 3573.49 $ 3573.49 0 0% 0% 0% 9 9 9 9 9 9 FD6117 Imp/abut fixed dent part man $ 3573.49 $ 3573.49 0 0% 0% 0% 9 9 9 9 9 9 FD6190 Radio/surgical implant index $ 380.49 $ 380.49 0 0% 0% 0% 9 9 9 9 9 9 F YD6194 Abut support retainer titani $ 1273.58 $ 1273.58 0 0% 0% 0% 9 9 9 9 9 9 F YD6199 Implant procedure $ 742.56 $ 742.56 0 0% 0% 0% 9 9 9 9 9 9 F YD6205 Pontic-indirect resin based $ 887.99 $ 887.99 0 0% 0% 0% 9 9 9 9 9 9 F YD6210 Prosthodont high noble metal $ 980.14 $ 980.14 0 0% 0% 0% 9 9 9 9 9 9 F YD6211 Bridge base metal cast $ 914.97 $ 914.97 0 0% 0% 0% 9 9 9 9 9 9 F YD6212 Bridge noble metal cast $ 930.12 $ 930.12 0 0% 0% 0% 9 9 9 9 9 9 F YD6214 Pontic titanium $ 1005.40 $ 1005.40 0 0% 0% 0% 9 9 9 9 9 9 F YD6240 Bridge porcelain high noble $ 1006.24 $ 1006.24 0 0% 0% 0% 9 9 9 9 9 9 F YD6241 Bridge porcelain base metal $ 930.12 $ 930.12 0 0% 0% 0% 9 9 9 9 9 9 F YD6242 Bridge porcelain nobel metal $ 954.62 $ 954.62 0 0% 0% 0% 9 9 9 9 9 9 F YD6245 Bridge porcelain/ceramic $ 1024.86 $ 1024.86 0 0% 0% 0% 9 9 9 9 9 9 F YD6250 Bridge resin w/high noble $ 968.31 $ 968.31 0 0% 0% 0% 9 9 9 9 9 9 F YD6251 Bridge resin base metal $ 951.28 $ 951.28 0 0% 0% 0% 9 9 9 9 9 9 F YD6252 Bridge resin w/noble metal $ 951.28 $ 951.28 0 0% 0% 0% 9 9 9 9 9 9 F YD6253 Provisional pontic $ 719.48 $ 719.48 0 0% 0% 0% 9 9 9 9 9 9 F YD6545 Dental retainr cast metl $ 770.33 $ 770.33 0 0% 0% 0% 9 9 9 9 9 9 F YD6548 Porcelain/ceramic retainer Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6549 Resin retainer By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 35
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D6600 Porcelain/ceramic inlay 2srf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6601 Porc/ceram inlay >= 3 surfac Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6602 Cst hgh nble mtl inlay 2 srf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6603 Cst hgh nble mtl inlay >=3sr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6604 Cst bse mtl inlay 2 surfaces Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6605 Cst bse mtl inlay >= 3 surfa Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6606 Cast noble metal inlay 2 sur Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6607 Cst noble mtl inlay >=3 surf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6608 Onlay porc/crmc 2 surfaces Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6609 Onlay porc/crmc >=3 surfaces Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6610 Onlay cst hgh nbl mtl 2 srfc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6611 Onlay cst hgh nbl mtl >=3srf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6612 Onlay cst base mtl 2 surface Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6613 Onlay cst base mtl >=3 surfa Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6614 Onlay cst nbl mtl 2 surfaces Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6615 Onlay cst nbl mtl >=3 surfac Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6624 Inlay titanium Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6634 Onlay titanium Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6710 Crown-indirect resin based $ 891.35 $ 891.35 0 0% 0% 0% 9 9 9 9 9 9 F YD6720 Retain crown resin w hi nble $ 953.79 $ 953.79 0 0% 0% 0% 9 9 9 9 9 9 F YD6721 Crown resin w/base metal $ 930.12 $ 930.12 0 0% 0% 0% 9 9 9 9 9 9 F YD6722 Crown resin w/noble metal $ 944.16 $ 944.16 0 0% 0% 0% 9 9 9 9 9 9 F YD6740 Crown porcelain/ceramic $ 1040.21 $ 1040.21 0 0% 0% 0% 9 9 9 9 9 9 F YD6750 Crown porcelain high noble $ 1010.50 $ 1010.50 0 0% 0% 0% 9 9 9 9 9 9 F YD6751 Crown porcelain base metal $ 914.97 $ 914.97 0 0% 0% 0% 9 9 9 9 9 9 F YD6752 Crown porcelain noble metal $ 945.38 $ 945.38 0 0% 0% 0% 9 9 9 9 9 9 F YD6780 Crown 3/4 high noble metal $ 968.31 $ 968.31 0 0% 0% 0% 9 9 9 9 9 9 F YD6781 Crown 3/4 cast based metal $ 929.28 $ 929.28 0 0% 0% 0% 9 9 9 9 9 9 F YD6782 Crown 3/4 cast noble metal $ 951.28 $ 951.28 0 0% 0% 0% 9 9 9 9 9 9 F YD6783 Crown 3/4 porcelain/ceramic $ 995.28 $ 995.28 0 0% 0% 0% 9 9 9 9 9 9 F YD6790 Crown full high noble metal $ 995.28 $ 995.28 0 0% 0% 0% 9 9 9 9 9 9 F YD6791 Crown full base metal cast $ 923.33 $ 923.33 0 0% 0% 0% 9 9 9 9 9 9 F YD6792 Crown full noble metal cast $ 945.38 $ 945.38 0 0% 0% 0% 9 9 9 9 9 9 F YD6793 Provisional retainer crown $ 494.25 $ 494.25 0 0% 0% 0% 9 9 9 9 9 9 F YD6794 Crown titanium $ 957.14 $ 957.14 0 0% 0% 0% 9 9 9 9 9 9 F YD6920 Dental connector bar $ 919.23 $ 919.23 0 0% 0% 0% 0 0 0 0 0 0 F YD6930 Recement/bond part denture $ 155.59 $ 155.59 0 0% 0% 0% 9 9 9 9 9 9 F YD6940 Stress breaker $ 394.00 $ 394.00 0 0% 0% 0% 9 9 9 9 9 9 F YD6950 Precision attachment $ 591.16 $ 591.16 0 0% 0% 0% 9 9 9 9 9 9 F YD6980 Fixed partial repair $ 356.10 $ 356.10 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 36
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D6985 Pediatric partial denture fx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D6999 Fixed prosthodontic proc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YD7111 Extraction coronal remnants $ 121.84 $ 121.84 0 0% 0% 0% 9 9 9 9 9 9 F D7140 Extraction erupted tooth/exr $ 156.43 $ 156.43 0 0% 0% 0% 9 9 9 9 9 9 F D7210 Rem imp tooth w mucoper flp $ 248.56 $ 248.56 0 0% 0% 0% 0 0 0 0 0 0 F D7220 Impact tooth remov soft tiss $ 281.60 $ 281.60 0 0% 0% 0% 0 0 0 0 0 0 F D7230 Impact tooth remov part bony $ 356.94 $ 356.94 0 0% 0% 0% 0 0 0 0 0 0 F D7240 Impact tooth remov comp bony $ 435.61 $ 435.61 0 0% 0% 0% 0 0 0 0 0 0 F D7241 Impact tooth rem bony w/comp $ 520.10 $ 520.10 0 0% 0% 0% 0 0 0 0 0 0 F D7250 Tooth root removal $ 281.60 $ 281.60 0 0% 0% 0% 0 0 0 0 0 0 F D7251 Coronectomy $ 409.63 $ 409.63 0 0% 0% 0% 9 9 9 9 9 9 F YD7260 Oral antral fistula closure $ 1073.03 $ 1073.03 0 0% 0% 0% 0 0 0 0 0 0 F D7261 Primary closure sinus perf $ 710.74 $ 710.74 0 0% 0% 0% 9 9 9 9 9 9 F D7270 Tooth reimplantation $ 507.51 $ 507.51 0 0% 0% 0% 9 9 9 9 9 9 F D7272 Tooth transplantation $ 691.97 $ 691.97 0 0% 0% 0% 9 9 9 9 9 9 F D7280 Exposure impact tooth orthod Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D7282 Mobilize erupted/malpos toot Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D7283 Place device impacted tooth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D7285 Biopsy of oral tissue hard $ 411.36 $ 411.36 0 0% 0% 0% 9 9 9 9 9 9 F YD7286 Biopsy of oral tissue soft $ 293.45 $ 293.45 0 0% 0% 0% 9 9 9 9 9 9 F YD7287 Exfoliative cytolog collect $ 169.05 $ 169.05 0 0% 0% 0% 9 9 9 9 9 9 F YD7288 Brush biopsy $ 175.79 $ 175.79 0 0% 0% 0% 9 9 9 9 9 9 F YD7290 Repositioning of teeth $ 469.20 $ 469.20 0 0% 0% 0% 9 9 9 9 9 9 F D7291 Transseptal fiberotomy $ 290.50 $ 290.50 0 0% 0% 0% 0 0 0 0 0 0 F YD7292 Screw retained plate $ 2794.80 $ 2794.80 0 0% 0% 0% 9 9 9 9 9 9 F D7293 Temp anchorage dev w flap $ 2217.89 $ 2217.89 0 0% 0% 0% 9 9 9 9 9 9 F D7294 Temp anchorage dev w/o flap $ 1474.51 $ 1474.51 0 0% 0% 0% 9 9 9 9 9 9 F D7295 Bone harvest,auto graft proc $ 773.57 $ 773.57 0 0% 0% 0% 9 9 9 9 9 9 F YD7310 Alveoplasty w/ extraction $ 271.15 $ 271.15 0 0% 0% 0% 9 9 9 9 9 9 F YD7311 Alveoloplasty w/extract 1-3 $ 280.78 $ 280.78 0 0% 0% 0% 9 9 9 9 9 9 F YD7320 Alveoplasty w/o extraction $ 401.60 $ 401.60 0 0% 0% 0% 9 9 9 9 9 9 F YD7321 Alveoloplasty not w/extracts $ 386.39 $ 386.39 0 0% 0% 0% 9 9 9 9 9 9 F YD7340 Vestibuloplasty ridge extens $ 1194.62 $ 1194.62 0 0% 0% 0% 9 9 9 9 9 9 F YD7350 Vestibuloplasty exten graft $ 2302.75 $ 2302.75 0 0% 0% 0% 9 9 9 9 9 9 F YD7410 Rad exc lesion up to 1.25 cm $ 384.70 $ 384.70 0 0% 0% 0% 9 9 9 9 9 9 F YD7411 Excision benign lesion>1.25c $ 572.02 $ 572.02 0 0% 0% 0% 9 9 9 9 9 9 F YD7412 Excision benign lesion compl $ 820.08 $ 820.08 0 0% 0% 0% 9 9 9 9 9 9 F YD7413 Excision malig lesion<=1.25c Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D7414 Excision malig lesion>1.25cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D7415 Excision malig les complicat Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 37
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D7440 Malig tumor exc to 1.25 cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D7441 Malig tumor > 1.25 cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D7450 Rem odontogen cyst to 1.25cm $ 563.97 $ 563.97 0 0% 0% 0% 9 9 9 9 9 9 F YD7451 Rem odontogen cyst > 1.25 cm $ 741.73 $ 741.73 0 0% 0% 0% 9 9 9 9 9 9 F YD7460 Rem nonodonto cyst to 1.25cm $ 531.94 $ 531.94 0 0% 0% 0% 9 9 9 9 9 9 F YD7461 Rem nonodonto cyst > 1.25 cm $ 845.59 $ 845.59 0 0% 0% 0% 9 9 9 9 9 9 F YD7465 Lesion destruction $ 420.24 $ 420.24 0 0% 0% 0% 9 9 9 9 9 9 F YD7471 Rem exostosis any site $ 625.80 $ 625.80 0 0% 0% 0% 9 9 9 9 9 9 F YD7472 Removal of torus palatinus $ 793.14 $ 793.14 0 0% 0% 0% 9 9 9 9 9 9 F YD7473 Remove torus mandibularis $ 717.80 $ 717.80 0 0% 0% 0% 9 9 9 9 9 9 F YD7485 Surg reduct osseoustuberosit $ 682.38 $ 682.38 0 0% 0% 0% 9 9 9 9 9 9 F YD7490 Maxilla or mandible resectio Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D7510 I&d absc intraoral soft tiss $ 211.43 $ 211.43 0 0% 0% 0% 9 9 9 9 9 9 F YD7511 Incision/drain abscess intra $ 325.58 $ 325.58 0 0% 0% 0% 9 9 9 9 9 9 F YD7520 I&d abscess extraoral $ 443.90 $ 443.90 0 0% 0% 0% 9 9 9 9 9 9 F YD7521 Incision/drain abscess extra $ 592.84 $ 592.84 0 0% 0% 0% 9 9 9 9 9 9 F YD7530 Removal fb skin/areolar tiss $ 328.00 $ 328.00 0 0% 0% 0% 9 9 9 9 9 9 F YD7540 Removal of fb reaction $ 621.54 $ 621.54 0 0% 0% 0% 9 9 9 9 9 9 F YD7550 Removal of sloughed off bone $ 543.73 $ 543.73 0 0% 0% 0% 9 9 9 9 9 9 F YD7560 Maxillary sinusotomy $ 1336.71 $ 1336.71 0 0% 0% 0% 9 9 9 9 9 9 F YD7610 Maxilla open reduct simple $ 4010.64 $ 4010.64 0 0% 0% 0% 9 9 9 9 9 9 F YD7620 Clsd reduct simpl maxilla fx $ 3028.08 $ 3028.08 0 0% 0% 0% 9 9 9 9 9 9 F YD7630 Open red simpl mandible fx $ 4024.21 $ 4024.21 0 0% 0% 0% 9 9 9 9 9 9 F YD7640 Clsd red simpl mandible fx $ 3010.35 $ 3010.35 0 0% 0% 0% 9 9 9 9 9 9 F YD7650 Open red simp malar/zygom fx $ 3434.54 $ 3434.54 0 0% 0% 0% 9 9 9 9 9 9 F YD7660 Clsd red simp malar/zygom fx $ 2883.37 $ 2883.37 0 0% 0% 0% 9 9 9 9 9 9 F YD7670 Closd rductn splint alveolus $ 1644.24 $ 1644.24 0 0% 0% 0% 9 9 9 9 9 9 F YD7671 Alveolus open reduction $ 1130.71 $ 1130.71 0 0% 0% 0% 9 9 9 9 9 9 F YD7680 Reduct simple facial bone fx $ 6042.87 $ 6042.87 0 0% 0% 0% 9 9 9 9 9 9 F YD7710 Maxilla open reduct compound $ 4115.90 $ 4115.90 0 0% 0% 0% 9 9 9 9 9 9 F YD7720 Clsd reduct compd maxilla fx $ 3087.32 $ 3087.32 0 0% 0% 0% 9 9 9 9 9 9 F YD7730 Open reduct compd mandble fx $ 4331.12 $ 4331.12 0 0% 0% 0% 9 9 9 9 9 9 F YD7740 Clsd reduct compd mandble fx $ 3199.90 $ 3199.90 0 0% 0% 0% 9 9 9 9 9 9 F YD7750 Open red comp malar/zygma fx $ 3823.40 $ 3823.40 0 0% 0% 0% 9 9 9 9 9 9 F YD7760 Clsd red comp malar/zygma fx $ 5292.58 $ 5292.58 0 0% 0% 0% 9 9 9 9 9 9 F YD7770 Open reduc compd alveolus fx $ 2461.64 $ 2461.64 0 0% 0% 0% 9 9 9 9 9 9 F YD7771 Alveolus clsd reduc stblz te $ 1709.83 $ 1709.83 0 0% 0% 0% 9 9 9 9 9 9 F YD7780 Reduct compnd facial bone fx $ 7645.17 $ 7645.17 0 0% 0% 0% 9 9 9 9 9 9 F YD7810 Tmj open reduct-dislocation $ 3787.47 $ 3787.47 0 0% 0% 0% 9 9 9 9 9 9 F YD7820 Closed tmp manipulation $ 570.71 $ 570.71 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 38
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D7830 Tmj manipulation under anest $ 902.26 $ 902.26 0 0% 0% 0% 9 9 9 9 9 9 F YD7840 Removal of tmj condyle $ 4791.21 $ 4791.21 0 0% 0% 0% 9 9 9 9 9 9 F YD7850 Tmj meniscectomy $ 4677.31 $ 4677.31 0 0% 0% 0% 9 9 9 9 9 9 F YD7852 Tmj repair of joint disc $ 5023.67 $ 5023.67 0 0% 0% 0% 9 9 9 9 9 9 F YD7854 Tmj excisn of joint membrane $ 4704.96 $ 4704.96 0 0% 0% 0% 9 9 9 9 9 9 F YD7856 Tmj cutting of a muscle $ 3146.58 $ 3146.58 0 0% 0% 0% 9 9 9 9 9 9 F YD7858 Tmj reconstruction $ 7524.78 $ 7524.78 0 0% 0% 0% 9 9 9 9 9 9 F YD7860 Tmj cutting into joint $ 2015.56 $ 2015.56 0 0% 0% 0% 9 9 9 9 9 9 F YD7865 Tmj reshaping components $ 5643.59 $ 5643.59 0 0% 0% 0% 9 9 9 9 9 9 F YD7870 Tmj aspiration joint fluid $ 511.63 $ 511.63 0 0% 0% 0% 9 9 9 9 9 9 F YD7871 Lysis + lavage w catheters $ 2640.38 $ 2640.38 0 0% 0% 0% 9 9 9 9 9 9 F YD7872 Tmj diagnostic arthroscopy $ 1746.82 $ 1746.82 0 0% 0% 0% 9 9 9 9 9 9 F YD7873 Tmj arthroscopy lysis adhesn $ 1914.80 $ 1914.80 0 0% 0% 0% 9 9 9 9 9 9 F YD7874 Tmj arthroscopy disc reposit $ 2418.68 $ 2418.68 0 0% 0% 0% 9 9 9 9 9 9 F YD7875 Tmj arthroscopy synovectomy $ 2586.65 $ 2586.65 0 0% 0% 0% 9 9 9 9 9 9 F YD7876 Tmj arthroscopy discectomy $ 2687.41 $ 2687.41 0 0% 0% 0% 9 9 9 9 9 9 F YD7877 Tmj arthroscopy debridement $ 2485.87 $ 2485.87 0 0% 0% 0% 9 9 9 9 9 9 F YD7880 Occlusal orthotic appliance $ 913.31 $ 913.31 0 0% 0% 0% 9 9 9 9 9 9 F YD7899 Tmj unspecified therapy $ 2485.87 $ 2485.87 0 0% 0% 0% 9 9 9 9 9 9 F YD7910 Dent sutur recent wnd to 5cm $ 274.92 $ 274.92 0 0% 0% 0% 9 9 9 9 9 9 F D7911 Dental suture wound to 5 cm $ 452.47 $ 452.47 0 0% 0% 0% 9 9 9 9 9 9 F D7912 Suture complicate wnd > 5 cm $ 751.43 $ 751.43 0 0% 0% 0% 9 9 9 9 9 9 F D7920 Dental skin graft $ 2339.68 $ 2339.68 0 0% 0% 0% 9 9 9 9 9 9 F D7921 Collect & appl blood product $ 379.44 $ 379.44 0 0% 0% 0% 9 9 9 9 9 9 F YD7940 Reshaping bone orthognathic $ 3537.27 $ 3537.27 0 0% 0% 0% 0 0 0 0 0 0 F D7941 Bone cutting ramus closed $ 7955.43 $ 7955.43 0 0% 0% 0% 9 9 9 9 9 9 F YD7943 Cutting ramus open w/graft $ 7616.43 $ 7616.43 0 0% 0% 0% 9 9 9 9 9 9 F YD7944 Bone cutting segmented $ 6237.24 $ 6237.24 0 0% 0% 0% 9 9 9 9 9 9 F YD7945 Bone cutting body mandible $ 6335.27 $ 6335.27 0 0% 0% 0% 9 9 9 9 9 9 F YD7946 Reconstruction maxilla total $ 7470.96 $ 7470.96 0 0% 0% 0% 9 9 9 9 9 9 F YD7947 Reconstruct maxilla segment $ 7323.77 $ 7323.77 0 0% 0% 0% 9 9 9 9 9 9 F YD7948 Reconstruct midface no graft $ 8642.08 $ 8642.08 0 0% 0% 0% 9 9 9 9 9 9 F YD7949 Reconstruct midface w/graft $ 10485.54 $ 10485.54 0 0% 0% 0% 9 9 9 9 9 9 F YD7950 Mandible graft $ 2793.17 $ 2793.17 0 0% 0% 0% 9 9 9 9 9 9 F YD7951 Sinus aug w bone or bone sub $ 2880.48 $ 2880.48 0 0% 0% 0% 9 9 9 9 9 9 F D7952 Sinus augmentation vertical $ 2046.53 $ 2046.53 0 0% 0% 0% 9 9 9 9 9 9 F YD7953 Bone replacement graft $ 706.66 $ 706.66 0 0% 0% 0% 9 9 9 9 9 9 F YD7955 Repair maxillofacial defects $ 3232.18 $ 3232.18 0 0% 0% 0% 9 9 9 9 9 9 F YD7960 Frenulectomy/frenectomy $ 399.10 $ 399.10 0 0% 0% 0% 9 9 9 9 9 9 F YD7963 Frenuloplasty $ 446.49 $ 446.49 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 39
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D7970 Excision hyperplastic tissue $ 465.02 $ 465.02 0 0% 0% 0% 9 9 9 9 9 9 F YD7971 Excision pericoronal gingiva $ 239.28 $ 239.28 0 0% 0% 0% 9 9 9 9 9 9 F D7972 Surg redct fibrous tuberosit $ 688.70 $ 688.70 0 0% 0% 0% 9 9 9 9 9 9 F YD7980 Sialolithotomy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D7981 Excision of salivary gland Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D7982 Sialodochoplasty $ 1555.87 $ 1555.87 0 0% 0% 0% 9 9 9 9 9 9 F D7983 Closure of salivary fistula $ 1385.93 $ 1385.93 0 0% 0% 0% 9 9 9 9 9 9 F D7990 Emergency tracheotomy $ 1316.59 $ 1316.59 0 0% 0% 0% 9 9 9 9 9 9 F D7991 Dental coronoidectomy $ 3664.54 $ 3664.54 0 0% 0% 0% 9 9 9 9 9 9 F YD7995 Synthetic graft facial bones $ 4016.94 $ 4016.94 0 0% 0% 0% 9 9 9 9 9 9 F D7996 Implant mandible for augment $ 4016.94 $ 4016.94 0 0% 0% 0% 9 9 9 9 9 9 F D7997 Appliance removal $ 317.91 $ 317.91 0 0% 0% 0% 9 9 9 9 9 9 F D7998 Intraoral place of fix dev $ 2287.44 $ 2287.44 0 0% 0% 0% 9 9 9 9 9 9 F D7999 Oral surgery procedure By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YD8010 Limited dental tx primary Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D8020 Limited dental tx transition Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D8030 Limited dental tx adolescent $ 2792.90 $ 2792.90 0 0% 0% 0% 9 9 9 9 9 9 F YD8040 Limited dental tx adult $ 2976.98 $ 2976.98 0 0% 0% 0% 9 9 9 9 9 9 F YD8050 Intercep dental tx primary Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D8060 Intercep dental tx transitn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D8070 Compre dental tx transition Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D8080 Compre dental tx adolescent $ 4679.73 $ 4679.73 0 0% 0% 0% 9 9 9 9 9 9 F YD8090 Compre dental tx adult $ 4702.58 $ 4702.58 0 0% 0% 0% 9 9 9 9 9 9 F YD8210 Orthodontic rem appliance tx $ 776.28 $ 776.28 0 0% 0% 0% 9 9 9 9 9 9 F YD8220 Fixed appliance therapy habt $ 912.29 $ 912.29 0 0% 0% 0% 9 9 9 9 9 9 F YD8660 Preorthodontic tx visit $ 367.11 $ 367.11 0 0% 0% 0% 9 9 9 9 9 9 F YD8670 Periodic orthodontc tx visit $ 240.13 $ 240.13 0 0% 0% 0% 9 9 9 9 9 9 F YD8680 Orthodontic retention $ 491.20 $ 491.20 0 0% 0% 0% 9 9 9 9 9 9 F YD8690 Orthodontic treatment $ 247.74 $ 247.74 0 0% 0% 0% 9 9 9 9 9 9 F YD8691 Repair ortho appliance $ 190.14 $ 190.14 0 0% 0% 0% 9 9 9 9 9 9 F YD8692 Replacement retainer $ 307.79 $ 307.79 0 0% 0% 0% 9 9 9 9 9 9 F YD8693 Rebond/recement retainers $ 301.36 $ 301.36 0 0% 0% 0% 9 9 9 9 9 9 F D8694 Repair fixed retainers By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YD8999 Orthodontic procedure By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YD9110 Tx dental pain minor proc $ 116.81 $ 116.81 0 0% 0% 0% 0 0 0 0 0 0 F D9120 Fix partial denture section $ 219.87 $ 219.87 0 0% 0% 0% 9 9 9 9 9 9 F D9210 Dent anesthesia w/o surgery $ 67.76 $ 67.76 0 0% 0% 0% 9 9 9 9 9 9 F D9211 Regional block anesthesia Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B D9212 Trigeminal block anesthesia Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B D9215 Local anesthesia Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 40
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
D9219 Eval for deep sed/gen anesth By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 ND9220 General anesthesia $ 351.92 $ 351.92 0 0% 0% 0% 9 9 9 9 9 9 F D9221 General anesthesia ea ad 15m $ 148.06 $ 148.06 0 0% 0% 0% 9 9 9 9 9 9 F D9230 Analgesia $ 71.94 $ 71.94 0 0% 0% 0% 0 0 0 0 0 0 F D9241 Intravenous sedation $ 370.46 $ 370.46 0 0% 0% 0% 9 9 9 9 9 9 F D9242 Iv sedation ea ad 15 m $ 147.23 $ 147.23 0 0% 0% 0% 9 9 9 9 9 9 F D9248 Sedation (non-iv) $ 300.29 $ 300.29 0 0% 0% 0% 9 9 9 9 9 9 F D9310 Dental consultation $ 120.17 $ 120.17 0 0% 0% 0% 9 9 9 9 9 9 F D9410 Dental house call $ 219.05 $ 219.05 0 0% 0% 0% 9 9 9 9 9 9 F D9420 Hospital/asc call $ 274.54 $ 274.54 0 0% 0% 0% 9 9 9 9 9 9 F D9430 Office visit during hours $ 71.10 $ 71.10 0 0% 0% 0% 9 9 9 9 9 9 F D9440 Office visit after hours $ 162.32 $ 162.32 0 0% 0% 0% 9 9 9 9 9 9 F D9450 Case presentation tx plan $ 134.97 $ 134.97 0 0% 0% 0% 9 9 9 9 9 9 F D9610 Dent therapeutic drug inject $ 97.91 $ 97.91 0 0% 0% 0% 9 9 9 9 9 9 F D9612 Thera par drugs 2 or > admin $ 172.18 $ 172.18 0 0% 0% 0% 9 9 9 9 9 9 F D9630 Other drugs/medicaments $ 46.38 $ 46.38 0 0% 0% 0% 0 0 0 0 0 0 F D9910 Dent appl desensitizing med $ 61.07 $ 61.07 0 0% 0% 0% 9 9 9 9 9 9 F D9911 Appl desensitizing resin $ 72.78 $ 72.78 0 0% 0% 0% 9 9 9 9 9 9 F D9920 Behavior management $ 142.80 $ 142.80 0 0% 0% 0% 9 9 9 9 9 9 F YD9930 Treatment of complications $ 119.33 $ 119.33 0 0% 0% 0% 0 0 0 0 0 0 F YD9931 Clean/inspect rem appliance By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 ND9940 Dental occlusal guard $ 549.64 $ 549.64 0 0% 0% 0% 0 0 0 0 0 0 F YD9941 Fabrication athletic guard $ 241.00 $ 241.00 0 0% 0% 0% 9 9 9 9 9 9 F D9942 Repair/reline occlusal guard $ 235.95 $ 235.95 0 0% 0% 0% 9 9 9 9 9 9 F YD9950 Occlusion analysis $ 325.52 $ 325.52 0 0% 0% 0% 0 0 0 0 0 0 F D9951 Limited occlusal adjustment $ 169.05 $ 169.05 0 0% 0% 0% 0 0 0 0 0 0 F D9952 Complete occlusal adjustment $ 631.65 $ 631.65 0 0% 0% 0% 0 0 0 0 0 0 F YD9970 Enamel microabrasion Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D9971 Odontoplasty 1-2 teeth $ 164.02 $ 164.02 0 0% 0% 0% 9 9 9 9 9 9 F D9972 Extrnl bleaching per arch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X D9973 Extrnl bleaching per tooth $ 218.21 $ 218.21 0 0% 0% 0% 9 9 9 9 9 9 F D9974 Intrnl bleaching per tooth $ 262.92 $ 262.92 0 0% 0% 0% 9 9 9 9 9 9 F D9975 External bleaching home app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XD9985 Sales tax Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XD9986 Missed appointment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XD9987 Cancelled appointment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XD9999 Adjunctive procedure By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0100-NU Cane adjust/fixed with tip $ 23.39 $ 23.39 0 0% 0% 0% 9 9 9 9 9 9 F E0105-NU Cane adjust/fixed quad/3 pro $ 54.52 $ 54.52 0 0% 0% 0% 9 9 9 9 9 9 F E0110-NU Crutch forearm pair $ 86.12 $ 86.12 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 41
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0111-NU Crutch forearm each $ 59.11 $ 59.11 0 0% 0% 0% 9 9 9 9 9 9 F E0112-NU Crutch underarm pair wood $ 41.07 $ 41.07 0 0% 0% 0% 9 9 9 9 9 9 F E0113-NU Crutch underarm each wood $ 23.46 $ 23.46 0 0% 0% 0% 9 9 9 9 9 9 F E0114-NU Crutch underarm pair no wood $ 49.40 $ 49.40 0 0% 0% 0% 9 9 9 9 9 9 F E0116-NU Crutch underarm each no wood $ 26.43 $ 26.43 0 0% 0% 0% 9 9 9 9 9 9 F E0117-NU Underarm springassist crutch $ 25.01 $ 25.01 0 0% 0% 0% 9 9 9 9 9 9 F E0118-RR Crutch substitute $ 59.90 $ 59.90 0 0% 0% 0% 9 9 9 9 9 9 F E0130-NU Walker rigid adjust/fixed ht $ 67.19 $ 67.19 0 0% 0% 0% 9 9 9 9 9 9 F E0130-RR Walker rigid adjust/fixed ht $ 6.72 $ 6.72 0 0% 0% 0% 9 9 9 9 9 9 F E0135-NU Walker folding adjust/fixed $ 80.21 $ 80.21 0 0% 0% 0% 9 9 9 9 9 9 F E0135-RR Walker folding adjust/fixed $ 8.02 $ 8.02 0 0% 0% 0% 9 9 9 9 9 9 F E0140-NU Walker w trunk support $ 345.08 $ 345.08 0 0% 0% 0% 9 9 9 9 9 9 F E0140-RR Walker w trunk support $ 34.51 $ 34.51 0 0% 0% 0% 9 9 9 9 9 9 F E0141-NU Rigid wheeled walker adj/fix $ 110.30 $ 110.30 0 0% 0% 0% 9 9 9 9 9 9 F E0141-RR Rigid wheeled walker adj/fix $ 11.03 $ 11.03 0 0% 0% 0% 9 9 9 9 9 9 F E0143-NU Walker folding wheeled w/o s $ 115.02 $ 115.02 0 0% 0% 0% 9 9 9 9 9 9 F E0143-RR Walker folding wheeled w/o s $ 11.50 $ 11.50 0 0% 0% 0% 9 9 9 9 9 9 F E0144-NU Enclosed walker w rear seat $ 316.70 $ 316.70 0 0% 0% 0% 9 9 9 9 9 9 F E0144-RR Enclosed walker w rear seat $ 31.67 $ 31.67 0 0% 0% 0% 9 9 9 9 9 9 F E0147-NU Walker variable wheel resist $ 549.90 $ 549.90 0 0% 0% 0% 9 9 9 9 9 9 F E0147-RR Walker variable wheel resist $ 54.99 $ 54.99 0 0% 0% 0% 9 9 9 9 9 9 F E0148-NU Heavyduty walker no wheels $ 121.56 $ 121.56 0 0% 0% 0% 9 9 9 9 9 9 F E0148-RR Heavyduty walker no wheels $ 12.16 $ 12.16 0 0% 0% 0% 9 9 9 9 9 9 F E0149-NU Heavy duty wheeled walker $ 213.53 $ 213.53 0 0% 0% 0% 9 9 9 9 9 9 F E0149-RR Heavy duty wheeled walker $ 21.35 $ 21.35 0 0% 0% 0% 9 9 9 9 9 9 F E0153-NU Forearm crutch platform atta $ 76.23 $ 76.23 0 0% 0% 0% 9 9 9 9 9 9 F E0153-RR Forearm crutch platform atta $ 7.62 $ 7.62 0 0% 0% 0% 9 9 9 9 9 9 F E0154-NU Walker platform attachment $ 67.46 $ 67.46 0 0% 0% 0% 9 9 9 9 9 9 F E0154-RR Walker platform attachment $ 6.75 $ 6.75 0 0% 0% 0% 9 9 9 9 9 9 F E0155-NU Walker wheel attachment,pair $ 25.65 $ 25.65 0 0% 0% 0% 9 9 9 9 9 9 F E0155-RR Walker wheel attachment,pair $ 2.57 $ 2.57 0 0% 0% 0% 9 9 9 9 9 9 F E0156-NU Walker seat attachment $ 25.29 $ 25.29 0 0% 0% 0% 9 9 9 9 9 9 F E0156-RR Walker seat attachment $ 2.53 $ 2.53 0 0% 0% 0% 9 9 9 9 9 9 F E0157-NU Walker crutch attachment $ 73.92 $ 73.92 0 0% 0% 0% 9 9 9 9 9 9 F E0157-RR Walker crutch attachment $ 7.39 $ 7.39 0 0% 0% 0% 9 9 9 9 9 9 F E0158-NU Walker leg extenders set of4 $ 30.78 $ 30.78 0 0% 0% 0% 9 9 9 9 9 9 F E0158-RR Walker leg extenders set of4 $ 3.08 $ 3.08 0 0% 0% 0% 9 9 9 9 9 9 F E0159-NU Brake for wheeled walker $ 17.09 $ 17.09 0 0% 0% 0% 9 9 9 9 9 9 F E0159-RR Brake for wheeled walker $ 1.71 $ 1.71 0 0% 0% 0% 9 9 9 9 9 9 F E0160-NU Sitz type bath or equipment $ 36.69 $ 36.69 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 42
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0161-NU Sitz bath/equipment w/faucet $ 29.11 $ 29.11 0 0% 0% 0% 9 9 9 9 9 9 F E0162-NU Sitz bath chair $ 137.47 $ 137.47 0 0% 0% 0% 9 9 9 9 9 9 F E0163-NU Commode chair with fixed arm $ 122.41 $ 122.41 0 0% 0% 0% 9 9 9 9 9 9 F E0165-NU Commode chair with detacharm $ 206.20 $ 206.20 0 0% 0% 0% 9 9 9 9 9 9 F E0167-NU Commode chair pail or pan $ 13.32 $ 13.32 0 0% 0% 0% 9 9 9 9 9 9 F E0168-NU Heavyduty/wide commode chair $ 167.52 $ 167.52 0 0% 0% 0% 9 9 9 9 9 9 F E0170-NU Commode chair electric $ 1757.60 $ 1757.60 0 0% 0% 0% 9 9 9 9 9 9 F E0171-NU Commode chair non-electric $ 316.30 $ 316.30 0 0% 0% 0% 9 9 9 9 9 9 F E0172-NU Seat lift mechanism toilet By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0172-RR Seat lift mechanism toilet By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0175-NU Commode chair foot rest $ 66.03 $ 66.03 0 0% 0% 0% 9 9 9 9 9 9 F E0181-NU Press pad alternating w/ pum $ 289.20 $ 289.20 0 0% 0% 0% 9 9 9 9 9 9 F E0181-RR Press pad alternating w/ pum $ 28.92 $ 28.92 0 0% 0% 0% 9 9 9 9 9 9 F E0182-NU Replace pump, alt press pad $ 290.50 $ 290.50 0 0% 0% 0% 9 9 9 9 9 9 F E0182-RR Replace pump, alt press pad $ 29.05 $ 29.05 0 0% 0% 0% 9 9 9 9 9 9 F E0184-NU Dry pressure mattress $ 216.11 $ 216.11 0 0% 0% 0% 9 9 9 9 9 9 F E0184-RR Dry pressure mattress $ 21.61 $ 21.61 0 0% 0% 0% 9 9 9 9 9 9 F E0185-NU Gel pressure mattress pad $ 355.02 $ 355.02 0 0% 0% 0% 9 9 9 9 9 9 F E0185-RR Gel pressure mattress pad $ 35.50 $ 35.50 0 0% 0% 0% 9 9 9 9 9 9 F E0186-NU Air pressure mattress $ 225.30 $ 225.30 0 0% 0% 0% 9 9 9 9 9 9 F E0186-RR Air pressure mattress $ 22.53 $ 22.53 0 0% 0% 0% 9 9 9 9 9 9 F E0187-NU Water pressure mattress $ 257.60 $ 257.60 0 0% 0% 0% 9 9 9 9 9 9 F E0187-RR Water pressure mattress $ 25.76 $ 25.76 0 0% 0% 0% 9 9 9 9 9 9 F E0188-NU Synthetic sheepskin pad $ 29.34 $ 29.34 0 0% 0% 0% 9 9 9 9 9 9 F E0189-NU Lambswool sheepskin pad $ 49.03 $ 49.03 0 0% 0% 0% 9 9 9 9 9 9 F E0190 Positioning cushion Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0191-NU Protector heel or elbow $ 9.43 $ 9.43 0 0% 0% 0% 9 9 9 9 9 9 F E0193-RR Powered air flotation bed $ 864.30 $ 864.30 0 0% 0% 0% 9 9 9 9 9 9 F YE0194-RR Air fluidized bed $ 3220.03 $ 3220.03 0 0% 0% 0% 9 9 9 9 9 9 F YE0196-NU Gel pressure mattress $ 360.60 $ 360.60 0 0% 0% 0% 9 9 9 9 9 9 F YE0196-RR Gel pressure mattress $ 36.06 $ 36.06 0 0% 0% 0% 9 9 9 9 9 9 F YE0197-NU Air pressure pad for mattres $ 245.94 $ 245.94 0 0% 0% 0% 9 9 9 9 9 9 F E0197-RR Air pressure pad for mattres $ 24.59 $ 24.59 0 0% 0% 0% 9 9 9 9 9 9 F E0198-NU Water pressure pad for mattr $ 580.46 $ 580.46 0 0% 0% 0% 9 9 9 9 9 9 F E0198-RR Water pressure pad for mattr $ 58.05 $ 58.05 0 0% 0% 0% 9 9 9 9 9 9 F E0199-NU Dry pressure pad for mattres $ 35.59 $ 35.59 0 0% 0% 0% 9 9 9 9 9 9 F E0200 Heat lamp without stand Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0202 Phototherapy light w/ photom Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0203 Therapeutic lightbox tabletp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0205 Heat lamp with stand Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 43
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0210 Electric heat pad standard Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0215 Electric heat pad moist Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0217 Water circ heat pad w pump Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0218 Water circ cold pad w pump Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0221 Infrared heating pad system Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0225 Hydrocollator unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0231-NU Wound warming device By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0231-RR Wound warming device By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0232-NU Warming card for nwt By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0232-RR Warming card for nwt By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0235 Paraffin bath unit portable Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0236 Pump for water circulating p Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0239 Hydrocollator unit portable Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0240-NU Bath/shower chair By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0241-NU Bath tub wall rail $ 30.38 $ 30.38 0 0% 0% 0% 9 9 9 9 9 9 F E0242-NU Bath tub rail floor $ 68.84 $ 68.84 0 0% 0% 0% 9 9 9 9 9 9 F E0243-NU Toilet rail $ 54.62 $ 54.62 0 0% 0% 0% 9 9 9 9 9 9 F E0244-NU Toilet seat raised $ 41.37 $ 41.37 0 0% 0% 0% 9 9 9 9 9 9 F E0245-NU Tub stool or bench $ 68.19 $ 68.19 0 0% 0% 0% 9 9 9 9 9 9 F E0246-NU Transfer tub rail attachment $ 93.08 $ 93.08 0 0% 0% 0% 9 9 9 9 9 9 F E0247-NU Trans bench w/wo comm open $ 67.22 $ 67.22 0 0% 0% 0% 9 9 9 9 9 9 F
E0248-NU Hdtrans bench w/wo comm open By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0249 Pad water circulating heat u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0250-NU Hosp bed fixed ht w/ mattres $ 890.00 $ 890.00 0 0% 0% 0% 9 9 9 9 9 9 F YE0250-RR Hosp bed fixed ht w/ mattres $ 89.00 $ 89.00 0 0% 0% 0% 9 9 9 9 9 9 F YE0251-NU Hosp bed fixd ht w/o mattres $ 661.10 $ 661.10 0 0% 0% 0% 9 9 9 9 9 9 F YE0251-RR Hosp bed fixd ht w/o mattres $ 66.11 $ 66.11 0 0% 0% 0% 9 9 9 9 9 9 F YE0255-NU Hospital bed var ht w/ mattr $ 1123.90 $ 1123.90 0 0% 0% 0% 9 9 9 9 9 9 F YE0255-RR Hospital bed var ht w/ mattr $ 112.39 $ 112.39 0 0% 0% 0% 9 9 9 9 9 9 F YE0256-NU Hospital bed var ht w/o matt $ 797.40 $ 797.40 0 0% 0% 0% 9 9 9 9 9 9 F YE0256-RR Hospital bed var ht w/o matt $ 79.74 $ 79.74 0 0% 0% 0% 9 9 9 9 9 9 F YE0260-NU Hosp bed semi-electr w/ matt $ 1343.80 $ 1343.80 0 0% 0% 0% 9 9 9 9 9 9 F YE0260-RR Hosp bed semi-electr w/ matt $ 134.38 $ 134.38 0 0% 0% 0% 9 9 9 9 9 9 F YE0261-NU Hosp bed semi-electr w/o mat $ 1310.10 $ 1310.10 0 0% 0% 0% 9 9 9 9 9 9 F YE0261-RR Hosp bed semi-electr w/o mat $ 131.01 $ 131.01 0 0% 0% 0% 9 9 9 9 9 9 F YE0265-NU Hosp bed total electr w/ mat $ 1912.30 $ 1912.30 0 0% 0% 0% 9 9 9 9 9 9 F YE0265-RR Hosp bed total electr w/ mat $ 191.23 $ 191.23 0 0% 0% 0% 9 9 9 9 9 9 F YE0266-NU Hosp bed total elec w/o matt $ 1699.00 $ 1699.00 0 0% 0% 0% 9 9 9 9 9 9 F YE0266-RR Hosp bed total elec w/o matt $ 169.90 $ 169.90 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 44
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0270-NU Hospital bed institutional t By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0270-RR Hospital bed institutional t By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0271-NU Mattress innerspring $ 212.42 $ 212.42 0 0% 0% 0% 9 9 9 9 9 9 F E0271-RR Mattress innerspring $ 21.24 $ 21.24 0 0% 0% 0% 9 9 9 9 9 9 F E0272-NU Mattress foam rubber $ 183.47 $ 183.47 0 0% 0% 0% 9 9 9 9 9 9 F E0272-RR Mattress foam rubber $ 18.35 $ 18.35 0 0% 0% 0% 9 9 9 9 9 9 F E0273-NU Bed board $ 42.51 $ 42.51 0 0% 0% 0% 9 9 9 9 9 9 F E0274-NU Over-bed table $ 68.35 $ 68.35 0 0% 0% 0% 9 9 9 9 9 9 F E0275-NU Bed pan standard $ 17.00 $ 17.00 0 0% 0% 0% 9 9 9 9 9 9 F E0276-NU Bed pan fracture $ 12.55 $ 12.55 0 0% 0% 0% 9 9 9 9 9 9 F E0277-RR Powered pres-redu air mattrs $ 673.05 $ 673.05 0 0% 0% 0% 9 9 9 9 9 9 F YE0280-NU Bed cradle $ 36.55 $ 36.55 0 0% 0% 0% 9 9 9 9 9 9 F E0290-NU Hosp bed fx ht w/o rails w/m $ 715.00 $ 715.00 0 0% 0% 0% 9 9 9 9 9 9 F YE0290-RR Hosp bed fx ht w/o rails w/m $ 71.50 $ 71.50 0 0% 0% 0% 9 9 9 9 9 9 F YE0291-NU Hosp bed fx ht w/o rail w/o $ 519.50 $ 519.50 0 0% 0% 0% 9 9 9 9 9 9 F YE0291-RR Hosp bed fx ht w/o rail w/o $ 51.95 $ 51.95 0 0% 0% 0% 9 9 9 9 9 9 F YE0292-NU Hosp bed var ht w/o rail w/o $ 803.90 $ 803.90 0 0% 0% 0% 9 9 9 9 9 9 F YE0292-RR Hosp bed var ht w/o rail w/o $ 80.39 $ 80.39 0 0% 0% 0% 9 9 9 9 9 9 F YE0293-NU Hosp bed var ht w/o rail w/ $ 674.20 $ 674.20 0 0% 0% 0% 9 9 9 9 9 9 F YE0293-RR Hosp bed var ht w/o rail w/ $ 67.42 $ 67.42 0 0% 0% 0% 9 9 9 9 9 9 F YE0294-NU Hosp bed semi-elect w/ mattr $ 1249.90 $ 1249.90 0 0% 0% 0% 9 9 9 9 9 9 F YE0294-RR Hosp bed semi-elect w/ mattr $ 124.99 $ 124.99 0 0% 0% 0% 9 9 9 9 9 9 F YE0295-NU Hosp bed semi-elect w/o matt $ 1163.00 $ 1163.00 0 0% 0% 0% 9 9 9 9 9 9 F YE0295-RR Hosp bed semi-elect w/o matt $ 116.30 $ 116.30 0 0% 0% 0% 9 9 9 9 9 9 F YE0296-NU Hosp bed total elect w/ matt $ 1570.80 $ 1570.80 0 0% 0% 0% 9 9 9 9 9 9 F YE0296-RR Hosp bed total elect w/ matt $ 157.08 $ 157.08 0 0% 0% 0% 9 9 9 9 9 9 F YE0297-NU Hosp bed total elect w/o mat $ 1345.70 $ 1345.70 0 0% 0% 0% 9 9 9 9 9 9 F YE0297-RR Hosp bed total elect w/o mat $ 134.57 $ 134.57 0 0% 0% 0% 9 9 9 9 9 9 F YE0300 Enclosed ped crib hosp grade Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0301-NU Hd hosp bed, 350-600 lbs $ 2590.00 $ 2590.00 0 0% 0% 0% 9 9 9 9 9 9 F YE0301-RR Hd hosp bed, 350-600 lbs $ 259.00 $ 259.00 0 0% 0% 0% 9 9 9 9 9 9 F YE0302-NU Ex hd hosp bed > 600 lbs $ 6844.30 $ 6844.30 0 0% 0% 0% 9 9 9 9 9 9 F YE0302-RR Ex hd hosp bed > 600 lbs $ 684.43 $ 684.43 0 0% 0% 0% 9 9 9 9 9 9 F YE0303-NU Hosp bed hvy dty xtra wide $ 2908.10 $ 2908.10 0 0% 0% 0% 9 9 9 9 9 9 F YE0303-RR Hosp bed hvy dty xtra wide $ 290.81 $ 290.81 0 0% 0% 0% 9 9 9 9 9 9 F YE0304-NU Hosp bed xtra hvy dty x wide $ 7372.80 $ 7372.80 0 0% 0% 0% 9 9 9 9 9 9 F YE0304-RR Hosp bed xtra hvy dty x wide $ 737.28 $ 737.28 0 0% 0% 0% 9 9 9 9 9 9 F YE0305-NU Rails bed side half length $ 170.20 $ 170.20 0 0% 0% 0% 9 9 9 9 9 9 F YE0305-RR Rails bed side half length $ 17.02 $ 17.02 0 0% 0% 0% 9 9 9 9 9 9 F YE0310-NU Rails bed side full length $ 185.72 $ 185.72 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 45
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0310-RR Rails bed side full length $ 18.57 $ 18.57 0 0% 0% 0% 9 9 9 9 9 9 F E0315-NU Bed accessory brd/tbl/supprt By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0315-RR Bed accessory brd/tbl/supprt By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0316-NU Bed safety enclosure $ 1942.80 $ 1942.80 0 0% 0% 0% 9 9 9 9 9 9 F E0316-RR Bed safety enclosure $ 194.28 $ 194.28 0 0% 0% 0% 9 9 9 9 9 9 F E0325-NU Urinal male jug-type $ 11.23 $ 11.23 0 0% 0% 0% 9 9 9 9 9 9 F E0326-NU Urinal female jug-type $ 11.65 $ 11.65 0 0% 0% 0% 9 9 9 9 9 9 F E0328 Ped hospital bed, manual Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0329 Ped hospital bed semi/elect Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0350-NU Control unit bowel system By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0352-NU Disposable pack w/bowel syst By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0370-NU Air elevator for heel By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0370-RR Air elevator for heel By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0371-NU Nonpower mattress overlay $ 4252.10 $ 4252.10 0 0% 0% 0% 9 9 9 9 9 9 F E0371-RR Nonpower mattress overlay $ 425.21 $ 425.21 0 0% 0% 0% 9 9 9 9 9 9 F E0372-NU Powered air mattress overlay $ 5159.50 $ 5159.50 0 0% 0% 0% 9 9 9 9 9 9 F E0372-RR Powered air mattress overlay $ 515.95 $ 515.95 0 0% 0% 0% 9 9 9 9 9 9 F E0373-NU Nonpowered pressure mattress $ 5878.40 $ 5878.40 0 0% 0% 0% 9 9 9 9 9 9 F E0373-RR Nonpowered pressure mattress $ 587.84 $ 587.84 0 0% 0% 0% 9 9 9 9 9 9 F E0424-RR Stationary compressed gas 02 $ 180.92 $ 180.92 0 0% 0% 0% 9 9 9 9 9 9 F YE0425 Gas system stationary compre Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0430 Oxygen system gas portable Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0431-RR Portable gaseous 02 $ 30.42 $ 30.42 0 0% 0% 0% 9 9 9 9 9 9 F YE0433-RR Portable liquid oxygen sys $ 51.63 $ 51.63 0 0% 0% 0% 9 9 9 9 9 9 FE0434-RR Portable liquid 02 $ 30.42 $ 30.42 0 0% 0% 0% 9 9 9 9 9 9 F YE0435 Oxygen system liquid portabl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0439-RR Stationary liquid 02 $ 180.92 $ 180.92 0 0% 0% 0% 9 9 9 9 9 9 F YE0440 Oxygen system liquid station Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0441-NU Stationary o2 contents, gas $ 77.45 $ 77.45 0 0% 0% 0% 9 9 9 9 9 9 F YE0442-NU Stationary o2 contents, liq $ 77.45 $ 77.45 0 0% 0% 0% 9 9 9 9 9 9 F YE0443-NU Portable 02 contents, gas $ 77.45 $ 77.45 0 0% 0% 0% 9 9 9 9 9 9 F YE0444-NU Portable 02 contents, liquid $ 77.45 $ 77.45 0 0% 0% 0% 9 9 9 9 9 9 F YE0445-RR Oximeter non-invasive By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0446-NU Topical ox deliver sys, nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NE0446-RR Topical ox deliver sys, nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NE0450-RR Vol control vent invasiv int $ 1416.90 $ 1416.90 0 0% 0% 0% 9 9 9 9 9 9 F YE0455-RR Oxygen tent excl croup/ped t By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0457-NU Chest shell $ 1599.72 $ 1599.72 0 0% 0% 0% 9 9 9 9 9 9 F E0457-RR Chest shell $ 159.97 $ 159.97 0 0% 0% 0% 9 9 9 9 9 9 F E0459-NU Chest wrap $ 1324.81 $ 1324.81 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 46
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0459-RR Chest wrap $ 132.48 $ 132.48 0 0% 0% 0% 9 9 9 9 9 9 F YE0460-NU Neg press vent portabl/statn $ 8142.20 $ 8142.20 0 0% 0% 0% 9 9 9 9 9 9 F YE0460-RR Neg press vent portabl/statn $ 814.22 $ 814.22 0 0% 0% 0% 9 9 9 9 9 9 F YE0461-NU Vol control vent noninv int $ 9005.50 $ 9005.50 0 0% 0% 0% 9 9 9 9 9 9 F E0461-RR Vol control vent noninv int $ 900.55 $ 900.55 0 0% 0% 0% 9 9 9 9 9 9 F E0462-NU Rocking bed w/ or w/o side r $ 2749.20 $ 2749.20 0 0% 0% 0% 9 9 9 9 9 9 F YE0462-RR Rocking bed w/ or w/o side r $ 274.92 $ 274.92 0 0% 0% 0% 9 9 9 9 9 9 F YE0463-NU Press supp vent invasive int $ 15610.20 $ 15610.20 0 0% 0% 0% 9 9 9 9 9 9 F E0463-RR Press supp vent invasive int $ 1561.02 $ 1561.02 0 0% 0% 0% 9 9 9 9 9 9 F E0464-NU Press supp vent noninv int $ 15610.20 $ 15610.20 0 0% 0% 0% 9 9 9 9 9 9 F E0464-RR Press supp vent noninv int $ 1561.02 $ 1561.02 0 0% 0% 0% 9 9 9 9 9 9 F E0470-NU Rad w/o backup non-inv intfc $ 2454.80 $ 2454.80 0 0% 0% 0% 9 9 9 9 9 9 F YE0470-RR Rad w/o backup non-inv intfc $ 245.48 $ 245.48 0 0% 0% 0% 9 9 9 9 9 9 F YE0471-NU Rad w/backup non inv intrfc $ 6143.40 $ 6143.40 0 0% 0% 0% 9 9 9 9 9 9 F YE0471-RR Rad w/backup non inv intrfc $ 614.34 $ 614.34 0 0% 0% 0% 9 9 9 9 9 9 F YE0472-NU Rad w backup invasive intrfc $ 6143.40 $ 6143.40 0 0% 0% 0% 9 9 9 9 9 9 F YE0472-RR Rad w backup invasive intrfc $ 614.34 $ 614.34 0 0% 0% 0% 9 9 9 9 9 9 F YE0480-NU Percussor elect/pneum home m $ 487.80 $ 487.80 0 0% 0% 0% 9 9 9 9 9 9 F E0480-RR Percussor elect/pneum home m $ 48.78 $ 48.78 0 0% 0% 0% 9 9 9 9 9 9 F E0481-NU Intrpulmnry percuss vent sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0481-RR Intrpulmnry percuss vent sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0482-NU Cough stimulating device $ 4773.10 $ 4773.10 0 0% 0% 0% 9 9 9 9 9 9 F YE0482-RR Cough stimulating device $ 477.31 $ 477.31 0 0% 0% 0% 9 9 9 9 9 9 F YE0483-NU Chest compression gen system $ 11800.20 $ 11800.20 0 0% 0% 0% 9 9 9 9 9 9 F E0483-RR Chest compression gen system $ 1180.02 $ 1180.02 0 0% 0% 0% 9 9 9 9 9 9 F E0484-NU Non-elec oscillatory pep dvc $ 40.99 $ 40.99 0 0% 0% 0% 9 9 9 9 9 9 F E0485-NU Oral device/appliance prefab By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0486-NU Oral device/appliance cusfab By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0487 Electronic spirometer Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0500 Ippb all types Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0550-RR Humidif extens supple w ippb $ 47.29 $ 47.29 0 0% 0% 0% 9 9 9 9 9 9 F YE0555-NU Humidifier for use w/ regula $ 20.42 $ 20.42 0 0% 0% 0% 9 9 9 9 9 9 F YE0560-NU Humidifier supplemental w/ i $ 164.08 $ 164.08 0 0% 0% 0% 9 9 9 9 9 9 F E0560-RR Humidifier supplemental w/ i $ 16.41 $ 16.41 0 0% 0% 0% 9 9 9 9 9 9 F E0561-NU Humidifier nonheated w pap $ 102.36 $ 102.36 0 0% 0% 0% 9 9 9 9 9 9 F E0562-NU Humidifier heated used w pap $ 288.17 $ 288.17 0 0% 0% 0% 9 9 9 9 9 9 F E0565-RR Compressor air power source $ 57.56 $ 57.56 0 0% 0% 0% 9 9 9 9 9 9 F E0570-NU Nebulizer with compression $ 178.70 $ 178.70 0 0% 0% 0% 9 9 9 9 9 9 F E0570-RR Nebulizer with compression $ 17.87 $ 17.87 0 0% 0% 0% 9 9 9 9 9 9 F E0572-NU Aerosol compressor adjust pr $ 422.70 $ 422.70 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 47
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0572-RR Aerosol compressor adjust pr $ 42.27 $ 42.27 0 0% 0% 0% 9 9 9 9 9 9 F E0574-NU Ultrasonic generator w svneb $ 446.90 $ 446.90 0 0% 0% 0% 9 9 9 9 9 9 F E0574-RR Ultrasonic generator w svneb $ 44.69 $ 44.69 0 0% 0% 0% 9 9 9 9 9 9 F E0575-NU Nebulizer ultrasonic $ 1140.80 $ 1140.80 0 0% 0% 0% 9 9 9 9 9 9 F E0575-RR Nebulizer ultrasonic $ 114.08 $ 114.08 0 0% 0% 0% 9 9 9 9 9 9 F E0580-NU Nebulizer for use w/ regulat $ 128.24 $ 128.24 0 0% 0% 0% 9 9 9 9 9 9 F E0585-NU Nebulizer w/ compressor & he $ 330.80 $ 330.80 0 0% 0% 0% 9 9 9 9 9 9 F E0585-RR Nebulizer w/ compressor & he $ 33.08 $ 33.08 0 0% 0% 0% 9 9 9 9 9 9 F E0600-NU Suction pump portab hom modl $ 508.20 $ 508.20 0 0% 0% 0% 9 9 9 9 9 9 F E0600-RR Suction pump portab hom modl $ 50.82 $ 50.82 0 0% 0% 0% 9 9 9 9 9 9 F E0601-NU Cont airway pressure device $ 1068.70 $ 1068.70 0 0% 0% 0% 9 9 9 9 9 9 F YE0601-RR Cont airway pressure device $ 106.87 $ 106.87 0 0% 0% 0% 9 9 9 9 9 9 F YE0602 Manual breast pump Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0603 Electric breast pump Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0604 Hosp grade elec breast pump Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0605-NU Vaporizer room type $ 29.34 $ 29.34 0 0% 0% 0% 9 9 9 9 9 9 F E0606-RR Drainage board postural $ 25.48 $ 25.48 0 0% 0% 0% 9 9 9 9 9 9 F YE0607-NU Blood glucose monitor home $ 74.16 $ 74.16 0 0% 0% 0% 9 9 9 9 9 9 F E0610-NU Pacemaker monitr audible/vis $ 224.41 $ 224.41 0 0% 0% 0% 9 9 9 9 9 9 F E0615-NU Pacemaker monitr digital/vis $ 531.45 $ 531.45 0 0% 0% 0% 9 9 9 9 9 9 F E0615-RR Pacemaker monitr digital/vis $ 53.15 $ 53.15 0 0% 0% 0% 9 9 9 9 9 9 F E0616-NU Cardiac event recorder By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0616-RR Cardiac event recorder By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0617-NU Automatic ext defibrillator $ 3374.70 $ 3374.70 0 0% 0% 0% 9 9 9 9 9 9 F YE0617-RR Automatic ext defibrillator $ 337.47 $ 337.47 0 0% 0% 0% 9 9 9 9 9 9 F YE0618 Apnea monitor Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0619 Apnea monitor w recorder Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0620-NU Cap bld skin piercing laser $ 1301.06 $ 1301.06 0 0% 0% 0% 9 9 9 9 9 9 F E0620-RR Cap bld skin piercing laser $ 130.11 $ 130.11 0 0% 0% 0% 9 9 9 9 9 9 F E0621-NU Patient lift sling or seat $ 106.54 $ 106.54 0 0% 0% 0% 9 9 9 9 9 9 F E0621-RR Patient lift sling or seat $ 10.65 $ 10.65 0 0% 0% 0% 9 9 9 9 9 9 F E0625-NU Patient lift bathroom or toi By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0625-RR Patient lift bathroom or toi By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0627-NU Seat lift incorp lift-chair $ 367.07 $ 367.07 0 0% 0% 0% 9 9 9 9 9 9 F YE0627-RR Seat lift incorp lift-chair $ 36.71 $ 36.71 0 0% 0% 0% 9 9 9 9 9 9 F YE0628-NU Seat lift for pt furn-electr $ 367.07 $ 367.07 0 0% 0% 0% 9 9 9 9 9 9 F YE0628-RR Seat lift for pt furn-electr $ 36.71 $ 36.71 0 0% 0% 0% 9 9 9 9 9 9 F YE0629-NU Seat lift for pt furn-non-el $ 367.07 $ 367.07 0 0% 0% 0% 9 9 9 9 9 9 F YE0629-RR Seat lift for pt furn-non-el $ 36.71 $ 36.71 0 0% 0% 0% 9 9 9 9 9 9 F YE0630-NU Patient lift hydraulic $ 1130.80 $ 1130.80 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 48
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0630-RR Patient lift hydraulic $ 113.08 $ 113.08 0 0% 0% 0% 9 9 9 9 9 9 F YE0635-NU Patient lift electric $ 3445.58 $ 3445.58 0 0% 0% 0% 9 9 9 9 9 9 F YE0635-RR Patient lift electric $ 344.56 $ 344.56 0 0% 0% 0% 9 9 9 9 9 9 F YE0636-NU Pt support & positioning sys $ 11705.10 $ 11705.10 0 0% 0% 0% 9 9 9 9 9 9 F E0636-RR Pt support & positioning sys $ 1170.51 $ 1170.51 0 0% 0% 0% 9 9 9 9 9 9 F E0637-NU Combination sit to stand sys $ 2982.98 $ 2982.98 0 0% 0% 0% 9 9 9 9 9 9 F YE0638-NU Standing frame sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0638-RR Standing frame sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0639-NU Moveable patient lift system By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0639-RR Moveable patient lift system By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0640-NU Fixed patient lift system By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0640-RR Fixed patient lift system By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0641-NU Multi-position stnd fram sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0641-RR Multi-position stnd fram sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0642-NU Dynamic standing frame By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0642-RR Dynamic standing frame By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
E0650-NU Pneuma compresor non-segment $ 799.40 $ 799.40 0 0% 0% 0% 9 9 9 9 9 9 F
E0650-RR Pneuma compresor non-segment $ 79.94 $ 79.94 0 0% 0% 0% 9 9 9 9 9 9 F E0651-NU Pneum compressor segmental $ 1019.39 $ 1019.39 0 0% 0% 0% 9 9 9 9 9 9 F E0651-RR Pneum compressor segmental $ 101.94 $ 101.94 0 0% 0% 0% 9 9 9 9 9 9 F E0652-NU Pneum compres w/cal pressure $ 5354.20 $ 5354.20 0 0% 0% 0% 9 9 9 9 9 9 F YE0652-RR Pneum compres w/cal pressure $ 535.42 $ 535.42 0 0% 0% 0% 9 9 9 9 9 9 F YE0655-NU Pneumatic appliance half arm $ 119.80 $ 119.80 0 0% 0% 0% 9 9 9 9 9 9 F E0655-RR Pneumatic appliance half arm $ 11.98 $ 11.98 0 0% 0% 0% 9 9 9 9 9 9 F E0656-NU Segmental pneumatic trunk $ 859.62 $ 859.62 0 0% 0% 0% 9 9 9 9 9 9 F E0656-RR Segmental pneumatic trunk $ 85.96 $ 85.96 0 0% 0% 0% 9 9 9 9 9 9 F E0657-NU Segmental pneumatic chest $ 807.59 $ 807.59 0 0% 0% 0% 9 9 9 9 9 9 F E0657-RR Segmental pneumatic chest $ 80.76 $ 80.76 0 0% 0% 0% 9 9 9 9 9 9 F E0660-NU Pneumatic appliance full leg $ 177.31 $ 177.31 0 0% 0% 0% 9 9 9 9 9 9 F E0660-RR Pneumatic appliance full leg $ 17.73 $ 17.73 0 0% 0% 0% 9 9 9 9 9 9 F E0665-NU Pneumatic appliance full arm $ 140.81 $ 140.81 0 0% 0% 0% 9 9 9 9 9 9 F E0665-RR Pneumatic appliance full arm $ 14.08 $ 14.08 0 0% 0% 0% 9 9 9 9 9 9 F E0666-NU Pneumatic appliance half leg $ 153.28 $ 153.28 0 0% 0% 0% 9 9 9 9 9 9 F E0666-RR Pneumatic appliance half leg $ 15.33 $ 15.33 0 0% 0% 0% 9 9 9 9 9 9 F E0667-NU Seg pneumatic appl full leg $ 359.37 $ 359.37 0 0% 0% 0% 9 9 9 9 9 9 F E0667-RR Seg pneumatic appl full leg $ 35.94 $ 35.94 0 0% 0% 0% 9 9 9 9 9 9 F E0668-NU Seg pneumatic appl full arm $ 490.46 $ 490.46 0 0% 0% 0% 9 9 9 9 9 9 F E0668-RR Seg pneumatic appl full arm $ 49.05 $ 49.05 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 49
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0669-NU Seg pneumatic appli half leg $ 203.47 $ 203.47 0 0% 0% 0% 9 9 9 9 9 9 F E0669-RR Seg pneumatic appli half leg $ 20.35 $ 20.35 0 0% 0% 0% 9 9 9 9 9 9 F E0670-NU Seg pneum int legs/trunk $ 1395.26 $ 1395.26 0 0% 0% 0% 9 9 9 9 9 9 FE0670-RR Seg pneum int legs/trunk $ 139.53 $ 139.53 0 0% 0% 0% 9 9 9 9 9 9 FE0671-NU Pressure pneum appl full leg $ 461.02 $ 461.02 0 0% 0% 0% 9 9 9 9 9 9 F E0671-RR Pressure pneum appl full leg $ 46.10 $ 46.10 0 0% 0% 0% 9 9 9 9 9 9 F E0672-NU Pressure pneum appl full arm $ 358.20 $ 358.20 0 0% 0% 0% 9 9 9 9 9 9 F E0672-RR Pressure pneum appl full arm $ 35.82 $ 35.82 0 0% 0% 0% 9 9 9 9 9 9 F E0673-NU Pressure pneum appl half leg $ 297.65 $ 297.65 0 0% 0% 0% 9 9 9 9 9 9 F E0673-RR Pressure pneum appl half leg $ 29.77 $ 29.77 0 0% 0% 0% 9 9 9 9 9 9 F E0675-NU Pneumatic compression device $ 4268.30 $ 4268.30 0 0% 0% 0% 9 9 9 9 9 9 F YE0675-RR Pneumatic compression device $ 426.83 $ 426.83 0 0% 0% 0% 9 9 9 9 9 9 F YE0676 Inter limb compress dev nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0691 Uvl pnl 2 sq ft or less Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0692 Uvl sys panel 4 ft Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0693 Uvl sys panel 6 ft Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0694 Uvl md cabinet sys 6 ft Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0700-NU Safety equipment By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0705-NU Transfer device $ 520.00 $ 520.00 0 0% 0% 0% 9 9 9 9 9 9 F E0705-RR Transfer device $ 52.00 $ 52.00 0 0% 0% 0% 9 9 9 9 9 9 F E0710-NU Restraints any type By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0720 Tens two lead Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0730 Tens four lead Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0731 Conductive garment for tens/ Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0740 Incontinence treatment systm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0744 Neuromuscular stim for scoli Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0745-RR Neuromuscular stim for shock $ 99.36 $ 99.36 0 0% 0% 0% 9 9 9 9 9 9 F YE0746-RR Electromyograph biofeedback By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0747-NU Elec osteogen stim not spine $ 4346.64 $ 4346.64 0 0% 0% 0% 9 9 9 9 9 9 F YE0747-RR Elec osteogen stim not spine $ 434.66 $ 434.66 0 0% 0% 0% 9 9 9 9 9 9 F YE0748-NU Elec osteogen stim spinal $ 4318.48 $ 4318.48 0 0% 0% 0% 9 9 9 9 9 9 F YE0748-RR Elec osteogen stim spinal $ 431.85 $ 431.85 0 0% 0% 0% 9 9 9 9 9 9 F YE0749-NU Elec osteogen stim implanted $ 3083.90 $ 3083.90 0 0% 0% 0% 9 9 9 9 9 9 F YE0749-RR Elec osteogen stim implanted $ 308.39 $ 308.39 0 0% 0% 0% 9 9 9 9 9 9 F YE0755 Electronic salivary reflex s Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0760-NU Osteogen ultrasound stimltor $ 3588.58 $ 3588.58 0 0% 0% 0% 9 9 9 9 9 9 F YE0760-RR Osteogen ultrasound stimltor $ 358.86 $ 358.86 0 0% 0% 0% 9 9 9 9 9 9 F YE0761-NU Nontherm electromgntc device By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0761-RR Nontherm electromgntc device By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E0762 Trans elec jt stim dev sys Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 50
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0764-NU Functional neuromuscularstim $ 12283.40 $ 12283.40 0 0% 0% 0% 9 9 9 9 9 9 F YE0764-RR Functional neuromuscularstim $ 1228.34 $ 1228.34 0 0% 0% 0% 9 9 9 9 9 9 F YE0765 Nerve stimulator for tx n&v Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0766 Elec stim cancer treatment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XE0769 Electric wound treatment dev Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0770-NU Functional electric stim nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0770-RR Functional electric stim nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0776-NU Iv pole $ 158.90 $ 158.90 0 0% 0% 0% 9 9 9 9 9 9 F E0776-RR Iv pole $ 15.89 $ 15.89 0 0% 0% 0% 9 9 9 9 9 9 F E0779-NU Amb infusion pump mechanical $ 185.60 $ 185.60 0 0% 0% 0% 9 9 9 9 9 9 F E0779-RR Amb infusion pump mechanical $ 18.56 $ 18.56 0 0% 0% 0% 9 9 9 9 9 9 F E0780-NU Mech amb infusion pump <8hrs $ 11.51 $ 11.51 0 0% 0% 0% 9 9 9 9 9 9 F E0781-RR External ambulatory infus pu $ 293.99 $ 293.99 0 0% 0% 0% 9 9 9 9 9 9 F YE0782-NU Non-programble infusion pump $ 4765.47 $ 4765.47 0 0% 0% 0% 9 9 9 9 9 9 F YE0782-RR Non-programble infusion pump $ 476.55 $ 476.55 0 0% 0% 0% 9 9 9 9 9 9 F YE0783-NU Programmable infusion pump $ 9087.04 $ 9087.04 0 0% 0% 0% 9 9 9 9 9 9 F YE0783-RR Programmable infusion pump $ 908.70 $ 908.70 0 0% 0% 0% 9 9 9 9 9 9 F YE0784-NU Ext amb infusn pump insulin $ 4633.90 $ 4633.90 0 0% 0% 0% 9 9 9 9 9 9 F YE0784-RR Ext amb infusn pump insulin $ 463.39 $ 463.39 0 0% 0% 0% 9 9 9 9 9 9 F YE0785-NU Replacement impl pump cathet $ 524.46 $ 524.46 0 0% 0% 0% 9 9 9 9 9 9 F YE0786-NU Implantable pump replacement $ 8863.85 $ 8863.85 0 0% 0% 0% 9 9 9 9 9 9 F YE0786-RR Implantable pump replacement $ 886.39 $ 886.39 0 0% 0% 0% 9 9 9 9 9 9 F YE0791-NU Parenteral infusion pump sta $ 3509.70 $ 3509.70 0 0% 0% 0% 9 9 9 9 9 9 F E0791-RR Parenteral infusion pump sta $ 350.97 $ 350.97 0 0% 0% 0% 9 9 9 9 9 9 F E0830 Ambulatory traction device Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B E0840-NU Tract frame attach headboard $ 81.32 $ 81.32 0 0% 0% 0% 9 9 9 9 9 9 F E0840-RR Tract frame attach headboard $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 F E0849-NU Cervical pneum trac equip $ 927.57 $ 927.57 0 0% 0% 0% 9 9 9 9 9 9 F E0849-RR Cervical pneum trac equip $ 92.76 $ 92.76 0 0% 0% 0% 9 9 9 9 9 9 F E0850-NU Traction stand free standing $ 116.60 $ 116.60 0 0% 0% 0% 9 9 9 9 9 9 F E0850-RR Traction stand free standing $ 11.66 $ 11.66 0 0% 0% 0% 9 9 9 9 9 9 F E0855-NU Cervical traction equipment $ 904.74 $ 904.74 0 0% 0% 0% 9 9 9 9 9 9 F E0855-RR Cervical traction equipment $ 90.47 $ 90.47 0 0% 0% 0% 9 9 9 9 9 9 F E0856-NU Cervic collar w air bladders $ 277.25 $ 277.25 0 0% 0% 0% 9 9 9 9 9 9 F E0856-RR Cervic collar w air bladders $ 27.73 $ 27.73 0 0% 0% 0% 9 9 9 9 9 9 F E0860-NU Tract equip cervical tract $ 42.41 $ 42.41 0 0% 0% 0% 9 9 9 9 9 9 F E0870-NU Tract frame attach footboard $ 129.11 $ 129.11 0 0% 0% 0% 9 9 9 9 9 9 F E0870-RR Tract frame attach footboard $ 12.91 $ 12.91 0 0% 0% 0% 9 9 9 9 9 9 F E0880-NU Trac stand free stand extrem $ 139.35 $ 139.35 0 0% 0% 0% 9 9 9 9 9 9 F E0880-RR Trac stand free stand extrem $ 13.94 $ 13.94 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 51
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0890-NU Traction frame attach pelvic $ 133.63 $ 133.63 0 0% 0% 0% 9 9 9 9 9 9 F E0890-RR Traction frame attach pelvic $ 13.36 $ 13.36 0 0% 0% 0% 9 9 9 9 9 9 F E0900-NU Trac stand free stand pelvic $ 142.22 $ 142.22 0 0% 0% 0% 9 9 9 9 9 9 F E0900-RR Trac stand free stand pelvic $ 14.22 $ 14.22 0 0% 0% 0% 9 9 9 9 9 9 F E0910-NU Trapeze bar attached to bed $ 178.70 $ 178.70 0 0% 0% 0% 9 9 9 9 9 9 F E0910-RR Trapeze bar attached to bed $ 17.87 $ 17.87 0 0% 0% 0% 9 9 9 9 9 9 F E0911-NU Hd trapeze bar attach to bed $ 476.80 $ 476.80 0 0% 0% 0% 9 9 9 9 9 9 F E0911-RR Hd trapeze bar attach to bed $ 47.68 $ 47.68 0 0% 0% 0% 9 9 9 9 9 9 F E0912-NU Hd trapeze bar free standing $ 1095.20 $ 1095.20 0 0% 0% 0% 9 9 9 9 9 9 F E0912-RR Hd trapeze bar free standing $ 109.52 $ 109.52 0 0% 0% 0% 9 9 9 9 9 9 F E0920-NU Fracture frame attached to b $ 473.60 $ 473.60 0 0% 0% 0% 9 9 9 9 9 9 F E0920-RR Fracture frame attached to b $ 47.36 $ 47.36 0 0% 0% 0% 9 9 9 9 9 9 F E0930-NU Fracture frame free standing $ 507.00 $ 507.00 0 0% 0% 0% 9 9 9 9 9 9 F E0930-RR Fracture frame free standing $ 50.70 $ 50.70 0 0% 0% 0% 9 9 9 9 9 9 F E0935-RR Cont pas motion exercise dev $ 25.24 $ 25.24 0 0% 0% 0% 9 9 9 9 9 9 F YE0936-RR Cpm device, other than knee By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE0940-NU Trapeze bar free standing $ 332.60 $ 332.60 0 0% 0% 0% 9 9 9 9 9 9 F YE0940-RR Trapeze bar free standing $ 33.26 $ 33.26 0 0% 0% 0% 9 9 9 9 9 9 F YE0941 Gravity assisted traction de Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E0942-NU Cervical head harness/halter $ 22.03 $ 22.03 0 0% 0% 0% 9 9 9 9 9 9 F E0944-NU Pelvic belt/harness/boot $ 47.36 $ 47.36 0 0% 0% 0% 9 9 9 9 9 9 F E0945-NU Belt/harness extremity $ 49.20 $ 49.20 0 0% 0% 0% 9 9 9 9 9 9 F E0946-RR Fracture frame dual w cross $ 65.67 $ 65.67 0 0% 0% 0% 9 9 9 9 9 9 F E0947-RR Fracture frame attachmnts pe $ 57.22 $ 57.22 0 0% 0% 0% 9 9 9 9 9 9 F E0948-RR Fracture frame attachmnts ce $ 65.11 $ 65.11 0 0% 0% 0% 9 9 9 9 9 9 F E0950-NU Tray $ 99.45 $ 99.45 0 0% 0% 0% 9 9 9 9 9 9 F E0950-RR Tray $ 9.95 $ 9.95 0 0% 0% 0% 9 9 9 9 9 9 F E0951-NU Loop heel $ 18.16 $ 18.16 0 0% 0% 0% 9 9 9 9 9 9 F E0952-NU Toe loop/holder, each $ 18.02 $ 18.02 0 0% 0% 0% 9 9 9 9 9 9 F E0955-NU Cushioned headrest $ 193.43 $ 193.43 0 0% 0% 0% 9 9 9 9 9 9 F E0955-RR Cushioned headrest $ 19.34 $ 19.34 0 0% 0% 0% 9 9 9 9 9 9 F E0956-NU W/c lateral trunk/hip suppor $ 94.30 $ 94.30 0 0% 0% 0% 9 9 9 9 9 9 F E0956-RR W/c lateral trunk/hip suppor $ 9.43 $ 9.43 0 0% 0% 0% 9 9 9 9 9 9 F E0957-NU W/c medial thigh support $ 131.96 $ 131.96 0 0% 0% 0% 9 9 9 9 9 9 F E0957-RR W/c medial thigh support $ 13.20 $ 13.20 0 0% 0% 0% 9 9 9 9 9 9 F E0958-NU Whlchr att- conv 1 arm drive $ 775.06 $ 775.06 0 0% 0% 0% 9 9 9 9 9 9 F YE0958-RR Whlchr att- conv 1 arm drive $ 77.51 $ 77.51 0 0% 0% 0% 9 9 9 9 9 9 F YE0959-NU Amputee adapter $ 49.07 $ 49.07 0 0% 0% 0% 9 9 9 9 9 9 F E0959-RR Amputee adapter $ 4.91 $ 4.91 0 0% 0% 0% 9 9 9 9 9 9 F E0960-NU W/c shoulder harness/straps $ 87.04 $ 87.04 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 52
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0960-RR W/c shoulder harness/straps $ 8.70 $ 8.70 0 0% 0% 0% 9 9 9 9 9 9 F E0961-NU Wheelchair brake extension $ 28.07 $ 28.07 0 0% 0% 0% 9 9 9 9 9 9 F E0961-RR Wheelchair brake extension $ 2.81 $ 2.81 0 0% 0% 0% 9 9 9 9 9 9 F E0966-NU Wheelchair head rest extensi $ 79.22 $ 79.22 0 0% 0% 0% 9 9 9 9 9 9 F E0966-RR Wheelchair head rest extensi $ 7.92 $ 7.92 0 0% 0% 0% 9 9 9 9 9 9 F E0967-NU Manual wc hand rim w project $ 72.90 $ 72.90 0 0% 0% 0% 9 9 9 9 9 9 F E0967-RR Manual wc hand rim w project $ 7.29 $ 7.29 0 0% 0% 0% 9 9 9 9 9 9 F E0968-NU Wheelchair commode seat $ 193.90 $ 193.90 0 0% 0% 0% 9 9 9 9 9 9 F YE0968-RR Wheelchair commode seat $ 19.39 $ 19.39 0 0% 0% 0% 9 9 9 9 9 9 F YE0969-NU Wheelchair narrowing device $ 173.86 $ 173.86 0 0% 0% 0% 9 9 9 9 9 9 F E0969-RR Wheelchair narrowing device $ 17.39 $ 17.39 0 0% 0% 0% 9 9 9 9 9 9 F E0970-NU Wheelchair no. 2 footplates $ 100.51 $ 100.51 0 0% 0% 0% 9 9 9 9 9 9 F YE0970-RR Wheelchair no. 2 footplates $ 10.05 $ 10.05 0 0% 0% 0% 9 9 9 9 9 9 F YE0971-NU Wheelchair anti-tipping devi $ 48.15 $ 48.15 0 0% 0% 0% 9 9 9 9 9 9 F E0971-RR Wheelchair anti-tipping devi $ 4.82 $ 4.82 0 0% 0% 0% 9 9 9 9 9 9 F E0973-NU W/ch access det adj armrest $ 93.49 $ 93.49 0 0% 0% 0% 9 9 9 9 9 9 F E0973-RR W/ch access det adj armrest $ 9.35 $ 9.35 0 0% 0% 0% 9 9 9 9 9 9 F E0974-NU W/ch access anti-rollback $ 87.03 $ 87.03 0 0% 0% 0% 9 9 9 9 9 9 F E0974-RR W/ch access anti-rollback $ 8.70 $ 8.70 0 0% 0% 0% 9 9 9 9 9 9 F E0978-NU W/c acc,saf belt pelv strap $ 40.85 $ 40.85 0 0% 0% 0% 9 9 9 9 9 9 F E0978-RR W/c acc,saf belt pelv strap $ 4.09 $ 4.09 0 0% 0% 0% 9 9 9 9 9 9 F E0980-NU Wheelchair safety vest $ 36.69 $ 36.69 0 0% 0% 0% 9 9 9 9 9 9 F E0980-RR Wheelchair safety vest $ 3.67 $ 3.67 0 0% 0% 0% 9 9 9 9 9 9 F E0981-NU Seat upholstery, replacement $ 45.11 $ 45.11 0 0% 0% 0% 9 9 9 9 9 9 F E0981-RR Seat upholstery, replacement $ 4.51 $ 4.51 0 0% 0% 0% 9 9 9 9 9 9 F E0982-NU Back upholstery, replacement $ 49.29 $ 49.29 0 0% 0% 0% 9 9 9 9 9 9 F E0982-RR Back upholstery, replacement $ 4.93 $ 4.93 0 0% 0% 0% 9 9 9 9 9 9 F E0983-NU Add pwr joystick $ 2774.20 $ 2774.20 0 0% 0% 0% 9 9 9 9 9 9 F YE0983-RR Add pwr joystick $ 277.42 $ 277.42 0 0% 0% 0% 9 9 9 9 9 9 F YE0984-NU Add pwr tiller $ 3394.01 $ 3394.01 0 0% 0% 0% 9 9 9 9 9 9 F YE0984-RR Add pwr tiller $ 339.40 $ 339.40 0 0% 0% 0% 9 9 9 9 9 9 F YE0985-NU W/c seat lift mechanism $ 225.16 $ 225.16 0 0% 0% 0% 9 9 9 9 9 9 F E0985-RR W/c seat lift mechanism $ 22.52 $ 22.52 0 0% 0% 0% 9 9 9 9 9 9 F E0986-NU Man w/c push-rim powr system $ 8640.98 $ 8640.98 0 0% 0% 0% 9 9 9 9 9 9 F YE0986-RR Man w/c push-rim powr system $ 864.10 $ 864.10 0 0% 0% 0% 9 9 9 9 9 9 F YE0988-NU Lever-activated wheel drive $ 738.18 $ 738.18 0 0% 0% 0% 9 9 9 9 9 9 FE0990-NU Wheelchair elevating leg res $ 95.49 $ 95.49 0 0% 0% 0% 9 9 9 9 9 9 F E0990-RR Wheelchair elevating leg res $ 9.55 $ 9.55 0 0% 0% 0% 9 9 9 9 9 9 F E0992-NU Wheelchair solid seat insert $ 105.62 $ 105.62 0 0% 0% 0% 9 9 9 9 9 9 F E0992-RR Wheelchair solid seat insert $ 10.56 $ 10.56 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 53
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E0994-NU Wheelchair arm rest $ 19.56 $ 19.56 0 0% 0% 0% 9 9 9 9 9 9 F E0994-RR Wheelchair arm rest $ 1.96 $ 1.96 0 0% 0% 0% 9 9 9 9 9 9 F E0995-NU Wheelchair calf rest $ 29.08 $ 29.08 0 0% 0% 0% 9 9 9 9 9 9 F E0995-RR Wheelchair calf rest $ 2.91 $ 2.91 0 0% 0% 0% 9 9 9 9 9 9 F E1002-NU Pwr seat tilt $ 3877.40 $ 3877.40 0 0% 0% 0% 9 9 9 9 9 9 F YE1002-RR Pwr seat tilt $ 387.74 $ 387.74 0 0% 0% 0% 9 9 9 9 9 9 F YE1003-NU Pwr seat recline $ 4201.10 $ 4201.10 0 0% 0% 0% 9 9 9 9 9 9 F YE1003-RR Pwr seat recline $ 420.11 $ 420.11 0 0% 0% 0% 9 9 9 9 9 9 F YE1004-NU Pwr seat recline mech $ 4657.90 $ 4657.90 0 0% 0% 0% 9 9 9 9 9 9 F YE1004-RR Pwr seat recline mech $ 465.79 $ 465.79 0 0% 0% 0% 9 9 9 9 9 9 F YE1005-NU Pwr seat recline pwr $ 5041.90 $ 5041.90 0 0% 0% 0% 9 9 9 9 9 9 F YE1005-RR Pwr seat recline pwr $ 504.19 $ 504.19 0 0% 0% 0% 9 9 9 9 9 9 F YE1006-NU Pwr seat combo w/o shear $ 6175.80 $ 6175.80 0 0% 0% 0% 9 9 9 9 9 9 F YE1006-RR Pwr seat combo w/o shear $ 617.58 $ 617.58 0 0% 0% 0% 9 9 9 9 9 9 F YE1007-NU Pwr seat combo w/shear $ 8362.60 $ 8362.60 0 0% 0% 0% 9 9 9 9 9 9 F YE1007-RR Pwr seat combo w/shear $ 836.26 $ 836.26 0 0% 0% 0% 9 9 9 9 9 9 F YE1008-NU Pwr seat combo pwr shear $ 8363.20 $ 8363.20 0 0% 0% 0% 9 9 9 9 9 9 F YE1008-RR Pwr seat combo pwr shear $ 836.32 $ 836.32 0 0% 0% 0% 9 9 9 9 9 9 F YE1009-NU Add mech leg elevation By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1009-RR Add mech leg elevation By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1010-NU Add pwr leg elevation $ 1094.30 $ 1094.30 0 0% 0% 0% 9 9 9 9 9 9 F E1010-RR Add pwr leg elevation $ 109.43 $ 109.43 0 0% 0% 0% 9 9 9 9 9 9 F E1011 Ped wc modify width adjustm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1014 Reclining back add ped w/c Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1015-NU Shock absorber for man w/c $ 127.32 $ 127.32 0 0% 0% 0% 9 9 9 9 9 9 F E1016-NU Shock absorber for power w/c $ 125.63 $ 125.63 0 0% 0% 0% 9 9 9 9 9 9 F E1017-NU Hd shck absrbr for hd man wc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1018-NU Hd shck absrber for hd powwc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1020-NU Residual limb support system $ 232.86 $ 232.86 0 0% 0% 0% 9 9 9 9 9 9 F E1020-RR Residual limb support system $ 23.29 $ 23.29 0 0% 0% 0% 9 9 9 9 9 9 F E1028-NU W/c manual swingaway $ 197.59 $ 197.59 0 0% 0% 0% 9 9 9 9 9 9 F E1028-RR W/c manual swingaway $ 19.76 $ 19.76 0 0% 0% 0% 9 9 9 9 9 9 F E1029-NU W/c vent tray fixed $ 353.40 $ 353.40 0 0% 0% 0% 9 9 9 9 9 9 F E1029-RR W/c vent tray fixed $ 35.34 $ 35.34 0 0% 0% 0% 9 9 9 9 9 9 F E1030-NU W/c vent tray gimbaled $ 1114.80 $ 1114.80 0 0% 0% 0% 9 9 9 9 9 9 F E1030-RR W/c vent tray gimbaled $ 111.48 $ 111.48 0 0% 0% 0% 9 9 9 9 9 9 F E1031-NU Rollabout chair with casters $ 560.70 $ 560.70 0 0% 0% 0% 9 9 9 9 9 9 F E1031-RR Rollabout chair with casters $ 56.07 $ 56.07 0 0% 0% 0% 9 9 9 9 9 9 F E1035-NU Patient transfer system <300 $ 6806.30 $ 6806.30 0 0% 0% 0% 9 9 9 9 9 9 F E1035-RR Patient transfer system <300 $ 680.63 $ 680.63 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 54
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E1036-RR Patient transfer system >300 $ 954.17 $ 954.17 0 0% 0% 0% 9 9 9 9 9 9 FE1037 Transport chair, ped size Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1038-NU Transport chair pt wt<=300lb $ 200.10 $ 200.10 0 0% 0% 0% 9 9 9 9 9 9 F E1038-RR Transport chair pt wt<=300lb $ 20.01 $ 20.01 0 0% 0% 0% 9 9 9 9 9 9 F E1039-NU Transport chair pt wt >300lb $ 379.50 $ 379.50 0 0% 0% 0% 9 9 9 9 9 9 F E1039-RR Transport chair pt wt >300lb $ 37.95 $ 37.95 0 0% 0% 0% 9 9 9 9 9 9 F E1050-NU Whelchr fxd full length arms $ 1130.30 $ 1130.30 0 0% 0% 0% 9 9 9 9 9 9 F YE1050-RR Whelchr fxd full length arms $ 113.03 $ 113.03 0 0% 0% 0% 9 9 9 9 9 9 F YE1060-NU Wheelchair detachable arms $ 1378.90 $ 1378.90 0 0% 0% 0% 9 9 9 9 9 9 F YE1060-RR Wheelchair detachable arms $ 137.89 $ 137.89 0 0% 0% 0% 9 9 9 9 9 9 F YE1070-NU Wheelchair detachable foot r $ 1215.80 $ 1215.80 0 0% 0% 0% 9 9 9 9 9 9 F YE1070-RR Wheelchair detachable foot r $ 121.58 $ 121.58 0 0% 0% 0% 9 9 9 9 9 9 F YE1083-NU Hemi-wheelchair fixed arms $ 874.00 $ 874.00 0 0% 0% 0% 9 9 9 9 9 9 F YE1083-RR Hemi-wheelchair fixed arms $ 87.40 $ 87.40 0 0% 0% 0% 9 9 9 9 9 9 F YE1084-NU Hemi-wheelchair detachable a $ 1088.90 $ 1088.90 0 0% 0% 0% 9 9 9 9 9 9 F YE1084-RR Hemi-wheelchair detachable a $ 108.89 $ 108.89 0 0% 0% 0% 9 9 9 9 9 9 F YE1085-NU Hemi-wheelchair fixed arms $ 1552.51 $ 1552.51 0 0% 0% 0% 9 9 9 9 9 9 F YE1085-RR Hemi-wheelchair fixed arms $ 155.25 $ 155.25 0 0% 0% 0% 9 9 9 9 9 9 F YE1086-NU Hemi-wheelchair detachable a $ 1890.88 $ 1890.88 0 0% 0% 0% 9 9 9 9 9 9 F YE1086-RR Hemi-wheelchair detachable a $ 189.08 $ 189.08 0 0% 0% 0% 9 9 9 9 9 9 F YE1087-NU Wheelchair lightwt fixed arm $ 1361.70 $ 1361.70 0 0% 0% 0% 9 9 9 9 9 9 F YE1087-RR Wheelchair lightwt fixed arm $ 136.17 $ 136.17 0 0% 0% 0% 9 9 9 9 9 9 F YE1088-NU Wheelchair lightweight det a $ 1673.50 $ 1673.50 0 0% 0% 0% 9 9 9 9 9 9 F YE1088-RR Wheelchair lightweight det a $ 167.35 $ 167.35 0 0% 0% 0% 9 9 9 9 9 9 F YE1089-NU Wheelchair lightwt fixed arm $ 2509.90 $ 2509.90 0 0% 0% 0% 9 9 9 9 9 9 F YE1089-RR Wheelchair lightwt fixed arm $ 250.99 $ 250.99 0 0% 0% 0% 9 9 9 9 9 9 F YE1090-NU Wheelchair lightweight det a $ 2587.52 $ 2587.52 0 0% 0% 0% 9 9 9 9 9 9 F YE1090-RR Wheelchair lightweight det a $ 258.75 $ 258.75 0 0% 0% 0% 9 9 9 9 9 9 F YE1092-NU Wheelchair wide w/ leg rests $ 1426.50 $ 1426.50 0 0% 0% 0% 9 9 9 9 9 9 F YE1092-RR Wheelchair wide w/ leg rests $ 142.65 $ 142.65 0 0% 0% 0% 9 9 9 9 9 9 F YE1093-NU Wheelchair wide w/ foot rest $ 1226.70 $ 1226.70 0 0% 0% 0% 9 9 9 9 9 9 F YE1093-RR Wheelchair wide w/ foot rest $ 122.67 $ 122.67 0 0% 0% 0% 9 9 9 9 9 9 F YE1100-NU Whchr s-recl fxd arm leg res $ 1152.10 $ 1152.10 0 0% 0% 0% 9 9 9 9 9 9 F YE1100-RR Whchr s-recl fxd arm leg res $ 115.21 $ 115.21 0 0% 0% 0% 9 9 9 9 9 9 F YE1110-NU Wheelchair semi-recl detach $ 996.50 $ 996.50 0 0% 0% 0% 9 9 9 9 9 9 F YE1110-RR Wheelchair semi-recl detach $ 99.65 $ 99.65 0 0% 0% 0% 9 9 9 9 9 9 F YE1130-NU Whlchr stand fxd arm ft rest $ 995.20 $ 995.20 0 0% 0% 0% 9 9 9 9 9 9 F YE1130-RR Whlchr stand fxd arm ft rest $ 99.52 $ 99.52 0 0% 0% 0% 9 9 9 9 9 9 F YE1140-NU Wheelchair standard detach a $ 1433.09 $ 1433.09 0 0% 0% 0% 9 9 9 9 9 9 F YE1140-RR Wheelchair standard detach a $ 143.31 $ 143.31 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 55
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E1150-NU Wheelchair standard w/ leg r $ 905.40 $ 905.40 0 0% 0% 0% 9 9 9 9 9 9 F YE1150-RR Wheelchair standard w/ leg r $ 90.54 $ 90.54 0 0% 0% 0% 9 9 9 9 9 9 F YE1160-NU Wheelchair fixed arms $ 693.80 $ 693.80 0 0% 0% 0% 9 9 9 9 9 9 F YE1160-RR Wheelchair fixed arms $ 69.38 $ 69.38 0 0% 0% 0% 9 9 9 9 9 9 F YE1161-NU Manual adult wc w tiltinspac $ 2626.20 $ 2626.20 0 0% 0% 0% 9 9 9 9 9 9 F YE1161-RR Manual adult wc w tiltinspac $ 262.62 $ 262.62 0 0% 0% 0% 9 9 9 9 9 9 F YE1170-NU Whlchr ampu fxd arm leg rest $ 842.80 $ 842.80 0 0% 0% 0% 9 9 9 9 9 9 F YE1170-RR Whlchr ampu fxd arm leg rest $ 84.28 $ 84.28 0 0% 0% 0% 9 9 9 9 9 9 F YE1171-NU Wheelchair amputee w/o leg r $ 889.70 $ 889.70 0 0% 0% 0% 9 9 9 9 9 9 F YE1171-RR Wheelchair amputee w/o leg r $ 88.97 $ 88.97 0 0% 0% 0% 9 9 9 9 9 9 F YE1172-NU Wheelchair amputee detach ar $ 1087.30 $ 1087.30 0 0% 0% 0% 9 9 9 9 9 9 F YE1172-RR Wheelchair amputee detach ar $ 108.73 $ 108.73 0 0% 0% 0% 9 9 9 9 9 9 F YE1180-NU Wheelchair amputee w/ foot r $ 956.10 $ 956.10 0 0% 0% 0% 9 9 9 9 9 9 F YE1180-RR Wheelchair amputee w/ foot r $ 95.61 $ 95.61 0 0% 0% 0% 9 9 9 9 9 9 F YE1190-NU Wheelchair amputee w/ leg re $ 1299.50 $ 1299.50 0 0% 0% 0% 9 9 9 9 9 9 F YE1190-RR Wheelchair amputee w/ leg re $ 129.95 $ 129.95 0 0% 0% 0% 9 9 9 9 9 9 F YE1195-NU Wheelchair amputee heavy dut $ 1394.40 $ 1394.40 0 0% 0% 0% 9 9 9 9 9 9 F YE1195-RR Wheelchair amputee heavy dut $ 139.44 $ 139.44 0 0% 0% 0% 9 9 9 9 9 9 F YE1200-NU Wheelchair amputee fixed arm $ 965.80 $ 965.80 0 0% 0% 0% 9 9 9 9 9 9 F YE1200-RR Wheelchair amputee fixed arm $ 96.58 $ 96.58 0 0% 0% 0% 9 9 9 9 9 9 F YE1220-NU Whlchr special size/constrc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE1221-NU Wheelchair spec size w foot $ 458.80 $ 458.80 0 0% 0% 0% 9 9 9 9 9 9 F YE1221-RR Wheelchair spec size w foot $ 45.88 $ 45.88 0 0% 0% 0% 9 9 9 9 9 9 F YE1222-NU Wheelchair spec size w/ leg $ 752.40 $ 752.40 0 0% 0% 0% 9 9 9 9 9 9 F YE1222-RR Wheelchair spec size w/ leg $ 75.24 $ 75.24 0 0% 0% 0% 9 9 9 9 9 9 F YE1223-NU Wheelchair spec size w foot $ 821.50 $ 821.50 0 0% 0% 0% 9 9 9 9 9 9 F YE1223-RR Wheelchair spec size w foot $ 82.15 $ 82.15 0 0% 0% 0% 9 9 9 9 9 9 F YE1224-NU Wheelchair spec size w/ leg $ 900.70 $ 900.70 0 0% 0% 0% 9 9 9 9 9 9 F YE1224-RR Wheelchair spec size w/ leg $ 90.07 $ 90.07 0 0% 0% 0% 9 9 9 9 9 9 F YE1225-NU Manual semi-reclining back $ 501.70 $ 501.70 0 0% 0% 0% 9 9 9 9 9 9 F YE1225-RR Manual semi-reclining back $ 50.17 $ 50.17 0 0% 0% 0% 9 9 9 9 9 9 F YE1226-NU Manual fully reclining back $ 605.65 $ 605.65 0 0% 0% 0% 9 9 9 9 9 9 F YE1226-RR Manual fully reclining back $ 60.57 $ 60.57 0 0% 0% 0% 9 9 9 9 9 9 F YE1227-NU Wheelchair spec sz spec ht a $ 308.01 $ 308.01 0 0% 0% 0% 9 9 9 9 9 9 F YE1227-RR Wheelchair spec sz spec ht a $ 30.80 $ 30.80 0 0% 0% 0% 9 9 9 9 9 9 F YE1228-NU Wheelchair spec sz spec ht b $ 306.90 $ 306.90 0 0% 0% 0% 9 9 9 9 9 9 F YE1228-RR Wheelchair spec sz spec ht b $ 30.69 $ 30.69 0 0% 0% 0% 9 9 9 9 9 9 F YE1229 Pediatric wheelchair nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1230-NU Power operated vehicle $ 2510.48 $ 2510.48 0 0% 0% 0% 9 9 9 9 9 9 F YE1231 Rigid ped w/c tilt-in-space Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 56
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E1232 Folding ped wc tilt-in-space Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1233 Rig ped wc tltnspc w/o seat Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1234 Fld ped wc tltnspc w/o seat Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1235 Rigid ped wc adjustable Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1236 Folding ped wc adjustable Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1237 Rgd ped wc adjstabl w/o seat Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1238 Fld ped wc adjstabl w/o seat Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1239 Ped power wheelchair nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1240-NU Whchr litwt det arm leg rest $ 1143.50 $ 1143.50 0 0% 0% 0% 9 9 9 9 9 9 F YE1240-RR Whchr litwt det arm leg rest $ 114.35 $ 114.35 0 0% 0% 0% 9 9 9 9 9 9 F YE1250-NU Wheelchair lightwt fixed arm $ 1532.61 $ 1532.61 0 0% 0% 0% 9 9 9 9 9 9 F YE1250-RR Wheelchair lightwt fixed arm $ 153.26 $ 153.26 0 0% 0% 0% 9 9 9 9 9 9 F YE1260-NU Wheelchair lightwt foot rest $ 1791.36 $ 1791.36 0 0% 0% 0% 9 9 9 9 9 9 F YE1260-RR Wheelchair lightwt foot rest $ 179.14 $ 179.14 0 0% 0% 0% 9 9 9 9 9 9 F YE1270-NU Wheelchair lightweight leg r $ 876.20 $ 876.20 0 0% 0% 0% 9 9 9 9 9 9 F YE1270-RR Wheelchair lightweight leg r $ 87.62 $ 87.62 0 0% 0% 0% 9 9 9 9 9 9 F YE1280-NU Whchr h-duty det arm leg res $ 1441.00 $ 1441.00 0 0% 0% 0% 9 9 9 9 9 9 F YE1280-RR Whchr h-duty det arm leg res $ 144.10 $ 144.10 0 0% 0% 0% 9 9 9 9 9 9 F YE1285-NU Wheelchair heavy duty fixed $ 2308.86 $ 2308.86 0 0% 0% 0% 9 9 9 9 9 9 F YE1285-RR Wheelchair heavy duty fixed $ 230.89 $ 230.89 0 0% 0% 0% 9 9 9 9 9 9 F YE1290-NU Wheelchair hvy duty detach a $ 2388.48 $ 2388.48 0 0% 0% 0% 9 9 9 9 9 9 F YE1290-RR Wheelchair hvy duty detach a $ 238.85 $ 238.85 0 0% 0% 0% 9 9 9 9 9 9 F YE1295-NU Wheelchair heavy duty fixed $ 1348.20 $ 1348.20 0 0% 0% 0% 9 9 9 9 9 9 F YE1295-RR Wheelchair heavy duty fixed $ 134.82 $ 134.82 0 0% 0% 0% 9 9 9 9 9 9 F YE1296-NU Wheelchair special seat heig $ 545.71 $ 545.71 0 0% 0% 0% 9 9 9 9 9 9 F E1296-RR Wheelchair special seat heig $ 54.57 $ 54.57 0 0% 0% 0% 9 9 9 9 9 9 F E1297-NU Wheelchair special seat dept $ 116.11 $ 116.11 0 0% 0% 0% 9 9 9 9 9 9 F E1297-RR Wheelchair special seat dept $ 11.61 $ 11.61 0 0% 0% 0% 9 9 9 9 9 9 F E1298-NU Wheelchair spec seat depth/w $ 470.24 $ 470.24 0 0% 0% 0% 9 9 9 9 9 9 F E1298-RR Wheelchair spec seat depth/w $ 47.02 $ 47.02 0 0% 0% 0% 9 9 9 9 9 9 F E1300 Whirlpool portable Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1310 Whirlpool non-portable Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E1352-RR O2 flow reg pos inspir press By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE1353-RR Oxygen supplies regulator $ 7.38 $ 7.38 0 0% 0% 0% 9 9 9 9 9 9 F YE1354-RR Wheeled cart, port cyl/conc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE1355-RR Oxygen supplies stand/rack $ 5.55 $ 5.55 0 0% 0% 0% 9 9 9 9 9 9 F YE1356-RR Batt pack/cart, port conc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE1357-RR Battery charger, port conc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE1358-RR Dc power adapter, port conc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE1372-NU Oxy suppl heater for nebuliz $ 180.95 $ 180.95 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 57
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E1372-RR Oxy suppl heater for nebuliz $ 18.10 $ 18.10 0 0% 0% 0% 9 9 9 9 9 9 F E1390-RR Oxygen concentrator $ 180.92 $ 180.92 0 0% 0% 0% 9 9 9 9 9 9 F YE1391-RR Oxygen concentrator, dual $ 180.92 $ 180.92 0 0% 0% 0% 9 9 9 9 9 9 F YE1392-RR Portable oxygen concentrator $ 51.63 $ 51.63 0 0% 0% 0% 9 9 9 9 9 9 F YE1399-NU Durable medical equipment mi By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1399-RR Durable medical equipment mi By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1405-RR O2/water vapor enrich w/heat $ 214.00 $ 214.00 0 0% 0% 0% 9 9 9 9 9 9 F YE1406-RR O2/water vapor enrich w/o he $ 198.79 $ 198.79 0 0% 0% 0% 9 9 9 9 9 9 F YE1500-RR Centrifuge By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1510-RR Kidney dialysate delivry sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1520-RR Heparin infusion pump By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1530-RR Replacement air bubble detec By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1540-RR Replacement pressure alarm By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1550-RR Bath conductivity meter By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1560-RR Replace blood leak detector By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1570-RR Adjustable chair for esrd pt By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1575-RR Transducer protect/fld bar By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1580-RR Unipuncture control system By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1590-RR Hemodialysis machine By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1592-RR Auto interm peritoneal dialy By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1594-RR Cycler dialysis machine By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1600-NU Deli/install chrg hemo equip By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1610-RR Reverse osmosis h2o puri sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1615-RR Deionizer h2o puri system By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1620-RR Replacement blood pump By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1625-RR Water softening system By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1630-RR Reciprocating peritoneal dia By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1632-RR Wearable artificial kidney By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1634-NU Peritoneal dialysis clamp By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1635-RR Compact travel hemodialyzer By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1636-NU Sorbent cartridges per 10 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1637-NU Hemostats for dialysis, each By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1639-RR Dialysis scale By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E1699-NU Dialysis equipment noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE1699-RR Dialysis equipment noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE1700-NU Jaw motion rehab system $ 325.40 $ 325.40 0 0% 0% 0% 9 9 9 9 9 9 F YE1700-RR Jaw motion rehab system $ 32.54 $ 32.54 0 0% 0% 0% 9 9 9 9 9 9 F YE1701-NU Repl cushions for jaw motion $ 11.14 $ 11.14 0 0% 0% 0% 9 9 9 9 9 9 F E1702-NU Repl measr scales jaw motion $ 23.70 $ 23.70 0 0% 0% 0% 9 9 9 9 9 9 F E1800-RR Adjust elbow ext/flex device $ 135.97 $ 135.97 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 58
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E1801-RR Sps elbow device $ 143.19 $ 143.19 0 0% 0% 0% 9 9 9 9 9 9 F E1802-RR Adjst forearm pro/sup device $ 362.74 $ 362.74 0 0% 0% 0% 9 9 9 9 9 9 F E1805-RR Adjust wrist ext/flex device $ 140.24 $ 140.24 0 0% 0% 0% 9 9 9 9 9 9 F E1806-RR Sps wrist device $ 117.57 $ 117.57 0 0% 0% 0% 9 9 9 9 9 9 F E1810-RR Adjust knee ext/flex device $ 138.28 $ 138.28 0 0% 0% 0% 9 9 9 9 9 9 F E1811-RR Sps knee device $ 148.87 $ 148.87 0 0% 0% 0% 9 9 9 9 9 9 F E1812-RR Knee ext/flex w act res ctrl $ 95.44 $ 95.44 0 0% 0% 0% 9 9 9 9 9 9 F E1815-RR Adjust ankle ext/flex device $ 140.24 $ 140.24 0 0% 0% 0% 9 9 9 9 9 9 F E1816-RR Sps ankle device $ 151.22 $ 151.22 0 0% 0% 0% 9 9 9 9 9 9 F E1818-RR Sps forearm device $ 154.38 $ 154.38 0 0% 0% 0% 9 9 9 9 9 9 F E1820-NU Soft interface material $ 85.58 $ 85.58 0 0% 0% 0% 9 9 9 9 9 9 F E1821-NU Replacement interface spsd $ 116.82 $ 116.82 0 0% 0% 0% 9 9 9 9 9 9 F E1825-RR Adjust finger ext/flex devc $ 140.24 $ 140.24 0 0% 0% 0% 9 9 9 9 9 9 F E1830-RR Adjust toe ext/flex device $ 140.24 $ 140.24 0 0% 0% 0% 9 9 9 9 9 9 F E1831-RR Static str toe dev ext/flex $ 73.34 $ 73.34 0 0% 0% 0% 9 9 9 9 9 9 FE1840-RR Adj shoulder ext/flex device $ 424.79 $ 424.79 0 0% 0% 0% 9 9 9 9 9 9 F E1841-RR Static str shldr dev rom adj $ 502.79 $ 502.79 0 0% 0% 0% 9 9 9 9 9 9 F E1902-RR Aac non-electronic board By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2000-RR Gastric suction pump hme mdl $ 57.53 $ 57.53 0 0% 0% 0% 9 9 9 9 9 9 F YE2100-NU Bld glucose monitor w voice $ 645.55 $ 645.55 0 0% 0% 0% 9 9 9 9 9 9 F E2101-NU Bld glucose monitor w lance $ 209.29 $ 209.29 0 0% 0% 0% 9 9 9 9 9 9 F E2120 Pulse gen sys tx endolymp fl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E2201-NU Man w/ch acc seat w>=20"<24" $ 414.13 $ 414.13 0 0% 0% 0% 9 9 9 9 9 9 F E2201-RR Man w/ch acc seat w>=20"<24" $ 41.41 $ 41.41 0 0% 0% 0% 9 9 9 9 9 9 F E2202-NU Seat width 24-27 in $ 526.08 $ 526.08 0 0% 0% 0% 9 9 9 9 9 9 F E2202-RR Seat width 24-27 in $ 52.61 $ 52.61 0 0% 0% 0% 9 9 9 9 9 9 F E2203-NU Frame depth less than 22 in $ 531.73 $ 531.73 0 0% 0% 0% 9 9 9 9 9 9 F E2203-RR Frame depth less than 22 in $ 53.17 $ 53.17 0 0% 0% 0% 9 9 9 9 9 9 F E2204-NU Frame depth 22 to 25 in $ 902.84 $ 902.84 0 0% 0% 0% 9 9 9 9 9 9 F E2204-RR Frame depth 22 to 25 in $ 90.28 $ 90.28 0 0% 0% 0% 9 9 9 9 9 9 F E2205-NU Manual wc accessory, handrim $ 36.26 $ 36.26 0 0% 0% 0% 9 9 9 9 9 9 F E2205-RR Manual wc accessory, handrim $ 3.63 $ 3.63 0 0% 0% 0% 9 9 9 9 9 9 F E2206-NU Complete wheel lock assembly $ 45.15 $ 45.15 0 0% 0% 0% 9 9 9 9 9 9 F E2206-RR Complete wheel lock assembly $ 4.52 $ 4.52 0 0% 0% 0% 9 9 9 9 9 9 F E2207-NU Crutch and cane holder $ 48.11 $ 48.11 0 0% 0% 0% 9 9 9 9 9 9 F E2207-RR Crutch and cane holder $ 4.81 $ 4.81 0 0% 0% 0% 9 9 9 9 9 9 F E2208-NU Cylinder tank carrier $ 113.64 $ 113.64 0 0% 0% 0% 9 9 9 9 9 9 F E2208-RR Cylinder tank carrier $ 11.36 $ 11.36 0 0% 0% 0% 9 9 9 9 9 9 F E2209-NU Arm trough each $ 102.52 $ 102.52 0 0% 0% 0% 9 9 9 9 9 9 F E2209-RR Arm trough each $ 10.25 $ 10.25 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 59
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E2210-NU Wheelchair bearings $ 6.26 $ 6.26 0 0% 0% 0% 9 9 9 9 9 9 F E2211-NU Pneumatic propulsion tire $ 45.41 $ 45.41 0 0% 0% 0% 9 9 9 9 9 9 F E2212-NU Pneumatic prop tire tube $ 6.52 $ 6.52 0 0% 0% 0% 9 9 9 9 9 9 F E2213-NU Pneumatic prop tire insert $ 33.76 $ 33.76 0 0% 0% 0% 9 9 9 9 9 9 F E2214-NU Pneumatic caster tire each $ 39.96 $ 39.96 0 0% 0% 0% 9 9 9 9 9 9 F E2215-NU Pneumatic caster tire tube $ 10.48 $ 10.48 0 0% 0% 0% 9 9 9 9 9 9 F E2216-NU Foam filled propulsion tire By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E2217-NU Foam filled caster tire each By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E2218-NU Foam propulsion tire each By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E2219-NU Foam caster tire any size ea $ 46.45 $ 46.45 0 0% 0% 0% 9 9 9 9 9 9 F E2220-NU Solid propulsion tire each $ 31.67 $ 31.67 0 0% 0% 0% 9 9 9 9 9 9 F E2221-NU Solid caster tire each $ 28.36 $ 28.36 0 0% 0% 0% 9 9 9 9 9 9 F E2222-NU Solid caster integrated whl $ 23.38 $ 23.38 0 0% 0% 0% 9 9 9 9 9 9 F E2224-NU Propulsion whl excludes tire $ 92.51 $ 92.51 0 0% 0% 0% 9 9 9 9 9 9 F E2225-NU Caster wheel excludes tire $ 19.32 $ 19.32 0 0% 0% 0% 9 9 9 9 9 9 F E2226-NU Caster fork replacement only $ 42.12 $ 42.12 0 0% 0% 0% 9 9 9 9 9 9 F E2227-NU Gear reduction drive wheel $ 2076.50 $ 2076.50 0 0% 0% 0% 9 9 9 9 9 9 F E2227-RR Gear reduction drive wheel $ 207.65 $ 207.65 0 0% 0% 0% 9 9 9 9 9 9 F E2228-NU Mwc acc, wheelchair brake $ 1039.21 $ 1039.21 0 0% 0% 0% 9 9 9 9 9 9 F E2228-RR Mwc acc, wheelchair brake $ 103.92 $ 103.92 0 0% 0% 0% 9 9 9 9 9 9 F E2230-NU Manual standing system By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2230-RR Manual standing system By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2231-NU Solid seat support base $ 170.57 $ 170.57 0 0% 0% 0% 9 9 9 9 9 9 F E2231-RR Solid seat support base $ 17.06 $ 17.06 0 0% 0% 0% 9 9 9 9 9 9 F E2291 Planar back for ped size wc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E2292 Planar seat for ped size wc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E2293 Contour back for ped size wc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E2294 Contour seat for ped size wc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E2295 Ped dynamic seating frame Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E2300-NU Pwr seat elevation sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2300-RR Pwr seat elevation sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2301-NU Pwr standing By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2301-RR Pwr standing By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2310-NU Electro connect btw control $ 1119.40 $ 1119.40 0 0% 0% 0% 9 9 9 9 9 9 F E2310-RR Electro connect btw control $ 111.94 $ 111.94 0 0% 0% 0% 9 9 9 9 9 9 F E2311-NU Electro connect btw 2 sys $ 2266.60 $ 2266.60 0 0% 0% 0% 9 9 9 9 9 9 F E2311-RR Electro connect btw 2 sys $ 226.66 $ 226.66 0 0% 0% 0% 9 9 9 9 9 9 F E2312-NU Mini-prop remote joystick $ 2238.40 $ 2238.40 0 0% 0% 0% 9 9 9 9 9 9 F E2312-RR Mini-prop remote joystick $ 223.84 $ 223.84 0 0% 0% 0% 9 9 9 9 9 9 F E2313-NU Pwc harness, expand control $ 355.70 $ 355.70 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 60
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E2313-RR Pwc harness, expand control $ 35.57 $ 35.57 0 0% 0% 0% 9 9 9 9 9 9 F E2321-NU Hand interface joystick $ 1520.40 $ 1520.40 0 0% 0% 0% 9 9 9 9 9 9 F E2321-RR Hand interface joystick $ 152.04 $ 152.04 0 0% 0% 0% 9 9 9 9 9 9 F E2322-NU Mult mech switches $ 1349.10 $ 1349.10 0 0% 0% 0% 9 9 9 9 9 9 F E2322-RR Mult mech switches $ 134.91 $ 134.91 0 0% 0% 0% 9 9 9 9 9 9 F E2323-NU Special joystick handle $ 66.17 $ 66.17 0 0% 0% 0% 9 9 9 9 9 9 F E2323-RR Special joystick handle $ 6.62 $ 6.62 0 0% 0% 0% 9 9 9 9 9 9 F E2324-NU Chin cup interface $ 41.92 $ 41.92 0 0% 0% 0% 9 9 9 9 9 9 F E2324-RR Chin cup interface $ 4.19 $ 4.19 0 0% 0% 0% 9 9 9 9 9 9 F E2325-NU Sip and puff interface $ 1288.60 $ 1288.60 0 0% 0% 0% 9 9 9 9 9 9 F E2325-RR Sip and puff interface $ 128.86 $ 128.86 0 0% 0% 0% 9 9 9 9 9 9 F E2326-NU Breath tube kit $ 332.20 $ 332.20 0 0% 0% 0% 9 9 9 9 9 9 F E2326-RR Breath tube kit $ 33.22 $ 33.22 0 0% 0% 0% 9 9 9 9 9 9 F E2327-NU Head control interface mech $ 2499.10 $ 2499.10 0 0% 0% 0% 9 9 9 9 9 9 F E2327-RR Head control interface mech $ 249.91 $ 249.91 0 0% 0% 0% 9 9 9 9 9 9 F E2328-NU Head/extremity control inter $ 4740.50 $ 4740.50 0 0% 0% 0% 9 9 9 9 9 9 F E2328-RR Head/extremity control inter $ 474.05 $ 474.05 0 0% 0% 0% 9 9 9 9 9 9 F E2329-NU Head control nonproportional $ 1689.60 $ 1689.60 0 0% 0% 0% 9 9 9 9 9 9 F E2329-RR Head control nonproportional $ 168.96 $ 168.96 0 0% 0% 0% 9 9 9 9 9 9 F E2330-NU Head control proximity switc $ 3273.70 $ 3273.70 0 0% 0% 0% 9 9 9 9 9 9 F E2330-RR Head control proximity switc $ 327.37 $ 327.37 0 0% 0% 0% 9 9 9 9 9 9 F E2331-NU Attendant control By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2331-RR Attendant control By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2340-NU W/c wdth 20-23 in seat frame $ 397.76 $ 397.76 0 0% 0% 0% 9 9 9 9 9 9 F E2340-RR W/c wdth 20-23 in seat frame $ 39.78 $ 39.78 0 0% 0% 0% 9 9 9 9 9 9 F E2341-NU W/c wdth 24-27 in seat frame $ 596.69 $ 596.69 0 0% 0% 0% 9 9 9 9 9 9 F E2341-RR W/c wdth 24-27 in seat frame $ 59.67 $ 59.67 0 0% 0% 0% 9 9 9 9 9 9 F E2342-NU W/c dpth 20-21 in seat frame $ 497.24 $ 497.24 0 0% 0% 0% 9 9 9 9 9 9 F E2342-RR W/c dpth 20-21 in seat frame $ 49.72 $ 49.72 0 0% 0% 0% 9 9 9 9 9 9 F E2343-NU W/c dpth 22-25 in seat frame $ 795.59 $ 795.59 0 0% 0% 0% 9 9 9 9 9 9 F E2343-RR W/c dpth 22-25 in seat frame $ 79.56 $ 79.56 0 0% 0% 0% 9 9 9 9 9 9 F E2351-NU Electronic sgd interface $ 668.60 $ 668.60 0 0% 0% 0% 9 9 9 9 9 9 F E2351-RR Electronic sgd interface $ 66.86 $ 66.86 0 0% 0% 0% 9 9 9 9 9 9 F E2358-NU Gr 34 nonsealed leadacid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NE2359-NU Gr34 sealed leadacid battery $ 193.29 $ 193.29 0 0% 0% 0% 9 9 9 9 9 9 FE2360-NU 22nf nonsealed leadacid $ 115.91 $ 115.91 0 0% 0% 0% 9 9 9 9 9 9 F E2360-RR 22nf nonsealed leadacid $ 11.59 $ 11.59 0 0% 0% 0% 9 9 9 9 9 9 F E2361-NU 22nf sealed leadacid battery $ 133.42 $ 133.42 0 0% 0% 0% 9 9 9 9 9 9 F E2361-RR 22nf sealed leadacid battery $ 13.34 $ 13.34 0 0% 0% 0% 9 9 9 9 9 9 F E2362-NU Gr24 nonsealed leadacid $ 102.10 $ 102.10 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 61
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E2362-RR Gr24 nonsealed leadacid $ 10.21 $ 10.21 0 0% 0% 0% 9 9 9 9 9 9 F E2363-NU Gr24 sealed leadacid battery $ 177.95 $ 177.95 0 0% 0% 0% 9 9 9 9 9 9 F E2363-RR Gr24 sealed leadacid battery $ 17.80 $ 17.80 0 0% 0% 0% 9 9 9 9 9 9 F E2364-NU U1nonsealed leadacid battery $ 115.91 $ 115.91 0 0% 0% 0% 9 9 9 9 9 9 F E2364-RR U1nonsealed leadacid battery $ 11.59 $ 11.59 0 0% 0% 0% 9 9 9 9 9 9 F E2365-NU U1 sealed leadacid battery $ 107.31 $ 107.31 0 0% 0% 0% 9 9 9 9 9 9 F E2365-RR U1 sealed leadacid battery $ 10.73 $ 10.73 0 0% 0% 0% 9 9 9 9 9 9 F E2366-NU Battery charger, single mode $ 252.20 $ 252.20 0 0% 0% 0% 9 9 9 9 9 9 F E2366-RR Battery charger, single mode $ 25.22 $ 25.22 0 0% 0% 0% 9 9 9 9 9 9 F E2367-NU Battery charger, dual mode $ 400.91 $ 400.91 0 0% 0% 0% 9 9 9 9 9 9 F E2367-RR Battery charger, dual mode $ 40.09 $ 40.09 0 0% 0% 0% 9 9 9 9 9 9 F E2368-NU Pwr wc drivewheel motor repl $ 494.19 $ 494.19 0 0% 0% 0% 9 9 9 9 9 9 F E2368-RR Pwr wc drivewheel motor repl $ 49.42 $ 49.42 0 0% 0% 0% 9 9 9 9 9 9 F E2369-NU Pwr wc drivewheel gear repl $ 430.44 $ 430.44 0 0% 0% 0% 9 9 9 9 9 9 F E2369-RR Pwr wc drivewheel gear repl $ 43.04 $ 43.04 0 0% 0% 0% 9 9 9 9 9 9 F E2370-NU Pwr wc dr wh motor/gear comb $ 768.05 $ 768.05 0 0% 0% 0% 9 9 9 9 9 9 F E2370-RR Pwr wc dr wh motor/gear comb $ 76.81 $ 76.81 0 0% 0% 0% 9 9 9 9 9 9 F E2371-NU Gr27 sealed leadacid battery $ 144.21 $ 144.21 0 0% 0% 0% 9 9 9 9 9 9 F E2372-NU Gr27 non-sealed leadacid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E2373-NU Hand/chin ctrl spec joystick $ 780.10 $ 780.10 0 0% 0% 0% 9 9 9 9 9 9 F E2373-RR Hand/chin ctrl spec joystick $ 78.01 $ 78.01 0 0% 0% 0% 9 9 9 9 9 9 F E2374-NU Hand/chin ctrl std joystick $ 511.00 $ 511.00 0 0% 0% 0% 9 9 9 9 9 9 F E2374-RR Hand/chin ctrl std joystick $ 51.10 $ 51.10 0 0% 0% 0% 9 9 9 9 9 9 F E2375-NU Non-expandable controller $ 819.44 $ 819.44 0 0% 0% 0% 9 9 9 9 9 9 F E2375-RR Non-expandable controller $ 81.94 $ 81.94 0 0% 0% 0% 9 9 9 9 9 9 F E2376-NU Expandable controller, repl $ 1284.10 $ 1284.10 0 0% 0% 0% 9 9 9 9 9 9 F E2376-RR Expandable controller, repl $ 128.41 $ 128.41 0 0% 0% 0% 9 9 9 9 9 9 F E2377-NU Expandable controller, initl $ 464.60 $ 464.60 0 0% 0% 0% 9 9 9 9 9 9 F E2377-RR Expandable controller, initl $ 46.46 $ 46.46 0 0% 0% 0% 9 9 9 9 9 9 F E2378-NU Pw actuator replacement $ 568.00 $ 568.00 0 0% 0% 0% 9 9 9 9 9 9 FE2381-NU Pneum drive wheel tire $ 71.65 $ 71.65 0 0% 0% 0% 9 9 9 9 9 9 F E2381-RR Pneum drive wheel tire $ 7.17 $ 7.17 0 0% 0% 0% 9 9 9 9 9 9 F E2382-NU Tube, pneum wheel drive tire $ 19.86 $ 19.86 0 0% 0% 0% 9 9 9 9 9 9 F E2382-RR Tube, pneum wheel drive tire $ 1.99 $ 1.99 0 0% 0% 0% 9 9 9 9 9 9 F E2383-NU Insert, pneum wheel drive $ 145.30 $ 145.30 0 0% 0% 0% 9 9 9 9 9 9 F E2383-RR Insert, pneum wheel drive $ 14.53 $ 14.53 0 0% 0% 0% 9 9 9 9 9 9 F E2384-NU Pneumatic caster tire $ 77.41 $ 77.41 0 0% 0% 0% 9 9 9 9 9 9 F E2384-RR Pneumatic caster tire $ 7.74 $ 7.74 0 0% 0% 0% 9 9 9 9 9 9 F E2385-NU Tube, pneumatic caster tire $ 47.36 $ 47.36 0 0% 0% 0% 9 9 9 9 9 9 F E2385-RR Tube, pneumatic caster tire $ 4.74 $ 4.74 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 62
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E2386-NU Foam filled drive wheel tire $ 143.98 $ 143.98 0 0% 0% 0% 9 9 9 9 9 9 F E2386-RR Foam filled drive wheel tire $ 14.40 $ 14.40 0 0% 0% 0% 9 9 9 9 9 9 F E2387-NU Foam filled caster tire $ 64.56 $ 64.56 0 0% 0% 0% 9 9 9 9 9 9 F E2387-RR Foam filled caster tire $ 6.46 $ 6.46 0 0% 0% 0% 9 9 9 9 9 9 F E2388-NU Foam drive wheel tire $ 48.19 $ 48.19 0 0% 0% 0% 9 9 9 9 9 9 F E2388-RR Foam drive wheel tire $ 4.82 $ 4.82 0 0% 0% 0% 9 9 9 9 9 9 F E2389-NU Foam caster tire $ 26.18 $ 26.18 0 0% 0% 0% 9 9 9 9 9 9 F E2389-RR Foam caster tire $ 2.62 $ 2.62 0 0% 0% 0% 9 9 9 9 9 9 F E2390-NU Solid drive wheel tire $ 40.93 $ 40.93 0 0% 0% 0% 9 9 9 9 9 9 F E2390-RR Solid drive wheel tire $ 4.09 $ 4.09 0 0% 0% 0% 9 9 9 9 9 9 F E2391-NU Solid caster tire $ 19.60 $ 19.60 0 0% 0% 0% 9 9 9 9 9 9 F E2391-RR Solid caster tire $ 1.96 $ 1.96 0 0% 0% 0% 9 9 9 9 9 9 F E2392-NU Solid caster tire, integrate $ 51.54 $ 51.54 0 0% 0% 0% 9 9 9 9 9 9 F E2392-RR Solid caster tire, integrate $ 5.15 $ 5.15 0 0% 0% 0% 9 9 9 9 9 9 F E2394-NU Drive wheel excludes tire $ 73.44 $ 73.44 0 0% 0% 0% 9 9 9 9 9 9 F E2394-RR Drive wheel excludes tire $ 7.34 $ 7.34 0 0% 0% 0% 9 9 9 9 9 9 F E2395-NU Caster wheel excludes tire $ 52.18 $ 52.18 0 0% 0% 0% 9 9 9 9 9 9 F E2395-RR Caster wheel excludes tire $ 5.22 $ 5.22 0 0% 0% 0% 9 9 9 9 9 9 F E2396-NU Caster fork $ 63.62 $ 63.62 0 0% 0% 0% 9 9 9 9 9 9 F E2396-RR Caster fork $ 6.36 $ 6.36 0 0% 0% 0% 9 9 9 9 9 9 F E2397-NU Pwc acc, lith-based battery $ 459.67 $ 459.67 0 0% 0% 0% 9 9 9 9 9 9 F E2397-RR Pwc acc, lith-based battery $ 45.97 $ 45.97 0 0% 0% 0% 9 9 9 9 9 9 F E2402-RR Neg press wound therapy pump $ 164.21 $ 164.21 0 0% 0% 0% 9 9 9 9 9 9 F YE2500-NU Sgd digitized pre-rec <=8min $ 434.10 $ 434.10 0 0% 0% 0% 9 9 9 9 9 9 F E2500-RR Sgd digitized pre-rec <=8min $ 43.41 $ 43.41 0 0% 0% 0% 9 9 9 9 9 9 F E2502-NU Sgd prerec msg >8min <=20min $ 1327.30 $ 1327.30 0 0% 0% 0% 9 9 9 9 9 9 F E2502-RR Sgd prerec msg >8min <=20min $ 132.73 $ 132.73 0 0% 0% 0% 9 9 9 9 9 9 F
E2504-NU Sgd prerec msg>20min <=40min $ 1751.10 $ 1751.10 0 0% 0% 0% 9 9 9 9 9 9 F
E2504-RR Sgd prerec msg>20min <=40min $ 175.11 $ 175.11 0 0% 0% 0% 9 9 9 9 9 9 F E2506-NU Sgd prerec msg > 40 min $ 2567.10 $ 2567.10 0 0% 0% 0% 9 9 9 9 9 9 F E2506-RR Sgd prerec msg > 40 min $ 256.71 $ 256.71 0 0% 0% 0% 9 9 9 9 9 9 F E2508-NU Sgd spelling phys contact $ 3969.80 $ 3969.80 0 0% 0% 0% 9 9 9 9 9 9 F E2508-RR Sgd spelling phys contact $ 396.98 $ 396.98 0 0% 0% 0% 9 9 9 9 9 9 F E2510-NU Sgd w multi methods msg/accs $ 7512.40 $ 7512.40 0 0% 0% 0% 9 9 9 9 9 9 F E2510-RR Sgd w multi methods msg/accs $ 751.24 $ 751.24 0 0% 0% 0% 9 9 9 9 9 9 F E2511-NU Sgd sftwre prgrm for pc/pda By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E2511-RR Sgd sftwre prgrm for pc/pda By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E2512-NU Sgd accessory, mounting sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 63
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
E2512-RR Sgd accessory, mounting sys By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E2599-NU Sgd accessory noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2599-RR Sgd accessory noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2601-NU Gen w/c cushion wdth < 22 in $ 58.50 $ 58.50 0 0% 0% 0% 9 9 9 9 9 9 F E2602-NU Gen w/c cushion wdth >=22 in $ 114.22 $ 114.22 0 0% 0% 0% 9 9 9 9 9 9 F E2603-NU Skin protect wc cus wd <22in $ 145.01 $ 145.01 0 0% 0% 0% 9 9 9 9 9 9 F E2604-NU Skin protect wc cus wd>=22in $ 180.25 $ 180.25 0 0% 0% 0% 9 9 9 9 9 9 F E2605-NU Position wc cush wdth <22 in $ 257.51 $ 257.51 0 0% 0% 0% 9 9 9 9 9 9 F E2606-NU Position wc cush wdth>=22 in $ 401.74 $ 401.74 0 0% 0% 0% 9 9 9 9 9 9 F E2607-NU Skin pro/pos wc cus wd <22in $ 277.29 $ 277.29 0 0% 0% 0% 9 9 9 9 9 9 F E2608-NU Skin pro/pos wc cus wd>=22in $ 333.00 $ 333.00 0 0% 0% 0% 9 9 9 9 9 9 F E2609-NU Custom fabricate w/c cushion By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2610-NU Powered w/c cushion By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N E2611-NU Gen use back cush wdth <22in $ 298.82 $ 298.82 0 0% 0% 0% 9 9 9 9 9 9 F E2612-NU Gen use back cush wdth>=22in $ 404.23 $ 404.23 0 0% 0% 0% 9 9 9 9 9 9 F E2613-NU Position back cush wd <22in $ 376.01 $ 376.01 0 0% 0% 0% 9 9 9 9 9 9 F E2614-NU Position back cush wd>=22in $ 520.37 $ 520.37 0 0% 0% 0% 9 9 9 9 9 9 F E2615-NU Pos back post/lat wdth <22in $ 432.71 $ 432.71 0 0% 0% 0% 9 9 9 9 9 9 F E2616-NU Pos back post/lat wdth>=22in $ 582.21 $ 582.21 0 0% 0% 0% 9 9 9 9 9 9 F E2617-NU Custom fab w/c back cushion By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YE2619-NU Replace cover w/c seat cush $ 49.09 $ 49.09 0 0% 0% 0% 9 9 9 9 9 9 F E2620-NU Wc planar back cush wd <22in $ 523.96 $ 523.96 0 0% 0% 0% 9 9 9 9 9 9 F E2621-NU Wc planar back cush wd>=22in $ 549.86 $ 549.86 0 0% 0% 0% 9 9 9 9 9 9 F E2622-NU Adj skin pro w/c cus wd<22in $ 317.10 $ 317.10 0 0% 0% 0% 9 9 9 9 9 9 FE2623-NU Adj skin pro wc cus wd>=22in $ 403.50 $ 403.50 0 0% 0% 0% 9 9 9 9 9 9 FE2624-NU Adj skin pro/pos cus<22in $ 319.71 $ 319.71 0 0% 0% 0% 9 9 9 9 9 9 FE2625-NU Adj skin pro/pos wc cus>=22 $ 404.73 $ 404.73 0 0% 0% 0% 9 9 9 9 9 9 FE2626-NU Seo mobile arm sup att to wc $ 667.16 $ 667.16 0 0% 0% 0% 9 9 9 9 9 9 FE2627-NU Arm supp att to wc rancho ty $ 1100.09 $ 1100.09 0 0% 0% 0% 9 9 9 9 9 9 FE2628-NU Mobile arm supports reclinin $ 799.40 $ 799.40 0 0% 0% 0% 9 9 9 9 9 9 FE2629-NU Friction dampening arm supp $ 1048.75 $ 1048.75 0 0% 0% 0% 9 9 9 9 9 9 F
E2630-NU Monosuspension arm/hand supp $ 733.39 $ 733.39 0 0% 0% 0% 9 9 9 9 9 9 FE2631-NU Elevat proximal arm support $ 269.15 $ 269.15 0 0% 0% 0% 9 9 9 9 9 9 FE2632-NU Offset/lat rocker arm w/ela $ 158.56 $ 158.56 0 0% 0% 0% 9 9 9 9 9 9 FE2633-NU Mobile arm support supinator $ 158.22 $ 158.22 0 0% 0% 0% 9 9 9 9 9 9 FE8000 Posterior gait trainer Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E8001 Upright gait trainer Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X E8002 Anterior gait trainer Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G0008 Admin influenza virus vac Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 64
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G0009 Admin pneumococcal vaccine Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B G0010 Admin hepatitis b vaccine Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B G0027 Semen analysis $ 12.39 $ 12.39 0 0% 0% 0% 9 9 9 9 9 9 L G0101 Ca screen;pelvic/breast exam $ 65.38 $ 46.78 0 0% 0% 0% 0 0 0 0 0 0 R G0102 Prostate ca screening; dre $ 34.19 $ 15.00 0 0% 0% 0% 0 9 9 9 9 9 R G0103 Psa screening $ 35.04 $ 35.04 0 0% 0% 0% 9 9 9 9 9 9 L YG0104 Ca screen;flexi sigmoidscope $ 239.92 $ 107.96 0 0% 0% 0% 0 2 0 1 0 0 R YG0105 Colorectal scrn; hi risk ind $ 650.78 $ 342.49 0 0% 0% 0% 0 2 0 1 0 0 R YG0105-53 Colorectal scrn; hi risk ind $ 239.92 $ 107.96 0 0% 0% 0% 0 2 0 1 0 0 R YG0106 Colon ca screen;barium enema $ 371.88 $ 371.88 0 0% 0% 0% 1 0 0 0 0 0 R YG0106-26 Colon ca screen;barium enema $ 85.17 $ 85.17 0 0% 0% 0% 1 0 0 0 0 0 R YG0106-TC Colon ca screen;barium enema $ 286.70 $ 286.70 0 0% 0% 0% 1 0 0 0 0 0 R YG0108 Diab manage trn per indiv $ 90.57 $ 90.57 0 0% 0% 0% 0 0 0 0 0 0 R G0109 Diab manage trn ind/group $ 23.99 $ 23.99 0 0% 0% 0% 0 0 0 0 0 0 R G0117 Glaucoma scrn hgh risk direc Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B G0118 Glaucoma scrn hgh risk direc Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B G0120 Colon ca scrn; barium enema $ 371.88 $ 371.88 0 0% 0% 0% 1 0 0 0 0 0 R G0120-26 Colon ca scrn; barium enema $ 85.17 $ 85.17 0 0% 0% 0% 1 0 0 0 0 0 R G0120-TC Colon ca scrn; barium enema $ 286.70 $ 286.70 0 0% 0% 0% 1 0 0 0 0 0 R G0121 Colon ca scrn not hi rsk ind $ 650.78 $ 342.49 0 0% 0% 0% 0 2 0 1 0 0 R G0121-53 Colon ca scrn not hi rsk ind $ 239.92 $ 107.96 0 0% 0% 0% 0 2 0 1 0 0 R G0122 Colon ca scrn; barium enema $ 471.44 $ 471.44 0 0% 0% 0% 1 9 9 9 9 9 R YG0122-26 Colon ca scrn; barium enema $ 84.57 $ 84.57 0 0% 0% 0% 1 9 9 9 9 9 R YG0122-TC Colon ca scrn; barium enema $ 386.27 $ 386.27 0 0% 0% 0% 1 9 9 9 9 9 R YG0123 Screen cerv/vag thin layer $ 38.60 $ 38.60 0 0% 0% 0% 9 9 9 9 9 9 L G0124 Screen c/v thin layer by md $ 55.78 $ 55.78 0 0% 0% 0% 0 0 0 0 0 0 R G0127 Trim nail(s) $ 40.19 $ 13.20 0 0% 0% 0% 0 2 0 1 0 0 R G0128 Corf skilled nursing service Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X G0129 Partial hosp prog service Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G0130 Single energy x-ray study $ 59.98 $ 59.98 0 0% 0% 0% 1 0 0 0 0 0 R G0130-26 Single energy x-ray study $ 19.19 $ 19.19 0 0% 0% 0% 1 0 0 0 0 0 R G0130-TC Single energy x-ray study $ 40.79 $ 40.79 0 0% 0% 0% 1 0 0 0 0 0 R G0141 Scr c/v cyto,autosys and md $ 55.78 $ 55.78 0 0% 0% 0% 0 0 0 0 0 0 R G0143 Scr c/v cyto,thinlayer,rescr $ 38.60 $ 38.60 0 0% 0% 0% 9 9 9 9 9 9 L G0144 Scr c/v cyto,thinlayer,rescr $ 40.71 $ 40.71 0 0% 0% 0% 9 9 9 9 9 9 L G0145 Scr c/v cyto,thinlayer,rescr $ 50.47 $ 50.47 0 0% 0% 0% 9 9 9 9 9 9 L G0147 Scr c/v cyto, automated sys $ 21.69 $ 21.69 0 0% 0% 0% 9 9 9 9 9 9 L G0148 Scr c/v cyto, autosys, rescr $ 28.95 $ 28.95 0 0% 0% 0% 9 9 9 9 9 9 L G0151 Hhcp-serv of pt,ea 15 min $ 39.33 $ 39.33 0 0% 0% 0% 9 9 9 9 9 9 F YG0152 Hhcp-serv of ot,ea 15 min $ 40.78 $ 40.78 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 65
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G0153 Hhcp-svs of s/l path,ea 15mn $ 40.78 $ 40.78 0 0% 0% 0% 9 9 9 9 9 9 F YG0154 Hhcp-svs of rn,ea 15 min $ 40.78 $ 40.78 0 0% 0% 0% 9 9 9 9 9 9 F YG0155 Hhcp-svs of csw,ea 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G0156 Hhcp-svs of aide,ea 15 min $ 6.84 $ 6.84 0 0% 0% 0% 9 9 9 9 9 9 F YG0157 Hhc pt assistant ea 15 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0158 Hhc ot assistant ea 15 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0159 Hhc pt maint ea 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0160 Hhc occup therapy ea 15 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0161 Hhc slp ea 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0162 Hhc rn e&m plan svs, 15 min $ 40.78 $ 40.78 0 0% 0% 0% 9 9 9 9 9 9 F YG0163 Hhc lpn/rn obs/asses ea 15 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0164 Hhc lis nurse train ea 15 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0166 Extrnl counterpulse, per tx $ 243.52 $ 243.52 0 0% 0% 0% 0 9 9 9 9 9 R G0168 Wound closure by adhesive $ 179.94 $ 46.78 0 0% 0% 0% 0 2 0 1 0 0 R G0175 Opps service,sched team conf Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0176 Opps/php;activity therapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G0177 Opps/php; train & educ serv Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0179 Md recertification hha pt Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0180 Md certification hha patient Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0181 Home health care supervision Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0182 Hospice care supervision Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0186 Dstry eye lesn,fdr vssl tech By Report By Report 90 0% 0% 0% 0 2 1 0 1 1 N G0202 Screeningmammographydigital Not Covered Not Covered 0 0% 0% 0% 1 0 2 0 0 0 X G0202-26 Screeningmammographydigital Not Covered Not Covered 0 0% 0% 0% 1 0 2 0 0 0 X G0202-TC Screeningmammographydigital Not Covered Not Covered 0 0% 0% 0% 1 0 2 0 0 0 X G0204 Diagnosticmammographydigital $ 286.10 $ 286.10 0 0% 0% 0% 1 0 2 0 0 0 R G0204-26 Diagnosticmammographydigital $ 74.38 $ 74.38 0 0% 0% 0% 1 0 2 0 0 0 R G0204-TC Diagnosticmammographydigital $ 212.33 $ 212.33 0 0% 0% 0% 1 0 2 0 0 0 R G0206 Diagnosticmammographydigital $ 225.52 $ 225.52 0 0% 0% 0% 1 0 0 0 0 0 R G0206-26 Diagnosticmammographydigital $ 59.38 $ 59.38 0 0% 0% 0% 1 0 0 0 0 0 R G0206-TC Diagnosticmammographydigital $ 166.14 $ 166.14 0 0% 0% 0% 1 0 0 0 0 0 R G0219 Pet img wholbod melano nonco Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0219-26 Pet img wholbod melano nonco Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0219-TC Pet img wholbod melano nonco Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0235 Pet not otherwise specified Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0235-26 Pet not otherwise specified Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0235-TC Pet not otherwise specified Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0237 Therapeutic procd strg endur $ 17.99 $ 17.99 0 0% 0% 0% 5 0 0 0 0 0 R G0238 Oth resp proc, indiv $ 18.59 $ 18.59 0 0% 0% 0% 5 0 0 0 0 0 R G0239 Oth resp proc, group $ 23.39 $ 23.39 0 0% 0% 0% 5 0 0 0 0 0 R
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 66
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G0245 Initial foot exam pt lops Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0246 Followup eval of foot pt lop Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0247 Routine footcare pt w lops Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0248 Demonstrate use home inr mon $ 198.53 $ 198.53 0 0% 0% 0% 3 0 0 0 0 0 R G0249 Provide inr test mater/equip $ 197.93 $ 197.93 0 0% 0% 0% 3 0 0 0 0 0 R G0250 Md inr test revie inter mgmt $ 15.59 $ 15.59 0 0% 0% 0% 2 0 0 0 0 0 R G0252 Pet imaging initial dx Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0252-26 Pet imaging initial dx Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0252-TC Pet imaging initial dx Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0255 Current percep threshold tst Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0255-26 Current percep threshold tst Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0255-TC Current percep threshold tst Not Covered Not Covered 0 0% 0% 0% 1 9 9 9 9 9 X G0257 Unsched dialysis esrd pt hos Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0259 Inject for sacroiliac joint Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0260 Inj for sacroiliac jt anesth Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0268 Removal of impacted wax md Not Covered Not Covered 0 0% 0% 0% 0 2 2 1 0 0 X G0269 Occlusive device in vein art Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0270 Mnt subs tx for change dx Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0271 Group mnt 2 or more 30 mins Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0276 Pild/placebo control clin tr Not Covered Not Covered 0 0% 0% 0% 0 2 2 2 1 0 XG0277 Hbot, full body chamber, 30m $ 82.77 $ 82.77 0 0% 0% 0% 3 0 0 0 0 0 RG0278 Iliac art angio,cardiac cath $ 22.19 $ 22.19 0 0% 0% 0% 0 0 0 0 0 0 R G0279 Tomosynthesis, mammo screen $ 96.57 $ 96.57 0 0% 0% 0% 1 0 2 9 0 0 RG0279-26 Tomosynthesis, mammo screen $ 51.58 $ 51.58 0 0% 0% 0% 1 0 2 9 0 0 RG0279-TC Tomosynthesis, mammo screen $ 45.58 $ 45.58 0 0% 0% 0% 1 0 2 9 0 0 RG0281 Elec stim unattend for press $ 23.99 $ 23.99 0 0% 0% 0% 0 5 0 0 0 0 R YG0282 Elect stim wound care not pd By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G0283 Elec stim other than wound $ 23.99 $ 23.99 0 0% 0% 0% 0 5 0 0 0 0 R G0288 Recon, cta for surg plan $ 58.18 $ 58.18 0 0% 0% 0% 3 0 0 0 0 0 R G0289 Arthro, loose body + chondro $ 145.75 $ 145.75 0 0% 0% 0% 0 0 1 0 0 0 R G0293 Non-cov surg proc,clin trial Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G0294 Non-cov proc, clinical trial Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G0295 Electromagnetic therapy onc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G0302 Pre-op service lvrs complete By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G0303 Pre-op service lvrs 10-15dos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G0304 Pre-op service lvrs 1-9 dos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G0305 Post op service lvrs min 6 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G0306 Cbc/diffwbc w/o platelet $ 14.81 $ 14.81 0 0% 0% 0% 9 9 9 9 9 9 L G0307 Cbc without platelet $ 12.33 $ 12.33 0 0% 0% 0% 9 9 9 9 9 9 L G0328 Fecal blood scrn immunoassay Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 67
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G0329 Electromagntic tx for ulcers Not Covered Not Covered 0 0% 0% 0% 0 5 0 0 0 0 X G0333 Dispense fee initial 30 day Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G0337 Hospice evaluation preelecti $ 122.96 $ 122.96 0 0% 0% 0% 9 9 9 9 9 9 R G0339 Robot lin-radsurg com, first Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0340 Robt lin-radsurg fractx 2-5 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0341 Percutaneous islet celltrans Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 1 0 X G0342 Laparoscopy islet cell trans Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X G0343 Laparotomy islet cell transp Not Covered Not Covered 90 9% 81% 10% 0 2 0 2 1 0 X G0364 Bone marrow aspirate &biopsy $ 21.59 $ 15.00 0 0% 0% 0% 0 0 0 0 0 0 R G0365 Vessel mapping hemo access $ 353.28 $ 353.28 0 0% 0% 0% 1 0 0 0 0 0 R G0365-26 Vessel mapping hemo access $ 20.39 $ 20.39 0 0% 0% 0% 1 0 0 0 0 0 R G0365-TC Vessel mapping hemo access $ 332.89 $ 332.89 0 0% 0% 0% 1 0 0 0 0 0 R G0372 Md service required for pmd Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0378 Hospital observation per hr Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0379 Direct refer hospital observ Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0380 Lev 1 hosp type b ed visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0381 Lev 2 hosp type b ed visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0382 Lev 3 hosp type b ed visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0383 Lev 4 hosp type b ed visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0384 Lev 5 hosp type b ed visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0389 Ultrasound exam aaa screen $ 203.33 $ 203.33 0 0% 0% 0% 1 0 0 0 0 0 R G0389-26 Ultrasound exam aaa screen $ 49.18 $ 49.18 0 0% 0% 0% 1 0 0 0 0 0 R G0389-TC Ultrasound exam aaa screen $ 154.15 $ 154.15 0 0% 0% 0% 1 0 0 0 0 0 R G0390 Trauma respons w/hosp criti Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0396 Alcohol/subs interv 15-30mn Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0397 Alcohol/subs interv >30 min Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0398 Home sleep test/type 2 porta By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N YG0399 Home sleep test/type 3 porta By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N YG0400 Home sleep test/type 4 porta By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N YG0402 Initial preventive exam Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0403 Ekg for initial prevent exam Not Covered Not Covered 0 0% 0% 0% 4 0 0 0 0 0 X G0404 Ekg tracing for initial prev Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X G0405 Ekg interpret & report preve Not Covered Not Covered 0 0% 0% 0% 2 0 0 0 0 0 X G0406 Inpt/tele follow up 15 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0407 Inpt/tele follow up 25 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0408 Inpt/tele follow up 35 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X G0409 Corf related serv 15 mins ea Not Covered Not Covered 0 0% 0% 0% 9 0 0 0 0 0 X G0410 Grp psych partial hosp 45-50 Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0411 Inter active grp psych parti Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O G0412 Open tx iliac spine uni/bil $ 1225.39 $ 1225.39 90 10% 69% 21% 0 2 0 2 2 0 R
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 68
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G0413 Pelvic ring fracture uni/bil $ 1796.40 $ 1796.40 90 10% 69% 21% 0 2 0 2 2 0 R G0414 Pelvic ring fx treat int fix $ 1642.85 $ 1642.85 90 10% 69% 21% 0 2 0 2 2 0 R G0415 Open tx post pelvic fxcture $ 2301.43 $ 2301.43 90 10% 69% 21% 0 2 0 2 2 0 R G0416 Prostate biopsy, any mthd Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X G0416-26 Prostate biopsy, any mthd Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X G0416-TC Prostate biopsy, any mthd Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X G0420 Ed svc ckd ind per session $ 182.34 $ 182.34 0 0% 0% 0% 0 0 0 0 0 0 R YG0421 Ed svc ckd grp per session $ 41.99 $ 41.99 0 0% 0% 0% 0 0 0 0 0 0 R YG0422 Intens cardiac rehab w/exerc $ 175.74 $ 175.74 0 0% 0% 0% 0 0 0 0 0 0 R YG0423 Intens cardiac rehab no exer $ 175.74 $ 175.74 0 0% 0% 0% 0 0 0 0 0 0 R YG0424 Pulmonary rehab w exer $ 52.18 $ 23.39 0 0% 0% 0% 0 0 0 0 0 0 R YG0425 Inpt/ed teleconsult30 $ 169.74 $ 169.74 0 0% 0% 0% 0 0 0 0 0 0 RG0426 Inpt/ed teleconsult50 $ 230.32 $ 230.32 0 0% 0% 0% 0 0 0 0 0 0 RG0427 Inpt/ed teleconsult70 $ 341.29 $ 341.29 0 0% 0% 0% 0 0 0 0 0 0 RG0428 Collagen meniscus implant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0429 Dermal filler injection(s) Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 XG0431 Drug screen multiple class $ 138.54 $ 138.54 0 0% 0% 0% 9 9 9 9 9 9 LG0432 Eia hiv-1/hiv-2 screen By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NG0433 Elisa hiv-1/hiv-2 screen By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NG0434 Drug screen multi drug class $ 27.71 $ 27.71 0 0% 0% 0% 9 9 9 9 9 9 LG0435 Oral hiv-1/hiv-2 screen By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NG0436 Tobacco-use counsel 3-10 min Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0437 Tobacco-use counsel>10min Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0438 Ppps, initial visit Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0439 Ppps, subseq visit Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0442 Annual alcohol screen 15 min Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0443 Brief alcohol misuse counsel Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0444 Depression screen annual Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0445 High inten beh couns std 30m Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0446 Intens behave ther cardio dx Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0447 Behavior counsel obesity 15m Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0448 Place perm pacing cardiovert Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0451 Devlopment test interpt&rep Not Covered Not Covered 0 0% 0% 0% 5 0 0 0 0 0 XG0452-26 Molecular pathology interpr $ 31.79 $ 31.79 0 0% 0% 0% 6 0 0 0 0 0 RG0453 Cont intraop neuro monitor Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0454 Md document visit by npp Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0455 Fecal microbiota prep instil Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 XG0458 Ldr prostate brachy comp rat Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0459 Telehealth inpt pharm mgmt Not Covered Not Covered 0 0% 0% 0% 0 0 0 9 0 0 XG0459 Telehealth inpt pharm mgmt Not Covered Not Covered 0 0% 0% 0% 0 0 0 9 0 0 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 69
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G0460 Autologous prp for ulcers Not Covered Not Covered 90 0% 0% 0% 0 0 0 9 0 0 XG0463 Hospital outpt clinic visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0464 Colorec ca scr, sto bas dna Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0466 Fqhc visit new patient Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0467 Fqhc visit, estab pt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0468 Fqhc visit, ippe or awv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0469 Fqhc visit, mh new pt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0470 Fqhc visit, mh estab pt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0471 Ven blood coll snf/hha Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0472 Hep c screen high risk/other Not Covered Not Covered 0 0% 0% 0% 3 9 9 9 9 9 XG0473 Group behave couns 2-10 $ 20.99 $ 19.79 0 0% 0% 0% 9 9 9 9 9 9 RG0913 Improve visual funct Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0914 Survey not complete Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0915 No improve visual funct Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0916 Satisfy with care Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0917 Satisfy survey not complete Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0918 No satisfy with care Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG3001 Admin + supply, tositumomab Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G6001 Echo guidance radiotherapy $ 88.77 $ 88.77 0 0% 0% 0% 1 0 0 0 0 0 R YG6001-26 Echo guidance radiotherapy $ 50.38 $ 50.38 0 0% 0% 0% 1 0 0 0 0 0 R YG6001-TC Echo guidance radiotherapy $ 38.39 $ 38.39 0 0% 0% 0% 1 0 0 0 0 0 R YG6002 Stereoscopic x-ray guidance $ 130.76 $ 130.76 0 0% 0% 0% 1 0 0 0 0 0 R YG6002-26 Stereoscopic x-ray guidance $ 34.19 $ 34.19 0 0% 0% 0% 1 0 0 0 0 0 R YG6002-TC Stereoscopic x-ray guidance $ 96.57 $ 96.57 0 0% 0% 0% 1 0 0 0 0 0 R YG6003 Radiation treatment delivery $ 286.10 $ 286.10 0 0% 0% 0% 3 0 0 0 0 0 R YG6004 Radiation treatment delivery $ 221.33 $ 221.33 0 0% 0% 0% 3 0 0 0 0 0 R YG6005 Radiation treatment delivery $ 247.72 $ 247.72 0 0% 0% 0% 3 0 0 0 0 0 R YG6006 Radiation treatment delivery $ 246.52 $ 246.52 0 0% 0% 0% 3 0 0 0 0 0 R YG6007 Radiation treatment delivery $ 455.25 $ 455.25 0 0% 0% 0% 3 0 0 0 0 0 R YG6008 Radiation treatment delivery $ 306.50 $ 306.50 0 0% 0% 0% 3 0 0 0 0 0 R YG6009 Radiation treatment delivery $ 339.49 $ 339.49 0 0% 0% 0% 3 0 0 0 0 0 R YG6010 Radiation treatment delivery $ 339.49 $ 339.49 0 0% 0% 0% 3 0 0 0 0 0 R YG6011 Radiation treatment delivery $ 487.04 $ 487.04 0 0% 0% 0% 3 0 0 0 0 0 R YG6012 Radiation treatment delivery $ 403.67 $ 403.67 0 0% 0% 0% 3 0 0 0 0 0 R YG6013 Radiation treatment delivery $ 454.05 $ 454.05 0 0% 0% 0% 3 0 0 0 0 0 R YG6014 Radiation treatment delivery $ 454.05 $ 454.05 0 0% 0% 0% 3 0 0 0 0 0 R YG6015 Radiation tx delivery imrt $ 707.76 $ 707.76 0 0% 0% 0% 3 0 0 0 0 0 R YG6016 Delivery comp imrt $ 707.16 $ 707.16 0 0% 0% 0% 3 0 0 0 0 0 R YG6017 Intrafraction track motion By Report By Report 90 0% 0% 0% 0 0 0 0 0 0 N YG6018 Ileoscopy w/stent $ 273.51 $ 273.51 0 0% 0% 0% 0 2 0 1 0 0 R Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 70
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G6019 Colonoscopy lesion removal $ 870.91 $ 458.25 0 0% 0% 0% 0 3 0 1 0 0 44388 R YG6020 Colonoscopy w/stent $ 449.25 $ 449.25 0 0% 0% 0% 0 3 0 1 0 0 44388 R YG6021 Unlisted px small intestine By Report By Report 90 0% 0% 0% 0 2 0 1 1 1 N YG6022 Sigmoidoscopy w/ablate tumr $ 585.40 $ 306.50 0 0% 0% 0% 0 3 0 1 0 0 45330 R YG6023 Sigmoidoscopy w/stent $ 286.70 $ 286.70 0 0% 0% 0% 0 3 0 1 0 0 45330 R YG6024 Lesion removal colonoscopy $ 960.88 $ 553.02 0 0% 0% 0% 0 3 0 1 0 0 45378 R YG6025 Colonoscopy w/stent $ 568.61 $ 568.61 0 0% 0% 0% 0 3 0 1 0 0 45378 R YG6027 Anoscopy hra w/spec collect By Report By Report 90 0% 0% 0% 0 0 0 1 0 0 N YG6028 Anoscopy hra w/biopsy By Report By Report 90 0% 0% 0% 0 0 0 1 0 0 N YG6030 Assay of amitriptyline $ 34.10 $ 34.10 0 0% 0% 0% 9 9 9 9 9 9 LG6031 Assay of benzodiazepines $ 35.24 $ 35.24 0 0% 0% 0% 9 9 9 9 9 9 LG6032 Assay of desipramine $ 32.79 $ 32.79 0 0% 0% 0% 9 9 9 9 9 9 LG6034 Assay of doxepin $ 29.53 $ 29.53 0 0% 0% 0% 9 9 9 9 9 9 LG6035 Assay of gold $ 31.02 $ 31.02 0 0% 0% 0% 9 9 9 9 9 9 LG6036 Assay of imipramine $ 32.79 $ 32.79 0 0% 0% 0% 9 9 9 9 9 9 LG6037 Assay of nortiptyline $ 25.82 $ 25.82 0 0% 0% 0% 9 9 9 9 9 9 LG6038 Assay of salicylate $ 13.52 $ 13.52 0 0% 0% 0% 9 9 9 9 9 9 LG6039 Assay of acetaminophen $ 34.40 $ 34.40 0 0% 0% 0% 9 9 9 9 9 9 LG6040 Assay of ethanol $ 20.58 $ 20.58 0 0% 0% 0% 9 9 9 9 9 9 LG6041 Assay of urine alkaloids $ 57.19 $ 57.19 0 0% 0% 0% 9 9 9 9 9 9 LG6042 Assay of amphetamines $ 29.61 $ 29.61 0 0% 0% 0% 9 9 9 9 9 9 LG6043 Assay of barbiturates $ 21.81 $ 21.81 0 0% 0% 0% 9 9 9 9 9 9 LG6044 Assay of cocaine $ 28.87 $ 28.87 0 0% 0% 0% 9 9 9 9 9 9 LG6045 Assay of dihydrocodeinone $ 39.34 $ 39.34 0 0% 0% 0% 9 9 9 9 9 9 LG6046 Assay of dihydromorphinone $ 48.97 $ 48.97 0 0% 0% 0% 9 9 9 9 9 9 LG6047 Assay of dihydrotestosterone Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG6048 Assay of dimethadione $ 26.39 $ 26.39 0 0% 0% 0% 9 9 9 9 9 9 LG6049 Asssay of epiandrosterone Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG6050 Assay of ethchlorvynol $ 32.93 $ 32.93 0 0% 0% 0% 9 9 9 9 9 9 LG6051 Assay of flurazepam $ 37.72 $ 37.72 0 0% 0% 0% 9 9 9 9 9 9 LG6052 Assay of meprobamate $ 33.57 $ 33.57 0 0% 0% 0% 9 9 9 9 9 9 LG6053 Assay of methadone $ 31.11 $ 31.11 0 0% 0% 0% 9 9 9 9 9 9 LG6054 Assay of methsuximide $ 28.22 $ 28.22 0 0% 0% 0% 9 9 9 9 9 9 LG6055 Assay of nicotine $ 45.12 $ 45.12 0 0% 0% 0% 9 9 9 9 9 9 LG6056 Assay of opiates $ 37.07 $ 37.07 0 0% 0% 0% 9 9 9 9 9 9 LG6057 Assay of phenothiazine $ 24.21 $ 24.21 0 0% 0% 0% 9 9 9 9 9 9 LG6058 Drug confirmation $ 25.24 $ 25.24 0 0% 0% 0% 9 9 9 9 9 9 LG8395 Lvef>=40% doc normal or mild Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8396 Lvef not performed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8397 Dil macula/fundus exam/w doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 71
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G8398 Dil macular/fundus not perfo Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8399 Pt w/dxa document or order Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8400 Pt w/dxa no document or orde Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8401 Pt inelig osteo screen measu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8404 Low extemity neur exam docum Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8405 Low extemity neur not perfor Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8410 Eval on foot documented Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8415 Eval on foot not performed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8416 Pt inelig footwear evaluatio Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8417 Calc bmi abv up param f/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8418 Calc bmi blw low param f/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8419 Calc bmi out nrm param nof/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8420 Calc bmi norm parameters Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8421 Bmi not calculated Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8422 Pt inelig bmi calculation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8427 Doc cur meds by prov Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8428 Cur meds not document Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8430 Pt inelig med check Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8431 Pos clin depres scrn f/u doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8432 Clin depression screen not d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8433 Pt inelig; scrn clin dep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8442 Pt inelig pain assessment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8450 Beta-bloc rx pt w/abn lvef Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8451 Pt w/abn lvef inelig b-bloc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8452 Pt w/abn lvef b-bloc no rx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8458 Pt inelig geno no antvir tx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8460 Pt inelig rna no antvir tx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8461 Pt rec antivir treat hep c Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8465 High risk recurrence pro ca Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8473 Ace/arb thxpy rx'd Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8474 Ace/arb not rx'd; doc reas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8475 Ace/arb thxpy not rx'd Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8476 Bp sys <140 and dias <90 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8477 Bp sys>=140 and/or dias >=90 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8478 Bp not performed/doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8482 Flu immunize order/admin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8483 Flu imm no admin doc rea Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8484 Flu immunize no admin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8485 Report, diabetes measures Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8486 Report, prev care measures Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 72
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G8487 Report ckd measures Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8489 Cad measures grp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8490 Ra measures grp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8491 Hiv/aids measures grp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8494 Dm meas qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8495 Ckd meas qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8496 Prev care mg qual act perfrm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8497 Cabg meas qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8498 Cad meas qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8499 Ra meas qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8500 Hiv meas qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8506 Pt rec ace/arb Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8509 Pos pain assess no f/u doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8510 Pt inelig neg scrn depres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8511 Clin depres scrn no f/u doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8530 Auto av fistula recd Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8531 Pt inelig; auto av fistula Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8532 No auto av fistula; no reas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8535 Pt inelig no eld mal scrn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8536 No doc elder mal scrn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8539 Doc funct and care plan Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8540 Pt inelig funct assess Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8541 No doc cur funct assess Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8542 Doc funct no deficiencies Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8543 Cur funct asses; no care pln Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8544 Cabg measures grp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G8545 Hepc measures grp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8548 Hf measures grp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8549 Hepc mg qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8551 Hf mg qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8559 Pt ref doc oto eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8560 Pt hx act drain prev 90 days Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8561 Pt inelig for ref oto eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8562 Pt no hx act drain 90 d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8563 Pt no ref oto reas no spec Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8564 Pt ref oto eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8565 Ver doc hear loss Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8566 Pt inelig ref oto eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8567 Pt no doc hear loss Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8568 Pt no ref otolo no spec Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 73
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G8569 Prol intubation req Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8570 No prol intub req Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8571 Ster wd ifx 30 d postop Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8572 No ster wd ifx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8573 Stk cabg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8574 No strk cabg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8575 Postop ren fail Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8576 No postop ren fail Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8577 Reop req bld grft oth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8578 No reop req bld grft oth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8598 Asp therp used Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8599 No asp therp used Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8600 Tpa initi w/in 3 hrs Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8601 No elig tpa init w/in 3 hrs Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8602 No tpa init w/in 3 hrs Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8627 Surg proc w/in 30 days Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8628 No surg proc w/in 30 days Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8633 Pharm ther osteo rx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8634 Pt no elg phar ther osteo Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8635 No pharm ther osteo rx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8645 Asthma measures grp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8646 Asthma mg qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8647 Fun stat score knee >= 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8648 Fun stat score knee < 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8649 Fun stat score knee pt noelg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8650 Fun stat score knee not done Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8651 Fun stat score hip >= 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8652 Fun stat score hip < 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8653 Fun stat score hip pt no elg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8654 Fun stat score hip not done Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8655 Fun stat score le >= 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8656 Fun stat score le < 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8657 Fun stat score le pt no elg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8658 Fun stat score le not done Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8659 Fun stat score ls >= 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8660 Fun stat score ls < 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8661 Fun stat score ls pt no elg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8662 Fun stat score ls not done Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8663 Fun stat score shdl >=0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8664 Fun stat score shdl < 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 74
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G8665 Fun stat score shdl pt no el Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8666 Fun stat score shdl not done Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8667 Fun stat score ue >=0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8668 Fun stat score ue < 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8669 Fun stat score ue pt no elg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8670 Fun stat score ue not done Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8671 Fun stat score neck/ts >=0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8672 Fun stat score neck/ts < 0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8673 Fun stat scor nek/ts pt no e Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8674 Fun stat scor nek/ts not don Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8694 Lvef <40% Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8696 Antithromb thx presc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8697 Antithromb no presc doc reas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8698 Antithromb no presc no reas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8708 Antibiotic not pres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8709 Med reas antibiotic pres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8710 Pt pres antibiotic Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8711 Pres antibiotic Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8712 Not pres antibiotic Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8713 Spkt/v great 1.2 kt/v Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8714 Hemodialysis 3 times week Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8717 Less 1.2 kt/v Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8718 Great 1.7 kt/v per week Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8720 Less 1.7 kt/v per week Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8721 Pt, pn, hist grade doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8722 Med reas pt, pn, not doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8723 Spec sit not prim tumor Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8724 Pt, pn, hist grade not doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8725 Lipid profile perf doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8726 Doc reas no lipid profile Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8728 Lipid profile not perf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8730 Pain doc pos and plan Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8731 Pain neg no plan Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8732 No doc of pain Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8733 Doc pos elder mal scrn plan Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8734 Doc neg elder mal no plan Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8735 Eld mal scrn pos no plan Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8749 Signs of melanoma absent Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8752 Sys bp less 140 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8753 Sys bp > or = 140 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 75
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G8754 Dias bp less 90 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8755 Dias bp > or = 90 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8756 No bp measure doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8757 Copd mg qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8758 Ibd mg qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8759 Osa mg qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8761 Dementia mg qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8762 Pd mg qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8765 Cataract mg qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8783 Bp scrn perf rec interval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8784 Pt no elig for bp assess Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8785 Bp scrn no perf at interval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8797 Specimen site not esophagus Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8798 Specimen site not prostate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8806 Transab or transvag us Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8807 Doc reas no us Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8808 No transab or transvag us Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8809 Rh-immunoglobulin order Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8810 Doc reas no rh-immuno Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8811 No rh-immunoglobulin order Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8815 Doc reas no statin therapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8816 Statin med pres at disch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8817 Doc reas no statin med disch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8818 Pt disch to home by day#7 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8825 Pt not disch to home day#7 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8826 Pt disch home day #2 evar Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8833 Pt not disch home day#2 evar Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8834 Pt disch home day #2 cea Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8838 Not disch home by day #2 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8839 Sleep apnea assess Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8840 Doc reas no sleep apnea Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8841 No sleep apnea assess Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8842 Ahi or rdi initial dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8843 Doc reas no ahi or rdi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8844 No ahi or rdi initial dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8845 Pos airway press prescribed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8846 Mod or severe osa Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8848 Mild osa Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8849 Doc reas no pos air press Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8850 No pap prescribed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 76
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G8851 Adhere pos air press therapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8852 Pos air press prescribe Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8853 Pos air press not prescribe Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8854 Reas no adhere pos air pres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8855 Pos air press adhere no perf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8856 Ref for oto eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8857 No elig ref for oto eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8858 Not ref for oto eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8861 Dxa ordered for osteo Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8863 No assess bone loss Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8864 Pneumococcal vaccine admin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8865 Doc med reas no pneumococcal Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8866 Doc pt reas no pneumococcal Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8867 No pneumococcal admin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8868 1st course antitnf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8869 Doc immun hep b 1st antitnf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8870 Hepb admin 1st antitnf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8871 No 1st antitnf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8872 Intraop image confirm excise Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8873 Specimen not intraop image Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8874 Tissue not image intraop Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8875 Breast cancer dx min invsive Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8876 Doc reas no min inv dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8877 No brst cncr dx min invasive Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8878 Sent lymph node biopsy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8879 Node neg inv brst cncr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8880 Doc reas no lymph node biop Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8881 Brst cncr stage > t1n0m0 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8882 No sent lymph node biopsy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8883 Rev, comm, track, doc biopsy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8884 Doc reas biopsy not review Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8885 No rev, comm, track biopsy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8898 Copd measures group Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8899 Inflammatory bowel dis mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8900 Obstructive sleep apnea mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8902 Dementia measures group Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8903 Parkinson's disease mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8906 Cataract measures group Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8907 Pt doc no events on discharg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8908 Pt doc w burn prior to d/c Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 77
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G8909 Pt doc no burn prior to d/c Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8910 Pt doc to have fall in asc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8911 Pt doc no fall in asc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8912 Pt doc with wrong event Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8913 Pt doc no wrong event Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8914 Pt trans to hosp post d/c Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8915 Pt not trans to hosp at d/c Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8916 Pt w iv ab given on time Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8917 Pt w iv ab not given on time Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8918 Pt w/o preop order iv ab pro Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8923 Lvef < 40% or lvsd Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8924 Spiro ev1/fvc <60% copd sym Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8925 Spiro>=60% or pt no copd sym Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8926 Spiro no perf or doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8927 Adj chem pres ajcc iii Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8928 Adj chem not pres rsn spec Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8929 Adj cmo not pres rsn not gvn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8934 Lvef <40% or dep lv sys fcn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8935 Rx ace or arb therapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8936 Pt not eligible ace/arb Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8937 No rx ace/arb therapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8938 Bmi calc, pt no f/u plan elg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8939 Pain assess doc, f/u no doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8940 Srn clin dep doc no f/u pln Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8941 No doc elder scrn, pt no el Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8942 Doc fcn/care plan w/30 days Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8944 Ajcc mel cnr stg 0 - iic Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8946 Mibm but no dx of breast ca Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8947 1 or more neuropsych Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8948 No neuropsych symptoms Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8950 Pre-htn or htn doc, f/u indc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8951 Pre-htn/htn doc, no pt f/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8952 Pre-htn/htn, no f/u, not gvn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8953 Oncology mg qual act perform Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8955 Most recent assess vol mgmt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8956 Pt rcv hedia outpt dyls fac Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8958 Assess vol mgmt not doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8959 Clin tx mdd comm to tx clin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8960 Clin tx mdd not comm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8961 Csit lowrisk surg pts preop Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 78
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G8962 Csit on pt any reas 30 days Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8963 Csi per asx pt w/pci 2 yrs Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8964 Csi any other than pci 2 yr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8965 Csit perf on low chd rsk Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8966 Csit perf sx or high chd rsk Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8967 Wrfrn or oral antigoag pres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8968 Md rsn no pres wrfrn or othr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8969 Pt rsn no pres wrfrn or othr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8970 No rsk fac or 1 mod risk te Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8971 Warfrn or othr antcog no rx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8972 1>=risk or>= mod risk for te Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8973 Mst rcnt hbb < 10g/dl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8974 Hgb not doc rns not gvn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8975 Hgb <10g/dl, med rsn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8976 Hgb >= 10 g/dl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8977 Oncology measures grp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8978 Mobility current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8979 Mobility goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8980 Mobility d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8981 Body pos current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8982 Body pos goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8983 Body pos d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8984 Carry current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8985 Carry goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8986 Carry d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8987 Self care current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8988 Self care goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8989 Self care d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8990 Other pt/ot current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8991 Other pt/ot goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8992 Other pt/ot d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8993 Sub pt/ot current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8994 Sub pt/ot goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8995 Sub pt/ot d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8996 Swallow current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8997 Swallow goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8998 Swallow d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG8999 Motor speech current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9001 Mccd, initial rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9002 Mccd,maintenance rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 79
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G9003 Mccd, risk adj hi, initial Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9004 Mccd, risk adj lo, initial Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9005 Mccd, risk adj, maintenance By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G9006 Mccd, home monitoring By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G9007 Mccd, sch team conf By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G9008 Mccd,phys coor-care ovrsght By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G9009 Mccd, risk adj, level 3 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G9010 Mccd, risk adj, level 4 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G9011 Mccd, risk adj, level 5 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G9012 Other specified case mgmt By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N G9013 Esrd demo bundle level i Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9014 Esrd demo bundle-level ii Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9016 Demo-smoking cessation coun Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9017 Amantadine hcl 100mg oral Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9018 Zanamivir,inhalation pwd 10m Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9019 Oseltamivir phosphate 75mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9020 Rimantadine hcl 100mg oral Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9033 Amantadine hcl oral brand Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9034 Zanamivir, inh pwdr, brand Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9035 Oseltamivir phosp, brand Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9036 Rimantadine hcl, brand Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9050 Oncology work-up evaluation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9051 Oncology tx decision-mgmt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9052 Onc surveillance for disease Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9053 Onc expectant management pt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9054 Onc supervision palliative Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9055 Onc visit unspecified nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9056 Onc prac mgmt adheres guide Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9057 Onc pract mgmt differs trial Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9058 Onc prac mgmt disagree w/gui Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9059 Onc prac mgmt pt opt alterna Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9060 Onc prac mgmt dif pt comorb Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9061 Onc prac cond noadd by guide Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9062 Onc prac guide differs nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9063 Onc dx nsclc stgi no progres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9064 Onc dx nsclc stg2 no progres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9065 Onc dx nsclc stg3a no progre Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9066 Onc dx nsclc stg3b-4 metasta Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9067 Onc dx nsclc dx unknown nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9068 Onc dx sclc/nsclc limited Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 80
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G9069 Onc dx sclc/nsclc ext at dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9070 Onc dx sclc/nsclc ext unknwn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9071 Onc dx brst stg1-2b hr,nopro Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9072 Onc dx brst stg1-2 noprogres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9073 Onc dx brst stg3-hr, no pro Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9074 Onc dx brst stg3-noprogress Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9075 Onc dx brst metastic/ recur Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9077 Onc dx prostate t1no progres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9078 Onc dx prostate t2no progres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9079 Onc dx prostate t3b-t4noprog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9080 Onc dx prostate w/rise psa Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9083 Onc dx prostate unknwn nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9084 Onc dx colon t1-3,n1-2,no pr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9085 Onc dx colon t4, n0 w/o prog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9086 Onc dx colon t1-4 no dx prog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9087 Onc dx colon metas evid dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9088 Onc dx colon metas noevid dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9089 Onc dx colon extent unknown Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9090 Onc dx rectal t1-2 no progr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9091 Onc dx rectal t3 n0 no prog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9092 Onc dx rectal t1-3,n1-2noprg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9093 Onc dx rectal t4,n,m0 no prg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9094 Onc dx rectal m1 w/mets prog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9095 Onc dx rectal extent unknwn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9096 Onc dx esophag t1-t3 noprog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9097 Onc dx esophageal t4 no prog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9098 Onc dx esophageal mets recur Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9099 Onc dx esophageal unknown Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9100 Onc dx gastric no recurrence Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9101 Onc dx gastric p r1-r2noprog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9102 Onc dx gastric unresectable Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9103 Onc dx gastric recurrent Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9104 Onc dx gastric unknown nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9105 Onc dx pancreatc p r0 res no Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9106 Onc dx pancreatc p r1/r2 no Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9107 Onc dx pancreatic unresectab Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9108 Onc dx pancreatic unknwn nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9109 Onc dx head/neck t1-t2no prg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9110 Onc dx head/neck t3-4 noprog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9111 Onc dx head/neck m1 mets rec Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 81
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G9112 Onc dx head/neck ext unknown Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9113 Onc dx ovarian stg1a-b no pr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9114 Onc dx ovarian stg1a-b or 2 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9115 Onc dx ovarian stg3/4 noprog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9116 Onc dx ovarian recurrence Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9117 Onc dx ovarian unknown nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9123 Onc dx cml chronic phase Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9124 Onc dx cml acceler phase Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9125 Onc dx cml blast phase Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9126 Onc dx cml remission Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9128 Onc dx multi myeloma stage i Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9129 Onc dx mult myeloma stg2 hig Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9130 Onc dx multi myeloma unknown Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9131 Onc dx brst unknown nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9132 Onc dx prostate mets no cast Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9133 Onc dx prostate clinical met Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9134 Onc nhlstg 1-2 no relap no Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9135 Onc dx nhl stg 3-4 not relap Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9136 Onc dx nhl trans to lg bcell Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9137 Onc dx nhl relapse/refractor Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9138 Onc dx nhl stg unknown Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9139 Onc dx cml dx status unknown Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9140 Frontier extended stay demo Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X G9143 Warfarin respon genetic test By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NG9147 Outpt iv insulin tx any mea By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YG9156 Evaluation for wheelchair Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9157 Transesoph doppl cardiac mon Not Covered Not Covered 0 0% 0% 0% 2 9 9 9 0 0 XG9158 Motor speech d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9159 Lang comp current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9160 Lang comp goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9161 Lang comp d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9162 Lang express current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9163 Lang express goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9164 Lang express d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9165 Atten current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9166 Atten goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9167 Atten d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9168 Memory current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9169 Memory goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9170 Memory d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 82
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G9171 Voice current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9172 Voice goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9173 Voice d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9174 Speech lang current status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9175 Speech lang goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9176 Speech lang d/c status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9186 Motor speech goal status Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9187 Bpci home visit Not Covered Not Covered 0 0% 0% 0% 0 0 0 9 9 9 XG9188 Beta not given no reason Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9189 Beta pres or already taking Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9190 Medical reason for no beta Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9191 Pt reason for no beta Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9192 System reason for no beta Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9196 Med reason for no ceph Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9197 Order for ceph Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9198 No order for ceph no reason Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9203 Hep c rna done prior to med Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9204 No reason for no hep c rna Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9205 Hep c antiviral started Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9206 Hep c therapy started Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9207 Hep c genotype prior to med Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9208 No reason for no hep c geno Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9209 Hep c rna 4to12 wk after med Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9210 No hepc rna after med docrsn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9211 No hepc rna after med no rsn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9212 Doc of dsm-iv init eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9213 No doc of dsm-iv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9217 No pcp proph low cd4 norsn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9219 No oder pjp for med reason Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9222 Pjp proph ordered low cd4 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9223 Pjp proph ordered cd4 low Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9225 Norsn no foot exam Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9226 3 comp foot exam completed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9227 Docrsn no care plan Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9228 Gc chl syp documented Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9229 Ptrsn no gc chl syp test Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9230 Norsn for gc chl syp test Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9231 Doc esrd dia trans preg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9232 Docrsn no comm comorb Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9233 Tkr composite Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 83
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G9234 Tkr intent Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9235 Gs mg composite Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9236 Op rad mg composite Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9237 Gs mg intent Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9238 Op rad mg intent Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9239 Docrsn for catheter Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9240 Doc pt w cath maint dia Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9241 Doc pt w out cath maint dia Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9242 Doc viral load >=200 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9243 Doc viral load <200 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9244 Antiviral not ordered Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9245 Antiviral ordered Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9246 No med visit in 24mo Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9247 1 med visit in 24mo Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9250 Doc of pain comfort 48hr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9251 Doc no pain comfort 48hr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9254 Doc pt dischg >2d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9255 Doc pt dischg <=2d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9256 Doc death after cas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9257 Doc stroke after cas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9258 Doc stroke after cea Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9259 Doc surv no stroke after cas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9260 Doc death after cea Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9261 Doc surv no stroke after cea Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9262 Doc death in hosp aaa repair Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9263 Doc surv in hosp aaa repair Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9264 Docrsn for cath maint dia Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9265 Doc cath >90d for maint dia Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9266 Norsn pt cath >=90d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9267 Doc comp or mort w in 30d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9268 Doc comp or mort w in 90d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9269 Doc no comp or mort w in 30d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9270 Doc no comp or mort w in 90d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9273 Sys<140 and dia<90 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9274 Bp out of nrml limits Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9275 Doc of non tobacco user Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9276 Doc of tobacco user Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9277 Doc daily aspirin or contra Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9278 Doc no daily aspirin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9279 Pne scrn done doc vac done Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 84
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G9280 Pne not given norsn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9281 Pne scrn done doc not ind Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9282 Doc medrsn no histo type Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9283 Hist type doc on report Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9284 No hist type doc on report Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9285 Site not small cell lung ca Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9286 Doc antibio order w in 7d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9287 No doc antibio order w in 7d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9288 Doc medrsn no hist type rpt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9289 Doc type nsm lung ca Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9290 No doc type nsm lung ca Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9291 Not nsm lung ca Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9292 Medrsn no pt category Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9293 No pt category on report Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9294 Pt cat and thck on report Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9295 Non cutaneous loc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9296 Doc share dec prior proc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9297 No doc share dec prior proc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9298 Eval risk vte card 30d prior Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9299 No eval riskk vte card prior Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9300 Doc medrsn no compl antibio Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9301 Doc compl inf antibio Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9302 Norsn incomp inf antibio Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9303 Norsn no pros info op rpt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9304 Pros info op rpt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9305 No interv req for leak Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9306 Interv req for leak Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9307 No ret for surg w in 30d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9308 Unplnd ret to surg w in 30d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9309 No unplnd hosp readm in 30d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9310 Unplnd hosp readm in 30d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9311 No surg site infection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9312 Surgical site infection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9313 Docrsn not first line amox Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9314 Norsn not first line amox Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9315 Doc first line amox Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9316 Doc comm risk calc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9317 No doc comm risk calc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9318 Image std nomenclature Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9319 Image not std nomenclature Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 85
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G9320 Medrsn no std nomenclature Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9321 Doc count of ct in 12mo Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9322 No doc count of ct in 12mo Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9323 Mdrsn no doc cnt of ct Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9324 Not all data norsn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9325 Medrsn no ct rpt to reg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9326 Norsn no ct rpt to reg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9327 Ct rpt to reg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9328 Medrsn no dicom format doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9329 Norsn no dicom format doc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9340 Dicom format doc on rpt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9341 Srch for ct w in 12 mos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9342 No srch for ct in 12mo norsn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9343 Medrsn no dicom srch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9344 Sysrsn no dicom srch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9345 Follow up pulm nod Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9346 No follow up pulm nod Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9347 No follow up pulm nod norsn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9348 Docrsn no sinus ct dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9349 Doc sinus ct 28d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9350 No doc sinus ct 28d or dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9351 Doc >1 sinus ct w 90d dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9352 Not >1 sinus ct w 90d dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9353 Medrsn >1 sinus ct w 90d dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9354 Norsn >1 sinus ct w 90d dx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9355 No early ind/delivery Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9356 Early ind/delivery Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9357 Pp eval/edu perf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9358 Pp eval/edu not perf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9359 Doc of neg or man pos tb scn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9360 No doc of neg or man pos tb Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9361 Med ind for induction Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9362 Mac or pnb w/o genanes >60m Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9363 Mac or pnb w/o genanes <60m Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9364 Sinus caus bac inx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9365 1high risk med ord Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9366 1high risk no ord Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9367 2high risk med ord Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9368 2high risk no ord Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9369 Fill 2 rx antipsych Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 86
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G9370 Not fill 2 rx antipsych Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9376 Contd ret attach at 6mth f/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9377 No ret attach after 6mt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9378 Contd ret attach f/u vis Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9379 No acheive flat ret 6mth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9380 Off assis eol iss Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9381 Doc med reas no offer eol Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9382 No off assis eol Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9383 Recd scrn hcv infec Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9384 Doc med reas no offer eol Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9385 Doc pt reas not rec hcv srn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9386 Scrn hcv infec not recd Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9389 Unpln rup post cap Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9390 No unpln rup post cap Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9391 Achv refrac +1d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9392 Not achv refrac +1d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9393 Ini phq9 >9 remiss <5 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9394 Dx bipol, death, nhres, hosp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9395 Ini phq9 >9 no remiss >=5 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9396 Ini phq9 >9 not assess Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9399 Doc disc tx choices Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9400 Doc reas no disc tx opt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9401 No disc tx choices Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9402 Recd f/u w/in 30d disch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9403 Doc reas no 30 day f/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9404 No 30 day f/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9405 Recd f/u w/in 7d disch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9406 Doc reas no 7d f/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9407 No 7d f/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9408 Card tamp w/in 30d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9409 No card tamp e/in 30d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9410 Admit w/in 180d req remov Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9411 No admit w/in 180d req remov Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9412 Admit w/in 180d req surg rev Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9413 No admit req surg rev Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9414 1dose menig vac btwn 11 & 13 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9415 No 1dose meni vac btwn 11&13 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9416 Tdap or td or 1tet/dipth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9417 No tdap or td or 1tet/dipth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9418 Lungcx bx rpt docs class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 87
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G9419 Med reas no rpt histo type Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9420 Spec site no lung Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9421 Lung cx bx rpt no doc class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9422 Rpt doc class histo type Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9423 Med reas rpt no histo type Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9424 Site no lung or lung cx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9425 Spec rpt no doc class histo Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9426 Impr med time edarr pain med Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9427 No impro med time pain med Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9428 Rpt pt cat and pt1 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9429 Doc med reas no pt cat Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9430 Spec site no cutaneous Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9431 No pt cat and pt1 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9432 Asth controlled Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9433 Death, nhres, hospice Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9434 Asth not controlled Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9435 Asp presc disch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9436 Asp not presc doc reas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9437 Asp not presc disch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9438 P2y inhib presc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9439 P2y inhib not presc doc reas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9440 P2y inhib not presc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9441 Statin presc disch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9442 Statin not presc doc reas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9443 Statin not presc disch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9448 Born 1945-1965 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9449 Hx bld transf b/f 1992 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9450 Hx injec drug use Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9451 1x scrn hcv infect Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9452 Doc med reas no scrn hcv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9453 Pt reas no hcv infect Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9454 No hcv infect srn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9455 Abd imag w/us, ct or mri Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9456 Doc med pt reas no hcc scrn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9457 No abd imag w/o reason Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9458 Tob user recd cess interv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9459 Tob non-user Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9460 No tob assess or cess inter Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9463 Sinusitis intent Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9464 Sinusitis comp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 88
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G9465 Aoe intent Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9466 Aoe comp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9467 Recd cortico >=10mg/day >60d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9468 No recd cortico>=10mg/d >60d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9469 Rec cortico>60d or 1rx 600mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9470 No rec cortico>60d 1rx 600mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9471 W/in 2yr dxa not order Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG9472 No dxa no med hx no rv sx Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XH0001 Alcohol and/or drug assess By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0002 Alcohol and/or drug screenin By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0003 Alcohol and/or drug screenin By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0004 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0005 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0006 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0007 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0008 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0009 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0010 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0011 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0012 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0013 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0014 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0015 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0016 Alcohol and/or drug services Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0017 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0018 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0019 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0020 Alcohol and/or drug services By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0021 Alcohol and/or drug training Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0022 Alcohol and/or drug interven Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0023 Alcohol and/or drug outreach Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0024 Alcohol and/or drug preventi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0025 Alcohol and/or drug preventi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0026 Alcohol and/or drug preventi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0027 Alcohol and/or drug preventi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0028 Alcohol and/or drug preventi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0029 Alcohol and/or drug preventi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0030 Alcohol and/or drug hotline Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0031 Mh health assess by non-md Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0032 Mh svc plan dev by non-md Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 89
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
H0033 Oral med adm direct observe Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0034 Med trng & support per 15min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0035 Mh partial hosp tx under 24h Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0036 Comm psy face-face per 15min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0037 Comm psy sup tx pgm per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0038 Self-help/peer svc per 15min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0039 Asser com tx face-face/15min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0040 Assert comm tx pgm per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0041 Fos c chld non-ther per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0042 Fos c chld non-ther per mon Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0043 Supported housing, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0044 Supported housing, per month Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0045 Respite not-in-home per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0046 Mental health service, nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H0047 Alcohol/drug abuse svc nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0048 Spec coll non-blood:a/d test By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N H0049 Alcohol/drug screening By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YH0050 Alcohol/drug service 15 min By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YH1000 Prenatal care atrisk assessm By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YH1001 Antepartum management By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YH1002 Carecoordination prenatal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YH1003 Prenatal at risk education By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YH1004 Follow up home visit/prental By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YH1005 Prenatalcare enhanced srv pk By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YH1010 Nonmed family planning ed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H1011 Family assessment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2000 Comp multidisipln evaluation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2001 Rehabilitation program 1/2 d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2010 Comprehensive med svc 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2011 Crisis interven svc, 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2012 Behav hlth day treat, per hr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2013 Psych hlth fac svc, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2014 Skills train and dev, 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2015 Comp comm supp svc, 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2016 Comp comm supp svc, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2017 Psysoc rehab svc, per 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2018 Psysoc rehab svc, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2019 Ther behav svc, per 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2020 Ther behav svc, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2021 Com wrap-around sv, 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 90
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
H2022 Com wrap-around sv, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2023 Supported employ, per 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2024 Supported employ, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2025 Supp maint employ, 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2026 Supp maint employ, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2027 Psychoed svc, per 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2028 Sex offend tx svc, 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2029 Sex offend tx svc, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2030 Mh clubhouse svc, per 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2031 Mh clubhouse svc, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2032 Activity therapy, per 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2033 Multisys ther/juvenile 15min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2034 A/d halfway house, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2035 A/d tx program, per hour Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2036 A/d tx program, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X H2037 Dev delay prev dp ch, 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0120 Tetracyclin injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0129 Abatacept injection $ 31.49 $ 31.49 0 0% 0% 0% 9 9 9 9 9 9 D YJ0130 Abciximab injection $ 1125.40 $ 1125.40 0 0% 0% 0% 9 9 9 9 9 9 D J0131 Acetaminophen injection $ 0.38 $ 0.38 0 0% 0% 0% 9 9 9 9 9 9 DJ0132 Acetylcysteine injection $ 3.38 $ 3.38 0 0% 0% 0% 9 9 9 9 9 9 D J0133 Acyclovir injection $ 0.05 $ 0.05 0 0% 0% 0% 9 9 9 9 9 9 D J0135 Adalimumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0153 Adenosine inj 1mg $ 1.94 $ 1.94 0 0% 0% 0% 9 9 9 9 9 9 DJ0171 Adrenalin epinephrine inject $ 0.52 $ 0.52 0 0% 0% 0% 9 9 9 9 9 9 DJ0178 Aflibercept injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ0180 Agalsidase beta injection $ 161.57 $ 161.57 0 0% 0% 0% 9 9 9 9 9 9 D J0190 Inj biperiden lactate/5 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0200 Alatrofloxacin mesylate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0205 Alglucerase injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0207 Amifostine $ 488.09 $ 488.09 0 0% 0% 0% 9 9 9 9 9 9 D J0210 Methyldopate hcl injection $ 45.00 $ 45.00 0 0% 0% 0% 9 9 9 9 9 9 D J0215 Alefacept Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0220 Alglucosidase alfa injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0221 Lumizyme injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ0256 Alpha 1 proteinase inhibitor $ 0.01 $ 0.01 0 0% 0% 0% 9 9 9 9 9 9 D J0257 Glassia injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ0270 Alprostadil for injection $ 2.55 $ 2.55 0 0% 0% 0% 9 9 9 9 9 9 D J0275 Alprostadil urethral suppos $ 63.32 $ 63.32 0 0% 0% 0% 9 9 9 9 9 9 D J0278 Amikacin sulfate injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 91
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J0280 Aminophyllin 250 mg inj $ 2.55 $ 2.55 0 0% 0% 0% 9 9 9 9 9 9 D J0282 Amiodarone hcl $ 0.31 $ 0.31 0 0% 0% 0% 9 9 9 9 9 9 D J0285 Amphotericin b $ 41.04 $ 41.04 0 0% 0% 0% 9 9 9 9 9 9 D J0287 Amphotericin b lipid complex $ 19.98 $ 19.98 0 0% 0% 0% 9 9 9 9 9 9 D J0288 Ampho b cholesteryl sulfate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0289 Amphotericin b liposome inj $ 33.91 $ 33.91 0 0% 0% 0% 9 9 9 9 9 9 D J0290 Ampicillin 500 mg inj $ 2.53 $ 2.53 0 0% 0% 0% 9 9 9 9 9 9 D J0295 Ampicillin sodium per 1.5 gm $ 2.00 $ 2.00 0 0% 0% 0% 9 9 9 9 9 9 D J0300 Amobarbital 125 mg inj $ 197.92 $ 197.92 0 0% 0% 0% 9 9 9 9 9 9 D J0330 Succinycholine chloride inj $ 0.34 $ 0.34 0 0% 0% 0% 9 9 9 9 9 9 D J0348 Anidulafungin injection $ 1.94 $ 1.94 0 0% 0% 0% 9 9 9 9 9 9 D J0350 Injection anistreplase 30 u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0360 Hydralazine hcl injection $ 11.25 $ 11.25 0 0% 0% 0% 9 9 9 9 9 9 D J0364 Apomorphine hydrochloride $ 35.82 $ 35.82 0 0% 0% 0% 9 9 9 9 9 9 D YJ0365 Aprotonin, 10,000 kiu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0380 Inj metaraminol bitartrate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0390 Chloroquine injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0395 Arbutamine hcl injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0400 Aripiprazole injection $ 0.77 $ 0.77 0 0% 0% 0% 9 9 9 9 9 9 D J0401 Inj aripiprazole ext rel 1mg $ 4.28 $ 4.28 0 0% 0% 0% 9 9 9 9 9 9 D YJ0456 Azithromycin $ 3.24 $ 3.24 0 0% 0% 0% 9 9 9 9 9 9 D J0461 Atropine sulfate injection $ 0.43 $ 0.43 0 0% 0% 0% 9 9 9 9 9 9 DJ0470 Dimecaprol injection $ 34.13 $ 34.13 0 0% 0% 0% 9 9 9 9 9 9 D J0475 Baclofen 10 mg injection $ 220.05 $ 220.05 0 0% 0% 0% 9 9 9 9 9 9 D J0476 Baclofen intrathecal trial $ 78.84 $ 78.84 0 0% 0% 0% 9 9 9 9 9 9 D J0480 Basiliximab $ 3066.12 $ 3066.12 0 0% 0% 0% 9 9 9 9 9 9 D J0485 Belatacept injection $ 3.99 $ 3.99 0 0% 0% 0% 9 9 9 9 9 9 D YJ0490 Belimumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ0500 Dicyclomine injection $ 61.59 $ 61.59 0 0% 0% 0% 9 9 9 9 9 9 D J0515 Inj benztropine mesylate $ 26.44 $ 26.44 0 0% 0% 0% 9 9 9 9 9 9 D J0520 Bethanechol chloride inject Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0558 Peng benzathine/procaine inj $ 6.25 $ 6.25 0 0% 0% 0% 9 9 9 9 9 9 DJ0561 Penicillin g benzathine inj $ 7.84 $ 7.84 0 0% 0% 0% 9 9 9 9 9 9 DJ0571 Buprenorphine oral 1mg $ 1.86 $ 1.86 0 0% 0% 0% 9 9 9 9 9 9 D YJ0572 Buprenorphin/nalox up to 3mg $ 4.24 $ 4.24 0 0% 0% 0% 9 9 9 9 9 9 D YJ0573 Buprenorph/nalox 3.1 to 6mg $ 7.60 $ 7.60 0 0% 0% 0% 9 9 9 9 9 9 D YJ0574 Buprenorph/nalox 6.1 to 10mg $ 7.60 $ 7.60 0 0% 0% 0% 9 9 9 9 9 9 D YJ0575 Buprenorph/nalox over 10mg $ 15.21 $ 15.21 0 0% 0% 0% 9 9 9 9 9 9 D YJ0583 Bivalirudin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0585 Injection,onabotulinumtoxina $ 6.03 $ 6.03 0 0% 0% 0% 9 9 9 9 9 9 D Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 92
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J0586 Abobotulinumtoxina $ 7.97 $ 7.97 0 0% 0% 0% 9 9 9 9 9 9 D YJ0587 Inj, rimabotulinumtoxinb $ 12.18 $ 12.18 0 0% 0% 0% 9 9 9 9 9 9 D YJ0588 Incobotulinumtoxin a $ 4.75 $ 4.75 0 0% 0% 0% 9 9 9 9 9 9 D YJ0592 Buprenorphine hydrochloride $ 4.16 $ 4.16 0 0% 0% 0% 9 9 9 9 9 9 D J0594 Busulfan injection $ 22.79 $ 22.79 0 0% 0% 0% 9 9 9 9 9 9 D YJ0595 Butorphanol tartrate 1 mg $ 1.18 $ 1.18 0 0% 0% 0% 9 9 9 9 9 9 D J0597 C-1 esterase, berinert Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ0598 C-1 esterase, cinryze Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ0600 Edetate calcium disodium inj $ 1163.26 $ 1163.26 0 0% 0% 0% 9 9 9 9 9 9 D J0610 Calcium gluconate injection $ 1.24 $ 1.24 0 0% 0% 0% 9 9 9 9 9 9 D J0620 Calcium glycer & lact/10 ml Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0630 Calcitonin salmon injection $ 4597.02 $ 4597.02 0 0% 0% 0% 9 9 9 9 9 9 D J0636 Inj calcitriol per 0.1 mcg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0637 Caspofungin acetate $ 36.47 $ 36.47 0 0% 0% 0% 9 9 9 9 9 9 D J0638 Canakinumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ0640 Leucovorin calcium injection $ 3.41 $ 3.41 0 0% 0% 0% 9 9 9 9 9 9 D J0641 Levoleucovorin injection $ 2.39 $ 2.39 0 0% 0% 0% 9 9 9 9 9 9 D J0670 Inj mepivacaine hcl/10 ml $ 1.36 $ 1.36 0 0% 0% 0% 9 9 9 9 9 9 D J0690 Cefazolin sodium injection $ 0.59 $ 0.59 0 0% 0% 0% 9 9 9 9 9 9 D J0692 Cefepime hcl for injection $ 2.08 $ 2.08 0 0% 0% 0% 9 9 9 9 9 9 D J0694 Cefoxitin sodium injection $ 6.48 $ 6.48 0 0% 0% 0% 9 9 9 9 9 9 D J0696 Ceftriaxone sodium injection $ 0.34 $ 0.34 0 0% 0% 0% 9 9 9 9 9 9 D J0697 Sterile cefuroxime injection $ 2.38 $ 2.38 0 0% 0% 0% 9 9 9 9 9 9 D J0698 Cefotaxime sodium injection $ 2.00 $ 2.00 0 0% 0% 0% 9 9 9 9 9 9 D
J0702 Betamethasone acet&sod phosp $ 6.91 $ 6.91 0 0% 0% 0% 9 9 9 9 9 9 D J0706 Caffeine citrate injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0710 Cephapirin sodium injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0712 Ceftaroline fosamil inj $ 2.27 $ 2.27 0 0% 0% 0% 9 9 9 9 9 9 DJ0713 Inj ceftazidime per 500 mg $ 1.79 $ 1.79 0 0% 0% 0% 9 9 9 9 9 9 D J0715 Ceftizoxime sodium / 500 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0716 Centruroides immune f(ab) $ 3937.50 $ 3937.50 0 0% 0% 0% 9 9 9 9 9 9 D YJ0717 Certolizumab pegol inj 1mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ0720 Chloramphenicol sodium injec $ 31.77 $ 31.77 0 0% 0% 0% 9 9 9 9 9 9 D J0725 Chorionic gonadotropin/1000u $ 23.85 $ 23.85 0 0% 0% 0% 9 9 9 9 9 9 D J0735 Clonidine hydrochloride $ 21.60 $ 21.60 0 0% 0% 0% 9 9 9 9 9 9 D J0740 Cidofovir injection $ 799.20 $ 799.20 0 0% 0% 0% 9 9 9 9 9 9 D J0743 Cilastatin sodium injection $ 4.86 $ 4.86 0 0% 0% 0% 9 9 9 9 9 9 D J0744 Ciprofloxacin iv $ 2.25 $ 2.25 0 0% 0% 0% 9 9 9 9 9 9 D J0745 Inj codeine phosphate /30 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 93
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J0760 Colchicine injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0770 Colistimethate sodium inj $ 25.92 $ 25.92 0 0% 0% 0% 9 9 9 9 9 9 D J0775 Collagenase, clost hist inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ0780 Prochlorperazine injection $ 19.98 $ 19.98 0 0% 0% 0% 9 9 9 9 9 9 D J0795 Corticorelin ovine triflutal Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J0800 Corticotropin injection $ 3098.09 $ 3098.09 0 0% 0% 0% 9 9 9 9 9 9 D J0833 Cosyntropin injection nos $ 86.62 $ 86.62 0 0% 0% 0% 9 9 9 9 9 9 DJ0834 Cosyntropin cortrosyn inj $ 115.11 $ 115.11 0 0% 0% 0% 9 9 9 9 9 9 DJ0840 Crotalidae poly immune fab $ 2643.84 $ 2643.84 0 0% 0% 0% 9 9 9 9 9 9 D YJ0850 Cytomegalovirus imm iv /vial $ 1320.84 $ 1320.84 0 0% 0% 0% 9 9 9 9 9 9 D J0878 Daptomycin injection $ 0.82 $ 0.82 0 0% 0% 0% 9 9 9 9 9 9 D J0881 Darbepoetin alfa, non-esrd $ 7.29 $ 7.29 0 0% 0% 0% 9 9 9 9 9 9 D J0882 Darbepoetin alfa, esrd use $ 7.29 $ 7.29 0 0% 0% 0% 9 9 9 9 9 9 D J0885 Epoetin alfa, non-esrd $ 15.63 $ 15.63 0 0% 0% 0% 9 9 9 9 9 9 D J0886 Epoetin alfa 1000 units esrd $ 15.63 $ 15.63 0 0% 0% 0% 9 9 9 9 9 9 D J0887 Epoetin beta esrd use $ 1.94 $ 1.94 0 0% 0% 0% 9 9 9 9 9 9 DJ0888 Epoetin beta non esrd $ 1.94 $ 1.94 0 0% 0% 0% 9 9 9 9 9 9 DJ0890 Peginesatide injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ0894 Decitabine injection $ 25.92 $ 25.92 0 0% 0% 0% 9 9 9 9 9 9 D YJ0895 Deferoxamine mesylate inj $ 8.45 $ 8.45 0 0% 0% 0% 9 9 9 9 9 9 D J0897 Denosumab injection $ 16.65 $ 16.65 0 0% 0% 0% 9 9 9 9 9 9 D YJ0945 Brompheniramine maleate inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1000 Depo-estradiol cypionate inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1020 Methylprednisolone 20 mg inj $ 1.94 $ 1.94 0 0% 0% 0% 9 9 9 9 9 9 D J1030 Methylprednisolone 40 mg inj $ 3.88 $ 3.88 0 0% 0% 0% 9 9 9 9 9 9 D J1040 Methylprednisolone 80 mg inj $ 7.78 $ 7.78 0 0% 0% 0% 9 9 9 9 9 9 D J1050 Medroxyprogesterone acetate $ 0.44 $ 0.44 0 0% 0% 0% 9 9 9 9 9 9 DJ1071 Inj testosterone cypionate $ 0.05 $ 0.05 0 0% 0% 0% 9 9 9 9 9 9 DJ1094 Inj dexamethasone acetate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1100 Dexamethasone sodium phos $ 0.04 $ 0.04 0 0% 0% 0% 9 9 9 9 9 9 D J1110 Inj dihydroergotamine mesylt $ 67.38 $ 67.38 0 0% 0% 0% 9 9 9 9 9 9 D J1120 Acetazolamid sodium injectio $ 43.20 $ 43.20 0 0% 0% 0% 9 9 9 9 9 9 D J1160 Digoxin injection $ 5.94 $ 5.94 0 0% 0% 0% 9 9 9 9 9 9 D J1162 Digoxin immune fab (ovine) $ 2452.68 $ 2452.68 0 0% 0% 0% 9 9 9 9 9 9 D J1165 Phenytoin sodium injection $ 0.36 $ 0.36 0 0% 0% 0% 9 9 9 9 9 9 D J1170 Hydromorphone injection $ 1.40 $ 1.40 0 0% 0% 0% 9 9 9 9 9 9 D J1180 Dyphylline injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1190 Dexrazoxane hcl injection $ 221.65 $ 221.65 0 0% 0% 0% 9 9 9 9 9 9 D J1200 Diphenhydramine hcl injectio $ 0.88 $ 0.88 0 0% 0% 0% 9 9 9 9 9 9 D J1205 Chlorothiazide sodium inj $ 112.28 $ 112.28 0 0% 0% 0% 9 9 9 9 9 9 D
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 94
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J1212 Dimethyl sulfoxide 50% 50 ml $ 122.52 $ 122.52 0 0% 0% 0% 9 9 9 9 9 9 D J1230 Methadone injection $ 10.07 $ 10.07 0 0% 0% 0% 9 9 9 9 9 9 D J1240 Dimenhydrinate injection $ 6.42 $ 6.42 0 0% 0% 0% 9 9 9 9 9 9 D J1245 Dipyridamole injection $ 0.96 $ 0.96 0 0% 0% 0% 9 9 9 9 9 9 D J1250 Inj dobutamine hcl/250 mg $ 5.63 $ 5.63 0 0% 0% 0% 9 9 9 9 9 9 D J1260 Dolasetron mesylate $ 5.76 $ 5.76 0 0% 0% 0% 9 9 9 9 9 9 D J1265 Dopamine injection $ 0.12 $ 0.12 0 0% 0% 0% 9 9 9 9 9 9 D J1267 Doripenem injection $ 0.83 $ 0.83 0 0% 0% 0% 9 9 9 9 9 9 D J1270 Injection, doxercalciferol Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1290 Ecallantide injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ1300 Eculizumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1320 Amitriptyline injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1322 Elosulfase alfa, injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ1324 Enfuvirtide injection $ 0.63 $ 0.63 0 0% 0% 0% 9 9 9 9 9 9 D J1325 Epoprostenol injection $ 12.49 $ 12.49 0 0% 0% 0% 9 9 9 9 9 9 D J1327 Eptifibatide injection $ 33.62 $ 33.62 0 0% 0% 0% 9 9 9 9 9 9 D J1330 Ergonovine maleate injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1335 Ertapenem injection $ 44.26 $ 44.26 0 0% 0% 0% 9 9 9 9 9 9 D J1364 Erythro lactobionate /500 mg $ 46.77 $ 46.77 0 0% 0% 0% 9 9 9 9 9 9 D J1380 Estradiol valerate 10 mg inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1410 Inj estrogen conjugate 25 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1430 Ethanolamine oleate 100 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1435 Injection estrone per 1 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1436 Etidronate disodium inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1438 Etanercept injection $ 393.41 $ 393.41 0 0% 0% 0% 9 9 9 9 9 9 D J1439 Inj ferric carboxymaltos 1mg $ 1.23 $ 1.23 0 0% 0% 0% 9 9 9 9 9 9 DJ1442 Inj, filgrastim g-csf 1mcg $ 1.08 $ 1.08 0 0% 0% 0% 9 9 9 9 9 9 DJ1446 Inj, tbo-filgrastim, 5 mcg $ 4.30 $ 4.30 0 0% 0% 0% 9 9 9 9 9 9 DJ1450 Fluconazole $ 3.47 $ 3.47 0 0% 0% 0% 9 9 9 9 9 9 D J1451 Fomepizole, 15 mg $ 10.19 $ 10.19 0 0% 0% 0% 9 9 9 9 9 9 D J1452 Intraocular fomivirsen na Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1453 Fosaprepitant injection $ 1.85 $ 1.85 0 0% 0% 0% 9 9 9 9 9 9 D J1455 Foscarnet sodium injection $ 13.57 $ 13.57 0 0% 0% 0% 9 9 9 9 9 9 D J1457 Gallium nitrate injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1458 Galsulfase injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1459 Inj ivig privigen 500 mg $ 70.20 $ 70.20 0 0% 0% 0% 9 9 9 9 9 9 D J1460 Gamma globulin 1 cc inj $ 30.76 $ 30.76 0 0% 0% 0% 9 9 9 9 9 9 D J1556 Inj, imm glob bivigam, 500mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ1557 Gammaplex injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ1559 Hizentra injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 95
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J1560 Gamma globulin > 10 cc inj $ 30.76 $ 30.76 0 0% 0% 0% 9 9 9 9 9 9 D J1561 Gamunex-c/gammaked $ 54.89 $ 54.89 0 0% 0% 0% 9 9 9 9 9 9 D YJ1562 Vivaglobin, inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1566 Immune globulin, powder $ 45.45 $ 45.45 0 0% 0% 0% 9 9 9 9 9 9 D J1568 Octagam injection $ 68.40 $ 68.40 0 0% 0% 0% 9 9 9 9 9 9 D YJ1569 Gammagard liquid injection $ 67.18 $ 67.18 0 0% 0% 0% 9 9 9 9 9 9 D YJ1570 Ganciclovir sodium injection $ 77.76 $ 77.76 0 0% 0% 0% 9 9 9 9 9 9 D J1571 Hepagam b im injection $ 69.12 $ 69.12 0 0% 0% 0% 9 9 9 9 9 9 D YJ1572 Flebogamma injection $ 45.30 $ 45.30 0 0% 0% 0% 9 9 9 9 9 9 D YJ1573 Hepagam b intravenous, inj $ 69.12 $ 69.12 0 0% 0% 0% 9 9 9 9 9 9 D YJ1580 Garamycin gentamicin inj $ 1.13 $ 1.13 0 0% 0% 0% 9 9 9 9 9 9 D J1590 Gatifloxacin injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1595 Injection glatiramer acetate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1599 Ivig non-lyophilized, nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NJ1600 Gold sodium thiomaleate inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1602 Golimumab for iv use 1mg $ 37.00 $ 37.00 0 0% 0% 0% 9 9 9 9 9 9 D YJ1610 Glucagon hydrochloride/1 mg $ 185.33 $ 185.33 0 0% 0% 0% 9 9 9 9 9 9 D J1620 Gonadorelin hydroch/ 100 mcg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1626 Granisetron hcl injection $ 2.59 $ 2.59 0 0% 0% 0% 9 9 9 9 9 9 D J1630 Haloperidol injection $ 1.30 $ 1.30 0 0% 0% 0% 9 9 9 9 9 9 D J1631 Haloperidol decanoate inj $ 2.05 $ 2.05 0 0% 0% 0% 9 9 9 9 9 9 D J1640 Hemin, 1 mg $ 22.63 $ 22.63 0 0% 0% 0% 9 9 9 9 9 9 D J1642 Inj heparin sodium per 10 u $ 0.22 $ 0.22 0 0% 0% 0% 9 9 9 9 9 9 D J1644 Inj heparin sodium per 1000u $ 0.19 $ 0.19 0 0% 0% 0% 9 9 9 9 9 9 D J1645 Dalteparin sodium $ 17.42 $ 17.42 0 0% 0% 0% 9 9 9 9 9 9 D J1650 Inj enoxaparin sodium $ 4.75 $ 4.75 0 0% 0% 0% 9 9 9 9 9 9 D J1652 Fondaparinux sodium $ 5.79 $ 5.79 0 0% 0% 0% 9 9 9 9 9 9 D J1655 Tinzaparin sodium injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1670 Tetanus immune globulin inj $ 407.82 $ 407.82 0 0% 0% 0% 9 9 9 9 9 9 D J1675 Histrelin acetate $ 4.41 $ 4.41 0 0% 0% 0% 9 9 9 9 9 9 D J1700 Hydrocortisone acetate inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1710 Hydrocortisone sodium ph inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1720 Hydrocortisone sodium succ i $ 2.16 $ 2.16 0 0% 0% 0% 9 9 9 9 9 9 D J1725 Hydroxyprogesterone caproate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ1730 Diazoxide injection $ 54.01 $ 54.01 0 0% 0% 0% 9 9 9 9 9 9 D J1740 Ibandronate sodium injection $ 90.00 $ 90.00 0 0% 0% 0% 9 9 9 9 9 9 D J1741 Ibuprofen injection $ 1.62 $ 1.62 0 0% 0% 0% 9 9 9 9 9 9 D YJ1742 Ibutilide fumarate injection $ 302.40 $ 302.40 0 0% 0% 0% 9 9 9 9 9 9 D J1743 Idursulfase injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1744 Icatibant injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 96
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J1745 Infliximab injection $ 100.25 $ 100.25 0 0% 0% 0% 9 9 9 9 9 9 D YJ1750 Inj iron dextran $ 16.97 $ 16.97 0 0% 0% 0% 9 9 9 9 9 9 D J1756 Iron sucrose injection $ 0.54 $ 0.54 0 0% 0% 0% 9 9 9 9 9 9 D YJ1786 Imuglucerase injection $ 42.82 $ 42.82 0 0% 0% 0% 9 9 9 9 9 9 DJ1790 Droperidol injection $ 2.18 $ 2.18 0 0% 0% 0% 9 9 9 9 9 9 D J1800 Propranolol injection $ 8.64 $ 8.64 0 0% 0% 0% 9 9 9 9 9 9 D J1810 Droperidol/fentanyl inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1815 Insulin injection $ 0.35 $ 0.35 0 0% 0% 0% 9 9 9 9 9 9 D J1817 Insulin for insulin pump use $ 7.60 $ 7.60 0 0% 0% 0% 9 9 9 9 9 9 D J1826 Interferon beta-1a inj $ 1011.15 $ 1011.15 0 0% 0% 0% 9 9 9 9 9 9 D YJ1830 Interferon beta-1b / .25 mg $ 346.17 $ 346.17 0 0% 0% 0% 9 9 9 9 9 9 D J1835 Itraconazole injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1840 Kanamycin sulfate 500 mg inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1850 Kanamycin sulfate 75 mg inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1885 Ketorolac tromethamine inj $ 0.43 $ 0.43 0 0% 0% 0% 9 9 9 9 9 9 D J1890 Cephalothin sodium injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1930 Lanreotide injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1931 Laronidase injection $ 100.98 $ 100.98 0 0% 0% 0% 9 9 9 9 9 9 D J1940 Furosemide injection $ 0.70 $ 0.70 0 0% 0% 0% 9 9 9 9 9 9 D J1945 Lepirudin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1950 Leuprolide acetate /3.75 mg $ 589.57 $ 589.57 0 0% 0% 0% 9 9 9 9 9 9 D J1953 Levetiracetam injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1955 Inj levocarnitine per 1 gm $ 12.38 $ 12.38 0 0% 0% 0% 9 9 9 9 9 9 D J1956 Levofloxacin injection $ 3.80 $ 3.80 0 0% 0% 0% 9 9 9 9 9 9 D J1960 Levorphanol tartrate inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J1980 Hyoscyamine sulfate inj $ 52.84 $ 52.84 0 0% 0% 0% 9 9 9 9 9 9 D J1990 Chlordiazepoxide injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2001 Lidocaine injection $ 0.05 $ 0.05 0 0% 0% 0% 9 9 9 9 9 9 D J2010 Lincomycin injection $ 10.56 $ 10.56 0 0% 0% 0% 9 9 9 9 9 9 D J2020 Linezolid injection $ 88.78 $ 88.78 0 0% 0% 0% 9 9 9 9 9 9 D J2060 Lorazepam injection $ 0.73 $ 0.73 0 0% 0% 0% 9 9 9 9 9 9 D J2150 Mannitol injection $ 1.64 $ 1.64 0 0% 0% 0% 9 9 9 9 9 9 D J2170 Mecasermin injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2175 Meperidine hydrochl /100 mg $ 1.48 $ 1.48 0 0% 0% 0% 9 9 9 9 9 9 D J2180 Meperidine/promethazine inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2185 Meropenem $ 1.02 $ 1.02 0 0% 0% 0% 9 9 9 9 9 9 D J2210 Methylergonovin maleate inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2212 Methylnaltrexone injection $ 0.59 $ 0.59 0 0% 0% 0% 9 9 9 9 9 9 D YJ2248 Micafungin sodium injection $ 2.02 $ 2.02 0 0% 0% 0% 9 9 9 9 9 9 D J2250 Inj midazolam hydrochloride $ 0.18 $ 0.18 0 0% 0% 0% 9 9 9 9 9 9 D
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 97
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J2260 Inj milrinone lactate / 5 mg $ 2.48 $ 2.48 0 0% 0% 0% 9 9 9 9 9 9 D J2265 Minocycline hydrochloride $ 0.96 $ 0.96 0 0% 0% 0% 9 9 9 9 9 9 DJ2270 Morphine sulfate injection $ 0.69 $ 0.69 0 0% 0% 0% 9 9 9 9 9 9 D J2274 In morphine preservativ free Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ2278 Ziconotide injection $ 7.40 $ 7.40 0 0% 0% 0% 9 9 9 9 9 9 D YJ2280 Inj, moxifloxacin 100 mg $ 12.54 $ 12.54 0 0% 0% 0% 9 9 9 9 9 9 D J2300 Inj nalbuphine hydrochloride $ 2.35 $ 2.35 0 0% 0% 0% 9 9 9 9 9 9 D J2310 Inj naloxone hydrochloride $ 17.82 $ 17.82 0 0% 0% 0% 9 9 9 9 9 9 D J2315 Naltrexone, depot form $ 3.61 $ 3.61 0 0% 0% 0% 9 9 9 9 9 9 D YJ2320 Nandrolone decanoate 50 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2323 Natalizumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2325 Nesiritide injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2353 Octreotide injection, depot $ 164.79 $ 164.79 0 0% 0% 0% 9 9 9 9 9 9 D YJ2354 Octreotide inj, non-depot $ 0.92 $ 0.92 0 0% 0% 0% 9 9 9 9 9 9 D YJ2355 Oprelvekin injection $ 434.97 $ 434.97 0 0% 0% 0% 9 9 9 9 9 9 D J2357 Omalizumab injection $ 30.25 $ 30.25 0 0% 0% 0% 9 9 9 9 9 9 D J2358 Olanzapine long-acting inj $ 3.71 $ 3.71 0 0% 0% 0% 9 9 9 9 9 9 D YJ2360 Orphenadrine injection $ 12.96 $ 12.96 0 0% 0% 0% 9 9 9 9 9 9 D J2370 Phenylephrine hcl injection $ 1.97 $ 1.97 0 0% 0% 0% 9 9 9 9 9 9 D J2400 Chloroprocaine hcl injection $ 19.48 $ 19.48 0 0% 0% 0% 9 9 9 9 9 9 D J2405 Ondansetron hcl injection $ 0.07 $ 0.07 0 0% 0% 0% 9 9 9 9 9 9 D J2410 Oxymorphone hcl injection $ 3.38 $ 3.38 0 0% 0% 0% 9 9 9 9 9 9 D J2425 Palifermin injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2426 Paliperidone palmitate inj $ 8.93 $ 8.93 0 0% 0% 0% 9 9 9 9 9 9 DJ2430 Pamidronate disodium /30 mg $ 12.91 $ 12.91 0 0% 0% 0% 9 9 9 9 9 9 D J2440 Papaverin hcl injection $ 5.40 $ 5.40 0 0% 0% 0% 9 9 9 9 9 9 D J2460 Oxytetracycline injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2469 Palonosetron hcl $ 44.39 $ 44.39 0 0% 0% 0% 9 9 9 9 9 9 D J2501 Paricalcitol Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2503 Pegaptanib sodium injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2504 Pegademase bovine, 25 iu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2505 Injection, pegfilgrastim 6mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2507 Pegloticase injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ2510 Penicillin g procaine inj $ 10.40 $ 10.40 0 0% 0% 0% 9 9 9 9 9 9 D J2513 Pentastarch 10% solution Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2515 Pentobarbital sodium inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2540 Penicillin g potassium inj $ 1.08 $ 1.08 0 0% 0% 0% 9 9 9 9 9 9 D J2543 Piperacillin/tazobactam $ 1.87 $ 1.87 0 0% 0% 0% 9 9 9 9 9 9 D J2545 Pentamidine non-comp unit $ 106.65 $ 106.65 0 0% 0% 0% 9 9 9 9 9 9 D J2550 Promethazine hcl injection $ 3.32 $ 3.32 0 0% 0% 0% 9 9 9 9 9 9 D
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 98
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J2560 Phenobarbital sodium inj $ 44.85 $ 44.85 0 0% 0% 0% 9 9 9 9 9 9 D J2562 Plerixafor injection $ 319.66 $ 319.66 0 0% 0% 0% 9 9 9 9 9 9 D YJ2590 Oxytocin injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2597 Inj desmopressin acetate $ 1.59 $ 1.59 0 0% 0% 0% 9 9 9 9 9 9 D J2650 Prednisolone acetate inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2670 Totazoline hcl injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2675 Inj progesterone per 50 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2680 Fluphenazine decanoate 25 mg $ 29.11 $ 29.11 0 0% 0% 0% 9 9 9 9 9 9 D J2690 Procainamide hcl injection $ 49.13 $ 49.13 0 0% 0% 0% 9 9 9 9 9 9 D J2700 Oxacillin sodium injeciton $ 2.13 $ 2.13 0 0% 0% 0% 9 9 9 9 9 9 D J2704 Inj, propofol, 10 mg $ 0.09 $ 0.09 0 0% 0% 0% 9 9 9 9 9 9 D YJ2710 Neostigmine methylslfte inj $ 1.45 $ 1.45 0 0% 0% 0% 9 9 9 9 9 9 D J2720 Inj protamine sulfate/10 mg $ 0.97 $ 0.97 0 0% 0% 0% 9 9 9 9 9 9 D J2724 Protein c concentrate $ 16.20 $ 16.20 0 0% 0% 0% 9 9 9 9 9 9 D YJ2725 Inj protirelin per 250 mcg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2730 Pralidoxime chloride inj $ 53.82 $ 53.82 0 0% 0% 0% 9 9 9 9 9 9 D J2760 Phentolaine mesylate inj $ 113.13 $ 113.13 0 0% 0% 0% 9 9 9 9 9 9 D J2765 Metoclopramide hcl injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2770 Quinupristin/dalfopristin $ 318.10 $ 318.10 0 0% 0% 0% 9 9 9 9 9 9 D J2778 Ranibizumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2780 Ranitidine hydrochloride inj $ 1.30 $ 1.30 0 0% 0% 0% 9 9 9 9 9 9 D J2783 Rasburicase Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2785 Regadenoson injection $ 59.14 $ 59.14 0 0% 0% 0% 9 9 9 9 9 9 D YJ2788 Rho d immune globulin 50 mcg $ 33.08 $ 33.08 0 0% 0% 0% 9 9 9 9 9 9 D J2790 Rho d immune globulin inj $ 97.95 $ 97.95 0 0% 0% 0% 9 9 9 9 9 9 D J2791 Rhophylac injection $ 11.55 $ 11.55 0 0% 0% 0% 9 9 9 9 9 9 D YJ2792 Rho(d) immune globulin h, sd $ 6.95 $ 6.95 0 0% 0% 0% 9 9 9 9 9 9 D J2793 Rilonacept injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ2794 Risperidone, long acting $ 14.75 $ 14.75 0 0% 0% 0% 9 9 9 9 9 9 D J2795 Ropivacaine hcl injection $ 0.04 $ 0.04 0 0% 0% 0% 9 9 9 9 9 9 D J2796 Romiplostim injection $ 60.50 $ 60.50 0 0% 0% 0% 9 9 9 9 9 9 D YJ2800 Methocarbamol injection $ 64.15 $ 64.15 0 0% 0% 0% 9 9 9 9 9 9 D J2805 Sincalide injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2810 Inj theophylline per 40 mg $ 0.47 $ 0.47 0 0% 0% 0% 9 9 9 9 9 9 D J2820 Sargramostim injection $ 48.82 $ 48.82 0 0% 0% 0% 9 9 9 9 9 9 D J2850 Inj secretin synthetic human Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2910 Aurothioglucose injeciton Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2916 Na ferric gluconate complex $ 6.87 $ 6.87 0 0% 0% 0% 9 9 9 9 9 9 D J2920 Methylprednisolone injection $ 3.76 $ 3.76 0 0% 0% 0% 9 9 9 9 9 9 D J2930 Methylprednisolone injection $ 3.52 $ 3.52 0 0% 0% 0% 9 9 9 9 9 9 D
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 99
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J2940 Somatrem injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2941 Somatropin injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2950 Promazine hcl injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2993 Reteplase injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2995 Inj streptokinase /250000 iu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J2997 Alteplase recombinant $ 60.40 $ 60.40 0 0% 0% 0% 9 9 9 9 9 9 D J3000 Streptomycin injection $ 20.25 $ 20.25 0 0% 0% 0% 9 9 9 9 9 9 D J3010 Fentanyl citrate injeciton $ 0.96 $ 0.96 0 0% 0% 0% 9 9 9 9 9 9 D J3030 Sumatriptan succinate / 6 mg $ 25.92 $ 25.92 0 0% 0% 0% 9 9 9 9 9 9 D J3060 Inj, taliglucerace alfa 10 u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ3070 Pentazocine injection $ 133.52 $ 133.52 0 0% 0% 0% 9 9 9 9 9 9 D J3095 Telavancin injection $ 4.68 $ 4.68 0 0% 0% 0% 9 9 9 9 9 9 DJ3101 Tenecteplase injection $ 89.70 $ 89.70 0 0% 0% 0% 9 9 9 9 9 9 D J3105 Terbutaline sulfate inj $ 4.32 $ 4.32 0 0% 0% 0% 9 9 9 9 9 9 D J3110 Teriparatide injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3121 Inj testostero enanthate 1mg $ 0.08 $ 0.08 0 0% 0% 0% 9 9 9 9 9 9 DJ3145 Testosterone undecanoate 1mg $ 1.19 $ 1.19 0 0% 0% 0% 9 9 9 9 9 9 DJ3230 Chlorpromazine hcl injection $ 23.76 $ 23.76 0 0% 0% 0% 9 9 9 9 9 9 D J3240 Thyrotropin injection $ 1461.24 $ 1461.24 0 0% 0% 0% 9 9 9 9 9 9 D J3243 Tigecycline injection $ 1.32 $ 1.32 0 0% 0% 0% 9 9 9 9 9 9 D J3246 Tirofiban hcl $ 11.18 $ 11.18 0 0% 0% 0% 9 9 9 9 9 9 D J3250 Trimethobenzamide hcl inj $ 27.10 $ 27.10 0 0% 0% 0% 9 9 9 9 9 9 D J3260 Tobramycin sulfate injection $ 1.22 $ 1.22 0 0% 0% 0% 9 9 9 9 9 9 D J3262 Tocilizumab injection $ 4.24 $ 4.24 0 0% 0% 0% 9 9 9 9 9 9 D YJ3265 Injection torsemide 10 mg/ml $ 2.22 $ 2.22 0 0% 0% 0% 9 9 9 9 9 9 D J3280 Thiethylperazine maleate inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3285 Treprostinil injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3300 Triamcinolone a inj prs-free $ 3.87 $ 3.87 0 0% 0% 0% 9 9 9 9 9 9 D J3301 Triamcinolone acet inj nos $ 2.38 $ 2.38 0 0% 0% 0% 9 9 9 9 9 9 D J3302 Triamcinolone diacetate inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3303 Triamcinolone hexacetonl inj $ 1.93 $ 1.93 0 0% 0% 0% 9 9 9 9 9 9 D J3305 Inj trimetrexate glucoronate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3310 Perphenazine injeciton Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3315 Triptorelin pamoate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3320 Spectinomycn di-hcl inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3350 Urea injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3355 Urofollitropin, 75 iu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3357 Ustekinumab injection $ 183.87 $ 183.87 0 0% 0% 0% 9 9 9 9 9 9 D YJ3360 Diazepam injection $ 2.26 $ 2.26 0 0% 0% 0% 9 9 9 9 9 9 D J3364 Urokinase 5000 iu injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 100
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J3365 Urokinase 250,000 iu inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3370 Vancomycin hcl injection $ 2.39 $ 2.39 0 0% 0% 0% 9 9 9 9 9 9 D J3385 Velaglucerase alfa Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ3396 Verteporfin injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3400 Triflupromazine hcl inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3410 Hydroxyzine hcl injection $ 0.46 $ 0.46 0 0% 0% 0% 9 9 9 9 9 9 D J3411 Thiamine hcl 100 mg $ 3.74 $ 3.74 0 0% 0% 0% 9 9 9 9 9 9 D YJ3415 Pyridoxine hcl 100 mg $ 9.71 $ 9.71 0 0% 0% 0% 9 9 9 9 9 9 D YJ3420 Vitamin b12 injection $ 0.45 $ 0.45 0 0% 0% 0% 9 9 9 9 9 9 D J3430 Vitamin k phytonadione inj $ 3.15 $ 3.15 0 0% 0% 0% 9 9 9 9 9 9 D J3465 Injection, voriconazole $ 6.87 $ 6.87 0 0% 0% 0% 9 9 9 9 9 9 D J3470 Hyaluronidase injection $ 60.26 $ 60.26 0 0% 0% 0% 9 9 9 9 9 9 D J3471 Ovine, up to 999 usp units $ 0.33 $ 0.33 0 0% 0% 0% 9 9 9 9 9 9 D J3472 Ovine, 1000 usp units $ 329.63 $ 329.63 0 0% 0% 0% 9 9 9 9 9 9 D J3473 Hyaluronidase recombinant $ 0.40 $ 0.40 0 0% 0% 0% 9 9 9 9 9 9 D J3475 Inj magnesium sulfate $ 0.06 $ 0.06 0 0% 0% 0% 9 9 9 9 9 9 D J3480 Inj potassium chloride $ 0.03 $ 0.03 0 0% 0% 0% 9 9 9 9 9 9 D J3485 Zidovudine $ 1.58 $ 1.58 0 0% 0% 0% 9 9 9 9 9 9 D J3486 Ziprasidone mesylate $ 14.14 $ 14.14 0 0% 0% 0% 9 9 9 9 9 9 D J3489 Zoledronic acid 1mg $ 66.15 $ 66.15 0 0% 0% 0% 9 9 9 9 9 9 D YJ3490 Drugs unclassified injection By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N J3520 Edetate disodium per 150 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3530 Nasal vaccine inhalation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3535 Metered dose inhaler drug Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B J3570 Laetrile amygdalin vit b17 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J3590 Unclassified biologics By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N J7030 Normal saline solution infus $ 1.53 $ 1.53 0 0% 0% 0% 9 9 9 9 9 9 D J7040 Normal saline solution infus $ 1.62 $ 1.62 0 0% 0% 0% 9 9 9 9 9 9 D J7042 5% dextrose/normal saline $ 1.49 $ 1.49 0 0% 0% 0% 9 9 9 9 9 9 D J7050 Normal saline solution infus $ 1.49 $ 1.49 0 0% 0% 0% 9 9 9 9 9 9 D J7060 5% dextrose/water $ 1.76 $ 1.76 0 0% 0% 0% 9 9 9 9 9 9 D J7070 D5w infusion $ 1.89 $ 1.89 0 0% 0% 0% 9 9 9 9 9 9 D J7100 Dextran 40 infusion $ 24.53 $ 24.53 0 0% 0% 0% 9 9 9 9 9 9 D J7110 Dextran 75 infusion Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7120 Ringers lactate infusion $ 1.71 $ 1.71 0 0% 0% 0% 9 9 9 9 9 9 D J7131 Hypertonic saline sol $ 0.02 $ 0.02 0 0% 0% 0% 9 9 9 9 9 9 DJ7178 Human fibrinogen conc inj $ 1.14 $ 1.14 0 0% 0% 0% 9 9 9 9 9 9 DJ7180 Factor xiii anti-hem factor Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ7181 Factor xiii recomb a-subunit $ 14.36 $ 14.36 0 0% 0% 0% 9 9 9 9 9 9 D YJ7182 Factor viii recomb novoeight $ 1.64 $ 1.64 0 0% 0% 0% 9 9 9 9 9 9 D Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 101
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J7183 Wilate injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ7185 Xyntha inj $ 1.64 $ 1.64 0 0% 0% 0% 9 9 9 9 9 9 DJ7186 Antihemophilic viii/vwf comp $ 1.22 $ 1.22 0 0% 0% 0% 9 9 9 9 9 9 D J7187 Humate-p, inj $ 1.20 $ 1.20 0 0% 0% 0% 9 9 9 9 9 9 D YJ7189 Factor viia $ 1.98 $ 1.98 0 0% 0% 0% 9 9 9 9 9 9 D J7190 Factor viii $ 1.33 $ 1.33 0 0% 0% 0% 9 9 9 9 9 9 D J7191 Factor viii (porcine) $ 5.57 $ 5.57 0 0% 0% 0% 9 9 9 9 9 9 D J7192 Factor viii recombinant nos $ 1.58 $ 1.58 0 0% 0% 0% 9 9 9 9 9 9 D J7193 Factor ix non-recombinant $ 1.31 $ 1.31 0 0% 0% 0% 9 9 9 9 9 9 D YJ7194 Factor ix complex $ 1.19 $ 1.19 0 0% 0% 0% 9 9 9 9 9 9 D J7195 Factor ix recombinant nos $ 1.40 $ 1.40 0 0% 0% 0% 9 9 9 9 9 9 D YJ7196 Antithrombin recombinant $ 3.03 $ 3.03 0 0% 0% 0% 9 9 9 9 9 9 D YJ7197 Antithrombin iii injection $ 4.10 $ 4.10 0 0% 0% 0% 9 9 9 9 9 9 D J7198 Anti-inhibitor $ 2.20 $ 2.20 0 0% 0% 0% 9 9 9 9 9 9 D J7199 Hemophilia clot factor noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N J7200 Factor ix recombinan rixubis $ 1.54 $ 1.54 0 0% 0% 0% 9 9 9 9 9 9 DJ7201 Factor ix fc fusion recomb $ 3.08 $ 3.08 0 0% 0% 0% 9 9 9 9 9 9 D YJ7300 Intraut copper contraceptive Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7301 Levonorgestrel iu 13.5 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ7302 Levonorgestrel iu 52 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7303 Contraceptive vaginal ring Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7304 Contraceptive hormone patch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7306 Levonorgestrel implant sys Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7307 Etonogestrel implant system Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7308 Aminolevulinic acid hcl top Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7309 Methyl aminolevulinate, top Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ7310 Ganciclovir long act implant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7311 Fluocinolone acetonide implt $ 20547.00 $ 20547.00 0 0% 0% 0% 9 9 9 9 9 9 D YJ7312 Dexamethasone intra implant $ 205.66 $ 205.66 0 0% 0% 0% 9 9 9 9 9 9 D YJ7315 Ophthalmic mitomycin $ 387.72 $ 387.72 0 0% 0% 0% 9 9 9 9 9 9 D YJ7316 Inj, ocriplasmin, 0.125 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ7321 Hyalgan/supartz inj per dose $ 205.20 $ 205.20 0 0% 0% 0% 9 9 9 9 9 9 D YJ7323 Euflexxa inj per dose $ 332.98 $ 332.98 0 0% 0% 0% 9 9 9 9 9 9 D YJ7324 Orthovisc inj per dose $ 350.75 $ 350.75 0 0% 0% 0% 9 9 9 9 9 9 D YJ7325 Synvisc or synvisc-one $ 25.03 $ 25.03 0 0% 0% 0% 9 9 9 9 9 9 D YJ7326 Gel-one $ 1053.00 $ 1053.00 0 0% 0% 0% 9 9 9 9 9 9 D YJ7327 Monovisc inj per dose $ 1053.00 $ 1053.00 0 0% 0% 0% 9 9 9 9 9 9 D YJ7330 Cultured chondrocytes implnt $ 33839.64 $ 33839.64 0 0% 0% 0% 9 9 9 9 9 9 D YJ7336 Capsaicin 8% patch $ 3.19 $ 3.19 0 0% 0% 0% 9 9 9 9 9 9 D YJ7500 Azathioprine oral 50mg $ 1.18 $ 1.18 0 0% 0% 0% 9 9 9 9 9 9 D
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 102
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J7501 Azathioprine parenteral Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7502 Cyclosporine oral 100 mg $ 4.94 $ 4.94 0 0% 0% 0% 9 9 9 9 9 9 D YJ7504 Lymphocyte immune globulin $ 1087.75 $ 1087.75 0 0% 0% 0% 9 9 9 9 9 9 D J7505 Monoclonal antibodies Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7506 Prednisone oral $ 0.02 $ 0.02 0 0% 0% 0% 9 9 9 9 9 9 D J7507 Tacrolimus imme rel oral 1mg $ 3.93 $ 3.93 0 0% 0% 0% 9 9 9 9 9 9 D J7508 Tacrolimus ex rel oral 0.1mg $ 0.43 $ 0.43 0 0% 0% 0% 9 9 9 9 9 9 D YJ7509 Methylprednisolone oral $ 1.29 $ 1.29 0 0% 0% 0% 9 9 9 9 9 9 D J7510 Prednisolone oral per 5 mg $ 7.75 $ 7.75 0 0% 0% 0% 9 9 9 9 9 9 D J7511 Antithymocyte globuln rabbit $ 753.49 $ 753.49 0 0% 0% 0% 9 9 9 9 9 9 D YJ7513 Daclizumab, parenteral Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7515 Cyclosporine oral 25 mg $ 2.59 $ 2.59 0 0% 0% 0% 9 9 9 9 9 9 D YJ7516 Cyclosporin parenteral 250mg $ 4.91 $ 4.91 0 0% 0% 0% 9 9 9 9 9 9 D YJ7517 Mycophenolate mofetil oral $ 3.57 $ 3.57 0 0% 0% 0% 9 9 9 9 9 9 D YJ7518 Mycophenolic acid Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7520 Sirolimus, oral $ 14.95 $ 14.95 0 0% 0% 0% 9 9 9 9 9 9 D J7525 Tacrolimus injection $ 162.16 $ 162.16 0 0% 0% 0% 9 9 9 9 9 9 D J7527 Oral everolimus $ 7.37 $ 7.37 0 0% 0% 0% 9 9 9 9 9 9 D YJ7599 Immunosuppressive drug noc Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B J7604 Acetylcysteine comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7605 Arformoterol non-comp unit $ 11.12 $ 11.12 0 0% 0% 0% 9 9 9 9 9 9 D J7606 Formoterol fumarate, inh $ 11.61 $ 11.61 0 0% 0% 0% 9 9 9 9 9 9 D J7607 Levalbuterol comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7608 Acetylcysteine non-comp unit $ 3.75 $ 3.75 0 0% 0% 0% 9 9 9 9 9 9 D J7609 Albuterol comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7610 Albuterol comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7611 Albuterol non-comp con $ 0.17 $ 0.17 0 0% 0% 0% 9 9 9 9 9 9 D J7612 Levalbuterol non-comp con $ 1.93 $ 1.93 0 0% 0% 0% 9 9 9 9 9 9 D J7613 Albuterol non-comp unit $ 0.01 $ 0.01 0 0% 0% 0% 9 9 9 9 9 9 D J7614 Levalbuterol non-comp unit $ 4.60 $ 4.60 0 0% 0% 0% 9 9 9 9 9 9 D J7615 Levalbuterol comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7620 Albuterol ipratrop non-comp $ 0.43 $ 0.43 0 0% 0% 0% 9 9 9 9 9 9 D J7622 Beclomethasone comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7624 Betamethasone comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7626 Budesonide non-comp unit $ 4.25 $ 4.25 0 0% 0% 0% 9 9 9 9 9 9 D J7627 Budesonide comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7628 Bitolterol mesylate comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7629 Bitolterol mesylate comp unt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7631 Cromolyn sodium noncomp unit $ 1.53 $ 1.53 0 0% 0% 0% 9 9 9 9 9 9 D J7632 Cromolyn sodium comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 103
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J7633 Budesonide non-comp con $ 9.41 $ 9.41 0 0% 0% 0% 9 9 9 9 9 9 D J7634 Budesonide comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7635 Atropine comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7636 Atropine comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7637 Dexamethasone comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7638 Dexamethasone comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7639 Dornase alfa non-comp unit $ 37.19 $ 37.19 0 0% 0% 0% 9 9 9 9 9 9 D J7640 Formoterol comp unit $ 3.98 $ 3.98 0 0% 0% 0% 9 9 9 9 9 9 D J7641 Flunisolide comp unit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N J7642 Glycopyrrolate comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7643 Glycopyrrolate comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7644 Ipratropium bromide non-comp $ 1.98 $ 1.98 0 0% 0% 0% 9 9 9 9 9 9 D J7645 Ipratropium bromide comp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7647 Isoetharine comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7648 Isoetharine non-comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7649 Isoetharine non-comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7650 Isoetharine comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7657 Isoproterenol comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7658 Isoproterenol non-comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7659 Isoproterenol non-comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7660 Isoproterenol comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7665 Mannitol for inhaler Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ7667 Metaproterenol comp con $ 0.30 $ 0.30 0 0% 0% 0% 9 9 9 9 9 9 D J7668 Metaproterenol non-comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7669 Metaproterenol non-comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7670 Metaproterenol comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7674 Methacholine chloride, neb $ 0.54 $ 0.54 0 0% 0% 0% 9 9 9 9 9 9 D J7676 Pentamidine comp unit dose Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7680 Terbutaline sulf comp con Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7681 Terbutaline sulf comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7682 Tobramycin non-comp unit $ 115.89 $ 115.89 0 0% 0% 0% 9 9 9 9 9 9 D J7683 Triamcinolone comp con By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N J7684 Triamcinolone comp unit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N J7685 Tobramycin comp unit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J7686 Treprostinil, non-comp unit $ 526.50 $ 526.50 0 0% 0% 0% 9 9 9 9 9 9 D YJ7699 Inhalation solution for dme Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B J7799 Non-inhalation drug for dme Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B J8498 Antiemetic rectal/supp nos Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B J8499 Oral prescrip drug non chemo Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B J8501 Oral aprepitant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 104
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J8510 Oral busulfan $ 13.31 $ 13.31 0 0% 0% 0% 9 9 9 9 9 9 D YJ8515 Cabergoline, oral 0.25mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J8520 Capecitabine, oral, 150 mg $ 10.55 $ 10.55 0 0% 0% 0% 9 9 9 9 9 9 D YJ8521 Capecitabine, oral, 500 mg $ 35.17 $ 35.17 0 0% 0% 0% 9 9 9 9 9 9 D YJ8530 Cyclophosphamide oral 25 mg $ 6.83 $ 6.83 0 0% 0% 0% 9 9 9 9 9 9 D YJ8540 Oral dexamethasone $ 0.09 $ 0.09 0 0% 0% 0% 9 9 9 9 9 9 D J8560 Etoposide oral 50 mg $ 63.77 $ 63.77 0 0% 0% 0% 9 9 9 9 9 9 D YJ8562 Oral fludarabine phosphate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J8565 Gefitinib oral Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J8597 Antiemetic drug oral nos Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B J8600 Melphalan oral 2 mg $ 10.27 $ 10.27 0 0% 0% 0% 9 9 9 9 9 9 D YJ8610 Methotrexate oral 2.5 mg $ 3.21 $ 3.21 0 0% 0% 0% 9 9 9 9 9 9 D YJ8650 Nabilone oral $ 34.75 $ 34.75 0 0% 0% 0% 9 9 9 9 9 9 D YJ8700 Temozolomide $ 10.81 $ 10.81 0 0% 0% 0% 9 9 9 9 9 9 D J8705 Topotecan oral $ 105.37 $ 105.37 0 0% 0% 0% 9 9 9 9 9 9 D YJ8999 Oral prescription drug chemo Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B YJ9000 Doxorubicin hcl injection $ 7.24 $ 7.24 0 0% 0% 0% 9 9 9 9 9 9 D YJ9010 Alemtuzumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9015 Aldesleukin injection $ 2643.10 $ 2643.10 0 0% 0% 0% 9 9 9 9 9 9 D YJ9017 Arsenic trioxide injection $ 60.91 $ 60.91 0 0% 0% 0% 9 9 9 9 9 9 D YJ9019 Erwinaze injection $ 386.79 $ 386.79 0 0% 0% 0% 9 9 9 9 9 9 D YJ9020 Asparaginase, nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9025 Azacitidine injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9027 Clofarabine injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9031 Bcg live intravesical vac $ 156.77 $ 156.77 0 0% 0% 0% 9 9 9 9 9 9 D YJ9033 Bendamustine injection $ 24.15 $ 24.15 0 0% 0% 0% 9 9 9 9 9 9 D YJ9035 Bevacizumab injection $ 73.30 $ 73.30 0 0% 0% 0% 9 9 9 9 9 9 D YJ9040 Bleomycin sulfate injection $ 35.73 $ 35.73 0 0% 0% 0% 9 9 9 9 9 9 D YJ9041 Bortezomib injection $ 49.46 $ 49.46 0 0% 0% 0% 9 9 9 9 9 9 D J9042 Brentuximab vedotin inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ9043 Cabazitaxel injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ9045 Carboplatin injection $ 4.52 $ 4.52 0 0% 0% 0% 9 9 9 9 9 9 D YJ9047 Injection, carfilzomib, 1 mg $ 31.16 $ 31.16 0 0% 0% 0% 9 9 9 9 9 9 D YJ9050 Carmustine injection $ 2073.36 $ 2073.36 0 0% 0% 0% 9 9 9 9 9 9 D YJ9055 Cetuximab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9060 Cisplatin 10 mg injection $ 3.24 $ 3.24 0 0% 0% 0% 9 9 9 9 9 9 D YJ9065 Inj cladribine per 1 mg $ 37.80 $ 37.80 0 0% 0% 0% 9 9 9 9 9 9 D YJ9070 Cyclophosphamide 100 mg inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9098 Cytarabine liposome inj $ 603.53 $ 603.53 0 0% 0% 0% 9 9 9 9 9 9 D YJ9100 Cytarabine hcl 100 mg inj $ 2.16 $ 2.16 0 0% 0% 0% 9 9 9 9 9 9 D Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 105
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J9120 Dactinomycin injection $ 965.09 $ 965.09 0 0% 0% 0% 9 9 9 9 9 9 D YJ9130 Dacarbazine 100 mg inj $ 5.72 $ 5.72 0 0% 0% 0% 9 9 9 9 9 9 D YJ9150 Daunorubicin injection $ 42.60 $ 42.60 0 0% 0% 0% 9 9 9 9 9 9 D YJ9151 Daunorubicin citrate inj $ 248.40 $ 248.40 0 0% 0% 0% 9 9 9 9 9 9 D YJ9155 Degarelix injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ9160 Denileukin diftitox inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9165 Diethylstilbestrol injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9171 Docetaxel injection $ 6.46 $ 6.46 0 0% 0% 0% 9 9 9 9 9 9 D YJ9175 Elliotts b solution per ml Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9178 Inj, epirubicin hcl, 2 mg $ 1.59 $ 1.59 0 0% 0% 0% 9 9 9 9 9 9 D YJ9179 Eribulin mesylate injection $ 103.36 $ 103.36 0 0% 0% 0% 9 9 9 9 9 9 D YJ9181 Etoposide injection $ 0.82 $ 0.82 0 0% 0% 0% 9 9 9 9 9 9 D YJ9185 Fludarabine phosphate inj $ 102.06 $ 102.06 0 0% 0% 0% 9 9 9 9 9 9 D YJ9190 Fluorouracil injection $ 2.70 $ 2.70 0 0% 0% 0% 9 9 9 9 9 9 D YJ9200 Floxuridine injection $ 128.52 $ 128.52 0 0% 0% 0% 9 9 9 9 9 9 D YJ9201 Gemcitabine hcl injection $ 9.68 $ 9.68 0 0% 0% 0% 9 9 9 9 9 9 D YJ9202 Goserelin acetate implant $ 491.35 $ 491.35 0 0% 0% 0% 9 9 9 9 9 9 D YJ9206 Irinotecan injection $ 5.62 $ 5.62 0 0% 0% 0% 9 9 9 9 9 9 D YJ9207 Ixabepilone injection $ 76.26 $ 76.26 0 0% 0% 0% 9 9 9 9 9 9 D YJ9208 Ifosfamide injection $ 39.68 $ 39.68 0 0% 0% 0% 9 9 9 9 9 9 D YJ9209 Mesna injection $ 2.59 $ 2.59 0 0% 0% 0% 9 9 9 9 9 9 D YJ9211 Idarubicin hcl injection $ 62.03 $ 62.03 0 0% 0% 0% 9 9 9 9 9 9 D YJ9212 Interferon alfacon-1 inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X YJ9213 Interferon alfa-2a inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X YJ9214 Interferon alfa-2b inj $ 21.76 $ 21.76 0 0% 0% 0% 9 9 9 9 9 9 D YJ9215 Interferon alfa-n3 inj $ 32.40 $ 32.40 0 0% 0% 0% 9 9 9 9 9 9 D YJ9216 Interferon gamma 1-b inj $ 4476.09 $ 4476.09 0 0% 0% 0% 9 9 9 9 9 9 D YJ9217 Leuprolide acetate suspnsion $ 1179.15 $ 1179.15 0 0% 0% 0% 9 9 9 9 9 9 D YJ9218 Leuprolide acetate injeciton $ 285.12 $ 285.12 0 0% 0% 0% 9 9 9 9 9 9 D YJ9219 Leuprolide acetate implant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9225 Vantas implant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9226 Supprelin la implant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9228 Ipilimumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ9230 Mechlorethamine hcl inj $ 251.30 $ 251.30 0 0% 0% 0% 9 9 9 9 9 9 D YJ9245 Inj melphalan hydrochl 50 mg $ 1763.32 $ 1763.32 0 0% 0% 0% 9 9 9 9 9 9 D YJ9250 Methotrexate sodium inj $ 0.18 $ 0.18 0 0% 0% 0% 9 9 9 9 9 9 D YJ9260 Methotrexate sodium inj $ 1.80 $ 1.80 0 0% 0% 0% 9 9 9 9 9 9 D YJ9261 Nelarabine injection $ 154.21 $ 154.21 0 0% 0% 0% 9 9 9 9 9 9 D YJ9262 Inj, omacetaxine mep, 0.01mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ9263 Oxaliplatin $ 1.08 $ 1.08 0 0% 0% 0% 9 9 9 9 9 9 D Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 106
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
J9264 Paclitaxel protein bound $ 11.17 $ 11.17 0 0% 0% 0% 9 9 9 9 9 9 D J9266 Pegaspargase injection $ 6464.24 $ 6464.24 0 0% 0% 0% 9 9 9 9 9 9 D YJ9267 Paclitaxel injection $ 0.29 $ 0.29 0 0% 0% 0% 9 9 9 9 9 9 DJ9268 Pentostatin injection $ 1814.40 $ 1814.40 0 0% 0% 0% 9 9 9 9 9 9 D YJ9270 Plicamycin (mithramycin) inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ9280 Mitomycin injection $ 49.14 $ 49.14 0 0% 0% 0% 9 9 9 9 9 9 D YJ9293 Mitoxantrone hydrochl / 5 mg $ 35.44 $ 35.44 0 0% 0% 0% 9 9 9 9 9 9 D YJ9300 Gemtuzumab ozogamicin inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9301 Obinutuzumab inj Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ9302 Ofatumumab injection $ 51.44 $ 51.44 0 0% 0% 0% 9 9 9 9 9 9 D YJ9303 Panitumumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9305 Pemetrexed injection $ 64.99 $ 64.99 0 0% 0% 0% 9 9 9 9 9 9 D J9306 Injection, pertuzumab, 1 mg $ 10.48 $ 10.48 0 0% 0% 0% 9 9 9 9 9 9 D YJ9307 Pralatrexate injection $ 216.81 $ 216.81 0 0% 0% 0% 9 9 9 9 9 9 D YJ9310 Rituximab injection $ 782.30 $ 782.30 0 0% 0% 0% 9 9 9 9 9 9 D YJ9315 Romidepsin injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ9320 Streptozocin injection $ 377.17 $ 377.17 0 0% 0% 0% 9 9 9 9 9 9 D YJ9328 Temozolomide injection $ 6.35 $ 6.35 0 0% 0% 0% 9 9 9 9 9 9 D YJ9330 Temsirolimus injection $ 160.84 $ 160.84 0 0% 0% 0% 9 9 9 9 9 9 D YJ9340 Thiotepa injection $ 642.20 $ 642.20 0 0% 0% 0% 9 9 9 9 9 9 D YJ9351 Topotecan injection $ 3.51 $ 3.51 0 0% 0% 0% 9 9 9 9 9 9 D YJ9354 Inj, ado-trastuzumab emt 1mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XJ9355 Trastuzumab injection $ 91.23 $ 91.23 0 0% 0% 0% 9 9 9 9 9 9 D YJ9357 Valrubicin injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9360 Vinblastine sulfate inj $ 3.58 $ 3.58 0 0% 0% 0% 9 9 9 9 9 9 D YJ9370 Vincristine sulfate 1 mg inj $ 5.78 $ 5.78 0 0% 0% 0% 9 9 9 9 9 9 D YJ9371 Inj, vincristine sul lip 1mg $ 2273.47 $ 2273.47 0 0% 0% 0% 9 9 9 9 9 9 D YJ9390 Vinorelbine tartrate inj $ 9.47 $ 9.47 0 0% 0% 0% 9 9 9 9 9 9 D YJ9395 Injection, fulvestrant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X J9400 Inj, ziv-aflibercept, 1mg $ 17.28 $ 17.28 0 0% 0% 0% 9 9 9 9 9 9 D YJ9600 Porfimer sodium injection $ 20795.51 $ 20795.51 0 0% 0% 0% 9 9 9 9 9 9 D YJ9999 Chemotherapy drug By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0001-NU Standard wheelchair $ 591.20 $ 591.20 0 0% 0% 0% 9 9 9 9 9 9 F YK0001-RR Standard wheelchair $ 59.12 $ 59.12 0 0% 0% 0% 9 9 9 9 9 9 F YK0002-NU Stnd hemi (low seat) whlchr $ 772.00 $ 772.00 0 0% 0% 0% 9 9 9 9 9 9 F YK0002-RR Stnd hemi (low seat) whlchr $ 77.20 $ 77.20 0 0% 0% 0% 9 9 9 9 9 9 F YK0003-NU Lightweight wheelchair $ 994.50 $ 994.50 0 0% 0% 0% 9 9 9 9 9 9 F YK0003-RR Lightweight wheelchair $ 99.45 $ 99.45 0 0% 0% 0% 9 9 9 9 9 9 F YK0004-NU High strength ltwt whlchr $ 1483.30 $ 1483.30 0 0% 0% 0% 9 9 9 9 9 9 F YK0004-RR High strength ltwt whlchr $ 148.33 $ 148.33 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 107
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
K0005-NU Ultralightweight wheelchair $ 2052.04 $ 2052.04 0 0% 0% 0% 9 9 9 9 9 9 F YK0005-RR Ultralightweight wheelchair $ 205.20 $ 205.20 0 0% 0% 0% 9 9 9 9 9 9 F YK0006-NU Heavy duty wheelchair $ 1392.10 $ 1392.10 0 0% 0% 0% 9 9 9 9 9 9 F YK0006-RR Heavy duty wheelchair $ 139.21 $ 139.21 0 0% 0% 0% 9 9 9 9 9 9 F YK0007-NU Extra heavy duty wheelchair $ 1981.20 $ 1981.20 0 0% 0% 0% 9 9 9 9 9 9 F YK0007-RR Extra heavy duty wheelchair $ 198.12 $ 198.12 0 0% 0% 0% 9 9 9 9 9 9 F YK0008 Cstm manual wheelchair/base By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NK0008-NU Cstm manual wheelchair/base By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NK0008-RR Cstm manual wheelchair/base By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NK0009-NU Other manual wheelchair/base $ 825.30 $ 825.30 0 0% 0% 0% 9 9 9 9 9 9 F YK0009-RR Other manual wheelchair/base $ 82.53 $ 82.53 0 0% 0% 0% 9 9 9 9 9 9 F YK0010-NU Stnd wt frame power whlchr $ 5371.46 $ 5371.46 0 0% 0% 0% 9 9 9 9 9 9 F YK0010-RR Stnd wt frame power whlchr $ 537.15 $ 537.15 0 0% 0% 0% 9 9 9 9 9 9 F YK0011-NU Stnd wt pwr whlchr w control $ 5686.00 $ 5686.00 0 0% 0% 0% 9 9 9 9 9 9 F YK0011-RR Stnd wt pwr whlchr w control $ 568.60 $ 568.60 0 0% 0% 0% 9 9 9 9 9 9 F YK0012-NU Ltwt portbl power whlchr $ 3606.50 $ 3606.50 0 0% 0% 0% 9 9 9 9 9 9 F YK0012-RR Ltwt portbl power whlchr $ 360.65 $ 360.65 0 0% 0% 0% 9 9 9 9 9 9 F YK0013 Custom power whlchr base By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NK0013-NU Custom power whlchr base By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NK0013-RR Custom power whlchr base By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NK0014-NU Other power whlchr base By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0014-RR Other power whlchr base By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0015-NU Detach non-adjus hght armrst $ 170.94 $ 170.94 0 0% 0% 0% 9 9 9 9 9 9 F K0015-RR Detach non-adjus hght armrst $ 17.09 $ 17.09 0 0% 0% 0% 9 9 9 9 9 9 F K0017-NU Detach adjust armrest base $ 48.89 $ 48.89 0 0% 0% 0% 9 9 9 9 9 9 F K0017-RR Detach adjust armrest base $ 4.89 $ 4.89 0 0% 0% 0% 9 9 9 9 9 9 F K0018-NU Detach adjust armrst upper $ 27.31 $ 27.31 0 0% 0% 0% 9 9 9 9 9 9 F K0018-RR Detach adjust armrst upper $ 2.73 $ 2.73 0 0% 0% 0% 9 9 9 9 9 9 F K0019-NU Arm pad each $ 16.48 $ 16.48 0 0% 0% 0% 9 9 9 9 9 9 F K0019-RR Arm pad each $ 1.65 $ 1.65 0 0% 0% 0% 9 9 9 9 9 9 F K0020-NU Fixed adjust armrest pair $ 44.45 $ 44.45 0 0% 0% 0% 9 9 9 9 9 9 F K0020-RR Fixed adjust armrest pair $ 4.45 $ 4.45 0 0% 0% 0% 9 9 9 9 9 9 F K0037-NU High mount flip-up footrest $ 46.07 $ 46.07 0 0% 0% 0% 9 9 9 9 9 9 F K0037-RR High mount flip-up footrest $ 4.61 $ 4.61 0 0% 0% 0% 9 9 9 9 9 9 F K0038-NU Leg strap each $ 23.22 $ 23.22 0 0% 0% 0% 9 9 9 9 9 9 F K0038-RR Leg strap each $ 2.32 $ 2.32 0 0% 0% 0% 9 9 9 9 9 9 F K0039-NU Leg strap h style each $ 51.54 $ 51.54 0 0% 0% 0% 9 9 9 9 9 9 F K0039-RR Leg strap h style each $ 5.15 $ 5.15 0 0% 0% 0% 9 9 9 9 9 9 F K0040-NU Adjustable angle footplate $ 71.44 $ 71.44 0 0% 0% 0% 9 9 9 9 9 9 F K0040-RR Adjustable angle footplate $ 7.14 $ 7.14 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 108
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
K0041-NU Large size footplate each $ 50.62 $ 50.62 0 0% 0% 0% 9 9 9 9 9 9 F K0041-RR Large size footplate each $ 5.06 $ 5.06 0 0% 0% 0% 9 9 9 9 9 9 F K0042-NU Standard size footplate each $ 29.63 $ 29.63 0 0% 0% 0% 9 9 9 9 9 9 F K0042-RR Standard size footplate each $ 2.96 $ 2.96 0 0% 0% 0% 9 9 9 9 9 9 F K0043-NU Ftrst lower extension tube $ 18.67 $ 18.67 0 0% 0% 0% 9 9 9 9 9 9 F K0043-RR Ftrst lower extension tube $ 1.87 $ 1.87 0 0% 0% 0% 9 9 9 9 9 9 F K0044-NU Ftrst upper hanger bracket $ 15.92 $ 15.92 0 0% 0% 0% 9 9 9 9 9 9 F K0044-RR Ftrst upper hanger bracket $ 1.59 $ 1.59 0 0% 0% 0% 9 9 9 9 9 9 F K0045-NU Footrest complete assembly $ 47.25 $ 47.25 0 0% 0% 0% 9 9 9 9 9 9 F K0045-RR Footrest complete assembly $ 4.73 $ 4.73 0 0% 0% 0% 9 9 9 9 9 9 F K0046-NU Elevat legrst low extension $ 18.67 $ 18.67 0 0% 0% 0% 9 9 9 9 9 9 F K0046-RR Elevat legrst low extension $ 1.87 $ 1.87 0 0% 0% 0% 9 9 9 9 9 9 F K0047-NU Elevat legrst up hangr brack $ 73.16 $ 73.16 0 0% 0% 0% 9 9 9 9 9 9 F K0047-RR Elevat legrst up hangr brack $ 7.32 $ 7.32 0 0% 0% 0% 9 9 9 9 9 9 F K0050-NU Ratchet assembly $ 31.09 $ 31.09 0 0% 0% 0% 9 9 9 9 9 9 F K0050-RR Ratchet assembly $ 3.11 $ 3.11 0 0% 0% 0% 9 9 9 9 9 9 F K0051-NU Cam relese assem ftrst/lgrst $ 50.32 $ 50.32 0 0% 0% 0% 9 9 9 9 9 9 F K0051-RR Cam relese assem ftrst/lgrst $ 5.03 $ 5.03 0 0% 0% 0% 9 9 9 9 9 9 F K0052-NU Swingaway detach footrest $ 88.44 $ 88.44 0 0% 0% 0% 9 9 9 9 9 9 F K0052-RR Swingaway detach footrest $ 8.84 $ 8.84 0 0% 0% 0% 9 9 9 9 9 9 F K0053-NU Elevate footrest articulate $ 97.59 $ 97.59 0 0% 0% 0% 9 9 9 9 9 9 F K0053-RR Elevate footrest articulate $ 9.76 $ 9.76 0 0% 0% 0% 9 9 9 9 9 9 F K0056-NU Seat ht <17 or >=21 ltwt wc $ 103.78 $ 103.78 0 0% 0% 0% 9 9 9 9 9 9 F K0056-RR Seat ht <17 or >=21 ltwt wc $ 10.38 $ 10.38 0 0% 0% 0% 9 9 9 9 9 9 F K0065-NU Spoke protectors $ 49.34 $ 49.34 0 0% 0% 0% 9 9 9 9 9 9 F K0069-NU Rear whl complete solid tire $ 109.02 $ 109.02 0 0% 0% 0% 9 9 9 9 9 9 F K0070-NU Rear whl compl pneum tire $ 199.91 $ 199.91 0 0% 0% 0% 9 9 9 9 9 9 F K0071-NU Front castr compl pneum tire $ 121.26 $ 121.26 0 0% 0% 0% 9 9 9 9 9 9 F K0072-NU Frnt cstr cmpl sem-pneum tir $ 67.45 $ 67.45 0 0% 0% 0% 9 9 9 9 9 9 F K0073-NU Caster pin lock each $ 38.63 $ 38.63 0 0% 0% 0% 9 9 9 9 9 9 F K0077-NU Front caster assem complete $ 65.33 $ 65.33 0 0% 0% 0% 9 9 9 9 9 9 F K0098-NU Drive belt power wheelchair $ 26.03 $ 26.03 0 0% 0% 0% 9 9 9 9 9 9 F K0105-NU Iv hanger $ 110.36 $ 110.36 0 0% 0% 0% 9 9 9 9 9 9 F K0105-RR Iv hanger $ 11.04 $ 11.04 0 0% 0% 0% 9 9 9 9 9 9 F K0108-NU W/c component-accessory nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0108-RR W/c component-accessory nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0195-NU Elevating whlchair leg rests $ 201.70 $ 201.70 0 0% 0% 0% 9 9 9 9 9 9 F K0195-RR Elevating whlchair leg rests $ 20.17 $ 20.17 0 0% 0% 0% 9 9 9 9 9 9 F K0455-NU Pump uninterrupted infusion $ 2939.90 $ 2939.90 0 0% 0% 0% 9 9 9 9 9 9 F K0455-RR Pump uninterrupted infusion $ 293.99 $ 293.99 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 109
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
K0462-RR Temporary replacement eqpmnt By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0552-NU Supply/ext inf pump syr type $ 2.74 $ 2.74 0 0% 0% 0% 9 9 9 9 9 9 F K0601-NU Repl batt silver oxide 1.5 v $ 1.23 $ 1.23 0 0% 0% 0% 9 9 9 9 9 9 F K0602-NU Repl batt silver oxide 3 v $ 7.05 $ 7.05 0 0% 0% 0% 9 9 9 9 9 9 F K0603-NU Repl batt alkaline 1.5 v $ 0.63 $ 0.63 0 0% 0% 0% 9 9 9 9 9 9 F K0604-NU Repl batt lithium 3.6 v $ 6.75 $ 6.75 0 0% 0% 0% 9 9 9 9 9 9 F K0605-NU Repl batt lithium 4.5 v $ 16.21 $ 16.21 0 0% 0% 0% 9 9 9 9 9 9 F K0606 Aed garment w elec analysis Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X K0607 Repl batt for aed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X K0608 Repl garment for aed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X K0609 Repl electrode for aed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X K0669-NU Seat/back cus no dmepdac ver By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N K0672-NU Removable soft interface le $ 82.30 $ 82.30 0 0% 0% 0% 9 9 9 9 9 9 F K0730 Ctrl dose inh drug deliv sys Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X K0733-NU 12-24hr sealed lead acid $ 28.90 $ 28.90 0 0% 0% 0% 9 9 9 9 9 9 F K0733-RR 12-24hr sealed lead acid $ 2.89 $ 2.89 0 0% 0% 0% 9 9 9 9 9 9 F K0738-RR Portable gas oxygen system $ 51.63 $ 51.63 0 0% 0% 0% 9 9 9 9 9 9 F YK0739 Repair/svc dme non-oxygen eq By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N K0740 Repair/svc oxygen equipment By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N K0743-RR Portable home suction pump By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0744-NU Absorp drg <= 16 suc pump By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NK0745-NU Absorp drg >16<=48 suc pump By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NK0746-NU Absorp drg >48 suc pump By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NK0800-NU Pov group 1 std up to 300lbs $ 1236.75 $ 1236.75 0 0% 0% 0% 9 9 9 9 9 9 F YK0801-NU Pov group 1 hd 301-450 lbs $ 1993.91 $ 1993.91 0 0% 0% 0% 9 9 9 9 9 9 F YK0802-NU Pov group 1 vhd 451-600 lbs $ 2256.47 $ 2256.47 0 0% 0% 0% 9 9 9 9 9 9 F YK0806-NU Pov group 2 std up to 300lbs $ 1496.13 $ 1496.13 0 0% 0% 0% 9 9 9 9 9 9 F YK0807-NU Pov group 2 hd 301-450 lbs $ 2270.23 $ 2270.23 0 0% 0% 0% 9 9 9 9 9 9 F YK0808-NU Pov group 2 vhd 451-600 lbs $ 0.00 $ 0.00 0 0% 0% 0% 9 9 9 9 9 9 F YK0812-NU Power operated vehicle noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0813-NU Pwc gp 1 std port seat/back $ 3461.80 $ 3461.80 0 0% 0% 0% 9 9 9 9 9 9 F YK0813-RR Pwc gp 1 std port seat/back $ 346.18 $ 346.18 0 0% 0% 0% 9 9 9 9 9 9 F YK0814-NU Pwc gp 1 std port cap chair $ 4431.40 $ 4431.40 0 0% 0% 0% 9 9 9 9 9 9 F YK0814-RR Pwc gp 1 std port cap chair $ 443.14 $ 443.14 0 0% 0% 0% 9 9 9 9 9 9 F YK0815-NU Pwc gp 1 std seat/back $ 5045.70 $ 5045.70 0 0% 0% 0% 9 9 9 9 9 9 F YK0815-RR Pwc gp 1 std seat/back $ 504.57 $ 504.57 0 0% 0% 0% 9 9 9 9 9 9 F YK0816-NU Pwc gp 1 std cap chair $ 4832.30 $ 4832.30 0 0% 0% 0% 9 9 9 9 9 9 F YK0816-RR Pwc gp 1 std cap chair $ 483.23 $ 483.23 0 0% 0% 0% 9 9 9 9 9 9 F YK0820-NU Pwc gp 2 std port seat/back $ 3697.60 $ 3697.60 0 0% 0% 0% 9 9 9 9 9 9 F YK0820-RR Pwc gp 2 std port seat/back $ 369.76 $ 369.76 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 110
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
K0821-NU Pwc gp 2 std port cap chair $ 4746.50 $ 4746.50 0 0% 0% 0% 9 9 9 9 9 9 F YK0821-RR Pwc gp 2 std port cap chair $ 474.65 $ 474.65 0 0% 0% 0% 9 9 9 9 9 9 F YK0822-NU Pwc gp 2 std seat/back $ 5736.50 $ 5736.50 0 0% 0% 0% 9 9 9 9 9 9 F YK0822-RR Pwc gp 2 std seat/back $ 573.65 $ 573.65 0 0% 0% 0% 9 9 9 9 9 9 F YK0823-NU Pwc gp 2 std cap chair $ 5774.20 $ 5774.20 0 0% 0% 0% 9 9 9 9 9 9 F YK0823-RR Pwc gp 2 std cap chair $ 577.42 $ 577.42 0 0% 0% 0% 9 9 9 9 9 9 F YK0824-NU Pwc gp 2 hd seat/back $ 6949.20 $ 6949.20 0 0% 0% 0% 9 9 9 9 9 9 F YK0824-RR Pwc gp 2 hd seat/back $ 694.92 $ 694.92 0 0% 0% 0% 9 9 9 9 9 9 F YK0825-NU Pwc gp 2 hd cap chair $ 6362.00 $ 6362.00 0 0% 0% 0% 9 9 9 9 9 9 F YK0825-RR Pwc gp 2 hd cap chair $ 636.20 $ 636.20 0 0% 0% 0% 9 9 9 9 9 9 F YK0826-NU Pwc gp 2 vhd seat/back $ 8996.80 $ 8996.80 0 0% 0% 0% 9 9 9 9 9 9 F YK0826-RR Pwc gp 2 vhd seat/back $ 899.68 $ 899.68 0 0% 0% 0% 9 9 9 9 9 9 F YK0827-NU Pwc gp vhd cap chair $ 7649.80 $ 7649.80 0 0% 0% 0% 9 9 9 9 9 9 F YK0827-RR Pwc gp vhd cap chair $ 764.98 $ 764.98 0 0% 0% 0% 9 9 9 9 9 9 F YK0828-NU Pwc gp 2 xtra hd seat/back $ 9913.30 $ 9913.30 0 0% 0% 0% 9 9 9 9 9 9 F YK0828-RR Pwc gp 2 xtra hd seat/back $ 991.33 $ 991.33 0 0% 0% 0% 9 9 9 9 9 9 F YK0829-NU Pwc gp 2 xtra hd cap chair $ 9103.40 $ 9103.40 0 0% 0% 0% 9 9 9 9 9 9 F YK0829-RR Pwc gp 2 xtra hd cap chair $ 910.34 $ 910.34 0 0% 0% 0% 9 9 9 9 9 9 F YK0830-NU Pwc gp2 std seat elevate s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0830-RR Pwc gp2 std seat elevate s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0831-NU Pwc gp2 std seat elevate cap By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0831-RR Pwc gp2 std seat elevate cap By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0835-NU Pwc gp2 std sing pow opt s/b $ 5822.40 $ 5822.40 0 0% 0% 0% 9 9 9 9 9 9 F YK0835-RR Pwc gp2 std sing pow opt s/b $ 582.24 $ 582.24 0 0% 0% 0% 9 9 9 9 9 9 F YK0836-NU Pwc gp2 std sing pow opt cap $ 6038.10 $ 6038.10 0 0% 0% 0% 9 9 9 9 9 9 F YK0836-RR Pwc gp2 std sing pow opt cap $ 603.81 $ 603.81 0 0% 0% 0% 9 9 9 9 9 9 F YK0837-NU Pwc gp 2 hd sing pow opt s/b $ 6949.20 $ 6949.20 0 0% 0% 0% 9 9 9 9 9 9 F YK0837-RR Pwc gp 2 hd sing pow opt s/b $ 694.92 $ 694.92 0 0% 0% 0% 9 9 9 9 9 9 F YK0838-NU Pwc gp 2 hd sing pow opt cap $ 6216.70 $ 6216.70 0 0% 0% 0% 9 9 9 9 9 9 F YK0838-RR Pwc gp 2 hd sing pow opt cap $ 621.67 $ 621.67 0 0% 0% 0% 9 9 9 9 9 9 F YK0839-NU Pwc gp2 vhd sing pow opt s/b $ 8996.80 $ 8996.80 0 0% 0% 0% 9 9 9 9 9 9 F YK0839-RR Pwc gp2 vhd sing pow opt s/b $ 899.68 $ 899.68 0 0% 0% 0% 9 9 9 9 9 9 F YK0840-NU Pwc gp2 xhd sing pow opt s/b $ 13629.80 $ 13629.80 0 0% 0% 0% 9 9 9 9 9 9 F YK0840-RR Pwc gp2 xhd sing pow opt s/b $ 1362.98 $ 1362.98 0 0% 0% 0% 9 9 9 9 9 9 F YK0841-NU Pwc gp2 std mult pow opt s/b $ 6197.40 $ 6197.40 0 0% 0% 0% 9 9 9 9 9 9 F YK0841-RR Pwc gp2 std mult pow opt s/b $ 619.74 $ 619.74 0 0% 0% 0% 9 9 9 9 9 9 F YK0842-NU Pwc gp2 std mult pow opt cap $ 6197.40 $ 6197.40 0 0% 0% 0% 9 9 9 9 9 9 F YK0842-RR Pwc gp2 std mult pow opt cap $ 619.74 $ 619.74 0 0% 0% 0% 9 9 9 9 9 9 F YK0843-NU Pwc gp2 hd mult pow opt s/b $ 7461.50 $ 7461.50 0 0% 0% 0% 9 9 9 9 9 9 F YK0843-RR Pwc gp2 hd mult pow opt s/b $ 746.15 $ 746.15 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 111
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
K0848-NU Pwc gp 3 std seat/back $ 7583.10 $ 7583.10 0 0% 0% 0% 9 9 9 9 9 9 F YK0848-RR Pwc gp 3 std seat/back $ 758.31 $ 758.31 0 0% 0% 0% 9 9 9 9 9 9 F YK0849-NU Pwc gp 3 std cap chair $ 7290.80 $ 7290.80 0 0% 0% 0% 9 9 9 9 9 9 F YK0849-RR Pwc gp 3 std cap chair $ 729.08 $ 729.08 0 0% 0% 0% 9 9 9 9 9 9 F YK0850-NU Pwc gp 3 hd seat/back $ 8796.20 $ 8796.20 0 0% 0% 0% 9 9 9 9 9 9 F YK0850-RR Pwc gp 3 hd seat/back $ 879.62 $ 879.62 0 0% 0% 0% 9 9 9 9 9 9 F YK0851-NU Pwc gp 3 hd cap chair $ 8457.50 $ 8457.50 0 0% 0% 0% 9 9 9 9 9 9 F YK0851-RR Pwc gp 3 hd cap chair $ 845.75 $ 845.75 0 0% 0% 0% 9 9 9 9 9 9 F YK0852-NU Pwc gp 3 vhd seat/back $ 10163.40 $ 10163.40 0 0% 0% 0% 9 9 9 9 9 9 F YK0852-RR Pwc gp 3 vhd seat/back $ 1016.34 $ 1016.34 0 0% 0% 0% 9 9 9 9 9 9 F YK0853-NU Pwc gp 3 vhd cap chair $ 10440.40 $ 10440.40 0 0% 0% 0% 9 9 9 9 9 9 F YK0853-RR Pwc gp 3 vhd cap chair $ 1044.04 $ 1044.04 0 0% 0% 0% 9 9 9 9 9 9 F YK0854-NU Pwc gp 3 xhd seat/back $ 13831.20 $ 13831.20 0 0% 0% 0% 9 9 9 9 9 9 F YK0854-RR Pwc gp 3 xhd seat/back $ 1383.12 $ 1383.12 0 0% 0% 0% 9 9 9 9 9 9 F YK0855-NU Pwc gp 3 xhd cap chair $ 13065.70 $ 13065.70 0 0% 0% 0% 9 9 9 9 9 9 F YK0855-RR Pwc gp 3 xhd cap chair $ 1306.57 $ 1306.57 0 0% 0% 0% 9 9 9 9 9 9 F YK0856-NU Pwc gp3 std sing pow opt s/b $ 8139.70 $ 8139.70 0 0% 0% 0% 9 9 9 9 9 9 F YK0856-RR Pwc gp3 std sing pow opt s/b $ 813.97 $ 813.97 0 0% 0% 0% 9 9 9 9 9 9 F YK0857-NU Pwc gp3 std sing pow opt cap $ 8302.80 $ 8302.80 0 0% 0% 0% 9 9 9 9 9 9 F YK0857-RR Pwc gp3 std sing pow opt cap $ 830.28 $ 830.28 0 0% 0% 0% 9 9 9 9 9 9 F YK0858-NU Pwc gp3 hd sing pow opt s/b $ 10099.00 $ 10099.00 0 0% 0% 0% 9 9 9 9 9 9 F YK0858-RR Pwc gp3 hd sing pow opt s/b $ 1009.90 $ 1009.90 0 0% 0% 0% 9 9 9 9 9 9 F YK0859-NU Pwc gp3 hd sing pow opt cap $ 9631.30 $ 9631.30 0 0% 0% 0% 9 9 9 9 9 9 F YK0859-RR Pwc gp3 hd sing pow opt cap $ 963.13 $ 963.13 0 0% 0% 0% 9 9 9 9 9 9 F YK0860-NU Pwc gp3 vhd sing pow opt s/b $ 14427.60 $ 14427.60 0 0% 0% 0% 9 9 9 9 9 9 F YK0860-RR Pwc gp3 vhd sing pow opt s/b $ 1442.76 $ 1442.76 0 0% 0% 0% 9 9 9 9 9 9 F YK0861-NU Pwc gp3 std mult pow opt s/b $ 8152.70 $ 8152.70 0 0% 0% 0% 9 9 9 9 9 9 F YK0861-RR Pwc gp3 std mult pow opt s/b $ 815.27 $ 815.27 0 0% 0% 0% 9 9 9 9 9 9 F YK0862-NU Pwc gp3 hd mult pow opt s/b $ 10099.00 $ 10099.00 0 0% 0% 0% 9 9 9 9 9 9 F YK0862-RR Pwc gp3 hd mult pow opt s/b $ 1009.90 $ 1009.90 0 0% 0% 0% 9 9 9 9 9 9 F YK0863-NU Pwc gp3 vhd mult pow opt s/b $ 14427.60 $ 14427.60 0 0% 0% 0% 9 9 9 9 9 9 F YK0863-RR Pwc gp3 vhd mult pow opt s/b $ 1442.76 $ 1442.76 0 0% 0% 0% 9 9 9 9 9 9 F YK0864-NU Pwc gp3 xhd mult pow opt s/b $ 17169.00 $ 17169.00 0 0% 0% 0% 9 9 9 9 9 9 F YK0864-RR Pwc gp3 xhd mult pow opt s/b $ 1716.90 $ 1716.90 0 0% 0% 0% 9 9 9 9 9 9 F YK0868-NU Pwc gp 4 std seat/back By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0868-RR Pwc gp 4 std seat/back By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0869-NU Pwc gp 4 std cap chair By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0869-RR Pwc gp 4 std cap chair By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0870-NU Pwc gp 4 hd seat/back By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0870-RR Pwc gp 4 hd seat/back By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 112
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
K0871-NU Pwc gp 4 vhd seat/back By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0871-RR Pwc gp 4 vhd seat/back By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0877-NU Pwc gp4 std sing pow opt s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0877-RR Pwc gp4 std sing pow opt s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0878-NU Pwc gp4 std sing pow opt cap By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0878-RR Pwc gp4 std sing pow opt cap By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0879-NU Pwc gp4 hd sing pow opt s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0879-RR Pwc gp4 hd sing pow opt s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0880-NU Pwc gp4 vhd sing pow opt s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0880-RR Pwc gp4 vhd sing pow opt s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0884-NU Pwc gp4 std mult pow opt s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0884-RR Pwc gp4 std mult pow opt s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0885-NU Pwc gp4 std mult pow opt cap By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0885-RR Pwc gp4 std mult pow opt cap By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0886-NU Pwc gp4 hd mult pow s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0886-RR Pwc gp4 hd mult pow s/b By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0890 Pwc gp5 ped sing pow opt s/b Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X K0891 Pwc gp5 ped mult pow opt s/b Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X K0898-NU Power wheelchair noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0898-RR Power wheelchair noc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0899-NU Pow mobil dev no dmepdac By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0899-RR Pow mobil dev no dmepdac By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YK0900 Cstm dme other than wheelchr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XK0901 Ko single upright pre ots $ 1005.89 $ 1005.89 0 0% 0% 0% 9 9 9 9 9 9 FK0901-NU Ko single upright pre ots $ 1005.89 $ 1005.89 0 0% 0% 0% 9 9 9 9 9 9 FK0902 Ko double upright pre ots $ 911.64 $ 911.64 0 0% 0% 0% 9 9 9 9 9 9 FK0902-NU Ko double upright pre ots $ 911.64 $ 911.64 0 0% 0% 0% 9 9 9 9 9 9 FL0112 Cranial cervical orthosis $ 1569.05 $ 1569.05 0 0% 0% 0% 9 9 9 9 9 9 F L0113 Cranial cervical torticollis $ 332.14 $ 332.14 0 0% 0% 0% 9 9 9 9 9 9 F L0120 Cerv flex n/adj foam pre ots $ 38.00 $ 38.00 0 0% 0% 0% 9 9 9 9 9 9 F L0130 Flex thermoplastic collar mo $ 211.40 $ 211.40 0 0% 0% 0% 9 9 9 9 9 9 F Y L0140 Cervical semi-rigid adjustab $ 91.67 $ 91.67 0 0% 0% 0% 9 9 9 9 9 9 F L0150 Cerv semi-rig adj molded chn $ 122.08 $ 122.08 0 0% 0% 0% 9 9 9 9 9 9 F L0160 Cerv sr wire occ/man pre ots $ 168.20 $ 168.20 0 0% 0% 0% 9 9 9 9 9 9 F L0170 Cervical collar molded to pt $ 815.90 $ 815.90 0 0% 0% 0% 9 9 9 9 9 9 F Y L0172 Cerv col sr foam 2pc pre ots $ 147.25 $ 147.25 0 0% 0% 0% 9 9 9 9 9 9 F L0174 Cerv sr 2pc thor ext pre ots $ 310.03 $ 310.03 0 0% 0% 0% 9 9 9 9 9 9 F L0180 Cer post col occ/man sup adj $ 452.03 $ 452.03 0 0% 0% 0% 9 9 9 9 9 9 F L0190 Cerv collar supp adj cerv ba $ 635.96 $ 635.96 0 0% 0% 0% 9 9 9 9 9 9 F L0200 Cerv col supp adj bar & thor $ 710.14 $ 710.14 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 113
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L0220 Thor rib belt custom fabrica $ 141.48 $ 141.48 0 0% 0% 0% 9 9 9 9 9 9 F L0450 Tlso flex trunk/thor pre ots $ 246.50 $ 246.50 0 0% 0% 0% 9 9 9 9 9 9 F L0452 Tlso flex custom fab thoraci By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L0454 Tlso trnk sj-t9 pre cst $ 388.81 $ 388.81 0 0% 0% 0% 9 9 9 9 9 9 F L0455 Tlso flex trnk sj-t9 pre ots $ 388.81 $ 388.81 0 0% 0% 0% 9 9 9 9 9 9 FL0456 Tlso flex trnk sj-ss pre cst $ 1114.98 $ 1114.98 0 0% 0% 0% 9 9 9 9 9 9 F L0457 Tlso flex trnk sj-ss pre ots $ 1114.98 $ 1114.98 0 0% 0% 0% 9 9 9 9 9 9 FL0458 Tlso 2mod symphis-xipho pre $ 999.79 $ 999.79 0 0% 0% 0% 9 9 9 9 9 9 F Y L0460 Tlso 2 shl symphys-stern cst $ 1125.32 $ 1125.32 0 0% 0% 0% 9 9 9 9 9 9 F Y L0462 Tlso 3mod sacro-scap pre $ 1399.75 $ 1399.75 0 0% 0% 0% 9 9 9 9 9 9 F Y L0464 Tlso 4mod sacro-scap pre $ 1666.37 $ 1666.37 0 0% 0% 0% 9 9 9 9 9 9 F Y L0466 Tlso r fram soft ant pre cst $ 506.70 $ 506.70 0 0% 0% 0% 9 9 9 9 9 9 F Y L0467 Tlso r fram soft pre ots $ 506.70 $ 506.70 0 0% 0% 0% 9 9 9 9 9 9 FL0468 Tlso rig fram pelvic pre cst $ 608.18 $ 608.18 0 0% 0% 0% 9 9 9 9 9 9 F L0469 Tlso rig fram pelvic pre ots $ 608.18 $ 608.18 0 0% 0% 0% 9 9 9 9 9 9 FL0470 Tlso rigid frame pre subclav $ 729.98 $ 729.98 0 0% 0% 0% 9 9 9 9 9 9 F L0472 Tlso rigid frame hyperex pre $ 518.38 $ 518.38 0 0% 0% 0% 9 9 9 9 9 9 F L0480 Tlso rigid plastic custom fa $ 1787.46 $ 1787.46 0 0% 0% 0% 9 9 9 9 9 9 F Y L0482 Tlso rigid lined custom fab $ 1821.71 $ 1821.71 0 0% 0% 0% 9 9 9 9 9 9 F Y L0484 Tlso rigid plastic cust fab $ 1908.59 $ 1908.59 0 0% 0% 0% 9 9 9 9 9 9 F Y L0486 Tlso rigidlined cust fab two $ 2024.92 $ 2024.92 0 0% 0% 0% 9 9 9 9 9 9 F Y L0488 Tlso rigid lined pre one pie $ 1125.32 $ 1125.32 0 0% 0% 0% 9 9 9 9 9 9 F L0490 Tlso rigid plastic pre one $ 317.15 $ 317.15 0 0% 0% 0% 9 9 9 9 9 9 F L0491 Tlso 2 piece rigid shell $ 860.96 $ 860.96 0 0% 0% 0% 9 9 9 9 9 9 F L0492 Tlso 3 piece rigid shell $ 566.29 $ 566.29 0 0% 0% 0% 9 9 9 9 9 9 F L0621 Sio flex pelvic/sacr pre ots $ 129.79 $ 129.79 0 0% 0% 0% 9 9 9 9 9 9 F L0622 Sio flex pelvisacral custom $ 344.45 $ 344.45 0 0% 0% 0% 9 9 9 9 9 9 F L0623 Sio rig pnl pelv/sac pre ots By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L0624 Sio panel custom By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L0625 Lo flex l1-below l5 pre ots $ 61.74 $ 61.74 0 0% 0% 0% 9 9 9 9 9 9 F L0626 Lo sag rig pnl stays pre cst $ 87.37 $ 87.37 0 0% 0% 0% 9 9 9 9 9 9 F L0627 Lo sag ri an/pos pnl pre cst $ 460.82 $ 460.82 0 0% 0% 0% 9 9 9 9 9 9 F L0628 Lso flex no ri stays pre ots $ 94.06 $ 94.06 0 0% 0% 0% 9 9 9 9 9 9 F L0629 Lso flex w/rigid stays cust By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L0630 Lso r post pnl sj-t9 pre cst $ 181.57 $ 181.57 0 0% 0% 0% 9 9 9 9 9 9 F L0631 Lso sag r an/pos pnl pre cst $ 1150.85 $ 1150.85 0 0% 0% 0% 9 9 9 9 9 9 F L0632 Lso sag rigid frame cust By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L0633 Lso sc r pos/lat pnl pre cst $ 321.47 $ 321.47 0 0% 0% 0% 9 9 9 9 9 9 F L0634 Lso flexion control custom By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L0635 Lso sagit rigid panel prefab $ 1184.62 $ 1184.62 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 114
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L0636 Lso sagittal rigid panel cus $ 1544.56 $ 1544.56 0 0% 0% 0% 9 9 9 9 9 9 F L0637 Lso sc r ant/pos pnl pre cst $ 1260.04 $ 1260.04 0 0% 0% 0% 9 9 9 9 9 9 F L0638 Lso sag-coronal panel custom $ 1478.57 $ 1478.57 0 0% 0% 0% 9 9 9 9 9 9 F L0639 Lso s/c shell/panel prefab $ 1260.04 $ 1260.04 0 0% 0% 0% 9 9 9 9 9 9 F L0640 Lso s/c shell/panel custom $ 1173.08 $ 1173.08 0 0% 0% 0% 9 9 9 9 9 9 F L0641 Lo rig pos pnl l1-l5 pre ots $ 87.37 $ 87.37 0 0% 0% 0% 9 9 9 9 9 9 FL0642 Lo sag ri an/pos pnl pre ots $ 460.82 $ 460.82 0 0% 0% 0% 9 9 9 9 9 9 FL0643 Lso sag ctr rigi pos pre ots $ 181.57 $ 181.57 0 0% 0% 0% 9 9 9 9 9 9 FL0648 Lso sag r an/pos pnl pre ots $ 1150.85 $ 1150.85 0 0% 0% 0% 9 9 9 9 9 9 FL0649 Lso sc r pos/lat pnl pre ots $ 321.47 $ 321.47 0 0% 0% 0% 9 9 9 9 9 9 FL0650 Lso sc r ant/pos pnl pre ots $ 1260.04 $ 1260.04 0 0% 0% 0% 9 9 9 9 9 9 FL0651 Lso sag-co shell pnl pre ots $ 1260.04 $ 1260.04 0 0% 0% 0% 9 9 9 9 9 9 FL0700 Ctlso a-p-l control molded $ 2171.26 $ 2171.26 0 0% 0% 0% 9 9 9 9 9 9 F Y L0710 Ctlso a-p-l control w/ inter $ 2452.39 $ 2452.39 0 0% 0% 0% 9 9 9 9 9 9 F Y L0810 Halo cervical into jckt vest $ 2952.86 $ 2952.86 0 0% 0% 0% 9 9 9 9 9 9 F Y L0820 Halo cervical into body jack $ 2899.93 $ 2899.93 0 0% 0% 0% 9 9 9 9 9 9 F Y L0830 Halo cerv into milwaukee typ $ 4067.56 $ 4067.56 0 0% 0% 0% 9 9 9 9 9 9 F Y L0859 Mri compatible system $ 1308.35 $ 1308.35 0 0% 0% 0% 9 9 9 9 9 9 F Y L0861 Halo repl liner/interface $ 241.63 $ 241.63 0 0% 0% 0% 9 9 9 9 9 9 F Y L0970 Tlso corset front $ 122.75 $ 122.75 0 0% 0% 0% 9 9 9 9 9 9 F L0972 Lso corset front $ 110.53 $ 110.53 0 0% 0% 0% 9 9 9 9 9 9 F L0974 Tlso full corset $ 198.95 $ 198.95 0 0% 0% 0% 9 9 9 9 9 9 F L0976 Lso full corset $ 210.24 $ 210.24 0 0% 0% 0% 9 9 9 9 9 9 F L0978 Axillary crutch extension $ 220.37 $ 220.37 0 0% 0% 0% 9 9 9 9 9 9 F L0980 Peroneal straps pair pre ots $ 19.94 $ 19.94 0 0% 0% 0% 9 9 9 9 9 9 F L0982 Stocking sup grips 4 pre ots $ 18.61 $ 18.61 0 0% 0% 0% 9 9 9 9 9 9 F L0984 Protect body sock ea pre ots $ 73.42 $ 73.42 0 0% 0% 0% 9 9 9 9 9 9 F L0999 Add to spinal orthosis nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L1000 Ctlso milwauke initial model $ 2611.48 $ 2611.48 0 0% 0% 0% 9 9 9 9 9 9 F Y L1001 Ctlso infant immobilizer Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L1005 Tension based scoliosis orth $ 3588.10 $ 3588.10 0 0% 0% 0% 9 9 9 9 9 9 F Y L1010 Ctlso axilla sling $ 74.76 $ 74.76 0 0% 0% 0% 9 9 9 9 9 9 F Y L1020 Kyphosis pad $ 109.60 $ 109.60 0 0% 0% 0% 9 9 9 9 9 9 F Y L1025 Kyphosis pad floating $ 133.92 $ 133.92 0 0% 0% 0% 9 9 9 9 9 9 F Y L1030 Lumbar bolster pad $ 70.19 $ 70.19 0 0% 0% 0% 9 9 9 9 9 9 F Y L1040 Lumbar or lumbar rib pad $ 103.64 $ 103.64 0 0% 0% 0% 9 9 9 9 9 9 F Y L1050 Sternal pad $ 110.06 $ 110.06 0 0% 0% 0% 9 9 9 9 9 9 F Y L1060 Thoracic pad $ 121.02 $ 121.02 0 0% 0% 0% 9 9 9 9 9 9 F Y L1070 Trapezius sling $ 109.39 $ 109.39 0 0% 0% 0% 9 9 9 9 9 9 F Y L1080 Outrigger $ 67.62 $ 67.62 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 115
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L1085 Outrigger bil w/ vert extens $ 176.50 $ 176.50 0 0% 0% 0% 9 9 9 9 9 9 F Y L1090 Lumbar sling $ 106.75 $ 106.75 0 0% 0% 0% 9 9 9 9 9 9 F Y L1100 Ring flange plastic/leather $ 193.99 $ 193.99 0 0% 0% 0% 9 9 9 9 9 9 F Y L1110 Ring flange plas/leather mol $ 321.00 $ 321.00 0 0% 0% 0% 9 9 9 9 9 9 F Y L1120 Covers for upright each $ 52.79 $ 52.79 0 0% 0% 0% 9 9 9 9 9 9 F Y L1200 Furnsh initial orthosis only $ 2243.64 $ 2243.64 0 0% 0% 0% 9 9 9 9 9 9 F Y L1210 Lateral thoracic extension $ 281.02 $ 281.02 0 0% 0% 0% 9 9 9 9 9 9 F Y L1220 Anterior thoracic extension $ 291.07 $ 291.07 0 0% 0% 0% 9 9 9 9 9 9 F Y L1230 Milwaukee type superstructur $ 610.50 $ 610.50 0 0% 0% 0% 9 9 9 9 9 9 F Y L1240 Lumbar derotation pad $ 89.14 $ 89.14 0 0% 0% 0% 9 9 9 9 9 9 F Y L1250 Anterior asis pad $ 81.53 $ 81.53 0 0% 0% 0% 9 9 9 9 9 9 F Y L1260 Anterior thoracic derotation $ 86.06 $ 86.06 0 0% 0% 0% 9 9 9 9 9 9 F Y L1270 Abdominal pad $ 83.21 $ 83.21 0 0% 0% 0% 9 9 9 9 9 9 F Y L1280 Rib gusset (elastic) each $ 96.38 $ 96.38 0 0% 0% 0% 9 9 9 9 9 9 F Y L1290 Lateral trochanteric pad $ 86.23 $ 86.23 0 0% 0% 0% 9 9 9 9 9 9 F Y L1300 Body jacket mold to patient $ 1814.24 $ 1814.24 0 0% 0% 0% 9 9 9 9 9 9 F Y L1310 Post-operative body jacket $ 2032.10 $ 2032.10 0 0% 0% 0% 9 9 9 9 9 9 F Y L1499 Spinal orthosis nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y L1600 Ho flex frejka w/cov pre cst $ 138.40 $ 138.40 0 0% 0% 0% 9 9 9 9 9 9 F L1610 Ho frejka cov only pre cst $ 47.15 $ 47.15 0 0% 0% 0% 9 9 9 9 9 9 F L1620 Ho flex pavlik harns pre cst $ 151.61 $ 151.61 0 0% 0% 0% 9 9 9 9 9 9 F L1630 Abduct control hip semi-flex $ 196.57 $ 196.57 0 0% 0% 0% 9 9 9 9 9 9 F Y L1640 Pelv band/spread bar thigh c $ 518.40 $ 518.40 0 0% 0% 0% 9 9 9 9 9 9 F Y L1650 Ho abduction hip adjustable $ 248.65 $ 248.65 0 0% 0% 0% 9 9 9 9 9 9 F L1652 Ho bi thighcuffs w sprdr bar $ 399.61 $ 399.61 0 0% 0% 0% 9 9 9 9 9 9 F L1660 Ho abduction static plastic $ 199.16 $ 199.16 0 0% 0% 0% 9 9 9 9 9 9 F L1680 Pelvic & hip control thigh c $ 1744.73 $ 1744.73 0 0% 0% 0% 9 9 9 9 9 9 F Y L1685 Post-op hip abduct custom fa $ 1277.47 $ 1277.47 0 0% 0% 0% 9 9 9 9 9 9 F Y L1686 Ho post-op hip abduction $ 993.42 $ 993.42 0 0% 0% 0% 9 9 9 9 9 9 F Y L1690 Combination bilateral ho $ 2167.84 $ 2167.84 0 0% 0% 0% 9 9 9 9 9 9 F Y L1700 Leg perthes orth toronto typ $ 1763.89 $ 1763.89 0 0% 0% 0% 9 9 9 9 9 9 F Y L1710 Legg perthes orth newington $ 2134.13 $ 2134.13 0 0% 0% 0% 9 9 9 9 9 9 F Y L1720 Legg perthes orthosis trilat $ 1488.74 $ 1488.74 0 0% 0% 0% 9 9 9 9 9 9 F Y L1730 Legg perthes orth scottish r $ 1270.21 $ 1270.21 0 0% 0% 0% 9 9 9 9 9 9 F Y L1755 Legg perthes patten bottom t $ 1700.36 $ 1700.36 0 0% 0% 0% 9 9 9 9 9 9 F Y L1810 Ko elastic with joints $ 122.45 $ 122.45 0 0% 0% 0% 9 9 9 9 9 9 F L1812 Ko elastic w/joints pre ots $ 122.45 $ 122.45 0 0% 0% 0% 9 9 9 9 9 9 FL1820 Ko elas w/ condyle pads & jo $ 154.93 $ 154.93 0 0% 0% 0% 9 9 9 9 9 9 F L1830 Ko immob canvas long pre ots $ 120.08 $ 120.08 0 0% 0% 0% 9 9 9 9 9 9 F L1831 Knee orth pos locking joint $ 329.94 $ 329.94 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 116
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L1832 Ko adj jnt pos r sup pre cst $ 652.94 $ 652.94 0 0% 0% 0% 9 9 9 9 9 9 F L1833 Ko adj jnt pos r sup pre ots $ 652.94 $ 652.94 0 0% 0% 0% 9 9 9 9 9 9 FL1834 Ko w/0 joint rigid molded to $ 833.69 $ 833.69 0 0% 0% 0% 9 9 9 9 9 9 F Y L1836 Ko rigid w/o joints pre ots $ 149.59 $ 149.59 0 0% 0% 0% 9 9 9 9 9 9 F L1840 Ko derot ant cruciate custom $ 1142.30 $ 1142.30 0 0% 0% 0% 9 9 9 9 9 9 F Y L1843 Ko single upright pre cst $ 1005.89 $ 1005.89 0 0% 0% 0% 9 9 9 9 9 9 F L1844 Ko w/adj jt rot cntrl molded $ 2259.56 $ 2259.56 0 0% 0% 0% 9 9 9 9 9 9 F L1845 Ko double upright pre cst $ 911.64 $ 911.64 0 0% 0% 0% 9 9 9 9 9 9 F L1846 Ko w adj flex/ext rotat mold $ 1373.10 $ 1373.10 0 0% 0% 0% 9 9 9 9 9 9 F Y L1847 Ko dbl upright w/air pre cst $ 644.80 $ 644.80 0 0% 0% 0% 9 9 9 9 9 9 F L1848 Ko dbl upright w/air pre ots $ 644.80 $ 644.80 0 0% 0% 0% 9 9 9 9 9 9 FL1850 Ko swedish type pre ots $ 345.20 $ 345.20 0 0% 0% 0% 9 9 9 9 9 9 F L1860 Ko supracondylar socket mold $ 1409.00 $ 1409.00 0 0% 0% 0% 9 9 9 9 9 9 F Y L1900 Afo sprng wir drsflx calf bd $ 319.42 $ 319.42 0 0% 0% 0% 9 9 9 9 9 9 F Y L1902 Afo ankle gauntlet pre ots $ 105.12 $ 105.12 0 0% 0% 0% 9 9 9 9 9 9 F L1904 Afo molded ankle gauntlet $ 505.03 $ 505.03 0 0% 0% 0% 9 9 9 9 9 9 F Y L1906 Afo multilig ank sup pre ots $ 129.16 $ 129.16 0 0% 0% 0% 9 9 9 9 9 9 F L1907 Afo supramalleolar custom $ 630.80 $ 630.80 0 0% 0% 0% 9 9 9 9 9 9 F Y L1910 Afo sing bar clasp attach sh $ 363.28 $ 363.28 0 0% 0% 0% 9 9 9 9 9 9 F L1920 Afo sing upright w/ adjust s $ 481.24 $ 481.24 0 0% 0% 0% 9 9 9 9 9 9 F Y L1930 Afo plastic $ 296.71 $ 296.71 0 0% 0% 0% 9 9 9 9 9 9 F L1932 Afo rig ant tib prefab tcf/= $ 1000.38 $ 1000.38 0 0% 0% 0% 9 9 9 9 9 9 F L1940 Afo molded to patient plasti $ 570.56 $ 570.56 0 0% 0% 0% 9 9 9 9 9 9 F Y L1945 Afo molded plas rig ant tib $ 1121.84 $ 1121.84 0 0% 0% 0% 9 9 9 9 9 9 F Y L1950 Afo spiral molded to pt plas $ 1066.60 $ 1066.60 0 0% 0% 0% 9 9 9 9 9 9 F Y L1951 Afo spiral prefabricated $ 941.50 $ 941.50 0 0% 0% 0% 9 9 9 9 9 9 F Y L1960 Afo pos solid ank plastic mo $ 595.28 $ 595.28 0 0% 0% 0% 9 9 9 9 9 9 F Y L1970 Afo plastic molded w/ankle j $ 794.42 $ 794.42 0 0% 0% 0% 9 9 9 9 9 9 F Y L1971 Afo w/ankle joint, prefab $ 525.47 $ 525.47 0 0% 0% 0% 9 9 9 9 9 9 F Y L1980 Afo sing solid stirrup calf $ 504.10 $ 504.10 0 0% 0% 0% 9 9 9 9 9 9 F Y L1990 Afo doub solid stirrup calf $ 609.12 $ 609.12 0 0% 0% 0% 9 9 9 9 9 9 F Y L2000 Kafo sing fre stirr thi/calf $ 1452.42 $ 1452.42 0 0% 0% 0% 9 9 9 9 9 9 F Y L2005 Kafo sng/dbl mechanical act $ 4593.78 $ 4593.78 0 0% 0% 0% 9 9 9 9 9 9 F L2010 Kafo sng solid stirrup w/o j $ 1311.13 $ 1311.13 0 0% 0% 0% 9 9 9 9 9 9 F Y L2020 Kafo dbl solid stirrup band/ $ 1672.03 $ 1672.03 0 0% 0% 0% 9 9 9 9 9 9 F Y L2030 Kafo dbl solid stirrup w/o j $ 1439.98 $ 1439.98 0 0% 0% 0% 9 9 9 9 9 9 F Y L2034 Kafo pla sin up w/wo k/a cus $ 2273.34 $ 2273.34 0 0% 0% 0% 9 9 9 9 9 9 F Y L2035 Kafo plastic pediatric size $ 201.72 $ 201.72 0 0% 0% 0% 9 9 9 9 9 9 F L2036 Kafo plas doub free knee mol $ 2570.53 $ 2570.53 0 0% 0% 0% 9 9 9 9 9 9 F Y L2037 Kafo plas sing free knee mol $ 2120.65 $ 2120.65 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 117
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L2038 Kafo w/o joint multi-axis an $ 1786.44 $ 1786.44 0 0% 0% 0% 9 9 9 9 9 9 F Y L2040 Hkafo torsion bil rot straps $ 245.38 $ 245.38 0 0% 0% 0% 9 9 9 9 9 9 F Y L2050 Hkafo torsion cable hip pelv $ 518.87 $ 518.87 0 0% 0% 0% 9 9 9 9 9 9 F Y L2060 Hkafo torsion ball bearing j $ 734.62 $ 734.62 0 0% 0% 0% 9 9 9 9 9 9 F Y L2070 Hkafo torsion unilat rot str $ 144.43 $ 144.43 0 0% 0% 0% 9 9 9 9 9 9 F Y L2080 Hkafo unilat torsion cable $ 445.31 $ 445.31 0 0% 0% 0% 9 9 9 9 9 9 F Y L2090 Hkafo unilat torsion ball br $ 627.90 $ 627.90 0 0% 0% 0% 9 9 9 9 9 9 F Y L2106 Afo tib fx cast plaster mold $ 752.68 $ 752.68 0 0% 0% 0% 9 9 9 9 9 9 F Y L2108 Afo tib fx cast molded to pt $ 1287.00 $ 1287.00 0 0% 0% 0% 9 9 9 9 9 9 F Y L2112 Afo tibial fracture soft $ 519.50 $ 519.50 0 0% 0% 0% 9 9 9 9 9 9 F L2114 Afo tib fx semi-rigid $ 637.49 $ 637.49 0 0% 0% 0% 9 9 9 9 9 9 F L2116 Afo tibial fracture rigid $ 764.56 $ 764.56 0 0% 0% 0% 9 9 9 9 9 9 F L2126 Kafo fem fx cast thermoplas $ 1286.04 $ 1286.04 0 0% 0% 0% 9 9 9 9 9 9 F Y L2128 Kafo fem fx cast molded to p $ 2455.43 $ 2455.43 0 0% 0% 0% 9 9 9 9 9 9 F Y L2132 Kafo femoral fx cast soft $ 866.35 $ 866.35 0 0% 0% 0% 9 9 9 9 9 9 F L2134 Kafo fem fx cast semi-rigid $ 1086.24 $ 1086.24 0 0% 0% 0% 9 9 9 9 9 9 F L2136 Kafo femoral fx cast rigid $ 1270.08 $ 1270.08 0 0% 0% 0% 9 9 9 9 9 9 F L2180 Plas shoe insert w ank joint $ 125.77 $ 125.77 0 0% 0% 0% 9 9 9 9 9 9 F L2182 Drop lock knee $ 115.74 $ 115.74 0 0% 0% 0% 9 9 9 9 9 9 F L2184 Limited motion knee joint $ 133.04 $ 133.04 0 0% 0% 0% 9 9 9 9 9 9 F L2186 Adj motion knee jnt lerman t $ 186.14 $ 186.14 0 0% 0% 0% 9 9 9 9 9 9 F L2188 Quadrilateral brim $ 348.52 $ 348.52 0 0% 0% 0% 9 9 9 9 9 9 F L2190 Waist belt $ 93.79 $ 93.79 0 0% 0% 0% 9 9 9 9 9 9 F L2192 Pelvic band & belt thigh fla $ 382.93 $ 382.93 0 0% 0% 0% 9 9 9 9 9 9 F L2200 Limited ankle motion ea jnt $ 68.08 $ 68.08 0 0% 0% 0% 9 9 9 9 9 9 F L2210 Dorsiflexion assist each joi $ 75.67 $ 75.67 0 0% 0% 0% 9 9 9 9 9 9 F L2220 Dorsi & plantar flex ass/res $ 103.93 $ 103.93 0 0% 0% 0% 9 9 9 9 9 9 F L2230 Split flat caliper stirr & p $ 101.17 $ 101.17 0 0% 0% 0% 9 9 9 9 9 9 F L2232 Rocker bottom, contact afo $ 111.56 $ 111.56 0 0% 0% 0% 9 9 9 9 9 9 F L2240 Round caliper and plate atta $ 90.66 $ 90.66 0 0% 0% 0% 9 9 9 9 9 9 F L2250 Foot plate molded stirrup at $ 508.82 $ 508.82 0 0% 0% 0% 9 9 9 9 9 9 F L2260 Reinforced solid stirrup $ 215.29 $ 215.29 0 0% 0% 0% 9 9 9 9 9 9 F L2265 Long tongue stirrup $ 126.48 $ 126.48 0 0% 0% 0% 9 9 9 9 9 9 F L2270 Varus/valgus strap padded/li $ 76.91 $ 76.91 0 0% 0% 0% 9 9 9 9 9 9 F L2275 Plastic mod low ext pad/line $ 167.98 $ 167.98 0 0% 0% 0% 9 9 9 9 9 9 F L2280 Molded inner boot $ 487.04 $ 487.04 0 0% 0% 0% 9 9 9 9 9 9 F Y L2300 Abduction bar jointed adjust $ 360.53 $ 360.53 0 0% 0% 0% 9 9 9 9 9 9 F L2310 Abduction bar-straight $ 176.16 $ 176.16 0 0% 0% 0% 9 9 9 9 9 9 F L2320 Non-molded lacer $ 282.29 $ 282.29 0 0% 0% 0% 9 9 9 9 9 9 F L2330 Lacer molded to patient mode $ 498.91 $ 498.91 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 118
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L2335 Anterior swing band $ 267.11 $ 267.11 0 0% 0% 0% 9 9 9 9 9 9 F L2340 Pre-tibial shell molded to p $ 592.72 $ 592.72 0 0% 0% 0% 9 9 9 9 9 9 F Y L2350 Prosthetic type socket molde $ 1079.64 $ 1079.64 0 0% 0% 0% 9 9 9 9 9 9 F Y L2360 Extended steel shank $ 74.09 $ 74.09 0 0% 0% 0% 9 9 9 9 9 9 F L2370 Patten bottom $ 294.60 $ 294.60 0 0% 0% 0% 9 9 9 9 9 9 F L2375 Torsion ank & half solid sti $ 121.34 $ 121.34 0 0% 0% 0% 9 9 9 9 9 9 F L2380 Torsion straight knee joint $ 134.60 $ 134.60 0 0% 0% 0% 9 9 9 9 9 9 F L2385 Straight knee joint heavy du $ 143.86 $ 143.86 0 0% 0% 0% 9 9 9 9 9 9 F L2387 Add le poly knee custom kafo $ 218.10 $ 218.10 0 0% 0% 0% 9 9 9 9 9 9 F L2390 Offset knee joint each $ 117.56 $ 117.56 0 0% 0% 0% 9 9 9 9 9 9 F L2395 Offset knee joint heavy duty $ 168.04 $ 168.04 0 0% 0% 0% 9 9 9 9 9 9 F L2397 Suspension sleeve lower ext $ 141.94 $ 141.94 0 0% 0% 0% 9 9 9 9 9 9 F L2405 Knee joint drop lock ea jnt $ 97.73 $ 97.73 0 0% 0% 0% 9 9 9 9 9 9 F L2415 Knee joint cam lock each joi $ 136.15 $ 136.15 0 0% 0% 0% 9 9 9 9 9 9 F L2425 Knee disc/dial lock/adj flex $ 160.70 $ 160.70 0 0% 0% 0% 9 9 9 9 9 9 F L2430 Knee jnt ratchet lock ea jnt $ 160.70 $ 160.70 0 0% 0% 0% 9 9 9 9 9 9 F L2492 Knee lift loop drop lock rin $ 113.56 $ 113.56 0 0% 0% 0% 9 9 9 9 9 9 F L2500 Thi/glut/ischia wgt bearing $ 363.78 $ 363.78 0 0% 0% 0% 9 9 9 9 9 9 F L2510 Th/wght bear quad-lat brim m $ 887.40 $ 887.40 0 0% 0% 0% 9 9 9 9 9 9 F Y L2520 Th/wght bear quad-lat brim c $ 522.80 $ 522.80 0 0% 0% 0% 9 9 9 9 9 9 F L2525 Th/wght bear nar m-l brim mo $ 1393.61 $ 1393.61 0 0% 0% 0% 9 9 9 9 9 9 F Y L2526 Th/wght bear nar m-l brim cu $ 980.82 $ 980.82 0 0% 0% 0% 9 9 9 9 9 9 F L2530 Thigh/wght bear lacer non-mo $ 263.47 $ 263.47 0 0% 0% 0% 9 9 9 9 9 9 F L2540 Thigh/wght bear lacer molded $ 572.71 $ 572.71 0 0% 0% 0% 9 9 9 9 9 9 F Y L2550 Thigh/wght bear high roll cu $ 336.54 $ 336.54 0 0% 0% 0% 9 9 9 9 9 9 F L2570 Hip clevis type 2 posit jnt $ 526.97 $ 526.97 0 0% 0% 0% 9 9 9 9 9 9 F L2580 Pelvic control pelvic sling $ 589.07 $ 589.07 0 0% 0% 0% 9 9 9 9 9 9 F L2600 Hip clevis/thrust bearing fr $ 255.49 $ 255.49 0 0% 0% 0% 9 9 9 9 9 9 F L2610 Hip clevis/thrust bearing lo $ 307.91 $ 307.91 0 0% 0% 0% 9 9 9 9 9 9 F L2620 Pelvic control hip heavy dut $ 337.78 $ 337.78 0 0% 0% 0% 9 9 9 9 9 9 F L2622 Hip joint adjustable flexion $ 329.34 $ 329.34 0 0% 0% 0% 9 9 9 9 9 9 F L2624 Hip adj flex ext abduct cont $ 355.63 $ 355.63 0 0% 0% 0% 9 9 9 9 9 9 F L2627 Plastic mold recipro hip & c $ 1841.10 $ 1841.10 0 0% 0% 0% 9 9 9 9 9 9 F Y L2628 Metal frame recipro hip & ca $ 2399.10 $ 2399.10 0 0% 0% 0% 9 9 9 9 9 9 F L2630 Pelvic control band & belt u $ 280.92 $ 280.92 0 0% 0% 0% 9 9 9 9 9 9 F L2640 Pelvic control band & belt b $ 437.82 $ 437.82 0 0% 0% 0% 9 9 9 9 9 9 F L2650 Pelv & thor control gluteal $ 171.84 $ 171.84 0 0% 0% 0% 9 9 9 9 9 9 F L2660 Thoracic control thoracic ba $ 200.17 $ 200.17 0 0% 0% 0% 9 9 9 9 9 9 F L2670 Thorac cont paraspinal uprig $ 189.40 $ 189.40 0 0% 0% 0% 9 9 9 9 9 9 F L2680 Thorac cont lat support upri $ 168.06 $ 168.06 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 119
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L2750 Plating chrome/nickel pr bar $ 105.47 $ 105.47 0 0% 0% 0% 9 9 9 9 9 9 F Y L2755 Carbon graphite lamination $ 146.50 $ 146.50 0 0% 0% 0% 9 9 9 9 9 9 F Y L2760 Extension per extension per $ 66.64 $ 66.64 0 0% 0% 0% 9 9 9 9 9 9 F L2768 Ortho sidebar disconnect $ 146.05 $ 146.05 0 0% 0% 0% 9 9 9 9 9 9 F Y L2780 Non-corrosive finish $ 96.91 $ 96.91 0 0% 0% 0% 9 9 9 9 9 9 F Y L2785 Drop lock retainer each $ 37.57 $ 37.57 0 0% 0% 0% 9 9 9 9 9 9 F L2795 Knee control full kneecap $ 113.12 $ 113.12 0 0% 0% 0% 9 9 9 9 9 9 F L2800 Knee cap medial or lateral p $ 131.33 $ 131.33 0 0% 0% 0% 9 9 9 9 9 9 F L2810 Knee control condylar pad $ 83.88 $ 83.88 0 0% 0% 0% 9 9 9 9 9 9 F L2820 Soft interface below knee se $ 93.26 $ 93.26 0 0% 0% 0% 9 9 9 9 9 9 F Y L2830 Soft interface above knee se $ 100.90 $ 100.90 0 0% 0% 0% 9 9 9 9 9 9 F Y L2840 Tibial length sock fx or equ $ 46.92 $ 46.92 0 0% 0% 0% 9 9 9 9 9 9 F L2850 Femoral lgth sock fx or equa $ 66.49 $ 66.49 0 0% 0% 0% 9 9 9 9 9 9 F L2861 Torsion mechanism knee/ankle By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YL2999 Lower extremity orthosis nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y L3000 Ft insert ucb berkeley shell $ 352.15 $ 352.15 0 0% 0% 0% 9 9 9 9 9 9 F L3001 Foot insert remov molded spe $ 148.28 $ 148.28 0 0% 0% 0% 9 9 9 9 9 9 F L3002 Foot insert plastazote or eq $ 181.06 $ 181.06 0 0% 0% 0% 9 9 9 9 9 9 F L3003 Foot insert silicone gel eac $ 195.36 $ 195.36 0 0% 0% 0% 9 9 9 9 9 9 F L3010 Foot longitudinal arch suppo $ 195.36 $ 195.36 0 0% 0% 0% 9 9 9 9 9 9 F L3020 Foot longitud/metatarsal sup $ 222.42 $ 222.42 0 0% 0% 0% 9 9 9 9 9 9 F L3030 Foot arch support remov prem $ 85.56 $ 85.56 0 0% 0% 0% 9 9 9 9 9 9 F L3031 Foot lamin/prepreg composite $ 142.69 $ 142.69 0 0% 0% 0% 9 9 9 9 9 9 F L3040 Ft arch suprt premold longit $ 52.75 $ 52.75 0 0% 0% 0% 9 9 9 9 9 9 F L3050 Foot arch supp premold metat $ 52.75 $ 52.75 0 0% 0% 0% 9 9 9 9 9 9 F L3060 Foot arch supp longitud/meta $ 82.68 $ 82.68 0 0% 0% 0% 9 9 9 9 9 9 F L3070 Arch suprt att to sho longit $ 35.60 $ 35.60 0 0% 0% 0% 9 9 9 9 9 9 F L3080 Arch supp att to shoe metata $ 35.60 $ 35.60 0 0% 0% 0% 9 9 9 9 9 9 F L3090 Arch supp att to shoe long/m $ 45.62 $ 45.62 0 0% 0% 0% 9 9 9 9 9 9 F L3100 Hallus-valgus nt dyn pre ots $ 48.47 $ 48.47 0 0% 0% 0% 9 9 9 9 9 9 F L3140 Abduction rotation bar shoe $ 99.82 $ 99.82 0 0% 0% 0% 9 9 9 9 9 9 F L3150 Abduct rotation bar w/o shoe $ 91.25 $ 91.25 0 0% 0% 0% 9 9 9 9 9 9 F L3160 Shoe styled positioning dev $ 19.51 $ 19.51 0 0% 0% 0% 9 9 9 9 9 9 F L3170 Foot plas heel stabi pre ots $ 57.06 $ 57.06 0 0% 0% 0% 9 9 9 9 9 9 F L3201 Oxford w supinat/pronat inf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3202 Oxford w/ supinat/pronator c Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3203 Oxford w/ supinator/pronator Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3204 Hightop w/ supp/pronator inf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3206 Hightop w/ supp/pronator chi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3207 Hightop w/ supp/pronator jun Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 120
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L3208 Surgical boot each infant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3209 Surgical boot each child Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3211 Surgical boot each junior Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3212 Benesch boot pair infant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3213 Benesch boot pair child Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3214 Benesch boot pair junior Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L3215 Orthopedic ftwear ladies oxf $ 136.55 $ 136.55 0 0% 0% 0% 9 9 9 9 9 9 F L3216 Orthoped ladies shoes dpth i $ 165.16 $ 165.16 0 0% 0% 0% 9 9 9 9 9 9 F L3217 Ladies shoes hightop depth i $ 179.15 $ 179.15 0 0% 0% 0% 9 9 9 9 9 9 F L3219 Orthopedic mens shoes oxford $ 153.46 $ 153.46 0 0% 0% 0% 9 9 9 9 9 9 F L3221 Orthopedic mens shoes dpth i $ 184.03 $ 184.03 0 0% 0% 0% 9 9 9 9 9 9 F L3222 Mens shoes hightop depth inl $ 203.20 $ 203.20 0 0% 0% 0% 9 9 9 9 9 9 F L3224 Woman's shoe oxford brace $ 63.16 $ 63.16 0 0% 0% 0% 9 9 9 9 9 9 F L3225 Man's shoe oxford brace $ 72.65 $ 72.65 0 0% 0% 0% 9 9 9 9 9 9 F L3230 Custom shoes depth inlay $ 239.29 $ 239.29 0 0% 0% 0% 9 9 9 9 9 9 F L3250 Custom mold shoe remov prost $ 465.58 $ 465.58 0 0% 0% 0% 9 9 9 9 9 9 F L3251 Shoe molded to pt silicone s $ 64.05 $ 64.05 0 0% 0% 0% 9 9 9 9 9 9 F L3252 Shoe molded plastazote cust $ 254.90 $ 254.90 0 0% 0% 0% 9 9 9 9 9 9 F L3253 Shoe molded plastazote cust $ 63.72 $ 63.72 0 0% 0% 0% 9 9 9 9 9 9 F L3254 Orth foot non-stndard size/w By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L3255 Orth foot non-standard size/ By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L3257 Orth foot add charge split s $ 46.17 $ 46.17 0 0% 0% 0% 9 9 9 9 9 9 F L3260 Ambulatory surgical boot eac $ 26.01 $ 26.01 0 0% 0% 0% 9 9 9 9 9 9 F L3265 Plastazote sandal each $ 28.29 $ 28.29 0 0% 0% 0% 9 9 9 9 9 9 F L3300 Sho lift taper to metatarsal $ 58.44 $ 58.44 0 0% 0% 0% 9 9 9 9 9 9 F L3310 Shoe lift elev heel/sole neo $ 91.25 $ 91.25 0 0% 0% 0% 9 9 9 9 9 9 F L3320 Shoe lift elev heel/sole cor $ 172.32 $ 172.32 0 0% 0% 0% 9 9 9 9 9 9 F L3330 Lifts elevation metal extens $ 634.45 $ 634.45 0 0% 0% 0% 9 9 9 9 9 9 F L3332 Shoe lifts tapered to one-ha $ 82.68 $ 82.68 0 0% 0% 0% 9 9 9 9 9 9 F L3334 Shoe lifts elevation heel /i $ 42.79 $ 42.79 0 0% 0% 0% 9 9 9 9 9 9 F L3340 Shoe wedge sach $ 95.56 $ 95.56 0 0% 0% 0% 9 9 9 9 9 9 F L3350 Shoe heel wedge $ 25.69 $ 25.69 0 0% 0% 0% 9 9 9 9 9 9 F L3360 Shoe sole wedge outside sole $ 39.91 $ 39.91 0 0% 0% 0% 9 9 9 9 9 9 F L3370 Shoe sole wedge between sole $ 55.57 $ 55.57 0 0% 0% 0% 9 9 9 9 9 9 F L3380 Shoe clubfoot wedge $ 55.57 $ 55.57 0 0% 0% 0% 9 9 9 9 9 9 F L3390 Shoe outflare wedge $ 55.57 $ 55.57 0 0% 0% 0% 9 9 9 9 9 9 F L3400 Shoe metatarsal bar wedge ro $ 45.62 $ 45.62 0 0% 0% 0% 9 9 9 9 9 9 F L3410 Shoe metatarsal bar between $ 104.08 $ 104.08 0 0% 0% 0% 9 9 9 9 9 9 F L3420 Full sole/heel wedge btween $ 61.32 $ 61.32 0 0% 0% 0% 9 9 9 9 9 9 F L3430 Sho heel count plast reinfor $ 179.65 $ 179.65 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 121
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L3440 Heel leather reinforced $ 85.56 $ 85.56 0 0% 0% 0% 9 9 9 9 9 9 F L3450 Shoe heel sach cushion type $ 118.34 $ 118.34 0 0% 0% 0% 9 9 9 9 9 9 F L3455 Shoe heel new leather standa $ 45.62 $ 45.62 0 0% 0% 0% 9 9 9 9 9 9 F L3460 Shoe heel new rubber standar $ 38.47 $ 38.47 0 0% 0% 0% 9 9 9 9 9 9 F L3465 Shoe heel thomas with wedge $ 65.59 $ 65.59 0 0% 0% 0% 9 9 9 9 9 9 F L3470 Shoe heel thomas extend to b $ 69.85 $ 69.85 0 0% 0% 0% 9 9 9 9 9 9 F L3480 Shoe heel pad & depress for $ 69.85 $ 69.85 0 0% 0% 0% 9 9 9 9 9 9 F L3485 Shoe heel pad removable for $ 26.01 $ 26.01 0 0% 0% 0% 9 9 9 9 9 9 F L3500 Ortho shoe add leather insol $ 32.78 $ 32.78 0 0% 0% 0% 9 9 9 9 9 9 F L3510 Orthopedic shoe add rub insl $ 32.78 $ 32.78 0 0% 0% 0% 9 9 9 9 9 9 F L3520 O shoe add felt w leath insl $ 35.60 $ 35.60 0 0% 0% 0% 9 9 9 9 9 9 F L3530 Ortho shoe add half sole $ 35.60 $ 35.60 0 0% 0% 0% 9 9 9 9 9 9 F L3540 Ortho shoe add full sole $ 57.06 $ 57.06 0 0% 0% 0% 9 9 9 9 9 9 F L3550 O shoe add standard toe tap $ 9.95 $ 9.95 0 0% 0% 0% 9 9 9 9 9 9 F L3560 O shoe add horseshoe toe tap $ 25.69 $ 25.69 0 0% 0% 0% 9 9 9 9 9 9 F L3570 O shoe add instep extension $ 95.56 $ 95.56 0 0% 0% 0% 9 9 9 9 9 9 F L3580 O shoe add instep velcro clo $ 72.71 $ 72.71 0 0% 0% 0% 9 9 9 9 9 9 F L3590 O shoe convert to sof counte $ 59.88 $ 59.88 0 0% 0% 0% 9 9 9 9 9 9 F L3595 Ortho shoe add march bar $ 47.04 $ 47.04 0 0% 0% 0% 9 9 9 9 9 9 F L3600 Trans shoe calip plate exist $ 85.56 $ 85.56 0 0% 0% 0% 9 9 9 9 9 9 F L3610 Trans shoe caliper plate new $ 112.63 $ 112.63 0 0% 0% 0% 9 9 9 9 9 9 F L3620 Trans shoe solid stirrup exi $ 85.56 $ 85.56 0 0% 0% 0% 9 9 9 9 9 9 F L3630 Trans shoe solid stirrup new $ 112.63 $ 112.63 0 0% 0% 0% 9 9 9 9 9 9 F L3640 Shoe dennis browne splint bo $ 48.47 $ 48.47 0 0% 0% 0% 9 9 9 9 9 9 F L3649 Orthopedic shoe modifica nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L3650 So 8 abd restraint pre ots $ 66.43 $ 66.43 0 0% 0% 0% 9 9 9 9 9 9 F L3660 So 8 ab rstr can/web pre ots $ 108.01 $ 108.01 0 0% 0% 0% 9 9 9 9 9 9 FL3670 So acro/clav can web pre ots $ 123.52 $ 123.52 0 0% 0% 0% 9 9 9 9 9 9 FL3671 So cap design w/o jnts cf $ 919.34 $ 919.34 0 0% 0% 0% 9 9 9 9 9 9 F L3674 So airplane w/wo joint cf $ 1205.99 $ 1205.99 0 0% 0% 0% 9 9 9 9 9 9 F YL3675 So vest canvas/web pre ots $ 179.05 $ 179.05 0 0% 0% 0% 9 9 9 9 9 9 FL3677 So hard plas stabili pre cst $ 212.12 $ 212.12 0 0% 0% 0% 9 9 9 9 9 9 F Y L3678 So hard plas stabili pre ots By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NL3702 Eo w/o joints cf $ 294.60 $ 294.60 0 0% 0% 0% 9 9 9 9 9 9 F L3710 Eo elas w/metal jnts pre ots $ 129.91 $ 129.91 0 0% 0% 0% 9 9 9 9 9 9 F L3720 Forearm/arm cuffs free motio $ 821.05 $ 821.05 0 0% 0% 0% 9 9 9 9 9 9 F L3730 Forearm/arm cuffs ext/flex a $ 1104.62 $ 1104.62 0 0% 0% 0% 9 9 9 9 9 9 F Y L3740 Cuffs adj lock w/ active con $ 1127.63 $ 1127.63 0 0% 0% 0% 9 9 9 9 9 9 F Y L3760 Eo withjoint, prefabricated $ 510.22 $ 510.22 0 0% 0% 0% 9 9 9 9 9 9 F L3762 Eo rigid w/o joints pre ots $ 109.70 $ 109.70 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 122
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L3763 Ewho rigid w/o jnts cf $ 754.30 $ 754.30 0 0% 0% 0% 9 9 9 9 9 9 F Y L3764 Ewho w/joint(s) cf $ 846.92 $ 846.92 0 0% 0% 0% 9 9 9 9 9 9 F Y L3765 Ewhfo rigid w/o jnts cf $ 1308.22 $ 1308.22 0 0% 0% 0% 9 9 9 9 9 9 F Y L3766 Ewhfo w/joint(s) cf $ 1385.30 $ 1385.30 0 0% 0% 0% 9 9 9 9 9 9 F Y L3806 Whfo w/joint(s) custom fab $ 463.45 $ 463.45 0 0% 0% 0% 9 9 9 9 9 9 F Y L3807 Whfo w/o joints pre cst $ 255.12 $ 255.12 0 0% 0% 0% 9 9 9 9 9 9 F L3808 Whfo, rigid w/o joints $ 367.64 $ 367.64 0 0% 0% 0% 9 9 9 9 9 9 F Y L3809 Whfo w/o joints pre ots $ 255.12 $ 255.12 0 0% 0% 0% 9 9 9 9 9 9 FL3891 Torsion mechanism wrist/elbo By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YL3900 Hinge extension/flex wrist/f $ 1530.49 $ 1530.49 0 0% 0% 0% 9 9 9 9 9 9 F Y L3901 Hinge ext/flex wrist finger $ 1892.16 $ 1892.16 0 0% 0% 0% 9 9 9 9 9 9 F Y L3904 Whfo electric custom fitted $ 3077.60 $ 3077.60 0 0% 0% 0% 9 9 9 9 9 9 F Y L3905 Who w/nontorsion jnt(s) cf $ 1011.80 $ 1011.80 0 0% 0% 0% 9 9 9 9 9 9 F Y L3906 Who w/o joints cf $ 435.53 $ 435.53 0 0% 0% 0% 9 9 9 9 9 9 F Y L3908 Who cock-up nonmolde pre ots $ 83.95 $ 83.95 0 0% 0% 0% 9 9 9 9 9 9 F L3912 Hfo flexion glove pre ots $ 132.89 $ 132.89 0 0% 0% 0% 9 9 9 9 9 9 F L3913 Hfo w/o joints cf $ 276.32 $ 276.32 0 0% 0% 0% 9 9 9 9 9 9 F Y L3915 Who nontorsion jnts pre cst $ 542.33 $ 542.33 0 0% 0% 0% 9 9 9 9 9 9 F L3916 Who nontorsion jnts pre ots $ 542.33 $ 542.33 0 0% 0% 0% 9 9 9 9 9 9 FL3917 Metacarp fx orthosis pre cst $ 107.81 $ 107.81 0 0% 0% 0% 9 9 9 9 9 9 F L3918 Metacarp fx orthosis pre ots $ 107.81 $ 107.81 0 0% 0% 0% 9 9 9 9 9 9 FL3919 Ho w/o joints cf $ 276.32 $ 276.32 0 0% 0% 0% 9 9 9 9 9 9 F Y L3921 Hfo w/joint(s) cf $ 327.72 $ 327.72 0 0% 0% 0% 9 9 9 9 9 9 F Y L3923 Hfo without joints pre cst $ 100.48 $ 100.48 0 0% 0% 0% 9 9 9 9 9 9 F L3924 Hfo without joints pre ots $ 100.48 $ 100.48 0 0% 0% 0% 9 9 9 9 9 9 FL3925 Fo pip dip jnt/sprng pre ots $ 65.22 $ 65.22 0 0% 0% 0% 9 9 9 9 9 9 F L3927 Fo pip dip no jt spr pre ots $ 35.66 $ 35.66 0 0% 0% 0% 9 9 9 9 9 9 F L3929 Hfo nontorsion jnts pre cst $ 99.54 $ 99.54 0 0% 0% 0% 9 9 9 9 9 9 F L3930 Hfo nontorsion jnts pre ots $ 99.54 $ 99.54 0 0% 0% 0% 9 9 9 9 9 9 FL3931 Whfo nontorsion joint prefab $ 196.57 $ 196.57 0 0% 0% 0% 9 9 9 9 9 9 F L3933 Fo w/o joints cf $ 217.68 $ 217.68 0 0% 0% 0% 9 9 9 9 9 9 F Y L3935 Fo nontorsion joint cf $ 225.38 $ 225.38 0 0% 0% 0% 9 9 9 9 9 9 F Y L3956 Add joint upper ext orthosis By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y L3960 Sewho airplan desig abdu pos $ 868.46 $ 868.46 0 0% 0% 0% 9 9 9 9 9 9 F L3961 Sewho cap design w/o jnts cf $ 1714.15 $ 1714.15 0 0% 0% 0% 9 9 9 9 9 9 F L3962 Sewho erbs palsey design abd $ 938.51 $ 938.51 0 0% 0% 0% 9 9 9 9 9 9 F L3967 Sewho airplane w/o jnts cf $ 2023.84 $ 2023.84 0 0% 0% 0% 9 9 9 9 9 9 F L3971 Sewho cap design w/jnt(s) cf $ 1921.10 $ 1921.10 0 0% 0% 0% 9 9 9 9 9 9 F L3973 Sewho airplane w/jnt(s) cf $ 2023.84 $ 2023.84 0 0% 0% 0% 9 9 9 9 9 9 F L3975 Sewhfo cap design w/o jnt cf $ 1714.15 $ 1714.15 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 123
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L3976 Sewhfo airplane w/o jnts cf $ 1714.15 $ 1714.15 0 0% 0% 0% 9 9 9 9 9 9 F L3977 Sewhfo cap desgn w/jnt(s) cf $ 1921.10 $ 1921.10 0 0% 0% 0% 9 9 9 9 9 9 F L3978 Sewhfo airplane w/jnt(s) cf $ 2023.84 $ 2023.84 0 0% 0% 0% 9 9 9 9 9 9 F L3980 Up ext fx orthos humeral nos $ 324.89 $ 324.89 0 0% 0% 0% 9 9 9 9 9 9 F L3981 Ue fx orth shoul cap forearm $ 1026.96 $ 1026.96 0 0% 0% 0% 9 9 9 9 9 9 FL3982 Upper ext fx orthosis rad/ul $ 392.33 $ 392.33 0 0% 0% 0% 9 9 9 9 9 9 F L3984 Upper ext fx orthosis wrist $ 377.54 $ 377.54 0 0% 0% 0% 9 9 9 9 9 9 F L3995 Sock fracture or equal each $ 38.15 $ 38.15 0 0% 0% 0% 9 9 9 9 9 9 F L3999 Upper limb orthosis nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y L4000 Repl girdle milwaukee orth $ 1555.69 $ 1555.69 0 0% 0% 0% 9 9 9 9 9 9 F Y L4002 Replace strap, any orthosis By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L4010 Replace trilateral socket br $ 859.58 $ 859.58 0 0% 0% 0% 9 9 9 9 9 9 F Y L4020 Replace quadlat socket brim $ 1029.12 $ 1029.12 0 0% 0% 0% 9 9 9 9 9 9 F Y L4030 Replace socket brim cust fit $ 709.63 $ 709.63 0 0% 0% 0% 9 9 9 9 9 9 F Y L4040 Replace molded thigh lacer $ 584.52 $ 584.52 0 0% 0% 0% 9 9 9 9 9 9 F Y L4045 Replace non-molded thigh lac $ 355.38 $ 355.38 0 0% 0% 0% 9 9 9 9 9 9 F Y L4050 Replace molded calf lacer $ 534.20 $ 534.20 0 0% 0% 0% 9 9 9 9 9 9 F Y L4055 Replace non-molded calf lace $ 291.25 $ 291.25 0 0% 0% 0% 9 9 9 9 9 9 F Y L4060 Replace high roll cuff $ 433.96 $ 433.96 0 0% 0% 0% 9 9 9 9 9 9 F Y L4070 Replace prox & dist upright $ 357.76 $ 357.76 0 0% 0% 0% 9 9 9 9 9 9 F Y L4080 Repl met band kafo-afo prox $ 128.65 $ 128.65 0 0% 0% 0% 9 9 9 9 9 9 F Y L4090 Repl met band kafo-afo calf/ $ 129.19 $ 129.19 0 0% 0% 0% 9 9 9 9 9 9 F Y L4100 Repl leath cuff kafo prox th $ 149.35 $ 149.35 0 0% 0% 0% 9 9 9 9 9 9 F Y L4110 Repl leath cuff kafo-afo cal $ 121.43 $ 121.43 0 0% 0% 0% 9 9 9 9 9 9 F Y L4130 Replace pretibial shell $ 710.45 $ 710.45 0 0% 0% 0% 9 9 9 9 9 9 F Y L4205 Ortho dvc repair per 15 min By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y L4210 Orth dev repair/repl minor p By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y L4350 Ankle control ortho pre ots $ 105.73 $ 105.73 0 0% 0% 0% 9 9 9 9 9 9 F L4360 Pneumat walking boot pre cst $ 396.49 $ 396.49 0 0% 0% 0% 9 9 9 9 9 9 F L4361 Pneuma/vac walk boot pre ots $ 396.49 $ 396.49 0 0% 0% 0% 9 9 9 9 9 9 FL4370 Pneum full leg splnt pre ots $ 270.34 $ 270.34 0 0% 0% 0% 9 9 9 9 9 9 F L4386 Non-pneum walk boot pre cst $ 177.74 $ 177.74 0 0% 0% 0% 9 9 9 9 9 9 F L4387 Non-pneum walk boot pre ots $ 177.74 $ 177.74 0 0% 0% 0% 9 9 9 9 9 9 FL4392 Replace afo soft interface $ 25.94 $ 25.94 0 0% 0% 0% 9 9 9 9 9 9 F L4394 Replace foot drop spint $ 18.90 $ 18.90 0 0% 0% 0% 9 9 9 9 9 9 F L4396 Static or dynami afo pre cst $ 184.98 $ 184.98 0 0% 0% 0% 9 9 9 9 9 9 F L4397 Static or dynami afo pre ots $ 184.98 $ 184.98 0 0% 0% 0% 9 9 9 9 9 9 FL4398 Foot drop splint pre ots $ 88.71 $ 88.71 0 0% 0% 0% 9 9 9 9 9 9 F L4631 Afo, walk boot type, cus fab $ 1786.41 $ 1786.41 0 0% 0% 0% 9 9 9 9 9 9 F YL5000 Sho insert w arch toe filler $ 602.20 $ 602.20 0 0% 0% 0% 9 9 9 9 9 9 F Y Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 124
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L5010 Mold socket ank hgt w/ toe f $ 1451.03 $ 1451.03 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5020 Tibial tubercle hgt w/ toe f $ 2690.94 $ 2690.94 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5050 Ank symes mold sckt sach ft $ 3212.80 $ 3212.80 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5060 Symes met fr leath socket ar $ 4263.29 $ 4263.29 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5100 Molded socket shin sach foot $ 3330.09 $ 3330.09 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5105 Plast socket jts/thgh lacer $ 4699.89 $ 4699.89 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5150 Mold sckt ext knee shin sach $ 4859.63 $ 4859.63 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5160 Mold socket bent knee shin s $ 5928.90 $ 5928.90 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5200 Kne sing axis fric shin sach $ 4854.99 $ 4854.99 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5210 No knee/ankle joints w/ ft b $ 3856.19 $ 3856.19 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5220 No knee joint with artic ali $ 4383.26 $ 4383.26 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5230 Fem focal defic constant fri $ 5862.34 $ 5862.34 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5250 Hip canad sing axi cons fric $ 7628.65 $ 7628.65 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5270 Tilt table locking hip sing $ 8173.13 $ 8173.13 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5280 Hemipelvect canad sing axis $ 8091.40 $ 8091.40 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5301 Bk mold socket sach ft endo $ 3339.09 $ 3339.09 0 0% 0% 0% 9 9 9 9 9 9 F YL5312 Knee disart, sach ft, endo $ 5241.79 $ 5241.79 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5321 Ak open end sach $ 5158.33 $ 5158.33 0 0% 0% 0% 9 9 9 9 9 9 F YL5331 Hip disart canadian sach ft $ 7319.05 $ 7319.05 0 0% 0% 0% 9 9 9 9 9 9 F YL5341 Hemipelvectomy canadian sach $ 7639.09 $ 7639.09 0 0% 0% 0% 9 9 9 9 9 9 F YL5400 Postop dress & 1 cast chg bk $ 1593.86 $ 1593.86 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5410 Postop dsg bk ea add cast ch $ 612.68 $ 612.68 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5420 Postop dsg & 1 cast chg ak/d $ 1925.15 $ 1925.15 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5430 Postop dsg ak ea add cast ch $ 600.91 $ 600.91 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5450 Postop app non-wgt bear dsg $ 525.86 $ 525.86 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5460 Postop app non-wgt bear dsg $ 696.26 $ 696.26 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5500 Init bk ptb plaster direct $ 1530.74 $ 1530.74 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5505 Init ak ischal plstr direct $ 2073.01 $ 2073.01 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5510 Prep bk ptb plaster molded $ 1880.23 $ 1880.23 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5520 Perp bk ptb thermopls direct $ 1713.95 $ 1713.95 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5530 Prep bk ptb thermopls molded $ 2391.85 $ 2391.85 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5535 Prep bk ptb open end socket $ 2470.59 $ 2470.59 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5540 Prep bk ptb laminated socket $ 2637.04 $ 2637.04 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5560 Prep ak ischial plast molded $ 2576.26 $ 2576.26 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5570 Prep ak ischial direct form $ 2709.73 $ 2709.73 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5580 Prep ak ischial thermo mold $ 3104.16 $ 3104.16 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5585 Prep ak ischial open end $ 3440.48 $ 3440.48 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5590 Prep ak ischial laminated $ 3011.98 $ 3011.98 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5595 Hip disartic sach thermopls $ 5380.30 $ 5380.30 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5600 Hip disart sach laminat mold $ 6781.50 $ 6781.50 0 0% 0% 0% 9 9 9 9 9 9 F Y Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 125
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L5610 Above knee hydracadence $ 3165.76 $ 3165.76 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5611 Ak 4 bar link w/fric swing $ 2102.76 $ 2102.76 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5613 Ak 4 bar ling w/hydraul swig $ 2920.89 $ 2920.89 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5614 4-bar link above knee w/swng $ 1974.40 $ 1974.40 0 0% 0% 0% 9 9 9 9 9 9 F YL5616 Ak univ multiplex sys frict $ 1618.74 $ 1618.74 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5617 Ak/bk self-aligning unit ea $ 654.64 $ 654.64 0 0% 0% 0% 9 9 9 9 9 9 F YL5618 Test socket symes $ 372.33 $ 372.33 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5620 Test socket below knee $ 353.54 $ 353.54 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5622 Test socket knee disarticula $ 498.63 $ 498.63 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5624 Test socket above knee $ 448.91 $ 448.91 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5626 Test socket hip disarticulat $ 651.75 $ 651.75 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5628 Test socket hemipelvectomy $ 720.60 $ 720.60 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5629 Below knee acrylic socket $ 378.76 $ 378.76 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5630 Syme typ expandabl wall sckt $ 603.61 $ 603.61 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5631 Ak/knee disartic acrylic soc $ 523.68 $ 523.68 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5632 Symes type ptb brim design s $ 352.86 $ 352.86 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5634 Symes type poster opening so $ 420.36 $ 420.36 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5636 Symes type medial opening so $ 374.65 $ 374.65 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5637 Below knee total contact $ 354.85 $ 354.85 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5638 Below knee leather socket $ 657.51 $ 657.51 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5639 Below knee wood socket $ 1506.11 $ 1506.11 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5640 Knee disarticulat leather so $ 997.49 $ 997.49 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5642 Above knee leather socket $ 984.58 $ 984.58 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5643 Hip flex inner socket ext fr $ 2129.56 $ 2129.56 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5644 Above knee wood socket $ 785.99 $ 785.99 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5645 Bk flex inner socket ext fra $ 950.98 $ 950.98 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5646 Below knee cushion socket $ 699.05 $ 699.05 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5647 Below knee suction socket $ 948.08 $ 948.08 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5648 Above knee cushion socket $ 784.69 $ 784.69 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5649 Isch containmt/narrow m-l so $ 2398.68 $ 2398.68 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5650 Tot contact ak/knee disart s $ 684.00 $ 684.00 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5651 Ak flex inner socket ext fra $ 1431.33 $ 1431.33 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5652 Suction susp ak/knee disart $ 519.63 $ 519.63 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5653 Knee disart expand wall sock $ 852.53 $ 852.53 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5654 Socket insert symes $ 461.75 $ 461.75 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5655 Socket insert below knee $ 413.75 $ 413.75 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5656 Socket insert knee articulat $ 589.49 $ 589.49 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5658 Socket insert above knee $ 577.81 $ 577.81 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5661 Multi-durometer symes $ 725.30 $ 725.30 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5665 Multi-durometer below knee $ 610.26 $ 610.26 0 0% 0% 0% 9 9 9 9 9 9 F Y Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 126
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L5666 Below knee cuff suspension $ 84.66 $ 84.66 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5668 Bk molded distal cushion $ 133.73 $ 133.73 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5670 Bk molded supracondylar susp $ 353.00 $ 353.00 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5671 Bk/ak locking mechanism $ 790.45 $ 790.45 0 0% 0% 0% 9 9 9 9 9 9 F YL5672 Bk removable medial brim sus $ 384.60 $ 384.60 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5673 Socket insert w lock mech $ 853.74 $ 853.74 0 0% 0% 0% 9 9 9 9 9 9 F YL5676 Bk knee joints single axis p $ 503.14 $ 503.14 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5677 Bk knee joints polycentric p $ 640.49 $ 640.49 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5678 Bk joint covers pair $ 56.40 $ 56.40 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5679 Socket insert w/o lock mech $ 711.45 $ 711.45 0 0% 0% 0% 9 9 9 9 9 9 F YL5680 Bk thigh lacer non-molded $ 422.59 $ 422.59 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5681 Intl custm cong/latyp insert $ 1539.06 $ 1539.06 0 0% 0% 0% 9 9 9 9 9 9 F YL5682 Bk thigh lacer glut/ischia m $ 753.58 $ 753.58 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5683 Initial custom socket insert $ 1539.06 $ 1539.06 0 0% 0% 0% 9 9 9 9 9 9 F YL5684 Bk fork strap $ 76.49 $ 76.49 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5685 Below knee sus/seal sleeve $ 149.86 $ 149.86 0 0% 0% 0% 9 9 9 9 9 9 F YL5686 Bk back check $ 75.98 $ 75.98 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5688 Bk waist belt webbing $ 83.19 $ 83.19 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5690 Bk waist belt padded and lin $ 126.50 $ 126.50 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5692 Ak pelvic control belt light $ 185.86 $ 185.86 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5694 Ak pelvic control belt pad/l $ 287.18 $ 287.18 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5695 Ak sleeve susp neoprene/equa $ 194.38 $ 194.38 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5696 Ak/knee disartic pelvic join $ 294.03 $ 294.03 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5697 Ak/knee disartic pelvic band $ 127.58 $ 127.58 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5698 Ak/knee disartic silesian ba $ 149.03 $ 149.03 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5699 Shoulder harness $ 292.98 $ 292.98 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5700 Replace socket below knee $ 4351.95 $ 4351.95 0 0% 0% 0% 9 9 9 9 9 9 F YL5701 Replace socket above knee $ 5288.53 $ 5288.53 0 0% 0% 0% 9 9 9 9 9 9 F YL5702 Replace socket hip $ 6332.55 $ 6332.55 0 0% 0% 0% 9 9 9 9 9 9 F YL5703 Symes ankle w/o (sach) foot $ 2920.43 $ 2920.43 0 0% 0% 0% 9 9 9 9 9 9 F YL5704 Custom shape cover bk $ 726.80 $ 726.80 0 0% 0% 0% 9 9 9 9 9 9 F YL5705 Custom shape cover ak $ 1193.19 $ 1193.19 0 0% 0% 0% 9 9 9 9 9 9 F YL5706 Custom shape cvr knee disart $ 1182.60 $ 1182.60 0 0% 0% 0% 9 9 9 9 9 9 F YL5707 Custom shape cvr hip disart $ 1681.13 $ 1681.13 0 0% 0% 0% 9 9 9 9 9 9 F YL5710 Kne-shin exo sng axi mnl loc $ 542.30 $ 542.30 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5711 Knee-shin exo mnl lock ultra $ 734.15 $ 734.15 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5712 Knee-shin exo frict swg & st $ 659.06 $ 659.06 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5714 Knee-shin exo variable frict $ 498.53 $ 498.53 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5716 Knee-shin exo mech stance ph $ 868.68 $ 868.68 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5718 Knee-shin exo frct swg & sta $ 1085.75 $ 1085.75 0 0% 0% 0% 9 9 9 9 9 9 F Y Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 127
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L5722 Knee-shin pneum swg frct exo $ 1264.20 $ 1264.20 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5724 Knee-shin exo fluid swing ph $ 1914.26 $ 1914.26 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5726 Knee-shin ext jnts fld swg e $ 2316.70 $ 2316.70 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5728 Knee-shin fluid swg & stance $ 3083.20 $ 3083.20 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5780 Knee-shin pneum/hydra pneum $ 1364.58 $ 1364.58 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5781 Lower limb pros vacuum pump $ 4681.54 $ 4681.54 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5782 Hd low limb pros vacuum pump $ 4935.40 $ 4935.40 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5785 Exoskeletal bk ultralt mater $ 739.74 $ 739.74 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5790 Exoskeletal ak ultra-light m $ 890.69 $ 890.69 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5795 Exoskel hip ultra-light mate $ 1279.69 $ 1279.69 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5810 Endoskel knee-shin mnl lock $ 662.64 $ 662.64 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5811 Endo knee-shin mnl lck ultra $ 869.24 $ 869.24 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5812 Endo knee-shin frct swg & st $ 752.28 $ 752.28 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5814 Endo knee-shin hydral swg ph $ 4345.41 $ 4345.41 0 0% 0% 0% 9 9 9 9 9 9 F YL5816 Endo knee-shin polyc mch sta $ 1013.61 $ 1013.61 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5818 Endo knee-shin frct swg & st $ 1144.58 $ 1144.58 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5822 Endo knee-shin pneum swg frc $ 2029.61 $ 2029.61 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5824 Endo knee-shin fluid swing p $ 1827.79 $ 1827.79 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5826 Miniature knee joint $ 3795.73 $ 3795.73 0 0% 0% 0% 9 9 9 9 9 9 F YL5828 Endo knee-shin fluid swg/sta $ 3365.73 $ 3365.73 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5830 Endo knee-shin pneum/swg pha $ 2934.66 $ 2934.66 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5840 Multi-axial knee/shin system $ 4810.55 $ 4810.55 0 0% 0% 0% 9 9 9 9 9 9 F YL5845 Knee-shin sys stance flexion $ 2097.15 $ 2097.15 0 0% 0% 0% 9 9 9 9 9 9 F YL5848 Knee-shin sys hydraul stance $ 1258.19 $ 1258.19 0 0% 0% 0% 9 9 9 9 9 9 F YL5850 Endo ak/hip knee extens assi $ 152.48 $ 152.48 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5855 Mech hip extension assist $ 490.78 $ 490.78 0 0% 0% 0% 9 9 9 9 9 9 F YL5856 Elec knee-shin swing/stance $ 28087.95 $ 28087.95 0 0% 0% 0% 9 9 9 9 9 9 F YL5857 Elec knee-shin swing only $ 9966.69 $ 9966.69 0 0% 0% 0% 9 9 9 9 9 9 F YL5858 Stance phase only $ 21745.54 $ 21745.54 0 0% 0% 0% 9 9 9 9 9 9 F YL5859 Knee-shin pro flex/ext cont $ 17990.24 $ 17990.24 0 0% 0% 0% 9 9 9 9 9 9 F YL5910 Endo below knee alignable sy $ 431.66 $ 431.66 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5920 Endo ak/hip alignable system $ 632.39 $ 632.39 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5925 Above knee manual lock $ 519.81 $ 519.81 0 0% 0% 0% 9 9 9 9 9 9 F YL5930 High activity knee frame $ 3938.28 $ 3938.28 0 0% 0% 0% 9 9 9 9 9 9 F YL5940 Endo bk ultra-light material $ 743.31 $ 743.31 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5950 Endo ak ultra-light material $ 1068.43 $ 1068.43 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5960 Endo hip ultra-light materia $ 1221.16 $ 1221.16 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5961 Endo poly hip, pneu/hyd/rot $ 5782.25 $ 5782.25 0 0% 0% 0% 9 9 9 9 9 9 F YL5962 Below knee flex cover system $ 934.09 $ 934.09 0 0% 0% 0% 9 9 9 9 9 9 F YL5964 Above knee flex cover system $ 1344.69 $ 1344.69 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 128
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L5966 Hip flexible cover system $ 1743.33 $ 1743.33 0 0% 0% 0% 9 9 9 9 9 9 F YL5968 Multiaxial ankle w dorsiflex $ 4251.86 $ 4251.86 0 0% 0% 0% 9 9 9 9 9 9 F YL5969 Ak/ft power asst incl motors $ 17724.38 $ 17724.38 0 0% 0% 0% 9 9 9 9 9 9 F YL5970 Foot external keel sach foot $ 292.36 $ 292.36 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5971 Sach foot, replacement $ 292.36 $ 292.36 0 0% 0% 0% 9 9 9 9 9 9 F YL5972 Flexible keel foot $ 467.24 $ 467.24 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5973 Ank-foot sys dors-plant flex Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XL5974 Foot single axis ankle/foot $ 370.31 $ 370.31 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5975 Combo ankle/foot prosthesis $ 542.41 $ 542.41 0 0% 0% 0% 9 9 9 9 9 9 F YL5976 Energy storing foot $ 746.15 $ 746.15 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5978 Ft prosth multiaxial ankl/ft $ 421.70 $ 421.70 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5979 Multi-axial ankle/ft prosth $ 3592.56 $ 3592.56 0 0% 0% 0% 9 9 9 9 9 9 F YL5980 Flex foot system $ 4831.80 $ 4831.80 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5981 Flex-walk sys low ext prosth $ 3904.09 $ 3904.09 0 0% 0% 0% 9 9 9 9 9 9 F YL5982 Exoskeletal axial rotation u $ 910.78 $ 910.78 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5984 Endoskeletal axial rotation $ 861.03 $ 861.03 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5985 Lwr ext dynamic prosth pylon $ 330.43 $ 330.43 0 0% 0% 0% 9 9 9 9 9 9 F YL5986 Multi-axial rotation unit $ 911.31 $ 911.31 0 0% 0% 0% 9 9 9 9 9 9 F Y YL5987 Shank ft w vert load pylon $ 8417.00 $ 8417.00 0 0% 0% 0% 9 9 9 9 9 9 F YL5988 Vertical shock reducing pylo $ 2337.41 $ 2337.41 0 0% 0% 0% 9 9 9 9 9 9 F YL5990 User adjustable heel height $ 2122.73 $ 2122.73 0 0% 0% 0% 9 9 9 9 9 9 F YL5999 Lowr extremity prosthes nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y YL6000 Part hand thumb rem $ 2111.48 $ 2111.48 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6010 Part hand little/ring $ 2349.73 $ 2349.73 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6020 Part hand no fingers $ 2190.75 $ 2190.75 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6026 Part hand myo exclu term dev $ 5204.94 $ 5204.94 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6050 Wrst mld sck flx hng tri pad $ 2587.63 $ 2587.63 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6055 Wrst mold sock w/exp interfa $ 3863.74 $ 3863.74 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6100 Elb mold sock flex hinge pad $ 2787.21 $ 2787.21 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6110 Elbow mold sock suspension t $ 2842.78 $ 2842.78 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6120 Elbow mold doub splt soc ste $ 3574.70 $ 3574.70 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6130 Elbow stump activated lock h $ 4113.85 $ 4113.85 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6200 Elbow mold outsid lock hinge $ 4221.91 $ 4221.91 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6205 Elbow molded w/ expand inter $ 5289.45 $ 5289.45 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6250 Elbow inter loc elbow forarm $ 3937.23 $ 3937.23 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6300 Shlder disart int lock elbow $ 5538.21 $ 5538.21 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6310 Shoulder passive restor comp $ 4597.16 $ 4597.16 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6320 Shoulder passive restor cap $ 2036.80 $ 2036.80 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6350 Thoracic intern lock elbow $ 6224.56 $ 6224.56 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6360 Thoracic passive restor comp $ 5061.71 $ 5061.71 0 0% 0% 0% 9 9 9 9 9 9 F Y Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 129
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L6370 Thoracic passive restor cap $ 2420.76 $ 2420.76 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6380 Postop dsg cast chg wrst/elb $ 1629.83 $ 1629.83 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6382 Postop dsg cast chg elb dis/ $ 1918.68 $ 1918.68 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6384 Postop dsg cast chg shlder/t $ 2429.05 $ 2429.05 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6386 Postop ea cast chg & realign $ 550.18 $ 550.18 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6388 Postop applicat rigid dsg on $ 604.71 $ 604.71 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6400 Below elbow prosth tiss shap $ 3085.69 $ 3085.69 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6450 Elb disart prosth tiss shap $ 4188.78 $ 4188.78 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6500 Above elbow prosth tiss shap $ 4236.65 $ 4236.65 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6550 Shldr disar prosth tiss shap $ 5667.44 $ 5667.44 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6570 Scap thorac prosth tiss shap $ 6317.56 $ 6317.56 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6580 Wrist/elbow bowden cable mol $ 2146.95 $ 2146.95 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6582 Wrist/elbow bowden cbl dir f $ 1706.11 $ 1706.11 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6584 Elbow fair lead cable molded $ 2898.80 $ 2898.80 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6586 Elbow fair lead cable dir fo $ 2477.45 $ 2477.45 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6588 Shdr fair lead cable molded $ 4194.84 $ 4194.84 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6590 Shdr fair lead cable direct $ 3865.20 $ 3865.20 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6600 Polycentric hinge pair $ 242.24 $ 242.24 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6605 Single pivot hinge pair $ 228.54 $ 228.54 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6610 Flexible metal hinge pair $ 208.43 $ 208.43 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6611 Additional switch, ext power $ 481.75 $ 481.75 0 0% 0% 0% 9 9 9 9 9 9 F YL6615 Disconnect locking wrist uni $ 254.73 $ 254.73 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6616 Disconnect insert locking wr $ 92.83 $ 92.83 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6620 Flexion/extension wrist unit $ 398.96 $ 398.96 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6621 Flex/ext wrist w/wo friction $ 2676.25 $ 2676.25 0 0% 0% 0% 9 9 9 9 9 9 F YL6623 Spring-ass rot wrst w/ latch $ 858.26 $ 858.26 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6624 Flex/ext/rotation wrist unit $ 4406.53 $ 4406.53 0 0% 0% 0% 9 9 9 9 9 9 F YL6625 Rotation wrst w/ cable lock $ 734.01 $ 734.01 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6628 Quick disconn hook adapter o $ 689.31 $ 689.31 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6629 Lamination collar w/ couplin $ 174.70 $ 174.70 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6630 Stainless steel any wrist $ 256.86 $ 256.86 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6632 Latex suspension sleeve each $ 77.44 $ 77.44 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6635 Lift assist for elbow $ 225.20 $ 225.20 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6637 Nudge control elbow lock $ 517.86 $ 517.86 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6638 Elec lock on manual pw elbow $ 2925.98 $ 2925.98 0 0% 0% 0% 9 9 9 9 9 9 F YL6640 Shoulder abduction joint pai $ 410.60 $ 410.60 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6641 Excursion amplifier pulley t $ 204.68 $ 204.68 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6642 Excursion amplifier lever ty $ 276.81 $ 276.81 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6645 Shoulder flexion-abduction j $ 472.50 $ 472.50 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6646 Multipo locking shoulder jnt $ 3690.33 $ 3690.33 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 130
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L6647 Shoulder lock actuator $ 607.51 $ 607.51 0 0% 0% 0% 9 9 9 9 9 9 F YL6648 Ext pwrd shlder lock/unlock $ 3806.04 $ 3806.04 0 0% 0% 0% 9 9 9 9 9 9 F YL6650 Shoulder universal joint $ 407.50 $ 407.50 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6655 Standard control cable extra $ 119.38 $ 119.38 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6660 Heavy duty control cable $ 126.36 $ 126.36 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6665 Teflon or equal cable lining $ 58.76 $ 58.76 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6670 Hook to hand cable adapter $ 60.76 $ 60.76 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6672 Harness chest/shlder saddle $ 230.73 $ 230.73 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6675 Harness figure of 8 sing con $ 143.14 $ 143.14 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6676 Harness figure of 8 dual con $ 175.96 $ 175.96 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6677 Ue triple control harness $ 347.09 $ 347.09 0 0% 0% 0% 9 9 9 9 9 9 F YL6680 Test sock wrist disart/bel e $ 283.54 $ 283.54 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6682 Test sock elbw disart/above $ 360.74 $ 360.74 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6684 Test socket shldr disart/tho $ 552.73 $ 552.73 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6686 Suction socket $ 792.43 $ 792.43 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6687 Frame typ socket bel elbow/w $ 687.48 $ 687.48 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6688 Frame typ sock above elb/dis $ 841.84 $ 841.84 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6689 Frame typ socket shoulder di $ 1030.35 $ 1030.35 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6690 Frame typ sock interscap-tho $ 1092.71 $ 1092.71 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6691 Removable insert each $ 472.74 $ 472.74 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6692 Silicone gel insert or equal $ 666.53 $ 666.53 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6693 Lockingelbow forearm cntrbal $ 3321.76 $ 3321.76 0 0% 0% 0% 9 9 9 9 9 9 F YL6694 Elbow socket ins use w/lock $ 853.74 $ 853.74 0 0% 0% 0% 9 9 9 9 9 9 F YL6695 Elbow socket ins use w/o lck $ 711.45 $ 711.45 0 0% 0% 0% 9 9 9 9 9 9 F YL6696 Cus elbo skt in for con/atyp $ 1539.06 $ 1539.06 0 0% 0% 0% 9 9 9 9 9 9 F YL6697 Cus elbo skt in not con/atyp $ 1539.06 $ 1539.06 0 0% 0% 0% 9 9 9 9 9 9 F YL6698 Below/above elbow lock mech $ 790.45 $ 790.45 0 0% 0% 0% 9 9 9 9 9 9 F YL6703 Term dev, passive hand mitt $ 393.50 $ 393.50 0 0% 0% 0% 9 9 9 9 9 9 F YL6704 Term dev, sport/rec/work att $ 746.90 $ 746.90 0 0% 0% 0% 9 9 9 9 9 9 F YL6706 Term dev mech hook vol open $ 475.10 $ 475.10 0 0% 0% 0% 9 9 9 9 9 9 F YL6707 Term dev mech hook vol close $ 1676.13 $ 1676.13 0 0% 0% 0% 9 9 9 9 9 9 F YL6708 Term dev mech hand vol open $ 1169.59 $ 1169.59 0 0% 0% 0% 9 9 9 9 9 9 F YL6709 Term dev mech hand vol close $ 1677.20 $ 1677.20 0 0% 0% 0% 9 9 9 9 9 9 F YL6711 Ped term dev, hook, vol open Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L6712 Ped term dev, hook, vol clos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L6713 Ped term dev, hand, vol open Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L6714 Ped term dev, hand, vol clos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L6715 Term device, multi art digit $ 3693.99 $ 3693.99 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6721 Hook/hand, hvy dty, vol open $ 2751.90 $ 2751.90 0 0% 0% 0% 9 9 9 9 9 9 F YL6722 Hook/hand, hvy dty, vol clos $ 2372.35 $ 2372.35 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 131
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L6805 Term dev modifier wrist unit $ 504.10 $ 504.10 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6810 Term dev precision pinch dev $ 238.54 $ 238.54 0 0% 0% 0% 9 9 9 9 9 9 F YL6880 Elec hand ind art digits $ 27955.34 $ 27955.34 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6881 Term dev auto grasp feature $ 4783.44 $ 4783.44 0 0% 0% 0% 9 9 9 9 9 9 F YL6882 Microprocessor control uplmb $ 3628.45 $ 3628.45 0 0% 0% 0% 9 9 9 9 9 9 F YL6883 Replc sockt below e/w disa $ 2442.40 $ 2442.40 0 0% 0% 0% 9 9 9 9 9 9 F YL6884 Replc sockt above elbow disa $ 3337.53 $ 3337.53 0 0% 0% 0% 9 9 9 9 9 9 F YL6885 Replc sockt shldr dis/interc $ 5061.71 $ 5061.71 0 0% 0% 0% 9 9 9 9 9 9 F YL6890 Prefab glove for term device $ 221.33 $ 221.33 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6895 Custom glove for term device $ 738.91 $ 738.91 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6900 Hand restorat thumb/1 finger $ 2314.26 $ 2314.26 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6905 Hand restoration multiple fi $ 2333.20 $ 2333.20 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6910 Hand restoration no fingers $ 1914.95 $ 1914.95 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6915 Hand restoration replacmnt g $ 865.43 $ 865.43 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6920 Wrist disarticul switch ctrl $ 9274.26 $ 9274.26 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6925 Wrist disart myoelectronic c $ 10142.74 $ 10142.74 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6930 Below elbow switch control $ 10062.46 $ 10062.46 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6935 Below elbow myoelectronic ct $ 10634.60 $ 10634.60 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6940 Elbow disarticulation switch $ 12047.64 $ 12047.64 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6945 Elbow disart myoelectronic c $ 13348.70 $ 13348.70 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6950 Above elbow switch control $ 12583.38 $ 12583.38 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6955 Above elbow myoelectronic ct $ 14234.99 $ 14234.99 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6960 Shldr disartic switch contro $ 15503.53 $ 15503.53 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6965 Shldr disartic myoelectronic $ 17507.85 $ 17507.85 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6970 Interscapular-thor switch ct $ 17383.18 $ 17383.18 0 0% 0% 0% 9 9 9 9 9 9 F Y YL6975 Interscap-thor myoelectronic $ 19046.44 $ 19046.44 0 0% 0% 0% 9 9 9 9 9 9 F Y YL7007 Adult electric hand $ 4158.20 $ 4158.20 0 0% 0% 0% 9 9 9 9 9 9 F YL7008 Pediatric electric hand Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X YL7009 Adult electric hook $ 4497.10 $ 4497.10 0 0% 0% 0% 9 9 9 9 9 9 F YL7040 Prehensile actuator $ 3589.91 $ 3589.91 0 0% 0% 0% 9 9 9 9 9 9 F Y YL7045 Pediatric electric hook Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X YL7170 Electronic elbow hosmer swit $ 7277.60 $ 7277.60 0 0% 0% 0% 9 9 9 9 9 9 F Y YL7180 Electronic elbow sequential $ 43666.93 $ 43666.93 0 0% 0% 0% 9 9 9 9 9 9 F Y YL7181 Electronic elbo simultaneous $ 46881.51 $ 46881.51 0 0% 0% 0% 9 9 9 9 9 9 F YL7185 Electron elbow adolescent sw $ 7644.20 $ 7644.20 0 0% 0% 0% 9 9 9 9 9 9 F YL7186 Electron elbow child switch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X YL7190 Elbow adolescent myoelectron $ 9496.46 $ 9496.46 0 0% 0% 0% 9 9 9 9 9 9 F Y YL7191 Elbow child myoelectronic ct Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X YL7259 Electronic wrist rotator any $ 4959.86 $ 4959.86 0 0% 0% 0% 9 9 9 9 9 9 F Y YL7360 Six volt bat otto bock/eq ea $ 316.33 $ 316.33 0 0% 0% 0% 9 9 9 9 9 9 F Y Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 132
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L7362 Battery chrgr six volt otto $ 327.89 $ 327.89 0 0% 0% 0% 9 9 9 9 9 9 F Y YL7364 Twelve volt battery utah/equ $ 621.08 $ 621.08 0 0% 0% 0% 9 9 9 9 9 9 F Y YL7366 Battery chrgr 12 volt utah/e $ 802.76 $ 802.76 0 0% 0% 0% 9 9 9 9 9 9 F Y YL7367 Replacemnt lithium ionbatter $ 455.54 $ 455.54 0 0% 0% 0% 9 9 9 9 9 9 F Y L7368 Lithium ion battery charger $ 590.51 $ 590.51 0 0% 0% 0% 9 9 9 9 9 9 F Y L7400 Add ue prost be/wd, ultlite $ 358.61 $ 358.61 0 0% 0% 0% 9 9 9 9 9 9 F Y L7401 Add ue prost a/e ultlite mat $ 401.46 $ 401.46 0 0% 0% 0% 9 9 9 9 9 9 F Y L7402 Add ue prost s/d ultlite mat $ 433.55 $ 433.55 0 0% 0% 0% 9 9 9 9 9 9 F Y L7403 Add ue prost b/e acrylic $ 430.88 $ 430.88 0 0% 0% 0% 9 9 9 9 9 9 F Y L7404 Add ue prost a/e acrylic $ 650.34 $ 650.34 0 0% 0% 0% 9 9 9 9 9 9 F Y L7405 Add ue prost s/d acrylic $ 850.55 $ 850.55 0 0% 0% 0% 9 9 9 9 9 9 F Y L7499 Upper extremity prosthes nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y YL7510 Prosthetic device repair rep By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y L7520 Repair prosthesis per 15 min By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y L7600 Prosthetic donning sleeve By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y L7900 Male vacuum erection system $ 633.55 $ 633.55 0 0% 0% 0% 9 9 9 9 9 9 F L7902 Tension ring, vac erect dev $ 23.30 $ 23.30 0 0% 0% 0% 9 9 9 9 9 9 F Y YL8000 Mastectomy bra $ 49.20 $ 49.20 0 0% 0% 0% 9 9 9 9 9 9 F L8001 Breast prosthesis bra & form $ 146.76 $ 146.76 0 0% 0% 0% 9 9 9 9 9 9 F L8002 Brst prsth bra & bilat form $ 193.03 $ 193.03 0 0% 0% 0% 9 9 9 9 9 9 F L8010 Mastectomy sleeve $ 65.68 $ 65.68 0 0% 0% 0% 9 9 9 9 9 9 F L8015 Ext breastprosthesis garment $ 72.84 $ 72.84 0 0% 0% 0% 9 9 9 9 9 9 F YL8020 Mastectomy form $ 287.15 $ 287.15 0 0% 0% 0% 9 9 9 9 9 9 F L8030 Breast prosthes w/o adhesive $ 376.01 $ 376.01 0 0% 0% 0% 9 9 9 9 9 9 F L8031 Breast prosthesis w adhesive $ 376.01 $ 376.01 0 0% 0% 0% 9 9 9 9 9 9 F YL8032 Reusable nipple prosthesis $ 47.59 $ 47.59 0 0% 0% 0% 9 9 9 9 9 9 F YL8035 Custom breast prosthesis $ 4286.64 $ 4286.64 0 0% 0% 0% 9 9 9 9 9 9 F YL8039 Breast prosthesis nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YL8040 Nasal prosthesis $ 2925.30 $ 2925.30 0 0% 0% 0% 9 9 9 9 9 9 F L8041 Midfacial prosthesis $ 3526.18 $ 3526.18 0 0% 0% 0% 9 9 9 9 9 9 F L8042 Orbital prosthesis $ 3961.96 $ 3961.96 0 0% 0% 0% 9 9 9 9 9 9 F L8043 Upper facial prosthesis $ 4437.40 $ 4437.40 0 0% 0% 0% 9 9 9 9 9 9 F L8044 Hemi-facial prosthesis $ 4912.84 $ 4912.84 0 0% 0% 0% 9 9 9 9 9 9 F L8045 Auricular prosthesis $ 3083.99 $ 3083.99 0 0% 0% 0% 9 9 9 9 9 9 F L8046 Partial facial prosthesis $ 3169.55 $ 3169.55 0 0% 0% 0% 9 9 9 9 9 9 F L8047 Nasal septal prosthesis $ 1624.39 $ 1624.39 0 0% 0% 0% 9 9 9 9 9 9 F L8048 Unspec maxillofacial prosth By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L8049 Repair maxillofacial prosth By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L8300 Truss single w/ standard pad $ 124.91 $ 124.91 0 0% 0% 0% 9 9 9 9 9 9 F L8310 Truss double w/ standard pad $ 174.96 $ 174.96 0 0% 0% 0% 9 9 9 9 9 9 F
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 133
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L8320 Truss addition to std pad wa $ 66.61 $ 66.61 0 0% 0% 0% 9 9 9 9 9 9 F L8330 Truss add to std pad scrotal $ 58.84 $ 58.84 0 0% 0% 0% 9 9 9 9 9 9 F L8400 Sheath below knee $ 22.11 $ 22.11 0 0% 0% 0% 9 9 9 9 9 9 F L8410 Sheath above knee $ 31.53 $ 31.53 0 0% 0% 0% 9 9 9 9 9 9 F L8415 Sheath upper limb $ 32.36 $ 32.36 0 0% 0% 0% 9 9 9 9 9 9 F L8417 Pros sheath/sock w gel cushn $ 87.99 $ 87.99 0 0% 0% 0% 9 9 9 9 9 9 F L8420 Prosthetic sock multi ply bk $ 23.91 $ 23.91 0 0% 0% 0% 9 9 9 9 9 9 F L8430 Prosthetic sock multi ply ak $ 27.31 $ 27.31 0 0% 0% 0% 9 9 9 9 9 9 F L8435 Pros sock multi ply upper lm $ 33.41 $ 33.41 0 0% 0% 0% 9 9 9 9 9 9 F L8440 Shrinker below knee $ 49.85 $ 49.85 0 0% 0% 0% 9 9 9 9 9 9 F L8460 Shrinker above knee $ 104.01 $ 104.01 0 0% 0% 0% 9 9 9 9 9 9 F L8465 Shrinker upper limb $ 58.14 $ 58.14 0 0% 0% 0% 9 9 9 9 9 9 F L8470 Pros sock single ply bk $ 7.95 $ 7.95 0 0% 0% 0% 9 9 9 9 9 9 F L8480 Pros sock single ply ak $ 14.63 $ 14.63 0 0% 0% 0% 9 9 9 9 9 9 F L8485 Pros sock single ply upper l $ 17.14 $ 17.14 0 0% 0% 0% 9 9 9 9 9 9 F L8499 Unlisted misc prosthetic ser By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L8500 Artificial larynx $ 930.49 $ 930.49 0 0% 0% 0% 9 9 9 9 9 9 F L8501 Tracheostomy speaking valve $ 143.98 $ 143.98 0 0% 0% 0% 9 9 9 9 9 9 F L8505 Artificial larynx, accessory By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N L8507 Trach-esoph voice pros pt in $ 49.01 $ 49.01 0 0% 0% 0% 9 9 9 9 9 9 F L8509 Trach-esoph voice pros md in $ 127.79 $ 127.79 0 0% 0% 0% 9 9 9 9 9 9 F L8510 Voice amplifier $ 295.65 $ 295.65 0 0% 0% 0% 9 9 9 9 9 9 F Y L8511 Indwelling trach insert $ 85.10 $ 85.10 0 0% 0% 0% 9 9 9 9 9 9 F L8512 Gel cap for trach voice pros $ 2.54 $ 2.54 0 0% 0% 0% 9 9 9 9 9 9 F L8513 Trach pros cleaning device $ 6.09 $ 6.09 0 0% 0% 0% 9 9 9 9 9 9 F L8514 Repl trach puncture dilator $ 110.33 $ 110.33 0 0% 0% 0% 9 9 9 9 9 9 F L8515 Gel cap app device for trach $ 73.85 $ 73.85 0 0% 0% 0% 9 9 9 9 9 9 F L8600 Implant breast silicone/eq $ 869.20 $ 869.20 0 0% 0% 0% 9 9 9 9 9 9 F Y L8603 Collagen imp urinary 2.5 ml $ 525.01 $ 525.01 0 0% 0% 0% 9 9 9 9 9 9 F Y L8604 Dextranomer/hyaluronic acid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YL8605 Inj bulking agent anal canal $ 838.03 $ 838.03 0 0% 0% 0% 9 9 9 9 9 9 F YL8606 Synthetic implnt urinary 1ml $ 266.23 $ 266.23 0 0% 0% 0% 9 9 9 9 9 9 F Y L8609 Artificial cornea Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L8610 Ocular implant $ 790.66 $ 790.66 0 0% 0% 0% 9 9 9 9 9 9 F Y L8612 Aqueous shunt prosthesis $ 863.19 $ 863.19 0 0% 0% 0% 9 9 9 9 9 9 F Y L8613 Ossicular implant $ 358.75 $ 358.75 0 0% 0% 0% 9 9 9 9 9 9 F Y L8614 Cochlear device Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y L8615 Coch implant headset replace $ 527.71 $ 527.71 0 0% 0% 0% 9 9 9 9 9 9 F YL8616 Coch implant microphone repl $ 122.91 $ 122.91 0 0% 0% 0% 9 9 9 9 9 9 F YL8617 Coch implant trans coil repl $ 107.35 $ 107.35 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 134
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
L8618 Coch implant tran cable repl $ 30.69 $ 30.69 0 0% 0% 0% 9 9 9 9 9 9 F YL8619 Coch imp ext proc/contr rplc $ 9611.90 $ 9611.90 0 0% 0% 0% 9 9 9 9 9 9 F YL8621 Repl zinc air battery $ 0.73 $ 0.73 0 0% 0% 0% 9 9 9 9 9 9 F YL8622 Repl alkaline battery $ 0.38 $ 0.38 0 0% 0% 0% 9 9 9 9 9 9 F YL8623 Lith ion batt cid,non-earlvl $ 75.68 $ 75.68 0 0% 0% 0% 9 9 9 9 9 9 F YL8624 Lith ion batt cid, ear level $ 188.69 $ 188.69 0 0% 0% 0% 9 9 9 9 9 9 F YL8627 Cid ext speech process repl $ 8108.26 $ 8108.26 0 0% 0% 0% 9 9 9 9 9 9 F YL8628 Cid ext controller repl $ 1503.63 $ 1503.63 0 0% 0% 0% 9 9 9 9 9 9 F YL8629 Cid transmit coil and cable $ 209.50 $ 209.50 0 0% 0% 0% 9 9 9 9 9 9 F YL8630 Metacarpophalangeal implant $ 401.54 $ 401.54 0 0% 0% 0% 9 9 9 9 9 9 F Y L8631 Mcp joint repl 2 pc or more $ 2540.06 $ 2540.06 0 0% 0% 0% 9 9 9 9 9 9 F Y L8641 Metatarsal joint implant $ 556.28 $ 556.28 0 0% 0% 0% 9 9 9 9 9 9 F Y L8642 Hallux implant $ 366.08 $ 366.08 0 0% 0% 0% 9 9 9 9 9 9 F Y L8658 Interphalangeal joint spacer $ 485.01 $ 485.01 0 0% 0% 0% 9 9 9 9 9 9 F Y L8659 Interphalangeal joint repl $ 2257.83 $ 2257.83 0 0% 0% 0% 9 9 9 9 9 9 F Y L8670 Vascular graft, synthetic $ 663.45 $ 663.45 0 0% 0% 0% 9 9 9 9 9 9 F Y L8679 Imp neurosti pls gn any type Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XL8680 Implt neurostim elctr each $ 565.30 $ 565.30 0 0% 0% 0% 9 9 9 9 9 9 F YL8681 Pt prgrm for implt neurostim $ 1285.78 $ 1285.78 0 0% 0% 0% 9 9 9 9 9 9 F YL8682 Implt neurostim radiofq rec $ 7246.18 $ 7246.18 0 0% 0% 0% 9 9 9 9 9 9 F YL8683 Radiofq trsmtr for implt neu $ 6378.28 $ 6378.28 0 0% 0% 0% 9 9 9 9 9 9 F YL8684 Radiof trsmtr implt scrl neu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X L8685 Implt nrostm pls gen sng rec $ 16092.97 $ 16092.97 0 0% 0% 0% 9 9 9 9 9 9 F YL8686 Implt nrostm pls gen sng non $ 10268.60 $ 10268.60 0 0% 0% 0% 9 9 9 9 9 9 F YL8687 Implt nrostm pls gen dua rec $ 20943.39 $ 20943.39 0 0% 0% 0% 9 9 9 9 9 9 F YL8688 Implt nrostm pls gen dua non $ 13363.57 $ 13363.57 0 0% 0% 0% 9 9 9 9 9 9 F YL8689 External recharg sys intern $ 2018.26 $ 2018.26 0 0% 0% 0% 9 9 9 9 9 9 F YL8690 Aud osseo dev, int/ext comp $ 5566.13 $ 5566.13 0 0% 0% 0% 9 9 9 9 9 9 F YL8691 Osseointegrated snd proc rpl $ 3119.99 $ 3119.99 0 0% 0% 0% 9 9 9 9 9 9 F YL8692 Non-osseointegrated snd proc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XL8693 Aud osseo dev, abutment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XL8695 External recharg sys extern $ 19.48 $ 19.48 0 0% 0% 0% 9 9 9 9 9 9 F YL8696 Ext antenna phren nerve stim Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XL8699 Prosthetic implant nos Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B L9900 O&p supply/accessory/service By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N M0075 Cellular therapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X M0076 Prolotherapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X M0100 Intragastric hypothermia Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X M0300 Iv chelationtherapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X M0301 Fabric wrapping of aneurysm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 135
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
P2028 Cephalin floculation test By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P2029 Congo red blood test By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P2031 Hair analysis Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X P2033 Blood thymol turbidity By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P2038 Blood mucoprotein $ 9.59 $ 9.59 0 0% 0% 0% 9 9 9 9 9 9 L P3000 Screen pap by tech w md supv $ 20.13 $ 20.13 0 0% 0% 0% 9 9 9 9 9 9 L P3001 Screening pap smear by phys $ 55.78 $ 55.78 0 0% 0% 0% 0 0 0 0 0 0 R P7001 Culture bacterial urine Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X P9010 Whole blood for transfusion By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9011 Blood split unit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9012 Cryoprecipitate each unit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9016 Rbc leukocytes reduced By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9017 Plasma 1 donor frz w/in 8 hr By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9019 Platelets, each unit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9020 Plaelet rich plasma unit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9021 Red blood cells unit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9022 Washed red blood cells unit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9023 Frozen plasma, pooled, sd By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9031 Platelets leukocytes reduced By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9032 Platelets, irradiated By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9033 Platelets leukoreduced irrad By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9034 Platelets, pheresis By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9035 Platelet pheres leukoreduced By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9036 Platelet pheresis irradiated By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9037 Plate pheres leukoredu irrad By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9038 Rbc irradiated By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9039 Rbc deglycerolized By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9040 Rbc leukoreduced irradiated By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9041 Albumin (human),5%, 50ml $ 10.33 $ 10.33 0 0% 0% 0% 9 9 9 9 9 9 D P9043 Plasma protein fract,5%,50ml $ 24.33 $ 24.33 0 0% 0% 0% 9 9 9 9 9 9 D P9044 Cryoprecipitatereducedplasma By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9045 Albumin (human), 5%, 250 ml $ 51.66 $ 51.66 0 0% 0% 0% 9 9 9 9 9 9 D P9046 Albumin (human), 25%, 20 ml $ 19.44 $ 19.44 0 0% 0% 0% 9 9 9 9 9 9 D P9047 Albumin (human), 25%, 50ml $ 48.60 $ 48.60 0 0% 0% 0% 9 9 9 9 9 9 D P9048 Plasmaprotein fract,5%,250ml $ 45.33 $ 45.33 0 0% 0% 0% 9 9 9 9 9 9 D P9050 Granulocytes, pheresis unit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9051 Blood, l/r, cmv-neg By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9052 Platelets, hla-m, l/r, unit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9053 Plt, pher, l/r cmv-neg, irr By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9054 Blood, l/r, froz/degly/wash By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 136
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
P9055 Plt, aph/pher, l/r, cmv-neg By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9056 Blood, l/r, irradiated By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9057 Rbc, frz/deg/wsh, l/r, irrad By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9058 Rbc, l/r, cmv-neg, irrad By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9059 Plasma, frz between 8-24hour By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9060 Fr frz plasma donor retested By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N P9603 One-way allow prorated miles $ 1.03 $ 1.03 0 0% 0% 0% 9 9 9 9 9 9 F P9604 One-way allow prorated trip Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X P9612 Catheterize for urine spec $ 4.20 $ 4.20 0 0% 0% 0% 9 9 9 9 9 9 L P9615 Urine specimen collect mult $ 4.20 $ 4.20 0 0% 0% 0% 9 9 9 9 9 9 L Q0035 Cardiokymography Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X Q0035-26 Cardiokymography Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X Q0035-TC Cardiokymography Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X Q0081 Infusion ther other than che Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O Q0083 Chemo by other than infusion Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O Q0084 Chemotherapy by infusion Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O Q0085 Chemo by both infusion and o Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O Q0091 Obtaining screen pap smear $ 77.97 $ 32.99 0 0% 0% 0% 0 0 0 0 0 0 R Q0092 Set up port xray equipment $ 44.39 $ 44.39 0 0% 0% 0% 3 0 0 0 0 0 R Q0111 Wet mounts/ w preparations $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 L Q0112 Potassium hydroxide preps $ 8.13 $ 8.13 0 0% 0% 0% 9 9 9 9 9 9 L Q0113 Pinworm examinations $ 10.30 $ 10.30 0 0% 0% 0% 9 9 9 9 9 9 L Q0114 Fern test $ 13.64 $ 13.64 0 0% 0% 0% 9 9 9 9 9 9 L Q0115 Post-coital mucous exam $ 18.84 $ 18.84 0 0% 0% 0% 9 9 9 9 9 9 L Q0138 Ferumoxytol, non-esrd $ 1.21 $ 1.21 0 0% 0% 0% 9 9 9 9 9 9 D YQ0139 Ferumoxytol, esrd use $ 1.21 $ 1.21 0 0% 0% 0% 9 9 9 9 9 9 D YQ0144 Azithromycin dihydrate, oral Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0161 Chlorpromazine hcl 5mg oral $ 0.43 $ 0.43 0 0% 0% 0% 9 9 9 9 9 9 DQ0162 Ondansetron oral Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ0163 Diphenhydramine hcl 50mg $ 0.04 $ 0.04 0 0% 0% 0% 9 9 9 9 9 9 D Q0164 Prochlorperazine maleate 5mg $ 0.53 $ 0.53 0 0% 0% 0% 9 9 9 9 9 9 D Q0166 Granisetron hcl 1 mg oral $ 6.30 $ 6.30 0 0% 0% 0% 9 9 9 9 9 9 D Q0167 Dronabinol 2.5mg oral $ 5.30 $ 5.30 0 0% 0% 0% 9 9 9 9 9 9 D Q0169 Promethazine hcl 12.5mg oral $ 0.14 $ 0.14 0 0% 0% 0% 9 9 9 9 9 9 D Q0173 Trimethobenzamide hcl 250mg $ 1.47 $ 1.47 0 0% 0% 0% 9 9 9 9 9 9 D Q0174 Thiethylperazine maleate10mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0175 Perphenazine 4mg oral $ 1.36 $ 1.36 0 0% 0% 0% 9 9 9 9 9 9 D Q0177 Hydroxyzine pamoate 25mg $ 0.26 $ 0.26 0 0% 0% 0% 9 9 9 9 9 9 D Q0180 Dolasetron mesylate oral $ 93.77 $ 93.77 0 0% 0% 0% 9 9 9 9 9 9 D Q0181 Unspecified oral anti-emetic By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 137
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
Q0478 Power adapter, combo vad Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ0479 Power module combo vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ0480 Driver pneumatic vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0481 Microprcsr cu elec vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0482 Microprcsr cu combo vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0483 Monitor elec vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0484 Monitor elec or comb vad rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0485 Monitor cable elec vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0486 Mon cable elec/pneum vad rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0487 Leads any type vad, rep only Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0488 Pwr pack base elec vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0489 Pwr pck base combo vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0490 Emr pwr source elec vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0491 Emr pwr source combo vad rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0492 Emr pwr cbl elec vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0493 Emr pwr cbl combo vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0494 Emr hd pmp elec/combo, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0495 Charger elec/combo vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0496 Battery elec/combo vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0497 Bat clps elec/comb vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0498 Holster elec/combo vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0499 Belt/vest elec/combo vad rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0500 Filters elec/combo vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0501 Shwr cov elec/combo vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0502 Mobility cart pneum vad, rep Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0503 Battery pneum vad replacemnt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0504 Pwr adpt pneum vad, rep veh Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0506 Lith-ion batt elec/pneum vad Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ0507 Misc sup/acc ext vad Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ0507 Misc sup/acc ext vad Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ0508 Mis sup/acc imp vad Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ0508 Mis sup/acc imp vad Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ0509 Mis sup/ac imp vad nopay med Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ0509 Mis sup/ac imp vad nopay med Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ0510 Dispens fee immunosupressive Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0511 Sup fee antiem,antica,immuno Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0512 Px sup fee anti-can sub pres Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0513 Disp fee inhal drugs/30 days Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0514 Disp fee inhal drugs/90 days Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q0515 Sermorelin acetate injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 138
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
Q1004 Ntiol category 4 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q1005 Ntiol category 5 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q2004 Bladder calculi irrig sol $ 36.27 $ 36.27 0 0% 0% 0% 9 9 9 9 9 9 D Q2009 Fosphenytoin inj pe $ 0.71 $ 0.71 0 0% 0% 0% 9 9 9 9 9 9 D Q2017 Teniposide, 50 mg $ 2106.00 $ 2106.00 0 0% 0% 0% 9 9 9 9 9 9 D Q2028 Inj, sculptra, 0.5mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ2034 Agriflu vaccine Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ2035 Afluria vacc, 3 yrs & >, im Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ2036 Flulaval vacc, 3 yrs & >, im Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ2037 Fluvirin vacc, 3 yrs & >, im Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ2038 Fluzone vacc, 3 yrs & >, im Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ2039 Nos flu vacc, 3 yrs & >, im Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ2043 Sipuleucel-t auto cd54+ Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ2049 Imported lipodox inj $ 518.03 $ 518.03 0 0% 0% 0% 9 9 9 9 9 9 D YQ2050 Doxorubicin inj 10mg By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ2052 Ivig demo, services/supplies Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ3001 Brachytherapy radioelements By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Q3014 Telehealth facility fee $ 36.04 $ 36.04 0 0% 0% 0% 9 9 9 9 9 9 F Q3027 Inj beta interferon im 1 mcg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ3028 Inj beta interferon sq 1 mcg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ3031 Collagen skin test Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Q4001 Cast sup body cast plaster $ 48.57 $ 48.57 0 0% 0% 0% 9 9 9 9 9 9 F Q4002 Cast sup body cast fiberglas $ 183.53 $ 183.53 0 0% 0% 0% 9 9 9 9 9 9 F Q4003 Cast sup shoulder cast plstr $ 34.88 $ 34.88 0 0% 0% 0% 9 9 9 9 9 9 F Q4004 Cast sup shoulder cast fbrgl $ 120.74 $ 120.74 0 0% 0% 0% 9 9 9 9 9 9 F Q4005 Cast sup long arm adult plst $ 12.86 $ 12.86 0 0% 0% 0% 9 9 9 9 9 9 F Q4006 Cast sup long arm adult fbrg $ 28.98 $ 28.98 0 0% 0% 0% 9 9 9 9 9 9 F Q4007 Cast sup long arm ped plster Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4008 Cast sup long arm ped fbrgls Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4009 Cast sup sht arm adult plstr $ 8.59 $ 8.59 0 0% 0% 0% 9 9 9 9 9 9 F Q4010 Cast sup sht arm adult fbrgl $ 19.33 $ 19.33 0 0% 0% 0% 9 9 9 9 9 9 F Q4011 Cast sup sht arm ped plaster Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4012 Cast sup sht arm ped fbrglas Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4013 Cast sup gauntlet plaster $ 15.63 $ 15.63 0 0% 0% 0% 9 9 9 9 9 9 F Q4014 Cast sup gauntlet fiberglass $ 26.36 $ 26.36 0 0% 0% 0% 9 9 9 9 9 9 F Q4015 Cast sup gauntlet ped plster Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4016 Cast sup gauntlet ped fbrgls Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4017 Cast sup lng arm splint plst $ 9.04 $ 9.04 0 0% 0% 0% 9 9 9 9 9 9 F Q4018 Cast sup lng arm splint fbrg $ 14.40 $ 14.40 0 0% 0% 0% 9 9 9 9 9 9 F Q4019 Cast sup lng arm splnt ped p Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 139
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
Q4020 Cast sup lng arm splnt ped f Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4021 Cast sup sht arm splint plst $ 6.69 $ 6.69 0 0% 0% 0% 9 9 9 9 9 9 F Q4022 Cast sup sht arm splint fbrg $ 12.07 $ 12.07 0 0% 0% 0% 9 9 9 9 9 9 F Q4023 Cast sup sht arm splnt ped p Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4024 Cast sup sht arm splnt ped f Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4025 Cast sup hip spica plaster $ 37.49 $ 37.49 0 0% 0% 0% 9 9 9 9 9 9 F Q4026 Cast sup hip spica fiberglas $ 117.07 $ 117.07 0 0% 0% 0% 9 9 9 9 9 9 F Q4027 Cast sup hip spica ped plstr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4028 Cast sup hip spica ped fbrgl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4029 Cast sup long leg plaster $ 28.67 $ 28.67 0 0% 0% 0% 9 9 9 9 9 9 F Q4030 Cast sup long leg fiberglass $ 75.48 $ 75.48 0 0% 0% 0% 9 9 9 9 9 9 F Q4031 Cast sup lng leg ped plaster Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4032 Cast sup lng leg ped fbrgls Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4033 Cast sup lng leg cylinder pl $ 26.75 $ 26.75 0 0% 0% 0% 9 9 9 9 9 9 F Q4034 Cast sup lng leg cylinder fb $ 66.52 $ 66.52 0 0% 0% 0% 9 9 9 9 9 9 F Q4035 Cast sup lngleg cylndr ped p Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4036 Cast sup lngleg cylndr ped f Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4037 Cast sup shrt leg plaster $ 16.31 $ 16.31 0 0% 0% 0% 9 9 9 9 9 9 F Q4038 Cast sup shrt leg fiberglass $ 40.87 $ 40.87 0 0% 0% 0% 9 9 9 9 9 9 F Q4039 Cast sup shrt leg ped plster Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4040 Cast sup shrt leg ped fbrgls Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4041 Cast sup lng leg splnt plstr $ 19.84 $ 19.84 0 0% 0% 0% 9 9 9 9 9 9 F Q4042 Cast sup lng leg splnt fbrgl $ 33.87 $ 33.87 0 0% 0% 0% 9 9 9 9 9 9 F Q4043 Cast sup lng leg splnt ped p Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4044 Cast sup lng leg splnt ped f Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4045 Cast sup sht leg splnt plstr $ 11.52 $ 11.52 0 0% 0% 0% 9 9 9 9 9 9 F Q4046 Cast sup sht leg splnt fbrgl $ 18.52 $ 18.52 0 0% 0% 0% 9 9 9 9 9 9 F Q4047 Cast sup sht leg splnt ped p Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4048 Cast sup sht leg splnt ped f Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4049 Finger splint, static $ 2.10 $ 2.10 0 0% 0% 0% 9 9 9 9 9 9 F Q4050 Cast supplies unlisted By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q4051 Splint supplies misc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q4074 Iloprost non-comp unit dose Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4081 Epoetin alfa, 100 units esrd $ 1.56 $ 1.56 0 0% 0% 0% 9 9 9 9 9 9 D Q4082 Drug/bio noc part b drug cap Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q4100 Skin substitute, nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q4101 Apligraf $ 89.78 $ 89.78 0 0% 0% 0% 9 9 9 9 9 9 D Q4102 Oasis wound matrix $ 13.22 $ 13.22 0 0% 0% 0% 9 9 9 9 9 9 D Q4103 Oasis burn matrix $ 13.22 $ 13.22 0 0% 0% 0% 9 9 9 9 9 9 D Q4104 Integra bmwd $ 25.56 $ 25.56 0 0% 0% 0% 9 9 9 9 9 9 D
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 140
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
Q4105 Integra drt $ 17.59 $ 17.59 0 0% 0% 0% 9 9 9 9 9 9 D Q4106 Dermagraft $ 44.45 $ 44.45 0 0% 0% 0% 9 9 9 9 9 9 D Q4107 Graftjacket $ 99.30 $ 99.30 0 0% 0% 0% 9 9 9 9 9 9 D Q4108 Integra matrix $ 30.20 $ 30.20 0 0% 0% 0% 9 9 9 9 9 9 D Q4110 Primatrix $ 40.19 $ 40.19 0 0% 0% 0% 9 9 9 9 9 9 D Q4111 Gammagraft $ 7.03 $ 7.03 0 0% 0% 0% 9 9 9 9 9 9 D Q4112 Cymetra injectable $ 424.92 $ 424.92 0 0% 0% 0% 9 9 9 9 9 9 D Q4113 Graftjacket xpress $ 424.92 $ 424.92 0 0% 0% 0% 9 9 9 9 9 9 D Q4114 Integra flowable wound matri $ 1344.52 $ 1344.52 0 0% 0% 0% 9 9 9 9 9 9 D Q4115 Alloskin $ 10.03 $ 10.03 0 0% 0% 0% 9 9 9 9 9 9 DQ4116 Alloderm $ 32.92 $ 32.92 0 0% 0% 0% 9 9 9 9 9 9 DQ4117 Hyalomatrix Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4118 Matristem micromatrix Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4119 Matristem wound matrix Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4120 Matristem burn matrix Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4121 Theraskin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4122 Dermacell Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4123 Alloskin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4124 Oasis tri-layer wound matrix Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4125 Arthroflex Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4126 Memoderm/derma/tranz/integup Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4127 Talymed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4128 Flexhd/allopatchhd/matrixhd Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4129 Unite biomatrix Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4130 Strattice tm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4131 Epifix Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4132 Grafix core Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4133 Grafix prime Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4134 Hmatrix Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4135 Mediskin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4136 Ezderm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4137 Amnioexcel or biodexcel, 1cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4138 Biodfence dryflex, 1cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4139 Amnio or biodmatrix, inj 1cc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4140 Biodfence 1cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4141 Alloskin ac, 1 cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4142 Xcm biologic tiss matrix 1cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4143 Repriza, 1cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4145 Epifix, inj, 1mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4146 Tensix, 1cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 141
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
Q4147 Architect ecm px fx 1 sq cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4148 Neox 1k, 1cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4149 Excellagen, 0.1 cc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4150 Allowrap ds or dry 1 sq cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4151 Amnioband, guardian 1 sq cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4152 Dermapure 1 square cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4153 Dermavest 1 square cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4154 Biovance 1 square cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4155 Neoxflo or clarixflo 1 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4156 Neox 100 1 square cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4157 Revitalon 1 square cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4158 Marigen 1 square cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4159 Affinity1 square cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ4160 Nushield 1 square cm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ5001 Hospice or home hlth in home By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ5002 Hospice/home hlth in asst lv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X Q5003 Hospice in lt/non-skilled nf By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ5004 Hospice in snf By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ5005 Hospice, inpatient hospital By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ5006 Hospice in hospice facility By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ5007 Hospice in ltch By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ5008 Hospice in inpatient psych By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ5009 Hospice/home hlth, place nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ5010 Hospice home care in hospice By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ5101 Inj filgrastim g-csf biosim Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ9951 Locm >= 400 mg/ml iodine,1ml By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q9953 Inj fe-based mr contrast,1ml By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q9954 Oral mr contrast, 100 ml By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q9955 Inj perflexane lip micros,ml By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q9956 Inj octafluoropropane mic,ml By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q9957 Inj perflutren lip micros,ml By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Q9958 Hocm <=149 mg/ml iodine, 1ml $ 0.14 $ 0.14 0 0% 0% 0% 9 9 9 9 9 9 D Q9959 Hocm 150-199mg/ml iodine,1ml $ 0.11 $ 0.11 0 0% 0% 0% 9 9 9 9 9 9 D Q9960 Hocm 200-249mg/ml iodine,1ml $ 0.14 $ 0.14 0 0% 0% 0% 9 9 9 9 9 9 D Q9961 Hocm 250-299mg/ml iodine,1ml $ 0.17 $ 0.17 0 0% 0% 0% 9 9 9 9 9 9 D Q9962 Hocm 300-349mg/ml iodine,1ml $ 0.19 $ 0.19 0 0% 0% 0% 9 9 9 9 9 9 D Q9963 Hocm 350-399mg/ml iodine,1ml $ 0.22 $ 0.22 0 0% 0% 0% 9 9 9 9 9 9 D Q9964 Hocm>= 400mg/ml iodine, 1ml $ 0.34 $ 0.34 0 0% 0% 0% 9 9 9 9 9 9 D Q9965 Locm 100-199mg/ml iodine,1ml $ 2.90 $ 2.90 0 0% 0% 0% 9 9 9 9 9 9 D Q9966 Locm 200-299mg/ml iodine,1ml $ 1.03 $ 1.03 0 0% 0% 0% 9 9 9 9 9 9 D
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 142
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
Q9967 Locm 300-399mg/ml iodine,1ml $ 0.92 $ 0.92 0 0% 0% 0% 9 9 9 9 9 9 D Q9968 Visualization adjunct By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NQ9969 Non-heu tc-99m add-on/dose By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 NQ9976 Inj Ferric Pyrophosphate Cit By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YQ9977 Compounded Drug NOC Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XQ9978 Netupitant Palonosetron oral $ 539.78 $ 539.78 0 0% 0% 0% 9 9 9 9 9 9 DR0070 Transport portable x-ray $ 173.75 $ 173.75 0 0% 0% 0% 3 0 0 0 0 0 F R0075 Transport port x-ray multipl $ 28.96 $ 28.96 0 0% 0% 0% 3 0 0 0 0 0 F R0075-UN Transport port x-ray multipl $ 86.87 $ 86.87 0 0% 0% 0% 3 9 9 9 9 9 F R0075-UP Transport port x-ray multipl $ 57.92 $ 57.92 0 0% 0% 0% 3 9 9 9 9 9 F
R0075-UQ Transport port x-ray multipl $ 43.43 $ 43.43 0 0% 0% 0% 3 9 9 9 9 9 F R0075-UR Transport port x-ray multipl $ 34.75 $ 34.75 0 0% 0% 0% 3 9 9 9 9 9 F R0075-US Transport port x-ray multipl $ 28.96 $ 28.96 0 0% 0% 0% 3 9 9 9 9 9 F R0076 Transport portable ekg Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B S0012 Butorphanol tartrate, nasal Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0014 Tacrine hydrochloride, 10 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0017 Injection, aminocaproic acid Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0020 Injection, bupivicaine hydro $ 1.54 $ 1.54 0 0% 0% 0% 9 9 9 9 9 9 D S0021 Injection, cefoperazone sod Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0023 Injection, cimetidine hydroc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0028 Injection, famotidine, 20 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0030 Injection, metronidazole Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0032 Injection, nafcillin sodium Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0034 Injection, ofloxacin, 400 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0039 Injection, sulfamethoxazole Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0040 Injection, ticarcillin disod Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0073 Injection, aztreonam, 500 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0074 Injection, cefotetan disodiu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0077 Injection, clindamycin phosp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0078 Injection, fosphenytoin sodi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0080 Injection, pentamidine iseth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0081 Injection, piperacillin sodi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0088 Imatinib 100 mg $ 82.90 $ 82.90 0 0% 0% 0% 9 9 9 9 9 9 D YS0090 Sildenafil citrate, 25 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0091 Granisetron 1mg $ 6.30 $ 6.30 0 0% 0% 0% 9 9 9 9 9 9 D S0092 Hydromorphone 250 mg $ 108.49 $ 108.49 0 0% 0% 0% 9 9 9 9 9 9 D YS0093 Morphine 500 mg $ 5.15 $ 5.15 0 0% 0% 0% 9 9 9 9 9 9 D YS0104 Zidovudine, oral, 100 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0106 Bupropion hcl sr 60 tablets Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 143
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S0108 Mercaptopurine 50 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0109 Methadone oral 5mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0117 Tretinoin topical 5 g Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0119 Ondansetron 4 mg $ 1.15 $ 1.15 0 0% 0% 0% 9 9 9 9 9 9 DS0122 Inj menotropins 75 iu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0126 Inj follitropin alfa 75 iu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0128 Inj follitropin beta 75 iu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0132 Inj ganirelix acetat 250 mcg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0136 Clozapine, 25 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0137 Didanosine, 25 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0138 Finasteride, 5 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0139 Minoxidil, 10 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0140 Saquinavir, 200 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0142 Colistimethate inh sol mg By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S0145 Peg interferon alfa-2a/180 $ 935.84 $ 935.84 0 0% 0% 0% 9 9 9 9 9 9 D YS0148 Peg interferon alfa-2b/10 $ 70.23 $ 70.23 0 0% 0% 0% 9 9 9 9 9 9 D YS0155 Epoprostenol dilutant By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YS0156 Exemestane, 25 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0157 Becaplermin gel 1%, 0.5 gm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0160 Dextroamphetamine Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0164 Injection pantroprazole $ 5.40 $ 5.40 0 0% 0% 0% 9 9 9 9 9 9 D S0166 Inj olanzapine 2.5mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0169 Calcitrol Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS0170 Anastrozole 1 mg $ 0.29 $ 0.29 0 0% 0% 0% 9 9 9 9 9 9 D YS0171 Bumetanide 0.5 mg $ 0.53 $ 0.53 0 0% 0% 0% 9 9 9 9 9 9 D S0172 Chlorambucil 2 mg $ 11.53 $ 11.53 0 0% 0% 0% 9 9 9 9 9 9 D YS0174 Dolasetron 50 mg $ 70.74 $ 70.74 0 0% 0% 0% 9 9 9 9 9 9 D S0175 Flutamide 125 mg $ 1.87 $ 1.87 0 0% 0% 0% 9 9 9 9 9 9 D YS0176 Hydroxyurea 500 mg $ 1.15 $ 1.15 0 0% 0% 0% 9 9 9 9 9 9 D YS0177 Levamisole 50 mg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0178 Lomustine 10 mg $ 18.51 $ 18.51 0 0% 0% 0% 9 9 9 9 9 9 D YS0179 Megestrol 20 mg $ 0.59 $ 0.59 0 0% 0% 0% 9 9 9 9 9 9 D YS0182 Procarbazine, oral $ 60.81 $ 60.81 0 0% 0% 0% 9 9 9 9 9 9 D S0183 Prochlorperazine 5 mg $ 0.53 $ 0.53 0 0% 0% 0% 9 9 9 9 9 9 D S0187 Tamoxifen 10 mg $ 1.70 $ 1.70 0 0% 0% 0% 9 9 9 9 9 9 D YS0189 Testosterone pellet 75 mg $ 95.63 $ 95.63 0 0% 0% 0% 9 9 9 9 9 9 D YS0190 Mifepristone, oral, 200 mg $ 97.20 $ 97.20 0 0% 0% 0% 9 9 9 9 9 9 D YS0191 Misoprostol, oral, 200 mcg $ 1.08 $ 1.08 0 0% 0% 0% 9 9 9 9 9 9 D YS0194 Vitamin suppl 100 caps Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0195 Pneumo vaccine 5-9 yrs Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 144
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S0197 Prenatal vitamins 30 day Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0199 Med abortion inc all ex drug By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S0201 Partial hospitalization serv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0207 Paramedicintercep nonhospals Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0208 Paramed intrcept nonvol Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0209 Wc van mileage per mi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0215 Nonemerg transp mileage Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0220 Medical conference by physic Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0221 Medical conference, 60 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0250 Comp geriatr assmt team Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0255 Hospice refer visit nonmd Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0257 End of life counseling Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0260 H&p for surgery Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0265 Genetic counsel 15 mins Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0270 Home std case rate 30 days Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0271 Home hospice case 30 days Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0272 Home episodic case 30 days Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0273 Md home visit outside cap Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0274 Nurse practr visit outs cap Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0280 Medical home, initial plan Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS0281 Medical home, maintenance Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS0302 Completed epsdt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0310 Hospitalist visit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0315 Disease management program Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0316 Follow-up/reassessment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0317 Disease mgmt per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0320 Rn telephone calls to dmp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0340 Lifestyle mod 1st stage Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0341 Lifestyle mod 2 or 3 stage Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0342 Lifestyle mod 4th stage Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0353 Cancer treatmentplan initial Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS0354 Cancer treatment plan change Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS0390 Rout foot care per visit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0395 Impression casting ft By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S0400 Global eswl kidney Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0500 Dispos cont lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0504 Singl prscrp lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0506 Bifoc prscp lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0508 Trifoc prscrp lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0510 Non-prscrp lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 145
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S0512 Daily cont lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0514 Color cont lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0515 Scleral lens liquid bandage Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0516 Safety frames Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0518 Sunglass frames Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0580 Polycarb lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0581 Nonstnd lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0590 Misc integral lens serv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0592 Comp cont lens eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0595 New lenses in pts old frame Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0596 Phakic iol refractive error Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS0601 Screening proctoscopy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0610 Annual gynecological examina Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0612 Annual gynecological examina Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0613 Ann breast exam Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0618 Audiometry for hearing aid Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0620 Routine ophthalmological exa Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0621 Routine ophthalmological exa Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0622 Phys exam for college Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0630 Removal of sutures Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0800 Laser in situ keratomileusis Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0810 Photorefractive keratectomy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S0812 Phototherap keratect Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S1001 Deluxe item Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S1002 Custom item Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S1015 Iv tubing extension set Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S1016 Non-pvc intravenous administ Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S1030 Gluc monitor purchase Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S1031 Gluc monitor rental Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S1034 Art pancreas system Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS1035 Art pancreas inv disp sensor Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS1036 Art pancreas ext transmitter Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS1037 Art pancreas ext receiver Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS1040 Cranial remolding orthosis Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S1090 Mometasone sinus implant By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YS2053 Transplantation of small int Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2054 Transplantation of multivisc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2055 Harvesting of donor multivis Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2060 Lobar lung transplantation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2061 Donor lobectomy (lung) Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 146
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S2065 Simult panc kidn trans Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2066 Breast gap flap reconst Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2067 Breast "stacked" diep/gap Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2068 Breast diep or siea flap Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2070 Cysto laser tx ureteral calc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2079 Lap esophagomyotomy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2080 Laup Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2083 Adjustment gastric band Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2095 Transcath emboliz microspher Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2102 Islet cell tissue transplant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2103 Adrenal tissue transplant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2107 Adoptive immunotherapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2112 Knee arthroscp harv By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S2115 Periacetabular osteotomy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2117 Arthroereisis, subtalar Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2118 Total hip resurfacing Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2120 Low density lipoprotein(ldl) Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2140 Cord blood harvesting Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2142 Cord blood-derived stem-cell Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2150 Bmt harv/transpl 28d pkg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2152 Solid organ transpl pkg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2202 Echosclerotherapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2205 Minimally invasive direct co Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2206 Minimally invasive direct co Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2207 Minimally invasive direct co Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2208 Minimally invasive direct co Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2209 Minimally invasive direct co Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2225 Myringotomy laser-assist Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2230 Implant semi-imp hear Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2235 Implant auditory brain imp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2260 Induced abortion 17-24 weeks Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2265 Induced abortion 25-28 wks Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2266 Induced abortion 29-31 wks Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2267 Induced abortion 32 or more Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2300 Arthroscopy, shoulder, surgi Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2325 Hip core decompression Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2340 Chemodenervation of abductor Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2341 Chemodenerv adduct vocal Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2342 Nasal endoscop po debrid Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2348 Decompress disc rf lumbar Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 147
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S2350 Diskectomy, anterior, with d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2351 Diskectomy, anterior, with d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2360 Vertebroplast cerv 1st Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2361 Vertebroplast cerv addl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2400 Fetal surg congen hernia Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2401 Fetal surg urin trac obstr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2402 Fetal surg cong cyst malf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2403 Fetal surg pulmon sequest Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2404 Fetal surg myelomeningo Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2405 Fetal surg sacrococ teratoma Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2409 Fetal surg noc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2411 Fetoscop laser ther ttts Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S2900 Robotic surgical system Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B S3000 Bilat dil retinal exam Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3005 Eval self-assess depression Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3600 Stat lab $ 13.60 $ 13.60 0 0% 0% 0% 9 9 9 9 9 9 F S3601 Stat lab home/nf $ 13.60 $ 13.60 0 0% 0% 0% 9 9 9 9 9 9 F S3620 Newborn metabolic screening Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3630 Eosinophil blood count Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3645 Hiv-1 antibody testing of or Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3650 Saliva test, hormone level; Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3652 Saliva test, hormone level; Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3655 Antisperm antibodies test Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3708 Gastrointestinal fat absorpt Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3721 Pca3 testing Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS3722 Dose optimization auc - 5fu Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS3800 Genetic testing als Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3840 Dna analysis ret-oncogene Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3841 Gene test retinoblastoma Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3842 Gene test hippel-lindau Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3844 Dna analysis deafness Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3845 Gene test alpha-thalassemia Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3846 Gene test beta-thalassemia Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3849 Gene test niemann-pick Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3850 Gene test sickle cell Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3852 Dna analysis apoe alzheimer Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3853 Gene test myo musclr dyst Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3854 Gene profile panel breast Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3861 Genetic test brugada Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3865 Comp genet test hyp cardiomy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 148
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S3866 Spec gene test hyp cardiomy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3870 Cgh test developmental delay Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3890 Fecal dna analysis Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3900 Surface emg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3902 Ballistocardiogram Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S3904 Masters two step Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4005 Interim labor facility globa Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4011 Ivf package Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4013 Compl gift case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4014 Compl zift case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4015 Complete ivf nos case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4016 Frozen ivf case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4017 Ivf canc a stim case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4018 F emb trns canc case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4020 Ivf canc a aspir case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4021 Ivf canc p aspir case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4022 Asst oocyte fert case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4023 Incompl donor egg case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4025 Donor serv ivf case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4026 Procure donor sperm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4027 Store prev froz embryos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4028 Microsurg epi sperm asp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4030 Sperm procure init visit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4031 Sperm procure subs visit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4035 Stimulated iui case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4037 Cryo embryo transf case rate Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4040 Monit store cryo embryo 30 d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4042 Ovulation mgmt per cycle Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4981 Insert levonorgestrel ius Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4989 Contracept iud Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4990 Nicotine patch legend Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4991 Nicotine patch nonlegend Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4993 Contraceptive pills for bc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S4995 Smoking cessation gum Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5000 Prescription drug, generic Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5001 Prescription drug,brand name Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5010 5% dextrose and 0.45% saline Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5011 5% dextrose in lactated ring Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5012 5% dextrose with potassium Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5013 5%dextrose/0.45%saline1000ml Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 149
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S5014 D5w/0.45ns w kcl and mgs04 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5035 Hit routine device maint Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5036 Hit device repair Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5100 Adult daycare services 15min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5101 Adult day care per half day Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5102 Adult day care per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5105 Centerbased day care perdiem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5108 Homecare train pt 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5109 Homecare train pt session Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5110 Family homecare training 15m Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5111 Family homecare train/sessio Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5115 Nonfamily homecare train/15m Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5116 Nonfamily hc train/session Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5120 Chore services per 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5121 Chore services per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5125 Attendant care service /15m Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5126 Attendant care service /diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5130 Homaker service nos per 15m Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5131 Homemaker service nos /diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5135 Adult companioncare per 15m Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5136 Adult companioncare per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5140 Adult foster care per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5141 Adult foster care per month Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5145 Child fostercare th per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5146 Ther fostercare child /month Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5150 Unskilled respite care /15m Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5151 Unskilled respitecare /diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5160 Emer response sys instal&tst By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YS5161 Emer rspns sys serv permonth By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YS5162 Emer rspns system purchase By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YS5165 Home modifications per serv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5170 Homedelivered prepared meal Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5175 Laundry serv,ext,prof,/order Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5180 Hh respiratory thrpy in eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5181 Hh respiratory thrpy nos/day Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5185 Med reminder serv per month Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5190 Wellness assessment by nonph Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5199 Personal care item nos each Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5497 Hit cath care noc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5498 Hit simple cath care Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 150
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S5501 Hit complex cath care Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5502 Hit interim cath care Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5517 Hit declotting kit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5518 Hit cath repair kit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5520 Hit picc insert kit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5521 Hit midline cath insert kit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5522 Hit picc insert no supp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5523 Hip midline cath insert kit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5550 Insulin rapid 5 u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5551 Insulin most rapid 5 u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5552 Insulin intermed 5 u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5553 Insulin long acting 5 u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5560 Insulin reuse pen 1.5 ml Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5561 Insulin reuse pen 3 ml Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5565 Insulin cartridge 150 u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5566 Insulin cartridge 300 u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5570 Insulin dispos pen 1.5 ml Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S5571 Insulin dispos pen 3 ml Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8030 Tantalum ring application Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8032 Low dose ct lung screening Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS8035 Magnetic source imaging Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8037 Mrcp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8040 Topographic brain mapping Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8042 Mri low field Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8055 Us guidance fetal reduct Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8080 Scintimammography Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8085 Fluorine-18 fluorodeoxygluco Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8092 Electron beam computed tomog Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8096 Portable peak flow meter Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8097 Asthma kit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8100 Spacer without mask Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8101 Spacer with mask Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8110 Peak expiratory flow rate (p Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8120 O2 contents gas cubic ft Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8121 O2 contents liquid lb Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8130 Interferential stim 2 chan Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS8131 Interferential stim 4 chan Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS8185 Flutter device Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8186 Swivel adaptor Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8189 Trach supply noc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 151
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S8210 Mucus trap Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8262 Mandib ortho repos device Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8265 Haberman feeder Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8270 Enuresis alarm Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8301 Infect control supplies nos By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YS8415 Supplies for home delivery Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8420 Custom gradient sleev/glov By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8421 Ready gradient sleev/glov By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8422 Custom grad sleeve med By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8423 Custom grad sleeve heavy By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8424 Ready gradient sleeve By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8425 Custom grad glove med By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8426 Custom grad glove heavy By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8427 Ready gradient glove By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8428 Ready gradient gauntlet By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8429 Gradient pressure wrap By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8430 Padding for comprssn bdg By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8431 Compression bandage By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N S8450 Splint digit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8451 Splint wrist or ankle Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8452 Splint elbow Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8460 Camisole post-mast Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8490 100 insulin syringes Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8930 Auricular electrostimulation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS8940 Hippotherapy per session Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8948 Low-level laser trmt 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8950 Complex lymphedema therapy, Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8990 Pt or manip for maint Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S8999 Resuscitation bag Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9001 Home uterine monitor with or Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9007 Ultrafiltration monitor Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9015 Automated eeg monitoring Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9024 Paranasal sinus ultrasound Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9025 Omnicardiogram/cardiointegra Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9034 Eswl for gallstones Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9055 Procuren or other growth fac Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9056 Coma stimulation per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9061 Medical supplies and equipme Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9083 Urgent care center global Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9088 Services provided in urgent Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 152
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S9090 Vertebral axial decompressio Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9097 Home visit wound care Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9098 Home phototherapy visit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9110 Telemonitoring/home per mnth Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS9117 Back school visit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9122 Home health aide or certifie $ 27.42 $ 27.42 0 0% 0% 0% 9 9 9 9 9 9 F YS9123 Nursing care in home rn $ 59.63 $ 59.63 0 0% 0% 0% 9 9 9 9 9 9 F YS9124 Nursing care, in the home; b $ 43.51 $ 43.51 0 0% 0% 0% 9 9 9 9 9 9 F YS9125 Respite care, in the home, p Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9126 Hospice care, in the home, p Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9127 Social work visit, in the ho Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9128 Speech therapy, in the home, Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9129 Occupational therapy, in the Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9131 Pt in the home per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9140 Diabetic management program, Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9141 Diabetic management program, Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9145 Insulin pump initiation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9150 Evaluation by ocularist Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9152 Speech therapy, re-eval Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9208 Home mgmt preterm labor Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9209 Home mgmt pprom Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9211 Home mgmt gest hypertension Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9212 Hm postpar hyper per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9213 Hm preeclamp per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9214 Hm gest dm per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9325 Hit pain mgmt per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9326 Hit cont pain per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9327 Hit int pain per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9328 Hit pain imp pump diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9329 Hit chemo per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9330 Hit cont chem diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9331 Hit intermit chemo diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9335 Ht hemodialysis diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9336 Hit cont anticoag diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9338 Hit immunotherapy diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9339 Hit periton dialysis diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9340 Hit enteral per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9341 Hit enteral grav diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9342 Hit enteral pump diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9343 Hit enteral bolus nurs Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 153
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S9345 Hit anti-hemophil diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9346 Hit alpha-1-proteinas diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9347 Hit longterm infusion diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9348 Hit sympathomim diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9349 Hit tocolysis diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9351 Hit cont antiemetic diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9353 Hit cont insulin diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9355 Hit chelation diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9357 Hit enzyme replace diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9359 Hit anti-tnf per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9361 Hit diuretic infus diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9363 Hit anti-spasmotic diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9364 Hit tpn total diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9365 Hit tpn 1 liter diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9366 Hit tpn 2 liter diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9367 Hit tpn 3 liter diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9368 Hit tpn over 3l diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9370 Ht inj antiemetic diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9372 Ht inj anticoag diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9373 Hit hydra total diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9374 Hit hydra 1 liter diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9375 Hit hydra 2 liter diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9376 Hit hydra 3 liter diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9377 Hit hydra over 3l diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9379 Hit noc per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9381 Hit high risk/escort Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9401 Anticoag clinic per session Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9430 Pharmacy comp/disp serv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9433 Medical food oral 100% nutr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9434 Mod solid food suppl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9435 Medical foods for inborn err Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9436 Lamaze class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9437 Childbirth refresher class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9438 Cesarean birth class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9439 Vbac class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9441 Asthma education Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9442 Birthing class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9443 Lactation class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9444 Parenting class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9445 Pt education noc individ $ 40.07 $ 40.07 0 0% 0% 0% 9 9 9 9 9 9 F Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 154
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S9446 Pt education noc group Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9447 Infant safety class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9449 Weight mgmt class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9451 Exercise class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9452 Nutrition class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9453 Smoking cessation class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9454 Stress mgmt class Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9455 Diabetic management program, Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9460 Diabetic management program, Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9465 Diabetic management program, Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9470 Nutritional counseling, diet Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9472 Cardiac rehabilitation progr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9473 Pulmonary rehabilitation pro Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9474 Enterostomal therapy by a re Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9475 Ambulatory setting substance Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9476 Vestibular rehab per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9480 Intensive outpatient psychia Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9482 Family stabilization 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9484 Crisis intervention per hour Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9485 Crisis intervention mental h Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9490 Hit corticosteroid/diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9494 Hit antibiotic total diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9497 Hit antibiotic q3h diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9500 Hit antibiotic q24h diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9501 Hit antibiotic q12h diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9502 Hit antibiotic q8h diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9503 Hit antibiotic q6h diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9504 Hit antibiotic q4h diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9529 Venipuncture home/snf Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9537 Ht hem horm inj diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9538 Hit blood products diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9542 Ht inj noc per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9558 Ht inj growth horm diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9559 Hit inj interferon diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9560 Ht inj hormone diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9562 Ht inj palivizumab diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9590 Ht irrigation diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9810 Ht pharm per hour Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9900 Christian sci pract visit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9901 Christian sci nurse visit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 155
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
S9960 Air ambulanc nonemerg fixed Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS9961 Air ambulan nonemerg rotary Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XS9970 Health club membership yr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9975 Transplant related per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9976 Lodging per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9977 Meals per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9981 Med record copy admin $ 25.94 $ 25.94 0 0% 0% 0% 9 9 9 9 9 9 F S9982 Med record copy per page $ 0.51 $ 0.51 0 0% 0% 0% 9 9 9 9 9 9 F S9986 Not medically necessary svc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9988 Serv part of phase i trial Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9989 Services outside us Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9990 Services provided as part of Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9991 Services provided as part of Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9992 Transportation costs to and Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9994 Lodging costs (e.g. hotel ch Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9996 Meals for clinical trial par Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X S9999 Sales tax Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1000 Private duty/independent nsg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1001 Nursing assessment/evaluatn Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1002 Rn services up to 15 minutes Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1003 Lpn/lvn services up to 15min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1004 Nsg aide service up to 15min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1005 Respite care service 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1006 Family/couple counseling Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1007 Treatment plan development Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1009 Child sitting services Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1010 Meals when receive services Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1012 Alcohol/substance abuse skil Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1013 Sign lang/oral interpreter Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1014 Telehealth transmit, per min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1015 Clinic service By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N T1016 Case management Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1017 Targeted case management Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1018 School-based iep ser bundled Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1019 Personal care ser per 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1020 Personal care ser per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1021 Hh aide or cn aide per visit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1022 Contracted services per day Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1023 Program intake assessment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1024 Team evaluation & management Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 156
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
T1025 Ped compr care pkg, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1026 Ped compr care pkg, per hour Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1027 Family training & counseling Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1028 Home environment assessment Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1029 Dwelling lead investigation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1030 Rn home care per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1031 Lpn home care per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1502 Medication admin visit Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1503 Med admin, not oral/inject Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T1505 Elec med comp dev, noc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XT1999 Noc retail items andsupplies Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2001 N-et; patient attend/escort Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2002 N-et; per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2003 N-et; encounter/trip Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2004 N-et; commerc carrier pass Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2005 N-et; stretcher van Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2007 Non-emer transport wait time Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2010 Pasrr level i Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2011 Pasrr level ii Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2012 Habil ed waiver, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2013 Habil ed waiver per hour Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2014 Habil prevoc waiver, per d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2015 Habil prevoc waiver per hr Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2016 Habil res waiver per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2017 Habil res waiver 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2018 Habil sup empl waiver/diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2019 Habil sup empl waiver 15min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2020 Day habil waiver per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2021 Day habil waiver per 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2022 Case management, per month Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2023 Targeted case mgmt per month Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2024 Serv asmnt/care plan waiver Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2025 Waiver service, nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2026 Special childcare waiver/d Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2027 Spec childcare waiver 15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2028 Special supply, nos waiver Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2029 Special med equip, noswaiver Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2030 Assist living waiver/month Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2031 Assist living waiver/diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2032 Res care, nos waiver/month Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 157
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
T2033 Res, nos waiver per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2034 Crisis interven waiver/diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2035 Utility services waiver Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2036 Camp overnite waiver/session Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2037 Camp day waiver/session Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2038 Comm trans waiver/service Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2039 Vehicle mod waiver/service Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2040 Financial mgt waiver/15min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2041 Support broker waiver/15 min Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2042 Hospice routine home care Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2043 Hospice continuous home care Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2044 Hospice respite care Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2045 Hospice general care Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2046 Hospice long term care, r&b Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2048 Bh ltc res r&b, per diem Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2049 N-et; stretcher van, mileage Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T2101 Breast milk proc/store/dist Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T4521 Adult size brief/diaper sm Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4522 Adult size brief/diaper med Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4523 Adult size brief/diaper lg Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4524 Adult size brief/diaper xl Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4525 Adult size pull-on sm Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4526 Adult size pull-on med Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4527 Adult size pull-on lg Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4528 Adult size pull-on xl Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4529 Ped size brief/diaper sm/med Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T4530 Ped size brief/diaper lg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T4531 Ped size pull-on sm/med Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T4532 Ped size pull-on lg Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T4533 Youth size brief/diaper Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4534 Youth size pull-on Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4535 Disposable liner/shield/pad Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4536 Reusable pull-on any size Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4537 Reusable underpad bed size Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4538 Diaper serv reusable diaper Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T4539 Reuse diaper/brief any size Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4540 Reusable underpad chair size Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4541 Large disposable underpad Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4542 Small disposable underpad Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B T4543 Adult disp brief/diap abv xl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 158
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
T4544 Adlt disp und/pull on abv xl Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 BT5001 Position seat spec orth need Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X T5999 Supply, nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V2020 Vision svcs frames purchases By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2025 Eyeglasses delux frames By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2100 Lens spher single plano 4.00 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2101 Single visn sphere 4.12-7.00 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2102 Singl visn sphere 7.12-20.00 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2103 Spherocylindr 4.00d/12-2.00d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2104 Spherocylindr 4.00d/2.12-4d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2105 Spherocylinder 4.00d/4.25-6d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2106 Spherocylinder 4.00d/>6.00d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2107 Spherocylinder 4.25d/12-2d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2108 Spherocylinder 4.25d/2.12-4d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2109 Spherocylinder 4.25d/4.25-6d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2110 Spherocylinder 4.25d/over 6d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2111 Spherocylindr 7.25d/.25-2.25 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2112 Spherocylindr 7.25d/2.25-4d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2113 Spherocylindr 7.25d/4.25-6d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2114 Spherocylinder over 12.00d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2115 Lens lenticular bifocal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2118 Lens aniseikonic single By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2121 Lenticular lens, single By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2199 Lens single vision not oth c By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2200 Lens spher bifoc plano 4.00d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2201 Lens sphere bifocal 4.12-7.0 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2202 Lens sphere bifocal 7.12-20. By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2203 Lens sphcyl bifocal 4.00d/.1 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2204 Lens sphcy bifocal 4.00d/2.1 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2205 Lens sphcy bifocal 4.00d/4.2 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2206 Lens sphcy bifocal 4.00d/ove By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2207 Lens sphcy bifocal 4.25-7d/. By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2208 Lens sphcy bifocal 4.25-7/2. By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2209 Lens sphcy bifocal 4.25-7/4. By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2210 Lens sphcy bifocal 4.25-7/ov By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2211 Lens sphcy bifo 7.25-12/.25- By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2212 Lens sphcyl bifo 7.25-12/2.2 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2213 Lens sphcyl bifo 7.25-12/4.2 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2214 Lens sphcyl bifocal over 12. By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2215 Lens lenticular bifocal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 159
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
V2218 Lens aniseikonic bifocal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2219 Lens bifocal seg width over By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2220 Lens bifocal add over 3.25d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2221 Lenticular lens, bifocal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2299 Lens bifocal speciality By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2300 Lens sphere trifocal 4.00d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2301 Lens sphere trifocal 4.12-7. By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2302 Lens sphere trifocal 7.12-20 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2303 Lens sphcy trifocal 4.0/.12- By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2304 Lens sphcy trifocal 4.0/2.25 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2305 Lens sphcy trifocal 4.0/4.25 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2306 Lens sphcyl trifocal 4.00/>6 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2307 Lens sphcy trifocal 4.25-7/. By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2308 Lens sphc trifocal 4.25-7/2. By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2309 Lens sphc trifocal 4.25-7/4. By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2310 Lens sphc trifocal 4.25-7/>6 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2311 Lens sphc trifo 7.25-12/.25- By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2312 Lens sphc trifo 7.25-12/2.25 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2313 Lens sphc trifo 7.25-12/4.25 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2314 Lens sphcyl trifocal over 12 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2315 Lens lenticular trifocal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2318 Lens aniseikonic trifocal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2319 Lens trifocal seg width > 28 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2320 Lens trifocal add over 3.25d By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2321 Lenticular lens, trifocal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2399 Lens trifocal speciality By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2410 Lens variab asphericity sing By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2430 Lens variable asphericity bi By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2499 Variable asphericity lens By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2500 Contact lens pmma spherical By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2501 Cntct lens pmma-toric/prism By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2502 Contact lens pmma bifocal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2503 Cntct lens pmma color vision By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2510 Cntct gas permeable sphericl By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2511 Cntct toric prism ballast By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2512 Cntct lens gas permbl bifocl By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2513 Contact lens extended wear By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2520 Contact lens hydrophilic By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2521 Cntct lens hydrophilic toric By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2522 Cntct lens hydrophil bifocl By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 160
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
V2523 Cntct lens hydrophil extend By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2530 Contact lens gas impermeable By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2531 Contact lens gas permeable By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2599 Contact lens/es other type By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV2600 Hand held low vision aids By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2610 Single lens spectacle mount By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2615 Telescop/othr compound lens By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2623 Plastic eye prosth custom By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2624 Polishing artifical eye By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2625 Enlargemnt of eye prosthesis By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2626 Reduction of eye prosthesis By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2627 Scleral cover shell By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2628 Fabrication & fitting By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2629 Prosthetic eye other type By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2630 Anter chamber intraocul lens $ 113.49 $ 113.49 0 0% 0% 0% 9 9 9 9 9 9 F V2631 Iris support intraoclr lens $ 113.49 $ 113.49 0 0% 0% 0% 9 9 9 9 9 9 F V2632 Post chmbr intraocular lens $ 113.49 $ 113.49 0 0% 0% 0% 9 9 9 9 9 9 F V2700 Balance lens By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2702 Deluxe lens feature By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2710 Glass/plastic slab off prism By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2715 Prism lens/es By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2718 Fresnell prism press-on lens By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2730 Special base curve By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2744 Tint photochromatic lens/es By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2745 Tint, any color/solid/grad By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2750 Anti-reflective coating By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2755 Uv lens/es By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2756 Eye glass case By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2760 Scratch resistant coating By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2761 Mirror coating By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2762 Polarization, any lens By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2770 Occluder lens/es By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2780 Oversize lens/es By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2781 Progressive lens per lens By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2782 Lens, 1.54-1.65 p/1.60-1.79g By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2783 Lens, >= 1.66 p/>=1.80 g By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2784 Lens polycarb or equal By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2785 Corneal tissue processing By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2786 Occupational multifocal lens By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2787 Astigmatism-correct function By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 161
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
V2788 Presbyopia-correct function Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V2790 Amniotic membrane By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2797 Vis item/svc in other code By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V2799 Misc vision item or service By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5008 Hearing screening $ 80.68 $ 80.68 0 0% 0% 0% 9 9 9 9 9 9 F YV5010 Assessment for hearing aid Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B V5011 Hearing aid fitting/checking Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B V5014 Hearing aid repair/modifying $ 53.79 $ 53.79 0 0% 0% 0% 9 9 9 9 9 9 F YV5020 Conformity evaluation Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B V5030 Body-worn hearing aid air By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5040 Body-worn hearing aid bone By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5050 Hearing aid monaural in ear By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5060 Behind ear hearing aid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5070 Glasses air conduction By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5080 Glasses bone conduction By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5090 Hearing aid dispensing fee Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5095 Implant mid ear hearing pros Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5100 Body-worn bilat hearing aid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5110 Hearing aid dispensing fee Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5120 Body-worn binaur hearing aid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5130 In ear binaural hearing aid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5140 Behind ear binaur hearing ai By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5150 Glasses binaural hearing aid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5160 Dispensing fee binaural $ 1527.66 $ 1527.66 0 0% 0% 0% 9 9 9 9 9 9 F YV5170 Within ear cros hearing aid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5180 Behind ear cros hearing aid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5190 Glasses cros hearing aid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5200 Cros hearing aid dispens fee $ 915.64 $ 915.64 0 0% 0% 0% 9 9 9 9 9 9 F YV5210 In ear bicros hearing aid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5220 Behind ear bicros hearing ai By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5230 Glasses bicros hearing aid By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5240 Dispensing fee bicros $ 915.64 $ 915.64 0 0% 0% 0% 9 9 9 9 9 9 F YV5241 Dispensing fee, monaural $ 763.83 $ 763.83 0 0% 0% 0% 9 9 9 9 9 9 F YV5242 Hearing aid, monaural, cic By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5243 Hearing aid, monaural, itc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5244 Hearing aid, prog, mon, cic By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5245 Hearing aid, prog, mon, itc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5246 Hearing aid, prog, mon, ite By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5247 Hearing aid, prog, mon, bte By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5248 Hearing aid, binaural, cic By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 162
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
V5249 Hearing aid, binaural, itc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5250 Hearing aid, prog, bin, cic By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5251 Hearing aid, prog, bin, itc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5252 Hearing aid, prog, bin, ite By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5253 Hearing aid, prog, bin, bte By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5254 Hearing id, digit, mon, cic By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5255 Hearing aid, digit, mon, itc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5256 Hearing aid, digit, mon, ite By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5257 Hearing aid, digit, mon, bte By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5258 Hearing aid, digit, bin, cic By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5259 Hearing aid, digit, bin, itc By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5260 Hearing aid, digit, bin, ite By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5261 Hearing aid, digit, bin, bte By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5262 Hearing aid, disp, monaural Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5263 Hearing aid, disp, binaural Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5264 Ear mold/insert By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5265 Ear mold/insert, disp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5266 Battery for hearing device $ 0.94 $ 0.94 0 0% 0% 0% 9 9 9 9 9 9 F V5267 Hearing aid sup/access/dev By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YV5268 Ald telephone amplifier Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5269 Alerting device, any type Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5270 Ald, tv amplifier, any type Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5271 Ald, tv caption decoder Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5272 Tdd Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5273 Ald for cochlear implant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5274 Ald unspecified Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5275 Ear impression Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5281 Ald fm/dm system, monaural Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XV5282 Ald fm/dm system binaural Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XV5283 Ald neck, loop ind receiver Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XV5284 Ald fm/dm ear level receiver Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XV5285 Ald fm/dm aud input receiver Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XV5286 Ald blu tooth fm/dm receiver Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XV5287 Ald fm/dm receiver, nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XV5288 Ald fm/dm transmitter ald Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XV5289 Ald fm/dm adapt/boot couplin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XV5290 Ald transmitter microphone Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XV5298 Hearing aid noc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X V5299 Hearing service Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X V5336 Repair communication device By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesHCPCS Level II
July 01, 2015
CPT®
only are copyright 2014 American Medical Association. All rights reserved. Page 163
HCPCS Level II FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
V5362 Speech screening By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V5363 Language screening By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N V5364 Dysphagia screening By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
Professional Services Fee SchedulesFacility Only Codes
July 01, 2015
Page 1
Professional Services Fee ScheduleFacility Only
Professional Services Fee SchedulesFacility Only Codes
July 01, 2015
Page 2
Facility Only FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIC1713 Anchor/screw bn/bn,tis/bn Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1714 Cath, trans atherectomy, dir Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1715 Brachytherapy needle Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1716 Brachytx, non-str, gold-198 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1717 Brachytx, non-str,hdr ir-192 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1719 Brachytx, ns, non-hdrir-192 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1721 Aicd, dual chamber Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1722 Aicd, single chamber Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1724 Cath, trans atherec,rotation Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1725 Cath, translumin non-laser Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1726 Cath, bal dil, non-vascular Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1727 Cath, bal tis dis, non-vas Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1728 Cath, brachytx seed adm Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1729 Cath, drainage Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1730 Cath, ep, 19 or few elect Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1731 Cath, ep, 20 or more elec Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1732 Cath, ep, diag/abl, 3d/vect Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1733 Cath, ep, othr than cool-tip Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1749 Endo, colon, retro imaging Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O YC1750 Cath, hemodialysis,long-term Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1751 Cath, inf, per/cent/midline Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1752 Cath,hemodialysis,short-term Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1753 Cath, intravas ultrasound Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1754 Catheter, intradiscal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1755 Catheter, intraspinal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1756 Cath, pacing, transesoph Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1757 Cath, thrombectomy/embolect Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1758 Catheter, ureteral Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1759 Cath, intra echocardiography Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1760 Closure dev, vasc Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1762 Conn tiss, human(inc fascia) Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1763 Conn tiss, non-human Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1764 Event recorder, cardiac Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1765 Adhesion barrier Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1766 Intro/sheath,strble,non-peel Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1767 Generator, neuro non-recharg Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1768 Graft, vascular Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1769 Guide wire Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1770 Imaging coil, mr, insertable Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1771 Rep dev, urinary, w/sling Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1772 Infusion pump, programmable Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O
HCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
Professional Services Fee SchedulesFacility Only Codes
July 01, 2015
Page 3
Facility Only FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C1773 Ret dev, insertable Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1776 Joint device (implantable) Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1777 Lead, aicd, endo single coil Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1778 Lead, neurostimulator Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1779 Lead, pmkr, transvenous vdd Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1780 Lens, intraocular (new tech) Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1781 Mesh (implantable) Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1782 Morcellator Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1783 Ocular imp, aqueous drain de Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1784 Ocular dev, intraop, det ret Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1785 Pmkr, dual, rate-resp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1786 Pmkr, single, rate-resp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1787 Patient progr, neurostim Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1788 Port, indwelling, imp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1789 Prosthesis, breast, imp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1813 Prosthesis, penile, inflatab Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1814 Retinal tamp, silicone oil Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1815 Pros, urinary sph, imp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1816 Receiver/transmitter, neuro Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1817 Septal defect imp sys Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1818 Integrated keratoprosthesis Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1819 Tissue localization-excision Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1820 Generator neuro rechg bat sy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1821 Interspinous implant Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1830 Power bone marrow bx needle Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1840 Telescopic intraocular lens Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1841 Retinal prosth int/ext comp Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1874 Stent, coated/cov w/del sys Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1875 Stent, coated/cov w/o del sy Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1876 Stent, non-coa/non-cov w/del Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1877 Stent, non-coat/cov w/o del Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1878 Matrl for vocal cord Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1880 Vena cava filter Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1881 Dialysis access system Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1882 Aicd, other than sing/dual Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1883 Adapt/ext, pacing/neuro lead Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1884 Embolization protect syst Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1885 Cath, translumin angio laser Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1886 Catheter, ablation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC1887 Catheter, guiding Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1888 Endovas non-cardiac abl cath Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O
Professional Services Fee SchedulesFacility Only Codes
July 01, 2015
Page 4
Facility Only FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C1891 Infusion pump,non-prog, perm Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1892 Intro/sheath,fixed,peel-away Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1893 Intro/sheath, fixed,non-peel Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1894 Intro/sheath, non-laser Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1895 Lead, aicd, endo dual coil Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1896 Lead, aicd, non sing/dual Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1897 Lead, neurostim test kit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1898 Lead, pmkr, other than trans Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1899 Lead, pmkr/aicd combination Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC1900 Lead, coronary venous Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2614 Probe, perc lumb disc Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2615 Sealant, pulmonary, liquid Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2616 Brachytx, non-str,yttrium-90 Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2617 Stent, non-cor, tem w/o del Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2618 Probe/needle, cryo Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2619 Pmkr, dual, non rate-resp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2620 Pmkr, single, non rate-resp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2621 Pmkr, other than sing/dual Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2622 Prosthesis, penile, non-inf Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2623 Cath, translumin, drug-coat Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2624 Wireless pressure sensor Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2625 Stent, non-cor, tem w/del sy Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2626 Infusion pump, non-prog,temp Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2627 Cath, suprapubic/cystoscopic Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2628 Catheter, occlusion Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2629 Intro/sheath, laser Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2630 Cath, ep, cool-tip Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2631 Rep dev, urinary, w/o sling Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC2634 Brachytx, non-str, ha, i-125 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2635 Brachytx, non-str, ha, p-103 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2636 Brachy linear, non-str,p-103 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2637 Brachy,non-str,ytterbium-169 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2638 Brachytx, stranded, i-125 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2639 Brachytx, non-stranded,i-125 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2640 Brachytx, stranded, p-103 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2641 Brachytx, non-stranded,p-103 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2642 Brachytx, stranded, c-131 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2643 Brachytx, non-stranded,c-131 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2698 Brachytx, stranded, nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC2699 Brachytx, non-stranded, nos Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5271 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesFacility Only Codes
July 01, 2015
Page 5
Facility Only FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C5272 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5273 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5274 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5275 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5276 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5277 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC5278 Low cost skin substitute app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC8900 Mra w/cont, abd Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8901 Mra w/o cont, abd Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8902 Mra w/o fol w/cont, abd Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8903 Mri w/cont, breast, uni Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8904 Mri w/o cont, breast, uni Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8905 Mri w/o fol w/cont, brst, un Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8906 Mri w/cont, breast, bi Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8907 Mri w/o cont, breast, bi Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8908 Mri w/o fol w/cont, breast, Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8909 Mra w/cont, chest Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8910 Mra w/o cont, chest Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8911 Mra w/o fol w/cont, chest Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8912 Mra w/cont, lwr ext Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8913 Mra w/o cont, lwr ext Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8914 Mra w/o fol w/cont, lwr ext Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8918 Mra w/cont, pelvis Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8919 Mra w/o cont, pelvis Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8920 Mra w/o fol w/cont, pelvis Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8921 Tte w or w/o fol w/cont, com Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC8922 Tte w or w/o fol w/cont, f/u Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC8923 2d tte w or w/o fol w/con,co Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8924 2d tte w or w/o fol w/con,fu Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8925 2d tee w or w/o fol w/con,in Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8926 Tee w or w/o fol w/cont,cong Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC8927 Tee w or w/o fol w/cont, mon Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8928 Tte w or w/o fol w/con,stres Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8929 Tte w or wo fol wcon,doppler Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8930 Tte w or w/o contr, cont ecg Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8931 Mra, w/dye, spinal canal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8932 Mra, w/o dye, spinal canal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8933 Mra, w/o&w/dye, spinal canal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8934 Mra, w/dye, upper extremity Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8935 Mra, w/o dye, upper extr Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC8936 Mra, w/o&w/dye, upper extr Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O
Professional Services Fee SchedulesFacility Only Codes
July 01, 2015
Page 6
Facility Only FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C8957 Prolonged iv inf, req pump Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9027 Injection, pembrolizumab $ 46.61 $ 46.61 0 0% 0% 0% 9 9 9 9 9 9 D YC9113 Inj pantoprazole sodium, via $ 3.26 $ 3.26 0 0% 0% 0% 9 9 9 9 9 9 DC9121 Injection, argatroban $ 25.53 $ 25.53 0 0% 0% 0% 9 9 9 9 9 9 DC9132 Kcentra, per i.u. $ 2.06 $ 2.06 0 0% 0% 0% 9 9 9 9 9 9 D YC9136 Factor viii (eloctate) $ 2.06 $ 2.06 0 0% 0% 0% 9 9 9 9 9 9 D YC9248 Inj, clevidipine butyrate $ 3.67 $ 3.67 0 0% 0% 0% 9 9 9 9 9 9 D YC9250 Artiss fibrin sealant $ 173.22 $ 173.22 0 0% 0% 0% 9 9 9 9 9 9 DC9254 Injection, lacosamide $ 0.30 $ 0.30 0 0% 0% 0% 9 9 9 9 9 9 DC9257 Bevacizumab injection Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9275 Hexaminolevulinate hcl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9285 Patch, lidocaine/tetracaine $ 14.63 $ 14.63 0 0% 0% 0% 9 9 9 9 9 9 DC9290 Inj, bupivacaine liposome $ 1.16 $ 1.16 0 0% 0% 0% 9 9 9 9 9 9 DC9293 Injection, glucarpidase $ 267.89 $ 267.89 0 0% 0% 0% 9 9 9 9 9 9 D YC9349 Fortaderm, fortaderm antimic Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9352 Neuragen nerve guide, per cm Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9353 Neurawrap nerve protector,cm Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9354 Veritas collagen matrix, cm2 Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9355 Neuromatrix nerve cuff, cm Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9356 Tenoglide tendon prot, cm2 Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9358 Surgimend, fetal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9359 Implnt,bon void filler-putty Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9360 Surgimend, neonatal Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9361 Neuromend nerve wrap Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9362 Implnt,bon void filler-strip Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9363 Integra meshed bil wound mat Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9364 Porcine implant, permacol Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9399 Unclassified drugs or biolog Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9442 Injection, belinostat $ 32.40 $ 32.40 0 0% 0% 0% 9 9 9 9 9 9 D YC9443 Injection, dalbavancin $ 32.18 $ 32.18 0 0% 0% 0% 9 9 9 9 9 9 DC9444 Injection, oritavancin $ 26.10 $ 26.10 0 0% 0% 0% 9 9 9 9 9 9 DC9445 C-1 esterase, Ruconest Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9446 Inj, tedizolid phosphate $ 1.27 $ 1.27 0 0% 0% 0% 9 9 9 9 9 9 DC9447 Inj, phenylephrine ketorolac Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9448 Oral netupitant palonosetron $ 514.08 $ 514.08 0 0% 0% 0% 9 9 9 9 9 9 DC9449 Inj, blinatumomab $ 98.08 $ 98.08 0 0% 0% 0% 9 9 9 9 9 9 D YC9450 Fluocinolone acetonide implt $ 539.78 $ 539.78 0 0% 0% 0% 9 9 9 9 9 9 D YC9451 Injection, peramivir $ 1.71 $ 1.71 0 0% 0% 0% 9 9 9 9 9 9 D YC9497 Loxapine, inhalation powder By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N YC9600 Perc drug-el cor stent sing Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9601 Perc drug-el cor stent bran Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesFacility Only Codes
July 01, 2015
Page 7
Facility Only FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
C9602 Perc d-e cor stent ather s Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9603 Perc d-e cor stent ather br Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9604 Perc d-e cor revasc t cabg s Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9605 Perc d-e cor revasc t cabg b Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9606 Perc d-e cor revasc w ami s Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9607 Perc d-e cor revasc chro sin Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9608 Perc d-e cor revasc chro add Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9724 Eps stomach plic Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9725 Place endorectal app Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9726 Rxt breast appl place/remov Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9727 Insert palate implants Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9728 Place device/marker, non pro Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9733 Non-ophthalmic fva Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9737 Lap esoph augmentation Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9739 Cystoscopy prostatic imp 1-3 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9740 Cysto impl 4 or more Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9742 Laryngoscopy with injection Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9800 Dermal filler inj px/suppl Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XC9898 Inpnt stay radiolabeled item Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OC9899 Inpt implant pros dev,no cov Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0175 OPPS Service,sched team conf Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0176 OPPS/PHP;activity therapy Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0177 OPPS/PHP; train & educ serv Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0257 Unsched dialysis ESRD pt hos Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0259 Inject for sacroiliac joint Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0260 Inj for sacroiliac jt anesth Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0269 Occlusive device in vein art Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0283 Elec stim other than wound $ 23.99 $ 23.99 0 0% 0% 0% 9 9 9 9 9 9 RG0293 Non-cov surg proc,clin trial Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0294 Non-cov proc, clinical trial Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0339 Robot lin-radsurg com, first Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0340 Robt lin-radsurg fractx 2-5 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 XG0378 Hospital observation per hr Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0379 Direct refer hospital observ Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0380 Lev 1 hosp type B ED visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0381 Lev 2 hosp type B ED visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0382 Lev 3 hosp type B ED visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0383 Lev 4 hosp type B ED visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0384 Lev 5 hosp type B ED visit Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0390 Trauma Respons w/hosp criti Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0410 Grp psych partial hosp 45-50 Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 O
Professional Services Fee SchedulesFacility Only Codes
July 01, 2015
Page 8
Facility Only FeesDOLLAR VALUE MODIFIERS
ABBREVIATED DESCRIPTION FSIHCPCS CODE
NON-FACILITY SETTING
FACILITY SETTING
FOL UP
PRE OP(-56)
INTRA OP(-54)
POST OP(-55)
PCTC(26/TC)
MSI(-51)
BSI(-50)
ASI(-80)
CSI(-62)
TSI(-66)
ENDOBASE
LIC REQ
PRIOR AUTH
G0411 Inter active grp psych parti Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OG0463 Hospital outpt clinic visit Facility Only Facility Only 1 0% 0% 0% 9 9 9 9 9 9 OQ0081 Infusion ther other than che Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OQ0083 Chemo by other than infusion Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OQ0084 Chemotherapy by infusion Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OQ0085 Chemo by both infusion and o Facility Only Facility Only 0 0% 0% 0% 9 9 9 9 9 9 OS0092 Hydromorphone 250 mg $ 108.49 $ 108.49 0 0% 0% 0% 9 9 9 9 9 9 DS0093 Morphine 500 mg $ 5.15 $ 5.15 0 0% 0% 0% 9 9 9 9 9 9 DS0201 Partial hospitalization serv Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
Professional Services Fee SchedulesLocal Codes
July 01, 2015
Page 1
Professional Services Fee ScheduleLocal Codes
Professional Services Fee SchedulesLocal Codes
July 01, 2015
Page 2
Local Code FeesLocal Code Description FACILITY FEE Payment Policy Reference
0010E Ankle weight purchase By Report By Report To reimburse claimant costs
0012E Wrist weight purchase By Report By Report To reimburse claimant costs
0301R Retraining, plan travel, mileage State Rate State Rate To reimburse claimant costs
0302R Retraining, plan travel, parking By Report By Report To reimburse claimant costs
0303R Retraining, plan travel, bridge/ferry toll By Report By Report To reimburse claimant costs
0304R Retraining, plan travel, commercial transportation By Report By Report To reimburse claimant costs
0375R Retraining, relocation costs By Report By Report To reimburse claimant costs0378R Stand alone job analysis, non-voc $ 9.24 $ 9.24 Professional Services0380R Job modification By Report By Report Professional Services0385R Pre-job accommodation By Report By Report Professional Services0388R Plan development services, non-voc By Report By Report Professional Services0389R Job mod/pre-job mod - non voc, job mod/pre-job mod $ 11.24 $ 11.24 Professional Services0390R Vocational evaluation - non voc, ea 6 minutes, work eval $ 9.24 $ 9.24 Professional Services0391R Travel / wait (non-voc), travel / wait 9non-voc) $ 5.09 $ 5.09 Professional Services0392R Mileage, non-vrc, per mile State Rate State Rate Professional Services0393R Ferry and bridge charges, non-vocational State Rate State Rate Professional Services0395R Dept of personnel rtrn to wrk srvcs By Report By Report
0401A Claimant - private transportation, per mile State Rate State Rate To reimburse claimant costs
0402A Claimant - parking By Report By Report To reimburse claimant costs
0403A Claimant - bridge ferry tolls By Report By Report To reimburse claimant costs
0405A Claimant - commercial fare (airlines, railroad) By Report By Report To reimburse claimant costs
0406A Claimant - lodging (hotel/motel) State Rate State Rate To reimburse claimant costs
0407A Claimant - breakfast State Rate State Rate To reimburse claimant costs
0408A Claimant - lunch State Rate State Rate To reimburse claimant costs
NON-FACILITY FEE
Professional Services Fee SchedulesLocal Codes
July 01, 2015
Page 3
Local Code FeesLocal Code Description FACILITY FEE Payment Policy ReferenceNON-FACILITY
FEE
0409A Claimant - dinner State Rate State Rate To reimburse claimant costs
0411A By Report By Report To reimburse claimant costs
0412A State Rate State Rate To reimburse claimant costs
0413A Claimant - miscellaneous travel (must specify) State Rate State Rate To reimburse claimant costs
0414A Claimant - taxi one way, or mileage By Report By Report To reimburse claimant costs
0415A Claimant - replacement of clothing By Report By Report To reimburse claimant costs
0420A Lumbar seat support By Report By Report To reimburse claimant costs
0426A Silicone elastomer/scar conformer By Report By Report To reimburse claimant costs
0440A Wt loss prog,joining fee,worker reimburs $ 163.13 $ 163.13 To reimburse claimant costs
0441A Wt loss prog,weekly fee,worker reimburse $ 32.63 $ 32.63 To reimburse claimant costs0800V Early intervention services $ 9.06 $ 9.06 Professional Services0801V Early intervention services - intern $ 7.72 $ 7.72 Professional Services0802V Early interv, graduated rtw - vrc $ 9.06 $ 9.06 Professional Services0803V Early interv, graduated rtw - intern $ 7.72 $ 7.72 Professional Services0808V Stand alone job analysis ref voc $ 9.06 $ 9.06 Professional Services0809V Stand alone job analysis ref intern $ 7.72 $ 7.72 Professional Services0810V Assessment services $ 9.06 $ 9.06 Professional Services0811V Assessment services - intern $ 7.72 $ 7.72 Professional Services0812V Assessment services exception- vrc $ 9.06 $ 9.06 Professional Services0813V Assessment services exception- intern $ 7.72 $ 7.72 Professional Services0821V Vocational evaluation $ 9.06 $ 9.06 Professional Services0823V Pre-job or job modification consult $ 9.06 $ 9.06 Professional Services0824V Pre-job or job mod consult-intern $ 7.72 $ 7.72 Professional Services0830V Plan development services $ 9.06 $ 9.06 Professional Services0831V Plan development services-intern $ 7.72 $ 7.72 Professional Services0840V Plan implementation services $ 9.06 $ 9.06 Professional Services0841V Plan implementation services-intern $ 7.72 $ 7.72 Professional Services0842V Plan implementation services exception - vrc $ 9.06 $ 9.06 Professional Services0843V Plan implementation services exception - intern $ 7.72 $ 7.72 Professional Services
Claimant - time lost from work to attend department or self-insurer requested imeClaimant - travel related to a department or self-insurer requested exam
Professional Services Fee SchedulesLocal Codes
July 01, 2015
Page 4
Local Code FeesLocal Code Description FACILITY FEE Payment Policy ReferenceNON-FACILITY
FEE0844V Resume services - vrc $ 9.06 $ 9.06 Professional Services0845V Resume services - intern $ 7.72 $ 7.72 Professional Services0881V Forensic services $ 10.84 $ 10.84 Professional Services0891V Travel/wait time $ 4.54 $ 4.54 Professional Services0892V Travel/wait time - intern $ 4.54 $ 4.54 Professional Services0893V Professional mileage, vrc, per mile State Rate State Rate Professional Services0894V Professional mileage, intern, per mile State Rate State Rate Professional Services0895V Air travel, vrc, intern, or forensic vrc By Report By Report Professional Services0896V Ferry and bridge charges (voc) By Report By Report Professional Services0897V Hotel charges (voc) [out-of-state only] By Report By Report Professional Services1001M Work hardening eval, per hour $ 123.34 $ 123.34 Professional Services1026M AP final report at request of insurer $ 26.35 $ 26.35 Professional Services1027M Lep form by a/p at insurer's request $ 19.95 $ 19.95 Professional Services1028M Review of job offer/analysis by a/p $ 38.89 $ 38.89 Professional Services1038M Revw job offer/analysis for empl,per job $ 51.84 $ 51.84 Professional Services1040M Accident report, completion $ 39.88 $ 39.88 Professional Services1041M Reopening application $ 51.84 $ 51.84 Professional Services1044M Pt in remote areas $ 45.38 $ 45.38 Professional Services1045M Physical capacities exam (pce) $ 743.90 $ 743.90 Professional Services1046M Provider travel per mile, round trip exc $ 5.12 $ 5.12 Professional Services1055M Occupational disease hx, detailed, non-i, occupati $ 193.47 $ 193.47 Professional Services
1061M Claimant - per diem lodging/meals By Report By Report To reimburse claimant costs1063M Ime-ap review requested by dept. $ 39.88 $ 39.88 Professional Services1065M Attending doctor ime review written repo $ 29.91 $ 29.91 Professional Services1066M Provider review of video materials with report By Report By Report Professional Services1067M Assess impeds to rtrn to work, mentor Not Covered Not Covered Special Pilot1068M Assess impediments to rtrn to wrk, app Not Covered Not Covered Special Pilot1070M Refer for assessment of impediments $ 31.90 $ 31.90 Special Pilot1071M Quality indicator incentive payment $ 108.96 $ 108.96 Special Pilot1073M Activity prescription form, insurer requested $ 51.84 $ 51.84 Professional Services1074M AP response to vrc/employer request re: RTW $ 31.90 $ 31.90 Professional Services1076M Opioid req for subacute pain w/o doc $ 31.90 $ 31.90 Professional Services1077M Opioid req for subacute pain w/doc $ 59.83 $ 59.83 Professional Services1078M Opioid request for chronic pain $ 31.90 $ 31.90 Professional Services1104M Ime-addendum report $ 119.52 $ 119.52 Professional Services1105M Ime-physical capacities estimate $ 31.90 $ 31.90 Professional Services1108M Ime-standard, single $ 520.22 $ 520.22 Professional Services1109M Ime-complex, single $ 650.25 $ 650.25 Professional Services
Professional Services Fee SchedulesLocal Codes
July 01, 2015
Page 5
Local Code FeesLocal Code Description FACILITY FEE Payment Policy ReferenceNON-FACILITY
FEE1111M Ime-no show fee, single,standard/complex $ 221.37 $ 221.37 Professional Services1112M Ime-additional examiner $ 520.22 $ 520.22 Professional Services1118M Ime-by psychiatrist $ 941.39 $ 941.39 Professional Services1120M Ime-no show fee, psych $ 343.14 $ 343.14 Professional Services1122M Ime pain management impairment rating $ 520.22 $ 520.22 Professional Services1123M Ime - communication issues $ 209.20 $ 209.20 Professional Services1124M Ime, other, by report By Report By Report Professional Services1125M Ime-phys travel per mile, round trip exc $ 5.12 $ 5.12 Professional Services1128M Ime - occupational disease hx $ 193.47 $ 193.47 Professional Services1129M Ime - extensive file review by examiner $ 1.06 $ 1.06 Professional Services1130M Ime - terminated examination $ 370.58 $ 370.58 Professional Services1132M Ime document handling fee, per page $ 0.07 $ 0.07 Professional Services1133M Ime, cac document processing fee $ 62.00 $ 62.00 Professional Services1134M Ime, late cancellation fee, per examiner $ 221.37 $ 221.37 Professional Services1135M Ime, late cancellation fee, psychiatrist $ 343.14 $ 343.14 Professional Services1136M IME, Two claims included in evaluation $ 105.41 $ 105.41 Professional Services1137M IME, Three claims included in evaluation $ 210.79 $ 210.79 Professional Services1138M IME, Four or more claims included in evaluation $ 316.20 $ 316.20 Professional Services1139M IME, no show fee for missed neuropsychological testing $ 930.22 $ 930.22 Professional Services1140M IME, no show fee for missed PCE $ 297.56 $ 297.56 Professional Services1151M Omd requested consultation By Report By Report Professional Services1152M Coord of hlth svcs, pt present, initial Not Covered Not Covered Special Pilot1153M Coord of hlth svcs, pt present, maint Not Covered Not Covered Special Pilot1154M Cervical motion template studies $ 64.85 $ 64.85 Professional Services1155M Record rvw and rpt by cons w/o pt, opioid use Contracted Contracted Professional Services1157M Omd contracted consultant claim review Contracted Contracted Professional Services1158M Complex claim coordination $ 510.00 $ 510.00 Professional Services1159M Interest, self-insurer bills only By Report By Report Self-insurer Only1160M PGAP Educational Materials $ 81.60 $ 81.60 Professional Services1191M Impairment rating by a/p, standard $ 520.22 $ 520.22 Professional Services1192M Impairment rating by a/p, complex $ 650.25 $ 650.25 Professional Services1194M Impairment rating by consult, standard $ 520.22 $ 520.22 Professional Services1195M Impairment rating by consult, complex $ 650.25 $ 650.25 Professional Services1198M Impairment rating, addendum report $ 119.52 $ 119.52 Professional Services1207M Ur contracted - outpatient rvw data coll Contracted Contracted1215M Ur contracted - retrospective audit/review Contracted Contracted1220M Nurse case mgmt phone call per unit $ 10.17 $ 10.17 Professional Services1221M Nurse case mgmt visits per unit $ 10.17 $ 10.17 Professional Services1222M Nurse case mgmt case planning per unit $ 10.17 $ 10.17 Professional Services
Professional Services Fee SchedulesLocal Codes
July 01, 2015
Page 6
Local Code FeesLocal Code Description FACILITY FEE Payment Policy ReferenceNON-FACILITY
FEE1223M Nurse case mgmt travel/wait per unit $ 5.00 $ 5.00 Professional Services1224M Nurse case management mileage, per mile State Rate State Rate Professional Services
1225M By Report By Report Professional Services1226M Ur contract: prospective review - inpatient Contracted Contracted1227M Ur contract: prospective review - outpatient Contracted Contracted1230M Ur contract: retrospective outpatient review Contracted Contracted1243M Ur contract: retrospective inpatient review without bill audit Contracted Contracted1245M Utilization review physical medicine Contracted Contracted1246M UR contracted, PT data collection Contracted Contracted1247M UR, advanced imaging, web-based Contracted Contracted1248M UR, advanced imaging, fax, phone, mail Contracted Contracted1249M UR, advanced imaging re-review & alternate criteria review Contracted Contracted1250M UR, advanced imaging goldcard providers Contracted Contracted
1301W Stay at work clothing By Report By Report To reimburse employer costs
1302W Stay at work tools & equipment By Report By Report To reimburse employer costs
1303W Stay at work tuition By Report By Report To reimburse employer costs
1304W Stay at work books By Report By Report To reimburse employer costs
1305W Stay at work fees By Report By Report To reimburse employer costs
1306W Stay at work materials By Report By Report To reimburse employer costs2010M Pain clinic - evaluation $ 1152.66 $ 1152.66 Facility Services2011M Pain clinic - treatment, per day $ 738.31 $ 738.31 Facility Services2014M Pain clinic follow-up services: face-to face/hr $ 1.54 $ 1.54 Facility Services2015M Pain clinic follow-up services: not face-to face/hr $ 1.22 $ 1.22 Facility Services2050A Level 1: chiropractic care $ 43.42 $ 43.42 Professional Services2051A Level 2: chiropractic care visit $ 55.61 $ 55.61 Professional Services2052A Level 3: chiropractic care visit $ 67.76 $ 67.76 Professional Services2130A Naturopathic initial visit, routine $ 122.49 $ 122.49 Professional Services2131A Naturopathic initial visit, extended $ 177.33 $ 177.33 Professional Services2132A Naturopathic initial visit, comprehensive $ 271.80 $ 271.80 Professional Services2133A Naturopathic follow up visit, routine incl eval & treatment $ 71.75 $ 71.75 Professional Services2134A Naturopathic follow up visit, extended incl eval & treatment $ 147.57 $ 147.57 Professional Services
Nurse case management travel expenses (parking, tolls, ferry, lodging, airfare)
Professional Services Fee SchedulesLocal Codes
July 01, 2015
Page 7
Local Code FeesLocal Code Description FACILITY FEE Payment Policy ReferenceNON-FACILITY
FEE
4570A Claimant - misc. Medical supplies (must specify) By Report By Report To reimburse claimant costs5091V Hearing aid restocking fee By Report By Report Professional Services5092V Heaing aid cleaning visit, hearing aid cleaning vi $ 25.09 $ 25.09 Professional Services5093V Hearing aid repair (manf invoice required) By Report By Report Professional Services8880H Nursing facility rehab - ultra high (per $ 667.51 $ 667.51 Facility Services8881H Nursing facility rehab - very high (per $ 500.06 $ 500.06 Facility Services8882H Nursing facility rehab - high (per day) $ 466.09 $ 466.09 Facility Services8883H Nursing facility rehab - medium (per day $ 430.88 $ 430.88 Facility Services8884H Nursing facility rehab - low (per day) $ 336.01 $ 336.01 Facility Services8885H Nursing facility extensive services (per $ 417.04 $ 417.04 Facility Services8886H Nursing facility special care (per day) $ 310.66 $ 310.66 Facility Services8887H Nursing facility clinically complex (per $ 308.94 $ 308.94 Facility Services8888H Nursing facility impaired cognition (per $ 227.90 $ 227.90 Facility Services8889H Nursing facility behavior only (per day) $ 226.22 $ 226.22 Facility Services8890H Nursing facility physical functn reduced $ 238.34 $ 238.34 Facility Services8893H L&I Residential facility, low level care $ 166.82 $ 166.82 Facility Services8894H L&I Residential facility, mid level care $ 202.59 $ 202.59 Facility Services8895H L&I Residential facility, high level care $ 238.34 $ 238.34 Facility Services8901H Attendant svcs by department approved sp $ 13.46 $ 13.46 Professional Services8902H Nursing home or residential care (group home, boarding home) By Report By Report Facility Services8914H Home modification, construction and design By Report By Report Professional Services8915H Vehicle modification By Report By Report Professional Services8916H Home modification evaluation and consultation By Report By Report Professional Services8917H Home/vehicle modification mileage, lodging, airfare, car rental State Rate State Rate Professional Services8918H Vehicle modification initial evaluation or consultation By Report By Report Professional Services8950H Comprehensive brain injury evaluation $ 4436.71 $ 4436.71 Facility Services8951H Post-acute brain injury rehab-full day $ 1006.44 $ 1006.44 Facility Services8952H Post-acute brain injury rehab-half day $ 700.96 $ 700.96 Facility Services9970M Video interpreting services - Spanish $ 1.57 $ 1.57 Professional Services9971M Video interpreting svcs - other than Spanish $ 2.03 $ 2.03 Professional Services9972M Video interpreting svcs – American sign language $ 3.16 $ 3.16 Professional Services9986M Interpreter mileage, per mile State Rate State Rate Professional Services9988M Group interpreter services, per minute $ 0.84 $ 0.84 Professional Services9989M Individual interpreter services, per minute $ 0.84 $ 0.84 Professional Services9996M Interpreter, ime no show fee $ 55.59 $ 55.59 Professional Services9997M Document translation at insurer request By Report By Report Professional Services9999M Telephone interpretation Contracted Contracted Professional Services
Professional Services Fee SchedulesLocal Codes
July 01, 2015
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Local Code FeesLocal Code Description FACILITY FEE Payment Policy ReferenceNON-FACILITY
FEE
R0310 Retraining tuition fees By Report By Report To reimburse claimant costs
R0312 Retraining supplies By Report By Report To reimburse claimant costs
R0315 Retraining equipment By Report By Report To reimburse claimant costs
R0320 Retraining examination and license fees By Report By Report To reimburse claimant costs
R0340 Retraining books By Report By Report To reimburse claimant costs
R0350 Retraining other By Report By Report To reimburse claimant costs
R0360 Retraining board By Report By Report To reimburse claimant costs
R0370 Retraining room By Report By Report To reimburse claimant costs
R0390 Retraining child care licensd 6 hr/less By Report By Report To reimburse claimant costs
R0392 Retraining child care licensd 7-9 hrs ea By Report By Report To reimburse claimant costs
V0028 Travel, vocational services, claimant State Rate State Rate To reimburse claimant costs
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
Page 1
Professional Services Fee ScheduleLocal Codes by Specialty
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
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Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceAU Audiology (AU)AU 5091V Hearing aid restocking fee By Report By Report Professional ServicesAU 5092V Hearing aid cleaning visit $ 25.09 $ 25.09 Professional ServicesAU 5093V Hearing aid repair (manf invoice required) By Report By Report Professional Services
BI Brain Injury (BI)BI 8950H Comprehensive brain injury evaluation $ 4436.71 $ 4436.71 Facility ServicesBI 8951H Post-acute brain injury rehab-full day $ 1006.44 $ 1006.44 Facility ServicesBI 8952H Post-acute brain injury rehab-half day $ 700.96 $ 700.96 Facility Services
CM Case Management (CM)CM 1220M Nurse case mgmt phone call per unit $ 10.17 $ 10.17 Professional ServicesCM 1221M Nurse case mgmt visits per unit $ 10.17 $ 10.17 Professional ServicesCM 1222M Nurse case mgmt case planning per unit $ 10.17 $ 10.17 Professional ServicesCM 1223M Nurse case mgmt travel/wait per unit $ 5.00 $ 5.00 Professional ServicesCM 1224M Nurse case management mileage, per mile State Rate State Rate Professional Services
CM 1225M By Report By Report Professional Services
CH Chiropractic Care (CH)CH 2050A Level 1: Chiropractic care visit (straightforward complexity) $ 43.42 $ 43.42 Professional ServicesCH 2051A Level 2: Chiropractic care visit (low complexity) $ 55.61 $ 55.61 Professional ServicesCH 2052A Level 3: Chiropractic care visit (moderate complexity) $ 67.76 $ 67.76 Professional Services
CL Claimant Only (CL) CL 0010E Ankle weight purchase By Report By Report To reimburse claimant costsCL 0012E Wrist weight purchase By Report By Report To reimburse claimant costsCL 0401A Claimant - Private transportation, per mile State Rate State Rate To reimburse claimant costsCL 0402A Claimant - Parking By Report By Report To reimburse claimant costsCL 0403A Claimant - Bridge and ferry tolls By Report By Report To reimburse claimant costsCL 0405A Claimant - Commercial fare (airlines, railroad) By Report By Report To reimburse claimant costsCL 0406A Claimant - Lodging (hotel/motel) State Rate State Rate To reimburse claimant costs
Specialty Code
NON-FACILITY FEE
Nurse case management travel expenses (parking, ferry and bridge tolls, lodging, airfare)
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
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Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceSpecialty
CodeNON-FACILITY
FEECL 0407A Claimant - Breakfast State Rate State Rate To reimburse claimant costsCL 0408A Claimant - Lunch State Rate State Rate To reimburse claimant costsCL 0409A Claimant - Dinner State Rate State Rate To reimburse claimant costsCL 0411A Claimant - time lost from work to attend department or self-insurer requested IME By Report By Report To reimburse claimant costsCL 0412A Claimant - Travel related to a department or self-insurer requested exam State Rate State Rate To reimburse claimant costsCL 0413A Claimant - Miscellaneous travel (must specify) State Rate State Rate To reimburse claimant costsCL 0414A Claimant - Taxi one way, or mileage By Report By Report To reimburse claimant costsCL 0415A Claimant - replacement of clothing By Report By Report To reimburse claimant costsCL 4570A Claimant - misc. Medical supplies (must specify) By Report By Report To reimburse claimant costsCL R0310 Retraining tuition fees By Report By Report To reimburse claimant costsCL R0312 Retraining supplies By Report By Report To reimburse claimant costsCL R0315 Retraining equipment By Report By Report To reimburse claimant costsCL R0320 Retraining examination and license fees By Report By Report To reimburse claimant costsCL R0340 Retraining books By Report By Report To reimburse claimant costsCL R0350 Retraining other By Report By Report To reimburse claimant costsCL R0360 Retraining board By Report By Report To reimburse claimant costsCL R0370 Retraining room By Report By Report To reimburse claimant costsCL R0390 Retraining child care licensd 6 hr/less By Report By Report To reimburse claimant costsCL R0392 Retraining child care licensd 7-9 hrs ea By Report By Report To reimburse claimant costsCL V0028 Travel, vocational services, claimant State Rate State Rate To reimburse claimant costsCL 1061M Claimant - per diem lodging/meals By Report By Report To reimburse claimant costs
DM Durable Medical Equipment (DM)DM 0010E Ankle weight purchase By Report By Report To reimburse claimant costsDM 0012E Wrist weight purchase By Report By Report To reimburse claimant costsDM 0420A Lumbar seat support By Report By Report To reimburse claimant costsDM 0426A Silicone elastomer/scar conformer By Report By Report To reimburse claimant costsDM 4570A Claimant - Misc. medical supplies (must specify) By Report By Report To reimburse claimant costs
EM Employer Only (EM)EM 1301W Stay at work clothing By Report By Report To reimburse employer costsEM 1302W Stay at work tools & equipment By Report By Report To reimburse employer costs
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
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Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceSpecialty
CodeNON-FACILITY
FEEEM 1303W Stay at work tuition By Report By Report To reimburse employer costsEM 1304W Stay at work books By Report By Report To reimburse employer costsEM 1305W Stay at work fees By Report By Report To reimburse employer costsEM 1306W Stay at work materials By Report By Report To reimburse employer costs
HM Home Modification (HM)HM 8914H Home modification, construction and design By Report By Report Professional ServicesHM 8916H Home modification evaluation and consultation By Report By Report Professional ServicesHM 8917H Home/vehicle modification mileage, lodging, airfare, car rental State Rate State Rate Professional Services
HC Home & Attendant Care (HC)HC 8901H Attendant services by department approved spouse provider (per hour) $ 13.46 $ 13.46 Professional Services
IM Independent Medical Exam (IM)IM 1063M IME - Attending doctor review of independent medical exam (IME) $ 39.88 $ 39.88 Professional ServicesIM 1104M IME - Addendum report $ 119.52 $ 119.52 Professional ServicesIM 1105M IME - Physical capacities estimate $ 31.90 $ 31.90 Professional ServicesIM 1108M IME - Standard, single $ 520.22 $ 520.22 Professional ServicesIM 1109M IME - Complex, single $ 650.25 $ 650.25 Professional ServicesIM 1111M IME - No show fee, single examiner, standard or complex $ 221.37 $ 221.37 Professional ServicesIM 1112M IME - Additional examiner $ 520.22 $ 520.22 Professional ServicesIM 1118M IME - by psychiatrist $ 941.39 $ 941.39 Professional ServicesIM 1120M IME - No show fee, psych $ 343.14 $ 343.14 Professional ServicesIM 1122M IME - Pain management impairment rating $ 520.22 $ 520.22 Professional ServicesIM 1123M IME - Communication issues $ 209.20 $ 209.20 Professional ServicesIM 1124M IME - Other By Report By Report Professional ServicesIM 1125M IME - Physician travel per mile; allowed when round trip exceeds 14 mi. $ 5.12 $ 5.12 Professional ServicesIM 1128M IME - Occupational disease history $ 193.47 $ 193.47 Professional ServicesIM 1129M IME - Extensive file review, per page $ 1.06 $ 1.06 Professional ServicesIM 1130M IME - Terminated examination $ 370.58 $ 370.58 Professional ServicesIM 1132M IME - document handling fee, per page $ 0.07 $ 0.07 Professional ServicesIM 1133M IME - cac document processing fee $ 62.00 $ 62.00 Professional Services
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
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Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceSpecialty
CodeNON-FACILITY
FEEIM 1134M Ime, late cancellation fee, per examiner $ 221.37 $ 221.37 Professional ServicesIM 1135M Ime, late cancellation fee, psychiatrist $ 343.14 $ 343.14 Professional ServicesIM 1136M IME, Two claims included in evaluation $ 105.41 $ 105.41 Professional ServicesIM 1137M IME, Three claims included in evaluation $ 210.79 $ 210.79 Professional ServicesIM 1138M IME, Four or more claims included in evaluation $ 316.20 $ 316.20 Professional ServicesIM 1139M IME, no show fee for missed neuropsychological testing $ 930.22 $ 930.22 Professional ServicesIM 1140M IME, no show fee for missed PCE $ 297.56 $ 297.56 Professional ServicesIM 9996M IME - Interpreter, ime no show fee $ 55.59 $ 55.59 Professional Services
IR Impairment Rating (IR)IR 1191M Impairment rating exam and report by attending doctor, standard $ 520.22 $ 520.22 Professional ServicesIR 1192M Impairment rating exam and report by attending doctor, complex $ 650.25 $ 650.25 Professional ServicesIR 1194M Impairment rating exam and report by consultant, standard $ 520.22 $ 520.22 Professional ServicesIR 1195M Impairment rating exam and report by consultant, complex $ 650.25 $ 650.25 Professional ServicesIR 1198M Impairment rating, addendum report $ 119.52 $ 119.52 Professional Services
IN Interpretive Services (IN)IN 9970M Video interpreting services - Spanish $ 1.57 $ 1.57 Professional ServicesIN 9971M Video interpreting svcs - other than Spanish $ 2.03 $ 2.03 Professional ServicesIN 9972M Video interpreting svcs – American sign language $ 3.16 $ 3.16 Professional ServicesIN 9986M Interpreter mileage, per mile State Rate State Rate Professional ServicesIN 9988M Group interpreter services, per minute $ 0.84 $ 0.84 Professional ServicesIN 9989M Individual interpreter services, per minute $ 0.84 $ 0.84 Professional ServicesIN 9996M Interpreter, ime no show fee $ 55.59 $ 55.59 Professional ServicesIN 9997M Document translation at insurer request By Report By Report Professional ServicesIN 9999M Telephone interpretation Contracted Contracted Professional Services
JM Job Modification (JM)JM 0378R Stand Alone Job Analysis, non-VRC, per 6 minutes $ 9.24 $ 9.24 Professional ServicesJM 0380R Job modification By Report By Report Professional ServicesJM 0385R Pre-job accommodation By Report By Report Professional ServicesJM 0389R Pre-job or job modification consultation, non-VRC, per 6 minutes $ 11.24 $ 11.24 Professional Services
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
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Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceSpecialty
CodeNON-FACILITY
FEEJM 0808V Stand Alone Job Analysis, VRC, per 6 minutes $ 9.06 $ 9.06 Professional ServicesJM 0809V Stand Alone Job Analysis, intern, per 6 minutes $ 7.72 $ 7.72 Professional ServicesJM 0823V Pre-job or job modification consultation, VRC, per 6 minutes $ 9.06 $ 9.06 Professional ServicesJM 0824V Pre-job or job modification consultation, intern, per 6 minutes $ 7.72 $ 7.72 Professional ServicesJM 1028M Review of job descriptions or job analysis, each additional review $ 38.89 $ 38.89 Professional ServicesJM 1038M Review of job descriptions or job analysis $ 51.84 $ 51.84 Professional Services
MS Miscellaneous & Special Services (MS)MS 1044M Pt in remote areas $ 45.38 $ 45.38 Professional ServicesMS 1045M Physical capacities exam (PCE) $ 743.90 $ 743.90 Professional ServicesTL 1046M Provider mileage, per mile, when round trip exceeds 14 miles. $ 5.12 $ 5.12 Professional ServicesMS 1067M Assess imped to rtrn to wrk, mentor Not Covered Not Covered Special PilotMS 1068M Assess impediments to rtrn to wrk, app Not Covered Not Covered Special PilotMS 1070M Refer for assessment of impediments $ 31.90 $ 31.90 Special PilotMS 1071M Quality indicator incentive payment $ 108.96 $ 108.96 Special PilotMS 1151M Omd requested consultation By Report By Report Professional ServicesMS 1152M Coord of hlth svcs, pt present, initial Not Covered Not Covered Special PilotMS 1153M Coord of hlth svcs, pt present, maint Not Covered Not Covered Special PilotMS 1154M Cervical motion template studies $ 64.85 $ 64.85 Professional ServicesMS 1155M Record rvw and rpt by cons w/o pt, opioid use Contracted Contracted Professional ServicesMS 1157M OMD contracted consultant claim review Contracted Contracted Professional ServicesMS 1158M Complex claim coordination $ 510.00 $ 510.00 Professional ServicesMS 1159M Interest, self-insurer bills only By Report By Report Self-insurer OnlyMS 1160M PGAP Educational Materials $ 81.60 $ 81.60 Professional Services
NC Naturopathic Care (NC)NC 2130A Naturopathic initial visit, routine $ 122.49 $ 122.49 Professional ServicesNC 2131A Naturopathic initial visit, extended $ 177.33 $ 177.33 Professional ServicesNC 2132A Naturopathic initial visit, comprehensive $ 271.80 $ 271.80 Professional ServicesNC 2133A Naturopathic follow up visit, routine incl eval & treatment $ 71.75 $ 71.75 Professional ServicesNC 2134A Naturopathic follow up visit, extended incl eval & treatment $ 147.57 $ 147.57 Professional Services
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
Page 7
Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceSpecialty
CodeNON-FACILITY
FEEPA Pain Treatment (PA)PA 2010M Pain clinic evaluation $ 1152.66 $ 1152.66 Facility ServicesPA 2011M Pain clinic treatment, per day $ 738.31 $ 738.31 Facility ServicesPA 2014M Pain clinic follow-up services: face-to face/hr $ 1.54 $ 1.54 Facility ServicesPA 2015M Pain clinic follow-up services: not face-to face/hr $ 1.22 $ 1.22 Facility Services
RS Residential Services (RS)RS 8880H Nursing home, rehab - ultra high (per day) $ 667.51 $ 667.51 Facility ServicesRS 8881H Nursing home, rehab - very high (per day) $ 500.06 $ 500.06 Facility ServicesRS 8882H Nursing home, rehab - high (per day) $ 466.09 $ 466.09 Facility ServicesRS 8883H Nursing home, rehab - medium (per day) $ 430.88 $ 430.88 Facility ServicesRS 8884H Nursing home, rehab - low (per day) $ 336.01 $ 336.01 Facility ServicesRS 8885H Nursing home, extensive services (per day) $ 417.04 $ 417.04 Facility ServicesRS 8886H Nursing home, special care (per day) $ 310.66 $ 310.66 Facility ServicesRS 8887H Nursing home, clinically complex (per day) $ 308.94 $ 308.94 Facility ServicesRS 8888H Nursing home, impaired cognition (per day) $ 227.90 $ 227.90 Facility ServicesRS 8889H Nursing home, behavior only (per day) $ 226.22 $ 226.22 Facility ServicesRS 8890H Nursing home, reduced physical function (per day) $ 238.34 $ 238.34 Facility ServicesRS 8893H L&I Residential facility, low level care $ 166.82 $ 166.82 Facility ServicesRS 8894H L&I Residential facility, mid level care $ 202.59 $ 202.59 Facility ServicesRS 8895H L&I Residential facility, high level care $ 238.34 $ 238.34 Facility ServicesRS 8902H Nursing home or residential care (group home, boarding home) By Report By Report Facility Services
RT Retraining (RT)RT 0301R Retraining, plan travel, mileage State Rate State Rate To reimburse claimant costsRT 0302R Retraining, plan travel, parking By Report By Report To reimburse claimant costsRT 0303R Retraining, plan travel, bridge and ferry tolls By Report By Report To reimburse claimant costsRT 0304R Retraining, plan travel, commercial transportation By Report By Report To reimburse claimant costsRT 0375R Retraining, relocation costs By Report By Report To reimburse claimant costsRT R0310 Retraining tuition fees By Report By Report To reimburse claimant costsRT R0312 Retraining supplies By Report By Report To reimburse claimant costsRT R0315 Retraining equipment By Report By Report To reimburse claimant costs
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
Page 8
Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceSpecialty
CodeNON-FACILITY
FEERT R0320 Retraining examination and license fees By Report By Report To reimburse claimant costsRT R0340 Retraining books By Report By Report To reimburse claimant costsRT R0350 Retraining other By Report By Report To reimburse claimant costsRT R0360 Retraining board By Report By Report To reimburse claimant costsRT R0370 Retraining room By Report By Report To reimburse claimant costsRT R0390 Retraining child care licensd 6 hr/less By Report By Report To reimburse claimant costsRT R0392 Retraining child care licensd 7-9 hrs ea By Report By Report To reimburse claimant costs
SR Special Reports (SR)SR 1026M AP final report at request of insurer $ 26.35 $ 26.35 Professional ServicesSR 1027M Loss of earning power form (LEP) $ 19.95 $ 19.95 Professional ServicesSR 1028M Review of job descriptions or job analysis, each additional review $ 38.89 $ 38.89 Professional ServicesSR 1038M Review of job descriptions or job analysis $ 51.84 $ 51.84 Professional ServicesSR 1040M Report of industrial injury or occupational disease/ report of accident (ROA) $ 39.88 $ 39.88 Professional ServicesSR 1041M Application to reopen claim $ 51.84 $ 51.84 Professional ServicesSR 1055M Occupational disease history form $ 193.47 $ 193.47 Professional ServicesSR 1063M Attending doctor review of independent medical exam (IME) $ 39.88 $ 39.88 Professional ServicesSR 1065M Attending doctor IME review written report $ 29.91 $ 29.91 Professional ServicesSR 1066M Review of video materials with report By Report By Report Professional ServicesSR 1067M Assess imped to rtrn to wrk, mentor Not Covered Not Covered Special pilotSR 1068M Assess impediments to rtrn to wrk, app Not Covered Not Covered Special pilotSR 1073M Activity prescription form, insurer requested $ 51.84 $ 51.84 Professional ServicesSR 1074M AP response to vrc/employer request re: RTW $ 31.90 $ 31.90 Professional ServicesSR 1076M Opioid req for subacute pain w/o doc $ 31.90 $ 31.90 Professional ServicesSR 1077M Opioid req for subacute pain w/doc $ 59.83 $ 59.83 Professional ServicesSR 1078M Opioid request for chronic pain $ 31.90 $ 31.90 Professional Services
TL Travel, Lodging & Meals (TL)TL 0301R Retraining, plan travel, mileage State Rate State Rate To reimburse claimant costsTL 0302R Retraining, plan travel, parking By Report By Report To reimburse claimant costsTL 0303R Retraining, plan travel, bridge and ferry tolls By Report By Report To reimburse claimant costsTL 0304R Retraining, plan travel, commercial transportation By Report By Report To reimburse claimant costs
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
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Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceSpecialty
CodeNON-FACILITY
FEETL 0375R Retraining, relocation costs By Report By Report To reimburse claimant costsTL 0391R Travel/wait time, non-VRC, per 6 minutes $ 5.09 $ 5.09 Professional ServicesTL 0392R Mileage, non-VRC, per mile State Rate State Rate Professional ServicesTL 0393R Ferry and bridge tolls, non-vocational State Rate State Rate Professional ServicesTL 0401A Claimant - Private transportation, per mile State Rate State Rate To reimburse claimant costsTL 0402A Claimant - Parking By Report By Report To reimburse claimant costsTL 0403A Claimant - Bridge and ferry tolls By Report By Report To reimburse claimant costsTL 0405A Claimant - Commercial fare (airlines, railroad) By Report By Report To reimburse claimant costsTL 0406A Claimant - Lodging (hotel/motel) State Rate State Rate To reimburse claimant costsTL 0407A Claimant - Breakfast State Rate State Rate To reimburse claimant costsTL 0408A Claimant - Lunch State Rate State Rate To reimburse claimant costsTL 0409A Claimant - Dinner State Rate State Rate To reimburse claimant costsTL 0411A Claimant - time lost from work to attend department or self-insurer requested IME By Report By Report To reimburse claimant costsTL 0412A Claimant - Travel related to a department or self-insurer requested exam State Rate State Rate To reimburse claimant costsTL 0413A Claimant - Miscellaneous travel (must specify) State Rate State Rate To reimburse claimant costsTL 0414A Claimant - Taxi one way, or mileage By Report By Report To reimburse claimant costsTL 0891V Travel/wait time, VRC or forensic VRC, per 6 minutes $ 4.54 $ 4.54 Professional ServicesTL 0892V Travel/wait time, intern, per 6 minutes $ 4.54 $ 4.54 Professional ServicesTL 0893V Professional mileage, VRC, per mile State Rate State Rate Professional ServicesTL 0894V Professional mileage, intern, per mile State Rate State Rate Professional ServicesTL 0895V Air travel, VRC, intern, or forensic VRC By Report By Report Professional ServicesTL 0896V Ferry and bridge tolls (Voc) By Report By Report Professional ServicesTL 0897V Hotel charges (Voc) [Out-of-state only] By Report By Report Professional ServicesTL 1046M Provider mileage, per mile, when round trip exceeds 14 miles. $ 5.12 $ 5.12 Professional ServicesTL 1061M Claimant - per diem lodging/meals By Report By Report To reimburse claimant costsTL 1125M IME - Physician travel per mile; allowed when round trip exceeds 14 mi. $ 5.12 $ 5.12 Professional ServicesTL 1223M Nurse case management travel/wait time, per 6 minutes $ 5.00 $ 5.00 Professional ServicesTL 1224M Nurse case management mileage, per mile State Rate State Rate Professional Services
TL 1225M By Report By Report Professional Services
TL 8917H Home/vehicle modification mileage, lodging, airfare, car rental State Rate State Rate Professional ServicesTL 9986M Interpreter mileage, per mile State Rate State Rate Professional Services
Nurse case management travel expenses (parking, ferry and bridge tolls, lodging, airfare)
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
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Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceSpecialty
CodeNON-FACILITY
FEETL V0028 Travel, vocational services, claimant State Rate State Rate To reimburse claimant costs
UR Utilization Review (UR)UR 1207M UR contracted - outpatient rvw data coll Contracted ContractedUR 1215M UR contracted - retrospective audit/review Contracted ContractedUR 1226M UR Contract: Prospective review - inpatient Contracted ContractedUR 1227M UR Contract: Prospective review - outpatient Contracted ContractedUR 1230M UR Contract: Retrospective outpatient review Contracted ContractedUR 1243M UR Contract: Retrospective inpatient review without bill audit Contracted ContractedUR 1245M Utilization review physical medicine Contracted ContractedUR 1246M UR contracted, PT data collection Contracted ContractedUR 1247M UR, advanced imaging, web-based Contracted ContractedUR 1248M UR, advanced imaging, fax, phone, mail Contracted ContractedUR 1249M UR, advanced imaging re-review & alternate criteria review Contracted ContractedUR 1250M UR, advanced imaging goldcard providers Contracted Contracted
VM Vehicle Modification (VM)VM 8915H Vehicle modification By Report By Report Professional ServicesVM 8917H Home/vehicle modification mileage, lodging, airfare, car rental State Rate State Rate Professional ServicesVM 8918H Vehicle modification initial evaluation or consultation By Report By Report Professional Services
VR Vocational & Related Services (VR)VR 0378R Stand Alone Job Analysis, non-VRC, per 6 minutes $ 9.24 $ 9.24 Professional ServicesVR 0380R Job modification By Report By Report Professional ServicesVR 0385R Pre-job accommodation By Report By Report Professional ServicesVR 0388R Plan development services, non-voc By Report By Report Professional ServicesVR 0389R Pre-job or job modification consultation, non-VRC, per 6 minutes $ 11.24 $ 11.24 Professional ServicesVR 0390R Work evaluation, non-VRC, per 6 minutes $ 9.24 $ 9.24 Professional ServicesVR 0391R Travel/wait time, non-VRC, per 6 minutes $ 5.09 $ 5.09 Professional ServicesVR 0392R Mileage, non-VRC, per mile State Rate State Rate Professional ServicesVR 0393R Ferry and bridge tolls, non-vocational State Rate State Rate Professional ServicesVR 0395R Dept of Personnel rtrn to wrk srvcs By Report By Report
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
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Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceSpecialty
CodeNON-FACILITY
FEEVR 0800V Early intervention services, VRC, per 6 minutes $ 9.06 $ 9.06 Professional ServicesVR 0801V Early intervention services, intern, per 6 minutes $ 7.72 $ 7.72 Professional ServicesVR 0802V Early Intervention Services Extension, VRC, per 6 minutes $ 9.06 $ 9.06 Professional ServicesVR 0803V Early Intervention Services Extension intern, per 6 minutes $ 7.72 $ 7.72 Professional ServicesVR 0808V Stand Alone Job Analysis, VRC, per 6 minutes $ 9.06 $ 9.06 Professional ServicesVR 0809V Stand Alone Job Analysis, intern, per 6 minutes $ 7.72 $ 7.72 Professional ServicesVR 0810V Assessment services, VRC, per 6 minutes $ 9.06 $ 9.06 Professional ServicesVR 0811V Assessment services, intern, per 6 minutes $ 7.72 $ 7.72 Professional ServicesVR 0812V Assessment services exception- vrc $ 9.06 $ 9.06 Professional ServicesVR 0813V Assessment services exception- intern $ 7.72 $ 7.72 Professional ServicesVR 0821V Work evaluation, VRC, per 6 minutes $ 9.06 $ 9.06 Professional ServicesVR 0823V Pre-job or job modification consultation, VRC, per 6 minutes $ 9.06 $ 9.06 Professional ServicesVR 0824V Pre-job or job modification consultation, intern, per 6 minutes $ 7.72 $ 7.72 Professional ServicesVR 0830V Plan development services, VRC, per 6 minutes $ 9.06 $ 9.06 Professional ServicesVR 0831V Plan development services, intern, per 6 minutes $ 7.72 $ 7.72 Professional ServicesVR 0840V Plan implementation services, VRC, per 6 minutes $ 9.06 $ 9.06 Professional ServicesVR 0841V Plan implementation services, intern, per 6 minutes $ 7.72 $ 7.72 Professional ServicesVR 0842V Plan implementation services exception - vrc $ 9.06 $ 9.06 Professional ServicesVR 0843V Plan implementation services exception - intern $ 7.72 $ 7.72 Professional ServicesVR 0844V Resume services - vrc $ 9.06 $ 9.06 Professional ServicesVR 0845V Resume services - intern $ 7.72 $ 7.72 Professional ServicesVR 0881V Forensic services, forensic VRC, per 6 minutes $ 10.84 $ 10.84 Professional ServicesVR 0891V Travel/wait time, VRC or forensic VRC, per 6 minutes $ 4.54 $ 4.54 Professional ServicesVR 0892V Travel/wait time, intern, per 6 minutes $ 4.54 $ 4.54 Professional ServicesVR 0893V Professional mileage, VRC, per mile State Rate State Rate Professional ServicesVR 0894V Professional mileage, intern, per mile State Rate State Rate Professional ServicesVR 0895V Air travel, VRC, intern, or forensic VRC By Report By Report Professional ServicesVR 0896V Ferry and bridge tolls (Voc) By Report By Report Professional ServicesVR 0897V Hotel charges (Voc) [Out-of-state only] By Report By Report Professional ServicesVR V0028 Travel, vocational services, claimant State Rate State Rate To reimburse claimant costs
WL Weight Loss (WL)
Professional Services Fee SchedulesLocal Codes by Specialty
July 01, 2015
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Local Code Fees by Specialty
Local Code Description FACILITY FEE Payment Policy ReferenceSpecialty
CodeNON-FACILITY
FEEWL 0440A Weight loss program, joining fee, worker reimbursement $ 163.13 $ 163.13 To reimburse claimant costsWL 0441A Weight loss program, weekly fee, worker reimbursement $ 32.63 $ 32.63 To reimburse claimant costs
WH Work Hardening (WH)WH 1001M Work hardening - Evaluation, per hour (max 6 hours) $ 123.34 $ 123.34 Professional Services
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