Read HCPCS Fee Schedule text version

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

Professional Services Fee Schedule

HCPCS Level II Fees

Effective for Dates of Service on or After

July 1, 2011

To Skip The Keys & Go To The Fees Click Here

Refer to Field Key for definitions

HCPCS Page 1

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

This document is also on the departments Internet web site at http://feeschedules.lni.wa.gov/. Updates to this manual can be found under ,,Updates and Corrections tab on the departments 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.

Refer to Field Key for definitions

HCPCS Page 2

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

HCPCS LEVEL II FEES FIELD KEY:

Column Title CPT CODE/ HCPCS CODE

®

Column Description 2011 CPT® or HCPCS code Abbreviated HCPCS code description. No descriptions are provided for CPT® codes. 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. 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.

Column Values

Value Definitions 2011 CPT® or HCPCS code Abbreviated description for reference purposes only. Refer to a 2011 CPT® or HCPCS code book for complete code descriptions.

ABBREVIATED DESCRIPTION

Dollar Value Bundled By Report

Maximum dollar amount payable for covered Bundled code, not separately payable. Service paid on a "by report" basis. Contracted service. Payable only to departments contracted vendor for State Fund claims. Payable to providers treating Self-Insured injured workers. Procedure code for facility outpatient use only. Procedure code is not covered.

DOLLAR VALUE NON-FACILITY SETTING

Contracted

Facility Only Not Covered

DOLLAR VALUE FACILITY SETTING

See "Dollar Value ­ Non-Facility Setting" above, for column values and definitions.

Refer to Field Key for definitions

HCPCS Page 3

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

Field Key: HCPCS Level II (continued)

Column Title FOL UP PRE OP (-56) INTRA OP (-54) POST OP (-55) Column Description Follow-up Days for Global Surgery Preoperative Percentage (Modifier ­56) Intraoperative Percentage (Modifier ­54) Postoperative Percentage (Modifier ­55) Column Values Number Value Definitions The number of days following surgery during which charges for normal postoperative care are bundled in the global surgery fee. The percent of the total global surgery dollar value that is allowed when modifier ­56 is billed. The percent of the total global surgery dollar value that is allowed when modifier -54 is billed. The percent of the total global surgery dollar value that is allowed when modifier -55 is billed. 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).

Percent Percent Percent

0

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.

1

2

Refer to Field Key for definitions

HCPCS Page 4

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

Field Key: HCPCS Level II (continued)

Column Title Column Description Column Values Value Definitions 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 physicians 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.

3

PCTC (26/TC) CONTINUED

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.

4

5

6

Refer to Field Key for definitions

HCPCS Page 5

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

Field Key: HCPCS Level II (continued)

Column Title Column Description Column Values

7

PCTC (26/TC) CONTINUED

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.

8

Value Definitions This indicator is not currently in use. 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. Modifier -51 is not valid . Payment adjustment rules for multiple surgeries do not apply. This indicator is not currently in use. 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. This indicator is not currently in use. Modifier -51 is not valid . Concept of multiple surgery does not apply.

9

0 1 Multiple Surgery Indicator (Modifier ­51) This field indicates whether multiple surgery payment rules apply to the service. 2

MSI

3

4 9

Refer to Field Key for definitions

HCPCS Page 6

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

Field Key: HCPCS Level II (continued)

Column Title Column Description Column Values 0 Value Definitions 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.

1

BSI

Bilateral Surgery Indicator (Modifier ­50) This field indicates whether the procedure is subject to a payment adjustment for bilateral surgery.

2

3

9

Refer to Field Key for definitions

HCPCS Page 7

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

Field Key: HCPCS Level II (continued)

Column Title Column Description Column Values Value Definitions 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. 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.

0

ASI

Assistant Surgeon Indicator (Modifiers ­80, -81, -82) This field indicates whether or not an assistant surgeon may be paid for the procedure.

1

2

9

0

CSI

Co-surgeons Indicator (Modifier ­62) This field indicates whether or not cosurgeons may be paid for the procedure.

1

2

9

Refer to Field Key for definitions

HCPCS Page 8

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

Field Key: HCPCS Level II (continued)

Column Title Column Description Column Values 0 Team Surgeons Indicator (Modifier -66) This field indicates whether or not team surgeons may be paid for the procedure. Value Definitions 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. Bundled code, not separately payable. Contracted service. Payable only to departments 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). Flat fee developed by the department Clinical lab fee No fee or RVUs available, code paid by report. For hospital outpatient use only. RBRVS fee State Rate Tracking code Non-covered code

1

TSI

2 9

ENDO BASE

Endoscopy Base Code

Code number

B C

FSI

Fee Schedule Indicator This column indicates the payment status for the procedure code.

D F L N O R S T X

Refer to Field Key for definitions

HCPCS Page 9

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

Field Key: HCPCS Level II (continued)

Column Title LIC REQ Column Description Column Values Y Licensure Required blank Prior authorization indicator This column indicates whether prior authorization and utilization review is required. Y Y-UR No special professional licensure is required to bill the department. Prior authorization required Prior authorization and UR required Value Definitions Appropriate professional licensure is required to bill the department for these codes.

PRIOR

AUTH

Refer to Field Key for definitions

HCPCS Page 10

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

HCPCS Level II Fees

HCPCS CODE ABBREVIATED DESCRIPTION DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING FOL UP PRE OP (-56) INTRA OP (-54) MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50) ASI (-80) CSI (-62) TSI (-66) ENDO BASE FSI LIC REQ PRIOR AUTH

A0021 A0080 A0090 A0100 A0110 A0120 A0130 A0140 A0160 A0170 A0180 A0190 A0200 A0210 A0225 A0380 A0382 A0384 A0390 A0392 A0394 A0396 A0398 A0420 A0422 A0424 A0425 A0426 A0427 A0428 A0429 A0430 A0431 A0432 A0433 A0434 A0435 A0436 A0888 A0998 A0999 A4206 A4207

Outside state ambulance serv Noninterest escort in non er Interest escort in non er Nonemergency transport taxi Nonemergency transport bus Noner transport mini-bus Noner transport wheelch van Nonemergency transport air Noner transport case worker Transport parking fees/tolls Noner transport lodgng recip Noner transport meals recip Noner transport lodgng escrt Noner transport meals escort Neonatal emergency transport Basic life support mileage Basic support routine suppls Bls defibrillation supplies Advanced life support mileag Als defibrillation supplies Als IV drug therapy supplies Als esophageal intub suppls Als routine disposble suppls Ambulance waiting 1/2 hr Ambulance 02 life sustaining Extra ambulance attendant Ground mileage Als 1 ALS1-emergency bls BLS-emergency Fixed wing air transport Rotary wing air transport PI volunteer ambulance co als 2 Specialty care transport Fixed wing air mileage Rotary wing air mileage Noncovered ambulance mileage Ambulance response/treatment Unlisted ambulance service 1 CC sterile syringe&needle 2 CC sterile syringe&needle

Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled $ 12.81 $ 633.83 $ 657.87 $ 346.24 $ 554.00 $ 5652.91 $ 6572.32 Not Covered $ 952.18 $ 1125.31 $ 31.47 $ 73.11 Not Covered Not Covered By Report Bundled Bundled

Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled $ 12.81 $ 633.83 $ 657.87 $ 346.24 $ 554.00 $ 5652.91 $ 6572.32 Not Covered $ 952.18 $ 1125.31 $ 31.47 $ 73.11 Not Covered Not Covered By Report Bundled Bundled

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X N N N N N N N N N N N N N X B B B B B B B B B B B F F F F F F F X F F F F X X N B B

HCPCS Page 11

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A4208 A4209 A4210 A4211 A4212 A4213 A4215 A4216 A4217 A4218 A4220 A4221 A4222 A4223 A4230 A4231 A4232 A4233 A4234 A4235 A4236 A4244 A4245 A4246 A4247 A4248 A4250 A4252 A4253 A4255 A4256 A4257 A4258 A4259 A4261 A4262 A4263 A4264 A4265 A4266 A4267 A4268 A4269 A4270 A4280

3 CC sterile syringe&needle 5+ CC sterile syringe&needle Nonneedle injection device Supp for self-adm injections Non coring needle or stylet 20+ CC syringe only Sterile needle Sterile water/saline, 10 ml Sterile water/saline, 500 ml Sterile saline or water Infusion pump refill kit Maint drug infus cath per wk Infusion supplies with pump Infusion supplies w/o pump Infus insulin pump non needl Infusion insulin pump needle Syringe w/needle insulin 3cc Alkalin batt for glucose mon J-cell batt for glucose mon Lithium batt for glucose mon Silvr oxide batt glucose mon Alcohol or peroxide per pint Alcohol wipes per box Betadine/phisohex solution Betadine/iodine swabs/wipes Chlorhexidine antisept Urine reagent strips/tablets Blood ketone test or strip Blood glucose/reagent strips Glucose monitor platforms Calibrator solution/chips Replace Lensshield Cartridge Lancet device each Lancets per box Cervical cap contraceptive Temporary tear duct plug Permanent tear duct plug Intratubal occlusion device Paraffin Diaphragm Male condom Female condom Spermicide Disposable endoscope sheath Brst prsths adhsv attchmnt

Bundled Bundled $ 1545.30 Bundled Bundled Bundled Bundled Bundled Bundled Bundled By Report $ 23.35 $ 46.33 By Report By Report By Report By Report $ 0.84 $ 3.81 $ 2.46 $ 1.76 Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled $ 4.32 Bundled Bundled Bundled Bundled Not Covered Bundled Bundled Not Covered Bundled Not Covered Not Covered Not Covered Not Covered Bundled $ 5.44

Bundled Bundled $ 1545.30 Bundled Bundled Bundled Bundled Bundled Bundled Bundled By Report $ 23.35 $ 46.33 By Report By Report By Report By Report $ 0.84 $ 3.81 $ 2.46 $ 1.76 Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled $ 4.32 Bundled Bundled Bundled Bundled Not Covered Bundled Bundled Not Covered Bundled Not Covered Not Covered Not Covered Not Covered Bundled $ 5.44

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

B B F B B B B B B B N F F N N N N F F F F B B B B B B B B F B B B B X B B X B X X X X B F

Y

Y Y Y Y

Y

Refer to Field Key for definitions

HCPCS Page 12

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A4281 A4282 A4283 A4284 A4285 A4286 A4290 A4300 A4301 A4305 A4306 A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4320 A4321 A4322 A4326 A4327 A4328 A4330 A4331 A4332 A4333 A4334 A4335 A4336 A4338 A4340 A4344 A4346 A4349 A4351 A4352 A4353 A4354 A4355 A4356 A4357 A4358 A4360

Replacement breastpump tube Replacement breastpump adpt Replacement breastpump cap Replcmnt breast pump shield Replcmnt breast pump bottle Replcmnt breastpump lok ring Sacral nerve stim test lead Cath impl vasc access portal Implantable access syst perc Drug delivery system >=50 ML Drug delivery system <=50 ml Insert tray w/o bag/cath Catheter w/o bag 2-way latex Cath w/o bag 2-way silicone Catheter w/bag 3-way Cath w/drainage 2-way latex Cath w/drainage 2-way silcne Cath w/drainage 3-way Irrigation tray Cath therapeutic irrig agent Irrigation syringe Male external catheter Fem urinary collect dev cup Fem urinary collect pouch Stool collection pouch Extension drainage tubing Lube sterile packet Urinary cath anchor device Urinary cath leg strap Incontinence supply Urethral insert Indwelling catheter latex Indwelling catheter special Cath indw foley 2 way silicn Cath indw foley 3 way Disposable male external cat Straight tip urine catheter Coude tip urinary catheter Intermittent urinary cath Cath insertion tray w/bag Bladder irrigation tubing Ext ureth clmp or compr dvc Bedside drainage bag Urinary leg or abdomen bag Disposable ext urethral dev

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X N B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B

Y

Refer to Field Key for definitions

HCPCS Page 13

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A4361 A4362 A4363 A4364 A4366 A4367 A4368 A4369 A4371 A4372 A4373 A4375 A4376 A4377 A4378 A4379 A4380 A4381 A4382 A4383 A4384 A4385 A4387 A4388 A4389 A4390 A4391 A4392 A4393 A4394 A4395 A4396 A4397 A4398 A4399 A4400 A4402 A4404 A4405 A4406 A4407 A4408 A4409 A4410 A4411

Ostomy face plate Solid skin barrier Ostomy clamp, replacement Adhesive, liquid or equal Ostomy vent Ostomy belt Ostomy filter Skin barrier liquid per oz Skin barrier powder per oz Skin barrier solid 4x4 equiv Skin barrier with flange Drainable plastic pch w fcpl Drainable rubber pch w fcplt Drainable plstic pch w/o fp Drainable rubber pch w/o fp Urinary plastic pouch w fcpl Urinary rubber pouch w fcplt Urinary plastic pouch w/o fp Urinary hvy plstc pch w/o fp Urinary rubber pouch w/o fp Ostomy faceplt/silicone ring Ost skn barrier sld ext wear Ost clsd pouch w att st barr Drainable pch w ex wear barr Drainable pch w st wear barr Drainable pch ex wear convex Urinary pouch w ex wear barr Urinary pouch w st wear barr Urine pch w ex wear bar conv Ostomy pouch liq deodorant Ostomy pouch solid deodorant Peristomal hernia supprt blt Irrigation supply sleeve Ostomy irrigation bag Ostomy irrig cone/cath w brs Ostomy irrigation set Lubricant per ounce Ostomy ring each Nonpectin based ostomy paste Pectin based ostomy paste Ext wear ost skn barr <=4sq" Ext wear ost skn barr >4sq" Ost skn barr convex <=4 sq i Ost skn barr extnd >4 sq Ost skn barr extnd =4sq

Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled

Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B

HCPCS Page 14

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A4412 A4413 A4414 A4415 A4416 A4417 A4418 A4419 A4420 A4421 A4422 A4423 A4424 A4425 A4426 A4427 A4428 A4429 A4430 A4431 A4432 A4433 A4434 A4450 A4452 A4455 A4456 A4458 A4461 A4463 A4465 A4466 A4470 A4480 A4481 A4483 A4490 A4495 A4500 A4510 A4520 A4550 A4554 A4556 A4557

Ost pouch drain high output 2 pc drainable ost pouch Ost sknbar w/o conv<=4 sq in Ost skn barr w/o conv >4 sqi Ost pch clsd w barrier/filtr Ost pch w bar/bltinconv/fltr Ost pch clsd w/o bar w filtr Ost pch for bar w flange/flt Ost pch clsd for bar w lk fl Ostomy supply misc Ost pouch absorbent material Ost pch for bar w lk fl/fltr Ost pch drain w bar & filter Ost pch drain for barrier fl Ost pch drain 2 piece system Ost pch drain/barr lk flng/f Urine ost pouch w faucet/tap Urine ost pouch w bltinconv Ost urine pch w b/bltin conv Ost pch urine w barrier/tapv Os pch urine w bar/fange/tap Urine ost pch bar w lock fln Ost pch urine w lock flng/ft Non-waterproof tape Waterproof tape Adhesive remover per ounce Adhesive remover, wipes Reusable enema bag Surgicl dress hold non-reuse Surgical dress holder reuse Non-elastic extremity binder Elastic garment/covering Gravlee jet washer Vabra aspirator Tracheostoma filter Moisture exchanger Above knee surgical stocking Thigh length surg stocking Below knee surgical stocking Full length surg stocking Incontinence garment anytype Surgical trays Disposable underpads Electrodes, pair Lead wires, pair

Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled $ 0.40 By Report $ 12.07 $ 12.07 $ 9.00 $ 21.82 Bundled Bundled Bundled Bundled Bundled

Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled $ 0.40 By Report $ 12.07 $ 12.07 $ 9.00 $ 21.82 Bundled Bundled Bundled Bundled Bundled

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B F N F F F F B B B B B

HCPCS Page 15

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A4558 A4559 A4561 A4562 A4565 A4566 A4570 A4575 A4580 A4590 A4595 A4600 A4601 A4604 A4605 A4606 A4608 A4611 A4612 A4613 A4614 A4615 A4616 A4617 A4618 A4619 A4620 A4623 A4624 A4625 A4626 A4627 A4628 A4629 A4630 A4633 A4634 A4635 A4636 A4637 A4638 A4639 A4640 A4641 A4642

Conductive gel or paste Coupling gel or paste Pessary rubber, any type Pessary, non rubber,any type Slings Should sling/vest/abrestrain Splint Hyperbaric o2 chamber disps Cast supplies (plaster) Special casting material TENS suppl 2 lead per month Sleeve, inter limb comp dev Lith ion batt, non-pros use Tubing with heating element Trach suction cath close sys Oxygen probe used w oximeter Transtracheal oxygen cath Heavy duty battery Battery cables Battery charger Hand-held PEFR meter Cannula nasal Tubing (oxygen) per foot Mouth piece Breathing circuits Face tent Variable concentration mask Tracheostomy inner cannula Tracheal suction tube Trach care kit for new trach Tracheostomy cleaning brush Spacer bag/reservoir Oropharyngeal suction cath Tracheostomy care kit Repl bat t.e.n.s. own by pt Uvl replacement bulb Replacement bulb th lightbox Underarm crutch pad Handgrip for cane etc Repl tip cane/crutch/walker Repl batt pulse gen sys Infrared ht sys replcmnt pad Alternating pressure pad Radiopharm dx agent noc In111 satumomab

Bundled Bundled Not Covered Not Covered $ 12.73 By Report Not Covered By Report Not Covered Not Covered Not Covered By Report By Report $ 60.40 $ 17.20 By Report $ 52.58 $ 175.15 $ 80.53 $ 151.27 $ 24.95 $ 0.75 $ 0.07 $ 3.25 $ 8.03 $ 1.27 $ 0.65 $ 6.87 $ 2.76 $ 6.84 $ 3.35 $ 30.05 $ 3.83 $ 4.84 Not Covered Not Covered Not Covered $ 5.37 $ 3.81 $ 1.64 Not Covered Not Covered $ 59.44 By Report $ 1591.25

Bundled Bundled Not Covered Not Covered $ 12.73 By Report Not Covered By Report Not Covered Not Covered Not Covered By Report By Report $ 60.40 $ 17.20 By Report $ 52.58 $ 175.15 $ 80.53 $ 151.27 $ 24.95 $ 0.75 $ 0.07 $ 3.25 $ 8.03 $ 1.27 $ 0.65 $ 6.87 $ 2.76 $ 6.84 $ 3.35 $ 30.05 $ 3.83 $ 4.84 Not Covered Not Covered Not Covered $ 5.37 $ 3.81 $ 1.64 Not Covered Not Covered $ 59.44 By Report $ 1591.25

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0

B B X X F N X N X X X N N F F N F F F F F F F F F F F F F F F F F F X X X F F F X X F N D

Y

Y

Refer to Field Key for definitions

HCPCS Page 16

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A4648 A4649 A4650 A4651 A4652 A4653 A4657 A4660 A4663 A4670 A4671 A4672 A4673 A4674 A4680 A4690 A4706 A4707 A4708 A4709 A4714 A4719 A4720 A4721 A4722 A4723 A4724 A4725 A4726 A4728 A4730 A4736 A4737 A4740 A4750 A4755 A4760 A4765 A4766 A4770 A4771 A4772 A4773 A4774 A4802

Implantable tissue marker Surgical supplies Implant radiation dosimeter Calibrated microcap tube Microcapillary tube sealant PD catheter anchor belt Syringe w/wo needle Sphyg/bp app w cuff and stet Dialysis blood pressure cuff Automatic bp monitor, dial Disposable cycler set Drainage ext line, dialysis Ext line w easy lock connect Chem/antisept solution, 8oz Activated carbon filter, ea Dialyzer, each Bicarbonate conc sol per gal Bicarbonate conc pow per pac Acetate conc sol per gallon Acid conc sol per gallon Treated water per gallon "Y set" tubing Dialysat sol fld vol > 249cc Dialysat sol fld vol > 999cc Dialys sol fld vol > 1999cc Dialys sol fld vol > 2999cc Dialys sol fld vol > 3999cc Dialys sol fld vol > 4999cc Dialys sol fld vol > 5999cc Dialysate solution, non-dex Fistula cannulation set, ea Topical anesthetic, per gram Inj anesthetic per 10 ml Shunt accessory Art or venous blood tubing Comb art/venous blood tubing Dialysate sol test kit, each Dialysate conc pow per pack Dialysate conc sol add 10 ml Blood collection tube/vacuum Serum clotting time tube Blood glucose test strips Occult blood test strips Ammonia test strips Protamine sulfate per 50 mg

By Report Bundled By Report By Report By Report By Report By Report $ 23.72 $ 45.45 Bundled By Report By Report By Report By Report $ 118.17 $ 1171.76 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 22.54 By Report By Report By Report By Report By Report By Report $ 47.27 $ 29.98 By Report $ 8.53

By Report Bundled By Report By Report By Report By Report By Report $ 23.72 $ 45.45 Bundled By Report By Report By Report By Report $ 118.17 $ 1171.76 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 22.54 By Report By Report By Report By Report By Report By Report $ 47.27 $ 29.98 By Report $ 8.53

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N B N N N N N F F B N N N N F F N N N N N N N N N N N N N N N N N N F N N N N N N F F N F

Y

Y

Refer to Field Key for definitions

HCPCS Page 17

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A4860 A4870 A4890 A4911 A4913 A4918 A4927 A4928 A4929 A4930 A4931 A4932 A5051 A5052 A5053 A5054 A5055 A5061 A5062 A5063 A5071 A5072 A5073 A5081 A5082 A5083 A5093 A5102 A5105 A5112 A5113 A5114 A5120 A5121 A5122 A5126 A5131 A5200 A5500 A5501 A5503 A5504 A5505 A5506 A5507

Disposable catheter tips Plumb/elec wk hm hemo equip Repair/maint cont hemo equip Drain bag/bottle Misc dialysis supplies noc Venous pressure clamp Non-sterile gloves Surgical mask Tourniquet for dialysis, ea Sterile, gloves per pair Reusable oral thermometer Reusable rectal thermometer Pouch clsd w barr attached Clsd ostomy pouch w/o barr Clsd ostomy pouch faceplate Clsd ostomy pouch w/flange Stoma cap Pouch drainable w barrier at Drnble ostomy pouch w/o barr Drain ostomy pouch w/flange Urinary pouch w/barrier Urinary pouch w/o barrier Urinary pouch on barr w/flng Continent stoma plug Continent stoma catheter Stoma absorptive cover Ostomy accessory convex inse Bedside drain btl w/wo tube Urinary suspensory Urinary leg bag Latex leg strap Foam/fabric leg strap Skin barrier, wipe or swab Solid skin barrier 6x6 Solid skin barrier 8x8 Disk/foam pad +or- adhesive Appliance cleaner Percutaneous catheter anchor Diab shoe for density insert Diabetic custom molded shoe Diabetic shoe w/roller/rockr Diabetic shoe with wedge Diab shoe w/metatarsal bar Diabetic shoe w/off set heel Modification diabetic shoe

By Report By Report By Report By Report By Report By Report $ 7.27 By Report $ 0.25 Bundled Not Covered Not Covered Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled $ 11.84 $ 66.69 $ 200.05 $ 32.60 $ 32.60 $ 32.60 $ 32.60 $ 32.60

By Report By Report By Report By Report By Report By Report $ 7.27 By Report $ 0.25 Bundled Not Covered Not Covered Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled $ 11.84 $ 66.69 $ 200.05 $ 32.60 $ 32.60 $ 32.60 $ 32.60 $ 32.60

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N N N F N F B X X B B B B B B B B B B B B B B B B B B B B B B B B B F F F F F F F F

Y Y

Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 18

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A5508 A5510 A5512 A5513 A6000 A6010 A6011 A6021 A6022 A6023 A6024 A6025 A6154 A6196 A6197 A6198 A6199 A6203 A6204 A6205 A6206 A6207 A6208 A6209 A6210 A6211 A6212 A6213 A6214 A6215 A6216 A6217 A6218 A6219 A6220 A6221 A6222 A6223 A6224 A6228 A6229 A6230 A6231 A6232 A6233

Diabetic deluxe shoe Compression form shoe insert Multi den insert direct form Multi den insert custom mold Wound warming wound cover Collagen based wound filler Collagen gel/paste wound fil Collagen dressing <=16 sq in Collagen drsg>16<=48 sq in Collagen dressing >48 sq in Collagen dsg wound filler Silicone gel sheet, each Wound pouch each Alginate dressing <=16 sq in Alginate drsg >16 <=48 sq in alginate dressing > 48 sq in Alginate drsg wound filler Composite drsg <= 16 sq in Composite drsg >16<=48 sq in Composite drsg > 48 sq in Contact layer <= 16 sq in Contact layer >16<= 48 sq in Contact layer > 48 sq in Foam drsg <=16 sq in w/o bdr Foam drg >16<=48 sq in w/o b Foam drg > 48 sq in w/o brdr Foam drg <=16 sq in w/border Foam drg >16<=48 sq in w/bdr Foam drg > 48 sq in w/border Foam dressing wound filler Non-sterile gauze<=16 sq in Non-sterile gauze>16<=48 sq Non-sterile gauze > 48 sq in Gauze <= 16 sq in w/border Gauze >16 <=48 sq in w/bordr Gauze > 48 sq in w/border Gauze <=16 in no w/sal w/o b Gauze >16<=48 no w/sal w/o b Gauze > 48 in no w/sal w/o b Gauze <= 16 sq in water/sal Gauze >16<=48 sq in watr/sal Gauze > 48 sq in water/salne Hydrogel dsg<=16 sq in Hydrogel dsg>16<=48 sq in Hydrogel dressing >48 sq in

By Report By Report $ 27.21 $ 40.61 By Report Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled

By Report By Report $ 27.21 $ 40.61 By Report Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N F F N B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B

Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 19

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A6234 A6235 A6236 A6237 A6238 A6239 A6240 A6241 A6242 A6243 A6244 A6245 A6246 A6247 A6248 A6250 A6251 A6252 A6253 A6254 A6255 A6256 A6257 A6258 A6259 A6260 A6261 A6262 A6266 A6402 A6403 A6404 A6407 A6410 A6411 A6412 A6413 A6441 A6442 A6443 A6444 A6445 A6446 A6447 A6448

Hydrocolld drg <=16 w/o bdr Hydrocolld drg >16<=48 w/o b Hydrocolld drg > 48 in w/o b Hydrocolld drg <=16 in w/bdr Hydrocolld drg >16<=48 w/bdr Hydrocolld drg > 48 in w/bdr Hydrocolld drg filler paste Hydrocolloid drg filler dry Hydrogel drg <=16 in w/o bdr Hydrogel drg >16<=48 w/o bdr Hydrogel drg >48 in w/o bdr Hydrogel drg <= 16 in w/bdr Hydrogel drg >16<=48 in w/b Hydrogel drg > 48 sq in w/b Hydrogel drsg gel filler Skin seal protect moisturizr Absorpt drg <=16 sq in w/o b Absorpt drg >16 <=48 w/o bdr Absorpt drg > 48 sq in w/o b Absorpt drg <=16 sq in w/bdr Absorpt drg >16<=48 in w/bdr Absorpt drg > 48 sq in w/bdr Transparent film <= 16 sq in Transparent film >16<=48 in Transparent film > 48 sq in Wound cleanser any type/size Wound filler gel/paste /oz Wound filler dry form / gram Impreg gauze no h20/sal/yard Sterile gauze <= 16 sq in Sterile gauze>16 <= 48 sq in Sterile gauze > 48 sq in Packing strips, non-impreg Sterile eye pad Non-sterile eye pad Occlusive eye patch Adhesive bandage, first-aid Pad band w>=3" <5"/yd Conform band n/s w<3"/yd Conform band n/s w>=3"<5"/yd Conform band n/s w>=5"/yd Conform band s w <3"/yd Conform band s w>=3" <5"/yd Conform band s w >=5"/yd Lt compres band <3"/yd

Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled

Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B B

HCPCS Page 20

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A6449 A6450 A6451 A6452 A6453 A6454 A6455 A6456 A6457 A6501 A6502 A6503 A6504 A6505 A6506 A6507 A6508 A6509 A6510 A6511 A6512 A6513 A6530 A6531 A6532 A6533 A6534 A6535 A6536 A6537 A6538 A6539 A6540 A6541 A6544 A6545 A6549 A6550 A7000 A7001 A7002 A7003 A7004 A7005 A7006

Lt compres band >=3" <5"/yd Lt compres band >=5"/yd Mod compres band w>=3"<5"/yd High compres band w>=3"<5"yd Self-adher band w <3"/yd Self-adher band w>=3" <5"/yd Self-adher band >=5"/yd Zinc paste band w >=3"<5"/yd Tubular dressing Compres burngarment bodysuit Compres burngarment chinstrp Compres burngarment facehood Cmprsburngarment glove-wrist Cmprsburngarment glove-elbow Cmprsburngrmnt glove-axilla Cmprs burngarment foot-knee Cmprs burngarment foot-thigh Compres burn garment jacket Compres burn garment leotard Compres burn garment panty Compres burn garment, noc Compress burn mask face/neck Compression stocking BK18-30 Compression stocking BK30-40 Compression stocking BK40-50 Gc stocking thighlngth 18-30 Gc stocking thighlngth 30-40 Gc stocking thighlngth 40-50 Gc stocking full lngth 18-30 Gc stocking full lngth 30-40 Gc stocking full lngth 40-50 Gc stocking waistlngth 18-30 Gc stocking waistlngth 30-40 Gc stocking waistlngth 40-50 Gc stocking garter belt Grad comp non-elastic BK G compression stocking Neg pres wound ther drsg set Disposable canister for pump Nondisposable pump canister Tubing used w suction pump Nebulizer administration set Disposable nebulizer sml vol Nondisposable nebulizer set Filtered nebulizer admin set

Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 45.38 $ 63.95 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 24.80 $ 8.62 $ 34.70 $ 4.02 $ 2.88 $ 1.89 $ 32.34 $ 10.01

Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 45.38 $ 63.95 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 24.80 $ 8.62 $ 34.70 $ 4.02 $ 2.88 $ 1.89 $ 32.34 $ 10.01

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

B B B B B B B B B N N N N N N N N N N N N N N F F N N N N N N N N N N N N F F F F F F F F

Y Y Y

Refer to Field Key for definitions

HCPCS Page 21

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A7007 A7008 A7009 A7010 A7011 A7012 A7013 A7014 A7015 A7016 A7017 A7018 A7020 A7025 A7026 A7027 A7028 A7029 A7030 A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7040 A7041 A7042 A7043 A7044 A7045 A7046 A7501 A7502 A7503 A7504 A7505 A7506 A7507 A7508 A7509 A7520

Lg vol nebulizer disposable Disposable nebulizer prefill Nebulizer reservoir bottle Disposable corrugated tubing Nondispos corrugated tubing Nebulizer water collec devic Disposable compressor filter Compressor nondispos filter Aerosol mask used w nebulize Nebulizer dome & mouthpiece Nebulizer not used w oxygen Water distilled w/nebulizer Interface, cough stim device Replace chest compress vest Replace chst cmprss sys hose Combination oral/nasal mask Repl oral cushion combo mask Repl nasal pillow comb mask CPAP full face mask Replacement facemask interfa Replacement nasal cushion Replacement nasal pillows Nasal application device Pos airway press headgear Pos airway press chinstrap Pos airway pressure tubing Pos airway pressure filter Filter, non disposable w pap One way chest drain valve Water seal drain container Implanted pleural catheter Vacuum drainagebottle/tubing PAP oral interface Repl exhalation port for PAP Repl water chamber, PAP dev Tracheostoma valve w diaphra Replacement diaphragm/fplate HMES filter holder or cap Tracheostoma HMES filter HMES or trach valve housing HMES/trachvalve adhesivedisk Integrated filter & holder Housing & Integrated Adhesiv Heat & moisture exchange sys Trach/laryn tube non-cuffed

$ 4.84 $ 11.54 $ 44.10 $ 24.75 $ 36.32 $ 3.97 $ 0.87 $ 4.71 $ 1.97 $ 7.60 $ 140.60 $ 0.40 By Report Not Covered Not Covered $ 195.65 $ 51.97 $ 21.23 $ 170.55 $ 63.08 $ 36.64 $ 25.68 $ 106.35 $ 35.93 $ 16.45 $ 37.08 $ 4.88 $ 13.86 $ 41.41 $ 77.82 $ 188.04 $ 29.49 $ 109.31 $ 17.60 $ 17.64 $ 110.17 $ 52.36 $ 11.89 $ 0.70 $ 4.91 $ 0.35 $ 2.61 $ 3.01 $ 1.48 $ 49.80

$ 4.84 $ 11.54 $ 44.10 $ 24.75 $ 36.32 $ 3.97 $ 0.87 $ 4.71 $ 1.97 $ 7.60 $ 140.60 $ 0.40 By Report Not Covered Not Covered $ 195.65 $ 51.97 $ 21.23 $ 170.55 $ 63.08 $ 36.64 $ 25.68 $ 106.35 $ 35.93 $ 16.45 $ 37.08 $ 4.88 $ 13.86 $ 41.41 $ 77.82 $ 188.04 $ 29.49 $ 109.31 $ 17.60 $ 17.64 $ 110.17 $ 52.36 $ 11.89 $ 0.70 $ 4.91 $ 0.35 $ 2.61 $ 3.01 $ 1.48 $ 49.80

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F N X X F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

HCPCS Page 22

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A7521 A7522 A7523 A7524 A7525 A7526 A7527 A8000 A8001 A8002 A8003 A8004 A9150 A9152 A9153 A9155 A9180 A9270 A9273 A9274 A9275 A9276 A9277 A9278 A9279 A9280 A9281 A9282 A9283 A9284 A9300 A9500 A9501 A9502 A9503 A9504 A9505 A9507 A9508 A9509 A9510 A9512 A9516 A9517 A9521

Trach/laryn tube cuffed Trach/laryn tube stainless Tracheostomy shower protect Tracheostoma stent/stud/bttn Tracheostomy mask Tracheostomy tube collar Trach/laryn tube plug/stop Soft protect helmet prefab Hard protect helmet prefab Soft protect helmet custom Hard protect helmet custom Repl soft interface, helmet Misc/exper non-prescript dru Single vitamin nos Multi-vitamin nos Artificial saliva Lice treatment, topical Non-covered item or service Hot/cold h2obot/cap/col/wrap Ext amb insulin delivery sys Disp home glucose monitor Disposable sensor, CGM sys External transmitter, CGM External receiver, CGM sys Monitoring feature/deviceNOC Alert device, noc Reaching/grabbing device Wig any type Foot press off load supp dev Non-electronic spirometer Exercise equipment Tc99m sestamibi Technetium TC-99m teboroxime Tc99m tetrofosmin Tc99m medronate Tc99m apcitide TL201 thallium In111 capromab I131 iodobenguate, dx Iodine I-123 sod iodide mil Tc99m disofenin Tc99m pertechnetate Iodine I-123 sod iodide mic I131 iodide cap, rx Tc99m exametazime

$ 49.35 $ 47.37 By Report $ 81.19 $ 2.17 $ 3.54 $ 3.76 $ 160.86 $ 160.86 By Report By Report By Report Bundled Not Covered Not Covered $ 6.04 Not Covered Not Covered Bundled By Report By Report By Report By Report By Report By Report By Report By Report Not Covered By Report By Report Not Covered $ 121.70 By Report $ 121.05 $ 23.75 $ 475.00 $ 33.23 $ 3568.78 $ 1325.25 By Report $ 43.70 $ 13.52 $ 103.47 By Report $ 567.61

$ 49.35 $ 47.37 By Report $ 81.19 $ 2.17 $ 3.54 $ 3.76 $ 160.86 $ 160.86 By Report By Report By Report Bundled Not Covered Not Covered $ 6.04 Not Covered Not Covered Bundled By Report By Report By Report By Report By Report By Report By Report By Report Not Covered By Report By Report Not Covered $ 121.70 By Report $ 121.05 $ 23.75 $ 475.00 $ 33.23 $ 3568.78 $ 1325.25 By Report $ 43.70 $ 13.52 $ 103.47 By Report $ 567.61

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0

F F N F F F F F F N N N B X X D X X B N N N N N N N N X N N X D N D D D D D D N D D D N D

Y Y Y Y Y

Y Y Y Y

Y Y

Y

Refer to Field Key for definitions

HCPCS Page 23

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A9524 A9526 A9527 A9528 A9529 A9530 A9531 A9532 A9536 A9537 A9538 A9539 A9540 A9541 A9542 A9543 A9544 A9545 A9546 A9547 A9548 A9550 A9551 A9552 A9553 A9554 A9555 A9556 A9557 A9558 A9559 A9560 A9561 A9562 A9563 A9564 A9566 A9567 A9568 A9569 A9570 A9571 A9572 A9576 A9577

I131 serum albumin, dx Nitrogen N-13 ammonia Iodine I-125 sodium iodide Iodine I-131 iodide cap, dx I131 iodide sol, dx I131 iodide sol, rx I131 max 100uCi I125 serum albumin, dx Tc99m depreotide Tc99m mebrofenin Tc99m pyrophosphate Tc99m pentetate Tc99m MAA Tc99m sulfur colloid In111 ibritumomab, dx Y90 ibritumomab, rx I131 tositumomab, dx I131 tositumomab, rx Co57/58 In111 oxyquinoline In111 pentetate Tc99m gluceptate Tc99m succimer F18 fdg Cr51 chromate I125 iothalamate, dx Rb82 rubidium Ga67 gallium Tc99m bicisate Xe133 xenon 10mci Co57 cyano Tc99m labeled rbc Tc99m oxidronate Tc99m mertiatide P32 Na phosphate P32 chromic phosphate Tc99m fanolesomab Technetium TC-99m aerosol Technetium tc99m arcitumomab Technetium TC-99m auto WBC Indium In-111 auto WBC Indium IN-111 auto platelet Indium In-111 pentetreotide Inj prohance multipack Inj multihance

$ 295.45 By Report By Report $ 261.76 By Report By Report By Report $ 567.36 $ 760.00 $ 9.46 $ 40.81 $ 2.54 $ 21.85 $ 1.00 Not Covered Not Covered $ 2641.95 $ 22896.90 By Report $ 291.61 $ 816.64 By Report $ 126.63 By Report $ 427.50 $ 21.35 $ 700.51 $ 330.25 $ 424.18 $ 38.96 $ 83.52 $ 106.48 $ 50.61 $ 588.24 $ 1746.48 $ 331.13 By Report By Report $ 1235.00 By Report By Report By Report By Report $ 6.22 $ 5.91

$ 295.45 By Report By Report $ 261.76 By Report By Report By Report $ 567.36 $ 760.00 $ 9.46 $ 40.81 $ 2.54 $ 21.85 $ 1.00 Not Covered Not Covered $ 2641.95 $ 22896.90 By Report $ 291.61 $ 816.64 By Report $ 126.63 By Report $ 427.50 $ 21.35 $ 700.51 $ 330.25 $ 424.18 $ 38.96 $ 83.52 $ 106.48 $ 50.61 $ 588.24 $ 1746.48 $ 331.13 By Report By Report $ 1235.00 By Report By Report By Report By Report $ 6.22 $ 5.91

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9

D N N F N N N F D D D D D D X X D D N D D N D N D D D D D D D D D D D D N N D N N N N D D

Y Y

Y Y

Y

Y Y Y

Y

Y Y

Refer to Field Key for definitions

HCPCS Page 24

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

A9578 A9579 A9580 A9581 A9582 A9583 A9600 A9604 A9698 A9699 A9700 A9900 A9901 A9999 B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 B4100 B4102 B4103 B4104 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185

Inj multihance multipack Gad-base MR contrast NOS,1ml Sodium fluoride F-18 Gadoxetate disodium inj Iodine I-123 iobenguane Gadofosveset trisodium inj Sr89 strontium Sm 153 lexidronam Non-rad contrast materialNOC Radiopharm rx agent noc Echocardiography Contrast Supply/accessory/service Delivery/set up/dispensing DME supply or accessory, nos Enter feed supkit syr by day Enteral feed supp pump per d Enteral feed sup kit grav by Enteral ng tubing w/ stylet Enteral ng tubing w/o stylet Enteral stomach tube levine Gastro/jejuno tube, std Gastro/jejuno tube, low-pro Food thickener oral EF adult fluids and electro EF ped fluid and electrolyte Additive for enteral formula EF blenderized foods EF complet w/intact nutrient EF calorie dense>/=1.5Kcal EF hydrolyzed/amino acids EF spec metabolic noninherit EF incomplete/modular EF special metabolic inherit EF ped complete intact nut EF ped complete soy based EF ped caloric dense>/=0.7kc EF ped hydrolyzed/amino acid EF ped specmetabolic inherit Parenteral 50% dextrose solu Parenteral sol amino acid 3. Parenteral sol amino acid 5. Parenteral sol amino acid 7Parenteral sol amino acid > Parenteral sol carb > 50% Parenteral sol 10 gm lipids

$ 6.22 By Report By Report $ 14.04 Not Covered $ 10.95 $ 882.79 Not Covered By Report By Report By Report Bundled By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report By Report By Report By Report By Report

$ 6.22 By Report By Report $ 14.04 Not Covered $ 10.95 $ 882.79 Not Covered By Report By Report By Report Bundled By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report By Report By Report By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 0 9 9 9 0 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 0 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 0 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 0 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 0 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 0 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D N N D X D D X N N N B N N N N N N N N N N N N X N N N N N N N N X X X X X N N N N N N N

Y

Y

Refer to Field Key for definitions

HCPCS Page 25

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9000 B9002 B9004 B9006 B9998 B9999 C1300 C1713 C1714 C1715 C1716 C1717 C1719 C1721 C1722 C1724 C1725 C1726 C1727 C1728 C1729

Parenteral sol amino acid & Parenteral sol 52-73 gm prot Parenteral sol 74-100 gm pro Parenteral sol > 100gm prote Parenteral nutrition additiv Parenteral supply kit premix Parenteral supply kit homemi Parenteral administration ki Parenteral sol renal-amirosy Parenteral sol hepatic-fream Parenteral sol stres-brnch c Enter infusion pump w/o alrm Enteral infusion pump w/ ala Parenteral infus pump portab Parenteral infus pump statio Enteral supp not otherwise c Parenteral supp not othrws c HYPERBARIC Oxygen Anchor/screw bn/bn,tis/bn Cath, trans atherectomy, dir Brachytherapy needle Brachytx, non-str, Gold-198 Brachytx, non-str,HDR Ir-192 Brachytx, NS, Non-HDRIr-192 AICD, dual chamber AICD, single chamber Cath, trans atherec,rotation Cath, translumin non-laser Cath, bal dil, non-vascular Cath, bal tis dis, non-vas Cath, brachytx seed adm Cath, drainage

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Facility Only Facility Only Facility Only Facility Only Not Covered Not Covered Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Facility Only Facility Only Facility Only Facility Only Not Covered Not Covered Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N N N N N N N N N N N N N N O O O O X X X O O O O O O O O Y

0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%

Refer to Field Key for definitions

HCPCS Page 26

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

C1730 C1731 C1732 C1733 C1749 C1750 C1751 C1752 C1753 C1754 C1755 C1756 C1757 C1758 C1759 C1760 C1762 C1763 C1764 C1765 C1766 C1767

Cath, EP, 19 or few elect Cath, EP, 20 or more elec Cath, EP, diag/abl, 3D/vect Cath, EP, othr than cool-tip Endo, colon, retro imaging Cath, hemodialysis,long-term Cath, inf, per/cent/midline Cath,hemodialysis,short-term Cath, intravas ultrasound Catheter, intradiscal Catheter, intraspinal Cath, pacing, transesoph Cath, thrombectomy/embolect Catheter, ureteral Cath, intra echocardiography Closure dev, vasc Conn tiss, human(inc fascia) Conn tiss, non-human Event recorder, cardiac Adhesion barrier Intro/sheath,strble,non-peel Generator, neuro non-recharg

Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

O O O O O O O O O O O O O O O O O O O O O O Y

Refer to Field Key for definitions

HCPCS Page 27

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

C1768 C1769 C1770 C1771 C1772 C1773 C1776 C1777 C1778 C1779 C1780 C1781 C1782 C1783 C1784 C1785 C1786 C1787 C1788 C1789 C1813 C1814

Graft, vascular Guide wire Imaging coil, MR, insertable Rep dev, urinary, w/sling Infusion pump, programmable Ret dev, insertable Joint device (implantable) Lead, AICD, endo single coil Lead, neurostimulator Lead, pmkr, transvenous VDD Lens, intraocular (new tech) Mesh (implantable) Morcellator Ocular imp, aqueous drain de Ocular dev, intraop, det ret Pmkr, dual, rate-resp Pmkr, single, rate-resp Patient progr, neurostim Port, indwelling, imp Prosthesis, breast, imp Prosthesis, penile, inflatab Retinal tamp, silicone oil

Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

O O O O O O O O O O O O O O O O O O O O O O

Refer to Field Key for definitions

HCPCS Page 28

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

C1815 C1816 C1817 C1818 C1819 C1820 C1821 C1874 C1875 C1876 C1877 C1878 C1879 C1880 C1881 C1882 C1883 C1884 C1885 C1887 C1888 C1891 C1892

Pros, urinary sph, imp Receiver/transmitter, neuro Septal defect imp sys Integrated keratoprosthesis Tissue localization-excision Generator neuro rechg bat sy Interspinous implant Stent, coated/cov w/del sys Stent, coated/cov w/o del sy Stent, non-coa/non-cov w/del Stent, non-coat/cov w/o del Matrl for vocal cord Tissue marker, implantable Vena cava filter Dialysis access system AICD, other than sing/dual Adapt/ext, pacing/neuro lead Embolization Protect syst Cath, translumin angio laser Catheter, guiding Endovas non-cardiac abl cath Infusion pump,non-prog, perm Intro/sheath,fixed,peel-away

Facility Only Facility Only Facility Only Facility Only Facility Only Not Covered Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

Facility Only Facility Only Facility Only Facility Only Facility Only Not Covered Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

O O O O O X X O O O O O O O O O O O O O O O O Y

Refer to Field Key for definitions

HCPCS Page 29

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

C1893 C1894 C1895 C1896 C1897 C1898 C1899 C1900 C2614 C2615 C2616 C2617 C2618 C2619 C2620 C2621 C2622 C2625 C2626 C2627 C2628 C2629 C2630

Intro/sheath, fixed,non-peel Intro/sheath, non-laser Lead, AICD, endo dual coil Lead, AICD, non sing/dual Lead, neurostim test kit Lead, pmkr, other than trans Lead, pmkr/AICD combination Lead, coronary venous Probe, perc lumb disc Sealant, pulmonary, liquid Brachytx, non-str,Yttrium-90 Stent, non-cor, tem w/o del Probe, cryoablation Pmkr, dual, non rate-resp Pmkr, single, non rate-resp Pmkr, other than sing/dual Prosthesis, penile, non-inf Stent, non-cor, tem w/del sy Infusion pump, non-prog,temp Cath, suprapubic/cystoscopic Catheter, occlusion Intro/sheath, laser Cath, EP, cool-tip

Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

O O O O O O O O X O O O O O O O O O O O O O O

HCPCS Page 30

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

C2631 C2634 C2635 C2636 C2637 C2638 C2639 C2640 C2641 C2642 C2643 C2698 C2699 C8900 C8901 C8902 C8903 C8904 C8905 C8906 C8907 C8908 C8909 C8910 C8911 C8912 C8913 C8914

Rep dev, urinary, w/o sling Brachytx, non-str, HA, I-125 Brachytx, non-str, HA, P-103 Brachy linear, non-str,P-103 Brachy,non-str,Ytterbium-169 Brachytx, stranded, I-125 Brachytx, non-stranded,I-125 Brachytx, stranded, P-103 Brachytx, non-stranded,P-103 Brachytx, stranded, C-131 Brachytx, non-stranded,C-131 Brachytx, stranded, NOS Brachytx, non-stranded, NOS MRA w/cont, abd MRA w/o cont, abd MRA w/o fol w/cont, abd MRI w/cont, breast, uni MRI w/o cont, breast, uni MRI w/o fol w/cont, brst, un MRI w/cont, breast, bi MRI w/o cont, breast, bi MRI w/o fol w/cont, breast, MRA w/cont, chest MRA w/o cont, chest MRA w/o fol w/cont, chest MRA w/cont, lwr ext MRA w/o cont, lwr ext MRA w/o fol w/cont, lwr ext

Facility Only Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

Facility Only Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only

0 0% 0 0 0 0 0 0 0 0 0 0 0 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

O X X X X X X X X X X X X O O O O O O O O O O O O O O O

0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%

Refer to Field Key for definitions

HCPCS Page 31

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

C8918 C8919 C8920 C8921 C8922 C8923 C8924 C8925 C8926 C8927 C8928 C8929 C8930 C8931 C8932 C8933 C8934 C8935 C8936 C8957 C9113 C9121 C9248 C9250 C9254 C9257 C9270 C9272

MRA w/cont, pelvis MRA w/o cont, pelvis MRA w/o fol w/cont, pelvis TTE w or w/o fol w/cont, com TTE w or w/o fol w/cont, f/u 2D TTE w or w/o fol w/con,co 2D TTE w or w/o fol w/con,fu 2D TEE w or w/o fol w/con,in TEE w or w/o fol w/cont,cong TEE w or w/o fol w/cont, mon TTE w or w/o fol w/con,stres TTE w or wo fol wcon,Doppler TTE w or w/o contr, cont ECG MRA, w/dye, spinal canal MRA, w/o dye, spinal canal MRA, w/o&w/dye, spinal canal MRA, w/dye, upper extremity MRA, w/o dye, upper extr MRA, w/o&w/dye, upper extr Prolonged IV inf, req pump Inj pantoprazole sodium, via Injection, argatroban Inj, clevidipine butyrate Artiss fibrin sealant Injection, lacosamide Bevacizumab injection Gammaplex IVIG Inj, denosumab

Facility Only Facility Only Facility Only Not Covered Not Covered Facility Only Facility Only Facility Only Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only $ 5.40 $ 28.37 $ 3.76 $ 183.38 $ 0.19 Not Covered Not Covered $ 14.85

Facility Only Facility Only Facility Only Not Covered Not Covered Facility Only Facility Only Facility Only Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only $ 5.40 $ 28.37 $ 3.76 $ 183.38 $ 0.19 Not Covered Not Covered $ 14.85

0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0 0 0 0 0 0 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

O O O X X O O O X O O O O O O O O O O O D D D D D X X D

Y

Y

Refer to Field Key for definitions

HCPCS Page 32

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

C9273 C9274 C9275 C9276 C9277 C9278 C9279 C9280 C9281 C9282 C9352 C9353 C9354 C9355 C9356 C9358 C9359 C9360 C9361 C9362 C9363 C9364 C9367 C9399 C9716 C9724 C9725 C9726 C9727 C9728

Sipuleucel-T, per infusion Crotalidae Poly Immune Fab Hexaminolevulinate HCl Cabazitaxel injection Lumizyme, 1 mg Incobotulinumtoxin A Injection, ibuprofen Injection, eribulin mesylate Injection, pegloticase Inj, ceftaroline fosamil Neuragen nerve guide, per cm Neurawrap nerve protector,cm Veritas collagen matrix, cm2 Neuromatrix nerve cuff, cm TenoGlide tendon prot, cm2 SurgiMend, fetal Implnt,bon void filler-putty SurgiMend, neonatal NeuroMend nerve wrap Implnt,bon void filler-strip Integra Meshed Bil Wound Mat Porcine implant, Permacol Endoform Dermal Template Unclassified drugs or biolog Radiofrequency energy to anu EPS gast cardia plic Place endorectal app Rxt breast appl place/remov Insert palate implants Place device/marker, non pro

Not Covered $ 2195.10 $ 648.00 Not Covered Not Covered $ 5.67 $ 1.42 $ 918.00 Not Covered $ 0.74 Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Not Covered $ 3.69 Facility Only Facility Only Facility Only Not Covered Not Covered Facility Only Not Covered

Not Covered $ 2195.10 $ 648.00 Not Covered Not Covered $ 5.67 $ 1.42 $ 918.00 Not Covered $ 0.74 Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Not Covered $ 3.69 Facility Only Facility Only Facility Only Not Covered Not Covered Facility Only Not Covered

0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X D D X X D D D X D O O O O O O O O O O O X D O O O X X O X

Y Y

Y Y Y

0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0%

Refer to Field Key for definitions

HCPCS Page 33

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

C9729 C9800 C9898 C9899 D0120 D0140 D0145 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0277 D0290 D0310 D0320 D0321 D0322 D0330 D0340 D0350 D0360 D0362 D0363 D0415 D0416 D0417 D0418 D0421 D0425 D0431 D0460 D0470 D0472 D0473

Percut lumbar lami Dermal filler inj px/suppl Inpnt stay radiolabeled item Inpt implant pros dev,no cov Periodic oral evaluation Limit oral eval problm focus Oral evaluation, pt < 3yrs Comprehensve oral evaluation Extensv oral eval prob focus Re-eval,est pt,problem focus Comp periodontal evaluation Intraor complete film series Intraoral periapical first f Intraoral periapical ea add Intraoral occlusal film Extraoral first film Extraoral ea additional film Dental bitewing single film Dental bitewings two films Bitewings - three films Dental bitewings four films Vert bitewings-sev to eight Dental film skull/facial bon Dental saliography Dental tmj arthrogram incl i Dental other tmj films Dental tomographic survey Dental panoramic film Dental cephalometric film Oral/facial photo images Cone beam ct Cone beam, two dimensional Cone beam, three dimensional Collection of microorganisms Viral culture Collect & prep saliva sample Analysis of saliva sample Gen tst suscept oral disease Caries susceptibility test Diag tst detect mucos abnorm Pulp vitality test Diagnostic casts Gross exam, prep & report Micro exam, prep & report

Not Covered Not Covered Facility Only Not Covered Not Covered $ 64.80 Not Covered $ 74.40 $ 135.95 $ 60.80 Not Covered $ 109.13 $ 24.00 $ 20.00 $ 36.33 $ 57.60 $ 48.80 $ 24.00 $ 38.12 $ 48.00 $ 56.00 $ 84.80 $ 117.36 Not Covered $ 510.35 $ 177.08 $ 459.39 $ 92.89 $ 105.08 $ 63.20 $ 493.41 $ 320.24 $ 344.61 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 48.00 $ 96.14 Not Covered Not Covered

Not Covered Not Covered Facility Only Not Covered Not Covered $ 64.80 Not Covered $ 74.40 $ 135.95 $ 60.80 Not Covered $ 109.13 $ 24.00 $ 20.00 $ 36.33 $ 57.60 $ 48.80 $ 24.00 $ 38.12 $ 48.00 $ 56.00 $ 84.80 $ 117.36 Not Covered $ 510.35 $ 177.08 $ 459.39 $ 92.89 $ 105.08 $ 63.20 $ 493.41 $ 320.24 $ 344.61 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 48.00 $ 96.14 Not Covered Not Covered

0 0% 0 0% 0 0% 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 0 9 9 9 9 9 9 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

9 9 9 9 9 9 9 0 9 9 9 9 9 9 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

9 9 9 9 9 9 9 0 9 9 9 9 9 9 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

9 9 9 9 9 9 9 0 9 9 9 9 9 9 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

9 9 9 9 9 9 9 0 9 9 9 9 9 9 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

9 9 9 9 9 9 9 0 9 9 9 9 9 9 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

X X O X X F X F F F X F F F F F F F F F F F F X F F F F F F F F F X X X X X X X F F X X

Y

Refer to Field Key for definitions

HCPCS Page 34

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D0474 D0475 D0476 D0477 D0478 D0479 D0480 D0481 D0482 D0483 D0484 D0485 D0486 D0502 D0999 D1110 D1120 D1203 D1204 D1206 D1310 D1320 D1330 D1351 D1352 D1510 D1515 D1520 D1525 D1550 D1555 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2410

Micro w exam of surg margins Decalcification procedure Spec stains for microorganis Spec stains not for microorg Immunohistochemical stains Tissue in-situ hybridization Cytopath smear prep & report Electron microscopy diagnost Direct immunofluorescence Indirect immunofluorescence Consult slides prep elsewher Consult inc prep of slides Access of transep cytol samp Other oral pathology procedu Unspecified diagnostic proce Dental prophylaxis adult Dental prophylaxis child Topical app fluoride child Topical app fluoride adult Topical fluoride varnish Nutri counsel-control caries Tobacco counseling Oral hygiene instruction Dental sealant per tooth Prev resin rest, perm tooth Space maintainer fxd unilat Fixed bilat space maintainer Remove unilat space maintain Remove bilat space maintain Recement space maintainer Remove fix space maintainer Amalgam one surface permanen Amalgam two surfaces permane Amalgam three surfaces perma Amalgam 4 or > surfaces perm Resin one surface-anterior Resin two surfaces-anterior Resin three surfaces-anterio Resin 4/> surf or w incis an Ant resin-based cmpst crown Post 1 srfc resinbased cmpst Post 2 srfc resinbased cmpst Post 3 srfc resinbased cmpst Post >=4srfc resinbase cmpst Dental gold foil one surface

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 144.00 By Report $ 76.80 Not Covered Not Covered Not Covered Not Covered Bundled Bundled Bundled Not Covered By Report $ 266.92 $ 363.91 $ 312.61 $ 413.41 $ 72.00 $ 66.40 $ 120.56 $ 152.05 $ 182.73 $ 217.60 $ 135.95 $ 169.79 $ 212.71 $ 266.92 $ 392.19 $ 149.60 $ 197.36 $ 241.79 $ 291.15 Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 144.00 By Report $ 76.80 Not Covered Not Covered Not Covered Not Covered Bundled Bundled Bundled Not Covered By Report $ 266.92 $ 363.91 $ 312.61 $ 413.41 $ 72.00 $ 66.40 $ 120.56 $ 152.05 $ 182.73 $ 217.60 $ 135.95 $ 169.79 $ 212.71 $ 266.92 $ 392.19 $ 149.60 $ 197.36 $ 241.79 $ 291.15 Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X F N F X X X X B B B X N F F F F F F F F F F F F F F F F F F F X

Y

Y

Refer to Field Key for definitions

HCPCS Page 35

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D2420 D2430 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2799 D2910 D2915 D2920 D2930 D2931 D2932 D2933

Dental gold foil two surface Dental gold foil three surfa Dental inlay metalic 1 surf Dental inlay metallic 2 surf Dental inlay metl 3/more sur Dental onlay metallic 2 surf Dental onlay metallic 3 surf Dental onlay metl 4/more sur Inlay porcelain/ceramic 1 su Inlay porcelain/ceramic 2 su Dental onlay porc 3/more sur Dental onlay porcelin 2 surf Dental onlay porcelin 3 surf Dental onlay porc 4/more sur Inlay composite/resin one su Inlay composite/resin two su Dental inlay resin 3/mre sur Dental onlay resin 2 surface Dental onlay resin 3 surface Dental onlay resin 4/mre sur Crown resin-based indirect Crown 3/4 resin-based compos Crown resin w/ high noble me Crown resin w/ base metal Crown resin w/ noble metal Crown porcelain/ceramic subs Crown porcelain w/ h noble m Crown porcelain fused base m Crown porcelain w/ noble met Crown 3/4 cast hi noble met Crown 3/4 cast base metal Crown 3/4 cast noble metal Crown 3/4 porcelain/ceramic Crown full cast high noble m Crown full cast base metal Crown full cast noble metal Crown-titanium Provisional crown Recement inlay onlay or part Recement cast or prefab post Dental recement crown Prefab stnlss steel crwn pri Prefab stnlss steel crown pe Prefabricated resin crown Prefab stainless steel crown

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 802.40 $ 854.96 $ 889.65 $ 849.32 $ 858.16 $ 970.59 $ 930.16 $ 889.65 $ 891.25 $ 892.85 $ 867.86 $ 858.96 $ 926.92 $ 932.56 $ 849.32 $ 884.85 $ 914.73 $ 376.05 $ 92.89 $ 96.14 $ 92.89 $ 229.69 $ 275.81 $ 297.60 $ 314.64

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 802.40 $ 854.96 $ 889.65 $ 849.32 $ 858.16 $ 970.59 $ 930.16 $ 889.65 $ 891.25 $ 892.85 $ 867.86 $ 858.96 $ 926.92 $ 932.56 $ 849.32 $ 884.85 $ 914.73 $ 376.05 $ 92.89 $ 96.14 $ 92.89 $ 229.69 $ 275.81 $ 297.60 $ 314.64

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 36

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D2934 D2940 D2950 D2951 D2952 D2953 D2954 D2955 D2957 D2960 D2961 D2962 D2970 D2971 D2975 D2980 D2999 D3110 D3120 D3220 D3221 D3222 D3230 D3240 D3310 D3320 D3330 D3331 D3332 D3333 D3346 D3347 D3348 D3351 D3352 D3353 D3354 D3410 D3421 D3425 D3426 D3430 D3450 D3460 D3470

Prefab steel crown primary Protective restoration Core build-up incl any pins Tooth pin retention Post and core cast + crown Each addtnl cast post Prefab post/core + crown Post removal Each addtnl prefab post Laminate labial veneer Lab labial veneer resin Lab labial veneer porcelain Temp crown (fractured tooth) Add proc construct new crown Coping Crown repair Dental unspec restorative pr Pulp cap direct Pulp cap indirect Therapeutic pulpotomy Gross pulpal debridement Part pulp for apexogenesis Pulpal therapy anterior prim Pulpal therapy posterior pri End thxpy, anterior tooth End thxpy, bicuspid tooth End thxpy, molar Non-surg tx root canal obs Incomplete endodontic tx Internal root repair Retreat root canal anterior Retreat root canal bicuspid Retreat root canal molar Apexification/recalc initial Apexification/recalc interim Apexification/recalc final Pulpal regeneration Apicoect/perirad surg anter Root surgery bicuspid Root surgery molar Root surgery ea add root Retrograde filling Root amputation Endodontic endosseous implan Intentional replantation

$ 308.94 $ 104.24 $ 230.54 $ 64.00 $ 359.91 $ 266.92 $ 283.11 $ 249.88 $ 173.84 $ 569.41 $ 829.04 $ 971.39 $ 323.53 $ 175.48 $ 511.95 $ 250.73 By Report $ 70.40 $ 72.80 $ 168.19 $ 202.16 Not Covered Not Covered Not Covered $ 617.84 $ 711.86 $ 855.76 $ 543.53 $ 383.29 $ 305.69 $ 726.35 $ 830.64 $ 984.28 $ 311.39 $ 222.49 $ 467.48 By Report $ 606.59 $ 672.94 $ 765.08 $ 347.86 $ 242.64 $ 412.61 $ 1275.39 $ 675.34

$ 308.94 $ 104.24 $ 230.54 $ 64.00 $ 359.91 $ 266.92 $ 283.11 $ 249.88 $ 173.84 $ 569.41 $ 829.04 $ 971.39 $ 323.53 $ 175.48 $ 511.95 $ 250.73 By Report $ 70.40 $ 72.80 $ 168.19 $ 202.16 Not Covered Not Covered Not Covered $ 617.84 $ 711.86 $ 855.76 $ 543.53 $ 383.29 $ 305.69 $ 726.35 $ 830.64 $ 984.28 $ 311.39 $ 222.49 $ 467.48 By Report $ 606.59 $ 672.94 $ 765.08 $ 347.86 $ 242.64 $ 412.61 $ 1275.39 $ 675.34

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

F F F F F F F F F F F F F F F F N F F F F X X X F F F F F F F F F F F F N F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y

Y Y Y

Y

Refer to Field Key for definitions

HCPCS Page 37

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D3910 D3920 D3950 D3999 D4210 D4211 D4230 D4231 D4240 D4241 D4245 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4268 D4270 D4271 D4273 D4274 D4275 D4276 D4320 D4321 D4341 D4342 D4355 D4381 D4910 D4920 D4999 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5225 D5226

Isolation- tooth w rubb dam Tooth splitting Canal prep/fitting of dowel Endodontic procedure Gingivectomy/plasty per quad Gingivectomy/plasty per toot Ana crown exp 4 or> per quad Ana crown exp 1-3 per quad Gingival flap proc w/ planin Gngvl flap w rootplan 1-3 th Apically positioned flap Crown lengthen hard tissue Osseous surgery per quadrant Osseous surgl-3teethperquad Bone replce graft first site Bone replce graft each add Bio mtrls to aid soft/os reg Guided tiss regen resorble Guided tiss regen nonresorb Surgical revision procedure Pedicle soft tissue graft pr Free soft tissue graft proc Subepithelial tissue graft Distal/proximal wedge proc Soft tissue allograft Con tissue w dble ped graft Provision splnt intracoronal Provisional splint extracoro Periodontal scaling & root Periodontal scaling 1-3teeth Full mouth debridement Localized delivery antimicro Periodontal maint procedures Unscheduled dressing change Unspecified periodontal proc Dentures complete maxillary Dentures complete mandible Dentures immediat maxillary Dentures immediat mandible Dentures maxill part resin Dentures mand part resin Dentures maxill part metal Dentures mandibl part metal Maxillary part denture flex Mandibular part denture flex

Bundled $ 397.93 $ 224.09 By Report $ 545.93 $ 263.72 $ 643.81 $ 516.00 $ 638.21 $ 545.93 $ 687.39 $ 651.91 $ 909.08 $ 768.28 $ 608.19 $ 490.21 $ 500.33 $ 715.86 $ 837.13 $ 688.99 $ 711.86 $ 768.28 $ 952.75 $ 567.01 $ 821.74 $ 911.53 $ 435.95 $ 404.52 Not Covered Not Covered Not Covered Not Covered Not Covered $ 85.60 By Report $ 1456.14 $ 1466.07 $ 1577.04 $ 1552.09 $ 1152.66 $ 1174.21 $ 1519.01 $ 1519.01 $ 1335.34 $ 1334.54

Bundled $ 397.93 $ 224.09 By Report $ 545.93 $ 263.72 $ 643.81 $ 516.00 $ 638.21 $ 545.93 $ 687.39 $ 651.91 $ 909.08 $ 768.28 $ 608.19 $ 490.21 $ 500.33 $ 715.86 $ 837.13 $ 688.99 $ 711.86 $ 768.28 $ 952.75 $ 567.01 $ 821.74 $ 911.53 $ 435.95 $ 404.52 Not Covered Not Covered Not Covered Not Covered Not Covered $ 85.60 By Report $ 1456.14 $ 1466.07 $ 1577.04 $ 1552.09 $ 1152.66 $ 1174.21 $ 1519.01 $ 1519.01 $ 1335.34 $ 1334.54

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 0 9 9 9 9 9 9 9 9 0 9 0 0 9 9 9 9 0 0 0 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 0 9 9 9 9 9 9 9 9 0 9 0 0 9 9 9 9 0 0 0 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 0 9 9 9 9 9 9 9 9 0 9 0 0 9 9 9 9 0 0 0 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 0 9 9 9 9 9 9 9 9 0 9 0 0 9 9 9 9 0 0 0 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 0 9 9 9 9 9 9 9 9 0 9 0 0 9 9 9 9 0 0 0 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 0 9 9 9 9 9 9 9 9 0 9 0 0 9 9 9 9 0 0 0 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9

B F F N F F F F F F F F F F F F F F F F F F F F F F F F X X X X X F N F F F F F F F F F F

Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 38

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5862 D5867 D5875 D5899 D5911 D5912 D5913 D5914 D5915 D5916

Removable partial denture Dentures adjust cmplt maxil Dentures adjust cmplt mand Dentures adjust part maxill Dentures adjust part mandbl Dentur repr broken compl bas Replace denture teeth complt Dentures repair resin base Rep part denture cast frame Rep partial denture clasp Replace part denture teeth Add tooth to partial denture Add clasp to partial denture Replc tth&acrlc on mtl frmwk Replc tth&acrlc mandibular Dentures rebase cmplt maxil Dentures rebase cmplt mand Dentures rebase part maxill Dentures rebase part mandbl Denture reln cmplt maxil ch Denture reln cmplt mand chr Denture reln part maxil chr Denture reln part mand chr Denture reln cmplt max lab Denture reln cmplt mand lab Denture reln part maxil lab Denture reln part mand lab Denture interm cmplt maxill Denture interm cmplt mandbl Denture interm part maxill Denture interm part mandbl Denture tiss conditn maxill Denture tiss condtin mandbl Overdenture complete Overdenture partial Precision attachment Replacement of precision att Prosthesis modification Removable prosthodontic proc Facial moulage sectional Facial moulage complete Nasal prosthesis Auricular prosthesis Orbital prosthesis Ocular prosthesis

$ 866.21 $ 76.80 $ 76.00 $ 76.00 $ 76.00 $ 180.33 $ 159.34 $ 173.04 $ 246.68 $ 225.69 $ 156.09 $ 190.92 $ 230.54 $ 635.81 $ 643.81 $ 494.21 $ 490.21 $ 477.18 $ 477.18 $ 315.44 $ 314.64 $ 308.94 $ 314.64 $ 403.58 $ 404.52 $ 400.33 $ 400.33 $ 735.25 $ 744.89 $ 596.14 $ 596.14 $ 177.88 $ 177.88 $ 1812.56 $ 1769.69 $ 606.59 $ 329.93 $ 333.32 By Report $ 254.97 $ 382.48 $ 6374.32 $ 6374.32 $ 8605.33 $ 8924.05

$ 866.21 $ 76.80 $ 76.00 $ 76.00 $ 76.00 $ 180.33 $ 159.34 $ 173.04 $ 246.68 $ 225.69 $ 156.09 $ 190.92 $ 230.54 $ 635.81 $ 643.81 $ 494.21 $ 490.21 $ 477.18 $ 477.18 $ 315.44 $ 314.64 $ 308.94 $ 314.64 $ 403.58 $ 404.52 $ 400.33 $ 400.33 $ 735.25 $ 744.89 $ 596.14 $ 596.14 $ 177.88 $ 177.88 $ 1812.56 $ 1769.69 $ 606.59 $ 329.93 $ 333.32 By Report $ 254.97 $ 382.48 $ 6374.32 $ 6374.32 $ 8605.33 $ 8924.05

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F N F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 39

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D5919 D5922 D5923 D5924 D5925 D5926 D5927 D5928 D5929 D5931 D5932 D5933 D5934 D5935 D5936 D5937 D5951 D5952 D5953 D5954 D5955 D5958 D5959 D5960 D5982 D5983 D5984 D5985 D5986 D5987 D5988 D5991 D5992 D5993 D5999 D6010 D6012 D6040 D6050 D6053 D6054 D6055 D6056 D6057 D6058

Facial prosthesis Nasal septal prosthesis Ocular prosthesis interim Cranial prosthesis Facial augmentation implant Replacement nasal prosthesis Auricular replacement Orbital replacement Facial replacement Surgical obturator Postsurgical obturator Refitting of obturator Mandibular flange prosthesis Mandibular denture prosth Temp obturator prosthesis Trismus appliance Feeding aid Pediatric speech aid Adult speech aid Superimposed prosthesis Palatal lift prosthesis Intraoral con def inter plt Intraoral con def mod palat Modify speech aid prosthesis Surgical stent Radiation applicator Radiation shield Radiation cone locator Fluoride applicator Commissure splint Surgical splint Topical medicament carrier Adjust max prost appliance Main/clean max prosthesis Maxillofacial prosthesis Odontics endosteal implant Endosteal implant Odontics eposteal implant Odontics transosteal implnt Implnt/abtmnt spprt remv dnt Implnt/abtmnt spprt remvprtl Implant connecting bar Prefabricated abutment Custom abutment Abutment supported crown

$ 8924.05 $ 4143.31 $ 5099.45 $ 5099.45 $ 5099.45 $ 3187.15 $ 3187.15 $ 4302.66 $ 4302.66 $ 2039.79 $ 4780.73 $ 956.15 $ 4780.73 $ 4780.73 $ 1752.95 $ 630.05 $ 736.75 Not Covered $ 1912.29 $ 4047.38 $ 4143.31 $ 2422.23 $ 765.01 $ 509.94 $ 377.60 Not Covered Not Covered Not Covered Not Covered $ 770.47 $ 645.40 Not Covered By Report By Report By Report $ 1698.30 $ 1337.55 $ 7013.25 $ 4918.60 $ 2568.90 $ 2372.75 $ 2504.50 $ 687.30 $ 808.70 $ 1234.15

$ 8924.05 $ 4143.31 $ 5099.45 $ 5099.45 $ 5099.45 $ 3187.15 $ 3187.15 $ 4302.66 $ 4302.66 $ 2039.79 $ 4780.73 $ 956.15 $ 4780.73 $ 4780.73 $ 1752.95 $ 630.05 $ 736.75 Not Covered $ 1912.29 $ 4047.38 $ 4143.31 $ 2422.23 $ 765.01 $ 509.94 $ 377.60 Not Covered Not Covered Not Covered Not Covered $ 770.47 $ 645.40 Not Covered By Report By Report By Report $ 1698.30 $ 1337.55 $ 7013.25 $ 4918.60 $ 2568.90 $ 2372.75 $ 2504.50 $ 687.30 $ 808.70 $ 1234.15

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F X F F F F F F F X X X X F F X N N N F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 40

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D6059 D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6080 D6090 D6091 D6092 D6093 D6094 D6095 D6100 D6190 D6194 D6199 D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6253

Abutment supported mtl crown Abutment supported mtl crown Abutment supported mtl crown Abutment supported mtl crown Abutment supported mtl crown Abutment supported mtl crown Implant supported crown Implant supported mtl crown Implant supported mtl crown Abutment supported retainer Abutment supported retainer Abutment supported retainer Abutment supported retainer Abutment supported retainer Abutment supported retainer Abutment supported retainer Implant supported retainer Implant supported retainer Implant supported retainer Implnt/abut suprtd fixd dent Implnt/abut suprtd fixd dent Implant maintenance Repair implant Repl semi/precision attach Recement supp crown Recement supp part denture Abut support crown titanium Odontics repr abutment Removal of implant Radio/surgical implant index Abut support retainer titani Implant procedure Pontic-indirect resin based Prosthodont high noble metal Bridge base metal cast Bridge noble metal cast Pontic titanium Bridge porcelain high noble Bridge porcelain base metal Bridge porcelain nobel metal Bridge porcelain/ceramic Bridge resin w/high noble Bridge resin base metal Bridge resin w/noble metal Provisional pontic

$ 1239.00 $ 1161.40 $ 1159.06 $ 1213.32 $ 1133.08 $ 1159.86 $ 1303.15 $ 1313.55 $ 1325.60 $ 1236.71 $ 1235.11 $ 1172.80 $ 1173.60 $ 1244.00 $ 1168.00 $ 1145.32 $ 1295.86 $ 1324.80 $ 1336.14 $ 4730.68 $ 3418.02 $ 267.72 $ 635.01 $ 522.96 $ 135.15 $ 154.49 $ 1136.28 $ 616.24 $ 646.26 $ 363.91 $ 1229.51 By Report $ 825.79 $ 926.12 $ 858.16 $ 880.85 $ 922.87 $ 942.31 $ 867.86 $ 889.65 $ 970.59 $ 897.04 $ 888.85 $ 877.65 $ 650.31

$ 1239.00 $ 1161.40 $ 1159.06 $ 1213.32 $ 1133.08 $ 1159.86 $ 1303.15 $ 1313.55 $ 1325.60 $ 1236.71 $ 1235.11 $ 1172.80 $ 1173.60 $ 1244.00 $ 1168.00 $ 1145.32 $ 1295.86 $ 1324.80 $ 1336.14 $ 4730.68 $ 3418.02 $ 267.72 $ 635.01 $ 522.96 $ 135.15 $ 154.49 $ 1136.28 $ 616.24 $ 646.26 $ 363.91 $ 1229.51 By Report $ 825.79 $ 926.12 $ 858.16 $ 880.85 $ 922.87 $ 942.31 $ 867.86 $ 889.65 $ 970.59 $ 897.04 $ 888.85 $ 877.65 $ 650.31

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F N F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 41

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D6254 D6545 D6548 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6793 D6794 D6795 D6920 D6930 D6940 D6950 D6970 D6972

Interim pontic Dental retainr cast metl Porcelain/ceramic retainer Porcelain/ceramic inlay 2srf Porc/ceram inlay >= 3 surfac Cst hgh nble mtl inlay 2 srf Cst hgh nble mtl inlay >=3sr Cst bse mtl inlay 2 surfaces Cst bse mtl inlay >= 3 surfa Cast noble metal inlay 2 sur Cst noble mtl inlay >=3 surf Onlay porc/crmc 2 surfaces Onlay porc/crmc >=3 surfaces Onlay cst hgh nbl mtl 2 srfc Onlay cst hgh nbl mtl >=3srf Onlay cst base mtl 2 surface Onlay cst base mtl >=3 surfa Onlay cst nbl mtl 2 surfaces Onlay cst nbl mtl >=3 surfac Inlay titanium Onlay titanium Crown-indirect resin based Retain crown resin w hi nble Crown resin w/base metal Crown resin w/noble metal Crown porcelain/ceramic Crown porcelain high noble Crown porcelain base metal Crown porcelain noble metal Crown 3/4 high noble metal Crown 3/4 cast based metal Crown 3/4 cast noble metal Crown 3/4 porcelain/ceramic Crown full high noble metal Crown full base metal cast Crown full noble metal cast Provisional retainer crown Crown titanium Interim retainer crown Dental connector bar Dental recement bridge Stress breaker Precision attachment Post & core plus retainer Prefab post & core plus reta

By Report $ 727.95 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 851.72 $ 895.44 $ 887.25 $ 889.65 $ 974.68 $ 950.35 $ 869.46 $ 889.65 $ 908.28 $ 870.26 $ 889.65 $ 926.12 $ 927.76 $ 858.16 $ 880.85 $ 472.33 $ 892.85 By Report $ 844.33 $ 146.40 $ 376.85 $ 563.81 $ 369.55 $ 290.35

By Report $ 727.95 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 851.72 $ 895.44 $ 887.25 $ 889.65 $ 974.68 $ 950.35 $ 869.46 $ 889.65 $ 908.28 $ 870.26 $ 889.65 $ 926.12 $ 927.76 $ 858.16 $ 880.85 $ 472.33 $ 892.85 By Report $ 844.33 $ 146.40 $ 376.85 $ 563.81 $ 369.55 $ 290.35

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9

N F X X X X X X X X X X X X X X X X X X X F F F F F F F F F F F F F F F F F N F F F F F F

Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 42

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D6973 D6975 D6976 D6977 D6980 D6985 D6999 D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7260 D7261 D7270 D7272 D7280 D7282 D7283 D7285 D7286 D7287 D7288 D7290 D7291 D7292 D7293 D7294 D7295 D7310 D7311 D7320 D7321 D7340 D7350 D7410 D7411 D7412 D7413 D7414 D7415

Core build up for retainer Coping metal Each addtnl cast post Each addtl prefab post Bridge repair Pediatric partial denture fx Fixed prosthodontic proc Extraction coronal remnants Extraction erupted tooth/exr Rem imp tooth w mucoper flp Impact tooth remov soft tiss Impact tooth remov part bony Impact tooth remov comp bony Impact tooth rem bony w/comp Tooth root removal Coronectomy Oral antral fistula closure Primary closure sinus perf Tooth reimplantation Tooth transplantation Exposure impact tooth orthod Mobilize erupted/malpos toot Place device impacted tooth Biopsy of oral tissue hard Biopsy of oral tissue soft Exfoliative cytolog collect Brush biopsy Repositioning of teeth Transseptal fiberotomy Screw retained plate Temp anchorage dev w flap Temp anchorage dev w/o flap Bone harvest,auto graft proc Alveoplasty w/ extraction Alveoloplasty w/extract 1-3 Alveoplasty w/o extraction Alveoloplasty not w/extracts Vestibuloplasty ridge extens Vestibuloplasty exten graft Rad exc lesion up to 1.25 cm Excision benign lesion>1.25c Excision benign lesion compl Excision malig lesion<=1.25c Excision malig lesion>1.25cm Excision malig les complicat

$ 230.54 $ 594.49 $ 245.08 $ 175.48 $ 325.13 Not Covered By Report $ 114.92 $ 149.60 $ 234.59 $ 266.92 $ 335.76 $ 416.66 $ 487.81 $ 264.52 By Report $ 947.11 $ 652.71 $ 485.41 $ 658.40 Not Covered Not Covered Not Covered $ 375.25 $ 278.26 $ 157.74 $ 167.39 $ 446.35 $ 270.92 $ 2746.64 $ 2300.28 $ 1449.46 By Report $ 251.53 $ 258.68 $ 384.14 $ 363.91 $ 1019.15 $ 2089.13 $ 357.51 $ 551.67 $ 729.55 Not Covered Not Covered Not Covered

$ 230.54 $ 594.49 $ 245.08 $ 175.48 $ 325.13 Not Covered By Report $ 114.92 $ 149.60 $ 234.59 $ 266.92 $ 335.76 $ 416.66 $ 487.81 $ 264.52 By Report $ 947.11 $ 652.71 $ 485.41 $ 658.40 Not Covered Not Covered Not Covered $ 375.25 $ 278.26 $ 157.74 $ 167.39 $ 446.35 $ 270.92 $ 2746.64 $ 2300.28 $ 1449.46 By Report $ 251.53 $ 258.68 $ 384.14 $ 363.91 $ 1019.15 $ 2089.13 $ 357.51 $ 551.67 $ 729.55 Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F X N F F F F F F F F N F F F F X X X F F F F F F F F F N F F F F F F F F F X X X

Y Y Y Y Y Y

Y

Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 43

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

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

Malig tumor exc to 1.25 cm Malig tumor > 1.25 cm Rem odontogen cyst to 1.25cm Rem odontogen cyst > 1.25 cm Rem nonodonto cyst to 1.25cm Rem nonodonto cyst > 1.25 cm Lesion destruction Rem exostosis any site Removal of torus palatinus Remove torus mandibularis Surg reduct osseoustuberosit Maxilla or mandible resectio I&d absc intraoral soft tiss Incision/drain abscess intra I&d abscess extraoral Incision/drain abscess extra Removal fb skin/areolar tiss Removal of fb reaction Removal of sloughed off bone Maxillary sinusotomy Maxilla open reduct simple Clsd reduct simpl maxilla fx Open red simpl mandible fx Clsd red simpl mandible fx Open red simp malar/zygom fx Clsd red simp malar/zygom fx Closd rductn splint alveolus Alveolus open reduction Reduct simple facial bone fx Maxilla open reduct compound Clsd reduct compd maxilla fx Open reduct compd mandble fx Clsd reduct compd mandble fx Open red comp malar/zygma fx Clsd red comp malar/zygma fx Open reduc compd alveolus fx Alveolus clsd reduc stblz te Reduct compnd facial bone fx Tmj open reduct-dislocation Closed tmp manipulation Tmj manipulation under anest Removal of tmj condyle Tmj meniscectomy Tmj repair of joint disc Tmj excisn of joint membrane

Not Covered Not Covered $ 538.68 $ 709.41 $ 491.81 $ 764.28 $ 417.46 $ 578.31 $ 750.54 $ 651.11 $ 646.26 Not Covered $ 202.16 $ 315.44 $ 407.76 $ 569.41 $ 307.29 $ 594.49 $ 532.52 $ 1200.99 $ 3688.24 $ 2986.96 $ 3821.51 $ 2969.93 $ 3308.94 $ 2759.76 $ 1612.85 $ 1080.66 $ 5543.53 $ 3758.64 $ 2952.99 $ 3964.38 $ 3053.36 $ 3582.26 $ 5134.40 $ 2353.74 $ 1633.84 $ 7236.47 $ 3582.26 $ 545.13 $ 833.04 $ 4589.93 $ 4437.18 $ 4721.84 $ 4387.06

Not Covered Not Covered $ 538.68 $ 709.41 $ 491.81 $ 764.28 $ 417.46 $ 578.31 $ 750.54 $ 651.11 $ 646.26 Not Covered $ 202.16 $ 315.44 $ 407.76 $ 569.41 $ 307.29 $ 594.49 $ 532.52 $ 1200.99 $ 3688.24 $ 2986.96 $ 3821.51 $ 2969.93 $ 3308.94 $ 2759.76 $ 1612.85 $ 1080.66 $ 5543.53 $ 3758.64 $ 2952.99 $ 3964.38 $ 3053.36 $ 3582.26 $ 5134.40 $ 2353.74 $ 1633.84 $ 7236.47 $ 3582.26 $ 545.13 $ 833.04 $ 4589.93 $ 4437.18 $ 4721.84 $ 4387.06

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X F F F F F F F F F X F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 44

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D7856 D7858 D7860 D7865 D7870 D7871 D7872 D7873 D7874 D7875 D7876 D7877 D7880 D7899 D7910 D7911 D7912 D7920 D7940 D7941 D7943 D7944 D7945 D7946 D7947 D7948 D7949 D7950 D7951 D7953 D7955 D7960 D7963 D7970 D7971 D7972 D7980 D7981 D7982 D7983 D7990 D7991 D7995 D7996 D7997

Tmj cutting of a muscle Tmj reconstruction Tmj cutting into joint Tmj reshaping components Tmj aspiration joint fluid Lysis + lavage w catheters Tmj diagnostic arthroscopy Tmj arthroscopy lysis adhesn Tmj arthroscopy disc reposit Tmj arthroscopy synovectomy Tmj arthroscopy discectomy Tmj arthroscopy debridement Occlusal orthotic appliance Tmj unspecified therapy Dent sutur recent wnd to 5cm Dental suture wound to 5 cm Suture complicate wnd > 5 cm Dental skin graft Reshaping bone orthognathic Bone cutting ramus closed Cutting ramus open w/graft Bone cutting segmented Bone cutting body mandible Reconstruction maxilla total Reconstruct maxilla segment Reconstruct midface no graft Reconstruct midface w/graft Mandible graft Sinus aug w bone/bone sup Bone replacement graft Repair maxillofacial defects Frenulectomy/frenectomy Frenuloplasty Excision hyperplastic tissue Excision pericoronal gingiva Surg redct fibrous tuberosit Sialolithotomy Excision of salivary gland Sialodochoplasty Closure of salivary fistula Emergency tracheotomy Dental coronoidectomy Synthetic graft facial bones Implant mandible for augment Appliance removal

$ 2992.66 $ 7139.24 $ 1912.29 $ 5354.42 $ 488.61 $ 2505.10 $ 1657.32 $ 1816.69 $ 2294.75 $ 2454.12 $ 2549.72 $ 2358.50 $ 902.64 $ 2358.50 $ 262.92 $ 435.95 $ 686.59 $ 2221.84 $ 3381.65 $ 7601.18 $ 7214.64 $ 5933.51 $ 5909.22 $ 6713.88 $ 6888.00 $ 8167.39 $ 9913.74 $ 2743.39 $ 2767.06 $ 930.96 $ 3182.73 $ 384.14 $ 425.46 $ 431.95 $ 224.09 $ 676.94 Not Covered Not Covered $ 1483.34 $ 1260.89 $ 1225.46 $ 3453.65 $ 3811.12 $ 3811.12 $ 303.29

$ 2992.66 $ 7139.24 $ 1912.29 $ 5354.42 $ 488.61 $ 2505.10 $ 1657.32 $ 1816.69 $ 2294.75 $ 2454.12 $ 2549.72 $ 2358.50 $ 902.64 $ 2358.50 $ 262.92 $ 435.95 $ 686.59 $ 2221.84 $ 3381.65 $ 7601.18 $ 7214.64 $ 5933.51 $ 5909.22 $ 6713.88 $ 6888.00 $ 8167.39 $ 9913.74 $ 2743.39 $ 2767.06 $ 930.96 $ 3182.73 $ 384.14 $ 425.46 $ 431.95 $ 224.09 $ 676.94 Not Covered Not Covered $ 1483.34 $ 1260.89 $ 1225.46 $ 3453.65 $ 3811.12 $ 3811.12 $ 303.29

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F X X F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y

Refer to Field Key for definitions

HCPCS Page 45

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D7998 D7999 D8010 D8020 D8030 D8040 D8050 D8060 D8070 D8080 D8090 D8210 D8220 D8660 D8670 D8680 D8690 D8691 D8692 D8693 D8999 D9110 D9120 D9210 D9211 D9212 D9215 D9220 D9221 D9230 D9241 D9242 D9248 D9310 D9410 D9420 D9430 D9440 D9450 D9610 D9612 D9630 D9910 D9911 D9920

Intraoral place of fix dev Oral surgery procedure Limited dental tx primary Limited dental tx transition Limited dental tx adolescent Limited dental tx adult Intercep dental tx primary Intercep dental tx transitn Compre dental tx transition Compre dental tx adolescent Compre dental tx adult Orthodontic rem appliance tx Fixed appliance therapy habt Preorthodontic tx visit Periodic orthodontc tx visit Orthodontic retention Orthodontic treatment Repair ortho appliance Replacement retainer Rebond/cement/repair retain Orthodontic procedure Tx dental pain minor proc Fix partial denture section Dent anesthesia w/o surgery Regional block anesthesia Trigeminal block anesthesia Local anesthesia General anesthesia General anesthesia ea ad 15m Analgesia Intravenous sedation IV sedation ea ad 30 m Sedation (non-iv) Dental consultation Dental house call Hospital/ASC call Office visit during hours Office visit after hours Case presentation tx plan Dent therapeutic drug inject Thera par drugs 2 or > admin Other drugs/medicaments Dent appl desensitizing med Appl desensitizing resin Behavior management

$ 2187.86 By Report Not Covered Not Covered $ 2680.19 $ 2905.36 Not Covered Not Covered Not Covered $ 4446.02 $ 4535.01 $ 738.87 $ 838.73 $ 363.91 $ 233.79 $ 468.28 $ 242.64 $ 181.93 $ 289.55 $ 291.15 By Report $ 109.93 $ 209.46 $ 64.80 Bundled Bundled Bundled $ 343.01 $ 146.40 $ 68.80 $ 363.91 $ 143.20 $ 285.51 $ 113.32 $ 215.15 $ 254.73 $ 67.20 $ 155.29 $ 125.46 $ 93.69 $ 161.74 $ 45.55 $ 56.80 $ 68.80 $ 141.60

$ 2187.86 By Report Not Covered Not Covered $ 2680.19 $ 2905.36 Not Covered Not Covered Not Covered $ 4446.02 $ 4535.01 $ 738.87 $ 838.73 $ 363.91 $ 233.79 $ 468.28 $ 242.64 $ 181.93 $ 289.55 $ 291.15 By Report $ 109.93 $ 209.46 $ 64.80 Bundled Bundled Bundled $ 343.01 $ 146.40 $ 68.80 $ 363.91 $ 143.20 $ 285.51 $ 113.32 $ 215.15 $ 254.73 $ 67.20 $ 155.29 $ 125.46 $ 93.69 $ 161.74 $ 45.55 $ 56.80 $ 68.80 $ 141.60

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9

F N X X F F X X X F F F F F F F F F F F N F F F B B B F F F F F F F F F F F F F F F F F F

Y

Y Y

Y Y Y Y Y Y Y Y Y Y Y

Y

Refer to Field Key for definitions

HCPCS Page 46

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

D9930 D9940 D9941 D9942 D9950 D9951 D9952 D9970 D9971 D9972 D9973 D9974 D9999 E0100-NU E0105-NU E0110-NU E0111-NU E0112-NU E0113-NU E0114-NU E0116-NU E0117-NU E0118-RR E0130-NU E0130-RR E0135-NU E0135-RR E0140-NU E0140-RR E0141-NU E0141-RR E0143-NU E0143-RR E0144-NU E0144-RR E0147-NU E0147-RR E0148-NU E0148-RR E0149-NU E0149-RR E0153-NU E0153-RR E0154-NU E0154-RR

Treatment of complications Dental occlusal guard Fabrication athletic guard Repair/reline occlusal guard Occlusion analysis Limited occlusal adjustment Complete occlusal adjustment Enamel microabrasion Odontoplasty 1-2 teeth Extrnl bleaching per arch Extrnl bleaching per tooth Intrnl bleaching per tooth Adjunctive procedure Cane adjust/fixed with tip Cane adjust/fixed quad/3 pro Crutch forearm pair Crutch forearm each Crutch underarm pair wood Crutch underarm each wood Crutch underarm pair no wood Crutch underarm each no wood Underarm springassist crutch Crutch substitute Walker rigid adjust/fixed ht Walker rigid adjust/fixed ht Walker folding adjust/fixed Walker folding adjust/fixed Walker w trunk support Walker w trunk support Rigid wheeled walker adj/fix Rigid wheeled walker adj/fix Walker folding wheeled w/o s Walker folding wheeled w/o s Enclosed walker w rear seat Enclosed walker w rear seat Walker variable wheel resist Walker variable wheel resist Heavyduty walker no wheels Heavyduty walker no wheels Heavy duty wheeled walker Heavy duty wheeled walker Forearm crutch platform atta Forearm crutch platform atta Walker platform attachment Walker platform attachment

$ 113.32 $ 519.25 $ 230.54 $ 222.49 $ 298.45 $ 159.34 $ 604.19 Not Covered $ 156.09 Not Covered $ 203.76 $ 251.53 By Report $ 22.10 $ 51.52 $ 81.39 $ 55.86 $ 38.81 $ 22.17 $ 46.69 $ 24.98 $ 25.01 $ 59.90 $ 63.50 $ 6.35 $ 75.80 $ 7.58 $ 326.11 $ 32.61 $ 104.24 $ 10.42 $ 108.70 $ 10.87 $ 287.91 $ 28.79 $ 519.68 $ 51.97 $ 114.87 $ 11.49 $ 201.80 $ 20.18 $ 72.04 $ 7.20 $ 63.75 $ 6.38

$ 113.32 $ 519.25 $ 230.54 $ 222.49 $ 298.45 $ 159.34 $ 604.19 Not Covered $ 156.09 Not Covered $ 203.76 $ 251.53 By Report $ 22.10 $ 51.52 $ 81.39 $ 55.86 $ 38.81 $ 22.17 $ 46.69 $ 24.98 $ 25.01 $ 59.90 $ 63.50 $ 6.35 $ 75.80 $ 7.58 $ 326.11 $ 32.61 $ 104.24 $ 10.42 $ 108.70 $ 10.87 $ 287.91 $ 28.79 $ 519.68 $ 51.97 $ 114.87 $ 11.49 $ 201.80 $ 20.18 $ 72.04 $ 7.20 $ 63.75 $ 6.38

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0 0 9 9 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 9 9 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 9 9 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 9 9 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 9 9 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 9 9 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F X F X F F N F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y

Y

Y

Refer to Field Key for definitions

HCPCS Page 47

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E0155-NU E0155-RR E0156-NU E0156-RR E0157-NU E0157-RR E0158-NU E0158-RR E0159-NU E0159-RR E0160-NU E0161-NU E0162-NU E0163-NU E0165-NU E0167-NU E0168-NU E0170-NU E0171-NU E0172-NU E0172-RR E0175-NU E0181-NU E0181-RR E0182-NU E0182-RR E0184-NU E0184-RR E0185-NU E0185-RR E0186-NU E0186-RR E0187-NU E0187-RR E0188-NU E0189-NU E0190 E0191-NU E0193-RR E0194-RR E0196-NU E0196-RR E0197-NU E0197-RR E0198-NU

Walker wheel attachment,pair Walker wheel attachment,pair Walker seat attachment Walker seat attachment Walker crutch attachment Walker crutch attachment Walker leg extenders set of4 Walker leg extenders set of4 Brake for wheeled walker Brake for wheeled walker Sitz type bath or equipment Sitz bath/equipment w/faucet Sitz bath chair Commode chair with fixed arm Commode chair with detacharm Commode chair pail or pan Heavyduty/wide commode chair Commode chair electric Commode chair non-electric Seat lift mechanism toilet Seat lift mechanism toilet Commode chair foot rest Press pad alternating w/ pum Press pad alternating w/ pum Replace pump, alt press pad Replace pump, alt press pad Dry pressure mattress Dry pressure mattress Gel pressure mattress pad Gel pressure mattress pad Air pressure mattress Air pressure mattress Water pressure mattress Water pressure mattress Synthetic sheepskin pad Lambswool sheepskin pad Positioning cushion Protector heel or elbow Powered air flotation bed Air fluidized bed Gel pressure mattress Gel pressure mattress Air pressure pad for mattres Air pressure pad for mattres Water pressure pad for mattr

$ 24.25 $ 2.43 $ 23.90 $ 2.39 $ 69.86 $ 6.99 $ 29.09 $ 2.91 $ 16.15 $ 1.62 $ 34.68 $ 27.51 $ 129.91 $ 115.68 $ 318.20 $ 12.59 $ 158.31 By Report By Report By Report By Report $ 62.40 $ 446.41 $ 44.64 $ 448.52 $ 44.85 $ 204.24 $ 20.42 $ 335.51 $ 33.55 $ 347.76 $ 34.78 $ 397.46 $ 39.75 $ 27.72 $ 46.33 Not Covered $ 8.91 $ 1333.82 $ 5574.32 $ 556.38 $ 55.64 $ 232.43 $ 23.24 $ 197.57

$ 24.25 $ 2.43 $ 23.90 $ 2.39 $ 69.86 $ 6.99 $ 29.09 $ 2.91 $ 16.15 $ 1.62 $ 34.68 $ 27.51 $ 129.91 $ 115.68 $ 318.20 $ 12.59 $ 158.31 By Report By Report By Report By Report $ 62.40 $ 446.41 $ 44.64 $ 448.52 $ 44.85 $ 204.24 $ 20.42 $ 335.51 $ 33.55 $ 347.76 $ 34.78 $ 397.46 $ 39.75 $ 27.72 $ 46.33 Not Covered $ 8.91 $ 1333.82 $ 5574.32 $ 556.38 $ 55.64 $ 232.43 $ 23.24 $ 197.57

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F N N N N F F F F F F F F F F F F F F F X F F F F F F F F

Y Y

Refer to Field Key for definitions

HCPCS Page 48

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E0198-RR E0199-NU E0200 E0202 E0203 E0205 E0210 E0215 E0217 E0218 E0221 E0225 E0231-NU E0231-RR E0232-NU E0232-RR E0235 E0236 E0239 E0240-NU E0241-NU E0242-NU E0243-NU E0244-NU E0245-NU E0246-NU E0247-NU E0248-NU E0249 E0250-NU E0250-RR E0251-NU E0251-RR E0255-NU E0255-RR E0256-NU E0256-RR E0260-NU E0260-RR E0261-NU E0261-RR E0265-NU E0265-RR E0266-NU E0266-RR

Water pressure pad for mattr Dry pressure pad for mattres Heat lamp without stand Phototherapy light w/ photom Therapeutic lightbox tabletp Heat lamp with stand Electric heat pad standard Electric heat pad moist Water circ heat pad w pump Water circ cold pad w pump Infrared heating pad system Hydrocollator unit Wound warming device Wound warming device Warming card for NWT Warming card for NWT Paraffin bath unit portable Pump for water circulating p Hydrocollator unit portable Bath/shower chair Bath tub wall rail Bath tub rail floor Toilet rail Toilet seat raised Tub stool or bench Transfer tub rail attachment Trans bench w/wo comm open HDtrans bench w/wo comm open Pad water circulating heat u Hosp bed fixed ht w/ mattres Hosp bed fixed ht w/ mattres Hosp bed fixd ht w/o mattres Hosp bed fixd ht w/o mattres Hospital bed var ht w/ mattr Hospital bed var ht w/ mattr Hospital bed var ht w/o matt Hospital bed var ht w/o matt Hosp bed semi-electr w/ matt Hosp bed semi-electr w/ matt Hosp bed semi-electr w/o mat Hosp bed semi-electr w/o mat Hosp bed total electr w/ mat Hosp bed total electr w/ mat Hosp bed total elec w/o matt Hosp bed total elec w/o matt

$ 19.76 $ 33.62 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report By Report Not Covered Not Covered Not Covered By Report $ 45.10 $ 102.20 $ 81.09 $ 61.42 $ 101.24 $ 138.18 $ 99.80 By Report Not Covered $ 1443.24 $ 144.32 $ 1093.56 $ 109.36 $ 1734.38 $ 173.44 $ 1230.59 $ 123.06 By Report By Report $ 2021.69 $ 202.17 $ 2950.96 $ 295.10 $ 2621.82 $ 262.18

$ 19.76 $ 33.62 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report By Report Not Covered Not Covered Not Covered By Report $ 45.10 $ 102.20 $ 81.09 $ 61.42 $ 101.24 $ 138.18 $ 99.80 By Report Not Covered $ 1443.24 $ 144.32 $ 1093.56 $ 109.36 $ 1734.38 $ 173.44 $ 1230.59 $ 123.06 By Report By Report $ 2021.69 $ 202.17 $ 2950.96 $ 295.10 $ 2621.82 $ 262.18

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F X X X X X X X X X X N N N N X X X N F F F F F F F N X F F F F F F F F N N F F F F F F

Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 49

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E0270-NU E0270-RR E0271-NU E0271-RR E0272-NU E0272-RR E0273-NU E0274-NU E0275-NU E0276-NU E0277-RR E0280-NU E0290-NU E0290-RR E0291-NU E0291-RR E0292-NU E0292-RR E0293-NU E0293-RR E0294-NU E0294-RR E0295-NU E0295-RR E0296-NU E0296-RR E0297-NU E0297-RR E0300 E0301-NU E0301-RR E0302-NU E0302-RR E0303-NU E0303-RR E0304-NU E0304-RR E0305-NU E0305-RR E0310-NU E0310-RR E0315-NU E0315-RR E0316-NU E0316-RR

Hospital bed institutional t Hospital bed institutional t Mattress innerspring Mattress innerspring Mattress foam rubber Mattress foam rubber Bed board Over-bed table Bed pan standard Bed pan fracture Powered pres-redu air mattrs Bed cradle Hosp bed fx ht w/o rails w/m Hosp bed fx ht w/o rails w/m Hosp bed fx ht w/o rail w/o Hosp bed fx ht w/o rail w/o Hosp bed var ht w/o rail w/o Hosp bed var ht w/o rail w/o Hosp bed var ht w/o rail w/ Hosp bed var ht w/o rail w/ Hosp bed semi-elect w/ mattr Hosp bed semi-elect w/ mattr Hosp bed semi-elect w/o matt Hosp bed semi-elect w/o matt Hosp bed total elect w/ matt Hosp bed total elect w/ matt Hosp bed total elect w/o mat Hosp bed total elect w/o mat Enclosed ped crib hosp grade HD hosp bed, 350-600 lbs HD hosp bed, 350-600 lbs Ex hd hosp bed > 600 lbs Ex hd hosp bed > 600 lbs Hosp bed hvy dty xtra wide Hosp bed hvy dty xtra wide Hosp bed xtra hvy dty x wide Hosp bed xtra hvy dty x wide Rails bed side half length Rails bed side half length Rails bed side full length Rails bed side full length Bed accessory brd/tbl/supprt Bed accessory brd/tbl/supprt Bed safety enclosure Bed safety enclosure

By Report By Report $ 200.75 $ 20.08 $ 173.39 $ 17.34 $ 48.94 $ 78.69 $ 16.06 $ 11.87 By Report $ 34.54 $ 1103.35 $ 110.34 $ 801.65 $ 80.17 $ 1240.76 $ 124.08 $ 1055.75 $ 105.58 $ 1928.80 $ 192.88 $ 1880.05 $ 188.01 $ 2424.14 $ 242.41 $ 2076.77 $ 207.68 Not Covered $ 3996.74 $ 399.67 $ 10562.32 $ 1056.23 $ 4487.86 $ 448.79 $ 11377.78 $ 1137.78 $ 262.74 $ 26.27 $ 175.52 $ 17.55 By Report By Report $ 3119.27 $ 311.93

By Report By Report $ 200.75 $ 20.08 $ 173.39 $ 17.34 $ 48.94 $ 78.69 $ 16.06 $ 11.87 By Report $ 34.54 $ 1103.35 $ 110.34 $ 801.65 $ 80.17 $ 1240.76 $ 124.08 $ 1055.75 $ 105.58 $ 1928.80 $ 192.88 $ 1880.05 $ 188.01 $ 2424.14 $ 242.41 $ 2076.77 $ 207.68 Not Covered $ 3996.74 $ 399.67 $ 10562.32 $ 1056.23 $ 4487.86 $ 448.79 $ 11377.78 $ 1137.78 $ 262.74 $ 26.27 $ 175.52 $ 17.55 By Report By Report $ 3119.27 $ 311.93

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N F F F F F F F F N F F F F F F F F F F F F F F F F F X F F F F F F F F F F F F N N F F

Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 50

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E0325-NU E0326-NU E0328 E0329 E0350-NU E0352-NU E0370-NU E0370-RR E0371-NU E0371-RR E0372-NU E0372-RR E0373-NU E0373-RR E0424-RR E0425 E0430 E0431-RR E0434-RR E0435 E0439-RR E0440 E0441-NU E0442-NU E0443-NU E0444-NU E0445-RR E0446-RR E0450-RR E0455-RR E0457-NU E0457-RR E0459-NU E0459-RR E0460-NU E0460-RR E0461-NU E0461-RR E0462-NU E0462-RR E0463-NU E0463-RR E0464-NU E0464-RR E0470-NU

Urinal male jug-type Urinal female jug-type Ped hospital bed, manual Ped hospital bed semi/elect Control unit bowel system Disposable pack w/bowel syst Air elevator for heel Air elevator for heel Nonpower mattress overlay Nonpower mattress overlay Powered air mattress overlay Powered air mattress overlay Nonpowered pressure mattress Nonpowered pressure mattress Stationary compressed gas 02 Gas system stationary compre Oxygen system gas portable Portable gaseous 02 Portable liquid 02 Oxygen system liquid portabl Stationary liquid 02 Oxygen system liquid station Stationary O2 contents, gas Stationary O2 contents, liq Portable 02 contents, gas Portable 02 contents, liquid Oximeter non-invasive Topical Ox Deliver sys, nos Vol control vent invasiv int Oxygen tent excl croup/ped t Chest shell Chest shell Chest wrap Chest wrap Neg press vent portabl/statn Neg press vent portabl/statn Vol control vent noninv int Vol control vent noninv int Rocking bed w/ or w/o side r Rocking bed w/ or w/o side r Press supp vent invasive int Press supp vent invasive int Press supp vent noninv int Press supp vent noninv int RAD w/o backup non-inv intfc

$ 10.61 $ 11.02 Not Covered Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 173.31 Not Covered Not Covered $ 28.74 $ 28.74 Not Covered $ 173.31 Not Covered $ 77.45 $ 77.45 $ 77.45 $ 77.45 By Report By Report $ 1634.99 By Report $ 644.59 $ 64.46 $ 871.70 $ 87.17 $ 12565.19 $ 1256.52 By Report By Report $ 4991.26 $ 499.13 By Report By Report By Report By Report $ 3788.31

$ 10.61 $ 11.02 Not Covered Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 173.31 Not Covered Not Covered $ 28.74 $ 28.74 Not Covered $ 173.31 Not Covered $ 77.45 $ 77.45 $ 77.45 $ 77.45 By Report By Report $ 1634.99 By Report $ 644.59 $ 64.46 $ 871.70 $ 87.17 $ 12565.19 $ 1256.52 By Report By Report $ 4991.26 $ 499.13 By Report By Report By Report By Report $ 3788.31

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F X X N N N N N N N N N N F X X F F X F X F F F F N N F N F F F F F F N N F F N N N N F

Y

Y Y Y Y Y Y Y Y Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 51

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E0470-RR E0471-NU E0471-RR E0472-NU E0472-RR E0480-NU E0480-RR E0481-NU E0481-RR E0482-NU E0482-RR E0483-NU E0483-RR E0484-NU E0485-NU E0486-NU E0487 E0500 E0550-RR E0555-NU E0560-NU E0560-RR E0561-NU E0562-NU E0565-RR E0570-NU E0570-RR E0571-NU E0571-RR E0572-NU E0572-RR E0574-NU E0574-RR E0575-NU E0575-RR E0580-NU E0585-NU E0585-RR E0600-NU E0600-RR E0601-NU E0601-RR E0602 E0603 E0604

RAD w/o backup non-inv intfc RAD w/backup non inv intrfc RAD w/backup non inv intrfc RAD w backup invasive intrfc RAD w backup invasive intrfc Percussor elect/pneum home m Percussor elect/pneum home m Intrpulmnry percuss vent sys Intrpulmnry percuss vent sys Cough stimulating device Cough stimulating device Chest compression gen system Chest compression gen system Non-elec oscillatory pep dvc Oral device/appliance prefab Oral device/appliance cusfab Electronic spirometer Ippb all types Humidif extens supple w ippb Humidifier for use w/ regula Humidifier supplemental w/ i Humidifier supplemental w/ i Humidifier nonheated w PAP Humidifier heated used w PAP Compressor air power source Nebulizer with compression Nebulizer with compression Aerosol compressor for svneb Aerosol compressor for svneb Aerosol compressor adjust pr Aerosol compressor adjust pr Ultrasonic generator w svneb Ultrasonic generator w svneb Nebulizer ultrasonic Nebulizer ultrasonic Nebulizer for use w/ regulat Nebulizer w/ compressor & he Nebulizer w/ compressor & he Suction pump portab hom modl Suction pump portab hom modl Cont airway pressure device Cont airway pressure device Manual breast pump Electric breast pump Hosp grade elec breast pump

$ 378.83 $ 9480.66 $ 948.07 $ 9480.66 $ 948.07 $ 752.71 $ 75.27 By Report By Report By Report By Report $ 18210.33 $ 1821.03 $ 38.73 By Report By Report Not Covered Not Covered $ 44.70 $ 13.43 $ 155.07 $ 15.51 $ 96.74 $ 272.33 $ 104.50 By Report By Report $ 513.38 $ 51.34 $ 652.34 $ 65.23 $ 689.57 $ 68.96 $ 1760.48 $ 176.05 $ 121.19 $ 600.71 $ 60.07 $ 784.38 $ 78.44 $ 1649.36 $ 164.94 Not Covered Not Covered Not Covered

$ 378.83 $ 9480.66 $ 948.07 $ 9480.66 $ 948.07 $ 752.71 $ 75.27 By Report By Report By Report By Report $ 18210.33 $ 1821.03 $ 38.73 By Report By Report Not Covered Not Covered $ 44.70 $ 13.43 $ 155.07 $ 15.51 $ 96.74 $ 272.33 $ 104.50 By Report By Report $ 513.38 $ 51.34 $ 652.34 $ 65.23 $ 689.57 $ 68.96 $ 1760.48 $ 176.05 $ 121.19 $ 600.71 $ 60.07 $ 784.38 $ 78.44 $ 1649.36 $ 164.94 Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F N N N N F F F N N X X F F F F F F F N N F F F F F F F F F F F F F F F X X X

Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 52

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E0605-NU E0606-RR E0607-NU E0610-NU E0615-NU E0615-RR E0616-NU E0616-RR E0617-NU E0617-RR E0618 E0619 E0620-NU E0620-RR E0621-NU E0621-RR E0625-NU E0625-RR E0627-NU E0627-RR E0628-NU E0628-RR E0629-NU E0629-RR E0630-NU E0630-RR E0635-NU E0635-RR E0636-NU E0636-RR E0637-NU E0638-NU E0638-RR E0639-NU E0639-RR E0640-NU E0640-RR E0641-NU E0641-RR E0642-NU E0642-RR E0650-NU E0650-RR E0651-NU E0651-RR

Vaporizer room type Drainage board postural Blood glucose monitor home Pacemaker monitr audible/vis Pacemaker monitr digital/vis Pacemaker monitr digital/vis Cardiac event recorder Cardiac event recorder Automatic ext defibrillator Automatic ext defibrillator Apnea monitor Apnea monitor w recorder Cap bld skin piercing laser Cap bld skin piercing laser Patient lift sling or seat Patient lift sling or seat Patient lift bathroom or toi Patient lift bathroom or toi Seat lift incorp lift-chair Seat lift incorp lift-chair Seat lift for pt furn-electr Seat lift for pt furn-electr Seat lift for pt furn-non-el Seat lift for pt furn-non-el Patient lift hydraulic Patient lift hydraulic Patient lift electric Patient lift electric PT support & positioning sys PT support & positioning sys Combination sit to stand sys Standing frame sys Standing frame sys Moveable patient lift system Moveable patient lift system Fixed patient lift system Fixed patient lift system Multi-position stnd fram sys Multi-position stnd fram sys Dynamic standing frame Dynamic standing frame Pneuma compresor non-segment Pneuma compresor non-segment Pneum compressor segmental Pneum compressor segmental

$ 27.72 $ 39.31 $ 70.09 $ 212.08 $ 502.26 $ 50.23 By Report By Report By Report By Report Not Covered Not Covered $ 917.19 $ 91.72 $ 100.69 $ 10.07 By Report By Report $ 346.90 $ 34.69 $ 346.90 $ 34.69 $ 346.90 $ 34.69 $ 1745.13 $ 174.51 $ 2095.96 $ 209.60 $ 18063.51 $ 1806.35 $ 3433.87 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 755.47 $ 75.55 $ 963.38 $ 96.34

$ 27.72 $ 39.31 $ 70.09 $ 212.08 $ 502.26 $ 50.23 By Report By Report By Report By Report Not Covered Not Covered $ 917.19 $ 91.72 $ 100.69 $ 10.07 By Report By Report $ 346.90 $ 34.69 $ 346.90 $ 34.69 $ 346.90 $ 34.69 $ 1745.13 $ 174.51 $ 2095.96 $ 209.60 $ 18063.51 $ 1806.35 $ 3433.87 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 755.47 $ 75.55 $ 963.38 $ 96.34

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F N N N N X X F F F F N N F F F F F F F F F F F F F N N N N N N N N N N F F F F

Y Y

Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 53

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E0652-NU E0652-RR E0655-NU E0655-RR E0656-NU E0656-RR E0657-NU E0657-RR E0660-NU E0660-RR E0665-NU E0665-RR E0666-NU E0666-RR E0667-NU E0667-RR E0668-NU E0668-RR E0669-NU E0669-RR E0671-NU E0671-RR E0672-NU E0672-RR E0673-NU E0673-RR E0675-NU E0675-RR E0676-NU E0676-RR E0691 E0692 E0693 E0694 E0700-NU E0705-NU E0705-RR E0710-NU E0720 E0730 E0731 E0740 E0744 E0745-RR E0746-RR

Pneum compres w/cal pressure Pneum compres w/cal pressure Pneumatic appliance half arm Pneumatic appliance half arm Segmental pneumatic trunk Segmental pneumatic trunk Segmental pneumatic chest Segmental pneumatic chest Pneumatic appliance full leg Pneumatic appliance full leg Pneumatic appliance full arm Pneumatic appliance full arm Pneumatic appliance half leg Pneumatic appliance half leg Seg pneumatic appl full leg Seg pneumatic appl full leg Seg pneumatic appl full arm Seg pneumatic appl full arm Seg pneumatic appli half leg Seg pneumatic appli half leg Pressure pneum appl full leg Pressure pneum appl full leg Pressure pneum appl full arm Pressure pneum appl full arm Pressure pneum appl half leg Pressure pneum appl half leg Pneumatic compression device Pneumatic compression device Inter limb compress dev NOS Inter limb compress dev NOS Uvl pnl 2 sq ft or less Uvl sys panel 4 ft Uvl sys panel 6 ft Uvl md cabinet sys 6 ft Safety equipment Transfer device Transfer device Restraints any type Tens two lead Tens four lead Conductive garment for tens/ Incontinence treatment systm Neuromuscular stim for scoli Neuromuscular stim for shock Electromyograph biofeedback

$ 5059.95 $ 506.00 $ 113.21 $ 11.32 $ 605.99 $ 60.53 $ 569.31 $ 56.83 $ 167.57 $ 16.76 $ 133.08 $ 13.31 $ 144.84 $ 14.48 $ 339.62 $ 33.96 $ 463.51 $ 46.35 $ 192.29 $ 19.23 $ 435.68 $ 43.57 $ 338.53 $ 33.85 $ 281.30 $ 28.13 $ 6586.89 $ 658.69 By Report By Report Not Covered Not Covered Not Covered Not Covered By Report $ 49.15 $ 4.92 By Report Not Covered Not Covered Not Covered Not Covered Not Covered $ 153.33 By Report

$ 5059.95 $ 506.00 $ 113.21 $ 11.32 $ 605.99 $ 60.53 $ 569.31 $ 56.83 $ 167.57 $ 16.76 $ 133.08 $ 13.31 $ 144.84 $ 14.48 $ 339.62 $ 33.96 $ 463.51 $ 46.35 $ 192.29 $ 19.23 $ 435.68 $ 43.57 $ 338.53 $ 33.85 $ 281.30 $ 28.13 $ 6586.89 $ 658.69 By Report By Report Not Covered Not Covered Not Covered Not Covered By Report $ 49.15 $ 4.92 By Report Not Covered Not Covered Not Covered Not Covered Not Covered $ 153.33 By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F N N X X X X N F F N X X X X X F N

Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 54

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E0747-NU E0747-RR E0748-NU E0748-RR E0749-NU E0749-RR E0755 E0760-NU E0760-RR E0761-NU E0761-RR E0762 E0764-NU E0764-RR E0765 E0769 E0770-NU E0770-RR E0776-NU E0776-RR E0779-NU E0779-RR E0780-NU E0781-RR E0782-NU E0782-RR E0783-NU E0783-RR E0784-NU E0784-RR E0785-NU E0786-NU E0786-RR E0791-NU E0791-RR E0830-NU E0830-RR E0840-NU E0840-RR E0849-NU E0849-RR E0850-NU E0850-RR E0855-NU E0855-RR

Elec osteogen stim not spine Elec osteogen stim not spine Elec osteogen stim spinal Elec osteogen stim spinal Elec osteogen stim implanted Elec osteogen stim implanted Electronic salivary reflex s Osteogen ultrasound stimltor Osteogen ultrasound stimltor Nontherm electromgntc device Nontherm electromgntc device Trans elec jt stim dev sys Functional neuromuscularstim Functional neuromuscularstim Nerve stimulator for tx n&v Electric wound treatment dev Functional electric stim NOS Functional electric stim NOS Iv pole Iv pole Amb infusion pump mechanical Amb infusion pump mechanical Mech amb infusion pump <8hrs External ambulatory infus pu Non-programble infusion pump Non-programble infusion pump Programmable infusion pump Programmable infusion pump Ext amb infusn pump insulin Ext amb infusn pump insulin Replacement impl pump cathet Implantable pump replacement Implantable pump replacement Parenteral infusion pump sta Parenteral infusion pump sta Ambulatory traction device Ambulatory traction device Tract frame attach headboard Tract frame attach headboard Cervical pneum trac equip Cervical pneum trac equip Traction stand free standing Traction stand free standing Cervical traction equipment Cervical traction equipment

$ 4107.76 $ 410.78 $ 4081.15 $ 408.12 By Report By Report Not Covered $ 3391.37 $ 339.14 By Report By Report Not Covered $ 11608.54 $ 1160.85 Not Covered Not Covered By Report By Report $ 150.17 $ 15.02 By Report By Report $ 10.88 $ 453.68 $ 4503.57 $ 450.36 $ 8587.66 $ 858.77 $ 7152.47 $ 715.25 $ 496.13 $ 8376.74 $ 837.67 $ 5416.18 $ 541.62 $ 510.00 $ 51.00 $ 76.86 $ 7.69 $ 540.54 $ 54.05 $ 110.20 $ 11.02 $ 527.23 $ 52.72

$ 4107.76 $ 410.78 $ 4081.15 $ 408.12 By Report By Report Not Covered $ 3391.37 $ 339.14 By Report By Report Not Covered $ 11608.54 $ 1160.85 Not Covered Not Covered By Report By Report $ 150.17 $ 15.02 By Report By Report $ 10.88 $ 453.68 $ 4503.57 $ 450.36 $ 8587.66 $ 858.77 $ 7152.47 $ 715.25 $ 496.13 $ 8376.74 $ 837.67 $ 5416.18 $ 541.62 $ 510.00 $ 51.00 $ 76.86 $ 7.69 $ 540.54 $ 54.05 $ 110.20 $ 11.02 $ 527.23 $ 52.72

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F N N X F F N N X F F X X N N F F N N F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y

Y Y

Y Y

Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 55

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E0856-NU E0856-RR E0860-NU E0870-NU E0870-RR E0880-NU E0880-RR E0890-NU E0890-RR E0900-NU E0900-RR E0910-NU E0910-RR E0911-NU E0911-RR E0912-NU E0912-RR E0920-NU E0920-RR E0930-NU E0930-RR E0935-RR E0936-RR E0940-NU E0940-RR E0941 E0942-NU E0944-NU E0945-NU E0946-RR E0947-RR E0948-RR E0950-NU E0950-RR E0951-NU E0952-NU E0955-NU E0955-RR E0956-NU E0956-RR E0957-NU E0957-RR E0958-NU E0958-RR E0959-NU

Cervic collar w air bladder Cervic collar w air bladder Tract equip cervical tract Tract frame attach footboard Tract frame attach footboard Trac stand free stand extrem Trac stand free stand extrem Traction frame attach pelvic Traction frame attach pelvic Trac stand free stand pelvic Trac stand free stand pelvic Trapeze bar attached to bed Trapeze bar attached to bed HD trapeze bar attach to bed HD trapeze bar attach to bed HD trapeze bar free standing HD trapeze bar free standing Fracture frame attached to b Fracture frame attached to b Fracture frame free standing Fracture frame free standing Cont pas motion exercise dev CPM device, other than knee Trapeze bar free standing Trapeze bar free standing Gravity assisted traction de Cervical head harness/halter Pelvic belt/harness/boot Belt/harness extremity Fracture frame dual w cross Fracture frame attachmnts pe Fracture frame attachmnts ce Tray Tray Loop heel Toe loop/holder, each Cushioned headrest Cushioned headrest W/c lateral trunk/hip suppor W/c lateral trunk/hip suppor W/c medial thigh support W/c medial thigh support Whlchr att- conv 1 arm drive Whlchr att- conv 1 arm drive Amputee adapter

$ 161.57 $ 16.14 $ 40.08 $ 122.01 $ 12.20 $ 131.69 $ 13.17 $ 126.30 $ 12.63 $ 134.40 $ 13.44 $ 295.37 $ 29.54 By Report By Report By Report By Report $ 790.33 $ 79.03 By Report By Report $ 40.00 By Report $ 513.38 $ 51.34 Not Covered $ 20.82 $ 44.76 $ 46.49 $ 101.34 $ 54.07 $ 61.53 $ 93.98 $ 9.40 $ 17.16 $ 17.02 $ 182.79 $ 18.28 $ 89.12 $ 8.91 $ 124.71 $ 12.47 $ 747.34 $ 74.73 $ 46.37

$ 161.57 $ 16.14 $ 40.08 $ 122.01 $ 12.20 $ 131.69 $ 13.17 $ 126.30 $ 12.63 $ 134.40 $ 13.44 $ 295.37 $ 29.54 By Report By Report By Report By Report $ 790.33 $ 79.03 By Report By Report $ 40.00 By Report $ 513.38 $ 51.34 Not Covered $ 20.82 $ 44.76 $ 46.49 $ 101.34 $ 54.07 $ 61.53 $ 93.98 $ 9.40 $ 17.16 $ 17.02 $ 182.79 $ 18.28 $ 89.12 $ 8.91 $ 124.71 $ 12.47 $ 747.34 $ 74.73 $ 46.37

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F N N N N F F N N F N F F X F F F F F F F F F F F F F F F F F F F

Y Y

Refer to Field Key for definitions

HCPCS Page 56

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E0959-RR E0960-NU E0960-RR E0961-NU E0961-RR E0966-NU E0966-RR E0967-NU E0967-RR E0968-NU E0968-RR E0969-NU E0969-RR E0970-NU E0970-RR E0971-NU E0971-RR E0973-NU E0973-RR E0974-NU E0974-RR E0978-NU E0978-RR E0980-NU E0980-RR E0981-NU E0981-RR E0982-NU E0982-RR E0983-NU E0983-RR E0984-NU E0984-RR E0985-NU E0985-RR E0986-NU E0986-RR E0990-NU E0990-RR E0992-NU E0992-RR E0994-NU E0994-RR E0995-NU E0995-RR

Amputee adapter W/c shoulder harness/straps W/c shoulder harness/straps Wheelchair brake extension Wheelchair brake extension Wheelchair head rest extensi Wheelchair head rest extensi Manual wc hand rim w project Manual wc hand rim w project Wheelchair commode seat Wheelchair commode seat Wheelchair narrowing device Wheelchair narrowing device Wheelchair no. 2 footplates Wheelchair no. 2 footplates Wheelchair anti-tipping devi Wheelchair anti-tipping devi W/Ch access det adj armrest W/Ch access det adj armrest W/Ch access anti-rollback W/Ch access anti-rollback W/C acc,saf belt pelv strap W/C acc,saf belt pelv strap Wheelchair safety vest Wheelchair safety vest Seat upholstery, replacement Seat upholstery, replacement Back upholstery, replacement Back upholstery, replacement Add pwr joystick Add pwr joystick Add pwr tiller Add pwr tiller W/c seat lift mechanism W/c seat lift mechanism Man w/c push-rim pow assist Man w/c push-rim pow assist Wheelchair elevating leg res Wheelchair elevating leg res Wheelchair solid seat insert Wheelchair solid seat insert Wheelchair arm rest Wheelchair arm rest Wheelchair calf rest Wheelchair calf rest

$ 4.64 $ 82.26 $ 8.23 $ 26.52 $ 2.65 $ 74.87 $ 7.49 $ 68.90 $ 6.89 $ 307.26 $ 30.73 $ 164.30 $ 16.43 $ 96.92 $ 9.69 $ 45.51 $ 4.55 $ 88.36 $ 8.84 $ 82.25 $ 8.23 $ 38.60 $ 3.86 $ 34.68 $ 3.47 $ 42.63 $ 4.26 $ 46.58 $ 4.66 $ 4281.16 $ 428.12 $ 2004.10 $ 200.41 $ 212.78 $ 21.28 $ 5102.34 $ 510.23 $ 90.24 $ 9.02 $ 99.81 $ 9.98 $ 18.49 $ 1.85 $ 27.48 $ 2.75

$ 4.64 $ 82.26 $ 8.23 $ 26.52 $ 2.65 $ 74.87 $ 7.49 $ 68.90 $ 6.89 $ 307.26 $ 30.73 $ 164.30 $ 16.43 $ 96.92 $ 9.69 $ 45.51 $ 4.55 $ 88.36 $ 8.84 $ 82.25 $ 8.23 $ 38.60 $ 3.86 $ 34.68 $ 3.47 $ 42.63 $ 4.26 $ 46.58 $ 4.66 $ 4281.16 $ 428.12 $ 2004.10 $ 200.41 $ 212.78 $ 21.28 $ 5102.34 $ 510.23 $ 90.24 $ 9.02 $ 99.81 $ 9.98 $ 18.49 $ 1.85 $ 27.48 $ 2.75

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 57

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E1002-NU E1002-RR E1003-NU E1003-RR E1004-NU E1004-RR E1005-NU E1005-RR E1006-NU E1006-RR E1007-NU E1007-RR E1008-NU E1008-RR E1009-NU E1009-RR E1010-NU E1010-RR E1011 E1014 E1015-NU E1016-NU E1017-NU E1018-NU E1020-NU E1020-RR E1028-NU E1028-RR E1029-NU E1029-RR E1030-NU E1030-RR E1031-NU E1031-RR E1035-NU E1035-RR E1037 E1038-NU E1038-RR E1039-NU E1039-RR E1050-NU E1050-RR E1060-NU E1060-RR

Pwr seat tilt Pwr seat tilt Pwr seat recline Pwr seat recline Pwr seat recline mech Pwr seat recline mech Pwr seat recline pwr Pwr seat recline pwr Pwr seat combo w/o shear Pwr seat combo w/o shear Pwr seat combo w/shear Pwr seat combo w/shear Pwr seat combo pwr shear Pwr seat combo pwr shear Add mech leg elevation Add mech leg elevation Add pwr leg elevation Add pwr leg elevation Ped wc modify width adjustm Reclining back add ped w/c Shock absorber for man w/c Shock absorber for power w/c HD shck absrbr for hd man wc HD shck absrber for hd powwc Residual limb support system Residual limb support system W/c manual swingaway W/c manual swingaway W/c vent tray fixed W/c vent tray fixed W/c vent tray gimbaled W/c vent tray gimbaled Rollabout chair with casters Rollabout chair with casters Patient transfer system <300 Patient transfer system <300 Transport chair, ped size Transport chair pt wt<=300lb Transport chair pt wt<=300lb Transport chair pt wt >300lb Transport chair pt wt >300lb Whelchr fxd full length arms Whelchr fxd full length arms Wheelchair detachable arms Wheelchair detachable arms

$ 3664.49 $ 366.45 $ 3970.16 $ 397.02 $ 4402.08 $ 440.21 $ 4764.91 $ 476.49 $ 5836.57 $ 583.66 $ 7902.94 $ 790.29 $ 7903.65 $ 790.37 By Report By Report $ 1034.09 $ 103.41 Not Covered Not Covered $ 120.32 $ 118.72 By Report By Report $ 220.07 $ 22.01 $ 186.73 $ 18.67 $ 334.10 $ 33.41 $ 1053.52 $ 105.35 $ 865.18 $ 86.52 By Report By Report Not Covered $ 308.80 $ 30.88 $ 585.74 $ 58.57 $ 1744.36 $ 174.44 $ 2159.29 $ 215.93

$ 3664.49 $ 366.45 $ 3970.16 $ 397.02 $ 4402.08 $ 440.21 $ 4764.91 $ 476.49 $ 5836.57 $ 583.66 $ 7902.94 $ 790.29 $ 7903.65 $ 790.37 By Report By Report $ 1034.09 $ 103.41 Not Covered Not Covered $ 120.32 $ 118.72 By Report By Report $ 220.07 $ 22.01 $ 186.73 $ 18.67 $ 334.10 $ 33.41 $ 1053.52 $ 105.35 $ 865.18 $ 86.52 By Report By Report Not Covered $ 308.80 $ 30.88 $ 585.74 $ 58.57 $ 1744.36 $ 174.44 $ 2159.29 $ 215.93

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F N N F F X X F F N N F F F F F F F F F F N N X F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 58

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E1070-NU E1070-RR E1083-NU E1083-RR E1084-NU E1084-RR E1085-NU E1085-RR E1086-NU E1086-RR E1087-NU E1087-RR E1088-NU E1088-RR E1089-NU E1089-RR E1090-NU E1090-RR E1092-NU E1092-RR E1093-NU E1093-RR E1100-NU E1100-RR E1110-NU E1110-RR E1130-NU E1130-RR E1140-NU E1140-RR E1150-NU E1150-RR E1160-NU E1160-RR E1161-NU E1161-RR E1170-NU E1170-RR E1171-NU E1171-RR E1172-NU E1172-RR E1180-NU E1180-RR E1190-NU

Wheelchair detachable foot r Wheelchair detachable foot r Hemi-wheelchair fixed arms Hemi-wheelchair fixed arms Hemi-wheelchair detachable a Hemi-wheelchair detachable a Hemi-wheelchair fixed arms Hemi-wheelchair fixed arms Hemi-wheelchair detachable a Hemi-wheelchair detachable a Wheelchair lightwt fixed arm Wheelchair lightwt fixed arm Wheelchair lightweight det a Wheelchair lightweight det a Wheelchair lightwt fixed arm Wheelchair lightwt fixed arm Wheelchair lightweight det a Wheelchair lightweight det a Wheelchair wide w/ leg rests Wheelchair wide w/ leg rests Wheelchair wide w/ foot rest Wheelchair wide w/ foot rest Whchr s-recl fxd arm leg res Whchr s-recl fxd arm leg res Wheelchair semi-recl detach Wheelchair semi-recl detach Whlchr stand fxd arm ft rest Whlchr stand fxd arm ft rest Wheelchair standard detach a Wheelchair standard detach a Wheelchair standard w/ leg r Wheelchair standard w/ leg r Wheelchair fixed arms Wheelchair fixed arms Manual adult wc w tiltinspac Manual adult wc w tiltinspac Whlchr ampu fxd arm leg rest Whlchr ampu fxd arm leg rest Wheelchair amputee w/o leg r Wheelchair amputee w/o leg r Wheelchair amputee detach ar Wheelchair amputee detach ar Wheelchair amputee w/ foot r Wheelchair amputee w/ foot r Wheelchair amputee w/ leg re

$ 1876.21 $ 187.62 $ 1348.82 $ 134.88 $ 1680.45 $ 168.05 $ 1496.98 $ 149.70 $ 1823.24 $ 182.32 $ 2166.97 $ 216.70 $ 2582.47 $ 258.25 $ 2420.11 $ 242.01 $ 2494.96 $ 249.50 $ 2201.32 $ 220.13 $ 1893.10 $ 189.31 $ 1778.14 $ 177.81 $ 1741.29 $ 174.13 $ 959.60 $ 95.96 $ 1381.82 $ 138.18 $ 1397.37 $ 139.74 $ 1070.72 $ 107.07 $ 2481.91 $ 248.19 $ 1529.79 $ 152.98 $ 1372.99 $ 137.30 $ 1677.77 $ 167.78 $ 1735.92 $ 173.59 $ 2005.18

$ 1876.21 $ 187.62 $ 1348.82 $ 134.88 $ 1680.45 $ 168.05 $ 1496.98 $ 149.70 $ 1823.24 $ 182.32 $ 2166.97 $ 216.70 $ 2582.47 $ 258.25 $ 2420.11 $ 242.01 $ 2494.96 $ 249.50 $ 2201.32 $ 220.13 $ 1893.10 $ 189.31 $ 1778.14 $ 177.81 $ 1741.29 $ 174.13 $ 959.60 $ 95.96 $ 1381.82 $ 138.18 $ 1397.37 $ 139.74 $ 1070.72 $ 107.07 $ 2481.91 $ 248.19 $ 1529.79 $ 152.98 $ 1372.99 $ 137.30 $ 1677.77 $ 167.78 $ 1735.92 $ 173.59 $ 2005.18

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 59

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E1190-RR E1195-NU E1195-RR E1200-NU E1200-RR E1220-NU E1221-NU E1221-RR E1222-NU E1222-RR E1223-NU E1223-RR E1224-NU E1224-RR E1225-NU E1225-RR E1226-NU E1226-RR E1227-NU E1227-RR E1228-NU E1228-RR E1229 E1230-NU E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1239 E1240-NU E1240-RR E1250-NU E1250-RR E1260-NU E1260-RR E1270-NU E1270-RR E1280-NU E1280-RR E1285-NU E1285-RR

Wheelchair amputee w/ leg re Wheelchair amputee heavy dut Wheelchair amputee heavy dut Wheelchair amputee fixed arm Wheelchair amputee fixed arm Whlchr special size/constrc Wheelchair spec size w foot Wheelchair spec size w foot Wheelchair spec size w/ leg Wheelchair spec size w/ leg Wheelchair spec size w foot Wheelchair spec size w foot Wheelchair spec size w/ leg Wheelchair spec size w/ leg Manual semi-reclining back Manual semi-reclining back Manual fully reclining back Manual fully reclining back Wheelchair spec sz spec ht a Wheelchair spec sz spec ht a Wheelchair spec sz spec ht b Wheelchair spec sz spec ht b Pediatric wheelchair NOS Power operated vehicle Rigid ped w/c tilt-in-space Folding ped wc tilt-in-space Rig ped wc tltnspc w/o seat Fld ped wc tltnspc w/o seat Rigid ped wc adjustable Folding ped wc adjustable Rgd ped wc adjstabl w/o seat Fld ped wc adjstabl w/o seat Ped power wheelchair NOS Whchr litwt det arm leg rest Whchr litwt det arm leg rest Wheelchair lightwt fixed arm Wheelchair lightwt fixed arm Wheelchair lightwt foot rest Wheelchair lightwt foot rest Wheelchair lightweight leg r Wheelchair lightweight leg r Whchr h-duty det arm leg res Whchr h-duty det arm leg res Wheelchair heavy duty fixed Wheelchair heavy duty fixed

$ 200.52 $ 2151.81 $ 215.18 $ 1490.45 $ 149.05 By Report $ 813.94 $ 81.39 $ 1161.12 $ 116.11 $ 1267.82 $ 126.78 $ 1390.08 $ 139.01 $ 774.21 $ 77.42 $ 572.36 $ 57.24 $ 291.09 $ 29.11 $ 479.99 $ 48.00 Not Covered $ 2372.51 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 1764.51 $ 176.45 $ 1477.78 $ 147.78 $ 1727.28 $ 172.73 $ 1352.27 $ 135.23 $ 2248.34 $ 224.83 $ 2226.27 $ 222.63

$ 200.52 $ 2151.81 $ 215.18 $ 1490.45 $ 149.05 By Report $ 813.94 $ 81.39 $ 1161.12 $ 116.11 $ 1267.82 $ 126.78 $ 1390.08 $ 139.01 $ 774.21 $ 77.42 $ 572.36 $ 57.24 $ 291.09 $ 29.11 $ 479.99 $ 48.00 Not Covered $ 2372.51 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 1764.51 $ 176.45 $ 1477.78 $ 147.78 $ 1727.28 $ 172.73 $ 1352.27 $ 135.23 $ 2248.34 $ 224.83 $ 2226.27 $ 222.63

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F N F F F F F F F F F F F F F F F F X F X X X X X X X X X F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 60

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E1290-NU E1290-RR E1295-NU E1295-RR E1296-NU E1296-RR E1297-NU E1297-RR E1298-NU E1298-RR E1300 E1310 E1353-RR E1354-RR E1355-RR E1356-RR E1357-RR E1358-RR E1372-NU E1372-RR E1390-RR E1391-RR E1392-RR E1399-NU E1399-RR E1405-RR E1406-RR E1500-RR E1510-RR E1520-RR E1530-RR E1540-RR E1550-RR E1560-RR E1570-RR E1575-RR E1580-RR E1590-RR E1592-RR E1594-RR E1600-NU E1610-RR E1615-RR E1620-RR E1625-RR

Wheelchair hvy duty detach a Wheelchair hvy duty detach a Wheelchair heavy duty fixed Wheelchair heavy duty fixed Wheelchair special seat heig Wheelchair special seat heig Wheelchair special seat dept Wheelchair special seat dept Wheelchair spec seat depth/w Wheelchair spec seat depth/w Whirlpool portable Whirlpool non-portable Oxygen supplies regulator Wheeled cart, port cyl/conc Oxygen supplies stand/rack Batt pack/cart, port conc Battery charger, port conc DC power adapter, port conc Oxy suppl heater for nebuliz Oxy suppl heater for nebuliz Oxygen concentrator Oxygen concentrator, dual Portable oxygen concentrator Durable medical equipment mi Durable medical equipment mi O2/water vapor enrich w/heat O2/water vapor enrich w/o he Centrifuge Kidney dialysate delivry sys Heparin infusion pump Replacement air bubble detec Replacement pressure alarm Bath conductivity meter Replace blood leak detector Adjustable chair for esrd pt Transducer protect/fld bar Unipuncture control system Hemodialysis machine Auto interm peritoneal dialy Cycler dialysis machine Deli/install chrg hemo equip Reverse osmosis h2o puri sys Deionizer H2O puri system Replacement blood pump Water softening system

$ 2303.04 $ 230.30 $ 2080.61 $ 208.06 $ 515.73 $ 51.57 $ 109.73 $ 10.97 $ 444.39 $ 44.44 Not Covered Not Covered $ 4.85 By Report $ 3.65 By Report By Report By Report $ 171.01 $ 17.10 $ 173.31 $ 173.31 $ 51.63 By Report By Report $ 204.57 $ 190.20 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

$ 2303.04 $ 230.30 $ 2080.61 $ 208.06 $ 515.73 $ 51.57 $ 109.73 $ 10.97 $ 444.39 $ 44.44 Not Covered Not Covered $ 4.85 By Report $ 3.65 By Report By Report By Report $ 171.01 $ 17.10 $ 173.31 $ 173.31 $ 51.63 By Report By Report $ 204.57 $ 190.20 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F X X F N F N N N F F F F F N N F F N N N N N N N N N N N N N N N N N N

Y Y Y Y

Y Y Y Y Y Y

Y Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 61

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E1630-RR E1632-RR E1634-NU E1635-RR E1636-NU E1637-NU E1639-RR E1699-NU E1699-RR E1700-NU E1700-RR E1701-NU E1702-NU E1800-RR E1801-RR E1802-RR E1805-RR E1806-RR E1810-RR E1811-RR E1812-RR E1815-RR E1816-RR E1818-RR E1820-NU E1821-NU E1825-RR E1830-RR E1831-RR E1840-RR E1841-RR E1902-RR E2000-RR E2100-NU E2101-NU E2120 E2201-NU E2201-RR E2202-NU E2202-RR E2203-NU E2203-RR E2204-NU E2204-RR E2205-NU

Reciprocating peritoneal dia Wearable artificial kidney Peritoneal dialysis clamp Compact travel hemodialyzer Sorbent cartridges per 10 Hemostats for dialysis, each Dialysis scale Dialysis equipment noc Dialysis equipment noc Jaw motion rehab system Jaw motion rehab system Repl cushions for jaw motion Repl measr scales jaw motion Adjust elbow ext/flex device SPS elbow device Adjst forearm pro/sup device Adjust wrist ext/flex device SPS wrist device Adjust knee ext/flex device SPS knee device Knee ext/flex w act res ctrl Adjust ankle ext/flex device SPS ankle device SPS forearm device Soft interface material Replacement interface SPSD Adjust finger ext/flex devc Adjust toe ext/flex device Static str toe dev ext/flex Adj shoulder ext/flex device Static str shldr dev rom adj AAC non-electronic board Gastric suction pump hme mdl Bld glucose monitor w voice Bld glucose monitor w lance Pulse gen sys tx endolymp fl Man w/ch acc seat w>=20"<24" Man w/ch acc seat w>=20"<24" Seat width 24-27 in Seat width 24-27 in Frame depth less than 22 in Frame depth less than 22 in Frame depth 22 to 25 in Frame depth 22 to 25 in Manual wc accessory, handrim

By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 307.46 $ 30.75 $ 11.14 $ 23.70 $ 128.50 $ 135.31 $ 342.80 $ 132.53 $ 111.10 $ 130.68 $ 140.69 $ 90.20 $ 132.53 $ 142.91 $ 145.89 $ 80.89 $ 110.40 $ 132.53 $ 132.53 By Report $ 401.45 $ 475.17 By Report $ 88.78 $ 610.07 $ 197.79 Not Covered $ 391.37 $ 39.14 $ 497.18 $ 49.72 $ 502.50 $ 50.25 $ 853.22 $ 85.32 $ 34.27

By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 307.46 $ 30.75 $ 11.14 $ 23.70 $ 128.50 $ 135.31 $ 342.80 $ 132.53 $ 111.10 $ 130.68 $ 140.69 $ 90.20 $ 132.53 $ 142.91 $ 145.89 $ 80.89 $ 110.40 $ 132.53 $ 132.53 By Report $ 401.45 $ 475.17 By Report $ 88.78 $ 610.07 $ 197.79 Not Covered $ 391.37 $ 39.14 $ 497.18 $ 49.72 $ 502.50 $ 50.25 $ 853.22 $ 85.32 $ 34.27

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N N N N N N F F F F F F F F F F F F F F F F F F F N F F N F F F X F F F F F F F F F

Y Y Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 62

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E2205-RR E2206-NU E2206-RR E2207-NU E2207-RR E2208-NU E2208-RR E2209-NU E2209-RR E2210-NU E2211-NU E2212-NU E2213-NU E2214-NU E2215-NU E2216-NU E2217-NU E2218-NU E2219-NU E2220-NU E2221-NU E2222-NU E2224-NU E2225-NU E2226-NU E2227-NU E2227-RR E2228-NU E2228-RR E2230-NU E2230-RR E2231-NU E2231-RR E2291 E2292 E2293 E2294 E2295 E2300-NU E2300-RR E2301-NU E2301-RR E2310-NU E2310-RR E2311-NU

Manual wc accessory, handrim Complete wheel lock assembly Complete wheel lock assembly Crutch and cane holder Crutch and cane holder Cylinder tank carrier Cylinder tank carrier Arm trough each Arm trough each Wheelchair bearings Pneumatic propulsion tire Pneumatic prop tire tube Pneumatic prop tire insert Pneumatic caster tire each Pneumatic caster tire tube Foam filled propulsion tire Foam filled caster tire each Foam propulsion tire each Foam caster tire any size ea Solid propulsion tire each Solid caster tire each Solid caster integrated whl Propulsion whl excludes tire Caster wheel excludes tire Caster fork replacement only Gear reduction drive wheel Gear reduction drive wheel Mwc acc, wheelchair brake Mwc acc, wheelchair brake Manual standing system Manual standing system Solid seat support base Solid seat support base Planar back for ped size wc Planar seat for ped size wc Contour back for ped size wc Contour seat for ped size wc Ped dynamic seating frame Pwr seat elevation sys Pwr seat elevation sys Pwr standing Pwr standing Electro connect btw control Electro connect btw control Electro connect btw 2 sys

$ 3.43 $ 42.67 $ 4.27 $ 45.47 $ 4.55 $ 107.39 $ 10.74 $ 96.88 $ 9.69 $ 5.92 $ 42.92 $ 6.16 $ 31.90 $ 37.76 $ 9.91 By Report By Report By Report $ 43.90 $ 29.92 $ 26.80 $ 22.09 $ 87.43 $ 18.25 $ 39.80 $ 1962.22 $ 196.22 $ 982.09 $ 98.21 By Report By Report $ 161.20 $ 16.12 Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report By Report $ 1058.01 $ 105.80 $ 2141.99

$ 3.43 $ 42.67 $ 4.27 $ 45.47 $ 4.55 $ 107.39 $ 10.74 $ 96.88 $ 9.69 $ 5.92 $ 42.92 $ 6.16 $ 31.90 $ 37.76 $ 9.91 By Report By Report By Report $ 43.90 $ 29.92 $ 26.80 $ 22.09 $ 87.43 $ 18.25 $ 39.80 $ 1962.22 $ 196.22 $ 982.09 $ 98.21 By Report By Report $ 161.20 $ 16.12 Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report By Report $ 1058.01 $ 105.80 $ 2141.99

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F N N N F F F F F F F F F F F N N F F X X X X X N N N N F F F

Y Y

Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 63

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E2311-RR E2312-NU E2312-RR E2313-NU E2313-RR E2321-NU E2321-RR E2322-NU E2322-RR E2323-NU E2323-RR E2324-NU E2324-RR E2325-NU E2325-RR E2326-NU E2326-RR E2327-NU E2327-RR E2328-NU E2328-RR E2329-NU E2329-RR E2330-NU E2330-RR E2331-NU E2331-RR E2340-NU E2340-RR E2341-NU E2341-RR E2342-NU E2342-RR E2343-NU E2343-RR E2351-NU E2351-RR E2360-NU E2360-RR E2361-NU E2361-RR E2362-NU E2362-RR E2363-NU E2363-RR

Electro connect btw 2 sys Mini-prop remote joystick Mini-prop remote joystick PWC harness, expand control PWC harness, expand control Hand interface joystick Hand interface joystick Mult mech switches Mult mech switches Special joystick handle Special joystick handle Chin cup interface Chin cup interface Sip and puff interface Sip and puff interface Breath tube kit Breath tube kit Head control interface mech Head control interface mech Head/extremity control inter Head/extremity control inter Head control nonproportional Head control nonproportional Head control proximity switc Head control proximity switc Attendant control Attendant control W/c wdth 20-23 in seat frame W/c wdth 20-23 in seat frame W/c wdth 24-27 in seat frame W/c wdth 24-27 in seat frame W/c dpth 20-21 in seat frame W/c dpth 20-21 in seat frame W/c dpth 22-25 in seat frame W/c dpth 22-25 in seat frame Electronic SGD interface Electronic SGD interface 22nf nonsealed leadacid 22nf nonsealed leadacid 22nf sealed leadacid battery 22nf sealed leadacid battery Gr24 nonsealed leadacid Gr24 nonsealed leadacid Gr24 sealed leadacid battery Gr24 sealed leadacid battery

$ 214.20 $ 2115.43 $ 211.54 $ 335.93 $ 33.59 $ 1436.70 $ 143.67 $ 1275.10 $ 127.51 $ 62.53 $ 6.25 $ 39.62 $ 3.96 $ 1217.66 $ 121.77 $ 313.85 $ 31.39 $ 2361.84 $ 236.18 $ 4480.08 $ 448.01 $ 1596.75 $ 159.68 $ 3093.89 $ 309.39 By Report By Report $ 375.90 $ 37.59 $ 563.90 $ 56.39 $ 469.91 $ 46.99 $ 751.87 $ 75.19 $ 631.63 $ 63.16 $ 109.54 $ 10.95 $ 126.09 $ 12.61 $ 96.48 $ 9.65 $ 168.16 $ 16.82

$ 214.20 $ 2115.43 $ 211.54 $ 335.93 $ 33.59 $ 1436.70 $ 143.67 $ 1275.10 $ 127.51 $ 62.53 $ 6.25 $ 39.62 $ 3.96 $ 1217.66 $ 121.77 $ 313.85 $ 31.39 $ 2361.84 $ 236.18 $ 4480.08 $ 448.01 $ 1596.75 $ 159.68 $ 3093.89 $ 309.39 By Report By Report $ 375.90 $ 37.59 $ 563.90 $ 56.39 $ 469.91 $ 46.99 $ 751.87 $ 75.19 $ 631.63 $ 63.16 $ 109.54 $ 10.95 $ 126.09 $ 12.61 $ 96.48 $ 9.65 $ 168.16 $ 16.82

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F N N F F F F F F F F F F F F F F F F F F

Y Y

Refer to Field Key for definitions

HCPCS Page 64

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E2364-NU E2364-RR E2365-NU E2365-RR E2366-NU E2366-RR E2367-NU E2367-RR E2368-NU E2368-RR E2369-NU E2369-RR E2370-NU E2370-RR E2371-NU E2372-NU E2373-NU E2373-RR E2374-NU E2374-RR E2375-NU E2375-RR E2376-NU E2376-RR E2377-NU E2377-RR E2381-NU E2381-RR E2382-NU E2382-RR E2383-NU E2383-RR E2384-NU E2384-RR E2385-NU E2385-RR E2386-NU E2386-RR E2387-NU E2387-RR E2388-NU E2388-RR E2389-NU E2389-RR E2390-NU

U1nonsealed leadacid battery U1nonsealed leadacid battery U1 sealed leadacid battery U1 sealed leadacid battery Battery charger, single mode Battery charger, single mode Battery charger, dual mode Battery charger, dual mode Power wc motor replacement Power wc motor replacement Pwr wc gear box replacement Pwr wc gear box replacement Pwr wc motor/gear box combo Pwr wc motor/gear box combo Gr27 sealed leadacid battery Gr27 non-sealed leadacid Hand/chin ctrl spec joystick Hand/chin ctrl spec joystick Hand/chin ctrl std joystick Hand/chin ctrl std joystick Non-expandable controller Non-expandable controller Expandable controller, repl Expandable controller, repl Expandable controller, initl Expandable controller, initl Pneum drive wheel tire Pneum drive wheel tire Tube, pneum wheel drive tire Tube, pneum wheel drive tire Insert, pneum wheel drive Insert, pneum wheel drive Pneumatic caster tire Pneumatic caster tire Tube, pneumatic caster tire Tube, pneumatic caster tire Foam filled drive wheel tire Foam filled drive wheel tire Foam filled caster tire Foam filled caster tire Foam drive wheel tire Foam drive wheel tire Foam caster tire Foam caster tire Solid drive wheel tire

$ 109.54 $ 10.95 $ 101.41 $ 10.14 $ 238.34 $ 23.83 $ 378.89 $ 37.89 $ 467.03 $ 46.70 $ 406.79 $ 40.68 $ 725.84 $ 72.58 $ 136.28 By Report $ 737.39 $ 73.74 $ 482.81 $ 48.28 $ 774.41 $ 77.44 $ 1213.54 $ 121.35 $ 439.13 $ 43.91 $ 67.71 $ 6.77 $ 18.78 $ 1.88 $ 137.31 $ 13.73 $ 73.15 $ 7.32 $ 44.76 $ 4.48 $ 136.07 $ 13.61 $ 61.02 $ 6.10 $ 45.55 $ 4.56 $ 24.74 $ 2.47 $ 38.68

$ 109.54 $ 10.95 $ 101.41 $ 10.14 $ 238.34 $ 23.83 $ 378.89 $ 37.89 $ 467.03 $ 46.70 $ 406.79 $ 40.68 $ 725.84 $ 72.58 $ 136.28 By Report $ 737.39 $ 73.74 $ 482.81 $ 48.28 $ 774.41 $ 77.44 $ 1213.54 $ 121.35 $ 439.13 $ 43.91 $ 67.71 $ 6.77 $ 18.78 $ 1.88 $ 137.31 $ 13.73 $ 73.15 $ 7.32 $ 44.76 $ 4.48 $ 136.07 $ 13.61 $ 61.02 $ 6.10 $ 45.55 $ 4.56 $ 24.74 $ 2.47 $ 38.68

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F N F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

HCPCS Page 65

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E2390-RR E2391-NU E2391-RR E2392-NU E2392-RR E2394-NU E2394-RR E2395-NU E2395-RR E2396-NU E2396-RR E2397-NU E2397-RR E2402-RR E2500-NU E2500-RR E2502-NU E2502-RR E2504-NU E2504-RR E2506-NU E2506-RR E2508-NU E2508-RR E2510-NU E2510-RR E2511-NU E2511-RR E2512-NU E2512-RR E2599-NU E2599-RR E2601-NU E2602-NU E2603-NU E2604-NU E2605-NU E2606-NU E2607-NU E2608-NU E2609-NU E2610-NU E2611-NU E2612-NU E2613-NU

Solid drive wheel tire Solid caster tire Solid caster tire Solid caster tire, integrate Solid caster tire, integrate Drive wheel excludes tire Drive wheel excludes tire Caster wheel excludes tire Caster wheel excludes tire Caster fork Caster fork Pwc acc, lith-based battery Pwc acc, lith-based battery Neg press wound therapy pump SGD digitized pre-rec <=8min SGD digitized pre-rec <=8min SGD prerec msg >8min <=20min SGD prerec msg >8min <=20min SGD prerec msg>20min <=40min SGD prerec msg>20min <=40min SGD prerec msg > 40 min SGD prerec msg > 40 min SGD spelling phys contact SGD spelling phys contact SGD w multi methods msg/accs SGD w multi methods msg/accs SGD sftwre prgrm for PC/PDA SGD sftwre prgrm for PC/PDA SGD accessory, mounting sys SGD accessory, mounting sys SGD accessory noc SGD accessory noc Gen w/c cushion wdth < 22 in Gen w/c cushion wdth >=22 in Skin protect wc cus wd <22in Skin protect wc cus wd>=22in Position wc cush wdth <22 in Position wc cush wdth>=22 in Skin pro/pos wc cus wd <22in Skin pro/pos wc cus wd>=22in Custom fabricate w/c cushion Powered w/c cushion Gen use back cush wdth <22in Gen use back cush wdth>=22in Position back cush wd <22in

$ 3.87 $ 18.53 $ 1.85 $ 48.71 $ 4.87 $ 69.39 $ 6.94 $ 49.32 $ 4.93 $ 60.13 $ 6.01 $ 434.41 $ 43.44 $ 2534.10 $ 410.20 $ 41.02 $ 1254.33 $ 125.43 $ 1654.63 $ 165.46 $ 2426.18 $ 242.62 $ 3751.68 $ 375.17 $ 7099.55 $ 709.96 By Report By Report By Report By Report By Report By Report $ 55.29 $ 107.95 $ 137.05 $ 170.34 $ 243.36 $ 379.66 $ 262.05 $ 314.70 By Report By Report $ 282.40 $ 382.02 $ 355.34

$ 3.87 $ 18.53 $ 1.85 $ 48.71 $ 4.87 $ 69.39 $ 6.94 $ 49.32 $ 4.93 $ 60.13 $ 6.01 $ 434.41 $ 43.44 $ 2534.10 $ 410.20 $ 41.02 $ 1254.33 $ 125.43 $ 1654.63 $ 165.46 $ 2426.18 $ 242.62 $ 3751.68 $ 375.17 $ 7099.55 $ 709.96 By Report By Report By Report By Report By Report By Report $ 55.29 $ 107.95 $ 137.05 $ 170.34 $ 243.36 $ 379.66 $ 262.05 $ 314.70 By Report By Report $ 282.40 $ 382.02 $ 355.34

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F N N N N N N F F F F F F F F N N F F F

Y

Y Y

Y

Refer to Field Key for definitions

HCPCS Page 66

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

E2614-NU E2615-NU E2616-NU E2617-NU E2619-NU E2620-NU E2621-NU E2622-NU E2623-NU E2624-NU E2625-NU E8000 E8001 E8002 G0008 G0009 G0010 G0027 G0101 G0102 G0103 G0104 G0105 G0105-53 G0106 G0106-26 G0106-TC G0108 G0109 G0117 G0118 G0120 G0120-26 G0120-TC G0121 G0121-53 G0122 G0122-26 G0122-TC G0123 G0124 G0127 G0128 G0129 G0130

Position back cush wd>=22in Pos back post/lat wdth <22in Pos back post/lat wdth>=22in Custom fab w/c back cushion Replace cover w/c seat cush WC planar back cush wd <22in WC planar back cush wd>=22in Adj skin pro w/c cus wd<22in Adj skin pro wc cus wd>=22in Adj skin pro/pos cus<22in Adj skin pro/pos wc cus>=22 Posterior gait trainer Upright gait trainer Anterior gait trainer Admin influenza virus vac Admin pneumococcal vaccine Admin hepatitis b vaccine Semen analysis CA screen;pelvic/breast exam Prostate ca screening; dre PSA screening CA screen;flexi sigmoidscope Colorectal scrn; hi risk ind Colorectal scrn; hi risk ind Colon CA screen;barium enema Colon CA screen;barium enema Colon CA screen;barium enema Diab manage trn per indiv Diab manage trn ind/group Glaucoma scrn hgh risk direc Glaucoma scrn hgh risk direc Colon ca scrn; barium enema Colon ca scrn; barium enema Colon ca scrn; barium enema Colon ca scrn not hi rsk ind Colon ca scrn not hi rsk ind Colon ca scrn; barium enema Colon ca scrn; barium enema Colon ca scrn; barium enema Screen cerv/vag thin layer Screen c/v thin layer by MD Trim nail(s) CORF skilled nursing service Partial hosp prog service Single energy x-ray study

$ 491.77 $ 408.94 $ 550.21 By Report $ 46.39 $ 495.17 $ 519.64 $299.68 $381.33 $302.14 $382.49 Not Covered Not Covered Not Covered Bundled Bundled Bundled $ 12.81 $ 60.32 $ 32.10 $ 36.25 $ 226.34 $ 646.92 $ 226.34 $ 352.52 $ 79.69 $ 272.83 $ 89.65 $ 30.99 Bundled Bundled $ 352.52 $ 79.69 $ 272.83 $ 646.92 $ 226.34 $ 445.49 $ 80.80 $ 364.69 $ 39.91 $ 47.04 $ 35.42 Not Covered Not Covered $ 54.79

$ 491.77 $ 408.94 $ 550.21 By Report $ 46.39 $ 495.17 $ 519.64 $299.68 $381.33 $302.14 $382.49 Not Covered Not Covered Not Covered Bundled Bundled Bundled $ 12.81 $ 44.27 $ 14.39 $ 36.25 $ 102.38 $ 355.84 $ 102.38 $ 352.52 $ 79.69 $ 272.83 $ 89.65 $ 30.99 Bundled Bundled $ 352.52 $ 79.69 $ 272.83 $ 355.84 $ 102.38 $ 445.49 $ 80.80 $ 364.69 $ 39.91 $ 47.04 $ 13.28 Not Covered Not Covered $ 54.79

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0 0 0 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0 0 0 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0 0 0 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 0 0 0 1 1 1 0 0 0 0 1 1 1 0 0 1 1 1 9 0 0 0 9 1

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 2 2 2 0 0 0 0 0 0 0 0 0 0 2 2 9 9 9 9 0 2 0 9 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9 9 9 0 0 0 9 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 9 9 9 9 0 1 0 9 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9 9 9 0 0 0 9 0

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 9 9 9 0 0 0 9 0

F F F N F F F F F F F X X X B B B L R R L R R R R R R R R B B R R R R R R R R L R R X X R

Y

Y Y Y Y Y Y Y

Y

Refer to Field Key for definitions

HCPCS Page 67

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G0130-26 G0130-TC G0141 G0143 G0144 G0145 G0147 G0148 G0151 G0152 G0153 G0154 G0155 G0156 G0157 G0158 G0159 G0160 G0161 G0162 G0163 G0164 G0166 G0168 G0173 G0175 G0176 G0177 G0179 G0180 G0181 G0182 G0186 G0202 G0202-26 G0202-TC G0204 G0204-26 G0204-TC G0206 G0206-26 G0206-TC G0219

Single energy x-ray study Single energy x-ray study Scr c/v cyto,autosys and md Scr c/v cyto,thinlayer,rescr Scr c/v cyto,thinlayer,rescr Scr c/v cyto,thinlayer,rescr Scr c/v cyto, automated sys Scr c/v cyto, autosys, rescr HHCP-serv of pt,ea 15 min HHCP-serv of ot,ea 15 min HHCP-svs of s/l path,ea 15mn HHCP-svs of rn,ea 15 min HHCP-svs of csw,ea 15 min HHCP-svs of aide,ea 15 min HHC PT assistant ea 15 HHC OT assistant ea 15 HHC PT maint ea 15 min HHC Occup Therapy ea 15 HHC SLP ea 15 min HHC RN E&M plan svs, 15 min HHC LPN/RN obs/asses ea 15 HHC lis nurse train ea 15 Extrnl counterpulse, per tx Wound closure by adhesive Linear acc stereo radsur com OPPS Service,sched team conf OPPS/PHP;activity therapy OPPS/PHP; train & educ serv MD recertification HHA PT MD certification HHA patient Home health care supervision Hospice care supervision Dstry eye lesn,fdr vssl tech Screeningmammographydigital Screeningmammographydigital Screeningmammographydigital Diagnosticmammographydigital Diagnosticmammographydigital Diagnosticmammographydigital Diagnosticmammographydigital Diagnosticmammographydigital Diagnosticmammographydigital PET img wholbod melano nonco

$ 17.71 $ 37.08 $ 47.04 $ 39.91 $ 42.08 $ 52.19 $ 22.43 $ 29.95 $ 37.32 $ 38.69 $ 38.69 $ 38.69 Not Covered $ 6.50 Not Covered Not Covered Not Covered Not Covered Not Covered $ 38.69 Not Covered Not Covered $ 254.56 $ 142.78 By Report Facility Only Not Covered Facility Only Not Covered Not Covered Not Covered Not Covered By Report $ 232.43 $ 57.00 $ 175.43 $ 277.81 $ 70.28 $ 207.53 $ 219.70 $ 57.00 $ 162.70 Not Covered

$ 17.71 $ 37.08 $ 47.04 $ 39.91 $ 42.08 $ 52.19 $ 22.43 $ 29.95 $ 37.32 $ 38.69 $ 38.69 $ 38.69 Not Covered $ 6.50 Not Covered Not Covered Not Covered Not Covered Not Covered $ 38.69 Not Covered Not Covered $ 254.56 $ 42.06 By Report Facility Only Not Covered Facility Only Not Covered Not Covered Not Covered Not Covered By Report $ 232.43 $ 57.00 $ 175.43 $ 277.81 $ 70.28 $ 207.53 $ 219.70 $ 57.00 $ 162.70 Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

1 1 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1

0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 2 9 9 9 9 0 0 0 0 2 0 0 0 0 0 0 0 0 0 9

0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 0 0 0 0 1 2 2 2 2 2 2 0 0 0 9

0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 1 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9

0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 0 0 0 0 1 0 0 0 0 0 0 0 0 0 9

0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 0 0 0 0 1 0 0 0 0 0 0 0 0 0 9

R R R L L L L L F F F F X F X X X X X F X X R R N O X O X X X X N R R R R R R R R R X

Y

Y

0 0% 0 0% 0 0% 0 0 0 0 90 0 0 0 0 0 0 0 0 0 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Refer to Field Key for definitions

HCPCS Page 68

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G0219-26 G0219-TC G0235 G0235-26 G0235-TC G0237 G0238 G0239 G0245 G0246 G0247 G0248 G0249 G0250 G0251 G0252 G0252-26 G0252-TC G0255 G0255-26 G0255-TC G0257 G0259 G0260 G0268 G0269 G0270 G0271 G0275 G0278 G0281 G0282 G0283 G0288 G0289 G0290 G0291 G0293 G0294 G0295 G0302

PET img wholbod melano nonco PET img wholbod melano nonco PET not otherwise specified PET not otherwise specified PET not otherwise specified Therapeutic procd strg endur Oth resp proc, indiv Oth resp proc, group Initial foot exam pt lops Followup eval of foot pt lop Routine footcare pt w lops Demonstrate use home inr mon Provide INR test mater/equip MD INR test revie inter mgmt Linear acc based stero radio PET imaging initial dx PET imaging initial dx PET imaging initial dx Current percep threshold tst Current percep threshold tst Current percep threshold tst Unsched dialysis ESRD pt hos Inject for sacroiliac joint Inj for sacroiliac jt anesth Removal of impacted wax md Occlusive device in vein art MNT subs tx for change dx Group MNT 2 or more 30 mins Renal angio, cardiac cath Iliac art angio,cardiac cath Elec stim unattend for press Elect stim wound care not pd Elec stim other than wound Recon, CTA for surg plan Arthro, loose body + chondro Drug-eluting stents, single Drug-eluting stents,each add Non-cov surg proc,clin trial Non-cov proc, clinical trial Electromagnetic therapy onc Pre-op service LVRS complete

Not Covered Not Covered Not Covered Not Covered Not Covered $ 16.60 $ 17.71 $ 19.92 Not Covered Not Covered Not Covered $ 232.98 $ 205.86 $ 14.94 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Facility Only Facility Only Facility Only Not Covered Facility Only Not Covered Not Covered $ 21.58 $ 21.58 $ 20.48 By Report $ 20.48 $ 144.44 $ 142.78 Not Covered Not Covered Not Covered Not Covered Not Covered By Report

Not Covered Not Covered Not Covered Not Covered Not Covered $ 16.60 $ 17.71 $ 19.92 Not Covered Not Covered Not Covered $ 232.98 $ 205.86 $ 14.94 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Facility Only Facility Only Facility Only Not Covered Facility Only Not Covered Not Covered $ 21.58 $ 21.58 $ 20.48 By Report $ 20.48 $ 144.44 $ 142.78 Not Covered Not Covered Not Covered Not Covered Not Covered By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

1 1 1 1 1 0 5 5 0 0 0 3 3 2 9 1 1 1 1 1 1 9 9 9 0 9 0 0 0 0 0 9 0 3 0 9 9 9 9 9 9

9 9 9 9 9 0 0 0 0 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 2 9 0 0 0 0 5 9 5 0 0 9 9 9 9 9 9

9 9 9 9 9 0 0 0 0 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 2 9 0 0 0 0 0 9 0 0 1 9 9 9 9 9 9

9 9 9 9 9 0 0 0 0 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 1 9 0 0 0 0 0 9 0 0 0 9 9 9 9 9 9

9 9 9 9 9 0 0 0 0 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 0 9 0 0 0 0 0 9 0 0 0 9 9 9 9 9 9

9 9 9 9 9 0 0 0 0 0 0 0 0 0 9 9 9 9 9 9 9 9 9 9 0 9 0 0 0 0 0 9 0 0 0 9 9 9 9 9 9

X X X X X R R R X X X R R R X X X X X X X O O O X O X X R R R N R R R X X X X X N

0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Y

Refer to Field Key for definitions

HCPCS Page 69

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G0303 G0304 G0305 G0306 G0307 G0328 G0329 G0333 G0337 G0339 G0340 G0341 G0342 G0343 G0364 G0365 G0365-26 G0365-TC G0372 G0378 G0379 G0380 G0381 G0382 G0383 G0384

Pre-op service LVRS 10-15dos Pre-op service LVRS 1-9 dos Post op service LVRS min 6 CBC/diffwbc w/o platelet CBC without platelet Fecal blood scrn immunoassay Electromagntic tx for ulcers Dispense fee initial 30 day Hospice evaluation preelecti Robot lin-radsurg com, first Robt lin-radsurg fractx 2-5 Percutaneous islet celltrans Laparoscopy islet cell trans Laparotomy islet cell transp Bone marrow aspirate &biopsy Vessel mapping hemo access Vessel mapping hemo access Vessel mapping hemo access MD service required for PMD Hospital observation per hr Direct refer hospital observ Lev 1 hosp type B ED visit Lev 2 hosp type B ED visit Lev 3 hosp type B ED visit Lev 4 hosp type B ED visit Lev 5 hosp type B ED visit

By Report By Report By Report $ 15.32 $ 12.75 Not Covered Not Covered Not Covered $ 118.43 Not Covered Not Covered Not Covered Not Covered Not Covered $ 19.92 $ 349.20 $ 20.48 $ 329.27 Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only $ 185.39 $ 47.59 $ 137.80 Facility Only Not Covered Not Covered By Report By Report By Report Not Covered Not Covered

By Report By Report By Report $ 15.32 $ 12.75 Not Covered Not Covered Not Covered $ 118.43 Not Covered Not Covered Not Covered Not Covered Not Covered $ 14.39 $ 349.20 $ 20.48 $ 329.27 Not Covered Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only Facility Only $ 185.39 $ 47.59 $ 137.80 Facility Only Not Covered Not Covered By Report By Report By Report Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 90 90 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 9% 9% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 81% 81% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 10% 10% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 0 9 9 0 0 0 0 0 0 1 1 1 0 9 9 9 9 9 9 9 1 1 1 9 0 0 1 1 1 0 4

9 9 9 9 9 9 5 9 9 0 0 2 2 2 0 0 0 0 0 9 9 9 9 9 9 9 0 0 0 9 0 0 0 0 0 0 0

9 9 9 9 9 9 0 9 9 0 0 0 0 0 0 0 0 0 0 9 9 9 9 9 9 9 0 0 0 9 0 0 0 0 0 0 0

9 9 9 9 9 9 0 9 9 0 0 0 2 2 0 0 0 0 0 9 9 9 9 9 9 9 0 0 0 9 0 0 0 0 0 0 0

9 9 9 9 9 9 0 9 9 0 0 1 1 1 0 0 0 0 0 9 9 9 9 9 9 9 0 0 0 9 0 0 0 0 0 0 0

9 9 9 9 9 9 0 9 9 0 0 0 0 0 0 0 0 0 0 9 9 9 9 9 9 9 0 0 0 9 0 0 0 0 0 0 0

N N N L L X X X R X X X X X R R R R X O O O O O O O R R R O X X N N N X X

0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 0 0 0 0 0 0% 0% 0% 0% 0% 0% 0%

G0389 Ultrasound exam AAA screen G0389-26 Ultrasound exam AAA screen G0389-TC Ultrasound exam AAA screen G0390 G0396 G0397 G0398 G0399 G0400 G0402 G0403 Trauma Respons w/hosp criti Alcohol/subs interv 15-30mn Alcohol/subs interv >30 min Home sleep test/type 2 Porta Home sleep test/type 3 Porta Home sleep test/type 4 Porta Initial preventive exam EKG for initial prevent exam

Y Y Y

Refer to Field Key for definitions

HCPCS Page 70

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G0404 G0405 G0406 G0407 G0408 G0409 G0410 G0411 G0412 G0413 G0414 G0415 G0416 G0416-26 G0416-TC G0417 G0417-26 G0417-TC G0418 G0418-26 G0418-TC G0419 G0419-26 G0419-TC G0420 G0421 G0422 G0423 G0424 G0425 G0426 G0427 G0428 G0429 G0431 G0432 G0433 G0434 G0435 G0436 G0437 G0438 G0439

EKG tracing for initial prev EKG interpret & report preve Telhealth inpt consult 15min Telheath inpt consult 25min Telhealth inpt consult 35min CORF related serv 15 mins ea Grp psych partial hosp 45-50 Inter active grp psych parti Open tx iliac spine uni/bil Pelvic ring fracture uni/bil Pelvic ring fx treat int fix Open tx post pelvic fxcture Sat biopsy prostate 1-20 spc Sat biopsy prostate 1-20 spc Sat biopsy prostate 1-20 spc Sat biopsy prostate 21-40 Sat biopsy prostate 21-40 Sat biopsy prostate 21-40 Sat biopsy prostate 41-60 Sat biopsy prostate 41-60 Sat biopsy prostate 41-60 Sat biopsy prostate: >60 Sat biopsy prostate: >60 Sat biopsy prostate: >60 Ed svc CKD ind per session Ed svc CKD grp per session Intens cardiac rehab w/exerc Intens cardiac rehab no exer Pulmonary rehab w exer Inpt telehealth consult 30m Inpt telehealth consult 50m Inpt telehealth con 70/>m Collagen Meniscus Implant Dermal filler injection(s) Drug screen multip class EIA HIV-1/HIV-2 screen ELISA HIV-1/HIV-2 screen Drug screen multi drug class Oral HIV-1/HIV-2 screen Tobacco-use counsel 3-10 min Tobacco-use counsel>10min PPPS, initial visit PPPS, subseq visit

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Facility Only Facility Only $ 1161.59 $ 1696.17 $ 1615.37 $ 2210.83 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 180.41 $ 42.61 $ 112.89 $ 112.89 $ 50.36 $ 163.25 $ 222.47 $ 327.06 Not Covered Not Covered $ 143.26 By Report By Report $ 28.66 By Report Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Facility Only Facility Only $ 1161.59 $ 1696.17 $ 1615.37 $ 2210.83 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 180.41 $ 42.61 $ 112.89 $ 112.89 $ 23.80 $ 163.25 $ 222.47 $ 327.06 Not Covered Not Covered $ 143.26 By Report By Report $ 28.66 By Report Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0

0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 69% 69% 69% 69% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 21% 21% 21% 21% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

3 2 0 0 0 9 9 9 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 9 0 9 9 9 9 9 0 0 0 0

0 0 0 0 0 0 9 9 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 2 9 9 9 9 9 0 0 0 0

0 0 0 0 0 0 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 9 9 9 9 9 0 0 0 0

0 0 0 0 0 0 9 9 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 9 9 9 9 9 0 0 0 0

0 0 0 0 0 0 9 9 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 9 9 9 9 9 0 0 0 0

0 0 0 0 0 0 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 0 9 9 9 9 9 0 0 0 0

X X X X X X O O R R R R X X X X X X X X X X X X R R R R R R R R X X L N N L N X X X X

0 0% 0 0% 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10% 10% 10% 10% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 71

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G0440 G0441 G3001 G8126 G8127 G8128 G8395 G8396 G8397 G8398 G8399 G8400 G8401 G8404 G8405 G8406 G8410 G8415 G8416 G8417 G8418 G8419 G8420 G8421 G8422 G8427 G8428 G8430 G8431 G8432 G8433 G8440 G8441 G8442 G8447 G8448 G8450 G8451 G8452 G8458 G8459 G8460 G8461 G8462 G8463

Skin/dermal subs init 25or< Skin/dermal subs each additi Admin + supply, tositumomab Pt treat w/antidepress12wks Pt not treat w/antidepres12w Pt inelig for antidepres med LVEF>=40% doc normal or mild LVEF not performed Dil macula/fundus exam/w doc Dil macular/fundus not perfo Pt w/DXA document or order Pt w/DXA no document or orde Pt inelig osteo screen measu Low extemity neur exam docum Low extemity neur not perfor Pt inelig lower extrem neuro Eval on foot documented Eval on foot not performed Pt inelig footwear evaluatio Calc BMI abv up param f/u Calc BMI blw low param f/u Calc BMI out nrm param nof/u Calc BMI norm parameters BMI not calculated Pt inelig BMI calculation Doc cur meds by prov Cur meds not document Pt inelig med check Pos clin depres scrn f/u doc Clin depression screen not d Pt inelig; scrn clin dep Pain assess f/u pln document No document of pain assess Pt inelig pain assessment Pt vis doc use EHR cer ATCB Pt vis doc w/PQRI qual EHR Beta-bloc rx pt w/abn lvef Pt w/abn lvef inelig b-bloc Pt w/abn lvef b-bloc no rx Pt inelig geno no antvir tx Doc pt rec antivir treat Pt inelig RNA no antvir tx Pt rec antivir treat hep c Pt inelig couns no antvir tx Pt rec antiviral treat doc

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

2 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 72

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G8464 G8465 G8468 G8469 G8470 G8471 G8472 G8473 G8474 G8475 G8476 G8477 G8478 G8482 G8483 G8484 G8485 G8486 G8487 G8489 G8490 G8491 G8492 G8493 G8494 G8495 G8496 G8497 G8498 G8499 G8500 G8501 G8502 G8506 G8508 G8509 G8510 G8511 G8524 G8525 G8526 G8530 G8531 G8532 G8534

Pt inelig; lo to no dter rsk High risk recurrence pro ca ACE/ARB rx pt w/abn lvef Pt w/abn lvef inelig ACE/ARB Pt w/ normal lvef LVEF not performed/doc ACE/ARB no rx pt w/abn lvef ACE/ARB thxpy rx'd ACE/ARB not rx'd; doc reas ACE/ARB thxpy not rx'd BP sys <130 and dias <80 BP sys>=130 and/or dias >=80 BP not performed/doc Flu immunize order/admin Flu imm no ord/admin doc rea Flu immunize no order/admin Report, Diabetes measures Report, Prev Care Measures Report CKD Measures CAD measures grp RA measures grp HIV/AIDS measures grp Periop Care measures grp Back pain measures grp DM meas qual act perform CKD meas qual act perform Prev Care MG qual act perfrm CABG meas qual act perform CAD meas qual act perform RA meas qual act perform HIV meas qual act perform Perio meas qual act perform Back Pain MG qual act perfrm Pt rec ACE/ARB Pt inelig; pain asses no f/u Pain assess no f/u pln doc Pt inelig neg scrn depres Clin depres scrn no f/u doc Patch closure conv CEA No patch closure CEA No patch closure conv CEA Auto AV fistula recd Pt inelig; auto AV fistula No auto AV fistula; no reas Doc elder mal scrn f/u plan

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 73

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G8535 G8536 G8537 G8538 G8539 G8540 G8541 G8542 G8543 G8544 G8545 G8546 G8547 G8548 G8549 G8550 G8551 G8552 G8553 G8556 G8557 G8558 G8559 G8560 G8561 G8562 G8563 G8564 G8565 G8566 G8567 G8568 G8569 G8570 G8571 G8572 G8573 G8574 G8575 G8576 G8577 G8578 G8579 G8580 G8581

Pt inelig no eld mal scrn No doc elder mal scrn Pt inelig eldmal scrn no f/u Eld mal scrn no f/u pln Cur funct assess & care pln Pt inelig funct assess No doc cur funct assess Pt inelig func asses no pln Cur funct asses; no care pln CABG measures grp HepC measures grp CAP measures grp IVD measures grp HF measures grp HepC MG qual act perform CAP MG qual act perform HF MG qual act perform IVD MG qual act perform 1 Rx via qualified eRx sys Ref to doc otolog eval Pt inelig ref otolog eval No ref to doc otolog eval Pt ref doc oto eval Pt hx act drain prev 90 days Pt inelig for ref oto eval Pt no hx act drain 90 d Pt no ref oto reas no spec Pt ref oto eval Ver doc hear loss Pt inelig ref oto eval Pt no doc hear loss Pt no ref otolo no spec Prol intubation req No prol intub req Ster wd ifx 30 d postop No ster wd ifx Stk/CVA CABG No strk/CVA CABG Postop ren insuf No postop ren insuf Reop req bld grft oth No reop req bld grft oth Antplt med disch Antplt med contraind no antplt med disch

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 74

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G8582 G8583 G8584 G8585 G8586 G8587 G8588 G8589 G8590 G8591 G8592 G8593 G8594 G8595 G8596 G8597 G8598 G8599 G8600 G8601 G8602 G8603 G8604 G8605 G8606 G8607 G8608 G8609 G8610 G8611 G8612 G8613 G8614 G8615 G8616 G8617 G8618 G8619 G8620 G8621 G8622 G8623 G8624 G8625 G8626

Bblock disch Bblock contraind No bblock disch Antilipid treat disch Antlip disch contra No antlipid treat disch Sys BP <140 Sys BP >= 140 Dia BP < 90 Dia BP >= 90 No BP measure Lipid pn results No lipid prof perf Ldl < 100 No LDL perf Ldl >= 100 Asp therp used No asp therp used tPA initi w/in 3 hrs No elig tPA init w/in 3 hrs No tPA init w/in 3 hrs Spok lang comp score No high score spok lang No spok lang comp score Attention score No high score attention No attention score Memory score No high score memory No memory score Moto speech score No high score moto speech No moto speech score Reading score No high score reading No reading score Spok lang exp score No high score spok lang exp No spok lang exp score Writing score No high score writing No writing score Swallowing score No high score swallowing No swallowing score

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 75

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G8627 G8628 G8629 G8630 G8631 G8632 G8633 G8634 G8635 G8636 G8637 G8638 G8639 G8640 G8641 G8642 G8643 G8644 G8645 G8646 G8647 G8648 G8649 G8650 G8651 G8652 G8653 G8654 G8655 G8656 G8657 G8658 G8659 G8660 G8661 G8662 G8663 G8664 G8665 G8666 G8667 G8668 G8669 G8670 G8671

Surg proc w/in 30 days No surg proc w/in 30 days Doc antibio order b/4 surg Doc antibio given b/4 surg Pt no elg 4 order antbi give Doc no antibi order b/4 surg Pharm ther osteo rx Pt no elg phar ther osteo No pharm ther osteo rx Flu immun admin/prev rec Pt no elg receiv flu immun Flu immun no admin/prev rec Flu immun admin or prev rec Pt no elg rec flu immun Flu immun not admin/pre rec Hrdshp rural w/o internet Hrdshp w/o suff pharm w/eRx EP no prescribe priv Asthma measures grp Asthma MG qual act perform Fun stat score knee >= 0 Fun stat score knee < 0 Fun stat score knee pt noelg Fun stat score knee not done Fun stat score hip >= 0 Fun stat score hip < 0 Fun stat score hip pt no elg Fun stat score hip not done Fun stat score LE >= 0 Fun stat score LE < 0 Fun stat score LE pt no elg Fun stat score LE not done Fun stat score LS >= 0 Fun stat score LS < 0 Fun stat score LS pt no elg Fun stat score LS not done Fun stat score shdl >=0 Fun stat score shdl < 0 Fun stat score shdl pt no el Fun stat score shdl not done Fun stat score UE >=0 Fun stat score UE < 0 Fun stat score UE pt no elg Fun stat score UE not done Fun stat score neck/TS >=0

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 76

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G8672 G8673 G8674 G8675 G8676 G8677 G8678 G8679 G8680 G8681 G8682 G8683 G8684 G8685 G8686 G8687 G8688 G8689 G8690 G8691 G8692 G8693 G9001 G9002 G9003 G9004 G9005 G9006 G9007 G9008 G9009 G9010 G9011 G9012 G9013 G9014 G9016 G9017 G9018 G9019 G9020 G9033 G9034 G9035 G9036

Fun stat score neck/TS < 0 Fun stat scor nek/TS pt no e Fun stat scor nek/TS not don BP Syst >= 140 mmHg BP Diast >= 90 mmHg BP Syst < 130 mmHg BP Syst >=130 - 139 mmHg BP Diast < 80 mmHg BP Diast 80-89 mmHg Pt hosp w/HF LVG test perf Pt not elig for LVF test Pt not hosp w/HF LVF test not perf Toba smkr curr or 2 hand exp No tob smkr cur no 2 hnd exp Smkls tob cur; no 2 hnd exp Toba use not assess Curr toba smkr or 2 hand exp No cur tob smkr no 2 hnd exp Curr smkls tob; no 2 hnd exp Tobacco no assess MCCD, initial rate MCCD,maintenance rate MCCD, risk adj hi, initial MCCD, risk adj lo, initial MCCD, risk adj, maintenance MCCD, Home monitoring MCCD, sch team conf Mccd,phys coor-care ovrsght MCCD, risk adj, level 3 MCCD, risk adj, level 4 MCCD, risk adj, level 5 Other Specified Case Mgmt ESRD demo bundle level I ESRD demo bundle-level II Demo-smoking cessation coun Amantadine HCL 100mg oral Zanamivir,inhalation pwd 10m Oseltamivir phosphate 75mg Rimantadine HCL 100mg oral Amantadine HCL oral brand Zanamivir, inh pwdr, brand Oseltamivir phosp, brand Rimantadine HCL, brand

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X N N N N N N N N X X X X X X X X X X X

HCPCS Page 77

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G9041 G9042 G9043 G9044 G9050 G9051 G9052 G9053 G9054 G9055 G9056 G9057 G9058 G9059 G9060 G9061 G9062 G9063 G9064 G9065 G9066 G9067 G9068 G9069 G9070 G9071 G9072 G9073 G9074 G9075 G9077 G9078 G9079 G9080 G9083 G9084 G9085 G9086 G9087 G9088 G9089 G9090 G9091 G9092 G9093

Low vision rehab occupationa Low vision rehab orient/mobi Low vision lowvision therapi Low vision rehabilate teache Oncology work-up evaluation Oncology tx decision-mgmt Onc surveillance for disease Onc expectant management pt Onc supervision palliative Onc visit unspecified NOS Onc prac mgmt adheres guide Onc pract mgmt differs trial Onc prac mgmt disagree w/gui Onc prac mgmt pt opt alterna Onc prac mgmt dif pt comorb Onc prac cond noadd by guide Onc prac guide differs nos Onc dx nsclc stgI no progres Onc dx nsclc stg2 no progres Onc dx nsclc stg3A no progre Onc dx nsclc stg3B-4 metasta Onc dx nsclc dx unknown nos Onc dx sclc/nsclc limited Onc dx sclc/nsclc ext at dx Onc dx sclc/nsclc ext unknwn Onc dx brst stg1-2B HR,nopro Onc dx brst stg1-2 noprogres Onc dx brst stg3-HR, no pro Onc dx brst stg3-noprogress Onc dx brst metastic/ recur Onc dx prostate T1no progres Onc dx prostate T2no progres Onc dx prostate T3b-T4noprog Onc dx prostate w/rise PSA Onc dx prostate unknwn nos Onc dx colon t1-3,n1-2,no pr Onc dx colon T4, N0 w/o prog Onc dx colon T1-4 no dx prog Onc dx colon metas evid dx Onc dx colon metas noevid dx Onc dx colon extent unknown Onc dx rectal T1-2 no progr Onc dx rectal T3 N0 no prog Onc dx rectal T1-3,N1-2noprg Onc dx rectal T4,N,M0 no prg

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 78

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

G9094 G9095 G9096 G9097 G9098 G9099 G9100 G9101 G9102 G9103 G9104 G9105 G9106 G9107 G9108 G9109 G9110 G9111 G9112 G9113 G9114 G9115 G9116 G9117 G9123 G9124 G9125 G9126 G9128 G9129 G9130 G9131 G9132 G9133 G9134 G9135 G9136 G9137 G9138 G9139 G9140 G9141 G9142 G9143 G9147

Onc dx rectal M1 w/mets prog Onc dx rectal extent unknwn Onc dx esophag T1-T3 noprog Onc dx esophageal T4 no prog Onc dx esophageal mets recur Onc dx esophageal unknown Onc dx gastric no recurrence Onc dx gastric p R1-R2noprog Onc dx gastric unresectable Onc dx gastric recurrent Onc dx gastric unknown NOS Onc dx pancreatc p R0 res no Onc dx pancreatc p R1/R2 no Onc dx pancreatic unresectab Onc dx pancreatic unknwn NOS Onc dx head/neck T1-T2no prg Onc dx head/neck T3-4 noprog Onc dx head/neck M1 mets rec Onc dx head/neck ext unknown Onc dx ovarian stg1A-B no pr Onc dx ovarian stg1A-B or 2 Onc dx ovarian stg3/4 noprog Onc dx ovarian recurrence Onc dx ovarian unknown NOS Onc dx CML chronic phase Onc dx CML acceler phase Onc dx CML blast phase Onc dx CML remission Onc dx multi myeloma stage I Onc dx mult myeloma stg2 hig Onc dx multi myeloma unknown Onc dx brst unknown NOS Onc dx prostate mets no cast Onc dx prostate clinical met Onc NHLstg 1-2 no relap no Onc dx NHL stg 3-4 not relap Onc dx NHL trans to lg Bcell Onc dx NHL relapse/refractor Onc dx NHL stg unknown Onc dx CML dx status unknown Frontier extended stay demo Influenza A H1N1,admin w cou Influenza A H1N1, vaccine Warfarin respon genetic test Outpt IV insulin tx any mea

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Bundled $ 0.00 By Report By Report

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Bundled $ 0.00 By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X B F N N

Y Y Y

Refer to Field Key for definitions

HCPCS Page 79

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

H0001 H0002 H0003 H0004 H0005 H0006 H0007 H0008 H0009 H0010 H0011 H0012 H0013 H0014 H0015 H0016 H0017 H0018 H0019 H0020 H0021 H0022 H0023 H0024 H0025 H0026 H0027 H0028 H0029 H0030 H0031 H0032 H0033 H0034 H0035 H0036 H0037 H0038 H0039 H0040 H0041 H0042 H0043 H0044 H0045

Alcohol and/or drug assess Alcohol and/or drug screenin Alcohol and/or drug screenin Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug services Alcohol and/or drug training Alcohol and/or drug interven Alcohol and/or drug outreach Alcohol and/or drug preventi Alcohol and/or drug preventi Alcohol and/or drug preventi Alcohol and/or drug preventi Alcohol and/or drug preventi Alcohol and/or drug preventi Alcohol and/or drug hotline MH health assess by non-md MH svc plan dev by non-md Oral med adm direct observe Med trng & support per 15min MH partial hosp tx under 24h Comm psy face-face per 15min Comm psy sup tx pgm per diem Self-help/peer svc per 15min Asser com tx face-face/15min Assert comm tx pgm per diem Fos c chld non-ther per diem Fos c chld non-ther per mon Supported housing, per diem Supported housing, per month Respite not-in-home per diem

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered By Report By Report By Report By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered By Report By Report By Report By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N N N N N N N N N N N N X N N N N X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 80

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

H0046 H0047 H0048 H0049 H0050 H1000 H1001 H1002 H1003 H1004 H1005 H1010 H1011 H2000 H2001 H2010 H2011 H2012 H2013 H2014 H2015 H2016 H2017 H2018 H2019 H2020 H2021 H2022 H2023 H2024 H2025 H2026 H2027 H2028 H2029 H2030 H2031 H2032 H2033 H2034 H2035 H2036 H2037 J0120 J0129

Mental health service, nos Alcohol/drug abuse svc nos Spec coll non-blood:a/d test Alcohol/drug screening Alcohol/drug service 15 min Prenatal care atrisk assessm Antepartum management Carecoordination prenatal Prenatal at risk education Follow up home visit/prental Prenatalcare enhanced srv pk Nonmed family planning ed Family assessment Comp multidisipln evaluation Rehabilitation program 1/2 d Comprehensive med svc 15 min Crisis interven svc, 15 min Behav hlth day treat, per hr Psych hlth fac svc, per diem Skills train and dev, 15 min Comp comm supp svc, 15 min Comp comm supp svc, per diem Psysoc rehab svc, per 15 min Psysoc rehab svc, per diem Ther behav svc, per 15 min Ther behav svc, per diem Com wrap-around sv, 15 min Com wrap-around sv, per diem Supported employ, per 15 min Supported employ, per diem Supp maint employ, 15 min Supp maint employ, per diem Psychoed svc, per 15 min Sex offend tx svc, 15 min Sex offend tx svc, per diem MH clubhouse svc, per 15 min MH clubhouse svc, per diem Activity therapy, per 15 min Multisys ther/juvenile 15min A/D halfway house, per diem A/D tx program, per hour A/D tx program, per diem Dev delay prev dp ch, 15 min Tetracyclin injection Abatacept injection

Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 4.00 $ 22.70

Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 4.00 $ 22.70

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X N N N N N N N N N N X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X D D

Y Y Y Y Y Y Y Y

Y

Refer to Field Key for definitions

HCPCS Page 81

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J0130 J0132 J0133 J0135 J0150 J0152 J0171 J0180 J0190 J0200 J0205 J0207 J0210 J0215 J0220 J0256 J0270 J0275 J0278 J0280 J0282 J0285 J0287 J0288 J0289 J0290 J0295 J0300 J0330 J0348 J0350 J0360 J0364 J0365 J0380 J0390 J0395 J0400 J0456 J0461 J0470 J0475 J0476 J0480 J0500

Abciximab injection Acetylcysteine injection Acyclovir injection Adalimumab injection Injection adenosine 6 MG Adenosine injection Adrenalin epinephrine inject Agalsidase beta injection Inj biperiden lactate/5 mg Alatrofloxacin mesylate Alglucerase injection Amifostine Methyldopate hcl injection Alefacept Alglucosidase alfa injection Alpha 1 proteinase inhibitor Alprostadil for injection Alprostadil urethral suppos Amikacin sulfate injection Aminophyllin 250 MG inj Amiodarone HCl Amphotericin B Amphotericin b lipid complex Ampho b cholesteryl sulfate Amphotericin b liposome inj Ampicillin 500 MG inj Ampicillin sodium per 1.5 gm Amobarbital 125 MG inj Succinycholine chloride inj Anidulafungin injection Injection anistreplase 30 u Hydralazine hcl injection Apomorphine hydrochloride Aprotonin, 10,000 kiu Inj metaraminol bitartrate Chloroquine injection Arbutamine hcl injection Aripiprazole injection Azithromycin Atropine sulfate injection Dimecaprol injection Baclofen 10 MG injection Baclofen intrathecal trial Basiliximab Dicyclomine injection

$ 743.04 $ 2.99 $ 0.16 Not Covered $ 0.15 $ 0.77 $ 0.43 $ 144.00 Not Covered $ 18.14 $ 42.82 $ 540.00 $ 0.86 Not Covered Not Covered $ 0.01 $ 1.70 $ 42.32 Not Covered $ 0.66 $ 0.26 $ 22.05 $ 21.60 $ 14.40 $ 33.91 $ 2.43 $ 2.86 $ 39.34 $ 0.17 $ 1.94 $ 2552.02 $ 4.74 $ 5.20 $ 2.93 $ 1.21 Not Covered Not Covered $ 0.42 $ 5.24 $ 0.02 $ 30.85 $ 220.05 $ 75.60 $ 2402.40 $ 15.44

$ 743.04 $ 2.99 $ 0.16 Not Covered $ 0.15 $ 0.77 $ 0.43 $ 144.00 Not Covered $ 18.14 $ 42.82 $ 540.00 $ 0.86 Not Covered Not Covered $ 0.01 $ 1.70 $ 42.32 Not Covered $ 0.66 $ 0.26 $ 22.05 $ 21.60 $ 14.40 $ 33.91 $ 2.43 $ 2.86 $ 39.34 $ 0.17 $ 1.94 $ 2552.02 $ 4.74 $ 5.20 $ 2.93 $ 1.21 Not Covered Not Covered $ 0.42 $ 5.24 $ 0.02 $ 30.85 $ 220.05 $ 75.60 $ 2402.40 $ 15.44

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D D D X D D D D X D D D D X X D D D X D D D D D D D D D D D D D D D D X X D D D D D D D D

Y

Refer to Field Key for definitions

HCPCS Page 82

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J0515 J0520 J0558 J0561 J0583 J0585 J0586 J0587 J0592 J0594 J0595 J0597 J0598 J0600 J0610 J0620 J0630 J0636 J0637 J0638 J0640 J0641 J0670 J0690 J0692 J0694 J0696 J0697 J0698 J0702 J0706 J0710 J0713 J0715 J0718 J0720 J0725 J0735 J0740 J0743 J0744 J0745 J0760 J0770 J0775

Inj benztropine mesylate Bethanechol chloride inject PenG benzathine/procaine inj Penicillin g benzathine inj Bivalirudin Injection,onabotulinumtoxinA AbobotulinumtoxinA Inj, rimabotulinumtoxinB Buprenorphine hydrochloride Busulfan injection Butorphanol tartrate 1 mg C-1 esterase, berinert C-1 esterase, cinryze Edetate calcium disodium inj Calcium gluconate injection Calcium glycer & lact/10 ML Calcitonin salmon injection Inj calcitriol per 0.1 mcg Caspofungin acetate Canakinumab injection Leucovorin calcium injection Levoleucovorin injection Inj mepivacaine HCL/10 ml Cefazolin sodium injection Cefepime HCl for injection Cefoxitin sodium injection Ceftriaxone sodium injection Sterile cefuroxime injection Cefotaxime sodium injection Betamethasone acet&sod phosp Caffeine citrate injection Cephapirin sodium injection Inj ceftazidime per 500 mg Ceftizoxime sodium / 500 MG Certolizumab pegol inj Chloramphenicol sodium injec Chorionic gonadotropin/1000u Clonidine hydrochloride Cidofovir injection Cilastatin sodium injection Ciprofloxacin iv Inj codeine phosphate /30 MG Colchicine injection Colistimethate sodium inj Collagenase, clost hist inj

$ 29.70 Not Covered $ 3.68 $ 4.62 Not Covered $ 5.67 $ 7.67 $ 10.78 $ 1.42 $ 19.84 $ 1.35 Not Covered Not Covered $ 205.20 $ 0.63 $ 13.86 $ 60.75 Not Covered $ 36.47 Not Covered $ 1.73 $ 1.91 $ 1.73 $ 0.57 $ 9.79 $ 8.79 $ 1.40 $ 2.38 $ 1.96 $ 6.91 Not Covered Not Covered $ 1.79 $ 5.34 Not Covered $ 25.87 $ 5.66 $ 45.36 $ 799.20 $ 18.74 $ 1.64 $ 1.37 Not Covered $ 27.00 Not Covered

$ 29.70 Not Covered $ 3.68 $ 4.62 Not Covered $ 5.67 $ 7.67 $ 10.78 $ 1.42 $ 19.84 $ 1.35 Not Covered Not Covered $ 205.20 $ 0.63 $ 13.86 $ 60.75 Not Covered $ 36.47 Not Covered $ 1.73 $ 1.91 $ 1.73 $ 0.57 $ 9.79 $ 8.79 $ 1.40 $ 2.38 $ 1.96 $ 6.91 Not Covered Not Covered $ 1.79 $ 5.34 Not Covered $ 25.87 $ 5.66 $ 45.36 $ 799.20 $ 18.74 $ 1.64 $ 1.37 Not Covered $ 27.00 Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D X D D X D D D D D D X X D D D D X D X D D D D D D D D D D X X D D X D D D D D D D X D X

Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 83

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J0780 J0795 J0800 J0833 J0834 J0850 J0878 J0881 J0882 J0885 J0886 J0894 J0895 J0900 J0945 J1000 J1020 J1030 J1040 J1051 J1055 J1056 J1060 J1070 J1080 J1094 J1100 J1110 J1120 J1160 J1162 J1165 J1170 J1180 J1190 J1200 J1205 J1212 J1230 J1240 J1245 J1250 J1260 J1265 J1267

Prochlorperazine injection Corticorelin ovine triflutal Corticotropin injection Cosyntropin injection NOS Cosyntropin cortrosyn inj Cytomegalovirus imm IV /vial Daptomycin injection Darbepoetin alfa, non-esrd Darbepoetin alfa, esrd use Epoetin alfa, non-esrd Epoetin alfa 1000 units ESRD Decitabine injection Deferoxamine mesylate inj Testosterone enanthate inj Brompheniramine maleate inj Depo-estradiol cypionate inj Methylprednisolone 20 MG inj Methylprednisolone 40 MG inj Methylprednisolone 80 MG inj Medroxyprogesterone inj Medrxyprogester acetate inj MA/EC contraceptiveinjection Testosterone cypionate 1 ML Testosterone cypionat 100 MG Testosterone cypionat 200 MG Inj dexamethasone acetate Dexamethasone sodium phos Inj dihydroergotamine mesylt Acetazolamid sodium injectio Digoxin injection Digoxin immune fab (ovine) Phenytoin sodium injection Hydromorphone injection Dyphylline injection Dexrazoxane HCl injection Diphenhydramine hcl injectio Chlorothiazide sodium inj Dimethyl sulfoxide 50% 50 ML Methadone injection Dimenhydrinate injection Dipyridamole injection Inj dobutamine HCL/250 mg Dolasetron mesylate Dopamine injection Doripenem injection

$ 3.24 Not Covered $ 2638.66 $ 86.62 $ 115.11 $ 1257.12 $ 0.52 $ 6.05 $ 6.05 $ 13.80 $ 13.80 $ 33.22 $ 9.93 $ 1.55 $ 1.50 Not Covered $ 1.94 $ 3.88 $ 7.78 Not Covered Not Covered Not Covered $ 5.91 $ 3.78 $ 7.56 $ 1.49 $ 0.06 $ 30.24 $ 48.60 $ 0.86 $ 646.36 $ 0.53 $ 0.74 $ 8.54 $ 221.65 $ 0.88 $ 321.52 $ 98.01 $ 6.73 $ 5.13 $ 0.96 $ 3.22 $ 4.21 $ 0.09 $ 0.91

$ 3.24 Not Covered $ 2638.66 $ 86.62 $ 115.11 $ 1257.12 $ 0.52 $ 6.05 $ 6.05 $ 13.80 $ 13.80 $ 33.22 $ 9.93 $ 1.55 $ 1.50 Not Covered $ 1.94 $ 3.88 $ 7.78 Not Covered Not Covered Not Covered $ 5.91 $ 3.78 $ 7.56 $ 1.49 $ 0.06 $ 30.24 $ 48.60 $ 0.86 $ 646.36 $ 0.53 $ 0.74 $ 8.54 $ 221.65 $ 0.88 $ 321.52 $ 98.01 $ 6.73 $ 5.13 $ 0.96 $ 3.22 $ 4.21 $ 0.09 $ 0.91

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D X D D D D D D D D D D D D D X D D D X X X D D D D D D D D D D D D D D D D D D D D D D D

Y

Refer to Field Key for definitions

HCPCS Page 84

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J1270 J1290 J1300 J1320 J1324 J1325 J1327 J1330 J1335 J1364 J1380 J1410 J1430 J1435 J1436 J1438 J1440 J1441 J1450 J1451 J1452 J1453 J1455 J1457 J1458 J1459 J1460 J1559 J1560 J1561 J1562 J1566 J1568 J1569 J1570 J1571 J1572 J1573 J1580 J1590 J1595 J1599 J1600 J1610 J1620

Injection, doxercalciferol Ecallantide injection Eculizumab injection Amitriptyline injection Enfuvirtide injection Epoprostenol injection Eptifibatide injection Ergonovine maleate injection Ertapenem injection Erythro lactobionate /500 MG Estradiol valerate 10 MG inj Inj estrogen conjugate 25 MG Ethanolamine oleate 100 mg Injection estrone per 1 MG Etidronate disodium inj Etanercept injection Filgrastim 300 mcg injection Filgrastim 480 mcg injection Fluconazole Fomepizole, 15 mg Intraocular Fomivirsen na Fosaprepitant injection Foscarnet sodium injection Gallium nitrate injection Galsulfase injection Inj IVIG privigen 500 mg Gamma globulin 1 CC inj Hizentra injection Gamma globulin > 10 CC inj Gamunex injection Vivaglobin, inj Immune globulin, powder Octagam injection Gammagard liquid injection Ganciclovir sodium injection Hepagam b im injection Flebogamma injection Hepagam b intravenous, inj Garamycin gentamicin inj Gatifloxacin injection Injection glatiramer acetate Ivig non-lyophilized, NOS Gold sodium thiomaleate inj Glucagon hydrochloride/1 MG Gonadorelin hydroch/ 100 mcg

Not Covered Not Covered Not Covered $ 2.38 $ 31.54 $ 12.49 $ 25.85 Not Covered $ 32.29 $ 12.25 Not Covered Not Covered Not Covered Not Covered $ 72.90 $ 230.71 $ 251.45 $ 417.37 $ 5.83 $ 10.78 $ 225.00 $ 1.84 $ 13.57 Not Covered Not Covered $ 59.94 $ 23.11 Not Covered $ 23.11 $ 52.20 $ 12.96 $ 45.45 $ 57.95 $ 62.06 $ 72.95 $ 69.12 $ 43.55 By Report $ 0.77 $ 0.92 Not Covered By Report $ 15.75 $ 86.40 $ 191.35

Not Covered Not Covered Not Covered $ 2.38 $ 31.54 $ 12.49 $ 25.85 Not Covered $ 32.29 $ 12.25 Not Covered Not Covered Not Covered Not Covered $ 72.90 $ 230.71 $ 251.45 $ 417.37 $ 5.83 $ 10.78 $ 225.00 $ 1.84 $ 13.57 Not Covered Not Covered $ 59.94 $ 23.11 Not Covered $ 23.11 $ 52.20 $ 12.96 $ 45.45 $ 57.95 $ 62.06 $ 72.95 $ 69.12 $ 43.55 By Report $ 0.77 $ 0.92 Not Covered By Report $ 15.75 $ 86.40 $ 191.35

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X D D D D X D D X X X X D D D D D D D D D X X D D X D D D D D D D D D N D D X N D D D

Y

Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 85

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J1626 J1630 J1631 J1640 J1642 J1644 J1645 J1650 J1652 J1655 J1670 J1675 J1680 J1700 J1710 J1720 J1730 J1740 J1742 J1743 J1745 J1750 J1756 J1786 J1790 J1800 J1810 J1815 J1817 J1826 J1830 J1835 J1840 J1850 J1885 J1890 J1930 J1931 J1940 J1945 J1950 J1953 J1955 J1956 J1960

Granisetron hcl injection Haloperidol injection Haloperidol decanoate inj Hemin, 1 mg Inj heparin sodium per 10 u Inj heparin sodium per 1000u Dalteparin sodium Inj enoxaparin sodium Fondaparinux sodium Tinzaparin sodium injection Tetanus immune globulin inj Histrelin acetate Human fibrinogen conc inj Hydrocortisone acetate inj Hydrocortisone sodium ph inj Hydrocortisone sodium succ i Diazoxide injection Ibandronate sodium injection Ibutilide fumarate injection Idursulfase injection Infliximab injection Inj iron dextran Iron sucrose injection Imuglucerase injection Droperidol injection Propranolol injection Droperidol/fentanyl inj Insulin injection Insulin for insulin pump use Interferon Beta-1A inj Interferon beta-1b / .25 MG Itraconazole injection Kanamycin sulfate 500 MG inj Kanamycin sulfate 75 MG inj Ketorolac tromethamine inj Cephalothin sodium injection Lanreotide injection Laronidase injection Furosemide injection Lepirudin Leuprolide acetate /3.75 MG Levetiracetam injection Inj levocarnitine per 1 gm Levofloxacin injection Levorphanol tartrate inj

$ 1.89 $ 1.19 $ 3.46 $ 11.04 $ 0.02 $ 0.25 $ 14.92 $ 7.30 $ 10.93 $ 4.73 $ 320.99 $ 3.22 $ 98.10 Not Covered Not Covered $ 2.10 $ 32.48 $ 158.10 $ 302.40 Not Covered $ 71.05 $ 12.99 $ 0.59 $ 42.82 $ 1.20 $ 8.37 Not Covered $ 0.17 $ 1.70 $ 779.76 $ 204.62 $ 42.37 $ 7.83 $ 1.17 $ 0.82 Not Covered Not Covered $ 27.37 $ 0.23 $ 319.63 $ 443.23 Not Covered $ 10.37 $ 17.45 $ 3.56

$ 1.89 $ 1.19 $ 3.46 $ 11.04 $ 0.02 $ 0.25 $ 14.92 $ 7.30 $ 10.93 $ 4.73 $ 320.99 $ 3.22 $ 98.10 Not Covered Not Covered $ 2.10 $ 32.48 $ 158.10 $ 302.40 Not Covered $ 71.05 $ 12.99 $ 0.59 $ 42.82 $ 1.20 $ 8.37 Not Covered $ 0.17 $ 1.70 $ 779.76 $ 204.62 $ 42.37 $ 7.83 $ 1.17 $ 0.82 Not Covered Not Covered $ 27.37 $ 0.23 $ 319.63 $ 443.23 Not Covered $ 10.37 $ 17.45 $ 3.56

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D D D D D D D D D D D D D X X D D D D X D D D D D D X D D D D D D D D X X D D D D X D D D

Y Y Y

Y

Refer to Field Key for definitions

HCPCS Page 86

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J1980 J1990 J2001 J2010 J2020 J2060 J2150 J2170 J2175 J2180 J2185 J2210 J2248 J2250 J2260 J2270 J2271 J2275 J2278 J2280 J2300 J2310 J2315 J2320 J2323 J2325 J2353 J2354 J2355 J2357 J2358 J2360 J2370 J2400 J2405 J2410 J2425 J2426 J2430 J2440 J2460 J2469 J2501 J2503 J2504

Hyoscyamine sulfate inj Chlordiazepoxide injection Lidocaine injection Lincomycin injection Linezolid injection Lorazepam injection Mannitol injection Mecasermin injection Meperidine hydrochl /100 MG Meperidine/promethazine inj Meropenem Methylergonovin maleate inj Micafungin sodium injection Inj midazolam hydrochloride Inj milrinone lactate / 5 MG Morphine sulfate injection Morphine so4 injection 100mg Morphine sulfate injection Ziconotide injection Inj, moxifloxacin 100 mg Inj nalbuphine hydrochloride Inj naloxone hydrochloride Naltrexone, depot form Nandrolone decanoate 50 MG Natalizumab injection Nesiritide injection Octreotide injection, depot Octreotide inj, non-depot Oprelvekin injection Omalizumab injection Olanzapine long-acting inj Orphenadrine injection Phenylephrine hcl injection Chloroprocaine hcl injection Ondansetron hcl injection Oxymorphone hcl injection Palifermin injection Paliperidone palmitate inj Pamidronate disodium /30 MG Papaverin hcl injection Oxytetracycline injection Palonosetron hcl Paricalcitol Pegaptanib sodium injection Pegademase bovine, 25 iu

$ 13.50 $ 22.73 $ 0.02 $ 6.27 $ 36.03 $ 0.81 $ 1.18 Not Covered $ 0.52 Not Covered $ 3.76 Not Covered $ 2.02 $ 0.21 $ 3.05 $ 0.69 Not Covered $ 5.23 $ 6.90 $ 9.45 $ 1.06 $ 5.83 $ 3.13 $ 3.64 Not Covered Not Covered $ 122.42 $ 1.51 $ 264.38 $ 22.11 $ 3.52 $ 17.71 $ 0.74 $ 8.79 $ 0.12 $ 2.82 Not Covered $ 7.05 $ 14.54 $ 1.08 $ 1.12 $ 38.88 Not Covered Not Covered Not Covered

$ 13.50 $ 22.73 $ 0.02 $ 6.27 $ 36.03 $ 0.81 $ 1.18 Not Covered $ 0.52 Not Covered $ 3.76 Not Covered $ 2.02 $ 0.21 $ 3.05 $ 0.69 Not Covered $ 5.23 $ 6.90 $ 9.45 $ 1.06 $ 5.83 $ 3.13 $ 3.64 Not Covered Not Covered $ 122.42 $ 1.51 $ 264.38 $ 22.11 $ 3.52 $ 17.71 $ 0.74 $ 8.79 $ 0.12 $ 2.82 Not Covered $ 7.05 $ 14.54 $ 1.08 $ 1.12 $ 38.88 Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D D D D D D D X D X D X D D D D X D D D D D D D X X D D D D D D D D D D X D D D D D X X X

Y

Y

Y Y

Refer to Field Key for definitions

HCPCS Page 87

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J2505 J2510 J2513 J2515 J2540 J2543 J2545 J2550 J2560 J2562 J2590 J2597 J2650 J2670 J2675 J2680 J2690 J2700 J2710 J2720 J2724 J2725 J2730 J2760 J2765 J2770 J2778 J2780 J2783 J2785 J2788 J2790 J2791 J2792 J2793 J2794 J2795 J2796 J2800 J2805 J2810 J2820 J2850 J2910 J2916

Injection, pegfilgrastim 6mg Penicillin g procaine inj Pentastarch 10% solution Pentobarbital sodium inj Penicillin g potassium inj Piperacillin/tazobactam Pentamidine non-comp unit Promethazine hcl injection Phenobarbital sodium inj Plerixafor injection Oxytocin injection Inj desmopressin acetate Prednisolone acetate inj Totazoline hcl injection Inj progesterone per 50 MG Fluphenazine decanoate 25 MG Procainamide hcl injection Oxacillin sodium injeciton Neostigmine methylslfte inj Inj protamine sulfate/10 MG Protein c concentrate Inj protirelin per 250 mcg Pralidoxime chloride inj Phentolaine mesylate inj Metoclopramide hcl injection Quinupristin/dalfopristin Ranibizumab injection Ranitidine hydrochloride inj Rasburicase Regadenoson injection Rho d immune globulin 50 mcg Rho d immune globulin inj Rhophylac injection Rho(D) immune globulin h, sd Rilonacept injection Risperidone, long acting Ropivacaine HCl injection Romiplostim injection Methocarbamol injection Sincalide injection Inj theophylline per 40 MG Sargramostim injection Inj secretin synthetic human Aurothioglucose injeciton Na ferric gluconate complex

Not Covered $ 15.40 $ 13.74 $ 19.96 $ 0.50 $ 4.31 $ 40.48 $ 2.00 $ 3.89 $ 295.31 Not Covered $ 1.59 $ 1.21 Not Covered Not Covered $ 1.73 $ 12.69 $ 11.60 $ 0.14 $ 0.46 $ 14.13 $ 23.11 $ 93.64 $ 75.60 Not Covered $ 187.45 Not Covered $ 1.08 Not Covered $ 56.84 $ 50.97 $ 119.25 $ 11.55 $ 24.33 Not Covered $ 5.50 $ 0.07 $ 48.71 $ 30.20 Not Covered $ 0.22 $ 33.84 Not Covered $ 26.46 $ 6.87

Not Covered $ 15.40 $ 13.74 $ 19.96 $ 0.50 $ 4.31 $ 40.48 $ 2.00 $ 3.89 $ 295.31 Not Covered $ 1.59 $ 1.21 Not Covered Not Covered $ 1.73 $ 12.69 $ 11.60 $ 0.14 $ 0.46 $ 14.13 $ 23.11 $ 93.64 $ 75.60 Not Covered $ 187.45 Not Covered $ 1.08 Not Covered $ 56.84 $ 50.97 $ 119.25 $ 11.55 $ 24.33 Not Covered $ 5.50 $ 0.07 $ 48.71 $ 30.20 Not Covered $ 0.22 $ 33.84 Not Covered $ 26.46 $ 6.87

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X D D D D D D D D D X D D X X D D D D D D D D D X D X D X D D D D D X D D D D X D D X D D

Y

Y

Y

Y

Y

Refer to Field Key for definitions

HCPCS Page 88

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J2920 J2930 J2940 J2941 J2950 J2993 J2995 J2997 J3000 J3010 J3030 J3070 J3095 J3101 J3105 J3110 J3120 J3130 J3140 J3150 J3230 J3240 J3243 J3246 J3250 J3260 J3262 J3265 J3280 J3285 J3300 J3301 J3302 J3303 J3305 J3310 J3315 J3320 J3350 J3355 J3357 J3360 J3364 J3365 J3370

Methylprednisolone injection Methylprednisolone injection Somatrem injection Somatropin injection Promazine hcl injection Reteplase injection Inj streptokinase /250000 IU Alteplase recombinant Streptomycin injection Fentanyl citrate injeciton Sumatriptan succinate / 6 MG Pentazocine injection Televancin injection Tenecteplase injection Terbutaline sulfate inj Teriparatide injection Testosterone enanthate inj Testosterone enanthate inj Testosterone suspension inj Testosteron propionate inj Chlorpromazine hcl injection Thyrotropin injection Tigecycline injection Tirofiban HCl Trimethobenzamide hcl inj Tobramycin sulfate injection Tocilizumab injection Injection torsemide 10 mg/ml Thiethylperazine maleate inj Treprostinil injection Triamcinolone A inj PRS-free Triamcinolone acet inj NOS Triamcinolone diacetate inj Triamcinolone hexacetonl inj Inj trimetrexate glucoronate Perphenazine injeciton Triptorelin pamoate Spectinomycn di-hcl inj Urea injection Urofollitropin, 75 iu Ustekinumab injection Diazepam injection Urokinase 5000 IU injection Urokinase 250,000 IU inj Vancomycin hcl injection

$ 1.95 $ 3.15 Not Covered Not Covered Not Covered $ 2335.34 $ 84.38 $ 46.97 $ 13.19 $ 0.24 $ 35.64 $ 4.37 $ 2.23 $ 63.54 $ 3.55 Not Covered $ 7.15 $ 15.29 Not Covered Not Covered $ 8.01 $ 1076.76 $ 1.32 $ 11.18 $ 2.43 $ 1.12 $ 3.59 $ 2.22 $ 13.36 Not Covered $ 3.65 $ 2.18 $ 0.29 $ 1.60 $ 158.90 Not Covered Not Covered $ 30.41 Not Covered Not Covered $ 123.15 $ 0.16 Not Covered $ 485.80 $ 2.86

$ 1.95 $ 3.15 Not Covered Not Covered Not Covered $ 2335.34 $ 84.38 $ 46.97 $ 13.19 $ 0.24 $ 35.64 $ 4.37 $ 2.23 $ 63.54 $ 3.55 Not Covered $ 7.15 $ 15.29 Not Covered Not Covered $ 8.01 $ 1076.76 $ 1.32 $ 11.18 $ 2.43 $ 1.12 $ 3.59 $ 2.22 $ 13.36 Not Covered $ 3.65 $ 2.18 $ 0.29 $ 1.60 $ 158.90 Not Covered Not Covered $ 30.41 Not Covered Not Covered $ 123.15 $ 0.16 Not Covered $ 485.80 $ 2.86

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D D X X X D D D D D D D D D D X D D X X D D D D D D D D D X D D D D D X X D X X D D X D D

Y

Y

Refer to Field Key for definitions

HCPCS Page 89

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J3385 J3396 J3400 J3410 J3411 J3415 J3420 J3430 J3465 J3470 J3471 J3472 J3473 J3475 J3480 J3485 J3486 J3487 J3488 J3490 J3520 J3530 J3535 J3570 J3590 J7030 J7040 J7042 J7050 J7060 J7070 J7100 J7110 J7120 J7130 J7184 J7185 J7186 J7187 J7189 J7190 J7191 J7192 J7193 J7194

Velaglucerase alfa Verteporfin injection Triflupromazine hcl inj Hydroxyzine hcl injection Thiamine hcl 100 mg Pyridoxine hcl 100 mg Vitamin b12 injection Vitamin k phytonadione inj Injection, voriconazole Hyaluronidase injection Ovine, up to 999 USP units Ovine, 1000 USP units Hyaluronidase recombinant Inj magnesium sulfate Inj potassium chloride Zidovudine Ziprasidone mesylate Zoledronic acid Reclast injection Drugs unclassified injection Edetate disodium per 150 mg Nasal vaccine inhalation Metered dose inhaler drug Laetrile amygdalin vit B17 Unclassified biologics Normal saline solution infus Normal saline solution infus 5% dextrose/normal saline Normal saline solution infus 5% dextrose/water D5w infusion Dextran 40 infusion Dextran 75 infusion Ringers lactate infusion Hypertonic saline solution Wilate injection Xyntha inj Antihemophilic viii/vwf comp Humate-P, inj Factor viia Factor viii Factor VIII (porcine) Factor viii recombinant NOS Factor IX non-recombinant Factor ix complex

Not Covered Not Covered Not Covered $ 0.46 $ 5.37 $ 9.71 $ 0.20 $ 4.32 $ 6.91 $ 21.60 $ 0.21 $ 211.50 $ 0.65 $ 0.03 $ 0.03 $ 1.48 $ 7.67 $ 239.42 $ 231.79 By Report $ 1.01 Not Covered Bundled Not Covered By Report $ 1.57 $ 1.35 $ 1.48 $ 1.36 $ 1.69 $ 1.89 $ 26.39 $ 12.96 $ 1.71 $ 0.69 Not Covered $ 1.49 $ 1.19 $ 1.08 $ 1.75 $ 0.91 $ 1.98 $ 1.47 $ 1.08 $ 0.81

Not Covered Not Covered Not Covered $ 0.46 $ 5.37 $ 9.71 $ 0.20 $ 4.32 $ 6.91 $ 21.60 $ 0.21 $ 211.50 $ 0.65 $ 0.03 $ 0.03 $ 1.48 $ 7.67 $ 239.42 $ 231.79 By Report $ 1.01 Not Covered Bundled Not Covered By Report $ 1.57 $ 1.35 $ 1.48 $ 1.36 $ 1.69 $ 1.89 $ 26.39 $ 12.96 $ 1.71 $ 0.69 Not Covered $ 1.49 $ 1.19 $ 1.08 $ 1.75 $ 0.91 $ 1.98 $ 1.47 $ 1.08 $ 0.81

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X D D D D D D D D D D D D D D D D N D X B X N D D D D D D D D D D X D D D D D D D D D

Y Y

Y

Y

Y

Y

Refer to Field Key for definitions

HCPCS Page 90

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J7195 J7196 J7197 J7198 J7199 J7300 J7302 J7303 J7304 J7306 J7307 J7308 J7309 J7310 J7311 J7312 J7321 J7323 J7324 J7325 J7330 J7335 J7500 J7501 J7502 J7504 J7505 J7506 J7507 J7509 J7510 J7511 J7513 J7515 J7516 J7517 J7518 J7520 J7525 J7599 J7604 J7605 J7606 J7607 J7608

Factor IX recombinant Antithrombin recombinant Antithrombin iii injection Anti-inhibitor Hemophilia clot factor noc Intraut copper contraceptive Levonorgestrel iu contracept Contraceptive vaginal ring Contraceptive hormone patch Levonorgestrel implant sys Etonogestrel implant system Aminolevulinic acid hcl top Methyl aminolevulinate, top Ganciclovir long act implant Fluocinolone acetonide implt Dexamethasone intra implant Hyalgan/supartz inj per dose Euflexxa inj per dose Orthovisc inj per dose Synvisc or Synvisc-One Cultured chondrocytes implnt Capsaicin 8% patch Azathioprine oral 50mg Azathioprine parenteral Cyclosporine oral 100 mg Lymphocyte immune globulin Monoclonal antibodies Prednisone oral Tacrolimus oral per 1 MG Methylprednisolone oral Prednisolone oral per 5 mg Antithymocyte globuln rabbit Daclizumab, parenteral Cyclosporine oral 25 mg Cyclosporin parenteral 250mg Mycophenolate mofetil oral Mycophenolic acid Sirolimus, oral Tacrolimus injection Immunosuppressive drug noc Acetylcysteine comp unit Arformoterol non-comp unit Formoterol fumarate, inh Levalbuterol comp con Acetylcysteine non-comp unit

$ 1.04 $ 153.90 $ 3.51 $ 1.95 By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 77.38 $ 17280.00 $ 19710.00 $ 199.80 $ 140.40 $ 203.81 $ 270.00 $ 17.98 $ 27588.60 $ 26.04 $ 0.76 $ 118.80 $ 5.38 $ 630.99 $ 1177.89 $ 0.04 $ 4.01 $ 0.44 $ 0.53 $ 611.50 $ 536.27 $ 1.19 $ 23.76 $ 0.84 Not Covered $ 11.44 $ 147.55 Bundled $ 0.22 $ 6.65 $ 6.37 $ 0.02 $ 2.70

$ 1.04 $ 153.90 $ 3.51 $ 1.95 By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 77.38 $ 17280.00 $ 19710.00 $ 199.80 $ 140.40 $ 203.81 $ 270.00 $ 17.98 $ 27588.60 $ 26.04 $ 0.76 $ 118.80 $ 5.38 $ 630.99 $ 1177.89 $ 0.04 $ 4.01 $ 0.44 $ 0.53 $ 611.50 $ 536.27 $ 1.19 $ 23.76 $ 0.84 Not Covered $ 11.44 $ 147.55 Bundled $ 0.22 $ 6.65 $ 6.37 $ 0.02 $ 2.70

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D D D D N X X X X X X X D D D D D D D D D D D D D D D D D D D D D D D D X D D B D D D D D

Y Y

Y Y Y Y Y Y Y Y Y

Y

Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 91

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J7609 J7610 J7611 J7612 J7613 J7614 J7615 J7620 J7622 J7624 J7626 J7627 J7628 J7629 J7631 J7632 J7633 J7634 J7635 J7636 J7637 J7638 J7639 J7640 J7641 J7642 J7643 J7644 J7645 J7647 J7648 J7649 J7650 J7657 J7658 J7659 J7660 J7667 J7668 J7669 J7670 J7674 J7676 J7680 J7681

Albuterol comp unit Albuterol comp con Albuterol non-comp con Levalbuterol non-comp con Albuterol non-comp unit Levalbuterol non-comp unit Levalbuterol comp unit Albuterol ipratrop non-comp Beclomethasone comp unit Betamethasone comp unit Budesonide non-comp unit Budesonide comp unit Bitolterol mesylate comp con Bitolterol mesylate comp unt Cromolyn sodium noncomp unit Cromolyn sodium comp unit Budesonide non-comp con Budesonide comp con Atropine comp con Atropine comp unit Dexamethasone comp con Dexamethasone comp unit Dornase alfa non-comp unit Formoterol comp unit Flunisolide comp unit Glycopyrrolate comp con Glycopyrrolate comp unit Ipratropium bromide non-comp Ipratropium bromide comp Isoetharine comp con Isoetharine non-comp con Isoetharine non-comp unit Isoetharine comp unit Isoproterenol comp con Isoproterenol non-comp con Isoproterenol non-comp unit Isoproterenol comp unit Metaproterenol comp con Metaproterenol non-comp con Metaproterenol non-comp unit Metaproterenol comp unit Methacholine chloride, neb Pentamidine comp unit dose Terbutaline sulf comp con Terbutaline sulf comp unit

$ 0.03 $ 0.03 $ 0.48 $ 0.01 $ 0.01 $ 1.60 $ 1.85 $ 1.97 By Report By Report $ 6.53 $ 0.17 Not Covered Not Covered $ 0.74 $ 0.09 $ 5.55 $ 0.08 Not Covered Not Covered Not Covered Not Covered $ 29.25 $ 2.73 By Report Not Covered Not Covered $ 0.03 $ 0.31 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 0.01 $ 0.06 $ 0.63 $ 1.11 $ 0.06 $ 0.40 $ 40.78 Not Covered Not Covered

$ 0.03 $ 0.03 $ 0.48 $ 0.01 $ 0.01 $ 1.60 $ 1.85 $ 1.97 By Report By Report $ 6.53 $ 0.17 Not Covered Not Covered $ 0.74 $ 0.09 $ 5.55 $ 0.08 Not Covered Not Covered Not Covered Not Covered $ 29.25 $ 2.73 By Report Not Covered Not Covered $ 0.03 $ 0.31 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 0.01 $ 0.06 $ 0.63 $ 1.11 $ 0.06 $ 0.40 $ 40.78 Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D D D D D D D D N N D D X X D D D D X X X X D D N X X D D X X X X X X X D D D D D D D X X

HCPCS Page 92

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J7682 J7683 J7684 J7685 J7686 J7699 J7799 J8498 J8499 J8501 J8510 J8515 J8520 J8521 J8530 J8540 J8560 J8562 J8565 J8597 J8600 J8610 J8650 J8700 J8705 J8999 J9000 J9001 J9010 J9015 J9017 J9020 J9025 J9027 J9031 J9033 J9035 J9040 J9041 J9045 J9050 J9055 J9060 J9065 J9070

Tobramycin non-comp unit Triamcinolone comp con Triamcinolone comp unit Tobramycin comp unit Treprostinil, non-comp unit Inhalation solution for DME Non-inhalation drug for DME Antiemetic rectal/supp NOS Oral prescrip drug non chemo Oral aprepitant Oral busulfan Cabergoline, oral 0.25mg Capecitabine, oral, 150 mg Capecitabine, oral, 500 mg Cyclophosphamide oral 25 MG Oral dexamethasone Etoposide oral 50 MG Oral fludarabine phosphate Gefitinib oral Antiemetic drug oral NOS Melphalan oral 2 MG Methotrexate oral 2.5 MG Nabilone oral Temozolomide Topotecan oral Oral prescription drug chemo Doxorubicin hcl injection Doxorubicin hcl liposome inj Alemtuzumab injection Aldesleukin injection Arsenic trioxide injection Asparaginase injection Azacitidine injection Clofarabine injection Bcg live intravesical vac Bendamustine injection Bevacizumab injection Bleomycin sulfate injection Bortezomib injection Carboplatin injection Carmustine injection Cetuximab injection Cisplatin 10 MG injection Inj cladribine per 1 MG Cyclophosphamide 100 MG inj

$ 83.88 By Report By Report $ 9.05 $ 452.70 Bundled Bundled Bundled Bundled Not Covered $ 4.02 Not Covered $ 5.39 $ 26.84 $ 1.88 $ 0.13 $ 51.60 $ 83.31 Not Covered Bundled $ 6.09 $ 0.36 $ 21.73 $ 8.79 $ 80.76 Bundled $ 7.02 $ 582.07 Not Covered $ 895.12 $ 42.76 $ 65.78 Not Covered Not Covered $ 178.95 $ 19.44 Not Covered $ 30.29 $ 43.14 $ 8.55 $ 185.12 Not Covered $ 3.67 $ 30.78 Not Covered

$ 83.88 By Report By Report $ 9.05 $ 452.70 Bundled Bundled Bundled Bundled Not Covered $ 4.02 Not Covered $ 5.39 $ 26.84 $ 1.88 $ 0.13 $ 51.60 $ 83.31 Not Covered Bundled $ 6.09 $ 0.36 $ 21.73 $ 8.79 $ 80.76 Bundled $ 7.02 $ 582.07 Not Covered $ 895.12 $ 42.76 $ 65.78 Not Covered Not Covered $ 178.95 $ 19.44 Not Covered $ 30.29 $ 43.14 $ 8.55 $ 185.12 Not Covered $ 3.67 $ 30.78 Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D N N D D B B B B X D X D D D D D D X B D D D D D B D D X D D D X X D D X D D D D X D D X

Y

Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 93

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J9098 J9100 J9120 J9130 J9150 J9151 J9155 J9160 J9165 J9171 J9175 J9178 J9181 J9185 J9190 J9200 J9201 J9202 J9206 J9207 J9208 J9209 J9211 J9212 J9213 J9214 J9215 J9216 J9217 J9218 J9219 J9225 J9226 J9230 J9245 J9250 J9260 J9261 J9263 J9264 J9265 J9266 J9268 J9270 J9280

Cytarabine liposome inj Cytarabine hcl 100 MG inj Dactinomycin injection Dacarbazine 100 mg inj Daunorubicin injection Daunorubicin citrate inj Degarelix injection Denileukin diftitox inj Diethylstilbestrol injection Docetaxel injection Elliotts b solution per ml Inj, epirubicin hcl, 2 mg Etoposide injection Fludarabine phosphate inj Fluorouracil injection Floxuridine injection Gemcitabine hcl injection Goserelin acetate implant Irinotecan injection Ixabepilone injection Ifosfomide injection Mesna injection Idarubicin hcl injection Interferon alfacon-1 inj Interferon alfa-2a inj Interferon alfa-2b inj Interferon alfa-n3 inj Interferon gamma 1-b inj Leuprolide acetate suspnsion Leuprolide acetate injeciton Leuprolide acetate implant Vantas implant Supprelin LA implant Mechlorethamine hcl inj Inj melphalan hydrochl 50 MG Methotrexate sodium inj Methotrexate sodium inj Nelarabine injection Oxaliplatin Paclitaxel protein bound Paclitaxel injection Pegaspargase injection Pentostatin injection Plicamycin (mithramycin) inj Mitomycin 5 MG inj

$ 529.20 $ 1.65 $ 610.20 $ 10.21 $ 16.85 $ 58.75 Not Covered $ 1677.24 Not Covered $ 22.24 Not Covered $ 2.61 $ 0.49 $ 145.58 $ 2.97 $ 108.94 $ 115.88 $ 406.07 $ 11.40 $ 67.38 $ 37.80 $ 4.32 $ 83.43 $ 9.70 $ 45.85 $ 16.75 $ 21.68 $ 604.40 $ 443.88 $ 129.60 Not Covered Not Covered Not Covered $ 160.83 $ 1661.04 $ 0.34 $ 3.43 $ 114.75 $ 6.45 $ 10.08 $ 9.56 $ 2952.00 $ 1412.96 $ 88.87 $ 21.60

$ 529.20 $ 1.65 $ 610.20 $ 10.21 $ 16.85 $ 58.75 Not Covered $ 1677.24 Not Covered $ 22.24 Not Covered $ 2.61 $ 0.49 $ 145.58 $ 2.97 $ 108.94 $ 115.88 $ 406.07 $ 11.40 $ 67.38 $ 37.80 $ 4.32 $ 83.43 $ 9.70 $ 45.85 $ 16.75 $ 21.68 $ 604.40 $ 443.88 $ 129.60 Not Covered Not Covered Not Covered $ 160.83 $ 1661.04 $ 0.34 $ 3.43 $ 114.75 $ 6.45 $ 10.08 $ 9.56 $ 2952.00 $ 1412.96 $ 88.87 $ 21.60

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D D D D D D X D X D X D D D D D D D D D D D D D D D D D D D X X X D D D D D D D D D D D D

Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 94

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

J9293 J9300 J9302 J9303 J9305 J9307 J9310 J9315 J9320 J9328 J9330 J9340 J9351 J9355 J9357 J9360 J9370 J9390 J9395 J9600 J9999 K0001-NU K0001-RR K0002-NU K0002-RR K0003-NU K0003-RR K0004-NU K0004-RR K0005-NU K0005-RR K0006-NU K0006-RR K0007-NU K0007-RR K0009-NU K0009-RR K0010-NU K0010-RR K0011-NU K0011-RR K0012-NU K0012-RR K0014-NU K0014-RR

Mitoxantrone hydrochl / 5 MG Gemtuzumab ozogamicin inj Ofatumumab injection Panitumumab injection Pemetrexed injection Pralatrexate injection Rituximab injection Romidepsin injection Streptozocin injection Temozolomide injection Temsirolimus injection Thiotepa injection Topotecan injection Trastuzumab injection Valrubicin injection Vinblastine sulfate inj Vincristine sulfate 1 MG inj Vinorelbine tartrate inj Injection, Fulvestrant Porfimer sodium injection Chemotherapy drug Standard wheelchair Standard wheelchair Stnd hemi (low seat) whlchr Stnd hemi (low seat) whlchr Lightweight wheelchair Lightweight wheelchair High strength ltwt whlchr High strength ltwt whlchr Ultralightweight wheelchair Ultralightweight wheelchair Heavy duty wheelchair Heavy duty wheelchair Extra heavy duty wheelchair Extra heavy duty wheelchair Other manual wheelchair/base Other manual wheelchair/base Stnd wt frame power whlchr Stnd wt frame power whlchr Stnd wt pwr whlchr w control Stnd wt pwr whlchr w control Ltwt portbl power whlchr Ltwt portbl power whlchr Other power whlchr base Other power whlchr base

$ 50.56 $ 2794.34 $ 47.52 Not Covered $ 56.43 $ 168.75 $ 629.69 Not Covered $ 301.73 $ 5.09 $ 52.84 $ 162.00 $ 16.20 $ 72.55 Not Covered $ 2.86 $ 5.67 $ 12.92 Not Covered $ 3089.83 By Report By Report By Report $ 857.66 $ 85.77 $ 939.05 $ 93.91 $ 1400.70 $ 140.07 $ 1939.26 $ 193.93 $ 1314.50 $ 131.45 $ 1871.06 $ 187.11 By Report By Report $ 4465.07 $ 446.51 By Report By Report $ 3405.64 $ 340.56 By Report By Report

$ 50.56 $ 2794.34 $ 47.52 Not Covered $ 56.43 $ 168.75 $ 629.69 Not Covered $ 301.73 $ 5.09 $ 52.84 $ 162.00 $ 16.20 $ 72.55 Not Covered $ 2.86 $ 5.67 $ 12.92 Not Covered $ 3089.83 By Report By Report By Report $ 857.66 $ 85.77 $ 939.05 $ 93.91 $ 1400.70 $ 140.07 $ 1939.26 $ 193.93 $ 1314.50 $ 131.45 $ 1871.06 $ 187.11 By Report By Report $ 4465.07 $ 446.51 By Report By Report $ 3405.64 $ 340.56 By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D D D X D D D X D D D D D D X D D D X D N N N F F F F F F F F F F F F N N F F N N F F N N

Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 95

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

K0015-NU K0015-RR K0017-NU K0017-RR K0018-NU K0018-RR K0019-NU K0019-RR K0020-NU K0020-RR K0037-NU K0037-RR K0038-NU K0038-RR K0039-NU K0039-RR K0040-NU K0040-RR K0041-NU K0041-RR K0042-NU K0042-RR K0043-NU K0043-RR K0044-NU K0044-RR K0045-NU K0045-RR K0046-NU K0046-RR K0047-NU K0047-RR K0050-NU K0050-RR K0051-NU K0051-RR K0052-NU K0052-RR K0053-NU K0053-RR K0056-NU K0056-RR K0065-NU K0069-NU K0070-NU

Detach non-adjus hght armrst Detach non-adjus hght armrst Detach adjust armrest base Detach adjust armrest base Detach adjust armrst upper Detach adjust armrst upper Arm pad each Arm pad each Fixed adjust armrest pair Fixed adjust armrest pair High mount flip-up footrest High mount flip-up footrest Leg strap each Leg strap each Leg strap h style each Leg strap h style each Adjustable angle footplate Adjustable angle footplate Large size footplate each Large size footplate each Standard size footplate each Standard size footplate each Ftrst lower extension tube Ftrst lower extension tube Ftrst upper hanger bracket Ftrst upper hanger bracket Footrest complete assembly Footrest complete assembly Elevat legrst low extension Elevat legrst low extension Elevat legrst up hangr brack Elevat legrst up hangr brack Ratchet assembly Ratchet assembly Cam relese assem ftrst/lgrst Cam relese assem ftrst/lgrst Swingaway detach footrest Swingaway detach footrest Elevate footrest articulate Elevate footrest articulate Seat ht <17 or >=21 ltwt wc Seat ht <17 or >=21 ltwt wc Spoke protectors Rear whl complete solid tire Rear whl compl pneum tire

$ 161.54 $ 16.15 $ 46.20 $ 4.62 $ 25.81 $ 2.58 $ 15.58 $ 1.56 $ 42.01 $ 4.20 $ 43.54 $ 4.35 $ 21.94 $ 2.19 $ 48.71 $ 4.87 $ 67.51 $ 6.75 $ 47.84 $ 4.78 $ 28.00 $ 2.80 $ 17.65 $ 1.77 $ 15.04 $ 1.50 $ 44.65 $ 4.47 $ 17.65 $ 1.77 $ 69.14 $ 6.91 $ 29.38 $ 2.94 $ 47.56 $ 4.76 $ 83.58 $ 8.36 $ 92.23 $ 9.22 $ 98.09 $ 9.81 $ 46.63 $ 103.04 $ 188.93

$ 161.54 $ 16.15 $ 46.20 $ 4.62 $ 25.81 $ 2.58 $ 15.58 $ 1.56 $ 42.01 $ 4.20 $ 43.54 $ 4.35 $ 21.94 $ 2.19 $ 48.71 $ 4.87 $ 67.51 $ 6.75 $ 47.84 $ 4.78 $ 28.00 $ 2.80 $ 17.65 $ 1.77 $ 15.04 $ 1.50 $ 44.65 $ 4.47 $ 17.65 $ 1.77 $ 69.14 $ 6.91 $ 29.38 $ 2.94 $ 47.56 $ 4.76 $ 83.58 $ 8.36 $ 92.23 $ 9.22 $ 98.09 $ 9.81 $ 46.63 $ 103.04 $ 188.93

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

HCPCS Page 96

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

K0071-NU K0072-NU K0073-NU K0077-NU K0098-NU K0105-NU K0105-RR K0108-NU K0108-RR K0195-NU K0195-RR K0455-NU K0455-RR K0462-RR K0552-NU K0601-NU K0602-NU K0603-NU K0604-NU K0605-NU K0606 K0607 K0608 K0609 K0669-NU K0672-NU K0730 K0733-NU K0733-RR K0738-RR K0739 K0740 K0800-NU K0801-NU K0802-NU K0806-NU K0807-NU K0808-NU K0812-NU K0813-NU K0813-RR K0814-NU K0814-RR K0815-NU K0815-RR

Front castr compl pneum tire Frnt cstr cmpl sem-pneum tir Caster pin lock each Front caster assem complete Drive belt power wheelchair Iv hanger Iv hanger W/c component-accessory NOS W/c component-accessory NOS Elevating whlchair leg rests Elevating whlchair leg rests Pump uninterrupted infusion Pump uninterrupted infusion Temporary replacement eqpmnt Supply/ext inf pump syr type Repl batt silver oxide 1.5 v Repl batt silver oxide 3 v Repl batt alkaline 1.5 v Repl batt lithium 3.6 v Repl batt lithium 4.5 v AED garment w elec analysis Repl batt for AED Repl garment for AED Repl electrode for AED Seat/back cus no dmepdac ver Removable soft interface LE Ctrl dose inh drug deliv sys 12-24hr sealed lead acid 12-24hr sealed lead acid Portable gas oxygen system Repair/svc DME non-oxygen eq Repair/svc oxygen equipment POV group 1 std up to 300lbs POV group 1 hd 301-450 lbs POV group 1 vhd 451-600 lbs POV group 2 std up to 300lbs POV group 2 hd 301-450 lbs POV group 2 vhd 451-600 lbs Power operated vehicle NOC PWC gp 1 std port seat/back PWC gp 1 std port seat/back PWC gp 1 std port cap chair PWC gp 1 std port cap chair PWC gp 1 std seat/back PWC gp 1 std seat/back

$ 114.60 $ 63.74 $ 36.50 $ 61.73 $ 24.61 $ 104.30 $ 10.43 By Report By Report By Report By Report By Report By Report By Report $ 2.74 $ 1.16 $ 6.67 $ 0.60 $ 6.38 $ 15.31 Not Covered Not Covered Not Covered Not Covered By Report $ 80.74 Not Covered $ 27.31 $ 2.73 $ 51.63 By Report By Report $ 1168.79 $ 1884.33 $ 2132.46 $ 1413.92 $ 2145.46 $ 0.00 By Report By Report By Report By Report By Report By Report By Report

$ 114.60 $ 63.74 $ 36.50 $ 61.73 $ 24.61 $ 104.30 $ 10.43 By Report By Report By Report By Report By Report By Report By Report $ 2.74 $ 1.16 $ 6.67 $ 0.60 $ 6.38 $ 15.31 Not Covered Not Covered Not Covered Not Covered By Report $ 80.74 Not Covered $ 27.31 $ 2.73 $ 51.63 By Report By Report $ 1168.79 $ 1884.33 $ 2132.46 $ 1413.92 $ 2145.46 $ 0.00 By Report By Report By Report By Report By Report By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F N N N N N N N F F F F F F X X X X N F X F F F N N F F F F F F N N N N N N N

Y Y

Y

Y

Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 97

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

K0816-NU K0816-RR K0820-NU K0820-RR K0821-NU K0821-RR K0822-NU K0822-RR K0823-NU K0823-RR K0824-NU K0824-RR K0825-NU K0825-RR K0826-NU K0826-RR K0827-NU K0827-RR K0828-NU K0828-RR K0829-NU K0829-RR K0830-NU K0830-RR K0831-NU K0831-RR K0835-NU K0835-RR K0836-NU K0836-RR K0837-NU K0837-RR K0838-NU K0838-RR K0839-NU K0839-RR K0840-NU K0840-RR K0841-NU K0841-RR K0842-NU K0842-RR K0843-NU K0843-RR K0848-NU

PWC gp 1 std cap chair PWC gp 1 std cap chair PWC gp 2 std port seat/back PWC gp 2 std port seat/back PWC gp 2 std port cap chair PWC gp 2 std port cap chair PWC gp 2 std seat/back PWC gp 2 std seat/back PWC gp 2 std cap chair PWC gp 2 std cap chair PWC gp 2 hd seat/back PWC gp 2 hd seat/back PWC gp 2 hd cap chair PWC gp 2 hd cap chair PWC gp 2 vhd seat/back PWC gp 2 vhd seat/back PWC gp vhd cap chair PWC gp vhd cap chair PWC gp 2 xtra hd seat/back PWC gp 2 xtra hd seat/back PWC gp 2 xtra hd cap chair PWC gp 2 xtra hd cap chair PWC gp2 std seat elevate s/b PWC gp2 std seat elevate s/b PWC gp2 std seat elevate cap PWC gp2 std seat elevate cap PWC gp2 std sing pow opt s/b PWC gp2 std sing pow opt s/b PWC gp2 std sing pow opt cap PWC gp2 std sing pow opt cap PWC gp 2 hd sing pow opt s/b PWC gp 2 hd sing pow opt s/b PWC gp 2 hd sing pow opt cap PWC gp 2 hd sing pow opt cap PWC gp2 vhd sing pow opt s/b PWC gp2 vhd sing pow opt s/b PWC gp2 xhd sing pow opt s/b PWC gp2 xhd sing pow opt s/b PWC gp2 std mult pow opt s/b PWC gp2 std mult pow opt s/b PWC gp2 std mult pow opt cap PWC gp2 std mult pow opt cap PWC gp2 hd mult pow opt s/b PWC gp2 hd mult pow opt s/b PWC gp 3 std seat/back

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 98

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

K0848-RR K0849-NU K0849-RR K0850-NU K0850-RR K0851-NU K0851-RR K0852-NU K0852-RR K0853-NU K0853-RR K0854-NU K0854-RR K0855-NU K0855-RR K0856-NU K0856-RR K0857-NU K0857-RR K0858-NU K0858-RR K0859-NU K0859-RR K0860-NU K0860-RR K0861-NU K0861-RR K0862-NU K0862-RR K0863-NU K0863-RR K0864-NU K0864-RR K0868-NU K0868-RR K0869-NU K0869-RR K0870-NU K0870-RR K0871-NU K0871-RR K0877-NU K0877-RR K0878-NU K0878-RR

PWC gp 3 std seat/back PWC gp 3 std cap chair PWC gp 3 std cap chair PWC gp 3 hd seat/back PWC gp 3 hd seat/back PWC gp 3 hd cap chair PWC gp 3 hd cap chair PWC gp 3 vhd seat/back PWC gp 3 vhd seat/back PWC gp 3 vhd cap chair PWC gp 3 vhd cap chair PWC gp 3 xhd seat/back PWC gp 3 xhd seat/back PWC gp 3 xhd cap chair PWC gp 3 xhd cap chair PWC gp3 std sing pow opt s/b PWC gp3 std sing pow opt s/b PWC gp3 std sing pow opt cap PWC gp3 std sing pow opt cap PWC gp3 hd sing pow opt s/b PWC gp3 hd sing pow opt s/b PWC gp3 hd sing pow opt cap PWC gp3 hd sing pow opt cap PWC gp3 vhd sing pow opt s/b PWC gp3 vhd sing pow opt s/b PWC gp3 std mult pow opt s/b PWC gp3 std mult pow opt s/b PWC gp3 hd mult pow opt s/b PWC gp3 hd mult pow opt s/b PWC gp3 vhd mult pow opt s/b PWC gp3 vhd mult pow opt s/b PWC gp3 xhd mult pow opt s/b PWC gp3 xhd mult pow opt s/b PWC gp 4 std seat/back PWC gp 4 std seat/back PWC gp 4 std cap chair PWC gp 4 std cap chair PWC gp 4 hd seat/back PWC gp 4 hd seat/back PWC gp 4 vhd seat/back PWC gp 4 vhd seat/back PWC gp4 std sing pow opt s/b PWC gp4 std sing pow opt s/b PWC gp4 std sing pow opt cap PWC gp4 std sing pow opt cap

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 99

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

K0879-NU K0879-RR K0880-NU K0880-RR K0884-NU K0884-RR K0885-NU K0885-RR K0886-NU K0886-RR K0890 K0891 K0898-NU K0898-RR K0899-NU K0899-RR L0112 L0113 L0120 L0130 L0140 L0150 L0160 L0170 L0172 L0174 L0180 L0190 L0200 L0220 L0430 L0450 L0452 L0454 L0456 L0458 L0460 L0462 L0464 L0466 L0468 L0470 L0472 L0480 L0482

PWC gp4 hd sing pow opt s/b PWC gp4 hd sing pow opt s/b PWC gp4 vhd sing pow opt s/b PWC gp4 vhd sing pow opt s/b PWC gp4 std mult pow opt s/b PWC gp4 std mult pow opt s/b PWC gp4 std mult pow opt cap PWC gp4 std mult pow opt cap PWC gp4 hd mult pow s/b PWC gp4 hd mult pow s/b PWC gp5 ped sing pow opt s/b PWC gp5 ped mult pow opt s/b Power wheelchair NOC Power wheelchair NOC Pow mobil dev no dmepdac Pow mobil dev no dmepdac Cranial cervical orthosis Cranial cervical torticollis Cerv flexible non-adjustable Flex thermoplastic collar mo Cervical semi-rigid adjustab Cerv semi-rig adj molded chn Cerv semi-rig wire occ/mand Cervical collar molded to pt Cerv col thermplas foam 2 pi Cerv col foam 2 piece w thor Cer post col occ/man sup adj Cerv collar supp adj cerv ba Cerv col supp adj bar & thor Thor rib belt custom fabrica Dewall posture protector TLSO flex prefab thoracic tlso flex custom fab thoraci TLSO flex prefab sacrococ-T9 TLSO flex prefab TLSO 2Mod symphis-xipho pre TLSO2Mod symphysis-stern pre TLSO 3Mod sacro-scap pre TLSO 4Mod sacro-scap pre TLSO rigid frame pre soft ap TLSO rigid frame prefab pelv TLSO rigid frame pre subclav TLSO rigid frame hyperex pre TLSO rigid plastic custom fa TLSO rigid lined custom fab

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered By Report By Report By Report By Report $ 1482.83 By Report $ 35.90 $ 199.79 $ 86.63 $ 115.37 $ 158.96 $ 771.07 $ 139.16 $ 292.99 $ 427.19 $ 601.02 $ 671.11 $ 133.72 $ 1359.97 $ 232.96 By Report $ 367.44 $ 1053.72 $ 944.84 $ 1063.48 $ 1322.82 $ 1574.78 $ 478.85 $ 574.76 $ 689.87 $ 489.90 $ 1689.24 $ 1721.60

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered By Report By Report By Report By Report $ 1482.83 By Report $ 35.90 $ 199.79 $ 86.63 $ 115.37 $ 158.96 $ 771.07 $ 139.16 $ 292.99 $ 427.19 $ 601.02 $ 671.11 $ 133.72 $ 1359.97 $ 232.96 By Report $ 367.44 $ 1053.72 $ 944.84 $ 1063.48 $ 1322.82 $ 1574.78 $ 478.85 $ 574.76 $ 689.87 $ 489.90 $ 1689.24 $ 1721.60

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N N N N N N N X X N N N N F N F F F F F F F F F F F F F F N F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y

Y Y Y Y

Y

Y

Y Y Y Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 100

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L0484 L0486 L0488 L0490 L0491 L0492 L0621 L0622 L0623 L0624 L0625 L0626 L0627 L0628 L0629 L0630 L0631 L0632 L0633 L0634 L0635 L0636 L0637 L0638 L0639 L0640 L0700 L0710 L0810 L0820 L0830 L0859 L0861 L0970 L0972 L0974 L0976 L0978 L0980 L0982 L0984 L0999 L1000 L1001 L1005

TLSO rigid plastic cust fab TLSO rigidlined cust fab two TLSO rigid lined pre one pie TLSO rigid plastic pre one TLSO 2 piece rigid shell TLSO 3 piece rigid shell SIO flex pelvisacral prefab SIO flex pelvisacral custom SIO panel prefab SIO panel custom LO flexibl L1-below L5 pre LO sag stays/panels pre-fab LO sagitt rigid panel prefab LO flex w/o rigid stays pre LSO flex w/rigid stays cust LSO post rigid panel pre LSO sag-coro rigid frame pre LSO sag rigid frame cust LSO flexion control prefab LSO flexion control custom LSO sagit rigid panel prefab LSO sagittal rigid panel cus LSO sag-coronal panel prefab LSO sag-coronal panel custom LSO s/c shell/panel prefab LSO s/c shell/panel custom Ctlso a-p-l control molded Ctlso a-p-l control w/ inter Halo cervical into jckt vest Halo cervical into body jack Halo cerv into milwaukee typ MRI compatible system Halo repl liner/interface Tlso corset front Lso corset front Tlso full corset Lso full corset Axillary crutch extension Peroneal straps pair Stocking supp grips set of f Protective body sock each Add to spinal orthosis NOS Ctlso milwauke initial model CTLSO infant immobilizer Tension based scoliosis orth

$ 1803.70 $ 1913.63 $ 1063.48 $ 299.71 $ 813.66 $ 535.19 $ 122.65 $ 325.52 By Report By Report $ 58.34 $ 82.57 $ 435.49 $ 88.88 By Report $ 171.59 $ 1087.61 By Report $ 303.80 By Report $ 1119.52 $ 1459.68 $ 1190.78 $ 1397.30 $ 1190.78 $ 1108.61 $ 2051.93 $ 2317.62 $ 2790.59 $ 2740.57 $ 3844.03 $ 1236.44 $ 228.35 $ 116.00 $ 104.45 $ 188.02 $ 198.68 $ 208.26 $ 18.84 $ 17.59 $ 69.38 By Report $ 2467.96 Not Covered $ 3390.90

$ 1803.70 $ 1913.63 $ 1063.48 $ 299.71 $ 813.66 $ 535.19 $ 122.65 $ 325.52 By Report By Report $ 58.34 $ 82.57 $ 435.49 $ 88.88 By Report $ 171.59 $ 1087.61 By Report $ 303.80 By Report $ 1119.52 $ 1459.68 $ 1190.78 $ 1397.30 $ 1190.78 $ 1108.61 $ 2051.93 $ 2317.62 $ 2790.59 $ 2740.57 $ 3844.03 $ 1236.44 $ 228.35 $ 116.00 $ 104.45 $ 188.02 $ 198.68 $ 208.26 $ 18.84 $ 17.59 $ 69.38 By Report $ 2467.96 Not Covered $ 3390.90

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F N N F F F F N F F N F N F F F F F F F F F F F F F F F F F F F F F N F X F

Y Y

Y Y Y Y Y Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 101

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

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

Ctlso axilla sling Kyphosis pad Kyphosis pad floating Lumbar bolster pad Lumbar or lumbar rib pad Sternal pad Thoracic pad Trapezius sling Outrigger Outrigger bil w/ vert extens Lumbar sling Ring flange plastic/leather Ring flange plas/leather mol Covers for upright each Furnsh initial orthosis only Lateral thoracic extension Anterior thoracic extension Milwaukee type superstructur Lumbar derotation pad Anterior asis pad Anterior thoracic derotation Abdominal pad Rib gusset (elastic) each Lateral trochanteric pad Body jacket mold to patient Post-operative body jacket Spinal orthosis NOS Thkao mobility frame Thkao standing frame Thkao swivel walker Abduct hip flex frejka w cvr Abduct hip flex frejka covr Abduct hip flex pavlik harne Abduct control hip semi-flex Pelv band/spread bar thigh c HO abduction hip adjustable HO bi thighcuffs w sprdr bar HO abduction static plastic Pelvic & hip control thigh c Post-op hip abduct custom fa HO post-op hip abduction Combination bilateral HO Leg perthes orth toronto typ Legg perthes orth newington Legg perthes orthosis trilat

$ 70.66 $ 103.57 $ 126.56 $ 66.34 $ 97.94 $ 104.02 $ 114.37 $ 103.37 $ 63.90 $ 166.80 $ 100.88 $ 183.32 $ 303.36 $ 49.88 $ 2120.34 $ 265.57 $ 275.08 $ 576.95 $ 84.24 $ 77.05 $ 81.32 $ 78.64 $ 91.09 $ 81.49 $ 1714.55 $ 1920.42 By Report $ 2251.92 $ 1434.52 $ 2800.38 $ 130.79 $ 44.56 $ 143.27 $ 185.76 $ 489.92 $ 234.98 $ 377.65 $ 188.23 $ 1648.85 $ 1207.26 $ 938.82 $ 2048.70 $ 1666.96 $ 2016.84 $ 1406.94

$ 70.66 $ 103.57 $ 126.56 $ 66.34 $ 97.94 $ 104.02 $ 114.37 $ 103.37 $ 63.90 $ 166.80 $ 100.88 $ 183.32 $ 303.36 $ 49.88 $ 2120.34 $ 265.57 $ 275.08 $ 576.95 $ 84.24 $ 77.05 $ 81.32 $ 78.64 $ 91.09 $ 81.49 $ 1714.55 $ 1920.42 By Report $ 2251.92 $ 1434.52 $ 2800.38 $ 130.79 $ 44.56 $ 143.27 $ 185.76 $ 489.92 $ 234.98 $ 377.65 $ 188.23 $ 1648.85 $ 1207.26 $ 938.82 $ 2048.70 $ 1666.96 $ 2016.84 $ 1406.94

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F N F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y

Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 102

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L1730 L1755 L1810 L1820 L1830 L1831 L1832 L1834 L1836 L1840 L1843 L1844 L1845 L1846 L1847 L1850 L1860 L1900 L1902 L1904 L1906 L1907 L1910 L1920 L1930 L1932 L1940 L1945 L1950 L1951 L1960 L1970 L1971 L1980 L1990 L2000 L2005 L2010 L2020 L2030 L2034 L2035 L2036 L2037 L2038

Legg perthes orth scottish r Legg perthes patten bottom t Ko elastic with joints Ko elas w/ condyle pads & jo Ko immobilizer canvas longit Knee orth pos locking joint KO adj jnt pos rigid support Ko w/0 joint rigid molded to Rigid KO wo joints Ko derot ant cruciate custom KO single upright custom fit Ko w/adj jt rot cntrl molded Ko w/ adj flex/ext rotat cus Ko w adj flex/ext rotat mold KO adjustable w air chambers Ko swedish type Ko supracondylar socket mold Afo sprng wir drsflx calf bd Afo ankle gauntlet Afo molded ankle gauntlet Afo multiligamentus ankle su AFO supramalleolar custom Afo sing bar clasp attach sh Afo sing upright w/ adjust s Afo plastic Afo rig ant tib prefab TCF/= Afo molded to patient plasti Afo molded plas rig ant tib Afo spiral molded to pt plas AFO spiral prefabricated Afo pos solid ank plastic mo Afo plastic molded w/ankle j AFO w/ankle joint, prefab Afo sing solid stirrup calf Afo doub solid stirrup calf Kafo sing fre stirr thi/calf KAFO sng/dbl mechanical act Kafo sng solid stirrup w/o j Kafo dbl solid stirrup band/ Kafo dbl solid stirrup w/o j KAFO pla sin up w/wo k/a cus KAFO plastic pediatric size Kafo plas doub free knee mol Kafo plas sing free knee mol Kafo w/o joint multi-axis an

$ 1200.41 $ 1606.91 $ 115.72 $ 146.41 $ 113.48 $ 311.81 $ 617.06 $ 787.87 $ 141.36 $ 1079.52 $ 950.60 $ 2135.38 $ 861.54 $ 1297.64 $ 609.36 $ 326.23 $ 1331.58 $ 301.86 $ 99.35 $ 477.28 $ 122.05 $ 596.14 $ 343.32 $ 454.79 $ 280.42 $ 945.41 $ 539.21 $ 1060.19 $ 1007.98 $ 889.76 $ 562.57 $ 750.76 $ 496.60 $ 476.39 $ 575.65 $ 1372.61 $ 4341.32 $ 1239.07 $ 1580.15 $ 1360.84 $ 2148.40 $ 190.64 $ 2429.26 $ 2004.11 $ 1688.26

$ 1200.41 $ 1606.91 $ 115.72 $ 146.41 $ 113.48 $ 311.81 $ 617.06 $ 787.87 $ 141.36 $ 1079.52 $ 950.60 $ 2135.38 $ 861.54 $ 1297.64 $ 609.36 $ 326.23 $ 1331.58 $ 301.86 $ 99.35 $ 477.28 $ 122.05 $ 596.14 $ 343.32 $ 454.79 $ 280.42 $ 945.41 $ 539.21 $ 1060.19 $ 1007.98 $ 889.76 $ 562.57 $ 750.76 $ 496.60 $ 476.39 $ 575.65 $ 1372.61 $ 4341.32 $ 1239.07 $ 1580.15 $ 1360.84 $ 2148.40 $ 190.64 $ 2429.26 $ 2004.11 $ 1688.26

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y

Y Y

Y

Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 103

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L2040 L2050 L2060 L2070 L2080 L2090 L2106 L2108 L2112 L2114 L2116 L2126 L2128 L2132 L2134 L2136 L2180 L2182 L2184 L2186 L2188 L2190 L2192 L2200 L2210 L2220 L2230 L2232 L2240 L2250 L2260 L2265 L2270 L2275 L2280 L2300 L2310 L2320 L2330 L2335 L2340 L2350 L2360 L2370 L2375

Hkafo torsion bil rot straps Hkafo torsion cable hip pelv Hkafo torsion ball bearing j Hkafo torsion unilat rot str Hkafo unilat torsion cable Hkafo unilat torsion ball br Afo tib fx cast plaster mold Afo tib fx cast molded to pt Afo tibial fracture soft Afo tib fx semi-rigid Afo tibial fracture rigid Kafo fem fx cast thermoplas Kafo fem fx cast molded to p Kafo femoral fx cast soft Kafo fem fx cast semi-rigid Kafo femoral fx cast rigid Plas shoe insert w ank joint Drop lock knee Limited motion knee joint Adj motion knee jnt lerman t Quadrilateral brim Waist belt Pelvic band & belt thigh fla Limited ankle motion ea jnt Dorsiflexion assist each joi Dorsi & plantar flex ass/res Split flat caliper stirr & p Rocker bottom, contact AFO Round caliper and plate atta Foot plate molded stirrup at Reinforced solid stirrup Long tongue stirrup Varus/valgus strap padded/li Plastic mod low ext pad/line Molded inner boot Abduction bar jointed adjust Abduction bar-straight Non-molded lacer Lacer molded to patient mode Anterior swing band Pre-tibial shell molded to p Prosthetic type socket molde Extended steel shank Patten bottom Torsion ank & half solid sti

$ 231.90 $ 490.34 $ 694.25 $ 136.49 $ 420.84 $ 593.40 $ 711.30 $ 1216.27 $ 490.96 $ 602.46 $ 722.54 $ 1215.36 $ 2320.49 $ 818.74 $ 1026.54 $ 1200.29 $ 118.86 $ 109.37 $ 125.72 $ 175.92 $ 329.36 $ 88.63 $ 361.88 $ 64.34 $ 71.51 $ 98.23 $ 95.62 $ 105.43 $ 85.68 $ 480.86 $ 203.46 $ 119.53 $ 72.67 $ 158.75 $ 460.27 $ 340.72 $ 166.48 $ 266.77 $ 471.49 $ 252.43 $ 560.15 $ 1020.29 $ 70.02 $ 278.41 $ 114.68

$ 231.90 $ 490.34 $ 694.25 $ 136.49 $ 420.84 $ 593.40 $ 711.30 $ 1216.27 $ 490.96 $ 602.46 $ 722.54 $ 1215.36 $ 2320.49 $ 818.74 $ 1026.54 $ 1200.29 $ 118.86 $ 109.37 $ 125.72 $ 175.92 $ 329.36 $ 88.63 $ 361.88 $ 64.34 $ 71.51 $ 98.23 $ 95.62 $ 105.43 $ 85.68 $ 480.86 $ 203.46 $ 119.53 $ 72.67 $ 158.75 $ 460.27 $ 340.72 $ 166.48 $ 266.77 $ 471.49 $ 252.43 $ 560.15 $ 1020.29 $ 70.02 $ 278.41 $ 114.68

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y

Y Y

Y

Y Y Y

Refer to Field Key for definitions

HCPCS Page 104

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L2380 L2385 L2387 L2390 L2395 L2397 L2405 L2415 L2425 L2430 L2492 L2500 L2510 L2520 L2525 L2526 L2530 L2540 L2550 L2570 L2580 L2600 L2610 L2620 L2622 L2624 L2627 L2628 L2630 L2640 L2650 L2660 L2670 L2680 L2750 L2755 L2760 L2768 L2780 L2785 L2795 L2800 L2810 L2820 L2830

Torsion straight knee joint Straight knee joint heavy du Add LE poly knee custom KAFO Offset knee joint each Offset knee joint heavy duty Suspension sleeve lower ext Knee joint drop lock ea jnt Knee joint cam lock each joi Knee disc/dial lock/adj flex Knee jnt ratchet lock ea jnt Knee lift loop drop lock rin Thi/glut/ischia wgt bearing Th/wght bear quad-lat brim m Th/wght bear quad-lat brim c Th/wght bear nar m-l brim mo Th/wght bear nar m-l brim cu Thigh/wght bear lacer non-mo Thigh/wght bear lacer molded Thigh/wght bear high roll cu Hip clevis type 2 posit jnt Pelvic control pelvic sling Hip clevis/thrust bearing fr Hip clevis/thrust bearing lo Pelvic control hip heavy dut Hip joint adjustable flexion Hip adj flex ext abduct cont Plastic mold recipro hip & c Metal frame recipro hip & ca Pelvic control band & belt u Pelvic control band & belt b Pelv & thor control gluteal Thoracic control thoracic ba Thorac cont paraspinal uprig Thorac cont lat support upri Plating chrome/nickel pr bar Carbon graphite lamination Extension per extension per Ortho sidebar disconnect Non-corrosive finish Drop lock retainer each Knee control full kneecap Knee cap medial or lateral p Knee control condylar pad Soft interface below knee se Soft interface above knee se

$ 127.21 $ 135.95 $ 206.11 $ 111.11 $ 158.80 $ 134.14 $ 92.36 $ 128.66 $ 151.86 $ 151.86 $ 107.32 $ 343.78 $ 838.63 $ 494.08 $ 1317.02 $ 926.92 $ 249.00 $ 541.25 $ 318.05 $ 498.01 $ 556.70 $ 241.44 $ 290.99 $ 319.21 $ 311.24 $ 336.10 $ 1739.93 $ 2267.26 $ 265.49 $ 413.76 $ 162.40 $ 189.17 $ 178.99 $ 158.83 $ 99.67 $ 138.44 $ 62.98 $ 138.02 $ 91.58 $ 35.51 $ 106.91 $ 124.10 $ 79.27 $ 88.14 $ 95.35

$ 127.21 $ 135.95 $ 206.11 $ 111.11 $ 158.80 $ 134.14 $ 92.36 $ 128.66 $ 151.86 $ 151.86 $ 107.32 $ 343.78 $ 838.63 $ 494.08 $ 1317.02 $ 926.92 $ 249.00 $ 541.25 $ 318.05 $ 498.01 $ 556.70 $ 241.44 $ 290.99 $ 319.21 $ 311.24 $ 336.10 $ 1739.93 $ 2267.26 $ 265.49 $ 413.76 $ 162.40 $ 189.17 $ 178.99 $ 158.83 $ 99.67 $ 138.44 $ 62.98 $ 138.02 $ 91.58 $ 35.51 $ 106.91 $ 124.10 $ 79.27 $ 88.14 $ 95.35

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y

Y

Y

Y Y Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 105

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L2840 L2850 L2861 L2999 L3000 L3001 L3002 L3003 L3010 L3020 L3030 L3031 L3040 L3050 L3060 L3070 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L3224 L3225 L3230 L3250

Tibial length sock fx or equ Femoral lgth sock fx or equa Torsion mechanism knee/ankle Lower extremity orthosis NOS Ft insert ucb berkeley shell Foot insert remov molded spe Foot insert plastazote or eq Foot insert silicone gel eac Foot longitudinal arch suppo Foot longitud/metatarsal sup Foot arch support remov prem Foot lamin/prepreg composite Ft arch suprt premold longit Foot arch supp premold metat Foot arch supp longitud/meta Arch suprt att to sho longit Arch supp att to shoe metata Arch supp att to shoe long/m Hallus-valgus nght dynamic s Abduction rotation bar shoe Abduct rotation bar w/o shoe Shoe styled positioning dev Foot plastic heel stabilizer Oxford w supinat/pronat inf Oxford w/ supinat/pronator c Oxford w/ supinator/pronator Hightop w/ supp/pronator inf Hightop w/ supp/pronator chi Hightop w/ supp/pronator jun Surgical boot each infant Surgical boot each child Surgical boot each junior Benesch boot pair infant Benesch boot pair child Benesch boot pair junior Orthopedic ftwear ladies oxf Orthoped ladies shoes dpth i Ladies shoes hightop depth i Orthopedic mens shoes oxford Orthopedic mens shoes dpth i Mens shoes hightop depth inl Woman's shoe oxford brace Man's shoe oxford brace Custom shoes depth inlay Custom mold shoe remov prost

$ 44.34 $ 62.84 By Report By Report $ 332.80 $ 140.12 $ 171.11 $ 184.62 $ 184.62 $ 210.20 $ 80.86 By Report $ 49.85 $ 49.85 $ 78.14 $ 33.65 $ 33.65 $ 43.13 $ 45.80 $ 94.33 $ 86.24 $ 19.74 $ 53.93 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 138.16 $ 167.11 $ 181.25 $ 155.26 $ 186.18 $ 205.60 $ 59.69 $ 68.65 $ 242.11 $ 471.05

$ 44.34 $ 62.84 By Report By Report $ 332.80 $ 140.12 $ 171.11 $ 184.62 $ 184.62 $ 210.20 $ 80.86 By Report $ 49.85 $ 49.85 $ 78.14 $ 33.65 $ 33.65 $ 43.13 $ 45.80 $ 94.33 $ 86.24 $ 19.74 $ 53.93 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 138.16 $ 167.11 $ 181.25 $ 155.26 $ 186.18 $ 205.60 $ 59.69 $ 68.65 $ 242.11 $ 471.05

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F N N F F F F F F F N F F F F F F F F F F F X X X X X X X X X X X X F F F F F F F F F F

Y Y

Refer to Field Key for definitions

HCPCS Page 106

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L3251 L3252 L3253 L3254 L3255 L3257 L3260 L3265 L3300 L3310 L3320 L3330 L3332 L3334 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 L3600 L3610

Shoe molded to pt silicone s Shoe molded plastazote cust Shoe molded plastazote cust Orth foot non-stndard size/w Orth foot non-standard size/ Orth foot add charge split s Ambulatory surgical boot eac Plastazote sandal each Sho lift taper to metatarsal Shoe lift elev heel/sole neo Shoe lift elev heel/sole cor Lifts elevation metal extens Shoe lifts tapered to one-ha Shoe lifts elevation heel /i Shoe wedge sach Shoe heel wedge Shoe sole wedge outside sole Shoe sole wedge between sole Shoe clubfoot wedge Shoe outflare wedge Shoe metatarsal bar wedge ro Shoe metatarsal bar between Full sole/heel wedge btween Sho heel count plast reinfor Heel leather reinforced Shoe heel sach cushion type Shoe heel new leather standa Shoe heel new rubber standar Shoe heel thomas with wedge Shoe heel thomas extend to b Shoe heel pad & depress for Shoe heel pad removable for Ortho shoe add leather insol Orthopedic shoe add rub insl O shoe add felt w leath insl Ortho shoe add half sole Ortho shoe add full sole O shoe add standard toe tap O shoe add horseshoe toe tap O shoe add instep extension O shoe add instep velcro clo O shoe convert to sof counte Ortho shoe add march bar Trans shoe calip plate exist Trans shoe caliper plate new

$ 64.80 $ 257.90 $ 64.47 By Report By Report $ 46.71 $ 26.32 $ 28.62 $ 55.22 $ 86.24 $ 174.34 $ 599.59 $ 78.14 $ 40.43 $ 90.29 $ 24.26 $ 37.73 $ 52.52 $ 52.52 $ 52.52 $ 43.13 $ 98.35 $ 57.94 $ 169.78 $ 80.86 $ 111.84 $ 43.13 $ 36.36 $ 61.99 $ 66.01 $ 66.01 $ 26.32 $ 30.98 $ 30.98 $ 33.65 $ 33.65 $ 53.93 $ 9.41 $ 24.26 $ 90.29 $ 68.71 $ 56.58 $ 44.46 $ 80.86 $ 106.43

$ 64.80 $ 257.90 $ 64.47 By Report By Report $ 46.71 $ 26.32 $ 28.62 $ 55.22 $ 86.24 $ 174.34 $ 599.59 $ 78.14 $ 40.43 $ 90.29 $ 24.26 $ 37.73 $ 52.52 $ 52.52 $ 52.52 $ 43.13 $ 98.35 $ 57.94 $ 169.78 $ 80.86 $ 111.84 $ 43.13 $ 36.36 $ 61.99 $ 66.01 $ 66.01 $ 26.32 $ 30.98 $ 30.98 $ 33.65 $ 33.65 $ 53.93 $ 9.41 $ 24.26 $ 90.29 $ 68.71 $ 56.58 $ 44.46 $ 80.86 $ 106.43

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F N N F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

HCPCS Page 107

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L3620 L3630 L3640 L3649 L3650 L3660 L3670 L3671 L3674 L3675 L3677 L3702 L3710 L3720 L3730 L3740 L3760 L3762 L3763 L3764 L3765 L3766 L3806 L3807 L3808 L3891 L3900 L3901 L3904 L3905 L3906 L3908 L3912 L3913 L3915 L3917 L3919 L3921 L3923 L3925 L3927 L3929 L3931 L3933 L3935

Trans shoe solid stirrup exi Trans shoe solid stirrup new Shoe dennis browne splint bo Orthopedic shoe modifica NOS Shlder fig 8 abduct restrain Abduct restrainer canvas&web Acromio/clavicular canvas&we SO cap design w/o jnts CF SO airplane w/wo joint CF Canvas vest SO SO hard plastic stabilizer EO w/o joints CF Elbow elastic with metal joi Forearm/arm cuffs free motio Forearm/arm cuffs ext/flex a Cuffs adj lock w/ active con EO withjoint, Prefabricated Rigid EO wo joints EWHO rigid w/o jnts CF EWHO w/joint(s) CF EWHFO rigid w/o jnts CF EWHFO w/joint(s) CF WHFO w/joint(s) custom fab WHFO,no joint, prefabricated WHFO, rigid w/o joints Torsion mechanism wrist/elbo Hinge extension/flex wrist/f Hinge ext/flex wrist finger Whfo electric custom fitted WHO w/nontorsion jnt(s) CF WHO w/o joints CF Wrist cock-up non-molded Flex glove w/elastic finger HFO w/o joints CF WHO w nontor jnt(s) prefab Prefab metacarpl fx orthosis HO w/o joints CF HFO w/joint(s) CF HFO w/o joints PF FO pip/dip with joint/spring FO pip/dip w/o joint/spring HFO nontorsion joint, prefab WHFO nontorsion joint prefab FO w/o joints CF FO nontorsion joint CF

$ 80.86 $ 106.43 $ 45.80 By Report $ 62.77 $ 112.04 $ 123.28 $ 868.82 $ 1139.72 $ 169.97 $ 190.79 $ 278.41 $ 122.77 $ 775.93 $ 1043.92 $ 1065.66 $ 482.18 $ 103.68 $ 712.84 $ 800.39 $ 1236.32 $ 1309.18 $ 437.98 $ 241.10 $ 347.44 By Report $ 1446.38 $ 1788.18 $ 2908.48 $ 956.21 $ 411.60 $ 79.34 $ 125.58 $ 261.14 $ 512.52 $ 101.87 $ 261.14 $ 309.72 $ 94.94 $ 61.64 By Report $ 94.07 $ 185.76 $ 205.73 $ 213.00

$ 80.86 $ 106.43 $ 45.80 By Report $ 62.77 $ 112.04 $ 123.28 $ 868.82 $ 1139.72 $ 169.97 $ 190.79 $ 278.41 $ 122.77 $ 775.93 $ 1043.92 $ 1065.66 $ 482.18 $ 103.68 $ 712.84 $ 800.39 $ 1236.32 $ 1309.18 $ 437.98 $ 241.10 $ 347.44 By Report $ 1446.38 $ 1788.18 $ 2908.48 $ 956.21 $ 411.60 $ 79.34 $ 125.58 $ 261.14 $ 512.52 $ 101.87 $ 261.14 $ 309.72 $ 94.94 $ 61.64 By Report $ 94.07 $ 185.76 $ 205.73 $ 213.00

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F N F F F F F F F F F F F F F F F F F F F F F N F F F F F F F F F F F F F F N F F F F

Y Y

Y Y

Y Y Y Y Y Y Y Y Y Y Y Y

Y

Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 108

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L3956 L3960 L3961 L3962 L3964 L3965 L3966 L3967 L3968 L3969 L3970 L3971 L3972 L3973 L3974 L3975 L3976 L3977 L3978 L3980 L3982 L3984 L3995 L3999 L4000 L4002 L4010 L4020 L4030 L4040 L4045 L4050 L4055 L4060 L4070 L4080 L4090 L4100 L4110 L4130 L4205 L4210 L4350 L4360 L4370

Add joint upper ext orthosis Sewho airplan desig abdu pos SEWHO cap design w/o jnts CF Sewho erbs palsey design abd Seo mobile arm sup att to wc Arm supp att to wc rancho ty Mobile arm supports reclinin SEWHO airplane w/o jnts CF Friction dampening arm supp Monosuspension arm/hand supp Elevat proximal arm support SEWHO cap design w/jnt(s) CF Offset/lat rocker arm w/ ela SEWHO airplane w/jnt(s) CF Mobile arm support supinator SEWHFO cap design w/o jnt CF SEWHFO airplane w/o jnts CF SEWHFO cap desgn w/jnt(s) CF SEWHFO airplane w/jnt(s) CF Upp ext fx orthosis humeral Upper ext fx orthosis rad/ul Upper ext fx orthosis wrist Sock fracture or equal each Upper limb orthosis NOS Repl girdle milwaukee orth Replace strap, any orthosis Replace trilateral socket br Replace quadlat socket brim Replace socket brim cust fit Replace molded thigh lacer Replace non-molded thigh lac Replace molded calf lacer Replace non-molded calf lace Replace high roll cuff Replace prox & dist upright Repl met band kafo-afo prox Repl met band kafo-afo calf/ Repl leath cuff kafo prox th Repl leath cuff kafo-afo cal Replace pretibial shell Ortho dvc repair per 15 min Orth dev repair/repl minor p Ankle control orthosi prefab Pneumati walking boot prefab Pneumatic full leg splint

By Report $ 820.74 $ 1619.95 $ 886.93 $ 781.82 $ 1247.56 $ 906.56 $ 1912.62 $ 1189.33 $ 831.71 $ 305.23 $ 1815.53 $ 179.82 $ 1912.62 $ 179.44 $ 1619.95 $ 1619.95 $ 1815.53 $ 1912.62 $ 307.04 $ 370.76 $ 356.78 $ 36.05 By Report $ 1470.19 By Report $ 812.33 $ 972.56 $ 670.63 $ 552.40 $ 335.84 $ 504.84 $ 275.24 $ 410.11 $ 338.09 $ 121.58 $ 122.10 $ 141.14 $ 114.76 $ 671.40 By Report By Report $ 99.92 $ 374.70 $ 255.48

By Report $ 820.74 $ 1619.95 $ 886.93 $ 781.82 $ 1247.56 $ 906.56 $ 1912.62 $ 1189.33 $ 831.71 $ 305.23 $ 1815.53 $ 179.82 $ 1912.62 $ 179.44 $ 1619.95 $ 1619.95 $ 1815.53 $ 1912.62 $ 307.04 $ 370.76 $ 356.78 $ 36.05 By Report $ 1470.19 By Report $ 812.33 $ 972.56 $ 670.63 $ 552.40 $ 335.84 $ 504.84 $ 275.24 $ 410.11 $ 338.09 $ 121.58 $ 122.10 $ 141.14 $ 114.76 $ 671.40 By Report By Report $ 99.92 $ 374.70 $ 255.48

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N F F F F F F F F F F F F F F F F F F F F F F N F N F F F F F F F F F F F F F F N N F F F

Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 109

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L4380 L4386 L4392 L4394 L4396 L4398 L4631 L5000 L5010 L5020 L5050 L5060 L5100 L5105 L5150 L5160 L5200 L5210 L5220 L5230 L5250 L5270 L5280 L5301 L5311 L5321 L5331 L5341 L5400 L5410 L5420 L5430 L5450 L5460 L5500 L5505 L5510 L5520 L5530 L5535 L5540 L5560 L5570 L5580 L5585

Pneumatic knee splint Non-pneum walk boot prefab Replace AFO soft interface Replace foot drop spint Static AFO Foot drop splint recumbent Afo, walk boot type, cus fab Sho insert w arch toe filler Mold socket ank hgt w/ toe f Tibial tubercle hgt w/ toe f Ank symes mold sckt sach ft Symes met fr leath socket ar Molded socket shin sach foot Plast socket jts/thgh lacer Mold sckt ext knee shin sach Mold socket bent knee shin s Kne sing axis fric shin sach No knee/ankle joints w/ ft b No knee joint with artic ali Fem focal defic constant fri Hip canad sing axi cons fric Tilt table locking hip sing Hemipelvect canad sing axis BK mold socket SACH ft endo Knee disart, SACH ft, endo AK open end SACH Hip disart canadian SACH ft Hemipelvectomy canadian SACH Postop dress & 1 cast chg bk Postop dsg bk ea add cast ch Postop dsg & 1 cast chg ak/d Postop dsg ak ea add cast ch Postop app non-wgt bear dsg Postop app non-wgt bear dsg Init bk ptb plaster direct Init ak ischal plstr direct Prep BK ptb plaster molded Perp BK ptb thermopls direct Prep BK ptb thermopls molded Prep BK ptb open end socket Prep BK ptb laminated socket Prep AK ischial plast molded Prep AK ischial direct form Prep AK ischial thermo mold Prep AK ischial open end

$ 139.81 $ 167.98 $ 24.52 $ 17.87 $ 174.82 $ 80.48 $ 1620.72 $ 569.10 $ 1371.28 $ 2543.05 $ 3036.24 $ 4029.00 $ 3147.09 $ 4441.59 $ 4592.56 $ 5603.06 $ 4588.18 $ 3644.26 $ 4142.38 $ 5540.16 $ 7209.41 $ 7723.96 $ 7646.72 $ 3155.58 $ 4953.73 $ 4874.84 $ 6916.82 $ 7219.29 $ 1506.28 $ 579.01 $ 1819.36 $ 567.90 $ 496.96 $ 658.01 $ 1446.61 $ 1959.10 $ 1776.89 $ 1619.76 $ 2260.40 $ 2334.81 $ 2492.11 $ 2434.68 $ 2560.80 $ 2933.58 $ 3251.39

$ 139.81 $ 167.98 $ 24.52 $ 17.87 $ 174.82 $ 80.48 $ 1620.72 $ 569.10 $ 1371.28 $ 2543.05 $ 3036.24 $ 4029.00 $ 3147.09 $ 4441.59 $ 4592.56 $ 5603.06 $ 4588.18 $ 3644.26 $ 4142.38 $ 5540.16 $ 7209.41 $ 7723.96 $ 7646.72 $ 3155.58 $ 4953.73 $ 4874.84 $ 6916.82 $ 7219.29 $ 1506.28 $ 579.01 $ 1819.36 $ 567.90 $ 496.96 $ 658.01 $ 1446.61 $ 1959.10 $ 1776.89 $ 1619.76 $ 2260.40 $ 2334.81 $ 2492.11 $ 2434.68 $ 2560.80 $ 2933.58 $ 3251.39

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 110

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L5590 L5595 L5600 L5610 L5611 L5613 L5614 L5616 L5617 L5618 L5620 L5622 L5624 L5626 L5628 L5629 L5630 L5631 L5632 L5634 L5636 L5637 L5638 L5639 L5640 L5642 L5643 L5644 L5645 L5646 L5647 L5648 L5649 L5650 L5651 L5652 L5653 L5654 L5655 L5656 L5658 L5661 L5665 L5666 L5668

Prep AK ischial laminated Hip disartic sach thermopls Hip disart sach laminat mold Above knee hydracadence Ak 4 bar link w/fric swing Ak 4 bar ling w/hydraul swig 4-bar link above knee w/swng Ak univ multiplex sys frict AK/BK self-aligning unit ea Test socket symes Test socket below knee Test socket knee disarticula Test socket above knee Test socket hip disarticulat Test socket hemipelvectomy Below knee acrylic socket Syme typ expandabl wall sckt Ak/knee disartic acrylic soc Symes type ptb brim design s Symes type poster opening so Symes type medial opening so Below knee total contact Below knee leather socket Below knee wood socket Knee disarticulat leather so Above knee leather socket Hip flex inner socket ext fr Above knee wood socket Bk flex inner socket ext fra Below knee cushion socket Below knee suction socket Above knee cushion socket Isch containmt/narrow m-l so Tot contact ak/knee disart s Ak flex inner socket ext fra Suction susp ak/knee disart Knee disart expand wall sock Socket insert symes Socket insert below knee Socket insert knee articulat Socket insert above knee Multi-durometer symes Multi-durometer below knee Below knee cuff suspension Socket insert w/o lock lower

$ 2846.46 $ 5084.62 $ 6408.81 $ 2991.79 $ 1987.21 $ 2760.36 $ 1865.89 $ 1529.78 $ 618.66 $ 351.85 $ 334.11 $ 471.21 $ 424.24 $ 615.91 $ 681.00 $ 357.95 $ 570.44 $ 494.90 $ 333.46 $ 397.26 $ 354.06 $ 335.34 $ 621.39 $ 1423.34 $ 942.68 $ 930.48 $ 2012.52 $ 742.80 $ 898.71 $ 660.64 $ 895.98 $ 741.56 $ 2266.85 $ 646.40 $ 1352.66 $ 491.06 $ 805.68 $ 436.38 $ 391.01 $ 557.10 $ 546.05 $ 685.44 $ 576.72 $ 80.01 $ 126.38

$ 2846.46 $ 5084.62 $ 6408.81 $ 2991.79 $ 1987.21 $ 2760.36 $ 1865.89 $ 1529.78 $ 618.66 $ 351.85 $ 334.11 $ 471.21 $ 424.24 $ 615.91 $ 681.00 $ 357.95 $ 570.44 $ 494.90 $ 333.46 $ 397.26 $ 354.06 $ 335.34 $ 621.39 $ 1423.34 $ 942.68 $ 930.48 $ 2012.52 $ 742.80 $ 898.71 $ 660.64 $ 895.98 $ 741.56 $ 2266.85 $ 646.40 $ 1352.66 $ 491.06 $ 805.68 $ 436.38 $ 391.01 $ 557.10 $ 546.05 $ 685.44 $ 576.72 $ 80.01 $ 126.38

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 111

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L5670 L5671 L5672 L5673 L5676 L5677 L5678 L5679 L5680 L5681 L5682 L5683 L5684 L5685 L5686 L5688 L5690 L5692 L5694 L5695 L5696 L5697 L5698 L5699 L5700 L5701 L5702 L5703 L5704 L5705 L5706 L5707 L5710 L5711 L5712 L5714 L5716 L5718 L5722 L5724 L5726 L5728 L5780 L5781 L5782

Bk molded supracondylar susp BK/AK locking mechanism Bk removable medial brim sus Socket insert w lock mech Bk knee joints single axis p Bk knee joints polycentric p Bk joint covers pair Socket insert w/o lock mech Bk thigh lacer non-molded Intl custm cong/latyp insert Bk thigh lacer glut/ischia m Initial custom socket insert Bk fork strap Below knee sus/seal sleeve Bk back check Bk waist belt webbing Bk waist belt padded and lin Ak pelvic control belt light Ak pelvic control belt pad/l Ak sleeve susp neoprene/equa Ak/knee disartic pelvic join Ak/knee disartic pelvic band Ak/knee disartic silesian ba Shoulder harness Replace socket below knee Replace socket above knee Replace socket hip Symes ankle w/o (SACH) foot Custom shape cover BK Custom shape cover AK Custom shape cvr knee disart Custom shape cvr hip disart Kne-shin exo sng axi mnl loc Knee-shin exo mnl lock ultra Knee-shin exo frict swg & st Knee-shin exo variable frict Knee-shin exo mech stance ph Knee-shin exo frct swg & sta Knee-shin pneum swg frct exo Knee-shin exo fluid swing ph Knee-shin ext jnts fld swg e Knee-shin fluid swg & stance Knee-shin pneum/hydra pneum Lower limb pros vacuum pump HD low limb pros vacuum pump

$ 333.60 $ 747.01 $ 363.46 $ 806.82 $ 475.48 $ 605.29 $ 53.30 $ 672.35 $ 399.35 $ 1454.48 $ 712.16 $ 1454.48 $ 72.29 $ 141.62 $ 71.80 $ 78.61 $ 119.54 $ 175.65 $ 271.39 $ 183.69 $ 277.86 $ 120.56 $ 140.85 $ 276.88 $ 4112.79 $ 4997.90 $ 5984.54 $ 2759.92 $ 686.86 $ 1127.61 $ 1117.61 $ 1588.74 $ 512.50 $ 693.80 $ 622.85 $ 471.12 $ 820.94 $ 1026.09 $ 1194.71 $ 1809.06 $ 2189.38 $ 2913.76 $ 1289.58 $ 4424.26 $ 4664.18

$ 333.60 $ 747.01 $ 363.46 $ 806.82 $ 475.48 $ 605.29 $ 53.30 $ 672.35 $ 399.35 $ 1454.48 $ 712.16 $ 1454.48 $ 72.29 $ 141.62 $ 71.80 $ 78.61 $ 119.54 $ 175.65 $ 271.39 $ 183.69 $ 277.86 $ 120.56 $ 140.85 $ 276.88 $ 4112.79 $ 4997.90 $ 5984.54 $ 2759.92 $ 686.86 $ 1127.61 $ 1117.61 $ 1588.74 $ 512.50 $ 693.80 $ 622.85 $ 471.12 $ 820.94 $ 1026.09 $ 1194.71 $ 1809.06 $ 2189.38 $ 2913.76 $ 1289.58 $ 4424.26 $ 4664.18

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 112

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L5785 L5790 L5795 L5810 L5811 L5812 L5814 L5816 L5818 L5822 L5824 L5826 L5828 L5830 L5840 L5845 L5848 L5850 L5855 L5856 L5857 L5858 L5910 L5920 L5925 L5930 L5940 L5950 L5960 L5961 L5962 L5964 L5966 L5968 L5970 L5971 L5972 L5973 L5974 L5975 L5976 L5978 L5979 L5980 L5981

Exoskeletal bk ultralt mater Exoskeletal ak ultra-light m Exoskel hip ultra-light mate Endoskel knee-shin mnl lock Endo knee-shin mnl lck ultra Endo knee-shin frct swg & st Endo knee-shin hydral swg ph Endo knee-shin polyc mch sta Endo knee-shin frct swg & st Endo knee-shin pneum swg frc Endo knee-shin fluid swing p Miniature knee joint Endo knee-shin fluid swg/sta Endo knee-shin pneum/swg pha Multi-axial knee/shin system Knee-shin sys stance flexion Knee-shin sys hydraul stance Endo ak/hip knee extens assi Mech hip extension assist Elec knee-shin swing/stance Elec knee-shin swing only Stance phase only Endo below knee alignable sy Endo ak/hip alignable system Above knee manual lock High activity knee frame Endo bk ultra-light material Endo ak ultra-light material Endo hip ultra-light materia Endo poly hip, pneu/hyd/rot Below knee flex cover system Above knee flex cover system Hip flexible cover system Multiaxial ankle w dorsiflex Foot external keel sach foot SACH foot, replacement Flexible keel foot Ank-foot sys dors-plant flex Foot single axis ankle/foot Combo ankle/foot prosthesis Energy storing foot Ft prosth multiaxial ankl/ft Multi-axial ankle/ft prosth Flex foot system Flex-walk sys low ext prosth

$ 699.09 $ 841.74 $ 1209.36 $ 626.24 $ 821.48 $ 710.94 $ 4106.61 $ 957.90 $ 1081.66 $ 1918.08 $ 1727.35 $ 3587.12 $ 3180.76 $ 2773.38 $ 4546.19 $ 1981.90 $ 1189.04 $ 144.09 $ 463.80 Not Covered Not Covered Not Covered $ 407.94 $ 597.64 $ 491.24 $ 3721.85 $ 702.46 $ 1009.70 $ 1154.05 By Report $ 882.75 $ 1270.79 $ 1647.52 $ 4018.20 $ 276.30 $ 276.30 $ 441.56 Not Covered $ 349.96 $ 512.61 $ 705.15 $ 398.52 $ 3395.12 $ 4566.26 $ 3689.52

$ 699.09 $ 841.74 $ 1209.36 $ 626.24 $ 821.48 $ 710.94 $ 4106.61 $ 957.90 $ 1081.66 $ 1918.08 $ 1727.35 $ 3587.12 $ 3180.76 $ 2773.38 $ 4546.19 $ 1981.90 $ 1189.04 $ 144.09 $ 463.80 Not Covered Not Covered Not Covered $ 407.94 $ 597.64 $ 491.24 $ 3721.85 $ 702.46 $ 1009.70 $ 1154.05 By Report $ 882.75 $ 1270.79 $ 1647.52 $ 4018.20 $ 276.30 $ 276.30 $ 441.56 Not Covered $ 349.96 $ 512.61 $ 705.15 $ 398.52 $ 3395.12 $ 4566.26 $ 3689.52

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F X X X F F F F F F F N F F F F F F F X F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 113

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L5982 L5984 L5985 L5986 L5987 L5988 L5990 L5999 L6000 L6010 L6020 L6025 L6050 L6055 L6100 L6110 L6120 L6130 L6200 L6205 L6250 L6300 L6310 L6320 L6350 L6360 L6370 L6380 L6382 L6384 L6386 L6388 L6400 L6450 L6500 L6550 L6570 L6580 L6582 L6584 L6586 L6588 L6590 L6600 L6605

Exoskeletal axial rotation u Endoskeletal axial rotation Lwr ext dynamic prosth pylon Multi-axial rotation unit Shank ft w vert load pylon Vertical shock reducing pylo User adjustable heel height Lowr extremity prosthes NOS Par hand robin-aids thum rem Hand robin-aids little/ring Part hand robin-aids no fing Part hand disart myoelectric Wrst MLd sck flx hng tri pad Wrst mold sock w/exp interfa Elb mold sock flex hinge pad Elbow mold sock suspension t Elbow mold doub splt soc ste Elbow stump activated lock h Elbow mold outsid lock hinge Elbow molded w/ expand inter Elbow inter loc elbow forarm Shlder disart int lock elbow Shoulder passive restor comp Shoulder passive restor cap Thoracic intern lock elbow Thoracic passive restor comp Thoracic passive restor cap Postop dsg cast chg wrst/elb Postop dsg cast chg elb dis/ Postop dsg cast chg shlder/t Postop ea cast chg & realign Postop applicat rigid dsg on Below elbow prosth tiss shap Elb disart prosth tiss shap Above elbow prosth tiss shap Shldr disar prosth tiss shap Scap thorac prosth tiss shap Wrist/elbow bowden cable mol Wrist/elbow bowden cbl dir f Elbow fair lead cable molded Elbow fair lead cable dir fo Shdr fair lead cable molded Shdr fair lead cable direct Polycentric hinge pair Single pivot hinge pair

$ 860.71 $ 813.71 $ 312.25 $ 861.24 $ 7954.44 $ 2208.96 $ 2006.05 By Report $ 1995.44 $ 2220.60 $ 2070.36 $ 8848.60 $ 2445.43 $ 3651.40 $ 2634.05 $ 2686.55 $ 3378.25 $ 3887.76 $ 3989.89 $ 4998.75 $ 3720.85 $ 5233.85 $ 4344.52 $ 1924.88 $ 5882.49 $ 4783.54 $ 2287.72 $ 1540.26 $ 1813.25 $ 2295.56 $ 519.95 $ 571.48 $ 2916.11 $ 3958.59 $ 4003.82 $ 5355.99 $ 5970.38 $ 2028.96 $ 1612.35 $ 2739.50 $ 2341.31 $ 3964.31 $ 3652.79 $ 228.92 $ 215.98

$ 860.71 $ 813.71 $ 312.25 $ 861.24 $ 7954.44 $ 2208.96 $ 2006.05 By Report $ 1995.44 $ 2220.60 $ 2070.36 $ 8848.60 $ 2445.43 $ 3651.40 $ 2634.05 $ 2686.55 $ 3378.25 $ 3887.76 $ 3989.89 $ 4998.75 $ 3720.85 $ 5233.85 $ 4344.52 $ 1924.88 $ 5882.49 $ 4783.54 $ 2287.72 $ 1540.26 $ 1813.25 $ 2295.56 $ 519.95 $ 571.48 $ 2916.11 $ 3958.59 $ 4003.82 $ 5355.99 $ 5970.38 $ 2028.96 $ 1612.35 $ 2739.50 $ 2341.31 $ 3964.31 $ 3652.79 $ 228.92 $ 215.98

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F N F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 114

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L6610 L6611 L6615 L6616 L6620 L6621 L6623 L6624 L6625 L6628 L6629 L6630 L6632 L6635 L6637 L6638 L6640 L6641 L6642 L6645 L6646 L6647 L6648 L6650 L6655 L6660 L6665 L6670 L6672 L6675 L6676 L6677 L6680 L6682 L6684 L6686 L6687 L6688 L6689 L6690 L6691 L6692 L6693 L6694 L6695

Flexible metal hinge pair Additional switch, ext power Disconnect locking wrist uni Disconnect insert locking wr Flexion/extension wrist unit Flex/ext wrist w/wo friction Spring-ass rot wrst w/ latch Flex/ext/rotation wrist unit Rotation wrst w/ cable lock Quick disconn hook adapter o Lamination collar w/ couplin Stainless steel any wrist Latex suspension sleeve each Lift assist for elbow Nudge control elbow lock Elec lock on manual pw elbow Shoulder abduction joint pai Excursion amplifier pulley t Excursion amplifier lever ty Shoulder flexion-abduction j Multipo locking shoulder jnt Shoulder lock actuator Ext pwrd shlder lock/unlock Shoulder universal joint Standard control cable extra Heavy duty control cable Teflon or equal cable lining Hook to hand cable adapter Harness chest/shlder saddle Harness figure of 8 sing con Harness figure of 8 dual con UE triple control harness Test sock wrist disart/bel e Test sock elbw disart/above Test socket shldr disart/tho Suction socket Frame typ socket bel elbow/w Frame typ sock above elb/dis Frame typ socket shoulder di Frame typ sock interscap-tho Removable insert each Silicone gel insert or equal Lockingelbow forearm cntrbal Elbow socket ins use w/lock Elbow socket ins use w/o lck

$ 196.98 $ 455.28 $ 240.72 $ 87.74 $ 377.04 $ 2529.18 $ 811.09 $ 4164.35 $ 693.66 $ 651.42 $ 165.10 $ 242.75 $ 73.19 $ 212.82 $ 489.40 $ 2765.19 $ 388.05 $ 193.42 $ 261.61 $ 446.52 $ 3487.51 $ 574.14 $ 3596.88 $ 385.11 $ 112.81 $ 119.42 $ 55.54 $ 57.42 $ 218.04 $ 135.26 $ 166.30 $ 328.01 $ 267.96 $ 340.91 $ 522.36 $ 748.88 $ 649.70 $ 795.58 $ 973.72 $ 1032.66 $ 446.75 $ 629.90 $ 3139.22 $ 806.82 $ 672.35

$ 196.98 $ 455.28 $ 240.72 $ 87.74 $ 377.04 $ 2529.18 $ 811.09 $ 4164.35 $ 693.66 $ 651.42 $ 165.10 $ 242.75 $ 73.19 $ 212.82 $ 489.40 $ 2765.19 $ 388.05 $ 193.42 $ 261.61 $ 446.52 $ 3487.51 $ 574.14 $ 3596.88 $ 385.11 $ 112.81 $ 119.42 $ 55.54 $ 57.42 $ 218.04 $ 135.26 $ 166.30 $ 328.01 $ 267.96 $ 340.91 $ 522.36 $ 748.88 $ 649.70 $ 795.58 $ 973.72 $ 1032.66 $ 446.75 $ 629.90 $ 3139.22 $ 806.82 $ 672.35

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 115

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L6696 L6697 L6698 L6703 L6704 L6706 L6707 L6708 L6709 L6711 L6712 L6713 L6714 L6721 L6722 L6805 L6810 L6881 L6882 L6883 L6884 L6885 L6890 L6895 L6900 L6905 L6910 L6915 L6920 L6925 L6930 L6935 L6940 L6945 L6950 L6955 L6960 L6965 L6970 L6975 L7007 L7008 L7009 L7040 L7045

Cus elbo skt in for con/atyp Cus elbo skt in not con/atyp Below/above elbow lock mech Term dev, passive hand mitt Term dev, sport/rec/work att Term dev mech hook vol open Term dev mech hook vol close Term dev mech hand vol open Term dev mech hand vol close Ped term dev, hook, vol open Ped term dev, hook, vol clos Ped term dev, hand, vol open Ped term dev, hand, vol clos Hook/hand, hvy dty, vol open Hook/hand, hvy dty, vol clos Term dev modifier wrist unit Term dev precision pinch dev Term dev auto grasp feature Microprocessor control uplmb Replc sockt below e/w disa Replc sockt above elbow disa Replc sockt shldr dis/interc Prefab glove for term device Custom glove for term device Hand restorat thumb/1 finger Hand restoration multiple fi Hand restoration no fingers Hand restoration replacmnt g Wrist disarticul switch ctrl Wrist disart myoelectronic c Below elbow switch control Below elbow myoelectronic ct Elbow disarticulation switch Elbow disart myoelectronic c Above elbow switch control Above elbow myoelectronic ct Shldr disartic switch contro Shldr disartic myoelectronic Interscapular-thor switch ct Interscap-thor myoelectronic Adult electric hand Pediatric electric hand Adult electric hook Prehensile actuator Pediatric electric hook

$ 1454.48 $ 1454.48 $ 747.01 $ 371.88 $ 705.85 $ 448.99 $ 1584.01 $ 1105.31 $ 1585.02 Not Covered Not Covered Not Covered Not Covered $ 2600.68 $ 2241.98 $ 476.40 $ 225.42 $ 4520.56 $ 3429.04 $ 2308.16 $ 3154.10 $ 4783.54 $ 209.15 $ 698.29 $ 2187.09 $ 2204.98 $ 1809.71 $ 817.88 $ 8764.59 $ 9585.34 $ 9509.48 $ 10050.17 $ 11385.54 $ 12615.11 $ 11891.85 $ 13452.70 $ 14651.51 $ 16545.69 $ 16427.86 $ 17999.74 $ 3929.69 Not Covered $ 4249.96 $ 3392.64 Not Covered

$ 1454.48 $ 1454.48 $ 747.01 $ 371.88 $ 705.85 $ 448.99 $ 1584.01 $ 1105.31 $ 1585.02 Not Covered Not Covered Not Covered Not Covered $ 2600.68 $ 2241.98 $ 476.40 $ 225.42 $ 4520.56 $ 3429.04 $ 2308.16 $ 3154.10 $ 4783.54 $ 209.15 $ 698.29 $ 2187.09 $ 2204.98 $ 1809.71 $ 817.88 $ 8764.59 $ 9585.34 $ 9509.48 $ 10050.17 $ 11385.54 $ 12615.11 $ 11891.85 $ 13452.70 $ 14651.51 $ 16545.69 $ 16427.86 $ 17999.74 $ 3929.69 Not Covered $ 4249.96 $ 3392.64 Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F F F F F F X X X X F F F F F F F F F F F F F F F F F F F F F F F F F F F F X F F X

Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y

Refer to Field Key for definitions

HCPCS Page 116

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L7170 L7180 L7181 L7185 L7186 L7190 L7191 L7260 L7261 L7266 L7272 L7274 L7360 L7362 L7364 L7366 L7367 L7368 L7400 L7401 L7402 L7403 L7404 L7405 L7499 L7500 L7510 L7520 L7600 L7900 L8000 L8001 L8002 L8010 L8015 L8020 L8030 L8031 L8032 L8035 L8039 L8040 L8041 L8042 L8043

Electronic elbow hosmer swit Electronic elbow sequential Electronic elbo simultaneous Electron elbow adolescent sw Electron elbow child switch Elbow adolescent myoelectron Elbow child myoelectronic ct Electron wrist rotator otto Electron wrist rotator utah Servo control steeper or equ Analogue control unb or equa Proportional ctl 12 volt uta Six volt bat otto bock/eq ea Battery chrgr six volt otto Twelve volt battery utah/equ Battery chrgr 12 volt utah/e Replacemnt lithium ionbatter Lithium ion battery charger Add UE prost be/wd, ultlite Add UE prost a/e ultlite mat Add UE prost s/d ultlite mat Add UE prost b/e acrylic Add UE prost a/e acrylic Add UE prost s/d acrylic Upper extremity prosthes NOS Prosthetic dvc repair hourly Prosthetic device repair rep Repair prosthesis per 15 min Prosthetic donning sleeve Male vacuum erection system Mastectomy bra Breast prosthesis bra & form Brst prsth bra & bilat form Mastectomy sleeve Ext breastprosthesis garment Mastectomy form Breast prosthes w/o adhesive Breast prosthesis w adhesive Reusable nipple prosthesis Custom breast prosthesis Breast prosthesis NOS Nasal prosthesis Midfacial prosthesis Orbital prosthesis Upper facial prosthesis

$ 6877.66 $ 41267.16 $ 44305.10 $ 7224.12 Not Covered $ 8974.58 Not Covered $ 2556.56 $ 5358.22 $ 1115.19 $ 2685.50 $ 8012.42 $ 298.94 $ 309.86 $ 586.94 $ 758.65 $ 430.50 $ 558.06 $ 338.90 $ 379.40 $ 409.71 $ 407.20 $ 614.59 $ 803.80 By Report By Report By Report By Report By Report $ 598.74 $ 46.51 $ 138.69 $ 182.41 $ 59.21 $ 68.84 $ 271.38 $ 355.35 By Report By Report $ 4051.06 By Report $ 2764.54 $ 3332.39 $ 3744.22 $ 4193.54

$ 6877.66 $ 41267.16 $ 44305.10 $ 7224.12 Not Covered $ 8974.58 Not Covered $ 2556.56 $ 5358.22 $ 1115.19 $ 2685.50 $ 8012.42 $ 298.94 $ 309.86 $ 586.94 $ 758.65 $ 430.50 $ 558.06 $ 338.90 $ 379.40 $ 409.71 $ 407.20 $ 614.59 $ 803.80 By Report By Report By Report By Report By Report $ 598.74 $ 46.51 $ 138.69 $ 182.41 $ 59.21 $ 68.84 $ 271.38 $ 355.35 By Report By Report $ 4051.06 By Report $ 2764.54 $ 3332.39 $ 3744.22 $ 4193.54

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F X F X F F F F F F F F F F F F F F F F F N N N N N F F F F F F F F N N F N F F F F

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y

Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 117

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L8044 L8045 L8046 L8047 L8048 L8049 L8300 L8310 L8320 L8330 L8400 L8410 L8415 L8417 L8420 L8430 L8435 L8440 L8460 L8465 L8470 L8480 L8485 L8499 L8500 L8501 L8505 L8507 L8509 L8510 L8511 L8512 L8513 L8514 L8515 L8600 L8603 L8604 L8606 L8609 L8610 L8612 L8613 L8614 L8615

Hemi-facial prosthesis Auricular prosthesis Partial facial prosthesis Nasal septal prosthesis Unspec maxillofacial prosth Repair maxillofacial prosth Truss single w/ standard pad Truss double w/ standard pad Truss addition to std pad wa Truss add to std pad scrotal Sheath below knee Sheath above knee Sheath upper limb Pros sheath/sock w gel cushn Prosthetic sock multi ply BK Prosthetic sock multi ply AK Pros sock multi ply upper lm Shrinker below knee Shrinker above knee Shrinker upper limb Pros sock single ply BK Pros sock single ply AK Pros sock single ply upper l Unlisted misc prosthetic ser Artificial larynx Tracheostomy speaking valve Artificial larynx, accessory Trach-esoph voice pros pt in Trach-esoph voice pros md in Voice amplifier Indwelling trach insert Gel cap for trach voice pros Trach pros cleaning device Repl trach puncture dilator Gel cap app device for trach Implant breast silicone/eq Collagen imp urinary 2.5 ml Dextranomer/hyaluronic acid Synthetic implnt urinary 1ml Artificial cornea Ocular implant Aqueous shunt prosthesis Ossicular implant Cochlear device Coch implant headset replace

$ 4642.85 $ 2914.50 $ 2995.38 $ 1535.12 By Report By Report $ 118.05 $ 165.35 $ 62.95 $ 55.61 $ 20.90 $ 29.79 $ 30.59 $ 83.15 $ 22.60 $ 25.81 $ 31.58 $ 47.10 $ 98.30 $ 54.94 $ 7.51 $ 13.81 $ 16.20 By Report $ 879.36 $ 136.06 By Report $ 46.32 $ 120.76 $ 279.40 $ 80.42 $ 2.39 $ 5.75 $ 104.28 $ 69.79 $ 821.44 $ 496.15 By Report $ 251.59 Not Covered $ 747.20 $ 815.74 $ 339.04 $ 21159.61 $ 498.70

$ 4642.85 $ 2914.50 $ 2995.38 $ 1535.12 By Report By Report $ 118.05 $ 165.35 $ 62.95 $ 55.61 $ 20.90 $ 29.79 $ 30.59 $ 83.15 $ 22.60 $ 25.81 $ 31.58 $ 47.10 $ 98.30 $ 54.94 $ 7.51 $ 13.81 $ 16.20 By Report $ 879.36 $ 136.06 By Report $ 46.32 $ 120.76 $ 279.40 $ 80.42 $ 2.39 $ 5.75 $ 104.28 $ 69.79 $ 821.44 $ 496.15 By Report $ 251.59 Not Covered $ 747.20 $ 815.74 $ 339.04 $ 21159.61 $ 498.70

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

F F F F N N F F F F F F F F F F F F F F F F F N F F N F F F F F F F F F F N F X F F F F F

Y

Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 118

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

L8616 L8617 L8618 L8619 L8621 L8622 L8623 L8624 L8627 L8628 L8629 L8630 L8631 L8641 L8642 L8658 L8659 L8670 L8680 L8681 L8682 L8683 L8684 L8685 L8686 L8687 L8688 L8689 L8690 L8691 L8692 L8693 L8695 L8699 L9900 M0064 M0075 M0076 M0100 M0300 M0301 P2028 P2029 P2031 P2033

Coch implant microphone repl Coch implant trans coil repl Coch implant tran cable repl Coch imp ext proc/contr rplc Repl zinc air battery Repl alkaline battery Lith ion batt CID,non-earlvl Lith ion batt CID, ear level CID ext speech process repl CID ext controller repl CID transmit coil and cable Metacarpophalangeal implant MCP joint repl 2 pc or more Metatarsal joint implant Hallux implant Interphalangeal joint spacer Interphalangeal joint repl Vascular graft, synthetic Implt neurostim elctr each Pt prgrm for implt neurostim Implt neurostim radiofq rec Radiofq trsmtr for implt neu Radiof trsmtr implt scrl neu Implt nrostm pls gen sng rec Implt nrostm pls gen sng non Implt nrostm pls gen dua rec Implt nrostm pls gen dua non External recharg sys intern Aud osseo dev, int/ext comp Osseointegrated snd proc rpl Non-osseointegrated snd proc Aud osseo dev, abutment External recharg sys extern Prosthetic implant NOS O&P supply/accessory/service Visit for drug monitoring Cellular therapy Prolotherapy Intragastric hypothermia IV chelationtherapy Fabric wrapping of aneurysm Cephalin floculation test Congo red blood test Hair analysis Blood thymol turbidity

$ 116.16 $ 101.45 $ 29.00 $ 9083.66 $ 0.69 $ 0.36 $ 71.53 $ 178.32 Not Covered Not Covered Not Covered $ 379.48 $ 2400.48 $ 525.70 $ 345.95 $ 458.36 $ 2133.75 $ 626.99 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 5260.22 $ 2948.52 Not Covered Not Covered $ 18.41 Bundled By Report $ 76.92 Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report Not Covered By Report

$ 116.16 $ 101.45 $ 29.00 $ 9083.66 $ 0.69 $ 0.36 $ 71.53 $ 178.32 Not Covered Not Covered Not Covered $ 379.48 $ 2400.48 $ 525.70 $ 345.95 $ 458.36 $ 2133.75 $ 626.99 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 5260.22 $ 2948.52 Not Covered Not Covered $ 18.41 Bundled By Report $ 26.01 Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report Not Covered By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9 9 9 9 9 9

F F F F F F F F X X X F F F F F F F X X X X X X X X X X F F X X F B N R X X X X X N N X N

Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y

Refer to Field Key for definitions

HCPCS Page 119

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

P2038 P3000 P3001 P7001 P9010 P9011 P9012 P9016 P9017 P9019 P9020 P9021 P9022 P9023 P9031 P9032 P9033 P9034 P9035 P9036 P9037 P9038 P9039 P9040 P9041 P9043 P9044 P9045 P9046 P9047 P9048 P9050 P9051 P9052 P9053 P9054 P9055 P9056 P9057 P9058 P9059 P9060 P9603 P9604 P9612

Blood mucoprotein Screen pap by tech w md supv Screening pap smear by phys Culture bacterial urine Whole blood for transfusion Blood split unit Cryoprecipitate each unit RBC leukocytes reduced Plasma 1 donor frz w/in 8 hr Platelets, each unit Plaelet rich plasma unit Red blood cells unit Washed red blood cells unit Frozen plasma, pooled, sd Platelets leukocytes reduced Platelets, irradiated Platelets leukoreduced irrad Platelets, pheresis Platelet pheres leukoreduced Platelet pheresis irradiated Plate pheres leukoredu irrad RBC irradiated RBC deglycerolized RBC leukoreduced irradiated Albumin (human),5%, 50ml Plasma protein fract,5%,50ml Cryoprecipitatereducedplasma Albumin (human), 5%, 250 ml Albumin (human), 25%, 20 ml Albumin (human), 25%, 50ml Plasmaprotein fract,5%,250ml Granulocytes, pheresis unit Blood, l/r, cmv-neg Platelets, hla-m, l/r, unit Plt, pher, l/r cmv-neg, irr Blood, l/r, froz/degly/wash Plt, aph/pher, l/r, cmv-neg Blood, l/r, irradiated RBC, frz/deg/wsh, l/r, irrad RBC, l/r, cmv-neg, irrad Plasma, frz between 8-24hour Fr frz plasma donor retested One-way allow prorated miles One-way allow prorated trip Catheterize for urine spec

$ 9.90 $ 20.82 $ 47.04 Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 9.04 $ 21.17 By Report $ 45.22 $ 20.76 $ 51.79 $ 39.47 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 0.94 Not Covered $ 4.20

$ 9.90 $ 20.82 $ 47.04 Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 9.04 $ 21.17 By Report $ 45.22 $ 20.76 $ 51.79 $ 39.47 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report $ 0.94 Not Covered $ 4.20

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

L L R X N N N N N N N N N N N N N N N N N N N N D D N D D D D N N N N N N N N N N N F X L

HCPCS Page 120

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

P9615 Q0035 Q0035-26 Q0035-TC Q0081 Q0083 Q0084 Q0085 Q0091 Q0092 Q0111 Q0112 Q0113 Q0114 Q0115 Q0138 Q0139 Q0144 Q0163 Q0164 Q0165 Q0166 Q0167 Q0168 Q0169 Q0170 Q0171 Q0172 Q0173 Q0174 Q0175 Q0176 Q0177 Q0178 Q0179 Q0180 Q0181 Q0478 Q0479 Q0480 Q0481

Urine specimen collect mult Cardiokymography Cardiokymography Cardiokymography Infusion ther other than che Chemo by other than infusion Chemotherapy by infusion Chemo by both infusion and o Obtaining screen pap smear Set up port xray equipment Wet mounts/ w preparations Potassium hydroxide preps Pinworm examinations Fern test Post-coital mucous exam Ferumoxytol, non-esrd Ferumoxytol, esrd use Azithromycin dihydrate, oral Diphenhydramine HCl 50mg Prochlorperazine maleate 5mg Prochlorperazine maleate10mg Granisetron hcl 1 mg oral Dronabinol 2.5mg oral Dronabinol 5mg oral Promethazine HCl 12.5mg oral Promethazine HCl 25 mg oral Chlorpromazine HCl 10mg oral Chlorpromazine HCl 25mg oral Trimethobenzamide HCl 250mg Thiethylperazine maleate10mg Perphenazine 4mg oral Perphenazine 8mg oral Hydroxyzine pamoate 25mg Hydroxyzine pamoate 50mg Ondansetron hcl 8 mg oral Dolasetron mesylate oral Unspecified oral anti-emetic Power adapter, combo vad Power module combo vad, rep Driver pneumatic vad, rep Microprcsr cu elec vad, rep

$ 4.20 Not Covered Not Covered Not Covered Facility Only Facility Only Facility Only Facility Only $ 71.39 $ 33.76 $ 8.41 $ 8.41 $ 10.65 $ 14.08 $ 19.50 $ 0.84 $ 0.84 Not Covered $ 0.02 $ 0.21 $ 0.31 $ 53.15 $ 5.30 $ 11.04 $ 0.27 $ 0.14 $ 0.29 $ 0.22 $ 1.58 $ 0.71 $ 0.97 $ 1.17 $ 0.27 $ 0.29 $ 10.82 $ 68.62 By Report Not Covered Not Covered Not Covered Not Covered

$ 4.20 Not Covered Not Covered Not Covered Facility Only Facility Only Facility Only Facility Only $ 30.44 $ 33.76 $ 8.41 $ 8.41 $ 10.65 $ 14.08 $ 19.50 $ 0.84 $ 0.84 Not Covered $ 0.02 $ 0.21 $ 0.31 $ 53.15 $ 5.30 $ 11.04 $ 0.27 $ 0.14 $ 0.29 $ 0.22 $ 1.58 $ 0.71 $ 0.97 $ 1.17 $ 0.27 $ 0.29 $ 10.82 $ 68.62 By Report Not Covered Not Covered Not Covered Not Covered

0 0 0 0

0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 1 1 1 9 9 9 9 0 3 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 0 0 0 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 0 0 0 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 0 0 0 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 0 0 0 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 0 0 0 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

L X X X O O O O R R L L L L L D D X D D D D D D D D D D D D D D D D D D N X X X X

0 0% 0 0% 0 0% 0 0% 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

Y Y

Refer to Field Key for definitions

HCPCS Page 121

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

Q0482 Q0483 Q0484 Q0485 Q0486 Q0487 Q0488 Q0489 Q0490 Q0491 Q0492 Q0493 Q0494 Q0495 Q0496 Q0497 Q0498 Q0499 Q0500 Q0501 Q0502 Q0503 Q0504 Q0505 Q0506 Q0510 Q0511 Q0512 Q0513 Q0514 Q0515 Q1003 Q1004 Q1005 Q2004 Q2009 Q2017 Q2035 Q2036 Q2037 Q2038 Q2039 Q2040 Q3001 Q3014

Microprcsr cu combo vad, rep Monitor elec vad, rep Monitor elec or comb vad rep Monitor cable elec vad, rep Mon cable elec/pneum vad rep Leads any type vad, rep only Pwr pack base elec vad, rep Pwr pck base combo vad, rep Emr pwr source elec vad, rep Emr pwr source combo vad rep Emr pwr cbl elec vad, rep Emr pwr cbl combo vad, rep Emr hd pmp elec/combo, rep Charger elec/combo vad, rep Battery elec/combo vad, rep Bat clps elec/comb vad, rep Holster elec/combo vad, rep Belt/vest elec/combo vad rep Filters elec/combo vad, rep Shwr cov elec/combo vad, rep Mobility cart pneum vad, rep Battery pneum vad replacemnt Pwr adpt pneum vad, rep veh Miscl supply/accessory vad Lith-ion batt elec/pneum VAD Dispens fee immunosupressive Sup fee antiem,antica,immuno Px sup fee anti-can sub pres Disp fee inhal drugs/30 days Disp fee inhal drugs/90 days Sermorelin acetate injection Ntiol category 3 Ntiol category 4 Ntiol category 5 Bladder calculi irrig sol Fosphenytoin inj PE Teniposide, 50 mg Afluria vacc, 3 yrs & >, im Flulaval vacc, 3 yrs & >, im Fluvirin vacc, 3 yrs & >, im Fluzone vacc, 3 yrs & >, im NOS flu vacc, 3 yrs & >, im Incobotulinumtoxin A Brachytherapy Radioelements Telehealth facility fee

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report $ 35.37 $ 0.55 $ 338.90 Not Covered Not Covered Not Covered Not Covered Not Covered $5.67 By Report $ 34.19

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report $ 35.37 $ 0.55 $ 338.90 Not Covered Not Covered Not Covered Not Covered Not Covered $5.67 By Report $ 34.19

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X N N N D D D X X X X X D N F

Y

Refer to Field Key for definitions

HCPCS Page 122

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

Q3025 Q3026 Q3031 Q4001 Q4002 Q4003 Q4004 Q4005 Q4006 Q4007 Q4008 Q4009 Q4010 Q4011 Q4012 Q4013 Q4014 Q4015 Q4016 Q4017 Q4018 Q4019 Q4020 Q4021 Q4022 Q4023 Q4024 Q4025 Q4026 Q4027 Q4028 Q4029 Q4030 Q4031 Q4032 Q4033 Q4034 Q4035 Q4036 Q4037 Q4038 Q4039 Q4040 Q4041 Q4042

IM inj interferon beta 1-a Subc inj interferon beta-1a Collagen skin test Cast sup body cast plaster Cast sup body cast fiberglas Cast sup shoulder cast plstr Cast sup shoulder cast fbrgl Cast sup long arm adult plst Cast sup long arm adult fbrg Cast sup long arm ped plster Cast sup long arm ped fbrgls Cast sup sht arm adult plstr Cast sup sht arm adult fbrgl Cast sup sht arm ped plaster Cast sup sht arm ped fbrglas Cast sup gauntlet plaster Cast sup gauntlet fiberglass Cast sup gauntlet ped plster Cast sup gauntlet ped fbrgls Cast sup lng arm splint plst Cast sup lng arm splint fbrg Cast sup lng arm splnt ped p Cast sup lng arm splnt ped f Cast sup sht arm splint plst Cast sup sht arm splint fbrg Cast sup sht arm splnt ped p Cast sup sht arm splnt ped f Cast sup hip spica plaster Cast sup hip spica fiberglas Cast sup hip spica ped plstr Cast sup hip spica ped fbrgl Cast sup long leg plaster Cast sup long leg fiberglass Cast sup lng leg ped plaster Cast sup lng leg ped fbrgls Cast sup lng leg cylinder pl Cast sup lng leg cylinder fb Cast sup lngleg cylndr ped p Cast sup lngleg cylndr ped f Cast sup shrt leg plaster Cast sup shrt leg fiberglass Cast sup shrt leg ped plster Cast sup shrt leg ped fbrgls Cast sup lng leg splnt plstr Cast sup lng leg splnt fbrgl

Not Covered Not Covered Bundled By Report By Report By Report By Report By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report

Not Covered Not Covered Bundled By Report By Report By Report By Report By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X B N N N N N N X X N N X X N N X X N N X X N N X X N N X X N N X X N N X X N N X X N N

HCPCS Page 123

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

Q4043 Q4044 Q4045 Q4046 Q4047 Q4048 Q4049 Q4050 Q4051 Q4074 Q4081 Q4082 Q4100 Q4101 Q4102 Q4103 Q4104 Q4105 Q4106 Q4107 Q4108 Q4110 Q4111 Q4112 Q4113 Q4114 Q4115 Q4116 Q4117 Q4118 Q4119 Q4120 Q4121 Q5001 Q5002 Q5003 Q5004 Q5005 Q5006 Q5007 Q5008 Q5009 Q5010 Q9951 Q9953

Cast sup lng leg splnt ped p Cast sup lng leg splnt ped f Cast sup sht leg splnt plstr Cast sup sht leg splnt fbrgl Cast sup sht leg splnt ped p Cast sup sht leg splnt ped f Finger splint, static Cast supplies unlisted Splint supplies misc Iloprost non-comp unit dose Epoetin alfa, 100 units ESRD Drug/bio NOC part B drug CAP Skin substitute, NOS Apligraf Oasis wound matrix Oasis burn matrix Integra BMWD Integra DRT Dermagraft Graftjacket Integra matrix Primatrix Gammagraft Cymetra injectable Graftjacket xpress Integra flowable wound matri Alloskin Alloderm Hyalomatrix Matristem micromatrix Matristem wound matrix Matristem burn matrix Theraskin Hospice in patient home Hospice in assisted living Hospice in LT/non-skilled NF Hospice in SNF Hospice, inpatient hospital Hospice in hospice facility Hospice in LTCH Hospice in inpatient psych Hospice care, NOS Hospice home care in hospice LOCM >= 400 mg/ml iodine,1ml Inj Fe-based MR contrast,1ml

Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report By Report Not Covered $ 1.41 Not Covered By Report $ 34.72 $ 4.76 $ 4.76 $ 15.75 $ 11.16 $ 40.15 $ 94.57 $ 21.35 $ 32.27 $ 7.31 $ 340.50 $ 340.50 $ 991.45 $ 6.19 $ 31.71 Not Covered Not Covered Not Covered Not Covered Not Covered By Report Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

Not Covered Not Covered By Report By Report Not Covered Not Covered By Report By Report By Report Not Covered $ 1.41 Not Covered By Report $ 34.72 $ 4.76 $ 4.76 $ 15.75 $ 11.16 $ 40.15 $ 94.57 $ 21.35 $ 32.27 $ 7.31 $ 340.50 $ 340.50 $ 991.45 $ 6.19 $ 31.71 Not Covered Not Covered Not Covered Not Covered Not Covered By Report Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X N N X X N N N X D X N D D D D D D D D D D D D D D D X X X X X N X N N N N N N N N N N

Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 124

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

Q9954 Q9955 Q9956 Q9957 Q9958 Q9959 Q9960 Q9961 Q9962 Q9963 Q9964 Q9965 Q9966 Q9967 Q9968 R0070 R0075 R0075-UN R0075-UP R0075-UQ R0075-UR R0075-US R0076 S0012 S0014 S0017 S0020 S0021 S0023 S0028 S0030 S0032 S0034 S0039 S0040 S0073 S0074 S0077 S0078 S0080 S0081 S0088 S0090 S0091 S0092

Oral MR contrast, 100 ml Inj perflexane lip micros,ml Inj octafluoropropane mic,ml Inj perflutren lip micros,ml HOCM <=149 mg/ml iodine, 1ml HOCM 150-199mg/ml iodine,1ml HOCM 200-249mg/ml iodine,1ml HOCM 250-299mg/ml iodine,1ml HOCM 300-349mg/ml iodine,1ml HOCM 350-399mg/ml iodine,1ml HOCM>= 400mg/ml iodine, 1ml LOCM 100-199mg/ml iodine,1ml LOCM 200-299mg/ml iodine,1ml LOCM 300-399mg/ml iodine,1ml Visualization adjunct Transport portable x-ray Transport port x-ray multipl Transport port x-ray multipl Transport port x-ray multipl Transport port x-ray multipl Transport port x-ray multipl Transport port x-ray multipl Transport portable EKG Butorphanol tartrate, nasal Tacrine hydrochloride, 10 mg Injection, aminocaproic acid Injection, bupivicaine hydro Injection, cefoperazone sod Injection, cimetidine hydroc Injection, famotidine, 20 mg Injection, metronidazole Injection, nafcillin sodium Injection, ofloxacin, 400 mg Injection, sulfamethoxazole Injection, ticarcillin disod Injection, aztreonam, 500 mg Injection, cefotetan disodiu Injection, clindamycin phosp Injection, fosphenytoin sodi Injection, pentamidine iseth Injection, piperacillin sodi Imatinib 100 mg Sildenafil citrate, 25 mg Granisetron 1mg Hydromorphone 250 mg

By Report By Report By Report By Report $ 0.14 $ 0.11 $ 0.14 $ 0.17 $ 0.19 $ 0.00 $ 0.34 $ 2.42 $ 1.03 $ 0.92 By Report $ 164.84 $ 27.48 $ 82.43 $ 54.95 $ 41.21 $ 32.97 $ 27.48 Bundled Not Covered Not Covered Not Covered $ 1.44 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 48.13 Not Covered $ 53.15 $ 103.32

By Report By Report By Report By Report $ 0.14 $ 0.11 $ 0.14 $ 0.17 $ 0.19 $ 0.00 $ 0.34 $ 2.42 $ 1.03 $ 0.92 By Report $ 164.84 $ 27.48 $ 82.43 $ 54.95 $ 41.21 $ 32.97 $ 27.48 Bundled Not Covered Not Covered Not Covered $ 1.44 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 48.13 Not Covered $ 53.15 $ 103.32

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 3 3 3 3 3 3 3 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N D D D D D D D D D D N F F F F F F F B X X X D X X X X X X X X X X X X X X D X D D

Y

Y

Refer to Field Key for definitions

HCPCS Page 125

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S0093 S0104 S0106 S0108 S0109 S0117 S0122 S0126 S0128 S0132 S0136 S0137 S0138 S0139 S0140 S0142 S0145 S0148 S0155 S0156 S0157 S0160 S0164 S0166 S0169 S0170 S0171 S0172 S0174 S0175 S0176 S0177 S0178 S0179 S0181 S0182 S0183 S0187 S0189 S0190 S0191 S0194 S0195 S0197 S0199

Morphine 500 mg Zidovudine, oral, 100 mg Bupropion HCL SR 60 tablets Mercaptopurine 50 mg Methadone oral 5mg Tretinoin topical 5 g Inj menotropins 75 iu Inj follitropin alfa 75 iu Inj follitropin beta 75 iu Inj ganirelix acetat 250 mcg Clozapine, 25 mg Didanosine, 25 mg Finasteride, 5 mg Minoxidil, 10 mg Saquinavir, 200 mg Colistimethate inh sol mg Peg interferon alfa-2A/180 Peg interferon alfa-2b/10 Epoprostenol dilutant Exemestane, 25 mg Becaplermin gel 1%, 0.5 gm Dextroamphetamine Injection pantroprazole Inj olanzapine 2.5mg Calcitrol Anastrozole 1 mg Bumetanide 0.5 mg Chlorambucil 2 mg Dolasetron 50 mg Flutamide 125 mg Hydroxyurea 500 mg Levamisole 50 mg Lomustine 10 mg Megestrol 20 mg Ondansetron 4 mg Procarbazine 5 mg Prochlorperazine 5 mg Tamoxifen 10 mg Testosterone pellet 75 mg Mifepristone, oral, 200 mg Misoprostol, oral, 200 mcg Vitamin suppl 100 caps Pneumo vaccine 5-9 yrs Prenatal vitamins 30 day Med abortion inc all ex drug

$ 3.97 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report $ 622.07 $ 43.59 By Report Not Covered Not Covered Not Covered $ 5.40 Not Covered Not Covered $ 0.29 $ 0.31 $ 3.48 $ 51.77 $ 1.87 $ 0.66 Not Covered $ 9.53 $ 0.59 $ 10.81 $ 50.11 $ 0.21 $ 1.70 $ 64.80 $ 81.00 $ 2.13 Not Covered Not Covered Not Covered By Report

$ 3.97 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report $ 622.07 $ 43.59 By Report Not Covered Not Covered Not Covered $ 5.40 Not Covered Not Covered $ 0.29 $ 0.31 $ 3.48 $ 51.77 $ 1.87 $ 0.66 Not Covered $ 9.53 $ 0.59 $ 10.81 $ 50.11 $ 0.21 $ 1.70 $ 64.80 $ 81.00 $ 2.13 Not Covered Not Covered Not Covered By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

D X X X X X X X X X X X X X X N D D N X X X D X X D D D D D D X D D D D D D D D D X X X N

Y

Y Y Y

Y Y Y Y Y Y

Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 126

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S0201 S0207 S0208 S0209 S0215 S0220 S0221 S0250 S0255 S0257 S0260 S0265 S0270 S0271 S0272 S0273 S0274 S0280 S0281 S0302 S0310 S0315 S0316 S0317 S0320 S0340 S0341 S0342 S0390 S0395 S0400 S0500 S0504 S0506 S0508 S0510 S0512 S0514 S0515 S0516 S0518 S0580 S0581 S0590 S0592

Partial hospitalization serv Paramedicintercep nonhospals Paramed intrcept nonvol WC van mileage per mi Nonemerg transp mileage Medical conference by physic Medical conference, 60 min Comp geriatr assmt team Hospice refer visit nonmd End of life counseling H&P for surgery Genetic counsel 15 mins Home std case rate 30 days Home hospice case 30 days Home episodic case 30 days MD home visit outside cap Nurse practr visit outs cap Medical home, initial plan Medical home, maintenance Completed EPSDT Hospitalist visit Disease management program Follow-up/reassessment Disease mgmt per diem RN telephone calls to DMP Lifestyle mod 1st stage Lifestyle mod 2 or 3 stage Lifestyle mod 4th stage Rout foot care per visit Impression casting ft Global eswl kidney Dispos cont lens Singl prscrp lens Bifoc prscp lens Trifoc prscrp lens Non-prscrp lens Daily cont lens Color cont lens Scleral lens liquid bandage Safety frames Sunglass frames Polycarb lens Nonstnd lens Misc integral lens serv Comp cont lens eval

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X N X X X X X X X X X X X X X X X

HCPCS Page 127

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S0595 S0601 S0610 S0612 S0613 S0618 S0620 S0621 S0622 S0625 S0630 S0800 S0810 S0812 S1001 S1002 S1015 S1016 S1030 S1031 S1040 S2053 S2054 S2055 S2060 S2061 S2065 S2066 S2067 S2068 S2070 S2079 S2080 S2083 S2095 S2102 S2103 S2107 S2112 S2115 S2117 S2118 S2120 S2140 S2142

New lenses in pts old frame Screening proctoscopy Annual gynecological examina Annual gynecological examina Ann breast exam Audiometry for hearing aid Routine ophthalmological exa Routine ophthalmological exa Phys exam for college Digital screening retina Removal of sutures Laser in situ keratomileusis Photorefractive keratectomy Phototherap keratect Deluxe item Custom item IV tubing extension set Non-pvc intravenous administ Gluc monitor purchase Gluc monitor rental Cranial remolding orthosis Transplantation of small int Transplantation of multivisc Harvesting of donor multivis Lobar lung transplantation Donor lobectomy (lung) Simult panc kidn trans Breast GAP flap reconst Breast "stacked" DIEP/GAP Breast DIEP or SIEA flap Cysto laser tx ureteral calc Lap esophagomyotomy Laup Adjustment gastric band Transcath emboliz microspher Islet cell tissue transplant Adrenal tissue transplant Adoptive immunotherapy Knee arthroscp harv Periacetabular osteotomy Arthroereisis, subtalar Total hip resurfacing Low density lipoprotein(LDL) Cord blood harvesting Cord blood-derived stem-cell

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X N X X X X X X

HCPCS Page 128

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S2150 S2152 S2202 S2205 S2206 S2207 S2208 S2209 S2225 S2230 S2235 S2260 S2265 S2266 S2267 S2270 S2300 S2325 S2340 S2341 S2342 S2344 S2348 S2350 S2351 S2360 S2361 S2400 S2401 S2402 S2403 S2404 S2405 S2409 S2411 S2900 S3000 S3005 S3600 S3601 S3620 S3625 S3626 S3628 S3630

BMT harv/transpl 28d pkg Solid organ transpl pkg Echosclerotherapy Minimally invasive direct co Minimally invasive direct co Minimally invasive direct co Minimally invasive direct co Minimally invasive direct co Myringotomy laser-assist Implant semi-imp hear Implant auditory brain imp Induced abortion 17-24 weeks Induced abortion 25-28 wks Induced abortion 29-31 wks Induced abortion 32 or more Insertion vaginal cylinder Arthroscopy, shoulder, surgi Hip core decompression Chemodenervation of abductor Chemodenerv adduct vocal Nasal endoscop po debrid Endosc balloon sinuplasty Decompress disc RF lumbar Diskectomy, anterior, with d Diskectomy, anterior, with d Vertebroplast cerv 1st Vertebroplast cerv addl Fetal surg congen hernia Fetal surg urin trac obstr Fetal surg cong cyst malf Fetal surg pulmon sequest Fetal surg myelomeningo Fetal surg sacrococ teratoma Fetal surg noc Fetoscop laser ther TTTS Robotic surgical system Bilat dil retinal exam Eval self-assess depression Stat lab Stat lab home/nf Newborn metabolic screening Maternal triple screen test Maternal serum quad screen PAMG-1 rapid assay for ROM Eosinophil blood count

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 12.91 $ 12.91 Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 12.91 $ 12.91 Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X F F X X X X X

HCPCS Page 129

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S3645 S3650 S3652 S3655 S3708 S3711 S3713 S3800 S3818 S3819 S3820 S3822 S3823 S3828 S3829 S3830 S3831 S3833 S3834 S3835 S3837 S3840 S3841 S3842 S3843 S3844 S3845 S3846 S3847 S3848 S3849 S3850 S3851 S3852 S3853 S3854 S3855 S3860 S3861 S3862 S3865 S3866 S3870 S3890 S3900

HIV-1 antibody testing of or Saliva test, hormone level; Saliva test, hormone level; Antisperm antibodies test Gastrointestinal fat absorpt Circulating tumor cell test KRAS mutation analysis Genetic testing ALS BRCA1 gene anal BRCA2 gene anal Comp BRCA1/BRCA2 Sing mutation brst/ovar 3 mutation brst/ovar Comp MLH1 gene Comp MSH2 gene Gene test HNPCC comp Gene test HNPCC single Comp APC sequence Sing mutation APC Gene test cystic fibrosis Gene test hemochromato DNA analysis RET-oncogene Gene test retinoblastoma Gene test Hippel-Lindau DNA analysis factor v DNA analysis deafness Gene test alpha-thalassemia Gene test beta-thalassemia Gene test Tay-Sachs Gene test Gaucher Gene test Niemann-Pick Gene test sickle cell Gene test canavan DNA analysis APOE alzheimer Gene test myo musclr dyst Gene profile panel breast Gene test presenilin-1 gene Genet test cardiac ion-comp Genetic test brugada Genet test cardiac ion-spec Comp genet test hyp cardiomy Spec gene test hyp cardiomy CGH test developmental delay Fecal DNA analysis Surface EMG

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 130

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S3902 S3904 S3905 S4005 S4011 S4013 S4014 S4015 S4016 S4017 S4018 S4020 S4021 S4022 S4023 S4025 S4026 S4027 S4028 S4030 S4031 S4035 S4037 S4040 S4042 S4981 S4989 S4990 S4991 S4993 S4995 S5000 S5001 S5010 S5011 S5012 S5013 S5014 S5035 S5036 S5100 S5101 S5102 S5105 S5108

Ballistocardiogram Masters two step Auto handheld diag nerv test Interim labor facility globa IVF package Compl GIFT case rate Compl ZIFT case rate Complete IVF nos case rate Frozen IVF case rate IVF canc a stim case rate F EMB trns canc case rate IVF canc a aspir case rate IVF canc p aspir case rate Asst oocyte fert case rate Incompl donor egg case rate Donor serv IVF case rate Procure donor sperm Store prev froz embryos Microsurg epi sperm asp Sperm procure init visit Sperm procure subs visit Stimulated IUI case rate Cryo embryo transf case rate Monit store cryo embryo 30 d Ovulation mgmt per cycle Insert levonorgestrel ius Contracept IUD Nicotine patch legend Nicotine patch nonlegend Contraceptive pills for bc Smoking cessation gum Prescription drug, generic Prescription drug,brand name 5% dextrose and 0.45% saline 5% dextrose in lactated ring 5% dextrose with potassium 5%dextrose/0.45%saline1000ml D5W/0.45NS w KCl and MGS04 HIT routine device maint HIT device repair Adult daycare services 15min Adult day care per half day Adult day care per diem Centerbased day care perdiem Homecare train pt 15 min

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 131

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S5109 S5110 S5111 S5115 S5116 S5120 S5121 S5125 S5126 S5130 S5131 S5135 S5136 S5140 S5141 S5145 S5146 S5150 S5151 S5160 S5161 S5162 S5165 S5170 S5175 S5180 S5181 S5185 S5190 S5199 S5497 S5498 S5501 S5502 S5517 S5518 S5520 S5521 S5522 S5523 S5550 S5551 S5552 S5553 S5560

Homecare train pt session Family homecare training 15m Family homecare train/sessio Nonfamily homecare train/15m Nonfamily HC train/session Chore services per 15 min Chore services per diem Attendant care service /15m Attendant care service /diem Homaker service nos per 15m Homemaker service nos /diem Adult companioncare per 15m Adult companioncare per diem Adult foster care per diem Adult foster care per month Child fostercare th per diem Ther fostercare child /month Unskilled respite care /15m Unskilled respitecare /diem Emer response sys instal&tst Emer rspns sys serv permonth Emer rspns system purchase Home modifications per serv Homedelivered prepared meal Laundry serv,ext,prof,/order HH respiratory thrpy in eval HH respiratory thrpy nos/day Med reminder serv per month Wellness assessment by nonph Personal care item nos each HIT cath care noc HIT simple cath care HIT complex cath care HIT interim cath care HIT declotting kit HIT cath repair kit HIT picc insert kit HIT midline cath insert kit HIT picc insert no supp HIP midline cath insert kit Insulin rapid 5 u Insulin most rapid 5 u Insulin intermed 5 u Insulin long acting 5 u Insulin reuse pen 1.5 ml

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X N N N X X X X X X X X X X X X X X X X X X X X X X X

Y Y Y

Refer to Field Key for definitions

HCPCS Page 132

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S5561 S5565 S5566 S5570 S5571 S8030 S8035 S8037 S8040 S8042 S8049 S8055 S8080 S8085 S8092 S8096 S8097 S8100 S8101 S8110 S8120 S8121 S8185 S8186 S8189 S8210 S8262 S8265 S8270 S8301 S8415 S8420 S8421 S8422 S8423 S8424 S8425 S8426 S8427 S8428 S8429 S8430 S8431 S8450 S8451

Insulin reuse pen 3 ml Insulin cartridge 150 u Insulin cartridge 300 u Insulin dispos pen 1.5 ml Insulin dispos pen 3 ml Tantalum ring application Magnetic source imaging mrcp Topographic brain mapping MRI low field Intraoperative radiation the Us guidance fetal reduct Scintimammography Fluorine-18 fluorodeoxygluco Electron beam computed tomog Portable peak flow meter Asthma kit Spacer without mask Spacer with mask Peak expiratory flow rate (p O2 contents gas cubic ft O2 contents liquid lb Flutter device Swivel adaptor Trach supply noc Mucus trap Mandib ortho repos device Haberman feeder Enuresis alarm Infect control supplies NOS Supplies for home delivery Custom gradient sleev/glov Ready gradient sleev/glov Custom grad sleeve med Custom grad sleeve heavy Ready gradient sleeve Custom grad glove med Custom grad glove heavy Ready gradient glove Ready gradient gauntlet Gradient pressure wrap Padding for comprssn bdg Compression bandage Splint digit Splint wrist or ankle

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X N X N N N N N N N N N N N N X X

Y

Refer to Field Key for definitions

HCPCS Page 133

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S8452 S8460 S8490 S8940 S8948 S8950 S8990 S8999 S9001 S9007 S9015 S9024 S9025 S9034 S9055 S9056 S9061 S9075 S9083 S9088 S9090 S9097 S9098 S9109 S9117 S9122 S9123 S9124 S9125 S9126 S9127 S9128 S9129 S9131 S9140 S9141 S9145 S9150 S9152 S9208 S9209 S9211 S9212 S9213 S9214

Splint elbow Camisole post-mast 100 insulin syringes Hippotherapy per session Low-level laser trmt 15 min Complex lymphedema therapy, Pt or manip for maint Resuscitation bag Home uterine monitor with or Ultrafiltration monitor Automated EEG monitoring Paranasal sinus ultrasound Omnicardiogram/cardiointegra ESWL for gallstones Procuren or other growth fac Coma stimulation per diem Medical supplies and equipme Smoking cessation treatment Urgent care center global Services provided in urgent Vertebral axial decompressio Home visit wound care Home phototherapy visit CHF telemonitoring month Back school visit Home health aide or certifie Nursing care in home RN Nursing care, in the home; b Respite care, in the home, p Hospice care, in the home, p Social work visit, in the ho Speech therapy, in the home, Occupational therapy, in the PT in the home per diem Diabetic Management Program, Diabetic Management Program, Insulin pump initiation Evaluation by ocularist Speech therapy, re-eval Home mgmt preterm labor Home mgmt PPROM Home mgmt gest hypertension Hm postpar hyper per diem Hm preeclamp per diem Hm gest dm per diem

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 26.01 $ 56.57 $ 41.29 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 26.01 $ 56.57 $ 41.29 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X F F F X X X X X X X X X X X X X X X X X

Y

Refer to Field Key for definitions

HCPCS Page 134

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S9325 S9326 S9327 S9328 S9329 S9330 S9331 S9335 S9336 S9338 S9339 S9340 S9341 S9342 S9343 S9345 S9346 S9347 S9348 S9349 S9351 S9353 S9355 S9357 S9359 S9361 S9363 S9364 S9365 S9366 S9367 S9368 S9370 S9372 S9373 S9374 S9375 S9376 S9377 S9379 S9381 S9401 S9430 S9433 S9434

HIT pain mgmt per diem HIT cont pain per diem HIT int pain per diem HIT pain imp pump diem HIT chemo per diem HIT cont chem diem HIT intermit chemo diem HT hemodialysis diem HIT cont anticoag diem HIT immunotherapy diem HIT periton dialysis diem HIT enteral per diem HIT enteral grav diem HIT enteral pump diem HIT enteral bolus nurs HIT anti-hemophil diem HIT alpha-1-proteinas diem HIT longterm infusion diem HIT sympathomim diem HIT tocolysis diem HIT cont antiemetic diem HIT cont insulin diem HIT chelation diem HIT enzyme replace diem HIT anti-tnf per diem HIT diuretic infus diem HIT anti-spasmotic diem HIT tpn total diem HIT tpn 1 liter diem HIT tpn 2 liter diem HIT tpn 3 liter diem HIT tpn over 3l diem HT inj antiemetic diem HT inj anticoag diem HIT hydra total diem HIT hydra 1 liter diem HIT hydra 2 liter diem HIT hydra 3 liter diem HIT hydra over 3l diem HIT noc per diem HIT high risk/escort Anticoag clinic per session Pharmacy comp/disp serv Medical food oral 100% nutr Mod solid food suppl

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 135

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S9435 S9436 S9437 S9438 S9439 S9441 S9442 S9443 S9444 S9445 S9446 S9447 S9449 S9451 S9452 S9453 S9454 S9455 S9460 S9465 S9470 S9472 S9473 S9474 S9475 S9476 S9480 S9482 S9484 S9485 S9490 S9494 S9497 S9500 S9501 S9502 S9503 S9504 S9529 S9537 S9538 S9542 S9558 S9559 S9560

Medical foods for inborn err Lamaze class Childbirth refresher class Cesarean birth class VBAC class Asthma education Birthing class Lactation class Parenting class PT education noc individ PT education noc group Infant safety class Weight mgmt class Exercise class Nutrition class Smoking cessation class Stress mgmt class Diabetic Management Program, Diabetic Management Program, Diabetic Management Program, Nutritional counseling, diet Cardiac rehabilitation progr Pulmonary rehabilitation pro Enterostomal therapy by a re Ambulatory setting substance Vestibular rehab per diem Intensive outpatient psychia Family stabilization 15 min Crisis intervention per hour Crisis intervention mental h HIT corticosteroid/diem HIT antibiotic total diem HIT antibiotic q3h diem HIT antibiotic q24h diem HIT antibiotic q12h diem HIT antibiotic q8h diem HIT antibiotic q6h diem HIT antibiotic q4h diem Venipuncture home/snf HT hem horm inj diem HIT blood products diem HT inj noc per diem HT inj growth horm diem HIT inj interferon diem HT inj hormone diem

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 38.01 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 38.01 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X F X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 136

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

S9562 S9590 S9810 S9900 S9970 S9975 S9976 S9977 S9981 S9982 S9986 S9988 S9989 S9990 S9991 S9992 S9994 S9996 S9999 T1000 T1001 T1002 T1003 T1004 T1005 T1006 T1007 T1009 T1010 T1012 T1013 T1014 T1015 T1016 T1017 T1018 T1019 T1020 T1021 T1022 T1023 T1024 T1025 T1026 T1027

HT inj palivizumab diem HT irrigation diem HT pharm per hour Christian Sci Pract visit Health club membership yr Transplant related per diem Lodging per diem Meals per diem Med record copy admin Med record copy per page Not medically necessary svc Serv part of phase I trial Services outside US Services provided as part of Services provided as part of Transportation costs to and Lodging costs (e.g. hotel ch Meals for clinical trial par Sales tax Private duty/independent nsg Nursing assessment/evaluatn RN services up to 15 minutes LPN/LVN services up to 15min Nsg aide service up to 15min Respite care service 15 min Family/Couple Counseling Treatment Plan Development Child Sitting Services Meals when Receive Services Alcohol/Substance Abuse Skil Sign Lang/Oral Interpreter Telehealth transmit, per min Clinic service Case management Targeted case management School-based IEP ser bundled Personal care ser per 15 min Personal care ser per diem HH Aide or cn aide per visit Contracted services per day Program intake assessment Team evaluation & management Ped compr care pkg, per diem Ped compr care pkg, per hour Family training & counseling

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 0.48 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered $ 0.48 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X F X X X X X X X X X X X X X X X X X X X X X X N X X X X X X X X X X X X

HCPCS Page 137

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

T1028 T1029 T1030 T1031 T1502 T1503 T1505 T1999 T2001 T2002 T2003 T2004 T2005 T2007 T2010 T2011 T2012 T2013 T2014 T2015 T2016 T2017 T2018 T2019 T2020 T2021 T2022 T2023 T2024 T2025 T2026 T2027 T2028 T2029 T2030 T2031 T2032 T2033 T2034 T2035 T2036 T2037 T2038 T2039 T2040

Home environment assessment Dwelling lead investigation RN home care per diem LPN home care per diem Medication admin visit Med admin, not oral/inject Elec med comp dev, noc NOC retail items andsupplies N-et; patient attend/escort N-et; per diem N-et; encounter/trip N-et; commerc carrier pass N-et; stretcher van Non-emer transport wait time PASRR Level I PASRR Level II Habil ed waiver, per diem Habil ed waiver per hour Habil prevoc waiver, per d Habil prevoc waiver per hr Habil res waiver per diem Habil res waiver 15 min Habil sup empl waiver/diem Habil sup empl waiver 15min Day habil waiver per diem Day habil waiver per 15 min Case management, per month Targeted case mgmt per month Serv asmnt/care plan waiver Waiver service, nos Special childcare waiver/d Spec childcare waiver 15 min Special supply, nos waiver Special med equip, noswaiver Assist living waiver/month Assist living waiver/diem Res care, nos waiver/month Res, nos waiver per diem Crisis interven waiver/diem Utility services waiver Camp overnite waiver/session Camp day waiver/session Comm trans waiver/service Vehicle mod waiver/service Financial mgt waiver/15min

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

HCPCS Page 138

Refer to Field Key for definitions

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

T2041 T2042 T2043 T2044 T2045 T2046 T2048 T2049 T2101 T4521 T4522 T4523 T4524 T4525 T4526 T4527 T4528 T4529 T4530 T4531 T4532 T4533 T4534 T4535 T4536 T4537 T4538 T4539 T4540 T4541 T4542 T4543 T5001 T5999 V2020 V2025 V2100 V2101 V2102 V2103 V2104 V2105 V2106 V2107 V2108

Support broker waiver/15 min Hospice routine home care Hospice continuous home care Hospice respite care Hospice general care Hospice long term care, r&b Bh ltc res r&b, per diem N-ET; stretcher van, mileage Breast milk proc/store/dist Adult size brief/diaper sm Adult size brief/diaper med Adult size brief/diaper lg Adult size brief/diaper xl Adult size pull-on sm Adult size pull-on med Adult size pull-on lg Adult size pull-on xl Ped size brief/diaper sm/med Ped size brief/diaper lg Ped size pull-on sm/med Ped size pull-on lg Youth size brief/diaper Youth size pull-on Disposable liner/shield/pad Reusable pull-on any size Reusable underpad bed size Diaper serv reusable diaper Reuse diaper/brief any size Reusable underpad chair size Large disposable underpad Small disposable underpad Disp bariatric brief/diaper Position seat spec orth need Supply, nos Vision svcs frames purchases Eyeglasses delux frames Lens spher single plano 4.00 Single visn sphere 4.12-7.00 Singl visn sphere 7.12-20.00 Spherocylindr 4.00d/12-2.00d Spherocylindr 4.00d/2.12-4d Spherocylinder 4.00d/4.25-6d Spherocylinder 4.00d/>6.00d Spherocylinder 4.25d/12-2d Spherocylinder 4.25d/2.12-4d

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Not Covered Not Covered Not Covered Not Covered Bundled Bundled Bundled Bundled Bundled Not Covered Bundled Bundled Bundled Bundled Not Covered Not Covered Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Bundled Bundled Bundled Bundled Bundled Bundled Bundled Bundled Not Covered Not Covered Not Covered Not Covered Bundled Bundled Bundled Bundled Bundled Not Covered Bundled Bundled Bundled Bundled Not Covered Not Covered Not Covered By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

X X X X X X X X X B B B B B B B B X X X X B B B B B X B B B B X X X N N N N N N N N N N N

Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 139

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

V2109 V2110 V2111 V2112 V2113 V2114 V2115 V2118 V2121 V2199 V2200 V2201 V2202 V2203 V2204 V2205 V2206 V2207 V2208 V2209 V2210 V2211 V2212 V2213 V2214 V2215 V2218 V2219 V2220 V2221 V2299 V2300 V2301 V2302 V2303 V2304 V2305 V2306 V2307 V2308 V2309 V2310 V2311 V2312 V2313

Spherocylinder 4.25d/4.25-6d Spherocylinder 4.25d/over 6d Spherocylindr 7.25d/.25-2.25 Spherocylindr 7.25d/2.25-4d Spherocylindr 7.25d/4.25-6d Spherocylinder over 12.00d Lens lenticular bifocal Lens aniseikonic single Lenticular lens, single Lens single vision not oth c Lens spher bifoc plano 4.00d Lens sphere bifocal 4.12-7.0 Lens sphere bifocal 7.12-20. Lens sphcyl bifocal 4.00d/.1 Lens sphcy bifocal 4.00d/2.1 Lens sphcy bifocal 4.00d/4.2 Lens sphcy bifocal 4.00d/ove Lens sphcy bifocal 4.25-7d/. Lens sphcy bifocal 4.25-7/2. Lens sphcy bifocal 4.25-7/4. Lens sphcy bifocal 4.25-7/ov Lens sphcy bifo 7.25-12/.25Lens sphcyl bifo 7.25-12/2.2 Lens sphcyl bifo 7.25-12/4.2 Lens sphcyl bifocal over 12. Lens lenticular bifocal Lens aniseikonic bifocal Lens bifocal seg width over Lens bifocal add over 3.25d Lenticular lens, bifocal Lens bifocal speciality Lens sphere trifocal 4.00d Lens sphere trifocal 4.12-7. Lens sphere trifocal 7.12-20 Lens sphcy trifocal 4.0/.12Lens sphcy trifocal 4.0/2.25 Lens sphcy trifocal 4.0/4.25 Lens sphcyl trifocal 4.00/>6 Lens sphcy trifocal 4.25-7/. Lens sphc trifocal 4.25-7/2. Lens sphc trifocal 4.25-7/4. Lens sphc trifocal 4.25-7/>6 Lens sphc trifo 7.25-12/.25Lens sphc trifo 7.25-12/2.25 Lens sphc trifo 7.25-12/4.25

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 140

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

V2314 V2315 V2318 V2319 V2320 V2321 V2399 V2410 V2430 V2499 V2500 V2501 V2502 V2503 V2510 V2511 V2512 V2513 V2520 V2521 V2522 V2523 V2530 V2531 V2599 V2600 V2610 V2615 V2623 V2624 V2625 V2626 V2627 V2628 V2629 V2630 V2631 V2632 V2700 V2702 V2710 V2715 V2718 V2730 V2744

Lens sphcyl trifocal over 12 Lens lenticular trifocal Lens aniseikonic trifocal Lens trifocal seg width > 28 Lens trifocal add over 3.25d Lenticular lens, trifocal Lens trifocal speciality Lens variab asphericity sing Lens variable asphericity bi Variable asphericity lens Contact lens pmma spherical Cntct lens pmma-toric/prism Contact lens pmma bifocal Cntct lens pmma color vision Cntct gas permeable sphericl Cntct toric prism ballast Cntct lens gas permbl bifocl Contact lens extended wear Contact lens hydrophilic Cntct lens hydrophilic toric Cntct lens hydrophil bifocl Cntct lens hydrophil extend Contact lens gas impermeable Contact lens gas permeable Contact lens/es other type Hand held low vision aids Single lens spectacle mount Telescop/othr compound lens Plastic eye prosth custom Polishing artifical eye Enlargemnt of eye prosthesis Reduction of eye prosthesis Scleral cover shell Fabrication & fitting Prosthetic eye other type Anter chamber intraocul lens Iris support intraoclr lens Post chmbr intraocular lens Balance lens Deluxe lens feature Glass/plastic slab off prism Prism lens/es Fresnell prism press-on lens Special base curve Tint photochromatic lens/es

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 141

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

V2745 V2750 V2755 V2756 V2760 V2761 V2762 V2770 V2780 V2781 V2782 V2783 V2784 V2785 V2786 V2787 V2788 V2790 V2797 V2799 V5008 V5010 V5011 V5014 V5020 V5030 V5040 V5050 V5060 V5070 V5080 V5090 V5095 V5100 V5110 V5120 V5130 V5140 V5150 V5160 V5170 V5180 V5190 V5200 V5210

Tint, any color/solid/grad Anti-reflective coating UV lens/es Eye glass case Scratch resistant coating Mirror coating Polarization, any lens Occluder lens/es Oversize lens/es Progressive lens per lens Lens, 1.54-1.65 p/1.60-1.79g Lens, >= 1.66 p/>=1.80 g Lens polycarb or equal Corneal tissue processing Occupational multifocal lens Astigmatism-correct function Presbyopia-correct function Amniotic membrane Vis item/svc in other code Miscellaneous vision service Hearing screening Assessment for hearing aid Hearing aid fitting/checking Hearing aid repair/modifying Conformity evaluation Body-worn hearing aid air Body-worn hearing aid bone Hearing aid monaural in ear Behind ear hearing aid Glasses air conduction Glasses bone conduction Hearing aid dispensing fee Implant mid ear hearing pros Body-worn bilat hearing aid Hearing aid dispensing fee Body-worn binaur hearing aid In ear binaural hearing aid Behind ear binaur hearing ai Glasses binaural hearing aid Dispensing fee binaural Within ear cros hearing aid Behind ear cros hearing aid Glasses cros hearing aid Cros hearing aid dispens fee In ear bicros hearing aid

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered By Report By Report By Report $ 76.55 Bundled Bundled $ 51.04 Bundled By Report By Report By Report By Report By Report By Report Not Covered Not Covered By Report Not Covered By Report By Report By Report By Report $ 1449.38 By Report By Report By Report $ 868.72 By Report

By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered By Report By Report By Report $ 76.55 Bundled Bundled $ 51.04 Bundled By Report By Report By Report By Report By Report By Report Not Covered Not Covered By Report Not Covered By Report By Report By Report By Report $ 1449.38 By Report By Report By Report $ 868.72 By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

N N N N N N N N N N N N N N N N X N N N F B B F B N N N N N N X X N X N N N N F N N N F N

Y

Y Y

Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y

Refer to Field Key for definitions

HCPCS Page 142

Professional Services Fee Schedule HCPCS Level II Effective July 1, 2011

DOLLAR VALUE NON-FACILITY FACILITY SETTING SETTING MODIFIERS POST OP PCTC MSI BSI (-55) (26/TC) (-51) (-50)

HCPCS CODE

ABBREVIATED DESCRIPTION

FOL UP

PRE OP (-56)

INTRA OP (-54)

ASI (-80)

CSI (-62)

TSI (-66)

ENDO BASE

FSI

LIC REQ

PRIOR AUTH

V5220 V5230 V5240 V5241 V5242 V5243 V5244 V5245 V5246 V5247 V5248 V5249 V5250 V5251 V5252 V5253 V5254 V5255 V5256 V5257 V5258 V5259 V5260 V5261 V5262 V5263 V5264 V5265 V5266 V5267 V5268 V5269 V5270 V5271 V5272 V5273 V5274 V5275 V5298 V5299 V5336 V5362 V5363 V5364

Behind ear bicros hearing ai Glasses bicros hearing aid Dispensing fee bicros Dispensing fee, monaural Hearing aid, monaural, cic Hearing aid, monaural, itc Hearing aid, prog, mon, cic Hearing aid, prog, mon, itc Hearing aid, prog, mon, ite Hearing aid, prog, mon, bte Hearing aid, binaural, cic Hearing aid, binaural, itc Hearing aid, prog, bin, cic Hearing aid, prog, bin, itc Hearing aid, prog, bin, ite Hearing aid, prog, bin, bte Hearing id, digit, mon, cic Hearing aid, digit, mon, itc Hearing aid, digit, mon, ite Hearing aid, digit, mon, bte Hearing aid, digit, bin, cic Hearing aid, digit, bin, itc Hearing aid, digit, bin, ite Hearing aid, digit, bin, bte Hearing aid, disp, monaural Hearing aid, disp, binaural Ear mold/insert Ear mold/insert, disp Battery for hearing device Hearing aid supply/accessory ALD Telephone Amplifier Alerting device, any type ALD, TV amplifier, any type ALD, TV caption decoder Tdd ALD for cochlear implant ALD unspecified Ear impression Hearing aid noc Hearing service Repair communication device Speech screening Language screening Dysphagia screening

By Report By Report $ 868.72 $ 724.69 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered By Report Not Covered $0.88 By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report By Report

By Report By Report $ 868.72 $ 724.69 By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report By Report Not Covered Not Covered By Report Not Covered $ 0.88 By Report Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered By Report By Report By Report By Report

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 9 9 9 9

N N F F N N N N N N N N N N N N N N N N N N N N X X N X F N X X X X X X X X X X N N N N

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y

Y

Refer to Field Key for definitions

HCPCS Page 143

Information

HCPCS Fee Schedule

143 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

33858

You might also be interested in

BETA
Microsoft Word - Proper_Use_of_Modifiers[1]_3.doc
School-Based Services Handbook
HCPCS Fee Schedule