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Oklahoma Workers= Compensation Court =

Schedule of Medical and Hospital Fees

Effective 01/01/06

Schedule of Medical and Hospital Fees

Adopted December 20, 2005

Effective January 1, 2006 Updated January 25, 2006

Marcia Davis Administrator

Oklahoma Workers= Compensation Court =

Schedule of Medical and Hospital Fees

Effective 01/01/06

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Schedule of Medical and Hospital Fees

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NOTICE

The five character codes included in the Schedule of Medical Fees are obtained from Current Procedural Terminology, (CPT®), copyright 2004 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five-character identifying codes and modifiers for reporting medical services and procedures performed by physicians. The responsibility for the content of the Schedule of Medical and Hospital Fees is with the State of Oklahoma Workers' Compensation Court and no endorsement by the AMA is intended or implied. The AMA disclaims any responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Schedule of Medical and Hospital Fees. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside the Schedule of Medical and Hospital Fees should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply. U.S. Government Rights: This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

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Table of Contents Foreword ................................................................................................................ Introduction ............................................................................................................ General Ground Rules ........................................................................................... Evaluation and Management ................................................................................ Anesthesia ............................................................................................................. Surgery ................................................................................................................... Radiology ............................................................................................................... 1 1 5 11 15 23 97

Pathology ............................................................................................................... 109 Medicine ................................................................................................................ 127 Physical Medicine ................................................................................................. 139 Durable Medical Equipment and Supplies ............................................................. 145 Pharmaceutical Services ....................................................................................... 147 Ambulatory Surgical Center Services ..................................................................... 151 In-Patient Hospital Services ................................................................................... 153

Oklahoma Workers= Compensation Court =

Schedule of Medical and Hospital Fees

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Oklahoma Workers= Compensation Court =

Schedule of Medical and Hospital Fees

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FOREWORD

The Schedule of Medical and Hospital Fees outlines maximum reimbursement levels for health care providers, including hospitals and ambulatory surgical centers, rendering health care services to injured employees as provided in the Workers' Compensation Act, 85 O.S., Section 1 et seq. It applies to all health care services rendered after December 31, 2005 to employees with compensable injuries, regardless of the employee's date of injury. The Schedule of Medical and Hospital Fees does not apply to: (1) (2) (3) (4) health care services performed under a certified workplace medical plan provided for in 85 O.S., Section 14.3; health care services performed under a written contract between a health care provider and an employer or insurance carrier entered into pursuant to 85 O.S., Section 14(F); health care services for which voluntary payments in excess of the reimbursement levels of the Schedule are made by a self-insured employer or an insurance carrier; or disability evaluations provided as medical-legal evidence and performed by independent medical examiners appointed by the Workers= Compensation Court as provided in 85 O.S., Section 17. Reimbursement of Court-appointed independent medical examiners is governed by Workers= Compensation Court Rule 44.

This Schedule was adopted on December 20, 2005 as provided in 85 O.S., Section 14. The Schedule of Medical Fees is based on the most current Relative Value Units (RVU) produced by the Centers for Medicare and Medicaid Services (CMS) for the Medicare Physician Fee Schedule. The hospital and ambulatory surgical center services portions of the Schedule utilize the Diagnosis Related Groups (DRG) system as the primary coding system for health care services rendered. The Schedule also adopts by reference the Centers for Medicare and Medicaid Services, CMS Common Procedures Coding System (HCPCS) for the coding of certain supplies and materials. INTRODUCTION 1. PROCEDURE CODES: For purposes of the Schedule of Medical Fees, health care services and procedures shall be described in accordance with current procedural terminology codes and descriptions listed in the Physicians' Current Procedural Terminology, (CPT7), copyright 2004 by the American Medical Association. The accompanying instructions and ground rules of the Schedule of Medical Fees explain the application of these procedure descriptors and values in medical practice. All matters not specifically governed by the provisions of the Schedule of Medical Fees shall be subject to the provisions of CPT 2005. If the provisions of the Schedule of Medical Fees conflict with the provisions of CPT 2005, the provisions of the Schedule of Medical Fees shall govern.

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The five character codes included in the Schedule of Medical Fees are obtained from Current Procedural Terminology, (CPT7), copyright 2004 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and fivecharacter identifying codes and modifiers for reporting medical services and procedures performed by physicians. The responsibility for the content of the Schedule of Medical and Hospital Fees is with the State of Oklahoma Workers= Compensation Court and no endorsement by the AMA is intended or implied. The AMA disclaims any responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Schedule of Medical and Hospital Fees. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside the Schedule of Medical and Hospital Fees should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply. Allowables found in the right hand column of the Schedule of Medical and Hospital Fees were developed by the Administrator of the Oklahoma Workers' Compensation Court pursuant to 85 O.S., Section 14. 2. FORMAT: The Oklahoma Schedule of Medical and Hospital Fees consists of eleven sections; Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology, Medicine, Physical Medicine, Durable Medical Equipment and Supplies, Pharmaceutical Services, Ambulatory Surgical Center Services, and In-Patient Hospital Services. The Schedule is divided into these sections for structural purposes only. Providers of medical services and/or suppliers are to use the section(s) which contain the procedures they perform, or the services they render. GROUND RULES: Introductory material, known as Ground Rules, follows the Introduction and precedes the separate sections of this Schedule. The Ground Rules contain the necessary general information, instructions, and general rules with which the user needs to become acquainted before undertaking the use of this Schedule. Familiarity with these general rules, which may include definitions, references, prohibitions, and directions for proper use, is necessary for all who use this Schedule. It cannot be emphasized too strongly that these rules need to be read before this Schedule is used. HOW TO INTERPRET THE FEE SCHEDULE DATA: Each section of the Schedule is divided into columns. The columns vary by section. Following is a description of the various columns: a. CPT CODE (CURRENT PROCEDURAL TERMINOLOGY CODE): The CPT Code column lists the American Medical Association=s (AMA) CPT code. CPT 2005 is used by arrangement with the AMA. DRG CODE (DIAGNOSIS RELATED GROUPS CODE): The DRG column lists the Centers for Medicare and Medicaid Services (CMS) Diagnosis Related Groups code as updated through August 12, 2005.

3.

4.

b.

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c.

ANES: The ANES column shows base units for anesthesia services provided. These units are used for reimbursement when an anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) provides anesthesia during a surgical procedure and bills using a surgical CPT code or when the operating surgeon provides regional or general anesthesia for surgery. FUD (FOLLOW-UP DAYS): The FUD column lists the number of follow-up days included in a surgical procedure=s global allowable. In counting follow-up days, day one is the day of surgery, not the discharge day. The follow-up days in this Schedule are derived from the Relative Values for Physicians published by St. Anthony Publishing/Medicode/Ingenix, Inc. PC (PROFESSIONAL COMPONENT): The PC column shows the maximum allowable reimbursement amount for that portion of the procedure that is professional. The total maximum allowable reimbursed should never be more than the professional and technical components combined. In the Medicine Section, if there is no allowable noted in the PC column, the MAR listed is for the professional component only and there is no technical component for the code. TC (TECHNICAL COMPONENT): The TC column shows the maximum allowable reimbursement amount for that portion of the procedure that is technical. The total maximum allowable reimbursed should never be more than the professional and technical components combined. In the Medicine Section, if no allowable is noted in the PC column, the MAR listed is for the professional component only and there is no technical component for the code. MAR (MAXIMUM ALLOWABLE REIMBURSEMENT): An MAR is listed for each code excluding Anesthesia codes, HCPCS codes and DRG codes. The MAR column lists the maximum allowable reimbursement for a particular service or procedure performed under a CPT code. Anesthesia codes shall be reimbursed as provided in the Anesthesia Ground Rules. HCPCS codes shall be reimbursed as provided in the Durable Medical Equipment and Supplies Ground Rules. DRG codes shall be reimbursed as provided in the Ambulatory Surgical Center Services Ground Rules or the In-Patient Hospital Services Ground Rules, as appropriate. BR (BY REPORT): Some services and procedures do not have a maximum allowable reimbursement amount because they are too variable or new. These Aby [email protected] services and procedures are identified with a [email protected] Reimbursement and billing for Aby [email protected] services and procedures are governed by the Aby [email protected] ground rule for the appropriate section.

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General Ground Rules

GENERAL GROUND RULES General Information and Instructions 1. REPRODUCTION OF MEDICAL RECORDS, INCLUDING X-RAYS AND OTHER PHOTOGRAPHS AND IMAGES: Under the provisions of 76 O.S., Section 19, medical providers (physicians, hospitals, medical professionals and institutions) may charge patients, former patients or the legal representative of any such person not more than One Dollar ($1.00) for the first page and fifty cents ($0.50) for each subsequent page for copies of medical records other than any x-ray or other photograph or image. The cost of each x-ray or other photograph or image shall not exceed Five Dollars ($5.00) or the actual cost of reproduction, whichever is less. Medical providers may charge a patient for the actual cost of mailing the patient=s requested medical records, but may not charge an additional fee for searching, retrieving, reviewing or preparing such records for copying. MEDICAL TESTIMONY, INCLUDING DEPOSITIONS: a. REIMBURSEMENT: Reimbursement for medical testimony given in person or by deposition shall be in accordance with the physician=s usual and customary charges, not to exceed Two Hundred Dollars ($200.00) per hour or any portion thereof, plus an allowance of Fifty Dollars ($50.00) for 15 minute increments thereafter. PREPARATION TIME: Preparation time for medical testimony, including depositions, shall be reimbursed at the examiner=s usual and customary charge, not to exceed One Hundred Dollars ($100.00). CANCELLATION FEE: A Two Hundred Dollar ($200.00) charge is allowable whenever a deposition or scheduled testimony is canceled by the employer or employee within three working days prior to the scheduled start of the deposition or scheduled testimony. ADVANCE PAYMENT: A physician may request not more than Two Hundred Dollars ($200.00) in advance in order to schedule a deposition. The advance payment shall be applied against amounts owed for testimony fees. BILLING: All bills submitted for payment shall be itemized, including the number of hours required to perform the services, and shall refer to this Ground Rule and CPT7 Code 99075 for proper reimbursement.

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This ground rule does not apply to reimbursement of a Court-appointed independent medical examiner for medical testimony given in person or by deposition. Reimbursement of Court-appointed independent medical examiners is governed by Workers= Compensation Court Rule 44. 3. WORK-RELATED OR MEDICAL DISABILITY EVALUATION SERVICES PERFORMED AT THE REQUEST OF A PARTY AND WHICH INCLUDE A CALCULATION OF IMPAIRMENT:

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a.

This Ground Rule applies to work-related or medical disability examinations described in CPT Code 99455 that are performed by the treating physician, at the request of a party, and to work-related or medical disability examinations described in CPT Code 99456 that are performed by a physician other than the treating physician, at the request of a party. CPT Codes 99455 and 99456 require, among other things, a calculation of impairment. This Ground Rule does not apply to: (1) disability evaluations provided as medical-legal evidence and performed by independent medical examiners appointed by the Workers= Compensation Court under 85 O.S., Section 17. Reimbursement of Court-appointed independent medical examiners is governed by Workers= Compensation Court Rule 44; or health care services (including work-related or medical disability services) performed under a written contract between a health care provider and an employer or insurance carrier entered into pursuant to 85 O.S., Section 14(F).

b.

(2)

c.

Services subject to this Ground Rule shall be reimbursed as follows: (1) REIMBURSEMENT: The review of records and information, the performance of any necessary examinations, and the preparation of the written report shall be billed and reimbursed at the physician=s usual and customary rate, not to exceed Two Hundred Dollars ($200.00) per hour, up to a maximum of three (3) hours. In a complex case, an additional fee of up to Two Hundred Dollars ($200.00) may be allowed. DIAGNOSTIC TESTS: Payment for any required diagnostic tests shall be in accordance with this Schedule of Medical and Hospital Fees. CANCELLATION AND NO-SHOW FEE: If an injured worker fails to appear for a scheduled examination, or if an examination is canceled by the employee or the employer within forty-eight (48) hours of the scheduled time, a Two Hundred Dollar ($200.00) fee is allowable for such failure to appear or cancellation. BILLING: All bills submitted for payment shall be itemized, including the number of hours required to perform the services, and shall refer to this Ground Rule and CPT Code 99455 or 99456, as appropriate, for proper reimbursement.

(2) (3)

(4)

4.

BILLING PROCEDURES: If a charge is billed using a procedure code not found in this fee schedule, but found in the Physicians' Current Procedural Terminology, by the American Medical Association (CPT) book, reimbursement should be made. Relativity should be maintained by using a fee schedule code and value as a reference.

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Medical providers may not bill more than their usual and customary charge for any procedure. Except as otherwise provided in the Ambulatory Surgical Center Services Ground Rules and the In-Patient Hospital Services Ground Rules, if a medical provider's total aggregate charges per billing do not exceed the total aggregate allowed by the fee schedule for such charges, after application of all appropriate ground rules and other instructions per the fee schedule, then the medical provider=s total aggregate charges should be reimbursed in full. For example, CPT Code 99203 95860-26 Provider=s = Charges $75.00 $100.00 $175.00 Maximum Allowable Per Fee Schedule $102.50 $ 87.42 $189.92

The provider should be paid $175.00 since the total billed charges are less than the total allowable per the fee schedule. 5. MODIFIERS: Modifiers augment CPT codes to more accurately describe the circumstances of services provided. When applicable, the circumstances should be identified by a modifier code; a two-digit number, alpha, or alpha-numeric combination placed after the usual procedure code, separated by a hyphen. If more than one modifier is needed, place the multiple modifiers code (-99) after the procedure code to indicate that two or more modifiers will follow. EXPLANATION OF BENEFITS: A payor must provide a health care provider with a written explanation of benefits (EOB) whenever a coded service is denied or not reimbursed in full as billed. The EOB must identify each coded service that was denied or not reimbursed in full as billed; the amount reimbursed, if applicable; the reason for each denial or reduced reimbursement (including the specific general instruction, ground rule, etc. of the Schedule of Medical and Hospital Fees serving as the basis for the denial or reduction); and the procedure code, if any, for which reimbursement was made when different from the code billed. DISPUTES REGARDING PAYMENT FOR HEALTH CARE SERVICES: Disputes regarding payment for health care services rendered as provided in the Workers' Compensation Act may be addressed using informal dispute resolution procedures available through the Workers' Compensation Court. The procedures include the Form 18 and Form 19 processes, voluntary mediation, and the judicial settlement conference process. A description of each follows. a. FORM 18 (ADMINISTRATIVE REVIEW OF DISPUTED CHARGES): Rule 1 of the Rules of the Administrator of the Workers' Compensation Court governs the review of payment disputes involving conflicting interpretations of the Schedule of Medical and Hospital Fees. A request for administrative review of disputed medical charges under Rule 1 may be made by the filing of a Form 18, Request for Administrative Review of Medical Charges. The Administrator may review the disputed charges

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only to determine if the entire bill submitted is reimbursed appropriately under the Schedule of Medical and Hospital Fees. The Administrator may not determine if the treatment rendered was necessary, nor may the Administrator resolve other matters requiring a judicial determination for resolution. If either party is aggrieved by the Administrator's order, an appeal of the decision may be made to a trial judge of the Workers' Compensation Court by filing a Form 9 (Motion to Set for Trial) and a Form 19, Part II., Notice of Appeal of Administrative Order. The appeal must be filed within ten (10) days of the file-stamped date of the Administrator=s order. b. FORM 19 (MAY INVOLVE JUDICIAL RESOLUTION OF DISPUTED CHARGES): Court Rule 50 governs the process for health care providers seeking to recover charges for health care services, medicines or supplies provided to an injured employee. Health care providers may file a Form 19, Part I., Request For Payment Of Charges For Health Or Rehabilitation Services, if they have not received payment within 60 days from the date the charges were submitted to the employer or insurance carrier, or if the employer or insurance carrier denies liability on a ground requiring judicial resolution. Such grounds include: (1) length of treatment; (2) necessity of treatment; (3) unauthorized physician; (4) denial of compensability of the claimant's claim; and (5) any other issues requiring a judicial determination. The Workers= Compensation Court will not set the Form 19 for hearing unless a = Form 9 (Motion to Set for Trial) also is filed. MEDIATION: A voluntary mediation program to address certain workers= compensation disputes (including disputes regarding payment for medical and rehabilitative services) is available through the Workers= Compensation Court. Mediation is the process of resolving disputes with the assistance of a mediator, outside of a formal court proceeding. The purpose of mediation is to identify issues, clarify misunderstandings, explore solutions, and negotiate settlement. It is an alternative to litigation. For information, call (405) 522-8760 or in-state toll free at (800) 522-8210. See also, Workers= Compensation Court Rule 52. JUDICIAL SETTLEMENT CONFERENCE: Informal dispute resolution of disputes regarding payment for health care services rendered to an injured worker may be addressed through in-person or telephone settlement conferences conducted by a judge other than the assigned trial judge in a case filed with the Workers= Compensation Court. A judicial settlement conference may be requested by a party or may be set by the Court upon its own motion. The purpose of the judicial settlement conference is to permit an informal discussion between the parties, attorneys, and the settlement judge on every aspect of the case bearing on its settlement value in an effort to resolve the matter before trial. The conference can come before or after a formal hearing request (Motion to Set for Trial). For more information, see 85 O.S., Section 3.4 and Workers= Compensation Court Rule 53.

c.

d.

Failure of an employer or insurance carrier to offer payment of medical charges within the 60-day period as required by the Workers= Compensation Court=s rules may limit = = the applicability of the Schedule of Medical and Hospital Fees.

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Under 85 O.S., Section 14(F), the right to recover charges for every type of medical care for compensable workers= compensation injuries lies solely with the Oklahoma Workers= Compensation Court. Additional information concerning the resolution of payment disputes may be obtained from the Medical Services Division of the Workers' Compensation Court, 1915 N. Stiles Avenue, Oklahoma City, Oklahoma 73105-4918, (405) 522-8794. 8. MEDICAL TREATMENT GUIDELINES: a. REQUIRED USE: Compliance with treatment guidelines adopted as provided in Title 85 of the Oklahoma Statutes shall be mandatory. When an accidental injury or occupational disease falls within the purview of the treatment guidelines, providers shall use the appropriate medical treatment guidelines then in effect to care for and treat the injured worker. Providers are expected to stay current with guideline changes and adoptions. If the treatment guidelines conflict with ground rules in the Schedule of Medical and Hospital Fees, the treatment guidelines shall govern. Pursuant to 85 O.S., Section 14.3, Certified Workplace Medical Plans may use medical treatment guidelines and protocols substantially similar to those adopted as provided in 85 O.S., Section 201.1 by the Physician Advisory Committee and the Court Administrator. PURPOSE AND APPLICATION OF GUIDELINES: The objective of the Medical Treatment Guidelines is to provide standards for prompt, reasonable and appropriate treatment for workplace injuries and to expedite optimum recovery and return to work, while containing medical costs in the workers' compensation system. The guidelines do not affect any determination of liability for an injury under the Oklahoma Workers' Compensation Act, 85 O.S., Section 1, et seq., and are not intended to expand or restrict a health care provider's scope of practice under any other statutes. STATUS OF GUIDELINES: For information on the status of medical treatment guidelines, call the Court=s Medical Services Division at (405) 522-8794 or in-state toll free at (800) 522-8210, or check the Court=s website at www.owcc.state.ok.us.

b.

c.

9.

CASE MANAGEMENT: Under 85 O.S., Section 3(3) case management is the ongoing coordination by a case manager of health care services provided to an injured or disabled worker. It is a utilization control designed to promote the timely delivery of quality, costeffective and medically appropriate health care services to an injured worker to assist the worker in reaching maximum medical improvement, and to promote prompt return to work as appropriate. Case management may be provided by agreement of the parties, by an insurer or certified workplace medical plan, or pursuant to a Court order requested by any party or on the Court=s own motion whenever the employee has more than three (3) lost workdays in succession and the insurer does not provide case management. If case management is used, it should be governed by the Case Management Guidelines recommended by the Physician Advisory Committee (85 O.S., Section 201.1) and adopted by the Court Administrator as provided by law. The Guidelines are available on the Workers= Compensation Court=s website at www.owcc.state.ok.us. Case types or situations which

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may benefit most from case management services include: a. b. c. d. Catastrophic injuries including burns, amputations, crush injuries, head injuries, spinal cord injuries (SCI) and complex regional pain syndrome (RSD) cases; When noncompliance issues with the medical treatment plan have been identified; When multiple medical providers or frequent changes in physician have occurred; When problems with certain issues would be more appropriately evaluated in person, which may include, but are not limited to, language barriers, transportation obstacles and socio-economic dynamics; In the event of re-injury to the same body part; When the injured worker, physician, payor, employer or attorney request medical case management; When the treatment plan exceeds usual and customary parameters as set forth by law, medical treatment guidelines recommended by the Physician Advisory Committee (85 O.S., Section 201.1) and adopted by the Court Administrator, or nationally recognized treatment guidelines; In cases where pre-existing medical conditions could impact the extent or duration of rehabilitation; Compromised communication; When assistance is needed with return-to-work issues.

e. f. g.

h. i. j.

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Evaluation and Management Ground Rules

EVALUATION AND MANAGEMENT GROUND RULES General Information and Instructions 1. GENERAL: Visits, examinations, consultations, and similar services as listed in this section reflect the wide variations in time and skill required in the diagnosis and treatment of illness or injury. Documentation for each aspect of the service performed should be included in the patient record to substantiate the level of service. The listed values for each code group apply only when these services are performed by or under the responsible supervision of a physician. BY REPORT ("BR") ITEMS: "BR" in the maximum allowable reimbursement (MAR) column indicates that the value of this service is to be determined "by report", because the service is too unusual or variable to be assigned a value. For any "by report" code, medical providers should identify a similar service and justify the difference between their charge and the value of the referenced service. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc. is to be furnished. A detailed clinical record is not necessary. CONCURRENT CARE: When more than one physician treats a patient for the same condition during the same period of time, payment is made only to one physician; the one whose specialty is most relevant to the diagnosis. When the condition of the patient requires the distinct and separate skills of two or more physicians to treat different conditions which do not fall within the scope of other physicians treating the patient at the same time, payment is due each physician who plays an active role in the treatment program. The services rendered by each physician shall be distinct, in different disciplines, identifiable and adequately documented in the records and reports. 4. ALTERNATING PHYSICIANS: When physicians of similar skills alternate in the care of a patient, (e.g., partners, groups or same facility; covering for another physician on weekends or vacation periods) each physician shall bill individually for the services each personally rendered. CONSULTATIONS AND REFERRALS: A consultation is a service rendered by a specialist at the request of the treating physician or other appropriate source seeking further evaluation and/or an opinion on how to proceed in the management of a patient's illness. Consultations always require a narrative report from the consultant to the treating physician requesting the opinion. A detailed narrative report is required and shall accompany the bill. A reproduction of a form report is not acceptable since the particulars relevant to one individual will not be applicable to another patient. When the consulting specialist assumes responsibility for the continuing care of the patient, any subsequent service rendered by him/her will cease to be a consultation. Subsequent care will be reimbursed according to the actual level of service rendered. A referral is the transfer of a patient to a specialist for diagnosis and, where necessary, treatment of a specific illness or injury, rather than for advice. A referral will be reimbursed according to the actual level of services rendered.

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Evaluation and Management Ground Rules

6.

NEW PATIENT: A new patient is one who has not received any professional services from the physician within the past three years. In the instance where a physician is on call for or covering for another physician, the patient is classified as a new patient if the other physician or a member of the providing physician's specialty group has not provided any professional service for the patient within three years. ESTABLISHED PATIENT: An established patient is one who has received professional services from the physician within the last three years. In the instance where a physician is covering for or on call for another physician, the patient is classified as an established patient if the other physician or a member of the providing physician's specialty group has provided services for the patient within the last three years. SIGNIFICANT, SEPARATELY IDENTIFIABLE EVALUATION AND MANAGEMENT SERVICE BY THE SAME PHYSICIAN ON THE DAY OF A PROCEDURE: Evaluation and Management services above and beyond normal pre- and post-operative care associated with a procedure and performed on the same day may be reimbursed. Services of this nature must be substantiated by report. Use modifier -25 to indicate this type of service. DURABLE MEDICAL EQUIPMENT AND SUPPLIES PROVIDED BY PHYSICIAN: Durable medical equipment and supplies provided by the physician over and above those usually included in a visit to the physician=s office or in other services rendered are governed by the Durable Medical Equipment and Supplies Ground Rules. UNLISTED SERVICES OR PROCEDURES: A service or procedure that is not identified by a particular CPT code should be listed under the appropriate AUnlisted [email protected] These procedures often have A99" as the final two digits. Values should be substantiated Aby [email protected] INITIAL ASSESSMENT LIMITATIONS: a. LOWER EXTREMITY INJURIES: (1) (2) (3) b. Arthroscopic examination is not necessary to make a clinical diagnosis of torn ligaments. Neither an MRI nor a CT is usually appropriate at the initial evaluation or within the first month of a lower extremity injury. Surface EMGs are not recommended for the evaluation of neurologic disease.

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UPPER EXTREMITY INJURIES: If psychometric testing is indicated as a portion of the initial screening process of a patient with upper extremity pain, the time for such testing should not exceed an additional two (2) hours of professional time. Psychometric testing has selected use in patients with delayed recovery or chronic pain syndromes, recurrent painful conditions, and for pre-operative evaluations, as well as possible predictive value for determining appropriate surgical candidate.

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12.

LEVELS AND COMPONENTS OF SERVICE: Reference should be made to the Physicians' Current Procedural Terminology, (CPT7 2005), copyright 2004 by the American Medical Association for information on Levels of Service and Components of Service.

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CPT Code 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99261 99262 99263 99271 99272 99273

MAR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 39.59 68.97 102.50 145.71 185.43 22.28 40.47 55.71 87.61 128.24 76.76 73.37 130.94 171.48 76.13 133.99 171.61 45.68 60.81 86.41 147.28 197.94 243.11 76.97 104.95 73.08 103.54 133.99 183.71 238.12 79.18 109.63 140.08 182.71 243.62 36.54 54.81 73.31 48.72 73.08 97.45

CPT Code 99274 99275 99281 99282 99283 99284 99285 99288 99289 99290 99291 99292 99293 99294 99295 99296 99298 99299 99301 99302 99303 99311 99312 99313 99315 99316 99321 99322 99323 99331 99332 99333 99341 99342 99343 99344 99345 99347 99348 99349 99350

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 133.99 176.62 34.69 55.95 92.31 139.88 207.01 223.80 267.42 137.13 274.28 122.76 893.65 446.19 1,026.11 449.31 167.95 144.04 71.98 95.46 117.75 37.28 61.21 96.91 69.58 88.78 45.06 67.86 103.15 39.63 54.29 70.57 62.95 93.05 136.03 178.70 221.32 48.86 77.77 120.82 178.70

CPT Code 99354 99355 99356 99357 99358 99359 99360 99361 99362 99371 99372 99373 99374 99375 99377 99378 99379 99380 99381 99391 99435 99436 99450 99455 99456 99499 99500 99501 99502 99503 99504 99505 99506 99507 99509 99510 99511 99512 99600 99601 99602

MAR $ 107.50 $ 106.58 $ 107.41 $ 99.61 $ 78.12 $ 39.05 $ 73.23 $ 60.90 $ 109.63 $ 12.18 $ 24.36 $ 36.54 $ 54.81 $ 103.54 $ 54.81 $ 103.54 $ 54.81 $ 103.54 $ 115.72 $ 97.45 $ 146.41 $ 146.41 $ 109.08 SEE GEN GR 3 SEE GEN GR 3 BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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ANESTHESIA GROUND RULES General Information and Instructions 1. GENERAL: a. The maximum allowable reimbursement for anesthesia services administered by an Anesthesiologist shall be in an amount calculated per these Ground Rules. The maximum allowable reimbursement for anesthesia services administered by a CRNA, shall not exceed ninety percent (90%) of that amount. A base allowable is listed for each anesthesia code. These allowables are to be used only when the anesthesia is personally administered by an Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) who remains in constant attendance during the procedure, for the sole purpose of rendering such anesthesia service. These allowables include usual pre- and post-operative visits, the administration of the anesthetic and the administration of fluids and/or blood incident to anesthesia or surgery. The Anesthesia allowable includes recovery room care. No additional time units are allowed for recovery room observation and monitoring.

b.

c. 2.

BILLING: Billing for anesthesia services will include, but not be limited to the procedure code number, time units, the amount of charges, provider information and any other information that pertains to the amount charged. UNLISTED SERVICES OR PROCEDURES: A service or procedure that is not identified by a particular CPT7 code should be listed under the appropriate AUnlisted [email protected] These procedures often have A99" as the final two digits. Values should be substantiated Aby [email protected] BY REPORT ([email protected]) ITEMS: "BR" in the base allowable column indicates that the value of this service is to be determined "by report". For any "by report" code, medical providers should identify a similar service and justify the difference between their charge and the value of the referenced service. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc. is to be furnished. A detailed clinical record is not necessary. DURABLE MEDICAL EQUIPMENT AND SUPPLIES PROVIDED BY PHYSICIAN: Durable medical equipment and supplies provided by the physician over and above those usually included in a visit to the physician=s office or in other services rendered are governed by the Durable Medical Equipment and Supplies Ground Rules. SUPPLEMENTAL SKILLS: When warranted by the necessity of supplemental skills, reimbursement for the services of two or more physicians and/or anesthetists will be allowed. Substantiate by report justifying the need.

3.

4.

5.

6.

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7. MONITORING SERVICES: When an anesthesiologist or anesthetist is required to participate in and be responsible for monitoring the general care of the patient during a surgical procedure but does not administer anesthesia, these services are charged on the basis of the extent of the services rendered. Payment will be made on the basis of the time units the anesthesiologist or anesthetist is in constant attendance for the sole purpose of the monitoring services. Anesthesia values will not be added. ANESTHESIA ADMINISTERED BY OTHER THAN AN ANESTHESIOLOGIST OR ANESTHETIST: Anesthesia fees are not payable when local infiltration, digital block or topical anesthesia is administered by the operating surgeon or surgical assistants. Such services are included in the value for the surgical procedure. ANESTHESIA PHYSICAL STATUS MODIFIERS: The following physical status modifiers are consistent with the American Society of Anesthesiologists= ranking of patient physical status, and distinguish various levels of complexity of the anesthesia service provided. All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100 01999) with the appropriate physical status modifier appended. Under certain circumstances, when another established modifier(s) is appropriate, it should be used in addition to the physical status modifier. Physical Status Modifiers: Physical Status modifiers are represented by the initial letter [email protected] followed by a single digit from 1 to 6 defined below: Physical Status Modifier P1 -- A normal healthy patient. P2 -- A patient with mild systemic disease. P3 -- A patient with severe systemic disease. P4 -- A patient with severe systemic disease that is a constant threat to life. P5 -- A moribund patient who is not expected to survive without the operation. P6 -- A declared brain-dead patient whose organs are being removed for donor purposes. 10. Allowable $0.00 $0.00 $39.00 $78.00 $120.00

8.

9.

$0.00

QUALIFYING CIRCUMSTANCES: More than one qualifying circumstance may be selected. Many anesthesia services are provided under particularly difficult circumstances, depending on factors such as extraordinary condition of patient, notable operative conditions, and/or unusual risk factors. This ground rule includes a list of important qualifying circumstances

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that significantly impact on the character of the anesthesia service provided. These procedures would not be reported alone but would be reported as additional procedure numbers qualifying an anesthesia procedure or service. CPT7 Code 7 99100 99116 99135 99140 Allowable $39.00 $195.00 $195.00 $78.00

An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part. 11. MONITORING EQUIPMENT: When a pulse oximeter monitor and a capnography monitor are not provided by the hospital and are owned and operated by the anesthesiologist during general anesthesia exceeding 30 minutes, $39.00 per monitor may be charged. CALCULATIONS OF TOTAL ANESTHESIA ALLOWABLES: The total Anesthesia allowable is calculated by adding the following: a. b. c. d. e. The Anesthesia Base Allowable listed for the service provided; The Allowable for the Physical Status Modifier; The Allowable for Qualifying Circumstances, if appropriate; The Allowable for Monitoring Equipment, if appropriate; and The Allowable for time units.

12.

Time units are computed by allowing one unit for each 15 minutes or significant fraction thereof of anesthesia time. Anesthesia time begins when the anesthesiologist or anesthetist starts physically to prepare the patient for the induction of anesthesia in the operating room area (or its equivalent) and ends not more than 15 minutes after service in operating room is concluded and the patient is placed under post-operative supervision. If the anesthesia time extends beyond two hours, 1.0 units for each 10 minutes or significant fraction thereof is allowed after the first two hours. This does not apply to obstetrical anesthesia for which 15 minute time increments are applicable for the entire duration of the service. The total time units are multiplied by $39.00 to determine the allowable for time units. Actual time of beginning and duration of anesthesia time may require documentation, such as a copy of the anesthesia record in the hospital file. Fees when applicable are identical for general, spinal, regional or refrigeration anesthesia. When multiple surgical procedures are performed during the same period of anesthesia,

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only the greatest allowable of the various surgical procedures will be used. To this allowable are added time units applicable for the entire period of anesthesia time for the multiple procedures performed. 13. MISCELLANEOUS: a. b. For cardiopulmonary resuscitation (separate procedure unrelated to the administration of anesthesia) see CPT code 92950. Values for office and hospital visits, consultations and other medical services, x-rays, surgery, and laboratory procedures are listed in the sections entitled AEvaluation and [email protected], [email protected], [email protected], [email protected], and [email protected] A consultation fee is not payable to an anesthesiologist examining the patient before administering anesthesia to that patient. No additional charge is to be made for routine follow-up care and observation.

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CPT Code 00100 00102 00103 00104 00120 00124 00126 00140 00142 00144 00145 00147 00148 00160 00162 00164 00170 00172 00174 00176 00190 00192 00210 00212 00214 00215 00216 00218 00220 00222 00300 00320 00322 00326 00350 00352 00400 00402 00404 00406 00410

MAR $195.00 $234.00 $195.00 $156.00 $195.00 $156.00 $156.00 $195.00 $234.00 $234.00 $234.00 $234.00 $156.00 $195.00 $273.00 $156.00 $195.00 $234.00 $234.00 $273.00 $195.00 $273.00 $429.00 $195.00 $351.00 $351.00 $585.00 $507.00 $390.00 $234.00 $195.00 $234.00 $117.00 $390.00 $390.00 $195.00 $117.00 $195.00 $195.00 $507.00 $156.00

CPT Code 00450 00452 00454 00470 00472 00474 00500 00520 00522 00524 00528 00529 00530 00532 00534 00537 00539 00540 00541 00542 00546 00548 00550 00560 00561 00562 00563 00566 00580 00600 00604 00620 00622 00630 00632 00634 00635 00640 00670 00700

MAR $195.00 $234.00 $117.00 $234.00 $390.00 $507.00 $585.00 $234.00 $156.00 $156.00 $312.00 $429.00 $156.00 $156.00 $273.00 $312.00 $663.00 $507.00 $585.00 $585.00 $585.00 $585.00 $390.00 $585.00 $819.00 $780.00 $975.00 $975.00 $780.00 $390.00 $507.00 $390.00 $507.00 $312.00 $273.00 $390.00 $156.00 $117.00 $507.00 $117.00

CPT Code 00702 00730 00740 00750 00752 00754 00756 00770 00790 00792 00794 00796 00797 00800 00802 00810 00820 00830 00832 00834 00836 00840 00842 00844 00846 00848 00851 00860 00862 00864 00865 00866 00868 00870 00872 00873 00880 00882 00902 00904

MAR $156.00 $195.00 $195.00 $156.00 $234.00 $273.00 $273.00 $585.00 $273.00 $507.00 $312.00 $1,170.00 $390.00 $117.00 $195.00 $195.00 $195.00 $156.00 $234.00 $195.00 $234.00 $234.00 $156.00 $273.00 $312.00 $312.00 $234.00 $234.00 $273.00 $312.00 $312.00 $390.00 $390.00 $195.00 $273.00 $195.00 $585.00 $390.00 $195.00 $273.00

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 00906 00908 00910 00912 00914 00916 00918 00920 00921 00922 00924 00926 00928 00930 00932 00934 00936 00938 00940 00942 00944 00948 00950 00952 01112 01120 01130 01140 01150 01160 01170 01173 01180 01190 01200 01202 01210 01212 01214 01215

MAR $156.00 $234.00 $117.00 $195.00 $195.00 $195.00 $195.00 $117.00 $117.00 $234.00 $156.00 $156.00 $234.00 $156.00 $156.00 $234.00 $312.00 $156.00 $117.00 $156.00 $234.00 $156.00 $195.00 $156.00 $195.00 $234.00 $117.00 $585.00 $312.00 $156.00 $312.00 $468.00 $117.00 $156.00 $156.00 $156.00 $234.00 $390.00 $312.00 $390.00

CPT Code 01220 01230 01232 01234 01250 01260 01270 01272 01274 01320 01340 01360 01380 01382 01390 01392 01400 01402 01404 01420 01430 01432 01440 01442 01444 01462 01464 01470 01472 01474 01480 01482 01484 01486 01490 01500 01502 01520 01522 01610

MAR $156.00 $234.00 $195.00 $312.00 $156.00 $117.00 $312.00 $156.00 $234.00 $156.00 $156.00 $195.00 $117.00 $117.00 $117.00 $156.00 $156.00 $273.00 $195.00 $117.00 $117.00 $234.00 $195.00 $312.00 $312.00 $117.00 $117.00 $117.00 $195.00 $195.00 $117.00 $156.00 $156.00 $273.00 $117.00 $312.00 $234.00 $117.00 $195.00 $195.00

CPT Code 01620 01622 01630 01632 01634 01636 01638 01650 01652 01654 01656 01670 01680 01682 01710 01712 01714 01716 01730 01732 01740 01742 01744 01756 01758 01760 01770 01772 01780 01782 01810 01820 01829 01830 01832 01840 01842 01844 01850 01852

MAR $156.00 $156.00 $195.00 $234.00 $351.00 $585.00 $390.00 $234.00 $390.00 $312.00 $390.00 $156.00 $117.00 $156.00 $117.00 $195.00 $195.00 $195.00 $117.00 $117.00 $156.00 $195.00 $195.00 $234.00 $195.00 $273.00 $234.00 $234.00 $117.00 $156.00 $117.00 $117.00 $117.00 $117.00 $234.00 $234.00 $234.00 $234.00 $117.00 $156.00

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 01860 01905 01916 01920 01922 01924 01925 01926 01930 01931 01932 01933 01951 01952 01953 01958 01960 01961 01962 01963 01964 01967 01968 01969 01990 01991 01992 01995 01996 01999

MAR $117.00 $195.00 $195.00 $273.00 $273.00 $234.00 $312.00 $390.00 $195.00 $273.00 $273.00 $312.00 $117.00 $195.00 $39.00 BR $195.00 $273.00 $312.00 $390.00 $156.00 $195.00 $117.00 $195.00 $273.00 $117.00 $195.00 $195.00 $117.00 BR

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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SURGERY GROUND RULES General Information and Instructions 1. PACKAGE OR GLOBAL FEE CONCEPT: The listed maximum allowable reimbursement (MAR) for all surgical procedures includes the surgery, local infiltration, digital block and/or topical anesthesia when used and the normal follow-up care for the period indicated in days in the follow-up days (FUD) column. Regional or general anesthesia provided by the operating surgeon can be charged for by using the corresponding Basic Anesthesia Value only. Anesthesia Ground Rule 1(a) governs calculation of the maximum allowable reimbursement (MAR) for such anesthesia services. Payment is for the procedure coded and described, irrespective of the method(s) or appliance(s) used to perform the procedure. The allowables are applicable to all physicians who perform the listed services. 2. IMMEDIATE PRE-OPERATIVE VISITS AND OTHER SERVICES BY THE SURGEON: Under most circumstances, including ordinary referrals, the immediate pre-operative visit in the hospital or elsewhere necessary to examine the patient, complete the hospital records, and initiate the treatment program is included in the listed maximum allowable reimbursement (MAR) for the surgical procedure. ADDITIONAL CHARGES MAY BE WARRANTED FOR PRE-OPERATIVE SERVICES UNDER THE FOLLOWING CIRCUMSTANCES: a. when the pre-operative visit is the initial visit (e.g., an emergency) and prolonged detention or evaluation is required to prepare the patient or to establish the need for and type of surgical procedure. when the pre-operative visit is an initial consultation. when procedures not usually part of the basic surgical procedure (e.g., myelography prior to laminectomy, bronchoscopy prior to chest surgery) are provided during the immediate pre-operative period.

3.

b. c.

4.

FOLLOW-UP CARE FOR DIAGNOSTIC PROCEDURES (E.G., ENDOSCOPY, INJECTION PROCEDURES FOR RADIOGRAPHY): includes only that care related to recovery from the diagnostic procedure itself. Care of the condition for which the diagnostic procedure was performed or of other concomitant conditions is not included and may be charged for in accordance with the services rendered. MULTIPLE OR BILATERAL PROCEDURES: When multiple procedures, unrelated to the major procedure and adding significant time or complexity are provided at the same operative session, reimbursement will be as provided in this Ground Rule for the procedure with the highest allowance, plus half of the lesser procedure(s), up to a total maximum allowance of twice the highest value.

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The same rule applies for bilateral procedures when such are not specifically identified in the schedule. Multiple related procedures shall not warrant any additional reimbursement except in those areas where separate codes are listed. Related procedures are those without which the principal procedure cannot be adequately performed. EXAMPLES: Related Procedures: a. Open reduction of a fracture: The excision of a previous scar(s), the incision of fascia(s) and muscle(s), the identification and retraction of nerves, muscles and area structures and the closure of the wound irrespective of type of closure are all related to the principal procedure of the bone repair and merit no additional reimbursement. Repair of a tendon: The skin incision and linear closure, as well as the identification, incision and retraction of adjacent or overlying structures are related to the principal procedure and merit no additional reimbursement.

b.

Unrelated Procedures: a. b. Multiple lacerations of an area such as the face when such lacerations are not continuous. Fractures of arm (humerus) and of the forearm (radius and/or ulna) in the same extremity are considered as two (2) distinct areas and when treated by reduction and/or suturing, the unrelated procedures rule applies. If, however, these are treated in an office or out-patient site after the follow-up period(s) expires, they will be considered as related procedures.

For incidental procedures (e.g., incidental appendectomy, incidental scar excisions, puncture of ovarian cysts, lysis of adhesions, etc.) an additional reimbursement is not warranted. The closure of an incision or laceration incidental to the repair of deeper structures such as nerves, tendons, etc., does not merit any additional reimbursement irrespective of the method of closure. When more than one identifiable surgical procedure or service related to the care of the same entity is rendered during the total follow-up period, an additional reimbursement may be warranted. Identify each and reimburse as follows: The major procedure at full value and fifty percent (50%) for the lesser procedure(s) up to a total maximum of twice the greater value (e.g., unsuccessful closed reduction of a fracture followed on a different day by open reduction). Applying traction prior to either planned subsequent closed or open reduction shall not warrant additional reimbursement. 6. FOLLOW-UP OR AFTERCARE: a. Follow-up care for therapeutic surgical procedures includes all normal post-operative care. Uncommon or unusual complications, recurrence or the presence of other

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diseases or injuries requiring significant additional services concurrent with the procedure(s) or during the listed period of follow-up care may warrant additional reimbursement. If such charges are made, explain by report with adequate description. b. When an additional surgical procedure(s) is performed during the stated follow-up period and is related to the previously performed procedure(s) but is not an intrinsic part of the latter, the additional procedure will be paid at fifty percent (50%). In these instances, the follow-up periods will continue concurrently to their normal termination. When multiple procedures and/or services are performed concurrently or sequentially within the same operative or treatment setting, the longest follow-up period will apply to all as one item.

c.

7.

SEPARATE OR INDEPENDENT PROCEDURES: Certain of the listed procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate charge. When such a procedure is carried out as a separate procedure not immediately related to other services, the indicated value for "Separate Procedure" is applicable. PRIMARY, SECONDARY OR DELAYED PROCEDURES: A primary procedure refers to one that is attempted or performed for the first time, irrespective of the time relationship to the date of injury or the onset of the condition being treated. Secondary refers to treatment of a condition that has been specifically treated previously and is being treated subsequently. For example, where a tendon is lacerated and it is elected to close the laceration without suturing the tendon, the first direct repair of the tendon would constitute a delayed but primary repair. In this example, if the first repair is unsuccessful any subsequent repair of the tendon would be a secondary procedure. Delayed procedures have the same values as primary procedures. OPERATIVE REPORT AND BILLING: A bill for an operative procedure(s) shall not be deemed properly submitted unless and until an operative report is received by the payer. If performed in a hospital operating site, a copy of the hospital operative report shall be submitted. If in other sites, identify the location as well as submitting an informative description of the surgery performed. BY REPORT ("BR") ITEMS: "BR" in the maximum allowable reimbursement (MAR) column indicates that the value of this service is to be determined "by report" because the service is too unusual or variable to be assigned a value. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc., is to be furnished, using any of the following as indicated: a. b. c. d. e. Diagnosis (post-operative), pertinent history and physical findings. Size, location and number of lesion(s) or procedure(s) where appropriate. Major surgical procedure with supplementary procedure(s). Whenever possible, list the closest similar procedure by number and value. The "BR" value shall be consistent in value with other values in the schedule. Estimated follow-up period, if not listed.

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8.

9.

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f. 11. Operative time.

UNLISTED SERVICES OR PROCEDURES: A service or procedure that is not identified by a particular CPT7 code should be listed under the appropriate AUnlisted [email protected] These procedures often have A99" as the final two digits. The "Unlisted Procedure" and accompanying code for SURGERY will be found at the end of the relevant section or subsection. Values should be substantiated Aby [email protected] CONCURRENT SERVICES BY MORE THAN ONE PHYSICIAN: Charges for concurrent services of two or more physicians may be warranted under the following circumstances: a. IDENTIFIABLE MEDICAL SERVICES: Identifiable medical services provided prior to or during the surgical procedure or in the post-operative period are to be charged for by the physician(s) rendering the service(s) identified by the appropriate code and value. Such services are unrelated to the surgeon's fees. ASSISTANT SURGEON: Identify surgery performed by CPT number and description of procedure(s). The code(s) must coincide with those of the primary surgeon. Reimbursement will be at twenty percent (20%) of the code allowable. Assistant surgeon fees are not payable when the hospital provides intern or resident staff to assist at surgery. c. TWO SURGEONS: Under certain circumstances the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical problem. When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding the modifier >-62' to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s), including add-on procedure(s), are performed during the same surgical session, separate code(s) may also be reported with the modifier >-62' added. Under these circumstances, the total allowable may be increased by twenty-five percent (25%) in lieu of the assistant=s charges. By prior agreement, the total allowable for the procedure(s) may be apportioned in relation to the responsibility and work done. Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier >-80' or modifier >-82' added, as appropriate. SURGICAL TEAM: Under some circumstances highly complex procedures (e.g., open heart or organ transplant surgery) requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment are carried out under the "surgical team" concept with a single fee charged for the total service. The services covered vary widely and a single value cannot be assigned. The situations should be identified. The value should be supported by a report to include itemization of the physician services, paramedical personnel and equipment involved.

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b.

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13.

SURGERY AND FOLLOW-UP CARE PROVIDED BY DIFFERENT PHYSICIANS: When one physician performs the surgical procedure itself and another provides the follow-up care, the allowable may be apportioned between them by agreement and in accordance with medical ethics. Identify and indicate whether the value is for the procedure or the follow-up care, rather than the whole. The "global fee" is not increased, but pro-rated between the physicians. PRORATION OF SCHEDULED ALLOWABLE: When the schedule specifies a maximum allowable reimbursement for a definite treatment with an inclusive period of after-care (follow-up days), and the patient is transferred from one to another physician, the employer or insurance carrier is only responsible for the total amount listed in the schedule, such amount to be apportioned between the physicians. The concerned physicians shall agree upon the amount of proration, and shall render separate bills accordingly. REPEAT PROCEDURE BY ANOTHER PHYSICIAN: A basic procedure performed by another physician may have to be repeated. Identify and submit an explanatory note. DURABLE MEDICAL EQUIPMENT AND SUPPLIES PROVIDED BY PHYSICIAN: Durable medical equipment and supplies provided by the physician over and above those usually included in a visit to the physician=s office or in other services rendered are governed by the Durable Medical Equipment and Supplies Ground Rules. PHYSICIAN'S ASSISTANT OR REGISTERED NURSE FIRST ASSISTANT, (RNFA) AS ASSISTANT TO SURGEON (in lieu of Assistant Surgeon): A Physician's Assistant with current certification or RNFA assisting in surgery shall identify surgery performed by CPT number, modifier -81 and description of procedure. The code(s) must coincide with those of the surgeon. Reimbursement will be at ten percent (10%) of the code allowable. Physician Assistant or RNFA fees are not payable when qualified hospital staff are provided to assist at surgery. An assistant surgeon, and Physician Assistant or RNFA cannot both be present or their services billed on the same surgical case.

14.

15. 16.

17.

18. 19.

POUND (#) PROCEDURES: Procedures flagged with a pound (#) sign are valued at their appropriate level and Surgery Ground Rule 5 will not apply. AMPERSAND (&) PROCEDURES: Procedures flagged with an ampersand (&) will be valued as follows: 64727 : 25% of the primary procedure 64783 : The lesser of the maximum allowable reimbursement or 25% procedure 64872: The lesser of the maximum allowable reimbursement or 25% procedure 64874: The lesser of the maximum allowable reimbursement or 25% procedure 64876: The lesser of the maximum allowable reimbursement or 25% procedure 69990: 25% of the primary procedure of the primary of the primary of the primary of the primary

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20.

MEASUREMENTS IN CODED DESCRIPTORS: Measurements listed in coded descriptors are the original wound(s) or defect(s) before any treatment is effected. The stated maximum allowable(s) is inclusive of any additional creation of a defect and the necessary preparations for repair merit no additional reimbursement. The depth of a wound is not a factor in the measurements when the descriptor is stated in terms of length or square centimeters or square inches. EPIDURAL STEROID INJECTION LIMITATIONS: a. LOW BACK: Epidural steroid injections are not to be used for low back pain alone. For diagnosed radiculopathy with or without low back pain, supported by appropriate diagnostic tests such as MRI, CT Scan and/or Myelogram, the number of epidural steroid injections shall be limited to three (3) per year, unless reasonable medical evidence indicates that more would be of benefit. CERVICAL (NECK): Following appropriate diagnostic tests such as MRI, CT Scan and/or Myelogram, cervical epidural steroid injections shall be limited to two (2) per year. No more than one (1) injection is permitted if the injection is performed with fluoroscopic guidance and epidurography is used to confirm successful access of the epidural space and if the patient does not respond and the target structures were successfully anesthetized with the initial injection of local anesthetic.

21.

b.

22.

IDET PROCEDURE: Unlisted Procedure Code 64999 should be used in lieu of Code 62292 to charge for the injection procedure, including diskography, integral to the IDET (intradiscal electrothermal annuloplasty) procedure. The maximum allowable reimbursement (MAR) for the IDET injection procedure, including diskography, shall be the lesser of the provider's usual and customary charge One Thousand Six Hundred Twenty-two Dollars and Eightyeight Cents ($1,622.88). Substantiation "by report" is not required. This reimbursement is in addition to reimbursement allowable for the IDET procedure under Codes 64640, 76001-26, 72295-26, and 99141, as appropriate. The number of follow-up days (FUD) for the IDET procedure is 180 days. Surgery Ground Rule 5 is not applicable. SCLEROTHERAPY B PROLOTHERAPY AND CHEMONUCLEOLYSIS: Sclerotherapy/prolotherapy is not considered a reasonable procedure with proven value in the management of low back, neck, upper extremity, or lower extremity injuries. Chemonucleolysis is not considered a reasonable standard for surgical intervention for low back pain or radiculopathy. PAIN MANAGEMENT LIMITATIONS: a. b. Sympathetically mediated pain, complex regional pain syndrome and reflex sympathetic dystrophy are not surgically remedial. IMPLANTABLE PAIN MANAGEMENT DEVICES: (1) A pre-implantation psychological evaluation is required for implantable pain management devices. If issues such as secondary gain, unrealistic expectations, psychosocial pathology, or psychologic pathology are

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uncovered, the implantation of a pain management device should be canceled or postponed until these issues can be resolved. (2) A temporary trial of the planned implantable pain management device is required. Evidence of subjective and objective improvement should be documented. If the trial does not result in subjective and objective improvement the patient should not be selected as a candidate for the implantable pain management device.

c.

SYMPATHETIC BLOCKS FOR REFLEX SYMPATHETIC DYSTROPHY (RSD): The frequency of sympathetic blocks early in the course of treatment may be 2 to 5 times per week, depending on response to treatment. The frequency should gradually decrease (e.g. 3 times per week for two weeks, two times per week for one week, one time per week, etc.) as the duration of pain relief increases. If no response occurs after 1 to 2 weeks of intensive treatment (e.g. improvement in pain, swelling, function, color or temperature), the blocks should not be continued.

25.

PRIOR AUTHORIZATION REQUIREMENT FOR SPINAL SURGERIES: Prior authorization is required for: a. b. Primary surgery for a new acute disc herniation with unilateral radiation of leg pain much greater than back pain; and Greater than 2 contiguous spinal levels to be fused.

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CPT Code 10021 10022 10040 10060 10061 10080 10081 10120 10121 10140 10160 10180 11000 11001 11004 11005 11006 11008 11010 11011 11012 11040 11041 11042 11043 11044 11055 11056 11057 11100 11101 11200 11201 11300 11301 11302 11303 11305 11306

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 0 5 3 5 0 3 3 3 3 3 3 3 3 3 3 3 3 0 3 0 3 3 3 3 3 3

FUD 0 0 10 10 10 10 10 10 10 10 10 10 0 0 0 0 0 0 10 0 0 0 0 0 10 10 0 0 0 0 0 10 0 0 0 0 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 138.07 156.59 90.51 98.60 190.56 169.68 264.37 136.98 273.93 136.57 114.94 309.65 78.29 39.15 871.04 1,194.01 1,096.14 450.20 738.41 714.44 978.70 97.87 146.80 215.32 357.29 476.39 48.93 68.51 88.08 83.09 68.51 82.85 39.15 97.87 146.80 176.16 215.32 117.45 166.38

CPT Code 11307 11308 11310 11311 11312 11313 11400 11401 11402 11403 11404 11406 11420 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11450 11451 11462 11463 11470 11471 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623

Surg

Anes 3 3 5 5 5 5 3 3 3 3 3 3 5 5 5 5 5 5 5 5 5 5 5 5 3 3 3 3 3 3 3 3 3 3 3 3 5 5 5 5

FUD 0 0 0 0 0 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 90 90 90 90 90 90 10 10 10 10 10 10 10 10 10 10 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 195.74 234.89 127.23 176.16 205.53 274.03 113.23 132.55 151.66 170.94 195.74 240.97 110.72 141.71 165.68 219.94 274.03 313.19 138.07 175.95 208.94 263.93 313.19 354.55 535.94 655.04 595.49 655.04 655.04 738.41 157.91 182.23 195.74 215.32 264.25 308.10 166.38 244.67 322.97 401.27

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CPT Code 11624 11626 11640 11641 11642 11643 11644 11646 11719 11720 11721 11730 11732 11740 11750 11752 11755 11760 11762 11765 11770 11771 11772 11900 11901 11920 11921 11922 11950 11951 11952 11954 11960 11970 11971 11975 11976 11977 11980 11981

Surg

Anes 5 5 5 5 5 5 5 5 3 3 3 3 0 3 3 3 3 3 3 3 5 5 5 3 3 3 3 0 3 3 3 3 3 3 3 3 3 3 3 3

FUD 10 10 10 10 10 10 10 10 0 0 0 0 0 0 10 10 0 10 10 10 10 90 90 0 0 0 0 0 0 0 0 0 90 90 90 0 0 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 479.56 557.86 264.25 362.12 459.99 557.86 655.73 753.60 29.36 48.93 88.08 97.87 68.51 58.72 297.75 451.03 176.16 313.19 459.99 98.51 250.10 774.13 952.79 48.93 60.25 342.54 685.09 489.35 137.02 274.03 548.07 195.74 1,321.24 1,468.04 441.26 107.66 145.91 391.48 107.66 137.02

CPT Code 11982 11983 12001 12002 12004 12005 12006 12007 12011 12013 12014 12015 12016 12017 12018 12020 12021 12031 12032 12034 12035 12036 12037 12041 12042 12044 12045 12046 12047 12051 12052 12053 12054 12055 12056 12057 13100 13101 13102 13120

Surg

Anes 3 3 5 5 5 5 5 5 5 5 5 5 5 5 5 3 3 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 3 3 0 5

FUD 0 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 0 10 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 166.38 283.82 151.40 165.68 197.95 235.61 293.63 330.45 159.83 175.47 207.93 262.02 310.99 303.40 342.54 263.19 176.16 182.65 255.24 254.46 351.04 393.96 443.00 202.50 245.48 264.25 363.16 438.32 450.56 234.26 245.27 293.61 352.33 411.06 491.89 528.49 293.15 350.74 146.80 304.55

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CPT Code 13121 13122 13131 13132 13133 13150 13151 13152 13153 13160 14000 14001 14020 14021 14040 14041 14060 14061 14300 14350 15000 15001 15050 15100 15101 15120 15121 15200 15201 15220 15221 15240 15241 15260 15261 15342 15343 15350 15351 15400

Surg #

Anes 5 0 5 5 0 5 5 5 0 3 3 3 5 5 5 5 5 5 5 3 3 0 3 3 0 5 0 3 0 5 0 5 0 5 0 5 0 3 0 3

FUD 10 0 10 10 0 10 10 10 0 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 0 90 0 90 0 90 0 90 0 90 0 10 0 90 0 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 375.94 146.80 333.76 487.13 176.16 354.87 379.79 606.80 225.10 750.59 774.13 893.24 734.02 929.76 1,044.72 1,429.17 1,548.28 1,516.98 1,614.85 952.79 342.54 176.16 456.79 889.04 219.57 1,310.08 401.27 720.05 195.74 750.32 293.61 1,131.43 391.48 1,429.17 587.22 264.25 68.51 425.58 156.59 332.72

CPT Code 15401 15570 15572 15574 15576 15600 15610 15620 15630 15650 15732 15734 15736 15738 15740 15750 15756 15757 15758 15760 15770 15775 15776 15780 15781 15782 15783 15786 15787 15788 15789 15792 15793 15810 15811 15819 15820 15821 15822 15823

Surg #

Anes 0 3 5 5 5 3 5 5 5 3 5 3 5 4 3 3 3 3 4 5 5 5 5 5 5 3 3 5 0 5 5 3 3 3 3 5 5 5 5 5

FUD 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 90 10 0 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 137.02 978.70 1,272.30 1,272.30 1,076.57 595.49 595.49 655.04 774.13 952.79 2,055.26 1,859.52 1,859.52 1,859.52 1,076.57 1,174.44 4,404.13 4,404.13 4,404.13 1,071.88 1,429.17 340.27 454.69 978.70 489.35 564.83 450.18 216.92 78.29 833.69 1,071.88 595.49 833.69 361.11 454.76 2,227.14 1,190.98 1,250.53 1,012.33 1,071.88

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CPT Code 15824 15825 15826 15828 15829 15831 15832 15833 15834 15835 15836 15837 15838 15839 15840 15841 15842 15845 15850 15851 15852 15860 15876 15877 15878 15879 15920 15922 15931 15933 15934 15935 15936 15937 15940 15941 15944 15945 15946 15950

Surg

Anes 5 5 5 5 3 5 3 3 3 3 3 3 5 3 5 5 5 3 3 3 3 3 5 4 3 3 6 6 5 6 5 6 5 6 3 6 3 6 6 5

FUD 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 812.31 694.88 587.22 1,986.75 1,986.75 2,381.96 1,977.02 1,977.02 1,977.02 1,977.02 1,190.98 988.51 952.79 1,076.57 2,348.87 2,740.35 3,425.44 2,446.74 244.67 342.54 176.16 244.67 479.56 861.25 479.56 861.25 636.15 831.89 636.87 1,076.57 884.58 1,272.30 978.70 1,419.11 782.96 1,076.57 978.70 1,174.44 1,957.39 548.94

CPT Code 15951 15952 15953 15956 15958 15999 16000 16010 16015 16020 16025 16030 16035 16036 17000 17003 17004 17106 17107 17108 17110 17111 17250 17260 17261 17262 17263 17264 17266 17270 17271 17272 17273 17274 17276 17280 17281 17282 17283 17284

Surg

Anes 6 5 6 5 6 5 3 3 3 0 0 0 3 0 3 0 3 3 3 3 3 3 3 3 3 3 3 3 3 5 5 5 5 5 5 5 5 5 5 5

FUD 90 90 90 90 90 0 0 0 0 0 0 0 90 0 10 0 10 90 90 90 10 10 0 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 786.78 814.17 978.70 1,125.50 1,321.24 72.54 97.87 195.74 84.82 150.14 195.74 508.93 244.67 107.19 19.58 381.11 500.21 952.79 1,429.17 90.23 119.09 78.29 127.23 166.38 225.10 254.46 274.03 332.75 165.68 205.53 244.67 293.61 362.12 450.20 156.59 244.67 283.82 371.90 479.56

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CPT Code 17286 17304 17305 17306 17307 17310 17340 17360 17380 17999 19000 19001 19020 19030 19100 19101 19102 19103 19110 19112 19120 19125 19126 19140 19160 19162 19180 19182 19200 19220 19240 19260 19271 19272 19290 19291 19295 19296 19297 19298

Surg # # # # #

Anes 5 5 5 5 5 5 5 5 5 5 3 0 3 3 3 3 3 3 3 3 3 3 0 3 3 5 3 3 5 13 5 6 13 13 3 0 0 3 0 3

FUD 10 0 0 0 0 0 10 10 0 0 0 0 90 0 0 10 0 0 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 626.36 744.36 342.54 342.54 342.54 102.97 59.55 117.61 68.51 117.45 29.36 401.11 176.00 136.42 314.56 254.46 598.97 512.12 500.21 595.49 833.69 342.54 833.69 714.59 2,024.67 1,238.62 1,190.98 1,859.52 2,544.61 2,262.86 1,663.78 2,740.35 3,425.44 166.38 88.08 195.74 4,891.21 146.80 1,858.02

CPT Code 19316 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19361 19364 19366 19367 19368 19369 19370 19371 19380 19396 19499 20000 20005 20100 20101 20102 20103 20150 20200 20205 20206 20220 20225 20240 20245 20250 20251 20500 20501

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 3 3 5 3 4 3 6 3 3 3 3 10 6 5 10 8 3 3

FUD 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 10 10 10 10 10 10 90 0 0 0 0 0 10 10 10 10 10 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,272.30 1,761.65 489.35 1,076.57 451.34 636.15 1,419.11 1,565.91 933.20 731.20 2,348.87 3,425.44 3,523.31 3,523.31 3,523.31 4,404.13 3,957.98 685.09 782.96 711.83 146.80 197.80 287.51 1,291.88 381.69 489.35 655.73 1,957.39 181.36 254.39 289.35 228.76 1,006.89 274.03 606.79 1,879.10 1,536.56 140.81 143.49

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CPT Code 20520 20525 20526 20550 20551 20552 20553 20600 20605 20610 20612 20615 20650 20660 20661 20662 20663 20664 20665 20670 20680 20690 20692 20693 20694 20802 20805 20808 20816 20822 20824 20827 20838 20900 20902 20910 20912 20920 20922 20924

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 4 5 5 6 4 5 5 3 5 3 3 3 3 6 6 6 6 6 6 6 8 3 6 6 5 4 4 4

FUD 10 10 0 0 0 0 0 0 0 0 0 10 10 0 90 90 90 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 202.50 504.83 79.53 60.79 59.65 58.72 176.16 54.60 59.62 71.91 58.78 362.12 191.31 233.53 432.62 598.30 598.30 1,021.72 141.14 515.37 485.55 598.30 1,076.94 543.08 461.52 6,361.52 6,361.52 5,872.18 2,845.63 2,476.62 3,131.83 2,691.41 6,361.52 575.86 625.91 570.69 570.69 400.56 583.71 520.63

CPT Code 20926 20930 20931 20936 20937 20938 20950 20955 20956 20957 20962 20969 20970 20972 20973 20974 20975 20979 20982 20999 21010 21015 21025 21026 21029 21030 21031 21032 21034 21040 21044 21045 21046 21047 21048 21049 21050 21060 21070 21076

Surg # # # # # #

Anes 3 0 0 0 0 0 3 8 6 8 8 8 6 8 8 5 3 0 0 5 5 5 5 5 5 5 5 5 5 5 7 5 5 5 5 5 5 5 5

FUD 90 0 0 0 0 0 0 90 90 90 90 90 90 90 90 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 433.12 $0.00 274.03 $0.00 401.27 440.41 315.94 5,970.05 5,970.05 5,970.05 2,811.18 2,995.90 5,970.05 5,970.05 5,970.05 293.61 313.19 195.74 4,457.83 1,272.30 782.96 920.81 978.70 1,076.57 1,272.30 665.51 587.22 1,565.91 782.96 1,556.12 3,816.91 1,044.78 1,409.32 1,073.90 1,360.39 1,810.59 1,468.04 1,859.52 2,025.90

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CPT Code 21077 21079 21080 21081 21082 21083 21084 21085 21086 21087 21088 21089 21100 21110 21116 21120 21121 21122 21123 21125 21127 21137 21138 21139 21141 21142 21143 21145 21146 21147 21150 21151 21154 21155 21159 21160 21172 21175 21179 21180

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 7 7 5 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

FUD 90 90 90 90 90 90 90 10 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 7,438.09 1,833.62 2,076.00 1,889.47 1,688.61 1,595.64 1,862.60 724.47 2,040.55 2,018.88 900.40 623.97 782.40 199.54 1,174.44 1,468.04 1,908.46 2,202.07 2,556.51 2,122.57 1,683.36 2,202.07 2,348.87 2,769.71 2,838.22 2,985.02 3,180.76 3,670.11 4,012.65 1,772.22 2,159.30 2,433.01 3,193.33 7,046.61 7,758.81 4,746.68 5,676.44 3,425.44 4,012.65

CPT Code 21181 21182 21183 21184 21188 21193 21194 21195 21196 21198 21199 21206 21208 21209 21210 21215 21230 21235 21240 21242 21243 21244 21245 21246 21247 21248 21249 21255 21256 21260 21261 21263 21267 21268 21270 21275 21280 21282 21295 21296

Surg

Anes 7 7 7 7 7 7 7 7 7 7 7 7 7 7 5 5 5 5 5 5 5 5 7 7 7 7 7 7 7 7 11 7 7 11 5 7 5 5 5 5

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,272.30 4,110.52 4,404.13 4,629.23 3,425.44 2,936.09 4,130.10 3,523.31 3,719.04 1,859.52 2,055.26 2,251.00 1,304.93 1,859.52 1,957.39 2,446.74 1,859.52 1,370.17 2,593.54 2,740.35 2,740.35 2,544.61 1,859.52 3,621.18 3,816.91 1,468.04 1,761.65 2,348.87 5,382.83 3,816.91 6,361.52 6,361.52 3,816.91 6,361.52 1,663.78 817.93 1,663.78 1,321.24 1,076.57 1,468.04

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CPT Code 21299 21300 21310 21315 21320 21325 21330 21335 21336 21337 21338 21339 21340 21343 21344 21345 21346 21347 21348 21355 21356 21360 21365 21366 21385 21386 21387 21390 21395 21400 21401 21406 21407 21408 21421 21422 21423 21431 21432 21433

Surg

Anes 5 7 5 5 5 5 5 5 5 5 5 5 5 5 5 7 7 7 7 5 5 7 7 7 7 7 7 7 7 5 5 7 7 7 5 7 7 5 7 7

FUD 90 0 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 127.23 112.23 227.61 411.06 493.99 978.70 1,761.65 802.53 353.05 1,468.04 1,683.36 1,663.78 1,370.17 2,613.12 978.70 1,468.04 1,683.36 2,681.63 902.05 883.64 1,301.66 1,468.04 2,348.87 1,331.03 1,761.65 1,761.65 1,859.52 2,525.03 161.74 1,370.17 1,565.91 1,761.65 2,016.12 1,223.37 1,468.04 2,084.62 1,565.91 1,859.52 2,153.13

CPT Code 21435 21436 21440 21445 21450 21451 21452 21453 21454 21461 21462 21465 21470 21480 21485 21490 21493 21494 21495 21497 21499 21501 21502 21510 21550 21555 21556 21557 21600 21610 21615 21616 21620 21627 21630 21632 21685 21700 21705 21720

Surg

Anes 7 7 7 7 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 0 5 6 10 5 5 5 6 6 6 6 6 6 10 13 12 12 5 6 5

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 2,348.87 3,219.91 1,555.58 1,914.56 412.82 782.96 581.62 851.47 1,468.04 1,419.11 1,683.36 1,419.11 1,859.52 274.03 851.47 1,272.30 156.48 1,370.17 1,859.52 1,272.30 543.08 754.78 478.64 227.57 405.86 598.30 1,468.04 662.73 2,393.20 1,914.56 2,439.22 2,393.20 957.28 2,991.50 4,786.39 959.19 782.40 1,500.35 782.40

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CPT Code 21725 21740 21742 21743 21750 21800 21805 21810 21820 21825 21899 21920 21925 21930 21935 22100 22101 22102 22103 22110 22112 22114 22116 22210 22212 22214 22216 22220 22222 22224 22226 22305 22310 22315 22318 22319 22325 22326 22327 22328

Surg

Anes 5 13 10 12 10 6 6 10 6 10 0 5 5 5 5 10 10 8 0 10 10 8 0 13 13 13 0 10 10 8 0 8 8 0 10 10 8 10 10 0

FUD 90 90 90 90 90 90 90 90 90 90 30 10 90 90 90 90 90 90 0 90 90 90 0 90 90 90 0 90 90 90 0 90 90 90 90 90 90 90 90 0 $ $ BR BR $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,021.72 2,348.87

CPT Code 22505 22520 22521 22522 22532 22533 22534 22548 22554 22556 22558 22585 22590 22595 22600 22610 22612 22614 22630 22632 22800 22802 22804 22808 22810 22812 22818 22819 22830 22840 22841 22842 22843 22844 22845 22846 22847 22848 22849 22850

Surg

Anes 3 5 5 0 10 8 0 13 10 10 8 0 10 10 10 10 8 0 8 0 13 13 13 13 13 13 13 13 13 13 10 13 13 13 13 13 13 13 13 13

FUD 10 10 10 0 90 90 0 90 90 90 90 0 90 90 90 90 90 0 90 0 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 182.47 2,736.01 2,495.17 420.84 1,670.67 1,567.42 394.93 3,376.50 2,544.61 2,936.09 2,740.35 782.96 3,131.83 3,131.83 2,544.61 2,446.74 2,936.09 880.83 2,808.19 842.45 2,936.09 4,110.52 4,893.48 3,425.44 4,012.65 4,306.26 3,523.31 4,061.59 1,761.65 1,087.76 0.00 1,761.65 1,908.46 2,153.13 1,663.78 1,761.65 1,957.39 831.89 1,520.63 978.70

#

1,957.39 119.66 1,196.60 2,871.84 303.76 1,196.60 215.92 399.97 443.39 1,468.04 1,084.23 880.94 948.70 332.75 1,355.29 1,355.29 1,288.64 332.75 3,180.76 2,740.35 2,642.48 880.83 3,033.96 3,033.96 3,033.96 880.83 244.67 355.99 926.06 3,131.83 3,376.50 1,761.65 2,544.61 2,348.87 685.09

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Schedule of Medical and Hospital Fees

Effective 01/01/06

Surgery Ground Rules

CPT Code 22851 22852 22855 22899 22900 22999 23000 23020 23030 23031 23035 23040 23044 23065 23066 23075 23076 23077 23100 23101 23105 23106 23107 23120 23125 23130 23140 23145 23146 23150 23155 23156 23170 23172 23174 23180 23182 23184 23190 23195

Surg #

Anes 13 13 13 3 4 4 5 5 5 5 5 5 5 3 5 3 5 5 5 5 5 5 5 5 6 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 0 90 90 90 90 0 90 90 10 10 90 90 90 10 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ BR $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 929.76 1,370.17 1,174.44 598.30 745.58 1,362.28 436.47 423.05 1,435.92 1,362.28 837.62 239.32 480.17 293.61 598.30 1,468.04 1,362.28 1,362.28 1,468.04 1,174.44 1,174.44 898.62 1,914.56 898.62 745.58 910.18 734.02 1,435.92 1,468.04 1,272.30 587.22 717.96 1,194.01 734.21 717.96 1,196.60 782.40 1,794.90

CPT Code 23200 23210 23220 23221 23222 23330 23331 23332 23350 23395 23397 23400 23405 23406 23410 23412 23415 23420 23430 23440 23450 23455 23460 23462 23465 23466 23470 23472 23480 23485 23490 23491 23500 23505 23515 23520 23525 23530 23532 23540

Surg

Anes 6 6 6 6 6 3 6 10 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 10 5 5 5 5 5 5 5 4 4 5 5 4

FUD 90 90 90 90 90 10 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,435.92 1,914.56 1,914.56 1,761.65 1,761.65 851.47 1,316.26 1,634.43 175.02 1,264.47 1,500.35 1,794.90 1,021.72 1,399.10 1,370.17 1,707.38 1,196.60 1,859.52 1,174.44 1,174.44 1,644.21 1,849.73 1,976.97 1,859.52 1,859.52 1,957.39 1,957.39 3,425.44 978.70 1,272.30 867.92 1,062.97 266.94 342.54 880.83 239.32 334.94 782.96 1,076.57 209.50

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Schedule of Medical and Hospital Fees

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Surgery Ground Rules

CPT Code 23545 23550 23552 23570 23575 23585 23600 23605 23615 23616 23620 23625 23630 23650 23655 23660 23665 23670 23675 23680 23700 23800 23802 23900 23920 23921 23929 23930 23931 23935 24000 24006 24065 24066 24075 24076 24077 24100 24101 24102

Surg

Anes 4 5 5 5 5 5 4 4 5 5 4 4 5 0 4 5 4 5 4 5 4 5 5 15 9 3 5 3 3 4 4 4 3 3 3 3 6 4 4 4

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 0 10 10 90 90 90 10 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 305.26 1,380.69 1,272.30 216.49 369.79 1,125.50 306.88 489.35 1,174.44 2,808.86 247.02 367.39 890.62 322.17 469.44 1,125.50 406.80 1,125.50 536.71 1,419.11 358.98 1,957.39 2,055.26 2,642.48 1,859.52 598.30 373.21 305.14 717.96 1,316.26 1,702.86 214.50 575.93 456.48 598.30 1,174.44 828.41 1,316.26 1,419.11

CPT Code 24105 24110 24115 24116 24120 24125 24126 24130 24134 24136 24138 24140 24145 24147 24149 24150 24151 24152 24153 24155 24160 24164 24200 24201 24220 24300 24301 24305 24310 24320 24330 24331 24332 24340 24341 24342 24343 24344 24345 24346

Surg

Anes 3 5 5 5 4 4 4 3 4 3 3 4 3 3 6 6 6 6 6 4 4 4 3 3 3 3 3 3 5 5 3 3 3 5 3 3 4 4 4 4

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 598.30 1,196.60 1,321.24 1,076.57 984.90 1,008.05 880.83 1,021.72 1,435.92 1,435.92 1,435.92 1,435.92 957.28 902.05 1,957.39 1,663.78 1,859.52 1,468.04 1,957.39 1,481.95 1,159.78 1,021.72 208.41 579.11 195.43 489.35 1,675.24 690.35 598.30 1,663.78 1,076.57 1,399.53 861.25 1,370.17 1,272.30 1,370.17 1,135.29 1,712.72 1,135.29 1,712.72

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Oklahoma Workers= Compensation Court =

Schedule of Medical and Hospital Fees

Effective 01/01/06

Surgery Ground Rules

CPT Code 24350 24351 24352 24354 24356 24360 24361 24362 24363 24365 24366 24400 24410 24420 24430 24435 24470 24495 24498 24500 24505 24515 24516 24530 24535 24538 24545 24546 24560 24565 24566 24575 24576 24577 24579 24582 24586 24587 24600 24605

Surg

Anes 3 3 3 3 4 4 4 4 7 4 4 5 5 5 5 5 4 3 5 3 3 4 4 3 3 3 4 4 3 3 3 4 3 3 4 3 4 4 0 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 598.30 717.96 957.28 837.62 898.62 2,153.13 2,153.13 2,251.00 2,740.35 1,196.60 1,316.26 1,331.03 1,516.98 1,516.98 1,663.78 1,957.39 831.89 1,435.92 978.70 330.73 616.57 1,546.34 1,546.34 357.29 613.67 880.83 1,360.39 2,074.84 297.75 506.05 714.44 978.70 311.42 528.80 978.70 782.96 1,507.19 2,153.13 374.96 452.33

CPT Code 24615 24620 24635 24640 24650 24655 24665 24666 24670 24675 24685 24800 24802 24900 24920 24925 24930 24931 24935 24940 24999 25000 25001 25020 25023 25024 25025 25028 25031 25035 25040 25065 25066 25075 25076 25077 25085 25100 25101 25105

Surg

Anes 4 3 4 3 3 3 3 3 3 3 3 4 3 6 6 6 6 6 6 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,037.42 587.22 1,174.44 239.32 242.13 426.95 782.96 910.18 272.14 444.28 812.31 1,614.85 1,957.39 978.70 890.62 555.88 880.83 1,125.50 1,468.04 1,468.04 543.08 518.71 662.73 1,159.80 1,203.79 1,947.60 548.81 488.55 852.63 662.73 210.78 456.03 393.09 598.30 1,174.44 644.32 598.30 708.76 957.28

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Schedule of Medical and Hospital Fees

Effective 01/01/06

Surgery Ground Rules

CPT Code 25107 25110 25111 25112 25115 25116 25118 25119 25120 25125 25126 25130 25135 25136 25145 25150 25151 25170 25210 25215 25230 25240 25246 25248 25250 25251 25259 25260 25263 25265 25270 25272 25274 25275 25280 25290 25295 25300 25301 25310

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 6 3 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 837.62 446.34 543.08 681.14 1,196.60 1,196.60 837.62 1,196.60 994.10 1,027.63 929.76 717.96 782.96 587.22 1,174.44 763.99 902.05 1,794.90 837.62 1,196.60 644.32 644.32 194.37 598.30 1,196.60 1,794.90 489.35 957.28 1,021.72 994.09 730.05 806.69 916.67 1,096.14 865.23 808.70 759.71 929.76 831.89 959.12

CPT Code 25312 25315 25316 25320 25332 25335 25337 25350 25355 25360 25365 25370 25375 25390 25391 25392 25393 25394 25400 25405 25415 25420 25425 25426 25430 25431 25440 25441 25442 25443 25444 25445 25446 25447 25449 25450 25455 25490 25491 25492

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 6 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,174.44 1,076.57 1,272.30 1,468.04 1,468.04 1,761.65 1,321.24 1,008.05 1,203.79 1,008.05 1,409.32 1,224.99 1,761.65 1,086.35 1,428.90 1,468.04 1,761.65 1,272.30 1,174.44 1,419.11 1,663.78 1,937.81 1,411.19 1,859.52 1,125.50 1,115.71 1,321.24 1,370.17 880.83 1,076.57 1,076.57 1,076.57 2,202.07 1,468.04 1,069.01 749.18 838.38 956.74 1,005.07 1,148.57

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Schedule of Medical and Hospital Fees

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Surgery Ground Rules

CPT Code 25500 25505 25515 25520 25525 25526 25530 25535 25545 25560 25565 25574 25575 25600 25605 25611 25620 25622 25624 25628 25630 25635 25645 25650 25651 25652 25660 25670 25671 25675 25676 25680 25685 25690 25695 25800 25805 25810 25820 25825

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 266.94 486.66 890.62 851.47 1,653.99 2,525.03 395.80 464.13 880.83 349.77 708.76 851.47 1,340.82 358.98 541.16 831.89 880.83 423.41 446.65 685.09 423.41 506.26 616.57 567.64 665.51 988.48 394.07 773.17 812.31 425.74 782.96 451.63 1,076.57 499.14 1,196.60 1,223.37 1,536.56 1,370.17 1,125.50 1,272.30

CPT Code 25830 25900 25905 25907 25909 25915 25920 25922 25924 25927 25929 25931 25999 26010 26011 26020 26025 26030 26034 26035 26037 26040 26045 26055 26060 26070 26075 26080 26100 26105 26110 26115 26116 26117 26121 26123 26125 26130 26135 26140

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 0 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,321.24 910.18 883.33 801.15 910.18 1,503.27 812.31 607.36 822.10 978.70 570.62 978.70 279.55 432.89 607.50 662.73 1,076.94 717.96 1,739.67 1,435.92 358.98 598.30 665.37 303.76 607.50 598.30 543.08 607.50 598.30 543.08 670.92 598.30 1,174.44 1,174.44 1,370.17 587.22 782.96 880.83 782.96

#

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Oklahoma Workers= Compensation Court =

Schedule of Medical and Hospital Fees

Effective 01/01/06

Surgery Ground Rules

CPT Code 26145 26160 26170 26180 26185 26200 26205 26210 26215 26230 26235 26236 26250 26255 26260 26261 26262 26320 26340 26350 26352 26356 26357 26358 26370 26372 26373 26390 26392 26410 26412 26415 26416 26418 26420 26426 26428 26432 26433 26434

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 880.83 611.60 543.08 598.30 567.64 745.58 734.02 644.32 636.15 662.73 598.30 598.30 978.70 1,272.30 1,027.63 1,223.37 978.70 598.30 440.41 826.55 1,125.50 1,063.77 984.70 1,223.37 957.28 1,353.08 980.35 923.86 1,316.26 663.29 837.62 1,021.72 1,196.60 659.89 826.09 779.19 880.83 717.96 717.96 782.96

CPT Code 26437 26440 26442 26445 26449 26450 26455 26460 26471 26474 26476 26477 26478 26479 26480 26483 26485 26489 26490 26492 26494 26496 26497 26498 26499 26500 26502 26504 26508 26510 26516 26517 26518 26520 26525 26530 26531 26535 26536 26540

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 717.96 736.95 975.75 717.96 957.28 478.64 598.30 428.51 694.88 673.29 650.19 654.28 713.51 700.67 880.83 1,174.44 1,008.05 1,301.66 998.27 1,291.88 1,174.44 1,370.17 1,174.44 1,614.85 1,614.85 705.40 782.96 820.02 782.96 782.96 790.21 916.63 1,096.14 767.34 771.82 782.96 978.70 782.96 978.70 1,027.63

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 26541 26542 26545 26546 26548 26550 26551 26553 26554 26555 26556 26560 26561 26562 26565 26567 26568 26580 26587 26590 26591 26593 26596 26600 26605 26607 26608 26615 26641 26645 26650 26665 26670 26675 26676 26685 26686 26700 26705 26706

Surg

Anes 3 3 3 3 3 3 6 6 6 3 6 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 0 3 3 3 3 0 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,125.50 978.70 775.76 1,017.84 853.60 2,153.13 5,382.83 5,382.83 6,361.52 1,450.22 5,382.83 1,196.60 1,702.86 1,565.91 831.89 764.44 1,001.79 1,957.39 983.96 1,352.56 685.09 663.55 1,174.44 226.34 303.76 598.30 883.64 837.62 350.22 478.64 902.05 1,261.03 327.30 420.49 506.99 717.96 957.28 307.96 393.27 478.64

CPT Code 26715 26720 26725 26727 26735 26740 26742 26746 26750 26755 26756 26765 26770 26775 26776 26785 26820 26841 26842 26843 26844 26850 26852 26860 26861 26862 26863 26910 26951 26952 26989 26990 26991 26992 27000 27001 27003 27005 27006 27025

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 0 3 3 3 3 3 3 3 3 3 3 3 0 3 0 3 3 3 3 6 6 6 4 4 4 4 4 4

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 0 90 90 90 0 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $

MAR 837.62 182.47 333.11 476.18 717.96 303.76 423.41 717.96 171.07 308.40 418.17 478.64 265.58 365.56 447.60 364.64 1,154.86 828.54 988.48 815.95 988.48 780.74 880.83 637.80 195.74 804.11 293.61 782.96 662.73 837.62 616.85 729.39 993.34 459.53 551.92 837.62 743.00 837.62 988.48

# #

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Schedule of Medical and Hospital Fees

Effective 01/01/06

Surgery Ground Rules

CPT Code 27030 27033 27035 27036 27040 27041 27047 27048 27049 27050 27052 27054 27060 27062 27065 27066 27067 27070 27071 27075 27076 27077 27078 27079 27080 27086 27087 27090 27091 27093 27095 27096 27097 27098 27100 27105 27110 27111 27120 27122

Surg

Anes 6 6 6 6 3 3 3 6 10 8 6 6 4 4 6 6 6 8 6 10 10 10 10 10 6 6 6 6 10 0 4 4 4 4 4 4 4 4 6 6

FUD 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 0 0 0 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,370.17 1,379.96 1,683.36 1,614.85 326.74 702.56 608.94 598.30 1,468.04 587.22 1,321.24 1,976.97 662.73 478.64 598.30 929.76 1,174.44 838.98 1,435.92 2,338.57 3,131.83 4,404.13 1,174.44 1,370.17 587.22 256.85 644.47 1,370.17 3,914.78 226.79 391.48 293.61 650.54 1,174.44 1,419.11 1,516.98 1,810.59 1,859.52 2,348.87 2,446.74

CPT Code 27125 27130 27132 27134 27137 27138 27140 27146 27147 27151 27156 27158 27161 27165 27170 27175 27176 27177 27178 27179 27181 27185 27187 27193 27194 27200 27202 27215 27216 27217 27218 27220 27222 27226 27227 27228 27230 27232 27235 27236

Surg

Anes 8 8 8 10 10 10 6 6 6 6 6 6 6 6 6 4 6 6 6 6 6 6 6 4 4 6 6 6 4 8 8 4 4 10 10 10 4 4 4 6

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 2,642.48 3,180.76 3,523.31 3,719.04 3,131.83 3,131.83 1,194.01 2,251.00 2,544.61 2,544.61 2,838.22 2,251.00 1,761.65 2,270.58 2,378.23 1,076.57 2,104.20 2,202.07 2,231.42 1,614.85 2,368.45 722.60 3,425.44 714.44 812.31 193.30 959.63 1,321.24 3,063.31 2,446.74 3,503.73 501.85 963.44 2,652.27 5,099.01 8,152.53 461.97 978.70 2,055.26 2,642.48

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 27238 27240 27244 27245 27246 27248 27250 27252 27253 27254 27256 27257 27258 27259 27265 27266 27275 27280 27282 27284 27286 27290 27295 27299 27301 27303 27305 27306 27307 27310 27315 27320 27323 27324 27327 27328 27329 27330 27331 27332

Surg

Anes 4 4 6 6 4 6 0 4 6 6 0 4 6 6 0 4 4 8 8 6 6 15 10 6 4 6 4 4 4 4 4 4 3 4 3 4 8 4 4 4

FUD 90 90 90 90 90 90 90 90 90 90 10 10 90 90 90 90 10 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 448.40 1,076.57 1,928.03 2,505.46 386.29 793.70 486.78 758.69 1,663.78 2,446.74 810.00 1,435.92 1,761.65 1,859.52 410.39 586.14 358.98 1,370.17 1,761.65 2,642.48 2,936.09 3,914.78 2,642.48 678.68 662.73 717.96 392.67 472.31 1,223.37 1,316.26 1,316.26 235.68 382.85 430.51 598.30 1,370.17 1,223.37 1,321.24 1,565.91

CPT Code 27333 27334 27335 27340 27345 27347 27350 27355 27356 27357 27358 27360 27365 27370 27372 27380 27381 27385 27386 27390 27391 27392 27393 27394 27395 27396 27397 27400 27403 27405 27407 27409 27412 27415 27418 27420 27422 27424 27425 27427

Surg

Anes 4 4 4 4 4 4 4 5 5 5 0 5 5 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

FUD 90 90 90 90 90 90 90 90 90 90 0 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,575.70 1,761.65 1,859.52 957.28 1,076.94 734.02 1,435.92 1,316.26 1,370.17 1,468.04 1,565.91 1,174.44 1,761.65 183.41 625.91 1,076.57 1,272.30 1,282.09 1,565.91 717.96 957.28 1,435.92 837.62 1,076.94 1,555.58 1,585.49 1,751.86 1,468.04 1,663.78 1,370.17 1,663.78 1,957.39 2,485.89 2,074.84 2,055.26 1,516.98 1,516.98 1,614.85 1,565.91 1,859.52

#

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

Page 47

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CPT Code 27428 27429 27430 27435 27437 27438 27440 27441 27442 27443 27445 27446 27447 27448 27450 27454 27455 27457 27465 27466 27468 27470 27472 27475 27477 27479 27485 27486 27487 27488 27495 27496 27497 27498 27499 27500 27501 27502 27503 27506

Surg

Anes 4 4 4 4 4 4 4 4 4 4 4 4 7 6 6 6 4 4 5 5 5 6 6 5 4 5 5 7 7 7 6 4 4 4 4 4 4 4 4 6

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 2,642.48 2,936.09 1,516.98 1,409.32 1,468.04 1,957.39 2,055.26 2,153.13 2,251.00 2,153.13 2,936.09 2,740.35 3,719.04 1,810.59 2,055.26 2,006.33 1,272.30 1,516.98 2,006.33 2,593.54 3,767.98 2,006.33 2,251.00 1,379.96 1,575.70 2,006.33 1,086.35 1,402.34 4,404.13 1,223.37 1,370.17 704.66 1,242.95 1,419.11 1,947.60 792.75 792.75 794.59 1,252.73 2,251.00

CPT Code 27507 27508 27509 27510 27511 27513 27514 27516 27517 27519 27520 27524 27530 27532 27535 27536 27538 27540 27550 27552 27556 27557 27558 27560 27562 27566 27570 27580 27590 27591 27592 27594 27596 27598 27599 27600 27601 27602 27603 27604

Surg

Anes 6 4 4 4 5 5 5 4 4 5 3 4 3 3 4 4 3 4 0 3 4 4 4 0 3 4 3 4 5 5 5 5 5 5 4 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 0 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $

MAR 1,820.38 587.22 959.12 822.10 1,771.44 2,378.23 1,957.39 685.09 919.97 2,251.00 312.96 1,174.44 374.81 615.81 1,242.95 1,791.01 636.15 1,399.53 489.15 628.02 1,516.98 1,663.78 1,957.39 355.17 447.04 1,184.22 358.98 2,055.26 1,419.11 1,468.04 1,565.91 512.87 1,370.17 1,370.17 717.96 957.28 1,316.26 598.30 434.91

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 27605 27606 27607 27610 27612 27613 27614 27615 27618 27619 27620 27625 27626 27630 27635 27637 27638 27640 27641 27645 27646 27647 27648 27650 27652 27654 27656 27658 27659 27664 27665 27675 27676 27680 27681 27685 27686 27687 27690 27691

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 3 5 5 5 3 3 3 3 3 3 3 3 3 3 3 5 3 3

FUD 10 10 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 421.43 317.99 600.99 1,086.14 1,196.60 358.98 598.30 1,223.37 459.45 744.65 1,086.14 1,174.44 1,272.30 505.91 1,261.03 1,272.30 1,272.30 1,174.44 1,174.44 1,859.52 1,272.30 1,761.65 175.87 1,076.57 1,370.17 1,565.91 717.96 636.15 782.96 420.84 587.22 662.73 782.40 598.30 717.96 694.88 782.96 743.81 782.96 978.70

CPT Code 27692 27695 27696 27698 27700 27702 27703 27704 27705 27707 27709 27712 27715 27720 27722 27724 27725 27727 27730 27732 27734 27740 27742 27745 27750 27752 27756 27758 27759 27760 27762 27766 27780 27781 27784 27786 27788 27792 27808 27810

Surg #

Anes 3 3 3 3 3 7 7 3 4 4 4 4 4 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3

FUD 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 195.74 978.70 1,370.17 1,516.98 1,957.39 3,033.96 2,887.15 1,316.26 1,223.37 685.09 1,468.04 1,781.23 2,397.81 1,761.65 1,908.46 2,055.26 2,740.35 2,153.13 1,125.50 606.80 1,331.03 1,810.59 2,202.07 1,487.62 548.07 685.09 831.89 1,242.95 1,242.95 315.10 480.49 919.97 279.74 410.11 812.31 299.07 417.94 880.83 311.78 489.35

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CPT Code 27814 27816 27818 27822 27823 27824 27825 27826 27827 27828 27829 27830 27831 27832 27840 27842 27846 27848 27860 27870 27871 27880 27881 27882 27884 27886 27888 27889 27892 27893 27894 27899 28001 28002 28003 28005 28008 28010 28011 28020

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 0 3 3 0 3 3 3 3 3 3 4 4 4 4 4 4 4 3 3 3 3 3 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 0 10 10 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $

MAR 1,223.37 297.90 636.15 1,419.11 1,526.77 381.69 763.38 1,145.08 1,830.17 2,123.77 685.09 338.89 378.59 792.75 348.40 479.38 1,076.57 1,194.01 182.95 1,702.93 710.94 1,419.11 1,565.91 1,027.63 598.30 1,794.90 1,125.50 1,125.50 1,242.95 1,242.95 1,947.60 236.98 399.35 619.77 625.04 386.59 219.28 314.23 745.58

CPT Code 28022 28024 28030 28035 28043 28045 28046 28050 28052 28054 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 28102 28103 28104 28106 28107 28108 28110 28111 28112 28113 28114 28116 28118 28119 28120 28122 28124 28126 28130 28140

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 478.64 396.35 1,435.92 1,196.60 358.98 598.30 1,174.44 745.58 478.64 358.98 662.73 1,125.50 606.80 418.42 543.08 1,196.60 782.40 478.64 362.77 745.58 685.09 587.22 589.09 587.22 500.00 478.64 382.78 543.08 478.64 598.30 1,435.92 837.62 837.62 598.30 717.96 591.08 432.62 423.41 978.70 717.96

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CPT Code 28150 28153 28160 28171 28173 28175 28190 28192 28193 28200 28202 28208 28210 28220 28222 28225 28226 28230 28232 28234 28238 28240 28250 28260 28261 28262 28264 28270 28272 28280 28285 28286 28288 28289 28290 28292 28293 28294 28296 28297

Surg

Anes 3 3 3 4 4 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 423.41 478.64 478.64 978.70 978.70 636.15 216.88 417.82 543.08 587.22 782.96 381.01 524.07 598.30 717.96 331.37 432.62 369.73 325.20 329.81 828.41 432.62 717.96 1,122.96 1,279.44 1,957.39 1,184.22 401.68 330.58 473.14 570.69 570.69 570.69 624.20 636.15 743.81 831.89 929.76 1,223.37 929.76

CPT Code 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28360 28400 28405 28406 28415 28420 28430 28435 28436 28445 28450 28455 28456 28465 28470 28475 28476 28485 28490 28495

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 685.09 1,223.37 939.55 880.83 792.75 978.70 704.66 802.53 548.07 889.44 464.26 413.06 428.73 406.20 782.96 729.71 978.70 1,174.44 587.22 782.96 1,013.76 254.46 392.81 548.69 1,239.56 1,370.17 264.25 362.12 440.62 1,138.16 254.46 313.19 381.69 597.01 266.94 303.76 386.59 597.01 125.61 154.00

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 28496 28505 28510 28515 28525 28530 28531 28540 28545 28546 28555 28570 28575 28576 28585 28600 28605 28606 28615 28630 28635 28636 28645 28660 28665 28666 28675 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28800 28805 28810

Surg

Anes 3 3 3 3 3 3 3 0 3 3 3 0 3 3 3 0 3 3 3 0 3 3 3 0 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 10 10 90 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 418.55 506.26 107.35 137.87 435.63 239.32 381.77 358.98 543.08 662.73 831.89 285.35 469.44 644.32 978.70 239.32 312.96 432.62 662.77 211.71 331.37 381.69 411.06 145.98 266.94 344.76 506.26 1,761.65 1,468.04 1,174.44 1,076.57 1,370.17 1,174.44 880.83 785.19 469.77 655.43 1,027.63 1,027.63 567.64

CPT Code 28820 28825 28899 29000 29010 29015 29020 29025 29035 29040 29044 29046 29049 29055 29058 29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29220 29240 29260 29280 29305 29325 29345 29355 29358 29365 29405 29425 29435 29440 29445

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 3 3 3 3 3 3 3 3 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 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 0 0 0 0 0 0 0 $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 486.54 427.86 489.35 313.19 381.69 313.19 381.69 217.89 274.03 247.88 234.89 127.23 195.74 127.23 90.39 83.05 88.33 78.29 86.28 65.33 127.23 48.93 127.23 56.14 55.71 63.83 52.70 52.89 219.88 240.51 131.19 135.14 143.98 117.33 85.80 97.87 146.80 52.19 156.59

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 29450 29505 29515 29520 29530 29540 29550 29580 29590 29700 29705 29710 29715 29720 29730 29740 29750 29799 29800 29804 29805 29806 29807 29819 29820 29821 29822 29823 29824 29825 29826 29827 29830 29834 29835 29836 29837 29838 29840 29843

Surg

Anes 3 3 3 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 5 4 5 5 5 5 5 5 5 5 5 5 5 3 4 4 4 4 4 3 3

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 150.56 75.72 66.11 56.07 55.29 39.05 37.32 50.51 127.23 59.56 66.03 119.24 86.74 75.20 65.22 94.99 98.20 782.40 1,555.58 636.15 1,771.44 1,722.51 1,435.92 1,555.58 1,914.56 1,684.92 1,741.07 1,076.57 837.62 1,572.58 1,859.52 598.30 1,196.60 1,435.92 1,914.56 1,196.60 1,179.44 865.23 902.05

CPT Code 29844 29845 29846 29847 29848 29850 29851 29855 29856 29860 29861 29862 29863 29866 29867 29868 29870 29871 29873 29874 29875 29876 29877 29879 29880 29881 29882 29883 29884 29885 29886 29887 29888 29889 29891 29892 29893 29894 29895 29897

Surg

Anes 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 911.26 1,076.94 1,100.81 1,168.99 850.96 1,125.50 1,751.86 1,242.95 1,340.82 1,242.63 1,331.03 1,722.51 1,722.51 1,624.64 1,937.82 2,622.91 763.83 902.05 525.88 1,196.60 1,572.58 1,797.24 1,572.58 1,572.58 2,033.13 1,572.58 1,965.73 2,512.86 1,914.56 1,914.56 1,914.56 2,098.65 2,897.30 3,137.78 1,125.50 1,076.57 587.22 1,076.94 1,076.94 1,076.94

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 29898 29899 29900 29901 29902 29999 30000 30020 30100 30110 30115 30117 30118 30120 30124 30125 30130 30140 30150 30160 30200 30210 30220 30300 30310 30320 30400 30410 30420 30430 30435 30450 30460 30462 30465 30520 30540 30545 30560 30580

Surg

Anes 3 3 3 3 3 4 5 5 4 5 5 5 5 5 5 5 5 5 7 7 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 90 90 90 90 90 90 10 10 0 10 90 90 90 90 90 90 90 90 90 90 0 10 10 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,196.60 1,047.21 763.38 841.68 900.40 217.75 187.60 116.40 234.89 607.50 637.41 902.05 1,076.94 275.36 1,021.72 362.93 557.86 827.95 1,360.39 96.06 128.86 228.75 221.20 254.46 745.58 1,536.56 2,113.99 2,184.75 930.17 1,500.35 1,914.56 1,638.42 2,991.50 1,810.59 1,076.57 1,638.42 2,080.24 236.41 978.70

CPT Code 30600 30620 30630 30801 30802 30901 30903 30905 30906 30915 30920 30930 30999 31000 31002 31020 31030 31032 31040 31050 31051 31070 31075 31080 31081 31084 31085 31086 31087 31090 31200 31201 31205 31225 31230 31231 31233 31235 31237 31238

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 7 5 5 5 5 7 7 7 7 7 7 5 5 5 5 7 7 5 5 5 5 5

FUD 90 90 90 10 10 0 0 0 0 90 90 10 0 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 978.70 978.70 1,076.57 204.70 265.09 105.83 171.44 283.82 256.75 1,500.35 1,794.90 117.98 158.68 208.05 538.28 1,321.24 1,370.17 1,957.39 831.89 978.70 1,027.63 1,565.91 1,614.85 1,614.85 2,348.87 2,348.87 1,761.65 1,761.65 2,446.74 685.09 1,125.50 1,419.11 2,202.07 2,740.35 176.86 260.44 440.41 330.19 528.49

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CPT Code 31239 31240 31254 31255 31256 31267 31276 31287 31288 31290 31291 31292 31293 31294 31299 31300 31320 31360 31365 31367 31368 31370 31375 31380 31382 31390 31395 31400 31420 31500 31502 31505 31510 31511 31512 31513 31515 31520 31525 31526

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 6 6

FUD 10 0 0 0 0 0 0 0 0 10 10 10 10 10 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,174.44 420.84 665.51 1,027.63 489.35 880.83 1,272.30 743.81 880.83 1,859.52 1,957.39 1,468.04 1,663.78 1,859.52 1,419.11 957.28 2,446.74 3,523.31 2,446.74 3,523.31 2,838.22 2,251.00 2,251.00 2,251.00 3,033.96 3,767.98 1,957.39 1,565.91 146.80 97.87 97.87 210.75 214.92 213.84 149.40 214.23 234.89 332.75 430.62

CPT Code 31527 31528 31529 31530 31531 31535 31536 31540 31541 31545 31546 31560 31561 31570 31571 31575 31576 31577 31578 31579 31580 31582 31584 31585 31586 31587 31588 31590 31595 31599 31600 31601 31603 31605 31610 31611 31612 31613 31614 31615

Surg

Anes 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 0 0 0 0 0 90 90 0 90 90 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $

MAR 518.71 313.19 184.93 411.06 518.71 411.06 518.71 420.84 528.49 597.00 910.19 1,066.78 1,301.66 548.07 685.09 176.16 226.33 479.56 538.28 244.16 2,446.74 2,397.81 2,397.81 460.15 769.93 2,838.22 1,101.22 1,957.39 1,565.91 446.06 450.20 450.20 450.20 837.62 519.34 82.46 570.69 1,288.64 244.67

# 6 6 6 6 6 6 6 6 6 6

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CPT Code 31620 31622 31623 31624 31625 31628 31629 31630 31631 31632 31633 31635 31636 31637 31638 31640 31641 31643 31645 31646 31656 31700 31708 31710 31715 31717 31720 31725 31730 31750 31755 31760 31766 31770 31775 31780 31781 31785 31786 31800

Surg #

Anes 0 6 6 6 6 6 6 6 6 0 0 6 6 0 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 18 18 18 18 18 18 6 17 6

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

275.47 459.99 459.99 459.99 401.27 433.42 718.29 450.20 381.69 78.59 95.04 450.20 371.90 137.02 411.05 469.77 685.09 489.35 538.28 459.99 430.62 244.67 139.14 137.02 88.08 405.74 59.80 342.54 401.27 2,251.00 2,446.74 2,446.74 2,446.74 2,446.74 2,446.74 2,446.74 2,740.35 2,446.74 3,131.83 2,393.20

CPT Code 31805 31820 31825 31830 31899 32000 32002 32005 32019 32020 32035 32036 32095 32100 32110 32120 32124 32140 32141 32150 32151 32160 32200 32201 32215 32220 32225 32310 32320 32400 32402 32405 32420 32440 32442 32445 32480 32482 32484 32486

Surg

Anes 17 6 6 6 17 4 4 6 6 6 6 6 12 12 12 12 12 12 12 12 12 15 12 12 12 15 15 15 15 4 12 4 4 12 18 12 12 12 12 18

FUD 90 90 90 90 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 0 90 0 0 90 90 90 90 90 90 90 $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 2,632.52 415.12 594.46 420.15 195.74 244.67 342.26 941.19 244.67 880.83 978.70 880.83 1,370.17 1,565.91 1,468.04 1,565.91 1,565.91 1,565.91 1,370.17 1,370.17 1,468.04 1,370.17 958.25 1,370.17 1,957.39 1,370.17 2,642.48 2,348.87 158.29 1,196.60 342.54 146.80 2,642.48 3,327.57 2,936.09 2,446.74 2,593.54 2,740.35 2,838.22

# #

# #

#

#

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CPT Code 32488 32491 32500 32501 32520 32522 32525 32540 32601 32602 32603 32604 32605 32606 32650 32651 32652 32653 32654 32655 32656 32657 32658 32659 32660 32661 32662 32663 32664 32665 32800 32810 32815 32820 32850 32851 32852 32853 32854 32855

Surg

Anes 12 12 12 0 15 15 15 12 8 8 8 15 8 12 15 15 15 12 12 12 12 12 15 15 15 15 12 12 12 12 12 12 17 10 7 20 20 20 20

FUD 90 90 90 0 90 90 90 90 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR

MAR 3,278.63 2,838.22 1,859.52 685.09 2,936.09 3,327.57 3,523.31 1,957.39 685.09 518.71 890.62 988.48 606.80 939.55 1,601.60 2,199.90 2,825.82 1,224.22 1,840.92 1,914.56 1,712.06 2,071.04 1,988.19 1,794.90 2,669.33 1,914.56 1,942.18 3,138.77 2,190.69 2,337.97 1,435.92 2,393.20 3,589.79 3,589.79 1,663.78 4,893.48 5,480.70 5,872.18 6,361.52

CPT Code 32856 32900 32905 32906 32940 32960 32997 32999 33010 33011 33015 33020 33025 33030 33031 33050 33120 33130 33140 33141 33200 33201 33206 33207 33208 33210 33211 33212 33213 33214 33215 33216 33217 33218 33220 33222 33223 33224 33225 33226

Surg

Anes 6 10 10 12 6 6 12 15 15 15 6 7 15 20 15 20 15 15 0 15 15 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3 4 0 4

FUD 90 90 90 90 90 0 0 90 0 0 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 0 0 0 BR $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,370.17 1,370.17 1,957.39 1,370.17 148.07 489.35 206.62 206.62 493.19 1,502.72 1,596.63 1,878.39 2,723.67 1,784.48 4,695.98 2,817.59 2,254.07 1,127.04 1,831.43 1,408.80 986.16 1,173.99 1,220.96 381.69 411.06 1,027.12 1,198.30 1,483.62 362.12 970.06 1,084.18 798.87 1,027.12 912.99 1,255.37 685.09 626.36 655.73

#

#

#

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CPT Code 33233 33234 33235 33236 33237 33238 33240 33241 33243 33244 33245 33246 33249 33250 33251 33253 33261 33282 33284 33300 33305 33310 33315 33320 33321 33322 33330 33332 33335 33400 33401 33403 33404 33405 33406 33410 33411 33412 33413 33414

Surg

Anes 4 4 4 15 15 12 7 7 15 7 15 15 7 15 20 20 20 4 4 15 20 15 20 15 15 20 15 15 20 20 20 20 20 20 20 20 20 20 20 20

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 365.19 1,746.10 1,940.11 1,925.36 2,066.24 2,254.07 1,369.49 970.06 3,991.59 2,738.98 2,168.36 2,582.79 2,535.83 2,348.00 3,005.43 4,038.54 2,676.71 385.08 291.15 2,254.07 3,099.35 2,254.07 3,756.78 3,381.11 3,756.78 4,226.39 4,226.39 4,414.22 5,259.50 3,756.78 3,568.95 3,850.71 1,861.65 4,038.54 4,414.22 4,132.47 4,320.30 4,320.30 4,789.91 4,132.47

CPT Code 33415 33416 33417 33420 33422 33425 33426 33427 33430 33460 33463 33464 33465 33468 33470 33471 33472 33474 33475 33476 33478 33496 33500 33501 33502 33503 33504 33505 33506 33508 33510 33511 33512 33513 33514 33516 33517 33518 33519 33521

Surg

Anes 20 20 20 15 20 20 20 20 20 20 20 20 20 20 15 15 20 20 20 20 20 20 20 15 15 15 20 20 20 0 20 20 20 20 20 20 20 20 20 20

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 0 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 3,944.63 3,944.63 4,038.54 3,005.43 4,038.54 4,226.39 4,226.39 4,226.39 4,226.39 3,756.78 4,038.54 4,273.34 3,850.71 3,756.78 2,817.59 3,052.39 3,193.26 3,475.02 4,038.54 3,944.63 3,944.63 3,991.59 3,287.19 2,188.33 2,629.75 2,911.51 3,756.78 4,038.54 4,038.54 19.58 3,944.63 4,226.39 4,508.15 4,789.91 5,071.67 5,259.50 253.58 516.56 770.14 1,033.11

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CPT Code 33522 33523 33530 33533 33534 33535 33536 33542 33545 33572 33600 33602 33606 33608 33610 33611 33612 33615 33617 33619 33641 33645 33647 33660 33665 33670 33681 33684 33688 33690 33692 33694 33697 33702 33710 33720 33722 33730 33732 33735

Surg # # #

Anes 20 20 0 20 20 20 20 20 20 0 20 20 20 20 20 20 20 20 20 20 20 15 20 20 20 20 20 20 20 15 20 20 20 20 20 20 20 20 20 15

FUD 0 0 0 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,286.70 1,549.68 751.35 4,132.47 4,414.22 4,695.98 4,977.74 4,320.30 4,977.74 657.44 4,132.47 4,038.54 4,226.39 4,320.30 4,226.39 4,508.15 4,602.06 4,414.22 4,649.03 5,071.67 3,193.26 3,475.02 3,475.02 4,085.51 4,414.22 4,508.15 3,521.99 4,132.47 4,132.47 2,254.07 4,132.47 4,226.39 4,649.03 3,803.75 4,132.47 3,850.71 4,038.54 3,850.71 3,756.78 2,441.91

CPT Code 33736 33737 33750 33755 33762 33764 33766 33767 33770 33771 33774 33775 33776 33777 33778 33779 33780 33781 33786 33788 33800 33802 33803 33813 33814 33820 33822 33824 33840 33845 33851 33852 33853 33860 33861 33863 33870 33875 33877 33910

Surg

Anes 20 20 15 15 15 15 15 15 20 20 20 20 20 20 20 20 20 20 20 20 15 20 20 15 20 15 15 15 20 20 20 15 20 20 20 20 20 20 20 20

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 2,911.51 2,629.75 2,817.59 2,817.59 2,817.59 2,441.91 2,817.59 3,061.78 4,414.22 4,602.06 4,132.47 4,273.34 4,461.18 4,395.44 4,742.94 4,771.12 4,865.04 4,808.68 4,695.98 2,817.59 2,066.24 2,254.07 2,629.75 2,629.75 3,662.87 1,878.39 1,878.39 2,348.00 2,817.59 3,099.35 3,099.35 3,287.19 4,226.39 4,789.91 4,836.86 5,071.67 5,259.50 4,742.94 4,977.74 3,568.95

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CPT Code 33915 33916 33917 33918 33919 33920 33922 33924 33930 33933 33935 33940 33944 33945 33960 33961 33967 33968 33970 33971 33973 33974 33975 33976 33977 33978 33979 33980 33999 34001 34051 34101 34111 34151 34201 34203 34401 34421 34451 34471

Surg

Anes 15 20 20 15 20 20 20 0 7 20 7 20 0 0 3 3 8 8 15 15 20 20 20 20 15 15 20 10 15 6 6 15 6 6 15 5 15 10

FUD 90 90 90 90 90 90 90 0 0 90 90 0 90 90 0 0 0 0 0 90 0 90 0 0 90 90 0 90 0 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ BR $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $

MAR 2,535.83 3,662.87 3,568.95 3,803.75 4,414.22 4,367.27 3,475.02 751.35 2,254.07 18,259.87 1,972.31 14,607.90 3,381.11 1,690.56 432.03 281.76 685.09 668.21 890.62 1,940.11 1,644.21 2,329.29 2,396.61 2,738.98 3,464.58 4,237.75 1,141.24 2,282.48 912.99 912.99 1,711.86 1,369.49 1,369.49 1,538.62 784.88 1,667.85 939.20

CPT Code 34490 34501 34502 34510 34520 34530 34800 34802 34803 34804 34805 34808 34812 34813 34820 34825 34826 34830 34831 34832 34833 34834 34900 35001 35002 35005 35011 35013 35021 35022 35045 35081 35082 35091 35092 35102 35103 35111 35112 35121

Surg

Anes 3 3 15 3 3 3 10 10 10 10 10 0 10 0 15 10 0 15 15 15 15 10 6 10 10 10 10 10 15 15 6 15 15 15 15 15 15 15 15 15

FUD 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 90 0 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 657.44 1,127.04 3,475.02 1,408.80 2,348.00 1,596.63 2,066.24 2,254.07 2,123.77 2,254.07 1,348.81 657.44 723.18 563.52 1,051.90 1,314.87 563.52 3,193.26 3,475.02 3,568.95 900.40 401.27 1,233.16 1,878.39 2,348.00 1,150.79 1,690.56 2,160.15 1,690.56 2,160.15 1,690.56 2,348.00 3,287.19 2,629.75 3,568.95 2,817.59 3,287.19 1,878.39 2,817.59 2,348.00

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CPT Code 35122 35131 35132 35141 35142 35151 35152 35180 35182 35184 35188 35189 35190 35201 35206 35207 35211 35216 35221 35226 35231 35236 35241 35246 35251 35256 35261 35266 35271 35276 35281 35286 35301 35311 35321 35331 35341 35351 35355 35361

Surg

Anes 15 15 15 8 8 8 8 10 15 6 10 15 6 10 4 6 20 15 15 8 10 6 20 15 15 8 10 6 20 15 15 8 10 15 6 15 15 15 15 15

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 2,817.59 1,878.39 2,629.75 1,690.56 2,066.24 1,878.39 2,348.00 1,878.39 2,441.91 1,878.39 2,066.24 3,005.43 2,066.24 2,396.61 2,396.61 2,212.93 3,099.35 2,254.07 2,535.83 1,521.50 2,441.91 2,441.91 3,475.02 2,348.00 3,052.39 2,085.01 1,502.72 1,502.72 3,005.43 2,066.24 1,878.39 1,784.48 2,282.48 2,348.00 2,054.24 2,254.07 2,066.24 2,066.24 2,160.15 2,254.07

CPT Code 35363 35371 35372 35381 35390 35400 35450 35452 35454 35456 35458 35459 35460 35470 35471 35472 35473 35474 35475 35476 35480 35481 35482 35483 35484 35485 35490 35491 35492 35493 35494 35495 35500 35501 35506 35507 35508 35509 35510 35511

Surg

Anes 15 6 6 8 0 0 15 15 15 8 6 8 3 6 6 10 6 6 6 5 15 15 8 8 6 8 6 10 6 6 6 6 0 10 10 10 10 10 10 8

FUD 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 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 2,441.91 1,690.56 1,784.48 1,878.39 563.52 563.52 959.12 685.09 822.10 822.10 822.10 822.10 822.10 3,737.56 4,229.48 2,736.61 2,527.34 3,637.44 2,538.87 1,955.55 1,096.14 753.60 655.73 802.53 1,037.42 939.55 1,086.35 753.60 626.36 802.53 1,037.42 939.55 371.81 1,408.80 1,878.39 1,878.39 1,878.39 1,878.39 1,419.43 2,066.24

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CPT Code 35512 35515 35516 35518 35521 35522 35525 35526 35531 35533 35536 35541 35546 35548 35549 35551 35556 35558 35560 35563 35565 35566 35571 35572 35583 35585 35587 35600 35601 35606 35612 35616 35621 35623 35626 35631 35636 35641 35642 35645

Surg

Anes 8 10 8 8 10 8 8 15 15 10 15 15 15 15 15 15 8 8 15 15 15 8 8 0 8 8 8 0 10 10 8 8 10 10 15 15 15 15 10 10

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,391.24 2,066.24 2,066.24 2,066.24 2,348.00 1,349.56 1,285.99 3,005.43 2,441.91 2,441.91 2,441.91 2,254.07 2,441.91 2,441.91 2,629.75 2,723.67 2,441.91 2,066.24 2,441.91 2,254.07 2,441.91 2,441.91 2,348.00 518.71 2,160.15 2,254.07 2,254.07 469.60 2,254.07 2,254.07 2,254.07 2,254.07 2,254.07 2,160.15 2,629.75 2,629.75 2,629.75 3,005.43 3,005.43 3,005.43

CPT Code 35646 35647 35650 35651 35654 35656 35661 35663 35665 35666 35671 35681 35682 35683 35685 35686 35691 35693 35694 35695 35697 35700 35701 35721 35741 35761 35800 35820 35840 35860 35870 35875 35876 35879 35881 35901 35903 35905 35907 36000

Surg

Anes 15 15 4 15 10 8 8 15 15 8 8 0 0 0 0 0 10 10 10 10 0 0 10 8 8 6 10 15 15 6 15 6 6 8 8 10 8 8 15 5

FUD 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 90 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 3,005.43 2,629.75 2,066.24 2,817.59 2,629.75 2,348.00 1,878.39 2,254.07 2,254.07 2,441.91 2,254.07 563.52 657.44 751.35 366.29 300.55 2,254.07 2,254.07 2,488.87 2,488.87 176.02 610.48 854.67 666.83 666.83 760.75 939.20 1,878.39 1,408.80 845.28 3,287.19 1,267.92 1,784.48 1,643.60 2,066.24 1,314.87 1,502.72 3,052.39 3,146.31 43.76

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CPT Code 36002 36005 36010 36011 36012 36013 36014 36015 36100 36120 36140 36145 36160 36200 36215 36216 36217 36218 36245 36246 36247 36248 36260 36261 36262 36299 36400 36405 36406 36410 36415 36416 36420 36425 36430 36440 36450 36455 36460 36468

Surg

Anes 6 5 5 5 5 7 7 7 5 5 5 6 5 5 5 5 5 0 5 5 5 0 7 4 4 6 3 3 3 3 0 0 3 3 3 3 3 3 6 3

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 196.06 330.80 836.65 1,190.28 871.36 918.90 893.27 1,048.58 591.13 493.48 571.68 562.88 622.16 758.18 1,227.84 1,332.11 2,371.79 237.23 1,418.77 1,365.61 2,148.58 197.65 741.81 741.81 513.56 37.56 56.35 65.74 28.18 18.79 9.79 93.92 75.14 39.08 112.70 657.44 939.20 939.20 84.53

CPT Code 36469 36470 36471 36475 36476 36478 36479 36481 36500 36510 36511 36512 36513 36514 36515 36516 36522 36540 36550 36555 36556 36557 36558 36560 36561 36563 36565 36566 36568 36569 36570 36571 36575 36576 36578 36580 36581 36582 36583 36584

Surg

Anes 5 3 3 4 0 4 0 4 4 4 0 0 0 0 0 0 0 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4

FUD 0 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 10 10 10 10 10 10 0 0 10 10 0 10 10 0 10 10 10 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 103.32 150.54 187.32 2,236.36 447.37 2,062.19 451.51 892.23 328.72 195.82 127.23 127.23 127.23 716.91 2,576.58 3,223.06 1,295.25 0.00 37.56 335.57 323.99 1,028.27 1,011.43 1,399.95 1,385.67 1,291.65 1,201.70 1,253.65 369.54 359.19 1,491.37 1,493.14 185.38 403.98 575.01 321.89 887.56 1,210.06 1,213.00 318.22

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CPT Code 36585 36589 36590 36595 36596 36597 36600 36620 36625 36640 36660 36680 36800 36810 36815 36818 36819 36820 36821 36822 36823 36825 36830 36831 36832 36833 36834 36835 36838 36860 36861 36870 37140 37145 37160 37180 37181 37182 37183 37195

Surg

Anes 4 4 4 4 4 4 3 6 6 6 6 3 3 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 15 15 15 15 15 7 7 10

FUD 10 10 10 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,260.86 187.37 278.02 810.75 172.63 144.54 37.56 103.32 140.88 134.23 131.49 107.66 205.53 616.57 411.06 1,145.07 1,597.74 1,352.45 1,483.62 1,255.37 1,314.11 1,654.80 1,483.62 563.52 845.28 892.23 1,654.80 1,483.62 1,301.18 156.65 187.84 2,229.09 2,911.51 2,817.59 2,911.51 2,911.51 3,756.78 1,282.09 606.80 657.44

CPT Code 37200 37201 37202 37203 37204 37205 37206 37207 37208 37209 37215 37216 37250 37251 37500 37501 37565 37600 37605 37606 37607 37609 37615 37616 37617 37618 37620 37650 37660 37700 37720 37730 37735 37760 37765 37766 37780 37785 37788 37790

Surg

Anes 6 6 6 6 6 6 0 6 0 6 10 10 0 0 3 3 5 5 5 5 5 5 5 15 15 4 10 3 10 3 3 3 3 3 3 3 3 3 3 3

FUD 0 0 0 0 0 0 0 0 0 0 90 90 0 0 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 751.35 1,127.04 807.70 1,463.75 2,441.91 1,615.42 807.70 1,615.42 835.88 610.48 1,693.14 1,634.42 216.02 140.88 831.89 1,141.24 855.93 912.99 1,141.24 912.99 306.54 912.99 2,282.48 1,711.86 1,141.24 1,408.80 798.87 1,296.04 456.49 798.87 1,141.24 1,997.17 1,878.39 502.06 613.42 283.19 371.07 1,337.36 1,878.39

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CPT Code 37799 38100 38101 38102 38115 38120 38129 38200 38204 38205 38206 38207 38208 38209 38210 38211 38212 38213 38214 38215 38220 38221 38230 38240 38241 38242 38300 38305 38308 38380 38381 38382 38500 38505 38510 38520 38525 38530 38542 38550

Surg

Anes 10 7 7 0 7 7 7 5 0 0 0 0 0 0 0 0 0 0 0 0 5 5 5 5 5 0 6 6 5 6 12 6 6 6 6 6 5 12 6 6

FUD 0 90 90 0 90 90 15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10 0 0 0 10 90 90 90 90 90 10 0 10 90 90 90 90 90 BR $ $ $ $ $ BR $ BR $ $ BR BR BR BR BR BR BR BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,914.56 1,914.56 929.76 1,914.56 1,914.56 195.74 117.45 117.45

CPT Code 38555 38562 38564 38570 38571 38572 38589 38700 38720 38724 38740 38745 38746 38747 38760 38765 38770 38780 38790 38792 38794 38999 39000 39010 39200 39220 39400 39499 39501 39502 39503 39520 39530 39531 39540 39541 39545 39560 39561 39599

Surg

Anes 6 6 6 6 6 6 6 6 6 6 5 5 0 0 3 6 6 6 3 3 6 0 8 12 12 12 8 12 12 7 7 12 12 12 7 7 12 7 7 12

FUD 90 90 90 10 10 10 15 90 90 90 90 90 0 0 90 90 90 90 0 0 90 0 90 90 90 90 10 0 90 90 90 90 90 90 90 90 90 90 90 0 $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ BR

MAR 1,196.60 1,196.60 1,435.92 1,174.44 1,761.65 2,055.26 1,435.92 2,512.86 2,512.86 957.28 1,675.24 597.01 655.73 957.28 2,153.88 2,153.88 3,230.82 335.47 195.74 478.64 681.00 1,120.87 1,699.99 1,699.99 737.75 1,746.68 1,606.58 5,573.16 1,587.90 1,774.71 1,774.71 1,774.71 1,774.71 1,120.87 1,868.12 2,428.55

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188.30 209.02 704.66 450.20 450.20 127.23 252.83 442.59 598.30 598.30 1,675.24 1,675.24 310.10 146.80 500.96 598.30 478.64 828.41 717.96 717.96

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CPT Code 40490 40500 40510 40520 40525 40527 40530 40650 40652 40654 40700 40701 40702 40720 40761 40799 40800 40801 40804 40805 40806 40808 40810 40812 40814 40816 40818 40819 40820 40830 40831 40840 40842 40843 40844 40845 40899 41000 41005 41006

Surg

Anes 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 10 10 10 10 0 10 10 10 90 90 90 90 10 10 10 90 90 90 90 90 0 10 10 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $

MAR 115.62 984.90 902.05 828.41 948.08 1,957.39 865.23 420.50 485.33 717.96 1,565.91 2,348.87 1,370.17 1,565.91 2,446.74 164.58 266.97 183.67 291.28 146.80 143.41 167.83 245.57 341.68 361.24 303.43 263.34 205.77 220.11 287.72 782.96 782.96 999.95 1,323.80 1,484.72 145.74 182.45 327.61

CPT Code 41007 41008 41009 41010 41015 41016 41017 41018 41100 41105 41108 41110 41112 41113 41114 41115 41116 41120 41130 41135 41140 41145 41150 41153 41155 41250 41251 41252 41500 41510 41520 41599 41800 41805 41806 41820 41821 41822 41823 41825

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 7 7 7 7 7 7 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 90 90 90 10 90 90 90 90 10 10 10 10 90 90 90 10 90 90 90 90 90 90 90 90 90 10 10 10 90 90 90 0 10 10 10 0 0 10 90 10 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $

MAR 334.04 329.85 351.05 176.46 383.38 397.10 398.02 463.91 164.77 150.75 125.47 180.32 292.32 323.38 653.58 202.86 274.16 1,016.35 1,111.56 2,153.13 2,152.32 2,740.35 2,153.13 2,740.35 2,936.09 189.70 225.87 358.98 598.30 1,196.60 297.64 150.63 156.86 258.19 391.48 78.29 252.48 361.09 174.95

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CPT Code 41826 41827 41828 41830 41850 41870 41872 41874 41899 42000 42100 42104 42106 42107 42120 42140 42145 42160 42180 42182 42200 42205 42210 42215 42220 42225 42226 42227 42235 42260 42280 42281 42299 42300 42305 42310 42320 42325 42326 42330

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 10 90 10 10 0 0 90 90 0 10 10 10 10 90 90 90 90 10 10 10 90 90 90 90 90 90 90 90 90 90 10 10 0 10 90 10 10 90 90 10 $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $

MAR 197.27 362.16 285.25 339.87 58.72 264.25 307.12 324.45 152.11 137.67 169.89 217.07 1,565.91 1,468.04 213.00 1,331.03 241.50 228.18 319.03 1,585.49 1,957.39 2,202.07 1,585.49 1,673.57 1,673.57 1,712.72 1,712.72 801.64 831.62 144.16 186.09 211.71 450.87 155.35 303.76 297.97 391.55 217.86

CPT Code 42335 42340 42400 42405 42408 42409 42410 42415 42420 42425 42426 42440 42450 42500 42505 42507 42508 42509 42510 42550 42600 42650 42660 42665 42699 42700 42720 42725 42800 42802 42804 42806 42808 42809 42810 42815 42820 42821 42825 42826

Surg

Anes 5 5 5 5 5 5 5 5 5 5 6 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 90 90 0 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 0 0 90 0 10 10 90 10 10 10 10 10 10 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 333.97 717.96 97.87 298.84 427.72 303.76 745.58 1,978.99 2,439.22 1,629.22 3,350.47 1,261.03 1,261.03 846.82 1,261.03 1,555.58 1,555.58 2,632.52 1,620.01 176.65 1,196.60 76.19 101.64 271.30 172.67 425.68 792.19 144.59 248.72 196.70 224.46 264.25 169.38 451.03 1,233.42 607.50 662.73 589.09 635.12

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CPT Code 42830 42831 42835 42836 42842 42844 42845 42860 42870 42890 42892 42894 42900 42950 42953 42955 42960 42961 42962 42970 42971 42972 42999 43020 43030 43045 43100 43101 43107 43108 43112 43113 43116 43117 43118 43121 43122 43123 43124 43130

Surg

Anes 5 5 5 5 7 7 7 5 5 7 7 7 5 5 7 5 5 5 5 5 5 5 5 6 6 15 6 15 15 15 15 15 15 15 15 15 15 15 15 6

FUD 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 10 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 349.77 386.59 322.17 349.77 1,822.51 2,181.49 2,181.49 358.98 625.91 1,435.92 1,914.56 2,273.54 459.99 1,500.35 1,500.35 737.20 178.77 437.83 543.36 400.29 471.72 538.56 1,370.17 1,272.30 1,859.52 1,468.04 2,153.13 4,502.00 5,187.09 4,697.74 5,382.83 4,697.74 4,599.87 4,893.48 4,550.94 4,550.94 4,893.48 4,110.52 1,321.24

CPT Code 43135 43200 43201 43202 43204 43205 43215 43216 43217 43219 43220 43226 43227 43228 43231 43232 43234 43235 43236 43237 43238 43239 43240 43241 43242 43243 43244 43245 43246 43247 43248 43249 43250 43251 43255 43256 43257 43258 43259 43260

Surg

Anes 15 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 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 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,957.39 293.61 342.54 342.54 557.86 597.01 411.06 420.84 430.62 440.41 391.48 401.27 557.86 557.86 489.35 734.02 303.40 411.06 420.84 240.72 300.00 420.84 685.09 411.06 880.83 685.09 685.09 508.93 694.88 508.93 489.35 440.41 518.71 528.49 665.51 978.70 469.77 685.09 831.89 831.89

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CPT Code 43261 43262 43263 43264 43265 43267 43268 43269 43271 43272 43280 43289 43300 43305 43310 43312 43313 43314 43320 43324 43325 43326 43330 43331 43340 43341 43350 43351 43352 43360 43361 43400 43401 43405 43410 43415 43420 43425 43450 43453

Surg

Anes 5 5 5 5 5 5 5 5 5 5 7 7 6 6 15 15 15 15 7 7 7 7 7 15 7 15 7 15 6 15 15 15 15 7 6 15 6 15 5 5

FUD 0 0 0 0 0 0 0 0 0 0 90 15 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 831.89 1,027.63 831.89 1,223.37 1,223.37 1,027.63 1,027.63 831.89 1,027.63 1,027.63 2,393.20 1,859.52 2,153.13 2,446.74 2,838.22 4,639.02 5,089.22 2,251.00 1,957.39 2,251.00 2,153.13 1,879.10 1,879.10 2,348.87 2,446.74 1,468.04 1,370.17 1,370.17 3,914.78 4,404.13 1,957.39 2,153.13 1,957.39 1,468.04 1,879.10 1,321.24 2,153.13 176.16 296.09

CPT Code 43456 43458 43460 43496 43499 43500 43501 43502 43510 43520 43600 43605 43610 43611 43620 43621 43622 43631 43632 43633 43634 43635 43638 43639 43640 43641 43644 43645 43651 43652 43653 43659 43750 43752 43760 43761 43800 43810 43820 43825

Surg

Anes 5 5 5 15 15 7 7 7 7 7 5 7 7 7 7 7 7 7 7 7 7 0 7 7 7 7 7 7 7 7 7 7 5 5 4 4 7 7 7 7

FUD 0 0 0 90 0 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 15 10 0 0 0 90 90 90 90 $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $

MAR 633.32 388.06 391.48 4,893.48 1,620.01 1,978.99 2,273.54 1,675.24 1,380.69 137.02 1,620.01 1,794.90 2,055.26 2,740.35 2,838.22 3,033.96 2,348.87 2,348.87 2,446.74 2,642.48 293.61 3,350.47 3,470.14 2,218.31 2,393.20 2,476.10 2,671.84 1,675.24 2,752.18 1,380.69 478.64 97.87 127.86 195.74 1,739.67 1,822.51 1,822.51 2,190.69

#

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CPT Code 43830 43831 43832 43840 43842 43843 43845 43846 43847 43848 43850 43855 43860 43865 43870 43880 43999 44005 44010 44015 44020 44021 44025 44050 44055 44100 44110 44111 44120 44121 44125 44126 44127 44128 44130 44132 44133 44135 44136 44137

Surg

Anes 7 7 7 7 10 10 10 10 10 10 7 7 7 7 7 7 7 6 7 0 6 6 6 6 7 5 6 6 7 0 7 7 7 0 7 7 7 7 7 7

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 0 90 90 90 90 90 0 90 90 90 0 90 90 90 0 90 0 0 0 0 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR BR BR BR

MAR 1,380.69 1,067.73 1,914.56 1,675.24 2,034.22 2,034.22 2,564.18 2,153.88 2,632.52 2,752.18 2,393.20 2,752.18 2,393.20 2,752.18 1,196.60 1,914.56 1,428.90 1,785.69 831.89 1,748.87 1,675.24 1,868.54 1,419.11 1,675.24 254.46 1,804.10 2,034.22 2,107.86 636.15 2,107.86 3,435.22 3,953.93 430.62 1,794.90

CPT Code 44139 44140 44141 44143 44144 44145 44146 44147 44150 44151 44152 44153 44155 44156 44160 44200 44201 44202 44203 44204 44205 44206 44207 44208 44210 44211 44212 44238 44239 44300 44310 44312 44314 44316 44320 44322 44340 44345 44346 44360

Surg #

Anes 0 7 7 7 7 7 7 7 7 7 7 7 7 7 7 6 6 6 0 6 6 7 7 7 7 7 7 7 6 6 6 6 6 6 6 6 6 6 6 5

FUD 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR $ $ $ $ $ $ $ $ $ $ $

MAR 313.19 1,810.59 1,957.39 1,859.52 1,839.94 2,084.62 2,251.00 2,446.74 2,446.74 2,642.48 3,131.83 4,159.46 2,936.09 3,131.83 2,273.54 1,748.87 1,675.24 2,107.86 411.06 2,378.23 2,113.99 1,859.52 2,084.62 2,251.00 2,446.74 4,159.46 2,936.09

#

#

#

#

1,076.94 1,739.67 514.99 1,914.56 2,632.52 1,380.69 1,435.92 512.93 1,435.92 1,500.35 440.41

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CPT Code 44361 44363 44364 44365 44366 44369 44370 44372 44373 44376 44377 44378 44379 44380 44382 44383 44385 44386 44388 44389 44390 44391 44392 44393 44394 44397 44500 44602 44603 44604 44605 44615 44620 44625 44626 44640 44650 44660 44661 44680

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 6

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 508.93 528.49 557.86 548.07 636.15 675.30 782.96 694.88 694.88 929.76 978.70 1,105.92 782.96 322.97 352.33 782.96 352.33 381.69 440.41 479.56 567.64 636.15 557.86 685.09 636.15 782.96 127.23 1,620.01 2,098.65 2,098.65 1,877.74 2,117.06 1,196.60 1,739.67 3,111.15 1,555.58 1,675.24 1,675.24 2,632.52 2,153.88

CPT Code 44700 44701 44715 44720 44721 44799 44800 44820 44850 44899 44900 44901 44950 44955 44960 44970 44979 45000 45005 45020 45100 45108 45110 45111 45112 45113 45114 45116 45119 45120 45121 45123 45126 45130 45135 45136 45150 45160 45170 45190

Surg # # #

Anes 6 0

FUD 90 0 90 0 0 0 90 90 90 0 90 0 90 0 90 90 15 90 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ BR $ $ BR $ $ $ BR $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 2,055.26 234.89 411.05 606.79 1,435.92 1,196.60 1,261.03 1,196.60 1,202.12 1,196.60 90.21 1,316.26 1,794.90 423.41 243.40 543.08 478.64 782.96 2,740.35 2,055.26 2,936.09 3,327.57 2,544.61 2,055.26 3,327.57 3,033.96 2,691.41 1,957.39 3,523.31 1,468.04 2,446.74 2,691.41 978.70 1,859.52 719.36 1,174.44

#

#

6 6 6 6 6 6 4 6 0 6 6 6 5 5 5 5 5 7 7 7 7 7 7 7 7 7 7 8 5 7 6 5 5 5 5

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CPT Code 45300 45303 45305 45307 45308 45309 45315 45317 45320 45321 45327 45330 45331 45332 45333 45334 45335 45337 45338 45339 45340 45341 45342 45345 45355 45378 45379 45380 45381 45382 45383 45384 45385 45386 45387 45391 45392 45500 45505 45520

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 74.91 724.21 144.99 244.67 215.32 264.25 274.03 293.61 303.40 293.61 587.22 128.74 176.16 269.17 264.10 342.54 186.47 254.46 301.55 362.12 317.47 489.35 587.22 538.28 391.48 499.14 831.89 645.94 645.94 782.96 831.89 724.23 782.96 831.89 782.96 440.41 557.86 978.70 1,076.57 86.63

CPT Code 45540 45541 45550 45560 45562 45563 45800 45805 45820 45825 45900 45905 45910 45915 45999 46020 46030 46040 46045 46050 46060 46070 46080 46083 46200 46210 46211 46220 46221 46230 46250 46255 46257 46258 46260 46261 46262 46270 46275 46280

Surg

Anes 6 5 7 5 5 6 6 6 6 6 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 3 5 5 5 5 5 5 5 5 5 5 5 5

FUD 90 90 90 90 90 90 90 90 90 90 10 10 10 10 0 10 10 90 90 10 90 90 10 10 90 90 90 10 10 10 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,712.72 1,742.08 2,113.99 685.09 1,663.78 2,544.61 1,859.52 2,055.26 1,859.52 2,055.26 266.94 183.93 189.44 304.70 352.33 106.66 432.69 305.61 149.78 831.89 193.30 202.48 158.52 478.64 314.17 489.35 157.15 192.10 232.56 489.35 782.96 831.89 880.83 831.89 831.89 880.83 587.22 812.31 880.83

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CPT Code 46285 46288 46320 46500 46600 46604 46606 46608 46610 46611 46612 46614 46615 46700 46705 46706 46715 46716 46730 46735 46740 46742 46744 46746 46748 46750 46751 46753 46754 46760 46761 46762 46900 46910 46916 46917 46922 46924 46934 46935

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 7 7 7 7 7 7 7 7 5 5 7 5 5 5 5 3 3 3 3 5 5 5 5

FUD 90 90 10 10 0 0 0 0 0 0 0 0 0 90 90 10 90 90 90 90 90 90 90 90 90 90 90 90 10 90 90 90 10 10 10 10 10 10 90 10 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 326.72 1,261.03 153.09 152.38 81.43 402.90 179.30 234.35 211.96 225.10 301.76 274.03 371.90 880.83 978.70 176.16 1,174.44 1,321.24 2,789.28 3,131.83 2,642.48 3,523.31 4,012.65 4,404.13 4,893.48 1,027.63 1,066.78 1,468.04 264.25 1,370.17 1,957.39 2,495.67 183.33 193.38 201.64 428.38 207.83 451.84 348.83 240.17

CPT Code 46936 46937 46938 46940 46942 46945 46946 46947 46999 47000 47001 47010 47011 47015 47100 47120 47122 47125 47130 47133 47135 47136 47140 47141 47142 47143 47144 47145 47146 47147 47300 47350 47360 47361 47362 47370 47371 47379 47380 47381

Surg

Anes 5 5 5 5 5 5 5 5 5 4 0 7 7 7 7 13 13 13 13 7 30 30 13 13 13

FUD 90 10 90 10 10 90 90 90 0 0 0 90 0 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR BR $ $ $ $ $ $ $ $ $ BR $ $

MAR 349.63 224.00 362.73 195.74 195.74 206.25 405.00 508.92 200.54 127.23 1,914.56 685.09 1,675.24 1,196.60 3,470.14 4,666.74 4,666.74 4,666.74 4,502.00 17,948.97 15,555.77 3,318.49 4,036.94 4,459.87

#

# # 7 13 13 13 13 7 7 7 7 7

518.71 606.79 1,663.78 1,663.78 2,153.13 3,914.78 1,419.11 1,663.78 1,565.91 1,947.60 1,928.03

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CPT Code 47382 47399 47400 47420 47425 47460 47480 47490 47500 47505 47510 47511 47525 47530 47550 47552 47553 47554 47555 47556 47560 47561 47562 47563 47564 47570 47579 47600 47605 47610 47612 47620 47630 47700 47701 47711 47712 47715 47716 47720

Surg

Anes 7 7 7 7 7 7 7 4 4 4 4 4 4 4 0 4 5 5 5 5 7 7 7 7 7 7 7 7 7 7 7 7 4 7 7 7 7 7 7 7

FUD 10 0 90 90 90 90 90 90 0 0 90 90 10 90 0 0 0 0 0 0 0 0 90 90 90 90 15 90 90 90 90 90 90 90 90 90 90 90 90 90 $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,164.65 2,512.86 2,273.54 2,696.95 2,512.86 1,500.35 543.08 234.89 264.25 837.62 1,076.94 815.81 1,534.13 538.28 469.77 499.14 743.81 616.57 685.09 489.35 567.64 1,702.86 1,914.56 2,393.20 2,512.86 1,702.86 1,914.56 2,393.20 2,512.86 2,632.52 837.62 2,153.88 3,218.64 2,991.50 4,188.10 2,393.20 2,034.22 1,794.90

CPT Code 47721 47740 47741 47760 47765 47780 47785 47800 47801 47802 47900 47999 48000 48001 48005 48020 48100 48102 48120 48140 48145 48146 48148 48150 48152 48153 48154 48155 48160 48180 48400 48500 48510 48511 48520 48540 48545 48547 48550 48551

Surg

Anes 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 4 7 8 8 8 7 8 8 8 8 8 8 7 0 7 7 7 7 7 7 7 7

FUD 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 10 90 90 90 90 90 90 90 90 90 90 0 90 0 90 90 0 90 90 90 90 0 90 $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ BR

MAR 2,273.54 2,034.22 2,991.50 2,512.86 2,393.20 2,871.84 4,307.75 2,632.52 1,316.26 2,153.88 2,752.18 2,034.22 2,273.54 2,549.52 2,393.20 1,794.90 508.06 2,098.65 2,393.20 2,871.84 3,589.79 2,153.88 4,188.10 3,948.78 4,188.10 3,948.78 2,871.84 2,991.50 234.89 1,794.90 2,393.20 965.41 2,034.22 2,393.20 2,218.31 3,055.93 2,936.09

#

#

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CPT Code 48552 48554 48556 48999 49000 49002 49010 49020 49021 49040 49041 49060 49061 49062 49080 49081 49085 49180 49200 49201 49215 49220 49250 49255 49320 49321 49322 49323 49329 49400 49419 49420 49421 49422 49423 49424 49425 49426 49427 49428

Surg #

Anes 7 7 7 6 6 6 6 4 7 7 6 5 6 4 4 6 5 7 7 10 7 6 7 6 6 6 6 6 4 6 6 6 4 4 4 7 7 4 7

FUD 0 90 90 0 90 90 90 90 0 90 0 90 0 90 0 0 90 0 90 90 90 90 90 90 10 10 10 90 15 0 90 0 90 10 0 0 90 90 0 10 $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $

MAR 352.33 5,624.02 3,180.76 1,261.34 1,092.82 1,366.03 1,423.67 943.76 1,370.17 913.39 1,174.44 904.13 1,435.92 210.37 153.67 1,125.50 293.61 1,675.24 2,512.86 2,057.70 2,632.52 957.28 1,196.60 957.28 978.70 978.70 1,435.92 200.17 499.14 146.80 371.42 448.52 595.55 195.74 1,500.35 2,393.20 254.46 557.86

CPT Code 49429 49491 49492 49495 49496 49500 49501 49505 49507 49520 49521 49525 49540 49550 49553 49555 49557 49560 49561 49565 49566 49568 49570 49572 49580 49582 49585 49587 49590 49600 49605 49606 49610 49611 49650 49651 49659 49900 49904 49905

Surg

Anes 7 6 6 5 5 5 5 4 4 4 4 4 6 4 4 4 4 6 7 6 7 0 4 4 4 4 4 4 4 7 7 7 7 7 6 6 6 6 13 0

FUD 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 15 90 90 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $

MAR 900.40 1,135.29 1,389.75 1,261.03 1,592.40 957.28 1,288.64 962.35 1,353.08 1,245.39 1,647.63 1,076.94 1,233.42 1,067.73 1,399.10 1,261.03 1,592.40 1,380.69 1,712.06 1,555.58 1,886.95 286.29 478.64 810.00 837.62 1,168.99 905.74 1,288.64 1,076.94 1,261.03 4,536.52 2,512.86 1,435.92 1,435.92 962.35 1,261.03 794.60 1,507.19 1,233.16

#

#

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CPT Code 49906 49999 50010 50020 50021 50040 50045 50060 50065 50070 50075 50080 50081 50100 50120 50125 50130 50135 50200 50205 50220 50225 50230 50234 50236 50240 50280 50290 50300 50320 50323 50325 50327 50328 50329 50340 50360 50365 50370 50380

Surg

Anes 7 7 7 7 6 7 7 7 7 7 7 7 7 15 7 7 7 7 6 7 7 7 7 7 7 7 7 6 7 7

FUD 90 0 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 0 90 90 90 90 0 0 90 90 90 90 90 $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR $ $ $ $ $ $ $ $

MAR 3,131.83 1,278.20 1,150.38 966.38 1,533.84 1,533.84 1,704.26 2,130.33 2,130.33 2,215.54 1,704.26 1,959.90 1,388.98 1,619.05 1,619.05 1,704.26 2,130.33 238.59 764.88 1,789.48 2,019.56 2,769.43 2,045.12 2,385.97 2,045.12 1,363.41 1,363.41 2,556.39 2,769.43

CPT Code 50390 50391 50392 50393 50394 50395 50396 50398 50400 50405 50500 50520 50525 50526 50540 50541 50542 50543 50544 50545 50546 50547 50548 50549 50551 50553 50555 50557 50561 50562 50570 50572 50574 50575 50576 50580 50590 50600 50605 50610

Surg

Anes 6 5 6 6 5 6 5 5 7 7 7 6 7 12 7 7 7 7 7 7 7 7 7 7 5 5 5 5 5 7 6 6 6 6 6 6 5 7 7 7

FUD 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 15 0 0 0 0 0 90 0 0 0 0 0 0 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 213.04 156.59 255.64 340.85 134.99 426.07 133.96 680.00 2,002.51 2,215.54 1,874.69 1,917.30 2,045.12 2,045.12 2,343.37 1,720.97 1,417.51 1,804.10 2,246.81 2,036.59 2,007.80 3,107.30 2,294.63 596.49 647.62 664.66 613.54 775.44 773.19 996.99 1,082.21 1,167.42 1,252.64 1,158.90 1,252.64 3,195.50 1,576.45 1,576.45 1,670.18

# # # 7 10 10 7 10

332.76 293.61 274.03 2,130.33 3,195.50 4,260.67 1,704.26 3,195.50

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CPT Code 50620 50630 50650 50660 50684 50686 50688 50690 50700 50715 50722 50725 50727 50728 50740 50750 50760 50770 50780 50782 50783 50785 50800 50810 50815 50820 50825 50830 50840 50845 50860 50900 50920 50930 50940 50945 50947 50948 50949 50951

Surg

Anes 6 6 7 7 5 5 6 4 7 7 6 7 6 6 7 7 6 7 6 6 6 6 6 6 6 6 6 6 7 6 7 7 7 6 6 6 6 6 6 5

FUD 90 90 90 90 0 0 10 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $

MAR 1,576.45 1,704.26 1,704.26 2,385.97 221.32 197.33 95.61 120.34 1,704.26 1,533.84 1,192.98 2,130.33 1,201.51 1,371.93 1,874.69 2,130.33 1,959.90 2,087.73 1,900.26 2,249.63 2,360.41 2,087.73 1,900.26 2,684.22 2,428.58 2,471.18 3,408.54 4,260.67 2,471.18 2,471.18 1,542.36 1,704.26 1,704.26 1,959.90 956.09 1,864.38 2,189.98 2,002.51 422.80

CPT Code 50953 50955 50957 50961 50970 50972 50974 50976 50980 51000 51005 51010 51020 51030 51040 51045 51050 51060 51065 51080 51500 51520 51525 51530 51535 51550 51555 51565 51570 51575 51580 51585 51590 51595 51596 51597 51600 51605 51610 51700

Surg

Anes 5 5 5 5 6 6 6 6 6 4 4 4 5 6 6 6 5 6 6 6 6 6 6 6 6 6 6 6 8 8 8 8 8 8 8 8 3 3 3 3

FUD 0 0 0 0 0 0 0 0 0 0 0 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 444.72 543.39 475.55 434.42 412.14 400.91 526.73 519.73 395.77 108.12 223.31 369.18 1,107.77 1,133.34 1,022.56 894.74 1,022.56 1,874.69 1,874.69 681.71 1,192.98 1,278.20 1,704.26 1,278.20 1,278.20 1,448.62 1,704.26 2,087.73 2,172.94 3,195.50 3,824.38 3,834.60 3,834.60 4,260.67 4,686.73 4,090.24 229.72 256.63 132.88 99.83

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CPT Code 51701 51702 51703 51705 51710 51715 51720 51725 51726 51736 51741 51772 51784 51785 51792 51795 51797 51798 51800 51820 51840 51841 51845 51860 51865 51880 51900 51920 51925 51940 51960 51980 51990 51992 52000 52001 52005 52007 52010 52204

Surg

Anes 3 3 3 4 4 3 3 3 3 3 3 3 3 3 3 3 3 0 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 3 3 3 3 3 3

FUD 0 0 0 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 82.02 100.87 168.81 131.19 239.03 426.07 153.35 279.21 360.26 49.45 81.29 283.69 219.39 236.56 277.08 345.16 290.46 19.58 1,704.26 2,556.39 1,278.20 1,533.84 1,704.26 1,278.20 1,533.84 553.89 2,556.39 1,619.05 2,343.37 3,834.60 2,556.39 1,533.84 1,147.31 1,338.53 214.34 434.71 315.72 755.04 540.53 653.13

CPT Code 52214 52224 52234 52235 52240 52250 52260 52265 52270 52275 52276 52277 52281 52282 52283 52285 52290 52300 52301 52305 52310 52315 52317 52318 52320 52325 52327 52330 52332 52334 52341 52342 52343 52344 52345 52346 52351 52352 52353 52354

Surg

Anes 3 3 5 5 5 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 5 5 5 3 6 3 3 3 3 3 3 3 5 5 3

FUD 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,601.89 1,514.62 400.69 822.10 1,233.16 274.03 228.60 634.70 566.25 796.11 548.07 587.22 392.64 587.22 315.42 312.40 274.03 411.06 450.20 411.06 302.60 559.26 1,391.42 949.34 518.13 548.07 1,431.27 1,688.67 343.22 411.06 775.44 783.96 826.56 835.09 843.61 954.39 749.87 954.39 1,073.69 1,048.12

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CPT Code 52355 52400 52402 52450 52500 52510 52601 52606 52612 52614 52620 52630 52640 52647 52648 52700 53000 53010 53020 53025 53040 53060 53080 53085 53200 53210 53215 53220 53230 53235 53240 53250 53260 53265 53270 53275 53400 53405 53410 53415

Surg

Anes 3 3 3 3 5 3 5 5 5 5 5 5 5 5 5 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 0 0 90 10 90 90 0 90 90 90 90 90 90 90 10 10 10 10 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,073.69 1,440.10 430.63 937.34 852.13 1,073.69 1,704.26 497.38 1,959.90 511.28 511.28 1,704.26 852.13 3,250.22 1,533.84 764.88 204.52 573.66 192.40 191.20 415.62 197.52 506.66 1,147.31 166.14 1,338.53 1,749.65 956.09 1,242.92 1,242.92 422.19 388.45 218.65 242.13 222.61 287.30 956.09 1,386.34 1,529.75 2,294.63

CPT Code 53420 53425 53430 53431 53440 53442 53444 53445 53446 53447 53448 53449 53450 53460 53500 53502 53505 53510 53515 53520 53600 53601 53605 53620 53621 53660 53661 53665 53850 53852 53853 53899 54000 54001 54015 54050 54055 54056 54057 54060

Surg

Anes 3 3 3 4 6 6 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 5 5 3 3 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 90 90 90 0 10 10 10 10 10 10 10 10 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $

MAR 1,912.18 1,704.26 1,201.51 1,610.53 1,704.26 721.89 1,158.90 2,300.75 1,073.69 844.89 1,934.35 766.92 398.35 478.05 780.15 975.22 975.22 1,150.38 1,704.26 556.85 97.21 91.76 144.86 147.63 138.54 81.16 81.22 110.78 3,968.49 3,788.31 2,320.33 178.65 217.99 333.88 117.96 113.69 118.75 189.34 203.31

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CPT Code 54065 54100 54105 54110 54111 54112 54115 54120 54125 54130 54135 54150 54152 54160 54161 54162 54163 54164 54200 54205 54220 54230 54231 54235 54240 54250 54300 54304 54308 54312 54316 54318 54322 54324 54326 54328 54332 54336 54340 54344

Surg

Anes 3 3 3 3 3 3 3 3 4 6 8 3 3 3 3 3 3 3 3 3 3 3 3 3

FUD 10 0 10 90 90 90 90 90 90 90 90 10 10 10 10 10 10 10 10 90 0 0 0 0 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 255.60 190.20 317.62 954.78 2,128.12 2,358.19 632.68 1,150.33 1,893.36 2,650.70 3,218.71 245.54 149.07 267.32 255.60 378.67 350.27 312.40 115.01 575.17 253.23 100.61 274.03 97.87 98.59 189.34 920.27 1,325.35 1,325.35 1,514.69 1,704.02 946.68 1,136.02 1,325.35 1,514.69 1,940.69 2,177.36 2,508.70 994.01 1,514.69

CPT Code 54348 54352 54360 54380 54385 54390 54400 54401 54405 54406 54408 54410 54411 54415 54416 54417 54420 54430 54435 54440 54450 54500 54505 54512 54520 54522 54530 54535 54550 54560 54600 54620 54640 54650 54660 54670 54680 54690 54692 54699

Surg

Anes 3 3 3 3 3 6 4 4 4 3 4 4 4 3 4 4 3 3 3 3 3 3 3 3 3 3 4 6 4 6 4 4 4 6 3 3 3 6 6 6

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 15 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR

MAR 1,893.36 3,171.38 760.16 920.27 1,150.33 1,320.51 1,380.40 1,610.47 2,340.10 1,173.88 1,230.68 1,457.89 1,590.42 870.95 1,136.02 1,391.62 1,437.92 1,437.92 409.70 85.96 81.59 356.60 880.41 724.71 1,003.48 1,092.82 1,437.92 954.78 1,322.89 1,150.33 350.27 1,265.37 2,013.09 460.14 920.27 1,150.33 1,437.92 1,265.37

3 3 3 3 3 3 3 3 3 3 3 3 3 3

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CPT Code 54700 54800 54820 54830 54840 54860 54861 54900 54901 55000 55040 55041 55060 55100 55110 55120 55150 55175 55180 55200 55250 55300 55400 55450 55500 55520 55530 55535 55540 55550 55559 55600 55605 55650 55680 55700 55705 55720 55725 55801

Surg

Anes 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 6 6 3 6 4 6 6 6 6 6 6 3 3 3 3 6

FUD 10 0 90 90 90 90 90 90 90 0 90 90 90 10 90 90 90 90 90 90 90 0 90 10 90 90 90 90 90 90 15 90 90 90 90 0 10 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $

MAR 226.47 140.82 644.18 690.20 920.27 920.27 1,380.40 1,893.36 2,840.04 141.82 920.27 1,380.40 701.70 234.01 575.17 338.72 468.11 920.27 1,380.40 653.75 580.12 244.67 1,893.36 447.47 690.20 690.20 920.27 1,092.82 1,092.82 920.27 805.24 870.95 2,300.67 2,300.67 228.22 776.28 977.79 1,610.47 2,082.70

CPT Code 55810 55812 55815 55821 55831 55840 55842 55845 55859 55860 55862 55865 55866 55870 55873 55899 56405 56420 56440 56441 56501 56515 56605 56606 56620 56625 56630 56631 56632 56633 56634 56637 56640 56700 56720 56740 56800 56805 56810 56820

Surg

Anes 7 7 7 7 7 7 7 7 3 6 6 6 7 3 3 3 3 3 3 3 3 3 3 0 4 4 7 7 7 7 7 7 7 3 3 3 3 3 3 3

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 0 10 10 10 10 10 10 0 0 90 90 90 90 90 90 90 90 90 10 0 10 10 90 10 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 2,461.37 2,698.04 3,313.38 1,893.36 1,893.36 2,461.37 2,603.37 3,313.38 1,893.36 1,325.35 1,893.36 2,840.04 2,544.61 172.79 3,029.38 232.76 148.82 465.52 157.42 136.62 465.52 114.94 57.46 1,280.19 1,803.91 1,542.01 2,107.09 2,490.20 1,838.91 2,298.65 2,423.16 2,777.54 306.49 105.36 383.11 430.99 1,210.86 526.77 117.76

#

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 56821 57000 57010 57020 57022 57023 57061 57065 57100 57105 57106 57107 57109 57110 57111 57112 57120 57130 57135 57150 57155 57160 57170 57180 57200 57210 57220 57230 57240 57250 57260 57265 57267 57268 57270 57280 57282 57283 57284 57287

Surg

Anes 3 4 4 3 3 3 3 3 3 3 4 4 6 4 4 6 4 3 3 3 3 3 3 3 4 4 3 4 4 4 4 4 0 4 6 6 6 6 4 6

FUD 0 10 90 0 10 10 10 10 0 10 90 90 90 90 90 90 90 10 10 0 90 0 0 10 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 159.31 402.26 640.10 103.64 402.26 402.26 119.17 402.26 95.35 144.46 957.77 1,723.99 2,107.09 1,340.88 2,107.09 2,298.65 1,431.48 478.89 354.37 66.44 660.86 78.53 97.29 153.28 698.29 756.48 872.86 814.67 1,000.88 931.05 1,512.96 1,687.53 440.41 1,163.81 1,454.76 1,629.34 1,629.34 1,047.20 1,676.09 1,628.21

CPT Code 57288 57289 57291 57292 57300 57305 57307 57308 57310 57311 57320 57330 57335 57400 57410 57415 57420 57421 57425 57452 57454 57455 57456 57460 57461 57500 57505 57510 57511 57513 57520 57522 57530 57531 57540 57545 57550 57555 57556 57700

Surg

Anes 6 4 7 7 5 6 6 5 4 4 6 6 3 3 3 3 3 3 6 3 3 3 3 3 3 3 3 3 3 3 3 3 3 8 6 6 6 6 6 4

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 10 0 0 90 0 0 0 0 0 0 0 10 10 10 10 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,629.34 1,454.76 2,633.87 3,256.41 1,292.99 1,676.09 1,867.66 1,436.65 1,687.53 584.24 1,745.72 1,978.48 2,633.87 191.55 191.55 152.10 225.10 254.46 964.46 220.28 249.02 254.46 254.46 392.68 401.27 139.86 139.66 145.28 174.57 306.49 581.91 523.72 581.91 2,298.65 1,396.57 1,745.72 1,396.57 1,745.72 1,745.72 1,105.62

#

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CPT Code 57720 57800 57820 58100 58120 58140 58145 58146 58150 58152 58180 58200 58210 58240 58260 58262 58263 58267 58270 58275 58280 58285 58290 58291 58292 58293 58294 58300 58301 58321 58322 58323 58340 58345 58346 58350 58353 58356 58400 58410

Surg

Anes 4 3 3 3 3 6 6 6 6 6 6 6 8 8 6 6 6 6 6 6 6 6 6 6 6 6 6 3 3 0 0 0 4 4 4 4 3 3 6 6

FUD 90 0 10 0 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 10 90 10 10 10 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 581.91 63.71 383.11 119.44 465.52 1,396.57 1,047.43 1,601.60 1,978.48 2,676.77 1,745.72 2,074.53 3,352.19 4,214.19 2,211.24 2,327.62 2,560.39 2,560.39 2,327.62 2,327.62 2,327.62 2,298.65 2,593.54 2,720.77 2,975.23 2,975.23 2,720.77 143.67 107.61 107.66 137.02 39.15 158.98 612.97 699.17 174.57 1,506.04 2,606.66 1,408.21 1,920.29

CPT Code 58520 58540 58545 58546 58550 58552 58553 58554 58555 58558 58559 58560 58561 58562 58563 58565 58578 58579 58600 58605 58611 58615 58660 58661 58662 58670 58671 58672 58673 58679 58700 58720 58740 58750 58752 58760 58770 58800 58805 58820

Surg

Anes 6 6 6 6 6 6 6 6 4 4 4 4 4 4 4 4 6 4 6 6 0 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

FUD 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 90 15 15 90 90 0 10 90 10 90 90 90 90 90 15 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $

MAR 1,280.19 2,094.86 1,096.14 1,428.90 1,915.54 2,319.51 2,133.55 2,515.25 274.03 411.06 450.20 508.93 616.55 450.20 2,399.06 2,194.10

#

1,163.81 872.86 383.11 929.03 1,163.81 1,407.92 1,163.81 1,163.81 1,163.81 1,222.00 1,163.81 1,091.86 1,478.11 1,920.29 2,444.00 1,920.29 1,978.48 1,978.48 581.91 1,396.57 581.91

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CPT Code 58822 58823 58825 58900 58920 58925 58940 58943 58950 58951 58952 58953 58954 58956 58960 58970 58974 58976 58999 59000 59001 59012 59015 59020 59025 59030 59050 59051 59070 59072 59074 59076 59100 59120 59121 59130 59135 59136 59140 59150

Surg

Anes 6 4 6 6 6 6 6 6 6 8 8 8 8 8 6 6 3 6 3 4 4 4 4

FUD 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,163.81 954.76 1,396.57 1,222.00 1,280.19 1,280.19 1,280.19 2,327.62 1,862.10 2,909.53 2,734.96 3,170.22 3,447.97 2,544.61 2,385.81 1,053.55 861.99 1,149.32 139.85 276.14 368.18 276.14 92.05 92.05 123.58 165.68 128.86 427.18 512.08 405.32 512.08 1,744.13 1,526.11 1,526.11 1,580.62 1,907.64 2,180.16 1,526.11 1,199.09

CPT Code 59151 59160 59200 59300 59320 59325 59350 59400 59409 59410 59412 59414 59425 59426 59430 59510 59514 59515 59525 59610 59612 59614 59618 59620 59622 59812 59820 59821 59830 59840 59841 59850 59851 59852 59855 59856 59857 59866 59870 59871

Surg

Anes 6 3 3 3 4 6 6 5 5 5 5 3

FUD 90 10 0 0 0 0 0 45 45 45 0 0 0 0 45 45 45 45 0 45 45 45 45 45 45 90 90 90 90 10 10 90 90 90 90 90 90 0 90 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,962.14 386.59 220.91 196.33 331.37 552.28 1,027.63 1,840.92 966.49 1,150.58 322.17 230.12 460.23 736.37 184.09 2,301.15 1,334.67 1,610.81 782.40 2,209.10 1,334.67 1,518.76 2,669.33 1,702.86 1,978.99 436.03 490.53 545.04 545.04 386.59 386.59 773.96 981.07 1,308.09 915.67 1,122.79 1,449.81 552.28 545.04 276.14

#

6 6 6 6 6 6 6 6 6 6 6 6 6 3 6

7 7 7 10 5 5 5 7 7 7 4 4 4 4 4 4 4 4 4 4 4 4 4 3 3

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CPT Code 59897 59898 59899 60000 60001 60100 60200 60210 60212 60220 60225 60240 60252 60254 60260 60270 60271 60280 60281 60500 60502 60505 60512 60520 60521 60522 60540 60545 60600 60605 60650 60659 60699 61000 61001 61020 61026 61050 61055 61070

Surg

Anes 0 6 0 5 3 3 6 6 6 6 6 6 6 6 6 12 6 6 6 6 6 12 0 6 12 12 10 10 6 10 10 0 0 5 5 5 5 5 5 5

FUD 90 15 0 10 0 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 15 0 0 0 0 0 0 0 0 BR BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR $ $ $ $ $ $ $

MAR

CPT Code 61105 61107 61108 61120 61140 61150 61151 61154 61156 61210 61215 61250 61253 61304 61305 61312 61313 61314 61315 61316 61320 61321 61322 61323 61330 61332 61333 61334 61340 61343 61345 61440 61450 61458 61460 61470 61480 61490 61500 61501

Surg #

Anes 9 9 9 9 9 9 9 9 9 9 9 9 9 11 13 11 11 13 13 0 11 13 11 11 11 11 11 11 11 13 13 13 13 13 11 11 11 11 11 11

FUD 90 0 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,186.71 1,044.97 2,373.42 1,186.71 2,610.76 2,610.76 2,670.09 2,148.55 2,099.72 781.29 830.70 1,464.92 2,490.37 3,418.15 3,613.47 3,515.81 3,711.13 4,394.76 4,785.41 107.66 3,125.17 3,418.15 2,221.64 2,339.08 2,929.84 3,906.45 3,906.45 3,906.45 2,148.55 4,394.76 1,904.40 2,539.19 3,418.15 3,808.79 3,711.13 3,711.13 3,711.13 2,441.53 3,515.81 3,418.15

#

151.42 146.46 146.46 1,186.49 1,483.11 2,076.36 1,898.38 2,135.68 2,491.63 3,084.87 3,440.82 2,017.04 2,728.92 1,952.87 1,423.78 1,423.78 2,171.27 2,135.68 2,728.92 634.68 1,904.04 2,343.44 2,831.66 2,313.65 2,669.60 2,372.97 2,906.90 2,313.65

#

#

195.33 136.73 195.33 292.98 244.15 400.41 156.26

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CPT Code 61510 61512 61514 61516 61517 61518 61519 61520 61521 61522 61524 61526 61530 61531 61533 61534 61535 61536 61537 61538 61539 61540 61541 61542 61543 61544 61545 61546 61548 61550 61552 61556 61557 61558 61559 61563 61564 61566 61567 61570

Surg

Anes 11 11 11 11 0 13 13 13 13 13 13 13 13 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11

FUD 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 3,906.45 4,101.77 3,613.47 3,613.47 107.66 4,297.10 4,883.07 4,883.07 6,514.01 4,297.10 4,297.10 4,883.07 4,883.07 3,906.45 3,759.96 3,711.13 2,832.17 3,773.89 1,755.87 4,297.10 4,297.10 2,092.49 5,713.19 5,176.05 2,929.84 3,711.13 7,129.27 4,150.61 3,857.62 2,441.53 2,734.52 2,734.52 3,125.17 3,808.79 4,297.10 3,711.13 4,785.41 2,131.15 2,432.26 4,260.30

CPT Code 61571 61575 61576 61580 61581 61582 61583 61584 61585 61586 61590 61591 61592 61595 61596 61597 61598 61600 61601 61605 61606 61607 61608 61609 61610 61611 61612 61613 61615 61616 61618 61619 61623 61624 61626 61680 61682 61684 61686 61690

Surg

Anes 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 11 0 0 0 0 15 13 13 11 11 10 10 6 15 15 15 15 15

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 0 0 90 90 90 90 90 0 0 0 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 4,785.41 2,734.52 3,682.53 3,906.45 4,492.42 4,052.94 4,590.08 4,492.42 4,980.72 3,418.15 5,469.03 5,713.19 5,176.05 3,808.79 4,638.92 4,883.07 4,345.93 3,320.48 3,564.64 3,759.96 5,029.56 4,687.74 5,469.03 1,318.42 4,638.92 976.62 4,394.76 5,371.37 4,150.61 5,615.52 2,148.55 2,636.86 753.60 1,849.73 1,575.70 5,859.68 6,836.29 6,347.98 7,324.60 6,347.98

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CPT Code 61692 61697 61698 61700 61702 61703 61705 61708 61710 61711 61720 61735 61750 61751 61760 61770 61790 61791 61793 61795 61850 61860 61863 61864 61867 61868 61870 61875 61880 61885 61886 61888 62000 62005 62010 62100 62115 62116 62117 62120

Surg

Anes 15 15 15 15 15 15 15 15 15 15 11 11 11 11 11 13 6 6 7 0 9 11 11 0 11 0 11 11 11 5 5 5 9 9 11 11 11 11 11 11

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 0 90 0 90 90 90 90 90 10 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 7,324.60 5,176.05 4,492.42 4,883.07 4,492.42 1,269.60 5,273.71 3,906.45 3,906.45 4,004.12 3,369.32 3,300.95 2,812.64 3,007.97 3,066.56 1,855.57 2,734.52 3,369.32 3,711.13 537.13 2,246.21 1,660.24 1,357.21 368.38 2,129.75 582.65 1,079.69 1,367.26 859.42 477.96 619.57 459.01 1,757.90 2,441.53 3,027.50 3,222.82 3,222.82 3,418.15 3,906.45 2,441.53

CPT Code 62121 62140 62141 62142 62143 62145 62146 62147 62148 62160 62161 62162 62163 62164 62165 62180 62190 62192 62194 62200 62201 62220 62223 62225 62230 62252 62256 62258 62263 62264 62268 62269 62270 62272 62273 62280 62281 62282 62284 62287

Surg

Anes 11 9 9 9 9 9 9 9 0 0 11 11 11 11 11 10 10 10 10 10 10 10 10 10 10 10 10 10 5 5 5 8 3 3 3 3 3 3 5 8

FUD 90 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 0 90 90 10 10 0 0 0 0 0 10 10 10 0 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 3,320.48 2,343.87 2,832.17 2,050.89 2,734.52 3,418.15 2,754.05 3,242.36 146.80 211.71 1,417.51 1,785.69 1,114.72 1,951.38 1,555.58 3,204.11 2,373.42 2,373.42 781.29 4,034.81 2,373.42 2,729.43 2,848.10 1,068.04 2,136.07 97.66 1,068.04 2,373.42 752.55 488.54 1,494.22 1,640.71 195.33 197.75 198.19 381.03 379.75 419.87 292.98 1,157.04

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CPT Code 62290 62291 62292 62294 62310 62311 62318 62319 62350 62351 62355 62360 62361 62362 62365 62367 62368 63001 63003 63005 63011 63012 63015 63016 63017 63020 63030 63035 63040 63042 63043 63044 63045 63046 63047 63048 63050 63051 63055 63056

Surg

Anes 5 5 5 5 3 3 3 3 8 10 5 5 5 5 5

FUD 0 0 90 90 0 0 0 0 90 90 90 90 90 90 90 0 0 90 90 90 90 90 90 90 90 90 90 0 90 90 0 0 90 90 90 0 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 403.70 354.71 593.35 745.55 266.57 254.25 306.71 271.24 878.95 1,289.13 683.63 292.98 683.63 878.95 683.63 78.13 117.19 3,418.15 3,418.15 3,222.82 3,027.50 3,027.50 3,906.45 3,906.45 3,906.45 3,125.17 2,929.84 585.97 3,418.15 3,418.15 683.63 683.63 3,418.15 3,418.15 3,418.15 683.63 3,425.44 3,719.04 3,515.81 3,320.48

CPT Code 63057 63064 63066 63075 63076 63077 63078 63081 63082 63085 63086 63087 63088 63090 63091 63101 63102 63103 63170 63172 63173 63180 63182 63185 63190 63191 63194 63195 63196 63197 63198 63199 63200 63250 63251 63252 63265 63266 63267 63268

Surg # # # # # # # #

Anes 0 10 0 10 0 10 0 10 0 13 0 13 0 8 0 13 13 0 10 13 13 10 10 8 8 10 10 10 10 10 10 10 8 13 13 13 10 10 8 8

FUD 0 90 0 90 0 90 0 90 0 90 0 90 0 90 0 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 488.31 3,711.13 537.13 2,734.52 732.46 2,929.84 732.46 4,101.77 854.53 4,394.76 880.83 4,394.76 854.53 4,101.77 683.63 2,209.63 2,209.63 315.47 4,101.77 3,320.48 3,320.48 4,101.77 4,492.42 3,320.48 3,613.47 3,613.47 3,613.47 3,613.47 3,711.13 3,711.13 4,248.27 4,248.27 3,662.30 4,394.76 4,394.76 5,371.37 3,906.45 3,906.45 3,515.81 3,515.81

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10 10 8 8 8 10 10 8 10 8 0 10 8 0 0 10 10 8 0 10 10 10 8

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CPT Code 63270 63271 63272 63273 63275 63276 63277 63278 63280 63281 63282 63283 63285 63286 63287 63290 63295 63300 63301 63302 63303 63304 63305 63306 63307 63308 63600 63610 63615 63650 63655 63660 63685 63688 63700 63702 63704 63706 63707 63709

Surg

Anes 10 10 8 8 10 10 8 8 10 10 8 6 10 10 8 13 0 10 10 10 8 10 10 10 8 0 5 5 5 5 8 8 5 5 8 8 8 8 8 8

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 0 90 0 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 4,101.77 4,101.77 3,711.13 3,711.13 3,906.45 3,906.45 3,515.81 3,515.81 4,101.77 4,101.77 3,711.13 3,711.13 4,883.07 4,883.07 4,883.07 5,078.39 499.13 4,394.76 4,883.07 4,883.07 4,883.07 4,394.76 4,883.07 4,883.07 4,883.07 585.97 2,343.87 2,644.21 2,832.17 1,074.27 1,367.26 830.13 937.54 683.63 2,539.19 2,734.52 2,929.84 3,125.17 3,125.17 3,125.17

CPT Code 63710 63740 63741 63744 63746 64400 64402 64405 64408 64410 64412 64413 64415 64416 64417 64418 64420 64421 64425 64430 64435 64445 64446 64447 64448 64449 64450 64470 64472 64475 64476 64479 64480 64483 64484 64505 64508 64510 64517 64520

Surg

Anes 8 8 8 8 8 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 5 0 5 0 5 0 5 0 3 3 3 3 5

FUD 90 90 90 90 90 0 0 0 0 0 0 0 0 10 0 0 0 0 0 0 0 0 10 0 10 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 3,027.50 3,085.44 2,136.07 1,542.72 1,186.71 244.15 175.79 113.90 122.68 158.23 152.66 131.88 171.72 264.25 178.81 157.63 199.19 304.43 146.49 160.08 160.69 166.82 244.67 117.45 225.10 169.60 104.26 355.35 145.56 322.64 123.80 380.74 176.18 382.25 183.11 126.96 175.13 184.39 200.25 253.94

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CPT Code 64530 64550 64553 64555 64560 64561 64565 64573 64575 64577 64580 64581 64585 64590 64595 64600 64605 64610 64612 64613 64614 64620 64622 64623 64626 64627 64630 64640 64680 64681 64702 64704 64708 64712 64713 64714 64716 64718 64719 64721

Surg

Anes 3 5 3 3 3 3 5 4 5 4 8 5 5 5 3 3 3 3 5 5 5 5 0 5 0 3 3 3 3 3 3 3 4 5 8 5 3 3 3

FUD 0 0 10 10 10 10 10 90 90 90 90 90 10 10 10 10 10 10 10 10 10 10 10 0 10 0 10 10 10 10 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 238.28 97.66 415.34 331.37 331.37 1,434.64 331.37 712.02 617.09 617.09 617.09 878.95 534.01 581.49 470.25 507.90 616.89 670.27 234.39 234.39 253.92 317.86 426.79 155.89 439.91 222.66 237.50 282.53 370.14 509.16 488.31 781.29 976.62 1,367.26 1,269.60 1,269.60 1,464.92 1,074.27 771.52 820.35

CPT Code 64722 64726 64727 64732 64734 64736 64738 64740 64742 64744 64746 64752 64755 64760 64761 64763 64766 64771 64772 64774 64776 64778 64782 64783 64784 64786 64787 64788 64790 64792 64795 64802 64804 64809 64818 64820 64821 64822 64823 64831

Surg

Anes 4 3 0 5 5 5 5 5 5 5 5 12 7 7 3 3 4 11 10 5 3 0 3 0 4 4 0 5 5 5 5 10 10 13 7 3 3 3 3 3

FUD 90 90 0 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 0 90 90 0 90 90 90 0 90 90 90 90 90 90 90 90 90

MAR $ 976.62 $ 468.78 SEE SURG GR 19 $ 830.70 $ 830.70 $ 1,186.71 $ 1,186.71 $ 593.35 $ 1,186.71 $ 890.03 $ 593.35 $ 1,720.72 $ 2,729.43 $ 1,661.39 $ 593.35 $ 712.02 $ 1,186.71 $ 1,305.38 $ 712.02 $ 474.68 $ 474.68 $ 199.58 $ 712.02 $ 292.98 $ 1,068.04 $ 1,246.04 $ 615.27 $ 747.63 $ 1,068.04 $ 1,305.38 $ 292.98 $ 1,720.72 $ 2,373.42 $ 2,373.42 $ 1,424.05 $ 1,464.92 $ 1,074.27 $ 1,074.27 $ 1,240.30 $ 700.65

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CPT Code 64832 64834 64835 64836 64837 64840 64856 64857 64858 64859 64861 64862 64864 64865 64866 64868 64870 64872 64874 64876 64885 64886 64890 64891 64892 64893 64895 64896 64897 64898 64901 64902 64905 64907 64999 65091 65093 65101 65103 65105

Surg #

Anes 0 3 3 3 0 3 3 3 3 0 5 8 5 11 5 5 5 0 0 0 5 5 3 3 4 4 3 3 4 4 0 0 4 4 0 5 5 5 5 5

FUD 0 90 90 90 0 90 90 90 90 0 90 90 90 90 90 90 90 0 0 0 90 90 90 90 90 90 90 90 90 90 0 0 90 90 0 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $

MAR 370.68 781.29 976.62 1,171.93 585.97 1,171.93 1,171.93 1,171.93 1,435.62 585.97 1,348.35 1,366.92 1,171.93 1,198.81 2,881.01 2,881.01 2,881.01 390.64 244.15 244.15 2,881.01 3,125.17 1,367.26 1,562.58 1,367.26 1,562.58 1,757.90 1,953.22 1,757.90 1,953.22 665.64 765.03 963.17 1,343.44 925.75 1,157.19 1,157.19 1,296.04 1,573.77

CPT Code 65110 65112 65114 65125 65130 65135 65140 65150 65155 65175 65205 65210 65220 65222 65235 65260 65265 65270 65272 65273 65275 65280 65285 65286 65290 65400 65410 65420 65426 65430 65435 65436 65450 65600 65710 65730 65750 65755 65760 65765

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 5 6

FUD 90 90 90 90 90 90 90 90 90 90 0 0 0 0 90 90 90 10 90 90 90 90 90 90 90 90 0 90 90 0 0 90 90 90 90 90 90 90 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,851.49 2,082.93 2,406.94 555.45 1,064.61 1,157.19 1,388.62 1,018.32 1,110.90 694.31 57.76 67.82 66.01 99.01 1,388.62 1,851.49 1,851.49 281.26 460.03 462.87 722.08 1,296.04 1,388.62 925.75 925.75 740.60 495.05 518.43 648.02 113.86 82.51 339.86 298.61 555.45 1,980.21 2,434.01 2,887.80 2,062.71 2,140.50 2,341.17

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CPT Code 65767 65770 65771 65772 65775 65780 65781 65782 65800 65805 65810 65815 65820 65850 65855 65860 65865 65870 65875 65880 65900 65920 65930 66020 66030 66130 66150 66155 66160 66165 66170 66172 66180 66185 66220 66225 66250 66500 66505 66600

Surg

Anes 5 6 5 5 5 5 5 5 5 5 5 5 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 6

FUD 0 90 0 90 90 90 90 90 0 0 90 90 90 90 10 90 90 90 90 90 90 90 90 10 10 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,872.94 2,475.26 936.47 1,402.64 1,815.19 841.09 1,291.45 1,112.19 247.53 206.27 825.08 1,237.63 972.04 1,481.19 825.08 453.62 972.04 879.46 925.75 972.04 1,203.47 1,851.49 925.75 231.44 249.95 703.70 1,342.34 1,296.04 1,296.04 1,388.62 1,388.62 1,666.34 1,342.34 972.04 1,650.17 1,980.21 825.08 648.02 648.02 1,296.04

CPT Code 66605 66625 66630 66635 66680 66682 66700 66710 66711 66720 66740 66761 66762 66770 66820 66821 66825 66830 66840 66850 66852 66920 66930 66940 66982 66983 66984 66985 66986 66990 66999 67005 67010 67015 67025 67027 67028 67030 67031 67036

Surg

Anes 6 6 6 6 5 5 5 5 5 5 5 6 6 5 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 0 5 6 6 6 6 6 6 6 6 6

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 90 90 0 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $

MAR 2,036.64 925.75 925.75 925.75 1,110.90 1,388.62 833.17 833.17 782.96 833.17 833.17 925.75 555.45 694.31 509.16 509.16 1,036.84 1,485.16 1,485.16 1,650.17 1,320.14 1,650.17 1,980.21 1,650.17 1,254.13 2,310.24 2,310.24 1,650.17 1,815.19 117.45 1,485.16 2,062.71 1,018.32 1,018.32 782.58 735.80 1,388.62 1,018.32 3,240.11

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CPT Code 67038 67039 67040 67101 67105 67107 67108 67110 67112 67115 67120 67121 67141 67145 67208 67210 67218 67220 67221 67225 67227 67228 67250 67255 67299 67311 67312 67314 67316 67318 67320 67331 67332 67334 67335 67340 67343 67345 67350 67399

Surg

Anes 6 6 6 6 6 6 6 6 6 5 5 6 6 6 6 6 6 6 6 0 6 6 5 5 5 5 5 5 5 5 0 0 0 0 0 0 5 5 5 5

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 0 90 90 90 90 0 90 90 90 90 90 0 0 0 0 0 0 90 10 0 0 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR

MAR 3,702.98 2,962.39 3,147.54 2,062.71 1,856.44 2,310.24 3,382.85 1,072.61 2,475.26 833.17 833.17 1,110.90 833.17 1,110.90 1,155.12 990.10 1,815.19 1,237.63 340.89 66.01 1,237.63 997.64 1,691.43 1,980.21 1,388.62 1,666.34 1,388.62 1,758.92 1,481.19 1,567.66 1,237.63 1,650.17 1,237.63 330.03 1,567.66 1,342.34 277.72 825.08

CPT Code 67400 67405 67412 67413 67414 67415 67420 67430 67440 67445 67450 67500 67505 67515 67550 67560 67570 67599 67700 67710 67715 67800 67801 67805 67808 67810 67820 67825 67830 67835 67840 67850 67875 67880 67882 67900 67901 67902 67903 67904

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 90 90 90 90 90 0 90 90 90 90 90 0 0 0 90 90 90 0 10 10 10 10 10 10 90 0 0 10 10 90 10 10 0 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,296.04 1,296.04 1,851.49 1,851.49 1,944.07 288.78 2,129.22 1,944.07 1,851.49 2,036.64 1,851.49 123.76 101.26 66.01 1,110.90 925.75 1,116.08 286.95 247.73 256.61 123.76 157.32 193.58 310.80 191.20 62.08 126.52 284.06 1,203.47 296.78 202.03 184.58 417.69 601.74 615.03 1,296.04 1,481.19 1,573.77 1,573.77

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CPT Code 67906 67908 67909 67911 67912 67914 67915 67916 67917 67921 67922 67923 67924 67930 67935 67938 67950 67961 67966 67971 67973 67974 67975 67999 68020 68040 68100 68110 68115 68130 68135 68200 68320 68325 68326 68328 68330 68335 68340 68360

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 10 90 10 90 90 90 90 90 90 90 0 10 0 0 10 10 90 10 0 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 1,481.19 1,110.90 1,110.90 1,666.34 965.40 402.45 366.86 833.17 1,110.90 384.09 358.66 833.17 1,064.61 429.04 740.60 261.95 1,110.90 1,342.34 1,481.19 1,573.77 1,666.34 1,851.49 740.60 114.02 64.48 182.52 233.20 330.03 555.45 185.15 82.51 1,203.47 1,296.04 1,296.04 1,481.19 925.75 1,296.04 519.18 555.45

CPT Code 68362 68371 68399 68400 68420 68440 68500 68505 68510 68520 68525 68530 68540 68550 68700 68705 68720 68745 68750 68760 68761 68770 68801 68810 68811 68815 68840 68850 68899 69000 69005 69020 69090 69100 69105 69110 69120 69140 69145 69150

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 90 10 0 10 10 10 90 90 0 90 0 10 90 90 90 10 90 90 90 10 10 90 10 10 10 10 10 0 0 10 10 10 0 0 0 90 90 90 90 90 $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $

MAR 1,018.32 398.75 297.57 335.59 120.21 1,157.19 1,110.90 480.80 1,203.47 272.61 800.34 1,388.62 1,573.77 1,110.90 248.64 1,388.62 1,320.14 1,573.77 210.35 156.77 694.31 114.93 222.62 296.24 453.10 115.79 68.70 173.77 359.80 216.91 73.64 100.43 126.42 654.18 736.37 1,058.53 335.74 1,380.69

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CPT Code 69155 69200 69205 69210 69220 69222 69300 69310 69320 69399 69400 69401 69405 69410 69420 69421 69424 69433 69436 69440 69450 69501 69502 69505 69511 69530 69535 69540 69550 69552 69554 69601 69602 69603 69604 69605 69610 69620 69631 69632

Surg

Anes 6 4 4 4 5 5 5 5 5 5 5 5 5 5 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 90 0 10 0 0 10 180 90 90 0 0 0 10 0 10 10 0 10 10 90 90 90 90 90 90 90 90 10 90 90 90 90 90 90 90 90 10 90 90 90 $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 2,163.09 124.28 218.06 55.23 126.30 208.15 1,104.55 1,840.92 1,840.92 118.77 75.04 250.23 94.05 178.55 228.96 120.39 218.06 368.18 1,199.33 1,253.84 1,141.37 1,380.69 2,080.24 2,365.59 2,844.23 2,844.23 194.96 1,896.15 2,844.23 3,792.30 1,426.72 1,684.45 2,163.09 1,997.40 2,163.09 407.86 1,610.81 2,163.09 2,347.18

CPT Code 69633 69635 69636 69637 69641 69642 69643 69644 69645 69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69710 69711 69714 69715 69717 69718 69720 69725 69740 69745 69799 69801 69802 69805 69806 69820 69840 69905 69910 69915 69930

Surg

Anes 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

FUD 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 0 90 90 90 90 90 90 90 90 90 90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $

MAR 2,347.18 2,255.13 2,347.18 2,347.18 2,577.29 2,853.43 2,761.38 2,761.38 2,577.29 2,853.43 1,242.63 2,163.09 2,429.36 2,393.20 1,840.92 1,794.90 1,840.92 1,656.83 717.74 685.09 874.71 1,196.60 1,656.83 1,288.64 1,748.87 2,393.20 3,681.84 2,761.38 3,405.70 1,932.97 2,577.29 2,301.15 2,669.33 2,301.15 1,564.78 2,163.09 2,577.29 3,608.20 3,083.55

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 69949 69950 69955 69960 69970 69979 69990

Surg

Anes 5 11 11 11 11 11 0

FUD 0 90 90 90 90 0 0 BR $ $ $ $ BR

MAR 3,497.75 3,589.79 3,313.66 4,142.07

#&

SEE SURG GR 19

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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RADIOLOGY GROUND RULES General Information and Instructions 1. 2. DIAGNOSTIC TESTS: Diagnostic tests shall not be repeated sooner than six (6) months from the date of the test unless agreed to by the parties or ordered by the Court PHOTOGRAPHIC MEDIA AND/OR IMAGING: The use of photographic media and/or imaging is not reported separately but is considered to be a component of the basic procedure, and shall not merit any additional payment. PROCEDURE CODES: Listed allowables for radiology procedures apply only when these services are performed by or under the supervision of a physician. a. b. The five-digit CPT7 code is used to identify the total radiology service including the professional services and the technical value of providing that service. Modifier -26 is added to the five-digit CPT code to indicate the use of the professional component only. The professional component includes examination of the patient, when indicated, performance and/or supervision of the procedure, interpretation and written report of the examination and consultation with referring physicians. Modifier -TC is added to the five-digit CPT code to indicate the use of the technical component only. The technical component includes personnel, materials, space, equipment and other allocated facility overhead normally included in providing the service.

3.

c.

4.

SUPERVISION AND INTERPRETATION ONLY: A code designated as ASupervision and Interpretation [email protected] is used to indicate radiological services provided by a radiologist and staff, in conjunction with services provided by another physician (i.e., injection, insertion of catheter). In this instance, a physician other than the radiologist should bill using the appropriate procedure code and the radiologist should bill using the appropriate ASupervision and Interpretation [email protected] code. If the radiologist and staff provide both portions of the service, current CPT requires reporting with the Supervision and Interpretation code and the appropriate procedure code. COMPLETE PROCEDURES: Procedures designated as a "complete" procedure are used to denote radiological services which are performed by the radiologist and staff only. If other physicians provide some part of the procedure, see Ground Rule 4, above. UNLISTED SERVICES OR PROCEDURES: A service or procedure that is not identified by a particular CPT code should be listed under the appropriate "Unlisted Procedure." These procedures often have A99" as the final two digits. Values should be substantiated Aby [email protected]

5.

6.

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7. SEPARATE OR INDEPENDENT PROCEDURES: Certain of the listed procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate charge. When such a procedure is carried out as a separate procedure not immediately related to other services, the indicated value for "Separate Procedure" is applicable. BY REPORT ("BR") ITEMS: "BR" in the PC, TC or MAR column indicates that the value of this service is to be determined "by report". For any "by report" code, medical providers should identify a similar service and justify the difference between their charge and the value of the referenced service. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc. is to be furnished. A detailed clinical record is not necessary. MULTIPLE SERVICES OTHER THAN DIAGNOSTIC RADIOLOGY: When multiple or bilateral procedures or services are provided at the same session, the highest valued procedure will be reported as listed. The other procedure(s) will be billed using modifier -50 for bilateral procedure(s) or modifier -51 for multiple procedures. Reimbursement will be made for the highest valued procedure and at fifty percent (50%) of the lesser procedure(s) up to a total maximum allowance of twice the highest valued procedure. REDUCED VALUE: If a physician elects to reduce the value of a procedure, modifier -52 should be added to the procedure code. Modifier -52 and the appropriate CPT code may be used to indicate a limited or follow-up CT scan. SERVICES OR PROCEDURES LISTED IN OTHER SECTIONS: Services or procedures provided by a radiologist may be listed in an alternate section of this reimbursement schedule (i.e., consultation listed in Evaluation and Management). The radiologist should use these procedure codes following the guidelines appropriate to that section. NECESSITY OF SERVICES OR PROCEDURES: When a patient is referred to radiologists or other physicians for services covered in the Radiology Section, they shall evaluate the patient's problem and determine the service(s) or procedure(s) medically necessary. Such evaluations and necessary consultation with the referring physician(s) is an integral part of the professional component allowable and does not merit any additional reimbursement. X-RAY LIMITATIONS: a. UNCOMPLICATED BACK INJURIES: For uncomplicated back injuries, an anteroposterior (AP) and lateral x-ray at the initial visit shall be allowed. Additional xrays for uncomplicated back injuries shall be prohibited unless supported by reasonable medical evidence or if determined necessary at the final evaluation. CERVICAL (NECK) INJURIES: For cervical injuries, if appropriate, an anteroposterior (AP) and lateral radiograph series at the initial visit should be allowed. Additional radiographs shall be prohibited unless supported by reasonable medical evidence. Initial views such as oblique views may be used to demonstrate conditions which could exist given the findings of the clinical diagnosis.

8.

9.

10.

11.

12.

13.

b.

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14. REPRODUCTIONS: When an insurance carrier or self-insured employer requests x-rays, photographs or other images and satisfactory reproductions thereof are furnished in lieu of the original, a fee not to exceed Five Dollars ($5.00) or the actual cost of reproduction, whichever is less, may be charged. Reproductions are not returnable to the physician. The bill for copying should accompany the reproduction. (The use of photographic media and/or imaging is not reported separately but is considered to be a component of the basic procedure.) In cases where the patient transfers from one physician to another the former treating physician will promptly forward all x-rays or other photographs and images or copies of such to the new attending physician. 15. DURABLE MEDICAL EQUIPMENT AND SUPPLIES PROVIDED BY PHYSICIAN: Durable medical equipment and supplies provided by the physician over and above those usually included in a visit to the physician=s office or in other services rendered are governed by the Durable Medical Equipment Ground Rules. (Listed values in this Radiology section do not include radiopharmaceutical or other radionuclide material costs.)

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CPT Code 70010 70015 70030 70100 70110 70120 70130 70134 70140 70150 70160 70170 70190 70200 70210 70220 70240 70250 70260 70300 70310 70320 70328 70330 70332 70336 70350 70355 70360 70370 70371 70373 70380 70390 70450 70460 70470 70480 70481

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

81.20 81.20 17.52 15.93 22.29 15.93 31.84 28.66 15.93 22.29 15.93 25.47 15.93 22.29 15.93 22.29 15.93 20.70 31.84 9.55 14.33 20.70 15.93 22.29 50.95 159.22 15.93 19.11 15.93 28.66 78.02 47.77 15.93 36.63 85.98 103.49 117.82 119.42 127.37 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

166.90 138.10 32.49 32.49 38.99 29.25 40.62 35.74 29.25 42.25 32.49 43.87 32.49 42.25 32.49 37.37 22.74 29.25 48.74 13.00 22.74 37.37 26.00 42.25 100.73 731.12 22.74 37.37 22.74 64.99 97.48 82.86 32.49 82.86 264.83 307.07 393.18 264.83 307.07 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

248.10 219.30 50.01 48.42 61.28 45.17 72.46 64.40 45.17 64.54 48.42 69.34 48.42 64.54 48.42 59.66 38.67 49.95 80.58 22.55 37.08 58.07 41.92 64.54 151.68 890.35 38.67 56.48 38.67 93.65 175.50 130.63 48.42 119.49 350.81 410.56 511.00 384.25 434.44

CPT Code 70482 70486 70487 70488 70490 70491 70492 70496 70498 70540 70542 70543 70544 70545 70546 70547 70548 70549 70551 70552 70553 70557 70558 70559 71010 71015 71020 71021 71022 71023 71030 71034 71035 71040 71060 71090 71100 71101 71110 71111

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

135.34 103.49 119.42 127.37 119.42 127.37 135.34 143.30 143.30 159.22 191.07 238.83 159.22 191.07 238.83 159.22 191.07 238.83 159.22 191.07 238.83 170.32 191.07 238.83 15.93 19.11 20.70 23.88 28.66 31.84 28.66 44.58 23.88 55.72 71.65 52.54 23.88 27.07 27.07 30.25 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

393.18 264.83 307.07 393.18 264.83 307.07 393.18 409.26 409.26 731.12 812.36 951.92 731.12 812.36 893.60 731.12 812.36 893.60 731.12 812.36 959.74 731.12 812.36 893.60 22.74 29.25 30.87 40.62 40.62 40.62 40.62 69.86 32.49 73.11 105.61 81.24 32.49 37.37 42.25 47.11 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

528.52 368.32 426.48 520.55 384.25 434.44 528.52 552.56 552.56 890.35 1,003.43 1,190.76 890.35 1,003.43 1,132.43 890.35 1,003.43 1,132.43 890.35 1,003.43 1,198.58 901.44 1,003.43 1,132.43 38.67 48.36 51.57 64.50 69.28 72.46 69.28 114.45 56.38 128.84 177.26 133.78 56.38 64.44 69.31 77.36

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 71120 71130 71250 71260 71270 71275 71550 71551 71552 71555 72010 72020 72040 72050 72052 72069 72070 72072 72074 72080 72090 72100 72110 72114 72120 72125 72126 72127 72128 72129 72130 72131 72132 72133 72141 72142 72146 72147 72148 72149

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

15.93 19.11 111.46 122.60 138.52 143.30 159.22 191.07 238.83 175.14 41.40 15.93 15.93 27.07 31.84 19.11 20.70 22.29 19.11 23.88 25.47 20.70 28.66 31.84 20.70 108.27 111.46 114.64 108.27 111.46 114.64 108.27 111.46 114.64 159.22 191.07 159.22 191.07 159.22 191.07

TC $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

32.49 32.49 315.19 368.81 459.80 473.20 731.12 812.36 949.26 771.74 64.99 19.49 32.49 50.37 64.99 37.37 32.49 40.62 48.74 32.49 32.49 32.49 43.87 55.24 40.62 311.94 373.69 467.92 311.94 373.69 467.92 311.94 373.69 467.92 731.12 812.36 731.12 812.36 731.12 812.36 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

48.42 51.60 426.65 491.41 598.32 616.50 890.35 1,003.43 1,188.09 946.88 106.39 35.42 48.42 77.44 96.83 56.48 53.19 62.91 67.85 56.38 57.97 53.19 72.52 87.08 61.32 420.22 485.14 582.56 420.22 485.14 582.56 420.22 485.14 582.56 890.35 1,003.43 890.35 1,003.43 890.35 1,003.43

CPT Code 72156 72157 72158 72159 72170 72190 72191 72192 72193 72194 72195 72196 72197 72198 72200 72202 72220 72240 72255 72265 72270 72275 72285 72295 73000 73010 73020 73030 73040 73050 73060 73070 73080 73085 73090 73092 73100 73110 73115 73120

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

238.83 238.83 238.83 175.14 15.93 20.70 143.30 95.53 103.49 111.46 159.22 193.35 238.83 175.14 20.70 22.29 20.70 71.65 66.87 66.87 95.53 95.53 71.65 71.65 14.33 15.93 12.74 17.52 55.72 15.93 15.93 12.74 15.93 55.72 15.93 15.93 15.93 17.52 50.95 12.74 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

959.74 959.74 959.74 771.74 32.49 37.37 460.01 316.82 357.44 446.80 731.12 805.62 953.26 771.74 27.62 29.25 27.62 183.23 166.90 157.09 235.45 162.47 398.06 373.69 24.37 27.62 22.74 26.00 97.48 32.49 29.25 29.25 27.62 97.48 24.37 24.37 24.37 26.00 76.36 22.74 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

1,198.58 1,198.58 1,198.58 946.88 48.42 58.07 603.31 412.35 460.93 558.26 890.35 998.96 1,192.09 946.88 48.32 51.54 48.32 254.88 233.77 223.96 330.98 258.00 469.71 445.34 38.70 43.54 35.48 43.52 153.21 48.42 45.17 41.99 43.54 153.21 40.30 40.30 40.30 43.52 127.31 35.48

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CPT Code 73130 73140 73200 73201 73202 73206 73218 73219 73220 73221 73222 73223 73225 73500 73510 73520 73525 73530 73540 73542 73550 73560 73562 73564 73565 73580 73590 73592 73600 73610 73615 73620 73630 73650 73660 73700 73701 73702 73706 73718

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

15.93 12.74 95.53 103.49 111.46 143.30 159.22 191.07 178.65 159.22 191.07 238.83 175.14 15.93 15.93 22.29 55.72 28.66 15.93 58.92 15.93 14.33 15.93 19.11 14.33 52.54 12.74 12.74 12.74 15.93 55.72 14.33 17.52 12.74 11.14 95.53 103.49 111.46 143.30 159.22 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

29.25 21.12 276.20 316.82 398.06 419.67 731.12 812.36 951.92 731.12 812.36 951.92 771.74 24.37 32.49 34.12 97.48 32.49 30.87 97.48 29.25 26.00 29.25 29.25 26.00 125.10 27.62 24.37 24.37 29.25 97.48 22.74 26.00 24.37 21.12 276.20 316.82 398.06 419.67 731.12 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

45.17 33.87 371.74 420.31 509.51 562.97 890.35 1,003.43 1,130.57 890.35 1,003.43 1,190.76 946.88 40.30 48.42 56.41 153.21 61.15 46.79 156.40 45.17 40.33 45.17 48.36 40.33 177.64 40.36 37.11 37.11 45.17 153.21 37.08 43.52 37.11 32.26 371.74 420.31 509.51 562.97 890.35

CPT Code 73719 73720 73721 73722 73723 73725 74000 74010 74020 74022 74150 74160 74170 74175 74181 74182 74183 74185 74190 74210 74220 74230 74235 74240 74241 74245 74246 74247 74249 74250 74251 74260 74270 74280 74283 74290 74291 74300 74301 74305

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

191.07 178.65 159.22 191.07 238.83 175.14 15.93 19.11 25.47 30.25 111.46 117.82 127.37 143.30 159.22 191.07 238.83 175.14 92.35 31.84 41.40 49.36 105.08 63.69 65.28 79.61 63.69 65.28 82.80 44.58 66.87 47.77 63.69 87.57 114.41 28.66 19.11 38.22 17.52 39.81 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

812.36 951.92 731.12 812.36 951.92 771.74 26.00 27.62 40.62 42.25 292.45 363.93 454.92 460.01 731.12 812.36 953.26 771.74 141.35 55.24 55.24 63.36 126.73 68.24 69.86 113.73 77.99 79.61 121.85 61.74 110.48 68.24 81.24 105.61 98.84 35.74 21.12 48.74 22.74 38.99 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

1,003.43 1,130.57 890.35 1,003.43 1,190.76 946.88 41.92 46.73 66.09 72.50 403.91 481.76 582.30 603.31 890.35 1,003.43 1,192.09 946.88 233.70 87.08 96.64 112.72 231.81 131.93 135.15 193.34 141.68 144.89 204.65 106.32 177.36 116.00 144.93 193.18 213.26 64.40 40.23 86.96 40.26 78.80

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CPT Code 74320 74327 74328 74329 74330 74340 74350 74355 74360 74363 74400 74410 74415 74420 74425 74430 74440 74445 74450 74455 74470 74475 74480 74485 74710 74740 74742 74775 75552 75553 75554 75555 75556 75600 75605 75625 75630 75635 75650 75658

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

50.95 238.83 63.69 63.69 63.69 52.54 68.47 68.47 49.36 270.68 44.58 47.77 47.77 31.84 31.84 31.84 31.84 103.49 31.84 35.02 50.95 71.65 135.34 50.95 31.84 31.84 57.32 55.72 159.22 191.07 159.22 111.46 159.22 39.81 65.60 79.61 191.07 143.30 84.74 79.61 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

151.10 97.48 151.10 151.10 151.10 125.10 123.48 123.48 149.47 235.45 81.24 87.73 97.48 121.85 64.99 48.74 56.87 56.87 68.24 74.74 56.87 243.71 243.71 147.85 51.99 64.99 152.72 69.86 731.12 812.36 731.12 536.16 731.12 485.82 485.82 485.82 506.47 606.28 485.82 485.82

MAR

$ 202.05 $ 336.32 $ 214.79 $ 214.79 $ 214.79 $ 177.64 $ 191.95 $ 191.95 $ 198.83 $ 506.13 $ 125.82 $ 135.50 $ 145.25 $ 153.70 $ 96.83 $ 80.58 $ 88.71 $ 160.36 $ 100.08 $ 109.77 $ 107.81 $ 315.36 $ 379.05 $ 198.80 $ 83.83 $ 96.83 $ 210.04 $ 125.59 $ 890.35 $ 1,003.43 $ 890.35 $ 647.62 $ 890.35 $ 525.63 $ 551.41 $ 565.43 $ 697.54 $ 749.58 $ 570.56 $ 565.43

CPT Code 75660 75662 75665 75671 75676 75680 75685 75705 75710 75716 75722 75724 75726 75731 75733 75736 75741 75743 75746 75756 75774 75790 75801 75803 75805 75807 75809 75810 75820 75822 75825 75827 75831 75833 75840 75842 75860 75870 75872 75880

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

79.61 159.22 79.61 159.22 79.61 159.22 79.61 124.69 65.55 74.47 79.61 119.42 119.42 79.61 119.42 79.61 101.90 114.64 79.61 79.61 36.63 164.00 79.61 79.61 79.61 85.98 31.84 64.47 39.85 60.23 64.80 64.63 64.80 95.53 65.17 95.53 65.22 65.22 65.79 47.77 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 250.20 208.78 243.71 235.45 237.21 81.24 485.82 92.61 139.73 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 485.82 178.72 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

565.43 645.04 565.43 645.04 565.43 645.04 565.43 610.51 551.37 560.29 565.43 605.23 605.23 565.43 605.23 565.43 587.72 600.46 565.43 565.43 522.44 414.20 288.39 323.32 315.06 323.20 113.08 550.29 132.45 199.96 550.62 550.45 550.62 581.35 550.99 581.35 551.03 551.03 551.61 226.49

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CPT Code 75885 75887 75889 75891 75893 75894 75896 75898 75900 75901 75902 75940 75945 75946 75952 75953 75954 75960 75961 75962 75964 75966 75968 75970 75978 75980 75982 75984 75989 75992 75993 75994 75995 75996 75998 76000 76001 76003 76005 76006

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

95.53 95.53 64.47 64.47 222.92 79.61 79.61 151.26 127.37 47.77 39.81 39.81 31.84 31.84 259.18 78.40 129.96 114.64 429.90 159.22 63.69 159.22 79.61 63.69 111.46 127.37 175.14 63.69 238.83 39.81 23.88 87.57 87.57 23.88 21.63 15.93 60.51 49.36 63.69 19.11 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

485.82 485.82 485.82 485.82 485.82 930.81 809.60 48.74 809.01 162.47 121.85 485.82 175.90 88.49 243.71 162.47 162.47 574.53 405.00 607.19 323.45 607.19 323.45 445.03 607.19 208.78 235.45 94.24 121.58 690.51 373.69 698.63 698.63 373.69 51.05 64.99 123.48 61.74 61.74 13.00

MAR

$ 581.35 $ 581.35 $ 550.29 $ 550.29 $ 708.73 $ 1,010.42 $ 889.21 $ 200.00 $ 936.39 $ 210.24 $ 161.66 $ 525.63 $ 207.75 $ 120.33 $ 502.88 $ 240.87 $ 292.43 $ 689.17 $ 834.89 $ 766.41 $ 387.14 $ 766.41 $ 403.06 $ 508.72 $ 718.65 $ 336.16 $ 410.59 $ 157.93 $ 360.41 $ 730.31 $ 397.57 $ 786.20 $ 786.20 $ 397.57 $ 72.68 $ 80.91 $ 183.99 $ 111.10 $ 125.43 $ 32.11

CPT Code 76010 76012 76013 76020 76040 76061 76062 76065 76066 76070 76071 76075 76076 76077 76078 76080 76082 76083 76086 76088 76090 76091 76092 76093 76094 76095 76096 76098 76100 76101 76102 76120 76125 76140 76150 76350 76355 76360 76362 76370

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

15.93 76.48 79.57 15.93 23.88 44.58 55.72 39.68 27.07 22.29 22.29 20.70 15.93 11.14 15.93 50.95 3.53 3.53 31.84 39.81 39.68 49.14 39.68 175.14 278.64 149.67 52.54 12.74 54.13 54.13 55.72 35.02 23.88 39.81 $0.00 28.66 111.46 111.46 226.07 76.42

TC

$ 24.37 $ 61.74 $ 97.48 $ 35.74 $ 37.37 $ 51.99 $ 73.11 $ 38.99 $ 51.99 $ 154.35 $ 154.35 $ 136.47 $ 81.24 $ 38.99 $ 32.49 $ 51.99 $ 16.00 $ 16.00 $ 126.73 $ 175.47 $ 50.37 $ 64.99 $ 50.37 $ 771.74 $ 1,096.69 $ 292.45 $ 110.48 $ 19.49 $ 58.49 $ 64.99 $ 81.24 $ 48.74 $ 40.62 $0.00 $ 32.49 $0.00 $ 438.67 $ 438.67 $ 438.67 $ 155.98

MAR

$ 40.30 $ 138.22 $ 177.05 $ 51.67 $ 61.25 $ 96.57 $ 128.84 $ 78.66 $ 79.06 $ 176.64 $ 176.64 $ 157.17 $ 97.16 $ 50.13 $ 48.42 $ 102.94 $ 19.53 $ 19.53 $ 158.57 $ 215.28 $ 90.05 $ 114.13 $ 90.05 $ 946.88 $ 1,375.33 $ 442.12 $ 163.02 $ 32.24 $ 112.63 $ 119.12 $ 136.96 $ 83.77 $ 64.50 $ 39.81 $ 32.49 $ 28.66 $ 550.13 $ 550.13 $ 664.74 $ 232.40

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Radiology Ground Rules

CPT Code 76375 76380 76390 76393 76394 76400 76496 76497 76498 76499 76506 76510 76511 76512 76513 76514 76516 76519 76529 76536 76604 76645 76700 76705 76770 76775 76778 76800 76801 76802 76805 76810 76811 76812 76815 76816 76817 76818 76819 76820

$ $ $ $ $ $ BR BR BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

15.93 76.42 127.37 159.22 240.81 159.22 $ $ $ $ $ $ BR BR BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

181.97 186.84 682.38 731.12 731.12 731.12

MAR $ $ $ $ $ $ BR BR BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 197.89 263.27 809.76 890.35 971.93 890.35

CPT Code 76821 76825 76826 76827 76828 76830 76831 76856 76857 76870 76872 76873 76880 76885 76886 76930 76932 76936 76937 76940 76941 76942 76945 76946 76948 76950 76965 76970 76975 76977 76986 76999 77261 77262 77263 77280 77285 77290 77295 77299

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ BR

PC

47.77 96.57 65.28 66.87 55.72 68.47 68.47 63.69 33.43 55.72 108.27 127.37 55.72 71.65 63.69 60.51 66.87 113.77 17.34 116.50 77.28 63.69 58.92 39.81 33.43 52.54 124.19 36.63 92.35 47.77 108.27 162.41 206.99 286.60 62.10 95.53 140.12 318.45 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR

TC

84.48 92.61 74.74 86.11 64.99 92.61 92.61 81.24 65.46 73.11 113.73 113.73 73.11 94.24 81.24 73.11 73.11 242.79 15.99 62.13 73.11 107.59 73.11 73.11 73.11 61.74 214.81 48.74 113.73 31.74 131.61 $0.00 $0.00 $0.00 146.22 227.46 268.08 1,218.54

MAR $ 132.25 $ 189.17 $ 140.02 $ 152.99 $ 120.71 $ 161.07 $ 161.07 $ 144.93 $ 98.89 $ 128.84 $ 222.01 $ 241.10 $ 128.84 $ 165.89 $ 144.93 $ 133.62 $ 139.99 $ 356.56 $ 33.33 $ 178.63 $ 150.39 $ 171.29 $ 132.03 $ 112.92 $ 106.55 $ 114.28 $ 339.00 $ 85.37 $ 206.08 $ 79.51 $ 239.88 BR $ 162.41 $ 206.99 $ 286.60 $ 208.32 $ 322.99 $ 408.19 $ 1,536.99 BR

60.51 108.27 56.55 60.51 60.51 10.59 50.95 50.95 55.72 54.13 47.77 55.72 76.42 55.72 70.06 55.72 79.61 82.80 56.63 47.77 87.57 152.86 111.46 103.79 55.72 52.54 42.99 71.65 68.47 35.02

64.99 110.48 77.69 73.11 73.11 2.05 58.49 58.49 64.99 64.99 64.99 56.87 89.36 68.24 90.99 68.24 89.36 97.48 89.36 64.99 97.48 222.58 178.72 89.36 69.86 51.99 97.48 79.61 76.36 84.48

125.50 218.76 134.24 133.62 133.62 12.64 109.44 109.44 120.71 119.12 112.76 112.59 165.78 123.96 161.05 123.96 168.97 180.28 145.99 112.76 185.06 375.44 290.18 193.15 125.59 104.53 140.47 151.26 144.83 119.51

$ $ $ $ BR

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Radiology Ground Rules

CPT Code 77300 77301 77305 77310 77315 77321 77326 77327 77328 77331 77332 77333 77334 77336 77370 77399 77401 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 77417 77418 77427 77431 77432 77470 77499 77520 77522 77523 77525

$ $ $ $ $ $ $ $ $ $ $ $ $

PC

55.72 589.12 63.69 95.53 141.71 84.39 79.61 127.37 183.11 78.02 49.36 74.83 113.05 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

TC

MAR

CPT Code 77600 77605 77610 77615 77620 77750 77761 77762 77763 77776 77777 77778 77781 77782 77783 77784 77789 77790 77799 78000 78001 78003 78006 78007 78010 78011 78015 78016 78018 78020 78070 78075 78099 78102 78103 78104 78110 78111 78120 78121

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $

PC

140.12 186.29 140.12 186.29 140.12 409.20 334.36 477.66 716.51 415.57 622.56 923.49 143.30 214.95 318.45 477.66 92.35 92.35 15.93 23.88 28.66 47.77 47.77 35.02 41.40 60.51 76.42 92.35 34.40 63.69 71.65 52.54 68.47 76.42 15.93 20.70 20.70 27.07

TC $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ 142.98 190.09 142.98 190.09 142.98 64.99 97.48 146.22 178.72 99.11 199.84 227.46 1,267.28 1,267.28 1,267.28 1,267.28 21.12 21.12

48.74 61.74 45.49 113.73 126.73 89.36 113.73 121.85 165.72 255.08 51.72 162.81 256.71 95.85 149.47 186.84 47.11 121.85 81.24 142.98 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $

MAR

283.09 376.38 283.09 376.38 283.09 474.19 431.85 623.89 895.22 514.68 822.41 1,150.95 1,410.58 1,482.23 1,585.73 1,744.95 113.47 113.47 64.67 85.62 74.15 161.50 174.50 124.38 155.13 182.36 242.14 347.43 86.11 226.50 328.36 148.40 217.94 263.27 63.04 142.55 101.94 170.04

BR

BR $ $ $ $ BR BR BR BR BR

541.36 175.14 764.27 118.17

$ 56.87 $ 112.59 $ 1,468.74 $ 2,057.87 $ 77.99 $ 141.68 $ 97.48 $ 193.02 $ 113.73 $ 255.44 $ 165.72 $ 250.11 $ 97.48 $ 177.09 $ 133.81 $ 261.19 $ 203.09 $ 386.20 $ 21.12 $ 99.14 $ 55.24 $ 104.59 $ 77.99 $ 152.82 $ 136.47 $ 249.52 $ 138.10 $ 138.10 $ 154.35 $ 154.35 BR BR $ 105.61 $ 105.61 $ 105.61 $ 105.61 $ 113.73 $ 113.73 $ 129.98 $ 129.98 $ 146.22 $ 146.22 $ 138.10 $ 138.10 $ 146.22 $ 146.22 $ 162.47 $ 162.47 $ 178.72 $ 178.72 $ 170.60 $ 170.60 $ 178.72 $ 178.72 $ 194.97 $ 194.97 $ 211.21 $ 211.21 $ 22.91 $ 22.91 BR $ 856.23 $0.00 $ 541.36 $0.00 $ 175.14 $0.00 $ 764.27 $ 430.16 $ 548.33 BR BR BR BR BR BR BR BR BR BR

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Radiology Ground Rules

CPT Code 78122 78130 78135 78140 78160 78162 78170 78172 78185 78190 78191 78195 78199 78201 78202 78205 78206 78215 78216 78220 78223 78230 78231 78232 78258 78261 78262 78264 78267 78268 78270 78271 78272 78278 78282 78290 78291 78299 78300 78305

$ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $

PC

39.81 55.72 60.51 60.51 31.84 39.81 39.81 47.77 39.81 79.61 55.72 68.76 39.81 47.77 63.69 79.61 46.17 54.13 47.77 76.42 39.81 47.77 44.58 66.87 63.69 63.69 71.65 4.77 47.77 20.70 22.29 31.84 87.57 47.77 63.69 78.02 55.72 71.65 $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $

TC

216.09 138.10 230.71 181.97 191.72 149.47 219.34 74.74 105.61 344.44 344.44 191.72 110.48 134.85 277.83 277.83 138.10 164.10 177.09 168.97 105.61 151.10 170.60 134.85 194.97 198.21 193.34 11.37 113.73 76.36 77.99 107.24 232.34 73.11 142.98 144.60 129.98 178.72 $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $

MAR

255.90 193.83 291.22 242.48 223.56 189.28 259.15 122.51 145.42 424.05 400.16 260.48 150.29 182.62 341.52 357.44 184.28 218.23 224.86 245.39 145.42 198.87 215.18 201.73 258.66 261.91 264.99 16.15 161.50 97.06 100.28 139.08 319.91 120.88 206.67 222.61 185.70 250.37

CPT Code 78306 78315 78320 78350 78351 78399 78414 78428 78445 78455 78456 78457 78458 78459 78460 78461 78464 78465 78466 78468 78469 78472 78473 78478 78480 78481 78483 78491 78492 78494 78496 78499 78580 78584 78585 78586 78587 78588 78591 78593 $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $

PC

71.65 79.61 92.35 19.11 22.29 79.61 71.65 47.77 70.06 79.61 71.65 79.61 87.70 76.42 109.87 97.12 130.57 62.10 71.65 81.20 87.57 114.64 47.77 47.77 87.57 114.64 101.22 121.98 79.61 39.81 70.06 87.57 95.53 39.81 44.58 79.61 36.63 42.99

TC

MAR

$ 203.09 $ 274.74 $ 224.21 $ 303.82 $ 277.83 $ 370.18 $ 35.74 $ 54.85 $ 82.86 $ 105.16 BR BR $ 324.94 $ 404.55 $ 105.61 $ 177.26 $ 89.36 $ 137.13 $ 180.35 $ 250.41 $ 154.87 $ 234.48 $ 121.85 $ 193.50 $ 193.34 $ 272.95 $ 1,730.23 $ 1,817.93 $ 112.10 $ 188.53 $ 222.58 $ 332.45 $ 333.07 $ 430.19 $ 554.03 $ 684.60 $ 123.48 $ 185.58 $ 172.22 $ 243.87 $ 246.96 $ 328.15 $ 258.33 $ 345.90 $ 438.67 $ 553.32 $ 82.86 $ 130.63 130.63 $ 82.86 $ $ 245.34 $ 332.91 $ 419.18 $ 533.82 $ 2,024.33 $ 2,125.55 $ 2,439.60 $ 2,561.58 363.93 $ 284.33 $ $ 271.53 $ 311.33 BR BR $ 162.47 $ 232.53 $ 154.35 $ 241.92 $ 259.96 $ 355.49 $ 121.85 $ 161.66 $ 133.23 $ 177.81 $ 194.97 $ 274.57 $ 133.23 $ 169.85 $ 167.35 $ 210.34

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Schedule of Medical and Hospital Fees

Effective 01/01/06

Radiology Ground Rules

CPT Code 78594 78596 78599 78600 78601 78605 78606 78607 78608 78609 78610 78615 78630 78635 78645 78647 78650 78660 78699 78700 78701 78704 78707 78708 78709 78710 78715 78725 78730 78740 78760 78761 78799 78800 78801 78802 78803 78804 78805 78806

$ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $

PC

47.77 119.42 39.81 47.77 47.77 55.72 109.87 86.51 101.22 27.07 38.22 63.69 55.72 55.72 90.76 55.72 47.77 39.81 44.58 66.87 84.39 111.46 133.75 58.92 31.84 31.84 36.63 55.72 63.69 66.87 60.51 71.65 79.61 97.12 61.25 63.69 74.83

TC

MAR

CPT Code 78807 78811 78812 78813 78814 78815 78816 78890 78891 78999 79005 79101 79200 79300 79403 79440 79445 79999

$ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ BR

PC

109.87 88.93 110.83 115.01 126.36 139.84 143.21 4.77 12.74 117.82 128.97 183.11 398.06 133.27 183.11 159.22 $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ BR

TC

308.70 3,249.44 3,249.44 3,249.44 3,249.44 3,249.44 3,249.44 60.11 116.98 134.85 134.85 121.85 121.85 163.30 121.85 136.47 $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ BR

MAR

418.56 3,338.37 3,360.27 3,364.45 3,375.80 3,389.28 3,392.65 64.89 129.72 252.68 263.83 304.96 519.91 296.57 304.96 295.70

$ 235.58 $ 283.35 $ 272.69 $ 392.10 BR BR $ 138.10 $ 177.91 $ 159.22 $ 206.99 $ 159.22 $ 206.99 $ 186.84 $ 242.57 $ 308.70 $ 418.56 $ 1,730.23 $ 1,816.74 $ 2,024.33 $ 2,125.55 $ 77.99 $ 105.05 $ 180.35 $ 218.56 $ 240.46 $ 304.15 $ 121.85 $ 177.58 $ 159.22 $ 214.95 $ 292.45 $ 383.21 271.81 $ 216.09 $ $ 99.11 $ 146.88 BR BR $ 144.60 $ 184.40 $ 173.84 $ 218.43 $ 183.60 $ 250.47 $ 214.46 $ 298.85 $ 214.46 $ 325.92 $ 256.71 $ 390.46 $ 277.83 $ 336.75 $ 73.11 $ 104.95 $ 89.36 $ 121.20 $ 64.99 $ 101.61 $ 105.61 $ 161.33 $ 121.85 $ 185.55 $ 149.47 $ 216.35 BR BR $ 164.10 $ 224.61 $ 203.09 $ 274.74 $ 259.96 $ 339.56 $ 308.70 $ 405.82 $ 421.94 $ 483.18 $ 162.47 $ 226.16 $ 263.20 $ 338.04

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

Page 108

Oklahoma Workers= Compensation Court =

Schedule of Medical and Hospital Fees

Effective 01/01/06

Pathology Ground Rules

PATHOLOGY GROUND RULES General Information and Instructions 1. COVERED SERVICES: Services or procedures under this section must be performed by a registered/licensed pathologist or laboratory. Allowables in this section include recording of the specimen, performance of the test, and reporting of the result. CHARGE FOR OBTAINING AND HANDLING SPECIMEN: The attending physician may charge twenty percent (20%) of the code allowable, not to exceed Ten Dollars ($10.00), for obtaining and handling a specimen. Billing should be identified by using procedure code 99000. DURABLE MEDICAL EQUIPMENT AND SUPPLIES PROVIDED BY PHYSICIAN: Durable medical equipment and supplies provided by the physician over and above those usually included in a visit to the physician=s office or in other services rendered are governed by the Durable Medical Equipment and Supplies Ground Rules. PROCEDURE CODES: The five-digit CPT7 code is used to represent both the professional and technical components. Modifier -26 is added to the five-digit CPT code to indicate the use of the professional component only. The professional component includes examination of the patient, when indicated, performance and/or supervision of the procedure or lab test, interpretation and/or written report concerning the examination or lab test and consultation with referring physicians. It does not include the cost of personnel, materials, space, equipment or other facilities. Modifier -TC is added to the five-digit CPT code to indicate the use of the technical component only. The technical component includes the charges for personnel, materials, space, equipment and other facilities. 5. REPORT OF FINDINGS: No bill for services or procedures included in this section shall be considered properly rendered unless it is accompanied by a report that includes the findings and the interpretation of such findings. SERVICES OR PROCEDURES LISTED IN OTHER SECTIONS: For the values of services common to all physicians, see the appropriate section of the schedule. Particular reference should be made to the Introduction and Ground Rules preceding the Medicine Section. BY REPORT ("BR") ITEMS: "BR" in the PC, TC or MAR column indicates that the value of this service is to be determined "by report". For any "by report" code, medical providers should identify a similar service and justify the difference between their charge and the value of the referenced service. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc. is to be furnished. A detailed clinical record is not necessary.

2.

3.

4.

6.

7.

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Pathology Ground Rules

8. INDICES OR RATIOS: Tests which produce an index or ratio based on mathematical calculations from two or more other results may not be billed as a separate independent test, e.g., A/G ratio, free thyroxin index. UNLISTED SERVICES OR PROCEDURES: A service or procedure that is not identified by a particular CPT code should be listed under the appropriate "Unlisted Procedure." These procedures often have A99" as the final two digits. Values should be substantiated Aby [email protected] EXCESSIVE OR UNNECESSARY PROCEDURES: Payment may be denied for procedures determined to be excessive or unnecessary for the management of the work related injury(ies) or disease(s).

9.

10.

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Pathology Ground Rules

CPT Code 80048 80050 80051 80053 80055 80061 80069 80074 80076 80100 80101 80102 80103 80150 80152 80154 80156 80157 80158 80160 80162 80164 80166 80168 80170 80172 80173 80174 80176 80178 80182 80184 80185 80186 80188 80190 80192 80194 80196

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

4.43 24.36 6.64 8.86 22.14 11.07 6.64 44.29 7.75 11.02 9.92 8.81 4.41 17.40 18.85 20.30 14.50 10.15 15.94 15.94 13.05 18.85 13.05 23.19 20.30 17.40 14.50 15.94 14.50 8.70 18.85 13.05 13.05 14.50 14.50 17.40 23.19 13.05 7.25 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

20.33 36.16 10.17 22.60 45.19 20.33 21.46 65.52 11.30 28.11 25.86 22.48 7.87 36.98 39.95 45.86 32.55 19.23 31.07 31.07 31.07 39.95 34.02 35.50 39.95 42.90 29.59 39.95 32.55 14.79 39.95 32.55 35.50 36.98 32.55 38.47 36.98 31.07 17.76

MAR

$ 24.76 $ 60.52 $ 16.81 $ 31.45 $ 67.33 $ 31.40 $ 28.11 $ 109.81 $ 19.04 $ 39.13 $ 35.78 $ 31.30 $ 12.27 $ 54.38 $ 58.80 $ 66.16 $ 47.05 $ 29.38 $ 47.01 $ 47.01 $ 44.11 $ 58.80 $ 47.07 $ 58.70 $ 60.24 $ 60.30 $ 44.09 $ 55.89 $ 47.05 $ 23.50 $ 58.80 $ 45.60 $ 48.55 $ 51.48 $ 47.05 $ 55.86 $ 60.18 $ 44.11 $ 25.01

CPT Code 80197 80198 80200 80201 80202 80299 80400 80402 80406 80408 80410 80412 80414 80415 80416 80417 80418 80420 80422 80424 80426 80428 80430 80432 80434 80435 80436 80438 80439 80440 80500 80502 81000 81001 81002 81003 81005 81007 81015 81020

$ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

14.50 8.70 18.85 14.50 18.85 24.40 55.98 55.98 100.47 71.77 229.66 35.88 37.32 114.83 114.83 344.48 43.06 24.40 35.88 71.77 25.83 33.01 74.64 64.59 64.59 45.94 33.01 43.06 47.37 67.97 142.53 5.42 5.42 3.62 1.80 1.80 1.80 3.62 5.42 $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

31.07 28.11 38.47 29.59 38.47 48.34 125.96 125.96 180.15 146.46 468.68 80.56 84.95 219.70 219.70 878.78 98.13 58.59 87.88 234.34 96.66 98.13 246.06 146.46 153.79 112.77 76.16 190.40 200.65 $0.00 $0.00 7.37 7.37 3.69 3.69 3.69 3.69 5.53 9.22

MAR

$ 45.57 $ 36.81 $ 57.32 $ 44.09 $ 57.32 $ 22.00 $ 72.74 $ 181.94 $ 181.94 $ 280.63 $ 218.23 $ 698.34 $ 116.44 $ 122.27 $ 334.52 $ 334.52 $1,223.27 $ 141.18 $ 82.98 $ 123.76 $ 306.11 $ 122.50 $ 131.14 $ 320.70 $ 211.06 $ 218.38 $ 158.71 $ 109.17 $ 233.46 $ 248.02 $ 67.97 $ 142.53 $ 12.79 $ 12.79 $ 7.30 $ 5.49 $ 5.49 $ 5.49 $ 9.14 $ 14.64

$ $ $ $ $ $ $ $

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Pathology Ground Rules

CPT Code 81025 81050 81099 82000 82003 82009 82010 82013 82016 82017 82024 82030 82040 82042 82043 82044 82045 82055 82075 82085 82088 82101 82103 82104 82105 82106 82108 82120 82127 82128 82131 82135 82136 82139 82140 82143 82145 82150 82154 82157

$ $ BR $ $ $ $ $ $ BR $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

3.62 18.06 10.46 13.44 4.48 10.46 10.46 14.94 31.37 23.90 4.48 4.48 5.98 2.99 13.44 13.44 10.46 38.84 25.40 10.46 10.46 11.95 11.95 19.42 4.48 14.94 14.94 17.93 17.93 19.42 19.42 16.43 11.95 13.44 7.47 29.88 23.90 $ $ BR $ $ $ $ $ $ BR $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

3.69 36.86 24.39 36.59 9.14 21.34 24.39 28.96 74.69 36.59 10.67 12.20 13.72 7.63 32.02 30.49 24.39 86.89 57.93 19.82 21.34 25.92 25.92 44.21 7.63 30.49 30.49 62.50 39.63 33.53 33.53 39.63 27.44 35.06 15.24 53.36 56.41

MAR

$ 10.17 $ 54.91 BR $ 34.85 $ 50.03 $ 13.63 $ 31.80 $ 34.85 $ 43.90 $ 27.11 $ 106.07 $ 60.49 $ 15.15 $ 16.68 $ 19.70 $ 10.62 $ 54.54 $ 45.46 $ 43.93 $ 34.85 $ 125.74 $ 83.33 $ 30.28 $ 31.80 $ 37.87 $ 37.87 $ 63.63 $ 12.11 $ 45.43 $ 45.43 $ 80.44 $ 57.56 $ 52.96 $ 52.96 $ 56.06 $ 39.39 $ 48.50 $ 22.71 $ 83.24 $ 80.31

CPT Code 82160 82163 82164 82172 82175 82180 82190 82205 82232 82239 82240 82247 82248 82252 82261 82270 82273 82274 82286 82300 82306 82307 82308 82310 82330 82331 82340 82355 82360 82365 82370 82373 82374 82375 82376 82378 82379 82380 82382 82383

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

29.88 16.43 13.44 14.94 20.91 11.95 11.95 13.44 19.42 11.95 20.91 4.48 4.48 4.48 17.93 2.99 2.99 5.98 4.48 20.91 35.85 26.89 25.40 4.48 14.94 5.98 5.98 13.44 13.44 11.95 10.46 7.47 4.48 13.44 4.48 11.95 17.93 8.96 16.43 25.40 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

60.98 42.69 30.49 33.53 45.73 24.39 22.87 33.53 41.16 21.34 47.26 10.67 10.67 10.67 35.06 4.57 9.14 13.72 12.20 45.73 73.18 53.36 60.98 10.67 36.59 13.72 12.20 28.96 28.96 30.49 21.34 15.24 9.14 33.53 10.67 30.49 35.06 21.34 36.59 60.98

MAR

$ 90.86 $ 59.12 $ 43.93 $ 48.47 $ 66.64 $ 36.34 $ 34.82 $ 46.98 $ 60.58 $ 33.29 $ 68.17 $ 15.15 $ 15.15 $ 15.15 $ 52.99 $ 7.56 $ 12.13 $ 25.55 $ 16.68 $ 66.64 $ 109.03 $ 80.25 $ 86.38 $ 15.15 $ 51.53 $ 19.70 $ 18.18 $ 42.40 $ 42.40 $ 42.44 $ 31.80 $ 29.01 $ 13.63 $ 46.98 $ 15.15 $ 42.44 $ 52.99 $ 30.30 $ 53.02 $ 86.38

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 82384 82387 82390 82397 82415 82435 82436 82438 82441 82465 82480 82482 82485 82486 82487 82488 82489 82491 82492 82495 82507 82520 82523 82525 82528 82530 82533 82540 82541 82542 82543 82544 82550 82552 82553 82554 82565 82570 82575 82585

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

25.40 13.44 10.46 10.46 11.95 2.99 5.98 5.98 7.47 2.99 8.96 11.95 11.95 19.42 19.42 26.89 20.91 23.90 17.93 22.41 22.41 11.95 23.90 13.44 17.93 16.43 13.44 4.48 17.93 17.93 17.93 17.93 5.98 13.44 8.96 8.96 2.99 4.48 11.95 4.48 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

60.98 33.53 24.39 21.34 27.44 9.14 13.72 12.20 15.24 9.14 24.39 27.44 39.63 39.63 41.16 53.36 44.21 57.93 39.63 44.21 54.88 25.92 36.59 33.53 38.12 36.59 35.06 9.14 39.63 39.63 39.63 39.63 16.77 32.02 18.29 18.29 15.24 13.72 24.39 16.77 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

86.38 46.98 34.85 31.80 39.39 12.13 19.70 18.18 22.71 12.13 33.35 39.39 51.58 59.05 60.58 80.25 65.12 81.83 57.56 66.62 77.29 37.87 60.49 46.98 56.05 53.02 48.50 13.63 57.56 57.56 57.56 57.56 22.75 45.46 27.25 27.25 18.23 18.20 36.34 21.25

CPT Code 82595 82600 82607 82608 82615 82626 82627 82633 82634 82638 82646 82649 82651 82652 82654 82656 82657 82658 82664 82666 82668 82670 82671 82672 82677 82679 82690 82693 82696 82705 82710 82715 82725 82726 82728 82731 82735 82742 82746 82747

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

7.47 16.43 16.43 17.93 7.47 26.89 16.43 32.86 32.86 10.46 14.94 23.90 23.90 35.85 14.94 17.93 17.93 17.93 23.90 19.42 25.40 23.90 22.41 23.90 28.38 29.88 10.46 26.89 7.47 17.93 14.94 11.95 17.93 10.46 14.94 16.43 17.93 17.93 13.44 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

16.77 39.63 41.16 38.12 16.77 56.41 35.06 79.27 79.27 22.87 36.59 36.59 36.59 86.89 36.59 39.63 39.63 38.12 57.93 44.21 59.45 60.98 57.93 48.78 67.08 44.21 22.87 53.36 12.20 41.16 30.49 27.44 39.63 24.39 30.49 33.53 41.16 36.59 27.44 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

24.24 56.06 57.59 56.05 24.24 83.30 51.49 112.13 112.13 33.33 51.53 60.49 60.49 122.75 51.53 18.54 57.56 57.56 56.05 81.83 63.63 84.85 84.88 80.34 72.68 95.46 74.09 33.33 80.25 19.67 59.09 45.43 39.39 57.56 34.85 103.49 49.97 59.09 54.52 40.88

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Effective 01/01/06

Pathology Ground Rules

CPT Code 82757 82759 82760 82775 82776 82784 82785 82787 82800 82803 82805 82810 82820 82926 82928 82938 82941 82943 82945 82946 82947 82948 82950 82951 82952 82953 82955 82960 82962 82963 82965 82975 82977 82978 82979 82980 82985 83001 83002 83003

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

14.94 16.43 11.95 19.42 4.48 5.98 14.94 20.99 8.96 22.41 28.38 11.95 7.47 7.47 5.98 22.41 20.91 16.43 4.48 10.46 4.48 2.99 5.98 10.46 4.48 19.42 10.46 5.98 1.49 23.90 8.96 11.95 5.98 10.46 7.47 13.44 16.43 16.43 17.93 13.44 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

35.06 36.59 25.92 45.73 15.24 15.24 30.49 45.51 22.87 51.83 39.63 27.44 15.24 21.34 10.67 44.21 44.21 36.59 7.63 30.49 10.67 4.57 10.67 21.34 10.67 38.12 25.92 13.72 6.10 51.83 18.29 27.44 16.77 25.92 18.29 45.73 41.16 39.63 41.16 36.59 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

50.00 53.02 37.87 65.15 19.72 21.22 45.43 66.50 31.83 74.24 68.02 39.39 22.71 28.81 16.65 66.62 65.12 53.02 12.11 40.95 15.15 7.56 16.65 31.80 15.15 57.54 36.38 19.70 7.59 75.73 27.25 39.39 22.75 36.38 25.76 59.17 57.59 56.06 59.09 50.03

CPT Code 83008 83009 83010 83012 83013 83014 83015 83018 83020 83021 83026 83030 83033 83036 83045 83050 83051 83055 83060 83065 83068 83069 83070 83071 83080 83088 83090 83150 83491 83497 83498 83499 83500 83505 83516 83518 83519 83520 83525 83527

$ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

13.44 11.95 19.42 52.29 8.96 20.91 22.41 21.94 17.93 7.47 8.96 5.98 7.47 5.98 8.96 8.96 5.98 8.96 8.96 7.47 4.48 5.98 7.47 14.94 25.40 17.93 22.41 14.94 14.94 28.38 20.91 29.88 29.88 11.95 10.46 10.46 8.96 11.95 14.94

TC

$ 33.53 BR $ 25.92 $ 30.49 $ 129.58 $ 18.29 $ 50.31 $ 56.41 $ 25.92 $ 36.59 $ 4.57 $ 16.77 $ 15.24 $ 13.72 $ 12.20 $ 18.29 $ 18.29 $ 12.20 $ 22.87 $ 16.77 $ 21.34 $ 10.67 $ 12.20 $ 18.29 $ 38.12 $ 57.93 $ 35.06 $ 45.73 $ 36.59 $ 33.53 $ 57.93 $ 50.31 $ 64.02 $ 76.22 $ 25.92 $ 19.82 $ 19.82 $ 19.82 $ 30.49 $ 33.53

MAR

$ 46.98 $ 104.64 $ 37.87 $ 49.91 $ 181.87 $ 27.25 $ 71.22 $ 78.82 $ 47.86 $ 54.52 $ 12.04 $ 25.73 $ 21.22 $ 21.19 $ 18.18 $ 27.25 $ 27.25 $ 18.18 $ 31.83 $ 25.73 $ 28.81 $ 15.15 $ 18.18 $ 25.76 $ 53.06 $ 83.33 $ 52.99 $ 68.14 $ 51.53 $ 48.47 $ 86.31 $ 71.22 $ 93.90 $ 106.10 $ 37.87 $ 30.28 $ 30.28 $ 28.78 $ 42.44 $ 48.47

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Effective 01/01/06

Pathology Ground Rules

CPT Code 83528 83540 83550 83570 83582 83586 83593 83605 83615 83625 83630 83632 83633 83634 83655 83661 83662 83663 83664 83670 83690 83715 83716 83718 83719 83721 83727 83735 83775 83785 83788 83789 83805 83825 83835 83840 83857 83858 83864 83866

$ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

19.42 5.98 7.47 10.46 11.95 17.93 25.40 8.96 7.47 8.96 19.42 5.98 13.44 11.95 7.47 13.44 10.46 4.48 7.47 8.96 7.47 26.89 7.47 19.42 7.47 19.42 7.47 7.47 23.90 17.93 17.93 20.91 14.94 16.43 19.42 11.95 16.43 11.95 10.46 $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

41.16 18.29 21.34 22.87 35.06 35.06 57.93 18.29 15.24 24.39 39.63 15.24 30.49 30.49 16.77 25.92 19.82 10.67 18.29 16.77 22.87 48.78 19.82 39.63 15.24 41.16 13.72 16.77 57.93 36.59 36.59 41.16 32.02 41.16 39.63 25.92 35.06 32.02 27.44 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

60.58 24.27 28.81 33.33 47.01 52.99 83.33 27.25 22.71 33.35 18.54 59.05 21.22 43.93 42.44 35.32 39.36 30.28 30.39 25.76 25.73 30.34 75.67 27.29 59.05 22.71 60.58 21.19 24.24 81.83 54.52 54.52 62.07 46.96 57.59 59.05 37.87 51.49 43.97 37.90

CPT Code 83872 83873 83874 83880 83883 83885 83887 83890 83891 83892 83893 83894 83896 83897 83898 83901 83902 83903 83904 83905 83906 83912 83915 83916 83918 83919 83921 83925 83930 83935 83937 83945 83950 83970 83986 83992 84022 84030 84035 84060

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

5.98 25.40 11.95 14.94 4.48 19.42 23.90 2.80 2.80 2.80 2.80 2.80 2.80 4.20 18.19 18.19 16.79 18.19 18.19 18.19 18.19 20.82 12.59 23.79 15.39 15.39 15.39 23.79 6.99 6.99 25.19 13.99 27.99 39.18 4.20 15.39 16.79 4.20 4.20 15.39 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

12.20 50.31 24.39 30.49 10.67 44.21 57.93 7.14 7.14 7.14 7.14 7.14 7.14 7.14 38.55 38.55 32.84 38.55 38.55 38.55 38.55 37.12 27.13 47.12 38.55 38.55 32.84 35.70 15.70 15.70 54.26 27.13 57.11 81.38 7.14 37.12 37.12 9.99 11.43 31.41

MAR

$ 18.18 $ 75.71 $ 36.34 $ 54.54 $ 21.85 $ 63.63 $ 81.83 $ 9.94 $ 9.94 $ 9.94 $ 9.94 $ 9.94 $ 9.94 $ 11.33 $ 56.74 $ 56.74 $ 49.63 $ 56.74 $ 56.74 $ 56.74 $ 56.74 $ 57.94 $ 39.73 $ 70.91 $ 53.94 $ 53.94 $ 48.24 $ 59.49 $ 22.70 $ 22.70 $ 79.45 $ 41.12 $ 103.49 $ 120.57 $ 11.33 $ 52.51 $ 53.91 $ 14.19 $ 15.62 $ 46.80

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

Page 115

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Schedule of Medical and Hospital Fees

Effective 01/01/06

Pathology Ground Rules

CPT Code 84061 84066 84075 84078 84080 84081 84085 84087 84100 84105 84106 84110 84119 84120 84126 84127 84132 84133 84134 84135 84138 84140 84143 84144 84146 84150 84152 84153 84154 84155 84156 84157 84160 84163 84165 84166 84181 84182 84202 84203

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

5.59 8.40 4.20 6.99 13.99 19.59 6.99 9.80 4.20 4.20 2.80 8.40 8.40 13.99 26.59 8.40 4.20 4.20 9.80 25.19 23.79 11.20 26.59 9.80 22.39 26.59 18.19 13.99 13.99 5.59 5.59 5.59 5.59 14.94 21.57 46.31 21.57 22.49 16.79 6.99 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

12.85 15.70 11.43 18.57 32.84 39.98 12.85 24.27 9.99 9.99 9.99 19.99 19.99 35.70 64.25 15.70 9.99 9.99 22.84 49.97 49.97 42.84 54.26 39.98 47.12 61.40 35.70 28.56 28.56 9.99 9.99 9.99 9.99 30.49 21.42 30.49 25.70 28.56 34.27 14.28 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

18.45 24.10 15.62 25.56 46.84 59.57 19.84 34.07 14.19 14.19 12.79 28.39 28.39 49.69 90.84 24.10 14.19 14.19 32.64 75.16 73.77 54.03 80.85 49.78 69.52 87.99 53.88 42.55 42.55 15.58 15.58 15.58 15.58 45.43 42.99 76.80 47.28 51.05 51.06 21.27

CPT Code 84206 84207 84210 84220 84228 84233 84234 84235 84238 84244 84252 84255 84260 84270 84275 84285 84295 84300 84302 84305 84307 84311 84315 84375 84376 84377 84378 84379 84392 84402 84403 84425 84430 84432 84436 84437 84439 84442 84443 84445

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

12.59 20.99 12.59 11.20 12.59 44.78 44.78 43.38 40.58 22.39 18.19 22.39 20.99 13.99 13.99 22.39 4.20 4.20 5.59 13.99 11.20 4.20 2.80 13.99 4.20 4.20 11.20 11.20 2.80 27.99 25.19 22.39 12.59 11.20 4.20 5.59 5.59 8.40 9.80 37.78

TC

$ 28.56 $ 49.97 $ 19.99 $ 22.84 $ 28.56 $ 105.66 $ 105.66 $ 104.24 $ 84.24 $ 44.26 $ 42.84 $ 54.26 $ 49.97 $ 32.84 $ 34.27 $ 55.69 $ 8.57 $ 8.57 $ 11.43 $ 29.98 $ 24.27 $ 9.99 $ 4.29 $ 34.27 $ 9.99 $ 9.99 $ 22.84 $ 22.84 $ 8.57 $ 64.25 $ 59.97 $ 48.55 $ 27.13 $ 25.70 $ 14.28 $ 11.43 $ 15.70 $ 25.70 $ 31.41 $ 88.52 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

41.15 70.96 32.59 34.04 41.15 150.44 150.44 147.61 124.83 66.65 61.02 76.65 70.96 46.84 48.26 78.08 12.76 12.76 17.02 43.98 35.47 14.19 7.08 48.26 14.19 14.19 34.04 34.04 11.36 92.24 85.16 70.94 39.73 36.90 18.47 17.02 21.30 34.10 41.21 126.31

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Effective 01/01/06

Pathology Ground Rules

CPT Code 84446 84449 84450 84460 84466 84478 84479 84480 84481 84482 84484 84485 84488 84490 84510 84512 84520 84525 84540 84545 84550 84560 84577 84578 84580 84583 84585 84586 84588 84590 84591 84597 84600 84620 84630 84681 84702 84703 84830 84999

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

13.99 16.79 4.20 5.59 9.80 4.20 6.99 11.20 19.59 19.59 8.40 5.59 5.59 5.59 11.20 6.99 4.20 2.80 5.59 6.99 5.59 4.20 13.99 2.80 6.99 4.20 13.99 30.78 30.78 13.99 11.20 13.99 16.79 11.20 11.20 22.39 16.79 15.39 6.99 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR

TC

31.41 32.84 9.99 11.43 19.99 11.43 12.85 21.42 41.41 39.98 19.99 14.28 14.28 14.28 24.27 15.70 11.43 7.14 11.43 17.13 9.99 11.43 29.98 7.14 15.70 9.99 32.84 62.83 62.83 28.56 22.84 34.27 39.98 27.13 24.27 45.69 35.70 34.27 15.70 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR

MAR

45.40 49.63 14.19 17.02 29.79 15.62 19.84 32.61 61.00 59.57 28.39 19.87 19.87 19.87 35.47 22.70 15.62 9.94 17.02 24.12 15.58 15.62 43.98 9.94 22.70 14.19 46.84 93.61 93.61 42.55 34.04 48.26 56.77 38.33 35.47 68.08 52.49 49.66 22.70

CPT Code 85002 85004 85007 85008 85009 85013 85014 85018 85025 85027 85032 85041 85044 85045 85046 85048 85049 85055 85060 85097 85130 85170 85175 85210 85220 85230 85240 85244 85245 85246 85247 85250 85260 85270 85280 85290 85291 85292 85293 85300 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR 10.17 $ 113.64 8.71 $ 4.36 $ 4.36 $ 11.62 $ 20.33 $ 18.88 $ 20.33 $ 20.33 $ 24.69 $ 24.69 $ 24.69 $ 18.88 $ 18.88 $ 18.88 $ 18.88 $ 17.43 $ 8.71 $ 23.24 $ 23.24 $ 13.07 $ 4.36 50.84 2.91 2.91 4.36 1.45 1.45 2.91 8.71 8.71 4.36 4.36 4.36 2.91 5.81 4.36 4.36

TC

8.90 96.34 5.92 4.44 7.42 4.44 4.44 4.44 20.75 17.78 10.38 5.92 8.90 5.92 11.86 5.92 10.38 25.20 $0.00 17.78 8.90 8.90 29.64 42.98 44.46 44.46 45.94 48.91 48.91 48.91 47.43 47.43 47.43 47.43 42.98 19.26 45.94 45.94 26.68

MAR

$ 13.26 $ 147.18 $ 8.83 $ 7.35 $ 11.78 $ 5.90 $ 5.90 $ 7.35 $ 29.46 $ 26.50 $ 14.74 $ 10.29 $ 13.26 $ 8.83 $ 17.67 $ 10.29 $ 14.74 $ 43.02 $ 35.36 $ 113.64 $ 26.50 $ 13.26 $ 13.26 $ 41.26 $ 63.31 $ 63.34 $ 64.80 $ 66.28 $ 73.60 $ 73.60 $ 73.60 $ 66.30 $ 66.30 $ 66.30 $ 66.30 $ 60.42 $ 27.98 $ 69.18 $ 69.18 $ 39.75

BR

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Schedule of Medical and Hospital Fees

Effective 01/01/06

Pathology Ground Rules

CPT Code 85301 85302 85303 85305 85306 85307 85335 85337 85345 85347 85348 85360 85362 85366 85370 85378 85379 85380 85384 85385 85390 85396 85400 85410 85415 85420 85421 85441 85445 85460 85461 85475 85520 85525 85530 85536 85540 85547 85549 85555

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

13.07 14.53 11.62 10.17 13.07 15.98 10.17 8.71 4.36 2.91 4.36 5.81 10.17 4.36 7.26 5.81 8.71 50.84 7.26 7.26 21.19 10.17 4.36 4.36 13.07 5.81 15.98 2.91 7.26 5.81 4.36 5.81 8.71 8.71 15.98 5.81 8.71 8.71 20.33 7.26 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

26.68 29.64 25.20 19.26 26.68 31.12 19.26 17.78 11.86 8.90 8.90 16.30 14.82 13.34 20.75 11.86 16.30 96.34 14.82 14.82 10.38 19.26 11.86 11.86 25.20 17.78 37.06 7.42 14.82 14.82 11.86 14.82 22.24 19.26 37.06 13.34 22.24 23.72 41.50 16.30

MAR $ 39.75 $ 44.17 $ 36.82 $ 29.43 $ 39.75 $ 47.10 $ 29.43 $ 26.50 $ 16.22 $ 11.80 $ 13.26 $ 22.12 $ 24.99 $ 17.70 $ 28.00 $ 17.67 $ 25.01 $ 147.18 $ 22.08 $ 22.08 $ 31.57 $ 29.43 $ 16.22 $ 16.22 $ 38.27 $ 23.60 $ 53.04 $ 10.32 $ 22.08 $ 20.64 $ 16.22 $ 20.64 $ 30.95 $ 27.98 $ 53.04 $ 19.15 $ 30.95 $ 32.43 $ 61.83 $ 23.56

CPT Code 85557 85576 85597 85610 85611 85612 85613 85635 85651 85652 85660 85670 85675 85705 85730 85732 85810 85999 86000 86001 86003 86005 86021 86022 86023 86038 86039 86060 86063 86064 86077 86078 86079 86140 86141 86146 86147 86148 86155 86156

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $

PC

13.07 22.32 13.07 2.91 2.91 8.71 5.81 11.62 2.91 2.91 4.36 4.36 5.81 5.81 4.36 7.26 5.81 10.44 6.96 8.70 6.96 19.15 29.58 15.66 12.18 10.44 5.22 10.44 43.51 43.51 41.76 6.96 60.90 29.58 38.28 34.80 13.92 5.22

TC

MAR

$ 32.60 $ 45.68 $ 22.24 $ 44.56 $ 29.64 $ 42.72 $ 5.92 $ 8.83 $ 5.92 $ 8.83 $ 22.24 $ 30.95 $ 14.82 $ 20.64 $ 25.20 $ 36.82 $ 8.90 $ 11.80 $ 8.90 $ 11.80 $ 8.90 $ 13.26 $ 13.34 $ 17.70 $ 11.86 $ 17.67 $ 11.86 $ 17.67 $ 10.38 $ 14.74 $ 16.30 $ 23.56 $ 20.75 $ 26.56 BR BR $ 19.53 $ 29.97 $ 12.43 $ 19.39 $ 17.76 $ 26.46 $ 10.65 $ 17.62 $ 47.94 $ 67.09 $ 63.92 $ 93.50 $ 30.19 $ 45.84 $ 24.86 $ 37.04 $ 21.31 $ 31.75 $ 15.98 $ 21.20 $ 24.86 $ 35.30 BR $ 49.23 $ 102.98 $ 146.49 $ 102.98 $ 146.49 $ 85.23 $ 126.99 $ 15.98 $ 22.94 $ 115.41 $ 176.32 $ 63.92 $ 93.50 $ 63.92 $ 102.20 $ 62.15 $ 96.95 $ 30.19 $ 44.10 $ 12.43 $ 17.65

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Schedule of Medical and Hospital Fees

Effective 01/01/06

Pathology Ground Rules

CPT Code 86157 86160 86161 86162 86171 86185 86215 86225 86226 86235 86243 86255 86256 86277 86280 86294 86300 86301 86304 86308 86309 86310 86316 86317 86318 86320 86325 86327 86329 86331 86332 86334 86335 86336 86337 86340 86341 86343 86344 86353

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

6.96 8.70 8.70 29.58 12.18 10.44 19.15 17.40 13.92 15.66 24.36 21.94 21.94 22.62 5.22 121.81 24.36 24.36 24.36 5.22 5.22 10.44 17.40 15.66 15.66 31.33 26.10 31.33 19.15 15.66 29.58 29.58 46.31 60.90 29.58 20.88 20.88 17.40 12.18 48.72

TC

$ 14.20 $ 26.63 $ 26.63 $ 58.59 $ 30.19 $ 21.31 $ 39.06 $ 40.84 $ 26.63 $ 37.29 $ 56.82 $ 28.41 $ 28.41 $ 44.39 $ 19.53 $ 230.83 $ 51.49 $ 51.49 $ 51.49 $ 8.88 $ 14.20 $ 21.31 $ 42.61 $ 33.74 $ 23.08 $ 47.94 $ 53.27 $ 69.25 $ 40.84 $ 37.29 $ 58.59 $ 74.58 $ 30.49 $ 115.41 $ 58.59 $ 42.61 $ 40.84 $ 35.51 $ 23.08 $ 115.41 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

21.17 35.34 35.34 88.17 42.37 31.75 58.21 58.24 40.55 52.95 81.18 50.35 50.35 67.01 24.75 352.64 75.85 75.85 75.85 14.09 19.42 31.75 60.01 49.39 38.74 79.27 79.37 100.57 59.98 52.95 88.17 104.15 76.80 176.32 88.17 63.50 61.72 52.91 35.26 164.14

CPT Code 86359 86360 86361 86376 86378 86379 86382 86384 86403 86406 86430 86431 86485 86490 86510 86580 86585 86586 86587 86590 86592 86593 86602 86603 86606 86609 86611 86612 86615 86617 86618 86619 86622 86625 86628 86631 86632 86635 86638 86641

$ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

40.02 52.20 34.80 17.40 24.36 22.62 13.92 6.96 8.70 6.96 10.44 6.96 8.70 6.96 6.96 6.96

TC

MAR

10.44 3.48 5.22 8.70 10.44 13.92 10.44 12.18 10.44 10.44 15.66 13.92 10.44 8.70 10.44 10.44 10.44 10.44 8.70 10.44 12.18

$ 83.45 $ 123.47 $ 106.54 $ 158.74 $ 71.02 $ 105.83 $ 39.06 $ 56.46 $ 49.72 $ 74.08 BR $ 49.23 $ 51.49 $ 74.12 $ 26.63 $ 40.55 $ 26.63 $ 33.60 $ 26.63 $ 35.34 $ 14.20 $ 21.17 $ 17.76 $ 28.20 $ 14.20 $ 21.17 $ 19.53 $ 28.23 $ 14.20 $ 21.17 $ 14.20 $ 21.17 $ 14.20 $ 21.17 BR BR BR $ 49.23 $ 19.53 $ 29.97 $ 10.65 $ 14.13 $ 12.43 $ 17.65 $ 19.53 $ 28.23 $ 23.08 $ 33.52 $ 26.63 $ 40.55 $ 23.08 $ 33.52 $ 24.86 $ 37.04 $ 24.86 $ 35.30 $ 24.86 $ 35.30 $ 31.96 $ 47.62 $ 30.19 $ 44.10 $ 24.86 $ 35.30 $ 17.76 $ 26.46 $ 24.86 $ 35.30 $ 23.08 $ 33.52 $ 23.08 $ 33.52 $ 23.08 $ 33.52 $ 21.31 $ 30.01 $ 23.08 $ 33.52 $ 23.08 $ 35.26

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Pathology Ground Rules

CPT Code 86644 86645 86648 86651 86652 86653 86654 86658 86663 86664 86665 86666 86668 86671 86674 86677 86682 86684 86687 86688 86689 86692 86694 86695 86696 86698 86701 86702 86703 86704 86705 86706 86707 86708 86709 86710 86713 86717 86720 86723

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

12.18 15.66 13.92 12.18 12.18 12.18 12.18 12.18 12.18 13.92 15.66 12.18 8.70 10.44 12.18 13.92 12.18 13.92 5.22 10.44 13.92 12.18 12.18 12.18 22.62 10.44 6.96 12.18 12.18 17.40 17.40 13.92 13.92 15.66 15.66 12.18 12.18 10.44 12.18 12.18 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

24.86 30.19 26.63 23.08 23.08 23.08 23.08 23.08 23.08 28.41 31.96 24.86 19.53 23.08 26.63 26.63 23.08 26.63 12.43 23.08 28.41 24.86 24.86 23.08 47.94 23.08 15.98 23.08 24.86 35.51 39.06 26.63 30.19 35.51 31.96 24.86 26.63 23.08 23.08 23.08 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

37.04 45.84 40.55 35.26 35.26 35.26 35.26 35.26 35.26 42.33 47.62 37.04 28.23 33.52 38.81 40.55 35.26 40.55 17.65 33.52 42.33 37.04 37.04 35.26 70.56 33.52 22.94 35.26 37.04 52.91 56.46 40.55 44.10 51.17 47.62 37.04 38.81 33.52 35.26 35.26

CPT Code 86727 86729 86732 86735 86738 86741 86744 86747 86750 86753 86756 86757 86759 86762 86765 86768 86771 86774 86777 86778 86781 86784 86787 86790 86793 86800 86803 86804 86805 86806 86807 86808 86812 86813 86816 86817 86821 86822 86849 86850

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $

PC

10.44 10.44 12.18 12.18 12.18 12.18 12.18 12.18 12.18 10.44 10.44 22.62 12.18 12.18 10.44 12.18 12.18 12.18 12.18 12.18 12.18 12.18 10.44 12.18 12.18 13.92 13.92 13.92 52.20 45.25 34.80 24.36 62.64 48.72 29.58 62.64 57.43 50.46 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR 5.74 $

TC

23.08 21.31 23.08 23.08 23.08 23.08 23.08 26.63 23.08 23.08 23.08 47.94 23.08 24.86 23.08 23.08 23.08 26.63 24.86 26.63 24.86 23.08 23.08 23.08 23.08 30.19 26.63 30.19 102.98 94.11 83.45 60.37 149.15 113.64 72.80 150.93 138.50 102.98

MAR

33.52 31.75 35.26 35.26 35.26 35.26 35.26 38.81 35.26 33.52 33.52 70.56 35.26 37.04 33.52 35.26 35.26 38.81 37.04 38.81 37.04 35.26 33.52 35.26 35.26 44.10 40.55 44.10 155.19 139.35 118.26 84.73 211.79 162.36 102.38 213.57 195.92 153.45 15.99

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR 10.25 $

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Effective 01/01/06

Pathology Ground Rules

CPT Code 86860 86870 86880 86885 86886 86890 86891 86900 86901 86903 86904 86905 86906 86910 86911 86920 86921 86922 86927 86930 86931 86932 86940 86941 86945 86950 86965 86970 86971 86972 86975 86976 86977 86978 86985 86999 87001 87003 87015 87040

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $

PC

20.09 8.61 5.74 5.74 5.74 14.35 35.88 4.31 5.74 7.18 8.61 2.87 4.31 33.01 8.61 5.74 10.05 10.05 7.18 60.29 60.29 63.16 7.18 11.48 14.35 38.75 10.05 15.79 7.18 8.61 21.53 21.53 21.53 25.83 14.35 15.01 18.00 7.50 9.00

TC

$ 39.54 $ $ 14.65 $ $ 11.72 $ $ 14.65 $ $ 13.18 $ $ 73.23 $ $ 84.95 $ $ 10.25 $ $ 10.25 $ $ 13.18 $ $ 17.57 $ $ 8.79 $ $ 10.25 $ $ 77.63 $ $ 17.57 $ $ 21.97 $ $ 21.97 $ $ 21.97 $ $ 21.97 $ $ 143.54 $ $ 143.54 $ $ 147.93 $ $ 17.57 $ $ 29.29 $ $ 32.22 $ $ 92.28 $ $ 24.90 $ $ 39.54 $ $ 20.51 $ $ 19.04 $ $ 49.80 $ $ 49.80 $ $ 49.80 $ $ 60.05 $ $ 29.29 $ BR BR $ 33.68 $ $ 38.27 $ $ 15.31 $ $ 16.84 $

MAR

59.63 23.26 17.46 20.39 18.92 87.58 120.83 14.55 15.99 20.36 26.18 11.66 14.55 110.64 26.18 27.71 32.02 32.02 29.15 203.83 203.83 211.08 24.75 40.77 46.57 131.03 34.94 55.33 27.68 27.66 71.33 71.33 71.33 85.88 43.64 48.69 56.28 22.81 25.83

CPT Code 87045 87046 87070 87071 87073 87075 87076 87077 87081 87084 87086 87088 87101 87102 87103 87106 87107 87109 87110 87116 87118 87140 87143 87147 87149 87152 87158 87164 87166 87168 87169 87172 87176 87177 87181 87184 87185 87186 87187 87188

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

10.51 3.00 6.00 4.50 4.50 9.00 12.01 7.50 4.50 10.51 4.50 9.00 9.00 9.00 15.01 10.51 10.51 12.01 13.51 10.51 10.51 10.51 15.01 12.01 21.00 6.00 3.00 20.82 10.51 4.50 4.50 4.50 7.50 9.00 6.00 4.50 4.50 6.00 4.50 7.50 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

21.44 4.59 13.78 10.72 10.72 16.84 22.96 15.31 12.25 22.96 15.31 16.84 19.90 19.90 29.09 26.03 21.44 26.03 32.14 26.03 26.03 24.49 32.14 26.03 42.86 10.72 10.72 22.96 24.49 9.18 9.18 9.18 15.31 16.84 12.25 13.78 10.72 16.84 24.49 18.37 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

31.94 15.16 19.78 15.22 15.22 25.83 34.97 22.81 16.74 33.47 19.81 25.83 28.90 28.90 44.10 36.53 31.94 38.03 45.65 36.53 36.53 35.00 47.15 38.03 63.87 16.72 13.72 43.78 35.00 13.68 13.68 13.68 22.81 25.83 18.24 18.28 15.22 22.83 28.99 25.87

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Effective 01/01/06

Pathology Ground Rules

CPT Code 87190 87197 87205 87206 87207 87210 87220 87230 87250 87252 87253 87254 87255 87260 87265 87267 87269 87270 87271 87272 87273 87274 87275 87276 87277 87278 87279 87280 87281 87283 87285 87290 87299 87300 87301 87320 87324 87327 87328 87329

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR

PC

3.00 13.51 4.50 4.50 22.32 3.00 6.00 15.01 18.00 19.50 13.51 4.50 150.02 12.01 12.01 52.51 12.01 52.51 12.01 12.01 12.01 12.01 12.01 12.01 12.01 12.01 12.01 12.01 12.01 12.01 12.01 12.01 6.00 12.01 12.01 12.01 12.01 12.01

TC

$ 7.65 $ 27.55 $ 10.72 $ 16.84 $ 9.18 $ 9.18 $ 10.72 $ 33.68 $ 27.55 $ 42.86 $ 32.14 $ 10.72 $ 306.18 $ 26.03 $ 26.03 $ 99.51 BR $ 26.03 $ 99.51 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 12.25 $ 26.03 $ 26.03 $ 26.03 $ 26.03 $ 26.03 BR

MAR

$ 10.65 $ 41.06 $ 15.22 $ 21.33 $ 31.50 $ 12.18 $ 16.72 $ 48.69 $ 45.56 $ 62.37 $ 45.65 $ 31.42 $ 456.20 $ 38.03 $ 38.03 $ 152.02 $ 19.27 $ 38.03 $ 152.02 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 18.24 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 38.03 $ 19.27

CPT Code 87332 87335 87336 87337 87338 87339 87340 87341 87350 87380 87385 87390 87391 87400 87420 87425 87427 87430 87449 87450 87451 87470 87471 87472 87475 87476 87477 87480 87481 87482 87485 87486 87487 87490 87491 87492 87495 87496 87497 87510

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

12.01 12.01 12.01 12.01 10.51 12.01 9.00 10.51 9.00 15.01 12.01 18.00 18.00 6.00 12.01 12.01 12.01 12.01 12.01 9.00 9.00 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 33.01 18.00 33.01 39.01 18.00 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

26.03 26.03 26.03 26.03 29.09 26.03 19.90 18.37 19.90 33.68 26.03 35.21 35.21 12.25 26.03 26.03 26.03 26.03 26.03 21.44 16.84 39.80 67.36 82.67 38.27 67.36 82.67 39.80 67.36 79.61 39.80 67.36 82.67 39.80 67.36 67.36 39.80 67.36 82.67 39.80 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

38.03 38.03 38.03 38.03 39.60 38.03 28.90 28.88 28.90 48.69 38.03 53.21 53.21 18.24 38.03 38.03 38.03 38.03 38.03 30.43 25.83 57.80 100.37 121.68 56.28 100.37 121.68 57.80 100.37 118.62 57.80 100.37 121.68 57.80 100.37 100.37 57.80 100.37 121.68 57.80

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Effective 01/01/06

Pathology Ground Rules

CPT Code 87511 87512 87515 87516 87517 87520 87521 87522 87525 87526 87527 87528 87529 87530 87531 87532 87533 87534 87535 87536 87537 87538 87539 87540 87541 87542 87550 87551 87552 87555 87556 87557 87560 87561 87562 87580 87581 87582 87590 87591

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 39.01 18.00 33.01 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC

67.36 79.61 39.80 67.36 82.67 39.80 67.36 82.67 39.80 67.36 79.61 39.80 67.36 82.67 39.80 67.36 79.61 39.80 67.36 79.61 39.80 67.36 82.67 39.80 67.36 79.61 39.80 67.36 82.67 39.80 67.36 82.67 39.80 67.36 82.67 39.80 67.36 79.61 39.80 67.36

MAR

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 100.37 118.62 57.80 100.37 121.68 57.80 100.37 121.68 57.80 100.37 118.62 57.80 100.37 121.68 57.80 100.37 118.62 57.80 100.37 136.72 57.80 100.37 121.68 57.80 100.37 118.62 57.80 100.37 121.68 57.80 100.37 121.68 57.80 100.37 121.68 57.80 100.37 118.62 57.80 100.37

CPT Code 87592 87620 87621 87622 87650 87651 87652 87660 87797 87798 87799 87800 87801 87802 87803 87804 87807 87810 87850 87880 87899 87901 87902 87903 87904 87999 88000 88005 88007 88012 88014 88016 88020 88025 88027 88028 88029 88036 88037 88040

PC

TC

MAR

$ 39.01 $ 82.67 $ 121.68 $ 18.00 $ 39.80 $ 57.80 $ 33.01 $ 67.36 $ 100.37 $ 39.01 $ 79.61 $ 118.62 $ 18.00 $ 39.80 $ 57.80 $ 33.01 $ 67.36 $ 100.37 $ 39.01 $ 79.61 $ 118.62 BR BR $ 32.22 $ 18.00 $ 39.80 $ 57.80 $ 33.01 $ 67.36 $ 100.37 $ 39.01 $ 82.67 $ 121.68 $ 21.00 $ 42.86 $ 63.87 $ 36.01 $ 75.02 $ 111.03 $ 52.51 $ 99.51 $ 152.02 $ 52.51 $ 99.51 $ 152.02 $ 52.51 $ 99.51 $ 152.02 $ 52.29 $ 99.09 $ 151.39 $ 12.01 $ 26.03 $ 38.03 $ 12.01 $ 26.03 $ 38.03 $ 12.01 $ 26.03 $ 38.03 $ 12.01 $ 26.03 $ 38.03 $ 264.05 $ 548.05 $ 812.10 $ 112.52 $ 237.29 $ 413.64 $ 501.09 $ 1,039.47 $1,540.56 $ 27.00 $ 55.11 $ 209.43 BR BR BR $ 411.49 $0.00 $ 411.49 $ 462.93 $0.00 $ 462.93 $ 514.36 $0.00 $ 514.36 $ 432.07 $0.00 $ 432.07 $ 432.07 $0.00 $ 432.07 $ 411.49 $0.00 $ 411.49 $ 514.36 $0.00 $ 514.36 $ 565.80 $0.00 $ 565.80 $ 617.24 $0.00 $ 617.24 $ 534.93 $0.00 $ 534.93 $ 534.93 $0.00 $ 534.93 $ 442.35 $0.00 $ 442.35 $ 360.05 $0.00 $ 360.05 $ 1,337.34 $0.00 $1,337.34

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Effective 01/01/06

Pathology Ground Rules

CPT Code 88045 88099 88104 88106 88107 88108 88112 88125 88130 88140 88141 88142 88143 88147 88148 88150 88152 88153 88154 88155 88160 88161 88162 88164 88165 88166 88167 88172 88173 88174 88175 88182 88184 88185 88187 88188 88189 88199 88230 88233 BR BR $ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $

MAR

CPT Code 88235 88237 88239 88240 88241 88245 88248 88249 88261 88262 88263 88264 88267 88269 88271 88272 88273 88274 88275 88280 88283 88285 88289 88291 88299 88300 88302 88304 88305 88307 88309 88311 88312 88313 88314 88318 88319 88321 88323 88325

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC

70.98 61.72 70.98 6.17 6.17 72.01 111.10 111.10 91.56 88.47 74.07 88.47 134.76 82.29 15.43 18.52 18.52 18.52 18.52 17.49 33.95 9.26 17.49 3.08 25.92 56.16 71.99 112.30 230.38 334.04 25.92 32.53 14.40 27.11 25.43 31.73 87.27 100.79 208.70 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $

TC

169.00 146.96 169.00 14.69 14.69 173.21 227.79 227.79 217.29 208.90 176.35 103.92 321.22 167.96 30.44 37.79 37.79 37.79 37.79 40.94 80.83 22.04 40.94 7.35

MAR

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 239.98 208.68 239.98 20.87 20.87 245.22 338.89 338.89 308.85 297.36 250.42 192.39 455.98 250.25 45.87 56.31 56.31 56.31 64.53 58.43 114.78 31.30 58.43 29.41 41.91 93.06 118.69 172.53 324.49 463.97 31.80 81.33 57.91 97.93 81.01 152.32 87.27 146.73 208.70

$ $ $ BR $ $

34.98 33.79 54.52 61.72 93.01 19.55 7.20 5.14 30.87 20.57 30.87 $0.00 20.57 6.17 8.23 20.57 20.57 6.17 30.04 30.04 46.06 20.57 30.87 20.57 25.71 51.44 102.87 61.72 61.72 46.49 $0.00 $0.00 162.84 203.17 267.42 56.58 67.90

23.33 42.18 45.94 36.90 81.13 46.18 17.85 12.59 $0.00 57.74 57.74 78.73 78.73 16.80 36.74 57.74 78.73 16.80 24.14 35.69 51.44 31.49 36.74 57.74 57.74 18.06 58.77 125.97 125.97 62.87 121.96 60.98 $0.00 $0.00 $0.00

58.31 75.97 100.46 98.63 174.15 65.73 25.05 17.74 30.87 78.31 88.61 78.73 99.30 22.97 44.98 78.31 99.30 22.97 54.18 65.72 97.49 52.06 67.61 78.31 83.45 69.49 161.64 187.69 187.69 109.37 121.96 60.98 162.84 203.17 267.42

BR $ 136.46 $ 161.65

193.04 229.55

16.00 36.90 46.70 60.23 94.12 129.93 5.88 48.79 43.52 70.83 55.58 120.59 $0.00 $ 45.94 $0.00

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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Effective 01/01/06

Pathology Ground Rules

CPT Code 88329 88331 88332 88342 88346 88347 88348 88349 88355 88356 88358 88360 88361 88362 88365 88367 88368 88371 88372 88380 88399 88400 89050 89051 89055 89060 89100 89105 89125 89130 89132 89135 89136 89140 89141 89160 89190 89220 89225 89230 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR BR

PC

67.68 90.71 47.52 51.12 100.79 129.59 188.62 188.62 111.57 181.11 105.11 146.41 76.52 244.78 72.02 170.31 185.25 21.60 22.32 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR BR

TC

$0.00 44.08 23.51 41.80 45.94 44.08 329.52 122.76 301.83 111.24 36.74 117.38 122.47 143.12 61.41 332.33 271.35 44.08 44.08

MAR

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 67.68 134.79 71.02 92.92 146.73 173.67 518.14 311.38 413.40 292.35 141.85 263.79 198.99 387.89 133.43 502.64 456.61 65.68 66.40

CPT Code 89235 89240 89250 89251 89253 89254 89255 89257 89258 89259 89260 89261 89264 89268 89272 89280 89281 89290 89291 89300 89310 89320 89321 89325 89329 89330 89335 89342 89343 89344 89346 89352 89353 89354 89356

PC BR BR $ 1,459.83 BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR $ 15.72 $ 11.23 $ 13.48 $ 17.97 $ 11.23 $ 51.66 $ 11.23 BR BR BR BR BR BR BR BR BR

TC

MAR

2.88 6.73 8.98 4.50 22.32 31.45 40.42 8.98 26.95 13.48 22.46 29.20 33.69 40.42 4.49 6.73

4.41 13.75 18.34 10.72 18.34 75.62 93.96 20.63 66.46 29.79 55.00 61.88 71.04 77.91 9.16 13.75

8.07 20.49 27.31 15.22 40.66 107.07 134.38 29.61 93.41 66.88 106.34 91.08 120.05 142.73 13.65 20.49 16.55 5.37 4.49

BR $ 8.84 BR BR $ 229.17 $1,689.00 BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR $ 32.08 $ 47.80 $ 29.79 $ 41.02 $ 34.38 $ 47.86 $ 38.96 $ 56.93 $ 29.79 $ 41.02 $ 91.67 $ 143.33 $ 29.79 $ 41.02 BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR

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MEDICINE GROUND RULES General Information and Instructions 1. 2. GENERAL: The allowables in this section apply only when these services are performed by or under the responsible and direct supervision of a physician unless otherwise stated. UNLISTED SERVICES OR PROCEDURES: A service or procedure that is not identified by a particular CPT7 code should be listed under the appropriate "Unlisted Procedure." These procedures often have A99" as the final two digits. Values should be substantiated Aby [email protected] BY REPORT ("BR") ITEMS: "BR" in the allowable column indicates that the value of this service is to be determined "by report", because the service is too unusual or variable to be assigned a value. For any "by report" code, medical providers should identify a similar service and justify the difference between their charge and the value of the referenced service. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc. is to be furnished. A detailed clinical record is not necessary. DURABLE MEDICAL EQUIPMENT AND SUPPLIES PROVIDED BY PHYSICIAN: Durable medical equipment and supplies provided by the physician over and above those usually included in a visit to the physician=s office or in other services rendered are governed by the Durable Medical Equipment and Supplies Ground Rules. SEPARATE PROCEDURES: Certain of the listed procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate charge. For example: multiple muscle strains, such as cervical and lumbar areas, extremity, etc., when treated by other than a specific descriptor listed in the Surgery Section will be considered as an entity and not carry cumulative and/or additional charges. When such a procedure is carried out as a separate entity not immediately related to other services, the indicated allowable for "Separate Procedure" is applicable. PRORATION OF SCHEDULED ALLOWABLE: When the schedule specifies an allowable for a definite treatment and period of after care, and the patient is transferred from one physician to another, the employer or insurance carrier is responsible for the amount stated in the schedule. The concerned physicians shall agree upon the amount of proration and shall render separate bills accordingly. PROCEDURE CODES: The five-digit CPT code is used to represent both the professional and technical components. If no allowable is noted in the PC column, the MAR listed is for the professional component only and there is no technical component for the code. Modifier -26 is added to the five-digit CPT code to indicate the use of the professional component only. The professional component includes examination of the patient, when indicated, performance and/or supervision of the procedure, interpretation and written report

3.

4.

5.

6.

7.

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concerning the examination and consultation with referring physicians. It does not include the cost of personnel, materials, space, equipment or other facilities. Modifier -TC is added to the five-digit CPT code to indicate the use of the technical component only. The allowable for the TC is the difference between the MAR and the PC allowable. As stated above, if no allowable is noted in the PC column, the MAR listed is for the professional component only and there is no technical component for the code. The technical component includes the charges for personnel, materials, space, equipment and other facilities. 8. NARRATIVE REPORTS requested by the insurance carrier or self-insured employer involving the review of medical data to clarify a patient=s status should be billed using code 99080. Maximum reimbursement will be as follows: First page .................................$34.41 Each additional page ...............$13.76 Not to exceed ...........................$68.81 9. WORKERS= COMPENSATION COURT FORM 4 (TREATING PHYSICIAN=S REPORT AND NOTICE OF TREATMENT) should be billed using AFORM4". Maximum reimbursement will be $7.48. IMMUNE GLOBULIN AND VACCINES/TOXOIDS: Codes 90281-90399 identify the immune globulin product only and must be reported in addition to the administration codes 9078090784 as appropriate. Codes 90465-90474 must be reported in addition to the vaccine and toxoid code(s) 90476-90749. Codes 90476-90749 identify the vaccine/toxoid product only and must be reported in addition to the immunization administration codes 90465- 90474. MISCELLANEOUS: Listings and allowables for other diagnostic therapeutics, evaluation and management, surgical, anesthetic, x-ray and laboratory procedures may be found within the sections entitled "Evaluation and Management", "Surgery", "Anesthesia", ARadiology" and "Pathology". When reporting services in which the allowable is predicated on the basis of time, information concerning the amount of time spent must be indicated.

10.

11.

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CPT Code 90281 90283 90287 90288 90291 90296 90371 90375 90376 90378 90379 90384 90385 90386 90389 90393 90396 90399 90465 90466 90467 90468 90471 90472 90473 90474 90476 90477 90581 90585 90586 90632 90633 90634 90636 90645 90646 90647 90648

Anes

PC

TC BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR $ $ $ $ $ $ BR BR BR BR BR BR BR BR BR BR BR BR BR BR BR

MAR

CPT Code 90655 90656 90657 90658 90660 90665 90669 90675 90676 90680 90690 90691 90692 90693 90698 90700 90701 90702 90703 90704 90705 90706 90707 90708 90710 90712 90713 90715 90716 90717 90718 90719 90720 90721 90723 90725 90727 90732 90733 90734

Anes

PC

TC $ BR $ $ BR BR BR BR BR BR BR BR BR BR BR $ $ $ BR $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ BR $ $ $ $ BR

MAR 19.40 19.40 19.40

17.57 15.62 9.76 9.76 9.76 9.76 21.48 13.67 23.43 11.72 7.81 29.29 11.72 5.86 3.91 19.53 23.43 11.72 5.86 15.62 19.72

19.26 11.60 14.86 7.43 19.26 11.72

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CPT Code 90735 90740 90743 90744 90746 90747 90748 90749 90780 90781 90782 90783 90784 90788 90799 90801 90802 90804 90805 90806 90807 90808 90809 90810 90811 90812 90813 90814 90815 90816 90817 90818 90819 90821 90822 90823 90824 90826 90827 90828

Anes

PC

TC $ BR BR $ BR $ BR BR $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 11.72

CPT Code 90829 90845 90846 90847 90849 90853 90857 90862 90865 90870 90871 90875 90876 90880 90882 90885 90887 90889 90899 90901 90911 90918 90919 90920 90921 90922 90923 90924 90925 90935 90937 90939 90940 90945 90947 90989 90993 90997 90999 91000

Anes

PC

TC

MAR $ 239.30 $ 139.70 $ 105.09 $ 128.06 $ 36.23 $ 35.47 $ 38.72 $ 56.81 $ 194.03 $ 155.53 $ 222.48 $ 54.98 $ 109.95 $ 135.65 $1.82 per min. $ 54.06 $2.43 per min. $1.94 per min. BR $ 42.71 $ 98.43 $ 1,070.02 $ 802.52 $ 668.77 $ 367.82 $ 50.16 $ 33.44 $ 26.75 $ 20.07 $ 133.75 $ 300.94 BR BR $ 107.01 $ 254.13 $ 334.38 $ 80.25 $ 601.88 BR $ 85.43

26.16 37.89

86.51 39.32 23.45 28.13 37.52 23.45 167.30 177.76 71.70 87.32 122.88 142.29 200.50 219.90 87.32 106.72 135.82 155.22 213.43 232.83 74.38 93.78 129.35 148.75 206.96 226.37 90.55 109.95 142.29 161.69 219.90

4 4

5

$ 68.73

$ 16.70

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CPT Code 91010 91011 91012 91020 91030 91034 91035 91037 91038 91040 91052 91055 91060 91065 91100 91105 91110 91120 91122 91123 91132 91133 91299 92002 92004 92012 92014 92015 92018 92019 92020 92060 92065 92070 92081 92082 92083 92100 92120 92130

Anes 5 5 5 5 5 $ $ $ $ $ $ $ $ $ $ $ $ $ $

PC 108.01 114.55 124.37 82.40 52.39 77.18 124.67 77.18 87.73 77.18 58.92 64.68 32.72 75.27

TC $ 150.66 $ 178.18 $ 198.71 $ 152.93 $ 79.88 $ 280.35 $ 582.46 $ 149.74 $ 106.86 $ 613.47 $ 82.14 $ 100.99 $ 68.94 $ 52.74 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 258.67 292.73 323.07 235.32 132.27 357.53 707.13 226.92 194.59 690.64 141.06 165.67 101.67 128.01 153.41 95.80 997.45 681.42 272.72 29.95 37.94 75.26 137.54 68.37 101.59 24.96 150.45 93.59 62.39 58.10 39.45 174.70 64.26 86.18 108.18 91.32 75.97 83.89

CPT Code 92135 92136 92140 92225 92226 92230 92235 92240 92250 92260 92265 92270 92275 92283 92284 92285 92286 92287 92310 92311 92312 92313 92314 92315 92316 92317 92325 92326 92330 92335 92340 92341 92342 92352 92353 92354 92355 92358 92370 92371

Anes 5

PC $ 21.08 $ 43.06

TC $ 24.29 $ 79.18 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 45.37 122.24 59.28 49.92 43.67 124.79 160.32 299.46 131.80 68.63 139.53 139.17 150.85 72.88 105.46 49.70 185.50 125.36 149.75 162.22 174.70 174.70 106.07 118.55 131.03 143.51 43.67 62.45 174.70 131.03 31.20 37.43 38.69 37.43 38.69 37.43 40.55 87.35 31.20 32.45

5 5 5 5 5 5

5 5 3 3 5

$ 208.39 $ 77.84 $ 101.75

$ 789.06 $ 603.58 $ 170.97

4 4 5 5 5 4 5 5 5 5 5 5 5 5 5

$ 74.88 $ 87.35 $ 81.12 $ $ $ $ $ $ $ 93.59 93.59 93.59 43.68 37.43 15.60 81.12

$ 85.45 $ 212.11 $ 50.68 $ 45.94 $ 45.57 $ 57.26 $ 29.20 $ 68.02 $ 34.10 $ 104.39

4 4 4 $ 41.34 $ 24.96 4 $ $ $ 34.32 46.80 62.39 $ 29.95 $ 39.38 $ 45.78 $ 16.76 $ 14.49

5 5

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CPT Code 92390 92391 92392 92393 92395 92396 92499 92502 92504 92506 92507 92508 92510 92511 92512 92516 92520 92526 92531 92532 92533 92534 92541 92542 92543 92544 92545 92546 92547 92548 92551 92552 92553 92555 92556 92557 92559 92560 92561 92562

Anes

PC

TC BR BR BR BR $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR

CPT Code 92563 92564 92565 92567 92568 92569 92571 92572 92573 92575 92576 92577 92579 92582 92583 92584 92585 92586 92587 92588 92590 92591 92592 92593 92594 92595 92596 92597 92601 92602 92603 92604 92605 92606 92607 92608 92609 92610 92611 92612

Anes

PC

TC $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR $ $ $ $ $ $

MAR 15.00 18.55 15.74 21.35 17.08 17.08 15.36 13.66 13.86 13.66 17.42 28.31 59.78 28.52 34.88 115.29 260.40 234.43 104.05 151.63 93.94 140.92 34.16 51.24 34.16 51.24 51.24 179.34 133.11 90.88 81.85 52.06

77.37 126.66 108.49 42.71 135.62 64.84 30.73 217.78 161.89 67.28 64.15 93.94 93.94 21.35 29.04 17.08 8.54 86.54 103.88 71.90 55.23 60.66 112.79 18.79 190.15 29.89 29.89 42.71 21.35 42.71 93.94 29.89 17.08 34.16 16.12

5 5

5 5 5 6

5 $51.24 $42.71 $25.62 $42.71 $209.15 $191.72 $ 78.43 $108.93

$ $ $ $ $ $

29.89 34.16 21.35 16.02 17.08 42.71

$ $ $ $ $ $

56.64 69.72 50.54 39.21 43.58 70.08

$ 76.87

$ 113.29

116.94 23.29 60.61 130.64 130.64 159.31

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CPT Code 92613 92614 92615 92616 92617 92620 92621 92625 92700 92950 92953 92960 92961 92970 92971 92973 92974 92975 92977 92978 92979 92980 92981 92982 92984 92986 92987 92990 92992 92993 92995 92996 92997 92998 93000 93005 93010 93012 93014 93015

Anes

PC

TC $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 46.85 150.26 41.48 210.73 51.85 66.62 17.46 65.32 327.84 473.07 430.06 516.07 313.95 120.42 373.30 421.46 799.92 713.90 735.49 389.69 2,709.40 1,354.70 2,150.32 1,075.16 4,149.77 3,377.72 3,474.22 4,680.55 4,970.07 1,821.75 672.62 1,797.66 688.10 58.49 29.99 33.75 229.56 33.75 277.46

CPT Code 93016 93017 93018 93024 93025 93040 93041 93042 93224 93225 93226 93227 93230 93231 93232 93233 93235 93236 93237 93268 93270 93271 93272 93278 93303 93304 93307 93308 93312 93313 93314 93315 93316 93317 93318 93320 93321 93325 93350 93501

Anes

PC

TC $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 65.61 142.48 51.74 227.42 501.22 37.50 22.49 29.99 299.97 116.23 93.74 127.48 299.97 116.23 93.74 127.48 149.98 131.24 134.98 307.80 59.99 229.56 37.50 144.46 417.81 227.57 448.42 250.53 538.56 127.48 433.57 568.39 112.49 455.46 305.92 212.65 121.82 238.57 549.11 1,645.30

$ 104.98 $ 51.74

$ 122.44 $ 449.48

4 12

0 0 7 7 0 0 7 0 8 0 10 10 10 7 7 8 0 7 0

$ 516.08 $ 258.04

$ 219.41 $ 131.65

7 7 7 7 7 7 7 7 7 7

$ 45.75 $ 149.98 $ 97.49 $ 149.98 $ 97.49 $ 232.47 $ 127.48 $ 269.97 $ 179.98 $ 212.23 $ 78.74 $ 29.99 $ 121.49 $ 277.46 $ 463.34

$ 98.71 $ 267.83 $ 130.08 $ 298.44 $ 153.03 $ 306.09 $ 306.08 $ 298.42 $ 275.48 $ 93.69 $ 133.91 $ 91.83 $ 117.08 $ 271.65 $1,181.96

7 4

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CPT Code 93503 93505 93508 93510 93511 93514 93524 93526 93527 93528 93529 93530 93531 93532 93533 93539 93540 93541 93542 93543 93544 93545 93555 93556 93561 93562 93571 93572 93580 93581 93600 93602 93603 93609 93610 93612 93613 93615 93616 93618

Anes 4 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

PC $ 501.94 $ 424.73 $ 463.34 $ 463.34 $ 849.45 $ 849.45 $ 810.83 $1,003.89 $ 926.66 $ 540.56 $ 494.22 $ 864.89 $1,081.11 $ 602.33

TC $ 197.00 $ 787.97 $2,757.92 $2,757.92 $2,600.33 $3,467.11 $3,585.30 $3,545.91 $3,545.91 $3,467.11 $1,071.65 $3,057.35 $2,994.32 $2,970.68 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 401.55 698.94 1,212.70 3,221.26 3,221.26 3,449.78 4,316.56 4,396.14 4,549.80 4,472.57 4,007.67 1,565.88 3,922.25 4,075.43 3,573.01 189.23 189.23 189.23 189.23 189.23 189.23 189.23 568.65 875.67 232.77 97.01 349.25 323.38 1,082.20 1,445.09 565.58 390.04 477.81 1,265.09 521.70 565.58 1,096.68 192.81 379.19 1,088.32

CPT Code 93619 93620 93621 93622 93623 93624 93631 93640 93641 93642 93650 93651 93652 93660 93662 93668 93701 93720 93721 93722 93724 93727 93731 93732 93733 93734 93735 93736 93740 93741 93742 93743 93744 93745 93760 93762 93770 93784 93786 93788

Anes 10 10 0 0 10 10 10 10 10 10 10 10

PC $1,290.19 $1,720.25 $1,978.29 $1,978.29 $ 688.10 $ 688.10 $ 946.15 $ 602.08 $1,075.16 $ 731.11 $1,548.23 $2,322.34 $2,494.37 $ 258.04 $ 240.84 $ 17.46 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

TC 658.26 877.68 877.68 877.68 43.88 87.77 526.60 614.38 482.72 614.37 526.61 394.96 351.07 307.19 219.42 57.37 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $

MAR 1,948.45 2,597.93 2,855.97 2,855.97 731.99 775.87 1,472.75 1,216.46 1,557.88 1,345.48 2,074.84 2,717.29 2,845.44 565.23 460.26 74.83 86.01 60.20 25.81 909.27 96.20 104.09 121.29 91.60 69.34 104.09 74.22 112.52 73.38 104.09 104.51 113.32 207.13 258.92 34.67 275.24 94.61 86.01

10 10 10 10 10 0 10 10 10 10 10

$ 90.32 $ 98.91 $ 177.62 $ 64.68 $ 129.35 $ 103.48 $ 388.06 $ 582.08 $ 240.84 $ 240.84 $ 240.84 $ 369.86 $ 240.84 $ 240.84 $778.94 $ 92.12 $ 171.06 $ 430.06

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

478.34 776.76 55.15 32.34 219.90 219.90 694.14 863.01 324.74 149.21 236.97 895.23 280.86 324.74 317.74 100.69 208.12 658.26

$ 602.08 $ 17.20 $ 60.21 $ 77.41 $ 27.53 $ 43.01 $ 60.21 $ 18.92 $ 77.41 $ 47.05 $ 60.21 $ 60.64 $ 69.44 $ 172.02 $ 215.03 $ 21.50

$ 307.19 $ 78.99 $ 43.87 $ 43.88 $ 64.07 $ 26.33 $ 43.87 $ 55.29 $ 35.11 $ 26.33 $ 43.87 $ 43.87 $ 43.88 $ $ $ 35.11 43.88 13.17

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CPT Code 93790 93797 93798 93799 93875 93880 93882 93886 93888 93890 93892 93893 93922 93923 93924 93925 93926 93930 93931 93965 93970 93971 93975 93976 93978 93979 93980 93981 93990 94010 94014 94015 94016 94060 94070 94150 94200 94240 94250 94260

Anes

PC

TC $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 103.21 68.81 68.81 138.39 272.19 188.54 324.24 245.77 351.84 374.48 367.37 174.56 259.89 294.75 318.56 194.03 284.57 200.50 154.39 260.58 168.16 408.00 240.20 284.57 200.50 336.32 239.30 181.09 67.91 54.98 64.68 34.28 129.35 233.93 12.82 43.36 87.70 30.08 87.59

CPT Code 94350 94360 94370 94375 94400 94450 94452 94453 94620 94621 94640 94642 94656 94657 94660 94662 94664 94667 94668 94680 94681 94690 94720 94725 94750 94760 94761 94762 94770 94772 94799 95004 95010 95015 95024 95027 95028 95044 95052 95056

Anes 3 2 2 8 8 8

PC $ 32.34 $ 25.87 $ 14.51 $ 43.01 $ 158.43 $ 158.43 $ 20.76 $ 26.53 $ 46.09 $ 79.48 $ 9.71

TC $ 54.08 $ 45.27 $ 35.57 $ 87.77 $ 28.14 $ 27.85 $ 46.73 $ 69.80 $ 88.00 $ 170.48 $ 19.40 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR BR $ $ $ $ $ $ $ $ $

MAR 86.42 71.14 50.08 130.78 186.57 186.29 67.49 96.33 134.09 249.95 29.11 86.01 161.30 73.78 161.30 161.30 54.98 47.31 34.41 323.02 323.02 178.77 70.01 160.29 83.11 46.09 69.13 57.61 56.74

$ 51.74 $ 64.68 $ 58.21 $ 77.61 $ 51.74 $ 80.85 $ 92.49 $ 92.49 $ 74.38 $ 109.95 $ 116.42 $ 64.68 $ 32.34 $ 51.74 $ 25.87 $ 51.74 $ 64.68 $ 32.34 $ 135.82 $ 68.82 $ 64.68 $ 32.34 $ 142.29 $ 71.14 $ 25.87 $ 38.81 $ 32.34 $ 32.34 10 10 1 2 3 3 2 $ $ $ $ $ $ $ 38.81 33.43 5.18 25.81 23.05 6.92 28.81

$86.65 $207.52 $130.33 $246.63 $194.03 $271.00 $281.99 $274.88 $100.18 $149.94 $178.33 $253.89 $161.69 $232.83 $174.63 $102.65 $195.90 $135.82 $272.18 $171.39 $219.90 $168.16 $194.03 $168.16 $155.22 $ 29.11 $ 22.64 $ 32.34 $ 90.55 $200.50 $ 7.65 $ 17.55 $ 64.66 $ 23.16 $ 58.79

2 10 5 10 5 3 4 2 3 3 3 3 3 3

$ 158.43 $ 158.43 $ 25.93 $ 25.93 $ 51.60 $ 34.56

$ $ $ $ $ $

164.59 164.59 152.84 44.09 108.69 48.54

1

$

28.81

$

27.93

4.53 18.77 11.98 6.47 35.42 12.94 8.64 9.59 6.58

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CPT Code 95060 95065 95070 95071 95075 95078 95115 95117 95120 95125 95130 95131 95132 95133 95134 95144 95145 95146 95147 95148 95149 95165 95170 95180 95199 95250 95805 95806 95807 95808 95810 95811 95812 95813 95816 95819 95822 95824 95827 95829

Anes

PC

TC

MAR $ 13.52 $ 12.90 $ 189.23 $ 215.03 $ 154.83 $ 43.01 $ 21.50 $ 30.10 $ 25.81 $ 38.70 $ 43.01 $ 60.20 $ 68.81 $ 77.41 $ 86.01 $ 12.04 $34.41 per test $ 38.70 $ 48.17 $ 57.63 $ 67.09 $ 15.48 BR $ 258.04 BR $ 154.73 $ 739.77 $ 609.11 $ 527.40 $ 744.80 $ 919.36 $ 1,006.10 $ 246.74 $ 287.58 $ 189.60 $ 181.83 $ 223.65 $ 161.69 $ 225.07 $ 1,447.19

CPT Code 95830 95831 95832 95833 95834 95851 95852 95857 95858 95860 95861 95863 95864 95867 95868 95869 95870 95872 95875 95900 95903 95904 95920 95921 95922 95923 95925 95926 95927 95928 95929 95930 95933 95934 95936 95937 95950 95951 95953 95954

Anes

PC

TC $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 199.95 29.72 45.27 97.01 116.42 27.17 40.75 48.51 146.32 125.45 167.70 217.10 266.51 106.72 185.72 99.70 64.86 194.03 134.95 87.22 98.91 78.39 265.17 74.96 83.62 113.53 219.90 219.90 219.90 255.47 265.82 117.76 72.45 80.97 87.32 67.91 291.04 1,063.15 517.41 378.92

$ $ $ $ $ $ $ $ $ $ $ $ $ $

108.32 258.04 93.66 275.25 297.51 323.38 109.95 122.88 65.41 65.41 65.41 45.27 91.19 365.29

$ 631.45 $ 351.07 $ 433.75 $ 469.56 $ 621.85 $ 682.72 $ 136.79 $ 164.69 $ 124.19 $ 116.42 $ 158.24 $ 116.42 $ 133.88 $1,081.91

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

94.58 87.42 121.04 154.66 188.29 77.61 146.22 60.21 47.31 142.29 97.01 46.17 63.52 42.62 194.03 52.33 57.75 54.38 58.21 58.21 58.21 122.24 122.24 38.81 42.04 54.70 61.45 42.04 97.01 362.69 194.03 258.04

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

51.74 38.03 46.66 62.44 78.22 29.11 39.50 39.49 17.55 51.74 37.94 41.04 35.40 35.77 71.14 22.63 25.87 59.14 161.69 161.69 161.69 133.23 143.58 78.96 30.41 26.27 25.87 25.87 194.03 700.47 323.38 120.88

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 95955 95956 95957 95958 95961 95962 95965 95966 95967 95970 95971 95972 95973 95974 95975 95978 95979 95990 95991 95999 96000 96001 96002 96003 96004 96100 96105 96110 96111 96115 96117 96150 96151 96152 96153 96154 96155 96400 96405 96406

Anes $ $ $ $ $ $

PC 129.02 185.91 120.42 559.08 258.04 258.04

TC $ 131.65 $ 539.09 $ 157.98 $ 87.77 $ 87.77 $ 87.77 $ $ $ $ $ $ BR BR BR $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

MAR 260.67 724.99 278.40 646.85 345.81 345.81

CPT Code 96408 96410 96412 96414 96420 96422 96423 96425 96440 96445 96450 96520 96530 96542 96545 96549 96567 96570 96571 96900 96902 96910 96912 96913 96920 96921 96922 96999 99000 99001 99002 99024 99026 99027 99050 99052 99054 99056 99058 99071

Anes

PC

TC $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ $ BR $ $ $ $ $ $ $ $ $ $ BR

MAR 77.41 146.22 120.42 146.22 111.90 196.55 80.97 182.56 404.90 400.94 345.49 156.45 112.96 222.51 60.20 115.06 105.79 53.29 25.81 43.01 37.98 48.33 181.49 145.99 149.51 223.55

52.15 64.51 120.42 77.41 236.53 141.92 276.17 133.88 57.55 89.60 176.84 210.82 40.93 38.61 180.70 172.04 188.86 151.99 170.10 199.20 209.55 50.20 47.88 45.56 10.81 45.56 44.79 31.82 109.87 148.83

1 6 4 4

SEE PATH GR 2

9.71 9.71 0.00 64.68 32.34 25.87 51.74 51.74 25.87 25.87

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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CPT Code 99075 99078 99080 99082 99090 99091 99100 99116 99135 99140 99141 99142 99170 99172 99173 99175 99183 99185 99186 99190 99191 99192 99195 99199

Anes

PC

TC

MAR SEE GEN GR 2 BR BR BR $ 142.29 $ 64.68 $ 35.88 $ 179.40 $ 179.40 $ 71.76 $ 84.08 $ 64.68 $ 143.95 BR BR $ 54.06 $ 226.79 $ 32.34 $ 109.95 $ 556.21 $ 413.93 $ 274.88 $ 32.34 BR

1 5 5 2

5

0

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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PHYSICAL MEDICINE GROUND RULES General Information and Instructions 1. COVERED SERVICES: The allowables in this section apply only when a physician determines the services are medically warranted and the services are performed by one or a combination of the following health care providers as authorized by law for the provider=s professional license: a. b. c. A physician; A licensed physical therapist; A licensed physical therapist assistant under the direct clinical on-site supervision of a licensed physical therapist or under the general supervision of a licensed physical therapist, as provided in the rules of the State Board of Medical Licensure and Supervision; A licensed occupational therapist; and/or A licensed occupational therapy assistant under the general supervision of a licensed occupational therapist, as provided in the rules of the State Board of Medical Licensure and Supervision.

d. e.

provided, supervised modalities under CPT7 codes 97010 through 97028 may be performed as authorized in the CPT book. 2. VISIT LIMITATIONS: If medically warranted, physical medicine treatments may be provided over the course of one or more visits, subject to the following: a. If treatment consists only of modalities under CPT codes 97010 through 97039, not more than four (4) visits is allowable unless prior authorization is obtained from the payor; and Treatment beyond eighteen (18) visits, in the aggregate, must be authorized. All care beyond eighteen visits in the aggregate shall require a specific treatment plan as provided in Ground Rule 4 of these ground rules.

b.

For purposes of this Ground Rule, a [email protected] occurs whenever the patient presents for and receives treatment. A patient=s return on the same day for additional treatment which is provided constitutes a separate visit. 3. TREATMENT LIMITATIONS: Visits are subject to the following treatment limitations: a. No more than one manipulation per day is allowable, except on the initial and next two consecutive visits. If additional manipulations are performed on the initial and/or next two consecutive visits, the attending doctor must submit a detailed report to the insurance carrier or employer regarding the need for such additional manipulations; and For injury resulting in treatment to one body region, any combination of four (4) physical medicine codes is allowable per day. For injury resulting in treatment to

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more than one body region, any combination of six (6) physical medicine codes is allowable per day. (An injury resulting in treatment to more than one body region must be substantiated by the appropriate diagnosis codes.) For purposes of this Ground Rule, each application of the same physical medicine code on the same day constitutes a separate code; and c. d. e. No more than four (4) modalities, (CPT codes 97010-97039) is allowable per day; and Bed traction is not an accepted modality for low back pain or neck pain; and Transcutaneous Electrical Nerve Stimulation (TENS) is not recommended in the treatment of typical mechanical low back pain without concomitant lower extremity pain (sciatica).

4.

TREATMENT PLAN: a. A patient=s medical record must include a treatment plan. The treatment plan must include the patient=s diagnosis, recommended treatment frequency, modalities and procedures to be used, active and passive care treatment recommendations, and both long term and short term goals with a measurable expected response (e.g., range of motion improved by fifty percent (50%), reduction in pain by seventy-five percent (75%), and full return to work within a specific number of weeks). If treatment is provided beyond eighteen (18) visits in the aggregate, the treatment plan must specifically identify the reason suspected for the patient=s non-response to prior treatment, identify any changes in the treatment plan, and include a demonstrated change in treatment with active care components and appropriate second opinion specialist referrals by the treating physician. Treatment plans must be made available upon request. No fee for preparation of the treatment plan is allowable.

b.

c. d. 5.

OFFICE VISITS: If an evaluation and management assessment is medically necessary, a physician may charge and be reimbursed for an office visit at the initial visit, after an interim corrective treatment, and at the final evaluation. This ground rule does not permit reimbursement for an office visit each time the patient presents for and receives treatment. BY REPORT ("BR") ITEMS: "BR" in the maximum allowable reimbursement (MAR) column indicates that the value of this service is to be determined "by report", because the service is too unusual or variable to be assigned a value. For any "by report" code, medical providers should identify a similar service and justify the difference between their charge and the value of the referenced service. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc. must be furnished. A detailed clinical record is not necessary.

6.

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7. UNLISTED SERVICES OR PROCEDURES: A service or procedure that is not identified by a particular CPT code should be listed under the appropriate "Unlisted Procedure." These procedures often have A99" as the final two digits. Values should be substantiated Aby [email protected] PHYSICAL THERAPY SERVICES: a. b. All physician referrals of a patient to a physical therapist for treatment must be in writing. Reimbursement and Billing: (1) (2) Physical therapists employed by others (i.e. not self-employed) may not bill separately from the employer. When a physical therapist renders physical therapy during after-care periods for fractures, dislocations or other post-operative procedures, charges for such therapy shall be in addition to those of the referring physician or of the physician for the after-care period. When a physical therapist renders treatment in a patient's home, add fifty percent (50%) to the listed allowable to determine the maximum allowable reimbursement amount. Mileage and the time it takes the physical therapist to travel to and from the patient=s home and to complete any required documentation of the services provided shall not be reimbursed separately. An explanation justifying the need for home therapy rather than therapy in an office or out-patient setting must be submitted with the bill. A licensed physical therapist may charge and be reimbursed for an initial evaluation and not more than two re-evaluations using codes 97001 and 97002, as appropriate. These codes are in addition to other codes allowed on the initial evaluation or re-evaluation of a patient. All physical therapists and physical therapist assistants must include their professional license number on all bills submitted for payment.

8.

(3)

(4)

(5) 9.

OCCUPATIONAL THERAPY SERVICES: a. b. All physician referrals of a patient to an occupational therapist for treatment must be in writing. Reimbursement and Billing (1) (2) Occupational therapists employed by others (i.e. not self-employed) may not bill separately from the employer. When an occupational therapist renders occupational therapy during afterPage 141

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care periods for fractures, dislocations or other post-operative procedures, charges for such therapy shall be in addition to those of the referring physician or of the physician for the after-care period. (3) When an occupational therapist renders treatment in a patient=s home, add fifty percent (50%) to the listed allowable to determine the maximum allowable reimbursement amount. Mileage and the time it takes the occupational therapist to travel to and from the patient=s home and to complete any required documentation of the services provided shall not be reimbursed separately. An explanation justifying the need for home therapy rather than therapy in an office or out-patient setting must be submitted with the bill. A licensed occupational therapist may charge and be reimbursed for an initial evaluation and not more than two re-evaluations using codes 97003 and 97004, as appropriate. These codes are in addition to other codes allowed on the initial evaluation or re-evaluation of a patient. All occupational therapists and occupational therapy assistants must include their professional license number on all bills submitted for payment.

(4)

(5) 10.

DURABLE MEDICAL EQUIPMENT AND SUPPLIES: Durable medical equipment and durable medical supplies used in the provision of physical medicine services are subject to different rules of reimbursement. Durable medical equipment provided by the health care provider over and beyond those usually included in a visit to the provider=s office or in other services rendered are governed by the Durable Medical Equipment and Supplies Ground Rules. However, durable medical supplies used in the provision of physical medicine services shall not be reimbursed separately since the maximum allowable reimbursement (MAR) for the physical medicine codes includes the supply of materials.

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CPT Code 97001 97002 97003 97004 97005 97006 97010 97012 97014 97016 97018 97020 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97504 97520 97530 97532 97533 97535 97537 97542 97545

MAR $ 81.41 $ 43.07 $ 86.47 $ 51.74 $ 46.09 $ 20.46 $ 9.59 $ 21.48 $ 16.78 $ 21.48 $ 14.38 $ 14.38 $ 21.48 $ 14.38 $ 9.59 $ 19.17 $ 21.48 $ 23.97 $ 18.46 $ 19.17 $ 26.37 $ 12.65 $ 30.12 $ 31.64 $ 34.21 $ 26.65 $ 25.38 $ 16.86 $ 28.50 $ 23.97 $ 32.56 $ 30.12 $ 31.57 $ 45.05 $ 45.05 $ 35.95 $ 35.95 $ 35.95 $ 115.04

CPT Code 97546 97597 97598 97602 97605 97606 97703 97750 97755 97799 97802 97803 97804 97810 97811 97813 97814 98925 98926 98927 98928 98929 98940 98941 98942 98943

MAR $ 57.52 $ 53.20 $ 67.58 BR BR BR $ 35.95 $ 45.54 $ 37.90 BR $ 35.88 $ 32.20 $ 14.26 $ 40.96 $ 31.68 $ 43.88 $ 35.78 $ 35.95 $ 44.29 $ 57.27 $ 67.79 $ 77.96 $ 35.95 $ 43.07 $ 51.82 $ 34.18

CPT only copyright 2004 American Medical Association. All rights reserved. Applicable FARS/DFARS restrictions apply to government use.

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DURABLE MEDICAL EQUIPMENT AND SUPPLIES GROUND RULES General Information and Instructions 1. CODING AND REIMBURSEMENT OF DURABLE MEDICAL EQUIPMENT AND SUPPLIES: The Oklahoma Workers= Compensation Court adopts by reference the Centers for Medicare and Medicaid Services, CMS Common Procedures Coding System (HCPCS) for the coding of durable medical equipment and supplies. The maximum allowable reimbursement for durable medical equipment and supplies provided or administered to a patient shall be the lesser of the provider=s usual and customary charge or the corresponding Oklahoma allowable, in effect on the date of rental or purchase, as reflected in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule, published by the Centers for Medicare and Medicaid Services. The Centers for Medicare and Medicaid Services Fee Schedule can be accessed via the Internet at http://www.cms.hhs.gov/DMEPOSFeeSched/. It also is available for purchase from the Records Department of the Workers= Compensation Court, 1915 N. Stiles, Oklahoma City, OK 73105, (405) 522-8640 or in-state toll free at (800) 522-8210. COVERED SERVICES: A payor shall reimburse for the purchase or rental of durable medical equipment and supplies that are medically warranted and substantiated by a written prescription or order. Durable medical equipment and supplies provided or administered in an in-patient hospital or ambulatory surgical center setting are not covered by this section since they are included in the Diagnosis Related Groups (DRG) payment rate. This section also does not apply to CPT7 codes 90281 through 90399, 90476 through 90749, 95120 through 95134, 95144 through 95170, and 96545, since the maximum allowable reimbursement (MAR) for each of these codes includes the supply of materials. PRIOR AUTHORIZATION FOR RENT/PURCHASE: Prior authorization by the employer or its insurer is required on whether to rent or purchase an item. The decision to rent or purchase shall be made within a reasonable time by the employer, an authorized representative, or the insurer, based on a cost comparison of the monthly rental fee, the prescribing health care provider's estimate of how long the item will be needed, and the purchase price. LISTED AND UNLISTED ITEMS: A provider of health care shall indicate on a bill presented to an insurer each code contained in HCPCS for durable medical equipment and supplies provided or administered to the patient. Use the miscellaneous HCPCS code, E1399 when no other HCPCS code is present for the durable medical equipment or supplies provided to the injured worker. When using E1399, a detailed description of the unlisted equipment/supply and documentation supporting the provider=s charge is required. Reimbursement under the miscellaneous HCPCS Code E1399 shall not exceed the cost of the item(s) to the provider plus a twenty-five percent (25%) mark-up. The mark-up shall not exceed Fifteen Dollars ($15.00) for a single item. ORTHOTICS AND PROSTHETICS: The primary coding system to be used in the billing for orthotics/prosthetics services is the HCPCS system. CPT codes shall be used only when the service rendered does not fit the descriptions/codes provided in the HCPCS system.

2.

3.

4.

5.

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6. TAX, FREIGHT AND HANDLING: Tax, and storage, shipping, handling, etc. shall not be reimbursed separately from the provider=s usual and customary charge.

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PHARMACEUTICAL SERVICES GROUND RULES General Information and Instructions 1. DEFINITIONS: The following words and terms, when used in the Pharmaceutical Services Ground Rules, have the following meanings, unless the context clearly indicates otherwise: a. Nonprescription Drug or Over-the-Counter Medication (OTC) - A non-narcotic drug that may be sold without a prescription and which is prepackaged for use by the consumer and labeled in compliance with state or federal law. Open Formulary - Includes all available Food and Drug Administration (FDA) approved prescription and nonprescription drugs, but does not include drugs that lack FDA approval, or non-drug items. Prescribing Practitioner - A licensed practitioner of allopathic or osteopathic medicine, including physician assistants under the supervision of a licensed physician, dentistry, optometry certified by the Board of Examiners in Optometry, or podiatry who prescribes prescription drugs or over-the-counter medications in accordance with the practitioner=s professional license and state and federal laws and rules. Prescription - An order from a prescribing practitioner for a prescription or nonprescription drug to be filled, compounded, or dispensed by a pharmacist. Prescription Drug (1) (2) A substance for which federal or state law requires a prescription before the substance may be legally dispensed to the public; or A drug which, under federal law, is required, before being dispensed or delivered, to be labeled with the statement, ACaution: Federal law prohibits dispensing without a [email protected]

b.

c.

d. e.

f.

Average Wholesale Price (AWP) (1) means the amount determined from the latest publication of the blue book, a universally subscribed pharmacist reference guide annually published by the Hearst Corporation. AWP may also be derived electronically from the drug pricing database synonymous with the latest publication of the blue book and furnished in the National Drug Data File (NDDF) by First Data Bank (FDB), a service of the Hearst Corporation. (1-800-633-3453, ext. 874)

(2)

2.

DRUG FORMULARY: There is hereby adopted an open formulary as defined in Ground Rule 1(b) of these ground rules. The payor shall pay for drugs that are reasonable and medically necessary to treat the compensable injury or occupational disease including prescriptions for off label indications when used in accordance with current medical

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standards and prescribed in compliance with published contraindications, precautions and warnings. Over-the-counter medications with a prescription filled by a pharmacist shall be reimbursed in accordance with Ground Rule 4(c) of these ground rules. 3. PHARMACEUTICAL SERVICES - PRESCRIPTIONS: a. A doctor providing care to an injured employee shall prescribe for the employee medically necessary prescription drugs and over-the-counter medication (OTC) alternatives as clinically appropriate and applicable in accordance with applicable state law and as provided in these ground rules. When prescribing an OTC medication alternative to a prescription drug, the prescribing practitioner is encouraged to indicate on the prescription the appropriate strength of the medication and the approximate quantity of the OTC medication that is reasonably required by the nature of the compensable injury or occupational disease. Effective July 1, 2005, physicians shall prescribe and pharmacies shall dispense generic equivalent drugs when available. The prescribing practitioner shall prescribe OTC medications in lieu of a prescription drug when clinically appropriate. When prescribing, the prescribing practitioner shall choose medications and drugs from the formulary adopted in Ground Rule 2 of these ground rules.

b.

c. d. e. 4.

REIMBURSEMENT METHODOLOGY: a. PRESCRIPTION DRUGS: Effective July 1, 2005, the maximum allowable reimbursement (MAR) for prescription drugs dispensed by a pharmacy for a compensable work-related injury or occupational disease shall be the lesser of: (1) (2) b. The pharmacy=s usual and customary charge for the same or similar service; or ninety percent (90%) of the average wholesale price of the prescription, plus a dispensing fee of Five Dollars ($5.00) per prescription.

PRESCRIPTION FOR GENERIC OR NON-BRAND-NAME DRUGS: When the prescribing practitioner has written a prescription for a generic prescription drug or a prescription that does not require the use of a brand-name drug, as provided in Ground Rule 3(c) of these ground rules, the pharmacist shall dispense and be reimbursed for the generic pharmaceutical medication.

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c. OVER-THE-COUNTER MEDICATIONS: When the prescribing practitioner=s prescription for an over-the-counter medication includes the appropriate strength of the medication and the approximate quantity of the OTC medication that is reasonably required by the nature of the compensable injury or occupational disease, reimbursement for the over-the-counter medication shall be the retail price of the lowest package quantity reasonably available that will fill the prescription. SCOPE OF THIS GROUND RULE: This ground rule applies to the dispensing of all drugs except in-patient drugs, ambulatory surgical center drugs and parenteral drugs.

d.

5.

BILLING: The date the item was dispensed, the metric quantity of the item dispensed, the National Drug Code number of the item dispensed, and the usual and customary charge of the pharmacy for the medication or drugs must be included on each billing. LIMITATIONS REGARDING OPIOIDS: a. CERVICAL (NECK) PAIN: Oral opioids may be used for no longer than two (2) weeks for severe disabling pain in the neck. Routine use of oral opioids is discouraged. CHRONIC PAIN PATIENTS: Long term opioid use may be appropriate for the treatment of a select subgroup of chronic pain patients identified by balancing the analgesic benefits of opioids against the potential adverse consequence of long term use. All patients who remain on opioid therapy after one (1) year are recommended to obtain a second opinion to continue on opioid therapy or an acceptable treatment plan be offered by the treating physician for continuation of opioid therapy.

6.

b.

7.

AUTHORIZED PRESCRIPTION NECESSARY: Any medication or drugs not specifically prescribed by a health care provider shall not be reimbursed.

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AMBULATORY SURGICAL CENTER SERVICES GROUND RULES General Information and Instructions 1. DEFINITIONS: For purposes of this section, a. AAmbulatory surgical [email protected] means an establishment with an organized medical staff of physicians, with permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures, with continuous physician services available on call, and registered professional nurse services on site, whenever a patient is in the facility, which provides services or other accommodations for patients to recover for a period not to exceed twenty-three (23) hours after surgery. The term "ambulatory surgical center" includes an outpatient surgery facility. [email protected] means those services indicated by revenue codes 274 (prosthetic/orthotic devices), 275 (pace maker), 276 (intraocular lens), and 278 (other implants), which involve an item or device intended for permanent placement in the body. "Implantable items" include rods, pins, screws, plates, prosthetic joint replacements, and other items properly indicated by revenue code 278 which are made of plastic, metallic, or of autogenous/non-autogenous graft material.

b.

2.

FEES: Fees charged by an ambulatory surgical center shall not include any professional component fees. Such fees are considered for payment according to separately billed Current Procedural Terminology (CPT7) code allowables. BILLING AND REIMBURSEMENT: The coding system to be used in the billing for ambulatory surgical center services is the Centers for Medicare and Medicaid Services (CMS) Diagnosis Related Groups (DRG) system. Except as provided in Ground Rule 5 of these ground rules, reimbursement for medically warranted ambulatory surgical center services provided for a compensable work-related injury shall be limited to the maximum allowable reimbursement per ambulatory surgical center stay as computed pursuant to Ground Rule 4 of these ground rules, or the ambulatory surgical center's usual and customary charge, whichever is less. COMPUTATION OF MAXIMUM ALLOWABLE REIMBURSEMENT: The maximum allowable reimbursement per ambulatory surgical center stay shall be computed as follows: MAXIMUM ALLOWABLE REIMBURSEMENT equals the DRG unit value under the In-Patient Hospital Fee Schedule multiplied by a conversion factor of Nine Hundred Twenty Dollars ($920.00).

3.

4.

5.

IMPLANTABLES: Generally, durable medical equipment and supplies provided or administered in an ambulatory surgical center setting are not separately reimbursed since they are included in the Diagnosis Related Groups (DRG) payment rate. However, surgical implantables as defined in Rule 1 of these Ground Rules which are medically necessary are excepted from this rule. Accordingly, additional reimbursement is allowable for medically necessary implantables.

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Reimbursement for the implantables shall be computed as follows: [Cost of the implantable to the ambulatory surgical center, net of discounts and rebates, less five percent (5%)] plus [ten percent (10%)]. Tax, freight and handling for implantables are included in the ambulatory surgical center=s costs and shall not be reimbursed separately. Reimbursement to an ambulatory surgical center for medically warranted implantables shall not exceed the maximum allowable reimbursement for the implantable computed pursuant to this ground rule. Rule 4 of the General Ground Rules (permits a medical provider to be reimbursed in full if the provider=s total aggregate charges per billing do not exceed the total aggregate allowed by the fee schedule for such charges, after application of all appropriate ground rules and other instructions per the fee schedule) does not apply. An invoice for the actual cost to the ambulatory surgical center of an implantable device shall be adjusted by the surgical center to reflect all applicable discounts, rebates, considerations and product replacement programs and must be provided to the payor by the surgery center as a condition of payment for the implantable device. The invoice must accompany the ambulatory surgical center=s bill for the implantable. The invoice is subject to applicable health privacy laws, rules and regulations.

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In-Patient Hospital Services Ground Rules

IN-PATIENT HOSPITAL SERVICES GROUND RULES General Information and Instructions 1. DEFINITIONS: For purposes of this Schedule of Hospital Fees, a. AAudited [email protected] means total charges less deducted charges. Deducted charges include, for example, charges for services which are not documented as rendered during the admission. Charges for items and services which are not related to the compensable injury or occupational disease also may be deducted. The formula to obtain audited charges is as follows: Total Charges - Deducted Charges = Audited Charges. [email protected] means those services indicated by revenue codes 274 (prosthetic/orthotic devices), 275 (pace maker), 276 (intraocular lens), and 278 (other implants), which involve an item or device intended for permanent placement in the body. "Implantable items" include rods, pins, screws, plates, prosthetic joint replacements, and other items properly indicated by revenue code 278 which are made of plastic, metallic, or of autogenous/non-autogenous graft material. [email protected] means being confined to a hospital setting for twenty-four (24) hours or more. An in-patient stay does not require official admission to the hospital.

b.

c. 2.

BY REPORT ([email protected]) ITEMS: "BR" in the unit value column indicates that the value of this service is to be determined "by report" because the service is too unusual or variable to be assigned a unit relativity. Pertinent information concerning the nature, extent and need for the procedure or service, the time, the skill and equipment necessary, etc. is to be furnished. For any DRG where the unit value is listed in the Schedule as "BR", the hospital shall provide a unit value consistent in relativity with other unit values shown in the Schedule. The insurer shall review all submitted unit values to ensure that the relativity consistency is maintained. REIMBURSEMENT AND BILLING: Except as otherwise provided in Ground Rules 5 and 6 of these ground rules, reimbursement for in-patient hospital services shall be limited to the maximum allowable reimbursement per in-patient stay as computed in Ground Rule 4 of these ground rules, or the hospital's usual and customary charge, whichever is less. All bills submitted for payment by hospitals for in-patient care must include the actual charges billed plus the DRG code. Workers' compensation patients may not be charged a higher fee than privately insured patients. COMPUTATION OF MAXIMUM ALLOWABLE REIMBURSEMENT: The maximum allowable reimbursement per in-patient stay shall be computed as follows: MAXIMUM ALLOWABLE REIMBURSEMENT equals the [DRG unit value under the In-Patient Hospital Fee Schedule multiplied by a conversion factor of Nine Hundred Twenty Dollars ($920.00)] plus [Four Hundred Fifty Dollars ($450.00) per twenty-four (24) hour stay in the hospital]

3.

4.

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For example: DRG #500 Back and Neck procedures except spinal fusion w/o CC with a hospital stay of 2 days would have a maximum allowable reimbursement of $3,200.00. Example: (2.5 X $920) + (2 X $450) = $3,200.00 5. IMPLANTABLES: Generally, durable medical equipment and supplies provided or administered in an in-patient hospital setting are not separately reimbursed since they are included in the Diagnosis Related Groups (DRG) payment rate. However, surgical implantables as defined in Rule 1 of these Ground Rules which are medically necessary are excepted from this rule. Accordingly, additional reimbursement is allowable for medically necessary implantables. Reimbursement for the implantables shall be computed as follows: [Cost of the implantable to the hospital, net of discounts and rebates, less five percent (5%)] plus [ten percent (10%)]. Tax, freight and handling for implantables are included in the hospital=s costs and shall not be reimbursed separately. Reimbursement to a hospital for medically warranted implantables shall not exceed the maximum allowable reimbursement for the implantable computed pursuant to this ground rule. Rule 4 of the General Ground Rules (permits a medical provider to be reimbursed in full if the provider=s total aggregate charges per billing do not exceed the total aggregate allowed by the fee schedule for such charges, after application of all appropriate ground rules and other instructions per the fee schedule) does not apply. An invoice for the actual cost to the hospital of an implantable device shall be adjusted by the hospital to reflect all applicable discounts, rebates, considerations and product replacement programs and must be provided to the payor by the hospital as a condition of payment for the implantable. The invoice must accompany the hospital=s bill for the implantable. The invoice is subject to applicable health privacy laws, rules and regulations. 6. STOP-LOSS METHOD: a. PURPOSE AND APPLICATION: Stop-loss is an independent reimbursement methodology that will reimburse the hospital for unusually costly services rendered during treatment to an injured worker. This methodology is to be used in place of and not in addition to the reimbursement provided in Ground Rules 4 and 5 of these ground rules; provided, however, reimbursement for medically necessary implantables under Ground Rule 5 of these ground rules is in addition to reimbursement under stop-loss, unless the hospital opts to include the implantables for reimbursement under the stop-loss method. If the hospital opts to include the implantables for reimbursement under the stop-loss method, reimbursement for the implantables is governed by division 2 of subparagraph b of this ground rule. COMPUTATION OF THE MAXIMUM ALLOWABLE REIMBURSEMENT: (1) WHEN NO IMPLANTABLES ARE INCLUDED FOR REIMBURSEMENT UNDER THE STOP-LOSS METHOD: To be eligible for the stop-loss

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payment, the total audited charges for the hospital in-patient stay must be at least Fifty Thousand Dollars ($50,000.00), the minimum stop-loss threshold. If the total audited charges for the hospital in-patient stay equal or exceed the minimum stop-loss threshold, the total audited charges are then multiplied by eighty percent (80%) to determine the maximum allowable reimbursement. (2) WHEN IMPLANTABLES ARE INCLUDED FOR REIMBURSEMENT UNDER THE STOP-LOSS METHOD: When a hospital bill with implantables is submitted for reimbursement under the stop-loss method, the maximum allowable reimbursement is calculated as follows: (A) Segregate the charges for medically necessary implantables from other audited charges. Calculate the maximum allowable reimbursement (MAR) for the implantables under Ground Rule 5 of these ground rules. The cost of the implantables to the hospital must be substantiated by an invoice or affidavit as provided in Ground Rule 5 of these ground rules. The MAR calculated for the implantables under Ground Rule 5 is the maximum charge attributable to the implantables for purposes of determining eligibility for, and reimbursement under, the stop-loss method. To be eligible for the stop-loss payment, the sum of the maximum charge attributable to the implantables and the other audited charges for the hospital in-patient stay must be at least Fifty Thousand Dollars ($50,000.00), the minimum stop-loss threshold. If the sum of the maximum charge attributable to the implantables and the other audited charges for the hospital in-patient stay equals or exceeds the minimum stop-loss threshold, the sum is then multiplied by eighty percent (80%) to determine the maximum allowable reimbursement.

(B)

c.

AUDIT: The payor may have the bill audited at its own expense.

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DRG Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

Description

Unit Value 13.3 7.0 11.2 0.0 0.0 1.5 9.3 2.8 3.9 3.6 2.0 2.0 1.9 3.2 1.7 2.5 1.2 2.6 1.0 5.5 4.4 1.6 3.0 2.9 1.1 1.8 6.8 3.9 1.9 1.1 1.8 0.8 0.4 4.1 1.5 2.5 2.7 1.2 2.1

CRANIOTOMY AGE >17 W CC CRANIOTOMY AGE >17 W/O CC CRANIOTOMY AGE 0-17 NO LONGER VALID NO LONGER VALID CARPAL TUNNEL RELEASE PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W CC PERIPH & CRANIAL NERVE & OTHER NERV SYST PROC W/O CC SPINAL DISORDERS & INJURIES NERVOUS SYSTEM NEOPLASMS W CC NERVOUS SYSTEM NEOPLASMS W/O CC DEGENERATIVE NERVOUS SYSTEM DISORDERS MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION NONSPECIFIC CVA & PRECEREBRAL OCCLUSION W/O INFARCT NONSPECIFIC CEREBROVASCULAR DISORDERS W CC NONSPECIFIC CEREBROVASCULAR DISORDERS W/O CC CRANIAL & PERIPHERAL NERVE DISORDERS W CC CRANIAL & PERIPHERAL NERVE DISORDERS W/O CC NERVOUS SYSTEM INFECTION EXCEPT VIRAL MENINGITIS VIRAL MENINGITIS HYPERTENSIVE ENCEPHALOPATHY NONTRAUMATIC STUPOR & COMA SEIZURE & HEADACHE AGE >17 W CC SEIZURE & HEADACHE AGE >17 W/O CC SEIZURE & HEADACHE AGE 0-17 TRAUMATIC STUPOR & COMA, COMA >1 HR TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W CC TRAUMATIC STUPOR & COMA, COMA <1 HR AGE >17 W/O CC TRAUMATIC STUPOR & COMA, COMA <1 HR AGE 0-17 CONCUSSION AGE >17 W CC CONCUSSION AGE >17 W/O CC CONCUSSION AGE 0-17 OTHER DISORDERS OF NERVOUS SYSTEM W CC OTHER DISORDERS OF NERVOUS SYSTEM W/O CC RETINAL PROCEDURES ORBITAL PROCEDURES PRIMARY IRIS PROCEDURES LENS PROCEDURES WITH OR WITHOUT VITRECTOMY

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DRG Number 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79

Description

EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE >17 EXTRAOCULAR PROCEDURES EXCEPT ORBIT AGE 0-17 INTRAOCULAR PROCEDURES EXCEPT RETINA, IRIS & LENS HYPHEMA ACUTE MAJOR EYE INFECTIONS NEUROLOGICAL EYE DISORDERS OTHER DISORDERS OF THE EYE AGE >17 W CC OTHER DISORDERS OF THE EYE AGE >17 W/O CC OTHER DISORDERS OF THE EYE AGE 0-17 MAJOR HEAD & NECK PROCEDURES SIALOADENECTOMY SALIVARY GLAND PROCEDURES EXCEPT SIALOADENECTOMY CLEFT LIP & PALATE REPAIR SINUS & MASTOID PROCEDURES AGE >17 SINUS & MASTOID PROCEDURES AGE 0-17 MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES RHINOPLASTY T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 T&A PROC, EXCEPT TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17 MYRINGOTOMY W TUBE INSERTION AGE >17 MYRINGOTOMY W TUBE INSERTION AGE 0-17 OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES EAR, NOSE, MOUTH & THROAT MALIGNANCY DYSEQUILIBRIUM EPISTAXIS EPIGLOTTITIS OTITIS MEDIA & URI AGE >17 W CC OTITIS MEDIA & URI AGE >17 W/O CC OTITIS MEDIA & URI AGE 0-17 LARYNGOTRACHEITIS NASAL TRAUMA & DEFORMITY OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE >17 OTHER EAR, NOSE, MOUTH & THROAT DIAGNOSES AGE 0-17 MAJOR CHEST PROCEDURES OTHER RESP SYSTEM O.R. PROCEDURES W CC OTHER RESP SYSTEM O.R. PROCEDURES W/O CC PULMONARY EMBOLISM RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W CC

Unit Value 1.8 1.1 2.4 0.1 0.6 1.8 1.6 0.6 0.8 11.1 2.4 2.2 2.6 2.7 2.6 1.7 1.6 3.2 0.8 1.3 0.5 2.2 1.3 4.3 3.7 0.7 1.0 3.9 1.7 1.1 1.6 1.5 1.4 2.3 1.0 11.9 7.8 4.5 4.2 7.2

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DRG Number 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119

Description

RESPIRATORY INFECTIONS & INFLAMMATIONS AGE >17 W/O CC RESPIRATORY INFECTIONS & INFLAMMATIONS AGE 0-17 RESPIRATORY NEOPLASMS MAJOR CHEST TRAUMA W CC MAJOR CHEST TRAUMA W/O CC PLEURAL EFFUSION W CC PLEURAL EFFUSION W/O CC PULMONARY EDEMA & RESPIRATORY FAILURE CHRONIC OBSTRUCTIVE PULMONARY DISEASE SIMPLE PNEUMONIA & PLEURISY AGE >17 W CC SIMPLE PNEUMONIA & PLEURISY AGE >17 W/O CC SIMPLE PNEUMONIA & PLEURISY AGE 0-17 INTERSTITIAL LUNG DISEASE W CC INTERSTITIAL LUNG DISEASE W/O CC PNEUMOTHORAX W CC PNEUMOTHORAX W/O CC BRONCHITIS & ASTHMA AGE >17 W CC BRONCHITIS & ASTHMA AGE >17 W/O CC BRONCHITIS & ASTHMA AGE 0-17 RESPIRATORY SIGNS & SYMPTOMS W CC RESPIRATORY SIGNS & SYMPTOMS W/O CC OTHER RESPIRATORY SYSTEM DIAGNOSES W CC OTHER RESPIRATORY SYSTEM DIAGNOSES W/O CC HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM CARDIAC VALVE & OTH MAJOR CARDIOTHORACIC PROC W CARD CATH CARDIAC VALVE & OTH MAJOR CARDIOTHORACIC PROC W/O CARD CATH CORONARY BYPASS W PTCA NO LONGER VALID OTHER CARDIOTHORACIC PROCEDURES NO LONGER VALID MAJOR CARDIOVASCULAR PROCEDURES W CC MAJOR CARDIOVASCULAR PROCEDURES W/O CC NO LONGER VALID AMPUTATION FOR CIRC SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS NO LONGER VALID NO LONGER VALID CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER DEVICE REPLACEMENT VEIN LIGATION & STRIPPING

Unit Value 3.8 2.9 3.5 2.1 1.1 3.2 2.0 6.3 3.6 4.0 2.2 3.0 4.0 2.3 4.7 1.9 2.7 1.7 1.9 2.6 1.6 3.1 1.9 BR 32.4 23.7 32.6 0.0 26.5 0.0 16.0 8.9 0.0 6.9 5.0 0.0 0.0 4.7 9.0 3.1

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DRG Number 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159

Description

OTHER CIRCULATORY SYSTEM O.R. PROCEDURES CIRCULATORY DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE CIRCULATORY DISORDERS W AMI W/O MAJOR COMP, DISCHARGED ALIVE CIRCULATORY DISORDERS W AMI, EXPIRED CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG CIRCULATORY DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG ACUTE & SUBACUTE ENDOCARDITIS HEART FAILURE & SHOCK DEEP VEIN THROMBOPHLEBITIS CARDIAC ARREST, UNEXPLAINED PERIPHERAL VASCULAR DISORDERS W CC PERIPHERAL VASCULAR DISORDERS W/O CC ATHEROSCLEROSIS W CC ATHEROSCLEROSIS W/O CC HYPERTENSION CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W CC CARDIAC CONGENITAL & VALVULAR DISORDERS AGE >17 W/O CC CARDIAC CONGENITAL & VALVULAR DISORDERS AGE 0-17 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC ANGINA PECTORIS SYNCOPE & COLLAPSE W CC SYNCOPE & COLLAPSE W/O CC CHEST PAIN OTHER CIRCULATORY SYSTEM DIAGNOSES W CC OTHER CIRCULATORY SYSTEM DIAGNOSES W/O CC RECTAL RESECTION W CC RECTAL RESECTION W/O CC MAJOR SMALL & LARGE BOWEL PROCEDURES W CC MAJOR SMALL & LARGE BOWEL PROCEDURES W/O CC PERITONEAL ADHESIOLYSIS W CC PERITONEAL ADHESIOLYSIS W/O CC MINOR SMALL & LARGE BOWEL PROCEDURES W CC MINOR SMALL & LARGE BOWEL PROCEDURES W/O CC STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/O CC STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES AGE 0-17 ANAL & STOMAL PROCEDURES W CC ANAL & STOMAL PROCEDURES W/O CC HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W CC

Unit Value 9.1 5.6 3.5 6.8 4.5 2.6 9.4 3.0 0.9 7.9 2.1 1.4 2.2 1.5 1.5 2.9 1.6 2.2 2.5 1.4 1.9 2.0 1.6 1.7 3.7 1.9 12.21 6.5 11.5 5.2 9.2 4.2 5.4 2.7 16.0 6.2 1.9 3.0 1.7 3.7

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DRG Number 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199

Description

HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W/O CC HERNIA PROCEDURES AGE 0-17 APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W CC APPENDECTOMY W/O COMPLICATED PRINCIPAL DIAG W/O CC MOUTH PROCEDURES W CC MOUTH PROCEDURES W/O CC OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC DIGESTIVE MALIGNANCY W CC DIGESTIVE MALIGNANCY W/O CC G.I. HEMORRHAGE W CC G.I. HEMORRHAGE W/O CC COMPLICATED PEPTIC ULCER UNCOMPLICATED PEPTIC ULCER W CC UNCOMPLICATED PEPTIC ULCER W/O CC INFLAMMATORY BOWEL DISEASE G.I. OBSTRUCTION W CC G.I. OBSTRUCTION W/O CC ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W CC ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O CC ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS AGE 0-17 DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17 DENTAL & ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0-17 DENTAL EXTRACTIONS & RESTORATIONS OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W CC OTHER DIGESTIVE SYSTEM DIAGNOSES AGE >17 W/O CC OTHER DIGESTIVE SYSTEM DIAGNOSES AGE 0-17 PANCREAS, LIVER & SHUNT PROCEDURES W CC PANCREAS, LIVER & SHUNT PROCEDURES W/O CC BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC CHOLECYSTECTOMY W C.D.E. W CC CHOLECYSTECTOMY W C.D.E. W/O CC CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY

Unit Value 2.0 2.4 1.4 2.5 8.6 4.6 5.3 2.6 5.8 2.4 10.1 4.7 3.4 2.1 2.8 1.9 2.8 1.5 1.4 2.6 2.3 1.1 1.7 1.0 1.5 2.4 0.9 1.7 2.9 1.4 2.8 19.2 15.8 10.2 5.8 8.0 4.9 6.0 3.0 7.3

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DRG Number 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239

Description

HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES CIRRHOSIS & ALCOHOLIC HEPATITIS MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC DISORDERS OF THE BILIARY TRACT W CC DISORDERS OF THE BILIARY TRACT W/O CC NO LONGER VALID HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/O CC HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0-17 AMPUTATION FOR MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS NO LONGER VALID NO LONGER VALID BIOPSIES OF MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE WND DEBRID & SKN GRFT EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W CC LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W/O CC LOWER EXTREM & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 0-17 NO LONGER VALID NO LONGER VALID MAJOR SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W CC SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC FOOT PROCEDURES SOFT TISSUE PROCEDURES W CC SOFT TISSUE PROCEDURES W/O CC MAJOR THUMB OR JOINT PROC,OR OTH HAND OR WRIST PROC W CC HAND OR WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC LOCAL EXCISION & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR NO LONGER VALID ARTHROSCOPY OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC FRACTURES OF FEMUR FRACTURES OF HIP & PELVIS SPRAINS, STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH OSTEOMYELITIS PATHOLOGICAL FRACTURES & MUSCULOSKELETAL & CONN TISS MALIGNANCY

Unit Value 10.1 10.2 3.6 3.1 3.0 3.6 2.0 2.4 1.4 0.0 5.7 3.9 5.1 5.4 0.0 0.0 5.4 10.0 5.0 3.3 2.9 0.0 0.0 4.1 2.4 2.5 4.5 2.6 3.4 2.1 2.7 0.0 3.6 5.6 2.8 3.0 1.7 0.9 4.2 1.5

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DRG Number 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279

Description

CONNECTIVE TISSUE DISORDERS W CC CONNECTIVE TISSUE DISORDERS W/O CC SEPTIC ARTHRITIS MEDICAL BACK PROBLEMS BONE DISEASES & SPECIFIC ARTHROPATHIES W CC BONE DISEASES & SPECIFIC ARTHROPATHIES W/O CC NON-SPECIFIC ARTHROPATHIES SIGNS & SYMPTOMS OF MUSCULOSKELETAL SYSTEM & CONN TISSUE TENDONITIS, MYOSITIS & BURSITIS AFTERCARE, MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W CC FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W/O CC FX, SPRN, STRN & DISL OF FOREARM, HAND, FOOT AGE 0-17 FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W CC FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W/O CC FX, SPRN, STRN & DISL OF UPARM,LOWLEG EX FOOT AGE 0-17 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES TOTAL MASTECTOMY FOR MALIGNANCY W CC TOTAL MASTECTOMY FOR MALIGNANCY W/O CC SUBTOTAL MASTECTOMY FOR MALIGNANCY W CC SUBTOTAL MASTECTOMY FOR MALIGNANCY W/O CC BREAST PROC FOR NON-MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION BREAST BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W CC SKIN GRAFT &/OR DEBRID FOR SKN ULCER OR CELLULITIS W/O CC SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W CC SKIN GRAFT &/OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC PERIANAL & PILONIDAL PROCEDURES SKIN, SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES OTHER SKIN, SUBCUT TISS & BREAST PROC W CC OTHER SKIN, SUBCUT TISS & BREAST PROC W/O CC SKIN ULCERS MAJOR SKIN DISORDERS W CC MAJOR SKIN DISORDERS W/O CC MALIGNANT BREAST DISORDERS W CC MALIGNANT BREAST DISORDERS W/O CC NON-MALIGNANT BREAST DISORDERS CELLULITIS AGE >17 W CC CELLULITIS AGE >17 W/O CC CELLULITIS AGE 0-17

Unit Value 2.9 1.4 3.7 1.4 1.2 1.1 0.8 1.1 1.0 2.0 1.4 0.9 1.0 1.6 0.6 1.2 1.8 2.6 2.4 3.4 2.0 2.1 1.5 7.7 3.9 4.7 2.5 2.2 2.5 4.9 2.5 2.5 2.5 1.2 3.1 1.7 1.6 2.1 1.1 1.8

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DRG Number 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319

Description

TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W CC TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE >17 W/O CC TRAUMA TO THE SKIN, SUBCUT TISS & BREAST AGE 0-17 MINOR SKIN DISORDERS W CC MINOR SKIN DISORDERS W/O CC AMPUTAT OF LOWER LIMB FOR ENDOCRINE,NUTRIT,& METABOL DISORDERS ADRENAL & PITUITARY PROCEDURES SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DISORDERS O.R. PROCEDURES FOR OBESITY PARATHYROID PROCEDURES THYROID PROCEDURES THYROGLOSSAL PROCEDURES OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W CC OTHER ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC DIABETES AGE >35 DIABETES AGE 0-35 NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W CC NUTRITIONAL & MISC METABOLIC DISORDERS AGE >17 W/O CC NUTRITIONAL & MISC METABOLIC DISORDERS AGE 0-17 INBORN ERRORS OF METABOLISM ENDOCRINE DISORDERS W CC ENDOCRINE DISORDERS W/O CC KIDNEY TRANSPLANT KIDNEY,URETER & MAJOR BLADDER PROCEDURES FOR NEOPLASM KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W CC KIDNEY,URETER & MAJOR BLADDER PROC FOR NON-NEOPL W/O CC PROSTATECTOMY W CC PROSTATECTOMY W/O CC MINOR BLADDER PROCEDURES W CC MINOR BLADDER PROCEDURES W/O CC TRANSURETHRAL PROCEDURES W CC TRANSURETHRAL PROCEDURES W/O CC URETHRAL PROCEDURES, AGE >17 W CC URETHRAL PROCEDURES, AGE >17 W/O CC URETHRAL PROCEDURES, AGE 0-17 OTHER KIDNEY & URINARY TRACT O.R. PROCEDURES RENAL FAILURE ADMIT FOR RENAL DIALYSIS KIDNEY & URINARY TRACT NEOPLASMS W CC KIDNEY & URINARY TRACT NEOPLASMS W/O CC

Unit Value 1.1 1.0 1.0 1.4 0.8 8.5 9.9 6.0 7.8 4.3 3.0 1.9 9.3 3.9 1.3 1.7 2.4 0.8 2.7 2.3 2.8 1.4 14.1 9.0 8.9 5.0 4.4 2.3 5.5 3.1 2.8 1.8 2.8 1.6 1.5 10.0 4.6 1.1 3.1 1.9

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DRG Number 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359

Description

KIDNEY & URINARY TRACT INFECTIONS AGE >17 W CC KIDNEY & URINARY TRACT INFECTIONS AGE >17 W/O CC KIDNEY & URINARY TRACT INFECTIONS AGE 0-17 URINARY STONES W CC, &/OR ESW LITHOTRIPSY URINARY STONES W/O CC KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE >17 W/O CC KIDNEY & URINARY TRACT SIGNS & SYMPTOMS AGE 0-17 URETHRAL STRICTURE AGE >17 W CC URETHRAL STRICTURE AGE >17 W/O CC URETHRAL STRICTURE AGE 0-17 OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W CC OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE >17 W/O CC OTHER KIDNEY & URINARY TRACT DIAGNOSES AGE 0-17 MAJOR MALE PELVIC PROCEDURES W CC MAJOR MALE PELVIC PROCEDURES W/O CC TRANSURETHRAL PROSTATECTOMY W CC TRANSURETHRAL PROSTATECTOMY W/O CC TESTES PROCEDURES, FOR MALIGNANCY TESTES PROCEDURES, NON-MALIGNANCY AGE >17 TESTES PROCEDURES, NON-MALIGNANCY AGE 0-17 PENIS PROCEDURES CIRCUMCISION AGE >17 CIRCUMCISION AGE 0-17 OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY OTHER MALE REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W CC MALIGNANCY, MALE REPRODUCTIVE SYSTEM, W/O CC BENIGN PROSTATIC HYPERTROPHY W CC BENIGN PROSTATIC HYPERTROPHY W/O CC INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM STERILIZATION, MALE OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES PELVIC EVISCERATION, RADICAL HYSTERECTOMY & RADICAL VULVECTOMY UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W CC UTERINE,ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W/O CC FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W CC UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC

Unit Value 2.5 1.2 2.0 2.1 2.0 1.4 1.2 1.7 1.7 1.1 0.6 2.8 1.4 2.6 5.2 3.7 2.8 1.9 2.6 2.0 1.6 4.1 1.6 1.2 3.6 2.9 2.5 1.5 1.9 1.4 1.4 1.0 1.4 7.0 4.6 2.3 1.6 7.2 3.6 2.3

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DRG Number 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399

Description

VAGINA, CERVIX & VULVA PROCEDURES LAPAROSCOPY & INCISIONAL TUBAL INTERRUPTION ENDOSCOPIC TUBAL INTERRUPTION D&C, CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY D&C, CONIZATION EXCEPT FOR MALIGNANCY OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W/O CC INFECTIONS, FEMALE REPRODUCTIVE SYSTEM MENSTRUAL & OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS CESAREAN SECTION W CC CESAREAN SECTION W/O CC VAGINAL DELIVERY W COMPLICATING DIAGNOSES VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES VAGINAL DELIVERY W STERILIZATION &/OR D&C VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE POSTPARTUM & POST ABORTION DIAGNOSES W O.R. PROCEDURE ECTOPIC PREGNANCY THREATENED ABORTION ABORTION W/O D&C ABORTION W D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FALSE LABOR OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE PREMATURITY W MAJOR PROBLEMS PREMATURITY W/O MAJOR PROBLEMS FULL TERM NEONATE W MAJOR PROBLEMS NEONATE W OTHER SIGNIFICANT PROBLEMS NORMAL NEWBORN SPLENECTOMY AGE >17 SPLENECTOMY AGE 0-17 OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS RED BLOOD CELL DISORDERS AGE >17 RED BLOOD CELL DISORDERS AGE 0-17 COAGULATION DISORDERS RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC

Unit Value 2.1 2.3 1.4 1.9 1.5 6.2 3.4 1.7 1.8 1.4 2.5 1.7 1.4 0.9 1.0 2.0 0.5 4.4 2.6 0.7 0.8 1.2 0.3 0.8 0.5 BR BR BR BR BR BR 0.3 14.3 4.4 4.7 2.3 1.0 2.9 4.1 2.0

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DRG Number 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439

Description

NO LONGER VALID LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC LYMPHOMA & NON-ACUTE LEUKEMIA W CC LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0-17 MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W CC MYELOPROLIF DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W/O CC MYELOPROLIF DISORD OR POORLY DIFF NEOPL W OTHER O.R.PROC RADIOTHERAPY CHEMOTHERAPY W/O ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS HISTORY OF MALIGNANCY W/O ENDOSCOPY HISTORY OF MALIGNANCY W ENDOSCOPY OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC OTHER MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC O.R. PROCEDURE FOR INFECTIOUS & PARASITIC DISEASES SEPTICEMIA AGE >17 SEPTICEMIA AGE 0-17 POSTOPERATIVE & POST-TRAUMATIC INFECTIONS FEVER OF UNKNOWN ORIGIN AGE >17 W CC FEVER OF UNKNOWN ORIGIN AGE >17 W/O CC VIRAL ILLNESS AGE >17 VIRAL ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0-17 OTHER INFECTIOUS & PARASITIC DISEASES DIAGNOSES O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS ACUTE ADJUSTMENT REACTION & PSYCHOSOCIAL DYSFUNCTION DEPRESSIVE NEUROSES NEUROSES EXCEPT DEPRESSIVE DISORDERS OF PERSONALITY & IMPULSE CONTROL ORGANIC DISTURBANCES & MENTAL RETARDATION PSYCHOSES CHILDHOOD MENTAL DISORDERS OTHER MENTAL DISORDER DIAGNOSES ALCOHOL/DRUG ABUSE OR DEPENDENCE, LEFT AMA NO LONGER VALID NO LONGER VALID NO LONGER VALID NO LONGER VALID NO LONGER VALID SKIN GRAFTS FOR INJURIES

Unit Value 0.0 7.3 2.9 4.9 2.2 3.6 9.5 5.0 3.3 2.8 1.8 1.4 1.3 3.7 2.2 13.2 5.9 3.0 2.2 2.7 1.5 1.6 2.2 5.0 7.0 1.5 0.8 0.6 1.2 1.6 0.9 1.1 2.2 1.0 0.0 0.0 0.0 0.0 0.0 6.8

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DRG Number 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479

Description

WOUND DEBRIDEMENTS FOR INJURIES HAND PROCEDURES FOR INJURIES OTHER O.R. PROCEDURES FOR INJURIES W CC OTHER O.R. PROCEDURES FOR INJURIES W/O CC TRAUMATIC INJURY AGE >17 W CC TRAUMATIC INJURY AGE >17 W/O CC TRAUMATIC INJURY AGE 0-17 ALLERGIC REACTIONS AGE >17 ALLERGIC REACTIONS AGE 0-17 POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W/O CC POISONING & TOXIC EFFECTS OF DRUGS AGE 0-17 COMPLICATIONS OF TREATMENT W CC COMPLICATIONS OF TREATMENT W/O CC OTHER INJURY, POISONING & TOXIC EFFECT DIAG W CC OTHER INJURY, POISONING & TOXIC EFFECT DIAG W/O CC NO LONGER VALID NO LONGER VALID NO LONGER VALID NO LONGER VALID NO LONGER VALID O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES REHABILITATION SIGNS & SYMPTOMS W CC SIGNS & SYMPTOMS W/O CC AFTERCARE W HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS AFTERCARE W/O HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS OTHER FACTORS INFLUENCING HEALTH STATUS EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE BILATERAL OR MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY NO LONGER VALID ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE >17 NO LONGER VALID RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NO LONGER VALID OTHER VASCULAR PROCEDURES W/O CC

Unit Value 8.2 3.3 8.4 5.2 2.3 1.0 1.8 1.2 0.5 2.1 1.4 2.0 2.8 1.5 2.8 1.2 0.0 0.0 0.0 0.0 0.0 3.3 3.1 1.9 1.3 0.9 1.7 1.3 9.6 0.0 BR 15.1 0.0 11.1 0.0 14.34 BR BR 0.0 BR

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DRG Number 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519

Description

LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT BONE MARROW TRANSPLANT TRACHEOSTOMY FOR FACE,MOUTH & NECK DIAGNOSES NO LONGER VALID CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA LIMB REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TRA OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA OTHER MULTIPLE SIGNIFICANT TRAUMA HIV W EXTENSIVE O.R. PROCEDURE HIV W MAJOR RELATED CONDITION HIV W OR W/O OTHER RELATED CONDITION MAJOR JOINT & LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITY CHEMOTHERAPY W ACUTE LEUKEMIA OR W USE OF HI DOSE CHEMOAGENT LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W CC LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W/O CC LUNG TRANSPLANT COMBINED ANTERIOR/POSTERIOR SPINAL FUSION SPINAL FUSION EXCEPT CERVICAL W CC SPINAL FUSION EXCEPT CERVICAL W/O CC BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W CC BACK & NECK PROCEDURES EXCEPT SPINAL FUSION W/O CC KNEE PROCEDURES W PDX OF INFECTION W CC KNEE PROCEDURES W PDX OF INFECTION W/O CC KNEE PROCEDURES W/O PDX OF INFECTION EXTEN. BURNS OR FULL THICKNESS BURN W/MV 96+HRS W/SKIN GFT EXTEN. BURNS OR FULL THICKNESS BURN W/MV 96+HRS W/O SKIN GFT FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA FULL THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA FULL THICKNESS BURN W/O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA FULL THICKNESS BURN W/O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA NON-EXTENSIVE BURNS W CC OR SIGNIFICANT TRAUMA NON-EXTENSIVE BURNS W/O CC OR SIGNIFICANT TRAUMA SIMULTANEOUS PANCREAS/KIDNEY TRANSPLANT PANCREAS TRANSPLANT NO LONGER VALID CARDIAC DEFIBRILLATOR IMPLANT W/O CARDIAC CATH NO LONGER VALID NO LONGER VALID PERC CARDIO PROC W/O CORONARY ARTERY STENT OR AMI CERVICAL SPINAL FUSION W CC

Unit Value BR BR BR 0.0 BR BR BR BR BR BR BR BR BR BR BR BR 9.2 6.5 3.8 3.0 2.5 5.6 3.8 3.0 33.3 5.7 10.5 4.7 4.0 2.2 3.3 2.1 BR BR 0.0 20.5 0.0 0.0 9.7 3.8

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DRG Number 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559

Description

CERVICAL SPINAL FUSION W/O CC ALCOHOL/DRUG ABUSE OR DEPENDENCE W CC ALC/DRUG ABUSE OR DEPEND W REHABILITATION THERAPY W/O CC ALC/DRUG ABUSE OR DEPEND W/O REHABILITATION THERAPY W/O CC TRANSIENT ISCHEMIA OTHER HEART ASSIST SYSTEM IMPLANT NO LONGER VALID NO LONGER VALID INTRACRANIAL VASCULAR PROC W PDX HEMORRHAGE VENTRICULAR SHUNT PROCEDURES W CC VENTRICULAR SHUNT PROCEDURES W/O CC SPINAL PROCEDURES W CC SPINAL PROCEDURES W/O CC EXTRACRANIAL PROCEDURES W CC EXTRACRANIAL PROCEDURES W/O CC CARDIAC DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK CARDIAC DEFIB IMPLANT W CARDIAC CATH W/O AMI/HF/SHOCK LOCAL EXCIS & REMOV OF INT FIX DEV EXCEPT HIP & FEMUR W CC LOCAL EXCIS & REMOV OF INT FIX DEV EXCEPT HIP & FEMUR W/O CC LYMPHOMA & LEUKEMIA W MAJOR OR PROCEDURE W CC LYMPHOMA & LEUKEMIA W MAJOR OR PROCEDURE W/O CC ECMO OR TRACH W MV 96+HRS OR PDX EXC FACE, MOUTH & NECK W MAJ O.R. TRACH W MV 96+HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R. CRANIOTOMY W/IMPLANT OF CHEMO AGENT OR ACUTE COMPLX CNS PDX MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY REVISION OF HIP OR KNEE REPLACEMENT SPINAL FUSION EXC CERV WITH CURVATURE OF THE SPINE OR MALIG CORONARY BYPASS W CARDIAC CATH W MAJOR CV DX CORONARY BYPASS W CARDIAC CATH W/O MAJOR CV DX CORONARY BYPASS W/O CARDIAC CATH W MAJOR CV DX CORONARY BYPASS W/O CARDIAC CATH W/O MAJOR CV DX PERMANENT CARDIAC PACEMAKER IMPL W MAJ CV DX OR AICD LEAD OR GNRTR OTHER PERMANENT CARDIAC PACEMAKER IMPLANT W/O MAJOR CV DX OTHER VASCULAR PROCEDURES W CC W MAJOR CV DX OTHER VASCULAR PROCEDURES W CC W/O MAJOR CV DX PERCUTANEOUS CARDIOVASCULAR PROC W MAJOR CV DX PERCUTANEOUS CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MAJ CV DX PERCUTANEOUS CARDIOVASCULAR PROC W DRUG-ELUTING STENT W MAJOR CV DX PERCUTANEOUS CARDIOVASCULAR PROC W DRUG-ELUTING STENT W/O MAJ CV DX ACUTE ISCHEMIC STROKE WITH USE OF THROMBOLYTIC AGENT

Unit Value 2.3 2.6 2.1 1.4 1.2 47.3 0.0 0.0 25.3 8.1 4.3 6.5 3.1 6.2 3.9 25.7 20.8 2.9 1.6 10.4 3.9 BR BR BR 6.9 8.7 12.9 27.8 21.1 23.1 16.4 15.1 11.8 BR BR 15.3 12.3 BR BR 5.8

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