Florida Workers’ Compensation Health Care Provider Reimbursement Manual Rule 69L-7.020, F.A.C.

Florida Workers’ Compensation

Health Care Provider Reimbursement Manual

Rule 69L-7.020, F.A.C.

20165 Edition



TABLE OF CONTENTS

CHAPTER 1 INTRODUCTION AND OVERVIEW .............................................. 6

Overview ----------------------------------------------------------------------------------------------------- 6

E-Alert System ---------------------------------------------------------------------------------------------- 6

How to Obtain or Purchase Manuals ------------------------------------------------------------------- 7

Characteristics of the Manual ---------------------------------------------------------------------------- 8

Identifying New Material --------------------------------------------------------------------------------- 9

Authorization ----------------------------------------------------------------------------------------------- 10

Health Care Provider Use of Codes, Descriptions and Modifiers -------------------------------- 12

Carrier Use of Codes, Descriptions, and References ------------------------------------------------ 12

General Reimbursement Information ----------------------------------------------------------------- 15

Co-Payments ----------------------------------------------------------------------------------------------- 15

Exceptions to Service Limitations ---------------------------------------------------------------------- 18

Disputing Reimbursement ------------------------------------------------------------------------------- 19

Classification of an Injured Worker’s Status -------------------------------------------------------- 20

CHAPTER 2 MEDICAL SERVICES ................................................................... 22

Anesthesia Services ---------------------------------------------------------------------------------------- 22

Biofeedback Services -------------------------------------------------------------------------------------- 27

Dental Services --------------------------------------------------------------------------------------------- 28

Electrodiagnostic Medicine ------------------------------------------------------------------------------ 29

Evaluation and Management Services ----------------------------------------------------------------- 30

Functional Capacity Evaluations (FCE) -------------------------------------------------------------- 31

Home Health Agency Services -------------------------------------------------------------------------- 32

Independent Medical Examinations ------------------------------------------------------------------- 33

Failure to Appear for IME ------------------------------------------------------------------------------ 34

2016 Edition Page 2 Effective Date: ___________



Consensus Independent Medical Examination ------------------------------------------------------ 34

Medications ------------------------------------------------------------------------------------------------- 34

Medical Supplies and Home Medical Equipment --------------------------------------------------- 39

Ophthalmologic Services --------------------------------------------------------------------------------- 40

Permanent Impairment Ratings (PIR) ---------------------------------------------------------------- 40

Psychiatric and Psychological Services ---------------------------------------------------------------- 41

Radiology---------------------------------------------------------------------------------------------------- 43

Thermography --------------------------------------------------------------------------------------------- 44

Physical Medicine and Rehabilitation Services ------------------------------------------------------ 45

Acupuncture ------------------------------------------------------------------------------------------------ 51

Orthotics and Prosthetics -------------------------------------------------------------------------------- 52

Tests and Measurements --------------------------------------------------------------------------------- 53

Physical Reconditioning Services ----------------------------------------------------------------------- 54

Physical Reconditioning Program ---------------------------------------------------------------------- 55

Chapter 2 Medical Services, continued ---------------------------------------------------------------- 56

Surgical Services ------------------------------------------------------------------------------------------- 59

CHAPTER 3 MAXIMUM REIMBURSEMENT ALLOWANCES ........................ 68

CHAPTER 4 BILLING INSTRUCTIONS AND FORMS ................................... 410

Bill Submission/Filing and Reporting Requirements --------------------------------------------- 410

Form DFS-F5-DWC-9 (CMS-1500) ------------------------------------------------------------------ 412

Form DFS-F5-DWC-10--------------------------------------------------------------------------------- 414

APPENDIX A: WORKERS’ COMPENSATION UNIQUE PROCEDURE CODES

.......................................................................................................................... 415

APPENDIX B OFFICIAL SOURCE FOR REFERENCES ............................... 416

APPENDIX C MEDICARE PAYMENT LOCALITIES (COUNTIES) ................ 419




APPENDIX D FORMS ..................................................................................... 420

APPENDIX E DEFINITIONS ............................................................................ 421




THIS PAGE LEFT INTENTIONALLY BLANK




Chapter 1 Introduction and Overview

Overview

Changes to the Manual Notification of approved changes to the Manual will be sent via the

Division of Workers’ Compensation E-Alert system. An update can be an approved change, addition, or correction to the policies. Updates

Reimbursement Manuals will be available under the ‘Reimbursement

Manuals’ section on the DWC web site .

It is important that health care providers (HCPs) and carriers read the updated material in the Manual. information. Both parties have a responsibility for performing specific duties when billing, reporting, or reimbursing medical services rendered to injured workers.

E-Alert System

The Division of Workers’ Compensation has an electronic alert system to notify subscribers of upcoming news impacting the Workers’ Compensation industry, dates of public meetings and workshops.

To subscribe to the “E-Alerts”, please go to the DWC web site to register for our mailing list. Look for the box entitled “Register”. Once registered completed, you will shall receive E-Alerts whenever they are provided by the Division.

Explanation of the

Update Log

The health care provider and carrier can use the update log to determine if all the updates to the Manual have been received.

Update No. is the year that the update was issued.

Effective Date is the date that the update is effective.

Instructions File the Manual as instructed. You may wish to retain the prior Manual for billing services prior to the effective date of this Manual or for comparing policy changes.

UPDATE NO.

2015

EFFECTIVE DATE

TBD




Chapter 1 Introduction and Overview, continued

Overview, continued

Preface

Background

Other Applicable

Rules

How to Obtain or

Purchase Manuals

This Chapter introduces the format used for the Florida Workers’

Compensation Provider Reimbursement Manual and tells the reader how to use the Manual.

There are 3 types of Workers’ Compensation Manuals:

•

Florida Workers’ Compensation Reimbursement Manual for

Ambulatory Surgical Centers, [ASC Manual], Rule 69L-7.100,

Florida Administrative Code (F.A.C.);

•

Florida Workers’ Compensation Health Care Provider

Reimbursement Manual, [HCP RM],Rule 69L-7.020, F.A.C.; and

•

Florida Workers’ Compensation Reimbursement Manual for

Hospitals, [Hospital Manual], Rule 69L-7.501, F.A.C.

In addition to this Manual, the Florida Workers’ Compensation Health

Care Provider Reimbursement Manual, Rule 69L-7.020, F.A.C., also recognizes the following resource:

1.

The Workers’ Compensation Medical Reimbursement and

Utilization Review, Rule Chapter 69L-7, F.A.C., and

2.

Selected Materials Incorporated by Reference For Use In Workers’

Compensation, Rule Chapter 69L-8, F.A.C.

Thise effective Manual can be obtained free of charge on the

DWC website , under the ‘Reimbursement Manuals’ section or Provider tab, then click on Reimbursement Manuals. The Manual may also be purchased in hard copy from the Department of Financial Services,

Document Processing Section, at 200 East Gaines Street, Tallahassee,

Florida 32399-0311.





Characteristics of the Manual

Format

Information Block

Label

Note:

Update Log

How Changes Are

Updated

The format styles used in the Manual represent a concise and consistent way of displaying complex, technical material.

Information Blocks replace the traditional paragraph and may consist of one or more paragraphs about a portion of a subject. Blocks are separated by horizontal lines.

Each block is identified or named with a label.

Labels or names are located in the left margin of each information block. The labels identify the content of the block in order to facilitate scanning and locating information quickly.

Note : is used most frequently to refer the user to pertinent material located elsewhere in the Manual, related Rules, specific statutory authority or to exceptions and limitations to a policy.

The first page of each Manual will contain an update log.

Every update will contain a new updated log page with the most recent update information added to the log. The health care provider can use the update log to determine if all updates to the current Manual have been received. Each update is designated by an “Update No.” and the

“Effective Date”.

The Manual will be updated as needed. When a Manual is updated, the resulting new Manual will be replaced with a new effective date at the bottom of each page of the Manual.





Identifying New Material

New Label

New Material will be identified by vertical lines. The following information blocks give examples of how new labels, new information blocks, and new or changed material within an information block will be indicated.

A new label for an existing information block will be indicated by a vertical line to the left and right of the label only.

New Label and New

Information Block

New Material in an

Existing Information

Block

A new label and a new information block will be identified by a vertical line to the left and right of the label and the information block.

A paragraph within an existing information block that has new or changed material will be indicated by a vertical line to the left and right of the paragraph.

Paragraph with new material will be indicated in this manner.

Existing material

New material within a list of bullets will be indicated in this manner.





Administrative Purpose of the Manual

The administrative purpose of the Florida Workers’ Compensation

Health Care Provider Reimbursement Manual, 20165 Edition, is to furnish health care providers, as defined in subsections. 440.13(1), F.S., with general information, billing and reimbursement policies, and

Maximum Reimbursement Allowances (MRAs) for covered services and procedures.

Authorization

Prior Authorization of

Services

Notification of

Emergency Treatment

Health care providers and out-of-state providers must have authorization by the Workers’ Compensation carrier or a self-insured employer prior to:

•

Rendering initial care, remedial medical services; and pharmacy services, or

•

Making a referral for the injured worker to facilities or other health care providers.

Note : Exceptions to prior authorization are:

•

Federal facilities;

•

Emergency room services and care, defined in section 395.002, F.S.; or

•

A provider referral for emergency treatment resulting from emergency services.

Any health care provider who renders emergency care must notify the carrier, in writing or by facsimile, by the close of the third business day after care has been rendered.

If the emergency care results in admission to a health care facility, the health care provider must notify the carrier by telephone within 24 hours after initial treatment.





Carrier Responsibilities at Authorization

Fraud Statement

An carrier is responsible for meeting its obligations under this Rule regardless of any business arrangements with any service company/TPA, submitter or any entity acting on behalf of a carrier which medical bills are paid, adjusted and paid, disallowed, denied, or otherwise processed or submitted to the Division.

At the time of authorization for medical service(s), a carrier must shall notify each health care provider, in writing, of additional form completion requirements or supporting documents that are necessary for reimbursement and provide the specific address for submitting a reimbursement request.

At the time of authorization for medical service(s), a carrier must shall inform out-of-state health care providers of the specific reporting, billing and submission requirements of this Rule and provide the specific address for submitting a reimbursement request.

A health care provider involved in the process of making a claim under the

Workers’ Compensation Program must shall provide his or her personal signature once per calendar year attesting that he or she has reviewed, understands, and acknowledges the following statement:

“Any person who, knowingly and with intent to injure, defraud, or deceive any employer or worker, insurance company, or self-insured program, files a statement of medical bill containing any false or misleading information commits insurance fraud, punishable as provided in Sections 817.234, F.S.”





Health Care Provider Use of Codes, Descriptions and Modifiers

Physicians and other health care providers must shall use the codes and descriptions, modifiers, policies, definitions and instructions of the referenced CPT

®

, CDT

®

, HCPCS

®

, ICD-9

®

, ICD-10

®

or Florida Workers’

Compensation unique codes or other materials referenced in

Chapter Rules 69L-8.071 and 69L-8.074, F.A.C. and:

•

The Minnesota Department of Labor and Industry Disability

Schedule, as adopted in Rule 69L-7.604, F.A.C.;

•

The Florida Impairment Rating Guide, as adopted in

Rule 69L-7.604, F.A.C.;

•

The 1996 Florida Uniform Permanent Impairment Rating

Schedule, as adopted in Rule 69L-7.604, F.A.C.; and

•

The American Medical Association’s Guide to the Evaluation of

Permanent Impairment, as adopted in Rule 69L-7.604, F.A.C

The use of HCPCS

®

Level II codes is allowed only when there is not a more specific CPT

®

code available for use.

All diagnosis codes must be reported at the highest level of specificity according to the ICD-9-CM

®

or the ICD-10-CM

®

valid number of digits, i.e., five (5) to seven (7) digits where notedion is made in the ICD-9-CM

® or ICD-10-CM

®

manual. upon the federal implementation date of ICD-10-

CM

®

.

Both ICD-9 and ICD-10 codes may not be reported on the same claim form.

Carrier Use of Codes,

Descriptions, and

References

Carriers must shall use the codes and descriptions, modifiers, policies, definitions, and instructions of the referenced CPT

®

, CDT

®

, HCPCS

®

,

ICD-9

®

, ICD-10 CM

® upon the federal implementation date, or Florida

Workers’ Compensation Unique Codes on the medical bill prior to making reimbursement decisions.

In addition, where not inconsistent with instructions in this Manual, carriers may utilize the National Correct Coding Initiative (NCCI) edits in effect on the date(s) of service as part of the bill review process.





Notice of Privacy

Practices

Disclosure to Carriers

Every health care provider and other recognized health care practitioner will shall, except in emergency treatment situations, make a good faith effort to obtain a written acknowledgement of receipt of notice of privacy practices no later than the first day of providing medical services to a workers’ compensation insured patient. If not obtained, document its good faith efforts to obtain such acknowledgement and the reason why the acknowledgement was not obtained.

In the event a patient, guardian, curator, or personal representative requests restriction(s) of the use or disclosure of identifiable health information that would prevent disclosure as necessary for treatment or payment for health care services, the provider or other recognized health care practitioner must shall notify the carrier immediately, if possible, or by close of business on the next regular business day.

Unless instructed otherwise, it is the responsibility of all health care providers to furnish, without charge, the following documentation to the carrier:

1.

A complete report of the patient’s symptoms, findings and plan of treatment pursuant to reporting requirements of the

DFS-F5-DWC-25;

•

An operative report when a surgical procedure is performed;

•

A narrative report when a consultation or an independent medical examination is rendered;

•

Copies of medical records, when requested at the time of authorization by the employer/carrier or designated entity, in order to determine the medical necessity of services that must be substantiated in more detail than previously disclosed;

•

A copy of the DFS-F5-DWC-25 associated with the recommended or rendered care or treatment.

•

Failure of the health care provider to forward information when requested by the carrier may result in the billed service being disallowed or denied payment until sufficient documentation is provided to render the necessary determination.

Moreover, a health care provider’s failure to release medical records or information upon a reasonable request or to release full and truthful medical reports of all of his or her findings will shall constitute a violation of

Chapter 440, F.S., subject to penalties imposed by the Division.





Disclosure to Workers

Injured Worker’s

Requests

Carrier’s Requests

Division or Judge of

Compensation Claims

Requests

A health care provider, upon request, must shall furnish the injured worker, injured worker’s attorney, the employer or carrier or its attorney, on demand, relevant portions of his or her office chart, records, and reports.

The relevant portions sought must be related to the particular injury or illness for which compensation is sought .

A health care provider may charge an injured worker or their representatives no more than $0.50 per page for copies of written medical records. The relevant portions of the medical record sought must be related to the particular injury or illness for which compensation is sought.

Payment must shall be made to a health care provider by the requesting party at the provider’s actual cost for x-rays, microfilm, or other non-written records.

A health care provider, upon request, must shall provide a copy of the injured worker’s medical records to a carrier or carrier’s representative or attorney.

A health care provider, upon request, must shall furnish a carrier or the carrier’s attorney a copy of the injured worker’s medical chart, records and reports.

A health care provider, upon request, must shall furnish the carrier or the carrier’s attorney, non-written medical records.

A health care provider, upon request, must shall provide medical records to the Division or a Judge of Compensation Claims without charge.





General Reimbursement Information

Billing the Injured

Worker

Co-Payments

Federal Facilities

Florida Health Care

Providers

Health care providers must shall not bill the injured worker for services rendered for a compensable work-related injury except when it is to collect a co-payment fee or when apportioning out the percentage of need for the care attributable to a pre-existing condition.

A health care provider is entitled to collect a co-payment of $10.00 per visit when providing medical services and care to an injured worker who has reached overall maximum medical improvement (MMI).

•

Co-payments may only be collected for evaluation and management visits after the injured worker has received an assignment of MMI.

•

The co-payment will shall not apply to emergency care or services provided to the worker; and

•

The co-payment is not in addition to the maximum reimbursement allowance or fee agreement. The reimbursement amount otherwise payable by the carrier will shall be reduced by the amount of the

co-payment.

Federal facilities are exempt from the reimbursement provisions and allowances in this Manual.

An carrier must shall reimburse a federal facility its usual charge.

Reimbursement will shall be made to a Florida health care provider after applying the appropriate reimbursement policies contained in this Manual.

A carrier will shall reimburse a health care provider either the MRA in the appropriate reimbursement schedule or a mutually agreed upon contract price.

Note : See Chapter 3 for MRAs and instructions on how to determine the

correct MRA.





General Reimbursement Information, continued

Out-of-State Providers Prior to the delivery of medical services, a carrier and health care provider must agree upon the amounts of reimbursement for the services at the time of authorization; or

If no agreement is made prior to the service being rendered, the carrier will shall reimburse the greater of either:

1.

The MRA according to the out-of-state fee schedule provider for the services provided; or

2.

The MRA according to Chapter 3 Part A of this Manual. or under the state Workers’ Compensation program in the state where the services are provided; whichever is greater.

Codes Paid by MRAs Reimbursement for procedure codes listed in this Manual with an MRA will shall be at the maximum reimbursement allowance after the application of any reimbursement policies contained in this Manual.

When the bBilled charges that are is less than the MRA, the reimbursement will shall be reimbursed the MRA amount in the Fee

Schedule.

Note : The only exception is when there is a clearly defined reimbursement amount between the health care provider and carrier provided in a contractual agreement.






Codes Paid

By Report (BR)

Reimbursement will shall be determined by the carrier for procedure codes listed in the Fee Schedule as By Report (BR).

Payment will shall be based on a provider’s documentation submitted to the carrier containing information on the complete description of the service or procedures actually performed, medical necessity, and cost of any additional supplies.

At a minimum, reimbursement will shall be:

•

The Florida Workers’ Compensation MRA for clinically similar procedure codes in the current fee schedule.

The health care provider must shall submit the required documentation to the carrier when the following situations occur:

•

The procedure code’s MRA is listed in the Fee Schedule as BR in

Chapter 3 of this Manual; or

•

There is a valid procedure code in the CPT

®

or the HCPCS

®

Level II Manual which corresponds to the date of service. The billed procedure code cannot be listed in this Manual.

Note: See Codes with No MRAs later in this Chapter.






Codes with No MRAs Carriers must shall have an established methodology for determining reimbursement for procedure codes that have no established MRAs, unlisted procedure codes, and codes that are paid By Report. Carriers must shall utilize the expertise of peer review physicians for concurrent review, including the appropriateness and cost of the medical services reported; billing and coding issues; and determining reimbursement.

•

Carriers will shall determine reimbursement by comparing the billed procedure code(s) with clinically similar procedure code(s) found in the appropriate CPT or HCPCS Manual ; and

•

Carriers will shall make reimbursement decisions based on all of the provider’s documentation, the carriers medical bills, relative value data, services and supplies and peer physician recommendations; and

•

Carriers will shall reimburse all work-related and medically necessary services provided in a documented medical or dental emergency.

This reimbursement methodology must also be available in response to

Reimbursement for

Failed Appointments

Exceptions to Service

Limitations any Petition for Reimbursement Dispute or upon request by the Division.

Reimbursement is not made for failed appointments.

Note : This exclusion does not apply to Independent Medical

Examinations pursuant to paragraph s.440.13(5)(d), F.S.

See Independent Medical Examination in Chapter 2.

When a health care provider deems it medically necessary in the treatment of an injured worker’s particular individual’s injury or illness to furnish medical services that exceed the number of services in reimbursement policies in this Manual, a health care provider must:

•

Submit documentation to the carrier substantiating the medical necessity for the request; and

•

Receive specific written authorization from the carrier to render the requested additional services before they are provided.






Services Unrelated to the Compensable

Injury

Carriers will not reimburse hospital charges for services unrelated to the treatment or care of a compensable injury except when the treat the patient’s compensable injury or condition.

treatment is required to stabilize or maintain the patient’s medical status in order to

Disputing

Reimbursement

Carriers shall not reimburse health care providers or other recognized health care practitioners for services unrelated to the treatment or care of a compensable injury.

The health care provider may elect to contest the disallowance or adjustment of payment under subsection 440.13(7), F.S. The election to contest the disallowance or adjustment of payment under subsection. 440.13(7), F.S. must be made by the health care provider within forty-five (45) calendar days of receipt of the Explanation of Bill Review (EOBR) or notice of disallowance or adjustment of payment.





Classification of an Injured Worker’s Status

General Policies Providers are to utilize the Workers’ Compensation specific patient classification levels when submitting the required treatment status on the

DFS-F5-DWC-25 to the carrier.

Classification System The following best describes the patient classification levels are:

•

Criteria based.

•

Comprised of descriptive categories to provide a means to promote decision-making, accountability and responsible medical bill handling practices.

•

Neither hierarchical nor severity indicators.

Purpose of Proper

Patient Classification

Proper classification of the patient is intended to:

•

Convey to carriers the complexity of services that may be required for optimal clinical management;

•

Distinguish the overall critical differences among cases that influence the intensity, scope, and cost of services provided;

•

Facilitate recognition of three varying clinical configurations that affect the medical treatment plan and treatment progress or other available benefits for an injured worker;

•

Assist the carrier in decisions related to authorization of recommended treatment plans or treatment plan revisions;

•

Ensure that on-going treatment plans and authorized reimbursable services are consistent with the high intensity, short duration treatment approach which focuses on specific clinical dysfunction before authorization is made to a provider.

•

Enhance communication between the provider and the carrier to facilitate the authorization process for the provision of medically necessary care.





Classification of an Injured worker Status, continued

Patient Classification

Levels

Level I: Key issue – specific, well defined medical condition, with clear correlation between objective relevant findings and patient’s subjective complaints. Treatment correlates to specific findings.

Level II: Key issue- regional or generalized de-conditioning (i.e., deficits in strength, flexibility, endurance, and motor control). Treatment includes physical reconditioning or functional restoration.

Level III: Key issue – poor correlation between patient’s complaints and objective, relevant physical findings, both somatic and non-somatic clinical factors. Treatment includes interdisciplinary management and rehabilitation.




Chapter 2 Medical Services

Anesthesia Services

Reimbursable

Providers

Anesthesia

Minutes

Anesthesia Time

Units

Anesthesia services are reimbursed to anesthesiologists, certified registered nurse anesthetists (CRNAs) and anesthesia assistants (AAs) practicing within the scope of state licensure. A surgeon may also be reimbursed for anesthesia services performed during surgery.

Anesthesia time begins when the provider starts to prepare the injured worker for anesthesia care in the operating room or in an equivalent area and stops when the provider is no longer in personal attendance, that is, when the injured worker may be safely placed under postoperative supervision.

Note : Anesthesia time must shall be billed as the total number of minutes of anesthesia. For example, one (1) hour and fifteen (15) minutes of anesthesia must be billed as seventy-five (75) minutes of anesthesia.

The minutes of anesthesia must be converted by the carrier into time units as follows:

1.

For anesthesiologists, each ten (10) minutes of anesthesia time equals one (1) time unit and each minute over a time unit has a value of onetenth (1/10) time unit.

2.

For CRNAs or AAs, each fifteen (15) minutes of anesthesia time equals one (1) time unit and each minute over has a value of one-fifteenth

(1/15) time unit.




Chapter 2 Medical Services, continued

Anesthesia Services, continued

Physical Status

Modifiers

Anesthesia services will shall warrant additional reimbursement for units based upon the injured worker’s condition and the complexity of the anesthesia service provided.

A physical status modifier will shall be determined by the provider (CRNA or anesthesiologist only) to rank the injured worker’s condition. Additional reimbursement will shall be based on the unit value for the specific physical status modifier, as assigned by the CPT

®

Manual.

A physical status modifier is required for billing and reimbursement of anesthesia bills.

Physical Status Modifiers Unit Values

P1 A normal healthy patient 0

P2 A patient with mild systemic disease 1

P3 A patient with severe systemic disease 2

P4 A patient with severe systemic disease

that is a constant threat to life 3

P5 A moribund patient who is not expected

to survive without the operation 4

P6 A declared brain dead patient whose organs

are being removed for donor purposes 5






Difficult or Anesthesia services, which are provided under particularly difficult

Qualifying

Circumstances circumstances, may warrant additional reimbursement for unit values based on unusual events. Listed below are the specific qualifying circumstances, as assigned by the CPT

®

Manual, that impact the anesthesia services provided.

These procedure codes are not to be reported alone, but are reported as additional procedure codes. The listed unit value must be added to the base value units to calculate the reimbursement. List each of the following codes below the primary anesthesia procedure code on the billing form.

Code Unit Value

99100 Anesthesia for patient of extreme age,

under one year and over seventy 1

99116 Anesthesia complicated by utilization of

total body hypothermia 5

99135 Anesthesia complicated by utilization of

controlled hypothermia 5

99140 Anesthesia complicated by

emergency conditions (specify) 2

Calculation of

Anesthesia

Reimbursement

All others 0

Select the applicable anesthesia procedure code and note the base value from the fee schedule in Chapter 3, Part A, of this Manual.

Determine the time units based on provider type. Determine any additional units that are justified by the physical status modifier and qualifying circumstances. Add the base value, time units, physical status modifier and any applicable qualifying circumstances to determine total anesthesia value.

Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the total anesthesia reimbursement.

Base Value (BV)

Time Units (TM)

Physical Status modifier units

+ Qualifying Circumstances Units = Total Anesthesia Units

Total Anesthesia Units x $29.49 = $ Reimbursement






Procedures Listed Certain anesthesia services do not have a listed time value component. as BV with No TM

Units

The reimbursement method for an anesthesia services that does not have time units associated with the anesthesia base value is as follows:

•

Select the applicable anesthesia procedure code and base value from the schedule in Chapter 3, Part A of this Manual.

•

Determine any additional units that are justified by the physical status modifiers or qualifying circumstances.

•

Add the base value, physical status modifier and any applicable qualifying circumstances to determine total anesthesia value.

•

Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the total anesthesia reimbursement.

Base Value

Physical Status Modifier units

+ Qualifying Status units = Total Anesthesia Units

Total Anesthesia Units x $29.49 = $ Reimbursement

Note : CRNAs and AAs reimbursement will shall be limited to 85% of the total

anesthesia reimbursement allowance for an anesthesiologist for any

procedure that has no TM units.






Medical Direction Reimbursement will shall only be made to the anesthesiologist for the direct of CRNA/AA by

Anesthesiologist supervision of anesthesia services which are provided by the anesthesiologist and billed under the name and license number of the physician.

Reimbursement will shall be made to an anesthesiologist for providing medical direction, including pre-operative and post-operative evaluations or specific consultations to a CRNA/AA as previously identified by the specific protocol.

Reimbursement for a CRNA/AA requiring medical direction by an anesthesiologist will shall be fifty percent (50%) of the anesthesia reimbursement allowance listed in Chapter 3, Part A or the agreed upon contract price.

Reimbursement for medical direction by an anesthesiologist will shall be fifty percent (50%) of the anesthesia reimbursement allowance listed in

Chapter 3, Part A of this Manual or the agreed upon contract price.

Reimbursement will shall not be made to either the anesthesiologist or the

CRNA/AA until the carrier has received and reviewed the medical bills and anesthesia reports from both providers.

No additional reimbursement will shall be made for general supervisory services rendered by the anesthesiologist.

Special Billing

Requirements for

Anesthesia

All anesthesia services must be billed on Form DFS-F5-DWC-9. Anesthesia services must include the CPT

®

code and the “P” code (physical status modifier) which corresponds with the procedure performed in Field 24D.

1.

Anesthesia providers must shall enter the date of service and the

5 digit qualifying circumstances code, which corresponds with the

procedure performed, in Field 24D on the next line, if applicable.

2.

Medical direction must shall be billed by the anesthesiologist by adding the HCPCS

®

Level II modifier QY to the anesthesia procedure code.

3.

When medical direction is required, the CRNA or AA must shall bill by appending the HCPCS

®

Level II modifier QX to the anesthesia procedure code. The CRNA or AA must shall provide his or her Florida

Department of Health (DOH) license number in Field 33b.

•

When a Certified Registered Nurse Anesthetist provides anesthesia services, the CRNA must enter his/her Florida Department of Health

(DOH) license number in Field 33b.

Note : See Chapter Rule 69L-7, F.A.C.






Anesthesia

Performed by a

Surgeon

When a surgeon provides regional or general anesthesia for a surgical procedure that he or she actually performs, modifier 47 is appended to the anesthesia procedure code to indicate that the operating surgeon performed the anesthesia.

An operating surgeon cannot report time units in the calculation of anesthesia reimbursement request on the medical bill. Reimbursement will shall be for the base value (BV) multiplied by the anesthesia conversion factor only for the anesthesia service rendered.

Base Value x $29.49 (anesthesia CF)= $ Reimbursement

Note: See Chapter 3, Part A of this Manual for anesthesia Base Values.

Biofeedback Services


Reimbursement

Limitations to

Biofeedback

Services

Reimbursement for the collection and interpretation of biofeedback data digitally stored and downloaded will shall be included in the reimbursement to the provider for the basic biofeedback service.

The written interpretation of the digitally stored biofeedback results must be signed and dated by the health care provider and maintained in the medical record.

Reimbursement for biofeedback training will shall be limited to twelve (12) visits per date of injury.

Note : This biofeedback training limitation does not include individual psychophysiological therapy incorporating biofeedback training by any modality with psychotherapy.





Dental Services

Reimbursable

Providers

Dental Codes and

Descriptions

Oral Surgery

Temporomandibular

Joint (TMJ)

Services

All dental services must shall be authorized by a carrier before the services are rendered.

A carrier will shall only reimburse a dentist or an oral surgeon for authorized services.

Note : Emergency oral surgery does not require prior authorization. The carrier must shall be notified by the provider no later than the close of the third business day after emergency treatment.

Dentists must shall use the dental guidelines, codes and descriptors from the

CDT

®

or the D codes in the HCPCS

®

for dental procedures.

Dental services are billed on Form DFS-F5-DWC-11.

Oral Surgeons must shall use the CPT

®

guidelines, codes, descriptors and modifiers for oral and maxillofacial surgical services.

Oral surgery services are billed on the DFS-F5-DWC-9 medical bill form.

Note : Oral Surgeons will shall refer to the label block “ Billing and

Reimbursement of Multiple Surgical Procedures” under Surgical Services in this Manual for information regarding reimbursement for multiple surgical procedures, as well as other surgical reimbursement guidelines.

Dentists must shall bill using a combination of the dental guidelines, codes and descriptors from the CDT

® manual and the D codes from the HCPCS

® manual.

•

Dentists who provide TMJ services may use a combination of CPT

®

codes and dental codes from the CDT

®

or HCPCS

®

.

•

Dentists will shall refer to the physical medicine section of this Manual for information on physical medicine reimbursement policies.





Dental Services, continued

Reimbursement to

Dentists and Oral

Surgeons

Reimbursement to a dentist or oral surgeon for dental procedures or services will shall be the MRA or the agreed upon contract price.

Note : See Chapter 3 for the MRAs for Dentists and Oral and Maxillofacial

Surgeons in this Manual.

Electrodiagnostic Medicine

Determining

Medical Necessity

Needle

Electromyography

(EMG)

Reimbursement

Policies for EMG

The referring physician must shall determine the medical necessity of an electromyography (EMG) or a nerve conduction study (NCS). Only a physician will shall determine the frequency of testing or the necessity of repeat testing.

Only a physician or a recognized practitioner specifically qualified by regulations in the state where the service is provided will shall be reimbursed for needle EMG testing.

Reimbursement must shall include the testing, interpretation of the studies and a written report of the findings.

When the initial evaluation and management service and needle EMG testing are performed during the same visit, reimbursement will shall be made for both services.

When a follow-up evaluation and management service and needle EMG testing are performed on the same day, reimbursement will shall be made to a physician for both services if the physician’s documentation validates the medical necessity for the follow-up evaluation and management service.

When needle EMG testing is performed in a hospital or other facility, reimbursement will shall be made to a physician for an interpretation and report of the testing. Modifier 26 must be appended to the appropriate procedure code for reimbursement.





Electrodiagnostic Medicine, continued

Nerve Conduction Only physicians or recognized practitioners specifically qualified by state

Studies

(NCS) regulations to perform Nerve Conduction Studies (NCS) will shall be reimbursed.

A physician or a recognized practitioner specifically qualified by regulations in their state will shall determine the nerves to be tested based on specific clinical findings during the examination performed at the time of the study will shall be reimbursed if authorized by the carrier for an NCS.

Reimbursement

Policies for NCS

When the initial evaluation and management service and the NCS are performed during the same visit, reimbursement will shall be made for both services.

When a follow-up evaluation and management service and NCS are performed on the same day, reimbursement will shall be made for both services only if the physician’s documentation validates the medical necessity of the follow-up evaluation and management service subsequent to findings from the initial visit.

A technologist under the direct supervision of the physician may perform a

NCS. However, the services must be billed under the name and Florida

Department of Health license number of the supervising physician or out-ofstate license number.

Reimbursement will shall include the testing, interpretation of the studies and a written report of the findings.

Evaluation and Management Services

Office Visits A carrier will shall reimburse a physician for evaluation and management services (new or established patient visits).

A new patient means an injured worker who is new to the health care provider or an established patient with a new compensable injury or illness and a new date of accident.

Note : Reimbursement is limited to one (1) visit per day at the level of care documented by the physician.





Evaluation and Management Services, continued

Consultations A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation or management of a specific problem is requested by another physician or other appropriate resource. A physician will shall be reimbursed for consultations, confirmatory consultations and follow-up consultation services.

Reimbursement will shall include a review of all submitted medical records, paper and non-paper; an examination of the injured worker; and a written report.

Home Visit

Services

A physician will shall be reimbursed for home visits when authorized by the carrier.

A physician must shall bill with the appropriate evaluation and management procedure code for a home visit to bill the service.

Functional Capacity Evaluations (FCE)

Reimbursement

Criteria

All FCE protocols must shall be evidence-based. Test design and written interpretation must shall, at a minimum, focus on identifying associated functional loss, limitations or restrictions and the correlation to work-related clinical dysfunction (i.e., correlate impairment with disability).

Reimbursement for an authorized FCE will shall be made at any time in the clinical continuum (see Patient Classification System in Chapter 1 of this

Manual), as long as the evaluation protocol matches the scope and specificity of the clinical situation and referral question(s).

Reimbursement will shall be made for the CPT

®

code 97750, specifically designated for use solely in reporting a FCE. The reimbursement for a FCE includes a written program plan and a written report. The provider must shall provide the results of the evaluation and recommendations to the injured worker, the carrier and the treating physician without additional charge.

Reimbursement for an FCE will shall be made only when a physical therapist or occupational therapist is directly and actively involved with the testing protocol, although additional professional personnel may be involved as well.

Note : Bill using CPT

®

code 97750.





Home Health Agency Services

Definition

Home Health Visit

Definition

General Policies

Treating Physician

Authorization

Home Health Services are medically necessary services which can be effectively and efficiently provided in the place of residence of an injured worker. Services include home health visits (nurses and home health aides), therapy services (speech therapy, physical therapy, occupational therapy), and authorized home medical equipment.

A Home Health Visit is a face-to-face encounter between a registered nurse, licensed practical nurse, home health aide, or licensed therapist employed by a

Home Health Agency and an injured worker at his or her place of residence.

A Home Health Visit is not limited to a specific length of time, but is defined as an entry into the injured worker’s place of residence for the length of time needed to provide the medically necessary nursing, home health aide, or therapy service(s). An injured worker’s residence cannot be in a facility such as a hospital, a nursing facility, or a rehabilitation facility of any type.

A Home Health Agency must have a signed order outlining the Home Health

Plan of Care from the authorized, treating physician in order to obtain carrier authorization of home health services. The Home Health Plan of Care must be renewed every thirty (30) calendar days and submitted to the carrier for approval before further services may be authorized by the carrier.

The authorized treating physician is the doctor responsible for the management and treatment of the injured worker’s compensable medical condition or the physician assigned by the Judge of Compensation Claims to treat the injured worker for the compensable condition. The treating physician cannot be a consulting physician unless there has been a complete transfer of care.

A Home Health Agency must shall obtain authorization from the carrier prior to assigning any licensed health care employees to render services in an injured worker’s residence. A Home Health Agency is required to obtain a separate, written or electronic authorization from the carrier for any Home Medical

Equipment needed. The carrier’s authorization to provide home health services does not authorize home medical equipment and supplies unless such authorization is expressly stated.





Home Health Agency Services, continued

Staff Skill Level A Home Health Agency must provide staff with the skill level designated and appropriate for each service prescribed in the treating physician order and approved plan of care as authorized by the carrier.

Staff Substitutions If a staff absence occurs, the Home Health Agency is responsible for providing and assuring that appropriate staff substitutions are made.

Licensure or discipline of the staff substitutions must be equivalent to, or

Reimbursement above, the discipline level as specified in the plan of care.

The carrier will shall reimburse the Home Health Agency at the reimbursement amounts mutually agreed upon between the Home Health Agency and the

Billing for Home

Health Agency

Services carrier in a contract prior to the services being delivered in the home.

The Home Health Agency must bill on the Form DFS-F5-DWC-90 and include a copy of their contractual agreement with the billing form to the carrier for proper reimbursement.

When a Home Health Agency is billing for authorized DME, on the

Form DFS-F5-DWC-90, a copy of the treating physician’s original order for the

DME item(s) must accompany the bill submitted to the carrier.

Independent Medical Examinations


Reimbursement

Reimbursement for IME

Reimbursement for an Independent Medical Examination (IME) shall include:

•

The review of applicable paper medical records;

•

The review of non-paper medical records; and

•

The examination of the injured worker with production of a written report.

A physician will shall be reimbursed by the party requesting the IME. IME services are reimbursed at either the MRA or a mutually agreed upon contract amount.

Note: The only procedure code for billing an IME is the Workers’

Compensation Unique code 99456.





Failure to Appear for IME

If an injured worker fails to appear for an IME, scheduled by the employer or carrier, without good cause and failed to advise the physician at least 24 hours before the scheduled date for the examination that he or she will not appear, the physician may bill his or her cancellation or no-show fee to the carrier.

Note: The physician must shall bill using the Workers’ Compensation unique code 99456 CN to indicate the injured worker failed to appear or the appointment was canceled without proper notice.

Consensus Independent Medical Examination


Reimbursement

Reimbursement for CIME

Reimbursement for a Consensus Independent Medical Examination (CIME) must shall include:

1.

The review of applicable paper and non-paper medical records;

2.

An examination of the injured worker including determination of

Maximum Medical Improvement (MMI);

3.

Assignment of a permanent impairment rating, as appropriate; and

4.

A written report.

Reimbursement for a CIME will shall be negotiated between the physician and the carrier prior to rendering the service. A physician will shall be reimbursed by the carrier for a CIME.

Note : CIME service must shall be billed with the Workers’ Compensation

Unique code 99457 for reimbursement.

Medications

General Policies Medicinal drugs, commonly known as legend or prescription drugs, dispensed to treat an injured worker must shall be ordered by a physician or other recognized health care practitioner and authorized by the carrier.

Medicinal drugs are dispensed, stored and sold only by a pharmacist licensed under Chapter 465, F.S., or a licensed dispensing practitioner according to the provisions in sections. 465.0276, F.S.





Medications, continued

Codes and

Descriptions for

Medications

Reimbursement for Injectable

Medications

Physicians and other recognized practitioners must shall refer to the HCPCS

® manual in effect for the date of service when reporting injection procedures, as well as immune globulin, or vaccine products.

Providers must shall use the J codes in the HCPCS

®

Level II Manual, as adopted as part of in Chapter 69L-8, F.A.C., this Manual for reporting other injectable medications.

If the specific medication is not listed in either of these references, the provider must shall bill the medication using the National Drug Code (NDC) number for reimbursement.

Reimbursement for injectable medications will shall be made to a health care provider as follows:

•

Reimbursement shall be made to a health care provider using CPT

®

or

HCPCS

®

J codes for specific injectable medications and CPT

®

codes for the administration of injectable medications.

•

Reimbursement will shall be at either the contract price or the listed

MRA in the appropriate schedule.

•

Reimbursement for an injection will shall include a local anesthetic, if necessary.

•

Reimbursement for multiple medications administered from the same syringe will shall be:



At either the contract price or the listed MRA, in Chapter

3, Part A of this Manual for the first reported drug; and



At either the contract price or fifty percent (50%) of the listed MRA in the appropriate schedule for each additional drug. Each additional drug must shall be reported by appending modifier 51 to the HCPCS

®

or

CPT

®

code.






Reimbursement for Injectable

Medications

(continued)

Reimbursement to a physician for codes 90749 or J3490 will shall be twenty percent (20%) above the actual cost of the injectable medication based on submission of:

1.

The name, strength and dosage of the medication, vaccine or toxoid; and

2.

Documentation verifying the cost of the medication, vaccine or toxoid.

3.

Applicable manufacturers Shipping and Handling will shall be reimbursed at the actual cost on the invoice.

Morphine via

Infusion Pump

Dispensing

Medications

A special provision is allowed for identification of the loading dose of

Morphine Sulfate administered via infusion pump.

Providers must shall utilize an appropriate HCPCS

®

code if deemed by the practitioner to be the most appropriate coding option.

Reimbursement will shall be twenty percent (20%) above the documented cost of the drug.

Applicable manufacturer’s Shipping and Handling will shall be reimbursed at the actual cost on the invoice.

The dispensing of medicinal drugs will shall be limited to a pharmacist or a licensed dispensing practitioner and billed under the NDC number. The reimbursement for prescription medications will shall be:

Average Wholesale Price (AWP) + $4.18 = $ Reimbursement

Note : see paragraph 440.13(12)(c), F.S. for the definition of Average

Wholesale Price.

For repackaged or relabeled prescription medications dispensed by a health care practitioner on or after date of service July 1, 2013, see paragraph

440.13(12)(c), F.S. to obtain the requirements for billing and reimbursement of repackaged prescription medications.

Note : See Chapter 69L-7, F.A.C. for proper billing of repackaged or relabeled

medications. Additionally, the pharmacist or dispensing practitioner

shall bill for medication dispensing by using the Workers’ Compensation

Unique code DSPNS.






Compounded

Drugs

Reimbursement for Compounded

Drugs

Unlisted

Medications

Medicinal drugs may be compounded by a pharmacist or a physician when the drug formulation prescribed is not commercially available. Compounded drugs do not have a NDC number.

The provision and reimbursement of compounded drugs will shall be limited to a pharmacist or a physician and billed under the NDC number of each component that is used to make up the compounded drug.

The provider must shall bill a professional fee for compounding by using the

Workers’ Compensation Unique code COMPD.

Reimbursement is the lesser of:

1.

[AWP (of each component)] + $4.18 = Reimbursement; or

2.

The amount the carrier has contracted for pursuant to paragraph 440.13(12)(c), F.S.

Note : Please refer to paragraph 440.13(12)(c), F.S. for the definition of

AWP.

Reimbursement for unlisted medications or medications with no MRA in

Chapter 3 of this Manual, will shall be twenty percent (20%) above the actual cost of the medication based on the submission of documentation which includes:

•

The name, strength, and dosage of the medication dispensed to the injured worker; and

•

The invoice verifying the actual cost of the medication.





Non-

Reimbursable

Drugs and

Supplies

Reimbursable

Materials and

Supplies

Unlisted Supply

Code

Reimbursement will shall not be made for oral vitamins, nutrient preparations or dietary supplements. Reimbursement will shall not be made for medical food pursuant to paragraph 440.13(3)(k), F.S.], as defined in 21 U.S.C s. 360ee

(b) (3), unless the self-insured employer or the carrier in its sole discretion authorizes the provision of such food. Such authorization may be limited by frequency, type, dosage, and reimbursement amount of such food as part of a proposed written course of medical treatment.

Reimbursement for supplies and materials not incidental to a service or a procedure will shall be reimbursed using the specific HCPCS

®

Level II supply codes.

When a more specific code is not available for reimbursable supplies and materials, bill using the HCPCS

®

miscellaneous supply code A9999 and submit documentation with the following:

•

A detailed description of the supply or material and the unique medical need for the injured worker; and

•

A copy of the actual invoice to document the cost of the item billed including unit(s) of supply and unit pricing information. If needed, please circle the items on any invoice that are specific to the injured worker when submitting the medical bill.

Supplies and

Materials Not

Separately

Reimbursed

Reimbursement for Supplies

Material and supplies which are necessary to perform a procedure or provide a service will shall be included in the reimbursement for the procedure or service and will shall not be reimbursed separately.

Reimbursement will shall be limited to twenty percent (20%) above the actual invoice cost of the supply(s) based on submission of the documentation that substantiates the provider’s cost.





Medical Supplies and Home Medical Equipment

General

Requirements

Authorization

Billing

Reimbursement

Medical supplies and home medical equipment must shall be prescribed by a physician and may be provided to an injured worker by a home medical equipment supplier through rental or purchase.

A home medical equipment supplier must shall obtain a specific written or electronic authorization and a written payment agreement from the carrier prior to furnishing an injured worker with medical supplies or equipment.

A home medical equipment supplier must shall provide the carrier with a copy of the physician’s original order with the medical bill when requesting reimbursement.

A home medical equipment supplier is required to bill on the Form

DFS-F5-DWC-10 using HCPCS

®

codes. The home medical equipment supplier is not required to provide invoices with the bill to document the acquisition costs of supplies and equipment.

Note : When no specific code is available to describe the item provided, bill using HCPCS

®

code A9999 unless specifically requested by the carrier at the time of authorization.

Reimbursement will shall be made by the carrier to a home medical equipment supplier for rental or purchase of medical equipment and supplies ordered or prescribed by a physician or recognized practitioner according to the written payment agreement obtained at the time of authorization.

•

The carrier may rent the item from the supplier for the injured worker; or

•

The carrier may write a provision in the payment agreement that when the amount received by the supplier from the rental payments equals the purchase price, the item will become the property of the carrier or injured worker; or

•

The carrier may purchase the item from the supplier.





Medical Supplies and Home Medical Equipment, continued

Limitations for No reimbursement will shall be made for supplies or equipment that are

Supplies and DME automatically supplied or refilled by the supplier. All services and refilled supplies require explicit carrier authorization as a requirement for reimbursement.

Ophthalmologic Services

General

Reimbursement

Requirements

Glasses, Contacts or Frames

Reimbursement for ophthalmologic services will shall be made for all medically necessary services. Authorization from the carrier is required unless the condition is an emergency situation.

Reimbursement will shall only be made for glasses, contact lens, or frames of comparable quality to the original when they are damaged, lost or required for treatment as a result of an injury or surgery to correct an injury.

Permanent Impairment Ratings (PIR)

Providers Eligible for

Reimbursement

Reimbursement

Components and

PIR

Only a physician licensed by the Chapters listed in paragraphs. 440.13(3)(b),

F.S. will shall be reimbursed by the carrier for addressing maximum medical improvement (MMI) and the assignment of a Permanent Impairment Rating

(PIR ).

Reimbursement will shall include an examination to include:

1.Evaluation of an injured worker’s condition to include the establishment of the MMI date and PI rating of zero (0) percent or greater; and

2.The systematic completion of the required reporting form, Form DFS-F5-

DWC-25, and submission to the appropriate parties in accordance with s.

440.15(3), F.S.

•

The Form DWC-25 does not replace physician notes or other medical records.

•

The Form DWC-25 must shall be fully completed and must shall document the method(s) and guide used to assign a PI rating.

Reimbursement will shall not be made for an evaluation and management code on the same date of service as a PI rating.

Note : The procedure code for billing a PI rating is the CPT

®

code 99455.





Psychiatric and Psychological Services


Reimbursement

Required

Documentation

Individual

Psychotherapy

Combined with

Evaluation and

Management

Codes

Reimbursement for psychiatric and psychological services will shall be made by the carrier to the following recognized practitioners to provide individual psychotherapy services within the scope of state licensure:

•

Medical doctors;

•

Osteopathic physician;

•

Psychologists;

•

Mental health practitioners;

•

Other qualified health professionals.

All psychiatric and psychotherapy procedure codes that are reimbursed based on face-to-face time with the injured worker patient must have a beginning and an ending time documented in the medical record.

Only a physician may be reimbursed for individual psychotherapy in combination with evaluation and management services provided by a physician at a therapy session. Documentation must support the services billed.

A physician will shall not be reimbursed for an evaluation and management procedure code (99201-99499) on the same day that reimbursement is made for psychotherapy combined with evaluation and management services.

Note : Refer to the CPT

®

for specific psychiatric procedure codes to identify the combined codes.

When more than one individual psychotherapy session is performed on the same day, only the session lasting the longest period of time will shall be reimbursed.

Multiple

Psychotherapy

Sessions on the

Same Day





Psychiatric and Psychological Service, continued

Family Reimbursement for family psychotherapy, with or without the injured worker

Psychotherapy present, will shall be made if the documentation supports that the purpose is related to the treatment of the injured worker’s compensable injury.

Reimbursement will shall not be made for psychiatric or psychological services provided directly to members of the injured worker’s family for support and assistance in adjusting to the injured worker’s condition.

Central Nervous

System Testing

Central Nervous System (CNS) Assessment and Testing must shall be specifically authorized by the carrier.

Reimbursement of

CNS Testing

Reimbursement will shall be made for CNS Assessment and Testing.

Reimbursement includes:

•

An assessment and administration of a test with interpretation and a written report;

•

The amount of reimbursement for these services shall be determined from Tthe number of hours (units of service) reported by the provider to perform the assessment and testing;

•

The procedure code used for billing shall indicatinge if the service is per hour or is all-inclusive.

Reimbursement will shall be the MRA in Chapter 3 of this Manual or the agreed upon contract price.

Behavioral

Assessment

Interventions

Billing

Reimbursement will shall be made for Health and Behavior Assessment and

Intervention Services when authorized by the carrier.

Providers must shall refer to the most specific Health and Behavior Assessment and Intervention procedure codes when billing for health and behavioral interventions.





Radiology

Reimbursable

Services

Components of

Radiology

Reimbursement

Global Services

Reimbursement

Policies

Reimbursement will shall be made for radiology services including diagnostic radiology (diagnostic imaging), diagnostic ultrasound and nuclear medicine.

Radiology services consist of two components: the technical component and the professional component.

•

Technical Component: modifier TC

When the technical component only [the actual performance of the radiological test and the production of film(s)] is reported separately, the service is billed by adding the HCPCS

®

modifier TC to the procedure code when requesting payment.

•

Professional Component: modifier 26

When the professional component (physician interpretation of radiological test results) is reported separately, the service is billed by adding the HCPCS

®

modifier 26 to the procedure code when requesting payment.

Global services may be reported when one practitioner provides both the technical and the professional components of a radiological procedure or service. The unmodified 5 digit procedure code is used to identify a global service inclusive of the professional service and the technical component of providing that service.

Reimbursement will shall not be made for a professional component (modifier

26) billed in the following situations:

•

A professional component billed by a physician for x-rays taken and interpreted by another physician and reviewed during an IME, CIME, medical visit or consultation.

•

A professional component billed by a physician for reviewing x-rays during an emergency department or hospital visit when the x-rays were interpreted by the radiologist at the hospital.

•

A professional component billed by a provider who is not the provider that reviewed, interpreted and signed the radiology report.





Radiology, continued

Independent

Radiology

Facilities

Reimbursement will shall be made to an independent radiology facility for the technical component of the service by appending the modifier TC to the five (5) digit procedure code.

No reimbursement will shall be made for the professional component of a service to an independent radiology facility. Only a technical component may be reimbursed to an independent radiology facility.

The professional component will be billed separately by the health care provider that interprets the radiology exam.

Thermography


Authorization

Thermography

Limitations

The carrier will shall not authorize a physician to perform thermography any earlier than forty-five (45) calendar days after the date of accident unless the documentation of medical necessity is submitted to the carrier along with the request for authorization.

Reimbursement for thermography is limited to one (1) body area; either major or limited.

1.

Major body areas. (The following areas include all views.)

•

Head;

•

Cervical spine and upper extremities;

•

Lumbosacral spine and lower extremities.

2.

Limited body areas. (The following areas include all views.)

•

Thoracic spine;

•

Any portion of a major area.





Reimbursement

Requirements

An authorization and a written reimbursement agreement must shall be obtained from the carrier for rental or purchase of a TENS unit prior to a physician or other recognized practitioner furnishing a TENS unit to the injured worker.

Reimbursement will shall be twenty percent (20%) above the provider’s documented cost when the TENS unit is purchased. A copy of the provider’s invoice must shall be submitted with the bill to substantiate the provider’s cost.

Training Sessions for TENS

Reimbursement will shall be made to an authorized physician or other recognized practitioner for furnishing training to an injured worker on the application and use of a TENS unit.

Note : Reimbursement is limited to four (4) training sessions per approved

TENS unit.

Physical Medicine and Rehabilitation Services

General

Information

Covered Services

Physical medicine and rehabilitation services will shall be considered as covered treatment only when such care is given based on a physician referral or prescription and when the medical necessity for such services is clearly supported in the recognized practitioner’s evaluation and in the specific physical medicine plan of care.

Carriers will shall reimburse authorized providers, as specified in this Manual, for the following physical medicine and rehabilitation services provided to injured workers for a compensable injury/illness:

1.

Modalities and therapeutic procedures applied to acute injuries to reduce symptoms, restore function, and return the injured worker to work.

2.

Physical reconditioning focused on injuries requiring intensive physical reconditioning services to restore the injured worker to pre-injury level of physical health and function. The goal will shall be for the worker to return to a job and/or become physically reconditioned.

3.

Interdisciplinary rehabilitation programs covering a variety of services that are coordinated, outcome focused and directed at the injured worker’s needs to increase the worker’s functioning or to return the worker to work.




Chapter 2 Medical Services

Physical Medicine and Rehabilitation Services, continued

Authorization of All services must shall be authorized in writing by the carrier prior to initiation

Services of services.

Reimbursement will shall only be made for physical medicine, therapeutic procedures, modalities and rehabilitation services up to six (6) months after the date of accident, based on a signed order or referral from an authorized, treating physician.

Exceptions to

Limitations

Exceptions may be made to the above limitation when the treating provider provides documented, objective, relevant medical findings that demonstrate the following:

1.

The injured worker has a specifically defined, relevant clinical dysfunction, consistent with the patient classifications outlined in

Chapter 1 of this Manual, that is reasonably expected to respond to the requested physical medicine modalities or procedures; and

2.

The injured worker does not conform to either the Level II or Level III patient classifications based on specific documentation of the following: a.

No systemic musculoskeletal deficit (strength, flexibility, endurance, coordination) or substantive functional loss requiring an indicators when compared with documented, objective, relevant findings.

Note : See Classification of an Injured Worker Status in Chapter 1 of this

Manual. intensive physical reconditioning program; b.

No behavioral or psychological issues that present a substantive factor in the rehabilitation effort or outcome; c.

No significant vocational or return to work issues; and d.

No significant disparity between the injured worker’s subjective complaints, response to intervention, and other relevant clinical






Physical Medicine The requirement of medically necessary physical medicine services (i.e.,

Plan of Care

(DWC-25) modalities and therapeutic services, physical reconditioning, or interdisciplinary rehabilitation programs) must shall be documented on the Form DWC-25 submitted to the carrier by the physician and supported in the evaluation with a specific physical medicine plan of care, regardless of the location of where the services are rendered or if rendered by a physician or other recognized practitioner.

•

If the carrier questions the appropriateness of the therapy listed in the plan of care, the carrier must shall contact the physician to obtain the rationale for the ordered therapy, prior to authorization.

•

It will shall be the responsibility of the physician to provide the documentation of medical necessity for the therapy to the carrier in order to avoid unnecessary delays in obtaining authorization for treatment or in initiating therapy.

Service

Limitations

Physical Medicine

Initial Evaluation by a Therapist

Reimbursement for physical medicine services is limited to one visit per day, unless specifically authorized by the carrier.

•

Reimbursement for an initial evaluation by a physician will shall be made as an evaluation and management service.

•

Reimbursement for an initial evaluation by a therapist will shall be made when billed using procedure code 97001 or 97003.

•

Separate reimbursement will shall not be made to a physician and to a physician-employed therapist for an evaluation by each on the same date of service.

•

Reimbursement for an initial evaluation will shall include the evaluation and a plan of care or treatment.

Note: Documentation of the evaluation and preparation of a plan of care must shall be submitted to the carrier with the medical bill. At a minimum, the documentation must shall include:

1.

The evaluation findings including any functional limitations;

2.

The proposed therapy specifying the frequency and duration of services; and

3.

The anticipated degree of restoration of function with measurable goals.






Evaluation by an

Athletic Trainer a.

Reimbursement for an initial evaluation, when performed by a physician, must shall be billed as an evaluation and management service. b.

Reimbursement for an initial evaluation by an athletic trainer will shall be made only after a referral from a physician and billed using procedure code 97005. c.

Separate reimbursement will shall not be made to a physician and to a physician-employed athletic trainer for an evaluation by each on the same date of service. d.

Reimbursement for an initial evaluation by an athletic trainer must shall include the evaluation and a plan of care or treatment.

Re-Evaluation by an Athletic

Trainer

Revised Plan of

Care

Reimbursement will shall be made for a re-evaluation by an athletic trainer, when ordered by a physician, and documented on the DWC-25 no more than once every four (4) weeks.

Re-evaluations must shall be billed using procedure code 97006.

1.

The physician must shall submit to the carrier a revised DWC-25 prepared by the physician to document the change in care or treatment, when appropriate.

2.

An authorized treating physician CIME service must shall be billed with the Workers’ Compensation Unique code 99457 for reimbursement from the carrier. The physician performing the CIME has the responsibility for providing documentation of medical necessity for therapy modifications, if questioned by the carrier.






Modalities and

Therapeutic

Procedures

Reimbursement to a physician or recognized practitioner will shall be made for the modalities and therapeutic procedures listed in the plan of care with the limitation that no more than four (4) units of service shall be reimbursed per visit.

•

Codes 97010-97028 will shall each equal one (1) reimbursable unit of service. The performance of the supervised modality codes is not timeoriented and each code may only be reported once during the visit.

•

Codes 97032-97542 will shall each equal one (1) reimbursable unit of service for each fifteen (15) minute increment of service performed.

•

Code 97150 will shall be restricted to one (1) reimbursable unit of service per visit.

Manipulative

Treatment

Reimbursement to a physician for a manipulative treatment will shall be limited to:

1.

One (1) visit per day,

2.

Two (2) body regions per visit.

Each of the following is one body region: a.

The entire spine; b.

Head; c.

Two (2) upper extremities; d.

Two (2) lower extremities; e.

One (1) upper and one (1) lower extremity; f.

Rib cage; g.

Abdomen.

Spinal

Manipulation by a Physician

The entire spine shall be reimbursed as one (1) region for Workers’

Compensation even though there are five spinal (5) regions: a.

Cervical; b.

Thoracic; c.

Lumbar; d.

Sacral; and e.

Pelvic.

Reimbursement will shall be made to a physician for spinal manipulation when billed using procedure code 97260.






Manipulation of

Extra-Spinal

Regions

When manipulative treatment is performed by a physician on the: a.

Head region; b.

Lower extremities; c.

Upper extremities; d.

One upper and one lower extremity; e.

Rib cage and abdomen; and f.

Viscera region.

Reimbursement will shall be made when the service is billed using procedure code 97261.

Osteopathic

Manipulative

Treatment (OMT)

Reimbursement for osteopathic manipulative treatment (OMT) to the two (2) body regions, spinal and extra-spinal, listed in this Chapter will shall be made for procedure codes 98926 and 98928, respectively.

•

Reimbursement will shall be made for code 98926 when used to bill for a spinal manipulation. The spine will shall be reimbursed as one (1) region for Workers’ Compensation, although there are five (5) spinal regions (cervical; thoracic; lumbar; sacral; and pelvic).

•

Reimbursement will shall be made for procedure code 98928 when used for manipulation to the head region; lower extremities; upper extremities; one upper and one lower extremity; rib cage and abdomen; and viscera region.

Chiropractic

Manipulative

Treatment (CMT)

Chiropractic

Spinal

Manipulations

Reimbursement for CMT to two (2) regions, spinal and extra-spinal, listed in this section will shall be made when billed with procedure codes 98941 and

98943, respectively.

These manipulation procedure codes are specifically designated for chiropractic physicians.

Reimbursement will shall be made for procedure code 98941 when used to bill for a spinal manipulation. The spine shall be reimbursed as one (1) region for

Workers’ Compensation, although there are five (5) spinal regions: cervical region (includes atlanto-occipital joint); thoracic region (includes costovertebral and costo-transverse joints); lumbar region; sacral region; and pelvic

(sacroiliac joint) region.






Chiropractic

Extra-Spinal

Manipulations

Reimbursement will shall be made for procedure code 98943, when used to bill for a manipulation to an extra-spinal region: head (including temporomandibular joint, excluding atlanto-occipital); lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints); and abdomen.

Acupuncture


Reimbursement

Reimbursement

Requirements

Limitations

Reimbursement for acupuncture will shall be made to a physician or a recognized practitioner specifically licensed by the Florida Department of

Health to diagnose and treat with acupuncture.

•

Reimbursement for acupuncture or electro-acupuncture service is based on fifteen (15) minute increments of face-to-face contact with the patient during a session.

•

Each treatment session consists of only one (1) initial fifteen minute (15 minute) increment.

•

If additional time is required to be reported, use the appropriate add-on codes.

•

Reinsertion of the acupuncture needle(s) is required for the use of acupuncture add-on codes.

•

Reimbursement is limited to one visit per day.

•

Only one (1) initial acupuncture treatment procedure code may be billed per injured worker per visit.

Note : A provider may not bill the initial acupuncture with electrical stimulation and without electrical stimulation for the same visit.





Orthotics and Prosthetics

Reimbursement

Policies

Reimbursement

Orthotic Fitter and Orthotic

Fitter Assistant

All prosthetic or orthotic devices must be prescribed by the treating physician.

Reimbursement will shall only be made to a licensed orthotics, prosthetics, occupational therapist, or physical therapist for custom fabricated orthotic or prosthetic device(s) when they directly provide the service. If the licensed provider is employed by a Home Medical Equipment supplier, a Home Health

Agency, or any other employer, the bill is submitted by the employing party.

When billing, orthotics and prosthetics must be billed using HCPCS

®

Level II codes that specifically describe the device.

Prior written authorization by the carrier is a requirement for reimbursement of fabricated orthotics and prosthetics.

Reimbursement for orthotics and prosthetics will shall be By Report (BR).

Orthotic Fitters and orthotic fitter assistants may be reimbursed for services provided within the scope of their licensure that are prescribed by a licensed treating health care provider.

These services must shall be billed on the DWC-9 claim form using HCPCS

®

Level II codes that specifically describe the service or supply provided. The

DOH license number of the orthotic fitter or orthotic fitter assistant must be on the claim form in Field 33b.

If the licensed provider is employed by a Home Medical Equipment supplier,

Home Health Agency, or any other employer the bill is submitted by the employing party.





Tests and Measurements

General Policies &

Limitations

Billing

Reimbursement

Reimbursement to a provider will shall be limited to one (1) visit by an injured worker per thirty (30) calendar days for tests and measurements to a selected body area or number of areas unless a different interval is outlined in the patient’s plan of care. A variation to the standard limitation for tests and measurements must be ordered by the treating physician and authorized by the carrier.

Providers must shall bill using the Workers’ Compensation unique code 97752, specifically designated for both the manual and automated testing.

Reimbursement for tests and measurements must shall include a written report of the testing results.

Manual muscle testing procedure codes and range of motion procedure codes will shall not be reimbursed when reported separately with procedure code

97752.

Reimbursement will shall be made for range of motion measurements.





Physical Reconditioning Services


Reimbursement

Authorization

Reimbursement for physical reconditioning services will shall only be made to an authorized occupational therapist, physical therapist, or athletic trainer.

Physical

Reconditioning

Assessment

Reimbursement will shall only be made for carrier authorized physical reconditioning based on a signed order from the authorized treating physician.

Physical reconditioning services must shall be authorized by the carrier prior to initiation and must shall not begin any earlier than thirty (30) calendar days after the injured worker’s date of accident.

Reimbursement for a physical reconditioning assessment and written report will shall be determined from the number of hours reported by the provider to perform the assessment and the listed MRA.

Note : Reimbursement is limited to eight (8) hours.

•

Reimbursement will shall be made for Workers’ Compensation Unique codes 97850 and 97851, specifically designated for use in reporting a physical conditioning assessment.

•

Reimbursement will shall be made for procedure code 97850 only when it is used to bill for the initial hour of a physical reconditioning assessment.

•

Reimbursement will shall be made for procedure code 97851 only for each additional thirty (30) minutes of a physical reconditioning assessment subsequent to procedure code 97850.





Physical Reconditioning Program

General

Reimbursement

Guidelines

Billing Guidelines

Multiple

Therapies by the

Same Provider

Limitations

Reimbursement for a physical reconditioning program will shall be paid based on the number of hours billed by the provider and the listed MRA.

Note : Reimbursement will shall be limited to a program lasting no longer than sixty (60) hours during a six (6) week period, which includes a physical reconditioning assessment.

Reimbursement will shall be made for Workers’ Compensation Unique procedure codes 97852 and 97853, specifically designated for use in reporting a physical reconditioning program.

•

Reimbursement will shall be made for procedure code 97852 to bill the initial per hour session of physical reconditioning each day.

•

Reimbursement will shall be made for procedure code 97853 when used to bill each additional thirty (30) minutes per session of physical reconditioning each day.

Reimbursement will shall be made for a physical reconditioning program when the services are provided alone, along with, or subsequent to modalities and procedures by the same authorized occupational therapist or physical therapist.

Reimbursement will shall be made to a therapist or athletic trainer for only one

(1) physical reconditioning program for an injured worker per date of accident, unless specifically authorized by the carrier for an exacerbation of the injury or surgical intervention, as documented by the treating physician.

Note : Reimbursement for an extension of the program will shall be limited to reimbursement of an additional twenty (20) hours during a two (2) week period.





Interdisciplinary Rehabilitation Programs

Authorization All services must shall be authorized prior to initiation of services.

Reimbursement will shall only be made to a facility for carrier authorized interdisciplinary services based on a signed order from the authorized treating physician.

Exceptions to

Policies

Approval beyond the policies provided in this section must be obtained from the carrier, in writing, prior to a health care provider furnishing the service. The unusual circumstances must be documented and forwarded by the health care provider to the carrier for review before an exception to the policies can be considered and a determination made by the carrier to authorize additional services.

CARF

Accreditation

Requirements

Reimbursement for Interdisciplinary Rehabilitation Programs will shall only be made to rehabilitation programs accredited by the Commission on

Accreditation of Rehabilitation Facilities (CARF), except for a facility operating pursuant to Chapter 395, F.S., as part of a hospital.

Rehabilitation Program services must be provided through a CARF accredited Outpatient Medical Rehabilitation Program, Occupational

Rehabilitation Program or Interdisciplinary Pain Rehabilitation Program.

Work Hardening

Programs

Reimbursement for a work hardening program will shall be made to a facility for the duration of the recommended individualized program.

Procedure codes 97545 and 97546 are specifically designated to use exclusively in reporting the services of a work hardening program as follows:

•

Bill the initial two (2) hours of a work hardening program each day using procedure code 97545;

•

Bill each additional hour of a work hardening program each day using procedure code 97546.





Interdisciplinary Rehabilitation Programs, continued

Pain Programs Reimbursement for an interdisciplinary pain management program will shall be made to a facility for the recommended time indicated in the injured worker’s

Pain Program

Components program plan.

The services provided must relate to the physical, psychological, social, functional and vocational goals of the worker’s program plan.

Services billed must shall reflect these components in the documentation

Reimbursement for Pain Programs submitted to the carrier for reimbursement.

Reimbursement will shall be made for biofeedback; physical and rehabilitation medicine services; pharmacy services; psychological and psychiatric services and testing; musculoskeletal services tests and measurements; neuromuscular services tests and studies, and other medically necessary services during the course of the program.

Discharge from an

Interdisciplinary

Program

Discharge Report

The facility’s program director must shall determine if the injured worker will shall be discharged from the work hardening or pain program before completion. If the injured worker has not completed the program and program director recommends discontinuance of the program, the director will shall provide discharge information to the injured worker, the carrier and the treating physician without charge.

Upon program completion, a report shall be sent by the facility’s program director without charge to the treating physician and to the carrier with the final bill. The report will shall include:

•

The injured worker’s current clinical status and plan for transition from the program; and

•

Return to work recommendations.

Functional

Capacity

Evaluation (FCE)

Reimbursement for an authorized FCE will shall be made at any time in the clinical continuum, as long as the evaluation protocol matches the scope and specificity of the clinical situation and referral question(s).

Note : See Patient Classification System in Chapter 1 of this Manual





Interdisciplinary Rehabilitation Programs, continued


FCE

All FCE protocols must be evidence-based. Test design and written interpretation must, at a minimum, focus on identifying associated functional loss, limitations or restrictions and the correlation to work-related clinical dysfunction (i.e. correlate impairment with disability).

Note: Reimbursement will shall only be made when a physical therapist or occupational therapist is directly or actively involved with the testing protocol, although additional professional personnel may be involved as well.

Billing and

Reimbursement for FCE

The provider must shall provide written results of the evaluation and recommendations to the injured worker, the carrier and the treating physician without additional charge. The reimbursement for FCE includes a written program plan and a written report.

Note: The Workers’ Compensation unique procedure code 97750 is designated for billing a FCE using the DFS-F5-DWC-9 Form.





Surgical Services

General

Reimbursement

Information

Global Surgical

Package

General reimbursement information from an authoritative resource is used to determine any limitations or reductions from the MRAs in Chapter 3. All procedure codes having indicators for multiple surgery pricing rules, bilateral surgery pricing rules, assistant at surgery, co-surgeon, team surgery and information are found in an authoritative resource, such as the National

Physician Fee Schedule Relative Value File Resource-Based Relative Value

File, copyrighted by the American Medical Association. The Relative Value

File is available from the American Medical Association, 515 N. State Street,

Chicago, IL 60610 or by calling 1-800-621-8335. These indicators will shall be used to determine reimbursement by the Division.

Reimbursement for a surgical package (global reimbursement) will shall include the provision of certain services before and after surgery. Payment for these services will shall include:

•

The immediate preoperative visit;

•

Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia;

•

The surgical procedure;

•

Immediate postoperative care, including dictating operative notes, talking with the family and other physicians;

•

Writing orders;

•

Evaluating the patient in the post-anesthesia recovery area;

•

Typical postoperative follow-up care; and

•

The time period for routine follow-up care related to the surgical procedure is listed in the Follow-Up Days (FUD) column in

Chapter 3, Part B.

1.

Reimbursement for a procedure code with a ZZZ designation for the global period will shall be the same as the other procedure code that is billed in conjunction with this “add-on” procedure code.

2.

Reimbursement for a procedure code with a YYY designation in the global period will shall be set by the carrier.

Note : The maximum reimbursement allowance (MRA) to physicians for surgical procedures will shall be found in Chapter 3, Part B of this Manual.





Surgical Services, continued

Services Reimbursement will shall be made for other services in addition to the surgical

Reimbursed in

Addition to Global

Package package only in the following situations when:

•

The preoperative visit is the initial visit made by the provider, when prolonged detention or evaluation is necessary to prepare an injured worker for surgery and when there is a need to establish the reason for a particular type of surgery;

•

The preoperative visit is a consultation;

•

The preoperative services are not part of the usual preparation for the particular surgical procedure; and

•

The services are to treat complications, exacerbations, recurrences or other diseases and injuries. Documentation substantiating the medical necessity of the additional services rendered must shall be submitted with the medical bill.

Surgery

Performed During

Post-Op Period

Assistant Surgeon

Reimbursement for surgical services will shall be made when an additional surgery is performed during the postoperative period of another surgical procedure.

Reimbursement for normal postoperative care must shall run concurrently and must shall be made according to the separate FUD periods listed in Chapter 3, Part B unless it is a procedure code with the YYY designation. For theses codes, the FUD period will shall be set by the carrier.

Reimbursement for an assistant surgeon will shall be twenty-five percent (25%) of the physician reimbursement listed in the MRAs in Chapter 3, Part B of this

Manual. The services provided must shall be identified by appending the modifier

80 to the specific procedure code.





Surgical Services, continued

Non-Physician Reimbursement will shall be made to a non-physician surgical assistant for surgical

Surgical Assistants services. Non-physician surgical assistants include: physician assistants, advanced registered nurse practitioners and registered nurse first assistants.

Billing


Non-Physician

Surgical Assistants

The surgical procedure code(s) must be appended with the HCPCS

®

Level II modifier AS to identify services rendered by a non-physician surgical assistant at surgery.

Non-physician surgical assistants must follow the billing requirements in Chapter

69L-7, F.A.C.

The non-physician surgical assistant must provide his or her Florida DOH license number in Field 33b on the DWC-9 medical bill form.

Note : No reimbursement is made to non-physician surgical assistants

employed by hospitals.

Reimbursement for Non-Physician

Surgical Assistants

Reimbursement will shall be made for non-physician surgical assistants performing surgical services. Reimbursement will shall be seventy-five percent (75%) of twenty-five percent (25%) of the MRA listed in Chapter 3, Part B when the carrier has determined:

•

The non-physician meets state licensure requirements and holds current

Division Health Care Provider Certification, and

•

Written authorization to the non-physician surgical assistant was provided by the carrier prior to the surgery or,

•

During a medical emergency, a physician was not available to assist at surgery.

Procedure codes having indicators for multiple surgery pricing rules, bilateral surgery pricing rules, assistant at surgery, co-surgeon, team surgery and other information shall be utilized for determining reimbursement for all claims. These indicators will come from an authoritative resource, such as the National Physician

Fee Schedule Relative Value File, Resource-Based Relative Value File, copyrighted by the American Medical Association. The Relative Value File is available from the American Medical Association, 515 N. State Street, Chicago, IL

60610 or by calling 1-800-621-8335. These indicators will shall be used to determine reimbursement by the Division.





Surgical Services, continued

Two Surgeons Reimbursements will shall be made to two (2) surgeons at the same operative

Distinct Parts session for performing distinct parts of a surgical procedure.

The services provided must shall be identified by the same procedure code with modifier 62 appended.

Two Surgeons

Separate

Procedures

Reimbursement will shall be made to two surgeons for rendering

Reimbursement to each surgeon will shall be:

•

The listed MRA in Chapter 3; Part B; or

•

The agreed upon contract price. separate surgical procedures during the same operative session. The services must shall be identified by billing different, unmodified procedure codes.

Surgical Team

Note : Reimbursement will not be made to either surgeon until the carrier has received and reviewed each surgeon’s bill and individual operative reports.

Reimbursement for a surgical team will shall be made By Report (BR) to each team member for each surgeon’s surgical service.

Each team member must shall identify the specific procedure they provided by appending modifier 66 to the procedure code(s) billed.

Note : Reimbursement will not be made until all surgical bills and individual operative reports are received and reviewed by the carrier.






Billing and

Reimbursement for Multiple

Surgical

Procedures

Billing and

Reimbursement for Procedures

Listed as Bilateral

Reimbursement will shall be made for all medically necessary surgical procedures when more than one (1) procedure is performed at a single operative session.

•

Each procedure performed must shall be identified by use of the appropriate five-digit CPT

®

code and listed separately.

•

The primary, or most significant procedure, must shall be reported first.

•

Each additional procedure code must shall be listed separately and reported with a modifier 51.

Reimbursement for the primary surgical procedure will shall be the MRA listed in

Chapter 3, Part B of this Manual or the agreed upon contract price.

Reimbursement for additional procedure(s) will shall be fifty percent (50%) of the listed MRA in Chapter 3, Part B of this Manual or the agreed upon contract price.

Note : Designated add-on procedure codes, listed in the CPT

®

Manual are exempt from modifier 51 billing and the multiple surgery pricing reduction rules. Add-on procedure codes must shall not be billed with a modifier 51.

Add-on procedure codes must shall be billed immediately following their primary procedure codes for proper identification and reimbursement.

Note : If there is an agreed upon contract between the health care provider and the carrier, the contract establishes the reimbursement at a specified contract price.

Bilateral procedures that are listed as “bilateral” in the CPT

®

description are exempt from modifier 50.

Bill using the five digit procedure code only.

Reimbursement will shall be:

•

The MRA listed in Chapter 3, Part B in this Manual; or

•

The agreed upon contract price.






Billing and

Reimbursement for Bilateral

Procedures Not

Listed as Bilateral

Procedures performed bilaterally that do not contain the word “bilateral” in CPT

® require a modifier to identify they are performed bilaterally for proper reimbursement. Bill the five digit procedure code on one line only using modifier

50.

Reimbursement for a bilateral procedure that does not include the word “bilateral” in the description will shall only be made when the payment policy indicators from an authoritative resource, such as the National Physician Fee Schedule Relative

Value File, allows bilateral reimbursement.

If the payment policy indicator allows bilateral reimbursement, the maximum reimbursement amount will shall be:

•

One hundred and fifty percent (150%) of the MRA, unless otherwise stated in this Manual; or

•

The agreed upon contract price.






Bilateral Procedures with Multiple Surgery

•

Bill the first procedure code on the first line using no modifier 51;

•

Bill additional procedure(s) using modifier 51 to indicate multiple procedures performed during the same operative session; and

•

For the bilateral procedure(s), use modifier 50 in the first modifier position followed by modifier 51 in the second modifier position, where appropriate.

Note : Add-on procedure codes, listed in the CPT

®

Manual, are exempt from modifier 51 billing and from the multiple surgery pricing reduction rules.

Add-on procedure codes must shall not be billed with a modifier 51.

Bilateral Procedures

Performed Unilaterally

Procedures

When a procedure is listed in the CPT

®

as a bilateral-procedure, but, it is performed only unilaterally, the procedure must shall be identified with a modifier 52.

Reimbursement will shall be fifty percent (50%) of:

•

The MRA listed in Chapter 3, Part B; or

•

The agreed upon contract amount for a bilateral procedure.

Terminated Procedures A bill submitted for reimbursement of a terminated surgery must include documentation that specifies the following:

1.

Reason for termination of surgery;

2.

Services, reported by CPT

®

3.

Services, reported by CPT

®

code, that were actually performed;

code, not performed that would have been performed if surgery had not been terminated;

4.

Supplies actually provided;

5.

Supplies not provided that would have been provided if the surgery had not been terminated;

6.

Time actually spent by the health care provider in each stage, e.g. pre-operative, operative, and post-operative;

7.

Time that would have been spent in each of these stages if the surgery had not been terminated; and

8.

Modifier 53 must be added to the procedure codes to identify the circumstances under which the services were terminated.






Reimbursement for

Terminated Procedures

Modifier 51 Exempt

Terminated Procedures will shall be reimbursed as follows:

•

No reimbursement will shall be made for a procedure that is terminated either for medical or non-medical reasons before the preoperative procedures are initiated by staff.

•

Reimbursement will shall be fifty percent (50%) of the amount allowed for the procedure(s), according to the policies in this

Manual, if a procedure is terminated due to the onset of medical complications after the patient has been taken to the operating suite, but before anesthesia has been induced.

•

Payment will shall be fifty percent (50%) of the amount allowed for the procedure(s), according to policies in this Manual, if a medical complication arises which causes the procedure to be terminated after induction of anesthesia.

A procedure code that is “Modifier 51 Exempt” is a HCPCS or CPT

® code typically performed with another procedure. These procedure codes are summarized, but not completely identified, in the CPT codebook incorporated by reference in Rule 69L-8.074, F.A.C.

“Modifier 51 Exempt” procedure codes do not require modifier 51 in Field

24d on DFS-F5-DWC-9 Claim Form and are reimbursed at 100% of the

Maximum Reimbursement Allowance (MRA).




THIS PAGE LEFT INTENTIONALLY BLANK




Chapter 3 Maximum Reimbursement Allowances

General Instructions

Part A

Part B

This chapter establishes the Maximum Reimbursement Allowances (MRAs) for services and procedures performed by workers’ compensation providers of this manual and for out-of-state providers who have not contracted with the carrier for an alternate reimbursement.

Part A establishes the Maximum Reimbursement Allowances (MRAs) for services and procedures performed by workers’ compensation providers not specifically addressed in this Manual and for out-of-state providers who have not contracted with the carrier for an alternate reimbursement.

Part A also includes the basic value (or base unit) on which reimbursement shall be calculated for all anesthesia services according to this Manual.

Part B establishes the Maximum Reimbursement Allowances (MRAs) for

Florida physician providers of surgical procedures and services. Physician assistants and advanced registered nurse practitioners will shall be paid eighty-five percent (85%) of the physician’s MRA when these nonphysician providers directly perform the surgical procedure or service.

Part C Part C establishes the Maximum Reimbursement Allowances (MRAs) for

Florida physicians, physical and occupational therapists, athletic trainers, audiologists, speech pathologists, and psychologist providers of non-surgical procedures and services. Physician assistants and advanced registered nurse practitioners will shall be paid eighty-five percent (85%) of the physician’s

MRA when these non-physician providers directly perform a non-surgical procedure or service.

Part C also establishes the MRAs for independent clinical laboratories, freestanding imaging/x-ray centers, dietitians, nutritionists, nutrition counselors and clinical social workers.

2015 Edition Page 68 Effective Date: ____________

Chapter 3 Maximum Reimbursement Allowances, continued

To determine the MRA to which a provider is entitled under Part B or Part C:

Determining the MRA A.

Determine the county location of the provider according to the

Medicare locality map in Appendix C.

B.

Determine whether the procedure should be paid according to the nonfacility MRA (services rendered in a provider’s office, urgent care center, diagnostic facility, nursing home, home health agency or home) or the facility MRA (services rendered in a hospital setting, ambulatory surgical center, skilled nursing facility, inpatient psychiatric facility, or comprehensive [Level III] outpatient rehabilitation facility).

C.

Identify the specific CPT

®

code in the far left column of the matrix and the correct locality/non-facility or facility column across the top row.

D.

Locate the point of intersection for the procedure code row and the appropriate non-facility or facility locality column on the reimbursement matrix.

E.

Compare the amount allowed at the point of intersection on the matrix to the amount listed in the 2003 column.

F.

Reimburse the provider the greater of the amount in the 2003 MRA column or the amount in the column at the point of intersection.



PART A

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

20165 Edition Page 70 Effective Date: __________

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2016 Edition

RULE- 69L-7.020, F.A.C., Effective ___________

00350

00352

00400

00402

00404

00406

00410

00450

00454

00470

00472

00210

00211

00212

00214

00215

00216

00218

00220

00222

00300

00320

00322

00474

00500

00520

00522

00524

00145

00147

00148

00160

00162

00164

00170

00172

00174

00176

00190

00192

Anesthesia

CPT Code BV + TM

00100 5 + TM

00102

00103

00104

6 + TM

5 + TM

4 + TM

00120

00124

00126

00140

00142

00144

5 + TM

4 + TM

4 + TM

5 + TM

4 + TM

6 + TM

6 + TM

6 + TM

4 + TM

5 + TM

7 + TM

4 + TM

5 + TM

6 + TM

6 + TM

7 + TM

5 + TM

7 + TM

10 + TM

5 + TM

3 + TM

5 + TM

5 + TM

13 + TM

4 + TM

5 + TM

3 + TM

6 + TM

10 + TM

11 + TM

10 + TM

5 + TM

9 + TM

9 + TM

15 + TM

13 + TM

10 + TM

6 + TM

5 + TM

6 + TM

3 + TM

13 + TM

15 + TM

6 + TM

4 + TM

4 + TM

Anesthesia

CPT Code BV + TM

00528 8 + TM

00529

00530

00532

00534

00537

00539

00540

00541

00542

00546

00548

00550

00560

00562

00563

00566

00567

00580

00600

00604

00620

00625

00626

00630

00632

00635

00640

00670

00700

00702

00730

00740

00750

00752

00754

00756

00770

00790

00792

00794

00796

00797

00800

00802

00810

00820

00830

00832

00840

11 + TM

4 + TM

4 + TM

7 + TM

10 + TM

18 + TM

12 + TM

15 + TM

15 + TM

15 + TM

17 + TM

10 + TM

15 + TM

20 + TM

25 + TM

25 + TM

18 + TM

20 + TM

10 + TM

13 + TM

10 + TM

13 + TM

15 + TM

8 + TM

7 + TM

4 + TM

3 + TM

13 + TM

4 + TM

4 + TM

5 + TM

5 + TM

4 + TM

6 + TM

7 + TM

7 + TM

15 + TM

7 + TM

13 + TM

8 + TM

30 + TM

11 + TM

4 + TM

5 + TM

5 + TM

5 + TM

4 + TM

6 + TM

6 + TM

00936

00938

00940

00942

00944

00948

00950

00952

01112

01120

01130

00914

00916

00918

00920

00921

00922

00924

00926

00928

00930

00932

00934

01140

01150

01160

01170

01173

00868

00870

00872

00873

00880

00882

00902

00904

00906

00908

00910

00912

Anesthesia

CPT Code BV + TM

00842 4 + TM

00844

00846

00848

7 + TM

8 + TM

8 + TM

00851

00860

00862

00864

00865

00866

6 + TM

6 + TM

7 + TM

8 + TM

7 + TM

10 + TM

10 + TM

5 + TM

7 + TM

5 + TM

15 + TM

10 + TM

5 + TM

7 + TM

4 + TM

6 + TM

3 + TM

5 + TM

8 + TM

4 + TM

3 + TM

4 + TM

6 + TM

4 + TM

5 + TM

4 + TM

5 + TM

6 + TM

3 + TM

5 + TM

5 + TM

5 + TM

3 + TM

3 + TM

6 + TM

4 + TM

4 + TM

6 + TM

4 + TM

4 + TM

6 + TM

15 + TM

10 + TM

4 + TM

8 + TM

12 + TM

CPT only © 2015 American Medical Association. All Rights Reserved.

PartA, 71



01232

01234

01250

01260

01270

01272

01274

01320

01340

01360

01380

01382

Anesthesia

CPT Code BV + TM

01180 3 + TM

01190

01200

01202

4 + TM

4 + TM

4 + TM

01210

01212

01214

01215

01220

01230

6 + TM

10 + TM

8 + TM

10 + TM

4 + TM

6 + TM

5 + TM

8 + TM

4 + TM

3 + TM

8 + TM

4 + TM

6 + TM

4 + TM

4 + TM

5 + TM

3 + TM

3 + TM

3 + TM

3 + TM

5 + TM

5 + TM

3 + TM

4 + TM

4 + TM

7 + TM

3 + TM

8 + TM

6 + TM

3 + TM

3 + TM

4 + TM

4 + TM

7 + TM

5 + TM

3 + TM

3 + TM

6 + TM

8 + TM

8 + TM

8 + TM

3 + TM

5 + TM

5 + TM

4 + TM

4 + TM

01464

01470

01472

01474

01480

01482

01484

01486

01490

01500

01502

01520

01390

01392

01400

01402

01404

01420

01430

01432

01440

01442

01444

01462

01522

01610

01620

01622

Anesthesia

CPT Code BV + TM

01630 5 + TM

01634

01636

01638

9 + TM

15 + TM

10 + TM

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

01860

01916

01920

01922

01924

01925

01926

01930

01931

01932

01933

01935

01936

6 + TM

10 + TM

8 + TM

10 + TM

4 + TM

3 + TM

4 + TM

3 + TM

5 + TM

5 + TM

5 + TM

3 + TM

3 + TM

4 + TM

5 + TM

5 + TM

6 + TM

5 + TM

7 + TM

6 + TM

6 + TM

3 + TM

4 + TM

3 + TM

3 + TM

3 + TM

3 + TM

6 + TM

6 + TM

6 + TM

6 + TM

3 + TM

4 + TM

3 + TM

5 + TM

7 + TM

7 + TM

6 + TM

8 + TM

10 + TM

5 + TM

7 + TM

7 + TM

8 + TM

5 + TM

5 + TM

Anesthesia

CPT Code BV + TM

01951 3 + TM

01952

01953

01960

5 + TM

1 + TM

5 + TM

01961

01962

01963

01967

01968

01969

7 + TM

8 + TM

10 + TM

5 + TM

3 + TM

5 + TM

01990

01991

01992

01996

01999

0

3 + TM

5 + TM

3

BR


PartA, 72

11056

11057

11100

11101

11200

11201

11300

11301

11302

11303

11305

11306

11307

11308

11006

11008

11010

11011

11012

11042

11043

11044

11045

11046

11047

11055

11310

11311

11312

11313

11400

10061

10080

10081

10120

10121

10140

10160

10180

11000

11001

11004

11005



Surgery

CPT Code

10021

MRA

$90.00

FUD

0

Surgery

CPT Code

11401

MRA

$114.00

FUD

10

Surgery

CPT Code

11760

MRA

$131.00

10022

10030

10035

10036

10040

10060

$92.00

$791.00

$544.00

$473.00

$54.00

$53.00

0

0

0

ZZZ

10

10

11402

11403

11404

11406

11420

11421

$145.00

$178.00

$200.00

$246.00

$98.00

$92.00

10

10

10

10

10

10

11762

11765

11770

11771

11772

11900

$223.00

$65.00

$275.00

$496.00

$585.00

$33.00

$133.00

$65.00

$203.00

$53.00

$169.00

$53.00

$45.00

$164.00

$45.00

$27.00

$564.00

$768.00

10

10

10

10

10

10

10

10

0

ZZZ

0

0

11422

11423

11424

11426

11440

11441

11442

11443

11444

11446

11450

11451

$157.00

$163.00

$221.00

$303.00

$105.00

$102.00

$174.00

$221.00

$276.00

$344.00

$282.00

$366.00

10

10

10

10

10

10

10

10

10

10

90

90

11901

11920

11921

11922

11950

11951

11952

11954

11960

11970

11971

11976

$37.00

$147.00

$172.00

$40.00

$107.00

$114.00

$155.00

$165.00

$829.00

$632.00

$280.00

$123.00

$35.00

$39.00

$78.00

$41.00

$66.00

$26.00

$59.00

$80.00

$96.00

$119.00

$61.00

$86.00

$100.00

$125.00

$710.00

$289.00

$348.00

$432.00

$597.00

$88.00

$210.00

$283.00

$43.00

$75.00

$127.00

$26.00

$75.00

$95.00

$110.00

$144.00

$81.00

0

ZZZ

10

0

0

0

0

0

ZZZ

ZZZ

ZZZ

0

0

0

0

ZZZ

10

ZZZ

0

0

0

0

0

0

0

0

0

0

0

0

10

11462

11463

11470

11471

11600

11601

11602

11603

11604

11606

11620

11621

11622

11623

11624

11626

11640

11641

11642

11643

11644

11646

11719

11720

11721

11730

11732

11740

11750

11752

11755

$264.00

$351.00

$320.00

$391.00

$148.00

$180.00

$199.00

$226.00

$249.00

$315.00

$150.00

$191.00

$223.00

$259.00

$305.00

$373.00

$168.00

$227.00

$260.00

$305.00

$380.00

$494.00

$22.00

$32.00

$50.00

$62.00

$31.00

$41.00

$156.00

$234.00

$106.00

90

90

90

90

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

0

0

0

0

ZZZ

0

10

10

0

12018

12020

12021

12031

12032

12034

12035

12036

12037

12041

12042

12044

12045

12046

12001

12002

12004

12005

12006

12007

12011

12013

12014

12015

12016

12017

12047

12051

12052

12053

12054

$515.00

$211.00

$87.00

$93.00

$110.00

$148.00

$223.00

$356.00

$411.00

$116.00

$141.00

$176.00

$250.00

$341.00

$84.00

$98.00

$122.00

$165.00

$203.00

$339.00

$98.00

$141.00

$165.00

$207.00

$268.00

$316.00

$363.00

$126.00

$148.00

$223.00

$301.00

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

0

10

10

0

0

0

0

0

0

0

0

0

0

0

0

90

90

0

ZZZ

0

0

0

0

90

0

0

0

90

90

0

FUD

10

10

10

10


Part A, 73

15040

15050

15100

15101

15110

15111

15115

15116

15120

15121

15130

15131

15135

15136

14021

14040

14041

14060

14061

14301

14302

14350

15002

15003

15004

15005

15150

15151

15152

15155

15156

13121

13122

13131

13132

13133

13151

13152

13153

13160

14000

14001

14020



Surgery

CPT Code

12055

MRA

$380.00

FUD

10

Surgery

CPT Code

15157

MRA

$196.00

FUD

ZZZ

Surgery

CPT Code

15793

MRA

$232.00

12056

12057

13100

13101

13102

13120

$487.00

$539.00

$178.00

$240.00

$89.00

$223.00

10

10

10

10

ZZZ

10

15200

15201

15220

15221

15240

15241

$644.00

$126.00

$687.00

$114.00

$763.00

$334.00

90

ZZZ

90

ZZZ

90

ZZZ

15819

15820

15821

15822

15823

15824

$780.00

$556.00

$607.00

$499.00

$718.00

BR

$348.00

$104.00

$252.00

$484.00

$154.00

$375.00

$542.00

$169.00

$655.00

$512.00

$695.00

$590.00

10

ZZZ

10

10

ZZZ

10

10

ZZZ

90

90

90

90

15260

15261

15271

15272

15273

15274

15275

15276

15277

15278

15570

15572

$841.00

$207.00

$143.00

$27.00

$299.00

$70.00

$155.00

$35.00

$320.00

$83.00

$748.00

$721.00

90

ZZZ

0

ZZZ

0

ZZZ

0

ZZZ

0

ZZZ

90

90

15825

15826

15828

15829

15830

15832

15833

15834

15835

15836

15837

15838

BR

BR

BR

BR

$1,072.00

$926.00

$833.00

$837.00

$865.00

$721.00

$696.00

$600.00

$258.00

$349.00

$679.00

$146.00

$815.00

$129.00

$766.00

$167.00

$788.00

$235.00

$677.00

$105.00

$820.00

$98.00

$818.00

$701.00

$936.00

$766.00

$1,330.00

$1,088.00

$228.00

$734.00

$351.00

$77.00

$407.00

$127.00

$677.00

$136.00

$167.00

$678.00

$177.00

90

90

90

90

90

90

ZZZ

90

0

ZZZ

0

ZZZ

0

90

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

ZZZ

90

ZZZ

15574

15576

15600

15610

15620

15630

15650

15731

15732

15734

15736

15738

15740

15750

15756

15757

15758

15760

15770

15775

15776

15777

15780

15781

15782

15783

15786

15787

15788

15789

15792

$775.00

$457.00

$259.00

$320.00

$506.00

$362.00

$427.00

$990.00

$1,465.00

$1,557.00

$1,862.00

$1,415.00

$913.00

$1,064.00

$2,892.00

$2,892.00

$2,884.00

$810.00

$674.00

$327.00

$475.00

$219.00

$532.00

$420.00

$314.00

$340.00

$146.00

$27.00

$194.00

$360.00

$130.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

0

0

ZZZ

90

90

90

90

10

ZZZ

90

90

90

15879

15920

15922

15931

15933

15934

15935

15936

15937

15940

15941

15944

15945

15946

15839

15840

15841

15842

15845

15850

15851

15852

15860

15876

15877

15878

15950

15951

15952

15953

15956

BR

$571.00

$771.00

$638.00

$860.00

$1,064.00

$1,184.00

$1,032.00

$1,223.00

$318.00

$919.00

$954.00

$1,078.00

$1,737.00

$643.00

$1,187.00

$1,859.00

$3,099.00

$1,116.00

$63.00

$40.00

$35.00

$151.00

BR

BR

BR

$549.00

$872.00

$876.00

$1,013.00

$1,382.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

0

90

90

0

0

0

0

0

0

90

90

0

90

90

90

90

90

90

0

90

90

90

90

90

0

0

0

90

90

0

FUD

90

90

90

90


Part A, 74

17282

17283

17284

17286

17311

17312

17313

17314

17315

17340

17360

17380

17999

19000

17262

17263

17264

17266

17270

17271

17272

17273

17274

17276

17280

17281

19001

19020

19030

19081

19082

16036

17000

17003

17004

17106

17107

17108

17110

17111

17250

17260

17261



Surgery

CPT Code

15958

MRA

$1,379.00

FUD

90

Surgery

CPT Code

19083

MRA

$677.00

FUD

0

Surgery

CPT Code

19369

MRA

$2,317.00

15999

16000

16020

16025

16030

16035

BR

$53.00

$49.00

$67.00

$153.00

$341.00

YYY

0

0

0

0

0

19084

19085

19086

19100

19101

19105

$543.00

$1,025.00

$817.00

$117.00

$338.00

$1,878.00

ZZZ

0

ZZZ

0

10

0

19370

19371

19380

19396

19499

20005

$662.00

$788.00

$780.00

$231.00

BR

$267.00

$81.00

$60.00

$16.00

$233.00

$341.00

$648.00

$1,015.00

$55.00

$83.00

$27.00

$96.00

$117.00

ZZZ

10

ZZZ

10

90

90

90

10

10

0

10

10

19110

19112

19120

19125

19126

19260

19271

19272

19281

19282

19283

19284

$406.00

$354.00

$429.00

$468.00

$201.00

$1,101.00

$1,561.00

$1,674.00

$246.00

$171.00

$279.00

$205.00

90

90

90

90

ZZZ

90

90

90

0

ZZZ

0

ZZZ

20100

20101

20102

20103

20150

20200

20205

20206

20220

20225

20240

20245

$727.00

$261.00

$314.00

$405.00

$1,141.00

$134.00

$243.00

$119.00

$128.00

$215.00

$279.00

$364.00

$194.00

$239.00

$282.00

$373.00

$629.00

$380.00

$575.00

$352.00

$74.00

$37.00

$96.00

BR

BR

$74.00

$150.00

$172.00

$189.00

$225.00

$125.00

$143.00

$170.00

$195.00

$240.00

$281.00

$123.00

$165.00

$40.00

$288.00

$98.00

$682.00

$551.00

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

0

ZZZ

0

ZZZ

ZZZ

10

10

0

YYY

0

ZZZ

90

0

0

ZZZ

19285

19286

19287

19288

19296

19297

19298

19300

19301

19302

19303

19304

19305

19306

19307

19316

19318

19324

19325

19328

19330

19340

19342

19350

19355

19357

19361

19364

19366

19367

19368

$472.00

$396.00

$875.00

$696.00

$4,903.00

$96.00

$1,841.00

$482.00

$367.00

$780.00

$788.00

$487.00

$964.00

$1,003.00

$1,008.00

$954.00

$1,313.00

$440.00

$656.00

$457.00

$569.00

$545.00

$963.00

$853.00

$755.00

$1,449.00

$1,667.00

$2,737.00

$1,676.00

$2,056.00

$2,444.00

0

ZZZ

0

ZZZ

0

ZZZ

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

20555

20600

20604

20605

20606

20610

20611

20612

20615

20650

20660

20661

20662

20663

20250

20251

20500

20501

20520

20525

20526

20527

20550

20551

20552

20553

20665

20670

20680

20690

20692

$301.00

$41.00

$73.00

$48.00

$81.00

$49.00

$93.00

$56.00

$94.00

$170.00

$320.00

$476.00

$559.00

$465.00

$447.00

$511.00

$59.00

$60.00

$75.00

$331.00

$64.00

$84.00

$40.00

$62.00

$62.00

$62.00

$105.00

$80.00

$332.00

$298.00

$516.00

10

0

90

90

90

0

0

10

0

0

0

10

10

90

90

90

0

0

0

0

0

0

0

0

0

0

10

10

0

0

10

10

10

10

0

0

0

10

90

0

FUD

90

90

90

90

0

YYY

10

10

10

10


Part A, 75

20970

20972

20973

20974

20975

20979

20982

20983

20985

20999

21010

21011

21012

21013

20926

20930

20931

20936

20937

20938

20950

20955

20956

20957

20962

20969

21014

21015

21016

21025

21026

20816

20822

20824

20827

20838

20900

20902

20910

20912

20920

20922

20924



Surgery

CPT Code

20693

MRA

$477.00

FUD

90

Surgery

CPT Code

21029

MRA

$700.00

FUD

90

Surgery

CPT Code

21155

MRA

$2,640.00

20694

20696

20697

20802

20805

20808

$421.00

$1,156.00

$1,860.00

$3,363.00

$4,317.00

$5,324.00

90

90

0

90

90

90

21030

21031

21032

21034

21040

21044

$496.00

$310.00

$315.00

$1,140.00

$227.00

$957.00

90

90

90

90

90

90

21159

21160

21172

21175

21179

21180

$3,302.00

$3,500.00

$2,111.00

$2,604.00

$1,826.00

$2,035.00

$3,060.00

$2,511.00

$3,027.00

$3,920.00

$3,484.00

$454.00

$658.00

$338.00

$549.00

$460.00

$634.00

$583.00

90

90

90

90

90

0

0

90

90

90

90

90

21045

21046

21047

21048

21049

21050

21060

21070

21073

21076

21077

21079

$1,313.00

$899.00

$1,109.00

$925.00

$1,051.00

$1,026.00

$972.00

$679.00

$337.00

$1,192.00

$3,002.00

$2,086.00

90

90

90

90

90

90

90

90

90

10

90

90

21181

21182

21183

21184

21188

21193

21194

21195

21196

21198

21199

21206

$813.00

$2,570.00

$2,770.00

$3,150.00

$1,786.00

$1,331.00

$1,540.00

$1,360.00

$1,764.00

$1,268.00

$1,018.00

$1,112.00

$3,650.00

$3,420.00

$3,821.00

$266.00

$334.00

$19.00

$4,231.00

$7,394.00

$140.00

BR

$854.00

$349.00

$341.00

$521.00

$444.00

BR

$156.00

BR

$234.00

$257.00

$123.00

$3,332.00

$3,167.00

$3,074.00

$3,122.00

$3,716.00

$528.00

$520.00

$1,063.00

$546.00

$413.00

90

0

ZZZ

0

ZZZ

ZZZ

0

90

90

90

90

90

90

90

90

0

0

0

0

0

ZZZ

YYY

90

90

90

90

90

90

90

90

90

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

$2,346.00

$2,138.00

$1,855.00

$1,802.00

$2,105.00

$801.00

$2,333.00

$2,217.00

BR

BR

$297.00

$371.00

$207.00

$500.00

$651.00

$700.00

$903.00

$656.00

$909.00

$797.00

$960.00

$1,168.00

$1,438.00

$1,527.00

$1,511.00

$1,513.00

$1,570.00

$1,639.00

$1,914.00

$2,264.00

$2,364.00

90

90

90

90

90

10

90

90

90

YYY

90

90

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

21247

21248

21249

21255

21256

21260

21261

21263

21267

21268

21270

21275

21280

21282

21208

21209

21210

21215

21230

21235

21240

21242

21243

21244

21245

21246

21295

21296

21299

21310

21315

$2,003.00

$1,023.00

$1,525.00

$1,459.00

$1,470.00

$1,372.00

$2,347.00

$2,361.00

$1,539.00

$1,946.00

$890.00

$963.00

$571.00

$360.00

$946.00

$576.00

$930.00

$970.00

$956.00

$707.00

$1,281.00

$1,207.00

$1,501.00

$1,062.00

$1,038.00

$1,010.00

$144.00

$384.00

BR

$81.00

$180.00

90

90

90

90

90

90

90

90

90

90

90

90

90

YYY

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

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 76

21422

21423

21431

21432

21433

21435

21436

21440

21445

21450

21451

21452

21453

21454

21366

21385

21386

21387

21390

21395

21400

21401

21406

21407

21408

21421

21461

21462

21465

21470

21480

21339

21340

21343

21344

21345

21346

21347

21348

21355

21356

21360

21365



Surgery

CPT Code

21320

MRA

$235.00

FUD

10

Surgery

CPT Code

21485

MRA

$318.00

FUD

90

Surgery

CPT Code

22102

MRA

$781.00

21325

21330

21335

21336

21337

21338

$348.00

$639.00

$852.00

$478.00

$300.00

$550.00

90

90

90

90

90

90

21490

21495

21497

21499

21501

21502

$865.00

$500.00

$372.00

BR

$315.00

$612.00

90

90

90

YYY

90

90

22103

22110

22112

22114

22116

22206

$198.00

$889.00

$1,090.00

$1,062.00

$195.00

$2,153.00

$689.00

$907.00

$1,043.00

$1,450.00

$738.00

$917.00

$1,048.00

$1,286.00

$295.00

$372.00

$590.00

$1,239.00

90

90

90

90

90

90

90

90

10

10

90

90

21510

21550

21552

21554

21555

21556

21557

21558

21600

21610

21615

21616

$534.00

$165.00

$453.00

$744.00

$337.00

$431.00

$794.00

$1,380.00

$631.00

$828.00

$938.00

$1,042.00

90

10

90

90

90

90

90

90

90

90

90

90

22207

22208

22210

22212

22214

22216

22220

22222

22224

22226

22305

22310

$2,126.00

$545.00

$1,892.00

$1,668.00

$819.00

$492.00

$1,801.00

$1,604.00

$1,731.00

$488.00

$213.00

$272.00

$761.00

$890.00

$598.00

$744.00

$1,981.00

$1,404.00

$2,045.00

$308.00

$533.00

$325.00

$498.00

$195.00

$902.00

$905.00

$1,386.00

$810.00

$812.00

$958.00

$920.00

$1,384.00

$143.00

$313.00

$852.00

$736.00

$1,007.00

$528.00

$769.00

$1,012.00

$923.00

$1,331.00

$82.00

90

90

90

90

90

90

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

21620

21627

21630

21632

21685

21700

21705

21720

21725

21740

21742

21743

21750

21811

21812

21813

21820

21825

21899

21920

21925

21930

21931

21932

21933

21935

21936

22010

22015

22100

22101

$689.00

$686.00

$1,455.00

$1,514.00

$918.00

$576.00

$746.00

$523.00

$588.00

$1,387.00

BR

BR

$1,009.00

$634.00

$761.00

$992.00

$143.00

$810.00

BR

$165.00

$371.00

$403.00

$478.00

$672.00

$749.00

$1,280.00

$1,442.00

$822.00

$815.00

$850.00

$862.00

90

90

90

90

90

90

90

90

90

90

90

90

90

0

0

0

90

90

YYY

10

90

90

90

90

90

90

90

90

90

90

90

22514

22515

22526

22527

22532

22533

22534

22548

22551

22552

22554

22556

22558

22585

22315

22318

22319

22325

22326

22327

22328

22505

22510

22511

22512

22513

22586

22590

22595

22600

22610

$7,462.00

$4,518.00

$2,013.00

$1,637.00

$1,618.00

$1,509.00

$381.00

$2,271.00

$1,759.00

$406.00

$1,727.00

$2,054.00

$1,907.00

$473.00

$711.00

$1,755.00

$1,983.00

$1,407.00

$1,710.00

$1,660.00

$391.00

$174.00

$1,804.00

$1,786.00

$1,001.00

$7,471.00

$1,926.00

$1,895.00

$1,960.00

$1,567.00

$1,494.00

ZZZ

90

90

90

ZZZ

ZZZ

90

90

ZZZ

90

90

90

90

90

90

90

10

ZZZ

10

10

ZZZ

10

90

90

90

ZZZ

10

10

ZZZ

90

90

90

90

90

90

90

ZZZ

90

90

90

FUD

90

ZZZ

90

90

90

ZZZ

90

90

ZZZ

90


Part A, 77

22858

22861

22862

22864

22865

22899

22900

22901

22902

22903

22904

22905

22999

23000

22844

22845

22846

22847

22848

22849

22850

22851

22852

22855

22856

22857

23020

23030

23031

23035

23040

22802

22804

22808

22810

22812

22818

22819

22830

22840

22841

22842

22843



Surgery

CPT Code

22612

MRA

$1,861.00

FUD

90

Surgery

CPT Code

23044

MRA

$708.00

FUD

90

Surgery

CPT Code

23450

MRA

$1,210.00

22614

22630

22632

22633

22634

22800

$530.00

$1,201.00

$442.00

$1,894.00

$511.00

$1,960.00

ZZZ

90

ZZZ

90

ZZZ

90

23065

23066

23071

23073

23075

23076

$171.00

$302.00

$426.00

$705.00

$247.00

$613.00

10

90

90

90

90

90

23455

23460

23462

23465

23466

23470

$1,340.00

$1,364.00

$1,383.00

$1,398.00

$1,332.00

$1,540.00

$2,633.00

$2,951.00

$2,157.00

$2,356.00

$2,675.00

$2,701.00

$2,968.00

$1,176.00

$943.00

BR

$2,352.00

$1,028.00

90

90

90

90

90

90

90

90

ZZZ

0

ZZZ

ZZZ

23077

23078

23100

23101

23105

23106

23107

23120

23125

23130

23140

23145

$1,228.00

$1,476.00

$616.00

$583.00

$814.00

$581.00

$851.00

$645.00

$865.00

$722.00

$597.00

$889.00

90

90

90

90

90

90

90

90

90

90

90

90

23472

23473

23474

23480

23485

23490

23491

23500

23505

23515

23520

23525

$1,570.00

$1,672.00

$1,807.00

$926.00

$1,181.00

$1,038.00

$1,251.00

$148.00

$293.00

$688.00

$205.00

$320.00

$527.00

$2,262.00

$1,690.00

$2,035.00

$1,646.00

BR

$446.00

$673.00

$436.00

$440.00

$1,069.00

$1,362.00

BR

$447.00

$1,277.00

$1,853.00

$999.00

$1,077.00

$529.00

$2,235.00

$872.00

$600.00

$854.00

$1,193.00

$1,701.00

$1,386.00

$807.00

$323.00

$185.00

$861.00

$898.00

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

90

90

ZZZ

90

90

90

90

ZZZ

90

90

90

90

YYY

90

90

90

90

90

90

YYY

90

90

10

10

90

90

23146

23150

23155

23156

23170

23172

23174

23180

23182

23184

23190

23195

23200

23210

23220

23330

23333

23334

23335

23350

23395

23397

23400

23405

23406

23410

23412

23415

23420

23430

23440

$704.00

$755.00

$945.00

$794.00

$645.00

$638.00

$882.00

$566.00

$865.00

$962.00

$656.00

$902.00

$1,095.00

$1,095.00

$1,307.00

$59.00

$466.00

$1,100.00

$1,312.00

$74.00

$1,366.00

$1,403.00

$1,196.00

$799.00

$977.00

$1,119.00

$1,229.00

$622.00

$1,276.00

$884.00

$906.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

10

90

90

90

0

90

90

90

90

90

90

90

90

90

90

90

23616

23620

23625

23630

23650

23655

23660

23665

23670

23675

23680

23700

23800

23802

23530

23532

23540

23545

23550

23552

23570

23575

23585

23600

23605

23615

23900

23920

23921

23929

23930

$1,895.00

$286.00

$422.00

$712.00

$296.00

$374.00

$712.00

$440.00

$759.00

$550.00

$1,064.00

$237.00

$1,346.00

$1,368.00

$659.00

$713.00

$148.00

$148.00

$701.00

$753.00

$88.00

$306.00

$809.00

$318.00

$511.00

$900.00

$1,561.00

$1,300.00

$497.00

BR

$71.00

90

90

10

90

90

90

90

90

90

90

90

90

90

90

YYY

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

FUD

90

90

90

90


Part A, 78

24152

24155

24160

24164

24200

24201

24220

24300

24301

24305

24310

24320

24330

24331

24120

24125

24126

24130

24134

24136

24138

24140

24145

24147

24149

24150

24332

24340

24341

24342

24343

24073

24075

24076

24077

24079

24100

24101

24102

24105

24110

24115

24116



Surgery

CPT Code

23931

MRA

$62.00

FUD

10

Surgery

CPT Code

24344

MRA

$971.00

FUD

90

Surgery

CPT Code

24670

MRA

$263.00

23935

24000

24006

24065

24066

24071

$630.00

$550.00

$793.00

$166.00

$461.00

$413.00

90

90

90

10

90

90

24345

24346

24357

24358

24359

24360

$643.00

$971.00

$408.00

$478.00

$587.00

$1,125.00

90

90

90

90

90

90

24675

24685

24800

24802

24900

24920

$490.00

$819.00

$984.00

$1,181.00

$858.00

$851.00

$704.00

$349.00

$529.00

$1,058.00

$1,357.00

$467.00

$591.00

$755.00

$360.00

$724.00

$898.00

$1,037.00

90

90

90

90

90

90

90

90

90

90

90

90

24361

24362

24363

24365

24366

24370

24371

24400

24410

24420

24430

24435

$1,215.00

$1,269.00

$1,663.00

$747.00

$850.00

$1,581.00

$1,826.00

$991.00

$1,319.00

$1,265.00

$1,209.00

$1,260.00

90

90

90

90

90

90

90

90

90

90

90

90

24925

24930

24931

24935

24940

24999

25000

25001

25020

25023

25024

25025

$661.00

$928.00

$1,063.00

$1,327.00

BR

BR

$381.00

$294.00

$594.00

$1,040.00

$683.00

$1,104.00

$829.00

$1,019.00

$533.00

$564.00

$58.00

$444.00

$89.00

$352.00

$869.00

$579.00

$511.00

$944.00

$845.00

$927.00

$595.00

$663.00

$731.00

$595.00

$966.00

$720.00

$697.00

$963.00

$592.00

$703.00

$1,224.00

$1,265.00

$487.00

$697.00

$702.00

$950.00

$643.00

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

24470

24495

24498

24500

24505

24515

24516

24530

24535

24538

24545

24546

24560

24565

24566

24575

24576

24577

24579

24582

24586

24587

24600

24605

24615

24620

24635

24650

24655

24665

24666

$774.00

$742.00

$1,076.00

$288.00

$574.00

$1,018.00

$1,029.00

$88.00

$671.00

$850.00

$946.00

$1,273.00

$266.00

$526.00

$705.00

$872.00

$295.00

$575.00

$964.00

$773.00

$1,314.00

$1,278.00

$360.00

$371.00

$836.00

$560.00

$1,329.00

$262.00

$436.00

$749.00

$905.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

25085

25100

25101

25105

25107

25109

25110

25111

25112

25115

25116

25118

25119

25120

25028

25031

25035

25040

25065

25066

25071

25073

25075

25076

25077

25078

25125

25126

25130

25135

25136

$562.00

$420.00

$492.00

$635.00

$600.00

$470.00

$403.00

$356.00

$441.00

$837.00

$807.00

$466.00

$653.00

$712.00

$417.00

$266.00

$794.00

$654.00

$164.00

$322.00

$432.00

$540.00

$352.00

$544.00

$957.00

$1,195.00

$803.00

$781.00

$502.00

$631.00

$546.00

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

90

90

90

90

90

YYY

90

90

90

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 79

25335

25337

25350

25355

25360

25365

25370

25375

25390

25391

25392

25393

25394

25400

25275

25280

25290

25295

25300

25301

25310

25312

25315

25316

25320

25332

25405

25415

25420

25425

25426

25240

25246

25248

25250

25251

25259

25260

25263

25265

25270

25272

25274



Surgery

CPT Code

25145

MRA

$713.00

FUD

90

Surgery

CPT Code

25430

MRA

$638.00

FUD

90

Surgery

CPT Code

25685

MRA

$887.00

25150

25151

25170

25210

25215

25230

$720.00

$771.00

$1,085.00

$561.00

$817.00

$531.00

90

90

90

90

90

90

25431

25440

25441

25442

25443

25444

$631.00

$931.00

$1,147.00

$936.00

$970.00

$1,031.00

90

90

90

90

90

90

25690

25695

25800

25805

25810

25820

$518.00

$520.00

$703.00

$1,078.00

$1,008.00

$2,276.00

$567.00

$72.00

$236.00

$616.00

$933.00

$348.00

$728.00

$809.00

$998.00

$549.00

$613.00

$887.00

90

0

90

90

90

90

90

90

90

90

90

90

25445

25446

25447

25449

25450

25455

25490

25491

25492

25500

25505

25515

$959.00

$1,542.00

$952.00

$395.00

$805.00

$899.00

$955.00

$1,006.00

$1,170.00

$200.00

$517.00

$800.00

90

90

90

90

90

90

90

90

90

90

90

90

25825

25830

25900

25905

25907

25909

25915

25920

25922

25924

25927

25929

$895.00

$991.00

$871.00

$900.00

$799.00

$849.00

$1,523.00

$771.00

$670.00

$768.00

$830.00

$645.00

$1,166.00

$946.00

$913.00

$1,014.00

$468.00

$1,216.00

$1,214.00

$1,280.00

$1,043.00

$1,349.00

$1,294.00

$1,473.00

$723.00

$1,112.00

$620.00

$670.00

$436.00

$562.00

$592.00

$757.00

$865.00

$968.00

$1,004.00

$1,203.00

$834.00

$1,022.00

$1,388.00

$1,343.00

$1,554.00

$1,403.00

$1,401.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

25520

25525

25526

25530

25535

25545

25560

25565

25574

25575

25600

25605

25606

25607

25608

25609

25622

25624

25628

25630

25635

25645

25650

25651

25652

25660

25670

25671

25675

25676

25680

$644.00

$1,097.00

$1,293.00

$270.00

$516.00

$803.00

$276.00

$590.00

$804.00

$974.00

$312.00

$540.00

$643.00

$645.00

$739.00

$942.00

$148.00

$482.00

$716.00

$148.00

$458.00

$668.00

$185.00

$379.00

$560.00

$378.00

$731.00

$462.00

$404.00

$741.00

$471.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

26055

26060

26070

26075

26080

26100

26105

26110

26111

26113

26115

26116

26117

26118

25931

25999

26010

26011

26020

26025

26030

26034

26035

26037

26040

26045

26121

26123

26125

26130

26135

$343.00

$293.00

$440.00

$400.00

$382.00

$398.00

$481.00

$282.00

$423.00

$557.00

$344.00

$544.00

$806.00

$1,076.00

$731.00

BR

$59.00

$223.00

$484.00

$548.00

$655.00

$601.00

$741.00

$730.00

$367.00

$621.00

$833.00

$959.00

$342.00

$629.00

$668.00

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

10

90

90

90

90

90

90

90

90

90

YYY

10

90

90

90

90

90

90

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 80

26415

26416

26418

26420

26426

26428

26432

26433

26434

26437

26440

26442

26445

26449

26350

26352

26356

26357

26358

26370

26372

26373

26390

26392

26410

26412

26450

26455

26460

26471

26474

26205

26210

26215

26230

26235

26236

26250

26260

26262

26320

26340

26341



Surgery

CPT Code

26140

MRA

$678.00

FUD

90

Surgery

CPT Code

26476

MRA

$543.00

FUD

90

Surgery

CPT Code

26593

MRA

$587.00

26145

26160

26170

26180

26185

26200

$660.00

$319.00

$452.00

$444.00

$511.00

$598.00

90

90

90

90

90

90

26477

26478

26479

26480

26483

26485

$553.00

$608.00

$653.00

$808.00

$986.00

$891.00

90

90

90

90

90

90

26596

26600

26605

26607

26608

26615

$809.00

$133.00

$296.00

$334.00

$497.00

$521.00

$788.00

$543.00

$731.00

$624.00

$612.00

$444.00

$814.00

$758.00

$624.00

$414.00

$266.00

$99.00

90

90

90

90

90

90

90

90

90

90

90

10

26489

26490

26492

26494

26496

26497

26498

26499

26500

26502

26508

26510

$738.00

$496.00

$971.00

$946.00

$949.00

$946.00

$1,317.00

$934.00

$557.00

$715.00

$334.00

$564.00

90

90

90

90

90

90

90

90

90

90

90

90

26641

26645

26650

26665

26670

26675

26676

26685

26686

26700

26705

26706

$71.00

$371.00

$533.00

$693.00

$148.00

$501.00

$527.00

$592.00

$710.00

$88.00

$296.00

$469.00

$846.00

$1,093.00

$444.00

$741.00

$733.00

$790.00

$430.00

$371.00

$656.00

$491.00

$458.00

$548.00

$455.00

$738.00

$715.00

$855.00

$886.00

$932.00

$979.00

$832.00

$945.00

$904.00

$889.00

$1,123.00

$371.00

$737.00

$353.00

$364.00

$346.00

$592.00

$586.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

26516

26517

26518

26520

26525

26530

26531

26535

26536

26540

26541

26542

26545

26546

26548

26550

26551

26553

26554

26555

26556

26560

26561

26562

26565

26567

26568

26580

26587

26590

26591

$630.00

$890.00

$877.00

$583.00

$531.00

$708.00

$877.00

$546.00

$770.00

$726.00

$926.00

$716.00

$722.00

$918.00

$665.00

$1,861.00

$3,901.00

$3,868.00

$4,551.00

$1,567.00

$4,005.00

$576.00

$1,067.00

$1,017.00

$730.00

$622.00

$1,003.00

$1,585.00

$792.00

$1,609.00

$431.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

26770

26775

26776

26785

26820

26841

26842

26843

26844

26850

26852

26860

26861

26862

26715

26720

26725

26727

26735

26740

26742

26746

26750

26755

26756

26765

26863

26910

26951

26952

26989

$79.00

$275.00

$401.00

$408.00

$854.00

$756.00

$901.00

$800.00

$875.00

$704.00

$829.00

$542.00

$151.00

$747.00

$526.00

$96.00

$187.00

$187.00

$532.00

$148.00

$148.00

$548.00

$96.00

$133.00

$366.00

$398.00

$317.00

$747.00

$444.00

$608.00

BR

90

90

90

ZZZ

90

90

90

90

90

90

90

ZZZ

90

90

90

YYY

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 81

27070

27071

27075

27076

27077

27078

27080

27086

27087

27090

27091

27093

27095

27096

27048

27049

27050

27052

27054

27057

27059

27060

27062

27065

27066

27067

27097

27098

27100

27105

27110

27006

27025

27027

27030

27033

27035

27036

27040

27041

27043

27045

27047



Surgery

CPT Code

26990

MRA

$592.00

FUD

90

Surgery

CPT Code

27111

MRA

$1,099.00

FUD

90

Surgery

CPT Code

27252

MRA

$520.00

26991

26992

27000

27001

27003

27005

$466.00

$1,146.00

$421.00

$550.00

$698.00

$738.00

90

90

90

90

90

90

27120

27122

27125

27130

27132

27134

$1,603.00

$1,406.00

$1,371.00

$1,853.00

$2,128.00

$2,576.00

90

90

90

90

90

90

27253

27254

27256

27257

27258

27259

$1,162.00

$1,478.00

$338.00

$455.00

$1,355.00

$1,803.00

$788.00

$896.00

$866.00

$1,148.00

$1,173.00

$1,413.00

$1,176.00

$196.00

$699.00

$476.00

$764.00

$535.00

90

90

90

90

90

90

90

10

90

90

90

90

27137

27138

27140

27146

27147

27151

27156

27158

27161

27165

27170

27175

$2,190.00

$2,025.00

$1,092.00

$1,432.00

$1,744.00

$1,732.00

$2,017.00

$1,588.00

$1,443.00

$1,572.00

$1,453.00

$491.00

90

90

90

90

90

90

90

90

90

90

90

90

27265

27266

27267

27268

27269

27275

27279

27280

27282

27284

27286

27290

$442.00

$614.00

$382.00

$470.00

$1,117.00

$220.00

$718.00

$1,179.00

$990.00

$1,435.00

$1,503.00

$2,073.00

$1,040.00

$1,112.00

$1,485.00

$1,859.00

$1,976.00

$1,164.00

$568.00

$57.00

$555.00

$981.00

$1,482.00

$62.00

$121.00

$491.00

$588.00

$1,162.00

$449.00

$624.00

$843.00

$972.00

$1,849.00

$491.00

$499.00

$583.00

$931.00

$1,234.00

$795.00

$799.00

$987.00

$946.00

$1,174.00

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

27176

27177

27178

27179

27181

27185

27187

27193

27194

27200

27202

27215

27216

27217

27218

27220

27222

27226

27227

27228

27230

27232

27235

27236

27238

27240

27244

27245

27246

27248

27250

$1,024.00

$1,257.00

$1,020.00

$1,107.00

$1,206.00

$676.00

$1,280.00

$425.00

$740.00

$180.00

$776.00

$954.00

$1,085.00

$1,285.00

$1,570.00

$444.00

$973.00

$1,350.00

$1,967.00

$2,195.00

$491.00

$916.00

$1,128.00

$1,421.00

$504.00

$1,043.00

$1,426.00

$1,691.00

$459.00

$980.00

$535.00

90

90

90

90

90

90

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

27327

27328

27329

27330

27331

27332

27333

27334

27335

27337

27339

27340

27345

27347

27295

27299

27301

27303

27305

27306

27307

27310

27323

27324

27325

27326

27350

27355

27356

27357

27358

$400.00

$503.00

$1,249.00

$492.00

$585.00

$786.00

$719.00

$840.00

$959.00

$425.00

$765.00

$405.00

$565.00

$394.00

$1,594.00

BR

$193.00

$520.00

$555.00

$377.00

$503.00

$877.00

$211.00

$433.00

$476.00

$451.00

$786.00

$763.00

$882.00

$950.00

$394.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

10

90

90

90

90

YYY

90

90

90

10

90

90

90

10

90

90

90

90

90

FUD

90

90

90

10


Part A, 82

27428

27429

27430

27435

27437

27438

27440

27441

27442

27443

27445

27446

27447

27448

27405

27407

27409

27412

27415

27416

27418

27420

27422

27424

27425

27427

27450

27454

27455

27457

27465

27385

27386

27390

27391

27392

27393

27394

27395

27396

27397

27400

27403



Surgery

CPT Code

27360

MRA

$977.00

FUD

90

Surgery

CPT Code

27466

MRA

$1,441.00

FUD

90

Surgery

CPT Code

27591

MRA

$1,182.00

27364

27365

27370

27372

27380

27381

$1,601.00

$1,421.00

$75.00

$371.00

$698.00

$1,118.00

90

90

0

90

90

90

27468

27470

27472

27475

27477

27479

$1,613.00

$1,501.00

$1,665.00

$782.00

$938.00

$1,123.00

90

90

90

90

90

90

27592

27594

27596

27598

27599

27600

$911.00

$600.00

$931.00

$976.00

BR

$517.00

$753.00

$1,064.00

$506.00

$647.00

$834.00

$608.00

$748.00

$1,093.00

$742.00

$989.00

$832.00

$792.00

90

90

90

90

90

90

90

90

90

90

90

90

27485

27486

27487

27488

27495

27496

27497

27498

27499

27500

27501

27502

$797.00

$1,771.00

$2,352.00

$1,438.00

$1,477.00

$563.00

$652.00

$701.00

$782.00

$520.00

$659.00

$909.00

90

90

90

90

90

90

90

90

90

90

90

90

27601

27602

27603

27604

27605

27606

27607

27610

27612

27613

27614

27615

$516.00

$621.00

$412.00

$308.00

$236.00

$362.00

$608.00

$777.00

$701.00

$165.00

$327.00

$1,106.00

$1,266.00

$2,333.00

$884.00

$501.00

$819.00

$1,065.00

$1,064.00

$1,006.00

$1,117.00

$1,037.00

$1,618.00

$1,764.00

$1,960.00

$1,060.00

$842.00

$918.00

$1,212.00

$1,605.00

$1,340.00

$878.00

$1,596.00

$927.00

$930.00

$927.00

$639.00

$1,118.00

$1,311.00

$1,524.00

$1,157.00

$1,209.00

$1,253.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

27503

27506

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

$911.00

$1,522.00

$1,297.00

$400.00

$649.00

$755.00

$1,281.00

$1,562.00

$1,508.00

$579.00

$820.00

$1,311.00

$266.00

$910.00

$408.00

$641.00

$1,075.00

$1,282.00

$487.00

$1,106.00

$296.00

$619.00

$832.00

$1,479.00

$1,529.00

$88.00

$514.00

$1,047.00

$184.00

$1,644.00

$1,059.00

90

90

90

90

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

27640

27641

27645

27646

27647

27648

27650

27652

27654

27656

27658

27659

27664

27665

27616

27618

27619

27620

27625

27626

27630

27632

27634

27635

27637

27638

27675

27676

27680

27681

27685

$1,122.00

$922.00

$1,302.00

$1,212.00

$1,044.00

$72.00

$869.00

$935.00

$937.00

$458.00

$527.00

$725.00

$504.00

$618.00

$1,297.00

$421.00

$730.00

$587.00

$796.00

$863.00

$430.00

$422.00

$697.00

$781.00

$921.00

$978.00

$656.00

$762.00

$523.00

$634.00

$565.00

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

10

90

90

90

90

90

90

10

10

90

90

90

FUD

90

90

90

90

90

YYY

90

90

90

90


Part A, 83

27756

27758

27759

27760

27762

27766

27767

27768

27769

27780

27781

27784

27786

27788

27724

27725

27726

27727

27730

27732

27734

27740

27742

27745

27750

27752

27792

27808

27810

27814

27816

27698

27700

27702

27703

27704

27705

27707

27709

27712

27715

27720

27722



Surgery

CPT Code

27686

MRA

$706.00

FUD

90

Surgery

CPT Code

27818

MRA

$613.00

FUD

90

Surgery

CPT Code

28055

MRA

$377.00

27687

27690

27691

27692

27695

27696

$589.00

$757.00

$889.00

$159.00

$658.00

$758.00

90

90

90

ZZZ

90

90

27822

27823

27824

27825

27826

27827

$1,201.00

$1,472.00

$384.00

$670.00

$1,080.00

$1,310.00

90

90

90

90

90

90

28060

28062

28070

28072

28080

28086

$495.00

$657.00

$476.00

$445.00

$392.00

$462.00

$881.00

$835.00

$1,278.00

$1,337.00

$683.00

$985.00

$484.00

$1,118.00

$1,227.00

$1,285.00

$1,147.00

$1,076.00

90

90

90

90

90

90

90

90

90

90

90

90

27828

27829

27830

27831

27832

27840

27842

27846

27848

27860

27870

27871

$1,823.00

$742.00

$412.00

$415.00

$617.00

$334.00

$373.00

$877.00

$1,224.00

$211.00

$1,269.00

$843.00

90

90

90

90

90

90

90

90

90

10

90

90

28088

28090

28092

28100

28102

28103

28104

28106

28107

28108

28110

28111

$414.00

$414.00

$330.00

$571.00

$700.00

$709.00

$491.00

$632.00

$517.00

$418.00

$421.00

$537.00

$708.00

$1,115.00

$1,262.00

$223.00

$495.00

$759.00

$233.00

$361.00

$622.00

$244.00

$296.00

$643.00

$223.00

$422.00

$1,402.00

$1,312.00

$823.00

$1,175.00

$647.00

$611.00

$766.00

$1,044.00

$1,045.00

$940.00

$319.00

$614.00

$706.00

$332.00

$567.00

$972.00

$386.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

27880

27881

27882

27884

27886

27888

27889

27892

27893

27894

27899

28001

28002

28003

28005

28008

28010

28011

28020

28022

28024

28035

28039

28041

28043

28045

28046

28047

28050

28052

28054

$1,015.00

$1,120.00

$854.00

$579.00

$835.00

$911.00

$879.00

$575.00

$574.00

$712.00

BR

$185.00

$362.00

$520.00

$520.00

$296.00

$235.00

$340.00

$509.00

$422.00

$371.00

$532.00

$525.00

$473.00

$305.00

$456.00

$814.00

$1,056.00

$414.00

$402.00

$236.00

90

90

90

90

90

90

90

90

90

90

YYY

10

10

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

28150

28153

28160

28171

28173

28175

28190

28192

28193

28200

28202

28208

28210

28220

28112

28113

28114

28116

28118

28119

28120

28122

28124

28126

28130

28140

28222

28225

28226

28230

28232

$416.00

$400.00

$412.00

$789.00

$747.00

$571.00

$75.00

$326.00

$341.00

$478.00

$613.00

$406.00

$609.00

$435.00

$457.00

$481.00

$890.00

$648.00

$568.00

$524.00

$601.00

$622.00

$480.00

$393.00

$727.00

$533.00

$555.00

$345.00

$334.00

$380.00

$286.00

90

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

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 84

28310

28312

28313

28315

28320

28322

28340

28341

28344

28345

28360

28400

28405

28406

28296

28297

28298

28299

28300

28302

28304

28305

28306

28307

28308

28309

28415

28420

28430

28435

28436

28264

28270

28272

28280

28285

28286

28288

28289

28290

28292

28293

28294



Surgery

CPT Code

28234

MRA

$178.00

FUD

90

Surgery

CPT Code

28445

MRA

$874.00

FUD

90

Surgery

CPT Code

28805

MRA

$731.00

28238

28240

28250

28260

28261

28262

$695.00

$370.00

$535.00

$641.00

$881.00

$1,363.00

90

90

90

90

90

90

28446

28450

28455

28456

28465

28470

$1,075.00

$148.00

$321.00

$288.00

$533.00

$178.00

90

90

90

90

90

90

28810

28820

28825

28890

28899

29000

$543.00

$377.00

$339.00

$358.00

BR

$247.00

$912.00

$266.00

$336.00

$426.00

$463.00

$441.00

$452.00

$458.00

$557.00

$666.00

$845.00

$797.00

90

90

90

90

90

90

90

90

90

90

90

90

28475

28476

28485

28490

28495

28496

28505

28510

28515

28525

28530

28531

$296.00

$364.00

$521.00

$80.00

$133.00

$261.00

$399.00

$75.00

$115.00

$345.00

$120.00

$243.00

90

90

90

90

90

90

90

90

90

90

90

90

29010

29015

29035

29040

29044

29046

29049

29055

29058

29065

29075

29085

$271.00

$289.00

$213.00

$260.00

$260.00

$286.00

$45.00

$180.00

$110.00

$88.00

$72.00

$59.00

$505.00

$469.00

$436.00

$462.00

$833.00

$667.00

$649.00

$753.00

$414.00

$557.00

$1,197.00

$266.00

$473.00

$616.00

$832.00

$838.00

$755.00

$829.00

$845.00

$930.00

$776.00

$1,030.00

$530.00

$614.00

$516.00

$955.00

$1,354.00

$1,619.00

$110.00

$371.00

$463.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

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

$145.00

$208.00

$325.00

$592.00

$189.00

$308.00

$382.00

$742.00

$144.00

$287.00

$487.00

$621.00

$145.00

$189.00

$318.00

$434.00

$106.00

$172.00

$309.00

$348.00

$1,353.00

$1,179.00

$1,015.00

$945.00

$961.00

$873.00

$690.00

$690.00

$466.00

$654.00

$731.00

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

29345

29355

29358

29365

29405

29425

29435

29440

29445

29450

29505

29515

29520

29530

29086

29105

29125

29126

29130

29131

29200

29240

29260

29280

29305

29325

29540

29550

29580

29581

29582

$126.00

$133.00

$241.00

$101.00

$96.00

$101.00

$133.00

$22.00

$214.00

$84.00

$75.00

$59.00

$22.00

$55.00

$54.00

$59.00

$45.00

$53.00

$26.00

$53.00

$29.00

$45.00

$26.00

$29.00

$223.00

$260.00

$41.00

$37.00

$39.00

$62.00

$71.00

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

FUD

90

90

90

90

90

YYY

0

0

0

0


Part A, 85

29840

29843

29844

29845

29846

29847

29848

29850

29851

29855

29856

29860

29861

29862

29823

29824

29825

29826

29827

29828

29830

29834

29835

29836

29837

29838

29863

29866

29867

29868

29870

29740

29750

29799

29800

29804

29805

29806

29807

29819

29820

29821

29822



Surgery

CPT Code

29583

MRA

$44.00

FUD

0

Surgery

CPT Code

29871

MRA

$631.00

FUD

90

Surgery

CPT Code

30200

MRA

$68.00

29584

29700

29705

29710

29720

29730

$71.00

$29.00

$26.00

$29.00

$29.00

$29.00

0

0

0

0

0

0

29873

29874

29875

29876

29877

29879

$489.00

$676.00

$639.00

$809.00

$852.00

$1,064.00

90

90

90

90

90

90

30210

30220

30300

30310

30320

30400

$75.00

$154.00

$45.00

$170.00

$419.00

$741.00

$37.00

$105.00

BR

$557.00

$902.00

$360.00

$1,003.00

$976.00

$756.00

$718.00

$863.00

$749.00

0

0

YYY

90

90

90

90

90

90

90

90

90

29880

29881

29882

29883

29884

29885

29886

29887

29888

29889

29891

29892

$1,169.00

$745.00

$819.00

$1,235.00

$721.00

$832.00

$697.00

$949.00

$1,296.00

$1,255.00

$796.00

$835.00

90

90

90

90

90

90

90

90

90

90

90

90

30410

30420

30430

30435

30450

30460

30462

30465

30520

30540

30545

30560

$1,173.00

$1,424.00

$626.00

$1,005.00

$1,445.00

$857.00

$1,633.00

$803.00

$533.00

$643.00

$981.00

$104.00

$501.00

$580.00

$612.00

$931.00

$976.00

$1,277.00

$608.00

$752.00

$1,137.00

$1,007.00

$1,231.00

$658.00

$845.00

$907.00

$1,330.00

$611.00

$941.00

$980.00

$1,058.00

$830.00

$524.00

$635.00

$612.00

$680.00

$830.00

$931.00

$880.00

$1,046.00

$1,250.00

$1,694.00

$460.00

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

29893

29894

29895

29897

29898

29899

29900

29901

29902

29904

29905

29906

29907

29914

29915

29916

29999

30000

30020

30100

30110

30115

30117

30118

30120

30124

30125

30130

30140

30150

30160

$472.00

$690.00

$679.00

$704.00

$863.00

$973.00

$434.00

$479.00

$514.00

$557.00

$601.00

$633.00

$775.00

$1,036.00

$1,057.00

$1,057.00

BR

$96.00

$117.00

$86.00

$157.00

$360.00

$301.00

$819.00

$500.00

$243.00

$599.00

$275.00

$320.00

$790.00

$875.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

YYY

10

10

0

10

90

90

90

90

90

90

90

90

90

90

30930

30999

31000

31002

31020

31030

31032

31040

31050

31051

31070

31075

31080

31081

30580

30600

30620

30630

30801

30802

30901

30903

30905

30906

30915

30920

31084

31085

31086

31087

31090

$213.00

BR

$81.00

$135.00

$281.00

$531.00

$604.00

$772.00

$489.00

$654.00

$410.00

$839.00

$942.00

$1,089.00

$566.00

$466.00

$564.00

$624.00

$88.00

$172.00

$75.00

$110.00

$224.00

$208.00

$596.00

$862.00

$1,210.00

$1,281.00

$1,081.00

$1,075.00

$877.00

90

90

90

90

90

10

90

90

90

90

90

90

90

90

90

90

0

90

90

10

YYY

10

0

0

0

90

10

10

90

90

10

90

90

90

90

90

90

90

90

90

10

90

90

90

90

90

FUD

0

10

10

10


Part A, 86

31365

31367

31368

31370

31375

31380

31382

31390

31395

31400

31420

31500

31502

31505

31290

31291

31292

31293

31294

31295

31296

31297

31299

31300

31320

31360

31510

31511

31512

31513

31515

31235

31237

31238

31239

31240

31254

31255

31256

31267

31276

31287

31288



Surgery

CPT Code

31200

MRA

$463.00

FUD

90

Surgery

CPT Code

31525

MRA

$234.00

FUD

0

Surgery

CPT Code

31633

MRA

$90.00

31201

31205

31225

31230

31231

31233

$716.00

$851.00

$1,683.00

$1,908.00

$122.00

$221.00

90

90

90

90

0

0

31526

31527

31528

31529

31530

31531

$222.00

$262.00

$202.00

$217.00

$284.00

$311.00

0

0

0

0

0

0

31634

31635

31636

31637

31638

31640

$1,886.00

$298.00

$241.00

$86.00

$268.00

$399.00

$217.00

$266.00

$311.00

$775.00

$224.00

$588.00

$601.00

$292.00

$453.00

$690.00

$339.00

$396.00

0

0

0

10

0

0

0

0

0

0

0

0

31535

31536

31540

31541

31545

31546

31560

31561

31570

31571

31575

31576

$272.00

$308.00

$357.00

$453.00

$384.00

$587.00

$446.00

$509.00

$369.00

$363.00

$128.00

$186.00

0

0

0

0

0

0

0

0

0

0

0

0

31641

31643

31645

31646

31647

31648

31649

31651

31652

31653

31654

31660

$304.00

$208.00

$208.00

$161.00

$228.00

$218.00

$71.00

$82.00

$921.00

$979.00

$147.00

$218.00

$2,238.00

$1,913.00

$2,478.00

$1,891.00

$1,720.00

$1,782.00

$1,822.00

$2,513.00

$2,937.00

$969.00

$969.00

$116.00

$74.00

$62.00

$1,462.00

$1,551.00

$1,235.00

$1,346.00

$1,587.00

$2,104.00

$2,136.00

$2,101.00

BR

$1,295.00

$508.00

$1,630.00

$145.00

$88.00

$197.00

$182.00

$160.00

10

10

10

10

10

0

0

0

YYY

90

90

90

90

90

90

90

90

90

90

90

90

90

90

0

0

0

0

0

0

0

0

31577

31578

31579

31580

31582

31584

31587

31588

31590

31595

31599

31600

31603

31605

31610

31611

31612

31613

31614

31615

31622

31623

31624

31625

31626

31627

31628

31629

31630

31631

31632

$230.00

$264.00

$219.00

$1,213.00

$1,881.00

$1,616.00

$913.00

$1,206.00

$691.00

$773.00

BR

$306.00

$343.00

$297.00

$794.00

$614.00

$99.00

$384.00

$736.00

$213.00

$230.00

$225.00

$217.00

$235.00

$450.00

$1,310.00

$269.00

$198.00

$308.00

$252.00

$73.00

0

0

0

90

90

90

90

90

90

90

YYY

0

0

0

90

90

0

90

90

0

0

0

0

0

0

ZZZ

0

0

0

0

ZZZ

31781

31785

31786

31800

31805

31820

31825

31830

31899

32035

32036

32096

32097

32098

31661

31717

31720

31725

31730

31750

31755

31760

31766

31770

31775

31780

32100

32110

32120

32124

32140

$1,936.00

$1,320.00

$1,866.00

$628.00

$1,175.00

$458.00

$659.00

$460.00

BR

$821.00

$908.00

$835.00

$836.00

$789.00

$230.00

$138.00

$89.00

$103.00

$199.00

$1,088.00

$1,448.00

$1,648.00

$2,315.00

$1,815.00

$1,973.00

$1,577.00

$1,120.00

$1,223.00

$1,077.00

$1,144.00

$1,284.00

90

90

90

90

90

90

90

90

90

90

YYY

90

90

90

90

90

90

90

90

90

90

90

0

0

90

90

90

90

0

ZZZ

0

0

0

0

0

0

0

ZZZ

ZZZ

0

FUD

ZZZ

0

0

0

ZZZ

0

0

0

0

0


Part A, 87

32553

32554

32555

32556

32557

32560

32561

32562

32601

32604

32606

32607

32608

32609

32488

32491

32501

32503

32504

32505

32506

32507

32540

32550

32551

32552

32650

32651

32652

32653

32654

32225

32310

32320

32400

32405

32440

32442

32445

32480

32482

32484

32486



Surgery

CPT Code

32141

MRA

$1,267.00

FUD

90

Surgery

CPT Code

32655

MRA

$1,213.00

FUD

90

Surgery

CPT Code

33207

MRA

$753.00

32150

32151

32160

32200

32215

32220

$1,226.00

$1,231.00

$842.00

$1,132.00

$1,024.00

$1,680.00

90

90

90

90

90

90

32656

32658

32659

32661

32662

32663

$1,222.00

$1,142.00

$1,141.00

$1,165.00

$1,459.00

$1,636.00

90

90

90

90

90

90

33208

33210

33211

33212

33213

33214

$573.00

$204.00

$210.00

$511.00

$437.00

$532.00

$1,268.00

$1,221.00

$1,787.00

$129.00

$159.00

$1,837.00

$2,093.00

$2,093.00

$1,622.00

$1,714.00

$1,771.00

$1,974.00

90

90

90

0

0

90

90

90

90

90

90

90

32664

32665

32666

32667

32668

32669

32670

32671

32672

32673

32674

32701

$1,197.00

$1,360.00

$902.00

$164.00

$164.00

$1,395.00

$1,658.00

$1,847.00

$1,584.00

$1,251.00

$224.00

$229.00

90

90

90

ZZZ

ZZZ

90

90

90

90

90

ZZZ

0

33215

33216

33217

33218

33220

33221

33222

33223

33224

33225

33226

33227

$304.00

$402.00

$428.00

$488.00

$390.00

$379.00

$471.00

$585.00

$490.00

$434.00

$472.00

$359.00

$597.00

$201.00

$300.00

$542.00

$578.00

$302.00

$97.00

$87.00

$456.00

$663.00

$637.00

$321.00

$394.00

$272.00

$2,094.00

$1,784.00

$374.00

$1,875.00

$2,145.00

$964.00

$164.00

$164.00

$1,308.00

$821.00

$171.00

$196.00

$957.00

$1,166.00

$1,615.00

$1,144.00

$1,096.00

90

90

ZZZ

90

90

90

ZZZ

ZZZ

90

0

0

10

0

0

0

0

0

0

0

0

0

0

0

0

0

0

90

90

90

90

90

32800

32810

32815

32820

32851

32852

32853

32854

32900

32905

32906

32940

32960

32997

32998

32999

33010

33011

33015

33020

33025

33030

33031

33050

33120

33130

33140

33141

33202

33203

33206

$1,166.00

$1,085.00

$1,917.00

$1,848.00

$3,100.00

$3,339.00

$3,787.00

$4,038.00

$1,532.00

$1,661.00

$2,100.00

$1,555.00

$126.00

$312.00

$2,809.00

BR

$124.00

$125.00

$555.00

$1,178.00

$1,165.00

$1,786.00

$1,816.00

$1,224.00

$2,358.00

$1,734.00

$1,571.00

$254.00

$749.00

$766.00

$642.00

90

90

90

90

90

90

90

90

90

90

90

90

0

0

0

YYY

0

0

90

90

90

90

90

90

90

90

90

ZZZ

90

90

90

33243

33244

33249

33250

33251

33254

33255

33256

33257

33258

33259

33261

33262

33263

33228

33229

33230

33231

33233

33234

33235

33236

33237

33238

33240

33241

33264

33265

33266

33270

33271

$1,650.00

$1,081.00

$1,271.00

$1,687.00

$2,071.00

$1,307.00

$1,573.00

$1,879.00

$565.00

$639.00

$839.00

$1,993.00

$394.00

$409.00

$374.00

$393.00

$408.00

$421.00

$270.00

$598.00

$587.00

$933.00

$1,184.00

$1,235.00

$648.00

$301.00

$427.00

$1,307.00

$1,789.00

$614.00

$517.00

ZZZ

ZZZ

90

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

0

90

90

90

90

90

90

90

90

90

0

90

90

90

90

90

90

FUD

90

90

0

0


Part A, 88

33413

33414

33415

33416

33417

33418

33419

33420

33422

33425

33426

33427

33430

33460

33367

33368

33369

33400

33401

33403

33404

33405

33406

33410

33411

33412

33463

33464

33465

33468

33470

33315

33320

33321

33322

33330

33335

33361

33362

33363

33364

33365

33366



Surgery

CPT Code

33272

MRA

$364.00

FUD

90

Surgery

CPT Code

33471

MRA

$1,929.00

FUD

90

Surgery

CPT Code

33641

MRA

$1,981.00

33273

33282

33284

33300

33305

33310

$418.00

$470.00

$365.00

$1,576.00

$1,889.00

$1,577.00

90

90

90

90

90

90

33474

33475

33476

33477

33478

33496

$2,173.00

$2,666.00

$2,270.00

$1,345.00

$2,544.00

$2,595.00

90

90

90

0

90

90

33645

33647

33660

33665

33670

33675

$2,352.00

$2,732.00

$2,444.00

$2,700.00

$2,820.00

$2,085.00

$1,875.00

$1,485.00

$1,890.00

$1,935.00

$1,726.00

$2,336.00

$1,404.00

$1,535.00

$1,589.00

$1,671.00

$1,843.00

$1,995.00

90

90

90

90

90

90

0

0

0

0

0

0

33500

33501

33502

33503

33504

33505

33506

33507

33508

33510

33511

33512

$2,370.00

$1,546.00

$1,938.00

$1,983.00

$2,416.00

$2,423.00

$2,448.00

$1,809.00

$17.00

$2,354.00

$2,546.00

$2,732.00

90

90

90

90

90

90

90

90

ZZZ

90

90

90

33676

33677

33681

33684

33688

33690

33692

33694

33697

33702

33710

33720

$2,151.00

$2,236.00

$2,657.00

$2,740.00

$2,602.00

$1,884.00

$2,816.00

$2,856.00

$3,064.00

$2,549.00

$2,731.00

$2,508.00

$3,282.00

$2,904.00

$2,563.00

$2,684.00

$2,756.00

$1,871.00

$440.00

$1,796.00

$2,431.00

$2,509.00

$2,806.00

$3,026.00

$2,891.00

$2,215.00

$644.00

$780.00

$1,030.00

$2,401.00

$2,228.00

$2,369.00

$2,698.00

$2,745.00

$2,962.00

$2,637.00

$2,981.00

$3,213.00

$2,396.00

$2,547.00

$2,665.00

$2,952.00

$1,749.00

ZZZ

ZZZ

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

33513

33514

33516

33517

33518

33519

33521

33522

33523

33530

33533

33534

33535

33536

33542

33545

33548

33572

33600

33602

33606

33608

33610

33611

33612

33615

33617

33619

33620

33621

33622

$2,933.00

$3,197.00

$3,404.00

$219.00

$414.00

$607.00

$801.00

$994.00

$1,189.00

$521.00

$2,415.00

$2,654.00

$2,899.00

$3,143.00

$2,693.00

$3,250.00

$2,381.00

$340.00

$2,644.00

$2,556.00

$2,831.00

$2,940.00

$2,871.00

$2,985.00

$3,152.00

$3,051.00

$3,272.00

$3,678.00

$1,527.00

$914.00

$3,597.00

90

90

90

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

33766

33767

33768

33770

33771

33774

33775

33776

33777

33778

33779

33780

33781

33782

33722

33724

33726

33730

33732

33735

33736

33737

33750

33755

33762

33764

33783

33786

33788

33800

33802

$2,119.00

$2,173.00

$449.00

$2,954.00

$2,924.00

$2,681.00

$2,654.00

$2,844.00

$2,724.00

$3,199.00

$3,121.00

$3,232.00

$3,057.00

$3,439.00

$2,704.00

$1,491.00

$1,963.00

$2,785.00

$2,622.00

$2,036.00

$2,288.00

$1,977.00

$1,877.00

$1,831.00

$1,900.00

$1,895.00

$3,834.00

$2,970.00

$2,288.00

$1,546.00

$1,752.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 89

33925

33926

33935

33945

33946

33947

33948

33949

33951

33952

33953

33954

33955

33956

33883

33884

33886

33889

33891

33910

33915

33916

33917

33920

33922

33924

33957

33958

33959

33962

33963

33845

33851

33852

33853

33860

33863

33864

33870

33875

33877

33880

33881



Surgery

CPT Code

33803

MRA

$1,746.00

FUD

90

Surgery

CPT Code

33964

MRA

$513.00

FUD

0

Surgery

CPT Code

34804

MRA

$1,279.00

33813

33814

33820

33822

33824

33840

$1,935.00

$2,464.00

$1,619.00

$1,559.00

$1,884.00

$2,029.00

90

90

90

90

90

90

33965

33966

33967

33968

33969

33970

$194.00

$246.00

$258.00

$51.00

$287.00

$576.00

0

0

0

0

0

0

34805

34806

34808

34812

34813

34820

$1,243.00

$100.00

$220.00

$359.00

$256.00

$519.00

$2,129.00

$2,129.00

$2,311.00

$3,057.00

$3,044.00

$3,183.00

$3,035.00

$3,638.00

$2,876.00

$3,767.00

$1,866.00

$1,603.00

90

90

90

90

90

90

90

90

90

90

90

90

33971

33973

33974

33975

33976

33977

33978

33979

33980

33981

33982

33983

$578.00

$756.00

$1,095.00

$1,758.00

$2,056.00

$1,561.00

$1,754.00

$2,496.00

$3,212.00

$879.00

$2,052.00

$2,418.00

90

0

90

0

0

0

0

0

0

0

0

0

34825

34826

34830

34831

34832

34833

34834

34900

35001

35002

35005

35011

$694.00

$220.00

$1,803.00

$1,950.00

$1,950.00

$650.00

$306.00

$960.00

$1,564.00

$1,547.00

$1,268.00

$1,007.00

$1,849.00

$2,499.00

$5,415.00

$3,813.00

$319.00

$353.00

$252.00

$245.00

$435.00

$449.00

$486.00

$502.00

$873.00

$875.00

$1,187.00

$441.00

$1,025.00

$882.00

$1,126.00

$1,987.00

$1,588.00

$2,096.00

$2,345.00

$2,981.00

$2,227.00

$421.00

$194.00

$191.00

$246.00

$249.00

$493.00

90

ZZZ

90

0

0

90

90

90

90

90

90

ZZZ

90

90

90

90

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

33984

33985

33986

33987

33988

33989

33990

33991

33992

33993

33999

34001

34051

34101

34111

34151

34201

34203

34401

34421

34451

34471

34490

34501

34502

34510

34520

34530

34800

34802

34803

$298.00

$541.00

$554.00

$218.00

$812.00

$525.00

$454.00

$662.00

$215.00

$188.00

BR

$1,012.00

$1,134.00

$800.00

$669.00

$1,288.00

$777.00

$949.00

$953.00

$779.00

$1,117.00

$685.00

$660.00

$910.00

$2,044.00

$1,108.00

$1,077.00

$1,368.00

$1,159.00

$1,279.00

$1,372.00

0

ZZZ

0

0

0

0

0

0

0

0

YYY

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

35121

35122

35131

35132

35141

35142

35151

35152

35180

35182

35184

35188

35189

35190

35013

35021

35022

35045

35081

35082

35091

35092

35102

35103

35111

35112

35201

35206

35207

35211

35216

$2,000.00

$2,382.00

$1,495.00

$1,742.00

$1,231.00

$1,339.00

$1,390.00

$1,229.00

$997.00

$1,345.00

$976.00

$1,048.00

$1,380.00

$1,018.00

$1,376.00

$1,635.00

$1,686.00

$995.00

$2,175.00

$2,661.00

$2,634.00

$2,872.00

$2,346.00

$2,587.00

$1,398.00

$1,351.00

$852.00

$835.00

$935.00

$1,833.00

$1,494.00

90

90

90

90

90

90

90

90

90

90

90

90

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

FUD

90

90

ZZZ

ZZZ

0

ZZZ

0

90

ZZZ

90


Part A, 90

35400

35450

35452

35458

35460

35471

35472

35475

35476

35500

35501

35506

35508

35509

35306

35311

35321

35331

35341

35351

35355

35361

35363

35371

35372

35390

35510

35511

35512

35515

35516

35256

35261

35266

35271

35276

35281

35286

35301

35302

35303

35304

35305



Surgery

CPT Code

35221

MRA

$1,243.00

FUD

90

Surgery

CPT Code

35518

MRA

$1,313.00

FUD

90

Surgery

CPT Code

35665

MRA

$1,333.00

35226

35231

35236

35241

35246

35251

$841.00

$1,053.00

$947.00

$1,926.00

$1,701.00

$1,260.00

90

90

90

90

90

90

35521

35522

35523

35525

35526

35531

$1,393.00

$1,253.00

$1,237.00

$1,197.00

$1,527.00

$2,000.00

90

90

90

90

90

90

35666

35671

35681

35682

35683

35685

$1,686.00

$1,315.00

$751.00

$627.00

$702.00

$216.00

$1,568.00

$1,008.00

$921.00

$1,814.00

$1,541.00

$1,396.00

$1,036.00

$1,486.00

$1,109.00

$1,218.00

$1,267.00

$1,218.00

90

90

90

90

90

90

90

90

90

90

90

90

35533

35535

35536

35537

35538

35539

35540

35556

35558

35560

35563

35565

$1,716.00

$1,816.00

$1,888.00

$2,141.00

$2,391.00

$2,248.00

$2,505.00

$1,745.00

$1,219.00

$1,899.00

$1,115.00

$1,312.00

90

90

90

90

90

90

90

90

90

90

90

90

35686

35691

35693

35694

35695

35697

35700

35701

35721

35741

35761

35800

$178.00

$1,546.00

$1,140.00

$1,353.00

$1,351.00

$166.00

$264.00

$494.00

$500.00

$499.00

$532.00

$567.00

$224.00

$643.00

$518.00

$804.00

$430.00

$626.00

$388.00

$569.00

$338.00

$423.00

$1,569.00

$1,641.00

$1,564.00

$1,529.00

$456.00

$1,999.00

$1,031.00

$1,724.00

$1,908.00

$1,555.00

$1,336.00

$1,859.00

$2,006.00

$1,006.00

$1,085.00

$225.00

$1,316.00

$1,256.00

$1,291.00

$1,387.00

$1,391.00

ZZZ

90

90

90

90

90

90

90

90

90

90

ZZZ

ZZZ

0

0

0

0

0

0

0

0

ZZZ

90

90

90

90

90

90

90

90

90

35566

35570

35571

35572

35583

35585

35587

35600

35601

35606

35612

35616

35621

35623

35626

35631

35632

35633

35634

35636

35637

35638

35642

35645

35646

35647

35650

35654

35656

35661

35663

$2,161.00

$1,455.00

$1,612.00

$369.00

$1,843.00

$2,277.00

$1,698.00

$273.00

$1,495.00

$1,539.00

$1,349.00

$1,346.00

$1,265.00

$1,193.00

$1,921.00

$1,891.00

$1,725.00

$1,926.00

$1,688.00

$1,656.00

$1,704.00

$1,731.00

$1,298.00

$1,304.00

$2,105.00

$1,555.00

$1,236.00

$1,603.00

$1,589.00

$1,145.00

$1,237.00

90

90

90

ZZZ

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

35905

35907

36000

36002

36005

36010

36011

36012

36013

36014

36015

36100

36120

36140

35820

35840

35860

35870

35875

35876

35879

35881

35883

35884

35901

35903

36147

36148

36160

36200

36215

$1,343.00

$1,335.00

$46.00

$181.00

$68.00

$136.00

$194.00

$186.00

$141.00

$159.00

$186.00

$176.00

$120.00

$106.00

$951.00

$771.00

$496.00

$1,583.00

$827.00

$1,232.00

$1,163.00

$1,275.00

$1,247.00

$1,324.00

$709.00

$818.00

$853.00

$265.00

$196.00

$240.00

$240.00

0

0

0

0

0

0

0

0

0

0

0

0

ZZZ

0

0

0

90

90

90

90

90

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

ZZZ

90

90

FUD

90

90

90

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

90

90


Part A, 91

36471

36475

36476

36478

36479

36481

36500

36511

36512

36513

36514

36515

36516

36522

36260

36261

36262

36299

36410

36415

36416

36425

36430

36455

36468

36470

36556

36558

36561

36563

36565

36225

36226

36227

36228

36245

36246

36247

36248

36251

36252

36253

36254



Surgery

CPT Code

36216

MRA

$270.00

FUD

0

Surgery

CPT Code

36566

MRA

$1,121.00

FUD

10

Surgery

CPT Code

37183

MRA

$425.00

36217

36218

36221

36222

36223

36224

$325.00

$79.00

$1,132.00

$1,433.00

$1,560.00

$1,715.00

0

ZZZ

0

0

0

0

36569

36571

36575

36576

36578

36580

$350.00

$1,550.00

$172.00

$429.00

$546.00

$307.00

0

10

0

10

10

0

37184

37185

37186

37187

37188

37191

$3,074.00

$1,002.00

$2,076.00

$2,991.00

$2,586.00

$2,683.00

$1,545.00

$1,749.00

$253.00

$1,190.00

$249.00

$272.00

$323.00

$53.00

$1,436.00

$1,561.00

$2,307.00

$2,211.00

0

0

ZZZ

ZZZ

0

0

0

ZZZ

0

0

0

0

36581

36582

36583

36584

36585

36589

36590

36591

36592

36593

36595

36596

$646.00

$1,210.00

$708.00

$321.00

$1,525.00

$176.00

$378.00

$21.00

$26.00

$37.00

$880.00

$194.00

10

10

10

0

10

10

10

0

0

0

0

0

37192

37193

37195

37197

37200

37211

37212

37213

37214

37215

37217

37218

$1,555.00

$1,638.00

$302.00

$1,541.00

$232.00

$419.00

$370.00

$258.00

$152.00

$1,095.00

$1,164.00

$861.00

$96.00

$2,216.00

$434.00

$2,041.00

$438.00

$499.00

$159.00

$92.00

$92.00

$92.00

$92.00

$92.00

$92.00

$305.00

$749.00

$388.00

$297.00

BR

$18.00

BR

BR

$86.00

$37.00

$141.00

BR

$76.00

$316.00

$703.00

$1,333.00

$1,679.00

$1,073.00

90

90

90

YYY

0

0

0

0

0

0

0

10

10

0

ZZZ

0

ZZZ

0

0

0

0

0

0

0

0

0

0

10

10

10

10

36597

36598

36600

36620

36625

36640

36680

36800

36810

36815

36818

36819

36820

36821

36823

36825

36830

36831

36832

36833

36835

36838

36860

36861

36870

37140

37145

37160

37180

37181

37182

$167.00

$130.00

$24.00

$64.00

$133.00

$130.00

$72.00

$159.00

$345.00

$236.00

$736.00

$977.00

$800.00

$721.00

$1,461.00

$867.00

$967.00

$488.00

$810.00

$780.00

$542.00

$1,230.00

$166.00

$224.00

$1,755.00

$1,666.00

$1,741.00

$1,681.00

$1,769.00

$1,923.00

$914.00

0

0

0

0

0

0

0

0

0

0

90

90

90

90

90

90

90

90

90

90

90

90

0

0

90

90

90

90

90

90

0

37232

37233

37234

37235

37236

37237

37238

37239

37241

37242

37243

37244

37252

37253

37220

37221

37222

37223

37224

37225

37226

37227

37228

37229

37230

37231

37500

37501

37565

37600

37605

$1,238.00

$1,486.00

$3,935.00

$4,017.00

$2,863.00

$1,243.00

$4,186.00

$2,081.00

$4,634.00

$7,805.00

$9,853.00

$6,899.00

$1,426.00

$222.00

$3,236.00

$4,750.00

$911.00

$2,638.00

$3,919.00

$11,190.00

$9,188.00

$15,065.00

$5,569.00

$11,021.00

$8,434.00

$13,463.00

$739.00

BR

$364.00

$414.00

$521.00

0

0

0

ZZZ

ZZZ

ZZZ

0

ZZZ

0

ZZZ

0

90

YYY

90

90

90

0

0

0

ZZZ

ZZZ

ZZZ

ZZZ

0

0

0

0

0

90

90

90

0

0

ZZZ

0

0

0

0

0

0

0

0

0

0

0

0

FUD

0

0

ZZZ

ZZZ


Part A, 92

38206

38220

38221

38230

38232

38240

38241

38242

38243

38300

38305

38308

38380

38381

37785

37788

37790

37799

38100

38101

38102

38115

38120

38129

38200

38205

38382

38500

38505

38510

38520

37619

37650

37660

37700

37718

37722

37735

37760

37761

37765

37766

37780



Surgery

CPT Code

37606

MRA

$563.00

FUD

90

Surgery

CPT Code

38525

MRA

$369.00

FUD

90

Surgery

CPT Code

40652

MRA

$436.00

37607

37609

37615

37616

37617

37618

$456.00

$278.00

$495.00

$1,128.00

$1,132.00

$514.00

90

10

90

90

90

90

38530

38542

38550

38555

38562

38564

$517.00

$507.00

$519.00

$1,115.00

$799.00

$831.00

90

90

90

90

90

90

40654

40700

40701

40702

40720

40761

$529.00

$1,009.00

$1,452.00

$1,030.00

$1,107.00

$1,202.00

$1,712.00

$430.00

$789.00

$336.00

$416.00

$495.00

$847.00

$813.00

$577.00

$462.00

$561.00

$301.00

90

90

90

90

90

90

90

90

90

90

90

90

38570

38571

38572

38589

38700

38720

38724

38740

38745

38746

38747

38760

$695.00

$902.00

$1,049.00

BR

$863.00

$1,328.00

$1,366.00

$539.00

$770.00

$312.00

$337.00

$699.00

10

10

10

YYY

90

90

90

90

90

ZZZ

ZZZ

90

40799

40800

40801

40804

40805

40806

40808

40810

40812

40814

40816

40818

BR

$110.00

$208.00

$105.00

$245.00

$38.00

$100.00

$141.00

$202.00

$319.00

$336.00

$249.00

$79.00

$212.00

$228.00

$265.00

$214.00

$128.00

$128.00

$90.00

$121.00

$104.00

$375.00

$425.00

$628.00

$1,087.00

$270.00

$1,654.00

$690.00

BR

$974.00

$982.00

$332.00

$1,020.00

$1,138.00

BR

$180.00

$79.00

$798.00

$234.00

$139.00

$349.00

$431.00

90

90

90

YYY

90

90

ZZZ

90

90

YYY

0

0

0

0

0

0

0

0

0

0

0

10

90

90

90

90

90

10

0

10

90

38765

38770

38780

38790

38792

38794

38900

38999

39000

39010

39200

39220

39401

39402

39499

39501

39503

39540

39541

39545

39560

39561

39599

40490

40500

40510

40520

40525

40527

40530

40650

$1,283.00

$1,111.00

$1,357.00

$158.00

$26.00

$298.00

$141.00

BR

$664.00

$1,148.00

$1,249.00

$1,542.00

$324.00

$423.00

BR

$1,083.00

$2,726.00

$1,133.00

$1,179.00

$1,102.00

$968.00

$1,328.00

BR

$108.00

$422.00

$469.00

$467.00

$714.00

$851.00

$501.00

$368.00

90

90

90

0

0

90

ZZZ

YYY

90

90

90

90

0

0

YYY

90

90

90

90

90

90

90

YYY

0

90

90

90

90

90

90

90

41006

41007

41008

41009

41010

41015

41016

41017

41018

41019

41100

41105

41108

41110

40819

40820

40830

40831

40840

40842

40843

40844

40845

40899

41000

41005

41112

41113

41114

41115

41116

$237.00

$283.00

$248.00

$319.00

$91.00

$267.00

$357.00

$300.00

$424.00

$444.00

$140.00

$136.00

$110.00

$159.00

$208.00

$104.00

$140.00

$213.00

$687.00

$684.00

$947.00

$1,232.00

$1,593.00

BR

$119.00

$109.00

$255.00

$301.00

$682.00

$176.00

$242.00

0

10

10

10

10

90

10

90

90

90

90

90

90

90

10

90

YYY

10

10

90

90

90

10

90

90

90

90

90

90

90

90

90

10

10

10

10

0

10

10

10

FUD

90

90

90

90

90

90

90

YYY

10

10


Part A, 93

41872

41874

41899

42000

42100

42104

42106

42107

42120

42140

42145

42160

42180

42182

41806

41820

41821

41822

41823

41825

41826

41827

41828

41830

41850

41870

42200

42205

42210

42215

42220

41155

41250

41251

41252

41500

41510

41512

41520

41530

41599

41800

41805



Surgery

CPT Code

41120

MRA

$813.00

FUD

90

Surgery

CPT Code

42225

MRA

$803.00

FUD

90

Surgery

CPT Code

42836

MRA

$286.00

41130

41135

41140

41145

41150

41153

$937.00

$1,869.00

$2,005.00

$2,406.00

$1,897.00

$2,091.00

90

90

90

90

90

90

42226

42227

42235

42260

42280

42281

$848.00

$762.00

$631.00

$491.00

$148.00

$160.00

90

90

90

90

10

10

42842

42844

42845

42860

42870

42890

$729.00

$1,173.00

$1,958.00

$207.00

$427.00

$1,047.00

$2,448.00

$168.00

$203.00

$294.00

$334.00

$313.00

$644.00

$255.00

$3,327.00

BR

$107.00

$115.00

90

10

10

10

90

90

90

90

0

YYY

10

10

42299

42300

42305

42310

42320

42330

42335

42340

42400

42405

42408

42409

BR

$165.00

$448.00

$145.00

$208.00

$184.00

$287.00

$411.00

$94.00

$258.00

$377.00

$266.00

YYY

10

90

10

10

10

90

90

0

10

90

90

42892

42894

42900

42950

42953

42955

42960

42961

42962

42970

42971

42972

$1,262.00

$1,825.00

$429.00

$745.00

$752.00

$561.00

$178.00

$406.00

$602.00

$284.00

$472.00

$562.00

$249.00

$193.00

BR

$106.00

$122.00

$161.00

$204.00

$409.00

$573.00

$174.00

$741.00

$176.00

$222.00

$324.00

$217.00

BR

BR

$237.00

$312.00

$144.00

$211.00

$322.00

$176.00

$156.00

BR

BR

$946.00

$863.00

$1,174.00

$766.00

$586.00

10

0

0

10

90

10

10

90

10

10

0

0

90

90

YYY

10

10

10

10

90

90

90

90

10

10

10

90

90

90

90

90

42410

42415

42420

42425

42426

42440

42450

42500

42505

42507

42509

42510

42550

42600

42650

42660

42665

42699

42700

42720

42725

42800

42804

42806

42808

42809

42810

42815

42821

42826

42831

$746.00

$1,364.00

$1,577.00

$1,097.00

$1,882.00

$634.00

$395.00

$407.00

$559.00

$522.00

$915.00

$711.00

$82.00

$445.00

$67.00

$89.00

$238.00

BR

$144.00

$270.00

$720.00

$123.00

$136.00

$167.00

$250.00

$152.00

$335.00

$659.00

$378.00

$320.00

$235.00

90

90

90

90

90

90

90

90

90

90

90

90

0

90

0

0

90

YYY

10

10

90

10

10

10

10

10

90

90

90

90

90

43118

43121

43122

43123

43124

43130

43135

43180

43191

43192

43193

43194

43195

43196

42999

43020

43030

43045

43100

43101

43107

43108

43112

43113

43116

43117

43197

43198

43200

43201

43202

$2,607.00

$2,350.00

$2,287.00

$2,661.00

$2,242.00

$1,020.00

$1,332.00

$573.00

$130.00

$155.00

$185.00

$168.00

$186.00

$203.00

BR

$696.00

$712.00

$1,574.00

$744.00

$1,248.00

$2,325.00

$2,664.00

$2,471.00

$2,755.00

$2,509.00

$2,469.00

$188.00

$210.00

$266.00

$245.00

$205.00

0

0

0

0

0

90

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

YYY

90

90

90

90

90

10

90

90

90

90

90

90

90

10

FUD

90

90

90

90


Part A, 94

43248

43249

43250

43251

43252

43253

43254

43255

43257

43259

43260

43261

43262

43263

43236

43237

43238

43239

43240

43241

43242

43243

43244

43245

43246

43247

43264

43265

43266

43270

43273

43214

43215

43216

43217

43220

43226

43227

43229

43231

43232

43233

43235



Surgery

CPT Code

43204

MRA

$228.00

FUD

0

Surgery

CPT Code

43274

MRA

$498.00

FUD

0

Surgery

CPT Code

43502

MRA

$1,247.00

43205

43206

43210

43211

43212

43213

$207.00

$337.00

$444.00

$253.00

$200.00

$1,253.00

0

0

0

0

0

0

43275

43276

43277

43278

43279

43280

$411.00

$518.00

$413.00

$470.00

$1,319.00

$1,314.00

0

0

0

0

90

90

43510

43520

43605

43610

43611

43620

$680.00

$599.00

$686.00

$861.00

$1,001.00

$1,691.00

$203.00

$160.00

$149.00

$176.00

$128.00

$142.00

$218.00

$739.00

$182.00

$252.00

$241.00

$239.00

0

0

0

0

0

0

0

0

0

0

0

0

43281

43282

43283

43289

43300

43305

43310

43312

43313

43314

43320

43325

$1,577.00

$1,774.00

$161.00

BR

$837.00

$1,428.00

$2,138.00

$2,331.00

$2,632.00

$2,891.00

$1,299.00

$1,261.00

90

90

ZZZ

YYY

90

90

90

90

90

90

90

90

43621

43622

43631

43632

43633

43634

43635

43640

43641

43644

43645

43651

$1,718.00

$1,798.00

$1,445.00

$1,443.00

$1,467.00

$1,786.00

$143.00

$1,119.00

$1,138.00

$1,598.00

$1,724.00

$716.00

$191.00

$175.00

$194.00

$224.00

$376.00

$280.00

$291.00

$343.00

$305.00

$271.00

$349.00

$362.00

$447.00

$386.00

$285.00

$219.00

$271.00

$246.00

$369.00

$157.00

$384.00

$276.00

$268.00

$214.00

$485.00

$229.00

$522.00

$527.00

$241.00

$737.00

$129.00

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

ZZZ

43327

43328

43330

43331

43332

43333

43334

43335

43336

43337

43338

43340

43341

43351

43352

43360

43361

43400

43401

43405

43410

43415

43420

43425

43450

43453

43460

43496

43499

43500

43501

$838.00

$1,193.00

$1,236.00

$1,378.00

$1,188.00

$1,292.00

$1,282.00

$1,374.00

$1,557.00

$1,681.00

$120.00

$1,292.00

$1,351.00

$1,180.00

$1,028.00

$2,277.00

$2,596.00

$1,261.00

$1,299.00

$1,330.00

$946.00

$1,382.00

$854.00

$1,338.00

$91.00

$102.00

$203.00

BR

BR

$649.00

$1,105.00

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

0

0

0

90

YYY

90

90

43771

43772

43773

43774

43775

43800

43810

43820

43825

43830

43831

43832

43840

43843

43652

43653

43659

43752

43753

43754

43755

43756

43757

43760

43761

43770

43845

43846

43847

43848

43850

$1,162.00

$885.00

$1,162.00

$888.00

$1,146.00

$793.00

$846.00

$896.00

$1,128.00

$592.00

$593.00

$904.00

$893.00

$1,249.00

$856.00

$617.00

BR

$36.00

$21.00

$92.00

$140.00

$214.00

$301.00

$81.00

$107.00

$1,009.00

$1,738.00

$1,528.00

$1,678.00

$1,795.00

$1,425.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

0

0

90

90

90

90

0

0

0

0

0

0

90

90

90

90

90

YYY

90

90

90

ZZZ

90

90

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 95

44141

44143

44144

44145

44146

44147

44150

44151

44155

44156

44157

44158

44160

44180

44111

44120

44121

44125

44126

44127

44128

44130

44133

44136

44139

44140

44186

44187

44188

44202

44203

43888

43999

44005

44010

44015

44020

44021

44025

44050

44055

44100

44110



Surgery

CPT Code

43855

MRA

$1,454.00

FUD

90

Surgery

CPT Code

44204

MRA

$1,353.00

FUD

90

Surgery

CPT Code

44403

MRA

$324.00

43860

43865

43870

43880

43886

43887

$1,435.00

$1,549.00

$590.00

$1,352.00

$280.00

$274.00

90

90

90

90

90

90

44205

44206

44207

44208

44210

44211

$1,198.00

$1,480.00

$1,620.00

$1,752.00

$1,551.00

$1,926.00

90

90

90

90

90

90

44404

44405

44406

44407

44408

44500

$434.00

$622.00

$247.00

$296.00

$250.00

$28.00

$389.00

BR

$1,171.00

$809.00

$1,171.00

$891.00

$888.00

$905.00

$862.00

$957.00

$117.00

$784.00

90

YYY

90

90

ZZZ

90

90

90

90

90

0

90

44212

44213

44227

44238

44300

44310

44312

44314

44316

44320

44322

44340

$1,800.00

$196.00

$1,536.00

BR

$697.00

$950.00

$453.00

$892.00

$1,229.00

$1,029.00

$1,015.00

$397.00

90

ZZZ

90

YYY

90

90

90

90

90

90

90

90

44602

44603

44604

44605

44615

44620

44625

44626

44640

44650

44660

44661

$815.00

$1,041.00

$1,027.00

$1,132.00

$994.00

$741.00

$1,277.00

$1,581.00

$1,036.00

$1,076.00

$1,050.00

$1,326.00

$1,488.00

$1,536.00

$1,442.00

$1,678.00

$1,840.00

$1,452.00

$1,661.00

$1,499.00

$1,892.00

$1,709.00

$1,952.00

$2,003.00

$1,236.00

$853.00

$963.00

$1,078.00

$308.00

$1,135.00

$1,951.00

$2,243.00

$242.00

$938.00

BR

BR

$154.00

$1,350.00

$600.00

$992.00

$1,088.00

$1,603.00

$235.00

90

90

ZZZ

90

90

90

ZZZ

90

0

0

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

44345

44346

44360

44361

44363

44364

44365

44366

44369

44370

44372

44373

44376

44377

44378

44379

44380

44381

44382

44384

44385

44386

44388

44388-53 $178.00

44389

44390

44391

44392

44394

44401

44402

$816.00

$923.00

$177.00

$195.00

$213.00

$255.00

$226.00

$300.00

$308.00

$253.00

$301.00

$238.00

$305.00

$320.00

$410.00

$396.00

$91.00

$1,016.00

$110.00

$164.00

$219.00

$183.00

$326.00

$301.00

$319.00

$376.00

$359.00

$395.00

$3,308.00

$282.00

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

44955

44960

44970

44979

45000

45005

45020

45100

45108

45110

45111

45112

45113

45114

44680

44700

44701

44720

44721

44799

44800

44820

44850

44899

44900

44950

45116

45119

45120

45121

45123

$136.00

$790.00

$631.00

BR

$329.00

$197.00

$364.00

$321.00

$419.00

$1,801.00

$1,270.00

$1,904.00

$1,885.00

$1,732.00

$1,049.00

$1,115.00

$161.00

$268.00

$393.00

BR

$791.00

$755.00

$708.00

BR

$644.00

$643.00

$1,485.00

$1,911.00

$1,845.00

$1,870.00

$1,126.00

90

90

90

90

90

YYY

90

10

90

90

90

90

90

90

90

90

YYY

90

90

ZZZ

90

90

90

90

90

0

0

0

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

0

0

0

FUD

0

0

0

0


Part A, 96

45346

45347

45349

45350

45379

45380

45381

45382

45384

45385

45386

45388

45389

45390

45327

45330

45331

45332

45333

45334

45335

45337

45338

45340

45341

45342

45391

45392

45393

45395

45397

45172

45190

45300

45303

45305

45307

45308

45309

45315

45317

45320

45321



Surgery

CPT Code

45126

MRA

$2,444.00

FUD

90

Surgery

CPT Code

45398

MRA

$744.00

FUD

0

Surgery

CPT Code

46601

MRA

$140.00

45130

45135

45136

45150

45160

45171

$1,041.00

$1,354.00

$1,526.00

$475.00

$949.00

$615.00

90

90

90

90

90

90

45400

45402

45500

45505

45520

45540

$1,058.00

$1,435.00

$584.00

$510.00

$46.00

$1,009.00

90

90

90

90

0

90

46604

46606

46607

46608

46610

46611

$92.00

$66.00

$195.00

$115.00

$114.00

$149.00

$835.00

$623.00

$75.00

$72.00

$102.00

$172.00

$137.00

$174.00

$211.00

$209.00

$230.00

$154.00

90

90

0

0

0

0

0

0

0

0

0

0

45541

45550

45560

45562

45563

45800

45805

45820

45825

45900

45905

45910

$888.00

$1,350.00

$618.00

$915.00

$1,412.00

$1,050.00

$1,273.00

$1,066.00

$1,241.00

$120.00

$133.00

$163.00

90

90

90

90

90

90

90

90

90

10

10

10

46612

46614

46615

46700

46706

46707

46710

46712

46715

46716

46730

46735

$196.00

$169.00

$202.00

$585.00

$140.00

$473.00

$953.00

$1,999.00

$545.00

$906.00

$1,584.00

$1,881.00

$3,167.00

$168.00

$214.00

$593.00

$415.00

$369.00

$388.00

$481.00

$415.00

$479.00

$739.00

$3,327.00

$311.00

$355.00

$96.00

$87.00

$120.00

$174.00

$176.00

$171.00

$144.00

$144.00

$212.00

$328.00

$153.00

$224.00

$283.00

$358.00

$271.00

$1,813.00

$1,969.00

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

90

90

45915

45990

45999

46020

46030

46040

46045

46050

46060

46080

46083

46200

46220

46221

46230

46250

46255

46257

46258

46260

46261

46262

46270

46275

46280

46285

46288

46320

46500

46505

46600

$142.00

$105.00

BR

$230.00

$94.00

$393.00

$312.00

$105.00

$482.00

$246.00

$98.00

$323.00

$118.00

$124.00

$198.00

$400.00

$501.00

$504.00

$539.00

$598.00

$655.00

$686.00

$328.00

$442.00

$514.00

$335.00

$521.00

$126.00

$109.00

$229.00

$38.00

10

0

YYY

10

10

90

90

10

90

10

10

90

10

10

10

90

90

90

90

90

90

90

90

90

90

90

90

10

10

10

0

46910

46916

46917

46922

46924

46930

46940

46942

46945

46946

46947

46999

47000

47001

46740

46742

46744

46746

46748

46750

46753

46754

46760

46761

46762

46900

47010

47015

47100

47120

47122

$144.00

$145.00

$228.00

$189.00

$297.00

$207.00

$165.00

$145.00

$199.00

$270.00

$328.00

BR

$218.00

$141.00

$1,671.00

$2,236.00

$2,412.00

$2,725.00

$2,933.00

$636.00

$511.00

$188.00

$846.00

$813.00

$731.00

$128.00

$788.00

$755.00

$550.00

$1,663.00

$2,512.00

90

90

YYY

0

ZZZ

10

10

90

10

10

90

90

90

90

90

90

90

90

10

10

10

10

90

90

90

90

10

90

90

90

90

90

90

90

90

10

90

90

90

90

0

0

0

0

0

0

FUD

0

0

0

0


Part A, 97

47538

47539

47540

47541

47542

47543

47544

47550

47552

47553

47554

47555

47556

47562

47420

47425

47460

47480

47490

47531

47532

47533

47534

47535

47536

47537

47563

47564

47570

47579

47600

47360

47361

47362

47370

47371

47379

47380

47381

47382

47383

47399

47400



Surgery

CPT Code

47125

MRA

$2,293.00

FUD

90

Surgery

CPT Code

47605

MRA

$935.00

FUD

90

Surgery

CPT Code

48999

MRA

BR

47130

47135

47146

47147

47300

47350

$2,482.00

$6,164.00

$337.00

$393.00

$778.00

$942.00

90

90

0

0

90

90

47610

47612

47620

47700

47701

47711

$1,164.00

$1,276.00

$1,295.00

$1,111.00

$1,913.00

$1,442.00

90

90

90

90

90

90

49000

49002

49010

49020

49040

49060

$862.00

$784.00

$915.00

$910.00

$763.00

$827.00

$1,305.00

$2,129.00

$849.00

$943.00

$889.00

BR

$1,107.00

$1,094.00

$660.00

$7,678.00

BR

$1,435.00

90

90

90

90

90

YYY

90

90

10

10

YYY

90

47712

47715

47720

47721

47740

47741

47760

47765

47780

47785

47800

47801

$1,793.00

$1,157.00

$1,040.00

$1,248.00

$1,188.00

$1,425.00

$1,568.00

$1,624.00

$1,635.00

$1,871.00

$1,485.00

$906.00

90

90

90

90

90

90

90

90

90

90

90

90

49062

49082

49083

49084

49180

49185

49203

49204

49205

49215

49220

49250

$892.00

$193.00

$300.00

$104.00

$212.00

$1,012.00

$1,049.00

$1,337.00

$1,530.00

$1,551.00

$1,182.00

$622.00

$4,584.00

$5,009.00

$5,208.00

$1,202.00

$526.00

$1,350.00

$831.00

$209.00

$364.00

$342.00

$594.00

$383.00

$425.00

$837.00

$1,222.00

$1,275.00

$1,039.00

$755.00

$467.00

$379.00

$835.00

$1,362.00

$1,678.00

$1,126.00

$831.00

$411.00

$900.00

$1,069.00

$961.00

BR

$868.00

90

90

90

90

10

0

0

0

0

0

0

0

0

0

0

0

ZZZ

ZZZ

ZZZ

ZZZ

0

0

0

0

0

90

90

90

90

YYY

90

47802

47900

47999

48000

48001

48020

48100

48102

48105

48120

48140

48145

48146

48148

48150

48152

48153

48154

48155

48160

48400

48500

48510

48520

48540

48545

48547

48548

48552

48554

48556

$1,352.00

$1,331.00

BR

$1,053.00

$1,305.00

$983.00

$779.00

$341.00

$2,505.00

$1,083.00

$1,546.00

$1,661.00

$1,830.00

$1,149.00

$3,101.00

$2,888.00

$3,099.00

$2,893.00

$1,855.00

BR

$100.00

$1,012.00

$938.00

$1,103.00

$1,350.00

$1,170.00

$1,630.00

$1,460.00

$230.00

$2,365.00

$1,117.00

90

90

YYY

90

90

90

90

10

90

90

90

90

90

90

90

90

90

90

90

0

ZZZ

90

90

90

90

90

90

90

0

90

90

49405

49406

49407

49411

49412

49418

49419

49421

49422

49423

49424

49425

49426

49427

49255

49320

49321

49322

49323

49324

49325

49326

49327

49329

49400

49402

49428

49429

49435

49436

49440

$886.00

$886.00

$749.00

$537.00

$83.00

$1,453.00

$405.00

$452.00

$468.00

$106.00

$54.00

$914.00

$725.00

$48.00

$591.00

$415.00

$443.00

$460.00

$712.00

$348.00

$374.00

$171.00

$133.00

BR

$127.00

$748.00

$184.00

$522.00

$110.00

$164.00

$1,113.00

0

0

90

90

0

0

ZZZ

0

90

0

10

10

10

ZZZ

10

10

YYY

0

90

0

0

0

10

90

10

10

ZZZ

ZZZ

90

90

90

90

10

10

90

90

90

0

0

0

90

90

90

90

0

0

FUD

YYY

90

90

90


Part A, 98

49610

49611

49650

49651

49652

49653

49654

49655

49656

49657

49659

49900

49904

49905

49561

49565

49566

49568

49570

49572

49585

49587

49590

49600

49605

49606

49906

49999

50010

50020

50040

49465

49505

49507

49520

49521

49525

49540

49550

49553

49555

49557

49560



Surgery

CPT Code

49441

MRA

$1,319.00

FUD

10

Surgery

CPT Code

50045

MRA

$1,137.00

FUD

90

Surgery

CPT Code

50500

MRA

$1,471.00

49442

49446

49450

49451

49452

49460

$1,075.00

$1,100.00

$771.00

$817.00

$998.00

$818.00

10

0

0

0

0

0

50060

50065

50070

50075

50080

50081

$1,394.00

$1,514.00

$1,476.00

$1,839.00

$1,186.00

$1,635.00

90

90

90

90

90

90

50520

50525

50526

50540

50541

50542

$1,281.00

$1,644.00

$1,639.00

$1,468.00

$1,037.00

$1,093.00

$170.00

$510.00

$636.00

$631.00

$730.00

$584.00

$668.00

$557.00

$598.00

$621.00

$715.00

$734.00

0

90

90

90

90

90

90

90

90

90

90

90

50100

50120

50125

50130

50135

50200

50205

50220

50225

50230

50234

50236

$1,250.00

$1,180.00

$1,228.00

$1,301.00

$1,506.00

$151.00

$807.00

$1,316.00

$1,554.00

$1,695.00

$1,671.00

$1,873.00

90

90

90

90

90

0

90

90

90

90

90

90

50543

50544

50545

50546

50547

50548

50549

50551

50553

50555

50557

50561

$1,374.00

$1,428.00

$1,273.00

$1,325.00

$1,702.00

$1,555.00

BR

$411.00

$447.00

$668.00

$676.00

$755.00

$784.00

$770.00

$484.00

$621.00

$700.00

$874.00

$795.00

$971.00

$864.00

$1,240.00

BR

$512.00

$1,394.00

$454.00

$856.00

$754.00

$881.00

$339.00

$411.00

$491.00

$444.00

$501.00

$585.00

$774.00

$1,648.00

$1,416.00

BR

BR

$886.00

$1,084.00

$910.00

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

YYY

90

90

ZZZ

90

YYY

90

90

90

50240

50250

50280

50290

50320

50327

50328

50329

50340

50360

50365

50370

50380

50382

50384

50385

50386

50387

50389

50390

50391

50395

50396

50400

50405

50430

50431

50432

50433

50434

50435

$1,679.00

$1,157.00

$1,170.00

$1,080.00

$1,680.00

$214.00

$187.00

$179.00

$1,083.00

$2,475.00

$2,941.00

$1,128.00

$1,507.00

$1,594.00

$1,540.00

$1,326.00

$857.00

$772.00

$529.00

$118.00

$139.00

$203.00

$101.00

$1,441.00

$1,802.00

$531.00

$165.00

$860.00

$1,158.00

$916.00

$481.00

90

90

90

90

90

0

0

0

90

90

90

90

90

0

0

0

0

0

0

0

0

0

0

90

90

0

0

0

0

0

0

50606

50610

50620

50630

50650

50660

50684

50686

50688

50690

50693

50694

50695

50700

50562

50570

50572

50574

50575

50576

50580

50590

50592

50593

50600

50605

50705

50706

50715

50722

50725

$538.00

$1,209.00

$1,152.00

$1,170.00

$1,297.00

$1,426.00

$74.00

$109.00

$89.00

$85.00

$1,078.00

$1,187.00

$1,447.00

$1,192.00

$580.00

$549.00

$728.00

$762.00

$991.00

$801.00

$726.00

$980.00

$5,936.00

$4,692.00

$1,150.00

$1,054.00

$1,735.00

$778.00

$1,397.00

$1,211.00

$1,371.00

0

0

0

0

90

90

90

90

0

0

10

ZZZ

ZZZ

90

90

90

10

90

90

ZZZ

90

90

0

90

10

0

0

0

90

0

0

0

0

0

90

90

90

YYY

0

0

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 99

50961

50970

50972

50974

50976

50980

51020

51030

51040

51045

51050

51060

51065

51080

50900

50920

50930

50940

50945

50947

50948

50949

50951

50953

50955

50957

51100

51101

51102

51500

51520

50782

50783

50785

50800

50810

50815

50820

50825

50830

50840

50845

50860



Surgery

CPT Code

50727

MRA

$640.00

FUD

90

Surgery

CPT Code

51525

MRA

$1,069.00

FUD

90

Surgery

CPT Code

51785-26

MRA

$80.00

50728

50740

50750

50760

50770

50780

$924.00

$1,386.00

$1,457.00

$1,389.00

$1,485.00

$1,391.00

90

90

90

90

90

90

51530

51535

51550

51555

51565

51570

$957.00

$932.00

$1,171.00

$1,514.00

$1,624.00

$1,762.00

90

90

90

90

90

90

51785-TC

51792

51792-26

51797-26

$155.00

$143.00

$60.00

51792-TC $213.00

51797 $109.00

$84.00

$1,465.00

$1,515.00

$1,548.00

$1,226.00

$1,527.00

$1,643.00

$1,729.00

$2,351.00

$2,292.00

$1,493.00

$1,513.00

$1,163.00

90

90

90

90

90

90

90

90

90

90

90

90

51575

51580

51585

51590

51595

51596

51597

51600

51605

51610

51700

51701

$2,284.00

$2,252.00

$2,601.00

$2,441.00

$2,900.00

$3,063.00

$2,914.00

$54.00

$83.00

$45.00

$29.00

$58.00

90

90

90

90

90

90

90

0

0

0

0

0

51797-TC $205.00

51798 $20.00

51800 $1,294.00

51820

51840

51841

51845

51860

51865

51880

51900

51920

$1,236.00

$858.00

$1,040.00

$843.00

$912.00

$1,150.00

$590.00

$1,050.00

$881.00

$510.00

$510.00

$408.00

$661.00

$641.00

$443.00

$587.00

$538.00

$439.00

$548.00

$596.00

$768.00

$704.00

$510.00

$1,043.00

$1,075.00

$1,380.00

$1,107.00

$1,096.00

$1,384.00

$1,265.00

BR

$414.00

$461.00

$546.00

$546.00

$63.00

$130.00

$335.00

$775.00

$764.00

90

90

90

90

90

90

90

YYY

0

0

0

0

0

0

0

0

0

0

90

90

90

90

90

90

90

90

0

0

0

90

90

51702

51703

51705

51710

51715

51720

51725

51725-26

51725-TC $199.00

51726

51726-26

51726-TC $274.00

51727 $314.00

51727-26 $111.00

51727-TC $203.00

51728 $315.00

51728-26 $108.00

51728-TC $207.00

51729 $341.00

51729-26 $131.00

51729-TC $211.00

51736

51736-26

51736-TC $15.00

51741

51741-26

51741-TC $17.00

51784

51784-26

51784-TC

51785

$92.00

$128.00

$37.00

$119.00

$322.00

$140.00

$116.00

$79.00

$136.00

$90.00

$47.00

$32.00

$81.00

$59.00

$119.00

$80.00

$136.00

$52.00

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

52214

52224

52234

52235

52240

52250

52260

52265

52270

52275

52276

52277

52281

52282

51925

51940

51960

51980

51990

51992

52000

52001

52005

52007

52010

52204

52283

52285

52287

52290

52300

$367.00

$339.00

$471.00

$546.00

$887.00

$311.00

$262.00

$243.00

$374.00

$446.00

$490.00

$448.00

$259.00

$560.00

$1,167.00

$2,082.00

$1,848.00

$858.00

$850.00

$925.00

$190.00

$133.00

$265.00

$230.00

$292.00

$286.00

$309.00

$375.00

$311.00

$304.00

$370.00

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FUD

0

0

0

0

0

ZZZ

ZZZ

ZZZ

0

90


Part A, 100

52630

52640

52647

52648

52649

52700

53000

53010

53020

53040

53060

53080

53085

53200

52352

52353

52354

52355

52356

52400

52402

52441

52442

52450

52500

52601

53210

53215

53220

53230

53235

52325

52327

52330

52332

52334

52341

52342

52343

52344

52345

52346

52351



Surgery

CPT Code

52301

MRA

$382.00

FUD

0

Surgery

CPT Code

53240

MRA

$506.00

FUD

90

Surgery

CPT Code

54100

MRA

$149.00

52305

52310

52315

52317

52318

52320

$370.00

$348.00

$553.00

$772.00

$684.00

$369.00

0

0

0

0

0

0

53250

53260

53265

53270

53275

53400

$464.00

$240.00

$295.00

$226.00

$332.00

$929.00

90

10

10

10

10

90

54105

54110

54111

54112

54115

54120

$261.00

$775.00

$1,035.00

$1,210.00

$588.00

$777.00

$494.00

$369.00

$507.00

$451.00

$340.00

$317.00

$344.00

$380.00

$407.00

$433.00

$488.00

$297.00

0

0

0

0

0

0

0

0

0

0

0

0

53405

53410

53415

53420

53425

53430

53431

53440

53442

53444

53445

53446

$1,088.00

$1,151.00

$1,381.00

$1,088.00

$1,150.00

$1,116.00

$1,053.00

$1,057.00

$639.00

$755.00

$1,197.00

$699.00

90

90

90

90

90

90

90

90

90

90

90

90

54125

54130

54135

54162

54163

54164

54200

54205

54220

54230

54231

54235

$1,092.00

$1,532.00

$1,945.00

$220.00

$207.00

$182.00

$78.00

$633.00

$189.00

$104.00

$172.00

$81.00

$653.00

$573.00

$858.00

$957.00

$973.00

$517.00

$224.00

$336.00

$153.00

$460.00

$180.00

$567.00

$836.00

$218.00

$349.00

$404.00

$372.00

$447.00

$424.00

$580.00

$279.00

$1,258.00

$962.00

$602.00

$705.00

$1,021.00

$904.00

$1,142.00

$546.00

$760.00

$607.00

0

0

0

0

0

90

0

0

ZZZ

90

90

90

90

90

90

90

90

90

10

90

0

90

10

90

90

0

90

90

90

90

90

53447

53448

53449

53450

53460

53500

53502

53505

53510

53515

53520

53600

53601

53605

53620

53621

53660

53661

53665

53850

53852

53855

53860

53899

54015

54050

54055

54056

54057

54060

54065

$991.00

$1,259.00

$784.00

$447.00

$494.00

$719.00

$590.00

$586.00

$777.00

$987.00

$661.00

$37.00

$37.00

$81.00

$59.00

$45.00

$49.00

$50.00

$50.00

$741.00

$728.00

$770.00

$1,546.00

BR

$348.00

$91.00

$106.00

$100.00

$149.00

$180.00

$281.00

90

90

90

90

90

90

90

90

90

90

90

0

0

0

0

0

0

0

0

90

90

0

90

YYY

10

10

10

10

10

10

10

54322

54324

54326

54328

54332

54336

54340

54344

54348

54352

54360

54380

54385

54390

54240

54240-26

$109.00

$68.00

54240-TC $24.00

54250 $104.00

54250-26 $116.00

54250-TC $9.00

54300

54304

54308

54312

54316

54318

$830.00

$988.00

$881.00

$1,067.00

$1,316.00

$900.00

54400

54401

54405

54406

54408

$784.00

$892.00

$1,294.00

$687.00

$724.00

$974.00

$1,260.00

$1,212.00

$1,201.00

$1,327.00

$1,672.00

$727.00

$1,360.00

$1,318.00

$1,820.00

$898.00

$1,054.00

$1,217.00

$1,635.00

90

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

0

0

0

0

0

10

10

10

10

90

0

90

90

90

90

90

90

FUD

0

10

90

90


Part A, 101

54700

54800

54830

54840

54860

54861

54865

54900

54901

55000

55040

55041

55060

55100

54550

54560

54600

54620

54640

54650

54660

54670

54680

54690

54692

54699

55110

55120

55150

55175

55180

54435

54437

54438

54440

54450

54500

54505

54512

54520

54522

54530

54535



Surgery

CPT Code

54410

MRA

$856.00

FUD

90

Surgery

CPT Code

55200

MRA

$310.00

FUD

90

Surgery

CPT Code

56625

MRA

$735.00

54411

54415

54416

54417

54420

54430

$933.00

$510.00

$665.00

$819.00

$899.00

$799.00

90

90

90

90

90

90

55250

55300

55400

55450

55500

55520

$349.00

$167.00

$660.00

$391.00

$445.00

$446.00

90

0

90

10

90

90

56630

56631

56632

56633

56634

56637

$1,061.00

$1,400.00

$1,636.00

$1,350.00

$1,537.00

$1,806.00

$503.00

$701.00

$1,413.00

BR

$88.00

$102.00

$259.00

$519.00

$445.00

$589.00

$683.00

$922.00

90

90

90

90

0

0

10

90

90

90

90

90

55530

55535

55540

55550

55559

55600

55605

55650

55680

55700

55705

55706

$467.00

$496.00

$572.00

$486.00

BR

$486.00

$609.00

$853.00

$426.00

$183.00

$368.00

$373.00

90

90

90

90

YYY

90

90

90

90

0

10

10

56640

56700

56740

56800

56805

56810

56820

56821

57000

57010

57020

57022

$1,777.00

$227.00

$321.00

$310.00

$1,349.00

$316.00

$119.00

$154.00

$237.00

$429.00

$118.00

$179.00

$133.00

$257.00

$411.00

$432.00

$503.00

$696.00

$333.00

$969.00

$1,340.00

$109.00

$439.00

$634.00

$430.00

$156.00

$588.00

$842.00

$524.00

$373.00

$594.00

$861.00

$401.00

$485.00

$948.00

$825.00

$850.00

BR

$223.00

$350.00

$562.00

$426.00

$796.00

90

90

90

10

90

90

90

90

90

90

90

YYY

10

0

90

90

90

90

90

90

90

0

90

90

90

10

90

90

90

90

90

55720

55725

55801

55810

55812

55815

55821

55831

55840

55842

55845

55860

55862

55865

55866

55870

55873

55875

55876

55899

55920

56405

56420

56440

56441

56442

56501

56515

56605

56606

56620

$555.00

$670.00

$1,331.00

$1,711.00

$1,989.00

$2,328.00

$1,153.00

$1,252.00

$1,705.00

$1,859.00

$2,222.00

$1,012.00

$1,351.00

$1,890.00

$1,615.00

$166.00

$1,127.00

$729.00

$147.00

BR

$420.00

$131.00

$130.00

$271.00

$183.00

$45.00

$122.00

$200.00

$96.00

$49.00

$607.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

0

90

90

0

YYY

0

10

10

10

10

0

10

10

0

ZZZ

90

57130

57135

57150

57155

57156

57160

57170

57180

57200

57210

57220

57230

57240

57250

57023

57061

57065

57100

57105

57106

57107

57109

57110

57111

57112

57120

57260

57265

57267

57268

57270

$220.00

$231.00

$50.00

$383.00

$198.00

$67.00

$74.00

$124.00

$313.00

$395.00

$378.00

$442.00

$536.00

$485.00

$290.00

$124.00

$251.00

$90.00

$132.00

$409.00

$1,467.00

$1,787.00

$1,015.00

$1,793.00

$1,907.00

$612.00

$700.00

$902.00

$284.00

$577.00

$867.00

90

90

90

90

90

0

10

90

0

0

0

90

90

ZZZ

90

90

90

90

90

10

10

0

0

10

90

90

90

90

90

0

10

10

10

10

10

90

10

0

0

10

90

90

90

90

10

10

FUD

90

90

90

90


Part A, 102

57455

57456

57460

57461

57500

57505

57510

57511

57513

57520

57522

57530

57531

57540

57330

57335

57400

57410

57415

57420

57421

57423

57425

57426

57452

57454

57545

57550

57555

57556

57558

57289

57291

57292

57295

57296

57300

57305

57307

57308

57310

57311

57320



Surgery

CPT Code

57280

MRA

$1,071.00

FUD

90

Surgery

CPT Code

57700

MRA

$279.00

FUD

90

Surgery

CPT Code

58552

MRA

$853.00

57282

57283

57284

57285

57287

57288

$734.00

$673.00

$950.00

$607.00

$685.00

$1,009.00

90

90

90

90

90

90

57720

57800

58100

58110

58120

58140

$328.00

$71.00

$74.00

$53.00

$297.00

$1,010.00

90

0

0

ZZZ

10

90

58553

58554

58555

58558

58559

58560

$1,096.00

$1,085.00

$261.00

$340.00

$436.00

$482.00

$879.00

$622.00

$925.00

$485.00

$880.00

$653.00

$995.00

$997.00

$769.00

$517.00

$612.00

$693.00

90

90

90

90

90

90

90

90

90

90

90

90

58145

58146

58150

58152

58180

58200

58210

58240

58260

58262

58263

58267

$677.00

$1,089.00

$1,110.00

$1,159.00

$1,118.00

$1,562.00

$2,080.00

$2,898.00

$926.00

$1,026.00

$1,120.00

$1,133.00

90

90

90

90

90

90

90

90

90

90

90

90

58561

58562

58563

58565

58570

58571

58572

58573

58578

58579

58600

58605

$677.00

$339.00

$450.00

$2,189.00

$844.00

$922.00

$1,047.00

$1,178.00

BR

BR

$337.00

$298.00

$149.00

$141.00

$223.00

$333.00

$89.00

$105.00

$140.00

$159.00

$191.00

$359.00

$319.00

$386.00

$2,036.00

$815.00

$916.00

$963.00

$70.00

$57.00

$75.00

$124.00

$162.00

$848.00

$902.00

$879.00

$96.00

$125.00

$700.00

$486.00

$774.00

$718.00

$120.00

90

90

0

0

10

0

0

90

90

90

0

0

0

0

0

0

0

10

10

10

10

90

90

90

90

90

90

90

90

90

10

58270

58275

58280

58285

58290

58291

58292

58293

58294

58301

58321

58322

58323

58340

58345

58346

58350

58353

58356

58400

58410

58520

58540

58541

58542

58543

58544

58545

58546

58548

58550

$1,019.00

$1,121.00

$1,132.00

$1,360.00

$1,089.00

$1,197.00

$1,268.00

$1,318.00

$1,168.00

$71.00

$81.00

$90.00

$24.00

$87.00

$335.00

$408.00

$103.00

$225.00

$531.00

$519.00

$752.00

$663.00

$923.00

$793.00

$877.00

$891.00

$965.00

$876.00

$1,104.00

$1,688.00

$1,038.00

90

90

90

90

90

90

90

90

90

0

0

0

0

0

10

90

10

10

10

90

90

90

90

90

90

90

90

90

90

90

90

58740

58750

58752

58760

58770

58800

58805

58820

58822

58825

58900

58920

58925

58940

58611

58615

58660

58661

58662

58670

58671

58672

58673

58679

58700

58720

58943

58950

58951

58952

58953

$508.00

$949.00

$893.00

$769.00

$763.00

$343.00

$509.00

$326.00

$603.00

$469.00

$489.00

$571.00

$820.00

$592.00

$47.00

$319.00

$793.00

$804.00

$807.00

$450.00

$463.00

$872.00

$928.00

BR

$544.00

$844.00

$1,368.00

$1,170.00

$1,703.00

$1,876.00

$1,839.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

YYY

90

90

90

90

90

10

90

90

90

90

90

YYY

90

90

ZZZ

10

90

90

90

90

90

90

YYY

0

0

0

0

0

0

FUD

90

90

90

0


Part A, 103

59320

59325

59350

59400

59409

59410

59412

59414

59425

59426

59430

59510

59514

59515

59100

59120

59121

59130

59135

59136

59140

59150

59151

59160

59200

59300

59525

59610

59612

59614

59618



Surgery

CPT Code

58954

MRA

$1,999.00

FUD

90

Surgery

CPT Code

59620

MRA

$1,293.00

FUD

0

Surgery

CPT Code

61026

MRA

$138.00

58956

58957

58958

58960

58999

59000

$1,329.00

$1,365.00

$1,511.00

$1,174.00

BR

$123.00

90

90

90

90

YYY

0

59622

59812

59820

59821

59830

59840

$1,397.00

$343.00

$389.00

$398.00

$496.00

$331.00

0

90

90

90

90

10

61050

61055

61070

61105

61107

61108

$106.00

$143.00

$67.00

$503.00

$863.00

$959.00

59001

59012

59015

$167.00

$267.00

$168.00

59020

59020-26

$85.00

$40.00

59020-TC $23.00

59025

59025-26

$54.00

$32.00

59025-TC $10.00

59030

59050

59051

$155.00

$71.00

$47.00

0

0

0

0

0

0

0

0

0

0

0

0

59841

59850

59851

59852

59855

59856

59857

59866

59870

59871

59898

59899

$443.00

$449.00

$464.00

$642.00

$477.00

$577.00

$711.00

$304.00

$348.00

$192.00

BR

BR

10

90

90

90

90

90

90

0

90

0

YYY

YYY

61120

61140

61150

61151

61154

61156

61210

61215

61250

61253

61304

61305

$733.00

$1,389.00

$1,503.00

$795.00

$1,393.00

$1,473.00

$527.00

$637.00

$888.00

$1,042.00

$2,005.00

$2,419.00

$196.00

$316.00

$375.00

$1,816.00

$1,019.00

$1,123.00

$141.00

$134.00

$414.00

$708.00

$140.00

$2,064.00

$1,199.00

$1,324.00

$633.00

$893.00

$768.00

$832.00

$1,083.00

$934.00

$461.00

$543.00

$690.00

$279.00

$79.00

$179.00

$591.00

$1,805.00

$1,113.00

$1,208.00

$2,035.00

90

90

90

90

90

90

90

90

90

10

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

ZZZ

0

0

0

0

60000

60100

60200

60210

60212

60220

60225

60240

60252

60254

60260

60270

60271

60280

60281

60300

60500

60502

60505

60512

60520

60521

60522

60540

60545

60600

60605

60650

60659

60699

61020

$114.00

$96.00

$744.00

$872.00

$1,170.00

$851.00

$1,107.00

$1,228.00

$1,427.00

$1,911.00

$1,022.00

$1,468.00

$1,210.00

$546.00

$670.00

$99.00

$1,232.00

$1,475.00

$1,631.00

$310.00

$1,405.00

$1,591.00

$1,820.00

$1,272.00

$1,505.00

$1,477.00

$1,624.00

$1,340.00

BR

BR

$150.00

10

0

90

90

90

90

90

90

90

90

90

90

90

90

90

0

90

90

90

ZZZ

90

90

90

90

90

90

90

90

YYY

YYY

0

61340

61343

61345

61450

61458

61460

61480

61500

61501

61510

61512

61514

61516

61517

61312

61313

61314

61315

61316

61320

61321

61322

61323

61330

61332

61333

61518

61519

61520

61521

61522

$1,584.00

$2,673.00

$2,259.00

$2,173.00

$2,433.00

$2,426.00

$1,922.00

$1,637.00

$1,353.00

$2,506.00

$2,981.00

$2,262.00

$2,253.00

$74.00

$2,187.00

$2,207.00

$2,200.00

$2,393.00

$88.00

$2,118.00

$2,310.00

$1,779.00

$1,842.00

$1,706.00

$2,307.00

$2,231.00

$3,163.00

$3,450.00

$4,349.00

$3,667.00

$2,415.00

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

0

90

90

90

0

90

90

90

90

FUD

0

0

0

0


Part A, 104

61576

61580

61581

61582

61583

61584

61585

61586

61590

61591

61592

61595

61596

61597

61552

61556

61557

61558

61559

61563

61564

61566

61567

61570

61571

61575

61598

61600

61601

61605

61606

61536

61537

61538

61539

61540

61541

61543

61544

61545

61546

61548

61550



Surgery

CPT Code

61524

MRA

$2,484.00

FUD

90

Surgery

CPT Code

61607

MRA

$2,961.00

FUD

90

Surgery

CPT Code

61799

MRA

$308.00

61526

61530

61531

61533

61534

61535

$3,918.00

$3,611.00

$1,344.00

$1,712.00

$1,535.00

$958.00

90

90

90

90

90

90

61608

61610

61611

61612

61613

61615

$3,458.00

$2,354.00

$584.00

$2,219.00

$3,375.00

$2,576.00

90

ZZZ

ZZZ

ZZZ

90

90

61800

61850

61860

61863

61864

61867

$156.00

$1,090.00

$1,197.00

$1,231.00

$295.00

$1,863.00

$2,862.00

$1,714.00

$2,466.00

$2,660.00

$2,069.00

$2,363.00

$2,307.00

$2,271.00

$3,474.00

$2,695.00

$1,964.00

$1,141.00

90

90

90

90

90

90

90

90

90

90

90

90

61616

61618

61619

61623

61624

61626

61630

61635

61640

61641

61642

61645

$3,535.00

$1,389.00

$1,682.00

$540.00

$1,073.00

$877.00

$1,245.00

$1,362.00

$555.00

$195.00

$390.00

$809.00

90

90

90

0

0

0

0

0

0

ZZZ

ZZZ

0

61868

61870

61880

61885

61886

61888

62000

62005

62010

62100

62115

62117

$491.00

$616.00

$559.00

$262.00

$678.00

$331.00

$848.00

$1,282.00

$1,754.00

$1,962.00

$1,686.00

$2,211.00

$3,772.00

$2,383.00

$2,674.00

$2,557.00

$2,972.00

$2,830.00

$3,142.00

$2,097.00

$3,299.00

$3,491.00

$3,245.00

$2,350.00

$2,827.00

$3,046.00

$1,463.00

$1,760.00

$1,807.00

$2,085.00

$2,700.00

$2,175.00

$2,597.00

$2,048.00

$2,340.00

$1,975.00

$2,140.00

$2,992.00

$2,693.00

$2,039.00

$2,279.00

$2,299.00

$3,178.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

61650

61651

61680

61682

61684

61686

61690

61692

61697

61698

61700

61702

61703

61705

61708

61710

61711

61720

61735

61750

61751

61760

61770

61781

61782

61783

61790

61791

61796

61797

61798

$540.00

$229.00

$2,758.00

$4,798.00

$3,341.00

$5,012.00

$2,556.00

$4,007.00

$3,231.00

$3,103.00

$4,037.00

$4,019.00

$1,444.00

$3,043.00

$2,546.00

$2,129.00

$3,150.00

$1,558.00

$1,664.00

$1,521.00

$1,628.00

$1,670.00

$1,867.00

$240.00

$197.00

$241.00

$952.00

$1,205.00

$1,027.00

$224.00

$1,404.00

0

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

ZZZ

ZZZ

90

90

90

ZZZ

90

62162

62163

62164

62165

62180

62190

62192

62194

62200

62201

62220

62223

62225

62230

62120

62121

62140

62141

62142

62143

62145

62146

62147

62148

62160

62161

62252

62252-26

$85.00

$49.00

62252-TC $42.00

62256

62258

$616.00

$1,308.00

$1,898.00

$1,822.00

$1,221.00

$1,955.00

$1,011.00

$1,096.00

$1,566.00

$1,327.00

$1,566.00

$120.00

$172.00

$1,229.00

$1,578.00

$999.00

$1,706.00

$1,336.00

$1,695.00

$1,034.00

$1,146.00

$239.00

$1,625.00

$1,200.00

$1,215.00

$1,199.00

$488.00

$935.00

90

90

90

90

90

90

90

90

90

10

90

0

0

0

90

90

ZZZ

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

10

90

90

90

FUD

ZZZ

ZZZ

90

90

90

ZZZ

90

ZZZ

90

90


Part A, 105

62365

62367

62368

62369

62370

63001

63003

63005

63011

63012

63015

63016

63017

63020

62304

62305

62310

62311

62318

62319

62350

62351

62355

62360

62361

62362

63030

63035

63040

63042

63043

62273

62280

62281

62282

62284

62287

62290

62291

62292

62294

62302

62303



Surgery

CPT Code

62263

MRA

$426.00

FUD

10

Surgery

CPT Code

63044

MRA

BR

FUD

ZZZ

Surgery

CPT Code

63271

MRA

$2,401.00

62264

62267

62268

62269

62270

62272

$593.00

$253.00

$285.00

$271.00

$109.00

$137.00

10

0

0

0

0

0

63045

63046

63047

63048

63050

63051

$1,647.00

$2,117.00

$1,907.00

$367.00

$1,411.00

$1,605.00

90

90

90

ZZZ

90

90

63272

63273

63275

63276

63277

63278

$2,206.00

$2,012.00

$2,166.00

$2,135.00

$1,905.00

$1,877.00

$130.00

$199.00

$186.00

$211.00

$196.00

$784.00

$235.00

$232.00

$1,064.00

$821.00

$246.00

$256.00

0

10

10

10

0

90

0

0

90

90

0

0

63055

63056

63057

63064

63066

63075

63076

63077

63078

63081

63082

63085

$2,029.00

$1,960.00

$421.00

$2,200.00

$263.00

$1,720.00

$383.00

$1,828.00

$261.00

$2,203.00

$391.00

$2,416.00

90

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

63280

63281

63282

63283

63285

63286

63287

63290

63295

63300

63301

63302

$2,529.00

$2,496.00

$2,305.00

$2,041.00

$2,934.00

$3,003.00

$3,012.00

$3,073.00

$319.00

$2,006.00

$2,209.00

$2,290.00

$418.00

$39.00

$53.00

$121.00

$128.00

$1,882.00

$1,591.00

$1,390.00

$1,151.00

$1,568.00

$1,862.00

$1,788.00

$1,489.00

$1,395.00

$244.00

$266.00

$200.00

$201.00

$208.00

$203.00

$488.00

$782.00

$402.00

$195.00

$390.00

$517.00

$1,145.00

$280.00

$1,764.00

$1,620.00

BR

0

0

0

0

0

0

10

90

10

10

10

10

10

0

0

0

0

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

ZZZ

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

63270

$282.00

$2,930.00

$381.00

$2,490.00

$249.00

$2,127.00

$2,127.00

$249.00

$1,788.00

$1,672.00

$1,851.00

$1,486.00

$1,711.00

$1,347.00

$1,610.00

$1,444.00

$1,593.00

$1,603.00

$1,810.00

$1,725.00

$1,956.00

$2,258.00

$1,569.00

$3,182.00

$3,207.00

$3,319.00

$1,940.00

$2,053.00

$1,651.00

$1,469.00

$2,197.00

ZZZ

90

ZZZ

90

ZZZ

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

63655

63661

63662

63663

63664

63685

63688

63700

63702

63704

63706

63707

63709

63710

63303

63304

63305

63306

63307

63308

63600

63610

63615

63620

63621

63650

63740

63741

63744

63746

64400

$1,064.00

$584.00

$792.00

$811.00

$820.00

$615.00

$707.00

$1,340.00

$1,512.00

$1,708.00

$1,873.00

$1,041.00

$1,310.00

$1,165.00

$2,357.00

$2,513.00

$2,574.00

$2,596.00

$2,522.00

$425.00

$797.00

$476.00

$1,348.00

$1,133.00

$256.00

$819.00

$1,062.00

$741.00

$738.00

$529.00

$78.00

90

90

90

90

90

10

90

10

10

90

90

90

90

90

90

0

90

ZZZ

10

90

10

90

90

90

ZZZ

90

0

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 106

64489

64490

64491

64492

64493

64494

64495

64505

64508

64510

64517

64520

64530

64550

64450

64455

64461

64462

64463

64479

64480

64483

64484

64486

64487

64488

64553

64555

64561

64565

64566

64417

64418

64420

64421

64425

64430

64435

64445

64446

64447

64448

64449



Surgery

CPT Code

64402

MRA

$75.00

FUD

0

Surgery

CPT Code

64568

MRA

$628.00

FUD

90

Surgery

CPT Code

64736

MRA

$388.00

64405

64408

64410

64413

64415

64416

$103.00

$120.00

$109.00

$128.00

$109.00

$159.00

0

0

0

0

0

0

64569

64570

64575

64580

64581

64585

$799.00

$709.00

$367.00

$343.00

$745.00

$37.00

90

90

90

90

90

10

64738

64740

64742

64744

64746

64755

$475.00

$461.00

$517.00

$798.00

$494.00

$1,042.00

$105.00

$108.00

$89.00

$128.00

$116.00

$130.00

$114.00

$68.00

$165.00

$77.00

$152.00

$152.00

0

0

0

0

0

0

0

0

0

0

0

0

64590

64595

64600

64605

64610

64611

64612

64615

64616

64617

64620

64630

$217.00

$153.00

$228.00

$319.00

$307.00

$114.00

$188.00

$146.00

$125.00

$193.00

$185.00

$202.00

10

10

10

10

10

10

10

10

10

10

10

10

64760

64763

64766

64771

64772

64774

64776

64778

64782

64783

64784

64786

$578.00

$561.00

$713.00

$632.00

$636.00

$392.00

$390.00

$249.00

$482.00

$298.00

$751.00

$1,281.00

$218.00

$196.00

$96.00

$97.00

$177.00

$88.00

$89.00

$104.00

$99.00

$103.00

$188.00

$131.00

$135.00

$23.00

$53.00

$49.00

$151.00

$86.00

$164.00

$224.00

$194.00

$206.00

$183.00

$127.00

$156.00

$156.00

$137.00

$131.00

$801.00

$121.00

$121.00

0

0

0

ZZZ

0

0

ZZZ

0

ZZZ

0

0

0

0

0

ZZZ

ZZZ

0

ZZZ

ZZZ

0

0

0

0

0

0

0

10

10

10

10

0

64632

64633

64634

64635

64636

64640

64642

64643

64644

64645

64646

64647

64650

64653

64680

64681

64702

64704

64708

64712

64713

64714

64716

64718

64719

64721

64722

64726

64727

64732

64734

$87.00

$441.00

$200.00

$435.00

$181.00

$208.00

$142.00

$93.00

$162.00

$114.00

$152.00

$176.00

$62.00

$71.00

$180.00

$464.00

$383.00

$402.00

$562.00

$678.00

$867.00

$715.00

$523.00

$558.00

$446.00

$439.00

$411.00

$271.00

$261.00

$405.00

$432.00

10

10

ZZZ

10

ZZZ

10

0

ZZZ

0

ZZZ

0

0

0

0

10

10

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

64823

64831

64832

64834

64835

64836

64837

64840

64856

64857

64858

64859

64861

64862

64787

64788

64790

64792

64795

64802

64804

64809

64818

64820

64821

64822

64864

64865

64866

64868

64872

$703.00

$592.00

$171.00

$711.00

$834.00

$856.00

$480.00

$1,058.00

$1,063.00

$1,137.00

$1,313.00

$341.00

$1,524.00

$1,798.00

$458.00

$381.00

$884.00

$1,148.00

$247.00

$711.00

$1,202.00

$1,080.00

$845.00

$838.00

$609.00

$609.00

$970.00

$1,250.00

$1,238.00

$1,162.00

$155.00

90

90

ZZZ

90

90

90

90

90

ZZZ

90

90

90

90

90

90

ZZZ

90

90

90

90

90

ZZZ

90

0

90

90

90

90

ZZZ

90

90

ZZZ

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 107

65150

65155

65175

65205

65210

65220

65222

65235

65260

65265

65270

65272

65273

65275

65091

65093

65101

65103

65105

65110

65112

65114

65125

65130

65135

65140

65280

65285

65286

65290

65400

64893

64895

64896

64897

64898

64901

64902

64905

64907

64910

64911

64999



Surgery

CPT Code

64874

MRA

$230.00

FUD

ZZZ

Surgery

CPT Code

65410

MRA

$142.00

FUD

0

Surgery

CPT Code

66185

MRA

$769.00

64876

64885

64886

64890

64891

64892

$189.00

$1,382.00

$1,636.00

$1,112.00

$1,243.00

$1,177.00

ZZZ

90

90

90

90

90

65420

65426

65430

65435

65436

65450

$448.00

$534.00

$81.00

$88.00

$319.00

$52.00

90

90

0

0

90

90

66220

66225

66250

66500

66505

66600

$711.00

$1,006.00

$602.00

$359.00

$359.00

$825.00

$1,321.00

$1,500.00

$1,185.00

$1,419.00

$1,549.00

$865.00

$982.00

$1,059.00

$1,472.00

$645.00

$783.00

BR

90

90

90

90

90

ZZZ

ZZZ

90

90

90

90

YYY

65600

65710

65730

65750

65755

65756

65770

65772

65775

65778

65779

65780

$325.00

$1,124.00

$1,314.00

$1,381.00

$1,373.00

$1,201.00

$1,461.00

$449.00

$595.00

$1,389.00

$1,238.00

$766.00

90

90

90

90

90

90

90

90

90

0

0

90

66605

66625

66630

66635

66680

66682

66700

66710

66711

66720

66740

66761

$1,136.00

$543.00

$623.00

$595.00

$526.00

$627.00

$506.00

$513.00

$507.00

$506.00

$473.00

$506.00

$652.00

$862.00

$654.00

$45.00

$53.00

$58.00

$62.00

$627.00

$956.00

$1,104.00

$88.00

$223.00

$376.00

$75.00

$678.00

$712.00

$726.00

$769.00

$846.00

$1,305.00

$1,386.00

$1,456.00

$312.00

$730.00

$678.00

$738.00

$711.00

$1,177.00

$692.00

$519.00

$603.00

90

90

90

90

90

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

65781

65782

65785

65800

65810

65815

65820

65850

65855

65860

65865

65870

65875

65880

65900

65920

65930

66020

66030

66130

66150

66155

66160

66170

66172

66174

66175

66179

66180

66183

66184

$1,169.00

$1,008.00

$2,144.00

$88.00

$516.00

$327.00

$813.00

$968.00

$441.00

$339.00

$540.00

$572.00

$597.00

$641.00

$945.00

$752.00

$700.00

$164.00

$160.00

$631.00

$798.00

$795.00

$942.00

$1,089.00

$1,264.00

$1,006.00

$1,140.00

$1,092.00

$1,313.00

$1,090.00

$796.00

90

90

90

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

66982

66983

66984

66985

66986

66990

66999

67005

67010

67015

67025

67027

67028

67030

66762

66770

66820

66821

66825

66830

66840

66850

66852

66920

66930

66940

67031

67036

67039

67040

67041

$846.00

$763.00

$898.00

$744.00

$1,038.00

$84.00

BR

$639.00

$647.00

$637.00

$774.00

$1,089.00

$338.00

$485.00

$433.00

$483.00

$433.00

$275.00

$753.00

$651.00

$707.00

$805.00

$878.00

$785.00

$906.00

$819.00

$402.00

$1,384.00

$1,490.00

$1,960.00

$1,065.00

90

90

90

0

90

90

90

ZZZ

YYY

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

90

90

90

90

90

90

90

90

FUD

90

90

90

90


Part A, 108

67331

67332

67334

67335

67340

67343

67345

67346

67399

67400

67405

67412

67413

67414

67227

67228

67229

67250

67255

67299

67311

67312

67314

67316

67318

67320

67415

67420

67430

67440

67445

67113

67115

67120

67121

67141

67145

67208

67210

67218

67220

67221

67225



Surgery

CPT Code

67042

MRA

$1,218.00

FUD

90

Surgery

CPT Code

67450

MRA

$1,300.00

FUD

90

Surgery

CPT Code

67973

MRA

$1,126.00

67043

67101

67105

67107

67108

67110

$1,279.00

$767.00

$941.00

$1,350.00

$1,878.00

$1,040.00

90

90

90

90

90

90

67500

67505

67515

67550

67560

67570

$75.00

$109.00

$53.00

$946.00

$936.00

$1,148.00

0

0

0

90

90

90

67974

67975

67999

68020

68040

68100

$1,140.00

$681.00

BR

$106.00

$75.00

$137.00

$1,405.00

$496.00

$751.00

$962.00

$536.00

$514.00

$655.00

$779.00

$1,217.00

$894.00

$325.00

$44.00

90

90

90

90

90

90

90

90

90

90

0

ZZZ

67599

67700

67710

67715

67800

67801

67805

67808

67810

67820

67825

67830

BR

$87.00

$117.00

$102.00

$119.00

$189.00

$208.00

$308.00

$133.00

$36.00

$130.00

$239.00

YYY

10

10

10

10

10

10

90

0

0

10

10

68110

68115

68130

68135

68200

68320

68325

68326

68328

68330

68335

68340

$172.00

$248.00

$378.00

$146.00

$59.00

$502.00

$672.00

$654.00

$741.00

$488.00

$636.00

$413.00

$560.00

$621.00

$447.00

$253.00

$559.00

$628.00

$275.00

$173.00

BR

$960.00

$799.00

$976.00

$909.00

$1,023.00

$652.00

$1,025.00

$926.00

$793.00

$872.00

BR

$616.00

$773.00

$688.00

$857.00

$663.00

$602.00

$146.00

$1,729.00

$1,203.00

$1,257.00

$1,269.00

10

10

90

90

90

YYY

90

90

90

90

90

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

90

10

0

YYY

90

90

90

90

90

0

90

90

90

90

67835

67840

67850

67875

67880

67882

67900

67901

67902

67903

67904

67906

67908

67909

67911

67912

67914

67915

67916

67917

67921

67922

67923

67924

67930

67935

67938

67950

67961

67966

67971

$500.00

$187.00

$143.00

$163.00

$442.00

$643.00

$487.00

$646.00

$650.00

$657.00

$720.00

$633.00

$550.00

$577.00

$517.00

$983.00

$487.00

$252.00

$675.00

$631.00

$419.00

$243.00

$718.00

$605.00

$280.00

$520.00

$67.00

$584.00

$571.00

$645.00

$875.00

90

10

10

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

10

90

10

90

90

90

90

68530

68540

68550

68700

68705

68720

68745

68750

68760

68761

68770

68801

68810

68811

68360

68362

68371

68399

68400

68420

68440

68500

68505

68510

68520

68525

68815

68816

68840

68850

68899

$379.00

$875.00

$1,107.00

$628.00

$176.00

$807.00

$704.00

$792.00

$109.00

$130.00

$634.00

$202.00

$290.00

$191.00

$449.00

$691.00

$363.00

BR

$154.00

$191.00

$96.00

$882.00

$921.00

$491.00

$687.00

$340.00

$399.00

$592.00

$100.00

$76.00

BR

10

90

10

10

10

90

10

90

90

90

10

0

90

0

10

90

90

YYY

10

10

10

90

90

10

10

10

0

YYY

90

90

90

90

90

10

10

0

90

90

90

90

10

0

0

10

10

90

FUD

90

90

90

YYY


Part A, 109

69511

69530

69535

69540

69550

69552

69554

69601

69602

69603

69604

69605

69610

69620

69631

69632

69633

69635

69636

69320

69399

69420

69421

69424

69433

69436

69440

69450

69501

69502

69505

69140

69145

69150

69155

69200

69205

69209

69210

69220

69222

69300

69310



Surgery

CPT Code

69000

MRA

$52.00

FUD

10

Surgery

CPT Code

69637

MRA

$1,370.00

FUD

90

Surgery

CPT Code

G0364

MRA

$12.00

69005

69020

69100

69105

69110

69120

$175.00

$109.00

$85.00

$87.00

$294.00

$274.00

10

10

0

0

90

90

69641

69642

69643

69644

69645

69646

$1,154.00

$1,519.00

$1,389.00

$1,529.00

$1,479.00

$1,620.00

90

90

90

90

90

90

G0412

G0413

G0414

G0415

G0429

$742.00

$1,092.00

$1,017.00

$1,407.00

$102.00

$722.00

$248.00

$1,111.00

$1,680.00

$53.00

$110.00

$13.00

$39.00

$78.00

$123.00

$522.00

$937.00

90

90

90

90

0

10

0

0

0

10

YYY

90

69650

69660

69661

69662

69666

69667

69670

69676

69700

69710

69711

69714

$879.00

$1,072.00

$1,412.00

$1,386.00

$887.00

$887.00

$988.00

$828.00

$702.00

BR

$878.00

$961.00

90

90

90

90

90

90

90

90

90

0

90

90

$1,434.00

BR

$117.00

$155.00

$84.00

$145.00

$182.00

$699.00

$525.00

$829.00

$1,118.00

$1,176.00

$1,221.00

$1,616.00

$2,824.00

$126.00

$998.00

$1,621.00

$2,600.00

$1,195.00

$1,225.00

$1,264.00

$1,263.00

$1,526.00

$41.00

$651.00

$985.00

$1,166.00

$1,110.00

$1,207.00

$1,381.00

90

YYY

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

90

90

90

69715

69717

69718

69720

69725

69740

69745

69799

69801

69805

69806

69820

69840

69905

69910

69915

69930

69949

69950

69955

69960

69970

69979

69990

G0127

G0168

G0247

G0289

G0341

G0342

G0343

$1,217.00

$996.00

$1,232.00

$1,307.00

$1,922.00

$1,274.00

$1,447.00

BR

$785.00

$1,187.00

$1,123.00

$876.00

$869.00

$1,013.00

$1,228.00

$1,754.00

$1,498.00

BR

$2,017.00

$2,185.00

$2,116.00

$2,306.00

BR

$262.00

$17.00

$75.00

$38.00

$82.00

$333.00

$622.00

$1,026.00

90

90

90

90

90

90

90

YYY

0

90

90

90

90

90

90

90

90

YYY

90

90

90

90

YYY

ZZZ

0

0

ZZZ

ZZZ

0

90

90

FUD

ZZZ

90

90

90

90

0


Part A, 110

$37.00

$34.00

$10.00

$22.00

$43.00

$14.00

$29.00

$32.00

$8.00

$22.00

$42.00

$12.00

$29.00

$26.00

$9.00

$28.00

$33.00

$9.00

$22.00

$42.00

$12.00

$29.00

$29.00

$8.00

$19.00

$52.00

$15.00

$19.00

$36.00

$12.00

$22.00

$32.00

$9.00

$22.00

$46.00

$17.00

$29.00

$45.00

$17.00

MRA

$70.00

$19.00

$51.00

$58.00

$31.00

$27.00

$24.00

$10.00

$15.00

$29.00

$9.00



70160-TC

70170

70170-26

70170-TC

70190

70190-26

70190-TC

70200

70200-26

70200-TC

70210

70210-26

70130-TC

70134

70134-26

70134-TC

70140

70140-26

70140-TC

70150

70150-26

70150-TC

70160

70160-26

70210-TC

70220

70220-26

70220-TC

70240

70240-26

Radiology

CPT Code

70010

70010-26

70010-TC

70015

70015-26

70015-TC

70030

70030-26

70030-TC

70100

70100-26

70100-TC

70110

70110-26

70110-TC

70120

70120-26

70120-TC

70130

70130-26

Radiology

CPT Code

70240-TC

70250

70250-26

70250-TC

70260

70260-26

70260-TC

70300

70300-26

70300-TC

70310

70310-26

70310-TC

70320

70320-26

70320-TC

70328

70328-26

70328-TC

70330

70330-26

70330-TC

70332

70332-26

70332-TC

70336

70336-26

70336-TC

70350

70350-26

70350-TC

70355

70355-26

70355-TC

70360

70360-26

70360-TC

70370

70370-26

70370-TC

70371

70371-26

70371-TC

70380

70380-26

70380-TC

70390

70390-26

70390-TC

70450

70492

70492-26

70492-TC

70496

70496-26

70496-TC

70498

70498-26

70498-TC

70540

70540-26

70540-TC

70487

70487-26

70487-TC

70488

70488-26

70488-TC

70490

70490-26

70490-TC

70491

70491-26

70491-TC

70542

70542-26

70542-TC

70543

70543-26

70543-TC

Radiology

CPT Code

70450-26

70450-TC

70460

70460-26

70460-TC

70470

70470-26

70470-TC

70480

70480-26

70480-TC

70481

70481-26

70481-TC

70482

70482-26

70482-TC

70486

70486-26

70486-TC

$8.00

$15.00

$65.00

$16.00

$48.00

$122.00

$43.00

$79.00

$34.00

$8.00

$24.00

$87.00

$19.00

$68.00

$221.00

$27.00

$80.00

$497.00

$72.00

$419.00

$24.00

$10.00

$14.00

$32.00

$10.00

$21.00

$24.00

$8.00

$15.00

$40.00

$11.00

$29.00

$28.00

$10.00

$18.00

$43.00

$12.00

$31.00

$107.00

MRA

$15.00

$35.00

$12.00

$22.00

$50.00

$17.00

$33.00

$15.00

$5.00

$10.00

$24.00

$366.00

$92.00

$270.00

$366.00

$92.00

$270.00

$482.00

$70.00

$413.00

$579.00

$82.00

$495.00

$1,029.00

$109.00

$916.00

$339.00

$72.00

$264.00

$244.00

$65.00

$176.00

$284.00

$70.00

$211.00

$340.00

$74.00

$264.00

$284.00

$70.00

$211.00

$340.00

$74.00

$264.00

$236.00

$58.00

$176.00

$279.00

$66.00

$211.00

MRA

$43.00

$176.00

$271.00

$58.00

$211.00

$332.00

$65.00

$264.00

$244.00

$65.00

$176.00


Part A, 111

$349.00

$425.00

$164.00

$376.00

$548.00

$164.00

$499.00

$27.00

$9.00

$17.00

$30.00

$10.00

$19.00

$35.00

$11.00

$502.00

$1,055.00

$120.00

$931.00

$618.00

$99.00

$520.00

BR

$118.00

BR

$392.00

$148.00

$419.00

$481.00

$61.00

$419.00

$914.00

$92.00

$820.00

$497.00

$76.00

$419.00

$596.00

$91.00

MRA

$481.00

$61.00

$419.00

$481.00

$61.00

$419.00

$914.00

$92.00

$820.00

$481.00

$61.00



70555-TC

70557

70557-26

70557-TC

70558

70558-26

70558-TC

70559

70559-26

70559-TC

71010

71010-26

70551-TC

70552

70552-26

70552-TC

70553

70553-26

70553-TC

70554

70554-26

70554-TC

70555

70555-26

71010-TC

71015

71015-26

71015-TC

71020

71020-26

Radiology

CPT Code

70544

70544-26

70544-TC

70545

70545-26

70545-TC

70546

70546-26

70546-TC

70547

70547-26

70547-TC

70548

70548-26

70548-TC

70549

70549-26

70549-TC

70551

70551-26

Radiology

CPT Code

71020-TC

71021

71021-26

71021-TC

71022

71022-26

71022-TC

71023

71023-26

71023-TC

71030

71030-26

71030-TC

71034

71034-26

71034-TC

71035

71035-26

71035-TC

71100

71100-26

71100-TC

71101

71101-26

71101-TC

71110

71110-26

71110-TC

71111

71111-26

71111-TC

71120

71120-26

71120-TC

71130

71130-26

71130-TC

71250

71250-26

71250-TC

71260

71260-26

71260-TC

71270

71270-26

71270-TC

71275

71275-26

71275-TC

71550

72080

72080-26

72080-TC

72081

72081-26

72081-TC

72082

72082-26

72082-TC

72083

72083-26

72083-TC

72052

72052-26

72052-TC

72070

72070-26

72070-TC

72072

72072-26

72072-TC

72074

72074-26

72074-TC

72084

72084-26

72084-TC

72100

72100-26

72100-TC

Radiology

CPT Code

71550-26

71550-TC

71551

71551-26

71551-TC

71552

71552-26

71552-TC

71555

71555-26

71555-TC

72020

72020-26

72020-TC

72040

72040-26

72040-TC

72050

72050-26

72050-TC

$11.00

$26.00

$282.00

$59.00

$220.00

$328.00

$63.00

$264.00

$402.00

$70.00

$330.00

$431.00

$100.00

$328.00

$490.00

$13.00

$24.00

$43.00

$13.00

$29.00

$49.00

$16.00

$33.00

$35.00

$10.00

$24.00

$38.00

$16.00

$29.00

$79.00

$23.00

$54.00

$56.00

$19.00

$38.00

$33.00

$11.00

$21.00

$38.00

MRA

$22.00

$41.00

$13.00

$28.00

$44.00

$16.00

$28.00

$49.00

$19.00

$29.00

$45.00

$39.00

$14.00

$25.00

$63.00

$16.00

$46.00

$68.00

$18.00

$50.00

$81.00

$21.00

$61.00

$36.00

$11.00

$24.00

$36.00

$11.00

$24.00

$39.00

$11.00

$28.00

$45.00

$11.00

$34.00

$36.00

$11.00

$24.00

$22.00

$7.00

$15.00

$34.00

$11.00

$22.00

$49.00

$16.00

$33.00

$61.00

$18.00

$42.00

MRA

$75.00

$415.00

$587.00

$88.00

$496.00

$1,029.00

$114.00

$911.00

$514.00

$92.00

$419.00


Part A, 112

$323.00

$503.00

$82.00

$419.00

$604.00

$99.00

$502.00

$549.00

$82.00

$465.00

$603.00

$98.00

$502.00

$543.00

$76.00

$264.00

$397.00

$65.00

$330.00

$282.00

$59.00

$220.00

$328.00

$62.00

$264.00

$391.00

$65.00

$220.00

$328.00

$62.00

$264.00

$397.00

$65.00

$330.00

$282.00

$59.00

$220.00

$328.00

$62.00

MRA

$50.00

$16.00

$34.00

$64.00

$18.00

$44.00

$45.00

$11.00

$33.00

$282.00

$59.00



72132-TC

72133

72133-26

72133-TC

72141

72141-26

72141-TC

72142

72142-26

72142-TC

72146

72146-26

72128-TC

72129

72129-26

72129-TC

72130

72130-26

72130-TC

72131

72131-26

72131-TC

72132

72132-26

72146-TC

72147

72147-26

72147-TC

72148

72148-26

Radiology

CPT Code

72110

72110-26

72110-TC

72114

72114-26

72114-TC

72120

72120-26

72120-TC

72125

72125-26

72125-TC

72126

72126-26

72126-TC

72127

72127-26

72127-TC

72128

72128-26

Radiology

CPT Code

72148-TC

72149

72149-26

72149-TC

72156

72156-26

72156-TC

72157

72157-26

72157-TC

72158

72158-26

72158-TC

72159

72159-26

72159-TC

72170

72170-26

72170-TC

72190

72190-26

72190-TC

72191

72191-26

72191-TC

72192

72192-26

72192-TC

72193

72193-26

72193-TC

72194

72194-26

72194-TC

72195

72195-26

72195-TC

72196

72196-26

72196-TC

72197

72197-26

72197-TC

72198

72198-26

72198-TC

72200

72200-26

72200-TC

72202

73020

73020-26

73020-TC

73030

73030-26

73030-TC

73040

73040-26

73040-TC

73050

73050-26

73050-TC

72285

72285-26

72285-TC

72295

72295-26

72295-TC

73000

73000-26

73000-TC

73010

73010-26

73010-TC

73060

73060-26

73060-TC

73070

73070-26

73070-TC

Radiology

CPT Code

72202-26

72202-TC

72220

72220-26

72220-TC

72240

72240-26

72240-TC

72255

72255-26

72255-TC

72265

72265-26

72265-TC

72270

72270-26

72270-TC

72275

72275-26

72275-TC

$74.00

$415.00

$526.00

$84.00

$442.00

$1,037.00

$114.00

$919.00

$517.00

$95.00

$419.00

$29.00

$9.00

$19.00

$33.00

$94.00

$315.00

$278.00

$56.00

$220.00

$317.00

$59.00

$256.00

$380.00

$62.00

$317.00

$491.00

$121.00

$931.00

$563.00

$94.00

$465.00

$29.00

$8.00

$19.00

$35.00

$10.00

$24.00

$413.00

MRA

$465.00

$597.00

$92.00

$502.00

$1,066.00

$131.00

$931.00

$1,066.00

$131.00

$931.00

$1,056.00

$31.00

$9.00

$21.00

$68.00

$17.00

$51.00

$35.00

$10.00

$24.00

$30.00

$8.00

$21.00

$27.00

$7.00

$19.00

$107.00

$13.00

$94.00

$28.00

$8.00

$19.00

$29.00

$8.00

$19.00

$26.00

$7.00

$17.00

$132.00

$28.00

$104.00

$176.00

$39.00

$137.00

$112.00

$34.00

$78.00

$101.00

$15.00

$86.00

MRA

$9.00

$22.00

$30.00

$8.00

$21.00

$132.00

$26.00

$106.00

$129.00

$28.00

$101.00


Part A, 113

$277.00

$375.00

$94.00

$277.00

$482.00

$68.00

$413.00

$579.00

$82.00

$495.00

$520.00

$78.00

$442.00

$482.00

$68.00

$19.00

$22.00

$7.00

$15.00

$242.00

$56.00

$185.00

$282.00

$59.00

$220.00

$342.00

$63.00

$18.00

$29.00

$8.00

$19.00

$54.00

$17.00

$37.00

$27.00

$8.00

$18.00

$29.00

$8.00

MRA

$30.00

$8.00

$21.00

$74.00

$19.00

$55.00

$28.00

$8.00

$19.00

$27.00

$8.00



73201-TC

73202

73202-26

73202-TC

73206

73206-26

73206-TC

73218

73218-26

73218-TC

73219

73219-26

73120-TC

73130

73130-26

73130-TC

73140

73140-26

73140-TC

73200

73200-26

73200-TC

73201

73201-26

73219-TC

73220

73220-26

73220-TC

73221

73221-26

Radiology

CPT Code

73080

73080-26

73080-TC

73085

73085-26

73085-TC

73090

73090-26

73090-TC

73100

73100-26

73100-TC

73110

73110-26

73110-TC

73115

73115-26

73115-TC

73120

73120-26

Radiology

CPT Code

73221-TC

73222

73222-26

73222-TC

73223

73223-26

73223-TC

73225

73225-26

73225-TC

73501

73501-26

73501-TC

73502

73502-26

73502-TC

73503

73503-26

73503-TC

73521

73521-26

73521-TC

73522

73522-26

73522-TC

73523

73523-26

73523-TC

73525

73525-26

73525-TC

73551

73551-26

73551-TC

73552

73552-26

73552-TC

73560

73560-26

73560-TC

73562

73562-26

73562-TC

73564

73564-26

73564-TC

73565

73565-26

73565-TC

73580

73702

73702-26

73702-TC

73706

73706-26

73706-TC

73718

73718-26

73718-TC

73719

73719-26

73719-TC

73650

73650-26

73650-TC

73660

73660-26

73660-TC

73700

73700-26

73700-TC

73701

73701-26

73701-TC

73720

73720-26

73720-TC

73721

73721-26

73721-TC

Radiology

CPT Code

73580-26

73580-TC

73590

73590-26

73590-TC

73600

73600-26

73600-TC

73610

73610-26

73610-TC

73615

73615-26

73615-TC

73620

73620-26

73620-TC

73630

73630-26

73630-TC

$10.00

$23.00

$29.00

$8.00

$19.00

$31.00

$9.00

$21.00

$35.00

$11.00

$22.00

$28.00

$8.00

$18.00

$84.00

$15.00

$34.00

$57.00

$16.00

$40.00

$84.00

$21.00

$63.00

$28.00

$9.00

$19.00

$33.00

$10.00

$20.00

$42.00

$11.00

$30.00

$52.00

$15.00

$37.00

$40.00

$12.00

$28.00

$49.00

MRA

$413.00

$579.00

$82.00

$495.00

$1,029.00

$109.00

$916.00

$513.00

$92.00

$419.00

$30.00

$379.00

$98.00

$277.00

$482.00

$68.00

$413.00

$579.00

$82.00

$495.00

$520.00

$78.00

$442.00

$482.00

$68.00

$413.00

$22.00

$7.00

$15.00

$242.00

$56.00

$185.00

$282.00

$61.00

$220.00

$341.00

$62.00

$277.00

$72.00

$19.00

$53.00

$27.00

$8.00

$18.00

$29.00

$8.00

$19.00

$26.00

$8.00

$17.00

MRA

$18.00

$66.00

$29.00

$8.00

$19.00

$27.00

$8.00

$18.00

$29.00

$8.00

$19.00


Part A, 114

$315.00

$219.00

$89.00

$130.00

$327.00

$93.00

$235.00

$381.00

$102.00

$279.00

$498.00

$85.00

$415.00

$587.00

$88.00

$211.00

$322.00

$65.00

$256.00

$390.00

$71.00

$317.00

$502.00

$112.00

$390.00

$418.00

$98.00

$19.00

$33.00

$11.00

$21.00

$37.00

$13.00

$22.00

$44.00

$16.00

$28.00

$274.00

$60.00

MRA

$579.00

$82.00

$495.00

$1,029.00

$109.00

$916.00

$515.00

$92.00

$419.00

$29.00

$9.00



74174-TC

74175

74175-26

74175-TC

74176

74176-26

74176-TC

74177

74177-26

74177-TC

74178

74178-26

74022-TC

74150

74150-26

74150-TC

74160

74160-26

74160-TC

74170

74170-26

74170-TC

74174

74174-26

74178-TC

74181

74181-26

74181-TC

74182

74182-26

Radiology

CPT Code

73722

73722-26

73722-TC

73723

73723-26

73723-TC

73725

73725-26

73725-TC

74000

74000-26

74000-TC

74010

74010-26

74010-TC

74020

74020-26

74020-TC

74022

74022-26

Radiology

CPT Code

74182-TC

74183

74183-26

74183-TC

74185

74185-26

74185-TC

74190

74190-26

74190-TC

74210

74210-26

74210-TC

74220

74220-26

74220-TC

74230

74230-26

74230-TC

74235

74235-26

74235-TC

74240

74240-26

74240-TC

74241

74241-26

74241-TC

74245

74245-26

74245-TC

74246

74246-26

74246-TC

74247

74247-26

74247-TC

74249

74249-26

74249-TC

74250

74250-26

74250-TC

74251

74251-26

74251-TC

74260

74260-26

74260-TC

74261

74330

74330-26

74330-TC

74340

74340-26

74340-TC

74355

74355-26

74355-TC

74360

74360-26

74360-TC

74300

74300-26

74300-TC

74301

74301-26

74301-TC

74328

74328-26

74328-TC

74329

74329-26

74329-TC

74363

74363-26

74363-TC

74400

74400-26

74400-TC

Radiology

CPT Code

74261-26

74261-TC

74262

74262-26

74262-TC

74263

74263-26

74263-TC

74270

74270-26

74270-TC

74280

74280-26

74280-TC

74283

74283-26

74283-TC

74290

74290-26

74290-TC

$35.00

$63.00

$144.00

$46.00

$96.00

$73.00

$23.00

$48.00

$85.00

$34.00

$48.00

$82.00

$25.00

$56.00

$248.00

$35.00

$55.00

$91.00

$35.00

$56.00

$137.00

$46.00

$89.00

$97.00

$35.00

$61.00

$99.00

$18.00

$44.00

$68.00

$23.00

$44.00

$77.00

$27.00

$48.00

$160.00

$60.00

$100.00

$91.00

MRA

$496.00

$1,037.00

$114.00

$919.00

$514.00

$92.00

$419.00

$73.00

$24.00

$49.00

$63.00

$121.00

$26.00

$95.00

$137.00

$38.00

$99.00

$145.00

$27.00

$118.00

$274.00

$44.00

$230.00

$89.00

$24.00

$63.00

$107.00

$11.00

$104.00

$155.00

$35.00

$120.00

$155.00

$35.00

$120.00

$165.00

$45.00

$120.00

$136.00

$50.00

$84.00

$201.00

$103.00

$95.00

$44.00

$16.00

$28.00

$31.00

$19.00

$104.00

MRA

$122.00

$126.00

$376.00

$127.00

$249.00

$757.00

$117.00

$639.00

$100.00

$35.00

$64.00


Part A, 115

$39.00

$426.00

$154.00

$273.00

$233.00

$91.00

$142.00

$68.00

$19.00

$49.00

$150.00

$30.00

$120.00

$88.00

$32.00

$46.00

$75.00

$16.00

$59.00

$74.00

$27.00

$47.00

$146.00

$27.00

$119.00

$57.00

$17.00

$50.00

$48.00

$14.00

$34.00

$62.00

$19.00

$43.00

$101.00

$57.00

$44.00

$60.00

$14.00

MRA

$98.00

$24.00

$72.00

$105.00

$24.00

$79.00

$117.00

$18.00

$97.00

$68.00

$18.00



74485-TC

74710

74710-26

74710-TC

74712

74712-26

74712-TC

74713

74713-26

74713-TC

74740

74740-26

74445-TC

74450

74450-26

74450-TC

74455

74455-26

74455-TC

74470

74470-26

74470-TC

74485

74485-26

74740-TC

74742

74742-26

74742-TC

74775

74775-26

Radiology

CPT Code

74410

74410-26

74410-TC

74415

74415-26

74415-TC

74420

74420-26

74420-TC

74425

74425-26

74425-TC

74430

74430-26

74430-TC

74440

74440-26

74440-TC

74445

74445-26

Radiology

CPT Code

74775-TC

75557

75557-26

75557-TC

75559

75559-26

75559-TC

75561

75561-26

75561-TC

75563

75563-26

75563-TC

75565

75565-26

75565-TC

75571

75571-26

75571-TC

75572

75572-26

75572-TC

75573

75573-26

75573-TC

75574

75574-26

75574-TC

75600

75600-26

75600-TC

75605

75605-26

75605-TC

75625

75625-26

75625-TC

75630

75630-26

75630-TC

75635

75635-26

75635-TC

75658

75658-26

75658-TC

75705

75705-26

75705-TC

75710

75791

75791-26

75791-TC

75801

75801-26

75801-TC

75803

75803-26

75803-TC

75805

75805-26

75805-TC

75743

75743-26

75743-TC

75746

75746-26

75746-TC

75756

75756-26

75756-TC

75774

75774-26

75774-TC

75807

75807-26

75807-TC

75809

75809-26

75809-TC

Radiology

CPT Code

75710-26

75710-TC

75716

75716-26

75716-TC

75726

75726-26

75726-TC

75731

75731-26

75731-TC

75733

75733-26

75733-TC

75736

75736-26

75736-TC

75741

75741-26

75741-TC

$15.00

$128.00

$239.00

$37.00

$202.00

$445.00

$75.00

$370.00

$540.00

$66.00

$474.00

$587.00

$109.00

$478.00

$194.00

$126.00

$222.00

$341.00

$119.00

$222.00

$497.00

$25.00

$472.00

$183.00

$20.00

$163.00

$143.00

$101.00

$526.00

$56.00

$13.00

$44.00

$50.00

$28.00

$22.00

$291.00

$87.00

$204.00

$349.00

MRA

$55.00

$462.00

$79.00

$344.00

$495.00

$99.00

$344.00

$656.00

$87.00

$525.00

$683.00

$245.00

$41.00

$204.00

$264.00

$58.00

$206.00

$271.00

$40.00

$231.00

$289.00

$58.00

$231.00

$54.00

$24.00

$30.00

$530.00

$56.00

$474.00

$183.00

$20.00

$163.00

$80.00

$3.00

$77.00

$331.00

$83.00

$248.00

$540.00

$65.00

$475.00

$530.00

$56.00

$474.00

$540.00

$65.00

$475.00

$253.00

$37.00

$216.00

MRA

$21.00

$173.00

$293.00

$35.00

$258.00

$530.00

$56.00

$474.00

$530.00

$56.00

$474.00


Part A, 116

$474.00

$72.00

$35.00

$37.00

$546.00

$71.00

$475.00

$546.00

$71.00

$475.00

$530.00

$56.00

$474.00

$530.00

$56.00

$474.00

$549.00

$73.00

$476.00

$531.00

$57.00

$474.00

$531.00

$57.00

$474.00

$530.00

$56.00

$173.00

$530.00

$56.00

$474.00

$54.00

$6.00

$48.00

$549.00

$74.00

$475.00

$531.00

$57.00

MRA

$530.00

$56.00

$474.00

$72.00

$35.00

$37.00

$111.00

$54.00

$57.00

$194.00

$21.00



75870-TC

75872

75872-26

75872-TC

75880

75880-26

75880-TC

75885

75885-26

75885-TC

75887

75887-26

75833-TC

75840

75840-26

75840-TC

75842

75842-26

75842-TC

75860

75860-26

75860-TC

75870

75870-26

75887-TC

75889

75889-26

75889-TC

75891

75891-26

Radiology

CPT Code

75810

75810-26

75810-TC

75820

75820-26

75820-TC

75822

75822-26

75822-TC

75825

75825-26

75825-TC

75827

75827-26

75827-TC

75831

75831-26

75831-TC

75833

75833-26

Radiology

CPT Code

75891-TC

75893

75893-26

75893-TC

75894

75894-26

75894-TC

75898

75898-26

75898-TC

75901

75901-26

75901-TC

75902

75902-26

75902-TC

75952

75952-26

75952-TC

75953

75953-26

75953-TC

75954

75954-26

75954-TC

75956

75956-26

75956-TC

75957

75957-26

75957-TC

75958

75958-26

75958-TC

75959

75959-26

75959-TC

75962

75962-26

75962-TC

75964

75964-26

75964-TC

75966

75966-26

75966-TC

75968

75968-26

75968-TC

75970

76120

76120-26

76120-TC

76125

76125-26

76125-TC

76140

76376

76376-26

76376-TC

76377

76377-26

76098

76098-26

76098-TC

76100

76100-26

76100-TC

76101

76101-26

76101-TC

76102

76102-26

76102-TC

76377-TC

76380

76380-26

76380-TC

76390

76390-26

Radiology

CPT Code

75970-26

75970-TC

75978

75978-26

75978-TC

75984

75984-26

75984-TC

75989

75989-26

75989-TC

76000

76000-26

76000-TC

76001

76001-26

76001-TC

76080

76080-26

76080-TC

$197.00

BR

$618.00

$27.00

$591.00

$333.00

$18.00

$315.00

$659.00

$66.00

$593.00

$333.00

$18.00

$315.00

$475.00

$132.00

BR

BR

$394.00

BR

BR

$338.00

BR

BR

$225.00

BR

BR

$23.00

$75.00

$93.00

$19.00

$74.00

BR

$254.00

BR

BR

$98.00

BR

BR

MRA

$474.00

$499.00

$26.00

$473.00

$972.00

$65.00

$907.00

$124.00

$84.00

$39.00

$98.00

$49.00

$17.00

$33.00

$31.00

$144.00

$11.00

$133.00

$185.00

$43.00

$142.00

$182.00

$50.00

$131.00

$493.00

$71.00

$77.00

$30.00

$46.00

$94.00

$36.00

$59.00

$95.00

$30.00

$65.00

$157.00

$56.00

$102.00

$58.00

$8.00

$48.00

$134.00

$34.00

$97.00

$67.00

$27.00

$40.00

$23.00

$8.00

$15.00

MRA

$42.00

$433.00

$617.00

$26.00

$591.00

$110.00

$36.00

$74.00

$180.00

$59.00

$121.00


Part A, 117

$31.00

$53.00

$86.00

$31.00

$53.00

$83.00

$31.00

$54.00

$78.00

$28.00

$48.00

$109.00

$37.00

$72.00

$90.00

$36.00

$60.00

$96.00

$36.00

$60.00

$12.00

$10.00

$3.00

$99.00

$37.00

$63.00

$88.00

BR

BR

$88.00

$33.00

$53.00

$171.00

$86.00

$85.00

$96.00

$48.00

$48.00

$96.00

MRA

$419.00

BR

BR

$79.00

BR

BR

$94.00

BR

BR

$280.00

BR



76516-26

76516-TC

76519

76519-26

76519-TC

76529

76529-26

76529-TC

76536

76536-26

76536-TC

76604

76511-26

76511-TC

76512

76512-26

76512-TC

76513

76513-26

76513-TC

76514

76514-26

76514-TC

76516

76604-26

76604-TC

76641

76641-26

76641-TC

76642

Radiology

CPT Code

76390-TC

76496

76496-26

76496-TC

76497

76497-26

76497-TC

76498

76498-26

76498-TC

76499

76499-26

76499-TC

76506

76506-26

76506-TC

76510

76510-26

76510-TC

76511

Radiology

CPT Code

76642-26

76642-TC

76700

76700-26

76700-TC

76705

76705-26

76705-TC

76770

76770-26

76770-TC

76775

76775-26

76775-TC

76776

76776-26

76776-TC

76800

76800-26

76800-TC

76801

76801-26

76801-TC

76802

76802-26

76802-TC

76805

76805-26

76805-TC

76810

76810-26

76810-TC

76811

76811-26

76811-TC

76812

76812-26

76812-TC

76813

76813-26

76813-TC

76814

76814-26

76814-TC

76815

76815-26

76815-TC

76816

76816-26

76816-TC

76831-TC

76856

76856-26

76856-TC

76857

76857-26

76857-TC

76870

76870-26

76870-TC

76872

76872-26

76826-TC

76827

76827-26

76827-TC

76828

76828-26

76828-TC

76830

76830-26

76830-TC

76831

76831-26

76872-TC

76873

76873-26

76873-TC

76881

76881-26

Radiology

CPT Code

76817

76817-26

76817-TC

76818

76818-26

76818-TC

76819

76819-26

76819-TC

76820

76820-26

76820-TC

76821

76821-26

76821-TC

76825

76825-26

76825-TC

76826

76826-26

$145.00

$94.00

$51.00

$125.00

$55.00

$71.00

$83.00

$46.00

$37.00

$88.00

$33.00

$53.00

$72.00

$30.00

$41.00

$73.00

$43.00

$30.00

$131.00

$51.00

$79.00

$252.00

$100.00

$151.00

$243.00

$100.00

$142.00

$84.00

$30.00

$53.00

$124.00

$36.00

$88.00

$112.00

$61.00

$54.00

$93.00

$51.00

$42.00

MRA

$35.00

$55.00

$116.00

$42.00

$73.00

$84.00

$30.00

$53.00

$112.00

$38.00

$73.00

$57.00

$59.00

$19.00

$39.00

$90.00

$33.00

$57.00

$93.00

$36.00

$57.00

$151.00

$68.00

$80.00

$120.00

$32.00

$65.00

$72.00

$29.00

$42.00

$93.00

$35.00

$57.00

$95.00

$37.00

$57.00

$93.00

$35.00

$66.00

$103.00

$38.00

$66.00

$160.00

$65.00

$73.00

$71.00

$46.00

$27.00

$97.00

$35.00

MRA

$96.00

$39.00

$57.00

$105.00

$40.00

$60.00

$101.00

$40.00

$60.00

$93.00

$27.00


Part A, 118

$84.00

$208.00

$60.00

$20.00

$39.00

$99.00

$41.00

$58.00

$34.00

$3.00

$31.00

BR

$61.00

$96.00

BR

$24.00

$68.00

$93.00

$34.00

$59.00

$78.00

$19.00

$59.00

$77.00

$19.00

$58.00

$281.00

$102.00

$236.00

$34.00

$17.00

$18.00

$171.00

$104.00

$68.00

$128.00

$69.00

$59.00

$92.00

MRA

$88.00

$36.00

$25.00

$11.00

$93.00

$34.00

$59.00

$93.00

$34.00

$59.00

$341.00



76948-26

76948-TC

76965

76965-26

76965-TC

76970

76970-26

76970-TC

76975

76975-26

76975-TC

76977

76941-26

76941-TC

76942

76942-26

76942-TC

76945

76945-26

76945-TC

76946

76946-26

76946-TC

76948

76977-26

76977-TC

76998

76998-26

76998-TC

76999

Radiology

CPT Code

76881-TC

76882

76882-26

76882-TC

76930

76930-26

76930-TC

76932

76932-26

76932-TC

76936

76936-26

76936-TC

76937

76937-26

76937-TC

76940

76940-26

76940-TC

76941

Radiology

CPT Code

76999-26

76999-TC

77001

77001-26

77001-TC

77002

77002-26

77002-TC

77003

77003-26

77003-TC

77011

77011-26

77011-TC

77012

77012-26

77012-TC

77013-26

77013-TC

77014

77014-26

77014-TC

77021

77021-26

77021-TC

77022

77022-26

77022-TC

77051

77051-26

77051-TC

77052

77052-26

77052-TC

77053

77053-26

77053-TC

77054

77054-26

77054-TC

77055

77055-26

77055-TC

77056

77056-26

77056-TC

77057

77057-26

77057-TC

77058

77081-TC

77084

77084-26

77084-TC

77085

77085-26

77085-TC

77086

77086-26

77086-TC

77261

77262

77075-TC

77077

77077-26

77077-TC

77078

77078-26

77078-TC

77080

77080-26

77080-TC

77081

77081-26

77263

77280

77280-26

77280-TC

77285

77285-26

Radiology

CPT Code

77058-26

77058-TC

77059

77059-26

77059-TC

77063

77063-26

77063-TC

77071

77072

77072-26

77072-TC

77073

77073-26

77073-TC

77074

77074-26

77074-TC

77075

77075-26

$17.00

$85.00

$126.00

$22.00

$104.00

$78.00

$33.00

$45.00

$97.00

$41.00

$56.00

$82.00

$33.00

$49.00

$804.00

$73.00

$280.00

BR

$204.00

$280.00

$17.00

$3.00

$14.00

$17.00

$3.00

$14.00

$102.00

$309.00

$58.00

$251.00

$306.00

$55.00

$251.00

$191.00

$297.00

$135.00

$41.00

$94.00

$353.00

MRA

BR

BR

$83.00

$18.00

$64.00

$75.00

$25.00

$50.00

$73.00

$27.00

$45.00

$280.00

$57.00

$16.00

$41.00

$36.00

$9.00

$27.00

$73.00

$110.00

$163.00

$166.00

$36.00

$130.00

$264.00

$53.00

$39.00

$84.00

$12.00

$72.00

$83.00

$11.00

$72.00

$40.00

$11.00

$29.00

$356.00

$77.00

$14.00

$42.00

$13.00

$29.00

$64.00

$22.00

$42.00

$89.00

$26.00

$63.00

$54.00

$15.00

MRA

$78.00

$726.00

$994.00

$78.00

$917.00

$56.00

$30.00

$25.00

$29.00

$22.00

$9.00


Part A, 119

$48.00

$150.00

$64.00

$45.00

$18.00

$78.00

$27.00

$50.00

$115.00

$43.00

$70.00

$187.00

$63.00

$121.00

$111.00

$151.00

$140.00

$191.00

$73.00

$117.00

$248.00

$96.00

$153.00

$358.00

$151.00

$207.00

$200.00

BR

BR

$87.00

$36.00

$52.00

$1,473.00

$415.00

$1,046.00

$151.00

$73.00

$78.00

$292.00

MRA

$209.00

$325.00

$79.00

$243.00

$432.00

$104.00

$328.00

$1,287.00

$232.00

$1,046.00

BR



77318-26

77318-TC

77321

77321-26

77321-TC

77331

77331-26

77331-TC

77332

77332-26

77332-TC

77333

77306-26

77306-TC

77307

77307-26

77307-TC

77316

77316-26

77316-TC

77317

77317-26

77317-TC

77318

77333-26

77333-TC

77334

77334-26

77334-TC

77336

Radiology

CPT Code

77285-TC

77290

77290-26

77290-TC

77293

77293-26

77293-TC

77295

77295-26

77295-TC

77299

77299-26

77299-TC

77300

77300-26

77300-TC

77301

77301-26

77301-TC

77306

Radiology

CPT Code

77338

77338-26

77338-TC

77370

77371

77372

77373

77399

77399-26

77399-TC

77401

77402

77407

77412

77417

77422

77423

77427

77431

77432

77435

77469

77470

77470-26

77470-TC

77499

77499-26

77499-TC

77520

77522

77523

77525

77600

77600-26

77600-TC

77605

77605-26

77605-TC

77610

77610-26

77610-TC

77615

77615-26

77615-TC

77620

77620-26

77620-TC

77750

77750-26

77750-TC

77790-TC

77799

77799-26

77799-TC

78012

78012-26

78012-TC

78013

78013-26

78013-TC

78014

78014-26

77771-TC

77772

77772-26

77772-TC

77778

77778-26

77778-TC

77789

77789-26

77789-TC

77790

77790-26

78014-TC

78015

78015-26

78015-TC

78016

78016-26

Radiology

CPT Code

77761

77761-26

77761-TC

77762

77762-26

77762-TC

77763

77763-26

77763-TC

77767

77767-26

77767-TC

77768

77768-26

77768-TC

77770

77770-26

77770-TC

77771

77771-26

$263.00

$108.00

$151.00

$195.00

$79.00

$113.00

$262.00

$106.00

$151.00

$196.00

$80.00

$113.00

$299.00

$248.00

$49.00

$106.00

$417.00

BR

BR

BR

BR

BR

BR

BR

$196.00

$80.00

$113.00

$66.00

$78.00

$87.00

$21.00

$70.00

$91.00

$166.00

$95.00

$417.00

$644.00

$313.00

$527.00

MRA

$502.00

$223.00

$279.00

$130.00

$1,151.00

$874.00

$1,630.00

BR

BR

BR

$66.00

BR

$78.00

$9.00

$69.00

$198.00

$18.00

$179.00

$240.00

$25.00

$215.00

$132.00

$34.00

$96.00

$173.00

$42.00

$640.00

$764.00

$568.00

$192.00

$74.00

$57.00

$16.00

$72.00

$53.00

$18.00

BR

BR

$172.00

$356.00

$73.00

$283.00

$324.00

$102.00

$222.00

$604.00

$199.00

$405.00

$922.00

$282.00

MRA

$284.00

$188.00

$93.00

$427.00

$289.00

$135.00

$605.00

$435.00

$167.00

$227.00

$55.00


Part A, 120

$11.00

$96.00

$78.00

$11.00

$65.00

$125.00

$16.00

$108.00

$196.00

$22.00

$171.00

$139.00

$32.00

$106.00

$216.00

$28.00

$77.00

$158.00

$39.00

$118.00

$194.00

$41.00

$152.00

$45.00

$9.00

$35.00

$108.00

$59.00

$298.00

$446.00

$80.00

$366.00

$242.00

$38.00

$202.00

BR

BR

BR

$106.00

MRA

$130.00

$248.00

$44.00

$202.00

$35.00

$30.00

$5.00

$112.00

$36.00

$68.00

$357.00



78110-26

78110-TC

78111

78111-26

78111-TC

78120

78120-26

78120-TC

78121

78121-26

78121-TC

78122

78099-26

78099-TC

78102

78102-26

78102-TC

78103

78103-26

78103-TC

78104

78104-26

78104-TC

78110

78122-26

78122-TC

78130

78130-26

78130-TC

78135

Radiology

CPT Code

78016-TC

78018

78018-26

78018-TC

78020

78020-26

78020-TC

78070

78070-26

78070-TC

78071

78071-26

78071-TC

78072

78072-26

78072-TC

78075

78075-26

78075-TC

78099

Radiology

CPT Code

78135-26

78135-TC

78140

78140-26

78140-TC

78185

78185-26

78185-TC

78190

78190-26

78190-TC

78191

78191-26

78191-TC

78195

78195-26

78195-TC

78199

78199-26

78199-TC

78201

78201-26

78201-TC

78202

78202-26

78202-TC

78205

78205-26

78205-TC

78206

78206-26

78206-TC

78215

78215-26

78215-TC

78216

78216-26

78216-TC

78226

78226-26

78226-TC

78227

78227-26

78227-TC

78230

78230-26

78230-TC

78231

78231-26

78231-TC

78278

78278-26

78278-TC

78282

78282-26

78282-TC

78290

78290-26

78290-TC

78291

78291-26

78291-TC

78266-TC

78267

78268

78270

78270-26

78270-TC

78271

78271-26

78271-TC

78272

78272-26

78272-TC

78299

78299-26

78299-TC

78300

78300-26

78300-TC

Radiology

CPT Code

78232

78232-26

78232-TC

78258

78258-26

78258-TC

78261

78261-26

78261-TC

78262

78262-26

78262-TC

78264

78264-26

78264-TC

78265

78265-26

78265-TC

78266

78266-26

$160.00

$29.00

$130.00

$339.00

$37.00

$301.00

$418.00

$45.00

$373.00

$106.00

$23.00

$82.00

$146.00

$27.00

$118.00

$135.00

$26.00

$108.00

$259.00

$36.00

$220.00

$265.00

$46.00

$214.00

$135.00

$24.00

$109.00

$307.00

$31.00

$274.00

$216.00

$49.00

$152.00

BR

BR

BR

$112.00

$22.00

$88.00

MRA

$33.00

$182.00

$179.00

$31.00

$147.00

$110.00

$20.00

$88.00

$272.00

$57.00

$214.00

$230.00

$19.00

$224.00

$149.00

$35.00

$113.00

$161.00

$45.00

$114.00

BR

BR

BR

$125.00

$32.00

$93.00

$68.00

$10.00

$58.00

$72.00

$10.00

$61.00

$100.00

$14.00

$87.00

$234.00

$50.00

$182.00

$159.00

$195.00

$40.00

$154.00

$381.00

$49.00

$332.00

$494.00

$54.00

$440.00

BR

BR

MRA

$157.00

$23.00

$132.00

$146.00

$38.00

$108.00

$190.00

$36.00

$152.00

$195.00

$35.00


Part A, 121

$51.00

$263.00

$446.00

$67.00

$379.00

$205.00

$49.00

$151.00

$140.00

$39.00

$99.00

$198.00

$46.00

$149.00

$755.00

$41.00

$84.00

$97.00

$28.00

$69.00

$351.00

$68.00

$283.00

$486.00

$80.00

$407.00

$313.00

$220.00

$40.00

$11.00

$29.00

$23.00

BR

BR

BR

BR

$23.00

BR

$126.00

MRA

$181.00

$42.00

$137.00

$205.00

$44.00

$159.00

$233.00

$52.00

$179.00

$276.00

$53.00



78452-26

78452-TC

78453

78453-26

78453-TC

78454

78454-26

78454-TC

78456

78456-26

78456-TC

78457

78414-26

78414-TC

78428

78428-26

78428-TC

78445

78445-26

78445-TC

78451

78451-26

78451-TC

78452

78457-26

78457-TC

78458

78458-26

78458-TC

78459

Radiology

CPT Code

78305

78305-26

78305-TC

78306

78306-26

78306-TC

78315

78315-26

78315-TC

78320

78320-26

78320-TC

78350

78350-26

78350-TC

78351

78399

78399-26

78399-TC

78414

Radiology

CPT Code

78459-26

78459-TC

78466

78466-26

78466-TC

78468

78468-26

78468-TC

78469

78469-26

78469-TC

78472

78472-26

78472-TC

78473

78473-26

78473-TC

78481

78481-26

78481-TC

78483

78483-26

78483-TC

78491

78491-26

78491-TC

78492

78492-26

78492-TC

78494

78494-26

78494-TC

78496

78496-26

78496-TC

78499

78499-26

78499-TC

78579

78579-26

78579-TC

78580

78580-26

78580-TC

78582

78582-26

78582-TC

78597

78597-26

78597-TC

78630-TC

78635

78635-26

78635-TC

78645

78645-26

78645-TC

78647

78647-26

78647-TC

78650

78650-26

78607-TC

78608

78608-26

78608-TC

78609

78609-26

78609-TC

78610

78610-26

78610-TC

78630

78630-26

78650-TC

78660

78660-26

78660-TC

78699

78699-26

Radiology

CPT Code

78598

78598-26

78598-TC

78599

78599-26

78599-TC

78600

78600-26

78600-TC

78601

78601-26

78601-TC

78605

78605-26

78605-TC

78606

78606-26

78606-TC

78607

78607-26

BR

BR

BR

$191.00

$24.00

$166.00

$167.00

$38.00

$128.00

$343.00

$53.00

$289.00

$206.00

$36.00

$171.00

$756.00

$85.00

$731.00

$764.00

$100.00

$731.00

$324.00

$59.00

$262.00

$92.00

$24.00

$66.00

$259.00

$50.00

$206.00

$387.00

$75.00

$308.00

$248.00

$51.00

$195.00

$373.00

$77.00

$294.00

MRA

$100.00

$731.00

$135.00

$36.00

$97.00

$180.00

$41.00

$137.00

$244.00

$47.00

$195.00

$95.00

$158.00

$29.00

$128.00

$268.00

$46.00

$220.00

$206.00

$31.00

$173.00

$107.00

$27.00

$79.00

BR

BR

$855.00

$51.00

$78.00

BR

$74.00

$15.00

$59.00

$223.00

$35.00

$188.00

$129.00

$32.00

$126.00

$155.00

$27.00

$126.00

$221.00

$45.00

$177.00

$311.00

$64.00

$245.00

$876.00

$78.00

MRA

$314.00

$42.00

$272.00

BR

BR

BR

$131.00

$22.00

$108.00

$154.00

$26.00


Part A, 122

$34.00

$126.00

$199.00

$40.00

$158.00

$252.00

$44.00

$207.00

$303.00

$56.00

$245.00

$227.00

$55.00

$171.00

$166.00

$18.00

$55.00

$109.00

$29.00

$79.00

$157.00

$36.00

$119.00

BR

BR

BR

$162.00

$61.00

$166.00

$241.00

$68.00

$166.00

$256.00

$34.00

$220.00

$87.00

$19.00

$66.00

$73.00

MRA

BR

$137.00

$22.00

$113.00

$158.00

$24.00

$133.00

$217.00

$49.00

$166.00

$231.00



78799-26

78799-TC

78800

78800-26

78800-TC

78801

78801-26

78801-TC

78802

78802-26

78802-TC

78803

78725-26

78725-TC

78730

78730-26

78730-TC

78740

78740-26

78740-TC

78761

78761-26

78761-TC

78799

78803-26

78803-TC

78804

78804-26

78804-TC

78805

Radiology

CPT Code

78699-TC

78700

78700-26

78700-TC

78701

78701-26

78701-TC

78707

78707-26

78707-TC

78708

78708-26

78708-TC

78709

78709-26

78709-TC

78710

78710-26

78710-TC

78725

Radiology

CPT Code

78805-26

78805-TC

78806

78806-26

78806-TC

78807

78807-26

78807-TC

78808

78811

78811-26

78811-TC

78812

78812-26

78812-TC

78813

78813-26

78813-TC

78814

78814-26

78814-TC

78815

78815-26

78815-TC

78816

78816-26

78816-TC

78999

78999-26

78999-TC

79005

79005-26

79005-TC

79101

79101-26

79101-TC

79200

79200-26

79200-TC

79300

79300-26

79300-TC

79403

79403-26

79403-TC

79440

79440-26

79440-TC

79445

79445-26

G6001-26

G6001-TC

G6002

G6002-26

G6002-TC

G6003

G6004

G6005

G6006

G6007

G6008

G6009

G0279-TC

G0288

G0297

G0297-26

G0297-TC

G0365

G0365-26

G0365-TC

G0389

G0389-26

G0389-TC

G6001

G6010

G6011

G6012

G6013

G6014

G6015

Radiology

CPT Code

79445-TC

79999

79999-26

79999-TC

G0130

G0130-26

G0130-TC

G0202

G0202-26

G0202-TC

G0204

G0204-26

G0204-TC

G0206

G0206-26

G0206-TC

G0252-26

G0278

G0279

G0279-26

$105.00

$203.00

$102.00

$97.00

BR

$83.00

BR

$287.00

$121.00

$165.00

$204.00

$104.00

$97.00

$232.00

$127.00

$950.00

$986.00

$132.00

$950.00

BR

BR

BR

$199.00

$94.00

$105.00

$207.00

$103.00

$855.00

$884.00

$102.00

$855.00

$885.00

$106.00

$855.00

$982.00

$116.00

$950.00

$985.00

$128.00

MRA

$38.00

$126.00

$286.00

$44.00

$241.00

$303.00

$57.00

$245.00

$47.00

$879.00

$83.00

$20.00

$55.00

$188.00

$146.00

$145.00

$145.00

$303.00

$202.00

$199.00

$199.00

$324.00

$266.00

$266.00

$266.00

$347.00

$52.00

$203.00

$164.00

$12.00

$152.00

$104.00

$27.00

$77.00

$52.00

$30.00

$22.00

$76.00

$40.00

$96.00

$109.00

$32.00

$77.00

$78.00

$13.00

$56.00

$30.00

$25.00

$201.00

$255.00

MRA

$105.00

BR

BR

BR

$34.00

$10.00

$24.00

$120.00

$32.00

$88.00

$136.00


Part A, 123



Radiology

CPT Code

G6016

Q0092

MRA

$346.00

$14.00


Part A, 124



80156-TC

80157

80157-26

80157-TC

80158

80158-26

80158-TC

80162

80162-26

80162-TC

80164

80164-26

80069-TC

80074

80074-26

80074-TC

80076

80076-26

80076-TC

80150

80150-26

80150-TC

80156

80156-26

80164-TC

80168

80168-26

80168-TC

80170

80170-26

Pathology & Laboratory

CPT Code

80048

80048-26

MRA

$23.00

$4.00

80048-TC

80050

80050-26

80050-TC

80051

80051-26

$19.00

$45.00

$18.00

$26.00

$16.00

$6.00

80051-TC

80053

80053-26

80053-TC

80055

80055-26

80055-TC

80061

80061-26

80061-TC

80069

80069-26

$10.00

$29.00

$8.00

$21.00

$67.00

$21.00

$43.00

$31.00

$11.00

$19.00

$26.00

$6.00

$23.00

$22.00

$8.00

$14.00

$35.00

$12.00

$22.00

$13.00

$3.00

$9.00

$43.00

$14.00

$20.00

$107.00

$43.00

$64.00

$18.00

$7.00

$11.00

$40.00

$13.00

$26.00

$35.00

$11.00

$29.00

$43.00

$17.00

$25.00

$18.00

$6.00


CPT Code

80170-TC

80173

80173-26

80173-TC

80176

80176-26

80176-TC

80178

80178-26

80178-TC

80184

80184-26

80184-TC

80185

80185-26

80185-TC

80186

80186-26

80186-TC

80188

80188-26

80188-TC

80190

80190-26

80190-TC

80192

80192-26

80192-TC

80194

80194-26

80194-TC

80197

80197-26

80197-TC

80198

80198-26

80198-TC

80200

80200-26

80200-TC

80201

80201-26

80201-TC

80202

80202-26

80202-TC

80299

80299-26

80299-TC

80400

MRA

$11.00

$33.00

$11.00

$22.00

$35.00

$11.00

$23.00

$17.00

$6.00

$11.00

$34.00

$10.00

$23.00

$36.00

$10.00

$25.00

$38.00

$11.00

$26.00

$35.00

$11.00

$23.00

$41.00

$13.00

$28.00

$44.00

$17.00

$26.00

$33.00

$10.00

$22.00

$34.00

$11.00

$22.00

$20.00

$5.00

$15.00

$24.00

$7.00

$16.00

$33.00

$11.00

$21.00

$42.00

$14.00

$28.00

BR

BR

BR

$54.00

80420

80420-26

80420-TC

80422

80422-26

80422-TC

80424

80424-26

80424-TC

80426

80426-26

80426-TC

80415

80415-26

80415-TC

80416

80416-26

80416-TC

80417

80417-26

80417-TC

80418

80418-26

80418-TC

80428

80428-26

80428-TC

80430

80430-26

80430-TC


CPT Code

80400-26

80400-TC

MRA

$18.00

$36.00

80402

80402-26

80402-TC

80406

80406-26

80406-TC

$138.00

$42.00

$95.00

$138.00

$42.00

$95.00

80408

80408-26

80408-TC

80410

80410-26

80410-TC

80412

80412-26

80412-TC

80414

80414-26

80414-TC

$213.00

$77.00

$136.00

$166.00

$54.00

$110.00

$533.00

$176.00

$355.00

$88.00

$26.00

$59.00

$107.00

$33.00

$74.00

$62.00

$18.00

$43.00

$94.00

$26.00

$67.00

$232.00

$54.00

$176.00

$93.00

$28.00

$64.00

$256.00

$88.00

$166.00

$256.00

$88.00

$166.00

$934.00

$266.00

$666.00

$93.00

$19.00

$73.00

$99.00

$24.00

$74.00


Part A, 125



81002-TC

81003

81003-26

81003-TC

81005

81005-26

81005-TC

81007

81007-26

81007-TC

81015

81015-26

80500-TC

80502

80502-26

80502-TC

81000

81000-26

81000-TC

81001

81001-26

81001-TC

81002

81002-26

81015-TC

81020

81020-26

81020-TC

81025

81025-26


CPT Code

80432

80432-26

MRA

$243.00

$56.00

80432-TC

80434

80434-26

80434-TC

80435

80435-26

$186.00

$161.00

$49.00

$110.00

$166.00

$49.00

80435-TC

80436

80436-26

80436-TC

80438

80438-26

80438-TC

80439

80439-26

80439-TC

80500

80500-26

$115.00

$119.00

$35.00

$85.00

$82.00

$24.00

$56.00

$176.00

$33.00

$144.00

$34.00

$34.00

$3.00

$5.00

$2.00

$3.00

$3.00

$1.00

$3.00

$5.00

$2.00

$4.00

$5.00

$3.00

BR

$72.00

$72.00

BR

$7.00

$3.00

$4.00

$7.00

$3.00

$4.00

$5.00

$3.00

$3.00

$8.00

$3.00

$5.00

$7.00

$4.00


CPT Code

81025-TC

81050

81050-26

81050-TC

81099

81099-26

81099-TC

82009

82009-26

82009-TC

82010

82010-26

82010-TC

82013

82013-26

82013-TC

82024

82024-26

82024-TC

82030

82030-26

82030-TC

82040

82040-26

82040-TC

82042

82042-26

82042-TC

82043

82043-26

82043-TC

82044

82044-26

82044-TC

82075

82075-26

82075-TC

82085

82085-26

82085-TC

82088

82088-26

82088-TC

82103

82103-26

82103-TC

82104

82104-26

82104-TC

82105

MRA

$4.00

$33.00

$11.00

$21.00

BR

BR

BR

$10.00

$3.00

$6.00

$22.00

$7.00

$15.00

$24.00

$7.00

$17.00

$26.00

$7.00

$18.00

$43.00

$17.00

$25.00

$11.00

$3.00

$7.00

$12.00

$3.00

$8.00

$14.00

$4.00

$10.00

$12.00

$4.00

$9.00

$32.00

$10.00

$21.00

$24.00

$7.00

$17.00

$91.00

$28.00

$62.00

$21.00

$7.00

$14.00

$22.00

$7.00

$15.00

$26.00

82143

82143-26

82143-TC

82150

82150-26

82150-TC

82154

82154-26

82154-TC

82157

82157-26

82157-TC

82135

82135-26

82135-TC

82136

82136-26

82136-TC

82139

82139-26

82139-TC

82140

82140-26

82140-TC

82160

82160-26

82160-TC

82163

82163-26

82163-TC


CPT Code

82105-26

82105-TC

MRA

$8.00

$18.00

82106

82106-26

82106-TC

82108

82108-26

82108-TC

$26.00

$8.00

$18.00

$45.00

$14.00

$32.00

82120

82120-26

82120-TC

82127

82127-26

82127-TC

82128

82128-26

82128-TC

82131

82131-26

82131-TC

$9.00

$3.00

$5.00

$33.00

$11.00

$22.00

$26.00

$6.00

$19.00

$57.00

$13.00

$44.00

$28.00

$8.00

$19.00

$16.00

$5.00

$11.00

$34.00

$13.00

$20.00

$57.00

$17.00

$40.00

$41.00

$13.00

$28.00

$38.00

$14.00

$23.00

$38.00

$14.00

$23.00

$40.00

$12.00

$28.00

$67.00

$21.00

$43.00

$42.00

$12.00

$31.00


Part A, 126



82252-TC

82261

82261-26

82261-TC

82270

82270-26

82270-TC

82274

82274-26

82274-TC

82286

82286-26

82239-TC

82240

82240-26

82240-TC

82247

82247-26

82247-TC

82248

82248-26

82248-TC

82252

82252-26

82286-TC

82300

82300-26

82300-TC

82306

82306-26


CPT Code

82164

82164-26

MRA

$32.00

$10.00

82164-TC

82172

82172-26

82172-TC

82175

82175-26

$21.00

$33.00

$10.00

$22.00

$48.00

$15.00

82175-TC

82180

82180-26

82180-TC

82190

82190-26

82190-TC

82232

82232-26

82232-TC

82239

82239-26

$33.00

$25.00

$8.00

$17.00

$24.00

$8.00

$16.00

$43.00

$14.00

$29.00

$23.00

$8.00

$7.00

$38.00

$13.00

$24.00

$5.00

$2.00

$3.00

BR

BR

BR

$12.00

$3.00

$15.00

$49.00

$15.00

$34.00

$10.00

$3.00

$7.00

$10.00

$3.00

$7.00

$11.00

$3.00

$8.00

$48.00

$15.00

$33.00

$79.00

$25.00


CPT Code

82306-TC

82308

82308-26

82308-TC

82310

82310-26

82310-TC

82330

82330-26

82330-TC

82331

82331-26

82331-TC

82340

82340-26

82340-TC

82355

82355-26

82355-TC

82360

82360-26

82360-TC

82365

82365-26

82365-TC

82370

82370-26

82370-TC

82373

82373-26

82373-TC

82374

82374-26

82374-TC

82375

82375-26

82375-TC

82376

82376-26

82376-TC

82378

82378-26

82378-TC

82379

82379-26

82379-TC

82380

82380-26

82380-TC

82382

MRA

$52.00

$62.00

$18.00

$43.00

$11.00

$3.00

$7.00

$37.00

$11.00

$25.00

$14.00

$4.00

$10.00

$13.00

$4.00

$8.00

$31.00

$10.00

$20.00

$31.00

$10.00

$20.00

$31.00

$8.00

$21.00

$22.00

$7.00

$15.00

$16.00

$5.00

$11.00

$10.00

$3.00

$6.00

$26.00

$7.00

$18.00

$11.00

$3.00

$7.00

$31.00

$8.00

$21.00

$38.00

$13.00

$24.00

$21.00

$6.00

$15.00

$38.00

82465

82465-26

82465-TC

82480

82480-26

82480-TC

82482

82482-26

82482-TC

82485

82485-26

82485-TC

82435

82435-26

82435-TC

82436

82436-26

82436-TC

82438

82438-26

82438-TC

82441

82441-26

82441-TC

82495

82495-26

82495-TC

82507

82507-26

82507-TC


CPT Code

82382-26

82382-TC

MRA

$12.00

$25.00

82383

82383-26

82383-TC

82384

82384-26

82384-TC

$62.00

$18.00

$43.00

$62.00

$18.00

$43.00

82387

82387-26

82387-TC

82390

82390-26

82390-TC

82397

82397-26

82397-TC

82415

82415-26

82415-TC

$34.00

$10.00

$23.00

$24.00

$7.00

$17.00

$22.00

$7.00

$15.00

$28.00

$8.00

$19.00

$8.00

$2.00

$6.00

$23.00

$6.00

$17.00

$23.00

$7.00

$15.00

$37.00

$8.00

$28.00

$8.00

$2.00

$6.00

$14.00

$4.00

$10.00

$13.00

$4.00

$8.00

$16.00

$5.00

$11.00

$48.00

$16.00

$32.00

$55.00

$16.00

$39.00


Part A, 127



82554-TC

82565

82565-26

82565-TC

82570

82570-26

82570-TC

82575

82575-26

82575-TC

82585

82585-26

82542-TC

82550

82550-26

82550-TC

82552

82552-26

82552-TC

82553

82553-26

82553-TC

82554

82554-26

82585-TC

82595

82595-26

82595-TC

82600

82600-26


CPT Code

82523

82523-26

MRA

$43.00

$17.00

82523-TC

82525

82525-26

82525-TC

82528

82528-26

$25.00

$34.00

$10.00

$23.00

$40.00

$13.00

82528-TC

82530

82530-26

82530-TC

82533

82533-26

82533-TC

82540

82540-26

82540-TC

82542

82542-26

$26.00

$38.00

$12.00

$25.00

$35.00

$10.00

$24.00

$10.00

$3.00

$6.00

$42.00

$13.00

$13.00

$13.00

$2.00

$11.00

$10.00

$2.00

$7.00

$25.00

$8.00

$17.00

$15.00

$3.00

$28.00

$16.00

$4.00

$12.00

$33.00

$10.00

$22.00

$16.00

$5.00

$11.00

$19.00

$6.00

$12.00

$31.00

$10.00

$21.00

$40.00

$12.00


CPT Code

82600-TC

82607

82607-26

82607-TC

82608

82608-26

82608-TC

82615

82615-26

82615-TC

82626

82626-26

82626-TC

82627

82627-26

82627-TC

82633

82633-26

82633-TC

82634

82634-26

82634-TC

82638

82638-26

82638-TC

82652

82652-26

82652-TC

82657

82657-26

82657-TC

82658

82658-26

82658-TC

82664

82664-26

82664-TC

82668

82668-26

82668-TC

82670

82670-26

82670-TC

82671

82671-26

82671-TC

82672

82672-26

82672-TC

82677

MRA

$28.00

$38.00

$10.00

$27.00

$40.00

$13.00

$26.00

$17.00

$5.00

$12.00

$59.00

$19.00

$40.00

$37.00

$12.00

$24.00

$81.00

$23.00

$56.00

$81.00

$23.00

$56.00

$23.00

$7.00

$16.00

$89.00

$25.00

$62.00

$42.00

$13.00

$28.00

$42.00

$13.00

$28.00

$40.00

$13.00

$26.00

$45.00

$14.00

$32.00

$61.00

$18.00

$42.00

$61.00

$17.00

$43.00

$57.00

$16.00

$41.00

$52.00

82746

82746-26

82746-TC

82747

82747-26

82747-TC

82757

82757-26

82757-TC

82759

82759-26

82759-TC

82725

82725-26

82725-TC

82726

82726-26

82726-TC

82728

82728-26

82728-TC

82735

82735-26

82735-TC

82760

82760-26

82760-TC

82775

82775-26

82775-TC


CPT Code

82677-26

82677-TC

MRA

$17.00

$35.00

82679

82679-26

82679-TC

82693

82693-26

82693-TC

$70.00

$20.00

$48.00

$23.00

$7.00

$16.00

82696

82696-26

82696-TC

82705

82705-26

82705-TC

82710

82710-26

82710-TC

82715

82715-26

82715-TC

$57.00

$19.00

$38.00

$14.00

$6.00

$9.00

$42.00

$13.00

$29.00

$33.00

$11.00

$21.00

$39.00

$13.00

$25.00

$29.00

$10.00

$19.00

$36.00

$11.00

$24.00

$38.00

$12.00

$25.00

$28.00

$8.00

$19.00

$42.00

$13.00

$28.00

$24.00

$7.00

$17.00

$36.00

$12.00

$23.00

$26.00

$8.00

$18.00

$47.00

$14.00

$33.00


Part A, 128



82941-TC

82943

82943-26

82943-TC

82945

82945-26

82945-TC

82946

82946-26

82946-TC

82947

82947-26

82805-TC

82810

82810-26

82810-TC

82820

82820-26

82820-TC

82938

82938-26

82938-TC

82941

82941-26

82947-TC

82948

82948-26

82948-TC

82950

82950-26


CPT Code

82776

82776-26

MRA

$14.00

$3.00

82776-TC

82784

82784-26

82784-TC

82785

82785-26

$11.00

$15.00

$5.00

$11.00

$33.00

$11.00

82785-TC

82787

82787-26

82787-TC

82800

82800-26

82800-TC

82803

82803-26

82803-TC

82805

82805-26

$21.00

$54.00

$17.00

$37.00

$22.00

$6.00

$16.00

$53.00

$16.00

$37.00

$36.00

$10.00

$32.00

$38.00

$12.00

$25.00

$9.00

$3.00

$5.00

$29.00

$7.00

$21.00

$11.00

$3.00

$24.00

$28.00

$8.00

$19.00

$16.00

$5.00

$11.00

$48.00

$16.00

$32.00

$47.00

$15.00

$7.00

$5.00

$3.00

$3.00

$12.00

$4.00


CPT Code

82950-TC

82951

82951-26

82951-TC

82952

82952-26

82952-TC

82955

82955-26

82955-TC

82960

82960-26

82960-TC

82962

82962-26

82962-TC

82963

82963-26

82963-TC

82965

82965-26

82965-TC

82977

82977-26

82977-TC

82978

82978-26

82978-TC

82979

82979-26

82979-TC

82985

82985-26

82985-TC

83001

83001-26

83001-TC

83002

83002-26

83002-TC

83003

83003-26

83003-TC

83010

83010-26

83010-TC

83012

83012-26

83012-TC

83013

MRA

$7.00

$22.00

$7.00

$15.00

$11.00

$3.00

$7.00

$25.00

$7.00

$18.00

$14.00

$4.00

$10.00

$5.00

$1.00

$4.00

$54.00

$17.00

$37.00

$16.00

$5.00

$11.00

$16.00

$4.00

$12.00

$25.00

$7.00

$18.00

$18.00

$5.00

$13.00

$41.00

$12.00

$29.00

$40.00

$12.00

$28.00

$42.00

$13.00

$29.00

$36.00

$10.00

$25.00

$26.00

$8.00

$18.00

$36.00

$14.00

$21.00

$133.00

83050

83050-26

83050-TC

83051

83051-26

83051-TC

83060

83060-26

83060-TC

83065

83065-26

83065-TC

83030

83030-26

83030-TC

83033

83033-26

83033-TC

83036

83036-26

83036-TC

83045

83045-26

83045-TC

83068

83068-26

83068-TC

83069

83069-26

83069-TC


CPT Code

83013-26

83013-TC

MRA

$38.00

$94.00

83014

83014-26

83014-TC

83015

83015-26

83015-TC

$19.00

$6.00

$13.00

$51.00

$15.00

$36.00

83018

83018-26

83018-TC

83020

83020-26

83020-TC

83021

83021-26

83021-TC

83026

83026-26

83026-TC

$56.00

$16.00

$40.00

$24.00

$6.00

$18.00

$39.00

$13.00

$25.00

$8.00

$5.00

$3.00

$16.00

$5.00

$11.00

$16.00

$5.00

$11.00

$22.00

$6.00

$16.00

$18.00

$6.00

$12.00

$18.00

$6.00

$12.00

$15.00

$4.00

$11.00

$15.00

$5.00

$10.00

$13.00

$4.00

$8.00

$20.00

$5.00

$15.00

$11.00

$3.00

$7.00


Part A, 129



83505-TC

83516

83516-26

83516-TC

83518

83518-26

83518-TC

83519

83519-26

83519-TC

83520

83520-26

83497-TC

83498

83498-26

83498-TC

83499

83499-26

83499-TC

83500

83500-26

83500-TC

83505

83505-26

83520-TC

83525

83525-26

83525-TC

83527

83527-26


CPT Code

83070

83070-26

MRA

$13.00

$4.00

83070-TC

83080

83080-26

83080-TC

83088

83088-26

$8.00

$38.00

$11.00

$26.00

$59.00

$18.00

83088-TC

83090

83090-26

83090-TC

83150

83150-26

83150-TC

83491

83491-26

83491-TC

83497

83497-26

$41.00

$38.00

$13.00

$25.00

$49.00

$16.00

$33.00

$37.00

$11.00

$25.00

$35.00

$11.00

$54.00

$26.00

$8.00

$18.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$20.00

$6.00

$23.00

$62.00

$20.00

$41.00

$51.00

$15.00

$36.00

$69.00

$21.00

$45.00

$77.00

$21.00

$14.00

$31.00

$8.00

$21.00

$35.00

$11.00


CPT Code

83527-TC

83528

83528-26

83528-TC

83540

83540-26

83540-TC

83550

83550-26

83550-TC

83570

83570-26

83570-TC

83582

83582-26

83582-TC

83586

83586-26

83586-TC

83593

83593-26

83593-TC

83605

83605-26

83605-TC

83615

83615-26

83615-TC

83625

83625-26

83625-TC

83632

83632-26

83632-TC

83655

83655-26

83655-TC

83670

83670-26

83670-TC

83690

83690-26

83690-TC

83718

83718-26

83718-TC

83719

83719-26

83719-TC

83721

MRA

$23.00

$43.00

$14.00

$29.00

$16.00

$3.00

$13.00

$20.00

$5.00

$15.00

$23.00

$7.00

$16.00

$34.00

$8.00

$24.00

$38.00

$13.00

$24.00

$59.00

$18.00

$41.00

$19.00

$6.00

$13.00

$16.00

$5.00

$11.00

$23.00

$6.00

$17.00

$42.00

$14.00

$28.00

$31.00

$8.00

$21.00

$18.00

$5.00

$13.00

$18.00

$6.00

$12.00

$16.00

$5.00

$11.00

$42.00

$14.00

$28.00

$16.00

83873

83873-26

83873-TC

83874

83874-26

83874-TC

83880

83880-26

83880-TC

83883

83883-26

83883-TC

83835

83835-26

83835-TC

83857

83857-26

83857-TC

83864

83864-26

83864-TC

83872

83872-26

83872-TC

83885

83885-26

83885-TC

83915

83915-26

83915-TC


CPT Code

83721-26

83721-TC

MRA

$5.00

$11.00

83727

83727-26

83727-TC

83735

83735-26

83735-TC

$43.00

$14.00

$29.00

$15.00

$5.00

$10.00

83775

83775-26

83775-TC

83785

83785-26

83785-TC

83789

83789-26

83789-TC

83825

83825-26

83825-TC

$17.00

$5.00

$12.00

$58.00

$17.00

$41.00

$39.00

$13.00

$25.00

$34.00

$11.00

$22.00

$54.00

$18.00

$36.00

$25.00

$8.00

$17.00

BR

BR

BR

$11.00

$3.00

$7.00

$41.00

$12.00

$29.00

$26.00

$8.00

$18.00

$32.00

$8.00

$22.00

$13.00

$4.00

$8.00

$45.00

$14.00

$32.00

$31.00

$10.00

$20.00


Part A, 130



83986-TC

83992

83992-26

83992-TC

84030

84030-26

84030-TC

84035

84035-26

84035-TC

84060

84060-26

83937-TC

83945

83945-26

83945-TC

83950

83950-26

83950-TC

83970

83970-26

83970-TC

83986

83986-26

84060-TC

84061

84061-26

84061-TC

84066

84066-26


CPT Code

83916

83916-26

MRA

$54.00

$18.00

83916-TC

83918

83918-26

83918-TC

83919

83919-26

$36.00

$41.00

$12.00

$29.00

$42.00

$12.00

83919-TC

83921

83921-26

83921-TC

83930

83930-26

83930-TC

83935

83935-26

83935-TC

83937

83937-26

$29.00

$37.00

$12.00

$25.00

$11.00

$3.00

$7.00

$17.00

$5.00

$12.00

$29.00

$10.00

$5.00

$40.00

$12.00

$28.00

$11.00

$3.00

$7.00

$12.00

$3.00

$8.00

$20.00

$6.00

$19.00

$32.00

$11.00

$20.00

BR

BR

BR

$94.00

$31.00

$62.00

$8.00

$3.00

$14.00

$14.00

$4.00

$10.00

$18.00

$6.00


CPT Code

84066-TC

84075

84075-26

84075-TC

84078

84078-26

84078-TC

84080

84080-26

84080-TC

84081

84081-26

84081-TC

84085

84085-26

84085-TC

84087

84087-26

84087-TC

84100

84100-26

84100-TC

84105

84105-26

84105-TC

84106

84106-26

84106-TC

84110

84110-26

84110-TC

84119

84119-26

84119-TC

84120

84120-26

84120-TC

84126

84126-26

84126-TC

84132

84132-26

84132-TC

84133

84133-26

84133-TC

84134

84134-26

84134-TC

84135

MRA

$12.00

$12.00

$3.00

$8.00

$19.00

$5.00

$14.00

$36.00

$11.00

$24.00

$45.00

$15.00

$31.00

$15.00

$5.00

$10.00

$25.00

$7.00

$18.00

$11.00

$3.00

$7.00

$11.00

$3.00

$7.00

$10.00

$2.00

$7.00

$21.00

$6.00

$15.00

$21.00

$6.00

$15.00

$38.00

$11.00

$26.00

$71.00

$20.00

$49.00

$11.00

$3.00

$7.00

$11.00

$3.00

$7.00

$24.00

$7.00

$17.00

$57.00

84160

84160-26

84160-TC

84165

84165-26

84165-TC

84166

84166-26

84166-TC

84181

84181-26

84181-TC

84152

84152-26

84152-TC

84153

84153-26

84153-TC

84154

84154-26

84154-TC

84155

84155-26

84155-TC

84182

84182-26

84182-TC

84202

84202-26

84202-TC


CPT Code

84135-26

84135-TC

MRA

$19.00

$38.00

84138

84138-26

84138-TC

84140

84140-26

84140-TC

$56.00

$18.00

$38.00

$41.00

$8.00

$33.00

84143

84143-26

84143-TC

84144

84144-26

84144-TC

84146

84146-26

84146-TC

84150

84150-26

84150-TC

$62.00

$20.00

$41.00

$38.00

$7.00

$31.00

$53.00

$17.00

$36.00

$69.00

$20.00

$47.00

$5.00

$2.00

$2.00

$24.00

$8.00

$16.00

BR

$20.00

BR

$29.00

$10.00

$19.00

$42.00

$14.00

$27.00

$33.00

$11.00

$21.00

$33.00

$11.00

$21.00

$12.00

$4.00

$7.00

$33.00

$11.00

$21.00

$39.00

$13.00

$25.00


Part A, 131



84244-TC

84252

84252-26

84252-TC

84255

84255-26

84255-TC

84260

84260-26

84260-TC

84270

84270-26

84233-TC

84234

84234-26

84234-TC

84235

84235-26

84235-TC

84238

84238-26

84238-TC

84244

84244-26

84270-TC

84275

84275-26

84275-TC

84285

84285-26


CPT Code

84203

84203-26

MRA

$16.00

$5.00

84203-TC

84206

84206-26

84206-TC

84207

84207-26

$11.00

$32.00

$10.00

$21.00

$54.00

$16.00

84207-TC

84210

84210-26

84210-TC

84220

84220-26

84220-TC

84228

84228-26

84228-TC

84233

84233-26

$38.00

$24.00

$10.00

$15.00

$25.00

$8.00

$17.00

$32.00

$10.00

$21.00

$116.00

$35.00

$32.00

$47.00

$14.00

$33.00

$58.00

$17.00

$41.00

$54.00

$16.00

$38.00

$36.00

$11.00

$81.00

$116.00

$35.00

$81.00

$114.00

$34.00

$80.00

$97.00

$32.00

$65.00

$47.00

$15.00

$24.00

$37.00

$11.00

$25.00

$59.00

$17.00


CPT Code

84285-TC

84295

84295-26

84295-TC

84300

84300-26

84300-TC

84302

84302-26

84302-TC

84305

84305-26

84305-TC

84307

84307-26

84307-TC

84311

84311-26

84311-TC

84315

84315-26

84315-TC

84375

84375-26

84375-TC

84376

84376-26

84376-TC

84377

84377-26

84377-TC

84378

84378-26

84378-TC

84379

84379-26

84379-TC

84392

84392-26

84392-TC

84402

84402-26

84402-TC

84403

84403-26

84403-TC

84425

84425-26

84425-TC

84430

MRA

$42.00

$10.00

$3.00

$6.00

$10.00

$3.00

$6.00

BR

BR

BR

$34.00

$11.00

$22.00

$26.00

$8.00

$18.00

$11.00

$3.00

$7.00

$5.00

$2.00

$3.00

$37.00

$11.00

$25.00

$10.00

$3.00

$7.00

$10.00

$3.00

$7.00

$25.00

$8.00

$17.00

$25.00

$8.00

$17.00

$8.00

$2.00

$6.00

$72.00

$21.00

$49.00

$67.00

$19.00

$45.00

$54.00

$17.00

$37.00

$31.00

84460

84460-26

84460-TC

84466

84466-26

84466-TC

84478

84478-26

84478-TC

84479

84479-26

84479-TC

84445

84445-26

84445-TC

84446

84446-26

84446-TC

84449

84449-26

84449-TC

84450

84450-26

84450-TC

84480

84480-26

84480-TC

84481

84481-26

84481-TC


CPT Code

84430-26

84430-TC

MRA

$10.00

$20.00

84432

84432-26

84432-TC

84436

84436-26

84436-TC

$28.00

$8.00

$19.00

$14.00

$3.00

$11.00

84437

84437-26

84437-TC

84439

84439-26

84439-TC

84442

84442-26

84442-TC

84443

84443-26

84443-TC

$13.00

$4.00

$8.00

$16.00

$4.00

$12.00

$25.00

$6.00

$19.00

$32.00

$7.00

$23.00

$13.00

$4.00

$8.00

$22.00

$7.00

$15.00

$12.00

$3.00

$8.00

$15.00

$5.00

$10.00

$98.00

$29.00

$69.00

$35.00

$11.00

$23.00

$38.00

$13.00

$24.00

$11.00

$3.00

$7.00

$20.00

$6.00

$14.00

$33.00

$10.00

$22.00


Part A, 132



84545-TC

84550

84550-26

84550-TC

84560

84560-26

84560-TC

84577

84577-26

84577-TC

84578

84578-26

84512-TC

84520

84520-26

84520-TC

84525

84525-26

84525-TC

84540

84540-26

84540-TC

84545

84545-26

84578-TC

84580

84580-26

84580-TC

84583

84583-26


CPT Code

84482

84482-26

MRA

$45.00

$15.00

84482-TC

84484

84484-26

84484-TC

84485

84485-26

$31.00

$21.00

$6.00

$15.00

$15.00

$4.00

84485-TC

84488

84488-26

84488-TC

84490

84490-26

84490-TC

84510

84510-26

84510-TC

84512

84512-26

$11.00

$15.00

$4.00

$11.00

$15.00

$4.00

$11.00

$26.00

$8.00

$18.00

$17.00

$5.00

$13.00

$12.00

$4.00

$7.00

$12.00

$3.00

$8.00

$34.00

$11.00

$22.00

$7.00

$2.00

$12.00

$12.00

$3.00

$8.00

$7.00

$2.00

$5.00

$13.00

$4.00

$8.00

$18.00

$5.00

$5.00

$17.00

$5.00

$12.00

$11.00

$3.00


CPT Code

84583-TC

84585

84585-26

84585-TC

84586

84586-26

84586-TC

84588

84588-26

84588-TC

84590

84590-26

84590-TC

84591

84591-26

84591-TC

84597

84597-26

84597-TC

84600

84600-26

84600-TC

84620

84620-26

84620-TC

84630

84630-26

84630-TC

84681

84681-26

84681-TC

84702

84702-26

84702-TC

84703

84703-26

84703-TC

84830

84830-26

84830-TC

84999

84999-26

84999-TC

85002

85002-26

85002-TC

85004

85004-26

85004-TC

85007

MRA

$7.00

$36.00

$11.00

$24.00

$42.00

$14.00

$27.00

$73.00

$23.00

$47.00

$33.00

$11.00

$21.00

$26.00

$9.00

$18.00

$37.00

$11.00

$25.00

$43.00

$13.00

$31.00

$29.00

$8.00

$20.00

$26.00

$8.00

$18.00

$52.00

$17.00

$35.00

$38.00

$11.00

$26.00

$22.00

$6.00

$15.00

$17.00

$5.00

$12.00

BR

BR

BR

$10.00

$3.00

$6.00

BR

BR

BR

$6.00

85045

85045-26

85045-TC

85046

85046-26

85046-TC

85048

85048-26

85048-TC

85049

85049-26

85049-TC

85027

85027-26

85027-TC

85032

85032-26

85032-TC

85041

85041-26

85041-TC

85044

85044-26

85044-TC

85060

85060-26

85060-TC

85097

85097-26

85097-TC


CPT Code

85007-26

85007-TC

MRA

$3.00

$4.00

85008

85008-26

85008-TC

85009

85009-26

85009-TC

$5.00

$2.00

$3.00

$8.00

$3.00

$5.00

85013

85013-26

85013-TC

85014

85014-26

85014-TC

85018

85018-26

85018-TC

85025

85025-26

85025-TC

$3.00

$1.00

$2.00

$4.00

$1.00

$3.00

$5.00

$2.00

$3.00

$20.00

$6.00

$14.00

$6.00

$2.00

$4.00

$13.00

$4.00

$9.00

$7.00

$3.00

$4.00

BR

BR

BR

$15.00

$5.00

$10.00

BR

BR

BR

$7.00

$3.00

$4.00

$10.00

$3.00

$6.00

$25.00

$7.00

$18.00

$59.00

$59.00

BR


Part A, 133



85247-TC

85250

85250-26

85250-TC

85260

85260-26

85260-TC

85270

85270-26

85270-TC

85280

85280-26

85240-TC

85244

85244-26

85244-TC

85245

85245-26

85245-TC

85246

85246-26

85246-TC

85247

85247-26

85280-TC

85290

85290-26

85290-TC

85291

85291-26


CPT Code

85130

85130-26

MRA

$19.00

$6.00

85130-TC

85170

85170-26

85170-TC

85175

85175-26

$13.00

$7.00

$2.00

$5.00

$10.00

$3.00

85175-TC

85210

85210-26

85210-TC

85220

85220-26

85220-TC

85230

85230-26

85230-TC

85240

85240-26

$6.00

$31.00

$8.00

$21.00

$47.00

$15.00

$32.00

$47.00

$14.00

$33.00

$48.00

$15.00

$36.00

$49.00

$14.00

$35.00

$49.00

$14.00

$35.00

$49.00

$14.00

$35.00

$49.00

$14.00

$33.00

$49.00

$15.00

$34.00

$54.00

$18.00

$36.00

$54.00

$18.00

$36.00

$54.00

$18.00

$35.00

$44.00

$13.00

$32.00

$20.00

$6.00


CPT Code

85291-TC

85292

85292-26

85292-TC

85293

85293-26

85293-TC

85300

85300-26

85300-TC

85301

85301-26

85301-TC

85302

85302-26

85302-TC

85303

85303-26

85303-TC

85305

85305-26

85305-TC

85306

85306-26

85306-TC

85307

85307-26

85307-TC

85335

85335-26

85335-TC

85337

85337-26

85337-TC

85345

85345-26

85345-TC

85347

85347-26

85347-TC

85348

85348-26

85348-TC

85360

85360-26

85360-TC

85362

85362-26

85362-TC

85366

MRA

$14.00

$51.00

$17.00

$34.00

$51.00

$17.00

$34.00

$35.00

$12.00

$23.00

$29.00

$10.00

$19.00

$33.00

$11.00

$21.00

$26.00

$8.00

$18.00

$21.00

$7.00

$14.00

$29.00

$10.00

$19.00

$35.00

$12.00

$23.00

$21.00

$7.00

$14.00

$19.00

$6.00

$13.00

$10.00

$2.00

$7.00

$8.00

$2.00

$6.00

$10.00

$3.00

$6.00

$16.00

$4.00

$12.00

$18.00

$7.00

$11.00

$13.00

85415-TC

85420

85420-26

85420-TC

85421

85421-26

85421-TC

85441

85441-26

85441-TC

85445

85445-26

85390

85390-26

85390-TC

85396

85400

85400-26

85400-TC

85410

85410-26

85410-TC

85415

85415-26

85445-TC

85460

85460-26

85460-TC

85461

85461-26


CPT Code

85366-26

85366-TC

MRA

$3.00

$10.00

85370

85370-26

85370-TC

85378

85378-26

85378-TC

$20.00

$5.00

$15.00

$13.00

$4.00

$8.00

85379

85379-26

85379-TC

85380

85380-26

85380-TC

85384

85384-26

85384-TC

85385

85385-26

85385-TC

$18.00

$6.00

$12.00

BR

BR

BR

$11.00

$3.00

$7.00

$16.00

$5.00

$11.00

$18.00

$16.00

$3.00

$13.00

$39.00

$12.00

$26.00

$7.00

$2.00

$5.00

$16.00

$5.00

$10.00

$2.00

$7.00

$22.00

$12.00

$3.00

$8.00

$12.00

$3.00

$8.00

$28.00

$10.00

$11.00

$15.00

$4.00

$11.00

$12.00

$3.00


Part A, 134



85576-26

85576-TC

85597

85597-26

85597-TC

85610

85610-26

85610-TC

85611

85611-26

85611-TC

85612

85547-26

85547-TC

85549

85549-26

85549-TC

85555

85555-26

85555-TC

85557

85557-26

85557-TC

85576

85612-26

85612-TC

85613

85613-26

85613-TC

85635


CPT Code

85461-TC

85475

MRA

$8.00

$15.00

85475-26

85475-TC

85520

85520-26

85520-TC

85525

$4.00

$11.00

$22.00

$6.00

$16.00

$20.00

85525-26

85525-TC

85530

85530-26

85530-TC

85536

85536-26

85536-TC

85540

85540-26

85540-TC

85547

$6.00

$14.00

$39.00

$12.00

$26.00

$14.00

$4.00

$10.00

$24.00

$7.00

$17.00

$23.00

$5.00

$16.00

$32.00

$10.00

$21.00

$6.00

$3.00

$4.00

$6.00

$2.00

$4.00

$22.00

$6.00

$17.00

$45.00

$15.00

$31.00

$17.00

$5.00

$12.00

$34.00

$10.00

$23.00

$21.00

$6.00

$16.00

$15.00

$4.00

$11.00

$26.00


CPT Code

85635-26

85635-TC

85651

85651-26

85651-TC

85652

85652-26

85652-TC

85660

85660-26

85660-TC

85670

85670-26

85670-TC

85675

85675-26

85675-TC

85705

85705-26

85705-TC

85730

85730-26

85730-TC

85732

85732-26

85732-TC

85810

85810-26

85810-TC

85999

85999-26

85999-TC

86000

86000-26

86000-TC

86001

86001-26

86001-TC

86003

86003-26

86003-TC

86005

86005-26

86005-TC

86021

86021-26

86021-TC

86022

86022-26

86022-TC

MRA

$8.00

$18.00

$8.00

$2.00

$6.00

$8.00

$2.00

$6.00

$10.00

$3.00

$6.00

$13.00

$3.00

$10.00

$13.00

$4.00

$8.00

$13.00

$4.00

$8.00

$11.00

$3.00

$7.00

$17.00

$5.00

$12.00

$19.00

$4.00

$15.00

BR

BR

BR

$16.00

$5.00

$11.00

$12.00

$4.00

$8.00

$6.00

$2.00

$3.00

$11.00

$4.00

$6.00

$41.00

$12.00

$29.00

$57.00

$18.00

$39.00

86146-TC

86147

86147-26

86147-TC

86148

86148-26

86148-TC

86153-26

86155

86155-26

86155-TC

86156

86078-TC

86079

86079-26

86079-TC

86140

86140-26

86140-TC

86141

86141-26

86141-TC

86146

86146-26

86156-26

86156-TC

86157

86157-26

86157-TC

86160


CPT Code

86023

86023-26

MRA

$28.00

$10.00

86023-TC

86038

86038-26

86038-TC

86039

86039-26

$18.00

$22.00

$7.00

$15.00

$19.00

$6.00

86039-TC

86060

86060-26

86060-TC

86063

86063-26

86063-TC

86077

86077-26

86077-TC

86078

86078-26

$13.00

$13.00

$3.00

$10.00

$21.00

$6.00

$15.00

$91.00

$26.00

$64.00

$91.00

$26.00

$39.00

$53.00

$16.00

$36.00

$59.00

$21.00

$38.00

$35.00

$26.00

$8.00

$18.00

$11.00

$64.00

$79.00

$25.00

$52.00

$14.00

$4.00

$10.00

BR

BR

BR

$58.00

$19.00

$3.00

$7.00

$13.00

$4.00

$8.00

$21.00


Part A, 135



86256

86256-26

86256-TC

86277

86277-26

86277-TC

86280

86280-26

86280-TC

86294

86294-26

86294-TC

86226

86226-26

86226-TC

86235

86235-26

86235-TC

86243

86243-26

86243-TC

86255

86255-26

86255-TC

86300

86300-26

86300-TC

86301

86301-26

86301-TC


CPT Code

86160-26

86160-TC

MRA

$5.00

$16.00

86161

86161-26

86161-TC

86162

86162-26

86162-TC

$21.00

$5.00

$16.00

$54.00

$18.00

$36.00

86171

86171-26

86171-TC

86185

86185-26

86185-TC

86215

86215-26

86215-TC

86225

86225-26

86225-TC

$25.00

$7.00

$18.00

$19.00

$6.00

$13.00

$36.00

$12.00

$23.00

$36.00

$11.00

$24.00

$25.00

$8.00

$17.00

$41.00

$14.00

$26.00

$15.00

$3.00

$12.00

BR

BR

BR

$24.00

$8.00

$16.00

$33.00

$10.00

$22.00

$50.00

$15.00

$35.00

$25.00

$8.00

$17.00

$47.00

$15.00

$32.00

$47.00

$15.00

$32.00


CPT Code

86304

86304-26

86304-TC

86308

86308-26

86308-TC

86309

86309-26

86309-TC

86310

86310-26

86310-TC

86316

86316-26

86316-TC

86317

86317-26

86317-TC

86318

86318-26

86318-TC

86320

86320-26

86320-TC

86325

86325-26

86325-TC

86327

86327-26

86327-TC

86329

86329-26

86329-TC

86331

86331-26

86331-TC

86332

86332-26

86332-TC

86334

86334-26

86334-TC

86335

86335-26

86335-TC

86336

86336-26

86336-TC

86337

86337-26

MRA

$47.00

$15.00

$32.00

$8.00

$3.00

$5.00

$12.00

$3.00

$8.00

$19.00

$6.00

$13.00

$37.00

$11.00

$25.00

$31.00

$10.00

$20.00

$23.00

$10.00

$14.00

$49.00

$19.00

$29.00

$49.00

$16.00

$33.00

$62.00

$19.00

$42.00

$37.00

$12.00

$24.00

$22.00

$6.00

$15.00

$54.00

$18.00

$36.00

$65.00

$18.00

$45.00

BR

$20.00

BR

BR

BR

BR

$54.00

$18.00

86382-26

86382-TC

86384

86384-26

86384-TC

86403

86403-26

86403-TC

86406

86406-26

86406-TC

86430

86360-26

86360-TC

86361

86361-26

86361-TC

86376

86376-26

86376-TC

86378

86378-26

86378-TC

86382

86430-26

86430-TC

86431

86431-26

86431-TC

86485


CPT Code

86337-TC

86340

MRA

$36.00

$39.00

86340-26

86340-TC

86341

86341-26

86341-TC

86343

$13.00

$25.00

$38.00

$13.00

$24.00

$33.00

86343-26

86343-TC

86344

86344-26

86344-TC

86353

86353-26

86353-TC

86359

86359-26

86359-TC

86360

$11.00

$21.00

$21.00

$7.00

$14.00

$102.00

$31.00

$72.00

$61.00

$19.00

$41.00

$99.00

$14.00

$32.00

$24.00

$8.00

$16.00

$18.00

$3.00

$14.00

$21.00

$5.00

$16.00

$13.00

$33.00

$67.00

$66.00

$21.00

$43.00

$35.00

$11.00

$23.00

$45.00

$15.00

$31.00

$45.00

$4.00

$8.00

$17.00

$6.00

$11.00

$13.00


Part A, 136



86609-TC

86611

86611-26

86611-TC

86612

86612-26

86612-TC

86615

86615-26

86615-TC

86617

86617-26

86593-TC

86602

86602-26

86602-TC

86603

86603-26

86603-TC

86606

86606-26

86606-TC

86609

86609-26

86617-TC

86618

86618-26

86618-TC

86619

86619-26


CPT Code

86485-26

86485-TC

MRA

$4.00

$8.00

86486

86490

86490-26

86490-TC

86510

86510-26

$6.00

$17.00

$5.00

$12.00

$13.00

$4.00

86510-TC

86580

86580-26

86580-TC

86590

86590-26

86590-TC

86592

86592-26

86592-TC

86593

86593-26

$8.00

$13.00

$4.00

$8.00

$18.00

$6.00

$12.00

$8.00

$2.00

$6.00

$11.00

$3.00

$14.00

$23.00

$8.00

$15.00

$21.00

$6.00

$15.00

$21.00

$6.00

$15.00

$29.00

$10.00

$7.00

$17.00

$5.00

$12.00

$20.00

$6.00

$14.00

$24.00

$8.00

$16.00

$20.00

$6.00

$19.00

$26.00

$8.00

$18.00

$21.00

$6.00


CPT Code

86619-TC

86622

86622-26

86622-TC

86625

86625-26

86625-TC

86628

86628-26

86628-TC

86631

86631-26

86631-TC

86632

86632-26

86632-TC

86635

86635-26

86635-TC

86638

86638-26

86638-TC

86641

86641-26

86641-TC

86644

86644-26

86644-TC

86645

86645-26

86645-TC

86648

86648-26

86648-TC

86651

86651-26

86651-TC

86652

86652-26

86652-TC

86653

86653-26

86653-TC

86654

86654-26

86654-TC

86658

86658-26

86658-TC

86663

MRA

$15.00

$16.00

$5.00

$11.00

$21.00

$6.00

$15.00

$20.00

$6.00

$14.00

$20.00

$6.00

$14.00

$20.00

$6.00

$14.00

$18.00

$5.00

$13.00

$20.00

$6.00

$14.00

$21.00

$7.00

$14.00

$22.00

$7.00

$15.00

$28.00

$10.00

$18.00

$24.00

$8.00

$16.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

86688

86688-26

86688-TC

86689

86689-26

86689-TC

86692

86692-26

86692-TC

86694

86694-26

86694-TC

86677

86677-26

86677-TC

86682

86682-26

86682-TC

86684

86684-26

86684-TC

86687

86687-26

86687-TC

86695

86695-26

86695-TC

86696

86696-26

86696-TC


CPT Code

86663-26

86663-TC

MRA

$7.00

$14.00

86664

86664-26

86664-TC

86665

86665-26

86665-TC

$53.00

$17.00

$36.00

$29.00

$10.00

$19.00

86666

86666-26

86666-TC

86668

86668-26

86668-TC

86671

86671-26

86671-TC

86674

86674-26

86674-TC

$23.00

$8.00

$15.00

$17.00

$5.00

$12.00

$20.00

$6.00

$14.00

$23.00

$7.00

$16.00

$20.00

$7.00

$14.00

$25.00

$8.00

$17.00

$22.00

$7.00

$15.00

$22.00

$7.00

$15.00

$24.00

$8.00

$16.00

$21.00

$7.00

$14.00

$24.00

$8.00

$16.00

$22.00

$7.00

$16.00

$21.00

$7.00

$14.00

$44.00

$14.00

$30.00


Part A, 137



86710-TC

86713

86713-26

86713-TC

86717

86717-26

86717-TC

86720

86720-26

86720-TC

86723

86723-26

86706-TC

86707

86707-26

86707-TC

86708

86708-26

86708-TC

86709

86709-26

86709-TC

86710

86710-26

86723-TC

86727

86727-26

86727-TC

86729

86729-26


CPT Code

86698

86698-26

MRA

$20.00

$6.00

86698-TC

86701

86701-26

86701-TC

86702

86702-26

$14.00

$21.00

$7.00

$15.00

$21.00

$7.00

86702-TC

86703

86703-26

86703-TC

86704

86704-26

86704-TC

86705

86705-26

86705-TC

86706

86706-26

$14.00

$22.00

$7.00

$15.00

$33.00

$11.00

$21.00

$35.00

$11.00

$23.00

$24.00

$8.00

$15.00

$23.00

$7.00

$16.00

$20.00

$6.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$16.00

$26.00

$8.00

$18.00

$32.00

$10.00

$21.00

$29.00

$10.00

$19.00

$22.00

$7.00

$14.00

$20.00

$6.00

$14.00

$19.00

$6.00


CPT Code

86729-TC

86732

86732-26

86732-TC

86735

86735-26

86735-TC

86738

86738-26

86738-TC

86741

86741-26

86741-TC

86744

86744-26

86744-TC

86747

86747-26

86747-TC

86750

86750-26

86750-TC

86753

86753-26

86753-TC

86756

86756-26

86756-TC

86757

86757-26

86757-TC

86759

86759-26

86759-TC

86762

86762-26

86762-TC

86765

86765-26

86765-TC

86768

86768-26

86768-TC

86771

86771-26

86771-TC

86774

86774-26

86774-TC

86777

MRA

$13.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$23.00

$7.00

$16.00

$21.00

$7.00

$14.00

$20.00

$6.00

$14.00

$20.00

$6.00

$14.00

$44.00

$14.00

$30.00

$21.00

$7.00

$14.00

$22.00

$7.00

$15.00

$20.00

$6.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$23.00

$7.00

$16.00

$22.00

86807

86807-26

86807-TC

86808

86808-26

86808-TC

86812

86812-26

86812-TC

86813

86813-26

86813-TC

86803

86803-26

86803-TC

86804

86804-26

86804-TC

86805

86805-26

86805-TC

86806

86806-26

86806-TC

86816

86816-26

86816-TC

86817

86817-26

86817-TC


CPT Code

86777-26

86777-TC

MRA

$7.00

$15.00

86778

86778-26

86778-TC

86784

86784-26

86784-TC

$23.00

$7.00

$16.00

$21.00

$7.00

$14.00

86787

86787-26

86787-TC

86790

86790-26

86790-TC

86793

86793-26

86793-TC

86800

86800-26

86800-TC

$20.00

$6.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$26.00

$8.00

$18.00

$74.00

$21.00

$51.00

$52.00

$15.00

$37.00

$108.00

$32.00

$75.00

$101.00

$29.00

$71.00

$24.00

$8.00

$16.00

$26.00

$8.00

$18.00

$97.00

$33.00

$64.00

$87.00

$28.00

$57.00

$64.00

$18.00

$44.00

$134.00

$39.00

$94.00


Part A, 138



86891-TC

86900

86900-26

86900-TC

86901

86901-26

86901-TC

86904

86904-26

86904-TC

86905

86905-26

86880-TC

86885

86885-26

86885-TC

86886

86886-26

86886-TC

86890

86890-26

86890-TC

86891

86891-26

86905-TC

86906

86906-26

86906-TC

86910

86910-26


CPT Code

86821

86821-26

MRA

$123.00

$36.00

86821-TC

86822

86822-26

86822-TC

86849

86849-26

$86.00

$96.00

$32.00

$64.00

BR

BR

86849-TC

86850

86850-26

86850-TC

86860

86860-26

86860-TC

86870

86870-26

86870-TC

86880

86880-26

BR

$10.00

$3.00

$6.00

$44.00

$15.00

$29.00

$17.00

$6.00

$11.00

$13.00

$4.00

$64.00

$10.00

$3.00

$6.00

$10.00

$3.00

$6.00

$19.00

$6.00

$13.00

$7.00

$1.00

$8.00

$15.00

$4.00

$11.00

$14.00

$4.00

$10.00

$67.00

$11.00

$54.00

$91.00

$26.00

$6.00

$11.00

$3.00

$7.00

$83.00

$24.00


CPT Code

86910-TC

86911

86911-26

86911-TC

86920

86920-26

86920-TC

86921

86921-26

86921-TC

86922

86922-26

86922-TC

86927

86927-26

86927-TC

86930

86930-26

86930-TC

86931

86931-26

86931-TC

86932

86932-26

86932-TC

86940

86940-26

86940-TC

86941

86941-26

86941-TC

86945

86945-26

86945-TC

86950

86950-26

86950-TC

86965

86965-26

86965-TC

86970

86970-26

86970-TC

86971

86971-26

86971-TC

86972

86972-26

86972-TC

86975

MRA

$57.00

$19.00

$6.00

$13.00

$19.00

$3.00

$15.00

$23.00

$7.00

$16.00

$20.00

$6.00

$14.00

$21.00

$5.00

$16.00

$155.00

$45.00

$108.00

$155.00

$45.00

$108.00

$161.00

$48.00

$111.00

$18.00

$5.00

$13.00

$31.00

$8.00

$21.00

$35.00

$11.00

$23.00

$99.00

$29.00

$70.00

$25.00

$7.00

$18.00

$41.00

$12.00

$29.00

$20.00

$5.00

$15.00

$20.00

$6.00

$14.00

$53.00

87070

87070-26

87070-TC

87071

87071-26

87071-TC

87073

87073-26

87073-TC

87075

87075-26

87075-TC

87015

87015-26

87015-TC

87040

87040-26

87040-TC

87045

87045-26

87045-TC

87046

87046-26

87046-TC

87076

87076-26

87076-TC

87077

87077-26

87077-TC


CPT Code

86975-26

86975-TC

MRA

$16.00

$37.00

86976

86976-26

86976-TC

86977

86977-26

86977-TC

$53.00

$16.00

$37.00

$53.00

$16.00

$37.00

86978

86978-26

86978-TC

86985

86985-26

86985-TC

86999

86999-26

86999-TC

87003

87003-26

87003-TC

$65.00

$19.00

$44.00

$35.00

$12.00

$23.00

BR

BR

BR

$40.00

$13.00

$26.00

$14.00

$4.00

$10.00

$11.00

$3.00

$8.00

$11.00

$3.00

$8.00

$18.00

$6.00

$12.00

$14.00

$5.00

$9.00

$18.00

$6.00

$12.00

$18.00

$6.00

$11.00

$5.00

$2.00

$3.00

$24.00

$8.00

$16.00

$16.00

$5.00

$11.00


Part A, 139



87110-TC

87116

87116-26

87116-TC

87118

87118-26

87118-TC

87140

87140-26

87140-TC

87143

87143-26

87103-TC

87106

87106-26

87106-TC

87107

87107-26

87107-TC

87109

87109-26

87109-TC

87110

87110-26

87143-TC

87147

87147-26

87147-TC

87149

87149-26


CPT Code

87081

87081-26

MRA

$12.00

$3.00

87081-TC

87084

87084-26

87084-TC

87086

87086-26

$8.00

$23.00

$7.00

$16.00

$14.00

$3.00

87086-TC

87088

87088-26

87088-TC

87101

87101-26

87101-TC

87102

87102-26

87102-TC

87103

87103-26

$11.00

$18.00

$6.00

$12.00

$20.00

$6.00

$14.00

$20.00

$6.00

$14.00

$32.00

$11.00

$15.00

$15.00

$3.00

$11.00

$28.00

$9.00

$20.00

$24.00

$7.00

$17.00

$34.00

$11.00

$20.00

$25.00

$7.00

$18.00

$23.00

$8.00

$15.00

$26.00

$8.00

$18.00

$23.00

$7.00

$22.00

$26.00

$8.00

$18.00

$46.00

$15.00


CPT Code

87149-TC

87152

87152-26

87152-TC

87158

87158-26

87158-TC

87164

87164-26

87164-TC

87166

87166-26

87166-TC

87168

87168-26

87168-TC

87169

87169-26

87169-TC

87172

87172-26

87172-TC

87176

87176-26

87176-TC

87177

87177-26

87177-TC

87181

87181-26

87181-TC

87184

87184-26

87184-TC

87185

87185-26

87185-TC

87186

87186-26

87186-TC

87187

87187-26

87187-TC

87188

87188-26

87188-TC

87190

87190-26

87190-TC

87197

MRA

$31.00

$12.00

$4.00

$8.00

$5.00

$1.00

$3.00

$24.00

$8.00

$16.00

$24.00

$7.00

$17.00

$10.00

$3.00

$7.00

$10.00

$3.00

$7.00

$10.00

$3.00

$7.00

$16.00

$5.00

$11.00

$18.00

$6.00

$12.00

$13.00

$3.00

$8.00

$13.00

$3.00

$10.00

$11.00

$3.00

$8.00

$16.00

$4.00

$12.00

$20.00

$3.00

$17.00

$18.00

$5.00

$13.00

$7.00

$2.00

$5.00

$29.00

87255

87255-26

87255-TC

87260

87260-26

87260-TC

87265

87265-26

87265-TC

87267

87267-26

87267-TC

87250

87250-26

87250-TC

87252

87252-26

87252-TC

87253

87253-26

87253-TC

87254

87254-26

87254-TC

87270

87270-26

87270-TC

87271

87271-26

87271-TC


CPT Code

87197-26

87197-TC

MRA

$10.00

$19.00

87205

87205-26

87205-TC

87206

87206-26

87206-TC

$11.00

$3.00

$7.00

$15.00

$3.00

$12.00

87207

87207-26

87207-TC

87210

87210-26

87210-TC

87220

87220-26

87220-TC

87230

87230-26

87230-TC

$10.00

$3.00

$6.00

$8.00

$2.00

$6.00

$12.00

$4.00

$7.00

$35.00

$11.00

$23.00

BR

BR

BR

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

BR

BR

BR

$33.00

$13.00

$19.00

$44.00

$14.00

$31.00

$33.00

$10.00

$22.00

$11.00

$3.00

$8.00

$26.00

$8.00

$18.00

BR

BR

BR


Part A, 140



87283-TC

87285

87285-26

87285-TC

87290

87290-26

87290-TC

87299

87299-26

87299-TC

87300

87300-26

87278-TC

87279

87279-26

87279-TC

87280

87280-26

87280-TC

87281

87281-26

87281-TC

87283

87283-26

87300-TC

87301

87301-26

87301-TC

87320

87320-26


CPT Code

87272

87272-26

MRA

$26.00

$8.00

87272-TC

87273

87273-26

87273-TC

87274

87274-26

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

87274-TC

87275

87275-26

87275-TC

87276

87276-26

87276-TC

87277

87277-26

87277-TC

87278

87278-26

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$19.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$13.00

$4.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$27.00

$9.00

$9.00

$26.00

$8.00

$18.00

$26.00

$8.00


CPT Code

87320-TC

87324

87324-26

87324-TC

87327

87327-26

87327-TC

87328

87328-26

87328-TC

87332

87332-26

87332-TC

87335

87335-26

87335-TC

87336

87336-26

87336-TC

87337

87337-26

87337-TC

87338

87338-26

87338-TC

87339

87339-26

87339-TC

87340

87340-26

87340-TC

87341

87341-26

87341-TC

87350

87350-26

87350-TC

87380

87380-26

87380-TC

87385

87385-26

87385-TC

87390

87390-26

87390-TC

87391

87391-26

87391-TC

87400

MRA

$18.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$27.00

$9.00

$19.00

$27.00

$7.00

$20.00

$27.00

$9.00

$19.00

$20.00

$6.00

$14.00

$23.00

$8.00

$15.00

$20.00

$6.00

$14.00

$35.00

$11.00

$23.00

$26.00

$8.00

$18.00

$38.00

$13.00

$24.00

$38.00

$13.00

$24.00

$13.00

87475

87475-26

87475-TC

87476

87476-26

87476-TC

87477

87477-26

87477-TC

87480

87480-26

87480-TC

87451

87451-26

87451-TC

87470

87470-26

87470-TC

87471

87471-26

87471-TC

87472

87472-26

87472-TC

87481

87481-26

87481-TC

87482

87482-26

87482-TC


CPT Code

87400-26

87400-TC

MRA

$4.00

$9.00

87420

87420-26

87420-TC

87425

87425-26

87425-TC

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

87427

87427-26

87427-TC

87430

87430-26

87430-TC

87449

87449-26

87449-TC

87450

87450-26

87450-TC

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$21.00

$6.00

$15.00

$40.00

$13.00

$26.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$19.00

$7.00

$12.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00


Part A, 141



87511-TC

87512

87512-26

87512-TC

87515

87515-26

87515-TC

87516

87516-26

87516-TC

87517

87517-26

87495-TC

87496

87496-26

87496-TC

87497

87497-26

87497-TC

87510

87510-26

87510-TC

87511

87511-26

87517-TC

87520

87520-26

87520-TC

87521

87521-26


CPT Code

87485

87485-26

MRA

$42.00

$13.00

87485-TC

87486

87486-26

87486-TC

87487

87487-26

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

87487-TC

87490

87490-26

87490-TC

87491

87491-26

87491-TC

87492

87492-26

87492-TC

87495

87495-26

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$73.00

$23.00

$48.00

$42.00

$13.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00


CPT Code

87521-TC

87522

87522-26

87522-TC

87525

87525-26

87525-TC

87526

87526-26

87526-TC

87527

87527-26

87527-TC

87528

87528-26

87528-TC

87529

87529-26

87529-TC

87530

87530-26

87530-TC

87531

87531-26

87531-TC

87532

87532-26

87532-TC

87533

87533-26

87533-TC

87534

87534-26

87534-TC

87535

87535-26

87535-TC

87536

87536-26

87536-TC

87537

87537-26

87537-TC

87538

87538-26

87538-TC

87539

87539-26

87539-TC

87540

MRA

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

87562

87562-26

87562-TC

87580

87580-26

87580-TC

87581

87581-26

87581-TC

87582

87582-26

87582-TC

87556

87556-26

87556-TC

87557

87557-26

87557-TC

87560

87560-26

87560-TC

87561

87561-26

87561-TC

87590

87590-26

87590-TC

87591

87591-26

87591-TC


CPT Code

87540-26

87540-TC

MRA

$13.00

$28.00

87541

87541-26

87541-TC

87542

87542-26

87542-TC

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

87550

87550-26

87550-TC

87551

87551-26

87551-TC

87552

87552-26

87552-TC

87555

87555-26

87555-TC

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00


Part A, 142



87803-TC

87804

87804-26

87804-TC

87810

87810-26

87810-TC

87850

87850-26

87850-TC

87880

87880-26

87799-TC

87800

87800-26

87800-TC

87801

87801-26

87801-TC

87802

87802-26

87802-TC

87803

87803-26

87880-TC

87899

87899-26

87899-TC

87901

87901-26


CPT Code

87592

87592-26

MRA

$88.00

$28.00

87592-TC

87650

87650-26

87650-TC

87651

87651-26

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

87651-TC

87652

87652-26

87652-TC

87797

87797-26

87797-TC

87798

87798-26

87798-TC

87799

87799-26

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

BR

BR

BR

BR

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$26.00

$8.00

$58.00

$46.00

$15.00

$31.00

$81.00

$26.00

$54.00

BR

BR

BR

BR

BR

$18.00

$26.00

$8.00

$18.00

$594.00

$196.00


CPT Code

87901-TC

87902

87902-26

87902-TC

87903

87903-26

87903-TC

87904

87904-26

87904-TC

87999

87999-26

87999-TC

88000

88000-26

88000-TC

88005

88005-26

88005-TC

88007

88007-26

88007-TC

88020

88020-26

88020-TC

88025

88025-26

88025-TC

88027

88027-26

88027-TC

88036

88036-26

88036-TC

88037

88037-26

88037-TC

88040

88040-26

88040-TC

88045

88045-26

88045-TC

88099

88099-26

88099-TC

88104

88104-26

88104-TC

88106

MRA

$398.00

BR

BR

BR

$1,126.00

$371.00

$755.00

$59.00

$20.00

$39.00

BR

BR

BR

$445.00

$445.00

BR

$500.00

$500.00

BR

$556.00

$556.00

BR

$556.00

$556.00

BR

$610.00

$610.00

BR

$666.00

$666.00

BR

$477.00

$477.00

BR

$389.00

$389.00

BR

$1,445.00

$1,445.00

BR

BR

BR

BR

BR

BR

BR

$49.00

$37.00

$10.00

$54.00

88147

88147-26

88147-TC

88148

88148-26

88148-TC

88150

88150-26

88150-TC

88152

88152-26

88152-TC

88140

88140-26

88140-TC

88141

88141-26

88141-TC

88142

88142-26

88142-TC

88143

88143-26

88143-TC

88153

88153-26

88153-TC

88154

88154-26

88154-TC


CPT Code

88106-26

88106-TC

MRA

$16.00

$38.00

88108

88108-26

88108-TC

88112

88112-26

88112-TC

$59.00

$47.00

$11.00

$121.00

$65.00

$56.00

88120

88120-26

88120-TC

88121

88121-26

88121-TC

88125

88125-26

88125-TC

88130

88130-26

88130-TC

$619.00

$59.00

$560.00

$535.00

$51.00

$484.00

$70.00

$20.00

$48.00

$25.00

$7.00

$18.00

$82.00

BR

$82.00

$104.00

$21.00

$82.00

$13.00

$3.00

$9.00

$46.00

$8.00

$38.00

$18.00

$5.00

$13.00

$33.00

BR

BR

$82.00

$21.00

$59.00

$94.00

$33.00

$59.00

$82.00

$21.00

$59.00

$104.00

$21.00

$82.00


Part A, 143



88174-TC

88175

88175-26

88175-TC

88177

88177-26

88177-TC

88182

88182-26

88182-TC

88184

88185

88166-TC

88167

88167-26

88167-TC

88172

88172-26

88172-TC

88173

88173-26

88173-TC

88174

88174-26

88187

88188

88189

88199

88199-26

88199-TC


CPT Code

88155

88155-26

MRA

$14.00

$3.00

88155-TC

88160

88160-26

88160-TC

88161

88161-26

$10.00

$45.00

$14.00

$24.00

$64.00

$19.00

88161-TC

88162

88162-26

88162-TC

88164

88164-26

88164-TC

88165

88165-26

88165-TC

88166

88166-26

$37.00

$77.00

$22.00

$53.00

$54.00

$21.00

$33.00

$72.00

$33.00

$38.00

$82.00

$21.00

BR

BR

BR

BR

$30.00

$22.00

$8.00

$88.00

$33.00

$54.00

$51.00

$25.00

$59.00

$87.00

$26.00

$59.00

$70.00

$54.00

$14.00

$95.00

$95.00

$26.00

BR

BR

$69.00

$86.00

$113.00

BR

BR

BR


CPT Code

88233

88233-26

88233-TC

88235

88235-26

88235-TC

88240

88240-26

88240-TC

88241

88241-26

88241-TC

88300

88300-26

88300-TC

88302

88302-26

88302-TC

88304

88304-26

88304-TC

88305

88305-26

88305-TC

88307

88307-26

88307-TC

88309

88309-26

88309-TC

88311

88311-26

88311-TC

88312

88312-26

88312-TC

88313

88313-26

88313-TC

88314

88314-26

88314-TC

88319

88319-26

88319-TC

88321

88321-26

88321-TC

88323

88323-26

MRA

$243.00

$73.00

$170.00

$256.00

$76.00

$177.00

$21.00

$6.00

$15.00

$21.00

$6.00

$15.00

$24.00

$19.00

$5.00

$53.00

$42.00

$11.00

$70.00

$54.00

$14.00

$108.00

$86.00

$21.00

$210.00

$168.00

$41.00

$322.00

$258.00

$64.00

$23.00

$19.00

$4.00

$23.00

$7.00

$16.00

$23.00

$7.00

$16.00

$21.00

$6.00

$15.00

$26.00

$13.00

$14.00

$43.00

$43.00

BR

$61.00

$61.00

88348-26

88348-TC

88350

88350-26

88350-TC

88355

88355-26

88355-TC

88356

88356-26

88356-TC

88358

88341-26

88341-TC

88342

88342-26

88342-TC

88344

88344-26

88344-TC

88346

88346-26

88346-TC

88348

88358-26

88358-TC

88360

88360-26

88360-TC

88361


CPT Code

88323-TC

88325

MRA

$32.00

$54.00

88325-26

88325-TC

88329

88329-26

88329-TC

88331

$54.00

BR

$51.00

$51.00

BR

$102.00

88331-26

88331-TC

88332

88332-26

88332-TC

88333

88333-26

88333-TC

88334

88334-26

88334-TC

88341

$70.00

$33.00

$53.00

$36.00

$17.00

$89.00

$67.00

$22.00

$47.00

$33.00

$14.00

$90.00

$145.00

$44.00

$72.00

$29.00

$44.00

$108.00

$80.00

$26.00

$108.00

$80.00

$26.00

$108.00

$28.00

$62.00

$53.00

$36.00

$17.00

$174.00

$41.00

$133.00

$96.00

$66.00

$28.00

$191.00

$80.00

$26.00

$110.00

$62.00

$49.00

$139.00


Part A, 144

88373-TC

88374

88374-26

88374-TC

88375

88377

88377-26

88377-TC

88380

88380-26

88380-TC

88381

88368-TC

88369

88369-26

88369-TC

88371

88371-26

88371-TC

88372

88372-26

88372-TC

88373

88373-26

88381-26

88381-TC

88387

88387-26

88387-TC

88388


CPT Code

88361-26

88361-TC

MRA

$55.00

$84.00

88362

88362-26

88362-TC

88363

88364

88364-26

$251.00

$119.00

$132.00

$22.00

$135.00

$35.00

88364-TC

88365

88365-26

88365-TC

88366

88366-26

88366-TC

88367

88367-26

88367-TC

88368

88368-26

$100.00

$24.00

$24.00

$68.00

$263.00

$65.00

$198.00

$210.00

$72.00

$138.00

$190.00

$78.00

$54.00

$346.00

$46.00

$300.00

$20.00

$412.00

$67.00

$346.00

$159.00

$71.00

$88.00

$213.00

$112.00

$108.00

$32.00

$77.00

$34.00

$10.00

$23.00

$38.00

$11.00

$26.00

$75.00

$21.00

$54.00

$159.00

$36.00

$29.00

$6.00

$33.00



89125-TC

89160

89160-26

89160-TC

89190

89190-26

89190-TC

89220

89230

G0124

G0141

G0416

G0416-26

G0416-TC

G0452-26

G0455


CPT Code

88388-26

88388-TC

MRA

$24.00

$9.00

88399

88399-26

88399-TC

89049

89050

89050-26

BR

BR

BR

$190.00

$10.00

$3.00

89050-TC

89051

89051-26

89051-TC

89055

89055-26

89055-TC

89060

89060-26

89060-TC

89125

89125-26

$6.00

$13.00

$4.00

$8.00

BR

BR

BR

$13.00

$5.00

$8.00

$14.00

$4.00

$10.00

$6.00

$2.00

$4.00

$10.00

$3.00

$6.00

$17.00

$5.00

$24.00

$24.00

$651.00

$184.00

$467.00

$19.00

$126.00


Part A, 145

BR

BR

$46.00

$82.00

$76.00

$226.00

BR

$80.00

$125.00

$943.00

$818.00

$461.00

$321.00

$651.00

$440.00

$93.00

$110.00

$32.00

$32.00

$143.00

$94.00

$74.00

$112.00

$112.00

$104.00

$49.00

$77.00

$14.00

$134.00

$144.00

$65.00

$66.00

$86.00

$84.00

$129.00

$111.00

$134.00

$64.00

$85.00

MRA

$25.00

$13.00

$4.00

$4.00

$13.00

$9.00

BR

BR

BR

BR

BR



90882

90885

90887

90889

90899

90901

90911

90935

90937

90940

90945

90947

90839

90840

90845

90846

90847

90849

90853

90865

90870

90875

90876

90880

90951

90954

90955

90956

90957

90958

90675

90746

90749

90785

90791

90792

90832

90833

90834

90836

90837

90838

Medicine

CPT Code

90460

90461

90471

90472

90473

90474

90632

90636

Medicine

CPT Code

90959

90960

90961

90962

90963

90964

90965

90966

90967

90968

90969

90970

90997

90999

91010

91010-26

91010-TC

91013

91013-26

91013-TC

91020

91020-26

91020-TC

91022

91022-26

91022-TC

91030

91030-26

91030-TC

91034

91034-26

91034-TC

91035

91035-26

91035-TC

91037

91037-26

91037-TC

91038

91038-26

91038-TC

91040

91040-26

91040-TC

91065

91065-26

91065-TC

91110

91110-26

91110-TC

92020

92025

92025-26

92025-TC

92060

92060-26

92060-TC

92065

92065-26

92065-TC

92071

92072

91200-26

91200-TC

91299

91299-26

91299-TC

92002

92004

92012

92014

92015

92018

92019

92081

92081-26

92081-TC

92082

92082-26

92082-TC

Medicine

CPT Code

91111

91111-26

91111-TC

91112

91112-26

91112-TC

91117

91120

91120-26

91120-TC

91122

91122-26

91122-TC

91132

91132-26

91132-TC

91133

91133-26

91133-TC

91200

$152.00

$52.00

$100.00

$130.00

$59.00

$72.00

$463.00

$52.00

$411.00

$34.00

$23.00

$14.00

$928.00

$185.00

$743.00

$227.00

$77.00

$150.00

$57.00

$47.00

$8.00

$240.00

$52.00

$188.00

$474.00

$84.00

$390.00

$8.00

$115.00

BR

$116.00

$76.00

$32.00

$24.00

$10.00

$14.00

$60.00

$49.00

$9.00

MRA

$298.00

$287.00

$241.00

$186.00

$552.00

$481.00

$456.00

$241.00

$18.00

$15.00

$15.00

$13.00

$40.00

$32.00

$7.00

$34.00

$19.00

$6.00

$39.00

$140.00

$32.00

$19.00

$6.00

$48.00

$24.00

$9.00

BR

BR

$63.00

$98.00

$53.00

$75.00

$34.00

$80.00

$70.00

$31.00

$29.00

$17.00

$122.00

$37.00

$156.00

$28.00

$127.00

$174.00

$34.00

$139.00

$32.00

$13.00

$19.00

BR

MRA

$743.00

$53.00

$690.00

$1,083.00

$113.00

$969.00

$152.00

$457.00

$52.00

$405.00

$169.00


Part A, 146

$7.00

$20.00

$53.00

$37.00

$10.00

$64.00

$45.00

$19.00

$80.00

$56.00

$17.00

$24.00

$10.00

$5.00

$192.00

$35.00

$22.00

$14.00

$58.00

$104.00

$46.00

$53.00

$132.00

$60.00

$67.00

$40.00

$24.00

$30.00

$16.00

$93.00

$29.00

$63.00

$38.00

$15.00

$9.00

$7.00

$45.00

$39.00

$14.00

MRA

$59.00

$31.00

$14.00

$40.00

$36.00

$20.00

$16.00

$45.00

$29.00

$16.00

$46.00



92240-TC

92250

92250-26

92250-TC

92260

92265

92265-26

92265-TC

92270

92270-26

92270-TC

92275

92225

92226

92227

92228

92228-26

92228-TC

92230

92235

92235-26

92235-TC

92240

92240-26

92275-26

92275-TC

92283

92283-26

92283-TC

92284

Medicine

CPT Code

92083

92083-26

92083-TC

92100

92132

92132-26

92132-TC

92133

92133-26

92133-TC

92134

92134-26

92134-TC

92136

92136-26

92136-TC

92140

92145

92145-26

92145-TC

Medicine

CPT Code

92284-26

92284-TC

92285

92285-26

92285-TC

92286

92286-26

92286-TC

92287

92287-26

92287-TC

92310

92311

92312

92313

92314

92315

92316

92317

92325

92326

92340

92341

92342

92358

92370

92371

92499

92499-26

92499-TC

92502

92504

92507

92508

92511

92512

92516

92520

92521

92522

92523

92524

92526

92531

92532

92533

92534

92537

92537-26

92537-TC

92560

92561

92562

92563

92564

92565

92567

92568

92570

92571

92572

92575

92546-TC

92547

92548

92548-26

92548-TC

92550

92551

92552

92553

92555

92556

92557

92576

92577

92579

92582

92583

92584

Medicine

CPT Code

92538

92538-26

92538-TC

92540

92540-26

92540-TC

92541

92541-26

92541-TC

92542

92542-26

92542-TC

92544

92544-26

92544-TC

92545

92545-26

92545-TC

92546

92546-26

$46.00

$36.00

$47.00

$114.00

$93.00

$193.00

$97.00

$48.00

$10.00

$14.00

$41.00

BR

$41.00

$32.00

$9.00

$43.00

$24.00

$35.00

$18.00

BR

BR

BR

$101.00

$24.00

$40.00

$42.00

$81.00

$86.00

$78.00

$89.00

$70.00

$54.00

$44.00

$59.00

$39.00

$14.00

$44.00

$32.00

$43.00

MRA

$151.00

$46.00

$26.00

$12.00

$6.00

$91.00

$53.00

$29.00

$99.00

$48.00

$77.00

$14.00

$17.00

$15.00

$20.00

$14.00

$33.00

$14.00

$3.00

$11.00

$17.00

$28.00

$28.00

$28.00

$34.00

$94.00

$30.00

$59.00

$21.00

$17.00

$16.00

$24.00

$14.00

$21.00

$46.00

$23.00

$27.00

$15.00

$10.00

$26.00

$16.00

$8.00

$22.00

$14.00

$8.00

$29.00

$17.00

$9.00

$21.00

$92.00

MRA

$21.00

$16.00

$5.00

$102.00

$81.00

$22.00

$37.00

$25.00

$9.00

$33.00

$20.00


Part A, 147

$12.00

$45.00

$86.00

$22.00

$53.00

BR

$561.00

$668.00

$623.00

$697.00

$623.00

$699.00

$699.00

$203.00

$35.00

$22.00

$59.00

$42.00

$46.00

$173.00

$43.00

$134.00

$39.00

$183.00

$48.00

$34.00

$45.00

BR

BR

BR

BR

BR

$22.00

$96.00

$88.00

$60.00

$94.00

$84.00

$109.00

MRA

$114.00

$52.00

$70.00

$70.00

$58.00

$8.00

$49.00

$78.00

$20.00

$57.00

$41.00



92617

92618

92620

92621

92625

92626

92627

92640

92700

92920

92924

92928

92605

92606

92607

92608

92609

92610

92611

92612

92613

92614

92615

92616

92933

92937

92941

92943

92950

92953

Medicine

CPT Code

92585

92585-26

92585-TC

92586

92587

92587-26

92587-TC

92588

92588-26

92588-TC

92590

92591

92592

92593

92594

92595

92596

92597

92603

92604

Medicine

CPT Code

92960

92961

92970

92971

92973

92974

92975

92977

92978

92978-26

92978-TC

92979

92979-26

92979-TC

92986

92987

92990

92992

92993

92997

92998

93000

93005

93010

93015

93016

93017

93018

93024

93024-26

93024-TC

93025

93025-26

93025-TC

93040

93041

93042

93050

93050-26

93050-TC

93224

93225

93226

93227

93228

93229

93260

93260-26

93260-TC

93261

93286-TC

93287

93287-26

93287-TC

93288

93288-26

93288-TC

93289

93289-26

93289-TC

93290

93290-26

93282-TC

93283

93283-26

93283-TC

93284

93284-26

93284-TC

93285

93285-26

93285-TC

93286

93286-26

93290-TC

93291

93291-26

93291-TC

93292

93292-26

Medicine

CPT Code

93261-26

93261-TC

93268

93270

93271

93272

93278

93278-26

93278-TC

93279

93279-26

93279-TC

93280

93280-26

93280-TC

93281

93281-26

93281-TC

93282

93282-26

$31.00

$9.00

$18.00

$9.00

$9.00

$159.00

$46.00

$83.00

$50.00

$27.00

$669.00

$68.00

$45.00

$22.00

$61.00

$12.00

$104.00

$25.00

$63.00

$54.00

$111.00

$71.00

$42.00

$277.00

$40.00

$299.00

$14.00

$163.00

$76.00

$86.00

$1,222.00

$1,271.00

$974.00

BR

BR

$765.00

$331.00

$26.00

$16.00

MRA

$162.00

$239.00

$201.00

$100.00

$174.00

$197.00

$400.00

$302.00

$269.00

$95.00

$170.00

$13.00

$37.00

$21.00

$16.00

$66.00

$46.00

$19.00

$31.00

$21.00

$9.00

$36.00

$21.00

$15.00

$32.00

$21.00

$24.00

$90.00

$63.00

$27.00

$42.00

$26.00

$16.00

$27.00

$15.00

$12.00

$36.00

$23.00

$17.00

$59.00

$39.00

$20.00

$68.00

$45.00

$23.00

$63.00

$43.00

$20.00

$82.00

$58.00

MRA

$39.00

$22.00

$109.00

$46.00

$90.00

$28.00

$58.00

$24.00

$44.00

$50.00

$33.00


Part A, 148

$236.00

$95.00

$141.00

$412.00

$114.00

$384.00

$86.00

$30.00

$65.00

$50.00

$10.00

$42.00

$114.00

$4.00

$110.00

$75.00

$322.00

$140.00

$182.00

$76.00

$212.00

$65.00

$144.00

$287.00

$144.00

$141.00

$78.00

$144.00

$114.00

$43.00

$73.00

$229.00

$64.00

$165.00

$196.00

$56.00

$144.00

$118.00

$46.00

MRA

$11.00

$54.00

$16.00

$38.00

$34.00

$68.00

$26.00

$27.00

$27.00

$215.00

$70.00



93315-26

93315-TC

93316

93317

93317-26

93317-TC

93318

93318-26

93318-TC

93320

93320-26

93320-TC

93307-TC

93308

93308-26

93308-TC

93312

93312-26

93312-TC

93313

93314

93314-26

93314-TC

93315

93321

93321-26

93321-TC

93325

93325-26

93325-TC

Medicine

CPT Code

93292-TC

93293

93293-26

93293-TC

93294

93295

93296

93297

93298

93303

93303-26

93303-TC

93304

93304-26

93304-TC

93306

93306-26

93306-TC

93307

93307-26

Medicine

CPT Code

93350

93350-26

93350-TC

93351

93351-26

93351-TC

93352

93355

93451

93451-26

93451-TC

93452

93452-26

93452-TC

93453

93453-26

93453-TC

93454

93454-26

93454-TC

93455

93455-26

93455-TC

93456

93456-26

93456-TC

93457

93457-26

93457-TC

93458

93458-26

93458-TC

93459

93459-26

93459-TC

93460

93460-26

93460-TC

93461

93461-26

93461-TC

93462

93463

93464

93464-26

93464-TC

93503

93505

93505-26

93505-TC

93582

93583

93600

93600-26

93600-TC

93602

93602-26

93602-TC

93603

93603-26

93603-TC

93609

93565

93566

93567

93568

93571

93571-26

93571-TC

93572

93572-26

93572-TC

93580

93581

93609-26

93609-TC

93610

93610-26

93610-TC

93612

Medicine

CPT Code

93530

93530-26

93530-TC

93531

93531-26

93531-TC

93532

93532-26

93532-TC

93533

93533-26

93533-TC

93561

93561-26

93561-TC

93562

93562-26

93562-TC

93563

93564

$1,284.00

$408.00

$875.00

$1,468.00

$451.00

$1,018.00

$215.00

$109.00

$284.00

$99.00

$186.00

$187.00

$318.00

$248.00

$74.00

$1,132.00

$341.00

$791.00

$1,280.00

$383.00

$897.00

$1,084.00

$326.00

$758.00

$1,197.00

$367.00

$830.00

$887.00

$265.00

$622.00

$1,149.00

$347.00

$801.00

$903.00

$267.00

$637.00

$1,052.00

$308.00

$744.00

MRA

$216.00

$77.00

$66.00

$282.00

$86.00

$195.00

$34.00

$230.00

$790.00

$151.00

$638.00

$129.00

$73.00

$159.00

$119.00

$42.00

$187.00

$127.00

$63.00

$578.00

$481.00

$101.00

$214.00

$166.00

$52.00

$224.00

$154.00

$270.00

$93.00

$170.00

$222.00

$74.00

$155.00

$974.00

$1,303.00

$697.00

$776.00

$198.00

$1,766.00

$59.00

$47.00

$20.00

$46.00

$33.00

$13.00

$57.00

$58.00

$44.00

$173.00

$142.00

MRA

$872.00

$250.00

$634.00

$2,268.00

$467.00

$1,815.00

$2,317.00

$569.00

$1,766.00

$2,131.00

$352.00


Part A, 149

$269.00

$613.00

$360.00

$269.00

$549.00

$295.00

$269.00

$282.00

$176.00

$106.00

$639.00

$865.00

$1,152.00

$432.00

$1,153.00

BR

BR

$167.00

BR

$333.00

$256.00

$74.00

$651.00

$420.00

$239.00

$467.00

$230.00

$148.00

$717.00

$444.00

$290.00

$358.00

$272.00

$91.00

BR

$769.00

BR

BR

$771.00

MRA

$167.00

$61.00

$377.00

$62.00

$49.00

$12.00

$94.00

$82.00

$12.00

$399.00

$258.00



93631-TC

93640

93640-26

93640-TC

93641

93641-26

93641-TC

93642

93642-26

93642-TC

93644

93644-26

93621-TC

93622

93622-26

93622-TC

93623

93623-26

93623-TC

93624

93624-26

93624-TC

93631

93631-26

93644-TC

93650

93653

93654

93655

93656

Medicine

CPT Code

93612-26

93612-TC

93613

93615

93615-26

93615-TC

93616

93616-26

93616-TC

93618

93618-26

93618-TC

93619

93619-26

93619-TC

93620

93620-26

93620-TC

93621

93621-26

Medicine

CPT Code

93657

93660

93660-26

93660-TC

93662

93662-26

93662-TC

93701

93701-26

93701-TC

93702

93724

93724-26

93724-TC

93740

93740-26

93740-TC

93750

93770

93770-26

93770-TC

93784

93786

93788

93790

93797

93798

93799

93799-26

93799-TC

93880

93880-26

93880-TC

93882

93882-26

93882-TC

93886

93886-26

93886-TC

93888

93888-26

93888-TC

93890

93890-26

93890-TC

93892

93892-26

93892-TC

93893

93893-26

93975-26

93975-TC

93976

93976-26

93976-TC

93978

93978-26

93978-TC

93979

93979-26

93979-TC

93980

93931-26

93931-TC

93965

93965-26

93965-TC

93970

93970-26

93970-TC

93971

93971-26

93971-TC

93975

93980-26

93980-TC

93981

93981-26

93981-TC

93982

Medicine

CPT Code

93893-TC

93922

93922-26

93922-TC

93923

93923-26

93923-TC

93924

93924-26

93924-TC

93925

93925-26

93925-TC

93926

93926-26

93926-TC

93930

93930-26

93930-TC

93931

$95.00

$215.00

$50.00

$162.00

$142.00

$33.00

$109.00

$241.00

$55.00

$185.00

$256.00

$63.00

$193.00

$251.00

$63.00

NC

NC

$17.00

$38.00

BR

BR

BR

$176.00

$31.00

$144.00

$117.00

$21.00

$411.00

$259.00

$148.00

$17.00

$12.00

$5.00

$55.00

NC

NC

NC

NC

NC

MRA

$433.00

$162.00

$103.00

$61.00

BR

$158.00

BR

$36.00

$9.00

$27.00

$109.00

$59.00

$121.00

$177.00

$34.00

$143.00

$122.00

$23.00

$98.00

$183.00

$65.00

$105.00

$148.00

$25.00

$124.00

$10.00

$26.00

$42.00

$189.00

$36.00

$154.00

$121.00

$23.00

$96.00

$277.00

$89.00

$181.00

$184.00

$31.00

$144.00

$117.00

$21.00

$96.00

$174.00

$26.00

$150.00

$118.00

$17.00

$101.00

$63.00

MRA

$188.00

$60.00

$16.00

$44.00

$112.00

$28.00

$85.00

$122.00

$31.00

$92.00

$175.00


Part A, 150

$15.00

$52.00

$16.00

$36.00

$74.00

$20.00

$53.00

$63.00

$91.00

$38.00

$54.00

$122.00

$71.00

$52.00

$19.00

$9.00

$12.00

$8.00

$5.00

$34.00

$16.00

$17.00

$40.00

$24.00

$14.00

$37.00

$20.00

$26.00

$57.00

$18.00

$36.00

$32.00

$11.00

$19.00

$8.00

$6.00

$3.00

$17.00

$7.00

MRA

$110.00

$14.00

$96.00

$84.00

$61.00

$45.00

$30.00

$12.00

$16.00

$39.00

$14.00



94400-TC

94450

94450-26

94450-TC

94452

94452-26

94452-TC

94453

94453-26

94453-TC

94610

94620

94150-TC

94200

94200-26

94200-TC

94250

94250-26

94250-TC

94375

94375-26

94375-TC

94400

94400-26

94620-26

94620-TC

94621

94621-26

94621-TC

94640

Medicine

CPT Code

93990

93990-26

93990-TC

94002

94003

94004

94010

94010-26

94010-TC

94014

94015

94016

94060

94060-26

94060-TC

94070

94070-26

94070-TC

94150

94150-26

Medicine

CPT Code

94642

94644

94645

94660

94662

94664

94667

94668

94669

94680

94680-26

94680-TC

94681

94681-26

94681-TC

94690

94690-26

94690-TC

94726

94726-26

94726-TC

94727

94727-26

94727-TC

94728

94728-26

94728-TC

94729

94729-26

94729-TC

94750

94750-26

94750-TC

94760

94761

94762

94770

94770-26

94770-TC

94799

94799-26

94799-TC

95004

95012

95017

95018

95024

95027

95028

95044

95805

95805-26

95805-TC

95806

95806-26

95806-TC

95807

95807-26

95807-TC

95808

95808-26

95808-TC

95147

95148

95149

95165

95170

95180

95199

95250

95251

95803

95803-26

95803-TC

95810

95810-26

95810-TC

95811

95811-26

95811-TC

95115

95117

95120

95125

95130

95131

95132

95133

95134

95144

95145

95146

Medicine

CPT Code

95052

95056

95060

95065

95070

95071

95076

95079

$30.00

$21.00

$9.00

$12.00

BR

BR

BR

$3.00

$19.00

$8.00

$20.00

$3.00

$5.00

$8.00

$7.00

$30.00

$40.00

$13.00

$28.00

$54.00

$9.00

$45.00

$37.00

$14.00

$21.00

$9.00

$20.00

$22.00

$60.00

$12.00

$43.00

$24.00

$4.00

$20.00

$53.00

$13.00

$41.00

$42.00

$13.00

MRA

BR

$36.00

$14.00

$54.00

$38.00

$18.00

$23.00

$16.00

$35.00

$47.00

$23.00

$232.00

$109.00

$137.00

$367.00

$98.00

$256.00

$456.00

$149.00

$256.00

$521.00

$183.00

$256.00

$644.00

$196.00

$423.00

$7.00

$13.00

$103.00

BR

$114.00

$28.00

$151.00

$44.00

$107.00

$334.00

$94.00

$237.00

$9.00

$17.00

$24.00

$33.00

$32.00

$36.00

BR

BR

BR

BR

BR

BR

MRA

$9.00

$6.00

$13.00

$7.00

$82.00

$105.00

$117.00

$84.00

$10.00

$9.00

BR


Part A, 151

$113.00

$86.00

$28.00

$138.00

$102.00

$35.00

$177.00

$114.00

$67.00

$119.00

$92.00

$27.00

$80.00

$71.00

$9.00

$6.00

$133.00

$26.00

$21.00

$34.00

$44.00

$18.00

$14.00

$40.00

$73.00

$53.00

$15.00

$56.00

$120.00

$58.00

$63.00

$51.00

$41.00

$10.00

$145.00

$59.00

$86.00

$328.00

$291.00

MRA

$137.00

$58.00

$68.00

$177.00

$89.00

$68.00

$133.00

$54.00

$78.00

$115.00

$58.00



95860

95860-26

95860-TC

95861

95861-26

95861-TC

95863

95863-26

95863-TC

95864

95864-26

95864-TC

95827-TC

95829

95829-26

95829-TC

95830

95831

95832

95833

95834

95851

95852

95857

95865

95865-26

95865-TC

95866

95866-26

95866-TC

Medicine

CPT Code

95812

95812-26

95812-TC

95813

95813-26

95813-TC

95816

95816-26

95816-TC

95819

95819-26

95819-TC

95822

95822-26

95822-TC

95824

95824-26

95824-TC

95827

95827-26

Medicine

CPT Code

95867

95867-26

95867-TC

95868

95868-26

95868-TC

95869

95869-26

95869-TC

95870

95870-26

95870-TC

95872

95872-26

95872-TC

95873

95873-26

95873-TC

95874

95874-26

95874-TC

95875

95875-26

95875-TC

95885

95885-26

95885-TC

95886

95886-26

95886-TC

95887

95887-26

95887-TC

95905

95905-26

95905-TC

95907

95907-26

95907-TC

95908

95908-26

95908-TC

95909

95909-26

95909-TC

95910

95910-26

95910-TC

95911

95911-26

95929-26

95929-TC

95930

95930-26

95930-TC

95933

95933-26

95933-TC

95937

95937-26

95937-TC

95938

95925-26

95925-TC

95926

95926-26

95926-TC

95927

95927-26

95927-TC

95928

95928-26

95928-TC

95929

95938-26

95938-TC

95939

95939-26

95939-TC

95940

Medicine

CPT Code

95911-TC

95912

95912-26

95912-TC

95913

95913-26

95913-TC

95921

95921-26

95921-TC

95922

95922-26

95922-TC

95923

95923-26

95923-TC

95924

95924-26

95924-TC

95925

$66.00

$95.00

$54.00

$42.00

$117.00

$67.00

$51.00

$142.00

$80.00

$61.00

$186.00

$107.00

$79.00

$226.00

$134.00

$7.00

$59.00

$19.00

$40.00

$92.00

$47.00

$45.00

$87.00

$38.00

$48.00

$68.00

$3.00

$8.00

$104.00

$81.00

$22.00

$29.00

$21.00

$8.00

$30.00

$21.00

$8.00

$43.00

$34.00

MRA

$66.00

$43.00

$21.00

$96.00

$71.00

$26.00

$29.00

$21.00

$8.00

$29.00

$21.00

$25.00

$11.00

$62.00

$33.00

$30.00

$40.00

$31.00

$9.00

$339.00

$47.00

$292.00

$495.00

$122.00

$373.00

$33.00

$34.00

$34.00

$67.00

$34.00

$34.00

$175.00

$84.00

$91.00

$182.00

$84.00

$98.00

$44.00

$50.00

$14.00

$105.00

$47.00

$57.00

$147.00

$90.00

$57.00

$94.00

$53.00

$41.00

$66.00

MRA

$92.00

$266.00

$161.00

$105.00

$308.00

$191.00

$117.00

$61.00

$46.00

$14.00

$65.00


Part A, 152

BR

BR

$184.00

BR

$22.00

$39.00

$78.00

$155.00

$88.00

$213.00

$98.00

$27.00

$10.00

$22.00

$57.00

$66.00

$216.00

$166.00

$48.00

$227.00

$176.00

$48.00

BR

$420.00

BR

BR

$210.00

$23.00

$130.00

$59.00

$74.00

$541.00

$166.00

$314.00

$171.00

$104.00

$64.00

$296.00

$230.00

MRA

$265.00

$84.00

$177.00

$34.00

$14.00

$20.00

$411.00

$165.00

$240.00

$208.00

$134.00



95965-TC

95966

95966-26

95966-TC

95967

95967-26

95967-TC

95970

95971

95972

95974

95975

95957-TC

95958

95958-26

95958-TC

95961

95961-26

95961-TC

95962

95962-26

95962-TC

95965

95965-26

95978

95979

95980

95981

95982

95990

Medicine

CPT Code

95950

95950-26

95950-TC

95951

95951-26

95951-TC

95953

95953-26

95953-TC

95954

95954-26

95954-TC

95955

95955-26

95955-TC

95956

95956-26

95956-TC

95957

95957-26

Medicine

CPT Code

95991

95992

95999

96000

96001

96002

96003

96004

96020

96020-26

96020-TC

96101

96102

96103

96105

96110

96111

96116

96118

96119

96120

96125

96127

96150

96151

96152

96153

96154

96155

96360

96361

96365

96366

96367

96368

96369

96370

96371

96372

96373

96374

96375

96401

96402

96405

96406

96409

96411

96413

96415

97010

97012

97014

97016

97018

97022

97024

97026

97028

97032

97033

97034

96912

96913

96920

96921

96922

96999

97001

97002

97003

97004

97005

97006

97035

97036

97039

97110

97112

97113

96450

96521

96522

96523

96542

96549

96567

96570

96571

96900

96904

96910

Medicine

CPT Code

96416

96417

96420

96422

96423

96425

96440

96446

$195.00

$15.00

$91.00

$25.00

$19.00

$56.00

$22.00

$53.00

$46.00

$57.00

$86.00

$122.00

$71.00

$173.00

$39.00

$26.00

$25.00

$24.00

$6.00

$24.00

$22.00

$57.00

$15.00

$69.00

$19.00

$30.00

$20.00

$97.00

$44.00

$28.00

$68.00

$88.00

$68.00

$109.00

$130.00

$66.00

$48.00

$57.00

$5.00

MRA

$84.00

$44.00

BR

$93.00

$111.00

$21.00

$20.00

$97.00

BR

$156.00

BR

$15.00

$10.00

$15.00

$10.00

$9.00

$10.00

$16.00

$16.00

$13.00

$11.00

$19.00

$15.00

$22.00

$23.00

$24.00

$155.00

$214.00

BR

$62.00

$29.00

$62.00

$29.00

BR

BR

$10.00

$16.00

$14.00

$28.00

$126.00

BR

$62.00

$69.00

$38.00

$17.00

$70.00

$21.00

$24.00

$53.00

$152.00

MRA

$186.00

$85.00

$46.00

$46.00

$17.00

$54.00

$156.00

$193.00

$134.00

$153.00

$111.00


Part A, 153



$54.00

$26.00

$54.00

$26.00

NC

$32.00

NC

$23.00

NC

NC

$32.00

NC

$23.00

$19.00

$9.00

$35.00

$31.00

$28.00

$26.00

BR

$26.00

$17.00

$7.00

$35.00

$27.00

$37.00

$30.00

$23.00

$17.00

$83.00

$41.00

$49.00

$62.00

BR

$34.00

$37.00

$121.00

BR

$48.00

MRA

$21.00

$19.00

$15.00

$26.00

$18.00

$23.00

$17.00

$22.00

$22.00

$24.00

$23.00

97811

97813

97814

97850

97851

97852

97853

98925

98926

98927

98928

98929

97610

97750

97752

97755

97760

97761

97762

97799

97802

97803

97804

97810

98940

98941

98942

98943

98960

98961

97532

97533

97535

97537

97542

97545

97546

97597

97598

97602

97605

97606

Medicine

CPT Code

97116

97124

97139

97140

97150

97260

97261

97530

Medicine

CPT Code

98962

99000

99001

99002

99026

99027

99070

99071

99075

99078

99082

99090

99172

99173

99174

99175

99183

99184

99190

99191

G0109

G0117

G0118

G0120

G0120-26

G0120-TC

G0121

G0121-53

G0122

G0122-26

G0122-TC

G0128

99192

99195

99199

G0101

G0102

G0104

G0105

G0105-53

G0106

G0106-26

G0106-TC

G0108

G0166

G0179

G0180

G0181

G0182

G0237

MRA

$7.00

$6.00

$4.00

$35.00

BR

BR

BR

NC

See 440.13

NC

BR

BR

BR

$3.00

$8.00

$53.00

$123.00

$232.00

BR

BR

BR

$16.00

NC

$32.00

$18.00

$115.00

$344.00

$115.00

$165.00

$46.00

$119.00

$24.00

$14.00

$40.00

$27.00

$179.00

$46.00

$132.00

$344.00

$115.00

$177.00

$45.00

$132.00

$4.00

$138.00

$41.00

$54.00

$99.00

$102.00

$12.00

$7.00

$17.00

$8.00

$9.00

$103.00

$103.00

$30.00

$33.00

$9.00

$49.00

$13.00

$112.00

MRA

$13.00

$11.00

$168.00

$124.00

$9.00

$43.00

$22.00

$13.00

$45.00

$10.00

$10.00

$48.00

$24.00

$19.00

$8.00

$11.00

$37.00

G0277

G0281

G0283

G0329

G0403

G0404

G0405

G0422

G0423

G0424

G0453

G0454

Medicine

CPT Code

G0238

G0239

G0248

G0249

G0250

G0268

G0270

G0271

G0459

G0473

G9157

G9187

P3001

Q0035

Q0035-26

Q0035-TC

Q0091


Part A, 154



99214

99215

99217

99218

99219

99220

99221

99222

99223

99224

99225

99226

Evaluation & Management

CPT Code

99201

99202

MRA

$35.00

$58.00

99203

99204

99205

99211

99212

99213

$58.00

$84.00

$84.00

$19.00

$31.00

$40.00

$40.00

$65.00

$65.00

$65.00

$109.00

$152.00

$66.00

$109.00

$152.00

$40.00

$73.00

$105.00

$212.00

$54.00

$70.00

$96.00

$138.00

$190.00

$18.00

$28.00

$60.00

$94.00

$103.00

$192.00

$33.00

$54.00

$77.00

$129.00

$173.00

$213.00

$66.00

$88.00

$54.00

$88.00

$117.00

$163.00

$95.00

$66.00

$88.00

$108.00

$34.00

$56.00

99245

99251

99252

99253

99254

99255

99281

99282

99283

99284

99285

99291

99231

99232

99233

99234

99235

99236

99238

99239

99241

99242

99243

99244

99292

99304

99305

99306

99307

99308


CPT Code

99309

99310

MRA

$80.00

$100.00

99315

99316

99318

99324

99325

99326

99327

99328

99334

99335

99336

99337

99339

99340

99341

99342

99343

99344

99345

99347

99348

99349

99350

99354

99355

99356

99357

99360

99363

99364

99366

99367

99368

99374

99375

99377

99378

99379

99380

99406

99407

99408

99409

99415

99416

99450

99455

99456

$60.00

$77.00

$66.00

$59.00

$86.00

$125.00

$164.00

$203.00

$45.00

$72.00

$111.00

$163.00

$67.00

$93.00

$59.00

$85.00

$109.00

$160.00

$193.00

$46.00

$71.00

$107.00

$156.00

$106.00

$104.00

$87.00

$88.00

$47.00

$108.00

$38.00

$37.00

$48.00

$31.00

$75.00

$75.00

$75.00

$104.00

$75.00

$104.00

$12.00

$24.00

$29.00

$58.00

$9.00

$5.00

NC

$90.00

BR

99499

99600

G0245

G0246

G0296

G0337

G0372

G0396

G0397

G0402

G0406

G0407

G0408

G0409


CPT Code

99457

99487

MRA

BR

$52.00

99489

99490

99495

99496

99497

99498

$41.00

$41.00

$164.00

$232.00

$86.00

$75.00

BR

BR

$58.00

$34.00

$29.00

$62.00

$13.00

$29.00

$56.00

$165.00

$39.00

$72.00

$104.00

$16.00


Part A, 155

$48.00

$13.00

$21.00

$81.00

$121.00

$102.00

$143.00

$14.00

$38.00

$44.00

$54.00

$67.00

$40.00

$61.00

$66.00

$34.00

$25.00

$13.00

$24.00

$30.00

BR

BR

BR

$54.00

BR

$29.00

$23.00

$7.00

$12.00

$20.00

$18.00

$36.00

$50.00

$204.00

$64.00

$105.00

$29.00

$40.00

$10.00

MRA

$17.00

$13.00

$20.00

$36.00

$18.00

$20.00

$40.00

$10.00

$5.00

$12.00

$20.00



D0999

D1110

D1310

D1320

D1330

D1351

D1510

D1515

D1520

D1525

D1550

D2140

D0330

D0340

D0350

D0415

D0425

D0460

D0470

D0472

D0473

D0474

D0480

D0502

D2150

D2160

D2161

D2330

D2331

D2332

D0230

D0240

D0250

D0270

D0272

D0274

D0277

D0290

D0310

D0320

D0321

D0322

Dental

D-Code

D0120

D0140

D0150

D0160

D0170

D0180

D0210

D0220

Dental

D-Code

D2335

D2390

D2391

D2392

D2393

D2394

D2410

D2420

D2430

D2510

D2520

D2530

D2542

D2543

D2544

D2610

D2620

D2630

D2642

D2643

D2644

D2650

D2651

D2652

D2662

D2663

D2664

D2710

D2720

D2721

D2722

D2740

D2750

D2751

D2752

D2780

D2781

D2782

D2783

D2790

D2791

D2792

D2799

D2910

D2920

D2930

D2931

D2932

D2933

D2940

D3425

D3426

D3430

D3450

D3460

D3470

D3910

D3920

D3950

D3999

D4210

D4211

D3330

D3331

D3332

D3333

D3346

D3347

D3348

D3351

D3352

D3353

D3410

D3421

D4240

D4241

D4245

D4249

D4260

D4261

D2961

D2962

D2980

D2999

D3110

D3120

D3220

D3221

D3230

D3240

D3310

D3320

Dental

D-Code

D2950

D2951

D2952

D2953

D2954

D2955

D2957

D2960

$368.00

$266.00

$306.00

$389.00

$389.00

$287.00

$328.00

$204.00

$29.00

$29.00

$81.00

$121.00

$77.00

$91.00

$29.00

$348.00

$266.00

$328.00

$348.00

$194.00

$410.00

$306.00

$348.00

$410.00

$451.00

$328.00

$368.00

$244.00

$302.00

$318.00

$348.00

$206.00

$266.00

$348.00

$287.00

$328.00

$378.00

$206.00

$266.00

MRA

$81.00

$57.00

$43.00

$55.00

$63.00

$69.00

$163.00

$203.00

$293.00

$155.00

$259.00

$102.00

$318.00

$204.00

$50.00

$102.00

$61.00

BR

$114.00

$50.00

$223.00

$63.00

$265.00

$208.00

$328.00

$164.00

$53.00

$225.00

$274.00

$337.00

$102.00

$81.00

$163.00

$179.00

$194.00

$206.00

$77.00

$55.00

BR

$25.00

$20.00

$61.00

$81.00

$70.00

$75.00

$206.00

$204.00

$287.00

$102.00

$110.00

MRA

$81.00

$20.00

$79.00

$133.00

$102.00

$81.00

$71.00

$121.00

$204.00

$294.00

$83.00

CDT © 2015 American Dental Association. All rights reserved. Part A, 156

$61.00

$83.00

$22.00

$53.00

$61.00

$102.00

$305.00

$305.00

$204.00

$204.00

$163.00

$163.00

$121.00

$121.00

$102.00

$563.00

$256.00

$259.00

$614.00

$614.00

$279.00

$27.00

$27.00

$27.00

$27.00

$61.00

$40.00

$77.00

$55.00

$79.00

$55.00

$50.00

$69.00

$40.00

$27.00

BR

$513.00

$513.00

$563.00

MRA

$195.00

$159.00

$96.00

$285.00

$328.00

$273.00

$155.00

$337.00

$208.00

$178.00

$194.00



D5422

D5510

D5520

D5610

D5620

D5630

D5640

D5650

D5660

D5670

D5671

D5710

D5110

D5120

D5130

D5140

D5211

D5212

D5213

D5214

D5281

D5410

D5411

D5421

D5711

D5720

D5721

D5730

D5731

D5740

D4274

D4275

D4276

D4320

D4321

D4341

D4342

D4355

D4381

D4910

D4920

D4999

Dental

D-Code

D4263

D4264

D4265

D4266

D4267

D4268

D4270

D4273

Dental

D-Code

D5741

D5750

D5751

D5760

D5761

D5810

D5811

D5820

D5821

D5850

D5851

D5862

D5867

D5875

D5899

D5911

D5912

D5913

D5914

D5915

D5916

D5919

D5922

D5923

D5924

D5925

D5926

D5927

D5928

D5929

D5931

D5932

D5933

D5934

D5935

D5936

D5937

D5951

D5953

D5954

D5955

D5958

D5959

D5960

D5982

D5983

D5984

D5985

D5986

D5987

D6199

D6210

D6211

D6212

D6240

D6241

D6242

D6245

D6250

D6251

D6252

D6253

D6070

D6071

D6072

D6073

D6074

D6075

D6076

D6077

D6080

D6090

D6095

D6100

D6545

D6548

D6600

D6601

D6602

D6603

D6058

D6059

D6060

D6061

D6062

D6063

D6064

D6065

D6066

D6067

D6068

D6069

Dental

D-Code

D5988

D5999

D6010

D6040

D6050

D6055

D6056

D6057

$563.00

BR

$614.00

$614.00

BR

$1,334.00

$780.00

$244.00

$163.00

$167.00

BR

BR

$574.00

$61.00

BR

$1,641.00

BR

BR

$1,026.00

$1,026.00

$1,384.00

BR

$656.00

$1,539.00

$306.00

$1,539.00

$1,539.00

$181.00

$36.00

$100.00

BR

$81.00

$121.00

$2,052.00

$2,052.00

$2,770.00

$2,874.00

BR

$1,334.00

MRA

$102.00

$132.00

$163.00

$100.00

$163.00

$244.00

$244.00

$194.00

$204.00

$46.00

$50.00

$328.00

$451.00

$368.00

$410.00

$309.00

$410.00

$287.00

$368.00

$51.00

$195.00

$281.00

$155.00

$166.00

$172.00

$203.00

$346.00

$350.00

$414.00

$402.00

$447.00

$71.00

$229.00

$247.00

$264.00

BR

$410.00

$287.00

$379.00

$365.00

$359.00

$377.00

$513.00

$513.00

$513.00

$365.00

$359.00

$322.00

$326.00

$365.00

MRA

$219.00

BR

$649.00

$3,016.00

$1,557.00

$769.00

$265.00

$303.00

$392.00

$418.00

$289.00


$111.00

$139.00

$147.00

$204.00

$81.00

$244.00

$147.00

$204.00

$121.00

$41.00

$106.00

$81.00

BR

$133.00

$77.00

$389.00

$287.00

$348.00

$30.00

$279.00

$40.00

$102.00

$155.00

$106.00

BR

$45.00

$70.00

$162.00

$410.00

$233.00

$348.00

$328.00

$356.00

$328.00

$410.00

$389.00

$320.00

$322.00

$324.00

MRA

$110.00

$141.00

$139.00

$151.00

$170.00

$178.00

$203.00

$217.00

$141.00

$155.00

$151.00



D6999

D7140

D7210

D7220

D7230

D7240

D7241

D7250

D7260

D7270

D7272

D7280

D6781

D6782

D6783

D6790

D6791

D6792

D6793

D6920

D6930

D6940

D6950

D6980

D7282

D7285

D7286

D7287

D7290

D7291

D6612

D6613

D6614

D6615

D6720

D6721

D6722

D6740

D6750

D6751

D6752

D6780

Dental

D-Code

D6604

D6605

D6606

D6607

D6608

D6609

D6610

D6611

Dental

D-Code

D7310

D7320

D7340

D7350

D7410

D7411

D7412

D7413

D7414

D7415

D7440

D7441

D7450

D7451

D7460

D7461

D7465

D7471

D7472

D7473

D7485

D7490

D7510

D7520

D7530

D7540

D7550

D7560

D7610

D7620

D7630

D7640

D7650

D7660

D7670

D7671

D7680

D7710

D7720

D7730

D7740

D7750

D7760

D7770

D7771

D7780

D7810

D7820

D7830

D7840

D7960

D7970

D7971

D7972

D7980

D7981

D7982

D7983

D7990

D7991

D7995

D7996

D7920

D7940

D7941

D7943

D7944

D7945

D7946

D7947

D7948

D7949

D7950

D7955

D7997

D7999

D8010

D8020

D8030

D8040

D7871

D7872

D7873

D7874

D7875

D7876

D7877

D7880

D7899

D7910

D7911

D7912

Dental

D-Code

D7850

D7852

D7854

D7856

D7858

D7860

D7865

D7870

$779.00

$1,949.00

$1,415.00

$903.00

$1,580.00

$922.00

$1,334.00

$1,046.00

$533.00

$73.00

$2,504.00

$1,292.00

$110.00

$186.00

$1,764.00

$121.00

$85.00

$121.00

$143.00

$266.00

$1,189.00

$984.00

$1,354.00

$820.00

$1,292.00

$780.00

$410.00

$247.00

$139.00

$179.00

$137.00

$195.00

$71.00

$174.00

$143.00

$147.00

$162.00

$2,545.00

$54.00

MRA

$85.00

$108.00

$195.00

$410.00

$102.00

$100.00

$139.00

$205.00

$180.00

$291.00

$161.00

BR

$169.00

$820.00

$306.00

$244.00

$340.00

$820.00

BR

BR

BR

BR

$451.00

$533.00

$718.00

$583.00

$2,914.00

$2,298.00

$2,319.00

$2,566.00

$2,566.00

$2,874.00

$4,186.00

$881.00

$922.00

$121.00

$137.00

$67.00

$737.00

$789.00

$820.00

$758.00

$291.00

BR

$73.00

$110.00

$163.00

$676.00

$841.00

$2,874.00

MRA

$1,682.00

$2,011.00

$2,052.00

BR

$2,298.00

$614.00

$1,723.00

$81.00

BR

$533.00

$584.00


$114.00

$46.00

$163.00

$83.00

$55.00

$113.00

$40.00

$50.00

BR

$58.00

$114.00

$46.00

$163.00

$83.00

$55.00

$46.00

$23.00

$41.00

BR

$20.00

$10.00

$21.00

$21.00

$32.00

$34.00

$204.00

$58.00

$67.00

$104.00

BR

$40.00

$14.00

$14.00

$13.00

$7.00

$18.00

$91.00

$41.00

$61.00

MRA

$676.00

$758.00

$1,867.00

$1,867.00

$1,949.00

$155.00

$179.00

$73.00

$54.00

$171.00

$71.00



Dental

D-Code

D9972

D9973

D9974

D9999

MRA

$113.00

$40.00

$50.00

BR

D9930

D9940

D9941

D9950

D9951

D9952

D9970

D9971

D9972

D9973

D9974

D9999

D9248

D9310

D9410

D9420

D9430

D9440

D9450

D9610

D9630

D9910

D9911

D9920

D9941

D9950

D9951

D9952

D9970

D9971

D8670

D8680

D8690

D8691

D8692

D8999

D9110

D9210

D9211

D9212

D9215

D9230

Dental

D-Code

D8050

D8060

D8070

D8080

D8090

D8210

D8220

D8660


BR

$6.00

$1.00

$3.00

$21.00

BR

BR

$22.00

BR

$3.00

BR

$10.00

$11.00

$6.00

$11.00

BR

BR

$11.00

$201.00

BR

$3.00

$3.00

$5.00

BR

$393.00

BR

BR

BR

BR

BR

BR

$2.00

$7.00

$2.00

$1.00

$2,408.00

$6.00

$1.00

$3.00

MRA

$12.00

BR

$3.00

BR

$38.00

BR

$7.00

BR

$101.00

$1.00

BR



J0585

J0587

J0592

J0595

J0600

J0610

J0620

J0630

J0636

J0637

J0640

J0670

J0360

J0380

J0390

J0395

J0456

J0470

J0475

J0476

J0500

J0515

J0520

J0583

J0690

J0692

J0694

J0696

J0697

J0698

J0256

J0280

J0282

J0285

J0287

J0288

J0289

J0290

J0295

J0300

J0330

J0350

Injections

J-Code

J0120

J0130

J0190

J0200

J0205

J0207

J0210

J0215

Injections

J-Code

J0702

J0710

J0713

J0715

J0720

J0725

J0735

J0740

J0743

J0744

J0745

J0760

J0770

J0780

J0800

J0850

J0895

J0945

J1000

J1020

J1030

J1040

J1094

J1100

J1110

J1120

J1160

J1165

J1170

J1180

J1190

J1200

J1205

J1212

J1230

J1240

J1245

J1250

J1260

J1270

J1320

J1325

J1327

J1330

J1335

J1364

J1380

J1410

J1435

J1436

J1810

J1815

J1817

J1830

J1835

J1840

J1850

J1885

J1890

J1940

J1950

J1955

J1655

J1670

J1700

J1710

J1720

J1730

J1742

J1745

J1750

J1756

J1790

J1800

J1956

J1960

J1980

J1990

J2001

J2010

J1595

J1600

J1610

J1620

J1626

J1630

J1631

J1642

J1644

J1645

J1650

J1652

Injections

J-Code

J1438

J1450

J1455

J1460

J1560

J1570

J1580

J1590

$1.00

$31.00

$49.00

BR

BR

$1.00

BR

BR

$2.00

BR

$6.00

$1.00

$33.00

$1.00

$68.00

$1.00

$10.00

$35.00

$2.00

$1.00

$1.00

$1.00

BR

$1.00

$9.00

$36.00

$1.00

$3.00

$32.00

$3.00

$18.00

$362.00

$10.00

$1.00

$3.00

$1.00

$2.00

$3.00

BR

MRA

$4.00

$3.00

$8.00

$6.00

$6.00

$3.00

BR

BR

$14.00

BR

$1.00

$76.00

BR

$7.00

$4.00

$7.00

$11.00

$1.00

$411.00

$37.00

BR

$2.00

$3.00

$8.00

BR

$2.00

$5.00

$4.00

$94.00

BR

BR

BR

BR

$4.00

$10.00

$6.00

BR

BR

$69.00

BR

$4.00

$28.00

$1.00

$1.00

BR

$16.00

BR

BR

$23.00

$1.00

MRA

BR

BR

$12.00

$2.00

BR

$36.00

$3.00

BR

BR

$10.00

$27.00

HCPCS © 2016 Part A, 160



$20.00

$1.00

BR

$16.00

$7.00

$2.00

$1.00

$1.00

$11.00

$29.00

$29.00

$2.00

BR

BR

BR

$2.00

$1.00

BR

BR

$1.00

$1.00

$1.00

BR

$105.00

$1.00

$5.00

$1.00

$2.00

$3.00

$5.00

BR

BR

BR

$2.00

$3.00

BR

$6.00

$3.00

$189.00

MRA

BR

$12.00

$3.00

$1.00

$3.00

BR

$3.00

$2.00

$32.00

$1.00

BR

J2550

J2560

J2590

J2597

J2650

J2670

J2680

J2690

J2700

J2710

J2720

J2725

J2405

J2410

J2430

J2440

J2460

J2501

J2505

J2510

J2515

J2540

J2543

J2545

J2730

J2760

J2765

J2770

J2780

J2783

J2260

J2270

J2280

J2300

J2310

J2320

J2353

J2354

J2355

J2360

J2370

J2400

Injections

J-Code

J2020

J2060

J2150

J2175

J2180

J2185

J2210

J2250

Injections

J-Code

J2790

J2792

J2795

J2800

J2810

J2820

J2910

J2916

J2920

J2930

J2940

J2941

J2950

J2993

J2995

J2997

J3000

J3010

J3030

J3070

J3105

J3230

J3240

J3250

J3260

J3265

J3280

J3301

J3302

J3303

J3305

J3310

J3320

J3350

J3360

J3364

J3365

J3370

J3400

J3410

J3411

J3415

J3420

J3430

J3465

J3470

J3475

J3480

J3485

J3486

MRA

$36.00

BR

BR

$3.00

$3.00

$115.00

$11.00

BR

$5.00

$13.00

BR

BR

$1.00

BR

BR

BR

$2.00

$2.00

$34.00

$4.00

$2.00

$2.00

$214.00

$1.00

$7.00

$2.00

$5.00

$1.00

$1.00

$1.00

$55.00

$5.00

$16.00

$72.00

$1.00

$52.00

$433.00

$9.00

$12.00

$1.00

BR

BR

$1.00

$2.00

BR

$7.00

$1.00

$1.00

BR

BR

$241.00

BR

$316.00

BR

$120.00

BR

$284.00

BR

BR

$98.00

$282.00

$576.00

MRA

BR

BR

$11.00

$10.00

$10.00

$10.00

$10.00

$11.00

$137.00

$93.00

$12.00

BR

BR

BR

$120.00

BR

$284.00

BR

BR

$98.00

$282.00

$576.00

BR

BR

BR

J7501

J7504

J7505

J7513

J7516

J7599

J7194

J7195

J7197

J7198

J7199

J7501

J7504

J7505

J7513

J7516

J7599

J7100

J7110

J7120

J7190

J7191

J7192

J7193

J7194

J7195

J7197

J7198

J7199

Injections

J-Code

J3490

J3590

J7030

J7040

J7042

J7050

J7060

J7070

HCPCS © 2016 Part A, 161


PART B


ALLOWANCES



RULE- 69L-7.020, F.A.C., Effective __________

Surgery

CPT Code FUD 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

11012

11042

11043

11044

11045

11046

11047

11055

11056

11057

11000

11001

11004

11005

11006

11008

11010

11011

10021

10022

10030

10035

10036

10040

10060

10061

10080

10081

10120

10121

10140

10160

10180

11305

11306

11307

11308

11310

11311

11312

11313

11400

11100

11101

11200

11201

11300

11301

11302

11303

ZZZ

ZZZ

0

0

0

0

0

0

0

ZZZ

0

ZZZ

0

0

0

ZZZ

10

0

10

10

10

10

10

10

10

10

0

0

0

0

ZZZ

10

10

0

0

0

0

0

0

0

0

10

0

ZZZ

10

ZZZ

0

0

0

0

$45.00

$27.00

--------

--------

--------

--------

$348.00

$432.00

$597.00

$88.00

$210.00

$283.00

--------

--------

--------

$26.00

$35.00

$39.00

$90.00

$92.00

--------

--------

--------

$54.00

$53.00

$133.00

$65.00

$203.00

$53.00

$169.00

$53.00

$45.00

$164.00

$78.00

$41.00

$66.00

$26.00

$59.00

$80.00

$96.00

$119.00

$61.00

$86.00

$100.00

$125.00

$75.00

$95.00

$110.00

$144.00

$81.00

$76.00

$30.00

$864.00

$1,178.00

$1,050.00

$414.00

$695.00

$759.00

$1,017.00

$163.00

$325.00

$451.00

$58.00

$106.00

$180.00

$66.00

$80.00

$91.00

$174.00

$197.00

$1,084.00

$737.00

$639.00

$144.00

$165.00

$292.00

$250.00

$377.00

$212.00

$387.00

$229.00

$183.00

$351.00

$144.00

$47.00

$123.00

$27.00

$134.00

$167.00

$196.00

$217.00

$138.00

$169.00

$200.00

$210.00

$158.00

$157.00

$224.00

$260.00

$173.00

$80.00

$32.00

$919.00

$1,261.00

$1,117.00

$444.00

$742.00

$812.00

$1,087.00

$173.00

$345.00

$479.00

$62.00

$113.00

$192.00

$69.00

$85.00

$96.00

$184.00

$209.00

$1,163.00

$787.00

$683.00

$153.00

$174.00

$309.00

$267.00

$401.00

$225.00

$411.00

$243.00

$194.00

$376.00

$153.00

$49.00

$131.00

$29.00

$143.00

$177.00

$209.00

$231.00

$146.00

$180.00

$213.00

$223.00

$168.00

$166.00

$238.00

$277.00

$184.00

$82.00

$33.00

$998.00

$1,387.00

$1,216.00

$489.00

$773.00

$851.00

$1,144.00

$178.00

$361.00

$505.00

$64.00

$120.00

$205.00

$70.00

$86.00

$98.00

$191.00

$215.00

$1,193.00

$796.00

$689.00

$160.00

$179.00

$321.00

$274.00

$415.00

$231.00

$427.00

$251.00

$201.00

$396.00

$158.00

$52.00

$136.00

$30.00

$147.00

$182.00

$215.00

$239.00

$149.00

$185.00

$219.00

$228.00

$172.00

$173.00

$246.00

$287.00

$189.00

$42.00

$21.00

$864.00

$1,178.00

$1,050.00

$414.00

$409.00

$442.00

$631.00

$89.00

$228.00

$340.00

$38.00

$83.00

$148.00

$23.00

$33.00

$43.00

$102.00

$95.00

$253.00

$127.00

$64.00

$126.00

$138.00

$257.00

$147.00

$245.00

$147.00

$268.00

$169.00

$137.00

$260.00

$71.00

$37.00

$104.00

$24.00

$51.00

$78.00

$92.00

$109.00

$57.00

$76.00

$97.00

$107.00

$69.00

$96.00

$114.00

$147.00

$114.00

$43.00

$22.00

$919.00

$1,261.00

$1,117.00

$444.00

$435.00

$471.00

$674.00

$94.00

$240.00

$360.00

$40.00

$88.00

$157.00

$24.00

$34.00

$44.00

$107.00

$100.00

$271.00

$132.00

$67.00

$134.00

$145.00

$271.00

$156.00

$259.00

$155.00

$284.00

$179.00

$145.00

$279.00

$75.00

$39.00

$110.00

$26.00

$54.00

$82.00

$97.00

$115.00

$60.00

$79.00

$102.00

$112.00

$73.00

$101.00

$121.00

$155.00

$121.00

$45.00

$23.00

$998.00

$1,387.00

$1,216.00

$489.00

$465.00

$510.00

$729.00

$99.00

$256.00

$386.00

$43.00

$95.00

$170.00

$25.00

$35.00

$46.00

$114.00

$105.00

$298.00

$139.00

$70.00

$140.00

$150.00

$283.00

$163.00

$273.00

$161.00

$300.00

$187.00

$151.00

$298.00

$79.00

$41.00

$115.00

$27.00

$57.00

$87.00

$103.00

$122.00

$62.00

$84.00

$108.00

$118.00

$77.00

$108.00

$128.00

$165.00

$127.00

CPT only © 2015 American Medical Association. All rights reserved.

Part B, 163



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

11600

11601

11602

11603

11604

11606

11620

11621

11622

11623

11444

11446

11450

11451

11462

11463

11470

11471

11401

11402

11403

11404

11406

11420

11421

11422

11423

11424

11426

11440

11441

11442

11443

11719

11720

11721

11730

11732

11740

11750

11752

11755

11624

11626

11640

11641

11642

11643

11644

11646

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

10

10

10

10

10

0

0

0

0

ZZZ

0

10

10

0

10

10

10

10

10

10

10

10

$276.00

$344.00

$282.00

$366.00

$264.00

$351.00

$320.00

$391.00

$148.00

$180.00

$199.00

$226.00

$249.00

$315.00

$150.00

$191.00

$223.00

$259.00

$114.00

$145.00

$178.00

$200.00

$246.00

$98.00

$92.00

$157.00

$163.00

$221.00

$303.00

$105.00

$102.00

$174.00

$221.00

$305.00

$373.00

$168.00

$227.00

$260.00

$305.00

$380.00

$494.00

$22.00

$32.00

$50.00

$62.00

$31.00

$41.00

$156.00

$234.00

$106.00

$400.00

$557.00

$539.00

$689.00

$525.00

$696.00

$585.00

$723.00

$269.00

$321.00

$348.00

$400.00

$445.00

$642.00

$272.00

$323.00

$361.00

$426.00

$209.00

$232.00

$271.00

$308.00

$448.00

$171.00

$220.00

$246.00

$285.00

$331.00

$477.00

$188.00

$236.00

$265.00

$317.00

$481.00

$582.00

$281.00

$335.00

$383.00

$453.00

$560.00

$736.00

$19.00

$45.00

$63.00

$138.00

$50.00

$69.00

$251.00

$457.00

$186.00

$425.00

$592.00

$577.00

$737.00

$562.00

$744.00

$626.00

$771.00

$286.00

$342.00

$371.00

$425.00

$474.00

$685.00

$290.00

$344.00

$384.00

$453.00

$222.00

$247.00

$289.00

$329.00

$479.00

$181.00

$233.00

$262.00

$304.00

$352.00

$509.00

$200.00

$251.00

$282.00

$337.00

$512.00

$620.00

$299.00

$356.00

$408.00

$482.00

$596.00

$783.00

$20.00

$47.00

$66.00

$146.00

$53.00

$73.00

$266.00

$484.00

$197.00

$446.00

$623.00

$606.00

$775.00

$587.00

$781.00

$657.00

$807.00

$296.00

$354.00

$385.00

$443.00

$495.00

$721.00

$300.00

$357.00

$399.00

$473.00

$230.00

$257.00

$301.00

$344.00

$507.00

$186.00

$242.00

$272.00

$317.00

$369.00

$538.00

$205.00

$260.00

$293.00

$353.00

$536.00

$653.00

$309.00

$370.00

$424.00

$504.00

$624.00

$824.00

$21.00

$48.00

$68.00

$149.00

$54.00

$74.00

$271.00

$500.00

$201.00

$329.00

$473.00

$367.00

$474.00

$349.00

$475.00

$409.00

$508.00

$171.00

$215.00

$236.00

$284.00

$313.00

$470.00

$174.00

$217.00

$249.00

$309.00

$148.00

$164.00

$212.00

$235.00

$360.00

$116.00

$158.00

$194.00

$227.00

$260.00

$401.00

$146.00

$188.00

$209.00

$257.00

$351.00

$432.00

$180.00

$226.00

$268.00

$336.00

$416.00

$580.00

$11.00

$21.00

$36.00

$74.00

$29.00

$46.00

$198.00

$376.00

$112.00

$349.00

$502.00

$392.00

$507.00

$373.00

$507.00

$437.00

$541.00

$182.00

$228.00

$250.00

$301.00

$333.00

$500.00

$185.00

$230.00

$264.00

$328.00

$157.00

$174.00

$226.00

$250.00

$385.00

$123.00

$167.00

$206.00

$241.00

$277.00

$427.00

$155.00

$200.00

$222.00

$273.00

$372.00

$460.00

$191.00

$240.00

$284.00

$356.00

$441.00

$615.00

$11.00

$22.00

$37.00

$76.00

$30.00

$48.00

$209.00

$396.00

$117.00

$370.00

$533.00

$420.00

$544.00

$398.00

$543.00

$467.00

$576.00

$191.00

$240.00

$264.00

$318.00

$353.00

$536.00

$195.00

$243.00

$278.00

$348.00

$165.00

$183.00

$239.00

$266.00

$413.00

$128.00

$175.00

$216.00

$254.00

$293.00

$457.00

$160.00

$209.00

$233.00

$288.00

$396.00

$492.00

$201.00

$253.00

$300.00

$377.00

$469.00

$656.00

$12.00

$23.00

$39.00

$80.00

$31.00

$50.00

$214.00

$413.00

$121.00


Part B, 164



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

12006

12007

12011

12013

12014

12015

12016

12017

12018

12020

11960

11970

11971

11976

12001

12002

12004

12005

11760

11762

11765

11770

11771

11772

11900

11901

11920

11921

11922

11950

11951

11952

11954

12042

12044

12045

12046

12047

12051

12052

12053

12054

12021

12031

12032

12034

12035

12036

12037

12041

0

0

0

0

10

0

0

0

0

0

0

0

0

90

90

90

0

0

0

0

0

ZZZ

0

0

0

0

10

10

10

10

90

90

0

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

$829.00

$632.00

$280.00

$123.00

$84.00

$98.00

$122.00

$165.00

$203.00

$339.00

$98.00

$141.00

$165.00

$207.00

$268.00

$316.00

$515.00

$211.00

$131.00

$223.00

$65.00

$275.00

$496.00

$585.00

$33.00

$37.00

$147.00

$172.00

$40.00

$107.00

$114.00

$155.00

$165.00

$87.00

$93.00

$110.00

$148.00

$223.00

$356.00

$411.00

$116.00

$141.00

$176.00

$250.00

$341.00

$363.00

$126.00

$148.00

$223.00

$301.00

$1,359.00

$880.00

$657.00

$202.00

$125.00

$153.00

$181.00

$229.00

$272.00

$319.00

$154.00

$161.00

$189.00

$229.00

$292.00

$228.00

$258.00

$411.00

$271.00

$393.00

$232.00

$395.00

$821.00

$996.00

$78.00

$99.00

$239.00

$280.00

$86.00

$103.00

$139.00

$186.00

$224.00

$238.00

$332.00

$425.00

$439.00

$539.00

$598.00

$679.00

$332.00

$407.00

$504.00

$568.00

$680.00

$737.00

$363.00

$414.00

$485.00

$508.00

$1,446.00

$936.00

$701.00

$213.00

$133.00

$162.00

$192.00

$243.00

$288.00

$339.00

$163.00

$171.00

$200.00

$243.00

$310.00

$240.00

$272.00

$440.00

$288.00

$415.00

$245.00

$423.00

$880.00

$1,066.00

$83.00

$105.00

$255.00

$298.00

$92.00

$109.00

$148.00

$198.00

$239.00

$254.00

$354.00

$452.00

$467.00

$575.00

$638.00

$724.00

$353.00

$433.00

$536.00

$605.00

$729.00

$788.00

$386.00

$441.00

$516.00

$540.00

$1,523.00

$991.00

$725.00

$222.00

$137.00

$168.00

$200.00

$254.00

$302.00

$357.00

$169.00

$178.00

$209.00

$254.00

$325.00

$260.00

$295.00

$462.00

$297.00

$426.00

$249.00

$446.00

$935.00

$1,132.00

$86.00

$109.00

$265.00

$311.00

$95.00

$111.00

$156.00

$208.00

$251.00

$268.00

$366.00

$468.00

$487.00

$599.00

$669.00

$761.00

$366.00

$450.00

$556.00

$629.00

$769.00

$829.00

$401.00

$458.00

$536.00

$562.00

$1,359.00

$880.00

$455.00

$137.00

$65.00

$85.00

$107.00

$140.00

$172.00

$217.00

$81.00

$85.00

$110.00

$138.00

$189.00

$228.00

$258.00

$284.00

$168.00

$264.00

$133.00

$271.00

$637.00

$840.00

$46.00

$70.00

$165.00

$195.00

$43.00

$73.00

$105.00

$142.00

$168.00

$205.00

$221.00

$281.00

$300.00

$350.00

$409.00

$479.00

$218.00

$290.00

$312.00

$392.00

$456.00

$506.00

$248.00

$295.00

$316.00

$324.00

$1,446.00

$936.00

$485.00

$143.00

$68.00

$90.00

$113.00

$147.00

$181.00

$230.00

$85.00

$90.00

$116.00

$146.00

$199.00

$240.00

$272.00

$303.00

$177.00

$276.00

$140.00

$290.00

$682.00

$899.00

$48.00

$74.00

$175.00

$207.00

$46.00

$77.00

$112.00

$150.00

$178.00

$218.00

$234.00

$298.00

$319.00

$372.00

$435.00

$510.00

$231.00

$308.00

$330.00

$416.00

$489.00

$541.00

$263.00

$313.00

$335.00

$343.00

$1,523.00

$991.00

$508.00

$152.00

$72.00

$96.00

$120.00

$158.00

$195.00

$248.00

$91.00

$96.00

$124.00

$156.00

$215.00

$260.00

$295.00

$325.00

$185.00

$287.00

$143.00

$313.00

$736.00

$964.00

$51.00

$79.00

$185.00

$220.00

$49.00

$79.00

$120.00

$159.00

$190.00

$231.00

$247.00

$314.00

$338.00

$396.00

$466.00

$546.00

$243.00

$324.00

$349.00

$440.00

$529.00

$581.00

$278.00

$330.00

$354.00

$364.00


Part B, 165



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

14061

14301

14302

14350

15002

15003

15004

15005

15040

15050

13160

14000

14001

14020

14021

14040

14041

14060

12055

12056

12057

13100

13101

13102

13120

13121

13122

13131

13132

13133

13151

13152

13153

15130

15131

15135

15136

15150

15151

15152

15155

15156

15100

15101

15110

15111

15115

15116

15120

15121

10

10

10

10

10

ZZZ

10

$380.00

$487.00

$539.00

$178.00

$240.00

$89.00

$223.00

10 $348.00

ZZZ $104.00

10

10

$252.00

$484.00

ZZZ $154.00

10

10

$375.00

$542.00

ZZZ $169.00

90

90

90

90

90

90

90

90

$655.00

$512.00

$695.00

$590.00

$818.00

$701.00

$936.00

$766.00

ZZZ

0

ZZZ

0

90

90 $1,330.00

90 --------

ZZZ

90

0

--------

$734.00

--------

--------

--------

--------

--------

$349.00

90

ZZZ

90

ZZZ

90

ZZZ

ZZZ

90

ZZZ

90 $679.00

ZZZ $146.00

90 --------

ZZZ

90

ZZZ

90

--------

--------

--------

$788.00

ZZZ $235.00

--------

--------

--------

--------

--------

--------

--------

--------

--------

$1,179.00

$882.00

$1,140.00

$987.00

$1,238.00

$1,082.00

$1,341.00

$1,106.00

$1,442.00

$1,538.00

$327.00

$1,004.00

$494.00

$108.00

$569.00

$179.00

$361.00

$797.00

$660.00

$772.00

$801.00

$470.00

$556.00

$172.00

$492.00

$601.00

$189.00

$542.00

$672.00

$255.00

$596.00

$717.00

$277.00

$1,230.00

$264.00

$1,154.00

$171.00

$1,182.00

$227.00

$1,218.00

$296.00

$963.00

$145.00

$1,208.00

$138.00

$1,019.00

$181.00

$223.00

$1,038.00

$234.00

$1,255.00

$940.00

$1,215.00

$1,050.00

$1,316.00

$1,149.00

$1,425.00

$1,174.00

$1,532.00

$1,636.00

$347.00

$1,056.00

$526.00

$115.00

$603.00

$191.00

$386.00

$848.00

$702.00

$822.00

$856.00

$500.00

$592.00

$184.00

$524.00

$640.00

$201.00

$577.00

$715.00

$271.00

$634.00

$763.00

$294.00

$1,313.00

$283.00

$1,225.00

$183.00

$1,252.00

$244.00

$1,296.00

$317.00

$1,027.00

$154.00

$1,280.00

$146.00

$1,092.00

$194.00

$239.00

$1,098.00

$250.00

$1,342.00

$985.00

$1,278.00

$1,097.00

$1,379.00

$1,202.00

$1,491.00

$1,229.00

$1,602.00

$1,719.00

$373.00

$1,105.00

$552.00

$121.00

$629.00

$202.00

$402.00

$884.00

$731.00

$858.00

$902.00

$519.00

$614.00

$193.00

$544.00

$664.00

$211.00

$600.00

$744.00

$284.00

$660.00

$796.00

$309.00

$1,389.00

$297.00

$1,294.00

$199.00

$1,318.00

$267.00

$1,364.00

$332.00

$1,084.00

$164.00

$1,342.00

$155.00

$1,180.00

$212.00

$261.00

$1,154.00

$272.00

$1,179.00

$727.00

$950.00

$821.00

$1,041.00

$915.00

$1,128.00

$975.00

$1,207.00

$1,285.00

$327.00

$1,004.00

$333.00

$68.00

$395.00

$135.00

$189.00

$641.00

$446.00

$549.00

$596.00

$300.00

$368.00

$110.00

$343.00

$390.00

$126.00

$364.00

$459.00

$193.00

$419.00

$509.00

$208.00

$1,044.00

$164.00

$1,016.00

$156.00

$1,042.00

$207.00

$1,018.00

$195.00

$821.00

$134.00

$1,069.00

$130.00

$939.00

$169.00

$210.00

$965.00

$223.00

$1,255.00

$774.00

$1,012.00

$872.00

$1,105.00

$970.00

$1,196.00

$1,033.00

$1,279.00

$1,364.00

$347.00

$1,056.00

$354.00

$72.00

$417.00

$143.00

$201.00

$681.00

$472.00

$583.00

$635.00

$317.00

$390.00

$117.00

$363.00

$413.00

$134.00

$385.00

$486.00

$204.00

$444.00

$539.00

$221.00

$1,113.00

$176.00

$1,076.00

$167.00

$1,102.00

$222.00

$1,081.00

$208.00

$875.00

$142.00

$1,130.00

$137.00

$1,007.00

$181.00

$225.00

$1,020.00

$238.00

$1,342.00

$818.00

$1,074.00

$919.00

$1,167.00

$1,022.00

$1,261.00

$1,088.00

$1,349.00

$1,447.00

$373.00

$1,105.00

$379.00

$78.00

$442.00

$155.00

$216.00

$716.00

$501.00

$618.00

$680.00

$336.00

$412.00

$125.00

$383.00

$437.00

$143.00

$408.00

$515.00

$217.00

$470.00

$571.00

$236.00

$1,188.00

$190.00

$1,145.00

$183.00

$1,167.00

$245.00

$1,149.00

$223.00

$931.00

$152.00

$1,193.00

$147.00

$1,094.00

$199.00

$247.00

$1,076.00

$260.00


Part B, 166



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

15620

15630

15650

15731

15732

15734

15736

15738

15740

15750

15277

15278

15570

15572

15574

15576

15600

15610

15157

15200

15201

15220

15221

15240

15241

15260

15261

15271

15272

15273

15274

15275

15276

15780

15781

15782

15783

15786

15787

15788

15789

15792

15756

15757

15758

15760

15770

15775

15776

15777

ZZZ

90

--------

$644.00

ZZZ $126.00

90 $687.00

ZZZ $114.00

90 $763.00

ZZZ $334.00

90 $841.00

ZZZ $207.00

0

ZZZ

0

--------

--------

--------

ZZZ

0

ZZZ

--------

--------

--------

0

ZZZ

90

90

90

90

90

90

--------

--------

$748.00

$721.00

$775.00

$457.00

$259.00

$320.00

90

90

90

90

$506.00

$362.00

$427.00

--------

90 $1,465.00

90 $1,557.00

90 $1,862.00

90 $1,415.00

90 $913.00

90 $1,064.00

90

90

90

90

10

ZZZ

90

90

90

90 $2,892.00

90 $2,892.00

90 $2,884.00

90

90

0

0

ZZZ

$810.00

$674.00

$327.00

$475.00

--------

$532.00

$420.00

$314.00

$340.00

$146.00

$27.00

$194.00

$360.00

$130.00

$461.00

$122.00

$1,304.00

$1,265.00

$1,304.00

$1,147.00

$449.00

$497.00

$618.00

$647.00

$711.00

$1,617.00

$1,837.00

$2,179.00

$1,904.00

$2,029.00

$1,452.00

$1,336.00

$254.00

$1,184.00

$209.00

$1,093.00

$193.00

$1,328.00

$262.00

$1,440.00

$306.00

$199.00

$39.00

$426.00

$102.00

$210.00

$49.00

$3,408.00

$3,365.00

$3,371.00

$1,215.00

$972.00

$429.00

$706.00

$316.00

$1,189.00

$784.00

$889.00

$658.00

$342.00

$68.00

$638.00

$774.00

$614.00

$490.00

$130.00

$1,390.00

$1,347.00

$1,386.00

$1,218.00

$480.00

$530.00

$659.00

$689.00

$757.00

$1,716.00

$1,945.00

$2,325.00

$2,028.00

$2,161.00

$1,543.00

$1,420.00

$268.00

$1,261.00

$223.00

$1,164.00

$206.00

$1,412.00

$279.00

$1,528.00

$326.00

$211.00

$41.00

$454.00

$109.00

$222.00

$52.00

$3,614.00

$3,564.00

$3,572.00

$1,290.00

$1,033.00

$455.00

$751.00

$336.00

$1,262.00

$835.00

$948.00

$700.00

$363.00

$72.00

$681.00

$825.00

$657.00

$516.00

$138.00

$1,465.00

$1,416.00

$1,455.00

$1,274.00

$494.00

$548.00

$683.00

$715.00

$788.00

$1,807.00

$2,035.00

$2,482.00

$2,151.00

$2,299.00

$1,616.00

$1,510.00

$284.00

$1,325.00

$233.00

$1,217.00

$214.00

$1,480.00

$291.00

$1,597.00

$340.00

$219.00

$43.00

$479.00

$116.00

$229.00

$54.00

$3,854.00

$3,794.00

$3,806.00

$1,349.00

$1,092.00

$476.00

$788.00

$363.00

$1,310.00

$870.00

$976.00

$727.00

$373.00

$74.00

$695.00

$857.00

$671.00

$332.00

$85.00

$1,071.00

$1,082.00

$1,113.00

$971.00

$295.00

$345.00

$468.00

$498.00

$550.00

$1,464.00

$1,616.00

$1,937.00

$1,666.00

$1,806.00

$1,238.00

$1,336.00

$238.00

$976.00

$116.00

$890.00

$105.00

$1,159.00

$164.00

$1,243.00

$206.00

$124.00

$26.00

$299.00

$69.00

$139.00

$37.00

$3,408.00

$3,365.00

$3,371.00

$1,026.00

$972.00

$326.00

$521.00

$316.00

$912.00

$624.00

$636.00

$518.00

$196.00

$25.00

$350.00

$595.00

$372.00

$351.00

$91.00

$1,140.00

$1,150.00

$1,182.00

$1,029.00

$314.00

$367.00

$498.00

$529.00

$585.00

$1,553.00

$1,709.00

$2,066.00

$1,773.00

$1,922.00

$1,313.00

$1,420.00

$251.00

$1,038.00

$123.00

$946.00

$112.00

$1,231.00

$174.00

$1,317.00

$218.00

$131.00

$27.00

$318.00

$73.00

$145.00

$38.00

$3,614.00

$3,564.00

$3,572.00

$1,088.00

$1,033.00

$344.00

$553.00

$336.00

$964.00

$664.00

$677.00

$550.00

$206.00

$26.00

$372.00

$632.00

$397.00

$377.00

$98.00

$1,214.00

$1,219.00

$1,250.00

$1,084.00

$328.00

$385.00

$522.00

$555.00

$615.00

$1,642.00

$1,798.00

$2,222.00

$1,896.00

$2,060.00

$1,386.00

$1,510.00

$268.00

$1,102.00

$133.00

$999.00

$120.00

$1,297.00

$186.00

$1,385.00

$232.00

$139.00

$29.00

$343.00

$80.00

$153.00

$41.00

$3,854.00

$3,794.00

$3,806.00

$1,146.00

$1,092.00

$365.00

$589.00

$363.00

$1,011.00

$697.00

$704.00

$577.00

$216.00

$28.00

$385.00

$664.00

$410.00


Part B, 167



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

15845

15850

15851

15852

15860

15876

15877

15878

15879

15920

15835

15836

15837

15838

15839

15840

15841

15842

15793

15819

15820

15821

15822

15823

15824

15825

15826

15828

15829

15830

15832

15833

15834

15941

15944

15945

15946

15950

15951

15952

15953

15956

15922

15931

15933

15934

15935

15936

15937

15940

0

0

0

0

90

90

90

90

90

90

90

90

90

90

0

90

90

90

90

90

$865.00

$721.00

$696.00

$600.00

$643.00

90 $1,187.00

90 $1,859.00

90 $3,099.00

0

0

0

0

90

90 $1,116.00

0 $63.00

0

0

0

$40.00

$35.00

$151.00

NC

NC

NC

NC

$571.00

$232.00

$780.00

$556.00

$607.00

$499.00

$718.00

NC

NC

NC

NC

NC

--------

$926.00

$833.00

$837.00

90

90

90

$771.00

$638.00

$860.00

90 $1,064.00

90 $1,184.00

90 $1,032.00

90 $1,223.00

90 $318.00

90

90

$919.00

$954.00

90 $1,078.00

90 $1,737.00

90 $549.00

90

90

$872.00

$876.00

90 $1,013.00

90 $1,382.00

$1,349.00

$1,108.00

$1,159.00

$830.00

$1,266.00

$1,465.00

$2,371.00

$3,851.00

$1,437.00

$125.00

$138.00

$69.00

$164.00

BR

BR

BR

BR

$883.00

$692.00

$1,066.00

$789.00

$852.00

$625.00

$851.00

BR

BR

BR

BR

BR

$1,711.00

$1,333.00

$1,249.00

$1,286.00

$1,128.00

$1,010.00

$1,238.00

$1,360.00

$1,599.00

$1,305.00

$1,510.00

$1,026.00

$1,308.00

$1,289.00

$1,421.00

$2,388.00

$863.00

$1,269.00

$1,298.00

$1,439.00

$1,683.00

$1,435.00

$1,181.00

$1,238.00

$879.00

$1,348.00

$1,550.00

$2,517.00

$4,089.00

$1,510.00

$133.00

$146.00

$73.00

$174.00

BR

BR

BR

BR

$944.00

$737.00

$1,130.00

$832.00

$899.00

$661.00

$897.00

BR

BR

BR

BR

BR

$1,822.00

$1,418.00

$1,328.00

$1,367.00

$1,200.00

$1,081.00

$1,322.00

$1,453.00

$1,706.00

$1,392.00

$1,610.00

$1,096.00

$1,394.00

$1,374.00

$1,513.00

$2,542.00

$922.00

$1,349.00

$1,379.00

$1,530.00

$1,794.00

$1,526.00

$1,261.00

$1,314.00

$927.00

$1,421.00

$1,638.00

$2,692.00

$4,365.00

$1,566.00

$137.00

$150.00

$79.00

$188.00

BR

BR

BR

BR

$1,014.00

$762.00

$1,195.00

$853.00

$926.00

$681.00

$920.00

BR

BR

BR

BR

BR

$1,947.00

$1,507.00

$1,410.00

$1,449.00

$1,270.00

$1,169.00

$1,418.00

$1,566.00

$1,831.00

$1,495.00

$1,725.00

$1,180.00

$1,489.00

$1,468.00

$1,616.00

$2,718.00

$990.00

$1,428.00

$1,462.00

$1,622.00

$1,921.00

$1,349.00

$1,108.00

$981.00

$830.00

$1,073.00

$1,465.00

$2,371.00

$3,851.00

$1,437.00

$61.00

$66.00

$69.00

$164.00

BR

BR

BR

BR

$883.00

$525.00

$1,066.00

$715.00

$770.00

$552.00

$767.00

BR

BR

BR

BR

BR

$1,711.00

$1,333.00

$1,249.00

$1,286.00

$1,128.00

$1,010.00

$1,238.00

$1,360.00

$1,599.00

$1,305.00

$1,510.00

$1,026.00

$1,308.00

$1,289.00

$1,421.00

$2,388.00

$863.00

$1,269.00

$1,298.00

$1,439.00

$1,683.00

$1,435.00

$1,181.00

$1,046.00

$879.00

$1,141.00

$1,550.00

$2,517.00

$4,089.00

$1,510.00

$64.00

$69.00

$73.00

$174.00

BR

BR

BR

BR

$944.00

$558.00

$1,130.00

$752.00

$810.00

$583.00

$806.00

BR

BR

BR

BR

BR

$1,822.00

$1,418.00

$1,328.00

$1,367.00

$1,200.00

$1,081.00

$1,322.00

$1,453.00

$1,706.00

$1,392.00

$1,610.00

$1,096.00

$1,394.00

$1,374.00

$1,513.00

$2,542.00

$922.00

$1,349.00

$1,379.00

$1,530.00

$1,794.00

$1,526.00

$1,261.00

$1,122.00

$927.00

$1,213.00

$1,638.00

$2,692.00

$4,365.00

$1,566.00

$68.00

$73.00

$79.00

$188.00

BR

BR

BR

BR

$1,014.00

$582.00

$1,195.00

$774.00

$836.00

$602.00

$829.00

BR

BR

BR

BR

BR

$1,947.00

$1,507.00

$1,410.00

$1,449.00

$1,270.00

$1,169.00

$1,418.00

$1,566.00

$1,831.00

$1,495.00

$1,725.00

$1,180.00

$1,489.00

$1,468.00

$1,616.00

$2,718.00

$990.00

$1,428.00

$1,462.00

$1,622.00

$1,921.00


Part B, 168



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

17270

17271

17272

17273

17274

17276

17280

17281

17282

17283

17111

17250

17260

17261

17262

17263

17264

17266

15958

15999

16000

16020

16025

16030

16035

16036

17000

17003

17004

17106

17107

17108

17110

17360

17380

17999

19000

19001

19020

19030

19081

19082

17284

17286

17311

17312

17313

17314

17315

17340

10

0

YYY

0

ZZZ

90

0

0

ZZZ

10

10

0

ZZZ

0

ZZZ

ZZZ

10

10

10

10

10

10

10

10

10

10

10

10

0

10

10

10

10

10

10

90 $1,379.00

YYY BR

0

0

0

0

0

$53.00

$49.00

$67.00

$153.00

$341.00

ZZZ

10

ZZZ

10

90

$81.00

$60.00

$16.00

$233.00

$341.00

90 $648.00

90 $1,015.00

10 $55.00

$83.00

$27.00

$96.00

$117.00

$150.00

$172.00

$189.00

$225.00

$125.00

$143.00

$170.00

$195.00

$240.00

$281.00

$123.00

$165.00

$194.00

$239.00

$282.00

$373.00

--------

--------

--------

--------

--------

$37.00

$96.00

NC

BR

$74.00

$40.00

$288.00

$98.00

--------

--------

$183.00

$110.00

$133.00

$201.00

$246.00

$269.00

$288.00

$327.00

$211.00

$229.00

$262.00

$293.00

$346.00

$402.00

$197.00

$250.00

$288.00

$346.00

$1,708.00

--------

$98.00

$114.00

$209.00

$264.00

$287.00

$120.00

$94.00

$8.00

$211.00

$482.00

$614.00

$909.00

$154.00

$396.00

$510.00

$930.00

$545.00

$868.00

$522.00

$113.00

$73.00

$182.00

BR

--------

$158.00

$39.00

$669.00

$231.00

$962.00

$790.00

$195.00

$117.00

$142.00

$214.00

$261.00

$286.00

$306.00

$348.00

$225.00

$243.00

$279.00

$311.00

$368.00

$427.00

$210.00

$266.00

$306.00

$367.00

$1,819.00

--------

$103.00

$121.00

$222.00

$281.00

$302.00

$127.00

$100.00

$9.00

$224.00

$512.00

$652.00

$965.00

$164.00

$420.00

$541.00

$989.00

$580.00

$924.00

$556.00

$120.00

$77.00

$193.00

BR

--------

$168.00

$41.00

$717.00

$245.00

$1,026.00

$845.00

$200.00

$120.00

$147.00

$221.00

$271.00

$297.00

$318.00

$362.00

$233.00

$252.00

$290.00

$323.00

$383.00

$445.00

$217.00

$277.00

$319.00

$383.00

$1,944.00

--------

$108.00

$125.00

$232.00

$294.00

$322.00

$137.00

$103.00

$9.00

$232.00

$533.00

$679.00

$1,011.00

$167.00

$438.00

$568.00

$1,028.00

$601.00

$958.00

$575.00

$125.00

$81.00

$202.00

BR

--------

$173.00

$43.00

$751.00

$251.00

$1,043.00

$854.00

$122.00

$53.00

$101.00

$132.00

$168.00

$187.00

$200.00

$234.00

$144.00

$160.00

$186.00

$209.00

$256.00

$308.00

$131.00

$180.00

$209.00

$261.00

$1,708.00

--------

$67.00

$78.00

$161.00

$195.00

$287.00

$120.00

$76.00

$4.00

$144.00

$397.00

$500.00

$761.00

$99.00

$305.00

$410.00

$554.00

$295.00

$497.00

$273.00

$78.00

$71.00

$142.00

BR

--------

$64.00

$32.00

$445.00

$113.00

$249.00

$125.00

$129.00

$56.00

$107.00

$140.00

$178.00

$198.00

$211.00

$247.00

$152.00

$169.00

$197.00

$221.00

$271.00

$325.00

$139.00

$191.00

$221.00

$276.00

$1,819.00

--------

$71.00

$82.00

$171.00

$207.00

$302.00

$127.00

$81.00

$4.00

$152.00

$420.00

$529.00

$807.00

$105.00

$322.00

$434.00

$586.00

$312.00

$525.00

$289.00

$82.00

$74.00

$151.00

BR

--------

$68.00

$34.00

$477.00

$118.00

$261.00

$131.00

$135.00

$59.00

$113.00

$147.00

$188.00

$209.00

$223.00

$261.00

$160.00

$178.00

$207.00

$233.00

$286.00

$344.00

$146.00

$201.00

$234.00

$292.00

$1,944.00

--------

$75.00

$86.00

$181.00

$220.00

$322.00

$137.00

$84.00

$4.00

$160.00

$441.00

$556.00

$852.00

$108.00

$341.00

$460.00

$623.00

$331.00

$559.00

$307.00

$87.00

$78.00

$159.00

BR

--------

$72.00

$36.00

$511.00

$124.00

$277.00

$138.00


Part B, 169



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

19296

19297

19298

19300

19301

19302

19303

19304

19305

19306

19281

19282

19283

19284

19285

19286

19287

19288

19083

19084

19085

19086

19100

19101

19105

19110

19112

19120

19125

19126

19260

19271

19272

19342

19350

19355

19357

19361

19364

19366

19367

19368

19307

19316

19318

19324

19325

19328

19330

19340

90

90

90

90

90

0

ZZZ

0

90

90

0

ZZZ

0

ZZZ

0

ZZZ

0

ZZZ

0

ZZZ

0

ZZZ

0

10

0

--------

--------

--------

--------

$117.00

$338.00

--------

90

90

90

90

$406.00

$354.00

$429.00

$468.00

ZZZ $201.00

90 $1,101.00

90 $1,561.00

90 $1,674.00

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

90

90

--------

$954.00

90 $1,313.00

90

90

90

90

90

$440.00

$656.00

$457.00

$569.00

$545.00

90

90

90

$963.00

$853.00

$755.00

90 $1,449.00

90 $1,667.00

90 $2,737.00

90 $1,676.00

90 $2,056.00

90 $2,444.00

$334.00

$233.00

$376.00

$282.00

$710.00

$621.00

$1,186.00

$953.00

$5,420.00

$143.00

$1,465.00

$750.00

$968.00

$1,335.00

$1,501.00

$844.00

$1,672.00

$1,778.00

$929.00

$760.00

$1,422.00

$1,122.00

$214.00

$487.00

$2,937.00

$692.00

$648.00

$716.00

$795.00

$244.00

$1,779.00

$2,396.00

$2,623.00

$1,774.00

$1,121.00

$1,603.00

$720.00

$926.00

$717.00

$919.00

$1,456.00

$1,336.00

$1,175.00

$1,022.00

$2,170.00

$2,295.00

$4,028.00

$2,065.00

$2,611.00

$3,218.00

$354.00

$248.00

$399.00

$301.00

$758.00

$665.00

$1,267.00

$1,019.00

$5,815.00

$153.00

$1,562.00

$804.00

$1,039.00

$1,432.00

$1,610.00

$905.00

$1,793.00

$1,909.00

$991.00

$812.00

$1,519.00

$1,200.00

$229.00

$522.00

$3,143.00

$742.00

$695.00

$768.00

$853.00

$261.00

$1,907.00

$2,568.00

$2,810.00

$1,903.00

$1,193.00

$1,703.00

$772.00

$984.00

$763.00

$978.00

$1,548.00

$1,420.00

$1,252.00

$1,097.00

$2,309.00

$2,438.00

$4,278.00

$2,198.00

$2,773.00

$3,417.00

$362.00

$252.00

$408.00

$306.00

$767.00

$670.00

$1,280.00

$1,027.00

$5,864.00

$169.00

$1,598.00

$852.00

$1,133.00

$1,564.00

$1,758.00

$978.00

$1,954.00

$2,081.00

$1,006.00

$821.00

$1,538.00

$1,210.00

$241.00

$551.00

$3,167.00

$784.00

$732.00

$823.00

$917.00

$289.00

$2,070.00

$2,772.00

$3,037.00

$2,074.00

$1,273.00

$1,811.00

$836.00

$1,040.00

$809.00

$1,038.00

$1,644.00

$1,504.00

$1,315.00

$1,179.00

$2,436.00

$2,596.00

$4,566.00

$2,360.00

$2,954.00

$3,645.00

$148.00

$75.00

$150.00

$76.00

$127.00

$64.00

$190.00

$95.00

$316.00

$143.00

$481.00

$603.00

$968.00

$1,335.00

$1,501.00

$844.00

$1,672.00

$1,778.00

$233.00

$117.00

$274.00

$135.00

$105.00

$326.00

$284.00

$500.00

$453.00

$609.00

$678.00

$244.00

$1,779.00

$2,396.00

$2,623.00

$1,774.00

$1,121.00

$1,603.00

$720.00

$926.00

$717.00

$919.00

$1,456.00

$1,336.00

$975.00

$847.00

$2,170.00

$2,295.00

$4,028.00

$2,065.00

$2,611.00

$3,218.00

$154.00

$78.00

$157.00

$80.00

$132.00

$67.00

$198.00

$98.00

$338.00

$153.00

$506.00

$646.00

$1,039.00

$1,432.00

$1,610.00

$905.00

$1,793.00

$1,909.00

$244.00

$122.00

$287.00

$141.00

$112.00

$349.00

$297.00

$536.00

$486.00

$653.00

$728.00

$261.00

$1,907.00

$2,568.00

$2,810.00

$1,903.00

$1,193.00

$1,703.00

$772.00

$984.00

$763.00

$978.00

$1,548.00

$1,420.00

$1,037.00

$909.00

$2,309.00

$2,438.00

$4,278.00

$2,198.00

$2,773.00

$3,417.00

$162.00

$82.00

$165.00

$84.00

$139.00

$70.00

$208.00

$103.00

$371.00

$169.00

$539.00

$694.00

$1,133.00

$1,564.00

$1,758.00

$978.00

$1,954.00

$2,081.00

$257.00

$129.00

$302.00

$148.00

$124.00

$379.00

$312.00

$578.00

$523.00

$708.00

$791.00

$289.00

$2,070.00

$2,772.00

$3,037.00

$2,074.00

$1,273.00

$1,811.00

$836.00

$1,040.00

$809.00

$1,038.00

$1,644.00

$1,504.00

$1,100.00

$991.00

$2,436.00

$2,596.00

$4,566.00

$2,360.00

$2,954.00

$3,645.00


Part B, 170



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

20520

20525

20526

20527

20550

20551

20552

20553

20555

20600

20220

20225

20240

20245

20250

20251

20500

20501

19369

19370

19371

19380

19396

19499

20005

20100

20101

20102

20103

20150

20200

20205

20206

20660

20661

20662

20663

20665

20670

20680

20690

20692

20604

20605

20606

20610

20611

20612

20615

20650

0

90

90

90

10

10

90

90

90

0

0

0

10

10

0

0

0

0

0

0

0

0

10

10

0

0

0

0

0

0

10

10

10

10

0

90 $2,317.00

90 $662.00

90

90

0

YYY

10

$788.00

$780.00

$231.00

BR

$267.00

0

0

0

10

10

10

10

$727.00

$261.00

$314.00

$405.00

90 $1,141.00

$134.00

$243.00

$119.00

$128.00

$215.00

$279.00

$364.00

$447.00

$511.00

$59.00

$60.00

$75.00

$331.00

$64.00

--------

$40.00

$62.00

$62.00

$62.00

--------

$41.00

--------

$48.00

--------

$49.00

--------

$56.00

$94.00

$170.00

$320.00

$476.00

$559.00

$465.00

$105.00

$80.00

$332.00

$298.00

$516.00

$236.00

$728.00

$226.00

$763.00

$578.00

$628.00

$147.00

$164.00

$287.00

$676.00

$110.00

$120.00

$83.00

$85.00

$78.00

$90.00

$480.00

$68.00

$2,991.00

$993.00

$1,136.00

$1,119.00

$390.00

--------

$442.00

$903.00

$636.00

$698.00

$825.00

$1,320.00

$293.00

$413.00

$327.00

$102.00

$71.00

$113.00

$86.00

$130.00

$86.00

$345.00

$294.00

$374.00

$746.00

$617.00

$680.00

$149.00

$527.00

$879.00

$871.00

$1,632.00

$250.00

$777.00

$239.00

$810.00

$622.00

$676.00

$155.00

$175.00

$305.00

$722.00

$117.00

$128.00

$88.00

$90.00

$82.00

$95.00

$506.00

$71.00

$3,178.00

$1,056.00

$1,208.00

$1,190.00

$416.00

--------

$470.00

$964.00

$682.00

$748.00

$880.00

$1,397.00

$315.00

$444.00

$349.00

$108.00

$75.00

$120.00

$91.00

$138.00

$91.00

$366.00

$312.00

$406.00

$810.00

$645.00

$727.00

$156.00

$563.00

$937.00

$928.00

$1,734.00

$255.00

$786.00

$254.00

$869.00

$678.00

$736.00

$160.00

$178.00

$316.00

$748.00

$124.00

$135.00

$92.00

$93.00

$85.00

$98.00

$538.00

$74.00

$3,395.00

$1,119.00

$1,281.00

$1,262.00

$430.00

--------

$493.00

$1,048.00

$713.00

$785.00

$918.00

$1,487.00

$330.00

$470.00

$354.00

$112.00

$78.00

$125.00

$96.00

$144.00

$94.00

$378.00

$324.00

$455.00

$883.00

$662.00

$774.00

$160.00

$576.00

$979.00

$996.00

$1,847.00

$106.00

$158.00

$226.00

$763.00

$578.00

$628.00

$121.00

$56.00

$210.00

$363.00

$84.00

$97.00

$61.00

$62.00

$55.00

$63.00

$480.00

$52.00

$2,991.00

$993.00

$1,136.00

$1,119.00

$205.00

--------

$341.00

$903.00

$310.00

$380.00

$510.00

$1,320.00

$142.00

$233.00

$86.00

$67.00

$54.00

$77.00

$67.00

$90.00

$61.00

$236.00

$226.00

$374.00

$746.00

$617.00

$680.00

$129.00

$212.00

$616.00

$871.00

$1,632.00

$111.00

$166.00

$239.00

$810.00

$622.00

$676.00

$127.00

$58.00

$223.00

$386.00

$89.00

$103.00

$64.00

$65.00

$58.00

$66.00

$506.00

$54.00

$3,178.00

$1,056.00

$1,208.00

$1,190.00

$217.00

--------

$361.00

$964.00

$332.00

$407.00

$542.00

$1,397.00

$153.00

$251.00

$90.00

$70.00

$57.00

$81.00

$71.00

$95.00

$64.00

$249.00

$239.00

$406.00

$810.00

$645.00

$727.00

$135.00

$225.00

$655.00

$928.00

$1,734.00

$115.00

$173.00

$254.00

$869.00

$678.00

$736.00

$132.00

$61.00

$234.00

$412.00

$96.00

$110.00

$67.00

$68.00

$60.00

$69.00

$538.00

$57.00

$3,395.00

$1,119.00

$1,281.00

$1,262.00

$231.00

--------

$384.00

$1,048.00

$363.00

$443.00

$579.00

$1,487.00

$168.00

$276.00

$94.00

$74.00

$60.00

$85.00

$76.00

$102.00

$68.00

$261.00

$251.00

$455.00

$883.00

$662.00

$774.00

$139.00

$236.00

$695.00

$996.00

$1,847.00


Part B, 171



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

20937

20938

20950

20955

20956

20957

20962

20969

20970

20972

20912

20920

20922

20924

20926

20930

20931

20936

20693

20694

20696

20697

20802

20805

20808

20816

20822

20824

20827

20838

20900

20902

20910

21010

21011

21012

21013

21014

21015

21016

21025

21026

20973

20974

20975

20979

20982

20983

20985

20999

90

90

$477.00

$421.00

90

0

--------

--------

90 $3,363.00

90 $4,317.00

90 $5,324.00

90 $3,060.00

90 $2,511.00

90 $3,027.00

90 $3,920.00

90 $3,484.00

0

0

90

$454.00

$658.00

$338.00

90

90

90

90

90

$549.00

$460.00

$634.00

$583.00

$444.00

0 BR

ZZZ $156.00

0 BR

ZZZ $234.00

ZZZ $257.00

0 $123.00

90 $3,332.00

90 $3,167.00

90 $3,074.00

90 $3,122.00

90 $3,716.00

90 $3,650.00

90 $3,420.00

90

90

90

90

90

90

90

90

90

90 $3,821.00

0 $266.00

0 $334.00

0

0

0

ZZZ

YYY

$19.00

--------

--------

--------

BR

$854.00

--------

--------

--------

--------

$520.00

--------

$546.00

$413.00

$696.00

$570.00

$881.00

$735.00

$626.00

--------

$173.00

--------

$254.00

$282.00

$352.00

$3,682.00

$3,926.00

$3,591.00

$3,083.00

$4,067.00

$4,352.00

$3,451.00

$647.00

$607.00

$1,762.00

$2,707.00

$3,523.00

$4,866.00

$5,915.00

$3,053.00

$2,612.00

$3,001.00

$2,688.00

$3,558.00

$590.00

$422.00

$594.00

$3,875.00

$109.00

$265.00

$74.00

$4,165.00

$9,971.00

$219.00

--------

$1,081.00

$494.00

$494.00

$741.00

$760.00

$1,036.00

$1,499.00

$1,292.00

$885.00

$738.00

$604.00

$945.00

$783.00

$666.00

--------

$188.00

--------

$273.00

$306.00

$377.00

$3,904.00

$4,193.00

$3,782.00

$3,221.00

$4,305.00

$4,672.00

$3,607.00

$687.00

$648.00

$1,877.00

$2,905.00

$3,712.00

$5,188.00

$6,296.00

$3,258.00

$2,771.00

$3,200.00

$2,868.00

$3,750.00

$630.00

$450.00

$629.00

$4,083.00

$116.00

$284.00

$79.00

$4,455.00

$10,688.00

$233.00

--------

$1,145.00

$528.00

$528.00

$790.00

$810.00

$1,103.00

$1,595.00

$1,375.00

$943.00

$778.00

$635.00

$1,009.00

$832.00

$708.00

--------

$212.00

--------

$302.00

$342.00

$386.00

$4,163.00

$4,533.00

$4,002.00

$3,369.00

$4,584.00

$5,101.00

$3,779.00

$727.00

$680.00

$2,009.00

$2,914.00

$3,942.00

$5,588.00

$6,759.00

$3,514.00

$2,943.00

$3,450.00

$3,086.00

$3,981.00

$653.00

$484.00

$662.00

$4,338.00

$122.00

$310.00

$82.00

$4,498.00

$10,760.00

$253.00

--------

$1,210.00

$550.00

$564.00

$829.00

$863.00

$1,174.00

$1,705.00

$1,443.00

$981.00

$696.00

$570.00

$737.00

$735.00

$626.00

--------

$173.00

--------

$254.00

$282.00

$133.00

$3,682.00

$3,926.00

$3,591.00

$3,083.00

$4,067.00

$4,352.00

$3,451.00

$647.00

$490.00

$1,762.00

$2,707.00

$3,523.00

$4,866.00

$5,915.00

$3,053.00

$2,612.00

$3,001.00

$2,688.00

$3,558.00

$280.00

$422.00

$594.00

$3,875.00

$74.00

$265.00

$47.00

$560.00

$599.00

$219.00

--------

$1,081.00

$374.00

$494.00

$583.00

$760.00

$1,036.00

$1,499.00

$1,102.00

$724.00

$738.00

$604.00

$790.00

$783.00

$666.00

--------

$188.00

--------

$273.00

$306.00

$142.00

$3,904.00

$4,193.00

$3,782.00

$3,221.00

$4,305.00

$4,672.00

$3,607.00

$687.00

$523.00

$1,877.00

$2,905.00

$3,712.00

$5,188.00

$6,296.00

$3,258.00

$2,771.00

$3,200.00

$2,868.00

$3,750.00

$297.00

$450.00

$629.00

$4,083.00

$79.00

$284.00

$50.00

$587.00

$634.00

$233.00

--------

$1,145.00

$399.00

$528.00

$621.00

$810.00

$1,103.00

$1,595.00

$1,171.00

$770.00

$778.00

$635.00

$854.00

$832.00

$708.00

--------

$212.00

--------

$302.00

$342.00

$151.00

$4,163.00

$4,533.00

$4,002.00

$3,369.00

$4,584.00

$5,101.00

$3,779.00

$727.00

$554.00

$2,009.00

$2,914.00

$3,942.00

$5,588.00

$6,759.00

$3,514.00

$2,943.00

$3,450.00

$3,086.00

$3,981.00

$319.00

$484.00

$662.00

$4,338.00

$84.00

$310.00

$53.00

$620.00

$676.00

$253.00

--------

$1,210.00

$421.00

$564.00

$659.00

$863.00

$1,174.00

$1,705.00

$1,238.00

$807.00


Part B, 172



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

21084

21085

21086

21087

21088

21089

21100

21110

21116

21120

21073

21076

21077

21079

21080

21081

21082

21083

21029

21030

21031

21032

21034

21040

21044

21045

21046

21047

21048

21049

21050

21060

21070

21141

21142

21143

21145

21146

21147

21150

21151

21154

21121

21122

21123

21125

21127

21137

21138

21139

90

90

$700.00

$496.00

90

90

$310.00

$315.00

90 $1,140.00

90 $227.00

90 $957.00

90 $1,313.00

90 $899.00

90 $1,109.00

90 $925.00

90 $1,051.00

90 $1,026.00

90 $972.00

90 $679.00

90 --------

10 $1,192.00

90 $3,002.00

90 $2,086.00

90 $2,346.00

90 $2,138.00

90 $1,855.00

90 $1,802.00

YYY

90

90

0

90

90 $2,105.00

10 $801.00

90 $2,333.00

90 $2,217.00

90 BR

BR

$297.00

$371.00

$207.00

$500.00

90

90

90

$651.00

$700.00

$903.00

90

90

90

90

$656.00

$909.00

$797.00

$960.00

90 $1,168.00

90 $1,438.00

90 $1,527.00

90 $1,511.00

90 $1,513.00

90 $1,570.00

90 $1,639.00

90 $1,914.00

90 $2,264.00

90 $2,364.00

$554.00

$1,468.00

$3,682.00

$2,476.00

$2,778.00

$2,565.00

$2,421.00

$2,304.00

$2,650.00

$1,106.00

$2,738.00

$2,733.00

--------

--------

$1,459.00

$1,151.00

$204.00

$939.00

$1,101.00

$747.00

$567.00

$576.00

$1,910.00

$752.00

$1,282.00

$1,800.00

$1,636.00

$1,944.00

$1,677.00

$1,780.00

$1,226.00

$1,161.00

$889.00

$1,165.00

$953.00

$1,358.00

$4,269.00

$6,161.00

$1,112.00

$1,284.00

$1,387.00

$1,966.00

$2,062.00

$2,075.00

$2,326.00

$2,269.00

$2,567.00

$2,459.00

$2,949.00

$3,072.00

$591.00

$1,561.00

$3,915.00

$2,633.00

$2,953.00

$2,728.00

$2,575.00

$2,451.00

$2,820.00

$1,177.00

$2,911.00

$2,907.00

--------

--------

$1,571.00

$1,228.00

$217.00

$1,002.00

$1,171.00

$796.00

$604.00

$614.00

$2,027.00

$802.00

$1,358.00

$1,907.00

$1,740.00

$2,062.00

$1,784.00

$1,882.00

$1,300.00

$1,232.00

$941.00

$1,242.00

$1,009.00

$1,446.00

$4,568.00

$6,597.00

$1,193.00

$1,352.00

$1,464.00

$2,088.00

$2,192.00

$2,200.00

$2,475.00

$2,398.00

$2,724.00

$2,601.00

$3,119.00

$3,270.00

$615.00

$1,651.00

$4,142.00

$2,784.00

$3,119.00

$2,882.00

$2,717.00

$2,582.00

$2,973.00

$1,238.00

$3,080.00

$3,075.00

--------

--------

$1,631.00

$1,271.00

$221.00

$1,037.00

$1,224.00

$830.00

$627.00

$638.00

$2,134.00

$835.00

$1,435.00

$2,020.00

$1,836.00

$2,192.00

$1,883.00

$1,994.00

$1,372.00

$1,300.00

$991.00

$1,296.00

$1,057.00

$1,523.00

$4,647.00

$6,697.00

$1,287.00

$1,409.00

$1,545.00

$2,216.00

$2,329.00

$2,334.00

$2,647.00

$2,540.00

$2,897.00

$2,750.00

$3,280.00

$3,500.00

$371.00

$1,244.00

$3,126.00

$2,080.00

$2,315.00

$2,130.00

$1,995.00

$1,851.00

$2,148.00

$842.00

$2,316.00

$2,311.00

--------

--------

$731.00

$971.00

$65.00

$750.00

$926.00

$609.00

$430.00

$426.00

$1,697.00

$610.00

$1,282.00

$1,800.00

$1,636.00

$1,944.00

$1,677.00

$1,780.00

$1,226.00

$1,161.00

$889.00

$981.00

$953.00

$1,358.00

$1,147.00

$1,311.00

$1,112.00

$1,284.00

$1,387.00

$1,966.00

$2,062.00

$2,075.00

$2,326.00

$2,269.00

$2,567.00

$2,459.00

$2,949.00

$3,072.00

$394.00

$1,321.00

$3,318.00

$2,208.00

$2,456.00

$2,261.00

$2,119.00

$1,966.00

$2,281.00

$894.00

$2,459.00

$2,453.00

--------

--------

$790.00

$1,036.00

$68.00

$800.00

$983.00

$648.00

$458.00

$454.00

$1,798.00

$649.00

$1,358.00

$1,907.00

$1,740.00

$2,062.00

$1,784.00

$1,882.00

$1,300.00

$1,232.00

$941.00

$1,044.00

$1,009.00

$1,446.00

$1,218.00

$1,394.00

$1,193.00

$1,352.00

$1,464.00

$2,088.00

$2,192.00

$2,200.00

$2,475.00

$2,398.00

$2,724.00

$2,601.00

$3,119.00

$3,270.00

$417.00

$1,411.00

$3,544.00

$2,358.00

$2,621.00

$2,414.00

$2,259.00

$2,096.00

$2,433.00

$954.00

$2,626.00

$2,620.00

--------

--------

$848.00

$1,077.00

$72.00

$835.00

$1,035.00

$682.00

$480.00

$477.00

$1,904.00

$683.00

$1,435.00

$2,020.00

$1,836.00

$2,192.00

$1,883.00

$1,994.00

$1,372.00

$1,300.00

$991.00

$1,098.00

$1,057.00

$1,523.00

$1,287.00

$1,478.00

$1,287.00

$1,409.00

$1,545.00

$2,216.00

$2,329.00

$2,334.00

$2,647.00

$2,540.00

$2,897.00

$2,750.00

$3,280.00

$3,500.00


Part B, 173



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

21230

21235

21240

21242

21243

21244

21245

21246

21247

21248

21196

21198

21199

21206

21208

21209

21210

21215

21155

21159

21160

21172

21175

21179

21180

21181

21182

21183

21184

21188

21193

21194

21195

21270

21275

21280

21282

21295

21296

21299

21310

21315

21249

21255

21256

21260

21261

21263

21267

21268

90 $2,640.00

90 $3,302.00

90 $3,500.00

90 $2,111.00

90 $2,604.00

90 $1,826.00

90 $2,035.00

90 $813.00

90 $2,570.00

90 $2,770.00

90 $3,150.00

90 $1,786.00

90 $1,331.00

90 $1,540.00

90 $1,360.00

90 $1,764.00

90 $1,268.00

90 $1,018.00

90 $1,112.00

90 $946.00

90

90

90

$576.00

$930.00

$970.00

90

90

$956.00

$707.00

90 $1,281.00

90 $1,207.00

90 $1,501.00

90 $1,062.00

90 $1,038.00

90 $1,010.00

90 $2,003.00

90 $1,023.00

90

90

90

90

90

90

YYY

0

10

90 $1,525.00

90 $1,459.00

90 $1,470.00

90 $1,372.00

90 $2,347.00

90 $2,361.00

90 $1,539.00

90 $1,946.00

$890.00

$963.00

$571.00

$360.00

$144.00

$384.00

BR

$81.00

$180.00

$2,170.00

$1,708.00

$1,577.00

$1,716.00

$2,674.00

$1,161.00

$3,238.00

$5,706.00

$1,042.00

$1,038.00

$1,648.00

$1,509.00

$2,498.00

$1,553.00

$1,601.00

$1,277.00

$2,276.00

$1,613.00

$3,149.00

$3,674.00

$4,658.00

$2,608.00

$3,125.00

$2,094.00

$2,260.00

$1,075.00

$2,858.00

$3,391.00

$3,139.00

$2,363.00

$1,783.00

$2,108.00

$1,954.00

$2,218.00

$2,026.00

$1,734.00

$2,021.00

$3,079.00

$2,842.00

$2,241.00

$2,536.00

$1,366.00

$1,217.00

$807.00

$541.00

$258.00

$621.00

--------

$184.00

$391.00

$2,303.00

$1,813.00

$1,675.00

$1,823.00

$2,854.00

$1,234.00

$3,461.00

$6,109.00

$1,102.00

$1,104.00

$1,751.00

$1,603.00

$2,654.00

$1,649.00

$1,699.00

$1,354.00

$2,408.00

$1,717.00

$3,308.00

$3,874.00

$4,949.00

$2,726.00

$3,292.00

$2,194.00

$2,385.00

$1,143.00

$3,026.00

$3,601.00

$3,308.00

$2,509.00

$1,890.00

$2,235.00

$2,068.00

$2,360.00

$2,153.00

$1,823.00

$2,147.00

$3,250.00

$3,000.00

$2,353.00

$2,678.00

$1,444.00

$1,294.00

$850.00

$573.00

$274.00

$659.00

--------

$196.00

$416.00

$2,434.00

$1,913.00

$1,787.00

$1,924.00

$2,927.00

$1,281.00

$3,546.00

$6,205.00

$1,165.00

$1,150.00

$1,859.00

$1,702.00

$2,820.00

$1,735.00

$1,775.00

$1,437.00

$2,551.00

$1,803.00

$3,460.00

$4,106.00

$5,268.00

$2,809.00

$3,455.00

$2,272.00

$2,522.00

$1,213.00

$3,229.00

$3,841.00

$3,516.00

$2,662.00

$2,009.00

$2,373.00

$2,176.00

$2,487.00

$2,274.00

$1,896.00

$2,265.00

$3,434.00

$3,168.00

$2,420.00

$2,825.00

$1,490.00

$1,373.00

$879.00

$594.00

$285.00

$688.00

--------

$200.00

$428.00

$2,170.00

$1,708.00

$1,577.00

$1,716.00

$1,220.00

$895.00

$1,272.00

$1,323.00

$1,042.00

$823.00

$1,648.00

$1,509.00

$2,498.00

$1,553.00

$1,294.00

$1,277.00

$2,276.00

$1,334.00

$3,149.00

$3,674.00

$4,658.00

$2,608.00

$3,125.00

$2,094.00

$2,260.00

$1,075.00

$2,858.00

$3,391.00

$3,139.00

$2,363.00

$1,783.00

$2,108.00

$1,954.00

$1,900.00

$2,026.00

$1,734.00

$2,021.00

$3,079.00

$2,842.00

$2,241.00

$2,536.00

$1,037.00

$1,217.00

$807.00

$541.00

$258.00

$621.00

--------

$40.00

$219.00

$2,303.00

$1,813.00

$1,675.00

$1,823.00

$1,293.00

$949.00

$1,352.00

$1,406.00

$1,102.00

$873.00

$1,751.00

$1,603.00

$2,654.00

$1,649.00

$1,370.00

$1,354.00

$2,408.00

$1,417.00

$3,308.00

$3,874.00

$4,949.00

$2,726.00

$3,292.00

$2,194.00

$2,385.00

$1,143.00

$3,026.00

$3,601.00

$3,308.00

$2,509.00

$1,890.00

$2,235.00

$2,068.00

$2,019.00

$2,153.00

$1,823.00

$2,147.00

$3,250.00

$3,000.00

$2,353.00

$2,678.00

$1,091.00

$1,294.00

$850.00

$573.00

$274.00

$659.00

--------

$42.00

$232.00

$2,434.00

$1,913.00

$1,787.00

$1,924.00

$1,362.00

$995.00

$1,431.00

$1,489.00

$1,165.00

$918.00

$1,859.00

$1,702.00

$2,820.00

$1,735.00

$1,445.00

$1,437.00

$2,551.00

$1,502.00

$3,460.00

$4,106.00

$5,268.00

$2,809.00

$3,455.00

$2,272.00

$2,522.00

$1,213.00

$3,229.00

$3,841.00

$3,516.00

$2,662.00

$2,009.00

$2,373.00

$2,176.00

$2,145.00

$2,274.00

$1,896.00

$2,265.00

$3,434.00

$3,168.00

$2,420.00

$2,825.00

$1,136.00

$1,373.00

$879.00

$594.00

$285.00

$688.00

--------

$45.00

$243.00


Part B, 174



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

21390

21395

21400

21401

21406

21407

21408

21421

21422

21423

21355

21356

21360

21365

21366

21385

21386

21387

21320

21325

21330

21335

21336

21337

21338

21339

21340

21343

21344

21345

21346

21347

21348

21451

21452

21453

21454

21461

21462

21465

21470

21480

21431

21432

21433

21435

21436

21440

21445

21450

10

90

90

90

90

90

90

$235.00

$348.00

$639.00

$852.00

$478.00

$300.00

$550.00

90

90

$689.00

$907.00

90 $1,043.00

90 $1,450.00

90 $738.00

90 $917.00

90 $1,048.00

90 $1,286.00

10

10

$295.00

$372.00

90 $590.00

90 $1,239.00

90 $1,386.00

90

90

90

$810.00

$812.00

$958.00

90 $920.00

90 $1,384.00

90

90

90

$143.00

$313.00

$852.00

90 $736.00

90 $1,007.00

90

90

90

$528.00

$761.00

$890.00

90

90

$598.00

$744.00

90 $1,981.00

90 $1,404.00

90 $2,045.00

90

90

90

$308.00

$533.00

$325.00

90

90

90

$498.00

$195.00

$902.00

90

90

$905.00

$769.00

90 $1,012.00

90 $923.00

90 $1,331.00

0 $82.00

$614.00

$717.00

$782.00

$1,627.00

$1,693.00

$988.00

$1,009.00

$1,035.00

$1,149.00

$1,461.00

$273.00

$628.00

$754.00

$935.00

$1,276.00

$1,080.00

$979.00

$1,190.00

$363.00

$676.00

$813.00

$1,050.00

$924.00

$574.00

$1,035.00

$1,105.00

$1,096.00

$1,740.00

$2,037.00

$1,164.00

$1,314.00

$1,644.00

$1,762.00

$1,066.00

$952.00

$2,536.00

$1,847.00

$3,096.00

$822.00

$1,106.00

$882.00

$1,091.00

$843.00

$1,306.00

$863.00

$3,021.00

$3,212.00

$1,401.00

$1,767.00

$139.00

$652.00

$763.00

$830.00

$1,725.00

$1,790.00

$1,045.00

$1,072.00

$1,096.00

$1,214.00

$1,551.00

$291.00

$669.00

$799.00

$990.00

$1,354.00

$1,152.00

$1,040.00

$1,264.00

$387.00

$720.00

$865.00

$1,114.00

$982.00

$612.00

$1,104.00

$1,172.00

$1,156.00

$1,852.00

$2,155.00

$1,236.00

$1,393.00

$1,749.00

$1,871.00

$1,135.00

$1,010.00

$2,691.00

$1,953.00

$3,330.00

$879.00

$1,180.00

$942.00

$1,164.00

$901.00

$1,393.00

$918.00

$3,230.00

$3,433.00

$1,489.00

$1,876.00

$148.00

$678.00

$795.00

$875.00

$1,830.00

$1,898.00

$1,097.00

$1,136.00

$1,154.00

$1,274.00

$1,646.00

$301.00

$693.00

$842.00

$1,041.00

$1,438.00

$1,195.00

$1,096.00

$1,336.00

$398.00

$747.00

$901.00

$1,168.00

$1,023.00

$634.00

$1,153.00

$1,220.00

$1,216.00

$1,948.00

$2,279.00

$1,291.00

$1,458.00

$1,842.00

$1,990.00

$1,186.00

$1,063.00

$2,863.00

$2,068.00

$3,636.00

$903.00

$1,224.00

$968.00

$1,203.00

$918.00

$1,439.00

$968.00

$3,296.00

$3,511.00

$1,577.00

$1,990.00

$152.00

$466.00

$549.00

$782.00

$1,627.00

$1,693.00

$988.00

$1,009.00

$1,035.00

$1,149.00

$1,461.00

$223.00

$415.00

$754.00

$935.00

$1,276.00

$917.00

$979.00

$1,190.00

$196.00

$676.00

$813.00

$1,050.00

$924.00

$425.00

$1,035.00

$1,105.00

$1,096.00

$1,740.00

$2,037.00

$950.00

$1,314.00

$1,644.00

$1,762.00

$1,066.00

$952.00

$2,536.00

$1,847.00

$3,096.00

$671.00

$907.00

$710.00

$921.00

$502.00

$1,125.00

$863.00

$1,357.00

$1,516.00

$1,401.00

$1,767.00

$47.00

$493.00

$583.00

$830.00

$1,725.00

$1,790.00

$1,045.00

$1,072.00

$1,096.00

$1,214.00

$1,551.00

$238.00

$440.00

$799.00

$990.00

$1,354.00

$977.00

$1,040.00

$1,264.00

$208.00

$720.00

$865.00

$1,114.00

$982.00

$452.00

$1,104.00

$1,172.00

$1,156.00

$1,852.00

$2,155.00

$1,006.00

$1,393.00

$1,749.00

$1,871.00

$1,135.00

$1,010.00

$2,691.00

$1,953.00

$3,330.00

$716.00

$966.00

$758.00

$982.00

$536.00

$1,199.00

$918.00

$1,445.00

$1,614.00

$1,489.00

$1,876.00

$50.00

$519.00

$614.00

$875.00

$1,830.00

$1,898.00

$1,097.00

$1,136.00

$1,154.00

$1,274.00

$1,646.00

$248.00

$463.00

$842.00

$1,041.00

$1,438.00

$1,019.00

$1,096.00

$1,336.00

$219.00

$747.00

$901.00

$1,168.00

$1,023.00

$473.00

$1,153.00

$1,220.00

$1,216.00

$1,948.00

$2,279.00

$1,060.00

$1,458.00

$1,842.00

$1,990.00

$1,186.00

$1,063.00

$2,863.00

$2,068.00

$3,636.00

$740.00

$1,010.00

$783.00

$1,021.00

$551.00

$1,244.00

$968.00

$1,506.00

$1,687.00

$1,577.00

$1,990.00

$53.00


Part B, 175



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

21685

21700

21705

21720

21725

21740

21742

21743

21750

21811

21600

21610

21615

21616

21620

21627

21630

21632

21485

21490

21495

21497

21499

21501

21502

21510

21550

21552

21554

21555

21556

21557

21558

21931

21932

21933

21935

21936

22010

22015

22100

22101

21812

21813

21820

21825

21899

21920

21925

21930

90

10

90

90

90

90

90

90

90

90

90

90

YYY

90

90

90

90

$631.00

$828.00

90 $938.00

90 $1,042.00

90 $689.00

90 $686.00

90 $1,455.00

90 $1,514.00

90

90

90

90

90

--------

$576.00

$746.00

$523.00

$588.00

90 $1,387.00

90 BR

90 BR

90 $1,009.00

0 --------

$318.00

$865.00

$500.00

$372.00

BR

$315.00

$612.00

$534.00

$165.00

--------

--------

$337.00

$431.00

$794.00

--------

0

0

90

90

YYY

10

90

90

--------

--------

$143.00

$810.00

BR

$165.00

$371.00

$403.00

90

90

90

--------

--------

--------

90 $1,280.00

90 --------

90

90

--------

--------

90

90

$850.00

$862.00

$816.00

$1,815.00

$926.00

$1,120.00

$744.00

$793.00

$1,794.00

$1,803.00

$1,463.00

$555.00

$831.00

$662.00

$785.00

$1,527.00

--------

--------

$1,023.00

$919.00

$1,003.00

$1,340.00

$1,012.00

$1,048.00

--------

$648.00

$786.00

$661.00

$372.00

$659.00

$1,082.00

$595.00

$777.00

$1,414.00

$1,996.00

$1,102.00

$1,438.00

$200.00

$799.00

--------

$364.00

$641.00

$680.00

$694.00

$979.00

$1,092.00

$1,518.00

$2,095.00

$1,416.00

$1,369.00

$1,301.00

$1,262.00

$873.00

$1,986.00

$992.00

$1,196.00

$795.00

$849.00

$1,915.00

$1,930.00

$1,548.00

$593.00

$890.00

$707.00

$845.00

$1,631.00

--------

--------

$1,096.00

$984.00

$1,071.00

$1,425.00

$1,076.00

$1,119.00

--------

$692.00

$843.00

$710.00

$396.00

$706.00

$1,156.00

$636.00

$828.00

$1,508.00

$2,130.00

$1,181.00

$1,538.00

$214.00

$856.00

--------

$388.00

$686.00

$728.00

$744.00

$1,049.00

$1,169.00

$1,624.00

$2,241.00

$1,528.00

$1,473.00

$1,410.00

$1,360.00

$934.00

$2,235.00

$1,086.00

$1,299.00

$858.00

$912.00

$2,072.00

$2,104.00

$1,636.00

$647.00

$980.00

$756.00

$921.00

$1,779.00

--------

--------

$1,199.00

$1,082.00

$1,104.00

$1,512.00

$1,116.00

$1,152.00

--------

$724.00

$914.00

$769.00

$409.00

$763.00

$1,249.00

$669.00

$886.00

$1,624.00

$2,304.00

$1,299.00

$1,691.00

$223.00

$925.00

--------

$401.00

$724.00

$770.00

$806.00

$1,138.00

$1,269.00

$1,760.00

$2,435.00

$1,670.00

$1,605.00

$1,549.00

$1,481.00

$816.00

$1,815.00

$926.00

$1,120.00

$744.00

$793.00

$1,794.00

$1,803.00

$1,463.00

$555.00

$831.00

$662.00

$785.00

$1,527.00

--------

--------

$1,023.00

$919.00

$843.00

$1,340.00

$1,012.00

$876.00

--------

$468.00

$786.00

$661.00

$229.00

$659.00

$1,082.00

$447.00

$777.00

$1,414.00

$1,996.00

$1,102.00

$1,438.00

$205.00

$799.00

--------

$232.00

$517.00

$535.00

$694.00

$979.00

$1,092.00

$1,518.00

$2,095.00

$1,416.00

$1,369.00

$1,301.00

$1,262.00

$873.00

$1,986.00

$992.00

$1,196.00

$795.00

$849.00

$1,915.00

$1,930.00

$1,548.00

$593.00

$890.00

$707.00

$845.00

$1,631.00

--------

--------

$1,096.00

$984.00

$899.00

$1,425.00

$1,076.00

$935.00

--------

$500.00

$843.00

$710.00

$243.00

$706.00

$1,156.00

$478.00

$828.00

$1,508.00

$2,130.00

$1,181.00

$1,538.00

$219.00

$856.00

--------

$247.00

$553.00

$572.00

$744.00

$1,049.00

$1,169.00

$1,624.00

$2,241.00

$1,528.00

$1,473.00

$1,410.00

$1,360.00

$934.00

$2,235.00

$1,086.00

$1,299.00

$858.00

$912.00

$2,072.00

$2,104.00

$1,636.00

$647.00

$980.00

$756.00

$921.00

$1,779.00

--------

--------

$1,199.00

$1,082.00

$933.00

$1,512.00

$1,116.00

$968.00

--------

$531.00

$914.00

$769.00

$255.00

$763.00

$1,249.00

$510.00

$886.00

$1,624.00

$2,304.00

$1,299.00

$1,691.00

$229.00

$925.00

--------

$260.00

$591.00

$613.00

$806.00

$1,138.00

$1,269.00

$1,760.00

$2,435.00

$1,670.00

$1,605.00

$1,549.00

$1,481.00


Part B, 176



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

22326

22327

22328

22505

22510

22511

22512

22513

22514

22515

22224

22226

22305

22310

22315

22318

22319

22325

22102

22103

22110

22112

22114

22116

22206

22207

22208

22210

22212

22214

22216

22220

22222

22554

22556

22558

22585

22586

22590

22595

22600

22610

22526

22527

22532

22533

22534

22548

22551

22552

90 $781.00

ZZZ $198.00

90 $889.00

90 $1,090.00

90 $1,062.00

ZZZ $195.00

90 --------

90

ZZZ

--------

--------

90 $1,892.00

90 $1,668.00

90 $819.00

ZZZ $492.00

90 $1,801.00

90 $1,604.00

90 $1,731.00

ZZZ $488.00

90

90

90

$213.00

$272.00

$711.00

90 $1,755.00

90 $1,983.00

90 $1,407.00

10

ZZZ

10

10

ZZZ

90 $1,710.00

90 $1,660.00

ZZZ $391.00

10 $174.00

10 --------

--------

--------

--------

--------

--------

10

ZZZ

90

--------

--------

--------

90

ZZZ

--------

--------

90 $2,271.00

90 --------

ZZZ --------

90 $1,727.00

90 $2,054.00

90 $1,907.00

ZZZ $473.00

90 --------

90 $1,895.00

90 $1,960.00

90 $1,567.00

90 $1,494.00

$2,353.00

$550.00

$274.00

$447.00

$1,290.00

$2,508.00

$2,796.00

$2,157.00

$2,255.00

$2,261.00

$433.00

$187.00

$2,459.00

$2,432.00

$1,364.00

$10,089.00

$10,073.00

$6,095.00

$1,160.00

$211.00

$1,568.00

$1,455.00

$1,460.00

$217.00

$3,677.00

$3,596.00

$884.00

$2,684.00

$2,207.00

$2,215.00

$551.00

$2,389.00

$2,297.00

$3,291.00

$2,722.00

$2,684.00

$2,463.00

$548.00

$3,037.00

$2,602.00

$615.00

$1,892.00

$2,511.00

$2,309.00

$503.00

$2,698.00

$2,403.00

$2,290.00

$1,944.00

$1,898.00

$2,526.00

$593.00

$292.00

$478.00

$1,387.00

$2,740.00

$3,063.00

$2,334.00

$2,450.00

$2,450.00

$470.00

$200.00

$2,623.00

$2,596.00

$1,457.00

$10,819.00

$10,802.00

$6,538.00

$1,239.00

$228.00

$1,698.00

$1,555.00

$1,560.00

$235.00

$3,969.00

$3,874.00

$953.00

$2,904.00

$2,375.00

$2,385.00

$593.00

$2,575.00

$2,453.00

$3,521.00

$2,915.00

$2,905.00

$2,642.00

$591.00

$3,332.00

$2,825.00

$668.00

$2,049.00

$2,713.00

$2,484.00

$543.00

$2,883.00

$2,618.00

$2,493.00

$2,111.00

$2,055.00

$2,747.00

$656.00

$308.00

$510.00

$1,489.00

$3,080.00

$3,462.00

$2,570.00

$2,724.00

$2,708.00

$527.00

$214.00

$2,668.00

$2,638.00

$1,484.00

$10,915.00

$10,893.00

$6,589.00

$1,330.00

$251.00

$1,871.00

$1,670.00

$1,674.00

$262.00

$4,380.00

$4,261.00

$1,056.00

$3,204.00

$2,592.00

$2,604.00

$656.00

$2,822.00

$2,643.00

$3,563.00

$2,939.00

$3,212.00

$2,875.00

$655.00

$3,773.00

$3,147.00

$750.00

$2,265.00

$2,995.00

$2,723.00

$603.00

$3,118.00

$2,924.00

$2,781.00

$2,338.00

$2,264.00

$2,353.00

$550.00

$250.00

$414.00

$1,139.00

$2,508.00

$2,796.00

$2,157.00

$2,255.00

$2,261.00

$433.00

$187.00

$664.00

$623.00

$312.00

$800.00

$745.00

$340.00

$1,160.00

$211.00

$1,568.00

$1,455.00

$1,460.00

$217.00

$3,677.00

$3,596.00

$884.00

$2,684.00

$2,207.00

$2,215.00

$551.00

$2,389.00

$2,297.00

$514.00

$235.00

$2,684.00

$2,463.00

$548.00

$3,037.00

$2,602.00

$615.00

$1,892.00

$2,511.00

$2,309.00

$503.00

$2,698.00

$2,403.00

$2,290.00

$1,944.00

$1,898.00

$2,526.00

$593.00

$267.00

$443.00

$1,224.00

$2,740.00

$3,063.00

$2,334.00

$2,450.00

$2,450.00

$470.00

$200.00

$698.00

$655.00

$329.00

$852.00

$793.00

$363.00

$1,239.00

$228.00

$1,698.00

$1,555.00

$1,560.00

$235.00

$3,969.00

$3,874.00

$953.00

$2,904.00

$2,375.00

$2,385.00

$593.00

$2,575.00

$2,453.00

$541.00

$247.00

$2,905.00

$2,642.00

$591.00

$3,332.00

$2,825.00

$668.00

$2,049.00

$2,713.00

$2,484.00

$543.00

$2,883.00

$2,618.00

$2,493.00

$2,111.00

$2,055.00

$2,747.00

$656.00

$283.00

$475.00

$1,326.00

$3,080.00

$3,462.00

$2,570.00

$2,724.00

$2,708.00

$527.00

$214.00

$737.00

$692.00

$352.00

$919.00

$855.00

$396.00

$1,330.00

$251.00

$1,871.00

$1,670.00

$1,674.00

$262.00

$4,380.00

$4,261.00

$1,056.00

$3,204.00

$2,592.00

$2,604.00

$656.00

$2,822.00

$2,643.00

$574.00

$263.00

$3,212.00

$2,875.00

$655.00

$3,773.00

$3,147.00

$750.00

$2,265.00

$2,995.00

$2,723.00

$603.00

$3,118.00

$2,924.00

$2,781.00

$2,338.00

$2,264.00


Part B, 177



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

22848

22849

22850

22851

22852

22855

22856

22857

22858

22861

22840

22841

22842

22843

22844

22845

22846

22847

22612

22614

22630

22632

22633

22634

22800

22802

22804

22808

22810

22812

22818

22819

22830

22904

22905

22999

23000

23020

23030

23031

23035

23040

22862

22864

22865

22899

22900

22901

22902

22903

90

90

YYY

90

90

10

10

90

90

90

90

90

YYY

90

90

90

90

90 $1,861.00

ZZZ $530.00

90 $1,201.00

ZZZ $442.00

90

ZZZ

--------

--------

90 $1,960.00

90 $2,633.00

90 $2,951.00

90 $2,157.00

90 $2,356.00

90 $2,675.00

90 $2,701.00

90 $2,968.00

90 $1,176.00

ZZZ $943.00

0 BR

ZZZ $2,352.00

ZZZ $1,028.00

ZZZ $1,277.00

ZZZ $1,853.00

ZZZ $999.00

ZZZ $1,077.00

ZZZ $529.00

90 $2,235.00

90 $872.00

ZZZ $600.00

90 $854.00

90 $1,193.00

90 --------

90

ZZZ

90

--------

--------

--------

--------

--------

--------

BR

$446.00

--------

--------

--------

--------

--------

BR

$447.00

$807.00

$323.00

$185.00

$861.00

$898.00

$1,164.00

--------

$1,167.00

$1,246.00

$1,493.00

$1,124.00

$1,168.00

$1,258.00

$546.00

$1,955.00

$1,080.00

$624.00

$1,034.00

$1,670.00

$2,450.00

$2,994.00

$772.00

$3,004.00

$2,387.00

$599.00

$2,374.00

$494.00

$2,799.00

$761.00

$2,016.00

$3,138.00

$3,634.00

$2,764.00

$3,050.00

$3,675.00

$3,223.00

$4,270.00

$1,213.00

$3,041.00

$3,162.00

$3,035.00

--------

$834.00

$985.00

$631.00

$649.00

$1,557.00

$1,978.00

--------

$828.00

$1,003.00

$625.00

$599.00

$986.00

$1,049.00

$1,260.00

--------

$1,263.00

$1,348.00

$1,607.00

$1,221.00

$1,268.00

$1,355.00

$588.00

$2,111.00

$1,165.00

$676.00

$1,115.00

$1,808.00

$2,650.00

$3,273.00

$838.00

$3,206.00

$2,574.00

$649.00

$2,578.00

$537.00

$3,027.00

$824.00

$2,169.00

$3,371.00

$3,906.00

$2,984.00

$3,284.00

$4,019.00

$3,441.00

$4,687.00

$1,308.00

$3,304.00

$3,458.00

$3,240.00

--------

$894.00

$1,055.00

$677.00

$695.00

$1,667.00

$2,117.00

--------

$885.00

$1,070.00

$669.00

$641.00

$1,052.00

$1,120.00

$1,405.00

--------

$1,409.00

$1,502.00

$1,774.00

$1,370.00

$1,422.00

$1,499.00

$649.00

$2,325.00

$1,275.00

$755.00

$1,218.00

$1,998.00

$2,932.00

$3,685.00

$940.00

$3,475.00

$2,830.00

$724.00

$2,866.00

$603.00

$3,347.00

$920.00

$2,367.00

$3,684.00

$4,278.00

$3,289.00

$3,610.00

$4,534.00

$3,721.00

$5,329.00

$1,431.00

$3,718.00

$3,903.00

$3,498.00

--------

$969.00

$1,146.00

$717.00

$754.00

$1,813.00

$2,306.00

--------

$921.00

$1,143.00

$698.00

$663.00

$1,124.00

$1,197.00

$1,164.00

--------

$1,167.00

$1,246.00

$1,493.00

$1,124.00

$1,168.00

$1,258.00

$546.00

$1,955.00

$1,080.00

$624.00

$1,034.00

$1,670.00

$2,450.00

$2,994.00

$772.00

$3,004.00

$2,387.00

$599.00

$2,374.00

$494.00

$2,799.00

$761.00

$2,016.00

$3,138.00

$3,634.00

$2,764.00

$3,050.00

$3,675.00

$3,223.00

$4,270.00

$1,213.00

$3,041.00

$3,162.00

$3,035.00

--------

$834.00

$985.00

$486.00

$649.00

$1,557.00

$1,978.00

--------

$537.00

$1,003.00

$374.00

$318.00

$986.00

$1,049.00

$1,260.00

--------

$1,263.00

$1,348.00

$1,607.00

$1,221.00

$1,268.00

$1,355.00

$588.00

$2,111.00

$1,165.00

$676.00

$1,115.00

$1,808.00

$2,650.00

$3,273.00

$838.00

$3,206.00

$2,574.00

$649.00

$2,578.00

$537.00

$3,027.00

$824.00

$2,169.00

$3,371.00

$3,906.00

$2,984.00

$3,284.00

$4,019.00

$3,441.00

$4,687.00

$1,308.00

$3,304.00

$3,458.00

$3,240.00

--------

$894.00

$1,055.00

$521.00

$695.00

$1,667.00

$2,117.00

--------

$573.00

$1,070.00

$399.00

$340.00

$1,052.00

$1,120.00

$1,405.00

--------

$1,409.00

$1,502.00

$1,774.00

$1,370.00

$1,422.00

$1,499.00

$649.00

$2,325.00

$1,275.00

$755.00

$1,218.00

$1,998.00

$2,932.00

$3,685.00

$940.00

$3,475.00

$2,830.00

$724.00

$2,866.00

$603.00

$3,347.00

$920.00

$2,367.00

$3,684.00

$4,278.00

$3,289.00

$3,610.00

$4,534.00

$3,721.00

$5,329.00

$1,431.00

$3,718.00

$3,903.00

$3,498.00

--------

$969.00

$1,146.00

$560.00

$754.00

$1,813.00

$2,306.00

--------

$608.00

$1,143.00

$427.00

$361.00

$1,124.00

$1,197.00


Part B, 178



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

23170

23172

23174

23180

23182

23184

23190

23195

23200

23210

23125

23130

23140

23145

23146

23150

23155

23156

23044

23065

23066

23071

23073

23075

23076

23077

23078

23100

23101

23105

23106

23107

23120

23400

23405

23406

23410

23412

23415

23420

23430

23440

23220

23330

23333

23334

23335

23350

23395

23397

90

10

90

90

90

90

90

$708.00

$171.00

$302.00

--------

--------

$247.00

$613.00

90 $1,228.00

90 --------

90

90

90

$616.00

$583.00

$814.00

90

90

90

$581.00

$851.00

$645.00

90

90

90

90

90

90

90

90

$865.00

$722.00

$597.00

$889.00

$704.00

$755.00

$945.00

$794.00

90

90

90

90

90

$645.00

$638.00

$882.00

$566.00

$865.00

90

90

$962.00

$656.00

90 $902.00

90 $1,095.00

90 $1,095.00

90 $1,307.00

10 $59.00

90 --------

90

90

--------

--------

0 $74.00

90 $1,366.00

90 $1,403.00

90 $1,196.00

90 $799.00

90 $977.00

90 $1,119.00

90 $1,229.00

90 $622.00

90 $1,276.00

90

90

$884.00

$906.00

$1,035.00

$886.00

$778.00

$1,014.00

$902.00

$955.00

$1,159.00

$985.00

$808.00

$822.00

$1,092.00

$973.00

$947.00

$1,070.00

$827.00

$1,099.00

$2,197.00

$2,615.00

$830.00

$310.00

$788.00

$618.00

$1,022.00

$669.00

$792.00

$1,694.00

$2,125.00

$723.00

$660.00

$928.00

$714.00

$959.00

$847.00

$2,861.00

$337.00

$656.00

$1,579.00

$1,881.00

$182.00

$1,882.00

$1,674.00

$1,424.00

$910.00

$1,120.00

$1,200.00

$1,245.00

$1,015.00

$1,416.00

$1,087.00

$1,103.00

$1,106.00

$947.00

$831.00

$1,084.00

$962.00

$1,018.00

$1,238.00

$1,051.00

$863.00

$878.00

$1,165.00

$1,040.00

$1,011.00

$1,142.00

$882.00

$1,173.00

$2,349.00

$2,790.00

$886.00

$329.00

$844.00

$662.00

$1,093.00

$717.00

$847.00

$1,812.00

$2,271.00

$772.00

$706.00

$990.00

$763.00

$1,023.00

$904.00

$3,050.00

$359.00

$698.00

$1,685.00

$2,008.00

$193.00

$2,007.00

$1,787.00

$1,520.00

$970.00

$1,192.00

$1,281.00

$1,329.00

$1,084.00

$1,511.00

$1,159.00

$1,177.00

$1,185.00

$1,010.00

$889.00

$1,160.00

$1,027.00

$1,085.00

$1,326.00

$1,122.00

$922.00

$935.00

$1,244.00

$1,115.00

$1,077.00

$1,221.00

$942.00

$1,256.00

$2,542.00

$3,008.00

$949.00

$344.00

$880.00

$715.00

$1,180.00

$754.00

$911.00

$1,963.00

$2,461.00

$822.00

$753.00

$1,057.00

$813.00

$1,091.00

$962.00

$3,284.00

$372.00

$741.00

$1,808.00

$2,158.00

$197.00

$2,151.00

$1,921.00

$1,633.00

$1,035.00

$1,271.00

$1,371.00

$1,422.00

$1,159.00

$1,618.00

$1,237.00

$1,259.00

$1,035.00

$886.00

$778.00

$1,014.00

$902.00

$955.00

$1,159.00

$985.00

$808.00

$822.00

$1,092.00

$973.00

$947.00

$1,070.00

$827.00

$1,099.00

$2,197.00

$2,615.00

$830.00

$243.00

$517.00

$618.00

$1,022.00

$477.00

$792.00

$1,694.00

$2,125.00

$723.00

$660.00

$928.00

$714.00

$959.00

$847.00

$2,861.00

$217.00

$656.00

$1,579.00

$1,881.00

$74.00

$1,882.00

$1,674.00

$1,424.00

$910.00

$1,120.00

$1,200.00

$1,245.00

$1,015.00

$1,416.00

$1,087.00

$1,103.00

$1,106.00

$947.00

$831.00

$1,084.00

$962.00

$1,018.00

$1,238.00

$1,051.00

$863.00

$878.00

$1,165.00

$1,040.00

$1,011.00

$1,142.00

$882.00

$1,173.00

$2,349.00

$2,790.00

$886.00

$258.00

$553.00

$662.00

$1,093.00

$510.00

$847.00

$1,812.00

$2,271.00

$772.00

$706.00

$990.00

$763.00

$1,023.00

$904.00

$3,050.00

$231.00

$698.00

$1,685.00

$2,008.00

$77.00

$2,007.00

$1,787.00

$1,520.00

$970.00

$1,192.00

$1,281.00

$1,329.00

$1,084.00

$1,511.00

$1,159.00

$1,177.00

$1,185.00

$1,010.00

$889.00

$1,160.00

$1,027.00

$1,085.00

$1,326.00

$1,122.00

$922.00

$935.00

$1,244.00

$1,115.00

$1,077.00

$1,221.00

$942.00

$1,256.00

$2,542.00

$3,008.00

$949.00

$273.00

$589.00

$715.00

$1,180.00

$546.00

$911.00

$1,963.00

$2,461.00

$822.00

$753.00

$1,057.00

$813.00

$1,091.00

$962.00

$3,284.00

$243.00

$741.00

$1,808.00

$2,158.00

$81.00

$2,151.00

$1,921.00

$1,633.00

$1,035.00

$1,271.00

$1,371.00

$1,422.00

$1,159.00

$1,618.00

$1,237.00

$1,259.00


Part B, 179



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

23550

23552

23570

23575

23585

23600

23605

23615

23616

23620

23505

23515

23520

23525

23530

23532

23540

23545

23450

23455

23460

23462

23465

23466

23470

23472

23473

23474

23480

23485

23490

23491

23500

23680

23700

23800

23802

23900

23920

23921

23929

23930

23625

23630

23650

23655

23660

23665

23670

23675

90 $1,210.00

90 $1,340.00

90 $1,364.00

90 $1,383.00

90 $1,398.00

90 $1,332.00

90 $1,540.00

90 $1,570.00

90 --------

90

90

--------

$926.00

90 $1,181.00

90 $1,038.00

90 $1,251.00

90 $148.00

90

90

90

90

90

90

90

90

$293.00

$688.00

$205.00

$320.00

$659.00

$713.00

$148.00

$148.00

90

90

90

90

90

$701.00

$753.00

$88.00

$306.00

$809.00

90

90

$318.00

$511.00

90 $900.00

90 $1,895.00

90 $286.00

90

90

90

90

90

90

90

90

$422.00

$712.00

$296.00

$374.00

$712.00

$440.00

$759.00

$550.00

90 $1,064.00

10 $237.00

90 $1,346.00

90 $1,368.00

90 $1,561.00

90 $1,300.00

90 $497.00

YYY

10

BR

$71.00

$505.00

$1,049.00

$320.00

$537.00

$801.00

$900.00

$319.00

$482.00

$819.00

$953.00

$331.00

$572.00

$1,436.00

$463.00

$664.00

$1,292.00

$1,823.00

$383.00

$1,384.00

$1,464.00

$1,601.00

$1,554.00

$1,628.00

$1,634.00

$1,766.00

$2,142.00

$2,394.00

$2,587.00

$1,201.00

$1,398.00

$1,229.00

$1,484.00

$311.00

$542.00

$1,139.00

$445.00

$578.00

$845.00

$608.00

$1,280.00

$791.00

$1,357.00

$286.00

$1,505.00

$1,850.00

$2,042.00

$1,650.00

$679.00

--------

$502.00

$539.00

$1,119.00

$342.00

$573.00

$854.00

$958.00

$340.00

$513.00

$872.00

$1,016.00

$353.00

$611.00

$1,531.00

$494.00

$708.00

$1,378.00

$1,944.00

$409.00

$1,476.00

$1,561.00

$1,709.00

$1,657.00

$1,735.00

$1,741.00

$1,883.00

$2,282.00

$2,552.00

$2,757.00

$1,283.00

$1,491.00

$1,309.00

$1,585.00

$331.00

$578.00

$1,215.00

$473.00

$617.00

$901.00

$649.00

$1,365.00

$844.00

$1,447.00

$305.00

$1,607.00

$1,972.00

$2,180.00

$1,762.00

$725.00

--------

$537.00

$568.00

$1,195.00

$359.00

$603.00

$911.00

$1,019.00

$356.00

$534.00

$928.00

$1,084.00

$371.00

$646.00

$1,641.00

$517.00

$747.00

$1,474.00

$2,087.00

$428.00

$1,583.00

$1,674.00

$1,838.00

$1,779.00

$1,858.00

$1,861.00

$2,021.00

$2,451.00

$2,743.00

$2,966.00

$1,377.00

$1,599.00

$1,398.00

$1,702.00

$347.00

$609.00

$1,297.00

$495.00

$653.00

$960.00

$684.00

$1,461.00

$892.00

$1,549.00

$326.00

$1,727.00

$2,112.00

$2,345.00

$1,894.00

$772.00

--------

$562.00

$479.00

$1,049.00

$325.00

$498.00

$801.00

$900.00

$325.00

$440.00

$819.00

$953.00

$340.00

$538.00

$1,436.00

$438.00

$611.00

$1,292.00

$1,823.00

$365.00

$1,384.00

$1,464.00

$1,601.00

$1,554.00

$1,628.00

$1,634.00

$1,766.00

$2,142.00

$2,394.00

$2,587.00

$1,201.00

$1,398.00

$1,229.00

$1,484.00

$316.00

$506.00

$1,139.00

$411.00

$578.00

$845.00

$568.00

$1,280.00

$724.00

$1,357.00

$286.00

$1,505.00

$1,850.00

$2,042.00

$1,650.00

$679.00

--------

$316.00

$511.00

$1,119.00

$347.00

$532.00

$854.00

$958.00

$346.00

$468.00

$872.00

$1,016.00

$364.00

$575.00

$1,531.00

$467.00

$652.00

$1,378.00

$1,944.00

$390.00

$1,476.00

$1,561.00

$1,709.00

$1,657.00

$1,735.00

$1,741.00

$1,883.00

$2,282.00

$2,552.00

$2,757.00

$1,283.00

$1,491.00

$1,309.00

$1,585.00

$337.00

$540.00

$1,215.00

$436.00

$617.00

$901.00

$606.00

$1,365.00

$772.00

$1,447.00

$305.00

$1,607.00

$1,972.00

$2,180.00

$1,762.00

$725.00

--------

$337.00

$540.00

$1,195.00

$364.00

$561.00

$911.00

$1,019.00

$362.00

$489.00

$928.00

$1,084.00

$382.00

$609.00

$1,641.00

$490.00

$691.00

$1,474.00

$2,087.00

$409.00

$1,583.00

$1,674.00

$1,838.00

$1,779.00

$1,858.00

$1,861.00

$2,021.00

$2,451.00

$2,743.00

$2,966.00

$1,377.00

$1,599.00

$1,398.00

$1,702.00

$353.00

$571.00

$1,297.00

$458.00

$653.00

$960.00

$642.00

$1,461.00

$821.00

$1,549.00

$326.00

$1,727.00

$2,112.00

$2,345.00

$1,894.00

$772.00

--------

$362.00


Part B, 180



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

24134

24136

24138

24140

24145

24147

24149

24150

24152

24155

24105

24110

24115

24116

24120

24125

24126

24130

23931

23935

24000

24006

24065

24066

24071

24073

24075

24076

24077

24079

24100

24101

24102

24310

24320

24330

24331

24332

24340

24341

24342

24343

24160

24164

24200

24201

24220

24300

24301

24305

90

90

90

90

90

90

90

90

90

90

90

10

90

0

90

90

90

10

90

90

90

10

90

90

$62.00

$630.00

$550.00

$793.00

$166.00

$461.00

--------

90

90

--------

$349.00

90 $529.00

90 $1,058.00

90 --------

90

90

90

$467.00

$591.00

$755.00

90

90

$360.00

$724.00

90 $898.00

90 $1,037.00

90 $595.00

90

90

90

$663.00

$731.00

$595.00

90

90

90

90

90

$966.00

$720.00

$697.00

$963.00

$592.00

90 $703.00

90 $1,224.00

90 $1,265.00

90 $829.00

90 $1,019.00

$533.00

$564.00

$58.00

$444.00

$89.00

$352.00

$869.00

$579.00

$511.00

$944.00

$845.00

$927.00

$487.00

$697.00

$702.00

$950.00

$643.00

$504.00

$842.00

$1,078.00

$1,263.00

$766.00

$889.00

$946.00

$736.00

$1,090.00

$904.00

$976.00

$1,019.00

$862.00

$901.00

$1,712.00

$2,296.00

$1,932.00

$1,236.00

$403.00

$733.00

$690.00

$1,028.00

$362.00

$890.00

$597.00

$1,018.00

$699.00

$794.00

$1,529.00

$1,955.00

$605.00

$725.00

$896.00

$1,855.00

$1,067.00

$293.00

$776.00

$224.00

$596.00

$1,092.00

$835.00

$682.00

$1,142.00

$1,048.00

$1,150.00

$890.00

$890.00

$1,083.00

$1,131.00

$1,024.00

$538.00

$898.00

$1,151.00

$1,349.00

$817.00

$946.00

$1,011.00

$785.00

$1,163.00

$960.00

$1,043.00

$1,087.00

$921.00

$962.00

$1,824.00

$2,451.00

$2,049.00

$1,319.00

$431.00

$782.00

$736.00

$1,095.00

$386.00

$953.00

$639.00

$1,089.00

$748.00

$849.00

$1,635.00

$2,089.00

$647.00

$773.00

$955.00

$1,977.00

$1,140.00

$312.00

$831.00

$238.00

$637.00

$1,163.00

$889.00

$726.00

$1,220.00

$1,120.00

$1,228.00

$951.00

$949.00

$1,156.00

$1,206.00

$1,092.00

$569.00

$956.00

$1,234.00

$1,448.00

$869.00

$1,004.00

$1,081.00

$835.00

$1,245.00

$1,013.00

$1,112.00

$1,161.00

$985.00

$1,024.00

$1,946.00

$2,642.00

$2,176.00

$1,415.00

$445.00

$831.00

$783.00

$1,168.00

$400.00

$1,000.00

$689.00

$1,174.00

$785.00

$911.00

$1,770.00

$2,261.00

$689.00

$822.00

$1,018.00

$2,122.00

$1,221.00

$324.00

$871.00

$243.00

$668.00

$1,242.00

$943.00

$770.00

$1,309.00

$1,200.00

$1,318.00

$1,016.00

$1,012.00

$1,229.00

$1,288.00

$1,161.00

$504.00

$842.00

$1,078.00

$1,263.00

$766.00

$889.00

$946.00

$736.00

$1,090.00

$904.00

$976.00

$1,019.00

$862.00

$901.00

$1,712.00

$2,296.00

$1,932.00

$1,236.00

$230.00

$733.00

$690.00

$1,028.00

$242.00

$607.00

$597.00

$1,018.00

$481.00

$794.00

$1,529.00

$1,955.00

$605.00

$725.00

$896.00

$1,855.00

$1,067.00

$202.00

$526.00

$101.00

$596.00

$1,092.00

$835.00

$682.00

$1,142.00

$1,048.00

$1,150.00

$890.00

$890.00

$1,083.00

$1,131.00

$1,024.00

$538.00

$898.00

$1,151.00

$1,349.00

$817.00

$946.00

$1,011.00

$785.00

$1,163.00

$960.00

$1,043.00

$1,087.00

$921.00

$962.00

$1,824.00

$2,451.00

$2,049.00

$1,319.00

$245.00

$782.00

$736.00

$1,095.00

$257.00

$649.00

$639.00

$1,089.00

$515.00

$849.00

$1,635.00

$2,089.00

$647.00

$773.00

$955.00

$1,977.00

$1,140.00

$215.00

$562.00

$105.00

$637.00

$1,163.00

$889.00

$726.00

$1,220.00

$1,120.00

$1,228.00

$951.00

$949.00

$1,156.00

$1,206.00

$1,092.00

$569.00

$956.00

$1,234.00

$1,448.00

$869.00

$1,004.00

$1,081.00

$835.00

$1,245.00

$1,013.00

$1,112.00

$1,161.00

$985.00

$1,024.00

$1,946.00

$2,642.00

$2,176.00

$1,415.00

$259.00

$831.00

$783.00

$1,168.00

$271.00

$695.00

$689.00

$1,174.00

$551.00

$911.00

$1,770.00

$2,261.00

$689.00

$822.00

$1,018.00

$2,122.00

$1,221.00

$227.00

$601.00

$110.00

$668.00

$1,242.00

$943.00

$770.00

$1,309.00

$1,200.00

$1,318.00

$1,016.00

$1,012.00

$1,229.00

$1,288.00

$1,161.00


Part B, 181



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

24505

24515

24516

24530

24535

24538

24545

24546

24560

24565

24410

24420

24430

24435

24470

24495

24498

24500

24344

24345

24346

24357

24358

24359

24360

24361

24362

24363

24365

24366

24370

24371

24400

24600

24605

24615

24620

24635

24650

24655

24665

24666

24566

24575

24576

24577

24579

24582

24586

24587

90

90

$971.00

$643.00

90

90

90

90

$971.00

--------

--------

--------

90 $1,125.00

90 $1,215.00

90 $1,269.00

90 $1,663.00

90 $747.00

90 $850.00

90

90

90

--------

--------

$991.00

90 $1,319.00

90 $1,265.00

90 $1,209.00

90 $1,260.00

90 $774.00

90 $742.00

90 $1,076.00

90 $288.00

90 $574.00

90 $1,018.00

90 $1,029.00

90 $88.00

90 $671.00

90

90

$850.00

$946.00

90 $1,273.00

90 $266.00

90 $526.00

90

90

90

$705.00

$872.00

$295.00

90

90

$575.00

$964.00

90 $773.00

90 $1,314.00

90 $1,278.00

90

90

90

$360.00

$371.00

$836.00

90 $560.00

90 $1,329.00

90

90

$262.00

$436.00

90

90

$749.00

$905.00

$1,551.00

$1,428.00

$1,546.00

$1,573.00

$822.00

$950.00

$1,266.00

$508.00

$714.00

$1,279.00

$1,258.00

$541.00

$883.00

$1,082.00

$1,358.00

$1,520.00

$453.00

$760.00

$1,603.00

$1,021.00

$1,598.00

$618.00

$756.00

$958.00

$1,295.00

$1,462.00

$1,556.00

$2,136.00

$927.00

$989.00

$2,288.00

$2,620.00

$1,191.00

$1,042.00

$1,062.00

$481.00

$780.00

$1,218.00

$1,168.00

$1,586.00

$1,581.00

$519.00

$678.00

$1,038.00

$794.00

$978.00

$369.00

$620.00

$945.00

$1,066.00

$1,656.00

$1,520.00

$1,648.00

$1,678.00

$868.00

$1,017.00

$1,351.00

$543.00

$762.00

$1,364.00

$1,343.00

$578.00

$942.00

$1,156.00

$1,449.00

$1,621.00

$483.00

$813.00

$1,712.00

$1,089.00

$1,704.00

$657.00

$806.00

$1,021.00

$1,381.00

$1,561.00

$1,662.00

$2,275.00

$990.00

$1,055.00

$2,443.00

$2,791.00

$1,271.00

$1,114.00

$1,132.00

$513.00

$833.00

$1,300.00

$1,246.00

$1,690.00

$1,683.00

$551.00

$724.00

$1,107.00

$846.00

$1,043.00

$394.00

$660.00

$1,008.00

$1,137.00

$1,779.00

$1,618.00

$1,766.00

$1,794.00

$916.00

$1,090.00

$1,446.00

$568.00

$804.00

$1,458.00

$1,439.00

$606.00

$998.00

$1,235.00

$1,551.00

$1,737.00

$504.00

$860.00

$1,835.00

$1,159.00

$1,822.00

$693.00

$856.00

$1,088.00

$1,478.00

$1,677.00

$1,786.00

$2,440.00

$1,059.00

$1,125.00

$2,632.00

$2,996.00

$1,360.00

$1,188.00

$1,207.00

$536.00

$881.00

$1,389.00

$1,325.00

$1,811.00

$1,801.00

$579.00

$769.00

$1,183.00

$898.00

$1,112.00

$411.00

$693.00

$1,072.00

$1,213.00

$1,551.00

$1,428.00

$1,546.00

$1,573.00

$822.00

$950.00

$1,266.00

$465.00

$650.00

$1,279.00

$1,258.00

$492.00

$819.00

$1,082.00

$1,358.00

$1,520.00

$408.00

$702.00

$1,603.00

$1,021.00

$1,598.00

$618.00

$756.00

$958.00

$1,295.00

$1,462.00

$1,556.00

$2,136.00

$927.00

$989.00

$2,288.00

$2,620.00

$1,191.00

$1,042.00

$1,062.00

$434.00

$720.00

$1,218.00

$1,168.00

$1,586.00

$1,581.00

$478.00

$678.00

$1,038.00

$794.00

$978.00

$341.00

$567.00

$945.00

$1,066.00

$1,656.00

$1,520.00

$1,648.00

$1,678.00

$868.00

$1,017.00

$1,351.00

$496.00

$693.00

$1,364.00

$1,343.00

$525.00

$874.00

$1,156.00

$1,449.00

$1,621.00

$434.00

$750.00

$1,712.00

$1,089.00

$1,704.00

$657.00

$806.00

$1,021.00

$1,381.00

$1,561.00

$1,662.00

$2,275.00

$990.00

$1,055.00

$2,443.00

$2,791.00

$1,271.00

$1,114.00

$1,132.00

$463.00

$768.00

$1,300.00

$1,246.00

$1,690.00

$1,683.00

$507.00

$724.00

$1,107.00

$846.00

$1,043.00

$363.00

$604.00

$1,008.00

$1,137.00

$1,779.00

$1,618.00

$1,766.00

$1,794.00

$916.00

$1,090.00

$1,446.00

$521.00

$734.00

$1,458.00

$1,439.00

$554.00

$930.00

$1,235.00

$1,551.00

$1,737.00

$455.00

$797.00

$1,835.00

$1,159.00

$1,822.00

$693.00

$856.00

$1,088.00

$1,478.00

$1,677.00

$1,786.00

$2,440.00

$1,059.00

$1,125.00

$2,632.00

$2,996.00

$1,360.00

$1,188.00

$1,207.00

$486.00

$816.00

$1,389.00

$1,325.00

$1,811.00

$1,801.00

$535.00

$769.00

$1,183.00

$898.00

$1,112.00

$380.00

$637.00

$1,072.00

$1,213.00


Part B, 182



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

25065

25066

25071

25073

25075

25076

25077

25078

25085

25100

25020

25023

25024

25025

25028

25031

25035

25040

24670

24675

24685

24800

24802

24900

24920

24925

24930

24931

24935

24940

24999

25000

25001

25116

25118

25119

25120

25125

25126

25130

25135

25136

25101

25105

25107

25109

25110

25111

25112

25115

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

$263.00

$490.00

90

90

$819.00

$984.00

90 $1,181.00

90 $858.00

90 $851.00

90

90

$661.00

$928.00

90 $1,063.00

90 $1,327.00

90 BR

YYY

90

90

BR

$381.00

$294.00

90

90

90

90

90

10

90

90

90

90

90 $594.00

90 $1,040.00

90 $683.00

90 $1,104.00

90 $417.00

90

90

90

$266.00

$794.00

$654.00

$164.00

$322.00

--------

--------

$352.00

$544.00

$957.00

--------

$562.00

$420.00

$492.00

$635.00

$600.00

--------

$403.00

$356.00

$441.00

$837.00

$807.00

$466.00

$653.00

$712.00

$803.00

$781.00

$502.00

$631.00

$546.00

$822.00

$1,593.00

$1,128.00

$1,765.00

$749.00

$518.00

$839.00

$815.00

$358.00

$518.00

$624.00

$775.00

$679.00

$749.00

$1,300.00

$1,714.00

$649.00

$497.00

$412.00

$648.00

$949.00

$1,212.00

$1,431.00

$1,069.00

$1,067.00

$800.00

$1,125.00

$1,168.00

$1,637.00

--------

--------

$482.00

$490.00

$580.00

$695.00

$888.00

$776.00

$493.00

$460.00

$557.00

$1,098.00

$864.00

$549.00

$713.00

$717.00

$844.00

$863.00

$642.00

$802.00

$709.00

$877.00

$1,699.00

$1,204.00

$1,879.00

$801.00

$553.00

$894.00

$868.00

$381.00

$554.00

$667.00

$827.00

$726.00

$799.00

$1,389.00

$1,831.00

$692.00

$531.00

$440.00

$691.00

$1,013.00

$1,295.00

$1,524.00

$1,141.00

$1,139.00

$855.00

$1,202.00

$1,233.00

$1,752.00

--------

--------

$515.00

$523.00

$618.00

$740.00

$946.00

$826.00

$527.00

$491.00

$594.00

$1,170.00

$920.00

$585.00

$760.00

$765.00

$900.00

$922.00

$683.00

$857.00

$758.00

$921.00

$1,805.00

$1,290.00

$2,013.00

$844.00

$586.00

$951.00

$923.00

$394.00

$587.00

$717.00

$883.00

$760.00

$851.00

$1,497.00

$1,976.00

$734.00

$564.00

$460.00

$728.00

$1,078.00

$1,388.00

$1,630.00

$1,223.00

$1,219.00

$915.00

$1,291.00

$1,305.00

$1,898.00

--------

--------

$542.00

$551.00

$654.00

$784.00

$1,002.00

$875.00

$558.00

$518.00

$630.00

$1,243.00

$974.00

$618.00

$804.00

$811.00

$961.00

$984.00

$721.00

$913.00

$808.00

$822.00

$1,593.00

$1,128.00

$1,765.00

$749.00

$518.00

$839.00

$815.00

$235.00

$518.00

$624.00

$775.00

$460.00

$749.00

$1,300.00

$1,714.00

$649.00

$497.00

$374.00

$594.00

$949.00

$1,212.00

$1,431.00

$1,069.00

$1,067.00

$800.00

$1,125.00

$1,168.00

$1,637.00

--------

--------

$482.00

$490.00

$580.00

$695.00

$888.00

$776.00

$493.00

$460.00

$557.00

$1,098.00

$864.00

$549.00

$713.00

$717.00

$844.00

$863.00

$642.00

$802.00

$709.00

$877.00

$1,699.00

$1,204.00

$1,879.00

$801.00

$553.00

$894.00

$868.00

$250.00

$554.00

$667.00

$827.00

$492.00

$799.00

$1,389.00

$1,831.00

$692.00

$531.00

$399.00

$634.00

$1,013.00

$1,295.00

$1,524.00

$1,141.00

$1,139.00

$855.00

$1,202.00

$1,233.00

$1,752.00

--------

--------

$515.00

$523.00

$618.00

$740.00

$946.00

$826.00

$527.00

$491.00

$594.00

$1,170.00

$920.00

$585.00

$760.00

$765.00

$900.00

$922.00

$683.00

$857.00

$758.00

$921.00

$1,805.00

$1,290.00

$2,013.00

$844.00

$586.00

$951.00

$923.00

$262.00

$587.00

$717.00

$883.00

$524.00

$851.00

$1,497.00

$1,976.00

$734.00

$564.00

$419.00

$670.00

$1,078.00

$1,388.00

$1,630.00

$1,223.00

$1,219.00

$915.00

$1,291.00

$1,305.00

$1,898.00

--------

--------

$542.00

$551.00

$654.00

$784.00

$1,002.00

$875.00

$558.00

$518.00

$630.00

$1,243.00

$974.00

$618.00

$804.00

$811.00

$961.00

$984.00

$721.00

$913.00

$808.00


Part B, 183



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

25300

25301

25310

25312

25315

25316

25320

25332

25335

25337

25265

25270

25272

25274

25275

25280

25290

25295

25145

25150

25151

25170

25210

25215

25230

25240

25246

25248

25250

25251

25259

25260

25263

25392

25393

25394

25400

25405

25415

25420

25425

25426

25350

25355

25360

25365

25370

25375

25390

25391

90

0

90

90

90

90

90

90

90

90

$713.00

$720.00

90 $771.00

90 $1,085.00

90

90

90

$561.00

$817.00

$531.00

$567.00

$72.00

$236.00

$616.00

$933.00

$348.00

$728.00

$809.00

90

90

90

90

90

90

90

90

$998.00

$549.00

$613.00

$887.00

$620.00

$670.00

$436.00

$562.00

90

90

90

90

$592.00

$757.00

$865.00

$968.00

90 $1,004.00

90 $1,203.00

90 $834.00

90 $1,022.00

90 $1,166.00

90 $946.00

90 $913.00

90 $1,014.00

90 $468.00

90 $1,216.00

90 $1,214.00

90 $1,280.00

90 $1,043.00

90 $1,349.00

90 $1,294.00

90 $1,473.00

90 $723.00

90 $1,112.00

90 $1,388.00

90 $1,343.00

90 $1,554.00

90 $1,403.00

90 $1,401.00

$1,089.00

$705.00

$800.00

$962.00

$973.00

$813.00

$629.00

$756.00

$987.00

$932.00

$896.00

$1,037.00

$1,125.00

$1,338.00

$1,428.00

$1,223.00

$1,175.00

$1,287.00

$750.00

$821.00

$847.00

$2,180.00

$702.00

$893.00

$624.00

$615.00

$227.00

$603.00

$754.00

$1,047.00

$592.00

$910.00

$898.00

$976.00

$1,097.00

$948.00

$1,332.00

$1,469.00

$1,395.00

$1,118.00

$1,460.00

$1,267.00

$1,649.00

$1,137.00

$1,170.00

$1,513.00

$1,409.00

$1,710.00

$1,411.00

$1,651.00

$1,162.00

$751.00

$852.00

$1,024.00

$1,037.00

$865.00

$671.00

$805.00

$1,051.00

$993.00

$954.00

$1,104.00

$1,201.00

$1,429.00

$1,521.00

$1,302.00

$1,239.00

$1,371.00

$801.00

$876.00

$905.00

$2,327.00

$747.00

$951.00

$665.00

$655.00

$241.00

$644.00

$801.00

$1,118.00

$632.00

$970.00

$956.00

$1,040.00

$1,169.00

$1,010.00

$1,421.00

$1,567.00

$1,490.00

$1,190.00

$1,559.00

$1,336.00

$1,751.00

$1,214.00

$1,247.00

$1,612.00

$1,503.00

$1,825.00

$1,507.00

$1,762.00

$1,242.00

$795.00

$906.00

$1,089.00

$1,102.00

$916.00

$710.00

$855.00

$1,116.00

$1,057.00

$1,013.00

$1,174.00

$1,286.00

$1,534.00

$1,614.00

$1,387.00

$1,312.00

$1,456.00

$854.00

$934.00

$966.00

$2,508.00

$789.00

$1,010.00

$705.00

$691.00

$247.00

$687.00

$844.00

$1,199.00

$662.00

$1,029.00

$1,014.00

$1,106.00

$1,250.00

$1,075.00

$1,522.00

$1,677.00

$1,600.00

$1,268.00

$1,675.00

$1,415.00

$1,863.00

$1,299.00

$1,332.00

$1,723.00

$1,613.00

$1,959.00

$1,618.00

$1,896.00

$1,089.00

$705.00

$800.00

$962.00

$973.00

$813.00

$629.00

$756.00

$987.00

$932.00

$896.00

$1,037.00

$1,125.00

$1,338.00

$1,428.00

$1,223.00

$1,175.00

$1,287.00

$750.00

$821.00

$847.00

$2,180.00

$702.00

$893.00

$624.00

$615.00

$110.00

$603.00

$754.00

$1,047.00

$592.00

$910.00

$898.00

$976.00

$1,097.00

$948.00

$1,332.00

$1,469.00

$1,395.00

$1,118.00

$1,460.00

$1,267.00

$1,649.00

$1,137.00

$1,170.00

$1,513.00

$1,409.00

$1,710.00

$1,411.00

$1,651.00

$1,162.00

$751.00

$852.00

$1,024.00

$1,037.00

$865.00

$671.00

$805.00

$1,051.00

$993.00

$954.00

$1,104.00

$1,201.00

$1,429.00

$1,521.00

$1,302.00

$1,239.00

$1,371.00

$801.00

$876.00

$905.00

$2,327.00

$747.00

$951.00

$665.00

$655.00

$115.00

$644.00

$801.00

$1,118.00

$632.00

$970.00

$956.00

$1,040.00

$1,169.00

$1,010.00

$1,421.00

$1,567.00

$1,490.00

$1,190.00

$1,559.00

$1,336.00

$1,751.00

$1,214.00

$1,247.00

$1,612.00

$1,503.00

$1,825.00

$1,507.00

$1,762.00

$1,242.00

$795.00

$906.00

$1,089.00

$1,102.00

$916.00

$710.00

$855.00

$1,116.00

$1,057.00

$1,013.00

$1,174.00

$1,286.00

$1,534.00

$1,614.00

$1,387.00

$1,312.00

$1,456.00

$854.00

$934.00

$966.00

$2,508.00

$789.00

$1,010.00

$705.00

$691.00

$120.00

$687.00

$844.00

$1,199.00

$662.00

$1,029.00

$1,014.00

$1,106.00

$1,250.00

$1,075.00

$1,522.00

$1,677.00

$1,600.00

$1,268.00

$1,675.00

$1,415.00

$1,863.00

$1,299.00

$1,332.00

$1,723.00

$1,613.00

$1,959.00

$1,618.00

$1,896.00


Part B, 184



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

25535

25545

25560

25565

25574

25575

25600

25605

25606

25607

25492

25500

25505

25515

25520

25525

25526

25530

25430

25431

25440

25441

25442

25443

25444

25445

25446

25447

25449

25450

25455

25490

25491

25650

25651

25652

25660

25670

25671

25675

25676

25680

25608

25609

25622

25624

25628

25630

25635

25645

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

$638.00

$631.00

90 $931.00

90 $1,147.00

90

90

$936.00

$970.00

90 $1,031.00

90 $959.00

90 $1,542.00

90

90

90

$952.00

$395.00

$805.00

90

90

$899.00

$955.00

90 $1,006.00

90

90

90

90

90

90

90

90

90

90

90 $1,170.00

90 $200.00

90

90

90

$517.00

$800.00

$644.00

90 $1,097.00

90 $1,293.00

90 $270.00

$516.00

$803.00

$276.00

$590.00

$804.00

$974.00

$312.00

$540.00

--------

--------

--------

--------

$148.00

$482.00

$716.00

$148.00

$458.00

$668.00

$185.00

$379.00

$560.00

$378.00

$731.00

$462.00

$404.00

$741.00

$471.00

$1,323.00

$387.00

$718.00

$972.00

$804.00

$1,141.00

$1,387.00

$370.00

$700.00

$902.00

$393.00

$743.00

$976.00

$1,313.00

$463.00

$782.00

$961.00

$1,066.00

$1,066.00

$1,146.00

$1,113.00

$1,354.00

$1,169.00

$1,141.00

$1,207.00

$1,050.00

$1,707.00

$1,199.00

$1,505.00

$751.00

$890.00

$1,049.00

$1,080.00

$1,197.00

$1,524.00

$430.00

$678.00

$1,046.00

$433.00

$606.00

$824.00

$454.00

$697.00

$905.00

$585.00

$879.00

$767.00

$617.00

$909.00

$680.00

$1,413.00

$413.00

$766.00

$1,037.00

$859.00

$1,217.00

$1,479.00

$395.00

$747.00

$963.00

$419.00

$792.00

$1,042.00

$1,401.00

$494.00

$833.00

$1,026.00

$1,137.00

$1,138.00

$1,222.00

$1,185.00

$1,436.00

$1,244.00

$1,219.00

$1,289.00

$1,119.00

$1,816.00

$1,277.00

$1,601.00

$793.00

$940.00

$1,121.00

$1,154.00

$1,277.00

$1,624.00

$458.00

$724.00

$1,114.00

$461.00

$645.00

$880.00

$484.00

$742.00

$965.00

$623.00

$937.00

$819.00

$657.00

$969.00

$722.00

$1,516.00

$431.00

$805.00

$1,105.00

$910.00

$1,298.00

$1,581.00

$412.00

$787.00

$1,024.00

$436.00

$835.00

$1,110.00

$1,497.00

$515.00

$879.00

$1,094.00

$1,211.00

$1,217.00

$1,307.00

$1,262.00

$1,520.00

$1,322.00

$1,306.00

$1,382.00

$1,194.00

$1,939.00

$1,358.00

$1,708.00

$836.00

$992.00

$1,200.00

$1,236.00

$1,362.00

$1,733.00

$478.00

$762.00

$1,186.00

$483.00

$675.00

$938.00

$506.00

$784.00

$1,027.00

$657.00

$998.00

$870.00

$688.00

$1,031.00

$762.00

$1,323.00

$357.00

$661.00

$972.00

$766.00

$1,141.00

$1,387.00

$337.00

$651.00

$902.00

$357.00

$676.00

$976.00

$1,313.00

$439.00

$738.00

$961.00

$1,066.00

$1,066.00

$1,146.00

$1,113.00

$1,354.00

$1,169.00

$1,141.00

$1,207.00

$1,050.00

$1,707.00

$1,199.00

$1,505.00

$751.00

$890.00

$1,049.00

$1,080.00

$1,197.00

$1,524.00

$393.00

$621.00

$1,046.00

$400.00

$545.00

$824.00

$427.00

$697.00

$905.00

$585.00

$879.00

$767.00

$566.00

$909.00

$680.00

$1,413.00

$380.00

$704.00

$1,037.00

$817.00

$1,217.00

$1,479.00

$360.00

$694.00

$963.00

$380.00

$720.00

$1,042.00

$1,401.00

$468.00

$786.00

$1,026.00

$1,137.00

$1,138.00

$1,222.00

$1,185.00

$1,436.00

$1,244.00

$1,219.00

$1,289.00

$1,119.00

$1,816.00

$1,277.00

$1,601.00

$793.00

$940.00

$1,121.00

$1,154.00

$1,277.00

$1,624.00

$419.00

$663.00

$1,114.00

$426.00

$579.00

$880.00

$455.00

$742.00

$965.00

$623.00

$937.00

$819.00

$601.00

$969.00

$722.00

$1,516.00

$398.00

$744.00

$1,105.00

$868.00

$1,298.00

$1,581.00

$376.00

$735.00

$1,024.00

$398.00

$763.00

$1,110.00

$1,497.00

$489.00

$832.00

$1,094.00

$1,211.00

$1,217.00

$1,307.00

$1,262.00

$1,520.00

$1,322.00

$1,306.00

$1,382.00

$1,194.00

$1,939.00

$1,358.00

$1,708.00

$836.00

$992.00

$1,200.00

$1,236.00

$1,362.00

$1,733.00

$438.00

$701.00

$1,186.00

$447.00

$608.00

$938.00

$477.00

$784.00

$1,027.00

$657.00

$998.00

$870.00

$632.00

$1,031.00

$762.00


Part B, 185



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

26020

26025

26030

26034

26035

26037

26040

26045

26055

26060

25922

25924

25927

25929

25931

25999

26010

26011

25685

25690

25695

25800

25805

25810

25820

25825

25830

25900

25905

25907

25909

25915

25920

26115

26116

26117

26118

26121

26123

26125

26130

26135

26070

26075

26080

26100

26105

26110

26111

26113

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

YYY

10

10

90

90

$887.00

$518.00

90

90

$520.00

$703.00

90 $1,078.00

90 $1,008.00

90 $2,276.00

90

90

90

90

90

$895.00

$991.00

$871.00

$900.00

$799.00

90 $849.00

90 $1,523.00

90 $771.00

$670.00

$768.00

$830.00

$645.00

$731.00

BR

$59.00

$223.00

$484.00

$548.00

$655.00

$601.00

$741.00

$730.00

$367.00

$621.00

$343.00

$293.00

90

90

90

90

90

90

90

90

$440.00

$400.00

$382.00

$398.00

$481.00

$282.00

--------

--------

90

90

90

$344.00

$544.00

$806.00

90

90

--------

$833.00

90 $959.00

ZZZ $342.00

90

90

$629.00

$668.00

$835.00

$887.00

$1,171.00

$861.00

$966.00

--------

$367.00

$543.00

$624.00

$609.00

$710.00

$776.00

$1,235.00

$822.00

$446.00

$677.00

$778.00

$379.00

$1,068.00

$686.00

$923.00

$1,063.00

$1,234.00

$1,259.00

$887.00

$1,093.00

$1,358.00

$1,030.00

$956.00

$848.00

$999.00

$1,726.00

$1,009.00

$450.00

$478.00

$560.00

$480.00

$478.00

$461.00

$605.00

$793.00

$711.00

$762.00

$1,088.00

$1,532.00

$864.00

$1,207.00

$405.00

$669.00

$793.00

$892.00

$945.00

$1,252.00

$920.00

$1,036.00

--------

$392.00

$581.00

$666.00

$649.00

$756.00

$827.00

$1,313.00

$875.00

$475.00

$723.00

$833.00

$404.00

$1,140.00

$733.00

$986.00

$1,132.00

$1,318.00

$1,340.00

$945.00

$1,164.00

$1,448.00

$1,099.00

$1,026.00

$905.00

$1,067.00

$1,838.00

$1,079.00

$479.00

$509.00

$597.00

$512.00

$510.00

$491.00

$645.00

$845.00

$759.00

$812.00

$1,159.00

$1,632.00

$921.00

$1,286.00

$431.00

$714.00

$844.00

$955.00

$1,010.00

$1,328.00

$985.00

$1,113.00

--------

$401.00

$598.00

$704.00

$687.00

$801.00

$878.00

$1,389.00

$931.00

$500.00

$767.00

$858.00

$425.00

$1,221.00

$777.00

$1,054.00

$1,205.00

$1,413.00

$1,426.00

$1,000.00

$1,233.00

$1,527.00

$1,173.00

$1,117.00

$968.00

$1,143.00

$1,968.00

$1,153.00

$504.00

$537.00

$631.00

$543.00

$538.00

$518.00

$685.00

$897.00

$790.00

$862.00

$1,234.00

$1,743.00

$978.00

$1,366.00

$464.00

$760.00

$894.00

$835.00

$887.00

$1,171.00

$861.00

$966.00

--------

$196.00

$266.00

$624.00

$609.00

$710.00

$776.00

$1,235.00

$822.00

$446.00

$677.00

$443.00

$379.00

$1,068.00

$686.00

$923.00

$1,063.00

$1,234.00

$1,259.00

$887.00

$1,093.00

$1,358.00

$1,030.00

$956.00

$848.00

$999.00

$1,726.00

$1,009.00

$450.00

$478.00

$560.00

$480.00

$478.00

$461.00

$605.00

$793.00

$479.00

$762.00

$1,088.00

$1,532.00

$864.00

$1,207.00

$405.00

$669.00

$793.00

$892.00

$945.00

$1,252.00

$920.00

$1,036.00

--------

$208.00

$283.00

$666.00

$649.00

$756.00

$827.00

$1,313.00

$875.00

$475.00

$723.00

$473.00

$404.00

$1,140.00

$733.00

$986.00

$1,132.00

$1,318.00

$1,340.00

$945.00

$1,164.00

$1,448.00

$1,099.00

$1,026.00

$905.00

$1,067.00

$1,838.00

$1,079.00

$479.00

$509.00

$597.00

$512.00

$510.00

$491.00

$645.00

$845.00

$511.00

$812.00

$1,159.00

$1,632.00

$921.00

$1,286.00

$431.00

$714.00

$844.00

$955.00

$1,010.00

$1,328.00

$985.00

$1,113.00

--------

$217.00

$299.00

$704.00

$687.00

$801.00

$878.00

$1,389.00

$931.00

$500.00

$767.00

$496.00

$425.00

$1,221.00

$777.00

$1,054.00

$1,205.00

$1,413.00

$1,426.00

$1,000.00

$1,233.00

$1,527.00

$1,173.00

$1,117.00

$968.00

$1,143.00

$1,968.00

$1,153.00

$504.00

$537.00

$631.00

$543.00

$538.00

$518.00

$685.00

$897.00

$540.00

$862.00

$1,234.00

$1,743.00

$978.00

$1,366.00

$464.00

$760.00

$894.00


Part B, 186



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

26358

26370

26372

26373

26390

26392

26410

26412

26415

26416

26262

26320

26340

26341

26350

26352

26356

26357

26140

26145

26160

26170

26180

26185

26200

26205

26210

26215

26230

26235

26236

26250

26260

26440

26442

26445

26449

26450

26455

26460

26471

26474

26418

26420

26426

26428

26432

26433

26434

26437

90

90

90

90

90

90

90

90

90

90

90

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

$624.00

$414.00

$266.00

--------

$715.00

$855.00

$886.00

$932.00

90

90

90

90

90

$979.00

$832.00

$945.00

$904.00

$889.00

90 $1,123.00

90 $371.00

90

90

$737.00

$846.00

90 $1,093.00

$678.00

$660.00

$319.00

$452.00

$444.00

$511.00

$598.00

$788.00

$543.00

$731.00

$624.00

$612.00

$444.00

$814.00

$758.00

$444.00

$741.00

$733.00

$790.00

$430.00

$371.00

$656.00

$491.00

$458.00

$548.00

$455.00

$738.00

$353.00

$364.00

$346.00

$592.00

$586.00

$901.00

$498.00

$472.00

$140.00

$996.00

$1,156.00

$1,254.00

$1,243.00

$1,384.00

$1,064.00

$1,244.00

$1,194.00

$1,193.00

$1,374.00

$791.00

$957.00

$1,089.00

$1,031.00

$727.00

$739.00

$803.00

$581.00

$636.00

$779.00

$649.00

$877.00

$636.00

$818.00

$720.00

$712.00

$636.00

$1,565.00

$1,162.00

$805.00

$994.00

$723.00

$1,063.00

$697.00

$744.00

$912.00

$875.00

$864.00

$1,359.00

$803.00

$1,000.00

$573.00

$563.00

$553.00

$861.00

$846.00

$956.00

$531.00

$505.00

$150.00

$1,064.00

$1,237.00

$1,337.00

$1,327.00

$1,478.00

$1,135.00

$1,328.00

$1,276.00

$1,276.00

$1,468.00

$845.00

$1,022.00

$1,161.00

$1,096.00

$774.00

$787.00

$859.00

$619.00

$676.00

$827.00

$691.00

$937.00

$678.00

$874.00

$766.00

$758.00

$678.00

$1,663.00

$1,235.00

$860.00

$1,060.00

$770.00

$1,136.00

$744.00

$794.00

$974.00

$934.00

$922.00

$1,449.00

$857.00

$1,064.00

$612.00

$601.00

$590.00

$918.00

$904.00

$1,007.00

$561.00

$526.00

$156.00

$1,110.00

$1,302.00

$1,407.00

$1,412.00

$1,576.00

$1,188.00

$1,398.00

$1,343.00

$1,353.00

$1,551.00

$882.00

$1,071.00

$1,223.00

$1,158.00

$820.00

$836.00

$887.00

$653.00

$714.00

$869.00

$732.00

$1,002.00

$717.00

$934.00

$812.00

$803.00

$718.00

$1,766.00

$1,310.00

$894.00

$1,111.00

$816.00

$1,193.00

$775.00

$829.00

$1,024.00

$978.00

$960.00

$1,521.00

$891.00

$1,125.00

$640.00

$627.00

$617.00

$959.00

$949.00

$901.00

$498.00

$472.00

$108.00

$996.00

$1,156.00

$1,254.00

$1,243.00

$1,384.00

$1,064.00

$1,244.00

$1,194.00

$1,193.00

$1,374.00

$791.00

$957.00

$1,089.00

$1,031.00

$727.00

$739.00

$478.00

$581.00

$636.00

$779.00

$649.00

$877.00

$636.00

$818.00

$720.00

$712.00

$636.00

$1,565.00

$1,162.00

$805.00

$994.00

$723.00

$1,063.00

$697.00

$744.00

$912.00

$875.00

$864.00

$1,359.00

$803.00

$1,000.00

$573.00

$563.00

$553.00

$861.00

$846.00

$956.00

$531.00

$505.00

$115.00

$1,064.00

$1,237.00

$1,337.00

$1,327.00

$1,478.00

$1,135.00

$1,328.00

$1,276.00

$1,276.00

$1,468.00

$845.00

$1,022.00

$1,161.00

$1,096.00

$774.00

$787.00

$510.00

$619.00

$676.00

$827.00

$691.00

$937.00

$678.00

$874.00

$766.00

$758.00

$678.00

$1,663.00

$1,235.00

$860.00

$1,060.00

$770.00

$1,136.00

$744.00

$794.00

$974.00

$934.00

$922.00

$1,449.00

$857.00

$1,064.00

$612.00

$601.00

$590.00

$918.00

$904.00

$1,007.00

$561.00

$526.00

$122.00

$1,110.00

$1,302.00

$1,407.00

$1,412.00

$1,576.00

$1,188.00

$1,398.00

$1,343.00

$1,353.00

$1,551.00

$882.00

$1,071.00

$1,223.00

$1,158.00

$820.00

$836.00

$536.00

$653.00

$714.00

$869.00

$732.00

$1,002.00

$717.00

$934.00

$812.00

$803.00

$718.00

$1,766.00

$1,310.00

$894.00

$1,111.00

$816.00

$1,193.00

$775.00

$829.00

$1,024.00

$978.00

$960.00

$1,521.00

$891.00

$1,125.00

$640.00

$627.00

$617.00

$959.00

$949.00


Part B, 187



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

26525

26530

26531

26535

26536

26540

26541

26542

26545

26546

26500

26502

26508

26510

26516

26517

26518

26520

26476

26477

26478

26479

26480

26483

26485

26489

26490

26492

26494

26496

26497

26498

26499

26561

26562

26565

26567

26568

26580

26587

26590

26591

26548

26550

26551

26553

26554

26555

26556

26560

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

$543.00

$553.00

$608.00

$653.00

$808.00

$986.00

$891.00

90

90

90

90

90

$738.00

$496.00

$971.00

$946.00

$949.00

90 $946.00

90 $1,317.00

90 $934.00

$557.00

$715.00

$334.00

$564.00

$630.00

$890.00

$877.00

$583.00

$531.00

$708.00

$877.00

$546.00

$770.00

$726.00

$926.00

$716.00

$722.00

$918.00

90 $665.00

90 $1,861.00

90 $3,901.00

90 $3,868.00

90 $4,551.00

90 $1,567.00

90 $4,005.00

90 $576.00

90 $1,067.00

90 $1,017.00

90 $730.00

90 $622.00

90 $1,003.00

90 $1,585.00

90 $792.00

90 $1,609.00

90 $431.00

$875.00

$978.00

$905.00

$831.00

$984.00

$1,170.00

$1,163.00

$908.00

$910.00

$774.00

$901.00

$605.00

$998.00

$924.00

$1,133.00

$953.00

$970.00

$1,404.00

$808.00

$813.00

$871.00

$857.00

$1,051.00

$1,188.00

$1,135.00

$1,283.00

$1,110.00

$1,232.00

$1,116.00

$1,214.00

$1,235.00

$1,642.00

$1,182.00

$1,072.00

$2,219.00

$4,138.00

$4,797.00

$4,816.00

$1,924.00

$4,982.00

$786.00

$1,321.00

$1,932.00

$953.00

$958.00

$1,275.00

$2,103.00

$1,325.00

$1,958.00

$606.00

$933.00

$1,041.00

$968.00

$885.00

$1,049.00

$1,250.00

$1,237.00

$970.00

$971.00

$825.00

$960.00

$643.00

$1,064.00

$985.00

$1,207.00

$1,016.00

$1,034.00

$1,497.00

$861.00

$867.00

$929.00

$912.00

$1,120.00

$1,267.00

$1,211.00

$1,364.00

$1,183.00

$1,310.00

$1,190.00

$1,293.00

$1,320.00

$1,754.00

$1,263.00

$1,142.00

$2,355.00

$4,364.00

$5,122.00

$5,078.00

$2,049.00

$5,321.00

$838.00

$1,406.00

$2,065.00

$1,016.00

$1,021.00

$1,363.00

$2,235.00

$1,402.00

$2,092.00

$647.00

$978.00

$1,088.00

$1,018.00

$923.00

$1,099.00

$1,321.00

$1,296.00

$1,011.00

$1,012.00

$874.00

$1,018.00

$678.00

$1,109.00

$1,032.00

$1,271.00

$1,065.00

$1,084.00

$1,576.00

$896.00

$906.00

$972.00

$951.00

$1,168.00

$1,330.00

$1,268.00

$1,426.00

$1,243.00

$1,375.00

$1,253.00

$1,361.00

$1,400.00

$1,869.00

$1,338.00

$1,200.00

$2,492.00

$4,625.00

$5,514.00

$5,386.00

$2,171.00

$5,725.00

$875.00

$1,482.00

$2,201.00

$1,066.00

$1,071.00

$1,437.00

$2,367.00

$1,488.00

$2,247.00

$671.00

$875.00

$978.00

$905.00

$831.00

$984.00

$1,170.00

$1,163.00

$908.00

$910.00

$774.00

$901.00

$605.00

$998.00

$924.00

$1,133.00

$953.00

$970.00

$1,404.00

$808.00

$813.00

$871.00

$857.00

$1,051.00

$1,188.00

$1,135.00

$1,283.00

$1,110.00

$1,232.00

$1,116.00

$1,214.00

$1,235.00

$1,642.00

$1,182.00

$1,072.00

$2,219.00

$4,138.00

$4,797.00

$4,816.00

$1,924.00

$4,982.00

$786.00

$1,321.00

$1,932.00

$953.00

$958.00

$1,275.00

$2,103.00

$1,325.00

$1,958.00

$606.00

$933.00

$1,041.00

$968.00

$885.00

$1,049.00

$1,250.00

$1,237.00

$970.00

$971.00

$825.00

$960.00

$643.00

$1,064.00

$985.00

$1,207.00

$1,016.00

$1,034.00

$1,497.00

$861.00

$867.00

$929.00

$912.00

$1,120.00

$1,267.00

$1,211.00

$1,364.00

$1,183.00

$1,310.00

$1,190.00

$1,293.00

$1,320.00

$1,754.00

$1,263.00

$1,142.00

$2,355.00

$4,364.00

$5,122.00

$5,078.00

$2,049.00

$5,321.00

$838.00

$1,406.00

$2,065.00

$1,016.00

$1,021.00

$1,363.00

$2,235.00

$1,402.00

$2,092.00

$647.00

$978.00

$1,088.00

$1,018.00

$923.00

$1,099.00

$1,321.00

$1,296.00

$1,011.00

$1,012.00

$874.00

$1,018.00

$678.00

$1,109.00

$1,032.00

$1,271.00

$1,065.00

$1,084.00

$1,576.00

$896.00

$906.00

$972.00

$951.00

$1,168.00

$1,330.00

$1,268.00

$1,426.00

$1,243.00

$1,375.00

$1,253.00

$1,361.00

$1,400.00

$1,869.00

$1,338.00

$1,200.00

$2,492.00

$4,625.00

$5,514.00

$5,386.00

$2,171.00

$5,725.00

$875.00

$1,482.00

$2,201.00

$1,066.00

$1,071.00

$1,437.00

$2,367.00

$1,488.00

$2,247.00

$671.00


Part B, 188



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

26735

26740

26742

26746

26750

26755

26756

26765

26770

26775

26686

26700

26705

26706

26715

26720

26725

26727

26593

26596

26600

26605

26607

26608

26615

26641

26645

26650

26665

26670

26675

26676

26685

26852

26860

26861

26862

26863

26910

26951

26952

26989

26776

26785

26820

26841

26842

26843

26844

26850

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

$401.00

$408.00

$854.00

$756.00

$901.00

$800.00

$875.00

$704.00

90

90

$829.00

$542.00

ZZZ $151.00

90 $747.00

ZZZ $317.00

90

90

$747.00

$444.00

90

YYY

$608.00

BR

$710.00

$88.00

$296.00

$469.00

$526.00

$96.00

$187.00

$187.00

$532.00

$148.00

$148.00

$548.00

$96.00

$133.00

$366.00

$398.00

$79.00

$275.00

$587.00

$809.00

$133.00

$296.00

$334.00

$497.00

$521.00

$71.00

$371.00

$533.00

$693.00

$148.00

$501.00

$527.00

$592.00

$907.00

$458.00

$594.00

$633.00

$824.00

$279.00

$478.00

$673.00

$861.00

$325.00

$524.00

$1,074.00

$260.00

$444.00

$597.00

$720.00

$390.00

$543.00

$839.00

$1,068.00

$415.00

$456.00

$654.00

$685.00

$832.00

$523.00

$603.00

$685.00

$917.00

$482.00

$646.00

$718.00

$831.00

$635.00

$789.00

$1,116.00

$1,023.00

$1,111.00

$1,048.00

$1,145.00

$973.00

$1,123.00

$789.00

$153.00

$1,023.00

$342.00

$1,020.00

$919.00

$908.00

--------

$969.00

$487.00

$633.00

$675.00

$878.00

$297.00

$510.00

$718.00

$918.00

$347.00

$559.00

$1,144.00

$276.00

$473.00

$637.00

$768.00

$413.00

$579.00

$895.00

$1,134.00

$443.00

$486.00

$697.00

$730.00

$887.00

$556.00

$643.00

$731.00

$980.00

$512.00

$690.00

$766.00

$886.00

$677.00

$841.00

$1,192.00

$1,091.00

$1,185.00

$1,121.00

$1,219.00

$1,037.00

$1,197.00

$843.00

$162.00

$1,091.00

$365.00

$1,088.00

$981.00

$968.00

--------

$1,036.00

$510.00

$665.00

$714.00

$929.00

$309.00

$534.00

$759.00

$974.00

$362.00

$587.00

$1,217.00

$288.00

$493.00

$670.00

$811.00

$432.00

$606.00

$934.00

$1,191.00

$461.00

$508.00

$738.00

$772.00

$940.00

$582.00

$679.00

$772.00

$1,045.00

$537.00

$729.00

$809.00

$939.00

$714.00

$891.00

$1,259.00

$1,146.00

$1,248.00

$1,185.00

$1,279.00

$1,088.00

$1,259.00

$879.00

$175.00

$1,145.00

$396.00

$1,148.00

$1,028.00

$1,016.00

--------

$907.00

$432.00

$547.00

$633.00

$824.00

$260.00

$434.00

$673.00

$861.00

$306.00

$479.00

$1,074.00

$260.00

$389.00

$597.00

$720.00

$362.00

$494.00

$839.00

$1,068.00

$392.00

$417.00

$654.00

$685.00

$832.00

$479.00

$557.00

$685.00

$917.00

$440.00

$596.00

$718.00

$831.00

$635.00

$789.00

$1,116.00

$1,023.00

$1,111.00

$1,048.00

$1,145.00

$973.00

$1,123.00

$789.00

$153.00

$1,023.00

$342.00

$1,020.00

$919.00

$908.00

--------

$969.00

$458.00

$583.00

$675.00

$878.00

$277.00

$462.00

$718.00

$918.00

$327.00

$510.00

$1,144.00

$277.00

$413.00

$637.00

$768.00

$384.00

$526.00

$895.00

$1,134.00

$418.00

$445.00

$697.00

$730.00

$887.00

$509.00

$594.00

$731.00

$980.00

$467.00

$637.00

$766.00

$886.00

$677.00

$841.00

$1,192.00

$1,091.00

$1,185.00

$1,121.00

$1,219.00

$1,037.00

$1,197.00

$843.00

$162.00

$1,091.00

$365.00

$1,088.00

$981.00

$968.00

--------

$1,036.00

$481.00

$615.00

$714.00

$929.00

$289.00

$486.00

$759.00

$974.00

$342.00

$538.00

$1,217.00

$288.00

$434.00

$670.00

$811.00

$402.00

$553.00

$934.00

$1,191.00

$436.00

$467.00

$738.00

$772.00

$940.00

$535.00

$629.00

$772.00

$1,045.00

$491.00

$676.00

$809.00

$939.00

$714.00

$891.00

$1,259.00

$1,146.00

$1,248.00

$1,185.00

$1,279.00

$1,088.00

$1,259.00

$879.00

$175.00

$1,145.00

$396.00

$1,148.00

$1,028.00

$1,016.00

--------


Part B, 189



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

27054

27057

27059

27060

27062

27065

27066

27067

27070

27071

27041

27043

27045

27047

27048

27049

27050

27052

26990

26991

26992

27000

27001

27003

27005

27006

27025

27027

27030

27033

27035

27036

27040

27091

27093

27095

27096

27097

27098

27100

27105

27110

27075

27076

27077

27078

27080

27086

27087

27090

90

90

$592.00

$466.00

90 $1,146.00

90 $421.00

90

90

90

$550.00

$698.00

$738.00

90

90

$788.00

$896.00

90 --------

90 $1,148.00

90 $1,173.00

90 $1,413.00

90 $1,176.00

10 $196.00

90

90

90

90

90

$699.00

--------

--------

$535.00

$588.00

90 $1,162.00

90 $449.00

90 $624.00

90

90

90

90

90

$843.00

--------

--------

$491.00

$499.00

90

90

$583.00

$931.00

90 $1,234.00

90 $1,040.00

90 $1,112.00

90 $1,485.00

90 $1,859.00

90 $1,976.00

90 $1,164.00

90 $568.00

10

90

90

$57.00

$555.00

$981.00

90 $1,482.00

0 $62.00

0 $121.00

0

90

90

90

$491.00

$795.00

$799.00

$987.00

90 $946.00

90 $1,174.00

$1,008.00

$695.00

$1,104.00

$672.00

$900.00

$1,997.00

$554.00

$838.00

$997.00

$1,490.00

$2,696.00

$672.00

$663.00

$742.00

$1,182.00

$1,498.00

$1,235.00

$1,337.00

$908.00

$1,004.00

$1,398.00

$603.00

$780.00

$866.00

$1,055.00

$1,071.00

$1,336.00

$1,319.00

$1,371.00

$1,424.00

$1,683.00

$1,477.00

$486.00

$3,096.00

$3,740.00

$4,208.00

$3,048.00

$751.00

$408.00

$915.00

$1,213.00

$2,352.00

$262.00

$337.00

$226.00

$981.00

$973.00

$1,193.00

$1,268.00

$1,416.00

$1,073.00

$745.00

$1,181.00

$719.00

$963.00

$2,133.00

$590.00

$895.00

$1,063.00

$1,591.00

$2,879.00

$718.00

$708.00

$791.00

$1,261.00

$1,596.00

$1,317.00

$1,427.00

$970.00

$1,072.00

$1,490.00

$640.00

$832.00

$925.00

$1,125.00

$1,142.00

$1,424.00

$1,408.00

$1,463.00

$1,519.00

$1,792.00

$1,575.00

$518.00

$3,304.00

$3,990.00

$4,492.00

$3,252.00

$804.00

$437.00

$976.00

$1,294.00

$2,509.00

$279.00

$359.00

$239.00

$1,047.00

$1,035.00

$1,271.00

$1,354.00

$1,512.00

$1,148.00

$808.00

$1,275.00

$762.00

$1,040.00

$2,312.00

$623.00

$955.00

$1,135.00

$1,713.00

$3,120.00

$765.00

$755.00

$842.00

$1,347.00

$1,708.00

$1,407.00

$1,525.00

$1,036.00

$1,127.00

$1,592.00

$677.00

$887.00

$987.00

$1,202.00

$1,219.00

$1,522.00

$1,511.00

$1,570.00

$1,630.00

$1,919.00

$1,687.00

$537.00

$3,565.00

$4,309.00

$4,859.00

$3,508.00

$864.00

$453.00

$1,045.00

$1,386.00

$2,698.00

$285.00

$367.00

$245.00

$1,119.00

$1,102.00

$1,357.00

$1,452.00

$1,621.00

$1,008.00

$695.00

$1,104.00

$531.00

$900.00

$1,997.00

$554.00

$838.00

$997.00

$1,490.00

$2,696.00

$672.00

$663.00

$742.00

$1,182.00

$1,498.00

$1,235.00

$1,337.00

$908.00

$758.00

$1,398.00

$603.00

$780.00

$866.00

$1,055.00

$1,071.00

$1,336.00

$1,319.00

$1,371.00

$1,424.00

$1,683.00

$1,477.00

$291.00

$3,096.00

$3,740.00

$4,208.00

$3,048.00

$751.00

$240.00

$915.00

$1,213.00

$2,352.00

$102.00

$121.00

$122.00

$981.00

$973.00

$1,193.00

$1,268.00

$1,416.00

$1,073.00

$745.00

$1,181.00

$568.00

$963.00

$2,133.00

$590.00

$895.00

$1,063.00

$1,591.00

$2,879.00

$718.00

$708.00

$791.00

$1,261.00

$1,596.00

$1,317.00

$1,427.00

$970.00

$809.00

$1,490.00

$640.00

$832.00

$925.00

$1,125.00

$1,142.00

$1,424.00

$1,408.00

$1,463.00

$1,519.00

$1,792.00

$1,575.00

$309.00

$3,304.00

$3,990.00

$4,492.00

$3,252.00

$804.00

$256.00

$976.00

$1,294.00

$2,509.00

$107.00

$127.00

$128.00

$1,047.00

$1,035.00

$1,271.00

$1,354.00

$1,512.00

$1,148.00

$808.00

$1,275.00

$610.00

$1,040.00

$2,312.00

$623.00

$955.00

$1,135.00

$1,713.00

$3,120.00

$765.00

$755.00

$842.00

$1,347.00

$1,708.00

$1,407.00

$1,525.00

$1,036.00

$863.00

$1,592.00

$677.00

$887.00

$987.00

$1,202.00

$1,219.00

$1,522.00

$1,511.00

$1,570.00

$1,630.00

$1,919.00

$1,687.00

$327.00

$3,565.00

$4,309.00

$4,859.00

$3,508.00

$864.00

$272.00

$1,045.00

$1,386.00

$2,698.00

$113.00

$135.00

$133.00

$1,119.00

$1,102.00

$1,357.00

$1,452.00

$1,621.00


Part B, 190



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

27181

27185

27187

27193

27194

27200

27202

27215

27216

27217

27161

27165

27170

27175

27176

27177

27178

27179

27111

27120

27122

27125

27130

27132

27134

27137

27138

27140

27146

27147

27151

27156

27158

27235

27236

27238

27240

27244

27245

27246

27248

27250

27218

27220

27222

27226

27227

27228

27230

27232

90 $1,099.00

90 $1,603.00

90 $1,406.00

90 $1,371.00

90 $1,853.00

90 $2,128.00

90 $2,576.00

90 $2,190.00

90 $2,025.00

90 $1,092.00

90 $1,432.00

90 $1,744.00

90 $1,732.00

90 $2,017.00

90 $1,588.00

90 $1,443.00

90 $1,572.00

90 $1,453.00

90 $491.00

90 $1,024.00

90 $1,257.00

90 $1,020.00

90 $1,107.00

90 $1,206.00

90 $676.00

90 $1,280.00

90 $425.00

90 $740.00

90

90

$180.00

$776.00

90 $954.00

90 $1,085.00

90 $1,285.00

90 $1,570.00

90 $444.00

90 $973.00

90 $1,350.00

90 $1,967.00

90 $2,195.00

90 $491.00

90 $916.00

90 $1,128.00

90 $1,421.00

90 $504.00

90 $1,043.00

90 $1,426.00

90 $1,691.00

90 $459.00

90

0

$980.00

$535.00

$1,783.00

$2,018.00

$1,729.00

$977.00

$1,317.00

$1,637.00

$1,345.00

$1,432.00

$1,407.00

$885.00

$1,453.00

$683.00

$1,032.00

$258.00

$772.00

$910.00

$1,350.00

$1,266.00

$1,317.00

$1,913.00

$1,613.00

$1,665.00

$1,996.00

$2,467.00

$2,829.00

$2,171.00

$2,256.00

$1,308.00

$1,893.00

$2,168.00

$2,340.00

$2,534.00

$2,108.00

$1,753.00

$770.00

$1,430.00

$1,551.00

$2,446.00

$2,791.00

$685.00

$1,105.00

$1,334.00

$1,758.00

$666.00

$1,402.00

$1,810.00

$1,809.00

$558.00

$1,089.00

$269.00

$1,901.00

$2,151.00

$1,844.00

$1,043.00

$1,404.00

$1,748.00

$1,436.00

$1,529.00

$1,484.00

$934.00

$1,550.00

$729.00

$1,099.00

$275.00

$823.00

$960.00

$1,424.00

$1,335.00

$1,407.00

$2,043.00

$1,720.00

$1,776.00

$2,128.00

$2,630.00

$3,016.00

$2,314.00

$2,405.00

$1,395.00

$2,022.00

$2,315.00

$2,496.00

$2,706.00

$2,260.00

$1,848.00

$822.00

$1,526.00

$1,654.00

$2,609.00

$2,977.00

$731.00

$1,176.00

$1,424.00

$1,875.00

$711.00

$1,496.00

$1,931.00

$1,930.00

$595.00

$1,161.00

$284.00

$2,041.00

$2,308.00

$1,982.00

$1,120.00

$1,504.00

$1,879.00

$1,541.00

$1,643.00

$1,571.00

$987.00

$1,662.00

$776.00

$1,174.00

$288.00

$878.00

$1,017.00

$1,508.00

$1,414.00

$1,510.00

$2,199.00

$1,846.00

$1,908.00

$2,289.00

$2,828.00

$3,249.00

$2,490.00

$2,588.00

$1,493.00

$2,177.00

$2,494.00

$2,687.00

$2,918.00

$2,454.00

$1,961.00

$876.00

$1,637.00

$1,776.00

$2,810.00

$3,209.00

$776.00

$1,263.00

$1,529.00

$2,014.00

$755.00

$1,605.00

$2,075.00

$2,073.00

$633.00

$1,246.00

$307.00

$1,783.00

$2,018.00

$1,729.00

$977.00

$1,317.00

$1,637.00

$1,345.00

$1,432.00

$1,407.00

$885.00

$1,453.00

$691.00

$1,032.00

$268.00

$772.00

$910.00

$1,350.00

$1,266.00

$1,317.00

$1,913.00

$1,613.00

$1,665.00

$1,996.00

$2,467.00

$2,829.00

$2,171.00

$2,256.00

$1,308.00

$1,893.00

$2,168.00

$2,340.00

$2,534.00

$2,108.00

$1,753.00

$764.00

$1,430.00

$1,551.00

$2,446.00

$2,791.00

$681.00

$1,105.00

$1,334.00

$1,758.00

$666.00

$1,402.00

$1,810.00

$1,809.00

$560.00

$1,089.00

$269.00

$1,901.00

$2,151.00

$1,844.00

$1,043.00

$1,404.00

$1,748.00

$1,436.00

$1,529.00

$1,484.00

$934.00

$1,550.00

$738.00

$1,099.00

$286.00

$823.00

$960.00

$1,424.00

$1,335.00

$1,407.00

$2,043.00

$1,720.00

$1,776.00

$2,128.00

$2,630.00

$3,016.00

$2,314.00

$2,405.00

$1,395.00

$2,022.00

$2,315.00

$2,496.00

$2,706.00

$2,260.00

$1,848.00

$815.00

$1,526.00

$1,654.00

$2,609.00

$2,977.00

$727.00

$1,176.00

$1,424.00

$1,875.00

$711.00

$1,496.00

$1,931.00

$1,930.00

$598.00

$1,161.00

$284.00

$2,041.00

$2,308.00

$1,982.00

$1,120.00

$1,504.00

$1,879.00

$1,541.00

$1,643.00

$1,571.00

$987.00

$1,662.00

$785.00

$1,174.00

$300.00

$878.00

$1,017.00

$1,508.00

$1,414.00

$1,510.00

$2,199.00

$1,846.00

$1,908.00

$2,289.00

$2,828.00

$3,249.00

$2,490.00

$2,588.00

$1,493.00

$2,177.00

$2,494.00

$2,687.00

$2,918.00

$2,454.00

$1,961.00

$869.00

$1,637.00

$1,776.00

$2,810.00

$3,209.00

$772.00

$1,263.00

$1,529.00

$2,014.00

$755.00

$1,605.00

$2,075.00

$2,073.00

$636.00

$1,246.00

$307.00


Part B, 191



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

27305

27306

27307

27310

27323

27324

27325

27326

27327

27328

27282

27284

27286

27290

27295

27299

27301

27303

27252

27253

27254

27256

27257

27258

27259

27265

27266

27267

27268

27269

27275

27279

27280

27339

27340

27345

27347

27350

27355

27356

27357

27358

27329

27330

27331

27332

27333

27334

27335

27337

90 $520.00

90 $1,162.00

90 $1,478.00

10 $338.00

10 $455.00

90 $1,355.00

90 $1,803.00

90

90

90

90

90

$442.00

$614.00

--------

--------

--------

10

90

$220.00

--------

90 $1,179.00

90

90

90

90

90

90

90

90

90

10

90 $990.00

90 $1,435.00

90 $1,503.00

90 $2,073.00

90 $1,594.00

YYY

90

90

BR

$193.00

$520.00

$555.00

$377.00

$503.00

$877.00

$211.00

$433.00

--------

--------

$400.00

$503.00

90 $1,249.00

90 $492.00

90 $585.00

90

90

90

90

90

$786.00

$719.00

$840.00

$959.00

--------

90

90

90

90

90

90

90

--------

$405.00

$565.00

$394.00

$786.00

$763.00

$882.00

90 $950.00

ZZZ $394.00

$1,204.00

$2,296.00

$2,402.00

$2,375.00

$1,861.00

--------

$962.00

$929.00

$697.00

$511.00

$669.00

$1,067.00

$384.00

$581.00

$794.00

$755.00

$655.00

$912.00

$1,111.00

$1,378.00

$1,863.00

$431.00

$534.00

$1,631.00

$2,290.00

$574.00

$847.00

$630.00

$774.00

$1,827.00

$263.00

$1,027.00

$2,037.00

$1,529.00

$606.00

$689.00

$932.00

$852.00

$995.00

$1,113.00

$616.00

$1,111.00

$537.00

$697.00

$769.00

$947.00

$875.00

$1,074.00

$1,188.00

$413.00

$1,282.00

$2,442.00

$2,555.00

$2,535.00

$1,987.00

--------

$1,030.00

$991.00

$744.00

$540.00

$713.00

$1,138.00

$410.00

$622.00

$847.00

$808.00

$701.00

$975.00

$1,184.00

$1,471.00

$1,986.00

$457.00

$571.00

$1,742.00

$2,445.00

$609.00

$905.00

$672.00

$826.00

$1,948.00

$281.00

$1,106.00

$2,196.00

$1,634.00

$648.00

$735.00

$995.00

$911.00

$1,062.00

$1,188.00

$660.00

$1,189.00

$574.00

$744.00

$821.00

$1,011.00

$934.00

$1,145.00

$1,268.00

$440.00

$1,368.00

$2,624.00

$2,737.00

$2,735.00

$2,146.00

--------

$1,087.00

$1,059.00

$791.00

$566.00

$758.00

$1,217.00

$426.00

$667.00

$903.00

$865.00

$736.00

$1,050.00

$1,270.00

$1,578.00

$2,134.00

$484.00

$614.00

$1,873.00

$2,634.00

$642.00

$967.00

$714.00

$880.00

$2,096.00

$298.00

$1,204.00

$2,413.00

$1,766.00

$690.00

$783.00

$1,062.00

$972.00

$1,134.00

$1,270.00

$713.00

$1,284.00

$610.00

$792.00

$875.00

$1,078.00

$997.00

$1,225.00

$1,358.00

$476.00

$1,204.00

$2,296.00

$2,402.00

$2,375.00

$1,861.00

--------

$732.00

$929.00

$697.00

$511.00

$669.00

$1,067.00

$258.00

$581.00

$794.00

$755.00

$458.00

$912.00

$1,111.00

$1,378.00

$1,863.00

$344.00

$534.00

$1,631.00

$2,290.00

$574.00

$847.00

$630.00

$774.00

$1,827.00

$263.00

$1,027.00

$2,037.00

$1,529.00

$606.00

$689.00

$932.00

$852.00

$995.00

$1,113.00

$616.00

$1,111.00

$537.00

$697.00

$769.00

$947.00

$875.00

$1,074.00

$1,188.00

$413.00

$1,282.00

$2,442.00

$2,555.00

$2,535.00

$1,987.00

--------

$783.00

$991.00

$744.00

$540.00

$713.00

$1,138.00

$275.00

$622.00

$847.00

$808.00

$490.00

$975.00

$1,184.00

$1,471.00

$1,986.00

$364.00

$571.00

$1,742.00

$2,445.00

$609.00

$905.00

$672.00

$826.00

$1,948.00

$281.00

$1,106.00

$2,196.00

$1,634.00

$648.00

$735.00

$995.00

$911.00

$1,062.00

$1,188.00

$660.00

$1,189.00

$574.00

$744.00

$821.00

$1,011.00

$934.00

$1,145.00

$1,268.00

$440.00

$1,368.00

$2,624.00

$2,737.00

$2,735.00

$2,146.00

--------

$839.00

$1,059.00

$791.00

$566.00

$758.00

$1,217.00

$291.00

$667.00

$903.00

$865.00

$524.00

$1,050.00

$1,270.00

$1,578.00

$2,134.00

$390.00

$614.00

$1,873.00

$2,634.00

$642.00

$967.00

$714.00

$880.00

$2,096.00

$298.00

$1,204.00

$2,413.00

$1,766.00

$690.00

$783.00

$1,062.00

$972.00

$1,134.00

$1,270.00

$713.00

$1,284.00

$610.00

$792.00

$875.00

$1,078.00

$997.00

$1,225.00

$1,358.00

$476.00


Part B, 192



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

27415

27416

27418

27420

27422

27424

27425

27427

27428

27429

27396

27397

27400

27403

27405

27407

27409

27412

27360

27364

27365

27370

27372

27380

27381

27385

27386

27390

27391

27392

27393

27394

27395

27445

27446

27447

27448

27450

27454

27455

27457

27465

27430

27435

27437

27438

27440

27441

27442

27443

90

90

$977.00

--------

90 $1,421.00

0 $75.00

90

90

$371.00

$698.00

90 $1,118.00

90 $753.00

90 $1,064.00

90

90

90

$506.00

$647.00

$834.00

90

90

$608.00

$748.00

90 $1,093.00

90

90

90

90

90

$742.00

$989.00

$832.00

$792.00

$842.00

90 $918.00

90 $1,212.00

90 --------

90

90

--------

--------

90 $1,596.00

90 $927.00

90 $930.00

90

90

$927.00

$639.00

90 $1,118.00

90 $1,266.00

90 $2,333.00

90

90

90

$884.00

$501.00

$819.00

90 $1,065.00

90 $1,064.00

90 $1,006.00

90 $1,117.00

90 $1,037.00

90 $1,618.00

90 $1,764.00

90 $1,960.00

90 $1,060.00

90 $1,311.00

90 $1,524.00

90 $1,157.00

90 $1,209.00

90 $1,253.00

$897.00

$1,322.00

$1,013.00

$932.00

$982.00

$1,135.00

$1,395.00

$2,434.00

$2,013.00

$1,434.00

$1,210.00

$1,086.00

$1,082.00

$1,093.00

$649.00

$1,038.00

$1,629.00

$1,820.00

$1,240.00

$2,313.00

$3,057.00

$216.00

$861.00

$861.00

$1,160.00

$831.00

$1,207.00

$649.00

$839.00

$1,033.00

$735.00

$920.00

$1,285.00

$1,078.00

$1,175.00

$964.00

$1,228.00

$1,168.00

$1,204.00

$1,271.00

$1,179.00

$1,834.00

$1,705.00

$1,996.00

$1,131.00

$1,480.00

$1,913.00

$1,378.00

$1,386.00

$1,815.00

$959.00

$1,412.00

$1,082.00

$995.00

$1,047.00

$1,211.00

$1,487.00

$2,598.00

$2,149.00

$1,531.00

$1,290.00

$1,158.00

$1,154.00

$1,168.00

$693.00

$1,106.00

$1,738.00

$1,941.00

$1,323.00

$2,471.00

$3,261.00

$230.00

$921.00

$919.00

$1,237.00

$887.00

$1,288.00

$693.00

$897.00

$1,101.00

$784.00

$975.00

$1,373.00

$1,150.00

$1,253.00

$1,029.00

$1,310.00

$1,247.00

$1,285.00

$1,356.00

$1,258.00

$1,956.00

$1,817.00

$2,128.00

$1,201.00

$1,578.00

$2,043.00

$1,471.00

$1,476.00

$1,935.00

$1,025.00

$1,514.00

$1,158.00

$1,062.00

$1,117.00

$1,296.00

$1,593.00

$2,796.00

$2,309.00

$1,643.00

$1,380.00

$1,239.00

$1,233.00

$1,251.00

$738.00

$1,181.00

$1,861.00

$2,075.00

$1,413.00

$2,675.00

$3,517.00

$235.00

$962.00

$978.00

$1,321.00

$942.00

$1,374.00

$737.00

$958.00

$1,173.00

$834.00

$1,026.00

$1,472.00

$1,228.00

$1,337.00

$1,102.00

$1,402.00

$1,338.00

$1,377.00

$1,452.00

$1,347.00

$2,101.00

$1,953.00

$2,288.00

$1,278.00

$1,690.00

$2,199.00

$1,578.00

$1,580.00

$2,078.00

$897.00

$1,322.00

$1,013.00

$932.00

$982.00

$1,135.00

$1,395.00

$2,434.00

$2,013.00

$1,434.00

$1,210.00

$1,086.00

$1,082.00

$1,093.00

$649.00

$1,038.00

$1,629.00

$1,820.00

$1,240.00

$2,313.00

$3,057.00

$74.00

$586.00

$861.00

$1,160.00

$831.00

$1,207.00

$649.00

$839.00

$1,033.00

$735.00

$920.00

$1,285.00

$1,078.00

$1,175.00

$964.00

$1,228.00

$1,168.00

$1,204.00

$1,271.00

$1,179.00

$1,834.00

$1,705.00

$1,996.00

$1,131.00

$1,480.00

$1,913.00

$1,378.00

$1,386.00

$1,815.00

$959.00

$1,412.00

$1,082.00

$995.00

$1,047.00

$1,211.00

$1,487.00

$2,598.00

$2,149.00

$1,531.00

$1,290.00

$1,158.00

$1,154.00

$1,168.00

$693.00

$1,106.00

$1,738.00

$1,941.00

$1,323.00

$2,471.00

$3,261.00

$78.00

$625.00

$919.00

$1,237.00

$887.00

$1,288.00

$693.00

$897.00

$1,101.00

$784.00

$975.00

$1,373.00

$1,150.00

$1,253.00

$1,029.00

$1,310.00

$1,247.00

$1,285.00

$1,356.00

$1,258.00

$1,956.00

$1,817.00

$2,128.00

$1,201.00

$1,578.00

$2,043.00

$1,471.00

$1,476.00

$1,935.00

$1,025.00

$1,514.00

$1,158.00

$1,062.00

$1,117.00

$1,296.00

$1,593.00

$2,796.00

$2,309.00

$1,643.00

$1,380.00

$1,239.00

$1,233.00

$1,251.00

$738.00

$1,181.00

$1,861.00

$2,075.00

$1,413.00

$2,675.00

$3,517.00

$82.00

$666.00

$978.00

$1,321.00

$942.00

$1,374.00

$737.00

$958.00

$1,173.00

$834.00

$1,026.00

$1,472.00

$1,228.00

$1,337.00

$1,102.00

$1,402.00

$1,338.00

$1,377.00

$1,452.00

$1,347.00

$2,101.00

$1,953.00

$2,288.00

$1,278.00

$1,690.00

$2,199.00

$1,578.00

$1,580.00

$2,078.00


Part B, 193



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

27509

27510

27511

27513

27514

27516

27517

27519

27520

27524

27499

27500

27501

27502

27503

27506

27507

27508

27466

27468

27470

27472

27475

27477

27479

27485

27486

27487

27488

27495

27496

27497

27498

27556

27557

27558

27560

27562

27566

27570

27580

27590

27530

27532

27535

27536

27538

27540

27550

27552

90 $1,441.00

90 $1,613.00

90 $1,501.00

90 $1,665.00

90

90

$782.00

$938.00

90 $1,123.00

90 $797.00

90 $1,771.00

90 $2,352.00

90 $1,438.00

90 $1,477.00

90

90

90

$563.00

$652.00

$701.00

90

90

90

90

90

$782.00

$520.00

$659.00

$909.00

$911.00

90 $1,522.00

90 $1,297.00

90 $400.00

90

90

$649.00

$755.00

90 $1,281.00

90 $1,562.00

90 $1,508.00

90

90

$579.00

$820.00

90 $1,311.00

90 $266.00

90 $910.00

90

90

$408.00

$641.00

90 $1,075.00

90 $1,282.00

90 $487.00

90 $1,106.00

90 $296.00

90 $619.00

90 $832.00

90 $1,479.00

90 $1,529.00

90

90

$88.00

$514.00

90 $1,047.00

10 $184.00

90 $1,644.00

90 $1,059.00

$1,016.00

$749.00

$730.00

$1,119.00

$1,173.00

$1,965.00

$1,429.00

$756.00

$931.00

$996.00

$1,467.00

$1,830.00

$1,422.00

$731.00

$986.00

$1,312.00

$459.00

$1,098.00

$1,728.00

$1,805.00

$1,724.00

$1,855.00

$966.00

$1,068.00

$1,150.00

$979.00

$2,068.00

$2,591.00

$1,762.00

$1,656.00

$786.00

$842.00

$942.00

$428.00

$890.00

$1,319.00

$1,747.00

$677.00

$1,182.00

$725.00

$909.00

$1,285.00

$1,546.00

$1,753.00

$516.00

$679.00

$1,305.00

$219.00

$2,109.00

$1,208.00

$1,084.00

$799.00

$780.00

$1,192.00

$1,252.00

$2,096.00

$1,524.00

$807.00

$993.00

$1,062.00

$1,564.00

$1,952.00

$1,517.00

$782.00

$1,054.00

$1,401.00

$490.00

$1,172.00

$1,842.00

$1,913.00

$1,839.00

$1,978.00

$1,032.00

$1,140.00

$1,213.00

$1,046.00

$2,205.00

$2,762.00

$1,879.00

$1,767.00

$840.00

$897.00

$1,006.00

$458.00

$950.00

$1,407.00

$1,864.00

$723.00

$1,261.00

$772.00

$970.00

$1,370.00

$1,651.00

$1,869.00

$549.00

$724.00

$1,393.00

$234.00

$2,250.00

$1,293.00

$1,158.00

$848.00

$831.00

$1,276.00

$1,342.00

$2,251.00

$1,638.00

$854.00

$1,055.00

$1,135.00

$1,683.00

$2,103.00

$1,631.00

$828.00

$1,131.00

$1,508.00

$512.00

$1,254.00

$1,975.00

$2,041.00

$1,973.00

$2,125.00

$1,104.00

$1,220.00

$1,285.00

$1,120.00

$2,369.00

$2,971.00

$2,017.00

$1,897.00

$895.00

$956.00

$1,076.00

$478.00

$1,010.00

$1,513.00

$2,001.00

$762.00

$1,349.00

$815.00

$1,035.00

$1,473.00

$1,781.00

$2,012.00

$576.00

$769.00

$1,493.00

$249.00

$2,415.00

$1,413.00

$1,016.00

$697.00

$725.00

$1,119.00

$1,173.00

$1,965.00

$1,429.00

$715.00

$931.00

$996.00

$1,467.00

$1,830.00

$1,422.00

$689.00

$986.00

$1,312.00

$420.00

$1,098.00

$1,728.00

$1,805.00

$1,724.00

$1,855.00

$966.00

$1,068.00

$1,150.00

$979.00

$2,068.00

$2,591.00

$1,762.00

$1,656.00

$786.00

$842.00

$942.00

$399.00

$839.00

$1,319.00

$1,747.00

$637.00

$1,182.00

$675.00

$909.00

$1,285.00

$1,546.00

$1,753.00

$478.00

$679.00

$1,305.00

$219.00

$2,109.00

$1,208.00

$1,084.00

$743.00

$774.00

$1,192.00

$1,252.00

$2,096.00

$1,524.00

$762.00

$993.00

$1,062.00

$1,564.00

$1,952.00

$1,517.00

$737.00

$1,054.00

$1,401.00

$448.00

$1,172.00

$1,842.00

$1,913.00

$1,839.00

$1,978.00

$1,032.00

$1,140.00

$1,213.00

$1,046.00

$2,205.00

$2,762.00

$1,879.00

$1,767.00

$840.00

$897.00

$1,006.00

$427.00

$895.00

$1,407.00

$1,864.00

$679.00

$1,261.00

$719.00

$970.00

$1,370.00

$1,651.00

$1,869.00

$508.00

$724.00

$1,393.00

$234.00

$2,250.00

$1,293.00

$1,158.00

$792.00

$826.00

$1,276.00

$1,342.00

$2,251.00

$1,638.00

$809.00

$1,055.00

$1,135.00

$1,683.00

$2,103.00

$1,631.00

$783.00

$1,131.00

$1,508.00

$471.00

$1,254.00

$1,975.00

$2,041.00

$1,973.00

$2,125.00

$1,104.00

$1,220.00

$1,285.00

$1,120.00

$2,369.00

$2,971.00

$2,017.00

$1,897.00

$895.00

$956.00

$1,076.00

$447.00

$955.00

$1,513.00

$2,001.00

$719.00

$1,349.00

$762.00

$1,035.00

$1,473.00

$1,781.00

$2,012.00

$535.00

$769.00

$1,493.00

$249.00

$2,415.00

$1,413.00


Part B, 194



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

27625

27626

27630

27632

27634

27635

27637

27638

27640

27641

27612

27613

27614

27615

27616

27618

27619

27620

27591

27592

27594

27596

27598

27599

27600

27601

27602

27603

27604

27605

27606

27607

27610

27658

27659

27664

27665

27675

27676

27680

27681

27685

27645

27646

27647

27648

27650

27652

27654

27656

90

90

90

90

10

10

90

90

90 $1,182.00

90 $911.00

90

90

90

YYY

90

$600.00

$931.00

$976.00

BR

$517.00

$516.00

$621.00

$412.00

$308.00

$236.00

$362.00

$608.00

$777.00

90

10

$701.00

$165.00

90 $327.00

90 $1,106.00

90 --------

90

90

90

$421.00

$730.00

$587.00

90

90

90

90

90

$796.00

$863.00

$430.00

--------

--------

90

90

$781.00

$921.00

90 $978.00

90 $1,122.00

90 $922.00

90

90

90

90

90

90

90

90

90

90 $1,302.00

90 $1,212.00

90 $1,044.00

0

90

90

90

90

$72.00

$869.00

$935.00

$937.00

$458.00

$527.00

$725.00

$504.00

$618.00

$656.00

$762.00

$523.00

$634.00

$565.00

$806.00

$356.00

$825.00

$1,508.00

$1,877.00

$640.00

$683.00

$658.00

$851.00

$898.00

$797.00

$609.00

$1,009.00

$855.00

$1,091.00

$1,114.00

$1,220.00

$975.00

$1,415.00

$1,022.00

$752.00

$1,081.00

$1,077.00

--------

$606.00

$649.00

$734.00

$760.00

$705.00

$481.00

$413.00

$886.00

$949.00

$2,618.00

$2,269.00

$1,482.00

$229.00

$955.00

$993.00

$1,027.00

$901.00

$539.00

$698.00

$521.00

$595.00

$705.00

$877.00

$623.00

$792.00

$946.00

$853.00

$379.00

$878.00

$1,609.00

$2,004.00

$684.00

$724.00

$699.00

$902.00

$952.00

$849.00

$651.00

$1,077.00

$910.00

$1,162.00

$1,186.00

$1,298.00

$1,035.00

$1,510.00

$1,093.00

$805.00

$1,157.00

$1,153.00

--------

$648.00

$693.00

$786.00

$812.00

$752.00

$510.00

$438.00

$944.00

$1,010.00

$2,793.00

$2,424.00

$1,537.00

$244.00

$1,013.00

$1,048.00

$1,085.00

$964.00

$571.00

$738.00

$553.00

$631.00

$744.00

$930.00

$662.00

$846.00

$1,004.00

$898.00

$391.00

$916.00

$1,735.00

$2,165.00

$715.00

$767.00

$739.00

$955.00

$1,008.00

$880.00

$700.00

$1,157.00

$969.00

$1,237.00

$1,264.00

$1,386.00

$1,100.00

$1,622.00

$1,189.00

$868.00

$1,256.00

$1,250.00

--------

$697.00

$743.00

$855.00

$854.00

$784.00

$522.00

$465.00

$1,006.00

$1,075.00

$3,010.00

$2,616.00

$1,592.00

$250.00

$1,070.00

$1,104.00

$1,144.00

$1,003.00

$600.00

$776.00

$582.00

$663.00

$782.00

$985.00

$700.00

$903.00

$1,040.00

$806.00

$235.00

$588.00

$1,508.00

$1,877.00

$447.00

$683.00

$658.00

$851.00

$898.00

$530.00

$609.00

$1,009.00

$855.00

$1,091.00

$1,114.00

$1,220.00

$975.00

$1,415.00

$1,022.00

$752.00

$1,081.00

$1,077.00

--------

$606.00

$649.00

$734.00

$567.00

$502.00

$266.00

$413.00

$886.00

$949.00

$2,618.00

$2,269.00

$1,482.00

$77.00

$955.00

$993.00

$1,027.00

$574.00

$539.00

$698.00

$521.00

$595.00

$705.00

$877.00

$623.00

$792.00

$672.00

$853.00

$248.00

$624.00

$1,609.00

$2,004.00

$477.00

$724.00

$699.00

$902.00

$952.00

$563.00

$651.00

$1,077.00

$910.00

$1,162.00

$1,186.00

$1,298.00

$1,035.00

$1,510.00

$1,093.00

$805.00

$1,157.00

$1,153.00

--------

$648.00

$693.00

$786.00

$606.00

$534.00

$279.00

$438.00

$944.00

$1,010.00

$2,793.00

$2,424.00

$1,537.00

$81.00

$1,013.00

$1,048.00

$1,085.00

$614.00

$571.00

$738.00

$553.00

$631.00

$744.00

$930.00

$662.00

$846.00

$710.00

$898.00

$260.00

$661.00

$1,735.00

$2,165.00

$508.00

$767.00

$739.00

$955.00

$1,008.00

$593.00

$700.00

$1,157.00

$969.00

$1,237.00

$1,264.00

$1,386.00

$1,100.00

$1,622.00

$1,189.00

$868.00

$1,256.00

$1,250.00

--------

$697.00

$743.00

$855.00

$647.00

$565.00

$291.00

$465.00

$1,006.00

$1,075.00

$3,010.00

$2,616.00

$1,592.00

$87.00

$1,070.00

$1,104.00

$1,144.00

$652.00

$600.00

$776.00

$582.00

$663.00

$782.00

$985.00

$700.00

$903.00

$745.00


Part B, 195



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

27730

27732

27734

27740

27742

27745

27750

27752

27756

27758

27712

27715

27720

27722

27724

27725

27726

27727

27686

27687

27690

27691

27692

27695

27696

27698

27700

27702

27703

27704

27705

27707

27709

27781

27784

27786

27788

27792

27808

27810

27814

27816

27759

27760

27762

27766

27767

27768

27769

27780

90

90

$706.00

$589.00

90

90

$757.00

$889.00

ZZZ $159.00

90 $658.00

90 $758.00

90

90

$881.00

$835.00

90 $1,278.00

90 $1,337.00

90 $683.00

90

90

$985.00

$484.00

90 $1,118.00

90 $1,227.00

90 $1,285.00

90 $1,147.00

90 $1,076.00

90 $1,402.00

90 $1,312.00

90 --------

90 $1,175.00

90

90

$647.00

$611.00

90 $766.00

90 $1,044.00

90 $1,045.00

90

90

90

90

$940.00

$319.00

$614.00

$708.00

90 $1,115.00

90

90

90

90

90

90

90

90

90

90 $1,262.00

90 $223.00

90 $495.00

90

90

90

90

90

$759.00

--------

--------

--------

$244.00

$296.00

$643.00

$223.00

$422.00

$706.00

$332.00

$567.00

$972.00

$386.00

$1,614.00

$1,572.00

$1,280.00

$1,286.00

$1,861.00

$1,768.00

$1,420.00

$1,522.00

$831.00

$588.00

$958.00

$1,034.00

$1,121.00

$1,103.00

$493.00

$774.00

$831.00

$1,303.00

$811.00

$657.00

$911.00

$1,089.00

$155.00

$688.00

$806.00

$933.00

$862.00

$1,414.00

$1,625.00

$839.00

$1,109.00

$583.00

$1,713.00

$1,465.00

$473.00

$680.00

$888.00

$399.00

$635.00

$1,067.00

$435.00

$604.00

$1,044.00

$449.00

$602.00

$951.00

$474.00

$668.00

$1,127.00

$454.00

$1,721.00

$1,678.00

$1,365.00

$1,372.00

$1,985.00

$1,885.00

$1,514.00

$1,625.00

$887.00

$626.00

$1,023.00

$1,105.00

$1,190.00

$1,176.00

$526.00

$826.00

$887.00

$1,390.00

$863.00

$696.00

$963.00

$1,157.00

$165.00

$728.00

$850.00

$988.00

$907.00

$1,504.00

$1,727.00

$893.00

$1,181.00

$622.00

$1,825.00

$1,563.00

$504.00

$724.00

$947.00

$426.00

$679.00

$1,139.00

$464.00

$644.00

$1,114.00

$478.00

$641.00

$1,014.00

$506.00

$712.00

$1,202.00

$484.00

$1,845.00

$1,803.00

$1,460.00

$1,470.00

$2,135.00

$2,019.00

$1,625.00

$1,746.00

$947.00

$663.00

$1,095.00

$1,183.00

$1,257.00

$1,258.00

$552.00

$875.00

$943.00

$1,489.00

$916.00

$733.00

$1,013.00

$1,227.00

$177.00

$767.00

$894.00

$1,046.00

$951.00

$1,607.00

$1,844.00

$950.00

$1,260.00

$659.00

$1,957.00

$1,678.00

$526.00

$762.00

$1,009.00

$445.00

$720.00

$1,219.00

$485.00

$678.00

$1,190.00

$500.00

$674.00

$1,081.00

$527.00

$749.00

$1,284.00

$506.00

$1,614.00

$1,572.00

$1,280.00

$1,286.00

$1,861.00

$1,768.00

$1,420.00

$1,522.00

$831.00

$588.00

$958.00

$1,034.00

$1,121.00

$1,103.00

$454.00

$718.00

$831.00

$1,303.00

$811.00

$657.00

$911.00

$1,089.00

$155.00

$688.00

$806.00

$933.00

$862.00

$1,414.00

$1,625.00

$839.00

$1,109.00

$583.00

$1,713.00

$1,465.00

$434.00

$623.00

$888.00

$402.00

$635.00

$1,067.00

$397.00

$562.00

$1,044.00

$408.00

$553.00

$951.00

$428.00

$610.00

$1,127.00

$410.00

$1,721.00

$1,678.00

$1,365.00

$1,372.00

$1,985.00

$1,885.00

$1,514.00

$1,625.00

$887.00

$626.00

$1,023.00

$1,105.00

$1,190.00

$1,176.00

$485.00

$766.00

$887.00

$1,390.00

$863.00

$696.00

$963.00

$1,157.00

$165.00

$728.00

$850.00

$988.00

$907.00

$1,504.00

$1,727.00

$893.00

$1,181.00

$622.00

$1,825.00

$1,563.00

$462.00

$663.00

$947.00

$428.00

$679.00

$1,139.00

$424.00

$600.00

$1,114.00

$435.00

$589.00

$1,014.00

$456.00

$649.00

$1,202.00

$436.00

$1,845.00

$1,803.00

$1,460.00

$1,470.00

$2,135.00

$2,019.00

$1,625.00

$1,746.00

$947.00

$663.00

$1,095.00

$1,183.00

$1,257.00

$1,258.00

$510.00

$815.00

$943.00

$1,489.00

$916.00

$733.00

$1,013.00

$1,227.00

$177.00

$767.00

$894.00

$1,046.00

$951.00

$1,607.00

$1,844.00

$950.00

$1,260.00

$659.00

$1,957.00

$1,678.00

$484.00

$701.00

$1,009.00

$447.00

$720.00

$1,219.00

$444.00

$633.00

$1,190.00

$456.00

$621.00

$1,081.00

$478.00

$686.00

$1,284.00

$458.00


Part B, 196



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

27886

27888

27889

27892

27893

27894

27899

28001

28002

28003

27848

27860

27870

27871

27880

27881

27882

27884

27818

27822

27823

27824

27825

27826

27827

27828

27829

27830

27831

27832

27840

27842

27846

28039

28041

28043

28045

28046

28047

28050

28052

28054

28005

28008

28010

28011

28020

28022

28024

28035

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90 $613.00

90 $1,201.00

90 $1,472.00

90 $384.00

90 $670.00

90 $1,080.00

90 $1,310.00

90 $1,823.00

90 $742.00

90

90

90

$412.00

$415.00

$617.00

90

90

90

$334.00

$373.00

$877.00

90

YYY

10

10

90

90

90

90

90

90

90 $1,224.00

10 $211.00

90 $1,269.00

90 $843.00

90 $1,015.00

90 $1,120.00

90 $854.00

90 $579.00

$835.00

$911.00

$879.00

$575.00

$574.00

$712.00

BR

$185.00

$362.00

$520.00

$520.00

$296.00

$235.00

$340.00

$509.00

$422.00

$371.00

$532.00

--------

--------

$305.00

$456.00

$814.00

--------

$414.00

$402.00

$236.00

$1,186.00

$254.00

$1,508.00

$997.00

$1,381.00

$1,297.00

$904.00

$861.00

$984.00

$1,010.00

$979.00

$810.00

$881.00

$1,259.00

--------

$393.00

$633.00

$1,017.00

$693.00

$1,225.00

$1,394.00

$448.00

$785.00

$1,211.00

$1,577.00

$1,896.00

$993.00

$545.00

$567.00

$1,105.00

$529.00

$719.00

$1,059.00

$836.00

$615.00

$331.00

$461.00

$773.00

$697.00

$657.00

$751.00

$731.00

$669.00

$569.00

$707.00

$1,062.00

$1,571.00

$604.00

$639.00

$556.00

$1,263.00

$270.00

$1,604.00

$1,062.00

$1,478.00

$1,386.00

$967.00

$922.00

$1,053.00

$1,077.00

$1,047.00

$864.00

$941.00

$1,344.00

--------

$414.00

$667.00

$1,073.00

$738.00

$1,306.00

$1,486.00

$478.00

$837.00

$1,291.00

$1,683.00

$2,022.00

$1,059.00

$583.00

$606.00

$1,180.00

$562.00

$767.00

$1,127.00

$877.00

$648.00

$348.00

$486.00

$821.00

$737.00

$695.00

$796.00

$774.00

$704.00

$601.00

$746.00

$1,116.00

$1,665.00

$636.00

$677.00

$588.00

$1,350.00

$286.00

$1,712.00

$1,131.00

$1,613.00

$1,500.00

$1,054.00

$999.00

$1,140.00

$1,157.00

$1,142.00

$925.00

$1,006.00

$1,447.00

--------

$424.00

$687.00

$1,112.00

$777.00

$1,392.00

$1,587.00

$502.00

$887.00

$1,375.00

$1,797.00

$2,165.00

$1,126.00

$615.00

$645.00

$1,263.00

$592.00

$815.00

$1,202.00

$913.00

$664.00

$357.00

$502.00

$849.00

$758.00

$713.00

$820.00

$801.00

$738.00

$616.00

$765.00

$1,171.00

$1,775.00

$649.00

$696.00

$600.00

$1,186.00

$254.00

$1,508.00

$997.00

$1,381.00

$1,297.00

$904.00

$861.00

$984.00

$1,010.00

$979.00

$810.00

$881.00

$1,259.00

--------

$244.00

$460.00

$821.00

$625.00

$1,225.00

$1,394.00

$436.00

$717.00

$1,211.00

$1,577.00

$1,896.00

$993.00

$510.00

$567.00

$1,105.00

$529.00

$719.00

$1,059.00

$836.00

$421.00

$299.00

$414.00

$524.00

$469.00

$439.00

$512.00

$509.00

$669.00

$377.00

$501.00

$1,062.00

$1,571.00

$401.00

$412.00

$351.00

$1,263.00

$270.00

$1,604.00

$1,062.00

$1,478.00

$1,386.00

$967.00

$922.00

$1,053.00

$1,077.00

$1,047.00

$864.00

$941.00

$1,344.00

--------

$255.00

$482.00

$862.00

$665.00

$1,306.00

$1,486.00

$465.00

$763.00

$1,291.00

$1,683.00

$2,022.00

$1,059.00

$545.00

$606.00

$1,180.00

$562.00

$767.00

$1,127.00

$877.00

$441.00

$314.00

$435.00

$553.00

$493.00

$461.00

$539.00

$536.00

$704.00

$396.00

$524.00

$1,116.00

$1,665.00

$419.00

$434.00

$368.00

$1,350.00

$286.00

$1,712.00

$1,131.00

$1,613.00

$1,500.00

$1,054.00

$999.00

$1,140.00

$1,157.00

$1,142.00

$925.00

$1,006.00

$1,447.00

--------

$264.00

$502.00

$901.00

$704.00

$1,392.00

$1,587.00

$489.00

$813.00

$1,375.00

$1,797.00

$2,165.00

$1,126.00

$578.00

$645.00

$1,263.00

$592.00

$815.00

$1,202.00

$913.00

$456.00

$323.00

$451.00

$580.00

$513.00

$478.00

$563.00

$562.00

$738.00

$410.00

$543.00

$1,171.00

$1,775.00

$431.00

$453.00

$379.00


Part B, 197



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

28118

28119

28120

28122

28124

28126

28130

28140

28150

28153

28107

28108

28110

28111

28112

28113

28114

28116

28055

28060

28062

28070

28072

28080

28086

28088

28090

28092

28100

28102

28103

28104

28106

28202

28208

28210

28220

28222

28225

28226

28230

28232

28160

28171

28173

28175

28190

28192

28193

28200

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

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

$517.00

$418.00

$421.00

$537.00

$457.00

$481.00

$890.00

$648.00

$568.00

$524.00

$601.00

$622.00

$480.00

$393.00

$727.00

$533.00

$416.00

$400.00

--------

$495.00

$657.00

$476.00

$445.00

$392.00

$462.00

$414.00

$414.00

$330.00

$571.00

$700.00

$709.00

$491.00

$632.00

$412.00

$789.00

$747.00

$571.00

$75.00

$326.00

$341.00

$478.00

$613.00

$406.00

$609.00

$435.00

$555.00

$345.00

$334.00

$380.00

$286.00

$797.00

$627.00

$659.00

$706.00

$698.00

$844.00

$1,544.00

$1,084.00

$850.00

$750.00

$973.00

$857.00

$679.00

$563.00

$930.00

$861.00

$610.00

$585.00

$541.00

$740.00

$837.00

$762.00

$723.00

$745.00

$784.00

$638.00

$671.00

$602.00

$869.00

$881.00

$564.00

$754.00

$670.00

$600.00

$1,227.00

$1,107.00

$706.00

$363.00

$673.00

$757.00

$699.00

$854.00

$676.00

$820.00

$641.00

$722.00

$583.00

$869.00

$620.00

$551.00

$843.00

$663.00

$698.00

$747.00

$739.00

$892.00

$1,637.00

$1,144.00

$901.00

$792.00

$1,032.00

$905.00

$716.00

$596.00

$983.00

$912.00

$645.00

$619.00

$564.00

$783.00

$883.00

$807.00

$767.00

$789.00

$834.00

$677.00

$710.00

$637.00

$923.00

$941.00

$588.00

$798.00

$703.00

$635.00

$1,273.00

$1,154.00

$737.00

$385.00

$711.00

$799.00

$740.00

$900.00

$716.00

$865.00

$677.00

$761.00

$617.00

$930.00

$655.00

$583.00

$866.00

$679.00

$715.00

$770.00

$760.00

$915.00

$1,701.00

$1,183.00

$931.00

$814.00

$1,071.00

$933.00

$733.00

$609.00

$1,035.00

$948.00

$662.00

$633.00

$584.00

$805.00

$906.00

$832.00

$790.00

$808.00

$863.00

$696.00

$729.00

$652.00

$955.00

$1,003.00

$607.00

$822.00

$733.00

$650.00

$1,318.00

$1,201.00

$764.00

$393.00

$730.00

$820.00

$760.00

$925.00

$735.00

$890.00

$693.00

$779.00

$632.00

$969.00

$670.00

$596.00

$539.00

$414.00

$416.00

$473.00

$452.00

$611.00

$1,213.00

$826.00

$598.00

$520.00

$722.00

$635.00

$474.00

$357.00

$930.00

$642.00

$405.00

$378.00

$541.00

$515.00

$588.00

$514.00

$479.00

$525.00

$523.00

$407.00

$444.00

$386.00

$597.00

$881.00

$564.00

$510.00

$670.00

$388.00

$1,227.00

$1,107.00

$706.00

$192.00

$453.00

$531.00

$463.00

$615.00

$449.00

$590.00

$433.00

$502.00

$373.00

$569.00

$407.00

$349.00

$566.00

$434.00

$437.00

$497.00

$476.00

$642.00

$1,281.00

$867.00

$630.00

$546.00

$763.00

$667.00

$496.00

$375.00

$983.00

$676.00

$425.00

$397.00

$564.00

$541.00

$615.00

$541.00

$506.00

$553.00

$554.00

$429.00

$467.00

$406.00

$631.00

$941.00

$588.00

$537.00

$703.00

$408.00

$1,273.00

$1,154.00

$737.00

$202.00

$476.00

$556.00

$487.00

$644.00

$472.00

$618.00

$454.00

$524.00

$391.00

$607.00

$426.00

$366.00

$588.00

$449.00

$454.00

$519.00

$495.00

$665.00

$1,345.00

$906.00

$660.00

$566.00

$800.00

$695.00

$512.00

$388.00

$1,035.00

$712.00

$441.00

$410.00

$584.00

$562.00

$637.00

$565.00

$528.00

$571.00

$583.00

$447.00

$485.00

$420.00

$662.00

$1,003.00

$607.00

$560.00

$733.00

$422.00

$1,318.00

$1,201.00

$764.00

$209.00

$494.00

$576.00

$507.00

$668.00

$491.00

$643.00

$469.00

$542.00

$406.00

$645.00

$441.00

$378.00


Part B, 198



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

28300

28302

28304

28305

28306

28307

28308

28309

28310

28312

28290

28292

28293

28294

28296

28297

28298

28299

28234

28238

28240

28250

28260

28261

28262

28264

28270

28272

28280

28285

28286

28288

28289

28360

28400

28405

28406

28415

28420

28430

28435

28436

28313

28315

28320

28322

28340

28341

28344

28345

90

90

90

90

90

90

90

90

90

90

$178.00

$695.00

90

90

90

90

$370.00

$535.00

$641.00

$881.00

90 $1,363.00

$912.00

$266.00

$336.00

$426.00

$463.00

$441.00

$452.00

$458.00

90

90

90

90

90

90

90

90

$557.00

$666.00

$845.00

$797.00

$832.00

$838.00

$755.00

$829.00

90

90

90

90

90

90

90

$845.00

$930.00

90 $776.00

90 $1,030.00

90 $530.00

$614.00

$516.00

$955.00

$505.00

$469.00

90

90

90

90

90

90

90

90

$436.00

$462.00

$833.00

$667.00

$649.00

$753.00

$414.00

$557.00

90 $1,197.00

90 $266.00

90 $473.00

90 $616.00

90 $1,354.00

90 $1,619.00

90 $110.00

90

90

$371.00

$463.00

$842.00

$1,127.00

$1,493.00

$1,102.00

$1,019.00

$1,165.00

$1,034.00

$1,287.00

$950.00

$1,046.00

$1,188.00

$968.00

$879.00

$976.00

$807.00

$1,322.00

$782.00

$726.00

$581.00

$962.00

$630.00

$834.00

$986.00

$1,412.00

$2,138.00

$1,448.00

$701.00

$562.00

$740.00

$763.00

$644.00

$863.00

$1,050.00

$757.00

$688.00

$887.00

$1,137.00

$827.00

$960.00

$672.00

$745.00

$1,342.00

$354.00

$565.00

$757.00

$1,614.00

$1,840.00

$337.00

$455.00

$648.00

$893.00

$1,189.00

$1,573.00

$1,166.00

$1,074.00

$1,232.00

$1,092.00

$1,355.00

$1,007.00

$1,117.00

$1,260.00

$1,018.00

$932.00

$1,037.00

$855.00

$1,399.00

$827.00

$769.00

$615.00

$1,015.00

$665.00

$884.00

$1,042.00

$1,488.00

$2,284.00

$1,548.00

$741.00

$593.00

$783.00

$806.00

$680.00

$914.00

$1,111.00

$803.00

$727.00

$937.00

$1,208.00

$868.00

$1,008.00

$715.00

$784.00

$1,416.00

$376.00

$599.00

$805.00

$1,715.00

$1,965.00

$359.00

$483.00

$692.00

$921.00

$1,222.00

$1,609.00

$1,206.00

$1,103.00

$1,276.00

$1,127.00

$1,400.00

$1,067.00

$1,196.00

$1,311.00

$1,070.00

$964.00

$1,074.00

$879.00

$1,483.00

$850.00

$789.00

$629.00

$1,048.00

$682.00

$915.00

$1,080.00

$1,544.00

$2,425.00

$1,633.00

$761.00

$605.00

$806.00

$828.00

$695.00

$940.00

$1,150.00

$829.00

$746.00

$988.00

$1,260.00

$889.00

$1,032.00

$743.00

$801.00

$1,497.00

$391.00

$626.00

$852.00

$1,824.00

$2,109.00

$373.00

$503.00

$732.00

$572.00

$865.00

$1,021.00

$794.00

$750.00

$844.00

$732.00

$980.00

$950.00

$1,046.00

$881.00

$968.00

$585.00

$653.00

$543.00

$1,322.00

$517.00

$460.00

$378.00

$705.00

$418.00

$588.00

$740.00

$1,126.00

$1,739.00

$1,117.00

$480.00

$365.00

$506.00

$543.00

$431.00

$619.00

$791.00

$519.00

$469.00

$887.00

$842.00

$595.00

$709.00

$454.00

$524.00

$1,342.00

$325.00

$515.00

$757.00

$1,614.00

$1,840.00

$301.00

$408.00

$648.00

$603.00

$907.00

$1,066.00

$835.00

$786.00

$887.00

$769.00

$1,026.00

$1,007.00

$1,117.00

$931.00

$1,018.00

$618.00

$691.00

$572.00

$1,399.00

$543.00

$484.00

$397.00

$740.00

$438.00

$621.00

$778.00

$1,181.00

$1,857.00

$1,192.00

$504.00

$382.00

$531.00

$570.00

$450.00

$651.00

$832.00

$548.00

$492.00

$937.00

$891.00

$619.00

$738.00

$482.00

$547.00

$1,416.00

$346.00

$545.00

$805.00

$1,715.00

$1,965.00

$321.00

$433.00

$692.00

$630.00

$939.00

$1,101.00

$874.00

$814.00

$930.00

$803.00

$1,071.00

$1,067.00

$1,196.00

$981.00

$1,070.00

$648.00

$727.00

$595.00

$1,483.00

$565.00

$503.00

$410.00

$772.00

$453.00

$651.00

$815.00

$1,237.00

$1,996.00

$1,277.00

$523.00

$394.00

$553.00

$591.00

$465.00

$677.00

$870.00

$573.00

$511.00

$988.00

$942.00

$639.00

$762.00

$509.00

$564.00

$1,497.00

$360.00

$573.00

$852.00

$1,824.00

$2,109.00

$335.00

$453.00

$732.00


Part B, 199



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

28570

28575

28576

28585

28600

28605

28606

28615

28630

28635

28515

28525

28530

28531

28540

28545

28546

28555

28445

28446

28450

28455

28456

28465

28470

28475

28476

28485

28490

28495

28496

28505

28510

28725

28730

28735

28737

28740

28750

28755

28760

28800

28636

28645

28660

28665

28666

28675

28705

28715

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

90

90

90

90

90

90

90

90

10

90

10

$318.00

$434.00

$106.00

10

10

$172.00

$309.00

90 $348.00

90 $1,353.00

90 $1,179.00

90 $1,015.00

90 $945.00

90 $961.00

90

90

90

90

90

90

$873.00

$690.00

$690.00

$466.00

$654.00

$731.00

$115.00

$345.00

$120.00

$243.00

$145.00

$208.00

$325.00

$592.00

$189.00

$308.00

$382.00

$742.00

$144.00

$287.00

$487.00

$621.00

$145.00

$189.00

$874.00

--------

$148.00

$321.00

$288.00

$533.00

$178.00

$296.00

$364.00

$521.00

$80.00

$133.00

$261.00

$399.00

$75.00

$229.00

$809.00

$163.00

$489.00

$294.00

$417.00

$792.00

$1,269.00

$317.00

$524.00

$564.00

$1,227.00

$310.00

$466.00

$572.00

$1,146.00

$224.00

$249.00

$1,553.00

$1,777.00

$307.00

$412.00

$457.00

$904.00

$312.00

$367.00

$504.00

$758.00

$206.00

$252.00

$620.00

$957.00

$176.00

$403.00

$942.00

$166.00

$220.00

$271.00

$835.00

$1,835.00

$1,367.00

$1,133.00

$1,066.00

$1,138.00

$1,001.00

$1,216.00

$1,168.00

$726.00

$1,132.00

$792.00

$242.00

$857.00

$173.00

$518.00

$311.00

$445.00

$848.00

$1,349.00

$338.00

$560.00

$603.00

$1,292.00

$330.00

$498.00

$608.00

$1,218.00

$237.00

$263.00

$1,650.00

$1,896.00

$326.00

$436.00

$489.00

$958.00

$331.00

$389.00

$537.00

$800.00

$219.00

$267.00

$661.00

$1,013.00

$186.00

$425.00

$996.00

$176.00

$232.00

$287.00

$886.00

$1,942.00

$1,453.00

$1,202.00

$1,129.00

$1,202.00

$1,054.00

$1,290.00

$1,240.00

$769.00

$1,196.00

$836.00

$249.00

$884.00

$178.00

$526.00

$320.00

$466.00

$874.00

$1,411.00

$352.00

$589.00

$639.00

$1,335.00

$341.00

$522.00

$642.00

$1,288.00

$246.00

$271.00

$1,758.00

$2,035.00

$338.00

$451.00

$513.00

$1,010.00

$344.00

$404.00

$561.00

$836.00

$225.00

$274.00

$677.00

$1,050.00

$192.00

$434.00

$1,029.00

$183.00

$240.00

$302.00

$916.00

$2,066.00

$1,543.00

$1,274.00

$1,193.00

$1,269.00

$1,107.00

$1,340.00

$1,288.00

$791.00

$1,236.00

$882.00

$203.00

$575.00

$146.00

$263.00

$266.00

$372.00

$473.00

$974.00

$270.00

$476.00

$564.00

$970.00

$268.00

$421.00

$572.00

$1,146.00

$159.00

$189.00

$1,553.00

$1,777.00

$275.00

$373.00

$457.00

$904.00

$292.00

$327.00

$504.00

$758.00

$178.00

$213.00

$335.00

$723.00

$171.00

$261.00

$702.00

$128.00

$188.00

$271.00

$594.00

$1,835.00

$1,367.00

$1,133.00

$1,066.00

$1,138.00

$1,001.00

$904.00

$858.00

$477.00

$835.00

$792.00

$214.00

$606.00

$154.00

$276.00

$281.00

$397.00

$505.00

$1,033.00

$288.00

$509.00

$603.00

$1,016.00

$285.00

$450.00

$608.00

$1,218.00

$168.00

$199.00

$1,650.00

$1,896.00

$292.00

$394.00

$489.00

$958.00

$310.00

$346.00

$537.00

$800.00

$189.00

$225.00

$356.00

$762.00

$182.00

$274.00

$738.00

$136.00

$198.00

$287.00

$628.00

$1,942.00

$1,453.00

$1,202.00

$1,129.00

$1,202.00

$1,054.00

$955.00

$907.00

$502.00

$878.00

$836.00

$221.00

$631.00

$158.00

$284.00

$290.00

$417.00

$531.00

$1,094.00

$302.00

$538.00

$639.00

$1,059.00

$296.00

$474.00

$642.00

$1,288.00

$176.00

$207.00

$1,758.00

$2,035.00

$304.00

$408.00

$513.00

$1,010.00

$323.00

$361.00

$561.00

$836.00

$195.00

$233.00

$370.00

$798.00

$187.00

$282.00

$770.00

$142.00

$206.00

$302.00

$657.00

$2,066.00

$1,543.00

$1,274.00

$1,193.00

$1,269.00

$1,107.00

$1,005.00

$954.00

$523.00

$916.00

$882.00


Part B, 200



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

29130

29131

29200

29240

29260

29280

29305

29325

29345

29355

29058

29065

29075

29085

29086

29105

29125

29126

28805

28810

28820

28825

28890

28899

29000

29010

29015

29035

29040

29044

29046

29049

29055

29505

29515

29520

29530

29540

29550

29580

29581

29582

29358

29365

29405

29425

29435

29440

29445

29450

0

0

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

YYY

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

$110.00

$88.00

$72.00

$59.00

$54.00

$59.00

$45.00

$53.00

$26.00

$53.00

$29.00

$45.00

$26.00

$29.00

$223.00

$260.00

$126.00

$133.00

$731.00

$543.00

$377.00

$339.00

--------

BR

$247.00

$271.00

$289.00

$213.00

$260.00

$260.00

$286.00

$45.00

$180.00

$241.00

$101.00

$96.00

$101.00

$133.00

$22.00

$214.00

$84.00

$75.00

$59.00

$22.00

$55.00

$41.00

$37.00

$39.00

--------

--------

$175.00

$137.00

$123.00

$136.00

$110.00

$125.00

$91.00

$108.00

$59.00

$72.00

$42.00

$41.00

$41.00

$42.00

$352.00

$388.00

$195.00

$202.00

$1,079.00

$635.00

$813.00

$774.00

$459.00

--------

$414.00

$338.00

$404.00

$276.00

$321.00

$398.00

$345.00

$120.00

$317.00

$229.00

$175.00

$116.00

$112.00

$166.00

$62.00

$192.00

$205.00

$118.00

$102.00

$44.00

$41.00

$37.00

$27.00

$75.00

$85.00

$97.00

$187.00

$146.00

$132.00

$145.00

$117.00

$133.00

$97.00

$115.00

$62.00

$76.00

$43.00

$42.00

$44.00

$44.00

$377.00

$416.00

$208.00

$215.00

$1,140.00

$674.00

$863.00

$822.00

$484.00

--------

$447.00

$360.00

$431.00

$293.00

$340.00

$423.00

$367.00

$128.00

$339.00

$245.00

$187.00

$124.00

$119.00

$177.00

$65.00

$203.00

$215.00

$125.00

$108.00

$46.00

$43.00

$39.00

$28.00

$79.00

$90.00

$103.00

$196.00

$153.00

$137.00

$151.00

$121.00

$138.00

$100.00

$119.00

$65.00

$79.00

$44.00

$43.00

$45.00

$46.00

$393.00

$435.00

$219.00

$227.00

$1,213.00

$719.00

$895.00

$851.00

$497.00

--------

$476.00

$374.00

$447.00

$303.00

$353.00

$434.00

$380.00

$134.00

$354.00

$257.00

$196.00

$129.00

$123.00

$185.00

$67.00

$211.00

$223.00

$129.00

$112.00

$47.00

$44.00

$40.00

$29.00

$82.00

$91.00

$103.00

$135.00

$99.00

$90.00

$98.00

$73.00

$86.00

$57.00

$70.00

$42.00

$48.00

$26.00

$27.00

$28.00

$29.00

$232.00

$260.00

$147.00

$155.00

$1,079.00

$635.00

$577.00

$540.00

$322.00

--------

$260.00

$214.00

$259.00

$174.00

$211.00

$218.00

$230.00

$91.00

$203.00

$152.00

$128.00

$87.00

$82.00

$120.00

$42.00

$151.00

$163.00

$72.00

$71.00

$27.00

$27.00

$26.00

$17.00

$51.00

$18.00

$23.00

$144.00

$106.00

$96.00

$104.00

$78.00

$91.00

$60.00

$74.00

$44.00

$50.00

$27.00

$27.00

$30.00

$31.00

$248.00

$278.00

$157.00

$165.00

$1,140.00

$674.00

$609.00

$570.00

$338.00

--------

$282.00

$228.00

$275.00

$184.00

$223.00

$230.00

$243.00

$96.00

$217.00

$163.00

$136.00

$92.00

$87.00

$128.00

$43.00

$159.00

$170.00

$76.00

$75.00

$27.00

$28.00

$27.00

$17.00

$54.00

$19.00

$23.00

$153.00

$112.00

$102.00

$110.00

$81.00

$96.00

$63.00

$77.00

$47.00

$53.00

$28.00

$28.00

$31.00

$32.00

$264.00

$298.00

$167.00

$176.00

$1,213.00

$719.00

$640.00

$598.00

$350.00

--------

$310.00

$242.00

$291.00

$193.00

$235.00

$241.00

$256.00

$102.00

$231.00

$174.00

$145.00

$97.00

$91.00

$136.00

$45.00

$166.00

$178.00

$80.00

$79.00

$28.00

$29.00

$28.00

$18.00

$57.00

$19.00

$23.00


Part B, 201



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

29827

29828

29830

29834

29835

29836

29837

29838

29840

29843

29819

29820

29821

29822

29823

29824

29825

29826

29583

29584

29700

29705

29710

29720

29730

29740

29750

29799

29800

29804

29805

29806

29807

29856

29860

29861

29862

29863

29866

29867

29868

29870

29844

29845

29846

29847

29848

29850

29851

29855

0

0

0

0

0

0

0

--------

--------

$29.00

$26.00

$29.00

$29.00

$29.00

0

0

YYY

90

90

$37.00

$105.00

BR

$557.00

$902.00

90 $360.00

90 $1,003.00

90 $976.00

90

90

90

90

$756.00

$718.00

$863.00

$749.00

90 $1,330.00

90

90

$611.00

$941.00

ZZZ $980.00

90

90

90

90

90

90 $1,058.00

90 --------

90

90

90

$524.00

$635.00

$612.00

$680.00

$830.00

$931.00

$501.00

$580.00

90

90

90

$612.00

$931.00

$976.00

90 $1,277.00

90 $608.00

90 $752.00

90 $1,137.00

90 $1,007.00

90 $1,231.00

90 $658.00

90 $845.00

90

90

90

90

90

90

$907.00

$880.00

--------

--------

--------

$460.00

$855.00

$776.00

$848.00

$823.00

$898.00

$968.00

$839.00

$261.00

$1,541.00

$1,329.00

$658.00

$704.00

$737.00

$825.00

$759.00

$853.00

$658.00

$705.00

$60.00

$97.00

$89.00

$96.00

$175.00

$121.00

$93.00

$143.00

$128.00

--------

$741.00

$940.00

$687.00

$1,557.00

$1,519.00

$717.00

$833.00

$753.00

$772.00

$740.00

$900.00

$1,294.00

$1,143.00

$1,463.00

$964.00

$1,049.00

$1,174.00

$1,174.00

$1,527.00

$1,856.00

$2,363.00

$834.00

$913.00

$826.00

$902.00

$874.00

$954.00

$1,029.00

$892.00

$279.00

$1,636.00

$1,413.00

$700.00

$749.00

$787.00

$877.00

$808.00

$908.00

$703.00

$753.00

$64.00

$103.00

$95.00

$102.00

$187.00

$129.00

$99.00

$153.00

$135.00

--------

$788.00

$1,000.00

$734.00

$1,662.00

$1,622.00

$762.00

$886.00

$802.00

$819.00

$789.00

$959.00

$1,375.00

$1,219.00

$1,563.00

$1,029.00

$1,116.00

$1,248.00

$1,249.00

$1,629.00

$1,981.00

$2,515.00

$891.00

$976.00

$876.00

$956.00

$926.00

$1,010.00

$1,089.00

$944.00

$302.00

$1,739.00

$1,503.00

$743.00

$792.00

$841.00

$928.00

$857.00

$966.00

$750.00

$803.00

$65.00

$103.00

$98.00

$107.00

$197.00

$135.00

$103.00

$163.00

$141.00

--------

$834.00

$1,061.00

$783.00

$1,784.00

$1,740.00

$807.00

$937.00

$850.00

$866.00

$837.00

$1,023.00

$1,467.00

$1,303.00

$1,679.00

$1,099.00

$1,188.00

$1,325.00

$1,326.00

$1,745.00

$2,128.00

$2,701.00

$934.00

$855.00

$776.00

$848.00

$823.00

$898.00

$968.00

$839.00

$261.00

$1,541.00

$1,329.00

$658.00

$704.00

$737.00

$825.00

$759.00

$853.00

$658.00

$705.00

$16.00

$23.00

$49.00

$69.00

$122.00

$65.00

$66.00

$104.00

$98.00

--------

$741.00

$940.00

$687.00

$1,557.00

$1,519.00

$717.00

$833.00

$753.00

$772.00

$740.00

$900.00

$1,294.00

$1,143.00

$1,463.00

$964.00

$1,049.00

$1,174.00

$1,174.00

$1,527.00

$1,856.00

$2,363.00

$600.00

$913.00

$826.00

$902.00

$874.00

$954.00

$1,029.00

$892.00

$279.00

$1,636.00

$1,413.00

$700.00

$749.00

$787.00

$877.00

$808.00

$908.00

$703.00

$753.00

$16.00

$23.00

$52.00

$74.00

$130.00

$70.00

$70.00

$111.00

$103.00

--------

$788.00

$1,000.00

$734.00

$1,662.00

$1,622.00

$762.00

$886.00

$802.00

$819.00

$789.00

$959.00

$1,375.00

$1,219.00

$1,563.00

$1,029.00

$1,116.00

$1,248.00

$1,249.00

$1,629.00

$1,981.00

$2,515.00

$641.00

$976.00

$876.00

$956.00

$926.00

$1,010.00

$1,089.00

$944.00

$302.00

$1,739.00

$1,503.00

$743.00

$792.00

$841.00

$928.00

$857.00

$966.00

$750.00

$803.00

$17.00

$23.00

$55.00

$79.00

$141.00

$75.00

$75.00

$120.00

$109.00

--------

$834.00

$1,061.00

$783.00

$1,784.00

$1,740.00

$807.00

$937.00

$850.00

$866.00

$837.00

$1,023.00

$1,467.00

$1,303.00

$1,679.00

$1,099.00

$1,188.00

$1,325.00

$1,326.00

$1,745.00

$2,128.00

$2,701.00

$682.00


Part B, 202



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

29898

29899

29900

29901

29902

29904

29905

29906

29907

29914

29888

29889

29891

29892

29893

29894

29895

29897

29871

29873

29874

29875

29876

29877

29879

29880

29881

29882

29883

29884

29885

29886

29887

30117

30118

30120

30124

30125

30130

30140

30150

30160

29915

29916

29999

30000

30020

30100

30110

30115

90

90

90

90

90

90

90

90

90

90

90

YYY

10

10

0

10

90

90

90

$631.00

$489.00

90

90

90

90

$676.00

$639.00

$809.00

$852.00

90 $1,064.00

90 $1,169.00

90 $745.00

90 $819.00

90 $1,235.00

90 $721.00

90

90

90

$832.00

$697.00

$949.00

90

90

90

90

90

90

90

90

90

90

90 $1,296.00

90 $1,255.00

90

90

90

$796.00

$835.00

$472.00

90

90

90

$690.00

$679.00

$704.00

$863.00

$973.00

$434.00

$479.00

$514.00

--------

--------

--------

--------

--------

--------

--------

BR

$96.00

$117.00

$86.00

$157.00

$360.00

$301.00

$819.00

$500.00

$243.00

$599.00

$275.00

$320.00

$790.00

$875.00

$1,446.00

$1,793.00

$984.00

$840.00

$868.00

$729.00

$693.00

$738.00

$823.00

$1,517.00

$650.00

$774.00

$810.00

$933.00

$1,001.00

$1,053.00

$1,285.00

$1,454.00

$750.00

$761.00

$783.00

$721.00

$962.00

$908.00

$967.00

$819.00

$789.00

$1,025.00

$1,232.00

$894.00

$1,098.00

$931.00

$1,092.00

$1,478.00

$1,480.00

--------

$323.00

$328.00

$199.00

$325.00

$617.00

$1,223.00

$1,106.00

$740.00

$409.00

$872.00

$540.00

$624.00

$1,107.00

$1,111.00

$1,543.00

$1,914.00

$1,044.00

$875.00

$915.00

$772.00

$733.00

$782.00

$871.00

$1,614.00

$685.00

$827.00

$860.00

$997.00

$1,069.00

$1,124.00

$1,372.00

$1,545.00

$802.00

$814.00

$836.00

$770.00

$1,028.00

$969.00

$1,032.00

$874.00

$842.00

$1,095.00

$1,314.00

$952.00

$1,172.00

$995.00

$1,166.00

$1,570.00

$1,572.00

--------

$345.00

$350.00

$212.00

$346.00

$655.00

$1,308.00

$1,173.00

$787.00

$434.00

$925.00

$574.00

$664.00

$1,176.00

$1,178.00

$1,654.00

$2,053.00

$1,106.00

$905.00

$934.00

$817.00

$773.00

$829.00

$921.00

$1,724.00

$708.00

$881.00

$906.00

$1,067.00

$1,143.00

$1,201.00

$1,471.00

$1,646.00

$856.00

$865.00

$892.00

$821.00

$1,099.00

$1,033.00

$1,103.00

$931.00

$897.00

$1,173.00

$1,407.00

$1,010.00

$1,253.00

$1,064.00

$1,248.00

$1,670.00

$1,672.00

--------

$354.00

$359.00

$217.00

$356.00

$681.00

$1,329.00

$1,231.00

$821.00

$452.00

$969.00

$594.00

$686.00

$1,235.00

$1,238.00

$1,446.00

$1,793.00

$984.00

$840.00

$612.00

$729.00

$693.00

$738.00

$823.00

$1,517.00

$650.00

$774.00

$810.00

$933.00

$1,001.00

$1,053.00

$1,285.00

$1,454.00

$750.00

$761.00

$783.00

$721.00

$962.00

$908.00

$967.00

$819.00

$789.00

$1,025.00

$1,232.00

$894.00

$1,098.00

$931.00

$1,092.00

$1,478.00

$1,480.00

--------

$170.00

$171.00

$99.00

$188.00

$617.00

$485.00

$1,106.00

$630.00

$409.00

$872.00

$540.00

$624.00

$1,107.00

$1,111.00

$1,543.00

$1,914.00

$1,044.00

$875.00

$641.00

$772.00

$733.00

$782.00

$871.00

$1,614.00

$685.00

$827.00

$860.00

$997.00

$1,069.00

$1,124.00

$1,372.00

$1,545.00

$802.00

$814.00

$836.00

$770.00

$1,028.00

$969.00

$1,032.00

$874.00

$842.00

$1,095.00

$1,314.00

$952.00

$1,172.00

$995.00

$1,166.00

$1,570.00

$1,572.00

--------

$180.00

$182.00

$105.00

$199.00

$655.00

$516.00

$1,173.00

$669.00

$434.00

$925.00

$574.00

$664.00

$1,176.00

$1,178.00

$1,654.00

$2,053.00

$1,106.00

$905.00

$660.00

$817.00

$773.00

$829.00

$921.00

$1,724.00

$708.00

$881.00

$906.00

$1,067.00

$1,143.00

$1,201.00

$1,471.00

$1,646.00

$856.00

$865.00

$892.00

$821.00

$1,099.00

$1,033.00

$1,103.00

$931.00

$897.00

$1,173.00

$1,407.00

$1,010.00

$1,253.00

$1,064.00

$1,248.00

$1,670.00

$1,672.00

--------

$188.00

$191.00

$110.00

$208.00

$681.00

$535.00

$1,231.00

$703.00

$452.00

$969.00

$594.00

$686.00

$1,235.00

$1,238.00


Part B, 203



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

30801

30802

30901

30903

30905

30906

30915

30920

30930

30999

30520

30540

30545

30560

30580

30600

30620

30630

30200

30210

30220

30300

30310

30320

30400

30410

30420

30430

30435

30450

30460

30462

30465

31070

31075

31080

31081

31084

31085

31086

31087

31090

31000

31002

31020

31030

31032

31040

31050

31051

0

90

90

10

YYY

10

10

0

0

0

90

90

90

10

90

90

90

90

0

10

10

10

10

90

90

$68.00

$75.00

$154.00

$45.00

$170.00

$419.00

$741.00

90 $1,173.00

90 $1,424.00

90 $626.00

90 $1,005.00

90 $1,445.00

90 $857.00

90 $1,633.00

90 $803.00

$533.00

$643.00

$981.00

$104.00

$566.00

$466.00

$564.00

$624.00

$88.00

$172.00

$75.00

$110.00

$224.00

$208.00

$596.00

$862.00

$213.00

BR

10

10

90

90

90

90

90

90

$81.00

$135.00

$281.00

$531.00

$604.00

$772.00

$489.00

$654.00

90

90

90

$410.00

$839.00

$942.00

90 $1,089.00

90 $1,210.00

90 $1,281.00

90 $1,081.00

90 $1,075.00

90 $877.00

$891.00

$992.00

$1,264.00

$376.00

$937.00

$843.00

$889.00

$891.00

$321.00

$410.00

$136.00

$311.00

$382.00

$490.00

$828.00

$1,203.00

$176.00

--------

$160.00

$212.00

$425.00

$261.00

$293.00

$633.00

$1,443.00

$1,693.00

$1,968.00

$1,364.00

$1,588.00

$2,151.00

$1,027.00

$2,250.00

$1,409.00

$259.00

$275.00

$681.00

$982.00

$824.00

$1,096.00

$696.00

$922.00

$626.00

$1,128.00

$1,486.00

$2,167.00

$1,664.00

$2,318.00

$1,619.00

$1,564.00

$1,462.00

$946.00

$1,053.00

$1,338.00

$402.00

$997.00

$896.00

$945.00

$945.00

$342.00

$437.00

$144.00

$331.00

$407.00

$523.00

$877.00

$1,275.00

$186.00

--------

$171.00

$225.00

$454.00

$278.00

$312.00

$672.00

$1,532.00

$1,796.00

$2,088.00

$1,455.00

$1,685.00

$2,279.00

$1,085.00

$2,392.00

$1,494.00

$276.00

$292.00

$727.00

$1,046.00

$874.00

$1,163.00

$740.00

$979.00

$665.00

$1,198.00

$1,575.00

$2,358.00

$1,762.00

$2,525.00

$1,714.00

$1,659.00

$1,552.00

$986.00

$1,099.00

$1,401.00

$410.00

$1,043.00

$936.00

$983.00

$988.00

$349.00

$449.00

$151.00

$340.00

$419.00

$537.00

$920.00

$1,340.00

$194.00

--------

$176.00

$232.00

$464.00

$284.00

$323.00

$699.00

$1,597.00

$1,878.00

$2,189.00

$1,511.00

$1,759.00

$2,391.00

$1,140.00

$2,530.00

$1,568.00

$283.00

$302.00

$745.00

$1,084.00

$914.00

$1,221.00

$773.00

$1,022.00

$691.00

$1,257.00

$1,647.00

$2,579.00

$1,846.00

$2,773.00

$1,793.00

$1,750.00

$1,616.00

$891.00

$992.00

$1,264.00

$196.00

$744.00

$647.00

$889.00

$891.00

$193.00

$272.00

$83.00

$119.00

$157.00

$202.00

$828.00

$1,203.00

$176.00

--------

$86.00

$142.00

$180.00

$150.00

$293.00

$633.00

$1,443.00

$1,693.00

$1,968.00

$1,364.00

$1,588.00

$2,151.00

$1,027.00

$2,250.00

$1,409.00

$152.00

$275.00

$510.00

$759.00

$824.00

$1,096.00

$696.00

$922.00

$626.00

$1,128.00

$1,486.00

$2,167.00

$1,664.00

$2,318.00

$1,619.00

$1,564.00

$1,462.00

$946.00

$1,053.00

$1,338.00

$208.00

$790.00

$686.00

$945.00

$945.00

$205.00

$289.00

$88.00

$125.00

$166.00

$213.00

$877.00

$1,275.00

$186.00

--------

$91.00

$151.00

$191.00

$160.00

$312.00

$672.00

$1,532.00

$1,796.00

$2,088.00

$1,455.00

$1,685.00

$2,279.00

$1,085.00

$2,392.00

$1,494.00

$161.00

$292.00

$542.00

$807.00

$874.00

$1,163.00

$740.00

$979.00

$665.00

$1,198.00

$1,575.00

$2,358.00

$1,762.00

$2,525.00

$1,714.00

$1,659.00

$1,552.00

$986.00

$1,099.00

$1,401.00

$216.00

$836.00

$725.00

$983.00

$988.00

$212.00

$301.00

$94.00

$134.00

$177.00

$227.00

$920.00

$1,340.00

$194.00

--------

$95.00

$157.00

$200.00

$165.00

$323.00

$699.00

$1,597.00

$1,878.00

$2,189.00

$1,511.00

$1,759.00

$2,391.00

$1,140.00

$2,530.00

$1,568.00

$168.00

$302.00

$560.00

$844.00

$914.00

$1,221.00

$773.00

$1,022.00

$691.00

$1,257.00

$1,647.00

$2,579.00

$1,846.00

$2,773.00

$1,793.00

$1,750.00

$1,616.00


Part B, 204



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

31294

31295

31296

31297

31299

31300

31320

31360

31365

31367

31267

31276

31287

31288

31290

31291

31292

31293

31200

31201

31205

31225

31230

31231

31233

31235

31237

31238

31239

31240

31254

31255

31256

31420

31500

31502

31505

31510

31511

31512

31513

31515

31368

31370

31375

31380

31382

31390

31395

31400

0

0

0

0

0

0

10

0

90

90

$463.00

$716.00

90 $851.00

90 $1,683.00

90 $1,908.00

0 $122.00

0 $221.00

$217.00

$266.00

$311.00

$775.00

$224.00

$588.00

$601.00

$292.00

0

0

0

0

$453.00

$690.00

$339.00

$396.00

10 $1,462.00

10 $1,551.00

10 $1,235.00

10 $1,346.00

10 $1,587.00

0 --------

0

0

YYY

--------

--------

BR

90 $1,295.00

90 $508.00

90 $1,630.00

90 $2,238.00

90 $1,913.00

0

0

0

0

90

0

0

0

0

90 $2,478.00

90 $1,891.00

90 $1,720.00

90 $1,782.00

90 $1,822.00

90 $2,513.00

90 $2,937.00

90 $969.00

$969.00

$116.00

$74.00

$62.00

$145.00

$88.00

$197.00

$182.00

$160.00

$466.00

$742.00

$340.00

$394.00

$1,693.00

$1,812.00

$1,461.00

$1,585.00

$1,813.00

$2,821.00

$2,879.00

$2,825.00

--------

$1,886.00

$983.00

$3,074.00

$3,802.00

$3,251.00

$799.00

$1,059.00

$1,266.00

$2,714.00

$3,020.00

$294.00

$372.00

$424.00

$368.00

$369.00

$883.00

$236.00

$400.00

$588.00

$290.00

$3,629.00

$3,058.00

$2,889.00

$2,856.00

$3,148.00

$4,236.00

$4,472.00

$1,414.00

$1,207.00

$162.00

$51.00

$117.00

$299.00

$302.00

$292.00

$193.00

$262.00

$492.00

$783.00

$359.00

$416.00

$1,793.00

$1,926.00

$1,545.00

$1,675.00

$1,916.00

$3,023.00

$3,084.00

$3,027.00

--------

$2,002.00

$1,046.00

$3,255.00

$4,024.00

$3,442.00

$845.00

$1,123.00

$1,333.00

$2,874.00

$3,199.00

$313.00

$396.00

$451.00

$391.00

$391.00

$929.00

$249.00

$423.00

$620.00

$306.00

$3,845.00

$3,242.00

$3,064.00

$3,027.00

$3,336.00

$4,483.00

$4,734.00

$1,500.00

$1,278.00

$169.00

$54.00

$125.00

$319.00

$321.00

$310.00

$204.00

$277.00

$524.00

$834.00

$381.00

$442.00

$1,908.00

$2,063.00

$1,637.00

$1,774.00

$2,032.00

$3,046.00

$3,111.00

$3,050.00

--------

$2,098.00

$1,081.00

$3,429.00

$4,249.00

$3,617.00

$864.00

$1,173.00

$1,372.00

$3,031.00

$3,384.00

$320.00

$408.00

$466.00

$406.00

$407.00

$968.00

$264.00

$449.00

$660.00

$325.00

$4,043.00

$3,401.00

$3,219.00

$3,175.00

$3,502.00

$4,728.00

$4,986.00

$1,567.00

$1,344.00

$180.00

$57.00

$128.00

$330.00

$334.00

$322.00

$216.00

$285.00

$466.00

$742.00

$340.00

$394.00

$1,693.00

$1,812.00

$1,461.00

$1,585.00

$1,813.00

$240.00

$288.00

$235.00

--------

$1,886.00

$983.00

$3,074.00

$3,802.00

$3,251.00

$799.00

$1,059.00

$1,266.00

$2,714.00

$3,020.00

$95.00

$199.00

$237.00

$236.00

$247.00

$883.00

$236.00

$400.00

$588.00

$290.00

$3,629.00

$3,058.00

$2,889.00

$2,856.00

$3,148.00

$4,236.00

$4,472.00

$1,414.00

$1,207.00

$162.00

$51.00

$71.00

$178.00

$191.00

$189.00

$193.00

$153.00

$492.00

$783.00

$359.00

$416.00

$1,793.00

$1,926.00

$1,545.00

$1,675.00

$1,916.00

$254.00

$305.00

$249.00

--------

$2,002.00

$1,046.00

$3,255.00

$4,024.00

$3,442.00

$845.00

$1,123.00

$1,333.00

$2,874.00

$3,199.00

$100.00

$211.00

$250.00

$249.00

$261.00

$929.00

$249.00

$423.00

$620.00

$306.00

$3,845.00

$3,242.00

$3,064.00

$3,027.00

$3,336.00

$4,483.00

$4,734.00

$1,500.00

$1,278.00

$169.00

$54.00

$75.00

$188.00

$202.00

$200.00

$204.00

$160.00

$524.00

$834.00

$381.00

$442.00

$1,908.00

$2,063.00

$1,637.00

$1,774.00

$2,032.00

$269.00

$324.00

$264.00

--------

$2,098.00

$1,081.00

$3,429.00

$4,249.00

$3,617.00

$864.00

$1,173.00

$1,372.00

$3,031.00

$3,384.00

$106.00

$223.00

$264.00

$264.00

$277.00

$968.00

$264.00

$449.00

$660.00

$325.00

$4,043.00

$3,401.00

$3,219.00

$3,175.00

$3,502.00

$4,728.00

$4,986.00

$1,567.00

$1,344.00

$180.00

$57.00

$78.00

$199.00

$214.00

$211.00

$216.00

$168.00


Part B, 205



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

31582

31584

31587

31588

31590

31595

31599

31600

31603

31605

31570

31571

31575

31576

31577

31578

31579

31580

31525

31526

31527

31528

31529

31530

31531

31535

31536

31540

31541

31545

31546

31560

31561

31624

31625

31626

31627

31628

31629

31630

31631

31632

31610

31611

31612

31613

31614

31615

31622

31623

0

0

0

ZZZ

0

0

0

0

ZZZ

90

90

0

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

$369.00

$363.00

$128.00

$186.00

$230.00

0

0

$264.00

$219.00

90 $1,213.00

90

YYY

0

0

0

90 $1,881.00

90 $1,616.00

90 $913.00

90 $1,206.00

90 $691.00

$773.00

BR

$306.00

$343.00

$297.00

$234.00

$222.00

$262.00

$202.00

$217.00

$284.00

$311.00

$272.00

$308.00

$357.00

$453.00

--------

--------

$446.00

$509.00

$794.00

$614.00

$99.00

$384.00

$736.00

$213.00

$230.00

$225.00

$217.00

$235.00

--------

--------

$269.00

$198.00

$308.00

$252.00

--------

$488.00

$369.00

$162.00

$318.00

$345.00

$398.00

$301.00

$1,758.00

$2,730.00

$2,191.00

$1,458.00

$1,646.00

$1,275.00

$1,099.00

--------

$593.00

$333.00

$275.00

$362.00

$232.00

$287.00

$213.00

$238.00

$292.00

$314.00

$280.00

$311.00

$357.00

$390.00

$536.00

$817.00

$463.00

$508.00

$1,035.00

$775.00

$120.00

$653.00

$1,086.00

$260.00

$428.00

$464.00

$440.00

$555.00

$1,263.00

$1,942.00

$585.00

$696.00

$294.00

$339.00

$106.00

$519.00

$390.00

$172.00

$338.00

$367.00

$423.00

$319.00

$1,865.00

$2,895.00

$2,324.00

$1,542.00

$1,744.00

$1,358.00

$1,166.00

--------

$631.00

$353.00

$292.00

$384.00

$245.00

$303.00

$225.00

$252.00

$309.00

$332.00

$296.00

$329.00

$377.00

$412.00

$566.00

$864.00

$489.00

$536.00

$1,099.00

$823.00

$128.00

$695.00

$1,154.00

$276.00

$454.00

$491.00

$465.00

$588.00

$1,347.00

$2,079.00

$618.00

$738.00

$309.00

$357.00

$111.00

$543.00

$415.00

$178.00

$349.00

$381.00

$440.00

$332.00

$1,950.00

$3,029.00

$2,447.00

$1,630.00

$1,830.00

$1,407.00

$1,218.00

--------

$684.00

$381.00

$317.00

$400.00

$259.00

$322.00

$238.00

$267.00

$328.00

$352.00

$314.00

$349.00

$401.00

$438.00

$601.00

$921.00

$520.00

$570.00

$1,157.00

$858.00

$134.00

$726.00

$1,207.00

$287.00

$467.00

$502.00

$476.00

$601.00

$1,368.00

$2,093.00

$631.00

$753.00

$327.00

$381.00

$114.00

$340.00

$369.00

$111.00

$181.00

$220.00

$253.00

$207.00

$1,758.00

$2,730.00

$2,191.00

$1,458.00

$1,646.00

$1,275.00

$1,099.00

--------

$593.00

$333.00

$275.00

$236.00

$232.00

$287.00

$213.00

$238.00

$292.00

$314.00

$280.00

$311.00

$357.00

$390.00

$536.00

$817.00

$463.00

$508.00

$1,035.00

$775.00

$72.00

$653.00

$1,086.00

$188.00

$211.00

$213.00

$215.00

$247.00

$310.00

$143.00

$274.00

$291.00

$294.00

$339.00

$72.00

$360.00

$390.00

$118.00

$191.00

$232.00

$267.00

$218.00

$1,865.00

$2,895.00

$2,324.00

$1,542.00

$1,744.00

$1,358.00

$1,166.00

--------

$631.00

$353.00

$292.00

$249.00

$245.00

$303.00

$225.00

$252.00

$309.00

$332.00

$296.00

$329.00

$377.00

$412.00

$566.00

$864.00

$489.00

$536.00

$1,099.00

$823.00

$77.00

$695.00

$1,154.00

$198.00

$221.00

$222.00

$224.00

$258.00

$325.00

$149.00

$285.00

$303.00

$309.00

$357.00

$75.00

$383.00

$415.00

$124.00

$202.00

$246.00

$284.00

$231.00

$1,950.00

$3,029.00

$2,447.00

$1,630.00

$1,830.00

$1,407.00

$1,218.00

--------

$684.00

$381.00

$317.00

$264.00

$259.00

$322.00

$238.00

$267.00

$328.00

$352.00

$314.00

$349.00

$401.00

$438.00

$601.00

$921.00

$520.00

$570.00

$1,157.00

$858.00

$82.00

$726.00

$1,207.00

$209.00

$233.00

$232.00

$234.00

$270.00

$343.00

$158.00

$297.00

$317.00

$327.00

$381.00

$78.00


Part B, 206



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

31730

31750

31755

31760

31766

31770

31775

31780

31781

31785

31652

31653

31654

31660

31661

31717

31720

31725

31633

31634

31635

31636

31637

31638

31640

31641

31643

31645

31646

31647

31648

31649

31651

32036

32096

32097

32098

32100

32110

32120

32124

32140

31786

31800

31805

31820

31825

31830

31899

32035

0

0

0

0

0

0

ZZZ

ZZZ

ZZZ

0

0

0

ZZZ

0

0

0

0

ZZZ

0

0

0

0

0

--------

--------

--------

--------

--------

$138.00

$89.00

$103.00

0 $199.00

90 $1,088.00

90 $1,448.00

90 $1,648.00

90 $2,315.00

90 $1,815.00

90 $1,973.00

90 $1,577.00

90 $1,936.00

90 $1,320.00

--------

--------

$298.00

--------

--------

--------

$399.00

$304.00

$208.00

$208.00

$161.00

--------

--------

--------

--------

90 $1,866.00

90 $628.00

90 $1,175.00

90

90

90

YYY

90

$458.00

$659.00

$460.00

BR

$821.00

90

90

90

$908.00

--------

--------

90 --------

90 $1,120.00

90 $1,223.00

90 $1,077.00

90 $1,144.00

90 $1,284.00

$1,254.00

$1,334.00

$202.00

$306.00

$321.00

$364.00

$75.00

$131.00

$1,700.00

$2,033.00

$2,534.00

$2,092.00

$2,694.00

$2,020.00

$1,897.00

$1,749.00

$2,132.00

$1,602.00

$131.00

$2,563.00

$493.00

$326.00

$108.00

$373.00

$374.00

$379.00

$258.00

$455.00

$408.00

$324.00

$299.00

$102.00

$117.00

$2,162.00

$1,059.00

$1,236.00

$622.00

$863.00

$637.00

--------

$1,071.00

$1,157.00

$1,209.00

$1,208.00

$1,146.00

$1,214.00

$2,195.00

$1,303.00

$1,388.00

$1,497.00

$1,335.00

$1,420.00

$214.00

$317.00

$333.00

$385.00

$78.00

$136.00

$1,822.00

$2,164.00

$2,695.00

$2,245.00

$2,889.00

$2,166.00

$1,981.00

$1,859.00

$2,254.00

$1,697.00

$138.00

$2,743.00

$521.00

$342.00

$112.00

$391.00

$393.00

$396.00

$269.00

$481.00

$431.00

$337.00

$311.00

$107.00

$123.00

$2,315.00

$1,125.00

$1,325.00

$662.00

$916.00

$678.00

--------

$1,147.00

$1,240.00

$1,295.00

$1,294.00

$1,228.00

$1,301.00

$2,351.00

$1,396.00

$1,487.00

$1,605.00

$1,355.00

$1,442.00

$219.00

$330.00

$346.00

$392.00

$81.00

$143.00

$1,846.00

$2,266.00

$2,801.00

$2,466.00

$3,185.00

$2,386.00

$2,074.00

$2,000.00

$2,404.00

$1,814.00

$142.00

$2,770.00

$538.00

$363.00

$117.00

$416.00

$416.00

$418.00

$281.00

$493.00

$441.00

$354.00

$325.00

$113.00

$132.00

$2,541.00

$1,175.00

$1,448.00

$690.00

$958.00

$709.00

--------

$1,248.00

$1,350.00

$1,419.00

$1,417.00

$1,344.00

$1,425.00

$2,577.00

$1,525.00

$1,627.00

$1,761.00

$342.00

$377.00

$99.00

$306.00

$321.00

$157.00

$75.00

$131.00

$221.00

$2,033.00

$2,534.00

$2,092.00

$2,694.00

$2,020.00

$1,897.00

$1,749.00

$2,132.00

$1,602.00

$93.00

$304.00

$276.00

$326.00

$108.00

$373.00

$374.00

$379.00

$258.00

$235.00

$203.00

$324.00

$299.00

$102.00

$117.00

$2,162.00

$1,059.00

$1,236.00

$478.00

$698.00

$500.00

--------

$1,071.00

$1,157.00

$1,209.00

$1,208.00

$1,146.00

$1,214.00

$2,195.00

$1,303.00

$1,388.00

$1,497.00

$356.00

$393.00

$103.00

$317.00

$333.00

$163.00

$78.00

$136.00

$235.00

$2,164.00

$2,695.00

$2,245.00

$2,889.00

$2,166.00

$1,981.00

$1,859.00

$2,254.00

$1,697.00

$96.00

$319.00

$289.00

$342.00

$112.00

$391.00

$393.00

$396.00

$269.00

$245.00

$212.00

$337.00

$311.00

$107.00

$123.00

$2,315.00

$1,125.00

$1,325.00

$506.00

$739.00

$531.00

--------

$1,147.00

$1,240.00

$1,295.00

$1,294.00

$1,228.00

$1,301.00

$2,351.00

$1,396.00

$1,487.00

$1,605.00

$373.00

$412.00

$108.00

$330.00

$346.00

$170.00

$81.00

$143.00

$255.00

$2,266.00

$2,801.00

$2,466.00

$3,185.00

$2,386.00

$2,074.00

$2,000.00

$2,404.00

$1,814.00

$101.00

$339.00

$305.00

$363.00

$117.00

$416.00

$416.00

$418.00

$281.00

$256.00

$221.00

$354.00

$325.00

$113.00

$132.00

$2,541.00

$1,175.00

$1,448.00

$535.00

$781.00

$562.00

--------

$1,248.00

$1,350.00

$1,419.00

$1,417.00

$1,344.00

$1,425.00

$2,577.00

$1,525.00

$1,627.00

$1,761.00


Part B, 207



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

32504

32505

32506

32507

32540

32550

32551

32552

32553

32554

32480

32482

32484

32486

32488

32491

32501

32503

32141

32150

32151

32160

32200

32215

32220

32225

32310

32320

32400

32405

32440

32442

32445

32606

32607

32608

32609

32650

32651

32652

32653

32654

32555

32556

32557

32560

32561

32562

32601

32604

90 $1,267.00

90 $1,226.00

90 $1,231.00

90 $842.00

90 $1,132.00

90 $1,024.00

90 $1,680.00

90 $1,268.00

90 $1,221.00

90 $1,787.00

0 $129.00

0 $159.00

90 $1,837.00

90 $2,093.00

90 $2,093.00

90 $1,622.00

90 $1,714.00

90 $1,771.00

90 $1,974.00

90 $2,094.00

90 $1,784.00

ZZZ $374.00

90 --------

0

0

10

0

0

90

90

ZZZ

ZZZ

--------

--------

--------

--------

90 $1,308.00

--------

--------

--------

--------

--------

0

0

0

0

0

0

0

0

--------

--------

--------

--------

--------

--------

$456.00

$663.00

0

0

0

$637.00

--------

--------

0

90

--------

$957.00

90 $1,166.00

90 $1,615.00

90 $1,144.00

90 $1,096.00

$2,223.00

$2,376.00

$2,165.00

$3,556.00

$3,607.00

$2,216.00

$372.00

$2,723.00

$3,109.00

$1,399.00

$238.00

$238.00

$2,614.00

$1,091.00

$253.00

$268.00

$825.00

$281.00

$2,297.00

$1,507.00

$1,502.00

$1,179.00

$1,699.00

$1,188.00

$2,375.00

$1,492.00

$1,363.00

$2,398.00

$214.00

$623.00

$2,355.00

$4,839.00

$5,344.00

$405.00

$749.00

$718.00

$342.00

$133.00

$121.00

$465.00

$729.00

$698.00

$465.00

$571.00

$389.00

$995.00

$1,648.00

$2,504.00

$1,591.00

$1,784.00

$2,381.00

$2,545.00

$2,320.00

$3,811.00

$3,863.00

$2,376.00

$399.00

$2,918.00

$3,331.00

$1,499.00

$255.00

$255.00

$2,801.00

$1,165.00

$267.00

$284.00

$876.00

$298.00

$2,461.00

$1,614.00

$1,608.00

$1,262.00

$1,819.00

$1,270.00

$2,544.00

$1,598.00

$1,458.00

$2,568.00

$226.00

$664.00

$2,523.00

$5,194.00

$5,721.00

$429.00

$798.00

$763.00

$366.00

$140.00

$127.00

$497.00

$782.00

$748.00

$498.00

$611.00

$416.00

$1,066.00

$1,766.00

$2,683.00

$1,704.00

$1,914.00

$2,614.00

$2,789.00

$2,551.00

$4,203.00

$4,247.00

$2,608.00

$442.00

$3,207.00

$3,663.00

$1,641.00

$283.00

$282.00

$3,078.00

$1,192.00

$288.00

$300.00

$891.00

$305.00

$2,705.00

$1,768.00

$1,757.00

$1,376.00

$1,984.00

$1,379.00

$2,785.00

$1,749.00

$1,592.00

$2,813.00

$232.00

$672.00

$2,770.00

$5,729.00

$6,285.00

$438.00

$809.00

$776.00

$376.00

$147.00

$134.00

$545.00

$862.00

$824.00

$547.00

$672.00

$455.00

$1,162.00

$1,937.00

$2,948.00

$1,867.00

$2,105.00

$2,223.00

$2,376.00

$2,165.00

$3,556.00

$3,607.00

$2,216.00

$372.00

$2,723.00

$3,109.00

$1,399.00

$238.00

$238.00

$2,614.00

$329.00

$253.00

$234.00

$284.00

$131.00

$2,297.00

$1,507.00

$1,502.00

$1,179.00

$1,699.00

$1,188.00

$2,375.00

$1,492.00

$1,363.00

$2,398.00

$128.00

$151.00

$2,355.00

$4,839.00

$5,344.00

$165.00

$181.00

$226.00

$116.00

$101.00

$92.00

$465.00

$729.00

$698.00

$465.00

$571.00

$389.00

$995.00

$1,648.00

$2,504.00

$1,591.00

$1,784.00

$2,381.00

$2,545.00

$2,320.00

$3,811.00

$3,863.00

$2,376.00

$399.00

$2,918.00

$3,331.00

$1,499.00

$255.00

$255.00

$2,801.00

$347.00

$267.00

$248.00

$296.00

$137.00

$2,461.00

$1,614.00

$1,608.00

$1,262.00

$1,819.00

$1,270.00

$2,544.00

$1,598.00

$1,458.00

$2,568.00

$133.00

$158.00

$2,523.00

$5,194.00

$5,721.00

$171.00

$189.00

$235.00

$123.00

$106.00

$96.00

$497.00

$782.00

$748.00

$498.00

$611.00

$416.00

$1,066.00

$1,766.00

$2,683.00

$1,704.00

$1,914.00

$2,614.00

$2,789.00

$2,551.00

$4,203.00

$4,247.00

$2,608.00

$442.00

$3,207.00

$3,663.00

$1,641.00

$283.00

$282.00

$3,078.00

$372.00

$288.00

$263.00

$310.00

$144.00

$2,705.00

$1,768.00

$1,757.00

$1,376.00

$1,984.00

$1,379.00

$2,785.00

$1,749.00

$1,592.00

$2,813.00

$139.00

$165.00

$2,770.00

$5,729.00

$6,285.00

$179.00

$198.00

$246.00

$133.00

$112.00

$103.00

$545.00

$862.00

$824.00

$547.00

$672.00

$455.00

$1,162.00

$1,937.00

$2,948.00

$1,867.00

$2,105.00


Part B, 208



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

32851

32852

32853

32854

32900

32905

32906

32940

32960

32997

32672

32673

32674

32701

32800

32810

32815

32820

32655

32656

32658

32659

32661

32662

32663

32664

32665

32666

32667

32668

32669

32670

32671

33031

33050

33120

33130

33140

33141

33202

33203

33206

32998

32999

33010

33011

33015

33020

33025

33030

90 $1,213.00

90 $1,222.00

90 $1,142.00

90 $1,141.00

90 $1,165.00

90 $1,459.00

90 $1,636.00

90 $1,197.00

90 $1,360.00

90

ZZZ

ZZZ

--------

--------

--------

90

90

90

--------

--------

--------

90

90

ZZZ

0

--------

--------

--------

--------

90 $1,166.00

90 $1,085.00

90 $1,917.00

90 $1,848.00

90 $3,100.00

90 $3,339.00

90 $3,787.00

90 $4,038.00

90 $1,532.00

90 $1,661.00

90 $2,100.00

90 $1,555.00

0 $126.00

0 $312.00

0

YYY

0

--------

BR

$124.00

0

90

$125.00

$555.00

90 $1,178.00

90 $1,165.00

90 $1,786.00

90 $1,816.00

90 $1,224.00

90 $2,358.00

90 $1,734.00

90 $1,571.00

ZZZ $254.00

90 --------

90

90

--------

$642.00

$2,296.00

$1,833.00

$328.00

$329.00

$1,420.00

$1,354.00

$4,219.00

$2,005.00

$4,985.00

$5,458.00

$6,952.00

$7,390.00

$2,104.00

$2,021.00

$2,500.00

$1,859.00

$205.00

$502.00

$1,435.00

$1,204.00

$1,070.00

$1,095.00

$1,203.00

$1,339.00

$2,111.00

$1,279.00

$1,843.00

$1,307.00

$239.00

$238.00

$2,029.00

$2,414.00

$2,673.00

$3,294.00

--------

$181.00

$182.00

$758.00

$1,320.00

$1,199.00

$3,024.00

$3,733.00

$1,498.00

$3,170.00

$2,076.00

$2,377.00

$200.00

$1,167.00

$1,214.00

$689.00

$2,461.00

$1,964.00

$352.00

$352.00

$1,523.00

$1,452.00

$4,519.00

$2,149.00

$5,346.00

$5,854.00

$7,453.00

$7,921.00

$2,252.00

$2,167.00

$2,680.00

$1,994.00

$218.00

$521.00

$1,538.00

$1,290.00

$1,147.00

$1,174.00

$1,291.00

$1,435.00

$2,262.00

$1,370.00

$1,973.00

$1,400.00

$256.00

$255.00

$2,175.00

$2,586.00

$2,863.00

$3,521.00

--------

$194.00

$195.00

$809.00

$1,414.00

$1,285.00

$3,240.00

$3,996.00

$1,603.00

$3,395.00

$2,224.00

$2,549.00

$214.00

$1,252.00

$1,302.00

$738.00

$2,705.00

$2,154.00

$389.00

$388.00

$1,670.00

$1,591.00

$4,968.00

$2,354.00

$5,897.00

$6,465.00

$8,229.00

$8,743.00

$2,462.00

$2,381.00

$2,950.00

$2,193.00

$231.00

$543.00

$1,685.00

$1,411.00

$1,256.00

$1,282.00

$1,415.00

$1,571.00

$2,486.00

$1,500.00

$2,164.00

$1,532.00

$283.00

$283.00

$2,391.00

$2,844.00

$3,149.00

$3,550.00

--------

$213.00

$215.00

$876.00

$1,548.00

$1,408.00

$3,566.00

$4,397.00

$1,753.00

$3,738.00

$2,440.00

$2,812.00

$237.00

$1,374.00

$1,431.00

$804.00

$2,296.00

$1,833.00

$328.00

$329.00

$1,420.00

$1,354.00

$4,219.00

$2,005.00

$4,985.00

$5,458.00

$6,952.00

$7,390.00

$2,104.00

$2,021.00

$2,500.00

$1,859.00

$149.00

$502.00

$1,435.00

$1,204.00

$1,070.00

$1,095.00

$1,203.00

$1,339.00

$2,111.00

$1,279.00

$1,843.00

$1,307.00

$239.00

$238.00

$2,029.00

$2,414.00

$2,673.00

$417.00

--------

$181.00

$182.00

$758.00

$1,320.00

$1,199.00

$3,024.00

$3,733.00

$1,498.00

$3,170.00

$2,076.00

$2,377.00

$200.00

$1,167.00

$1,214.00

$689.00

$2,461.00

$1,964.00

$352.00

$352.00

$1,523.00

$1,452.00

$4,519.00

$2,149.00

$5,346.00

$5,854.00

$7,453.00

$7,921.00

$2,252.00

$2,167.00

$2,680.00

$1,994.00

$158.00

$521.00

$1,538.00

$1,290.00

$1,147.00

$1,174.00

$1,291.00

$1,435.00

$2,262.00

$1,370.00

$1,973.00

$1,400.00

$256.00

$255.00

$2,175.00

$2,586.00

$2,863.00

$434.00

--------

$194.00

$195.00

$809.00

$1,414.00

$1,285.00

$3,240.00

$3,996.00

$1,603.00

$3,395.00

$2,224.00

$2,549.00

$214.00

$1,252.00

$1,302.00

$738.00

$2,705.00

$2,154.00

$389.00

$388.00

$1,670.00

$1,591.00

$4,968.00

$2,354.00

$5,897.00

$6,465.00

$8,229.00

$8,743.00

$2,462.00

$2,381.00

$2,950.00

$2,193.00

$171.00

$543.00

$1,685.00

$1,411.00

$1,256.00

$1,282.00

$1,415.00

$1,571.00

$2,486.00

$1,500.00

$2,164.00

$1,532.00

$283.00

$283.00

$2,391.00

$2,844.00

$3,149.00

$455.00

--------

$213.00

$215.00

$876.00

$1,548.00

$1,408.00

$3,566.00

$4,397.00

$1,753.00

$3,738.00

$2,440.00

$2,812.00

$237.00

$1,374.00

$1,431.00

$804.00


Part B, 209



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

33233

33234

33235

33236

33237

33238

33240

33241

33243

33244

33224

33225

33226

33227

33228

33229

33230

33231

33207

33208

33210

33211

33212

33213

33214

33215

33216

33217

33218

33220

33221

33222

33223

33259

33261

33262

33263

33264

33265

33266

33270

33271

33249

33250

33251

33254

33255

33256

33257

33258

90

90

90

90

90

90

90

90

90

90

0

0

90

90

90

0 $490.00

ZZZ $434.00

0

90

90

$472.00

--------

--------

90

90

90

--------

--------

--------

90

90

90

90

$270.00

$598.00

$587.00

$933.00

90 $1,184.00

90 $1,235.00

90 $648.00

90 $301.00

90 $1,650.00

90 $1,081.00

$753.00

$573.00

$204.00

$210.00

$511.00

$437.00

$532.00

$304.00

$402.00

$428.00

$488.00

$390.00

--------

$471.00

$585.00

90 $1,271.00

90 $1,687.00

90 $2,071.00

90

90

90

ZZZ

ZZZ

--------

--------

--------

--------

--------

ZZZ --------

90 $1,993.00

90 --------

90

90

90

90

90

90

--------

--------

--------

--------

--------

--------

$776.00

$705.00

$743.00

$523.00

$545.00

$575.00

$593.00

$617.00

$359.00

$741.00

$965.00

$1,173.00

$1,261.00

$1,396.00

$564.00

$338.00

$2,056.00

$1,299.00

$737.00

$798.00

$270.00

$276.00

$498.00

$519.00

$730.00

$462.00

$570.00

$559.00

$596.00

$597.00

$556.00

$517.00

$626.00

$1,387.00

$2,212.00

$2,446.00

$2,066.00

$2,437.00

$2,951.00

$872.00

$980.00

$1,266.00

$2,473.00

$574.00

$597.00

$622.00

$2,045.00

$2,787.00

$881.00

$741.00

$831.00

$756.00

$796.00

$560.00

$585.00

$616.00

$635.00

$661.00

$384.00

$794.00

$1,034.00

$1,258.00

$1,352.00

$1,494.00

$605.00

$363.00

$2,202.00

$1,392.00

$789.00

$855.00

$289.00

$296.00

$533.00

$556.00

$782.00

$496.00

$610.00

$599.00

$639.00

$640.00

$596.00

$554.00

$671.00

$1,486.00

$2,372.00

$2,619.00

$2,215.00

$2,605.00

$3,164.00

$934.00

$1,048.00

$1,355.00

$2,650.00

$615.00

$640.00

$667.00

$2,189.00

$2,986.00

$945.00

$795.00

$914.00

$832.00

$874.00

$610.00

$637.00

$671.00

$694.00

$721.00

$416.00

$866.00

$1,127.00

$1,376.00

$1,478.00

$1,630.00

$660.00

$393.00

$2,414.00

$1,520.00

$863.00

$935.00

$318.00

$325.00

$581.00

$606.00

$852.00

$541.00

$664.00

$652.00

$695.00

$696.00

$649.00

$601.00

$730.00

$1,625.00

$2,612.00

$2,874.00

$2,434.00

$2,854.00

$3,483.00

$1,020.00

$1,145.00

$1,481.00

$2,913.00

$671.00

$698.00

$728.00

$2,397.00

$3,284.00

$1,030.00

$865.00

$776.00

$705.00

$743.00

$523.00

$545.00

$575.00

$593.00

$617.00

$359.00

$741.00

$965.00

$1,173.00

$1,261.00

$1,396.00

$564.00

$338.00

$2,056.00

$1,299.00

$737.00

$798.00

$270.00

$276.00

$498.00

$519.00

$730.00

$462.00

$570.00

$559.00

$596.00

$597.00

$556.00

$517.00

$626.00

$1,387.00

$2,212.00

$2,446.00

$2,066.00

$2,437.00

$2,951.00

$872.00

$980.00

$1,266.00

$2,473.00

$574.00

$597.00

$622.00

$2,045.00

$2,787.00

$881.00

$741.00

$831.00

$756.00

$796.00

$560.00

$585.00

$616.00

$635.00

$661.00

$384.00

$794.00

$1,034.00

$1,258.00

$1,352.00

$1,494.00

$605.00

$363.00

$2,202.00

$1,392.00

$789.00

$855.00

$289.00

$296.00

$533.00

$556.00

$782.00

$496.00

$610.00

$599.00

$639.00

$640.00

$596.00

$554.00

$671.00

$1,486.00

$2,372.00

$2,619.00

$2,215.00

$2,605.00

$3,164.00

$934.00

$1,048.00

$1,355.00

$2,650.00

$615.00

$640.00

$667.00

$2,189.00

$2,986.00

$945.00

$795.00

$914.00

$832.00

$874.00

$610.00

$637.00

$671.00

$694.00

$721.00

$416.00

$866.00

$1,127.00

$1,376.00

$1,478.00

$1,630.00

$660.00

$393.00

$2,414.00

$1,520.00

$863.00

$935.00

$318.00

$325.00

$581.00

$606.00

$852.00

$541.00

$664.00

$652.00

$695.00

$696.00

$649.00

$601.00

$730.00

$1,625.00

$2,612.00

$2,874.00

$2,434.00

$2,854.00

$3,483.00

$1,020.00

$1,145.00

$1,481.00

$2,913.00

$671.00

$698.00

$728.00

$2,397.00

$3,284.00

$1,030.00

$865.00


Part B, 210



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

33401

33403

33404

33405

33406

33410

33411

33412

33413

33414

33363

33364

33365

33366

33367

33368

33369

33400

33272

33273

33282

33284

33300

33305

33310

33315

33320

33321

33322

33330

33335

33361

33362

33426

33427

33430

33460

33463

33464

33465

33468

33470

33415

33416

33417

33418

33419

33420

33422

33425

90

90

--------

--------

90

90

$470.00

$365.00

90 $1,576.00

90 $1,889.00

90 $1,577.00

90 $1,875.00

90 $1,485.00

90 $1,890.00

90 $1,935.00

90 $1,726.00

90 $2,336.00

0 --------

0 --------

0

0

0

0

ZZZ

--------

--------

--------

--------

--------

ZZZ

ZZZ

--------

--------

90 $2,401.00

90 $2,228.00

90 $2,369.00

90 $2,698.00

90 $2,745.00

90 $2,962.00

90 $2,637.00

90 $2,981.00

90 $3,213.00

90 $3,282.00

90 $2,904.00

90 $2,563.00

90 $2,684.00

90 $2,756.00

90

ZZZ

--------

--------

90 $1,796.00

90 $2,431.00

90 $2,509.00

90 $2,806.00

90 $3,026.00

90 $2,891.00

90 $2,215.00

90 $2,396.00

90 $2,547.00

90 $2,665.00

90 $2,952.00

90 $1,749.00

$2,336.00

$2,451.00

$2,698.00

$2,921.00

$948.00

$1,138.00

$1,504.00

$3,438.00

$2,175.00

$2,235.00

$2,660.00

$3,429.00

$4,350.00

$3,826.00

$5,077.00

$4,814.00

$4,929.00

$3,277.00

$524.00

$593.00

$354.00

$312.00

$3,706.00

$6,215.00

$1,772.00

$2,887.00

$1,600.00

$1,853.00

$2,094.00

$2,147.00

$2,818.00

$2,057.00

$2,250.00

$3,052.00

$3,069.00

$2,531.00

$2,702.00

$636.00

$2,203.00

$2,522.00

$4,134.00

$3,597.00

$3,694.00

$4,227.00

$3,700.00

$4,674.00

$3,687.00

$4,168.00

$3,738.00

$1,950.00

$2,502.00

$2,626.00

$2,892.00

$3,131.00

$1,014.00

$1,220.00

$1,613.00

$3,679.00

$2,333.00

$2,397.00

$2,852.00

$3,671.00

$4,659.00

$4,093.00

$5,435.00

$5,162.00

$5,286.00

$3,516.00

$562.00

$627.00

$379.00

$335.00

$3,970.00

$6,657.00

$1,900.00

$3,091.00

$1,714.00

$1,989.00

$2,243.00

$2,298.00

$3,012.00

$2,204.00

$2,411.00

$3,261.00

$3,288.00

$2,715.00

$2,887.00

$678.00

$2,363.00

$2,700.00

$4,427.00

$3,851.00

$3,954.00

$4,526.00

$3,970.00

$5,003.00

$3,945.00

$4,462.00

$4,010.00

$2,092.00

$2,759.00

$2,899.00

$3,192.00

$3,460.00

$1,118.00

$1,353.00

$1,788.00

$4,044.00

$2,563.00

$2,634.00

$3,142.00

$4,038.00

$5,130.00

$4,497.00

$5,985.00

$5,708.00

$5,840.00

$3,883.00

$612.00

$666.00

$411.00

$363.00

$4,375.00

$7,347.00

$2,088.00

$3,400.00

$1,882.00

$2,186.00

$2,463.00

$2,522.00

$3,302.00

$2,431.00

$2,662.00

$3,573.00

$3,617.00

$2,988.00

$3,157.00

$741.00

$2,601.00

$2,963.00

$4,873.00

$4,235.00

$4,352.00

$4,979.00

$4,386.00

$5,508.00

$4,336.00

$4,911.00

$4,431.00

$2,293.00

$2,336.00

$2,451.00

$2,698.00

$2,921.00

$948.00

$1,138.00

$1,504.00

$3,438.00

$2,175.00

$2,235.00

$2,660.00

$3,429.00

$4,350.00

$3,826.00

$5,077.00

$4,814.00

$4,929.00

$3,277.00

$524.00

$593.00

$354.00

$312.00

$3,706.00

$6,215.00

$1,772.00

$2,887.00

$1,600.00

$1,853.00

$2,094.00

$2,147.00

$2,818.00

$2,057.00

$2,250.00

$3,052.00

$3,069.00

$2,531.00

$2,702.00

$636.00

$2,203.00

$2,522.00

$4,134.00

$3,597.00

$3,694.00

$4,227.00

$3,700.00

$4,674.00

$3,687.00

$4,168.00

$3,738.00

$1,950.00

$2,502.00

$2,626.00

$2,892.00

$3,131.00

$1,014.00

$1,220.00

$1,613.00

$3,679.00

$2,333.00

$2,397.00

$2,852.00

$3,671.00

$4,659.00

$4,093.00

$5,435.00

$5,162.00

$5,286.00

$3,516.00

$562.00

$627.00

$379.00

$335.00

$3,970.00

$6,657.00

$1,900.00

$3,091.00

$1,714.00

$1,989.00

$2,243.00

$2,298.00

$3,012.00

$2,204.00

$2,411.00

$3,261.00

$3,288.00

$2,715.00

$2,887.00

$678.00

$2,363.00

$2,700.00

$4,427.00

$3,851.00

$3,954.00

$4,526.00

$3,970.00

$5,003.00

$3,945.00

$4,462.00

$4,010.00

$2,092.00

$2,759.00

$2,899.00

$3,192.00

$3,460.00

$1,118.00

$1,353.00

$1,788.00

$4,044.00

$2,563.00

$2,634.00

$3,142.00

$4,038.00

$5,130.00

$4,497.00

$5,985.00

$5,708.00

$5,840.00

$3,883.00

$612.00

$666.00

$411.00

$363.00

$4,375.00

$7,347.00

$2,088.00

$3,400.00

$1,882.00

$2,186.00

$2,463.00

$2,522.00

$3,302.00

$2,431.00

$2,662.00

$3,573.00

$3,617.00

$2,988.00

$3,157.00

$741.00

$2,601.00

$2,963.00

$4,873.00

$4,235.00

$4,352.00

$4,979.00

$4,386.00

$5,508.00

$4,336.00

$4,911.00

$4,431.00

$2,293.00


Part B, 211



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

33518

33519

33521

33522

33523

33530

33533

33534

33535

33536

33508

33510

33511

33512

33513

33514

33516

33517

33471

33474

33475

33476

33477

33478

33496

33500

33501

33502

33503

33504

33505

33506

33507

33610

33611

33612

33615

33617

33619

33620

33621

33622

33542

33545

33548

33572

33600

33602

33606

33608

90 $1,929.00

90 $2,173.00

90 $2,666.00

90 $2,270.00

0 --------

90 $2,544.00

90 $2,595.00

90 $2,370.00

90 $1,546.00

90 $1,938.00

90 $1,983.00

90 $2,416.00

90 $2,423.00

90 $2,448.00

90 --------

ZZZ $17.00

90 $2,354.00

90 $2,546.00

90 $2,732.00

90 $2,933.00

90 $3,197.00

90 $3,404.00

ZZZ $219.00

ZZZ $414.00

ZZZ $607.00

ZZZ $801.00

ZZZ $994.00

ZZZ $1,189.00

ZZZ $521.00

90 $2,415.00

90 $2,654.00

90 $2,899.00

90 $3,143.00

90 $2,693.00

90 $3,250.00

90 --------

ZZZ $340.00

90 $2,644.00

90 $2,556.00

90 $2,831.00

90 $2,940.00

90 $2,871.00

90 $2,985.00

90 $3,152.00

90 $3,051.00

90 $3,272.00

90 $3,678.00

90 --------

90

90

--------

--------

$24.00

$2,917.00

$3,206.00

$3,647.00

$3,753.00

$3,949.00

$4,133.00

$285.00

$625.00

$827.00

$992.00

$1,112.00

$1,265.00

$800.00

$2,821.00

$3,320.00

$3,703.00

$3,993.00

$2,084.00

$3,316.00

$3,519.00

$2,309.00

$1,925.00

$2,387.00

$2,524.00

$2,359.00

$1,709.00

$1,933.00

$2,008.00

$2,223.00

$3,150.00

$3,134.00

$2,627.00

$3,973.00

$4,694.00

$4,476.00

$350.00

$2,610.00

$2,533.00

$2,816.00

$2,735.00

$2,697.00

$3,114.00

$3,054.00

$3,038.00

$3,293.00

$4,146.00

$2,514.00

$1,413.00

$5,510.00

$26.00

$3,122.00

$3,433.00

$3,904.00

$4,018.00

$4,225.00

$4,432.00

$305.00

$669.00

$885.00

$1,061.00

$1,191.00

$1,353.00

$856.00

$3,020.00

$3,555.00

$3,964.00

$4,273.00

$2,236.00

$3,557.00

$3,767.00

$2,477.00

$2,031.00

$2,560.00

$2,705.00

$2,523.00

$1,833.00

$2,073.00

$2,154.00

$2,385.00

$3,379.00

$3,362.00

$2,818.00

$4,254.00

$5,030.00

$4,791.00

$375.00

$2,800.00

$2,717.00

$3,021.00

$2,934.00

$2,894.00

$3,341.00

$3,276.00

$3,259.00

$3,533.00

$4,448.00

$2,696.00

$1,516.00

$5,911.00

$29.00

$3,432.00

$3,774.00

$4,295.00

$4,421.00

$4,646.00

$4,893.00

$337.00

$740.00

$978.00

$1,173.00

$1,315.00

$1,494.00

$947.00

$3,319.00

$3,909.00

$4,360.00

$4,699.00

$2,450.00

$3,925.00

$4,143.00

$2,725.00

$2,179.00

$2,817.00

$2,977.00

$2,763.00

$2,015.00

$2,277.00

$2,364.00

$2,622.00

$3,737.00

$3,715.00

$3,111.00

$4,685.00

$5,550.00

$5,271.00

$414.00

$3,082.00

$2,991.00

$3,316.00

$3,232.00

$3,187.00

$3,673.00

$3,617.00

$3,594.00

$3,898.00

$4,903.00

$2,976.00

$1,667.00

$6,508.00

$24.00

$2,917.00

$3,206.00

$3,647.00

$3,753.00

$3,949.00

$4,133.00

$285.00

$625.00

$827.00

$992.00

$1,112.00

$1,265.00

$800.00

$2,821.00

$3,320.00

$3,703.00

$3,993.00

$2,084.00

$3,316.00

$3,519.00

$2,309.00

$1,925.00

$2,387.00

$2,524.00

$2,359.00

$1,709.00

$1,933.00

$2,008.00

$2,223.00

$3,150.00

$3,134.00

$2,627.00

$3,973.00

$4,694.00

$4,476.00

$350.00

$2,610.00

$2,533.00

$2,816.00

$2,735.00

$2,697.00

$3,114.00

$3,054.00

$3,038.00

$3,293.00

$4,146.00

$2,514.00

$1,413.00

$5,510.00

$26.00

$3,122.00

$3,433.00

$3,904.00

$4,018.00

$4,225.00

$4,432.00

$305.00

$669.00

$885.00

$1,061.00

$1,191.00

$1,353.00

$856.00

$3,020.00

$3,555.00

$3,964.00

$4,273.00

$2,236.00

$3,557.00

$3,767.00

$2,477.00

$2,031.00

$2,560.00

$2,705.00

$2,523.00

$1,833.00

$2,073.00

$2,154.00

$2,385.00

$3,379.00

$3,362.00

$2,818.00

$4,254.00

$5,030.00

$4,791.00

$375.00

$2,800.00

$2,717.00

$3,021.00

$2,934.00

$2,894.00

$3,341.00

$3,276.00

$3,259.00

$3,533.00

$4,448.00

$2,696.00

$1,516.00

$5,911.00

$29.00

$3,432.00

$3,774.00

$4,295.00

$4,421.00

$4,646.00

$4,893.00

$337.00

$740.00

$978.00

$1,173.00

$1,315.00

$1,494.00

$947.00

$3,319.00

$3,909.00

$4,360.00

$4,699.00

$2,450.00

$3,925.00

$4,143.00

$2,725.00

$2,179.00

$2,817.00

$2,977.00

$2,763.00

$2,015.00

$2,277.00

$2,364.00

$2,622.00

$3,737.00

$3,715.00

$3,111.00

$4,685.00

$5,550.00

$5,271.00

$414.00

$3,082.00

$2,991.00

$3,316.00

$3,232.00

$3,187.00

$3,673.00

$3,617.00

$3,594.00

$3,898.00

$4,903.00

$2,976.00

$1,667.00

$6,508.00


Part B, 212



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

33732

33735

33736

33737

33750

33755

33762

33764

33766

33767

33697

33702

33710

33720

33722

33724

33726

33730

33641

33645

33647

33660

33665

33670

33675

33676

33677

33681

33684

33688

33690

33692

33694

33779

33780

33781

33782

33783

33786

33788

33800

33802

33768

33770

33771

33774

33775

33776

33777

33778

90 $1,981.00

90 $2,352.00

90 $2,732.00

90 $2,444.00

90 $2,700.00

90 $2,820.00

90 --------

90

90

--------

--------

90 $2,657.00

90 $2,740.00

90 $2,602.00

90 $1,884.00

90 $2,816.00

90 $2,856.00

90 $3,064.00

90 $2,549.00

90 $2,731.00

90 $2,508.00

90 $2,704.00

90

90

--------

--------

90 $2,785.00

90 $2,622.00

90 $2,036.00

90 $2,288.00

90 $1,977.00

90 $1,877.00

90 $1,831.00

90 $1,900.00

90 $1,895.00

90 $2,119.00

90 $2,173.00

ZZZ --------

90 $2,954.00

90 $2,924.00

90 $2,681.00

90 $2,654.00

90 $2,844.00

90 $2,724.00

90 $3,199.00

90 $3,121.00

90 $3,232.00

90 $3,057.00

90

90

--------

--------

90 $2,970.00

90 $2,288.00

90 $1,546.00

90 $1,752.00

$3,134.00

$2,348.00

$3,277.00

$2,349.00

$2,474.00

$2,342.00

$3,100.00

$3,052.00

$2,502.00

$1,963.00

$2,132.00

$2,043.00

$1,916.00

$1,995.00

$2,027.00

$1,995.00

$2,024.00

$2,161.00

$2,496.00

$2,635.00

$2,770.00

$2,676.00

$2,917.00

$3,012.00

$3,006.00

$3,232.00

$3,359.00

$2,793.00

$3,014.00

$2,875.00

$1,816.00

$3,134.00

$3,114.00

$638.00

$3,390.00

$3,497.00

$2,734.00

$2,939.00

$3,105.00

$3,011.00

$3,746.00

$3,731.00

$3,616.00

$3,715.00

$4,930.00

$5,602.00

$3,470.00

$2,433.00

$1,499.00

$1,641.00

$3,362.00

$2,519.00

$3,515.00

$2,520.00

$2,653.00

$2,513.00

$3,325.00

$3,274.00

$2,684.00

$2,106.00

$2,287.00

$2,192.00

$2,056.00

$2,140.00

$2,174.00

$2,140.00

$2,171.00

$2,318.00

$2,677.00

$2,826.00

$2,971.00

$2,871.00

$3,129.00

$3,231.00

$3,225.00

$3,467.00

$3,603.00

$2,996.00

$3,233.00

$3,084.00

$1,948.00

$3,362.00

$3,341.00

$684.00

$3,637.00

$3,752.00

$2,932.00

$3,153.00

$3,331.00

$3,230.00

$4,019.00

$4,002.00

$3,878.00

$3,985.00

$5,289.00

$6,009.00

$3,723.00

$2,610.00

$1,608.00

$1,760.00

$3,712.00

$2,773.00

$3,866.00

$2,774.00

$2,926.00

$2,770.00

$3,671.00

$3,612.00

$2,955.00

$2,313.00

$2,514.00

$2,402.00

$2,263.00

$2,351.00

$2,386.00

$2,351.00

$2,390.00

$2,554.00

$2,953.00

$3,118.00

$3,279.00

$3,168.00

$3,454.00

$3,573.00

$3,560.00

$3,813.00

$3,962.00

$3,298.00

$3,554.00

$3,409.00

$2,138.00

$3,700.00

$3,673.00

$759.00

$4,002.00

$4,131.00

$3,229.00

$3,462.00

$3,656.00

$3,549.00

$4,418.00

$4,406.00

$4,288.00

$4,388.00

$5,849.00

$6,616.00

$4,113.00

$2,866.00

$1,769.00

$1,931.00

$3,134.00

$2,348.00

$3,277.00

$2,349.00

$2,474.00

$2,342.00

$3,100.00

$3,052.00

$2,502.00

$1,963.00

$2,132.00

$2,043.00

$1,916.00

$1,995.00

$2,027.00

$1,995.00

$2,024.00

$2,161.00

$2,496.00

$2,635.00

$2,770.00

$2,676.00

$2,917.00

$3,012.00

$3,006.00

$3,232.00

$3,359.00

$2,793.00

$3,014.00

$2,875.00

$1,816.00

$3,134.00

$3,114.00

$638.00

$3,390.00

$3,497.00

$2,734.00

$2,939.00

$3,105.00

$3,011.00

$3,746.00

$3,731.00

$3,616.00

$3,715.00

$4,930.00

$5,602.00

$3,470.00

$2,433.00

$1,499.00

$1,641.00

$3,362.00

$2,519.00

$3,515.00

$2,520.00

$2,653.00

$2,513.00

$3,325.00

$3,274.00

$2,684.00

$2,106.00

$2,287.00

$2,192.00

$2,056.00

$2,140.00

$2,174.00

$2,140.00

$2,171.00

$2,318.00

$2,677.00

$2,826.00

$2,971.00

$2,871.00

$3,129.00

$3,231.00

$3,225.00

$3,467.00

$3,603.00

$2,996.00

$3,233.00

$3,084.00

$1,948.00

$3,362.00

$3,341.00

$684.00

$3,637.00

$3,752.00

$2,932.00

$3,153.00

$3,331.00

$3,230.00

$4,019.00

$4,002.00

$3,878.00

$3,985.00

$5,289.00

$6,009.00

$3,723.00

$2,610.00

$1,608.00

$1,760.00

$3,712.00

$2,773.00

$3,866.00

$2,774.00

$2,926.00

$2,770.00

$3,671.00

$3,612.00

$2,955.00

$2,313.00

$2,514.00

$2,402.00

$2,263.00

$2,351.00

$2,386.00

$2,351.00

$2,390.00

$2,554.00

$2,953.00

$3,118.00

$3,279.00

$3,168.00

$3,454.00

$3,573.00

$3,560.00

$3,813.00

$3,962.00

$3,298.00

$3,554.00

$3,409.00

$2,138.00

$3,700.00

$3,673.00

$759.00

$4,002.00

$4,131.00

$3,229.00

$3,462.00

$3,656.00

$3,549.00

$4,418.00

$4,406.00

$4,288.00

$4,388.00

$5,849.00

$6,616.00

$4,113.00

$2,866.00

$1,769.00

$1,931.00


Part B, 213



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

33891

33910

33915

33916

33917

33920

33922

33924

33925

33926

33875

33877

33880

33881

33883

33884

33886

33889

33803

33813

33814

33820

33822

33824

33840

33845

33851

33852

33853

33860

33863

33864

33870

33953

33954

33955

33956

33957

33958

33959

33962

33963

33935

33945

33946

33947

33948

33949

33951

33952

90 $1,746.00

90 $1,935.00

90 $2,464.00

90 $1,619.00

90 $1,559.00

90 $1,884.00

90 $2,029.00

90 $2,129.00

90 $2,129.00

90 $2,311.00

90 $3,057.00

90 $3,044.00

90 $3,183.00

90 --------

90 $3,638.00

90 $2,876.00

90 $3,767.00

90

90

90

--------

--------

--------

ZZZ

90

0

--------

--------

--------

0 --------

90 $1,987.00

90 $1,588.00

90 $2,096.00

90 $2,345.00

90 $2,981.00

90 $2,227.00

ZZZ $421.00

90 --------

90 --------

0

0

0

0

0

0

0

0

0

0

0

0

0

0

90 $5,415.00

90 $3,813.00

0 --------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

$4,167.00

$5,543.00

$2,755.00

$2,366.00

$1,709.00

$628.00

$1,476.00

$1,214.00

$1,498.00

$3,977.00

$1,934.00

$6,395.00

$2,210.00

$2,882.00

$2,108.00

$438.00

$2,617.00

$3,873.00

$1,747.00

$1,949.00

$2,312.00

$1,469.00

$1,609.00

$1,787.00

$1,878.00

$2,021.00

$1,928.00

$2,122.00

$2,785.00

$4,863.00

$4,773.00

$4,883.00

$3,807.00

$7,565.00

$7,361.00

$461.00

$509.00

$363.00

$353.00

$623.00

$653.00

$696.00

$730.00

$1,245.00

$1,274.00

$276.00

$273.00

$351.00

$361.00

$702.00

$4,464.00

$5,939.00

$2,948.00

$2,532.00

$1,827.00

$672.00

$1,578.00

$1,300.00

$1,605.00

$4,258.00

$2,068.00

$6,860.00

$2,370.00

$3,091.00

$2,261.00

$469.00

$2,808.00

$4,155.00

$1,874.00

$2,091.00

$2,480.00

$1,576.00

$1,726.00

$1,916.00

$2,014.00

$2,168.00

$2,069.00

$2,276.00

$2,988.00

$5,207.00

$5,110.00

$5,230.00

$4,076.00

$8,095.00

$7,887.00

$489.00

$541.00

$384.00

$374.00

$658.00

$700.00

$734.00

$783.00

$1,310.00

$1,364.00

$291.00

$288.00

$369.00

$386.00

$739.00

$4,921.00

$6,564.00

$3,251.00

$2,791.00

$2,007.00

$743.00

$1,736.00

$1,442.00

$1,786.00

$4,686.00

$2,282.00

$7,587.00

$2,606.00

$3,397.00

$2,487.00

$521.00

$3,099.00

$4,572.00

$2,063.00

$2,290.00

$2,728.00

$1,732.00

$1,891.00

$2,105.00

$2,213.00

$2,383.00

$2,274.00

$2,504.00

$3,291.00

$5,737.00

$5,635.00

$5,770.00

$4,486.00

$8,898.00

$8,698.00

$533.00

$590.00

$417.00

$406.00

$706.00

$774.00

$788.00

$866.00

$1,396.00

$1,508.00

$310.00

$309.00

$393.00

$424.00

$787.00

$4,167.00

$5,543.00

$2,755.00

$2,366.00

$1,709.00

$628.00

$1,476.00

$1,214.00

$1,498.00

$3,977.00

$1,934.00

$6,395.00

$2,210.00

$2,882.00

$2,108.00

$438.00

$2,617.00

$3,873.00

$1,747.00

$1,949.00

$2,312.00

$1,469.00

$1,609.00

$1,787.00

$1,878.00

$2,021.00

$1,928.00

$2,122.00

$2,785.00

$4,863.00

$4,773.00

$4,883.00

$3,807.00

$7,565.00

$7,361.00

$461.00

$509.00

$363.00

$353.00

$623.00

$653.00

$696.00

$730.00

$1,245.00

$1,274.00

$276.00

$273.00

$351.00

$361.00

$702.00

$4,464.00

$5,939.00

$2,948.00

$2,532.00

$1,827.00

$672.00

$1,578.00

$1,300.00

$1,605.00

$4,258.00

$2,068.00

$6,860.00

$2,370.00

$3,091.00

$2,261.00

$469.00

$2,808.00

$4,155.00

$1,874.00

$2,091.00

$2,480.00

$1,576.00

$1,726.00

$1,916.00

$2,014.00

$2,168.00

$2,069.00

$2,276.00

$2,988.00

$5,207.00

$5,110.00

$5,230.00

$4,076.00

$8,095.00

$7,887.00

$489.00

$541.00

$384.00

$374.00

$658.00

$700.00

$734.00

$783.00

$1,310.00

$1,364.00

$291.00

$288.00

$369.00

$386.00

$739.00

$4,921.00

$6,564.00

$3,251.00

$2,791.00

$2,007.00

$743.00

$1,736.00

$1,442.00

$1,786.00

$4,686.00

$2,282.00

$7,587.00

$2,606.00

$3,397.00

$2,487.00

$521.00

$3,099.00

$4,572.00

$2,063.00

$2,290.00

$2,728.00

$1,732.00

$1,891.00

$2,105.00

$2,213.00

$2,383.00

$2,274.00

$2,504.00

$3,291.00

$5,737.00

$5,635.00

$5,770.00

$4,486.00

$8,898.00

$8,698.00

$533.00

$590.00

$417.00

$406.00

$706.00

$774.00

$788.00

$866.00

$1,396.00

$1,508.00

$310.00

$309.00

$393.00

$424.00

$787.00


Part B, 214



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

33988

33989

33990

33991

33992

33993

33999

34001

34051

34101

33980

33981

33982

33983

33984

33985

33986

33987

33964

33965

33966

33967

33968

33969

33970

33971

33973

33974

33975

33976

33977

33978

33979

34490

34501

34502

34510

34520

34530

34800

34802

34803

34111

34151

34201

34203

34401

34421

34451

34471

0

0

0

0

0

0

0

--------

--------

--------

$258.00

$51.00

--------

$576.00

90

0

$578.00

$756.00

90 $1,095.00

0 $1,758.00

0 $2,056.00

0 $1,561.00

0 $1,754.00

0 $2,496.00

0

0

0 $3,212.00

0 --------

0

--------

--------

--------

0

0

ZZZ

--------

--------

--------

0

0

0

0

0

--------

--------

--------

--------

--------

0

YYY

--------

BR

90 $1,012.00

90 $1,134.00

90 $800.00

90 $669.00

90 $1,288.00

90 $777.00

90

90

$949.00

$953.00

90 $779.00

90 $1,117.00

90 $685.00

90

90

$660.00

$910.00

90 $2,044.00

90 $1,108.00

90 $1,077.00

90 $1,368.00

90 $1,159.00

90 $1,279.00

90 --------

$2,717.00

$1,275.00

$3,013.00

$3,530.00

$434.00

$771.00

$803.00

$317.00

$1,181.00

$762.00

$667.00

$972.00

$315.00

$277.00

--------

$1,491.00

$1,496.00

$923.00

$734.00

$276.00

$357.00

$393.00

$51.00

$409.00

$539.00

$1,067.00

$781.00

$1,334.00

$2,002.00

$2,440.00

$1,715.00

$2,030.00

$2,976.00

$919.00

$2,152.00

$1,587.00

$1,470.00

$2,207.00

$1,119.00

$2,224.00

$1,666.00

$933.00

$1,489.00

$2,333.00

$1,807.00

$1,543.00

$1,654.00

$1,737.00

$1,915.00

$1,980.00

$2,912.00

$1,367.00

$3,224.00

$3,781.00

$464.00

$812.00

$858.00

$339.00

$1,264.00

$815.00

$716.00

$1,042.00

$338.00

$296.00

--------

$1,597.00

$1,605.00

$989.00

$774.00

$291.00

$382.00

$421.00

$54.00

$430.00

$577.00

$1,142.00

$835.00

$1,428.00

$2,144.00

$2,615.00

$1,837.00

$2,174.00

$3,189.00

$985.00

$2,305.00

$1,700.00

$1,575.00

$2,359.00

$1,197.00

$2,378.00

$1,785.00

$1,000.00

$1,597.00

$2,494.00

$1,940.00

$1,653.00

$1,771.00

$1,859.00

$2,049.00

$2,118.00

$3,217.00

$1,516.00

$3,559.00

$4,182.00

$512.00

$865.00

$943.00

$374.00

$1,395.00

$897.00

$791.00

$1,151.00

$373.00

$327.00

--------

$1,759.00

$1,762.00

$1,088.00

$829.00

$310.00

$421.00

$465.00

$59.00

$458.00

$637.00

$1,248.00

$921.00

$1,559.00

$2,369.00

$2,892.00

$2,027.00

$2,399.00

$3,529.00

$1,083.00

$2,543.00

$1,876.00

$1,736.00

$2,583.00

$1,315.00

$2,626.00

$1,976.00

$1,099.00

$1,753.00

$2,736.00

$2,130.00

$1,824.00

$1,931.00

$2,048.00

$2,256.00

$2,334.00

$2,717.00

$1,275.00

$3,013.00

$3,530.00

$434.00

$771.00

$803.00

$317.00

$1,181.00

$762.00

$667.00

$972.00

$315.00

$277.00

--------

$1,491.00

$1,496.00

$923.00

$734.00

$276.00

$357.00

$393.00

$51.00

$409.00

$539.00

$1,067.00

$781.00

$1,334.00

$2,002.00

$2,440.00

$1,715.00

$2,030.00

$2,976.00

$919.00

$2,152.00

$1,587.00

$1,470.00

$2,207.00

$1,119.00

$2,224.00

$1,666.00

$933.00

$1,489.00

$2,333.00

$1,807.00

$1,543.00

$1,654.00

$1,737.00

$1,915.00

$1,980.00

$2,912.00

$1,367.00

$3,224.00

$3,781.00

$464.00

$812.00

$858.00

$339.00

$1,264.00

$815.00

$716.00

$1,042.00

$338.00

$296.00

--------

$1,597.00

$1,605.00

$989.00

$774.00

$291.00

$382.00

$421.00

$54.00

$430.00

$577.00

$1,142.00

$835.00

$1,428.00

$2,144.00

$2,615.00

$1,837.00

$2,174.00

$3,189.00

$985.00

$2,305.00

$1,700.00

$1,575.00

$2,359.00

$1,197.00

$2,378.00

$1,785.00

$1,000.00

$1,597.00

$2,494.00

$1,940.00

$1,653.00

$1,771.00

$1,859.00

$2,049.00

$2,118.00

$3,217.00

$1,516.00

$3,559.00

$4,182.00

$512.00

$865.00

$943.00

$374.00

$1,395.00

$897.00

$791.00

$1,151.00

$373.00

$327.00

--------

$1,759.00

$1,762.00

$1,088.00

$829.00

$310.00

$421.00

$465.00

$59.00

$458.00

$637.00

$1,248.00

$921.00

$1,559.00

$2,369.00

$2,892.00

$2,027.00

$2,399.00

$3,529.00

$1,083.00

$2,543.00

$1,876.00

$1,736.00

$2,583.00

$1,315.00

$2,626.00

$1,976.00

$1,099.00

$1,753.00

$2,736.00

$2,130.00

$1,824.00

$1,931.00

$2,048.00

$2,256.00

$2,334.00


Part B, 215



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

35081

35082

35091

35092

35102

35103

35111

35112

35121

35122

35001

35002

35005

35011

35013

35021

35022

35045

34804

34805

34806

34808

34812

34813

34820

34825

34826

34830

34831

34832

34833

34834

34900

35184

35188

35189

35190

35201

35206

35207

35211

35216

35131

35132

35141

35142

35151

35152

35180

35182

90 $1,279.00

90 --------

ZZZ --------

ZZZ $220.00

0 $359.00

ZZZ $256.00

0 $519.00

90 $694.00

ZZZ $220.00

90 $1,803.00

90 $1,950.00

90 $1,950.00

0

0

90

$650.00

$306.00

$960.00

90 $1,564.00

90 $1,547.00

90 $1,268.00

90 $1,007.00

90 $1,376.00

90 $1,635.00

90 $1,686.00

90 $995.00

90 $2,175.00

90 $2,661.00

90 $2,634.00

90 $2,872.00

90 $2,346.00

90 $2,587.00

90 $1,398.00

90 $1,351.00

90 $2,000.00

90 $2,382.00

90 $1,495.00

90 $1,742.00

90 $1,231.00

90 $1,339.00

90 $1,390.00

90 $1,229.00

90 $997.00

90 $1,345.00

90 $976.00

90 $1,048.00

90 $1,380.00

90 $1,018.00

90 $852.00

90

90

$835.00

$935.00

90 $1,833.00

90 $1,494.00

$1,721.00

$1,754.00

$1,639.00

$1,541.00

$1,926.00

$1,907.00

$2,111.00

$1,520.00

$2,693.00

$3,384.00

$2,772.00

$4,010.00

$2,917.00

$3,467.00

$2,326.00

$2,803.00

$2,533.00

$3,274.00

$1,914.00

$1,836.00

$155.00

$320.00

$521.00

$366.00

$759.00

$1,064.00

$317.00

$2,722.00

$2,939.00

$2,912.00

$939.00

$420.00

$1,375.00

$2,138.00

$2,518.00

$1,704.00

$2,038.00

$1,915.00

$2,163.00

$1,392.00

$2,715.00

$1,599.00

$1,719.00

$2,361.00

$1,163.00

$1,447.00

$1,184.00

$1,109.00

$2,086.00

$3,107.00

$1,843.00

$1,879.00

$1,743.00

$1,652.00

$2,064.00

$2,045.00

$2,248.00

$1,628.00

$2,885.00

$3,626.00

$2,969.00

$4,294.00

$3,126.00

$3,714.00

$2,495.00

$3,001.00

$2,714.00

$3,510.00

$2,048.00

$1,967.00

$166.00

$343.00

$558.00

$392.00

$813.00

$1,138.00

$339.00

$2,912.00

$3,150.00

$3,112.00

$1,006.00

$450.00

$1,472.00

$2,290.00

$2,694.00

$1,826.00

$2,183.00

$2,051.00

$2,317.00

$1,479.00

$2,912.00

$1,716.00

$1,826.00

$2,528.00

$1,247.00

$1,549.00

$1,267.00

$1,179.00

$2,233.00

$3,329.00

$2,031.00

$2,080.00

$1,886.00

$1,822.00

$2,275.00

$2,251.00

$2,444.00

$1,788.00

$3,188.00

$4,008.00

$3,289.00

$4,749.00

$3,456.00

$4,109.00

$2,742.00

$3,289.00

$3,000.00

$3,857.00

$2,256.00

$2,173.00

$184.00

$382.00

$619.00

$436.00

$901.00

$1,247.00

$375.00

$3,219.00

$3,494.00

$3,437.00

$1,114.00

$498.00

$1,619.00

$2,527.00

$2,979.00

$2,015.00

$2,409.00

$2,265.00

$2,566.00

$1,582.00

$3,209.00

$1,891.00

$1,949.00

$2,793.00

$1,370.00

$1,697.00

$1,390.00

$1,257.00

$2,451.00

$3,660.00

$1,721.00

$1,754.00

$1,639.00

$1,541.00

$1,926.00

$1,907.00

$2,111.00

$1,520.00

$2,693.00

$3,384.00

$2,772.00

$4,010.00

$2,917.00

$3,467.00

$2,326.00

$2,803.00

$2,533.00

$3,274.00

$1,914.00

$1,836.00

$155.00

$320.00

$521.00

$366.00

$759.00

$1,064.00

$317.00

$2,722.00

$2,939.00

$2,912.00

$939.00

$420.00

$1,375.00

$2,138.00

$2,518.00

$1,704.00

$2,038.00

$1,915.00

$2,163.00

$1,392.00

$2,715.00

$1,599.00

$1,719.00

$2,361.00

$1,163.00

$1,447.00

$1,184.00

$1,109.00

$2,086.00

$3,107.00

$1,843.00

$1,879.00

$1,743.00

$1,652.00

$2,064.00

$2,045.00

$2,248.00

$1,628.00

$2,885.00

$3,626.00

$2,969.00

$4,294.00

$3,126.00

$3,714.00

$2,495.00

$3,001.00

$2,714.00

$3,510.00

$2,048.00

$1,967.00

$166.00

$343.00

$558.00

$392.00

$813.00

$1,138.00

$339.00

$2,912.00

$3,150.00

$3,112.00

$1,006.00

$450.00

$1,472.00

$2,290.00

$2,694.00

$1,826.00

$2,183.00

$2,051.00

$2,317.00

$1,479.00

$2,912.00

$1,716.00

$1,826.00

$2,528.00

$1,247.00

$1,549.00

$1,267.00

$1,179.00

$2,233.00

$3,329.00

$2,031.00

$2,080.00

$1,886.00

$1,822.00

$2,275.00

$2,251.00

$2,444.00

$1,788.00

$3,188.00

$4,008.00

$3,289.00

$4,749.00

$3,456.00

$4,109.00

$2,742.00

$3,289.00

$3,000.00

$3,857.00

$2,256.00

$2,173.00

$184.00

$382.00

$619.00

$436.00

$901.00

$1,247.00

$375.00

$3,219.00

$3,494.00

$3,437.00

$1,114.00

$498.00

$1,619.00

$2,527.00

$2,979.00

$2,015.00

$2,409.00

$2,265.00

$2,566.00

$1,582.00

$3,209.00

$1,891.00

$1,949.00

$2,793.00

$1,370.00

$1,697.00

$1,390.00

$1,257.00

$2,451.00

$3,660.00


Part B, 216



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

35341

35351

35355

35361

35363

35371

35372

35390

35400

35450

35302

35303

35304

35305

35306

35311

35321

35331

35221

35226

35231

35236

35241

35246

35251

35256

35261

35266

35271

35276

35281

35286

35301

35501

35506

35508

35509

35510

35511

35512

35515

35516

35452

35458

35460

35471

35472

35475

35476

35500

90 $1,243.00

90 $841.00

90 $1,053.00

90 $947.00

90 $1,926.00

90 $1,701.00

90 $1,260.00

90 $1,568.00

90 $1,008.00

90 $921.00

90 $1,814.00

90 $1,541.00

90 $1,396.00

90 $1,036.00

90 $1,486.00

90

90

90

90

ZZZ

--------

--------

--------

--------

--------

90 $1,999.00

90 $1,031.00

90 $1,724.00

90 $1,908.00

90 $1,555.00

90 $1,336.00

90 $1,859.00

90 $2,006.00

90 $1,006.00

90 $1,085.00

ZZZ $225.00

ZZZ $224.00

0 $643.00

0

0

0

$518.00

$804.00

$430.00

0

0

0

0

$626.00

$388.00

$569.00

$338.00

ZZZ $423.00

90 $1,569.00

90 $1,641.00

90 $1,564.00

90 $1,529.00

90 --------

90 $1,256.00

90 --------

90 $1,387.00

90 $1,391.00

$1,734.00

$1,919.00

$1,980.00

$1,896.00

$708.00

$2,249.00

$1,369.00

$2,234.00

$2,107.00

$1,975.00

$1,598.00

$2,375.00

$2,689.00

$1,262.00

$1,513.00

$246.00

$231.00

$781.00

$2,221.00

$1,277.00

$1,832.00

$1,500.00

$2,066.00

$2,389.00

$2,605.00

$1,565.00

$1,622.00

$1,336.00

$2,076.00

$2,209.00

$2,481.00

$1,436.00

$1,742.00

$527.00

$759.00

$483.00

$3,562.00

$2,565.00

$2,168.00

$1,983.00

$493.00

$2,304.00

$1,973.00

$2,096.00

$2,180.00

$1,904.00

$1,734.00

$1,886.00

$2,157.00

$1,889.00

$1,857.00

$2,056.00

$2,120.00

$2,030.00

$759.00

$2,411.00

$1,467.00

$2,392.00

$2,257.00

$2,115.00

$1,712.00

$2,544.00

$2,883.00

$1,352.00

$1,621.00

$263.00

$247.00

$837.00

$2,380.00

$1,368.00

$1,950.00

$1,604.00

$2,187.00

$2,558.00

$2,792.00

$1,676.00

$1,739.00

$1,431.00

$2,220.00

$2,369.00

$2,659.00

$1,539.00

$1,867.00

$564.00

$814.00

$518.00

$3,816.00

$2,749.00

$2,316.00

$2,120.00

$528.00

$2,467.00

$2,114.00

$2,250.00

$2,333.00

$2,040.00

$1,858.00

$2,021.00

$2,273.00

$2,024.00

$2,049.00

$2,268.00

$2,340.00

$2,241.00

$842.00

$2,672.00

$1,618.00

$2,641.00

$2,492.00

$2,337.00

$1,891.00

$2,817.00

$3,182.00

$1,490.00

$1,788.00

$292.00

$275.00

$928.00

$2,622.00

$1,506.00

$2,107.00

$1,762.00

$2,351.00

$2,810.00

$3,081.00

$1,846.00

$1,915.00

$1,576.00

$2,432.00

$2,608.00

$2,932.00

$1,694.00

$2,060.00

$624.00

$901.00

$572.00

$3,904.00

$2,813.00

$2,357.00

$2,152.00

$586.00

$2,727.00

$2,343.00

$2,496.00

$2,581.00

$2,261.00

$2,060.00

$2,238.00

$2,414.00

$2,243.00

$1,734.00

$1,919.00

$1,980.00

$1,896.00

$708.00

$2,249.00

$1,369.00

$2,234.00

$2,107.00

$1,975.00

$1,598.00

$2,375.00

$2,689.00

$1,262.00

$1,513.00

$246.00

$231.00

$781.00

$2,221.00

$1,277.00

$1,832.00

$1,500.00

$2,066.00

$2,389.00

$2,605.00

$1,565.00

$1,622.00

$1,336.00

$2,076.00

$2,209.00

$2,481.00

$1,436.00

$1,742.00

$527.00

$759.00

$483.00

$794.00

$542.00

$499.00

$402.00

$493.00

$2,304.00

$1,973.00

$2,096.00

$2,180.00

$1,904.00

$1,734.00

$1,886.00

$2,157.00

$1,889.00

$1,857.00

$2,056.00

$2,120.00

$2,030.00

$759.00

$2,411.00

$1,467.00

$2,392.00

$2,257.00

$2,115.00

$1,712.00

$2,544.00

$2,883.00

$1,352.00

$1,621.00

$263.00

$247.00

$837.00

$2,380.00

$1,368.00

$1,950.00

$1,604.00

$2,187.00

$2,558.00

$2,792.00

$1,676.00

$1,739.00

$1,431.00

$2,220.00

$2,369.00

$2,659.00

$1,539.00

$1,867.00

$564.00

$814.00

$518.00

$847.00

$579.00

$525.00

$423.00

$528.00

$2,467.00

$2,114.00

$2,250.00

$2,333.00

$2,040.00

$1,858.00

$2,021.00

$2,273.00

$2,024.00

$2,049.00

$2,268.00

$2,340.00

$2,241.00

$842.00

$2,672.00

$1,618.00

$2,641.00

$2,492.00

$2,337.00

$1,891.00

$2,817.00

$3,182.00

$1,490.00

$1,788.00

$292.00

$275.00

$928.00

$2,622.00

$1,506.00

$2,107.00

$1,762.00

$2,351.00

$2,810.00

$3,081.00

$1,846.00

$1,915.00

$1,576.00

$2,432.00

$2,608.00

$2,932.00

$1,694.00

$2,060.00

$624.00

$901.00

$572.00

$926.00

$636.00

$561.00

$451.00

$586.00

$2,727.00

$2,343.00

$2,496.00

$2,581.00

$2,261.00

$2,060.00

$2,238.00

$2,414.00

$2,243.00


Part B, 217



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

35583

35585

35587

35600

35601

35606

35612

35616

35621

35623

35558

35560

35563

35565

35566

35570

35571

35572

35518

35521

35522

35523

35525

35526

35531

35533

35535

35536

35537

35538

35539

35540

35556

35642

35645

35646

35647

35650

35654

35656

35661

35663

35626

35631

35632

35633

35634

35636

35637

35638

90 $1,313.00

90 $1,393.00

90

90

--------

--------

90 --------

90 $1,527.00

90 $2,000.00

90 $1,716.00

90 --------

90 $1,888.00

90 --------

90 --------

90

90

--------

--------

90 $1,745.00

90 $1,219.00

90 $1,899.00

90 $1,115.00

90 $1,312.00

90 $2,161.00

90 --------

90 $1,612.00

ZZZ $369.00

90 $1,843.00

90 $2,277.00

90 $1,698.00

ZZZ $273.00

90 $1,495.00

90 $1,539.00

90 $1,349.00

90 $1,346.00

90 $1,265.00

90 $1,193.00

90 $1,921.00

90 $1,891.00

90 --------

90

90

--------

--------

90 $1,656.00

90 --------

90 --------

90 $1,298.00

90 $1,304.00

90 $2,105.00

90 $1,555.00

90 $1,236.00

90 $1,603.00

90 $1,589.00

90 $1,145.00

90 $1,237.00

$1,898.00

$2,654.00

$2,053.00

$2,043.00

$2,584.00

$2,349.00

$2,055.00

$534.00

$2,235.00

$2,596.00

$2,108.00

$388.00

$2,166.00

$1,812.00

$1,656.00

$1,707.00

$1,697.00

$2,034.00

$1,793.00

$1,910.00

$1,863.00

$1,972.00

$1,762.00

$2,605.00

$3,120.00

$2,313.00

$2,965.00

$2,617.00

$3,382.00

$3,630.00

$3,391.00

$3,799.00

$2,162.00

$2,414.00

$2,860.00

$2,790.00

$3,096.00

$2,734.00

$2,481.00

$2,661.00

$2,721.00

$1,522.00

$1,563.00

$2,651.00

$2,403.00

$1,663.00

$2,116.00

$1,674.00

$1,673.00

$1,935.00

$2,032.00

$2,841.00

$2,196.00

$2,188.00

$2,767.00

$2,517.00

$2,201.00

$572.00

$2,394.00

$2,781.00

$2,257.00

$415.00

$2,320.00

$1,940.00

$1,775.00

$1,829.00

$1,818.00

$2,179.00

$1,922.00

$2,046.00

$1,995.00

$2,111.00

$1,886.00

$2,789.00

$3,341.00

$2,474.00

$3,178.00

$2,804.00

$3,626.00

$3,886.00

$3,627.00

$4,070.00

$2,316.00

$2,586.00

$3,064.00

$2,987.00

$3,315.00

$2,927.00

$2,659.00

$2,849.00

$2,915.00

$1,631.00

$1,676.00

$2,839.00

$2,575.00

$1,781.00

$2,267.00

$1,793.00

$1,792.00

$2,071.00

$2,238.00

$3,143.00

$2,424.00

$2,415.00

$3,058.00

$2,782.00

$2,431.00

$634.00

$2,643.00

$3,074.00

$2,490.00

$457.00

$2,562.00

$2,142.00

$1,961.00

$2,027.00

$2,007.00

$2,414.00

$2,129.00

$2,266.00

$2,201.00

$2,323.00

$2,079.00

$3,069.00

$3,692.00

$2,735.00

$3,524.00

$3,109.00

$4,013.00

$4,303.00

$4,011.00

$4,514.00

$2,556.00

$2,849.00

$3,389.00

$3,307.00

$3,664.00

$3,242.00

$2,949.00

$3,143.00

$3,220.00

$1,803.00

$1,846.00

$3,135.00

$2,844.00

$1,962.00

$2,503.00

$1,977.00

$1,976.00

$2,281.00

$1,898.00

$2,654.00

$2,053.00

$2,043.00

$2,584.00

$2,349.00

$2,055.00

$534.00

$2,235.00

$2,596.00

$2,108.00

$388.00

$2,166.00

$1,812.00

$1,656.00

$1,707.00

$1,697.00

$2,034.00

$1,793.00

$1,910.00

$1,863.00

$1,972.00

$1,762.00

$2,605.00

$3,120.00

$2,313.00

$2,965.00

$2,617.00

$3,382.00

$3,630.00

$3,391.00

$3,799.00

$2,162.00

$2,414.00

$2,860.00

$2,790.00

$3,096.00

$2,734.00

$2,481.00

$2,661.00

$2,721.00

$1,522.00

$1,563.00

$2,651.00

$2,403.00

$1,663.00

$2,116.00

$1,674.00

$1,673.00

$1,935.00

$2,032.00

$2,841.00

$2,196.00

$2,188.00

$2,767.00

$2,517.00

$2,201.00

$572.00

$2,394.00

$2,781.00

$2,257.00

$415.00

$2,320.00

$1,940.00

$1,775.00

$1,829.00

$1,818.00

$2,179.00

$1,922.00

$2,046.00

$1,995.00

$2,111.00

$1,886.00

$2,789.00

$3,341.00

$2,474.00

$3,178.00

$2,804.00

$3,626.00

$3,886.00

$3,627.00

$4,070.00

$2,316.00

$2,586.00

$3,064.00

$2,987.00

$3,315.00

$2,927.00

$2,659.00

$2,849.00

$2,915.00

$1,631.00

$1,676.00

$2,839.00

$2,575.00

$1,781.00

$2,267.00

$1,793.00

$1,792.00

$2,071.00

$2,238.00

$3,143.00

$2,424.00

$2,415.00

$3,058.00

$2,782.00

$2,431.00

$634.00

$2,643.00

$3,074.00

$2,490.00

$457.00

$2,562.00

$2,142.00

$1,961.00

$2,027.00

$2,007.00

$2,414.00

$2,129.00

$2,266.00

$2,201.00

$2,323.00

$2,079.00

$3,069.00

$3,692.00

$2,735.00

$3,524.00

$3,109.00

$4,013.00

$4,303.00

$4,011.00

$4,514.00

$2,556.00

$2,849.00

$3,389.00

$3,307.00

$3,664.00

$3,242.00

$2,949.00

$3,143.00

$3,220.00

$1,803.00

$1,846.00

$3,135.00

$2,844.00

$1,962.00

$2,503.00

$1,977.00

$1,976.00

$2,281.00


Part B, 218



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

35875

35876

35879

35881

35883

35884

35901

35903

35905

35907

35721

35741

35761

35800

35820

35840

35860

35870

35665

35666

35671

35681

35682

35683

35685

35686

35691

35693

35694

35695

35697

35700

35701

36015

36100

36120

36140

36147

36148

36160

36200

36215

36000

36002

36005

36010

36011

36012

36013

36014

0

0

ZZZ

0

0

0

0

0

0

0

0

0

0

0

0

0

0

90 $1,333.00

90 $1,686.00

90 $1,315.00

ZZZ $751.00

ZZZ $627.00

ZZZ $702.00

ZZZ $216.00

ZZZ $178.00

90 $1,546.00

90 $1,140.00

90 $1,353.00

90 $1,351.00

ZZZ --------

ZZZ $264.00

90 $494.00

90

90

90

90

90

$500.00

$499.00

$532.00

$567.00

$951.00

90

90

$771.00

$496.00

90 $1,583.00

90 $827.00

90 $1,232.00

90 $1,163.00

90 $1,275.00

90 --------

90

90

--------

$709.00

90 $818.00

90 $1,343.00

90 $1,335.00

$46.00

$181.00

$68.00

$136.00

$194.00

$186.00

$141.00

$159.00

$186.00

$176.00

$120.00

$106.00

--------

--------

$196.00

$240.00

$240.00

$695.00

$784.00

$586.00

$1,075.00

$3,044.00

$1,797.00

$1,289.00

$1,921.00

$914.00

$1,456.00

$1,423.00

$1,574.00

$1,867.00

$1,916.00

$724.00

$863.00

$2,604.00

$2,956.00

$1,810.00

$1,954.00

$1,721.00

$124.00

$547.00

$639.00

$308.00

$251.00

$1,478.00

$1,248.00

$1,528.00

$1,618.00

$229.00

$237.00

$851.00

$36.00

$232.00

$449.00

$700.00

$1,158.00

$1,197.00

$1,087.00

$1,124.00

$1,205.00

$704.00

$591.00

$612.00

$1,167.00

$364.00

$687.00

$873.00

$1,564.00

$744.00

$840.00

$627.00

$1,147.00

$3,259.00

$1,924.00

$1,380.00

$2,057.00

$980.00

$1,560.00

$1,524.00

$1,686.00

$1,999.00

$2,052.00

$776.00

$925.00

$2,789.00

$3,167.00

$1,938.00

$2,093.00

$1,843.00

$132.00

$586.00

$685.00

$330.00

$269.00

$1,581.00

$1,329.00

$1,637.00

$1,733.00

$245.00

$254.00

$906.00

$38.00

$246.00

$480.00

$748.00

$1,238.00

$1,279.00

$1,163.00

$1,201.00

$1,286.00

$754.00

$633.00

$655.00

$1,246.00

$389.00

$733.00

$935.00

$1,672.00

$814.00

$916.00

$677.00

$1,244.00

$3,587.00

$2,109.00

$1,518.00

$2,275.00

$1,078.00

$1,720.00

$1,680.00

$1,860.00

$2,208.00

$2,272.00

$851.00

$1,012.00

$3,088.00

$3,505.00

$2,137.00

$2,306.00

$2,028.00

$146.00

$650.00

$761.00

$366.00

$299.00

$1,743.00

$1,450.00

$1,812.00

$1,912.00

$272.00

$281.00

$975.00

$39.00

$257.00

$487.00

$766.00

$1,259.00

$1,301.00

$1,178.00

$1,219.00

$1,303.00

$779.00

$649.00

$672.00

$1,269.00

$395.00

$746.00

$962.00

$1,703.00

$695.00

$784.00

$586.00

$1,075.00

$3,044.00

$1,797.00

$1,289.00

$1,921.00

$914.00

$1,456.00

$1,423.00

$1,574.00

$1,867.00

$1,916.00

$724.00

$863.00

$2,604.00

$2,956.00

$1,810.00

$1,954.00

$1,721.00

$124.00

$547.00

$639.00

$308.00

$251.00

$1,478.00

$1,248.00

$1,528.00

$1,618.00

$229.00

$237.00

$851.00

$14.00

$158.00

$72.00

$184.00

$235.00

$260.00

$187.00

$223.00

$254.00

$235.00

$152.00

$156.00

$278.00

$73.00

$183.00

$233.00

$351.00

$744.00

$840.00

$627.00

$1,147.00

$3,259.00

$1,924.00

$1,380.00

$2,057.00

$980.00

$1,560.00

$1,524.00

$1,686.00

$1,999.00

$2,052.00

$776.00

$925.00

$2,789.00

$3,167.00

$1,938.00

$2,093.00

$1,843.00

$132.00

$586.00

$685.00

$330.00

$269.00

$1,581.00

$1,329.00

$1,637.00

$1,733.00

$245.00

$254.00

$906.00

$14.00

$167.00

$77.00

$194.00

$248.00

$274.00

$196.00

$234.00

$266.00

$250.00

$161.00

$166.00

$293.00

$77.00

$192.00

$249.00

$371.00

$814.00

$916.00

$677.00

$1,244.00

$3,587.00

$2,109.00

$1,518.00

$2,275.00

$1,078.00

$1,720.00

$1,680.00

$1,860.00

$2,208.00

$2,272.00

$851.00

$1,012.00

$3,088.00

$3,505.00

$2,137.00

$2,306.00

$2,028.00

$146.00

$650.00

$761.00

$366.00

$299.00

$1,743.00

$1,450.00

$1,812.00

$1,912.00

$272.00

$281.00

$975.00

$15.00

$178.00

$82.00

$210.00

$266.00

$294.00

$209.00

$249.00

$280.00

$273.00

$175.00

$182.00

$313.00

$82.00

$203.00

$274.00

$398.00


Part B, 219



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

36410

36415

36416

36425

36430

36455

36468

36470

36471

36475

36251

36252

36253

36254

36260

36261

36262

36299

36216

36217

36218

36221

36222

36223

36224

36225

36226

36227

36228

36245

36246

36247

36248

36514

36515

36516

36522

36556

36558

36561

36563

36565

36476

36478

36479

36481

36500

36511

36512

36513

0

0

10

10

0

0

0

0

0

0

0

0

0

0

90

90

90

YYY

0

0

ZZZ

ZZZ

0

0

0

ZZZ

0

0

ZZZ

0

0

0

0

0

0

10

10

0

0

0

10

10

ZZZ

0

ZZZ

0

0

0

0

0

--------

--------

--------

--------

$749.00

$388.00

$297.00

BR

$18.00

BR

BR

$86.00

$37.00

$141.00

NC

$76.00

$96.00

--------

$270.00

$325.00

$79.00

--------

--------

--------

--------

--------

--------

--------

--------

$249.00

$272.00

$323.00

$53.00

--------

--------

--------

$499.00

$159.00

$92.00

$92.00

$92.00

$92.00

$92.00

$92.00

$305.00

--------

--------

--------

--------

--------

$1,984.00

$2,162.00

$3,141.00

$3,071.00

$939.00

$594.00

$452.00

--------

$24.00

--------

--------

$59.00

$48.00

$189.00

BR

$211.00

$249.00

$2,138.00

$1,665.00

$2,726.00

$270.00

$1,529.00

$1,837.00

$2,146.00

$2,527.00

$2,097.00

$2,564.00

$358.00

$1,694.00

$1,904.00

$1,252.00

$2,198.00

$214.00

$425.00

$1,684.00

$439.00

$2,819.00

$272.00

$135.00

$136.00

$143.00

$744.00

$2,834.00

$2,855.00

$1,920.00

$331.00

$1,096.00

$1,644.00

$1,863.00

$1,373.00

$2,126.00

$2,318.00

$3,357.00

$3,292.00

$1,008.00

$637.00

$485.00

--------

$25.00

--------

--------

$62.00

$51.00

$202.00

BR

$226.00

$265.00

$2,291.00

$1,782.00

$2,920.00

$288.00

$1,638.00

$1,969.00

$2,300.00

$2,709.00

$2,247.00

$2,750.00

$384.00

$1,816.00

$2,037.00

$1,340.00

$2,352.00

$228.00

$455.00

$1,804.00

$470.00

$3,010.00

$288.00

$140.00

$141.00

$151.00

$794.00

$3,037.00

$3,063.00

$2,055.00

$350.00

$1,168.00

$1,758.00

$1,998.00

$1,472.00

$2,173.00

$2,384.00

$3,402.00

$3,370.00

$1,101.00

$691.00

$524.00

--------

$26.00

--------

--------

$66.00

$52.00

$221.00

BR

$234.00

$278.00

$2,340.00

$1,827.00

$2,975.00

$296.00

$1,676.00

$2,019.00

$2,355.00

$2,773.00

$2,300.00

$2,815.00

$402.00

$1,858.00

$2,075.00

$1,382.00

$2,401.00

$233.00

$477.00

$1,849.00

$491.00

$3,043.00

$311.00

$145.00

$146.00

$160.00

$803.00

$3,054.00

$3,084.00

$2,066.00

$362.00

$1,196.00

$1,804.00

$2,059.00

$1,527.00

$425.00

$569.00

$562.00

$660.00

$939.00

$594.00

$452.00

--------

$14.00

--------

--------

$59.00

$48.00

$189.00

BR

$122.00

$149.00

$425.00

$416.00

$494.00

$80.00

$326.00

$447.00

$488.00

$544.00

$480.00

$546.00

$172.00

$352.00

$380.00

$407.00

$479.00

$74.00

$207.00

$422.00

$206.00

$514.00

$272.00

$135.00

$136.00

$143.00

$135.00

$129.00

$105.00

$146.00

$178.00

$408.00

$526.00

$573.00

$526.00

$453.00

$608.00

$589.00

$706.00

$1,008.00

$637.00

$485.00

--------

$14.00

--------

--------

$62.00

$51.00

$202.00

BR

$130.00

$158.00

$454.00

$443.00

$526.00

$85.00

$348.00

$477.00

$521.00

$582.00

$512.00

$585.00

$184.00

$377.00

$403.00

$433.00

$508.00

$77.00

$221.00

$449.00

$219.00

$536.00

$288.00

$140.00

$141.00

$151.00

$142.00

$136.00

$112.00

$153.00

$186.00

$430.00

$559.00

$614.00

$563.00

$495.00

$669.00

$626.00

$776.00

$1,101.00

$691.00

$524.00

--------

$15.00

--------

--------

$66.00

$52.00

$221.00

BR

$138.00

$170.00

$497.00

$483.00

$573.00

$92.00

$382.00

$523.00

$571.00

$640.00

$560.00

$643.00

$202.00

$414.00

$436.00

$473.00

$552.00

$82.00

$243.00

$490.00

$240.00

$562.00

$311.00

$145.00

$146.00

$160.00

$148.00

$144.00

$124.00

$158.00

$198.00

$457.00

$600.00

$671.00

$615.00


Part B, 220



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

36625

36640

36680

36800

36810

36815

36818

36819

36820

36821

36592

36593

36595

36596

36597

36598

36600

36620

36566

36569

36571

36575

36576

36578

36580

36581

36582

36583

36584

36585

36589

36590

36591

36860

36861

36870

37140

37145

37160

37180

37181

37182

36823

36825

36830

36831

36832

36833

36835

36838

0

90

90

90

90

0

0

0

0

0

0

0

0

0

0

0

0

0

10

10

10

0

10

10

10

0

10

0

10

0

10

10

0

90 $1,461.00

90 $867.00

90 $967.00

90

90

90

90

90

$488.00

$810.00

$780.00

$542.00

--------

0

0

$166.00

$224.00

90 $1,755.00

90 $1,666.00

90 $1,741.00

90 $1,681.00

90 $1,769.00

90 $1,923.00

0 $914.00

--------

--------

--------

--------

--------

--------

$24.00

$64.00

$133.00

$130.00

$72.00

$159.00

$345.00

$236.00

--------

$977.00

$800.00

$721.00

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

$36.00

$43.00

$818.00

$186.00

$179.00

$154.00

$44.00

$75.00

$156.00

$172.00

$87.00

$184.00

$324.00

$222.00

$1,063.00

$1,124.00

$1,120.00

$1,018.00

$7,501.00

$350.00

$1,818.00

$232.00

$552.00

$731.00

$300.00

$1,070.00

$1,538.00

$1,909.00

$285.00

$1,603.00

$238.00

$422.00

$32.00

$2,026.00

$1,226.00

$1,025.00

$946.00

$1,161.00

$1,246.00

$742.00

$1,761.00

$293.00

$200.00

$2,541.00

$3,465.00

$3,243.00

$3,331.00

$3,044.00

$3,508.00

$1,227.00

$39.00

$46.00

$870.00

$198.00

$190.00

$164.00

$47.00

$78.00

$165.00

$179.00

$92.00

$194.00

$344.00

$237.00

$1,139.00

$1,205.00

$1,201.00

$1,091.00

$8,044.00

$371.00

$1,947.00

$247.00

$590.00

$779.00

$320.00

$1,141.00

$1,645.00

$2,048.00

$303.00

$1,714.00

$252.00

$450.00

$34.00

$2,170.00

$1,314.00

$1,098.00

$1,014.00

$1,245.00

$1,335.00

$797.00

$1,887.00

$309.00

$214.00

$2,717.00

$3,718.00

$3,482.00

$3,577.00

$3,237.00

$3,767.00

$1,277.00

$39.00

$47.00

$887.00

$203.00

$195.00

$167.00

$48.00

$82.00

$178.00

$185.00

$99.00

$209.00

$372.00

$261.00

$1,251.00

$1,326.00

$1,320.00

$1,199.00

$8,117.00

$378.00

$1,992.00

$251.00

$615.00

$802.00

$326.00

$1,160.00

$1,684.00

$2,103.00

$308.00

$1,748.00

$265.00

$475.00

$35.00

$2,377.00

$1,443.00

$1,207.00

$1,115.00

$1,367.00

$1,467.00

$868.00

$2,083.00

$317.00

$235.00

$2,750.00

$4,093.00

$3,836.00

$3,939.00

$3,505.00

$4,150.00

$1,336.00

$36.00

$43.00

$272.00

$66.00

$90.00

$54.00

$23.00

$75.00

$156.00

$172.00

$87.00

$184.00

$324.00

$222.00

$1,063.00

$1,124.00

$1,120.00

$1,018.00

$575.00

$134.00

$481.00

$52.00

$294.00

$319.00

$99.00

$289.00

$455.00

$508.00

$97.00

$421.00

$202.00

$304.00

$32.00

$2,026.00

$1,226.00

$1,025.00

$946.00

$1,161.00

$1,246.00

$742.00

$1,761.00

$161.00

$200.00

$442.00

$3,465.00

$3,243.00

$3,331.00

$3,044.00

$3,508.00

$1,227.00

$39.00

$46.00

$284.00

$69.00

$94.00

$57.00

$24.00

$78.00

$165.00

$179.00

$92.00

$194.00

$344.00

$237.00

$1,139.00

$1,205.00

$1,201.00

$1,091.00

$613.00

$140.00

$512.00

$55.00

$313.00

$338.00

$103.00

$303.00

$483.00

$545.00

$102.00

$446.00

$214.00

$323.00

$34.00

$2,170.00

$1,314.00

$1,098.00

$1,014.00

$1,245.00

$1,335.00

$797.00

$1,887.00

$168.00

$214.00

$466.00

$3,718.00

$3,482.00

$3,577.00

$3,237.00

$3,767.00

$1,277.00

$39.00

$47.00

$300.00

$73.00

$99.00

$59.00

$25.00

$82.00

$178.00

$185.00

$99.00

$209.00

$372.00

$261.00

$1,251.00

$1,326.00

$1,320.00

$1,199.00

$665.00

$146.00

$553.00

$58.00

$338.00

$359.00

$109.00

$320.00

$519.00

$595.00

$106.00

$476.00

$227.00

$348.00

$35.00

$2,377.00

$1,443.00

$1,207.00

$1,115.00

$1,367.00

$1,467.00

$868.00

$2,083.00

$174.00

$235.00

$492.00

$4,093.00

$3,836.00

$3,939.00

$3,505.00

$4,150.00

$1,336.00


Part B, 221



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

37224

37225

37226

37227

37228

37229

37230

37231

37232

37233

37214

37215

37217

37218

37220

37221

37222

37223

37183

37184

37185

37186

37187

37188

37191

37192

37193

37195

37197

37200

37211

37212

37213

37243

37244

37252

37253

37500

37501

37565

37600

37605

37234

37235

37236

37237

37238

37239

37241

37242

0

0

0

ZZZ

ZZZ

0

0

0

0

0

0

90

90

90

0

0

ZZZ

ZZZ

0

0

0

0

0

0

0

0

0

0

ZZZ

ZZZ

0

0

0

0

0

ZZZ

ZZZ

90

YYY

90

90

90

ZZZ

ZZZ

0

ZZZ

0

ZZZ

0

0

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

$425.00

--------

--------

--------

--------

--------

--------

--------

--------

$302.00

--------

$232.00

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

$739.00

BR

$364.00

$414.00

$521.00

$203.00

$1,526.00

$1,670.00

$1,242.00

$4,383.00

$6,450.00

$1,240.00

$3,579.00

$5,311.00

$15,183.00

$12,490.00

$20,496.00

$7,538.00

$14,980.00

$11,469.00

$18,418.00

$1,687.00

$2,049.00

$8,140.00

$3,175.00

$1,011.00

$1,921.00

$2,872.00

$2,466.00

$3,633.00

$2,165.00

$2,231.00

--------

$2,118.00

$324.00

$603.00

$529.00

$370.00

$5,353.00

$5,648.00

$5,694.00

$3,400.00

$5,790.00

$2,803.00

$6,595.00

$10,565.00

$13,409.00

$9,365.00

$1,927.00

$307.00

$1,144.00

--------

$1,083.00

$1,067.00

$1,214.00

$214.00

$1,634.00

$1,786.00

$1,324.00

$4,699.00

$6,915.00

$1,329.00

$3,839.00

$5,694.00

$16,286.00

$13,396.00

$21,985.00

$8,082.00

$16,067.00

$12,301.00

$19,756.00

$1,809.00

$2,196.00

$8,715.00

$3,402.00

$1,084.00

$2,058.00

$3,072.00

$2,637.00

$3,891.00

$2,316.00

$2,383.00

--------

$2,265.00

$337.00

$639.00

$560.00

$390.00

$5,741.00

$6,056.00

$6,099.00

$3,646.00

$6,204.00

$3,005.00

$7,064.00

$11,317.00

$14,361.00

$10,019.00

$2,067.00

$329.00

$1,228.00

--------

$1,153.00

$1,138.00

$1,301.00

$230.00

$1,797.00

$1,961.00

$1,443.00

$4,779.00

$7,016.00

$1,364.00

$3,884.00

$5,780.00

$16,433.00

$13,521.00

$22,169.00

$8,194.00

$16,229.00

$12,451.00

$19,936.00

$1,846.00

$2,255.00

$8,766.00

$3,479.00

$1,113.00

$2,102.00

$3,131.00

$2,676.00

$3,928.00

$2,370.00

$2,429.00

--------

$2,309.00

$353.00

$692.00

$605.00

$418.00

$5,804.00

$6,135.00

$6,176.00

$3,688.00

$6,259.00

$3,036.00

$7,137.00

$11,397.00

$14,448.00

$10,102.00

$2,088.00

$342.00

$1,338.00

--------

$1,242.00

$1,236.00

$1,430.00

$203.00

$1,526.00

$1,670.00

$1,242.00

$635.00

$780.00

$287.00

$329.00

$698.00

$948.00

$822.00

$1,141.00

$854.00

$1,106.00

$1,089.00

$1,184.00

$310.00

$506.00

$579.00

$698.00

$256.00

$379.00

$613.00

$438.00

$357.00

$554.00

$548.00

--------

$475.00

$324.00

$603.00

$529.00

$370.00

$435.00

$618.00

$686.00

$325.00

$473.00

$228.00

$678.00

$737.00

$865.00

$1,014.00

$141.00

$113.00

$1,144.00

--------

$1,083.00

$1,067.00

$1,214.00

$214.00

$1,634.00

$1,786.00

$1,324.00

$678.00

$833.00

$307.00

$351.00

$744.00

$1,014.00

$878.00

$1,219.00

$911.00

$1,181.00

$1,164.00

$1,265.00

$331.00

$540.00

$603.00

$744.00

$273.00

$404.00

$648.00

$462.00

$376.00

$587.00

$577.00

--------

$502.00

$337.00

$639.00

$560.00

$390.00

$465.00

$659.00

$726.00

$347.00

$500.00

$242.00

$716.00

$773.00

$903.00

$1,059.00

$150.00

$121.00

$1,228.00

--------

$1,153.00

$1,138.00

$1,301.00

$230.00

$1,797.00

$1,961.00

$1,443.00

$746.00

$915.00

$338.00

$387.00

$816.00

$1,116.00

$966.00

$1,342.00

$1,001.00

$1,300.00

$1,281.00

$1,392.00

$364.00

$594.00

$631.00

$813.00

$300.00

$443.00

$700.00

$494.00

$403.00

$637.00

$617.00

--------

$541.00

$353.00

$692.00

$605.00

$418.00

$513.00

$722.00

$787.00

$380.00

$538.00

$265.00

$771.00

$822.00

$950.00

$1,116.00

$166.00

$134.00

$1,338.00

--------

$1,242.00

$1,236.00

$1,430.00


Part B, 222



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

38100

38101

38102

38115

38120

38129

38200

38205

38206

38220

37761

37765

37766

37780

37785

37788

37790

37799

37606

37607

37609

37615

37616

37617

37618

37619

37650

37660

37700

37718

37722

37735

37760

38305

38308

38380

38381

38382

38500

38505

38510

38520

38221

38230

38232

38240

38241

38242

38243

38300

90

90

90

90

90

90

90

90

90

90

$563.00

$456.00

10

90

$278.00

$495.00

90 $1,128.00

90 $1,132.00

90 $514.00

--------

$430.00

$789.00

$336.00

--------

--------

$847.00

$813.00

90

90

90

90

90

--------

--------

--------

$301.00

$270.00

90 $1,654.00

90 $690.00

YYY BR

90

90

$974.00

$982.00

ZZZ $332.00

90 $1,020.00

90 $1,138.00

YYY

0

0

0

0

BR

$180.00

$79.00

$79.00

$212.00

0

0

0

0

10

0

0

0

$228.00

$265.00

--------

$128.00

$128.00

$90.00

--------

$104.00

90

90

90

$375.00

$425.00

$628.00

90 $1,087.00

90 $798.00

10

0

$234.00

$139.00

10

90

$349.00

$431.00

$836.00

$953.00

$1,136.00

$384.00

$519.00

$1,890.00

$736.00

--------

$1,732.00

$1,735.00

$396.00

$1,898.00

$1,576.00

--------

$172.00

$119.00

$120.00

$230.00

$868.00

$571.00

$447.00

$752.00

$1,661.00

$2,021.00

$577.00

$2,487.00

$770.00

$1,776.00

$376.00

$662.00

$730.00

$1,039.00

$938.00

$233.00

$290.00

$289.00

$322.00

$241.00

$169.00

$169.00

$394.00

$703.00

$662.00

$831.00

$1,202.00

$921.00

$481.00

$178.00

$757.00

$687.00

$895.00

$1,019.00

$1,214.00

$411.00

$556.00

$1,986.00

$778.00

--------

$1,857.00

$1,858.00

$424.00

$2,029.00

$1,691.00

--------

$178.00

$124.00

$125.00

$245.00

$931.00

$612.00

$478.00

$797.00

$1,780.00

$2,162.00

$617.00

$2,662.00

$825.00

$1,904.00

$403.00

$710.00

$783.00

$1,115.00

$1,005.00

$247.00

$305.00

$304.00

$335.00

$251.00

$176.00

$175.00

$421.00

$753.00

$710.00

$880.00

$1,289.00

$984.00

$516.00

$189.00

$808.00

$734.00

$977.00

$1,082.00

$1,293.00

$447.00

$592.00

$2,100.00

$825.00

--------

$2,036.00

$2,032.00

$466.00

$2,217.00

$1,849.00

--------

$187.00

$128.00

$129.00

$251.00

$1,010.00

$668.00

$503.00

$844.00

$1,952.00

$2,370.00

$670.00

$2,929.00

$902.00

$2,107.00

$437.00

$776.00

$858.00

$1,218.00

$1,103.00

$251.00

$323.00

$321.00

$345.00

$258.00

$181.00

$180.00

$440.00

$814.00

$771.00

$929.00

$1,410.00

$1,073.00

$551.00

$194.00

$860.00

$793.00

$836.00

$679.00

$831.00

$384.00

$394.00

$1,890.00

$736.00

--------

$1,732.00

$1,735.00

$396.00

$1,898.00

$1,576.00

--------

$172.00

$119.00

$120.00

$90.00

$868.00

$571.00

$307.00

$752.00

$1,661.00

$2,021.00

$577.00

$2,487.00

$770.00

$1,776.00

$376.00

$662.00

$730.00

$1,039.00

$938.00

$108.00

$290.00

$289.00

$322.00

$241.00

$169.00

$169.00

$270.00

$703.00

$662.00

$831.00

$1,202.00

$921.00

$377.00

$103.00

$623.00

$687.00

$895.00

$725.00

$887.00

$411.00

$422.00

$1,986.00

$778.00

--------

$1,857.00

$1,858.00

$424.00

$2,029.00

$1,691.00

--------

$178.00

$124.00

$125.00

$95.00

$931.00

$612.00

$328.00

$797.00

$1,780.00

$2,162.00

$617.00

$2,662.00

$825.00

$1,904.00

$403.00

$710.00

$783.00

$1,115.00

$1,005.00

$112.00

$305.00

$304.00

$335.00

$251.00

$176.00

$175.00

$288.00

$753.00

$710.00

$880.00

$1,289.00

$984.00

$404.00

$108.00

$664.00

$734.00

$977.00

$788.00

$965.00

$447.00

$457.00

$2,100.00

$825.00

--------

$2,036.00

$2,032.00

$466.00

$2,217.00

$1,849.00

--------

$187.00

$128.00

$129.00

$100.00

$1,010.00

$668.00

$353.00

$844.00

$1,952.00

$2,370.00

$670.00

$2,929.00

$902.00

$2,107.00

$437.00

$776.00

$858.00

$1,218.00

$1,103.00

$116.00

$323.00

$321.00

$345.00

$258.00

$181.00

$180.00

$306.00

$814.00

$771.00

$929.00

$1,410.00

$1,073.00

$439.00

$113.00

$716.00

$793.00


Part B, 223



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

38792

38794

38900

38999

39000

39010

39200

39220

39401

39402

38745

38746

38747

38760

38765

38770

38780

38790

38525

38530

38542

38550

38555

38562

38564

38570

38571

38572

38589

38700

38720

38724

38740

39599

40490

40500

40510

40520

40525

40527

40530

40650

39499

39501

39503

39540

39541

39545

39560

39561

90

90

$369.00

$517.00

90

90

$507.00

$519.00

90 $1,115.00

90 $799.00

90 $831.00

10

10

$695.00

$902.00

10 $1,049.00

YYY BR

90 $863.00

90 $1,328.00

90 $1,366.00

90 $539.00

90 $770.00

ZZZ $312.00

ZZZ $337.00

90 $699.00

90 $1,283.00

90 $1,111.00

90 $1,357.00

0 $158.00

0

90

ZZZ

YYY

90

$26.00

$298.00

--------

BR

$664.00

90 $1,148.00

90 $1,249.00

90 $1,542.00

0 --------

0 --------

YYY

0

90

90

90

90

90

90

90

YYY BR

90 $1,083.00

90 $2,726.00

90 $1,133.00

90 $1,179.00

90 $1,102.00

90 $968.00

90 $1,328.00

BR

$108.00

$422.00

$469.00

$467.00

$714.00

$851.00

$501.00

$368.00

$1,307.00

$327.00

$403.00

$1,252.00

$1,924.00

$1,187.00

$1,506.00

$122.00

$58.00

$433.00

$209.00

--------

$739.00

$1,181.00

$1,325.00

$1,708.00

$469.00

$614.00

$648.00

$813.00

$762.00

$749.00

$1,496.00

$1,036.00

$1,047.00

$742.00

$978.00

$1,380.00

--------

$1,184.00

$1,986.00

$2,141.00

$1,034.00

--------

$1,267.00

$9,268.00

$1,296.00

$1,415.00

$1,339.00

$1,190.00

$1,850.00

--------

$183.00

$723.00

$696.00

$703.00

$807.00

$906.00

$776.00

$629.00

$1,401.00

$350.00

$432.00

$1,340.00

$2,054.00

$1,254.00

$1,593.00

$130.00

$61.00

$454.00

$224.00

--------

$791.00

$1,265.00

$1,420.00

$1,827.00

$503.00

$658.00

$696.00

$870.00

$810.00

$803.00

$1,605.00

$1,104.00

$1,120.00

$787.00

$1,029.00

$1,470.00

--------

$1,253.00

$2,107.00

$2,266.00

$1,109.00

--------

$1,357.00

$9,948.00

$1,388.00

$1,517.00

$1,434.00

$1,274.00

$1,982.00

--------

$194.00

$770.00

$741.00

$748.00

$857.00

$959.00

$826.00

$670.00

$1,530.00

$387.00

$477.00

$1,457.00

$2,235.00

$1,338.00

$1,701.00

$138.00

$64.00

$470.00

$247.00

--------

$857.00

$1,384.00

$1,557.00

$1,998.00

$554.00

$726.00

$757.00

$940.00

$865.00

$870.00

$1,751.00

$1,189.00

$1,219.00

$844.00

$1,091.00

$1,591.00

--------

$1,331.00

$2,253.00

$2,411.00

$1,209.00

--------

$1,480.00

$10,980.00

$1,517.00

$1,661.00

$1,568.00

$1,390.00

$2,162.00

--------

$201.00

$799.00

$772.00

$779.00

$906.00

$1,012.00

$863.00

$694.00

$1,307.00

$327.00

$403.00

$1,252.00

$1,924.00

$1,187.00

$1,506.00

$122.00

$58.00

$433.00

$209.00

--------

$739.00

$1,181.00

$1,325.00

$1,708.00

$469.00

$614.00

$648.00

$813.00

$762.00

$749.00

$1,496.00

$1,036.00

$1,047.00

$742.00

$978.00

$1,380.00

--------

$1,184.00

$1,986.00

$2,141.00

$1,034.00

--------

$1,267.00

$9,268.00

$1,296.00

$1,415.00

$1,339.00

$1,190.00

$1,850.00

--------

$107.00

$530.00

$522.00

$525.00

$807.00

$906.00

$591.00

$435.00

$1,401.00

$350.00

$432.00

$1,340.00

$2,054.00

$1,254.00

$1,593.00

$130.00

$61.00

$454.00

$224.00

--------

$791.00

$1,265.00

$1,420.00

$1,827.00

$503.00

$658.00

$696.00

$870.00

$810.00

$803.00

$1,605.00

$1,104.00

$1,120.00

$787.00

$1,029.00

$1,470.00

--------

$1,253.00

$2,107.00

$2,266.00

$1,109.00

--------

$1,357.00

--------

$1,480.00

$9,948.00

$10,980.00

$1,388.00

$1,517.00

$1,434.00

$1,274.00

$1,982.00

$1,517.00

$1,661.00

$1,568.00

$1,390.00

$2,162.00

--------

$113.00

$563.00

$555.00

$557.00

$857.00

$959.00

$628.00

$462.00

--------

$120.00

$591.00

$585.00

$588.00

$906.00

$1,012.00

$663.00

$485.00

$1,530.00

$387.00

$477.00

$1,457.00

$2,235.00

$1,338.00

$1,701.00

$138.00

$64.00

$470.00

$247.00

--------

$857.00

$1,384.00

$1,557.00

$1,998.00

$554.00

$726.00

$757.00

$940.00

$865.00

$870.00

$1,751.00

$1,189.00

$1,219.00

$844.00

$1,091.00

$1,591.00

--------

$1,331.00

$2,253.00

$2,411.00

$1,209.00


Part B, 224



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

40840

40842

40843

40844

40845

40899

41000

41005

41006

41007

40812

40814

40816

40818

40819

40820

40830

40831

40652

40654

40700

40701

40702

40720

40761

40799

40800

40801

40804

40805

40806

40808

40810

41100

41105

41108

41110

41112

41113

41114

41115

41116

41008

41009

41010

41015

41016

41017

41018

41019

10

10

10

10

90

90

90

10

90

90

90

10

90

90

90

90

0

YYY

10

10

10

10

0

10

10

90

90

$436.00

$529.00

90 $1,009.00

90 $1,452.00

90 $1,030.00

90 $1,107.00

90 $1,202.00

BR

$110.00

$208.00

$105.00

$245.00

$38.00

$100.00

$141.00

10

90

90

90

90

10

10

10

$202.00

$319.00

$336.00

$249.00

$208.00

$104.00

$140.00

$213.00

YYY

10

10

90

90

90

90

$687.00

$684.00

90 $947.00

90 $1,232.00

90 $1,593.00

BR

$119.00

$109.00

$237.00

$283.00

$248.00

$319.00

$91.00

$267.00

$357.00

$300.00

$424.00

--------

$140.00

$136.00

$110.00

$159.00

$255.00

$301.00

$682.00

$176.00

$242.00

$418.00

$560.00

$585.00

$514.00

$458.00

$379.00

$381.00

$485.00

$1,180.00

$1,135.00

$1,580.00

$1,894.00

$2,133.00

--------

$235.00

$325.00

$518.00

$506.00

$696.00

$816.00

$1,327.00

$1,492.00

$1,235.00

$1,497.00

$1,585.00

--------

$304.00

$457.00

$273.00

$523.00

$159.00

$267.00

$297.00

$550.00

$584.00

$289.00

$657.00

$642.00

$648.00

$739.00

$681.00

$243.00

$247.00

$213.00

$305.00

$485.00

$531.00

$937.00

$357.00

$478.00

$446.00

$597.00

$623.00

$547.00

$489.00

$405.00

$406.00

$517.00

$1,255.00

$1,204.00

$1,681.00

$2,007.00

$2,262.00

--------

$250.00

$347.00

$551.00

$538.00

$742.00

$869.00

$1,403.00

$1,574.00

$1,287.00

$1,591.00

$1,684.00

--------

$325.00

$487.00

$291.00

$553.00

$170.00

$285.00

$316.00

$586.00

$623.00

$309.00

$700.00

$684.00

$690.00

$787.00

$709.00

$258.00

$263.00

$227.00

$325.00

$517.00

$566.00

$994.00

$381.00

$510.00

$462.00

$621.00

$648.00

$562.00

$507.00

$414.00

$417.00

$534.00

$1,314.00

$1,258.00

$1,767.00

$2,102.00

$2,379.00

--------

$259.00

$355.00

$571.00

$557.00

$770.00

$906.00

$1,484.00

$1,667.00

$1,324.00

$1,690.00

$1,791.00

--------

$334.00

$505.00

$299.00

$559.00

$172.00

$292.00

$325.00

$610.00

$647.00

$316.00

$728.00

$712.00

$719.00

$822.00

$736.00

$267.00

$272.00

$234.00

$335.00

$535.00

$588.00

$1,049.00

$393.00

$526.00

$292.00

$450.00

$467.00

$396.00

$353.00

$250.00

$241.00

$329.00

$928.00

$889.00

$1,260.00

$1,548.00

$1,809.00

--------

$165.00

$183.00

$371.00

$357.00

$512.00

$620.00

$1,327.00

$1,492.00

$1,235.00

$1,497.00

$1,585.00

--------

$192.00

$328.00

$171.00

$321.00

$46.00

$158.00

$187.00

$399.00

$433.00

$158.00

$517.00

$519.00

$522.00

$612.00

$681.00

$159.00

$164.00

$133.00

$193.00

$372.00

$413.00

$937.00

$225.00

$324.00

$310.00

$479.00

$497.00

$420.00

$377.00

$266.00

$256.00

$350.00

$985.00

$941.00

$1,338.00

$1,636.00

$1,915.00

--------

$176.00

$194.00

$393.00

$378.00

$543.00

$659.00

$1,403.00

$1,574.00

$1,287.00

$1,591.00

$1,684.00

--------

$205.00

$349.00

$182.00

$337.00

$49.00

$169.00

$199.00

$424.00

$460.00

$167.00

$550.00

$552.00

$555.00

$650.00

$709.00

$169.00

$175.00

$142.00

$205.00

$396.00

$439.00

$994.00

$239.00

$344.00

$326.00

$502.00

$521.00

$435.00

$394.00

$274.00

$267.00

$366.00

$1,043.00

$994.00

$1,423.00

$1,730.00

$2,031.00

--------

$184.00

$202.00

$413.00

$396.00

$571.00

$695.00

$1,484.00

$1,667.00

$1,324.00

$1,690.00

$1,791.00

--------

$213.00

$366.00

$189.00

$342.00

$50.00

$175.00

$207.00

$447.00

$484.00

$174.00

$577.00

$580.00

$583.00

$685.00

$736.00

$177.00

$184.00

$148.00

$214.00

$414.00

$460.00

$1,049.00

$251.00

$360.00


Part B, 225



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

41823

41825

41826

41827

41828

41830

41850

41870

41872

41874

41530

41599

41800

41805

41806

41820

41821

41822

41120

41130

41135

41140

41145

41150

41153

41155

41250

41251

41252

41500

41510

41512

41520

42145

42160

42180

42182

42200

42205

42210

42215

42220

41899

42000

42100

42104

42106

42107

42120

42140

10

0

0

90

90

90

10

10

90

10

0

YYY

10

10

10

0

0

10

90

90

$813.00

$937.00

90 $1,869.00

90 $2,005.00

90 $2,406.00

90 $1,897.00

90 $2,091.00

90 $2,448.00

10 $168.00

10

10

90

$203.00

$294.00

$334.00

90

90

90

$313.00

--------

$255.00

--------

BR

$107.00

$115.00

$217.00

NC

NC

$237.00

$312.00

$144.00

$211.00

$322.00

$176.00

$156.00

NC

NC

$249.00

$193.00

YYY

10

10

10

10

90

90

90

BR

$106.00

$122.00

$161.00

$204.00

$409.00

$573.00

$174.00

90

10

10

$741.00

$176.00

$222.00

10

90

$324.00

$946.00

90 $863.00

90 $1,174.00

90

90

$766.00

$586.00

$1,394.00

--------

$386.00

$369.00

$514.00

BR

BR

$425.00

$623.00

$305.00

$457.00

$640.00

$452.00

$574.00

BR

BR

$531.00

$547.00

$1,580.00

$1,952.00

$3,221.00

$3,242.00

$4,127.00

$3,267.00

$3,561.00

$4,477.00

$383.00

$419.00

$455.00

$599.00

$611.00

$968.00

$513.00

--------

$229.00

$217.00

$311.00

$396.00

$671.00

$1,494.00

$363.00

$1,032.00

$334.00

$354.00

$466.00

$1,249.00

$1,304.00

$1,457.00

$962.00

$729.00

$1,491.00

--------

$412.00

$395.00

$548.00

BR

BR

$453.00

$664.00

$325.00

$487.00

$682.00

$482.00

$612.00

BR

BR

$565.00

$584.00

$1,680.00

$2,073.00

$3,414.00

$3,437.00

$4,377.00

$3,463.00

$3,773.00

$4,744.00

$408.00

$447.00

$484.00

$635.00

$650.00

$1,028.00

$547.00

--------

$244.00

$231.00

$332.00

$422.00

$715.00

$1,587.00

$387.00

$1,093.00

$356.00

$376.00

$495.00

$1,322.00

$1,380.00

$1,542.00

$1,020.00

$770.00

$1,514.00

--------

$420.00

$404.00

$568.00

BR

BR

$470.00

$690.00

$335.00

$504.00

$707.00

$503.00

$636.00

BR

BR

$584.00

$606.00

$1,747.00

$2,166.00

$3,593.00

$3,605.00

$4,607.00

$3,638.00

$3,969.00

$5,010.00

$419.00

$462.00

$503.00

$654.00

$670.00

$1,069.00

$567.00

--------

$252.00

$240.00

$342.00

$437.00

$743.00

$1,658.00

$398.00

$1,149.00

$368.00

$391.00

$518.00

$1,394.00

$1,458.00

$1,631.00

$1,073.00

$810.00

$547.00

--------

$213.00

$254.00

$384.00

BR

BR

$271.00

$479.00

$180.00

$314.00

$455.00

$318.00

$423.00

BR

BR

$378.00

$380.00

$1,580.00

$1,952.00

$3,221.00

$3,242.00

$4,127.00

$3,267.00

$3,561.00

$4,477.00

$224.00

$268.00

$310.00

$599.00

$611.00

$968.00

$380.00

--------

$152.00

$161.00

$205.00

$264.00

$512.00

$1,494.00

$226.00

$1,032.00

$216.00

$271.00

$377.00

$1,249.00

$1,304.00

$1,457.00

$962.00

$729.00

$582.00

--------

$226.00

$271.00

$409.00

BR

BR

$288.00

$509.00

$192.00

$334.00

$483.00

$338.00

$450.00

BR

BR

$402.00

$405.00

$1,680.00

$2,073.00

$3,414.00

$3,437.00

$4,377.00

$3,463.00

$3,773.00

$4,744.00

$238.00

$285.00

$329.00

$635.00

$650.00

$1,028.00

$405.00

--------

$162.00

$171.00

$218.00

$280.00

$544.00

$1,587.00

$240.00

$1,093.00

$229.00

$287.00

$399.00

$1,322.00

$1,380.00

$1,542.00

$1,020.00

$770.00

$603.00

--------

$234.00

$280.00

$428.00

BR

BR

$305.00

$535.00

$201.00

$350.00

$508.00

$359.00

$473.00

BR

BR

$421.00

$426.00

$1,747.00

$2,166.00

$3,593.00

$3,605.00

$4,607.00

$3,638.00

$3,969.00

$5,010.00

$248.00

$300.00

$347.00

$654.00

$670.00

$1,069.00

$424.00

--------

$169.00

$180.00

$228.00

$294.00

$572.00

$1,658.00

$250.00

$1,149.00

$241.00

$301.00

$422.00

$1,394.00

$1,458.00

$1,631.00

$1,073.00

$810.00


Part B, 226



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

42426

42440

42450

42500

42505

42507

42509

42510

42550

42600

42400

42405

42408

42409

42410

42415

42420

42425

42225

42226

42227

42235

42260

42280

42281

42299

42300

42305

42310

42320

42330

42335

42340

42804

42806

42808

42809

42810

42815

42821

42826

42831

42650

42660

42665

42699

42700

42720

42725

42800

10

10

10

10

90

90

90

90

90

0

0

90

YYY

10

10

90

10

YYY

10

90

10

10

10

90

90

90

90

90

90

90

10

10

0

10

90

90

90

$94.00

$258.00

$377.00

$266.00

$746.00

90 $1,364.00

90 $1,577.00

90 $1,097.00

90

90

90

0

90

90 $1,882.00

90 $634.00

90

90

90

$395.00

$407.00

$559.00

$522.00

$915.00

$711.00

$82.00

$445.00

$803.00

$848.00

$762.00

$631.00

$491.00

$148.00

$160.00

BR

$165.00

$448.00

$145.00

$208.00

$184.00

$287.00

$411.00

$67.00

$89.00

$238.00

BR

$144.00

$270.00

$720.00

$123.00

$136.00

$167.00

$250.00

$152.00

$335.00

$659.00

$378.00

$320.00

$235.00

$151.00

$433.00

$654.00

$478.00

$917.00

$1,556.00

$1,749.00

$1,231.00

$1,991.00

$606.00

$654.00

$628.00

$807.00

$753.00

$1,237.00

$940.00

$191.00

$692.00

$1,277.00

$1,307.00

$1,244.00

$1,066.00

$1,187.00

$240.00

$296.00

--------

$303.00

$635.00

$233.00

$361.00

$336.00

$541.00

$671.00

$120.00

$187.00

$445.00

--------

$273.00

$664.00

$1,205.00

$228.00

$279.00

$315.00

$328.00

$291.00

$557.00

$817.00

$442.00

$368.00

$327.00

$160.00

$459.00

$694.00

$509.00

$973.00

$1,646.00

$1,850.00

$1,303.00

$2,105.00

$641.00

$696.00

$668.00

$857.00

$800.00

$1,310.00

$998.00

$202.00

$735.00

$1,355.00

$1,388.00

$1,323.00

$1,132.00

$1,259.00

$256.00

$315.00

--------

$322.00

$673.00

$247.00

$384.00

$357.00

$576.00

$713.00

$128.00

$202.00

$473.00

--------

$290.00

$704.00

$1,277.00

$243.00

$298.00

$335.00

$349.00

$310.00

$593.00

$867.00

$468.00

$390.00

$346.00

$164.00

$479.00

$722.00

$526.00

$1,034.00

$1,746.00

$1,964.00

$1,382.00

$2,239.00

$678.00

$724.00

$694.00

$894.00

$840.00

$1,378.00

$1,049.00

$206.00

$764.00

$1,412.00

$1,449.00

$1,389.00

$1,177.00

$1,319.00

$267.00

$327.00

--------

$334.00

$711.00

$256.00

$398.00

$370.00

$597.00

$741.00

$133.00

$216.00

$490.00

--------

$300.00

$741.00

$1,353.00

$252.00

$306.00

$345.00

$363.00

$321.00

$613.00

$910.00

$493.00

$410.00

$363.00

$80.00

$333.00

$478.00

$324.00

$917.00

$1,556.00

$1,749.00

$1,231.00

$1,991.00

$606.00

$525.00

$502.00

$666.00

$753.00

$1,237.00

$940.00

$93.00

$510.00

$1,277.00

$1,307.00

$1,244.00

$1,066.00

$979.00

$163.00

$221.00

--------

$224.00

$635.00

$181.00

$257.00

$242.00

$379.00

$493.00

$86.00

$134.00

$300.00

--------

$198.00

$579.00

$1,205.00

$163.00

$165.00

$193.00

$238.00

$180.00

$421.00

$817.00

$442.00

$368.00

$327.00

$85.00

$352.00

$506.00

$343.00

$973.00

$1,646.00

$1,850.00

$1,303.00

$2,105.00

$641.00

$557.00

$532.00

$705.00

$800.00

$1,310.00

$998.00

$96.00

$540.00

$1,355.00

$1,388.00

$1,323.00

$1,132.00

$1,036.00

$174.00

$235.00

--------

$237.00

$673.00

$192.00

$273.00

$257.00

$402.00

$522.00

$91.00

$145.00

$318.00

--------

$210.00

$613.00

$1,277.00

$173.00

$175.00

$205.00

$252.00

$190.00

$446.00

$867.00

$468.00

$390.00

$346.00

$88.00

$371.00

$533.00

$360.00

$1,034.00

$1,746.00

$1,964.00

$1,382.00

$2,239.00

$678.00

$585.00

$559.00

$743.00

$840.00

$1,378.00

$1,049.00

$101.00

$569.00

$1,412.00

$1,449.00

$1,389.00

$1,177.00

$1,095.00

$184.00

$246.00

--------

$249.00

$711.00

$201.00

$287.00

$270.00

$422.00

$549.00

$95.00

$158.00

$334.00

--------

$219.00

$649.00

$1,353.00

$182.00

$183.00

$214.00

$266.00

$201.00

$466.00

$910.00

$493.00

$410.00

$363.00


Part B, 227



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

43100

43101

43107

43108

43112

43113

43116

43117

43118

43121

42962

42970

42971

42972

42999

43020

43030

43045

42836

42842

42844

42845

42860

42870

42890

42892

42894

42900

42950

42953

42955

42960

42961

43193

43194

43195

43196

43197

43198

43200

43201

43202

43122

43123

43124

43130

43135

43180

43191

43192

90

90

$286.00

$729.00

90 $1,173.00

90 $1,958.00

90

90

$207.00

$427.00

90 $1,047.00

90 $1,262.00

90 $1,825.00

10

90

90

$429.00

$745.00

$752.00

90

10

90

$561.00

$178.00

$406.00

90

90

90

90

YYY

$602.00

$284.00

$472.00

$562.00

BR

90

90

$696.00

$712.00

90 $1,574.00

90 $744.00

90 $1,248.00

90 $2,325.00

90 $2,664.00

90 $2,471.00

90 $2,755.00

90 $2,509.00

90 $2,469.00

90 $2,607.00

90 $2,350.00

0

0

0

0

0

0

0

0

0

90 $2,287.00

90 $2,661.00

90 $2,242.00

90 $1,020.00

90 $1,332.00

90

0

0

--------

--------

--------

--------

--------

--------

--------

--------

--------

$266.00

$245.00

$205.00

$760.00

$587.00

$670.00

$751.00

--------

$786.00

$765.00

$1,964.00

$918.00

$1,530.00

$3,853.00

$6,905.00

$4,074.00

$6,836.00

$7,481.00

$3,732.00

$5,586.00

$4,349.00

$352.00

$1,493.00

$2,050.00

$3,320.00

$274.00

$873.00

$2,119.00

$2,804.00

$3,526.00

$497.00

$1,197.00

$1,439.00

$1,131.00

$249.00

$621.00

$3,869.00

$7,141.00

$5,787.00

$1,165.00

$2,239.00

$811.00

$227.00

$251.00

$250.00

$288.00

$272.00

$292.00

$267.00

$298.00

$380.00

$387.00

$505.00

$805.00

$618.00

$710.00

$795.00

--------

$841.00

$810.00

$2,107.00

$971.00

$1,640.00

$4,132.00

$7,377.00

$4,369.00

$7,314.00

$7,878.00

$4,002.00

$5,985.00

$4,666.00

$373.00

$1,584.00

$2,174.00

$3,514.00

$291.00

$928.00

$2,246.00

$2,972.00

$3,734.00

$525.00

$1,272.00

$1,531.00

$1,201.00

$264.00

$658.00

$4,148.00

$7,658.00

$6,197.00

$1,237.00

$2,397.00

$857.00

$240.00

$265.00

$265.00

$305.00

$288.00

$309.00

$285.00

$317.00

$405.00

$412.00

$539.00

$847.00

$642.00

$750.00

$839.00

--------

$910.00

$860.00

$2,312.00

$1,028.00

$1,798.00

$4,542.00

$8,072.00

$4,811.00

$8,013.00

$8,374.00

$4,406.00

$6,594.00

$5,146.00

$392.00

$1,656.00

$2,276.00

$3,700.00

$304.00

$960.00

$2,356.00

$3,126.00

$3,928.00

$555.00

$1,322.00

$1,589.00

$1,247.00

$278.00

$692.00

$4,555.00

$8,428.00

$6,814.00

$1,322.00

$2,629.00

$908.00

$255.00

$281.00

$281.00

$328.00

$305.00

$329.00

$294.00

$329.00

$415.00

$423.00

$551.00

$760.00

$587.00

$670.00

$751.00

--------

$786.00

$765.00

$1,964.00

$918.00

$1,530.00

$3,853.00

$6,905.00

$4,074.00

$6,836.00

$7,481.00

$3,732.00

$5,586.00

$4,349.00

$352.00

$1,493.00

$2,050.00

$3,320.00

$274.00

$873.00

$2,119.00

$2,804.00

$3,526.00

$497.00

$1,197.00

$1,439.00

$1,131.00

$249.00

$621.00

$3,869.00

$7,141.00

$5,787.00

$1,165.00

$2,239.00

$811.00

$227.00

$251.00

$250.00

$288.00

$272.00

$292.00

$123.00

$148.00

$139.00

$161.00

$161.00

$805.00

$618.00

$710.00

$795.00

--------

$841.00

$810.00

$2,107.00

$971.00

$1,640.00

$4,132.00

$7,377.00

$4,369.00

$7,314.00

$7,878.00

$4,002.00

$5,985.00

$4,666.00

$373.00

$1,584.00

$2,174.00

$3,514.00

$291.00

$928.00

$2,246.00

$2,972.00

$3,734.00

$525.00

$1,272.00

$1,531.00

$1,201.00

$264.00

$658.00

$4,148.00

$7,658.00

$6,197.00

$1,237.00

$2,397.00

$857.00

$240.00

$265.00

$265.00

$305.00

$288.00

$309.00

$130.00

$156.00

$147.00

$170.00

$171.00

$847.00

$642.00

$750.00

$839.00

--------

$910.00

$860.00

$2,312.00

$1,028.00

$1,798.00

$4,542.00

$8,072.00

$4,811.00

$8,013.00

$8,374.00

$4,406.00

$6,594.00

$5,146.00

$392.00

$1,656.00

$2,276.00

$3,700.00

$304.00

$960.00

$2,356.00

$3,126.00

$3,928.00

$555.00

$1,322.00

$1,589.00

$1,247.00

$278.00

$692.00

$4,555.00

$8,428.00

$6,814.00

$1,322.00

$2,629.00

$908.00

$255.00

$281.00

$281.00

$328.00

$305.00

$329.00

$139.00

$167.00

$156.00

$181.00

$181.00


Part B, 228



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

43240

43241

43242

43243

43244

43245

43246

43247

43248

43249

43231

43232

43233

43235

43236

43237

43238

43239

43204

43205

43206

43210

43211

43212

43213

43214

43215

43216

43217

43220

43226

43227

43229

43260

43261

43262

43263

43264

43265

43266

43270

43273

43250

43251

43252

43253

43254

43255

43257

43259

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

ZZZ

0

0

0

0

0

0

0

0

$182.00

$252.00

--------

$239.00

$285.00

--------

--------

$246.00

$369.00

$157.00

$384.00

$276.00

$268.00

$214.00

$485.00

$229.00

$191.00

$175.00

$228.00

$207.00

--------

--------

--------

--------

--------

--------

$160.00

$149.00

$176.00

$128.00

$142.00

$218.00

--------

$194.00

$224.00

--------

--------

--------

$343.00

--------

$271.00

$349.00

$362.00

$447.00

$386.00

$522.00

$527.00

--------

--------

--------

$560.00

$669.00

$348.00

$435.00

$540.00

$299.00

$355.00

$554.00

$594.00

$220.00

$400.00

$362.00

$374.00

$853.00

$307.00

$583.00

$571.00

$1,478.00

$209.00

$217.00

$463.00

$630.00

$359.00

$293.00

$1,693.00

$294.00

$586.00

$576.00

$625.00

$1,557.00

$532.00

$963.00

$1,002.00

$637.00

$697.00

$516.00

$399.00

$412.00

$1,012.00

$356.00

$345.00

$489.00

$513.00

$541.00

$542.00

$551.00

$655.00

$346.00

$1,045.00

$179.00

$596.00

$711.00

$367.00

$463.00

$576.00

$315.00

$373.00

$590.00

$625.00

$233.00

$421.00

$381.00

$393.00

$911.00

$325.00

$621.00

$608.00

$1,581.00

$220.00

$229.00

$493.00

$663.00

$378.00

$311.00

$1,809.00

$309.00

$625.00

$614.00

$666.00

$1,667.00

$567.00

$1,028.00

$1,070.00

$680.00

$742.00

$549.00

$420.00

$434.00

$1,080.00

$375.00

$363.00

$514.00

$540.00

$569.00

$570.00

$580.00

$688.00

$365.00

$1,114.00

$188.00

$612.00

$730.00

$390.00

$476.00

$590.00

$333.00

$395.00

$605.00

$662.00

$247.00

$445.00

$404.00

$416.00

$932.00

$347.00

$640.00

$624.00

$1,600.00

$232.00

$242.00

$508.00

$702.00

$400.00

$335.00

$1,838.00

$328.00

$642.00

$628.00

$685.00

$1,683.00

$583.00

$1,047.00

$1,091.00

$699.00

$762.00

$566.00

$443.00

$459.00

$1,101.00

$397.00

$383.00

$544.00

$572.00

$602.00

$604.00

$613.00

$729.00

$388.00

$1,138.00

$199.00

$246.00

$303.00

$348.00

$190.00

$214.00

$299.00

$355.00

$215.00

$594.00

$220.00

$400.00

$362.00

$374.00

$271.00

$307.00

$272.00

$256.00

$236.00

$209.00

$217.00

$209.00

$630.00

$359.00

$293.00

$393.00

$294.00

$220.00

$207.00

$248.00

$184.00

$203.00

$254.00

$302.00

$262.00

$301.00

$259.00

$399.00

$412.00

$307.00

$356.00

$345.00

$489.00

$513.00

$541.00

$542.00

$551.00

$655.00

$346.00

$355.00

$179.00

$259.00

$318.00

$367.00

$201.00

$226.00

$315.00

$373.00

$226.00

$625.00

$233.00

$421.00

$381.00

$393.00

$286.00

$325.00

$287.00

$269.00

$249.00

$220.00

$229.00

$220.00

$663.00

$378.00

$311.00

$414.00

$309.00

$233.00

$218.00

$262.00

$194.00

$215.00

$268.00

$319.00

$277.00

$317.00

$273.00

$420.00

$434.00

$323.00

$375.00

$363.00

$514.00

$540.00

$569.00

$570.00

$580.00

$688.00

$365.00

$373.00

$188.00

$274.00

$335.00

$390.00

$212.00

$239.00

$333.00

$395.00

$240.00

$662.00

$247.00

$445.00

$404.00

$416.00

$305.00

$347.00

$305.00

$284.00

$264.00

$232.00

$242.00

$234.00

$702.00

$400.00

$335.00

$439.00

$328.00

$249.00

$230.00

$280.00

$206.00

$229.00

$284.00

$338.00

$296.00

$336.00

$290.00

$443.00

$459.00

$342.00

$397.00

$383.00

$544.00

$572.00

$602.00

$604.00

$613.00

$729.00

$388.00

$395.00

$199.00


Part B, 229



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

43332

43333

43334

43335

43336

43337

43338

43340

43341

43351

43313

43314

43320

43325

43327

43328

43330

43331

43274

43275

43276

43277

43278

43279

43280

43281

43282

43283

43289

43300

43305

43310

43312

43420

43425

43450

43453

43460

43496

43499

43500

43501

43352

43360

43361

43400

43401

43405

43410

43415

0

0

--------

--------

0

0

0

90

--------

--------

--------

--------

90 $1,314.00

90

90

ZZZ

YYY

90

--------

--------

--------

BR

$837.00

90 $1,428.00

90 $2,138.00

90 $2,331.00

90 $2,632.00

90 $2,891.00

90 $1,299.00

90 $1,261.00

90 --------

90 --------

90 $1,236.00

90 $1,378.00

90

90

90

90

90

--------

--------

--------

--------

--------

90

ZZZ

--------

--------

90 $1,292.00

90 $1,351.00

90 $1,180.00

90 $1,028.00

90 $2,277.00

90 $2,596.00

90 $1,261.00

90 $1,299.00

90 $1,330.00

90 $946.00

90 $1,382.00

90 $854.00

90 $1,338.00

0 $91.00

0

0

90

YYY

$102.00

$203.00

BR

BR

90 $649.00

90 $1,105.00

$3,997.00

$4,615.00

$2,092.00

$2,011.00

$1,229.00

$1,712.00

$1,994.00

$2,025.00

$1,745.00

$1,903.00

$1,892.00

$2,030.00

$2,276.00

$2,455.00

$177.00

$2,049.00

$2,121.00

$1,930.00

$699.00

$570.00

$728.00

$573.00

$654.00

$1,945.00

$1,623.00

$2,325.00

$2,614.00

$241.00

--------

$905.00

$1,620.00

$2,248.00

$2,446.00

$1,608.00

$3,559.00

$3,860.00

$2,185.00

$2,347.00

$2,200.00

$1,572.00

$3,882.00

$1,497.00

$2,164.00

$295.00

$1,328.00

$317.00

--------

--------

$1,171.00

$2,017.00

$4,213.00

$4,914.00

$2,245.00

$2,156.00

$1,319.00

$1,835.00

$2,139.00

$2,170.00

$1,872.00

$2,041.00

$2,028.00

$2,176.00

$2,439.00

$2,634.00

$190.00

$2,197.00

$2,275.00

$2,061.00

$735.00

$600.00

$766.00

$603.00

$688.00

$2,086.00

$1,741.00

$2,493.00

$2,803.00

$258.00

--------

$958.00

$1,715.00

$2,412.00

$2,621.00

$1,724.00

$3,817.00

$4,137.00

$2,301.00

$2,519.00

$2,360.00

$1,686.00

$4,160.00

$1,581.00

$2,314.00

$314.00

$1,422.00

$334.00

--------

--------

$1,253.00

$2,162.00

$4,474.00

$5,321.00

$2,465.00

$2,362.00

$1,443.00

$2,018.00

$2,344.00

$2,380.00

$2,054.00

$2,240.00

$2,231.00

$2,397.00

$2,675.00

$2,894.00

$210.00

$2,410.00

$2,501.00

$2,243.00

$778.00

$635.00

$810.00

$638.00

$728.00

$2,291.00

$1,909.00

$2,739.00

$3,080.00

$285.00

--------

$1,011.00

$1,823.00

$2,656.00

$2,888.00

$1,887.00

$4,187.00

$4,552.00

$2,433.00

$2,772.00

$2,591.00

$1,840.00

$4,571.00

$1,676.00

$2,528.00

$322.00

$1,433.00

$353.00

--------

--------

$1,367.00

$2,370.00

$3,997.00

$4,615.00

$2,092.00

$2,011.00

$1,229.00

$1,712.00

$1,994.00

$2,025.00

$1,745.00

$1,903.00

$1,892.00

$2,030.00

$2,276.00

$2,455.00

$177.00

$2,049.00

$2,121.00

$1,930.00

$699.00

$570.00

$728.00

$573.00

$654.00

$1,945.00

$1,623.00

$2,325.00

$2,614.00

$241.00

--------

$905.00

$1,620.00

$2,248.00

$2,446.00

$1,608.00

$3,559.00

$3,860.00

$2,185.00

$2,347.00

$2,200.00

$1,572.00

$3,882.00

$1,497.00

$2,164.00

$125.00

$135.00

$317.00

--------

--------

$1,171.00

$2,017.00

$4,213.00

$4,914.00

$2,245.00

$2,156.00

$1,319.00

$1,835.00

$2,139.00

$2,170.00

$1,872.00

$2,041.00

$2,028.00

$2,176.00

$2,439.00

$2,634.00

$190.00

$2,197.00

$2,275.00

$2,061.00

$735.00

$600.00

$766.00

$603.00

$688.00

$2,086.00

$1,741.00

$2,493.00

$2,803.00

$258.00

--------

$958.00

$1,715.00

$2,412.00

$2,621.00

$1,724.00

$3,817.00

$4,137.00

$2,301.00

$2,519.00

$2,360.00

$1,686.00

$4,160.00

$1,581.00

$2,314.00

$132.00

$142.00

$334.00

--------

--------

$1,253.00

$2,162.00

$4,474.00

$5,321.00

$2,465.00

$2,362.00

$1,443.00

$2,018.00

$2,344.00

$2,380.00

$2,054.00

$2,240.00

$2,231.00

$2,397.00

$2,675.00

$2,894.00

$210.00

$2,410.00

$2,501.00

$2,243.00

$778.00

$635.00

$810.00

$638.00

$728.00

$2,291.00

$1,909.00

$2,739.00

$3,080.00

$285.00

--------

$1,011.00

$1,823.00

$2,656.00

$2,888.00

$1,887.00

$4,187.00

$4,552.00

$2,433.00

$2,772.00

$2,591.00

$1,840.00

$4,571.00

$1,676.00

$2,528.00

$139.00

$150.00

$353.00

--------

--------

$1,367.00

$2,370.00


Part B, 230



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

43753

43754

43755

43756

43757

43760

43761

43770

43771

43772

43641

43644

43645

43651

43652

43653

43659

43752

43502

43510

43520

43605

43610

43611

43620

43621

43622

43631

43632

43633

43634

43635

43640

43831

43832

43840

43843

43845

43846

43847

43848

43850

43773

43774

43775

43800

43810

43820

43825

43830

90 $1,247.00

90 $680.00

90

90

$599.00

$686.00

90 $861.00

90 $1,001.00

90 $1,691.00

90 $1,718.00

90 $1,798.00

90 $1,445.00

90 $1,443.00

90 $1,467.00

90 $1,786.00

ZZZ $143.00

90 $1,119.00

0

0

90

90

90

0

0

0

0

0

90 $1,138.00

90 --------

90

90

90

--------

$716.00

$856.00

90

YYY

0

$617.00

BR

BR

--------

--------

--------

--------

--------

$81.00

$107.00

--------

--------

--------

90

90

90

--------

--------

--------

90

90

$793.00

$846.00

90 $896.00

90 $1,128.00

90 $592.00

90

90

90

$593.00

$904.00

$893.00

90 $1,249.00

90 --------

90 $1,528.00

90 $1,678.00

90 $1,795.00

90 $1,425.00

$1,775.00

$2,603.00

$2,784.00

$971.00

$1,145.00

$851.00

--------

$60.00

$32.00

$147.00

$198.00

$284.00

$402.00

$670.00

$169.00

$1,674.00

$1,907.00

$1,421.00

$2,287.00

$1,411.00

$1,029.00

$1,251.00

$1,469.00

$1,834.00

$2,941.00

$3,421.00

$3,492.00

$2,176.00

$3,058.00

$2,889.00

$3,183.00

$170.00

$1,767.00

$1,899.00

$1,437.00

$1,660.00

$1,392.00

$1,525.00

$2,012.00

$1,960.00

$1,042.00

$866.00

$1,558.00

$2,038.00

$1,917.00

$2,951.00

$2,422.00

$2,658.00

$2,891.00

$2,428.00

$1,899.00

$2,791.00

$2,986.00

$1,039.00

$1,230.00

$913.00

--------

$62.00

$34.00

$156.00

$212.00

$304.00

$430.00

$718.00

$177.00

$1,796.00

$2,046.00

$1,523.00

$2,453.00

$1,515.00

$1,103.00

$1,341.00

$1,574.00

$1,967.00

$3,150.00

$3,669.00

$3,749.00

$2,333.00

$3,280.00

$3,098.00

$3,412.00

$183.00

$1,895.00

$2,034.00

$1,541.00

$1,773.00

$1,493.00

$1,636.00

$2,158.00

$2,103.00

$1,117.00

$929.00

$1,669.00

$2,186.00

$2,056.00

$3,165.00

$2,596.00

$2,842.00

$3,100.00

$2,596.00

$2,069.00

$3,063.00

$3,280.00

$1,129.00

$1,346.00

$993.00

--------

$66.00

$36.00

$158.00

$220.00

$308.00

$437.00

$725.00

$185.00

$1,964.00

$2,240.00

$1,666.00

$2,694.00

$1,659.00

$1,208.00

$1,466.00

$1,724.00

$2,155.00

$3,458.00

$4,038.00

$4,131.00

$2,559.00

$3,607.00

$3,405.00

$3,748.00

$202.00

$2,076.00

$2,223.00

$1,686.00

$1,945.00

$1,635.00

$1,792.00

$2,366.00

$2,307.00

$1,216.00

$1,010.00

$1,826.00

$2,396.00

$2,253.00

$3,476.00

$2,848.00

$3,104.00

$3,402.00

$2,831.00

$1,775.00

$2,603.00

$2,784.00

$971.00

$1,145.00

$851.00

--------

$60.00

$32.00

$47.00

$91.00

$75.00

$114.00

$70.00

$151.00

$1,674.00

$1,907.00

$1,421.00

$2,287.00

$1,411.00

$1,029.00

$1,251.00

$1,469.00

$1,834.00

$2,941.00

$3,421.00

$3,492.00

$2,176.00

$3,058.00

$2,889.00

$3,183.00

$170.00

$1,767.00

$1,899.00

$1,437.00

$1,660.00

$1,392.00

$1,525.00

$2,012.00

$1,960.00

$1,042.00

$866.00

$1,558.00

$2,038.00

$1,917.00

$2,951.00

$2,422.00

$2,658.00

$2,891.00

$2,428.00

$1,899.00

$2,791.00

$2,986.00

$1,039.00

$1,230.00

$913.00

--------

$62.00

$34.00

$49.00

$97.00

$79.00

$120.00

$73.00

$158.00

$1,796.00

$2,046.00

$1,523.00

$2,453.00

$1,515.00

$1,103.00

$1,341.00

$1,574.00

$1,967.00

$3,150.00

$3,669.00

$3,749.00

$2,333.00

$3,280.00

$3,098.00

$3,412.00

$183.00

$1,895.00

$2,034.00

$1,541.00

$1,773.00

$1,493.00

$1,636.00

$2,158.00

$2,103.00

$1,117.00

$929.00

$1,669.00

$2,186.00

$2,056.00

$3,165.00

$2,596.00

$2,842.00

$3,100.00

$2,596.00

$2,069.00

$3,063.00

$3,280.00

$1,129.00

$1,346.00

$993.00

--------

$66.00

$36.00

$51.00

$105.00

$83.00

$126.00

$78.00

$166.00

$1,964.00

$2,240.00

$1,666.00

$2,694.00

$1,659.00

$1,208.00

$1,466.00

$1,724.00

$2,155.00

$3,458.00

$4,038.00

$4,131.00

$2,559.00

$3,607.00

$3,405.00

$3,748.00

$202.00

$2,076.00

$2,223.00

$1,686.00

$1,945.00

$1,635.00

$1,792.00

$2,366.00

$2,307.00

$1,216.00

$1,010.00

$1,826.00

$2,396.00

$2,253.00

$3,476.00

$2,848.00

$3,104.00

$3,402.00

$2,831.00


Part B, 231



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

44126

44127

44128

44130

44133

44136

44139

44140

44141

44143

44050

44055

44100

44110

44111

44120

44121

44125

43855

43860

43865

43870

43880

43886

43887

43888

43999

44005

44010

44015

44020

44021

44025

44157

44158

44160

44180

44186

44187

44188

44202

44203

44144

44145

44146

44147

44150

44151

44155

44156

90 $1,454.00

90 $1,435.00

90 $1,549.00

90 $590.00

90 $1,352.00

90 --------

90 --------

90

YYY

--------

BR

90 $1,171.00

90 $809.00

ZZZ $1,171.00

90

90

90

$891.00

$888.00

$905.00

90

90

0

90

90

$862.00

$957.00

$117.00

$784.00

$963.00

90 $1,078.00

ZZZ $308.00

90 $1,135.00

90 $1,951.00

90 $2,243.00

ZZZ $242.00

90 $938.00

0 BR

0 BR

ZZZ $154.00

90 $1,350.00

90 $1,488.00

90 $1,536.00

90 $1,442.00

90 $1,678.00

90 $1,840.00

90 $1,452.00

90 $1,661.00

90 $1,499.00

90 $1,892.00

90 $1,709.00

90

90

--------

--------

90 $1,236.00

90

90

90

90

--------

--------

--------

--------

90 $1,603.00

ZZZ $235.00

$1,402.00

$2,239.00

$161.00

$1,274.00

$1,472.00

$1,836.00

$366.00

$1,770.00

$3,711.00

$4,256.00

$371.00

$1,967.00

--------

--------

$183.00

$2,010.00

$2,732.00

$2,494.00

$2,456.00

$2,456.00

$2,559.00

$1,063.00

$2,400.00

$532.00

$478.00

$678.00

--------

$1,640.00

$1,286.00

$216.00

$1,460.00

$1,458.00

$1,476.00

$2,656.00

$2,483.00

$3,163.00

$2,919.00

$2,790.00

$3,200.00

$3,102.00

$3,436.00

$3,215.00

$3,140.00

$1,860.00

$1,374.00

$975.00

$1,640.00

$1,824.00

$2,080.00

$364.00

$1,503.00

$2,398.00

$169.00

$1,365.00

$1,574.00

$1,967.00

$392.00

$1,894.00

$3,983.00

$4,558.00

$398.00

$2,106.00

--------

--------

$196.00

$2,153.00

$2,926.00

$2,671.00

$2,618.00

$2,632.00

$2,744.00

$1,139.00

$2,572.00

$571.00

$512.00

$727.00

--------

$1,757.00

$1,373.00

$231.00

$1,565.00

$1,562.00

$1,580.00

$2,844.00

$2,654.00

$3,379.00

$3,124.00

$2,985.00

$3,427.00

$3,309.00

$3,680.00

$3,436.00

$3,318.00

$1,991.00

$1,472.00

$1,046.00

$1,750.00

$1,951.00

$2,228.00

$390.00

$1,645.00

$2,627.00

$180.00

$1,491.00

$1,717.00

$2,156.00

$432.00

$2,071.00

$4,381.00

$4,999.00

$440.00

$2,304.00

--------

--------

$216.00

$2,356.00

$3,194.00

$2,921.00

$2,842.00

$2,888.00

$3,013.00

$1,242.00

$2,821.00

$614.00

$553.00

$787.00

--------

$1,925.00

$1,491.00

$255.00

$1,714.00

$1,707.00

$1,727.00

$3,112.00

$2,896.00

$3,675.00

$3,422.00

$3,248.00

$3,740.00

$3,585.00

$4,016.00

$3,736.00

$3,533.00

$2,176.00

$1,608.00

$1,143.00

$1,889.00

$2,116.00

$2,438.00

$428.00

$1,402.00

$2,239.00

$161.00

$1,274.00

$1,472.00

$1,836.00

$366.00

$1,770.00

$3,711.00

$4,256.00

$371.00

$1,967.00

--------

--------

$183.00

$2,010.00

$2,732.00

$2,494.00

$2,456.00

$2,456.00

$2,559.00

$1,063.00

$2,400.00

$532.00

$478.00

$678.00

--------

$1,640.00

$1,286.00

$216.00

$1,460.00

$1,458.00

$1,476.00

$2,656.00

$2,483.00

$3,163.00

$2,919.00

$2,790.00

$3,200.00

$3,102.00

$3,436.00

$3,215.00

$3,140.00

$1,860.00

$1,374.00

$975.00

$1,640.00

$1,824.00

$2,080.00

$364.00

$1,503.00

$2,398.00

$169.00

$1,365.00

$1,574.00

$1,967.00

$392.00

$1,894.00

$3,983.00

$4,558.00

$398.00

$2,106.00

--------

--------

$196.00

$2,153.00

$2,926.00

$2,671.00

$2,618.00

$2,632.00

$2,744.00

$1,139.00

$2,572.00

$571.00

$512.00

$727.00

--------

$1,757.00

$1,373.00

$231.00

$1,565.00

$1,562.00

$1,580.00

$2,844.00

$2,654.00

$3,379.00

$3,124.00

$2,985.00

$3,427.00

$3,309.00

$3,680.00

$3,436.00

$3,318.00

$1,991.00

$1,472.00

$1,046.00

$1,750.00

$1,951.00

$2,228.00

$390.00

$1,645.00

$2,627.00

$180.00

$1,491.00

$1,717.00

$2,156.00

$432.00

$2,071.00

$4,381.00

$4,999.00

$440.00

$2,304.00

--------

--------

$216.00

$2,356.00

$3,194.00

$2,921.00

$2,842.00

$2,888.00

$3,013.00

$1,242.00

$2,821.00

$614.00

$553.00

$787.00

--------

$1,925.00

$1,491.00

$255.00

$1,714.00

$1,707.00

$1,727.00

$3,112.00

$2,896.00

$3,675.00

$3,422.00

$3,248.00

$3,740.00

$3,585.00

$4,016.00

$3,736.00

$3,533.00

$2,176.00

$1,608.00

$1,143.00

$1,889.00

$2,116.00

$2,438.00

$428.00


Part B, 232



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

44363

44364

44365

44366

44369

44370

44372

44373

44376

44377

44316

44320

44322

44340

44345

44346

44360

44361

44204

44205

44206

44207

44208

44210

44211

44212

44213

44227

44238

44300

44310

44312

44314

44378

44379

44380

44381

44382

44384

44385

44386

44388

44388-53

44389

44390

44391

44392

44394

44401

44402

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

90 $1,353.00

90 $1,198.00

90 $1,480.00

90 $1,620.00

90 $1,752.00

90 $1,551.00

90 $1,926.00

90 $1,800.00

ZZZ --------

90

YYY

90

--------

BR

$697.00

90

90

90

$950.00

$453.00

$892.00

0

0

0

0

0

0

0

0

0

0

90 $1,229.00

90 $1,029.00

90 $1,015.00

90 $397.00

90 $816.00

90

0

0

$923.00

$177.00

$195.00

$213.00

$255.00

$226.00

$300.00

$308.00

$253.00

$301.00

$238.00

$305.00

$320.00

$410.00

$396.00

$91.00

--------

$110.00

--------

$219.00

$183.00

$326.00

--------

$301.00

$319.00

$376.00

$359.00

$395.00

--------

--------

$2,127.00

$1,795.00

$1,477.00

$927.00

$1,568.00

$1,765.00

$221.00

$244.00

$294.00

$312.00

$273.00

$366.00

$374.00

$406.00

$367.00

$295.00

$432.00

$456.00

$2,303.00

$2,001.00

$2,626.00

$2,722.00

$2,965.00

$2,651.00

$3,243.00

$3,038.00

$283.00

$2,500.00

--------

$1,260.00

$1,560.00

$873.00

$1,492.00

$582.00

$619.00

$305.00

$1,372.00

$442.00

$233.00

$338.00

$474.00

$496.00

$246.00

$623.00

$624.00

$1,066.00

$589.00

$662.00

$4,467.00

$401.00

$2,284.00

$1,921.00

$1,585.00

$992.00

$1,676.00

$1,886.00

$233.00

$257.00

$309.00

$328.00

$286.00

$385.00

$394.00

$428.00

$387.00

$311.00

$455.00

$480.00

$2,461.00

$2,138.00

$2,808.00

$2,903.00

$3,162.00

$2,823.00

$3,448.00

$3,229.00

$302.00

$2,675.00

--------

$1,351.00

$1,667.00

$930.00

$1,591.00

$612.00

$652.00

$326.00

$1,470.00

$472.00

$245.00

$360.00

$506.00

$529.00

$262.00

$663.00

$663.00

$1,137.00

$627.00

$705.00

$4,787.00

$424.00

$2,509.00

$2,095.00

$1,711.00

$1,074.00

$1,822.00

$2,052.00

$246.00

$272.00

$328.00

$347.00

$299.00

$407.00

$416.00

$455.00

$411.00

$331.00

$483.00

$509.00

$2,683.00

$2,329.00

$3,063.00

$3,158.00

$3,431.00

$3,053.00

$3,719.00

$3,475.00

$330.00

$2,924.00

--------

$1,477.00

$1,815.00

$1,002.00

$1,722.00

$648.00

$690.00

$332.00

$1,483.00

$480.00

$258.00

$368.00

$516.00

$548.00

$269.00

$682.00

$684.00

$1,162.00

$650.00

$729.00

$4,826.00

$452.00

$2,127.00

$1,795.00

$1,477.00

$927.00

$1,568.00

$1,765.00

$221.00

$244.00

$294.00

$312.00

$273.00

$366.00

$374.00

$406.00

$367.00

$295.00

$432.00

$456.00

$2,303.00

$2,001.00

$2,626.00

$2,722.00

$2,965.00

$2,651.00

$3,243.00

$3,038.00

$283.00

$2,500.00

--------

$1,260.00

$1,560.00

$873.00

$1,492.00

$582.00

$619.00

$91.00

$134.00

$116.00

$233.00

$114.00

$139.00

$242.00

$119.00

$264.00

$322.00

$352.00

$305.00

$346.00

$371.00

$401.00

$2,284.00

$1,921.00

$1,585.00

$992.00

$1,676.00

$1,886.00

$233.00

$257.00

$309.00

$328.00

$286.00

$385.00

$394.00

$428.00

$387.00

$311.00

$455.00

$480.00

$2,461.00

$2,138.00

$2,808.00

$2,903.00

$3,162.00

$2,823.00

$3,448.00

$3,229.00

$302.00

$2,675.00

--------

$1,351.00

$1,667.00

$930.00

$1,591.00

$612.00

$652.00

$96.00

$142.00

$123.00

$245.00

$120.00

$147.00

$256.00

$125.00

$279.00

$339.00

$371.00

$322.00

$365.00

$392.00

$424.00

$2,509.00

$2,095.00

$1,711.00

$1,074.00

$1,822.00

$2,052.00

$246.00

$272.00

$328.00

$347.00

$299.00

$407.00

$416.00

$455.00

$411.00

$331.00

$483.00

$509.00

$2,683.00

$2,329.00

$3,063.00

$3,158.00

$3,431.00

$3,053.00

$3,719.00

$3,475.00

$330.00

$2,924.00

--------

$1,477.00

$1,815.00

$1,002.00

$1,722.00

$648.00

$690.00

$102.00

$151.00

$129.00

$258.00

$127.00

$156.00

$274.00

$133.00

$297.00

$358.00

$393.00

$344.00

$389.00

$418.00

$452.00


Part B, 233



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

44721

44799

44800

44820

44850

44899

44900

44950

44955

44960

44640

44650

44660

44661

44680

44700

44701

44720

44403

44404

44405

44406

44407

44408

44500

44602

44603

44604

44605

44615

44620

44625

44626

45111

45112

45113

45114

45116

45119

45120

45121

45123

44970

44979

45000

45005

45020

45100

45108

45110

0

0

0

0

0

0

0

--------

--------

--------

--------

--------

--------

$28.00

90 $815.00

90 $1,041.00

90 $1,027.00

90 $1,132.00

90 $994.00

90 $741.00

90 $1,277.00

90 $1,581.00

90 $1,036.00

90 $1,076.00

90 $1,050.00

90 $1,326.00

90 $1,049.00

90 $1,115.00

ZZZ $161.00

0 --------

0

0

90

90

90

--------

BR

$791.00

$755.00

$708.00

YYY

90

BR

$644.00

90 $643.00

ZZZ $136.00

90 $790.00

90

YYY

90

$631.00

BR

$329.00

10

90

90

90

$197.00

$364.00

$321.00

$419.00

90 $1,801.00

90 $1,270.00

90 $1,904.00

90 $1,885.00

90 $1,732.00

90 $1,485.00

90 $1,911.00

90 $1,845.00

90 $1,870.00

90 $1,126.00

$2,102.00

$2,173.00

$1,976.00

$2,319.00

$1,597.00

$1,518.00

$254.00

$417.00

$584.00

--------

$1,137.00

$1,253.00

$1,123.00

--------

$1,154.00

$963.00

$127.00

$1,310.00

$460.00

$598.00

$852.00

$352.00

$422.00

$355.00

$36.00

$2,124.00

$2,432.00

$1,586.00

$1,956.00

$1,612.00

$1,296.00

$1,517.00

$2,407.00

$897.00

--------

$622.00

$390.00

$844.00

$438.00

$541.00

$2,747.00

$1,617.00

$2,797.00

$2,794.00

$2,731.00

$2,466.00

$2,890.00

$2,216.00

$2,605.00

$1,659.00

$2,248.00

$2,323.00

$2,095.00

$2,473.00

$1,711.00

$1,615.00

$272.00

$448.00

$627.00

--------

$1,217.00

$1,341.00

$1,203.00

--------

$1,237.00

$1,032.00

$135.00

$1,405.00

$486.00

$637.00

$909.00

$372.00

$446.00

$376.00

$37.00

$2,275.00

$2,604.00

$1,698.00

$2,094.00

$1,726.00

$1,385.00

$1,618.00

$2,575.00

$962.00

--------

$662.00

$417.00

$902.00

$467.00

$580.00

$2,928.00

$1,726.00

$2,974.00

$2,951.00

$2,931.00

$2,642.00

$3,072.00

$2,339.00

$2,793.00

$1,762.00

$2,457.00

$2,538.00

$2,257.00

$2,691.00

$1,871.00

$1,747.00

$298.00

$496.00

$694.00

--------

$1,323.00

$1,462.00

$1,313.00

--------

$1,350.00

$1,130.00

$149.00

$1,540.00

$517.00

$657.00

$931.00

$397.00

$476.00

$401.00

$39.00

$2,498.00

$2,854.00

$1,859.00

$2,289.00

$1,887.00

$1,506.00

$1,758.00

$2,818.00

$1,050.00

--------

$709.00

$435.00

$973.00

$498.00

$628.00

$3,169.00

$1,873.00

$3,217.00

$3,146.00

$3,221.00

$2,893.00

$3,311.00

$2,490.00

$3,061.00

$1,896.00

$2,102.00

$2,173.00

$1,976.00

$2,319.00

$1,597.00

$1,518.00

$254.00

$417.00

$584.00

--------

$1,137.00

$1,253.00

$1,123.00

--------

$1,154.00

$963.00

$127.00

$1,310.00

$460.00

$266.00

$282.00

$352.00

$422.00

$355.00

$36.00

$2,124.00

$2,432.00

$1,586.00

$1,956.00

$1,612.00

$1,296.00

$1,517.00

$2,407.00

$897.00

--------

$622.00

$236.00

$844.00

$438.00

$541.00

$2,747.00

$1,617.00

$2,797.00

$2,794.00

$2,731.00

$2,466.00

$2,890.00

$2,216.00

$2,605.00

$1,659.00

$2,248.00

$2,323.00

$2,095.00

$2,473.00

$1,711.00

$1,615.00

$272.00

$448.00

$627.00

--------

$1,217.00

$1,341.00

$1,203.00

--------

$1,237.00

$1,032.00

$135.00

$1,405.00

$486.00

$281.00

$299.00

$372.00

$446.00

$376.00

$37.00

$2,275.00

$2,604.00

$1,698.00

$2,094.00

$1,726.00

$1,385.00

$1,618.00

$2,575.00

$962.00

--------

$662.00

$253.00

$902.00

$467.00

$580.00

$2,928.00

$1,726.00

$2,974.00

$2,951.00

$2,931.00

$2,642.00

$3,072.00

$2,339.00

$2,793.00

$1,762.00

$2,457.00

$2,538.00

$2,257.00

$2,691.00

$1,871.00

$1,747.00

$298.00

$496.00

$694.00

--------

$1,323.00

$1,462.00

$1,313.00

--------

$1,350.00

$1,130.00

$149.00

$1,540.00

$517.00

$300.00

$319.00

$397.00

$476.00

$401.00

$39.00

$2,498.00

$2,854.00

$1,859.00

$2,289.00

$1,887.00

$1,506.00

$1,758.00

$2,818.00

$1,050.00

--------

$709.00

$270.00

$973.00

$498.00

$628.00

$3,169.00

$1,873.00

$3,217.00

$3,146.00

$3,221.00

$2,893.00

$3,311.00

$2,490.00

$3,061.00

$1,896.00


Part B, 234



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

45333

45334

45335

45337

45338

45340

45341

45342

45346

45347

45315

45317

45320

45321

45327

45330

45331

45332

45126

45130

45135

45136

45150

45160

45171

45172

45190

45300

45303

45305

45307

45308

45309

45386

45388

45389

45390

45391

45392

45393

45395

45397

45349

45350

45379

45380

45381

45382

45384

45385

0

0

0

0

0

0

0

90

90

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

90

90

0

0

0

90 $2,444.00

90 $1,041.00

90 $1,354.00

90 $1,526.00

90

90

90

$475.00

$949.00

--------

--------

$623.00

$75.00

$72.00

$102.00

$172.00

$137.00

$174.00

$211.00

$209.00

$230.00

$154.00

$96.00

$87.00

$120.00

$174.00

$176.00

$171.00

$144.00

$144.00

$212.00

$328.00

$153.00

$224.00

--------

--------

--------

--------

$415.00

$369.00

$388.00

$481.00

$415.00

$479.00

$739.00

--------

--------

--------

--------

--------

--------

--------

--------

$316.00

$343.00

$345.00

$159.00

$183.00

$232.00

$355.00

$433.00

$484.00

$841.00

$400.00

$180.00

$453.00

$675.00

$192.00

$260.00

$4,269.00

$238.00

$4,154.00

$1,610.00

$2,049.00

$2,666.00

$569.00

$1,527.00

$882.00

$1,190.00

$1,019.00

$172.00

$1,321.00

$274.00

$331.00

$304.00

$319.00

$304.00

$805.00

$673.00

$657.00

$632.00

$1,104.00

$723.00

$692.00

$913.00

$4,495.00

$442.00

$505.00

$392.00

$462.00

$387.00

$2,935.00

$3,192.00

$335.00

$366.00

$370.00

$170.00

$196.00

$248.00

$379.00

$462.00

$517.00

$899.00

$427.00

$190.00

$483.00

$722.00

$202.00

$274.00

$4,576.00

$251.00

$4,416.00

$1,709.00

$2,196.00

$2,817.00

$602.00

$1,638.00

$941.00

$1,266.00

$1,083.00

$184.00

$1,416.00

$293.00

$355.00

$326.00

$342.00

$321.00

$861.00

$715.00

$699.00

$672.00

$1,177.00

$770.00

$735.00

$973.00

$4,815.00

$466.00

$533.00

$413.00

$487.00

$408.00

$3,122.00

$3,389.00

$341.00

$380.00

$387.00

$184.00

$214.00

$253.00

$386.00

$474.00

$528.00

$912.00

$434.00

$203.00

$495.00

$732.00

$214.00

$290.00

$4,604.00

$266.00

$4,772.00

$1,835.00

$2,402.00

$2,997.00

$636.00

$1,791.00

$1,006.00

$1,355.00

$1,156.00

$189.00

$1,431.00

$303.00

$372.00

$340.00

$357.00

$342.00

$874.00

$740.00

$719.00

$692.00

$1,203.00

$796.00

$761.00

$997.00

$4,856.00

$495.00

$569.00

$437.00

$516.00

$435.00

$3,364.00

$3,641.00

$152.00

$173.00

$165.00

$159.00

$183.00

$82.00

$106.00

$165.00

$147.00

$183.00

$106.00

$180.00

$187.00

$123.00

$192.00

$260.00

$247.00

$238.00

$4,154.00

$1,610.00

$2,049.00

$2,666.00

$569.00

$1,527.00

$882.00

$1,190.00

$1,019.00

$79.00

$136.00

$116.00

$159.00

$133.00

$142.00

$304.00

$157.00

$365.00

$307.00

$307.00

$395.00

$350.00

$388.00

$325.00

$413.00

$442.00

$505.00

$392.00

$462.00

$387.00

$2,935.00

$3,192.00

$159.00

$184.00

$177.00

$170.00

$196.00

$87.00

$112.00

$174.00

$156.00

$193.00

$112.00

$190.00

$197.00

$130.00

$202.00

$274.00

$260.00

$251.00

$4,416.00

$1,709.00

$2,196.00

$2,817.00

$602.00

$1,638.00

$941.00

$1,266.00

$1,083.00

$84.00

$145.00

$124.00

$171.00

$142.00

$152.00

$321.00

$166.00

$385.00

$324.00

$323.00

$416.00

$370.00

$409.00

$342.00

$436.00

$466.00

$533.00

$413.00

$487.00

$408.00

$3,122.00

$3,389.00

$165.00

$197.00

$193.00

$184.00

$214.00

$92.00

$118.00

$185.00

$166.00

$204.00

$119.00

$203.00

$209.00

$138.00

$214.00

$290.00

$276.00

$266.00

$4,772.00

$1,835.00

$2,402.00

$2,997.00

$636.00

$1,791.00

$1,006.00

$1,355.00

$1,156.00

$89.00

$156.00

$133.00

$187.00

$155.00

$165.00

$342.00

$177.00

$409.00

$343.00

$342.00

$440.00

$394.00

$434.00

$364.00

$464.00

$495.00

$569.00

$437.00

$516.00

$435.00

$3,364.00

$3,641.00


Part B, 235



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

46030

46040

46045

46050

46060

46080

46083

46200

46220

46221

45825

45900

45905

45910

45915

45990

45999

46020

45398

45400

45402

45500

45505

45520

45540

45541

45550

45560

45562

45563

45800

45805

45820

46270

46275

46280

46285

46288

46320

46500

46505

46600

46230

46250

46255

46257

46258

46260

46261

46262

90

90

90

90

90

10

10

10

0

10

90

90

90

90

90

90

90

0

90

--------

--------

90

90

90

0

--------

$584.00

$510.00

$46.00

90 $1,009.00

90 $888.00

90 $1,350.00

90

90

$618.00

$915.00

90 $1,412.00

90 $1,050.00

90 $1,273.00

90 $1,066.00

10

10

90

10

10

10

90

90

10

90

90 $1,241.00

10 $120.00

10

10

10

$133.00

$163.00

$142.00

0

YYY

10

--------

BR

$230.00

$94.00

$393.00

$312.00

$105.00

$482.00

$246.00

$98.00

$323.00

$118.00

$124.00

$198.00

$400.00

$501.00

$504.00

$539.00

$598.00

$655.00

$686.00

$328.00

$442.00

$514.00

$335.00

$521.00

$126.00

$109.00

--------

$38.00

$2,033.00

$298.00

$248.00

$285.00

$471.00

$159.00

--------

$397.00

$198.00

$769.00

$636.00

$283.00

$696.00

$355.00

$249.00

$631.00

$292.00

$379.00

$1,021.00

$1,688.00

$2,257.00

$759.00

$870.00

$217.00

$1,570.00

$1,398.00

$2,164.00

$1,003.00

$1,663.00

$2,467.00

$1,782.00

$2,190.00

$1,751.00

$389.00

$663.00

$726.00

$617.00

$689.00

$698.00

$766.00

$807.00

$728.00

$769.00

$684.00

$761.00

$804.00

$261.00

$274.00

$410.00

$124.00

$2,143.00

$318.00

$264.00

$303.00

$502.00

$170.00

--------

$424.00

$211.00

$822.00

$680.00

$302.00

$743.00

$380.00

$265.00

$674.00

$312.00

$404.00

$1,090.00

$1,792.00

$2,398.00

$803.00

$927.00

$232.00

$1,669.00

$1,493.00

$2,300.00

$1,057.00

$1,776.00

$2,648.00

$1,895.00

$2,351.00

$1,849.00

$415.00

$709.00

$776.00

$658.00

$739.00

$745.00

$815.00

$859.00

$779.00

$820.00

$728.00

$812.00

$856.00

$278.00

$292.00

$437.00

$132.00

$2,273.00

$342.00

$282.00

$322.00

$522.00

$183.00

--------

$447.00

$221.00

$867.00

$729.00

$312.00

$792.00

$401.00

$275.00

$701.00

$324.00

$419.00

$1,118.00

$1,927.00

$2,587.00

$848.00

$991.00

$236.00

$1,798.00

$1,613.00

$2,477.00

$1,116.00

$1,923.00

$2,897.00

$2,041.00

$2,573.00

$1,965.00

$435.00

$744.00

$816.00

$703.00

$801.00

$799.00

$872.00

$917.00

$820.00

$860.00

$774.00

$851.00

$913.00

$291.00

$302.00

$460.00

$136.00

$2,033.00

$298.00

$248.00

$285.00

$330.00

$159.00

--------

$342.00

$132.00

$606.00

$636.00

$141.00

$696.00

$236.00

$154.00

$470.00

$173.00

$275.00

$360.00

$1,688.00

$2,257.00

$759.00

$870.00

$58.00

$1,570.00

$1,398.00

$2,164.00

$1,003.00

$1,663.00

$2,467.00

$1,782.00

$2,190.00

$1,751.00

$253.00

$462.00

$519.00

$617.00

$689.00

$698.00

$766.00

$807.00

$572.00

$602.00

$684.00

$599.00

$804.00

$162.00

$177.00

$348.00

$59.00

$2,143.00

$318.00

$264.00

$303.00

$350.00

$170.00

--------

$364.00

$140.00

$648.00

$680.00

$151.00

$743.00

$252.00

$164.00

$501.00

$185.00

$292.00

$381.00

$1,792.00

$2,398.00

$803.00

$927.00

$61.00

$1,669.00

$1,493.00

$2,300.00

$1,057.00

$1,776.00

$2,648.00

$1,895.00

$2,351.00

$1,849.00

$269.00

$494.00

$554.00

$658.00

$739.00

$745.00

$815.00

$859.00

$611.00

$641.00

$728.00

$638.00

$856.00

$173.00

$189.00

$370.00

$63.00

$2,273.00

$342.00

$282.00

$322.00

$369.00

$183.00

--------

$387.00

$149.00

$692.00

$729.00

$160.00

$792.00

$272.00

$174.00

$528.00

$197.00

$306.00

$407.00

$1,927.00

$2,587.00

$848.00

$991.00

$64.00

$1,798.00

$1,613.00

$2,477.00

$1,116.00

$1,923.00

$2,897.00

$2,041.00

$2,573.00

$1,965.00

$288.00

$528.00

$594.00

$703.00

$801.00

$799.00

$872.00

$917.00

$652.00

$681.00

$774.00

$677.00

$913.00

$184.00

$198.00

$393.00

$67.00


Part B, 236



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

46748

46750

46753

46754

46760

46761

46762

46900

46910

46916

46715

46716

46730

46735

46740

46742

46744

46746

46601

46604

46606

46607

46608

46610

46611

46612

46614

46615

46700

46706

46707

46710

46712

46947

46999

47000

47001

47010

47015

47100

47120

47122

46917

46922

46924

46930

46940

46942

46945

46946

0

0

0

90

10

90

90

90

0

0

0

0

0

0

0

90

90

$545.00

$906.00

90 $1,584.00

90 $1,881.00

90 $1,671.00

90 $2,236.00

90 $2,412.00

90 $2,725.00

90

90

10

10

10

90 $2,933.00

90 $636.00

90

10

90

$511.00

$188.00

$846.00

$813.00

$731.00

$128.00

$144.00

$145.00

--------

$92.00

$66.00

--------

$115.00

$114.00

$149.00

$196.00

$169.00

$202.00

$585.00

$140.00

--------

--------

--------

10

10

10

90

10

10

90

90

$228.00

$189.00

$297.00

--------

$165.00

$145.00

$199.00

$270.00

90

YYY

0

--------

BR

$218.00

ZZZ $141.00

90 $788.00

90

90

$755.00

$550.00

90 $1,663.00

90 $2,512.00

$802.00

$1,617.00

$2,669.00

$3,094.00

$3,209.00

$3,611.00

$5,296.00

$5,373.00

$5,837.00

$1,103.00

$906.00

$416.00

$1,594.00

$1,353.00

$1,356.00

$341.00

$362.00

$323.00

$193.00

$851.00

$315.00

$271.00

$325.00

$317.00

$248.00

$362.00

$181.00

$206.00

$958.00

$241.00

$698.00

$1,544.00

$3,156.00

$625.00

$377.00

$744.00

$289.00

$325.00

$306.00

$436.00

$445.00

$564.00

--------

$504.00

$157.00

$1,798.00

$1,707.00

$1,257.00

$3,496.00

$5,174.00

$861.00

$1,708.00

$2,815.00

$3,263.00

$3,445.00

$3,851.00

$5,686.00

$5,662.00

$6,150.00

$1,166.00

$973.00

$441.00

$1,684.00

$1,431.00

$1,435.00

$364.00

$387.00

$344.00

$203.00

$912.00

$337.00

$286.00

$348.00

$339.00

$264.00

$388.00

$193.00

$220.00

$1,018.00

$255.00

$745.00

$1,635.00

$3,346.00

$667.00

$403.00

$795.00

$308.00

$346.00

$326.00

$466.00

$475.00

$603.00

--------

$536.00

$169.00

$1,926.00

$1,826.00

$1,347.00

$3,750.00

$5,552.00

$934.00

$1,803.00

$2,981.00

$3,458.00

$3,769.00

$4,169.00

$6,249.00

$6,015.00

$6,535.00

$1,238.00

$1,058.00

$458.00

$1,781.00

$1,521.00

$1,524.00

$375.00

$401.00

$354.00

$208.00

$921.00

$346.00

$294.00

$358.00

$350.00

$273.00

$401.00

$200.00

$231.00

$1,085.00

$269.00

$798.00

$1,740.00

$3,585.00

$679.00

$418.00

$814.00

$317.00

$361.00

$339.00

$484.00

$494.00

$650.00

--------

$544.00

$186.00

$2,100.00

$1,986.00

$1,467.00

$4,115.00

$6,115.00

$802.00

$1,617.00

$2,669.00

$3,094.00

$3,209.00

$3,611.00

$5,296.00

$5,373.00

$5,837.00

$1,103.00

$906.00

$329.00

$1,594.00

$1,353.00

$1,356.00

$199.00

$196.00

$207.00

$135.00

$97.00

$112.00

$183.00

$120.00

$120.00

$120.00

$139.00

$95.00

$137.00

$958.00

$241.00

$698.00

$1,544.00

$3,156.00

$191.00

$198.00

$268.00

$210.00

$215.00

$192.00

$324.00

$325.00

$564.00

--------

$150.00

$157.00

$1,798.00

$1,707.00

$1,257.00

$3,496.00

$5,174.00

$861.00

$1,708.00

$2,815.00

$3,263.00

$3,445.00

$3,851.00

$5,686.00

$5,662.00

$6,150.00

$1,166.00

$973.00

$348.00

$1,684.00

$1,431.00

$1,435.00

$211.00

$208.00

$219.00

$141.00

$103.00

$119.00

$192.00

$127.00

$128.00

$127.00

$148.00

$101.00

$146.00

$1,018.00

$255.00

$745.00

$1,635.00

$3,346.00

$202.00

$211.00

$285.00

$223.00

$227.00

$203.00

$346.00

$347.00

$603.00

--------

$157.00

$169.00

$1,926.00

$1,826.00

$1,347.00

$3,750.00

$5,552.00

$934.00

$1,803.00

$2,981.00

$3,458.00

$3,769.00

$4,169.00

$6,249.00

$6,015.00

$6,535.00

$1,238.00

$1,058.00

$364.00

$1,781.00

$1,521.00

$1,524.00

$222.00

$222.00

$229.00

$146.00

$110.00

$127.00

$200.00

$137.00

$138.00

$136.00

$161.00

$107.00

$157.00

$1,085.00

$269.00

$798.00

$1,740.00

$3,585.00

$212.00

$226.00

$303.00

$232.00

$242.00

$216.00

$363.00

$366.00

$650.00

--------

$164.00

$186.00

$2,100.00

$1,986.00

$1,467.00

$4,115.00

$6,115.00


Part B, 237



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

47490

47531

47532

47533

47534

47535

47536

47537

47538

47539

47382

47383

47399

47400

47420

47425

47460

47480

47125

47130

47135

47146

47147

47300

47350

47360

47361

47362

47370

47371

47379

47380

47381

47554

47555

47556

47562

47563

47564

47570

47579

47600

47540

47541

47542

47543

47544

47550

47552

47553

90 $2,293.00

90 $2,482.00

90 $6,164.00

0 --------

0

90

90

--------

$778.00

$942.00

90 $1,305.00

90 $2,129.00

90

90

90

$849.00

$943.00

$889.00

YYY BR

90 $1,107.00

90 $1,094.00

0

0

0

0

0

10

0

0

0

0

10

10

$660.00

--------

YYY BR

90 $1,435.00

90 $1,222.00

90 $1,275.00

90 $1,039.00

90 $755.00

$467.00

--------

--------

--------

--------

--------

--------

--------

--------

--------

0

0

ZZZ

--------

--------

--------

ZZZ

ZZZ

--------

--------

ZZZ $209.00

0 $364.00

0 $342.00

0

0

0

$594.00

$383.00

$425.00

90

90

$837.00

$900.00

90 $1,069.00

90 $961.00

YYY

90

BR

$868.00

$6,919.00

$10,361.00

--------

$3,229.00

$2,010.00

$2,028.00

$1,875.00

$1,301.00

$479.00

$516.00

$1,138.00

$1,855.00

$2,288.00

$1,532.00

$1,127.00

$560.00

$6,184.00

$6,765.00

$4,622.00

$4,966.00

$8,061.00

$499.00

$580.00

$1,691.00

$2,049.00

$2,787.00

$4,538.00

$2,172.00

$1,870.00

$1,647.00

--------

$2,161.00

$1,949.00

$7,038.00

$1,637.00

$723.00

$1,833.00

$1,135.00

$251.00

$457.00

$452.00

$708.00

$541.00

$615.00

$982.00

$1,068.00

$1,666.00

$1,145.00

--------

$1,598.00

$7,388.00

$11,103.00

--------

$3,462.00

$2,156.00

$2,175.00

$2,010.00

$1,395.00

$503.00

$550.00

$1,212.00

$1,979.00

$2,440.00

$1,636.00

$1,202.00

$598.00

$6,620.00

$7,237.00

$4,958.00

$5,327.00

$8,647.00

$536.00

$622.00

$1,813.00

$2,196.00

$2,986.00

$4,859.00

$2,331.00

$2,006.00

$1,719.00

--------

$2,314.00

$2,033.00

$7,526.00

$1,745.00

$775.00

$1,967.00

$1,211.00

$269.00

$477.00

$470.00

$746.00

$563.00

$640.00

$1,053.00

$1,146.00

$1,787.00

$1,228.00

--------

$1,713.00

$7,459.00

$11,184.00

--------

$3,798.00

$2,361.00

$2,382.00

$2,198.00

$1,516.00

$520.00

$558.00

$1,232.00

$2,011.00

$2,482.00

$1,663.00

$1,216.00

$608.00

$6,661.00

$7,287.00

$5,452.00

$5,861.00

$9,486.00

$593.00

$687.00

$1,980.00

$2,401.00

$3,269.00

$5,326.00

$2,554.00

$2,199.00

$1,791.00

--------

$2,532.00

$2,118.00

$7,583.00

$1,772.00

$800.00

$2,000.00

$1,235.00

$297.00

$499.00

$492.00

$797.00

$589.00

$670.00

$1,151.00

$1,253.00

$1,955.00

$1,344.00

--------

$1,875.00

$1,130.00

$725.00

--------

$3,229.00

$2,010.00

$2,028.00

$1,875.00

$1,301.00

$479.00

$140.00

$318.00

$452.00

$600.00

$346.00

$216.00

$147.00

$483.00

$653.00

$4,622.00

$4,966.00

$8,061.00

$499.00

$580.00

$1,691.00

$2,049.00

$2,787.00

$4,538.00

$2,172.00

$1,870.00

$1,647.00

--------

$2,161.00

$1,949.00

$780.00

$417.00

$202.00

$254.00

$319.00

$251.00

$457.00

$452.00

$708.00

$541.00

$615.00

$982.00

$1,068.00

$1,666.00

$1,145.00

--------

$1,598.00

$1,177.00

$765.00

--------

$3,462.00

$2,156.00

$2,175.00

$2,010.00

$1,395.00

$503.00

$147.00

$332.00

$474.00

$628.00

$363.00

$226.00

$155.00

$503.00

$680.00

$4,958.00

$5,327.00

$8,647.00

$536.00

$622.00

$1,813.00

$2,196.00

$2,986.00

$4,859.00

$2,331.00

$2,006.00

$1,719.00

--------

$2,314.00

$2,033.00

$812.00

$435.00

$217.00

$272.00

$335.00

$269.00

$477.00

$470.00

$746.00

$563.00

$640.00

$1,053.00

$1,146.00

$1,787.00

$1,228.00

--------

$1,713.00

$1,231.00

$816.00

--------

$3,798.00

$2,361.00

$2,382.00

$2,198.00

$1,516.00

$520.00

$153.00

$350.00

$502.00

$665.00

$386.00

$236.00

$164.00

$526.00

$711.00

$5,452.00

$5,861.00

$9,486.00

$593.00

$687.00

$1,980.00

$2,401.00

$3,269.00

$5,326.00

$2,554.00

$2,199.00

$1,791.00

--------

$2,532.00

$2,118.00

$849.00

$458.00

$240.00

$301.00

$357.00

$297.00

$499.00

$492.00

$797.00

$589.00

$670.00

$1,151.00

$1,253.00

$1,955.00

$1,344.00

--------

$1,875.00


Part B, 238



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

48001

48020

48100

48102

48105

48120

48140

48145

48146

48148

47780

47785

47800

47801

47802

47900

47999

48000

47605

47610

47612

47620

47700

47701

47711

47712

47715

47720

47721

47740

47741

47760

47765

48510

48520

48540

48545

48547

48548

48552

48554

48556

48150

48152

48153

48154

48155

48160

48400

48500

90 $935.00

90 $1,164.00

90 $1,276.00

90 $1,295.00

90 $1,111.00

90 $1,913.00

90 $1,442.00

90 $1,793.00

90 $1,157.00

90 $1,040.00

90 $1,248.00

90 $1,188.00

90 $1,425.00

90 $1,568.00

90 $1,624.00

90 $1,635.00

90 $1,871.00

90 $1,485.00

90 $906.00

90 $1,352.00

90 $1,331.00

YYY BR

90 $1,053.00

90 $1,305.00

90 $983.00

90

10

90

$779.00

$341.00

--------

90 $1,083.00

90 $1,546.00

90 $1,661.00

90 $1,830.00

90 $1,149.00

90 $3,101.00

90 $2,888.00

90 $3,099.00

90 $2,893.00

90 $1,855.00

0 BR

ZZZ $100.00

90 $1,012.00

90 $938.00

90 $1,103.00

90 $1,350.00

90 $1,170.00

90 $1,630.00

90

0

--------

--------

90 $2,365.00

90 $1,117.00

$3,715.00

$4,887.00

$2,361.00

$1,469.00

$2,258.00

$2,051.00

--------

$2,807.00

$3,439.00

$1,753.00

$1,325.00

$749.00

$4,286.00

$1,660.00

$2,346.00

$2,441.00

$2,812.00

$1,865.00

$1,683.00

$1,882.00

$1,906.00

$2,066.00

$1,549.00

$2,529.00

$2,331.00

$2,984.00

$1,996.00

$1,720.00

$2,033.00

$1,946.00

$2,201.00

$3,394.00

$4,562.00

$4,679.00

$4,313.00

$4,653.00

$4,367.00

$2,725.00

--------

$156.00

$1,674.00

$1,625.00

$1,638.00

$1,951.00

$1,998.00

$2,688.00

$2,497.00

$354.00

$3,797.00

$1,890.00

$3,984.00

$5,243.00

$2,533.00

$1,549.00

$2,418.00

$2,200.00

--------

$3,008.00

$3,684.00

$1,880.00

$1,420.00

$793.00

$4,595.00

$1,780.00

$2,516.00

$2,619.00

$3,017.00

$2,001.00

$1,806.00

$2,018.00

$2,044.00

$2,217.00

$1,659.00

$2,697.00

$2,500.00

$3,199.00

$2,142.00

$1,846.00

$2,182.00

$2,085.00

$2,360.00

$3,642.00

$4,893.00

$5,021.00

$4,626.00

$4,991.00

$4,689.00

$2,926.00

--------

$164.00

$1,787.00

$1,742.00

$1,757.00

$2,093.00

$2,142.00

$2,883.00

$2,678.00

$379.00

$4,071.00

$2,027.00

$4,376.00

$5,768.00

$2,777.00

$1,643.00

$2,640.00

$2,408.00

--------

$3,297.00

$4,044.00

$2,057.00

$1,551.00

$811.00

$5,047.00

$1,949.00

$2,761.00

$2,875.00

$3,303.00

$2,190.00

$1,978.00

$2,213.00

$2,242.00

$2,434.00

$1,806.00

$2,926.00

$2,741.00

$3,507.00

$2,348.00

$2,018.00

$2,392.00

$2,277.00

$2,583.00

$4,002.00

$5,379.00

$5,518.00

$5,079.00

$5,483.00

$5,155.00

$3,207.00

--------

$173.00

$1,934.00

$1,900.00

$1,925.00

$2,297.00

$2,346.00

$3,165.00

$2,938.00

$417.00

$4,421.00

$2,208.00

$3,715.00

$4,887.00

$2,361.00

$1,469.00

$2,258.00

$2,051.00

--------

$2,807.00

$3,439.00

$1,753.00

$1,325.00

$355.00

$4,286.00

$1,660.00

$2,346.00

$2,441.00

$2,812.00

$1,865.00

$1,683.00

$1,882.00

$1,906.00

$2,066.00

$1,549.00

$2,529.00

$2,331.00

$2,984.00

$1,996.00

$1,720.00

$2,033.00

$1,946.00

$2,201.00

$3,394.00

$4,562.00

$4,679.00

$4,313.00

$4,653.00

$4,367.00

$2,725.00

--------

$156.00

$1,674.00

$1,625.00

$1,638.00

$1,951.00

$1,998.00

$2,688.00

$2,497.00

$354.00

$3,797.00

$1,890.00

$3,984.00

$5,243.00

$2,533.00

$1,549.00

$2,418.00

$2,200.00

--------

$3,008.00

$3,684.00

$1,880.00

$1,420.00

$370.00

$4,595.00

$1,780.00

$2,516.00

$2,619.00

$3,017.00

$2,001.00

$1,806.00

$2,018.00

$2,044.00

$2,217.00

$1,659.00

$2,697.00

$2,500.00

$3,199.00

$2,142.00

$1,846.00

$2,182.00

$2,085.00

$2,360.00

$3,642.00

$4,893.00

$5,021.00

$4,626.00

$4,991.00

$4,689.00

$2,926.00

--------

$164.00

$1,787.00

$1,742.00

$1,757.00

$2,093.00

$2,142.00

$2,883.00

$2,678.00

$379.00

$4,071.00

$2,027.00

$4,376.00

$5,768.00

$2,777.00

$1,643.00

$2,640.00

$2,408.00

--------

$3,297.00

$4,044.00

$2,057.00

$1,551.00

$387.00

$5,047.00

$1,949.00

$2,761.00

$2,875.00

$3,303.00

$2,190.00

$1,978.00

$2,213.00

$2,242.00

$2,434.00

$1,806.00

$2,926.00

$2,741.00

$3,507.00

$2,348.00

$2,018.00

$2,392.00

$2,277.00

$2,583.00

$4,002.00

$5,379.00

$5,518.00

$5,079.00

$5,483.00

$5,155.00

$3,207.00

--------

$173.00

$1,934.00

$1,900.00

$1,925.00

$2,297.00

$2,346.00

$3,165.00

$2,938.00

$417.00

$4,421.00

$2,208.00


Part B, 239



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

49323

49324

49325

49326

49327

49329

49400

49402

49405

49406

49205

49215

49220

49250

49255

49320

49321

49322

48999

49000

49002

49010

49020

49040

49060

49062

49082

49083

49084

49180

49185

49203

49204

49424

49425

49426

49427

49428

49429

49435

49436

49440

49407

49411

49412

49418

49419

49421

49422

49423

0

90

90

0

10

10

ZZZ

10

10

0

0

ZZZ

0

90

0

10

0

90

0

0

0

0

0

90

90

YYY

90

90

90

90

90

90

90

10

10

ZZZ

ZZZ

YYY

0

90

0

0

90 --------

90 $1,551.00

90 $1,182.00

90 $622.00

90 $591.00

10

10

10

$415.00

$443.00

$460.00

$712.00

--------

--------

--------

--------

BR

$127.00

--------

--------

--------

BR

$862.00

$784.00

$915.00

$910.00

$763.00

$827.00

$892.00

--------

--------

--------

$212.00

--------

--------

--------

--------

--------

--------

--------

$405.00

$452.00

$468.00

$106.00

$54.00

$914.00

$725.00

$48.00

$184.00

$522.00

--------

--------

--------

$2,632.00

$3,315.00

$1,302.00

$872.00

$1,176.00

$482.00

$512.00

$544.00

$943.00

$583.00

$622.00

$287.00

$198.00

--------

$195.00

$1,281.00

$1,214.00

$1,214.00

--------

$1,151.00

$1,567.00

$1,397.00

$2,382.00

$1,494.00

$1,645.00

$1,097.00

$268.00

$410.00

$163.00

$230.00

$1,369.00

$1,787.00

$2,289.00

$1,018.00

$764.00

$126.00

$1,984.00

$659.00

$348.00

$569.00

$758.00

$203.00

$1,090.00

$914.00

$68.00

$645.00

$687.00

$183.00

$277.00

$1,441.00

$2,817.00

$3,542.00

$1,367.00

$934.00

$1,258.00

$514.00

$548.00

$579.00

$1,006.00

$624.00

$666.00

$308.00

$213.00

--------

$206.00

$1,372.00

$1,292.00

$1,293.00

--------

$1,232.00

$1,678.00

$1,494.00

$2,550.00

$1,600.00

$1,759.00

$1,173.00

$286.00

$435.00

$174.00

$243.00

$1,464.00

$1,910.00

$2,447.00

$1,083.00

$811.00

$135.00

$2,120.00

$703.00

$373.00

$609.00

$810.00

$217.00

$1,162.00

$976.00

$72.00

$693.00

$737.00

$196.00

$297.00

$1,537.00

$3,080.00

$3,860.00

$1,438.00

$1,015.00

$1,366.00

$555.00

$594.00

$624.00

$1,087.00

$680.00

$727.00

$340.00

$236.00

--------

$214.00

$1,500.00

$1,310.00

$1,310.00

--------

$1,344.00

$1,836.00

$1,631.00

$2,788.00

$1,747.00

$1,920.00

$1,277.00

$292.00

$443.00

$191.00

$249.00

$1,477.00

$2,081.00

$2,670.00

$1,104.00

$826.00

$149.00

$2,143.00

$758.00

$410.00

$664.00

$817.00

$220.00

$1,259.00

$1,064.00

$77.00

$758.00

$808.00

$217.00

$322.00

$1,556.00

$2,632.00

$3,315.00

$1,302.00

$872.00

$1,176.00

$482.00

$512.00

$544.00

$943.00

$583.00

$622.00

$287.00

$198.00

--------

$139.00

$1,281.00

$311.00

$311.00

--------

$1,151.00

$1,567.00

$1,397.00

$2,382.00

$1,494.00

$1,645.00

$1,097.00

$109.00

$159.00

$163.00

$125.00

$181.00

$1,787.00

$2,289.00

$335.00

$289.00

$126.00

$321.00

$659.00

$348.00

$569.00

$106.00

$56.00

$1,090.00

$914.00

$68.00

$645.00

$687.00

$183.00

$277.00

$325.00

$2,817.00

$3,542.00

$1,367.00

$934.00

$1,258.00

$514.00

$548.00

$579.00

$1,006.00

$624.00

$666.00

$308.00

$213.00

--------

$145.00

$1,372.00

$323.00

$323.00

--------

$1,232.00

$1,678.00

$1,494.00

$2,550.00

$1,600.00

$1,759.00

$1,173.00

$115.00

$166.00

$174.00

$131.00

$189.00

$1,910.00

$2,447.00

$350.00

$302.00

$135.00

$336.00

$703.00

$373.00

$609.00

$110.00

$59.00

$1,162.00

$976.00

$72.00

$693.00

$737.00

$196.00

$297.00

$339.00

$3,080.00

$3,860.00

$1,438.00

$1,015.00

$1,366.00

$555.00

$594.00

$624.00

$1,087.00

$680.00

$727.00

$340.00

$236.00

--------

$154.00

$1,500.00

$338.00

$338.00

--------

$1,344.00

$1,836.00

$1,631.00

$2,788.00

$1,747.00

$1,920.00

$1,277.00

$121.00

$173.00

$191.00

$137.00

$198.00

$2,081.00

$2,670.00

$368.00

$315.00

$149.00

$353.00

$758.00

$410.00

$664.00

$115.00

$61.00

$1,259.00

$1,064.00

$77.00

$758.00

$808.00

$217.00

$322.00

$355.00


Part B, 240



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

49570

49572

49585

49587

49590

49600

49605

49606

49610

49611

49553

49555

49557

49560

49561

49565

49566

49568

49441

49442

49446

49450

49451

49452

49460

49465

49505

49507

49520

49521

49525

49540

49550

49659

49900

49904

49905

49906

49999

50010

50020

50040

49650

49651

49652

49653

49654

49655

49656

49657

0

90

90

90

90

90

90

90

10

10

0

0

0

0

0

90

90

90

90

90

$598.00

$621.00

$715.00

$734.00

$856.00

90

90

$754.00

$881.00

ZZZ $339.00

90

90

90

90

90

$411.00

$491.00

$444.00

$501.00

$585.00

90 $774.00

90 $1,648.00

90 $1,416.00

90 $784.00

90 $770.00

--------

--------

--------

--------

--------

--------

--------

--------

$510.00

$636.00

$631.00

$730.00

$584.00

$668.00

$557.00

90

90

90

90

90

90

90

90

$484.00

$621.00

--------

--------

--------

--------

--------

--------

YYY

90

BR

$512.00

90 $1,394.00

ZZZ $454.00

90 BR

YYY

90

BR

$886.00

90 $1,084.00

90 $910.00

$941.00

$891.00

$1,081.00

$1,101.00

$1,392.00

$1,146.00

$1,405.00

$404.00

$617.00

$767.00

$660.00

$706.00

$852.00

$1,042.00

$7,465.00

$1,671.00

$1,029.00

$904.00

$1,627.00

$1,340.00

$1,383.00

$920.00

$1,005.00

$1,244.00

$1,010.00

$225.00

$775.00

$872.00

$943.00

$1,069.00

$853.00

$1,001.00

$857.00

$636.00

$827.00

$1,111.00

$1,387.00

$1,264.00

$1,544.00

$1,375.00

$1,978.00

--------

$1,209.00

$2,114.00

$532.00

--------

--------

$1,086.00

$1,481.00

$1,348.00

$1,009.00

$956.00

$1,160.00

$1,180.00

$1,493.00

$1,228.00

$1,506.00

$433.00

$661.00

$823.00

$707.00

$757.00

$914.00

$1,110.00

$8,014.00

$1,788.00

$1,105.00

$970.00

$1,738.00

$1,429.00

$1,477.00

$984.00

$1,075.00

$1,329.00

$1,082.00

$240.00

$831.00

$935.00

$1,011.00

$1,147.00

$915.00

$1,072.00

$919.00

$682.00

$887.00

$1,192.00

$1,487.00

$1,356.00

$1,656.00

$1,474.00

$2,121.00

--------

$1,295.00

$2,258.00

$568.00

--------

--------

$1,152.00

$1,555.00

$1,413.00

$1,101.00

$1,044.00

$1,268.00

$1,289.00

$1,634.00

$1,341.00

$1,649.00

$478.00

$717.00

$896.00

$768.00

$823.00

$996.00

$1,199.00

$8,845.00

$1,953.00

$1,209.00

$1,060.00

$1,765.00

$1,446.00

$1,492.00

$992.00

$1,085.00

$1,342.00

$1,089.00

$243.00

$904.00

$1,019.00

$1,104.00

$1,254.00

$997.00

$1,169.00

$1,002.00

$741.00

$964.00

$1,302.00

$1,625.00

$1,483.00

$1,812.00

$1,613.00

$2,324.00

--------

$1,405.00

$2,443.00

$622.00

--------

--------

$1,235.00

$1,638.00

$1,487.00

$941.00

$891.00

$1,081.00

$1,101.00

$1,392.00

$1,146.00

$1,405.00

$404.00

$617.00

$767.00

$660.00

$706.00

$852.00

$1,042.00

$7,465.00

$1,671.00

$1,029.00

$904.00

$379.00

$324.00

$239.00

$99.00

$134.00

$206.00

$71.00

$45.00

$775.00

$872.00

$943.00

$1,069.00

$853.00

$1,001.00

$857.00

$636.00

$827.00

$1,111.00

$1,387.00

$1,264.00

$1,544.00

$1,375.00

$1,978.00

--------

$1,209.00

$2,114.00

$532.00

--------

--------

$1,086.00

$1,481.00

$1,348.00

$1,009.00

$956.00

$1,160.00

$1,180.00

$1,493.00

$1,228.00

$1,506.00

$433.00

$661.00

$823.00

$707.00

$757.00

$914.00

$1,110.00

$8,014.00

$1,788.00

$1,105.00

$970.00

$398.00

$338.00

$249.00

$103.00

$140.00

$214.00

$74.00

$47.00

$831.00

$935.00

$1,011.00

$1,147.00

$915.00

$1,072.00

$919.00

$682.00

$887.00

$1,192.00

$1,487.00

$1,356.00

$1,656.00

$1,474.00

$2,121.00

--------

$1,295.00

$2,258.00

$568.00

--------

--------

$1,152.00

$1,555.00

$1,413.00

$1,101.00

$1,044.00

$1,268.00

$1,289.00

$1,634.00

$1,341.00

$1,649.00

$478.00

$717.00

$896.00

$768.00

$823.00

$996.00

$1,199.00

$8,845.00

$1,953.00

$1,209.00

$1,060.00

$422.00

$353.00

$261.00

$108.00

$147.00

$224.00

$78.00

$49.00

$904.00

$1,019.00

$1,104.00

$1,254.00

$997.00

$1,169.00

$1,002.00

$741.00

$964.00

$1,302.00

$1,625.00

$1,483.00

$1,812.00

$1,613.00

$2,324.00

--------

$1,405.00

$2,443.00

$622.00

--------

--------

$1,235.00

$1,638.00

$1,487.00


Part B, 241



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

50320

50327

50328

50329

50340

50360

50365

50370

50380

50382

50225

50230

50234

50236

50240

50250

50280

50290

50045

50060

50065

50070

50075

50080

50081

50100

50120

50125

50130

50135

50200

50205

50220

50396

50400

50405

50430

50431

50432

50433

50434

50435

50384

50385

50386

50387

50389

50390

50391

50395

90 $1,137.00

90 $1,394.00

90 $1,514.00

90 $1,476.00

90 $1,839.00

90 $1,186.00

90 $1,635.00

90 $1,250.00

90 $1,180.00

90 $1,228.00

90 $1,301.00

90 $1,506.00

0

90

$151.00

$807.00

90 $1,316.00

90 $1,554.00

90 $1,695.00

90 $1,671.00

90 $1,873.00

90 $1,679.00

90 --------

90 $1,170.00

90 $1,080.00

90 $1,680.00

0 --------

0

0

--------

--------

90 $1,083.00

90 $2,475.00

90 $2,941.00

90 $1,128.00

90 $1,507.00

0 --------

0

0

0

0

0

0

0

0

--------

--------

--------

--------

--------

$118.00

--------

$203.00

0

0

0

0

0 $101.00

90 $1,441.00

90 $1,802.00

0

0

--------

--------

--------

--------

--------

--------

$1,760.00

$1,872.00

$1,898.00

$2,140.00

$1,930.00

$1,772.00

$1,391.00

$1,307.00

$2,149.00

$327.00

$287.00

$267.00

$1,389.00

$3,617.00

$4,216.00

$1,784.00

$2,958.00

$1,647.00

$1,408.00

$1,666.00

$1,761.00

$1,727.00

$2,124.00

$1,266.00

$1,860.00

$1,554.00

$1,382.00

$1,507.00

$1,503.00

$1,664.00

$852.00

$1,122.00

$1,533.00

$1,316.00

$1,581.00

$1,033.00

$753.00

$411.00

$142.00

$175.00

$261.00

$171.00

$1,690.00

$2,037.00

$724.00

$226.00

$1,171.00

$1,575.00

$1,246.00

$653.00

$1,851.00

$1,964.00

$1,991.00

$2,244.00

$2,024.00

$1,857.00

$1,462.00

$1,371.00

$2,298.00

$350.00

$307.00

$285.00

$1,488.00

$3,875.00

$4,509.00

$1,909.00

$3,175.00

$1,755.00

$1,486.00

$1,748.00

$1,846.00

$1,810.00

$2,226.00

$1,328.00

$1,949.00

$1,646.00

$1,449.00

$1,589.00

$1,576.00

$1,750.00

$908.00

$1,200.00

$1,616.00

$1,401.00

$1,687.00

$1,101.00

$804.00

$438.00

$147.00

$184.00

$273.00

$179.00

$1,773.00

$2,136.00

$770.00

$240.00

$1,247.00

$1,678.00

$1,328.00

$696.00

$1,961.00

$2,075.00

$2,101.00

$2,366.00

$2,134.00

$1,954.00

$1,543.00

$1,442.00

$2,489.00

$385.00

$338.00

$311.00

$1,615.00

$4,235.00

$4,905.00

$2,076.00

$3,463.00

$1,778.00

$1,579.00

$1,843.00

$1,944.00

$1,906.00

$2,345.00

$1,397.00

$2,053.00

$1,757.00

$1,525.00

$1,685.00

$1,658.00

$1,854.00

$920.00

$1,307.00

$1,718.00

$1,422.00

$1,709.00

$1,118.00

$812.00

$443.00

$154.00

$192.00

$285.00

$186.00

$1,871.00

$2,251.00

$783.00

$244.00

$1,264.00

$1,700.00

$1,345.00

$704.00

$1,760.00

$1,872.00

$1,898.00

$2,140.00

$1,930.00

$1,772.00

$1,391.00

$1,307.00

$2,149.00

$327.00

$287.00

$267.00

$1,389.00

$3,617.00

$4,216.00

$1,784.00

$2,958.00

$397.00

$1,408.00

$1,666.00

$1,761.00

$1,727.00

$2,124.00

$1,266.00

$1,860.00

$1,554.00

$1,382.00

$1,507.00

$1,503.00

$1,664.00

$208.00

$1,122.00

$1,533.00

$361.00

$340.00

$258.00

$143.00

$80.00

$142.00

$143.00

$261.00

$171.00

$1,690.00

$2,037.00

$244.00

$96.00

$323.00

$399.00

$306.00

$148.00

$1,851.00

$1,964.00

$1,991.00

$2,244.00

$2,024.00

$1,857.00

$1,462.00

$1,371.00

$2,298.00

$350.00

$307.00

$285.00

$1,488.00

$3,875.00

$4,509.00

$1,909.00

$3,175.00

$414.00

$1,486.00

$1,748.00

$1,846.00

$1,810.00

$2,226.00

$1,328.00

$1,949.00

$1,646.00

$1,449.00

$1,589.00

$1,576.00

$1,750.00

$217.00

$1,200.00

$1,616.00

$376.00

$355.00

$271.00

$148.00

$83.00

$147.00

$150.00

$273.00

$179.00

$1,773.00

$2,136.00

$255.00

$101.00

$337.00

$416.00

$319.00

$155.00

$1,961.00

$2,075.00

$2,101.00

$2,366.00

$2,134.00

$1,954.00

$1,543.00

$1,442.00

$2,489.00

$385.00

$338.00

$311.00

$1,615.00

$4,235.00

$4,905.00

$2,076.00

$3,463.00

$433.00

$1,579.00

$1,843.00

$1,944.00

$1,906.00

$2,345.00

$1,397.00

$2,053.00

$1,757.00

$1,525.00

$1,685.00

$1,658.00

$1,854.00

$227.00

$1,307.00

$1,718.00

$394.00

$373.00

$285.00

$155.00

$87.00

$154.00

$157.00

$285.00

$186.00

$1,871.00

$2,251.00

$266.00

$105.00

$351.00

$434.00

$333.00

$161.00


Part B, 242



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

50575

50576

50580

50590

50592

50593

50600

50605

50606

50610

50553

50555

50557

50561

50562

50570

50572

50574

50500

50520

50525

50526

50540

50541

50542

50543

50544

50545

50546

50547

50548

50549

50551

50693

50694

50695

50700

50705

50706

50715

50722

50725

50620

50630

50650

50660

50684

50686

50688

50690

90 $1,471.00

90 $1,281.00

90 $1,644.00

90 $1,639.00

90 $1,468.00

90 $1,037.00

90 $1,093.00

90 $1,374.00

90 $1,428.00

90 $1,273.00

90 $1,325.00

90 $1,702.00

90 $1,555.00

YYY BR

0 $411.00

0

0

0

0

0

0

0

90

$447.00

$668.00

$676.00

$755.00

$580.00

$549.00

$728.00

$762.00

0

0

0

90

10

$991.00

$801.00

$726.00

$980.00

--------

10 --------

90 $1,150.00

90 $1,054.00

ZZZ --------

90 $1,209.00

90 $1,152.00

90 $1,170.00

90 $1,297.00

90 $1,426.00

0 $74.00

0

10

0

$109.00

$89.00

$85.00

0

0

0

--------

--------

--------

90 $1,192.00

ZZZ --------

ZZZ --------

90 $1,397.00

90 $1,211.00

90 $1,371.00

$550.00

$592.00

$604.00

$686.00

$848.00

$720.00

$779.00

$828.00

$1,046.00

$828.00

$892.00

$1,027.00

$3,505.00

$6,378.00

$1,378.00

$1,457.00

$735.00

$1,428.00

$1,905.00

$1,676.00

$2,113.00

$2,174.00

$1,686.00

$1,340.00

$1,700.00

$2,167.00

$1,816.00

$1,955.00

$1,757.00

$2,392.00

$1,967.00

--------

$518.00

$1,322.00

$1,298.00

$1,509.00

$1,677.00

$148.00

$202.00

$115.00

$140.00

$1,463.00

$1,615.00

$1,970.00

$1,358.00

$2,348.00

$1,060.00

$1,802.00

$1,487.00

$1,652.00

$578.00

$622.00

$636.00

$722.00

$889.00

$754.00

$815.00

$867.00

$1,095.00

$867.00

$934.00

$1,083.00

$3,745.00

$6,822.00

$1,448.00

$1,550.00

$783.00

$1,503.00

$2,041.00

$1,789.00

$2,247.00

$2,291.00

$1,774.00

$1,406.00

$1,783.00

$2,272.00

$1,902.00

$2,050.00

$1,845.00

$2,554.00

$2,062.00

--------

$545.00

$1,388.00

$1,362.00

$1,584.00

$1,761.00

$158.00

$214.00

$121.00

$147.00

$1,560.00

$1,720.00

$2,098.00

$1,426.00

$2,512.00

$1,129.00

$1,916.00

$1,562.00

$1,740.00

$603.00

$651.00

$665.00

$755.00

$937.00

$795.00

$861.00

$915.00

$1,156.00

$917.00

$987.00

$1,126.00

$3,779.00

$6,872.00

$1,531.00

$1,675.00

$798.00

$1,593.00

$2,233.00

$1,942.00

$2,427.00

$2,432.00

$1,884.00

$1,481.00

$1,878.00

$2,392.00

$2,004.00

$2,162.00

$1,950.00

$2,771.00

$2,175.00

--------

$569.00

$1,463.00

$1,434.00

$1,669.00

$1,859.00

$161.00

$221.00

$125.00

$152.00

$1,579.00

$1,743.00

$2,127.00

$1,504.00

$2,537.00

$1,146.00

$2,068.00

$1,646.00

$1,849.00

$455.00

$497.00

$507.00

$578.00

$848.00

$720.00

$779.00

$828.00

$1,046.00

$828.00

$892.00

$824.00

$528.00

$700.00

$1,378.00

$1,457.00

$232.00

$1,428.00

$1,905.00

$1,676.00

$2,113.00

$2,174.00

$1,686.00

$1,340.00

$1,700.00

$2,167.00

$1,816.00

$1,955.00

$1,757.00

$2,392.00

$1,967.00

--------

$431.00

$1,322.00

$1,298.00

$1,509.00

$1,677.00

$73.00

$128.00

$115.00

$102.00

$320.00

$413.00

$525.00

$1,358.00

$297.00

$275.00

$1,802.00

$1,487.00

$1,652.00

$476.00

$521.00

$531.00

$606.00

$889.00

$754.00

$815.00

$867.00

$1,095.00

$867.00

$934.00

$865.00

$551.00

$731.00

$1,448.00

$1,550.00

$243.00

$1,503.00

$2,041.00

$1,789.00

$2,247.00

$2,291.00

$1,774.00

$1,406.00

$1,783.00

$2,272.00

$1,902.00

$2,050.00

$1,845.00

$2,554.00

$2,062.00

--------

$451.00

$1,388.00

$1,362.00

$1,584.00

$1,761.00

$76.00

$135.00

$121.00

$107.00

$333.00

$431.00

$547.00

$1,426.00

$312.00

$287.00

$1,916.00

$1,562.00

$1,740.00

$501.00

$549.00

$560.00

$639.00

$937.00

$795.00

$861.00

$915.00

$1,156.00

$917.00

$987.00

$908.00

$575.00

$763.00

$1,531.00

$1,675.00

$256.00

$1,593.00

$2,233.00

$1,942.00

$2,427.00

$2,432.00

$1,884.00

$1,481.00

$1,878.00

$2,392.00

$2,004.00

$2,162.00

$1,950.00

$2,771.00

$2,175.00

--------

$476.00

$1,463.00

$1,434.00

$1,669.00

$1,859.00

$80.00

$141.00

$125.00

$111.00

$348.00

$450.00

$571.00

$1,504.00

$330.00

$301.00

$2,068.00

$1,646.00

$1,849.00


Part B, 243



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

50945

50947

50948

50949

50951

50953

50955

50957

50961

50970

50830

50840

50845

50860

50900

50920

50930

50940

50727

50728

50740

50750

50760

50770

50780

50782

50783

50785

50800

50810

50815

50820

50825

51050

51060

51065

51080

51100

51101

51102

51500

51520

50972

50974

50976

50980

51020

51030

51040

51045

90

90

90

90

0

0

0

90

90

0

90

90

90

90

0

0

0

90

90

$640.00

$924.00

90 $1,386.00

90 $1,457.00

90 $1,389.00

90 $1,485.00

90 $1,391.00

90 $1,465.00

90 $1,515.00

90 $1,548.00

90 $1,226.00

90 $1,527.00

90 $1,643.00

90 $1,729.00

90 $2,351.00

90 $2,292.00

90 $1,493.00

90 $1,513.00

90 $1,163.00

90 $1,043.00

90 $1,075.00

90 $1,380.00

90 $1,107.00

0

0

0

0

0

90 $1,096.00

90 $1,384.00

90 $1,265.00

YYY BR

0 $414.00

$461.00

$546.00

$546.00

$510.00

$510.00

$408.00

$661.00

$641.00

$443.00

$587.00

$538.00

$439.00

$548.00

$596.00

$768.00

$704.00

$510.00

--------

--------

--------

$775.00

$764.00

$2,646.00

$1,795.00

$1,820.00

$1,376.00

$1,259.00

$1,283.00

$1,746.00

$1,289.00

$1,417.00

$2,029.00

$1,863.00

--------

$541.00

$571.00

$612.00

$618.00

$557.00

$545.00

$736.00

$1,018.00

$1,834.00

$1,680.00

$1,659.00

$1,680.00

$1,621.00

$1,572.00

$1,653.00

$1,771.00

$1,346.00

$1,842.00

$1,784.00

$1,920.00

$2,420.00

$531.00

$693.00

$681.00

$518.00

$680.00

$688.00

$417.00

$716.00

$684.00

$846.00

$839.00

$594.00

$87.00

$174.00

$321.00

$928.00

$870.00

$2,776.00

$1,883.00

$1,909.00

$1,442.00

$1,328.00

$1,344.00

$1,862.00

$1,351.00

$1,484.00

$2,128.00

$1,953.00

--------

$569.00

$600.00

$644.00

$650.00

$585.00

$570.00

$774.00

$1,069.00

$1,969.00

$1,761.00

$1,752.00

$1,763.00

$1,707.00

$1,678.00

$1,735.00

$1,859.00

$1,414.00

$1,938.00

$1,872.00

$2,016.00

$2,539.00

$558.00

$725.00

$713.00

$543.00

$714.00

$722.00

$439.00

$757.00

$719.00

$888.00

$881.00

$624.00

$92.00

$185.00

$339.00

$975.00

$915.00

$2,932.00

$1,984.00

$2,009.00

$1,517.00

$1,411.00

$1,410.00

$2,021.00

$1,418.00

$1,562.00

$2,246.00

$2,059.00

--------

$594.00

$627.00

$674.00

$679.00

$612.00

$602.00

$815.00

$1,123.00

$2,161.00

$1,854.00

$1,869.00

$1,860.00

$1,810.00

$1,840.00

$1,833.00

$1,963.00

$1,491.00

$2,051.00

$1,972.00

$2,130.00

$2,682.00

$592.00

$766.00

$752.00

$572.00

$749.00

$755.00

$460.00

$804.00

$754.00

$931.00

$925.00

$655.00

$95.00

$190.00

$351.00

$1,026.00

$964.00

$2,646.00

$1,795.00

$1,820.00

$1,376.00

$1,259.00

$1,283.00

$1,746.00

$1,289.00

$1,417.00

$2,029.00

$1,863.00

--------

$449.00

$475.00

$516.00

$519.00

$464.00

$545.00

$736.00

$1,018.00

$1,834.00

$1,680.00

$1,659.00

$1,680.00

$1,621.00

$1,572.00

$1,653.00

$1,771.00

$1,346.00

$1,842.00

$1,784.00

$1,920.00

$2,420.00

$531.00

$693.00

$681.00

$518.00

$680.00

$688.00

$417.00

$716.00

$684.00

$846.00

$839.00

$594.00

$58.00

$76.00

$211.00

$928.00

$870.00

$2,776.00

$1,883.00

$1,909.00

$1,442.00

$1,328.00

$1,344.00

$1,862.00

$1,351.00

$1,484.00

$2,128.00

$1,953.00

--------

$470.00

$498.00

$540.00

$543.00

$486.00

$570.00

$774.00

$1,069.00

$1,969.00

$1,761.00

$1,752.00

$1,763.00

$1,707.00

$1,678.00

$1,735.00

$1,859.00

$1,414.00

$1,938.00

$1,872.00

$2,016.00

$2,539.00

$558.00

$725.00

$713.00

$543.00

$714.00

$722.00

$439.00

$757.00

$719.00

$888.00

$881.00

$624.00

$60.00

$80.00

$221.00

$975.00

$915.00

$2,932.00

$1,984.00

$2,009.00

$1,517.00

$1,411.00

$1,410.00

$2,021.00

$1,418.00

$1,562.00

$2,246.00

$2,059.00

--------

$496.00

$525.00

$570.00

$573.00

$513.00

$602.00

$815.00

$1,123.00

$2,161.00

$1,854.00

$1,869.00

$1,860.00

$1,810.00

$1,840.00

$1,833.00

$1,963.00

$1,491.00

$2,051.00

$1,972.00

$2,130.00

$2,682.00

$592.00

$766.00

$752.00

$572.00

$749.00

$755.00

$460.00

$804.00

$754.00

$931.00

$925.00

$655.00

$64.00

$85.00

$233.00

$1,026.00

$964.00


Part B, 244



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

51605

51610

51700

51701

51702

51703

51705

51710

51715

51720

51725

51725-26

51725-TC

51726

51726-26

51726-TC

51727

51727-26

51525

51530

51535

51550

51555

51565

51570

51575

51580

51585

51590

51595

51596

51597

51600

51727-TC

51728

51728-26

51728-TC

51729

51729-26

51729-TC

51736

51736-26

51736-TC

51741

51741-26

51741-TC

51784

51784-26

51784-TC

51785

0

0

0

0

0

0

0

0

0

0

0

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 $1,069.00

90 $957.00

90 $932.00

90 $1,171.00

90 $1,514.00

90 $1,624.00

90 $1,762.00

90 $2,284.00

90 $2,252.00

90 $2,601.00

90 $2,441.00

90 $2,900.00

90 $3,063.00

90 $2,914.00

0 $54.00

$83.00

$45.00

$29.00

$58.00

$92.00

$128.00

$37.00

$119.00

$322.00

$140.00

$116.00

--------

--------

$136.00

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

$47.00

--------

--------

$81.00

--------

--------

$119.00

--------

--------

$52.00

$55.00

$150.00

$117.00

$77.00

$98.00

$183.00

$128.00

$181.00

$413.00

$155.00

$261.00

$111.00

$150.00

$364.00

$124.00

$240.00

$432.00

$155.00

$1,251.00

$1,165.00

$1,133.00

$1,409.00

$1,853.00

$1,899.00

$2,158.00

$2,661.00

$2,764.00

$3,077.00

$2,826.00

$3,195.00

$3,433.00

$3,359.00

$254.00

$277.00

$435.00

$152.00

$284.00

$472.00

$183.00

$288.00

$22.00

$12.00

$10.00

$22.00

$12.00

$10.00

$268.00

$111.00

$156.00

$370.00

$58.00

$158.00

$124.00

$81.00

$104.00

$193.00

$135.00

$192.00

$436.00

$163.00

$276.00

$115.00

$161.00

$387.00

$129.00

$258.00

$459.00

$162.00

$1,313.00

$1,230.00

$1,189.00

$1,484.00

$1,948.00

$1,995.00

$2,264.00

$2,789.00

$2,896.00

$3,225.00

$2,963.00

$3,348.00

$3,597.00

$3,525.00

$271.00

$297.00

$462.00

$158.00

$305.00

$500.00

$191.00

$309.00

$23.00

$12.00

$11.00

$24.00

$12.00

$11.00

$284.00

$116.00

$168.00

$397.00

$61.00

$162.00

$128.00

$84.00

$107.00

$200.00

$139.00

$198.00

$453.00

$170.00

$282.00

$120.00

$162.00

$394.00

$134.00

$260.00

$467.00

$169.00

$1,383.00

$1,308.00

$1,250.00

$1,572.00

$2,061.00

$2,109.00

$2,391.00

$2,941.00

$3,052.00

$3,401.00

$3,128.00

$3,531.00

$3,793.00

$3,727.00

$275.00

$299.00

$471.00

$164.00

$306.00

$510.00

$199.00

$311.00

$24.00

$13.00

$11.00

$24.00

$13.00

$12.00

$290.00

$121.00

$169.00

$413.00

$55.00

$93.00

$66.00

$41.00

$44.00

$118.00

$75.00

$116.00

$292.00

$117.00

$261.00

$111.00

$150.00

$364.00

$124.00

$240.00

$432.00

$155.00

$1,251.00

$1,165.00

$1,133.00

$1,409.00

$1,853.00

$1,899.00

$2,158.00

$2,661.00

$2,764.00

$3,077.00

$2,826.00

$3,195.00

$3,433.00

$3,359.00

$65.00

$277.00

$435.00

$152.00

$284.00

$472.00

$183.00

$288.00

$22.00

$12.00

$10.00

$22.00

$12.00

$10.00

$268.00

$111.00

$156.00

$370.00

$58.00

$97.00

$69.00

$43.00

$46.00

$124.00

$79.00

$122.00

$306.00

$122.00

$276.00

$115.00

$161.00

$387.00

$129.00

$258.00

$459.00

$162.00

$1,313.00

$1,230.00

$1,189.00

$1,484.00

$1,948.00

$1,995.00

$2,264.00

$2,789.00

$2,896.00

$3,225.00

$2,963.00

$3,348.00

$3,597.00

$3,525.00

$68.00

$297.00

$462.00

$158.00

$305.00

$500.00

$191.00

$309.00

$23.00

$12.00

$11.00

$24.00

$12.00

$11.00

$284.00

$116.00

$168.00

$397.00

$61.00

$101.00

$73.00

$45.00

$49.00

$130.00

$83.00

$128.00

$322.00

$128.00

$282.00

$120.00

$162.00

$394.00

$134.00

$260.00

$467.00

$169.00

$1,383.00

$1,308.00

$1,250.00

$1,572.00

$2,061.00

$2,109.00

$2,391.00

$2,941.00

$3,052.00

$3,401.00

$3,128.00

$3,531.00

$3,793.00

$3,727.00

$71.00

$299.00

$471.00

$164.00

$306.00

$510.00

$199.00

$311.00

$24.00

$13.00

$11.00

$24.00

$13.00

$12.00

$290.00

$121.00

$169.00

$413.00


Part B, 245



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

52276

52277

52281

52282

52283

52285

52287

52290

52300

52234

52235

52240

52250

52260

52265

52270

52275

51990

51992

52000

52001

52005

52007

52010

52204

52214

52224

51865

51880

51900

51920

51925

51940

51960

51980

51785-26

51785-TC

0

0

--------

--------

51792

51792-26

51792-TC

51797

0

0

0

51797-26 ZZZ

$143.00

--------

--------

ZZZ $109.00

--------

51797-TC ZZZ

51798 0

51800

51820

51840

90

90

90

--------

$20.00

$1,294.00

$1,236.00

$858.00

51841

51845

51860

90

90

90

$1,040.00

$843.00

$912.00

0

0

0

0

0

90 $2,082.00

90 $1,848.00

90 $858.00

90

90

0

0

0

90 $1,150.00

90 $590.00

90 $1,050.00

90 $881.00

90 $1,167.00

$850.00

$925.00

$190.00

$133.00

$265.00

$230.00

$292.00

$286.00

$367.00

$339.00

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

$471.00

$546.00

$887.00

$311.00

$262.00

$243.00

$374.00

$446.00

$490.00

$448.00

$259.00

$560.00

$309.00

$375.00

--------

$304.00

$370.00

$1,307.00

$682.00

$1,217.00

$1,285.00

$1,623.00

$2,425.00

$2,032.00

$1,035.00

$1,090.00

$1,223.00

$288.00

$531.00

$372.00

$616.00

$520.00

$512.00

$911.00

$955.00

$131.00

$239.00

$292.00

$80.00

$212.00

$155.00

$58.00

$97.00

$26.00

$1,516.00

$1,628.00

$954.00

$1,134.00

$852.00

$1,091.00

$360.00

$422.00

$574.00

$351.00

$307.00

$510.00

$498.00

$672.00

$387.00

$473.00

$383.00

$493.00

$394.00

$397.00

$438.00

$357.00

$410.00

$1,376.00

$719.00

$1,280.00

$1,380.00

$1,742.00

$2,553.00

$2,133.00

$1,086.00

$1,144.00

$1,285.00

$305.00

$560.00

$394.00

$655.00

$552.00

$545.00

$971.00

$1,017.00

$141.00

$256.00

$311.00

$84.00

$227.00

$164.00

$61.00

$104.00

$29.00

$1,591.00

$1,718.00

$1,002.00

$1,192.00

$895.00

$1,153.00

$377.00

$442.00

$601.00

$368.00

$322.00

$542.00

$528.00

$712.00

$406.00

$496.00

$405.00

$516.00

$415.00

$419.00

$463.00

$374.00

$430.00

$1,457.00

$759.00

$1,350.00

$1,508.00

$1,909.00

$2,718.00

$2,252.00

$1,141.00

$1,204.00

$1,355.00

$315.00

$584.00

$406.00

$669.00

$568.00

$557.00

$988.00

$1,036.00

$155.00

$258.00

$317.00

$88.00

$229.00

$167.00

$63.00

$104.00

$29.00

$1,676.00

$1,830.00

$1,055.00

$1,258.00

$942.00

$1,226.00

$397.00

$466.00

$634.00

$388.00

$339.00

$556.00

$543.00

$733.00

$428.00

$523.00

$418.00

$545.00

$432.00

$435.00

$478.00

$394.00

$453.00

$1,307.00

$682.00

$1,217.00

$1,285.00

$1,623.00

$2,425.00

$2,032.00

$1,035.00

$1,090.00

$1,223.00

$184.00

$420.00

$194.00

$242.00

$244.00

$207.00

$258.00

$299.00

$131.00

$239.00

$292.00

$80.00

$212.00

$155.00

$58.00

$97.00

$26.00

$1,516.00

$1,628.00

$954.00

$1,134.00

$852.00

$1,091.00

$360.00

$422.00

$574.00

$351.00

$307.00

$238.00

$265.00

$363.00

$387.00

$473.00

$222.00

$493.00

$294.00

$286.00

$247.00

$357.00

$410.00

$1,376.00

$719.00

$1,280.00

$1,380.00

$1,742.00

$2,553.00

$2,133.00

$1,086.00

$1,144.00

$1,285.00

$193.00

$440.00

$203.00

$253.00

$257.00

$217.00

$270.00

$312.00

$141.00

$256.00

$311.00

$84.00

$227.00

$164.00

$61.00

$104.00

$29.00

$1,591.00

$1,718.00

$1,002.00

$1,192.00

$895.00

$1,153.00

$377.00

$442.00

$601.00

$368.00

$322.00

$249.00

$278.00

$380.00

$406.00

$496.00

$233.00

$516.00

$308.00

$300.00

$259.00

$374.00

$430.00

$1,457.00

$759.00

$1,350.00

$1,508.00

$1,909.00

$2,718.00

$2,252.00

$1,141.00

$1,204.00

$1,355.00

$203.00

$464.00

$214.00

$267.00

$271.00

$228.00

$286.00

$330.00

$155.00

$258.00

$317.00

$88.00

$229.00

$167.00

$63.00

$104.00

$29.00

$1,676.00

$1,830.00

$1,055.00

$1,258.00

$942.00

$1,226.00

$397.00

$466.00

$634.00

$388.00

$339.00

$263.00

$292.00

$401.00

$428.00

$523.00

$245.00

$545.00

$325.00

$316.00

$273.00

$394.00

$453.00


Part B, 246



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

52356

52400

52402

52441

52442

52450

52500

52601

52630

52640

52344

52345

52346

52351

52352

52353

52354

52355

52301

52305

52310

52315

52317

52318

52320

52325

52327

52330

52332

52334

52341

52342

52343

53060

53080

53085

53200

53210

53215

53220

53230

53235

52647

52648

52649

52700

53000

53010

53020

53040

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

$407.00

$433.00

$488.00

$297.00

$349.00

$404.00

$372.00

$447.00

0

90

0

0

ZZZ

--------

$580.00

--------

--------

--------

90

90

$602.00

$705.00

90 $1,021.00

90 $653.00

90 $573.00

$382.00

$370.00

$348.00

$553.00

$772.00

$684.00

$369.00

$494.00

$369.00

$507.00

$451.00

$340.00

$317.00

$344.00

$380.00

90

90

90

90

10

90

0

90

$858.00

$957.00

--------

$517.00

$224.00

$336.00

$153.00

$460.00

10

90

90

$180.00

$567.00

$836.00

0

90

$218.00

$904.00

90 $1,142.00

90 $546.00

90

90

$760.00

$607.00

$541.00

$578.00

$653.00

$443.00

$518.00

$574.00

$610.00

$684.00

$609.00

$696.00

$391.00

$1,710.00

$1,298.00

$681.00

$707.00

$1,231.00

$579.00

$454.00

$424.00

$408.00

$344.00

$585.00

$1,121.00

$694.00

$361.00

$470.00

$384.00

$693.00

$676.00

$375.00

$416.00

$452.00

$503.00

$2,467.00

$2,542.00

$1,196.00

$639.00

$214.00

$426.00

$141.00

$568.00

$263.00

$608.00

$969.00

$226.00

$1,120.00

$1,354.00

$660.00

$879.00

$918.00

$567.00

$605.00

$684.00

$464.00

$543.00

$601.00

$639.00

$716.00

$638.00

$730.00

$409.00

$1,826.00

$1,390.00

$715.00

$743.00

$1,291.00

$608.00

$478.00

$444.00

$428.00

$364.00

$618.00

$1,190.00

$727.00

$378.00

$493.00

$402.00

$734.00

$720.00

$393.00

$435.00

$474.00

$527.00

$2,625.00

$2,704.00

$1,255.00

$671.00

$225.00

$448.00

$148.00

$596.00

$277.00

$639.00

$1,019.00

$238.00

$1,174.00

$1,420.00

$694.00

$922.00

$963.00

$599.00

$639.00

$721.00

$489.00

$572.00

$634.00

$674.00

$756.00

$673.00

$768.00

$433.00

$1,852.00

$1,400.00

$750.00

$779.00

$1,358.00

$637.00

$499.00

$468.00

$451.00

$377.00

$641.00

$1,221.00

$767.00

$398.00

$520.00

$425.00

$757.00

$734.00

$414.00

$459.00

$499.00

$556.00

$2,679.00

$2,762.00

$1,319.00

$704.00

$235.00

$468.00

$156.00

$625.00

$289.00

$669.00

$1,069.00

$250.00

$1,235.00

$1,496.00

$730.00

$969.00

$1,012.00

$541.00

$578.00

$653.00

$443.00

$518.00

$574.00

$610.00

$684.00

$609.00

$696.00

$391.00

$335.00

$89.00

$681.00

$707.00

$1,231.00

$579.00

$454.00

$424.00

$408.00

$222.00

$401.00

$509.00

$694.00

$361.00

$470.00

$384.00

$386.00

$227.00

$375.00

$416.00

$452.00

$503.00

$940.00

$1,003.00

$1,196.00

$639.00

$214.00

$426.00

$141.00

$568.00

$238.00

$608.00

$969.00

$208.00

$1,120.00

$1,354.00

$660.00

$879.00

$918.00

$567.00

$605.00

$684.00

$464.00

$543.00

$601.00

$639.00

$716.00

$638.00

$730.00

$409.00

$352.00

$93.00

$715.00

$743.00

$1,291.00

$608.00

$478.00

$444.00

$428.00

$232.00

$420.00

$533.00

$727.00

$378.00

$493.00

$402.00

$404.00

$238.00

$393.00

$435.00

$474.00

$527.00

$987.00

$1,053.00

$1,255.00

$671.00

$225.00

$448.00

$148.00

$596.00

$250.00

$639.00

$1,019.00

$218.00

$1,174.00

$1,420.00

$694.00

$922.00

$963.00

$599.00

$639.00

$721.00

$489.00

$572.00

$634.00

$674.00

$756.00

$673.00

$768.00

$433.00

$373.00

$99.00

$750.00

$779.00

$1,358.00

$637.00

$499.00

$468.00

$451.00

$245.00

$443.00

$563.00

$767.00

$398.00

$520.00

$425.00

$426.00

$251.00

$414.00

$459.00

$499.00

$556.00

$1,036.00

$1,107.00

$1,319.00

$704.00

$235.00

$468.00

$156.00

$625.00

$262.00

$669.00

$1,069.00

$230.00

$1,235.00

$1,496.00

$730.00

$969.00

$1,012.00


Part B, 247



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

53460

53500

53502

53505

53510

53515

53520

53600

53601

53605

53442

53444

53445

53446

53447

53448

53449

53450

53240

53250

53260

53265

53270

53275

53400

53405

53410

53415

53420

53425

53430

53431

53440

53860

53899

54015

54050

54055

54056

54057

54060

54065

53620

53621

53660

53661

53665

53850

53852

53855

90

YYY

10

10

10

10

10

10

10

0

0

90

90

0

0

0

0

90

90

10

10

10

10

90

$506.00

$464.00

$240.00

$295.00

$226.00

$332.00

$929.00

90 $1,088.00

90 $1,151.00

90 $1,381.00

90 $1,088.00

90 $1,150.00

90 $1,116.00

90 $1,053.00

90 $1,057.00

90

90

0

0

0

90

90

90

90

90

90

90

$639.00

$755.00

90 $1,197.00

90 $699.00

90 $991.00

90 $1,259.00

90 $784.00

90 $447.00

$494.00

--------

$590.00

$586.00

$777.00

$987.00

$661.00

$37.00

$37.00

$81.00

$59.00

$45.00

$49.00

$50.00

$50.00

$741.00

$728.00

--------

--------

BR

$348.00

$91.00

$106.00

$100.00

$149.00

$180.00

$281.00

$1,135.00

$1,152.00

$1,092.00

$932.00

$1,174.00

$1,875.00

$887.00

$593.00

$663.00

$1,087.00

$705.00

$707.00

$917.00

$1,156.00

$807.00

$119.00

$115.00

$95.00

$620.00

$602.00

$290.00

$312.00

$300.00

$381.00

$1,165.00

$1,270.00

$1,423.00

$1,646.00

$1,242.00

$1,363.00

$1,403.00

$1,688.00

$1,093.00

$165.00

$155.00

$99.00

$97.00

$57.00

$2,858.00

$2,640.00

$1,060.00

$2,116.00

--------

$451.00

$186.00

$168.00

$200.00

$191.00

$253.00

$311.00

$1,192.00

$1,208.00

$1,146.00

$979.00

$1,232.00

$1,968.00

$931.00

$623.00

$696.00

$1,141.00

$740.00

$743.00

$962.00

$1,213.00

$847.00

$125.00

$121.00

$99.00

$653.00

$638.00

$305.00

$329.00

$316.00

$400.00

$1,223.00

$1,332.00

$1,492.00

$1,726.00

$1,304.00

$1,429.00

$1,472.00

$1,771.00

$1,147.00

$174.00

$164.00

$105.00

$103.00

$59.00

$3,047.00

$2,812.00

$1,134.00

$2,263.00

--------

$474.00

$198.00

$178.00

$213.00

$202.00

$268.00

$329.00

$1,251.00

$1,269.00

$1,204.00

$1,028.00

$1,295.00

$2,076.00

$978.00

$653.00

$730.00

$1,201.00

$777.00

$780.00

$1,011.00

$1,275.00

$888.00

$130.00

$126.00

$105.00

$686.00

$678.00

$320.00

$343.00

$331.00

$420.00

$1,287.00

$1,401.00

$1,570.00

$1,818.00

$1,372.00

$1,504.00

$1,551.00

$1,868.00

$1,205.00

$181.00

$170.00

$108.00

$106.00

$63.00

$3,098.00

$2,865.00

$1,144.00

$2,286.00

--------

$499.00

$204.00

$184.00

$220.00

$208.00

$278.00

$343.00

$1,135.00

$1,152.00

$1,092.00

$932.00

$1,174.00

$1,875.00

$887.00

$593.00

$663.00

$1,087.00

$705.00

$707.00

$917.00

$1,156.00

$807.00

$93.00

$78.00

$95.00

$620.00

$602.00

$262.00

$270.00

$270.00

$381.00

$1,165.00

$1,270.00

$1,423.00

$1,646.00

$1,242.00

$1,363.00

$1,403.00

$1,688.00

$1,093.00

$127.00

$105.00

$61.00

$59.00

$57.00

$879.00

$904.00

$121.00

$329.00

--------

$451.00

$150.00

$133.00

$159.00

$136.00

$188.00

$250.00

$1,192.00

$1,208.00

$1,146.00

$979.00

$1,232.00

$1,968.00

$931.00

$623.00

$696.00

$1,141.00

$740.00

$743.00

$962.00

$1,213.00

$847.00

$97.00

$82.00

$99.00

$653.00

$638.00

$275.00

$283.00

$284.00

$400.00

$1,223.00

$1,332.00

$1,492.00

$1,726.00

$1,304.00

$1,429.00

$1,472.00

$1,771.00

$1,147.00

$133.00

$111.00

$64.00

$62.00

$59.00

$924.00

$948.00

$127.00

$346.00

--------

$474.00

$159.00

$140.00

$168.00

$144.00

$198.00

$264.00

$1,251.00

$1,269.00

$1,204.00

$1,028.00

$1,295.00

$2,076.00

$978.00

$653.00

$730.00

$1,201.00

$777.00

$780.00

$1,011.00

$1,275.00

$888.00

$102.00

$86.00

$105.00

$686.00

$678.00

$290.00

$298.00

$300.00

$420.00

$1,287.00

$1,401.00

$1,570.00

$1,818.00

$1,372.00

$1,504.00

$1,551.00

$1,868.00

$1,205.00

$140.00

$116.00

$67.00

$65.00

$63.00

$968.00

$996.00

$134.00

$363.00

--------

$499.00

$166.00

$147.00

$176.00

$150.00

$207.00

$277.00


Part B, 248



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

54220

54230

54231

54235

54240

54240-26

54240-TC

54250

54250-26

54250-TC

54300

54304

54308

54312

54316

54318

54322

54324

54100

54105

54110

54111

54112

54115

54120

54125

54130

54135

54162

54163

54164

54200

54205

54360

54380

54385

54390

54400

54401

54405

54406

54408

54326

54328

54332

54336

54340

54344

54348

54352

0

10

$149.00

$261.00

90 $775.00

90 $1,035.00

90 $1,210.00

90 $588.00

90 $777.00

90 $1,092.00

90 $1,532.00

90 $1,945.00

10 $220.00

10 $207.00

10

10

90

$182.00

$78.00

$633.00

0

0

0

0

0

0

0

0

$189.00

$104.00

$172.00

$81.00

$109.00

--------

--------

$104.00

0

0

90

90

90

--------

--------

$830.00

$988.00

$881.00

90 $1,067.00

90 $1,316.00

90

90

$900.00

$974.00

90 $1,260.00

90 $1,212.00

90 $1,201.00

90 $1,327.00

90 $1,672.00

90 $727.00

90 $1,360.00

90 $1,318.00

90 $1,820.00

90 $898.00

90 $1,054.00

90 $1,217.00

90 $1,635.00

90 $784.00

90 $892.00

90 $1,294.00

90

90

$687.00

$724.00

$290.00

$138.00

$201.00

$128.00

$146.00

$98.00

$48.00

$174.00

$159.00

$15.00

$930.00

$1,090.00

$1,039.00

$1,254.00

$1,531.00

$1,089.00

$1,116.00

$1,450.00

$280.00

$377.00

$919.00

$1,164.00

$1,368.00

$651.00

$917.00

$1,182.00

$1,733.00

$2,182.00

$366.00

$316.00

$278.00

$151.00

$772.00

$1,376.00

$1,367.00

$1,561.00

$1,825.00

$826.00

$1,538.00

$1,475.00

$2,064.00

$1,047.00

$1,162.00

$1,423.00

$1,904.00

$769.00

$949.00

$1,176.00

$1,062.00

$1,148.00

$307.00

$146.00

$211.00

$135.00

$154.00

$103.00

$51.00

$182.00

$165.00

$16.00

$976.00

$1,143.00

$1,090.00

$1,322.00

$1,614.00

$1,149.00

$1,168.00

$1,521.00

$297.00

$397.00

$966.00

$1,221.00

$1,436.00

$685.00

$963.00

$1,241.00

$1,815.00

$2,281.00

$387.00

$332.00

$293.00

$159.00

$810.00

$1,443.00

$1,434.00

$1,645.00

$1,924.00

$868.00

$1,644.00

$1,547.00

$2,164.00

$1,098.00

$1,219.00

$1,501.00

$2,007.00

$807.00

$998.00

$1,233.00

$1,114.00

$1,204.00

$319.00

$152.00

$221.00

$141.00

$162.00

$110.00

$52.00

$189.00

$173.00

$17.00

$1,025.00

$1,202.00

$1,145.00

$1,401.00

$1,711.00

$1,216.00

$1,225.00

$1,597.00

$308.00

$413.00

$1,017.00

$1,284.00

$1,512.00

$717.00

$1,011.00

$1,307.00

$1,909.00

$2,392.00

$402.00

$347.00

$306.00

$164.00

$850.00

$1,517.00

$1,508.00

$1,742.00

$2,041.00

$910.00

$1,786.00

$1,628.00

$2,278.00

$1,154.00

$1,281.00

$1,590.00

$2,129.00

$848.00

$1,045.00

$1,296.00

$1,171.00

$1,266.00

$196.00

$116.00

$169.00

$106.00

$146.00

$98.00

$48.00

$174.00

$159.00

$15.00

$930.00

$1,090.00

$1,039.00

$1,254.00

$1,531.00

$1,089.00

$1,116.00

$1,450.00

$183.00

$309.00

$919.00

$1,164.00

$1,368.00

$615.00

$917.00

$1,182.00

$1,733.00

$2,182.00

$289.00

$316.00

$278.00

$120.00

$772.00

$1,376.00

$1,367.00

$1,561.00

$1,825.00

$826.00

$1,538.00

$1,475.00

$2,064.00

$1,047.00

$1,162.00

$1,423.00

$1,904.00

$769.00

$949.00

$1,176.00

$1,062.00

$1,148.00

$206.00

$121.00

$177.00

$112.00

$154.00

$103.00

$51.00

$182.00

$165.00

$16.00

$976.00

$1,143.00

$1,090.00

$1,322.00

$1,614.00

$1,149.00

$1,168.00

$1,521.00

$193.00

$324.00

$966.00

$1,221.00

$1,436.00

$647.00

$963.00

$1,241.00

$1,815.00

$2,281.00

$303.00

$332.00

$293.00

$126.00

$810.00

$1,443.00

$1,434.00

$1,645.00

$1,924.00

$868.00

$1,644.00

$1,547.00

$2,164.00

$1,098.00

$1,219.00

$1,501.00

$2,007.00

$807.00

$998.00

$1,233.00

$1,114.00

$1,204.00

$218.00

$127.00

$186.00

$117.00

$162.00

$110.00

$52.00

$189.00

$173.00

$17.00

$1,025.00

$1,202.00

$1,145.00

$1,401.00

$1,711.00

$1,216.00

$1,225.00

$1,597.00

$203.00

$340.00

$1,017.00

$1,284.00

$1,512.00

$678.00

$1,011.00

$1,307.00

$1,909.00

$2,392.00

$318.00

$347.00

$306.00

$131.00

$850.00

$1,517.00

$1,508.00

$1,742.00

$2,041.00

$910.00

$1,786.00

$1,628.00

$2,278.00

$1,154.00

$1,281.00

$1,590.00

$2,129.00

$848.00

$1,045.00

$1,296.00

$1,171.00

$1,266.00


Part B, 249



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

54640

54650

54660

54670

54680

54690

54692

54699

54700

54800

54520

54522

54530

54535

54550

54560

54600

54620

54410

54411

54415

54416

54417

54420

54430

54435

54437

54438

54440

54450

54500

54505

54512

55040

55041

55060

55100

55110

55120

55150

55175

55180

54830

54840

54860

54861

54865

54900

54901

55000

90

90

YYY

10

0

90

90

90

90

90

90

90

90

90

90

90

90

10

90

90

90

90

0

0

10

90

90

90

90

90

90

90

90

90

90

90

10

90

90

90

90

90

90

90

90

$411.00

$432.00

$503.00

90

90

$696.00

--------

90 $969.00

90 $1,340.00

0 $109.00

$439.00

$634.00

$430.00

$156.00

$223.00

$350.00

$562.00

$426.00

$796.00

$445.00

$589.00

$683.00

$922.00

$588.00

$842.00

$524.00

$373.00

$594.00

$861.00

$401.00

$485.00

$948.00

$825.00

$850.00

BR

$133.00

$257.00

$856.00

$933.00

$510.00

$665.00

$819.00

$899.00

$799.00

$503.00

--------

--------

BR

$88.00

$102.00

$259.00

$519.00

$473.00

$908.00

$733.00

$1,081.00

$716.00

$998.00

$661.00

$438.00

$696.00

$1,030.00

$517.00

$585.00

$1,152.00

$1,098.00

$1,274.00

--------

$311.00

$186.00

$1,249.00

$1,491.00

$766.00

$1,029.00

$1,306.00

$1,024.00

$929.00

$602.00

$991.00

$2,008.00

--------

$101.00

$108.00

$305.00

$784.00

$540.00

$465.00

$607.00

$822.00

$519.00

$1,227.00

$1,620.00

$167.00

$490.00

$739.00

$552.00

$307.00

$562.00

$517.00

$714.00

$524.00

$1,006.00

$498.00

$963.00

$771.00

$1,133.00

$753.00

$1,047.00

$694.00

$460.00

$733.00

$1,080.00

$543.00

$615.00

$1,209.00

$1,177.00

$1,368.00

--------

$328.00

$195.00

$1,310.00

$1,563.00

$804.00

$1,081.00

$1,369.00

$1,074.00

$975.00

$632.00

$1,043.00

$2,116.00

--------

$106.00

$113.00

$320.00

$824.00

$568.00

$489.00

$637.00

$863.00

$545.00

$1,294.00

$1,708.00

$176.00

$516.00

$777.00

$581.00

$325.00

$592.00

$544.00

$751.00

$551.00

$1,058.00

$525.00

$1,029.00

$809.00

$1,191.00

$791.00

$1,101.00

$728.00

$483.00

$772.00

$1,132.00

$569.00

$643.00

$1,271.00

$1,285.00

$1,499.00

--------

$346.00

$206.00

$1,377.00

$1,643.00

$844.00

$1,134.00

$1,439.00

$1,129.00

$1,024.00

$662.00

$1,099.00

$2,248.00

--------

$111.00

$119.00

$335.00

$867.00

$596.00

$513.00

$668.00

$905.00

$571.00

$1,371.00

$1,811.00

$183.00

$542.00

$816.00

$610.00

$338.00

$622.00

$571.00

$790.00

$578.00

$1,113.00

$473.00

$908.00

$733.00

$1,081.00

$716.00

$998.00

$661.00

$438.00

$696.00

$1,030.00

$517.00

$585.00

$1,152.00

$1,098.00

$1,274.00

--------

$311.00

$186.00

$1,249.00

$1,491.00

$766.00

$1,029.00

$1,306.00

$1,024.00

$929.00

$602.00

$991.00

$2,008.00

--------

$84.00

$108.00

$305.00

$784.00

$540.00

$465.00

$607.00

$822.00

$519.00

$1,227.00

$1,620.00

$124.00

$490.00

$739.00

$552.00

$241.00

$562.00

$517.00

$714.00

$524.00

$1,006.00

$498.00

$963.00

$771.00

$1,133.00

$753.00

$1,047.00

$694.00

$460.00

$733.00

$1,080.00

$543.00

$615.00

$1,209.00

$1,177.00

$1,368.00

--------

$328.00

$195.00

$1,310.00

$1,563.00

$804.00

$1,081.00

$1,369.00

$1,074.00

$975.00

$632.00

$1,043.00

$2,116.00

--------

$88.00

$113.00

$320.00

$824.00

$568.00

$489.00

$637.00

$863.00

$545.00

$1,294.00

$1,708.00

$130.00

$516.00

$777.00

$581.00

$254.00

$592.00

$544.00

$751.00

$551.00

$1,058.00

$525.00

$1,029.00

$809.00

$1,191.00

$791.00

$1,101.00

$728.00

$483.00

$772.00

$1,132.00

$569.00

$643.00

$1,271.00

$1,285.00

$1,499.00

--------

$346.00

$206.00

$1,377.00

$1,643.00

$844.00

$1,134.00

$1,439.00

$1,129.00

$1,024.00

$662.00

$1,099.00

$2,248.00

--------

$94.00

$119.00

$335.00

$867.00

$596.00

$513.00

$668.00

$905.00

$571.00

$1,371.00

$1,811.00

$137.00

$542.00

$816.00

$610.00

$267.00

$622.00

$571.00

$790.00

$578.00

$1,113.00


Part B, 250



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

55812

55815

55821

55831

55840

55842

55845

55860

55862

55865

55680

55700

55705

55706

55720

55725

55801

55810

55200

55250

55300

55400

55450

55500

55520

55530

55535

55540

55550

55559

55600

55605

55650

56420

56440

56441

56442

56501

56515

56605

56606

56620

55866

55870

55873

55875

55876

55899

55920

56405

90

90

90

90

YYY

90

90

90

90

90

0

90

10

90

90

90

0

10

10

90

$426.00

$183.00

$368.00

--------

$555.00

90 $670.00

90 $1,331.00

90 $1,711.00

90 $1,989.00

90 $2,328.00

90 $1,153.00

90 $1,252.00

90 $1,705.00

90 $1,859.00

90 $2,222.00

90 $1,012.00

90 $1,351.00

90 $1,890.00

$310.00

$349.00

$167.00

$660.00

$391.00

$445.00

$446.00

$467.00

$496.00

$572.00

$486.00

BR

$486.00

$609.00

$853.00

10

10

10

0

10

10

0

ZZZ

90

90 $1,615.00

0 $166.00

90 $1,127.00

90

0

YYY

0

10

--------

--------

BR

--------

$131.00

$130.00

$271.00

$183.00

--------

$122.00

$200.00

$96.00

$49.00

$607.00

$515.00

$308.00

$387.00

$542.00

$657.00

$860.00

$1,605.00

$1,927.00

$2,346.00

$2,586.00

$1,272.00

$1,377.00

$1,707.00

$1,706.00

$1,989.00

$1,274.00

$1,683.00

$1,944.00

$614.00

$539.00

$273.00

$744.00

$509.00

$578.00

$669.00

$509.00

$623.00

$802.00

$623.00

--------

$611.00

$798.00

$1,045.00

$2,024.00

$251.00

$9,706.00

$1,107.00

$192.00

--------

$651.00

$155.00

$172.00

$261.00

$205.00

$68.00

$185.00

$323.00

$117.00

$54.00

$755.00

$543.00

$326.00

$406.00

$569.00

$690.00

$903.00

$1,686.00

$2,023.00

$2,459.00

$2,712.00

$1,334.00

$1,443.00

$1,791.00

$1,789.00

$2,085.00

$1,336.00

$1,774.00

$2,037.00

$650.00

$571.00

$286.00

$785.00

$537.00

$612.00

$717.00

$536.00

$655.00

$858.00

$654.00

--------

$641.00

$842.00

$1,096.00

$2,130.00

$265.00

$10,388.00

$1,161.00

$203.00

--------

$680.00

$164.00

$182.00

$275.00

$216.00

$72.00

$196.00

$342.00

$123.00

$57.00

$804.00

$570.00

$337.00

$426.00

$597.00

$724.00

$948.00

$1,780.00

$2,137.00

$2,590.00

$2,864.00

$1,404.00

$1,519.00

$1,886.00

$1,883.00

$2,197.00

$1,406.00

$1,882.00

$2,145.00

$671.00

$587.00

$302.00

$832.00

$557.00

$649.00

$776.00

$562.00

$687.00

$930.00

$686.00

--------

$672.00

$890.00

$1,153.00

$2,224.00

$276.00

$10,478.00

$1,217.00

$210.00

--------

$712.00

$171.00

$189.00

$289.00

$225.00

$75.00

$204.00

$359.00

$129.00

$60.00

$858.00

$515.00

$203.00

$387.00

$542.00

$657.00

$860.00

$1,605.00

$1,927.00

$2,346.00

$2,586.00

$1,272.00

$1,377.00

$1,707.00

$1,706.00

$1,989.00

$1,274.00

$1,683.00

$1,944.00

$403.00

$327.00

$273.00

$744.00

$373.00

$578.00

$669.00

$509.00

$623.00

$802.00

$623.00

--------

$611.00

$798.00

$1,045.00

$2,024.00

$208.00

$1,118.00

$1,107.00

$146.00

--------

$651.00

$154.00

$131.00

$261.00

$197.00

$68.00

$164.00

$290.00

$87.00

$43.00

$755.00

$543.00

$213.00

$406.00

$569.00

$690.00

$903.00

$1,686.00

$2,023.00

$2,459.00

$2,712.00

$1,334.00

$1,443.00

$1,791.00

$1,789.00

$2,085.00

$1,336.00

$1,774.00

$2,037.00

$424.00

$345.00

$286.00

$785.00

$392.00

$612.00

$717.00

$536.00

$655.00

$858.00

$654.00

--------

$641.00

$842.00

$1,096.00

$2,130.00

$218.00

$1,174.00

$1,161.00

$153.00

--------

$680.00

$163.00

$138.00

$275.00

$208.00

$72.00

$173.00

$306.00

$92.00

$46.00

$804.00

$570.00

$225.00

$426.00

$597.00

$724.00

$948.00

$1,780.00

$2,137.00

$2,590.00

$2,864.00

$1,404.00

$1,519.00

$1,886.00

$1,883.00

$2,197.00

$1,406.00

$1,882.00

$2,145.00

$444.00

$360.00

$302.00

$832.00

$411.00

$649.00

$776.00

$562.00

$687.00

$930.00

$686.00

--------

$672.00

$890.00

$1,153.00

$2,224.00

$229.00

$1,236.00

$1,217.00

$160.00

--------

$712.00

$170.00

$145.00

$289.00

$218.00

$75.00

$181.00

$324.00

$97.00

$49.00

$858.00


Part B, 251



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

57105

57106

57107

57109

57110

57111

57112

57120

57130

57135

57000

57010

57020

57022

57023

57061

57065

57100

56625

56630

56631

56632

56633

56634

56637

56640

56700

56740

56800

56805

56810

56820

56821

57220

57230

57240

57250

57260

57265

57267

57268

57270

57150

57155

57156

57160

57170

57180

57200

57210

90

90

90

90

90

90

ZZZ

90

90

0

0

10

90

90

0

0

0

90 $735.00

90 $1,061.00

90 $1,400.00

90 $1,636.00

90 $1,350.00

90 $1,537.00

90 $1,806.00

90 $1,777.00

10 $227.00

10

10

$321.00

$310.00

90 $1,349.00

10

0

0

$316.00

$119.00

$154.00

10

90

0

10

10

10

10

0

$237.00

$429.00

$118.00

$179.00

$290.00

$124.00

$251.00

$90.00

10

90

$132.00

$409.00

90 $1,467.00

90 $1,787.00

90 $1,015.00

90 $1,793.00

90 $1,907.00

90

10

10

$612.00

$220.00

$231.00

$50.00

$383.00

--------

$67.00

$74.00

$124.00

$313.00

$395.00

$378.00

$442.00

$536.00

$485.00

$700.00

$902.00

--------

$577.00

$867.00

$269.00

$620.00

$133.00

$243.00

$444.00

$161.00

$279.00

$127.00

$194.00

$716.00

$2,134.00

$2,573.00

$1,283.00

$2,325.00

$2,745.00

$729.00

$251.00

$274.00

$919.00

$1,365.00

$1,747.00

$2,025.00

$1,790.00

$1,943.00

$2,231.00

$2,253.00

$266.00

$434.00

$346.00

$1,685.00

$374.00

$161.00

$212.00

$63.00

$609.00

$279.00

$107.00

$87.00

$198.00

$434.00

$526.00

$455.00

$565.00

$964.00

$969.00

$1,196.00

$1,310.00

$371.00

$693.00

$1,153.00

$283.00

$653.00

$140.00

$256.00

$467.00

$170.00

$296.00

$135.00

$206.00

$760.00

$2,269.00

$2,757.00

$1,348.00

$2,447.00

$2,938.00

$767.00

$264.00

$289.00

$980.00

$1,457.00

$1,867.00

$2,162.00

$1,912.00

$2,086.00

$2,384.00

$2,413.00

$280.00

$459.00

$364.00

$1,780.00

$394.00

$171.00

$224.00

$67.00

$641.00

$293.00

$113.00

$91.00

$209.00

$459.00

$554.00

$479.00

$594.00

$1,013.00

$1,019.00

$1,256.00

$1,376.00

$389.00

$730.00

$1,214.00

$297.00

$686.00

$147.00

$270.00

$491.00

$177.00

$312.00

$142.00

$216.00

$809.00

$2,448.00

$3,016.00

$1,421.00

$2,591.00

$3,208.00

$806.00

$276.00

$304.00

$1,054.00

$1,577.00

$2,026.00

$2,339.00

$2,075.00

$2,284.00

$2,592.00

$2,635.00

$293.00

$487.00

$384.00

$1,896.00

$415.00

$180.00

$236.00

$69.00

$660.00

$301.00

$117.00

$96.00

$217.00

$484.00

$583.00

$502.00

$625.00

$1,066.00

$1,073.00

$1,324.00

$1,450.00

$411.00

$769.00

$1,285.00

$269.00

$620.00

$117.00

$243.00

$444.00

$140.00

$252.00

$98.00

$181.00

$716.00

$2,134.00

$2,573.00

$1,283.00

$2,325.00

$2,745.00

$729.00

$227.00

$249.00

$919.00

$1,365.00

$1,747.00

$2,025.00

$1,790.00

$1,943.00

$2,231.00

$2,253.00

$266.00

$434.00

$346.00

$1,685.00

$374.00

$127.00

$168.00

$42.00

$420.00

$211.00

$68.00

$70.00

$151.00

$434.00

$526.00

$455.00

$565.00

$964.00

$969.00

$1,196.00

$1,310.00

$371.00

$693.00

$1,153.00

$283.00

$653.00

$123.00

$256.00

$467.00

$148.00

$267.00

$103.00

$192.00

$760.00

$2,269.00

$2,757.00

$1,348.00

$2,447.00

$2,938.00

$767.00

$239.00

$262.00

$980.00

$1,457.00

$1,867.00

$2,162.00

$1,912.00

$2,086.00

$2,384.00

$2,413.00

$280.00

$459.00

$364.00

$1,780.00

$394.00

$134.00

$178.00

$44.00

$438.00

$219.00

$71.00

$74.00

$159.00

$459.00

$554.00

$479.00

$594.00

$1,013.00

$1,019.00

$1,256.00

$1,376.00

$389.00

$730.00

$1,214.00

$297.00

$686.00

$130.00

$270.00

$491.00

$155.00

$283.00

$110.00

$202.00

$809.00

$2,448.00

$3,016.00

$1,421.00

$2,591.00

$3,208.00

$806.00

$250.00

$277.00

$1,054.00

$1,577.00

$2,026.00

$2,339.00

$2,075.00

$2,284.00

$2,592.00

$2,635.00

$293.00

$487.00

$384.00

$1,896.00

$415.00

$143.00

$189.00

$46.00

$457.00

$227.00

$75.00

$78.00

$167.00

$484.00

$583.00

$502.00

$625.00

$1,066.00

$1,073.00

$1,324.00

$1,450.00

$411.00

$769.00

$1,285.00


Part B, 252



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

57415

57420

57421

57423

57425

57426

57452

57454

57455

57456

57308

57310

57311

57320

57330

57335

57400

57410

57280

57282

57283

57284

57285

57287

57288

57289

57291

57292

57295

57296

57300

57305

57307

57522

57530

57531

57540

57545

57550

57555

57556

57558

57460

57461

57500

57505

57510

57511

57513

57520

90

0

0

0

0

10

0

0

90

90

90

90

90

90

90

90

0

0

90

90

90

90

90

90

90

90

90 $1,071.00

90 $734.00

90

90

90

90

--------

$950.00

--------

$685.00

90 $1,009.00

$879.00

$622.00

$925.00

--------

--------

$653.00

$995.00

$997.00

$769.00

$517.00

$612.00

$693.00

$916.00

$963.00

$70.00

$57.00

$75.00

$124.00

$162.00

--------

--------

--------

$96.00

$125.00

$149.00

$141.00

10

10

10

10

90

0

0

0

$223.00

$333.00

$89.00

$105.00

$140.00

$159.00

$191.00

$359.00

90

90

$319.00

$386.00

90 $2,036.00

90

90

90

90

90

10

$815.00

$700.00

$486.00

$774.00

$718.00

--------

$952.00

$666.00

$763.00

$771.00

$1,072.00

$1,636.00

$195.00

$156.00

$229.00

$168.00

$226.00

$1,312.00

$1,394.00

$1,211.00

$155.00

$218.00

$203.00

$191.00

$1,372.00

$716.00

$988.00

$1,173.00

$966.00

$976.00

$1,028.00

$1,057.00

$881.00

$1,182.00

$684.00

$1,362.00

$815.00

$1,371.00

$1,600.00

$396.00

$449.00

$179.00

$144.00

$186.00

$205.00

$207.00

$438.00

$374.00

$499.00

$2,707.00

$1,126.00

$1,225.00

$580.00

$858.00

$812.00

$176.00

$1,006.00

$700.00

$802.00

$812.00

$1,124.00

$1,716.00

$207.00

$164.00

$241.00

$179.00

$240.00

$1,378.00

$1,465.00

$1,273.00

$164.00

$230.00

$214.00

$202.00

$1,443.00

$753.00

$1,039.00

$1,232.00

$1,014.00

$1,026.00

$1,080.00

$1,109.00

$934.00

$1,244.00

$719.00

$1,432.00

$864.00

$1,459.00

$1,717.00

$420.00

$476.00

$190.00

$153.00

$197.00

$217.00

$219.00

$464.00

$395.00

$527.00

$2,898.00

$1,186.00

$1,297.00

$610.00

$902.00

$855.00

$186.00

$1,066.00

$733.00

$842.00

$854.00

$1,181.00

$1,806.00

$220.00

$174.00

$253.00

$189.00

$253.00

$1,455.00

$1,545.00

$1,340.00

$172.00

$241.00

$224.00

$211.00

$1,523.00

$791.00

$1,095.00

$1,298.00

$1,068.00

$1,076.00

$1,135.00

$1,164.00

$988.00

$1,312.00

$756.00

$1,511.00

$921.00

$1,574.00

$1,878.00

$435.00

$493.00

$196.00

$159.00

$206.00

$226.00

$230.00

$487.00

$414.00

$556.00

$3,163.00

$1,255.00

$1,385.00

$639.00

$948.00

$899.00

$194.00

$952.00

$666.00

$763.00

$771.00

$1,072.00

$1,636.00

$195.00

$156.00

$229.00

$134.00

$182.00

$1,312.00

$1,394.00

$1,211.00

$133.00

$195.00

$160.00

$149.00

$1,372.00

$716.00

$988.00

$1,173.00

$966.00

$976.00

$1,028.00

$1,057.00

$881.00

$1,182.00

$684.00

$1,362.00

$815.00

$1,371.00

$1,600.00

$235.00

$271.00

$109.00

$131.00

$166.00

$188.00

$192.00

$396.00

$348.00

$499.00

$2,707.00

$1,126.00

$1,225.00

$580.00

$858.00

$812.00

$161.00

$1,006.00

$700.00

$802.00

$812.00

$1,124.00

$1,716.00

$207.00

$164.00

$241.00

$141.00

$192.00

$1,378.00

$1,465.00

$1,273.00

$140.00

$205.00

$168.00

$156.00

$1,443.00

$753.00

$1,039.00

$1,232.00

$1,014.00

$1,026.00

$1,080.00

$1,109.00

$934.00

$1,244.00

$719.00

$1,432.00

$864.00

$1,459.00

$1,717.00

$247.00

$285.00

$115.00

$139.00

$174.00

$198.00

$203.00

$418.00

$367.00

$527.00

$2,898.00

$1,186.00

$1,297.00

$610.00

$902.00

$855.00

$170.00

$1,066.00

$733.00

$842.00

$854.00

$1,181.00

$1,806.00

$220.00

$174.00

$253.00

$151.00

$206.00

$1,455.00

$1,545.00

$1,340.00

$148.00

$216.00

$178.00

$165.00

$1,523.00

$791.00

$1,095.00

$1,298.00

$1,068.00

$1,076.00

$1,135.00

$1,164.00

$988.00

$1,312.00

$756.00

$1,511.00

$921.00

$1,574.00

$1,878.00

$261.00

$302.00

$121.00

$145.00

$183.00

$207.00

$215.00

$442.00

$386.00

$556.00

$3,163.00

$1,255.00

$1,385.00

$639.00

$948.00

$899.00

$178.00


Part B, 253



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

58290

58291

58292

58293

58294

58301

58321

58322

58323

58340

58260

58262

58263

58267

58270

58275

58280

58285

57700

57720

57800

58100

58110

58120

58140

58145

58146

58150

58152

58180

58200

58210

58240

58540

58541

58542

58543

58544

58545

58546

58548

58550

58345

58346

58350

58353

58356

58400

58410

58520

90

90

$279.00

$328.00

0

0

ZZZ

10

$71.00

$74.00

--------

$297.00

90 $1,010.00

90 $677.00

90 $1,089.00

90 $1,110.00

90 $1,159.00

90 $1,118.00

90 $1,562.00

90 $2,080.00

90 $2,898.00

90 $926.00

90 $1,026.00

90 $1,120.00

90 $1,133.00

90 $1,019.00

90 $1,121.00

90 $1,132.00

90 $1,360.00

0

0

0

0

0

90 $1,089.00

90 $1,197.00

90 $1,268.00

90 $1,318.00

90 $1,168.00

$71.00

$81.00

$90.00

$24.00

$87.00

10

90

10

10

10

90

90

90

$335.00

$408.00

$103.00

$225.00

--------

$519.00

$752.00

$663.00

90

90

90

$923.00

--------

--------

90

90

--------

--------

90 $876.00

90 $1,104.00

90 --------

90 $1,038.00

$1,184.00

$1,324.00

$1,419.00

$1,514.00

$1,265.00

$1,414.00

$1,504.00

$1,943.00

$1,653.00

$1,782.00

$1,883.00

$1,956.00

$1,751.00

$134.00

$108.00

$121.00

$22.00

$165.00

$455.00

$437.00

$86.00

$155.00

$69.00

$368.00

$1,333.00

$789.00

$1,651.00

$1,470.00

$1,800.00

$1,391.00

$2,012.00

$2,724.00

$4,294.00

$390.00

$637.00

$135.00

$1,379.00

$2,579.00

$631.00

$1,181.00

$1,250.00

$1,299.00

$1,027.00

$1,177.00

$1,189.00

$1,301.00

$1,305.00

$1,610.00

$2,809.00

$1,265.00

$1,245.00

$1,392.00

$1,491.00

$1,592.00

$1,330.00

$1,487.00

$1,579.00

$2,055.00

$1,737.00

$1,871.00

$1,977.00

$2,053.00

$1,840.00

$142.00

$114.00

$128.00

$23.00

$176.00

$482.00

$460.00

$91.00

$164.00

$72.00

$389.00

$1,406.00

$832.00

$1,733.00

$1,555.00

$1,894.00

$1,466.00

$2,142.00

$2,907.00

$4,575.00

$409.00

$664.00

$142.00

$1,473.00

$2,756.00

$664.00

$1,247.00

$1,340.00

$1,364.00

$1,079.00

$1,237.00

$1,249.00

$1,371.00

$1,376.00

$1,691.00

$2,999.00

$1,330.00

$1,312.00

$1,469.00

$1,573.00

$1,681.00

$1,403.00

$1,572.00

$1,664.00

$2,199.00

$1,835.00

$1,973.00

$2,086.00

$2,166.00

$1,943.00

$148.00

$119.00

$133.00

$23.00

$180.00

$508.00

$482.00

$95.00

$171.00

$76.00

$408.00

$1,494.00

$880.00

$1,827.00

$1,659.00

$2,006.00

$1,556.00

$2,316.00

$3,156.00

$4,957.00

$430.00

$686.00

$147.00

$1,493.00

$2,793.00

$698.00

$1,327.00

$1,464.00

$1,437.00

$1,137.00

$1,306.00

$1,317.00

$1,453.00

$1,463.00

$1,783.00

$3,259.00

$1,402.00

$1,184.00

$1,324.00

$1,419.00

$1,514.00

$1,265.00

$1,414.00

$1,504.00

$1,943.00

$1,653.00

$1,782.00

$1,883.00

$1,956.00

$1,751.00

$98.00

$71.00

$84.00

$17.00

$83.00

$455.00

$437.00

$70.00

$126.00

$59.00

$315.00

$1,333.00

$789.00

$1,651.00

$1,470.00

$1,800.00

$1,391.00

$2,012.00

$2,724.00

$4,294.00

$390.00

$637.00

$111.00

$313.00

$498.00

$631.00

$1,181.00

$1,250.00

$1,299.00

$1,027.00

$1,177.00

$1,189.00

$1,301.00

$1,305.00

$1,610.00

$2,809.00

$1,265.00

$1,245.00

$1,392.00

$1,491.00

$1,592.00

$1,330.00

$1,487.00

$1,579.00

$2,055.00

$1,737.00

$1,871.00

$1,977.00

$2,053.00

$1,840.00

$102.00

$74.00

$89.00

$18.00

$88.00

$482.00

$460.00

$74.00

$133.00

$62.00

$332.00

$1,406.00

$832.00

$1,733.00

$1,555.00

$1,894.00

$1,466.00

$2,142.00

$2,907.00

$4,575.00

$409.00

$664.00

$117.00

$329.00

$523.00

$664.00

$1,247.00

$1,340.00

$1,364.00

$1,079.00

$1,237.00

$1,249.00

$1,371.00

$1,376.00

$1,691.00

$2,999.00

$1,330.00

$1,312.00

$1,469.00

$1,573.00

$1,681.00

$1,403.00

$1,572.00

$1,664.00

$2,199.00

$1,835.00

$1,973.00

$2,086.00

$2,166.00

$1,943.00

$108.00

$78.00

$94.00

$19.00

$92.00

$508.00

$482.00

$77.00

$140.00

$65.00

$351.00

$1,494.00

$880.00

$1,827.00

$1,659.00

$2,006.00

$1,556.00

$2,316.00

$3,156.00

$4,957.00

$430.00

$686.00

$122.00

$346.00

$554.00

$698.00

$1,327.00

$1,464.00

$1,437.00

$1,137.00

$1,306.00

$1,317.00

$1,453.00

$1,463.00

$1,783.00

$3,259.00

$1,402.00


Part B, 254



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

58662

58670

58671

58672

58673

58679

58700

58720

58740

58750

58578

58579

58600

58605

58611

58615

58660

58661

58552

58553

58554

58555

58558

58559

58560

58561

58562

58563

58565

58570

58571

58572

58573

58900

58920

58925

58940

58943

58950

58951

58952

58953

58752

58760

58770

58800

58805

58820

58822

58825

YYY

90

90

90

90

90

90

90

90

90

YYY

YYY

90

90

ZZZ

10

90

10

0

0

0

90

90

90

90

90

90 $853.00

90 $1,096.00

90 $1,085.00

0 $261.00

0

0

0

$340.00

$436.00

$482.00

$677.00

$339.00

$450.00

--------

--------

--------

--------

--------

BR

BR

$337.00

$298.00

$47.00

$319.00

$793.00

$804.00

$807.00

$450.00

$463.00

$872.00

$928.00

BR

$544.00

$844.00

$508.00

$949.00

90

90

90

90

90

90

90

90

$893.00

$769.00

$763.00

$343.00

$509.00

$326.00

$603.00

$469.00

90

90

90

$489.00

$571.00

$820.00

90 $592.00

90 $1,368.00

90 $1,170.00

90 $1,703.00

90 $1,876.00

90 $1,839.00

--------

--------

$519.00

$470.00

$111.00

$347.00

$972.00

$941.00

$1,023.00

$522.00

$521.00

$1,052.00

$1,144.00

--------

$1,134.00

$1,071.00

$1,279.00

$1,436.00

$1,426.00

$1,636.00

$1,922.00

$437.00

$571.00

$492.00

$554.00

$786.00

$591.00

$2,288.00

$2,560.00

$1,119.00

$1,307.00

$1,472.00

$1,770.00

$1,341.00

$1,185.00

$1,361.00

$451.00

$576.00

$444.00

$1,102.00

$999.00

$665.00

$1,124.00

$1,082.00

$764.00

$1,732.00

$1,663.00

$2,143.00

$2,425.00

$3,001.00

--------

--------

$546.00

$494.00

$117.00

$365.00

$1,025.00

$993.00

$1,079.00

$550.00

$548.00

$1,104.00

$1,202.00

--------

$1,201.00

$1,135.00

$1,352.00

$1,542.00

$1,504.00

$1,721.00

$2,028.00

$463.00

$604.00

$516.00

$581.00

$825.00

$625.00

$2,443.00

$2,733.00

$1,178.00

$1,387.00

$1,552.00

$1,876.00

$1,420.00

$1,251.00

$1,461.00

$475.00

$606.00

$467.00

$1,180.00

$1,051.00

$712.00

$1,205.00

$1,144.00

$812.00

$1,848.00

$1,775.00

$2,286.00

$2,588.00

$3,203.00

--------

--------

$573.00

$518.00

$123.00

$383.00

$1,088.00

$1,057.00

$1,144.00

$578.00

$576.00

$1,164.00

$1,267.00

--------

$1,284.00

$1,215.00

$1,440.00

$1,691.00

$1,597.00

$1,822.00

$2,159.00

$479.00

$628.00

$546.00

$614.00

$873.00

$650.00

$2,477.00

$2,773.00

$1,244.00

$1,488.00

$1,647.00

$2,012.00

$1,518.00

$1,330.00

$1,602.00

$496.00

$635.00

$489.00

$1,284.00

$1,109.00

$770.00

$1,316.00

$1,220.00

$869.00

$2,003.00

$1,924.00

$2,480.00

$2,811.00

$3,479.00

--------

--------

$519.00

$470.00

$111.00

$347.00

$972.00

$941.00

$1,023.00

$522.00

$521.00

$1,052.00

$1,144.00

--------

$1,134.00

$1,071.00

$1,279.00

$1,436.00

$1,426.00

$1,636.00

$1,922.00

$272.00

$384.00

$492.00

$554.00

$786.00

$417.00

$491.00

$619.00

$1,119.00

$1,307.00

$1,472.00

$1,770.00

$1,341.00

$1,185.00

$1,361.00

$425.00

$576.00

$444.00

$1,102.00

$999.00

$665.00

$1,124.00

$1,082.00

$764.00

$1,732.00

$1,663.00

$2,143.00

$2,425.00

$3,001.00

--------

--------

$546.00

$494.00

$117.00

$365.00

$1,025.00

$993.00

$1,079.00

$550.00

$548.00

$1,104.00

$1,202.00

--------

$1,201.00

$1,135.00

$1,352.00

$1,542.00

$1,504.00

$1,721.00

$2,028.00

$286.00

$403.00

$516.00

$581.00

$825.00

$438.00

$515.00

$651.00

$1,178.00

$1,387.00

$1,552.00

$1,876.00

$1,420.00

$1,251.00

$1,461.00

$447.00

$606.00

$467.00

$1,180.00

$1,051.00

$712.00

$1,205.00

$1,144.00

$812.00

$1,848.00

$1,775.00

$2,286.00

$2,588.00

$3,203.00

--------

--------

$573.00

$518.00

$123.00

$383.00

$1,088.00

$1,057.00

$1,144.00

$578.00

$576.00

$1,164.00

$1,267.00

--------

$1,284.00

$1,215.00

$1,440.00

$1,691.00

$1,597.00

$1,822.00

$2,159.00

$302.00

$427.00

$546.00

$614.00

$873.00

$463.00

$544.00

$684.00

$1,244.00

$1,488.00

$1,647.00

$2,012.00

$1,518.00

$1,330.00

$1,602.00

$468.00

$635.00

$489.00

$1,284.00

$1,109.00

$770.00

$1,316.00

$1,220.00

$869.00

$2,003.00

$1,924.00

$2,480.00

$2,811.00

$3,479.00


Part B, 255



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

59135

59136

59140

59150

59151

59160

59200

59300

59320

59325

59025-TC

59030

59050

59051

59100

59120

59121

59130

58954

58956

58957

58958

58960

58999

59000

59001

59012

59015

59020

59020-26

59020-TC

59025

59025-26

59430

59510

59514

59515

59525

59610

59612

59614

59618

59350

59400

59409

59410

59412

59414

59425

59426

0

0

0

0

0

0

0

0

90 $1,999.00

90 --------

90

90

--------

--------

90 $1,174.00

YYY BR

0 $123.00

$167.00

$267.00

$168.00

$85.00

--------

--------

$54.00

--------

0

0

0

0

90

90

90

90

--------

$155.00

$71.00

$47.00

$633.00

$893.00

$768.00

$832.00

10

0

0

0

0

90 $1,083.00

90 $934.00

90

90

90

$461.00

$543.00

$690.00

$279.00

$79.00

$179.00

$196.00

$316.00

0 $375.00

0 $1,816.00

0 $1,019.00

0

0

0 $1,123.00

0 $141.00

0

$134.00

$414.00

$708.00

0 $140.00

0 $2,064.00

0 $1,199.00

0 $1,324.00

ZZZ $591.00

0 $1,805.00

0 $1,113.00

0 $1,208.00

0 $2,035.00

$25.00

$146.00

$77.00

$64.00

$1,170.00

$1,185.00

$1,189.00

$1,391.00

$1,199.00

$1,251.00

$583.00

$1,151.00

$1,117.00

$300.00

$104.00

$283.00

$228.00

$365.00

$3,263.00

$2,032.00

$2,346.00

$2,574.00

$1,434.00

--------

$182.00

$271.00

$306.00

$230.00

$102.00

$55.00

$46.00

$70.00

$45.00

$395.00

$3,098.00

$1,223.00

$1,559.00

$156.00

$139.00

$667.00

$1,190.00

$270.00

$3,448.00

$1,381.00

$1,896.00

$728.00

$3,270.00

$1,385.00

$1,720.00

$3,497.00

$27.00

$152.00

$82.00

$68.00

$1,242.00

$1,274.00

$1,280.00

$1,497.00

$1,248.00

$1,330.00

$619.00

$1,239.00

$1,201.00

$323.00

$111.00

$304.00

$246.00

$393.00

$3,484.00

$2,167.00

$2,506.00

$2,746.00

$1,532.00

--------

$195.00

$291.00

$329.00

$247.00

$109.00

$59.00

$50.00

$75.00

$48.00

$419.00

$3,325.00

$1,312.00

$1,673.00

$167.00

$149.00

$715.00

$1,275.00

$289.00

$3,708.00

$1,484.00

$2,039.00

$782.00

$3,518.00

$1,490.00

$1,851.00

$3,762.00

$28.00

$158.00

$91.00

$76.00

$1,335.00

$1,401.00

$1,409.00

$1,650.00

$1,292.00

$1,433.00

$659.00

$1,364.00

$1,320.00

$351.00

$119.00

$329.00

$270.00

$434.00

$3,788.00

$2,346.00

$2,724.00

$2,979.00

$1,662.00

--------

$208.00

$322.00

$364.00

$269.00

$116.00

$65.00

$50.00

$80.00

$52.00

$454.00

$3,631.00

$1,447.00

$1,843.00

$185.00

$166.00

$773.00

$1,376.00

$311.00

$4,066.00

$1,640.00

$2,252.00

$864.00

$3,860.00

$1,653.00

$2,051.00

$4,129.00

$25.00

$146.00

$77.00

$64.00

$1,170.00

$1,185.00

$1,189.00

$1,391.00

$1,199.00

$1,251.00

$583.00

$1,151.00

$1,117.00

$259.00

$67.00

$223.00

$228.00

$365.00

$3,263.00

$2,032.00

$2,346.00

$2,574.00

$1,434.00

--------

$121.00

$271.00

$306.00

$198.00

$102.00

$55.00

$46.00

$70.00

$45.00

$395.00

$3,098.00

$1,223.00

$1,559.00

$156.00

$139.00

$534.00

$940.00

$209.00

$3,448.00

$1,381.00

$1,896.00

$728.00

$3,270.00

$1,385.00

$1,720.00

$3,497.00

$27.00

$152.00

$82.00

$68.00

$1,242.00

$1,274.00

$1,280.00

$1,497.00

$1,248.00

$1,330.00

$619.00

$1,239.00

$1,201.00

$278.00

$72.00

$240.00

$246.00

$393.00

$3,484.00

$2,167.00

$2,506.00

$2,746.00

$1,532.00

--------

$130.00

$291.00

$329.00

$213.00

$109.00

$59.00

$50.00

$75.00

$48.00

$419.00

$3,325.00

$1,312.00

$1,673.00

$167.00

$149.00

$572.00

$1,007.00

$223.00

$3,708.00

$1,484.00

$2,039.00

$782.00

$3,518.00

$1,490.00

$1,851.00

$3,762.00

$28.00

$158.00

$91.00

$76.00

$1,335.00

$1,401.00

$1,409.00

$1,650.00

$1,292.00

$1,433.00

$659.00

$1,364.00

$1,320.00

$306.00

$79.00

$264.00

$270.00

$434.00

$3,788.00

$2,346.00

$2,724.00

$2,979.00

$1,662.00

--------

$143.00

$322.00

$364.00

$235.00

$116.00

$65.00

$50.00

$80.00

$52.00

$454.00

$3,631.00

$1,447.00

$1,843.00

$185.00

$166.00

$630.00

$1,107.00

$246.00

$4,066.00

$1,640.00

$2,252.00

$864.00

$3,860.00

$1,653.00

$2,051.00

$4,129.00


Part B, 256



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

60212

60220

60225

60240

60252

60254

60260

60270

60271

60280

59870

59871

59898

59899

60000

60100

60200

60210

59620

59622

59812

59820

59821

59830

59840

59841

59850

59851

59852

59855

59856

59857

59866

60522

60540

60545

60600

60605

60650

60659

60699

61020

60281

60300

60500

60502

60505

60512

60520

60521

10

90

90

90

90

90

90

0

0 $1,293.00

0 $1,397.00

90

90

90

90

10

$343.00

$389.00

$398.00

$496.00

$331.00

$443.00

$449.00

$464.00

$642.00

$477.00

$577.00

$711.00

$304.00

90

0

YYY

YYY

10

0

90

90

$348.00

$192.00

BR

BR

$114.00

$96.00

$744.00

$872.00

90 $1,170.00

90 $851.00

90 $1,107.00

90 $1,228.00

90 $1,427.00

90 $1,911.00

90 $1,022.00

90 $1,468.00

90 $1,210.00

90 $546.00

90

0

$670.00

--------

90 $1,232.00

90 $1,475.00

90 $1,631.00

ZZZ $310.00

90 $1,405.00

90 $1,591.00

90 $1,820.00

90 $1,272.00

90 $1,505.00

90 $1,477.00

90 $1,624.00

90 $1,340.00

YYY BR

YYY

0

BR

$150.00

$698.00

$200.00

--------

--------

$245.00

$161.00

$971.00

$1,047.00

$1,491.00

$1,044.00

$1,378.00

$1,364.00

$1,962.00

$2,482.00

$1,620.00

$2,034.00

$1,568.00

$646.00

$1,415.00

$1,950.00

$469.00

$556.00

$562.00

$649.00

$321.00

$568.00

$501.00

$531.00

$724.00

$619.00

$729.00

$747.00

$313.00

$858.00

$167.00

$1,432.00

$1,914.00

$2,056.00

$365.00

$1,558.00

$1,684.00

$2,039.00

$1,572.00

$1,805.00

$2,091.00

$2,592.00

$1,777.00

--------

--------

$152.00

$751.00

$215.00

--------

--------

$260.00

$169.00

$1,033.00

$1,116.00

$1,589.00

$1,111.00

$1,469.00

$1,453.00

$2,090.00

$2,638.00

$1,724.00

$2,168.00

$1,669.00

$685.00

$1,518.00

$2,099.00

$505.00

$598.00

$604.00

$698.00

$345.00

$611.00

$523.00

$554.00

$756.00

$666.00

$785.00

$778.00

$326.00

$908.00

$177.00

$1,529.00

$2,044.00

$2,190.00

$390.00

$1,669.00

$1,804.00

$2,183.00

$1,673.00

$1,921.00

$2,231.00

$2,767.00

$1,894.00

--------

--------

$164.00

$817.00

$236.00

--------

--------

$271.00

$175.00

$1,107.00

$1,203.00

$1,715.00

$1,194.00

$1,583.00

$1,570.00

$2,260.00

$2,841.00

$1,858.00

$2,350.00

$1,800.00

$723.00

$1,675.00

$2,321.00

$549.00

$646.00

$656.00

$765.00

$376.00

$668.00

$540.00

$572.00

$780.00

$731.00

$863.00

$805.00

$337.00

$959.00

$181.00

$1,657.00

$2,220.00

$2,368.00

$426.00

$1,822.00

$1,975.00

$2,393.00

$1,808.00

$2,078.00

$2,434.00

$3,030.00

$2,057.00

--------

--------

$181.00

$698.00

$200.00

--------

--------

$221.00

$116.00

$971.00

$1,047.00

$1,491.00

$1,044.00

$1,378.00

$1,364.00

$1,962.00

$2,482.00

$1,620.00

$2,034.00

$1,568.00

$646.00

$1,415.00

$1,950.00

$439.00

$525.00

$529.00

$649.00

$309.00

$539.00

$501.00

$531.00

$724.00

$619.00

$729.00

$747.00

$313.00

$858.00

$73.00

$1,432.00

$1,914.00

$2,056.00

$365.00

$1,558.00

$1,684.00

$2,039.00

$1,572.00

$1,805.00

$2,091.00

$2,592.00

$1,777.00

--------

--------

$152.00

$751.00

$215.00

--------

--------

$235.00

$121.00

$1,033.00

$1,116.00

$1,589.00

$1,111.00

$1,469.00

$1,453.00

$2,090.00

$2,638.00

$1,724.00

$2,168.00

$1,669.00

$685.00

$1,518.00

$2,099.00

$472.00

$565.00

$568.00

$698.00

$332.00

$580.00

$523.00

$554.00

$756.00

$666.00

$785.00

$778.00

$326.00

$908.00

$77.00

$1,529.00

$2,044.00

$2,190.00

$390.00

$1,669.00

$1,804.00

$2,183.00

$1,673.00

$1,921.00

$2,231.00

$2,767.00

$1,894.00

--------

--------

$164.00

$817.00

$236.00

--------

--------

$246.00

$126.00

$1,107.00

$1,203.00

$1,715.00

$1,194.00

$1,583.00

$1,570.00

$2,260.00

$2,841.00

$1,858.00

$2,350.00

$1,800.00

$723.00

$1,675.00

$2,321.00

$516.00

$613.00

$619.00

$765.00

$363.00

$637.00

$540.00

$572.00

$780.00

$731.00

$863.00

$805.00

$337.00

$959.00

$81.00

$1,657.00

$2,220.00

$2,368.00

$426.00

$1,822.00

$1,975.00

$2,393.00

$1,808.00

$2,078.00

$2,434.00

$3,030.00

$2,057.00

--------

--------

$181.00


Part B, 257



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

61316

61320

61321

61322

61323

61330

61332

61333

61340

61343

61250

61253

61304

61305

61312

61313

61314

61315

61026

61050

61055

61070

61105

61107

61108

61120

61140

61150

61151

61154

61156

61210

61215

61512

61514

61516

61517

61518

61519

61520

61521

61522

61345

61450

61458

61460

61480

61500

61501

61510

0

0

0

0

90

0

90

$138.00

$106.00

$143.00

$67.00

$503.00

$863.00

$959.00

90 $733.00

90 $1,389.00

90 $1,503.00

90 $795.00

90 $1,393.00

90 $1,473.00

0 $527.00

90 $637.00

90 $888.00

90 $1,042.00

90 $2,005.00

90 $2,419.00

90 $2,187.00

90 $2,207.00

90 $2,200.00

90 $2,393.00

ZZZ $88.00

90 $2,118.00

90 $2,310.00

90 $1,779.00

90 $1,842.00

90 $1,706.00

90 $2,307.00

90 $2,231.00

90 $1,584.00

90 $2,673.00

90 $2,259.00

90 $2,173.00

90 $2,433.00

90 $2,426.00

90 $1,922.00

90 $1,637.00

90 $1,353.00

90 $2,506.00

90 $2,981.00

90 $2,262.00

90 $2,253.00

ZZZ $74.00

90 $3,163.00

90 $3,450.00

90 $4,349.00

90 $3,667.00

90 $2,415.00

$1,225.00

$1,201.00

$2,540.00

$3,101.00

$3,222.00

$3,067.00

$2,813.00

$3,200.00

$138.00

$2,941.00

$3,246.00

$3,683.00

$3,738.00

$2,351.00

$2,567.00

$2,662.00

$2,191.00

$3,396.00

$151.00

$125.00

$178.00

$85.00

$691.00

$494.00

$1,385.00

$1,141.00

$1,946.00

$2,064.00

$1,538.00

$1,951.00

$1,921.00

$580.00

$768.00

$3,147.00

$2,979.00

$3,104.00

$3,279.00

$2,375.00

$2,005.00

$1,744.00

$3,372.00

$3,945.00

$2,932.00

$2,861.00

$138.00

$4,263.00

$4,536.00

$5,817.00

$4,885.00

$3,355.00

$1,325.00

$1,269.00

$2,782.00

$3,400.00

$3,532.00

$3,360.00

$3,080.00

$3,508.00

$152.00

$3,222.00

$3,554.00

$4,038.00

$4,104.00

$2,473.00

$2,682.00

$2,793.00

$2,392.00

$3,721.00

$160.00

$131.00

$189.00

$90.00

$754.00

$542.00

$1,514.00

$1,249.00

$2,130.00

$2,260.00

$1,687.00

$2,135.00

$2,105.00

$637.00

$839.00

$3,449.00

$3,267.00

$3,401.00

$3,600.00

$2,504.00

$2,174.00

$1,889.00

$3,694.00

$4,322.00

$3,210.00

$3,132.00

$152.00

$4,671.00

$4,967.00

$6,355.00

$5,354.00

$3,675.00

$1,461.00

$1,346.00

$3,146.00

$3,854.00

$4,007.00

$3,802.00

$3,481.00

$3,975.00

$174.00

$3,648.00

$4,023.00

$4,581.00

$4,672.00

$2,585.00

$2,766.00

$2,909.00

$2,689.00

$4,215.00

$170.00

$137.00

$203.00

$97.00

$838.00

$620.00

$1,694.00

$1,403.00

$2,402.00

$2,554.00

$1,907.00

$2,403.00

$2,381.00

$730.00

$934.00

$3,909.00

$3,708.00

$3,854.00

$4,092.00

$2,655.00

$2,413.00

$2,088.00

$4,178.00

$4,902.00

$3,630.00

$3,540.00

$174.00

$5,294.00

$5,632.00

$7,179.00

$6,081.00

$4,165.00

$1,225.00

$1,201.00

$2,540.00

$3,101.00

$3,222.00

$3,067.00

$2,813.00

$3,200.00

$138.00

$2,941.00

$3,246.00

$3,683.00

$3,738.00

$2,351.00

$2,567.00

$2,662.00

$2,191.00

$3,396.00

$151.00

$125.00

$178.00

$85.00

$691.00

$494.00

$1,385.00

$1,141.00

$1,946.00

$2,064.00

$1,538.00

$1,951.00

$1,921.00

$580.00

$768.00

$3,147.00

$2,979.00

$3,104.00

$3,279.00

$2,375.00

$2,005.00

$1,744.00

$3,372.00

$3,945.00

$2,932.00

$2,861.00

$138.00

$4,263.00

$4,536.00

$5,817.00

$4,885.00

$3,355.00

$1,325.00

$1,269.00

$2,782.00

$3,400.00

$3,532.00

$3,360.00

$3,080.00

$3,508.00

$152.00

$3,222.00

$3,554.00

$4,038.00

$4,104.00

$2,473.00

$2,682.00

$2,793.00

$2,392.00

$3,721.00

$160.00

$131.00

$189.00

$90.00

$754.00

$542.00

$1,514.00

$1,249.00

$2,130.00

$2,260.00

$1,687.00

$2,135.00

$2,105.00

$637.00

$839.00

$3,449.00

$3,267.00

$3,401.00

$3,600.00

$2,504.00

$2,174.00

$1,889.00

$3,694.00

$4,322.00

$3,210.00

$3,132.00

$152.00

$4,671.00

$4,967.00

$6,355.00

$5,354.00

$3,675.00

$1,461.00

$1,346.00

$3,146.00

$3,854.00

$4,007.00

$3,802.00

$3,481.00

$3,975.00

$174.00

$3,648.00

$4,023.00

$4,581.00

$4,672.00

$2,585.00

$2,766.00

$2,909.00

$2,689.00

$4,215.00

$170.00

$137.00

$203.00

$97.00

$838.00

$620.00

$1,694.00

$1,403.00

$2,402.00

$2,554.00

$1,907.00

$2,403.00

$2,381.00

$730.00

$934.00

$3,909.00

$3,708.00

$3,854.00

$4,092.00

$2,655.00

$2,413.00

$2,088.00

$4,178.00

$4,902.00

$3,630.00

$3,540.00

$174.00

$5,294.00

$5,632.00

$7,179.00

$6,081.00

$4,165.00


Part B, 258



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

61559

61563

61564

61566

61567

61570

61571

61575

61576

61580

61545

61546

61548

61550

61552

61556

61557

61558

61524

61526

61530

61531

61533

61534

61535

61536

61537

61538

61539

61540

61541

61543

61544

61592

61595

61596

61597

61598

61600

61601

61605

61606

61581

61582

61583

61584

61585

61586

61590

61591

90 $2,484.00

90 $3,918.00

90 $3,611.00

90 $1,344.00

90 $1,712.00

90 $1,535.00

90 $958.00

90 $2,862.00

90 --------

90 $2,466.00

90 $2,660.00

90 --------

90 $2,363.00

90 $2,307.00

90 $2,271.00

90 $3,474.00

90 $2,695.00

90 $1,964.00

90 $1,141.00

90 $1,463.00

90 $1,760.00

90 $1,807.00

90 $2,085.00

90 $2,700.00

90 $2,175.00

90 $2,597.00

90 --------

90 --------

90 $1,975.00

90 $2,140.00

90 $2,992.00

90 $3,772.00

90 $2,383.00

90 $2,674.00

90 $2,557.00

90 $2,972.00

90 $2,830.00

90 $3,142.00

90 $2,097.00

90 $3,299.00

90 $3,491.00

90 $3,245.00

90 $2,350.00

90 $2,827.00

90 $3,046.00

90 $2,693.00

90 $2,039.00

90 $2,279.00

90 $2,299.00

90 $3,178.00

$4,970.00

$3,599.00

$2,407.00

$1,414.00

$1,705.00

$2,397.00

$2,449.00

$2,919.00

$3,150.00

$2,942.00

$3,527.00

$3,481.00

$3,995.00

$2,884.00

$3,077.00

$3,180.00

$5,382.00

$3,727.00

$3,205.00

$5,709.00

$4,811.00

$1,872.00

$2,348.00

$2,498.00

$1,526.00

$4,027.00

$3,819.00

$4,163.00

$3,632.00

$3,402.00

$3,349.00

$3,251.00

$2,964.00

$3,893.00

$4,372.00

$4,424.00

$4,363.00

$4,961.00

$3,644.00

$4,517.00

$4,631.00

$4,855.00

$3,521.00

$3,577.00

$4,306.00

$4,344.00

$3,173.00

$3,682.00

$3,200.00

$4,553.00

$5,458.00

$3,951.00

$2,619.00

$1,495.00

$1,798.00

$2,593.00

$2,666.00

$3,204.00

$3,367.00

$3,214.00

$3,828.00

$3,817.00

$4,386.00

$3,161.00

$3,375.00

$3,371.00

$5,745.00

$4,002.00

$3,514.00

$6,271.00

$5,285.00

$2,050.00

$2,573.00

$2,729.00

$1,670.00

$4,423.00

$4,187.00

$4,571.00

$3,977.00

$3,735.00

$3,676.00

$3,541.00

$3,254.00

$4,125.00

$4,757.00

$4,835.00

$4,768.00

$5,438.00

$3,980.00

$4,816.00

$4,961.00

$5,301.00

$3,779.00

$3,779.00

$4,689.00

$4,755.00

$3,400.00

$4,018.00

$3,398.00

$4,959.00

$6,213.00

$4,496.00

$2,934.00

$1,584.00

$1,908.00

$2,875.00

$2,984.00

$3,635.00

$3,654.00

$3,628.00

$4,267.00

$4,331.00

$4,989.00

$3,581.00

$3,828.00

$3,612.00

$6,191.00

$4,335.00

$3,986.00

$7,152.00

$6,026.00

$2,312.00

$2,913.00

$3,070.00

$1,877.00

$5,037.00

$4,758.00

$5,209.00

$4,505.00

$4,247.00

$4,180.00

$3,972.00

$3,699.00

$4,361.00

$5,258.00

$5,425.00

$5,345.00

$6,132.00

$4,419.00

$5,181.00

$5,385.00

$5,942.00

$4,101.00

$4,000.00

$5,249.00

$5,339.00

$3,670.00

$4,486.00

$3,617.00

$5,542.00

$4,970.00

$3,599.00

$2,407.00

$1,414.00

$1,705.00

$2,397.00

$2,449.00

$2,919.00

$3,150.00

$2,942.00

$3,527.00

$3,481.00

$3,995.00

$2,884.00

$3,077.00

$3,180.00

$5,382.00

$3,727.00

$3,205.00

$5,709.00

$4,811.00

$1,872.00

$2,348.00

$2,498.00

$1,526.00

$4,027.00

$3,819.00

$4,163.00

$3,632.00

$3,402.00

$3,349.00

$3,251.00

$2,964.00

$3,893.00

$4,372.00

$4,424.00

$4,363.00

$4,961.00

$3,644.00

$4,517.00

$4,631.00

$4,855.00

$3,521.00

$3,577.00

$4,306.00

$4,344.00

$3,173.00

$3,682.00

$3,200.00

$4,553.00

$5,458.00

$3,951.00

$2,619.00

$1,495.00

$1,798.00

$2,593.00

$2,666.00

$3,204.00

$3,367.00

$3,214.00

$3,828.00

$3,817.00

$4,386.00

$3,161.00

$3,375.00

$3,371.00

$5,745.00

$4,002.00

$3,514.00

$6,271.00

$5,285.00

$2,050.00

$2,573.00

$2,729.00

$1,670.00

$4,423.00

$4,187.00

$4,571.00

$3,977.00

$3,735.00

$3,676.00

$3,541.00

$3,254.00

$4,125.00

$4,757.00

$4,835.00

$4,768.00

$5,438.00

$3,980.00

$4,816.00

$4,961.00

$5,301.00

$3,779.00

$3,779.00

$4,689.00

$4,755.00

$3,400.00

$4,018.00

$3,398.00

$4,959.00

$6,213.00

$4,496.00

$2,934.00

$1,584.00

$1,908.00

$2,875.00

$2,984.00

$3,635.00

$3,654.00

$3,628.00

$4,267.00

$4,331.00

$4,989.00

$3,581.00

$3,828.00

$3,612.00

$6,191.00

$4,335.00

$3,986.00

$7,152.00

$6,026.00

$2,312.00

$2,913.00

$3,070.00

$1,877.00

$5,037.00

$4,758.00

$5,209.00

$4,505.00

$4,247.00

$4,180.00

$3,972.00

$3,699.00

$4,361.00

$5,258.00

$5,425.00

$5,345.00

$6,132.00

$4,419.00

$5,181.00

$5,385.00

$5,942.00

$4,101.00

$4,000.00

$5,249.00

$5,339.00

$3,670.00

$4,486.00

$3,617.00

$5,542.00


Part B, 259



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

61684

61686

61690

61692

61697

61698

61700

61702

61703

61705

61640

61641

61642

61645

61650

61651

61680

61682

61607

61608

61610

61611

61612

61613

61615

61616

61618

61619

61623

61624

61626

61630

61635

61770

61781

61782

61783

61790

61791

61796

61797

61798

61708

61710

61711

61720

61735

61750

61751

61760

90 $2,961.00

90 $3,458.00

ZZZ $2,354.00

ZZZ $584.00

ZZZ $2,219.00

90 $3,375.00

90 $2,576.00

0

0

0

90 $3,535.00

90 $1,389.00

90 $1,682.00

0 $540.00

0 $1,073.00

$877.00

--------

--------

0

ZZZ

ZZZ

0

0

--------

--------

--------

--------

--------

ZZZ --------

90 $2,758.00

90 $4,798.00

90 $3,341.00

90 $5,012.00

90 $2,556.00

90 $4,007.00

90 $3,231.00

90 $3,103.00

90 $4,037.00

90 $4,019.00

90 $1,444.00

90 $3,043.00

90 $2,546.00

90 $2,129.00

90 $3,150.00

90 $1,558.00

90 $1,664.00

90 $1,521.00

90 $1,628.00

90 $1,670.00

90 $1,867.00

ZZZ --------

ZZZ --------

ZZZ

90

--------

$952.00

90 $1,205.00

90 --------

ZZZ

90

--------

--------

$956.00

$335.00

$671.00

$1,171.00

$777.00

$330.00

$3,465.00

$6,469.00

$4,442.00

$6,981.00

$3,351.00

$5,665.00

$6,573.00

$7,220.00

$5,276.00

$6,245.00

$2,108.00

$3,960.00

$4,089.00

$4,988.00

$2,296.00

$574.00

$2,158.00

$4,934.00

$3,347.00

$5,088.00

$1,978.00

$2,181.00

$861.00

$1,733.00

$1,281.00

$2,010.00

$2,151.00

$3,123.00

$3,357.00

$4,019.00

$1,970.00

$2,437.00

$2,176.00

$2,133.00

$2,458.00

$2,510.00

$369.00

$261.00

$361.00

$1,355.00

$1,640.00

$1,567.00

$347.00

$2,143.00

$1,006.00

$353.00

$706.00

$1,248.00

$825.00

$350.00

$3,794.00

$7,092.00

$4,878.00

$7,660.00

$3,670.00

$6,211.00

$7,211.00

$7,928.00

$5,783.00

$6,853.00

$2,312.00

$4,324.00

$4,405.00

$5,451.00

$2,417.00

$604.00

$2,272.00

$5,380.00

$3,544.00

$5,540.00

$2,150.00

$2,353.00

$926.00

$1,864.00

$1,352.00

$2,163.00

$2,306.00

$3,296.00

$3,686.00

$4,403.00

$2,162.00

$2,672.00

$2,386.00

$2,339.00

$2,698.00

$2,753.00

$404.00

$276.00

$394.00

$1,484.00

$1,789.00

$1,717.00

$382.00

$2,348.00

$1,072.00

$376.00

$753.00

$1,367.00

$896.00

$381.00

$4,295.00

$8,073.00

$5,556.00

$8,727.00

$4,154.00

$7,062.00

$8,210.00

$9,047.00

$6,568.00

$7,805.00

$2,619.00

$4,874.00

$4,836.00

$6,133.00

$2,576.00

$644.00

$2,421.00

$6,024.00

$3,762.00

$6,189.00

$2,398.00

$2,592.00

$1,024.00

$2,066.00

$1,451.00

$2,388.00

$2,531.00

$3,506.00

$4,196.00

$4,994.00

$2,449.00

$3,027.00

$2,704.00

$2,644.00

$3,063.00

$3,125.00

$462.00

$295.00

$446.00

$1,672.00

$2,007.00

$1,940.00

$438.00

$2,661.00

$956.00

$335.00

$671.00

$1,171.00

$777.00

$330.00

$3,465.00

$6,469.00

$4,442.00

$6,981.00

$3,351.00

$5,665.00

$6,573.00

$7,220.00

$5,276.00

$6,245.00

$2,108.00

$3,960.00

$4,089.00

$4,988.00

$2,296.00

$574.00

$2,158.00

$4,934.00

$3,347.00

$5,088.00

$1,978.00

$2,181.00

$861.00

$1,733.00

$1,281.00

$2,010.00

$2,151.00

$3,123.00

$3,357.00

$4,019.00

$1,970.00

$2,437.00

$2,176.00

$2,133.00

$2,458.00

$2,510.00

$369.00

$261.00

$361.00

$1,355.00

$1,640.00

$1,567.00

$347.00

$2,143.00

$1,006.00

$353.00

$706.00

$1,248.00

$825.00

$350.00

$3,794.00

$7,092.00

$4,878.00

$7,660.00

$3,670.00

$6,211.00

$7,211.00

$7,928.00

$5,783.00

$6,853.00

$2,312.00

$4,324.00

$4,405.00

$5,451.00

$2,417.00

$604.00

$2,272.00

$5,380.00

$3,544.00

$5,540.00

$2,150.00

$2,353.00

$926.00

$1,864.00

$1,352.00

$2,163.00

$2,306.00

$3,296.00

$3,686.00

$4,403.00

$2,162.00

$2,672.00

$2,386.00

$2,339.00

$2,698.00

$2,753.00

$404.00

$276.00

$394.00

$1,484.00

$1,789.00

$1,717.00

$382.00

$2,348.00

$1,072.00

$376.00

$753.00

$1,367.00

$896.00

$381.00

$4,295.00

$8,073.00

$5,556.00

$8,727.00

$4,154.00

$7,062.00

$8,210.00

$9,047.00

$6,568.00

$7,805.00

$2,619.00

$4,874.00

$4,836.00

$6,133.00

$2,576.00

$644.00

$2,421.00

$6,024.00

$3,762.00

$6,189.00

$2,398.00

$2,592.00

$1,024.00

$2,066.00

$1,451.00

$2,388.00

$2,531.00

$3,506.00

$4,196.00

$4,994.00

$2,449.00

$3,027.00

$2,704.00

$2,644.00

$3,063.00

$3,125.00

$462.00

$295.00

$446.00

$1,672.00

$2,007.00

$1,940.00

$438.00

$2,661.00


Part B, 260



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

62142

62143

62145

62146

62147

62148

62160

62161

62162

62163

62010

62100

62115

62117

62120

62121

62140

62141

61799

61800

61850

61860

61863

61864

61867

61868

61870

61880

61885

61886

61888

62000

62005

62164

62165

62180

62190

62192

62194

62200

62201

62220

62223

62225

62230

62252

62252-26

62252-TC

62256

62258

ZZZ

ZZZ

--------

--------

90 $1,090.00

90 $1,197.00

90

ZZZ

90

--------

--------

--------

ZZZ

90

90

90

90

--------

$616.00

$559.00

$262.00

$678.00

10

90

$331.00

$848.00

90 $1,282.00

90 $1,754.00

90 $1,962.00

90 $1,686.00

90 $2,211.00

90 $1,898.00

90 $1,822.00

90 $1,221.00

90 $1,955.00

90 $1,011.00

90 $1,096.00

90 $1,566.00

90 $1,327.00

90 $1,566.00

ZZZ $120.00

ZZZ $172.00

90 $1,229.00

90 $1,578.00

90 $999.00

90 $1,706.00

90 $1,336.00

90 $1,695.00

90 $1,034.00

90 $1,146.00

10 $239.00

90 $1,625.00

90 $1,200.00

90 $1,215.00

90 $1,199.00

90 $488.00

90

0

0

0

$935.00

$85.00

--------

--------

90 $616.00

90 $1,308.00

$2,360.00

$2,445.00

$1,922.00

$2,401.00

$2,442.00

$2,389.00

$1,577.00

$1,739.00

$1,355.00

$1,592.00

$2,170.00

$1,915.00

$2,168.00

$200.00

$299.00

$2,348.00

$2,924.00

$1,679.00

$478.00

$240.00

$1,519.00

$2,435.00

$2,316.00

$447.00

$3,531.00

$784.00

$1,749.00

$868.00

$777.00

$1,279.00

$606.00

$1,593.00

$1,910.00

$3,210.00

$2,349.00

$2,466.00

$1,346.00

$1,496.00

$703.00

$2,129.00

$1,858.00

$1,580.00

$1,602.00

$797.00

$1,291.00

$126.00

$72.00

$53.00

$910.00

$1,729.00

$2,586.00

$2,663.00

$2,026.00

$2,532.00

$2,587.00

$2,568.00

$1,718.00

$1,895.00

$1,480.00

$1,741.00

$2,373.00

$2,098.00

$2,359.00

$220.00

$329.00

$2,573.00

$3,208.00

$1,809.00

$526.00

$264.00

$1,665.00

$2,673.00

$2,538.00

$492.00

$3,870.00

$861.00

$1,901.00

$948.00

$846.00

$1,396.00

$662.00

$1,747.00

$2,087.00

$3,517.00

$2,545.00

$2,702.00

$1,467.00

$1,636.00

$767.00

$2,334.00

$2,036.00

$1,728.00

$1,750.00

$871.00

$1,411.00

$136.00

$79.00

$57.00

$995.00

$1,891.00

$2,924.00

$2,986.00

$2,150.00

$2,685.00

$2,735.00

$2,798.00

$1,922.00

$2,122.00

$1,659.00

$1,959.00

$2,674.00

$2,369.00

$2,640.00

$253.00

$378.00

$2,911.00

$3,639.00

$1,984.00

$602.00

$300.00

$1,882.00

$3,035.00

$2,867.00

$563.00

$4,390.00

$985.00

$2,117.00

$1,057.00

$936.00

$1,551.00

$743.00

$1,974.00

$2,350.00

$3,979.00

$2,825.00

$3,057.00

$1,639.00

$1,839.00

$854.00

$2,644.00

$2,296.00

$1,944.00

$1,960.00

$970.00

$1,586.00

$148.00

$90.00

$58.00

$1,111.00

$2,128.00

$2,360.00

$2,445.00

$1,922.00

$2,401.00

$2,442.00

$2,389.00

$1,577.00

$1,739.00

$1,355.00

$1,592.00

$2,170.00

$1,915.00

$2,168.00

$200.00

$299.00

$2,348.00

$2,924.00

$1,679.00

$478.00

$240.00

$1,519.00

$2,435.00

$2,316.00

$447.00

$3,531.00

$784.00

$1,749.00

$868.00

$777.00

$1,279.00

$606.00

$1,593.00

$1,910.00

$3,210.00

$2,349.00

$2,466.00

$1,346.00

$1,496.00

$703.00

$2,129.00

$1,858.00

$1,580.00

$1,602.00

$797.00

$1,291.00

$126.00

$72.00

$53.00

$910.00

$1,729.00

$2,586.00

$2,663.00

$2,026.00

$2,532.00

$2,587.00

$2,568.00

$1,718.00

$1,895.00

$1,480.00

$1,741.00

$2,373.00

$2,098.00

$2,359.00

$220.00

$329.00

$2,573.00

$3,208.00

$1,809.00

$526.00

$264.00

$1,665.00

$2,673.00

$2,538.00

$492.00

$3,870.00

$861.00

$1,901.00

$948.00

$846.00

$1,396.00

$662.00

$1,747.00

$2,087.00

$3,517.00

$2,545.00

$2,702.00

$1,467.00

$1,636.00

$767.00

$2,334.00

$2,036.00

$1,728.00

$1,750.00

$871.00

$1,411.00

$136.00

$79.00

$57.00

$995.00

$1,891.00

$2,924.00

$2,986.00

$2,150.00

$2,685.00

$2,735.00

$2,798.00

$1,922.00

$2,122.00

$1,659.00

$1,959.00

$2,674.00

$2,369.00

$2,640.00

$253.00

$378.00

$2,911.00

$3,639.00

$1,984.00

$602.00

$300.00

$1,882.00

$3,035.00

$2,867.00

$563.00

$4,390.00

$985.00

$2,117.00

$1,057.00

$936.00

$1,551.00

$743.00

$1,974.00

$2,350.00

$3,979.00

$2,825.00

$3,057.00

$1,639.00

$1,839.00

$854.00

$2,644.00

$2,296.00

$1,944.00

$1,960.00

$970.00

$1,586.00

$148.00

$90.00

$58.00

$1,111.00

$2,128.00


Part B, 261



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

62318

62319

62350

62351

62355

62360

62361

62362

62365

62367

62292

62294

62302

62303

62304

62305

62310

62311

62263

62264

62267

62268

62269

62270

62272

62273

62280

62281

62282

62284

62287

62290

62291

63015

63016

63017

63020

63030

63035

63040

63042

63043

62368

62369

62370

63001

63003

63005

63011

63012

0

10

10

10

0

90

0

0

10

10

0

0

0

0

0

10

10

10

10

0

0

0

10

90

10

0

0

0

90 $1,064.00

90 $821.00

0

0

0

--------

--------

--------

--------

$200.00

$201.00

$208.00

$203.00

$488.00

$782.00

$402.00

$195.00

$390.00

$517.00

$418.00

BR

$426.00

$593.00

--------

$285.00

$271.00

$109.00

$137.00

$130.00

$199.00

$186.00

$211.00

$196.00

$784.00

$235.00

$232.00

0

0

0

BR

--------

--------

90 $1,882.00

90 $1,591.00

90 $1,390.00

90 $1,151.00

90 $1,568.00

90 $1,862.00

90 $1,788.00

90 $1,489.00

90 $1,395.00

90 $1,145.00

ZZZ $280.00

90 $1,764.00

90 $1,620.00

ZZZ BR

$839.00

$1,134.00

$339.00

$352.00

$336.00

$366.00

$336.00

$310.00

$323.00

$237.00

$592.00

$1,305.00

$396.00

$461.00

$532.00

$573.00

$439.00

$59.00

$913.00

$596.00

$353.00

$378.00

$397.00

$225.00

$285.00

$246.00

$431.00

$342.00

$412.00

$256.00

$824.00

$470.00

$465.00

$81.00

$168.00

$177.00

$1,898.00

$1,883.00

$1,792.00

$1,641.00

$1,804.00

$2,271.00

$2,314.00

$1,908.00

$1,754.00

$1,456.00

$293.00

$2,107.00

$1,949.00

--------

$877.00

$1,185.00

$359.00

$373.00

$355.00

$387.00

$356.00

$329.00

$341.00

$250.00

$630.00

$1,413.00

$423.00

$493.00

$569.00

$613.00

$471.00

$62.00

$967.00

$629.00

$372.00

$395.00

$416.00

$239.00

$306.00

$259.00

$458.00

$363.00

$438.00

$272.00

$866.00

$497.00

$492.00

$85.00

$178.00

$188.00

$2,069.00

$2,048.00

$1,948.00

$1,768.00

$1,957.00

$2,478.00

$2,517.00

$2,078.00

$1,902.00

$1,576.00

$317.00

$2,283.00

$2,105.00

--------

$907.00

$1,225.00

$368.00

$382.00

$364.00

$396.00

$363.00

$335.00

$348.00

$257.00

$675.00

$1,554.00

$453.00

$531.00

$614.00

$662.00

$507.00

$64.00

$985.00

$645.00

$383.00

$413.00

$439.00

$247.00

$318.00

$267.00

$472.00

$377.00

$450.00

$278.00

$906.00

$510.00

$502.00

$88.00

$182.00

$192.00

$2,319.00

$2,287.00

$2,167.00

$1,938.00

$2,173.00

$2,780.00

$2,810.00

$2,321.00

$2,107.00

$1,736.00

$354.00

$2,532.00

$2,317.00

--------

$839.00

$1,134.00

$179.00

$182.00

$176.00

$184.00

$157.00

$130.00

$145.00

$139.00

$592.00

$1,305.00

$396.00

$461.00

$532.00

$573.00

$439.00

$37.00

$488.00

$347.00

$233.00

$378.00

$397.00

$114.00

$124.00

$166.00

$235.00

$229.00

$211.00

$125.00

$824.00

$251.00

$248.00

$52.00

$52.00

$68.00

$1,898.00

$1,883.00

$1,792.00

$1,641.00

$1,804.00

$2,271.00

$2,314.00

$1,908.00

$1,754.00

$1,456.00

$293.00

$2,107.00

$1,949.00

--------

$877.00

$1,185.00

$187.00

$190.00

$184.00

$192.00

$164.00

$136.00

$150.00

$145.00

$630.00

$1,413.00

$423.00

$493.00

$569.00

$613.00

$471.00

$39.00

$511.00

$362.00

$243.00

$395.00

$416.00

$121.00

$133.00

$173.00

$247.00

$242.00

$223.00

$131.00

$866.00

$263.00

$259.00

$54.00

$55.00

$71.00

$2,069.00

$2,048.00

$1,948.00

$1,768.00

$1,957.00

$2,478.00

$2,517.00

$2,078.00

$1,902.00

$1,576.00

$317.00

$2,283.00

$2,105.00

--------

$907.00

$1,225.00

$195.00

$198.00

$192.00

$200.00

$171.00

$141.00

$156.00

$152.00

$675.00

$1,554.00

$453.00

$531.00

$614.00

$662.00

$507.00

$41.00

$527.00

$377.00

$253.00

$413.00

$439.00

$128.00

$145.00

$180.00

$261.00

$255.00

$234.00

$138.00

$906.00

$274.00

$269.00

$57.00

$57.00

$75.00

$2,319.00

$2,287.00

$2,167.00

$1,938.00

$2,173.00

$2,780.00

$2,810.00

$2,321.00

$2,107.00

$1,736.00

$354.00

$2,532.00

$2,317.00

--------


Part B, 262



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

63091

63101

63102

63103

63170

63172

63173

63180

63182

63185

63078

63081

63082

63085

63086

63087

63088

63090

63044

63045

63046

63047

63048

63050

63051

63055

63056

63057

63064

63066

63075

63076

63077

63200

63250

63251

63252

63265

63266

63267

63268

63270

63190

63191

63194

63195

63196

63197

63198

63199

ZZZ BR

90 $1,647.00

90 $2,117.00

90 $1,907.00

ZZZ $367.00

90 --------

90 --------

90 $2,029.00

90 $1,960.00

ZZZ $421.00

90 $2,200.00

ZZZ $263.00

90 $1,720.00

ZZZ $383.00

90 $1,828.00

ZZZ $261.00

90 $2,203.00

ZZZ $391.00

90 $2,416.00

ZZZ $282.00

90 $2,930.00

ZZZ $381.00

90 $2,490.00

ZZZ $249.00

90 --------

90

ZZZ

--------

--------

90 $1,788.00

90 $1,672.00

90 $1,851.00

90 $1,486.00

90 $1,711.00

90 $1,347.00

90 $1,610.00

90 $1,444.00

90 $1,593.00

90 $1,603.00

90 $1,810.00

90 $1,725.00

90 $1,956.00

90 $2,258.00

90 $1,569.00

90 $3,182.00

90 $3,207.00

90 $3,319.00

90 $1,940.00

90 $2,053.00

90 $1,651.00

90 $1,469.00

90 $2,197.00

$293.00

$2,667.00

$409.00

$2,898.00

$291.00

$3,647.00

$396.00

$2,927.00

$267.00

$3,528.00

$3,436.00

$449.00

$2,473.00

$2,124.00

$2,645.00

$2,305.00

$2,101.00

$1,700.00

--------

$1,961.00

$1,844.00

$1,662.00

$324.00

$2,251.00

$2,587.00

$2,491.00

$2,245.00

$490.00

$2,693.00

$326.00

$2,054.00

$379.00

$2,265.00

$1,882.00

$2,074.00

$2,478.00

$2,389.00

$2,078.00

$2,660.00

$2,448.00

$2,570.00

$2,358.00

$4,311.00

$4,723.00

$4,717.00

$2,562.00

$2,634.00

$2,083.00

$2,204.00

$3,226.00

$315.00

$2,890.00

$443.00

$3,136.00

$315.00

$3,943.00

$428.00

$3,140.00

$286.00

$3,836.00

$3,716.00

$486.00

$2,713.00

$2,317.00

$2,898.00

$2,528.00

$2,262.00

$1,832.00

--------

$2,134.00

$1,999.00

$1,800.00

$351.00

$2,435.00

$2,799.00

$2,715.00

$2,431.00

$531.00

$2,925.00

$359.00

$2,228.00

$412.00

$2,446.00

$2,020.00

$2,262.00

$2,718.00

$2,622.00

$2,190.00

$2,919.00

$2,580.00

$2,708.00

$2,580.00

$4,687.00

$5,183.00

$5,175.00

$2,798.00

$2,875.00

$2,264.00

$2,412.00

$3,539.00

$347.00

$3,210.00

$497.00

$3,481.00

$352.00

$4,371.00

$476.00

$3,430.00

$313.00

$4,285.00

$4,112.00

$543.00

$3,075.00

$2,599.00

$3,279.00

$2,863.00

$2,494.00

$2,007.00

--------

$2,381.00

$2,211.00

$1,987.00

$393.00

$2,691.00

$3,099.00

$3,046.00

$2,696.00

$594.00

$3,262.00

$412.00

$2,472.00

$462.00

$2,702.00

$2,201.00

$2,535.00

$3,079.00

$2,974.00

$2,327.00

$3,311.00

$2,741.00

$2,877.00

$2,910.00

$5,257.00

$5,899.00

$5,888.00

$3,148.00

$3,232.00

$2,524.00

$2,719.00

$4,019.00

$293.00

$2,667.00

$409.00

$2,898.00

$291.00

$3,647.00

$396.00

$2,927.00

$267.00

$3,528.00

$3,436.00

$449.00

$2,473.00

$2,124.00

$2,645.00

$2,305.00

$2,101.00

$1,700.00

--------

$1,961.00

$1,844.00

$1,662.00

$324.00

$2,251.00

$2,587.00

$2,491.00

$2,245.00

$490.00

$2,693.00

$326.00

$2,054.00

$379.00

$2,265.00

$1,882.00

$2,074.00

$2,478.00

$2,389.00

$2,078.00

$2,660.00

$2,448.00

$2,570.00

$2,358.00

$4,311.00

$4,723.00

$4,717.00

$2,562.00

$2,634.00

$2,083.00

$2,204.00

$3,226.00

$315.00

$2,890.00

$443.00

$3,136.00

$315.00

$3,943.00

$428.00

$3,140.00

$286.00

$3,836.00

$3,716.00

$486.00

$2,713.00

$2,317.00

$2,898.00

$2,528.00

$2,262.00

$1,832.00

--------

$2,134.00

$1,999.00

$1,800.00

$351.00

$2,435.00

$2,799.00

$2,715.00

$2,431.00

$531.00

$2,925.00

$359.00

$2,228.00

$412.00

$2,446.00

$2,020.00

$2,262.00

$2,718.00

$2,622.00

$2,190.00

$2,919.00

$2,580.00

$2,708.00

$2,580.00

$4,687.00

$5,183.00

$5,175.00

$2,798.00

$2,875.00

$2,264.00

$2,412.00

$3,539.00

$347.00

$3,210.00

$497.00

$3,481.00

$352.00

$4,371.00

$476.00

$3,430.00

$313.00

$4,285.00

$4,112.00

$543.00

$3,075.00

$2,599.00

$3,279.00

$2,863.00

$2,494.00

$2,007.00

--------

$2,381.00

$2,211.00

$1,987.00

$393.00

$2,691.00

$3,099.00

$3,046.00

$2,696.00

$594.00

$3,262.00

$412.00

$2,472.00

$462.00

$2,702.00

$2,201.00

$2,535.00

$3,079.00

$2,974.00

$2,327.00

$3,311.00

$2,741.00

$2,877.00

$2,910.00

$5,257.00

$5,899.00

$5,888.00

$3,148.00

$3,232.00

$2,524.00

$2,719.00

$4,019.00


Part B, 263



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

63307

63308

63600

63610

63615

63620

63621

63650

63655

63661

63295

63300

63301

63302

63303

63304

63305

63306

63271

63272

63273

63275

63276

63277

63278

63280

63281

63282

63283

63285

63286

63287

63290

63706

63707

63709

63710

63740

63741

63744

63746

64400

63662

63663

63664

63685

63688

63700

63702

63704

90 $2,401.00

90 $2,206.00

90 $2,012.00

90 $2,166.00

90 $2,135.00

90 $1,905.00

90 $1,877.00

90 $2,529.00

90 $2,496.00

90 $2,305.00

90 $2,041.00

90 $2,934.00

90 $3,003.00

90 $3,012.00

90 $3,073.00

ZZZ --------

90 $2,006.00

90 $2,209.00

90 $2,290.00

90 $2,357.00

90 $2,513.00

90 $2,574.00

90 $2,596.00

90 $2,522.00

ZZZ $425.00

90

0

$797.00

$476.00

90 $1,348.00

90

ZZZ

--------

--------

10 $819.00

90 $1,064.00

10 --------

90

10

90

--------

--------

--------

10

10

$615.00

$707.00

90 $1,340.00

90 $1,512.00

90 $1,708.00

90 $1,873.00

90 $1,041.00

90 $1,310.00

90 $1,165.00

90 $1,062.00

90

90

$741.00

$738.00

90

0

$529.00

$78.00

$523.00

$2,813.00

$3,417.00

$3,360.00

$3,582.00

$3,604.00

$3,733.00

$3,490.00

$3,517.00

$502.00

$1,317.00

$623.00

$1,435.00

$1,726.00

$399.00

$1,849.00

$1,246.00

$821.00

$3,187.00

$2,894.00

$2,881.00

$2,762.00

$2,739.00

$2,361.00

$2,466.00

$3,260.00

$3,217.00

$3,024.00

$2,912.00

$4,068.00

$4,000.00

$4,286.00

$4,261.00

$1,256.00

$1,122.00

$1,295.00

$543.00

$547.00

$1,727.00

$1,880.00

$2,553.00

$2,543.00

$1,384.00

$1,661.00

$1,632.00

$1,436.00

$1,023.00

$1,021.00

$918.00

$181.00

$574.00

$3,067.00

$3,749.00

$3,684.00

$3,930.00

$3,944.00

$4,073.00

$3,764.00

$3,813.00

$547.00

$1,380.00

$647.00

$1,512.00

$1,891.00

$439.00

$1,968.00

$1,352.00

$874.00

$3,487.00

$3,157.00

$3,158.00

$3,018.00

$2,991.00

$2,567.00

$2,706.00

$3,570.00

$3,520.00

$3,306.00

$3,188.00

$4,464.00

$4,385.00

$4,707.00

$4,660.00

$1,364.00

$1,190.00

$1,404.00

$581.00

$584.00

$1,845.00

$2,004.00

$2,800.00

$2,736.00

$1,499.00

$1,798.00

$1,765.00

$1,566.00

$1,112.00

$1,113.00

$1,004.00

$193.00

$658.00

$3,442.00

$4,257.00

$4,176.00

$4,467.00

$4,460.00

$4,586.00

$4,150.00

$4,242.00

$619.00

$1,438.00

$674.00

$1,606.00

$2,138.00

$503.00

$1,999.00

$1,495.00

$904.00

$3,943.00

$3,547.00

$3,577.00

$3,399.00

$3,366.00

$2,865.00

$3,066.00

$4,039.00

$3,977.00

$3,728.00

$3,601.00

$5,075.00

$4,974.00

$5,359.00

$5,268.00

$1,508.00

$1,230.00

$1,552.00

$626.00

$629.00

$1,989.00

$2,152.00

$3,165.00

$2,994.00

$1,654.00

$1,987.00

$1,947.00

$1,750.00

$1,233.00

$1,240.00

$1,124.00

$202.00

$523.00

$2,813.00

$3,417.00

$3,360.00

$3,582.00

$3,604.00

$3,733.00

$3,490.00

$3,517.00

$502.00

$1,317.00

$623.00

$1,435.00

$1,726.00

$399.00

$600.00

$1,246.00

$470.00

$3,187.00

$2,894.00

$2,881.00

$2,762.00

$2,739.00

$2,361.00

$2,466.00

$3,260.00

$3,217.00

$3,024.00

$2,912.00

$4,068.00

$4,000.00

$4,286.00

$4,261.00

$1,256.00

$663.00

$1,295.00

$543.00

$547.00

$1,727.00

$1,880.00

$2,553.00

$2,543.00

$1,384.00

$1,661.00

$1,632.00

$1,436.00

$1,023.00

$1,021.00

$918.00

$104.00

$574.00

$3,067.00

$3,749.00

$3,684.00

$3,930.00

$3,944.00

$4,073.00

$3,764.00

$3,813.00

$547.00

$1,380.00

$647.00

$1,512.00

$1,891.00

$439.00

$628.00

$1,352.00

$497.00

$3,487.00

$3,157.00

$3,158.00

$3,018.00

$2,991.00

$2,567.00

$2,706.00

$3,570.00

$3,520.00

$3,306.00

$3,188.00

$4,464.00

$4,385.00

$4,707.00

$4,660.00

$1,364.00

$697.00

$1,404.00

$581.00

$584.00

$1,845.00

$2,004.00

$2,800.00

$2,736.00

$1,499.00

$1,798.00

$1,765.00

$1,566.00

$1,112.00

$1,113.00

$1,004.00

$111.00

$658.00

$3,442.00

$4,257.00

$4,176.00

$4,467.00

$4,460.00

$4,586.00

$4,150.00

$4,242.00

$619.00

$1,438.00

$674.00

$1,606.00

$2,138.00

$503.00

$655.00

$1,495.00

$527.00

$3,943.00

$3,547.00

$3,577.00

$3,399.00

$3,366.00

$2,865.00

$3,066.00

$4,039.00

$3,977.00

$3,728.00

$3,601.00

$5,075.00

$4,974.00

$5,359.00

$5,268.00

$1,508.00

$735.00

$1,552.00

$626.00

$629.00

$1,989.00

$2,152.00

$3,165.00

$2,994.00

$1,654.00

$1,987.00

$1,947.00

$1,750.00

$1,233.00

$1,240.00

$1,124.00

$120.00


Part B, 264



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

64463

64479

64480

64483

64484

64486

64487

64488

64489

64490

64446

64447

64448

64449

64450

64455

64461

64462

64402

64405

64408

64410

64413

64415

64416

64417

64418

64420

64421

64425

64430

64435

64445

64517

64520

64530

64550

64553

64555

64561

64565

64566

64491

64492

64493

64494

64495

64505

64508

64510

0

10

10

10

0

0

0

10

0

ZZZ

ZZZ

0

ZZZ

ZZZ

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

ZZZ

$165.00

$77.00

$152.00

--------

$53.00

--------

--------

--------

0

0

0

0

0

0

0

--------

$224.00

ZZZ $194.00

0 $206.00

ZZZ $183.00

--------

--------

--------

--------

--------

$75.00

$103.00

$120.00

$109.00

$128.00

$109.00

$159.00

$105.00

$108.00

$89.00

$128.00

$116.00

$130.00

$114.00

$68.00

--------

--------

--------

--------

--------

$104.00

$99.00

$103.00

--------

$131.00

$135.00

$23.00

$137.00

$131.00

$801.00

$121.00

--------

$115.00

$169.00

$104.00

$123.00

$112.00

$68.00

$209.00

$119.00

$227.00

$332.00

$159.00

$308.00

$124.00

$175.00

$215.00

$216.00

$299.00

$268.00

$186.00

$144.00

$145.00

$172.00

$180.00

$167.00

$115.00

$182.00

$204.00

$158.00

$212.00

$188.00

$195.00

$192.00

$192.00

$133.00

$134.00

$243.00

$122.00

$123.00

$149.00

$90.00

$178.00

$257.00

$260.00

$267.00

$22.00

$295.00

$298.00

$1,139.00

$267.00

$176.00

$119.00

$178.00

$107.00

$128.00

$118.00

$71.00

$221.00

$125.00

$239.00

$350.00

$168.00

$326.00

$130.00

$185.00

$228.00

$229.00

$317.00

$283.00

$199.00

$154.00

$152.00

$181.00

$191.00

$175.00

$119.00

$192.00

$217.00

$167.00

$224.00

$198.00

$206.00

$203.00

$203.00

$140.00

$141.00

$257.00

$129.00

$130.00

$157.00

$95.00

$188.00

$270.00

$276.00

$282.00

$23.00

$311.00

$315.00

$1,212.00

$283.00

$187.00

$125.00

$183.00

$112.00

$134.00

$121.00

$74.00

$227.00

$129.00

$245.00

$359.00

$173.00

$333.00

$134.00

$190.00

$234.00

$235.00

$325.00

$290.00

$209.00

$161.00

$157.00

$186.00

$198.00

$180.00

$124.00

$198.00

$222.00

$172.00

$230.00

$205.00

$213.00

$210.00

$210.00

$144.00

$145.00

$263.00

$133.00

$133.00

$163.00

$101.00

$193.00

$278.00

$281.00

$288.00

$24.00

$320.00

$325.00

$1,239.00

$293.00

$191.00

$115.00

$97.00

$104.00

$123.00

$66.00

$51.00

$126.00

$80.00

$122.00

$191.00

$92.00

$163.00

$76.00

$92.00

$108.00

$117.00

$131.00

$154.00

$116.00

$93.00

$108.00

$101.00

$118.00

$95.00

$115.00

$103.00

$111.00

$99.00

$133.00

$136.00

$119.00

$121.00

$106.00

$88.00

$89.00

$132.00

$76.00

$77.00

$126.00

$106.00

$106.00

$177.00

$117.00

$133.00

$13.00

$224.00

$221.00

$440.00

$190.00

$45.00

$119.00

$100.00

$107.00

$128.00

$69.00

$53.00

$131.00

$83.00

$127.00

$200.00

$96.00

$170.00

$79.00

$96.00

$113.00

$122.00

$137.00

$161.00

$124.00

$99.00

$112.00

$105.00

$125.00

$98.00

$119.00

$108.00

$116.00

$103.00

$139.00

$142.00

$125.00

$127.00

$111.00

$92.00

$93.00

$138.00

$79.00

$80.00

$132.00

$112.00

$111.00

$184.00

$122.00

$139.00

$13.00

$235.00

$232.00

$462.00

$200.00

$47.00

$125.00

$105.00

$112.00

$134.00

$72.00

$55.00

$138.00

$87.00

$132.00

$208.00

$100.00

$177.00

$82.00

$101.00

$119.00

$128.00

$144.00

$168.00

$134.00

$107.00

$117.00

$109.00

$132.00

$103.00

$124.00

$113.00

$121.00

$108.00

$144.00

$149.00

$131.00

$134.00

$117.00

$95.00

$97.00

$144.00

$83.00

$84.00

$138.00

$118.00

$115.00

$191.00

$127.00

$144.00

$13.00

$243.00

$242.00

$486.00

$210.00

$50.00


Part B, 265



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

64636

64640

64642

64643

64644

64645

64646

64647

64650

64653

64616

64617

64620

64630

64632

64633

64634

64635

64568

64569

64570

64575

64580

64581

64585

64590

64595

64600

64605

64610

64611

64612

64615

64716

64718

64719

64721

64722

64726

64727

64732

64734

64680

64681

64702

64704

64708

64712

64713

64714

ZZZ

0

0

0

0

ZZZ

10

0

ZZZ

0

10

10

10

10

10

10

ZZZ

10

10

10

10

10

10

10

10

10

90

90

90

90

90

90

10

10

10

90

90

90

90

90

90

$180.00

--------

$383.00

$402.00

$562.00

$678.00

$867.00

$715.00

90

90

90

$523.00

$558.00

$446.00

90

90

$439.00

$411.00

90 $271.00

ZZZ $261.00

90

90

$405.00

$432.00

--------

--------

$185.00

$202.00

--------

--------

--------

--------

--------

$208.00

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

--------

$367.00

$343.00

$745.00

$37.00

$217.00

$153.00

$228.00

$319.00

$307.00

--------

$188.00

--------

$186.00

$284.00

$290.00

$334.00

$121.00

$594.00

$265.00

$587.00

$241.00

$187.00

$205.00

$135.00

$235.00

$166.00

$218.00

$258.00

$110.00

$139.00

$988.00

$1,183.00

$977.00

$466.00

$446.00

$967.00

$344.00

$373.00

$344.00

$554.00

$1,082.00

$1,085.00

$170.00

$190.00

$214.00

$434.00

$483.00

$720.00

$457.00

$721.00

$838.00

$1,066.00

$933.00

$779.00

$858.00

$580.00

$620.00

$538.00

$394.00

$274.00

$544.00

$598.00

$202.00

$307.00

$304.00

$354.00

$126.00

$628.00

$282.00

$620.00

$256.00

$197.00

$220.00

$144.00

$251.00

$178.00

$234.00

$277.00

$117.00

$150.00

$1,071.00

$1,283.00

$1,057.00

$497.00

$478.00

$1,014.00

$365.00

$396.00

$366.00

$592.00

$1,173.00

$1,175.00

$185.00

$203.00

$232.00

$460.00

$509.00

$766.00

$481.00

$769.00

$893.00

$1,134.00

$985.00

$828.00

$916.00

$619.00

$663.00

$574.00

$413.00

$293.00

$579.00

$634.00

$222.00

$330.00

$314.00

$372.00

$130.00

$641.00

$286.00

$633.00

$260.00

$202.00

$235.00

$155.00

$268.00

$190.00

$251.00

$297.00

$122.00

$160.00

$1,183.00

$1,423.00

$1,166.00

$531.00

$518.00

$1,071.00

$376.00

$408.00

$375.00

$617.00

$1,259.00

$1,271.00

$200.00

$216.00

$257.00

$471.00

$521.00

$809.00

$501.00

$817.00

$954.00

$1,218.00

$1,042.00

$875.00

$975.00

$658.00

$704.00

$611.00

$428.00

$318.00

$615.00

$667.00

$164.00

$187.00

$247.00

$281.00

$99.00

$328.00

$100.00

$323.00

$87.00

$133.00

$161.00

$108.00

$176.00

$124.00

$174.00

$203.00

$62.00

$82.00

$988.00

$1,183.00

$977.00

$466.00

$446.00

$967.00

$207.00

$232.00

$182.00

$322.00

$625.00

$742.00

$150.00

$171.00

$188.00

$240.00

$276.00

$720.00

$457.00

$721.00

$838.00

$1,066.00

$933.00

$779.00

$858.00

$580.00

$617.00

$538.00

$394.00

$274.00

$544.00

$598.00

$178.00

$203.00

$258.00

$298.00

$103.00

$343.00

$104.00

$338.00

$91.00

$139.00

$172.00

$116.00

$188.00

$133.00

$187.00

$218.00

$66.00

$88.00

$1,071.00

$1,283.00

$1,057.00

$497.00

$478.00

$1,014.00

$218.00

$245.00

$193.00

$343.00

$682.00

$807.00

$164.00

$183.00

$204.00

$252.00

$287.00

$766.00

$481.00

$769.00

$893.00

$1,134.00

$985.00

$828.00

$916.00

$619.00

$659.00

$574.00

$413.00

$293.00

$579.00

$634.00

$198.00

$226.00

$268.00

$316.00

$106.00

$355.00

$108.00

$350.00

$94.00

$144.00

$187.00

$126.00

$205.00

$146.00

$203.00

$238.00

$71.00

$98.00

$1,183.00

$1,423.00

$1,166.00

$531.00

$518.00

$1,071.00

$228.00

$257.00

$202.00

$367.00

$767.00

$902.00

$179.00

$195.00

$229.00

$262.00

$299.00

$809.00

$501.00

$817.00

$954.00

$1,218.00

$1,042.00

$875.00

$975.00

$658.00

$700.00

$611.00

$428.00

$318.00

$615.00

$667.00


Part B, 266



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

64795

64802

64804

64809

64818

64820

64821

64822

64823

64831

64782

64783

64784

64786

64787

64788

64790

64792

64736

64738

64740

64742

64744

64746

64755

64760

64763

64766

64771

64772

64774

64776

64778

64858

64859

64861

64862

64864

64865

64866

64868

64872

64832

64834

64835

64836

64837

64840

64856

64857

90

90

$388.00

$475.00

90

90

90

90

$461.00

$517.00

$798.00

$494.00

90 $1,042.00

90

90

90

90

90

$578.00

$561.00

$713.00

$632.00

$636.00

90

90

$392.00

$390.00

ZZZ $249.00

90 $482.00

ZZZ $298.00

90 $751.00

90 $1,281.00

ZZZ $458.00

90

90

$381.00

$884.00

90 $1,148.00

90

90

90

90

90

0

90

$247.00

$711.00

90 $1,202.00

90 $1,080.00

90 $845.00

$838.00

$609.00

$609.00

$703.00

$592.00

ZZZ $171.00

90 $711.00

90 $834.00

90 $856.00

ZZZ $480.00

90 $1,058.00

90 $1,063.00

90 $1,137.00

90 $1,313.00

ZZZ $341.00

90 $1,524.00

90 $1,798.00

90 $970.00

90 $1,250.00

90 $1,238.00

90 $1,162.00

ZZZ $155.00

$656.00

$325.00

$1,067.00

$1,580.00

$358.00

$584.00

$1,246.00

$1,832.00

$289.00

$967.00

$1,512.00

$1,539.00

$903.00

$1,054.00

$996.00

$996.00

$1,136.00

$995.00

$576.00

$615.00

$662.00

$695.00

$740.00

$668.00

$1,379.00

$746.00

$747.00

$877.00

$870.00

$821.00

$607.00

$567.00

$209.00

$499.00

$1,081.00

$1,184.00

$1,188.00

$548.00

$1,512.00

$1,491.00

$1,546.00

$1,663.00

$372.00

$1,961.00

$2,359.00

$1,286.00

$1,646.00

$1,678.00

$1,482.00

$178.00

$692.00

$344.00

$1,135.00

$1,687.00

$379.00

$625.00

$1,340.00

$2,007.00

$311.00

$1,018.00

$1,638.00

$1,674.00

$952.00

$1,117.00

$1,058.00

$1,058.00

$1,205.00

$1,060.00

$612.00

$650.00

$702.00

$730.00

$808.00

$719.00

$1,481.00

$797.00

$798.00

$927.00

$926.00

$877.00

$647.00

$601.00

$217.00

$530.00

$1,150.00

$1,263.00

$1,268.00

$580.00

$1,633.00

$1,590.00

$1,646.00

$1,767.00

$394.00

$2,094.00

$2,588.00

$1,362.00

$1,747.00

$1,776.00

$1,570.00

$189.00

$728.00

$367.00

$1,211.00

$1,817.00

$405.00

$670.00

$1,462.00

$2,264.00

$342.00

$1,069.00

$1,827.00

$1,870.00

$1,015.00

$1,184.00

$1,117.00

$1,117.00

$1,276.00

$1,126.00

$646.00

$686.00

$737.00

$754.00

$899.00

$785.00

$1,625.00

$862.00

$862.00

$981.00

$983.00

$941.00

$690.00

$634.00

$226.00

$570.00

$1,225.00

$1,355.00

$1,360.00

$619.00

$1,793.00

$1,709.00

$1,762.00

$1,890.00

$421.00

$2,266.00

$2,932.00

$1,444.00

$1,850.00

$1,872.00

$1,661.00

$203.00

$656.00

$325.00

$1,067.00

$1,580.00

$358.00

$584.00

$1,246.00

$1,832.00

$289.00

$967.00

$1,512.00

$1,539.00

$903.00

$1,054.00

$996.00

$996.00

$1,136.00

$995.00

$576.00

$615.00

$662.00

$695.00

$740.00

$668.00

$1,379.00

$746.00

$747.00

$877.00

$870.00

$821.00

$607.00

$567.00

$209.00

$499.00

$1,081.00

$1,184.00

$1,188.00

$548.00

$1,512.00

$1,491.00

$1,546.00

$1,663.00

$372.00

$1,961.00

$2,359.00

$1,286.00

$1,646.00

$1,678.00

$1,482.00

$178.00

$692.00

$344.00

$1,135.00

$1,687.00

$379.00

$625.00

$1,340.00

$2,007.00

$311.00

$1,018.00

$1,638.00

$1,674.00

$952.00

$1,117.00

$1,058.00

$1,058.00

$1,205.00

$1,060.00

$612.00

$650.00

$702.00

$730.00

$808.00

$719.00

$1,481.00

$797.00

$798.00

$927.00

$926.00

$877.00

$647.00

$601.00

$217.00

$530.00

$1,150.00

$1,263.00

$1,268.00

$580.00

$1,633.00

$1,590.00

$1,646.00

$1,767.00

$394.00

$2,094.00

$2,588.00

$1,362.00

$1,747.00

$1,776.00

$1,570.00

$189.00

$728.00

$367.00

$1,211.00

$1,817.00

$405.00

$670.00

$1,462.00

$2,264.00

$342.00

$1,069.00

$1,827.00

$1,870.00

$1,015.00

$1,184.00

$1,117.00

$1,117.00

$1,276.00

$1,126.00

$646.00

$686.00

$737.00

$754.00

$899.00

$785.00

$1,625.00

$862.00

$862.00

$981.00

$983.00

$941.00

$690.00

$634.00

$226.00

$570.00

$1,225.00

$1,355.00

$1,360.00

$619.00

$1,793.00

$1,709.00

$1,762.00

$1,890.00

$421.00

$2,266.00

$2,932.00

$1,444.00

$1,850.00

$1,872.00

$1,661.00

$203.00


Part B, 267



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

65105

65110

65112

65114

65125

65130

65135

65140

65150

65155

64907

64910

64911

64999

65091

65093

65101

65103

64874

64876

64885

64886

64890

64891

64892

64893

64895

64896

64897

64898

64901

64902

64905

65270

65272

65273

65275

65280

65285

65286

65290

65400

65175

65205

65210

65220

65222

65235

65260

65265

ZZZ $230.00

ZZZ $189.00

90 $1,382.00

90 $1,636.00

90 $1,112.00

90 $1,243.00

90 $1,177.00

90 $1,321.00

90 $1,500.00

90 $1,185.00

90 $1,419.00

90 $1,549.00

ZZZ $865.00

ZZZ $982.00

90 $1,059.00

90 $1,472.00

90 --------

90

YYY

90

--------

BR

$678.00

90

90

90

$712.00

$726.00

$769.00

90

90

90

90

90

90 $846.00

90 $1,305.00

90 $1,386.00

90 $1,456.00

90 $312.00

$730.00

$678.00

$738.00

$652.00

$862.00

90

0

0

$654.00

$45.00

$53.00

0

0

90

90

$58.00

$62.00

$627.00

$956.00

90 $1,104.00

10

90

90

$88.00

$223.00

$376.00

90

90

$75.00

$711.00

90 $1,177.00

90 $692.00

90

90

$519.00

$603.00

$2,067.00

$1,201.00

$1,473.00

--------

$888.00

$878.00

$1,031.00

$1,077.00

$1,188.00

$1,719.00

$2,001.00

$2,102.00

$633.00

$1,023.00

$1,039.00

$1,129.00

$799.00

$1,184.00

$255.00

$261.00

$1,684.00

$1,910.00

$1,593.00

$1,705.00

$1,525.00

$1,658.00

$1,969.00

$2,099.00

$1,814.00

$2,016.00

$825.00

$973.00

$1,504.00

$919.00

$78.00

$96.00

$82.00

$93.00

$999.00

$1,350.00

$1,522.00

$369.00

$698.00

$537.00

$807.00

$945.00

$1,562.00

$979.00

$688.00

$950.00

$2,240.00

$1,278.00

$1,564.00

--------

$934.00

$924.00

$1,085.00

$1,133.00

$1,249.00

$1,806.00

$2,103.00

$2,209.00

$671.00

$1,076.00

$1,092.00

$1,188.00

$841.00

$1,245.00

$271.00

$275.00

$1,787.00

$2,021.00

$1,691.00

$1,811.00

$1,618.00

$1,761.00

$2,100.00

$2,225.00

$1,918.00

$2,153.00

$870.00

$1,028.00

$1,600.00

$967.00

$82.00

$101.00

$86.00

$98.00

$1,049.00

$1,416.00

$1,596.00

$391.00

$737.00

$563.00

$850.00

$991.00

$1,637.00

$1,033.00

$722.00

$1,000.00

$2,484.00

$1,359.00

$1,658.00

--------

$956.00

$946.00

$1,110.00

$1,159.00

$1,280.00

$1,857.00

$2,168.00

$2,277.00

$683.00

$1,101.00

$1,119.00

$1,216.00

$860.00

$1,275.00

$292.00

$293.00

$1,901.00

$2,145.00

$1,797.00

$1,928.00

$1,719.00

$1,873.00

$2,259.00

$2,364.00

$2,030.00

$2,324.00

$927.00

$1,098.00

$1,706.00

$990.00

$84.00

$103.00

$90.00

$100.00

$1,076.00

$1,454.00

$1,640.00

$398.00

$752.00

$578.00

$869.00

$1,018.00

$1,683.00

$1,054.00

$742.00

$1,023.00

$2,067.00

$1,201.00

$1,473.00

--------

$888.00

$878.00

$1,031.00

$1,077.00

$1,188.00

$1,719.00

$2,001.00

$2,102.00

$410.00

$1,023.00

$1,039.00

$1,129.00

$799.00

$1,184.00

$255.00

$261.00

$1,684.00

$1,910.00

$1,593.00

$1,705.00

$1,525.00

$1,658.00

$1,969.00

$2,099.00

$1,814.00

$2,016.00

$825.00

$973.00

$1,504.00

$919.00

$62.00

$75.00

$61.00

$74.00

$999.00

$1,350.00

$1,522.00

$198.00

$494.00

$537.00

$651.00

$945.00

$1,562.00

$698.00

$688.00

$847.00

$2,240.00

$1,278.00

$1,564.00

--------

$934.00

$924.00

$1,085.00

$1,133.00

$1,249.00

$1,806.00

$2,103.00

$2,209.00

$432.00

$1,076.00

$1,092.00

$1,188.00

$841.00

$1,245.00

$271.00

$275.00

$1,787.00

$2,021.00

$1,691.00

$1,811.00

$1,618.00

$1,761.00

$2,100.00

$2,225.00

$1,918.00

$2,153.00

$870.00

$1,028.00

$1,600.00

$967.00

$65.00

$78.00

$64.00

$77.00

$1,049.00

$1,416.00

$1,596.00

$208.00

$518.00

$563.00

$683.00

$991.00

$1,637.00

$732.00

$722.00

$890.00

$2,484.00

$1,359.00

$1,658.00

--------

$956.00

$946.00

$1,110.00

$1,159.00

$1,280.00

$1,857.00

$2,168.00

$2,277.00

$443.00

$1,101.00

$1,119.00

$1,216.00

$860.00

$1,275.00

$292.00

$293.00

$1,901.00

$2,145.00

$1,797.00

$1,928.00

$1,719.00

$1,873.00

$2,259.00

$2,364.00

$2,030.00

$2,324.00

$927.00

$1,098.00

$1,706.00

$990.00

$66.00

$80.00

$67.00

$79.00

$1,076.00

$1,454.00

$1,640.00

$214.00

$532.00

$578.00

$702.00

$1,018.00

$1,683.00

$752.00

$742.00

$913.00


Part B, 268



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

65810

65815

65820

65850

65855

65860

65865

65870

65875

65880

65775

65778

65779

65780

65781

65782

65785

65800

65410

65420

65426

65430

65435

65436

65450

65600

65710

65730

65750

65755

65756

65770

65772

66160

66170

66172

66174

66175

66179

66180

66183

66184

65900

65920

65930

66020

66030

66130

66150

66155

90

90

90

90

90

90

90

90

90

10

90

0

0

90

90

90

90

0

0

90

90

0

0

90

90

$142.00

$448.00

$534.00

$81.00

$88.00

$319.00

$52.00

90 $325.00

90 $1,124.00

90 $1,314.00

90 $1,381.00

90 $1,373.00

90 --------

90 $1,461.00

90 $449.00

$595.00

--------

--------

--------

--------

--------

--------

$88.00

$516.00

$327.00

$813.00

$968.00

$441.00

$339.00

$540.00

$572.00

$597.00

$641.00

90

90

90

10

10

90

90

90

$945.00

$752.00

$700.00

$164.00

$160.00

$631.00

$798.00

$795.00

90 $942.00

90 $1,089.00

90 $1,264.00

90

90

--------

--------

90 --------

90 $1,313.00

90

90

--------

--------

$774.00

$1,954.00

$1,643.00

$1,006.00

$1,877.00

$1,619.00

$2,905.00

$167.00

$654.00

$887.00

$1,050.00

$1,182.00

$381.00

$432.00

$663.00

$829.00

$884.00

$929.00

$199.00

$716.00

$906.00

$160.00

$111.00

$544.00

$454.00

$550.00

$1,555.00

$1,726.00

$1,737.00

$1,728.00

$1,671.00

$1,979.00

$631.00

$1,349.00

$1,108.00

$896.00

$259.00

$230.00

$972.00

$1,229.00

$1,228.00

$1,386.00

$1,360.00

$1,709.00

$1,334.00

$1,398.00

$1,514.00

$1,599.00

$1,447.00

$1,101.00

$813.00

$2,094.00

$1,757.00

$1,059.00

$1,968.00

$1,698.00

$3,108.00

$175.00

$686.00

$936.00

$1,103.00

$1,239.00

$402.00

$454.00

$697.00

$871.00

$929.00

$975.00

$210.00

$757.00

$957.00

$168.00

$117.00

$571.00

$478.00

$580.00

$1,632.00

$1,810.00

$1,821.00

$1,811.00

$1,750.00

$2,073.00

$664.00

$1,415.00

$1,163.00

$940.00

$274.00

$243.00

$1,023.00

$1,292.00

$1,291.00

$1,456.00

$1,430.00

$1,802.00

$1,398.00

$1,465.00

$1,589.00

$1,678.00

$1,519.00

$1,157.00

$834.00

$2,103.00

$1,769.00

$1,083.00

$2,022.00

$1,744.00

$3,145.00

$180.00

$704.00

$955.00

$1,130.00

$1,273.00

$410.00

$465.00

$714.00

$893.00

$952.00

$1,001.00

$215.00

$771.00

$976.00

$172.00

$119.00

$586.00

$489.00

$592.00

$1,675.00

$1,859.00

$1,871.00

$1,861.00

$1,800.00

$2,132.00

$679.00

$1,452.00

$1,193.00

$965.00

$279.00

$247.00

$1,047.00

$1,323.00

$1,322.00

$1,493.00

$1,464.00

$1,841.00

$1,437.00

$1,505.00

$1,631.00

$1,723.00

$1,559.00

$1,186.00

$774.00

$83.00

$216.00

$1,006.00

$1,877.00

$1,619.00

$555.00

$130.00

$654.00

$671.00

$1,050.00

$1,182.00

$336.00

$357.00

$663.00

$829.00

$884.00

$929.00

$147.00

$529.00

$672.00

$146.00

$98.00

$523.00

$450.00

$483.00

$1,555.00

$1,726.00

$1,737.00

$1,728.00

$1,671.00

$1,979.00

$571.00

$1,349.00

$1,108.00

$896.00

$185.00

$155.00

$801.00

$1,229.00

$1,228.00

$1,386.00

$1,360.00

$1,709.00

$1,334.00

$1,398.00

$1,514.00

$1,599.00

$1,447.00

$1,101.00

$813.00

$87.00

$225.00

$1,059.00

$1,968.00

$1,698.00

$587.00

$136.00

$686.00

$705.00

$1,103.00

$1,239.00

$354.00

$374.00

$697.00

$871.00

$929.00

$975.00

$154.00

$557.00

$706.00

$152.00

$102.00

$549.00

$474.00

$507.00

$1,632.00

$1,810.00

$1,821.00

$1,811.00

$1,750.00

$2,073.00

$600.00

$1,415.00

$1,163.00

$940.00

$194.00

$164.00

$840.00

$1,292.00

$1,291.00

$1,456.00

$1,430.00

$1,802.00

$1,398.00

$1,465.00

$1,589.00

$1,678.00

$1,519.00

$1,157.00

$834.00

$89.00

$233.00

$1,083.00

$2,022.00

$1,744.00

$616.00

$140.00

$704.00

$723.00

$1,130.00

$1,273.00

$362.00

$385.00

$714.00

$893.00

$952.00

$1,001.00

$159.00

$570.00

$724.00

$157.00

$105.00

$563.00

$485.00

$520.00

$1,675.00

$1,859.00

$1,871.00

$1,861.00

$1,800.00

$2,132.00

$615.00

$1,452.00

$1,193.00

$965.00

$199.00

$168.00

$864.00

$1,323.00

$1,322.00

$1,493.00

$1,464.00

$1,841.00

$1,437.00

$1,505.00

$1,631.00

$1,723.00

$1,559.00

$1,186.00


Part B, 269



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

66825

66830

66840

66850

66852

66920

66930

66940

66982

66983

66711

66720

66740

66761

66762

66770

66820

66821

66185

66220

66225

66250

66500

66505

66600

66605

66625

66630

66635

66680

66682

66700

66710

67025

67027

67028

67030

67031

67036

67039

67040

67041

66984

66985

66986

66990

66999

67005

67010

67015

90

90

90

90

90

90

90

90

90

90

90

90

90

10

90

90

90

90

90

90

$769.00

$711.00

90 $1,006.00

90 $602.00

90

90

90

$359.00

$359.00

$825.00

90 $1,136.00

90 $543.00

90

90

90

$623.00

$595.00

$526.00

90

90

90

$627.00

$506.00

$513.00

--------

$506.00

$473.00

$506.00

$433.00

$483.00

$433.00

$275.00

$753.00

$651.00

$707.00

$805.00

$878.00

$785.00

$906.00

$819.00

$846.00

$763.00

90

90

$898.00

$744.00

90 $1,038.00

ZZZ

YYY

90

90

90

$84.00

BR

$639.00

$647.00

$637.00

90 $774.00

90 $1,089.00

0 $338.00

90

90

$485.00

$402.00

90 $1,384.00

90 $1,490.00

90 $1,960.00

90 --------

$901.00

$662.00

$612.00

$413.00

$664.00

$738.00

$548.00

$460.00

$1,065.00

$1,001.00

$980.00

$1,115.00

$1,189.00

$1,061.00

$1,206.00

$1,101.00

$1,120.00

$1,039.00

$1,186.00

$1,047.00

$1,311.00

$1,042.00

$494.00

$542.00

$1,166.00

$1,487.00

$603.00

$800.00

$808.00

$727.00

$892.00

$629.00

$616.00

$899.00

$1,082.00

$1,279.00

$129.00

--------

$664.00

$763.00

$814.00

$1,015.00

$1,201.00

$144.00

$745.00

$544.00

$1,269.00

$1,360.00

$1,470.00

$1,626.00

$946.00

$698.00

$644.00

$436.00

$699.00

$777.00

$578.00

$485.00

$1,120.00

$1,050.00

$1,028.00

$1,170.00

$1,246.00

$1,113.00

$1,265.00

$1,155.00

$1,174.00

$1,086.00

$1,246.00

$1,100.00

$1,375.00

$1,100.00

$521.00

$571.00

$1,226.00

$1,559.00

$633.00

$840.00

$848.00

$763.00

$939.00

$662.00

$647.00

$943.00

$1,136.00

$1,341.00

$134.00

--------

$697.00

$801.00

$855.00

$1,068.00

$1,259.00

$151.00

$784.00

$572.00

$1,331.00

$1,425.00

$1,541.00

$1,703.00

$970.00

$714.00

$659.00

$445.00

$715.00

$795.00

$590.00

$496.00

$1,147.00

$1,078.00

$1,055.00

$1,201.00

$1,280.00

$1,143.00

$1,300.00

$1,186.00

$1,206.00

$1,112.00

$1,278.00

$1,128.00

$1,413.00

$1,122.00

$532.00

$584.00

$1,257.00

$1,602.00

$649.00

$861.00

$870.00

$783.00

$961.00

$678.00

$663.00

$968.00

$1,165.00

$1,377.00

$139.00

--------

$715.00

$822.00

$876.00

$1,093.00

$1,293.00

$155.00

$803.00

$586.00

$1,367.00

$1,464.00

$1,584.00

$1,751.00

$901.00

$594.00

$553.00

$332.00

$599.00

$680.00

$548.00

$435.00

$1,065.00

$1,001.00

$980.00

$1,115.00

$1,189.00

$1,061.00

$1,206.00

$1,101.00

$1,120.00

$1,039.00

$1,186.00

$1,047.00

$1,311.00

$783.00

$494.00

$542.00

$1,166.00

$1,487.00

$603.00

$800.00

$808.00

$727.00

$892.00

$553.00

$552.00

$899.00

$1,082.00

$1,279.00

$129.00

--------

$664.00

$763.00

$814.00

$889.00

$1,201.00

$142.00

$745.00

$501.00

$1,269.00

$1,360.00

$1,470.00

$1,626.00

$946.00

$625.00

$580.00

$348.00

$629.00

$714.00

$578.00

$458.00

$1,120.00

$1,050.00

$1,028.00

$1,170.00

$1,246.00

$1,113.00

$1,265.00

$1,155.00

$1,174.00

$1,086.00

$1,246.00

$1,100.00

$1,375.00

$822.00

$521.00

$571.00

$1,226.00

$1,559.00

$633.00

$840.00

$848.00

$763.00

$939.00

$580.00

$580.00

$943.00

$1,136.00

$1,341.00

$134.00

--------

$697.00

$801.00

$855.00

$933.00

$1,259.00

$148.00

$784.00

$527.00

$1,331.00

$1,425.00

$1,541.00

$1,703.00

$970.00

$641.00

$595.00

$358.00

$645.00

$732.00

$590.00

$469.00

$1,147.00

$1,078.00

$1,055.00

$1,201.00

$1,280.00

$1,143.00

$1,300.00

$1,186.00

$1,206.00

$1,112.00

$1,278.00

$1,128.00

$1,413.00

$844.00

$532.00

$584.00

$1,257.00

$1,602.00

$649.00

$861.00

$870.00

$783.00

$961.00

$595.00

$595.00

$968.00

$1,165.00

$1,377.00

$139.00

--------

$715.00

$822.00

$876.00

$958.00

$1,293.00

$153.00

$803.00

$540.00

$1,367.00

$1,464.00

$1,584.00

$1,751.00


Part B, 270



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

67255

67299

67311

67312

67314

67316

67318

67320

67331

67332

67218

67220

67221

67225

67227

67228

67229

67250

67042

67043

67101

67105

67107

67108

67110

67113

67115

67120

67121

67141

67145

67208

67210

67405

67412

67413

67414

67415

67420

67430

67440

67445

67334

67335

67340

67343

67345

67346

67399

67400

90

90

90

90

90

90

90

90

90

90

--------

--------

90

90

$767.00

$941.00

90 $1,350.00

90 $1,878.00

90 $1,040.00

--------

$496.00

$751.00

$962.00

$536.00

$514.00

$655.00

$779.00

90 $1,217.00

90 $894.00

0

ZZZ

10

$325.00

$44.00

$652.00

10 $1,025.00

90 --------

90 $793.00

90

YYY

90

90

90

$872.00

BR

$616.00

$773.00

$688.00

90

90

$857.00

$663.00

ZZZ $602.00

ZZZ $560.00

ZZZ $621.00

ZZZ $447.00

ZZZ $253.00

ZZZ $559.00

90

10

0

YYY

90

$628.00

$275.00

--------

BR

$960.00

90

90

90

$799.00

$976.00

$909.00

90 $1,023.00

0 $146.00

90 $1,729.00

90 $1,203.00

90 $1,257.00

90 $1,269.00

$1,954.00

$748.00

$402.00

$42.00

$406.00

$478.00

$1,584.00

$1,095.00

$958.00

--------

$841.00

$1,003.00

$947.00

$1,128.00

$990.00

$459.00

$436.00

$473.00

$1,626.00

$1,717.00

$1,095.00

$1,007.00

$1,433.00

$1,819.00

$1,063.00

$1,985.00

$701.00

$917.00

$1,279.00

$733.00

$738.00

$841.00

$726.00

$430.00

$211.00

$511.00

$919.00

$345.00

$275.00

--------

$1,304.00

$1,115.00

$1,193.00

$1,201.00

$1,867.00

$149.00

$2,283.00

$1,741.00

$1,692.00

$1,976.00

$2,045.00

$786.00

$422.00

$44.00

$426.00

$502.00

$1,664.00

$1,151.00

$1,007.00

--------

$882.00

$1,051.00

$993.00

$1,183.00

$1,038.00

$479.00

$455.00

$493.00

$1,703.00

$1,798.00

$1,153.00

$1,059.00

$1,502.00

$1,913.00

$1,119.00

$2,082.00

$737.00

$966.00

$1,341.00

$771.00

$776.00

$883.00

$763.00

$448.00

$220.00

$533.00

$965.00

$366.00

$288.00

--------

$1,371.00

$1,174.00

$1,255.00

$1,264.00

$1,959.00

$155.00

$2,399.00

$1,831.00

$1,781.00

$2,074.00

$2,105.00

$805.00

$432.00

$45.00

$437.00

$515.00

$1,728.00

$1,180.00

$1,032.00

--------

$906.00

$1,080.00

$1,020.00

$1,216.00

$1,066.00

$495.00

$470.00

$510.00

$1,752.00

$1,850.00

$1,180.00

$1,084.00

$1,544.00

$1,959.00

$1,145.00

$2,139.00

$755.00

$988.00

$1,377.00

$790.00

$795.00

$906.00

$782.00

$463.00

$228.00

$550.00

$991.00

$382.00

$298.00

--------

$1,406.00

$1,206.00

$1,288.00

$1,299.00

$2,017.00

$160.00

$2,475.00

$1,881.00

$1,833.00

$2,137.00

$1,954.00

$703.00

$303.00

$39.00

$362.00

$434.00

$1,584.00

$1,095.00

$958.00

--------

$841.00

$1,003.00

$947.00

$1,128.00

$990.00

$459.00

$436.00

$473.00

$1,626.00

$1,717.00

$948.00

$906.00

$1,433.00

$1,819.00

$977.00

$1,985.00

$701.00

$784.00

$1,279.00

$685.00

$700.00

$814.00

$703.00

$430.00

$211.00

$511.00

$919.00

$312.00

$275.00

--------

$1,304.00

$1,115.00

$1,193.00

$1,201.00

$1,867.00

$149.00

$2,283.00

$1,741.00

$1,692.00

$1,976.00

$2,045.00

$738.00

$316.00

$41.00

$379.00

$454.00

$1,664.00

$1,151.00

$1,007.00

--------

$882.00

$1,051.00

$993.00

$1,183.00

$1,038.00

$479.00

$455.00

$493.00

$1,703.00

$1,798.00

$994.00

$950.00

$1,502.00

$1,913.00

$1,027.00

$2,082.00

$737.00

$823.00

$1,341.00

$720.00

$735.00

$854.00

$738.00

$448.00

$220.00

$533.00

$965.00

$331.00

$288.00

--------

$1,371.00

$1,174.00

$1,255.00

$1,264.00

$1,959.00

$155.00

$2,399.00

$1,831.00

$1,781.00

$2,074.00

$2,105.00

$757.00

$326.00

$42.00

$389.00

$467.00

$1,728.00

$1,180.00

$1,032.00

--------

$906.00

$1,080.00

$1,020.00

$1,216.00

$1,066.00

$495.00

$470.00

$510.00

$1,752.00

$1,850.00

$1,021.00

$976.00

$1,544.00

$1,959.00

$1,052.00

$2,139.00

$755.00

$845.00

$1,377.00

$738.00

$754.00

$877.00

$757.00

$463.00

$228.00

$550.00

$991.00

$347.00

$298.00

--------

$1,406.00

$1,206.00

$1,288.00

$1,299.00

$2,017.00

$160.00

$2,475.00

$1,881.00

$1,833.00

$2,137.00


Part B, 271



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

67880

67882

67900

67901

67902

67903

67904

67906

67908

67909

67810

67820

67825

67830

67835

67840

67850

67875

67450

67500

67505

67515

67550

67560

67570

67599

67700

67710

67715

67800

67801

67805

67808

67923

67924

67930

67935

67938

67950

67961

67966

67971

67911

67912

67914

67915

67916

67917

67921

67922

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

0

0

10

10

90

10

10

0

YYY

10

10

10

10

10

10

90

90 $1,300.00

0 $75.00

0

0

90

90

$109.00

$53.00

$946.00

$936.00

90 $1,148.00

BR

$87.00

$117.00

$102.00

$119.00

$189.00

$208.00

$308.00

$133.00

$36.00

$130.00

$239.00

$500.00

$187.00

$143.00

$163.00

$442.00

$643.00

$487.00

$646.00

$650.00

$657.00

$720.00

$633.00

$550.00

$577.00

$517.00

--------

$487.00

$252.00

$675.00

$631.00

$419.00

$243.00

$718.00

$605.00

$280.00

$520.00

$67.00

$584.00

$571.00

$645.00

$875.00

$239.00

$70.00

$179.00

$367.00

$616.00

$380.00

$298.00

$238.00

$639.00

$786.00

$895.00

$1,054.00

$1,021.00

$829.00

$1,022.00

$715.00

$688.00

$747.00

$1,764.00

$112.00

$125.00

$136.00

$1,353.00

$1,387.00

$1,646.00

--------

$369.00

$307.00

$328.00

$177.00

$227.00

$282.00

$519.00

$792.00

$1,223.00

$650.00

$404.00

$823.00

$839.00

$636.00

$400.00

$821.00

$876.00

$507.00

$830.00

$333.00

$799.00

$800.00

$1,076.00

$1,021.00

$254.00

$73.00

$189.00

$390.00

$647.00

$403.00

$317.00

$252.00

$674.00

$828.00

$944.00

$1,112.00

$1,071.00

$873.00

$1,077.00

$750.00

$725.00

$788.00

$1,856.00

$116.00

$131.00

$143.00

$1,423.00

$1,459.00

$1,742.00

--------

$392.00

$326.00

$349.00

$187.00

$238.00

$297.00

$545.00

$832.00

$1,298.00

$688.00

$428.00

$870.00

$885.00

$674.00

$424.00

$868.00

$925.00

$534.00

$876.00

$353.00

$843.00

$844.00

$1,132.00

$1,070.00

$261.00

$75.00

$193.00

$396.00

$664.00

$410.00

$325.00

$256.00

$689.00

$847.00

$969.00

$1,137.00

$1,104.00

$895.00

$1,104.00

$771.00

$742.00

$807.00

$1,911.00

$121.00

$135.00

$147.00

$1,460.00

$1,498.00

$1,815.00

--------

$397.00

$330.00

$355.00

$191.00

$244.00

$304.00

$560.00

$855.00

$1,325.00

$701.00

$435.00

$888.00

$905.00

$685.00

$431.00

$885.00

$944.00

$546.00

$900.00

$357.00

$864.00

$863.00

$1,162.00

$1,102.00

$104.00

$75.00

$170.00

$195.00

$616.00

$223.00

$193.00

$137.00

$518.00

$664.00

$720.00

$813.00

$1,021.00

$682.00

$842.00

$715.00

$596.00

$617.00

$1,764.00

$103.00

$115.00

$126.00

$1,353.00

$1,387.00

$1,646.00

--------

$164.00

$136.00

$153.00

$146.00

$189.00

$232.00

$519.00

$792.00

$694.00

$459.00

$277.00

$607.00

$645.00

$435.00

$276.00

$606.00

$645.00

$340.00

$627.00

$162.00

$653.00

$640.00

$928.00

$1,021.00

$109.00

$78.00

$179.00

$205.00

$647.00

$234.00

$204.00

$144.00

$544.00

$697.00

$756.00

$853.00

$1,071.00

$716.00

$884.00

$750.00

$627.00

$649.00

$1,856.00

$107.00

$120.00

$132.00

$1,423.00

$1,459.00

$1,742.00

--------

$172.00

$144.00

$161.00

$153.00

$198.00

$244.00

$545.00

$832.00

$731.00

$483.00

$292.00

$638.00

$678.00

$458.00

$291.00

$636.00

$677.00

$356.00

$658.00

$170.00

$687.00

$672.00

$973.00

$1,070.00

$115.00

$80.00

$183.00

$210.00

$664.00

$241.00

$211.00

$149.00

$559.00

$716.00

$781.00

$878.00

$1,104.00

$737.00

$909.00

$771.00

$643.00

$667.00

$1,911.00

$112.00

$124.00

$136.00

$1,460.00

$1,498.00

$1,815.00

--------

$177.00

$147.00

$166.00

$157.00

$203.00

$250.00

$560.00

$855.00

$757.00

$495.00

$298.00

$656.00

$696.00

$469.00

$298.00

$653.00

$696.00

$367.00

$681.00

$174.00

$707.00

$691.00

$1,002.00

$1,102.00


Part B, 272



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

68400

68420

68440

68500

68505

68510

68520

68525

68530

68540

68328

68330

68335

68340

68360

68362

68371

68399

67973

67974

67975

67999

68020

68040

68100

68110

68115

68130

68135

68200

68320

68325

68326

68770

68801

68810

68811

68815

68816

68840

68850

68899

68550

68700

68705

68720

68745

68750

68760

68761

0

90

0

10

90

10

10

10

90

90

90

90

90

90

90

90

10

YYY

10

10

90

10

0

90

90

90

90 $1,126.00

90 $1,140.00

90

YYY

10

0

0

$681.00

BR

$106.00

$75.00

$137.00

$172.00

$248.00

$378.00

$146.00

$59.00

$502.00

$672.00

$654.00

$741.00

$488.00

$636.00

$413.00

$449.00

$691.00

--------

BR

$154.00

$191.00

$96.00

$882.00

$921.00

$491.00

$687.00

$340.00

$379.00

$875.00

90

10

10

10

10

10

10

0

YYY

90 $1,107.00

90 $628.00

10 $176.00

90

90

90

10

10

$807.00

$704.00

$792.00

$109.00

$130.00

$634.00

$202.00

$290.00

$191.00

$399.00

--------

$100.00

$76.00

BR

$998.00

$840.00

$911.00

$757.00

$740.00

$924.00

$580.00

--------

$391.00

$445.00

$142.00

$1,371.00

$1,363.00

$621.00

$968.00

$376.00

$593.00

$1,309.00

$1,314.00

$1,311.00

$965.00

--------

$167.00

$88.00

$235.00

$312.00

$431.00

$748.00

$219.00

$58.00

$1,006.00

$928.00

$909.00

$1,571.00

$850.00

$328.00

$1,065.00

$1,068.00

$1,106.00

$279.00

$205.00

$884.00

$139.00

$270.00

$233.00

$549.00

$882.00

$178.00

$86.00

--------

$1,047.00

$887.00

$956.00

$799.00

$782.00

$969.00

$609.00

--------

$415.00

$471.00

$150.00

$1,439.00

$1,430.00

$655.00

$1,018.00

$392.00

$627.00

$1,375.00

$1,377.00

$1,374.00

$1,013.00

--------

$176.00

$92.00

$249.00

$330.00

$456.00

$790.00

$231.00

$61.00

$1,063.00

$974.00

$954.00

$1,657.00

$892.00

$347.00

$1,118.00

$1,121.00

$1,162.00

$295.00

$216.00

$928.00

$147.00

$286.00

$246.00

$582.00

$941.00

$188.00

$91.00

--------

$1,077.00

$905.00

$981.00

$815.00

$799.00

$995.00

$624.00

--------

$421.00

$480.00

$153.00

$1,477.00

$1,469.00

$669.00

$1,047.00

$406.00

$639.00

$1,413.00

$1,417.00

$1,415.00

$1,042.00

--------

$180.00

$94.00

$253.00

$336.00

$464.00

$806.00

$236.00

$63.00

$1,084.00

$1,002.00

$980.00

$1,726.00

$916.00

$354.00

$1,149.00

$1,151.00

$1,194.00

$301.00

$220.00

$952.00

$149.00

$291.00

$251.00

$591.00

$950.00

$191.00

$93.00

--------

$998.00

$648.00

$911.00

$561.00

$580.00

$924.00

$580.00

--------

$186.00

$238.00

$138.00

$1,371.00

$1,363.00

$415.00

$968.00

$376.00

$364.00

$1,309.00

$1,314.00

$1,311.00

$965.00

--------

$155.00

$72.00

$137.00

$209.00

$259.00

$579.00

$212.00

$49.00

$757.00

$928.00

$909.00

$1,571.00

$850.00

$234.00

$1,065.00

$1,068.00

$1,106.00

$205.00

$167.00

$884.00

$121.00

$212.00

$233.00

$312.00

$283.00

$163.00

$79.00

--------

$1,047.00

$681.00

$956.00

$590.00

$610.00

$969.00

$609.00

--------

$195.00

$250.00

$146.00

$1,439.00

$1,430.00

$434.00

$1,018.00

$392.00

$381.00

$1,375.00

$1,377.00

$1,374.00

$1,013.00

--------

$163.00

$75.00

$144.00

$219.00

$272.00

$608.00

$223.00

$52.00

$796.00

$974.00

$954.00

$1,657.00

$892.00

$246.00

$1,118.00

$1,121.00

$1,162.00

$216.00

$175.00

$928.00

$127.00

$223.00

$246.00

$328.00

$298.00

$172.00

$83.00

--------

$1,077.00

$699.00

$981.00

$605.00

$627.00

$995.00

$624.00

--------

$200.00

$257.00

$149.00

$1,477.00

$1,469.00

$448.00

$1,047.00

$406.00

$393.00

$1,413.00

$1,417.00

$1,415.00

$1,042.00

--------

$167.00

$77.00

$148.00

$224.00

$279.00

$623.00

$229.00

$53.00

$817.00

$1,002.00

$980.00

$1,726.00

$916.00

$253.00

$1,149.00

$1,151.00

$1,194.00

$221.00

$179.00

$952.00

$130.00

$228.00

$251.00

$337.00

$305.00

$176.00

$86.00

--------


Part B, 273



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

69424

69433

69436

69440

69450

69501

69502

69505

69511

69530

69220

69222

69300

69310

69320

69399

69420

69421

69000

69005

69020

69100

69105

69110

69120

69140

69145

69150

69155

69200

69205

69209

69210

69604

69605

69610

69620

69631

69632

69633

69635

69636

69535

69540

69550

69552

69554

69601

69602

69603

10

10

10

0

0

90

90

$52.00

$175.00

$109.00

$85.00

$87.00

$294.00

$274.00

90

90

$722.00

$248.00

90 $1,111.00

90 $1,680.00

0 $53.00

10

0

0

$110.00

--------

$39.00

0

10

$78.00

$123.00

YYY $522.00

90 $937.00

90 $1,434.00

YYY

10

10

BR

$117.00

$155.00

0

10

10

90

90

$84.00

$145.00

$182.00

$699.00

$525.00

90 $829.00

90 $1,118.00

90 $1,176.00

90 $1,221.00

90 $1,616.00

90 $2,824.00

10 $126.00

90 $998.00

90 $1,621.00

90 $2,600.00

90 $1,195.00

90 $1,225.00

90 $1,264.00

90 $1,263.00

90 $1,526.00

10 $41.00

90

90

$651.00

$985.00

90 $1,166.00

90 $1,110.00

90 $1,207.00

90 $1,381.00

$156.00

$310.00

$1,046.00

$1,568.00

$2,230.00

--------

$271.00

$215.00

$180.00

$287.00

$232.00

$994.00

$784.00

$1,063.00

$1,410.00

$1,733.00

$1,771.00

$2,396.00

$264.00

$306.00

$328.00

$141.00

$197.00

$648.00

$580.00

$1,255.00

$561.00

$1,518.00

$2,427.00

$140.00

$146.00

$18.00

$70.00

$3,915.00

$294.00

$1,499.00

$2,265.00

$3,550.00

$1,517.00

$1,576.00

$1,838.00

$1,612.00

$2,256.00

$552.00

$989.00

$1,276.00

$1,556.00

$1,510.00

$1,783.00

$1,993.00

$167.00

$330.00

$1,111.00

$1,668.00

$2,371.00

--------

$289.00

$228.00

$192.00

$306.00

$246.00

$1,055.00

$833.00

$1,127.00

$1,495.00

$1,840.00

$1,880.00

$2,542.00

$280.00

$325.00

$350.00

$150.00

$210.00

$691.00

$616.00

$1,334.00

$598.00

$1,611.00

$2,570.00

$148.00

$155.00

$19.00

$74.00

$4,154.00

$314.00

$1,592.00

$2,402.00

$3,756.00

$1,608.00

$1,671.00

$1,953.00

$1,709.00

$2,394.00

$586.00

$1,053.00

$1,354.00

$1,651.00

$1,603.00

$1,895.00

$2,116.00

$172.00

$339.00

$1,149.00

$1,734.00

$2,478.00

--------

$297.00

$239.00

$197.00

$315.00

$258.00

$1,101.00

$866.00

$1,181.00

$1,569.00

$1,917.00

$1,959.00

$2,661.00

$288.00

$338.00

$359.00

$154.00

$216.00

$714.00

$640.00

$1,382.00

$614.00

$1,693.00

$2,706.00

$153.00

$162.00

$19.00

$77.00

$4,389.00

$322.00

$1,656.00

$2,516.00

$3,959.00

$1,685.00

$1,751.00

$2,041.00

$1,791.00

$2,502.00

$612.00

$1,089.00

$1,413.00

$1,726.00

$1,676.00

$1,979.00

$2,205.00

$76.00

$197.00

$693.00

$1,568.00

$2,230.00

--------

$174.00

$215.00

$90.00

$192.00

$232.00

$994.00

$784.00

$1,063.00

$1,410.00

$1,733.00

$1,771.00

$2,396.00

$171.00

$228.00

$204.00

$71.00

$92.00

$466.00

$580.00

$1,255.00

$359.00

$1,518.00

$2,427.00

$69.00

$146.00

$18.00

$48.00

$3,915.00

$182.00

$1,499.00

$2,265.00

$3,550.00

$1,517.00

$1,576.00

$1,838.00

$1,612.00

$2,256.00

$425.00

$708.00

$1,276.00

$1,556.00

$1,510.00

$1,783.00

$1,993.00

$80.00

$209.00

$733.00

$1,668.00

$2,371.00

--------

$184.00

$228.00

$96.00

$203.00

$246.00

$1,055.00

$833.00

$1,127.00

$1,495.00

$1,840.00

$1,880.00

$2,542.00

$181.00

$241.00

$217.00

$75.00

$98.00

$496.00

$616.00

$1,334.00

$382.00

$1,611.00

$2,570.00

$72.00

$155.00

$19.00

$50.00

$4,154.00

$194.00

$1,592.00

$2,402.00

$3,756.00

$1,608.00

$1,671.00

$1,953.00

$1,709.00

$2,394.00

$449.00

$751.00

$1,354.00

$1,651.00

$1,603.00

$1,895.00

$2,116.00

$85.00

$217.00

$770.00

$1,734.00

$2,478.00

--------

$193.00

$239.00

$101.00

$213.00

$258.00

$1,101.00

$866.00

$1,181.00

$1,569.00

$1,917.00

$1,959.00

$2,661.00

$188.00

$254.00

$226.00

$80.00

$103.00

$518.00

$640.00

$1,382.00

$397.00

$1,693.00

$2,706.00

$76.00

$162.00

$19.00

$53.00

$4,389.00

$201.00

$1,656.00

$2,516.00

$3,959.00

$1,685.00

$1,751.00

$2,041.00

$1,791.00

$2,502.00

$475.00

$786.00

$1,413.00

$1,726.00

$1,676.00

$1,979.00

$2,205.00


Part B, 274



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

69725

69740

69745

69799

69801

69805

69806

69820

69840

69905

69700

69710

69711

69714

69715

69717

69718

69720

69637

69641

69642

69643

69644

69645

69646

69650

69660

69661

69662

69666

69667

69670

69676

69979

69990

G0127

G0168

G0247

G0276

G0289

G0341

G0342

69910

69915

69930

69949

69950

69955

69960

69970

90 $1,370.00

90 $1,154.00

90 $1,519.00

90 $1,389.00

90 $1,529.00

90 $1,479.00

90 $1,620.00

90 $879.00

90 $1,072.00

90 $1,412.00

90 $1,386.00

90 $887.00

90

90

90

$887.00

$988.00

$828.00

90

0

90

90

$702.00

BR

$878.00

$961.00

90 $1,217.00

90 $996.00

90 $1,232.00

90 $1,307.00

90 $1,922.00

90 $1,274.00

90 $1,447.00

YYY BR

0 $785.00

90 $1,187.00

90 $1,123.00

90

90

$876.00

$869.00

90 $1,013.00

90 $1,228.00

90 $1,754.00

90 $1,498.00

YYY BR

90 $2,017.00

90 $2,185.00

90 $2,116.00

90 $2,306.00

YYY BR

ZZZ $262.00

0 --------

0

ZZZ

0

ZZZ

0

90

--------

--------

--------

--------

--------

--------

$992.00

--------

$1,250.00

$1,567.00

$1,937.00

$1,646.00

$1,956.00

$1,770.00

$2,744.00

$1,699.00

$2,060.00

--------

$280.00

$1,534.00

$1,373.00

$1,240.00

$1,299.00

$1,328.00

$1,982.00

$1,507.00

$1,936.00

$1,775.00

$2,134.00

$2,099.00

$2,232.00

$1,165.00

$1,345.00

$1,755.00

$1,685.00

$1,170.00

$1,170.00

$1,373.00

$1,200.00

$1,479.00

$2,247.00

$1,786.00

--------

$2,609.00

$2,913.00

$2,803.00

$3,137.00

--------

$342.00

$32.00

$142.00

$100.00

$585.00

$130.00

$3,170.00

$1,024.00

$1,052.00

--------

$1,326.00

$1,661.00

$2,050.00

$1,744.00

$2,071.00

$1,885.00

$2,904.00

$1,799.00

$2,220.00

--------

$298.00

$1,625.00

$1,455.00

$1,315.00

$1,375.00

$1,408.00

$2,104.00

$1,599.00

$2,053.00

$1,882.00

$2,265.00

$2,228.00

$2,368.00

$1,236.00

$1,426.00

$1,861.00

$1,786.00

$1,241.00

$1,241.00

$1,456.00

$1,273.00

$1,567.00

$2,377.00

$1,891.00

--------

$2,759.00

$3,084.00

$2,962.00

$3,321.00

--------

$375.00

$34.00

$151.00

$106.00

$620.00

$138.00

$3,385.00

$1,079.00

$1,100.00

--------

$1,386.00

$1,746.00

$2,159.00

$1,833.00

$2,181.00

$1,988.00

$3,063.00

$1,893.00

$2,405.00

--------

$310.00

$1,709.00

$1,528.00

$1,376.00

$1,427.00

$1,474.00

$2,193.00

$1,673.00

$2,151.00

$1,973.00

$2,365.00

$2,327.00

$2,475.00

$1,292.00

$1,496.00

$1,954.00

$1,878.00

$1,298.00

$1,299.00

$1,526.00

$1,329.00

$1,647.00

$2,508.00

$1,993.00

--------

$2,917.00

$3,256.00

$3,123.00

$3,512.00

--------

$428.00

$34.00

$154.00

$108.00

$667.00

$150.00

$3,417.00

$1,144.00

$992.00

--------

$1,250.00

$1,567.00

$1,937.00

$1,646.00

$1,956.00

$1,770.00

$2,744.00

$1,699.00

$2,060.00

--------

$185.00

$1,534.00

$1,373.00

$1,240.00

$1,299.00

$1,328.00

$1,982.00

$1,507.00

$1,936.00

$1,775.00

$2,134.00

$2,099.00

$2,232.00

$1,165.00

$1,345.00

$1,755.00

$1,685.00

$1,170.00

$1,170.00

$1,373.00

$1,200.00

$1,479.00

$2,247.00

$1,786.00

--------

$2,609.00

$2,913.00

$2,803.00

$3,137.00

--------

$342.00

$11.00

$40.00

$33.00

$585.00

$130.00

$547.00

$1,024.00

$1,052.00

--------

$1,326.00

$1,661.00

$2,050.00

$1,744.00

$2,071.00

$1,885.00

$2,904.00

$1,799.00

$2,220.00

--------

$195.00

$1,625.00

$1,455.00

$1,315.00

$1,375.00

$1,408.00

$2,104.00

$1,599.00

$2,053.00

$1,882.00

$2,265.00

$2,228.00

$2,368.00

$1,236.00

$1,426.00

$1,861.00

$1,786.00

$1,241.00

$1,241.00

$1,456.00

$1,273.00

$1,567.00

$2,377.00

$1,891.00

--------

$2,759.00

$3,084.00

$2,962.00

$3,321.00

--------

$375.00

$11.00

$43.00

$34.00

$620.00

$138.00

$570.00

$1,079.00

$1,100.00

--------

$1,386.00

$1,746.00

$2,159.00

$1,833.00

$2,181.00

$1,988.00

$3,063.00

$1,893.00

$2,405.00

--------

$207.00

$1,709.00

$1,528.00

$1,376.00

$1,427.00

$1,474.00

$2,193.00

$1,673.00

$2,151.00

$1,973.00

$2,365.00

$2,327.00

$2,475.00

$1,292.00

$1,496.00

$1,954.00

$1,878.00

$1,298.00

$1,299.00

$1,526.00

$1,329.00

$1,647.00

$2,508.00

$1,993.00

--------

$2,917.00

$3,256.00

$3,123.00

$3,512.00

--------

$428.00

$12.00

$45.00

$36.00

$667.00

$150.00

$594.00

$1,144.00


Part B, 275



Surgery


Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

G0343

G0364

G0412

G0413

G0414

G0415

G0429

90

ZZZ

90

90

90

90

0

--------

--------

--------

--------

--------

--------

--------

$1,849.00

$17.00

$1,051.00

$1,570.00

$1,412.00

$2,019.00

$139.00

$1,985.00

$18.00

$1,121.00

$1,676.00

$1,494.00

$2,154.00

$148.00

$2,175.00

$19.00

$1,203.00

$1,802.00

$1,581.00

$2,320.00

$154.00

$1,849.00

$13.00

$1,051.00

$1,570.00

$1,412.00

$2,019.00

$103.00

$1,985.00

$13.00

$1,121.00

$1,676.00

$1,494.00

$2,154.00

$109.00

$2,175.00

$13.00

$1,203.00

$1,802.00

$1,581.00

$2,320.00

$115.00


Part B, 276


PART C


ALLOWANCES




Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA) (Facility MRA)

70120-TC

70130

70130-26

70130-TC

70134

70134-26

70134-TC

70140

70140-26

70140-TC

70150

70150-26

70150-TC

70160

70160-26

70160-TC

70010

70010-26

70010-TC

70015

70015-26

70015-TC

70030

70030-26

70030-TC

70100

70100-26

70100-TC

70110

70110-26

70110-TC

70120

70120-26

70170

70170-26

70170-TC

70190

70190-26

70190-TC

70200

70200-26

70200-TC

70210

70210-26

70210-TC

70220

70220-26

70220-TC

70240

70240-26

$22.00

$46.00

$17.00

$29.00

$45.00

$17.00

$28.00

$33.00

$9.00

$22.00

$42.00

$12.00

$29.00

$29.00

$8.00

$19.00

$70.00

NC

NC

$58.00

NC

NC

$24.00

$10.00

$15.00

$29.00

$9.00

$19.00

$36.00

$12.00

$22.00

$32.00

$9.00

$52.00

NC

NC

$34.00

$10.00

$22.00

$43.00

$14.00

$29.00

$32.00

$8.00

$22.00

$42.00

$12.00

$29.00

$26.00

$9.00

$26.00

$59.00

$19.00

$39.00

$55.00

$20.00

$36.00

$32.00

$12.00

$20.00

$45.00

$15.00

$30.00

$35.00

$10.00

$25.00

$69.00

BR

BR

$167.00

$71.00

$97.00

$30.00

$9.00

$21.00

$35.00

$10.00

$25.00

$41.00

$14.00

$27.00

$36.00

$10.00

$388.00

$17.00

$371.00

$38.00

$13.00

$26.00

$45.00

$16.00

$30.00

$32.00

$10.00

$22.00

$40.00

$14.00

$26.00

$32.00

$11.00

$28.00

$62.00

$20.00

$42.00

$59.00

$20.00

$38.00

$34.00

$12.00

$22.00

$47.00

$15.00

$32.00

$37.00

$10.00

$27.00

$72.00

BR

BR

$178.00

$74.00

$104.00

$32.00

$10.00

$22.00

$38.00

$11.00

$27.00

$43.00

$15.00

$29.00

$39.00

$11.00

$415.00

$18.00

$398.00

$41.00

$13.00

$28.00

$48.00

$16.00

$32.00

$34.00

$10.00

$24.00

$43.00

$15.00

$28.00

$34.00

$11.00

$29.00

$64.00

$21.00

$43.00

$59.00

$20.00

$39.00

$35.00

$13.00

$22.00

$48.00

$16.00

$32.00

$38.00

$11.00

$27.00

$75.00

BR

BR

$182.00

$78.00

$104.00

$33.00

$10.00

$23.00

$38.00

$11.00

$27.00

$44.00

$15.00

$29.00

$40.00

$11.00

$418.00

$18.00

$399.00

$42.00

$13.00

$28.00

$49.00

$16.00

$32.00

$35.00

$11.00

$24.00

$44.00

$15.00

$29.00

$35.00

$12.00

$26.00

$59.00

$19.00

$39.00

$55.00

$20.00

$36.00

$32.00

$12.00

$20.00

$45.00

$15.00

$30.00

$35.00

$10.00

$25.00

$69.00

BR

BR

$167.00

$71.00

$97.00

$30.00

$9.00

$21.00

$35.00

$10.00

$25.00

$41.00

$14.00

$27.00

$36.00

$10.00

$388.00

$17.00

$371.00

$38.00

$13.00

$26.00

$45.00

$16.00

$30.00

$32.00

$10.00

$22.00

$40.00

$14.00

$26.00

$32.00

$11.00

$28.00

$62.00

$20.00

$42.00

$59.00

$20.00

$38.00

$34.00

$12.00

$22.00

$47.00

$15.00

$32.00

$37.00

$10.00

$27.00

$72.00

BR

BR

$178.00

$74.00

$104.00

$32.00

$10.00

$22.00

$38.00

$11.00

$27.00

$43.00

$15.00

$29.00

$39.00

$11.00

$415.00

$18.00

$398.00

$41.00

$13.00

$28.00

$48.00

$16.00

$32.00

$34.00

$10.00

$24.00

$43.00

$15.00

$28.00

$34.00

$11.00

(Facility MRA)

$29.00

$64.00

$21.00

$43.00

$59.00

$20.00

$39.00

$35.00

$13.00

$22.00

$48.00

$16.00

$32.00

$38.00

$11.00

$27.00

$75.00

BR

BR

$182.00

$78.00

$104.00

$33.00

$10.00

$23.00

$38.00

$11.00

$27.00

$44.00

$15.00

$29.00

$40.00

$11.00

$418.00

$18.00

$399.00

$42.00

$13.00

$28.00

$49.00

$16.00

$32.00

$35.00

$11.00

$24.00

$44.00

$15.00

$29.00

$35.00

$12.00


Part C, 278



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


70328-26

70328-TC

70330

70330-26

70330-TC

70332

70332-26

70332-TC

70336

70336-26

70336-TC

70350

70350-26

70350-TC

70355

70355-26

70240-TC

70250

70250-26

70250-TC

70260

70260-26

70260-TC

70300

70300-26

70300-TC

70310

70310-26

70310-TC

70320

70320-26

70320-TC

70328

70355-TC

70360

70360-26

70360-TC

70370

70370-26

70370-TC

70371

70371-26

70371-TC

70380

70380-26

70380-TC

70390

70390-26

70390-TC

70450

$10.00

$18.00

$43.00

$12.00

$31.00

$107.00

NC

NC

$497.00

$72.00

$419.00

$24.00

$10.00

$14.00

$32.00

$10.00

$15.00

$35.00

$12.00

$22.00

$50.00

$17.00

$33.00

$15.00

$5.00

$10.00

$24.00

$8.00

$15.00

$40.00

$11.00

$29.00

$28.00

$21.00

$24.00

$8.00

$15.00

$65.00

$16.00

$48.00

$122.00

$43.00

$79.00

$34.00

$8.00

$24.00

$87.00

NC

NC

$221.00

$10.00

$23.00

$51.00

$14.00

$36.00

$88.00

$35.00

$53.00

$345.00

$83.00

$262.00

$22.00

$12.00

$10.00

$23.00

$13.00

$21.00

$39.00

$14.00

$25.00

$49.00

$20.00

$30.00

$16.00

$7.00

$10.00

$39.00

$9.00

$30.00

$56.00

$13.00

$43.00

$33.00

$10.00

$30.00

$9.00

$21.00

$82.00

$18.00

$64.00

$99.00

$48.00

$51.00

$39.00

$10.00

$28.00

$101.00

$21.00

$80.00

$126.00

$11.00

$25.00

$54.00

$15.00

$39.00

$93.00

$37.00

$57.00

$367.00

$86.00

$281.00

$23.00

$12.00

$11.00

$24.00

$13.00

$23.00

$41.00

$15.00

$27.00

$52.00

$20.00

$32.00

$17.00

$7.00

$10.00

$42.00

$9.00

$33.00

$60.00

$14.00

$46.00

$35.00

$11.00

$32.00

$10.00

$23.00

$88.00

$19.00

$69.00

$105.00

$50.00

$55.00

$41.00

$11.00

$31.00

$107.00

$22.00

$85.00

$133.00

$11.00

$25.00

$55.00

$15.00

$40.00

$95.00

$38.00

$57.00

$371.00

$88.00

$283.00

$24.00

$13.00

$12.00

$25.00

$14.00

$23.00

$42.00

$15.00

$27.00

$53.00

$21.00

$32.00

$18.00

$7.00

$11.00

$43.00

$10.00

$33.00

$61.00

$14.00

$47.00

$36.00

$11.00

$33.00

$10.00

$23.00

$89.00

$19.00

$69.00

$107.00

$51.00

$55.00

$42.00

$11.00

$31.00

$109.00

$23.00

$86.00

$135.00

$10.00

$23.00

$51.00

$14.00

$36.00

$88.00

$35.00

$53.00

$345.00

$83.00

$262.00

$22.00

$12.00

$10.00

$23.00

$13.00

$21.00

$39.00

$14.00

$25.00

$49.00

$20.00

$30.00

$16.00

$7.00

$10.00

$39.00

$9.00

$30.00

$56.00

$13.00

$43.00

$33.00

$10.00

$30.00

$9.00

$21.00

$82.00

$18.00

$64.00

$99.00

$48.00

$51.00

$39.00

$10.00

$28.00

$101.00

$21.00

$80.00

$126.00

$11.00

$25.00

$54.00

$15.00

$39.00

$93.00

$37.00

$57.00

$367.00

$86.00

$281.00

$23.00

$12.00

$11.00

$24.00

$13.00

$23.00

$41.00

$15.00

$27.00

$52.00

$20.00

$32.00

$17.00

$7.00

$10.00

$42.00

$9.00

$33.00

$60.00

$14.00

$46.00

$35.00

$11.00

$32.00

$10.00

$23.00

$88.00

$19.00

$69.00

$105.00

$50.00

$55.00

$41.00

$11.00

$31.00

$107.00

$22.00

$85.00

$133.00

(Facility MRA)

$11.00

$25.00

$55.00

$15.00

$40.00

$95.00

$38.00

$57.00

$371.00

$88.00

$283.00

$24.00

$13.00

$12.00

$25.00

$14.00

$23.00

$42.00

$15.00

$27.00

$53.00

$21.00

$32.00

$18.00

$7.00

$11.00

$43.00

$10.00

$33.00

$61.00

$14.00

$47.00

$36.00

$11.00

$33.00

$10.00

$23.00

$89.00

$19.00

$69.00

$107.00

$51.00

$55.00

$42.00

$11.00

$31.00

$109.00

$23.00

$86.00

$135.00


Part C, 279



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


70486

70486-26

70486-TC

70487

70487-26

70487-TC

70488

70488-26

70488-TC

70490

70490-26

70490-TC

70491

70491-26

70491-TC

70492

70450-26

70450-TC

70460

70460-26

70460-TC

70470

70470-26

70470-TC

70480

70480-26

70480-TC

70481

70481-26

70481-TC

70482

70482-26

70482-TC

70492-26

70492-TC

70496

70496-26

70496-TC

70498

70498-26

70498-TC

70540

70540-26

70540-TC

70542

70542-26

70542-TC

70543

70543-26

70543-TC

$236.00

$58.00

$176.00

$279.00

$66.00

$211.00

$339.00

$72.00

$264.00

$244.00

$65.00

$176.00

$284.00

$70.00

$211.00

$340.00

$43.00

$176.00

$271.00

$58.00

$211.00

$332.00

$65.00

$264.00

$244.00

$65.00

$176.00

$284.00

$70.00

$211.00

$340.00

$74.00

$264.00

$74.00

$264.00

$366.00

$92.00

$270.00

$366.00

$92.00

$270.00

$482.00

$70.00

$413.00

$579.00

$82.00

$495.00

$1,029.00

$109.00

$916.00

$151.00

$48.00

$103.00

$182.00

$63.00

$118.00

$221.00

$71.00

$150.00

$191.00

$72.00

$119.00

$254.00

$78.00

$176.00

$299.00

$48.00

$78.00

$175.00

$63.00

$111.00

$207.00

$72.00

$135.00

$191.00

$72.00

$119.00

$297.00

$78.00

$219.00

$324.00

$81.00

$243.00

$82.00

$218.00

$317.00

$98.00

$219.00

$316.00

$98.00

$218.00

$364.00

$76.00

$288.00

$431.00

$91.00

$340.00

$528.00

$121.00

$407.00

$160.00

$50.00

$111.00

$193.00

$66.00

$127.00

$235.00

$74.00

$161.00

$202.00

$75.00

$128.00

$270.00

$81.00

$189.00

$318.00

$50.00

$83.00

$185.00

$66.00

$120.00

$220.00

$74.00

$145.00

$202.00

$75.00

$128.00

$316.00

$80.00

$236.00

$345.00

$84.00

$261.00

$84.00

$234.00

$337.00

$102.00

$235.00

$336.00

$102.00

$234.00

$388.00

$78.00

$310.00

$459.00

$94.00

$365.00

$562.00

$125.00

$437.00

$163.00

$51.00

$111.00

$195.00

$67.00

$128.00

$238.00

$76.00

$162.00

$205.00

$77.00

$128.00

$273.00

$83.00

$190.00

$321.00

$51.00

$84.00

$188.00

$67.00

$120.00

$223.00

$76.00

$146.00

$205.00

$77.00

$128.00

$319.00

$83.00

$237.00

$349.00

$87.00

$262.00

$87.00

$235.00

$341.00

$105.00

$237.00

$340.00

$105.00

$235.00

$392.00

$81.00

$311.00

$464.00

$97.00

$367.00

$568.00

$129.00

$439.00

$151.00

$48.00

$103.00

$182.00

$63.00

$118.00

$221.00

$71.00

$150.00

$191.00

$72.00

$119.00

$254.00

$78.00

$176.00

$299.00

$48.00

$78.00

$175.00

$63.00

$111.00

$207.00

$72.00

$135.00

$191.00

$72.00

$119.00

$297.00

$78.00

$219.00

$324.00

$81.00

$243.00

$82.00

$218.00

$317.00

$98.00

$219.00

$316.00

$98.00

$218.00

$364.00

$76.00

$288.00

$431.00

$91.00

$340.00

$528.00

$121.00

$407.00

$160.00

$50.00

$111.00

$193.00

$66.00

$127.00

$235.00

$74.00

$161.00

$202.00

$75.00

$128.00

$270.00

$81.00

$189.00

$318.00

$50.00

$83.00

$185.00

$66.00

$120.00

$220.00

$74.00

$145.00

$202.00

$75.00

$128.00

$316.00

$80.00

$236.00

$345.00

$84.00

$261.00

$84.00

$234.00

$337.00

$102.00

$235.00

$336.00

$102.00

$234.00

$388.00

$78.00

$310.00

$459.00

$94.00

$365.00

$562.00

$125.00

$437.00

(Facility MRA)

$163.00

$51.00

$111.00

$195.00

$67.00

$128.00

$238.00

$76.00

$162.00

$205.00

$77.00

$128.00

$273.00

$83.00

$190.00

$321.00

$51.00

$84.00

$188.00

$67.00

$120.00

$223.00

$76.00

$146.00

$205.00

$77.00

$128.00

$319.00

$83.00

$237.00

$349.00

$87.00

$262.00

$87.00

$235.00

$341.00

$105.00

$237.00

$340.00

$105.00

$235.00

$392.00

$81.00

$311.00

$464.00

$97.00

$367.00

$568.00

$129.00

$439.00


Part C, 280



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


70549-TC

70551

70551-26

70551-TC

70552

70552-26

70552-TC

70553

70553-26

70553-TC

70554

70554-26

70554-TC

70555

70555-26

70555-TC

70544

70544-26

70544-TC

70545

70545-26

70545-TC

70546

70546-26

70546-TC

70547

70547-26

70547-TC

70548

70548-26

70548-TC

70549

70549-26

70557

70557-26

70557-TC

70558

70558-26

70558-TC

70559

70559-26

70559-TC

71010

71010-26

71010-TC

71015

71015-26

71015-TC

71020

71020-26

$820.00

$497.00

$76.00

$419.00

$596.00

$91.00

$502.00

$1,055.00

$120.00

$931.00

---------

---------

---------

---------

---------

---------

$481.00

$61.00

$419.00

$481.00

$61.00

$419.00

$914.00

$92.00

$820.00

$481.00

$61.00

$419.00

$481.00

$61.00

$419.00

$914.00

$92.00

---------

$27.00

$9.00

$17.00

$30.00

$10.00

$19.00

$35.00

$11.00

---------

---------

---------

---------

---------

---------

---------

---------

$479.00

$249.00

$83.00

$165.00

$344.00

$100.00

$244.00

$407.00

$129.00

$278.00

$485.00

$120.00

$365.00

BR

$142.00

BR

$356.00

$68.00

$288.00

$415.00

$68.00

$347.00

$580.00

$101.00

$479.00

$356.00

$68.00

$288.00

$442.00

$68.00

$374.00

$580.00

$101.00

$452.00

$164.00

$288.00

$659.00

$181.00

$478.00

$3,046.00

$183.00

$2,863.00

$24.00

$10.00

$14.00

$30.00

$12.00

$18.00

$30.00

$12.00

$380.00

$70.00

$310.00

$442.00

$70.00

$373.00

$619.00

$105.00

$514.00

$380.00

$70.00

$310.00

$472.00

$70.00

$402.00

$619.00

$105.00

$514.00

$264.00

$86.00

$178.00

$366.00

$104.00

$262.00

$432.00

$133.00

$299.00

$516.00

$124.00

$392.00

BR

$147.00

BR

$479.00

$170.00

$309.00

$700.00

$187.00

$513.00

$3,262.00

$189.00

$3,072.00

$26.00

$11.00

$15.00

$32.00

$13.00

$19.00

$32.00

$13.00

$384.00

$72.00

$311.00

$446.00

$72.00

$374.00

$624.00

$108.00

$516.00

$384.00

$72.00

$311.00

$476.00

$72.00

$404.00

$624.00

$108.00

$516.00

$267.00

$89.00

$178.00

$370.00

$107.00

$264.00

$438.00

$138.00

$300.00

$522.00

$128.00

$394.00

BR

$151.00

BR

$486.00

$175.00

$311.00

$708.00

$193.00

$515.00

$3,277.00

$196.00

$3,082.00

$27.00

$11.00

$16.00

$33.00

$13.00

$20.00

$33.00

$13.00

(Facility MRA)

$514.00

$264.00

$86.00

$178.00

$366.00

$104.00

$262.00

$432.00

$133.00

$299.00

$516.00

$124.00

$392.00

BR

$147.00

BR

$380.00

$70.00

$310.00

$442.00

$70.00

$373.00

$619.00

$105.00

$514.00

$380.00

$70.00

$310.00

$472.00

$70.00

$402.00

$619.00

$105.00

$479.00

$170.00

$309.00

$700.00

$187.00

$486.00

$175.00

$311.00

$708.00

$193.00

$513.00

$515.00

$3,262.00

$3,277.00

$189.00

$196.00

$3,072.00

$3,082.00

$26.00

$27.00

$11.00

$15.00

$32.00

$11.00

$16.00

$33.00

$13.00

$19.00

$32.00

$13.00

$13.00

$20.00

$33.00

$13.00

$516.00

$267.00

$89.00

$178.00

$370.00

$107.00

$264.00

$438.00

$138.00

$300.00

$522.00

$128.00

$394.00

BR

$151.00

BR

$384.00

$72.00

$311.00

$446.00

$72.00

$374.00

$624.00

$108.00

$516.00

$384.00

$72.00

$311.00

$476.00

$72.00

$404.00

$624.00

$108.00

$479.00

$249.00

$83.00

$165.00

$344.00

$100.00

$244.00

$407.00

$129.00

$278.00

$485.00

$120.00

$365.00

BR

$142.00

BR

$356.00

$68.00

$288.00

$415.00

$68.00

$347.00

$580.00

$101.00

$479.00

$356.00

$68.00

$288.00

$442.00

$68.00

$374.00

$580.00

$101.00

$452.00

$164.00

$288.00

$659.00

$181.00

$478.00

$3,046.00

$183.00

$2,863.00

$24.00

$10.00

$14.00

$30.00

$12.00

$18.00

$30.00

$12.00


Part C, 281



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


71035-26

71035-TC

71100

71100-26

71100-TC

71101

71101-26

71101-TC

71110

71110-26

71110-TC

71111

71111-26

71111-TC

71120

71120-26

71020-TC

71021

71021-26

71021-TC

71022

71022-26

71022-TC

71023

71023-26

71023-TC

71030

71030-26

71030-TC

71034

71034-26

71034-TC

71035

71120-TC

71130

71130-26

71130-TC

71250

71250-26

71250-TC

71260

71260-26

71260-TC

71270

71270-26

71270-TC

71275

71275-26

71275-TC

71550

$19.00

$38.00

$33.00

$11.00

$21.00

$38.00

$13.00

$24.00

$43.00

$13.00

$29.00

$49.00

$16.00

$33.00

$35.00

$10.00

$22.00

$41.00

$13.00

$28.00

$44.00

$16.00

$28.00

$49.00

$19.00

$29.00

$45.00

$16.00

$29.00

$79.00

$23.00

$54.00

$56.00

$24.00

$38.00

$11.00

$26.00

$282.00

$59.00

$220.00

$328.00

$63.00

$264.00

$402.00

$70.00

$330.00

$431.00

$100.00

$328.00

$490.00

$10.00

$25.00

$35.00

$13.00

$23.00

$39.00

$15.00

$24.00

$40.00

$15.00

$25.00

$52.00

$19.00

$33.00

$32.00

$11.00

$18.00

$37.00

$15.00

$21.00

$45.00

$18.00

$27.00

$68.00

$21.00

$47.00

$45.00

$18.00

$27.00

$90.00

$27.00

$63.00

$35.00

$21.00

$39.00

$13.00

$26.00

$177.00

$58.00

$119.00

$247.00

$70.00

$177.00

$296.00

$78.00

$218.00

$323.00

$102.00

$221.00

$370.00

$11.00

$27.00

$38.00

$13.00

$25.00

$42.00

$16.00

$26.00

$43.00

$16.00

$27.00

$55.00

$19.00

$36.00

$34.00

$12.00

$19.00

$39.00

$16.00

$23.00

$48.00

$19.00

$29.00

$73.00

$22.00

$51.00

$48.00

$18.00

$29.00

$96.00

$28.00

$68.00

$38.00

$22.00

$41.00

$13.00

$28.00

$187.00

$60.00

$128.00

$262.00

$73.00

$190.00

$315.00

$80.00

$234.00

$343.00

$106.00

$237.00

$394.00

$11.00

$27.00

$38.00

$13.00

$25.00

$43.00

$17.00

$26.00

$44.00

$16.00

$27.00

$56.00

$20.00

$36.00

$35.00

$12.00

$20.00

$39.00

$16.00

$23.00

$48.00

$19.00

$29.00

$74.00

$23.00

$51.00

$49.00

$19.00

$30.00

$97.00

$29.00

$69.00

$38.00

$23.00

$42.00

$13.00

$29.00

$190.00

$62.00

$128.00

$265.00

$75.00

$191.00

$318.00

$83.00

$235.00

$347.00

$109.00

$239.00

$398.00

$10.00

$25.00

$35.00

$13.00

$23.00

$39.00

$15.00

$24.00

$40.00

$15.00

$25.00

$52.00

$19.00

$33.00

$32.00

$11.00

$18.00

$37.00

$15.00

$21.00

$45.00

$18.00

$27.00

$68.00

$21.00

$47.00

$45.00

$18.00

$27.00

$90.00

$27.00

$63.00

$35.00

$21.00

$39.00

$13.00

$26.00

$177.00

$58.00

$119.00

$247.00

$70.00

$177.00

$296.00

$78.00

$218.00

$323.00

$102.00

$221.00

$370.00

$11.00

$27.00

$38.00

$13.00

$25.00

$42.00

$16.00

$26.00

$43.00

$16.00

$27.00

$55.00

$19.00

$36.00

$34.00

$12.00

$19.00

$39.00

$16.00

$23.00

$48.00

$19.00

$29.00

$73.00

$22.00

$51.00

$48.00

$18.00

$29.00

$96.00

$28.00

$68.00

$38.00

$22.00

$41.00

$13.00

$28.00

$187.00

$60.00

$128.00

$262.00

$73.00

$190.00

$315.00

$80.00

$234.00

$343.00

$106.00

$237.00

$394.00

(Facility MRA)

$11.00

$27.00

$38.00

$13.00

$25.00

$43.00

$17.00

$26.00

$44.00

$16.00

$27.00

$56.00

$20.00

$36.00

$35.00

$12.00

$20.00

$39.00

$16.00

$23.00

$48.00

$19.00

$29.00

$74.00

$23.00

$51.00

$49.00

$19.00

$30.00

$97.00

$29.00

$69.00

$38.00

$23.00

$42.00

$13.00

$29.00

$190.00

$62.00

$128.00

$265.00

$75.00

$191.00

$318.00

$83.00

$235.00

$347.00

$109.00

$239.00

$398.00


Part C, 282



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


72050

72050-26

72050-TC

72052

72052-26

72052-TC

72070

72070-26

72070-TC

72072

72072-26

72072-TC

72074

72074-26

72074-TC

72080

71550-26

71550-TC

71551

71551-26

71551-TC

71552

71552-26

71552-TC

71555

71555-26

71555-TC

72020

72020-26

72020-TC

72040

72040-26

72040-TC

72080-26

72080-TC

72081

72081-26

72081-TC

72082

72082-26

72082-TC

72083

72083-26

72083-TC

72084

72084-26

72084-TC

72100

72100-26

72100-TC

$49.00

$16.00

$33.00

$61.00

$18.00

$42.00

$36.00

$11.00

$24.00

$39.00

$11.00

$28.00

$45.00

$11.00

$34.00

$36.00

$75.00

$415.00

$587.00

$88.00

$496.00

$1,029.00

$114.00

$911.00

$514.00

$92.00

$419.00

$22.00

$7.00

$15.00

$34.00

$11.00

$22.00

$11.00

$24.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$36.00

$11.00

$24.00

$49.00

$18.00

$31.00

$61.00

$21.00

$40.00

$37.00

$13.00

$24.00

$37.00

$12.00

$25.00

$42.00

$12.00

$30.00

$33.00

$82.00

$288.00

$491.00

$97.00

$394.00

$606.00

$128.00

$479.00

$427.00

$101.00

$326.00

$24.00

$9.00

$15.00

$36.00

$13.00

$23.00

$12.00

$21.00

$42.00

$15.00

$27.00

$67.00

$18.00

$49.00

$73.00

$20.00

$53.00

$87.00

$23.00

$64.00

$38.00

$13.00

$25.00

$52.00

$18.00

$33.00

$64.00

$21.00

$43.00

$39.00

$13.00

$26.00

$40.00

$13.00

$27.00

$45.00

$13.00

$32.00

$35.00

$85.00

$310.00

$524.00

$100.00

$423.00

$646.00

$132.00

$514.00

$454.00

$104.00

$350.00

$26.00

$9.00

$16.00

$38.00

$13.00

$25.00

$13.00

$23.00

$45.00

$16.00

$29.00

$71.00

$19.00

$53.00

$77.00

$20.00

$57.00

$92.00

$24.00

$69.00

$40.00

$13.00

$27.00

$53.00

$19.00

$34.00

$66.00

$22.00

$44.00

$40.00

$13.00

$26.00

$40.00

$13.00

$27.00

$46.00

$13.00

$33.00

$36.00

$87.00

$311.00

$529.00

$104.00

$425.00

$652.00

$136.00

$516.00

$458.00

$107.00

$352.00

$26.00

$9.00

$17.00

$39.00

$13.00

$25.00

$13.00

$23.00

$46.00

$16.00

$29.00

$73.00

$19.00

$53.00

$79.00

$21.00

$58.00

$94.00

$24.00

$69.00

$41.00

$13.00

$27.00

$49.00

$18.00

$31.00

$61.00

$21.00

$40.00

$37.00

$13.00

$24.00

$37.00

$12.00

$25.00

$42.00

$12.00

$30.00

$33.00

$82.00

$288.00

$491.00

$97.00

$394.00

$606.00

$128.00

$479.00

$427.00

$101.00

$326.00

$24.00

$9.00

$15.00

$36.00

$13.00

$23.00

$12.00

$21.00

$42.00

$15.00

$27.00

$67.00

$18.00

$49.00

$73.00

$20.00

$53.00

$87.00

$23.00

$64.00

$38.00

$13.00

$25.00

$52.00

$18.00

$33.00

$64.00

$21.00

$43.00

$39.00

$13.00

$26.00

$40.00

$13.00

$27.00

$45.00

$13.00

$32.00

$35.00

$85.00

$310.00

$524.00

$100.00

$423.00

$646.00

$132.00

$514.00

$454.00

$104.00

$350.00

$26.00

$9.00

$16.00

$38.00

$13.00

$25.00

$13.00

$23.00

$45.00

$16.00

$29.00

$71.00

$19.00

$53.00

$77.00

$20.00

$57.00

$92.00

$24.00

$69.00

$40.00

$13.00

$27.00

(Facility MRA)

$53.00

$19.00

$34.00

$66.00

$22.00

$44.00

$40.00

$13.00

$26.00

$40.00

$13.00

$27.00

$46.00

$13.00

$33.00

$36.00

$87.00

$311.00

$529.00

$104.00

$425.00

$652.00

$136.00

$516.00

$458.00

$107.00

$352.00

$26.00

$9.00

$17.00

$39.00

$13.00

$25.00

$13.00

$23.00

$46.00

$16.00

$29.00

$73.00

$19.00

$53.00

$79.00

$21.00

$58.00

$94.00

$24.00

$69.00

$41.00

$13.00

$27.00


Part C, 283



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


72127-TC

72128

72128-26

72128-TC

72129

72129-26

72129-TC

72130

72130-26

72130-TC

72131

72131-26

72131-TC

72132

72132-26

72132-TC

72110

72110-26

72110-TC

72114

72114-26

72114-TC

72120

72120-26

72120-TC

72125

72125-26

72125-TC

72126

72126-26

72126-TC

72127

72127-26

72133

72133-26

72133-TC

72141

72141-26

72141-TC

72142

72142-26

72142-TC

72146

72146-26

72146-TC

72147

72147-26

72147-TC

72148

72148-26

$330.00

$282.00

$59.00

$220.00

$328.00

$62.00

$264.00

$397.00

$65.00

$330.00

$282.00

$59.00

$220.00

$328.00

$62.00

$264.00

$50.00

$16.00

$34.00

$64.00

$18.00

$44.00

$45.00

$11.00

$33.00

$282.00

$59.00

$220.00

$328.00

$62.00

$264.00

$397.00

$65.00

$391.00

$65.00

$323.00

$503.00

$82.00

$419.00

$604.00

$99.00

$502.00

$549.00

$82.00

$465.00

$603.00

$98.00

$502.00

$543.00

$76.00

$220.00

$175.00

$56.00

$119.00

$247.00

$69.00

$178.00

$293.00

$71.00

$222.00

$175.00

$56.00

$119.00

$246.00

$69.00

$177.00

$53.00

$18.00

$35.00

$67.00

$19.00

$49.00

$43.00

$13.00

$31.00

$179.00

$60.00

$119.00

$247.00

$69.00

$178.00

$291.00

$71.00

$291.00

$72.00

$219.00

$242.00

$84.00

$158.00

$350.00

$101.00

$249.00

$242.00

$84.00

$158.00

$346.00

$100.00

$246.00

$241.00

$84.00

$236.00

$186.00

$58.00

$128.00

$262.00

$71.00

$191.00

$312.00

$74.00

$238.00

$186.00

$58.00

$128.00

$262.00

$71.00

$191.00

$56.00

$18.00

$38.00

$71.00

$19.00

$52.00

$46.00

$13.00

$33.00

$190.00

$62.00

$128.00

$262.00

$71.00

$191.00

$310.00

$74.00

$310.00

$74.00

$236.00

$257.00

$87.00

$170.00

$372.00

$105.00

$267.00

$257.00

$87.00

$170.00

$368.00

$104.00

$264.00

$255.00

$87.00

$237.00

$189.00

$60.00

$128.00

$265.00

$73.00

$192.00

$315.00

$76.00

$239.00

$189.00

$60.00

$128.00

$265.00

$73.00

$191.00

$57.00

$19.00

$38.00

$73.00

$20.00

$53.00

$47.00

$13.00

$34.00

$193.00

$64.00

$128.00

$265.00

$73.00

$192.00

$313.00

$76.00

$313.00

$77.00

$237.00

$260.00

$89.00

$171.00

$377.00

$108.00

$269.00

$260.00

$89.00

$171.00

$372.00

$107.00

$266.00

$259.00

$89.00

$220.00

$175.00

$56.00

$119.00

$247.00

$69.00

$178.00

$293.00

$71.00

$222.00

$175.00

$56.00

$119.00

$246.00

$69.00

$177.00

$53.00

$18.00

$35.00

$67.00

$19.00

$49.00

$43.00

$13.00

$31.00

$179.00

$60.00

$119.00

$247.00

$69.00

$178.00

$291.00

$71.00

$291.00

$72.00

$219.00

$242.00

$84.00

$158.00

$350.00

$101.00

$249.00

$242.00

$84.00

$158.00

$346.00

$100.00

$246.00

$241.00

$84.00

$236.00

$186.00

$58.00

$128.00

$262.00

$71.00

$191.00

$312.00

$74.00

$238.00

$186.00

$58.00

$128.00

$262.00

$71.00

$191.00

$56.00

$18.00

$38.00

$71.00

$19.00

$52.00

$46.00

$13.00

$33.00

$190.00

$62.00

$128.00

$262.00

$71.00

$191.00

$310.00

$74.00

$310.00

$74.00

$236.00

$257.00

$87.00

$170.00

$372.00

$105.00

$267.00

$257.00

$87.00

$170.00

$368.00

$104.00

$264.00

$255.00

$87.00

(Facility MRA)

$237.00

$189.00

$60.00

$128.00

$265.00

$73.00

$192.00

$315.00

$76.00

$239.00

$189.00

$60.00

$128.00

$265.00

$73.00

$191.00

$57.00

$19.00

$38.00

$73.00

$20.00

$53.00

$47.00

$13.00

$34.00

$193.00

$64.00

$128.00

$265.00

$73.00

$192.00

$313.00

$76.00

$313.00

$77.00

$237.00

$260.00

$89.00

$171.00

$377.00

$108.00

$269.00

$260.00

$89.00

$171.00

$372.00

$107.00

$266.00

$259.00

$89.00


Part C, 284



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


72170-26

72170-TC

72190

72190-26

72190-TC

72191

72191-26

72191-TC

72192

72192-26

72192-TC

72193

72193-26

72193-TC

72194

72194-26

72148-TC

72149

72149-26

72149-TC

72156

72156-26

72156-TC

72157

72157-26

72157-TC

72158

72158-26

72158-TC

72159

72159-26

72159-TC

72170

72194-TC

72195

72195-26

72195-TC

72196

72196-26

72196-TC

72197

72197-26

72197-TC

72198

72198-26

72198-TC

72200

72200-26

72200-TC

72202

$8.00

$19.00

$35.00

$10.00

$24.00

$413.00

$94.00

$315.00

$278.00

$56.00

$220.00

$317.00

$59.00

$256.00

$380.00

$62.00

$465.00

$597.00

$92.00

$502.00

$1,066.00

$131.00

$931.00

$1,066.00

$131.00

$931.00

$1,056.00

$121.00

$931.00

$563.00

$94.00

$465.00

$29.00

$317.00

$491.00

$74.00

$415.00

$526.00

$84.00

$442.00

$1,037.00

$114.00

$919.00

$517.00

$95.00

$419.00

$29.00

$9.00

$19.00

$33.00

$10.00

$24.00

$41.00

$12.00

$29.00

$329.00

$102.00

$228.00

$158.00

$62.00

$97.00

$243.00

$66.00

$178.00

$280.00

$69.00

$157.00

$346.00

$101.00

$245.00

$409.00

$129.00

$280.00

$410.00

$129.00

$281.00

$408.00

$129.00

$279.00

$448.00

$102.00

$346.00

$34.00

$211.00

$371.00

$82.00

$288.00

$442.00

$98.00

$344.00

$543.00

$128.00

$416.00

$431.00

$101.00

$330.00

$31.00

$10.00

$21.00

$35.00

$10.00

$26.00

$44.00

$13.00

$31.00

$350.00

$105.00

$244.00

$167.00

$64.00

$104.00

$259.00

$68.00

$191.00

$298.00

$71.00

$169.00

$368.00

$105.00

$263.00

$434.00

$133.00

$301.00

$435.00

$133.00

$302.00

$433.00

$133.00

$300.00

$477.00

$105.00

$371.00

$36.00

$227.00

$395.00

$85.00

$310.00

$471.00

$101.00

$369.00

$578.00

$132.00

$446.00

$458.00

$104.00

$354.00

$33.00

$10.00

$23.00

$38.00

$11.00

$27.00

$44.00

$13.00

$31.00

$355.00

$109.00

$246.00

$170.00

$65.00

$104.00

$262.00

$70.00

$192.00

$301.00

$73.00

$169.00

$373.00

$108.00

$264.00

$440.00

$138.00

$302.00

$441.00

$138.00

$303.00

$439.00

$138.00

$301.00

$481.00

$108.00

$373.00

$37.00

$228.00

$399.00

$88.00

$311.00

$475.00

$104.00

$371.00

$584.00

$136.00

$448.00

$463.00

$107.00

$356.00

$33.00

$11.00

$23.00

$38.00

$10.00

$24.00

$41.00

$12.00

$29.00

$329.00

$102.00

$228.00

$158.00

$62.00

$97.00

$243.00

$66.00

$178.00

$280.00

$69.00

$157.00

$346.00

$101.00

$245.00

$409.00

$129.00

$280.00

$410.00

$129.00

$281.00

$408.00

$129.00

$279.00

$448.00

$102.00

$346.00

$34.00

$211.00

$371.00

$82.00

$288.00

$442.00

$98.00

$344.00

$543.00

$128.00

$416.00

$431.00

$101.00

$330.00

$31.00

$10.00

$21.00

$35.00

$10.00

$26.00

$44.00

$13.00

$31.00

$350.00

$105.00

$244.00

$167.00

$64.00

$104.00

$259.00

$68.00

$191.00

$298.00

$71.00

$169.00

$368.00

$105.00

$263.00

$434.00

$133.00

$301.00

$435.00

$133.00

$302.00

$433.00

$133.00

$300.00

$477.00

$105.00

$371.00

$36.00

$227.00

$395.00

$85.00

$310.00

$471.00

$101.00

$369.00

$578.00

$132.00

$446.00

$458.00

$104.00

$354.00

$33.00

$10.00

$23.00

$38.00

(Facility MRA)

$11.00

$27.00

$44.00

$13.00

$31.00

$355.00

$109.00

$246.00

$170.00

$65.00

$104.00

$262.00

$70.00

$192.00

$301.00

$73.00

$169.00

$373.00

$108.00

$264.00

$440.00

$138.00

$302.00

$441.00

$138.00

$303.00

$439.00

$138.00

$301.00

$481.00

$108.00

$373.00

$37.00

$228.00

$399.00

$88.00

$311.00

$475.00

$104.00

$371.00

$584.00

$136.00

$448.00

$463.00

$107.00

$356.00

$33.00

$11.00

$23.00

$38.00


Part C, 285



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


72275

72275-26

72275-TC

72285

72285-26

72285-TC

72295

72295-26

72295-TC

73000

73000-26

73000-TC

73010

73010-26

73010-TC

73020

72202-26

72202-TC

72220

72220-26

72220-TC

72240

72240-26

72240-TC

72255

72255-26

72255-TC

72265

72265-26

72265-TC

72270

72270-26

72270-TC

73020-26

73020-TC

73030

73030-26

73030-TC

73040

73040-26

73040-TC

73050

73050-26

73050-TC

73060

73060-26

73060-TC

73070

73070-26

73070-TC

$112.00

NC

NC

$101.00

NC

NC

$107.00

NC

NC

$28.00

$8.00

$19.00

$29.00

$8.00

$19.00

$26.00

$9.00

$22.00

$30.00

$8.00

$21.00

$132.00

NC

NC

$129.00

NC

NC

$132.00

NC

NC

$176.00

NC

NC

$7.00

$17.00

$31.00

$9.00

$21.00

$68.00

NC

NC

$35.00

$10.00

$24.00

$30.00

$8.00

$21.00

$27.00

$7.00

$19.00

$125.00

$44.00

$81.00

$124.00

$68.00

$56.00

$107.00

$49.00

$58.00

$30.00

$9.00

$20.00

$32.00

$10.00

$22.00

$25.00

$11.00

$25.00

$30.00

$10.00

$21.00

$106.00

$51.00

$55.00

$106.00

$52.00

$54.00

$100.00

$47.00

$53.00

$139.00

$75.00

$63.00

$9.00

$16.00

$31.00

$11.00

$21.00

$108.00

$31.00

$77.00

$38.00

$12.00

$26.00

$31.00

$9.00

$22.00

$29.00

$9.00

$20.00

$132.00

$46.00

$87.00

$131.00

$71.00

$60.00

$114.00

$51.00

$63.00

$32.00

$10.00

$22.00

$34.00

$11.00

$24.00

$26.00

$11.00

$27.00

$32.00

$10.00

$22.00

$112.00

$53.00

$59.00

$112.00

$54.00

$58.00

$106.00

$49.00

$57.00

$146.00

$78.00

$68.00

$9.00

$17.00

$33.00

$11.00

$22.00

$114.00

$32.00

$83.00

$40.00

$12.00

$28.00

$33.00

$10.00

$23.00

$31.00

$9.00

$22.00

$134.00

$47.00

$87.00

$134.00

$73.00

$61.00

$116.00

$53.00

$63.00

$32.00

$10.00

$22.00

$35.00

$11.00

$24.00

$27.00

$11.00

$27.00

$33.00

$11.00

$23.00

$114.00

$55.00

$60.00

$114.00

$56.00

$58.00

$108.00

$50.00

$58.00

$149.00

$81.00

$69.00

$9.00

$18.00

$34.00

$11.00

$23.00

$116.00

$33.00

$83.00

$41.00

$13.00

$29.00

$34.00

$10.00

$24.00

$32.00

$10.00

$22.00

$125.00

$44.00

$81.00

$124.00

$68.00

$56.00

$107.00

$49.00

$58.00

$30.00

$9.00

$20.00

$32.00

$10.00

$22.00

$25.00

$11.00

$25.00

$30.00

$10.00

$21.00

$106.00

$51.00

$55.00

$106.00

$52.00

$54.00

$100.00

$47.00

$53.00

$139.00

$75.00

$63.00

$9.00

$16.00

$31.00

$11.00

$21.00

$108.00

$31.00

$77.00

$38.00

$12.00

$26.00

$31.00

$9.00

$22.00

$29.00

$9.00

$20.00

$132.00

$46.00

$87.00

$131.00

$71.00

$60.00

$114.00

$51.00

$63.00

$32.00

$10.00

$22.00

$34.00

$11.00

$24.00

$26.00

$11.00

$27.00

$32.00

$10.00

$22.00

$112.00

$53.00

$59.00

$112.00

$54.00

$58.00

$106.00

$49.00

$57.00

$146.00

$78.00

$68.00

$9.00

$17.00

$33.00

$11.00

$22.00

$114.00

$32.00

$83.00

$40.00

$12.00

$28.00

$33.00

$10.00

$23.00

$31.00

$9.00

$22.00

(Facility MRA)

$134.00

$47.00

$87.00

$134.00

$73.00

$61.00

$116.00

$53.00

$63.00

$32.00

$10.00

$22.00

$35.00

$11.00

$24.00

$27.00

$11.00

$27.00

$33.00

$11.00

$23.00

$114.00

$55.00

$60.00

$114.00

$56.00

$58.00

$108.00

$50.00

$58.00

$149.00

$81.00

$69.00

$9.00

$18.00

$34.00

$11.00

$23.00

$116.00

$33.00

$83.00

$41.00

$13.00

$29.00

$34.00

$10.00

$24.00

$32.00

$10.00

$22.00


Part C, 286



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


73115-TC

73120

73120-26

73120-TC

73130

73130-26

73130-TC

73140

73140-26

73140-TC

73200

73200-26

73200-TC

73201

73201-26

73201-TC

73080

73080-26

73080-TC

73085

73085-26

73085-TC

73090

73090-26

73090-TC

73100

73100-26

73100-TC

73110

73110-26

73110-TC

73115

73115-26

73202

73202-26

73202-TC

73206

73206-26

73206-TC

73218

73218-26

73218-TC

73219

73219-26

73219-TC

73220

73220-26

73220-TC

73221

73221-26

NC

$27.00

$8.00

$18.00

$29.00

$8.00

$19.00

$22.00

$7.00

$15.00

$242.00

$56.00

$185.00

$282.00

$59.00

$220.00

$30.00

$8.00

$21.00

$74.00

NC

NC

$28.00

$8.00

$19.00

$27.00

$8.00

$18.00

$29.00

$8.00

$19.00

$54.00

NC

$342.00

$63.00

$277.00

$375.00

$94.00

$277.00

$482.00

$68.00

$413.00

$579.00

$82.00

$495.00

$520.00

$78.00

$442.00

$482.00

$68.00

$83.00

$28.00

$9.00

$19.00

$33.00

$10.00

$23.00

$34.00

$8.00

$26.00

$175.00

$56.00

$119.00

$240.00

$66.00

$174.00

$33.00

$10.00

$24.00

$105.00

$32.00

$72.00

$28.00

$9.00

$18.00

$31.00

$9.00

$22.00

$38.00

$10.00

$28.00

$115.00

$32.00

$298.00

$69.00

$230.00

$351.00

$101.00

$250.00

$365.00

$76.00

$288.00

$434.00

$92.00

$342.00

$537.00

$121.00

$415.00

$255.00

$77.00

$89.00

$30.00

$10.00

$20.00

$35.00

$10.00

$25.00

$36.00

$8.00

$28.00

$186.00

$58.00

$128.00

$255.00

$68.00

$187.00

$36.00

$10.00

$25.00

$111.00

$34.00

$78.00

$30.00

$10.00

$20.00

$33.00

$10.00

$23.00

$40.00

$10.00

$30.00

$122.00

$33.00

$318.00

$71.00

$247.00

$373.00

$104.00

$268.00

$389.00

$79.00

$310.00

$462.00

$95.00

$368.00

$571.00

$125.00

$446.00

$270.00

$79.00

$90.00

$31.00

$10.00

$21.00

$36.00

$11.00

$25.00

$37.00

$9.00

$28.00

$189.00

$60.00

$128.00

$258.00

$70.00

$188.00

$36.00

$11.00

$26.00

$113.00

$35.00

$78.00

$30.00

$10.00

$20.00

$34.00

$10.00

$24.00

$41.00

$11.00

$31.00

$124.00

$35.00

$321.00

$73.00

$248.00

$377.00

$108.00

$270.00

$393.00

$81.00

$311.00

$467.00

$97.00

$369.00

$577.00

$129.00

$448.00

$274.00

$82.00

$83.00

$28.00

$9.00

$19.00

$33.00

$10.00

$23.00

$34.00

$8.00

$26.00

$175.00

$56.00

$119.00

$240.00

$66.00

$174.00

$33.00

$10.00

$24.00

$105.00

$32.00

$72.00

$28.00

$9.00

$18.00

$31.00

$9.00

$22.00

$38.00

$10.00

$28.00

$115.00

$32.00

$298.00

$69.00

$230.00

$351.00

$101.00

$250.00

$365.00

$76.00

$288.00

$434.00

$92.00

$342.00

$537.00

$121.00

$415.00

$255.00

$77.00

$89.00

$30.00

$10.00

$20.00

$35.00

$10.00

$25.00

$36.00

$8.00

$28.00

$186.00

$58.00

$128.00

$255.00

$68.00

$187.00

$36.00

$10.00

$25.00

$111.00

$34.00

$78.00

$30.00

$10.00

$20.00

$33.00

$10.00

$23.00

$40.00

$10.00

$30.00

$122.00

$33.00

$318.00

$71.00

$247.00

$373.00

$104.00

$268.00

$389.00

$79.00

$310.00

$462.00

$95.00

$368.00

$571.00

$125.00

$446.00

$270.00

$79.00

(Facility MRA)

$90.00

$31.00

$10.00

$21.00

$36.00

$11.00

$25.00

$37.00

$9.00

$28.00

$189.00

$60.00

$128.00

$258.00

$70.00

$188.00

$36.00

$11.00

$26.00

$113.00

$35.00

$78.00

$30.00

$10.00

$20.00

$34.00

$10.00

$24.00

$41.00

$11.00

$31.00

$124.00

$35.00

$321.00

$73.00

$248.00

$377.00

$108.00

$270.00

$393.00

$81.00

$311.00

$467.00

$97.00

$369.00

$577.00

$129.00

$448.00

$274.00

$82.00


Part C, 287



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


73503-26

73503-TC

73521

73521-26

73521-TC

73522

73522-26

73522-TC

73523

73523-26

73523-TC

73525

73525-26

73525-TC

73551

73551-26

73221-TC

73222

73222-26

73222-TC

73223

73223-26

73223-TC

73225

73225-26

73225-TC

73501

73501-26

73501-TC

73502

73502-26

73502-TC

73503

73551-TC

73552

73552-26

73552-TC

73560

73560-26

73560-TC

73562

73562-26

73562-TC

73564

73564-26

73564-TC

73565

73565-26

73565-TC

73580

---------

---------

---------

$84.00

NC

NC

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$413.00

$579.00

$82.00

$495.00

$1,029.00

$109.00

$916.00

$513.00

$92.00

$419.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$29.00

$8.00

$19.00

$31.00

$9.00

$21.00

$35.00

$11.00

$22.00

$28.00

$8.00

$18.00

$84.00

$16.00

$39.00

$43.00

$13.00

$30.00

$53.00

$17.00

$36.00

$61.00

$18.00

$43.00

$109.00

$32.00

$77.00

$30.00

$9.00

$178.00

$406.00

$92.00

$314.00

$504.00

$121.00

$383.00

$435.00

$96.00

$339.00

$32.00

$11.00

$21.00

$44.00

$13.00

$32.00

$56.00

$21.00

$35.00

$11.00

$24.00

$33.00

$9.00

$24.00

$38.00

$11.00

$28.00

$42.00

$13.00

$30.00

$38.00

$10.00

$28.00

$124.00

$17.00

$42.00

$45.00

$13.00

$32.00

$56.00

$18.00

$38.00

$65.00

$19.00

$46.00

$116.00

$34.00

$83.00

$32.00

$10.00

$191.00

$432.00

$95.00

$338.00

$536.00

$125.00

$411.00

$463.00

$100.00

$364.00

$34.00

$11.00

$23.00

$47.00

$13.00

$34.00

$59.00

$22.00

$37.00

$11.00

$26.00

$36.00

$10.00

$26.00

$41.00

$11.00

$30.00

$45.00

$13.00

$32.00

$41.00

$10.00

$31.00

$132.00

$17.00

$43.00

$46.00

$14.00

$32.00

$57.00

$18.00

$39.00

$66.00

$19.00

$47.00

$118.00

$35.00

$83.00

$33.00

$10.00

$192.00

$437.00

$97.00

$339.00

$541.00

$129.00

$412.00

$468.00

$103.00

$365.00

$35.00

$11.00

$23.00

$48.00

$13.00

$35.00

$60.00

$23.00

$38.00

$11.00

$27.00

$36.00

$10.00

$26.00

$42.00

$11.00

$30.00

$46.00

$13.00

$32.00

$42.00

$11.00

$31.00

$134.00

$16.00

$39.00

$43.00

$13.00

$30.00

$53.00

$17.00

$36.00

$61.00

$18.00

$43.00

$109.00

$32.00

$77.00

$30.00

$9.00

$178.00

$406.00

$92.00

$314.00

$504.00

$121.00

$383.00

$435.00

$96.00

$339.00

$32.00

$11.00

$21.00

$44.00

$13.00

$32.00

$56.00

$21.00

$35.00

$11.00

$24.00

$33.00

$9.00

$24.00

$38.00

$11.00

$28.00

$42.00

$13.00

$30.00

$38.00

$10.00

$28.00

$124.00

$17.00

$42.00

$45.00

$13.00

$32.00

$56.00

$18.00

$38.00

$65.00

$19.00

$46.00

$116.00

$34.00

$83.00

$32.00

$10.00

$191.00

$432.00

$95.00

$338.00

$536.00

$125.00

$411.00

$463.00

$100.00

$364.00

$34.00

$11.00

$23.00

$47.00

$13.00

$34.00

$59.00

$22.00

$37.00

$11.00

$26.00

$36.00

$10.00

$26.00

$41.00

$11.00

$30.00

$45.00

$13.00

$32.00

$41.00

$10.00

$31.00

$132.00

(Facility MRA)

$17.00

$43.00

$46.00

$14.00

$32.00

$57.00

$18.00

$39.00

$66.00

$19.00

$47.00

$118.00

$35.00

$83.00

$33.00

$10.00

$192.00

$437.00

$97.00

$339.00

$541.00

$129.00

$412.00

$468.00

$103.00

$365.00

$35.00

$11.00

$23.00

$48.00

$13.00

$35.00

$60.00

$23.00

$38.00

$11.00

$27.00

$36.00

$10.00

$26.00

$42.00

$11.00

$30.00

$46.00

$13.00

$32.00

$42.00

$11.00

$31.00

$134.00


Part C, 288



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


73630

73630-26

73630-TC

73650

73650-26

73650-TC

73660

73660-26

73660-TC

73700

73700-26

73700-TC

73701

73701-26

73701-TC

73702

73580-26

73580-TC

73590

73590-26

73590-TC

73600

73600-26

73600-TC

73610

73610-26

73610-TC

73615

73615-26

73615-TC

73620

73620-26

73620-TC

73702-26

73702-TC

73706

73706-26

73706-TC

73718

73718-26

73718-TC

73719

73719-26

73719-TC

73720

73720-26

73720-TC

73721

73721-26

73721-TC

$29.00

$8.00

$19.00

$26.00

$8.00

$17.00

$22.00

$7.00

$15.00

$242.00

$56.00

$185.00

$282.00

$61.00

$220.00

$341.00

NC

NC

$29.00

$8.00

$19.00

$27.00

$8.00

$18.00

$29.00

$8.00

$19.00

$72.00

NC

NC

$27.00

$8.00

$18.00

$62.00

$277.00

$379.00

$98.00

$277.00

$482.00

$68.00

$413.00

$579.00

$82.00

$495.00

$520.00

$78.00

$442.00

$482.00

$68.00

$413.00

$31.00

$9.00

$22.00

$29.00

$9.00

$20.00

$30.00

$8.00

$23.00

$175.00

$56.00

$119.00

$243.00

$66.00

$178.00

$295.00

$32.00

$92.00

$31.00

$9.00

$21.00

$32.00

$9.00

$23.00

$33.00

$10.00

$24.00

$113.00

$32.00

$80.00

$28.00

$9.00

$19.00

$68.00

$227.00

$357.00

$107.00

$250.00

$365.00

$76.00

$288.00

$434.00

$91.00

$342.00

$540.00

$121.00

$418.00

$255.00

$77.00

$178.00

$33.00

$10.00

$23.00

$31.00

$9.00

$22.00

$32.00

$8.00

$25.00

$186.00

$58.00

$128.00

$259.00

$68.00

$191.00

$314.00

$33.00

$99.00

$33.00

$10.00

$23.00

$34.00

$10.00

$25.00

$36.00

$10.00

$25.00

$120.00

$33.00

$86.00

$30.00

$9.00

$21.00

$71.00

$243.00

$379.00

$110.00

$269.00

$389.00

$79.00

$310.00

$462.00

$94.00

$368.00

$574.00

$125.00

$449.00

$271.00

$79.00

$192.00

$34.00

$10.00

$24.00

$32.00

$10.00

$22.00

$33.00

$8.00

$25.00

$189.00

$60.00

$128.00

$262.00

$70.00

$192.00

$317.00

$35.00

$99.00

$33.00

$10.00

$23.00

$35.00

$10.00

$25.00

$36.00

$11.00

$26.00

$121.00

$34.00

$87.00

$31.00

$9.00

$21.00

$73.00

$244.00

$384.00

$114.00

$270.00

$393.00

$81.00

$311.00

$466.00

$97.00

$369.00

$580.00

$129.00

$451.00

$275.00

$82.00

$193.00

$31.00

$9.00

$22.00

$29.00

$9.00

$20.00

$30.00

$8.00

$23.00

$175.00

$56.00

$119.00

$243.00

$66.00

$178.00

$295.00

$32.00

$92.00

$31.00

$9.00

$21.00

$32.00

$9.00

$23.00

$33.00

$10.00

$24.00

$113.00

$32.00

$80.00

$28.00

$9.00

$19.00

$68.00

$227.00

$357.00

$107.00

$250.00

$365.00

$76.00

$288.00

$434.00

$91.00

$342.00

$540.00

$121.00

$418.00

$255.00

$77.00

$178.00

$33.00

$10.00

$23.00

$31.00

$9.00

$22.00

$32.00

$8.00

$25.00

$186.00

$58.00

$128.00

$259.00

$68.00

$191.00

$314.00

$33.00

$99.00

$33.00

$10.00

$23.00

$34.00

$10.00

$25.00

$36.00

$10.00

$25.00

$120.00

$33.00

$86.00

$30.00

$9.00

$21.00

$71.00

$243.00

$379.00

$110.00

$269.00

$389.00

$79.00

$310.00

$462.00

$94.00

$368.00

$574.00

$125.00

$449.00

$271.00

$79.00

$192.00

(Facility MRA)

$34.00

$10.00

$24.00

$32.00

$10.00

$22.00

$33.00

$8.00

$25.00

$189.00

$60.00

$128.00

$262.00

$70.00

$192.00

$317.00

$35.00

$99.00

$33.00

$10.00

$23.00

$35.00

$10.00

$25.00

$36.00

$11.00

$26.00

$121.00

$34.00

$87.00

$31.00

$9.00

$21.00

$73.00

$244.00

$384.00

$114.00

$270.00

$393.00

$81.00

$311.00

$466.00

$97.00

$369.00

$580.00

$129.00

$451.00

$275.00

$82.00

$193.00


Part C, 289



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


74020-TC

74022

74022-26

74022-TC

74150

74150-26

74150-TC

74160

74160-26

74160-TC

74170

74170-26

74170-TC

74174

74174-26

74174-TC

73722

73722-26

73722-TC

73723

73723-26

73723-TC

73725

73725-26

73725-TC

74000

74000-26

74000-TC

74010

74010-26

74010-TC

74020

74020-26

74175

74175-26

74175-TC

74176

74176-26

74176-TC

74177

74177-26

74177-TC

74178

74178-26

74178-TC

74181

74181-26

74181-TC

74182

74182-26

$22.00

$44.00

$16.00

$28.00

$274.00

$60.00

$211.00

$322.00

$65.00

$256.00

$390.00

$71.00

$317.00

---------

---------

---------

$579.00

$82.00

$495.00

$1,029.00

$109.00

$916.00

$515.00

$92.00

$419.00

$29.00

$9.00

$19.00

$33.00

$11.00

$21.00

$37.00

$13.00

$418.00

$98.00

$315.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

$498.00

$85.00

$415.00

$587.00

$88.00

$25.00

$48.00

$18.00

$30.00

$162.00

$67.00

$95.00

$249.00

$72.00

$177.00

$282.00

$79.00

$204.00

$419.00

$123.00

$296.00

$410.00

$92.00

$318.00

$506.00

$121.00

$384.00

$431.00

$101.00

$330.00

$26.00

$10.00

$15.00

$38.00

$13.00

$25.00

$41.00

$15.00

$331.00

$102.00

$229.00

$218.00

$98.00

$119.00

$335.00

$103.00

$233.00

$380.00

$113.00

$267.00

$358.00

$82.00

$276.00

$487.00

$98.00

$27.00

$51.00

$19.00

$32.00

$172.00

$69.00

$102.00

$264.00

$74.00

$190.00

$300.00

$82.00

$219.00

$445.00

$127.00

$317.00

$436.00

$95.00

$342.00

$538.00

$125.00

$413.00

$459.00

$105.00

$354.00

$27.00

$11.00

$16.00

$40.00

$13.00

$27.00

$43.00

$16.00

$351.00

$105.00

$246.00

$230.00

$102.00

$128.00

$356.00

$106.00

$250.00

$404.00

$117.00

$287.00

$381.00

$85.00

$296.00

$519.00

$101.00

$27.00

$52.00

$19.00

$33.00

$174.00

$72.00

$103.00

$267.00

$76.00

$191.00

$304.00

$84.00

$219.00

$450.00

$132.00

$319.00

$441.00

$97.00

$343.00

$543.00

$129.00

$415.00

$464.00

$108.00

$356.00

$28.00

$11.00

$17.00

$41.00

$14.00

$27.00

$44.00

$17.00

$356.00

$108.00

$247.00

$234.00

$105.00

$129.00

$360.00

$109.00

$251.00

$409.00

$120.00

$288.00

$385.00

$87.00

$298.00

$524.00

$104.00

$25.00

$48.00

$18.00

$30.00

$162.00

$67.00

$95.00

$249.00

$72.00

$177.00

$282.00

$79.00

$204.00

$419.00

$123.00

$296.00

$410.00

$92.00

$318.00

$506.00

$121.00

$384.00

$431.00

$101.00

$330.00

$26.00

$10.00

$15.00

$38.00

$13.00

$25.00

$41.00

$15.00

$331.00

$102.00

$229.00

$218.00

$98.00

$119.00

$335.00

$103.00

$233.00

$380.00

$113.00

$267.00

$358.00

$82.00

$276.00

$487.00

$98.00

$27.00

$51.00

$19.00

$32.00

$172.00

$69.00

$102.00

$264.00

$74.00

$190.00

$300.00

$82.00

$219.00

$445.00

$127.00

$317.00

$436.00

$95.00

$342.00

$538.00

$125.00

$413.00

$459.00

$105.00

$354.00

$27.00

$11.00

$16.00

$40.00

$13.00

$27.00

$43.00

$16.00

$351.00

$105.00

$246.00

$230.00

$102.00

$128.00

$356.00

$106.00

$250.00

$404.00

$117.00

$287.00

$381.00

$85.00

$296.00

$519.00

$101.00

(Facility MRA)

$27.00

$52.00

$19.00

$33.00

$174.00

$72.00

$103.00

$267.00

$76.00

$191.00

$304.00

$84.00

$219.00

$450.00

$132.00

$319.00

$441.00

$97.00

$343.00

$543.00

$129.00

$415.00

$464.00

$108.00

$356.00

$28.00

$11.00

$17.00

$41.00

$14.00

$27.00

$44.00

$17.00

$356.00

$108.00

$247.00

$234.00

$105.00

$129.00

$360.00

$109.00

$251.00

$409.00

$120.00

$288.00

$385.00

$87.00

$298.00

$524.00

$104.00


Part C, 290



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


74230-26

74230-TC

74235

74235-26

74235-TC

74240

74240-26

74240-TC

74241

74241-26

74241-TC

74245

74245-26

74245-TC

74246

74246-26

74182-TC

74183

74183-26

74183-TC

74185

74185-26

74185-TC

74190

74190-26

74190-TC

74210

74210-26

74210-TC

74220

74220-26

74220-TC

74230

74246-TC

74247

74247-26

74247-TC

74249

74249-26

74249-TC

74250

74250-26

74250-TC

74251

74251-26

74251-TC

74260

74260-26

74260-TC

74261

$27.00

$48.00

$160.00

NC

NC

$91.00

$35.00

$55.00

$91.00

$35.00

$56.00

$137.00

$46.00

$89.00

$97.00

$35.00

$496.00

$1,037.00

$114.00

$919.00

$514.00

$92.00

$419.00

$73.00

NC

NC

$63.00

$18.00

$44.00

$68.00

$23.00

$44.00

$77.00

$61.00

$99.00

$35.00

$63.00

$144.00

$46.00

$96.00

$73.00

$23.00

$48.00

$85.00

$34.00

$48.00

$82.00

$25.00

$56.00

---------

$30.00

$106.00

---------

$72.00

BR

$122.00

$39.00

$83.00

$127.00

$39.00

$88.00

$185.00

$51.00

$133.00

$137.00

$39.00

$389.00

$544.00

$128.00

$417.00

$433.00

$101.00

$332.00

$397.00

$27.00

$371.00

$83.00

$20.00

$63.00

$95.00

$26.00

$69.00

$136.00

$98.00

$145.00

$39.00

$106.00

$198.00

$51.00

$146.00

$112.00

$26.00

$85.00

$241.00

$39.00

$202.00

$231.00

$28.00

$202.00

$255.00

$31.00

$114.00

---------

$77.00

BR

$130.00

$40.00

$89.00

$135.00

$40.00

$94.00

$196.00

$53.00

$143.00

$146.00

$40.00

$418.00

$579.00

$132.00

$447.00

$461.00

$104.00

$357.00

$425.00

$27.00

$398.00

$89.00

$21.00

$68.00

$102.00

$27.00

$75.00

$145.00

$105.00

$155.00

$40.00

$114.00

$210.00

$53.00

$157.00

$119.00

$27.00

$92.00

$258.00

$40.00

$217.00

$247.00

$29.00

$217.00

$268.00

$32.00

$114.00

---------

$84.00

BR

$131.00

$42.00

$90.00

$137.00

$42.00

$95.00

$198.00

$55.00

$144.00

$148.00

$42.00

$420.00

$585.00

$136.00

$449.00

$466.00

$107.00

$358.00

$428.00

$28.00

$399.00

$90.00

$21.00

$69.00

$103.00

$28.00

$75.00

$146.00

$106.00

$157.00

$42.00

$115.00

$213.00

$55.00

$158.00

$120.00

$28.00

$92.00

$260.00

$42.00

$218.00

$249.00

$30.00

$218.00

$273.00

$30.00

$106.00

---------

$72.00

BR

$122.00

$39.00

$83.00

$127.00

$39.00

$88.00

$185.00

$51.00

$133.00

$137.00

$39.00

$389.00

$544.00

$128.00

$417.00

$433.00

$101.00

$332.00

$397.00

$27.00

$371.00

$83.00

$20.00

$63.00

$95.00

$26.00

$69.00

$136.00

$98.00

$145.00

$39.00

$106.00

$198.00

$51.00

$146.00

$112.00

$26.00

$85.00

$241.00

$39.00

$202.00

$231.00

$28.00

$202.00

$255.00

$31.00

$114.00

---------

$77.00

BR

$130.00

$40.00

$89.00

$135.00

$40.00

$94.00

$196.00

$53.00

$143.00

$146.00

$40.00

$418.00

$579.00

$132.00

$447.00

$461.00

$104.00

$357.00

$425.00

$27.00

$398.00

$89.00

$21.00

$68.00

$102.00

$27.00

$75.00

$145.00

$105.00

$155.00

$40.00

$114.00

$210.00

$53.00

$157.00

$119.00

$27.00

$92.00

$258.00

$40.00

$217.00

$247.00

$29.00

$217.00

$268.00

(Facility MRA)

$32.00

$114.00

---------

$84.00

BR

$131.00

$42.00

$90.00

$137.00

$42.00

$95.00

$198.00

$55.00

$144.00

$148.00

$42.00

$420.00

$585.00

$136.00

$449.00

$466.00

$107.00

$358.00

$428.00

$28.00

$399.00

$90.00

$21.00

$69.00

$103.00

$28.00

$75.00

$146.00

$106.00

$157.00

$42.00

$115.00

$213.00

$55.00

$158.00

$120.00

$28.00

$92.00

$260.00

$42.00

$218.00

$249.00

$30.00

$218.00

$273.00


Part C, 291



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


74290

74290-26

74290-TC

74300

74300-26

74300-TC

74301

74301-26

74301-TC

74328

74328-26

74328-TC

74329

74329-26

74329-TC

74330

74261-26

74261-TC

74262

74262-26

74262-TC

74263

74263-26

74263-TC

74270

74270-26

74270-TC

74280

74280-26

74280-TC

74283

74283-26

74283-TC

74330-26

74330-TC

74340

74340-26

74340-TC

74355

74355-26

74355-TC

74360

74360-26

74360-TC

74363

74363-26

74363-TC

74400

74400-26

74400-TC

$44.00

$16.00

$28.00

$31.00

NC

NC

BR

NC

NC

$155.00

NC

NC

$155.00

NC

NC

$165.00

---------

---------

---------

---------

---------

---------

---------

---------

$100.00

$35.00

$64.00

$136.00

$50.00

$84.00

$201.00

$103.00

$95.00

NC

NC

$121.00

NC

NC

$137.00

NC

NC

$145.00

NC

NC

$274.00

NC

NC

$89.00

$24.00

$63.00

$75.00

$18.00

$57.00

---------

$21.00

BR

---------

$12.00

BR

---------

$40.00

BR

---------

$40.00

BR

---------

$136.00

$119.00

$390.00

$141.00

$249.00

$806.00

$126.00

$680.00

$145.00

$39.00

$106.00

$229.00

$56.00

$173.00

$224.00

$115.00

$109.00

$51.00

BR

---------

$30.00

BR

---------

$44.00

BR

---------

$32.00

BR

---------

$48.00

BR

$118.00

$28.00

$91.00

$80.00

$19.00

$62.00

---------

$21.00

BR

---------

$12.00

BR

---------

$41.00

BR

---------

$42.00

BR

---------

$140.00

$128.00

$413.00

$146.00

$268.00

$860.00

$130.00

$730.00

$155.00

$40.00

$114.00

$243.00

$58.00

$185.00

$236.00

$119.00

$117.00

$53.00

BR

---------

$31.00

BR

---------

$46.00

BR

---------

$33.00

BR

---------

$50.00

BR

$126.00

$29.00

$97.00

$81.00

$19.00

$62.00

---------

$22.00

BR

---------

$13.00

BR

---------

$42.00

BR

---------

$43.00

BR

---------

$145.00

$128.00

$419.00

$150.00

$269.00

$865.00

$132.00

$733.00

$157.00

$42.00

$115.00

$246.00

$60.00

$186.00

$240.00

$123.00

$117.00

$55.00

BR

---------

$32.00

BR

---------

$48.00

BR

---------

$35.00

BR

---------

$51.00

BR

$127.00

$30.00

$98.00

$75.00

$18.00

$57.00

---------

$21.00

BR

---------

$12.00

BR

---------

$40.00

BR

---------

$40.00

BR

---------

$136.00

$119.00

$390.00

$141.00

$249.00

$806.00

$126.00

$680.00

$145.00

$39.00

$106.00

$229.00

$56.00

$173.00

$224.00

$115.00

$109.00

$51.00

BR

---------

$30.00

BR

---------

$44.00

BR

---------

$32.00

BR

---------

$48.00

BR

$118.00

$28.00

$91.00

$80.00

$19.00

$62.00

---------

$21.00

BR

---------

$12.00

BR

---------

$41.00

BR

---------

$42.00

BR

---------

$140.00

$128.00

$413.00

$146.00

$268.00

$860.00

$130.00

$730.00

$155.00

$40.00

$114.00

$243.00

$58.00

$185.00

$236.00

$119.00

$117.00

$53.00

BR

---------

$31.00

BR

---------

$46.00

BR

---------

$33.00

BR

---------

$50.00

BR

$126.00

$29.00

$97.00

(Facility MRA)

$81.00

$19.00

$62.00

---------

$22.00

BR

---------

$13.00

BR

---------

$42.00

BR

---------

$43.00

BR

---------

$145.00

$128.00

$419.00

$150.00

$269.00

$865.00

$132.00

$733.00

$157.00

$42.00

$115.00

$246.00

$60.00

$186.00

$240.00

$123.00

$117.00

$55.00

BR

---------

$32.00

BR

---------

$48.00

BR

---------

$35.00

BR

---------

$51.00

BR

$127.00

$30.00

$98.00


Part C, 292



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


74440-TC

74445

74445-26

74445-TC

74450

74450-26

74450-TC

74455

74455-26

74455-TC

74470

74470-26

74470-TC

74485

74485-26

74485-TC

74410

74410-26

74410-TC

74415

74415-26

74415-TC

74420

74420-26

74420-TC

74425

74425-26

74425-TC

74430

74430-26

74430-TC

74440

74440-26

74710

74710-26

74710-TC

74712

74712-26

74712-TC

74713

74713-26

74713-TC

74740

74740-26

74740-TC

74742

74742-26

74742-TC

74775

74775-26

NC

$101.00

NC

NC

$60.00

NC

NC

$75.00

NC

NC

$74.00

NC

NC

$146.00

NC

NC

$98.00

$24.00

$72.00

$105.00

$24.00

$79.00

$117.00

$18.00

$97.00

$68.00

NC

NC

$48.00

NC

NC

$62.00

NC

$57.00

$17.00

$39.00

---------

---------

---------

---------

---------

---------

$68.00

NC

NC

$150.00

NC

NC

$88.00

$32.00

$67.00

$431.00

$60.00

$371.00

$221.00

$19.00

$202.00

$88.00

$19.00

$69.00

$400.00

$30.00

$371.00

$99.00

$29.00

$70.00

$116.00

$27.00

$89.00

$147.00

$28.00

$119.00

$390.00

$20.00

$371.00

$390.00

$20.00

$371.00

$41.00

$18.00

$23.00

$87.00

$20.00

$40.00

$19.00

$21.00

$458.00

$169.00

$288.00

$251.00

$101.00

$150.00

$80.00

$21.00

$59.00

---------

$33.00

BR

$237.00

$35.00

$72.00

$460.00

$62.00

$398.00

$236.00

$19.00

$217.00

$93.00

$19.00

$74.00

$428.00

$31.00

$398.00

$105.00

$30.00

$75.00

$124.00

$28.00

$96.00

$156.00

$29.00

$128.00

$418.00

$20.00

$398.00

$418.00

$20.00

$398.00

$43.00

$19.00

$25.00

$93.00

$21.00

$42.00

$20.00

$22.00

$485.00

$175.00

$310.00

$265.00

$104.00

$161.00

$86.00

$22.00

$64.00

---------

$34.00

BR

$253.00

$36.00

$72.00

$462.00

$63.00

$399.00

$238.00

$20.00

$218.00

$94.00

$20.00

$75.00

$431.00

$32.00

$399.00

$106.00

$31.00

$76.00

$125.00

$29.00

$96.00

$158.00

$30.00

$128.00

$420.00

$20.00

$399.00

$420.00

$21.00

$399.00

$44.00

$19.00

$25.00

$93.00

$21.00

$43.00

$21.00

$23.00

$492.00

$180.00

$311.00

$269.00

$107.00

$162.00

$87.00

$23.00

$64.00

---------

$36.00

BR

$256.00

$38.00

$67.00

$431.00

$60.00

$371.00

$221.00

$19.00

$202.00

$88.00

$19.00

$69.00

$400.00

$30.00

$371.00

$99.00

$29.00

$70.00

$116.00

$27.00

$89.00

$147.00

$28.00

$119.00

$390.00

$20.00

$371.00

$390.00

$20.00

$371.00

$41.00

$18.00

$23.00

$87.00

$20.00

$40.00

$19.00

$21.00

$458.00

$169.00

$288.00

$251.00

$101.00

$150.00

$80.00

$21.00

$59.00

---------

$33.00

BR

$237.00

$35.00

$72.00

$460.00

$62.00

$398.00

$236.00

$19.00

$217.00

$93.00

$19.00

$74.00

$428.00

$31.00

$398.00

$105.00

$30.00

$75.00

$124.00

$28.00

$96.00

$156.00

$29.00

$128.00

$418.00

$20.00

$398.00

$418.00

$20.00

$398.00

$43.00

$19.00

$25.00

$93.00

$21.00

$42.00

$20.00

$22.00

$485.00

$175.00

$310.00

$265.00

$104.00

$161.00

$86.00

$22.00

$64.00

---------

$34.00

BR

$253.00

$36.00

(Facility MRA)

$72.00

$462.00

$63.00

$399.00

$238.00

$20.00

$218.00

$94.00

$20.00

$75.00

$431.00

$32.00

$399.00

$106.00

$31.00

$76.00

$125.00

$29.00

$96.00

$158.00

$30.00

$128.00

$420.00

$20.00

$399.00

$420.00

$21.00

$399.00

$44.00

$19.00

$25.00

$93.00

$21.00

$43.00

$21.00

$23.00

$492.00

$180.00

$311.00

$269.00

$107.00

$162.00

$87.00

$23.00

$64.00

---------

$36.00

BR

$256.00

$38.00


Part C, 293



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


75571-26

75571-TC

75572

75572-26

75572-TC

75573

75573-26

75573-TC

75574

75574-26

75574-TC

75600

75600-26

75600-TC

75605

75605-26

74775-TC

75557

75557-26

75557-TC

75559

75559-26

75559-TC

75561

75561-26

75561-TC

75563

75563-26

75563-TC

75565

75565-26

75565-TC

75571

75605-TC

75625

75625-26

75625-TC

75630

75630-26

75630-TC

75635

75635-26

75635-TC

75658

75658-26

75658-TC

75705

75705-26

75705-TC

75710

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$497.00

NC

NC

$183.00

NC

$55.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

NC

$143.00

NC

NC

$239.00

NC

NC

$445.00

NC

NC

$540.00

NC

NC

$587.00

NC

NC

$194.00

$32.00

$14.00

$306.00

$97.00

$209.00

$391.00

$142.00

$250.00

$382.00

$133.00

$249.00

$212.00

$28.00

$185.00

$152.00

$63.00

$202.00

$344.00

$130.00

$214.00

$470.00

$160.00

$310.00

$456.00

$143.00

$313.00

$540.00

$164.00

$376.00

$59.00

$14.00

$45.00

$46.00

$88.00

$152.00

$64.00

$88.00

$188.00

$100.00

$88.00

$384.00

$134.00

$250.00

$183.00

$73.00

$110.00

$269.00

$131.00

$138.00

$179.00

$33.00

$15.00

$325.00

$101.00

$224.00

$414.00

$146.00

$268.00

$405.00

$137.00

$268.00

$227.00

$29.00

$198.00

$161.00

$66.00

$217.00

$364.00

$134.00

$230.00

$497.00

$165.00

$333.00

$483.00

$148.00

$336.00

$573.00

$169.00

$404.00

$62.00

$14.00

$48.00

$48.00

$95.00

$161.00

$67.00

$94.00

$199.00

$105.00

$94.00

$407.00

$139.00

$269.00

$195.00

$76.00

$119.00

$286.00

$137.00

$148.00

$191.00

$34.00

$15.00

$329.00

$103.00

$226.00

$420.00

$150.00

$270.00

$410.00

$141.00

$269.00

$229.00

$30.00

$199.00

$164.00

$69.00

$218.00

$368.00

$137.00

$231.00

$502.00

$168.00

$334.00

$489.00

$152.00

$337.00

$578.00

$173.00

$406.00

$63.00

$14.00

$48.00

$50.00

$95.00

$166.00

$71.00

$95.00

$205.00

$110.00

$95.00

$413.00

$143.00

$270.00

$200.00

$81.00

$120.00

$296.00

$146.00

$149.00

$195.00

$32.00

$14.00

$306.00

$97.00

$209.00

$391.00

$142.00

$250.00

$382.00

$133.00

$249.00

$212.00

$28.00

$185.00

$152.00

$63.00

$202.00

$344.00

$130.00

$214.00

$470.00

$160.00

$310.00

$456.00

$143.00

$313.00

$540.00

$164.00

$376.00

$59.00

$14.00

$45.00

$46.00

$88.00

$152.00

$64.00

$88.00

$188.00

$100.00

$88.00

$384.00

$134.00

$250.00

$183.00

$73.00

$110.00

$269.00

$131.00

$138.00

$179.00

$33.00

$15.00

$325.00

$101.00

$224.00

$414.00

$146.00

$268.00

$405.00

$137.00

$268.00

$227.00

$29.00

$198.00

$161.00

$66.00

$217.00

$364.00

$134.00

$230.00

$497.00

$165.00

$333.00

$483.00

$148.00

$336.00

$573.00

$169.00

$404.00

$62.00

$14.00

$48.00

$48.00

$95.00

$161.00

$67.00

$94.00

$199.00

$105.00

$94.00

$407.00

$139.00

$269.00

$195.00

$76.00

$119.00

$286.00

$137.00

$148.00

$191.00

(Facility MRA)

$34.00

$15.00

$329.00

$103.00

$226.00

$420.00

$150.00

$270.00

$410.00

$141.00

$269.00

$229.00

$30.00

$199.00

$164.00

$69.00

$218.00

$368.00

$137.00

$231.00

$502.00

$168.00

$334.00

$489.00

$152.00

$337.00

$578.00

$173.00

$406.00

$63.00

$14.00

$48.00

$50.00

$95.00

$166.00

$71.00

$95.00

$205.00

$110.00

$95.00

$413.00

$143.00

$270.00

$200.00

$81.00

$120.00

$296.00

$146.00

$149.00

$195.00


Part C, 294



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


75741

75741-26

75741-TC

75743

75743-26

75743-TC

75746

75746-26

75746-TC

75756

75756-26

75756-TC

75774

75774-26

75774-TC

75791

75710-26

75710-TC

75716

75716-26

75716-TC

75726

75726-26

75726-TC

75731

75731-26

75731-TC

75733

75733-26

75733-TC

75736

75736-26

75736-TC

75791-26

75791-TC

75801

75801-26

75801-TC

75803

75803-26

75803-TC

75805

75805-26

75805-TC

75807

75807-26

75807-TC

75809

75809-26

75809-TC

$540.00

NC

NC

$253.00

NC

NC

$530.00

NC

NC

$183.00

NC

NC

$80.00

NC

NC

---------

NC

NC

$293.00

NC

NC

$530.00

NC

NC

$530.00

NC

NC

$540.00

NC

NC

$530.00

NC

NC

---------

---------

$245.00

NC

NC

$264.00

NC

NC

$271.00

NC

NC

$289.00

NC

NC

$54.00

NC

NC

$165.00

$72.00

$94.00

$186.00

$91.00

$95.00

$166.00

$63.00

$102.00

$183.00

$64.00

$119.00

$95.00

$20.00

$75.00

$353.00

$64.00

$114.00

$205.00

$74.00

$132.00

$163.00

$63.00

$100.00

$187.00

$64.00

$123.00

$200.00

$71.00

$129.00

$176.00

$63.00

$113.00

$99.00

$254.00

$254.00

$52.00

$202.00

$769.00

$66.00

$703.00

$749.00

$46.00

$703.00

$2,930.00

$66.00

$2,863.00

$107.00

$27.00

$80.00

$67.00

$123.00

$218.00

$77.00

$142.00

$173.00

$65.00

$108.00

$198.00

$66.00

$132.00

$212.00

$73.00

$138.00

$186.00

$65.00

$121.00

$175.00

$74.00

$100.00

$196.00

$94.00

$102.00

$176.00

$65.00

$110.00

$195.00

$67.00

$128.00

$101.00

$21.00

$81.00

$377.00

$104.00

$273.00

$272.00

$55.00

$217.00

$823.00

$68.00

$755.00

$802.00

$47.00

$755.00

$3,141.00

$69.00

$3,072.00

$114.00

$28.00

$86.00

$71.00

$124.00

$224.00

$81.00

$143.00

$176.00

$67.00

$108.00

$201.00

$68.00

$133.00

$214.00

$75.00

$140.00

$191.00

$69.00

$122.00

$178.00

$77.00

$101.00

$200.00

$98.00

$102.00

$179.00

$68.00

$111.00

$200.00

$72.00

$128.00

$103.00

$22.00

$81.00

$386.00

$112.00

$274.00

$278.00

$60.00

$218.00

$827.00

$70.00

$757.00

$806.00

$49.00

$757.00

$3,152.00

$71.00

$3,082.00

$116.00

$29.00

$87.00

(Facility MRA)

$175.00

$74.00

$100.00

$196.00

$94.00

$102.00

$176.00

$65.00

$110.00

$195.00

$67.00

$128.00

$101.00

$21.00

$81.00

$377.00

$67.00

$123.00

$218.00

$77.00

$142.00

$173.00

$65.00

$108.00

$198.00

$66.00

$132.00

$212.00

$73.00

$138.00

$186.00

$65.00

$121.00

$104.00

$273.00

$272.00

$55.00

$217.00

$823.00

$68.00

$755.00

$112.00

$274.00

$278.00

$60.00

$218.00

$827.00

$70.00

$757.00

$802.00

$47.00

$806.00

$49.00

$755.00

$757.00

$3,141.00

$3,152.00

$69.00

$71.00

$3,072.00

$3,082.00

$114.00

$116.00

$28.00

$86.00

$29.00

$87.00

$178.00

$77.00

$101.00

$200.00

$98.00

$102.00

$179.00

$68.00

$111.00

$200.00

$72.00

$128.00

$103.00

$22.00

$81.00

$386.00

$71.00

$124.00

$224.00

$81.00

$143.00

$176.00

$67.00

$108.00

$201.00

$68.00

$133.00

$214.00

$75.00

$140.00

$191.00

$69.00

$122.00

$165.00

$72.00

$94.00

$186.00

$91.00

$95.00

$166.00

$63.00

$102.00

$183.00

$64.00

$119.00

$95.00

$20.00

$75.00

$353.00

$64.00

$114.00

$205.00

$74.00

$132.00

$163.00

$63.00

$100.00

$187.00

$64.00

$123.00

$200.00

$71.00

$129.00

$176.00

$63.00

$113.00

$99.00

$254.00

$254.00

$52.00

$202.00

$769.00

$66.00

$703.00

$749.00

$46.00

$703.00

$2,930.00

$66.00

$2,863.00

$107.00

$27.00

$80.00


Part C, 295



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


75831-TC

75833

75833-26

75833-TC

75840

75840-26

75840-TC

75842

75842-26

75842-TC

75860

75860-26

75860-TC

75870

75870-26

75870-TC

75810

75810-26

75810-TC

75820

75820-26

75820-TC

75822

75822-26

75822-TC

75825

75825-26

75825-TC

75827

75827-26

75827-TC

75831

75831-26

75872

75872-26

75872-TC

75880

75880-26

75880-TC

75885

75885-26

75885-TC

75887

75887-26

75887-TC

75889

75889-26

75889-TC

75891

75891-26

NC

$549.00

NC

NC

$531.00

NC

NC

$549.00

NC

NC

$531.00

NC

NC

$531.00

NC

NC

$530.00

NC

NC

$72.00

NC

NC

$111.00

NC

NC

$194.00

NC

NC

$530.00

NC

NC

$54.00

NC

$530.00

NC

NC

$72.00

NC

NC

$546.00

NC

NC

$546.00

NC

NC

$530.00

NC

NC

$530.00

NC

$91.00

$181.00

$83.00

$99.00

$162.00

$64.00

$97.00

$197.00

$84.00

$113.00

$156.00

$63.00

$93.00

$161.00

$64.00

$97.00

$2,928.00

$65.00

$2,863.00

$125.00

$39.00

$86.00

$150.00

$59.00

$91.00

$150.00

$64.00

$85.00

$152.00

$65.00

$88.00

$154.00

$63.00

$153.00

$60.00

$93.00

$154.00

$41.00

$114.00

$173.00

$78.00

$95.00

$174.00

$79.00

$95.00

$157.00

$62.00

$95.00

$158.00

$63.00

$3,139.00

$67.00

$3,072.00

$133.00

$41.00

$92.00

$159.00

$62.00

$98.00

$159.00

$67.00

$92.00

$162.00

$68.00

$94.00

$163.00

$65.00

$98.00

$193.00

$87.00

$106.00

$171.00

$66.00

$105.00

$208.00

$86.00

$121.00

$166.00

$66.00

$100.00

$170.00

$66.00

$104.00

$162.00

$62.00

$100.00

$164.00

$42.00

$122.00

$183.00

$81.00

$102.00

$184.00

$81.00

$102.00

$166.00

$64.00

$102.00

$168.00

$65.00

$3,151.00

$69.00

$3,082.00

$136.00

$43.00

$93.00

$163.00

$64.00

$98.00

$164.00

$71.00

$92.00

$167.00

$72.00

$95.00

$167.00

$69.00

$99.00

$199.00

$92.00

$107.00

$173.00

$68.00

$105.00

$211.00

$89.00

$122.00

$169.00

$68.00

$101.00

$173.00

$68.00

$104.00

$165.00

$65.00

$100.00

$166.00

$43.00

$123.00

$186.00

$84.00

$102.00

$187.00

$84.00

$103.00

$169.00

$66.00

$103.00

$170.00

$67.00

(Facility MRA)

$162.00

$62.00

$100.00

$164.00

$42.00

$122.00

$183.00

$81.00

$102.00

$184.00

$81.00

$102.00

$166.00

$64.00

$102.00

$168.00

$65.00

$98.00

$193.00

$87.00

$106.00

$171.00

$66.00

$105.00

$208.00

$86.00

$121.00

$166.00

$66.00

$100.00

$170.00

$66.00

$104.00

$3,139.00

$3,151.00

$67.00

$69.00

$3,072.00

$3,082.00

$133.00

$136.00

$41.00

$92.00

$159.00

$62.00

$98.00

$43.00

$93.00

$163.00

$64.00

$98.00

$159.00

$67.00

$92.00

$162.00

$68.00

$94.00

$163.00

$65.00

$164.00

$71.00

$92.00

$167.00

$72.00

$95.00

$167.00

$69.00

$99.00

$199.00

$92.00

$107.00

$173.00

$68.00

$105.00

$211.00

$89.00

$122.00

$169.00

$68.00

$101.00

$173.00

$68.00

$104.00

$165.00

$65.00

$100.00

$166.00

$43.00

$123.00

$186.00

$84.00

$102.00

$187.00

$84.00

$103.00

$169.00

$66.00

$103.00

$170.00

$67.00

$91.00

$181.00

$83.00

$99.00

$162.00

$64.00

$97.00

$197.00

$84.00

$113.00

$156.00

$63.00

$93.00

$161.00

$64.00

$97.00

$2,928.00

$65.00

$2,863.00

$125.00

$39.00

$86.00

$150.00

$59.00

$91.00

$150.00

$64.00

$85.00

$152.00

$65.00

$88.00

$154.00

$63.00

$153.00

$60.00

$93.00

$154.00

$41.00

$114.00

$173.00

$78.00

$95.00

$174.00

$79.00

$95.00

$157.00

$62.00

$95.00

$158.00

$63.00


Part C, 296



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


75952-26

75952-TC

75953

75953-26

75953-TC

75954

75954-26

75954-TC

75956

75956-26

75956-TC

75957

75957-26

75957-TC

75958

75958-26

75891-TC

75893

75893-26

75893-TC

75894

75894-26

75894-TC

75898

75898-26

75898-TC

75901

75901-26

75901-TC

75902

75902-26

75902-TC

75952

75958-TC

75959

75959-26

75959-TC

75962

75962-26

75962-TC

75964

75964-26

75964-TC

75966

75966-26

75966-TC

75968

75968-26

75968-TC

75970

---------

---------

---------

---------

---------

---------

---------

---------

NC

NC

BR

NC

NC

BR

NC

NC

NC

$499.00

NC

NC

$972.00

NC

NC

$124.00

$84.00

$39.00

$98.00

NC

NC

$93.00

NC

NC

BR

---------

---------

---------

---------

$618.00

NC

NC

$333.00

NC

NC

$659.00

NC

NC

$333.00

NC

NC

$475.00

$260.00

BR

---------

$79.00

BR

---------

$132.00

BR

BR

$406.00

BR

BR

$349.00

BR

BR

$232.00

$95.00

$128.00

$30.00

$98.00

---------

$75.00

BR

$799.00

$96.00

$703.00

$190.00

$27.00

$163.00

$78.00

$21.00

$56.00

---------

BR

BR

$203.00

BR

$152.00

$30.00

$122.00

$96.00

$21.00

$75.00

$187.00

$73.00

$114.00

$95.00

$20.00

$74.00

---------

$275.00

BR

---------

$84.00

BR

---------

$140.00

BR

BR

$431.00

BR

BR

$370.00

BR

BR

$246.00

$102.00

$136.00

$31.00

$105.00

---------

$79.00

BR

$855.00

$100.00

$755.00

$203.00

$28.00

$176.00

$83.00

$22.00

$61.00

---------

BR

BR

$215.00

BR

$163.00

$32.00

$131.00

$103.00

$22.00

$81.00

$199.00

$76.00

$123.00

$101.00

$21.00

$80.00

---------

$299.00

BR

---------

$91.00

BR

---------

$153.00

BR

BR

$469.00

BR

BR

$404.00

BR

BR

$268.00

$103.00

$138.00

$32.00

$106.00

---------

$83.00

BR

$863.00

$106.00

$757.00

$205.00

$29.00

$176.00

$84.00

$23.00

$61.00

---------

BR

BR

$235.00

BR

$165.00

$34.00

$132.00

$105.00

$23.00

$82.00

$204.00

$80.00

$124.00

$102.00

$22.00

$80.00

---------

$260.00

BR

---------

$79.00

BR

---------

$132.00

BR

BR

$406.00

BR

BR

$349.00

BR

BR

$232.00

$95.00

$128.00

$30.00

$98.00

---------

$75.00

BR

$799.00

$96.00

$703.00

$190.00

$27.00

$163.00

$78.00

$21.00

$56.00

---------

BR

BR

$203.00

BR

$152.00

$30.00

$122.00

$96.00

$21.00

$75.00

$187.00

$73.00

$114.00

$95.00

$20.00

$74.00

---------

$275.00

BR

---------

$84.00

BR

---------

$140.00

BR

BR

$431.00

BR

BR

$370.00

BR

BR

$246.00

$102.00

$136.00

$31.00

$105.00

---------

$79.00

BR

$855.00

$100.00

$755.00

$203.00

$28.00

$176.00

$83.00

$22.00

$61.00

---------

BR

BR

$215.00

BR

$163.00

$32.00

$131.00

$103.00

$22.00

$81.00

$199.00

$76.00

$123.00

$101.00

$21.00

$80.00

---------

(Facility MRA)

$299.00

BR

---------

$91.00

BR

---------

$153.00

BR

BR

$469.00

BR

BR

$404.00

BR

BR

$268.00

$103.00

$138.00

$32.00

$106.00

---------

$83.00

BR

$863.00

$106.00

$757.00

$205.00

$29.00

$176.00

$84.00

$23.00

$61.00

---------

BR

BR

$235.00

BR

$165.00

$34.00

$132.00

$105.00

$23.00

$82.00

$204.00

$80.00

$124.00

$102.00

$22.00

$80.00

---------


Part C, 297



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


76080

76080-26

76080-TC

76098

76098-26

76098-TC

76100

76100-26

76100-TC

76101

76101-26

76101-TC

76102

76102-26

76102-TC

76120

75970-26

75970-TC

75978

75978-26

75978-TC

75984

75984-26

75984-TC

75989

75989-26

75989-TC

76000

76000-26

76000-TC

76001

76001-26

76001-TC

76120-26

76120-TC

76125

76125-26

76125-TC

76140

76376

76376-26

76376-TC

76377

76377-26

76377-TC

76380

76380-26

76380-TC

76390

76390-26

$67.00

NC

NC

$23.00

$8.00

$15.00

$77.00

$30.00

$46.00

$94.00

$36.00

$59.00

$95.00

$30.00

$65.00

$157.00

NC

NC

$617.00

NC

NC

$110.00

NC

NC

$180.00

NC

NC

$58.00

$8.00

$48.00

$134.00

$34.00

$97.00

$56.00

$102.00

$49.00

$17.00

$33.00

$31.00

---------

---------

---------

---------

---------

---------

$182.00

$50.00

$131.00

$493.00

$71.00

$60.00

$30.00

$31.00

$18.00

$9.00

$9.00

$100.00

$36.00

$64.00

$141.00

$38.00

$104.00

$187.00

$38.00

$149.00

$90.00

$45.00

BR

$150.00

$30.00

$120.00

$115.00

$40.00

$76.00

$132.00

$66.00

$66.00

$51.00

$10.00

$41.00

---------

$41.00

---------

$22.00

$68.00

---------

$16.00

---------

---------

$25.00

$11.00

$14.00

$78.00

$45.00

$33.00

$120.00

$55.00

$64.00

$475.00

$78.00

$64.00

$31.00

$33.00

$19.00

$9.00

$10.00

$106.00

$37.00

$69.00

$150.00

$39.00

$111.00

$200.00

$40.00

$160.00

$96.00

$47.00

BR

$161.00

$32.00

$129.00

$122.00

$41.00

$81.00

$139.00

$68.00

$71.00

$55.00

$10.00

$44.00

---------

$43.00

---------

$22.00

$73.00

---------

$17.00

---------

---------

$27.00

$11.00

$15.00

$82.00

$46.00

$36.00

$126.00

$57.00

$69.00

$506.00

$80.00

$65.00

$32.00

$34.00

$20.00

$10.00

$10.00

$108.00

$39.00

$70.00

$152.00

$40.00

$112.00

$202.00

$41.00

$161.00

$97.00

$49.00

BR

$163.00

$34.00

$130.00

$124.00

$42.00

$82.00

$142.00

$70.00

$71.00

$56.00

$11.00

$45.00

---------

$45.00

---------

$23.00

$74.00

---------

$18.00

---------

---------

$27.00

$12.00

$16.00

$84.00

$48.00

$36.00

$129.00

$59.00

$70.00

$509.00

$81.00

$60.00

$30.00

$31.00

$18.00

$9.00

$9.00

$100.00

$36.00

$64.00

$141.00

$38.00

$104.00

$187.00

$38.00

$149.00

$90.00

$45.00

BR

$150.00

$30.00

$120.00

$115.00

$40.00

$76.00

$132.00

$66.00

$66.00

$51.00

$10.00

$41.00

---------

$41.00

---------

$22.00

$68.00

---------

$16.00

---------

---------

$25.00

$11.00

$14.00

$78.00

$45.00

$33.00

$120.00

$55.00

$64.00

$475.00

$78.00

$64.00

$31.00

$33.00

$19.00

$9.00

$10.00

$106.00

$37.00

$69.00

$150.00

$39.00

$111.00

$200.00

$40.00

$160.00

$96.00

$47.00

BR

$161.00

$32.00

$129.00

$122.00

$41.00

$81.00

$139.00

$68.00

$71.00

$55.00

$10.00

$44.00

---------

$43.00

---------

$22.00

$73.00

---------

$17.00

---------

---------

$27.00

$11.00

$15.00

$82.00

$46.00

$36.00

$126.00

$57.00

$69.00

$506.00

$80.00

(Facility MRA)

$65.00

$32.00

$34.00

$20.00

$10.00

$10.00

$108.00

$39.00

$70.00

$152.00

$40.00

$112.00

$202.00

$41.00

$161.00

$97.00

$49.00

BR

$163.00

$34.00

$130.00

$124.00

$42.00

$82.00

$142.00

$70.00

$71.00

$56.00

$11.00

$45.00

---------

$45.00

---------

$23.00

$74.00

---------

$18.00

---------

---------

$27.00

$12.00

$16.00

$84.00

$48.00

$36.00

$129.00

$59.00

$70.00

$509.00

$81.00


Part C, 298



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


76510-26

76510-TC

76511

76511-26

76511-TC

76512

76512-26

76512-TC

76513

76513-26

76513-TC

76514

76514-26

76514-TC

76516

76516-26

76390-TC

76496

76496-26

76496-TC

76497

76497-26

76497-TC

76498

76498-26

76498-TC

76499

76499-26

76499-TC

76506

76506-26

76506-TC

76510

76516-TC

76519

76519-26

76519-TC

76529

76529-26

76529-TC

76536

76536-26

76536-TC

76604

76604-26

76604-TC

76641

76641-26

76641-TC

76642

---------

---------

$96.00

$48.00

$48.00

$96.00

$36.00

$60.00

$96.00

$36.00

$60.00

---------

---------

---------

$99.00

$37.00

$419.00

BR

BR

BR

BR

BR

BR

BR

BR

BR

BR

BR

BR

$88.00

$33.00

$53.00

---------

$63.00

$88.00

$31.00

$53.00

$86.00

$31.00

$53.00

$83.00

$31.00

$54.00

$78.00

$28.00

$48.00

---------

---------

---------

---------

$98.00

$87.00

$110.00

$58.00

$52.00

$101.00

$58.00

$42.00

$103.00

$39.00

$64.00

$17.00

$11.00

$6.00

$85.00

$34.00

$398.00

---------

---------

$64.00

---------

---------

$64.00

---------

---------

$288.00

---------

---------

---------

$129.00

$36.00

$92.00

$185.00

$51.00

$91.00

$34.00

$56.00

$86.00

$36.00

$50.00

$126.00

$32.00

$94.00

$96.00

$30.00

$65.00

$117.00

$41.00

$76.00

$96.00

$101.00

$93.00

$115.00

$60.00

$55.00

$106.00

$60.00

$46.00

$109.00

$40.00

$68.00

$18.00

$11.00

$6.00

$90.00

$35.00

$427.00

---------

---------

$69.00

---------

---------

$69.00

---------

---------

$309.00

---------

---------

---------

$137.00

$38.00

$99.00

$194.00

$55.00

$96.00

$35.00

$61.00

$91.00

$37.00

$54.00

$134.00

$33.00

$101.00

$101.00

$31.00

$70.00

$124.00

$42.00

$81.00

$102.00

$102.00

$94.00

$116.00

$60.00

$56.00

$107.00

$60.00

$46.00

$110.00

$41.00

$69.00

$18.00

$12.00

$7.00

$91.00

$36.00

$428.00

---------

---------

$69.00

---------

---------

$69.00

---------

---------

$311.00

---------

---------

---------

$139.00

$39.00

$100.00

$195.00

$55.00

$97.00

$36.00

$61.00

$92.00

$37.00

$54.00

$135.00

$34.00

$102.00

$103.00

$32.00

$71.00

$126.00

$44.00

$82.00

$104.00

$98.00

$87.00

$110.00

$58.00

$52.00

$101.00

$58.00

$42.00

$103.00

$39.00

$64.00

$17.00

$11.00

$6.00

$85.00

$34.00

$398.00

---------

---------

$64.00

---------

---------

$64.00

---------

---------

$288.00

---------

---------

---------

$129.00

$36.00

$92.00

$185.00

$51.00

$91.00

$34.00

$56.00

$86.00

$36.00

$50.00

$126.00

$32.00

$94.00

$96.00

$30.00

$65.00

$117.00

$41.00

$76.00

$96.00

$101.00

$93.00

$115.00

$60.00

$55.00

$106.00

$60.00

$46.00

$109.00

$40.00

$68.00

$18.00

$11.00

$6.00

$90.00

$35.00

$427.00

---------

---------

$69.00

---------

---------

$69.00

---------

---------

$309.00

---------

---------

---------

$137.00

$38.00

$99.00

$194.00

$55.00

$96.00

$35.00

$61.00

$91.00

$37.00

$54.00

$134.00

$33.00

$101.00

$101.00

$31.00

$70.00

$124.00

$42.00

$81.00

$102.00

(Facility MRA)

$102.00

$94.00

$116.00

$60.00

$56.00

$107.00

$60.00

$46.00

$110.00

$41.00

$69.00

$18.00

$12.00

$7.00

$91.00

$36.00

$428.00

---------

---------

$69.00

---------

---------

$69.00

---------

---------

$311.00

---------

---------

---------

$139.00

$39.00

$100.00

$195.00

$55.00

$97.00

$36.00

$61.00

$92.00

$37.00

$54.00

$135.00

$34.00

$102.00

$103.00

$32.00

$71.00

$126.00

$44.00

$82.00

$104.00


Part C, 299



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


76800

76800-26

76800-TC

76801

76801-26

76801-TC

76802

76802-26

76802-TC

76805

76805-26

76805-TC

76810

76810-26

76810-TC

76811

76642-26

76642-TC

76700

76700-26

76700-TC

76705

76705-26

76705-TC

76770

76770-26

76770-TC

76775

76775-26

76775-TC

76776

76776-26

76776-TC

76811-26

76811-TC

76812

76812-26

76812-TC

76813

76813-26

76813-TC

76814

76814-26

76814-TC

76815

76815-26

76815-TC

76816

76816-26

76816-TC

$112.00

$61.00

$54.00

$93.00

$51.00

$42.00

$73.00

$43.00

$30.00

$131.00

$51.00

$79.00

$252.00

$100.00

$151.00

$243.00

---------

---------

$116.00

$42.00

$73.00

$84.00

$30.00

$53.00

$112.00

$38.00

$73.00

$84.00

$30.00

$53.00

---------

---------

---------

$100.00

$142.00

$145.00

$94.00

$51.00

---------

---------

---------

---------

---------

---------

$88.00

$33.00

$53.00

$72.00

$30.00

$41.00

$155.00

$69.00

$86.00

$134.00

$56.00

$78.00

$72.00

$48.00

$24.00

$155.00

$57.00

$98.00

$103.00

$57.00

$46.00

$201.00

$38.00

$58.00

$133.00

$45.00

$88.00

$99.00

$33.00

$66.00

$123.00

$41.00

$82.00

$63.00

$32.00

$31.00

$170.00

$43.00

$127.00

$111.00

$90.00

$227.00

$104.00

$123.00

$133.00

$69.00

$64.00

$90.00

$58.00

$32.00

$92.00

$37.00

$55.00

$126.00

$50.00

$77.00

$166.00

$73.00

$93.00

$142.00

$58.00

$84.00

$75.00

$50.00

$26.00

$164.00

$59.00

$105.00

$108.00

$59.00

$49.00

$212.00

$40.00

$62.00

$141.00

$47.00

$94.00

$105.00

$34.00

$71.00

$131.00

$43.00

$88.00

$67.00

$33.00

$34.00

$181.00

$44.00

$137.00

$116.00

$97.00

$240.00

$109.00

$132.00

$141.00

$72.00

$69.00

$95.00

$61.00

$34.00

$98.00

$38.00

$59.00

$134.00

$52.00

$82.00

$171.00

$78.00

$93.00

$145.00

$60.00

$84.00

$77.00

$52.00

$26.00

$167.00

$61.00

$106.00

$111.00

$61.00

$50.00

$218.00

$41.00

$63.00

$143.00

$48.00

$95.00

$107.00

$35.00

$72.00

$133.00

$44.00

$88.00

$68.00

$34.00

$34.00

$183.00

$45.00

$137.00

$121.00

$98.00

$246.00

$113.00

$132.00

$145.00

$75.00

$70.00

$98.00

$64.00

$35.00

$99.00

$39.00

$60.00

$137.00

$54.00

$83.00

$155.00

$69.00

$86.00

$134.00

$56.00

$78.00

$72.00

$48.00

$24.00

$155.00

$57.00

$98.00

$103.00

$57.00

$46.00

$201.00

$38.00

$58.00

$133.00

$45.00

$88.00

$99.00

$33.00

$66.00

$123.00

$41.00

$82.00

$63.00

$32.00

$31.00

$170.00

$43.00

$127.00

$111.00

$90.00

$227.00

$104.00

$123.00

$133.00

$69.00

$64.00

$90.00

$58.00

$32.00

$92.00

$37.00

$55.00

$126.00

$50.00

$77.00

$166.00

$73.00

$93.00

$142.00

$58.00

$84.00

$75.00

$50.00

$26.00

$164.00

$59.00

$105.00

$108.00

$59.00

$49.00

$212.00

$40.00

$62.00

$141.00

$47.00

$94.00

$105.00

$34.00

$71.00

$131.00

$43.00

$88.00

$67.00

$33.00

$34.00

$181.00

$44.00

$137.00

$116.00

$97.00

$240.00

$109.00

$132.00

$141.00

$72.00

$69.00

$95.00

$61.00

$34.00

$98.00

$38.00

$59.00

$134.00

$52.00

$82.00

(Facility MRA)

$171.00

$78.00

$93.00

$145.00

$60.00

$84.00

$77.00

$52.00

$26.00

$167.00

$61.00

$106.00

$111.00

$61.00

$50.00

$218.00

$41.00

$63.00

$143.00

$48.00

$95.00

$107.00

$35.00

$72.00

$133.00

$44.00

$88.00

$68.00

$34.00

$34.00

$183.00

$45.00

$137.00

$121.00

$98.00

$246.00

$113.00

$132.00

$145.00

$75.00

$70.00

$98.00

$64.00

$35.00

$99.00

$39.00

$60.00

$137.00

$54.00

$83.00


Part C, 300



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


76825-TC

76826

76826-26

76826-TC

76827

76827-26

76827-TC

76828

76828-26

76828-TC

76830

76830-26

76830-TC

76831

76831-26

76831-TC

76817

76817-26

76817-TC

76818

76818-26

76818-TC

76819

76819-26

76819-TC

76820

76820-26

76820-TC

76821

76821-26

76821-TC

76825

76825-26

76856

76856-26

76856-TC

76857

76857-26

76857-TC

76870

76870-26

76870-TC

76872

76872-26

76872-TC

76873

76873-26

76873-TC

76881

76881-26

$73.00

$71.00

$46.00

$27.00

$97.00

$35.00

$65.00

$72.00

$29.00

$42.00

$93.00

$35.00

$57.00

$95.00

$37.00

$57.00

$96.00

$39.00

$57.00

$105.00

$40.00

$60.00

$101.00

$40.00

$60.00

---------

---------

---------

---------

---------

---------

$160.00

$65.00

$93.00

$35.00

$57.00

$59.00

$19.00

$39.00

$90.00

$33.00

$57.00

$93.00

$36.00

$57.00

$151.00

$68.00

$80.00

---------

---------

$206.00

$177.00

$46.00

$131.00

$83.00

$32.00

$50.00

$59.00

$32.00

$27.00

$133.00

$39.00

$94.00

$129.00

$42.00

$87.00

$106.00

$43.00

$63.00

$134.00

$62.00

$72.00

$97.00

$45.00

$53.00

$52.00

$29.00

$23.00

$102.00

$41.00

$61.00

$301.00

$94.00

$119.00

$39.00

$81.00

$52.00

$28.00

$24.00

$74.00

$36.00

$38.00

$102.00

$37.00

$65.00

$183.00

$87.00

$96.00

$124.00

$35.00

$222.00

$188.00

$48.00

$140.00

$88.00

$33.00

$54.00

$62.00

$33.00

$29.00

$141.00

$40.00

$100.00

$137.00

$43.00

$94.00

$113.00

$45.00

$68.00

$142.00

$64.00

$78.00

$103.00

$47.00

$57.00

$55.00

$30.00

$25.00

$108.00

$43.00

$66.00

$319.00

$98.00

$127.00

$40.00

$87.00

$55.00

$29.00

$26.00

$78.00

$37.00

$41.00

$108.00

$38.00

$70.00

$193.00

$89.00

$103.00

$132.00

$36.00

$223.00

$190.00

$49.00

$141.00

$89.00

$34.00

$55.00

$64.00

$35.00

$29.00

$143.00

$42.00

$101.00

$139.00

$45.00

$95.00

$115.00

$46.00

$69.00

$146.00

$67.00

$79.00

$106.00

$48.00

$57.00

$57.00

$31.00

$25.00

$111.00

$44.00

$66.00

$324.00

$101.00

$129.00

$41.00

$87.00

$57.00

$30.00

$27.00

$80.00

$38.00

$41.00

$109.00

$39.00

$70.00

$195.00

$91.00

$104.00

$133.00

$37.00

$206.00

$177.00

$46.00

$131.00

$83.00

$32.00

$50.00

$59.00

$32.00

$27.00

$133.00

$39.00

$94.00

$129.00

$42.00

$87.00

$106.00

$43.00

$63.00

$134.00

$62.00

$72.00

$97.00

$45.00

$53.00

$52.00

$29.00

$23.00

$102.00

$41.00

$61.00

$301.00

$94.00

$119.00

$39.00

$81.00

$52.00

$28.00

$24.00

$74.00

$36.00

$38.00

$102.00

$37.00

$65.00

$183.00

$87.00

$96.00

$124.00

$35.00

$222.00

$188.00

$48.00

$140.00

$88.00

$33.00

$54.00

$62.00

$33.00

$29.00

$141.00

$40.00

$100.00

$137.00

$43.00

$94.00

$113.00

$45.00

$68.00

$142.00

$64.00

$78.00

$103.00

$47.00

$57.00

$55.00

$30.00

$25.00

$108.00

$43.00

$66.00

$319.00

$98.00

$127.00

$40.00

$87.00

$55.00

$29.00

$26.00

$78.00

$37.00

$41.00

$108.00

$38.00

$70.00

$193.00

$89.00

$103.00

$132.00

$36.00

(Facility MRA)

$223.00

$190.00

$49.00

$141.00

$89.00

$34.00

$55.00

$64.00

$35.00

$29.00

$143.00

$42.00

$101.00

$139.00

$45.00

$95.00

$115.00

$46.00

$69.00

$146.00

$67.00

$79.00

$106.00

$48.00

$57.00

$57.00

$31.00

$25.00

$111.00

$44.00

$66.00

$324.00

$101.00

$129.00

$41.00

$87.00

$57.00

$30.00

$27.00

$80.00

$38.00

$41.00

$109.00

$39.00

$70.00

$195.00

$91.00

$104.00

$133.00

$37.00


Part C, 301



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


76940-26

76940-TC

76941

76941-26

76941-TC

76942

76942-26

76942-TC

76945

76945-26

76945-TC

76946

76946-26

76946-TC

76948

76948-26

76881-TC

76882

76882-26

76882-TC

76930

76930-26

76930-TC

76932

76932-26

76932-TC

76936

76936-26

76936-TC

76937

76937-26

76937-TC

76940

76948-TC

76965

76965-26

76965-TC

76970

76970-26

76970-TC

76975

76975-26

76975-TC

76977

76977-26

76977-TC

76998

76998-26

76998-TC

76999

---------

---------

$128.00

NC

NC

$92.00

NC

NC

$93.00

NC

NC

$78.00

NC

NC

$77.00

NC

---------

---------

---------

---------

$93.00

NC

NC

$93.00

NC

NC

$341.00

$102.00

$236.00

---------

---------

---------

---------

NC

$281.00

$84.00

$208.00

$60.00

$20.00

$39.00

$99.00

NC

NC

$34.00

$3.00

$31.00

---------

---------

---------

BR

$118.00

BR

---------

$78.00

BR

$67.00

$38.00

$29.00

---------

$39.00

BR

$36.00

$22.00

$14.00

$76.00

$34.00

$89.00

$40.00

$28.00

$12.00

---------

$37.00

BR

---------

$37.00

BR

$299.00

$113.00

$186.00

$34.00

$16.00

$18.00

BR

$42.00

$99.00

$74.00

$25.00

$100.00

$22.00

$79.00

$210.00

$48.00

$162.00

$8.00

$3.00

$5.00

BR

$73.00

BR

---------

$124.00

BR

---------

$81.00

BR

$70.00

$39.00

$32.00

---------

$41.00

BR

$38.00

$23.00

$15.00

$81.00

$35.00

$96.00

$42.00

$29.00

$13.00

---------

$38.00

BR

---------

$38.00

BR

$318.00

$119.00

$199.00

$36.00

$17.00

$19.00

BR

$45.00

$103.00

$76.00

$27.00

$107.00

$22.00

$85.00

$224.00

$50.00

$174.00

$9.00

$3.00

$5.00

BR

$78.00

BR

---------

$131.00

BR

---------

$85.00

BR

$72.00

$40.00

$32.00

---------

$43.00

BR

$40.00

$24.00

$16.00

$83.00

$37.00

$96.00

$43.00

$30.00

$14.00

---------

$39.00

BR

---------

$39.00

BR

$327.00

$127.00

$201.00

$37.00

$17.00

$20.00

BR

$46.00

$105.00

$77.00

$28.00

$108.00

$23.00

$85.00

$227.00

$52.00

$175.00

$9.00

$4.00

$5.00

BR

$85.00

BR

---------

$118.00

BR

---------

$78.00

BR

$67.00

$38.00

$29.00

---------

$39.00

BR

$36.00

$22.00

$14.00

$76.00

$34.00

$89.00

$40.00

$28.00

$12.00

---------

$37.00

BR

---------

$37.00

BR

$299.00

$113.00

$186.00

$34.00

$16.00

$18.00

BR

$42.00

$99.00

$74.00

$25.00

$100.00

$22.00

$79.00

$210.00

$48.00

$162.00

$8.00

$3.00

$5.00

BR

$73.00

BR

---------

$124.00

BR

---------

$81.00

BR

$70.00

$39.00

$32.00

---------

$41.00

BR

$38.00

$23.00

$15.00

$81.00

$35.00

$96.00

$42.00

$29.00

$13.00

---------

$38.00

BR

---------

$38.00

BR

$318.00

$119.00

$199.00

$36.00

$17.00

$19.00

BR

$45.00

$103.00

$76.00

$27.00

$107.00

$22.00

$85.00

$224.00

$50.00

$174.00

$9.00

$3.00

$5.00

BR

$78.00

BR

---------

(Facility MRA)

$131.00

BR

---------

$85.00

BR

$72.00

$40.00

$32.00

---------

$43.00

BR

$40.00

$24.00

$16.00

$83.00

$37.00

$96.00

$43.00

$30.00

$14.00

---------

$39.00

BR

---------

$39.00

BR

$327.00

$127.00

$201.00

$37.00

$17.00

$20.00

BR

$46.00

$105.00

$77.00

$28.00

$108.00

$23.00

$85.00

$227.00

$52.00

$175.00

$9.00

$4.00

$5.00

BR

$85.00

BR

---------


Part C, 302



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


77013-26

77013-TC

77014

77014-26

77014-TC

77021

77021-26

77021-TC

77022

77022-26

77022-TC

77051

77051-26

77051-TC

77052

77052-26

76999-26

76999-TC

77001

77001-26

77001-TC

77002

77002-26

77002-TC

77003

77003-26

77003-TC

77011

77011-26

77011-TC

77012

77012-26

77012-TC

77052-TC

77053

77053-26

77053-TC

77054

77054-26

77054-TC

77055

77055-26

77055-TC

77056

77056-26

77056-TC

77057

77057-26

77057-TC

77058

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$220.00

BR

$128.00

$49.00

$79.00

$433.00

$85.00

$348.00

BR

$239.00

BR

$9.00

$3.00

$6.00

$9.00

$3.00

---------

---------

$76.00

$21.00

$54.00

$101.00

$32.00

$69.00

$93.00

$34.00

$59.00

$240.00

$70.00

$170.00

$136.00

$65.00

$71.00

$6.00

$63.00

$20.00

$43.00

$83.00

$26.00

$57.00

$97.00

$39.00

$58.00

$125.00

$49.00

$76.00

$89.00

$39.00

$50.00

$570.00

$227.00

BR

$135.00

$50.00

$85.00

$461.00

$87.00

$374.00

BR

$247.00

BR

$9.00

$3.00

$6.00

$9.00

$3.00

---------

---------

$81.00

$22.00

$58.00

$107.00

$33.00

$74.00

$98.00

$35.00

$63.00

$255.00

$73.00

$183.00

$144.00

$67.00

$77.00

$6.00

$67.00

$21.00

$46.00

$88.00

$27.00

$62.00

$103.00

$41.00

$62.00

$132.00

$51.00

$81.00

$94.00

$41.00

$53.00

$609.00

$234.00

BR

$137.00

$52.00

$85.00

$466.00

$90.00

$375.00

BR

$255.00

BR

$9.00

$3.00

$6.00

$9.00

$3.00

---------

---------

$82.00

$23.00

$59.00

$109.00

$34.00

$75.00

$100.00

$36.00

$64.00

$259.00

$75.00

$184.00

$146.00

$69.00

$77.00

$6.00

$68.00

$21.00

$47.00

$90.00

$28.00

$62.00

$104.00

$42.00

$62.00

$134.00

$52.00

$82.00

$96.00

$42.00

$54.00

$614.00

$220.00

BR

$128.00

$49.00

$79.00

$433.00

$85.00

$348.00

BR

$239.00

BR

$9.00

$3.00

$6.00

$9.00

$3.00

---------

---------

$76.00

$21.00

$54.00

$101.00

$32.00

$69.00

$93.00

$34.00

$59.00

$240.00

$70.00

$170.00

$136.00

$65.00

$71.00

$6.00

$63.00

$20.00

$43.00

$83.00

$26.00

$57.00

$97.00

$39.00

$58.00

$125.00

$49.00

$76.00

$89.00

$39.00

$50.00

$570.00

$227.00

BR

$135.00

$50.00

$85.00

$461.00

$87.00

$374.00

BR

$247.00

BR

$9.00

$3.00

$6.00

$9.00

$3.00

---------

---------

$81.00

$22.00

$58.00

$107.00

$33.00

$74.00

$98.00

$35.00

$63.00

$255.00

$73.00

$183.00

$144.00

$67.00

$77.00

$6.00

$67.00

$21.00

$46.00

$88.00

$27.00

$62.00

$103.00

$41.00

$62.00

$132.00

$51.00

$81.00

$94.00

$41.00

$53.00

$609.00

(Facility MRA)

$234.00

BR

$137.00

$52.00

$85.00

$466.00

$90.00

$375.00

BR

$255.00

BR

$9.00

$3.00

$6.00

$9.00

$3.00

---------

---------

$82.00

$23.00

$59.00

$109.00

$34.00

$75.00

$100.00

$36.00

$64.00

$259.00

$75.00

$184.00

$146.00

$69.00

$77.00

$6.00

$68.00

$21.00

$47.00

$90.00

$28.00

$62.00

$104.00

$42.00

$62.00

$134.00

$52.00

$82.00

$96.00

$42.00

$54.00

$614.00


Part C, 303



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


77074-TC

77075

77075-26

77075-TC

77077

77077-26

77077-TC

77078

77078-26

77078-TC

77080

77080-26

77080-TC

77081

77081-26

77081-TC

77058-26

77058-TC

77059

77059-26

77059-TC

77063

77063-26

77063-TC

77071

77072

77072-26

77072-TC

77073

77073-26

77073-TC

77074

77074-26

77084

77084-26

77084-TC

77085

77085-26

77085-TC

77086

77086-26

77086-TC

77261

77262

77263

77280

77280-26

77280-TC

77285

77285-26

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$73.00

$110.00

$163.00

$166.00

$36.00

$130.00

$264.00

$53.00

$44.00

$94.00

$30.00

$64.00

$41.00

$18.00

$22.00

$78.00

$14.00

$64.00

$44.00

$11.00

$33.00

$30.00

$12.00

$18.00

$92.00

$479.00

$570.00

$92.00

$479.00

$60.00

$34.00

$27.00

$53.00

$25.00

$11.00

$15.00

$39.00

$16.00

$23.00

$70.00

$26.00

$379.00

$90.00

$288.00

$61.00

$17.00

$44.00

$38.00

$10.00

$28.00

$84.00

$126.00

$185.00

$293.00

$40.00

$253.00

$462.00

$61.00

$47.00

$100.00

$31.00

$69.00

$43.00

$19.00

$24.00

$83.00

$14.00

$69.00

$47.00

$12.00

$36.00

$32.00

$13.00

$20.00

$95.00

$514.00

$609.00

$95.00

$514.00

$63.00

$35.00

$29.00

$57.00

$27.00

$11.00

$16.00

$41.00

$17.00

$25.00

$74.00

$27.00

$403.00

$93.00

$310.00

$65.00

$18.00

$47.00

$41.00

$10.00

$31.00

$88.00

$131.00

$192.00

$313.00

$41.00

$272.00

$494.00

$63.00

$48.00

$102.00

$32.00

$69.00

$44.00

$19.00

$25.00

$84.00

$14.00

$70.00

$48.00

$12.00

$36.00

$33.00

$13.00

$20.00

$97.00

$516.00

$614.00

$97.00

$516.00

$64.00

$36.00

$29.00

$59.00

$27.00

$11.00

$16.00

$42.00

$17.00

$25.00

$75.00

$28.00

$407.00

$96.00

$311.00

$66.00

$19.00

$47.00

$42.00

$11.00

$31.00

$90.00

$136.00

$200.00

$315.00

$42.00

$273.00

$497.00

$64.00

$44.00

$94.00

$30.00

$64.00

$41.00

$18.00

$22.00

$78.00

$14.00

$64.00

$44.00

$11.00

$33.00

$30.00

$12.00

$18.00

$92.00

$479.00

$570.00

$92.00

$479.00

$60.00

$34.00

$27.00

$53.00

$25.00

$11.00

$15.00

$39.00

$16.00

$23.00

$70.00

$26.00

$379.00

$90.00

$288.00

$61.00

$17.00

$44.00

$38.00

$10.00

$28.00

$84.00

$126.00

$185.00

$293.00

$40.00

$253.00

$462.00

$61.00

$47.00

$100.00

$31.00

$69.00

$43.00

$19.00

$24.00

$83.00

$14.00

$69.00

$47.00

$12.00

$36.00

$32.00

$13.00

$20.00

$95.00

$514.00

$609.00

$95.00

$514.00

$63.00

$35.00

$29.00

$57.00

$27.00

$11.00

$16.00

$41.00

$17.00

$25.00

$74.00

$27.00

$403.00

$93.00

$310.00

$65.00

$18.00

$47.00

$41.00

$10.00

$31.00

$88.00

$131.00

$192.00

$313.00

$41.00

$272.00

$494.00

$63.00

(Facility MRA)

$48.00

$102.00

$32.00

$69.00

$44.00

$19.00

$25.00

$84.00

$14.00

$70.00

$48.00

$12.00

$36.00

$33.00

$13.00

$20.00

$97.00

$516.00

$614.00

$97.00

$516.00

$64.00

$36.00

$29.00

$59.00

$27.00

$11.00

$16.00

$42.00

$17.00

$25.00

$75.00

$28.00

$407.00

$96.00

$311.00

$66.00

$19.00

$47.00

$42.00

$11.00

$31.00

$90.00

$136.00

$200.00

$315.00

$42.00

$273.00

$497.00

$64.00


Part C, 304



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


77318-TC

77321

77321-26

77321-TC

77331

77331-26

77331-TC

77332

77332-26

77332-TC

77333

77333-26

77333-TC

77334

77334-26

77334-TC

77336

77285-TC

77290

77290-26

77290-TC

77293

77293-26

77293-TC

77295

77295-26

$209.00

$325.00

$79.00

$243.00

---------

---------

---------

$1,287.00

$232.00

77295-TC $1,046.00

77299 BR

77299-26 BR

77299-TC

77300

77300-26

77300-TC

77301

BR

$87.00

$36.00

$52.00

$1,473.00

77301-26 $415.00

77301-TC $1,046.00

77306

77306-26

77306-TC

---------

---------

---------

77307

77307-26

77307-TC

---------

---------

---------

77316

77316-26

77316-TC

77317

77317-26

77317-TC

77318

77318-26

---------

---------

---------

---------

---------

---------

---------

---------

---------

$200.00

$48.00

$150.00

$64.00

$45.00

$18.00

$78.00

$27.00

$50.00

$115.00

$43.00

$70.00

$187.00

$63.00

$121.00

$111.00

$459.00

$1,648.00

$163.00

$81.00

$82.00

$315.00

$166.00

$149.00

$205.00

$81.00

$124.00

$267.00

$105.00

$162.00

$386.00

$166.00

$402.00

$553.00

$90.00

$463.00

$502.00

$115.00

$387.00

$534.00

$246.00

$288.00

---------

---------

---------

$73.00

$36.00

$37.00

$2,106.00

$219.00

$101.00

$55.00

$47.00

$70.00

$50.00

$20.00

$90.00

$31.00

$58.00

$59.00

$48.00

$10.00

$166.00

$71.00

$95.00

$86.00

$431.00

$590.00

$93.00

$497.00

$534.00

$119.00

$416.00

$563.00

$254.00

$309.00

---------

---------

---------

$77.00

$37.00

$40.00

$2,244.00

$473.00

$1,771.00

$172.00

$83.00

$89.00

$331.00

$171.00

$160.00

$217.00

$83.00

$134.00

$283.00

$109.00

$174.00

$407.00

$171.00

$236.00

$107.00

$56.00

$50.00

$73.00

$52.00

$22.00

$95.00

$32.00

$63.00

$61.00

$50.00

$11.00

$175.00

$73.00

$102.00

$93.00

$433.00

$594.00

$95.00

$499.00

$539.00

$122.00

$417.00

$571.00

$259.00

$312.00

---------

---------

---------

$78.00

$38.00

$40.00

$2,268.00

$484.00

$1,784.00

$174.00

$85.00

$89.00

$336.00

$175.00

$161.00

$220.00

$85.00

$135.00

$287.00

$111.00

$176.00

$414.00

$175.00

$239.00

$108.00

$58.00

$51.00

$75.00

$53.00

$22.00

$96.00

$33.00

$63.00

$63.00

$51.00

$12.00

$177.00

$75.00

$102.00

$95.00

(Facility MRA)

$236.00

$107.00

$56.00

$50.00

$73.00

$52.00

$22.00

$95.00

$32.00

$63.00

$61.00

$50.00

$11.00

$175.00

$73.00

$102.00

$93.00

$431.00

$590.00

$93.00

$497.00

$534.00

$119.00

$416.00

$563.00

$254.00

$433.00

$594.00

$95.00

$499.00

$539.00

$122.00

$417.00

$571.00

$259.00

$309.00

---------

---------

$312.00

---------

---------

---------

$77.00

$37.00

$40.00

---------

$78.00

$38.00

$40.00

$2,244.00

$2,268.00

$473.00

$484.00

$1,771.00

$1,784.00

$172.00

$83.00

$89.00

$174.00

$85.00

$89.00

$331.00

$171.00

$160.00

$336.00

$175.00

$161.00

$217.00

$83.00

$134.00

$283.00

$109.00

$174.00

$407.00

$171.00

$220.00

$85.00

$135.00

$287.00

$111.00

$176.00

$414.00

$175.00

$239.00

$108.00

$58.00

$51.00

$75.00

$53.00

$22.00

$96.00

$33.00

$63.00

$63.00

$51.00

$12.00

$177.00

$75.00

$102.00

$95.00

$459.00

$1,648.00

$163.00

$81.00

$82.00

$315.00

$166.00

$149.00

$205.00

$81.00

$124.00

$267.00

$105.00

$162.00

$386.00

$166.00

$402.00

$553.00

$90.00

$463.00

$502.00

$115.00

$387.00

$534.00

$246.00

$288.00

---------

---------

---------

$73.00

$36.00

$37.00

$2,106.00

$219.00

$101.00

$55.00

$47.00

$70.00

$50.00

$20.00

$90.00

$31.00

$58.00

$59.00

$48.00

$10.00

$166.00

$71.00

$95.00

$86.00


Part C, 305



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


77427

77431

77432

77435

77469

77470

77470-26

77470-TC

77499

77499-26

77499-TC

77520

77522

77523

77525

77600

77338

77338-26

77338-TC

77370

77371

77372

77373

77399

77399-26

77399-TC

77401

77402

77407

77412

77417

77422

77423

77600-26

77600-TC

77605

77605-26

77605-TC

77610

77610-26

77610-TC

77615

77615-26

77615-TC

77620

77620-26

77620-TC

77750

77750-26

77750-TC

$166.00

$95.00

$417.00

---------

---------

$527.00

$106.00

$417.00

BR

BR

BR

BR

BR

BR

BR

$196.00

---------

---------

---------

$130.00

---------

---------

---------

BR

BR

BR

$66.00

$66.00

$78.00

$87.00

$21.00

---------

---------

$80.00

$113.00

$263.00

$108.00

$151.00

$195.00

$79.00

$113.00

$262.00

$106.00

$151.00

$196.00

$80.00

$113.00

$299.00

$248.00

$49.00

$207.00

$114.00

$467.00

$704.00

$358.00

$172.00

$120.00

$52.00

---------

---------

---------

---------

---------

---------

---------

$453.00

$552.00

$246.00

$306.00

$132.00

BR

$1,147.00

$1,458.00

---------

---------

---------

$26.00

---------

---------

---------

$12.00

BR

BR

$91.00

$362.00

$862.00

$133.00

$729.00

$1,067.00

$99.00

$968.00

$1,140.00

$119.00

$1,021.00

$414.00

$90.00

$324.00

$408.00

$286.00

$122.00

$583.00

$254.00

$329.00

$143.00

BR

$1,232.00

$1,566.00

---------

---------

---------

$28.00

---------

---------

---------

$13.00

BR

BR

$215.00

$118.00

$485.00

$732.00

$373.00

$179.00

$124.00

$56.00

---------

---------

---------

---------

---------

---------

---------

$483.00

$94.00

$389.00

$923.00

$141.00

$782.00

$1,145.00

$106.00

$1,039.00

$1,219.00

$123.00

$1,096.00

$441.00

$93.00

$348.00

$426.00

$295.00

$131.00

$592.00

$259.00

$332.00

$147.00

BR

$1,241.00

$1,577.00

---------

---------

---------

$28.00

---------

---------

---------

$13.00

BR

BR

$223.00

$122.00

$503.00

$759.00

$385.00

$183.00

$127.00

$56.00

---------

---------

---------

---------

---------

---------

---------

$488.00

$97.00

$391.00

$938.00

$152.00

$786.00

$1,158.00

$115.00

$1,043.00

$1,228.00

$126.00

$1,102.00

$445.00

$95.00

$351.00

$435.00

$302.00

$132.00

(Facility MRA)

$215.00

$118.00

$485.00

$732.00

$373.00

$179.00

$124.00

$56.00

---------

---------

---------

---------

---------

---------

---------

$483.00

$583.00

$254.00

$329.00

$143.00

$592.00

$259.00

$332.00

$147.00

BR BR

$1,232.00

$1,241.00

$1,566.00

$1,577.00

-----------------

-----------------

---------

$28.00

---------

---------

---------

$13.00

BR

BR

---------

$28.00

---------

---------

---------

$13.00

BR

BR

$223.00

$122.00

$503.00

$759.00

$385.00

$183.00

$127.00

$56.00

---------

---------

---------

---------

---------

---------

---------

$488.00

$94.00

$389.00

$923.00

$141.00

$782.00

$97.00

$391.00

$938.00

$152.00

$786.00

$1,145.00

$1,158.00

$106.00

$115.00

$1,039.00

$1,043.00

$1,219.00

$1,228.00

$123.00

$126.00

$1,096.00

$1,102.00

$441.00

$445.00

$93.00

$95.00

$348.00

$426.00

$295.00

$131.00

$351.00

$435.00

$302.00

$132.00

$207.00

$114.00

$467.00

$704.00

$358.00

$172.00

$120.00

$52.00

---------

---------

---------

---------

---------

---------

---------

$453.00

$552.00

$246.00

$306.00

$132.00

BR

$1,147.00

$1,458.00

---------

---------

---------

$26.00

---------

---------

---------

$12.00

BR

BR

$91.00

$362.00

$862.00

$133.00

$729.00

$1,067.00

$99.00

$968.00

$1,140.00

$119.00

$1,021.00

$414.00

$90.00

$324.00

$408.00

$286.00

$122.00


Part C, 306



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


77770-TC

77771

77771-26

77771-TC

77772

77772-26

77772-TC

77778

77778-26

77778-TC

77789

77789-26

77789-TC

77790

77790-26

77790-TC

77761

77761-26

77761-TC

77762

77762-26

77762-TC

77763

77763-26

77763-TC

77767

77767-26

77767-TC

77768

77768-26

77768-TC

77770

77770-26

77799

77799-26

77799-TC

78012

78012-26

78012-TC

78013

78013-26

78013-TC

78014

78014-26

78014-TC

78015

78015-26

78015-TC

78016

78016-26

---------

---------

---------

---------

---------

---------

---------

$764.00

$568.00

$192.00

$74.00

$57.00

$16.00

$72.00

$53.00

$18.00

$284.00

$188.00

$93.00

$427.00

$289.00

$135.00

$605.00

$435.00

$167.00

---------

---------

---------

---------

---------

---------

---------

---------

BR

BR

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

$132.00

$34.00

$96.00

$173.00

$42.00

$235.00

$647.00

$218.00

$429.00

$987.00

$310.00

$678.00

$852.00

$458.00

$395.00

$130.00

$66.00

$64.00

$16.00

---------

---------

$425.00

$219.00

$206.00

$567.00

$330.00

$237.00

$804.00

$497.00

$307.00

$243.00

$61.00

$182.00

$380.00

$80.00

$300.00

$347.00

$112.00

---------

---------

---------

$88.00

$11.00

$77.00

$212.00

$21.00

$191.00

$268.00

$28.00

$240.00

$244.00

$37.00

$208.00

$309.00

$38.00

$448.00

$226.00

$222.00

$595.00

$341.00

$255.00

$843.00

$513.00

$330.00

$259.00

$63.00

$196.00

$405.00

$83.00

$322.00

$368.00

$115.00

$253.00

$686.00

$225.00

$461.00

$1,048.00

$319.00

$729.00

$897.00

$472.00

$425.00

$137.00

$68.00

$69.00

$17.00

---------

---------

---------

---------

---------

$94.00

$11.00

$83.00

$226.00

$21.00

$205.00

$287.00

$29.00

$258.00

$261.00

$38.00

$223.00

$330.00

$39.00

$456.00

$232.00

$224.00

$606.00

$349.00

$257.00

$859.00

$525.00

$334.00

$262.00

$64.00

$197.00

$409.00

$85.00

$325.00

$373.00

$118.00

$255.00

$694.00

$230.00

$464.00

$1,061.00

$327.00

$734.00

$913.00

$483.00

$430.00

$139.00

$70.00

$70.00

$18.00

---------

---------

---------

---------

---------

$95.00

$11.00

$84.00

$229.00

$22.00

$207.00

$289.00

$30.00

$260.00

$263.00

$39.00

$225.00

$333.00

$39.00

(Facility MRA)

---------

---------

---------

$94.00

$11.00

$83.00

$226.00

$21.00

$205.00

$287.00

$29.00

$258.00

$261.00

$38.00

$223.00

$330.00

$39.00

$448.00

$226.00

$222.00

$595.00

$341.00

$255.00

$843.00

$513.00

$330.00

$259.00

$63.00

$196.00

$405.00

$83.00

$322.00

$368.00

$115.00

$253.00

$686.00

$225.00

$461.00

$255.00

$694.00

$230.00

$464.00

$1,048.00

$1,061.00

$319.00

$729.00

$897.00

$327.00

$734.00

$913.00

$472.00

$425.00

$137.00

$68.00

$69.00

$17.00

---------

---------

$483.00

$430.00

$139.00

$70.00

$70.00

$18.00

---------

---------

$456.00

$232.00

$224.00

$606.00

$349.00

$257.00

$859.00

$525.00

$334.00

$262.00

$64.00

$197.00

$409.00

$85.00

$325.00

$373.00

$118.00

---------

---------

---------

$95.00

$11.00

$84.00

$229.00

$22.00

$207.00

$289.00

$30.00

$260.00

$263.00

$39.00

$225.00

$333.00

$39.00

$235.00

$647.00

$218.00

$429.00

$987.00

$310.00

$678.00

$852.00

$458.00

$395.00

$130.00

$66.00

$64.00

$16.00

---------

---------

$425.00

$219.00

$206.00

$567.00

$330.00

$237.00

$804.00

$497.00

$307.00

$243.00

$61.00

$182.00

$380.00

$80.00

$300.00

$347.00

$112.00

---------

---------

---------

$88.00

$11.00

$77.00

$212.00

$21.00

$191.00

$268.00

$28.00

$240.00

$244.00

$37.00

$208.00

$309.00

$38.00


Part C, 307



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


78075-26

78075-TC

78099

78099-26

78099-TC

78102

78102-26

78102-TC

78103

78103-26

78103-TC

78104

78104-26

78104-TC

78110

78110-26

78016-TC

78018

78018-26

78018-TC

78020

78020-26

78020-TC

78070

78070-26

78070-TC

78071

78071-26

78071-TC

78072

78072-26

78072-TC

78075

78110-TC

78111

78111-26

78111-TC

78120

78120-26

78120-TC

78121

78121-26

78121-TC

78122

78122-26

78122-TC

78130

78130-26

78130-TC

78135

$38.00

$202.00

BR

BR

BR

$106.00

$28.00

$77.00

$158.00

$39.00

$118.00

$194.00

$41.00

$152.00

$45.00

$9.00

$130.00

$248.00

$44.00

$202.00

$35.00

$30.00

$5.00

$112.00

$36.00

$68.00

---------

---------

---------

---------

---------

---------

$242.00

$35.00

$108.00

$11.00

$96.00

$78.00

$11.00

$65.00

$125.00

$16.00

$108.00

$196.00

$22.00

$171.00

$139.00

$32.00

$106.00

$216.00

$39.00

$434.00

---------

---------

---------

$188.00

$30.00

$158.00

$247.00

$41.00

$206.00

$272.00

$43.00

$229.00

$104.00

$11.00

$271.00

$347.00

$47.00

$300.00

$93.00

$31.00

$62.00

$332.00

$44.00

$289.00

$398.00

$66.00

$332.00

$459.00

$86.00

$373.00

$473.00

$93.00

$107.00

$12.00

$95.00

$104.00

$13.00

$91.00

$113.00

$18.00

$95.00

$109.00

$24.00

$85.00

$187.00

$34.00

$153.00

$387.00

$41.00

$466.00

---------

---------

---------

$201.00

$31.00

$170.00

$264.00

$42.00

$222.00

$291.00

$44.00

$246.00

$112.00

$11.00

$292.00

$371.00

$48.00

$323.00

$99.00

$32.00

$67.00

$355.00

$45.00

$310.00

$424.00

$68.00

$356.00

$489.00

$88.00

$401.00

$507.00

$101.00

$114.00

$13.00

$102.00

$112.00

$13.00

$98.00

$121.00

$19.00

$103.00

$116.00

$25.00

$91.00

$199.00

$35.00

$165.00

$414.00

$41.00

$469.00

---------

---------

---------

$204.00

$32.00

$172.00

$267.00

$43.00

$223.00

$293.00

$46.00

$248.00

$113.00

$11.00

$294.00

$374.00

$49.00

$325.00

$100.00

$33.00

$68.00

$358.00

$46.00

$312.00

$429.00

$70.00

$359.00

$494.00

$91.00

$403.00

$511.00

$102.00

$116.00

$13.00

$103.00

$113.00

$14.00

$99.00

$123.00

$19.00

$104.00

$118.00

$25.00

$92.00

$202.00

$35.00

$166.00

$417.00

$39.00

$434.00

---------

---------

---------

$188.00

$30.00

$158.00

$247.00

$41.00

$206.00

$272.00

$43.00

$229.00

$104.00

$11.00

$271.00

$347.00

$47.00

$300.00

$93.00

$31.00

$62.00

$332.00

$44.00

$289.00

$398.00

$66.00

$332.00

$459.00

$86.00

$373.00

$473.00

$93.00

$107.00

$12.00

$95.00

$104.00

$13.00

$91.00

$113.00

$18.00

$95.00

$109.00

$24.00

$85.00

$187.00

$34.00

$153.00

$387.00

$41.00

$466.00

---------

---------

---------

$201.00

$31.00

$170.00

$264.00

$42.00

$222.00

$291.00

$44.00

$246.00

$112.00

$11.00

$292.00

$371.00

$48.00

$323.00

$99.00

$32.00

$67.00

$355.00

$45.00

$310.00

$424.00

$68.00

$356.00

$489.00

$88.00

$401.00

$507.00

$101.00

$114.00

$13.00

$102.00

$112.00

$13.00

$98.00

$121.00

$19.00

$103.00

$116.00

$25.00

$91.00

$199.00

$35.00

$165.00

$414.00

(Facility MRA)

$41.00

$469.00

---------

---------

---------

$204.00

$32.00

$172.00

$267.00

$43.00

$223.00

$293.00

$46.00

$248.00

$113.00

$11.00

$294.00

$374.00

$49.00

$325.00

$100.00

$33.00

$68.00

$358.00

$46.00

$312.00

$429.00

$70.00

$359.00

$494.00

$91.00

$403.00

$511.00

$102.00

$116.00

$13.00

$103.00

$113.00

$14.00

$99.00

$123.00

$19.00

$104.00

$118.00

$25.00

$92.00

$202.00

$35.00

$166.00

$417.00


Part C, 308



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


78199

78199-26

78199-TC

78201

78201-26

78201-TC

78202

78202-26

78202-TC

78205

78205-26

78205-TC

78206

78206-26

78206-TC

78215

78135-26

78135-TC

78140

78140-26

78140-TC

78185

78185-26

78185-TC

78190

78190-26

78190-TC

78191

78191-26

78191-TC

78195

78195-26

78195-TC

78215-26

78215-TC

78216

78216-26

78216-TC

78226

78226-26

78226-TC

78227

78227-26

78227-TC

78230

78230-26

78230-TC

78231

78231-26

78231-TC

BR

BR

BR

$112.00

$22.00

$88.00

$135.00

$26.00

$108.00

$259.00

$36.00

$220.00

$265.00

$46.00

$214.00

$135.00

$33.00

$182.00

$179.00

$31.00

$147.00

$110.00

$20.00

$88.00

$272.00

$57.00

$214.00

$307.00

$31.00

$274.00

$216.00

$49.00

$152.00

$24.00

$109.00

$160.00

$29.00

$130.00

---------

---------

---------

---------

---------

---------

$106.00

$23.00

$82.00

$146.00

$27.00

$118.00

---------

---------

---------

$208.00

$24.00

$185.00

$224.00

$27.00

$197.00

$235.00

$38.00

$197.00

$380.00

$52.00

$328.00

$216.00

$36.00

$351.00

$152.00

$34.00

$118.00

$235.00

$22.00

$212.00

$435.00

$60.00

$374.00

$187.00

$34.00

$153.00

$396.00

$66.00

$329.00

$27.00

$189.00

$140.00

$31.00

$109.00

$368.00

$41.00

$327.00

$401.00

$50.00

$351.00

$157.00

$21.00

$135.00

$145.00

$30.00

$115.00

---------

---------

---------

$223.00

$24.00

$198.00

$239.00

$28.00

$212.00

$251.00

$39.00

$212.00

$406.00

$54.00

$352.00

$231.00

$37.00

$377.00

$162.00

$35.00

$127.00

$251.00

$23.00

$228.00

$464.00

$62.00

$402.00

$199.00

$35.00

$165.00

$422.00

$69.00

$354.00

$28.00

$203.00

$149.00

$32.00

$118.00

$394.00

$42.00

$351.00

$429.00

$52.00

$377.00

$167.00

$22.00

$146.00

$155.00

$31.00

$124.00

---------

---------

---------

$225.00

$25.00

$200.00

$241.00

$28.00

$213.00

$253.00

$40.00

$213.00

$410.00

$56.00

$354.00

$233.00

$38.00

$379.00

$164.00

$36.00

$128.00

$253.00

$24.00

$230.00

$468.00

$63.00

$405.00

$202.00

$35.00

$166.00

$427.00

$71.00

$356.00

$29.00

$204.00

$152.00

$33.00

$119.00

$397.00

$44.00

$353.00

$432.00

$53.00

$379.00

$169.00

$22.00

$147.00

$157.00

$32.00

$125.00

---------

---------

---------

$208.00

$24.00

$185.00

$224.00

$27.00

$197.00

$235.00

$38.00

$197.00

$380.00

$52.00

$328.00

$216.00

$36.00

$351.00

$152.00

$34.00

$118.00

$235.00

$22.00

$212.00

$435.00

$60.00

$374.00

$187.00

$34.00

$153.00

$396.00

$66.00

$329.00

$27.00

$189.00

$140.00

$31.00

$109.00

$368.00

$41.00

$327.00

$401.00

$50.00

$351.00

$157.00

$21.00

$135.00

$145.00

$30.00

$115.00

---------

---------

---------

$223.00

$24.00

$198.00

$239.00

$28.00

$212.00

$251.00

$39.00

$212.00

$406.00

$54.00

$352.00

$231.00

$37.00

$377.00

$162.00

$35.00

$127.00

$251.00

$23.00

$228.00

$464.00

$62.00

$402.00

$199.00

$35.00

$165.00

$422.00

$69.00

$354.00

$28.00

$203.00

$149.00

$32.00

$118.00

$394.00

$42.00

$351.00

$429.00

$52.00

$377.00

$167.00

$22.00

$146.00

$155.00

$31.00

$124.00

(Facility MRA)

---------

---------

---------

$225.00

$25.00

$200.00

$241.00

$28.00

$213.00

$253.00

$40.00

$213.00

$410.00

$56.00

$354.00

$233.00

$38.00

$379.00

$164.00

$36.00

$128.00

$253.00

$24.00

$230.00

$468.00

$63.00

$405.00

$202.00

$35.00

$166.00

$427.00

$71.00

$356.00

$29.00

$204.00

$152.00

$33.00

$119.00

$397.00

$44.00

$353.00

$432.00

$53.00

$379.00

$169.00

$22.00

$147.00

$157.00

$32.00

$125.00


Part C, 309



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


78265-TC

78266

78266-26

78266-TC

78267

78268

78270

78270-26

78270-TC

78271

78271-26

78271-TC

78272

78272-26

78272-TC

78278

78232

78232-26

78232-TC

78258

78258-26

78258-TC

78261

78261-26

78261-TC

78262

78262-26

78262-TC

78264

78264-26

78264-TC

78265

78265-26

78278-26

78278-TC

78282

78282-26

78282-TC

78290

78290-26

78290-TC

78291

78291-26

78291-TC

78299

78299-26

78299-TC

78300

78300-26

78300-TC

---------

---------

---------

---------

BR

BR

$68.00

$10.00

$58.00

$72.00

$10.00

$61.00

$100.00

$14.00

$87.00

$234.00

$157.00

$23.00

$132.00

$146.00

$38.00

$108.00

$190.00

$36.00

$152.00

$195.00

$35.00

$159.00

$195.00

$40.00

$154.00

---------

---------

$50.00

$182.00

BR

$19.00

BR

$149.00

$35.00

$113.00

$161.00

$45.00

$114.00

BR

BR

BR

$125.00

$32.00

$93.00

$351.00

$525.00

$60.00

$465.00

---------

---------

$112.00

$12.00

$100.00

$100.00

$11.00

$89.00

$107.00

$15.00

$92.00

$387.00

$110.00

$22.00

$88.00

$246.00

$41.00

$205.00

$276.00

$38.00

$237.00

$271.00

$37.00

$234.00

$371.00

$41.00

$330.00

$405.00

$54.00

$55.00

$333.00

$372.00

$21.00

$350.00

$370.00

$38.00

$332.00

$280.00

$47.00

$233.00

---------

---------

---------

$201.00

$35.00

$166.00

$377.00

$562.00

$62.00

$500.00

---------

---------

$120.00

$12.00

$108.00

$107.00

$12.00

$95.00

$115.00

$15.00

$99.00

$414.00

$117.00

$22.00

$95.00

$263.00

$42.00

$221.00

$295.00

$40.00

$255.00

$290.00

$38.00

$252.00

$397.00

$42.00

$354.00

$433.00

$56.00

$57.00

$357.00

$398.00

$22.00

$376.00

$396.00

$39.00

$357.00

$299.00

$49.00

$250.00

---------

---------

---------

$215.00

$36.00

$178.00

$380.00

$566.00

$64.00

$502.00

---------

---------

$122.00

$13.00

$109.00

$109.00

$12.00

$97.00

$116.00

$16.00

$101.00

$418.00

$118.00

$23.00

$96.00

$266.00

$44.00

$222.00

$298.00

$41.00

$257.00

$292.00

$39.00

$253.00

$400.00

$44.00

$357.00

$437.00

$57.00

$58.00

$360.00

$400.00

$23.00

$377.00

$400.00

$40.00

$359.00

$301.00

$50.00

$252.00

---------

---------

---------

$218.00

$38.00

$180.00

$351.00

$525.00

$60.00

$465.00

---------

---------

$112.00

$12.00

$100.00

$100.00

$11.00

$89.00

$107.00

$15.00

$92.00

$387.00

$110.00

$22.00

$88.00

$246.00

$41.00

$205.00

$276.00

$38.00

$237.00

$271.00

$37.00

$234.00

$371.00

$41.00

$330.00

$405.00

$54.00

$55.00

$333.00

$372.00

$21.00

$350.00

$370.00

$38.00

$332.00

$280.00

$47.00

$233.00

---------

---------

---------

$201.00

$35.00

$166.00

$377.00

$562.00

$62.00

$500.00

---------

---------

$120.00

$12.00

$108.00

$107.00

$12.00

$95.00

$115.00

$15.00

$99.00

$414.00

$117.00

$22.00

$95.00

$263.00

$42.00

$221.00

$295.00

$40.00

$255.00

$290.00

$38.00

$252.00

$397.00

$42.00

$354.00

$433.00

$56.00

$57.00

$357.00

$398.00

$22.00

$376.00

$396.00

$39.00

$357.00

$299.00

$49.00

$250.00

---------

---------

---------

$215.00

$36.00

$178.00

(Facility MRA)

$380.00

$566.00

$64.00

$502.00

---------

---------

$122.00

$13.00

$109.00

$109.00

$12.00

$97.00

$116.00

$16.00

$101.00

$418.00

$118.00

$23.00

$96.00

$266.00

$44.00

$222.00

$298.00

$41.00

$257.00

$292.00

$39.00

$253.00

$400.00

$44.00

$357.00

$437.00

$57.00

$58.00

$360.00

$400.00

$23.00

$377.00

$400.00

$40.00

$359.00

$301.00

$50.00

$252.00

---------

---------

---------

$218.00

$38.00

$180.00


Part C, 310



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


78399-26

78399-TC

78414

78414-26

78414-TC

78428

78428-26

78428-TC

78445

78445-26

78445-TC

78451

78451-26

78451-TC

78452

78452-26

78305

78305-26

78305-TC

78306

78306-26

78306-TC

78315

78315-26

78315-TC

78320

78320-26

78320-TC

78350

78350-26

78350-TC

78351

78399

78452-TC

78453

78453-26

78453-TC

78454

78454-26

78454-TC

78456

78456-26

78456-TC

78457

78457-26

78457-TC

78458

78458-26

78458-TC

78459

BR

BR

BR

$23.00

BR

$126.00

$41.00

$84.00

$97.00

$28.00

$69.00

---------

---------

---------

---------

---------

$181.00

$42.00

$137.00

$205.00

$44.00

$159.00

$233.00

$52.00

$179.00

$276.00

$53.00

$220.00

$40.00

$11.00

$29.00

$23.00

BR

---------

---------

---------

---------

---------

---------

---------

$205.00

$49.00

$151.00

$140.00

$39.00

$99.00

$198.00

$46.00

$149.00

BR

---------

---------

---------

$25.00

---------

$201.00

$42.00

$158.00

$194.00

$26.00

$168.00

$379.00

$75.00

$304.00

$525.00

$88.00

$257.00

$46.00

$211.00

$280.00

$48.00

$233.00

$385.00

$56.00

$329.00

$254.00

$56.00

$197.00

$36.00

$12.00

$24.00

$17.00

---------

$437.00

$338.00

$55.00

$283.00

$485.00

$75.00

$411.00

$351.00

$54.00

$296.00

$210.00

$43.00

$166.00

$186.00

$43.00

$144.00

$1,433.00

$274.00

$48.00

$226.00

$299.00

$49.00

$250.00

$411.00

$58.00

$353.00

$270.00

$58.00

$212.00

$38.00

$13.00

$25.00

$18.00

---------

---------

---------

---------

$26.00

---------

$214.00

$43.00

$170.00

$208.00

$27.00

$181.00

$404.00

$77.00

$327.00

$560.00

$91.00

$469.00

$361.00

$57.00

$304.00

$518.00

$77.00

$441.00

$374.00

$56.00

$318.00

$224.00

$45.00

$179.00

$198.00

$43.00

$155.00

$1,534.00

$277.00

$49.00

$228.00

$303.00

$51.00

$252.00

$415.00

$60.00

$355.00

$273.00

$60.00

$214.00

$39.00

$13.00

$26.00

$18.00

---------

---------

---------

---------

$26.00

---------

$216.00

$44.00

$172.00

$210.00

$27.00

$182.00

$408.00

$79.00

$329.00

$566.00

$93.00

$473.00

$364.00

$59.00

$306.00

$523.00

$80.00

$444.00

$378.00

$57.00

$320.00

$228.00

$47.00

$180.00

$200.00

$44.00

$156.00

$1,540.00

(Facility MRA)

---------

---------

---------

$26.00

---------

$214.00

$43.00

$170.00

$208.00

$27.00

$181.00

$404.00

$77.00

$327.00

$560.00

$91.00

$274.00

$48.00

$226.00

$299.00

$49.00

$250.00

$411.00

$58.00

$353.00

$270.00

$58.00

$212.00

$38.00

$13.00

$25.00

$18.00

---------

$469.00

$361.00

$57.00

$304.00

$518.00

$77.00

$441.00

$374.00

$473.00

$364.00

$59.00

$306.00

$523.00

$80.00

$444.00

$378.00

$56.00

$318.00

$224.00

$45.00

$179.00

$57.00

$320.00

$228.00

$47.00

$180.00

$198.00

$43.00

$200.00

$44.00

$155.00

$156.00

$1,534.00

$1,540.00

---------

---------

---------

$26.00

---------

$216.00

$44.00

$172.00

$210.00

$27.00

$182.00

$408.00

$79.00

$329.00

$566.00

$93.00

$277.00

$49.00

$228.00

$303.00

$51.00

$252.00

$415.00

$60.00

$355.00

$273.00

$60.00

$214.00

$39.00

$13.00

$26.00

$18.00

---------

---------

---------

---------

$25.00

---------

$201.00

$42.00

$158.00

$194.00

$26.00

$168.00

$379.00

$75.00

$304.00

$525.00

$88.00

$257.00

$46.00

$211.00

$280.00

$48.00

$233.00

$385.00

$56.00

$329.00

$254.00

$56.00

$197.00

$36.00

$12.00

$24.00

$17.00

---------

$437.00

$338.00

$55.00

$283.00

$485.00

$75.00

$411.00

$351.00

$54.00

$296.00

$210.00

$43.00

$166.00

$186.00

$43.00

$144.00

$1,433.00


Part C, 311



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


78481

78481-26

78481-TC

78483

78483-26

78483-TC

78491

78491-26

78491-TC

78492

78492-26

78492-TC

78494

78494-26

78494-TC

78496

78459-26

78459-TC

78466

78466-26

78466-TC

78468

78468-26

78468-TC

78469

78469-26

78469-TC

78472

78472-26

78472-TC

78473

78473-26

78473-TC

78496-26

78496-TC

78499

78499-26

78499-TC

78579

78579-26

78579-TC

78580

78580-26

78580-TC

78582

78582-26

78582-TC

78597

78597-26

78597-TC

$248.00

$51.00

$195.00

$373.00

$77.00

$294.00

BR

$85.00

BR

BR

$100.00

BR

$324.00

$59.00

$262.00

$92.00

$100.00

BR

$135.00

$36.00

$97.00

$180.00

$41.00

$137.00

$244.00

$47.00

$195.00

$259.00

$50.00

$206.00

$387.00

$75.00

$308.00

$24.00

$66.00

BR

BR

BR

---------

---------

---------

$167.00

$38.00

$128.00

---------

---------

---------

---------

---------

---------

$194.00

$53.00

$141.00

$269.00

$80.00

$189.00

$1,433.00

$80.00

$1,353.00

$1,453.00

$100.00

$1,353.00

$250.00

$65.00

$185.00

$50.00

$79.00

$1,353.00

$212.00

$39.00

$173.00

$220.00

$44.00

$176.00

$252.00

$51.00

$201.00

$255.00

$54.00

$202.00

$322.00

$80.00

$242.00

$27.00

$22.00

---------

---------

---------

$207.00

$26.00

$181.00

$266.00

$41.00

$225.00

$372.00

$59.00

$313.00

$225.00

$40.00

$185.00

$81.00

$1,452.00

$226.00

$40.00

$186.00

$234.00

$45.00

$189.00

$268.00

$52.00

$216.00

$272.00

$55.00

$217.00

$342.00

$82.00

$260.00

$206.00

$55.00

$151.00

$285.00

$82.00

$204.00

$1,534.00

$82.00

$1,452.00

$1,555.00

$103.00

$1,452.00

$266.00

$67.00

$199.00

$52.00

$28.00

$24.00

---------

---------

---------

$221.00

$27.00

$194.00

$284.00

$42.00

$242.00

$398.00

$61.00

$337.00

$240.00

$41.00

$199.00

$83.00

$1,457.00

$228.00

$41.00

$187.00

$237.00

$46.00

$191.00

$271.00

$54.00

$217.00

$275.00

$57.00

$218.00

$346.00

$84.00

$262.00

$208.00

$56.00

$152.00

$289.00

$84.00

$205.00

$1,541.00

$84.00

$1,457.00

$1,562.00

$105.00

$1,457.00

$269.00

$68.00

$201.00

$53.00

$29.00

$25.00

---------

---------

---------

$224.00

$28.00

$196.00

$287.00

$44.00

$243.00

$402.00

$63.00

$339.00

$242.00

$42.00

$200.00

(Facility MRA)

$28.00

$24.00

---------

---------

---------

$221.00

$27.00

$194.00

$284.00

$42.00

$242.00

$398.00

$61.00

$337.00

$240.00

$41.00

$199.00

$81.00

$83.00

$1,452.00

$1,457.00

$226.00

$228.00

$40.00

$41.00

$186.00

$234.00

$45.00

$189.00

$268.00

$187.00

$237.00

$46.00

$191.00

$271.00

$52.00

$216.00

$272.00

$55.00

$217.00

$342.00

$82.00

$260.00

$54.00

$217.00

$275.00

$57.00

$218.00

$346.00

$84.00

$262.00

$206.00

$55.00

$151.00

$285.00

$82.00

$208.00

$56.00

$152.00

$289.00

$84.00

$204.00

$205.00

$1,534.00

$1,541.00

$82.00

$84.00

$1,452.00

$1,457.00

$1,555.00

$1,562.00

$103.00

$105.00

$1,452.00

$1,457.00

$266.00

$269.00

$67.00

$199.00

$52.00

$68.00

$201.00

$53.00

$29.00

$25.00

---------

---------

---------

$224.00

$28.00

$196.00

$287.00

$44.00

$243.00

$402.00

$63.00

$339.00

$242.00

$42.00

$200.00

$194.00

$53.00

$141.00

$269.00

$80.00

$189.00

$1,433.00

$80.00

$1,353.00

$1,453.00

$100.00

$1,353.00

$250.00

$65.00

$185.00

$50.00

$79.00

$1,353.00

$212.00

$39.00

$173.00

$220.00

$44.00

$176.00

$252.00

$51.00

$201.00

$255.00

$54.00

$202.00

$322.00

$80.00

$242.00

$27.00

$22.00

---------

---------

---------

$207.00

$26.00

$181.00

$266.00

$41.00

$225.00

$372.00

$59.00

$313.00

$225.00

$40.00

$185.00


Part C, 312



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


78606-TC

78607

78607-26

78607-TC

78608

78608-26

78608-TC

78609

78609-26

78609-TC

78610

78610-26

78610-TC

78630

78630-26

78630-TC

78598

78598-26

78598-TC

78599

78599-26

78599-TC

78600

78600-26

78600-TC

78601

78601-26

78601-TC

78605

78605-26

78605-TC

78606

78606-26

78635

78635-26

78635-TC

78645

78645-26

78645-TC

78647

78647-26

78647-TC

78650

78650-26

78650-TC

78660

78660-26

78660-TC

78699

78699-26

$177.00

$311.00

$64.00

$245.00

BR

---------

---------

BR

---------

---------

$74.00

$15.00

$59.00

$223.00

$35.00

$188.00

---------

---------

---------

BR

BR

BR

$131.00

$22.00

$108.00

$154.00

$26.00

$126.00

$155.00

$27.00

$126.00

$221.00

$45.00

$129.00

$32.00

$95.00

$158.00

$29.00

$128.00

$268.00

$46.00

$220.00

$206.00

$31.00

$173.00

$107.00

$27.00

$79.00

BR

BR

$332.00

$390.00

$66.00

$323.00

$1,434.00

$80.00

$1,353.00

$83.00

$83.00

BR

$194.00

$17.00

$177.00

$375.00

$38.00

$337.00

$341.00

$47.00

$294.00

---------

---------

---------

$206.00

$25.00

$180.00

$237.00

$28.00

$209.00

$221.00

$30.00

$191.00

$367.00

$35.00

$375.00

$34.00

$341.00

$358.00

$31.00

$326.00

$388.00

$51.00

$338.00

$365.00

$34.00

$331.00

$200.00

$30.00

$170.00

---------

---------

$364.00

$48.00

$316.00

---------

---------

---------

$220.00

$26.00

$194.00

$254.00

$29.00

$225.00

$236.00

$31.00

$205.00

$393.00

$36.00

$356.00

$416.00

$68.00

$348.00

$1,535.00

$83.00

$1,452.00

$85.00

$85.00

BR

$208.00

$18.00

$190.00

$402.00

$39.00

$363.00

$402.00

$35.00

$367.00

$383.00

$32.00

$351.00

$415.00

$52.00

$363.00

$391.00

$35.00

$356.00

$214.00

$31.00

$183.00

---------

---------

$368.00

$49.00

$318.00

---------

---------

---------

$223.00

$27.00

$195.00

$256.00

$30.00

$226.00

$239.00

$32.00

$207.00

$396.00

$37.00

$359.00

$420.00

$70.00

$350.00

$1,542.00

$85.00

$1,457.00

$86.00

$86.00

BR

$210.00

$18.00

$192.00

$405.00

$40.00

$365.00

$405.00

$36.00

$369.00

$386.00

$33.00

$353.00

$419.00

$54.00

$365.00

$394.00

$36.00

$358.00

$216.00

$32.00

$184.00

---------

---------

(Facility MRA)

$402.00

$35.00

$367.00

$383.00

$32.00

$351.00

$415.00

$52.00

$363.00

$391.00

$35.00

$356.00

$214.00

$31.00

$183.00

---------

---------

$364.00

$48.00

$316.00

---------

---------

---------

$220.00

$26.00

$194.00

$254.00

$29.00

$225.00

$236.00

$31.00

$205.00

$393.00

$36.00

$356.00

$416.00

$68.00

$348.00

$359.00

$420.00

$70.00

$350.00

$1,535.00

$1,542.00

$83.00

$85.00

$1,452.00

$1,457.00

$85.00

$86.00

$85.00

BR

$208.00

$18.00

$190.00

$402.00

$39.00

$363.00

$86.00

BR

$210.00

$18.00

$192.00

$405.00

$40.00

$365.00

$368.00

$49.00

$318.00

---------

---------

---------

$223.00

$27.00

$195.00

$256.00

$30.00

$226.00

$239.00

$32.00

$207.00

$396.00

$37.00

$405.00

$36.00

$369.00

$386.00

$33.00

$353.00

$419.00

$54.00

$365.00

$394.00

$36.00

$358.00

$216.00

$32.00

$184.00

---------

---------

$332.00

$390.00

$66.00

$323.00

$1,434.00

$80.00

$1,353.00

$83.00

$83.00

BR

$194.00

$17.00

$177.00

$375.00

$38.00

$337.00

$341.00

$47.00

$294.00

---------

---------

---------

$206.00

$25.00

$180.00

$237.00

$28.00

$209.00

$221.00

$30.00

$191.00

$367.00

$35.00

$375.00

$34.00

$341.00

$358.00

$31.00

$326.00

$388.00

$51.00

$338.00

$365.00

$34.00

$331.00

$200.00

$30.00

$170.00

---------

---------


Part C, 313



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


78710-26

78710-TC

78725

78725-26

78725-TC

78730

78730-26

78730-TC

78740

78740-26

78740-TC

78761

78761-26

78761-TC

78799

78799-26

78699-TC

78700

78700-26

78700-TC

78701

78701-26

78701-TC

78707

78707-26

78707-TC

78708

78708-26

78708-TC

78709

78709-26

78709-TC

78710

78799-TC

78800

78800-26

78800-TC

78801

78801-26

78801-TC

78802

78802-26

78802-TC

78803

78803-26

78803-TC

78804

78804-26

78804-TC

78805

$34.00

$220.00

$87.00

$19.00

$66.00

$73.00

$18.00

$55.00

$109.00

$29.00

$79.00

$157.00

$36.00

$119.00

BR

BR

BR

$137.00

$22.00

$113.00

$158.00

$24.00

$133.00

$217.00

$49.00

$166.00

$231.00

$61.00

$166.00

$241.00

$68.00

$166.00

$256.00

BR

$162.00

$34.00

$126.00

$199.00

$40.00

$158.00

$252.00

$44.00

$207.00

$303.00

$56.00

$245.00

---------

---------

---------

$166.00

$34.00

$188.00

$121.00

$21.00

$100.00

$84.00

$9.00

$76.00

$242.00

$31.00

$211.00

$232.00

$40.00

$192.00

---------

---------

---------

$191.00

$25.00

$166.00

$234.00

$26.00

$207.00

$259.00

$52.00

$206.00

$195.00

$66.00

$128.00

$404.00

$77.00

$327.00

$222.00

---------

$213.00

$38.00

$175.00

$290.00

$45.00

$245.00

$361.00

$47.00

$314.00

$378.00

$58.00

$319.00

$628.00

$58.00

$570.00

$203.00

$35.00

$202.00

$129.00

$21.00

$108.00

$90.00

$9.00

$81.00

$258.00

$32.00

$227.00

$248.00

$42.00

$206.00

---------

---------

---------

$204.00

$26.00

$178.00

$250.00

$27.00

$223.00

$276.00

$54.00

$221.00

$207.00

$68.00

$138.00

$431.00

$79.00

$352.00

$237.00

---------

$228.00

$40.00

$188.00

$310.00

$47.00

$263.00

$385.00

$48.00

$337.00

$403.00

$60.00

$343.00

$673.00

$60.00

$612.00

$216.00

$36.00

$204.00

$131.00

$22.00

$109.00

$91.00

$9.00

$82.00

$260.00

$32.00

$228.00

$250.00

$43.00

$208.00

---------

---------

---------

$206.00

$26.00

$180.00

$252.00

$28.00

$224.00

$279.00

$56.00

$223.00

$210.00

$70.00

$140.00

$435.00

$82.00

$354.00

$240.00

---------

$231.00

$42.00

$189.00

$314.00

$49.00

$265.00

$389.00

$50.00

$339.00

$407.00

$62.00

$345.00

$678.00

$62.00

$616.00

$219.00

$34.00

$188.00

$121.00

$21.00

$100.00

$84.00

$9.00

$76.00

$242.00

$31.00

$211.00

$232.00

$40.00

$192.00

---------

---------

---------

$191.00

$25.00

$166.00

$234.00

$26.00

$207.00

$259.00

$52.00

$206.00

$195.00

$66.00

$128.00

$404.00

$77.00

$327.00

$222.00

---------

$213.00

$38.00

$175.00

$290.00

$45.00

$245.00

$361.00

$47.00

$314.00

$378.00

$58.00

$319.00

$628.00

$58.00

$570.00

$203.00

$35.00

$202.00

$129.00

$21.00

$108.00

$90.00

$9.00

$81.00

$258.00

$32.00

$227.00

$248.00

$42.00

$206.00

---------

---------

---------

$204.00

$26.00

$178.00

$250.00

$27.00

$223.00

$276.00

$54.00

$221.00

$207.00

$68.00

$138.00

$431.00

$79.00

$352.00

$237.00

---------

$228.00

$40.00

$188.00

$310.00

$47.00

$263.00

$385.00

$48.00

$337.00

$403.00

$60.00

$343.00

$673.00

$60.00

$612.00

$216.00

(Facility MRA)

$36.00

$204.00

$131.00

$22.00

$109.00

$91.00

$9.00

$82.00

$260.00

$32.00

$228.00

$250.00

$43.00

$208.00

---------

---------

---------

$206.00

$26.00

$180.00

$252.00

$28.00

$224.00

$279.00

$56.00

$223.00

$210.00

$70.00

$140.00

$435.00

$82.00

$354.00

$240.00

---------

$231.00

$42.00

$189.00

$314.00

$49.00

$265.00

$389.00

$50.00

$339.00

$407.00

$62.00

$345.00

$678.00

$62.00

$616.00

$219.00


Part C, 314



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


78813-TC

78814

78814-26

78814-TC

78815

78815-26

78815-TC

78816

78816-26

78816-TC

78999

78999-26

78999-TC

79005

79005-26

79005-TC

78805-26

78805-TC

78806

78806-26

78806-TC

78807

78807-26

78807-TC

78808

78811

78811-26

78811-TC

78812

78812-26

78812-TC

78813

78813-26

79101

79101-26

79101-TC

79200

79200-26

79200-TC

79300

79300-26

79300-TC

79403

79403-26

79403-TC

79440

79440-26

79440-TC

79445

79445-26

---------

---------

BR

BR

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$38.00

$126.00

$286.00

$44.00

$241.00

$303.00

$57.00

$245.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$203.00

$102.00

$97.00

BR

$83.00

BR

---------

---------

---------

$204.00

$104.00

$97.00

---------

---------

$1,353.00

$1,475.00

$121.00

$1,353.00

$1,487.00

$134.00

$1,353.00

$1,489.00

$135.00

$1,353.00

---------

---------

---------

$151.00

$98.00

$53.00

$40.00

$163.00

$370.00

$47.00

$323.00

$378.00

$58.00

$320.00

$50.00

$1,440.00

$87.00

$1,353.00

$1,459.00

$105.00

$1,353.00

$1,463.00

$110.00

$158.00

$107.00

$51.00

$176.00

$114.00

$63.00

---------

$89.00

---------

$213.00

$124.00

$89.00

$160.00

$106.00

$54.00

BR

$129.00

$42.00

$175.00

$395.00

$48.00

$347.00

$403.00

$60.00

$343.00

$54.00

$1,542.00

$90.00

$1,452.00

$1,561.00

$108.00

$1,452.00

$1,566.00

$114.00

$1,452.00

$1,577.00

$125.00

$1,452.00

$1,590.00

$138.00

$1,452.00

$1,592.00

$139.00

$1,452.00

---------

---------

---------

$158.00

$101.00

$57.00

$165.00

$110.00

$55.00

$185.00

$117.00

$67.00

---------

$91.00

---------

$223.00

$128.00

$95.00

$167.00

$109.00

$58.00

BR

$133.00

$43.00

$176.00

$399.00

$50.00

$349.00

$407.00

$61.00

$346.00

$55.00

$1,549.00

$93.00

$1,457.00

$1,568.00

$111.00

$1,457.00

$1,573.00

$117.00

$1,457.00

$1,585.00

$129.00

$1,457.00

$1,599.00

$142.00

$1,457.00

$1,600.00

$143.00

$1,457.00

---------

---------

---------

$162.00

$104.00

$58.00

$168.00

$112.00

$55.00

$188.00

$120.00

$68.00

---------

$93.00

---------

$227.00

$131.00

$97.00

$170.00

$111.00

$58.00

BR

$137.00

(Facility MRA)

$165.00

$110.00

$55.00

$185.00

$117.00

$67.00

---------

$91.00

---------

$223.00

$128.00

$95.00

$167.00

$109.00

$58.00

BR

$133.00

$42.00

$175.00

$395.00

$48.00

$347.00

$403.00

$60.00

$343.00

$54.00

$43.00

$176.00

$399.00

$50.00

$349.00

$407.00

$61.00

$346.00

$55.00

$1,542.00

$1,549.00

$90.00

$93.00

$1,452.00

$1,457.00

$1,561.00

$1,568.00

$108.00

$111.00

$1,452.00

$1,457.00

$1,566.00

$1,573.00

$114.00

$117.00

$1,452.00

$1,457.00

$1,577.00

$1,585.00

$125.00

$129.00

$1,452.00

$1,457.00

$1,590.00

$1,599.00

$138.00

$142.00

$1,452.00

$1,457.00

$1,592.00

$1,600.00

$139.00

$143.00

$1,452.00

$1,457.00

---------

---------

---------

---------

---------

---------

$158.00

$101.00

$57.00

$162.00

$104.00

$58.00

$168.00

$112.00

$55.00

$188.00

$120.00

$68.00

---------

$93.00

---------

$227.00

$131.00

$97.00

$170.00

$111.00

$58.00

BR

$137.00

$1,353.00

$1,475.00

$121.00

$1,353.00

$1,487.00

$134.00

$1,353.00

$1,489.00

$135.00

$1,353.00

---------

---------

---------

$151.00

$98.00

$53.00

$40.00

$163.00

$370.00

$47.00

$323.00

$378.00

$58.00

$320.00

$50.00

$1,440.00

$87.00

$1,353.00

$1,459.00

$105.00

$1,353.00

$1,463.00

$110.00

$158.00

$107.00

$51.00

$176.00

$114.00

$63.00

---------

$89.00

---------

$213.00

$124.00

$89.00

$160.00

$106.00

$54.00

BR

$129.00


Part C, 315



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


G0278

G0279

G0279-26

G0279-TC

G0288

G0297

G0297-26

G0297-TC

G0365

G0365-26

G0365-TC

G0389

G0389-26

G0389-TC

G6001

G6001-26

79445-TC

79999

79999-26

79999-TC

G0130

G0130-26

G0130-TC

G0202

G0202-26

G0202-TC

G0204

G0204-26

G0204-TC

G0206

G0206-26

G0206-TC

G0252-26

G6007

G6008

G6009

G6010

G6011

G6012

G6013

G6014

G6015

G6001-TC

G6002

G6002-26

G6002-TC

G6003

G6004

G6005

G6006

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

BR

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$16.00

$60.00

$34.00

$27.00

$40.00

$271.00

$56.00

$215.00

$176.00

$14.00

$162.00

$125.00

$33.00

$92.00

$57.00

$33.00

BR

---------

---------

---------

$37.00

$13.00

$24.00

$144.00

$39.00

$105.00

$177.00

$49.00

$128.00

$139.00

$39.00

$100.00

$83.00

$24.00

$81.00

$22.00

$59.00

$199.00

$154.00

$154.00

$153.00

$320.00

$213.00

$211.00

$210.00

$342.00

$281.00

$281.00

$281.00

$367.00

$18.00

$63.00

$35.00

$29.00

$44.00

$289.00

$58.00

$231.00

$189.00

$15.00

$174.00

$133.00

$34.00

$99.00

$59.00

$34.00

BR

---------

---------

---------

$39.00

$13.00

$26.00

$153.00

$40.00

$113.00

$188.00

$51.00

$137.00

$147.00

$40.00

$107.00

$85.00

$25.00

$86.00

$23.00

$63.00

$214.00

$165.00

$165.00

$165.00

$343.00

$229.00

$226.00

$226.00

$367.00

$301.00

$302.00

$302.00

$395.00

$19.00

$64.00

$36.00

$29.00

$47.00

$291.00

$59.00

$232.00

$191.00

$16.00

$175.00

$135.00

$35.00

$100.00

$60.00

$35.00

BR

---------

---------

---------

$40.00

$13.00

$27.00

$155.00

$42.00

$114.00

$190.00

$52.00

$138.00

$149.00

$42.00

$108.00

$86.00

$26.00

$87.00

$24.00

$64.00

$215.00

$166.00

$166.00

$165.00

$345.00

$230.00

$227.00

$227.00

$368.00

$302.00

$303.00

$303.00

$397.00

$16.00

$60.00

$34.00

$27.00

$40.00

$271.00

$56.00

$215.00

$176.00

$14.00

$162.00

$125.00

$33.00

$92.00

$57.00

$33.00

BR

---------

---------

---------

$37.00

$13.00

$24.00

$144.00

$39.00

$105.00

$177.00

$49.00

$128.00

$139.00

$39.00

$100.00

$83.00

$24.00

$81.00

$22.00

$59.00

$199.00

$154.00

$154.00

$153.00

$320.00

$213.00

$211.00

$210.00

$342.00

$281.00

$281.00

$281.00

$367.00

$18.00

$63.00

$35.00

$29.00

$44.00

$289.00

$58.00

$231.00

$189.00

$15.00

$174.00

$133.00

$34.00

$99.00

$59.00

$34.00

BR

---------

---------

---------

$39.00

$13.00

$26.00

$153.00

$40.00

$113.00

$188.00

$51.00

$137.00

$147.00

$40.00

$107.00

$85.00

$25.00

$86.00

$23.00

$63.00

$214.00

$165.00

$165.00

$165.00

$343.00

$229.00

$226.00

$226.00

$367.00

$301.00

$302.00

$302.00

$395.00

(Facility MRA)

$19.00

$64.00

$36.00

$29.00

$47.00

$291.00

$59.00

$232.00

$191.00

$16.00

$175.00

$135.00

$35.00

$100.00

$60.00

$35.00

BR

---------

---------

---------

$40.00

$13.00

$27.00

$155.00

$42.00

$114.00

$190.00

$52.00

$138.00

$149.00

$42.00

$108.00

$86.00

$26.00

$87.00

$24.00

$64.00

$215.00

$166.00

$166.00

$165.00

$345.00

$230.00

$227.00

$227.00

$368.00

$302.00

$303.00

$303.00

$397.00


Part C, 316



Radiology

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


G6016

Q0092

---------

---------

$366.00

$27.00

$393.00

$29.00

$394.00

$29.00

$366.00

$27.00

$393.00

$29.00

(Facility MRA)

$394.00

$29.00


Part C, 317




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


80061-TC

80069

80069-26

80069-TC

80074

80074-26

80074-TC

80076

80076-26

80076-TC

80150

80150-26

80150-TC

80156

80156-26

80156-TC

80048

80048-26

80048-TC

80050

80050-26

80050-TC

80051

80051-26

80051-TC

80053

80053-26

80053-TC

80055

80055-26

80055-TC

80061

80061-26

80157

80157-26

80157-TC

80158

80158-26

80158-TC

80162

80162-26

80162-TC

80164

80164-26

80164-TC

80168

80168-26

80168-TC

80170

80170-26

$19.00

$26.00

$6.00

$20.00

$107.00

$43.00

$64.00

$18.00

$7.00

$11.00

$40.00

$13.00

$26.00

$35.00

$11.00

$23.00

$23.00

$4.00

$19.00

$45.00

$18.00

$26.00

$16.00

$6.00

$10.00

$29.00

$8.00

$21.00

$67.00

$21.00

$43.00

$31.00

$11.00

$22.00

$8.00

$14.00

$35.00

$12.00

$22.00

$13.00

$3.00

$9.00

$43.00

$14.00

$29.00

$43.00

$17.00

$25.00

$18.00

$6.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 318




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


80186-26

80186-TC

80188

80188-26

80188-TC

80190

80190-26

80190-TC

80192

80192-26

80192-TC

80194

80194-26

80194-TC

80197

80197-26

80170-TC

80173

80173-26

80173-TC

80176

80176-26

80176-TC

80178

80178-26

80178-TC

80184

80184-26

80184-TC

80185

80185-26

80185-TC

80186

80197-TC

80198

80198-26

80198-TC

80200

80200-26

80200-TC

80201

80201-26

80201-TC

80202

80202-26

80202-TC

80299

80299-26

80299-TC

80400

$11.00

$26.00

$35.00

$11.00

$23.00

$41.00

$13.00

$28.00

$44.00

$17.00

$26.00

$33.00

$10.00

$22.00

$34.00

$11.00

$11.00

$33.00

$11.00

$22.00

$35.00

$11.00

$23.00

$17.00

$6.00

$11.00

$34.00

$10.00

$23.00

$36.00

$10.00

$25.00

$38.00

$22.00

$20.00

$5.00

$15.00

$24.00

$7.00

$16.00

$33.00

$11.00

$21.00

$42.00

$14.00

$28.00

BR

BR

BR

$54.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 319




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


80414

80414-26

80414-TC

80415

80415-26

80415-TC

80416

80416-26

80416-TC

80417

80417-26

80417-TC

80418

80418-26

80418-TC

80420

80400-26

80400-TC

80402

80402-26

80402-TC

80406

80406-26

80406-TC

80408

80408-26

80408-TC

80410

80410-26

80410-TC

80412

80412-26

80412-TC

80420-26

80420-TC

80422

80422-26

80422-TC

80424

80424-26

80424-TC

80426

80426-26

80426-TC

80428

80428-26

80428-TC

80430

80430-26

80430-TC

$88.00

$26.00

$59.00

$93.00

$28.00

$64.00

$256.00

$88.00

$166.00

$256.00

$88.00

$166.00

$934.00

$266.00

$666.00

$107.00

$18.00

$36.00

$138.00

$42.00

$95.00

$138.00

$42.00

$95.00

$213.00

$77.00

$136.00

$166.00

$54.00

$110.00

$533.00

$176.00

$355.00

$33.00

$74.00

$62.00

$18.00

$43.00

$94.00

$26.00

$67.00

$232.00

$54.00

$176.00

$93.00

$19.00

$73.00

$99.00

$24.00

$74.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 320




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


80439-TC

80500

80500-26

80500-TC

80502

80502-26

80502-TC

81000

81000-26

81000-TC

81001

81001-26

81001-TC

81002

81002-26

81002-TC

80432

80432-26

80432-TC

80434

80434-26

80434-TC

80435

80435-26

80435-TC

80436

80436-26

80436-TC

80438

80438-26

80438-TC

80439

80439-26

81003

81003-26

81003-TC

81005

81005-26

81005-TC

81007

81007-26

81007-TC

81015

81015-26

81015-TC

81020

81020-26

81020-TC

81025

81025-26

$3.00

$4.00

$7.00

$3.00

$4.00

$5.00

$3.00

$3.00

$144.00

$34.00

$34.00

BR

$72.00

$72.00

BR

$7.00

$243.00

$56.00

$186.00

$161.00

$49.00

$110.00

$166.00

$49.00

$115.00

$119.00

$35.00

$85.00

$82.00

$24.00

$56.00

$176.00

$33.00

$4.00

$5.00

$3.00

$3.00

$8.00

$3.00

$5.00

$7.00

$4.00

$5.00

$2.00

$3.00

$3.00

$1.00

$3.00

$5.00

$2.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

$24.00

---------

---------

$79.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$25.00

---------

---------

$82.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$26.00

---------

---------

$84.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$22.00

---------

---------

$77.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$22.00

---------

---------

$79.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

$23.00

---------

---------

$81.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 321




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


82024-26

82024-TC

82030

82030-26

82030-TC

82040

82040-26

82040-TC

82042

82042-26

82042-TC

82043

82043-26

82043-TC

82044

82044-26

81025-TC

81050

81050-26

81050-TC

81099

81099-26

81099-TC

82009

82009-26

82009-TC

82010

82010-26

82010-TC

82013

82013-26

82013-TC

82024

82044-TC

82075

82075-26

82075-TC

82085

82085-26

82085-TC

82088

82088-26

82088-TC

82103

82103-26

82103-TC

82104

82104-26

82104-TC

82105

$7.00

$18.00

$43.00

$17.00

$25.00

$11.00

$3.00

$7.00

$12.00

$3.00

$8.00

$14.00

$4.00

$10.00

$12.00

$4.00

$4.00

$33.00

$11.00

$21.00

BR

BR

BR

$10.00

$3.00

$6.00

$22.00

$7.00

$15.00

$24.00

$7.00

$17.00

$26.00

$9.00

$32.00

$10.00

$21.00

$24.00

$7.00

$17.00

$91.00

$28.00

$62.00

$21.00

$7.00

$14.00

$22.00

$7.00

$15.00

$26.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 322




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


82131

82131-26

82131-TC

82135

82135-26

82135-TC

82136

82136-26

82136-TC

82139

82139-26

82139-TC

82140

82140-26

82140-TC

82143

82105-26

82105-TC

82106

82106-26

82106-TC

82108

82108-26

82108-TC

82120

82120-26

82120-TC

82127

82127-26

82127-TC

82128

82128-26

82128-TC

82143-26

82143-TC

82150

82150-26

82150-TC

82154

82154-26

82154-TC

82157

82157-26

82157-TC

82160

82160-26

82160-TC

82163

82163-26

82163-TC

$57.00

$13.00

$44.00

$41.00

$13.00

$28.00

$38.00

$14.00

$23.00

$38.00

$14.00

$23.00

$40.00

$12.00

$28.00

$28.00

$8.00

$18.00

$26.00

$8.00

$18.00

$45.00

$14.00

$32.00

$9.00

$3.00

$5.00

$33.00

$11.00

$22.00

$26.00

$6.00

$19.00

$8.00

$19.00

$16.00

$5.00

$11.00

$34.00

$13.00

$20.00

$57.00

$17.00

$40.00

$67.00

$21.00

$43.00

$42.00

$12.00

$31.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 323




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


82232-TC

82239

82239-26

82239-TC

82240

82240-26

82240-TC

82247

82247-26

82247-TC

82248

82248-26

82248-TC

82252

82252-26

82252-TC

82164

82164-26

82164-TC

82172

82172-26

82172-TC

82175

82175-26

82175-TC

82180

82180-26

82180-TC

82190

82190-26

82190-TC

82232

82232-26

82261

82261-26

82261-TC

82270

82270-26

82270-TC

82274

82274-26

82274-TC

82286

82286-26

82286-TC

82300

82300-26

82300-TC

82306

82306-26

$29.00

$23.00

$8.00

$15.00

$49.00

$15.00

$34.00

$10.00

$3.00

$7.00

$10.00

$3.00

$7.00

$11.00

$3.00

$7.00

$32.00

$10.00

$21.00

$33.00

$10.00

$22.00

$48.00

$15.00

$33.00

$25.00

$8.00

$17.00

$24.00

$8.00

$16.00

$43.00

$14.00

$38.00

$13.00

$24.00

$5.00

$2.00

$3.00

BR

BR

BR

$12.00

$3.00

$8.00

$48.00

$15.00

$33.00

$79.00

$25.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 324




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


82355-26

82355-TC

82360

82360-26

82360-TC

82365

82365-26

82365-TC

82370

82370-26

82370-TC

82373

82373-26

82373-TC

82374

82374-26

82306-TC

82308

82308-26

82308-TC

82310

82310-26

82310-TC

82330

82330-26

82330-TC

82331

82331-26

82331-TC

82340

82340-26

82340-TC

82355

82374-TC

82375

82375-26

82375-TC

82376

82376-26

82376-TC

82378

82378-26

82378-TC

82379

82379-26

82379-TC

82380

82380-26

82380-TC

82382

$10.00

$20.00

$31.00

$10.00

$20.00

$31.00

$8.00

$21.00

$22.00

$7.00

$15.00

$16.00

$5.00

$11.00

$10.00

$3.00

$52.00

$62.00

$18.00

$43.00

$11.00

$3.00

$7.00

$37.00

$11.00

$25.00

$14.00

$4.00

$10.00

$13.00

$4.00

$8.00

$31.00

$6.00

$26.00

$7.00

$18.00

$11.00

$3.00

$7.00

$31.00

$8.00

$21.00

$38.00

$13.00

$24.00

$21.00

$6.00

$15.00

$38.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 325




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


82415

82415-26

82415-TC

82435

82435-26

82435-TC

82436

82436-26

82436-TC

82438

82438-26

82438-TC

82441

82441-26

82441-TC

82465

82382-26

82382-TC

82383

82383-26

82383-TC

82384

82384-26

82384-TC

82387

82387-26

82387-TC

82390

82390-26

82390-TC

82397

82397-26

82397-TC

82465-26

82465-TC

82480

82480-26

82480-TC

82482

82482-26

82482-TC

82485

82485-26

82485-TC

82495

82495-26

82495-TC

82507

82507-26

82507-TC

$28.00

$8.00

$19.00

$8.00

$2.00

$6.00

$14.00

$4.00

$10.00

$13.00

$4.00

$8.00

$16.00

$5.00

$11.00

$8.00

$12.00

$25.00

$62.00

$18.00

$43.00

$62.00

$18.00

$43.00

$34.00

$10.00

$23.00

$24.00

$7.00

$17.00

$22.00

$7.00

$15.00

$2.00

$6.00

$23.00

$6.00

$17.00

$23.00

$7.00

$15.00

$37.00

$8.00

$28.00

$48.00

$16.00

$32.00

$55.00

$16.00

$39.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

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---------

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---------

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---------

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---------

---------

---------

---------

---------

---------

---------

---------


Part C, 326




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


82540-TC

82542

82542-26

82542-TC

82550

82550-26

82550-TC

82552

82552-26

82552-TC

82553

82553-26

82553-TC

82554

82554-26

82554-TC

82523

82523-26

82523-TC

82525

82525-26

82525-TC

82528

82528-26

82528-TC

82530

82530-26

82530-TC

82533

82533-26

82533-TC

82540

82540-26

82565

82565-26

82565-TC

82570

82570-26

82570-TC

82575

82575-26

82575-TC

82585

82585-26

82585-TC

82595

82595-26

82595-TC

82600

82600-26

$6.00

$42.00

$13.00

$28.00

$16.00

$4.00

$12.00

$33.00

$10.00

$22.00

$16.00

$5.00

$11.00

$19.00

$6.00

$13.00

$43.00

$17.00

$25.00

$34.00

$10.00

$23.00

$40.00

$13.00

$26.00

$38.00

$12.00

$25.00

$35.00

$10.00

$24.00

$10.00

$3.00

$13.00

$2.00

$11.00

$10.00

$2.00

$7.00

$25.00

$8.00

$17.00

$15.00

$3.00

$12.00

$31.00

$10.00

$21.00

$40.00

$12.00

---------

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---------

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---------

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---------

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---------

---------

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---------

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---------

---------

---------

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---------

---------

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---------

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---------

---------

---------

---------

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---------

---------

---------

---------

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---------

---------

---------

---------

---------

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---------

---------

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---------

---------

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---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 327




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


82633-26

82633-TC

82634

82634-26

82634-TC

82638

82638-26

82638-TC

82652

82652-26

82652-TC

82657

82657-26

82657-TC

82658

82658-26

82600-TC

82607

82607-26

82607-TC

82608

82608-26

82608-TC

82615

82615-26

82615-TC

82626

82626-26

82626-TC

82627

82627-26

82627-TC

82633

82658-TC

82664

82664-26

82664-TC

82668

82668-26

82668-TC

82670

82670-26

82670-TC

82671

82671-26

82671-TC

82672

82672-26

82672-TC

82677

$23.00

$56.00

$81.00

$23.00

$56.00

$23.00

$7.00

$16.00

$89.00

$25.00

$62.00

$42.00

$13.00

$28.00

$42.00

$13.00

$28.00

$38.00

$10.00

$27.00

$40.00

$13.00

$26.00

$17.00

$5.00

$12.00

$59.00

$19.00

$40.00

$37.00

$12.00

$24.00

$81.00

$28.00

$40.00

$13.00

$26.00

$45.00

$14.00

$32.00

$61.00

$18.00

$42.00

$61.00

$17.00

$43.00

$57.00

$16.00

$41.00

$52.00

---------

---------

---------

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---------

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---------

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---------

---------

---------

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---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 328




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


82715

82715-26

82715-TC

82725

82725-26

82725-TC

82726

82726-26

82726-TC

82728

82728-26

82728-TC

82735

82735-26

82735-TC

82746

82677-26

82677-TC

82679

82679-26

82679-TC

82693

82693-26

82693-TC

82696

82696-26

82696-TC

82705

82705-26

82705-TC

82710

82710-26

82710-TC

82746-26

82746-TC

82747

82747-26

82747-TC

82757

82757-26

82757-TC

82759

82759-26

82759-TC

82760

82760-26

82760-TC

82775

82775-26

82775-TC

$33.00

$11.00

$21.00

$28.00

$8.00

$19.00

$42.00

$13.00

$28.00

$24.00

$7.00

$17.00

$36.00

$12.00

$23.00

$39.00

$17.00

$35.00

$70.00

$20.00

$48.00

$23.00

$7.00

$16.00

$57.00

$19.00

$38.00

$14.00

$6.00

$9.00

$42.00

$13.00

$29.00

$13.00

$25.00

$29.00

$10.00

$19.00

$36.00

$11.00

$24.00

$38.00

$12.00

$25.00

$26.00

$8.00

$18.00

$47.00

$14.00

$33.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 329




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


82803-TC

82805

82805-26

82805-TC

82810

82810-26

82810-TC

82820

82820-26

82820-TC

82938

82938-26

82938-TC

82941

82941-26

82941-TC

82776

82776-26

82776-TC

82784

82784-26

82784-TC

82785

82785-26

82785-TC

82787

82787-26

82787-TC

82800

82800-26

82800-TC

82803

82803-26

82943

82943-26

82943-TC

82945

82945-26

82945-TC

82946

82946-26

82946-TC

82947

82947-26

82947-TC

82948

82948-26

82948-TC

82950

82950-26

$37.00

$36.00

$10.00

$24.00

$28.00

$8.00

$19.00

$16.00

$5.00

$11.00

$48.00

$16.00

$32.00

$47.00

$15.00

$32.00

$14.00

$3.00

$11.00

$15.00

$5.00

$11.00

$33.00

$11.00

$21.00

$54.00

$17.00

$37.00

$22.00

$6.00

$16.00

$53.00

$16.00

$38.00

$12.00

$25.00

$9.00

$3.00

$5.00

$29.00

$7.00

$21.00

$11.00

$3.00

$7.00

$5.00

$3.00

$3.00

$12.00

$4.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 330




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


82963-26

82963-TC

82965

82965-26

82965-TC

82977

82977-26

82977-TC

82978

82978-26

82978-TC

82979

82979-26

82979-TC

82985

82985-26

82950-TC

82951

82951-26

82951-TC

82952

82952-26

82952-TC

82955

82955-26

82955-TC

82960

82960-26

82960-TC

82962

82962-26

82962-TC

82963

82985-TC

83001

83001-26

83001-TC

83002

83002-26

83002-TC

83003

83003-26

83003-TC

83010

83010-26

83010-TC

83012

83012-26

83012-TC

83013

$17.00

$37.00

$16.00

$5.00

$11.00

$16.00

$4.00

$12.00

$25.00

$7.00

$18.00

$18.00

$5.00

$13.00

$41.00

$12.00

$7.00

$22.00

$7.00

$15.00

$11.00

$3.00

$7.00

$25.00

$7.00

$18.00

$14.00

$4.00

$10.00

$5.00

$1.00

$4.00

$54.00

$29.00

$40.00

$12.00

$28.00

$42.00

$13.00

$29.00

$36.00

$10.00

$25.00

$26.00

$8.00

$18.00

$36.00

$14.00

$21.00

$133.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 331




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


83026

83026-26

83026-TC

83030

83030-26

83030-TC

83033

83033-26

83033-TC

83036

83036-26

83036-TC

83045

83045-26

83045-TC

83050

83013-26

83013-TC

83014

83014-26

83014-TC

83015

83015-26

83015-TC

83018

83018-26

83018-TC

83020

83020-26

83020-TC

83021

83021-26

83021-TC

83050-26

83050-TC

83051

83051-26

83051-TC

83060

83060-26

83060-TC

83065

83065-26

83065-TC

83068

83068-26

83068-TC

83069

83069-26

83069-TC

$8.00

$5.00

$3.00

$18.00

$6.00

$12.00

$15.00

$4.00

$11.00

$15.00

$5.00

$10.00

$13.00

$4.00

$8.00

$16.00

$38.00

$94.00

$19.00

$6.00

$13.00

$51.00

$15.00

$36.00

$56.00

$16.00

$40.00

$24.00

$6.00

$18.00

$39.00

$13.00

$25.00

$5.00

$11.00

$16.00

$5.00

$11.00

$22.00

$6.00

$16.00

$18.00

$6.00

$12.00

$20.00

$5.00

$15.00

$11.00

$3.00

$7.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 332




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


83491-TC

83497

83497-26

83497-TC

83498

83498-26

83498-TC

83499

83499-26

83499-TC

83500

83500-26

83500-TC

83505

83505-26

83505-TC

83070

83070-26

83070-TC

83080

83080-26

83080-TC

83088

83088-26

83088-TC

83090

83090-26

83090-TC

83150

83150-26

83150-TC

83491

83491-26

83516

83516-26

83516-TC

83518

83518-26

83518-TC

83519

83519-26

83519-TC

83520

83520-26

83520-TC

83525

83525-26

83525-TC

83527

83527-26

$25.00

$35.00

$11.00

$23.00

$62.00

$20.00

$41.00

$51.00

$15.00

$36.00

$69.00

$21.00

$45.00

$77.00

$21.00

$54.00

$13.00

$4.00

$8.00

$38.00

$11.00

$26.00

$59.00

$18.00

$41.00

$38.00

$13.00

$25.00

$49.00

$16.00

$33.00

$37.00

$11.00

$26.00

$8.00

$18.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$20.00

$6.00

$14.00

$31.00

$8.00

$21.00

$35.00

$11.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 333




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


83586-26

83586-TC

83593

83593-26

83593-TC

83605

83605-26

83605-TC

83615

83615-26

83615-TC

83625

83625-26

83625-TC

83632

83632-26

83527-TC

83528

83528-26

83528-TC

83540

83540-26

83540-TC

83550

83550-26

83550-TC

83570

83570-26

83570-TC

83582

83582-26

83582-TC

83586

83632-TC

83655

83655-26

83655-TC

83670

83670-26

83670-TC

83690

83690-26

83690-TC

83718

83718-26

83718-TC

83719

83719-26

83719-TC

83721

$13.00

$24.00

$59.00

$18.00

$41.00

$19.00

$6.00

$13.00

$16.00

$5.00

$11.00

$23.00

$6.00

$17.00

$42.00

$14.00

$23.00

$43.00

$14.00

$29.00

$16.00

$3.00

$13.00

$20.00

$5.00

$15.00

$23.00

$7.00

$16.00

$34.00

$8.00

$24.00

$38.00

$28.00

$31.00

$8.00

$21.00

$18.00

$5.00

$13.00

$18.00

$6.00

$12.00

$16.00

$5.00

$11.00

$42.00

$14.00

$28.00

$16.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 334




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


83825

83825-26

83825-TC

83835

83835-26

83835-TC

83857

83857-26

83857-TC

83864

83864-26

83864-TC

83872

83872-26

83872-TC

83873

83721-26

83721-TC

83727

83727-26

83727-TC

83735

83735-26

83735-TC

83775

83775-26

83775-TC

83785

83785-26

83785-TC

83789

83789-26

83789-TC

83873-26

83873-TC

83874

83874-26

83874-TC

83880

83880-26

83880-TC

83883

83883-26

83883-TC

83885

83885-26

83885-TC

83915

83915-26

83915-TC

$34.00

$11.00

$22.00

$41.00

$12.00

$29.00

$26.00

$8.00

$18.00

$32.00

$8.00

$22.00

$13.00

$4.00

$8.00

$54.00

$5.00

$11.00

$43.00

$14.00

$29.00

$15.00

$5.00

$10.00

$17.00

$5.00

$12.00

$58.00

$17.00

$41.00

$39.00

$13.00

$25.00

$18.00

$36.00

$25.00

$8.00

$17.00

BR

BR

BR

$11.00

$3.00

$7.00

$45.00

$14.00

$32.00

$31.00

$10.00

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 335




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


83935-TC

83937

83937-26

83937-TC

83945

83945-26

83945-TC

83950

83950-26

83950-TC

83970

83970-26

83970-TC

83986

83986-26

83986-TC

83916

83916-26

83916-TC

83918

83918-26

83918-TC

83919

83919-26

83919-TC

83921

83921-26

83921-TC

83930

83930-26

83930-TC

83935

83935-26

83992

83992-26

83992-TC

84030

84030-26

84030-TC

84035

84035-26

84035-TC

84060

84060-26

84060-TC

84061

84061-26

84061-TC

84066

84066-26

$12.00

$29.00

$10.00

$19.00

$32.00

$11.00

$20.00

BR

BR

BR

$94.00

$31.00

$62.00

$8.00

$3.00

$5.00

$54.00

$18.00

$36.00

$41.00

$12.00

$29.00

$42.00

$12.00

$29.00

$37.00

$12.00

$25.00

$11.00

$3.00

$7.00

$17.00

$5.00

$40.00

$12.00

$28.00

$11.00

$3.00

$7.00

$12.00

$3.00

$8.00

$20.00

$6.00

$14.00

$14.00

$4.00

$10.00

$18.00

$6.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 336




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


84087-26

84087-TC

84100

84100-26

84100-TC

84105

84105-26

84105-TC

84106

84106-26

84106-TC

84110

84110-26

84110-TC

84119

84119-26

84066-TC

84075

84075-26

84075-TC

84078

84078-26

84078-TC

84080

84080-26

84080-TC

84081

84081-26

84081-TC

84085

84085-26

84085-TC

84087

84119-TC

84120

84120-26

84120-TC

84126

84126-26

84126-TC

84132

84132-26

84132-TC

84133

84133-26

84133-TC

84134

84134-26

84134-TC

84135

$7.00

$18.00

$11.00

$3.00

$7.00

$11.00

$3.00

$7.00

$10.00

$2.00

$7.00

$21.00

$6.00

$15.00

$21.00

$6.00

$12.00

$12.00

$3.00

$8.00

$19.00

$5.00

$14.00

$36.00

$11.00

$24.00

$45.00

$15.00

$31.00

$15.00

$5.00

$10.00

$25.00

$15.00

$38.00

$11.00

$26.00

$71.00

$20.00

$49.00

$11.00

$3.00

$7.00

$11.00

$3.00

$7.00

$24.00

$7.00

$17.00

$57.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 337




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


84150

84150-26

84150-TC

84152

84152-26

84152-TC

84153

84153-26

84153-TC

84154

84154-26

84154-TC

84155

84155-26

84155-TC

84160

84135-26

84135-TC

84138

84138-26

84138-TC

84140

84140-26

84140-TC

84143

84143-26

84143-TC

84144

84144-26

84144-TC

84146

84146-26

84146-TC

84160-26

84160-TC

84165

84165-26

84165-TC

84166

84166-26

84166-TC

84181

84181-26

84181-TC

84182

84182-26

84182-TC

84202

84202-26

84202-TC

$69.00

$20.00

$47.00

$42.00

$14.00

$27.00

$33.00

$11.00

$21.00

$33.00

$11.00

$21.00

$12.00

$4.00

$7.00

$5.00

$19.00

$38.00

$56.00

$18.00

$38.00

$41.00

$8.00

$33.00

$62.00

$20.00

$41.00

$38.00

$7.00

$31.00

$53.00

$17.00

$36.00

$2.00

$2.00

$24.00

$8.00

$16.00

---------

---------

---------

$29.00

$10.00

$19.00

$33.00

$11.00

$21.00

$39.00

$13.00

$25.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

BR

$20.00

BR

---------

$20.00

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

BR

$21.00

BR

---------

$21.00

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

BR

$21.00

BR

---------

$21.00

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

BR

$20.00

BR

---------

$20.00

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

BR

$21.00

BR

---------

$21.00

---------

---------

$21.00

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

BR

$21.00

BR

---------

$21.00

---------

---------

$21.00

---------

---------

---------

---------


Part C, 338




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


84228-TC

84233

84233-26

84233-TC

84234

84234-26

84234-TC

84235

84235-26

84235-TC

84238

84238-26

84238-TC

84244

84244-26

84244-TC

84203

84203-26

84203-TC

84206

84206-26

84206-TC

84207

84207-26

84207-TC

84210

84210-26

84210-TC

84220

84220-26

84220-TC

84228

84228-26

84252

84252-26

84252-TC

84255

84255-26

84255-TC

84260

84260-26

84260-TC

84270

84270-26

84270-TC

84275

84275-26

84275-TC

84285

84285-26

$21.00

$116.00

$35.00

$81.00

$116.00

$35.00

$81.00

$114.00

$34.00

$80.00

$97.00

$32.00

$65.00

$47.00

$15.00

$32.00

$16.00

$5.00

$11.00

$32.00

$10.00

$21.00

$54.00

$16.00

$38.00

$24.00

$10.00

$15.00

$25.00

$8.00

$17.00

$32.00

$10.00

$47.00

$14.00

$33.00

$58.00

$17.00

$41.00

$54.00

$16.00

$38.00

$36.00

$11.00

$24.00

$37.00

$11.00

$25.00

$59.00

$17.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 339




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


84311-26

84311-TC

84315

84315-26

84315-TC

84375

84375-26

84375-TC

84376

84376-26

84376-TC

84377

84377-26

84377-TC

84378

84378-26

84285-TC

84295

84295-26

84295-TC

84300

84300-26

84300-TC

84302

84302-26

84302-TC

84305

84305-26

84305-TC

84307

84307-26

84307-TC

84311

84378-TC

84379

84379-26

84379-TC

84392

84392-26

84392-TC

84402

84402-26

84402-TC

84403

84403-26

84403-TC

84425

84425-26

84425-TC

84430

$3.00

$7.00

$5.00

$2.00

$3.00

$37.00

$11.00

$25.00

$10.00

$3.00

$7.00

$10.00

$3.00

$7.00

$25.00

$8.00

$42.00

$10.00

$3.00

$6.00

$10.00

$3.00

$6.00

BR

BR

BR

$34.00

$11.00

$22.00

$26.00

$8.00

$18.00

$11.00

$17.00

$25.00

$8.00

$17.00

$8.00

$2.00

$6.00

$72.00

$21.00

$49.00

$67.00

$19.00

$45.00

$54.00

$17.00

$37.00

$31.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 340




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


84443

84443-26

84443-TC

84445

84445-26

84445-TC

84446

84446-26

84446-TC

84449

84449-26

84449-TC

84450

84450-26

84450-TC

84460

84430-26

84430-TC

84432

84432-26

84432-TC

84436

84436-26

84436-TC

84437

84437-26

84437-TC

84439

84439-26

84439-TC

84442

84442-26

84442-TC

84460-26

84460-TC

84466

84466-26

84466-TC

84478

84478-26

84478-TC

84479

84479-26

84479-TC

84480

84480-26

84480-TC

84481

84481-26

84481-TC

$32.00

$7.00

$23.00

$98.00

$29.00

$69.00

$35.00

$11.00

$23.00

$38.00

$13.00

$24.00

$11.00

$3.00

$7.00

$13.00

$10.00

$20.00

$28.00

$8.00

$19.00

$14.00

$3.00

$11.00

$13.00

$4.00

$8.00

$16.00

$4.00

$12.00

$25.00

$6.00

$19.00

$4.00

$8.00

$22.00

$7.00

$15.00

$12.00

$3.00

$8.00

$15.00

$5.00

$10.00

$20.00

$6.00

$14.00

$33.00

$10.00

$22.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 341




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


84510-TC

84512

84512-26

84512-TC

84520

84520-26

84520-TC

84525

84525-26

84525-TC

84540

84540-26

84540-TC

84545

84545-26

84545-TC

84482

84482-26

84482-TC

84484

84484-26

84484-TC

84485

84485-26

84485-TC

84488

84488-26

84488-TC

84490

84490-26

84490-TC

84510

84510-26

84550

84550-26

84550-TC

84560

84560-26

84560-TC

84577

84577-26

84577-TC

84578

84578-26

84578-TC

84580

84580-26

84580-TC

84583

84583-26

$18.00

$17.00

$5.00

$12.00

$12.00

$3.00

$8.00

$7.00

$2.00

$5.00

$13.00

$4.00

$8.00

$18.00

$5.00

$13.00

$45.00

$15.00

$31.00

$21.00

$6.00

$15.00

$15.00

$4.00

$11.00

$15.00

$4.00

$11.00

$15.00

$4.00

$11.00

$26.00

$8.00

$12.00

$4.00

$7.00

$12.00

$3.00

$8.00

$34.00

$11.00

$22.00

$7.00

$2.00

$5.00

$17.00

$5.00

$12.00

$11.00

$3.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 342




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


84597-26

84597-TC

84600

84600-26

84600-TC

84620

84620-26

84620-TC

84630

84630-26

84630-TC

84681

84681-26

84681-TC

84702

84702-26

84583-TC

84585

84585-26

84585-TC

84586

84586-26

84586-TC

84588

84588-26

84588-TC

84590

84590-26

84590-TC

84591

84591-26

84591-TC

84597

84702-TC

84703

84703-26

84703-TC

84830

84830-26

84830-TC

84999

84999-26

84999-TC

85002

85002-26

85002-TC

85004

85004-26

85004-TC

85007

$11.00

$25.00

$43.00

$13.00

$31.00

$29.00

$8.00

$20.00

$26.00

$8.00

$18.00

$52.00

$17.00

$35.00

$38.00

$11.00

$7.00

$36.00

$11.00

$24.00

$42.00

$14.00

$27.00

$73.00

$23.00

$47.00

$33.00

$11.00

$21.00

$26.00

$9.00

$18.00

$37.00

$26.00

$22.00

$6.00

$15.00

$17.00

$5.00

$12.00

BR

BR

BR

$10.00

$3.00

$6.00

BR

BR

BR

$6.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 343




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


85025

85025-26

85025-TC

85027

85027-26

85027-TC

85032

85032-26

85032-TC

85041

85041-26

85041-TC

85044

85044-26

85044-TC

85045

85007-26

85007-TC

85008

85008-26

85008-TC

85009

85009-26

85009-TC

85013

85013-26

85013-TC

85014

85014-26

85014-TC

85018

85018-26

85018-TC

85045-26

85045-TC

85046

85046-26

85046-TC

85048

85048-26

85048-TC

85049

85049-26

85049-TC

85060

85060-26

85060-TC

85097

85097-26

85097-TC

$20.00

$6.00

$14.00

$15.00

$5.00

$10.00

BR

BR

BR

$7.00

$3.00

$4.00

$10.00

$3.00

$6.00

$6.00

$1.00

$2.00

$4.00

$1.00

$3.00

$5.00

$2.00

$3.00

$3.00

$4.00

$5.00

$2.00

$3.00

$8.00

$3.00

$5.00

$3.00

$2.00

$4.00

$13.00

$4.00

$9.00

$7.00

$3.00

$4.00

BR

BR

BR

$25.00

$7.00

$18.00

$59.00

$59.00

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$28.00

---------

---------

$98.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$29.00

---------

---------

$103.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$29.00

---------

---------

$105.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$28.00

---------

---------

$56.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$29.00

---------

---------

$58.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$29.00

---------

---------

$59.00

---------

---------


Part C, 344




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


85230-TC

85240

85240-26

85240-TC

85244

85244-26

85244-TC

85245

85245-26

85245-TC

85246

85246-26

85246-TC

85247

85247-26

85247-TC

85130

85130-26

85130-TC

85170

85170-26

85170-TC

85175

85175-26

85175-TC

85210

85210-26

85210-TC

85220

85220-26

85220-TC

85230

85230-26

85250

85250-26

85250-TC

85260

85260-26

85260-TC

85270

85270-26

85270-TC

85280

85280-26

85280-TC

85290

85290-26

85290-TC

85291

85291-26

$33.00

$48.00

$15.00

$33.00

$49.00

$15.00

$34.00

$54.00

$18.00

$36.00

$54.00

$18.00

$36.00

$54.00

$18.00

$36.00

$19.00

$6.00

$13.00

$7.00

$2.00

$5.00

$10.00

$3.00

$6.00

$31.00

$8.00

$21.00

$47.00

$15.00

$32.00

$47.00

$14.00

$49.00

$14.00

$35.00

$49.00

$14.00

$35.00

$49.00

$14.00

$35.00

$49.00

$14.00

$35.00

$44.00

$13.00

$32.00

$20.00

$6.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 345




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


85303-26

85303-TC

85305

85305-26

85305-TC

85306

85306-26

85306-TC

85307

85307-26

85307-TC

85335

85335-26

85335-TC

85337

85337-26

85291-TC

85292

85292-26

85292-TC

85293

85293-26

85293-TC

85300

85300-26

85300-TC

85301

85301-26

85301-TC

85302

85302-26

85302-TC

85303

85337-TC

85345

85345-26

85345-TC

85347

85347-26

85347-TC

85348

85348-26

85348-TC

85360

85360-26

85360-TC

85362

85362-26

85362-TC

85366

$8.00

$18.00

$21.00

$7.00

$14.00

$29.00

$10.00

$19.00

$35.00

$12.00

$23.00

$21.00

$7.00

$14.00

$19.00

$6.00

$14.00

$51.00

$17.00

$34.00

$51.00

$17.00

$34.00

$35.00

$12.00

$23.00

$29.00

$10.00

$19.00

$33.00

$11.00

$21.00

$26.00

$13.00

$10.00

$2.00

$7.00

$8.00

$2.00

$6.00

$10.00

$3.00

$6.00

$16.00

$4.00

$12.00

$18.00

$7.00

$11.00

$13.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 346




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


85385

85385-26

85385-TC

85390

85390-26

85390-TC

85396

85400

85400-26

85400-TC

85410

85410-26

85410-TC

85415

85415-26

85415-TC

85366-26

85366-TC

85370

85370-26

85370-TC

85378

85378-26

85378-TC

85379

85379-26

85379-TC

85380

85380-26

85380-TC

85384

85384-26

85384-TC

85420

85420-26

85420-TC

85421

85421-26

85421-TC

85441

85441-26

85441-TC

85445

85445-26

85445-TC

85460

85460-26

85460-TC

85461

85461-26

$16.00

$5.00

$11.00

$10.00

$2.00

$7.00

---------

$12.00

$3.00

$8.00

$12.00

$3.00

$8.00

$28.00

$10.00

$18.00

$3.00

$10.00

$20.00

$5.00

$15.00

$13.00

$4.00

$8.00

$18.00

$6.00

$12.00

BR

BR

BR

$11.00

$3.00

$7.00

$16.00

$3.00

$13.00

$39.00

$12.00

$26.00

$7.00

$2.00

$5.00

$16.00

$5.00

$11.00

$15.00

$4.00

$11.00

$12.00

$3.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

$23.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

$24.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

$25.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

$23.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

$24.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

$25.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 347




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


85540-26

85540-TC

85547

85547-26

85547-TC

85549

85549-26

85549-TC

85555

85555-26

85555-TC

85557

85557-26

85557-TC

85576

85576-26

85461-TC

85475

85475-26

85475-TC

85520

85520-26

85520-TC

85525

85525-26

85525-TC

85530

85530-26

85530-TC

85536

85536-26

85536-TC

85540

85576-TC

85597

85597-26

85597-TC

85610

85610-26

85610-TC

85611

85611-26

85611-TC

85612

85612-26

85612-TC

85613

85613-26

85613-TC

85635

$7.00

$17.00

$23.00

$6.00

$17.00

$45.00

$15.00

$31.00

$17.00

$5.00

$12.00

$34.00

$10.00

$23.00

$21.00

$5.00

$8.00

$15.00

$4.00

$11.00

$22.00

$6.00

$16.00

$20.00

$6.00

$14.00

$39.00

$12.00

$26.00

$14.00

$4.00

$10.00

$24.00

$16.00

$32.00

$10.00

$21.00

$6.00

$3.00

$4.00

$6.00

$2.00

$4.00

$22.00

$6.00

$16.00

$15.00

$4.00

$11.00

$26.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 348




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


85705

85705-26

85705-TC

85730

85730-26

85730-TC

85732

85732-26

85732-TC

85810

85810-26

85810-TC

85999

85999-26

85999-TC

86000

85635-26

85635-TC

85651

85651-26

85651-TC

85652

85652-26

85652-TC

85660

85660-26

85660-TC

85670

85670-26

85670-TC

85675

85675-26

85675-TC

86000-26

86000-TC

86001

86001-26

86001-TC

86003

86003-26

86003-TC

86005

86005-26

86005-TC

86021

86021-26

86021-TC

86022

86022-26

86022-TC

$13.00

$4.00

$8.00

$11.00

$3.00

$7.00

$17.00

$5.00

$12.00

$19.00

$4.00

$15.00

BR

BR

BR

$16.00

$8.00

$18.00

$8.00

$2.00

$6.00

$8.00

$2.00

$6.00

$10.00

$3.00

$6.00

$13.00

$3.00

$10.00

$13.00

$4.00

$8.00

$5.00

$11.00

$12.00

$4.00

$8.00

$6.00

$2.00

$3.00

$11.00

$4.00

$6.00

$41.00

$12.00

$29.00

$57.00

$18.00

$39.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 349




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86077-TC

86078

86078-26

86078-TC

86079

86079-26

86079-TC

86140

86140-26

86140-TC

86141

86141-26

86141-TC

86146

86146-26

86146-TC

86023

86023-26

86023-TC

86038

86038-26

86038-TC

86039

86039-26

86039-TC

86060

86060-26

86060-TC

86063

86063-26

86063-TC

86077

86077-26

86147

86147-26

86147-TC

86148

86148-26

86148-TC

86153-26

86155

86155-26

86155-TC

86156

86156-26

86156-TC

86157

86157-26

86157-TC

86160

$64.00

$91.00

$26.00

$64.00

$79.00

$25.00

$52.00

$14.00

$4.00

$10.00

BR

BR

BR

$58.00

$19.00

$39.00

$28.00

$10.00

$18.00

$22.00

$7.00

$15.00

$19.00

$6.00

$13.00

$13.00

$3.00

$10.00

$21.00

$6.00

$15.00

$91.00

$26.00

$53.00

$16.00

$36.00

$59.00

$21.00

$38.00

---------

$26.00

$8.00

$18.00

$11.00

$3.00

$7.00

$13.00

$4.00

$8.00

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

$62.00

---------

---------

$62.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$63.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$38.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$65.00

---------

---------

$64.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$65.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$39.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$66.00

---------

---------

$66.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$67.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$40.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$58.00

---------

---------

$57.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$58.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$38.00

---------

---------

$60.00

---------

---------

$59.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$60.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$39.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

$62.00

---------

---------

$61.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$62.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$40.00

---------


Part C, 350




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86225

86225-26

86225-TC

86226

86226-26

86226-TC

86235

86235-26

86235-TC

86243

86243-26

86243-TC

86255

86255-26

86255-TC

86256

86160-26

86160-TC

86161

86161-26

86161-TC

86162

86162-26

86162-TC

86171

86171-26

86171-TC

86185

86185-26

86185-TC

86215

86215-26

86215-TC

86256-26

86256-TC

86277

86277-26

86277-TC

86280

86280-26

86280-TC

86294

86294-26

86294-TC

86300

86300-26

86300-TC

86301

86301-26

86301-TC

$36.00

$11.00

$24.00

$24.00

$8.00

$16.00

$33.00

$10.00

$22.00

$50.00

$15.00

$35.00

$25.00

$8.00

$17.00

$25.00

$5.00

$16.00

$21.00

$5.00

$16.00

$54.00

$18.00

$36.00

$25.00

$7.00

$18.00

$19.00

$6.00

$13.00

$36.00

$12.00

$23.00

$8.00

$17.00

$41.00

$14.00

$26.00

$15.00

$3.00

$12.00

BR

BR

BR

$47.00

$15.00

$32.00

$47.00

$15.00

$32.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------


Part C, 351




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86317-TC

86318

86318-26

86318-TC

86320

86320-26

86320-TC

86325

86325-26

86325-TC

86327

86327-26

86327-TC

86329

86329-26

86329-TC

86304

86304-26

86304-TC

86308

86308-26

86308-TC

86309

86309-26

86309-TC

86310

86310-26

86310-TC

86316

86316-26

86316-TC

86317

86317-26

86331

86331-26

86331-TC

86332

86332-26

86332-TC

86334

86334-26

86334-TC

86335

86335-26

86335-TC

86336

86336-26

86336-TC

86337

86337-26

$20.00

$23.00

$10.00

$14.00

$49.00

$19.00

$29.00

$49.00

$16.00

$33.00

$62.00

$19.00

$42.00

$37.00

$12.00

$24.00

$47.00

$15.00

$32.00

$8.00

$3.00

$5.00

$12.00

$3.00

$8.00

$19.00

$6.00

$13.00

$37.00

$11.00

$25.00

$31.00

$10.00

$22.00

$6.00

$15.00

$54.00

$18.00

$36.00

$65.00

$18.00

$45.00

---------

---------

---------

BR

BR

BR

$54.00

$18.00

---------

---------

---------

---------

---------

$20.00

---------

---------

$20.00

---------

---------

$23.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

BR

$20.00

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

$21.00

---------

---------

$24.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

BR

$21.00

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

$21.00

---------

---------

$24.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

BR

$21.00

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

$20.00

---------

---------

$23.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

BR

$20.00

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

$21.00

---------

---------

$24.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

BR

$21.00

BR

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

$21.00

---------

---------

$21.00

---------

---------

$24.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

BR

$21.00

BR

---------

---------

---------

---------

---------


Part C, 352




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86359-26

86359-TC

86360

86360-26

86360-TC

86361

86361-26

86361-TC

86376

86376-26

86376-TC

86378

86378-26

86378-TC

86382

86382-26

86337-TC

86340

86340-26

86340-TC

86341

86341-26

86341-TC

86343

86343-26

86343-TC

86344

86344-26

86344-TC

86353

86353-26

86353-TC

86359

86382-TC

86384

86384-26

86384-TC

86403

86403-26

86403-TC

86406

86406-26

86406-TC

86430

86430-26

86430-TC

86431

86431-26

86431-TC

86485

$19.00

$41.00

$99.00

$33.00

$67.00

$66.00

$21.00

$43.00

$35.00

$11.00

$23.00

$45.00

$15.00

$31.00

$45.00

$14.00

$36.00

$39.00

$13.00

$25.00

$38.00

$13.00

$24.00

$33.00

$11.00

$21.00

$21.00

$7.00

$14.00

$102.00

$31.00

$72.00

$61.00

$32.00

$24.00

$8.00

$16.00

$18.00

$3.00

$14.00

$21.00

$5.00

$16.00

$13.00

$4.00

$8.00

$17.00

$6.00

$11.00

$13.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 353




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86592-TC

86593

86593-26

86593-TC

86602

86602-26

86602-TC

86603

86603-26

86603-TC

86606

86606-26

86606-TC

86609

86609-26

86609-TC

86485-26

86485-TC

86486

86490

86490-26

86490-TC

86510

86510-26

86510-TC

86580

86580-26

86580-TC

86590

86590-26

86590-TC

86592

86592-26

86611

86611-26

86611-TC

86612

86612-26

86612-TC

86615

86615-26

86615-TC

86617

86617-26

86617-TC

86618

86618-26

86618-TC

86619

86619-26

$6.00

$11.00

$3.00

$7.00

$17.00

$5.00

$12.00

$20.00

$6.00

$14.00

$24.00

$8.00

$16.00

$20.00

$6.00

$14.00

$4.00

$8.00

---------

$17.00

$5.00

$12.00

$13.00

$4.00

$8.00

$13.00

$4.00

$8.00

$18.00

$6.00

$12.00

$8.00

$2.00

$23.00

$8.00

$15.00

$21.00

$6.00

$15.00

$21.00

$6.00

$15.00

$29.00

$10.00

$19.00

$26.00

$8.00

$18.00

$21.00

$6.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$8.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

$5.00

$75.00

---------

---------

$7.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$9.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

$6.00

$80.00

---------

---------

$7.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$6.00

$81.00

---------

---------

$7.00

---------

---------

$10.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$8.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

$5.00

$75.00

---------

---------

$7.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$6.00

$80.00

---------

---------

$7.00

---------

---------

$9.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$6.00

$81.00

---------

---------

$7.00

---------

---------

$10.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 354




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86635-26

86635-TC

86638

86638-26

86638-TC

86641

86641-26

86641-TC

86644

86644-26

86644-TC

86645

86645-26

86645-TC

86648

86648-26

86619-TC

86622

86622-26

86622-TC

86625

86625-26

86625-TC

86628

86628-26

86628-TC

86631

86631-26

86631-TC

86632

86632-26

86632-TC

86635

86648-TC

86651

86651-26

86651-TC

86652

86652-26

86652-TC

86653

86653-26

86653-TC

86654

86654-26

86654-TC

86658

86658-26

86658-TC

86663

$5.00

$13.00

$20.00

$6.00

$14.00

$21.00

$7.00

$14.00

$22.00

$7.00

$15.00

$28.00

$10.00

$18.00

$24.00

$8.00

$15.00

$16.00

$5.00

$11.00

$21.00

$6.00

$15.00

$20.00

$6.00

$14.00

$20.00

$6.00

$14.00

$20.00

$6.00

$14.00

$18.00

$16.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 355




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86674

86674-26

86674-TC

86677

86677-26

86677-TC

86682

86682-26

86682-TC

86684

86684-26

86684-TC

86687

86687-26

86687-TC

86688

86663-26

86663-TC

86664

86664-26

86664-TC

86665

86665-26

86665-TC

86666

86666-26

86666-TC

86668

86668-26

86668-TC

86671

86671-26

86671-TC

86688-26

86688-TC

86689

86689-26

86689-TC

86692

86692-26

86692-TC

86694

86694-26

86694-TC

86695

86695-26

86695-TC

86696

86696-26

86696-TC

$23.00

$7.00

$16.00

$24.00

$8.00

$16.00

$21.00

$7.00

$14.00

$24.00

$8.00

$16.00

$22.00

$7.00

$16.00

$20.00

$7.00

$14.00

$53.00

$17.00

$36.00

$29.00

$10.00

$19.00

$23.00

$8.00

$15.00

$17.00

$5.00

$12.00

$20.00

$6.00

$14.00

$7.00

$14.00

$25.00

$8.00

$17.00

$22.00

$7.00

$15.00

$22.00

$7.00

$15.00

$21.00

$7.00

$14.00

$44.00

$14.00

$30.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 356




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86705-TC

86706

86706-26

86706-TC

86707

86707-26

86707-TC

86708

86708-26

86708-TC

86709

86709-26

86709-TC

86710

86710-26

86710-TC

86698

86698-26

86698-TC

86701

86701-26

86701-TC

86702

86702-26

86702-TC

86703

86703-26

86703-TC

86704

86704-26

86704-TC

86705

86705-26

86713

86713-26

86713-TC

86717

86717-26

86717-TC

86720

86720-26

86720-TC

86723

86723-26

86723-TC

86727

86727-26

86727-TC

86729

86729-26

$23.00

$24.00

$8.00

$16.00

$26.00

$8.00

$18.00

$32.00

$10.00

$21.00

$29.00

$10.00

$19.00

$22.00

$7.00

$15.00

$20.00

$6.00

$14.00

$21.00

$7.00

$15.00

$21.00

$7.00

$14.00

$22.00

$7.00

$15.00

$33.00

$11.00

$21.00

$35.00

$11.00

$23.00

$7.00

$16.00

$20.00

$6.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$20.00

$6.00

$14.00

$19.00

$6.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 357




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86747-26

86747-TC

86750

86750-26

86750-TC

86753

86753-26

86753-TC

86756

86756-26

86756-TC

86757

86757-26

86757-TC

86759

86759-26

86729-TC

86732

86732-26

86732-TC

86735

86735-26

86735-TC

86738

86738-26

86738-TC

86741

86741-26

86741-TC

86744

86744-26

86744-TC

86747

86759-TC

86762

86762-26

86762-TC

86765

86765-26

86765-TC

86768

86768-26

86768-TC

86771

86771-26

86771-TC

86774

86774-26

86774-TC

86777

$7.00

$16.00

$21.00

$7.00

$14.00

$20.00

$6.00

$14.00

$20.00

$6.00

$14.00

$44.00

$14.00

$30.00

$21.00

$7.00

$13.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$23.00

$14.00

$22.00

$7.00

$15.00

$20.00

$6.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$23.00

$7.00

$16.00

$22.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 358




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86800

86800-26

86800-TC

86803

86803-26

86803-TC

86804

86804-26

86804-TC

86805

86805-26

86805-TC

86806

86806-26

86806-TC

86807

86777-26

86777-TC

86778

86778-26

86778-TC

86784

86784-26

86784-TC

86787

86787-26

86787-TC

86790

86790-26

86790-TC

86793

86793-26

86793-TC

86807-26

86807-TC

86808

86808-26

86808-TC

86812

86812-26

86812-TC

86813

86813-26

86813-TC

86816

86816-26

86816-TC

86817

86817-26

86817-TC

$26.00

$8.00

$18.00

$24.00

$8.00

$16.00

$26.00

$8.00

$18.00

$97.00

$33.00

$64.00

$87.00

$28.00

$57.00

$74.00

$7.00

$15.00

$23.00

$7.00

$16.00

$21.00

$7.00

$14.00

$20.00

$6.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$51.00

$52.00

$15.00

$37.00

$108.00

$32.00

$75.00

$101.00

$29.00

$71.00

$64.00

$18.00

$44.00

$134.00

$39.00

$94.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 359




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86870-TC

86880

86880-26

86880-TC

86885

86885-26

86885-TC

86886

86886-26

86886-TC

86890

86890-26

86890-TC

86891

86891-26

86891-TC

86821

86821-26

86821-TC

86822

86822-26

86822-TC

86849

86849-26

86849-TC

86850

86850-26

86850-TC

86860

86860-26

86860-TC

86870

86870-26

86900

86900-26

86900-TC

86901

86901-26

86901-TC

86904

86904-26

86904-TC

86905

86905-26

86905-TC

86906

86906-26

86906-TC

86910

86910-26

$11.00

$13.00

$4.00

$8.00

$15.00

$4.00

$11.00

$14.00

$4.00

$10.00

$67.00

$11.00

$54.00

$91.00

$26.00

$64.00

$123.00

$36.00

$86.00

$96.00

$32.00

$64.00

BR

BR

BR

$10.00

$3.00

$6.00

$44.00

$15.00

$29.00

$17.00

$6.00

$10.00

$3.00

$6.00

$10.00

$3.00

$6.00

$19.00

$6.00

$13.00

$7.00

$1.00

$6.00

$11.00

$3.00

$7.00

$83.00

$24.00

---------

---------

---------

---------

---------

---------

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---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 360




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


86930-26

86930-TC

86931

86931-26

86931-TC

86932

86932-26

86932-TC

86940

86940-26

86940-TC

86941

86941-26

86941-TC

86945

86945-26

86910-TC

86911

86911-26

86911-TC

86920

86920-26

86920-TC

86921

86921-26

86921-TC

86922

86922-26

86922-TC

86927

86927-26

86927-TC

86930

86945-TC

86950

86950-26

86950-TC

86965

86965-26

86965-TC

86970

86970-26

86970-TC

86971

86971-26

86971-TC

86972

86972-26

86972-TC

86975

$45.00

$108.00

$155.00

$45.00

$108.00

$161.00

$48.00

$111.00

$18.00

$5.00

$13.00

$31.00

$8.00

$21.00

$35.00

$11.00

$57.00

$19.00

$6.00

$13.00

$19.00

$3.00

$15.00

$23.00

$7.00

$16.00

$20.00

$6.00

$14.00

$21.00

$5.00

$16.00

$155.00

$23.00

$99.00

$29.00

$70.00

$25.00

$7.00

$18.00

$41.00

$12.00

$29.00

$20.00

$5.00

$15.00

$20.00

$6.00

$14.00

$53.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 361




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87003

87003-26

87003-TC

87015

87015-26

87015-TC

87040

87040-26

87040-TC

87045

87045-26

87045-TC

87046

87046-26

87046-TC

87070

86975-26

86975-TC

86976

86976-26

86976-TC

86977

86977-26

86977-TC

86978

86978-26

86978-TC

86985

86985-26

86985-TC

86999

86999-26

86999-TC

87070-26

87070-TC

87071

87071-26

87071-TC

87073

87073-26

87073-TC

87075

87075-26

87075-TC

87076

87076-26

87076-TC

87077

87077-26

87077-TC

$40.00

$13.00

$26.00

$14.00

$5.00

$9.00

$18.00

$6.00

$12.00

$18.00

$6.00

$11.00

$5.00

$2.00

$3.00

$14.00

$16.00

$37.00

$53.00

$16.00

$37.00

$53.00

$16.00

$37.00

$65.00

$19.00

$44.00

$35.00

$12.00

$23.00

BR

BR

BR

$4.00

$10.00

$11.00

$3.00

$8.00

$11.00

$3.00

$8.00

$18.00

$6.00

$12.00

$24.00

$8.00

$16.00

$16.00

$5.00

$11.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 362




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87102-TC

87103

87103-26

87103-TC

87106

87106-26

87106-TC

87107

87107-26

87107-TC

87109

87109-26

87109-TC

87110

87110-26

87110-TC

87081

87081-26

87081-TC

87084

87084-26

87084-TC

87086

87086-26

87086-TC

87088

87088-26

87088-TC

87101

87101-26

87101-TC

87102

87102-26

87116

87116-26

87116-TC

87118

87118-26

87118-TC

87140

87140-26

87140-TC

87143

87143-26

87143-TC

87147

87147-26

87147-TC

87149

87149-26

$14.00

$32.00

$11.00

$20.00

$25.00

$7.00

$18.00

$23.00

$8.00

$15.00

$26.00

$8.00

$18.00

$23.00

$7.00

$15.00

$12.00

$3.00

$8.00

$23.00

$7.00

$16.00

$14.00

$3.00

$11.00

$18.00

$6.00

$12.00

$20.00

$6.00

$14.00

$20.00

$6.00

$15.00

$3.00

$11.00

$28.00

$9.00

$20.00

$24.00

$7.00

$17.00

$34.00

$11.00

$22.00

$26.00

$8.00

$18.00

$46.00

$15.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 363




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87169-26

87169-TC

87172

87172-26

87172-TC

87176

87176-26

87176-TC

87177

87177-26

87177-TC

87181

87181-26

87181-TC

87184

87184-26

87149-TC

87152

87152-26

87152-TC

87158

87158-26

87158-TC

87164

87164-26

87164-TC

87166

87166-26

87166-TC

87168

87168-26

87168-TC

87169

87184-TC

87185

87185-26

87185-TC

87186

87186-26

87186-TC

87187

87187-26

87187-TC

87188

87188-26

87188-TC

87190

87190-26

87190-TC

87197

$3.00

$7.00

$10.00

$3.00

$7.00

$16.00

$5.00

$11.00

$18.00

$6.00

$12.00

$13.00

$3.00

$8.00

$13.00

$3.00

$31.00

$12.00

$4.00

$8.00

$5.00

$1.00

$3.00

$24.00

$8.00

$16.00

$24.00

$7.00

$17.00

$10.00

$3.00

$7.00

$10.00

$10.00

$11.00

$3.00

$8.00

$16.00

$4.00

$12.00

$20.00

$3.00

$17.00

$18.00

$5.00

$13.00

$7.00

$2.00

$5.00

$29.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 364




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87230

87230-26

87230-TC

87250

87250-26

87250-TC

87252

87252-26

87252-TC

87253

87253-26

87253-TC

87254

87254-26

87254-TC

87255

87197-26

87197-TC

87205

87205-26

87205-TC

87206

87206-26

87206-TC

87207

87207-26

87207-TC

87210

87210-26

87210-TC

87220

87220-26

87220-TC

87255-26

87255-TC

87260

87260-26

87260-TC

87265

87265-26

87265-TC

87267

87267-26

87267-TC

87270

87270-26

87270-TC

87271

87271-26

87271-TC

$35.00

$11.00

$23.00

$33.00

$13.00

$19.00

$44.00

$14.00

$31.00

$33.00

$10.00

$22.00

$11.00

$3.00

$8.00

BR

$10.00

$19.00

$11.00

$3.00

$7.00

$15.00

$3.00

$12.00

$10.00

$3.00

$6.00

$8.00

$2.00

$6.00

$12.00

$4.00

$7.00

BR

BR

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

BR

BR

BR

$26.00

$8.00

$18.00

BR

BR

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 365




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87277-TC

87278

87278-26

87278-TC

87279

87279-26

87279-TC

87280

87280-26

87280-TC

87281

87281-26

87281-TC

87283

87283-26

87283-TC

87272

87272-26

87272-TC

87273

87273-26

87273-TC

87274

87274-26

87274-TC

87275

87275-26

87275-TC

87276

87276-26

87276-TC

87277

87277-26

87285

87285-26

87285-TC

87290

87290-26

87290-TC

87299

87299-26

87299-TC

87300

87300-26

87300-TC

87301

87301-26

87301-TC

87320

87320-26

$19.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$27.00

$9.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$13.00

$4.00

$9.00

$26.00

$8.00

$18.00

$26.00

$8.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 366




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87336-26

87336-TC

87337

87337-26

87337-TC

87338

87338-26

87338-TC

87339

87339-26

87339-TC

87340

87340-26

87340-TC

87341

87341-26

87320-TC

87324

87324-26

87324-TC

87327

87327-26

87327-TC

87328

87328-26

87328-TC

87332

87332-26

87332-TC

87335

87335-26

87335-TC

87336

87341-TC

87350

87350-26

87350-TC

87380

87380-26

87380-TC

87385

87385-26

87385-TC

87390

87390-26

87390-TC

87391

87391-26

87391-TC

87400

$9.00

$19.00

$27.00

$9.00

$19.00

$27.00

$7.00

$20.00

$27.00

$9.00

$19.00

$20.00

$6.00

$14.00

$23.00

$8.00

$18.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$27.00

$15.00

$20.00

$6.00

$14.00

$35.00

$11.00

$23.00

$26.00

$8.00

$18.00

$38.00

$13.00

$24.00

$38.00

$13.00

$24.00

$13.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 367




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87450

87450-26

87450-TC

87451

87451-26

87451-TC

87470

87470-26

87470-TC

87471

87471-26

87471-TC

87472

87472-26

87472-TC

87475

87400-26

87400-TC

87420

87420-26

87420-TC

87425

87425-26

87425-TC

87427

87427-26

87427-TC

87430

87430-26

87430-TC

87449

87449-26

87449-TC

87475-26

87475-TC

87476

87476-26

87476-TC

87477

87477-26

87477-TC

87480

87480-26

87480-TC

87481

87481-26

87481-TC

87482

87482-26

87482-TC

$21.00

$6.00

$15.00

$19.00

$7.00

$12.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$40.00

$4.00

$9.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$13.00

$26.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 368




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87492-TC

87495

87495-26

87495-TC

87496

87496-26

87496-TC

87497

87497-26

87497-TC

87510

87510-26

87510-TC

87511

87511-26

87511-TC

87485

87485-26

87485-TC

87486

87486-26

87486-TC

87487

87487-26

87487-TC

87490

87490-26

87490-TC

87491

87491-26

87491-TC

87492

87492-26

87512

87512-26

87512-TC

87515

87515-26

87515-TC

87516

87516-26

87516-TC

87517

87517-26

87517-TC

87520

87520-26

87520-TC

87521

87521-26

$48.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$73.00

$23.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 369




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87529-26

87529-TC

87530

87530-26

87530-TC

87531

87531-26

87531-TC

87532

87532-26

87532-TC

87533

87533-26

87533-TC

87534

87534-26

87521-TC

87522

87522-26

87522-TC

87525

87525-26

87525-TC

87526

87526-26

87526-TC

87527

87527-26

87527-TC

87528

87528-26

87528-TC

87529

87534-TC

87535

87535-26

87535-TC

87536

87536-26

87536-TC

87537

87537-26

87537-TC

87538

87538-26

87538-TC

87539

87539-26

87539-TC

87540

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 370




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87555

87555-26

87555-TC

87556

87556-26

87556-TC

87557

87557-26

87557-TC

87560

87560-26

87560-TC

87561

87561-26

87561-TC

87562

87540-26

87540-TC

87541

87541-26

87541-TC

87542

87542-26

87542-TC

87550

87550-26

87550-TC

87551

87551-26

87551-TC

87552

87552-26

87552-TC

87562-26

87562-TC

87580

87580-26

87580-TC

87581

87581-26

87581-TC

87582

87582-26

87582-TC

87590

87590-26

87590-TC

87591

87591-26

87591-TC

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 371




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


87798-TC

87799

87799-26

87799-TC

87800

87800-26

87800-TC

87801

87801-26

87801-TC

87802

87802-26

87802-TC

87803

87803-26

87803-TC

87592

87592-26

87592-TC

87650

87650-26

87650-TC

87651

87651-26

87651-TC

87652

87652-26

87652-TC

87797

87797-26

87797-TC

87798

87798-26

87804

87804-26

87804-TC

87810

87810-26

87810-TC

87850

87850-26

87850-TC

87880

87880-26

87880-TC

87899

87899-26

87899-TC

87901

87901-26

$48.00

$88.00

$28.00

$58.00

$46.00

$15.00

$31.00

$81.00

$26.00

$54.00

BR

BR

BR

BR

BR

BR

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

BR

BR

BR

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$594.00

$196.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------


Part C, 372




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


88005-26

88005-TC

88007

88007-26

88007-TC

88020

88020-26

88020-TC

88025

88025-26

88025-TC

88027

88027-26

88027-TC

88036

88036-26

87901-TC

87902

87902-26

87902-TC

87903

87903-26

87903-TC

87904

87904-26

87904-TC

87999

87999-26

87999-TC

88000

88000-26

88000-TC

88005

88036-TC

88037

88037-26

88037-TC

88040

88040-26

88040-TC

88045

88045-26

88045-TC

88099

88099-26

88099-TC

88104

88104-26

88104-TC

88106

$500.00

BR

$556.00

$556.00

BR

$556.00

$556.00

BR

$610.00

$610.00

BR

$666.00

$666.00

BR

$477.00

$477.00

$398.00

BR

BR

BR

$1,126.00

$371.00

$755.00

$59.00

$20.00

$39.00

BR

BR

BR

$445.00

$445.00

BR

$500.00

BR

$389.00

$389.00

BR

$1,445.00

$1,445.00

BR

BR

BR

BR

BR

BR

BR

$49.00

$37.00

$10.00

$54.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$82.00

$33.00

$49.00

$81.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$87.00

$34.00

$53.00

$86.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$87.00

$34.00

$53.00

$87.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$82.00

$33.00

$49.00

$81.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$87.00

$34.00

$53.00

$86.00

---------

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$87.00

$34.00

$53.00

$87.00


Part C, 373




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


88130

88130-26

88130-TC

88140

88140-26

88140-TC

88141

88141-26

88141-TC

88142

88142-26

88142-TC

88143

88143-26

88143-TC

88147

88106-26

88106-TC

88108

88108-26

88108-TC

88112

88112-26

88112-TC

88120

88120-26

88120-TC

88121

88121-26

88121-TC

88125

88125-26

88125-TC

88147-26

88147-TC

88148

88148-26

88148-TC

88150

88150-26

88150-TC

88152

88152-26

88152-TC

88153

88153-26

88153-TC

88154

88154-26

88154-TC

$25.00

$7.00

$18.00

$18.00

$5.00

$13.00

$33.00

NC

NC

$82.00

$21.00

$59.00

$94.00

$33.00

$59.00

$82.00

$16.00

$38.00

$59.00

$47.00

$11.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

$70.00

$20.00

$48.00

NC

$82.00

$104.00

$21.00

$82.00

$13.00

$3.00

$9.00

$46.00

$8.00

$38.00

$82.00

$21.00

$59.00

$104.00

$21.00

$82.00

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$36.00

BR

$22.00

$58.00

$78.00

$26.00

$52.00

$78.00

$32.00

$46.00

$678.00

$66.00

$612.00

$592.00

$57.00

$535.00

$26.00

$15.00

$10.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

---------

---------

---------

---------

---------

---------

---------

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$37.00

BR

$23.00

$63.00

$83.00

$27.00

$56.00

$82.00

$32.00

$49.00

$725.00

$68.00

$657.00

$632.00

$58.00

$574.00

$27.00

$16.00

$11.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

---------

---------

---------

---------

---------

---------

---------

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$38.00

BR

$23.00

$63.00

$84.00

$27.00

$57.00

$83.00

$33.00

$50.00

$728.00

$69.00

$660.00

$635.00

$59.00

$576.00

$28.00

$17.00

$12.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

---------

---------

---------

---------

---------

---------

---------

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$36.00

BR

$22.00

$58.00

$78.00

$26.00

$52.00

$78.00

$32.00

$46.00

$678.00

$66.00

$612.00

$592.00

$57.00

$535.00

$26.00

$15.00

$10.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$37.00

BR

BR

---------

---------

---------

---------

---------

---------

---------

$23.00

$63.00

$83.00

$27.00

$56.00

$82.00

$32.00

$49.00

$725.00

$68.00

$657.00

$632.00

$58.00

$574.00

$27.00

$16.00

$11.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

---------

---------

---------

---------

---------

---------

---------

(Facility MRA)

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$38.00

BR

$23.00

$63.00

$84.00

$27.00

$57.00

$83.00

$33.00

$50.00

$728.00

$69.00

$660.00

$635.00

$59.00

$576.00

$28.00

$17.00

$12.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

---------

---------

---------

---------

---------

---------

---------


Part C, 374




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


88165-TC

88166

88166-26

88166-TC

88167

88167-26

88167-TC

88172

88172-26

88172-TC

88173

88173-26

88173-TC

88174

88174-26

88174-TC

88155

88155-26

88155-TC

88160

88160-26

88160-TC

88161

88161-26

88161-TC

88162

88162-26

88162-TC

88164

88164-26

88164-TC

88165

88165-26

88175

88175-26

88175-TC

88177

88177-26

88177-TC

88182

88182-26

88182-TC

88184

88185

88187

88188

88189

88199

88199-26

88199-TC

$38.00

$82.00

$21.00

$59.00

$87.00

$26.00

$59.00

$70.00

$54.00

$14.00

$95.00

$95.00

$26.00

BR

BR

BR

$14.00

$3.00

$10.00

$45.00

$14.00

$24.00

$64.00

$19.00

$37.00

$77.00

$22.00

$53.00

$54.00

$21.00

$33.00

$72.00

$33.00

BR

BR

BR

---------

---------

---------

$88.00

$33.00

$54.00

---------

---------

---------

---------

---------

BR

BR

BR

---------

---------

---------

---------

---------

---------

---------

$63.00

$41.00

$21.00

$167.00

$81.00

$86.00

---------

---------

---------

---------

---------

---------

$78.00

$30.00

$49.00

$70.00

$29.00

$42.00

$113.00

$45.00

$68.00

---------

---------

---------

---------

---------

---------

---------

---------

$33.00

$25.00

$8.00

$121.00

$41.00

$80.00

$81.00

$49.00

$80.00

$102.00

$126.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$66.00

$43.00

$23.00

$176.00

$83.00

$93.00

---------

---------

---------

---------

---------

---------

$83.00

$31.00

$52.00

$74.00

$29.00

$45.00

$120.00

$46.00

$74.00

---------

---------

---------

---------

---------

---------

---------

---------

$35.00

$26.00

$9.00

$128.00

$42.00

$86.00

$87.00

$53.00

$83.00

$106.00

$129.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$67.00

$43.00

$23.00

$178.00

$84.00

$94.00

---------

---------

---------

---------

---------

---------

$83.00

$31.00

$53.00

$75.00

$30.00

$45.00

$121.00

$47.00

$74.00

---------

---------

---------

---------

---------

---------

---------

---------

$35.00

$26.00

$9.00

$130.00

$42.00

$88.00

$87.00

$53.00

$85.00

$109.00

$133.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$63.00

$41.00

$21.00

$167.00

$81.00

$86.00

---------

---------

---------

---------

---------

---------

$78.00

$30.00

$49.00

$70.00

$29.00

$42.00

$113.00

$45.00

$68.00

---------

---------

---------

---------

---------

---------

---------

---------

$33.00

$25.00

$8.00

$121.00

$41.00

$80.00

$81.00

$49.00

$80.00

$102.00

$126.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$66.00

$43.00

$23.00

$176.00

$83.00

$93.00

---------

---------

---------

---------

---------

---------

$83.00

$31.00

$52.00

$74.00

$29.00

$45.00

$120.00

$46.00

$74.00

---------

---------

---------

---------

---------

---------

---------

---------

$35.00

$26.00

$9.00

$128.00

$42.00

$86.00

$87.00

$53.00

$83.00

$106.00

$129.00

---------

---------

---------

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

$67.00

$43.00

$23.00

$178.00

$84.00

$94.00

---------

---------

---------

---------

---------

---------

$83.00

$31.00

$53.00

$75.00

$30.00

$45.00

$121.00

$47.00

$74.00

---------

---------

---------

---------

---------

---------

---------

---------

$35.00

$26.00

$9.00

$130.00

$42.00

$88.00

$87.00

$53.00

$85.00

$109.00

$133.00

---------

---------

---------


Part C, 375




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


88302-TC

88304

88304-26

88304-TC

88305

88305-26

88305-TC

88307

88307-26

88307-TC

88309

88309-26

88309-TC

88311

88311-26

88311-TC

88233

88233-26

88233-TC

88235

88235-26

88235-TC

88240

88240-26

88240-TC

88241

88241-26

88241-TC

88300

88300-26

88300-TC

88302

88302-26

88312

88312-26

88312-TC

88313

88313-26

88313-TC

88314

88314-26

88314-TC

88319

88319-26

88319-TC

88321

88321-26

88321-TC

88323

88323-26

$11.00

$70.00

$54.00

$14.00

$108.00

$86.00

$21.00

$210.00

$168.00

$41.00

$322.00

$258.00

$64.00

$23.00

$19.00

$4.00

$243.00

$73.00

$170.00

$256.00

$76.00

$177.00

$21.00

$6.00

$15.00

$21.00

$6.00

$15.00

$24.00

$19.00

$5.00

$53.00

$42.00

$23.00

$7.00

$16.00

$23.00

$7.00

$16.00

$21.00

$6.00

$15.00

$26.00

$13.00

$14.00

$43.00

$43.00

NC

$61.00

$61.00

$27.00

$49.00

$13.00

$36.00

$80.00

$43.00

$36.00

$333.00

$95.00

$238.00

$506.00

$169.00

$338.00

$24.00

$15.00

$9.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$17.00

$5.00

$11.00

$35.00

$8.00

$105.00

$31.00

$75.00

$74.00

$14.00

$60.00

$83.00

$25.00

$58.00

$96.00

$31.00

$65.00

$113.00

---------

BR

$152.00

$98.00

$29.00

$53.00

$13.00

$39.00

$84.00

$45.00

$39.00

$353.00

$98.00

$255.00

$536.00

$174.00

$363.00

$25.00

$15.00

$10.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$18.00

$5.00

$12.00

$38.00

$9.00

$112.00

$32.00

$80.00

$79.00

$14.00

$64.00

$88.00

$26.00

$62.00

$102.00

$32.00

$70.00

$117.00

---------

BR

$158.00

$100.00

$29.00

$53.00

$14.00

$40.00

$85.00

$45.00

$40.00

$356.00

$99.00

$257.00

$541.00

$176.00

$365.00

$26.00

$15.00

$10.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$19.00

$6.00

$13.00

$38.00

$9.00

$113.00

$32.00

$81.00

$79.00

$15.00

$65.00

$89.00

$26.00

$62.00

$103.00

$32.00

$71.00

$120.00

---------

BR

$160.00

$101.00

$27.00

$49.00

$13.00

$36.00

$80.00

$43.00

$36.00

$333.00

$95.00

$238.00

$506.00

$169.00

$338.00

$24.00

$15.00

$9.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$17.00

$5.00

$11.00

$35.00

$8.00

$105.00

$31.00

$75.00

$74.00

$14.00

$60.00

$83.00

$25.00

$58.00

$96.00

$31.00

$65.00

$96.00

---------

BR

$152.00

$98.00

$29.00

$53.00

$13.00

$39.00

$84.00

$45.00

$39.00

$353.00

$98.00

$255.00

$536.00

$174.00

$363.00

$25.00

$15.00

$10.00

---------

---------

---------

$18.00

$5.00

$12.00

$38.00

$9.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

$112.00

$32.00

$80.00

$79.00

$14.00

$64.00

$88.00

$26.00

$62.00

$102.00

$32.00

$70.00

$100.00

---------

BR

$158.00

$100.00

(Facility MRA)

$29.00

$53.00

$14.00

$40.00

$85.00

$45.00

$40.00

$356.00

$99.00

$257.00

$541.00

$176.00

$365.00

$26.00

$15.00

$10.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$19.00

$6.00

$13.00

$38.00

$9.00

$113.00

$32.00

$81.00

$79.00

$15.00

$65.00

$89.00

$26.00

$62.00

$103.00

$32.00

$71.00

$102.00

---------

BR

$160.00

$101.00


Part C, 376




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


88334-26

88334-TC

88341

88341-26

88341-TC

88342

88342-26

88342-TC

88344

88344-26

88344-TC

88346

88346-26

88346-TC

88348

88348-26

88323-TC

88325

88325-26

88325-TC

88329

88329-26

88329-TC

88331

88331-26

88331-TC

88332

88332-26

88332-TC

88333

88333-26

88333-TC

88334

88348-TC

88350

88350-26

88350-TC

88355

88355-26

88355-TC

88356

88356-26

88356-TC

88358

88358-26

88358-TC

88360

88360-26

88360-TC

88361

---------

---------

---------

---------

---------

$53.00

$36.00

$17.00

---------

---------

---------

$96.00

$66.00

$28.00

$191.00

$145.00

NC

$54.00

$54.00

NC

$51.00

$51.00

NC

$102.00

$70.00

$33.00

$53.00

$36.00

$17.00

---------

---------

---------

---------

$44.00

---------

---------

---------

$108.00

$80.00

$26.00

$108.00

$80.00

$26.00

$108.00

$80.00

$26.00

---------

---------

---------

---------

$44.00

$24.00

$96.00

$30.00

$66.00

$115.00

$41.00

$74.00

$185.00

$45.00

$141.00

$101.00

$42.00

$59.00

$372.00

$86.00

$54.00

$190.00

---------

BR

$56.00

---------

BR

$105.00

$71.00

$33.00

$55.00

$35.00

$20.00

$110.00

$72.00

$38.00

$68.00

$285.00

$77.00

$31.00

$46.00

$170.00

$92.00

$78.00

$224.00

$135.00

$89.00

$93.00

$51.00

$42.00

$131.00

$62.00

$69.00

$160.00

$46.00

$25.00

$102.00

$31.00

$71.00

$122.00

$42.00

$80.00

$197.00

$46.00

$151.00

$106.00

$43.00

$63.00

$395.00

$89.00

$58.00

$198.00

---------

BR

$58.00

---------

BR

$110.00

$74.00

$36.00

$58.00

$36.00

$22.00

$115.00

$74.00

$41.00

$71.00

$307.00

$82.00

$32.00

$49.00

$178.00

$93.00

$84.00

$233.00

$138.00

$95.00

$97.00

$52.00

$45.00

$137.00

$63.00

$74.00

$169.00

$46.00

$26.00

$102.00

$32.00

$71.00

$123.00

$43.00

$80.00

$198.00

$47.00

$152.00

$107.00

$44.00

$64.00

$399.00

$90.00

$58.00

$202.00

---------

BR

$60.00

---------

BR

$111.00

$75.00

$36.00

$59.00

$36.00

$22.00

$116.00

$75.00

$41.00

$72.00

$309.00

$82.00

$32.00

$50.00

$179.00

$94.00

$85.00

$236.00

$139.00

$97.00

$98.00

$52.00

$46.00

$139.00

$64.00

$75.00

$171.00

$44.00

$24.00

$96.00

$30.00

$66.00

$115.00

$41.00

$74.00

$185.00

$45.00

$141.00

$101.00

$42.00

$59.00

$372.00

$86.00

$54.00

$152.00

---------

BR

$42.00

---------

BR

$105.00

$71.00

$33.00

$55.00

$35.00

$20.00

$110.00

$72.00

$38.00

$68.00

$285.00

$77.00

$31.00

$46.00

$170.00

$92.00

$78.00

$224.00

$135.00

$89.00

$93.00

$51.00

$42.00

$131.00

$62.00

$69.00

$160.00

$46.00

$25.00

$102.00

$31.00

$71.00

$122.00

$42.00

$80.00

$197.00

$46.00

$151.00

$106.00

$43.00

$63.00

$395.00

$89.00

$58.00

$157.00

---------

BR

$43.00

---------

BR

$110.00

$74.00

$36.00

$58.00

$36.00

$22.00

$115.00

$74.00

$41.00

$71.00

$307.00

$82.00

$32.00

$49.00

$178.00

$93.00

$84.00

$233.00

$138.00

$95.00

$97.00

$52.00

$45.00

$137.00

$63.00

$74.00

$169.00

(Facility MRA)

$46.00

$26.00

$102.00

$32.00

$71.00

$123.00

$43.00

$80.00

$198.00

$47.00

$152.00

$107.00

$44.00

$64.00

$399.00

$90.00

$58.00

$161.00

---------

BR

$45.00

---------

BR

$111.00

$75.00

$36.00

$59.00

$36.00

$22.00

$116.00

$75.00

$41.00

$72.00

$309.00

$82.00

$32.00

$50.00

$179.00

$94.00

$85.00

$236.00

$139.00

$97.00

$98.00

$52.00

$46.00

$139.00

$64.00

$75.00

$171.00


Part C, 377




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


88367-TC

88368

88368-26

88368-TC

88369

88369-26

88369-TC

88371

88371-26

88371-TC

88372

88372-26

88372-TC

88373

88373-26

88373-TC

88361-26

88361-TC

88362

88362-26

88362-TC

88363

88364

88364-26

88364-TC

88365

88365-26

88365-TC

88366

88366-26

88366-TC

88367

88367-26

88374

88374-26

88374-TC

88375

88377

88377-26

88377-TC

88380

88380-26

88380-TC

88381

88381-26

88381-TC

88387

88387-26

88387-TC

88388

---------

---------

---------

---------

---------

---------

---------

$34.00

$10.00

$23.00

$38.00

$11.00

$26.00

---------

---------

---------

---------

---------

BR

BR

BR

---------

---------

---------

---------

$24.00

$24.00

BR

---------

---------

---------

---------

---------

BR

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

$75.00

$123.00

$45.00

$78.00

$116.00

$35.00

$81.00

---------

$20.00

---------

---------

$20.00

---------

$80.00

$24.00

$57.00

$67.00

$94.00

$281.00

$123.00

$157.00

$25.00

$144.00

$38.00

$106.00

$190.00

$50.00

$140.00

$280.00

$71.00

$210.00

$114.00

$39.00

$367.00

$51.00

$317.00

$55.00

$438.00

$73.00

$365.00

$156.00

$64.00

$92.00

$126.00

$28.00

$98.00

$46.00

$36.00

$10.00

$38.00

$81.00

$129.00

$46.00

$83.00

$123.00

$36.00

$87.00

---------

$21.00

---------

---------

$21.00

---------

$85.00

$24.00

$61.00

$68.00

$101.00

$296.00

$127.00

$169.00

$26.00

$153.00

$40.00

$114.00

$202.00

$51.00

$150.00

$298.00

$73.00

$225.00

$121.00

$40.00

$392.00

$52.00

$340.00

$57.00

$466.00

$74.00

$392.00

$165.00

$66.00

$99.00

$134.00

$29.00

$105.00

$48.00

$38.00

$11.00

$40.00

$82.00

$130.00

$46.00

$84.00

$124.00

$36.00

$88.00

---------

$21.00

---------

---------

$21.00

---------

$85.00

$24.00

$61.00

$69.00

$101.00

$299.00

$129.00

$170.00

$27.00

$155.00

$40.00

$114.00

$203.00

$52.00

$151.00

$300.00

$74.00

$226.00

$122.00

$40.00

$394.00

$52.00

$341.00

$59.00

$469.00

$75.00

$394.00

$167.00

$67.00

$100.00

$135.00

$29.00

$106.00

$49.00

$38.00

$11.00

$40.00

$75.00

$123.00

$45.00

$78.00

$116.00

$35.00

$81.00

---------

$20.00

---------

---------

$20.00

---------

$80.00

$24.00

$57.00

$67.00

$94.00

$281.00

$123.00

$157.00

$22.00

$144.00

$38.00

$106.00

$190.00

$50.00

$140.00

$280.00

$71.00

$210.00

$114.00

$39.00

$367.00

$51.00

$317.00

$55.00

$438.00

$73.00

$365.00

$156.00

$64.00

$92.00

$126.00

$28.00

$98.00

$46.00

$36.00

$10.00

$38.00

$81.00

$129.00

$46.00

$83.00

$123.00

$36.00

$87.00

---------

$21.00

---------

---------

$21.00

---------

$85.00

$24.00

$61.00

$68.00

$101.00

$296.00

$127.00

$169.00

$23.00

$153.00

$40.00

$114.00

$202.00

$51.00

$150.00

$298.00

$73.00

$225.00

$121.00

$40.00

$392.00

$52.00

$340.00

$57.00

$466.00

$74.00

$392.00

$165.00

$66.00

$99.00

$134.00

$29.00

$105.00

$48.00

$38.00

$11.00

$40.00

(Facility MRA)

$82.00

$130.00

$46.00

$84.00

$124.00

$36.00

$88.00

---------

$21.00

---------

---------

$21.00

---------

$85.00

$24.00

$61.00

$69.00

$101.00

$299.00

$129.00

$170.00

$23.00

$155.00

$40.00

$114.00

$203.00

$52.00

$151.00

$300.00

$74.00

$226.00

$122.00

$40.00

$394.00

$52.00

$341.00

$59.00

$469.00

$75.00

$394.00

$167.00

$67.00

$100.00

$135.00

$29.00

$106.00

$49.00

$38.00

$11.00

$40.00


Part C, 378




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


89060-TC

89125

89125-26

89125-TC

89160

89160-26

89160-TC

89190

89190-26

89190-TC

89220

89230

G0124

G0141

G0416

G0416-26

G0416-TC

G0452-26

G0455

88388-26

88388-TC

88399

88399-26

88399-TC

89049

89050

89050-26

89050-TC

89051

89051-26

89051-TC

89055

89055-26

89055-TC

89060

89060-26

$3.00

$6.00

---------

---------

---------

---------

---------

---------

$8.00

$14.00

$4.00

$10.00

$6.00

$2.00

$4.00

$10.00

---------

---------

---------

---------

---------

BR

BR

BR

---------

$10.00

$3.00

$6.00

$13.00

$4.00

$8.00

BR

BR

BR

$13.00

$5.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$18.00

$6.00

$36.00

$36.00

$570.00

$172.00

$398.00

$20.00

$142.00

$27.00

$11.00

---------

---------

---------

$282.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$19.00

$6.00

$37.00

$37.00

$604.00

$177.00

$427.00

$21.00

$151.00

$28.00

$12.00

---------

---------

---------

$300.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$19.00

$7.00

$38.00

$38.00

$608.00

$179.00

$429.00

$21.00

$156.00

$28.00

$12.00

---------

---------

---------

$304.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$18.00

$6.00

$36.00

$36.00

$570.00

$172.00

$398.00

$20.00

$84.00

$27.00

$11.00

---------

---------

---------

$74.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$19.00

$6.00

$37.00

$37.00

$604.00

$177.00

$427.00

$21.00

$88.00

$28.00

$12.00

---------

---------

---------

$77.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00

(Facility MRA)

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$19.00

$7.00

$38.00

$38.00

$608.00

$179.00

$429.00

$21.00

$93.00

$28.00

$12.00

---------

---------

---------

$80.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$21.00


Part C, 379



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

90849

90853

90865

90870

90875

90876

90880

90882

90836

90837

90838

90839

90840

90845

90846

90847

90746

90749

90785

90791

90792

90832

90833

90834

90460

90461

90471

90472

90473

90474

90632

90636

90675

90940

90945

90947

90951

90954

90955

90956

90957

90958

90885

90887

90889

90899

90901

90911

90935

90937

---------

---------

---------

---------

---------

$85.00

$93.00

$110.00

$32.00

$32.00

$143.00

$94.00

$74.00

$112.00

$112.00

$104.00

BR

BR

---------

---------

---------

---------

---------

---------

---------

---------

$4.00

$4.00

BR

BR

BR

BR

BR

$49.00

$77.00

BR

BR

$46.00

$82.00

$76.00

$226.00

BR

$80.00

$125.00

---------

---------

---------

---------

---------

---------

$93.00

$142.00

$123.00

$147.00

$70.00

$102.00

$114.00

$118.00

$38.00

$28.00

$183.00

$194.00

$68.00

$119.00

$112.00

---------

$27.00

$14.00

$27.00

$14.00

$27.00

$14.00

---------

---------

---------

---------

---------

$15.00

$146.00

$162.00

$71.00

$73.00

$94.00

$55.00

$98.00

---------

---------

$41.00

$92.00

$81.00

$116.00

---------

$96.00

$139.00

$1,054.00

$910.00

$509.00

$355.00

$719.00

$486.00

$95.00

$145.00

$126.00

$151.00

$72.00

$104.00

$117.00

$121.00

$39.00

$29.00

$190.00

$203.00

$71.00

$124.00

$115.00

---------

$29.00

$14.00

$29.00

$14.00

$29.00

$14.00

---------

---------

---------

---------

---------

$16.00

$150.00

$166.00

$72.00

$75.00

$96.00

$57.00

$102.00

---------

---------

$43.00

$97.00

$84.00

$120.00

---------

$99.00

$143.00

$1,094.00

$942.00

$527.00

$368.00

$745.00

$503.00

$98.00

$148.00

$129.00

$154.00

$73.00

$106.00

$120.00

$124.00

$40.00

$30.00

$193.00

$206.00

$73.00

$128.00

$118.00

---------

$29.00

$15.00

$29.00

$15.00

$29.00

$15.00

---------

---------

---------

---------

---------

$16.00

$153.00

$170.00

$74.00

$77.00

$98.00

$59.00

$105.00

---------

---------

$44.00

$99.00

$86.00

$124.00

---------

$102.00

$148.00

$1,135.00

$974.00

$544.00

$379.00

$769.00

$519.00

$92.00

$140.00

$122.00

$147.00

$70.00

$101.00

$114.00

$117.00

$34.00

$28.00

$143.00

$123.00

$68.00

$108.00

$104.00

---------

$27.00

$14.00

$27.00

$14.00

$27.00

$14.00

---------

---------

---------

---------

---------

$15.00

$142.00

$157.00

$70.00

$72.00

$94.00

$55.00

$85.00

---------

---------

$22.00

$50.00

$81.00

$116.00

---------

$96.00

$139.00

$1,054.00

$910.00

$509.00

$355.00

$719.00

$486.00

$94.00

$143.00

$125.00

$150.00

$71.00

$104.00

$116.00

$120.00

$35.00

$29.00

$147.00

$126.00

$71.00

$112.00

$107.00

---------

$29.00

$14.00

$29.00

$14.00

$29.00

$14.00

---------

---------

---------

---------

---------

$16.00

$145.00

$161.00

$72.00

$74.00

$96.00

$57.00

$87.00

---------

---------

$23.00

$52.00

$84.00

$120.00

---------

$99.00

$143.00

$1,094.00

$942.00

$527.00

$368.00

$745.00

$503.00

$97.00

$147.00

$128.00

$153.00

$73.00

$106.00

$119.00

$123.00

$36.00

$29.00

$150.00

$129.00

$73.00

$115.00

$109.00

---------

$29.00

$15.00

$29.00

$15.00

$29.00

$15.00

---------

---------

---------

---------

---------

$16.00

$148.00

$165.00

$73.00

$76.00

$98.00

$59.00

$90.00

---------

---------

$23.00

$54.00

$86.00

$124.00

---------

$102.00

$148.00

$1,135.00

$974.00

$544.00

$379.00

$769.00

$519.00


Part C, 380



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

91013

91013-26

91013-TC

91020

91020-26

91020-TC

91022

91022-26

91022-TC

91030

91030-26

91030-TC

91034

91034-26

91034-TC

91035

90959

90960

90961

90962

90963

90964

90965

90966

90967

90968

90969

90970

90997

90999

91010

91010-26

91010-TC

91035-26

91035-TC

91037

91037-26

91037-TC

91038

91038-26

91038-TC

91040

91040-26

91040-TC

91065

91065-26

91065-TC

91110

91110-26

91110-TC

---------

---------

---------

$60.00

$49.00

$9.00

---------

---------

---------

$57.00

$47.00

$8.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$115.00

BR

$116.00

$76.00

$32.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$34.00

$23.00

$14.00

---------

---------

---------

$25.00

$11.00

$14.00

$253.00

$84.00

$169.00

$182.00

$84.00

$98.00

$147.00

$53.00

$95.00

$205.00

$58.00

$147.00

$516.00

$330.00

$316.00

$265.00

$204.00

$607.00

$530.00

$505.00

$264.00

$20.00

$17.00

$17.00

$9.00

$104.00

---------

$191.00

$75.00

$116.00

$95.00

$422.00

$173.00

$57.00

$117.00

$481.00

$64.00

$417.00

$465.00

$56.00

$410.00

$84.00

$11.00

$72.00

$948.00

$212.00

$736.00

$26.00

$11.00

$15.00

$268.00

$87.00

$181.00

$192.00

$86.00

$105.00

$156.00

$54.00

$102.00

$218.00

$60.00

$158.00

$551.00

$342.00

$327.00

$275.00

$212.00

$628.00

$550.00

$523.00

$274.00

$21.00

$18.00

$18.00

$9.00

$108.00

---------

$203.00

$78.00

$124.00

$98.00

$453.00

$184.00

$59.00

$125.00

$514.00

$66.00

$448.00

$497.00

$57.00

$440.00

$90.00

$12.00

$78.00

$1,009.00

$219.00

$790.00

$27.00

$11.00

$15.00

$272.00

$89.00

$183.00

$194.00

$88.00

$106.00

$158.00

$56.00

$102.00

$221.00

$62.00

$159.00

$556.00

$352.00

$337.00

$283.00

$218.00

$648.00

$567.00

$539.00

$282.00

$21.00

$19.00

$18.00

$9.00

$111.00

---------

$206.00

$81.00

$125.00

$102.00

$454.00

$186.00

$60.00

$126.00

$518.00

$68.00

$449.00

$499.00

$58.00

$441.00

$90.00

$12.00

$78.00

$1,017.00

$224.00

$793.00

$25.00

$11.00

$14.00

$253.00

$84.00

$169.00

$182.00

$84.00

$98.00

$147.00

$53.00

$95.00

$205.00

$58.00

$147.00

$516.00

$330.00

$316.00

$265.00

$204.00

$607.00

$530.00

$505.00

$264.00

$20.00

$17.00

$17.00

$9.00

$104.00

---------

$191.00

$75.00

$116.00

$95.00

$422.00

$173.00

$57.00

$117.00

$481.00

$64.00

$417.00

$465.00

$56.00

$410.00

$84.00

$11.00

$72.00

$948.00

$212.00

$736.00

$26.00

$11.00

$15.00

$268.00

$87.00

$181.00

$192.00

$86.00

$105.00

$156.00

$54.00

$102.00

$218.00

$60.00

$158.00

$551.00

$342.00

$327.00

$275.00

$212.00

$628.00

$550.00

$523.00

$274.00

$21.00

$18.00

$18.00

$9.00

$108.00

---------

$203.00

$78.00

$124.00

$98.00

$453.00

$184.00

$59.00

$125.00

$514.00

$66.00

$448.00

$497.00

$57.00

$440.00

$90.00

$12.00

$78.00

$1,009.00

$219.00

$790.00

$27.00

$11.00

$15.00

$272.00

$89.00

$183.00

$194.00

$88.00

$106.00

$158.00

$56.00

$102.00

$221.00

$62.00

$159.00

$556.00

$352.00

$337.00

$283.00

$218.00

$648.00

$567.00

$539.00

$282.00

$21.00

$19.00

$18.00

$9.00

$111.00

---------

$206.00

$81.00

$125.00

$102.00

$454.00

$186.00

$60.00

$126.00

$518.00

$68.00

$449.00

$499.00

$58.00

$441.00

$90.00

$12.00

$78.00

$1,017.00

$224.00

$793.00


Part C, 381



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

92002

92004

92012

92014

92015

92018

92019

92020

91133-26

91133-TC

91200

91200-26

91200-TC

91299

91299-26

91299-TC

91111

91111-26

91111-TC

91112

91112-26

91112-TC

91117

91120

91120-26

91120-TC

91122

91122-26

91122-TC

91132

91132-26

91132-TC

91133

92025

92025-26

92025-TC

92060

92060-26

92060-TC

92065

92065-26

92065-TC

92071

92072

92081

92081-26

92081-TC

92082

92082-26

92082-TC

$34.00

BR

---------

---------

---------

BR

BR

BR

$63.00

$98.00

$53.00

$75.00

$34.00

$80.00

$70.00

$31.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$169.00

$122.00

$37.00

BR

$28.00

BR

BR

---------

---------

---------

$40.00

$32.00

$7.00

$34.00

$19.00

$6.00

---------

---------

$32.00

$19.00

$6.00

$48.00

$24.00

$9.00

$39.00

$146.00

$34.00

$15.00

$20.00

---------

---------

---------

$88.00

$162.00

$93.00

$135.00

$22.00

$161.00

$80.00

$29.00

$774.00

$59.00

$715.00

$1,156.00

$123.00

$1,033.00

$155.00

$456.00

$57.00

$399.00

$247.00

$102.00

$145.00

$167.00

$32.00

$135.00

$185.00

$41.00

$22.00

$19.00

$71.00

$42.00

$28.00

$58.00

$20.00

$38.00

$42.00

$148.00

$37.00

$18.00

$19.00

$52.00

$24.00

$28.00

$40.00

$157.00

$36.00

$15.00

$21.00

---------

---------

---------

$92.00

$169.00

$97.00

$141.00

$23.00

$166.00

$82.00

$30.00

$828.00

$61.00

$768.00

$1,236.00

$127.00

$1,109.00

$161.00

$487.00

$59.00

$428.00

$262.00

$106.00

$156.00

$178.00

$34.00

$145.00

$197.00

$44.00

$23.00

$21.00

$74.00

$43.00

$31.00

$61.00

$21.00

$40.00

$43.00

$154.00

$39.00

$19.00

$20.00

$55.00

$25.00

$30.00

$41.00

$158.00

$37.00

$15.00

$22.00

---------

---------

---------

$93.00

$172.00

$99.00

$143.00

$23.00

$170.00

$84.00

$31.00

$833.00

$62.00

$770.00

$1,243.00

$131.00

$1,112.00

$166.00

$491.00

$61.00

$430.00

$267.00

$110.00

$157.00

$181.00

$36.00

$145.00

$199.00

$44.00

$23.00

$21.00

$75.00

$44.00

$31.00

$62.00

$21.00

$41.00

$44.00

$156.00

$39.00

$19.00

$21.00

$56.00

$25.00

$31.00

$39.00

$146.00

$34.00

$15.00

$20.00

---------

---------

---------

$53.00

$110.00

$58.00

$89.00

$22.00

$161.00

$80.00

$23.00

$774.00

$59.00

$715.00

$1,156.00

$123.00

$1,033.00

$155.00

$456.00

$57.00

$399.00

$247.00

$102.00

$145.00

$167.00

$32.00

$135.00

$185.00

$41.00

$22.00

$19.00

$71.00

$42.00

$28.00

$58.00

$20.00

$38.00

$37.00

$114.00

$37.00

$18.00

$19.00

$52.00

$24.00

$28.00

$40.00

$157.00

$36.00

$15.00

$21.00

---------

---------

---------

$55.00

$114.00

$60.00

$92.00

$22.00

$166.00

$82.00

$24.00

$828.00

$61.00

$768.00

$1,236.00

$127.00

$1,109.00

$161.00

$487.00

$59.00

$428.00

$262.00

$106.00

$156.00

$178.00

$34.00

$145.00

$197.00

$44.00

$23.00

$21.00

$74.00

$43.00

$31.00

$61.00

$21.00

$40.00

$38.00

$118.00

$39.00

$19.00

$20.00

$55.00

$25.00

$30.00

$41.00

$158.00

$37.00

$15.00

$22.00

---------

---------

---------

$56.00

$116.00

$62.00

$94.00

$23.00

$170.00

$84.00

$24.00

$833.00

$62.00

$770.00

$1,243.00

$131.00

$1,112.00

$166.00

$491.00

$61.00

$430.00

$267.00

$110.00

$157.00

$181.00

$36.00

$145.00

$199.00

$44.00

$23.00

$21.00

$75.00

$44.00

$31.00

$62.00

$21.00

$41.00

$39.00

$120.00

$39.00

$19.00

$21.00

$56.00

$25.00

$31.00


Part C, 382



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

92145

92145-26

92145-TC

92225

92226

92227

92228

92228-26

92228-TC

92230

92235

92235-26

92235-TC

92240

92240-26

92240-TC

92083

92083-26

92083-TC

92100

92132

92132-26

92132-TC

92133

92133-26

92133-TC

92134

92134-26

92134-TC

92136

92136-26

92136-TC

92140

92250

92250-26

92250-TC

92260

92265

92265-26

92265-TC

92270

92270-26

92270-TC

92275

92275-26

92275-TC

92283

92283-26

92283-TC

92284

---------

---------

---------

$45.00

$39.00

---------

---------

---------

---------

$58.00

$104.00

$46.00

$53.00

$132.00

$60.00

$67.00

$59.00

$31.00

$14.00

$40.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

$93.00

$29.00

$63.00

$38.00

$40.00

$24.00

$7.00

$20.00

$53.00

$37.00

$10.00

$64.00

$45.00

$19.00

$80.00

$56.00

$17.00

$24.00

$10.00

$5.00

$192.00

$17.00

$9.00

$7.00

$29.00

$27.00

$16.00

$38.00

$23.00

$15.00

$63.00

$118.00

$52.00

$67.00

$274.00

$70.00

$204.00

$70.00

$31.00

$39.00

$86.00

$38.00

$21.00

$17.00

$48.00

$31.00

$17.00

$49.00

$32.00

$18.00

$97.00

$34.00

$63.00

$69.00

$85.00

$27.00

$58.00

$20.00

$86.00

$48.00

$38.00

$99.00

$46.00

$53.00

$160.00

$60.00

$100.00

$60.00

$10.00

$49.00

$66.00

$18.00

$10.00

$8.00

$31.00

$28.00

$17.00

$39.00

$24.00

$16.00

$67.00

$125.00

$53.00

$72.00

$291.00

$73.00

$219.00

$73.00

$32.00

$42.00

$91.00

$40.00

$22.00

$18.00

$50.00

$32.00

$19.00

$51.00

$33.00

$19.00

$103.00

$35.00

$68.00

$72.00

$90.00

$27.00

$63.00

$21.00

$91.00

$49.00

$41.00

$105.00

$47.00

$57.00

$169.00

$61.00

$108.00

$64.00

$11.00

$53.00

$70.00

$18.00

$10.00

$8.00

$31.00

$29.00

$17.00

$40.00

$24.00

$16.00

$68.00

$126.00

$54.00

$72.00

$293.00

$73.00

$219.00

$74.00

$32.00

$42.00

$92.00

$41.00

$22.00

$18.00

$51.00

$32.00

$19.00

$52.00

$33.00

$19.00

$104.00

$36.00

$68.00

$73.00

$91.00

$28.00

$63.00

$21.00

$92.00

$50.00

$42.00

$106.00

$48.00

$58.00

$170.00

$62.00

$109.00

$64.00

$11.00

$53.00

$71.00

$17.00

$9.00

$7.00

$23.00

$21.00

$16.00

$38.00

$23.00

$15.00

$37.00

$118.00

$52.00

$67.00

$274.00

$70.00

$204.00

$70.00

$31.00

$39.00

$38.00

$38.00

$21.00

$17.00

$48.00

$31.00

$17.00

$49.00

$32.00

$18.00

$97.00

$34.00

$63.00

$30.00

$85.00

$27.00

$58.00

$12.00

$86.00

$48.00

$38.00

$99.00

$46.00

$53.00

$160.00

$60.00

$100.00

$60.00

$10.00

$49.00

$66.00

$18.00

$10.00

$8.00

$24.00

$22.00

$17.00

$39.00

$24.00

$16.00

$39.00

$125.00

$53.00

$72.00

$291.00

$73.00

$219.00

$73.00

$32.00

$42.00

$39.00

$40.00

$22.00

$18.00

$50.00

$32.00

$19.00

$51.00

$33.00

$19.00

$103.00

$35.00

$68.00

$31.00

$90.00

$27.00

$63.00

$13.00

$91.00

$49.00

$41.00

$105.00

$47.00

$57.00

$169.00

$61.00

$108.00

$64.00

$11.00

$53.00

$70.00

$18.00

$10.00

$8.00

$24.00

$22.00

$17.00

$40.00

$24.00

$16.00

$40.00

$126.00

$54.00

$72.00

$293.00

$73.00

$219.00

$74.00

$32.00

$42.00

$39.00

$41.00

$22.00

$18.00

$51.00

$32.00

$19.00

$52.00

$33.00

$19.00

$104.00

$36.00

$68.00

$32.00

$91.00

$28.00

$63.00

$13.00

$92.00

$50.00

$42.00

$106.00

$48.00

$58.00

$170.00

$62.00

$109.00

$64.00

$11.00

$53.00

$71.00


Part C, 383



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

92316

92317

92325

92326

92340

92341

92342

92358

92370

92371

92499

92499-26

92499-TC

92502

92504

92507

92284-26

92284-TC

92285

92285-26

92285-TC

92286

92286-26

92286-TC

92287

92287-26

92287-TC

92310

92311

92312

92313

92314

92315

92508

92511

92512

92516

92520

92521

92522

92523

92524

92526

92531

92532

92533

92534

92537

92537-26

92537-TC

$59.00

$39.00

$14.00

$44.00

$32.00

$43.00

$43.00

$24.00

$35.00

$18.00

BR

BR

BR

$101.00

$24.00

$40.00

$151.00

$46.00

$26.00

$12.00

$6.00

$91.00

$53.00

$29.00

$99.00

---------

---------

$86.00

$78.00

$89.00

$70.00

$54.00

$44.00

$42.00

$81.00

$46.00

$36.00

$47.00

---------

---------

---------

---------

$48.00

$10.00

$14.00

$41.00

BR

---------

---------

---------

$99.00

$82.00

$45.00

$38.00

$39.00

$44.00

$48.00

$12.00

$34.00

$13.00

---------

---------

---------

$109.00

$33.00

$87.00

$14.00

$52.00

$22.00

$4.00

$19.00

$42.00

$25.00

$17.00

$148.00

$51.00

$96.00

$105.00

$110.00

$127.00

$105.00

$86.00

$78.00

$26.00

$122.00

$66.00

$76.00

$83.00

$122.00

$102.00

$213.00

$99.00

$95.00

---------

---------

---------

---------

$44.00

$35.00

$9.00

$104.00

$87.00

$48.00

$40.00

$41.00

$46.00

$50.00

$13.00

$35.00

$14.00

---------

---------

---------

$114.00

$35.00

$90.00

$14.00

$56.00

$24.00

$4.00

$20.00

$44.00

$25.00

$19.00

$156.00

$53.00

$104.00

$110.00

$115.00

$133.00

$110.00

$91.00

$83.00

$27.00

$129.00

$70.00

$81.00

$88.00

$127.00

$106.00

$222.00

$103.00

$98.00

---------

---------

---------

---------

$46.00

$36.00

$10.00

$105.00

$88.00

$49.00

$41.00

$41.00

$47.00

$51.00

$14.00

$36.00

$14.00

---------

---------

---------

$117.00

$35.00

$92.00

$15.00

$57.00

$25.00

$4.00

$21.00

$45.00

$26.00

$19.00

$158.00

$53.00

$104.00

$112.00

$117.00

$134.00

$112.00

$93.00

$84.00

$27.00

$131.00

$72.00

$82.00

$90.00

$130.00

$108.00

$226.00

$105.00

$100.00

---------

---------

---------

---------

$47.00

$37.00

$10.00

$37.00

$25.00

$45.00

$38.00

$21.00

$27.00

$30.00

$12.00

$18.00

$13.00

---------

---------

---------

$109.00

$11.00

$87.00

$14.00

$52.00

$22.00

$4.00

$19.00

$42.00

$25.00

$17.00

$148.00

$51.00

$96.00

$67.00

$62.00

$71.00

$53.00

$39.00

$24.00

$26.00

$44.00

$32.00

$26.00

$47.00

$122.00

$102.00

$213.00

$99.00

$95.00

---------

---------

---------

---------

$44.00

$35.00

$9.00

$37.00

$26.00

$48.00

$40.00

$22.00

$28.00

$31.00

$13.00

$19.00

$14.00

---------

---------

---------

$114.00

$11.00

$90.00

$14.00

$56.00

$24.00

$4.00

$20.00

$44.00

$25.00

$19.00

$156.00

$53.00

$104.00

$69.00

$64.00

$73.00

$54.00

$40.00

$25.00

$27.00

$46.00

$34.00

$27.00

$49.00

$127.00

$106.00

$222.00

$103.00

$98.00

---------

---------

---------

---------

$46.00

$36.00

$10.00

$38.00

$26.00

$49.00

$41.00

$22.00

$29.00

$32.00

$14.00

$19.00

$14.00

---------

---------

---------

$117.00

$11.00

$92.00

$15.00

$57.00

$25.00

$4.00

$21.00

$45.00

$26.00

$19.00

$158.00

$53.00

$104.00

$71.00

$65.00

$74.00

$55.00

$42.00

$26.00

$27.00

$47.00

$35.00

$28.00

$50.00

$130.00

$108.00

$226.00

$105.00

$100.00

---------

---------

---------

---------

$47.00

$37.00

$10.00


Part C, 384



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

92550

92551

92552

92553

92555

92556

92557

92560

92545-TC

92546

92546-26

92546-TC

92547

92548

92548-26

92548-TC

92538

92538-26

92538-TC

92540

92540-26

92540-TC

92541

92541-26

92541-TC

92542

92542-26

92542-TC

92544

92544-26

92544-TC

92545

92545-26

92571

92572

92575

92576

92577

92579

92582

92583

92584

92561

92562

92563

92564

92565

92567

92568

92570

$8.00

$29.00

$17.00

$9.00

$21.00

$92.00

$30.00

$59.00

---------

$17.00

$16.00

$24.00

$14.00

$21.00

$46.00

$23.00

---------

---------

---------

---------

---------

---------

$37.00

$25.00

$9.00

$33.00

$20.00

$10.00

$26.00

$16.00

$8.00

$22.00

$14.00

$27.00

$15.00

$14.00

$17.00

$15.00

$20.00

$14.00

---------

$14.00

$3.00

$11.00

$17.00

$28.00

$28.00

$28.00

$34.00

$94.00

$2.00

$111.00

$16.00

$94.00

$6.00

$110.00

$29.00

$81.00

$24.00

$13.00

$33.00

$40.00

$25.00

$40.00

$41.00

---------

$23.00

$18.00

$5.00

$112.00

$88.00

$24.00

$27.00

$23.00

$4.00

$31.00

$28.00

$3.00

$18.00

$16.00

$3.00

$17.00

$15.00

$41.00

$50.00

$33.00

$30.00

$17.00

$16.00

$18.00

$36.00

$29.00

$38.00

$77.00

$38.00

$18.00

$47.00

$72.00

$56.00

$79.00

$3.00

$119.00

$17.00

$102.00

$7.00

$117.00

$30.00

$87.00

$24.00

$14.00

$36.00

$43.00

$27.00

$43.00

$43.00

---------

$24.00

$18.00

$6.00

$116.00

$91.00

$25.00

$28.00

$24.00

$4.00

$32.00

$29.00

$4.00

$19.00

$16.00

$3.00

$18.00

$15.00

$44.00

$53.00

$36.00

$32.00

$19.00

$17.00

$18.00

$37.00

$32.00

$41.00

$83.00

$41.00

$19.00

$49.00

$78.00

$60.00

$85.00

$3.00

$120.00

$17.00

$102.00

$7.00

$119.00

$31.00

$88.00

$25.00

$14.00

$36.00

$43.00

$27.00

$43.00

$44.00

---------

$24.00

$18.00

$6.00

$118.00

$92.00

$26.00

$28.00

$24.00

$4.00

$33.00

$29.00

$4.00

$20.00

$16.00

$3.00

$18.00

$15.00

$45.00

$54.00

$36.00

$33.00

$19.00

$17.00

$19.00

$38.00

$32.00

$42.00

$84.00

$42.00

$20.00

$50.00

$79.00

$61.00

$85.00

$2.00

$111.00

$16.00

$94.00

$6.00

$110.00

$29.00

$81.00

$24.00

$13.00

$33.00

$40.00

$25.00

$40.00

$37.00

---------

$23.00

$18.00

$5.00

$112.00

$88.00

$24.00

$27.00

$23.00

$4.00

$31.00

$28.00

$3.00

$18.00

$16.00

$3.00

$17.00

$15.00

$41.00

$50.00

$33.00

$30.00

$17.00

$12.00

$17.00

$33.00

$29.00

$38.00

$77.00

$38.00

$18.00

$42.00

$72.00

$56.00

$79.00

$3.00

$119.00

$17.00

$102.00

$7.00

$117.00

$30.00

$87.00

$24.00

$14.00

$36.00

$43.00

$27.00

$43.00

$38.00

---------

$24.00

$18.00

$6.00

$116.00

$91.00

$25.00

$28.00

$24.00

$4.00

$32.00

$29.00

$4.00

$19.00

$16.00

$3.00

$18.00

$15.00

$44.00

$53.00

$36.00

$32.00

$19.00

$13.00

$18.00

$35.00

$32.00

$41.00

$83.00

$41.00

$19.00

$44.00

$78.00

$60.00

$85.00

$3.00

$120.00

$17.00

$102.00

$7.00

$119.00

$31.00

$88.00

$25.00

$14.00

$36.00

$43.00

$27.00

$43.00

$39.00

---------

$24.00

$18.00

$6.00

$118.00

$92.00

$26.00

$28.00

$24.00

$4.00

$33.00

$29.00

$4.00

$20.00

$16.00

$3.00

$18.00

$15.00

$45.00

$54.00

$36.00

$33.00

$19.00

$13.00

$19.00

$36.00

$32.00

$42.00

$84.00

$42.00

$20.00

$45.00

$79.00

$61.00

$85.00


Part C, 385



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

92610

92611

92612

92613

92614

92615

92616

92617

92597

92603

92604

92605

92606

92607

92608

92609

92585

92585-26

92585-TC

92586

92587

92587-26

92587-TC

92588

92588-26

92588-TC

92590

92591

92592

92593

92594

92595

92596

92920

92924

92928

92933

92937

92941

92943

92950

92953

92618

92620

92621

92625

92626

92627

92640

92700

$96.00

$88.00

$60.00

BR

BR

$109.00

$22.00

$59.00

$42.00

$46.00

$173.00

BR

$134.00

BR

$183.00

BR

$114.00

$52.00

$70.00

$70.00

$58.00

$8.00

$49.00

$78.00

$20.00

$57.00

$41.00

BR

BR

BR

BR

BR

$22.00

---------

---------

---------

---------

---------

---------

---------

BR

---------

---------

---------

---------

---------

---------

---------

$203.00

$35.00

$80.00

$167.00

$98.00

$104.00

$92.00

$139.00

$58.00

$121.00

$94.00

$96.00

$202.00

$43.00

$159.00

$38.00

$228.00

$47.00

$146.00

$30.00

$116.00

$91.00

$24.00

$20.00

$4.00

$36.00

$32.00

$4.00

---------

---------

---------

---------

---------

---------

$45.00

$38.00

$104.00

$25.00

$77.00

$99.00

$24.00

$125.00

---------

$648.00

$770.00

$720.00

$806.00

$720.00

$807.00

$807.00

$337.00

$13.00

$83.00

$174.00

$103.00

$107.00

$96.00

$145.00

$60.00

$126.00

$98.00

$101.00

$214.00

$45.00

$168.00

$39.00

$240.00

$49.00

$156.00

$31.00

$125.00

$98.00

$25.00

$21.00

$4.00

$38.00

$33.00

$5.00

---------

---------

---------

---------

---------

---------

$49.00

$39.00

$108.00

$25.00

$80.00

$102.00

$25.00

$130.00

---------

$694.00

$825.00

$771.00

$863.00

$771.00

$865.00

$864.00

$354.00

$13.00

$85.00

$177.00

$104.00

$110.00

$98.00

$147.00

$61.00

$128.00

$100.00

$104.00

$217.00

$47.00

$171.00

$41.00

$244.00

$50.00

$157.00

$31.00

$126.00

$99.00

$26.00

$21.00

$4.00

$38.00

$33.00

$5.00

---------

---------

---------

---------

---------

---------

$50.00

$41.00

$110.00

$26.00

$82.00

$104.00

$26.00

$132.00

---------

$766.00

$910.00

$851.00

$952.00

$851.00

$954.00

$953.00

$366.00

$14.00

$80.00

$136.00

$75.00

$99.00

$80.00

$139.00

$58.00

$121.00

$81.00

$96.00

$76.00

$43.00

$76.00

$37.00

$114.00

$47.00

$146.00

$30.00

$116.00

$91.00

$24.00

$20.00

$4.00

$36.00

$32.00

$4.00

---------

---------

---------

---------

---------

---------

$45.00

$37.00

$92.00

$21.00

$69.00

$85.00

$20.00

$107.00

---------

$648.00

$770.00

$720.00

$806.00

$720.00

$807.00

$807.00

$213.00

$13.00

$83.00

$141.00

$78.00

$103.00

$82.00

$145.00

$60.00

$126.00

$84.00

$101.00

$79.00

$45.00

$79.00

$39.00

$118.00

$49.00

$156.00

$31.00

$125.00

$98.00

$25.00

$21.00

$4.00

$38.00

$33.00

$5.00

---------

---------

---------

---------

---------

---------

$49.00

$38.00

$95.00

$22.00

$72.00

$87.00

$21.00

$110.00

---------

$694.00

$825.00

$771.00

$863.00

$771.00

$865.00

$864.00

$221.00

$13.00

$85.00

$144.00

$79.00

$106.00

$85.00

$147.00

$61.00

$128.00

$86.00

$104.00

$82.00

$47.00

$81.00

$40.00

$122.00

$50.00

$157.00

$31.00

$126.00

$99.00

$26.00

$21.00

$4.00

$38.00

$33.00

$5.00

---------

---------

---------

---------

---------

---------

$50.00

$40.00

$97.00

$22.00

$73.00

$89.00

$21.00

$112.00

---------

$766.00

$910.00

$851.00

$952.00

$851.00

$954.00

$953.00

$232.00

$14.00


Part C, 386



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

92992

92993

92997

92998

93000

93005

93010

93015

93016

93017

93018

93024

93024-26

93024-TC

93025

93025-26

92960

92961

92970

92971

92973

92974

92975

92977

92978

92978-26

92978-TC

92979

92979-26

92979-TC

92986

92987

92990

93025-TC

93040

93041

93042

93050

93050-26

93050-TC

93224

93225

93226

93227

93228

93229

93260

93260-26

93260-TC

93261

BR

BR

$765.00

$331.00

$26.00

$16.00

$12.00

$104.00

$25.00

$63.00

$54.00

$111.00

$71.00

$42.00

$277.00

---------

$162.00

$239.00

$201.00

$100.00

$174.00

$197.00

$400.00

$302.00

$269.00

$95.00

$170.00

$163.00

$76.00

$86.00

$1,222.00

$1,271.00

$974.00

---------

$14.00

$31.00

$9.00

---------

---------

---------

$159.00

$46.00

$83.00

$50.00

---------

---------

---------

---------

---------

---------

---------

---------

$779.00

$383.00

$19.00

$9.00

$9.00

$83.00

$25.00

$42.00

$16.00

$122.00

$64.00

$59.00

$172.00

$41.00

$226.00

$306.00

$218.00

$119.00

$210.00

$192.00

$464.00

$68.00

---------

$113.00

---------

---------

$90.00

---------

$1,573.00

$1,621.00

$1,279.00

$131.00

$14.00

$6.00

$8.00

$19.00

$9.00

$10.00

$99.00

$28.00

$41.00

$29.00

$29.00

$776.00

$73.00

$50.00

$24.00

$66.00

---------

---------

$835.00

$410.00

$20.00

$10.00

$10.00

$87.00

$26.00

$45.00

$17.00

$128.00

$65.00

$63.00

$183.00

$42.00

$238.00

$327.00

$231.00

$128.00

$225.00

$205.00

$496.00

$74.00

---------

$120.00

---------

---------

$96.00

---------

$1,685.00

$1,736.00

$1,371.00

$141.00

$15.00

$7.00

$8.00

$20.00

$10.00

$10.00

$105.00

$31.00

$44.00

$30.00

$30.00

$833.00

$77.00

$51.00

$25.00

$69.00

---------

---------

$922.00

$452.00

$20.00

$10.00

$10.00

$89.00

$26.00

$46.00

$17.00

$130.00

$67.00

$64.00

$184.00

$43.00

$243.00

$357.00

$249.00

$140.00

$248.00

$226.00

$547.00

$79.00

---------

$131.00

---------

---------

$105.00

---------

$1,847.00

$1,900.00

$1,501.00

$141.00

$16.00

$7.00

$9.00

$21.00

$10.00

$11.00

$106.00

$31.00

$44.00

$31.00

$31.00

$837.00

$78.00

$52.00

$26.00

$70.00

---------

---------

$779.00

$383.00

$19.00

$9.00

$9.00

$83.00

$25.00

$42.00

$16.00

$122.00

$64.00

$59.00

$172.00

$41.00

$137.00

$306.00

$218.00

$119.00

$210.00

$192.00

$464.00

$68.00

---------

$113.00

---------

---------

$90.00

---------

$1,573.00

$1,621.00

$1,279.00

$131.00

$14.00

$6.00

$8.00

$19.00

$9.00

$10.00

$99.00

$28.00

$41.00

$29.00

$29.00

$776.00

$73.00

$50.00

$24.00

$66.00

---------

---------

$835.00

$410.00

$20.00

$10.00

$10.00

$87.00

$26.00

$45.00

$17.00

$128.00

$65.00

$63.00

$183.00

$42.00

$143.00

$327.00

$231.00

$128.00

$225.00

$205.00

$496.00

$74.00

---------

$120.00

---------

---------

$96.00

---------

$1,685.00

$1,736.00

$1,371.00

$141.00

$15.00

$7.00

$8.00

$20.00

$10.00

$10.00

$105.00

$31.00

$44.00

$30.00

$30.00

$833.00

$77.00

$51.00

$25.00

$69.00

---------

---------

$922.00

$452.00

$20.00

$10.00

$10.00

$89.00

$26.00

$46.00

$17.00

$130.00

$67.00

$64.00

$184.00

$43.00

$147.00

$357.00

$249.00

$140.00

$248.00

$226.00

$547.00

$79.00

---------

$131.00

---------

---------

$105.00

---------

$1,847.00

$1,900.00

$1,501.00

$141.00

$16.00

$7.00

$9.00

$21.00

$10.00

$11.00

$106.00

$31.00

$44.00

$31.00

$31.00

$837.00

$78.00

$52.00

$26.00

$70.00


Part C, 387



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

93281-TC

93282

93282-26

93282-TC

93283

93283-26

93283-TC

93284

93284-26

93284-TC

93285

93285-26

93285-TC

93286

93286-26

93286-TC

93261-26

93261-TC

93268

93270

93271

93272

93278

93278-26

93278-TC

93279

93279-26

93279-TC

93280

93280-26

93280-TC

93281

93281-26

93287

93287-26

93287-TC

93288

93288-26

93288-TC

93289

93289-26

93289-TC

93290

93290-26

93290-TC

93291

93291-26

93291-TC

93292

93292-26

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$109.00

$46.00

$90.00

$28.00

$58.00

$24.00

$44.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$25.00

$69.00

$47.00

$22.00

$89.00

$64.00

$25.00

$99.00

$70.00

$29.00

$46.00

$29.00

$17.00

$30.00

$17.00

$13.00

$43.00

$24.00

$220.00

$10.00

$182.00

$28.00

$33.00

$14.00

$19.00

$54.00

$36.00

$19.00

$64.00

$43.00

$21.00

$75.00

$50.00

$40.00

$26.00

$14.00

$40.00

$24.00

$17.00

$72.00

$51.00

$21.00

$34.00

$24.00

$10.00

$40.00

$24.00

$16.00

$36.00

$24.00

$27.00

$72.00

$48.00

$23.00

$93.00

$66.00

$27.00

$103.00

$72.00

$31.00

$48.00

$30.00

$19.00

$31.00

$17.00

$14.00

$44.00

$25.00

$235.00

$11.00

$195.00

$29.00

$35.00

$14.00

$21.00

$57.00

$37.00

$20.00

$67.00

$44.00

$23.00

$78.00

$51.00

$42.00

$26.00

$15.00

$42.00

$24.00

$18.00

$75.00

$52.00

$23.00

$36.00

$25.00

$11.00

$42.00

$25.00

$17.00

$38.00

$25.00

$27.00

$73.00

$49.00

$24.00

$95.00

$67.00

$28.00

$105.00

$74.00

$31.00

$49.00

$31.00

$19.00

$32.00

$18.00

$14.00

$45.00

$26.00

$237.00

$11.00

$196.00

$30.00

$35.00

$14.00

$21.00

$58.00

$37.00

$21.00

$68.00

$45.00

$23.00

$79.00

$52.00

$43.00

$27.00

$16.00

$43.00

$25.00

$18.00

$76.00

$53.00

$23.00

$37.00

$25.00

$12.00

$43.00

$25.00

$17.00

$39.00

$25.00

$25.00

$69.00

$47.00

$22.00

$89.00

$64.00

$25.00

$99.00

$70.00

$29.00

$46.00

$29.00

$17.00

$30.00

$17.00

$13.00

$43.00

$24.00

$220.00

$10.00

$182.00

$28.00

$33.00

$14.00

$19.00

$54.00

$36.00

$19.00

$64.00

$43.00

$21.00

$75.00

$50.00

$40.00

$26.00

$14.00

$40.00

$24.00

$17.00

$72.00

$51.00

$21.00

$34.00

$24.00

$10.00

$40.00

$24.00

$16.00

$36.00

$24.00

$27.00

$72.00

$48.00

$23.00

$93.00

$66.00

$27.00

$103.00

$72.00

$31.00

$48.00

$30.00

$19.00

$31.00

$17.00

$14.00

$44.00

$25.00

$235.00

$11.00

$195.00

$29.00

$35.00

$14.00

$21.00

$57.00

$37.00

$20.00

$67.00

$44.00

$23.00

$78.00

$51.00

$42.00

$26.00

$15.00

$42.00

$24.00

$18.00

$75.00

$52.00

$23.00

$36.00

$25.00

$11.00

$42.00

$25.00

$17.00

$38.00

$25.00

$27.00

$73.00

$49.00

$24.00

$95.00

$67.00

$28.00

$105.00

$74.00

$31.00

$49.00

$31.00

$19.00

$32.00

$18.00

$14.00

$45.00

$26.00

$237.00

$11.00

$196.00

$30.00

$35.00

$14.00

$21.00

$58.00

$37.00

$21.00

$68.00

$45.00

$23.00

$79.00

$52.00

$43.00

$27.00

$16.00

$43.00

$25.00

$18.00

$76.00

$53.00

$23.00

$37.00

$25.00

$12.00

$43.00

$25.00

$17.00

$39.00

$25.00


Part C, 388



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

93306-TC

93307

93307-26

93307-TC

93308

93308-26

93308-TC

93312

93312-26

93312-TC

93313

93314

93314-26

93314-TC

93315

93315-26

93292-TC

93293

93293-26

93293-TC

93294

93295

93296

93297

93298

93303

93303-26

93303-TC

93304

93304-26

93304-TC

93306

93306-26

93315-TC

93316

93317

93317-26

93317-TC

93318

93318-26

93318-TC

93320

93320-26

93320-TC

93321

93321-26

93321-TC

93325

93325-26

93325-TC

---------

$196.00

$56.00

$144.00

$118.00

$46.00

$75.00

$322.00

$140.00

$182.00

$76.00

$212.00

$65.00

$144.00

$287.00

$144.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

$215.00

$70.00

$144.00

$114.00

$43.00

$73.00

---------

---------

$141.00

$78.00

$236.00

$95.00

$141.00

BR

$114.00

BR

$86.00

$30.00

$65.00

$50.00

$10.00

$42.00

$114.00

$4.00

$110.00

$175.00

$141.00

$50.00

$91.00

$134.00

$29.00

$106.00

$333.00

$135.00

$197.00

$26.00

$326.00

$117.00

$209.00

$894.00

$158.00

$12.00

$57.00

$17.00

$40.00

$38.00

$76.00

$28.00

$30.00

$30.00

$257.00

$71.00

$186.00

$168.00

$41.00

$127.00

$246.00

$71.00

$736.00

$44.00

---------

$120.00

---------

$867.00

$131.00

$736.00

$59.00

$20.00

$38.00

$29.00

$8.00

$21.00

$27.00

$4.00

$24.00

$188.00

$149.00

$52.00

$98.00

$143.00

$30.00

$113.00

$351.00

$139.00

$212.00

$26.00

$347.00

$122.00

$225.00

$953.00

$163.00

$13.00

$61.00

$18.00

$43.00

$39.00

$78.00

$30.00

$31.00

$31.00

$273.00

$73.00

$200.00

$179.00

$42.00

$137.00

$261.00

$73.00

$790.00

$45.00

---------

$125.00

---------

$926.00

$136.00

$790.00

$62.00

$21.00

$41.00

$31.00

$9.00

$23.00

$29.00

$4.00

$26.00

$190.00

$151.00

$53.00

$98.00

$144.00

$30.00

$114.00

$356.00

$142.00

$213.00

$28.00

$354.00

$128.00

$226.00

$959.00

$167.00

$13.00

$62.00

$18.00

$44.00

$41.00

$81.00

$30.00

$32.00

$32.00

$276.00

$75.00

$201.00

$180.00

$43.00

$137.00

$264.00

$74.00

$792.00

$47.00

---------

$131.00

---------

$934.00

$141.00

$792.00

$62.00

$21.00

$41.00

$32.00

$9.00

$23.00

$29.00

$4.00

$26.00

$175.00

$141.00

$50.00

$91.00

$134.00

$29.00

$106.00

$333.00

$135.00

$197.00

$26.00

$326.00

$117.00

$209.00

$894.00

$158.00

$12.00

$57.00

$17.00

$40.00

$38.00

$76.00

$28.00

$30.00

$30.00

$257.00

$71.00

$186.00

$168.00

$41.00

$127.00

$246.00

$71.00

$736.00

$44.00

---------

$120.00

---------

$867.00

$131.00

$736.00

$59.00

$20.00

$38.00

$29.00

$8.00

$21.00

$27.00

$4.00

$24.00

$188.00

$149.00

$52.00

$98.00

$143.00

$30.00

$113.00

$351.00

$139.00

$212.00

$26.00

$347.00

$122.00

$225.00

$953.00

$163.00

$13.00

$61.00

$18.00

$43.00

$39.00

$78.00

$30.00

$31.00

$31.00

$273.00

$73.00

$200.00

$179.00

$42.00

$137.00

$261.00

$73.00

$790.00

$45.00

---------

$125.00

---------

$926.00

$136.00

$790.00

$62.00

$21.00

$41.00

$31.00

$9.00

$23.00

$29.00

$4.00

$26.00

$190.00

$151.00

$53.00

$98.00

$144.00

$30.00

$114.00

$356.00

$142.00

$213.00

$28.00

$354.00

$128.00

$226.00

$959.00

$167.00

$13.00

$62.00

$18.00

$44.00

$41.00

$81.00

$30.00

$32.00

$32.00

$276.00

$75.00

$201.00

$180.00

$43.00

$137.00

$264.00

$74.00

$792.00

$47.00

---------

$131.00

---------

$934.00

$141.00

$792.00

$62.00

$21.00

$41.00

$32.00

$9.00

$23.00

$29.00

$4.00

$26.00


Part C, 389



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

93454

93454-26

93454-TC

93455

93455-26

93455-TC

93456

93456-26

93456-TC

93457

93457-26

93457-TC

93458

93458-26

93458-TC

93459

93350

93350-26

93350-TC

93351

93351-26

93351-TC

93352

93355

93451

93451-26

93451-TC

93452

93452-26

93452-TC

93453

93453-26

93453-TC

93459-26

93459-TC

93460

93460-26

93460-TC

93461

93461-26

93461-TC

93462

93463

93464

93464-26

93464-TC

93503

93505

93505-26

93505-TC

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$216.00

$77.00

$66.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$187.00

$318.00

$248.00

$74.00

$982.00

$300.00

$682.00

$1,143.00

$347.00

$796.00

$1,231.00

$385.00

$846.00

$1,392.00

$432.00

$960.00

$1,179.00

$367.00

$812.00

$1,303.00

$260.00

$79.00

$181.00

$293.00

$95.00

$199.00

$37.00

$255.00

$852.00

$169.00

$682.00

$967.00

$296.00

$671.00

$1,249.00

$392.00

$857.00

$414.00

$890.00

$1,399.00

$461.00

$938.00

$1,599.00

$509.00

$1,091.00

$247.00

$111.00

$297.00

$98.00

$200.00

$148.00

$838.00

$274.00

$565.00

$1,052.00

$320.00

$732.00

$1,225.00

$370.00

$855.00

$1,319.00

$410.00

$908.00

$1,491.00

$461.00

$1,030.00

$1,263.00

$391.00

$872.00

$1,396.00

$276.00

$82.00

$194.00

$311.00

$97.00

$213.00

$39.00

$264.00

$913.00

$180.00

$733.00

$1,035.00

$314.00

$721.00

$1,338.00

$417.00

$921.00

$441.00

$955.00

$1,499.00

$491.00

$1,007.00

$1,713.00

$542.00

$1,171.00

$265.00

$115.00

$315.00

$100.00

$215.00

$153.00

$897.00

$291.00

$606.00

$1,085.00

$350.00

$735.00

$1,263.00

$404.00

$859.00

$1,361.00

$448.00

$913.00

$1,538.00

$503.00

$1,035.00

$1,303.00

$427.00

$876.00

$1,441.00

$279.00

$83.00

$196.00

$314.00

$99.00

$215.00

$40.00

$274.00

$932.00

$196.00

$736.00

$1,066.00

$342.00

$724.00

$1,381.00

$456.00

$925.00

$482.00

$959.00

$1,549.00

$537.00

$1,012.00

$1,769.00

$593.00

$1,176.00

$291.00

$119.00

$319.00

$103.00

$216.00

$161.00

$927.00

$318.00

$609.00

$982.00

$300.00

$682.00

$1,143.00

$347.00

$796.00

$1,231.00

$385.00

$846.00

$1,392.00

$432.00

$960.00

$1,179.00

$367.00

$812.00

$1,303.00

$260.00

$79.00

$181.00

$293.00

$95.00

$199.00

$37.00

$255.00

$852.00

$169.00

$682.00

$967.00

$296.00

$671.00

$1,249.00

$392.00

$857.00

$414.00

$890.00

$1,399.00

$461.00

$938.00

$1,599.00

$509.00

$1,091.00

$247.00

$111.00

$297.00

$98.00

$200.00

$148.00

$838.00

$274.00

$565.00

$1,052.00

$320.00

$732.00

$1,225.00

$370.00

$855.00

$1,319.00

$410.00

$908.00

$1,491.00

$461.00

$1,030.00

$1,263.00

$391.00

$872.00

$1,396.00

$276.00

$82.00

$194.00

$311.00

$97.00

$213.00

$39.00

$264.00

$913.00

$180.00

$733.00

$1,035.00

$314.00

$721.00

$1,338.00

$417.00

$921.00

$441.00

$955.00

$1,499.00

$491.00

$1,007.00

$1,713.00

$542.00

$1,171.00

$265.00

$115.00

$315.00

$100.00

$215.00

$153.00

$897.00

$291.00

$606.00

$1,085.00

$350.00

$735.00

$1,263.00

$404.00

$859.00

$1,361.00

$448.00

$913.00

$1,538.00

$503.00

$1,035.00

$1,303.00

$427.00

$876.00

$1,441.00

$279.00

$83.00

$196.00

$314.00

$99.00

$215.00

$40.00

$274.00

$932.00

$196.00

$736.00

$1,066.00

$342.00

$724.00

$1,381.00

$456.00

$925.00

$482.00

$959.00

$1,549.00

$537.00

$1,012.00

$1,769.00

$593.00

$1,176.00

$291.00

$119.00

$319.00

$103.00

$216.00

$161.00

$927.00

$318.00

$609.00


Part C, 390



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

93583

93600

93600-26

93600-TC

93602

93602-26

93602-TC

93603

93603-26

93603-TC

93609

93609-26

93609-TC

93610

93610-26

93610-TC

93612

93562-TC

93563

93564

93565

93566

93567

93568

93571

93571-26

93571-TC

93572

93572-26

93572-TC

93580

93581

93582

93530

93530-26

93530-TC

93531

$872.00

$250.00

$634.00

$2,268.00

93531-26 $467.00

93531-TC $1,815.00

93532

93532-26

$2,317.00

$569.00

93532-TC $1,766.00

93533

93533-26

$2,131.00

$352.00

93533-TC $1,766.00

93561

93561-26

93561-TC

93562

93562-26

$59.00

$47.00

$20.00

$46.00

$33.00

$13.00

---------

---------

---------

---------

---------

---------

$270.00

$93.00

$170.00

$222.00

$74.00

$155.00

$974.00

$1,303.00

---------

---------

$198.00

$129.00

$73.00

$159.00

$119.00

$42.00

$187.00

$127.00

$63.00

$578.00

$481.00

$101.00

$214.00

$166.00

$52.00

$224.00

---------

$69.00

$73.00

$54.00

$188.00

$156.00

$169.00

---------

$113.00

---------

---------

$90.00

---------

$1,157.00

$1,584.00

$792.00

---------

$257.00

---------

---------

$502.00

---------

---------

$628.00

---------

---------

$419.00

---------

---------

$29.00

---------

---------

$9.00

$894.00

---------

$139.00

---------

---------

$136.00

---------

---------

$136.00

---------

---------

$325.00

---------

---------

$193.00

---------

---------

---------

$73.00

$78.00

$58.00

$201.00

$167.00

$181.00

---------

$120.00

---------

---------

$96.00

---------

$1,237.00

$1,699.00

$847.00

---------

$272.00

---------

---------

$529.00

---------

---------

$670.00

---------

---------

$447.00

---------

---------

$30.00

---------

---------

$9.00

$956.00

---------

$148.00

---------

---------

$145.00

---------

---------

$145.00

---------

---------

$346.00

---------

---------

$206.00

---------

---------

---------

$80.00

$86.00

$63.00

$208.00

$175.00

$187.00

---------

$131.00

---------

---------

$105.00

---------

$1,359.00

$1,876.00

$931.00

---------

$294.00

---------

---------

$569.00

---------

---------

$734.00

---------

---------

$488.00

---------

---------

$32.00

---------

---------

$10.00

$1,050.00

---------

$161.00

---------

---------

$158.00

---------

---------

$158.00

---------

---------

$377.00

---------

---------

$224.00

---------

---------

---------

$69.00

$73.00

$54.00

$55.00

$62.00

$56.00

---------

$113.00

---------

---------

$90.00

---------

$1,157.00

$1,584.00

$792.00

---------

$257.00

---------

---------

$502.00

---------

---------

$628.00

---------

---------

$419.00

---------

---------

$29.00

---------

---------

$9.00

$894.00

---------

$139.00

---------

---------

$136.00

---------

---------

$136.00

---------

---------

$325.00

---------

---------

$193.00

---------

---------

---------

$73.00

$78.00

$58.00

$58.00

$66.00

$60.00

---------

$120.00

---------

---------

$96.00

---------

$1,237.00

$1,699.00

$847.00

---------

$272.00

---------

---------

$529.00

---------

---------

$670.00

---------

---------

$447.00

---------

---------

$30.00

---------

---------

$9.00

$956.00

---------

$148.00

---------

---------

$145.00

---------

---------

$145.00

---------

---------

$346.00

---------

---------

$206.00

---------

---------

---------

$80.00

$86.00

$63.00

$64.00

$73.00

$65.00

---------

$131.00

---------

---------

$105.00

---------

$1,359.00

$1,876.00

$931.00

---------

$294.00

---------

---------

$569.00

---------

---------

$734.00

---------

---------

$488.00

---------

---------

$32.00

---------

---------

$10.00

$1,050.00

---------

$161.00

---------

---------

$158.00

---------

---------

$158.00

---------

---------

$377.00

---------

---------

$224.00

---------

---------


Part C, 391



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

93620-TC

93621

93621-26

93621-TC

93622

93622-26

93622-TC

93623

93623-26

93623-TC

93624

93624-26

93624-TC

93631

93631-26

93631-TC

93612-26

93612-TC

93613

93615

93615-26

93615-TC

93616

93616-26

93616-TC

93618

93618-26

93618-TC

93619

93619-26

93619-TC

93620

93620-26

93640

93640-26

93640-TC

93641

93641-26

93641-TC

93642

93642-26

93642-TC

93644

93644-26

93644-TC

93650

93653

93654

93655

93656

$91.00

BR

$769.00

BR

BR

$771.00

BR

BR

$167.00

BR

$333.00

$256.00

$74.00

$651.00

$420.00

$239.00

$167.00

$61.00

$377.00

$62.00

$49.00

$12.00

$94.00

$82.00

$12.00

$399.00

$258.00

$148.00

$717.00

$444.00

$290.00

$358.00

$272.00

$467.00

$230.00

$269.00

$613.00

$360.00

$269.00

$549.00

$295.00

$269.00

---------

---------

---------

$639.00

---------

---------

---------

---------

---------

---------

$137.00

---------

---------

$200.00

---------

---------

$186.00

---------

---------

$308.00

---------

---------

$470.00

---------

$191.00

---------

$470.00

---------

$58.00

---------

---------

$73.00

---------

---------

$277.00

---------

---------

$474.00

---------

---------

$752.00

---------

$226.00

---------

---------

$383.00

---------

$481.00

$318.00

$163.00

$305.00

$192.00

$113.00

$712.00

$1,003.00

$1,337.00

$502.00

$1,337.00

---------

---------

$146.00

---------

---------

$214.00

---------

---------

$198.00

---------

---------

$329.00

---------

---------

$501.00

---------

$204.00

---------

$503.00

---------

$60.00

---------

---------

$74.00

---------

---------

$296.00

---------

---------

$505.00

---------

---------

$801.00

---------

$241.00

---------

---------

$409.00

---------

$515.00

$339.00

$176.00

$319.00

$198.00

$121.00

$763.00

$1,075.00

$1,432.00

$537.00

$1,433.00

---------

---------

$159.00

---------

---------

$233.00

---------

---------

$216.00

---------

---------

$359.00

---------

---------

$550.00

---------

$222.00

---------

$553.00

---------

$62.00

---------

---------

$77.00

---------

---------

$322.00

---------

---------

$551.00

---------

---------

$873.00

---------

$263.00

---------

---------

$446.00

---------

$547.00

$370.00

$177.00

$323.00

$201.00

$122.00

$838.00

$1,182.00

$1,575.00

$591.00

$1,576.00

---------

---------

$137.00

---------

---------

$200.00

---------

---------

$186.00

---------

---------

$308.00

---------

---------

$470.00

---------

$191.00

---------

$470.00

---------

$58.00

---------

---------

$73.00

---------

---------

$277.00

---------

---------

$474.00

---------

---------

$752.00

---------

$226.00

---------

---------

$383.00

---------

$481.00

$318.00

$163.00

$305.00

$192.00

$113.00

$712.00

$1,003.00

$1,337.00

$502.00

$1,337.00

---------

---------

$146.00

---------

---------

$214.00

---------

---------

$198.00

---------

---------

$329.00

---------

---------

$501.00

---------

$204.00

---------

$503.00

---------

$60.00

---------

---------

$74.00

---------

---------

$296.00

---------

---------

$505.00

---------

---------

$801.00

---------

$241.00

---------

---------

$409.00

---------

$515.00

$339.00

$176.00

$319.00

$198.00

$121.00

$763.00

$1,075.00

$1,432.00

$537.00

$1,433.00

---------

---------

$159.00

---------

---------

$233.00

---------

---------

$216.00

---------

---------

$359.00

---------

---------

$550.00

---------

$222.00

---------

$553.00

---------

$62.00

---------

---------

$77.00

---------

---------

$322.00

---------

---------

$551.00

---------

---------

$873.00

---------

$263.00

---------

---------

$446.00

---------

$547.00

$370.00

$177.00

$323.00

$201.00

$122.00

$838.00

$1,182.00

$1,575.00

$591.00

$1,576.00


Part C, 392



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

93750

93770

93770-26

93770-TC

93784

93786

93788

93790

93797

93798

93799

93799-26

93799-TC

93880

93880-26

93880-TC

93657

93660

93660-26

93660-TC

93662

93662-26

93662-TC

93701

93701-26

93701-TC

93702

93724

93724-26

93724-TC

93740

93740-26

93740-TC

93882

93882-26

93882-TC

93886

93886-26

93886-TC

93888

93888-26

93888-TC

93890

93890-26

93890-TC

93892

93892-26

93892-TC

93893

93893-26

---------

NC

NC

NC

NC

NC

NC

NC

$17.00

$38.00

BR

BR

BR

$176.00

$31.00

$144.00

---------

$162.00

$103.00

$61.00

BR

$158.00

BR

$36.00

$9.00

$27.00

---------

$411.00

$259.00

$148.00

$17.00

$12.00

$5.00

$117.00

$21.00

$95.00

$215.00

$50.00

$162.00

$142.00

$33.00

$109.00

---------

---------

---------

---------

---------

---------

---------

---------

$63.00

NC

NC

NC

NC

NC

NC

NC

$18.00

$28.00

---------

---------

---------

$207.00

$45.00

$162.00

$502.00

$173.00

$105.00

$68.00

---------

$159.00

---------

$26.00

---------

---------

$115.00

$300.00

$270.00

$30.00

$9.00

---------

---------

$141.00

$29.00

$112.00

$215.00

$53.00

$162.00

$160.00

$29.00

$131.00

$220.00

$58.00

$162.00

$166.00

$69.00

$97.00

$165.00

$67.00

$66.00

NC

NC

NC

NC

NC

NC

NC

$19.00

$29.00

---------

---------

---------

$221.00

$47.00

$174.00

$538.00

$181.00

$108.00

$73.00

---------

$164.00

---------

$28.00

---------

---------

$124.00

$310.00

$278.00

$32.00

$9.00

---------

---------

$151.00

$31.00

$120.00

$229.00

$56.00

$173.00

$171.00

$30.00

$141.00

$234.00

$60.00

$174.00

$177.00

$72.00

$105.00

$174.00

$70.00

$69.00

NC

NC

NC

NC

NC

NC

NC

$19.00

$30.00

---------

---------

---------

$225.00

$49.00

$175.00

$591.00

$184.00

$110.00

$74.00

---------

$167.00

---------

$28.00

---------

---------

$125.00

$316.00

$283.00

$33.00

$10.00

---------

---------

$154.00

$33.00

$121.00

$232.00

$58.00

$174.00

$173.00

$31.00

$142.00

$237.00

$62.00

$175.00

$181.00

$76.00

$105.00

$177.00

$72.00

$53.00

NC

NC

NC

NC

NC

NC

NC

$10.00

$16.00

---------

---------

---------

$207.00

$45.00

$162.00

$502.00

$173.00

$105.00

$68.00

---------

$159.00

---------

$26.00

---------

---------

$115.00

$300.00

$270.00

$30.00

$9.00

---------

---------

$141.00

$29.00

$112.00

$215.00

$53.00

$162.00

$160.00

$29.00

$131.00

$220.00

$58.00

$162.00

$166.00

$69.00

$97.00

$165.00

$67.00

$55.00

NC

NC

NC

NC

NC

NC

NC

$10.00

$16.00

---------

---------

---------

$221.00

$47.00

$174.00

$538.00

$181.00

$108.00

$73.00

---------

$164.00

---------

$28.00

---------

---------

$124.00

$310.00

$278.00

$32.00

$9.00

---------

---------

$151.00

$31.00

$120.00

$229.00

$56.00

$173.00

$171.00

$30.00

$141.00

$234.00

$60.00

$174.00

$177.00

$72.00

$105.00

$174.00

$70.00

$58.00

NC

NC

NC

NC

NC

NC

NC

$11.00

$17.00

---------

---------

---------

$225.00

$49.00

$175.00

$591.00

$184.00

$110.00

$74.00

---------

$167.00

---------

$28.00

---------

---------

$125.00

$316.00

$283.00

$33.00

$10.00

---------

---------

$154.00

$33.00

$121.00

$232.00

$58.00

$174.00

$173.00

$31.00

$142.00

$237.00

$62.00

$175.00

$181.00

$76.00

$105.00

$177.00

$72.00


Part C, 393



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

93930-26

93930-TC

93931

93931-26

93931-TC

93965

93965-26

93965-TC

93970

93970-26

93970-TC

93971

93971-26

93971-TC

93975

93975-26

93893-TC

93922

93922-26

93922-TC

93923

93923-26

93923-TC

93924

93924-26

93924-TC

93925

93925-26

93925-TC

93926

93926-26

93926-TC

93930

93975-TC

93976

93976-26

93976-TC

93978

93978-26

93978-TC

93979

93979-26

93979-TC

93980

93980-26

93980-TC

93981

93981-26

93981-TC

93982

$26.00

$150.00

$118.00

$17.00

$101.00

$63.00

$26.00

$42.00

$189.00

$36.00

$154.00

$121.00

$23.00

$96.00

$277.00

$89.00

---------

$60.00

$16.00

$44.00

$112.00

$28.00

$85.00

$122.00

$31.00

$92.00

$175.00

$31.00

$144.00

$117.00

$21.00

$96.00

$174.00

$181.00

$184.00

$59.00

$121.00

$177.00

$34.00

$143.00

$122.00

$23.00

$98.00

$183.00

$65.00

$105.00

$148.00

$25.00

$124.00

---------

$45.00

$162.00

$141.00

$28.00

$112.00

$130.00

$20.00

$110.00

$201.00

$39.00

$162.00

$131.00

$25.00

$106.00

$227.00

$66.00

$97.00

$97.00

$14.00

$82.00

$151.00

$26.00

$125.00

$189.00

$28.00

$160.00

$206.00

$44.00

$162.00

$167.00

$28.00

$139.00

$208.00

$162.00

$178.00

$45.00

$132.00

$208.00

$46.00

$162.00

$131.00

$28.00

$103.00

$132.00

$68.00

$64.00

$80.00

$25.00

$55.00

$47.00

$47.00

$174.00

$150.00

$30.00

$121.00

$139.00

$21.00

$118.00

$215.00

$41.00

$174.00

$140.00

$27.00

$113.00

$242.00

$68.00

$105.00

$103.00

$15.00

$88.00

$161.00

$27.00

$134.00

$202.00

$30.00

$172.00

$220.00

$46.00

$173.00

$178.00

$29.00

$149.00

$222.00

$173.00

$189.00

$47.00

$142.00

$222.00

$48.00

$174.00

$140.00

$30.00

$110.00

$139.00

$70.00

$68.00

$85.00

$26.00

$59.00

$50.00

$50.00

$175.00

$153.00

$31.00

$121.00

$141.00

$22.00

$119.00

$218.00

$43.00

$175.00

$142.00

$28.00

$114.00

$246.00

$71.00

$105.00

$105.00

$16.00

$89.00

$164.00

$28.00

$135.00

$204.00

$31.00

$173.00

$222.00

$48.00

$174.00

$181.00

$30.00

$150.00

$225.00

$174.00

$191.00

$48.00

$143.00

$226.00

$51.00

$175.00

$143.00

$32.00

$111.00

$141.00

$72.00

$69.00

$87.00

$28.00

$60.00

$52.00

$45.00

$162.00

$141.00

$28.00

$112.00

$130.00

$20.00

$110.00

$201.00

$39.00

$162.00

$131.00

$25.00

$106.00

$227.00

$66.00

$97.00

$97.00

$14.00

$82.00

$151.00

$26.00

$125.00

$189.00

$28.00

$160.00

$206.00

$44.00

$162.00

$167.00

$28.00

$139.00

$208.00

$162.00

$178.00

$45.00

$132.00

$208.00

$46.00

$162.00

$131.00

$28.00

$103.00

$132.00

$68.00

$64.00

$80.00

$25.00

$55.00

$47.00

$47.00

$174.00

$150.00

$30.00

$121.00

$139.00

$21.00

$118.00

$215.00

$41.00

$174.00

$140.00

$27.00

$113.00

$242.00

$68.00

$105.00

$103.00

$15.00

$88.00

$161.00

$27.00

$134.00

$202.00

$30.00

$172.00

$220.00

$46.00

$173.00

$178.00

$29.00

$149.00

$222.00

$173.00

$189.00

$47.00

$142.00

$222.00

$48.00

$174.00

$140.00

$30.00

$110.00

$139.00

$70.00

$68.00

$85.00

$26.00

$59.00

$50.00

$50.00

$175.00

$153.00

$31.00

$121.00

$141.00

$22.00

$119.00

$218.00

$43.00

$175.00

$142.00

$28.00

$114.00

$246.00

$71.00

$105.00

$105.00

$16.00

$89.00

$164.00

$28.00

$135.00

$204.00

$31.00

$173.00

$222.00

$48.00

$174.00

$181.00

$30.00

$150.00

$225.00

$174.00

$191.00

$48.00

$143.00

$226.00

$51.00

$175.00

$143.00

$32.00

$111.00

$141.00

$72.00

$69.00

$87.00

$28.00

$60.00

$52.00


Part C, 394



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

94070-TC

94150

94150-26

94150-TC

94200

94200-26

94200-TC

94250

94250-26

94250-TC

94375

94375-26

94375-TC

94400

94400-26

94400-TC

93990

93990-26

93990-TC

94002

94003

94004

94010

94010-26

94010-TC

94014

94015

94016

94060

94060-26

94060-TC

94070

94070-26

94450

94450-26

94450-TC

94452

94452-26

94452-TC

94453

94453-26

94453-TC

94610

94620

94620-26

94620-TC

94621

94621-26

94621-TC

94640

$19.00

$8.00

$6.00

$3.00

$17.00

$7.00

$9.00

$12.00

$8.00

$5.00

$34.00

$16.00

$17.00

$40.00

$24.00

$14.00

$110.00

$14.00

$96.00

---------

---------

---------

$30.00

$12.00

$16.00

$39.00

$14.00

$26.00

$57.00

$18.00

$36.00

$32.00

$11.00

$37.00

$20.00

$15.00

---------

---------

---------

---------

---------

---------

---------

$91.00

$38.00

$54.00

$122.00

$71.00

$52.00

$19.00

$33.00

$27.00

$4.00

$23.00

$27.00

$6.00

$21.00

$28.00

$6.00

$22.00

$43.00

$17.00

$26.00

$61.00

$22.00

$39.00

$126.00

$29.00

$97.00

$105.00

$76.00

$55.00

$39.00

$9.00

$30.00

$61.00

$33.00

$28.00

$66.00

$15.00

$51.00

$65.00

$32.00

$74.00

$22.00

$52.00

$62.00

$16.00

$46.00

$86.00

$21.00

$65.00

$67.00

$62.00

$34.00

$27.00

$178.00

$77.00

$101.00

$20.00

$36.00

$29.00

$5.00

$25.00

$29.00

$7.00

$23.00

$30.00

$6.00

$24.00

$45.00

$17.00

$28.00

$64.00

$23.00

$42.00

$134.00

$30.00

$104.00

$109.00

$78.00

$57.00

$42.00

$10.00

$32.00

$65.00

$36.00

$29.00

$70.00

$15.00

$55.00

$69.00

$33.00

$79.00

$23.00

$55.00

$66.00

$17.00

$50.00

$92.00

$22.00

$70.00

$69.00

$65.00

$35.00

$29.00

$188.00

$79.00

$108.00

$21.00

$36.00

$30.00

$5.00

$25.00

$30.00

$7.00

$23.00

$31.00

$7.00

$25.00

$46.00

$17.00

$29.00

$65.00

$23.00

$42.00

$138.00

$33.00

$105.00

$114.00

$82.00

$59.00

$42.00

$10.00

$32.00

$66.00

$36.00

$30.00

$71.00

$15.00

$55.00

$70.00

$34.00

$80.00

$24.00

$56.00

$67.00

$17.00

$50.00

$93.00

$23.00

$71.00

$71.00

$66.00

$36.00

$30.00

$191.00

$81.00

$109.00

$22.00

$33.00

$27.00

$4.00

$23.00

$27.00

$6.00

$21.00

$28.00

$6.00

$22.00

$43.00

$17.00

$26.00

$61.00

$22.00

$39.00

$126.00

$29.00

$97.00

$105.00

$76.00

$55.00

$39.00

$9.00

$30.00

$61.00

$33.00

$28.00

$66.00

$15.00

$51.00

$65.00

$32.00

$74.00

$22.00

$52.00

$62.00

$16.00

$46.00

$86.00

$21.00

$65.00

$67.00

$62.00

$34.00

$27.00

$178.00

$77.00

$101.00

$20.00

$36.00

$29.00

$5.00

$25.00

$29.00

$7.00

$23.00

$30.00

$6.00

$24.00

$45.00

$17.00

$28.00

$64.00

$23.00

$42.00

$134.00

$30.00

$104.00

$109.00

$78.00

$57.00

$42.00

$10.00

$32.00

$65.00

$36.00

$29.00

$70.00

$15.00

$55.00

$69.00

$33.00

$79.00

$23.00

$55.00

$66.00

$17.00

$50.00

$92.00

$22.00

$70.00

$69.00

$65.00

$35.00

$29.00

$188.00

$79.00

$108.00

$21.00

$36.00

$30.00

$5.00

$25.00

$30.00

$7.00

$23.00

$31.00

$7.00

$25.00

$46.00

$17.00

$29.00

$65.00

$23.00

$42.00

$138.00

$33.00

$105.00

$114.00

$82.00

$59.00

$42.00

$10.00

$32.00

$66.00

$36.00

$30.00

$71.00

$15.00

$55.00

$70.00

$34.00

$80.00

$24.00

$56.00

$67.00

$17.00

$50.00

$93.00

$23.00

$71.00

$71.00

$66.00

$36.00

$30.00

$191.00

$81.00

$109.00

$22.00


Part C, 395



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

94690-TC

94726

94726-26

94726-TC

94727

94727-26

94727-TC

94728

94728-26

94728-TC

94729

94729-26

94729-TC

94750

94750-26

94750-TC

94642

94644

94645

94660

94662

94664

94667

94668

94669

94680

94680-26

94680-TC

94681

94681-26

94681-TC

94690

94690-26

94760

94761

94762

94770

94770-26

94770-TC

94799

94799-26

94799-TC

95004

95012

95017

95018

95024

95027

95028

95044

$20.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$37.00

$14.00

$21.00

BR

---------

---------

$54.00

$38.00

$18.00

$23.00

$16.00

---------

$47.00

$23.00

$22.00

$60.00

$12.00

$43.00

$24.00

$4.00

BR

$3.00

---------

---------

---------

$3.00

$5.00

$8.00

$7.00

$9.00

$20.00

$30.00

$21.00

$9.00

$12.00

BR

BR

$49.00

$57.00

$14.00

$43.00

$46.00

$14.00

$32.00

$44.00

$14.00

$30.00

$59.00

$10.00

$49.00

$87.00

$13.00

$74.00

---------

$47.00

$15.00

$70.00

$42.00

$19.00

$28.00

$31.00

$35.00

$62.00

$14.00

$48.00

$57.00

$11.00

$46.00

$54.00

$4.00

$4.00

$5.00

$26.00

$8.00

---------

---------

---------

---------

---------

$7.00

$21.00

$9.00

$22.00

$8.00

$5.00

$15.00

$6.00

$53.00

$61.00

$14.00

$47.00

$49.00

$14.00

$34.00

$46.00

$15.00

$32.00

$63.00

$11.00

$52.00

$93.00

$13.00

$80.00

---------

$51.00

$16.00

$73.00

$44.00

$20.00

$31.00

$34.00

$38.00

$66.00

$15.00

$51.00

$61.00

$11.00

$49.00

$58.00

$5.00

$4.00

$6.00

$28.00

$9.00

---------

---------

---------

---------

---------

$8.00

$22.00

$9.00

$24.00

$9.00

$6.00

$16.00

$7.00

$53.00

$61.00

$14.00

$47.00

$49.00

$14.00

$35.00

$47.00

$15.00

$32.00

$64.00

$11.00

$53.00

$94.00

$13.00

$80.00

---------

$51.00

$17.00

$75.00

$46.00

$21.00

$31.00

$35.00

$39.00

$67.00

$15.00

$52.00

$62.00

$12.00

$50.00

$58.00

$5.00

$4.00

$6.00

$29.00

$9.00

---------

---------

---------

---------

---------

$8.00

$23.00

$9.00

$24.00

$10.00

$6.00

$16.00

$7.00

$49.00

$57.00

$14.00

$43.00

$46.00

$14.00

$32.00

$44.00

$14.00

$30.00

$59.00

$10.00

$49.00

$87.00

$13.00

$74.00

---------

$47.00

$15.00

$43.00

$42.00

$19.00

$28.00

$31.00

$35.00

$62.00

$14.00

$48.00

$57.00

$11.00

$46.00

$54.00

$4.00

$4.00

$5.00

$26.00

$8.00

---------

---------

---------

---------

---------

$7.00

$21.00

$4.00

$8.00

$1.00

$5.00

$15.00

$6.00

$53.00

$61.00

$14.00

$47.00

$49.00

$14.00

$34.00

$46.00

$15.00

$32.00

$63.00

$11.00

$52.00

$93.00

$13.00

$80.00

---------

$51.00

$16.00

$45.00

$44.00

$20.00

$31.00

$34.00

$38.00

$66.00

$15.00

$51.00

$61.00

$11.00

$49.00

$58.00

$5.00

$4.00

$6.00

$28.00

$9.00

---------

---------

---------

---------

---------

$8.00

$22.00

$4.00

$8.00

$1.00

$6.00

$16.00

$7.00

$53.00

$61.00

$14.00

$47.00

$49.00

$14.00

$35.00

$47.00

$15.00

$32.00

$64.00

$11.00

$53.00

$94.00

$13.00

$80.00

---------

$51.00

$17.00

$46.00

$46.00

$21.00

$31.00

$35.00

$39.00

$67.00

$15.00

$52.00

$62.00

$12.00

$50.00

$58.00

$5.00

$4.00

$6.00

$29.00

$9.00

---------

---------

---------

---------

---------

$8.00

$23.00

$5.00

$9.00

$2.00

$6.00

$16.00

$7.00


Part C, 396



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

95144

95145

95146

95147

95148

95149

95165

95170

95180

95199

95250

95251

95803

95803-26

95803-TC

95805

95117

95120

95125

95130

95131

95132

95133

95134

95052

95056

95060

95065

95070

95071

95076

95079

95115

95805-26

95805-TC

95806

95806-26

95806-TC

95807

95807-26

95807-TC

95808

95808-26

95808-TC

95810

95810-26

95810-TC

95811

95811-26

95811-TC

$9.00

$17.00

$24.00

$33.00

$32.00

$36.00

$7.00

$13.00

$103.00

BR

$114.00

---------

---------

---------

---------

$334.00

$9.00

BR

BR

BR

BR

BR

BR

BR

$9.00

$6.00

$13.00

$7.00

$82.00

$105.00

---------

---------

$10.00

$94.00

$237.00

$232.00

$109.00

$137.00

$367.00

$98.00

$256.00

$456.00

$149.00

$256.00

$521.00

$183.00

$256.00

$644.00

$196.00

$423.00

$13.00

$23.00

$42.00

$38.00

$56.00

$75.00

$14.00

$10.00

$147.00

---------

$169.00

$49.00

$153.00

$49.00

$104.00

$461.00

$7.00

$48.00

$38.00

$27.00

$33.00

$38.00

$128.00

$91.00

$10.00

$11.00

---------

---------

---------

---------

---------

---------

---------

$66.00

$395.00

$183.00

$68.00

$115.00

$515.00

$70.00

$446.00

$679.00

$98.00

$581.00

$673.00

$136.00

$537.00

$708.00

$142.00

$566.00

$14.00

$25.00

$45.00

$40.00

$60.00

$81.00

$15.00

$11.00

$153.00

---------

$182.00

$50.00

$163.00

$50.00

$112.00

$492.00

$8.00

$51.00

$40.00

$29.00

$35.00

$41.00

$133.00

$95.00

$10.00

$12.00

---------

---------

---------

---------

---------

---------

---------

$68.00

$424.00

$193.00

$70.00

$123.00

$551.00

$72.00

$479.00

$726.00

$102.00

$624.00

$718.00

$140.00

$577.00

$755.00

$146.00

$608.00

$15.00

$25.00

$45.00

$41.00

$60.00

$81.00

$15.00

$11.00

$156.00

---------

$184.00

$52.00

$164.00

$52.00

$113.00

$497.00

$8.00

$52.00

$41.00

$30.00

$36.00

$41.00

$135.00

$96.00

$11.00

$12.00

---------

---------

---------

---------

---------

---------

---------

$70.00

$428.00

$195.00

$72.00

$124.00

$556.00

$74.00

$482.00

$733.00

$104.00

$629.00

$725.00

$144.00

$582.00

$763.00

$150.00

$613.00

$4.00

$4.00

$4.00

$4.00

$4.00

$4.00

$4.00

$4.00

$113.00

---------

$169.00

$49.00

$153.00

$49.00

$104.00

$461.00

$7.00

$48.00

$38.00

$27.00

$33.00

$38.00

$82.00

$75.00

$10.00

$11.00

---------

---------

---------

---------

---------

---------

---------

$66.00

$395.00

$183.00

$68.00

$115.00

$515.00

$70.00

$446.00

$679.00

$98.00

$581.00

$673.00

$136.00

$537.00

$708.00

$142.00

$566.00

$4.00

$4.00

$4.00

$4.00

$4.00

$4.00

$4.00

$4.00

$116.00

---------

$182.00

$50.00

$163.00

$50.00

$112.00

$492.00

$8.00

$51.00

$40.00

$29.00

$35.00

$41.00

$84.00

$77.00

$10.00

$12.00

---------

---------

---------

---------

---------

---------

---------

$68.00

$424.00

$193.00

$70.00

$123.00

$551.00

$72.00

$479.00

$726.00

$102.00

$624.00

$718.00

$140.00

$577.00

$755.00

$146.00

$608.00

$119.00

---------

$184.00

$52.00

$164.00

$52.00

$113.00

$497.00

$4.00

$4.00

$4.00

$4.00

$4.00

$4.00

$4.00

$4.00

$8.00

$52.00

$41.00

$30.00

$36.00

$41.00

$86.00

$78.00

$11.00

$12.00

---------

---------

---------

---------

---------

---------

---------

$70.00

$428.00

$195.00

$72.00

$124.00

$556.00

$74.00

$482.00

$733.00

$104.00

$629.00

$725.00

$144.00

$582.00

$763.00

$150.00

$613.00


Part C, 397



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

95831

95832

95833

95834

95851

95852

95857

95860

95824-TC

95827

95827-26

95827-TC

95829

95829-26

95829-TC

95830

95812

95812-26

95812-TC

95813

95813-26

95813-TC

95816

95816-26

95816-TC

95819

95819-26

95819-TC

95822

95822-26

95822-TC

95824

95824-26

95860-26

95860-TC

95861

95861-26

95861-TC

95863

95863-26

95863-TC

95864

95864-26

95864-TC

95865

95865-26

95865-TC

95866

95866-26

95866-TC

$10.00

$145.00

$59.00

$86.00

$328.00

$291.00

$6.00

$133.00

$26.00

$21.00

$34.00

$44.00

$18.00

$14.00

$40.00

$73.00

$137.00

$58.00

$68.00

$177.00

$89.00

$68.00

$133.00

$54.00

$78.00

$115.00

$58.00

$56.00

$120.00

$58.00

$63.00

$51.00

$41.00

$53.00

$15.00

$113.00

$86.00

$28.00

$138.00

$102.00

$35.00

$177.00

$114.00

$67.00

---------

---------

---------

---------

---------

---------

---------

$750.00

$64.00

$686.00

$2,031.00

$380.00

$1,652.00

$267.00

$33.00

$32.00

$41.00

$56.00

$20.00

$18.00

$59.00

$133.00

$376.00

$65.00

$311.00

$456.00

$103.00

$353.00

$390.00

$65.00

$326.00

$446.00

$65.00

$381.00

$402.00

$65.00

$337.00

---------

$44.00

$58.00

$75.00

$187.00

$93.00

$94.00

$232.00

$112.00

$120.00

$262.00

$122.00

$141.00

$158.00

$95.00

$63.00

$146.00

$75.00

$71.00

---------

$804.00

$66.00

$737.00

$2,168.00

$396.00

$1,773.00

$284.00

$35.00

$34.00

$43.00

$59.00

$21.00

$19.00

$63.00

$140.00

$401.00

$67.00

$334.00

$486.00

$107.00

$379.00

$417.00

$67.00

$350.00

$476.00

$67.00

$410.00

$429.00

$67.00

$362.00

---------

$46.00

$60.00

$81.00

$198.00

$96.00

$101.00

$245.00

$115.00

$129.00

$278.00

$126.00

$151.00

$167.00

$99.00

$68.00

$153.00

$77.00

$76.00

---------

$811.00

$68.00

$743.00

$2,192.00

$412.00

$1,780.00

$289.00

$36.00

$36.00

$43.00

$61.00

$22.00

$19.00

$64.00

$142.00

$405.00

$69.00

$336.00

$491.00

$110.00

$381.00

$420.00

$69.00

$352.00

$481.00

$69.00

$412.00

$433.00

$69.00

$364.00

---------

$47.00

$61.00

$81.00

$201.00

$99.00

$102.00

$248.00

$118.00

$130.00

$283.00

$131.00

$152.00

$171.00

$102.00

$69.00

$156.00

$79.00

$77.00

---------

$750.00

$64.00

$686.00

$2,031.00

$380.00

$1,652.00

$104.00

$17.00

$18.00

$24.00

$35.00

$9.00

$7.00

$33.00

$133.00

$376.00

$65.00

$311.00

$456.00

$103.00

$353.00

$390.00

$65.00

$326.00

$446.00

$65.00

$381.00

$402.00

$65.00

$337.00

---------

$44.00

$58.00

$75.00

$187.00

$93.00

$94.00

$232.00

$112.00

$120.00

$262.00

$122.00

$141.00

$158.00

$95.00

$63.00

$146.00

$75.00

$71.00

---------

$804.00

$66.00

$737.00

$2,168.00

$396.00

$1,773.00

$108.00

$18.00

$19.00

$25.00

$36.00

$9.00

$7.00

$35.00

$140.00

$401.00

$67.00

$334.00

$486.00

$107.00

$379.00

$417.00

$67.00

$350.00

$476.00

$67.00

$410.00

$429.00

$67.00

$362.00

---------

$46.00

$60.00

$81.00

$198.00

$96.00

$101.00

$245.00

$115.00

$129.00

$278.00

$126.00

$151.00

$167.00

$99.00

$68.00

$153.00

$77.00

$76.00

---------

$811.00

$68.00

$743.00

$2,192.00

$412.00

$1,780.00

$112.00

$19.00

$20.00

$25.00

$38.00

$9.00

$7.00

$36.00

$142.00

$405.00

$69.00

$336.00

$491.00

$110.00

$381.00

$420.00

$69.00

$352.00

$481.00

$69.00

$412.00

$433.00

$69.00

$364.00

---------

$47.00

$61.00

$81.00

$201.00

$99.00

$102.00

$248.00

$118.00

$130.00

$283.00

$131.00

$152.00

$171.00

$102.00

$69.00

$156.00

$79.00

$77.00


Part C, 398



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

95873-TC

95874

95874-26

95874-TC

95875

95875-26

95875-TC

95885

95885-26

95885-TC

95886

95886-26

95886-TC

95887

95887-26

95887-TC

95867

95867-26

95867-TC

95868

95868-26

95868-TC

95869

95869-26

95869-TC

95870

95870-26

95870-TC

95872

95872-26

95872-TC

95873

95873-26

95905

95905-26

95905-TC

95907

95907-26

95907-TC

95908

95908-26

95908-TC

95909

95909-26

95909-TC

95910

95910-26

95910-TC

95911

95911-26

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$43.00

$34.00

$7.00

---------

$66.00

$43.00

$21.00

$96.00

$71.00

$26.00

$29.00

$21.00

$8.00

$29.00

$21.00

$8.00

$104.00

$81.00

$22.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$57.00

$79.00

$22.00

$57.00

$136.00

$66.00

$70.00

$64.00

$21.00

$42.00

$99.00

$52.00

$48.00

$88.00

$43.00

$46.00

$103.00

$47.00

$56.00

$145.00

$71.00

$74.00

$100.00

$22.00

$78.00

$100.00

$22.00

$78.00

$217.00

$172.00

$45.00

$79.00

$22.00

$75.00

$3.00

$72.00

$104.00

$60.00

$45.00

$130.00

$75.00

$55.00

$158.00

$90.00

$68.00

$210.00

$120.00

$91.00

$254.00

$150.00

$61.00

$84.00

$23.00

$61.00

$144.00

$69.00

$75.00

$67.00

$22.00

$45.00

$105.00

$54.00

$51.00

$93.00

$44.00

$49.00

$109.00

$48.00

$60.00

$153.00

$74.00

$79.00

$107.00

$23.00

$84.00

$107.00

$23.00

$84.00

$226.00

$178.00

$48.00

$84.00

$23.00

$81.00

$3.00

$77.00

$110.00

$62.00

$48.00

$136.00

$77.00

$59.00

$166.00

$93.00

$73.00

$221.00

$124.00

$97.00

$267.00

$155.00

$61.00

$85.00

$24.00

$61.00

$147.00

$71.00

$76.00

$68.00

$23.00

$46.00

$106.00

$55.00

$51.00

$95.00

$45.00

$49.00

$110.00

$50.00

$61.00

$156.00

$76.00

$80.00

$108.00

$24.00

$84.00

$108.00

$23.00

$85.00

$232.00

$183.00

$49.00

$85.00

$23.00

$82.00

$4.00

$78.00

$112.00

$63.00

$49.00

$139.00

$79.00

$60.00

$169.00

$95.00

$74.00

$225.00

$127.00

$98.00

$272.00

$159.00

$57.00

$79.00

$22.00

$57.00

$136.00

$66.00

$70.00

$64.00

$21.00

$42.00

$99.00

$52.00

$48.00

$88.00

$43.00

$46.00

$103.00

$47.00

$56.00

$145.00

$71.00

$74.00

$100.00

$22.00

$78.00

$100.00

$22.00

$78.00

$217.00

$172.00

$45.00

$79.00

$22.00

$75.00

$3.00

$72.00

$104.00

$60.00

$45.00

$130.00

$75.00

$55.00

$158.00

$90.00

$68.00

$210.00

$120.00

$91.00

$254.00

$150.00

$61.00

$84.00

$23.00

$61.00

$144.00

$69.00

$75.00

$67.00

$22.00

$45.00

$105.00

$54.00

$51.00

$93.00

$44.00

$49.00

$109.00

$48.00

$60.00

$153.00

$74.00

$79.00

$107.00

$23.00

$84.00

$107.00

$23.00

$84.00

$226.00

$178.00

$48.00

$84.00

$23.00

$81.00

$3.00

$77.00

$110.00

$62.00

$48.00

$136.00

$77.00

$59.00

$166.00

$93.00

$73.00

$221.00

$124.00

$97.00

$267.00

$155.00

$61.00

$85.00

$24.00

$61.00

$147.00

$71.00

$76.00

$68.00

$23.00

$46.00

$106.00

$55.00

$51.00

$95.00

$45.00

$49.00

$110.00

$50.00

$61.00

$156.00

$76.00

$80.00

$108.00

$24.00

$84.00

$108.00

$23.00

$85.00

$232.00

$183.00

$49.00

$85.00

$23.00

$82.00

$4.00

$78.00

$112.00

$63.00

$49.00

$139.00

$79.00

$60.00

$169.00

$95.00

$74.00

$225.00

$127.00

$98.00

$272.00

$159.00


Part C, 399



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

95924-26

95924-TC

95925

95925-26

95925-TC

95926

95926-26

95926-TC

95927

95927-26

95927-TC

95928

95928-26

95928-TC

95929

95929-26

95911-TC

95912

95912-26

95912-TC

95913

95913-26

95913-TC

95921

95921-26

95921-TC

95922

95922-26

95922-TC

95923

95923-26

95923-TC

95924

95929-TC

95930

95930-26

95930-TC

95933

95933-26

95933-TC

95937

95937-26

95937-TC

95938

95938-26

95938-TC

95939

95939-26

95939-TC

95940

---------

---------

$94.00

$53.00

$41.00

$66.00

$34.00

$34.00

$67.00

$34.00

$34.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$61.00

$46.00

$14.00

$65.00

$50.00

$14.00

$105.00

$47.00

$57.00

---------

---------

$44.00

$25.00

$11.00

$62.00

$33.00

$30.00

$40.00

$31.00

$9.00

---------

---------

---------

---------

---------

---------

---------

$100.00

$63.00

$168.00

$32.00

$136.00

$149.00

$31.00

$118.00

$154.00

$31.00

$123.00

$244.00

$90.00

$154.00

$246.00

$91.00

$104.00

$285.00

$178.00

$107.00

$326.00

$210.00

$116.00

$94.00

$51.00

$44.00

$110.00

$54.00

$56.00

$178.00

$52.00

$126.00

$164.00

$155.00

$139.00

$21.00

$119.00

$82.00

$35.00

$47.00

$89.00

$38.00

$50.00

$368.00

$52.00

$316.00

$541.00

$134.00

$407.00

$37.00

$104.00

$68.00

$179.00

$33.00

$147.00

$159.00

$32.00

$127.00

$164.00

$32.00

$132.00

$258.00

$93.00

$165.00

$261.00

$94.00

$112.00

$299.00

$184.00

$115.00

$342.00

$218.00

$124.00

$99.00

$52.00

$47.00

$116.00

$56.00

$60.00

$189.00

$54.00

$135.00

$172.00

$167.00

$149.00

$21.00

$128.00

$86.00

$36.00

$50.00

$94.00

$40.00

$54.00

$393.00

$53.00

$340.00

$576.00

$139.00

$437.00

$38.00

$107.00

$69.00

$181.00

$34.00

$148.00

$160.00

$33.00

$128.00

$166.00

$33.00

$134.00

$262.00

$95.00

$166.00

$265.00

$97.00

$113.00

$304.00

$189.00

$116.00

$348.00

$223.00

$125.00

$101.00

$54.00

$47.00

$118.00

$57.00

$60.00

$192.00

$56.00

$136.00

$176.00

$167.00

$150.00

$22.00

$128.00

$88.00

$37.00

$51.00

$95.00

$41.00

$54.00

$396.00

$55.00

$341.00

$582.00

$143.00

$440.00

$40.00

$100.00

$63.00

$168.00

$32.00

$136.00

$149.00

$31.00

$118.00

$154.00

$31.00

$123.00

$244.00

$90.00

$154.00

$246.00

$91.00

$104.00

$285.00

$178.00

$107.00

$326.00

$210.00

$116.00

$94.00

$51.00

$44.00

$110.00

$54.00

$56.00

$178.00

$52.00

$126.00

$164.00

$155.00

$139.00

$21.00

$119.00

$82.00

$35.00

$47.00

$89.00

$38.00

$50.00

$368.00

$52.00

$316.00

$541.00

$134.00

$407.00

$37.00

$104.00

$68.00

$179.00

$33.00

$147.00

$159.00

$32.00

$127.00

$164.00

$32.00

$132.00

$258.00

$93.00

$165.00

$261.00

$94.00

$112.00

$299.00

$184.00

$115.00

$342.00

$218.00

$124.00

$99.00

$52.00

$47.00

$116.00

$56.00

$60.00

$189.00

$54.00

$135.00

$172.00

$167.00

$149.00

$21.00

$128.00

$86.00

$36.00

$50.00

$94.00

$40.00

$54.00

$393.00

$53.00

$340.00

$576.00

$139.00

$437.00

$38.00

$107.00

$69.00

$181.00

$34.00

$148.00

$160.00

$33.00

$128.00

$166.00

$33.00

$134.00

$262.00

$95.00

$166.00

$265.00

$97.00

$113.00

$304.00

$189.00

$116.00

$348.00

$223.00

$125.00

$101.00

$54.00

$47.00

$118.00

$57.00

$60.00

$192.00

$56.00

$136.00

$176.00

$167.00

$150.00

$22.00

$128.00

$88.00

$37.00

$51.00

$95.00

$41.00

$54.00

$396.00

$55.00

$341.00

$582.00

$143.00

$440.00

$40.00


Part C, 400



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

95956-TC

95957

95957-26

95957-TC

95958

95958-26

95958-TC

95961

95961-26

95961-TC

95962

95962-26

95962-TC

95965

95965-26

95965-TC

95950

95950-26

95950-TC

95951

95951-26

95951-TC

95953

95953-26

95953-TC

95954

95954-26

95954-TC

95955

95955-26

95955-TC

95956

95956-26

95972

95974

95975

95978

95979

95980

95981

95982

95990

95966

95966-26

95966-TC

95967

95967-26

95967-TC

95970

95971

$314.00

$171.00

$104.00

$64.00

$296.00

$230.00

$66.00

$216.00

$166.00

$48.00

$227.00

$176.00

$48.00

BR

$420.00

BR

$265.00

$84.00

$177.00

$34.00

$14.00

$20.00

$411.00

$165.00

$240.00

$208.00

$134.00

$23.00

$130.00

$59.00

$74.00

$541.00

$166.00

BR

$210.00

BR

BR

$184.00

BR

$22.00

$39.00

$78.00

$155.00

$88.00

---------

---------

---------

---------

---------

$57.00

$1,553.00

$342.00

$118.00

$224.00

$624.00

$254.00

$370.00

$324.00

$183.00

$140.00

$289.00

$195.00

$94.00

---------

$471.00

---------

$358.00

$90.00

$268.00

---------

$358.00

---------

$459.00

$184.00

$275.00

$488.00

$140.00

$349.00

$234.00

$61.00

$173.00

$1,767.00

$215.00

---------

$238.00

---------

---------

$208.00

---------

$74.00

$56.00

$65.00

$231.00

$125.00

$278.00

$121.00

$54.00

$35.00

$59.00

$98.00

$1,668.00

$363.00

$122.00

$241.00

$662.00

$264.00

$398.00

$343.00

$192.00

$151.00

$304.00

$203.00

$101.00

---------

$487.00

---------

$381.00

$93.00

$288.00

---------

$371.00

---------

$486.00

$191.00

$296.00

$519.00

$145.00

$375.00

$249.00

$63.00

$186.00

$1,891.00

$222.00

---------

$247.00

---------

---------

$215.00

---------

$78.00

$59.00

$68.00

$243.00

$131.00

$292.00

$127.00

$57.00

$37.00

$62.00

$106.00

$1,679.00

$367.00

$125.00

$242.00

$674.00

$274.00

$401.00

$352.00

$201.00

$152.00

$311.00

$210.00

$101.00

---------

$500.00

---------

$385.00

$95.00

$290.00

---------

$381.00

---------

$494.00

$196.00

$297.00

$526.00

$149.00

$377.00

$252.00

$65.00

$187.00

$1,907.00

$229.00

---------

$254.00

---------

---------

$221.00

---------

$80.00

$61.00

$71.00

$252.00

$135.00

$304.00

$131.00

$62.00

$39.00

$65.00

$107.00

$1,553.00

$342.00

$118.00

$224.00

$624.00

$254.00

$370.00

$324.00

$183.00

$140.00

$289.00

$195.00

$94.00

---------

$471.00

---------

$358.00

$90.00

$268.00

---------

$358.00

---------

$459.00

$184.00

$275.00

$488.00

$140.00

$349.00

$234.00

$61.00

$173.00

$1,767.00

$215.00

---------

$238.00

---------

---------

$208.00

---------

$27.00

$46.00

$47.00

$185.00

$105.00

$218.00

$101.00

$54.00

$20.00

$42.00

$98.00

$1,668.00

$363.00

$122.00

$241.00

$662.00

$264.00

$398.00

$343.00

$192.00

$151.00

$304.00

$203.00

$101.00

---------

$487.00

---------

$381.00

$93.00

$288.00

---------

$371.00

---------

$486.00

$191.00

$296.00

$519.00

$145.00

$375.00

$249.00

$63.00

$186.00

$1,891.00

$222.00

---------

$247.00

---------

---------

$215.00

---------

$28.00

$48.00

$49.00

$193.00

$109.00

$228.00

$106.00

$57.00

$21.00

$44.00

$106.00

$1,679.00

$367.00

$125.00

$242.00

$674.00

$274.00

$401.00

$352.00

$201.00

$152.00

$311.00

$210.00

$101.00

---------

$500.00

---------

$385.00

$95.00

$290.00

---------

$381.00

---------

$494.00

$196.00

$297.00

$526.00

$149.00

$377.00

$252.00

$65.00

$187.00

$1,907.00

$229.00

---------

$254.00

---------

---------

$221.00

---------

$29.00

$50.00

$52.00

$202.00

$114.00

$239.00

$110.00

$62.00

$23.00

$47.00

$107.00


Part C, 401



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

96152

96153

96154

96155

96360

96361

96365

96366

96116

96118

96119

96120

96125

96127

96150

96151

95991

95992

95999

96000

96001

96002

96003

96004

96020

96020-26

96020-TC

96101

96102

96103

96105

96110

96111

96375

96401

96402

96405

96406

96409

96411

96413

96415

96367

96368

96369

96370

96371

96372

96373

96374

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

$93.00

$111.00

$21.00

$20.00

$97.00

---------

---------

---------

---------

---------

---------

$68.00

$88.00

$68.00

---------

---------

---------

See formula

---------

---------

---------

---------

---------

---------

---------

$57.00

$86.00

---------

---------

---------

---------

$103.00

$108.00

$87.00

$53.00

$129.00

$6.00

$24.00

$23.00

$22.00

$5.00

$22.00

$25.00

$62.00

$17.00

$75.00

$20.00

$132.00

$48.00

---------

$107.00

$121.00

$25.00

$19.00

$131.00

BR

$183.00

BR

$89.00

$69.00

$31.00

$118.00

$10.00

$144.00

$33.00

$22.00

$206.00

$16.00

$78.00

$27.00

$21.00

$61.00

$24.00

$80.00

$35.00

$89.00

$126.00

$119.00

$67.00

$146.00

$31.00

$107.00

$112.00

$92.00

$56.00

$134.00

$6.00

$25.00

$24.00

$23.00

$5.00

$22.00

$26.00

$66.00

$18.00

$80.00

$22.00

$140.00

$50.00

---------

$111.00

$127.00

$25.00

$20.00

$136.00

BR

$189.00

BR

$91.00

$73.00

$32.00

$123.00

$10.00

$149.00

$35.00

$24.00

$220.00

$17.00

$83.00

$29.00

$22.00

$66.00

$26.00

$86.00

$37.00

$94.00

$134.00

$128.00

$72.00

$156.00

$33.00

$110.00

$114.00

$92.00

$57.00

$136.00

$7.00

$25.00

$24.00

$23.00

$6.00

$23.00

$27.00

$67.00

$18.00

$81.00

$22.00

$142.00

$51.00

---------

$114.00

$134.00

$26.00

$20.00

$141.00

BR

$194.00

BR

$93.00

$74.00

$33.00

$126.00

$11.00

$153.00

$36.00

$24.00

$222.00

$17.00

$83.00

$29.00

$23.00

$67.00

$26.00

$88.00

$38.00

$95.00

$136.00

$131.00

$73.00

$159.00

$33.00

$97.00

$88.00

$26.00

$29.00

$129.00

$6.00

$24.00

$23.00

$22.00

$5.00

$21.00

$25.00

$62.00

$17.00

$75.00

$20.00

$45.00

$42.00

---------

$107.00

$121.00

$25.00

$19.00

$131.00

BR

$183.00

BR

$89.00

$26.00

$30.00

$118.00

$10.00

$137.00

$33.00

$22.00

$206.00

$16.00

$78.00

$27.00

$21.00

$61.00

$24.00

$80.00

$35.00

$33.00

$52.00

$119.00

$67.00

$146.00

$31.00

$100.00

$90.00

$27.00

$30.00

$134.00

$6.00

$24.00

$23.00

$22.00

$5.00

$22.00

$26.00

$66.00

$18.00

$80.00

$22.00

$47.00

$43.00

---------

$111.00

$127.00

$25.00

$20.00

$136.00

BR

$189.00

BR

$91.00

$27.00

$31.00

$123.00

$10.00

$141.00

$35.00

$24.00

$220.00

$17.00

$83.00

$29.00

$22.00

$66.00

$26.00

$86.00

$37.00

$35.00

$54.00

$128.00

$72.00

$156.00

$33.00

$103.00

$92.00

$28.00

$32.00

$136.00

$7.00

$25.00

$24.00

$23.00

$6.00

$23.00

$27.00

$67.00

$18.00

$81.00

$22.00

$48.00

$44.00

---------

$114.00

$134.00

$26.00

$20.00

$141.00

BR

$194.00

BR

$93.00

$28.00

$33.00

$126.00

$11.00

$145.00

$36.00

$24.00

$222.00

$17.00

$83.00

$29.00

$23.00

$67.00

$26.00

$88.00

$38.00

$36.00

$56.00

$131.00

$73.00

$159.00

$33.00


Part C, 402



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

96999

97001

97002

97003

97004

97005

97006

97010

96900

96904

96910

96912

96913

96920

96921

96922

96521

96522

96523

96542

96549

96567

96570

96571

96416

96417

96420

96422

96423

96425

96440

96446

96450

97032

97033

97034

97035

97036

97039

97110

97112

97113

97012

97014

97016

97018

97022

97024

97026

97028

$17.00

---------

$21.00

$24.00

$53.00

$152.00

$155.00

$214.00

BR

$62.00

$29.00

$62.00

$29.00

NC

NC

$10.00

---------

---------

$46.00

$46.00

$17.00

$54.00

$156.00

---------

$134.00

---------

---------

---------

$126.00

BR

$62.00

$69.00

$38.00

$16.00

$14.00

$15.00

$10.00

$15.00

$10.00

$9.00

$10.00

$16.00

$16.00

$13.00

$11.00

$19.00

$15.00

$22.00

$23.00

$24.00

$22.00

$67.00

$76.00

$97.00

$140.00

$169.00

$186.00

$258.00

---------

$83.00

$46.00

$93.00

$57.00

BR

BR

$7.00

$151.00

$67.00

$114.00

$182.00

$85.00

$195.00

$914.00

$218.00

$198.00

$148.00

$122.00

$27.00

$131.00

---------

$144.00

$67.00

$31.00

$18.00

$17.00

$21.00

$12.00

$25.00

$7.00

$7.00

$8.00

$21.00

$29.00

$20.00

$14.00

$36.00

---------

$35.00

$37.00

$47.00

$24.00

$72.00

$82.00

$105.00

$150.00

$178.00

$196.00

$272.00

---------

$86.00

$48.00

$97.00

$60.00

BR

BR

$7.00

$163.00

$72.00

$122.00

$196.00

$91.00

$210.00

$981.00

$236.00

$210.00

$159.00

$131.00

$29.00

$139.00

---------

$155.00

$71.00

$32.00

$18.00

$18.00

$22.00

$13.00

$27.00

$8.00

$7.00

$9.00

$22.00

$30.00

$21.00

$15.00

$38.00

---------

$37.00

$39.00

$49.00

$24.00

$73.00

$82.00

$105.00

$152.00

$181.00

$198.00

$276.00

---------

$88.00

$48.00

$99.00

$61.00

BR

BR

$7.00

$165.00

$74.00

$125.00

$200.00

$93.00

$215.00

$1,001.00

$245.00

$214.00

$162.00

$134.00

$29.00

$142.00

---------

$156.00

$77.00

$33.00

$19.00

$19.00

$22.00

$13.00

$27.00

$8.00

$7.00

$9.00

$22.00

$30.00

$21.00

$15.00

$38.00

---------

$38.00

$39.00

$49.00

$22.00

$67.00

$76.00

$97.00

$140.00

$74.00

$84.00

$136.00

---------

$83.00

$46.00

$93.00

$57.00

BR

BR

$7.00

$151.00

$67.00

$114.00

$182.00

$85.00

$195.00

$163.00

$35.00

$91.00

$148.00

$122.00

$27.00

$47.00

---------

$144.00

$67.00

$31.00

$18.00

$17.00

$21.00

$12.00

$25.00

$7.00

$7.00

$8.00

$21.00

$29.00

$20.00

$14.00

$36.00

---------

$35.00

$37.00

$47.00

$24.00

$72.00

$82.00

$105.00

$150.00

$77.00

$87.00

$141.00

---------

$86.00

$48.00

$97.00

$60.00

BR

BR

$7.00

$163.00

$72.00

$122.00

$196.00

$91.00

$210.00

$175.00

$40.00

$95.00

$159.00

$131.00

$29.00

$49.00

---------

$155.00

$71.00

$32.00

$18.00

$18.00

$22.00

$13.00

$27.00

$8.00

$7.00

$9.00

$22.00

$30.00

$21.00

$15.00

$38.00

---------

$37.00

$39.00

$49.00

$24.00

$73.00

$82.00

$105.00

$152.00

$79.00

$89.00

$145.00

---------

$88.00

$48.00

$99.00

$61.00

BR

BR

$7.00

$165.00

$74.00

$125.00

$200.00

$93.00

$215.00

$192.00

$48.00

$98.00

$162.00

$134.00

$29.00

$51.00

---------

$156.00

$77.00

$33.00

$19.00

$19.00

$22.00

$13.00

$27.00

$8.00

$7.00

$9.00

$22.00

$30.00

$21.00

$15.00

$38.00

---------

$38.00

$39.00

$49.00


Part C, 403



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

97761

97762

97799

97802

97803

97804

97810

97811

97602

97605

97606

97610

97750

97752

97755

97760

97533

97535

97537

97542

97545

97546

97597

97598

97116

97124

97139

97140

97150

97260

97261

97530

97532

98927

98928

98929

98940

98941

98942

98943

98960

98961

97813

97814

97850

97851

97852

97853

98925

98926

BR

---------

---------

---------

BR

$48.00

---------

---------

---------

---------

BR

$26.00

$17.00

$7.00

---------

---------

$21.00

$19.00

$15.00

$26.00

$18.00

$23.00

$17.00

$22.00

$22.00

$24.00

$23.00

$23.00

$17.00

$83.00

$41.00

---------

---------

---------

---------

$54.00

$26.00

$54.00

$26.00

NC

$32.00

NC

$23.00

NC

NC

$32.00

NC

$23.00

---------

---------

---------

$45.00

$53.00

$128.00

BR

---------

$39.00

$41.00

$36.00

$51.00

---------

$38.00

$33.00

$18.00

$40.00

$30.00

$31.00

$29.00

---------

$33.00

$19.00

---------

---------

$38.00

$29.00

$32.00

$38.00

$33.00

$34.00

---------

---------

$81.00

$27.00

$43.00

$34.00

---------

---------

---------

---------

NC

$50.00

NC

$80.00

NC

NC

$45.00

NC

$30.00

$30.00

$15.00

---------

$47.00

$55.00

$137.00

BR

---------

$41.00

$43.00

$38.00

$54.00

---------

$40.00

$34.00

$18.00

$42.00

$31.00

$32.00

$30.00

---------

$34.00

$20.00

---------

---------

$40.00

$30.00

$33.00

$40.00

$34.00

$35.00

---------

---------

$86.00

$28.00

$45.00

$35.00

---------

---------

---------

---------

NC

$53.00

NC

$83.00

NC

NC

$46.00

NC

$32.00

$33.00

$16.00

---------

$48.00

$56.00

$137.00

BR

---------

$41.00

$44.00

$38.00

$55.00

---------

$40.00

$35.00

$19.00

$43.00

$32.00

$33.00

$30.00

---------

$34.00

$20.00

---------

---------

$40.00

$31.00

$33.00

$41.00

$35.00

$36.00

---------

---------

$87.00

$28.00

$46.00

$36.00

---------

---------

---------

---------

NC

$54.00

NC

$85.00

NC

NC

$47.00

NC

$32.00

$33.00

$16.00

---------

$28.00

$30.00

$18.00

BR

---------

$39.00

$41.00

$36.00

$51.00

---------

$36.00

$30.00

$17.00

$34.00

$28.00

$31.00

$29.00

---------

$33.00

$19.00

---------

---------

$38.00

$29.00

$32.00

$38.00

$33.00

$34.00

---------

---------

$26.00

$12.00

$37.00

$31.00

---------

---------

---------

---------

NC

$40.00

NC

$67.00

NC

NC

$38.00

NC

$26.00

$30.00

$15.00

---------

$29.00

$31.00

$18.00

BR

---------

$41.00

$43.00

$38.00

$54.00

---------

$37.00

$32.00

$17.00

$36.00

$29.00

$32.00

$30.00

---------

$34.00

$20.00

---------

---------

$40.00

$30.00

$33.00

$40.00

$34.00

$35.00

---------

---------

$27.00

$13.00

$38.00

$32.00

---------

---------

---------

---------

NC

$42.00

NC

$69.00

NC

NC

$39.00

NC

$27.00

$33.00

$16.00

---------

$29.00

$32.00

$18.00

BR

---------

$41.00

$44.00

$38.00

$55.00

---------

$38.00

$32.00

$18.00

$37.00

$30.00

$33.00

$30.00

---------

$34.00

$20.00

---------

---------

$40.00

$31.00

$33.00

$41.00

$35.00

$36.00

---------

---------

$27.00

$13.00

$40.00

$33.00

---------

---------

---------

---------

NC

$43.00

NC

$71.00

NC

NC

$40.00

NC

$28.00

$33.00

$16.00


Part C, 404



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

99184

99190

99191

99192

99195

99199

G0101

G0102

G0104

G0105

G0105-53

G0106

G0106-26

G0106-TC

G0108

G0109

99078

99082

99090

99172

99173

99174

99175

99183

98962

99000

99001

99002

99026

99027

99070

99071

99075

G0117

G0118

G0120

G0120-26

G0120-TC

G0121

G0121-53

G0122

G0122-26

G0122-TC

G0128

G0166

G0179

G0180

G0181

G0182

G0237

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

BR

BR

$16.00

NC

---------

---------

---------

$6.00

$4.00

$35.00

BR

BR

BR

NC

See 440.13

NC

BR

BR

BR

BR

---------

$53.00

$123.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$256.00

---------

---------

---------

$107.00

NC

$42.00

$21.00

$182.00

$419.00

$209.00

$228.00

$56.00

$173.00

$58.00

$16.00

$11.00

---------

---------

---------

---------

---------

---------

NC

---------

NC

---------

---------

---------

$4.00

BR

$18.00

$125.00

$59.00

$48.00

$231.00

$58.00

$173.00

$419.00

$209.00

$288.00

$55.00

$233.00

$8.00

$148.00

$45.00

$59.00

$119.00

$120.00

$11.00

$265.00

---------

---------

---------

$116.00

NC

$45.00

$22.00

$195.00

$445.00

$222.00

$243.00

$57.00

$185.00

$61.00

$16.00

$12.00

---------

---------

---------

---------

---------

---------

NC

---------

NC

---------

---------

---------

$4.00

BR

$20.00

$131.00

$62.00

$51.00

$246.00

$61.00

$185.00

$446.00

$222.00

$306.00

$56.00

$250.00

$9.00

$159.00

$47.00

$62.00

$125.00

$125.00

$12.00

$274.00

---------

---------

---------

$118.00

NC

$46.00

$23.00

$199.00

$460.00

$229.00

$245.00

$59.00

$186.00

$62.00

$17.00

$12.00

---------

---------

---------

---------

---------

---------

NC

---------

NC

---------

---------

---------

$4.00

BR

$20.00

$139.00

$63.00

$51.00

$250.00

$64.00

$186.00

$461.00

$229.00

$309.00

$57.00

$251.00

$10.00

$160.00

$48.00

$63.00

$128.00

$128.00

$12.00

$256.00

---------

---------

---------

$107.00

NC

$31.00

$10.00

$65.00

$222.00

$112.00

$228.00

$56.00

$173.00

$58.00

$16.00

$11.00

---------

---------

---------

---------

---------

---------

NC

---------

NC

---------

---------

---------

$4.00

BR

$18.00

$125.00

$59.00

$48.00

$231.00

$58.00

$173.00

$223.00

$111.00

$288.00

$55.00

$233.00

$8.00

$148.00

$45.00

$59.00

$119.00

$120.00

$11.00

$265.00

---------

---------

---------

$116.00

NC

$33.00

$10.00

$68.00

$235.00

$118.00

$243.00

$57.00

$185.00

$61.00

$16.00

$12.00

---------

---------

---------

---------

---------

---------

NC

---------

NC

---------

---------

---------

$4.00

BR

$20.00

$131.00

$62.00

$51.00

$246.00

$61.00

$185.00

$235.00

$117.00

$306.00

$56.00

$250.00

$9.00

$159.00

$47.00

$62.00

$125.00

$125.00

$12.00

$274.00

---------

---------

---------

$118.00

NC

$34.00

$11.00

$72.00

$249.00

$125.00

$245.00

$59.00

$186.00

$62.00

$17.00

$12.00

---------

---------

---------

---------

---------

---------

NC

---------

NC

---------

---------

---------

$4.00

BR

$20.00

$139.00

$63.00

$51.00

$250.00

$64.00

$186.00

$250.00

$125.00

$309.00

$57.00

$251.00

$10.00

$160.00

$48.00

$63.00

$128.00

$128.00

$12.00


Part C, 405



Medicine

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02

(Facility MRA)

Locality 03

(Facility MRA)

Locality 04

(Facility MRA)

G0281

G0283

G0329

G0403

G0404

G0405

G0422

G0423

G0238

G0239

G0248

G0249

G0250

G0268

G0270

G0271

G0277

G0424

G0453

G0454

G0459

G0473

G9157

G9187

P3001

Q0035

Q0035-26

Q0035-TC

Q0091

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$32.00

$37.00

$10.00

$46.00

$14.00

$110.00

$48.00

$36.00

$23.00

$10.00

$13.00

$49.00

$11.00

$14.00

$119.00

$119.00

$10.00

$60.00

$33.00

$18.00

$48.00

$15.00

$15.00

$10.00

$19.00

$9.00

$9.00

$113.00

$113.00

$34.00

$38.00

$11.00

$47.00

$14.00

$114.00

$52.00

$37.00

$24.00

$10.00

$14.00

$52.00

$12.00

$15.00

$128.00

$128.00

$11.00

$63.00

$34.00

$18.00

$51.00

$16.00

$16.00

$11.00

$20.00

$10.00

$10.00

$118.00

$118.00

$35.00

$40.00

$11.00

$48.00

$15.00

$119.00

$53.00

$38.00

$25.00

$11.00

$14.00

$53.00

$13.00

$16.00

$129.00

$128.00

$11.00

$66.00

$35.00

$19.00

$52.00

$16.00

$16.00

$11.00

$20.00

$10.00

$10.00

$121.00

$121.00

$15.00

$37.00

$10.00

$46.00

$13.00

$110.00

$48.00

$36.00

$23.00

$10.00

$13.00

$22.00

$11.00

$14.00

$119.00

$119.00

$10.00

$39.00

$30.00

$17.00

$48.00

$15.00

$15.00

$10.00

$19.00

$9.00

$9.00

$113.00

$113.00

$16.00

$38.00

$11.00

$47.00

$13.00

$114.00

$52.00

$37.00

$24.00

$10.00

$14.00

$23.00

$12.00

$15.00

$128.00

$128.00

$11.00

$41.00

$32.00

$17.00

$51.00

$16.00

$16.00

$11.00

$20.00

$10.00

$10.00

$118.00

$118.00

$17.00

$40.00

$11.00

$48.00

$14.00

$119.00

$53.00

$38.00

$25.00

$11.00

$14.00

$25.00

$13.00

$16.00

$129.00

$128.00

$11.00

$44.00

$32.00

$18.00

$52.00

$16.00

$16.00

$11.00

$20.00

$10.00

$10.00

$121.00

$121.00


Part C, 406



Evaluation and Management

CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


99236

99238

99239

99241

99242

99243

99244

99245

99224

99225

99226

99231

99232

99233

99234

99235

99215

99217

99218

99219

99220

99221

99222

99223

99201

99202

99203

99204

99205

99211

99212

99213

99214

99284

99285

99291

99292

99304

99305

99306

99307

99308

99251

99252

99253

99254

99255

99281

99282

99283

---------

---------

---------

$33.00

$54.00

$77.00

$129.00

$173.00

$213.00

$66.00

$88.00

$54.00

$88.00

$117.00

$163.00

$212.00

$35.00

$58.00

$58.00

$84.00

$84.00

$19.00

$31.00

$40.00

$40.00

$65.00

$65.00

$65.00

$109.00

$152.00

$66.00

$109.00

$152.00

$54.00

$70.00

$96.00

$138.00

$190.00

$18.00

$28.00

$60.00

$94.00

$103.00

$192.00

$95.00

---------

---------

---------

---------

---------

$44.00

$81.00

$117.00

$44.00

$80.00

$116.00

$149.00

$188.00

$242.00

$80.00

$119.00

$52.00

$99.00

$135.00

$202.00

$247.00

$48.00

$82.00

$119.00

$182.00

$229.00

$22.00

$47.00

$80.00

$118.00

$159.00

$81.00

$111.00

$151.00

$206.00

$114.00

$153.00

$226.00

$55.00

$83.00

$128.00

$186.00

$224.00

$24.00

$47.00

$70.00

$133.00

$196.00

$306.00

$137.00

$102.00

$145.00

$184.00

$50.00

$77.00

$46.00

$84.00

$121.00

$46.00

$83.00

$120.00

$155.00

$195.00

$252.00

$83.00

$124.00

$55.00

$103.00

$141.00

$211.00

$257.00

$51.00

$86.00

$126.00

$191.00

$240.00

$23.00

$50.00

$84.00

$123.00

$167.00

$84.00

$116.00

$157.00

$214.00

$119.00

$159.00

$235.00

$56.00

$86.00

$132.00

$192.00

$232.00

$25.00

$49.00

$73.00

$138.00

$204.00

$320.00

$143.00

$106.00

$150.00

$191.00

$52.00

$80.00

$48.00

$87.00

$125.00

$48.00

$86.00

$125.00

$162.00

$203.00

$261.00

$86.00

$127.00

$56.00

$105.00

$144.00

$216.00

$264.00

$52.00

$89.00

$130.00

$198.00

$249.00

$23.00

$51.00

$86.00

$127.00

$171.00

$87.00

$120.00

$162.00

$222.00

$125.00

$166.00

$244.00

$58.00

$89.00

$136.00

$198.00

$240.00

$26.00

$51.00

$76.00

$145.00

$214.00

$332.00

$149.00

$109.00

$155.00

$197.00

$53.00

$82.00

$44.00

$81.00

$117.00

$44.00

$80.00

$116.00

$149.00

$188.00

$242.00

$80.00

$119.00

$36.00

$76.00

$107.00

$171.00

$212.00

$30.00

$56.00

$86.00

$146.00

$189.00

$10.00

$28.00

$57.00

$87.00

$124.00

$81.00

$111.00

$151.00

$206.00

$114.00

$153.00

$226.00

$55.00

$83.00

$128.00

$186.00

$224.00

$24.00

$47.00

$70.00

$133.00

$196.00

$251.00

$126.00

$102.00

$145.00

$184.00

$50.00

$77.00

$46.00

$84.00

$121.00

$46.00

$83.00

$120.00

$155.00

$195.00

$252.00

$83.00

$124.00

$38.00

$79.00

$110.00

$177.00

$219.00

$31.00

$59.00

$90.00

$152.00

$198.00

$11.00

$29.00

$59.00

$91.00

$129.00

$84.00

$116.00

$157.00

$214.00

$119.00

$159.00

$235.00

$56.00

$86.00

$132.00

$192.00

$232.00

$25.00

$49.00

$73.00

$138.00

$204.00

$261.00

$131.00

$106.00

$150.00

$191.00

$52.00

$80.00

(Facility MRA)

$48.00

$87.00

$125.00

$48.00

$86.00

$125.00

$162.00

$203.00

$261.00

$86.00

$127.00

$39.00

$81.00

$114.00

$183.00

$226.00

$33.00

$61.00

$95.00

$159.00

$207.00

$11.00

$31.00

$61.00

$94.00

$133.00

$87.00

$120.00

$162.00

$222.00

$125.00

$166.00

$244.00

$58.00

$89.00

$136.00

$198.00

$240.00

$26.00

$51.00

$76.00

$145.00

$214.00

$273.00

$137.00

$109.00

$155.00

$197.00

$53.00

$82.00


Part C, 407




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


99354

99355

99356

99357

99360

99363

99364

99366

99342

99343

99344

99345

99347

99348

99349

99350

99328

99334

99335

99336

99337

99339

99340

99341

99309

99310

99315

99316

99318

99324

99325

99326

99327

99406

99407

99408

99409

99415

99416

99450

99455

99456

99367

99368

99374

99375

99377

99378

99379

99380

$85.00

$109.00

$160.00

$193.00

$46.00

$71.00

$107.00

$156.00

$106.00

$104.00

$87.00

$88.00

BR

---------

---------

---------

---------

---------

$60.00

$77.00

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

$59.00

---------

---------

$75.00

$75.00

$75.00

$104.00

$75.00

$104.00

---------

---------

---------

---------

---------

---------

NC

$90.00

BR

$88.00

$145.00

$203.00

$246.00

$62.00

$94.00

$142.00

$198.00

$111.00

$108.00

$102.00

$101.00

$68.00

$139.00

$48.00

$48.00

$101.00

$150.00

$81.00

$117.00

$106.00

$62.00

$90.00

$155.00

$206.00

$241.00

$67.00

$106.00

$149.00

$214.00

$85.00

$120.00

$61.00

$63.00

$41.00

$77.00

$116.00

$77.00

$116.00

$77.00

$116.00

$16.00

$31.00

$39.00

$76.00

$10.00

$5.00

NC

---------

---------

$91.00

$150.00

$210.00

$255.00

$64.00

$97.00

$148.00

$206.00

$116.00

$112.00

$106.00

$105.00

$71.00

$146.00

$50.00

$49.00

$105.00

$157.00

$84.00

$122.00

$110.00

$64.00

$93.00

$160.00

$214.00

$250.00

$70.00

$110.00

$155.00

$223.00

$89.00

$125.00

$64.00

$65.00

$42.00

$81.00

$120.00

$81.00

$120.00

$81.00

$120.00

$16.00

$32.00

$40.00

$79.00

$10.00

$6.00

NC

---------

---------

$94.00

$155.00

$218.00

$264.00

$66.00

$101.00

$153.00

$213.00

$120.00

$116.00

$109.00

$109.00

$73.00

$149.00

$51.00

$51.00

$108.00

$162.00

$87.00

$126.00

$114.00

$66.00

$96.00

$166.00

$221.00

$258.00

$72.00

$113.00

$160.00

$230.00

$91.00

$128.00

$66.00

$67.00

$44.00

$83.00

$124.00

$83.00

$124.00

$83.00

$124.00

$17.00

$33.00

$42.00

$81.00

$11.00

$6.00

NC

---------

---------

$88.00

$145.00

$203.00

$246.00

$62.00

$94.00

$142.00

$198.00

$104.00

$101.00

$102.00

$101.00

$68.00

$94.00

$36.00

$47.00

$101.00

$150.00

$81.00

$117.00

$106.00

$62.00

$90.00

$155.00

$206.00

$241.00

$67.00

$106.00

$149.00

$214.00

$85.00

$120.00

$61.00

$63.00

$41.00

$63.00

$98.00

$63.00

$98.00

$63.00

$98.00

$14.00

$29.00

$37.00

$74.00

$10.00

$5.00

NC

---------

---------

$91.00

$150.00

$210.00

$255.00

$64.00

$97.00

$148.00

$206.00

$108.00

$104.00

$106.00

$105.00

$71.00

$97.00

$37.00

$48.00

$105.00

$157.00

$84.00

$122.00

$110.00

$64.00

$93.00

$160.00

$214.00

$250.00

$70.00

$110.00

$155.00

$223.00

$89.00

$125.00

$64.00

$65.00

$42.00

$65.00

$102.00

$65.00

$102.00

$65.00

$102.00

$14.00

$30.00

$38.00

$77.00

$10.00

$6.00

NC

---------

---------

(Facility MRA)

$94.00

$155.00

$218.00

$264.00

$66.00

$101.00

$153.00

$213.00

$112.00

$108.00

$109.00

$109.00

$73.00

$100.00

$38.00

$50.00

$108.00

$162.00

$87.00

$126.00

$114.00

$66.00

$96.00

$166.00

$221.00

$258.00

$72.00

$113.00

$160.00

$230.00

$91.00

$128.00

$66.00

$67.00

$44.00

$67.00

$105.00

$67.00

$105.00

$67.00

$105.00

$15.00

$31.00

$40.00

$79.00

$11.00

$6.00

NC

---------

---------


Part C, 408




CPT Code 2003 MRA

Locality 01/02

(Non-Facility MRA)

Locality 03

(Non-Facility MRA)

Locality 04

(Non-Facility MRA)

Locality 01/02


99600

G0245

G0246

G0296

G0337

G0372

G0396

G0397

G0402

G0406

G0407

G0408

G0409

99457

99487

99489

99490

99495

99496

99497

99498

99499

BR

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

---------

BR

BR

BR

BR

$45.00

$180.00

$254.00

$95.00

$83.00

---------

---------

$73.00

$42.00

$31.00

$80.00

$10.00

$40.00

$79.00

$183.00

$43.00

$79.00

$114.00

$13.00

BR

BR

BR

$47.00

$188.00

$266.00

$98.00

$86.00

---------

---------

$76.00

$44.00

$33.00

$83.00

$10.00

$41.00

$82.00

$191.00

$45.00

$82.00

$118.00

$14.00

BR

BR

BR

$48.00

$193.00

$272.00

$101.00

$89.00

---------

---------

$78.00

$45.00

$34.00

$86.00

$11.00

$43.00

$85.00

$196.00

$47.00

$84.00

$121.00

$14.00

BR

BR

BR

$35.00

$123.00

$178.00

$88.00

$82.00

---------

---------

$48.00

$24.00

$30.00

$80.00

$10.00

$38.00

$77.00

$141.00

$43.00

$79.00

$114.00

$13.00

BR

BR

BR

$36.00

$127.00

$184.00

$91.00

$85.00

---------

---------

$50.00

$25.00

$31.00

$83.00

$10.00

$39.00

$79.00

$146.00

$45.00

$82.00

$118.00

$14.00

(Facility MRA)

BR

BR

BR

$37.00

$131.00

$190.00

$94.00

$89.00

---------

---------

$52.00

$26.00

$32.00

$86.00

$11.00

$40.00

$82.00

$151.00

$47.00

$84.00

$121.00

$14.00


Part C, 409

Chapter 4 Billing Instructions and Forms

Bill Submission/Filing and Reporting Requirements

Carrier Responsibilities A carrier is responsible for meeting its obligations under this Rule regardless of any business arrangements with any service company/TPA, submitter, or any entity acting behalf of the carrier under which medical bills are paid, adjusted and paid, disallowed, denied, or otherwise processed or submitted to the Division.

At the time of authorization for medical service(s) or upon receipt of notification of emergency care, a carrier must shall notify each health care provider in writing, of additional form completion requirements or supporting documentation that are necessary for reimbursement determinations that are in addition to the requirements of this Manual and

Rule 69L-7.740, F.A.C.

At the time of authorization for medical service(s), or upon receipt of notification of emergency care, a carrier must shall inform out-of-state health care providers of the specific reporting, billing and submission requirements of this Manual and Rule 69L-7.740, F.A.C. and provide instate and out-of-state health care providers the specific address for submitting a reimbursement request.

Provider Responsibilities All health care providers are required to meet their obligations under this

Rule, regardless of any business arrangement with any entity under which

Billing When Paid Under

Payment Plan(s) medical bills are prepared, processed or submitted to the carrier.

Health care providers receiving reimbursement under any payment plans

(pre-payment, prospective payment, or capitation, etc.) are required to accurately complete the Form DFS-F5-DWC-9 and submit the form to the carrier for all services rendered to injured workers.

2015 Edition Page 410 Effective Date: ____________

Chapter 4 Billing Instructions and Forms, continued

Bill Submission/Filing and Reporting Requirements, continued

Additional Information All health care providers are required to submit any additional form

Requested by Carrier completion information and supporting documentation requested in writing, by the carrier at the time of authorization.

Bill Completion Bills must shall be legibly and accurately completed by all health care providers.

A carrier can require a health care provider or other recognized practitioner to complete additional data elements that are not required by the Division on

Forms DFS-F5-DWC-9, DFS-F5-DWC-10, DFS-F5-DWC-11, or DFS-F5-

DWC-90 if requested by the carrier at the time of authorization.

Form DFS-F5-DWC-25 Physicians must shall utilize only the Form DFS-F5-DWC-25 to request authorization for treatment and to report the injured worker’s medical treatment/status.:

•

No other reporting forms may be used in lieu of, or supplemental to, the Form DFS-F5-DWC-25.

•

Failure to accurately complete and submit the DFS-F5-DWC-25, in accordance with the instructions provided in this Manual, may result in the Division imposing sanctions or penalties pursuant to subsection 440.13(8), F.S. or subsection 440.13(11) F.S.

•

Form DFS-F5-DWC-25 does not replace physician notes, medical records or Division-required medical reports.

•

All information submitted on physician notes, medical records, medical records or Division-required medical reports must be consistent with information documented on the DFS-F5-DWC-25.

•

Carriers must shall utilize the information submitted on the DWC-25 form to monitor the medical necessity of services provided and services requested based on the medical condition being treated during the authorization process.

Note : Interactive Form DFS-F5-DWC-25 is available under the “Forms” section on the DWC web site .




Billing for a All medical bills and form(s) for medical bill(s) related to services rendered

Compensable Injury for a compensable injury must shall be submitted by a health care providerd to the carrier, service company/TPA or any entity acting on behalf of the

Methods for Billing carrier, as a requirement for billing.

Medical claim form(s) or medical bill(s) may be electronically filed or submitted via facsimile by a health care provider to the carrier, service company/TPA or any entity acting on behalf of the carrier, provided the

Bill Corrections carrier agrees.

Health care providers are responsible for correcting and resubmitting any billing forms returned by the carrier, service company/TPA or any entity acting on behalf of the carrier.

Form DFS-F5-DWC-9 (CMS-1500)

Recognized Practitioners

Who Bill on the

DFS-F5-DWC-9

(CMS 1500)

Home Medical

Equipment

Recognized practitioners, except physician assistants, advanced registered nurse practitioners, certified registered nurse anesthetists and anesthesia assistants, who are salaried workers of an authorized treating physician and who render direct billable services for which reimbursement is sought from a carrier, service company/TPA or any entity acting on behalf of the carrier, service company/TPA, must shall report and bill for such services on a Form

DFS-F5-DWC-9 by entering the employing physician’s Florida DOH license number in Field 33b on the Form DFS-F5-DWC-9.

Physicians, physician assistants and ARNPs billing for Home Medical

Equipment must shall enter the applicable HCPCS code in Field 24D and attach documentation indicating the cost of the supply.




Form DFS-F5-DWC-9 (CMS-1500), continued

Dispensing Prescription

Medications

Physicians, Physician Assistants and ARNPs must shall enter the NDC number in the universal 5-4-2 format in Form Field 24D with each segment separated by a dash (-).

The Workers’ Compensation Unique code DSPNS is billed in addition to the

NDC code in Field 24D if the drug is dispensed from the practitioner’s office for the injured worker’s use at home.

Compounded Drugs When a physician or pharmacist compounds a drug that is not commercially available for prescription use by the worker at home, the physician or pharmacist may bill with the Workers’ Compensation Unique code COMPD

Administration of

Injectable Medications

Over-the-Counter

Medications in Field 24D. The individual component drugs used in compounding are to be identified by the NDC numbers.

Health care providers must shall use the appropriate HCPCS code in Fields

24D when available. If no HCPCS code is available, use the NDC number in the universal NDC 5-4-2 format in Field 24D.

Health care providers must shall use the appropriate HCPCS code in Field

24D when available. If no HCPCS code is available, use the NDC number in the universal 5-4-2 format in Field 24D.

Medication Management

Therapy Sessions

Non-Physician

Surgical Assistant

Pharmacists who provide Medication Management Therapy Sessions that are ordered by a treating physician must shall bill by entering the appropriate

CPT

®

code in Field 24D.

Note: A copy of the physician’s written prescription order for Medication

Management Therapy must be submitted with the bill for reimbursement.

A certified physician assistant or registered nurse first assistant who provides services as a surgical assistant, in lieu of a second physician, must shall enter the CPT

®

code(s) which represents the service(s) provided plus modifier AS in Field 24D.




Form DFS-F5-DWC-10

Providers Who Bill on the DFS-F5-DWC-10

Billing Policy

Compounded Drugs

Over the Counter

Medications

Home Medical

Equipment

Pharmacists must shall bill using the Form DFS-F5-DWC-10 for pharmaceuticals and medical supplies prescribed by a physician or recognized practitioner.

Medical Suppliers must shall bill using the Form DFS-F5-DWC-10 and are required to bill using HCPCS codes for medical supplies and equipment prescribed by a physician or recognized practitioner.

Note : Pharmacists and Medical suppliers may only bill on an alternate to

DFS-F5-DWC-10 when a carrier has pre-approved the use of an alternate form. Forms DFS-F5-DWC-9, DFS-F5-DWC-11 or DFSW-F5-DWC-90 must shall not be approved for use as an alternate form.

Pharmacists must shall enter the NDC number, in the universal 5-4-2 format, in form Field 9, with each segment separated by a dash (-).

When a pharmacist compounds a drug that is not commercially available, the pharmacist must shall enter the Workers’ Compensation unique code

COMPD in Field 9 of the DWC-10. The individual component drugs used in compounding must shall be identified by the NDC numbers in the universal 5-4-2 format separated by a dash (-).

Pharmacists must shall enter the NDC number, in the universal 5-4-2 format, in form Field 9, with each segment separated by a dash (-).

Pharmacists must shall enter the applicable HCPCS code(s) in Field 21 of the DFS-F5-DWC-10. Enter the quantity or units dispensed in Field 22.

Home Medical Equipment Suppliers must shall enter the applicable HCPCS code(s) in Field 21. Enter quantity or units dispensed in Field 22.

The license number of the pharmacist or the home medical supplier must shall be entered in Form Locator 29.


Appendix A: Workers’ Compensation Unique Procedure Codes

DSPNS Legend or prescription drugs dispensed by a licensed practitioner.

(See Chapter Rule 69L-7.730(2)(l), F.A.C. for the specific use of this code).

COMPD Compounded drugs dispensed by a pharmacist or physician.

(See Chapter Rule 69L-7.730(2)(l), F.A.C. for the specific use of this code).

97260 Manipulation of spine by a physician other than an osteopathic or chiropractic physician.

97261 Manipulation of the temporomandibular joint; upper extremities including the hand and wrist; the lower extremities; and other regions by a physician other than an osteopathic or chiropractic physician.

97752 Muscle testing manually or by automated equipment with written report

97850 Physical reconditioning assessment; per hour

97851 Physical reconditioning assessment; additional thirty minutes

97852 Physical reconditioning program; per hour

97853 Physical reconditioning program; additional thirty minutes

99456 Independent Medical Examination

99456 CN Independent Medical Examination; cancelled less than 24 hours before

appointment without good cause or failed to appear.

99457 Consensus Independent Medical Examination (CIME)


Appendix B Official Source for References

As medical information pertaining to coding systems and policies are evolving, users of this manual seeking up-to-date information should use the appropriate listed reference address, telephone/fax number or web site for specific answers to questions, inquiries and products.

♦

2009 Relative Value Guide: A Guide for Anesthesia Values

American Society of Anesthesiologists

520 N. Northwest Highway

Park Ridge, Il. 60068-2573

(847) 825-5586

Web Site: http://www.asahq.org

♦

Complete Global Service Data for Orthopaedic Surgery, Vol. 1 & 2

American Academy of Orthopaedic Surgeons

6300 North River Road

Rosemont, Illinois 60018-4262

(847) 823-7186

(800) 626-6726

(847) 823-8125 Fax

(800) 823-8025 Fax

Web site: http://www.aaos.org/


♦

Current Dental Procedure Codes Terminology ( CDT)

American Dental Association

211 East Chicago Avenue, 6 th

Floor

Chicago, Illinois 60611-2678

(312) 440-2653

(800) 621-8099

(312) 440-7494 Fax

Web site: www.ada.org

ADA Order Department

American Dental Association

Post Office Box 776

St. Charles, Illinois 60174

(800) 947-4746

(888) 476-1880 Fax

Web site link: ADA e Customer

♦ Drug Topics Red Book

Medical Economics Company, Inc.

Five Paragon Drive

Montvale, New Jersey 07645-1742

(201) 358-7200

(800) 232-7379

(201) 722-2680 Fax

Web site: www.pdr.net.

♦ MediSpan

Wolters Kluwer Health

8425 Woodfield Crossing Boulevard, Suite 490

Indianapolis, IN 46240

(855) 539-7686

(317) 735-5300

WebSite: www.wolterskluwer.com/Pages/Home.aspx

https://pricerx.medispan.com/NDCNumber.aspx


♦ Current Procedural Terminology, (CPT

®

)

CPT

®

Assistant

♦ Guide To The Evaluation of Permanent Impairment, 6 th

Edition

♦ HCPCS ®

♦ ICD-9-CM ®

.ICD-10-CM

®

♦ National Physician Fee Schedule Relative Value File

American Medical Association (AMA) – MAIN OFFICE

515 North State Street

Chicago, Illinois 60610

(312) 464-5000

(312) 464-4184 Fax

Web site: www.ama-assn.org

AMA Order Department

P.O. Box 930876

Atlanta, Georgia 31193-0876

(800) 621–8335

(800) 262-3211

(312) 464-5600 Fax

For questions regarding the use of CPT

®

® codes, please contact the American Medical

Association, CPT Information and Education Services, at 1-800-634-6922.

♦ 1996 Florida Uniform Permanent Impairment Rating Schedule

Florida Workers’ Compensation Institute

P. O. Box 200

Tallahassee, Florida 32302

(850) 425-8156

(850) 222-9766 Fax

Web site: http://www.fwciweb.org


Appendix C Medicare Payment Localities (Counties)

Locality 01 / Locality 02:

Franklin Lake Putnam Alachua

Baker Gadsden Leon Santa Rosa

Bay Gilchrist Levy Sarasota

Bradford Glades Liberty Seminole

Brevard Gulf Madison St. Johns

Calhoun Hamilton Manatee Sumter

Charlotte Hardee Marion Suwannee

Citrus Hendry Nassau Taylor

Clay Hernando Okaloosa Union

Columbia Highlands Okeechobee Volusia

De Soto Hillsborough Orange Wakulla

Dixie Holmes Osceola Walton

Duval Jackson Pasco Washington

Escambia Jefferson Pinellas

Flagler Lafayette Polk

Locality 03:

Broward

Collier

Martin

Indian River

Lee

Locality 04:

Dade

Monroe


Appendix D Forms

Note: The following Forms and Form Completion Instructions are incorporated by reference in

Rule 69L-7.720, F.A.C.

Forms Incorporated by Reference for Medical Billing, Filing and Reporting.

•

Form DFS-F5-DWC-9 (CMS-1500 Health Insurance Medical bill Form, Rev

02/12).

•

Form DFS-F5-DWC-10 (Statement of Charges for Drugs and Medical Supplies

Form).

•

Form DFS-F5-DWC-11 (American Dental Association Dental Medical bill Form,

Rev. 2006).

•

Form DFS-F5-DWC-25 (Florida Workers’ Compensation Uniform Medical

Treatment/Status Reporting Form), Rev.2/14/06.

•

Form DFS-F5-DWC-90 (UB-04 CMS-1450, Uniform Bill, Rev. 2006).

Form Completion Instructions are available at the following link:

DWC website , Click on Chapter 69L-7.


Appendix E Definitions

1.

“Add-on Code(s) means a procedure performed in addition to a primary procedure performed by the same physician. An ‘add-on’ code describes additional or supplemental procedure(s) associated with the primary service and are designated with a

‘

+

’

sign in the

CPT

®

codebook.

2.

“Ambulatory Surgical Center (ASC) means a health care facility as defined in s. 440.13(1)(f), F.S.

3.

“Authorization” means the approval given to a health care provider by the carrier , self-insured employer or entity representing the carrier or self-insured employer for the provision of medical services to an injured worker.

4.

“Division” means the Division of Workers’ Compensation of the

Department of Financial Services as defined in s. 440.02(14), F.S.

5.

“Home Medical Equipment” is defined in s.400.925 (6) F.S.

6.

“Home Medical Equipment provider” is defined in s.400.925 (7),

F.S.

7.

“Emergency Care and Services” means emergency services and care as defined in s. 395.002, F.S.

8.

“Health Care Provider” means a provider as defined in

s.440.13 (1)(g), F.S.

9.

“Home Health Agency” means an agency as defined in Chapter

400, Part III, F.S.

10.

“Maximum Reimbursement Allowance (MRA)” means the specifically listed maximum dollar amount in the schedule adopted by the Three Member Panel for reimbursement of medical service(s) rendered to an injured worker by a health care provider.

11.

“Medically Necessary or Medical Necessity” means any medical service or medical supply that satisfies the criteria for those terms as defined in which meets the definition of the terms according to s. 440.13(1)(k), F.S.


12.

“Medical Record” means patient records maintained in accordance with the form and content required under Chapter 395, F.S.

13.

“Medical Record Review” means a review of the medical record of the injured worker in order to verify the medical necessity of the services and the care as they relate to the itemized statement for a specific bill.

14.

“Modifier 51 Exempt” means a procedure code that is a HCPCS or a CPT

® code that does not have multiple surgery pricing reduction applied for reimbursement.

Note : See the CPT codebook for a list of “Modifier 51 Exempt” codes”.

15.

“NDC Number” means the National Drug Code number as defined in Rule 69L-7.710(1)(oo), F.A.C.

16.

“Physician” means a physician as defined in s. 440.13(1) (p), F.S.

17.

“Repackaged NDC number” means the National Drug Code number as defined in Rule 69L-7.710(1)(oo), F.A.C.

18.

“Unlisted Medication” means a medication which lacks assignment of a National Drug Code (NDC number) or a HCPCS procedure code.


Florida Workers’ Compensation Health Care Provider Reimbursement Manual Rule 69L-7.020, F.A.C.

Florida Workers’ Compensation

TABLE OF CONTENTS

THIS PAGE LEFT INTENTIONALLY BLANK

Authorization

Chapter 2 Medical Services

THIS PAGE LEFT INTENTIONALLY BLANK

PART A

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

PART B

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

PART C

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

Appendix A: Workers’ Compensation Unique Procedure Codes

Appendix B Official Source for References

Appendix C Medicare Payment Localities (Counties)

Appendix D Forms

Appendix E Definitions

‘

’

Related documents

Products

Support

Florida Workers’ Compensation Health Care Provider Reimbursement Manual Rule 69L-7.020, F.A.C.

Florida Workers’ Compensation

TABLE OF CONTENTS

THIS PAGE LEFT INTENTIONALLY BLANK

Authorization

Chapter 2 Medical Services

THIS PAGE LEFT INTENTIONALLY BLANK

PART A

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

PART B

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

PART C

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

Appendix A: Workers’ Compensation Unique Procedure Codes

Appendix B Official Source for References

Appendix C Medicare Payment Localities (Counties)

Appendix D Forms

Appendix E Definitions

‘

’

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