2003 EDITION FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER

FLORIDA WORKERS’ COMPENSATION

HEALTH CARE PROVIDER

REIMBURSEMENT MANUAL

2003 EDITION

Department of Financial Services

Division of Workers’ Compensation

200 East Gaines Street

Tallahassee, Florida 32399

05 / 30 /03 -Revised (0

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition

4L- 7.020 Florida Workers’ Compensation Health Care Provider Reimbursement Manual.

(1) The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003

Edition, is adopted by reference as part of this rule. The manual contains reimbursement policies, guidelines, codes and maximum reimbursement allowances for medical services and supplies provided by health care providers. The manual provides reimbursement policies and payment methodologies for pharmacists and medical suppliers. The Florida Workers’ Compensation Health

Care Provider Reimbursement Manual, 2003 Edition, is available for inspection during normal business hours at the Florida Department of Financial Services, Document Processing Section, 200

E. Gaines Street, Tallahassee, Florida 32399-0311, or via the Department’s web site at http://www.fldfs.com

(2) The Physicians’ Current Procedural Terminology (CPT ® ), 2003 Professional Edition,

Copyright 2002, American Medical Association, the Current Dental Terminology (CDT-4), Fourth

Edition, Copyright 2002, American Dental Association and for D codes, injectable J codes, and the other medical services and supply codes, the American Medical Association “Healthcare Common

Procedure Coding System, Medicare’s National Level II Codes, HCPCS 2003”, Fifteenth Edition,

Copyright 2002, Ingenix Publishing Group, are adopted by reference as part of this rule. When a health care provider performs a procedure or service, which is not listed in the Florida Workers’

Compensation Health Care Provider Reimbursement Manual, 2003 Edition, the provider must use a code contained in the CPT ® , CDT-4 or HCPCS section as specified .

Specific Authority 440.13(7), (8), (11)-(14), 440.591 F.S. Law Implemented 440.13(6)-(8), (11)-(14) F.S. History-

New 10-1-82, Amended 3-16-83, 11-6-83, 5-21-85, Formerly 38F-7.20, Amended 4-1-88, 7-20-88, 6-1-91, 4-29-92,

2-18-96, 9-1-97, 12-15-97, 9-17-98, 9-30-01, 7-7-02, Formerly 38F-7.020, Amended 00-00-03. i


FLORIDA WORKERS’ COMPENSATION

HEALTH CARE PROVIDER

REIMBURSEMENT MANUAL

2003 EDITION

Rule 4L-7.020, Florida Administrative Code

In accordance with section 440.13, Florida Statutes (F.S.), this manual provides reimbursement policies and a schedule of maximum reimbursement allowances, as applicable, for licensed physicians, licensed health care providers, licensed pharmacists and medical suppliers rendering medical services and supplies to Florida’s injured workers. The maximum reimbursement allowances and procedure codes are listed in Section X.

NOTICES AND DISCLAIMERS

The Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition, provides five-digit codes and two-digit modifiers for reporting medical services and procedures that were selected from the following references by the State of Florida for inclusion in this publication.

When a service or procedure is performed that does not have a code listed in the Florida Workers’

Compensation Health Care Provider Reimbursement Manual, 2003 Edition, the physician or health care provider must use a code listed in the following materials:

Physicians’ Current Procedural Terminology (CPT ®

Copyright 2002, American Medical Association.

), 2003 Professional Edition,

Current Dental Terminology (CDT-4), Fourth Edition, Copyright 2002, American

Dental Association.

The CPT and CDT-4 contain listings of descriptive terms and identifying codes used by physicians and dentists for reporting medical and dental services and procedures.

HCPCS is used in part for the listing of descriptive terms and codes for dental services and procedures performed by dentists. HCPCS also contains a listing of injectable medications and codes used to report injections administered by physicians as well as other codes used to report medical services and supplies.

It is expressly understood and agreed that the American Medical Association’s rights include, but not limited to, common law and statutory rights of literary property in the CPT and in any update thereto, including all descriptive terms and identifying codes and modifiers for reporting procedures and medical services and/or any other information or materials contained in the CPT and in any update thereto are not assigned or released as a result of the agreement between the American Medical

Association and the State of Florida, but are at all times reserved and retained by the American

Medical Association.

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CPT codes, descriptions and material only are copyright 2002 American Medical Association. All

Rights Reserved. No fee schedules, basic units, relative values or related listings are included in

CPT. The American Medical Association assumes no liability for the data contained or not contained herein.

This product includes CPT, which is commercial technical data and/or computer databases and/or commercial computer software and/or commercial software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State

Street, Chicago, Illinois 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-

7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and

DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. iii


CONTENTS

SECTION I: ADMINISTRATIVE PURPOSE OF MANUAL ......................................................1

SECTION II: BASIC PROGRAM REQUIREMENTS

Provider

Authorization..............................................................................................................1

Materials Adopted for Reference ...............................................................................1

SECTION III: DENTAL SERVICES ................................................................................................5

SECTION IV: DISPENSING OF MEDICATION

Patent, Proprietary or Over-the-Counter Drugs .........................................................7

SECTION V: MEDICAL SUPPLIER SERVICES

Appliances..................................................................................................................7

Devices.......................................................................................................................7

Aids ................................................................................................................7

Orthotics.....................................................................................................................7

Prosthetics ..................................................................................................................7

SECTION VI: MEDICAL SERVICES

Electrodiagnostic

Evaluation and Management Services .......................................................................9

Home Health Services................................................................................................9

Independent Medical Examination, Consensus .......................................................10

Injectable

Medical and Surgical Supplies.................................................................................11

Psychiatric and Psychological Services ...................................................................11

Radiology .................................................................................................................12

Thermography..........................................................................................................13

Transcutaneous

SECTION VII: PHYSICAL MEDICINE AND REHABILITATION SERVICES

Level I: Physical Medicine Services...................................................................14

Evaluation..............................................................................................15

Modalities and Therapeutic Procedures ................................................16

Acupuncture ..........................................................................................17 iv


Level II: Physical Reconditioning Services .........................................................18

Physical Reconditioning Assessment....................................................18

Physical Reconditioning Program .........................................................18

Level III: Rehabilitation Programs ........................................................................19

Functional Capacity Evaluation ............................................................19

Work Hardening Program .....................................................................20

SECTION VIII. SURGICAL SERVICES

Surgical Package (Global Reimbursement) .............................................................21

Procedures .................................................................................................22

Procedures .................................................................................................23

SECTION IX. ANESTHESIA SERVICES

Base Value or Base Unit ..........................................................................................23

Physical Status Modifiers.........................................................................................24

Circumstances........................................................................................25

Methodology..................................................................................25

SECTION X. SCHEDULE OF MAXIMUM REIMBURSEMENT ALLOWANCES

Anesthesia ................................................................................................................28

Surgery .....................................................................................................................30

Radiology .................................................................................................................64

Pathology..................................................................................................................78

Medicine.................................................................................................................100

Evaluation and Management..................................................................................108

Dental .....................................................................................................................109

Injections................................................................................................................113

APPENDIX.

APPENDIX A. DEFINITIONS ................................................................................................116

APPENDIX B. DIRECTORY OF REFERENCES ..................................................................119

APPENDIX C. MODIFIERS....................................................................................................122

APPENDIX D. WORKERS’ COMPENSATION UNIQUE CODES .....................................124

INDEX ...............................................................................................................................................126 v


SECTION I: ADMINISTRATIVE PURPOSE OF MANUAL.

The administrative purpose of the Florida Workers’ Compensation Health Care Provider

Reimbursement Manual, 2003 Edition, is to provide reimbursement guidelines, codes and maximum reimbursement allowances for licensed physicians and health care providers rendering medically necessary services to Florida’s injured workers.

This manual also contains reimbursement policies and payment methodologies for pharmacists and medical suppliers.

The use of Physicians’ Current Procedural Terminology (CPT ® ) or Healthcare

Common Procedure Coding System (HCPCS) codes is not required to receive reimbursement for services rendered by these providers.

Federal facilities are exempt from the reimbursement guidelines and maximum reimbursement allowances provided in this manual for services rendered in federal facilities.

SECTION II: BASIC PROGRAM REQUIREMENTS.

A. Provider Eligibility.

Florida health care providers must comply with provider eligibility requirements in section

440.13, Florida Statutes (F.S.), in order to qualify for reimbursement for rendering medical services to injured employees.

B. Authorization.

1. Florida health care providers, out-of-state providers and federal facilities must be authorized by the employer’s workers’ compensation carrier or a self-insured employer prior to rendering initial and remedial medical services or referring the injured employee to facilities or other certified health care providers.

2. Carriers must comply with the statutory requirements in section 440.13, F.S., in responding to authorization requests.

3. Emergency care, defined in section 395.002, F.S., does not require authorization by a carrier nor does a provider referral for emergency treatment resulting from emergency care. These are the only exceptions to the requirements of prior authorization for medical care and treatment.

C. Materials Adopted for Reference.

1. The following publications are adopted for reference to the listings of descriptive terms and identifying codes for reporting medical services and procedures provided to injured employees by physicians and other health care providers: a. Physicians’ Current Procedural Terminology (CPT ® ), 2003 Professional Edition,

Copyright 2002, American Medical Association. b. Current Dental Terminology (CDT-4), Fourth Edition, Copyright 2002, American Dental

Association.

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition c. HCPCS 2003, Fifteenth Edition, Copyright 2002, Ingenix Publishing Group, for D codes, injectable J codes, and the other medical services and supply codes.

2. Physicians and providers shall use the codes and descriptions, modifiers, guidelines, definitions and instructions of the referenced CPT, CDT-4 and HCPCS in part for dental codes, injection codes, and the other medical services and supply codes. Physicians shall use the Category III CPT codes for emerging technology, services and procedures when available instead of a Category I CPT unlisted code. The code descriptors, guidelines, definitions, and instructions of the aforementioned references are not provided in this manual. Any modification to a code descriptor by the workers’ compensation program shall be specified and shall take precedence over any descriptor contained in the referenced CPT, CDT-4 or

HCPCS.

D. Medical Records.

Unless instructed otherwise, it is the responsibility of all health care providers to furnish without charge, the following documentation to the carrier. a. A complete report of the patient’s symptoms, findings and plan of treatment pursuant to reporting requirements in section 440.13, F.S.

b. An operative report when a surgical procedure is performed. c. A narrative report when a consultation or an independent medical examination is rendered. d. A narrative report, computerized report or other explanatory report form when a report is listed as part of a code’s descriptor, when a report is provided as an explanation of the results of the testing procedures or when anesthesia, pathology, or radiology services are performed.

2. Additional written documentation.

If requested, a health care provider must provide additional written documentation to a carrier, without charge, when the medical necessity of medical care must be substantiated in more detail than the information contained in the medical record. Failure to forward the following information, when requested by the carrier, may result in the billed service being disallowed and not reimbursed. a. Objective findings that support the need for medical care, as well as continuing treatment. b. The estimated period of time and number of services required for treatment. c. The anticipated benefits of the treatment to the patient.

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A health care provider, when requested, shall provide medical records or information with respect to the injured employee’s remedial treatment, care and attendance to a state agency without charge. Failure to forward the requested information shall result in administrative action pursuant to the provisions in section 440.13, F.S.

E. Reimbursement Information.

3. Special carrier requests (Code 99080).

Carriers may request physicians to prepare special narrative reports or to complete information on forms not required by the Division of Workers’ Compensation (Division) or the Agency for Health Care Administration (Agency). Prior to a provider’s provision of a special request, the carrier and provider shall agree upon reimbursement for completion of the special report or form. Reimbursement for special requests shall be made by the carrier at the agreed upon reimbursement amount.

Federal facilities are exempt from the reimbursement provisions and allowances in this reimbursement manual. A carrier shall reimburse a federal facility its usual and customary charges. b. Florida health care providers.

Reimbursement shall be made to a Florida health care provider for medical services.

After applying the appropriate reimbursement guidelines contained in this manual, a carrier shall reimburse a provider either the provider’s usual and customary charge, the agreed upon contract price, or the maximum reimbursement allowance in this manual, whichever is less. However, the provision requiring reimbursement at the lesser of the usual and customary charge, the contract price, or the maximum reimbursement allowance will be superceded by statutory amendment effective October 1, 2003.

For services provided on October 1, 2003 and subsequently, a provider shall be reimbursed either the agreed upon contract price or the maximum reimbursement allowance in the appropriate schedule. c. Out-of-state

(1) Prior to the delivery of medical services, a carrier may mutually agree with an out-ofstate provider upon the amounts of reimbursement to be made by the carrier for the services to be provided. The carrier shall make reimbursement at the reimbursement amounts agreed upon by the provider and carrier.

(2) If a reimbursement agreement is not made, the carrier shall reimburse the provider the greater of the applicable maximum reimbursement allowances for the services in this manual, or the maximum reimbursement allowances under the workers’ compensation program in the state where the services are provided.

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition a. Codes paid by maximum reimbursement allowances (MRAs).

Reimbursement for codes, listed in this manual with MRAs, shall be at the maximum reimbursement allowances after the application of any reimbursement policies contained in this manual by the carrier. b. Codes paid by report (BR).

(1) Reimbursement shall be determined by the carrier for codes paid by report (BR).

Payment shall be based on a provider’s documentation submitted to the carrier in a special report containing information on the complete description of the services or procedures, medical necessity, pertinent clinical data, prevailing charges, fees, relative values and reimbursement for similar procedures or cost of the services or supplies.

(2) The provider shall submit a special report in addition to the requirements in Section

II.D.

to satisfy the following:

(a) Codes listed in this manual that do not have an established MRA but a BR in the

MRA column.

(b) Codes for non-referenced medical procedures with a generic code ending in “99” that are listed in this manual with BR in the MRA column.

(c) Category III codes, which are temporary five character alphanumeric codes, that are in the published CPT or provided electronically on the American Medical

Association’s web site but are not contained in this manual.

(d) Valid codes that are not listed in this manual, but are contained in the materials adopted for reference in Section II. C.

(e) Codes with valid modifiers that do not have an established MRA.

c. Codes not covered (NC).

Reimbursement shall not be made for services or supplies that are not covered (NC) under Florida’s workers’ compensation program. These codes are listed in this manual with NC in the MRA column. d. Exclusion.

Reimbursement shall not be made for failed appointments. This exclusion does not apply to the statutory provisions for independent medical examinations contained in section 440.13, F.S.

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition e. Exceptions.

All health care providers are subject to the reimbursement guidelines contained in this manual. If a provider deems it is medically necessary in the treatment of a particular individual’s injury or illness to furnish medical services that exceed the number of services in specific reimbursement policy guidelines , a provider must:

(1) Submit documentation to the carrier substantiating the medical necessity for the request.

(2) Receive specific written authorization from the carrier to render the requested services before services are provided.

3. Carrier reimbursement responsibilities. a. Carriers shall use the codes and descriptions, guidelines, definitions and instructions in the referenced CPT, CDT-4 and HCPCS, in part for dental services, injections, and other medical services and supply codes, when reviewing bills prior to making reimbursement decisions. b. Carriers shall use a methodology, available upon request by the state agency, for determining reimbursement for codes that have no established MRAs, including Category

III codes, unlisted codes and codes that are paid BR.

(1) Carriers 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 reimbursement determinations.

(2) Carriers shall make reimbursement decisions based on all the provider documentation; the carrier medical claims data; relative value studies; prevailing charges and reimbursement for procedures, services and supplies; and peer review physician recommendations. c. Carriers shall reimburse all work-related medically necessary services provided in a documented medical or dental emergency. d. Carriers shall reimburse all authorized services including those prior authorized services that exceed the reimbursement guidelines set forth in this manual.

SECTION III: DENTAL SERVICES.

A. All dental services shall be authorized by a carrier before the services are initiated. A carrier shall only reimburse a dentist or oral surgeon for authorized services.

B. Dentists shall use the dental guidelines, codes and descriptors from the CDT-4 or the D codes in the HCPCS for dental procedures.

C. Dentists shall use the appropriate guidelines, codes and descriptors from the CPT and CDT-4 or

D codes in the HCPCS for temporomandibular joint services.

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1 . Dentists who provide temporomandibular joint services may use a combination of CPT codes and dental codes from the CDT-4 or HCPCS.

2. Dentists shall refer to the physical medicine section of this manual for information on physical therapy reimbursement guidelines.

D. Oral surgeons shall use the CPT surgical guidelines, codes, descriptors and modifiers for oral and maxillofacial surgical services.

1. Surgeons shall refer to surgical services section of this manual for information on reimbursement for multiple surgical procedures, as well as other surgical reimbursement guidelines.

2. Surgeons may refer to other sections in this manual and may use CPT codes.

E. Reimbursement to a provider shall be as follows:

1. Reimbursement to a dentist or oral surgeon for a dental procedure or service shall be the provider’s charge, or the listed MRA, whichever is less.

2. Reimbursement to a surgeon for an oral and maxillofacial consultation shall be limited to one

(1) consultative visit per date of accident.

SECTION IV: DISPENSING OF MEDICATION.

A.

Medicinal drugs.

1. Medicinal drugs, commonly known as legend or prescription drugs, shall be ordered for an injured employee by a licensed physician, authorized by the carrier to treat the employee.

2. Medicinal drugs are dispensed, stored and sold only by a pharmacist licensed under Chapter

465, F.S., or a dispensing practitioner, according to the provisions in section 465.0276, F.S.

3. Medicinal drugs may be compounded by a pharmacist or physician when the drug formulation prescribed is not commercially available. a. The Food and Drug Administration requires drug manufacturers to register and list manufactured drug products. The National Drug Code (NDC) is assigned by the manufacturer and placed on all prescription stock packages. b. The Food and Drug Administration considers the “compounding of drugs” to be the practice of pharmacy/medicine. A compounded drug does not have a NDC.

5. Reimbursement limitations. a. Reimbursement shall only be made to a licensed pharmacist or licensed, dispensing physician for provision of medicinal drugs. A physician shall use the workers’ compensation unique code 96370 to bill for prescription drugs furnished to a patient.

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition b. Until October 1, 2003, medicinal drugs shall be reimbursed the lesser of:

(1) The pharmaceutical reimbursement formula:

Average Wholesale Price (AWP) x 1.2 + $4.18 = Reimbursement; or

(2) The contracted reimbursement amount determined in accordance with the contractual arrangement between the provider and carrier. c. Beginning October 1, 2003, medicinal drugs shall be reimbursed only the average wholesale price plus $4.18 for the dispensing fee, except where the carrier has contracted for less. d. A pharmacist or physician shall be reimbursed for a professional service for compounding drugs whose formulations are not commercially available. The amount of reimbursement to be made by the carrier shall be mutually agreed upon by the provider and carrier prior to the compounding.

B. Patent, proprietary or over-the-counter drugs.

1. Reimbursement shall be made to a pharmacist for dispensing over-the-counter drugs at the pharmacist’s usual charge for the drugs.

2. Reimbursement to a physician shall be as follows: a. Reimbursement shall be made to a physician for furnishing over-the-counter drugs. A physician shall use code 99070 and submit an invoice to the carrier that provides the names, dosages, package sizes and costs of drugs, including shipping and handling and taxes, when applicable. b. Reimbursement shall be made at the physician’s charge or no greater than twenty (20) percent above the actual cost of each drug furnished. c. Reimbursement shall not be made for oral vitamins, nutrient preparations and dietary supplements.

SECTION V: MEDICAL SUPPLIER SERVICES.

A. Medical supplies, durable medical equipment (DME), appliances, devices, transcutaneous neurostimulators (TNS), ocular and hearing aids, prosthetics or orthotics shall be prescribed by a physician and may be provided to an injured employee by a medical supplier through rental or purchase.

B. A medical supplier shall obtain and accept written authorization and payment agreement from the carrier prior to furnishing an injured employee medical supplies or equipment.

C. A medical supplier shall provide the carrier with a copy of the physician’s original order with the bill for reimbursement. A medical supplier is not required to submit codes or to provide invoices with the bill to document the actual costs of supplies and equipment.

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D. Reimbursement.

1. Reimbursement shall be made to a medical supplier by the carrier for rental or purchase of

medical equipment, appliances, transcutaneous neurostimulators, ocular and hearing aids, prosthetics, esthetics and supplies. a. The carrier may rent the item from the supplier for the injured employee. 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 employee. b. The carrier may purchase the item from the supplier.

2. A carrier shall reimburse a medical supplier at the price stated in the payment agreement, upon receipt of a bill and copy of the physician’s original order.

SECTION VI: MEDICAL SERVICES.

A. Biofeedback Services.

1. Reimbursement to a health care provider for biofeedback training shall be limited to twelve

(12) visits per date of accident by the injured employee. This biofeedback training limitation does not include individual psychophysiological therapy incorporating biofeedback training by any modality with psychotherapy.

2. Reimbursement shall be made to a provider for the collection and interpretation of biofeedback data digitally stored or transmitted by the injured worker to the provider.

3. Downloading of biofeedback data by a health care provider during an injured employee’s visit for an evaluation and management service or physical medicine service shall not be reimbursed.

B . Electrodiagnostic Medicine. a. Only a physician or a recognized practitioner specifically qualified by regulations in

Florida shall be reimbursed for needle electromyography (EMG) testing.

(1) The physician shall prescribe the appropriate number of studies to be performed, including the frequency and necessity of repeat testing.

(2) Reimbursement for needle electromyography shall include the EMG testing of selected muscles, the interpretation of the studies and a report of the findings. b. When an initial evaluation and management service and needle EMG testing are performed during a visit, reimbursement shall be made to a physician for both services. c. When a follow-up evaluation and management service and needle EMG testing are performed on the same day, reimbursement shall be made to a physician for both services

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition if the physician’s documentation validates the medical necessity of the follow-up evaluation and management service. d. When needle EMG testing is performed in a hospital or other facility, reimbursement shall be made to a physician for an interpretation of the testing if modifier –26 is added to the appropriate code.

2. Nerve conduction studies (NCSs). a. Only a physician shall be reimbursed for nerve conduction studies (NCOs).

Reimbursement shall include the testing, interpretation and report.

(1) A physician shall perform an initial evaluation to determine the nerves to test and the appropriate NCS to be performed.

(2) A physician, or a technologist under the direct supervision of the physician, may perform a NCS.

(3) Only a physician shall interpret a NCS.

(4) A physician shall determine the frequency and necessity of repeat testing. b. When an initial evaluation and management service and NCSs are performed during the same visit, reimbursement shall be made to a physician for both services. c. When a follow-up evaluation and management service and NCSs are performed on the same day, reimbursement shall be made to a physician for both services if the physician’s documentation validates the medical necessity of the follow-up evaluation and management service.

C. Evaluation and Management Services.

1. Office

A physician shall be reimbursed by a carrier for evaluation and management services (new patient and established patient visits). Reimbursement is limited to one (1) visit a day at the highest level of care provided by the physician.

2. Consultations, confirmatory consultations and follow-up consultation services.

A physician shall be reimbursed for consultations, confirmatory consultations and follow-up consultation services. Reimbursement shall include a review of all submitted medical records, paper and non-paper; an examination of the injured employee; and a written report.

D. Home Health Services.

1. A physician shall be reimbursed for home visits when authorized by the carrier. A physician shall use the appropriate evaluation and management home visit code to report the service.

2. A home health agency shall be reimbursed for carrier authorized home health services provided in a patient’s residence, based on a signed order from the authorized, treating

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition physician. The carrier shall reimburse a home health agency at the reimbursement amounts agreed upon by the agency and the carrier.

E. Impairment Rating (Code 99455).

1. A physician shall be reimbursed by the carrier for an impairment rating.

2.

Reimbursement shall include the performance of an examination to evaluate an injured employee’s condition; the establishment of the date of maximum medical improvement and the assignment of an impairment rating of zero (0) percent or greater; and the completion and submission of the required reporting form to the appropriate parties in accordance with section 440.15, F.S.

F. Independent Medical Examination (Code 99456).

A physician shall be reimbursed by the carrier for an independent medical examination (IME). 1.

2. Reimbursement for an IME shall include the review of applicable paper and non-paper medical records; an examination of the injured employee; and a written report.

G. Independent Medical Examination, Consensus (99457), effective October 1, 2003.

1. A physician shall be reimbursed by the carrier for a consensus independent medical examination (CIME).

2. Reimbursement for a CIME shall include the review of applicable paper and non-paper medical records, an examination of the injured employee, and a written report.

3. Reimbursement for a CIME shall be negotiated between the physician and the carrier prior to rendering the service.

H. Injectable Medications.

Reimbursement for injectable medications is separate and is not included in the reimbursement for the administration of an injection or reimbursement for a procedure in which an injectable medication is administered in conjunction with the procedure. Payment for injectable medications shall be made to physicians as follows:

1. Reimbursement shall be made to a physician, using HCPCS J codes or CPT codes, for injectable medications at the provider’s charge, or the maximum reimbursement allowance, whichever is less.

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

3. Reimbursement for multiple medications, administered from the same syringe, shall be as follows: a. At the provider’s charge, or the MRA, whichever is less, for the first reported drug; and

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Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition b. At the provider’s charge, or fifty (50) percent of the MRA, whichever is less, for each additional drug. Each additional drug shall be reported by adding modifier –51 to the

HCPCS or CPT code.

4. Reimbursement to a physician for codes 99070, 90749 or J3490, shall be limited to no more than twenty (20) percent above the actual cost of the injectable medication, based on submission of: a. The name, strength and dosage of the medication, vaccine or toxoid; and b. An invoice, verifying the cost of the medication, vaccine or toxoid, including shipping and handling and taxes, when applicable.

I. Medical and Surgical Supplies (99070 or Specific HCPCS Level II Codes).

1 . Reimbursement for supplies that are necessary to perform a procedure or provide a service shall be included in the reimbursement for the service and shall not be made separately.

2 .

Reimbursement for special supplies and materials shall be limited to an amount not to exceed twenty (20) percent above the actual cost of the supplies and materials, when the provider submits an invoice to the carrier that substantiates the provider’s cost of the item, including shipping and handling, and taxes, when applicable.

J. Ophthalmological

1. Reimbursement for ophthalmological services shall be made for all medically necessary services.

2. Reimbursement shall only be made for spectacles, 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.

K. Psychiatric and Psychological Services.

1. Reimbursement for psychiatric and psychological services shall be made by the carrier to an authorized, licensed medical doctor, osteopathic physician, a psychologist, mental health practitioner or health professional providing services in compliance with state licensure.

2. Reimbursement shall be made for individual psychotherapy services.

3. Reimbursement shall be made to a physician for individual psychotherapy with medical evaluation and management services provided at the therapy session by a physician. An evaluation and management service provided on the same day as individual psychotherapy with medical evaluation and management services by the physician shall not be reimbursed.

4. Reimbursement shall only be made for an evaluation and management service when individual psychotherapy is not provided. Reimbursement shall only be made to physicians for evaluation and management services.

5. When multiple individual psychotherapy sessions are provided on the same day, only the session lasting the longest period of time shall be reimbursed.

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6. Reimbursement for family psychotherapy with or without the injured employee shall be made if the documentation supports that the purpose is related to the treatment of the injured employee’s compensable injury. Reimbursement shall not be made for psychological services provided directly to members of the injured employee’s family for support and assistance in adjusting to the injured employee’s condition.

7. Reimbursement shall be made for central nervous system assessments/testing. a. Reimbursement includes an assessment and administration of a test with interpretation and report. b. The amount of reimbursement for these services shall be determined from the number of hours (units of service) reported by the provider to perform the assessment/test and the listed MRA. The procedure code’s descriptor shall indicate if the service is per hour or all inclusive.

L. Radiology.

1. Reimbursement shall be made for radiology services, including nuclear medicine and diagnostic ultrasound services.

2. Reimbursement for radiological services, provided in a hospital, ambulatory surgical center or similar facility, shall be made only to radiologists for the professional component, when modifier –26 is added to the radiology code.

3. Reimbursement shall not be made for a professional component (modifier –26) billed in the following situations: a. A professional component billed by a physician for x-rays taken and interpreted by another physician and reviewed during an IME, medical visit or consultation. b. 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.

4. Reimbursement shall be made to an independent radiology facility for a facility charge in certain circumstances. Reimbursement for a facility charge shall be made BR when a radiologist bills the following related services: an injection procedure; radiological supervision and interpretation; and the use of a freestanding radiology facility. a. In addition to the injection procedure, the code with the descriptor “radiological supervision and interpretation” must be reported twice as follows:

(1) The five-digit code to identify the specific “supervision and interpretation” radiological service provided.

(2) The five-digit code plus the workers’ compensation unique modifier – FC to indicate the service was rendered in an independent or freestanding radiology facility, not a hospital.

12

Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition b. When both a technical component (modifier –TC) and a facility charge (modifier –FC) are billed with the “supervision and interpretation” code on the same date of service, reimbursement shall only be made for the facility charge (modifier –FC).

M. Thermography.

1. Authorization.

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

2. Reimbursement. a. Reimbursement for thermography shall be limited to one (1) body area, either major or limited.

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

(a) Head.

(b) Cervical spine and upper extremities.

(c) Lumbosacral spine and lower extremities.

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

(a) Thoracic spine.

(b) Any portion of a major area. b. Reimbursement for thermography to a major body area shall be made at the provider’s charge or the MRA, whichever is less. c. Reimbursement for thermography to a limited body area, reported by adding modifier –52 to the code shall be made at the provider’s charge, or fifty (50) percent of the MRA, whichever is less.

N. Transcutaneous Neurostimulator.

1. Reimbursement shall be made to an authorized physician or other health care provider for furnishing an injured employee with a transcutaneous (surface) neurostimulator (TNS), prescribed by a physician. a. Authorization and a payment agreement shall be obtained from the carrier for rental or purchase of a TNS prior to a physician or provider furnishing a TNS to the injured employee. b. Reimbursement for a TNS shall be made at the price agreed upon between the provider and the carrier when authorization is given by the carrier. c. Reimbursement shall not exceed twenty (20) percent above the provider’s documented cost when the TNS is purchased. A copy of the provider’s invoice shall be submitted

13

Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition with the bill, substantiating the actual cost, including shipping and handling and taxes, when applicable.

2. Reimbursement shall be made to an authorized physician or provider for furnishing training to an injured employee on the application of a transcutaneous neurostimulator. Reimbursement is limited to no more than four (4) training sessions.

SECTION VII: PHYSICAL MEDICINE AND REHABILITATION SERVICES.

A. General Information.

1. Physical medicine and rehabilitation services shall be prescribed by a physician.

2. The Florida workers’ compensation program shall reimburse authorized providers, as specified in this section, for three (3) levels of physical medicine and rehabilitation services: a. Level I applies to acute injuries which are evaluated, tested and treated with modalities and therapeutic procedures to reduce symptoms, restore function and return the injured employee to work. b. Level II focuses on injuries requiring intensive physical reconditioning services to restore the injured employee to pre-injury level of physical health and function. The goal shall be for the employee to return to a job or become physically reconditioned. c. Level III covers a variety of services that are coordinated, outcomes-focused and directed at the injured employee’s needs to increase the employee’s functioning or to return the employee to work. Specifically, work hardening services and pain program services shall only be performed in rehabilitation programs accredited by the Commission on

Accreditation of Rehabilitation Facilities (CARF). These services are provided through the following CARF programs: Outpatient Medical Rehabilitation Program; Occupational

Rehabilitation Program; or Interdisciplinary Pain Rehabilitation Program.

3. Approval for the provision and payment of medically necessary services beyond the guidelines provided in Section VII for any of the Levels must be obtained from the carrier, in writing, prior to a provider furnishing the service. The unusual circumstances must be documented and forwarded by the provider to the carrier for review before an exception to the guidelines can be considered and a determination made by the carrier to authorize additional services.

B. Level I: Physical Medicine Services.

1. Authorization. a. Reimbursement shall only be made for carrier authorized Level I services, based on a signed order from an authorized, treating physician. All services shall be authorized prior to initiation of services. b. Reimbursement for physical medicine services shall only be made to the following:

14


(1) A licensed physician, including physical medicine services provided by a physician-

employed therapist and billed by the physician.

(2) A licensed therapist or health care provider, not employed by a physician. c. Reimbursement for physical medicine services shall not exceed one (1) visit per day, unless specifically authorized by the carrier. d. Reimbursement for Level I services shall only be made for six (6) months after the date of injury, unless specifically ordered by the treating physician and authorized by the carrier. e. Reimbursement shall only be made to licensed occupational and physical therapists for a carrier authorized custom fabricated orthotic or prosthetic devise, whether reported using

CPT codes or appropriate Level II HCPCS codes that specifically describe the devise, when it is ordered by a physician. evaluation. a. Reimbursement for an initial evaluation, provided by a physician or a physicianemployed therapist, shall be made when billed by a physician as an evaluation and management service. Separate reimbursement shall not be made to a physician and to a physician-employed therapist for an evaluation by each. b. Reimbursement for an initial evaluation, performed in a freestanding facility by a therapist not employed by a physician, shall be made when billed by the therapist under code 97001 or 97003. c. Reimbursement for an initial evaluation shall include the evaluation and a plan of care or treatment.

(1) Documentation of the evaluation and plan of care shall be submitted to the carrier with the claim form. At a minimum, the documentation shall contain:

(a) The evaluation findings, including any functional limitations.

(b) The proposed therapy, specifying the frequency and duration of the services.

(c) The anticipated degree of restoration of function with measurable goals.

(2) If the carrier questions the appropriateness of the therapy listed in the plan of care, the carrier shall immediately contact the physician, who ordered the therapy, for the treatment rationale. It shall be the responsibility of the physician to provide the documentation of medical necessity for the therapy to the carrier timely in order to avoid unnecessary delays in obtaining authorization for treatment or in initiating therapy.

15


3. Re-evaluation.

Reimbursement shall be made for a re-evaluation ordered by a physician and performed by a therapist, not employed by a physician, in a freestanding facility. A re-evaluation must be billed using either code 97002 or 97004.

4. Revised plan. a. The physician or therapist shall submit to the carrier a revised plan of care or treatment, when appropriate. b. An authorized treating physician has the responsibility of providing documentation of medical necessity for therapy modifications if questioned by the carrier.

5. Modalities and therapeutic procedures. a. Reimbursement to a provider for therapy shall be limited to one (1) visit a day. b. Reimbursement to a provider 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.

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

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

(3) Code 97150 shall be restricted to one (1) reimbursable unit of service per visit. a. Reimbursement to a physician for a manipulative treatment shall be limited to one (1) visit a day. b. Reimbursement for manipulative treatment under workers’ compensation shall be limited to two (2) body regions.

(1) The entire spine is one (1) region.

(2) Each of the following is one (1) region: head; two (2) upper extremities; two (2) lower extremities; one (1) upper and one (1) lower extremity; rib cage; and abdomen. c. Reimbursement for manipulative treatment to the two (2) regions, listed in Section

VII.B.6.b., shall be made for workers’ compensation unique codes 97260 and 97261, specifically designated for physicians other than osteopaths and chiropractors.

(1) Reimbursement shall be made for code 97260, when used to bill for a spinal manipulation. The spine shall be reimbursed as one (1) entity for workers’

16

Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition compensation, although there are five (5) spinal regions (cervical; thoracic; lumbar; sacral; and pelvic).

(2) Reimbursement shall be made for code 97261, when used to bill for a manipulation of the temporomandibular joint; the upper extremities, including the hand and wrist; the lower extremities; and other regions. d. Reimbursement for osteopathic manipulative treatment (OMT) to the two (2) regions, listed in Section VII.B.6.b., shall be made for codes 98926 and 98928.

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

(2) Reimbursement shall be made for code 98928, when used to bill for a manipulation to the head region; lower extremities; upper extremities; rib cage region; and abdomen and viscera region. e. Reimbursement for chiropractic manipulative treatment (CMT) to the two (2) regions, listed in Section VII.B.6.b., shall be made for codes 98941 and 98943. These manipulation codes are specifically designated for chiropractic physicians.

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

(2) Reimbursement shall be made for code 98943, when used to bill for a manipulation to an extraspinal region: head (including temporomandibular joint, excluding atlantooccipital); lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints); and abdomen.

7. Acupuncture. a. Reimbursement for acupuncture shall be limited to one (1) visit a day. b. Reimbursement for acupuncture with one (1) or more needles shall be made to a physician or licensed provider not employed by a physician.

8. Tests a. Reimbursement to a provider shall be limited to one (1) visit by an injured employee per thirty (30) days for tests and measurements to a select 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. b. Reimbursement shall be made for the workers’ compensation unique code 97752, specifically designated for both manual and automated testing. Reimbursement shall

17

Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition include a report of the testing results. Manual muscle testing (95831-95834) and range of motion codes (95851-95852) shall not be reimbursed when reported separately with code

97752. c. Reimbursement shall be made for range of motion measurements. Code 95851 may be reported and paid for either manual or computerized range of motion measurements and report.

9. Medical supplies (Code 99070). a. Reimbursement shall be made to a provider when medical supplies are used in addition to the normal supplies for a physical medicine service. b. Reimbursement to a provider shall not exceed twenty (20) percent above the provider’s actual cost of a supply. An invoice substantiating the provider’s cost of the item, shall be submitted to the carrier with the claim form, including shipping and handling and taxes, when applicable.

C. Level II: Physical Reconditioning Services.

1. Authorization. a. Reimbursement shall only be made for carrier authorized Level II services, based on a signed order from the authorized, treating physician. Physical reconditioning services shall be authorized prior to initiation and shall not begin any earlier than thirty (30) days following the employee’s date of accident. b. Reimbursement for physical reconditioning services shall only be made to an authorized occupational or physical therapist not employed by a physician.

2. Physical reconditioning assessment. a. Reimbursement for a physical reconditioning assessment and written report shall be determined from the number of hours reported by the provider to perform the assessment and the listed MRA. Reimbursement shall be limited to eight (8) hours. b. Reimbursement shall be made for workers’ compensation unique codes 97850 and

97851, specifically designated to use in reporting a physical reconditioning assessment.

(1) Reimbursement shall be made for code 97850, when used to bill per hour charges for a physical reconditioning assessment.

(2) Reimbursement shall be made for code 97851, when used to bill each additional thirty (30) minutes of a physical reconditioning assessment.

3. Physical reconditioning program. a. Reimbursement for a physical reconditioning program shall be paid based on the number of hours billed by the provider and the listed MRA. Reimbursement shall be limited to a program lasting no longer than sixty (60) hours during a six (6) week period, including a physical reconditioning assessment.

18

Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition b. Reimbursement shall be made for workers’ compensation unique codes 97852 and

97853, specifically designated to use in reporting for physical reconditioning.

(1) Reimbursement shall be made for code 97852, when used to bill per hour charges for physical reconditioning.

(2) Reimbursement shall be made for code 97853, when used to bill each additional thirty (30) minutes for physical reconditioning. c. Reimbursement shall be made for a physical reconditioning program when the services are provided alone, concurrently with or subsequent to Level I services by the same authorized occupational or physical therapist. d. Reimbursement shall be made to a therapist for only one (1) physical reconditioning program for an injured employee per date of accident, unless authorized by the carrier for an exacerbation of the injury or surgical intervention, documented by the treating physician. e. Reimbursement for an extension of the program shall be limited to reimbursement for an additional twenty (20) hours during a two (2) week period. An extension shall be ordered by the physician and authorized by the carrier.

4. Discharge from the physical reconditioning program. a. The treating physician shall determine if the injured employee shall be discharged from the physical reconditioning program before completion. If the injured employee has not completed the program and the treating physician recommends discontinuance of the program, the physician shall provide discharge information to the injured employee, the carrier and the therapist without charge. b. Upon program completion, a report of the following shall be sent by the therapist without charge to the treating physician and the carrier with the final bill:

(1) The injured employee’s current clinical status and degree of reconditioning/restoration; and

(2) Return to work recommendations.

D. Level III. Rehabilitation Programs. a. Reimbursement shall only be made to a facility for carrier authorized Level III services, based on a signed order from the authorized, treating physician. All services shall be authorized prior to initiation of services. b. Reimbursement for Level III services 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. Level

III services must be provided through a CARF accredited Outpatient Medical

Rehabilitation Program, Occupational Rehabilitation Program or Interdisciplinary Pain

Rehabilitation Program.

19


2. Functional Capacity Evaluation (FCE). a. Reimbursement for a functional capacity evaluation to determine the injured worker’s functional or vocational status shall be made only when the evaluation is provided as a art part of Level III services. Reimbursement shall be made for workers’ compensation unique code 97750, specifically designated for use solely in reporting a functional capacity evaluation. b. The reimbursement for a functional capacity evaluation includes a written program plan or a written report. The facility shall provide the results of the evaluation and recommendations to the injured employee, the carrier and the treating physician without additional charge.

3. Work hardening program. a. Reimbursement for a work hardening program shall be made to a facility for the duration of the recommended individualized program. b. Reimbursement shall be made for workers’ compensation unique codes 97545 and

97546, specifically designated to use exclusively in reporting a work hardening program.

(1) Reimbursement shall be made for code 97545 when used to bill the initial two (2) hours each day of a work hardening program.

(2) Reimbursement shall be made for code 97546 when used to bill each additional hour each day of a work hardening program. a. Reimbursement for an interdisciplinary pain management program shall be made to a facility for the recommended time indicated in the injured employee’s individual program plan. b. Reimbursement shall be made for codes submitted with documentation of the services rendered. The services provided must relate to the physical, psychological, social, functional and vocational goals of the program’s plan for the employee.

5. Discharge from a CARF accredited program. a. The facility’s program director shall determine if the injured employee shall be discharged from the work hardening or pain program before completion. If the injured employee has not completed the program and the program director recommends discontinuance of the program, the director shall provide discharge information to the injured employee, the carrier and the treating physician without charge. c. Reimbursement 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.

20

Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition b. 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 shall include:

(1) The injured employee’s current clinical status and plan for transition from the program; and

(2) Return to work recommendations.

SECTION VIII: SURGICAL SERVICES.

A. General reimbursement information.

1. Reimbursement for a surgical package (global reimbursement) shall be made to a physician for the provision of certain services before and after surgery. Payment for these services include: a. The immediate preoperative visit. b. Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia. c. The surgical procedure and operative report. d. The time period for follow-up care listed in the follow-up days column (FU days) in

Section X.

(1) Reimbursement for a procedure code with a YYY designation for the global period shall be set by the carrier.

(2) Reimbursement for a procedure code with a ZZZ designation for the global period shall be the same as the other procedure code that is billed in conjunction with this

“add-on” procedure code.

2. Reimbursement shall be made for other services in addition to the surgical package in the following situations when: a. A preoperative visit is the initial visit, when prolonged detention or evaluation is necessary to prepare an injured employee and when there is a need to establish the reason for a particular type of surgery. b. The preoperative visit is a consultation. d. The preoperative services are not part of the usual preparation for the particular surgical procedure. e . The services are to treat complications, exacerbations, recurrences, or other diseases and injuries. Documentation substantiating the medical necessity of the additional services rendered shall be submitted with the claim form.

21


3. Reimbursement shall be made for additional surgery performed during the follow-up period. a. Reimbursement for surgical services shall be made when an additional surgery is performed during the postoperative period of another surgical procedure. b. Reimbursement for normal postoperative care shall run concurrently and shall be made according to the separate follow-up day periods (FU days) listed in Section X. unless it is a procedure code with a YYY designation. For these codes the follow-up day period shall be set by the carrier.

B. Reimbursement for surgical assistants, two (2) surgeons and surgical team. a. Reimbursement for surgical assistant services shall be the physician’s usual and customary charge or twenty-five (25) percent of the MRA, whichever is less. b. Reimbursement shall be made to a non-physician assistant for surgical services.

Reimbursement by the carrier shall not exceed seventy-five (75) percent of the allowance addressed in Section VIII.B1.a. when the carrier has:

(1) Determined the non-physician assistant meets state licensure requirements and holds current certification, as applicable, and

(2) Provided written authorization to the non-physician assistant prior to the surgery; or

(3) Verified that during a medical emergency a physician was not available to assist at surgery. a. Reimbursement shall be made to two (2) surgeons at the same operative session for performing distinct parts of a surgical procedure. The services provided shall be identified by the same code with modifier –62 added. Reimbursement to each surgeon shall be made at each provider’s usual and customary charge, or sixty-two and one-half

(62.5) percent of the MRA, whichever is less. b. Reimbursement shall be made to two (2) surgeons at the same operative session for rendering separate surgical procedures, identified by different, unmodified codes.

Reimbursement to each surgeon shall be made at each surgeon’s usual and customary charge, or the MRA, whichever is less. c. Reimbursement shall not be made to either surgeon until the carrier has received and reviewed each surgeon’s bill and individual operative report.

Reimbursement for a surgical team shall be made BR to each team member for each surgeon’s surgical service. Each team member shall identify the specific procedure with modifier –66 added to the code.

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C. Reimbursement for multiple procedures.

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

2. Reimbursement for the primary surgical procedure shall be made at the provider’s charge, or the MRA, whichever is less.

3. Reimbursement for an additional procedure shall be made at the provider’s charge, or fifty

(50) percent of the listed MRA, whichever is less. The additional procedure shall be identified when modifier –51 is added to the code to indicate the performance of multiple procedures.

D. Reimbursement for bilateral procedures.

1. Reimbursement shall be made for bilateral procedures that are performed at the same operative session.

2. Reimbursement for a bilateral procedure that contains the word “bilateral” in the descriptor shall be made at the provider’s charge, or the listed MRA, whichever is less.

3. Reimbursement for a bilateral procedure that does not indicate that it is bilateral shall be made, as follows, when the procedure is billed twice: a. Reimbursement for the first procedure shall be made at the provider’s charge, or the listed MRA, whichever is less. b. Reimbursement for the second procedure, identified by adding modifier –50 to the procedure code, shall be made at the provider’s charge, or fifty (50) percent of the listed

MRA, whichever is less.

SECTION IX: ANESTHESIA SERVICES.

A.

Reimbursement for anesthesia services shall be made to a physician or certified registered nurse anesthetist (CRNA).

1. Reimbursement shall be based on application of the following values, physical status modifiers and certain qualifying circumstances.

a. Basic value (BV) or base unit.

(1) The usual preoperative and postoperative visits, the anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services (ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry) are included in the basic value.

(2) When multiple surgical procedures are performed during an operative session, the basic value for the anesthesia procedure with the highest value is billed and reimbursed.

23


(3) The basic value units, listed in Section X. under Anesthesia, for each anesthesia procedure code, are used in calculating reimbursement. b. Time (TM) units.

(1) Anesthesia time begins when the provider starts to prepare the injured employee for anesthesia care in the operating room or in an equivalent area and stops when the provider is no longer in personal attendance.

(2) Anesthesia time 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.

(3) The minutes of anesthesia must be converted into time (TM) units as follows:

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

(b) For CRNAs, each fifteen (15) minutes of anesthesia time equals one (1) minute over a unit has a value of one-fifteenth (1/15) unit.

(c) For codes providing BV + TM, time units shall be calculated and added to the listed BV to determine the reimbursement for the anesthesia services.

(d) Only the BV units apply for codes without a time unit (TM) after the base unit.

For some anesthesia services, time is not reported additionally. Therefore, additional units of time are not calculated for these codes when determining reimbursement. c. Physical status modifiers.

(1) Anesthesia services shall warrant additional reimbursement for units based upon the injured employee’s condition and the complexity of the anesthesia service provided.

(2) A physical status modifier shall be determined to rank the injured employee’s condition. Additional reimbursement shall be based on the unit value for the specific physical status modifier (see Section IX. A.2.a.(5).

Modifiers

Unit

Values

0

0

1

P1 A normal healthy patient

P2 A patient with mild systemic disease

P3 A patient with severe systemic disease

P4 A patient with severe systemic disease that is a constant threat to life

P5 A moribund patient who is not expected to survive without the operation

P6 A declared brain-dead patient whose organs are being removed for donor purposes

2

3

0

24

Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition d. Qualifying circumstances.

Anesthesia services, which are provided under particularly difficult circumstances, may warrant additional reimbursement for unit values based on unusual events. This subsection includes a list of important qualifying circumstances that impact the anesthesia service provided. These procedures are not reported alone but are reported as additional procedure numbers qualifying an anesthesia procedure for additional reimbursement. The listed unit value must be added to the basic unit values to obtain the reimbursement (see

Section IX. A. 2.a.(5). List each of the following codes separately in addition to the procedure code for the primary anesthesia procedure.

Unit

Qualifying Circumstances Values

99100

99116

Anesthesia for patient of extreme age, under one year and over seventy

Anesthesia complicated by utilization of total body hypothermia

99135 Anesthesia complicated by utilization

of

99140 Anesthesia complicated by emergency

(specify)

1

5

5

2

2 .

Reimbursement for anesthesia services shall be made at the provider’s usual charge or the anesthesia reimbursement allowance (ARA), whichever is less. a . Methodology for calculating the anesthesia reimbursement allowance (ARA) for procedures that are listed basic value (BV) + time (TM).

(1) Select the applicable anesthesia procedure code and basic value from the schedule in

Section X.

(2) Determine the time units according to Section IX.A.1.b.(3) (ten [10] minutes = one

[1] time unit for an anesthesiologist and fifteen [15] minutes = one [1] time unit for a

CRNA).

(3) Any minutes that exceed a whole unit are counted as partial units (fractions of units), such as one (1) minute is one-tenth (1/10) unit for an anesthesiologist and onefifteenth (1/15) unit for a CRNA.

(4) Determine any additional units that are justified by the physical status modifiers or qualifying circumstances addressed above in Section IX.A.1.c. and IX.A.1.d.

(5) Add the basic value, time units, physical status modifier and any applicable qualifying circumstances to determine the total anesthesia value.

(6) Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the anesthesia reimbursement allowance.

25

Florida Workers’ Compensation Health Care Provider Reimbursement Manual, 2003 Edition b. Methodology for calculating the anesthesia reimbursement allowance (ARA) for procedures that are listed only basic value (BV) and no time.

Multiply the basic value by the conversion factor of $29.49 to obtain the anesthesia reimbursement allowance. c. Methodology for calculating the anesthesia reimbursement allowance (ARA) for monitored anesthesia care.

(1) Follow the guidelines, as applicable, in Section IX.A.2.a. as though anesthesia was administered (basic value + time).

(2) Multiply the total anesthesia value by the conversion factor of $29.49 to obtain the anesthesia reimbursement allowance.

B. Reimbursement for medical direction provided by anesthesiologist.

1. Medical direction for CRNA employed by anesthesiologist. a. Reimbursement shall be made to the anesthesiologist only for anesthesia services which are billed under the name and license number of the physician-employer. b. No additional reimbursement shall be made for supervisory services rendered by the physician.

2. Medical direction for a CRNA not employed by the anesthesiologist. a. A CRNA shall bill on the number of units of time to perform the surgical procedure. The reimbursement shall be calculated by dividing the total anesthesia time by fifteen (15) minute intervals for CRNAs. b. Reimbursement shall be made to an anesthesiologist for providing medical direction, including preoperative and postoperative evaluations to a CRNA not employed by the physician.

(1) Medical direction shall be billed by the anesthesiologist by adding a unique workers’ compensation modifier –QY to the anesthesia procedure code.

(2) Reimbursement for medical direction by anesthesiologists shall be the provider’s charges, or fifty (50) percent of the anesthesia reimbursement allowance, whichever is less.

26


SECTION X

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

27

00320

00322

00350

00352

00400

00402

00404

00406

00410

00450

00452

00454

00470

00472

00474

00500

00520

00522

00524

00176

00190

00192

00210

00212

00214

00215

00216

00218

00220

00222

00300

Florida Workers' Compensation Health Care Provider Reimbursement Manual, 2003 Edition

Anesthesia Anesthesia Anesthesia

CPT Code BV + TM CPT Code BV + TM CPT Code BV + TM

00100 5 + TM 00528 8 + TM 00844 7 + TM

00102

00103

00104

00120

00124

00126

6 + TM

5 + TM

4 + TM

5 + TM

4 + TM

4 + TM

00530

00532

00534

00537

00539

00540

4 + TM

4 + TM

7 + TM

8 + TM

17 + TM

13 + TM

00846

00848

00851

00860

00862

00864

8 + TM

8 + TM

6 + TM

6 + TM

7 + TM

8 + TM

00140

00142

00144

00145

00147

00148

00160

00162

00164

00170

00172

00174

5 + TM

6 + TM

6 + TM

6 + TM

6 + TM

4 + TM

5 + TM

7 + TM

4 + TM

5 + TM

6 + TM

6 + TM

00541

00542

00544

00546

00548

00550

00560

00562

00563

00566

00580

00600

15 + TM

15 + TM

15 + TM

15 + TM

15 + TM

10 + TM

15 + TM

20 + TM

25 + TM

25 + TM

20 + TM

10 + TM

00865

00866

00868

00870

00872

00873

00880

00882

00902

00904

00906

00908

8 + TM

10 + TM

10 + TM

5 + TM

7 + TM

5 + TM

15 + TM

10 + TM

4 + TM

7 + TM

4 + TM

6 + TM

7 + TM

5 + TM

7 + TM

11 + TM

5 + TM

9 + TM

9 + TM

15 + TM

13 + TM

10 + TM

6 + TM

5 + TM

6 + TM

3 + TM

10 + TM

5 + TM

3 + TM

5 + TM

5 + TM

13 + TM

4 + TM

5 + TM

6 + TM

3 + TM

6 + TM

10 + TM

13 + TM

15 + TM

6 + TM

4 + TM

4 + TM

00604

00620

00622

00630

00632

00634

00635

00640

00670

00700

00702

00730

00740

00750

00752

00754

00756

00770

00790

00792

00794

00796

00797

00800

00802

00810

00820

00830

00832

00840

00842

13 + TM

10 + TM

13 + TM

8 + TM

7 + TM

10 + TM

4 + TM

3 + TM

13 + TM

3 + 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

10 + TM

3 + TM

5 + TM

5 + TM

5 + TM

4 + TM

6 + TM

6 + TM

4 + TM

00932

00934

00936

00938

00940

00942

00944

00948

00950

00952

01112

01120

01130

01140

01150

01160

01170

01180

01190

00910

00912

00914

00916

00918

00920

00921

00922

00924

00926

00928

00930

4 + TM

6 + TM

8 + TM

4 + TM

3 + TM

4 + TM

6 + TM

4 + TM

5 + TM

4 + TM

5 + TM

3 + TM

5 + TM

5 + TM

5 + TM

5 + TM

3 + TM

3 + TM

6 + TM

4 + TM

4 + TM

6 + TM

4 + TM

6 + TM

3 + TM

15 + TM

8 + TM

4 + TM

8 + TM

3 + TM

4 + TM

CPT only © 2002 American Medical Association. All Rights Reserved. 28

01462

01464

01470

01472

01474

01480

01482

01484

01486

01490

01500

01502

01520

01522

01610

01620

01622

01630

01632

01382

01390

01392

01400

01402

01404

01420

01430

01432

01440

01442

01444


Anesthesia Anesthesia Anesthesia

CPT Code BV + TM CPT Code BV + TM CPT Code BV + TM

01200 4 + TM 01634 9 + TM 01953 1 + TM

01202

01210

01212

01214

01215

01220

4 + TM

6 + TM

10 + TM

8 + TM

10 + TM

4 + TM

01636

01638

01650

01652

01654

01656

15 + TM

10 + TM

6 + TM

10 + TM

8 + TM

10 + TM

01960

01961

01962

01963

01964

01967

5 + TM

7 + TM

8 + TM

10 + TM

4 + TM

5 + TM

01230

01232

01234

01250

01260

01270

01272

01274

01320

01340

01360

01380

6 + TM

5 + TM

8 + TM

4 + TM

3 + TM

8 + TM

4 + TM

6 + TM

4 + TM

4 + TM

5 + TM

3 + TM

01670

01680

01682

01710

01712

01714

01716

01730

01732

01740

01742

01744

4 + TM

3 + TM

4 + TM

3 + TM

5 + TM

5 + TM

5 + TM

3 + TM

3 + TM

4 + TM

5 + TM

5 + TM

01968

01969

01990

01991

01992

01995

01996

01999

3 + TM

5 + TM

0

3 + TM

5 + TM

5

3

BR

3 + TM

3 + TM

4 + TM

4 + TM

7 + TM

5 + TM

3 + TM

3 + TM

6 + TM

5 + TM

8 + TM

8 + 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

5 + TM

5 + TM

4 + TM

4 + TM

5 + TM

6 + TM

01756

01758

01760

01770

01772

01780

01782

01810

01820

01829

01830

01832

01840

01842

01844

01850

01852

01860

01905

01916

01920

01922

01924

01925

01926

01930

01931

01932

01933

01951

01952

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

5 + TM

7 + TM

7 + TM

6 + TM

8 + TM

10 + TM

5 + TM

7 + TM

7 + TM

8 + TM

3 + TM

5 + TM



$86.00

$100.00

$125.00

$75.00

$95.00

$110.00

$144.00

$81.00

$114.00

$145.00

$178.00

$200.00

$246.00

$98.00

$92.00

$157.00

$26.00

$35.00

$39.00

$78.00

$41.00

$66.00

$26.00

$59.00

$80.00

$96.00

$119.00

$61.00

$45.00

$164.00

$45.00

$27.00

$348.00

$432.00

$597.00

$43.00

$45.00

$88.00

$210.00

$283.00

MRA

$90.00

$92.00

$54.00

$53.00

$133.00

$65.00

$203.00

$53.00

$169.00

$53.00

10

10

10

10

10

10

10

10

0

0

0

0

0

0

0

10

ZZZ

0

0

0

0

0

0

ZZZ

10

0

0

0

0

10

10

0

0

0

10

10

0

ZZZ

10

0

FU Days

0

0

10

10

10

10

10

10

10

10

11401

11402

11403

11404

11406

11420

11421

11422

11306

11307

11308

11310

11311

11312

11313

11400

11055

11056

11057

11100

11101

11200

11201

11300

11301

11302

11303

11305

10160

10180

11000

11001

11010

11011

11012

11040

11041

11042

11043

11044

Surgery

CPT Code

10021

10022

10040

10060

10061

10080

10081

10120

10121

10140

Surgery

CPT Code

11423

11424

11426

11440

11441

11442

11443

11444

11446

11450

11451

11462

11463

11470

11471

11600

11601

11602

11603

11604

11606

11620

11621

11622

11623

11624

11626

11640

11641

11642

11643

11644

11646

11719

11720

11721

11730

11732

11740

11750

11752

11755

11760

11762

11765

11770

11771

11772

11900

11901

MRA

$163.00

$221.00

$303.00

$105.00

$102.00

$174.00

$221.00

$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

$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

$131.00

$223.00

$65.00

$275.00

$496.00

$585.00

$33.00

$37.00

10

90

90

10

10

10

0

0

ZZZ

0

10

0

0

0

10

0

10

10

0

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

90

90

10

90

90

90

FU Days

10

10

10

10

10

10

90

10

10

10

12055

12056

12057

13100

13101

13102

13120

13121

12044

12045

12046

12047

12051

12052

12053

12054

12017

12018

12020

12021

12031

12032

12034

12035

12036

12037

12041

12042

11976

12001

12002

12004

12005

12006

12007

12011

12013

12014

12015

12016

Surgery

CPT Code

11920

11921

11922

11950

11951

11952

11954

11960

11970

11971

$176.00

$250.00

$341.00

$363.00

$126.00

$148.00

$223.00

$301.00

$380.00

$487.00

$539.00

$178.00

$240.00

$89.00

$223.00

$348.00

$316.00

$515.00

$211.00

$87.00

$93.00

$110.00

$148.00

$223.00

$356.00

$411.00

$116.00

$141.00

$123.00

$84.00

$98.00

$122.00

$165.00

$203.00

$339.00

$98.00

$141.00

$165.00

$207.00

$268.00

MRA

$147.00

$172.00

$40.00

$107.00

$114.00

$155.00

$165.00

$829.00

$632.00

$280.00

10

10

10

10

10

ZZZ

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

10

0

10

10

FU Days

0

0

ZZZ

0

90

90

90

0

0

0



$118.00

$25.00

$232.00

$66.00

$223.00

$66.00

$748.00

$721.00

$775.00

$457.00

$259.00

$320.00

$506.00

$362.00

$427.00

$1,465.00

$679.00

$146.00

$788.00

$235.00

$644.00

$126.00

$687.00

$114.00

$763.00

$334.00

$841.00

$207.00

$695.00

$590.00

$818.00

$701.00

$936.00

$766.00

$1,330.00

$1,040.00

$734.00

$287.00

$70.00

$349.00

MRA

$104.00

$252.00

$484.00

$154.00

$260.00

$375.00

$542.00

$169.00

$655.00

$512.00

90

90

90

90

90

90

90

90

10

ZZZ

90

ZZZ

90

ZZZ

90

90

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

90

90

0

ZZZ

90

90

90

90

90

90

90

FU Days

ZZZ

10

10

ZZZ

10

10

10

ZZZ

90

90

15574

15576

15600

15610

15620

15630

15650

15732

15342

15343

15350

15351

15400

15401

15570

15572

15100

15101

15120

15121

15200

15201

15220

15221

15240

15241

15260

15261

14001

14020

14021

14040

14041

14060

14061

14300

14350

15000

15001

15050

Surgery

CPT Code

13122

13131

13132

13133

13150

13151

13152

13153

13160

14000

Surgery

CPT Code

15734

15736

15738

15740

15750

15756

15757

15758

15760

15770

15775

15776

15780

15781

15782

15783

15786

15787

15788

15789

15792

15793

15810

15811

15819

15820

15821

15822

15823

15824

15825

15826

15828

15829

15831

15832

15833

15834

15835

15836

15837

15838

15839

15840

15841

15842

15845

15850

15851

15852

MRA

$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

$532.00

$420.00

$314.00

$340.00

$146.00

$27.00

$194.00

$360.00

$130.00

$232.00

$401.00

$440.00

$780.00

$556.00

$607.00

$499.00

$718.00

NC

NC

NC

NC

NC

$990.00

$926.00

$833.00

$837.00

$865.00

$721.00

$696.00

$600.00

$643.00

$1,187.00

$1,859.00

$3,099.00

$1,116.00

$63.00

$40.00

$35.00

90

90

0

90

90

90

0

0

90

90

90

90

90

90

90

90

0

0

0

90

0

0

90

90

90

90

90

90

10

ZZZ

90

90

90

90

90

90

90

0

0

90

FU Days

90

90

90

90

90

90

90

90

90

90

17260

17261

17262

17263

17264

17266

17270

17271

17003

17004

17106

17107

17108

17110

17111

17250

15956

15958

15999

16000

16010

16015

16020

16025

16030

16035

16036

17000

15935

15936

15937

15940

15941

15944

15945

15946

15950

15951

15952

15953

Surgery

CPT Code

15860

15876

15877

15878

15879

15920

15922

15931

15933

15934

$16.00

$233.00

$341.00

$648.00

$1,015.00

$55.00

$83.00

$27.00

$96.00

$117.00

$150.00

$172.00

$189.00

$225.00

$125.00

$143.00

$1,382.00

$1,379.00

BR

$53.00

$59.00

$213.00

$49.00

$67.00

$153.00

$341.00

$81.00

$60.00

$1,184.00

$1,032.00

$1,223.00

$318.00

$919.00

$954.00

$1,078.00

$1,737.00

$549.00

$872.00

$876.00

$1,013.00

MRA

$151.00

NC

NC

NC

NC

$571.00

$771.00

$638.00

$860.00

$1,064.00

10

10

10

10

10

10

10

10

ZZZ

10

90

90

90

10

10

0

0

0

0

90

ZZZ

10

90

90

YYY

0

0

0

90

90

90

90

90

90

90

90

90

90

90

90

FU Days

0

0

0

0

90

90

90

0

90

90



$1,054.00

$689.00

$628.00

$1,192.00

$1,211.00

$1,195.00

$1,101.00

$1,561.00

$1,674.00

$101.00

$52.00

$103.00

$954.00

$1,313.00

$440.00

$656.00

$98.00

$117.00

$338.00

$263.00

$601.00

$406.00

$354.00

$429.00

$468.00

$201.00

$541.00

$485.00

$590.00

$247.00

$227.00

$232.00

$62.00

$37.00

$96.00

NC

BR

$74.00

$40.00

$288.00

MRA

$170.00

$195.00

$240.00

$281.00

$123.00

$165.00

$194.00

$239.00

$282.00

$373.00

90

0

ZZZ

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

0

0

90

0

0

10

10

0

YYY

0

ZZZ

90

0

0

10

0

0

0

FU Days

10

10

10

10

10

10

10

10

10

10

19272

19290

19291

19295

19316

19318

19324

19325

19162

19180

19182

19200

19220

19240

19260

19271

19030

19100

19101

19102

19103

19110

19112

19120

19125

19126

19140

19160

17304

17305

17306

17307

17310

17340

17360

17380

17999

19000

19001

19020

Surgery

CPT Code

17272

17273

17274

17276

17280

17281

17282

17283

17284

17286

Surgery

CPT Code

19328

19330

19340

19342

19350

19355

19357

19361

19364

19366

19367

19368

19369

19370

19371

19380

19396

19499

20000

20005

20100

20101

20102

20103

20150

20200

20205

20206

20220

20225

20240

20245

20250

20251

20500

20501

20520

20525

20526

20550

20551

20552

20553

20600

20605

20610

20612

20615

20650

20660

MRA

$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

$2,317.00

$662.00

$788.00

$780.00

$231.00

BR

$45.00

$267.00

$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

$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

0

0

10

0

0

0

10

0

10

0

0

10

0

10

0

0

10

10

10

0

0

10

0

0

0

10

10

90

0

YYY

10

10

10

10

90

90

90

90

90

90

FU Days

90

90

ZZZ

90

90

90

90

90

90

90

20979

20999

21010

21015

21025

21026

21029

21030

20957

20962

20969

20970

20972

20973

20974

20975

20920

20922

20924

20926

20930

20931

20936

20937

20938

20950

20955

20956

20802

20805

20808

20816

20822

20824

20827

20838

20900

20902

20910

20912

Surgery

CPT Code

20661

20662

20663

20665

20670

20680

20690

20692

20693

20694

$3,074.00

$3,122.00

$3,716.00

$3,650.00

$3,420.00

$3,821.00

$266.00

$334.00

$19.00

BR

$854.00

$520.00

$546.00

$413.00

$700.00

$496.00

$460.00

$634.00

$583.00

$444.00

BR

$156.00

BR

$234.00

$257.00

$123.00

$3,332.00

$3,167.00

$3,363.00

$4,317.00

$5,324.00

$3,060.00

$2,511.00

$3,027.00

$3,920.00

$3,484.00

$454.00

$658.00

$338.00

$549.00

MRA

$476.00

$559.00

$465.00

$105.00

$80.00

$332.00

$298.00

$516.00

$477.00

$421.00

0

YYY

90

90

90

90

90

90

90

90

90

90

90

90

0

0

0

ZZZ

ZZZ

0

90

90

90

90

90

90

0

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

FU Days

90

90

90

10

90

90

90

10

90

90



$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

$2,640.00

$3,302.00

$3,500.00

$2,333.00

$2,217.00

BR

BR

$297.00

$371.00

$207.00

$500.00

$651.00

$700.00

$903.00

$656.00

$1,026.00

$972.00

$679.00

$1,192.00

$3,002.00

$2,086.00

$2,346.00

$2,138.00

$1,855.00

$1,802.00

$2,105.00

$801.00

MRA

$310.00

$315.00

$1,140.00

$227.00

$957.00

$1,313.00

$899.00

$1,109.00

$925.00

$1,051.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

0

90

90

90

90

90

90

90

90

90

90

10

90

90

90

10

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

21146

21147

21150

21151

21154

21155

21159

21160

21127

21137

21138

21139

21141

21142

21143

21145

21086

21087

21088

21089

21100

21110

21116

21120

21121

21122

21123

21125

21050

21060

21070

21076

21077

21079

21080

21081

21082

21083

21084

21085

Surgery

CPT Code

21031

21032

21034

21040

21044

21045

21046

21047

21048

21049

Surgery

CPT Code

21172

21175

21179

21180

21181

21182

21183

21184

21188

21193

21194

21195

21196

21198

21199

21206

21208

21209

21210

21215

21230

21235

21240

21242

21243

21244

21245

21246

21247

21248

21249

21255

21256

21260

21261

21263

21267

21268

21270

21275

21280

21282

21295

21296

21299

21300

21310

21315

21320

21325

MRA

$2,111.00

$2,604.00

$1,826.00

$2,035.00

$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

$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

$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

$144.00

$384.00

BR

$107.00

$81.00

$180.00

$235.00

$348.00

90

90

YYY

0

0

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

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

21454

21461

21462

21465

21470

21480

21485

21490

21435

21436

21440

21445

21450

21451

21452

21453

21395

21400

21401

21406

21407

21408

21421

21422

21423

21431

21432

21433

21346

21347

21348

21355

21356

21360

21365

21366

21385

21386

21387

21390

Surgery

CPT Code

21330

21335

21336

21337

21338

21339

21340

21343

21344

21345

$1,404.00

$2,045.00

$308.00

$533.00

$325.00

$498.00

$195.00

$902.00

$905.00

$769.00

$1,012.00

$923.00

$1,331.00

$82.00

$318.00

$865.00

$1,384.00

$143.00

$313.00

$852.00

$736.00

$1,007.00

$528.00

$761.00

$890.00

$598.00

$744.00

$1,981.00

$917.00

$1,048.00

$1,286.00

$295.00

$372.00

$590.00

$1,239.00

$1,386.00

$810.00

$812.00

$958.00

$920.00

MRA

$639.00

$852.00

$478.00

$300.00

$550.00

$689.00

$907.00

$1,043.00

$1,450.00

$738.00

90

90

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

10

10

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90



$165.00

$371.00

$403.00

$1,280.00

$850.00

$862.00

$781.00

$198.00

$889.00

$1,090.00

$1,062.00

$195.00

$1,892.00

$1,668.00

$819.00

$492.00

$523.00

$588.00

$1,387.00

BR

BR

$1,009.00

$84.00

$236.00

$540.00

$143.00

$810.00

BR

$431.00

$794.00

$631.00

$828.00

$938.00

$1,042.00

$689.00

$686.00

$1,455.00

$1,514.00

$576.00

$746.00

MRA

$107.00

$529.00

$500.00

$372.00

BR

$315.00

$612.00

$534.00

$165.00

$337.00

90

90

90

ZZZ

90

90

90

ZZZ

90

90

90

10

90

90

90

ZZZ

90

90

90

90

90

YYY

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FU Days

90

90

90

90

YYY

90

90

90

10

90

22110

22112

22114

22116

22210

22212

22214

22216

21920

21925

21930

21935

22100

22101

22102

22103

21720

21725

21740

21742

21743

21750

21800

21805

21810

21820

21825

21899

21556

21557

21600

21610

21615

21616

21620

21627

21630

21632

21700

21705

Surgery

CPT Code

21493

21494

21495

21497

21499

21501

21502

21510

21550

21555

Surgery

CPT Code

22220

22222

22224

22226

22305

22310

22315

22318

22319

22325

22326

22327

22328

22505

22520

22521

22522

22548

22554

22556

22558

22585

22590

22595

22600

22610

22612

22614

22630

22632

22800

22802

22804

22808

22810

22812

22818

22819

22830

22840

22841

22842

22843

22844

22845

22846

22847

22848

22849

22850

MRA

$1,801.00

$1,604.00

$1,731.00

$488.00

$213.00

$272.00

$711.00

$1,755.00

$1,983.00

$1,407.00

$1,710.00

$1,660.00

$391.00

$174.00

$509.00

$477.00

$231.00

$2,271.00

$1,727.00

$2,054.00

$1,907.00

$473.00

$1,895.00

$1,960.00

$1,567.00

$1,494.00

$1,861.00

$530.00

$1,201.00

$442.00

$1,960.00

$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

$1,277.00

$1,853.00

$999.00

$1,077.00

$529.00

$2,235.00

$872.00

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

90

90

90

90

90

90

90

ZZZ

0

ZZZ

90

ZZZ

90

90

90

90

90

90

90

90

90

ZZZ

ZZZ

90

90

90

90

ZZZ

90

90

ZZZ

10

10

10

FU Days

90

90

90

ZZZ

90

90

90

90

90

90

23220

23221

23222

23330

23331

23332

23350

23395

23174

23180

23182

23184

23190

23195

23200

23210

23107

23120

23125

23130

23140

23145

23146

23150

23155

23156

23170

23172

23035

23040

23044

23065

23066

23075

23076

23077

23100

23101

23105

23106

Surgery

CPT Code

22851

22852

22855

22899

22900

22999

23000

23020

23030

23031

$882.00

$566.00

$865.00

$962.00

$656.00

$902.00

$1,095.00

$1,095.00

$1,307.00

$1,559.00

$1,921.00

$59.00

$520.00

$1,029.00

$74.00

$1,366.00

$851.00

$645.00

$865.00

$722.00

$597.00

$889.00

$704.00

$755.00

$945.00

$794.00

$645.00

$638.00

$861.00

$898.00

$708.00

$171.00

$302.00

$247.00

$613.00

$1,228.00

$616.00

$583.00

$814.00

$581.00

MRA

$600.00

$854.00

$1,193.00

BR

$446.00

BR

$447.00

$807.00

$323.00

$185.00

10

90

90

90

90

90

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

10

90

10

90

90

90

FU Days

ZZZ

90

90

YYY

90

YYY

90

90

10

10



$306.00

$809.00

$318.00

$511.00

$900.00

$1,895.00

$286.00

$422.00

$712.00

$296.00

$374.00

$712.00

$440.00

$759.00

$550.00

$1,064.00

$148.00

$293.00

$688.00

$205.00

$320.00

$659.00

$713.00

$148.00

$148.00

$701.00

$753.00

$88.00

$1,210.00

$1,340.00

$1,364.00

$1,383.00

$1,398.00

$1,332.00

$1,540.00

$1,570.00

$926.00

$1,181.00

$1,038.00

$1,251.00

MRA

$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

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

23630

23650

23655

23660

23665

23670

23675

23680

23575

23585

23600

23605

23615

23616

23620

23625

23500

23505

23515

23520

23525

23530

23532

23540

23545

23550

23552

23570

23450

23455

23460

23462

23465

23466

23470

23472

23480

23485

23490

23491

Surgery

CPT Code

23397

23400

23405

23406

23410

23412

23415

23420

23430

23440

Surgery

CPT Code

23700

23800

23802

23900

23920

23921

23929

23930

23931

23935

24000

24006

24065

24066

24075

24076

24077

24100

24101

24102

24105

24110

24115

24116

24120

24125

24126

24130

24134

24136

24138

24140

24145

24147

24149

24150

24151

24152

24153

24155

24160

24164

24200

24201

24220

24300

24301

24305

24310

24320

MRA

$237.00

$1,346.00

$1,368.00

$1,561.00

$1,300.00

$497.00

BR

$71.00

$62.00

$630.00

$550.00

$793.00

$166.00

$461.00

$349.00

$529.00

$1,058.00

$467.00

$591.00

$755.00

$360.00

$724.00

$898.00

$1,037.00

$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

$1,383.00

$829.00

$936.00

$1,019.00

$533.00

$564.00

$58.00

$444.00

$89.00

$352.00

$869.00

$579.00

$511.00

$944.00

90

90

90

10

90

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

10

FU Days

10

90

90

90

90

90

YYY

10

10

90

24576

24577

24579

24582

24586

24587

24600

24605

24535

24538

24545

24546

24560

24565

24566

24575

24410

24420

24430

24435

24470

24495

24498

24500

24505

24515

24516

24530

24350

24351

24352

24354

24356

24360

24361

24362

24363

24365

24366

24400

Surgery

CPT Code

24330

24331

24332

24340

24341

24342

24343

24344

24345

24346

$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

$1,319.00

$1,265.00

$1,209.00

$1,260.00

$774.00

$742.00

$1,076.00

$288.00

$574.00

$1,018.00

$1,029.00

$88.00

$444.00

$522.00

$585.00

$578.00

$634.00

$1,125.00

$1,215.00

$1,269.00

$1,663.00

$747.00

$850.00

$991.00

MRA

$845.00

$927.00

$487.00

$697.00

$702.00

$950.00

$643.00

$971.00

$643.00

$971.00

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

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90



$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

$594.00

$1,040.00

$683.00

$1,104.00

$417.00

$266.00

$794.00

$654.00

$164.00

$322.00

$352.00

$544.00

$984.00

$1,181.00

$858.00

$851.00

$661.00

$928.00

$1,063.00

$1,327.00

BR

BR

$381.00

$294.00

MRA

$836.00

$560.00

$1,329.00

$262.00

$436.00

$749.00

$905.00

$263.00

$490.00

$819.00

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

YYY

90

90

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

25112

25115

25116

25118

25119

25120

25125

25126

25077

25085

25100

25101

25105

25107

25110

25111

25020

25023

25024

25025

25028

25031

25035

25040

25065

25066

25075

25076

24800

24802

24900

24920

24925

24930

24931

24935

24940

24999

25000

25001

Surgery

CPT Code

24615

24620

24635

24650

24655

24665

24666

24670

24675

24685

Surgery

CPT Code

25130

25135

25136

25145

25150

25151

25170

25210

25215

25230

25240

25246

25248

25250

25251

25259

25260

25263

25265

25270

25272

25274

25275

25280

25290

25295

25300

25301

25310

25312

25315

25316

25320

25332

25335

25337

25350

25355

25360

25365

25370

25375

25390

25391

25392

25393

25394

25400

25405

25415

MRA

$502.00

$631.00

$546.00

$713.00

$720.00

$771.00

$1,085.00

$561.00

$817.00

$531.00

$567.00

$72.00

$236.00

$616.00

$933.00

$348.00

$728.00

$809.00

$998.00

$549.00

$613.00

$887.00

$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

$1,166.00

$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

$1,388.00

$1,343.00

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

90

90

0

90

FU Days

90

90

90

90

90

90

90

90

90

90

25650

25651

25652

25660

25670

25671

25675

25676

25611

25620

25622

25624

25628

25630

25635

25645

25520

25525

25526

25530

25535

25545

25560

25565

25574

25575

25600

25605

25445

25446

25447

25449

25450

25455

25490

25491

25492

25500

25505

25515

Surgery

CPT Code

25420

25425

25426

25430

25431

25440

25441

25442

25443

25444

$707.00

$769.00

$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

$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

$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

MRA

$1,554.00

$1,403.00

$1,401.00

$638.00

$631.00

$931.00

$1,147.00

$936.00

$970.00

$1,031.00

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

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90



$440.00

$400.00

$382.00

$398.00

$481.00

$282.00

$344.00

$544.00

$806.00

$833.00

$959.00

$342.00

$629.00

$668.00

$678.00

$660.00

$59.00

$223.00

$484.00

$548.00

$655.00

$601.00

$741.00

$730.00

$367.00

$621.00

$343.00

$293.00

$871.00

$900.00

$799.00

$849.00

$1,523.00

$771.00

$670.00

$768.00

$830.00

$645.00

$731.00

BR

MRA

$471.00

$887.00

$518.00

$520.00

$703.00

$1,078.00

$1,008.00

$2,276.00

$895.00

$991.00

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

10

10

90

90

90

90

90

90

YYY

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

26117

26121

26123

26125

26130

26135

26140

26145

26070

26075

26080

26100

26105

26110

26115

26116

26010

26011

26020

26025

26030

26034

26035

26037

26040

26045

26055

26060

25900

25905

25907

25909

25915

25920

25922

25924

25927

25929

25931

25999

Surgery

CPT Code

25680

25685

25690

25695

25800

25805

25810

25820

25825

25830

Surgery

CPT Code

26160

26170

26180

26185

26200

26205

26210

26215

26230

26235

26236

26250

26255

26260

26261

26262

26320

26340

26350

26352

26356

26357

26358

26370

26372

26373

26390

26392

26410

26412

26415

26416

26418

26420

26426

26428

26432

26433

26434

26437

26440

26442

26445

26449

26450

26455

26460

26471

26474

26476

MRA

$319.00

$452.00

$444.00

$511.00

$598.00

$788.00

$543.00

$731.00

$624.00

$612.00

$444.00

$814.00

$1,184.00

$758.00

$949.00

$624.00

$414.00

$266.00

$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

$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

$353.00

$364.00

$346.00

$592.00

$586.00

$543.00

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

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

26562

26565

26567

26568

26580

26587

26590

26591

26550

26551

26553

26554

26555

26556

26560

26561

26520

26525

26530

26531

26535

26536

26540

26541

26542

26545

26546

26548

26496

26497

26498

26499

26500

26502

26504

26508

26510

26516

26517

26518

Surgery

CPT Code

26477

26478

26479

26480

26483

26485

26489

26490

26492

26494

$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

$583.00

$531.00

$708.00

$877.00

$546.00

$770.00

$726.00

$926.00

$716.00

$722.00

$918.00

$665.00

$949.00

$946.00

$1,317.00

$934.00

$557.00

$715.00

$761.00

$334.00

$564.00

$630.00

$890.00

$877.00

MRA

$553.00

$608.00

$653.00

$808.00

$986.00

$891.00

$738.00

$496.00

$971.00

$946.00

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

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90



$408.00

$854.00

$756.00

$901.00

$800.00

$875.00

$704.00

$829.00

$542.00

$151.00

$747.00

$317.00

$747.00

$444.00

$608.00

BR

$187.00

$532.00

$148.00

$148.00

$548.00

$96.00

$133.00

$366.00

$398.00

$79.00

$275.00

$401.00

$693.00

$148.00

$501.00

$527.00

$592.00

$710.00

$88.00

$296.00

$469.00

$526.00

$96.00

$187.00

MRA

$587.00

$809.00

$133.00

$296.00

$334.00

$497.00

$521.00

$71.00

$371.00

$533.00

90

ZZZ

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

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

26860

26861

26862

26863

26910

26951

26952

26989

26785

26820

26841

26842

26843

26844

26850

26852

26727

26735

26740

26742

26746

26750

26755

26756

26765

26770

26775

26776

26665

26670

26675

26676

26685

26686

26700

26705

26706

26715

26720

26725

Surgery

CPT Code

26593

26596

26600

26605

26607

26608

26615

26641

26645

26650

Surgery

CPT Code

26990

26991

26992

27000

27001

27003

27005

27006

27025

27030

27033

27035

27036

27040

27041

27047

27048

27049

27050

27052

27054

27060

27062

27065

27066

27067

27070

27071

27075

27076

27077

27078

27079

27080

27086

27087

27090

27091

27093

27095

27096

27097

27098

27100

27105

27110

27111

27120

27122

27125

MRA

$592.00

$466.00

$1,146.00

$421.00

$550.00

$698.00

$738.00

$788.00

$896.00

$1,148.00

$1,173.00

$1,413.00

$1,176.00

$196.00

$699.00

$535.00

$588.00

$1,162.00

$449.00

$624.00

$843.00

$491.00

$499.00

$583.00

$931.00

$1,234.00

$1,040.00

$1,112.00

$1,485.00

$1,859.00

$1,976.00

$1,164.00

$1,170.00

$568.00

$57.00

$555.00

$981.00

$1,482.00

$62.00

$121.00

$491.00

$795.00

$799.00

$987.00

$946.00

$1,174.00

$1,099.00

$1,603.00

$1,406.00

$1,371.00

90

90

90

90

90

90

90

90

90

0

0

10

90

90

0

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

FU Days

90

90

90

90

90

90

90

90

90

90

27245

27246

27248

27250

27252

27253

27254

27256

27228

27230

27232

27235

27236

27238

27240

27244

27193

27194

27200

27202

27215

27216

27217

27218

27220

27222

27226

27227

27158

27161

27165

27170

27175

27176

27177

27178

27179

27181

27185

27187

Surgery

CPT Code

27130

27132

27134

27137

27138

27140

27146

27147

27151

27156

$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

$520.00

$1,162.00

$1,478.00

$338.00

$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

$1,588.00

$1,443.00

$1,572.00

$1,453.00

$491.00

$1,024.00

$1,257.00

$1,020.00

$1,107.00

$1,206.00

$676.00

$1,280.00

MRA

$1,853.00

$2,128.00

$2,576.00

$2,190.00

$2,025.00

$1,092.00

$1,432.00

$1,744.00

$1,732.00

$2,017.00

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

FU Days

90

90

90

90

90

90

90

90

90

90



$394.00

$786.00

$763.00

$882.00

$950.00

$394.00

$977.00

$1,421.00

$75.00

$371.00

$698.00

$1,118.00

$753.00

$1,064.00

$506.00

$647.00

$433.00

$400.00

$503.00

$1,249.00

$492.00

$585.00

$786.00

$719.00

$840.00

$959.00

$405.00

$565.00

$2,073.00

$1,594.00

BR

$193.00

$520.00

$555.00

$377.00

$503.00

$877.00

$570.00

$522.00

$211.00

MRA

$455.00

$1,355.00

$1,803.00

$442.00

$614.00

$220.00

$1,179.00

$990.00

$1,435.00

$1,503.00

90

90

90

0

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

10

90

90

90

90

90

YYY

90

90

90

FU Days

10

90

90

90

90

90

90

90

10

90

27370

27372

27380

27381

27385

27386

27390

27391

27347

27350

27355

27356

27357

27358

27360

27365

27324

27327

27328

27329

27330

27331

27332

27333

27334

27335

27340

27345

27290

27295

27299

27301

27303

27305

27306

27307

27310

27315

27320

27323

Surgery

CPT Code

27257

27258

27259

27265

27266

27275

27280

27282

27284

27286

Surgery

CPT Code

27392

27393

27394

27395

27396

27397

27400

27403

27405

27407

27409

27418

27420

27422

27424

27425

27427

27428

27429

27430

27435

27437

27438

27440

27441

27442

27443

27445

27446

27447

27448

27450

27454

27455

27457

27465

27466

27468

27470

27472

27475

27477

27479

27485

27486

27487

27488

27495

27496

27497

MRA

$834.00

$608.00

$748.00

$1,093.00

$742.00

$989.00

$832.00

$792.00

$842.00

$918.00

$1,212.00

$1,596.00

$927.00

$930.00

$927.00

$639.00

$1,118.00

$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

$1,311.00

$1,524.00

$1,157.00

$1,209.00

$1,253.00

$1,441.00

$1,613.00

$1,501.00

$1,665.00

$782.00

$938.00

$1,123.00

$797.00

$1,771.00

$2,352.00

$1,438.00

$1,477.00

$563.00

$652.00

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

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

27600

27601

27602

27603

27604

27605

27606

27607

27580

27590

27591

27592

27594

27596

27598

27599

27536

27538

27540

27550

27552

27556

27557

27558

27560

27562

27566

27570

27510

27511

27513

27514

27516

27517

27519

27520

27524

27530

27532

27535

Surgery

CPT Code

27498

27499

27500

27501

27502

27503

27506

27507

27508

27509

$1,644.00

$1,059.00

$1,182.00

$911.00

$600.00

$931.00

$976.00

BR

$517.00

$516.00

$621.00

$412.00

$308.00

$236.00

$362.00

$608.00

$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

$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

MRA

$701.00

$782.00

$520.00

$659.00

$909.00

$911.00

$1,522.00

$1,297.00

$400.00

$649.00

90

90

10

90

90

90

10

90

90

90

90

90

90

90

90

YYY

90

90

10

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90



$589.00

$757.00

$889.00

$159.00

$658.00

$758.00

$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

$937.00

$458.00

$527.00

$725.00

$504.00

$618.00

$656.00

$762.00

$523.00

$634.00

$565.00

$706.00

$430.00

$781.00

$921.00

$978.00

$1,122.00

$922.00

$1,302.00

$1,212.00

$1,044.00

$72.00

$869.00

$935.00

MRA

$777.00

$701.00

$165.00

$327.00

$1,106.00

$421.00

$730.00

$587.00

$796.00

$863.00

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

0

90

90

90

90

90

90

90

90

90

90

90

FU Days

90

90

10

90

90

90

90

90

90

90

27702

27703

27704

27705

27707

27709

27712

27715

27687

27690

27691

27692

27695

27696

27698

27700

27654

27656

27658

27659

27664

27665

27675

27676

27680

27681

27685

27686

27630

27635

27637

27638

27640

27641

27645

27646

27647

27648

27650

27652

Surgery

CPT Code

27610

27612

27613

27614

27615

27618

27619

27620

27625

27626

Surgery

CPT Code

27720

27722

27724

27725

27727

27730

27732

27734

27740

27742

27745

27750

27752

27756

27758

27759

27760

27762

27766

27780

27781

27784

27786

27788

27792

27808

27810

27814

27816

27818

27822

27823

27824

27825

27826

27827

27828

27829

27830

27831

27832

27840

27842

27846

27848

27860

27870

27871

27880

27881

MRA

$1,147.00

$1,076.00

$1,402.00

$1,312.00

$1,175.00

$647.00

$611.00

$766.00

$1,044.00

$1,045.00

$940.00

$319.00

$614.00

$708.00

$1,115.00

$1,262.00

$223.00

$495.00

$759.00

$244.00

$296.00

$643.00

$223.00

$422.00

$706.00

$332.00

$567.00

$972.00

$386.00

$613.00

$1,201.00

$1,472.00

$384.00

$670.00

$1,080.00

$1,310.00

$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

$1,015.00

$1,120.00

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

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

28108

28110

28111

28112

28113

28114

28116

28118

28090

28092

28100

28102

28103

28104

28106

28107

28045

28046

28050

28052

28054

28060

28062

28070

28072

28080

28086

28088

28002

28003

28005

28008

28010

28011

28020

28022

28024

28030

28035

28043

Surgery

CPT Code

27882

27884

27886

27888

27889

27892

27893

27894

27899

28001

$414.00

$330.00

$571.00

$700.00

$709.00

$491.00

$632.00

$517.00

$418.00

$421.00

$537.00

$457.00

$481.00

$890.00

$648.00

$568.00

$456.00

$814.00

$414.00

$402.00

$236.00

$495.00

$657.00

$476.00

$445.00

$392.00

$462.00

$414.00

$362.00

$520.00

$520.00

$296.00

$235.00

$340.00

$509.00

$422.00

$371.00

$453.00

$532.00

$305.00

MRA

$854.00

$579.00

$835.00

$911.00

$879.00

$575.00

$574.00

$712.00

BR

$185.00

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

90

10

90

90

FU Days

90

90

90

90

90

90

90

90

YYY

10



$266.00

$336.00

$426.00

$463.00

$441.00

$452.00

$458.00

$557.00

$666.00

$845.00

$797.00

$832.00

$838.00

$755.00

$829.00

$845.00

$345.00

$334.00

$380.00

$286.00

$178.00

$695.00

$370.00

$535.00

$641.00

$881.00

$1,363.00

$912.00

$789.00

$747.00

$571.00

$75.00

$326.00

$341.00

$478.00

$613.00

$406.00

$609.00

$435.00

$555.00

MRA

$524.00

$601.00

$622.00

$480.00

$393.00

$727.00

$533.00

$416.00

$400.00

$412.00

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

10

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

28292

28293

28294

28296

28297

28298

28299

28300

28270

28272

28280

28285

28286

28288

28289

28290

28225

28226

28230

28232

28234

28238

28240

28250

28260

28261

28262

28264

28171

28173

28175

28190

28192

28193

28200

28202

28208

28210

28220

28222

Surgery

CPT Code

28119

28120

28122

28124

28126

28130

28140

28150

28153

28160

Surgery

CPT Code

28302

28304

28305

28306

28307

28308

28309

28310

28312

28313

28315

28320

28322

28340

28341

28344

28345

28360

28400

28405

28406

28415

28420

28430

28435

28436

28445

28450

28455

28456

28465

28470

28475

28476

28485

28490

28495

28496

28505

28510

28515

28525

28530

28531

28540

28545

28546

28555

28570

28575

MRA

$930.00

$776.00

$1,030.00

$530.00

$614.00

$516.00

$955.00

$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

$1,354.00

$1,619.00

$110.00

$371.00

$463.00

$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

$115.00

$345.00

$120.00

$243.00

$145.00

$208.00

$325.00

$592.00

$189.00

$308.00

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

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

29065

29075

29085

29086

29105

29125

29126

29130

29025

29035

29040

29044

29046

29049

29055

29058

28755

28760

28800

28805

28810

28820

28825

28899

29000

29010

29015

29020

28660

28665

28666

28675

28705

28715

28725

28730

28735

28737

28740

28750

Surgery

CPT Code

28576

28585

28600

28605

28606

28615

28630

28635

28636

28645

$188.00

$213.00

$260.00

$260.00

$286.00

$45.00

$180.00

$110.00

$88.00

$72.00

$59.00

$54.00

$59.00

$45.00

$53.00

$26.00

$466.00

$654.00

$731.00

$731.00

$543.00

$377.00

$339.00

BR

$247.00

$271.00

$289.00

$237.00

$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

MRA

$382.00

$742.00

$144.00

$287.00

$487.00

$621.00

$145.00

$189.00

$318.00

$434.00

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

90

YYY

0

0

0

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

10

10

10

FU Days

90

90

90

90

10

10

90

90

90

10



BR

$557.00

$902.00

$360.00

$1,003.00

$976.00

$756.00

$718.00

$863.00

$749.00

$1,330.00

$611.00

$941.00

$980.00

$1,058.00

$524.00

$41.00

$37.00

$39.00

$32.00

$29.00

$26.00

$29.00

$109.00

$29.00

$29.00

$37.00

$105.00

$241.00

$101.00

$96.00

$101.00

$133.00

$22.00

$214.00

$84.00

$75.00

$59.00

$22.00

$55.00

MRA

$53.00

$29.00

$37.00

$45.00

$26.00

$29.00

$223.00

$260.00

$126.00

$133.00

90

90

90

90

90

90

90

90

YYY

90

90

90

90

90

90

90

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

FU Days

0

0

0

0

0

0

0

0

0

0

29821

29822

29823

29824

29825

29826

29827

29830

29799

29800

29804

29805

29806

29807

29819

29820

29540

29550

29580

29590

29700

29705

29710

29715

29720

29730

29740

29750

29358

29365

29405

29425

29435

29440

29445

29450

29505

29515

29520

29530

Surgery

CPT Code

29131

29200

29220

29240

29260

29280

29305

29325

29345

29355

Surgery

CPT Code

29834

29835

29836

29837

29838

29840

29843

29844

29845

29846

29847

29848

29850

29851

29855

29856

29860

29861

29862

29863

29870

29871

29873

29874

29875

29876

29877

29879

29880

29881

29882

29883

29884

29885

29886

29887

29888

29889

29891

29892

29893

29894

29895

29897

29898

29899

29900

29901

29902

29999

MRA

$635.00

$612.00

$680.00

$830.00

$931.00

$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

$880.00

$460.00

$631.00

$489.00

$676.00

$639.00

$809.00

$852.00

$1,064.00

$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

$472.00

$690.00

$679.00

$704.00

$863.00

$973.00

$434.00

$479.00

$514.00

BR

90

90

90

90

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

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

30906

30915

30920

30930

30999

31000

31002

31020

30600

30620

30630

30801

30802

30901

30903

30905

30420

30430

30435

30450

30460

30462

30465

30520

30540

30545

30560

30580

30130

30140

30150

30160

30200

30210

30220

30300

30310

30320

30400

30410

Surgery

CPT Code

30000

30020

30100

30110

30115

30117

30118

30120

30124

30125

$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

$81.00

$135.00

$281.00

$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

$566.00

$275.00

$320.00

$790.00

$875.00

$68.00

$75.00

$154.00

$45.00

$170.00

$419.00

$741.00

$1,173.00

MRA

$96.00

$117.00

$86.00

$157.00

$360.00

$301.00

$819.00

$500.00

$243.00

$599.00

0

90

90

10

YYY

10

10

90

10

10

0

90

90

90

0

0

90

10

90

90

90

90

90

90

90

90

90

90

90

90

90

10

10

10

90

0

10

90

90

90

FU Days

10

10

0

10

90

90

90

90

90

90



$1,551.00

$1,235.00

$1,346.00

$1,587.00

BR

$1,295.00

$508.00

$1,630.00

$2,238.00

$1,913.00

$2,478.00

$1,891.00

$1,720.00

$1,782.00

$1,822.00

$2,513.00

$266.00

$311.00

$775.00

$224.00

$588.00

$601.00

$292.00

$453.00

$690.00

$339.00

$396.00

$1,462.00

$1,281.00

$1,081.00

$1,075.00

$877.00

$463.00

$716.00

$851.00

$1,683.00

$1,908.00

$122.00

$221.00

$217.00

MRA

$531.00

$604.00

$772.00

$489.00

$654.00

$410.00

$839.00

$942.00

$1,089.00

$1,210.00

90

90

90

90

90

90

90

90

10

10

10

10

YYY

90

90

90

0

0

10

0

0

0

0

0

0

0

0

10

0

0

0

90

90

90

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

31365

31367

31368

31370

31375

31380

31382

31390

31291

31292

31293

31294

31299

31300

31320

31360

31237

31238

31239

31240

31254

31255

31256

31267

31276

31287

31288

31290

31085

31086

31087

31090

31200

31201

31205

31225

31230

31231

31233

31235

Surgery

CPT Code

31030

31032

31040

31050

31051

31070

31075

31080

31081

31084

Surgery

CPT Code

31395

31400

31420

31500

31502

31505

31510

31511

31512

31513

31515

31525

31526

31527

31528

31529

31530

31531

31535

31536

31540

31541

31560

31561

31570

31571

31575

31576

31577

31578

31579

31580

31582

31584

31585

31586

31587

31588

31590

31595

31599

31600

31603

31605

31610

31611

31612

31613

31614

31615

MRA

$2,937.00

$969.00

$969.00

$116.00

$74.00

$62.00

$145.00

$88.00

$197.00

$182.00

$160.00

$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

$369.00

$363.00

$128.00

$186.00

$230.00

$264.00

$219.00

$1,213.00

$1,881.00

$1,616.00

$474.00

$778.00

$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

90

0

90

0

0

90

90

0

90

90

90

90

90

90

YYY

0

90

90

90

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

FU Days

90

90

90

0

0

0

0

0

0

0

32020

32035

32036

32095

32100

32110

32120

32124

31805

31820

31825

31830

31899

32000

32002

32005

31730

31750

31755

31760

31766

31770

31775

31780

31781

31785

31786

31800

31641

31643

31645

31646

31656

31700

31708

31710

31715

31717

31720

31725

Surgery

CPT Code

31622

31623

31624

31625

31628

31629

31630

31631

31635

31640

$1,175.00

$458.00

$659.00

$460.00

BR

$136.00

$116.00

$147.00

$286.00

$821.00

$908.00

$848.00

$1,120.00

$1,223.00

$1,077.00

$1,144.00

$199.00

$1,088.00

$1,448.00

$1,648.00

$2,315.00

$1,815.00

$1,973.00

$1,577.00

$1,936.00

$1,320.00

$1,866.00

$628.00

$304.00

$208.00

$208.00

$161.00

$127.00

$114.00

$76.00

$74.00

$57.00

$138.00

$89.00

$103.00

MRA

$230.00

$225.00

$217.00

$235.00

$269.00

$198.00

$308.00

$252.00

$298.00

$399.00

90

90

90

0

90

90

90

90

90

90

90

90

YYY

0

0

0

90

90

90

90

90

90

90

90

90

0

90

90

0

0

0

0

0

0

0

0

0

0

0

0

FU Days

0

0

0

0

0

0

0

0

0

0



$663.00

$550.00

$637.00

$957.00

$1,166.00

$1,615.00

$1,144.00

$1,096.00

$1,213.00

$1,222.00

$1,261.00

$1,142.00

$1,141.00

$1,691.00

$1,165.00

$1,459.00

$1,974.00

$2,094.00

$1,784.00

$1,331.00

$374.00

$1,935.00

$2,102.00

$2,264.00

$1,308.00

$456.00

$494.00

$585.00

$1,221.00

$1,787.00

$129.00

$798.00

$159.00

$116.00

$1,837.00

$2,093.00

$2,093.00

$1,622.00

$1,714.00

$1,771.00

MRA

$1,284.00

$1,267.00

$1,226.00

$1,231.00

$842.00

$1,132.00

$387.00

$1,024.00

$1,680.00

$1,268.00

90

90

90

90

90

90

90

90

90

90

90

0

0

0

90

90

0

0

0

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

0

0

90

90

0

FU Days

90

90

90

90

90

90

90

90

90

0

32655

32656

32657

32658

32659

32660

32661

32662

32604

32605

32606

32650

32651

32652

32653

32654

32486

32488

32491

32500

32501

32520

32522

32525

32540

32601

32602

32603

32310

32320

32400

32402

32405

32420

32440

32442

32445

32480

32482

32484

Surgery

CPT Code

32140

32141

32150

32151

32160

32200

32201

32215

32220

32225

Surgery

CPT Code

32663

32664

32665

32800

32810

32815

32820

32851

32852

32853

32854

32900

32905

32906

32940

32960

32997

32999

33010

33011

33015

33020

33025

33030

33031

33050

33120

33130

33140

33141

33200

33201

33206

33207

33208

33210

33211

33212

33213

33214

33215

33216

33217

33218

33220

33222

33223

33224

33225

33226

MRA

$1,636.00

$1,197.00

$1,360.00

$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

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

$1,170.00

$1,052.00

$642.00

$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

$490.00

$434.00

$472.00

90

90

90

90

90

90

ZZZ

90

90

90

90

90

0

0

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

90

0

YYY

0

0

90

90

90

90

0

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

33417

33420

33422

33425

33426

33427

33430

33460

33406

33410

33411

33412

33413

33414

33415

33416

33315

33320

33321

33322

33330

33332

33335

33400

33401

33403

33404

33405

33245

33246

33249

33250

33251

33253

33261

33282

33284

33300

33305

33310

Surgery

CPT Code

33233

33234

33235

33236

33237

33238

33240

33241

33243

33244

$2,962.00

$2,637.00

$2,981.00

$3,213.00

$3,282.00

$2,904.00

$2,563.00

$2,684.00

$2,756.00

$1,796.00

$2,431.00

$2,509.00

$2,806.00

$3,026.00

$2,891.00

$2,215.00

$1,875.00

$1,485.00

$1,890.00

$1,935.00

$1,726.00

$1,915.00

$2,336.00

$2,401.00

$2,228.00

$2,369.00

$2,698.00

$2,745.00

$1,400.00

$1,888.00

$1,271.00

$1,687.00

$2,071.00

$2,563.00

$1,993.00

$470.00

$365.00

$1,576.00

$1,889.00

$1,577.00

MRA

$270.00

$598.00

$587.00

$933.00

$1,184.00

$1,235.00

$648.00

$301.00

$1,650.00

$1,081.00

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

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90



$2,654.00

$2,899.00

$3,143.00

$2,693.00

$3,250.00

$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

$2,732.00

$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

$2,544.00

$2,595.00

$2,370.00

$1,546.00

$1,938.00

$1,983.00

$2,416.00

$2,423.00

$2,448.00

$17.00

$2,354.00

$2,546.00

MRA

$2,396.00

$2,547.00

$2,665.00

$2,952.00

$1,749.00

$1,929.00

$2,001.00

$2,173.00

$2,666.00

$2,270.00

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

90

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

90

90

90

90

90

ZZZ

ZZZ

90

90

90

ZZZ

90

90

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

33606

33608

33610

33611

33612

33615

33617

33619

33534

33535

33536

33542

33545

33572

33600

33602

33512

33513

33514

33516

33517

33518

33519

33521

33522

33523

33530

33533

33478

33496

33500

33501

33502

33503

33504

33505

33506

33508

33510

33511

Surgery

CPT Code

33463

33464

33465

33468

33470

33471

33472

33474

33475

33476

Surgery

CPT Code

33641

33645

33647

33660

33665

33670

33681

33684

33688

33690

33692

33694

33697

33702

33710

33720

33722

33730

33732

33735

33736

33737

33750

33755

33762

33764

33766

33767

33770

33771

33774

33775

33776

33777

33778

33779

33780

33781

33786

33788

33800

33802

33803

33813

33814

33820

33822

33824

33840

33845

MRA

$1,981.00

$2,352.00

$2,732.00

$2,444.00

$2,700.00

$2,820.00

$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

$2,704.00

$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

$2,119.00

$2,173.00

$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

$2,970.00

$2,288.00

$1,546.00

$1,752.00

$1,746.00

$1,935.00

$2,464.00

$1,619.00

$1,559.00

$1,884.00

$2,029.00

$2,129.00

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

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

34401

34421

34451

34471

34490

34501

34502

34510

33999

34001

34051

34101

34111

34151

34201

34203

33967

33968

33970

33971

33973

33974

33975

33976

33977

33978

33979

33980

33915

33916

33917

33918

33919

33920

33922

33924

33935

33945

33960

33961

Surgery

CPT Code

33851

33852

33853

33860

33861

33863

33870

33875

33877

33910

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

$258.00

$51.00

$576.00

$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

$1,588.00

$2,096.00

$2,345.00

$2,349.00

$2,873.00

$2,981.00

$2,227.00

$421.00

$5,415.00

$3,813.00

$1,221.00

$800.00

MRA

$2,129.00

$2,311.00

$3,057.00

$3,044.00

$3,069.00

$3,183.00

$3,638.00

$2,876.00

$3,767.00

$1,987.00

90

90

90

90

90

90

90

90

YYY

90

90

90

90

90

90

90

90

0

90

0

0

90

90

0

90

0

0

0

90

ZZZ

90

90

0

ZZZ

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90



$2,382.00

$1,495.00

$1,742.00

$1,231.00

$1,339.00

$1,390.00

$1,229.00

$1,516.00

$1,633.00

$997.00

$1,345.00

$976.00

$1,048.00

$1,380.00

$1,018.00

$852.00

$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

$2,000.00

$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

$1,376.00

MRA

$1,077.00

$1,368.00

$1,159.00

$1,279.00

$1,279.00

$220.00

$359.00

$256.00

$519.00

$694.00

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

ZZZ

90

90

90

0

0

FU Days

90

90

90

90

90

ZZZ

0

ZZZ

0

90

35162

35180

35182

35184

35188

35189

35190

35201

35122

35131

35132

35141

35142

35151

35152

35161

35021

35022

35045

35081

35082

35091

35092

35102

35103

35111

35112

35121

34826

34830

34831

34832

34833

34834

34900

35001

35002

35005

35011

35013

Surgery

CPT Code

34520

34530

34800

34802

34804

34808

34812

34813

34820

34825

Surgery

CPT Code

35206

35207

35211

35216

35221

35226

35231

35236

35241

35246

35251

35256

35261

35266

35271

35276

35281

35286

35301

35311

35321

35331

35341

35351

35355

35361

35363

35371

35372

35381

35390

35400

35450

35452

35454

35456

35458

35459

35460

35470

35471

35472

35473

35474

35475

35476

35480

35481

35482

35483

MRA

$835.00

$935.00

$1,833.00

$1,494.00

$1,243.00

$841.00

$1,053.00

$947.00

$1,926.00

$1,701.00

$1,260.00

$1,568.00

$1,008.00

$921.00

$1,814.00

$1,541.00

$1,396.00

$1,036.00

$1,486.00

$1,999.00

$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

$1,278.00

$225.00

$224.00

$643.00

$518.00

$520.00

$631.00

$804.00

$736.00

$430.00

$537.00

$626.00

$388.00

$375.00

$456.00

$569.00

$338.00

$935.00

$565.00

$577.00

$696.00

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

90

90

ZZZ

ZZZ

0

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

35606

35612

35616

35621

35623

35626

35631

35636

35571

35572

35582

35583

35585

35587

35600

35601

35536

35541

35546

35548

35549

35551

35556

35558

35560

35563

35565

35566

35506

35507

35508

35509

35511

35515

35516

35518

35521

35526

35531

35533

Surgery

CPT Code

35484

35485

35490

35491

35492

35493

35494

35495

35500

35501

$1,612.00

$369.00

$2,166.00

$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

$1,656.00

$1,888.00

$2,005.00

$2,022.00

$1,751.00

$1,902.00

$2,036.00

$1,745.00

$1,219.00

$1,899.00

$1,115.00

$1,312.00

$2,161.00

$1,641.00

$1,606.00

$1,564.00

$1,529.00

$1,256.00

$1,387.00

$1,391.00

$1,313.00

$1,393.00

$1,527.00

$2,000.00

$1,716.00

MRA

$853.00

$670.00

$691.00

$423.00

$423.00

$523.00

$605.00

$532.00

$423.00

$1,569.00

90

90

90

90

90

90

90

90

90

ZZZ

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

90

FU Days

0

0

0

0

0

0

0

0

ZZZ

90



$1,232.00

$1,163.00

$1,275.00

$709.00

$818.00

$1,343.00

$1,335.00

$46.00

$181.00

$68.00

$136.00

$194.00

$186.00

$141.00

$159.00

$186.00

$1,351.00

$264.00

$494.00

$500.00

$499.00

$532.00

$567.00

$951.00

$771.00

$496.00

$1,583.00

$827.00

$1,237.00

$1,333.00

$1,686.00

$1,315.00

$751.00

$627.00

$702.00

$216.00

$178.00

$1,546.00

$1,140.00

$1,353.00

MRA

$1,966.00

$1,298.00

$1,304.00

$2,105.00

$1,555.00

$1,236.00

$2,055.00

$1,603.00

$1,589.00

$1,145.00

0

0

0

0

0

0

0

0

90

90

90

90

90

90

90

0

90

90

90

90

90

90

90

ZZZ

90

90

90

90

ZZZ

ZZZ

ZZZ

90

90

90

90

90

90

90

ZZZ

ZZZ

FU Days

90

90

90

90

90

90

90

90

90

90

36002

36005

36010

36011

36012

36013

36014

36015

35876

35879

35881

35901

35903

35905

35907

36000

35695

35700

35701

35721

35741

35761

35800

35820

35840

35860

35870

35875

35663

35665

35666

35671

35681

35682

35683

35685

35686

35691

35693

35694

Surgery

CPT Code

35641

35642

35645

35646

35647

35650

35651

35654

35656

35661

Surgery

CPT Code

36100

36120

36140

36145

36160

36200

36215

36216

36217

36218

36245

36246

36247

36248

36260

36261

36262

36299

36410

36415

36416

36425

36430

36455

36468

36469

36470

36471

36481

36489

36491

36493

36500

36511

36512

36513

36514

36515

36516

36522

36530

36531

36532

36533

36534

36535

36536

36537

36540

36550

MRA

$176.00

$120.00

$106.00

$10.00

$196.00

$240.00

$240.00

$270.00

$325.00

$79.00

$249.00

$272.00

$323.00

$53.00

$749.00

$388.00

$297.00

BR

$18.00

BR

BR

$86.00

$37.00

$141.00

NC

NC

$76.00

$96.00

$499.00

$134.00

$87.00

$65.00

$159.00

$92.00

$92.00

$92.00

$92.00

$92.00

$92.00

$305.00

$493.00

$412.00

$237.00

$448.00

$235.00

$213.00

$1,375.00

$312.00

BR

$37.00

10

0

0

10

10

10

0

0

0

0

0

0

0

0

10

10

0

0

0

0

0

0

0

10

10

0

0

0

90

YYY

0

0

0

0

ZZZ

90

90

0

0

0

FU Days

0

0

0

0

0

0

ZZZ

0

0

0

37251

37500

37501

37565

37600

37605

37606

37607

37203

37204

37205

37206

37207

37208

37209

37250

36870

37140

37145

37160

37180

37181

37182

37183

37195

37200

37201

37202

36821

36822

36823

36825

36830

36831

36832

36833

36834

36835

36860

36861

Surgery

CPT Code

36600

36620

36625

36640

36680

36800

36810

36815

36819

36820

$287.00

$957.00

$589.00

$288.00

$613.00

$299.00

$116.00

$112.00

$85.00

$739.00

BR

$364.00

$414.00

$521.00

$563.00

$456.00

$1,755.00

$1,666.00

$1,741.00

$1,681.00

$1,769.00

$1,923.00

$914.00

$425.00

$302.00

$232.00

$408.00

$340.00

$721.00

$630.00

$1,461.00

$867.00

$967.00

$488.00

$810.00

$780.00

$761.00

$542.00

$166.00

$224.00

MRA

$24.00

$64.00

$133.00

$130.00

$72.00

$159.00

$345.00

$236.00

$977.00

$800.00

ZZZ

0

0

90

90

90

90

90

0

0

0

ZZZ

0

ZZZ

0

ZZZ

0

0

0

0

0

0

90

90

90

90

90

90

90

0

0

90

90

90

90

90

90

90

90

90

FU Days

0

0

0

0

0

90

90

0

0

0



$375.00

$425.00

$628.00

$1,087.00

$798.00

$234.00

$139.00

$349.00

$431.00

$369.00

$517.00

$507.00

$519.00

$1,115.00

$799.00

$831.00

$1,138.00

BR

$180.00

$79.00

$79.00

$212.00

$228.00

$265.00

$128.00

$128.00

$90.00

$104.00

$624.00

$847.00

$813.00

$301.00

$270.00

$1,654.00

$690.00

BR

$974.00

$982.00

$332.00

$1,020.00

MRA

$278.00

$495.00

$1,128.00

$1,132.00

$514.00

$818.00

$430.00

$789.00

$336.00

$480.00

90

90

90

90

90

90

90

90

90

90

10

90

90

90

0

10

0

0

10

0

10

0

90

YYY

0

0

0

0

90

YYY

90

90

ZZZ

90

90

90

90

90

90

90

FU Days

10

90

90

90

90

90

90

90

90

90

38520

38525

38530

38542

38550

38555

38562

38564

38305

38308

38380

38381

38382

38500

38505

38510

38120

38129

38200

38205

38206

38220

38221

38230

38240

38241

38242

38300

37730

37735

37760

37780

37785

37788

37790

37799

38100

38101

38102

38115

Surgery

CPT Code

37609

37615

37616

37617

37618

37620

37650

37660

37700

37720

Surgery

CPT Code

38570

38571

38572

38589

38700

38720

38724

38740

38745

38746

38747

38760

38765

38770

38780

38790

38792

38794

38999

39000

39010

39200

39220

39400

39499

39501

39502

39503

39520

39530

39531

39540

39541

39545

39560

39561

39599

40490

40500

40510

40520

40525

40527

40530

40650

40652

40654

40700

40701

40702

MRA

$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

$1,283.00

$1,111.00

$1,357.00

$158.00

$26.00

$298.00

BR

$664.00

$1,148.00

$1,249.00

$1,542.00

$614.00

BR

$1,083.00

$1,268.00

$2,726.00

$1,345.00

$1,295.00

$1,243.00

$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

$436.00

$529.00

$1,009.00

$1,452.00

$1,030.00

90

90

90

90

90

90

90

90

90

90

YYY

0

90

90

90

90

90

90

90

90

90

90

90

10

YYY

90

90

90

0

90

YYY

90

90

90

ZZZ

90

90

90

90

0

FU Days

10

10

10

YYY

90

90

90

90

90

ZZZ

41115

41116

41120

41130

41135

41140

41145

41150

41018

41100

41105

41108

41110

41112

41113

41114

40845

40899

41000

41005

41006

41007

41008

41009

41010

41015

41016

41017

40812

40814

40816

40818

40819

40820

40830

40831

40840

40842

40843

40844

Surgery

CPT Code

40720

40761

40799

40800

40801

40804

40805

40806

40808

40810

$424.00

$140.00

$136.00

$110.00

$159.00

$255.00

$301.00

$682.00

$176.00

$242.00

$813.00

$937.00

$1,869.00

$2,005.00

$2,406.00

$1,897.00

$1,593.00

BR

$119.00

$109.00

$237.00

$283.00

$248.00

$319.00

$91.00

$267.00

$357.00

$300.00

$202.00

$319.00

$336.00

$249.00

$208.00

$104.00

$140.00

$213.00

$687.00

$684.00

$947.00

$1,232.00

MRA

$1,107.00

$1,202.00

BR

$110.00

$208.00

$105.00

$245.00

$38.00

$100.00

$141.00

90

90

90

10

90

90

90

90

10

10

90

90

10

10

90

90

90

90

90

90

90

10

90

YYY

10

10

90

90

90

90

90

10

10

90

90

90

10

10

90

90

FU Days

90

90

YYY

10

0

10

10

10

10

10



$176.00

$222.00

$324.00

$946.00

$863.00

$1,174.00

$766.00

$586.00

$803.00

$848.00

$762.00

$631.00

$491.00

$148.00

$160.00

BR

NC

$249.00

$193.00

BR

$106.00

$122.00

$161.00

$204.00

$409.00

$573.00

$174.00

$741.00

$115.00

$217.00

NC

NC

$237.00

$312.00

$144.00

$211.00

$322.00

$176.00

$156.00

NC

MRA

$2,091.00

$2,448.00

$168.00

$203.00

$294.00

$334.00

$313.00

$255.00

BR

$107.00

90

90

10

90

90

90

10

YYY

90

90

90

10

10

10

90

90

90

90

90

10

10

90

0

90

90

YYY

10

10

10

10

0

10

10

90

0

10

90

10

10

0

FU Days

90

90

10

10

10

90

90

90

YYY

10

42225

42226

42227

42235

42260

42280

42281

42299

42160

42180

42182

42200

42205

42210

42215

42220

41870

41872

41874

41899

42000

42100

42104

42106

42107

42120

42140

42145

41805

41806

41820

41821

41822

41823

41825

41826

41827

41828

41830

41850

Surgery

CPT Code

41153

41155

41250

41251

41252

41500

41510

41520

41599

41800

Surgery

CPT Code

42300

42305

42310

42320

42325

42326

42330

42335

42340

42400

42405

42408

42409

42410

42415

42420

42425

42426

42440

42450

42500

42505

42507

42508

42509

42510

42550

42600

42650

42660

42665

42699

42700

42720

42725

42800

42802

42804

42806

42808

42809

42810

42815

42821

42826

42831

42836

42842

42844

42845

MRA

$165.00

$448.00

$145.00

$208.00

$245.00

$369.00

$184.00

$287.00

$411.00

$94.00

$258.00

$377.00

$266.00

$746.00

$1,364.00

$1,577.00

$1,097.00

$1,882.00

$634.00

$395.00

$407.00

$559.00

$522.00

$767.00

$915.00

$711.00

$82.00

$445.00

$67.00

$89.00

$238.00

BR

$144.00

$270.00

$720.00

$123.00

$150.00

$136.00

$167.00

$250.00

$152.00

$335.00

$659.00

$378.00

$320.00

$235.00

$286.00

$729.00

$1,173.00

$1,958.00

90

90

90

90

90

90

90

90

10

10

10

90

10

10

10

90

0

0

90

YYY

10

10

90

0

90

90

90

90

90

90

90

90

90

90

90

90

90

10

90

90

FU Days

10

90

10

10

90

90

0

90

90

10

43219

43220

43226

43227

43228

43231

43232

43234

43200

43201

43202

43204

43205

43215

43216

43217

43108

43112

43113

43116

43117

43118

43121

43122

43123

43124

43130

43135

42961

42962

42970

42971

42972

42999

43020

43030

43045

43100

43101

43107

Surgery

CPT Code

42860

42870

42890

42892

42894

42900

42950

42953

42955

42960

$266.00

$245.00

$205.00

$228.00

$207.00

$160.00

$149.00

$176.00

$171.00

$128.00

$142.00

$218.00

$230.00

$182.00

$252.00

$193.00

$2,664.00

$2,471.00

$2,755.00

$2,509.00

$2,469.00

$2,607.00

$2,350.00

$2,287.00

$2,661.00

$2,242.00

$1,020.00

$1,332.00

$406.00

$602.00

$284.00

$472.00

$562.00

BR

$696.00

$712.00

$1,574.00

$744.00

$1,248.00

$2,325.00

MRA

$207.00

$427.00

$1,047.00

$1,262.00

$1,825.00

$429.00

$745.00

$752.00

$561.00

$178.00

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

YYY

FU Days

90

90

90

90

90

90

10

90

10

90



$2,138.00

$2,331.00

$2,632.00

$2,891.00

$1,299.00

$1,280.00

$1,261.00

$1,198.00

$1,236.00

$1,378.00

$1,292.00

$1,351.00

$986.00

$1,180.00

$1,028.00

$2,277.00

$386.00

$522.00

$527.00

$434.00

$446.00

$410.00

$437.00

$401.00

$1,314.00

BR

$837.00

$1,428.00

$229.00

$191.00

$175.00

$194.00

$224.00

$343.00

$235.00

$276.00

$271.00

$349.00

$362.00

$447.00

MRA

$239.00

$285.00

$246.00

$369.00

$157.00

$384.00

$276.00

$268.00

$214.00

$485.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

0

0

90

YYY

90

90

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

FU Days

0

0

0

0

0

0

0

0

0

0

43330

43331

43340

43341

43350

43351

43352

43360

43310

43312

43313

43314

43320

43324

43325

43326

43263

43264

43265

43267

43268

43269

43271

43272

43280

43289

43300

43305

43247

43248

43249

43250

43251

43255

43256

43258

43259

43260

43261

43262

Surgery

CPT Code

43235

43236

43239

43240

43241

43242

43243

43244

43245

43246

Surgery

CPT Code

43361

43400

43401

43405

43410

43415

43420

43425

43450

43453

43456

43458

43460

43496

43499

43500

43501

43502

43510

43520

43600

43605

43610

43611

43620

43621

43622

43631

43632

43633

43634

43635

43638

43639

43640

43641

43651

43652

43653

43659

43750

43752

43760

43761

43800

43810

43820

43825

43830

43831

MRA

$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

$149.00

$164.00

$203.00

BR

BR

$649.00

$1,105.00

$1,247.00

$680.00

$599.00

$96.00

$686.00

$861.00

$1,001.00

$1,691.00

$1,718.00

$1,798.00

$1,445.00

$1,443.00

$1,467.00

$1,786.00

$143.00

$1,575.00

$1,605.00

$1,119.00

$1,138.00

$716.00

$856.00

$617.00

BR

$278.00

BR

$81.00

$107.00

$793.00

$846.00

$896.00

$1,128.00

$592.00

$593.00

90

90

90

0

0

90

90

90

90

90

90

90

90

YYY

10

0

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

0

90

90

90

90

0

0

0

90

YYY

90

FU Days

90

90

90

90

90

0

0

90

90

90

44150

44151

44152

44153

44155

44156

44160

44200

44139

44140

44141

44143

44144

44145

44146

44147

44100

44110

44111

44120

44121

44125

44126

44127

44128

44130

44133

44136

43865

43870

43880

43999

44005

44010

44015

44020

44021

44025

44050

44055

Surgery

CPT Code

43832

43840

43842

43843

43846

43847

43848

43850

43855

43860

$154.00

$1,350.00

$1,488.00

$1,536.00

$1,442.00

$1,678.00

$1,840.00

$1,452.00

$1,661.00

$1,499.00

$1,890.00

$2,110.00

$1,892.00

$1,709.00

$1,236.00

$1,046.00

$117.00

$784.00

$963.00

$1,078.00

$308.00

$1,135.00

$1,951.00

$2,243.00

$242.00

$938.00

BR

BR

$1,549.00

$590.00

$1,352.00

BR

$1,171.00

$809.00

$1,171.00

$891.00

$888.00

$905.00

$862.00

$957.00

MRA

$904.00

$893.00

$1,260.00

$1,249.00

$1,528.00

$1,678.00

$1,795.00

$1,425.00

$1,454.00

$1,435.00

90

90

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

90

90

90

ZZZ

90

0

0

0

90

90

90

ZZZ

90

ZZZ

90

90

90

90

90

90

90

90

YYY

90

90

FU Days

90

90

90

90

90

90

90

90

90

90



$320.00

$410.00

$396.00

$91.00

$110.00

$165.00

$219.00

$183.00

$326.00

$301.00

$319.00

$376.00

$359.00

$413.00

$395.00

$259.00

$923.00

$177.00

$195.00

$213.00

$255.00

$226.00

$300.00

$308.00

$253.00

$301.00

$238.00

$305.00

$1,800.00

BR

BR

$697.00

$950.00

$453.00

$892.00

$1,229.00

$1,029.00

$1,015.00

$397.00

$816.00

MRA

$649.00

$1,603.00

$235.00

$1,353.00

$1,198.00

$1,480.00

$1,620.00

$1,752.00

$1,551.00

$1,926.00

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

0

0

90

90

90

90

90

90

90

YYY

YYY

90

90

90

FU Days

90

90

ZZZ

90

90

90

90

90

90

90

44388

44389

44390

44391

44392

44393

44394

44397

44377

44378

44379

44380

44382

44383

44385

44386

44346

44360

44361

44363

44364

44365

44366

44369

44370

44372

44373

44376

44212

44238

44239

44300

44310

44312

44314

44316

44320

44322

44340

44345

Surgery

CPT Code

44201

44202

44203

44204

44205

44206

44207

44208

44210

44211

Surgery

CPT Code

44500

44602

44603

44604

44605

44615

44620

44625

44626

44640

44650

44660

44661

44680

44700

44701

44799

44800

44820

44850

44899

44900

44901

44950

44955

44960

44970

44979

45000

45005

45020

45100

45108

45110

45111

45112

45113

45114

45116

45119

45120

45121

45123

45126

45130

45135

45136

45150

45160

45170

MRA

$28.00

$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

$1,049.00

$1,115.00

$161.00

BR

$791.00

$755.00

$708.00

BR

$644.00

$310.00

$643.00

$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

$1,485.00

$1,911.00

$1,845.00

$1,870.00

$1,126.00

$2,444.00

$1,041.00

$1,354.00

$1,526.00

$475.00

$949.00

$697.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

10

90

0

90

ZZZ

90

90

YYY

YYY

90

90

90

YYY

90

90

90

90

90

90

ZZZ

FU Days

0

90

90

90

90

90

90

90

90

90

45560

45562

45563

45800

45805

45820

45825

45900

45386

45387

45500

45505

45520

45540

45541

45550

45341

45342

45345

45355

45378

45379

45380

45381

45382

45383

45384

45385

45321

45327

45330

45331

45332

45333

45334

45335

45337

45338

45339

45340

Surgery

CPT Code

45190

45300

45303

45305

45307

45308

45309

45315

45317

45320

$739.00

$322.00

$584.00

$510.00

$46.00

$1,009.00

$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

$153.00

$224.00

$164.00

$185.00

$341.00

$415.00

$369.00

$388.00

$481.00

$482.00

$415.00

$479.00

$154.00

$96.00

$87.00

$120.00

$174.00

$176.00

$171.00

$144.00

$144.00

$212.00

$237.00

$328.00

MRA

$623.00

$75.00

$72.00

$102.00

$172.00

$137.00

$174.00

$211.00

$209.00

$230.00

90

90

90

90

90

90

90

10

90

0

90

0

0

90

90

90

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

FU Days

90

0

0

0

0

0

0

0

0

0



$66.00

$115.00

$114.00

$149.00

$196.00

$169.00

$202.00

$585.00

$140.00

$545.00

$906.00

$1,584.00

$1,881.00

$1,671.00

$2,236.00

$2,412.00

$598.00

$655.00

$686.00

$328.00

$442.00

$514.00

$335.00

$521.00

$126.00

$109.00

$38.00

$92.00

$246.00

$98.00

$323.00

$196.00

$353.00

$118.00

$124.00

$198.00

$400.00

$501.00

$504.00

$539.00

MRA

$133.00

$163.00

$142.00

BR

$230.00

$94.00

$393.00

$312.00

$105.00

$482.00

90

90

90

0

90

90

90

90

0

0

0

0

0

0

0

90

10

0

0

90

90

10

90

90

90

90

90

90

90

90

90

10

10

90

90

90

10

10

10

90

FU Days

10

10

10

YYY

90

10

90

10

10

90

46706

46715

46716

46730

46735

46740

46742

46744

46606

46608

46610

46611

46612

46614

46615

46700

46260

46261

46262

46270

46275

46280

46285

46288

46320

46500

46600

46604

46080

46083

46200

46210

46211

46220

46221

46230

46250

46255

46257

46258

Surgery

CPT Code

45905

45910

45915

45999

46020

46030

46040

46045

46050

46060

Surgery

CPT Code

46746

46748

46750

46753

46754

46760

46761

46762

46900

46910

46916

46917

46922

46924

46934

46935

46936

46937

46938

46940

46942

46945

46946

46999

47000

47001

47010

47011

47015

47100

47120

47122

47125

47130

47134

47135

47136

47300

47350

47360

47361

47362

47370

47371

47379

47380

47381

47382

47399

47400

MRA

$2,725.00

$2,933.00

$636.00

$511.00

$188.00

$846.00

$813.00

$731.00

$128.00

$144.00

$145.00

$228.00

$189.00

$297.00

$249.00

$202.00

$316.00

$268.00

$405.00

$165.00

$145.00

$199.00

$270.00

BR

$218.00

$141.00

$788.00

$347.00

$755.00

$550.00

$1,663.00

$2,512.00

$2,293.00

$2,482.00

$2,711.00

$6,164.00

$4,985.00

$778.00

$942.00

$1,305.00

$2,129.00

$849.00

$943.00

$889.00

BR

$1,107.00

$1,094.00

$660.00

BR

$1,435.00

90

90

YYY

90

90

10

YYY

90

90

90

90

0

90

90

90

90

90

90

90

90

90

90

90

YYY

0

ZZZ

90

0

10

10

90

90

10

90

10

90

10

10

10

10

FU Days

90

90

90

90

90

10

10

10

90

90

47780

47785

47800

47801

47802

47900

47999

48000

47715

47716

47720

47721

47740

47741

47760

47765

47570

47579

47600

47605

47610

47612

47620

47630

47700

47701

47711

47712

47530

47550

47552

47553

47554

47555

47556

47560

47561

47562

47563

47564

Surgery

CPT Code

47420

47425

47460

47480

47490

47500

47505

47510

47511

47525

$1,157.00

$989.00

$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

$1,352.00

$1,331.00

BR

$1,053.00

$961.00

BR

$868.00

$935.00

$1,164.00

$1,276.00

$1,295.00

$465.00

$1,111.00

$1,913.00

$1,442.00

$1,793.00

$35.00

$209.00

$364.00

$342.00

$594.00

$383.00

$425.00

$345.00

$388.00

$837.00

$900.00

$1,069.00

MRA

$1,222.00

$1,275.00

$1,039.00

$755.00

$467.00

$103.00

$96.00

$487.00

$627.00

$295.00

90

90

90

90

90

90

YYY

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

YYY

90

90

90

90

90

90

90

0

0

0

0

0

0

90

ZZZ

0

FU Days

90

90

90

90

90

90

10

90

0

0



$305.00

$827.00

$288.00

$892.00

$123.00

$98.00

$632.00

$212.00

$823.00

$1,180.00

$1,551.00

$1,182.00

$622.00

$591.00

$415.00

$443.00

$1,350.00

$1,170.00

$1,630.00

$2,365.00

$1,117.00

BR

$862.00

$784.00

$915.00

$910.00

$290.00

$763.00

$3,101.00

$2,888.00

$3,099.00

$2,893.00

$1,855.00

BR

$1,616.00

$100.00

$1,012.00

$938.00

$286.00

$1,103.00

MRA

$1,305.00

$1,533.00

$983.00

$779.00

$341.00

$1,083.00

$1,546.00

$1,661.00

$1,830.00

$1,149.00

90

90

90

90

90

90

10

10

90

0

0

0

90

0

90

0

90

0

90

90

90

90

90

90

90

90

90

YYY

90

ZZZ

90

90

0

90

90

90

0

90

90

90

FU Days

90

90

90

90

90

90

90

10

90

90

49200

49201

49215

49220

49250

49255

49320

49321

49041

49060

49061

49062

49080

49081

49085

49180

48540

48545

48547

48554

48556

48999

49000

49002

49010

49020

49021

49040

48150

48152

48153

48154

48155

48160

48180

48400

48500

48510

48511

48520

Surgery

CPT Code

48001

48005

48020

48100

48102

48120

48140

48145

48146

48148

Surgery

CPT Code

49322

49323

49329

49400

49419

49420

49421

49422

49423

49424

49425

49426

49427

49428

49429

49505

49507

49520

49521

49525

49540

49550

49553

49555

49557

49560

49561

49565

49566

49568

49570

49572

49585

49587

49590

49600

49605

49606

49610

49611

49650

49651

49659

49900

49904

49905

49906

49999

50010

50020

MRA

$460.00

$712.00

BR

$127.00

$405.00

$162.00

$452.00

$468.00

$106.00

$54.00

$914.00

$725.00

$48.00

$184.00

$522.00

$510.00

$636.00

$631.00

$730.00

$584.00

$668.00

$557.00

$598.00

$621.00

$715.00

$734.00

$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

$784.00

$770.00

$484.00

$621.00

BR

$512.00

$1,394.00

$454.00

BR

BR

$886.00

$1,084.00

YYY

90

0

ZZZ

90

YYY

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

10

10

90

90

90

0

FU Days

10

90

YYY

0

10

0

0

0

0

90

50526

50540

50541

50542

50543

50544

50545

50546

50395

50396

50398

50400

50405

50500

50520

50525

50280

50290

50320

50340

50360

50365

50370

50380

50390

50392

50393

50394

50120

50125

50130

50135

50200

50205

50220

50225

50230

50234

50236

50240

Surgery

CPT Code

50021

50040

50045

50060

50065

50070

50075

50080

50081

50100

$203.00

$101.00

$99.00

$1,441.00

$1,802.00

$1,471.00

$1,281.00

$1,644.00

$1,639.00

$1,468.00

$1,037.00

$1,093.00

$1,374.00

$1,428.00

$1,273.00

$1,325.00

$1,170.00

$1,080.00

$1,680.00

$1,083.00

$2,475.00

$2,941.00

$1,128.00

$1,507.00

$118.00

$189.00

$235.00

$64.00

$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

$1,679.00

MRA

$335.00

$910.00

$1,137.00

$1,394.00

$1,514.00

$1,476.00

$1,839.00

$1,186.00

$1,635.00

$1,250.00

90

90

90

90

90

90

90

90

90

90

90

0

0

0

90

90

0

0

0

90

90

0

90

90

90

90

90

90

90

90

90

90

90

90

90

0

90

90

90

90

FU Days

0

90

90

90

90

90

90

90

90

90



$924.00

$1,386.00

$1,457.00

$1,389.00

$1,485.00

$1,391.00

$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

$1,170.00

$1,297.00

$1,426.00

$74.00

$109.00

$89.00

$85.00

$1,192.00

$1,397.00

$1,211.00

$1,371.00

$640.00

$549.00

$728.00

$762.00

$991.00

$801.00

$711.00

$726.00

$980.00

$1,150.00

$1,054.00

$1,209.00

$1,152.00

MRA

$1,702.00

$1,555.00

BR

$411.00

$447.00

$668.00

$676.00

$396.00

$755.00

$580.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

0

90

90

0

0

10

90

90

90

90

90

90

0

90

90

0

0

0

0

0

0

FU Days

90

90

YYY

0

0

0

0

0

0

0

50785

50800

50810

50815

50820

50825

50830

50840

50728

50740

50750

50760

50770

50780

50782

50783

50630

50650

50660

50684

50686

50688

50690

50700

50715

50722

50725

50727

50570

50572

50574

50575

50576

50578

50580

50590

50600

50605

50610

50620

Surgery

CPT Code

50547

50548

50549

50551

50553

50555

50557

50559

50561

50562

Surgery

CPT Code

50845

50860

50900

50920

50930

50940

50945

50947

50948

50949

50951

50953

50955

50957

50959

50961

50970

50972

50974

50976

50978

50980

51000

51005

51010

51020

51030

51040

51045

51050

51060

51065

51080

51500

51520

51525

51530

51535

51550

51555

51565

51570

51575

51580

51585

51590

51595

51596

51597

51600

MRA

$1,513.00

$1,163.00

$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

$316.00

$510.00

$510.00

$408.00

$661.00

$641.00

$379.00

$443.00

$75.00

$87.00

$191.00

$587.00

$538.00

$439.00

$548.00

$596.00

$768.00

$704.00

$510.00

$775.00

$764.00

$1,069.00

$957.00

$932.00

$1,171.00

$1,514.00

$1,624.00

$1,762.00

$2,284.00

$2,252.00

$2,601.00

$2,441.00

$2,900.00

$3,063.00

$2,914.00

$54.00

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

0

0

10

0

0

0

0

0

0

0

0

0

0

0

0

FU Days

90

90

90

90

90

90

90

90

90

YYY

52204

52214

52224

52234

52235

52240

52250

52260

51980

51990

51992

52000

52001

52005

52007

52010

51820

51840

51841

51845

51860

51865

51880

51900

51920

51925

51940

51960

51725

51726

51736

51741

51772

51784

51785

51792

51795

51797

51798

51800

Surgery

CPT Code

51605

51610

51700

51701

51702

51703

51705

51710

51715

51720

$858.00

$850.00

$925.00

$190.00

$133.00

$265.00

$230.00

$292.00

$286.00

$367.00

$339.00

$471.00

$546.00

$887.00

$311.00

$262.00

$1,236.00

$858.00

$1,040.00

$843.00

$912.00

$1,150.00

$590.00

$1,050.00

$881.00

$1,167.00

$2,082.00

$1,848.00

$116.00

$136.00

$47.00

$81.00

$96.00

$119.00

$52.00

$143.00

$132.00

$109.00

$20.00

$1,294.00

MRA

$83.00

$45.00

$29.00

$58.00

$92.00

$128.00

$37.00

$119.00

$322.00

$140.00

0

0

0

0

0

0

0

0

0

0

0

90

90

90

0

0

90

90

90

90

90

90

90

90

90

90

90

90

0

0

90

0

0

0

0

0

0

0

0

0

FU Days

0

0

0

0

10

0

0

0

0

10



$447.00

$580.00

$602.00

$705.00

$604.00

$1,021.00

$581.00

$711.00

$609.00

$554.00

$653.00

$573.00

$858.00

$957.00

$517.00

$224.00

$340.00

$317.00

$344.00

$380.00

$407.00

$433.00

$488.00

$281.00

$297.00

$349.00

$404.00

$372.00

$370.00

$382.00

$370.00

$348.00

$553.00

$772.00

$684.00

$369.00

$494.00

$369.00

$507.00

$451.00

MRA

$243.00

$374.00

$446.00

$490.00

$448.00

$259.00

$560.00

$309.00

$375.00

$304.00

90

90

90

90

90

90

90

10

90

90

90

0

90

90

90

90

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

FU Days

0

0

0

0

0

0

0

0

0

0

52614

52620

52630

52640

52647

52648

52700

53000

52355

52400

52450

52500

52510

52601

52606

52612

52334

52341

52342

52343

52344

52345

52346

52347

52351

52352

52353

52354

52300

52301

52305

52310

52315

52317

52318

52320

52325

52327

52330

52332

Surgery

CPT Code

52265

52270

52275

52276

52277

52281

52282

52283

52285

52290

Surgery

CPT Code

53010

53020

53040

53060

53080

53085

53200

53210

53215

53220

53230

53235

53240

53250

53260

53265

53270

53275

53400

53405

53410

53415

53420

53425

53430

53431

53440

53442

53444

53445

53446

53447

53448

53449

53450

53460

53502

53505

53510

53515

53520

53600

53601

53605

53620

53621

53660

53661

53665

53850

MRA

$336.00

$153.00

$460.00

$180.00

$567.00

$836.00

$218.00

$904.00

$1,142.00

$546.00

$760.00

$607.00

$506.00

$464.00

$240.00

$295.00

$226.00

$332.00

$929.00

$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

$991.00

$1,259.00

$784.00

$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

0

0

0

0

0

0

0

90

90

90

90

90

90

90

90

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

10

10

90

90

10

10

90

90

90

FU Days

90

0

90

10

90

90

90

90

90

0

54336

54340

54344

54348

54352

54360

54380

54385

54312

54316

54318

54322

54324

54326

54328

54332

54164

54200

54205

54220

54230

54231

54235

54240

54250

54300

54304

54308

54100

54105

54110

54111

54112

54115

54120

54125

54130

54135

54162

54163

Surgery

CPT Code

53852

53853

53899

54015

54050

54055

54056

54057

54060

54065

$1,067.00

$1,316.00

$900.00

$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

$182.00

$78.00

$633.00

$189.00

$104.00

$172.00

$81.00

$109.00

$104.00

$830.00

$988.00

$881.00

$149.00

$261.00

$775.00

$1,035.00

$1,210.00

$588.00

$777.00

$1,092.00

$1,532.00

$1,945.00

$220.00

$207.00

MRA

$728.00

$2,073.00

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

90

90

90

90

90

90

90

90

0

0

0

0

0

0

10

10

90

90

10

10

90

90

90

90

90

90

0

10

90

FU Days

90

90

YYY

10

10

10

10

10

10

10



BR

$133.00

$257.00

$379.00

$411.00

$432.00

$503.00

$696.00

$969.00

$1,340.00

$109.00

$439.00

$634.00

$430.00

$156.00

$223.00

$922.00

$588.00

$842.00

$524.00

$373.00

$594.00

$861.00

$401.00

$485.00

$948.00

$825.00

$850.00

$819.00

$899.00

$799.00

$503.00

BR

$88.00

$102.00

$259.00

$519.00

$445.00

$589.00

$683.00

MRA

$1,635.00

$784.00

$892.00

$1,294.00

$687.00

$724.00

$856.00

$933.00

$510.00

$665.00

90

90

90

90

90

0

10

90

YYY

10

0

90

90

90

90

90

90

90

90

90

90

90

90

10

90

90

90

90

90

90

90

0

10

90

90

90

0

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

54900

54901

55000

55040

55041

55060

55100

55110

54699

54700

54800

54820

54830

54840

54860

54861

54535

54550

54560

54600

54620

54640

54650

54660

54670

54680

54690

54692

54417

54420

54430

54435

54440

54450

54500

54505

54512

54520

54522

54530

Surgery

CPT Code

54390

54400

54401

54405

54406

54408

54410

54411

54415

54416

Surgery

CPT Code

55120

55150

55175

55180

55200

55250

55300

55400

55450

55500

55520

55530

55535

55540

55550

55559

55600

55605

55650

55680

55700

55705

55720

55725

55801

55810

55812

55815

55821

55831

55840

55842

55845

55859

55860

55862

55865

55866

55870

55873

55899

56405

56420

56440

56441

56501

56515

56605

56606

56620

MRA

$350.00

$562.00

$426.00

$796.00

$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

$426.00

$183.00

$368.00

$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

$843.00

$1,012.00

$1,351.00

$1,890.00

$1,615.00

$166.00

$1,127.00

BR

$131.00

$130.00

$271.00

$183.00

$122.00

$200.00

$96.00

$49.00

$607.00

10

10

0

10

10

10

ZZZ

90

90

0

90

90

90

90

YYY

10

90

90

90

90

90

90

90

90

90

90

90

90

90

0

10

90

90

90

90

90

90

90

90

YYY

FU Days

90

90

90

90

90

10

90

90

90

0

57230

57240

57250

57260

57265

57268

57270

57280

57150

57155

57160

57170

57180

57200

57210

57220

57065

57100

57105

57106

57107

57109

57110

57111

57112

57120

57130

57135

56740

56800

56805

56810

56820

56821

57000

57010

57020

57022

57023

57061

Surgery

CPT Code

56625

56630

56631

56632

56633

56634

56637

56640

56700

56720

$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

$1,071.00

$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

$220.00

$231.00

$321.00

$310.00

$1,349.00

$316.00

$119.00

$154.00

$237.00

$429.00

$118.00

$179.00

$290.00

$124.00

MRA

$735.00

$1,061.00

$1,400.00

$1,636.00

$1,350.00

$1,537.00

$1,806.00

$1,777.00

$227.00

$72.00

90

90

90

90

90

90

90

90

0

10

90

0

90

0

90

90

90

10

10

90

90

90

90

90

90

10

0

10

10

10

10

10

90

0

10

0

0

10

10

90

FU Days

90

90

90

90

90

10

0

90

90

90



$386.00

$2,036.00

$815.00

$700.00

$486.00

$774.00

$718.00

$279.00

$328.00

$71.00

$182.00

$74.00

$297.00

$1,010.00

$677.00

$1,089.00

$125.00

$149.00

$141.00

$223.00

$333.00

$89.00

$105.00

$140.00

$159.00

$191.00

$359.00

$319.00

$769.00

$517.00

$612.00

$693.00

$916.00

$963.00

$70.00

$57.00

$75.00

$124.00

$162.00

$96.00

MRA

$734.00

$950.00

$685.00

$1,009.00

$879.00

$622.00

$925.00

$653.00

$995.00

$997.00

0

10

90

90

0

10

90

90

90

90

90

90

90

90

90

90

10

90

90

10

10

10

0

0

0

0

0

0

0

0

0

0

0

10

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

57720

57800

57820

58100

58120

58140

58145

58146

57530

57531

57540

57545

57550

57555

57556

57700

57454

57455

57456

57460

57461

57500

57505

57510

57511

57513

57520

57522

57308

57310

57311

57320

57330

57335

57400

57410

57415

57420

57421

57452

Surgery

CPT Code

57282

57284

57287

57288

57289

57291

57292

57300

57305

57307

Surgery

CPT Code

58150

58152

58180

58200

58210

58240

58260

58262

58263

58267

58270

58275

58280

58285

58290

58291

58292

58293

58294

58300

58301

58321

58322

58323

58340

58345

58346

58350

58353

58400

58410

58520

58540

58545

58546

58550

58552

58553

58554

58555

58558

58559

58560

58561

58562

58563

58578

58579

58600

58605

MRA

$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

$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

$96.00

$71.00

$81.00

$90.00

$24.00

$87.00

$335.00

$408.00

$103.00

$225.00

$519.00

$752.00

$663.00

$923.00

$876.00

$1,104.00

$1,038.00

$853.00

$1,096.00

$1,085.00

$261.00

$340.00

$436.00

$482.00

$677.00

$339.00

$450.00

BR

BR

$337.00

$298.00

0

0

0

0

YYY

YYY

90

90

10

10

0

10

10

10

0

0

90

90

10

10

90

90

10

90

10

0

0

0

0

0

0

90

90

90

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

59050

59051

59100

59120

59121

59130

59135

59136

58999

59000

59001

59012

59015

59020

59025

59030

58825

58900

58920

58925

58940

58943

58950

58951

58952

58953

58954

58960

58700

58720

58740

58750

58752

58760

58770

58800

58805

58820

58822

58823

Surgery

CPT Code

58611

58615

58660

58661

58662

58670

58671

58672

58673

58679

BR

$123.00

$167.00

$267.00

$168.00

$85.00

$54.00

$155.00

$71.00

$47.00

$633.00

$893.00

$768.00

$832.00

$1,083.00

$934.00

$469.00

$489.00

$571.00

$820.00

$592.00

$1,368.00

$1,170.00

$1,703.00

$1,876.00

$1,839.00

$1,999.00

$1,174.00

$544.00

$844.00

$508.00

$949.00

$893.00

$769.00

$763.00

$343.00

$509.00

$326.00

$603.00

$216.00

MRA

$47.00

$319.00

$793.00

$804.00

$807.00

$450.00

$463.00

$872.00

$928.00

BR

90

90

90

0

0

90

90

90

YYY

0

0

0

0

0

0

0

90

90

90

90

90

90

90

90

90

90

90

90

90

90

0

90

90

90

90

90

90

90

90

90

FU Days

ZZZ

10

90

10

90

90

90

90

90

YYY



59820

59821

59830

59840

59841

59850

59851

59852

59855

59856

59857

59866

59870

59871

59898

59899

60000

60001

60100

60200

60210

60212

Surgery

CPT Code

59140

59150

59151

59160

MRA

$461.00

$543.00

$690.00

$279.00

FU Days

90

90

90

10

Surgery

CPT Code

60220

60225

60240

60252

MRA

$851.00

$1,107.00

$1,228.00

$1,427.00

FU Days

90

90

90

90

Surgery

CPT Code

61321

61322

61323

61330

MRA

$2,310.00

$1,779.00

$1,842.00

$1,706.00

FU Days

90

90

90

90

59200

59300

59320

$79.00

$179.00

$196.00

0

0

0

60254

60260

60270

$1,911.00

$1,022.00

$1,468.00

90

90

90

61332

61333

61334

$2,307.00

$2,231.00

$1,525.00

90

90

90

59325 $316.00

0 60271 $1,210.00

90 61340 $1,584.00

90

59350 $375.00

0 60280 $546.00

90 61343 $2,673.00

90

59400 $1,816.00

0 60281 $670.00 90 61345 $2,259.00 90

59409 $1,019.00 0 60500 $1,232.00 90 61440 $2,110.00 90

59410 $1,123.00 0 60502 $1,475.00 90 61450 $2,173.00 90

59412 $141.00 0 6 0505 $1,631.00 90 61458 $2,433.00 90

59414 $134.00 0 60512 $310.00 ZZZ 61460 $2,426.00 90

59425 $414.00 0 60520 $1,405.00 90 61470 $1,982.00 90

59426 $708.00 0 60521 $1,591.00 90 61480 $1,922.00 90

59430 $140.00 0 60522 $1,820.00 90 61490 $1,687.00 90

59510 $2,064.00 0 60540 $1,272.00 90 61500 $1,637.00 90

59514 $1,199.00 0 60545 $1,505.00 90 61501 $1,353.00 90

59515 $1,324.00 0 60600 $1,477.00 90 61510 $2,506.00 90

59525 $591.00

ZZZ 60605 $1,624.00

90 61512 $2,981.00

90

59610 $1,805.00 0 60650 $1,340.00 90 61514 $2,262.00 90

59612 $1,113.00 0 60659 BR YYY 61516 $2,253.00 90

59614 $1,208.00 0 60699 BR YYY 61517 $74.00 ZZZ

59618 $2,035.00 0 61020 $150.00 0 61518 $3,163.00 90

59620 $1,293.00 0 61026 $138.00 0 61519 $3,450.00 90

59622 $1,397.00 0 61050 $106.00 0 61520 $4,349.00 90

59812 $343.00

90 61055 $143.00

0 61521 $3,667.00

90

$389.00

$398.00

$496.00

$331.00

$443.00

$449.00

$464.00

$642.00

$477.00

$577.00

$711.00

$304.00

$348.00

$192.00

BR

BR

$114.00

$88.00

$96.00

$744.00

$872.00

$1,170.00

90

90

90

10

10

90

90

90

90

90

90

0

90

0

YYY

YYY

10

0

0

90

90

90

61070

61105

61107

61108

61120

61140

61150

61151

61154

61156

61210

61215

61250

61253

61304

61305

61312

61313

61314

61315

61316

61320

$67.00

$503.00

$863.00

$959.00

$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

$2,187.00

$2,207.00

$2,200.00

$2,393.00

$88.00

$2,118.00

0

90

0

90

90

90

90

90

90

90

0

90

90

90

90

90

90

90

90

90

ZZZ

90

61522

61524

61526

61530

61531

61533

61534

61535

61536

61538

61539

61541

61542

61543

61544

61545

61546

61548

61550

61552

61556

61557

$2,415.00

$2,484.00

$3,918.00

$3,611.00

$1,344.00

$1,712.00

$1,535.00

$958.00

$2,862.00

$2,466.00

$2,660.00

$2,363.00

$2,533.00

$2,307.00

$2,271.00

$3,474.00

$2,695.00

$1,964.00

$1,141.00

$1,463.00

$1,760.00

$1,807.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90



$3,535.00

$1,389.00

$1,682.00

$540.00

$1,073.00

$877.00

$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

$2,039.00

$2,279.00

$2,299.00

$3,178.00

$2,961.00

$3,458.00

$798.00

$2,354.00

$584.00

$2,219.00

$3,375.00

$2,576.00

$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

$2,693.00

MRA

$2,085.00

$2,700.00

$2,175.00

$2,597.00

$1,975.00

$2,140.00

$2,992.00

$3,772.00

$2,383.00

$2,674.00

90

90

90

90

90

90

90

90

0

0

0

90

90

90

90

90

ZZZ

ZZZ

ZZZ

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

61684

61686

61690

61692

61697

61698

61700

61702

61616

61618

61619

61623

61624

61626

61680

61682

61600

61601

61605

61606

61607

61608

61609

61610

61611

61612

61613

61615

61582

61583

61584

61585

61586

61590

61591

61592

61595

61596

61597

61598

Surgery

CPT Code

61558

61559

61563

61564

61570

61571

61575

61576

61580

61581

Surgery

CPT Code

61703

61705

61708

61710

61711

61720

61735

61750

61751

61760

61770

61790

61791

61793

61795

61850

61860

61862

61870

61875

61880

61885

61886

61888

62000

62005

62010

62100

62115

62116

62117

62120

62121

62140

62141

62142

62143

62145

62146

62147

62148

62160

62161

62162

62163

62164

62165

62180

62190

62192

MRA

$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

$952.00

$1,205.00

$1,594.00

$371.00

$1,090.00

$1,197.00

$1,551.00

$616.00

$984.00

$559.00

$262.00

$678.00

$331.00

$848.00

$1,282.00

$1,754.00

$1,962.00

$1,686.00

$1,928.00

$2,211.00

$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

0

0

90

0

0

0

90

90

90

90

90

90

90

90

ZZZ

ZZZ

90

90

90

90

90

90

90

90

90

90

10

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

FU Days

90

90

90

90

90

90

90

90

90

90

63011

63012

63015

63016

63017

63020

63030

63035

62361

62362

62365

62367

62368

63001

63003

63005

62290

62291

62292

62294

62310

62311

62318

62319

62350

62351

62355

62360

62263

62264

62268

62269

62270

62272

62273

62280

62281

62282

62284

62287

Surgery

CPT Code

62194

62200

62201

62220

62223

62225

62230

62252

62256

62258

$390.00

$517.00

$418.00

BR

BR

$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

$1,145.00

$280.00

$235.00

$232.00

$1,064.00

$821.00

$200.00

$201.00

$208.00

$203.00

$488.00

$782.00

$402.00

$195.00

$426.00

$593.00

$285.00

$271.00

$109.00

$137.00

$130.00

$199.00

$186.00

$211.00

$196.00

$784.00

MRA

$239.00

$1,625.00

$1,200.00

$1,215.00

$1,199.00

$488.00

$935.00

$85.00

$616.00

$1,308.00

90

90

90

90

90

90

90

ZZZ

0

0

90

90

90

90

90

90

90

90

90

0

0

90

90

0

0

0

0

90

10

0

90

0

10

10

0

0

0

10

0

0

FU Days

10

90

90

90

0

90

90

90

90

90



$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

$2,401.00

$2,206.00

$381.00

$2,490.00

$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

$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

$282.00

$2,930.00

MRA

$1,764.00

$1,620.00

BR

BR

$1,647.00

$2,117.00

$1,907.00

$367.00

$2,029.00

$1,960.00

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

ZZZ

90

ZZZ

90

90

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

ZZZ

90

FU Days

90

90

ZZZ

ZZZ

90

90

90

ZZZ

90

90

63252

63265

63266

63267

63268

63270

63271

63272

63195

63196

63197

63198

63199

63200

63250

63251

63088

63090

63091

63170

63172

63173

63180

63182

63185

63190

63191

63194

63057

63064

63066

63075

63076

63077

63078

63081

63082

63085

63086

63087

Surgery

CPT Code

63040

63042

63043

63044

63045

63046

63047

63048

63055

63056

Surgery

CPT Code

63273

63275

63276

63277

63278

63280

63281

63282

63283

63285

63286

63287

63290

63300

63301

63302

63303

63304

63305

63306

63307

63308

63600

63610

63615

63650

63655

63660

63685

63688

63700

63702

63704

63706

63707

63709

63710

63740

63741

63744

63746

64400

64402

64405

64408

64410

64412

64413

64415

64416

MRA

$2,012.00

$2,166.00

$2,135.00

$1,905.00

$1,877.00

$2,529.00

$2,496.00

$2,305.00

$2,041.00

$2,934.00

$3,003.00

$3,012.00

$3,073.00

$2,006.00

$2,209.00

$2,290.00

$2,357.00

$2,513.00

$2,574.00

$2,596.00

$2,522.00

$425.00

$797.00

$476.00

$1,348.00

$819.00

$1,064.00

$707.00

$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

$1,062.00

$741.00

$738.00

$529.00

$78.00

$75.00

$103.00

$120.00

$109.00

$89.00

$128.00

$109.00

$159.00

0

0

0

0

0

0

0

0

90

90

90

90

90

90

90

0

90

90

90

90

90

90

90

90

90

90

0

90

90

90

90

90

90

ZZZ

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90

64612

64613

64614

64620

64622

64623

64626

64627

64580

64581

64585

64590

64595

64600

64605

64610

64510

64520

64530

64550

64553

64555

64560

64561

64565

64573

64575

64577

64448

64450

64470

64472

64475

64476

64479

64480

64483

64484

64505

64508

Surgery

CPT Code

64417

64418

64420

64421

64425

64430

64435

64445

64446

64447

$343.00

$745.00

$37.00

$217.00

$153.00

$228.00

$319.00

$307.00

$188.00

$168.00

$200.00

$185.00

$333.00

$113.00

$262.00

$151.00

$103.00

$131.00

$135.00

$23.00

$137.00

$131.00

$197.00

$801.00

$121.00

$464.00

$367.00

$381.00

$152.00

$53.00

$206.00

$166.00

$183.00

$166.00

$224.00

$194.00

$206.00

$183.00

$104.00

$99.00

MRA

$105.00

$108.00

$89.00

$128.00

$116.00

$130.00

$114.00

$68.00

$165.00

$77.00

10

10

10

10

10

ZZZ

10

ZZZ

10

10

10

90

90

10

10

10

90

90

90

10

10

10

0

10

10

0

0

0

0

ZZZ

0

ZZZ

0

0

0

0

0

ZZZ

0

ZZZ

FU Days

0

0

0

0

0

0

0

0

0

0



$249.00

$482.00

$298.00

$751.00

$1,281.00

$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

$798.00

$494.00

$560.00

$1,042.00

$578.00

$495.00

$561.00

$713.00

$632.00

$636.00

$392.00

$390.00

$558.00

$446.00

$439.00

$411.00

$271.00

$261.00

$405.00

$432.00

$388.00

$475.00

$461.00

$517.00

MRA

$202.00

$208.00

$180.00

$383.00

$402.00

$562.00

$678.00

$867.00

$715.00

$523.00

90

90

90

90

0

90

90

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

90

90

ZZZ

FU Days

10

10

10

90

90

90

90

90

90

90

64792

64795

64802

64804

64809

64818

64820

64821

64778

64782

64783

64784

64786

64787

64788

64790

64744

64746

64752

64755

64760

64761

64763

64766

64771

64772

64774

64776

64718

64719

64721

64722

64726

64727

64732

64734

64736

64738

64740

64742

Surgery

CPT Code

64630

64640

64680

64702

64704

64708

64712

64713

64714

64716

Surgery

CPT Code

64822

64823

64831

64832

64834

64835

64836

64837

64840

64856

64857

64858

64859

64861

64862

64864

64865

64866

64868

64870

64872

64874

64876

64885

64886

64890

64891

64892

64893

64895

64896

64897

64898

64901

64902

64905

64907

64999

65091

65093

65101

65103

65105

65110

65112

65114

65125

65130

65135

65140

MRA

$609.00

$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

$970.00

$1,250.00

$1,238.00

$1,162.00

$1,313.00

$155.00

$230.00

$189.00

$1,382.00

$1,636.00

$1,112.00

$1,243.00

$1,177.00

$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

BR

$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

90

90

90

90

90

90

90

90

ZZZ

90

90

YYY

90

90

90

90

90

90

90

90

90

ZZZ

ZZZ

90

90

90

90

90

90

90

90

90

ZZZ

ZZZ

90

90

ZZZ

90

90

90

FU Days

90

90

90

ZZZ

90

90

90

ZZZ

90

90

65865

65870

65875

65880

65900

65920

65930

66020

65800

65805

65810

65815

65820

65850

65855

65860

65430

65435

65436

65450

65600

65710

65730

65750

65755

65770

65772

65775

65270

65272

65273

65275

65280

65285

65286

65290

65400

65410

65420

65426

Surgery

CPT Code

65150

65155

65175

65205

65210

65220

65222

65235

65260

65265

$88.00

$178.00

$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

$81.00

$88.00

$319.00

$52.00

$325.00

$1,124.00

$1,314.00

$1,381.00

$1,373.00

$1,461.00

$449.00

$595.00

$88.00

$223.00

$376.00

$75.00

$711.00

$1,177.00

$692.00

$519.00

$603.00

$142.00

$448.00

$534.00

MRA

$652.00

$862.00

$654.00

$45.00

$53.00

$58.00

$62.00

$627.00

$956.00

$1,104.00

90

90

90

90

90

90

90

10

90

90

90

0

0

90

10

90

90

90

90

90

90

90

90

90

90

0

0

90

0

90

90

90

90

90

90

90

90

10

90

90

FU Days

90

90

90

0

90

90

90

0

0

0



$805.00

$878.00

$785.00

$906.00

$819.00

$846.00

$763.00

$898.00

$744.00

$1,038.00

$84.00

BR

$639.00

$647.00

$637.00

$774.00

$506.00

$513.00

$506.00

$473.00

$506.00

$433.00

$483.00

$433.00

$275.00

$753.00

$651.00

$707.00

$711.00

$1,006.00

$602.00

$359.00

$359.00

$825.00

$1,136.00

$543.00

$623.00

$595.00

$526.00

$627.00

MRA

$160.00

$631.00

$798.00

$795.00

$942.00

$769.00

$1,089.00

$1,264.00

$1,313.00

$769.00

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

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FU Days

10

90

90

90

90

90

90

90

90

90

66985

66986

66990

66999

67005

67010

67015

67025

66850

66852

66920

66930

66940

66982

66983

66984

66700

66710

66720

66740

66761

66762

66770

66820

66821

66825

66830

66840

66220

66225

66250

66500

66505

66600

66605

66625

66630

66635

66680

66682

Surgery

CPT Code

66030

66130

66150

66155

66160

66165

66170

66172

66180

66185

Surgery

CPT Code

67027

67028

67030

67031

67036

67038

67039

67040

67101

67105

67107

67108

67110

67112

67115

67120

67121

67141

67145

67208

67210

67218

67220

67221

67225

67227

67228

67250

67255

67299

67311

67312

67314

67316

67318

67320

67331

67332

67334

67335

67340

67343

67345

67350

67399

67400

67405

67412

67413

67414

MRA

$1,089.00

$338.00

$485.00

$402.00

$1,384.00

$1,860.00

$1,490.00

$1,960.00

$767.00

$941.00

$1,350.00

$1,878.00

$1,040.00

$1,500.00

$496.00

$751.00

$962.00

$536.00

$514.00

$655.00

$779.00

$1,217.00

$894.00

$325.00

$44.00

$652.00

$1,025.00

$793.00

$872.00

BR

$616.00

$773.00

$688.00

$857.00

$663.00

$602.00

$560.00

$621.00

$447.00

$253.00

$559.00

$628.00

$275.00

$240.00

BR

$960.00

$799.00

$976.00

$909.00

$1,023.00

10

0

YYY

90

90

90

90

90

90

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

ZZZ

90

90

YYY

90

90

90

90

90

0

ZZZ

90

90

90

90

90

90

90

90

90

90

90

90

90

90

90

FU Days

90

0

90

90

90

90

90

90

90

90

67917

67921

67922

67923

67924

67930

67935

67938

67904

67906

67908

67909

67911

67914

67915

67916

67825

67830

67835

67840

67850

67875

67880

67882

67900

67901

67902

67903

67560

67570

67599

67700

67710

67715

67800

67801

67805

67808

67810

67820

Surgery

CPT Code

67415

67420

67430

67440

67445

67450

67500

67505

67515

67550

$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

$130.00

$239.00

$500.00

$187.00

$143.00

$163.00

$442.00

$643.00

$487.00

$646.00

$650.00

$657.00

$936.00

$1,148.00

BR

$87.00

$117.00

$102.00

$119.00

$189.00

$208.00

$308.00

$133.00

$36.00

MRA

$146.00

$1,729.00

$1,203.00

$1,257.00

$1,269.00

$1,300.00

$75.00

$109.00

$53.00

$946.00

90

90

10

90

90

90

90

10

90

90

90

90

90

90

90

90

90

90

90

90

90

90

10

10

0

10

10

90

90

0

0

10

10

10

90

90

YYY

10

10

10

FU Days

0

90

90

90

0

0

90

90

90

0



$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

$399.00

$100.00

$413.00

$449.00

$691.00

BR

$154.00

$191.00

$96.00

$882.00

$921.00

$491.00

$687.00

$340.00

$137.00

$172.00

$248.00

$378.00

$146.00

$59.00

$502.00

$672.00

$654.00

$741.00

$488.00

$636.00

MRA

$584.00

$571.00

$645.00

$875.00

$1,126.00

$1,140.00

$681.00

BR

$106.00

$75.00

10

10

10

10

10

90

10

10

90

10

90

10

90

90

90

90

0

90

0

10

90

90

90

90

90

YYY

10

10

90

90

90

90

90

90

90

10

0

0

10

10

FU Days

90

90

90

90

90

90

90

YYY

10

0

68760

68761

68770

68801

68810

68811

68815

68840

68530

68540

68550

68700

68705

68720

68745

68750

68340

68360

68362

68399

68400

68420

68440

68500

68505

68510

68520

68525

68100

68110

68115

68130

68135

68200

68320

68325

68326

68328

68330

68335

Surgery

CPT Code

67950

67961

67966

67971

67973

67974

67975

67999

68020

68040

Surgery

CPT Code

68850

68899

69000

69005

69020

69100

69105

69110

69120

69140

69145

69150

69155

69200

69205

69210

69220

69222

69300

69310

69320

69399

69400

69401

69405

69410

69420

69421

69424

69433

69436

69440

69450

69501

69502

69505

69511

69530

69535

69540

69550

69552

69554

69601

69602

69603

69604

69605

69610

69620

MRA

$76.00

BR

$52.00

$175.00

$109.00

$85.00

$87.00

$294.00

$274.00

$722.00

$248.00

$1,111.00

$1,680.00

$53.00

$110.00

$39.00

$78.00

$123.00

$522.00

$937.00

$1,434.00

BR

$76.00

$52.00

$176.00

$53.00

$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

90

90

90

90

90

90

10

90

90

90

10

90

90

90

90

90

90

90

90

0

10

10

0

10

10

0

0

10

0

10

YYY

90

90

YYY

0

10

0

90

90

90

FU Days

0

YYY

10

10

90

90

90

10

0

0

69805

69806

69820

69840

69905

69910

69915

69930

69949

69950

69955

69960

69970

69979

69990

69711

69714

69715

69717

69718

69720

69725

69740

69745

69799

69801

69802

69645

69646

69650

69660

69661

69662

69666

69667

69670

69676

69700

69710

Surgery

CPT Code

69631

69632

69633

69635

69636

69637

69641

69642

69643

69644

$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

$878.00

$961.00

$1,217.00

$996.00

$1,232.00

$1,307.00

$1,922.00

$1,274.00

$1,447.00

BR

$785.00

$1,115.00

$1,479.00

$1,620.00

$879.00

$1,072.00

$1,412.00

$1,386.00

$887.00

$887.00

$988.00

$828.00

$702.00

BR

MRA

$985.00

$1,166.00

$1,110.00

$1,207.00

$1,381.00

$1,370.00

$1,154.00

$1,519.00

$1,389.00

$1,529.00

YYY

90

90

90

90

YYY

ZZZ

90

90

90

90

90

90

90

90

90

90

90

YYY

90

90

90

90

90

90

90

90

90

90

0

90

90

90

90

90

90

90

90

90

FU Days

90

90

90

90

90

90

90

90

90

90



$32.00

$8.00

$22.00

$42.00

$12.00

$29.00

$26.00

$9.00

NC

NC

$34.00

$10.00

$22.00

$43.00

$14.00

$29.00

$17.00

$28.00

$33.00

$9.00

$22.00

$42.00

$12.00

$29.00

$29.00

$8.00

$19.00

$52.00

$9.00

$19.00

$36.00

$12.00

$22.00

$32.00

$9.00

$22.00

$46.00

$17.00

$29.00

$45.00

MRA

$70.00

NC

NC

$58.00

NC

NC

$24.00

$10.00

$15.00

$29.00

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

70134-26

70134-TC

70140

70140-26

70140-TC

70150

70150-26

70150-TC

70160

70160-26

70160-TC

70170

70100-26

70100-TC

70110

70110-26

70110-TC

70120

70120-26

70120-TC

70130

70130-26

70130-TC

70134

Radiology

CPT Code

70010

70010-26

70010-TC

70015

70015-26

70015-TC

70030

70030-26

70030-TC

70100

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

70373

70373-26

70373-TC

70380

70380-26

70380-TC

70390

$24.00

$8.00

$15.00

$65.00

$16.00

$48.00

$122.00

$43.00

$79.00

$90.00

NC

NC

$34.00

$8.00

$24.00

$87.00

$107.00

NC

NC

$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

MRA

$15.00

$35.00

$12.00

$22.00

$50.00

$17.00

$33.00

$15.00

$5.00

$10.00

70491-TC

70492

70492-26

70492-TC

70496

70496-26

70496-TC

70498

70498-26

70498-TC

70540

70540-26

70540-TC

70542

70542-26

70542-TC

70486-TC

70487

70487-26

70487-TC

70488

70488-26

70488-TC

70490

70490-26

70490-TC

70491

70491-26

70470-TC

70480

70480-26

70480-TC

70481

70481-26

70481-TC

70482

70482-26

70482-TC

70486

70486-26

Radiology

CPT Code

70390-26

70390-TC

70450

70450-26

70450-TC

70460

70460-26

70460-TC

70470

70470-26

$211.00

$340.00

$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

$176.00

$279.00

$66.00

$211.00

$339.00

$72.00

$264.00

$244.00

$65.00

$176.00

$284.00

$70.00

$264.00

$244.00

$65.00

$176.00

$284.00

$70.00

$211.00

$340.00

$74.00

$264.00

$236.00

$58.00

MRA

NC

NC

$221.00

$43.00

$176.00

$271.00

$58.00

$211.00

$332.00

$65.00



$44.00

$16.00

$28.00

$49.00

$19.00

$29.00

$45.00

$16.00

$10.00

$19.00

$35.00

$11.00

$22.00

$41.00

$13.00

$28.00

$76.00

$419.00

$596.00

$91.00

$502.00

$1,055.00

$120.00

$931.00

$27.00

$9.00

$17.00

$30.00

$92.00

$820.00

$481.00

$61.00

$419.00

$481.00

$61.00

$419.00

$914.00

$92.00

$820.00

$497.00

MRA

$1,029.00

$109.00

$916.00

$481.00

$61.00

$419.00

$481.00

$61.00

$419.00

$914.00

71015-26

71015-TC

71020

71020-26

71020-TC

71021

71021-26

71021-TC

71022

71022-26

71022-TC

71023

71023-26

71023-TC

71030

71030-26

70551-26

70551-TC

70552

70552-26

70552-TC

70553

70553-26

70553-TC

71010

71010-26

71010-TC

71015

70546-26

70546-TC

70547

70547-26

70547-TC

70548

70548-26

70548-TC

70549

70549-26

70549-TC

70551

Radiology

CPT Code

70543

70543-26

70543-TC

70544

70544-26

70544-TC

70545

70545-26

70545-TC

70546

Radiology

CPT Code

71030-TC

71034

71034-26

71034-TC

71035

71035-26

71035-TC

71040

71040-26

71040-TC

71060

71060-26

71060-TC

71090

71090-26

71090-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

71550-26

71550-TC

71551

$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

$75.00

$415.00

$587.00

$43.00

$13.00

$29.00

$49.00

$16.00

$33.00

$35.00

$10.00

$24.00

$38.00

$11.00

$26.00

$108.00

NC

NC

$92.00

NC

NC

$33.00

$11.00

$21.00

$38.00

$13.00

$24.00

MRA

$29.00

$79.00

$23.00

$54.00

$56.00

$19.00

$38.00

$34.00

NC

NC

72074-TC

72080

72080-26

72080-TC

72090

72090-26

72090-TC

72100

72100-26

72100-TC

72110

72110-26

72110-TC

72114

72114-26

72114-TC

72052-TC

72069

72069-26

72069-TC

72070

72070-26

72070-TC

72072

72072-26

72072-TC

72074

72074-26

72010-TC

72020

72020-26

72020-TC

72040

72040-26

72040-TC

72050

72050-26

72050-TC

72052

72052-26

Radiology

CPT Code

71551-26

71551-TC

71552

71552-26

71552-TC

71555

71555-26

71555-TC

72010

72010-26

$11.00

$24.00

$50.00

$16.00

$34.00

$64.00

$18.00

$44.00

$34.00

$36.00

$11.00

$24.00

$39.00

$14.00

$24.00

$36.00

$42.00

$40.00

$17.00

$24.00

$36.00

$11.00

$24.00

$39.00

$11.00

$28.00

$45.00

$11.00

$38.00

$22.00

$7.00

$15.00

$34.00

$11.00

$22.00

$49.00

$16.00

$33.00

$61.00

$18.00

MRA

$88.00

$496.00

$1,029.00

$114.00

$911.00

$514.00

$92.00

$419.00

$62.00

$22.00



$99.00

$502.00

$549.00

$82.00

$465.00

$603.00

$98.00

$502.00

$543.00

$76.00

$465.00

$597.00

$92.00

$502.00

$1,066.00

$131.00

$59.00

$220.00

$328.00

$62.00

$264.00

$391.00

$65.00

$323.00

$503.00

$82.00

$419.00

$604.00

$65.00

$330.00

$282.00

$59.00

$220.00

$328.00

$62.00

$264.00

$397.00

$65.00

$330.00

$282.00

MRA

$45.00

$11.00

$33.00

$282.00

$59.00

$220.00

$328.00

$62.00

$264.00

$397.00

72142-26

72142-TC

72146

72146-26

72146-TC

72147

72147-26

72147-TC

72148

72148-26

72148-TC

72149

72149-26

72149-TC

72156

72156-26

72131-26

72131-TC

72132

72132-26

72132-TC

72133

72133-26

72133-TC

72141

72141-26

72141-TC

72142

72127-26

72127-TC

72128

72128-26

72128-TC

72129

72129-26

72129-TC

72130

72130-26

72130-TC

72131

Radiology

CPT Code

72120

72120-26

72120-TC

72125

72125-26

72125-TC

72126

72126-26

72126-TC

72127

Radiology

CPT Code

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

72202-26

72202-TC

72220

72220-26

72220-TC

72240

$1,037.00

$114.00

$919.00

$517.00

$95.00

$419.00

$29.00

$9.00

$19.00

$33.00

$9.00

$22.00

$30.00

$8.00

$21.00

$132.00

$317.00

$59.00

$256.00

$380.00

$62.00

$317.00

$491.00

$74.00

$415.00

$526.00

$84.00

$442.00

$29.00

$8.00

$19.00

$35.00

$10.00

$24.00

$413.00

$94.00

$315.00

$278.00

$56.00

$220.00

MRA

$931.00

$1,066.00

$131.00

$931.00

$1,056.00

$121.00

$931.00

$563.00

$94.00

$465.00

73040-TC

73050

73050-26

73050-TC

73060

73060-26

73060-TC

73070

73070-26

73070-TC

73080

73080-26

73080-TC

73085

73085-26

73085-TC

73000-TC

73010

73010-26

73010-TC

73020

73020-26

73020-TC

73030

73030-26

73030-TC

73040

73040-26

72270-TC

72275

72275-26

72275-TC

72285

72285-26

72285-TC

72295

72295-26

72295-TC

73000

73000-26

Radiology

CPT Code

72240-26

72240-TC

72255

72255-26

72255-TC

72265

72265-26

72265-TC

72270

72270-26

$7.00

$19.00

$30.00

$8.00

$21.00

$74.00

NC

NC

NC

$35.00

$10.00

$24.00

$30.00

$8.00

$21.00

$27.00

$19.00

$29.00

$8.00

$19.00

$26.00

$7.00

$17.00

$31.00

$9.00

$21.00

$68.00

NC

NC

$112.00

NC

NC

$101.00

NC

NC

$107.00

NC

NC

$28.00

$8.00

MRA

NC

NC

$129.00

NC

NC

$132.00

NC

NC

$176.00

NC



$68.00

$413.00

$579.00

$82.00

$495.00

$520.00

$78.00

$442.00

$482.00

$68.00

$413.00

$579.00

$82.00

$495.00

$1,029.00

$109.00

$56.00

$185.00

$282.00

$59.00

$220.00

$342.00

$63.00

$277.00

$375.00

$94.00

$277.00

$482.00

NC

NC

$27.00

$8.00

$18.00

$29.00

$8.00

$19.00

$22.00

$7.00

$15.00

$242.00

MRA

$28.00

$8.00

$19.00

$27.00

$8.00

$18.00

$29.00

$8.00

$19.00

$54.00

73218-26

73218-TC

73219

73219-26

73219-TC

73220

73220-26

73220-TC

73221

73221-26

73221-TC

73222

73222-26

73222-TC

73223

73223-26

73200-26

73200-TC

73201

73201-26

73201-TC

73202

73202-26

73202-TC

73206

73206-26

73206-TC

73218

73115-26

73115-TC

73120

73120-26

73120-TC

73130

73130-26

73130-TC

73140

73140-26

73140-TC

73200

Radiology

CPT Code

73090

73090-26

73090-TC

73100

73100-26

73100-TC

73110

73110-26

73110-TC

73115

Radiology

CPT Code

73223-TC

73225

73225-26

73225-TC

73500

73500-26

73500-TC

73510

73510-26

73510-TC

73520

73520-26

73520-TC

73525

73525-26

73525-TC

73530

73530-26

73530-TC

73542

73542-26

73542-TC

73550

73550-26

73550-TC

73560

73560-26

73560-TC

73562

73562-26

73562-TC

73564

73564-26

73564-TC

73565

73565-26

73565-TC

73580

73580-26

73580-TC

73590

73590-26

73590-TC

73600

73600-26

73600-TC

73610

73610-26

73610-TC

73615

$19.00

$27.00

$8.00

$18.00

$29.00

$8.00

$19.00

$72.00

$28.00

$8.00

$18.00

$84.00

NC

NC

$29.00

$8.00

$30.00

$8.00

$21.00

$29.00

$8.00

$19.00

$31.00

$9.00

$21.00

$35.00

$11.00

$22.00

$38.00

$12.00

$24.00

$84.00

NC

NC

$34.00

$14.00

$19.00

$108.00

NC

NC

MRA

$916.00

$513.00

$92.00

$419.00

$27.00

$8.00

$17.00

$32.00

$10.00

$21.00

73720-TC

73721

73721-26

73721-TC

73722

73722-26

73722-TC

73723

73723-26

73723-TC

73725

73725-26

73725-TC

74000

74000-26

74000-TC

73702-TC

73706

73706-26

73706-TC

73718

73718-26

73718-TC

73719

73719-26

73719-TC

73720

73720-26

73650-TC

73660

73660-26

73660-TC

73700

73700-26

73700-TC

73701

73701-26

73701-TC

73702

73702-26

Radiology

CPT Code

73615-26

73615-TC

73620

73620-26

73620-TC

73630

73630-26

73630-TC

73650

73650-26

$442.00

$482.00

$68.00

$413.00

$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

$277.00

$379.00

$98.00

$277.00

$482.00

$68.00

$413.00

$579.00

$82.00

$495.00

$520.00

$78.00

$17.00

$22.00

$7.00

$15.00

$242.00

$56.00

$185.00

$282.00

$61.00

$220.00

$341.00

$62.00

MRA

NC

NC

$27.00

$8.00

$18.00

$29.00

$8.00

$19.00

$26.00

$8.00



NC

NC

$63.00

$18.00

$44.00

$68.00

$23.00

$44.00

$77.00

$27.00

$48.00

$160.00

NC

NC

$91.00

$35.00

$85.00

$415.00

$587.00

$88.00

$496.00

$1,037.00

$114.00

$919.00

$514.00

$92.00

$419.00

$73.00

$60.00

$211.00

$322.00

$65.00

$256.00

$390.00

$71.00

$317.00

$418.00

$98.00

$315.00

$498.00

MRA

$33.00

$11.00

$21.00

$37.00

$13.00

$22.00

$44.00

$16.00

$28.00

$274.00

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

74181-26

74181-TC

74182

74182-26

74182-TC

74183

74183-26

74183-TC

74185

74185-26

74185-TC

74190

74150-26

74150-TC

74160

74160-26

74160-TC

74170

74170-26

74170-TC

74175

74175-26

74175-TC

74181

Radiology

CPT Code

74010

74010-26

74010-TC

74020

74020-26

74020-TC

74022

74022-26

74022-TC

74150

Radiology

CPT Code

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

74270

74270-26

74270-TC

74280

74280-26

74280-TC

74283

74283-26

74283-TC

74290

74290-26

74290-TC

74291

74291-26

74291-TC

74300

74300-26

74300-TC

74301

74301-26

74301-TC

74305

74305-26

74305-TC

74320

$44.00

$16.00

$28.00

$26.00

$10.00

$15.00

$31.00

NC

NC

BR

NC

NC

$51.00

NC

NC

$145.00

$82.00

$25.00

$56.00

$100.00

$35.00

$64.00

$136.00

$50.00

$84.00

$201.00

$103.00

$95.00

$99.00

$35.00

$63.00

$144.00

$46.00

$96.00

$73.00

$23.00

$48.00

$85.00

$34.00

$48.00

MRA

$55.00

$91.00

$35.00

$56.00

$137.00

$46.00

$89.00

$97.00

$35.00

$61.00

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

74355-TC

74360

74360-26

74360-TC

74363

74363-26

74363-TC

74400

74400-26

74400-TC

74410

74410-26

74329-TC

74330

74330-26

74330-TC

74340

74340-26

74340-TC

74350

74350-26

74350-TC

74355

74355-26

Radiology

CPT Code

74320-26

74320-TC

74327

74327-26

74327-TC

74328

74328-26

74328-TC

74329

74329-26

$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

NC

NC

$145.00

NC

NC

$274.00

NC

NC

$89.00

$24.00

$63.00

$98.00

$24.00

NC

$165.00

NC

NC

$121.00

NC

NC

$158.00

NC

NC

$137.00

NC

MRA

NC

NC

$103.00

NC

NC

$155.00

NC

NC

$155.00

NC



$82.00

$419.00

$524.00

$100.00

$419.00

$517.00

$94.00

$419.00

$513.00

$91.00

$419.00

$497.00

NC

NC

$183.00

NC

$17.00

$39.00

$68.00

NC

NC

$150.00

NC

NC

$88.00

$32.00

$55.00

$503.00

NC

NC

$181.00

NC

NC

$181.00

NC

NC

$146.00

NC

NC

$57.00

MRA

$101.00

NC

NC

$60.00

NC

NC

$75.00

NC

NC

$74.00

75552-26

75552-TC

75553

75553-26

75553-TC

75554

75554-26

75554-TC

75555

75555-26

75555-TC

75600

75600-26

75600-TC

75605

75605-26

74710-26

74710-TC

74740

74740-26

74740-TC

74742

74742-26

74742-TC

74775

74775-26

74775-TC

75552

74470-26

74470-TC

74475

74475-26

74475-TC

74480

74480-26

74480-TC

74485

74485-26

74485-TC

74710

Radiology

CPT Code

74445

74445-26

74445-TC

74450

74450-26

74450-TC

74455

74455-26

74455-TC

74470

Radiology

CPT Code

75605-TC

75625

75625-26

75625-TC

75630

75630-26

75630-TC

75635

75635-26

75635-TC

75650

75650-26

75650-TC

75658

75658-26

75658-TC

75660

75660-26

75660-TC

75662

75662-26

75662-TC

75665

75665-26

75665-TC

75671

75671-26

75671-TC

75676

75676-26

75676-TC

75680

75680-26

75680-TC

75685

75685-26

75685-TC

75705

75705-26

75705-TC

75710

75710-26

75710-TC

75716

75716-26

75716-TC

75722

75722-26

75722-TC

75724

$160.00

NC

NC

$587.00

NC

NC

$194.00

NC

NC

$293.00

NC

NC

$206.00

NC

NC

$214.00

$540.00

NC

NC

$219.00

NC

NC

$540.00

NC

NC

$207.00

NC

NC

$218.00

NC

NC

$540.00

NC

NC

$540.00

NC

NC

$560.00

NC

NC

MRA

NC

$143.00

NC

NC

$239.00

NC

NC

$445.00

NC

NC

75801-TC

75803

75803-26

75803-TC

75805

75805-26

75805-TC

75807

75807-26

75807-TC

75809

75809-26

75809-TC

75810

75810-26

75810-TC

75746-TC

75756

75756-26

75756-TC

75774

75774-26

75774-TC

75790

75790-26

75790-TC

75801

75801-26

75733-TC

75736

75736-26

75736-TC

75741

75741-26

75741-TC

75743

75743-26

75743-TC

75746

75746-26

Radiology

CPT Code

75724-26

75724-TC

75726

75726-26

75726-TC

75731

75731-26

75731-TC

75733

75733-26

NC

$264.00

NC

NC

$271.00

NC

NC

$289.00

NC

NC

$54.00

NC

NC

$530.00

NC

NC

NC

$183.00

NC

NC

$80.00

NC

NC

$146.00

NC

NC

$245.00

NC

NC

$530.00

NC

NC

$540.00

NC

NC

$253.00

NC

NC

$530.00

NC

MRA

NC

NC

$530.00

NC

NC

$530.00

NC

NC

$540.00

NC



NC

NC

$546.00

NC

NC

$546.00

NC

NC

$530.00

NC

NC

$530.00

NC

NC

$499.00

NC

NC

NC

$531.00

NC

NC

$531.00

NC

NC

$530.00

NC

NC

$72.00

NC

NC

$54.00

NC

NC

$549.00

NC

NC

$531.00

NC

NC

$549.00

MRA

$72.00

NC

NC

$111.00

NC

NC

$194.00

NC

NC

$530.00

75880-26

75880-TC

75885

75885-26

75885-TC

75887

75887-26

75887-TC

75889

75889-26

75889-TC

75891

75891-26

75891-TC

75893

75893-26

75842-26

75842-TC

75860

75860-26

75860-TC

75870

75870-26

75870-TC

75872

75872-26

75872-TC

75880

75827-26

75827-TC

75831

75831-26

75831-TC

75833

75833-26

75833-TC

75840

75840-26

75840-TC

75842

Radiology

CPT Code

75820

75820-26

75820-TC

75822

75822-26

75822-TC

75825

75825-26

75825-TC

75827

Radiology

CPT Code

75893-TC

75894

75894-26

75894-TC

75896

75896-26

75896-TC

75898

75898-26

75898-TC

75900

75900-26

75900-TC

75901

75901-26

75901-TC

75902

75902-26

75902-TC

75940

75940-26

75940-TC

75945

75945-26

75945-TC

75946

75946-26

75946-TC

75952

75952-26

75952-TC

75953

75953-26

75953-TC

75954

75954-26

75954-TC

75960

75960-26

75960-TC

75961

75961-26

75961-TC

75962

75962-26

75962-TC

75964

75964-26

75964-TC

75966

BR

NC

NC

$600.00

NC

NC

$616.00

NC

NC

$618.00

NC

NC

$333.00

NC

NC

$659.00

$192.00

NC

NC

$108.00

NC

NC

BR

NC

NC

BR

NC

NC

$810.00

NC

NC

$98.00

NC

NC

$93.00

NC

NC

$151.00

NC

NC

MRA

NC

$972.00

NC

NC

$241.00

NC

NC

$124.00

$84.00

$39.00

75995-TC

75996

75996-26

75996-TC

76000

76000-26

76000-TC

76001

76001-26

76001-TC

76003

76003-26

76003-TC

76005

76005-26

76005-TC

75989-TC

75992

75992-26

75992-TC

75993

75993-26

75993-TC

75994

75994-26

75994-TC

75995

75995-26

75978-TC

75980

75980-26

75980-TC

75982

75982-26

75982-TC

75984

75984-26

75984-TC

75989

75989-26

Radiology

CPT Code

75966-26

75966-TC

75968

75968-26

75968-TC

75970

75970-26

75970-TC

75978

75978-26

NC

$332.00

NC

NC

$58.00

$8.00

$48.00

$134.00

$34.00

$97.00

$78.00

$28.00

$48.00

$79.00

$29.00

$48.00

NC

$618.00

NC

NC

$333.00

NC

NC

$659.00

NC

NC

$658.00

NC

NC

$277.00

NC

NC

$303.00

NC

NC

$110.00

NC

NC

$180.00

NC

MRA

NC

NC

$333.00

NC

NC

$475.00

NC

NC

$617.00

NC



$39.00

$10.00

$29.00

$67.00

NC

NC

$18.00

$3.00

$14.00

$117.00

NC

NC

$161.00

NC

NC

$68.00

$123.00

$13.00

$110.00

$121.00

$11.00

$110.00

$132.00

$15.00

$115.00

$40.00

$11.00

$29.00

$44.00

$14.00

$29.00

$61.00

$22.00

$37.00

$82.00

$27.00

$54.00

$58.00

$16.00

$41.00

MRA

$19.00

BR

NC

NC

BR

NC

NC

$29.00

$9.00

$19.00

76078

76078-26

76078-TC

76080

76080-26

76080-TC

76085

76085-26

76085-TC

76086

76086-26

76086-TC

76088

76088-26

76088-TC

76090

76070

76070-26

76070-TC

76071

76071-26

76071-TC

76075

76075-26

76075-TC

76076

76076-26

76076-TC

76040

76040-26

76040-TC

76061

76061-26

76061-TC

76062

76062-26

76062-TC

76066

76066-26

76066-TC

Radiology

CPT Code

76006

76012

76012-26

76012-TC

76013

76013-26

76013-TC

76020

76020-26

76020-TC

Radiology

CPT Code

76090-26

76090-TC

76091

76091-26

76091-TC

76093

76093-26

76093-TC

76094

76094-26

76094-TC

76095

76095-26

76095-TC

76096

76096-26

76096-TC

76098

76098-26

76098-TC

76100

76100-26

76100-TC

76101

76101-26

76101-TC

76102

76102-26

76102-TC

76120

76120-26

76120-TC

76125

76125-26

76125-TC

76140

76150

76350

76355

76355-26

76355-TC

76360

76360-26

76360-TC

76362

76362-26

76362-TC

76370

76370-26

76370-TC

$33.00

$31.00

$15.00

BR

$372.00

$62.00

$308.00

$168.00

NC

NC

$550.00

$203.00

$341.00

$155.00

$43.00

$110.00

$46.00

$94.00

$36.00

$59.00

$95.00

$30.00

$65.00

$157.00

$56.00

$102.00

$49.00

$17.00

$894.00

$351.00

NC

NC

$79.00

NC

NC

$23.00

$8.00

$15.00

$77.00

$30.00

MRA

$17.00

$39.00

$85.00

$30.00

$48.00

$745.00

$83.00

$658.00

$980.00

$83.00

76506-26

76506-TC

76511

76511-26

76511-TC

76512

76512-26

76512-TC

76513

76513-26

76513-TC

76516

76516-26

76516-TC

76519

76519-26

76496-26

76496-TC

76497

76497-26

76497-TC

76498

76498-26

76498-TC

76499

76499-26

76499-TC

76506

76393-26

76393-TC

76394

76394-26

76394-TC

76400

76400-26

76400-TC

76490

76490-26

76490-TC

76496

Radiology

CPT Code

76375

76375-26

76375-TC

76380

76380-26

76380-TC

76390

76390-26

76390-TC

76393

$96.00

$36.00

$60.00

$99.00

$37.00

$63.00

$88.00

$31.00

$33.00

$53.00

$96.00

$48.00

$48.00

$96.00

$36.00

$60.00

BR

BR

BR

BR

BR

$88.00

BR

BR

BR

BR

BR

BR

NC

NC

$671.00

$216.00

$449.00

$503.00

$81.00

$419.00

$169.00

$106.00

$63.00

BR

MRA

$140.00

$8.00

$132.00

$182.00

$50.00

$131.00

$493.00

$71.00

$419.00

$496.00



$73.00

$43.00

$30.00

$131.00

$51.00

$79.00

$252.00

$100.00

$151.00

$243.00

$100.00

$142.00

$145.00

$94.00

$51.00

$88.00

$84.00

$30.00

$53.00

$112.00

$38.00

$73.00

$112.00

$61.00

$54.00

$93.00

$51.00

$42.00

$69.00

$31.00

$40.00

$116.00

$42.00

$73.00

$84.00

$30.00

$53.00

$112.00

$38.00

$73.00

MRA

$53.00

$86.00

$31.00

$53.00

$83.00

$31.00

$54.00

$78.00

$28.00

$48.00

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

76815

76775

76775-26

76775-TC

76778

76778-26

76778-TC

76800

76800-26

76800-TC

76801

76801-26

76801-TC

76645

76645-26

76645-TC

76700

76700-26

76700-TC

76705

76705-26

76705-TC

76770

76770-26

76770-TC

Radiology

CPT Code

76519-TC

76529

76529-26

76529-TC

76536

76536-26

76536-TC

76604

76604-26

76604-TC

Radiology

CPT Code

76815-26

76815-TC

76816

76816-26

76816-TC

76817

76817-26

76817-TC

76818

76818-26

76818-TC

76819

76819-26

76819-TC

76825

76825-26

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

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

76880

76880-26

76880-TC

$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

$85.00

$32.00

$54.00

$65.00

$72.00

$29.00

$42.00

$93.00

$35.00

$57.00

$95.00

$37.00

$57.00

$93.00

$35.00

$60.00

$101.00

$40.00

$60.00

$160.00

$65.00

$73.00

$71.00

$46.00

$27.00

$97.00

$35.00

MRA

$33.00

$53.00

$72.00

$30.00

$41.00

$96.00

$39.00

$57.00

$105.00

$40.00

76975-26

76975-TC

76977

76977-26

76977-TC

76986

76986-26

76986-TC

76999

76999-26

76999-TC

77261

77262

77263

77280

77280-26

76948-26

76948-TC

76950

76950-26

76950-TC

76965

76965-26

76965-TC

76970

76970-26

76970-TC

76975

76941-26

76941-TC

76942

76942-26

76942-TC

76945

76945-26

76945-TC

76946

76946-26

76946-TC

76948

Radiology

CPT Code

76930

76930-26

76930-TC

76932

76932-26

76932-TC

76936

76936-26

76936-TC

76941

NC

NC

$34.00

$3.00

$31.00

$162.00

$62.00

$97.00

BR

BR

BR

$73.00

$110.00

$163.00

$166.00

$36.00

NC

NC

$80.00

$30.00

$48.00

$281.00

$84.00

$208.00

$60.00

$20.00

$39.00

$99.00

NC

NC

$92.00

NC

NC

$93.00

NC

NC

$78.00

NC

NC

$77.00

MRA

$93.00

NC

NC

$93.00

NC

NC

$341.00

$102.00

$236.00

$128.00



$202.00

$71.00

$130.00

$295.00

$106.00

$185.00

$64.00

$45.00

$18.00

$78.00

$27.00

$50.00

$115.00

$43.00

$70.00

$187.00

$142.00

$53.00

$87.00

$181.00

$79.00

$99.00

$200.00

$48.00

$150.00

$137.00

$47.00

$88.00

BR

BR

BR

$87.00

$36.00

$52.00

$1,473.00

$415.00

$1,046.00

$106.00

$36.00

$69.00

MRA

$130.00

$264.00

$53.00

$209.00

$325.00

$79.00

$243.00

$1,287.00

$232.00

$1,046.00

77327

77327-26

77327-TC

77328

77328-26

77328-TC

77331

77331-26

77331-TC

77332

77332-26

77332-TC

77333

77333-26

77333-TC

77334

77310

77310-26

77310-TC

77315

77315-26

77315-TC

77321

77321-26

77321-TC

77326

77326-26

77326-TC

77299

77299-26

77299-TC

77300

77300-26

77300-TC

77301

77301-26

77301-TC

77305

77305-26

77305-TC

Radiology

CPT Code

77280-TC

77285

77285-26

77285-TC

77290

77290-26

77290-TC

77295

77295-26

77295-TC

Radiology

CPT Code

77334-26

77334-TC

77336

77370

77399

77399-26

77399-TC

77401

77402

77403

77404

77406

77407

77408

77409

77411

77412

77413

77414

77416

77417

77418

77427

77431

77432

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

BR

$196.00

$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

$166.00

$95.00

$417.00

$527.00

$106.00

$417.00

BR

BR

BR

BR

BR

BR

$66.00

$66.00

$78.00

$78.00

$78.00

$78.00

$87.00

$87.00

$87.00

$87.00

$21.00

$609.00

MRA

$63.00

$121.00

$111.00

$130.00

BR

BR

BR

$66.00

$66.00

$66.00

77789-26

77789-TC

77790

77790-26

77790-TC

77799

77799-26

77799-TC

78000

78000-26

78000-TC

78001

78001-26

78001-TC

78003

78003-26

77781-26

77781-TC

77782

77782-26

77782-TC

77783

77783-26

77783-TC

77784

77784-26

77784-TC

77789

77763-26

77763-TC

77776

77776-26

77776-TC

77777

77777-26

77777-TC

77778

77778-26

77778-TC

77781

Radiology

CPT Code

77750

77750-26

77750-TC

77761

77761-26

77761-TC

77762

77762-26

77762-TC

77763

$46.00

$9.00

$36.00

$62.00

$12.00

$48.00

$54.00

$17.00

$57.00

$16.00

$72.00

$53.00

$18.00

BR

BR

BR

$85.00

$759.00

$890.00

$127.00

$759.00

$956.00

$189.00

$759.00

$1,055.00

$284.00

$759.00

$74.00

$435.00

$167.00

$316.00

$233.00

$82.00

$540.00

$378.00

$158.00

$764.00

$568.00

$192.00

$847.00

MRA

$299.00

$248.00

$49.00

$284.00

$188.00

$93.00

$427.00

$289.00

$135.00

$605.00



$106.00

$28.00

$77.00

$158.00

$39.00

$118.00

$194.00

$41.00

$152.00

$45.00

$9.00

$35.00

$108.00

$11.00

$96.00

$78.00

$35.00

$30.00

$5.00

$112.00

$36.00

$68.00

$242.00

$38.00

$202.00

BR

BR

BR

$114.00

$22.00

$90.00

$132.00

$34.00

$96.00

$173.00

$42.00

$130.00

$248.00

$44.00

$202.00

MRA

$36.00

$115.00

$24.00

$89.00

$122.00

$25.00

$96.00

$89.00

$19.00

$68.00

78102

78102-26

78102-TC

78103

78103-26

78103-TC

78104

78104-26

78104-TC

78110

78110-26

78110-TC

78111

78111-26

78111-TC

78120

78020

78020-26

78020-TC

78070

78070-26

78070-TC

78075

78075-26

78075-TC

78099

78099-26

78099-TC

78011

78011-26

78011-TC

78015

78015-26

78015-TC

78016

78016-26

78016-TC

78018

78018-26

78018-TC

Radiology

CPT Code

78003-TC

78006

78006-26

78006-TC

78007

78007-26

78007-TC

78010

78010-26

78010-TC

Radiology

CPT Code

78120-26

78120-TC

78121

78121-26

78121-TC

78122

78122-26

78122-TC

78130

78130-26

78130-TC

78135

78135-26

78135-TC

78140

78140-26

78140-TC

78160

78160-26

78160-TC

78162

78162-26

78162-TC

78170

78170-26

78170-TC

78172

78172-26

78172-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

$214.00

$307.00

$31.00

$274.00

$216.00

$49.00

$152.00

BR

BR

BR

$112.00

$22.00

$88.00

$135.00

$26.00

$108.00

$119.00

$220.00

$20.00

$198.00

BR

$27.00

BR

$110.00

$20.00

$88.00

$272.00

$57.00

$106.00

$216.00

$33.00

$182.00

$179.00

$31.00

$147.00

$155.00

$17.00

$137.00

$143.00

$23.00

MRA

$11.00

$65.00

$125.00

$16.00

$108.00

$196.00

$22.00

$171.00

$139.00

$32.00

78262-26

78262-TC

78264

78264-26

78264-TC

78267

78268

78270

78270-26

78270-TC

78271

78271-26

78271-TC

78272

78272-26

78272-TC

78231-26

78231-TC

78232

78232-26

78232-TC

78258

78258-26

78258-TC

78261

78261-26

78261-TC

78262

78216-26

78216-TC

78220

78220-26

78220-TC

78223

78223-26

78223-TC

78230

78230-26

78230-TC

78231

Radiology

CPT Code

78205

78205-26

78205-TC

78206

78206-26

78206-TC

78215

78215-26

78215-TC

78216

$35.00

$159.00

$195.00

$40.00

$154.00

BR

BR

$68.00

$10.00

$58.00

$72.00

$10.00

$61.00

$100.00

$14.00

$87.00

$27.00

$118.00

$157.00

$23.00

$132.00

$146.00

$38.00

$108.00

$190.00

$36.00

$152.00

$195.00

$29.00

$130.00

$165.00

$24.00

$139.00

$181.00

$43.00

$137.00

$106.00

$23.00

$82.00

$146.00

MRA

$259.00

$36.00

$220.00

$265.00

$46.00

$214.00

$135.00

$24.00

$109.00

$160.00



BR

BR

BR

BR

$23.00

BR

$126.00

$41.00

$84.00

$97.00

$28.00

$69.00

$187.00

$38.00

$148.00

$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

$45.00

$114.00

BR

BR

BR

$125.00

$32.00

$93.00

$181.00

$42.00

$137.00

$205.00

MRA

$234.00

$50.00

$182.00

BR

$19.00

BR

$149.00

$35.00

$113.00

$161.00

78399

78399-26

78399-TC

78414

78414-26

78414-TC

78428

78428-26

78428-TC

78445

78445-26

78445-TC

78455

78455-26

78455-TC

78456

78306-26

78306-TC

78315

78315-26

78315-TC

78320

78320-26

78320-TC

78350

78350-26

78350-TC

78351

78291-26

78291-TC

78299

78299-26

78299-TC

78300

78300-26

78300-TC

78305

78305-26

78305-TC

78306

Radiology

CPT Code

78278

78278-26

78278-TC

78282

78282-26

78282-TC

78290

78290-26

78290-TC

78291

Radiology

CPT Code

78456-26

78456-TC

78457

78457-26

78457-TC

78458

78458-26

78458-TC

78459

78459-26

78459-TC

78460

78460-26

78460-TC

78461

78461-26

78461-TC

78464

78464-26

78464-TC

78465

78465-26

78465-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

78478

78478-26

78478-TC

78480

78480-26

78480-TC

78481

78481-26

78481-TC

78483

78483-26

78483-TC

$206.00

$387.00

$75.00

$308.00

$91.00

$32.00

$58.00

$91.00

$32.00

$58.00

$248.00

$51.00

$195.00

$373.00

$77.00

$294.00

$441.00

$135.00

$36.00

$97.00

$180.00

$41.00

$137.00

$244.00

$47.00

$195.00

$259.00

$50.00

BR

$134.00

$44.00

$88.00

$294.00

$82.00

$213.00

$322.00

$56.00

$264.00

$519.00

$75.00

MRA

$49.00

$151.00

$140.00

$39.00

$99.00

$198.00

$46.00

$149.00

BR

$100.00

78591-26

78591-TC

78593

78593-26

78593-TC

78594

78594-26

78594-TC

78596

78596-26

78596-TC

78599

78599-26

78599-TC

78600

78600-26

78585-26

78585-TC

78586

78586-26

78586-TC

78587

78587-26

78587-TC

78588

78588-26

78588-TC

78591

78496-26

78496-TC

78499

78499-26

78499-TC

78580

78580-26

78580-TC

78584

78584-26

78584-TC

78585

Radiology

CPT Code

78491

78491-26

78491-TC

78492

78492-26

78492-TC

78494

78494-26

78494-TC

78496

$20.00

$106.00

$151.00

$24.00

$126.00

$214.00

$27.00

$186.00

$332.00

$65.00

$264.00

BR

BR

BR

$131.00

$22.00

$36.00

$133.00

$118.00

$20.00

$96.00

$131.00

$24.00

$105.00

$239.00

$53.00

$192.00

$128.00

$24.00

$66.00

BR

BR

BR

$167.00

$38.00

$128.00

$171.00

$50.00

$119.00

$171.00

MRA

BR

$85.00

BR

BR

$100.00

BR

$324.00

$59.00

$262.00

$92.00



$31.00

$173.00

$107.00

$27.00

$79.00

BR

BR

BR

$137.00

$22.00

$113.00

$158.00

$24.00

$133.00

$187.00

$38.00

$35.00

$188.00

$129.00

$32.00

$95.00

$158.00

$29.00

$128.00

$268.00

$46.00

$220.00

$206.00

$311.00

$64.00

$245.00

BR

BR

$74.00

$15.00

$59.00

$166.00

$21.00

$143.00

$223.00

MRA

$108.00

$154.00

$26.00

$126.00

$155.00

$27.00

$126.00

$221.00

$45.00

$177.00

78650-26

78650-TC

78660

78660-26

78660-TC

78699

78699-26

78699-TC

78700

78700-26

78700-TC

78701

78701-26

78701-TC

78704

78704-26

78630-26

78630-TC

78635

78635-26

78635-TC

78645

78645-26

78645-TC

78647

78647-26

78647-TC

78650

78607

78607-26

78607-TC

78608

78609

78610

78610-26

78610-TC

78615

78615-26

78615-TC

78630

Radiology

CPT Code

78600-TC

78601

78601-26

78601-TC

78605

78605-26

78605-TC

78606

78606-26

78606-TC

Radiology

CPT Code

78704-TC

78707

78707-26

78707-TC

78708

78708-26

78708-TC

78709

78709-26

78709-TC

78710

78710-26

78710-TC

78715

78715-26

78715-TC

78725

78725-26

78725-TC

78730

78730-26

78730-TC

78740

78740-26

78740-TC

78760

78760-26

78760-TC

78761

78761-26

78761-TC

78799

78799-26

78799-TC

78800

78800-26

78800-TC

78801

78801-26

78801-TC

78802

78802-26

78802-TC

78803

78803-26

78803-TC

78805

78805-26

78805-TC

78806

$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

$38.00

$126.00

$286.00

$109.00

$29.00

$79.00

$135.00

$34.00

$99.00

$157.00

$36.00

$119.00

BR

BR

BR

$256.00

$34.00

$220.00

$74.00

$15.00

$59.00

$87.00

$19.00

$66.00

$73.00

$18.00

$55.00

MRA

$147.00

$217.00

$49.00

$166.00

$231.00

$61.00

$166.00

$241.00

$68.00

$166.00

79100-26

79100-TC

79200

79200-26

79200-TC

79300

79300-26

79300-TC

79400

79400-26

79400-TC

79420

79420-26

79420-TC

79440

79440-26

79001-26

79001-TC

79020

79020-26

79020-TC

79030

79030-26

79030-TC

79035

79035-26

79035-TC

79100

78890-TC

78891

78891-26

78891-TC

78990

78999

78999-26

78999-TC

79000

79000-26

79000-TC

79001

Radiology

CPT Code

78806-26

78806-TC

78807

78807-26

78807-TC

78810

78810-26

78810-TC

78890

78890-26

$68.00

$97.00

$203.00

$102.00

$97.00

BR

$83.00

BR

$201.00

$101.00

$97.00

BR

$77.00

BR

$204.00

$104.00

$54.00

$48.00

$192.00

$92.00

$97.00

$208.00

$107.00

$97.00

$230.00

$129.00

$97.00

$168.00

$48.00

$104.00

$5.00

$97.00

BR

BR

BR

BR

$192.00

$92.00

$97.00

$104.00

MRA

$44.00

$241.00

$303.00

$57.00

$245.00

BR

$103.00

BR

$52.00

$3.00



Radiology

CPT Code

79440-TC

79900

79999

79999-26

79999-TC

MRA

$97.00

BR

BR

BR

BR



80103

80103-26

80103-TC

80150

80150-26

80150-TC

80152

80152-26

80152-TC

80154

80154-26

80154-TC

80156

80156-26

80076

80076-26

80076-TC

80100

80100-26

80100-TC

80101

80101-26

80101-TC

80102

80102-26

80102-TC

80055

80055-26

80055-TC

80061

80061-26

80061-TC

80069

80069-26

80069-TC

80074

80074-26

80074-TC

Pathology & Laboratory

CPT Code MRA

80048 $23.00

80048-26

80048-TC

80050

$4.00

$19.00

$45.00

80050-26

80050-TC

80051

80051-26

80051-TC

80053

80053-26

80053-TC

$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

$19.00

$26.00

$6.00

$20.00

$107.00

$43.00

$64.00

$12.00

$4.00

$7.00

$40.00

$13.00

$26.00

$43.00

$14.00

$29.00

$49.00

$15.00

$34.00

$35.00

$11.00

$18.00

$7.00

$11.00

$38.00

$11.00

$26.00

$13.00

$3.00

$9.00

$23.00

$6.00

$16.00


CPT Code MRA

80156-TC $23.00

80157

80157-26

80157-TC

80158

80158-26

80158-TC

80160

80160-26

80160-TC

80162

80162-26

80162-TC

80164

80164-26

80164-TC

80166

80166-26

80166-TC

80168

80168-26

80168-TC

80170

80170-26

80170-TC

80172

80172-26

80172-TC

80173

80173-26

80173-TC

80174

80174-26

80174-TC

80176

80176-26

80176-TC

80178

80178-26

80178-TC

80182

80182-26

80182-TC

80184

80184-26

80184-TC

80185

80185-26

80185-TC

80186

$22.00

$8.00

$14.00

$35.00

$12.00

$22.00

$35.00

$12.00

$22.00

$13.00

$3.00

$9.00

$43.00

$14.00

$29.00

$35.00

$10.00

$24.00

$43.00

$17.00

$25.00

$18.00

$6.00

$11.00

$44.00

$13.00

$32.00

$33.00

$11.00

$22.00

$41.00

$12.00

$29.00

$35.00

$11.00

$23.00

$17.00

$6.00

$11.00

$43.00

$14.00

$29.00

$34.00

$10.00

$23.00

$36.00

$10.00

$25.00

$38.00

CPT only © 2002 American Medical Association. All Rights Reserved.

80400-26

80400-TC

80402

80402-26

80402-TC

80406

80406-26

80406-TC

80408

80408-26

80408-TC

80410

80410-26

80410-TC

80200-26

80200-TC

80201

80201-26

80201-TC

80202

80202-26

80202-TC

80299

80299-26

80299-TC

80400

80194-26

80194-TC

80196

80196-26

80196-TC

80197

80197-26

80197-TC

80198

80198-26

80198-TC

80200


CPT Code MRA

80186-26 $11.00

80186-TC

80188

80188-26

$26.00

$35.00

$11.00

80188-TC

80190

80190-26

80190-TC

80192

80192-26

80192-TC

80194

$23.00

$41.00

$13.00

$28.00

$44.00

$17.00

$26.00

$33.00

$10.00

$22.00

$13.00

$3.00

$9.00

$34.00

$11.00

$22.00

$20.00

$5.00

$15.00

$24.00

$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

$7.00

$16.00

$33.00

$11.00

$21.00

$42.00

$14.00

$28.00

BR

BR

BR

$54.00

78


80432

80432-26

80432-TC

80434

80434-26

80434-TC

80435

80435-26

80435-TC

80436

80436-26

80436-TC

80438

80438-26

80424

80424-26

80424-TC

80426

80426-26

80426-TC

80428

80428-26

80428-TC

80430

80430-26

80430-TC

80417

80417-26

80417-TC

80418

80418-26

80418-TC

80420

80420-26

80420-TC

80422

80422-26

80422-TC


CPT Code MRA

80412 $533.00

80412-26

80412-TC

80414

$176.00

$355.00

$88.00

80414-26

80414-TC

80415

80415-26

80415-TC

80416

80416-26

80416-TC

$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

$33.00

$74.00

$62.00

$18.00

$43.00

$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

$94.00

$26.00

$67.00

$232.00

$54.00

$176.00

$93.00

$19.00

$73.00

$99.00

$24.00

$74.00


CPT Code MRA

80438-TC $56.00

80439

80439-26

80439-TC

80440

80440-26

80440-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

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

81025-TC

81050

81050-26

81050-TC

81099

81099-26

81099-TC

82000

82000-26

82000-TC

82003

$176.00

$33.00

$144.00

$188.00

$36.00

$151.00

$34.00

$34.00

BR

$72.00

$72.00

BR

$7.00

$3.00

$4.00

$7.00

$3.00

$4.00

$5.00

$3.00

$3.00

$5.00

$2.00

$3.00

$3.00

$1.00

$3.00

$5.00

$2.00

$4.00

$5.00

$3.00

$3.00

$8.00

$3.00

$5.00

$7.00

$4.00

$4.00

$33.00

$11.00

$21.00

BR

BR

BR

$24.00

$7.00

$17.00

$36.00


82085-26

82085-TC

82088

82088-26

82088-TC

82101

82101-26

82101-TC

82103

82103-26

82103-TC

82104

82104-26

82104-TC

82043-26

82043-TC

82044

82044-26

82044-TC

82055

82055-26

82055-TC

82075

82075-26

82075-TC

82085

82024-26

82024-TC

82030

82030-26

82030-TC

82040

82040-26

82040-TC

82042

82042-26

82042-TC

82043


CPT Code MRA

82003-26 $10.00

82003-TC

82009

82009-26

$25.00

$10.00

$3.00

82009-TC

82010

82010-26

82010-TC

82013

82013-26

82013-TC

82024

$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

$7.00

$17.00

$91.00

$28.00

$62.00

$59.00

$18.00

$41.00

$21.00

$7.00

$14.00

$22.00

$7.00

$15.00

$4.00

$10.00

$12.00

$4.00

$9.00

$33.00

$10.00

$22.00

$32.00

$10.00

$21.00

$24.00

79


82145

82145-26

82145-TC

82150

82150-26

82150-TC

82154

82154-26

82154-TC

82157

82157-26

82157-TC

82160

82160-26

82136

82136-26

82136-TC

82139

82139-26

82139-TC

82140

82140-26

82140-TC

82143

82143-26

82143-TC

82127

82127-26

82127-TC

82128

82128-26

82128-TC

82131

82131-26

82131-TC

82135

82135-26

82135-TC


CPT Code MRA

82105 $26.00

82105-26

82105-TC

82106

$8.00

$18.00

$26.00

82106-26

82106-TC

82108

82108-26

82108-TC

82120

82120-26

82120-TC

$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

$57.00

$13.00

$44.00

$41.00

$13.00

$28.00

$35.00

$10.00

$24.00

$16.00

$5.00

$11.00

$34.00

$13.00

$20.00

$57.00

$17.00

$40.00

$67.00

$21.00

$38.00

$14.00

$23.00

$38.00

$14.00

$23.00

$40.00

$12.00

$28.00

$28.00

$8.00

$19.00


CPT Code MRA

82160-TC $43.00

82163

82163-26

82163-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

82205

82205-26

82205-TC

82232

82232-26

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

82261

82261-26

82261-TC

82270

82270-26

82270-TC

82273

82273-26

82273-TC

82274

$42.00

$12.00

$31.00

$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

$34.00

$10.00

$23.00

$43.00

$14.00

$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

$38.00

$13.00

$24.00

$5.00

$2.00

$3.00

$8.00

$2.00

$6.00

BR


82365-26

82365-TC

82370

82370-26

82370-TC

82373

82373-26

82373-TC

82374

82374-26

82374-TC

82375

82375-26

82375-TC

82331-26

82331-TC

82340

82340-26

82340-TC

82355

82355-26

82355-TC

82360

82360-26

82360-TC

82365

82307-26

82307-TC

82308

82308-26

82308-TC

82310

82310-26

82310-TC

82330

82330-26

82330-TC

82331


CPT Code MRA

82274-26 BR

82274-TC

82286

82286-26

BR

$12.00

$3.00

82286-TC

82300

82300-26

82300-TC

82306

82306-26

82306-TC

82307

$8.00

$48.00

$15.00

$33.00

$79.00

$25.00

$52.00

$57.00

$19.00

$38.00

$62.00

$18.00

$43.00

$11.00

$3.00

$7.00

$37.00

$11.00

$25.00

$14.00

$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

$4.00

$10.00

$13.00

$4.00

$8.00

$31.00

$10.00

$20.00

$31.00

$10.00

$20.00

$31.00

80


82436

82436-26

82436-TC

82438

82438-26

82438-TC

82441

82441-26

82441-TC

82465

82465-26

82465-TC

82480

82480-26

82390

82390-26

82390-TC

82397

82397-26

82397-TC

82415

82415-26

82415-TC

82435

82435-26

82435-TC

82382

82382-26

82382-TC

82383

82383-26

82383-TC

82384

82384-26

82384-TC

82387

82387-26

82387-TC


CPT Code MRA

82376 $11.00

82376-26

82376-TC

82378

$3.00

$7.00

$31.00

82378-26

82378-TC

82379

82379-26

82379-TC

82380

82380-26

82380-TC

$8.00

$21.00

$38.00

$13.00

$24.00

$21.00

$6.00

$15.00

$38.00

$12.00

$25.00

$62.00

$18.00

$43.00

$62.00

$18.00

$43.00

$34.00

$10.00

$23.00

$14.00

$4.00

$10.00

$13.00

$4.00

$8.00

$16.00

$5.00

$11.00

$8.00

$2.00

$6.00

$23.00

$6.00

$24.00

$7.00

$17.00

$22.00

$7.00

$15.00

$28.00

$8.00

$19.00

$8.00

$2.00

$6.00


CPT Code MRA

82480-TC $17.00

82482

82482-26

82482-TC

82485

82485-26

82485-TC

82486

82486-26

82486-TC

82487

82487-26

82487-TC

82488

82488-26

82488-TC

82489

82489-26

82489-TC

82491

82491-26

82491-TC

82492

82492-26

82492-TC

82495

82495-26

82495-TC

82507

82507-26

82507-TC

82520

82520-26

82520-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

$23.00

$7.00

$15.00

$37.00

$8.00

$28.00

$42.00

$14.00

$27.00

$43.00

$14.00

$29.00

$57.00

$19.00

$38.00

$47.00

$15.00

$32.00

$58.00

$17.00

$41.00

$42.00

$13.00

$28.00

$48.00

$16.00

$32.00

$55.00

$16.00

$39.00

$26.00

$8.00

$18.00

$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


82585-26

82585-TC

82595

82595-26

82595-TC

82600

82600-26

82600-TC

82607

82607-26

82607-TC

82608

82608-26

82608-TC

82554-26

82554-TC

82565

82565-26

82565-TC

82570

82570-26

82570-TC

82575

82575-26

82575-TC

82585

82544-26

82544-TC

82550

82550-26

82550-TC

82552

82552-26

82552-TC

82553

82553-26

82553-TC

82554


CPT Code MRA

82540-26 $3.00

82540-TC

82541

82541-26

$6.00

$42.00

$13.00

82541-TC

82542

82542-26

82542-TC

82543

82543-26

82543-TC

82544

$28.00

$42.00

$13.00

$28.00

$42.00

$13.00

$28.00

$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

$3.00

$12.00

$31.00

$10.00

$21.00

$40.00

$12.00

$28.00

$38.00

$10.00

$27.00

$40.00

$13.00

$26.00

$6.00

$13.00

$13.00

$2.00

$11.00

$10.00

$2.00

$7.00

$25.00

$8.00

$17.00

$15.00

81


82658

82658-26

82658-TC

82664

82664-26

82664-TC

82666

82666-26

82666-TC

82668

82668-26

82668-TC

82670

82670-26

82651

82651-26

82651-TC

82652

82652-26

82652-TC

82654

82654-26

82654-TC

82657

82657-26

82657-TC

82634

82634-26

82634-TC

82638

82638-26

82638-TC

82646

82646-26

82646-TC

82649

82649-26

82649-TC


CPT Code MRA

82615 $17.00

82615-26

82615-TC

82626

$5.00

$12.00

$59.00

82626-26

82626-TC

82627

82627-26

82627-TC

82633

82633-26

82633-TC

$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

$37.00

$11.00

$25.00

$43.00

$17.00

$25.00

$42.00

$13.00

$28.00

$40.00

$13.00

$26.00

$58.00

$17.00

$41.00

$45.00

$14.00

$32.00

$61.00

$18.00

$43.00

$17.00

$25.00

$89.00

$25.00

$62.00

$37.00

$11.00

$25.00

$42.00

$13.00

$28.00


CPT Code MRA

82670-TC $42.00

82671

82671-26

82671-TC

82672

82672-26

82672-TC

82677

82677-26

82677-TC

82679

82679-26

82679-TC

82690

82690-26

82690-TC

82693

82693-26

82693-TC

82696

82696-26

82696-TC

82705

82705-26

82705-TC

82710

82710-26

82710-TC

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

82742

82742-26

82742-TC

82746

82746-26

82746-TC

82747

$61.00

$17.00

$43.00

$57.00

$16.00

$41.00

$52.00

$17.00

$35.00

$70.00

$20.00

$48.00

$53.00

$21.00

$32.00

$23.00

$7.00

$16.00

$57.00

$19.00

$38.00

$14.00

$6.00

$9.00

$42.00

$13.00

$29.00

$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

$42.00

$13.00

$29.00

$39.00

$13.00

$25.00

$29.00


82810-26

82810-TC

82820

82820-26

82820-TC

82926

82926-26

82926-TC

82928

82928-26

82928-TC

82938

82938-26

82938-TC

82787-26

82787-TC

82800

82800-26

82800-TC

82803

82803-26

82803-TC

82805

82805-26

82805-TC

82810

82775-26

82775-TC

82776

82776-26

82776-TC

82784

82784-26

82784-TC

82785

82785-26

82785-TC

82787


CPT Code MRA

82747-26 $10.00

82747-TC

82757

82757-26

$19.00

$36.00

$11.00

82757-TC

82759

82759-26

82759-TC

82760

82760-26

82760-TC

82775

$24.00

$38.00

$12.00

$25.00

$26.00

$8.00

$18.00

$47.00

$14.00

$33.00

$14.00

$3.00

$11.00

$15.00

$5.00

$11.00

$33.00

$11.00

$21.00

$54.00

$8.00

$19.00

$16.00

$5.00

$11.00

$20.00

$5.00

$15.00

$12.00

$4.00

$7.00

$48.00

$16.00

$32.00

$17.00

$37.00

$22.00

$6.00

$16.00

$53.00

$16.00

$37.00

$36.00

$10.00

$24.00

$28.00

82


82962

82962-26

82962-TC

82963

82963-26

82963-TC

82965

82965-26

82965-TC

82975

82975-26

82975-TC

82977

82977-26

82952

82952-26

82952-TC

82953

82953-26

82953-TC

82955

82955-26

82955-TC

82960

82960-26

82960-TC

82947

82947-26

82947-TC

82948

82948-26

82948-TC

82950

82950-26

82950-TC

82951

82951-26

82951-TC


CPT Code MRA

82941 $47.00

82941-26

82941-TC

82943

$15.00

$32.00

$38.00

82943-26

82943-TC

82945

82945-26

82945-TC

82946

82946-26

82946-TC

$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

$7.00

$22.00

$7.00

$15.00

$5.00

$1.00

$4.00

$54.00

$17.00

$37.00

$16.00

$5.00

$11.00

$28.00

$8.00

$19.00

$16.00

$4.00

$11.00

$3.00

$7.00

$41.00

$14.00

$26.00

$25.00

$7.00

$18.00

$14.00

$4.00

$10.00


CPT Code MRA

82977-TC $12.00

82978

82978-26

82978-TC

82979

82979-26

82979-TC

82980

82980-26

82980-TC

82985

82985-26

82985-TC

83001

83001-26

83001-TC

83002

83002-26

83002-TC

83003

83003-26

83003-TC

83008

83008-26

83008-TC

83010

83010-26

83010-TC

83012

83012-26

83012-TC

83013

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

83026

$25.00

$7.00

$18.00

$18.00

$5.00

$13.00

$15.00

$3.00

$11.00

$41.00

$12.00

$29.00

$40.00

$12.00

$28.00

$42.00

$13.00

$29.00

$36.00

$10.00

$25.00

$34.00

$10.00

$23.00

$26.00

$8.00

$18.00

$36.00

$14.00

$21.00

$133.00

$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

$8.00


83070-26

83070-TC

83071

83071-26

83071-TC

83080

83080-26

83080-TC

83088

83088-26

83088-TC

83090

83090-26

83090-TC

83060-26

83060-TC

83065

83065-26

83065-TC

83068

83068-26

83068-TC

83069

83069-26

83069-TC

83070

83045-26

83045-TC

83050

83050-26

83050-TC

83051

83051-26

83051-TC

83055

83055-26

83055-TC

83060


CPT Code MRA

83026-26 $5.00

83026-TC

83030

83030-26

$3.00

$18.00

$6.00

83030-TC

83033

83033-26

83033-TC

83036

83036-26

83036-TC

83045

$12.00

$15.00

$4.00

$11.00

$15.00

$5.00

$10.00

$13.00

$4.00

$8.00

$16.00

$5.00

$11.00

$16.00

$5.00

$11.00

$13.00

$4.00

$8.00

$22.00

$4.00

$8.00

$18.00

$5.00

$13.00

$38.00

$11.00

$26.00

$59.00

$18.00

$41.00

$38.00

$13.00

$25.00

$6.00

$16.00

$18.00

$6.00

$12.00

$20.00

$5.00

$15.00

$11.00

$3.00

$7.00

$13.00

83


83527

83527-26

83527-TC

83528

83528-26

83528-TC

83540

83540-26

83540-TC

83550

83550-26

83550-TC

83570

83570-26

83518

83518-26

83518-TC

83519

83519-26

83519-TC

83520

83520-26

83520-TC

83525

83525-26

83525-TC

83499

83499-26

83499-TC

83500

83500-26

83500-TC

83505

83505-26

83505-TC

83516

83516-26

83516-TC


CPT Code MRA

83150 $49.00

83150-26

83150-TC

83491

$16.00

$33.00

$37.00

83491-26

83491-TC

83497

83497-26

83497-TC

83498

83498-26

83498-TC

$11.00

$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

$26.00

$8.00

$18.00

$35.00

$11.00

$23.00

$43.00

$14.00

$29.00

$16.00

$3.00

$13.00

$20.00

$5.00

$15.00

$23.00

$7.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$20.00

$6.00

$14.00

$31.00

$8.00

$21.00


CPT Code MRA

83570-TC $16.00

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

83715

83715-26

83715-TC

83716

83716-26

83716-TC

83718

83718-26

83718-TC

83719

83719-26

83719-TC

83721

83721-26

83721-TC

83727

83727-26

83727-TC

83735

$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

$21.00

$5.00

$16.00

$54.00

$19.00

$35.00

$16.00

$5.00

$11.00

$42.00

$14.00

$28.00

$16.00

$5.00

$11.00

$43.00

$14.00

$29.00

$15.00


83866-26

83866-TC

83872

83872-26

83872-TC

83873

83873-26

83873-TC

83874

83874-26

83874-TC

83880

83880-26

83880-TC

83840-26

83840-TC

83857

83857-26

83857-TC

83858

83858-26

83858-TC

83864

83864-26

83864-TC

83866

83789-26

83789-TC

83805

83805-26

83805-TC

83825

83825-26

83825-TC

83835

83835-26

83835-TC

83840


CPT Code MRA

83735-26 $5.00

83735-TC

83775

83775-26

$10.00

$17.00

$5.00

83775-TC

83785

83785-26

83785-TC

83788

83788-26

83788-TC

83789

$12.00

$58.00

$17.00

$41.00

$39.00

$13.00

$25.00

$39.00

$13.00

$25.00

$44.00

$15.00

$29.00

$34.00

$11.00

$22.00

$41.00

$12.00

$29.00

$42.00

$7.00

$19.00

$13.00

$4.00

$8.00

$54.00

$18.00

$36.00

$25.00

$8.00

$17.00

BR

BR

BR

$14.00

$28.00

$26.00

$8.00

$18.00

$37.00

$12.00

$24.00

$32.00

$8.00

$22.00

$26.00

84


83902

83902-26

83902-TC

83903

83903-26

83903-TC

83904

83904-26

83904-TC

83905

83905-26

83905-TC

83906

83906-26

83896

83896-26

83896-TC

83897

83897-26

83897-TC

83898

83898-26

83898-TC

83901

83901-26

83901-TC

83891

83891-26

83891-TC

83892

83892-26

83892-TC

83893

83893-26

83893-TC

83894

83894-26

83894-TC


CPT Code MRA

83883 $11.00

83883-26

83883-TC

83885

$3.00

$7.00

$45.00

83885-26

83885-TC

83887

83887-26

83887-TC

83890

83890-26

83890-TC

$14.00

$32.00

$58.00

$17.00

$41.00

$7.00

$2.00

$5.00

$7.00

$2.00

$5.00

$7.00

$2.00

$5.00

$7.00

$2.00

$5.00

$7.00

$2.00

$5.00

$38.00

$13.00

$24.00

$44.00

$14.00

$29.00

$44.00

$14.00

$29.00

$44.00

$14.00

$29.00

$44.00

$14.00

$7.00

$2.00

$5.00

$9.00

$3.00

$5.00

$43.00

$14.00

$29.00

$44.00

$14.00

$29.00


CPT Code MRA

83906-TC $29.00

83912

83912-26

83912-TC

83915

83915-26

83915-TC

83916

83916-26

83916-TC

83918

83918-26

83918-TC

83919

83919-26

83919-TC

83921

83921-26

83921-TC

83925

83925-26

83925-TC

83930

83930-26

83930-TC

83935

83935-26

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

83992

83992-26

83992-TC

84022

84022-26

84022-TC

84030

$39.00

$11.00

$28.00

$31.00

$10.00

$20.00

$54.00

$18.00

$36.00

$41.00

$12.00

$29.00

$42.00

$12.00

$29.00

$37.00

$12.00

$25.00

$13.00

$3.00

$9.00

$11.00

$3.00

$7.00

$17.00

$5.00

$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

$40.00

$12.00

$28.00

$41.00

$13.00

$28.00

$11.00


84105-26

84105-TC

84106

84106-26

84106-TC

84110

84110-26

84110-TC

84119

84119-26

84119-TC

84120

84120-26

84120-TC

84081-26

84081-TC

84085

84085-26

84085-TC

84087

84087-26

84087-TC

84100

84100-26

84100-TC

84105

84066-26

84066-TC

84075

84075-26

84075-TC

84078

84078-26

84078-TC

84080

84080-26

84080-TC

84081


CPT Code MRA

84030-26 $3.00

84030-TC

84035

84035-26

$7.00

$12.00

$3.00

84035-TC

84060

84060-26

84060-TC

84061

84061-26

84061-TC

84066

$8.00

$20.00

$6.00

$14.00

$14.00

$4.00

$10.00

$18.00

$6.00

$12.00

$12.00

$3.00

$8.00

$19.00

$5.00

$14.00

$36.00

$11.00

$24.00

$45.00

$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

$15.00

$31.00

$15.00

$5.00

$10.00

$25.00

$7.00

$18.00

$11.00

$3.00

$7.00

$11.00

85


84152

84152-26

84152-TC

84153

84153-26

84153-TC

84154

84154-26

84154-TC

84155

84155-26

84155-TC

84160

84160-26

84143

84143-26

84143-TC

84144

84144-26

84144-TC

84146

84146-26

84146-TC

84150

84150-26

84150-TC

84134

84134-26

84134-TC

84135

84135-26

84135-TC

84138

84138-26

84138-TC

84140

84140-26

84140-TC


CPT Code MRA

84126 $71.00

84126-26

84126-TC

84127

$20.00

$49.00

$18.00

84127-26

84127-TC

84132

84132-26

84132-TC

84133

84133-26

84133-TC

$6.00

$12.00

$11.00

$3.00

$7.00

$11.00

$3.00

$7.00

$24.00

$7.00

$17.00

$57.00

$19.00

$38.00

$56.00

$18.00

$38.00

$41.00

$8.00

$33.00

$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

$2.00

$62.00

$20.00

$41.00

$38.00

$7.00

$31.00

$53.00

$17.00

$36.00

$69.00

$20.00

$47.00


CPT Code MRA

84160-TC $2.00

84165

84165-26

84165-TC

84181

84181-26

84181-TC

84182

84182-26

84182-TC

84202

84202-26

84202-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

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

84252

84252-26

84252-TC

84255

$24.00

$8.00

$16.00

$29.00

$10.00

$19.00

$33.00

$11.00

$21.00

$39.00

$13.00

$25.00

$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

$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

$47.00

$14.00

$33.00

$58.00


84375-26

84375-TC

84376

84376-26

84376-TC

84377

84377-26

84377-TC

84378

84378-26

84378-TC

84379

84379-26

84379-TC

84305-26

84305-TC

84307

84307-26

84307-TC

84311

84311-26

84311-TC

84315

84315-26

84315-TC

84375

84285-26

84285-TC

84295

84295-26

84295-TC

84300

84300-26

84300-TC

84302

84302-26

84302-TC

84305


CPT Code MRA

84255-26 $17.00

84255-TC

84260

84260-26

$41.00

$54.00

$16.00

84260-TC

84270

84270-26

84270-TC

84275

84275-26

84275-TC

84285

$38.00

$36.00

$11.00

$24.00

$37.00

$11.00

$25.00

$59.00

$17.00

$42.00

$10.00

$3.00

$6.00

$10.00

$3.00

$6.00

BR

BR

BR

$34.00

$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

$11.00

$22.00

$26.00

$8.00

$18.00

$11.00

$3.00

$7.00

$5.00

$2.00

$3.00

$37.00

86


84446

84446-26

84446-TC

84449

84449-26

84449-TC

84450

84450-26

84450-TC

84460

84460-26

84460-TC

84466

84466-26

84439

84439-26

84439-TC

84442

84442-26

84442-TC

84443

84443-26

84443-TC

84445

84445-26

84445-TC

84430

84430-26

84430-TC

84432

84432-26

84432-TC

84436

84436-26

84436-TC

84437

84437-26

84437-TC


CPT Code MRA

84392 $8.00

84392-26

84392-TC

84402

$2.00

$6.00

$72.00

84402-26

84402-TC

84403

84403-26

84403-TC

84425

84425-26

84425-TC

$21.00

$49.00

$67.00

$19.00

$45.00

$54.00

$17.00

$37.00

$31.00

$10.00

$20.00

$28.00

$8.00

$19.00

$14.00

$3.00

$11.00

$13.00

$4.00

$8.00

$35.00

$11.00

$23.00

$38.00

$13.00

$24.00

$11.00

$3.00

$7.00

$13.00

$4.00

$8.00

$22.00

$7.00

$16.00

$4.00

$12.00

$25.00

$6.00

$19.00

$32.00

$7.00

$23.00

$98.00

$29.00

$69.00


CPT Code MRA

84466-TC $15.00

84478

84478-26

84478-TC

84479

84479-26

84479-TC

84480

84480-26

84480-TC

84481

84481-26

84481-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

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

84550

84550-26

84550-TC

84560

$12.00

$3.00

$8.00

$15.00

$5.00

$10.00

$20.00

$6.00

$14.00

$33.00

$10.00

$22.00

$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

$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

$12.00

$4.00

$7.00

$12.00


84620-26

84620-TC

84630

84630-26

84630-TC

84681

84681-26

84681-TC

84702

84702-26

84702-TC

84703

84703-26

84703-TC

84590-26

84590-TC

84591

84591-26

84591-TC

84597

84597-26

84597-TC

84600

84600-26

84600-TC

84620

84583-26

84583-TC

84585

84585-26

84585-TC

84586

84586-26

84586-TC

84588

84588-26

84588-TC

84590


CPT Code MRA

84560-26 $3.00

84560-TC

84577

84577-26

$8.00

$34.00

$11.00

84577-TC

84578

84578-26

84578-TC

84580

84580-26

84580-TC

84583

$22.00

$7.00

$2.00

$5.00

$17.00

$5.00

$12.00

$11.00

$3.00

$7.00

$36.00

$11.00

$24.00

$42.00

$14.00

$27.00

$73.00

$23.00

$47.00

$33.00

$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

$11.00

$21.00

$26.00

$9.00

$18.00

$37.00

$11.00

$25.00

$43.00

$13.00

$31.00

$29.00

87


85032

85032-26

85032-TC

85041

85041-26

85041-TC

85044

85044-26

85044-TC

85045

85045-26

85045-TC

85046

85046-26

85014

85014-26

85014-TC

85018

85018-26

85018-TC

85025

85025-26

85025-TC

85027

85027-26

85027-TC

85007

85007-26

85007-TC

85008

85008-26

85008-TC

85009

85009-26

85009-TC

85013

85013-26

85013-TC


CPT Code MRA

84830 $17.00

84830-26

84830-TC

84999

$5.00

$12.00

BR

84999-26

84999-TC

85002

85002-26

85002-TC

85004

85004-26

85004-TC

BR

BR

$10.00

$3.00

$6.00

BR

BR

BR

$6.00

$3.00

$4.00

$5.00

$2.00

$3.00

$8.00

$3.00

$5.00

$3.00

$1.00

$2.00

BR

BR

BR

$7.00

$3.00

$4.00

$10.00

$3.00

$6.00

$6.00

$2.00

$4.00

$13.00

$4.00

$4.00

$1.00

$3.00

$5.00

$2.00

$3.00

$20.00

$6.00

$14.00

$15.00

$5.00

$10.00


CPT Code MRA

85046-TC $9.00

85048

85048-26

85048-TC

85049

85049-26

85049-TC

85060

85060-26

85060-TC

85097

85097-26

85097-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

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

85250

85250-26

85250-TC

85260

$7.00

$3.00

$4.00

BR

BR

BR

$25.00

$7.00

$18.00

$59.00

$59.00

BR

$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

$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

$49.00

$14.00

$35.00

$49.00


85306-26

85306-TC

85307

85307-26

85307-TC

85335

85335-26

85335-TC

85337

85337-26

85337-TC

85345

85345-26

85345-TC

85301-26

85301-TC

85302

85302-26

85302-TC

85303

85303-26

85303-TC

85305

85305-26

85305-TC

85306

85291-26

85291-TC

85292

85292-26

85292-TC

85293

85293-26

85293-TC

85300

85300-26

85300-TC

85301


CPT Code MRA

85260-26 $14.00

85260-TC

85270

85270-26

$35.00

$49.00

$14.00

85270-TC

85280

85280-26

85280-TC

85290

85290-26

85290-TC

85291

$35.00

$49.00

$14.00

$35.00

$44.00

$13.00

$32.00

$20.00

$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

$35.00

$12.00

$23.00

$21.00

$7.00

$14.00

$19.00

$6.00

$13.00

$10.00

$2.00

$7.00

$10.00

$19.00

$33.00

$11.00

$21.00

$26.00

$8.00

$18.00

$21.00

$7.00

$14.00

$29.00

88


85400

85400-26

85400-TC

85410

85410-26

85410-TC

85415

85415-26

85415-TC

85420

85420-26

85420-TC

85421

85421-26

85380

85380-26

85380-TC

85384

85384-26

85384-TC

85385

85385-26

85385-TC

85390

85390-26

85390-TC

85366

85366-26

85366-TC

85370

85370-26

85370-TC

85378

85378-26

85378-TC

85379

85379-26

85379-TC


CPT Code MRA

85347 $8.00

85347-26

85347-TC

85348

$2.00

$6.00

$10.00

85348-26

85348-TC

85360

85360-26

85360-TC

85362

85362-26

85362-TC

$3.00

$6.00

$16.00

$4.00

$12.00

$18.00

$7.00

$11.00

$13.00

$3.00

$10.00

$20.00

$5.00

$15.00

$13.00

$4.00

$8.00

$18.00

$6.00

$12.00

$12.00

$3.00

$8.00

$12.00

$3.00

$8.00

$28.00

$10.00

$18.00

$16.00

$3.00

$13.00

$39.00

$12.00

BR

BR

BR

$11.00

$3.00

$7.00

$16.00

$5.00

$11.00

$10.00

$2.00

$7.00


CPT Code MRA

85421-TC $26.00

85441

85441-26

85441-TC

85445

85445-26

85445-TC

85460

85460-26

85460-TC

85461

85461-26

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

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

85576-TC

85597

85597-26

85597-TC

85610

$7.00

$2.00

$5.00

$16.00

$5.00

$11.00

$15.00

$4.00

$11.00

$12.00

$3.00

$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

$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

$16.00

$32.00

$10.00

$21.00

$6.00


85732-26

85732-TC

85810

85810-26

85810-TC

85999

85999-26

85999-TC

86000

86000-26

86000-TC

86001

86001-26

86001-TC

85670-26

85670-TC

85675

85675-26

85675-TC

85705

85705-26

85705-TC

85730

85730-26

85730-TC

85732

85635-26

85635-TC

85651

85651-26

85651-TC

85652

85652-26

85652-TC

85660

85660-26

85660-TC

85670


CPT Code MRA

85610-26 $3.00

85610-TC

85611

85611-26

$4.00

$6.00

$2.00

85611-TC

85612

85612-26

85612-TC

85613

85613-26

85613-TC

85635

$4.00

$22.00

$6.00

$16.00

$15.00

$4.00

$11.00

$26.00

$8.00

$18.00

$8.00

$2.00

$6.00

$8.00

$2.00

$6.00

$10.00

$3.00

$6.00

$13.00

$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

$3.00

$10.00

$13.00

$4.00

$8.00

$13.00

$4.00

$8.00

$11.00

$3.00

$7.00

$17.00

89


86140

86140-26

86140-TC

86141

86141-26

86141-TC

86146

86146-26

86146-TC

86147

86147-26

86147-TC

86148

86148-26

86063

86063-26

86063-TC

86077

86077-26

86077-TC

86078

86078-26

86078-TC

86079

86079-26

86079-TC

86023

86023-26

86023-TC

86038

86038-26

86038-TC

86039

86039-26

86039-TC

86060

86060-26

86060-TC


CPT Code MRA

86003 $6.00

86003-26

86003-TC

86005

$2.00

$3.00

$11.00

86005-26

86005-TC

86021

86021-26

86021-TC

86022

86022-26

86022-TC

$4.00

$6.00

$41.00

$12.00

$29.00

$57.00

$18.00

$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

$14.00

$4.00

$10.00

BR

BR

BR

$58.00

$19.00

$39.00

$53.00

$16.00

$36.00

$59.00

$21.00

$21.00

$6.00

$15.00

$91.00

$26.00

$64.00

$91.00

$26.00

$64.00

$79.00

$25.00

$52.00


CPT Code MRA

86148-TC $38.00

86155

86155-26

86155-TC

86156

86156-26

86156-TC

86157

86157-26

86157-TC

86160

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

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

86256-26

86256-TC

86277

86277-26

86277-TC

86280

$26.00

$8.00

$18.00

$11.00

$3.00

$7.00

$13.00

$4.00

$8.00

$21.00

$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

$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

$8.00

$17.00

$41.00

$14.00

$26.00

$15.00


86325-26

86325-TC

86327

86327-26

86327-TC

86329

86329-26

86329-TC

86331

86331-26

86331-TC

86332

86332-26

86332-TC

86316-26

86316-TC

86317

86317-26

86317-TC

86318

86318-26

86318-TC

86320

86320-26

86320-TC

86325

86304-26

86304-TC

86308

86308-26

86308-TC

86309

86309-26

86309-TC

86310

86310-26

86310-TC

86316


CPT Code MRA

86280-26 $3.00

86280-TC

86294

86294-26

$12.00

BR

BR

86294-TC

86300

86300-26

86300-TC

86301

86301-26

86301-TC

86304

BR

$47.00

$15.00

$32.00

$47.00

$15.00

$32.00

$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

$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

$11.00

$25.00

$31.00

$10.00

$20.00

$23.00

$10.00

$14.00

$49.00

$19.00

$29.00

$49.00

90


86378

86378-26

86378-TC

86382

86382-26

86382-TC

86384

86384-26

86384-TC

86403

86403-26

86403-TC

86406

86406-26

86359

86359-26

86359-TC

86360

86360-26

86360-TC

86361

86361-26

86361-TC

86376

86376-26

86376-TC

86341

86341-26

86341-TC

86343

86343-26

86343-TC

86344

86344-26

86344-TC

86353

86353-26

86353-TC


CPT Code MRA

86334 $65.00

86334-26

86334-TC

86336

$18.00

$45.00

BR

86336-26

86336-TC

86337

86337-26

86337-TC

86340

86340-26

86340-TC

BR

BR

$54.00

$18.00

$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

$45.00

$15.00

$31.00

$45.00

$14.00

$32.00

$24.00

$8.00

$16.00

$18.00

$3.00

$14.00

$21.00

$5.00

$61.00

$19.00

$41.00

$99.00

$33.00

$67.00

$66.00

$21.00

$43.00

$35.00

$11.00

$23.00


CPT Code MRA

86406-TC $16.00

86430

86430-26

86430-TC

86431

86431-26

86431-TC

86485

86485-26

86485-TC

86490

86490-26

86490-TC

86510

86510-26

86510-TC

86580

86580-26

86580-TC

86585

86585-26

86585-TC

86586

86586-26

86586-TC

86590

86590-26

86590-TC

86592

86592-26

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

86611

86611-26

86611-TC

86612

$13.00

$4.00

$8.00

$17.00

$6.00

$11.00

$13.00

$4.00

$8.00

$17.00

$5.00

$12.00

$13.00

$4.00

$8.00

$13.00

$4.00

$8.00

$10.00

$3.00

$6.00

BR

BR

BR

$18.00

$6.00

$12.00

$8.00

$2.00

$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

$23.00

$8.00

$15.00

$21.00


86641-26

86641-TC

86644

86644-26

86644-TC

86645

86645-26

86645-TC

86648

86648-26

86648-TC

86651

86651-26

86651-TC

86631-26

86631-TC

86632

86632-26

86632-TC

86635

86635-26

86635-TC

86638

86638-26

86638-TC

86641

86619-26

86619-TC

86622

86622-26

86622-TC

86625

86625-26

86625-TC

86628

86628-26

86628-TC

86631


CPT Code MRA

86612-26 $6.00

86612-TC

86615

86615-26

$15.00

$21.00

$6.00

86615-TC

86617

86617-26

86617-TC

86618

86618-26

86618-TC

86619

$15.00

$29.00

$10.00

$19.00

$26.00

$8.00

$18.00

$21.00

$6.00

$15.00

$16.00

$5.00

$11.00

$21.00

$6.00

$15.00

$20.00

$6.00

$14.00

$20.00

$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

$6.00

$14.00

$20.00

$6.00

$14.00

$18.00

$5.00

$13.00

$20.00

$6.00

$14.00

$21.00

91


86682

86682-26

86682-TC

86684

86684-26

86684-TC

86687

86687-26

86687-TC

86688

86688-26

86688-TC

86689

86689-26

86668

86668-26

86668-TC

86671

86671-26

86671-TC

86674

86674-26

86674-TC

86677

86677-26

86677-TC

86663

86663-26

86663-TC

86664

86664-26

86664-TC

86665

86665-26

86665-TC

86666

86666-26

86666-TC


CPT Code MRA

86652 $21.00

86652-26

86652-TC

86653

$7.00

$14.00

$21.00

86653-26

86653-TC

86654

86654-26

86654-TC

86658

86658-26

86658-TC

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$53.00

$17.00

$36.00

$29.00

$10.00

$19.00

$23.00

$8.00

$15.00

$21.00

$7.00

$14.00

$24.00

$8.00

$16.00

$22.00

$7.00

$16.00

$20.00

$7.00

$14.00

$25.00

$8.00

$17.00

$5.00

$12.00

$20.00

$6.00

$14.00

$23.00

$7.00

$16.00

$24.00

$8.00

$16.00


CPT Code MRA

86689-TC $17.00

86692

86692-26

86692-TC

86694

86694-26

86694-TC

86695

86695-26

86695-TC

86696

86696-26

86696-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

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

86713

86713-26

86713-TC

86717

$22.00

$7.00

$15.00

$22.00

$7.00

$15.00

$21.00

$7.00

$14.00

$44.00

$14.00

$30.00

$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

$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

$23.00

$7.00

$16.00

$20.00


86753-26

86753-TC

86756

86756-26

86756-TC

86757

86757-26

86757-TC

86759

86759-26

86759-TC

86762

86762-26

86762-TC

86741-26

86741-TC

86744

86744-26

86744-TC

86747

86747-26

86747-TC

86750

86750-26

86750-TC

86753

86729-26

86729-TC

86732

86732-26

86732-TC

86735

86735-26

86735-TC

86738

86738-26

86738-TC

86741


CPT Code MRA

86717-26 $6.00

86717-TC

86720

86720-26

$14.00

$21.00

$7.00

86720-TC

86723

86723-26

86723-TC

86727

86727-26

86727-TC

86729

$14.00

$21.00

$7.00

$14.00

$20.00

$6.00

$14.00

$19.00

$6.00

$13.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$21.00

$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

$7.00

$14.00

$21.00

$7.00

$14.00

$23.00

$7.00

$16.00

$21.00

$7.00

$14.00

$20.00

92


86803

86803-26

86803-TC

86804

86804-26

86804-TC

86805

86805-26

86805-TC

86806

86806-26

86806-TC

86807

86807-26

86787

86787-26

86787-TC

86790

86790-26

86790-TC

86793

86793-26

86793-TC

86800

86800-26

86800-TC

86777

86777-26

86777-TC

86778

86778-26

86778-TC

86781

86781-26

86781-TC

86784

86784-26

86784-TC


CPT Code MRA

86765 $20.00

86765-26

86765-TC

86768

$6.00

$14.00

$21.00

86768-26

86768-TC

86771

86771-26

86771-TC

86774

86774-26

86774-TC

$7.00

$14.00

$21.00

$7.00

$14.00

$23.00

$7.00

$16.00

$22.00

$7.00

$15.00

$23.00

$7.00

$16.00

$22.00

$7.00

$15.00

$21.00

$7.00

$14.00

$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

$21.00

$20.00

$6.00

$14.00

$21.00

$7.00

$14.00

$21.00

$7.00

$14.00

$26.00

$8.00

$18.00


CPT Code MRA

86807-TC $51.00

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

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

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

86900

$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

$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

$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

$10.00


86930-26

86930-TC

86931

86931-26

86931-TC

86932

86932-26

86932-TC

86940

86940-26

86940-TC

86941

86941-26

86941-TC

86920-26

86920-TC

86921

86921-26

86921-TC

86922

86922-26

86922-TC

86927

86927-26

86927-TC

86930

86905-26

86905-TC

86906

86906-26

86906-TC

86910

86910-26

86910-TC

86911

86911-26

86911-TC

86920


CPT Code MRA

86900-26 $3.00

86900-TC

86901

86901-26

$6.00

$10.00

$3.00

86901-TC

86903

86903-26

86903-TC

86904

86904-26

86904-TC

86905

$6.00

$15.00

$5.00

$10.00

$19.00

$6.00

$13.00

$7.00

$1.00

$6.00

$11.00

$3.00

$7.00

$83.00

$24.00

$57.00

$19.00

$6.00

$13.00

$19.00

$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

$3.00

$15.00

$23.00

$7.00

$16.00

$20.00

$6.00

$14.00

$21.00

$5.00

$16.00

$155.00

93


87001

87001-26

87001-TC

87003

87003-26

87003-TC

87015

87015-26

87015-TC

87040

87040-26

87040-TC

87045

87045-26

86977

86977-26

86977-TC

86978

86978-26

86978-TC

86985

86985-26

86985-TC

86999

86999-26

86999-TC

86971

86971-26

86971-TC

86972

86972-26

86972-TC

86975

86975-26

86975-TC

86976

86976-26

86976-TC


CPT Code MRA

86945 $35.00

86945-26

86945-TC

86950

$11.00

$23.00

$99.00

86950-26

86950-TC

86965

86965-26

86965-TC

86970

86970-26

86970-TC

$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

$16.00

$37.00

$53.00

$16.00

$37.00

$35.00

$11.00

$23.00

$40.00

$13.00

$26.00

$14.00

$5.00

$9.00

$18.00

$6.00

$12.00

$18.00

$6.00

$53.00

$16.00

$37.00

$65.00

$19.00

$44.00

$35.00

$12.00

$23.00

BR

BR

BR


CPT Code MRA

87045-TC $11.00

87046

87046-26

87046-TC

87070

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

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

87102-TC

87103

87103-26

87103-TC

87106

87106-26

87106-TC

87107

87107-26

87107-TC

87109

$5.00

$2.00

$3.00

$14.00

$4.00

$10.00

$11.00

$3.00

$8.00

$11.00

$3.00

$8.00

$18.00

$6.00

$12.00

$24.00

$8.00

$16.00

$16.00

$5.00

$11.00

$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

$14.00

$32.00

$11.00

$20.00

$25.00

$7.00

$18.00

$23.00

$8.00

$15.00

$26.00


87168-26

87168-TC

87169

87169-26

87169-TC

87172

87172-26

87172-TC

87176

87176-26

87176-TC

87177

87177-26

87177-TC

87152-26

87152-TC

87158

87158-26

87158-TC

87164

87164-26

87164-TC

87166

87166-26

87166-TC

87168

87140-26

87140-TC

87143

87143-26

87143-TC

87147

87147-26

87147-TC

87149

87149-26

87149-TC

87152


CPT Code MRA

87109-26 $8.00

87109-TC

87110

87110-26

$18.00

$23.00

$7.00

87110-TC

87116

87116-26

87116-TC

87118

87118-26

87118-TC

87140

$15.00

$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

$31.00

$12.00

$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

$4.00

$8.00

$5.00

$1.00

$3.00

$24.00

$8.00

$16.00

$24.00

$7.00

$17.00

$10.00

94


87220

87220-26

87220-TC

87230

87230-26

87230-TC

87250

87250-26

87250-TC

87252

87252-26

87252-TC

87253

87253-26

87205

87205-26

87205-TC

87206

87206-26

87206-TC

87207

87207-26

87207-TC

87210

87210-26

87210-TC

87187

87187-26

87187-TC

87188

87188-26

87188-TC

87190

87190-26

87190-TC

87197

87197-26

87197-TC


CPT Code MRA

87181 $13.00

87181-26

87181-TC

87184

$3.00

$8.00

$13.00

87184-26

87184-TC

87185

87185-26

87185-TC

87186

87186-26

87186-TC

$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

$10.00

$19.00

$12.00

$4.00

$7.00

$35.00

$11.00

$23.00

$33.00

$13.00

$19.00

$44.00

$14.00

$31.00

$33.00

$10.00

$11.00

$3.00

$7.00

$15.00

$3.00

$12.00

$10.00

$3.00

$6.00

$8.00

$2.00

$6.00


CPT Code MRA

87253-TC $22.00

87254

87254-26

87254-TC

87255

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

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

87277-TC

87278

87278-26

87278-TC

87279

87279-26

87279-TC

87280

87280-26

87280-TC

87281

$11.00

$3.00

$8.00

BR

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

$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

$19.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$27.00


87335-26

87335-TC

87336

87336-26

87336-TC

87337

87337-26

87337-TC

87338

87338-26

87338-TC

87339

87339-26

87339-TC

87324-26

87324-TC

87327

87327-26

87327-TC

87328

87328-26

87328-TC

87332

87332-26

87332-TC

87335

87299-26

87299-TC

87300

87300-26

87300-TC

87301

87301-26

87301-TC

87320

87320-26

87320-TC

87324


CPT Code MRA

87281-26 $9.00

87281-TC

87283

87283-26

$19.00

$27.00

$9.00

87283-TC

87285

87285-26

87285-TC

87290

87290-26

87290-TC

87299

$19.00

$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

$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

$8.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$26.00

95


87449

87449-26

87449-TC

87450

87450-26

87450-TC

87451

87451-26

87451-TC

87470

87470-26

87470-TC

87471

87471-26

87420

87420-26

87420-TC

87425

87425-26

87425-TC

87427

87427-26

87427-TC

87430

87430-26

87430-TC

87385

87385-26

87385-TC

87390

87390-26

87390-TC

87391

87391-26

87391-TC

87400

87400-26

87400-TC


CPT Code MRA

87340 $20.00

87340-26

87340-TC

87341

$6.00

$14.00

$23.00

87341-26

87341-TC

87350

87350-26

87350-TC

87380

87380-26

87380-TC

$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

$4.00

$9.00

$26.00

$8.00

$18.00

$21.00

$6.00

$15.00

$19.00

$7.00

$12.00

$42.00

$13.00

$28.00

$73.00

$23.00

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$27.00

$9.00

$19.00

$26.00

$8.00

$18.00


CPT Code MRA

87471-TC $48.00

87472

87472-26

87472-TC

87475

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

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

87492-TC

87495

87495-26

87495-TC

87496

87496-26

87496-TC

87497

87497-26

87497-TC

87510

$88.00

$28.00

$58.00

$40.00

$13.00

$26.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$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

$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


87528-26

87528-TC

87529

87529-26

87529-TC

87530

87530-26

87530-TC

87531

87531-26

87531-TC

87532

87532-26

87532-TC

87522-26

87522-TC

87525

87525-26

87525-TC

87526

87526-26

87526-TC

87527

87527-26

87527-TC

87528

87516-26

87516-TC

87517

87517-26

87517-TC

87520

87520-26

87520-TC

87521

87521-26

87521-TC

87522


CPT Code MRA

87510-26 $13.00

87510-TC

87511

87511-26

$28.00

$73.00

$23.00

87511-TC

87512

87512-26

87512-TC

87515

87515-26

87515-TC

87516

$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

$88.00

$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

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

96


87552

87552-26

87552-TC

87555

87555-26

87555-TC

87556

87556-26

87556-TC

87557

87557-26

87557-TC

87560

87560-26

87541

87541-26

87541-TC

87542

87542-26

87542-TC

87550

87550-26

87550-TC

87551

87551-26

87551-TC

87537

87537-26

87537-TC

87538

87538-26

87538-TC

87539

87539-26

87539-TC

87540

87540-26

87540-TC


CPT Code MRA

87533 $86.00

87533-26

87533-TC

87534

$28.00

$56.00

$42.00

87534-26

87534-TC

87535

87535-26

87535-TC

87536

87536-26

87536-TC

$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

$88.00

$28.00

$58.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00

$88.00

$28.00

$58.00

$42.00

$13.00

$73.00

$23.00

$48.00

$86.00

$28.00

$56.00

$42.00

$13.00

$28.00

$73.00

$23.00

$48.00


CPT Code MRA

87560-TC $28.00

87561

87561-26

87561-TC

87562

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

87592

87592-26

87592-TC

87620

87620-26

87620-TC

87621

87621-26

87621-TC

87622

87622-26

87622-TC

87650

87650-26

87650-TC

87651

87651-26

87651-TC

87652

87652-26

87652-TC

87797

87797-26

87797-TC

87798

87798-26

87798-TC

87799

$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

$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


87903-26

87903-TC

87904

87904-26

87904-TC

87999

87999-26

87999-TC

88000

88000-26

88000-TC

88005

88005-26

88005-TC

87880-26

87880-TC

87899

87899-26

87899-TC

87901

87901-26

87901-TC

87902

87902-26

87902-TC

87903

87803-26

87803-TC

87804

87804-26

87804-TC

87810

87810-26

87810-TC

87850

87850-26

87850-TC

87880


CPT Code MRA

87799-26 $28.00

87799-TC

87800

87800-26

$58.00

$46.00

$15.00

87800-TC

87801

87801-26

87801-TC

87802

87802-26

87802-TC

87803

$31.00

$81.00

$26.00

$54.00

BR

BR

BR

BR

BR

BR

BR

BR

BR

$26.00

$8.00

$18.00

$26.00

$8.00

$18.00

$26.00

$371.00

$755.00

$59.00

$20.00

$39.00

BR

BR

BR

$445.00

$445.00

BR

$500.00

$500.00

BR

$8.00

$18.00

$26.00

$8.00

$18.00

$594.00

$196.00

$398.00

BR

BR

BR

$1,126.00

97


88108

88108-26

88108-TC

88125

88125-26

88125-TC

88130

88130-26

88130-TC

88140

88140-26

88140-TC

88141

88141-26

88099

88099-26

88099-TC

88104

88104-26

88104-TC

88106

88106-26

88106-TC

88107

88107-26

88107-TC

88036

88036-26

88036-TC

88037

88037-26

88037-TC

88040

88040-26

88040-TC

88045

88045-26

88045-TC


CPT Code MRA

88007 $556.00

88007-26

88007-TC

88020

$556.00

BR

$556.00

88020-26

88020-TC

88025

88025-26

88025-TC

88027

88027-26

88027-TC

$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

$59.00

$47.00

$11.00

$70.00

$20.00

$48.00

$25.00

$7.00

$18.00

$18.00

$5.00

$13.00

$33.00

NC

BR

BR

BR

$49.00

$37.00

$10.00

$54.00

$16.00

$38.00

$74.00

$57.00

$15.00


CPT Code MRA

88141-TC NC

88142

88142-26

88142-TC

88143

88143-26

88143-TC

88147

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

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

88165-TC

88166

88166-26

88166-TC

88167

88167-26

88167-TC

88172

$82.00

$21.00

$59.00

$94.00

$33.00

$59.00

$82.00

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

$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

$38.00

$82.00

$21.00

$59.00

$87.00

$26.00

$59.00

$70.00


88302-26

88302-TC

88304

88304-26

88304-TC

88305

88305-26

88305-TC

88307

88307-26

88307-TC

88309

88309-26

88309-TC

88235-26

88235-TC

88240

88240-26

88240-TC

88241

88241-26

88241-TC

88300

88300-26

88300-TC

88302

88180-26

88180-TC

88182

88182-26

88182-TC

88199

88199-26

88199-TC

88233

88233-26

88233-TC

88235


CPT Code MRA

88172-26 $54.00

88172-TC

88173

88173-26

$14.00

$95.00

$95.00

88173-TC

88174

88174-26

88174-TC

88175

88175-26

88175-TC

88180

$26.00

BR

BR

BR

BR

BR

BR

$88.00

$33.00

$54.00

$88.00

$33.00

$54.00

BR

BR

BR

$243.00

$73.00

$170.00

$256.00

$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

$76.00

$177.00

$21.00

$6.00

$15.00

$21.00

$6.00

$15.00

$24.00

$19.00

$5.00

$53.00

98


88342

88342-26

88342-TC

88346

88346-26

88346-TC

88347

88347-26

88347-TC

88348

88348-26

88348-TC

88349

88349-26

88325

88325-26

88325-TC

88329

88329-26

88329-TC

88331

88331-26

88331-TC

88332

88332-26

88332-TC

88318

88318-26

88318-TC

88319

88319-26

88319-TC

88321

88321-26

88321-TC

88323

88323-26

88323-TC


CPT Code MRA

88311 $23.00

88311-26

88311-TC

88312

$19.00

$4.00

$23.00

88312-26

88312-TC

88313

88313-26

88313-TC

88314

88314-26

88314-TC

$7.00

$16.00

$23.00

$7.00

$16.00

$21.00

$6.00

$15.00

$33.00

$14.00

$18.00

$26.00

$13.00

$14.00

$43.00

$43.00

NC

$61.00

$61.00

NC

$53.00

$36.00

$17.00

$96.00

$66.00

$28.00

$133.00

$99.00

$33.00

$191.00

$145.00

$44.00

$191.00

$145.00

$54.00

$54.00

NC

$51.00

$51.00

NC

$102.00

$70.00

$33.00

$53.00

$36.00

$17.00


CPT Code MRA

88349-TC $44.00

88355

88355-26

88355-TC

88356

88356-26

88356-TC

88358

88358-26

88358-TC

88362

88362-26

88362-TC

88365

88365-26

88365-TC

88371

88371-26

88371-TC

88372

88372-26

88372-TC

88380

88380-26

88380-TC

88399

88399-26

88399-TC

88400

88400-26

88400-TC

89050

89050-26

89050-TC

89051

89051-26

89051-TC

89055

89055-26

89055-TC

89060

89060-26

89060-TC

89100

89100-26

89100-TC

89105

89105-26

89105-TC

89125

$108.00

$80.00

$26.00

$108.00

$80.00

$26.00

$108.00

$80.00

$26.00

BR

BR

BR

$24.00

$24.00

BR

$34.00

$10.00

$23.00

$38.00

$11.00

$26.00

BR

BR

BR

BR

BR

BR

$5.00

$2.00

$3.00

$10.00

$3.00

$6.00

$13.00

$4.00

$8.00

BR

BR

BR

$13.00

$5.00

$8.00

$51.00

$15.00

$36.00

$65.00

$19.00

$44.00

$14.00

89190-26

89190-TC

89350

89350-26

89350-TC

89355

89355-26

89355-TC

89360

89360-26

89360-TC

89365

89365-26

89365-TC

89399

89399-26

89399-TC

89136-26

89136-TC

89140

89140-26

89140-TC

89141

89141-26

89141-TC

89160

89160-26

89160-TC

89190


CPT Code MRA

89125-26 $4.00

89125-TC

89130

89130-26

$10.00

$44.00

$13.00

89130-TC

89132

89132-26

89132-TC

89135

89135-26

89135-TC

89136

$32.00

$20.00

$6.00

$14.00

$37.00

$11.00

$25.00

$43.00

$14.00

$29.00

$50.00

$16.00

$34.00

$56.00

$19.00

$37.00

$6.00

$2.00

$4.00

$10.00

$3.00

$6.00

$18.00

$6.00

$12.00

$10.00

$3.00

$6.00

$15.00

$4.00

$11.00

$24.00

$7.00

$17.00

BR

BR

BR



$96.00

$102.00

$144.00

$149.00

$73.00

$78.00

$103.00

$107.00

$146.00

$150.00

$85.00

$93.00

$110.00

$32.00

$32.00

$31.00

$94.00

$101.00

$144.00

$149.00

$69.00

$77.00

$101.00

$107.00

$143.00

$149.00

$64.00

$70.00

BR

$42.00

$20.00

$5.00

$15.00

$20.00

$6.00

BR

$140.00

$143.00

$62.00

$68.00

BR

BR

BR

BR

BR

BR

MRA

$4.00

$4.00

BR

BR

90828

90829

90845

90846

90847

90849

90853

90857

90818

90819

90821

90822

90823

90824

90826

90827

90806

90807

90808

90809

90810

90811

90812

90813

90814

90815

90816

90817

90749

90780

90781

90782

90783

90784

90788

90799

90801

90802

90804

90805

Medicine

CPT Code

90471

90472

90473

90474

90632

90636

90675

90703

90718

90746

Medicine

CPT Code

90862

90865

90870

90871

90875

90876

90880

90882

90885

90887

90889

90899

90901

90911

90921

90925

90935

90937

90939

90940

90945

90947

90997

90999

91000

91000-26

91000-TC

91010

91010-26

91010-TC

91011

91011-26

91011-TC

91012

91012-26

91012-TC

91020

91020-26

91020-TC

91030

91030-26

91030-TC

91032

91032-26

91032-TC

91033

91033-26

91033-TC

91052

91052-26

$95.00

$45.00

$60.00

$49.00

$9.00

$57.00

$47.00

$8.00

$108.00

$71.00

$30.00

$141.00

$82.00

$53.00

$67.00

$52.00

$115.00

BR

$43.00

$40.00

$2.00

$116.00

$76.00

$32.00

$141.00

$89.00

$39.00

$143.00

BR

BR

$46.00

$82.00

$259.00

$8.00

$76.00

$226.00

BR

BR

$80.00

$125.00

MRA

$50.00

$143.00

$94.00

$135.00

$74.00

$112.00

$112.00

$104.00

$49.00

$77.00

92060-26

92060-TC

92065

92065-26

92065-TC

92070

92081

92081-26

92081-TC

92082

92082-26

92082-TC

92083

92083-26

92083-TC

92100

91299

91299-26

91299-TC

92002

92004

92012

92014

92015

92018

92019

92020

92060

91100

91105

91122

91122-26

91122-TC

91123

91132

91132-26

91132-TC

91133

91133-26

91133-TC

Medicine

CPT Code

91052-TC

91055

91055-26

91055-TC

91060

91060-26

91060-TC

91065

91065-26

91065-TC

$6.00

$48.00

$24.00

$9.00

$59.00

$31.00

$14.00

$40.00

$32.00

$7.00

$34.00

$19.00

$6.00

$66.00

$32.00

$19.00

BR

BR

BR

$63.00

$98.00

$53.00

$75.00

$34.00

$80.00

$70.00

$31.00

$40.00

$57.00

$35.00

$169.00

$122.00

$37.00

BR

BR

$28.00

BR

BR

$34.00

BR

MRA

$12.00

$63.00

$46.00

$11.00

$35.00

$27.00

$8.00

$34.00

$23.00

$14.00



$192.00

$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

$53.00

$37.00

$10.00

$64.00

$45.00

$19.00

$80.00

$56.00

$17.00

$24.00

$10.00

$5.00

$39.00

$58.00

$104.00

$46.00

$53.00

$132.00

$60.00

$67.00

$40.00

$24.00

$7.00

$20.00

MRA

$32.00

$56.00

$69.00

$18.00

$49.00

$93.00

$29.00

$63.00

$38.00

$45.00

92284

92284-26

92284-TC

92285

92285-26

92285-TC

92286

92286-26

92286-TC

92287

92310

92311

92312

92313

92314

92315

92265

92265-26

92265-TC

92270

92270-26

92270-TC

92275

92275-26

92275-TC

92283

92283-26

92283-TC

92226

92230

92235

92235-26

92235-TC

92240

92240-26

92240-TC

92250

92250-26

92250-TC

92260

Medicine

CPT Code

92120

92130

92135

92135-26

92135-TC

92136

92136-26

92136-TC

92140

92225

Medicine

CPT Code

92316

92317

92325

92326

92330

92335

92340

92341

92342

92352

92353

92354

92355

92358

92370

92371

92390

92391

92392

92393

92395

92396

92499

92499-26

92499-TC

92502

92504

92506

92507

92508

92510

92511

92512

92516

92520

92526

92531

92532

92533

92534

92541

92541-26

92541-TC

92542

92542-26

92542-TC

92543

92543-26

92543-TC

92544

$9.00

$33.00

$20.00

$10.00

$28.00

$19.00

$10.00

$26.00

$47.00

$48.00

$10.00

$14.00

$41.00

BR

$37.00

$25.00

BR

BR

BR

$101.00

$24.00

$63.00

$40.00

$42.00

$114.00

$81.00

$46.00

$36.00

$38.00

$221.00

$107.00

$24.00

$35.00

$18.00

$61.00

$83.00

$84.00

$264.00

$35.00

$52.00

MRA

$59.00

$39.00

$14.00

$44.00

$79.00

$65.00

$32.00

$43.00

$43.00

$31.00

92582

92583

92584

92585

92585-26

92585-TC

92586

92587

92587-26

92587-TC

92588

92588-26

92588-TC

92589

92590

92591

92564

92565

92567

92568

92569

92571

92572

92573

92575

92576

92577

92579

92548-26

92548-TC

92551

92552

92553

92555

92556

92557

92560

92561

92562

92563

Medicine

CPT Code

92544-26

92544-TC

92545

92545-26

92545-TC

92546

92546-26

92546-TC

92547

92548

$28.00

$34.00

$94.00

$114.00

$52.00

$70.00

$70.00

$58.00

$8.00

$49.00

$78.00

$20.00

$57.00

$54.00

$41.00

BR

$17.00

$15.00

$20.00

$14.00

$15.00

$14.00

$3.00

$13.00

$11.00

$17.00

$28.00

$28.00

$30.00

$59.00

$17.00

$16.00

$24.00

$14.00

$21.00

$46.00

$23.00

$27.00

$15.00

$14.00

MRA

$16.00

$8.00

$22.00

$14.00

$8.00

$29.00

$17.00

$9.00

$21.00

$92.00



$170.00

$163.00

$76.00

$86.00

$952.00

$268.00

$705.00

$191.00

$1,222.00

$1,271.00

$974.00

BR

BR

$776.00

$210.00

$765.00

$203.00

$35.00

$162.00

$239.00

$201.00

$100.00

$174.00

$197.00

$400.00

$302.00

$269.00

$95.00

$109.00

$22.00

$59.00

$42.00

$46.00

$173.00

BR

$134.00

BR

$183.00

BR

BR

MRA

BR

BR

BR

BR

$22.00

$96.00

$88.00

$60.00

BR

BR

92986

92987

92990

92992

92993

92995

92996

92997

92978-TC

92979

92979-26

92979-TC

92980

92981

92982

92984

92950

92953

92960

92961

92970

92971

92973

92974

92975

92977

92978

92978-26

92607

92608

92609

92610

92611

92612

92613

92614

92615

92616

92617

92700

Medicine

CPT Code

92592

92593

92594

92595

92596

92597

92603

92604

92605

92606

Medicine

CPT Code

92998

93000

93005

93010

93012

93014

93015

93016

93017

93018

93024

93024-26

93024-TC

93025

93040

93041

93042

93224

93225

93226

93227

93230

93231

93232

93233

93235

93236

93237

93268

93270

93271

93272

93278

93278-26

93278-TC

93303

93303-26

93303-TC

93304

93304-26

93304-TC

93307

93307-26

93307-TC

93308

93308-26

93308-TC

93312

93312-26

93312-TC

$44.00

$215.00

$70.00

$144.00

$114.00

$43.00

$73.00

$196.00

$56.00

$144.00

$118.00

$46.00

$75.00

$322.00

$140.00

$182.00

$57.00

$82.00

$55.00

$123.00

$97.00

$28.00

$109.00

$46.00

$90.00

$28.00

$58.00

$24.00

$111.00

$71.00

$42.00

$277.00

$14.00

$31.00

$9.00

$159.00

$46.00

$83.00

$50.00

$168.00

MRA

$331.00

$26.00

$16.00

$12.00

$90.00

$28.00

$104.00

$25.00

$63.00

$54.00

93508-26

93508-TC

93510

93510-26

93510-TC

93511

93511-26

93511-TC

93514

93514-26

93514-TC

93524

93524-26

93524-TC

93526

93526-26

93325-TC

93350

93350-26

93350-TC

93501

93501-26

93501-TC

93503

93505

93505-26

93505-TC

93508

93317-TC

93318

93318-26

93318-TC

93320

93320-26

93320-TC

93321

93321-26

93321-TC

93325

93325-26

Medicine

CPT Code

93313

93314

93314-26

93314-TC

93315

93315-26

93315-TC

93316

93317

93317-26

$232.00

$469.00

$1,628.00

$247.00

$1,388.00

$1,629.00

$270.00

$1,350.00

$2,208.00

$525.00

$1,683.00

$2,150.00

$392.00

$1,766.00

$2,147.00

$363.00

$110.00

$216.00

$77.00

$66.00

$674.00

$160.00

$634.00

$187.00

$318.00

$248.00

$74.00

$698.00

$141.00

BR

$114.00

BR

$86.00

$30.00

$65.00

$50.00

$10.00

$42.00

$114.00

$4.00

MRA

$76.00

$212.00

$65.00

$144.00

$287.00

$144.00

$141.00

$78.00

$236.00

$95.00



$368.00

$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

BR

BR

$45.00

$49.00

$38.00

$38.00

$213.00

$30.00

$240.00

$278.00

$42.00

$234.00

$414.00

$44.00

$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

$1,766.00

MRA

$1,815.00

$2,186.00

$451.00

$1,766.00

$2,266.00

$482.00

$1,766.00

$2,032.00

$262.00

$1,766.00

93556-TC

93561

93561-26

93561-TC

93562

93562-26

93562-TC

93571

93571-26

93571-TC

93572

93572-26

93572-TC

93580

93580-26

93580-TC

93539

93540

93541

93542

93543

93544

93545

93555

93555-26

93555-TC

93556

93556-26

93530

93530-26

93530-TC

93531

93531-26

93531-TC

93532

93532-26

93532-TC

93533

93533-26

93533-TC

Medicine

CPT Code

93526-TC

93527

93527-26

93527-TC

93528

93528-26

93528-TC

93529

93529-26

93529-TC

Medicine

CPT Code

93581

93581-26

93581-TC

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

93612-26

93612-TC

93613

93613-26

93613-TC

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

93621-TC

93622

93622-26

93622-TC

93623

93623-26

93623-TC

93624

93624-26

$444.00

$290.00

$358.00

$272.00

$91.00

BR

$769.00

BR

BR

$771.00

BR

BR

$167.00

BR

$333.00

$256.00

$378.00

BR

$62.00

$49.00

$12.00

$94.00

$82.00

$12.00

$399.00

$258.00

$148.00

$717.00

$127.00

$63.00

$578.00

$481.00

$101.00

$214.00

$166.00

$52.00

$224.00

$167.00

$61.00

$377.00

MRA

$1,303.00

BR

BR

$198.00

$129.00

$73.00

$159.00

$119.00

$42.00

$187.00

93731-26

93731-TC

93732

93732-26

93732-TC

93733

93733-26

93733-TC

93734

93734-26

93734-TC

93735

93735-26

93735-TC

93736

93736-26

93668

93701

93701-26

93701-TC

93720

93721

93722

93724

93724-26

93724-TC

93727

93731

93642

93642-26

93642-TC

93650

93651

93652

93660

93660-26

93660-TC

93662

93662-26

93662-TC

Medicine

CPT Code

93624-TC

93631

93631-26

93631-TC

93640

93640-26

93640-TC

93641

93641-26

93641-TC

$34.00

$21.00

$13.00

$30.00

$20.00

$7.00

$33.00

$10.00

$24.00

$18.00

$68.00

$48.00

$19.00

$38.00

$11.00

$28.00

BR

$36.00

$9.00

$27.00

$43.00

$27.00

$24.00

$411.00

$259.00

$148.00

$28.00

$43.00

$549.00

$295.00

$269.00

$639.00

$985.00

$1,044.00

$162.00

$103.00

$61.00

BR

$158.00

BR

MRA

$74.00

$651.00

$420.00

$239.00

$467.00

$230.00

$269.00

$613.00

$360.00

$269.00



$31.00

$144.00

$117.00

$21.00

$95.00

$215.00

$50.00

$162.00

$142.00

$33.00

$109.00

$60.00

$16.00

$44.00

$112.00

$28.00

NC

NC

NC

$17.00

$38.00

BR

BR

BR

$55.00

$17.00

$42.00

$176.00

$78.00

$43.00

$32.00

$88.00

$48.00

$43.00

$314.00

$378.00

NC

NC

NC

NC

MRA

$24.00

$17.00

$12.00

$5.00

$68.00

$33.00

$32.00

$77.00

$37.00

$43.00

93880-26

93880-TC

93882

93882-26

93882-TC

93886

93886-26

93886-TC

93888

93888-26

93888-TC

93922

93922-26

93922-TC

93923

93923-26

93786

93788

93790

93797

93798

93799

93799-26

93799-TC

93875

93875-26

93875-TC

93880

93743

93743-26

93743-TC

93744

93744-26

93744-TC

93760

93762

93770

93770-26

93770-TC

93784

Medicine

CPT Code

93736-TC

93740

93740-26

93740-TC

93741

93741-26

93741-TC

93742

93742-26

93742-TC

Medicine

CPT Code

93923-TC

93924

93924-26

93924-TC

93925

93925-26

93925-TC

93926

93926-26

93926-TC

93930

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

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

93990

93990-26

93990-TC

94010

94010-26

94010-TC

94014

$122.00

$23.00

$98.00

$183.00

$65.00

$105.00

$148.00

$25.00

$124.00

$110.00

$14.00

$96.00

$30.00

$12.00

$16.00

$39.00

$121.00

$23.00

$96.00

$277.00

$89.00

$181.00

$184.00

$59.00

$121.00

$177.00

$34.00

$143.00

$174.00

$26.00

$150.00

$118.00

$17.00

$101.00

$63.00

$26.00

$42.00

$189.00

$36.00

$154.00

MRA

$85.00

$122.00

$31.00

$92.00

$175.00

$31.00

$144.00

$117.00

$21.00

$96.00

94375-TC

94400

94400-26

94400-TC

94450

94450-26

94450-TC

94620

94620-26

94620-TC

94621

94621-26

94621-TC

94640

94642

94656

94260-TC

94350

94350-26

94350-TC

94360

94360-26

94360-TC

94370

94370-26

94370-TC

94375

94375-26

94150-TC

94200

94200-26

94200-TC

94240

94240-26

94240-TC

94250

94250-26

94250-TC

94260

94260-26

Medicine

CPT Code

94015

94016

94060

94060-26

94060-TC

94070

94070-26

94070-TC

94150

94150-26

$17.00

$40.00

$24.00

$14.00

$37.00

$20.00

$15.00

$91.00

$38.00

$54.00

$122.00

$71.00

$52.00

$19.00

BR

$75.00

$18.00

$36.00

$14.00

$20.00

$37.00

$11.00

$26.00

$33.00

$18.00

$12.00

$34.00

$16.00

$3.00

$17.00

$7.00

$9.00

$43.00

$15.00

$26.00

$12.00

$8.00

$5.00

$27.00

$8.00

MRA

$14.00

$26.00

$57.00

$18.00

$36.00

$32.00

$11.00

$19.00

$8.00

$6.00



$11.00

$11.00

$3.00

$5.00

$8.00

$7.00

$9.00

$6.00

$13.00

$7.00

$82.00

$105.00

$82.00

$9.00

$10.00

$9.00

$14.00

$21.00

$9.00

$20.00

$30.00

$21.00

$9.00

$12.00

BR

BR

BR

$3.00

$12.00

$43.00

$24.00

$4.00

$20.00

$49.00

$15.00

$31.00

$79.00

$14.00

$64.00

$37.00

MRA

$44.00

$54.00

$38.00

$18.00

$23.00

$16.00

$47.00

$23.00

$22.00

$60.00

95060

95065

95070

95071

95075

95078

95115

95117

95010

95015

95024

95027

95028

95044

95052

95056

94750-26

94750-TC

94760

94761

94762

94770

94770-26

94770-TC

94799

94799-26

94799-TC

95004

94681-26

94681-TC

94690

94690-26

94690-TC

94720

94720-26

94720-TC

94725

94725-26

94725-TC

94750

Medicine

CPT Code

94657

94660

94662

94664

94667

94668

94680

94680-26

94680-TC

94681

Medicine

CPT Code

95120

95125

95130

95131

95132

95133

95134

95144

95145

95146

95147

95148

95149

95165

95170

95180

95199

95250

95805

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

95812

95812-26

95812-TC

95813

95813-26

95813-TC

95816

95816-26

95816-TC

95819

95819-26

95819-TC

95822

95822-26

$196.00

$423.00

$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

$109.00

$137.00

$367.00

$98.00

$256.00

$456.00

$149.00

$256.00

$521.00

$183.00

$256.00

$644.00

$33.00

$32.00

$36.00

$7.00

$13.00

$103.00

BR

$114.00

$334.00

$94.00

$237.00

$232.00

MRA

BR

BR

BR

BR

BR

BR

BR

$9.00

$17.00

$24.00

95867-26

95867-TC

95868

95868-26

95868-TC

95869

95869-26

95869-TC

95870

95870-26

95870-TC

95872

95872-26

95872-TC

95875

95875-26

95860-26

95860-TC

95861

95861-26

95861-TC

95863

95863-26

95863-TC

95864

95864-26

95864-TC

95867

95830

95831

95832

95833

95834

95851

95852

95857

95858

95858-26

95858-TC

95860

Medicine

CPT Code

95822-TC

95824

95824-26

95824-TC

95827

95827-26

95827-TC

95829

95829-26

95829-TC

$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

$43.00

$34.00

$53.00

$15.00

$113.00

$86.00

$28.00

$138.00

$102.00

$35.00

$177.00

$114.00

$67.00

$66.00

$133.00

$26.00

$21.00

$34.00

$44.00

$18.00

$14.00

$40.00

$65.00

$56.00

$10.00

$73.00

MRA

$63.00

$51.00

$41.00

$10.00

$145.00

$59.00

$86.00

$328.00

$291.00

$6.00



$62.00

$33.00

$30.00

$36.00

$28.00

$8.00

$39.00

$30.00

$8.00

$40.00

$31.00

$9.00

$265.00

$84.00

$177.00

$34.00

$94.00

$53.00

$41.00

$66.00

$34.00

$34.00

$67.00

$34.00

$34.00

$44.00

$25.00

$11.00

$168.00

$118.00

$48.00

$61.00

$46.00

$14.00

$65.00

$50.00

$14.00

$105.00

$47.00

$57.00

MRA

$7.00

$37.00

$24.00

$10.00

$43.00

$33.00

$9.00

$31.00

$20.00

$8.00

95933

95933-26

95933-TC

95934

95934-26

95934-TC

95936

95936-26

95936-TC

95937

95937-26

95937-TC

95950

95950-26

95950-TC

95951

95925

95925-26

95925-TC

95926

95926-26

95926-TC

95927

95927-26

95927-TC

95930

95930-26

95930-TC

95920

95920-26

95920-TC

95921

95921-26

95921-TC

95922

95922-26

95922-TC

95923

95923-26

95923-TC

Medicine

CPT Code

95875-TC

95900

95900-26

95900-TC

95903

95903-26

95903-TC

95904

95904-26

95904-TC

Medicine

CPT Code

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

95957-TC

95958

95958-26

95958-TC

95961

95961-26

95961-TC

95962

95962-26

95962-TC

95965

95965-26

95965-TC

95966

95966-26

95966-TC

95967

95967-26

95967-TC

95970

95971

95972

95973

95974

95975

95990

95999

96000

96001

96002

96003

96004

96100

96105

BR

$22.00

$39.00

$78.00

$47.00

$155.00

$88.00

$57.00

BR

$93.00

$111.00

$21.00

$20.00

$97.00

$68.00

$68.00

$48.00

$227.00

$176.00

$48.00

BR

$420.00

BR

BR

$210.00

BR

BR

$184.00

$74.00

$541.00

$166.00

$314.00

$171.00

$104.00

$64.00

$296.00

$230.00

$66.00

$216.00

$166.00

MRA

$14.00

$20.00

$411.00

$165.00

$240.00

$208.00

$134.00

$23.00

$130.00

$59.00

97010

97012

97014

97016

97018

97020

97022

97024

96922

96999

97001

97002

97003

97004

97005

97006

96545

96549

96567

96570

96571

96900

96902

96910

96912

96913

96920

96921

96412

96414

96420

96422

96423

96425

96440

96445

96450

96520

96530

96542

Medicine

CPT Code

96110

96111

96115

96117

96370

96400

96405

96406

96408

96410

$214.00

BR

$62.00

$29.00

$62.00

$29.00

NC

NC

$10.00

$16.00

$14.00

$15.00

$10.00

$10.00

$15.00

$10.00

BR

BR

$62.00

$69.00

$38.00

$17.00

$24.00

$21.00

$24.00

$53.00

$152.00

$155.00

MRA

$88.00

$68.00

$68.00

$68.00

See formula

$20.00

$57.00

$86.00

$36.00

$5.00

$43.00

$50.00

$46.00

$46.00

$17.00

$54.00

$156.00

$157.00

$134.00

$33.00

$49.00

$126.00


$26.00

NC

$32.00

NC

$23.00

NC

NC

$32.00

BR

BR

$26.00

$17.00

$7.00

$54.00

$26.00

$54.00

$24.00

$23.00

$23.00

$17.00

$83.00

$41.00

$42.00

BR

$15.00

BR

$48.00

$32.00

$24.00

$21.00

$19.00

$15.00

$26.00

$18.00

$23.00

$17.00

$23.00

$23.00

$22.00

$22.00

MRA

$9.00

$10.00

$16.00

$16.00

$13.00

$11.00

$19.00

$15.00

$22.00

$23.00


Medicine

CPT Code

98942

98943

MRA

NC

$23.00

97853

98925

98926

98927

98928

98929

98940

98941

97781

97799

97802

97803

97804

97850

97851

97852

97533

97535

97537

97542

97545

97546

97601

97602

97703

97750

97752

97780

97113

97116

97124

97139

97140

97150

97260

97261

97504

97520

97530

97532

Medicine

CPT Code

97026

97028

97032

97033

97034

97035

97036

97039

97110

97112



99214

99215

99217

99218

99219

99220

99221

99222

99223

99231

99232

99233

99234

99235

99236

99191

99192

99195

99199

99201

99202

99203

99204

99205

99211

99212

99213

99082

99090

99091

99141

99142

99172

99173

99175

99183

99185

99186

99190

Evaluation & Management

CPT Code

99000

99001

MRA

$6.00

$4.00


CPT Code

99238

99239

MRA

$66.00

$88.00


CPT Code

99348

99349

MRA

$71.00

$107.00

99002

99025

99026

$35.00

$31.00

BR

99241

99242

99243

$54.00

$88.00

$117.00

99350

99354

99355

$156.00

$106.00

$104.00

99027 BR 99244 $163.00 99356 $87.00

99070 BR 99245 $212.00

99357 $88.00

99071 NC 99251 $54.00

99358 BR

99075 See 440.13

99252 $70.00 99359 BR

99078 NC 99253 $96.00

99360 BR

99080 BR 99254 $138.00

99361 BR

BR

BR

BR

$80.00

$66.00

BR

BR

$53.00

$123.00

$23.00

$78.00

BR

BR

BR

$16.00

NC

$35.00

$58.00

$58.00

$84.00

$84.00

$19.00

$31.00

$40.00

99255

99261

99262

99263

99271

99272

99273

99274

99275

99281

99282

99283

99284

99285

99288

99291

99292

99295

99296

99301

99302

99303

99311

99312

$190.00

$24.00

$44.00

$65.00

$49.00

$61.00

$86.00

$116.00

$149.00

$18.00

$28.00

$60.00

$94.00

$103.00

BR

$192.00

$95.00

$800.00

$399.00

$58.00

$65.00

$108.00

$23.00

$52.00

99362

99371

99372

99373

99374

99375

99377

99378

99379

99380

99450

99455

99456

99457

99499

99600

BR

NC

$17.00

$22.00

$75.00

$75.00

$75.00

$104.00

$75.00

$104.00

NC

$90.00

BR

BR

BR

BR

$40.00

$65.00

$65.00

$65.00

$109.00

$152.00

$66.00

$109.00

$152.00

$33.00

$54.00

$77.00

$129.00

$173.00

$213.00

99313

99315

99316

99321

99322

99323

99331

99332

99333

99341

99342

99343

99344

99345

99347

$72.00

$60.00

$77.00

$42.00

$60.00

$79.00

$36.00

$47.00

$59.00

$59.00

$85.00

$109.00

$160.00

$193.00

$46.00



$40.00

$23.00

$48.00

$13.00

$21.00

$81.00

$121.00

$102.00

$143.00

$14.00

$38.00

$44.00

$54.00

$67.00

$34.00

$25.00

$13.00

$24.00

$30.00

BR

BR

BR

$54.00

BR

$29.00

$10.00

$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

$14.00

D1205

D1310

D1320

D1330

D1351

D1510

D1515

D1520

D1525

D1550

D2140

D2150

D2160

D2161

D0415

D0425

D0460

D0470

D0472

D0473

D0474

D0480

D0502

D0999

D1110

D1204

D0270

D0272

D0274

D0277

D0290

D0310

D0320

D0321

D0322

D0330

D0340

D0350

Dental

CPT Code

D0120

D0140

D0150

D0160

D0170

D0180

D0210

D0220

D0230

D0240

D0250

D0260

Dental

CPT Code

D2330

D2331

D2332

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

$328.00

$368.00

$368.00

$266.00

$306.00

$389.00

$389.00

$287.00

$328.00

$204.00

$29.00

$29.00

$81.00

$121.00

$206.00

$266.00

$348.00

$266.00

$328.00

$348.00

$194.00

$410.00

$306.00

$348.00

$410.00

$451.00

$155.00

$259.00

$244.00

$302.00

$318.00

$348.00

$206.00

$266.00

$348.00

$287.00

$328.00

$378.00

MRA

$40.00

$61.00

$66.00

$81.00

$57.00

$43.00

$55.00

$63.00

$69.00

$163.00

$203.00

$293.00

D3425

D3426

D3430

D3450

D3460

D3470

D3910

D3920

D3950

D3999

D4210

D4211

D4240

D4241

D3330

D3331

D3332

D3333

D3346

D3347

D3348

D3351

D3352

D3353

D3410

D3421

D2962

D2970

D2980

D2999

D3110

D3120

D3220

D3221

D3230

D3240

D3310

D3320

Dental

CPT Code

D2932

D2933

D2940

D2950

D2951

D2952

D2953

D2954

D2955

D2957

D2960

D2961

$206.00

$77.00

$55.00

$102.00

$318.00

$204.00

$50.00

$102.00

$61.00

BR

$114.00

$50.00

$223.00

$63.00

$287.00

$102.00

$110.00

$53.00

$225.00

$274.00

$337.00

$102.00

$81.00

$163.00

$179.00

$194.00

$294.00

$81.00

$83.00

BR

$25.00

$20.00

$61.00

$81.00

$70.00

$75.00

$206.00

$204.00

MRA

$77.00

$91.00

$29.00

$81.00

$20.00

$79.00

$133.00

$102.00

$81.00

$71.00

$121.00

$204.00

HCPCS © 2002 109


$27.00

$27.00

$61.00

$40.00

$61.00

$83.00

$22.00

$53.00

$61.00

$102.00

$305.00

$305.00

$204.00

$204.00

BR

$513.00

$513.00

$563.00

$563.00

$256.00

$259.00

$614.00

$614.00

$279.00

$27.00

$27.00

$337.00

$208.00

$178.00

$194.00

$77.00

$55.00

$79.00

$55.00

$50.00

$69.00

$40.00

$27.00

MRA

$265.00

$208.00

$328.00

$164.00

$195.00

$159.00

$96.00

$285.00

$328.00

$273.00

$155.00

$206.00

D5421

D5422

D5510

D5520

D5610

D5620

D5630

D5640

D5650

D5660

D5670

D5671

D5710

D5711

D4999

D5110

D5120

D5130

D5140

D5211

D5212

D5213

D5214

D5281

D5410

D5411

D4273

D4274

D4275

D4276

D4320

D4321

D4341

D4342

D4355

D4381

D4910

D4920

Dental

CPT Code

D4245

D4249

D4260

D4261

D4263

D4264

D4265

D4266

D4267

D4268

D4270

D4271

Dental

CPT Code

D5720

D5721

D5730

D5731

D5740

D5741

D5750

D5751

D5760

D5761

D5810

D5811

D5820

D5821

D5850

D5851

D5860

D5861

D5862

D5867

D5875

D5899

D5911

D5912

D5913

D5914

D5915

D5916

D5919

D5922

D5923

D5924

D5925

D5926

D5927

D5928

D5929

D5931

D5932

D5933

D5934

D5935

D5936

D5937

D5951

D5953

D5954

D5955

D5958

D5959

BR

$656.00

$1,539.00

$306.00

$1,539.00

$1,539.00

$563.00

BR

$614.00

$614.00

BR

$1,334.00

$780.00

$244.00

$2,052.00

$2,052.00

$2,770.00

$2,874.00

BR

$1,334.00

$1,641.00

BR

BR

$1,026.00

$1,026.00

$1,384.00

$194.00

$204.00

$46.00

$50.00

$543.00

$553.00

$181.00

$36.00

$100.00

BR

$81.00

$121.00

MRA

$163.00

$163.00

$121.00

$121.00

$102.00

$102.00

$132.00

$163.00

$100.00

$163.00

$244.00

$244.00

D6076

D6077

D6078

D6079

D6080

D6090

D6095

D6100

D6199

D6210

D6211

D6212

D6240

D6241

D6064

D6065

D6066

D6067

D6068

D6069

D6070

D6071

D6072

D6073

D6074

D6075

D6050

D6053

D6054

D6055

D6056

D6057

D6058

D6059

D6060

D6061

D6062

D6063

Dental

CPT Code

D5960

D5982

D5983

D5984

D5985

D5986

D5987

D5988

D5999

D6010

D6020

D6040

$402.00

$447.00

$1,026.00

$884.00

$71.00

$229.00

$247.00

$264.00

BR

$410.00

$287.00

$328.00

$451.00

$368.00

$377.00

$513.00

$513.00

$513.00

$365.00

$359.00

$322.00

$326.00

$365.00

$346.00

$350.00

$414.00

$1,557.00

$82.00

$61.00

$769.00

$265.00

$303.00

$392.00

$418.00

$289.00

$379.00

$365.00

$359.00

MRA

$163.00

$167.00

BR

BR

$574.00

$61.00

BR

$219.00

BR

$649.00

$259.00

$3,016.00

HCPCS © 2002 110


$287.00

$348.00

$30.00

$279.00

$40.00

$102.00

$155.00

$163.00

$113.00

$121.00

$111.00

$214.00

$88.00

$46.00

$410.00

$233.00

$348.00

$328.00

$356.00

$328.00

$410.00

$389.00

$320.00

$322.00

$324.00

$389.00

$110.00

$141.00

$139.00

$151.00

$170.00

$178.00

$203.00

$217.00

$141.00

$155.00

$151.00

$162.00

MRA

$410.00

$309.00

$410.00

$287.00

$368.00

$51.00

$195.00

$281.00

$155.00

$166.00

$172.00

$203.00

D6791

D6792

D6793

D6920

D6930

D6940

D6950

D6970

D6971

D6972

D6973

D6975

D6976

D6977

D6720

D6721

D6722

D6740

D6750

D6751

D6752

D6780

D6781

D6782

D6783

D6790

D6604

D6605

D6606

D6607

D6608

D6609

D6610

D6611

D6612

D6613

D6614

D6615

Dental

CPT Code

D6242

D6245

D6250

D6251

D6252

D6253

D6545

D6548

D6600

D6601

D6602

D6603

Dental

CPT Code

D6980

D6999

D7140

D7210

D7220

D7230

D7240

D7241

D7250

D7260

D7261

D7270

D7272

D7280

D7281

D7282

D7285

D7286

D7287

D7290

D7291

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

$195.00

$71.00

$174.00

$143.00

$147.00

$162.00

$2,545.00

$54.00

$121.00

$85.00

$121.00

$143.00

$266.00

$1,189.00

$410.00

$102.00

$100.00

$139.00

$205.00

$180.00

$291.00

$161.00

$247.00

$139.00

$179.00

$137.00

$204.00

$121.00

$81.00

$41.00

$106.00

$81.00

BR

$133.00

$77.00

$85.00

$108.00

$195.00

MRA

$106.00

BR

$45.00

$70.00

$111.00

$139.00

$147.00

$204.00

$81.00

$244.00

BR

$147.00

D7880

D7899

D7910

D7911

D7912

D7920

D7940

D7941

D7943

D7944

D7945

D7946

D7947

D7948

D7856

D7858

D7860

D7865

D7870

D7871

D7872

D7873

D7874

D7875

D7876

D7877

D7750

D7760

D7770

D7771

D7780

D7810

D7820

D7830

D7840

D7850

D7852

D7854

Dental

CPT Code

D7620

D7630

D7640

D7650

D7660

D7670

D7671

D7680

D7710

D7720

D7730

D7740

$291.00

BR

$73.00

$110.00

$163.00

$676.00

$841.00

$2,874.00

$2,914.00

$2,298.00

$2,319.00

$2,566.00

$2,566.00

$2,874.00

BR

$2,298.00

$614.00

$1,723.00

$81.00

BR

$533.00

$584.00

$737.00

$789.00

$820.00

$758.00

$1,334.00

$1,046.00

$533.00

$73.00

$2,504.00

$1,292.00

$110.00

$186.00

$1,764.00

$1,682.00

$2,011.00

$2,052.00

MRA

$984.00

$1,354.00

$820.00

$1,292.00

$780.00

$410.00

$779.00

$1,949.00

$1,415.00

$903.00

$1,580.00

$922.00

HCPCS © 2002 111

D9210

D9211

D9212

D9215

D9220

D9221

D9230

D9241

D9242

D9248

D9310

D9410

D9420

D9430

D8080

D8090

D8210

D8220

D8660

D8670

D8680

D8690

D8691

D8692

D8999

D9110

D7991

D7995

D7996

D7997

D7999

D8010

D8020

D8030

D8040

D8050

D8060

D8070

Dental

CPT Code

D7949

D7950

D7955

D7960

D7970

D7971

D7972

D7980

D7981

D7982

D7983

D7990


Dental

CPT Code

D9440

D9450

D9610

D9630

D9910

D9911

D9920

D9930

D9940

D9941

D9950

D9951

D9952

D9970

D9971

D9972

D9973

D9974

D9999

MRA

$41.00

BR

$20.00

$10.00

$21.00

$21.00

$32.00

$34.00

$204.00

$58.00

$114.00

$46.00

$163.00

$83.00

$55.00

$113.00

$40.00

$50.00

BR

$14.00

$14.00

$13.00

$7.00

$111.00

$40.00

$18.00

$122.00

$45.00

$91.00

$41.00

$61.00

$46.00

$23.00

$1,867.00

$1,949.00

$155.00

$179.00

$73.00

$54.00

$171.00

$71.00

$67.00

$104.00

BR

$40.00

$820.00

BR

BR

BR

BR

$451.00

$533.00

$718.00

$583.00

$676.00

$758.00

$1,867.00

MRA

$4,186.00

$881.00

$922.00

$121.00

$137.00

$67.00

BR

$169.00

$820.00

$306.00

$244.00

$340.00

HCPCS © 2002 112


$4.00

$8.00

$21.00

$6.00

$9.00

$26.00

$393.00

BR

BR

$6.00

$1.00

$3.00

$21.00

BR

BR

$22.00

$6.00

$1.00

$3.00

BR

BR

$1.00

$11.00

$201.00

BR

$3.00

$3.00

$5.00

$101.00

$1.00

BR

BR

BR

BR

BR

$2.00

$7.00

$2.00

$1.00

$2,408.00

MRA

$12.00

BR

$27.00

BR

$1.00

$3.00

BR

$38.00

BR

$7.00

J0592

J0600

J0610

J0620

J0630

J0636

J0637

J0640

J0530

J0540

J0550

J0560

J0570

J0580

J0585

J0587

J0360

J0380

J0390

J0395

J0456

J0460

J0470

J0475

J0476

J0500

J0515

J0520

J0256

J0280

J0282

J0285

J0287

J0288

J0289

J0290

J0295

J0300

J0330

J0350

Injections

CPT Code

J0120

J0130

J0150

J0151

J0170

J0190

J0200

J0205

J0207

J0210

Injections

CPT Code

J0670

J0690

J0692

J0694

J0696

J0697

J0698

J0702

J0704

J0710

J0713

J0715

J0720

J0725

J0735

J0740

J0743

J0744

J0745

J0760

J0770

J0780

J0800

J0835

J0850

J0880

J0895

J0900

J0945

J0970

J1000

J1020

J1030

J1040

J1055

J1060

J1070

J1080

J1094

J1100

J1110

J1120

J1160

J1165

J1170

J1180

J1190

J1200

J1205

J1212

$2.00

$1.00

$1.00

$1.00

BR

$1.00

$9.00

$36.00

BR

$1.00

$1.00

$2.00

BR

$1.00

$10.00

$35.00

$18.00

$12.00

$362.00

BR

$10.00

$1.00

$1.00

$1.00

$3.00

$1.00

$2.00

$3.00

$8.00

$6.00

$6.00

$3.00

BR

BR

$14.00

BR

$1.00

$3.00

$32.00

$3.00

MRA

NC

$3.00

BR

$10.00

$11.00

$6.00

$11.00

$4.00

$2.00

$3.00

J1630

J1631

J1642

J1644

J1645

J1650

J1652

J1655

J1565

J1570

J1580

J1590

J1600

J1610

J1620

J1626

J1470

J1480

J1490

J1500

J1510

J1520

J1530

J1540

J1550

J1560

J1563

J1564

J1364

J1380

J1390

J1410

J1435

J1436

J1438

J1440

J1441

J1450

J1455

J1460

Injections

CPT Code

J1230

J1240

J1245

J1250

J1260

J1270

J1320

J1325

J1327

J1330

$4.00

$28.00

$1.00

$1.00

BR

$16.00

BR

BR

BR

$36.00

$3.00

BR

$10.00

$27.00

$69.00

BR

$4.00

$7.00

$9.00

$11.00

$13.00

$15.00

$17.00

$20.00

$22.00

BR

BR

BR

$6.00

$1.00

$1.00

$33.00

$1.00

$68.00

BR

$158.00

$254.00

BR

$12.00

$2.00

MRA

$1.00

$1.00

$31.00

$49.00

BR

BR

$1.00

BR

BR

$2.00

HCPCS © 2002 113


$13.00

$2.00

$3.00

$5.00

$6.00

$8.00

BR

BR

$3.00

$1.00

$3.00

$3.00

$2.00

$32.00

$1.00

BR

$9.00

$1.00

$411.00

$37.00

BR

$2.00

$3.00

$8.00

$7.00

$2.00

BR

$12.00

$4.00

$10.00

$6.00

BR

BR

BR

$76.00

BR

$7.00

$4.00

$7.00

$11.00

MRA

$23.00

$1.00

$5.00

$4.00

$94.00

BR

BR

BR

BR

$4.00

J2275

J2300

J2310

J2320

J2321

J2322

J2324

J2355

J2150

J2175

J2180

J2210

J2250

J2260

J2270

J2271

J1910

J1940

J1950

J1955

J1956

J1960

J1980

J1990

J2000

J2010

J2020

J2060

J1790

J1800

J1810

J1815

J1817

J1825

J1830

J1835

J1840

J1850

J1885

J1890

Injections

CPT Code

J1670

J1700

J1710

J1720

J1730

J1742

J1745

J1750

J1756

J1785

Injections

CPT Code

J2360

J2370

J2400

J2405

J2410

J2430

J2440

J2460

J2501

J2510

J2515

J2540

J2543

J2545

J2550

J2560

J2590

J2597

J2650

J2670

J2680

J2690

J2700

J2710

J2720

J2725

J2730

J2760

J2765

J2770

J2780

J2790

J2792

J2795

J2800

J2810

J2820

J2910

J2912

J2916

J2920

J2930

J2940

J2941

J2950

J2993

J2995

J2997

J3000

J3010

BR

BR

$1.00

BR

BR

BR

$2.00

$2.00

$3.00

$3.00

$115.00

$11.00

$1.00

BR

$5.00

$13.00

$2.00

$1.00

$1.00

$11.00

$29.00

$29.00

$2.00

BR

BR

$36.00

BR

BR

$1.00

$1.00

BR

$105.00

$1.00

$5.00

$1.00

$20.00

$1.00

BR

$16.00

$7.00

MRA

$2.00

$3.00

BR

$6.00

$3.00

$189.00

$2.00

$1.00

BR

$1.00

J7060

J7070

J7100

J7110

J7120

J7130

J7190

J7191

J3485

J3490

J3590

J7030

J7040

J7042

J7050

J7051

J3360

J3364

J3365

J3370

J3395

J3400

J3410

J3420

J3430

J3470

J3475

J3480

J3245

J3250

J3260

J3265

J3280

J3301

J3302

J3303

J3305

J3310

J3320

J3350

Injections

CPT Code

J3030

J3070

J3100

J3105

J3120

J3130

J3140

J3150

J3230

J3240

BR

BR

BR

$11.00

$10.00

$10.00

$10.00

$1.00

$10.00

$11.00

$137.00

$93.00

$12.00

$6.00

$241.00

BR

$1.00

$52.00

$433.00

$9.00

BR

$12.00

$1.00

$1.00

$2.00

$7.00

$1.00

$1.00

BR

$1.00

$7.00

$2.00

$5.00

$1.00

$1.00

$1.00

$55.00

$5.00

$16.00

$72.00

MRA

$34.00

$4.00

BR

$2.00

$1.00

$1.00

$1.00

$1.00

$2.00

$214.00

HCPCS © 2002 114


J7350

J7501

J7504

J7505

J7513

J7516

J7599

Injections

CPT Code

J7192

J7193

J7194

J7195

J7197

J7198

J7199

J7310

J7317

J7320

MRA

$316.00

BR

$120.00

BR

$284.00

BR

BR

BR

BR

BR

BR

$98.00

$282.00

$576.00

BR

BR

BR

HCPCS © 2002 115


APPENDIX A

DEFINITIONS

116


APPENDIX A. DEFINITIONS.

(1)

“

Agency” means the Agency for Health Care Administration.

(2) “Anesthesia Reimbursement Allowance (ARA)” means the maximum reimbursement allowance paid to a provider for an anesthesia procedure.

(3) “Authorization” means the approval given to a health care provider by the carrier or self-insured employer for the provision of medical services to an employee.

(4) “Basic Value (BV) or base unit” means the value of all usual anesthesia services, except the time actually spent in anesthesia care and any modifiers.

(5) “Billing” means the completion and submission of a form to the carrier in order to receive reimbursement for health care services provided to an injured employee.

(6) “Coding system” means a systematic listing of codes to identify either established diagnosis or procedures and services rendered by health care providers.

(7) “Commission on Accreditation of Rehabilitation Facilities (CARF)” is a not-for-profit organization whose mission is to promote the quality, value and optimal outcomes of services through a consultative accreditation process that centers on enhancing the lives of people in need of rehabilitation and served by CARF accredited organizations and rehabilitation programs.

(8) “CRNA” means a certified registered nurse anesthetist licensed by Chapter 464, F.S.

(9) “Descriptor” means the narrative description of a procedure or service which is represented in a coding system by a specific code.

(10) “Division” means the Division of Workers’ Compensation.

(11) “Durable medical equipment” (DME) means articles of a permanent nature which are prescribed for prolonged or continuous use.

(12) “Exception” means payment may be made for services or supplies exceeding reimbursement guidelines if documented and authorized by the carrier.

(13) “Exclusion” means a procedure, service or supply that is not reimbursable under the workers’ compensation program.

(14) “Health care provider” is defined in section 440.13, F.S.

(15) “Limitations” mean the restrictions placed on the reimbursement of medical services.

(16) “Maximum reimbursement allowance (MRA)” means the maximum dollar amount established to reimburse a health care provider for medical services or supplies.

(17) “Medical record” means the medical file that contains information that identifies the patient, supports the diagnosis, justifies the treatment and documents the care provided.

117


(18) “Medical supplier” means an individual or entity who furnishes medical equipment, supplies, appliances, devices, transcutaneous neurostimulators, ocular and hearing aids, prosthetics or orthotics as prescribed by a physician.

(19) “New patient” means an injured employee who is new to the health care provider or is an established patient with a new compensable injury or illness.

(20) “Non-physician surgical assistant” means a physician assistant licensed pursuant to section 458.347, F.S., or section 459.022, F.S., or a licensed registered nurse certified pursuant to section 464.027, F.S.

(21) “Not covered or non-covered (NC)” means a service or supply that is not reimbursable under the workers’ compensation program. These services and supplies are identified by “NC” in the MRA column in the schedule of maximum reimbursement allowances.

(22) “Orthotics” mean mechanical appliances that are used to support and correct deformities.

(23) “Peer review” is defined in section 440.13, F.S.

(24) “Physician” is defined in section 440.13, F.S.

(25) “Procedure” means a medical service rendered to an injured employee during the course of treatment.

(26) “Professional component” means that portion of a diagnostic procedure that consists of the physician’s professional services. This includes examination of the patient when indicated; the performance, supervision and interpretation of the procedure; and the provision of a written report.

(27) “Prosthetics” mean artificial substitutes that are used to replace missing parts or devices to augment performance of a natural function.

(28) “Technical component” means the portion of certain diagnostic procedures that includes the provision of personnel, materials and equipment to perform the procedures or studies.

(29) “Time (TM) Units” mean the number of units of time that a procedure requires, which is calculated by dividing the total anesthesia time (total minutes) by either ten (10) minute intervals for anesthesiologists, or fifteen (15) minute intervals for CRNAs.

(30) “Unlisted procedure” means a procedure code that is not listed in this schedule, but is contained in the Physicians’ Current Procedural Terminology, 2003 Professional

Edition, Copyright 2002, American Medical Association; the Current Dental

Terminology, Fourth Edition, Copyright 2002, American Dental Association; or the

HCPCS 2003, Fifteenth Edition, Copyright 2002, Ingenix Publishing Group.

(31) “Usual charge” means the customary fee billed by a health care provider.

118


APPENDIX B

DIRECTORY OF REFERENCES

119


APPENDIX B: DIRECTORY OF REFERENCES

This directory includes a listing of references published by medical specialty societies, national professional associations and publishing organizations. The references are listed with “ ♦ ” before the title of the publication.

As medical information pertaining to coding systems and guidelines 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.

♦ 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: www.aaos.org/

♦ Current Dental Terminology (CDT-4)

American Dental Association

211 East Chicago Avenue, 6 th

Chicago, Illinois 60611-2678

Floor

(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:

www.

adacatalog

.org/

♦ 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.

120


♦ Physicians’ Current Procedural Terminology, 4 th Edition (CPT ® )

♦ CPT Assistant ®

♦ Guide To The Evaluation of Permanent Impairment, 5 th Edition

♦

♦ ICD-9-CM, 6

HCPCS, 15 th Edition th Edition

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

Web site: www.ama-assn.org

♦ 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: www.fwciweb.org

121


APPENDIX C

MODIFIERS

122


APPENDIX C. MODIFIERS.

1. Modifiers change the basic services reported and require different reimbursements from the MRAs listed for the unmodified basic services. Modifiers are two (2) characters: alpha, numeric or an alpha-numeric combination.

2. The CPT has a two-digit numeric modifier series. The modifier, when appropriate, must be added to the procedure code of the basic procedure. a. Reimbursement shall be made for all of the two-digit numeric modifiers provided in the CPT, when the service is medically necessary.

(1) The guidelines in the CPT must be followed for each modifier reported by the provider.

(2) In some situations, it may be necessary for the provider to submit a report with the bill to explain the circumstances in order for a carrier to determine payment.

(3) Certain modifiers shall be reimbursed the provider’s charge, or the listed MRA, whichever is less. b. There is no additional reimbursement for any two-digit CPT Level II modifiers reported by the provider.

3. In addition to the CPT modifiers, there are three (3) workers’ compensation unique modifiers for reporting a change to the basic service. These two (2) character alpha modifiers include the following: a. Modifier –FC (Facility Charge/“Supervision and Interpretation” Radiology Services)

When a radiology procedure’s descriptor indicates that the service is for “supervision and interpretation” and the procedure is performed by a radiologist in a radiology facility, the facility charge shall be billed by adding modifier –FC to the basic radiology procedure code.

Additional reimbursement shall be made by BR to a radiologist in an independent radiology facility for a facility charge. b. Modifier –TC (Technical Component)

When the technical component of a procedure (personnel, materials, equipment, space and supplies) is rendered by a health care provider other than the physician performing the professional component of the procedure, the provider shall bill the technical component by adding modifier –TC to the appropriate procedure code. Reimbursement shall be the provider’s charge, or the listed MRA whichever is less. c. Modifier –QY (Medical Direction/CRNA Anesthesia Services)

When an anesthesiologist is not personally administering the anesthesia but is providing medical direction for the anesthesia services provided by a nurse anesthetist, not employed by the anesthesiologist, the physician shall bill for the medical direction service by adding modifier –QY to the anesthesia procedure code. The medical direction service includes the preoperative and postoperative anesthesia care. Reimbursement for medical direction services by an anesthesiologist shall be the provider’s charge, or fifty (50) percent of the anesthesia reimbursement allowance, whichever is less.

123


APPENDIX D

WORKERS’ COMPENSATION UNIQUE CODES

124


APPENDIX D. WORKERS’ COMPENSATION UNIQUE CODES

96370 Legend or prescription drugs dispensed by a physician

97260

97261

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

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.

97545

97546

Work hardening program; initial two (2) hours each day.

Work hardening program; each additional hour each day.

97750

97752

Functional capacity evaluation (FCE) with written report.

Muscle testing manually or by automated equipment with

97850 Physical reconditioning assessment; per hour.

97851 Physical reconditioning assessment; additional thirty (30)

minutes.

97852 Physical reconditioning program; per hour.

97853

99457

Physical reconditioning program; additional thirty (30) minutes.

Consensus Independent Medical Examination (CIME)

Page 6

Page 16

Page 16

Page 20

Page 20

Page 19

Page 17

Page 18

Page 18

Page 18

Page 19

Page 10

125


INDEX

126


INDEX

A

Acupuncture, 17

Anesthesia, 23

Anesthesia Reimbursement Allowance

(ARA), 25

Basic value (BV), 23

Conversion factor, 25

Physical status modifiers, 24

Qualifying circumstances, 25

Reimbursement methodology, 25

Time (TM) Units, 24

Authorization, 1

Average Wholesale Price (AWP), 7

C

B

Biofeedback, 8

By Report (BR), 4

Category III CPT codes, 2

Chiropractic manipulative treatment (CMT), 17

Commission on Accreditation of

Rehabilitation Facilities (CARF), 117

Compounding drugs, 6

Consensus Independent Medical Examination

(CIME), 10

Consultations, 9

D

Dental services, 5

Oral and maxillofacial surgery, 6

Temporomandibular joint services, 5

Drugs, 6

Average Wholesale Price (AWP), 7

Compounded, 6

National Drug Code (NDC), 6

Over-the-counter drugs, 7

Medicinal drugs, 6

Reimbursement formula, 7

Durable medical equipment (DME), 7

E

Electrodiagnostic medicine, 8

Electromyography, 8

Eligibility, 1

Evaluation and management services, 9

F

Failed appointments, 4

Federal facilities, 3

Follow-up days, 21

Functional capacity evaluation (FCE), 19

G

Global reimbursement, 21

H

Health care provider(s), 117

Home health agency, 9

Home health services, 9

I

Impairment rating, 10

Independent Medical Examination (IME), 10

Independent Medical Examination, Consensus

(CIME), 10

Individual psychotherapy, 11

Interdisciplinary pain rehabilitation program, 14

Injectable medications, 10

L

J

J codes, 10

Level I: Physical Medicine Services, 14

Level II: Physical Reconditioning Services, 18

Level III: Rehabilitation Program, 19

127


M

Manipulative treatment, 16

Maximum reimbursement allowance

(MRA), 117

Medical records, 2

Medical supplier services, 7

Medical and surgical supplies, 11

Medicinal drugs, 6

Modifiers, 123

N

National Drug Code (NDC), 6

Nerve conduction studies (NCS), 9

New patient, 118

O

Office visits, 9

Ophthalmological services, 11

Osteopathic manipulative treatment

(OMT), 17

Out-of-state providers, 3

P

Pain program, 20

Pharmaceutical reimbursement formula, 7

Physical medicine and rehabilitation, 14

General information, 14

Initial evaluation and plan of care, 15

Manipulative treatment, 16

Medical supplies, 18

Modalities and therapeutic procedures, 16

Physical reconditioning assessment, 18

Physical reconditioning program, 18

Rehabilitation program, 19

Revised plan of care, 16

Tests and measurements, 17

Therapy re-evaluation, 15

Work hardening program, 20

Professional component, 118

Provider eligibility, 1

Psychiatric services, 11

Psychological services, 11

Psychotherapy, 11

Q

Qualifying circumstances, 25

R

Radiology, 12

Facility charge modifier, 123

Professional component modifier, 118

Technical component modifier, 118

Reference materials, 120

Reimbursement information, 3

S

Section X Schedule of MRA’s, 27

Supplies, 11

Surgical services, 21

Bilateral procedures, 23

Follow-up day period, 21

General reimbursement information, 21

Global reimbursement, 21

Multiple procedures, 22

Non-physician surgical assistant, 22

Surgical assistants, 22

Surgical team, 22

Two surgeons, 22

T

Technical component, 118

Temporomandibular joint services, 5

Thermography, 13

Transcutaneous neurostimulator (TNS), 13

U

Unique codes, 125

Unlisted procedures, 118

V

Visit(s), 9

Consultation, 9

Confirmatory consultation, 9

Office visit, 9

Postoperative, 21

Preoperative, 21

W

Work hardening program, 20

Workers’ compensation unique codes, 125

Workers’ compensation unique modifiers, 123

128


X

X-rays, 12

Y

YYY Follow-up designation, 21

Z

ZZZ Follow-up designation, 21

129

2003 EDITION FLORIDA WORKERS’ COMPENSATION HEALTH CARE PROVIDER

FLORIDA WORKERS’ COMPENSATION

HEALTH CARE PROVIDER

REIMBURSEMENT MANUAL

2003 EDITION

SECTION X

SCHEDULE OF MAXIMUM REIMBURSEMENT

ALLOWANCES

APPENDIX A

DEFINITIONS

APPENDIX A. DEFINITIONS.

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APPENDIX B

DIRECTORY OF REFERENCES

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MODIFIERS

APPENDIX D

WORKERS’ COMPENSATION UNIQUE CODES

INDEX

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