CPT CODE FEE SCHEDULE NEW MEXICO MEDICAID FEE FOR … · 11057 Y $56.92 General Fee Schedule - 8/1/2016 11100 Y $75.10 General Fee Schedule - 12/1/2009 11101 Y $27.82 General Fee

NEW MEXICO MEDICAID FEE FOR SERVICECPT CODE FEE SCHEDULE

Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright © 2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Current Procedural Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright © 2015 American Medical Association. All rights reserved.Some procedure codes may be on other fee schedule tables. As explained in the CPT Disclaimer and Agreement, this table is not to be used as a guide to coverage of services by the Medicaid Program. The reimbursement amount will be $0.00 for vaccination antigen procedure codes for which "VFC Antigen" is listed and the recipient is 18 years old or younger because the antigen is distributed for free for children by the New Mexico Department of Health Vaccines for Children (VFC) Program. Use modifier 26 for professional component pricing and modifier TC for technical component pricing. The pricing notes "TC Fee Schedule" and "TC by Report" are for the technical component rates when modifier TC is used. The pricing notes "General Fee Schedule" and "General by Report" and "Manual Review Fee Schedule" are for the global rates. Rates that are $0.00 are priced and/or reviewed by the State. Some procedure codes are only payable for Alternative Benefit Plan (ABP) recipients. Please refer to the appropriate ABP resources on the HSD website. Only laboratory molecular pathology tests that involve clinical utility are reimbursed by New Mexico Medicaid and are subject to retrospective review. A test that has clinical utility means that the test results can be used to pursue effective treatment or provide other concrete clinical benefits for recipients who have a disease diagnosis relevant for the specific molecular pathology testing.

CPT Code

Tax Rate PRICING NOTE VFC MODIFIER RATE 2 PRICE START DATE

0437T Y $0.00 General Fee Schedule - 7/1/2016







10021 Y $113.18 General Fee Schedule - 1/1/2017














CPT FEES01/03/2018 at 6:55:00 AM - 1 - REF-FeeSchedC-1017


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15730 Y $1,426.74 General Fee Schedule - 1/1/2018





















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15847 Y $0.00 General by Report - 1/1/2007

























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29999 Y $0.00 Manual Review Fee Schedule - 1/1/2002














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44405 Y $0.00 26 by Report - 1/1/2015


44405 Y $0.00 TC by Report - 1/1/2015






























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51725 Y $72.96 26 Fee Schedule (FS) - 1/1/2017


51725 Y $96.03 TC Fee Schedule - 1/1/2017

51726 Y $81.63 26 Fee Schedule (FS) - 1/1/2017


51726 Y $154.29 TC Fee Schedule - 1/1/2017

51727 Y $99.94 26 Fee Schedule (FS) - 8/1/2016


51727 Y $162.90 TC Fee Schedule - 1/1/2010

51728 Y $98.56 26 Fee Schedule (FS) - 8/1/2016


51728 Y $163.86 TC Fee Schedule - 1/1/2010

51729 Y $116.67 26 Fee Schedule (FS) - 8/1/2016


51729 Y $165.79 TC Fee Schedule - 1/1/2010

51736 Y $7.97 26 Fee Schedule (FS) - 1/1/2017


51736 Y $6.27 TC Fee Schedule - 1/1/2017

51741 Y $7.97 26 Fee Schedule (FS) - 1/1/2017


51741 Y $6.58 TC Fee Schedule - 1/1/2017

51784 Y $73.32 26 Fee Schedule (FS) - 1/1/2017



CPT Code



51784 Y $100.13 TC Fee Schedule - 1/1/2017

51785 Y $79.98 26 Fee Schedule (FS) - 12/1/2009


51785 Y $136.62 TC Fee Schedule - 12/1/2009

51792 Y $53.03 26 Fee Schedule (FS) - 1/1/2017


51792 Y $135.73 TC Fee Schedule - 1/1/2017

51797 Y $38.34 26 Fee Schedule (FS) - 1/1/2017


51797 Y $62.21 TC Fee Schedule - 1/1/2017

























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54240 Y $64.38 26 Fee Schedule (FS) - 1/1/2017


54240 Y $22.61 TC Fee Schedule - 12/1/2009

54250 Y $105.87 26 Fee Schedule (FS) - 8/1/2016


54250 Y $7.20 TC Fee Schedule - 1/1/2006


















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59020 Y $39.91 26 Fee Schedule (FS) - 12/1/2009


59020 Y $21.25 TC Fee Schedule - 12/1/2009

59025 Y $32.14 26 Fee Schedule (FS) - 12/1/2009


59025 Y $8.57 TC Fee Schedule - 12/1/2009















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59510 Y $0.00 General Fee Schedule U1 $2,164.73 11/1/2013

















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62252 Y $45.89 26 Fee Schedule (FS) - 8/1/2016


62252 Y $34.13 TC Fee Schedule - 1/1/2017
























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70010 Y $61.01 26 Fee Schedule (FS) - 12/1/2009


70010 Y $156.19 TC Fee Schedule - 12/1/2009

70015 Y $44.42 26 Fee Schedule (FS) - 12/1/2009


70015 Y $48.98 TC Fee Schedule - 12/1/2009

70030 Y $7.97 26 Fee Schedule (FS) - 1/1/2017


70030 Y $15.07 TC Fee Schedule - 12/1/2009

70100 Y $8.62 26 Fee Schedule (FS) - 1/1/2017




CPT Code


70100 Y $18.50 TC Fee Schedule - 12/1/2009

70110 Y $11.91 26 Fee Schedule (FS) - 1/1/2017


70110 Y $21.71 TC Fee Schedule - 8/1/2016

70120 Y $8.62 26 Fee Schedule (FS) - 1/1/2017


70120 Y $21.71 TC Fee Schedule - 8/1/2016

70130 Y $16.25 26 Fee Schedule (FS) - 1/1/2017


70130 Y $28.44 TC Fee Schedule - 12/1/2009

70134 Y $16.49 26 Fee Schedule (FS) - 1/1/2017


70134 Y $26.71 TC Fee Schedule - 12/1/2009

70140 Y $9.35 26 Fee Schedule (FS) - 8/1/2016


70140 Y $16.49 TC Fee Schedule - 1/1/2017

70150 Y $12.59 26 Fee Schedule (FS) - 8/1/2016


70150 Y $24.22 TC Fee Schedule - 1/1/2017

70160 Y $8.28 26 Fee Schedule (FS) - 1/1/2017


70160 Y $18.50 TC Fee Schedule - 12/1/2009

70170 Y $14.58 26 Fee Schedule (FS) - 8/1/2016

70190 Y $10.41 26 Fee Schedule (FS) - 8/1/2016


70190 Y $21.13 TC Fee Schedule - 1/1/2017

70200 Y $13.23 26 Fee Schedule (FS) - 1/1/2017


70200 Y $24.22 TC Fee Schedule - 1/1/2017

70210 Y $8.28 26 Fee Schedule (FS) - 1/1/2017


70210 Y $18.03 TC Fee Schedule - 1/1/2017

70220 Y $11.91 26 Fee Schedule (FS) - 1/1/2017



CPT Code



70220 Y $21.44 TC Fee Schedule - 1/1/2017

70240 Y $9.35 26 Fee Schedule (FS) - 8/1/2016


70240 Y $15.07 TC Fee Schedule - 12/1/2009

70250 Y $11.86 26 Fee Schedule (FS) - 8/1/2016


70250 Y $20.20 TC Fee Schedule - 1/1/2017

70260 Y $16.88 26 Fee Schedule (FS) - 8/1/2016


70260 Y $24.22 TC Fee Schedule - 1/1/2017

70300 Y $5.68 26 Fee Schedule (FS) - 8/1/2016


70300 Y $7.82 TC Fee Schedule - 1/1/2017

70310 Y $7.63 26 Fee Schedule (FS) - 1/1/2017


70310 Y $15.07 TC Fee Schedule - 12/1/2009

70320 Y $11.12 26 Fee Schedule (FS) - 8/1/2016


70320 Y $28.44 TC Fee Schedule - 12/1/2009

70328 Y $8.62 26 Fee Schedule (FS) - 1/1/2017


70328 Y $17.47 TC Fee Schedule - 12/1/2009

70330 Y $11.86 26 Fee Schedule (FS) - 8/1/2016


70330 Y $29.27 TC Fee Schedule - 8/1/2016

70332 Y $27.24 26 Fee Schedule (FS) - 8/1/2016


70332 Y $43.41 TC Fee Schedule - 1/1/2017

70336 Y $69.37 26 Fee Schedule (FS) - 1/1/2017


70336 Y $213.72 TC Fee Schedule - 1/1/2017

70350 Y $8.84 26 Fee Schedule (FS) - 8/1/2016



CPT Code



70350 Y $8.44 TC Fee Schedule - 1/1/2017

70355 Y $10.04 26 Fee Schedule (FS) - 8/1/2016


70355 Y $8.13 TC Fee Schedule - 1/1/2017

70360 Y $7.97 26 Fee Schedule (FS) - 1/1/2017


70360 Y $15.07 TC Fee Schedule - 12/1/2009

70370 Y $15.48 26 Fee Schedule (FS) - 8/1/2016


70370 Y $47.27 TC Fee Schedule - 12/1/2009

70371 Y $40.46 26 Fee Schedule (FS) - 1/1/2017


70371 Y $41.87 TC Fee Schedule - 1/1/2017

70380 Y $8.60 26 Fee Schedule (FS) - 8/1/2016


70380 Y $23.35 TC Fee Schedule - 8/1/2016

70390 Y $17.92 26 Fee Schedule (FS) - 1/1/2017


70390 Y $62.49 TC Fee Schedule - 8/1/2016

70450 Y $40.18 26 Fee Schedule (FS) - 1/1/2017


70450 Y $63.22 TC Fee Schedule - 1/1/2017

70460 Y $53.40 26 Fee Schedule (FS) - 1/1/2017


70460 Y $90.77 TC Fee Schedule - 1/1/2017

70470 Y $60.06 26 Fee Schedule (FS) - 1/1/2017


70470 Y $110.26 TC Fee Schedule - 1/1/2017

70480 Y $60.71 26 Fee Schedule (FS) - 1/1/2017


70480 Y $97.26 TC Fee Schedule - 1/1/2017

70481 Y $65.39 26 Fee Schedule (FS) - 1/1/2017



CPT Code



70481 Y $178.98 TC Fee Schedule - 1/1/2017

70482 Y $68.37 26 Fee Schedule (FS) - 1/1/2017


70482 Y $198.25 TC Fee Schedule - 1/1/2017

70486 Y $40.49 26 Fee Schedule (FS) - 1/1/2017


70486 Y $83.96 TC Fee Schedule - 1/1/2017

70487 Y $53.40 26 Fee Schedule (FS) - 1/1/2017


70487 Y $96.34 TC Fee Schedule - 1/1/2017

70488 Y $60.06 26 Fee Schedule (FS) - 1/1/2017


70488 Y $122.33 TC Fee Schedule - 1/1/2017

70490 Y $60.71 26 Fee Schedule (FS) - 1/1/2017


70490 Y $96.95 TC Fee Schedule - 1/1/2017

70491 Y $65.70 26 Fee Schedule (FS) - 1/1/2017


70491 Y $143.69 TC Fee Schedule - 1/1/2017

70492 Y $68.37 26 Fee Schedule (FS) - 1/1/2017


70492 Y $177.43 TC Fee Schedule - 1/1/2017

70496 Y $82.65 26 Fee Schedule (FS) - 1/1/2017


70496 Y $179.05 TC Fee Schedule - 1/1/2017

70498 Y $82.65 26 Fee Schedule (FS) - 1/1/2017


70498 Y $177.82 TC Fee Schedule - 1/1/2017

70540 Y $63.76 26 Fee Schedule (FS) - 1/1/2017


70540 Y $236.01 TC Fee Schedule - 1/1/2017

70542 Y $76.65 26 Fee Schedule (FS) - 1/1/2017



CPT Code



70542 Y $277.79 TC Fee Schedule - 1/1/2017

70543 Y $101.24 26 Fee Schedule (FS) - 1/1/2017


70543 Y $332.88 TC Fee Schedule - 1/1/2017

70544 Y $56.77 26 Fee Schedule (FS) - 1/1/2017


70544 Y $236.01 TC Fee Schedule - 1/1/2017

70545 Y $56.77 26 Fee Schedule (FS) - 1/1/2017


70545 Y $283.35 TC Fee Schedule - 1/1/2017

70546 Y $84.96 26 Fee Schedule (FS) - 1/1/2017


70546 Y $391.69 TC Fee Schedule - 1/1/2017

70547 Y $57.08 26 Fee Schedule (FS) - 1/1/2017


70547 Y $236.01 TC Fee Schedule - 1/1/2017

70548 Y $56.77 26 Fee Schedule (FS) - 1/1/2017


70548 Y $305.64 TC Fee Schedule - 1/1/2017

70549 Y $84.96 26 Fee Schedule (FS) - 1/1/2017


70549 Y $391.69 TC Fee Schedule - 1/1/2017

70551 Y $69.99 26 Fee Schedule (FS) - 1/1/2017


70551 Y $135.02 TC Fee Schedule - 1/1/2017

70552 Y $84.28 26 Fee Schedule (FS) - 1/1/2017


70552 Y $199.18 TC Fee Schedule - 1/1/2017

70553 Y $108.51 26 Fee Schedule (FS) - 1/1/2017


70553 Y $227.03 TC Fee Schedule - 1/1/2017

70554 Y $88.03 26 Fee Schedule (FS) - 12/1/2009



CPT Code



70554 Y $298.30 TC Fee Schedule - 1/1/2017

70555 Y $25.71 26 Fee Schedule (FS) - 12/1/2009

70557 Y $138.05 26 Fee Schedule (FS) - 1/1/2017

70558 Y $151.95 26 Fee Schedule (FS) - 1/1/2017

70559 Y $153.13 26 Fee Schedule (FS) - 1/1/2017

71045 Y $8.58 26 Fee Schedule (FS) - 1/1/2018


71045 Y $9.46 TC Fee Schedule - 1/1/2018

71046 Y $10.23 26 Fee Schedule (FS) - 1/1/2018


71046 Y $17.25 TC Fee Schedule - 1/1/2018

71047 Y $13.13 26 Fee Schedule (FS) - 1/1/2018


71047 Y $21.93 TC Fee Schedule - 1/1/2018

71048 Y $15.09 26 Fee Schedule (FS) - 1/1/2018


71048 Y $22.55 TC Fee Schedule - 1/1/2018

71100 Y $10.78 26 Fee Schedule (FS) - 8/1/2016


71100 Y $18.65 TC Fee Schedule - 1/1/2017

71101 Y $12.97 26 Fee Schedule (FS) - 1/1/2017


71101 Y $19.58 TC Fee Schedule - 1/1/2017

71110 Y $12.89 26 Fee Schedule (FS) - 1/1/2017


71110 Y $20.51 TC Fee Schedule - 1/1/2017

71111 Y $15.48 26 Fee Schedule (FS) - 8/1/2016


71111 Y $27.01 TC Fee Schedule - 1/1/2017

71120 Y $9.61 26 Fee Schedule (FS) - 1/1/2017


71120 Y $16.80 TC Fee Schedule - 1/1/2017



CPT Code


71130 Y $10.78 26 Fee Schedule (FS) - 8/1/2016


71130 Y $21.44 TC Fee Schedule - 1/1/2017

71250 Y $48.46 26 Fee Schedule (FS) - 1/1/2017


71250 Y $96.95 TC Fee Schedule - 1/1/2017

71260 Y $59.04 26 Fee Schedule (FS) - 1/1/2017


71260 Y $144.31 TC Fee Schedule - 1/1/2017

71270 Y $65.39 26 Fee Schedule (FS) - 1/1/2017


71270 Y $178.05 TC Fee Schedule - 1/1/2017

71275 Y $85.94 26 Fee Schedule (FS) - 1/1/2017


71275 Y $180.29 TC Fee Schedule - 1/1/2017

71550 Y $69.01 26 Fee Schedule (FS) - 1/1/2017


71550 Y $236.01 TC Fee Schedule - 1/1/2017

71551 Y $81.68 26 Fee Schedule (FS) - 1/1/2017


71551 Y $322.04 TC Fee Schedule - 1/1/2017

71552 Y $106.89 26 Fee Schedule (FS) - 1/1/2017


71552 Y $391.76 TC Fee Schedule - 1/1/2017

71555 Y $84.59 26 Fee Schedule (FS) - 1/1/2017


71555 Y $266.34 TC Fee Schedule - 1/1/2017

72020 Y $7.30 26 Fee Schedule (FS) - 1/1/2017


72020 Y $12.46 TC Fee Schedule - 1/1/2017

72040 Y $10.78 26 Fee Schedule (FS) - 8/1/2016


72040 Y $18.96 TC Fee Schedule - 1/1/2017



CPT Code


72050 Y $15.10 26 Fee Schedule (FS) - 8/1/2016


72050 Y $25.15 TC Fee Schedule - 1/1/2017

72052 Y $17.24 26 Fee Schedule (FS) - 1/1/2017


72052 Y $32.89 TC Fee Schedule - 1/1/2017

72070 Y $10.78 26 Fee Schedule (FS) - 8/1/2016


72070 Y $19.58 TC Fee Schedule - 1/1/2017

72072 Y $10.27 26 Fee Schedule (FS) - 1/1/2017


72072 Y $20.51 TC Fee Schedule - 1/1/2017

72074 Y $10.27 26 Fee Schedule (FS) - 1/1/2017


72074 Y $24.53 TC Fee Schedule - 1/1/2017

72080 Y $10.27 26 Fee Schedule (FS) - 1/1/2017


72080 Y $17.11 TC Fee Schedule - 1/1/2017

72081 Y $12.63 26 Fee Schedule (FS) - 8/1/2016


72081 Y $22.05 TC Fee Schedule - 8/1/2016

72082 Y $15.25 26 Fee Schedule (FS) - 8/1/2016


72082 Y $40.01 TC Fee Schedule - 8/1/2016

72083 Y $16.59 26 Fee Schedule (FS) - 8/1/2016


72083 Y $43.41 TC Fee Schedule - 8/1/2016

72084 Y $19.23 26 Fee Schedule (FS) - 8/1/2016


72084 Y $52.08 TC Fee Schedule - 8/1/2016

72100 Y $10.78 26 Fee Schedule (FS) - 8/1/2016


72100 Y $20.51 TC Fee Schedule - 1/1/2017



CPT Code


72110 Y $15.10 26 Fee Schedule (FS) - 8/1/2016


72110 Y $28.56 TC Fee Schedule - 1/1/2017

72114 Y $15.59 26 Fee Schedule (FS) - 1/1/2017


72114 Y $39.70 TC Fee Schedule - 1/1/2017

72120 Y $10.78 26 Fee Schedule (FS) - 8/1/2016


72120 Y $25.15 TC Fee Schedule - 1/1/2017

72125 Y $50.76 26 Fee Schedule (FS) - 1/1/2017


72125 Y $96.95 TC Fee Schedule - 1/1/2017

72126 Y $57.75 26 Fee Schedule (FS) - 1/1/2017


72126 Y $145.24 TC Fee Schedule - 1/1/2017

72127 Y $60.06 26 Fee Schedule (FS) - 1/1/2017


72127 Y $179.29 TC Fee Schedule - 1/1/2017

72128 Y $47.48 26 Fee Schedule (FS) - 1/1/2017


72128 Y $96.95 TC Fee Schedule - 1/1/2017

72129 Y $57.75 26 Fee Schedule (FS) - 1/1/2017


72129 Y $145.55 TC Fee Schedule - 1/1/2017

72130 Y $60.06 26 Fee Schedule (FS) - 1/1/2017


72130 Y $180.83 TC Fee Schedule - 1/1/2017

72131 Y $47.48 26 Fee Schedule (FS) - 1/1/2017


72131 Y $96.95 TC Fee Schedule - 1/1/2017

72132 Y $57.75 26 Fee Schedule (FS) - 1/1/2017


72132 Y $144.62 TC Fee Schedule - 1/1/2017



CPT Code


72133 Y $60.14 26 Fee Schedule (FS) - 1/1/2017


72133 Y $178.98 TC Fee Schedule - 1/1/2017

72141 Y $70.39 26 Fee Schedule (FS) - 1/1/2017


72141 Y $128.84 TC Fee Schedule - 1/1/2017

72142 Y $84.99 26 Fee Schedule (FS) - 1/1/2017


72142 Y $203.20 TC Fee Schedule - 1/1/2017

72146 Y $70.39 26 Fee Schedule (FS) - 1/1/2017


72146 Y $129.15 TC Fee Schedule - 1/1/2017

72147 Y $84.28 26 Fee Schedule (FS) - 1/1/2017


72147 Y $200.72 TC Fee Schedule - 1/1/2017

72148 Y $70.39 26 Fee Schedule (FS) - 1/1/2017


72148 Y $127.91 TC Fee Schedule - 1/1/2017

72149 Y $84.68 26 Fee Schedule (FS) - 1/1/2017


72149 Y $199.80 TC Fee Schedule - 1/1/2017

72156 Y $108.51 26 Fee Schedule (FS) - 1/1/2017


72156 Y $228.58 TC Fee Schedule - 1/1/2017

72157 Y $108.51 26 Fee Schedule (FS) - 1/1/2017


72157 Y $228.89 TC Fee Schedule - 1/1/2017

72158 Y $108.51 26 Fee Schedule (FS) - 1/1/2017


72158 Y $227.65 TC Fee Schedule - 1/1/2017

72159 Y $80.66 26 Fee Schedule (FS) - 8/1/2016


72159 Y $265.24 TC Fee Schedule - 8/1/2016



CPT Code


72170 Y $8.28 26 Fee Schedule (FS) - 1/1/2017


72170 Y $18.50 TC Fee Schedule - 12/1/2009

72190 Y $10.41 26 Fee Schedule (FS) - 8/1/2016


72190 Y $23.35 TC Fee Schedule - 8/1/2016

72191 Y $85.38 26 Fee Schedule (FS) - 1/1/2017


72191 Y $185.87 TC Fee Schedule - 1/1/2017

72192 Y $51.44 26 Fee Schedule (FS) - 1/1/2017


72192 Y $78.70 TC Fee Schedule - 1/1/2017

72193 Y $55.11 26 Fee Schedule (FS) - 1/1/2017


72193 Y $144.93 TC Fee Schedule - 1/1/2017

72194 Y $57.44 26 Fee Schedule (FS) - 1/1/2017


72194 Y $172.47 TC Fee Schedule - 1/1/2017

72195 Y $69.01 26 Fee Schedule (FS) - 1/1/2017


72195 Y $236.01 TC Fee Schedule - 1/1/2017

72196 Y $81.98 26 Fee Schedule (FS) - 1/1/2017


72196 Y $280.88 TC Fee Schedule - 1/1/2017

72197 Y $106.89 26 Fee Schedule (FS) - 1/1/2017


72197 Y $339.38 TC Fee Schedule - 1/1/2017

72198 Y $84.34 26 Fee Schedule (FS) - 1/1/2017


72198 Y $269.12 TC Fee Schedule - 1/1/2017

72200 Y $8.28 26 Fee Schedule (FS) - 1/1/2017


72200 Y $17.11 TC Fee Schedule - 1/1/2017



CPT Code


72202 Y $8.96 26 Fee Schedule (FS) - 1/1/2017


72202 Y $20.20 TC Fee Schedule - 1/1/2017

72220 Y $8.28 26 Fee Schedule (FS) - 1/1/2017


72220 Y $16.80 TC Fee Schedule - 1/1/2017

72240 Y $43.13 26 Fee Schedule (FS) - 1/1/2017


72240 Y $44.96 TC Fee Schedule - 1/1/2017

72255 Y $43.92 26 Fee Schedule (FS) - 8/1/2016


72255 Y $44.03 TC Fee Schedule - 1/1/2017

72265 Y $40.30 26 Fee Schedule (FS) - 8/1/2016


72265 Y $43.41 TC Fee Schedule - 1/1/2017

72270 Y $63.39 26 Fee Schedule (FS) - 1/1/2017


72270 Y $51.77 TC Fee Schedule - 1/1/2017

72275 Y $36.06 26 Fee Schedule (FS) - 8/1/2016


72275 Y $66.32 TC Fee Schedule - 1/1/2017

72285 Y $57.14 26 Fee Schedule (FS) - 8/1/2016


72285 Y $46.20 TC Fee Schedule - 1/1/2017

72295 Y $41.63 26 Fee Schedule (FS) - 8/1/2016


72295 Y $48.05 TC Fee Schedule - 1/1/2017

73000 Y $7.90 26 Fee Schedule (FS) - 8/1/2016


73000 Y $16.49 TC Fee Schedule - 1/1/2017

73010 Y $8.60 26 Fee Schedule (FS) - 8/1/2016


73010 Y $17.76 TC Fee Schedule - 8/1/2016



CPT Code


73020 Y $7.30 26 Fee Schedule (FS) - 1/1/2017


73020 Y $13.08 TC Fee Schedule - 1/1/2017

73030 Y $8.98 26 Fee Schedule (FS) - 8/1/2016


73030 Y $16.80 TC Fee Schedule - 1/1/2017

73040 Y $25.86 26 Fee Schedule (FS) - 1/1/2017


73040 Y $62.91 TC Fee Schedule - 1/1/2017

73050 Y $10.04 26 Fee Schedule (FS) - 8/1/2016


73050 Y $21.74 TC Fee Schedule - 1/1/2017

73060 Y $7.94 26 Fee Schedule (FS) - 1/1/2017


73060 Y $17.72 TC Fee Schedule - 1/1/2017

73070 Y $7.54 26 Fee Schedule (FS) - 8/1/2016


73070 Y $16.80 TC Fee Schedule - 1/1/2017

73080 Y $8.28 26 Fee Schedule (FS) - 1/1/2017


73080 Y $19.27 TC Fee Schedule - 1/1/2017

73085 Y $26.92 26 Fee Schedule (FS) - 8/1/2016


73085 Y $59.50 TC Fee Schedule - 1/1/2017

73090 Y $7.90 26 Fee Schedule (FS) - 8/1/2016


73090 Y $14.94 TC Fee Schedule - 1/1/2017

73092 Y $7.63 26 Fee Schedule (FS) - 1/1/2017


73092 Y $16.77 TC Fee Schedule - 8/1/2016

73100 Y $7.90 26 Fee Schedule (FS) - 8/1/2016


73100 Y $16.77 TC Fee Schedule - 8/1/2016



CPT Code


73110 Y $8.28 26 Fee Schedule (FS) - 1/1/2017


73110 Y $18.83 TC Fee Schedule - 12/1/2009

73115 Y $26.58 26 Fee Schedule (FS) - 8/1/2016


73115 Y $57.55 TC Fee Schedule - 12/1/2009

73120 Y $7.90 26 Fee Schedule (FS) - 8/1/2016


73120 Y $15.25 TC Fee Schedule - 1/1/2017

73130 Y $8.28 26 Fee Schedule (FS) - 1/1/2017


73130 Y $18.08 TC Fee Schedule - 8/1/2016

73140 Y $6.46 26 Fee Schedule (FS) - 8/1/2016


73140 Y $15.07 TC Fee Schedule - 12/1/2009

73200 Y $47.48 26 Fee Schedule (FS) - 1/1/2017


73200 Y $96.95 TC Fee Schedule - 1/1/2017

73201 Y $55.11 26 Fee Schedule (FS) - 1/1/2017


73201 Y $142.15 TC Fee Schedule - 1/1/2017

73202 Y $57.75 26 Fee Schedule (FS) - 1/1/2017


73202 Y $187.33 TC Fee Schedule - 1/1/2017

73206 Y $84.99 26 Fee Schedule (FS) - 1/1/2017


73206 Y $204.12 TC Fee Schedule - 1/1/2017

73218 Y $64.07 26 Fee Schedule (FS) - 1/1/2017


73218 Y $236.01 TC Fee Schedule - 1/1/2017

73219 Y $76.65 26 Fee Schedule (FS) - 1/1/2017


73219 Y $279.64 TC Fee Schedule - 1/1/2017



CPT Code


73220 Y $101.86 26 Fee Schedule (FS) - 1/1/2017


73220 Y $339.38 TC Fee Schedule - 1/1/2017

73221 Y $64.38 26 Fee Schedule (FS) - 1/1/2017


73221 Y $145.32 TC Fee Schedule - 1/1/2017

73222 Y $76.96 26 Fee Schedule (FS) - 1/1/2017


73222 Y $256.74 TC Fee Schedule - 1/1/2017

73223 Y $101.86 26 Fee Schedule (FS) - 1/1/2017


73223 Y $312.76 TC Fee Schedule - 1/1/2017

73225 Y $80.66 26 Fee Schedule (FS) - 8/1/2016


73225 Y $265.24 TC Fee Schedule - 8/1/2016

73501 Y $8.93 26 Fee Schedule (FS) - 8/1/2016


73501 Y $17.72 TC Fee Schedule - 8/1/2016

73502 Y $10.58 26 Fee Schedule (FS) - 8/1/2016


73502 Y $26.08 TC Fee Schedule - 8/1/2016

73503 Y $13.59 26 Fee Schedule (FS) - 8/1/2016


73503 Y $32.27 TC Fee Schedule - 8/1/2016

73521 Y $10.89 26 Fee Schedule (FS) - 8/1/2016


73521 Y $24.53 TC Fee Schedule - 8/1/2016

73522 Y $14.26 26 Fee Schedule (FS) - 8/1/2016


73522 Y $29.18 TC Fee Schedule - 8/1/2016

73523 Y $15.25 26 Fee Schedule (FS) - 8/1/2016


73523 Y $35.05 TC Fee Schedule - 8/1/2016



CPT Code


73525 Y $26.92 26 Fee Schedule (FS) - 8/1/2016


73525 Y $63.22 TC Fee Schedule - 1/1/2017

73551 Y $7.94 26 Fee Schedule (FS) - 8/1/2016


73551 Y $16.80 TC Fee Schedule - 8/1/2016

73552 Y $8.93 26 Fee Schedule (FS) - 8/1/2016


73552 Y $19.89 TC Fee Schedule - 8/1/2016

73560 Y $7.94 26 Fee Schedule (FS) - 1/1/2017


73560 Y $18.50 TC Fee Schedule - 12/1/2009

73562 Y $8.98 26 Fee Schedule (FS) - 8/1/2016


73562 Y $20.90 TC Fee Schedule - 12/1/2009

73564 Y $10.78 26 Fee Schedule (FS) - 8/1/2016


73564 Y $22.61 TC Fee Schedule - 12/1/2009

73565 Y $8.25 26 Fee Schedule (FS) - 1/1/2017


73565 Y $17.47 TC Fee Schedule - 12/1/2009

73580 Y $26.59 26 Fee Schedule (FS) - 8/1/2016


73580 Y $75.29 TC Fee Schedule - 1/1/2017

73590 Y $7.94 26 Fee Schedule (FS) - 1/1/2017


73590 Y $17.76 TC Fee Schedule - 8/1/2016

73592 Y $7.63 26 Fee Schedule (FS) - 1/1/2017


73592 Y $16.77 TC Fee Schedule - 8/1/2016

73600 Y $7.90 26 Fee Schedule (FS) - 8/1/2016


73600 Y $17.47 TC Fee Schedule - 12/1/2009



CPT Code


73610 Y $8.28 26 Fee Schedule (FS) - 1/1/2017


73610 Y $18.08 TC Fee Schedule - 8/1/2016

73615 Y $26.92 26 Fee Schedule (FS) - 8/1/2016


73615 Y $66.32 TC Fee Schedule - 1/1/2017

73620 Y $7.32 26 Fee Schedule (FS) - 1/1/2017


73620 Y $15.87 TC Fee Schedule - 1/1/2017

73630 Y $7.97 26 Fee Schedule (FS) - 1/1/2017


73630 Y $18.08 TC Fee Schedule - 8/1/2016

73650 Y $7.63 26 Fee Schedule (FS) - 1/1/2017


73650 Y $16.11 TC Fee Schedule - 8/1/2016

73660 Y $6.32 26 Fee Schedule (FS) - 1/1/2017


73660 Y $15.07 TC Fee Schedule - 12/1/2009

73700 Y $47.48 26 Fee Schedule (FS) - 1/1/2017


73700 Y $96.95 TC Fee Schedule - 1/1/2017

73701 Y $55.11 26 Fee Schedule (FS) - 1/1/2017


73701 Y $145.24 TC Fee Schedule - 1/1/2017

73702 Y $57.44 26 Fee Schedule (FS) - 1/1/2017


73702 Y $185.16 TC Fee Schedule - 1/1/2017

73706 Y $89.34 26 Fee Schedule (FS) - 1/1/2017


73706 Y $204.52 TC Fee Schedule - 1/1/2017

73718 Y $64.07 26 Fee Schedule (FS) - 1/1/2017


73718 Y $236.01 TC Fee Schedule - 1/1/2017



CPT Code


73719 Y $76.65 26 Fee Schedule (FS) - 1/1/2017


73719 Y $279.64 TC Fee Schedule - 1/1/2017

73720 Y $101.55 26 Fee Schedule (FS) - 1/1/2017


73720 Y $341.85 TC Fee Schedule - 1/1/2017

73721 Y $64.38 26 Fee Schedule (FS) - 1/1/2017


73721 Y $145.62 TC Fee Schedule - 1/1/2017

73722 Y $76.96 26 Fee Schedule (FS) - 1/1/2017


73722 Y $260.15 TC Fee Schedule - 1/1/2017

73723 Y $101.55 26 Fee Schedule (FS) - 1/1/2017


73723 Y $314.00 TC Fee Schedule - 1/1/2017

73725 Y $85.01 26 Fee Schedule (FS) - 1/1/2017


73725 Y $269.43 TC Fee Schedule - 1/1/2017

74018 Y $8.58 26 Fee Schedule (FS) - 1/1/2018


74018 Y $19.12 TC Fee Schedule - 1/1/2018

74019 Y $10.87 26 Fee Schedule (FS) - 1/1/2018


74019 Y $19.12 TC Fee Schedule - 1/1/2018

74021 Y $12.93 26 Fee Schedule (FS) - 1/1/2018


74021 Y $22.24 TC Fee Schedule - 1/1/2018

74022 Y $15.48 26 Fee Schedule (FS) - 8/1/2016


74022 Y $24.53 TC Fee Schedule - 1/1/2017

74150 Y $56.43 26 Fee Schedule (FS) - 1/1/2017


74150 Y $77.46 TC Fee Schedule - 1/1/2017



CPT Code


74160 Y $60.06 26 Fee Schedule (FS) - 1/1/2017


74160 Y $144.31 TC Fee Schedule - 1/1/2017

74170 Y $66.37 26 Fee Schedule (FS) - 1/1/2017


74170 Y $165.98 TC Fee Schedule - 1/1/2017

74174 Y $99.20 26 Fee Schedule (FS) - 8/1/2016


74174 Y $240.96 TC Fee Schedule - 1/1/2017

74175 Y $85.63 26 Fee Schedule (FS) - 1/1/2017


74175 Y $186.80 TC Fee Schedule - 1/1/2017

74176 Y $80.27 26 Fee Schedule (FS) - 8/1/2016


74176 Y $96.95 TC Fee Schedule - 1/1/2017

74177 Y $84.12 26 Fee Schedule (FS) - 8/1/2016


74177 Y $190.12 TC Fee Schedule - 1/1/2017

74178 Y $93.16 26 Fee Schedule (FS) - 8/1/2016


74178 Y $218.05 TC Fee Schedule - 1/1/2017

74181 Y $69.01 26 Fee Schedule (FS) - 1/1/2017


74181 Y $224.87 TC Fee Schedule - 1/1/2017

74182 Y $81.98 26 Fee Schedule (FS) - 1/1/2017


74182 Y $318.02 TC Fee Schedule - 1/1/2017

74183 Y $106.89 26 Fee Schedule (FS) - 1/1/2017


74183 Y $340.31 TC Fee Schedule - 1/1/2017

74185 Y $84.65 26 Fee Schedule (FS) - 1/1/2017


74185 Y $271.28 TC Fee Schedule - 1/1/2017



CPT Code


74190 Y $22.29 26 Fee Schedule (FS) - 1/1/2017

74210 Y $16.93 26 Fee Schedule (FS) - 1/1/2017


74210 Y $42.82 TC Fee Schedule - 12/1/2009

74220 Y $21.93 26 Fee Schedule (FS) - 1/1/2017


74220 Y $42.82 TC Fee Schedule - 12/1/2009

74230 Y $25.21 26 Fee Schedule (FS) - 1/1/2017


74230 Y $47.27 TC Fee Schedule - 12/1/2009

74235 Y $57.96 26 Fee Schedule (FS) - 8/1/2016

74240 Y $32.85 26 Fee Schedule (FS) - 1/1/2017


74240 Y $52.75 TC Fee Schedule - 12/1/2009

74241 Y $32.85 26 Fee Schedule (FS) - 1/1/2017


74241 Y $53.78 TC Fee Schedule - 12/1/2009

74245 Y $43.13 26 Fee Schedule (FS) - 1/1/2017


74245 Y $86.32 TC Fee Schedule - 12/1/2009

74246 Y $32.54 26 Fee Schedule (FS) - 1/1/2017


74246 Y $59.61 TC Fee Schedule - 12/1/2009

74247 Y $32.85 26 Fee Schedule (FS) - 1/1/2017


74247 Y $61.31 TC Fee Schedule - 12/1/2009

74249 Y $43.13 26 Fee Schedule (FS) - 1/1/2017


74249 Y $93.17 TC Fee Schedule - 12/1/2009

74250 Y $22.26 26 Fee Schedule (FS) - 1/1/2017


74250 Y $47.27 TC Fee Schedule - 12/1/2009

74251 Y $31.80 26 Fee Schedule (FS) - 8/1/2016



CPT Code



74251 Y $47.27 TC Fee Schedule - 12/1/2009

74260 Y $23.58 26 Fee Schedule (FS) - 1/1/2017


74260 Y $53.78 TC Fee Schedule - 12/1/2009

74261 Y $106.17 26 Fee Schedule (FS) - 1/1/2010


74261 Y $97.26 TC Fee Schedule - 1/1/2017

74262 Y $111.87 26 Fee Schedule (FS) - 8/1/2016


74262 Y $204.05 TC Fee Schedule - 1/1/2017

74263 Y $0.00 26 by Report - 1/1/2010


74263 Y $0.00 TC by Report - 1/1/2010

74270 Y $32.85 26 Fee Schedule (FS) - 1/1/2017


74270 Y $62.00 TC Fee Schedule - 12/1/2009

74280 Y $47.14 26 Fee Schedule (FS) - 1/1/2017


74280 Y $81.19 TC Fee Schedule - 12/1/2009

74283 Y $78.60 26 Fee Schedule (FS) - 12/1/2009


74283 Y $89.12 TC Fee Schedule - 8/1/2016

74290 Y $15.48 26 Fee Schedule (FS) - 8/1/2016


74290 Y $26.71 TC Fee Schedule - 12/1/2009

74300 Y $17.32 26 Fee Schedule (FS) - 1/1/2017

74301 Y $10.02 26 Fee Schedule (FS) - 1/1/2017

74328 Y $34.15 26 Fee Schedule (FS) - 8/1/2016

74329 Y $34.15 26 Fee Schedule (FS) - 8/1/2016

74330 Y $42.79 26 Fee Schedule (FS) - 1/1/2017

74340 Y $25.55 26 Fee Schedule (FS) - 1/1/2017

74355 Y $36.99 26 Fee Schedule (FS) - 8/1/2016



CPT Code


74360 Y $26.64 26 Fee Schedule (FS) - 8/1/2016

74363 Y $40.57 26 Fee Schedule (FS) - 1/1/2017

74400 Y $23.25 26 Fee Schedule (FS) - 1/1/2017


74400 Y $61.31 TC Fee Schedule - 12/1/2009

74410 Y $22.94 26 Fee Schedule (FS) - 1/1/2017


74410 Y $68.07 TC Fee Schedule - 8/1/2016

74415 Y $23.25 26 Fee Schedule (FS) - 1/1/2017


74415 Y $77.07 TC Fee Schedule - 12/1/2009

74420 Y $16.53 26 Fee Schedule (FS) - 1/1/2017

74425 Y $16.62 26 Fee Schedule (FS) - 1/1/2017

74430 Y $14.96 26 Fee Schedule (FS) - 1/1/2017


74430 Y $18.65 TC Fee Schedule - 1/1/2017

74440 Y $17.21 26 Fee Schedule (FS) - 1/1/2017


74440 Y $40.76 TC Fee Schedule - 12/1/2009

74445 Y $39.54 26 Fee Schedule (FS) - 12/1/2009

74450 Y $15.61 26 Fee Schedule (FS) - 1/1/2017

74455 Y $15.61 26 Fee Schedule (FS) - 1/1/2017


74455 Y $55.25 TC Fee Schedule - 8/1/2016

74470 Y $24.93 26 Fee Schedule (FS) - 1/1/2017

74485 Y $24.54 26 Fee Schedule (FS) - 1/1/2017


74485 Y $57.34 TC Fee Schedule - 1/1/2017

74710 Y $16.25 26 Fee Schedule (FS) - 1/1/2017


74710 Y $16.80 TC Fee Schedule - 1/1/2017

74712 Y $151.43 26 Fee Schedule (FS) - 1/1/2016




CPT Code


74712 Y $251.07 TC Fee Schedule - 1/1/2016

74713 Y $89.66 26 Fee Schedule (FS) - 1/1/2016


74713 Y $130.47 TC Fee Schedule - 1/1/2016

74740 Y $17.92 26 Fee Schedule (FS) - 1/1/2017


74740 Y $45.38 TC Fee Schedule - 8/1/2016

74742 Y $27.98 26 Fee Schedule (FS) - 1/1/2017

74775 Y $29.56 26 Fee Schedule (FS) - 1/1/2017

75557 Y $97.40 26 Fee Schedule (FS) - 12/1/2009


75557 Y $174.64 TC Fee Schedule - 1/1/2017

75559 Y $124.12 26 Fee Schedule (FS) - 12/1/2009


75559 Y $252.63 TC Fee Schedule - 1/1/2017

75561 Y $107.73 26 Fee Schedule (FS) - 12/1/2009


75561 Y $254.88 TC Fee Schedule - 1/1/2017

75563 Y $128.96 26 Fee Schedule (FS) - 12/1/2009


75563 Y $307.19 TC Fee Schedule - 1/1/2017

75565 Y $11.58 26 Fee Schedule (FS) - 8/1/2016


75565 Y $36.83 TC Fee Schedule - 1/1/2017

75571 Y $25.86 26 Fee Schedule (FS) - 8/1/2016


75571 Y $11.22 TC Fee Schedule - 1/1/2017

75572 Y $78.46 26 Fee Schedule (FS) - 8/1/2016


75572 Y $158.40 TC Fee Schedule - 1/1/2010

75573 Y $112.35 26 Fee Schedule (FS) - 8/1/2016


75573 Y $204.12 TC Fee Schedule - 1/1/2017



CPT Code


75574 Y $106.92 26 Fee Schedule (FS) - 8/1/2016


75574 Y $204.12 TC Fee Schedule - 1/1/2017

75600 Y $23.10 26 Fee Schedule (FS) - 1/1/2017


75600 Y $150.81 TC Fee Schedule - 1/1/2017

75605 Y $53.14 26 Fee Schedule (FS) - 1/1/2017


75605 Y $72.19 TC Fee Schedule - 1/1/2017

75625 Y $53.38 26 Fee Schedule (FS) - 1/1/2017


75625 Y $71.58 TC Fee Schedule - 1/1/2017

75630 Y $84.04 26 Fee Schedule (FS) - 1/1/2017


75630 Y $71.58 TC Fee Schedule - 1/1/2017

75635 Y $112.61 26 Fee Schedule (FS) - 1/1/2017


75635 Y $204.52 TC Fee Schedule - 1/1/2017

75705 Y $109.08 26 Fee Schedule (FS) - 8/1/2016


75705 Y $112.51 TC Fee Schedule - 1/1/2017

75710 Y $53.69 26 Fee Schedule (FS) - 1/1/2017


75710 Y $93.32 TC Fee Schedule - 1/1/2017

75716 Y $61.35 26 Fee Schedule (FS) - 1/1/2017


75716 Y $107.02 TC Fee Schedule - 1/1/2017

75726 Y $52.66 26 Fee Schedule (FS) - 1/1/2017


75726 Y $81.48 TC Fee Schedule - 1/1/2017

75731 Y $54.05 26 Fee Schedule (FS) - 1/1/2017


75731 Y $100.13 TC Fee Schedule - 1/1/2017



CPT Code


75733 Y $59.69 26 Fee Schedule (FS) - 1/1/2017


75733 Y $104.86 TC Fee Schedule - 1/1/2017

75736 Y $52.52 26 Fee Schedule (FS) - 1/1/2017


75736 Y $91.16 TC Fee Schedule - 1/1/2017

75741 Y $60.24 26 Fee Schedule (FS) - 1/1/2017


75741 Y $75.91 TC Fee Schedule - 1/1/2017

75743 Y $76.30 26 Fee Schedule (FS) - 1/1/2017


75743 Y $76.84 TC Fee Schedule - 1/1/2017

75746 Y $53.20 26 Fee Schedule (FS) - 1/1/2017


75746 Y $83.42 TC Fee Schedule - 1/1/2017

75756 Y $53.77 26 Fee Schedule (FS) - 1/1/2017


75756 Y $95.80 TC Fee Schedule - 1/1/2017

75774 Y $16.70 26 Fee Schedule (FS) - 1/1/2017


75774 Y $61.05 TC Fee Schedule - 1/1/2017

75801 Y $41.13 26 Fee Schedule (FS) - 8/1/2016

75803 Y $55.37 26 Fee Schedule (FS) - 1/1/2017

75805 Y $38.52 26 Fee Schedule (FS) - 1/1/2017

75807 Y $56.92 26 Fee Schedule (FS) - 8/1/2016

75809 Y $20.96 26 Fee Schedule (FS) - 12/1/2009


75809 Y $28.44 TC Fee Schedule - 12/1/2009

75810 Y $54.13 26 Fee Schedule (FS) - 1/1/2017

75820 Y $28.21 26 Fee Schedule (FS) - 12/1/2009


75820 Y $34.60 TC Fee Schedule - 12/1/2009

75822 Y $43.22 26 Fee Schedule (FS) - 12/1/2009



CPT Code



75822 Y $53.43 TC Fee Schedule - 12/1/2009

75825 Y $54.00 26 Fee Schedule (FS) - 1/1/2017


75825 Y $69.72 TC Fee Schedule - 1/1/2017

75827 Y $53.77 26 Fee Schedule (FS) - 1/1/2017


75827 Y $71.58 TC Fee Schedule - 1/1/2017

75831 Y $52.52 26 Fee Schedule (FS) - 1/1/2017


75831 Y $74.05 TC Fee Schedule - 1/1/2017

75833 Y $69.29 26 Fee Schedule (FS) - 1/1/2017


75833 Y $80.01 TC Fee Schedule - 1/1/2017

75840 Y $54.05 26 Fee Schedule (FS) - 1/1/2017


75840 Y $79.32 TC Fee Schedule - 1/1/2017

75842 Y $70.33 26 Fee Schedule (FS) - 1/1/2017


75842 Y $92.08 TC Fee Schedule - 1/1/2017

75860 Y $53.05 26 Fee Schedule (FS) - 1/1/2017


75860 Y $75.91 TC Fee Schedule - 1/1/2017

75870 Y $54.05 26 Fee Schedule (FS) - 1/1/2017


75870 Y $78.70 TC Fee Schedule - 1/1/2017

75872 Y $50.81 26 Fee Schedule (FS) - 1/1/2017


75872 Y $75.60 TC Fee Schedule - 1/1/2017

75880 Y $28.21 26 Fee Schedule (FS) - 12/1/2009


75880 Y $34.60 TC Fee Schedule - 12/1/2009

75885 Y $65.63 26 Fee Schedule (FS) - 1/1/2017



CPT Code



75885 Y $77.15 TC Fee Schedule - 1/1/2017

75887 Y $65.87 26 Fee Schedule (FS) - 1/1/2017


75887 Y $77.46 TC Fee Schedule - 1/1/2017

75889 Y $52.27 26 Fee Schedule (FS) - 1/1/2017


75889 Y $77.15 TC Fee Schedule - 1/1/2017

75891 Y $52.89 26 Fee Schedule (FS) - 1/1/2017


75891 Y $77.77 TC Fee Schedule - 1/1/2017

75893 Y $25.55 26 Fee Schedule (FS) - 1/1/2017


75893 Y $79.32 TC Fee Schedule - 1/1/2017

75894 Y $63.22 26 Fee Schedule (FS) - 1/1/2017

75898 Y $48.67 26 Fee Schedule (FS) - 12/1/2009

75901 Y $22.63 26 Fee Schedule (FS) - 1/1/2017


75901 Y $73.53 TC Fee Schedule - 12/1/2009

75902 Y $18.02 26 Fee Schedule (FS) - 1/1/2017


75902 Y $45.89 TC Fee Schedule - 1/1/2017

75956 Y $339.26 26 Fee Schedule (FS) - 1/1/2017

75957 Y $291.28 26 Fee Schedule (FS) - 1/1/2017

75958 Y $193.27 26 Fee Schedule (FS) - 1/1/2017

75959 Y $168.59 26 Fee Schedule (FS) - 1/1/2017

75970 Y $37.96 26 Fee Schedule (FS) - 1/1/2017

75984 Y $33.24 26 Fee Schedule (FS) - 1/1/2017


75984 Y $61.98 TC Fee Schedule - 1/1/2017

75989 Y $55.20 26 Fee Schedule (FS) - 1/1/2017


75989 Y $53.94 TC Fee Schedule - 1/1/2017



CPT Code


76000 Y $8.27 26 Fee Schedule (FS) - 8/1/2016


76000 Y $33.51 TC Fee Schedule - 1/1/2017

76001 Y $33.37 26 Fee Schedule (FS) - 8/1/2016

76010 Y $8.62 26 Fee Schedule (FS) - 1/1/2017


76010 Y $14.63 TC Fee Schedule - 1/1/2017

76080 Y $25.24 26 Fee Schedule (FS) - 8/1/2016


76080 Y $24.84 TC Fee Schedule - 1/1/2017

76098 Y $7.63 26 Fee Schedule (FS) - 1/1/2017


76098 Y $7.51 TC Fee Schedule - 1/1/2017

76100 Y $28.72 26 Fee Schedule (FS) - 8/1/2016


76100 Y $45.21 TC Fee Schedule - 12/1/2009

76101 Y $29.92 26 Fee Schedule (FS) - 12/1/2009


76101 Y $51.38 TC Fee Schedule - 12/1/2009

76102 Y $29.92 26 Fee Schedule (FS) - 12/1/2009


76102 Y $63.37 TC Fee Schedule - 12/1/2009

76120 Y $18.23 26 Fee Schedule (FS) - 1/1/2017


76120 Y $38.02 TC Fee Schedule - 12/1/2009

76125 Y $13.30 26 Fee Schedule (FS) - 8/1/2016


76125 Y $28.15 TC Fee Schedule - 12/1/2009


76376 Y $9.30 26 Fee Schedule (FS) - 1/1/2017


76376 Y $11.53 TC Fee Schedule - 1/1/2017

76377 Y $37.53 26 Fee Schedule (FS) - 1/1/2017



CPT Code



76377 Y $21.44 TC Fee Schedule - 1/1/2017

76380 Y $46.49 26 Fee Schedule (FS) - 1/1/2017


76380 Y $52.70 TC Fee Schedule - 1/1/2017





76499 Y $0.00 26 by Report - 6/1/1981


76506 Y $30.60 26 Fee Schedule (FS) - 1/1/2017


76506 Y $51.38 TC Fee Schedule - 12/1/2009

76510 Y $64.62 26 Fee Schedule (FS) - 12/1/2009


76510 Y $71.27 TC Fee Schedule - 1/1/2017

76511 Y $47.34 26 Fee Schedule (FS) - 8/1/2016


76511 Y $42.18 TC Fee Schedule - 1/1/2017

76512 Y $42.39 26 Fee Schedule (FS) - 12/1/2009


76512 Y $34.74 TC Fee Schedule - 1/1/2017

76513 Y $33.14 26 Fee Schedule (FS) - 1/1/2017


76513 Y $51.77 TC Fee Schedule - 1/1/2017

76514 Y $4.68 26 Fee Schedule (FS) - 12/1/2009


76514 Y $2.06 TC Fee Schedule - 12/1/2009

76516 Y $26.61 26 Fee Schedule (FS) - 12/1/2009


76516 Y $41.98 TC Fee Schedule - 8/1/2016

76519 Y $28.22 26 Fee Schedule (FS) - 8/1/2016



CPT Code



76519 Y $45.38 TC Fee Schedule - 8/1/2016

76529 Y $26.19 26 Fee Schedule (FS) - 12/1/2009


76529 Y $39.39 TC Fee Schedule - 8/1/2016

76536 Y $26.54 26 Fee Schedule (FS) - 1/1/2017


76536 Y $51.38 TC Fee Schedule - 12/1/2009

76604 Y $25.58 26 Fee Schedule (FS) - 1/1/2017


76604 Y $47.27 TC Fee Schedule - 12/1/2009

76641 Y $34.42 26 Fee Schedule (FS) - 8/1/2016


76641 Y $63.25 TC Fee Schedule - 8/1/2016

76642 Y $32.06 26 Fee Schedule (FS) - 8/1/2016


76642 Y $48.41 TC Fee Schedule - 8/1/2016

76700 Y $38.13 26 Fee Schedule (FS) - 1/1/2017


76700 Y $68.73 TC Fee Schedule - 8/1/2016

76705 Y $27.85 26 Fee Schedule (FS) - 1/1/2017


76705 Y $51.38 TC Fee Schedule - 12/1/2009

76706 Y $26.29 26 Fee Schedule (FS) - 1/1/2017


76706 Y $58.13 TC Fee Schedule - 1/1/2017

76770 Y $34.85 26 Fee Schedule (FS) - 1/1/2017


76770 Y $66.63 TC Fee Schedule - 1/1/2017

76775 Y $27.20 26 Fee Schedule (FS) - 1/1/2017


76775 Y $25.46 TC Fee Schedule - 1/1/2017

76776 Y $31.80 26 Fee Schedule (FS) - 12/1/2009



CPT Code



76776 Y $72.23 TC Fee Schedule - 12/1/2009

76800 Y $42.90 26 Fee Schedule (FS) - 12/1/2009


76800 Y $50.86 TC Fee Schedule - 12/1/2009

76801 Y $60.77 26 Fee Schedule (FS) - 12/1/2009


76801 Y $90.94 TC Fee Schedule - 12/1/2009

76802 Y $39.74 26 Fee Schedule (FS) - 12/1/2009


76802 Y $47.73 TC Fee Schedule - 12/1/2009

76805 Y $60.67 26 Fee Schedule (FS) - 12/1/2009


76805 Y $90.94 TC Fee Schedule - 12/1/2009

76810 Y $44.95 26 Fee Schedule (FS) - 12/1/2009


76810 Y $51.85 TC Fee Schedule - 12/1/2009

76811 Y $112.77 26 Fee Schedule (FS) - 12/1/2009


76811 Y $161.97 TC Fee Schedule - 12/1/2009

76812 Y $68.66 26 Fee Schedule (FS) - 12/1/2009


76812 Y $59.66 TC Fee Schedule - 12/1/2009

76813 Y $56.18 26 Fee Schedule (FS) - 12/1/2009


76813 Y $76.25 TC Fee Schedule - 12/1/2009

76814 Y $37.55 26 Fee Schedule (FS) - 12/1/2009


76814 Y $39.94 TC Fee Schedule - 12/1/2009

76815 Y $40.48 26 Fee Schedule (FS) - 12/1/2009


76815 Y $61.17 TC Fee Schedule - 12/1/2009

76816 Y $40.58 26 Fee Schedule (FS) - 12/1/2009



CPT Code



76816 Y $47.71 TC Fee Schedule - 12/1/2009

76817 Y $44.29 26 Fee Schedule (FS) - 12/1/2009


76817 Y $64.42 TC Fee Schedule - 12/1/2009

76818 Y $54.38 26 Fee Schedule (FS) - 12/1/2009


76818 Y $69.73 TC Fee Schedule - 12/1/2009

76819 Y $48.02 26 Fee Schedule (FS) - 12/1/2009


76819 Y $69.73 TC Fee Schedule - 12/1/2009

76820 Y $31.95 26 Fee Schedule (FS) - 12/1/2009


76820 Y $70.56 TC Fee Schedule - 12/1/2009

76821 Y $44.41 26 Fee Schedule (FS) - 12/1/2009


76821 Y $70.56 TC Fee Schedule - 12/1/2009

76825 Y $75.72 26 Fee Schedule (FS) - 12/1/2009


76825 Y $85.22 TC Fee Schedule - 12/1/2009

76826 Y $32.87 26 Fee Schedule (FS) - 12/1/2009


76826 Y $30.99 TC Fee Schedule - 12/1/2009

76827 Y $36.04 26 Fee Schedule (FS) - 12/1/2009


76827 Y $75.04 TC Fee Schedule - 12/1/2009

76828 Y $33.79 26 Fee Schedule (FS) - 12/1/2009


76828 Y $48.54 TC Fee Schedule - 12/1/2009

76830 Y $32.85 26 Fee Schedule (FS) - 1/1/2017


76830 Y $55.49 TC Fee Schedule - 12/1/2009

76831 Y $37.15 26 Fee Schedule (FS) - 12/1/2009



CPT Code



76831 Y $55.49 TC Fee Schedule - 12/1/2009

76856 Y $32.54 26 Fee Schedule (FS) - 1/1/2017


76856 Y $55.49 TC Fee Schedule - 12/1/2009

76857 Y $19.47 26 Fee Schedule (FS) - 12/1/2009


76857 Y $19.89 TC Fee Schedule - 1/1/2017

76870 Y $30.24 26 Fee Schedule (FS) - 1/1/2017


76870 Y $31.03 TC Fee Schedule - 1/1/2017

76872 Y $31.45 26 Fee Schedule (FS) - 1/1/2017


76872 Y $53.01 TC Fee Schedule - 1/1/2017

76873 Y $63.13 26 Fee Schedule (FS) - 12/1/2009


76873 Y $74.65 TC Fee Schedule - 8/1/2016

76881 Y $27.42 26 Fee Schedule (FS) - 8/1/2016


76881 Y $73.12 TC Fee Schedule - 1/1/2017

76882 Y $19.83 26 Fee Schedule (FS) - 1/1/2011


76882 Y $9.30 TC Fee Schedule - 8/1/2016

76885 Y $35.84 26 Fee Schedule (FS) - 8/1/2016


76885 Y $55.49 TC Fee Schedule - 12/1/2009

76886 Y $28.86 26 Fee Schedule (FS) - 1/1/2017


76886 Y $51.38 TC Fee Schedule - 12/1/2009

76930 Y $30.86 26 Fee Schedule (FS) - 1/1/2017


76930 Y $55.49 TC Fee Schedule - 12/1/2009

76932 Y $30.55 26 Fee Schedule (FS) - 1/1/2017



CPT Code


76936 Y $94.21 26 Fee Schedule (FS) - 1/1/2017


76936 Y $151.20 TC Fee Schedule - 1/1/2017

76937 Y $13.00 26 Fee Schedule (FS) - 12/1/2009


76937 Y $14.85 TC Fee Schedule - 1/1/2017

76940 Y $68.18 26 Fee Schedule (FS) - 12/1/2009

76941 Y $49.64 26 Fee Schedule (FS) - 12/1/2009

76942 Y $31.56 26 Fee Schedule (FS) - 1/1/2017


76942 Y $24.22 TC Fee Schedule - 1/1/2017

76945 Y $31.88 26 Fee Schedule (FS) - 8/1/2016


76945 Y $55.01 TC Fee Schedule - 1/1/2010

76946 Y $18.61 26 Fee Schedule (FS) - 1/1/2017


76946 Y $11.53 TC Fee Schedule - 1/1/2017

76948 Y $19.81 26 Fee Schedule (FS) - 12/1/2009


76948 Y $55.49 TC Fee Schedule - 12/1/2009

76965 Y $62.17 26 Fee Schedule (FS) - 1/1/2017


76965 Y $20.82 TC Fee Schedule - 1/1/2017

76970 Y $18.27 26 Fee Schedule (FS) - 1/1/2017


76970 Y $38.02 TC Fee Schedule - 12/1/2009

76975 Y $37.14 26 Fee Schedule (FS) - 8/1/2016

76977 Y $2.70 26 Fee Schedule (FS) - 1/1/2017


76977 Y $3.80 TC Fee Schedule - 1/1/2017

76998 Y $61.09 26 Fee Schedule (FS) - 1/1/2017


76998 Y $112.09 TC Fee Schedule - 1/1/2011



CPT Code


76999 Y $0.00 26 by Report - 6/1/1981


77001 Y $16.21 26 Fee Schedule (FS) - 12/1/2009


77001 Y $44.57 TC Fee Schedule - 1/1/2017

77002 Y $22.69 26 Fee Schedule (FS) - 12/1/2009


77002 Y $40.60 TC Fee Schedule - 12/1/2009

77003 Y $24.42 26 Fee Schedule (FS) - 12/1/2009


77003 Y $37.19 TC Fee Schedule - 12/1/2009

77011 Y $51.70 26 Fee Schedule (FS) - 12/1/2009


77011 Y $139.04 TC Fee Schedule - 1/1/2017

77012 Y $49.32 26 Fee Schedule (FS) - 12/1/2009


77012 Y $57.96 TC Fee Schedule - 1/1/2017

77013 Y $184.84 26 Fee Schedule (FS) - 1/1/2017


77013 Y $404.93 TC Fee Schedule - 1/1/2011

77014 Y $36.45 26 Fee Schedule (FS) - 12/1/2009


77014 Y $64.46 TC Fee Schedule - 1/1/2017

77021 Y $65.11 26 Fee Schedule (FS) - 12/1/2009


77021 Y $284.52 TC Fee Schedule - 1/1/2017

77022 Y $204.80 26 Fee Schedule (FS) - 8/1/2016


77022 Y $528.25 TC Fee Schedule - 1/1/2011

77053 Y $15.51 26 Fee Schedule (FS) - 12/1/2009


77053 Y $35.05 TC Fee Schedule - 1/1/2017

77054 Y $19.24 26 Fee Schedule (FS) - 12/1/2009



CPT Code



77054 Y $46.81 TC Fee Schedule - 1/1/2017

77058 Y $69.31 26 Fee Schedule (FS) - 12/1/2009


77058 Y $391.76 TC Fee Schedule - 1/1/2017

77059 Y $69.31 26 Fee Schedule (FS) - 12/1/2009


77059 Y $391.76 TC Fee Schedule - 1/1/2017

77061 Y $0.00 26 by Report - 1/1/2015


77061 Y $0.00 TC by Report - 1/1/2015

77062 Y $0.00 26 by Report - 1/1/2015


77062 Y $0.00 TC by Report - 1/1/2015

77063 Y $15.10 26 Fee Schedule (FS) - 1/1/2015


77063 Y $22.36 TC Fee Schedule - 1/1/2017

77065 Y $0.00 26 by Report - 1/1/2017


77065 Y $0.00 TC by Report - 1/1/2017

77066 Y $0.00 26 by Report - 1/1/2017


77066 Y $0.00 TC by Report - 1/1/2017

77067 Y $0.00 26 by Report - 1/1/2017


77067 Y $0.00 TC by Report - 1/1/2017


77072 Y $7.80 26 Fee Schedule (FS) - 12/1/2009


77072 Y $11.16 TC Fee Schedule - 12/1/2009

77073 Y $11.48 26 Fee Schedule (FS) - 12/1/2009


77073 Y $18.96 TC Fee Schedule - 1/1/2017



CPT Code


77074 Y $19.24 26 Fee Schedule (FS) - 12/1/2009


77074 Y $34.41 TC Fee Schedule - 12/1/2009

77075 Y $23.31 26 Fee Schedule (FS) - 12/1/2009


77075 Y $49.40 TC Fee Schedule - 8/1/2016

77076 Y $29.75 26 Fee Schedule (FS) - 12/1/2009


77076 Y $31.93 TC Fee Schedule - 12/1/2009

77077 Y $13.49 26 Fee Schedule (FS) - 12/1/2009


77077 Y $18.34 TC Fee Schedule - 1/1/2017

77078 Y $10.47 26 Fee Schedule (FS) - 12/1/2009


77078 Y $52.70 TC Fee Schedule - 1/1/2017

77080 Y $9.00 26 Fee Schedule (FS) - 8/1/2016


77080 Y $27.01 TC Fee Schedule - 1/1/2017

77081 Y $9.78 26 Fee Schedule (FS) - 12/1/2009


77081 Y $14.94 TC Fee Schedule - 1/1/2017

77084 Y $68.26 26 Fee Schedule (FS) - 12/1/2009


77084 Y $236.01 TC Fee Schedule - 1/1/2017

77085 Y $14.29 26 Fee Schedule (FS) - 1/1/2017


77085 Y $35.36 TC Fee Schedule - 1/1/2017

77086 Y $8.45 26 Fee Schedule (FS) - 8/1/2016


77086 Y $23.77 TC Fee Schedule - 8/1/2016






CPT Code


77280 Y $33.73 26 Fee Schedule (FS) - 1/1/2017


77280 Y $125.36 TC Fee Schedule - 12/1/2009

77285 Y $51.74 26 Fee Schedule (FS) - 8/1/2016


77285 Y $201.74 TC Fee Schedule - 12/1/2009

77290 Y $76.89 26 Fee Schedule (FS) - 8/1/2016


77290 Y $235.66 TC Fee Schedule - 12/1/2009

77293 Y $97.75 26 Fee Schedule (FS) - 8/1/2016


77293 Y $301.62 TC Fee Schedule - 1/1/2014

77295 Y $206.92 26 Fee Schedule (FS) - 1/1/2017


77295 Y $234.70 TC Fee Schedule - 1/1/2017

77299 Y $0.00 26 by Report - 6/1/1981


77300 Y $30.55 26 Fee Schedule (FS) - 8/1/2016


77300 Y $30.10 TC Fee Schedule - 1/1/2017

77301 Y $385.14 26 Fee Schedule (FS) - 1/1/2017


77301 Y $1,010.11 TC Fee Schedule - 12/1/2009

77306 Y $66.60 26 Fee Schedule (FS) - 8/1/2016


77306 Y $64.83 TC Fee Schedule - 8/1/2016

77307 Y $138.31 26 Fee Schedule (FS) - 8/1/2016


77307 Y $118.53 TC Fee Schedule - 8/1/2016

77316 Y $67.00 26 Fee Schedule (FS) - 8/1/2016


77316 Y $100.52 TC Fee Schedule - 8/1/2016

77317 Y $88.26 26 Fee Schedule (FS) - 8/1/2016



CPT Code



77317 Y $131.16 TC Fee Schedule - 8/1/2016

77318 Y $139.10 26 Fee Schedule (FS) - 8/1/2016


77318 Y $177.91 TC Fee Schedule - 8/1/2016

77321 Y $46.71 26 Fee Schedule (FS) - 8/1/2016


77321 Y $38.15 TC Fee Schedule - 1/1/2017

77331 Y $24.95 26 Fee Schedule (FS) - 12/1/2009


77331 Y $16.49 TC Fee Schedule - 1/1/2017

77332 Y $26.59 26 Fee Schedule (FS) - 8/1/2016


77332 Y $46.37 TC Fee Schedule - 8/1/2016

77333 Y $41.33 26 Fee Schedule (FS) - 8/1/2016


77333 Y $8.44 TC Fee Schedule - 1/1/2017

77334 Y $61.08 26 Fee Schedule (FS) - 8/1/2016


77334 Y $77.15 TC Fee Schedule - 1/1/2017


77336 Y $57.03 TC Fee Schedule - 12/1/2009

77338 Y $206.48 26 Fee Schedule (FS) - 8/1/2016


77338 Y $224.56 TC Fee Schedule - 1/1/2010


77370 Y $68.00 TC Fee Schedule - 12/1/2009




77385 Y $0.00 26 by Report - 1/1/2015


77385 Y $0.00 TC by Report - 1/1/2015



CPT Code


77386 Y $0.00 26 by Report - 1/1/2015


77386 Y $0.00 TC by Report - 1/1/2015

77387 Y $0.00 26 by Report - 1/1/2015


77387 Y $0.00 TC by Report - 1/1/2015

77399 Y $0.00 26 by Report - 6/1/1981








77424 Y $0.00 26 by Report - 1/1/2012


77424 Y $0.00 TC by Report - 1/1/2012

77425 Y $0.00 26 by Report - 1/1/2012


77425 Y $0.00 TC by Report - 1/1/2012





77469 Y $0.00 26 by Report - 1/1/2012


77469 Y $0.00 TC by Report - 1/1/2012

77470 Y $100.83 26 Fee Schedule (FS) - 1/1/2017


77470 Y $42.25 TC Fee Schedule - 1/1/2017

77499 Y $0.00 26 by Report - 6/1/1981





CPT Code





77600 Y $68.90 26 Fee Schedule (FS) - 12/1/2009


77600 Y $109.17 TC Fee Schedule - 12/1/2009

77605 Y $92.56 26 Fee Schedule (FS) - 12/1/2009


77605 Y $145.45 TC Fee Schedule - 12/1/2009

77610 Y $76.29 26 Fee Schedule (FS) - 12/1/2009


77610 Y $110.29 TC Fee Schedule - 12/1/2009

77615 Y $97.55 26 Fee Schedule (FS) - 8/1/2016


77615 Y $146.95 TC Fee Schedule - 12/1/2009

77620 Y $74.97 26 Fee Schedule (FS) - 8/1/2016


77620 Y $110.29 TC Fee Schedule - 12/1/2009

77750 Y $119.93 26 Fee Schedule (FS) - 12/1/2009


77750 Y $47.95 TC Fee Schedule - 12/1/2009

77761 Y $112.53 26 Fee Schedule (FS) - 12/1/2009


77761 Y $90.77 TC Fee Schedule - 12/1/2009

77762 Y $169.57 26 Fee Schedule (FS) - 12/1/2009


77762 Y $130.50 TC Fee Schedule - 12/1/2009

77763 Y $240.57 26 Fee Schedule (FS) - 12/1/2009


77763 Y $162.01 TC Fee Schedule - 12/1/2009

77767 Y $50.94 26 Fee Schedule (FS) - 8/1/2016


77767 Y $148.80 TC Fee Schedule - 8/1/2016



CPT Code


77768 Y $67.45 26 Fee Schedule (FS) - 8/1/2016


77768 Y $244.61 TC Fee Schedule - 8/1/2016

77770 Y $93.87 26 Fee Schedule (FS) - 8/1/2016


77770 Y $192.53 TC Fee Schedule - 8/1/2016

77771 Y $183.44 26 Fee Schedule (FS) - 8/1/2016


77771 Y $350.62 TC Fee Schedule - 8/1/2016

77772 Y $260.18 26 Fee Schedule (FS) - 8/1/2016


77772 Y $553.44 TC Fee Schedule - 8/1/2016

77778 Y $274.58 26 Fee Schedule (FS) - 12/1/2009


77778 Y $183.42 TC Fee Schedule - 12/1/2009

77789 Y $29.62 26 Fee Schedule (FS) - 12/1/2009


77789 Y $16.10 TC Fee Schedule - 12/1/2009

77790 Y $28.68 26 Fee Schedule (FS) - 12/1/2009


77790 Y $17.81 TC Fee Schedule - 12/1/2009


78012 Y $8.63 26 Fee Schedule (FS) - 8/1/2016


78012 Y $62.99 TC Fee Schedule - 1/1/2017

78013 Y $16.60 26 Fee Schedule (FS) - 8/1/2016


78013 Y $155.62 TC Fee Schedule - 1/1/2017

78014 Y $22.40 26 Fee Schedule (FS) - 8/1/2016


78014 Y $192.45 TC Fee Schedule - 8/1/2016

78015 Y $30.86 26 Fee Schedule (FS) - 1/1/2017




CPT Code


78015 Y $93.17 TC Fee Schedule - 12/1/2009

78016 Y $32.34 26 Fee Schedule (FS) - 1/1/2017


78016 Y $125.70 TC Fee Schedule - 12/1/2009

78018 Y $38.89 26 Fee Schedule (FS) - 1/1/2017


78018 Y $196.27 TC Fee Schedule - 12/1/2009

78020 Y $26.25 26 Fee Schedule (FS) - 1/1/2017


78020 Y $47.69 TC Fee Schedule - 8/1/2016

78070 Y $36.87 26 Fee Schedule (FS) - 1/1/2017


78070 Y $150.33 TC Fee Schedule - 12/1/2009

78071 Y $53.12 26 Fee Schedule (FS) - 8/1/2016


78071 Y $268.44 TC Fee Schedule - 8/1/2016

78072 Y $73.33 26 Fee Schedule (FS) - 8/1/2016

78072 Y $0.00 TC by Report - 1/1/2013

78075 Y $33.21 26 Fee Schedule (FS) - 1/1/2017


78075 Y $196.27 TC Fee Schedule - 12/1/2009

78099 Y $0.00 26 by Report - 6/1/1981


78102 Y $24.96 26 Fee Schedule (FS) - 1/1/2017


78102 Y $74.33 TC Fee Schedule - 12/1/2009

78103 Y $34.25 26 Fee Schedule (FS) - 1/1/2017


78103 Y $114.74 TC Fee Schedule - 12/1/2009

78104 Y $36.25 26 Fee Schedule (FS) - 1/1/2017


78104 Y $147.28 TC Fee Schedule - 12/1/2009

78110 Y $8.96 26 Fee Schedule (FS) - 1/1/2017



CPT Code



78110 Y $34.60 TC Fee Schedule - 12/1/2009

78111 Y $10.27 26 Fee Schedule (FS) - 1/1/2017


78111 Y $77.00 TC Fee Schedule - 1/1/2017

78120 Y $10.92 26 Fee Schedule (FS) - 1/1/2017


78120 Y $63.37 TC Fee Schedule - 12/1/2009

78121 Y $15.28 26 Fee Schedule (FS) - 1/1/2017


78121 Y $77.62 TC Fee Schedule - 1/1/2017

78122 Y $20.27 26 Fee Schedule (FS) - 1/1/2017


78122 Y $69.26 TC Fee Schedule - 1/1/2017

78130 Y $28.44 26 Fee Schedule (FS) - 1/1/2017


78130 Y $102.75 TC Fee Schedule - 12/1/2009

78135 Y $30.16 26 Fee Schedule (FS) - 1/1/2017


78135 Y $175.72 TC Fee Schedule - 12/1/2009

78140 Y $28.84 26 Fee Schedule (FS) - 1/1/2017


78140 Y $95.57 TC Fee Schedule - 1/1/2017

78185 Y $18.89 26 Fee Schedule (FS) - 1/1/2017


78185 Y $85.63 TC Fee Schedule - 12/1/2009

78191 Y $28.44 26 Fee Schedule (FS) - 1/1/2017


78191 Y $125.06 TC Fee Schedule - 1/1/2017

78195 Y $55.54 26 Fee Schedule (FS) - 1/1/2017


78195 Y $147.28 TC Fee Schedule - 12/1/2009

78199 Y $0.00 26 by Report - 1/1/1996



CPT Code



78201 Y $19.94 26 Fee Schedule (FS) - 1/1/2017


78201 Y $85.63 TC Fee Schedule - 12/1/2009

78202 Y $22.60 26 Fee Schedule (FS) - 1/1/2017


78202 Y $103.79 TC Fee Schedule - 12/1/2009

78205 Y $31.89 26 Fee Schedule (FS) - 1/1/2017


78205 Y $160.88 TC Fee Schedule - 1/1/2017

78206 Y $44.19 26 Fee Schedule (FS) - 1/1/2017


78206 Y $206.82 TC Fee Schedule - 12/1/2009

78215 Y $22.94 26 Fee Schedule (FS) - 1/1/2017


78215 Y $105.84 TC Fee Schedule - 12/1/2009

78216 Y $25.94 26 Fee Schedule (FS) - 1/1/2017


78216 Y $88.76 TC Fee Schedule - 1/1/2017

78226 Y $32.97 26 Fee Schedule (FS) - 8/1/2016


78226 Y $258.09 TC Fee Schedule - 8/1/2016

78227 Y $39.69 26 Fee Schedule (FS) - 8/1/2016


78227 Y $268.84 TC Fee Schedule - 2/6/2012

78230 Y $18.02 26 Fee Schedule (FS) - 1/1/2017


78230 Y $79.47 TC Fee Schedule - 12/1/2009

78231 Y $24.56 26 Fee Schedule (FS) - 1/1/2017


78231 Y $94.03 TC Fee Schedule - 1/1/2017

78232 Y $18.70 26 Fee Schedule (FS) - 1/1/2017




CPT Code


78232 Y $71.43 TC Fee Schedule - 1/1/2017

78258 Y $34.54 26 Fee Schedule (FS) - 1/1/2017


78258 Y $103.79 TC Fee Schedule - 12/1/2009

78261 Y $32.23 26 Fee Schedule (FS) - 1/1/2017


78261 Y $148.31 TC Fee Schedule - 12/1/2009

78262 Y $31.19 26 Fee Schedule (FS) - 1/1/2017


78262 Y $153.44 TC Fee Schedule - 12/1/2009

78264 Y $34.54 26 Fee Schedule (FS) - 1/1/2017


78264 Y $149.34 TC Fee Schedule - 12/1/2009

78265 Y $45.49 26 Fee Schedule (FS) - 8/1/2016


78265 Y $287.01 TC Fee Schedule - 8/1/2016

78266 Y $50.48 26 Fee Schedule (FS) - 8/1/2016


78266 Y $379.24 TC Fee Schedule - 8/1/2016



78270 Y $10.04 26 Fee Schedule (FS) - 8/1/2016


78270 Y $56.53 TC Fee Schedule - 12/1/2009

78271 Y $9.61 26 Fee Schedule (FS) - 1/1/2017


78271 Y $59.61 TC Fee Schedule - 12/1/2009

78272 Y $12.58 26 Fee Schedule (FS) - 1/1/2017


78272 Y $75.45 TC Fee Schedule - 1/1/2017

78278 Y $46.13 26 Fee Schedule (FS) - 1/1/2017


78278 Y $175.72 TC Fee Schedule - 12/1/2009



CPT Code


78282 Y $17.92 26 Fee Schedule (FS) - 1/1/2017

78290 Y $31.89 26 Fee Schedule (FS) - 1/1/2017


78290 Y $110.29 TC Fee Schedule - 12/1/2009

78291 Y $39.87 26 Fee Schedule (FS) - 1/1/2017


78291 Y $110.64 TC Fee Schedule - 12/1/2009

78299 Y $0.00 26 by Report - 6/1/1981


78300 Y $29.56 26 Fee Schedule (FS) - 1/1/2017


78300 Y $90.08 TC Fee Schedule - 12/1/2009

78305 Y $38.89 26 Fee Schedule (FS) - 1/1/2017


78305 Y $132.21 TC Fee Schedule - 12/1/2009

78306 Y $40.20 26 Fee Schedule (FS) - 1/1/2017


78306 Y $154.13 TC Fee Schedule - 12/1/2009

78315 Y $47.14 26 Fee Schedule (FS) - 1/1/2017


78315 Y $172.64 TC Fee Schedule - 12/1/2009

78320 Y $47.51 26 Fee Schedule (FS) - 1/1/2017


78320 Y $160.57 TC Fee Schedule - 1/1/2017



78399 Y $0.00 26 by Report - 1/1/1996


78414 Y $20.89 26 Fee Schedule (FS) - 1/1/2017

78428 Y $35.49 26 Fee Schedule (FS) - 1/1/2017


78428 Y $81.87 TC Fee Schedule - 12/1/2009

78445 Y $21.93 26 Fee Schedule (FS) - 1/1/2017



CPT Code



78445 Y $67.82 TC Fee Schedule - 12/1/2009

78451 Y $61.67 26 Fee Schedule (FS) - 8/1/2016


78451 Y $138.49 TC Fee Schedule - 1/1/2010

78452 Y $72.91 26 Fee Schedule (FS) - 8/1/2016


78452 Y $267.59 TC Fee Schedule - 1/1/2010

78453 Y $44.78 26 Fee Schedule (FS) - 8/1/2016


78453 Y $129.18 TC Fee Schedule - 1/1/2010

78454 Y $59.40 26 Fee Schedule (FS) - 8/1/2016


78454 Y $108.62 TC Fee Schedule - 1/1/2010

78456 Y $45.77 26 Fee Schedule (FS) - 1/1/2017


78456 Y $146.63 TC Fee Schedule - 12/1/2009

78457 Y $36.41 26 Fee Schedule (FS) - 1/1/2017


78457 Y $96.25 TC Fee Schedule - 12/1/2009

78458 Y $35.74 26 Fee Schedule (FS) - 1/1/2017


78458 Y $117.24 TC Fee Schedule - 1/1/2017

78459 Y $66.48 26 Fee Schedule (FS) - 1/1/2017


78459 Y $1,321.08 TC Fee Schedule - 12/1/2009

78466 Y $32.77 26 Fee Schedule (FS) - 1/1/2017


78466 Y $94.89 TC Fee Schedule - 12/1/2009

78468 Y $36.78 26 Fee Schedule (FS) - 1/1/2017


78468 Y $132.21 TC Fee Schedule - 12/1/2009

78469 Y $42.76 26 Fee Schedule (FS) - 1/1/2017



CPT Code



78469 Y $164.59 TC Fee Schedule - 1/1/2017

78472 Y $45.18 26 Fee Schedule (FS) - 1/1/2017


78472 Y $164.59 TC Fee Schedule - 1/1/2017

78473 Y $67.02 26 Fee Schedule (FS) - 1/1/2017


78473 Y $197.48 TC Fee Schedule - 1/1/2017

78481 Y $44.78 26 Fee Schedule (FS) - 1/1/2017


78481 Y $114.68 TC Fee Schedule - 1/1/2017

78483 Y $67.02 26 Fee Schedule (FS) - 1/1/2017


78483 Y $154.38 TC Fee Schedule - 1/1/2017

78491 Y $67.10 26 Fee Schedule (FS) - 1/1/2017


78491 Y $1,321.08 TC Fee Schedule - 12/1/2009

78492 Y $84.29 26 Fee Schedule (FS) - 1/1/2017


78492 Y $1,585.31 TC Fee Schedule - 12/1/2009

78494 Y $54.42 26 Fee Schedule (FS) - 1/1/2017


78494 Y $150.97 TC Fee Schedule - 1/1/2017

78496 Y $22.88 26 Fee Schedule (FS) - 1/1/2017


78496 Y $18.03 TC Fee Schedule - 1/1/2017

78499 Y $0.00 26 by Report - 6/1/1981


78579 Y $21.78 26 Fee Schedule (FS) - 8/1/2016


78579 Y $138.80 TC Fee Schedule - 2/6/2012

78580 Y $34.54 26 Fee Schedule (FS) - 1/1/2017




CPT Code


78580 Y $124.00 TC Fee Schedule - 12/1/2009

78582 Y $47.07 26 Fee Schedule (FS) - 8/1/2016


78582 Y $239.23 TC Fee Schedule - 8/1/2016

78597 Y $32.34 26 Fee Schedule (FS) - 8/1/2016


78597 Y $142.83 TC Fee Schedule - 8/1/2016

78598 Y $36.84 26 Fee Schedule (FS) - 8/1/2016


78598 Y $231.45 TC Fee Schedule - 8/1/2016

78599 Y $0.00 26 by Report - 6/1/1981


78600 Y $20.94 26 Fee Schedule (FS) - 1/1/2017


78600 Y $103.79 TC Fee Schedule - 12/1/2009

78601 Y $23.61 26 Fee Schedule (FS) - 1/1/2017


78601 Y $122.97 TC Fee Schedule - 12/1/2009

78605 Y $25.21 26 Fee Schedule (FS) - 1/1/2017


78605 Y $122.97 TC Fee Schedule - 12/1/2009

78606 Y $29.53 26 Fee Schedule (FS) - 1/1/2017


78606 Y $140.10 TC Fee Schedule - 12/1/2009

78607 Y $55.85 26 Fee Schedule (FS) - 1/1/2017


78607 Y $237.03 TC Fee Schedule - 12/1/2009

78608 Y $67.80 26 Fee Schedule (FS) - 1/1/2017


78608 Y $1,321.08 TC Fee Schedule - 12/1/2009

78609 Y $77.44 26 Fee Schedule (FS) - 12/1/2009


78609 Y $1,321.08 TC Fee Schedule - 12/1/2009



CPT Code


78610 Y $14.29 26 Fee Schedule (FS) - 1/1/2017


78610 Y $57.55 TC Fee Schedule - 12/1/2009

78630 Y $31.89 26 Fee Schedule (FS) - 1/1/2017


78630 Y $182.22 TC Fee Schedule - 12/1/2009

78635 Y $28.84 26 Fee Schedule (FS) - 1/1/2017


78635 Y $92.14 TC Fee Schedule - 12/1/2009

78645 Y $26.25 26 Fee Schedule (FS) - 1/1/2017


78645 Y $124.00 TC Fee Schedule - 12/1/2009

78647 Y $42.48 26 Fee Schedule (FS) - 1/1/2017


78647 Y $213.73 TC Fee Schedule - 12/1/2009

78650 Y $28.22 26 Fee Schedule (FS) - 1/1/2017


78650 Y $167.49 TC Fee Schedule - 12/1/2009

78660 Y $25.21 26 Fee Schedule (FS) - 1/1/2017


78660 Y $77.07 TC Fee Schedule - 12/1/2009

78699 Y $0.00 26 by Report - 6/1/1981


78700 Y $20.89 26 Fee Schedule (FS) - 1/1/2017


78700 Y $110.29 TC Fee Schedule - 12/1/2009

78701 Y $22.24 26 Fee Schedule (FS) - 1/1/2017


78701 Y $128.45 TC Fee Schedule - 12/1/2009

78707 Y $44.19 26 Fee Schedule (FS) - 1/1/2017


78707 Y $154.88 TC Fee Schedule - 8/1/2016

78708 Y $55.79 26 Fee Schedule (FS) - 1/1/2017



CPT Code



78708 Y $104.32 TC Fee Schedule - 1/1/2017

78709 Y $64.46 26 Fee Schedule (FS) - 1/1/2017


78709 Y $161.33 TC Fee Schedule - 12/1/2009

78710 Y $28.97 26 Fee Schedule (FS) - 1/1/2017


78710 Y $153.14 TC Fee Schedule - 1/1/2017

78725 Y $17.30 26 Fee Schedule (FS) - 1/1/2017


78725 Y $65.09 TC Fee Schedule - 12/1/2009

78730 Y $7.30 26 Fee Schedule (FS) - 1/1/2017


78730 Y $52.75 TC Fee Schedule - 12/1/2009

78740 Y $25.86 26 Fee Schedule (FS) - 1/1/2017


78740 Y $77.07 TC Fee Schedule - 12/1/2009

78761 Y $33.52 26 Fee Schedule (FS) - 1/1/2017


78761 Y $115.77 TC Fee Schedule - 12/1/2009

78799 Y $0.00 26 by Report - 6/1/1981


78800 Y $32.00 26 Fee Schedule (FS) - 1/1/2017


78800 Y $122.97 TC Fee Schedule - 12/1/2009

78801 Y $38.01 26 Fee Schedule (FS) - 1/1/2017


78801 Y $152.42 TC Fee Schedule - 12/1/2009

78802 Y $39.50 26 Fee Schedule (FS) - 1/1/2017


78802 Y $200.38 TC Fee Schedule - 12/1/2009

78803 Y $48.88 26 Fee Schedule (FS) - 1/1/2017




CPT Code


78803 Y $237.03 TC Fee Schedule - 12/1/2009

78804 Y $48.82 26 Fee Schedule (FS) - 1/1/2017


78804 Y $390.06 TC Fee Schedule - 12/1/2009

78805 Y $33.89 26 Fee Schedule (FS) - 1/1/2017


78805 Y $122.97 TC Fee Schedule - 12/1/2009

78806 Y $39.50 26 Fee Schedule (FS) - 1/1/2017


78806 Y $232.92 TC Fee Schedule - 12/1/2009

78807 Y $48.88 26 Fee Schedule (FS) - 1/1/2017


78807 Y $237.03 TC Fee Schedule - 12/1/2009


78811 Y $72.72 26 Fee Schedule (FS) - 1/1/2017


78811 Y $2,040.69 TC Fee Schedule - 12/1/2009

78812 Y $88.63 26 Fee Schedule (FS) - 1/1/2017


78812 Y $2,040.69 TC Fee Schedule - 12/1/2009

78813 Y $92.31 26 Fee Schedule (FS) - 1/1/2017


78813 Y $2,040.69 TC Fee Schedule - 12/1/2009

78814 Y $102.23 26 Fee Schedule (FS) - 1/1/2017


78814 Y $2,167.54 TC Fee Schedule - 12/1/2009

78815 Y $112.56 26 Fee Schedule (FS) - 1/1/2017


78815 Y $2,167.54 TC Fee Schedule - 12/1/2009

78816 Y $113.65 26 Fee Schedule (FS) - 1/1/2017


78816 Y $2,167.54 TC Fee Schedule - 12/1/2009

78999 Y $0.00 26 by Report - 6/1/1981



CPT Code



79005 Y $75.06 26 Fee Schedule (FS) - 12/1/2009


79005 Y $43.18 TC Fee Schedule - 1/1/2017

79101 Y $78.49 26 Fee Schedule (FS) - 12/1/2009


79101 Y $41.87 TC Fee Schedule - 1/1/2017

79200 Y $79.37 26 Fee Schedule (FS) - 12/1/2009


79200 Y $51.23 TC Fee Schedule - 1/1/2017

79300 Y $74.72 26 Fee Schedule (FS) - 1/1/2017

79403 Y $104.50 26 Fee Schedule (FS) - 8/1/2016


79403 Y $72.05 TC Fee Schedule - 1/1/2017

79440 Y $79.64 26 Fee Schedule (FS) - 12/1/2009


79440 Y $44.03 TC Fee Schedule - 1/1/2017

79445 Y $108.73 26 Fee Schedule (FS) - 1/1/2017

79999 Y $0.00 26 by Report - 6/1/1981

















CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code

















83020 Y $17.08 26 Fee Schedule (FS) - 1/1/2018




















CPT Code





































CPT Code





































CPT Code





































CPT Code















84165 Y $17.08 26 Fee Schedule (FS) - 1/1/2018


84166 Y $17.08 26 Fee Schedule (FS) - 1/1/2018


84181 Y $17.08 26 Fee Schedule (FS) - 1/1/2018


84182 Y $17.08 26 Fee Schedule (FS) - 1/1/2018
















CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code



85390 Y $17.08 26 Fee Schedule (FS) - 1/1/2018























85576 Y $17.08 26 Fee Schedule (FS) - 1/1/2018











CPT Code

































86153 Y $32.19 26 Fee Schedule (FS) - 1/1/2018




CPT Code














86255 Y $17.08 26 Fee Schedule (FS) - 1/1/2018


86256 Y $17.08 26 Fee Schedule (FS) - 1/1/2018















86320 Y $17.08 26 Fee Schedule (FS) - 1/1/2018


86325 Y $17.08 26 Fee Schedule (FS) - 1/1/2018




CPT Code


86327 Y $19.36 26 Fee Schedule (FS) - 1/1/2018





86334 Y $17.08 26 Fee Schedule (FS) - 1/1/2018


86335 Y $17.08 26 Fee Schedule (FS) - 1/1/2018




























CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code

























87164 Y $17.08 26 Fee Schedule (FS) - 1/1/2018












CPT Code










87207 Y $17.08 26 Fee Schedule (FS) - 1/1/2018



























CPT Code





































CPT Code





































CPT Code





































CPT Code





































CPT Code












88104 Y $27.14 26 Fee Schedule (FS) - 1/1/2018


88104 Y $38.45 TC Fee Schedule - 1/1/2018

88106 Y $18.64 26 Fee Schedule (FS) - 1/1/2018


88106 Y $39.38 TC Fee Schedule - 1/1/2018

88108 Y $21.59 26 Fee Schedule (FS) - 1/1/2018


88108 Y $33.45 TC Fee Schedule - 1/1/2018

88112 Y $26.82 26 Fee Schedule (FS) - 1/1/2018


88112 Y $35.33 TC Fee Schedule - 1/1/2018

88120 Y $55.48 26 Fee Schedule (FS) - 1/1/2018


88120 Y $510.10 TC Fee Schedule - 1/1/2018

88121 Y $47.48 26 Fee Schedule (FS) - 1/1/2018


88121 Y $423.97 TC Fee Schedule - 1/1/2018

88125 Y $13.42 26 Fee Schedule (FS) - 1/1/2018


88125 Y $11.02 TC Fee Schedule - 1/1/2018





CPT Code











88160 Y $24.83 26 Fee Schedule (FS) - 1/1/2018


88160 Y $40.63 TC Fee Schedule - 1/1/2018

88161 Y $23.89 26 Fee Schedule (FS) - 1/1/2018


88161 Y $35.64 TC Fee Schedule - 1/1/2018

88162 Y $37.01 26 Fee Schedule (FS) - 1/1/2018


88162 Y $50.71 TC Fee Schedule - 1/1/2018





88172 Y $34.68 26 Fee Schedule (FS) - 1/1/2018


88172 Y $18.19 TC Fee Schedule - 1/1/2018

88173 Y $68.03 26 Fee Schedule (FS) - 1/1/2018


88173 Y $72.21 TC Fee Schedule - 1/1/2018



88177 Y $21.23 26 Fee Schedule (FS) - 1/1/2018


88177 Y $6.85 TC Fee Schedule - 1/1/2018



CPT Code


88182 Y $37.03 26 Fee Schedule (FS) - 1/1/2018


88182 Y $81.06 TC Fee Schedule - 1/1/2018






88199 Y $0.00 26 by Report - 6/1/1981



























CPT Code






88300 Y $4.32 26 Fee Schedule (FS) - 1/1/2018


88300 Y $10.71 TC Fee Schedule - 1/1/2018

88302 Y $6.93 26 Fee Schedule (FS) - 1/1/2018


88302 Y $20.99 TC Fee Schedule - 1/1/2018

88304 Y $11.16 26 Fee Schedule (FS) - 1/1/2018


88304 Y $25.66 TC Fee Schedule - 1/1/2018

88305 Y $36.36 26 Fee Schedule (FS) - 1/1/2018


88305 Y $26.29 TC Fee Schedule - 1/1/2018

88307 Y $79.77 26 Fee Schedule (FS) - 1/1/2018


88307 Y $157.92 TC Fee Schedule - 1/1/2018

88309 Y $141.50 26 Fee Schedule (FS) - 1/1/2018


88309 Y $220.36 TC Fee Schedule - 1/1/2018

88311 Y $12.14 26 Fee Schedule (FS) - 1/1/2018


88311 Y $8.22 TC Fee Schedule - 1/1/2018

88312 Y $25.53 26 Fee Schedule (FS) - 1/1/2018


88312 Y $61.82 TC Fee Schedule - 1/1/2018

88313 Y $11.52 26 Fee Schedule (FS) - 1/1/2018


88313 Y $51.53 TC Fee Schedule - 1/1/2018

88314 Y $21.61 26 Fee Schedule (FS) - 1/1/2018




CPT Code


88314 Y $54.96 TC Fee Schedule - 1/1/2018

88319 Y $25.51 26 Fee Schedule (FS) - 1/1/2018


88319 Y $53.72 TC Fee Schedule - 1/1/2018


88323 Y $83.27 26 Fee Schedule (FS) - 1/1/2018


88323 Y $29.09 TC Fee Schedule - 1/1/2018



88331 Y $60.44 26 Fee Schedule (FS) - 1/1/2018


88331 Y $28.78 TC Fee Schedule - 1/1/2018

88332 Y $29.69 26 Fee Schedule (FS) - 1/1/2018


88332 Y $18.81 TC Fee Schedule - 1/1/2018

88333 Y $60.47 26 Fee Schedule (FS) - 1/1/2018


88333 Y $21.93 TC Fee Schedule - 1/1/2018

88334 Y $36.94 26 Fee Schedule (FS) - 1/1/2018


88334 Y $14.02 TC Fee Schedule - 1/1/2018

88341 Y $27.14 26 Fee Schedule (FS) - 1/1/2018


88341 Y $56.10 TC Fee Schedule - 1/1/2018

88342 Y $34.08 26 Fee Schedule (FS) - 1/1/2018


88342 Y $64.31 TC Fee Schedule - 1/1/2018

88344 Y $37.34 26 Fee Schedule (FS) - 1/1/2018


88344 Y $119.16 TC Fee Schedule - 1/1/2018

88346 Y $34.37 26 Fee Schedule (FS) - 1/1/2018




CPT Code


88346 Y $50.29 TC Fee Schedule - 1/1/2018

88348 Y $72.63 26 Fee Schedule (FS) - 1/1/2018


88348 Y $238.04 TC Fee Schedule - 1/1/2018

88350 Y $27.50 26 Fee Schedule (FS) - 1/1/2018


88350 Y $37.71 TC Fee Schedule - 1/1/2018

88355 Y $78.10 26 Fee Schedule (FS) - 1/1/2018


88355 Y $42.19 TC Fee Schedule - 1/1/2018

88356 Y $118.53 26 Fee Schedule (FS) - 1/1/2018


88356 Y $83.24 TC Fee Schedule - 1/1/2018

88358 Y $44.57 26 Fee Schedule (FS) - 1/1/2018


88358 Y $41.56 TC Fee Schedule - 1/1/2018

88360 Y $42.49 26 Fee Schedule (FS) - 1/1/2018


88360 Y $77.71 TC Fee Schedule - 1/1/2018

88361 Y $45.20 26 Fee Schedule (FS) - 1/1/2018


88361 Y $85.50 TC Fee Schedule - 1/1/2018

88362 Y $105.61 26 Fee Schedule (FS) - 1/1/2018


88362 Y $84.68 TC Fee Schedule - 1/1/2018


88364 Y $33.45 26 Fee Schedule (FS) - 1/1/2018


88364 Y $85.19 TC Fee Schedule - 1/1/2018

88365 Y $42.24 26 Fee Schedule (FS) - 1/1/2018


88365 Y $118.85 TC Fee Schedule - 1/1/2018

88366 Y $59.61 26 Fee Schedule (FS) - 1/1/2018



CPT Code



88366 Y $175.57 TC Fee Schedule - 1/1/2018

88367 Y $33.10 26 Fee Schedule (FS) - 1/1/2018


88367 Y $63.37 TC Fee Schedule - 1/1/2018

88368 Y $39.75 26 Fee Schedule (FS) - 1/1/2018


88368 Y $69.30 TC Fee Schedule - 1/1/2018

88369 Y $30.85 26 Fee Schedule (FS) - 1/1/2018


88369 Y $67.43 TC Fee Schedule - 1/1/2018

88371 Y $17.08 26 Fee Schedule (FS) - 1/1/2018


88372 Y $17.08 26 Fee Schedule (FS) - 1/1/2018


88373 Y $26.24 26 Fee Schedule (FS) - 1/1/2018


88373 Y $44.57 TC Fee Schedule - 1/1/2018

88374 Y $41.92 26 Fee Schedule (FS) - 1/1/2018


88374 Y $264.40 TC Fee Schedule - 1/1/2018


88377 Y $61.08 26 Fee Schedule (FS) - 1/1/2018


88377 Y $303.78 TC Fee Schedule - 1/1/2018

88380 Y $52.44 26 Fee Schedule (FS) - 1/1/2018


88380 Y $71.59 TC Fee Schedule - 1/1/2018

88381 Y $23.95 26 Fee Schedule (FS) - 1/1/2018


88381 Y $85.62 TC Fee Schedule - 1/1/2018

88387 Y $27.05 26 Fee Schedule (FS) - 1/1/2018




CPT Code


88387 Y $5.41 TC Fee Schedule - 1/1/2018

88388 Y $22.85 26 Fee Schedule (FS) - 1/1/2018


88388 Y $8.84 TC Fee Schedule - 1/1/2018

88399 Y $0.00 26 by Report - 6/1/1981











89060 Y $17.08 26 Fee Schedule (FS) - 1/1/2018




















CPT Code




























90620 Y $169.60 General Fee Schedule VFC Antigen

- 2/1/2015


- 2/1/2015





- 4/1/2011



CPT Code



- 4/1/2011




- 4/1/2011


- 4/1/2011


- 4/1/2011


- 4/1/2011




- 10/1/2013


- 10/1/2013


- 10/1/2017


- 10/1/2012


- 4/1/2011


- 10/1/2012








- 4/1/2017




- 10/1/2017




CPT Code




- 4/1/2011


- 4/1/2011









- 4/1/2011



- 4/1/2011


- 4/1/2011


- 4/1/2011


- 4/1/2011


- 4/1/2011


- 4/1/2011


- 1/1/2018


- 1/1/2018


- 4/1/2011



- 4/1/2011


- 1/1/2018




CPT Code



- 4/1/2011






- 10/1/2017


- 7/1/2017




























CPT Code
















91010 Y $62.77 26 Fee Schedule (FS) - 8/1/2016


91010 Y $94.79 TC Fee Schedule - 1/1/2017

91013 Y $8.93 26 Fee Schedule (FS) - 1/1/2017


91013 Y $12.08 TC Fee Schedule - 8/1/2016

91020 Y $71.79 26 Fee Schedule (FS) - 8/1/2016


91020 Y $134.77 TC Fee Schedule - 8/1/2016

91022 Y $70.65 26 Fee Schedule (FS) - 1/1/2017


91022 Y $80.24 TC Fee Schedule - 1/1/2017

91030 Y $44.28 26 Fee Schedule (FS) - 1/1/2017


91030 Y $73.27 TC Fee Schedule - 12/1/2009

91034 Y $49.10 26 Fee Schedule (FS) - 8/1/2016


91034 Y $120.48 TC Fee Schedule - 1/1/2017

91035 Y $79.32 26 Fee Schedule (FS) - 8/1/2016



CPT Code



91035 Y $339.53 TC Fee Schedule - 8/1/2016

91037 Y $47.62 26 Fee Schedule (FS) - 1/1/2017


91037 Y $91.08 TC Fee Schedule - 12/1/2009

91038 Y $54.25 26 Fee Schedule (FS) - 1/1/2017


91038 Y $65.07 TC Fee Schedule - 12/1/2009

91040 Y $46.84 26 Fee Schedule (FS) - 1/1/2017


91040 Y $335.27 TC Fee Schedule - 1/1/2017

91065 Y $9.61 26 Fee Schedule (FS) - 1/1/2017


91065 Y $48.28 TC Fee Schedule - 12/1/2009

91110 Y $179.93 26 Fee Schedule (FS) - 8/1/2016


91110 Y $603.92 TC Fee Schedule - 1/1/2017

91111 Y $46.62 26 Fee Schedule (FS) - 12/1/2009


91111 Y $542.11 TC Fee Schedule - 8/1/2016

91112 Y $104.43 26 Fee Schedule (FS) - 8/1/2016


91112 Y $847.81 TC Fee Schedule - 1/1/2017


91120 Y $47.48 26 Fee Schedule (FS) - 1/1/2017


91120 Y $327.53 TC Fee Schedule - 1/1/2017

91122 Y $85.43 26 Fee Schedule (FS) - 1/1/2017


91122 Y $119.01 TC Fee Schedule - 1/1/2017

91132 Y $26.64 26 Fee Schedule (FS) - 8/1/2016


91132 Y $102.89 TC Fee Schedule - 8/1/2016



CPT Code


91133 Y $32.37 26 Fee Schedule (FS) - 1/1/2017


91133 Y $119.86 TC Fee Schedule - 1/1/2017

91200 Y $12.27 26 Fee Schedule (FS) - 1/1/2017


91200 Y $13.39 TC Fee Schedule - 1/1/2017






92014 Y $39.52 TC Fee Schedule - 12/1/2009





92025 Y $14.85 26 Fee Schedule (FS) - 12/1/2009


92025 Y $10.23 TC Fee Schedule - 12/1/2009

92060 Y $35.77 26 Fee Schedule (FS) - 8/1/2016


92060 Y $15.41 TC Fee Schedule - 12/1/2009



92081 Y $15.13 26 Fee Schedule (FS) - 1/1/2017


92081 Y $15.25 TC Fee Schedule - 1/1/2017

92082 Y $20.05 26 Fee Schedule (FS) - 1/1/2017


92082 Y $22.67 TC Fee Schedule - 1/1/2017

92083 Y $26.08 26 Fee Schedule (FS) - 8/1/2016


92083 Y $31.65 TC Fee Schedule - 1/1/2017



CPT Code



92132 Y $17.75 26 Fee Schedule (FS) - 1/1/2017


92132 Y $13.94 TC Fee Schedule - 8/1/2016

92133 Y $25.90 26 Fee Schedule (FS) - 1/1/2017


92133 Y $13.94 TC Fee Schedule - 8/1/2016

92134 Y $26.52 26 Fee Schedule (FS) - 1/1/2017


92134 Y $13.94 TC Fee Schedule - 8/1/2016

92136 Y $28.22 26 Fee Schedule (FS) - 8/1/2016


92136 Y $48.66 TC Fee Schedule - 8/1/2016

92145 Y $8.45 26 Fee Schedule (FS) - 8/1/2016


92145 Y $5.96 TC Fee Schedule - 8/1/2016




92228 Y $16.99 26 Fee Schedule (FS) - 1/1/2011


92228 Y $11.46 TC Fee Schedule - 8/1/2016


92235 Y $42.84 26 Fee Schedule (FS) - 8/1/2016


92235 Y $54.87 TC Fee Schedule - 1/1/2017

92240 Y $58.20 26 Fee Schedule (FS) - 8/1/2016


92240 Y $167.22 TC Fee Schedule - 1/1/2017

92242 Y $51.48 26 Fee Schedule (FS) - 1/1/2017


92242 Y $150.01 TC Fee Schedule - 1/1/2017

92250 Y $22.01 26 Fee Schedule (FS) - 1/1/2017



CPT Code



92250 Y $44.37 TC Fee Schedule - 8/1/2016


92265 Y $40.54 26 Fee Schedule (FS) - 8/1/2016


92265 Y $31.03 TC Fee Schedule - 1/1/2017

92270 Y $38.66 26 Fee Schedule (FS) - 1/1/2017


92270 Y $41.78 TC Fee Schedule - 12/1/2009

92275 Y $49.89 26 Fee Schedule (FS) - 1/1/2017


92275 Y $52.39 TC Fee Schedule - 12/1/2009

92283 Y $8.59 26 Fee Schedule (FS) - 1/1/2017


92283 Y $26.70 TC Fee Schedule - 12/1/2009

92284 Y $11.57 26 Fee Schedule (FS) - 1/1/2017


92284 Y $41.87 TC Fee Schedule - 1/1/2017

92286 Y $20.36 26 Fee Schedule (FS) - 1/1/2017


92286 Y $14.01 TC Fee Schedule - 1/1/2017















CPT Code



















92537 Y $29.66 26 Fee Schedule (FS) - 8/1/2016


92537 Y $7.51 TC Fee Schedule - 8/1/2016

92538 Y $14.82 26 Fee Schedule (FS) - 8/1/2016


92538 Y $4.11 TC Fee Schedule - 8/1/2016

92540 Y $71.43 26 Fee Schedule (FS) - 8/1/2016


92540 Y $14.85 TC Fee Schedule - 1/1/2010

92541 Y $19.43 26 Fee Schedule (FS) - 1/1/2017


92541 Y $2.87 TC Fee Schedule - 1/1/2017

92542 Y $18.56 26 Fee Schedule (FS) - 12/1/2009


92542 Y $2.56 TC Fee Schedule - 1/1/2017

92544 Y $13.20 26 Fee Schedule (FS) - 1/1/2017



CPT Code



92544 Y $2.25 TC Fee Schedule - 1/1/2017

92545 Y $12.21 26 Fee Schedule (FS) - 8/1/2016


92545 Y $1.94 TC Fee Schedule - 1/1/2017

92546 Y $13.87 26 Fee Schedule (FS) - 1/1/2017


92546 Y $64.37 TC Fee Schedule - 12/1/2009


92548 Y $24.43 26 Fee Schedule (FS) - 1/1/2017


92548 Y $66.32 TC Fee Schedule - 1/1/2017
























CPT Code








92585 Y $25.05 26 Fee Schedule (FS) - 1/1/2017


92585 Y $68.51 TC Fee Schedule - 12/1/2009


92587 Y $7.41 26 Fee Schedule (FS) - 12/1/2009


92587 Y $2.87 TC Fee Schedule - 1/1/2017

92588 Y $19.72 26 Fee Schedule (FS) - 12/1/2009


92588 Y $3.49 TC Fee Schedule - 1/1/2017




















CPT Code





































CPT Code



92978 Y $92.04 26 Fee Schedule (FS) - 8/1/2016


92979 Y $73.75 26 Fee Schedule (FS) - 8/1/2016
















93024 Y $53.35 26 Fee Schedule (FS) - 1/1/2017


93024 Y $41.11 TC Fee Schedule - 12/1/2009

93025 Y $34.48 26 Fee Schedule (FS) - 1/1/2017


93025 Y $106.86 TC Fee Schedule - 1/1/2017




93050 Y $7.99 26 Fee Schedule (FS) - 8/1/2016


93050 Y $7.82 TC Fee Schedule - 1/1/2017





CPT Code






93260 Y $42.41 26 Fee Schedule (FS) - 8/1/2016


93260 Y $18.72 TC Fee Schedule - 8/1/2016

93261 Y $35.92 26 Fee Schedule (FS) - 1/1/2017


93261 Y $18.72 TC Fee Schedule - 8/1/2016





93278 Y $11.60 26 Fee Schedule (FS) - 1/1/2017


93278 Y $15.56 TC Fee Schedule - 1/1/2017

93279 Y $30.10 26 Fee Schedule (FS) - 1/1/2017


93279 Y $15.25 TC Fee Schedule - 1/1/2017

93280 Y $35.77 26 Fee Schedule (FS) - 1/1/2017


93280 Y $17.11 TC Fee Schedule - 1/1/2017

93281 Y $42.01 26 Fee Schedule (FS) - 1/1/2017


93281 Y $20.20 TC Fee Schedule - 1/1/2017

93282 Y $39.71 26 Fee Schedule (FS) - 1/1/2017


93282 Y $17.72 TC Fee Schedule - 1/1/2017

93283 Y $53.48 26 Fee Schedule (FS) - 8/1/2016


93283 Y $20.82 TC Fee Schedule - 1/1/2017

93284 Y $58.91 26 Fee Schedule (FS) - 1/1/2017



CPT Code



93284 Y $23.60 TC Fee Schedule - 1/1/2017

93285 Y $24.49 26 Fee Schedule (FS) - 1/1/2017


93285 Y $14.01 TC Fee Schedule - 1/1/2017

93286 Y $13.80 26 Fee Schedule (FS) - 8/1/2016


93286 Y $10.30 TC Fee Schedule - 8/1/2016

93287 Y $19.97 26 Fee Schedule (FS) - 8/1/2016


93287 Y $11.53 TC Fee Schedule - 1/1/2017

93288 Y $19.91 26 Fee Schedule (FS) - 1/1/2017


93288 Y $13.70 TC Fee Schedule - 1/1/2017

93289 Y $40.82 26 Fee Schedule (FS) - 12/1/2009


93289 Y $17.11 TC Fee Schedule - 1/1/2017

93290 Y $19.36 26 Fee Schedule (FS) - 8/1/2016


93290 Y $8.44 TC Fee Schedule - 1/1/2017

93291 Y $20.22 26 Fee Schedule (FS) - 1/1/2017


93291 Y $12.77 TC Fee Schedule - 1/1/2017

93292 Y $19.91 26 Fee Schedule (FS) - 1/1/2017


93292 Y $9.67 TC Fee Schedule - 1/1/2017

93293 Y $14.57 26 Fee Schedule (FS) - 1/1/2017


93293 Y $32.89 TC Fee Schedule - 1/1/2017







CPT Code




93303 Y $59.97 26 Fee Schedule (FS) - 1/1/2017


93303 Y $140.44 TC Fee Schedule - 12/1/2009

93304 Y $34.48 26 Fee Schedule (FS) - 1/1/2017


93304 Y $71.26 TC Fee Schedule - 12/1/2009

93306 Y $59.66 26 Fee Schedule (FS) - 1/1/2017


93306 Y $143.15 TC Fee Schedule - 1/1/2017

93307 Y $42.38 26 Fee Schedule (FS) - 1/1/2017


93307 Y $74.05 TC Fee Schedule - 1/1/2017

93308 Y $24.21 26 Fee Schedule (FS) - 1/1/2017


93308 Y $71.26 TC Fee Schedule - 12/1/2009

93312 Y $110.13 26 Fee Schedule (FS) - 8/1/2016


93312 Y $139.78 TC Fee Schedule - 12/1/2009


93314 Y $65.73 26 Fee Schedule (FS) - 12/1/2009


93314 Y $139.78 TC Fee Schedule - 12/1/2009

93315 Y $133.81 26 Fee Schedule (FS) - 1/1/2017


93317 Y $92.49 26 Fee Schedule (FS) - 8/1/2016

93318 Y $101.94 26 Fee Schedule (FS) - 8/1/2016

93320 Y $17.21 26 Fee Schedule (FS) - 1/1/2017


93320 Y $31.26 TC Fee Schedule - 1/1/2017

93321 Y $6.99 26 Fee Schedule (FS) - 1/1/2017




CPT Code


93321 Y $17.33 TC Fee Schedule - 1/1/2017

93325 Y $2.98 26 Fee Schedule (FS) - 1/1/2017


93325 Y $19.50 TC Fee Schedule - 1/1/2017

93350 Y $66.60 26 Fee Schedule (FS) - 1/1/2017


93350 Y $65.10 TC Fee Schedule - 12/1/2009

93351 Y $79.85 26 Fee Schedule (FS) - 1/1/2017


93351 Y $147.80 TC Fee Schedule - 1/1/2011



93451 Y $141.74 26 Fee Schedule (FS) - 8/1/2016


93451 Y $559.19 TC Fee Schedule - 8/1/2016

93452 Y $248.52 26 Fee Schedule (FS) - 8/1/2016


93452 Y $534.17 TC Fee Schedule - 8/1/2016

93453 Y $325.69 26 Fee Schedule (FS) - 8/1/2016


93453 Y $698.53 TC Fee Schedule - 8/1/2016

93454 Y $250.44 26 Fee Schedule (FS) - 8/1/2016


93454 Y $556.41 TC Fee Schedule - 8/1/2016

93455 Y $289.02 26 Fee Schedule (FS) - 8/1/2016


93455 Y $652.20 TC Fee Schedule - 8/1/2016

93456 Y $320.46 26 Fee Schedule (FS) - 8/1/2016


93456 Y $689.58 TC Fee Schedule - 8/1/2016

93457 Y $359.40 26 Fee Schedule (FS) - 8/1/2016


93457 Y $785.02 TC Fee Schedule - 8/1/2016



CPT Code


93458 Y $305.59 26 Fee Schedule (FS) - 8/1/2016


93458 Y $668.26 TC Fee Schedule - 8/1/2016

93459 Y $343.82 26 Fee Schedule (FS) - 8/1/2016


93459 Y $731.89 TC Fee Schedule - 8/1/2016

93460 Y $383.05 26 Fee Schedule (FS) - 8/1/2016


93460 Y $768.96 TC Fee Schedule - 8/1/2016

93461 Y $422.66 26 Fee Schedule (FS) - 8/1/2016


93461 Y $896.56 TC Fee Schedule - 8/1/2016



93464 Y $82.24 26 Fee Schedule (FS) - 1/1/2017


93464 Y $148.69 TC Fee Schedule - 1/1/2011


93505 Y $227.09 26 Fee Schedule (FS) - 8/1/2016


93530 Y $214.45 26 Fee Schedule (FS) - 1/1/2017


93531 Y $418.29 26 Fee Schedule (FS) - 1/1/2017


93532 Y $533.08 26 Fee Schedule (FS) - 8/1/2016

93533 Y $355.52 26 Fee Schedule (FS) - 8/1/2016

93561 Y $24.45 26 Fee Schedule (FS) - 8/1/2016


93562 Y $7.63 26 Fee Schedule (FS) - 1/1/2017







CPT Code





93571 Y $91.05 26 Fee Schedule (FS) - 8/1/2016


93572 Y $71.13 26 Fee Schedule (FS) - 8/1/2016








93600 Y $111.14 26 Fee Schedule (FS) - 8/1/2016


93602 Y $111.14 26 Fee Schedule (FS) - 8/1/2016


93603 Y $111.15 26 Fee Schedule (FS) - 8/1/2016


93609 Y $260.93 26 Fee Schedule (FS) - 8/1/2016


93610 Y $157.99 26 Fee Schedule (FS) - 8/1/2016


93612 Y $158.32 26 Fee Schedule (FS) - 8/1/2016



93615 Y $46.55 26 Fee Schedule (FS) - 8/1/2016


93616 Y $62.20 26 Fee Schedule (FS) - 1/1/2017

93618 Y $222.33 26 Fee Schedule (FS) - 8/1/2016


93619 Y $392.63 26 Fee Schedule (FS) - 8/1/2016




CPT Code


93620 Y $614.66 26 Fee Schedule (FS) - 8/1/2016


93620 Y $310.95 TC Fee Schedule - 12/1/2009

93621 Y $109.74 26 Fee Schedule (FS) - 8/1/2016

93622 Y $161.93 26 Fee Schedule (FS) - 8/1/2016

93623 Y $148.72 26 Fee Schedule (FS) - 8/1/2016

93624 Y $261.11 26 Fee Schedule (FS) - 8/1/2016


93624 Y $72.62 TC Fee Schedule - 12/1/2009

93631 Y $391.84 26 Fee Schedule (FS) - 1/1/2017

93640 Y $182.72 26 Fee Schedule (FS) - 8/1/2016


93641 Y $309.22 26 Fee Schedule (FS) - 8/1/2016


93642 Y $258.76 26 Fee Schedule (FS) - 8/1/2016


93642 Y $133.10 TC Fee Schedule - 1/1/2017

93644 Y $161.76 26 Fee Schedule (FS) - 1/1/2017


93644 Y $93.43 TC Fee Schedule - 8/1/2016







93660 Y $88.36 26 Fee Schedule (FS) - 1/1/2017


93660 Y $55.88 TC Fee Schedule - 8/1/2016

93662 Y $133.80 26 Fee Schedule (FS) - 1/1/2017


93701 Y $9.30 26 Fee Schedule (FS) - 12/1/2009




CPT Code


93701 Y $31.51 TC Fee Schedule - 12/1/2009


93724 Y $227.09 26 Fee Schedule (FS) - 1/1/2017


93724 Y $24.53 TC Fee Schedule - 1/1/2017


93745 Y $17.02 26 Fee Schedule (FS) - 1/1/2011


93745 Y $39.73 TC Fee Schedule - 1/1/2011












93880 Y $31.39 26 Fee Schedule (FS) - 12/1/2009


93880 Y $132.63 TC Fee Schedule - 1/1/2017

93882 Y $21.61 26 Fee Schedule (FS) - 12/1/2009


93882 Y $91.39 TC Fee Schedule - 1/1/2017

93886 Y $44.84 26 Fee Schedule (FS) - 1/1/2017


93886 Y $132.24 TC Fee Schedule - 1/1/2017

93888 Y $24.28 26 Fee Schedule (FS) - 1/1/2017


93888 Y $106.55 TC Fee Schedule - 1/1/2017

93890 Y $48.71 26 Fee Schedule (FS) - 1/1/2017



CPT Code



93890 Y $132.24 TC Fee Schedule - 1/1/2017

93892 Y $57.89 26 Fee Schedule (FS) - 1/1/2017


93892 Y $79.63 TC Fee Schedule - 1/1/2017

93893 Y $56.40 26 Fee Schedule (FS) - 1/1/2017


93893 Y $79.63 TC Fee Schedule - 1/1/2017

93895 Y $0.00 26 by Report - 1/1/2015


93895 Y $0.00 TC by Report - 1/1/2015

93922 Y $12.07 26 Fee Schedule (FS) - 1/1/2017


93922 Y $66.94 TC Fee Schedule - 1/1/2017

93923 Y $21.44 26 Fee Schedule (FS) - 1/1/2017


93923 Y $101.68 TC Fee Schedule - 1/1/2017

93924 Y $23.74 26 Fee Schedule (FS) - 1/1/2017


93924 Y $130.46 TC Fee Schedule - 1/1/2017

93925 Y $30.61 26 Fee Schedule (FS) - 12/1/2009


93925 Y $132.24 TC Fee Schedule - 1/1/2017

93926 Y $20.89 26 Fee Schedule (FS) - 12/1/2009


93926 Y $113.13 TC Fee Schedule - 1/1/2017

93930 Y $24.62 26 Fee Schedule (FS) - 12/1/2009


93930 Y $132.63 TC Fee Schedule - 1/1/2017

93931 Y $16.43 26 Fee Schedule (FS) - 12/1/2009


93931 Y $91.08 TC Fee Schedule - 1/1/2017

93970 Y $33.04 26 Fee Schedule (FS) - 1/1/2017



CPT Code



93970 Y $132.63 TC Fee Schedule - 1/1/2017

93971 Y $21.37 26 Fee Schedule (FS) - 1/1/2017


93971 Y $85.81 TC Fee Schedule - 1/1/2017

93975 Y $55.05 26 Fee Schedule (FS) - 1/1/2017


93975 Y $132.24 TC Fee Schedule - 1/1/2017

93976 Y $37.56 26 Fee Schedule (FS) - 1/1/2017


93976 Y $108.10 TC Fee Schedule - 1/1/2017

93978 Y $34.69 26 Fee Schedule (FS) - 12/1/2009


93978 Y $132.63 TC Fee Schedule - 1/1/2017

93979 Y $22.22 26 Fee Schedule (FS) - 8/1/2016


93979 Y $83.34 TC Fee Schedule - 1/1/2017

93980 Y $57.67 26 Fee Schedule (FS) - 1/1/2017


93980 Y $52.08 TC Fee Schedule - 1/1/2017

93981 Y $21.10 26 Fee Schedule (FS) - 1/1/2017


93981 Y $44.96 TC Fee Schedule - 1/1/2017

93990 Y $13.77 26 Fee Schedule (FS) - 12/1/2009


93990 Y $79.32 TC Fee Schedule - 1/1/2017






94010 Y $7.97 26 Fee Schedule (FS) - 1/1/2017




CPT Code


94010 Y $21.92 TC Fee Schedule - 12/1/2009







94060 Y $12.27 26 Fee Schedule (FS) - 1/1/2017


94060 Y $35.63 TC Fee Schedule - 12/1/2009

94070 Y $27.26 26 Fee Schedule (FS) - 1/1/2017


94070 Y $25.38 TC Fee Schedule - 12/1/2009


94200 Y $5.40 26 Fee Schedule (FS) - 8/1/2016


94200 Y $14.72 TC Fee Schedule - 12/1/2009

94250 Y $5.02 26 Fee Schedule (FS) - 1/1/2017


94250 Y $18.34 TC Fee Schedule - 1/1/2017

94375 Y $13.93 26 Fee Schedule (FS) - 1/1/2017


94375 Y $18.15 TC Fee Schedule - 12/1/2009

94400 Y $18.58 26 Fee Schedule (FS) - 1/1/2017


94400 Y $26.72 TC Fee Schedule - 12/1/2009

94450 Y $18.89 26 Fee Schedule (FS) - 1/1/2017


94450 Y $25.69 TC Fee Schedule - 12/1/2009

94452 Y $13.62 26 Fee Schedule (FS) - 1/1/2017


94452 Y $32.53 TC Fee Schedule - 12/1/2009

94453 Y $17.96 26 Fee Schedule (FS) - 1/1/2017



CPT Code



94453 Y $48.28 TC Fee Schedule - 12/1/2009


94617 Y $31.39 26 Fee Schedule (FS) - 1/1/2018


94617 Y $54.76 TC Fee Schedule - 1/1/2018

94618 Y $21.47 26 Fee Schedule (FS) - 1/1/2018


94618 Y $10.09 TC Fee Schedule - 1/1/2018

94621 Y $64.72 26 Fee Schedule (FS) - 1/1/2017


94621 Y $64.05 TC Fee Schedule - 12/1/2009











94680 Y $11.93 26 Fee Schedule (FS) - 1/1/2017


94680 Y $39.08 TC Fee Schedule - 1/1/2017

94681 Y $9.30 26 Fee Schedule (FS) - 1/1/2017


94681 Y $37.53 TC Fee Schedule - 1/1/2017

94690 Y $3.57 26 Fee Schedule (FS) - 8/1/2016


94690 Y $40.32 TC Fee Schedule - 1/1/2017

94726 Y $11.52 26 Fee Schedule (FS) - 8/1/2016




CPT Code


94726 Y $35.36 TC Fee Schedule - 1/1/2017

94727 Y $11.52 26 Fee Schedule (FS) - 8/1/2016


94727 Y $26.36 TC Fee Schedule - 8/1/2016

94728 Y $11.52 26 Fee Schedule (FS) - 8/1/2016


94728 Y $24.22 TC Fee Schedule - 1/1/2017

94729 Y $8.00 26 Fee Schedule (FS) - 2/6/2012


94729 Y $39.83 TC Fee Schedule - 8/1/2016

94750 Y $10.61 26 Fee Schedule (FS) - 1/1/2017


94750 Y $44.86 TC Fee Schedule - 12/1/2009




94770 Y $7.51 26 Fee Schedule (FS) - 12/1/2009


94770 Y $26.72 TC Fee Schedule - 12/1/2009








94799 Y $0.00 26 by Report - 1/10/1986









CPT Code
































95782 Y $119.60 26 Fee Schedule (FS) - 8/1/2016


95782 Y $787.21 TC Fee Schedule - 1/1/2017



CPT Code


95783 Y $130.75 26 Fee Schedule (FS) - 8/1/2016


95783 Y $821.03 TC Fee Schedule - 1/1/2017

95800 Y $48.68 26 Fee Schedule (FS) - 1/1/2017


95800 Y $109.95 TC Fee Schedule - 1/1/2017

95801 Y $46.46 26 Fee Schedule (FS) - 1/1/2017


95801 Y $35.98 TC Fee Schedule - 1/1/2017

95803 Y $41.16 26 Fee Schedule (FS) - 1/1/2017


95803 Y $85.19 TC Fee Schedule - 1/1/2017

95805 Y $55.68 26 Fee Schedule (FS) - 1/1/2017


95805 Y $321.84 TC Fee Schedule - 1/1/2017

95806 Y $57.36 26 Fee Schedule (FS) - 1/1/2017


95806 Y $93.55 TC Fee Schedule - 1/1/2017

95807 Y $58.76 26 Fee Schedule (FS) - 1/1/2017


95807 Y $363.93 TC Fee Schedule - 1/1/2017

95808 Y $82.47 26 Fee Schedule (FS) - 1/1/2017


95808 Y $435.97 TC Fee Schedule - 12/1/2009

95810 Y $114.80 26 Fee Schedule (FS) - 1/1/2017


95810 Y $438.37 TC Fee Schedule - 1/1/2017

95811 Y $119.49 26 Fee Schedule (FS) - 1/1/2017


95811 Y $461.66 TC Fee Schedule - 1/1/2017

95812 Y $54.19 26 Fee Schedule (FS) - 1/1/2017


95812 Y $126.71 TC Fee Schedule - 12/1/2009



CPT Code


95813 Y $86.24 26 Fee Schedule (FS) - 1/1/2017


95813 Y $152.04 TC Fee Schedule - 12/1/2009

95816 Y $54.19 26 Fee Schedule (FS) - 1/1/2017


95816 Y $115.07 TC Fee Schedule - 12/1/2009

95819 Y $54.19 26 Fee Schedule (FS) - 1/1/2017


95819 Y $90.07 TC Fee Schedule - 12/1/2009

95822 Y $54.19 26 Fee Schedule (FS) - 1/1/2017


95822 Y $146.58 TC Fee Schedule - 12/1/2009

95824 Y $37.01 26 Fee Schedule (FS) - 1/1/2017

95827 Y $53.57 26 Fee Schedule (FS) - 1/1/2017


95827 Y $83.58 TC Fee Schedule - 12/1/2009

95829 Y $321.91 26 Fee Schedule (FS) - 8/1/2016


95829 Y $985.68 TC Fee Schedule - 12/1/2009









95860 Y $48.44 26 Fee Schedule (FS) - 1/1/2017


95860 Y $34.92 TC Fee Schedule - 12/1/2009

95861 Y $77.97 26 Fee Schedule (FS) - 1/1/2017


95861 Y $27.06 TC Fee Schedule - 12/1/2009



CPT Code


95863 Y $93.74 26 Fee Schedule (FS) - 1/1/2017


95863 Y $34.25 TC Fee Schedule - 12/1/2009

95864 Y $101.59 26 Fee Schedule (FS) - 1/1/2017


95864 Y $65.43 TC Fee Schedule - 12/1/2009

95865 Y $79.77 26 Fee Schedule (FS) - 1/1/2017


95865 Y $24.32 TC Fee Schedule - 12/1/2009

95866 Y $62.93 26 Fee Schedule (FS) - 1/1/2017


95866 Y $7.89 TC Fee Schedule - 12/1/2009

95867 Y $39.31 26 Fee Schedule (FS) - 1/1/2017


95867 Y $21.23 TC Fee Schedule - 12/1/2009

95868 Y $59.50 26 Fee Schedule (FS) - 1/1/2017


95868 Y $25.70 TC Fee Schedule - 12/1/2009

95869 Y $18.81 26 Fee Schedule (FS) - 1/1/2017


95869 Y $7.89 TC Fee Schedule - 12/1/2009

95870 Y $18.51 26 Fee Schedule (FS) - 1/1/2017


95870 Y $7.89 TC Fee Schedule - 12/1/2009

95872 Y $82.24 26 Fee Schedule (FS) - 12/1/2009


95872 Y $22.26 TC Fee Schedule - 12/1/2009

95873 Y $18.73 26 Fee Schedule (FS) - 1/1/2017


95873 Y $7.54 TC Fee Schedule - 12/1/2009

95874 Y $18.81 26 Fee Schedule (FS) - 1/1/2017


95874 Y $7.54 TC Fee Schedule - 12/1/2009



CPT Code


95875 Y $55.56 26 Fee Schedule (FS) - 1/1/2017


95875 Y $35.63 TC Fee Schedule - 12/1/2009

95885 Y $16.55 26 Fee Schedule (FS) - 8/1/2016


95885 Y $33.55 TC Fee Schedule - 8/1/2016

95886 Y $43.22 26 Fee Schedule (FS) - 1/1/2017


95886 Y $36.82 TC Fee Schedule - 2/6/2012

95887 Y $34.68 26 Fee Schedule (FS) - 8/1/2016


95887 Y $35.94 TC Fee Schedule - 8/1/2016

95905 Y $2.68 26 Fee Schedule (FS) - 8/1/2016


95905 Y $59.20 TC Fee Schedule - 1/1/2017

95907 Y $48.30 26 Fee Schedule (FS) - 8/1/2016


95907 Y $36.60 TC Fee Schedule - 1/1/2017

95908 Y $60.68 26 Fee Schedule (FS) - 8/1/2016


95908 Y $45.55 TC Fee Schedule - 8/1/2016

95909 Y $72.43 26 Fee Schedule (FS) - 8/1/2016


95909 Y $54.88 TC Fee Schedule - 8/1/2016

95910 Y $96.89 26 Fee Schedule (FS) - 8/1/2016


95910 Y $70.76 TC Fee Schedule - 8/1/2016

95911 Y $121.04 26 Fee Schedule (FS) - 8/1/2016


95911 Y $82.19 TC Fee Schedule - 8/1/2016

95912 Y $145.20 26 Fee Schedule (FS) - 8/1/2016


95912 Y $87.36 TC Fee Schedule - 1/1/2017



CPT Code


95913 Y $172.19 26 Fee Schedule (FS) - 8/1/2016


95913 Y $94.17 TC Fee Schedule - 1/1/2017

95921 Y $42.70 26 Fee Schedule (FS) - 1/1/2017


95921 Y $13.70 TC Fee Schedule - 12/1/2009

95922 Y $45.66 26 Fee Schedule (FS) - 1/1/2017


95922 Y $13.70 TC Fee Schedule - 12/1/2009

95923 Y $43.79 26 Fee Schedule (FS) - 1/1/2017


95923 Y $54.11 TC Fee Schedule - 12/1/2009

95924 Y $81.25 26 Fee Schedule (FS) - 8/1/2016


95924 Y $51.77 TC Fee Schedule - 1/1/2017

95925 Y $26.48 26 Fee Schedule (FS) - 1/1/2017


95925 Y $33.22 TC Fee Schedule - 12/1/2009

95926 Y $25.86 26 Fee Schedule (FS) - 1/1/2017


95926 Y $33.22 TC Fee Schedule - 12/1/2009

95927 Y $25.86 26 Fee Schedule (FS) - 1/1/2017


95927 Y $33.22 TC Fee Schedule - 12/1/2009

95928 Y $75.31 26 Fee Schedule (FS) - 1/1/2017


95928 Y $82.52 TC Fee Schedule - 12/1/2009

95929 Y $75.78 26 Fee Schedule (FS) - 1/1/2017


95929 Y $89.03 TC Fee Schedule - 12/1/2009

95930 Y $17.13 26 Fee Schedule (FS) - 1/1/2017


95930 Y $72.25 TC Fee Schedule - 12/1/2009



CPT Code


95933 Y $29.40 26 Fee Schedule (FS) - 1/1/2017


95933 Y $28.77 TC Fee Schedule - 12/1/2009

95937 Y $32.43 26 Fee Schedule (FS) - 1/1/2017


95937 Y $12.34 TC Fee Schedule - 12/1/2009

95938 Y $40.78 26 Fee Schedule (FS) - 8/1/2016


95938 Y $231.11 TC Fee Schedule - 2/6/2012

95939 Y $107.34 26 Fee Schedule (FS) - 8/1/2016


95939 Y $306.31 TC Fee Schedule - 8/1/2016

95940 Y $0.00 26 by Report - 1/1/2013


95940 Y $0.00 TC by Report - 1/1/2013

95943 Y $0.00 26 by Report - 1/1/2013


95943 Y $0.00 TC by Report - 1/1/2013

95950 Y $75.03 26 Fee Schedule (FS) - 1/1/2017


95950 Y $127.84 TC Fee Schedule - 12/1/2009

95951 Y $300.06 26 Fee Schedule (FS) - 1/1/2017


95951 Y $620.37 TC Fee Schedule - 12/1/2009

95953 Y $154.09 26 Fee Schedule (FS) - 1/1/2017


95953 Y $222.97 TC Fee Schedule - 8/1/2016

95954 Y $117.92 26 Fee Schedule (FS) - 1/1/2017


95954 Y $111.29 TC Fee Schedule - 12/1/2009

95955 Y $50.91 26 Fee Schedule (FS) - 8/1/2016


95955 Y $73.32 TC Fee Schedule - 12/1/2009



CPT Code


95956 Y $168.92 26 Fee Schedule (FS) - 12/1/2009


95956 Y $499.31 TC Fee Schedule - 12/1/2009

95957 Y $98.84 26 Fee Schedule (FS) - 1/1/2017


95957 Y $62.35 TC Fee Schedule - 12/1/2009

95958 Y $213.02 26 Fee Schedule (FS) - 1/1/2017


95958 Y $64.41 TC Fee Schedule - 12/1/2009

95961 Y $153.46 26 Fee Schedule (FS) - 1/1/2017


95961 Y $47.27 TC Fee Schedule - 12/1/2009

95962 Y $163.21 26 Fee Schedule (FS) - 1/1/2017


95962 Y $47.27 TC Fee Schedule - 12/1/2009

95965 Y $394.45 26 Fee Schedule (FS) - 1/1/2017

95966 Y $199.93 26 Fee Schedule (FS) - 1/1/2017

95966 Y $304.30 TC Fee Schedule - 12/1/2009

95967 Y $173.40 26 Fee Schedule (FS) - 8/1/2016

95967 Y $251.45 TC Fee Schedule - 12/1/2009
















CPT Code








96020 Y $31.89 26 Fee Schedule (FS) - 12/1/2009





























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99170 Y $118.44 26 Fee Schedule (FS) - 12/1/2009
















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Documents

CPT CODE FEE SCHEDULE NEW MEXICO MEDICAID FEE FOR … · 11057 Y $56.92 General Fee Schedule - 8/1/2016 11100 Y $75.10 General Fee Schedule - 12/1/2009 11101 Y $27.82 General Fee