This fee schedule applies to charges submitted by the following providers: Advanced Practice Nurses, Dentists providing medical services, Fee-For-Service Hospitals, Imaging Centers,

Independent Diagnostic Testing Facilities (IDTFs), Independent Laboratories, Local Health Departments, Optometrists providing medical services, Physicians, and Portable X-ray Companies.

Encounter Rate Clinics (ERCs), Federally Qualified Health Centers (FQHCs), and Rural Health Centers (RHCs) should utilize this fee schedule for a listing of covered services billable as detail codes.

Please note the appearance of a code on this fee schedule does not guarantee payment. Services for which medical necessity is not clearly established are not covered by the Department's Medical

Programs. See Chapter 100, Topic 104 and Chapter A-200, Section 204 for additional exclusions. Updates are based on periodic modifications to the HCPCS/CPT code set.

CPT codes and descriptions only are copyright 2015 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. National Correct Coding Institute (NCCI) edits apply.

*2.7% rate reductions shown in a separate column do not apply to: Physicians, Dentists, Advanced Practice Nurses, FQHCs, RHCs, ERCs, or Local Health Departments.

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

00100 04 Y I 3

00102 04 Y M 3

00103 04 Y M 5

00104 04 04/01/15 N N 44.40 43.20

00120 04 Y M 4

00124 04 Y I 3

00126 04 Y I 3

00140 04 Y M 5

00142 04 Y M 5

00144 04 Y M 5

00145 04 Y M 5

00147 04 Y M 5

00148 04 Y I 3

00160 04 Y M 4

00162 04 Y M 4

00164 04 Y I 4

00170 04 Y I 5

00172 04 Y M 5

00174 04 Y M 4

00176 04 Y M 4

00190 04 Y M 4

00192 04 Y M 4

00210 04 Y M 9

00211 04 01/01/09 Y M 9

00212 04 Y M 4

00214 04 Y M 9

00215 04 Y M 9

00216 04 Y M 9

00218 04 Y M 9

00220 04 Y M 11

00222 04 Y M 9

Rate reduced

by 2.7%

Illinois Department of Healthcare and Family Services

Practitioner Fee Schedule Effective 01/01/2018 Updated 03/06/2018

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

00300 04 Y M 3

00320 04 Y M 6

00322 04 Y M 3

00326 04 Y M 4

00350 04 Y M 15

00352 04 Y M 5

00400 04 Y I 3

00402 04 Y M 4

00404 04 Y M 4

00406 04 Y M 4

00410 04 N I 112.40 109.37

00450 04 Y M 3

00454 04 Y I 3

00470 04 Y M 4

00472 04 Y M 7

00474 04 Y M 5

00500 04 Y M 9

00520 04 Y M 4

00522 04 Y I 4

00524 04 Y M 4

00528 04 Y M 4

00529 04 Y N 5

00530 04 Y M 5

00532 04 Y I 3

00534 04 Y M 5

00537 04 Y I 5

00539 04 Y M 11

00540 04 Y M 11

00541 04 Y M 11

00542 04 Y M 11

00546 04 Y M 7

00548 04 Y M 11

00550 04 Y M 3

00560 04 Y M 20

00561 04 Y M 20

00562 04 Y M 20

00563 04 Y M 20

00566 04 Y M 20

00567 04 01/01/09 Y M 20

00580 04 Y M 20

00600 04 Y M 8

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

00604 04 Y M 8

00620 04 Y M 8

00625 04 01/01/07 Y M 10

00626 04 01/01/07 Y N 10

00630 04 Y M 7

00632 04 Y M 4

00635 04 Y I 3

00640 04 Y M 8

00670 04 Y M 7

00700 04 Y M 4

00702 04 Y I 3

00730 04 Y M 4

00731 04 01/01/18 Y M 4

00732 04 01/01/18 Y M 4

00750 04 Y M 3

00752 04 Y M 3

00754 04 Y M 3

00756 04 Y M 6

00770 04 Y M 15

00790 04 Y M 6

00792 04 Y M 12

00794 04 Y M 6

00796 04 Y M 12

00797 04 Y M 5

00800 04 Y M 4

00802 04 Y M 3

00811 04 01/01/18 Y M 4

00812 04 01/01/18 Y I 3

00813 04 01/01/18 Y M 4

00820 04 Y M 4

00830 04 Y M 3

00832 04 Y M 3

00834 04 Y M 3

00836 04 Y M 3

00840 04 Y M 4

00842 04 Y I 4

00844 04 Y M 6

00846 04 Y M 5

00848 04 Y M 6

00851 04 01/01/12 Y M 4

00860 04 Y M 4

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

00862 04 Y M 5

00864 04 Y M 7

00865 04 Y M 6

00866 04 Y M 9

00868 04 Y M 5

00870 04 Y M 5

00872 04 Y M 3

00873 04 Y M 3

00880 04 Y M 4

00882 04 Y M 5

00902 04 Y M 4

00904 04 Y M 3

00906 04 Y M 3

00908 04 Y M 6

00910 04 Y M 3

00912 04 Y M 3

00914 04 Y M 5

00916 04 Y M 5

00918 04 Y M 3

00920 04 Y M 3

00921 04 Y M 3

00922 04 Y M 3

00924 04 Y M 4

00926 04 Y M 3

00928 04 Y M 4

00930 04 Y M 3

00932 04 Y M 3

00934 04 Y M 4

00936 04 Y M 4

00938 04 Y M 3

00940 04 Y I 3

00942 04 Y M 3

00944 04 Y M 5

00948 04 Y I 3

00950 04 Y I 3

00952 04 Y I 3

01112 04 Y I 3

01120 04 Y M 3

01130 04 Y I 3

01140 04 Y M 11

01150 04 Y M 11

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

01160 04 Y M 3

01170 04 Y M 3

01173 04 Y M 3

01200 04 Y M 5

01202 04 Y M 3

01210 04 Y M 3

01212 04 Y M 8

01214 04 Y M 3

01215 04 Y I 3

01220 04 Y M 3

01230 04 Y M 4

01232 04 Y M 3

01234 04 Y M 6

01250 04 Y M 3

01260 04 Y M 10

01270 04 Y M 10

01272 04 Y M 5

01274 04 Y M 5

01320 04 Y M 3

01340 04 Y M 3

01360 04 Y M 4

01380 04 Y M 3

01382 04 Y M 3

01390 04 Y M 4

01392 04 Y M 4

01400 04 Y M 3

01402 04 Y M 3

01404 04 Y M 3

01420 04 Y I 3

01430 04 Y M 5

01432 04 Y M 5

01440 04 Y M 5

01442 04 Y M 5

01444 04 Y M 5

01462 04 Y M 3

01464 04 Y M 3

01470 03 Y M 4

01472 04 Y M 3

01474 04 Y M 3

01480 04 Y M 3

01482 04 Y M 3

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

01484 04 Y M 3

01486 04 Y M 3

01490 04 Y I 3

01500 04 Y M 10

01502 04 Y M 5

01520 04 Y M 10

01522 04 Y M 5

01610 04 Y M 3

01620 04 Y M 3

01622 04 Y M 3

01630 04 Y M 3

01634 04 Y M 5

01636 04 Y M 11

01638 04 Y M 3

01650 04 Y M 5

01652 04 Y M 15

01654 04 Y M 10

01656 04 Y M 10

01670 04 Y M 10

01680 04 Y I 3

01710 04 Y M 3

01712 04 Y M 3

01714 04 Y M 3

01716 04 Y M 3

01730 04 Y M 3

01732 04 Y M 3

01740 04 Y M 3

01742 04 Y M 3

01744 04 Y M 3

01756 04 Y M 3

01758 04 Y M 3

01760 04 Y M 3

01770 04 Y M 5

01772 04 Y M 5

01780 04 Y M 5

01782 04 Y M 3

01810 04 Y M 3

01820 04 Y M 3

01829 04 Y M 3

01830 04 Y M 3

01832 04 Y M 3

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

01840 04 Y M 5

01842 04 Y M 5

01844 04 Y M 5

01850 04 Y M 10

01852 04 Y M 3

01860 04 Y M 3

01916 04 Y I 3

01920 04 Y M 3

01922 04 Y I 3

01924 04 Y M 3

01925 04 Y M 3

01926 04 Y I 3

01930 04 Y M 5

01931 04 Y M 8

01932 04 Y M 6

01933 04 Y M 9

01935 04 01/01/08 Y M 5

01936 04 01/01/08 Y M 5

01951 04 Y I 3

01952 04 Y I 3

01953 04 Y I 3

01958 04 Y M 4

01960 09 Y M 4

01961 04 Y M 5

01962 04 Y M 5

01963 04 Y M 5

01965 04 Y M 3

01966 04 07/01/08 Y M 3

01967 04 Y M 3

01968 04 Y M 3

01969 04 Y M 3

01991 04 Y I 3

01992 04 Y I 3

01996 04 N I 14.25 13.87

01999 04 Y M 3

10021 04 N I 3 49.80 48.46

10022 04 N I 3 56.70 55.17

10030 04 01/01/14 N I 4 Y 95.05 92.48

10035 04 01/01/16 N I 3 Y 53.40 51.96

10036 A 04 01/01/16 N I 3 Y 23.93 23.28

10040 04 N I 3 35.20 34.25

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

10060 04 N I 3 36.00 35.03

10061 04 N I 3 66.50 64.70

10080 04 N I 3 70.65 68.74

10081 04 N I 4 131.80 128.24

10120 04 N I 3 39.05 38.00

10121 04 N I 3 77.60 75.50

10140 04 N I 3 41.50 40.38

10160 04 N I 3 35.95 34.98

10180 04 N I 3 Y 130.55 127.03

11000 04 N I 3 77.70 75.60

11001 04 N I 3 20.85 20.29

11004 04 N M 3 Y Y 154.43 150.26

11005 04 N M 3 Y Y 154.43 150.26

11006 04 N M 3 Y Y 154.43 150.26

11008 04 N M 3 Y Y 154.43 150.26

11010 04 N I 3 127.60 124.15

11011 04 N I 3 157.90 153.64

11012 04 N I 3 218.40 212.50

11042 04 01/01/10 N I 3 70.55 68.65

11043 04 07/01/12 N I 3 170.55 165.95

11044 04 07/01/12 N M 3 219.35 213.43

11045 04 01/01/11 Y I 3

11046 04 01/01/11 Y I 3 Y

11047 04 01/01/11 Y I 3 Y

11055 04 N I 3 22.15 21.55

11056 04 04/01/14 N I 3 13.93 13.55

11057 04 04/01/14 N I 3 18.21 17.72

11100 04 N I 3 50.20 17.00 48.84

11101 04 N I 3 22.15 21.55

11200 04 N I 3 35.65 17.00 34.69

11201 04 N I 3 15.20 14.79

11300 04 N I 3 21.10 20.53

11301 04 N I 3 29.20 28.41

11302 04 N I 3 37.50 36.49

11303 04 N I 3 45.70 44.47

11305 04 N I 3 22.25 21.65

11306 04 N I 3 31.25 30.41

11307 04 N I 3 37.50 36.49

11308 04 N I 3 45.70 44.47

11310 04 N I 3 32.40 31.53

11311 04 N I 3 40.55 39.46

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

11312 04 N I 3 48.80 47.48

11313 04 N I 3 57.10 55.56

11400 04 N I 3 39.05 17.00 38.00

11401 04 N I 3 50.20 17.00 48.84

11402 04 N I 3 64.80 17.00 63.05

11403 04 N I 3 77.90 17.00 75.80

11404 04 N I 3 92.40 17.00 89.91

11406 04 N I 3 108.00 17.00 105.08

11420 04 N I 3 38.30 17.00 37.27

11421 04 N I 3 50.85 17.00 49.48

11422 04 N I 3 64.80 17.00 63.05

11423 04 N I 3 77.90 17.00 75.80

11424 04 N I 3 92.40 17.00 89.91

11426 04 N I 3 127.48 17.00 124.04

11440 04 N I 3 54.15 17.00 52.69

11441 04 N I 3 75.30 17.00 73.27

11442 04 N I 3 96.40 17.00 93.80

11443 04 N I 3 111.00 17.00 108.00

11444 04 N I 3 117.55 17.00 114.38

11446 04 N I 3 146.37 17.00 142.42

11450 04 12/20/17 N M 3 215.40 34.00 209.58

11451 04 N M 3 Y 244.10 34.00 237.51

11462 04 N M 3 Y 215.40 34.00 209.58

11463 04 N M 3 Y 232.20 225.93

11470 04 N M 3 Y 291.30 283.43

11471 04 N M 3 Y 297.00 288.98

11600 04 N I 3 54.15 17.00 52.69

11601 04 N I 3 75.30 17.00 73.27

11602 04 N I 3 96.40 17.00 93.80

11603 04 N I 3 117.55 17.00 114.38

11604 04 N I 3 138.75 17.00 135.00

11606 04 N M 3 185.52 17.00 180.51

11620 04 N I 3 54.15 17.00 52.69

11621 04 N I 3 75.30 17.00 73.27

11622 04 N I 3 96.40 17.00 93.80

11623 04 N I 3 117.55 17.00 114.38

11624 04 N I 3 138.75 17.00 135.00

11626 04 N M 3 185.52 17.00 180.51

11640 04 N I 3 107.00 17.00 104.11

11641 04 N I 3 149.25 17.00 145.22

11642 04 N M 3 192.95 17.00 187.74

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

11643 04 N M 3 235.20 17.00 228.85

11644 04 N M 3 278.80 17.00 271.27

11646 04 N M 3 294.77 17.00 286.81

11719 04 N I 3 15.90 15.47

11720 04 N I 15.90 15.47

11721 04 N I 18.10 17.61

11730 04 N I 3 34.30 17.00 33.37

11732 04 N I 3 14.45 14.06

11740 04 N I 3 36.00 35.03

11750 04 N I 3 61.85 34.00 60.18

11755 04 N I 3 38.80 37.75

11760 04 N I 3 60.80 17.00 59.16

11762 04 N I 3 87.75 17.00 85.38

11765 04 N I 3 38.40 37.36

11770 04 N M 4 215.40 34.00 209.58

11771 04 N M 4 Y 291.30 283.43

11772 04 N M 4 341.25 332.04

11900 04 N I 3 21.10 17.00 20.53

11901 04 09/01/14 N I 3 29.63 28.83

11920 04 09/01/14 N I 70.11 68.22

11921 04 N I 63.57 61.85

11922 04 N I 16.13 15.69

11950 09 Y M

11951 09 Y M

11952 09 Y M

11954 09 Y M

11960 04 N M 3 Y 350.05 340.60

11970 04 N M 3 475.70 462.86

11971 04 06/01/16 N M 3 Y 135.00 131.36

11976 04 N I 3 108.00 105.08

11980 04 N M 3 108.00 105.08

11981 04 10/01/14 N I 3 88.00 85.62

11982 04 10/01/14 N I 3 Y 99.00 96.33

11983 04 10/01/14 N I 3 Y 143.00 139.14

12001 04 01/01/10 N I 3 53.10 17.00 51.67

12002 04 N I 3 58.40 17.00 56.82

12004 04 N I 3 69.70 17.00 67.82

12005 04 N I 3 100.40 17.00 97.69

12006 04 N I 3 145.80 17.00 141.86

12007 04 N M 3 195.80 17.00 190.51

12011 04 N I 3 56.40 17.00 54.88

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

12013 04 N I 3 64.00 17.00 62.27

12014 04 N I 3 112.90 17.00 109.85

12015 04 N I 3 125.50 17.00 122.11

12016 04 N I 3 200.75 17.00 195.33

12017 04 N M 3 259.20 17.00 252.20

12018 04 N M 3 272.63 265.27

12020 04 N I 3 139.30 17.00 135.54

12021 04 N I 3 88.70 17.00 86.31

12031 04 N I 3 64.70 17.00 62.95

12032 04 N I 3 81.60 17.00 79.40

12034 04 N I 3 106.65 17.00 103.77

12035 04 N I 3 144.30 17.00 140.40

12036 04 N M 3 194.50 17.00 189.25

12037 04 N M 3 261.12 254.07

12041 04 N I 3 72.10 17.00 70.15

12042 04 N I 3 94.10 17.00 91.56

12044 04 N I 3 119.20 17.00 115.98

12045 04 N I 3 156.85 17.00 152.62

12046 04 N M 3 207.10 17.00 201.51

12047 04 N M 3 270.45 263.15

12051 04 N I 3 74.70 17.00 72.68

12052 04 N I 3 94.10 17.00 91.56

12053 04 N I 3 112.90 17.00 109.85

12054 04 N I 3 131.80 17.00 128.24

12055 04 N I 3 169.40 17.00 164.83

12056 04 N M 3 219.60 17.00 213.67

12057 04 N M 3 305.68 297.43

13100 04 N I 3 110.04 107.07

13101 04 N I 3 127.57 124.13

13102 04 Y I 3

13120 04 N I 3 114.98 111.88

13121 04 N I 3 138.55 134.81

13122 04 Y I 3

13131 04 N I 3 127.85 124.40

13132 04 N I 3 178.18 173.37

13133 04 Y I 3

13151 04 N I 3 160.83 156.49

13152 04 N I 3 205.55 200.00

13153 04 Y I 3

13160 04 N M 3 Y 295.88 287.89

14000 04 N M 3 224.25 218.20

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

14001 04 N M 3 291.69 283.81

14020 04 N M 3 Y 244.40 237.80

14021 04 N M 3 Y 328.07 319.21

14040 04 N M 3 Y 277.07 269.59

14041 04 N M 3 Y 375.10 364.97

14060 04 N M 3 Y 299.29 291.21

14061 04 N M 3 Y 405.20 394.26

14301 04 01/01/10 N M 3 Y 496.65 483.24

14302 04 01/01/10 Y M 3 Y

14350 04 N M 3 270.20 262.90

15002 04 11/01/14 N I 3 Y 87.85 85.48

15003 04 01/01/07 Y M 3 Y

15004 04 11/01/14 N I 3 Y 102.63 99.86

15005 04 01/01/07 Y M 3 Y

15040 04 N M 3 71.01 69.09

15050 04 N M 3 Y 131.80 128.24

15100 04 11/01/14 N M 3 263.55 256.43

15101 04 Y M 3

15110 04 N M 3 71.01 69.09

15111 04 Y M 3 Y

15115 04 Y M 3 Y

15116 04 Y M 3 Y

15120 04 11/01/14 N M 3 307.90 299.59

15121 04 Y M 3 Y

15130 04 N M 3 Y 297.44 289.41

15131 04 Y M 3 Y

15135 04 N M 3 Y 414.03 402.85

15136 04 Y M 3 Y

15150 04 N M 3 330.87 321.94

15151 04 N M 3 66.75 64.95

15152 04 Y M 3

15155 04 N M 3 354.66 345.08

15156 04 Y M 3

15157 04 Y M 3 Y

15200 04 N M 3 Y 318.60 310.00

15201 04 Y M 3 Y

15220 04 N M 3 Y 307.90 299.59

15221 04 Y M 3 Y

15240 04 N M 3 Y 308.96 300.62

15241 04 Y M 3 Y

15260 04 N M 3 Y 332.72 323.74

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

15261 04 Y M 3

15271 04 07/01/12 N I 3 52.87 51.44

15272 04 07/01/12 Y I

15273 04 07/01/12 N I 3 126.08 122.68

15274 04 07/01/12 Y I 3

15275 04 07/01/12 N I 3 61.61 59.95

15276 04 07/01/12 Y I 3

15277 04 07/01/12 N I 3 130.46 126.94

15278 04 09/01/14 N I 3 Y 33.62 32.71

15570 04 N M 3 Y 298.24 290.19

15572 04 N M 3 Y 292.34 284.45

15574 04 N M 3 Y 466.61 454.01

15576 04 N M 3 Y 296.30 288.30

15600 04 N M 3 Y 259.81 252.80

15610 04 N M 3 Y 97.47 94.84

15620 04 N M 3 Y 158.26 153.99

15630 04 N M 3 Y 310.61 302.22

15650 04 N M 3 Y 168.27 163.73

15730 04 01/01/18 N M 5 Y 554.17 539.21

15731 04 01/01/07 N M 5 Y 168.27 163.73

15733 04 01/01/18 N M 5 Y 633.58 3 1,900.74 1,849.42

15734 04 N M 3 Y Y 569.25 553.88

15736 04 N M 3 Y 512.70 498.86

15738 04 N M 3 Y 520.25 506.20

15740 04 N M 3 Y 321.69 313.00

15750 04 N M 3 Y 339.54 330.37

15756 04 N M 3 Y Y 1,306.65 1,271.37

15757 04 N M 3 Y Y 1,306.65 1,271.37

15758 04 N M 3 Y Y 1,306.65 1,271.37

15760 04 N M 3 Y 300.05 291.95

15770 04 N M 3 Y 307.90 299.59

15775 09 Y M

15776 09 Y M

15777 04 01/01/12 N M 130.27 126.75

15780 09 Y M

15781 09 Y M

15782 09 Y M

15783 09 Y M

15786 09 Y I

15787 09 Y M

15819 04 N M 3 Y 274.36 266.95

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

15820 04 N M 3 651.10 633.52

15821 04 N M 3 651.10 633.52

15822 04 N M 3 651.10 633.52

15823 04 N M 3 651.10 633.52

15830 04 01/01/10 Y M 5 Y Y

15832 04 N M 3 340.15 330.97

15833 04 N M 3 306.75 298.47

15834 04 N M 3 308.30 299.98

15835 04 N M 3 319.10 310.48

15836 04 N M 3 265.30 258.14

15837 04 N M 3 255.00 248.12

15838 04 N M 3 Y 219.35 213.43

15839 04 N M 3 Y 237.80 231.38

15840 04 N M 3 Y 891.10 867.04

15841 04 N M 3 Y 663.96 646.03

15842 04 N M 3 Y 1,063.03 1,034.33

15845 04 N M 3 Y 355.83 346.22

15847 04 01/01/07 Y M 10 Y

15850 04 N I 3 31.40 30.55

15851 04 N I 3 48.60 47.29

15852 04 N I 3 Y 31.95 31.09

15860 04 N I 3 Y 55.50 54.00

15876 04 Y M 3

15877 04 Y M 3

15878 04 Y M 3

15879 04 Y M 3

15920 04 N M 4 Y 374.55 364.44

15922 04 N M 4 Y 449.50 437.36

15931 04 N M 3 Y Y 449.50 437.36

15933 04 N M 3 Y 674.20 656.00

15934 04 N M 3 Y Y 749.20 728.97

15935 04 N M 3 Y Y 749.20 728.97

15936 04 N M 3 Y 749.20 728.97

15937 04 N M 3 Y Y 749.20 728.97

15940 04 N M 3 Y 449.50 437.36

15941 04 N M 3 Y 524.40 510.24

15944 04 N M 3 Y 524.40 510.24

15945 04 N M 3 Y 600.00 583.80

15946 04 N M 3 Y 674.20 656.00

15950 04 N M 3 Y 449.50 437.36

15951 04 N M 3 Y 524.40 510.24

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

15952 04 N M 3 Y 524.40 510.24

15953 04 N M 3 Y 599.35 583.17

15956 04 N M 3 Y 727.40 707.76

15958 04 N M 3 Y 727.40 707.76

15999 04 Y M 3 Y Y

16000 04 01/01/10 N I 45.80 44.56

16020 04 N I 24.90 17.00 24.23

16025 04 N I 49.50 34.00 48.16

16030 04 N I 61.65 34.00 59.99

16035 04 08/16/17 N I 3 92.79 34.00 90.28

16036 04 08/16/17 N I 3 36.74 35.75

17000 04 N I 52.70 51.28

17003 04 N I 3 8.85 13 115.05 8.61 111.94

17004 04 N I 3 86.59 84.25

17106 04 N I 3 125.35 121.97

17107 04 N M 3 238.80 232.35

17108 04 N M 3 372.30 362.25

17110 04 N I 3 74.90 72.88

17111 04 N I 3 43.05 41.89

17250 04 N I 3 18.90 18.39

17260 04 N I 3 40.60 39.50

17261 04 N I 3 60.70 59.06

17262 04 N I 3 80.85 78.67

17263 04 N I 3 100.90 98.18

17264 04 N I 3 117.55 114.38

17266 04 N M 3 162.00 157.63

17270 04 N I 3 45.25 44.03

17271 04 N I 3 64.50 62.76

17272 04 N I 3 85.60 83.29

17273 04 N I 3 106.75 103.87

17274 04 N I 3 117.20 114.04

17276 04 07/01/12 N I 3 162.00 157.63

17280 04 N I 3 96.20 93.60

17281 04 N I 3 127.70 124.25

17282 04 N M 3 171.30 166.67

17283 04 N M 3 213.60 207.83

17284 04 N M 3 257.10 250.16

17286 04 09/01/14 N I 3 170.96 166.34

17311 04 01/01/07 N M 3 216.00 210.17

17312 04 09/01/14 N I 3 121.19 5 605.95 117.92 589.59

17313 04 01/01/10 N M 3 191.09 185.93

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

17314 04 09/01/14 N I 3 112.46 5 562.30 109.42 547.12

17315 04 09/01/14 N I 3 31.73 5 158.65 30.87 154.37

17340 04 N I 3 26.20 25.49

17360 04 N I 3 38.65 37.61

17999 04 Y M 3 Y Y

19000 04 N I 3 37.40 36.39

19001 04 N I 3 17.80 17.32

19020 04 N I 3 135.90 132.23

19030 04 N I 3 102.50 99.73

19081 04 01/01/14 N I 3 Y 114.67 111.57

19082 04 04/01/14 N I 3 Y 53.87 5 269.35 262.08

19083 04 01/01/14 N I 3 Y 107.27 104.37

19084 04 01/01/14 N I 3 Y 50.57 5 252.85 246.02

19085 04 01/01/14 N I 3 Y 125.10 121.72

19086 04 01/01/14 N I 3 Y 53.80 5 269.40 262.13

19100 04 N I 3 59.60 57.99

19101 04 N M 3 192.85 34.00 187.64

19105 04 09/01/14 N I 5 116.96 113.80

19110 04 N M 3 240.00 34.00 233.52

19112 04 N M 3 240.00 233.52

19120 04 N M 3 240.00 34.00 233.52

19125 04 N M 3 240.00 233.52

19126 04 N M 3 74.45 72.44

19260 04 N M 4 Y 430.64 419.01

19271 04 N M 4 Y 534.45 520.02

19272 04 N M 4 Y 598.34 582.18

19281 04 01/01/14 N I 3 Y 62.74 61.05

19282 04 03/01/14 N I 3 Y 29.56 8 236.48 230.10

19283 04 01/01/14 N I 3 Y 63.32 61.61

19284 04 03/01/14 N I 3 Y 29.75 5 148.75 144.73

19285 04 01/01/14 N I 3 Y 53.69 52.24

19286 04 03/01/14 N I 3 Y 25.55 5 127.75 124.30

19287 04 01/01/14 N I 3 Y 89.26 86.85

19288 04 03/01/14 N I 3 Y 38.20 5 191.00 185.84

19294 09 01/01/18 Y

19296 04 N I 3 109.01 106.07

19297 04 N I 3 109.01 106.07

19298 04 N I 3 109.01 106.07

19300 04 01/01/07 N M 3 Y 374.55 364.44

19301 04 01/01/07 N M 3 Y 310.80 302.41

19302 04 01/01/07 N M 5 Y 601.45 585.21

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

19303 04 01/01/07 N M 3 Y 461.95 449.48

19304 04 01/01/07 N M 3 Y 574.35 558.84

19305 04 01/01/07 N M 5 Y 787.95 766.68

19306 04 01/01/07 N M 4 Y 948.90 923.28

19307 04 01/01/07 N M 5 Y 738.10 718.17

19316 04 01/19/16 N M 3 Y Y 567.10 551.79

19318 04 N M 3 Y Y 374.60 364.49

19324 04 N M 3 Y 567.10 551.79

19325 04 N M 3 Y 567.10 551.79

19328 04 N M 3 Y 240.00 233.52

19330 04 N M 3 Y 240.00 233.52

19340 04 N M 3 Y 310.80 302.41

19342 04 03/14/16 N M 3 Y Y 354.20 344.64

19350 04 N M 3 Y 310.55 302.17

19355 04 N M 3 Y Y 275.00 267.58

19357 04 N M 3 Y 532.30 517.93

19361 04 N M 3 Y 609.80 593.34

19364 04 N M 3 Y 558.15 543.08

19366 04 N M 3 Y 558.15 543.08

19367 04 N M 3 Y Y 755.20 734.81

19368 04 N M 3 Y 1,306.65 1,271.37

19369 04 N M 3 Y 852.25 829.24

19370 04 08/16/17 N M 3 242.70 236.15

19371 04 08/16/17 N M 3 297.00 288.98

19380 04 08/16/17 N M 3 280.40 272.83

19396 04 N M 3 136.88 133.18

19499 04 Y M 3 Y

20005 04 N I 3 125.50 17.00 122.11

20100 04 N M 3 Y 372.65 362.59

20101 04 N M 3 Y 599.35 583.17

20102 04 N M 4 Y 480.00 467.04

20103 04 09/01/14 N I 3 Y 213.31 207.55

20150 04 09/01/14 N M 3 Y Y 562.01 546.84

20200 04 N I 3 113.60 17.00 110.53

20205 04 N M 3 252.35 17.00 245.54

20206 04 N I 3 53.50 17.00 52.06

20220 04 N I 90.10 87.67

20225 04 N I 3 187.30 34.00 182.24

20240 04 N M 3 220.55 214.60

20245 04 N M 3 289.90 282.07

20250 04 N M 3 163.05 158.65

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

20251 04 N M 3 277.50 270.01

20500 04 N I 3 61.40 59.74

20501 04 N I 3 105.90 103.04

20520 04 03/09/17 N I 3 107.00 17.00 104.11

20525 04 04/19/17 N I 3 167.80 163.27

20526 04 N I 31.35 30.50

20527 04 01/01/12 N I 35.65 34.69

20550 04 N I 3 31.75 30.89

20551 04 N I 3 31.75 30.89

20552 04 N I 3 31.75 30.89

20553 04 N I 3 31.75 30.89

20555 04 01/01/08 N I 3 176.10 171.35

20600 04 N I 3 30.40 17.00 29.58

20604 04 01/01/15 N I 3 28.22 27.46

20605 04 N I 3 33.00 17.00 32.11

20606 04 01/01/15 N I 3 32.29 31.42

20610 04 N I 3 31.80 17.00 30.94

20611 04 01/01/15 N I 3 38.11 37.08

20612 04 N I 31.80 30.94

20615 04 N I 3 73.35 71.37

20650 04 N I 3 Y 141.50 137.68

20660 04 N M 3 Y 192.85 187.64

20661 04 N M 3 192.85 187.64

20662 04 N I 3 203.85 198.35

20663 04 N I 3 170.05 165.46

20664 04 N M 3 Y 271.45 264.12

20665 04 N I 3 134.60 130.97

20670 04 N I 3 134.60 130.97

20680 04 N M 3 Y 233.00 226.71

20690 04 N I 3 Y Y 172.80 168.13

20692 04 N I 3 Y 297.00 288.98

20693 04 N I 3 Y 243.00 236.44

20694 04 N I 3 Y 152.95 148.82

20696 04 01/01/09 N M 3 Y 332.64 323.66

20697 04 12/08/14 N I 3 Y Y 349.27 339.84

20802 04 09/01/14 N M 5 Y Y 1,403.92 1,366.01

20805 04 09/01/14 N M 5 Y Y 1,892.05 1,840.96

20808 04 09/01/14 N M 5 Y Y 2,441.73 2,375.80

20816 04 09/01/14 N M 5 Y Y 1,205.49 1,172.94

20822 04 09/01/14 N M 3 Y Y 1,113.83 1,083.76

20824 04 09/01/14 N M 3 Y Y 1,307.75 1,272.44

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

20827 04 09/01/14 N M 3 Y Y 1,114.45 1,084.36

20838 04 09/01/14 N M 5 Y Y 1,565.50 1,523.23

20900 04 04/04/16 N I 3 Y Y 224.70 218.63

20902 04 N I 7 Y Y 374.55 364.44

20910 04 09/01/14 N M 7 Y 245.83 239.19

20912 04 09/08/14 N M 5 Y 290.49 282.65

20920 04 N M 3 Y Y 168.10 163.56

20922 04 N M 3 Y Y 231.10 224.86

20924 04 N M 4 Y Y 212.90 207.15

20926 04 09/08/14 N M 3 265.43 258.26

20930 09 Y M

20931 09 Y M

20936 09 Y M

20937 09 Y M

20938 09 Y M

20939 09 01/01/18 Y M

20950 04 N I 3 44.80 43.59

20955 04 09/08/14 N M 5 Y Y 1,543.48 1,501.81

20956 04 09/08/14 N M 5 Y Y 1,626.36 1,582.45

20957 04 09/08/14 N M 5 Y Y 1,432.31 1,393.64

20962 04 09/08/14 N M 5 Y Y 1,366.93 1,330.02

20969 04 09/08/14 N M 5 Y Y 1,706.77 1,660.69

20970 04 09/08/14 N M 5 Y Y 1,760.01 1,712.49

20972 04 09/08/14 N M 3 Y 1,347.30 1,310.92

20973 04 09/08/14 N M 3 Y Y 1,697.32 1,651.49

20974 09 Y M

20975 04 N I 3 Y 82.90 80.66

20979 04 N I 176.70 171.93

20982 04 N I 4 Y 220.57 214.61

20983 04 03/23/15 N I 3 242.35 235.81

20985 04 01/01/08 N M 5 Y 83.23 80.98

20999 04 Y M 3 Y

21010 04 N M 3 Y 374.55 364.44

21011 04 01/01/10 N M 3 Y 135.00 131.36

21012 04 01/01/10 N M 3 Y 186.15 181.12

21013 04 01/01/10 N M 3 Y 219.07 213.16

21014 04 01/01/10 N M 3 Y 287.92 280.15

21015 04 01/01/10 N M 4 Y 333.35 324.35

21016 04 01/01/10 N M 4 Y 583.64 567.88

21025 04 N M 4 Y Y 299.70 291.61

21026 04 N M 4 Y Y 299.70 291.61

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

21029 04 09/08/14 N M 4 Y 394.09 383.45

21030 04 N M 3 Y 299.70 291.61

21031 04 N M 3 Y 299.70 291.61

21032 04 N M 3 Y 299.70 291.61

21034 04 N M 4 Y Y 421.10 409.73

21040 04 N M 3 Y 299.70 291.61

21044 04 N M 4 Y 350.55 341.09

21045 04 N M 4 Y Y 1,678.65 1,633.33

21046 04 N M 5 Y Y 397.20 386.48

21047 04 09/08/14 N M 5 Y Y 792.69 771.29

21048 04 09/08/14 N M 5 Y Y 684.04 665.57

21049 04 09/08/14 N M 5 Y Y 740.52 720.53

21050 04 N M 5 Y 524.40 510.24

21060 04 N M 5 Y 524.40 510.24

21070 04 N M 4 Y 299.70 291.61

21073 04 01/01/08 N M 3 Y 188.93 183.83

21076 04 09/08/14 N I 3 Y 508.05 494.33

21077 04 09/08/14 N I 3 Y 1,284.83 1,250.14

21079 04 09/08/14 N M 3 847.88 824.99

21080 04 09/08/14 N M 3 947.01 921.44

21081 04 09/08/14 N M 3 Y 870.11 846.62

21082 04 09/08/14 N M 3 Y 817.64 795.56

21083 04 09/08/14 N M 3 Y 729.84 710.13

21084 04 09/08/14 N M 3 Y 877.57 853.88

21085 04 09/08/14 N I 3 Y 403.82 392.92

21086 04 09/08/14 N M 3 Y 947.78 922.19

21087 04 09/08/14 N M 3 Y 947.78 922.19

21088 04 Y I 3

21089 04 Y I 3

21100 04 N M 3 192.85 187.64

21110 04 N M 3 Y 176.70 171.93

21116 04 N I 3 73.20 71.22

21120 04 N M 5 Y Y 1,198.70 1,166.34

21121 04 N M 5 Y Y 1,198.70 1,166.34

21122 04 N M 5 Y Y 1,414.70 1,376.50

21123 04 N M 5 Y Y 1,522.70 1,481.59

21125 04 N M 5 Y Y 1,198.70 1,166.34

21127 04 N M 5 Y Y 1,306.65 1,271.37

21137 04 N M 5 Y Y 958.60 932.72

21138 04 N M 5 Y Y 1,198.70 1,166.34

21139 04 N M 7 Y Y 1,522.70 1,481.59

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

21141 04 N M 5 Y Y 1,198.70 1,166.34

21142 04 N M 5 Y Y 1,306.65 1,271.37

21143 04 N M 5 Y Y 1,414.70 1,376.50

21145 04 N M 5 Y Y 1,306.65 1,271.37

21146 04 N M 5 Y Y 1,522.70 1,481.59

21147 04 N M 5 Y Y 1,522.70 1,481.59

21150 04 N M 5 Y Y 1,306.65 1,271.37

21151 04 N M 5 Y Y 1,522.70 1,481.59

21154 04 N M 5 Y Y 1,306.65 1,271.37

21155 04 N M 5 Y Y 1,522.70 1,481.59

21159 04 N M 7 Y Y 1,522.70 1,481.59

21160 04 N M 7 Y Y 1,522.70 1,481.59

21172 04 N M 7 Y Y 1,522.70 1,481.59

21175 04 N M 7 Y Y 1,522.70 1,481.59

21179 04 N M 7 Y Y 1,414.70 1,376.50

21180 04 N M 7 Y Y 1,522.70 1,481.59

21181 04 N M 5 Y Y 958.60 932.72

21182 04 N M 7 Y Y 1,522.70 1,481.59

21183 04 N M 7 Y Y 1,522.70 1,481.59

21184 04 N M 7 Y Y 1,630.70 1,586.67

21188 04 N M 5 Y Y 1,306.65 1,271.37

21193 04 N M 5 Y Y 1,198.70 1,166.34

21194 04 N M 5 Y Y 1,414.70 1,376.50

21195 04 N M 5 Y Y 1,198.70 1,166.34

21196 04 N M 5 Y Y 1,198.70 1,166.34

21198 04 N M 5 Y Y 958.60 932.72

21199 04 N M 5 Y Y 700.70 681.78

21206 04 N M 4 Y 1,198.70 1,166.34

21208 04 N M 4 Y Y 1,198.70 1,166.34

21209 04 N M 4 Y Y 1,198.70 1,166.34

21210 04 N M 7 Y Y 636.80 619.61

21215 04 N M 7 Y Y 1,048.85 1,020.53

21230 04 N M 7 Y Y 957.25 931.40

21235 04 N M 7 Y Y 449.50 437.36

21240 04 N M 5 Y Y 599.35 583.17

21242 04 N M 5 Y Y 599.35 583.17

21243 04 N M 5 Y Y 1,198.70 1,166.34

21244 04 N M 5 Y Y 1,198.70 1,166.34

21245 04 N M 5 Y Y 1,198.70 1,166.34

21246 04 N M 5 Y Y 1,198.70 1,166.34

21247 04 N M 5 Y Y 1,306.65 1,271.37

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

21248 04 N M 5 Y Y 1,198.70 1,166.34

21249 04 N M 5 Y Y 1,198.70 1,166.34

21255 04 N M 5 Y Y 1,306.65 1,271.37

21256 04 N M 5 Y Y 1,306.65 1,271.37

21260 04 N M 7 Y Y 1,306.65 1,271.37

21261 04 N M 7 Y Y 1,522.70 1,481.59

21263 04 N M 7 Y Y 1,522.70 1,481.59

21267 04 N M 7 Y Y 1,306.65 1,271.37

21268 04 N M 7 Y Y 1,522.70 1,481.59

21270 04 N M 7 Y Y 1,048.85 1,020.53

21275 04 N M 5 Y Y 1,048.85 1,020.53

21280 04 N M 5 Y Y 359.30 349.60

21282 04 N M 5 Y Y 359.30 349.60

21295 04 N M 5 Y Y 449.50 437.36

21296 04 N M 5 Y Y 449.50 437.36

21299 04 Y M 7 Y Y

21310 04 N I 4 138.75 135.00

21315 04 N M 4 176.20 171.44

21320 04 N M 4 280.25 272.68

21325 04 N M 4 Y 337.10 328.00

21330 04 N M 4 Y 424.45 412.99

21335 04 N M 4 Y 571.60 556.17

21336 04 N M 4 Y 337.10 328.00

21337 04 N M 4 Y Y 224.70 218.63

21338 04 N M 4 Y Y 334.40 325.37

21339 04 N M 4 Y Y 457.70 445.34

21340 04 N M 6 Y Y 749.20 728.97

21343 04 N M 4 Y 898.95 874.68

21344 04 N M 4 Y 1,048.85 1,020.53

21345 04 N M 4 Y Y 749.20 728.97

21346 04 N M 4 Y Y 749.20 728.97

21347 04 N M 4 Y Y 766.90 746.19

21348 04 N M 4 Y 954.20 928.44

21355 04 N M 4 Y 149.80 145.76

21356 04 N M 4 Y 539.65 525.08

21360 04 N M 4 Y 539.65 525.08

21365 04 N M 4 Y Y 689.50 670.88

21366 04 N M 4 Y Y 954.20 928.44

21385 04 N M 4 Y Y 599.35 583.17

21386 04 N M 5 Y Y 599.35 583.17

21387 04 N M 5 Y Y 749.20 728.97

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

21390 04 N M 5 Y Y 861.50 838.24

21395 04 N M 5 Y Y 861.50 838.24

21400 04 N I 149.80 145.76

21401 04 N M 5 Y 224.70 218.63

21406 04 N M 5 Y 599.35 583.17

21407 04 N M 5 Y 749.20 728.97

21408 04 N M 4 Y 749.20 728.97

21421 04 N M 4 Y 457.70 445.34

21422 04 N M 4 Y 678.40 660.08

21423 04 N M 4 Y 828.20 805.84

21431 04 N M 4 Y 524.40 510.24

21432 04 N M 4 Y 749.20 728.97

21433 04 N M 6 Y Y 898.95 874.68

21435 04 N M 6 Y Y 1,048.85 1,020.53

21436 04 N M 4 Y 1,048.85 1,020.53

21440 04 N M 4 374.55 364.44

21445 04 N M 4 Y 599.35 583.17

21450 04 N I 117.60 114.42

21451 04 N M 4 Y Y 498.10 484.65

21452 04 N I 4 Y Y 112.40 109.37

21453 04 N M 4 Y Y 498.10 484.65

21454 04 N M 4 Y Y 498.10 484.65

21461 04 N M 4 Y 706.15 687.08

21462 04 N M 4 Y 706.15 687.08

21465 04 N M 4 Y 498.10 484.65

21470 04 N M 4 Y 885.20 861.30

21480 04 N M 3 240.00 233.52

21485 04 N M 4 240.00 233.52

21490 04 N M 4 Y 749.20 728.97

21497 04 N M 4 149.80 145.76

21499 04 Y M Y

21501 04 N I 3 115.30 17.00 112.19

21502 04 N M 3 224.70 218.63

21510 04 N M 3 224.70 218.63

21550 04 N I 3 99.10 17.00 96.42

21552 04 01/01/10 N M 3 Y 251.32 244.53

21554 04 01/01/10 N M 3 Y 413.28 402.12

21555 04 01/01/10 N M 3 124.00 17.00 120.65

21556 04 01/01/10 N M 3 270.27 262.97

21557 04 01/01/10 N M 3 Y Y 460.66 448.22

21558 04 01/01/10 N M 3 Y Y 778.24 757.23

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

21600 04 N M 3 Y 299.70 291.61

21610 04 N M 3 Y 399.50 388.71

21615 04 N M 4 Y 449.50 437.36

21616 04 N M 6 Y 599.35 583.17

21620 04 N M 3 Y 250.40 243.64

21627 04 09/08/14 N M 3 Y 331.00 322.06

21630 04 N M 6 Y Y 749.20 728.97

21632 04 N M 6 Y Y 749.20 728.97

21685 04 N M 4 Y 491.50 478.23

21700 04 N M 4 Y 374.55 364.44

21705 04 N M 4 Y 449.50 437.36

21720 04 N M 4 Y 577.10 561.52

21725 04 N M 4 Y 599.35 583.17

21740 04 N M 5 Y 898.95 874.68

21742 04 N M 5 Y 898.95 874.68

21743 04 N M 5 Y 898.95 874.68

21750 04 N M 3 Y 368.20 358.26

21811 04 03/23/15 N I 3 Y 379.33 369.09

21812 04 03/23/15 N I 3 Y 455.05 442.76

21813 04 03/23/15 N I 3 Y 618.97 602.26

21820 04 N I 3 74.90 72.88

21825 04 N M 3 374.55 364.44

21899 04 Y M

21920 04 N I 3 113.50 17.00 110.44

21925 04 N M 3 180.20 17.00 175.33

21930 04 N M 3 149.80 145.76

21931 04 01/01/10 N M 3 Y 263.72 256.60

21932 04 01/01/10 N M 3 Y 378.77 368.54

21933 04 01/01/10 N M 3 Y 418.56 407.26

21935 04 01/01/10 N M 3 Y 581.85 566.14

21936 04 01/01/10 N M 3 Y 812.41 790.47

22010 04 N M 3 Y 453.30 441.06

22015 04 N M 3 Y 449.25 437.12

22100 04 N M 7 Y 311.40 302.99

22101 04 N M 7 Y 315.50 306.98

22102 04 N M 7 Y 299.70 291.61

22103 04 09/08/14 N M 7 Y Y 89.55 5 447.75 87.13 435.66

22110 04 N M 7 Y 718.70 699.30

22112 04 N M 7 Y 718.70 699.30

22114 04 N M 7 Y 718.70 699.30

22116 04 09/08/14 N M 7 Y Y 87.81 5 439.05 85.44 427.20

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

22206 04 01/01/08 N M 7 Y Y 1270.13 1,235.84

22207 04 01/01/08 N M 7 Y Y 1253.30 1,219.46

22208 04 01/01/08 N M 7 Y Y 325.80 317.00

22210 04 N M 7 Y Y 973.90 947.60

22212 04 N M 7 Y Y 973.90 947.60

22214 04 N M 7 Y Y 973.90 947.60

22216 04 09/08/14 N M 7 Y Y 227.91 5 1,139.55 221.76 1,108.78

22220 04 N M 7 Y Y 973.90 947.60

22222 04 N M 7 Y Y 973.90 947.60

22224 04 N M 7 Y Y 973.90 947.60

22226 04 09/08/14 N M 7 Y Y 229.27 5 1,146.35 223.08 1,115.40

22310 04 N I 98.80 96.13

22315 04 N M 3 276.20 268.74

22318 04 N M 7 Y Y 1,417.20 1,378.94

22319 04 N M 7 Y Y 1,558.90 1,516.81

22325 04 N M 3 Y 599.35 583.17

22326 04 N M 4 Y 627.30 610.36

22327 04 N M 3 Y 608.50 592.07

22328 04 09/08/14 N M 7 Y Y 178.43 5 892.15 173.61 868.06

22505 04 N I 3 149.80 145.76

22510 04 03/23/15 N I 7 279.51 271.96

22511 04 03/23/15 N I 7 262.43 255.34

22512 04 03/23/15 N I 7 131.73 5 658.65 128.17 640.87

22513 04 01/01/15 N I 3 336.16 327.08

22514 04 01/01/15 N I 3 312.97 304.52

22515 04 01/01/15 N I 3 143.05 5 715.25 139.19 695.94

22532 04 01/01/10 N M 7 Y Y 876.68 853.01

22533 04 01/01/10 N M 7 Y Y 816.43 794.39

22534 04 09/08/14 N M 7 Y Y 227.91 5 1,139.55 221.76 1,108.78

22548 04 N M 7 Y 1,642.15 1,597.81

22551 04 01/01/11 N M 7 Y Y 1,062.48 1,033.79

22552 04 09/08/14 N M 7 Y Y 248.18 5 1,240.90 241.48 1,207.40

22554 04 N M 7 Y Y 1,642.65 1,598.30

22556 04 N M 7 Y Y 1,642.65 1,598.30

22558 04 N M 7 Y Y 1,642.65 1,598.30

22585 04 09/08/14 N M 7 Y Y 211.55 5 1,057.75 205.84 1,029.19

22586 04 01/01/13 N M 7 Y Y 950.83 925.16

22590 04 N M 7 Y Y 1,198.70 1,166.34

22595 04 N M 7 Y Y 1,198.70 1,166.34

22600 04 N M 7 Y Y 1,198.70 1,166.34

22610 04 N M 7 Y Y 1,198.70 1,166.34

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

22612 04 N M 7 Y Y 1,198.70 1,166.34

22614 04 Y M 7 Y Y

22630 04 N M 7 Y Y 1,198.70 1,166.34

22632 04 Y M 7 Y Y

22633 04 01/01/12 N M 7 Y Y 1,132.79 1,102.20

22634 04 01/01/12 Y M 7 Y Y

22800 04 N M 7 Y Y 1,086.30 1,056.97

22802 04 N M 7 Y Y 1,086.30 1,056.97

22804 04 N M 7 Y Y 1,782.30 1,734.18

22808 04 N M 7 Y Y 1,086.30 1,056.97

22810 04 N M 7 Y Y 1,086.30 1,056.97

22812 04 N M 7 Y Y 1,086.30 1,056.97

22818 04 N M 7 Y Y 1,610.65 1,567.16

22819 04 N M 7 Y Y 1,610.65 1,567.16

22830 04 N M 7 Y Y 443.39 431.42

22840 04 N M 7 Y Y 1,872.90 1,822.33

22841 04 N M 7 Y Y 1,872.90 1,822.33

22842 04 N M 7 Y Y 1,872.90 1,822.33

22843 04 N M 7 Y Y 1,872.90 1,822.33

22844 04 N M 7 Y Y 1,872.90 1,822.33

22845 04 N M 7 Y Y 1,872.90 1,822.33

22846 04 N M 7 Y Y 1,872.90 1,822.33

22847 04 N M 7 Y Y 1,872.90 1,822.33

22848 04 N M 7 Y Y 351.00 341.52

22849 04 N M 7 Y Y 1,134.10 1,103.48

22850 04 N M 7 Y 449.50 437.36

22852 04 N M 7 Y Y 449.50 437.36

22853 04 01/01/17 N M 7 Y Y 167.52 5 837.60 163.00 814.98

22854 04 01/01/17 N M 7 Y Y 216.85 5 1,084.25 211.00 1,054.98

22855 04 N M 7 Y 449.50 437.36

22856 04 01/01/09 N M 8 Y Y 925.00 900.03

22857 04 01/01/10 N M 8 Y Y 938.71 913.36

22858 04 01/01/15 N M 8 Y Y 317.99 309.40

22859 04 01/01/17 N M 7 Y Y 216.85 5 1,084.25 211.00 1,054.98

22861 04 01/01/09 N M 8 Y Y 1,121.23 1,090.96

22862 04 01/01/10 N M 8 Y Y 1104.45 1,074.63

22864 04 01/01/10 N M 8 Y Y 1051.39 1,023.00

22865 04 01/01/10 N M 8 Y Y 1166.35 1,134.86

22867 04 01/01/17 N M 7 616.05 599.42

22868 04 01/01/17 N M 7 Y Y 156.26 152.04

22869 04 01/01/17 N M 7 335.39 326.33

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

22870 04 01/01/17 N M 7 Y Y 90.92 88.47

22899 04 Y M Y Y

22900 04 01/01/10 N M 3 Y Y 224.70 218.63

22901 04 01/01/10 N M 3 Y Y 373.91 363.81

22902 04 01/01/10 N M 3 Y Y 185.37 180.37

22903 04 01/01/10 N M 3 Y Y 245.80 239.16

22904 04 01/01/10 N M 4 Y Y 588.58 572.69

22905 04 01/01/10 N M 4 Y Y 763.23 742.62

22999 04 Y M Y

23000 04 N M 3 Y 359.30 349.60

23020 04 N M 3 Y 299.70 291.61

23030 04 N I 3 125.50 17.00 122.11

23031 04 N I 3 99.10 17.00 96.42

23035 04 N M 3 Y 317.40 308.83

23040 04 N M 3 Y 599.35 583.17

23044 04 N M 3 Y 599.35 583.17

23065 04 N I 3 113.60 17.00 110.53

23066 04 N I 3 149.25 17.00 145.22

23071 04 01/01/10 N M 3 Y 233.57 227.26

23073 04 01/01/10 N M 3 Y 387.83 377.36

23075 04 N M 3 224.70 218.63

23076 04 01/01/10 N M 3 449.50 437.36

23077 04 01/01/10 N M 7 Y Y 641.38 624.06

23078 04 01/01/10 N M 7 Y Y 794.53 773.08

23100 04 N M 3 Y 374.55 364.44

23101 04 N M 3 Y 599.35 583.17

23105 04 N M 3 Y 599.35 583.17

23106 04 N M 3 Y 599.35 583.17

23107 04 N M 3 Y Y 473.50 460.72

23120 04 N M 3 Y 362.00 352.23

23125 04 N M 3 Y 718.70 699.30

23130 04 N M 3 Y 362.00 352.23

23140 04 N M 3 Y 264.90 257.75

23145 04 N M 3 Y 480.00 467.04

23146 04 N M 3 Y 480.00 467.04

23150 04 N M 3 Y 275.80 268.35

23155 04 N M 3 Y 480.00 467.04

23156 04 N M 3 Y 480.00 467.04

23170 04 N M 3 Y 240.00 233.52

23172 04 N M 3 Y 240.00 233.52

23174 04 N M 3 Y 480.00 467.04

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

23180 04 N M 3 Y 299.70 291.61

23182 04 N M 3 Y 480.00 467.04

23184 04 N M 3 Y 480.00 467.04

23190 04 N M 3 Y 480.00 467.04

23195 04 N M 3 Y 599.35 583.17

23200 04 01/01/10 N M 6 Y Y 718.70 699.30

23210 04 01/01/10 N M 6 Y Y 718.70 699.30

23220 04 01/01/10 N M 6 Y Y 718.70 699.30

23330 04 N I 3 17.00 107.00 16.54 104.11

23333 04 01/01/14 N M 3 Y 275.21 267.78

23334 04 01/01/14 N M 3 654.38 636.71

23335 04 01/01/14 N M 3 Y 782.09 760.97

23350 04 N I 3 88.30 85.92

23395 04 N M 3 Y 501.35 487.81

23397 04 N M 3 Y 599.35 583.17

23400 04 N M 6 Y 839.35 816.69

23405 04 N M 3 Y 299.70 291.61

23406 04 N M 3 Y 449.50 437.36

23410 04 N M 3 Y 779.70 758.65

23412 04 N M 3 Y 779.70 758.65

23415 04 N M 3 Y 674.20 656.00

23420 04 N M 3 Y 674.20 656.00

23430 04 N M 3 Y 449.50 437.36

23440 04 N M 3 Y 449.50 437.36

23450 04 N M 3 Y 839.35 816.69

23455 04 N M 3 Y 839.35 816.69

23460 04 N M 3 Y 839.35 816.69

23462 04 N M 3 Y 839.35 816.69

23465 04 N M 3 Y 733.85 714.04

23466 04 N M 3 Y 584.40 568.62

23470 04 N M 3 Y 839.35 816.69

23472 04 N M 3 Y 1,498.30 1,457.85

23473 04 01/01/13 N M 3 Y Y 984.68 958.09

23474 04 01/01/13 N M 3 Y Y 1,064.97 1,036.22

23480 04 N M 3 Y 480.00 467.04

23485 04 N M 3 Y 486.90 473.75

23490 04 N M 3 Y Y 379.40 369.16

23491 04 N M 3 Y Y 464.45 451.91

23500 04 N I 3 112.40 109.37

23505 04 N M 3 187.30 182.24

23515 04 N M 3 Y 419.00 407.69

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

23520 04 N I 112.40 109.37

23525 04 N M 3 162.30 157.92

23530 04 N M 3 Y 720.00 700.56

23532 04 N I 3 Y 786.60 765.36

23540 04 N I 112.40 109.37

23545 04 N M 3 228.90 222.72

23550 04 N M 3 Y 503.60 490.00

23552 04 N M 3 Y Y 561.85 546.68

23570 04 N I 79.60 77.45

23575 04 N M 3 241.35 234.83

23585 04 N M 3 Y 449.50 437.36

23600 04 N M 194.20 188.96

23605 04 N M 3 277.50 270.01

23615 04 N M 3 Y 545.25 530.53

23616 04 N M 3 Y 975.25 948.92

23620 04 N I 111.00 108.00

23625 04 N M 3 163.70 159.28

23630 04 N M 3 Y 524.40 510.24

23650 04 N M 178.90 174.07

23655 04 N M 3 255.20 248.31

23660 04 N M 3 Y 419.00 407.69

23665 04 N M 3 206.70 201.12

23670 04 N M 3 Y 842.10 819.36

23675 04 N M 3 299.70 291.61

23680 04 N M 3 Y 599.35 583.17

23700 04 N M 3 194.20 188.96

23800 04 N M 3 Y 839.35 816.69

23802 04 N M 3 Y 839.35 816.69

23900 04 N M 11 Y 1198.70 1,166.34

23920 04 N M 5 Y 1048.85 1,020.53

23921 04 N M 3 Y 224.70 218.63

23929 04 Y M 3 Y

23930 04 N M 3 179.70 17.00 174.85

23931 04 N I 3 141.30 17.00 137.48

23935 04 N M 3 Y 240.00 233.52

24000 04 N M 3 Y 299.70 291.61

24006 04 N M 3 Y 380.15 369.89

24065 04 N I 3 113.60 17.00 110.53

24066 04 N M 3 Y 264.25 17.00 257.12

24071 04 01/01/10 N M 3 Y 226.29 220.18

24073 04 01/01/10 N M 3 Y 389.59 379.07

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

24075 04 N M 3 149.80 145.76

24076 04 01/01/10 N M 3 224.70 218.63

24077 04 01/01/10 N M 7 Y 319.02 310.41

24079 04 01/01/10 N M 7 Y Y 731.94 712.18

24100 04 N M 3 Y 299.70 291.61

24101 04 N M 3 Y 480.00 467.04

24102 04 N M 3 Y 524.40 510.24

24105 04 N M 3 380.15 369.89

24110 04 N M 3 Y 527.20 512.97

24115 04 N M 3 Y 749.20 728.97

24116 04 N M 3 Y 749.20 728.97

24120 04 N M 3 Y 449.50 437.36

24125 04 N M 7 Y 749.20 728.97

24126 04 N M 7 Y 749.20 728.97

24130 04 N M 3 Y 492.55 479.25

24134 04 N M 3 Y 351.00 341.52

24136 04 N M 3 Y 262.80 255.70

24138 04 N M 3 Y 254.80 247.92

24140 04 N M 3 Y 480.00 467.04

24145 04 N M 3 Y 480.00 467.04

24147 04 N M 3 Y 480.00 467.04

24149 04 10/24/14 N M 6 Y Y 708.52 689.39

24150 04 01/01/10 N M 6 Y Y 1198.70 1,166.34

24152 04 01/01/10 N M 6 Y Y 958.60 932.72

24155 04 N M 3 Y 749.20 728.97

24160 04 N M 3 Y 299.70 291.61

24164 04 N M 3 492.55 479.25

24200 04 N M 3 169.30 164.73

24201 04 N M 3 Y 245.55 238.92

24220 04 N I 3 105.15 102.31

24300 04 N I 3 66.70 64.90

24301 04 N M 3 Y 453.70 441.45

24305 04 N M 3 Y 359.30 349.60

24310 04 N M 3 Y 188.70 183.61

24320 04 N M 3 Y 599.35 583.17

24330 04 N M 3 Y 599.35 583.17

24331 04 N M 3 Y 599.35 583.17

24332 04 N M 3 Y 326.30 317.49

24340 04 N M 3 Y 299.70 291.61

24341 04 N M 3 Y 274.20 266.80

24342 04 N M 3 Y 535.45 520.99

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

24343 04 N M 3 Y 430.15 418.54

24344 04 N M 3 Y 651.95 634.35

24345 04 N M 3 Y 430.15 418.54

24346 04 N M 3 Y 651.95 634.35

24357 04 01/01/08 N M 3 Y 233.94 227.62

24358 04 01/01/08 N M 3 Y 275.71 268.27

24359 04 01/01/08 N M 3 Y 341.04 331.83

24360 04 N M 3 Y 718.70 699.30

24361 04 N M 3 Y 1123.70 1,093.36

24362 04 N M 3 Y 1123.70 1,093.36

24363 04 N M 3 Y 1123.70 1,093.36

24365 04 N M 3 Y 1123.70 1,093.36

24366 04 N M 3 Y 1123.70 1,093.36

24370 04 01/01/13 N M 3 Y 928.46 903.39

24371 04 01/01/13 N M 3 Y 1,070.94 1,042.02

24400 04 N M 3 Y 541.05 526.44

24410 04 N M 3 Y 481.65 468.65

24420 04 N M 3 Y 898.95 874.68

24430 04 N M 3 Y 636.80 619.61

24435 04 N M 7 Y 958.60 932.72

24470 04 N M 3 Y 374.55 364.44

24495 04 N M 3 Y 299.70 291.61

24498 04 N M 3 Y Y 491.50 478.23

24500 04 N M 153.95 149.79

24505 04 N M 3 295.50 287.52

24515 04 N M 3 Y Y 624.30 607.44

24516 04 N M 3 Y 624.30 607.44

24530 04 N M 299.70 291.61

24535 04 N M 3 334.40 325.37

24538 04 05/27/15 N M 3 405.10 394.16

24545 04 N M 3 Y 718.70 699.30

24546 04 N M 3 Y 718.70 699.30

24560 04 N M 199.75 194.36

24565 04 N M 3 242.80 236.24

24566 04 N M 3 Y 257.30 250.35

24575 04 N M 3 Y 718.70 699.30

24576 04 N M 188.70 183.61

24577 04 N M 3 245.55 238.92

24579 04 N M 3 Y 718.70 699.30

24582 04 N M Y 405.10 394.16

24586 04 N M 3 Y 480.65 467.67

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

24587 04 N M 3 Y 1123.70 1,093.36

24600 04 N M 208.05 202.43

24605 04 N M 3 242.80 236.24

24615 04 N M 3 Y Y 419.00 407.69

24620 04 N M 3 259.40 252.40

24635 04 N M 3 Y 482.80 469.76

24640 04 06/23/15 N I 3 Y 180.30 175.43

24650 04 N I 3 142.90 139.04

24655 04 N M 3 Y 208.05 202.43

24665 04 N M 3 Y 400.90 390.08

24666 04 N M 3 Y 449.50 437.36

24670 04 N M 3 181.65 176.75

24675 04 N M 3 206.70 201.12

24685 04 N M 3 Y 556.35 541.33

24800 04 N M 3 Y 718.70 699.30

24802 04 N M 3 Y 839.35 816.69

24900 04 N M 3 Y 313.50 305.04

24920 04 N M 3 Y 595.20 579.13

24925 04 N M 3 Y 262.20 255.12

24930 04 N M 3 Y 595.20 579.13

24931 04 N M 3 Y 674.20 656.00

24935 04 N M 3 Y 599.35 583.17

24940 04 N M 3 Y 621.10 604.33

24999 04 Y M 0 Y

25000 04 N M 3 351.00 341.52

25001 04 N M 3 Y 207.95 202.34

25020 04 N M 3 Y 388.50 378.01

25023 04 N M 3 Y 394.80 384.14

25024 04 N M 3 Y 458.20 445.83

25025 04 N M 3 Y 588.15 572.27

25028 04 N I 3 179.25 17.00 174.41

25031 04 N M 3 232.55 17.00 226.27

25035 04 N M 3 287.60 279.83

25040 04 N M 3 Y 480.00 467.04

25065 04 N I 3 113.60 17.00 110.53

25066 04 N I 3 149.25 17.00 145.22

25071 04 01/01/10 N M 3 Y 236.70 230.31

25073 04 01/01/10 N M 3 Y 293.97 286.03

25075 04 01/01/10 N M 3 149.80 145.76

25076 04 01/01/10 N M 3 262.20 255.12

25077 04 01/01/10 N M 7 467.49 454.87

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

25078 04 01/01/10 N M 3 Y 637.84 620.62

25085 04 N M 3 Y 262.20 255.12

25100 04 N M 3 Y 419.00 407.69

25101 04 N M 3 Y 480.00 467.04

25105 04 N M 3 Y 480.00 467.04

25107 04 N M 3 Y 480.00 467.04

25109 04 01/01/07 N M 3 Y 240.00 233.52

25110 04 N M 3 217.80 211.92

25111 04 N M 3 214.00 34.00 208.22

25112 04 N M 3 214.00 34.00 208.22

25115 04 N M 3 Y 599.35 583.17

25116 04 N M 3 Y 599.35 583.17

25118 04 N M 3 Y 480.00 467.04

25119 04 N M 3 Y 659.00 641.21

25120 04 N M 3 Y 599.35 583.17

25125 04 N M 7 Y 674.20 656.00

25126 04 N M 7 Y 674.20 656.00

25130 04 N M 3 Y 299.70 291.61

25135 04 N M 7 Y 449.50 437.36

25136 04 N M 7 Y 449.50 437.36

25145 04 N M 3 Y 359.30 349.60

25150 04 01/01/10 N M 3 Y 359.30 349.60

25151 04 01/01/10 N M 3 Y Y 359.30 349.60

25170 04 01/01/10 N M 3 Y Y 721.98 702.49

25210 04 N M 3 Y 480.00 467.04

25215 04 N M 3 Y 480.00 467.04

25230 04 N M 3 Y 299.70 291.61

25240 04 N M 3 Y 359.30 349.60

25246 04 N I 3 96.90 94.28

25248 04 N M 3 181.25 176.36

25250 04 N M 3 224.70 218.63

25251 04 N M 3 339.50 330.33

25259 04 N M 3 230.15 223.94

25260 04 N M 3 Y 283.50 275.85

25263 04 N M 3 Y 302.60 294.43

25265 04 N M 3 Y 484.20 471.13

25270 04 N M 3 Y 369.05 359.09

25272 04 N M 3 Y 256.85 249.92

25274 04 N M 3 Y 359.30 349.60

25275 04 N M 3 Y 442.50 430.55

25280 04 N M 3 Y 359.30 349.60

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

25290 04 N M 3 Y 302.40 294.24

25295 04 N M 3 Y 277.50 270.01

25300 04 N M 4 Y 359.30 349.60

25301 04 N M 4 Y 359.30 349.60

25310 04 N M 4 Y 480.00 467.04

25312 04 N M 4 Y 524.40 510.24

25315 04 N M 3 Y 480.00 467.04

25316 04 N M 3 Y 524.40 510.24

25320 04 N M 3 Y 449.50 437.36

25332 04 N M 3 Y 749.20 728.97

25335 04 N M 3 Y 749.20 728.97

25337 04 N M 3 Y 718.70 699.30

25350 04 N M 3 Y 374.55 364.44

25355 04 N M 3 Y 480.00 467.04

25360 04 N M 3 Y 316.10 307.57

25365 04 N M 3 Y 561.85 546.68

25370 04 N M 3 Y 480.00 467.04

25375 04 N M 3 Y 524.40 510.24

25390 04 N M 3 Y 599.35 583.17

25391 04 N M 7 Y 898.95 874.68

25392 04 N M 3 Y 898.95 874.68

25393 04 N M 7 Y 898.95 874.68

25394 04 N M 3 Y 514.80 500.90

25400 04 N M 3 Y 524.40 510.24

25405 04 N M 7 Y 599.35 583.17

25415 04 N M 3 Y 488.00 474.82

25420 04 N M 7 Y 839.35 816.69

25425 04 N M 7 Y 599.35 583.17

25426 04 N M 7 Y 749.20 728.97

25430 04 N M 3 Y 451.90 439.70

25431 04 N M 3 Y 449.10 436.97

25440 04 N M 3 Y 599.35 583.17

25441 04 N M 3 Y 659.00 641.21

25442 04 N M 3 Y 659.00 641.21

25443 04 N M 3 Y 749.20 728.97

25444 04 N M 3 Y 749.20 728.97

25445 04 N M 3 Y 749.20 728.97

25446 04 N M 3 Y 898.95 874.68

25447 04 01/01/12 N M 3 Y Y 494.84 481.48

25449 04 N M 3 Y 659.00 641.21

25450 04 N M 3 Y 299.70 291.61

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

25455 04 N M 3 Y 449.50 437.36

25490 04 N M 3 Y Y 356.50 346.87

25491 04 N M 3 Y Y 365.60 355.73

25492 04 N M 3 Y Y 459.05 446.66

25500 04 N I 3 112.40 109.37

25505 04 N M 3 210.90 205.21

25515 04 N M 3 Y 554.90 539.92

25520 04 N M 3 267.80 260.57

25525 04 N M 3 Y 443.95 431.96

25526 04 10/01/14 N M 3 Y Y 577.42 561.83

25530 04 N M 199.75 194.36

25535 04 N M 3 240.00 233.52

25545 04 N M 3 Y 538.20 523.67

25560 04 N M 3 176.20 171.44

25565 04 N M 3 292.60 284.70

25574 04 N M 3 Y 538.20 523.67

25575 04 11/24/14 N M 3 Y Y 592.40 576.41

25600 04 N M 155.35 151.16

25605 04 N M 3 294.10 286.16

25606 04 01/01/07 N M 3 301.00 292.87

25607 04 01/01/07 N M 3 443.95 431.96

25608 04 01/01/07 N M 3 Y 443.95 431.96

25609 04 01/01/07 N M Y 443.95 431.96

25622 04 N I 147.10 143.13

25624 04 N I 3 181.10 176.21

25628 04 N M 3 Y 335.70 326.64

25630 04 N M 201.10 195.67

25635 04 N I 3 174.60 169.89

25645 04 N M 3 Y 335.70 326.64

25650 04 N I 3 Y Y 126.90 123.47

25651 04 N M 3 Y 271.25 263.93

25652 04 N M 3 Y 374.00 363.90

25660 04 N I 3 139.00 135.25

25670 04 N M 3 Y 266.70 259.50

25671 04 N M 3 Y 205.30 199.76

25675 04 N I 3 168.25 163.71

25676 04 N M 3 Y 270.40 263.10

25680 04 N M 3 240.00 233.52

25685 04 N M 3 Y 449.50 437.36

25690 04 N I 3 188.65 183.56

25695 04 N M 3 Y 276.50 269.03

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price

State

Max

Rate reduced

by 2.7%

25800 04 N M 3 Y 718.70 699.30

25805 04 N M 3 Y 786.60 765.36

25810 04 N M 3 Y 839.35 816.69

25820 04 N M 3 Y 664.25 646.32

25825 04 N M 7 Y 718.70 699.30

25830 04 N M 3 Y 786.60 765.36

25900 04 N M 3 Y 359.30 349.60

25905 04 N M 3 Y 359.30 349.60

25907 04 N M 3 Y 290.30 282.46

25909 04 N M 3 Y 359.30 349.60

25915 04 N M 3 Y 1198.70 1,166.34

25920 04 N M 3 Y 359.30 349.60

25922 04 N M 3 Y 244.50 237.90

25924 04 N M 3 Y 359.30 349.60

25927 04 N M 3 Y 302.60 294.43

25929 04 N M 3 Y 236.30 229.92

25931 04 N M 3 Y 285.80 278.08

25999 04 Y M

26010 04 N I 3 76.25 74.19

26011 04 N I 3 97.40 94.77

26020 04 N M 3 191.80 186.62

26025 04 N M 3 201.60 196.16

26030 04 N M 3 Y 237.15 230.75

26034 04 N M 3 Y 240.00 233.52

26035 04 N M 3 Y 321.65 312.97

26037 04 N M 3 Y 265.20 258.04

26040 04 N M 3 Y 264.90 257.75

26045 04 N M 3 Y 449.50 437.36

26055 04 N M 3 Y 235.80 229.43

26060 04 N I 3 Y 107.90 104.99

26070 04 N M 3 Y 224.70 218.63

26075 04 N M 3 Y 224.70 218.63

26080 04 N M 3 Y 187.30 182.24

26100 04 N M 3 Y 299.70 291.61

26105 04 N M 3 Y 262.20 255.12

26110 04 N M 3 Y 187.30 182.24

26111 04 01/01/10 N M 3 Y 228.07 221.91

26113 04 01/01/10 N M 3 Y 299.94 291.84

26115 04 01/01/10 N M 3 149.80 145.76

26116 04 01/01/10 N M 3 224.70 218.63

26117 04 01/01/10 N M 7 380.08 369.82

Add-On

Procedure

CodeNote

Prog

CovEff Date HP

NDC

Ind

Surg

IndAV

M1

(26)

M2

(TC)

Asst

Surg

Co-

Surg

Unit

priceMax Qty

State

MaxSurg Child Adult

Unit

price