Reimbursement by Procedure Codes 70000 - 79999 … · Reimbursement by Procedure Codes 70000 - 79999 Effective Jan. 1, 2015 CPT Code Reimbursement 70010 $64.79 ... 75574 $230.50 75600

Reimbursement by Procedure Codes 70000 - 79999

Effective Jan. 1, 2015

CPT Code Reimbursement

70010 $64.79

70015 $91.23

70030 $17.79

70100 $20.54

70110 $24.53

70120 $21.82

70130 $34.88

70134 $28.72

70140 $18.84

70150 $26.65

70160 $20.55

70170 $33.27

70190 $22.22

70200 $27.49

70210 $19.28

70220 $24.11

70240 $18.41

70250 $23.05

70260 $29.36

70300 $8.92

70310 $23.32

70320 $46.00

70328 $19.27

70330 $30.06

70332 $53.08

70336 $258.43

70350 $13.12

70355 $13.31

70360 $17.15

70370 $36.00

70371 $58.42

70373 $51.16

70380 $24.58

70390 $63.35

70450 $122.42

70460 $159.53

70470 $193.05

70480 $159.73

70481 $227.71

70482 $252.29

70486 $155.50

70487 $196.85

70488 $239.36

70490 $159.73

70491 $192.77

70492 $232.97

Confidential

These rates are provided for informational purposes only

and are not to be considered a guarantee of payment.

Actual payment will be based on Health Options policies,

procedures, and Customer Benefit Plans. 1 of 37




70496 $264.49

70498 $264.49

70540 $254.89

70542 $321.65

70543 $397.79

70544 $250.39

70545 $308.96

70546 $387.68

70547 $250.39

70548 $308.96

70549 $387.54

70551 $249.95

70552 $326.78

70553 $401.25

70554 $355.37

70555 $565.00

70557 $157.52

70558 $173.95

70559 $174.62

71010 $14.60

71015 $18.62

71020 $19.25

71021 $23.67

71022 $28.96

71023 $31.00

71030 $28.74

71034 $54.00

71035 $22.03

71100 $20.09

71101 $24.52

71110 $25.37

71111 $32.77

71120 $19.90

71130 $23.28

71250 $151.97

71260 $193.70

71270 $237.97

71275 $269.40

71550 $258.01

71551 $324.76

71552 $401.55

71555 $345.94

72010 $46.13

72020 $14.83

72040 $24.19

72050 $32.84

Confidential








72052 $41.72

72069 $23.13

72070 $21.16

72072 $23.49

72074 $27.73

72080 $22.70

72090 $30.66

72100 $25.25

72110 $34.54

72114 $46.32

72120 $32.05

72125 $151.97

72126 $193.29

72127 $234.43

72128 $151.97

72129 $193.72

72130 $234.64

72131 $151.97

72132 $193.29

72133 $234.43

72141 $248.07

72142 $330.73

72146 $248.07

72147 $328.19

72148 $248.38

72149 $326.78

72156 $401.61

72157 $401.98

72158 $400.41

72159 $382.67

72170 $16.79

72190 $26.11

72191 $266.21

72192 $151.28

72193 $183.35

72194 $235.10

72195 $258.50

72196 $325.19

72197 $401.34

72198 $344.46

72200 $18.43

72202 $21.60

72220 $18.22

72240 $89.84

72255 $84.40

72265 $85.72

Confidential








72270 $133.38

72275 $69.21

72285 $91.40

72291 $98.80

72292 $211.81

72295 $80.63

73000 $17.80

73010 $18.92

73020 $14.62

73030 $19.12

73040 $67.01

73050 $23.78

73060 $18.22

73070 $17.59

73080 $21.19

73085 $50.00

73090 $17.37

73092 $19.07

73100 $19.13

73110 $22.67

73115 $50.00

73120 $17.16

73130 $19.91

73140 $19.51

73200 $151.82

73201 $186.53

73202 $238.91

73206 $265.87

73218 $254.97

73219 $321.86

73220 $398.22

73221 $255.59

73222 $321.86

73223 $398.01

73225 $376.55

73500 $16.58

73510 $23.98

73520 $25.23

73525 $62.34

73530 $21.90

73540 $25.27

73550 $17.64

73560 $18.92

73562 $22.73

73564 $26.10

73565 $21.04

Confidential








73580 $82.00

73590 $17.15

73592 $19.28

73600 $17.59

73610 $20.12

73615 $50.00

73620 $16.94

73630 $19.70

73650 $17.37

73660 $18.24

73700 $151.82

73701 $188.23

73702 $240.19

73706 $268.99

73718 $254.89

73719 $321.65

73720 $398.01

73721 $255.38

73722 $322.21

73723 $398.01

73725 $345.29

74000 $15.45

74010 $23.69

74020 $24.95

74022 $30.01

74150 $153.62

74160 $208.12

74170 $251.05

74174 $349.65

74175 $269.13

74176 $133.34

74177 $210.54

74178 $266.73

74181 $258.01

74182 $324.98

74183 $401.12

74185 $343.82

74190 $45.41

74210 $48.88

74220 $56.09

74230 $56.90

74235 $164.00

74240 $69.47

74241 $73.78

74245 $110.22

74246 $74.98

Confidential








74247 $74.98

74249 $116.16

74250 $66.28

74251 $109.43

74260 $69.09

74261 $249.66

74262 $379.19

74263 $538.23

74270 $75.20

74280 $118.45

74283 $114.23

74290 $42.53

74291 $39.84

74301 $46.39

74305 $32.99

74320 $67.30

74327 $85.21

74328 $101.34

74329 $75.00

74330 $107.26

74340 $76.12

74355 $142.00

74360 $88.48

74363 $284.00

74400 $69.66

74410 $71.78

74415 $74.00

74420 $77.47

74425 $44.32

74430 $37.86

74440 $39.00

74445 $63.98

74450 $47.18

74455 $55.90

74470 $45.16

74475 $69.63

74480 $69.84

74485 $68.78

74710 $24.48

74740 $49.28

74742 $89.95

74775 $82.00

75557 $278.35

75559 $306.07

75561 $377.44

75563 $427.72

Confidential








75565 $46.18

75571 $45.77

75572 $181.66

75573 $235.09

75574 $230.50

75600 $168.76

75605 $133.49

75625 $133.48

75630 $155.38

75635 $284.25

75658 $148.60

75705 $176.38

75710 $145.10

75716 $167.40

75726 $143.81

75731 $146.23

75733 $168.27

75736 $143.40

75741 $135.86

75743 $151.85

75746 $139.22

75756 $149.15

75774 $99.23

75791 $150.76

75801 $222.00

75803 $240.00

75805 $245.00

75807 $265.50

75809 $60.76

75810 $479.00

75820 $75.00

75822 $95.34

75825 $127.90

75827 $129.46

75831 $132.44

75833 $149.98

75840 $129.90

75842 $150.40

75860 $132.14

75870 $130.52

75872 $153.38

75880 $106.81

75885 $139.39

75887 $140.68

75889 $130.31

75891 $130.52

Confidential








75893 $111.16

75894 $648.25

75896 $569.34

75898 $77.96

75901 $85.50

75902 $47.78

75945 $206.52

75946 $118.00

75952 $674.82

75953 $73.91

75954 $121.46

75956 $396.34

75957 $339.56

75958 $226.39

75959 $198.19

75962 $132.44

75964 $82.39

75966 $158.65

75968 $80.92

75970 $313.60

75978 $132.65

75980 $255.00

75982 $276.00

75984 $71.36

75989 $83.95

76000 $48.35

76001 $89.59

76010 $17.15

76080 $38.65

76098 $11.86

76100 $65.85

76101 $109.77

76102 $147.61

76120 $47.65

76125 $45.00

76140 $31.00

76376 $29.22

76377 $57.73

76380 $100.28

76390 $453.89

76506 $58.04

76510 $101.71

76511 $61.48

76512 $56.80

76513 $54.43

76514 $8.45

Confidential








76516 $44.52

76519 $48.19

76529 $45.42

76536 $73.65

76604 $54.56

76645 $55.12

76700 $84.25

76705 $66.41

76770 $82.17

76775 $66.66

76776 $94.25

76800 $82.58

76801 $80.82

76802 $43.14

76805 $89.74

76810 $60.46

76811 $119.61

76812 $92.30

76813 $78.52

76814 $49.84

76815 $56.77

76816 $64.35

76817 $61.23

76818 $75.91

76819 $56.97

76820 $28.84

76821 $59.98

76825 $134.89

76826 $70.72

76827 $41.11

76828 $30.08

76830 $77.81

76831 $78.01

76856 $77.60

76857 $50.62

76870 $75.29

76872 $81.35

76873 $107.29

76881 $71.22

76882 $18.35

76885 $61.37

76886 $57.63

76930 $56.33

76932 $55.19

76936 $127.77

76937 $21.38

Confidential








76940 $111.29

76941 $79.17

76942 $74.54

76945 $58.82

76946 $23.39

76948 $23.67

76950 $42.65

76965 $72.61

76970 $50.96

76975 $64.15

76977 $6.40

76998 $106.37

77001 $71.21

77002 $46.71

77003 $38.40

77011 $228.56

77012 $101.23

77013 $529.00

77014 $125.03

77021 $269.57

77022 $631.45

77051 $7.03

77052 $7.03

77053 $42.08

77054 $56.95

77055 $53.33

77056 $68.23

77057 $49.94

77058 $382.55

77059 $382.55

77071 $26.00

77072 $14.59

77073 $24.09

77074 $43.37

77075 $63.47

77076 $62.24

77077 $25.97

77078 $51.35

77080 $49.99

77081 $17.76

77082 $16.96

77084 $262.87

77261 $74.70

77262 $111.91

77263 $165.18

77280 $171.00

Confidential








77285 $272.00

77290 $335.00

77293 $414.48

77295 $488.08

77300 $67.72

77301 $1,514.00

77305 $60.00

77310 $86.52

77315 $136.60

77321 $92.14

77326 $133.00

77327 $196.00

77328 $274.62

77331 $63.79

77332 $80.00

77333 $52.88

77334 $151.58

77336 $76.11

77338 $438.50

77370 $116.38

77371 $1,173.65

77372 $890.69

77373 $1,272.83

77401 $20.35

77402 $72.39

77403 $69.00

77404 $72.39

77406 $72.39

77407 $85.07

77408 $82.00

77409 $82.00

77411 $82.00

77412 $91.00

77413 $91.00

77414 $91.00

77416 $92.00

77417 $14.15

77418 $401.88

77421 $74.96

77422 $42.58

77423 $50.60

77427 $173.59

77431 $98.69

77432 $416.01

77435 $628.46

77469 $298.36

Confidential








77470 $155.26

77600 $205.00

77605 $255.00

77610 $205.67

77615 $273.79

77620 $210.11

77750 $308.00

77761 $291.00

77762 $420.00

77763 $600.00

77776 $318.75

77777 $542.00

77778 $771.00

77785 $190.22

77786 $488.95

77787 $778.97

77789 $75.00

77790 $75.04

78012 $51.73

78013 $130.95

78014 $151.17

78015 $133.63

78016 $189.43

78018 $198.03

78020 $53.25

78070 $102.56

78071 $225.08

78072 $400.00

78075 $265.09

78102 $103.22

78103 $136.13

78104 $154.78

78110 $34.00

78111 $54.32

78120 $34.00

78121 $62.54

78122 $69.68

78130 $96.03

78135 $187.00

78140 $86.13

78185 $95.00

78190 $140.89

78191 $109.82

78195 $160.00

78201 $115.30

78202 $125.89

Confidential








78205 $141.25

78206 $193.94

78215 $119.38

78216 $80.92

78226 $204.73

78227 $280.46

78230 $103.06

78231 $79.82

78232 $72.71

78258 $141.73

78261 $155.27

78262 $152.31

78264 $172.40

78267 $6.64

78268 $56.87

78270 $50.45

78271 $53.21

78272 $56.42

78278 $178.85

78282 $67.00

78290 $169.91

78291 $156.77

78300 $109.33

78305 $144.36

78306 $157.29

78315 $183.08

78320 $151.37

78350 $33.21

78351 $15.34

78414 $60.37

78428 $120.27

78445 $62.00

78451 $211.66

78452 $296.75

78453 $181.96

78454 $262.96

78456 $156.08

78457 $121.05

78458 $121.54

78459 $737.03

78466 $112.05

78468 $135.96

78469 $160.09

78472 $156.37

78473 $206.51

78481 $130.49

Confidential








78483 $180.83

78491 $737.66

78492 $750.03

78494 $166.43

78496 $45.71

78579 $108.68

78580 $111.00

78582 $200.39

78597 $122.44

78598 $188.32

78600 $82.00

78601 $132.53

78605 $122.54

78606 $156.00

78607 $215.00

78608 $695.57

78609 $77.51

78610 $110.30

78630 $194.00

78635 $172.00

78645 $167.08

78647 $215.98

78650 $204.97

78660 $78.00

78700 $80.00

78701 $132.32

78707 $147.47

78708 $111.59

78709 $227.41

78710 $138.32

78725 $63.57

78730 $46.45

78740 $137.59

78761 $131.91

78800 $116.02

78801 $156.91

78802 $203.12

78803 $218.20

78804 $234.00

78805 $114.28

78806 $197.00

78807 $217.85

78808 $26.62

78811 $698.42

78812 $709.37

78813 $711.94

Confidential








78814 $717.41

78815 $724.97

78816 $726.21

79005 $137.84

79101 $145.71

79200 $160.03

79300 $194.00

79403 $196.13

79440 $147.62

79445 $240.00

7001526 $48.17

7003026 $6.84

7010026 $7.40

7011026 $9.89

7012026 $7.40

7013026 $13.50

7013426 $13.50

7014026 $7.96

7015026 $10.45

7016026 $6.84

7017026 $12.20

7019026 $8.50

7020026 $11.28

7021026 $7.13

7022026 $9.89

7024026 $7.67

7025026 $9.90

7026026 $13.50

7030026 $4.63

7031026 $7.14

7032026 $12.13

7032826 $7.40

7033026 $9.90

7033226 $23.05

7033626 $59.16

7035026 $7.69

7035526 $8.51

7036026 $6.84

7037026 $12.94

7037126 $33.28

7037326 $17.10

7038026 $7.41

7039026 $15.54

7045026 $34.02

7046026 $45.30

7047026 $51.22

Confidential








7048026 $51.50

7048126 $55.56

7048226 $58.06

7048626 $45.86

7048726 $52.33

7048826 $56.94

7049026 $51.50

7049126 $55.38

7049226 $58.06

7049626 $70.64

7049826 $70.64

7054026 $54.17

7054226 $65.08

7054326 $85.97

7054426 $48.16

7054526 $48.16

7054626 $72.48

7054726 $48.16

7054826 $48.16

7054926 $72.30

7055126 $59.45

7055226 $71.93

7055326 $94.94

7055426 $85.43

7055526 $104.29

7055726 $141.57

7055826 $131.18

7055926 $132.60

7101026 $7.12

7101526 $8.22

7102026 $8.78

7102126 $10.72

7102226 $12.39

7102326 $15.45

7103026 $12.39

7103426 $12.00

7103526 $7.40

7110026 $8.78

7110126 $10.72

7111026 $10.72

7111126 $12.66

7112026 $7.95

7113026 $8.78

7125026 $41.16

7126026 $50.11

7127026 $55.38

Confidential








7127526 $77.48

7155026 $58.33

7155126 $69.24

7155226 $90.98

7155526 $73.14

7201026 $18.30

7202026 $6.29

7204026 $9.43

7205026 $12.76

7205226 $14.70

7206926 $9.43

7207026 $9.06

7207226 $8.78

7207426 $8.78

7208026 $9.43

7209026 $12.12

7210026 $9.43

7211026 $12.76

7211426 $15.17

7212026 $9.43

7212526 $41.16

7212626 $49.00

7212726 $50.94

7212826 $41.16

7212926 $49.28

7213026 $50.94

7213126 $41.16

7213226 $49.28

7213326 $50.94

7214126 $64.53

7214226 $77.19

7214626 $64.53

7214726 $77.48

7214826 $59.82

7214926 $71.93

7215626 $103.63

7215726 $103.63

7215826 $95.31

7215926 $72.87

7217026 $7.50

7219026 $9.16

7219126 $73.22

7219226 $43.64

7219326 $46.78

7219426 $49.00

7219526 $58.98

Confidential








7219626 $69.80

7219726 $90.70

7219826 $72.30

7220026 $6.84

7220226 $7.67

7222026 $6.84

7224026 $36.70

7225526 $36.24

7226526 $33.47

7227026 $53.44

7227526 $27.00

7228526 $37.00

7229126 $57.35

7229226 $59.19

7229526 $34.04

7300026 $6.57

7301026 $7.50

7302026 $6.01

7303026 $8.05

7304026 $22.10

7305026 $8.88

7306026 $7.13

7307026 $6.29

7308026 $6.84

7308526 $21.00

7309026 $6.57

7309226 $6.57

7310026 $7.22

7311026 $7.13

7311526 $21.00

7312026 $6.57

7313026 $6.84

7314026 $5.46

7320026 $40.97

7320126 $46.78

7320226 $49.00

7320626 $72.77

7321826 $54.27

7321926 $65.36

7322026 $86.54

7322126 $55.10

7322226 $65.36

7322326 $86.26

7322526 $70.10

7350026 $7.50

7351026 $9.16

Confidential








7352026 $10.82

7352526 $22.66

7353026 $11.93

7354026 $8.60

7355026 $7.21

7356026 $7.50

7356226 $8.05

7356426 $9.43

7356526 $7.78

7358026 $23.42

7359026 $6.84

7359226 $6.57

7360026 $6.57

7361026 $6.84

7361526 $21.00

7362026 $6.28

7363026 $6.84

7365026 $6.57

7366026 $5.18

7370026 $40.97

7370126 $46.78

7370226 $49.28

7370626 $76.93

7371826 $54.17

7371926 $65.08

7372026 $86.26

7372126 $54.82

7372226 $65.83

7372326 $86.26

7372526 $73.13

7400026 $7.12

7401026 $9.06

7402026 $10.72

7402226 $12.66

7415026 $47.89

7416026 $51.22

7417026 $56.39

7417526 $76.83

7418126 $58.62

7418226 $69.52

7418326 $90.41

7418526 $72.30

7419026 $19.60

7421026 $14.33

7422026 $18.58

7423026 $21.36

Confidential








7423526 $52.40

7424026 $27.92

7424126 $27.46

7424526 $36.70

7424626 $27.92

7424726 $27.92

7424926 $36.70

7425026 $18.86

7425126 $27.92

7426026 $19.97

7427026 $27.92

7428026 $39.75

7428326 $52.00

7429026 $12.66

7429126 $7.95

7430126 $8.87

7430526 $17.10

7432026 $21.91

7432726 $29.67

7432826 $28.95

7432926 $28.95

7433026 $37.08

7434026 $22.10

7435526 $31.54

7436026 $23.51

7436326 $36.15

7440026 $19.69

7441026 $19.98

7441526 $19.69

7442026 $14.70

7442526 $14.70

7443026 $12.66

7444026 $15.00

7444526 $47.35

7445026 $13.59

7445526 $13.22

7447026 $20.00

7447526 $21.91

7448026 $21.91

7448526 $21.91

7471026 $13.50

7474026 $15.17

7477526 $25.34

7560026 $20.54

7560526 $46.80

7562526 $46.50

Confidential








7563026 $72.58

7563526 $97.38

7565826 $51.94

7570526 $87.86

7571026 $45.58

7571626 $53.16

7572626 $46.13

7573126 $47.10

7573326 $54.88

7573626 $45.86

7574126 $53.07

7574326 $67.31

7574626 $46.23

7575626 $50.70

7577426 $14.70

7580126 $34.94

7580326 $47.89

7580526 $33.19

7580726 $48.18

7580926 $19.14

7581026 $47.06

7582026 $28.48

7582226 $42.62

7582526 $45.57

7582726 $45.10

7583126 $48.80

7583326 $58.59

7584026 $47.95

7584226 $60.00

7586026 $46.98

7587026 $45.94

7587226 $49.34

7588026 $29.05

7588526 $58.06

7588726 $57.79

7588926 $45.94

7589126 $45.94

7589326 $21.26

7589426 $54.26

7589626 $54.83

7589826 $69.16

7590126 $19.69

7590226 $15.71

7594526 $16.45

7594626 $16.54

7595226 $185.76

Confidential








7595326 $56.54

7595426 $82.00

7595626 $290.96

7595726 $249.02

7595826 $165.32

7595926 $145.24

7596226 $21.63

7596426 $14.60

7596626 $53.74

7596826 $14.62

7597026 $14.00

7597826 $21.35

7598026 $43.00

7598426 $14.00

7598926 $47.52

7600026 $6.84

7600126 $23.00

7601026 $7.40

7608026 $21.91

7609826 $6.57

7610026 $24.80

7610126 $26.77

7610226 $27.14

7612026 $15.25

7612526 $11.66

7637626 $8.23

7637726 $31.81

7638026 $39.30

7639026 $70.96

7650626 $25.42

7651026 $73.74

7651126 $41.60

7651226 $42.16

7651326 $27.68

7651426 $7.69

7651626 $23.81

7651926 $24.46

7652926 $25.86

7653626 $22.46

7660426 $21.90

7664526 $21.82

7670026 $32.35

7670526 $23.58

7677026 $29.58

7677526 $23.58

7677626 $30.42

Confidential








7680026 $44.55

7680126 $39.67

7680226 $33.29

7680526 $39.67

7681026 $39.11

7681126 $76.10

7681226 $71.10

7681326 $47.06

7681426 $39.38

7681526 $25.70

7681626 $34.12

7681726 $29.95

7681826 $42.17

7681926 $31.07

7682026 $19.88

7682126 $28.30

7682526 $66.48

7682626 $33.01

7682726 $22.93

7682826 $22.38

7683026 $27.74

7683126 $28.85

7685626 $27.74

7685726 $15.82

7687026 $25.98

7687226 $28.49

7687326 $63.07

7688526 $29.86

7688626 $25.16

7693026 $27.67

7693226 $28.50

7693626 $81.62

7693726 $12.20

7694026 $83.56

7694126 $55.30

7694226 $27.09

7694526 $27.38

7694626 $15.17

7695026 $23.58

7696526 $55.03

7697026 $16.26

7697526 $34.79

7697726 $2.81

7699826 $51.10

7700126 $15.54

7700226 $22.20

Confidential








7700326 $23.85

7701126 $49.30

7701226 $46.22

7701326 $163.26

7701426 $41.30

7702126 $61.02

7702226 $172.58

7705126 $2.40

7705226 $2.40

7728026 $36.00

7728526 $54.15

7729026 $80.54

7729526 $221.57

7730026 $32.07

7730126 $406.00

7730526 $36.00

7731026 $54.15

7731526 $80.54

7732126 $48.83

7732626 $47.76

7732726 $71.95

7732826 $107.95

7733126 $44.89

7733226 $28.13

7733326 $43.46

7733426 $63.82

7742126 $19.99

7747026 $107.95

7762026 $79.28

7775026 $257.33

7776126 $194.21

7776226 $296.29

7776326 $447.07

7777626 $219.77

7777726 $364.23

7777826 $583.35

7778926 $58.00

7779026 $53.48

7801526 $26.52

7801626 $30.46

7801826 $33.73

7802026 $23.28

7807026 $32.63

7807526 $29.02

7810226 $21.62

7810326 $29.29

Confidential








7810426 $31.51

7811026 $7.67

7811126 $8.50

7812026 $9.34

7812126 $12.66

7812226 $17.38

7813026 $24.87

7813526 $25.98

7814026 $24.59

7818526 $16.00

7819026 $43.17

7819126 $24.59

7819526 $47.88

7820126 $17.37

7820226 $19.30

7820526 $28.19

7820626 $37.90

7821526 $19.69

7821626 $22.46

7823026 $18.02

7823126 $20.43

7823226 $17.73

7825826 $29.68

7826126 $27.92

7826226 $26.53

7826426 $30.97

7827026 $7.95

7827126 $7.95

7827226 $10.44

7827826 $39.47

7828226 $15.54

7829026 $27.37

7829126 $35.03

7830026 $24.97

7830526 $32.90

7830626 $34.30

7831526 $40.58

7832026 $41.13

7835026 $11.03

7841426 $18.02

7842826 $31.91

7844526 $19.04

7845626 $41.36

7845726 $30.69

7845826 $34.45

7845926 $60.65

Confidential








7846626 $28.30

7846826 $33.31

7846926 $38.59

7847226 $39.86

7847326 $60.31

7848126 $41.09

7848326 $62.02

7849126 $61.50

7849226 $77.98

7849426 $49.03

7849626 $20.45

7858026 $29.40

7858226 $40.35

7860026 $17.66

7860126 $20.24

7860526 $21.64

7860626 $25.14

7860726 $48.06

7860826 $59.70

7860926 $77.51

7861026 $12.11

7863026 $27.18

7863526 $24.32

7864526 $22.74

7864726 $35.30

7865026 $24.30

7866026 $16.00

7870026 $18.30

7870126 $19.69

7870726 $37.90

7870826 $48.07

7870926 $55.92

7871026 $25.42

7872526 $14.88

7873026 $6.58

7874026 $23.30

7876126 $28.75

7880026 $26.25

7880126 $31.52

7880226 $34.02

7880326 $42.79

7880426 $42.24

7880526 $29.02

7880626 $34.02

7880726 $42.32

7881126 $63.50

Confidential








7881226 $78.11

7881326 $81.54

7881426 $88.82

7881526 $98.90

7881626 $100.55

7900526 $88.34

7910126 $95.48

7920026 $97.15

7930026 $81.20

7940326 $113.00

7944026 $97.60

7944526 $117.73

70015TC $55.00

70030TC $12.66

70100TC $14.99

70110TC $17.12

70120TC $16.27

70130TC $24.76

70134TC $18.60

70140TC $12.87

70150TC $18.82

70160TC $15.42

70190TC $15.84

70200TC $19.03

70210TC $13.93

70220TC $16.69

70240TC $12.66

70250TC $15.63

70260TC $19.24

70300TC $5.44

70310TC $17.96

70320TC $33.00

70328TC $13.72

70330TC $22.63

70332TC $35.79

70336TC $214.05

70350TC $7.36

70355TC $6.93

70360TC $12.02

70370TC $16.00

70371TC $33.46

70373TC $38.34

70380TC $19.03

70390TC $51.71

70450TC $83.39

70460TC $115.46

Confidential








70470TC $142.79

70480TC $121.10

70481TC $186.04

70482TC $208.75

70486TC $121.10

70487TC $157.60

70488TC $196.65

70490TC $121.10

70491TC $151.24

70492TC $189.44

70496TC $211.51

70498TC $211.51

70540TC $214.27

70542TC $272.84

70543TC $333.32

70544TC $214.27

70545TC $272.84

70546TC $333.32

70547TC $214.27

70548TC $272.84

70549TC $333.32

70551TC $175.22

70552TC $249.56

70553TC $285.27

70554TC $291.30

71010TC $9.26

71015TC $12.44

71020TC $12.66

71021TC $15.63

71022TC $19.66

71023TC $15.00

71030TC $19.45

71034TC $41.09

71035TC $16.48

71100TC $13.51

71101TC $16.48

71110TC $17.33

71111TC $23.27

71120TC $13.93

71130TC $16.69

71250TC $121.10

71260TC $156.12

71270TC $196.44

71275TC $211.30

71550TC $214.27

71551TC $272.84

Confidential








71552TC $333.32

71555TC $291.09

72010TC $32.39

72020TC $10.11

72040TC $17.12

72050TC $23.27

72052TC $30.70

72069TC $15.00

72070TC $14.36

72072TC $16.90

72074TC $21.15

72080TC $3.00

72090TC $21.57

72100TC $18.17

72110TC $24.97

72114TC $34.94

72120TC $24.97

72125TC $121.10

72126TC $156.54

72127TC $196.22

72128TC $121.10

72129TC $156.76

72130TC $196.44

72131TC $121.10

72132TC $156.33

72133TC $196.22

72141TC $172.68

72142TC $251.02

72146TC $172.68

72147TC $247.73

72148TC $172.68

72149TC $246.28

72156TC $285.64

72157TC $286.00

72158TC $283.82

72159TC $351.96

72170TC $11.17

72190TC $19.24

72191TC $211.30

72192TC $99.06

72193TC $148.27

72194TC $198.35

72195TC $214.27

72196TC $272.84

72197TC $333.32

72198TC $290.24

Confidential








72200TC $9.00

72202TC $15.84

72220TC $13.09

72240TC $45.00

72255TC $45.00

72265TC $60.62

72270TC $93.30

72275TC $46.19

72285TC $55.69

72295TC $55.10

73000TC $12.87

73010TC $13.30

73020TC $10.11

73030TC $13.09

73040TC $50.44

73050TC $17.12

73060TC $12.87

73070TC $12.87

73080TC $16.06

73085TC $29.00

73090TC $12.44

73092TC $14.14

73100TC $13.72

73110TC $17.33

73115TC $29.00

73120TC $12.23

73130TC $14.78

73140TC $13.00

73200TC $121.10

73201TC $151.45

73202TC $202.17

73206TC $211.30

73218TC $214.27

73219TC $272.84

73220TC $333.32

73221TC $190.16

73222TC $272.84

73223TC $333.32

73225TC $323.98

73500TC $10.96

73510TC $17.12

73520TC $17.12

73525TC $45.34

73540TC $18.82

73550TC $12.23

73560TC $13.30

Confidential








73562TC $16.69

73564TC $19.03

73565TC $15.20

73580TC $53.00

73590TC $12.02

73592TC $14.36

73600TC $12.66

73610TC $14.99

73615TC $29.00

73620TC $12.23

73630TC $14.57

73650TC $12.44

73660TC $14.36

73700TC $121.10

73701TC $153.14

73702TC $203.23

73706TC $211.30

73718TC $214.27

73719TC $272.84

73720TC $333.32

73721TC $190.53

73722TC $272.84

73723TC $333.32

73725TC $290.45

74000TC $10.11

74010TC $16.90

74020TC $16.90

74022TC $20.51

74150TC $96.87

74160TC $169.70

74170TC $208.75

74175TC $211.51

74181TC $214.05

74182TC $272.84

74183TC $333.32

74185TC $289.60

74210TC $38.12

74220TC $42.16

74230TC $40.88

74240TC $48.52

74241TC $53.19

74245TC $82.69

74246TC $54.04

74247TC $54.04

74249TC $88.63

74250TC $52.13

Confidential








74251TC $88.49

74260TC $54.11

74270TC $54.25

74280TC $88.63

74283TC $54.04

74290TC $33.03

74291TC $33.88

74320TC $22.00

74327TC $60.50

74400TC $41.00

74410TC $51.00

74415TC $26.00

74430TC $26.55

74440TC $24.00

74455TC $37.00

74475TC $49.00

74480TC $49.00

74485TC $49.00

74710TC $14.36

74740TC $37.91

75600TC $153.36

75605TC $98.39

75625TC $97.97

75630TC $97.24

75635TC $211.22

75658TC $109.64

75705TC $110.49

75710TC $110.92

75716TC $127.53

75726TC $109.22

75731TC $110.92

75733TC $127.11

75736TC $109.01

75741TC $96.06

75743TC $101.36

75746TC $104.55

75756TC $111.13

75774TC $82.66

75809TC $46.40

75820TC $33.00

75822TC $33.00

75825TC $92.86

75827TC $95.41

75831TC $95.85

75833TC $106.03

75840TC $93.94

Confidential








75842TC $105.40

75860TC $96.91

75870TC $96.06

75872TC $101.62

75880TC $70.00

75885TC $95.85

75887TC $97.33

75889TC $95.85

75891TC $96.06

75893TC $95.21

75901TC $62.00

75902TC $36.00

75962TC $116.22

75964TC $71.44

75966TC $113.64

75968TC $69.96

75978TC $116.65

75984TC $49.58

75989TC $48.31

76000TC $43.22

76010TC $11.60

76080TC $22.21

76098TC $6.93

76100TC $47.25

76101TC $89.69

76102TC $127.25

76120TC $36.22

76376TC $19.26

76377TC $33.88

76380TC $70.81

76390TC $382.94

76506TC $38.98

76510TC $46.40

76511TC $30.27

76512TC $25.18

76513TC $33.67

76514TC $2.68

76516TC $26.66

76519TC $29.85

76529TC $26.03

76536TC $56.80

76604TC $38.12

76645TC $38.76

76700TC $59.98

76705TC $48.00

76770TC $59.98

Confidential








76775TC $37.48

76776TC $71.44

76800TC $49.16

76801TC $51.07

76802TC $18.17

76805TC $59.98

76810TC $31.12

76811TC $62.53

76812TC $38.98

76813TC $43.22

76814TC $20.30

76815TC $37.49

76816TC $38.76

76817TC $38.76

76818TC $44.28

76819TC $33.67

76820TC $13.93

76821TC $38.76

76825TC $85.03

76826TC $26.02

76827TC $23.90

76828TC $13.30

76830TC $57.01

76831TC $56.38

76856TC $56.80

76857TC $35.65

76870TC $42.94

76872TC $45.56

76873TC $59.98

76885TC $38.98

76886TC $38.76

76930TC $35.58

76936TC $66.56

76937TC $12.23

76942TC $40.76

76946TC $12.02

76950TC $21.81

76965TC $23.99

76970TC $38.76

76977TC $4.31

77001TC $56.00

77002TC $30.06

77003TC $20.51

77011TC $166.47

77012TC $66.56

77014TC $81.20

Confidential








77021TC $223.81

77051TC $5.23

77052TC $5.23

77280TC $135.00

77285TC $217.00

77290TC $254.00

77295TC $266.52

77300TC $35.65

77301TC $1,091.00

77305TC $23.99

77310TC $32.38

77315TC $56.07

77321TC $43.31

77326TC $92.00

77327TC $133.56

77328TC $166.67

77331TC $18.89

77332TC $52.00

77333TC $9.42

77334TC $87.77

77421TC $54.97

77470TC $47.31

77620TC $123.46

77750TC $53.68

77761TC $98.00

77762TC $146.08

77763TC $131.00

77776TC $88.88

77777TC $171.00

77778TC $202.00

77789TC $18.00

77790TC $19.97

78015TC $113.74

78016TC $166.58

78018TC $172.73

78020TC $35.79

78070TC $78.08

78075TC $243.33

78102TC $65.00

78103TC $84.00

78104TC $105.00

78110TC $21.00

78111TC $47.95

78120TC $21.00

78121TC $53.05

78130TC $58.00

Confidential








78135TC $143.00

78140TC $67.69

78185TC $54.00

78190TC $108.50

78191TC $91.38

78195TC $111.00

78201TC $89.00

78202TC $111.40

78205TC $120.10

78206TC $165.52

78215TC $104.61

78216TC $64.08

78230TC $89.54

78231TC $64.51

78232TC $59.41

78258TC $119.47

78261TC $134.32

78262TC $132.41

78264TC $149.18

78270TC $44.49

78271TC $47.25

78272TC $48.59

78278TC $149.25

78290TC $149.39

78291TC $130.51

78300TC $90.61

78305TC $119.68

78306TC $131.56

78315TC $152.65

78320TC $120.53

78428TC $96.34

78445TC $30.00

78456TC $125.06

78457TC $98.03

78458TC $95.70

78466TC $90.82

78468TC $110.98

78469TC $131.14

78472TC $126.47

78473TC $161.27

78481TC $99.67

78483TC $134.32

78494TC $129.65

78496TC $21.08

78580TC $51.00

78600TC $23.00

Confidential








78601TC $85.00

78605TC $68.00

78606TC $82.00

78607TC $133.00

78610TC $74.00

78630TC $30.00

78635TC $86.00

78645TC $86.00

78647TC $189.50

78650TC $125.00

78660TC $62.00

78700TC $34.00

78701TC $117.56

78707TC $119.05

78708TC $75.54

78709TC $185.47

78710TC $119.26

78725TC $45.00

78730TC $41.52

78740TC $84.00

78761TC $110.34

78800TC $96.34

78801TC $133.26

78802TC $177.62

78803TC $186.10

78804TC $184.00

78805TC $92.51

78806TC $120.00

78807TC $186.10

79005TC $49.50

79101TC $50.23

79200TC $56.79

79403TC $82.56

79440TC $48.41

Confidential





Documents

Reimbursement by Procedure Codes 70000 - 79999 … · Reimbursement by Procedure Codes 70000 - 79999 Effective Jan. 1, 2015 CPT Code Reimbursement 70010 $64.79 ... 75574 $230.50 75600