2020 surgery max unit list 01/01/20 - 12/31/21 op surgery max/… · 2020 surgery max unit list...

2020 Surgery Max Unit List 01/01/20 - 12/31/21

Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

10005 3 196.00$ 588.00$

10007 3 196.00$ 588.00$

10009 3 196.00$ 588.00$

10011 3 196.00$ 588.00$

10021 1 100.00$ 100.00$

10030 1 196.00$ 196.00$

10035 16 196.00$ 3,136.00$

10036 16 196.00$ 3,136.00$

10040 1 100.00$ 100.00$

10060 1 100.00$ 100.00$

10061 16 196.00$ 3,136.00$

10080 1 100.00$ 100.00$

10081 1 196.00$ 196.00$

10120 1 100.00$ 100.00$

10121 1 196.00$ 196.00$

10140 1 100.00$ 100.00$

10160 1 100.00$ 100.00$

10180 16 196.00$ 3,136.00$

11000 1 196.00$ 196.00$

11001 1 196.00$ 196.00$

11004 16 196.00$ 3,136.00$

11005 16 196.00$ 3,136.00$

11006 16 196.00$ 3,136.00$

11008 8 196.00$ 1,568.00$

11010 16 196.00$ 3,136.00$

11011 16 196.00$ 3,136.00$

11012 16 196.00$ 3,136.00$

11042 16 196.00$ 3,136.00$

11043 16 196.00$ 3,136.00$

11044 16 196.00$ 3,136.00$

11045 16 196.00$ 3,136.00$

11046 16 196.00$ 3,136.00$

11047 16 196.00$ 3,136.00$

11055 1 196.00$ 196.00$

11056 1 196.00$ 196.00$

11057 2 196.00$ 392.00$

11102 3 196.00$ 588.00$ #N/A

11104 3 196.00$ 588.00$ #N/A

11106 3 196.00$ 588.00$ #N/A

1


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

11200 1 100.00$ 100.00$

11201 1 100.00$ 100.00$

11300 1 100.00$ 100.00$

11301 16 196.00$ 3,136.00$

11302 16 196.00$ 3,136.00$

11303 16 196.00$ 3,136.00$

11305 1 196.00$ 196.00$

11306 16 196.00$ 3,136.00$

11307 16 196.00$ 3,136.00$

11308 16 196.00$ 3,136.00$

11310 1 100.00$ 100.00$

11311 16 196.00$ 3,136.00$

11312 16 196.00$ 3,136.00$

11313 16 196.00$ 3,136.00$

11400 1 196.00$ 196.00$

11401 1 196.00$ 196.00$

11402 1 196.00$ 196.00$

11403 1 196.00$ 196.00$

11404 16 196.00$ 3,136.00$

11406 16 196.00$ 3,136.00$

11420 1 196.00$ 196.00$

11421 1 196.00$ 196.00$

11422 1 196.00$ 196.00$

11423 1 196.00$ 196.00$

11424 16 196.00$ 3,136.00$

11426 16 196.00$ 3,136.00$

11440 1 196.00$ 196.00$

11441 16 196.00$ 3,136.00$

11442 1 196.00$ 196.00$

11443 16 196.00$ 3,136.00$

11444 16 196.00$ 3,136.00$

11446 16 196.00$ 3,136.00$

11450 16 196.00$ 3,136.00$

11451 16 196.00$ 3,136.00$

11462 16 196.00$ 3,136.00$

11463 16 196.00$ 3,136.00$

11470 16 196.00$ 3,136.00$

11471 16 196.00$ 3,136.00$

11600 1 196.00$ 196.00$

2


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

11601 1 196.00$ 196.00$

11602 1 196.00$ 196.00$

11603 1 196.00$ 196.00$

11604 16 196.00$ 3,136.00$

11606 16 196.00$ 3,136.00$

11620 1 196.00$ 196.00$

11621 1 196.00$ 196.00$

11622 1 196.00$ 196.00$

11623 16 196.00$ 3,136.00$

11624 16 196.00$ 3,136.00$

11626 16 196.00$ 3,136.00$

11640 1 196.00$ 196.00$

11641 1 196.00$ 196.00$

11642 1 196.00$ 196.00$

11643 1 196.00$ 196.00$

11644 16 196.00$ 3,136.00$

11646 16 196.00$ 3,136.00$

11730 1 100.00$ 100.00$

11732 1 196.00$ 196.00$

11740 1 196.00$ 196.00$

11750 1 196.00$ 196.00$

11755 16 196.00$ 3,136.00$

11760 1 196.00$ 196.00$

11762 16 196.00$ 3,136.00$

11765 1 196.00$ 196.00$

11770 16 196.00$ 3,136.00$

11771 16 196.00$ 3,136.00$

11772 16 196.00$ 3,136.00$

11900 1 100.00$ 100.00$

11901 1 100.00$ 100.00$

11960 16 196.00$ 3,136.00$

11970 16 196.00$ 3,136.00$

11971 16 196.00$ 3,136.00$

12001 1 100.00$ 100.00$

12002 1 100.00$ 100.00$

12004 1 100.00$ 100.00$

12005 16 196.00$ 3,136.00$

12006 16 196.00$ 3,136.00$

12007 16 196.00$ 3,136.00$

3


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

12011 1 100.00$ 100.00$

12013 1 100.00$ 100.00$

12014 1 196.00$ 196.00$

12015 1 196.00$ 196.00$

12016 16 196.00$ 3,136.00$

12017 16 196.00$ 3,136.00$

12018 16 196.00$ 3,136.00$

12020 16 196.00$ 3,136.00$

12021 16 196.00$ 3,136.00$

12031 1 100.00$ 100.00$

12032 1 100.00$ 100.00$

12034 16 196.00$ 3,136.00$

12035 16 196.00$ 3,136.00$

12036 16 196.00$ 3,136.00$

12037 16 196.00$ 3,136.00$

12041 16 196.00$ 3,136.00$

12042 16 196.00$ 3,136.00$

12044 16 196.00$ 3,136.00$

12045 16 196.00$ 3,136.00$

12046 16 196.00$ 3,136.00$

12047 16 196.00$ 3,136.00$

12051 1 100.00$ 100.00$

12052 1 196.00$ 196.00$

12053 16 196.00$ 3,136.00$

12054 16 196.00$ 3,136.00$

12055 16 196.00$ 3,136.00$

12056 16 196.00$ 3,136.00$

12057 16 196.00$ 3,136.00$

13100 16 196.00$ 3,136.00$

13101 16 196.00$ 3,136.00$

13102 16 196.00$ 3,136.00$

13120 16 196.00$ 3,136.00$

13121 16 196.00$ 3,136.00$

13122 16 196.00$ 3,136.00$

13131 16 196.00$ 3,136.00$

13132 16 196.00$ 3,136.00$

13133 16 196.00$ 3,136.00$

13151 16 196.00$ 3,136.00$

13152 16 196.00$ 3,136.00$

4


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

13153 16 196.00$ 3,136.00$

13160 16 196.00$ 3,136.00$

14000 16 196.00$ 3,136.00$

14001 16 196.00$ 3,136.00$

14020 16 196.00$ 3,136.00$

14021 16 196.00$ 3,136.00$

14040 16 196.00$ 3,136.00$

14041 16 196.00$ 3,136.00$

14060 16 196.00$ 3,136.00$

14061 16 196.00$ 3,136.00$

14301 16 196.00$ 3,136.00$

14302 16 196.00$ 3,136.00$

14350 16 196.00$ 3,136.00$

15000 16 196.00$ 3,136.00$

15001 16 196.00$ 3,136.00$

15002 16 196.00$ 3,136.00$

15003 16 196.00$ 3,136.00$

15004 16 196.00$ 3,136.00$

15005 16 196.00$ 3,136.00$

15040 3 196.00$ 588.00$ 4

15050 16 196.00$ 3,136.00$

15100 16 196.00$ 3,136.00$

15101 16 196.00$ 3,136.00$

15110 3 196.00$ 588.00$ 16

15111 2 196.00$ 392.00$

15115 3 196.00$ 588.00$ 16

15116 2 196.00$ 392.00$

15120 16 196.00$ 3,136.00$

15121 16 196.00$ 3,136.00$

15130 3 196.00$ 588.00$ 15

15131 2 196.00$ 392.00$

15135 3 196.00$ 588.00$ 15

15136 2 196.00$ 392.00$

15150 3 196.00$ 588.00$ 16

15151 2 196.00$ 392.00$

15152 2 196.00$ 392.00$

15155 3 196.00$ 588.00$ 16

15156 2 196.00$ 392.00$

15157 2 196.00$ 392.00$

5


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

15200 16 196.00$ 3,136.00$

15201 16 196.00$ 3,136.00$

15220 16 196.00$ 3,136.00$

15221 16 196.00$ 3,136.00$

15240 16 196.00$ 3,136.00$

15241 16 196.00$ 3,136.00$

15260 16 196.00$ 3,136.00$

15261 16 196.00$ 3,136.00$

15271 16 196.00$ 3,136.00$

15273 16 196.00$ 3,136.00$

15275 16 196.00$ 3,136.00$

15277 16 196.00$ 3,136.00$

15342 16 196.00$ 3,136.00$

15343 16 196.00$ 3,136.00$

15350 16 196.00$ 3,136.00$

15351 16 196.00$ 3,136.00$

15570 16 196.00$ 3,136.00$

15572 16 196.00$ 3,136.00$

15574 16 196.00$ 3,136.00$

15576 16 196.00$ 3,136.00$

15600 16 196.00$ 3,136.00$

15610 16 196.00$ 3,136.00$

15620 16 196.00$ 3,136.00$

15630 16 196.00$ 3,136.00$

15650 16 196.00$ 3,136.00$

15730 16 196.00$ 3,136.00$

15731 6 196.00$ 1,176.00$

15733 16 196.00$ 3,136.00$

15734 16 196.00$ 3,136.00$

15736 16 196.00$ 3,136.00$

15738 16 196.00$ 3,136.00$

15740 16 196.00$ 3,136.00$

15750 16 196.00$ 3,136.00$

15756 16 196.00$ 3,136.00$

15757 16 196.00$ 3,136.00$

15758 16 196.00$ 3,136.00$

15760 16 196.00$ 3,136.00$

15769 1 196.00$ 196.00$

15770 16 196.00$ 3,136.00$

6


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

15771 1 196.00$ 196.00$

15772 3 196.00$ 588.00$ #N/A

15823 16 196.00$ 3,136.00$

15830 16 196.00$ 3,136.00$

15831 16 196.00$ 3,136.00$

15840 16 196.00$ 3,136.00$

15841 16 196.00$ 3,136.00$

15842 16 196.00$ 3,136.00$

15845 16 196.00$ 3,136.00$

15851 16 196.00$ 3,136.00$

15852 16 196.00$ 3,136.00$

15920 16 196.00$ 3,136.00$

15922 16 196.00$ 3,136.00$

15931 16 196.00$ 3,136.00$

15933 16 196.00$ 3,136.00$

15934 16 196.00$ 3,136.00$

15935 16 196.00$ 3,136.00$

15936 16 196.00$ 3,136.00$

15937 16 196.00$ 3,136.00$

15940 16 196.00$ 3,136.00$

15941 16 196.00$ 3,136.00$

15944 16 196.00$ 3,136.00$

15945 16 196.00$ 3,136.00$

15946 16 196.00$ 3,136.00$

15950 16 196.00$ 3,136.00$

15951 16 196.00$ 3,136.00$

15952 16 196.00$ 3,136.00$

15953 16 196.00$ 3,136.00$

15956 16 196.00$ 3,136.00$

15958 16 196.00$ 3,136.00$

15999 16 196.00$ 3,136.00$

16000 16 196.00$ 3,136.00$

16010 16 196.00$ 3,136.00$

16015 16 196.00$ 3,136.00$

16020 1 100.00$ 100.00$

16025 16 196.00$ 3,136.00$

16030 16 196.00$ 3,136.00$

16035 16 196.00$ 3,136.00$

16036 16 196.00$ 3,136.00$

7


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

17000 16 196.00$ 3,136.00$

17003 16 196.00$ 3,136.00$

17004 16 196.00$ 3,136.00$

17106 1 196.00$ 196.00$

17107 4 196.00$ 784.00$

17108 16 196.00$ 3,136.00$

17110 16 196.00$ 3,136.00$

17111 16 196.00$ 3,136.00$

17250 1 196.00$ 196.00$

17260 1 100.00$ 100.00$

17261 16 196.00$ 3,136.00$

17262 16 196.00$ 3,136.00$

17263 16 196.00$ 3,136.00$

17264 16 196.00$ 3,136.00$

17266 16 196.00$ 3,136.00$

17270 1 100.00$ 100.00$

17271 16 196.00$ 3,136.00$

17272 16 196.00$ 3,136.00$

17273 16 196.00$ 3,136.00$

17274 16 196.00$ 3,136.00$

17276 16 196.00$ 3,136.00$

17280 1 100.00$ 100.00$

17281 16 196.00$ 3,136.00$

17282 16 196.00$ 3,136.00$

17283 16 196.00$ 3,136.00$

17284 16 196.00$ 3,136.00$

17286 16 196.00$ 3,136.00$

17304 4 196.00$ 784.00$

17311 4 196.00$ 784.00$

17312 4 196.00$ 784.00$

17313 4 196.00$ 784.00$

17314 4 196.00$ 784.00$

17315 1 100.00$ 100.00$

17340 1 100.00$ 100.00$

17999 16 196.00$ 3,136.00$

19000 1 100.00$ 100.00$

19001 1 100.00$ 100.00$

19020 16 196.00$ 3,136.00$

19081 16 196.00$ 3,136.00$

8


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

19083 16 196.00$ 3,136.00$

19085 16 196.00$ 3,136.00$

19100 1 100.00$ 100.00$

19101 16 196.00$ 3,136.00$

19110 16 196.00$ 3,136.00$

19112 16 196.00$ 3,136.00$

19120 5 196.00$ 980.00$

19125 16 196.00$ 3,136.00$

19126 16 196.00$ 3,136.00$

19140 16 196.00$ 3,136.00$

19160 16 196.00$ 3,136.00$

19162 16 196.00$ 3,136.00$

19180 16 196.00$ 3,136.00$

19182 16 196.00$ 3,136.00$

19240 16 196.00$ 3,136.00$

19281 16 196.00$ 3,136.00$

19283 16 196.00$ 3,136.00$

19285 16 196.00$ 3,136.00$

19287 16 196.00$ 3,136.00$

19296 16 196.00$ 3,136.00$

19297 4 196.00$ 784.00$

19298 16 196.00$ 3,136.00$

19300 16 196.00$ 3,136.00$

19301 8 196.00$ 1,568.00$

19302 12 196.00$ 2,352.00$

19303 16 196.00$ 3,136.00$

19307 16 196.00$ 3,136.00$

19316 16 196.00$ 3,136.00$

19318 16 196.00$ 3,136.00$

19325 16 196.00$ 3,136.00$

19328 16 196.00$ 3,136.00$

19330 16 196.00$ 3,136.00$

19340 16 196.00$ 3,136.00$

19342 16 196.00$ 3,136.00$

19350 16 196.00$ 3,136.00$

19355 16 196.00$ 3,136.00$

19357 16 196.00$ 3,136.00$

19361 16 196.00$ 3,136.00$

19364 16 196.00$ 3,136.00$

9


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

19366 16 196.00$ 3,136.00$

19367 16 196.00$ 3,136.00$

19368 16 196.00$ 3,136.00$

19369 16 196.00$ 3,136.00$

19370 16 196.00$ 3,136.00$

19371 16 196.00$ 3,136.00$

19380 16 196.00$ 3,136.00$

20100 16 196.00$ 3,136.00$

20101 16 196.00$ 3,136.00$

20102 16 196.00$ 3,136.00$

20103 16 196.00$ 3,136.00$

20150 16 196.00$ 3,136.00$

20200 16 196.00$ 3,136.00$

20205 16 196.00$ 3,136.00$

20206 1 100.00$ 100.00$

20220 16 196.00$ 3,136.00$

20225 16 196.00$ 3,136.00$

20240 16 196.00$ 3,136.00$

20245 16 196.00$ 3,136.00$

20250 16 196.00$ 3,136.00$

20251 16 196.00$ 3,136.00$

20500 1 100.00$ 100.00$

20501 1 100.00$ 100.00$

20520 1 100.00$ 100.00$

20525 16 196.00$ 3,136.00$

20550 1 100.00$ 100.00$

20551 1 196.00$ 196.00$

20552 1 196.00$ 196.00$

20553 1 196.00$ 196.00$

20555 2 196.00$ 392.00$

20600 1 100.00$ 100.00$

20604 1 100.00$ 100.00$

20605 1 100.00$ 100.00$

20606 1 100.00$ 100.00$

20610 1 100.00$ 100.00$

20611 1 100.00$ 100.00$

20615 16 196.00$ 3,136.00$

20650 1 100.00$ 100.00$

20660 16 196.00$ 3,136.00$

10


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

20661 16 196.00$ 3,136.00$

20662 16 196.00$ 3,136.00$

20663 16 196.00$ 3,136.00$

20664 16 196.00$ 3,136.00$

20665 1 100.00$ 100.00$

20670 1 100.00$ 100.00$

20680 5 196.00$ 980.00$

20690 16 196.00$ 3,136.00$

20692 16 196.00$ 3,136.00$

20693 16 196.00$ 3,136.00$

20694 16 196.00$ 3,136.00$

20700 2 196.00$ 392.00$

20701 2 196.00$ 392.00$

20702 3 196.00$ 588.00$ #N/A

20703 2 196.00$ 392.00$

20704 3 196.00$ 588.00$ #N/A

20705 2 196.00$ 392.00$

20827 16 196.00$ 3,136.00$

20900 16 196.00$ 3,136.00$

20902 16 196.00$ 3,136.00$

20912 16 196.00$ 3,136.00$

20920 16 196.00$ 3,136.00$

20922 16 196.00$ 3,136.00$

20924 16 196.00$ 3,136.00$

20931 16 196.00$ 3,136.00$

20937 16 196.00$ 3,136.00$

20938 16 196.00$ 3,136.00$

20955 16 196.00$ 3,136.00$

20956 16 196.00$ 3,136.00$

20957 16 196.00$ 3,136.00$

20962 16 196.00$ 3,136.00$

20969 16 196.00$ 3,136.00$

20970 16 196.00$ 3,136.00$

20972 16 196.00$ 3,136.00$

20973 16 196.00$ 3,136.00$

20975 16 196.00$ 3,136.00$

20982 16 196.00$ 3,136.00$

20983 16 196.00$ 3,136.00$

21010 16 196.00$ 3,136.00$

11


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

21011 16 196.00$ 3,136.00$

21012 16 196.00$ 3,136.00$

21013 16 196.00$ 3,136.00$

21014 16 196.00$ 3,136.00$

21015 16 196.00$ 3,136.00$

21016 16 196.00$ 3,136.00$

21025 16 196.00$ 3,136.00$

21026 16 196.00$ 3,136.00$

21029 16 196.00$ 3,136.00$

21030 16 196.00$ 3,136.00$

21031 16 196.00$ 3,136.00$

21032 16 196.00$ 3,136.00$

21034 16 196.00$ 3,136.00$

21040 16 196.00$ 3,136.00$

21044 16 196.00$ 3,136.00$

21048 3 196.00$ 588.00$ 16

21050 16 196.00$ 3,136.00$

21060 16 196.00$ 3,136.00$

21070 16 196.00$ 3,136.00$

21081 16 196.00$ 3,136.00$

21082 16 196.00$ 3,136.00$

21083 16 196.00$ 3,136.00$

21084 16 196.00$ 3,136.00$

21086 16 196.00$ 3,136.00$

21087 16 196.00$ 3,136.00$

21100 16 196.00$ 3,136.00$

21110 16 196.00$ 3,136.00$

21116 16 196.00$ 3,136.00$

21125 16 196.00$ 3,136.00$

21127 16 196.00$ 3,136.00$

21181 16 196.00$ 3,136.00$

21198 16 196.00$ 3,136.00$

21199 16 196.00$ 3,136.00$

21206 16 196.00$ 3,136.00$

21208 16 196.00$ 3,136.00$

21209 16 196.00$ 3,136.00$

21210 16 196.00$ 3,136.00$

21215 16 196.00$ 3,136.00$

21230 16 196.00$ 3,136.00$

12


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

21235 16 196.00$ 3,136.00$

21240 16 196.00$ 3,136.00$

21242 16 196.00$ 3,136.00$

21243 16 196.00$ 3,136.00$

21244 16 196.00$ 3,136.00$

21245 16 196.00$ 3,136.00$

21246 16 196.00$ 3,136.00$

21248 16 196.00$ 3,136.00$

21249 16 196.00$ 3,136.00$

21255 16 196.00$ 3,136.00$

21256 16 196.00$ 3,136.00$

21267 16 196.00$ 3,136.00$

21270 16 196.00$ 3,136.00$

21275 16 196.00$ 3,136.00$

21280 16 196.00$ 3,136.00$

21282 16 196.00$ 3,136.00$

21300 1 125.00$ 125.00$

21310 1 125.00$ 125.00$

21315 1 125.00$ 125.00$

21320 1 125.00$ 125.00$

21325 16 196.00$ 3,136.00$

21330 16 196.00$ 3,136.00$

21335 16 196.00$ 3,136.00$

21336 16 196.00$ 3,136.00$

21337 16 196.00$ 3,136.00$

21338 16 196.00$ 3,136.00$

21339 16 196.00$ 3,136.00$

21340 16 196.00$ 3,136.00$

21343 16 196.00$ 3,136.00$

21355 16 196.00$ 3,136.00$

21356 16 196.00$ 3,136.00$

21360 16 196.00$ 3,136.00$

21365 16 196.00$ 3,136.00$

21366 16 196.00$ 3,136.00$

21385 16 196.00$ 3,136.00$

21386 16 196.00$ 3,136.00$

21387 16 196.00$ 3,136.00$

21390 16 196.00$ 3,136.00$

21395 16 196.00$ 3,136.00$

13


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

21400 1 125.00$ 125.00$

21401 16 196.00$ 3,136.00$

21406 16 196.00$ 3,136.00$

21407 16 196.00$ 3,136.00$

21408 16 196.00$ 3,136.00$

21421 16 196.00$ 3,136.00$

21422 16 196.00$ 3,136.00$

21440 16 196.00$ 3,136.00$

21445 16 196.00$ 3,136.00$

21450 16 196.00$ 3,136.00$

21451 16 196.00$ 3,136.00$

21452 16 196.00$ 3,136.00$

21453 16 196.00$ 3,136.00$

21454 16 196.00$ 3,136.00$

21461 16 196.00$ 3,136.00$

21462 16 196.00$ 3,136.00$

21465 16 196.00$ 3,136.00$

21470 16 196.00$ 3,136.00$

21480 1 125.00$ 125.00$

21485 16 196.00$ 3,136.00$

21490 16 196.00$ 3,136.00$

21493 16 196.00$ 3,136.00$

21494 16 196.00$ 3,136.00$

21497 16 196.00$ 3,136.00$

21501 16 196.00$ 3,136.00$

21502 16 196.00$ 3,136.00$

21510 16 196.00$ 3,136.00$

21550 16 196.00$ 3,136.00$

21552 16 196.00$ 3,136.00$

21554 16 196.00$ 3,136.00$

21555 16 196.00$ 3,136.00$

21556 16 196.00$ 3,136.00$

21557 16 196.00$ 3,136.00$

21558 16 196.00$ 3,136.00$

21600 16 196.00$ 3,136.00$

21601 16 196.00$ 3,136.00$

21602 16 196.00$ 3,136.00$

21603 16 196.00$ 3,136.00$

21610 16 196.00$ 3,136.00$

14


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

21620 16 196.00$ 3,136.00$

21627 16 196.00$ 3,136.00$

21630 16 196.00$ 3,136.00$

21632 16 196.00$ 3,136.00$

21685 16 196.00$ 3,136.00$

21700 16 196.00$ 3,136.00$

21720 16 196.00$ 3,136.00$

21725 16 196.00$ 3,136.00$

21740 16 196.00$ 3,136.00$

21820 16 196.00$ 3,136.00$

21920 16 196.00$ 3,136.00$

21925 16 196.00$ 3,136.00$

21930 16 196.00$ 3,136.00$

21931 16 196.00$ 3,136.00$

21932 16 196.00$ 3,136.00$

21933 16 196.00$ 3,136.00$

21935 16 196.00$ 3,136.00$

21936 16 196.00$ 3,136.00$

22100 16 196.00$ 3,136.00$

22101 16 196.00$ 3,136.00$

22102 16 196.00$ 3,136.00$

22103 16 196.00$ 3,136.00$

22206 4 196.00$ 784.00$

22207 4 196.00$ 784.00$

22310 1 125.00$ 125.00$

22315 16 196.00$ 3,136.00$

22325 16 196.00$ 3,136.00$

22326 16 196.00$ 3,136.00$

22327 16 196.00$ 3,136.00$

22328 16 196.00$ 3,136.00$

22505 16 196.00$ 3,136.00$

22510 16 196.00$ 3,136.00$

22511 16 196.00$ 3,136.00$

22512 16 196.00$ 3,136.00$

22513 16 196.00$ 3,136.00$

22514 16 196.00$ 3,136.00$

22515 16 196.00$ 3,136.00$

22551 16 196.00$ 3,136.00$

22552 16 196.00$ 3,136.00$

15


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

22554 16 196.00$ 3,136.00$

22556 16 196.00$ 3,136.00$

22558 16 196.00$ 3,136.00$

22633 16 196.00$ 3,136.00$

22800 16 196.00$ 3,136.00$

22849 16 196.00$ 3,136.00$

22852 16 196.00$ 3,136.00$

22854 16 196.00$ 3,136.00$

22855 16 196.00$ 3,136.00$

22900 16 196.00$ 3,136.00$

22901 16 196.00$ 3,136.00$

22902 16 196.00$ 3,136.00$

22903 16 196.00$ 3,136.00$

22904 16 196.00$ 3,136.00$

22905 16 196.00$ 3,136.00$

23000 16 196.00$ 3,136.00$

23020 16 196.00$ 3,136.00$

23030 16 196.00$ 3,136.00$

23035 16 196.00$ 3,136.00$

23040 16 196.00$ 3,136.00$

23044 16 196.00$ 3,136.00$

23065 16 196.00$ 3,136.00$

23066 16 196.00$ 3,136.00$

23071 16 196.00$ 3,136.00$

23073 16 196.00$ 3,136.00$

23075 16 196.00$ 3,136.00$

23076 16 196.00$ 3,136.00$

23077 16 196.00$ 3,136.00$

23078 16 196.00$ 3,136.00$

23100 16 196.00$ 3,136.00$

23101 16 196.00$ 3,136.00$

23105 16 196.00$ 3,136.00$

23106 16 196.00$ 3,136.00$

23107 16 196.00$ 3,136.00$

23120 16 196.00$ 3,136.00$

23125 16 196.00$ 3,136.00$

23130 16 196.00$ 3,136.00$

23140 16 196.00$ 3,136.00$

23145 16 196.00$ 3,136.00$

16


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

23146 16 196.00$ 3,136.00$

23150 16 196.00$ 3,136.00$

23155 16 196.00$ 3,136.00$

23156 16 196.00$ 3,136.00$

23170 16 196.00$ 3,136.00$

23172 16 196.00$ 3,136.00$

23174 16 196.00$ 3,136.00$

23180 16 196.00$ 3,136.00$

23182 16 196.00$ 3,136.00$

23184 16 196.00$ 3,136.00$

23190 16 196.00$ 3,136.00$

23195 16 196.00$ 3,136.00$

23220 16 196.00$ 3,136.00$

23330 16 196.00$ 3,136.00$

23333 16 196.00$ 3,136.00$

23334 16 196.00$ 3,136.00$

23335 16 196.00$ 3,136.00$

23350 1 196.00$ 196.00$

23395 16 196.00$ 3,136.00$

23397 16 196.00$ 3,136.00$

23400 16 196.00$ 3,136.00$

23405 16 196.00$ 3,136.00$

23406 16 196.00$ 3,136.00$

23410 16 196.00$ 3,136.00$

23412 16 196.00$ 3,136.00$

23415 16 196.00$ 3,136.00$

23420 16 196.00$ 3,136.00$

23430 16 196.00$ 3,136.00$

23440 16 196.00$ 3,136.00$

23450 16 196.00$ 3,136.00$

23455 16 196.00$ 3,136.00$

23460 16 196.00$ 3,136.00$

23462 16 196.00$ 3,136.00$

23466 16 196.00$ 3,136.00$

23470 16 196.00$ 3,136.00$

23472 16 196.00$ 3,136.00$

23473 16 196.00$ 3,136.00$

23480 16 196.00$ 3,136.00$

23485 16 196.00$ 3,136.00$

17


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

23490 16 196.00$ 3,136.00$

23491 16 196.00$ 3,136.00$

23500 1 125.00$ 125.00$

23505 1 125.00$ 125.00$

23515 16 196.00$ 3,136.00$

23520 1 125.00$ 125.00$

23525 1 125.00$ 125.00$

23530 16 196.00$ 3,136.00$

23532 16 196.00$ 3,136.00$

23540 1 125.00$ 125.00$

23545 1 125.00$ 125.00$

23550 16 196.00$ 3,136.00$

23552 16 196.00$ 3,136.00$

23570 1 125.00$ 125.00$

23575 1 125.00$ 125.00$

23585 16 196.00$ 3,136.00$

23600 1 125.00$ 125.00$

23605 1 125.00$ 125.00$

23615 16 196.00$ 3,136.00$

23616 16 196.00$ 3,136.00$

23620 1 125.00$ 125.00$

23625 1 125.00$ 125.00$

23630 16 196.00$ 3,136.00$

23650 1 125.00$ 125.00$

23655 16 196.00$ 3,136.00$

23660 16 196.00$ 3,136.00$

23665 1 125.00$ 125.00$

23670 16 196.00$ 3,136.00$

23675 16 196.00$ 3,136.00$

23680 16 196.00$ 3,136.00$

23700 16 196.00$ 3,136.00$

23800 16 196.00$ 3,136.00$

23802 16 196.00$ 3,136.00$

23921 16 196.00$ 3,136.00$

23930 16 196.00$ 3,136.00$

23931 16 196.00$ 3,136.00$

23935 16 196.00$ 3,136.00$

24000 16 196.00$ 3,136.00$

24006 16 196.00$ 3,136.00$

18


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

24065 1 100.00$ 100.00$

24066 16 196.00$ 3,136.00$

24071 16 196.00$ 3,136.00$

24073 16 196.00$ 3,136.00$

24075 1 100.00$ 100.00$

24076 16 196.00$ 3,136.00$

24077 16 196.00$ 3,136.00$

24079 16 196.00$ 3,136.00$

24100 16 196.00$ 3,136.00$

24101 16 196.00$ 3,136.00$

24102 16 196.00$ 3,136.00$

24105 16 196.00$ 3,136.00$

24110 16 196.00$ 3,136.00$

24115 16 196.00$ 3,136.00$

24116 16 196.00$ 3,136.00$

24120 16 196.00$ 3,136.00$

24125 16 196.00$ 3,136.00$

24126 16 196.00$ 3,136.00$

24130 16 196.00$ 3,136.00$

24134 16 196.00$ 3,136.00$

24136 16 196.00$ 3,136.00$

24138 16 196.00$ 3,136.00$

24140 16 196.00$ 3,136.00$

24145 16 196.00$ 3,136.00$

24147 16 196.00$ 3,136.00$

24149 16 196.00$ 3,136.00$

24150 16 196.00$ 3,136.00$

24152 16 196.00$ 3,136.00$

24155 16 196.00$ 3,136.00$

24160 16 196.00$ 3,136.00$

24164 16 196.00$ 3,136.00$

24200 16 196.00$ 3,136.00$

24201 16 196.00$ 3,136.00$

24300 16 196.00$ 3,136.00$

24301 16 196.00$ 3,136.00$

24305 16 196.00$ 3,136.00$

24310 16 196.00$ 3,136.00$

24320 16 196.00$ 3,136.00$

24330 16 196.00$ 3,136.00$

19


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

24331 16 196.00$ 3,136.00$

24332 16 196.00$ 3,136.00$

24340 16 196.00$ 3,136.00$

24341 16 196.00$ 3,136.00$

24342 16 196.00$ 3,136.00$

24343 16 196.00$ 3,136.00$

24344 16 196.00$ 3,136.00$

24345 16 196.00$ 3,136.00$

24346 16 196.00$ 3,136.00$

24350 16 196.00$ 3,136.00$

24351 16 196.00$ 3,136.00$

24352 16 196.00$ 3,136.00$

24354 16 196.00$ 3,136.00$

24356 16 196.00$ 3,136.00$

24358 3 196.00$ 588.00$ 13

24359 3 196.00$ 588.00$ 14

24360 16 196.00$ 3,136.00$

24361 16 196.00$ 3,136.00$

24362 16 196.00$ 3,136.00$

24363 16 196.00$ 3,136.00$

24365 16 196.00$ 3,136.00$

24366 16 196.00$ 3,136.00$

24400 16 196.00$ 3,136.00$

24410 16 196.00$ 3,136.00$

24420 16 196.00$ 3,136.00$

24430 16 196.00$ 3,136.00$

24435 16 196.00$ 3,136.00$

24470 16 196.00$ 3,136.00$

24495 16 196.00$ 3,136.00$

24498 16 196.00$ 3,136.00$

24500 1 125.00$ 125.00$

24505 1 125.00$ 125.00$

24515 16 196.00$ 3,136.00$

24516 16 196.00$ 3,136.00$

24530 1 125.00$ 125.00$

24535 1 125.00$ 125.00$

24538 16 196.00$ 3,136.00$

24545 16 196.00$ 3,136.00$

24546 16 196.00$ 3,136.00$

20


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

24560 1 125.00$ 125.00$

24565 1 125.00$ 125.00$

24566 16 196.00$ 3,136.00$

24575 16 196.00$ 3,136.00$

24576 1 125.00$ 125.00$

24577 1 125.00$ 125.00$

24579 16 196.00$ 3,136.00$

24582 16 196.00$ 3,136.00$

24586 16 196.00$ 3,136.00$

24587 16 196.00$ 3,136.00$

24600 1 125.00$ 125.00$

24605 16 196.00$ 3,136.00$

24615 16 196.00$ 3,136.00$

24620 1 125.00$ 125.00$

24635 16 196.00$ 3,136.00$

24640 1 125.00$ 125.00$

24650 1 196.00$ 196.00$

24655 1 125.00$ 125.00$

24665 16 196.00$ 3,136.00$

24666 16 196.00$ 3,136.00$

24670 1 125.00$ 125.00$

24675 1 125.00$ 125.00$

24685 16 196.00$ 3,136.00$

24800 16 196.00$ 3,136.00$

24802 16 196.00$ 3,136.00$

24925 16 196.00$ 3,136.00$

25000 16 196.00$ 3,136.00$

25001 16 196.00$ 3,136.00$

25020 16 196.00$ 3,136.00$

25023 16 196.00$ 3,136.00$

25024 16 196.00$ 3,136.00$

25025 16 196.00$ 3,136.00$

25028 16 196.00$ 3,136.00$

25031 16 196.00$ 3,136.00$

25035 16 196.00$ 3,136.00$

25040 16 196.00$ 3,136.00$

25065 1 100.00$ 100.00$

25066 16 196.00$ 3,136.00$

25071 16 196.00$ 3,136.00$

21


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

25073 16 196.00$ 3,136.00$

25075 1 100.00$ 100.00$

25076 16 196.00$ 3,136.00$

25077 16 196.00$ 3,136.00$

25078 16 196.00$ 3,136.00$

25085 16 196.00$ 3,136.00$

25100 16 196.00$ 3,136.00$

25101 16 196.00$ 3,136.00$

25105 16 196.00$ 3,136.00$

25107 16 196.00$ 3,136.00$

25109 16 196.00$ 3,136.00$

25110 16 196.00$ 3,136.00$

25111 16 196.00$ 3,136.00$

25112 16 196.00$ 3,136.00$

25115 16 196.00$ 3,136.00$

25116 16 196.00$ 3,136.00$

25118 16 196.00$ 3,136.00$

25119 16 196.00$ 3,136.00$

25120 16 196.00$ 3,136.00$

25125 16 196.00$ 3,136.00$

25126 16 196.00$ 3,136.00$

25130 16 196.00$ 3,136.00$

25135 16 196.00$ 3,136.00$

25136 16 196.00$ 3,136.00$

25145 16 196.00$ 3,136.00$

25150 16 196.00$ 3,136.00$

25151 16 196.00$ 3,136.00$

25170 16 196.00$ 3,136.00$

25210 16 196.00$ 3,136.00$

25215 16 196.00$ 3,136.00$

25230 16 196.00$ 3,136.00$

25240 16 196.00$ 3,136.00$

25248 16 196.00$ 3,136.00$

25250 16 196.00$ 3,136.00$

25251 16 196.00$ 3,136.00$

25259 16 196.00$ 3,136.00$

25260 16 196.00$ 3,136.00$

25263 16 196.00$ 3,136.00$

25265 16 196.00$ 3,136.00$

22


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

25270 16 196.00$ 3,136.00$

25272 16 196.00$ 3,136.00$

25274 16 196.00$ 3,136.00$

25275 16 196.00$ 3,136.00$

25280 16 196.00$ 3,136.00$

25290 16 196.00$ 3,136.00$

25295 16 196.00$ 3,136.00$

25300 16 196.00$ 3,136.00$

25301 16 196.00$ 3,136.00$

25310 16 196.00$ 3,136.00$

25312 16 196.00$ 3,136.00$

25315 16 196.00$ 3,136.00$

25316 16 196.00$ 3,136.00$

25320 16 196.00$ 3,136.00$

25332 16 196.00$ 3,136.00$

25335 16 196.00$ 3,136.00$

25337 16 196.00$ 3,136.00$

25350 16 196.00$ 3,136.00$

25355 16 196.00$ 3,136.00$

25360 16 196.00$ 3,136.00$

25365 16 196.00$ 3,136.00$

25370 16 196.00$ 3,136.00$

25375 16 196.00$ 3,136.00$

25390 16 196.00$ 3,136.00$

25391 16 196.00$ 3,136.00$

25392 16 196.00$ 3,136.00$

25393 16 196.00$ 3,136.00$

25394 16 196.00$ 3,136.00$

25400 16 196.00$ 3,136.00$

25405 16 196.00$ 3,136.00$

25415 16 196.00$ 3,136.00$

25420 16 196.00$ 3,136.00$

25425 16 196.00$ 3,136.00$

25426 16 196.00$ 3,136.00$

25430 16 196.00$ 3,136.00$

25431 16 196.00$ 3,136.00$

25440 16 196.00$ 3,136.00$

25441 16 196.00$ 3,136.00$

25442 16 196.00$ 3,136.00$

23


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

25443 16 196.00$ 3,136.00$

25444 16 196.00$ 3,136.00$

25445 16 196.00$ 3,136.00$

25446 16 196.00$ 3,136.00$

25447 16 196.00$ 3,136.00$

25449 16 196.00$ 3,136.00$

25450 16 196.00$ 3,136.00$

25455 16 196.00$ 3,136.00$

25490 16 196.00$ 3,136.00$

25491 16 196.00$ 3,136.00$

25492 16 196.00$ 3,136.00$

25500 1 125.00$ 125.00$

25505 1 125.00$ 125.00$

25515 16 196.00$ 3,136.00$

25520 1 125.00$ 125.00$

25525 16 196.00$ 3,136.00$

25526 16 196.00$ 3,136.00$

25530 1 125.00$ 125.00$

25535 1 125.00$ 125.00$

25545 16 196.00$ 3,136.00$

25560 1 125.00$ 125.00$

25565 1 125.00$ 125.00$

25574 16 196.00$ 3,136.00$

25575 16 196.00$ 3,136.00$

25600 1 125.00$ 125.00$

25605 16 196.00$ 3,136.00$

25606 10 196.00$ 1,960.00$

25607 16 196.00$ 3,136.00$

25608 16 196.00$ 3,136.00$

25609 16 196.00$ 3,136.00$

25611 16 196.00$ 3,136.00$

25620 16 196.00$ 3,136.00$

25622 1 125.00$ 125.00$

25624 1 125.00$ 125.00$

25628 16 196.00$ 3,136.00$

25630 1 125.00$ 125.00$

25635 1 125.00$ 125.00$

25645 16 196.00$ 3,136.00$

25650 1 125.00$ 125.00$

24


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

25651 16 196.00$ 3,136.00$

25652 16 196.00$ 3,136.00$

25660 1 125.00$ 125.00$

25670 16 196.00$ 3,136.00$

25671 16 196.00$ 3,136.00$

25675 1 125.00$ 125.00$

25676 16 196.00$ 3,136.00$

25680 1 125.00$ 125.00$

25685 16 196.00$ 3,136.00$

25690 1 125.00$ 125.00$

25695 16 196.00$ 3,136.00$

25800 16 196.00$ 3,136.00$

25805 16 196.00$ 3,136.00$

25810 16 196.00$ 3,136.00$

25820 16 196.00$ 3,136.00$

25825 16 196.00$ 3,136.00$

25830 16 196.00$ 3,136.00$

25900 16 196.00$ 3,136.00$

25907 16 196.00$ 3,136.00$

25922 16 196.00$ 3,136.00$

25929 16 196.00$ 3,136.00$

25931 16 196.00$ 3,136.00$

26010 1 100.00$ 100.00$

26011 1 100.00$ 100.00$

26020 16 196.00$ 3,136.00$

26025 16 196.00$ 3,136.00$

26030 16 196.00$ 3,136.00$

26034 16 196.00$ 3,136.00$

26035 16 196.00$ 3,136.00$

26037 16 196.00$ 3,136.00$

26040 16 196.00$ 3,136.00$

26045 16 196.00$ 3,136.00$

26055 16 196.00$ 3,136.00$

26060 16 196.00$ 3,136.00$

26070 16 196.00$ 3,136.00$

26075 16 196.00$ 3,136.00$

26080 16 196.00$ 3,136.00$

26100 16 196.00$ 3,136.00$

26105 16 196.00$ 3,136.00$

25


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

26110 16 196.00$ 3,136.00$

26111 16 196.00$ 3,136.00$

26113 16 196.00$ 3,136.00$

26115 16 196.00$ 3,136.00$

26116 16 196.00$ 3,136.00$

26117 16 196.00$ 3,136.00$

26118 16 196.00$ 3,136.00$

26121 16 196.00$ 3,136.00$

26123 16 196.00$ 3,136.00$

26125 16 196.00$ 3,136.00$

26130 16 196.00$ 3,136.00$

26135 16 196.00$ 3,136.00$

26140 16 196.00$ 3,136.00$

26145 16 196.00$ 3,136.00$

26160 16 196.00$ 3,136.00$

26170 16 196.00$ 3,136.00$

26180 16 196.00$ 3,136.00$

26185 16 196.00$ 3,136.00$

26200 16 196.00$ 3,136.00$

26205 16 196.00$ 3,136.00$

26210 16 196.00$ 3,136.00$

26215 16 196.00$ 3,136.00$

26230 16 196.00$ 3,136.00$

26235 16 196.00$ 3,136.00$

26236 16 196.00$ 3,136.00$

26250 16 196.00$ 3,136.00$

26260 16 196.00$ 3,136.00$

26262 16 196.00$ 3,136.00$

26320 16 196.00$ 3,136.00$

26340 16 196.00$ 3,136.00$

26350 16 196.00$ 3,136.00$

26352 16 196.00$ 3,136.00$

26356 16 196.00$ 3,136.00$

26357 16 196.00$ 3,136.00$

26358 16 196.00$ 3,136.00$

26370 16 196.00$ 3,136.00$

26372 16 196.00$ 3,136.00$

26373 16 196.00$ 3,136.00$

26390 16 196.00$ 3,136.00$

26


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

26392 16 196.00$ 3,136.00$

26410 16 196.00$ 3,136.00$

26412 16 196.00$ 3,136.00$

26415 16 196.00$ 3,136.00$

26416 16 196.00$ 3,136.00$

26418 16 196.00$ 3,136.00$

26420 16 196.00$ 3,136.00$

26426 16 196.00$ 3,136.00$

26428 16 196.00$ 3,136.00$

26432 16 196.00$ 3,136.00$

26433 16 196.00$ 3,136.00$

26434 16 196.00$ 3,136.00$

26437 16 196.00$ 3,136.00$

26440 16 196.00$ 3,136.00$

26442 16 196.00$ 3,136.00$

26445 16 196.00$ 3,136.00$

26449 16 196.00$ 3,136.00$

26450 16 196.00$ 3,136.00$

26455 16 196.00$ 3,136.00$

26460 16 196.00$ 3,136.00$

26471 16 196.00$ 3,136.00$

26474 16 196.00$ 3,136.00$

26476 16 196.00$ 3,136.00$

26477 16 196.00$ 3,136.00$

26478 16 196.00$ 3,136.00$

26479 16 196.00$ 3,136.00$

26480 16 196.00$ 3,136.00$

26483 16 196.00$ 3,136.00$

26485 16 196.00$ 3,136.00$

26489 16 196.00$ 3,136.00$

26490 16 196.00$ 3,136.00$

26492 16 196.00$ 3,136.00$

26494 16 196.00$ 3,136.00$

26496 16 196.00$ 3,136.00$

26497 16 196.00$ 3,136.00$

26498 16 196.00$ 3,136.00$

26499 16 196.00$ 3,136.00$

26500 16 196.00$ 3,136.00$

26502 16 196.00$ 3,136.00$

27


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

26504 16 196.00$ 3,136.00$

26508 16 196.00$ 3,136.00$

26510 16 196.00$ 3,136.00$

26516 16 196.00$ 3,136.00$

26517 16 196.00$ 3,136.00$

26518 16 196.00$ 3,136.00$

26520 16 196.00$ 3,136.00$

26525 16 196.00$ 3,136.00$

26530 16 196.00$ 3,136.00$

26531 16 196.00$ 3,136.00$

26535 16 196.00$ 3,136.00$

26536 16 196.00$ 3,136.00$

26540 16 196.00$ 3,136.00$

26541 16 196.00$ 3,136.00$

26542 16 196.00$ 3,136.00$

26545 16 196.00$ 3,136.00$

26546 16 196.00$ 3,136.00$

26548 16 196.00$ 3,136.00$

26550 16 196.00$ 3,136.00$

26551 16 196.00$ 3,136.00$

26553 16 196.00$ 3,136.00$

26554 16 196.00$ 3,136.00$

26555 16 196.00$ 3,136.00$

26556 16 196.00$ 3,136.00$

26560 16 196.00$ 3,136.00$

26561 16 196.00$ 3,136.00$

26562 16 196.00$ 3,136.00$

26565 16 196.00$ 3,136.00$

26567 16 196.00$ 3,136.00$

26568 16 196.00$ 3,136.00$

26580 16 196.00$ 3,136.00$

26587 16 196.00$ 3,136.00$

26590 16 196.00$ 3,136.00$

26591 16 196.00$ 3,136.00$

26593 16 196.00$ 3,136.00$

26596 16 196.00$ 3,136.00$

26600 1 125.00$ 125.00$

26605 1 125.00$ 125.00$

26607 1 125.00$ 125.00$

28


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

26608 16 196.00$ 3,136.00$

26615 16 196.00$ 3,136.00$

26641 1 125.00$ 125.00$

26645 1 125.00$ 125.00$

26650 16 196.00$ 3,136.00$

26665 16 196.00$ 3,136.00$

26670 1 125.00$ 125.00$

26675 16 196.00$ 3,136.00$

26676 16 196.00$ 3,136.00$

26685 16 196.00$ 3,136.00$

26686 16 196.00$ 3,136.00$

26700 1 125.00$ 125.00$

26705 16 196.00$ 3,136.00$

26706 16 196.00$ 3,136.00$

26715 16 196.00$ 3,136.00$

26720 1 125.00$ 125.00$

26725 1 125.00$ 125.00$

26727 16 196.00$ 3,136.00$

26735 16 196.00$ 3,136.00$

26740 1 125.00$ 125.00$

26742 16 196.00$ 3,136.00$

26746 16 196.00$ 3,136.00$

26750 1 125.00$ 125.00$

26755 1 125.00$ 125.00$

26756 16 196.00$ 3,136.00$

26765 16 196.00$ 3,136.00$

26770 1 125.00$ 125.00$

26775 16 196.00$ 3,136.00$

26776 16 196.00$ 3,136.00$

26785 16 196.00$ 3,136.00$

26820 16 196.00$ 3,136.00$

26841 16 196.00$ 3,136.00$

26842 16 196.00$ 3,136.00$

26843 16 196.00$ 3,136.00$

26844 16 196.00$ 3,136.00$

26850 16 196.00$ 3,136.00$

26852 16 196.00$ 3,136.00$

26860 16 196.00$ 3,136.00$

26861 16 196.00$ 3,136.00$

29


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

26862 16 196.00$ 3,136.00$

26863 16 196.00$ 3,136.00$

26910 16 196.00$ 3,136.00$

26951 16 196.00$ 3,136.00$

26952 16 196.00$ 3,136.00$

26990 16 196.00$ 3,136.00$

26991 16 196.00$ 3,136.00$

26992 16 196.00$ 3,136.00$

27000 16 196.00$ 3,136.00$

27001 16 196.00$ 3,136.00$

27003 16 196.00$ 3,136.00$

27005 16 196.00$ 3,136.00$

27006 16 196.00$ 3,136.00$

27025 16 196.00$ 3,136.00$

27030 16 196.00$ 3,136.00$

27033 16 196.00$ 3,136.00$

27035 16 196.00$ 3,136.00$

27036 16 196.00$ 3,136.00$

27040 16 196.00$ 3,136.00$

27041 16 196.00$ 3,136.00$

27043 16 196.00$ 3,136.00$

27045 16 196.00$ 3,136.00$

27047 16 196.00$ 3,136.00$

27048 16 196.00$ 3,136.00$

27049 16 196.00$ 3,136.00$

27050 16 196.00$ 3,136.00$

27052 16 196.00$ 3,136.00$

27059 16 196.00$ 3,136.00$

27060 16 196.00$ 3,136.00$

27062 16 196.00$ 3,136.00$

27065 16 196.00$ 3,136.00$

27066 16 196.00$ 3,136.00$

27070 16 196.00$ 3,136.00$

27071 16 196.00$ 3,136.00$

27080 16 196.00$ 3,136.00$

27086 16 196.00$ 3,136.00$

27087 16 196.00$ 3,136.00$

27090 16 196.00$ 3,136.00$

27095 16 196.00$ 3,136.00$

30


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

27096 16 196.00$ 3,136.00$

27097 16 196.00$ 3,136.00$

27098 16 196.00$ 3,136.00$

27100 16 196.00$ 3,136.00$

27105 16 196.00$ 3,136.00$

27110 16 196.00$ 3,136.00$

27111 16 196.00$ 3,136.00$

27161 16 196.00$ 3,136.00$

27165 16 196.00$ 3,136.00$

27176 16 196.00$ 3,136.00$

27178 16 196.00$ 3,136.00$

27197 16 196.00$ 3,136.00$

27198 16 196.00$ 3,136.00$

27200 1 125.00$ 125.00$

27202 16 196.00$ 3,136.00$

27220 1 125.00$ 125.00$

27226 16 196.00$ 3,136.00$

27227 16 196.00$ 3,136.00$

27228 16 196.00$ 3,136.00$

27230 1 125.00$ 125.00$

27232 16 196.00$ 3,136.00$

27235 16 196.00$ 3,136.00$

27236 16 196.00$ 3,136.00$

27238 1 125.00$ 125.00$

27246 1 125.00$ 125.00$

27250 1 125.00$ 125.00$

27252 16 196.00$ 3,136.00$

27256 1 125.00$ 125.00$

27257 16 196.00$ 3,136.00$

27258 16 196.00$ 3,136.00$

27259 16 196.00$ 3,136.00$

27265 1 125.00$ 125.00$

27266 16 196.00$ 3,136.00$

27267 2 196.00$ 392.00$

27268 2 196.00$ 392.00$

27269 2 196.00$ 392.00$

27275 16 196.00$ 3,136.00$

27279 16 196.00$ 3,136.00$

27301 16 196.00$ 3,136.00$

31


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

27303 16 196.00$ 3,136.00$

27305 16 196.00$ 3,136.00$

27306 16 196.00$ 3,136.00$

27307 16 196.00$ 3,136.00$

27310 16 196.00$ 3,136.00$

27315 16 196.00$ 3,136.00$

27320 16 196.00$ 3,136.00$

27323 16 196.00$ 3,136.00$

27324 16 196.00$ 3,136.00$

27325 5 196.00$ 980.00$

27326 5 196.00$ 980.00$

27327 16 196.00$ 3,136.00$

27328 16 196.00$ 3,136.00$

27330 16 196.00$ 3,136.00$

27331 16 196.00$ 3,136.00$

27332 16 196.00$ 3,136.00$

27333 16 196.00$ 3,136.00$

27334 16 196.00$ 3,136.00$

27335 16 196.00$ 3,136.00$

27337 16 196.00$ 3,136.00$

27339 16 196.00$ 3,136.00$

27340 16 196.00$ 3,136.00$

27345 16 196.00$ 3,136.00$

27347 16 196.00$ 3,136.00$

27350 16 196.00$ 3,136.00$

27355 16 196.00$ 3,136.00$

27356 16 196.00$ 3,136.00$

27357 16 196.00$ 3,136.00$

27360 16 196.00$ 3,136.00$

27364 16 196.00$ 3,136.00$

27365 16 196.00$ 3,136.00$

27372 16 196.00$ 3,136.00$

27380 16 196.00$ 3,136.00$

27381 16 196.00$ 3,136.00$

27385 16 196.00$ 3,136.00$

27386 16 196.00$ 3,136.00$

27390 16 196.00$ 3,136.00$

27391 16 196.00$ 3,136.00$

27392 16 196.00$ 3,136.00$

32


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

27393 16 196.00$ 3,136.00$

27394 16 196.00$ 3,136.00$

27395 16 196.00$ 3,136.00$

27396 16 196.00$ 3,136.00$

27397 16 196.00$ 3,136.00$

27400 16 196.00$ 3,136.00$

27403 16 196.00$ 3,136.00$

27405 16 196.00$ 3,136.00$

27407 16 196.00$ 3,136.00$

27409 16 196.00$ 3,136.00$

27416 4 196.00$ 784.00$

27418 16 196.00$ 3,136.00$

27420 16 196.00$ 3,136.00$

27422 16 196.00$ 3,136.00$

27424 16 196.00$ 3,136.00$

27425 16 196.00$ 3,136.00$

27427 16 196.00$ 3,136.00$

27428 16 196.00$ 3,136.00$

27429 16 196.00$ 3,136.00$

27430 16 196.00$ 3,136.00$

27435 16 196.00$ 3,136.00$

27437 16 196.00$ 3,136.00$

27438 16 196.00$ 3,136.00$

27440 16 196.00$ 3,136.00$

27441 16 196.00$ 3,136.00$

27442 16 196.00$ 3,136.00$

27443 16 196.00$ 3,136.00$

27445 16 196.00$ 3,136.00$

27446 16 196.00$ 3,136.00$

27447 16 196.00$ 3,136.00$

27455 16 196.00$ 3,136.00$

27470 16 196.00$ 3,136.00$

27472 16 196.00$ 3,136.00$

27475 16 196.00$ 3,136.00$

27477 16 196.00$ 3,136.00$

27479 16 196.00$ 3,136.00$

27485 16 196.00$ 3,136.00$

27486 16 196.00$ 3,136.00$

27487 16 196.00$ 3,136.00$

33


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

27488 16 196.00$ 3,136.00$

27489 16 196.00$ 3,136.00$

27500 1 125.00$ 125.00$

27501 1 125.00$ 125.00$

27502 1 125.00$ 125.00$

27503 16 196.00$ 3,136.00$

27507 16 196.00$ 3,136.00$

27508 1 125.00$ 125.00$

27509 16 196.00$ 3,136.00$

27510 1 125.00$ 125.00$

27511 16 196.00$ 3,136.00$

27513 16 196.00$ 3,136.00$

27514 16 196.00$ 3,136.00$

27516 1 125.00$ 125.00$

27517 1 125.00$ 125.00$

27520 1 125.00$ 125.00$

27524 16 196.00$ 3,136.00$

27530 1 125.00$ 125.00$

27532 1 125.00$ 125.00$

27535 16 196.00$ 3,136.00$

27536 16 196.00$ 3,136.00$

27538 1 125.00$ 125.00$

27550 1 125.00$ 125.00$

27552 16 196.00$ 3,136.00$

27556 16 196.00$ 3,136.00$

27560 1 125.00$ 125.00$

27562 16 196.00$ 3,136.00$

27566 16 196.00$ 3,136.00$

27570 16 196.00$ 3,136.00$

27580 16 196.00$ 3,136.00$

27596 16 196.00$ 3,136.00$

27600 16 196.00$ 3,136.00$

27603 16 196.00$ 3,136.00$

27604 16 196.00$ 3,136.00$

27605 16 196.00$ 3,136.00$

27606 16 196.00$ 3,136.00$

27607 16 196.00$ 3,136.00$

27610 16 196.00$ 3,136.00$

27612 16 196.00$ 3,136.00$

34


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

27613 1 100.00$ 100.00$

27614 16 196.00$ 3,136.00$

27615 16 196.00$ 3,136.00$

27616 16 196.00$ 3,136.00$

27618 1 100.00$ 100.00$

27619 16 196.00$ 3,136.00$

27620 16 196.00$ 3,136.00$

27625 16 196.00$ 3,136.00$

27626 16 196.00$ 3,136.00$

27630 16 196.00$ 3,136.00$

27632 16 196.00$ 3,136.00$

27634 16 196.00$ 3,136.00$

27635 16 196.00$ 3,136.00$

27637 16 196.00$ 3,136.00$

27638 16 196.00$ 3,136.00$

27640 16 196.00$ 3,136.00$

27641 16 196.00$ 3,136.00$

27645 16 196.00$ 3,136.00$

27647 16 196.00$ 3,136.00$

27650 16 196.00$ 3,136.00$

27652 16 196.00$ 3,136.00$

27654 16 196.00$ 3,136.00$

27656 16 196.00$ 3,136.00$

27658 16 196.00$ 3,136.00$

27659 16 196.00$ 3,136.00$

27664 16 196.00$ 3,136.00$

27665 16 196.00$ 3,136.00$

27675 16 196.00$ 3,136.00$

27676 16 196.00$ 3,136.00$

27680 16 196.00$ 3,136.00$

27681 16 196.00$ 3,136.00$

27685 16 196.00$ 3,136.00$

27686 16 196.00$ 3,136.00$

27687 16 196.00$ 3,136.00$

27690 16 196.00$ 3,136.00$

27691 16 196.00$ 3,136.00$

27692 16 196.00$ 3,136.00$

27695 16 196.00$ 3,136.00$

27696 16 196.00$ 3,136.00$

35


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

27698 16 196.00$ 3,136.00$

27700 16 196.00$ 3,136.00$

27704 16 196.00$ 3,136.00$

27705 16 196.00$ 3,136.00$

27707 16 196.00$ 3,136.00$

27709 16 196.00$ 3,136.00$

27715 16 196.00$ 3,136.00$

27720 16 196.00$ 3,136.00$

27722 16 196.00$ 3,136.00$

27724 16 196.00$ 3,136.00$

27725 16 196.00$ 3,136.00$

27726 4 196.00$ 784.00$

27727 16 196.00$ 3,136.00$

27730 16 196.00$ 3,136.00$

27732 16 196.00$ 3,136.00$

27734 16 196.00$ 3,136.00$

27740 16 196.00$ 3,136.00$

27742 16 196.00$ 3,136.00$

27745 16 196.00$ 3,136.00$

27750 1 125.00$ 125.00$

27752 1 125.00$ 125.00$

27756 16 196.00$ 3,136.00$

27758 16 196.00$ 3,136.00$

27759 16 196.00$ 3,136.00$

27760 1 125.00$ 125.00$

27762 1 125.00$ 125.00$

27766 16 196.00$ 3,136.00$

27767 2 196.00$ 392.00$

27768 2 196.00$ 392.00$

27769 2 196.00$ 392.00$

27780 1 125.00$ 125.00$

27781 1 125.00$ 125.00$

27784 16 196.00$ 3,136.00$

27786 1 125.00$ 125.00$

27788 16 196.00$ 3,136.00$

27792 16 196.00$ 3,136.00$

27808 1 125.00$ 125.00$

27810 1 125.00$ 125.00$

27814 16 196.00$ 3,136.00$

36


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

27816 1 125.00$ 125.00$

27818 1 125.00$ 125.00$

27822 16 196.00$ 3,136.00$

27823 16 196.00$ 3,136.00$

27824 16 196.00$ 3,136.00$

27825 16 196.00$ 3,136.00$

27826 16 196.00$ 3,136.00$

27827 16 196.00$ 3,136.00$

27828 16 196.00$ 3,136.00$

27829 16 196.00$ 3,136.00$

27830 1 125.00$ 125.00$

27831 16 196.00$ 3,136.00$

27832 16 196.00$ 3,136.00$

27840 1 125.00$ 125.00$

27842 16 196.00$ 3,136.00$

27846 16 196.00$ 3,136.00$

27848 16 196.00$ 3,136.00$

27860 16 196.00$ 3,136.00$

27870 16 196.00$ 3,136.00$

27871 16 196.00$ 3,136.00$

27884 16 196.00$ 3,136.00$

27886 16 196.00$ 3,136.00$

27892 16 196.00$ 3,136.00$

27893 16 196.00$ 3,136.00$

27894 16 196.00$ 3,136.00$

28001 1 100.00$ 100.00$

28002 16 196.00$ 3,136.00$

28003 16 196.00$ 3,136.00$

28005 16 196.00$ 3,136.00$

28008 16 196.00$ 3,136.00$

28010 1 196.00$ 196.00$

28011 2 196.00$ 392.00$

28020 16 196.00$ 3,136.00$

28022 16 196.00$ 3,136.00$

28030 16 196.00$ 3,136.00$

28035 16 196.00$ 3,136.00$

28039 16 196.00$ 3,136.00$

28041 16 196.00$ 3,136.00$

28043 1 125.00$ 125.00$

37


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

28045 16 196.00$ 3,136.00$

28046 16 196.00$ 3,136.00$

28047 16 196.00$ 3,136.00$

28050 16 196.00$ 3,136.00$

28054 16 196.00$ 3,136.00$

28055 5 196.00$ 980.00$

28060 16 196.00$ 3,136.00$

28062 16 196.00$ 3,136.00$

28070 16 196.00$ 3,136.00$

28072 16 196.00$ 3,136.00$

28080 16 196.00$ 3,136.00$

28086 16 196.00$ 3,136.00$

28088 16 196.00$ 3,136.00$

28090 16 196.00$ 3,136.00$

28092 16 196.00$ 3,136.00$

28100 16 196.00$ 3,136.00$

28102 16 196.00$ 3,136.00$

28103 16 196.00$ 3,136.00$

28104 16 196.00$ 3,136.00$

28106 16 196.00$ 3,136.00$

28107 16 196.00$ 3,136.00$

28108 16 196.00$ 3,136.00$

28110 16 196.00$ 3,136.00$

28111 16 196.00$ 3,136.00$

28112 16 196.00$ 3,136.00$

28113 16 196.00$ 3,136.00$

28114 16 196.00$ 3,136.00$

28116 16 196.00$ 3,136.00$

28118 16 196.00$ 3,136.00$

28119 16 196.00$ 3,136.00$

28120 16 196.00$ 3,136.00$

28122 16 196.00$ 3,136.00$

28124 16 196.00$ 3,136.00$

28126 16 196.00$ 3,136.00$

28130 16 196.00$ 3,136.00$

28140 16 196.00$ 3,136.00$

28150 16 196.00$ 3,136.00$

28153 16 196.00$ 3,136.00$

28160 16 196.00$ 3,136.00$

38


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

28171 16 196.00$ 3,136.00$

28173 16 196.00$ 3,136.00$

28175 16 196.00$ 3,136.00$

28190 1 125.00$ 125.00$

28192 16 196.00$ 3,136.00$

28193 16 196.00$ 3,136.00$

28200 16 196.00$ 3,136.00$

28202 16 196.00$ 3,136.00$

28208 16 196.00$ 3,136.00$

28210 16 196.00$ 3,136.00$

28220 16 196.00$ 3,136.00$

28222 16 196.00$ 3,136.00$

28225 16 196.00$ 3,136.00$

28226 16 196.00$ 3,136.00$

28230 16 196.00$ 3,136.00$

28232 16 196.00$ 3,136.00$

28234 16 196.00$ 3,136.00$

28238 16 196.00$ 3,136.00$

28240 16 196.00$ 3,136.00$

28250 16 196.00$ 3,136.00$

28260 16 196.00$ 3,136.00$

28261 16 196.00$ 3,136.00$

28262 16 196.00$ 3,136.00$

28264 16 196.00$ 3,136.00$

28270 16 196.00$ 3,136.00$

28272 16 196.00$ 3,136.00$

28280 16 196.00$ 3,136.00$

28285 16 196.00$ 3,136.00$

28286 16 196.00$ 3,136.00$

28288 16 196.00$ 3,136.00$

28289 16 196.00$ 3,136.00$

28291 16 196.00$ 3,136.00$

28292 16 196.00$ 3,136.00$

28295 16 196.00$ 3,136.00$

28296 16 196.00$ 3,136.00$

28297 16 196.00$ 3,136.00$

28298 16 196.00$ 3,136.00$

28299 16 196.00$ 3,136.00$

28300 16 196.00$ 3,136.00$

39


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

28302 16 196.00$ 3,136.00$

28304 16 196.00$ 3,136.00$

28305 16 196.00$ 3,136.00$

28306 16 196.00$ 3,136.00$

28307 16 196.00$ 3,136.00$

28308 16 196.00$ 3,136.00$

28309 16 196.00$ 3,136.00$

28310 16 196.00$ 3,136.00$

28312 16 196.00$ 3,136.00$

28313 16 196.00$ 3,136.00$

28315 16 196.00$ 3,136.00$

28320 16 196.00$ 3,136.00$

28322 16 196.00$ 3,136.00$

28340 16 196.00$ 3,136.00$

28341 16 196.00$ 3,136.00$

28344 16 196.00$ 3,136.00$

28345 16 196.00$ 3,136.00$

28360 3 196.00$ 588.00$ 16

28400 1 125.00$ 125.00$

28405 1 125.00$ 125.00$

28406 1 125.00$ 125.00$

28415 16 196.00$ 3,136.00$

28420 16 196.00$ 3,136.00$

28430 1 125.00$ 125.00$

28435 1 125.00$ 125.00$

28436 1 125.00$ 125.00$

28445 16 196.00$ 3,136.00$

28446 2 196.00$ 392.00$

28450 1 125.00$ 125.00$

28455 1 125.00$ 125.00$

28456 1 125.00$ 125.00$

28465 16 196.00$ 3,136.00$

28470 1 125.00$ 125.00$

28475 1 125.00$ 125.00$

28476 1 125.00$ 125.00$

28485 16 196.00$ 3,136.00$

28490 1 125.00$ 125.00$

28495 1 125.00$ 125.00$

28496 1 125.00$ 125.00$

40


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

28505 16 196.00$ 3,136.00$

28510 1 125.00$ 125.00$

28515 1 125.00$ 125.00$

28525 16 196.00$ 3,136.00$

28530 1 125.00$ 125.00$

28531 16 196.00$ 3,136.00$

28540 1 125.00$ 125.00$

28545 16 196.00$ 3,136.00$

28546 1 125.00$ 125.00$

28555 16 196.00$ 3,136.00$

28570 1 125.00$ 125.00$

28575 16 196.00$ 3,136.00$

28576 16 196.00$ 3,136.00$

28585 16 196.00$ 3,136.00$

28600 1 125.00$ 125.00$

28605 16 196.00$ 3,136.00$

28606 1 125.00$ 125.00$

28615 16 196.00$ 3,136.00$

28630 1 125.00$ 125.00$

28635 16 196.00$ 3,136.00$

28636 16 196.00$ 3,136.00$

28645 16 196.00$ 3,136.00$

28660 1 125.00$ 125.00$

28665 16 196.00$ 3,136.00$

28666 16 196.00$ 3,136.00$

28675 16 196.00$ 3,136.00$

28705 16 196.00$ 3,136.00$

28715 16 196.00$ 3,136.00$

28725 16 196.00$ 3,136.00$

28730 16 196.00$ 3,136.00$

28735 16 196.00$ 3,136.00$

28737 16 196.00$ 3,136.00$

28740 16 196.00$ 3,136.00$

28750 16 196.00$ 3,136.00$

28755 16 196.00$ 3,136.00$

28760 16 196.00$ 3,136.00$

28800 16 196.00$ 3,136.00$

28805 16 196.00$ 3,136.00$

28810 16 196.00$ 3,136.00$

41


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

28820 16 196.00$ 3,136.00$

28825 16 196.00$ 3,136.00$

29010 1 196.00$ 196.00$

29035 16 196.00$ 3,136.00$

29055 16 196.00$ 3,136.00$

29058 1 196.00$ 196.00$

29065 16 196.00$ 3,136.00$

29075 16 196.00$ 3,136.00$

29085 16 196.00$ 3,136.00$

29105 1 196.00$ 196.00$

29125 1 196.00$ 196.00$

29126 16 196.00$ 3,136.00$

29130 1 196.00$ 196.00$

29305 16 196.00$ 3,136.00$

29325 16 196.00$ 3,136.00$

29345 16 196.00$ 3,136.00$

29355 16 196.00$ 3,136.00$

29358 1 196.00$ 196.00$

29365 16 196.00$ 3,136.00$

29405 16 196.00$ 3,136.00$

29425 1 196.00$ 196.00$

29435 1 196.00$ 196.00$

29445 16 196.00$ 3,136.00$

29450 16 196.00$ 3,136.00$

29505 1 196.00$ 196.00$

29515 1 196.00$ 196.00$

29530 1 196.00$ 196.00$

29540 1 196.00$ 196.00$

29550 1 196.00$ 196.00$

29580 1 196.00$ 196.00$

29581 16 196.00$ 3,136.00$

29584 16 196.00$ 3,136.00$

29700 1 196.00$ 196.00$

29705 1 196.00$ 196.00$

29710 1 196.00$ 196.00$

29720 16 196.00$ 3,136.00$

29750 1 196.00$ 196.00$

29800 16 196.00$ 3,136.00$

29804 16 196.00$ 3,136.00$

42


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

29805 16 196.00$ 3,136.00$

29806 16 196.00$ 3,136.00$

29807 16 196.00$ 3,136.00$

29819 16 196.00$ 3,136.00$

29820 16 196.00$ 3,136.00$

29821 16 196.00$ 3,136.00$

29822 16 196.00$ 3,136.00$

29823 16 196.00$ 3,136.00$

29824 16 196.00$ 3,136.00$

29825 16 196.00$ 3,136.00$

29826 16 196.00$ 3,136.00$

29827 16 196.00$ 3,136.00$

29828 4 196.00$ 784.00$

29830 16 196.00$ 3,136.00$

29834 16 196.00$ 3,136.00$

29835 16 196.00$ 3,136.00$

29836 16 196.00$ 3,136.00$

29837 16 196.00$ 3,136.00$

29838 16 196.00$ 3,136.00$

29840 16 196.00$ 3,136.00$

29843 16 196.00$ 3,136.00$

29844 16 196.00$ 3,136.00$

29845 16 196.00$ 3,136.00$

29846 16 196.00$ 3,136.00$

29847 16 196.00$ 3,136.00$

29848 16 196.00$ 3,136.00$

29850 16 196.00$ 3,136.00$

29851 16 196.00$ 3,136.00$

29855 16 196.00$ 3,136.00$

29856 16 196.00$ 3,136.00$

29860 16 196.00$ 3,136.00$

29861 16 196.00$ 3,136.00$

29862 16 196.00$ 3,136.00$

29863 16 196.00$ 3,136.00$

29870 16 196.00$ 3,136.00$

29871 16 196.00$ 3,136.00$

29873 16 196.00$ 3,136.00$

29874 16 196.00$ 3,136.00$

29875 16 196.00$ 3,136.00$

43


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

29876 16 196.00$ 3,136.00$

29877 16 196.00$ 3,136.00$

29879 16 196.00$ 3,136.00$

29880 16 196.00$ 3,136.00$

29881 16 196.00$ 3,136.00$

29882 16 196.00$ 3,136.00$

29883 16 196.00$ 3,136.00$

29884 16 196.00$ 3,136.00$

29885 16 196.00$ 3,136.00$

29886 16 196.00$ 3,136.00$

29887 16 196.00$ 3,136.00$

29888 16 196.00$ 3,136.00$

29889 16 196.00$ 3,136.00$

29891 16 196.00$ 3,136.00$

29892 16 196.00$ 3,136.00$

29893 16 196.00$ 3,136.00$

29894 16 196.00$ 3,136.00$

29895 16 196.00$ 3,136.00$

29897 16 196.00$ 3,136.00$

29898 16 196.00$ 3,136.00$

29899 16 196.00$ 3,136.00$

29900 16 196.00$ 3,136.00$

29901 16 196.00$ 3,136.00$

29902 16 196.00$ 3,136.00$

29904 3 196.00$ 588.00$ #N/A

29905 3 196.00$ 588.00$ #N/A

29906 3 196.00$ 588.00$ #N/A

29907 3 196.00$ 588.00$ #N/A

29914 16 196.00$ 3,136.00$

29915 16 196.00$ 3,136.00$

29916 16 196.00$ 3,136.00$

30000 1 100.00$ 100.00$

30020 1 100.00$ 100.00$

30100 16 196.00$ 3,136.00$

30110 16 196.00$ 3,136.00$

30115 16 196.00$ 3,136.00$

30117 16 196.00$ 3,136.00$

30118 16 196.00$ 3,136.00$

30120 16 196.00$ 3,136.00$

44


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

30124 16 196.00$ 3,136.00$

30125 16 196.00$ 3,136.00$

30130 16 196.00$ 3,136.00$

30140 16 196.00$ 3,136.00$

30150 16 196.00$ 3,136.00$

30160 16 196.00$ 3,136.00$

30210 1 100.00$ 100.00$

30220 16 196.00$ 3,136.00$

30300 1 100.00$ 100.00$

30310 16 196.00$ 3,136.00$

30320 16 196.00$ 3,136.00$

30400 16 196.00$ 3,136.00$

30410 16 196.00$ 3,136.00$

30420 16 196.00$ 3,136.00$

30430 16 196.00$ 3,136.00$

30435 16 196.00$ 3,136.00$

30450 16 196.00$ 3,136.00$

30460 16 196.00$ 3,136.00$

30462 16 196.00$ 3,136.00$

30465 16 196.00$ 3,136.00$

30520 9 196.00$ 1,764.00$

30540 16 196.00$ 3,136.00$

30560 16 196.00$ 3,136.00$

30580 16 196.00$ 3,136.00$

30600 16 196.00$ 3,136.00$

30620 16 196.00$ 3,136.00$

30630 16 196.00$ 3,136.00$

30801 1 100.00$ 100.00$

30802 16 196.00$ 3,136.00$

30901 1 100.00$ 100.00$

30903 16 196.00$ 3,136.00$

30905 16 196.00$ 3,136.00$

30906 16 196.00$ 3,136.00$

30915 16 196.00$ 3,136.00$

30920 16 196.00$ 3,136.00$

30930 16 196.00$ 3,136.00$

31000 16 196.00$ 3,136.00$

31002 16 196.00$ 3,136.00$

31020 16 196.00$ 3,136.00$

45


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

31030 16 196.00$ 3,136.00$

31032 16 196.00$ 3,136.00$

31050 16 196.00$ 3,136.00$

31051 16 196.00$ 3,136.00$

31070 16 196.00$ 3,136.00$

31075 16 196.00$ 3,136.00$

31080 16 196.00$ 3,136.00$

31081 16 196.00$ 3,136.00$

31084 16 196.00$ 3,136.00$

31085 16 196.00$ 3,136.00$

31086 16 196.00$ 3,136.00$

31087 16 196.00$ 3,136.00$

31090 16 196.00$ 3,136.00$

31200 16 196.00$ 3,136.00$

31201 16 196.00$ 3,136.00$

31205 16 196.00$ 3,136.00$

31225 16 196.00$ 3,136.00$

31231 1 100.00$ 100.00$

31233 1 100.00$ 100.00$

31235 1 100.00$ 100.00$

31237 16 196.00$ 3,136.00$

31238 16 196.00$ 3,136.00$

31239 16 196.00$ 3,136.00$

31240 16 196.00$ 3,136.00$

31241 16 196.00$ 3,136.00$

31253 16 196.00$ 3,136.00$

31254 16 196.00$ 3,136.00$

31255 16 196.00$ 3,136.00$

31256 16 196.00$ 3,136.00$

31257 16 196.00$ 3,136.00$

31259 16 196.00$ 3,136.00$

31267 16 196.00$ 3,136.00$

31276 16 196.00$ 3,136.00$

31287 16 196.00$ 3,136.00$

31288 16 196.00$ 3,136.00$

31290 16 196.00$ 3,136.00$

31291 16 196.00$ 3,136.00$

31292 16 196.00$ 3,136.00$

31293 16 196.00$ 3,136.00$

46


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

31294 16 196.00$ 3,136.00$

31295 16 196.00$ 3,136.00$

31296 16 196.00$ 3,136.00$

31297 16 196.00$ 3,136.00$

31298 16 196.00$ 3,136.00$

31300 16 196.00$ 3,136.00$

31360 16 196.00$ 3,136.00$

31365 16 196.00$ 3,136.00$

31390 16 196.00$ 3,136.00$

31400 16 196.00$ 3,136.00$

31420 16 196.00$ 3,136.00$

31500 16 196.00$ 3,136.00$

31502 16 196.00$ 3,136.00$

31505 1 100.00$ 100.00$

31510 16 196.00$ 3,136.00$

31511 16 196.00$ 3,136.00$

31512 16 196.00$ 3,136.00$

31513 16 196.00$ 3,136.00$

31515 16 196.00$ 3,136.00$

31520 1 100.00$ 100.00$

31525 1 100.00$ 100.00$

31526 16 196.00$ 3,136.00$

31527 16 196.00$ 3,136.00$

31528 16 196.00$ 3,136.00$

31529 16 196.00$ 3,136.00$

31530 16 196.00$ 3,136.00$

31531 16 196.00$ 3,136.00$

31535 16 196.00$ 3,136.00$

31536 16 196.00$ 3,136.00$

31540 16 196.00$ 3,136.00$

31541 16 196.00$ 3,136.00$

31545 16 196.00$ 3,136.00$

31546 16 196.00$ 3,136.00$

31551 16 196.00$ 3,136.00$

31552 16 196.00$ 3,136.00$

31553 16 196.00$ 3,136.00$

31554 16 196.00$ 3,136.00$

31560 16 196.00$ 3,136.00$

31561 16 196.00$ 3,136.00$

47


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

31570 16 196.00$ 3,136.00$

31571 16 196.00$ 3,136.00$

31575 1 100.00$ 100.00$

31576 16 196.00$ 3,136.00$

31577 16 196.00$ 3,136.00$

31578 16 196.00$ 3,136.00$

31579 16 196.00$ 3,136.00$

31580 16 196.00$ 3,136.00$

31584 16 196.00$ 3,136.00$

31585 16 196.00$ 3,136.00$

31586 16 196.00$ 3,136.00$

31590 16 196.00$ 3,136.00$

31600 16 196.00$ 3,136.00$

31603 16 196.00$ 3,136.00$

31611 16 196.00$ 3,136.00$

31612 16 196.00$ 3,136.00$

31613 16 196.00$ 3,136.00$

31614 16 196.00$ 3,136.00$

31615 16 196.00$ 3,136.00$

31622 1 100.00$ 100.00$

31623 16 196.00$ 3,136.00$

31624 16 196.00$ 3,136.00$

31625 16 196.00$ 3,136.00$

31628 16 196.00$ 3,136.00$

31629 16 196.00$ 3,136.00$

31630 16 196.00$ 3,136.00$

31631 16 196.00$ 3,136.00$

31632 16 196.00$ 3,136.00$

31634 1 100.00$ 100.00$

31635 16 196.00$ 3,136.00$

31636 12 196.00$ 2,352.00$

31637 2 196.00$ 392.00$

31638 12 196.00$ 2,352.00$

31640 16 196.00$ 3,136.00$

31641 16 196.00$ 3,136.00$

31643 16 196.00$ 3,136.00$

31645 16 196.00$ 3,136.00$

31646 16 196.00$ 3,136.00$

31647 16 196.00$ 3,136.00$

48


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

31648 16 196.00$ 3,136.00$

31652 16 196.00$ 3,136.00$

31653 16 196.00$ 3,136.00$

31654 16 196.00$ 3,136.00$

31700 16 196.00$ 3,136.00$

31710 16 196.00$ 3,136.00$

31715 16 196.00$ 3,136.00$

31717 16 196.00$ 3,136.00$

31720 1 100.00$ 100.00$

31730 16 196.00$ 3,136.00$

31750 16 196.00$ 3,136.00$

31755 16 196.00$ 3,136.00$

31760 16 196.00$ 3,136.00$

31785 16 196.00$ 3,136.00$

31800 16 196.00$ 3,136.00$

31820 16 196.00$ 3,136.00$

31825 16 196.00$ 3,136.00$

31830 16 196.00$ 3,136.00$

32000 16 196.00$ 3,136.00$

32002 16 196.00$ 3,136.00$

32005 16 196.00$ 3,136.00$

32019 10 196.00$ 1,960.00$

32020 16 196.00$ 3,136.00$

32096 16 196.00$ 3,136.00$

32097 16 196.00$ 3,136.00$

32098 16 196.00$ 3,136.00$

32110 16 196.00$ 3,136.00$

32120 16 196.00$ 3,136.00$

32400 1 100.00$ 100.00$

32405 16 196.00$ 3,136.00$

32505 16 196.00$ 3,136.00$

32520 16 196.00$ 3,136.00$

32550 3 196.00$ 588.00$ 6

32551 3 196.00$ 588.00$ 5

32552 16 196.00$ 3,136.00$

32553 16 196.00$ 3,136.00$

32554 3 196.00$ 588.00$ 4

32555 3 196.00$ 588.00$ 4

32556 3 196.00$ 588.00$ 4

49


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

32557 3 196.00$ 588.00$ 4

32560 3 196.00$ 588.00$ 4

32607 16 196.00$ 3,136.00$

32608 16 196.00$ 3,136.00$

32609 16 196.00$ 3,136.00$

32666 16 196.00$ 3,136.00$

32669 16 196.00$ 3,136.00$

32670 16 196.00$ 3,136.00$

32671 16 196.00$ 3,136.00$

32672 16 196.00$ 3,136.00$

32673 16 196.00$ 3,136.00$

32994 16 196.00$ 3,136.00$

32998 16 196.00$ 3,136.00$

33016 5 196.00$ 980.00$

33017 6 196.00$ 1,176.00$

33018 7 196.00$ 1,372.00$

33019 6 196.00$ 1,176.00$

33140 16 196.00$ 3,136.00$

33206 16 196.00$ 3,136.00$

33207 16 196.00$ 3,136.00$

33208 16 196.00$ 3,136.00$

33210 16 196.00$ 3,136.00$

33211 16 196.00$ 3,136.00$

33212 16 196.00$ 3,136.00$

33213 16 196.00$ 3,136.00$

33214 16 196.00$ 3,136.00$

33215 3 196.00$ 588.00$ 12

33216 1 196.00$ 196.00$

33217 16 196.00$ 3,136.00$

33218 16 196.00$ 3,136.00$

33220 16 196.00$ 3,136.00$

33221 16 196.00$ 3,136.00$

33222 16 196.00$ 3,136.00$

33223 16 196.00$ 3,136.00$

33224 8 196.00$ 1,568.00$

33226 3 196.00$ 588.00$ 13

33227 16 196.00$ 3,136.00$

33228 16 196.00$ 3,136.00$

33229 16 196.00$ 3,136.00$

50


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

33230 16 196.00$ 3,136.00$

33231 16 196.00$ 3,136.00$

33233 16 196.00$ 3,136.00$

33234 16 196.00$ 3,136.00$

33235 16 196.00$ 3,136.00$

33236 16 196.00$ 3,136.00$

33237 16 196.00$ 3,136.00$

33238 16 196.00$ 3,136.00$

33240 16 196.00$ 3,136.00$

33241 16 196.00$ 3,136.00$

33242 16 196.00$ 3,136.00$

33243 16 196.00$ 3,136.00$

33244 16 196.00$ 3,136.00$

33249 16 196.00$ 3,136.00$

33262 16 196.00$ 3,136.00$

33263 16 196.00$ 3,136.00$

33264 16 196.00$ 3,136.00$

33270 16 196.00$ 3,136.00$

33271 16 196.00$ 3,136.00$

33272 16 196.00$ 3,136.00$

33273 16 196.00$ 3,136.00$

33310 16 196.00$ 3,136.00$

33320 16 196.00$ 3,136.00$

33366 16 196.00$ 3,136.00$

33858 16 196.00$ 3,136.00$

33859 16 196.00$ 3,136.00$

33871 16 196.00$ 3,136.00$

33967 16 196.00$ 3,136.00$

33970 16 196.00$ 3,136.00$

33971 16 196.00$ 3,136.00$

34101 16 196.00$ 3,136.00$

34111 16 196.00$ 3,136.00$

34151 16 196.00$ 3,136.00$

34510 16 196.00$ 3,136.00$

34520 16 196.00$ 3,136.00$

34841 16 196.00$ 3,136.00$

34842 16 196.00$ 3,136.00$

34843 16 196.00$ 3,136.00$

34844 16 196.00$ 3,136.00$

51


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

34845 16 196.00$ 3,136.00$

34846 16 196.00$ 3,136.00$

34847 16 196.00$ 3,136.00$

34848 16 196.00$ 3,136.00$

35011 16 196.00$ 3,136.00$

35045 16 196.00$ 3,136.00$

35081 16 196.00$ 3,136.00$

35082 16 196.00$ 3,136.00$

35102 16 196.00$ 3,136.00$

35161 16 196.00$ 3,136.00$

35184 16 196.00$ 3,136.00$

35190 16 196.00$ 3,136.00$

35206 16 196.00$ 3,136.00$

35207 16 196.00$ 3,136.00$

35226 16 196.00$ 3,136.00$

35266 16 196.00$ 3,136.00$

35301 16 196.00$ 3,136.00$

35321 16 196.00$ 3,136.00$

35500 16 196.00$ 3,136.00$

35702 1 196.00$ 196.00$

35703 16 196.00$ 3,136.00$

35875 16 196.00$ 3,136.00$

35876 16 196.00$ 3,136.00$

35879 16 196.00$ 3,136.00$

35881 16 196.00$ 3,136.00$

35883 12 196.00$ 2,352.00$

35884 12 196.00$ 2,352.00$

35901 16 196.00$ 3,136.00$

35903 16 196.00$ 3,136.00$

35905 16 196.00$ 3,136.00$

35907 16 196.00$ 3,136.00$

36000 1 196.00$ 196.00$

36002 16 196.00$ 3,136.00$

36005 16 196.00$ 3,136.00$

36010 16 196.00$ 3,136.00$

36011 16 196.00$ 3,136.00$

36012 16 196.00$ 3,136.00$

36013 16 196.00$ 3,136.00$

36014 16 196.00$ 3,136.00$

52


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

36015 16 196.00$ 3,136.00$

36140 16 196.00$ 3,136.00$

36160 16 196.00$ 3,136.00$

36200 16 196.00$ 3,136.00$

36215 16 196.00$ 3,136.00$

36216 16 196.00$ 3,136.00$

36217 16 196.00$ 3,136.00$

36218 16 196.00$ 3,136.00$

36221 16 196.00$ 3,136.00$

36222 16 196.00$ 3,136.00$

36223 16 196.00$ 3,136.00$

36224 16 196.00$ 3,136.00$

36225 16 196.00$ 3,136.00$

36226 16 196.00$ 3,136.00$

36227 6 196.00$ 1,176.00$

36245 16 196.00$ 3,136.00$

36246 16 196.00$ 3,136.00$

36247 16 196.00$ 3,136.00$

36248 16 196.00$ 3,136.00$

36251 16 196.00$ 3,136.00$

36252 16 196.00$ 3,136.00$

36253 16 196.00$ 3,136.00$

36254 16 196.00$ 3,136.00$

36260 16 196.00$ 3,136.00$

36261 16 196.00$ 3,136.00$

36262 16 196.00$ 3,136.00$

36410 16 196.00$ 3,136.00$

36430 16 196.00$ 3,136.00$

36440 1 196.00$ 196.00$

36475 16 196.00$ 3,136.00$

36476 16 196.00$ 3,136.00$

36478 16 196.00$ 3,136.00$

36479 16 196.00$ 3,136.00$

36481 16 196.00$ 3,136.00$

36488 16 196.00$ 3,136.00$

36489 16 196.00$ 3,136.00$

36490 16 196.00$ 3,136.00$

36491 16 196.00$ 3,136.00$

36493 16 196.00$ 3,136.00$

53


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

36500 1 100.00$ 100.00$

36510 1 100.00$ 100.00$

36514 3 196.00$ 588.00$ 4

36516 6 196.00$ 1,176.00$

36522 16 196.00$ 3,136.00$

36530 16 196.00$ 3,136.00$

36531 16 196.00$ 3,136.00$

36532 1 100.00$ 100.00$

36533 16 196.00$ 3,136.00$

36534 16 196.00$ 3,136.00$

36535 1 100.00$ 100.00$

36555 16 196.00$ 3,136.00$

36556 16 196.00$ 3,136.00$

36557 16 196.00$ 3,136.00$

36558 16 196.00$ 3,136.00$

36560 16 196.00$ 3,136.00$

36561 16 196.00$ 3,136.00$

36563 16 196.00$ 3,136.00$

36565 16 196.00$ 3,136.00$

36566 16 196.00$ 3,136.00$

36568 16 196.00$ 3,136.00$

36569 16 196.00$ 3,136.00$

36570 16 196.00$ 3,136.00$

36571 16 196.00$ 3,136.00$

36572 4 196.00$ 784.00$

36573 3 196.00$ 588.00$ #N/A

36575 16 196.00$ 3,136.00$

36576 16 196.00$ 3,136.00$

36578 16 196.00$ 3,136.00$

36580 16 196.00$ 3,136.00$

36581 16 196.00$ 3,136.00$

36582 16 196.00$ 3,136.00$

36583 16 196.00$ 3,136.00$

36584 16 196.00$ 3,136.00$

36585 16 196.00$ 3,136.00$

36589 16 196.00$ 3,136.00$

36590 16 196.00$ 3,136.00$

36595 16 196.00$ 3,136.00$

36596 16 196.00$ 3,136.00$

54


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

36597 16 196.00$ 3,136.00$

36598 16 196.00$ 3,136.00$

36620 16 196.00$ 3,136.00$

36625 1 100.00$ 100.00$

36640 1 100.00$ 100.00$

36660 1 100.00$ 100.00$

36800 16 196.00$ 3,136.00$

36810 16 196.00$ 3,136.00$

36815 16 196.00$ 3,136.00$

36818 10 196.00$ 1,960.00$

36819 16 196.00$ 3,136.00$

36820 16 196.00$ 3,136.00$

36821 16 196.00$ 3,136.00$

36823 16 196.00$ 3,136.00$

36825 16 196.00$ 3,136.00$

36830 16 196.00$ 3,136.00$

36831 16 196.00$ 3,136.00$

36832 16 196.00$ 3,136.00$

36833 16 196.00$ 3,136.00$

36835 16 196.00$ 3,136.00$

36838 16 196.00$ 3,136.00$

36860 16 196.00$ 3,136.00$

36861 16 196.00$ 3,136.00$

36870 16 196.00$ 3,136.00$

36901 16 196.00$ 3,136.00$

36902 16 196.00$ 3,136.00$

36903 16 196.00$ 3,136.00$

36904 16 196.00$ 3,136.00$

36905 16 196.00$ 3,136.00$

37184 8 196.00$ 1,568.00$

37185 3 196.00$ 588.00$ #N/A

37186 3 196.00$ 588.00$ 4

37187 8 196.00$ 1,568.00$

37188 8 196.00$ 1,568.00$

37191 16 196.00$ 3,136.00$

37192 16 196.00$ 3,136.00$

37193 16 196.00$ 3,136.00$

37211 16 196.00$ 3,136.00$

37212 16 196.00$ 3,136.00$

55


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

37213 16 196.00$ 3,136.00$

37214 16 196.00$ 3,136.00$

37217 16 196.00$ 3,136.00$

37220 16 196.00$ 3,136.00$

37221 16 196.00$ 3,136.00$

37222 16 196.00$ 3,136.00$

37223 16 196.00$ 3,136.00$

37224 16 196.00$ 3,136.00$

37225 16 196.00$ 3,136.00$

37226 16 196.00$ 3,136.00$

37227 16 196.00$ 3,136.00$

37228 16 196.00$ 3,136.00$

37229 16 196.00$ 3,136.00$

37230 16 196.00$ 3,136.00$

37231 16 196.00$ 3,136.00$

37232 16 196.00$ 3,136.00$

37233 16 196.00$ 3,136.00$

37234 16 196.00$ 3,136.00$

37235 16 196.00$ 3,136.00$

37236 16 196.00$ 3,136.00$

37238 16 196.00$ 3,136.00$

37241 16 196.00$ 3,136.00$

37242 16 196.00$ 3,136.00$

37243 16 196.00$ 3,136.00$

37244 16 196.00$ 3,136.00$

37246 8 196.00$ 1,568.00$

37247 2 196.00$ 392.00$

37248 8 196.00$ 1,568.00$

37252 16 196.00$ 3,136.00$

37253 16 196.00$ 3,136.00$

37607 16 196.00$ 3,136.00$

37609 16 196.00$ 3,136.00$

37615 16 196.00$ 3,136.00$

37618 16 196.00$ 3,136.00$

37619 16 196.00$ 3,136.00$

37650 16 196.00$ 3,136.00$

37700 16 196.00$ 3,136.00$

37718 5 196.00$ 980.00$

37720 16 196.00$ 3,136.00$

56


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

37722 5 196.00$ 980.00$

37730 16 196.00$ 3,136.00$

37735 16 196.00$ 3,136.00$

37760 16 196.00$ 3,136.00$

37761 16 196.00$ 3,136.00$

37765 16 196.00$ 3,136.00$

37766 16 196.00$ 3,136.00$

37780 16 196.00$ 3,136.00$

37785 16 196.00$ 3,136.00$

38100 16 196.00$ 3,136.00$

38102 16 196.00$ 3,136.00$

38206 12 196.00$ 2,352.00$

38207 16 196.00$ 3,136.00$

38214 2 196.00$ 392.00$

38215 16 196.00$ 3,136.00$

38220 16 196.00$ 3,136.00$

38221 16 196.00$ 3,136.00$

38222 6 196.00$ 1,176.00$

38230 16 196.00$ 3,136.00$

38300 1 100.00$ 100.00$

38305 16 196.00$ 3,136.00$

38308 16 196.00$ 3,136.00$

38500 1 100.00$ 100.00$

38505 16 196.00$ 3,136.00$

38510 16 196.00$ 3,136.00$

38520 16 196.00$ 3,136.00$

38525 16 196.00$ 3,136.00$

38530 16 196.00$ 3,136.00$

38531 8 196.00$ 1,568.00$

38542 16 196.00$ 3,136.00$

38550 16 196.00$ 3,136.00$

38555 16 196.00$ 3,136.00$

38570 6 196.00$ 1,176.00$

38571 16 196.00$ 3,136.00$

38572 16 196.00$ 3,136.00$

38573 16 196.00$ 3,136.00$

38700 16 196.00$ 3,136.00$

38720 16 196.00$ 3,136.00$

38724 16 196.00$ 3,136.00$

57


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

38740 16 196.00$ 3,136.00$

38745 16 196.00$ 3,136.00$

38746 16 196.00$ 3,136.00$

38747 16 196.00$ 3,136.00$

38760 16 196.00$ 3,136.00$

38765 16 196.00$ 3,136.00$

38900 16 196.00$ 3,136.00$

39000 16 196.00$ 3,136.00$

39010 16 196.00$ 3,136.00$

39200 1 100.00$ 100.00$

39220 1 100.00$ 100.00$

39400 16 196.00$ 3,136.00$

39401 16 196.00$ 3,136.00$

39402 16 196.00$ 3,136.00$

39503 16 196.00$ 3,136.00$

39540 16 196.00$ 3,136.00$

40490 1 100.00$ 100.00$

40500 16 196.00$ 3,136.00$

40510 16 196.00$ 3,136.00$

40520 16 196.00$ 3,136.00$

40525 16 196.00$ 3,136.00$

40527 16 196.00$ 3,136.00$

40530 16 196.00$ 3,136.00$

40650 16 196.00$ 3,136.00$

40652 16 196.00$ 3,136.00$

40654 16 196.00$ 3,136.00$

40700 16 196.00$ 3,136.00$

40702 16 196.00$ 3,136.00$

40720 16 196.00$ 3,136.00$

40761 16 196.00$ 3,136.00$

40800 1 100.00$ 100.00$

40801 16 196.00$ 3,136.00$

40804 1 100.00$ 100.00$

40805 16 196.00$ 3,136.00$

40806 16 196.00$ 3,136.00$

40808 1 100.00$ 100.00$

40810 1 100.00$ 100.00$

40812 16 196.00$ 3,136.00$

40814 16 196.00$ 3,136.00$

58


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

40816 16 196.00$ 3,136.00$

40818 16 196.00$ 3,136.00$

40819 16 196.00$ 3,136.00$

40820 16 196.00$ 3,136.00$

40830 16 196.00$ 3,136.00$

40831 16 196.00$ 3,136.00$

40840 16 196.00$ 3,136.00$

40842 16 196.00$ 3,136.00$

40843 16 196.00$ 3,136.00$

40844 16 196.00$ 3,136.00$

40845 16 196.00$ 3,136.00$

41000 1 100.00$ 100.00$

41005 1 100.00$ 100.00$

41006 16 196.00$ 3,136.00$

41007 16 196.00$ 3,136.00$

41008 16 196.00$ 3,136.00$

41009 16 196.00$ 3,136.00$

41010 16 196.00$ 3,136.00$

41015 16 196.00$ 3,136.00$

41016 16 196.00$ 3,136.00$

41017 16 196.00$ 3,136.00$

41018 16 196.00$ 3,136.00$

41019 4 196.00$ 784.00$

41100 1 196.00$ 196.00$

41105 16 196.00$ 3,136.00$

41108 16 196.00$ 3,136.00$

41110 16 196.00$ 3,136.00$

41112 16 196.00$ 3,136.00$

41113 16 196.00$ 3,136.00$

41114 16 196.00$ 3,136.00$

41115 16 196.00$ 3,136.00$

41116 16 196.00$ 3,136.00$

41120 16 196.00$ 3,136.00$

41140 16 196.00$ 3,136.00$

41145 16 196.00$ 3,136.00$

41150 16 196.00$ 3,136.00$

41153 16 196.00$ 3,136.00$

41155 16 196.00$ 3,136.00$

41250 16 196.00$ 3,136.00$

59


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

41251 16 196.00$ 3,136.00$

41252 16 196.00$ 3,136.00$

41510 16 196.00$ 3,136.00$

41520 16 196.00$ 3,136.00$

41800 1 100.00$ 100.00$

41805 16 196.00$ 3,136.00$

41806 16 196.00$ 3,136.00$

41820 16 196.00$ 3,136.00$

41821 16 196.00$ 3,136.00$

41822 16 196.00$ 3,136.00$

41823 16 196.00$ 3,136.00$

41825 16 196.00$ 3,136.00$

41826 16 196.00$ 3,136.00$

41827 16 196.00$ 3,136.00$

41828 16 196.00$ 3,136.00$

41830 16 196.00$ 3,136.00$

41850 16 196.00$ 3,136.00$

41870 16 196.00$ 3,136.00$

41872 16 196.00$ 3,136.00$

41874 16 196.00$ 3,136.00$

42000 1 100.00$ 100.00$

42100 1 100.00$ 100.00$

42104 16 196.00$ 3,136.00$

42106 16 196.00$ 3,136.00$

42107 16 196.00$ 3,136.00$

42120 16 196.00$ 3,136.00$

42140 16 196.00$ 3,136.00$

42145 16 196.00$ 3,136.00$

42160 16 196.00$ 3,136.00$

42180 16 196.00$ 3,136.00$

42182 16 196.00$ 3,136.00$

42200 16 196.00$ 3,136.00$

42205 16 196.00$ 3,136.00$

42210 16 196.00$ 3,136.00$

42215 16 196.00$ 3,136.00$

42220 16 196.00$ 3,136.00$

42225 16 196.00$ 3,136.00$

42227 16 196.00$ 3,136.00$

42235 16 196.00$ 3,136.00$

60


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

42260 16 196.00$ 3,136.00$

42281 16 196.00$ 3,136.00$

42300 1 100.00$ 100.00$

42305 16 196.00$ 3,136.00$

42310 1 100.00$ 100.00$

42320 1 100.00$ 100.00$

42325 16 196.00$ 3,136.00$

42330 16 196.00$ 3,136.00$

42335 16 196.00$ 3,136.00$

42340 16 196.00$ 3,136.00$

42400 1 100.00$ 100.00$

42405 16 196.00$ 3,136.00$

42408 16 196.00$ 3,136.00$

42409 16 196.00$ 3,136.00$

42410 16 196.00$ 3,136.00$

42415 16 196.00$ 3,136.00$

42420 16 196.00$ 3,136.00$

42425 16 196.00$ 3,136.00$

42440 16 196.00$ 3,136.00$

42450 16 196.00$ 3,136.00$

42500 16 196.00$ 3,136.00$

42505 16 196.00$ 3,136.00$

42507 16 196.00$ 3,136.00$

42509 16 196.00$ 3,136.00$

42510 16 196.00$ 3,136.00$

42600 16 196.00$ 3,136.00$

42650 1 100.00$ 100.00$

42660 1 100.00$ 100.00$

42665 16 196.00$ 3,136.00$

42700 1 100.00$ 100.00$

42720 16 196.00$ 3,136.00$

42725 16 196.00$ 3,136.00$

42800 16 196.00$ 3,136.00$

42802 16 196.00$ 3,136.00$

42804 16 196.00$ 3,136.00$

42806 16 196.00$ 3,136.00$

42808 16 196.00$ 3,136.00$

42809 16 196.00$ 3,136.00$

42810 16 196.00$ 3,136.00$

61


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

42815 16 196.00$ 3,136.00$

42820 6 196.00$ 1,176.00$

42821 1 196.00$ 196.00$

42825 16 196.00$ 3,136.00$

42826 1 196.00$ 196.00$

42830 16 196.00$ 3,136.00$

42831 1 196.00$ 196.00$

42835 16 196.00$ 3,136.00$

42836 1 196.00$ 196.00$

42842 16 196.00$ 3,136.00$

42860 16 196.00$ 3,136.00$

42870 16 196.00$ 3,136.00$

42890 16 196.00$ 3,136.00$

42900 16 196.00$ 3,136.00$

42950 16 196.00$ 3,136.00$

42955 16 196.00$ 3,136.00$

42960 16 196.00$ 3,136.00$

42961 16 196.00$ 3,136.00$

42962 16 196.00$ 3,136.00$

42970 16 196.00$ 3,136.00$

43020 16 196.00$ 3,136.00$

43030 16 196.00$ 3,136.00$

43130 16 196.00$ 3,136.00$

43180 16 196.00$ 3,136.00$

43191 16 196.00$ 3,136.00$

43192 16 196.00$ 3,136.00$

43193 16 196.00$ 3,136.00$

43194 16 196.00$ 3,136.00$

43195 16 196.00$ 3,136.00$

43196 16 196.00$ 3,136.00$

43197 16 196.00$ 3,136.00$

43198 16 196.00$ 3,136.00$

43200 1 100.00$ 100.00$

43202 16 196.00$ 3,136.00$

43204 16 196.00$ 3,136.00$

43205 16 196.00$ 3,136.00$

43210 16 196.00$ 3,136.00$

43211 16 196.00$ 3,136.00$

43212 16 196.00$ 3,136.00$

62


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

43213 16 196.00$ 3,136.00$

43214 16 196.00$ 3,136.00$

43215 16 196.00$ 3,136.00$

43216 16 196.00$ 3,136.00$

43217 16 196.00$ 3,136.00$

43219 16 196.00$ 3,136.00$

43220 16 196.00$ 3,136.00$

43226 16 196.00$ 3,136.00$

43227 16 196.00$ 3,136.00$

43228 16 196.00$ 3,136.00$

43229 16 196.00$ 3,136.00$

43233 16 196.00$ 3,136.00$

43235 1 100.00$ 100.00$

43236 2 196.00$ 392.00$

43237 16 196.00$ 3,136.00$

43238 16 196.00$ 3,136.00$

43239 4 196.00$ 784.00$

43240 16 196.00$ 3,136.00$

43241 16 196.00$ 3,136.00$

43242 3 196.00$ 588.00$ 7

43243 16 196.00$ 3,136.00$

43244 16 196.00$ 3,136.00$

43245 16 196.00$ 3,136.00$

43246 16 196.00$ 3,136.00$

43247 16 196.00$ 3,136.00$

43248 16 196.00$ 3,136.00$

43249 16 196.00$ 3,136.00$

43250 16 196.00$ 3,136.00$

43251 16 196.00$ 3,136.00$

43253 16 196.00$ 3,136.00$

43254 16 196.00$ 3,136.00$

43255 16 196.00$ 3,136.00$

43259 16 196.00$ 3,136.00$

43260 16 196.00$ 3,136.00$

43261 16 196.00$ 3,136.00$

43262 16 196.00$ 3,136.00$

43263 16 196.00$ 3,136.00$

43264 16 196.00$ 3,136.00$

43265 16 196.00$ 3,136.00$

63


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

43266 16 196.00$ 3,136.00$

43270 16 196.00$ 3,136.00$

43274 16 196.00$ 3,136.00$

43275 16 196.00$ 3,136.00$

43276 16 196.00$ 3,136.00$

43277 16 196.00$ 3,136.00$

43278 16 196.00$ 3,136.00$

43279 3 196.00$ 588.00$ 16

43280 16 196.00$ 3,136.00$

43283 16 196.00$ 3,136.00$

43305 16 196.00$ 3,136.00$

43312 16 196.00$ 3,136.00$

43313 16 196.00$ 3,136.00$

43314 16 196.00$ 3,136.00$

43320 16 196.00$ 3,136.00$

43325 16 196.00$ 3,136.00$

43450 1 100.00$ 100.00$

43453 16 196.00$ 3,136.00$

43496 16 196.00$ 3,136.00$

43500 16 196.00$ 3,136.00$

43501 16 196.00$ 3,136.00$

43502 16 196.00$ 3,136.00$

43520 16 196.00$ 3,136.00$

43610 16 196.00$ 3,136.00$

43620 16 196.00$ 3,136.00$

43621 16 196.00$ 3,136.00$

43622 16 196.00$ 3,136.00$

43631 16 196.00$ 3,136.00$

43632 16 196.00$ 3,136.00$

43633 16 196.00$ 3,136.00$

43634 16 196.00$ 3,136.00$

43635 16 196.00$ 3,136.00$

43638 16 196.00$ 3,136.00$

43639 16 196.00$ 3,136.00$

43640 16 196.00$ 3,136.00$

43641 16 196.00$ 3,136.00$

43653 3 196.00$ 588.00$ #N/A

43750 1 100.00$ 100.00$

43753 2 196.00$ 392.00$

64


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

43754 2 196.00$ 392.00$

43755 2 196.00$ 392.00$

43756 4 196.00$ 784.00$

43757 16 196.00$ 3,136.00$

43761 1 196.00$ 196.00$

43762 2 196.00$ 392.00$

43763 4 196.00$ 784.00$

43774 16 196.00$ 3,136.00$

43825 16 196.00$ 3,136.00$

43830 16 196.00$ 3,136.00$

43831 16 196.00$ 3,136.00$

43832 16 196.00$ 3,136.00$

43840 16 196.00$ 3,136.00$

43870 16 196.00$ 3,136.00$

43880 16 196.00$ 3,136.00$

44005 16 196.00$ 3,136.00$

44015 16 196.00$ 3,136.00$

44025 16 196.00$ 3,136.00$

44100 16 196.00$ 3,136.00$

44110 16 196.00$ 3,136.00$

44120 16 196.00$ 3,136.00$

44130 16 196.00$ 3,136.00$

44140 16 196.00$ 3,136.00$

44141 16 196.00$ 3,136.00$

44143 16 196.00$ 3,136.00$

44144 16 196.00$ 3,136.00$

44145 16 196.00$ 3,136.00$

44150 16 196.00$ 3,136.00$

44151 16 196.00$ 3,136.00$

44152 16 196.00$ 3,136.00$

44153 16 196.00$ 3,136.00$

44155 16 196.00$ 3,136.00$

44156 16 196.00$ 3,136.00$

44160 16 196.00$ 3,136.00$

44180 11 196.00$ 2,156.00$

44186 11 196.00$ 2,156.00$

44200 16 196.00$ 3,136.00$

44203 16 196.00$ 3,136.00$

44204 16 196.00$ 3,136.00$

65


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

44205 16 196.00$ 3,136.00$

44213 8 196.00$ 1,568.00$

44300 16 196.00$ 3,136.00$

44312 16 196.00$ 3,136.00$

44320 16 196.00$ 3,136.00$

44340 16 196.00$ 3,136.00$

44345 16 196.00$ 3,136.00$

44346 16 196.00$ 3,136.00$

44360 16 196.00$ 3,136.00$

44361 16 196.00$ 3,136.00$

44363 16 196.00$ 3,136.00$

44364 16 196.00$ 3,136.00$

44365 16 196.00$ 3,136.00$

44366 16 196.00$ 3,136.00$

44369 16 196.00$ 3,136.00$

44370 16 196.00$ 3,136.00$

44372 16 196.00$ 3,136.00$

44373 16 196.00$ 3,136.00$

44376 16 196.00$ 3,136.00$

44377 16 196.00$ 3,136.00$

44378 16 196.00$ 3,136.00$

44379 16 196.00$ 3,136.00$

44380 1 100.00$ 100.00$

44381 16 196.00$ 3,136.00$

44382 16 196.00$ 3,136.00$

44384 16 196.00$ 3,136.00$

44385 1 100.00$ 100.00$

44386 16 196.00$ 3,136.00$

44388 1 100.00$ 100.00$

44389 16 196.00$ 3,136.00$

44390 16 196.00$ 3,136.00$

44391 16 196.00$ 3,136.00$

44392 16 196.00$ 3,136.00$

44394 16 196.00$ 3,136.00$

44401 16 196.00$ 3,136.00$

44402 16 196.00$ 3,136.00$

44403 16 196.00$ 3,136.00$

44404 16 196.00$ 3,136.00$

44405 16 196.00$ 3,136.00$

66


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

44406 16 196.00$ 3,136.00$

44407 16 196.00$ 3,136.00$

44408 16 196.00$ 3,136.00$

44500 1 100.00$ 100.00$

44602 16 196.00$ 3,136.00$

44603 16 196.00$ 3,136.00$

44604 16 196.00$ 3,136.00$

44615 16 196.00$ 3,136.00$

44620 16 196.00$ 3,136.00$

44625 16 196.00$ 3,136.00$

44700 16 196.00$ 3,136.00$

44705 8 196.00$ 1,568.00$

44799 16 196.00$ 3,136.00$

44950 16 196.00$ 3,136.00$

44955 16 196.00$ 3,136.00$

44960 16 196.00$ 3,136.00$

44970 16 196.00$ 3,136.00$

44979 16 196.00$ 3,136.00$

45000 16 196.00$ 3,136.00$

45005 16 196.00$ 3,136.00$

45020 16 196.00$ 3,136.00$

45100 16 196.00$ 3,136.00$

45108 16 196.00$ 3,136.00$

45110 16 196.00$ 3,136.00$

45120 16 196.00$ 3,136.00$

45150 16 196.00$ 3,136.00$

45171 16 196.00$ 3,136.00$

45172 16 196.00$ 3,136.00$

45190 16 196.00$ 3,136.00$

45300 1 100.00$ 100.00$

45303 16 196.00$ 3,136.00$

45305 16 196.00$ 3,136.00$

45307 16 196.00$ 3,136.00$

45308 16 196.00$ 3,136.00$

45309 16 196.00$ 3,136.00$

45315 16 196.00$ 3,136.00$

45317 16 196.00$ 3,136.00$

45320 16 196.00$ 3,136.00$

45321 16 196.00$ 3,136.00$

67


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

45327 16 196.00$ 3,136.00$

45330 1 100.00$ 100.00$

45331 16 196.00$ 3,136.00$

45332 16 196.00$ 3,136.00$

45333 16 196.00$ 3,136.00$

45334 16 196.00$ 3,136.00$

45335 16 196.00$ 3,136.00$

45337 16 196.00$ 3,136.00$

45338 16 196.00$ 3,136.00$

45340 16 196.00$ 3,136.00$

45341 16 196.00$ 3,136.00$

45342 16 196.00$ 3,136.00$

45346 16 196.00$ 3,136.00$

45347 16 196.00$ 3,136.00$

45349 16 196.00$ 3,136.00$

45350 16 196.00$ 3,136.00$

45378 1 100.00$ 100.00$

45379 16 196.00$ 3,136.00$

45380 4 196.00$ 784.00$

45381 16 196.00$ 3,136.00$

45382 16 196.00$ 3,136.00$

45384 16 196.00$ 3,136.00$

45385 16 196.00$ 3,136.00$

45386 16 196.00$ 3,136.00$

45388 16 196.00$ 3,136.00$

45389 16 196.00$ 3,136.00$

45390 16 196.00$ 3,136.00$

45391 16 196.00$ 3,136.00$

45392 16 196.00$ 3,136.00$

45393 16 196.00$ 3,136.00$

45398 16 196.00$ 3,136.00$

45500 16 196.00$ 3,136.00$

45505 16 196.00$ 3,136.00$

45560 16 196.00$ 3,136.00$

45900 16 196.00$ 3,136.00$

45905 16 196.00$ 3,136.00$

45910 16 196.00$ 3,136.00$

45915 16 196.00$ 3,136.00$

45990 1 196.00$ 196.00$

68


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

46020 1 100.00$ 100.00$

46030 1 100.00$ 100.00$

46040 16 196.00$ 3,136.00$

46045 16 196.00$ 3,136.00$

46050 1 100.00$ 100.00$

46060 16 196.00$ 3,136.00$

46080 16 196.00$ 3,136.00$

46083 16 196.00$ 3,136.00$

46200 16 196.00$ 3,136.00$

46220 16 196.00$ 3,136.00$

46221 16 196.00$ 3,136.00$

46230 16 196.00$ 3,136.00$

46250 16 196.00$ 3,136.00$

46255 16 196.00$ 3,136.00$

46257 16 196.00$ 3,136.00$

46258 16 196.00$ 3,136.00$

46260 16 196.00$ 3,136.00$

46261 16 196.00$ 3,136.00$

46262 16 196.00$ 3,136.00$

46270 16 196.00$ 3,136.00$

46275 16 196.00$ 3,136.00$

46280 16 196.00$ 3,136.00$

46285 16 196.00$ 3,136.00$

46288 16 196.00$ 3,136.00$

46320 16 196.00$ 3,136.00$

46500 1 100.00$ 100.00$

46505 1 196.00$ 196.00$

46600 1 100.00$ 100.00$

46604 16 196.00$ 3,136.00$

46606 16 196.00$ 3,136.00$

46608 16 196.00$ 3,136.00$

46610 16 196.00$ 3,136.00$

46611 16 196.00$ 3,136.00$

46612 16 196.00$ 3,136.00$

46614 16 196.00$ 3,136.00$

46615 16 196.00$ 3,136.00$

46700 16 196.00$ 3,136.00$

46705 16 196.00$ 3,136.00$

46706 16 196.00$ 3,136.00$

69


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

46730 16 196.00$ 3,136.00$

46742 16 196.00$ 3,136.00$

46744 16 196.00$ 3,136.00$

46746 16 196.00$ 3,136.00$

46748 16 196.00$ 3,136.00$

46750 16 196.00$ 3,136.00$

46751 16 196.00$ 3,136.00$

46753 16 196.00$ 3,136.00$

46754 16 196.00$ 3,136.00$

46760 16 196.00$ 3,136.00$

46910 16 196.00$ 3,136.00$

46916 16 196.00$ 3,136.00$

46917 16 196.00$ 3,136.00$

46922 16 196.00$ 3,136.00$

46924 16 196.00$ 3,136.00$

46930 2 196.00$ 392.00$

46934 16 196.00$ 3,136.00$

46945 16 196.00$ 3,136.00$

46946 16 196.00$ 3,136.00$

46947 10 196.00$ 1,960.00$

46948 9 196.00$ 1,764.00$

47000 1 100.00$ 100.00$

47001 16 196.00$ 3,136.00$

47010 16 196.00$ 3,136.00$

47015 16 196.00$ 3,136.00$

47100 16 196.00$ 3,136.00$

47370 16 196.00$ 3,136.00$

47371 16 196.00$ 3,136.00$

47379 16 196.00$ 3,136.00$

47380 16 196.00$ 3,136.00$

47381 16 196.00$ 3,136.00$

47382 16 196.00$ 3,136.00$

47383 16 196.00$ 3,136.00$

47400 16 196.00$ 3,136.00$

47460 16 196.00$ 3,136.00$

47531 16 196.00$ 3,136.00$

47532 16 196.00$ 3,136.00$

47533 16 196.00$ 3,136.00$

47534 16 196.00$ 3,136.00$

70


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

47535 16 196.00$ 3,136.00$

47536 16 196.00$ 3,136.00$

47537 16 196.00$ 3,136.00$

47538 16 196.00$ 3,136.00$

47539 16 196.00$ 3,136.00$

47540 16 196.00$ 3,136.00$

47541 16 196.00$ 3,136.00$

47542 16 196.00$ 3,136.00$

47543 16 196.00$ 3,136.00$

47544 16 196.00$ 3,136.00$

47552 1 100.00$ 100.00$

47553 16 196.00$ 3,136.00$

47554 16 196.00$ 3,136.00$

47555 16 196.00$ 3,136.00$

47556 16 196.00$ 3,136.00$

47562 16 196.00$ 3,136.00$

47563 16 196.00$ 3,136.00$

47564 16 196.00$ 3,136.00$

47570 16 196.00$ 3,136.00$

47600 16 196.00$ 3,136.00$

47605 16 196.00$ 3,136.00$

47610 16 196.00$ 3,136.00$

47612 16 196.00$ 3,136.00$

47620 16 196.00$ 3,136.00$

47760 16 196.00$ 3,136.00$

47765 16 196.00$ 3,136.00$

48100 16 196.00$ 3,136.00$

48102 16 196.00$ 3,136.00$

48150 16 196.00$ 3,136.00$

48400 16 196.00$ 3,136.00$

49000 16 196.00$ 3,136.00$

49002 16 196.00$ 3,136.00$

49010 16 196.00$ 3,136.00$

49020 16 196.00$ 3,136.00$

49040 16 196.00$ 3,136.00$

49060 16 196.00$ 3,136.00$

49082 1 100.00$ 100.00$

49083 1 100.00$ 100.00$

49084 1 100.00$ 100.00$

71


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

49085 1 100.00$ 100.00$

49180 1 196.00$ 196.00$

49185 16 196.00$ 3,136.00$

49200 16 196.00$ 3,136.00$

49201 16 196.00$ 3,136.00$

49203 4 196.00$ 784.00$

49204 4 196.00$ 784.00$

49205 4 196.00$ 784.00$

49250 16 196.00$ 3,136.00$

49255 16 196.00$ 3,136.00$

49320 16 196.00$ 3,136.00$

49321 16 196.00$ 3,136.00$

49322 16 196.00$ 3,136.00$

49323 16 196.00$ 3,136.00$

49324 4 196.00$ 784.00$

49325 4 196.00$ 784.00$

49326 2 196.00$ 392.00$

49327 16 196.00$ 3,136.00$

49400 1 100.00$ 100.00$

49402 1 196.00$ 196.00$

49405 16 196.00$ 3,136.00$

49406 16 196.00$ 3,136.00$

49407 16 196.00$ 3,136.00$

49411 16 196.00$ 3,136.00$

49412 16 196.00$ 3,136.00$

49418 16 196.00$ 3,136.00$

49419 16 196.00$ 3,136.00$

49421 16 196.00$ 3,136.00$

49422 16 196.00$ 3,136.00$

49423 16 196.00$ 3,136.00$

49424 16 196.00$ 3,136.00$

49425 16 196.00$ 3,136.00$

49426 16 196.00$ 3,136.00$

49428 16 196.00$ 3,136.00$

49429 16 196.00$ 3,136.00$

49435 4 196.00$ 784.00$

49436 4 196.00$ 784.00$

49440 4 196.00$ 784.00$

49441 4 196.00$ 784.00$

72


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

49442 4 196.00$ 784.00$

49446 4 196.00$ 784.00$

49450 4 196.00$ 784.00$

49451 4 196.00$ 784.00$

49452 4 196.00$ 784.00$

49460 4 196.00$ 784.00$

49491 16 196.00$ 3,136.00$

49495 16 196.00$ 3,136.00$

49496 16 196.00$ 3,136.00$

49500 16 196.00$ 3,136.00$

49501 16 196.00$ 3,136.00$

49505 7 196.00$ 1,372.00$

49507 16 196.00$ 3,136.00$

49520 16 196.00$ 3,136.00$

49521 16 196.00$ 3,136.00$

49525 16 196.00$ 3,136.00$

49540 16 196.00$ 3,136.00$

49550 16 196.00$ 3,136.00$

49553 16 196.00$ 3,136.00$

49555 16 196.00$ 3,136.00$

49557 16 196.00$ 3,136.00$

49560 16 196.00$ 3,136.00$

49561 16 196.00$ 3,136.00$

49565 16 196.00$ 3,136.00$

49566 16 196.00$ 3,136.00$

49568 16 196.00$ 3,136.00$

49570 16 196.00$ 3,136.00$

49572 16 196.00$ 3,136.00$

49580 16 196.00$ 3,136.00$

49582 16 196.00$ 3,136.00$

49585 5 196.00$ 980.00$

49587 5 196.00$ 980.00$

49590 16 196.00$ 3,136.00$

49650 16 196.00$ 3,136.00$

49651 16 196.00$ 3,136.00$

49652 3 196.00$ 588.00$ 16

49653 3 196.00$ 588.00$ 16

49654 3 196.00$ 588.00$ 16

49655 3 196.00$ 588.00$ 16

73


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

49656 3 196.00$ 588.00$ 16

49657 3 196.00$ 588.00$ 16

49900 16 196.00$ 3,136.00$

50020 16 196.00$ 3,136.00$

50040 16 196.00$ 3,136.00$

50045 16 196.00$ 3,136.00$

50080 16 196.00$ 3,136.00$

50081 16 196.00$ 3,136.00$

50120 16 196.00$ 3,136.00$

50200 16 196.00$ 3,136.00$

50205 16 196.00$ 3,136.00$

50220 16 196.00$ 3,136.00$

50225 16 196.00$ 3,136.00$

50230 16 196.00$ 3,136.00$

50234 16 196.00$ 3,136.00$

50236 16 196.00$ 3,136.00$

50280 16 196.00$ 3,136.00$

50340 16 196.00$ 3,136.00$

50365 16 196.00$ 3,136.00$

50382 5 196.00$ 980.00$

50384 5 196.00$ 980.00$

50385 4 196.00$ 784.00$

50386 4 196.00$ 784.00$

50387 2 196.00$ 392.00$

50389 1 196.00$ 196.00$

50390 1 100.00$ 100.00$

50391 1 196.00$ 196.00$

50396 16 196.00$ 3,136.00$

50400 16 196.00$ 3,136.00$

50430 16 196.00$ 3,136.00$

50431 16 196.00$ 3,136.00$

50432 16 196.00$ 3,136.00$

50433 16 196.00$ 3,136.00$

50434 16 196.00$ 3,136.00$

50435 16 196.00$ 3,136.00$

50436 7 196.00$ 1,372.00$

50437 7 196.00$ 1,372.00$

50520 16 196.00$ 3,136.00$

50543 16 196.00$ 3,136.00$

74


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

50551 16 196.00$ 3,136.00$

50553 16 196.00$ 3,136.00$

50555 16 196.00$ 3,136.00$

50557 16 196.00$ 3,136.00$

50559 16 196.00$ 3,136.00$

50561 16 196.00$ 3,136.00$

50562 16 196.00$ 3,136.00$

50570 16 196.00$ 3,136.00$

50572 16 196.00$ 3,136.00$

50574 16 196.00$ 3,136.00$

50575 16 196.00$ 3,136.00$

50576 16 196.00$ 3,136.00$

50578 16 196.00$ 3,136.00$

50580 16 196.00$ 3,136.00$

50590 16 196.00$ 3,136.00$

50592 11 196.00$ 2,156.00$

50593 4 196.00$ 784.00$

50600 16 196.00$ 3,136.00$

50605 16 196.00$ 3,136.00$

50606 16 196.00$ 3,136.00$

50684 16 196.00$ 3,136.00$

50688 16 196.00$ 3,136.00$

50690 16 196.00$ 3,136.00$

50693 16 196.00$ 3,136.00$

50694 16 196.00$ 3,136.00$

50695 16 196.00$ 3,136.00$

50700 16 196.00$ 3,136.00$

50706 16 196.00$ 3,136.00$

50727 16 196.00$ 3,136.00$

50770 16 196.00$ 3,136.00$

50780 16 196.00$ 3,136.00$

50782 16 196.00$ 3,136.00$

50845 16 196.00$ 3,136.00$

50945 16 196.00$ 3,136.00$

50951 16 196.00$ 3,136.00$

50953 16 196.00$ 3,136.00$

50955 16 196.00$ 3,136.00$

50957 16 196.00$ 3,136.00$

50959 16 196.00$ 3,136.00$

75


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

50961 16 196.00$ 3,136.00$

50970 16 196.00$ 3,136.00$

50972 16 196.00$ 3,136.00$

50974 16 196.00$ 3,136.00$

50976 16 196.00$ 3,136.00$

50978 16 196.00$ 3,136.00$

50980 16 196.00$ 3,136.00$

51000 1 100.00$ 100.00$

51005 1 100.00$ 100.00$

51010 16 196.00$ 3,136.00$

51020 16 196.00$ 3,136.00$

51030 16 196.00$ 3,136.00$

51040 16 196.00$ 3,136.00$

51045 16 196.00$ 3,136.00$

51050 16 196.00$ 3,136.00$

51100 2 196.00$ 392.00$

51101 2 196.00$ 392.00$

51102 2 196.00$ 392.00$

51500 16 196.00$ 3,136.00$

51570 16 196.00$ 3,136.00$

51575 16 196.00$ 3,136.00$

51580 16 196.00$ 3,136.00$

51585 16 196.00$ 3,136.00$

51590 16 196.00$ 3,136.00$

51595 16 196.00$ 3,136.00$

51596 16 196.00$ 3,136.00$

51597 16 196.00$ 3,136.00$

51600 16 196.00$ 3,136.00$

51605 16 196.00$ 3,136.00$

51610 16 196.00$ 3,136.00$

51700 1 100.00$ 100.00$

51705 1 100.00$ 100.00$

51710 1 100.00$ 100.00$

51715 16 196.00$ 3,136.00$

51720 16 196.00$ 3,136.00$

51800 16 196.00$ 3,136.00$

51840 16 196.00$ 3,136.00$

51841 16 196.00$ 3,136.00$

51845 16 196.00$ 3,136.00$

76


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

51860 16 196.00$ 3,136.00$

51865 16 196.00$ 3,136.00$

51880 16 196.00$ 3,136.00$

51900 16 196.00$ 3,136.00$

51920 16 196.00$ 3,136.00$

51925 16 196.00$ 3,136.00$

51980 16 196.00$ 3,136.00$

51990 16 196.00$ 3,136.00$

51992 16 196.00$ 3,136.00$

52000 5 196.00$ 980.00$

52001 16 196.00$ 3,136.00$

52005 16 196.00$ 3,136.00$

52007 16 196.00$ 3,136.00$

52010 16 196.00$ 3,136.00$

52204 16 196.00$ 3,136.00$

52214 16 196.00$ 3,136.00$

52224 16 196.00$ 3,136.00$

52234 16 196.00$ 3,136.00$

52235 16 196.00$ 3,136.00$

52240 16 196.00$ 3,136.00$

52250 16 196.00$ 3,136.00$

52260 16 196.00$ 3,136.00$

52265 16 196.00$ 3,136.00$

52270 16 196.00$ 3,136.00$

52275 16 196.00$ 3,136.00$

52276 16 196.00$ 3,136.00$

52277 16 196.00$ 3,136.00$

52281 16 196.00$ 3,136.00$

52282 16 196.00$ 3,136.00$

52283 16 196.00$ 3,136.00$

52285 16 196.00$ 3,136.00$

52287 16 196.00$ 3,136.00$

52290 16 196.00$ 3,136.00$

52300 16 196.00$ 3,136.00$

52301 16 196.00$ 3,136.00$

52305 16 196.00$ 3,136.00$

52310 16 196.00$ 3,136.00$

52315 16 196.00$ 3,136.00$

52317 16 196.00$ 3,136.00$

77


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

52318 16 196.00$ 3,136.00$

52320 16 196.00$ 3,136.00$

52325 16 196.00$ 3,136.00$

52327 16 196.00$ 3,136.00$

52330 16 196.00$ 3,136.00$

52332 16 196.00$ 3,136.00$

52334 16 196.00$ 3,136.00$

52341 16 196.00$ 3,136.00$

52342 16 196.00$ 3,136.00$

52343 16 196.00$ 3,136.00$

52344 16 196.00$ 3,136.00$

52345 16 196.00$ 3,136.00$

52346 16 196.00$ 3,136.00$

52351 16 196.00$ 3,136.00$

52352 16 196.00$ 3,136.00$

52353 16 196.00$ 3,136.00$

52354 16 196.00$ 3,136.00$

52355 16 196.00$ 3,136.00$

52356 16 196.00$ 3,136.00$

52400 16 196.00$ 3,136.00$

52402 16 196.00$ 3,136.00$

52441 5 196.00$ 980.00$

52442 5 196.00$ 980.00$

52450 16 196.00$ 3,136.00$

52500 16 196.00$ 3,136.00$

52510 16 196.00$ 3,136.00$

52601 16 196.00$ 3,136.00$

52630 16 196.00$ 3,136.00$

52640 16 196.00$ 3,136.00$

52647 16 196.00$ 3,136.00$

52648 16 196.00$ 3,136.00$

52649 7 196.00$ 1,372.00$

52700 16 196.00$ 3,136.00$

53000 16 196.00$ 3,136.00$

53010 16 196.00$ 3,136.00$

53020 16 196.00$ 3,136.00$

53025 16 196.00$ 3,136.00$

53040 16 196.00$ 3,136.00$

53060 16 196.00$ 3,136.00$

78


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

53085 16 196.00$ 3,136.00$

53200 16 196.00$ 3,136.00$

53210 16 196.00$ 3,136.00$

53215 16 196.00$ 3,136.00$

53220 16 196.00$ 3,136.00$

53230 16 196.00$ 3,136.00$

53235 16 196.00$ 3,136.00$

53240 16 196.00$ 3,136.00$

53250 16 196.00$ 3,136.00$

53260 16 196.00$ 3,136.00$

53265 16 196.00$ 3,136.00$

53270 16 196.00$ 3,136.00$

53275 16 196.00$ 3,136.00$

53400 16 196.00$ 3,136.00$

53405 16 196.00$ 3,136.00$

53410 16 196.00$ 3,136.00$

53415 16 196.00$ 3,136.00$

53420 16 196.00$ 3,136.00$

53425 16 196.00$ 3,136.00$

53430 16 196.00$ 3,136.00$

53431 16 196.00$ 3,136.00$

53440 16 196.00$ 3,136.00$

53442 16 196.00$ 3,136.00$

53444 16 196.00$ 3,136.00$

53445 16 196.00$ 3,136.00$

53446 16 196.00$ 3,136.00$

53447 16 196.00$ 3,136.00$

53448 16 196.00$ 3,136.00$

53449 16 196.00$ 3,136.00$

53450 16 196.00$ 3,136.00$

53460 16 196.00$ 3,136.00$

53500 16 196.00$ 3,136.00$

53502 16 196.00$ 3,136.00$

53505 16 196.00$ 3,136.00$

53510 16 196.00$ 3,136.00$

53515 16 196.00$ 3,136.00$

53520 16 196.00$ 3,136.00$

53600 1 100.00$ 100.00$

53601 1 100.00$ 100.00$

79


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

53605 16 196.00$ 3,136.00$

53620 1 100.00$ 100.00$

53621 1 100.00$ 100.00$

53660 16 196.00$ 3,136.00$

53661 16 196.00$ 3,136.00$

53665 16 196.00$ 3,136.00$

53850 16 196.00$ 3,136.00$

53852 16 196.00$ 3,136.00$

54001 16 196.00$ 3,136.00$

54015 16 196.00$ 3,136.00$

54050 1 100.00$ 100.00$

54055 1 100.00$ 100.00$

54057 16 196.00$ 3,136.00$

54060 16 196.00$ 3,136.00$

54065 16 196.00$ 3,136.00$

54100 1 100.00$ 100.00$

54105 16 196.00$ 3,136.00$

54110 16 196.00$ 3,136.00$

54115 16 196.00$ 3,136.00$

54120 16 196.00$ 3,136.00$

54125 16 196.00$ 3,136.00$

54130 16 196.00$ 3,136.00$

54135 16 196.00$ 3,136.00$

54150 16 196.00$ 3,136.00$

54152 16 196.00$ 3,136.00$

54160 16 196.00$ 3,136.00$

54161 6 196.00$ 1,176.00$

54162 16 196.00$ 3,136.00$

54163 16 196.00$ 3,136.00$

54164 16 196.00$ 3,136.00$

54200 1 100.00$ 100.00$

54205 16 196.00$ 3,136.00$

54220 16 196.00$ 3,136.00$

54230 16 196.00$ 3,136.00$

54231 16 196.00$ 3,136.00$

54235 16 196.00$ 3,136.00$

54300 16 196.00$ 3,136.00$

54304 16 196.00$ 3,136.00$

54308 16 196.00$ 3,136.00$

80


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

54322 16 196.00$ 3,136.00$

54324 16 196.00$ 3,136.00$

54326 16 196.00$ 3,136.00$

54328 16 196.00$ 3,136.00$

54332 16 196.00$ 3,136.00$

54336 16 196.00$ 3,136.00$

54340 16 196.00$ 3,136.00$

54344 16 196.00$ 3,136.00$

54348 16 196.00$ 3,136.00$

54352 16 196.00$ 3,136.00$

54360 16 196.00$ 3,136.00$

54380 16 196.00$ 3,136.00$

54385 16 196.00$ 3,136.00$

54390 16 196.00$ 3,136.00$

54400 16 196.00$ 3,136.00$

54401 16 196.00$ 3,136.00$

54405 16 196.00$ 3,136.00$

54406 16 196.00$ 3,136.00$

54408 16 196.00$ 3,136.00$

54410 16 196.00$ 3,136.00$

54411 16 196.00$ 3,136.00$

54415 16 196.00$ 3,136.00$

54416 16 196.00$ 3,136.00$

54417 16 196.00$ 3,136.00$

54420 16 196.00$ 3,136.00$

54435 16 196.00$ 3,136.00$

54437 16 196.00$ 3,136.00$

54440 16 196.00$ 3,136.00$

54450 16 196.00$ 3,136.00$

54500 16 196.00$ 3,136.00$

54505 16 196.00$ 3,136.00$

54512 16 196.00$ 3,136.00$

54520 16 196.00$ 3,136.00$

54530 16 196.00$ 3,136.00$

54535 16 196.00$ 3,136.00$

54550 16 196.00$ 3,136.00$

54560 16 196.00$ 3,136.00$

54600 16 196.00$ 3,136.00$

54620 16 196.00$ 3,136.00$

81


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

54640 16 196.00$ 3,136.00$

54650 16 196.00$ 3,136.00$

54660 16 196.00$ 3,136.00$

54670 16 196.00$ 3,136.00$

54680 16 196.00$ 3,136.00$

54690 16 196.00$ 3,136.00$

54692 16 196.00$ 3,136.00$

54700 16 196.00$ 3,136.00$

54800 16 196.00$ 3,136.00$

54820 16 196.00$ 3,136.00$

54830 16 196.00$ 3,136.00$

54840 16 196.00$ 3,136.00$

54860 16 196.00$ 3,136.00$

54861 16 196.00$ 3,136.00$

54865 7 196.00$ 1,372.00$

54900 16 196.00$ 3,136.00$

54901 16 196.00$ 3,136.00$

55000 1 100.00$ 100.00$

55040 16 196.00$ 3,136.00$

55041 16 196.00$ 3,136.00$

55060 16 196.00$ 3,136.00$

55100 1 100.00$ 100.00$

55110 16 196.00$ 3,136.00$

55120 16 196.00$ 3,136.00$

55150 16 196.00$ 3,136.00$

55175 16 196.00$ 3,136.00$

55180 16 196.00$ 3,136.00$

55200 16 196.00$ 3,136.00$

55250 16 196.00$ 3,136.00$

55500 16 196.00$ 3,136.00$

55520 16 196.00$ 3,136.00$

55530 16 196.00$ 3,136.00$

55535 16 196.00$ 3,136.00$

55540 16 196.00$ 3,136.00$

55550 16 196.00$ 3,136.00$

55600 16 196.00$ 3,136.00$

55605 16 196.00$ 3,136.00$

55650 16 196.00$ 3,136.00$

55680 16 196.00$ 3,136.00$

82


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

55700 16 196.00$ 3,136.00$

55705 16 196.00$ 3,136.00$

55706 3 196.00$ 588.00$

55720 16 196.00$ 3,136.00$

55810 16 196.00$ 3,136.00$

55812 16 196.00$ 3,136.00$

55815 16 196.00$ 3,136.00$

55840 16 196.00$ 3,136.00$

55842 16 196.00$ 3,136.00$

55845 16 196.00$ 3,136.00$

55859 16 196.00$ 3,136.00$

55865 16 196.00$ 3,136.00$

55873 11 196.00$ 2,156.00$

55875 11 196.00$ 2,156.00$

55876 5 196.00$ 980.00$

55920 4 196.00$ 784.00$

56405 1 100.00$ 100.00$

56420 1 100.00$ 100.00$

56440 16 196.00$ 3,136.00$

56441 16 196.00$ 3,136.00$

56442 1 196.00$ 196.00$

56501 16 196.00$ 3,136.00$

56515 16 196.00$ 3,136.00$

56605 1 100.00$ 100.00$

56606 1 100.00$ 100.00$

56620 16 196.00$ 3,136.00$

56625 16 196.00$ 3,136.00$

56630 16 196.00$ 3,136.00$

56631 16 196.00$ 3,136.00$

56632 16 196.00$ 3,136.00$

56633 16 196.00$ 3,136.00$

56634 16 196.00$ 3,136.00$

56637 16 196.00$ 3,136.00$

56640 16 196.00$ 3,136.00$

56700 16 196.00$ 3,136.00$

56720 1 100.00$ 100.00$

56740 16 196.00$ 3,136.00$

56800 16 196.00$ 3,136.00$

56805 16 196.00$ 3,136.00$

83


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

56810 16 196.00$ 3,136.00$

57000 16 196.00$ 3,136.00$

57010 16 196.00$ 3,136.00$

57020 1 100.00$ 100.00$

57022 16 196.00$ 3,136.00$

57023 16 196.00$ 3,136.00$

57061 16 196.00$ 3,136.00$

57065 16 196.00$ 3,136.00$

57100 1 100.00$ 100.00$

57105 16 196.00$ 3,136.00$

57106 16 196.00$ 3,136.00$

57107 16 196.00$ 3,136.00$

57109 16 196.00$ 3,136.00$

57110 16 196.00$ 3,136.00$

57111 16 196.00$ 3,136.00$

57112 16 196.00$ 3,136.00$

57130 16 196.00$ 3,136.00$

57135 16 196.00$ 3,136.00$

57150 1 100.00$ 100.00$

57155 16 196.00$ 3,136.00$

57156 16 196.00$ 3,136.00$

57180 16 196.00$ 3,136.00$

57200 16 196.00$ 3,136.00$

57210 16 196.00$ 3,136.00$

57220 16 196.00$ 3,136.00$

57230 16 196.00$ 3,136.00$

57240 16 196.00$ 3,136.00$

57250 16 196.00$ 3,136.00$

57260 16 196.00$ 3,136.00$

57265 16 196.00$ 3,136.00$

57267 16 196.00$ 3,136.00$

57268 16 196.00$ 3,136.00$

57283 16 196.00$ 3,136.00$

57285 4 196.00$ 784.00$

57287 16 196.00$ 3,136.00$

57288 16 196.00$ 3,136.00$

57295 5 196.00$ 980.00$

57300 16 196.00$ 3,136.00$

57308 16 196.00$ 3,136.00$

84


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

57310 16 196.00$ 3,136.00$

57311 16 196.00$ 3,136.00$

57320 16 196.00$ 3,136.00$

57335 16 196.00$ 3,136.00$

57400 16 196.00$ 3,136.00$

57410 16 196.00$ 3,136.00$

57415 16 196.00$ 3,136.00$

57423 4 196.00$ 784.00$

57425 16 196.00$ 3,136.00$

57429 16 196.00$ 3,136.00$

57452 1 100.00$ 100.00$

57454 1 100.00$ 100.00$

57455 1 100.00$ 100.00$

57460 16 196.00$ 3,136.00$

57461 2 196.00$ 392.00$

57500 1 100.00$ 100.00$

57505 16 196.00$ 3,136.00$

57510 16 196.00$ 3,136.00$

57511 16 196.00$ 3,136.00$

57513 16 196.00$ 3,136.00$

57520 5 196.00$ 980.00$

57522 16 196.00$ 3,136.00$

57530 16 196.00$ 3,136.00$

57531 16 196.00$ 3,136.00$

57540 16 196.00$ 3,136.00$

57545 16 196.00$ 3,136.00$

57550 16 196.00$ 3,136.00$

57555 16 196.00$ 3,136.00$

57556 16 196.00$ 3,136.00$

57558 5 196.00$ 980.00$

57700 16 196.00$ 3,136.00$

57720 16 196.00$ 3,136.00$

57800 1 100.00$ 100.00$

57820 7 196.00$ 1,372.00$

58100 1 100.00$ 100.00$

58110 1 196.00$ 196.00$

58120 5 196.00$ 980.00$

58140 16 196.00$ 3,136.00$

58145 16 196.00$ 3,136.00$

85


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

58150 16 196.00$ 3,136.00$

58152 16 196.00$ 3,136.00$

58180 16 196.00$ 3,136.00$

58200 16 196.00$ 3,136.00$

58210 16 196.00$ 3,136.00$

58240 16 196.00$ 3,136.00$

58260 16 196.00$ 3,136.00$

58262 16 196.00$ 3,136.00$

58263 16 196.00$ 3,136.00$

58267 16 196.00$ 3,136.00$

58270 16 196.00$ 3,136.00$

58275 16 196.00$ 3,136.00$

58280 16 196.00$ 3,136.00$

58285 16 196.00$ 3,136.00$

58290 16 196.00$ 3,136.00$

58291 16 196.00$ 3,136.00$

58292 16 196.00$ 3,136.00$

58293 16 196.00$ 3,136.00$

58294 16 196.00$ 3,136.00$

58300 1 100.00$ 100.00$

58301 1 100.00$ 100.00$

58340 16 196.00$ 3,136.00$

58345 16 196.00$ 3,136.00$

58353 16 196.00$ 3,136.00$

58356 10 196.00$ 1,960.00$

58400 16 196.00$ 3,136.00$

58520 16 196.00$ 3,136.00$

58541 16 196.00$ 3,136.00$

58542 16 196.00$ 3,136.00$

58543 16 196.00$ 3,136.00$

58544 16 196.00$ 3,136.00$

58545 16 196.00$ 3,136.00$

58550 16 196.00$ 3,136.00$

58552 16 196.00$ 3,136.00$

58553 16 196.00$ 3,136.00$

58554 16 196.00$ 3,136.00$

58555 16 196.00$ 3,136.00$

58558 16 196.00$ 3,136.00$

58559 16 196.00$ 3,136.00$

86


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

58560 16 196.00$ 3,136.00$

58561 16 196.00$ 3,136.00$

58562 16 196.00$ 3,136.00$

58563 16 196.00$ 3,136.00$

58565 6 196.00$ 1,176.00$

58570 16 196.00$ 3,136.00$

58571 16 196.00$ 3,136.00$

58572 16 196.00$ 3,136.00$

58573 16 196.00$ 3,136.00$

58600 8 196.00$ 1,568.00$

58605 16 196.00$ 3,136.00$

58611 16 196.00$ 3,136.00$

58615 16 196.00$ 3,136.00$

58660 16 196.00$ 3,136.00$

58661 16 196.00$ 3,136.00$

58662 16 196.00$ 3,136.00$

58670 16 196.00$ 3,136.00$

58671 16 196.00$ 3,136.00$

58672 16 196.00$ 3,136.00$

58673 16 196.00$ 3,136.00$

58700 16 196.00$ 3,136.00$

58720 16 196.00$ 3,136.00$

58740 16 196.00$ 3,136.00$

58770 16 196.00$ 3,136.00$

58800 16 196.00$ 3,136.00$

58805 16 196.00$ 3,136.00$

58820 16 196.00$ 3,136.00$

58900 16 196.00$ 3,136.00$

58920 16 196.00$ 3,136.00$

58925 16 196.00$ 3,136.00$

58940 16 196.00$ 3,136.00$

59000 1 100.00$ 100.00$

59012 16 196.00$ 3,136.00$

59030 1 100.00$ 100.00$

59120 16 196.00$ 3,136.00$

59121 16 196.00$ 3,136.00$

59140 16 196.00$ 3,136.00$

59150 16 196.00$ 3,136.00$

59151 16 196.00$ 3,136.00$

87


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

59160 16 196.00$ 3,136.00$

59200 16 196.00$ 3,136.00$

59300 16 196.00$ 3,136.00$

59320 16 196.00$ 3,136.00$

59325 16 196.00$ 3,136.00$

59409 16 196.00$ 3,136.00$

59410 16 196.00$ 3,136.00$

59412 1 100.00$ 100.00$

59414 16 196.00$ 3,136.00$

59430 16 196.00$ 3,136.00$

59514 16 196.00$ 3,136.00$

59515 16 196.00$ 3,136.00$

59612 16 196.00$ 3,136.00$

59614 16 196.00$ 3,136.00$

59620 16 196.00$ 3,136.00$

59622 16 196.00$ 3,136.00$

59812 4 196.00$ 784.00$

59820 16 196.00$ 3,136.00$

59821 16 196.00$ 3,136.00$

59830 16 196.00$ 3,136.00$

59840 16 196.00$ 3,136.00$

59841 16 196.00$ 3,136.00$

59850 16 196.00$ 3,136.00$

59851 16 196.00$ 3,136.00$

59852 16 196.00$ 3,136.00$

59855 16 196.00$ 3,136.00$

59856 16 196.00$ 3,136.00$

59857 16 196.00$ 3,136.00$

59870 16 196.00$ 3,136.00$

59871 16 196.00$ 3,136.00$

60000 16 196.00$ 3,136.00$

60001 16 196.00$ 3,136.00$

60100 16 196.00$ 3,136.00$

60200 16 196.00$ 3,136.00$

60210 16 196.00$ 3,136.00$

60212 16 196.00$ 3,136.00$

60220 16 196.00$ 3,136.00$

60225 16 196.00$ 3,136.00$

60240 16 196.00$ 3,136.00$

88


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

60252 16 196.00$ 3,136.00$

60254 16 196.00$ 3,136.00$

60271 16 196.00$ 3,136.00$

60280 16 196.00$ 3,136.00$

60281 16 196.00$ 3,136.00$

60300 2 196.00$ 392.00$

60500 16 196.00$ 3,136.00$

60540 16 196.00$ 3,136.00$

61020 16 196.00$ 3,136.00$

61026 16 196.00$ 3,136.00$

61050 16 196.00$ 3,136.00$

61055 16 196.00$ 3,136.00$

61070 16 196.00$ 3,136.00$

61154 16 196.00$ 3,136.00$

61210 16 196.00$ 3,136.00$

61215 16 196.00$ 3,136.00$

61304 16 196.00$ 3,136.00$

61333 16 196.00$ 3,136.00$

61500 16 196.00$ 3,136.00$

61526 16 196.00$ 3,136.00$

61546 16 196.00$ 3,136.00$

61548 16 196.00$ 3,136.00$

61750 16 196.00$ 3,136.00$

61751 16 196.00$ 3,136.00$

61782 16 196.00$ 3,136.00$

61790 16 196.00$ 3,136.00$

61791 16 196.00$ 3,136.00$

61796 3 196.00$ 588.00$ 13

61797 16 196.00$ 3,136.00$

61798 3 196.00$ 588.00$ #N/A

61799 16 196.00$ 3,136.00$

61800 16 196.00$ 3,136.00$

61885 16 196.00$ 3,136.00$

61886 16 196.00$ 3,136.00$

61888 16 196.00$ 3,136.00$

62140 16 196.00$ 3,136.00$

62180 16 196.00$ 3,136.00$

62194 16 196.00$ 3,136.00$

62223 16 196.00$ 3,136.00$

89


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

62225 16 196.00$ 3,136.00$

62230 16 196.00$ 3,136.00$

62252 TC 1 100.00$ 100.00$

62256 16 196.00$ 3,136.00$

62263 16 196.00$ 3,136.00$

62264 16 196.00$ 3,136.00$

62267 2 196.00$ 392.00$

62268 16 196.00$ 3,136.00$

62269 16 196.00$ 3,136.00$

62270 16 196.00$ 3,136.00$

62272 16 196.00$ 3,136.00$

62273 16 196.00$ 3,136.00$

62280 16 196.00$ 3,136.00$

62281 16 196.00$ 3,136.00$

62282 16 196.00$ 3,136.00$

62284 16 196.00$ 3,136.00$

62287 16 196.00$ 3,136.00$

62288 16 196.00$ 3,136.00$

62289 16 196.00$ 3,136.00$

62290 16 196.00$ 3,136.00$

62292 16 196.00$ 3,136.00$

62294 16 196.00$ 3,136.00$

62302 16 196.00$ 3,136.00$

62303 16 196.00$ 3,136.00$

62304 16 196.00$ 3,136.00$

62305 16 196.00$ 3,136.00$

62320 16 196.00$ 3,136.00$

62321 16 196.00$ 3,136.00$

62322 16 196.00$ 3,136.00$

62324 16 196.00$ 3,136.00$

62326 16 196.00$ 3,136.00$

62328 3 196.00$ 588.00$ #N/A

62329 4 196.00$ 784.00$

62350 16 196.00$ 3,136.00$

62351 16 196.00$ 3,136.00$

62355 16 196.00$ 3,136.00$

62360 16 196.00$ 3,136.00$

62361 16 196.00$ 3,136.00$

62362 16 196.00$ 3,136.00$

90


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

62365 16 196.00$ 3,136.00$

63001 16 196.00$ 3,136.00$

63005 16 196.00$ 3,136.00$

63012 16 196.00$ 3,136.00$

63015 16 196.00$ 3,136.00$

63017 16 196.00$ 3,136.00$

63020 16 196.00$ 3,136.00$

63030 16 196.00$ 3,136.00$

63035 16 196.00$ 3,136.00$

63042 16 196.00$ 3,136.00$

63047 16 196.00$ 3,136.00$

63050 16 196.00$ 3,136.00$

63075 16 196.00$ 3,136.00$

63185 16 196.00$ 3,136.00$

63190 16 196.00$ 3,136.00$

63300 16 196.00$ 3,136.00$

63610 16 196.00$ 3,136.00$

63620 3 196.00$ 588.00$ #N/A

63650 16 196.00$ 3,136.00$

63655 16 196.00$ 3,136.00$

63661 8 196.00$ 1,568.00$

63662 16 196.00$ 3,136.00$

63663 16 196.00$ 3,136.00$

63664 16 196.00$ 3,136.00$

63685 16 196.00$ 3,136.00$

63688 16 196.00$ 3,136.00$

63744 16 196.00$ 3,136.00$

63746 16 196.00$ 3,136.00$

63951 16 196.00$ 3,136.00$

64400 1 100.00$ 100.00$

64405 1 100.00$ 100.00$

64408 1 100.00$ 100.00$

64412 1 100.00$ 100.00$

64415 1 100.00$ 100.00$

64417 1 100.00$ 100.00$

64418 1 100.00$ 100.00$

64420 1 100.00$ 100.00$

64421 1 100.00$ 100.00$

64425 1 100.00$ 100.00$

91


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

64430 1 100.00$ 100.00$

64435 1 100.00$ 100.00$

64445 1 100.00$ 100.00$

64450 1 100.00$ 100.00$

64455 2 196.00$ 392.00$

64461 16 196.00$ 3,136.00$

64462 16 196.00$ 3,136.00$

64463 16 196.00$ 3,136.00$

64479 1 100.00$ 100.00$

64480 1 100.00$ 100.00$

64483 16 196.00$ 3,136.00$

64484 1 100.00$ 100.00$

64486 4 196.00$ 784.00$

64487 16 196.00$ 3,136.00$

64488 8 196.00$ 1,568.00$

64489 16 196.00$ 3,136.00$

64490 16 196.00$ 3,136.00$

64491 16 196.00$ 3,136.00$

64492 16 196.00$ 3,136.00$

64493 16 196.00$ 3,136.00$

64494 16 196.00$ 3,136.00$

64495 16 196.00$ 3,136.00$

64505 1 100.00$ 100.00$

64510 1 100.00$ 100.00$

64520 1 100.00$ 100.00$

64530 1 100.00$ 100.00$

64553 1 196.00$ 196.00$

64561 16 196.00$ 3,136.00$

64568 16 196.00$ 3,136.00$

64570 1 196.00$ 196.00$

64575 16 196.00$ 3,136.00$

64581 16 196.00$ 3,136.00$

64585 2 196.00$ 392.00$

64590 16 196.00$ 3,136.00$

64595 16 196.00$ 3,136.00$

64600 16 196.00$ 3,136.00$

64605 16 196.00$ 3,136.00$

64610 16 196.00$ 3,136.00$

64611 16 196.00$ 3,136.00$

92


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

64612 16 196.00$ 3,136.00$

64616 16 196.00$ 3,136.00$

64617 16 196.00$ 3,136.00$

64620 16 196.00$ 3,136.00$

64630 16 196.00$ 3,136.00$

64632 3 196.00$ 588.00$ #N/A

64633 16 196.00$ 3,136.00$

64635 16 196.00$ 3,136.00$

64640 4 196.00$ 784.00$

64642 2 196.00$ 392.00$

64643 2 196.00$ 392.00$

64644 2 196.00$ 392.00$

64645 2 196.00$ 392.00$

64646 2 196.00$ 392.00$

64647 2 196.00$ 392.00$

64650 1 196.00$ 196.00$

64653 1 196.00$ 196.00$

64680 16 196.00$ 3,136.00$

64681 16 196.00$ 3,136.00$

64702 16 196.00$ 3,136.00$

64704 16 196.00$ 3,136.00$

64708 16 196.00$ 3,136.00$

64712 16 196.00$ 3,136.00$

64713 16 196.00$ 3,136.00$

64714 16 196.00$ 3,136.00$

64716 16 196.00$ 3,136.00$

64718 16 196.00$ 3,136.00$

64719 16 196.00$ 3,136.00$

64721 6 196.00$ 1,176.00$

64722 16 196.00$ 3,136.00$

64726 16 196.00$ 3,136.00$

64727 16 196.00$ 3,136.00$

64732 16 196.00$ 3,136.00$

64734 16 196.00$ 3,136.00$

64736 16 196.00$ 3,136.00$

64738 16 196.00$ 3,136.00$

64740 16 196.00$ 3,136.00$

64742 16 196.00$ 3,136.00$

64744 16 196.00$ 3,136.00$

93


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

64746 16 196.00$ 3,136.00$

64755 16 196.00$ 3,136.00$

64760 16 196.00$ 3,136.00$

64771 16 196.00$ 3,136.00$

64772 16 196.00$ 3,136.00$

64774 16 196.00$ 3,136.00$

64776 16 196.00$ 3,136.00$

64778 16 196.00$ 3,136.00$

64782 16 196.00$ 3,136.00$

64783 16 196.00$ 3,136.00$

64784 16 196.00$ 3,136.00$

64786 16 196.00$ 3,136.00$

64787 16 196.00$ 3,136.00$

64788 16 196.00$ 3,136.00$

64790 16 196.00$ 3,136.00$

64792 16 196.00$ 3,136.00$

64795 16 196.00$ 3,136.00$

64802 16 196.00$ 3,136.00$

64818 16 196.00$ 3,136.00$

64820 16 196.00$ 3,136.00$

64821 16 196.00$ 3,136.00$

64822 16 196.00$ 3,136.00$

64823 16 196.00$ 3,136.00$

64831 16 196.00$ 3,136.00$

64832 16 196.00$ 3,136.00$

64834 16 196.00$ 3,136.00$

64835 16 196.00$ 3,136.00$

64836 16 196.00$ 3,136.00$

64837 16 196.00$ 3,136.00$

64840 16 196.00$ 3,136.00$

64856 16 196.00$ 3,136.00$

64857 16 196.00$ 3,136.00$

64858 16 196.00$ 3,136.00$

64859 16 196.00$ 3,136.00$

64861 16 196.00$ 3,136.00$

64862 16 196.00$ 3,136.00$

64864 16 196.00$ 3,136.00$

64865 16 196.00$ 3,136.00$

64872 16 196.00$ 3,136.00$

94


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

64874 16 196.00$ 3,136.00$

64876 16 196.00$ 3,136.00$

64885 16 196.00$ 3,136.00$

64890 16 196.00$ 3,136.00$

64891 16 196.00$ 3,136.00$

64892 16 196.00$ 3,136.00$

64893 16 196.00$ 3,136.00$

64895 16 196.00$ 3,136.00$

64896 16 196.00$ 3,136.00$

64897 16 196.00$ 3,136.00$

64898 16 196.00$ 3,136.00$

64901 16 196.00$ 3,136.00$

64902 16 196.00$ 3,136.00$

64905 16 196.00$ 3,136.00$

64907 16 196.00$ 3,136.00$

64910 16 196.00$ 3,136.00$

64911 16 196.00$ 3,136.00$

64912 16 196.00$ 3,136.00$

64913 16 196.00$ 3,136.00$

65091 16 196.00$ 3,136.00$

65093 16 196.00$ 3,136.00$

65101 16 196.00$ 3,136.00$

65103 16 196.00$ 3,136.00$

65105 16 196.00$ 3,136.00$

65110 16 196.00$ 3,136.00$

65112 16 196.00$ 3,136.00$

65114 16 196.00$ 3,136.00$

65130 16 196.00$ 3,136.00$

65135 16 196.00$ 3,136.00$

65140 16 196.00$ 3,136.00$

65150 16 196.00$ 3,136.00$

65155 16 196.00$ 3,136.00$

65175 16 196.00$ 3,136.00$

65205 1 100.00$ 100.00$

65210 1 100.00$ 100.00$

65220 1 100.00$ 100.00$

65222 1 100.00$ 100.00$

65235 16 196.00$ 3,136.00$

65260 16 196.00$ 3,136.00$

95


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

65265 16 196.00$ 3,136.00$

65270 16 196.00$ 3,136.00$

65272 16 196.00$ 3,136.00$

65275 16 196.00$ 3,136.00$

65280 16 196.00$ 3,136.00$

65285 16 196.00$ 3,136.00$

65286 16 196.00$ 3,136.00$

65290 16 196.00$ 3,136.00$

65400 16 196.00$ 3,136.00$

65410 1 100.00$ 100.00$

65420 16 196.00$ 3,136.00$

65426 16 196.00$ 3,136.00$

65430 16 196.00$ 3,136.00$

65436 16 196.00$ 3,136.00$

65450 16 196.00$ 3,136.00$

65710 16 196.00$ 3,136.00$

65730 16 196.00$ 3,136.00$

65750 16 196.00$ 3,136.00$

65755 16 196.00$ 3,136.00$

65756 5 196.00$ 980.00$

65770 16 196.00$ 3,136.00$

65775 16 196.00$ 3,136.00$

65780 16 196.00$ 3,136.00$

65781 16 196.00$ 3,136.00$

65782 16 196.00$ 3,136.00$

65800 1 100.00$ 100.00$

65805 1 100.00$ 100.00$

65810 16 196.00$ 3,136.00$

65815 16 196.00$ 3,136.00$

65820 16 196.00$ 3,136.00$

65850 16 196.00$ 3,136.00$

65855 16 196.00$ 3,136.00$

65865 16 196.00$ 3,136.00$

65870 16 196.00$ 3,136.00$

65875 16 196.00$ 3,136.00$

65880 16 196.00$ 3,136.00$

65900 16 196.00$ 3,136.00$

65920 16 196.00$ 3,136.00$

65930 16 196.00$ 3,136.00$

96


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

66020 16 196.00$ 3,136.00$

66030 16 196.00$ 3,136.00$

66130 16 196.00$ 3,136.00$

66150 16 196.00$ 3,136.00$

66155 16 196.00$ 3,136.00$

66160 16 196.00$ 3,136.00$

66170 16 196.00$ 3,136.00$

66172 16 196.00$ 3,136.00$

66179 16 196.00$ 3,136.00$

66180 16 196.00$ 3,136.00$

66183 8 196.00$ 1,568.00$

66184 16 196.00$ 3,136.00$

66185 16 196.00$ 3,136.00$

66225 16 196.00$ 3,136.00$

66250 16 196.00$ 3,136.00$

66500 16 196.00$ 3,136.00$

66505 16 196.00$ 3,136.00$

66600 16 196.00$ 3,136.00$

66605 16 196.00$ 3,136.00$

66625 16 196.00$ 3,136.00$

66630 16 196.00$ 3,136.00$

66635 16 196.00$ 3,136.00$

66680 16 196.00$ 3,136.00$

66682 16 196.00$ 3,136.00$

66700 16 196.00$ 3,136.00$

66710 16 196.00$ 3,136.00$

66711 16 196.00$ 3,136.00$

66720 16 196.00$ 3,136.00$

66740 16 196.00$ 3,136.00$

66761 16 196.00$ 3,136.00$

66762 16 196.00$ 3,136.00$

66770 16 196.00$ 3,136.00$

66820 16 196.00$ 3,136.00$

66821 16 196.00$ 3,136.00$

66825 16 196.00$ 3,136.00$

66830 16 196.00$ 3,136.00$

66840 16 196.00$ 3,136.00$

66850 16 196.00$ 3,136.00$

66852 16 196.00$ 3,136.00$

97


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

66920 16 196.00$ 3,136.00$

66930 16 196.00$ 3,136.00$

66940 16 196.00$ 3,136.00$

66982 16 196.00$ 3,136.00$

66983 16 196.00$ 3,136.00$

66984 8 196.00$ 1,568.00$

66985 16 196.00$ 3,136.00$

66986 16 196.00$ 3,136.00$

66987 11 196.00$ 2,156.00$

66988 11 196.00$ 2,156.00$

67005 16 196.00$ 3,136.00$

67010 16 196.00$ 3,136.00$

67015 16 196.00$ 3,136.00$

67025 16 196.00$ 3,136.00$

67027 16 196.00$ 3,136.00$

67028 16 196.00$ 3,136.00$

67030 16 196.00$ 3,136.00$

67031 16 196.00$ 3,136.00$

67036 16 196.00$ 3,136.00$

67038 16 196.00$ 3,136.00$

67039 16 196.00$ 3,136.00$

67040 16 196.00$ 3,136.00$

67041 4 196.00$ 784.00$

67042 4 196.00$ 784.00$

67043 4 196.00$ 784.00$

67101 16 196.00$ 3,136.00$

67105 16 196.00$ 3,136.00$

67107 16 196.00$ 3,136.00$

67108 16 196.00$ 3,136.00$

67110 16 196.00$ 3,136.00$

67113 4 196.00$ 784.00$

67115 16 196.00$ 3,136.00$

67120 16 196.00$ 3,136.00$

67121 16 196.00$ 3,136.00$

67141 16 196.00$ 3,136.00$

67145 16 196.00$ 3,136.00$

67208 16 196.00$ 3,136.00$

67210 16 196.00$ 3,136.00$

67218 16 196.00$ 3,136.00$

98


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

67220 16 196.00$ 3,136.00$

67221 16 196.00$ 3,136.00$

67225 16 196.00$ 3,136.00$

67227 16 196.00$ 3,136.00$

67228 16 196.00$ 3,136.00$

67229 2 196.00$ 392.00$

67250 16 196.00$ 3,136.00$

67255 16 196.00$ 3,136.00$

67311 16 196.00$ 3,136.00$

67312 16 196.00$ 3,136.00$

67314 16 196.00$ 3,136.00$

67316 16 196.00$ 3,136.00$

67318 16 196.00$ 3,136.00$

67320 16 196.00$ 3,136.00$

67331 16 196.00$ 3,136.00$

67332 16 196.00$ 3,136.00$

67334 16 196.00$ 3,136.00$

67335 16 196.00$ 3,136.00$

67340 16 196.00$ 3,136.00$

67343 16 196.00$ 3,136.00$

67345 16 196.00$ 3,136.00$

67346 4 196.00$ 784.00$

67350 16 196.00$ 3,136.00$

67400 16 196.00$ 3,136.00$

67405 16 196.00$ 3,136.00$

67412 16 196.00$ 3,136.00$

67413 16 196.00$ 3,136.00$

67414 16 196.00$ 3,136.00$

67415 16 196.00$ 3,136.00$

67420 16 196.00$ 3,136.00$

67430 16 196.00$ 3,136.00$

67440 16 196.00$ 3,136.00$

67445 16 196.00$ 3,136.00$

67450 16 196.00$ 3,136.00$

67500 16 196.00$ 3,136.00$

67505 2 196.00$ 392.00$

67550 16 196.00$ 3,136.00$

67560 16 196.00$ 3,136.00$

67570 16 196.00$ 3,136.00$

99


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

67700 1 100.00$ 100.00$

67710 1 100.00$ 100.00$

67715 1 100.00$ 100.00$

67800 1 100.00$ 100.00$

67801 1 100.00$ 100.00$

67805 1 100.00$ 100.00$

67808 16 196.00$ 3,136.00$

67810 1 100.00$ 100.00$

67820 1 100.00$ 100.00$

67825 16 196.00$ 3,136.00$

67830 16 196.00$ 3,136.00$

67835 16 196.00$ 3,136.00$

67840 1 100.00$ 100.00$

67850 1 100.00$ 100.00$

67875 16 196.00$ 3,136.00$

67880 16 196.00$ 3,136.00$

67882 16 196.00$ 3,136.00$

67900 16 196.00$ 3,136.00$

67901 16 196.00$ 3,136.00$

67902 16 196.00$ 3,136.00$

67903 16 196.00$ 3,136.00$

67904 16 196.00$ 3,136.00$

67906 16 196.00$ 3,136.00$

67908 16 196.00$ 3,136.00$

67909 16 196.00$ 3,136.00$

67911 16 196.00$ 3,136.00$

67912 16 196.00$ 3,136.00$

67914 16 196.00$ 3,136.00$

67916 16 196.00$ 3,136.00$

67917 16 196.00$ 3,136.00$

67921 16 196.00$ 3,136.00$

67922 16 196.00$ 3,136.00$

67923 16 196.00$ 3,136.00$

67924 16 196.00$ 3,136.00$

67930 16 196.00$ 3,136.00$

67935 16 196.00$ 3,136.00$

67938 1 100.00$ 100.00$

67950 16 196.00$ 3,136.00$

67961 16 196.00$ 3,136.00$

100


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

67966 16 196.00$ 3,136.00$

67971 16 196.00$ 3,136.00$

67973 16 196.00$ 3,136.00$

67974 16 196.00$ 3,136.00$

67975 16 196.00$ 3,136.00$

68100 16 196.00$ 3,136.00$

68110 16 196.00$ 3,136.00$

68115 16 196.00$ 3,136.00$

68130 16 196.00$ 3,136.00$

68320 16 196.00$ 3,136.00$

68325 16 196.00$ 3,136.00$

68326 16 196.00$ 3,136.00$

68328 16 196.00$ 3,136.00$

68330 16 196.00$ 3,136.00$

68335 16 196.00$ 3,136.00$

68340 16 196.00$ 3,136.00$

68360 16 196.00$ 3,136.00$

68362 16 196.00$ 3,136.00$

68371 16 196.00$ 3,136.00$

68400 16 196.00$ 3,136.00$

68420 16 196.00$ 3,136.00$

68500 16 196.00$ 3,136.00$

68505 16 196.00$ 3,136.00$

68510 16 196.00$ 3,136.00$

68520 16 196.00$ 3,136.00$

68525 16 196.00$ 3,136.00$

68530 16 196.00$ 3,136.00$

68540 16 196.00$ 3,136.00$

68550 16 196.00$ 3,136.00$

68700 16 196.00$ 3,136.00$

68720 16 196.00$ 3,136.00$

68745 16 196.00$ 3,136.00$

68750 16 196.00$ 3,136.00$

68760 16 196.00$ 3,136.00$

68761 16 196.00$ 3,136.00$

68801 16 196.00$ 3,136.00$

68810 16 196.00$ 3,136.00$

68811 16 196.00$ 3,136.00$

68815 16 196.00$ 3,136.00$

101


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

68816 3 196.00$ 588.00$ 6

68840 1 100.00$ 100.00$

68850 1 100.00$ 100.00$

69000 1 100.00$ 100.00$

69005 16 196.00$ 3,136.00$

69020 1 100.00$ 100.00$

69100 1 100.00$ 100.00$

69105 1 100.00$ 100.00$

69110 16 196.00$ 3,136.00$

69120 16 196.00$ 3,136.00$

69140 16 196.00$ 3,136.00$

69145 16 196.00$ 3,136.00$

69150 16 196.00$ 3,136.00$

69200 1 100.00$ 100.00$

69205 16 196.00$ 3,136.00$

69209 16 196.00$ 3,136.00$

69210 16 196.00$ 3,136.00$

69220 16 196.00$ 3,136.00$

69222 16 196.00$ 3,136.00$

69310 16 196.00$ 3,136.00$

69320 16 196.00$ 3,136.00$

69420 16 196.00$ 3,136.00$

69421 16 196.00$ 3,136.00$

69424 16 196.00$ 3,136.00$

69433 16 196.00$ 3,136.00$

69436 5 196.00$ 980.00$

69440 16 196.00$ 3,136.00$

69450 16 196.00$ 3,136.00$

69501 16 196.00$ 3,136.00$

69502 16 196.00$ 3,136.00$

69505 16 196.00$ 3,136.00$

69511 16 196.00$ 3,136.00$

69530 16 196.00$ 3,136.00$

69540 16 196.00$ 3,136.00$

69550 16 196.00$ 3,136.00$

69552 16 196.00$ 3,136.00$

69601 16 196.00$ 3,136.00$

69602 16 196.00$ 3,136.00$

69603 16 196.00$ 3,136.00$

102


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

69604 16 196.00$ 3,136.00$

69605 16 196.00$ 3,136.00$

69610 16 196.00$ 3,136.00$

69620 16 196.00$ 3,136.00$

69631 16 196.00$ 3,136.00$

69632 16 196.00$ 3,136.00$

69633 16 196.00$ 3,136.00$

69635 16 196.00$ 3,136.00$

69636 16 196.00$ 3,136.00$

69637 16 196.00$ 3,136.00$

69641 16 196.00$ 3,136.00$

69642 16 196.00$ 3,136.00$

69643 16 196.00$ 3,136.00$

69644 16 196.00$ 3,136.00$

69645 16 196.00$ 3,136.00$

69646 16 196.00$ 3,136.00$

69650 16 196.00$ 3,136.00$

69660 16 196.00$ 3,136.00$

69661 16 196.00$ 3,136.00$

69662 16 196.00$ 3,136.00$

69666 16 196.00$ 3,136.00$

69667 16 196.00$ 3,136.00$

69670 16 196.00$ 3,136.00$

69676 16 196.00$ 3,136.00$

69700 16 196.00$ 3,136.00$

69710 16 196.00$ 3,136.00$

69711 16 196.00$ 3,136.00$

69714 16 196.00$ 3,136.00$

69715 16 196.00$ 3,136.00$

69717 16 196.00$ 3,136.00$

69718 16 196.00$ 3,136.00$

69720 16 196.00$ 3,136.00$

69725 16 196.00$ 3,136.00$

69740 16 196.00$ 3,136.00$

69745 16 196.00$ 3,136.00$

69801 16 196.00$ 3,136.00$

69805 16 196.00$ 3,136.00$

69806 16 196.00$ 3,136.00$

69905 16 196.00$ 3,136.00$

103


Service

Code Mod Max Unit

Per Unit

Amount

Maximum

Reimbursement

Units Eff

05/01/20

69910 16 196.00$ 3,136.00$

69915 16 196.00$ 3,136.00$

69930 16 196.00$ 3,136.00$

90870 1 196.00$ 196.00$

S2325 16 196.00$ 3,136.00$

104

2020 surgery max unit list 01/01/20 - 12/31/21 op surgery max/… · 2020 surgery max unit list...

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