appendix c for administrative order no. 20-053 ambulatory ...note: listing of a payment amount does...

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0023

Effective April 1, 2020 Link to medical fee and payment rules

HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment

(Implantable Devices

are Paid Seperately)

HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



10004 N packaged 11446 Y $1,692.88 12042 Y $278.2110005 Y $125.08 11450 Y $1,692.88 12044 Y $432.2410006 N packaged 11451 Y $1,692.88 12045 Y $432.2410007 Y $387.28 11462 Y $1,692.88 12046 Y $278.2110008 N packaged 11463 Y $1,692.88 12047 Y $1,409.1110009 Y $513.61 11470 Y $1,692.88 12051 Y $278.2110010 N packaged 11471 Y $1,692.88 12052 Y $278.2110011 Y $513.61 11600 Y $226.71 12053 Y $278.2110012 N packaged 11601 Y $252.58 12054 N $278.2110021 Y $101.99 11602 Y $278.21 12055 Y $278.2110030 Y $513.61 11603 Y $292.27 12056 N $278.2110035 N packaged 11604 Y $513.61 12057 Y $278.2110036 N packaged 11606 Y $966.11 13100 Y $432.2410040 N packaged 11620 Y $228.66 13101 Y $432.2410060 Y $130.01 11621 Y $253.18 13102 N packaged10061 Y $199.01 11622 Y $274.83 13120 Y $432.2410080 Y $275.43 11623 Y $303.67 13121 Y $432.2410081 Y $347.59 11624 Y $966.11 13122 N packaged10120 Y $184.09 11626 Y $1,692.88 13131 Y $278.2110121 Y $966.11 11640 Y $233.93 13132 Y $432.2410140 Y $184.50 11641 Y $261.00 13133 N packaged10160 Y $143.66 11642 Y $285.65 13151 Y $432.2410180 Y $1,692.88 11643 Y $314.56 13152 Y $432.2411000 Y $59.02 11644 Y $966.11 13153 N packaged11001 N packaged 11646 Y $1,692.88 13160 Y $1,409.1111004 Y 80% of billed 11719 N packaged 14000 Y $1,409.1111005 Y 80% of billed 11720 N packaged 14001 Y $1,409.1111006 Y 80% of billed 11721 N packaged 14020 Y $1,409.1111008 Y 80% of billed 11730 N packaged 14021 Y $1,409.1111010 Y $513.61 11732 N packaged 14040 Y $1,409.1111011 Y $513.61 11740 N packaged 14041 Y $1,409.1111012 Y $1,692.88 11750 Y $171.03 14060 Y $1,409.1111042 Y $278.21 11755 Y $128.09 14061 Y $1,409.1111043 Y $432.24 11760 Y $432.24 14301 Y $2,561.4811044 Y $966.11 11762 Y $321.26 14302 N packaged11045 N packaged 11765 N packaged 14350 Y $1,409.1111046 N packaged 11770 Y $1,692.88 15002 Y $1,409.1111047 N packaged 11771 Y $1,692.88 15003 N packaged11055 N packaged 11772 Y $1,692.88 15004 Y $432.2411056 N packaged 11900 N packaged 15005 N packaged11057 Y $100.14 11901 N packaged 15040 Y $1,409.1111102 Y $130.63 11920 Y $213.67 15050 Y $432.2411103 N packaged 11921 Y $236.65 15100 Y $1,409.1111104 Y $152.17 11922 N packaged 15101 N packaged11105 N packaged 11950 Y $80.25 15110 Y $1,409.1111106 Y $200.25 11951 Y $103.11 15111 N packaged11107 N packaged 11952 Y $132.92 15115 Y $1,409.1111200 N packaged 11954 Y $147.38 15116 N packaged11201 N packaged 11960 Y $2,561.48 15120 Y $2,561.4811300 N packaged 11970 Y $3,735.27 15121 N packaged11301 N packaged 11971 N $1,692.88 15130 Y $1,409.1111302 N packaged 11976 N $125.69 15131 N packaged11303 N packaged 11980 N packaged 15135 Y $2,561.4811305 N packaged 11981 N packaged 15136 N packaged11306 N packaged 11982 N packaged 15150 Y $1,409.1111307 Y $152.17 11983 N packaged 15151 N packaged11308 N packaged 12001 N packaged 15152 N packaged11310 Y $149.29 12002 N packaged 15155 Y $2,561.4811311 Y $152.17 12004 N packaged 15156 N packaged11312 Y $191.55 12005 N $278.21 15157 N packaged11313 Y $212.08 12006 N $278.21 15200 Y $1,409.1111400 Y $153.95 12007 Y $152.17 15201 N packaged11401 Y $181.59 12011 N packaged 15220 Y $1,409.1111402 Y $191.84 12013 N packaged 15221 N packaged11403 Y $208.07 12014 N packaged 15240 Y $1,409.1111404 Y $966.11 12015 N $152.17 15241 N packaged11406 Y $966.11 12016 N $278.21 15260 Y $1,409.1111420 Y $148.81 12017 N $278.21 15261 N packaged11421 Y $173.80 12018 N $152.17 15271 Y $1,409.1111422 Y $193.57 12020 Y $432.24 15272 N packaged11423 Y $209.90 12021 Y $278.21 15273 Y $2,561.4811424 Y $966.11 12031 Y $278.21 15274 N packaged11426 Y $1,692.88 12032 Y $278.21 15275 Y $1,409.1111440 Y $168.98 12034 Y $278.21 15276 N packaged11441 Y $190.03 12035 Y $278.21 15277 Y $1,409.1111442 Y $205.68 12036 Y $432.24 15278 N packaged11443 Y $229.26 12037 Y $1,409.11 15570 Y $1,409.1111444 Y $966.11 12041 N $278.21 15572 Y $2,561.48

Appendix C for Administrative Order No. 20-053

Ambulatory Surgery Center Fee Schedule Amounts for Surgical Procedures

CPT only copyright 2019 American Medical Association. All rights reserved

2020 Appendix C of 26

https://wcd.oregon.gov/Rules/div_009/9-20060.pdf



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






15574 Y $1,409.11 15940 Y $1,692.88 19287 N packaged15576 Y $1,409.11 15941 Y $1,692.88 19288 N packaged15600 Y $2,561.48 15944 Y $2,561.48 19294 N packaged15610 Y $1,409.11 15945 Y $1,409.11 19296 Y $4,976.6715620 Y $1,409.11 15946 Y $1,409.11 19297 N packaged15630 Y $1,409.11 15950 Y $966.11 19298 Y $3,684.9115650 Y $1,409.11 15951 Y $1,692.88 19300 Y $1,908.5915730 Y $2,561.48 15952 Y $1,409.11 19301 Y $1,908.5915731 Y $2,561.48 15953 Y $2,561.48 19302 Y $3,684.9115733 Y $2,561.48 15956 Y $1,409.11 19303 Y $3,684.9115734 Y $2,561.48 15958 Y $2,561.48 19305 Y 80% of billed15736 Y $1,409.11 15999 Y $513.63 19306 Y 80% of billed15738 Y $2,561.48 16000 N packaged 19307 Y $4,446.2715740 Y $1,409.11 16020 N packaged 19316 Y $3,684.9115750 Y $2,561.48 16025 Y $152.17 19318 Y $3,684.9115756 Y 80% of billed 16030 Y $278.21 19324 Y $3,193.3215757 Y 80% of billed 16035 Y $278.21 19325 Y $3,193.3215758 Y 80% of billed 16036 Y 80% of billed 19328 N $1,908.5915760 Y $1,409.11 17000 N packaged 19330 N $1,908.5915769 Y $2,561.48 17003 N packaged 19340 Y $3,684.9115770 Y $2,561.48 17004 Y $185.95 19342 Y $3,193.3215771 Y $2,561.48 17106 Y $278.21 19350 Y $1,908.5915772 N packaged 17107 Y $432.24 19355 Y $1,908.5915773 Y $1,409.11 17108 Y $607.19 19357 Y $5,615.0115774 N packaged 17110 N packaged 19361 Y 80% of billed15775 Y $278.21 17111 N packaged 19364 Y 80% of billed15776 Y $278.21 17250 N packaged 19366 Y $3,684.9115777 N packaged 17260 N packaged 19367 Y 80% of billed15780 Y $963.42 17261 N packaged 19368 Y 80% of billed15781 Y $513.61 17262 N packaged 19369 Y 80% of billed15782 Y $644.53 17263 N packaged 19370 Y $1,908.5915783 Y $278.21 17264 Y $227.62 19371 Y $1,908.5915786 N packaged 17266 Y $250.62 19380 Y $3,684.9115787 N packaged 17270 Y $152.17 19396 Y $1,908.5915788 N packaged 17271 Y $152.17 19499 Y $2,612.3515789 Y $432.24 17272 N packaged 20100 Y $384.2015792 N packaged 17273 Y $224.49 20101 Y $1,409.1615793 N packaged 17274 Y $253.10 20102 Y $1,409.1615819 Y $1,409.11 17276 Y $278.21 20103 Y $513.6115820 Y $1,409.11 17280 N packaged 20150 Y $2,110.4915821 Y $1,409.11 17281 Y $194.65 20200 Y $966.1115822 Y $1,409.11 17282 Y $218.91 20205 Y $1,692.8815823 Y $1,409.11 17283 Y $247.51 20206 Y $966.1115824 Y $1,409.11 17284 Y $272.68 20220 Y $966.1115825 Y $2,561.48 17286 Y $324.87 20225 Y $966.1115826 Y $2,561.48 17311 Y $432.24 20240 Y $1,692.8815828 Y $2,561.48 17312 N packaged 20245 Y $1,692.8815829 Y $2,561.48 17313 Y $432.24 20250 Y $2,110.4915830 Y $3,684.91 17314 N packaged 20251 Y $3,735.2715832 Y $1,692.88 17315 N packaged 20500 Y $111.2515833 Y $1,692.88 17340 N packaged 20501 N packaged15834 Y $1,692.88 17360 N packaged 20520 Y $232.8815835 Y $1,692.88 17380 Y $432.24 20525 Y $1,692.8815836 Y $1,692.88 17999 Y $152.17 20526 Y $71.5015837 Y $1,692.88 19000 Y $129.88 20527 Y $77.7215838 Y $1,692.88 19001 N packaged 20550 Y $44.7515839 Y $1,692.88 19020 Y $966.11 20551 Y $47.2515840 Y $2,561.48 19030 N packaged 20552 Y $52.2315841 Y $2,561.48 19081 Y $966.11 20553 Y $60.9415842 Y $1,409.11 19082 N packaged 20555 Y $2,110.4915845 Y $2,561.48 19083 Y $966.11 20560 Y 80% of billed15847 N packaged 19084 N packaged 20561 Y 80% of billed15850 Y $432.24 19085 Y $966.11 20600 Y $42.9115851 Y $122.81 19086 N packaged 20604 Y $74.0015852 N packaged 19100 Y $966.11 20605 Y $44.7515860 N packaged 19101 Y $1,908.59 20606 Y $80.1015876 Y $2,561.48 19105 Y $1,908.59 20610 Y $53.4815877 Y $2,561.48 19110 Y $1,908.59 20611 Y $90.1615878 Y $1,409.11 19112 Y $1,908.59 20612 Y $60.3215879 Y $2,561.48 19120 Y $1,908.59 20615 Y $270.0115920 Y $1,692.88 19125 Y $1,908.59 20650 Y $2,110.4915922 Y $2,561.48 19126 N packaged 20660 Y $1,176.7615931 Y $1,692.88 19281 N packaged 20661 Y 80% of billed15933 Y $1,692.88 19282 N packaged 20662 Y $1,225.0715934 Y $2,561.48 19283 N packaged 20663 Y $2,110.4915935 Y $2,561.48 19284 N packaged 20664 Y 80% of billed15936 Y $1,409.11 19285 N packaged 20665 N $308.6415937 Y $1,409.11 19286 N packaged 20670 N $966.11





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






20680 N $1,692.88 21076 Y $683.87 21282 Y $1,791.3320690 Y $5,005.01 21077 Y $1,627.36 21295 Y $899.0520692 Y $7,492.34 21079 Y $1,186.90 21296 Y $1,791.3320693 Y $3,735.27 21080 Y $1,385.43 21299 Y $176.5220694 N $1,225.07 21081 Y $1,242.59 21310 Y $187.5420696 Y $7,640.58 21082 Y $1,212.62 21315 Y $899.0520697 Y $1,225.07 21083 Y $1,195.47 21320 Y $1,791.3320700 N packaged 21084 Y $1,340.70 21325 Y $1,791.3320701 N packaged 21085 Y $176.50 21330 Y $3,690.3920702 N packaged 21086 Y $1,264.72 21335 Y $1,791.3320703 N packaged 21087 Y $1,223.63 21336 Y $2,110.4920704 N packaged 21088 Y $1,791.33 21337 Y $1,791.3320705 N packaged 21089 Y $176.52 21338 Y $5,387.8820802 Y 80% of billed 21100 Y $3,690.39 21339 Y $3,690.3920805 Y 80% of billed 21110 N $899.05 21340 Y $1,791.3320808 Y 80% of billed 21116 N packaged 21343 Y 80% of billed20816 Y 80% of billed 21120 Y $3,690.39 21344 Y 80% of billed20822 Y $1,225.07 21121 Y $1,791.33 21345 Y $899.0520824 Y 80% of billed 21122 Y $3,690.39 21346 Y $4,026.2520827 Y 80% of billed 21123 Y $1,791.33 21347 Y 80% of billed20838 Y 80% of billed 21125 Y $3,690.39 21348 Y 80% of billed20900 Y $3,735.27 21127 Y $3,690.39 21355 Y $1,791.3320902 Y $3,735.27 21137 Y $1,791.33 21356 Y $3,690.3920910 Y $432.24 21138 Y $3,690.39 21360 Y $3,690.3920912 Y $2,561.48 21139 Y $3,690.39 21365 Y $4,026.2520920 Y $1,409.11 21141 Y 80% of billed 21366 Y 80% of billed20922 Y $1,409.11 21142 Y 80% of billed 21385 Y $4,026.2520924 Y $3,735.27 21143 Y 80% of billed 21386 Y $4,026.2520930 N packaged 21145 Y 80% of billed 21387 Y $4,026.2520931 N packaged 21146 Y 80% of billed 21390 Y $3,690.3920932 N packaged 21147 Y 80% of billed 21395 Y $4,026.2520933 N packaged 21150 Y $3,690.39 21400 Y $384.1720934 N packaged 21151 Y 80% of billed 21401 Y $899.0520936 N packaged 21154 Y 80% of billed 21406 Y $3,690.3920937 N packaged 21155 Y 80% of billed 21407 Y $3,690.3920938 N packaged 21159 Y 80% of billed 21408 Y $4,026.2520939 N packaged 21160 Y 80% of billed 21421 Y $1,791.3320950 Y $513.61 21172 Y $4,026.25 21422 Y 80% of billed20955 Y 80% of billed 21175 Y $4,026.25 21423 Y 80% of billed20956 Y 80% of billed 21179 Y 80% of billed 21431 Y 80% of billed20957 Y 80% of billed 21180 Y 80% of billed 21432 Y 80% of billed20962 Y 80% of billed 21181 Y $3,690.39 21433 Y 80% of billed20969 Y 80% of billed 21182 Y 80% of billed 21435 Y 80% of billed20970 Y 80% of billed 21183 Y 80% of billed 21436 Y 80% of billed20972 Y $3,735.27 21184 Y 80% of billed 21440 Y $866.4320973 Y $3,735.27 21188 Y 80% of billed 21445 Y $3,690.3920974 Y 80% of billed 21193 Y $4,026.25 21450 Y $384.1720975 N packaged 21194 Y 80% of billed 21451 Y $899.0520979 N packaged 21195 Y $4,026.25 21452 Y $3,690.3920982 Y $3,735.27 21196 Y 80% of billed 21453 Y $3,690.3920983 Y $5,058.04 21198 Y $3,690.39 21454 Y $3,690.3920985 N packaged 21199 Y $3,690.39 21461 Y $5,180.4620999 Y $187.54 21206 Y $3,690.39 21462 Y $5,073.5321010 Y $1,791.33 21208 Y $4,840.48 21465 Y $3,690.3921011 Y $414.36 21209 Y $3,690.39 21470 Y $4,026.2521012 Y $966.11 21210 Y $3,690.39 21480 Y $187.5421013 Y $535.94 21215 Y $3,690.39 21485 Y $899.0521014 Y $1,692.88 21230 Y $3,690.39 21490 Y $1,791.3321015 Y $1,692.88 21235 Y $3,690.39 21497 Y $899.0521016 Y $1,692.88 21240 Y $3,690.39 21499 Y $176.5221025 Y $3,690.39 21242 Y $3,690.39 21501 Y $1,692.8821026 Y $3,690.39 21243 Y $7,793.54 21502 Y $2,110.4921029 Y $1,791.33 21244 Y $3,690.39 21510 Y 80% of billed21030 Y $515.78 21245 Y $3,690.39 21550 Y $966.1121031 Y $460.78 21246 Y $3,690.39 21552 Y $1,692.8821032 Y $458.34 21247 Y 80% of billed 21554 Y $1,692.8821034 Y $3,690.39 21248 Y $3,690.39 21555 Y $966.1121040 Y $1,791.33 21249 Y $3,690.39 21556 Y $1,692.8821044 Y $3,690.39 21255 Y 80% of billed 21557 Y $1,692.8821045 Y 80% of billed 21256 Y $4,026.25 21558 Y $1,692.8821046 Y $3,690.39 21260 Y $3,690.39 21600 Y $3,735.2721047 Y $3,690.39 21261 Y $4,026.25 21601 Y $1,994.9121048 Y $3,690.39 21263 Y $4,026.25 21602 Y 80% of billed21049 Y $4,026.25 21267 Y $3,690.39 21603 Y 80% of billed21050 Y $3,690.39 21268 Y 80% of billed 21610 Y $2,110.4921060 Y $3,690.39 21270 Y $3,690.39 21615 Y 80% of billed21070 Y $3,690.39 21275 Y $3,690.39 21616 Y 80% of billed21073 Y $431.13 21280 Y $1,791.33 21620 Y 80% of billed





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






21627 Y 80% of billed 22610 Y 80% of billed 23155 Y $3,735.2721630 Y 80% of billed 22612 Y $7,924.42 23156 Y $5,785.8121632 Y 80% of billed 22614 N packaged 23170 Y $2,110.4921685 Y $3,690.39 22630 Y 80% of billed 23172 Y $2,110.4921700 Y $3,735.27 22632 Y 80% of billed 23174 Y $3,735.2721705 Y 80% of billed 22633 Y $5,536.22 23180 Y $3,735.2721720 Y $2,110.49 22634 N packaged 23182 Y $3,735.2721725 Y $513.61 22800 Y 80% of billed 23184 Y $3,735.2721740 Y 80% of billed 22802 Y 80% of billed 23190 Y $2,110.4921742 Y $2,269.63 22804 Y 80% of billed 23195 Y $3,735.2721743 Y $2,269.63 22808 Y 80% of billed 23200 Y 80% of billed21750 Y 80% of billed 22810 Y 80% of billed 23210 Y 80% of billed21811 Y $4,027.55 22812 Y 80% of billed 23220 Y 80% of billed21812 Y $4,027.55 22818 Y 80% of billed 23330 Y $513.6121813 Y $1,176.76 22819 Y 80% of billed 23333 Y $1,692.8821820 Y $187.54 22830 Y 80% of billed 23334 Y $1,692.8821825 Y 80% of billed 22840 N packaged 23335 Y 80% of billed21899 Y $176.52 22841 Y 80% of billed 23350 N packaged21920 Y $298.21 22842 N packaged 23395 Y $3,735.2721925 Y $966.11 22843 Y 80% of billed 23397 Y $3,735.2721930 Y $966.11 22844 Y 80% of billed 23400 Y $3,735.2721931 Y $966.11 22845 N packaged 23405 Y $3,735.2721932 Y $1,692.88 22846 Y 80% of billed 23406 Y $5,354.6421933 Y $1,692.88 22847 Y 80% of billed 23410 Y $3,735.2721935 Y $1,692.88 22848 Y 80% of billed 23412 Y $3,735.2721936 Y $1,692.88 22849 Y 80% of billed 23415 Y $3,735.2722010 Y 80% of billed 22850 Y 80% of billed 23420 Y $3,735.2722015 Y 80% of billed 22852 Y 80% of billed 23430 Y $3,735.2722100 Y $4,027.55 22853 N packaged 23440 Y $3,735.2722101 Y $4,027.55 22854 N packaged 23450 Y $3,735.2722102 Y $3,735.27 22855 Y 80% of billed 23455 Y $3,735.2722103 N packaged 22856 Y $7,599.21 23460 Y $3,735.2722110 Y 80% of billed 22857 Y 80% of billed 23462 Y $3,735.2722112 Y 80% of billed 22858 N packaged 23465 Y $3,735.2722114 Y 80% of billed 22859 N packaged 23466 Y $3,735.2722116 Y 80% of billed 22861 Y 80% of billed 23470 Y $5,536.2222206 Y 80% of billed 22862 Y 80% of billed 23472 Y 80% of billed22207 Y 80% of billed 22864 Y 80% of billed 23473 Y $5,536.2222208 Y 80% of billed 22865 Y 80% of billed 23474 Y 80% of billed22210 Y 80% of billed 22867 Y $7,881.57 23480 Y $3,735.2722212 Y 80% of billed 22868 N packaged 23485 Y $7,234.2322214 Y 80% of billed 22869 Y $9,091.09 23490 Y $3,735.2722216 Y 80% of billed 22870 N packaged 23491 Y $7,369.4922220 Y 80% of billed 22899 Y $187.54 23500 Y $187.5422222 Y 80% of billed 22900 Y $1,692.88 23505 Y $1,225.0722224 Y 80% of billed 22901 Y $1,692.88 23515 Y $5,125.7022226 Y 80% of billed 22902 Y $966.11 23520 Y $1,225.0722310 Y $187.54 22903 Y $1,692.88 23525 Y $187.5422315 Y $2,110.49 22904 Y $1,692.88 23530 Y $3,735.2722318 Y 80% of billed 22905 Y $1,692.88 23532 Y $3,735.2722319 Y 80% of billed 22999 Y $187.54 23540 Y $187.5422325 Y 80% of billed 23000 Y $1,692.88 23545 Y $187.5422326 Y 80% of billed 23020 Y $2,110.49 23550 Y $3,735.2722327 Y 80% of billed 23030 Y $1,692.88 23552 Y $5,092.7922328 Y 80% of billed 23031 Y $1,692.88 23570 Y $187.5422505 Y $1,225.07 23035 Y $1,225.07 23575 Y $1,225.0722510 Y $2,110.49 23040 Y $2,110.49 23585 Y $3,735.2722511 Y $2,110.49 23044 Y $2,110.49 23600 Y $187.5422512 N packaged 23065 Y $228.05 23605 Y $1,225.0722513 Y $3,735.27 23066 Y $1,692.88 23615 Y $7,631.7322514 Y $3,735.27 23071 Y $966.11 23616 Y $7,511.6722515 N packaged 23073 Y $1,692.88 23620 Y $187.5422526 Y 80% of billed 23075 Y $966.11 23625 Y $1,225.0722527 Y 80% of billed 23076 Y $1,692.88 23630 Y $4,938.8122532 Y 80% of billed 23077 Y $1,692.88 23650 Y $187.5422533 Y 80% of billed 23078 Y $1,692.88 23655 Y $1,225.0722534 Y 80% of billed 23100 Y $2,110.49 23660 Y $3,735.2722548 Y 80% of billed 23101 Y $2,110.49 23665 Y $1,225.0722551 Y $7,751.48 23105 Y $3,735.27 23670 Y $3,735.2722552 N packaged 23106 Y $2,110.49 23675 Y $1,225.0722554 Y $7,758.19 23107 Y $3,735.27 23680 Y $7,707.6122556 Y 80% of billed 23120 Y $2,110.49 23700 Y $1,225.0722558 Y 80% of billed 23125 Y $2,110.49 23800 Y $3,735.2722585 N packaged 23130 Y $2,110.49 23802 Y $5,272.5822586 Y 80% of billed 23140 Y $2,110.49 23900 Y 80% of billed22590 Y 80% of billed 23145 Y $2,110.49 23920 Y 80% of billed22595 Y 80% of billed 23146 Y $3,735.27 23921 Y $1,409.1122600 Y 80% of billed 23150 Y $2,110.49 23929 Y $187.54





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






23930 Y $1,692.88 24535 Y $1,225.07 25210 Y $2,110.4923931 Y $966.11 24538 Y $3,735.27 25215 Y $2,110.4923935 Y $2,110.49 24545 Y $7,554.29 25230 Y $2,110.4924000 Y $2,110.49 24546 Y $7,060.01 25240 Y $2,110.4924006 Y $2,110.49 24560 Y $187.54 25246 N packaged24065 Y $302.45 24565 Y $1,225.07 25248 Y $1,225.0724066 Y $1,692.88 24566 Y $1,225.07 25250 N $1,225.0724071 Y $1,692.88 24575 Y $6,824.35 25251 N $2,110.4924073 Y $1,692.88 24576 Y $187.54 25259 Y $1,225.0724075 Y $966.11 24577 Y $1,225.07 25260 Y $2,110.4924076 Y $1,692.88 24579 Y $6,941.01 25263 Y $3,735.2724077 Y $1,692.88 24582 Y $3,735.27 25265 Y $2,110.4924079 Y $1,692.88 24586 Y $5,272.58 25270 Y $2,110.4924100 Y $2,110.49 24587 Y $7,604.88 25272 Y $2,110.4924101 Y $2,110.49 24600 Y $187.54 25274 Y $2,110.4924102 Y $2,110.49 24605 Y $1,225.07 25275 Y $2,110.4924105 Y $2,110.49 24615 Y $3,735.27 25280 Y $2,110.4924110 Y $2,110.49 24620 Y $1,225.07 25290 Y $2,110.4924115 Y $3,735.27 24635 Y $5,213.11 25295 Y $2,110.4924116 Y $3,735.27 24640 Y $96.28 25300 Y $2,110.4924120 Y $2,110.49 24650 Y $187.54 25301 Y $2,110.4924125 Y $2,110.49 24655 Y $1,225.07 25310 Y $2,110.4924126 Y $5,691.82 24665 Y $3,735.27 25312 Y $2,110.4924130 Y $2,110.49 24666 Y $8,361.66 25315 Y $3,735.2724134 Y $3,735.27 24670 Y $187.54 25316 Y $3,735.2724136 Y $2,110.49 24675 Y $1,225.07 25320 Y $3,735.2724138 Y $3,735.27 24685 Y $4,907.73 25332 Y $2,110.4924140 Y $2,110.49 24800 Y $3,735.27 25335 Y $2,110.4924145 Y $3,735.27 24802 Y $5,272.58 25337 Y $3,735.2724147 Y $2,110.49 24900 Y 80% of billed 25350 Y $5,786.5324149 Y $3,735.27 24920 Y 80% of billed 25355 Y $2,110.4924150 Y $4,027.55 24925 Y $2,110.49 25360 Y $3,735.2724152 Y $3,735.27 24930 Y 80% of billed 25365 Y $5,272.5824155 Y $2,110.49 24931 Y 80% of billed 25370 Y $2,110.4924160 N $2,110.49 24935 Y $4,027.55 25375 Y $2,110.4924164 N $2,110.49 24940 Y 80% of billed 25390 Y $5,259.1924200 Y $246.82 24999 Y $187.54 25391 Y $7,402.5224201 Y $1,692.88 25000 Y $1,225.07 25392 Y $3,735.2724220 N packaged 25001 Y $2,110.49 25393 Y $3,735.2724300 Y $1,225.07 25020 Y $1,225.07 25394 Y $2,110.4924301 Y $3,735.27 25023 Y $2,110.49 25400 Y $5,269.0624305 Y $2,110.49 25024 Y $2,110.49 25405 Y $5,210.1724310 Y $2,110.49 25025 Y $1,225.07 25415 Y $5,390.8524320 Y $3,735.27 25028 Y $2,110.49 25420 Y $3,735.2724330 Y $3,735.27 25031 Y $1,225.07 25425 Y $3,735.2724331 Y $3,735.27 25035 Y $3,735.27 25426 Y $2,110.4924332 Y $2,110.49 25040 Y $2,110.49 25430 Y $2,110.4924340 Y $3,735.27 25065 Y $306.09 25431 Y $3,735.2724341 Y $3,735.27 25066 Y $1,692.88 25440 Y $3,735.2724342 Y $3,735.27 25071 Y $966.11 25441 Y $8,597.0624343 Y $2,110.49 25073 Y $1,692.88 25442 Y $8,224.5124344 Y $3,735.27 25075 Y $966.11 25443 Y $5,207.9824345 Y $3,735.27 25076 Y $966.11 25444 Y $8,667.7724346 Y $5,272.58 25077 Y $1,692.88 25445 Y $5,262.8324357 Y $2,110.49 25078 Y $1,692.88 25446 Y $8,272.6224358 Y $2,110.49 25085 Y $2,110.49 25447 Y $2,110.4924359 Y $2,110.49 25100 Y $2,110.49 25449 Y $3,735.2724360 Y $3,735.27 25101 Y $2,110.49 25450 Y $2,110.4924361 Y $7,861.37 25105 Y $2,110.49 25455 Y $2,110.4924362 Y $5,272.58 25107 Y $2,110.49 25490 Y $3,735.2724363 Y $7,855.59 25109 Y $2,110.49 25491 Y $5,272.5824365 Y $7,905.32 25110 Y $1,225.07 25492 Y $2,110.4924366 Y $8,404.51 25111 Y $1,225.07 25500 Y $187.5424370 Y $7,763.87 25112 Y $1,225.07 25505 Y $1,225.0724371 Y $7,040.28 25115 Y $1,225.07 25515 Y $5,013.7924400 Y $3,735.27 25116 Y $2,110.49 25520 Y $1,225.0724410 Y $5,272.58 25118 Y $1,225.07 25525 Y $3,735.2724420 Y $3,735.27 25119 Y $2,110.49 25526 Y $4,965.1624430 Y $7,387.54 25120 Y $2,110.49 25530 Y $187.5424435 Y $7,440.71 25125 Y $1,225.07 25535 Y $187.5424470 Y $2,110.49 25126 Y $2,110.49 25545 Y $4,917.9824495 Y $3,735.27 25130 Y $2,110.49 25560 Y $187.5424498 Y $7,284.82 25135 Y $3,735.27 25565 Y $1,225.0724500 Y $187.54 25136 Y $4,948.69 25574 Y $5,289.5324505 Y $1,225.07 25145 Y $2,110.49 25575 Y $5,142.8924515 Y $7,195.51 25150 Y $2,110.49 25600 Y $187.5424516 Y $7,298.23 25151 Y $2,110.49 25605 Y $1,225.0724530 Y $187.54 25170 Y $4,027.55 25606 Y $2,110.49





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






25607 Y $5,379.14 26230 Y $2,110.49 26555 Y $3,735.2725608 Y $5,356.10 26235 Y $1,225.07 26556 Y 80% of billed25609 Y $5,378.03 26236 Y $1,225.07 26560 Y $1,225.0725622 Y $187.54 26250 Y $2,110.49 26561 Y $2,110.4925624 Y $1,225.07 26260 Y $2,110.49 26562 Y $2,110.4925628 Y $3,735.27 26262 Y $1,225.07 26565 Y $2,110.4925630 Y $187.54 26320 N $966.11 26567 Y $2,110.4925635 Y $1,225.07 26340 Y $1,225.07 26568 Y $3,735.2725645 Y $2,110.49 26341 Y $122.99 26580 Y $2,110.4925650 Y $187.54 26350 Y $2,110.49 26587 Y $2,110.4925651 Y $2,110.49 26352 Y $3,735.27 26590 Y $1,225.0725652 Y $3,735.27 26356 Y $2,110.49 26591 Y $2,110.4925660 Y $187.54 26357 Y $2,110.49 26593 Y $2,110.4925670 Y $3,735.27 26358 Y $3,735.27 26596 Y $2,110.4925671 Y $2,110.49 26370 Y $2,110.49 26600 Y $187.5425675 Y $187.54 26372 Y $3,735.27 26605 Y $187.5425676 Y $3,735.27 26373 Y $2,110.49 26607 Y $2,110.4925680 Y $187.54 26390 Y $4,956.37 26608 Y $2,110.4925685 Y $3,735.27 26392 Y $3,735.27 26615 Y $2,110.4925690 Y $1,225.07 26410 Y $1,225.07 26641 Y $187.5425695 Y $3,735.27 26412 Y $2,110.49 26645 Y $1,225.0725800 Y $5,431.80 26415 Y $2,110.49 26650 Y $2,110.4925805 Y $5,401.09 26416 Y $2,110.49 26665 Y $2,110.4925810 Y $7,321.98 26418 Y $1,225.07 26670 Y $187.5425820 Y $5,077.42 26420 Y $2,110.49 26675 Y $1,225.0725825 Y $5,048.17 26426 Y $2,110.49 26676 Y $2,110.4925830 Y $4,950.15 26428 Y $2,110.49 26685 Y $2,110.4925900 Y 80% of billed 26432 Y $1,225.07 26686 Y $2,110.4925905 Y 80% of billed 26433 Y $2,110.49 26700 Y $187.5425907 Y $2,110.49 26434 Y $2,110.49 26705 Y $1,225.0725909 Y $4,027.55 26437 Y $2,110.49 26706 Y $2,110.4925915 Y 80% of billed 26440 Y $1,225.07 26715 Y $2,110.4925920 Y 80% of billed 26442 Y $2,110.49 26720 Y $187.5425922 Y $1,225.07 26445 Y $2,110.49 26725 Y $187.5425924 Y 80% of billed 26449 Y $2,110.49 26727 Y $2,110.4925927 Y 80% of billed 26450 Y $2,110.49 26735 Y $2,110.4925929 Y $1,409.11 26455 Y $1,225.07 26740 Y $187.5425931 Y $2,110.49 26460 Y $1,225.07 26742 Y $1,225.0725999 Y $187.54 26471 Y $2,110.49 26746 Y $2,110.4926010 Y $152.17 26474 Y $1,225.07 26750 Y $187.5426011 Y $966.11 26476 Y $2,110.49 26755 Y $187.5426020 Y $2,110.49 26477 Y $2,110.49 26756 Y $2,110.4926025 Y $2,110.49 26478 Y $2,110.49 26765 Y $2,110.4926030 Y $2,110.49 26479 Y $2,110.49 26770 Y $187.5426034 Y $1,225.07 26480 Y $2,110.49 26775 Y $200.1126035 Y $2,110.49 26483 Y $2,110.49 26776 Y $2,110.4926037 Y $2,110.49 26485 Y $2,110.49 26785 Y $2,110.4926040 Y $1,225.07 26489 Y $2,110.49 26820 Y $5,122.4126045 Y $2,110.49 26490 Y $2,110.49 26841 Y $3,735.2726055 Y $1,225.07 26492 Y $2,110.49 26842 Y $3,735.2726060 Y $1,225.07 26494 Y $2,110.49 26843 Y $3,735.2726070 Y $1,225.07 26496 Y $2,110.49 26844 Y $3,735.2726075 Y $2,110.49 26497 Y $2,110.49 26850 Y $3,735.2726080 Y $1,225.07 26498 Y $2,110.49 26852 Y $3,735.2726100 Y $2,110.49 26499 Y $2,110.49 26860 Y $2,110.4926105 Y $2,110.49 26500 Y $3,735.27 26861 N packaged26110 Y $1,225.07 26502 Y $2,110.49 26862 Y $2,110.4926111 Y $966.11 26508 Y $2,110.49 26863 N packaged26113 Y $966.11 26510 Y $2,110.49 26910 Y $2,110.4926115 Y $966.11 26516 Y $2,110.49 26951 Y $2,110.4926116 Y $966.11 26517 Y $2,110.49 26952 Y $2,110.4926117 Y $1,692.88 26518 Y $3,735.27 26989 Y $187.5426118 Y $1,692.88 26520 Y $2,110.49 26990 Y $2,110.4926121 Y $2,110.49 26525 Y $1,225.07 26991 Y $1,225.0726123 Y $2,110.49 26530 Y $3,735.27 26992 Y 80% of billed26125 N packaged 26531 Y $5,357.93 27000 Y $1,225.0726130 Y $2,110.49 26535 Y $2,110.49 27001 Y $2,110.4926135 Y $2,110.49 26536 Y $4,957.84 27003 Y $3,735.2726140 Y $1,225.07 26540 Y $2,110.49 27005 Y 80% of billed26145 Y $1,225.07 26541 Y $2,110.49 27006 Y $2,269.6326160 Y $1,225.07 26542 Y $2,110.49 27025 Y 80% of billed26170 Y $1,225.07 26545 Y $2,110.49 27027 Y $4,027.5526180 Y $1,225.07 26546 Y $3,735.27 27030 Y 80% of billed26185 Y $1,225.07 26548 Y $2,110.49 27033 Y $3,735.2726200 Y $1,225.07 26550 Y $2,110.49 27035 Y $2,110.4926205 Y $3,735.27 26551 Y 80% of billed 27036 Y 80% of billed26210 Y $1,225.07 26553 Y 80% of billed 27040 Y $966.1126215 Y $2,110.49 26554 Y 80% of billed 27041 Y $966.11





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






27043 Y $1,692.88 27240 Y 80% of billed 27412 Y $4,027.5527045 Y $1,692.88 27244 Y 80% of billed 27415 Y $8,663.6527047 Y $1,692.88 27245 Y 80% of billed 27416 Y $3,735.2727048 Y $1,692.88 27246 Y $187.54 27418 Y $3,735.2727049 Y $1,692.88 27248 Y 80% of billed 27420 Y $3,735.2727050 Y $1,225.07 27250 Y $187.54 27422 Y $3,735.2727052 Y $1,225.07 27252 Y $1,225.07 27424 Y $3,735.2727054 Y 80% of billed 27253 Y 80% of billed 27425 Y $2,110.4927057 Y $1,176.76 27254 Y 80% of billed 27427 Y $4,837.8827059 Y $1,692.88 27256 Y $187.54 27428 Y $7,104.6527060 Y $3,735.27 27257 Y $1,225.07 27429 Y $9,311.0027062 Y $2,110.49 27258 Y 80% of billed 27430 Y $3,735.2727065 Y $3,735.27 27259 Y 80% of billed 27435 Y $2,110.4927066 Y $2,110.49 27265 Y $187.54 27437 Y $3,735.2727067 Y $3,735.27 27266 Y $1,225.07 27438 Y $7,241.9727070 Y 80% of billed 27267 Y $2,110.49 27440 Y $7,787.6127071 Y 80% of billed 27268 Y 80% of billed 27441 Y $5,272.5827075 Y 80% of billed 27269 Y 80% of billed 27442 Y $7,802.5827076 Y 80% of billed 27275 Y $1,225.07 27443 Y $7,610.5627077 Y 80% of billed 27279 Y $8,355.83 27445 Y 80% of billed27078 Y 80% of billed 27280 Y 80% of billed 27446 Y $7,743.2227080 Y $2,110.49 27282 Y 80% of billed 27447 Y $7,926.4827086 Y $981.31 27284 Y 80% of billed 27448 Y 80% of billed27087 Y $2,110.49 27286 Y 80% of billed 27450 Y 80% of billed27090 Y 80% of billed 27290 Y 80% of billed 27454 Y 80% of billed27091 Y 80% of billed 27295 Y 80% of billed 27455 Y 80% of billed27093 N packaged 27299 Y $187.54 27457 Y 80% of billed27095 N packaged 27301 Y $1,692.88 27465 Y 80% of billed27096 Y 80% of billed 27303 Y 80% of billed 27466 Y 80% of billed27097 Y $2,110.49 27305 Y $2,110.49 27468 Y 80% of billed27098 Y $2,110.49 27306 Y $2,110.49 27470 Y 80% of billed27100 Y $3,735.27 27307 Y $2,110.49 27472 Y 80% of billed27105 Y $2,110.49 27310 Y $2,110.49 27475 Y $3,735.2727110 Y $3,735.27 27323 Y $966.11 27477 Y $4,027.5527111 Y $2,110.49 27324 Y $1,692.88 27479 Y $3,735.2727120 Y 80% of billed 27325 Y $1,366.57 27485 Y $4,027.5527122 Y 80% of billed 27326 Y $1,366.57 27486 Y 80% of billed27125 Y 80% of billed 27327 Y $966.11 27487 Y 80% of billed27130 Y $5,536.22 27328 Y $1,692.88 27488 Y 80% of billed27132 Y 80% of billed 27329 Y $1,692.88 27495 Y 80% of billed27134 Y 80% of billed 27330 Y $2,110.49 27496 Y $2,110.4927137 Y 80% of billed 27331 Y $2,110.49 27497 Y $2,110.4927138 Y 80% of billed 27332 Y $2,110.49 27498 Y $1,225.0727140 Y 80% of billed 27333 Y $2,110.49 27499 Y $3,735.2727146 Y 80% of billed 27334 Y $2,110.49 27500 Y $187.5427147 Y 80% of billed 27335 Y $3,735.27 27501 Y $187.5427151 Y 80% of billed 27337 Y $1,692.88 27502 Y $1,225.0727156 Y 80% of billed 27339 Y $1,692.88 27503 Y $1,225.0727158 Y 80% of billed 27340 Y $2,110.49 27506 Y 80% of billed27161 Y 80% of billed 27345 Y $2,110.49 27507 Y 80% of billed27165 Y 80% of billed 27347 Y $2,110.49 27508 Y $187.5427170 Y 80% of billed 27350 Y $3,735.27 27509 Y $3,735.2727175 Y 80% of billed 27355 Y $2,110.49 27510 Y $1,225.0727176 Y 80% of billed 27356 Y $5,272.58 27511 Y 80% of billed27177 Y 80% of billed 27357 Y $3,735.27 27513 Y 80% of billed27178 Y 80% of billed 27358 N packaged 27514 Y 80% of billed27179 Y $4,027.55 27360 Y $2,110.49 27516 Y $187.5427181 Y 80% of billed 27364 Y $1,692.88 27517 Y $1,225.0727185 Y 80% of billed 27365 Y 80% of billed 27519 Y 80% of billed27187 Y 80% of billed 27369 N packaged 27520 Y $187.5427197 Y $187.54 27372 Y $1,692.88 27524 Y $3,735.2727198 Y $187.54 27380 Y $3,735.27 27530 Y $187.5427200 Y $187.54 27381 Y $3,735.27 27532 Y $2,110.4927202 Y $2,110.49 27385 Y $3,735.27 27535 Y 80% of billed27215 Y 80% of billed 27386 Y $3,735.27 27536 Y 80% of billed27216 Y 80% of billed 27390 Y $2,110.49 27538 Y $187.5427217 Y 80% of billed 27391 Y $2,110.49 27540 Y 80% of billed27218 Y 80% of billed 27392 Y $2,110.49 27550 Y $187.5427220 Y $187.54 27393 Y $3,735.27 27552 Y $1,225.0727222 Y 80% of billed 27394 Y $3,735.27 27556 Y 80% of billed27226 Y 80% of billed 27395 Y $2,110.49 27557 Y 80% of billed27227 Y 80% of billed 27396 Y $3,735.27 27558 Y 80% of billed27228 Y 80% of billed 27397 Y $3,735.27 27560 Y $187.5427230 Y $187.54 27400 Y $3,735.27 27562 Y $187.5427232 Y 80% of billed 27403 Y $4,934.80 27566 Y $3,735.2727235 Y $4,027.55 27405 Y $3,735.27 27570 Y $1,225.0727236 Y 80% of billed 27407 Y $3,735.27 27580 Y 80% of billed27238 Y $1,225.07 27409 Y $3,735.27 27590 Y 80% of billed





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






27591 Y 80% of billed 27745 Y $5,203.60 28086 Y $2,110.4927592 Y 80% of billed 27750 Y $187.54 28088 Y $2,110.4927594 Y $2,110.49 27752 Y $1,225.07 28090 Y $1,225.0727596 Y 80% of billed 27756 Y $5,457.40 28092 Y $1,225.0727598 Y 80% of billed 27758 Y $7,450.53 28100 Y $2,110.4927599 Y $187.54 27759 Y $7,356.07 28102 Y $3,735.2727600 Y $2,110.49 27760 Y $187.54 28103 Y $3,735.2727601 Y $2,110.49 27762 Y $1,225.07 28104 Y $2,110.4927602 Y $2,110.49 27766 Y $3,735.27 28106 Y $3,735.2727603 Y $1,692.88 27767 Y $187.54 28107 Y $3,735.2727604 Y $2,110.49 27768 Y $1,225.07 28108 Y $1,225.0727605 Y $1,225.07 27769 Y $3,735.27 28110 Y $2,110.4927606 Y $2,110.49 27780 Y $187.54 28111 Y $2,110.4927607 Y $2,110.49 27781 Y $1,225.07 28112 Y $2,110.4927610 Y $2,110.49 27784 Y $3,735.27 28113 Y $2,110.4927612 Y $2,110.49 27786 Y $187.54 28114 Y $2,110.4927613 Y $285.51 27788 Y $187.54 28116 Y $2,110.4927614 Y $1,692.88 27792 Y $4,936.64 28118 Y $2,110.4927615 Y $1,692.88 27808 Y $187.54 28119 Y $2,110.4927616 Y $1,692.88 27810 Y $1,225.07 28120 Y $2,110.4927618 Y $966.11 27814 Y $5,014.88 28122 Y $2,110.4927619 Y $1,692.88 27816 Y $187.54 28124 Y $495.0427620 Y $2,110.49 27818 Y $1,225.07 28126 Y $2,110.4927625 Y $2,110.49 27822 Y $4,993.67 28130 Y $5,574.4227626 Y $2,110.49 27823 Y $4,977.23 28140 Y $2,110.4927630 Y $2,110.49 27824 Y $187.54 28150 Y $2,110.4927632 Y $1,692.88 27825 Y $1,225.07 28153 Y $2,110.4927634 Y $1,692.88 27826 Y $5,217.49 28160 Y $2,110.4927635 Y $2,110.49 27827 Y $7,380.84 28171 Y $2,110.4927637 Y $3,735.27 27828 Y $7,509.89 28173 Y $2,110.4927638 Y $3,735.27 27829 Y $3,735.27 28175 Y $1,225.0727640 Y $2,110.49 27830 Y $187.54 28190 Y $303.6827641 Y $2,110.49 27831 Y $2,110.49 28192 Y $966.1127645 Y 80% of billed 27832 Y $3,735.27 28193 Y $966.1127646 Y 80% of billed 27840 Y $187.54 28200 Y $2,110.4927647 Y $2,110.49 27842 Y $1,225.07 28202 Y $3,735.2727648 N packaged 27846 Y $3,735.27 28208 Y $2,110.4927650 Y $3,735.27 27848 Y $5,502.75 28210 Y $3,735.2727652 Y $3,735.27 27860 Y $2,110.49 28220 Y $489.8727654 Y $3,735.27 27870 Y $7,777.81 28222 Y $2,110.4927656 Y $2,110.49 27871 Y $7,495.95 28225 Y $2,110.4927658 Y $2,110.49 27880 Y 80% of billed 28226 Y $2,110.4927659 Y $3,735.27 27881 Y 80% of billed 28230 Y $483.0627664 Y $3,735.27 27882 Y 80% of billed 28232 Y $450.8027665 Y $3,735.27 27884 Y $2,110.49 28234 Y $1,225.0727675 Y $2,110.49 27886 Y 80% of billed 28238 Y $3,735.2727676 Y $3,735.27 27888 Y 80% of billed 28240 Y $2,110.4927680 Y $2,110.49 27889 Y $3,735.27 28250 Y $2,110.4927681 Y $2,110.49 27892 Y $2,110.49 28260 Y $2,110.4927685 Y $2,110.49 27893 Y $3,735.27 28261 Y $1,225.0727686 Y $2,110.49 27894 Y $2,110.49 28262 Y $5,907.9627687 Y $2,110.49 27899 Y $187.54 28264 Y $1,225.0727690 Y $3,735.27 28001 Y $303.06 28270 Y $2,110.4927691 Y $3,735.27 28002 Y $1,225.07 28272 Y $435.3127692 N packaged 28003 Y $2,110.49 28280 Y $2,110.4927695 Y $3,735.27 28005 Y $2,110.49 28285 Y $2,110.4927696 Y $3,735.27 28008 Y $2,110.49 28286 Y $2,110.4927698 Y $3,735.27 28010 Y $213.94 28288 Y $2,110.4927700 Y $3,735.27 28011 Y $1,225.07 28289 Y $2,110.4927702 Y 80% of billed 28020 Y $2,110.49 28291 Y $5,730.2227703 Y 80% of billed 28022 Y $2,110.49 28292 Y $2,110.4927704 N $2,110.49 28024 Y $1,225.07 28295 Y $2,110.4927705 Y $5,379.87 28035 Y $1,366.57 28296 Y $2,110.4927707 Y $2,110.49 28039 Y $1,692.88 28297 Y $5,357.5627709 Y $5,272.58 28041 Y $1,692.88 28298 Y $3,735.2727712 Y 80% of billed 28043 Y $966.11 28299 Y $3,735.2727715 Y 80% of billed 28045 Y $1,692.88 28300 Y $4,995.8627720 Y $5,126.79 28046 Y $1,692.88 28302 Y $3,735.2727722 Y $4,027.55 28047 Y $1,692.88 28304 Y $3,735.2727724 Y 80% of billed 28050 Y $2,110.49 28305 Y $5,379.1427725 Y 80% of billed 28052 Y $2,110.49 28306 Y $3,735.2727726 Y $5,222.61 28054 Y $2,110.49 28307 Y $3,735.2727727 Y 80% of billed 28055 Y $1,366.57 28308 Y $2,110.4927730 Y $2,110.49 28060 Y $2,110.49 28309 Y $3,735.2727732 Y $2,110.49 28062 Y $2,110.49 28310 Y $3,735.2727734 Y $2,110.49 28070 Y $3,735.27 28312 Y $2,110.4927740 Y $2,110.49 28072 Y $2,110.49 28313 Y $2,110.4927742 Y $2,110.49 28080 Y $1,225.07 28315 Y $2,110.49





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






28320 Y $8,173.24 29049 Y $106.98 29861 Y $3,735.2728322 Y $5,094.98 29055 Y $200.11 29862 Y $3,735.2728340 Y $2,110.49 29058 Y $120.03 29863 Y $2,110.4928341 Y $2,110.49 29065 Y $103.87 29866 Y $3,735.2728344 Y $2,110.49 29075 Y $95.17 29867 Y $7,811.8928345 Y $1,225.07 29085 Y $103.27 29868 Y $4,027.5528360 Y $4,027.55 29086 Y $93.95 29870 Y $2,110.4928400 Y $187.54 29105 Y $85.84 29871 Y $2,110.4928405 Y $187.54 29125 N packaged 29873 Y $2,110.4928406 Y $3,735.27 29126 N packaged 29874 Y $2,110.4928415 Y $5,163.01 29130 N packaged 29875 Y $2,110.4928420 Y $7,595.59 29131 N packaged 29876 Y $2,110.4928430 Y $187.54 29200 Y $32.36 29877 Y $2,110.4928435 Y $1,225.07 29240 N packaged 29879 Y $2,110.4928436 Y $3,735.27 29260 N packaged 29880 Y $2,110.4928445 Y $4,847.03 29280 N packaged 29881 Y $2,110.4928446 Y $3,735.27 29305 Y $200.11 29882 Y $2,110.4928450 Y $187.54 29325 Y $200.11 29883 Y $2,110.4928455 Y $288.35 29345 Y $135.60 29884 Y $2,110.4928456 Y $3,735.27 29355 Y $138.08 29885 Y $3,735.2728465 Y $5,104.84 29358 Y $174.15 29886 Y $2,110.4928470 Y $187.54 29365 Y $128.12 29887 Y $3,735.2728475 Y $187.54 29405 Y $83.34 29888 Y $5,160.8128476 Y $2,110.49 29425 Y $78.36 29889 Y $7,053.5528485 Y $4,972.47 29435 Y $115.69 29891 Y $2,110.4928490 Y $170.20 29440 Y $37.94 29892 Y $3,735.2728495 Y $187.54 29445 Y $106.98 29893 Y $2,110.4928496 Y $2,110.49 29450 Y $112.59 29894 Y $2,110.4928505 Y $2,110.49 29505 Y $100.15 29895 Y $2,110.4928510 Y $134.79 29515 Y $72.77 29897 Y $2,110.4928515 Y $182.00 29520 N packaged 29898 Y $2,110.4928525 Y $2,110.49 29530 N packaged 29899 Y $4,843.0028530 Y $129.20 29540 Y $24.25 29900 Y $2,110.4928531 Y $3,735.27 29550 N packaged 29901 Y $2,110.4928540 Y $187.54 29580 Y $72.77 29902 Y $1,225.0728545 Y $2,110.49 29581 Y $116.49 29904 Y $2,110.4928546 Y $1,225.07 29584 Y $116.49 29905 Y $3,735.2728555 Y $3,735.27 29700 Y $69.65 29906 Y $2,110.4928570 Y $187.54 29705 Y $59.10 29907 Y $7,237.8428575 Y $2,110.49 29710 Y $116.30 29914 Y $3,735.2728576 Y $3,735.27 29720 Y $97.67 29915 Y $3,735.2728585 Y $5,508.95 29730 Y $55.99 29916 Y $3,735.2728600 Y $187.54 29740 Y $91.43 29999 Y $187.5428605 Y $187.54 29750 Y $95.78 30000 Y $176.5028606 Y $2,110.49 29799 Y $116.49 30020 Y $344.7828615 Y $4,870.79 29800 Y $2,110.49 30100 Y $179.5928630 Y $153.43 29804 Y $2,110.49 30110 Y $296.2928635 Y $1,225.07 29805 Y $2,110.49 30115 Y $1,791.3328636 Y $2,110.49 29806 Y $3,735.27 30117 Y $1,791.3328645 Y $2,110.49 29807 Y $3,735.27 30118 Y $1,791.3328660 Y $118.64 29819 Y $2,110.49 30120 Y $1,791.3328665 Y $200.11 29820 Y $3,735.27 30124 Y $899.0528666 Y $2,110.49 29821 Y $2,110.49 30125 Y $3,690.3928675 Y $2,110.49 29822 Y $2,110.49 30130 Y $1,791.3328705 Y $7,452.51 29823 Y $2,110.49 30140 Y $1,791.3328715 Y $8,137.10 29824 Y $2,110.49 30150 Y $3,690.3928725 Y $7,474.27 29825 Y $2,110.49 30160 Y $3,690.3928730 Y $8,041.60 29826 N packaged 30200 Y $142.2628735 Y $8,122.13 29827 Y $3,735.27 30210 Y $178.9928737 Y $7,721.02 29828 Y $3,735.27 30220 Y $899.0528740 Y $5,522.50 29830 Y $2,110.49 30300 N packaged28750 Y $5,421.19 29834 Y $2,110.49 30310 Y $1,791.3328755 Y $3,735.27 29835 Y $2,110.49 30320 Y $899.0528760 Y $3,735.27 29836 Y $3,735.27 30400 Y $3,690.3928800 Y 80% of billed 29837 Y $2,110.49 30410 Y $3,690.3928805 Y $2,269.63 29838 Y $2,110.49 30420 Y $3,690.3928810 Y $2,110.49 29840 Y $2,110.49 30430 Y $3,690.3928820 Y $2,110.49 29843 Y $2,110.49 30435 Y $3,690.3928825 Y $2,110.49 29844 Y $2,110.49 30450 Y $3,690.3928890 Y $336.71 29845 Y $2,110.49 30460 Y $3,690.3928899 Y $187.54 29846 Y $2,110.49 30462 Y $3,690.3929000 Y $200.11 29847 Y $3,735.27 30465 Y $3,690.3929010 Y $200.11 29848 Y $1,225.07 30520 Y $1,791.3329015 Y $200.11 29850 Y $1,225.07 30540 Y $3,690.3929035 Y $200.11 29851 Y $1,225.07 30545 Y $3,690.3929040 Y $200.11 29855 Y $5,733.14 30560 Y $384.1729044 Y $116.49 29856 Y $7,220.81 30580 Y $3,690.3929046 Y $200.11 29860 Y $3,735.27 30600 Y $3,690.39





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






30620 Y $3,690.39 31510 Y $2,086.31 31652 Y $2,086.3130630 Y $1,791.33 31511 Y $136.35 31653 Y $2,086.3130801 Y $899.05 31512 Y $2,086.31 31654 N packaged30802 Y $899.05 31513 Y $328.94 31660 Y $4,096.0130901 N packaged 31515 Y $328.94 31661 Y $4,096.0130903 Y $94.90 31520 Y $328.94 31717 Y $328.9430905 Y $94.90 31525 Y $1,047.94 31720 N packaged30906 Y $176.50 31526 Y $1,047.94 31725 Y 80% of billed30915 Y $1,873.09 31527 Y $2,086.31 31730 Y $1,047.9430920 Y $1,873.09 31528 Y $2,086.31 31750 Y $3,690.3930930 Y $1,791.33 31529 Y $2,086.31 31755 Y $3,690.3930999 Y $176.52 31530 Y $1,047.94 31760 Y 80% of billed31000 Y $176.50 31531 Y $2,086.31 31766 Y 80% of billed31002 Y $899.05 31535 Y $2,086.31 31770 Y 80% of billed31020 Y $1,791.33 31536 Y $2,086.31 31775 Y 80% of billed31030 Y $3,690.39 31540 Y $2,086.31 31780 Y 80% of billed31032 Y $3,690.39 31541 Y $2,086.31 31781 Y 80% of billed31040 Y $3,690.39 31545 Y $2,086.31 31785 Y $4,026.2531050 Y $3,690.39 31546 Y $2,824.83 31786 Y 80% of billed31051 Y $3,690.39 31551 Y $3,690.39 31800 Y 80% of billed31070 Y $3,690.39 31552 Y $3,690.39 31805 Y 80% of billed31075 Y $3,690.39 31553 Y $3,690.39 31820 Y $1,791.3331080 Y $3,690.39 31554 Y $3,690.39 31825 Y $1,791.3331081 Y $3,690.39 31560 Y $2,824.83 31830 Y $1,791.3331084 Y $3,690.39 31561 Y $2,824.83 31899 Y $136.3631085 Y $3,690.39 31570 Y $2,086.31 32035 Y 80% of billed31086 Y $3,690.39 31571 Y $2,086.31 32036 Y 80% of billed31087 Y $3,690.39 31572 Y $2,086.31 32096 Y 80% of billed31090 Y $3,690.39 31573 Y $313.46 32097 Y 80% of billed31200 Y $3,690.39 31574 Y $1,047.94 32098 Y 80% of billed31201 Y $899.05 31575 Y $136.35 32100 Y 80% of billed31205 Y $1,791.33 31576 Y $1,047.94 32110 Y 80% of billed31225 Y 80% of billed 31577 Y $328.94 32120 Y 80% of billed31230 Y 80% of billed 31578 Y $2,086.31 32124 Y 80% of billed31231 Y $136.35 31579 Y $206.41 32140 Y 80% of billed31233 Y $328.94 31580 Y $3,690.39 32141 Y 80% of billed31235 Y $1,047.94 31584 Y $4,026.25 32150 Y 80% of billed31237 Y $1,047.94 31587 Y $4,026.25 32151 Y 80% of billed31238 Y $1,047.94 31590 Y $3,690.39 32160 Y 80% of billed31239 Y $2,086.31 31591 Y $3,690.39 32200 Y 80% of billed31240 Y $1,047.94 31592 Y $3,690.39 32215 Y 80% of billed31241 Y $1,238.46 31599 Y $176.52 32220 Y 80% of billed31253 Y $2,824.83 31600 Y $2,247.18 32225 Y 80% of billed31254 Y $2,824.83 31601 Y $4,026.25 32310 Y 80% of billed31255 Y $2,824.83 31603 Y $899.05 32320 Y 80% of billed31256 Y $2,086.31 31605 Y $176.50 32400 Y $966.1131257 Y $2,824.83 31610 Y $4,026.25 32405 Y $966.1131259 Y $2,824.83 31611 Y $1,791.33 32440 Y 80% of billed31267 Y $2,824.83 31612 Y $1,791.33 32442 Y 80% of billed31276 Y $2,824.83 31613 Y $1,791.33 32445 Y 80% of billed31287 Y $2,824.83 31614 Y $3,690.39 32480 Y 80% of billed31288 Y $2,824.83 31615 Y $384.17 32482 Y 80% of billed31290 Y 80% of billed 31622 Y $1,047.94 32484 Y 80% of billed31291 Y 80% of billed 31623 Y $1,047.94 32486 Y 80% of billed31292 Y $4,096.01 31624 Y $1,047.94 32488 Y 80% of billed31293 Y $4,096.01 31625 Y $1,047.94 32491 Y 80% of billed31294 Y $4,096.01 31626 Y $2,824.83 32501 Y 80% of billed31295 Y $2,713.90 31627 N packaged 32503 Y 80% of billed31296 Y $2,728.43 31628 Y $2,086.31 32504 Y 80% of billed31297 Y $2,706.91 31629 Y $2,086.31 32505 Y 80% of billed31298 Y $2,824.83 31630 Y $2,086.31 32506 Y 80% of billed31299 Y $176.52 31631 Y $2,824.83 32507 Y 80% of billed31300 Y $1,791.33 31632 N packaged 32540 Y 80% of billed31360 Y 80% of billed 31633 N packaged 32550 Y $2,089.2831365 Y 80% of billed 31634 Y $2,824.83 32551 Y $1,197.8131367 Y 80% of billed 31635 Y $1,047.94 32552 N $537.5731368 Y 80% of billed 31636 Y $4,133.55 32553 N $1,078.4831370 Y 80% of billed 31637 N packaged 32554 Y $537.5731375 Y 80% of billed 31638 Y $2,824.83 32555 Y $537.5731380 Y 80% of billed 31640 Y $2,086.31 32556 Y $1,036.9831382 Y 80% of billed 31641 Y $2,086.31 32557 Y $842.7631390 Y 80% of billed 31643 Y $1,047.94 32560 Y $537.5931395 Y 80% of billed 31645 Y $1,047.94 32561 Y $537.5931400 Y $3,690.39 31646 Y $328.94 32562 Y $537.5931420 Y $3,690.39 31647 Y $3,682.19 32601 Y $3,995.4431500 Y $176.50 31648 Y $2,086.31 32604 Y $3,995.4431502 Y $176.50 31649 N $1,047.94 32606 Y $3,995.4431505 Y $110.73 31651 N packaged 32607 Y $3,995.44





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






32608 Y $3,995.44 33225 N packaged 33426 Y 80% of billed32609 Y $3,995.44 33226 Y $1,873.09 33427 Y 80% of billed32650 Y 80% of billed 33227 Y $2,752.25 33430 Y 80% of billed32651 Y 80% of billed 33228 Y $4,891.69 33440 Y 80% of billed32652 Y 80% of billed 33229 Y $7,103.51 33460 Y 80% of billed32653 Y 80% of billed 33230 Y $8,783.16 33463 Y 80% of billed32654 Y 80% of billed 33231 Y $11,159.46 33464 Y 80% of billed32655 Y 80% of billed 33233 N $2,430.42 33465 Y 80% of billed32656 Y 80% of billed 33234 N $2,056.83 33468 Y 80% of billed32658 Y 80% of billed 33235 N $2,662.19 33470 Y 80% of billed32659 Y 80% of billed 33236 Y 80% of billed 33471 Y 80% of billed32661 Y 80% of billed 33237 Y 80% of billed 33474 Y 80% of billed32662 Y 80% of billed 33238 Y 80% of billed 33475 Y 80% of billed32663 Y 80% of billed 33240 Y $8,691.39 33476 Y 80% of billed32664 Y 80% of billed 33241 N $2,056.83 33477 Y 80% of billed32665 Y 80% of billed 33243 Y 80% of billed 33478 Y 80% of billed32666 Y 80% of billed 33244 Y $2,056.91 33496 Y 80% of billed32667 Y 80% of billed 33249 Y $11,184.33 33500 Y 80% of billed32668 Y 80% of billed 33250 Y 80% of billed 33501 Y 80% of billed32669 Y 80% of billed 33251 Y 80% of billed 33502 Y 80% of billed32670 Y 80% of billed 33254 Y 80% of billed 33503 Y 80% of billed32671 Y 80% of billed 33255 Y 80% of billed 33504 Y 80% of billed32672 Y 80% of billed 33256 Y 80% of billed 33505 Y 80% of billed32673 Y 80% of billed 33257 Y 80% of billed 33506 Y 80% of billed32674 Y 80% of billed 33258 Y 80% of billed 33507 Y 80% of billed32701 Y 80% of billed 33259 Y 80% of billed 33508 N packaged32800 Y 80% of billed 33261 Y 80% of billed 33510 Y 80% of billed32810 Y 80% of billed 33262 Y $8,586.35 33511 Y 80% of billed32815 Y 80% of billed 33263 Y $8,707.58 33512 Y 80% of billed32820 Y 80% of billed 33264 Y $11,200.49 33513 Y 80% of billed32850 Y 80% of billed 33265 Y 80% of billed 33514 Y 80% of billed32851 Y 80% of billed 33266 Y 80% of billed 33516 Y 80% of billed32852 Y 80% of billed 33270 Y $11,084.24 33517 Y 80% of billed32853 Y 80% of billed 33271 Y $2,842.18 33518 Y 80% of billed32854 Y 80% of billed 33272 Y $2,056.91 33519 Y 80% of billed32855 Y 80% of billed 33273 Y $2,056.83 33521 Y 80% of billed32856 Y 80% of billed 33274 Y $9,420.61 33522 Y 80% of billed32900 Y 80% of billed 33275 Y $1,873.09 33523 Y 80% of billed32905 Y 80% of billed 33285 Y $3,022.02 33530 Y 80% of billed32906 Y 80% of billed 33286 N $513.61 33533 Y 80% of billed32940 Y 80% of billed 33289 Y $3,589.70 33534 Y 80% of billed32960 Y $537.57 33300 Y 80% of billed 33535 Y 80% of billed32994 Y $3,589.05 33305 Y 80% of billed 33536 Y 80% of billed32997 Y 80% of billed 33310 Y 80% of billed 33542 Y 80% of billed32998 Y $3,589.05 33315 Y 80% of billed 33545 Y 80% of billed32999 Y $537.59 33320 Y 80% of billed 33548 Y 80% of billed33016 Y $842.76 33321 Y 80% of billed 33572 Y 80% of billed33017 Y 80% of billed 33322 Y 80% of billed 33600 Y 80% of billed33018 Y 80% of billed 33330 Y 80% of billed 33602 Y 80% of billed33019 Y 80% of billed 33335 Y 80% of billed 33606 Y 80% of billed33020 Y 80% of billed 33340 Y 80% of billed 33608 Y 80% of billed33025 Y 80% of billed 33361 Y 80% of billed 33610 Y 80% of billed33030 Y 80% of billed 33362 Y 80% of billed 33611 Y 80% of billed33031 Y 80% of billed 33363 Y 80% of billed 33612 Y 80% of billed33050 Y 80% of billed 33364 Y 80% of billed 33615 Y 80% of billed33120 Y 80% of billed 33365 Y 80% of billed 33617 Y 80% of billed33130 Y 80% of billed 33366 Y 80% of billed 33619 Y 80% of billed33140 Y 80% of billed 33367 Y 80% of billed 33620 Y 80% of billed33141 Y 80% of billed 33368 Y 80% of billed 33621 Y 80% of billed33202 Y 80% of billed 33369 Y 80% of billed 33622 Y 80% of billed33203 Y 80% of billed 33390 Y 80% of billed 33641 Y 80% of billed33206 Y $4,732.12 33391 Y 80% of billed 33645 Y 80% of billed33207 Y $4,891.10 33404 Y 80% of billed 33647 Y 80% of billed33208 Y $5,008.49 33405 Y 80% of billed 33660 Y 80% of billed33210 Y $1,726.42 33406 Y 80% of billed 33665 Y 80% of billed33211 Y $2,663.67 33410 Y 80% of billed 33670 Y 80% of billed33212 Y $2,815.64 33411 Y 80% of billed 33675 Y 80% of billed33213 Y $4,940.43 33412 Y 80% of billed 33676 Y 80% of billed33214 Y $4,847.71 33413 Y 80% of billed 33677 Y 80% of billed33215 Y $1,873.09 33414 Y 80% of billed 33681 Y 80% of billed33216 Y $2,483.33 33415 Y 80% of billed 33684 Y 80% of billed33217 Y $3,029.97 33416 Y 80% of billed 33688 Y 80% of billed33218 Y $2,056.83 33417 Y 80% of billed 33690 Y 80% of billed33220 Y $2,901.41 33418 Y 80% of billed 33692 Y 80% of billed33221 Y $7,055.32 33419 N packaged 33694 Y 80% of billed33222 Y $1,409.11 33420 Y 80% of billed 33697 Y 80% of billed33223 Y $1,409.11 33422 Y 80% of billed 33702 Y 80% of billed33224 Y $5,021.86 33425 Y 80% of billed 33710 Y 80% of billed





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






33720 Y 80% of billed 33948 Y 80% of billed 34808 Y 80% of billed33722 Y 80% of billed 33949 Y 80% of billed 34812 Y 80% of billed33724 Y 80% of billed 33951 Y 80% of billed 34813 Y 80% of billed33726 Y 80% of billed 33952 Y 80% of billed 34820 Y 80% of billed33730 Y 80% of billed 33953 Y 80% of billed 34830 Y 80% of billed33732 Y 80% of billed 33954 Y 80% of billed 34831 Y 80% of billed33735 Y 80% of billed 33955 Y 80% of billed 34832 Y 80% of billed33736 Y 80% of billed 33956 Y 80% of billed 34833 Y 80% of billed33737 Y 80% of billed 33957 Y 80% of billed 34834 Y 80% of billed33750 Y 80% of billed 33958 Y 80% of billed 34839 Y 80% of billed33755 Y 80% of billed 33959 Y 80% of billed 34841 Y 80% of billed33762 Y 80% of billed 33962 Y 80% of billed 34842 Y 80% of billed33764 Y 80% of billed 33963 Y 80% of billed 34843 Y 80% of billed33766 Y 80% of billed 33964 Y 80% of billed 34844 Y 80% of billed33767 Y 80% of billed 33965 Y 80% of billed 34845 Y 80% of billed33768 Y 80% of billed 33966 Y 80% of billed 34846 Y 80% of billed33770 Y 80% of billed 33967 Y 80% of billed 34847 Y 80% of billed33771 Y 80% of billed 33968 Y 80% of billed 34848 Y 80% of billed33774 Y 80% of billed 33969 Y 80% of billed 35001 Y 80% of billed33775 Y 80% of billed 33970 Y 80% of billed 35002 Y 80% of billed33776 Y 80% of billed 33971 Y 80% of billed 35005 Y 80% of billed33777 Y 80% of billed 33973 Y 80% of billed 35011 Y $3,350.3533778 Y 80% of billed 33974 Y 80% of billed 35013 Y 80% of billed33779 Y 80% of billed 33975 Y 80% of billed 35021 Y 80% of billed33780 Y 80% of billed 33976 Y 80% of billed 35022 Y 80% of billed33781 Y 80% of billed 33977 Y 80% of billed 35045 Y $3,350.3533782 Y 80% of billed 33978 Y 80% of billed 35081 Y 80% of billed33783 Y 80% of billed 33979 Y 80% of billed 35082 Y 80% of billed33786 Y 80% of billed 33980 Y 80% of billed 35091 Y 80% of billed33788 Y 80% of billed 33981 Y 80% of billed 35092 Y 80% of billed33800 Y 80% of billed 33982 Y 80% of billed 35102 Y 80% of billed33802 Y 80% of billed 33983 Y 80% of billed 35103 Y 80% of billed33803 Y 80% of billed 33984 Y 80% of billed 35111 Y 80% of billed33813 Y 80% of billed 33985 Y 80% of billed 35112 Y 80% of billed33814 Y 80% of billed 33986 Y 80% of billed 35121 Y 80% of billed33820 Y 80% of billed 33987 Y 80% of billed 35122 Y 80% of billed33822 Y 80% of billed 33988 Y 80% of billed 35131 Y 80% of billed33824 Y 80% of billed 33989 Y 80% of billed 35132 Y 80% of billed33840 Y 80% of billed 33990 Y 80% of billed 35141 Y 80% of billed33845 Y 80% of billed 33991 Y 80% of billed 35142 Y 80% of billed33851 Y 80% of billed 33992 Y 80% of billed 35151 Y 80% of billed33852 Y 80% of billed 33993 Y 80% of billed 35152 Y 80% of billed33853 Y 80% of billed 33999 Y $537.59 35180 Y $537.5933858 Y 80% of billed 34001 Y 80% of billed 35182 Y 80% of billed33859 Y 80% of billed 34051 Y 80% of billed 35184 Y $1,955.6533863 Y 80% of billed 34101 Y $3,350.35 35188 Y $3,349.3833864 Y 80% of billed 34111 Y $3,350.35 35189 Y 80% of billed33866 N packaged 34151 Y 80% of billed 35190 Y $3,350.3533871 Y 80% of billed 34201 Y $3,350.35 35201 Y $3,350.3533875 Y 80% of billed 34203 Y $3,350.35 35206 Y $1,955.6533877 Y 80% of billed 34401 Y 80% of billed 35207 Y $1,873.0933880 Y 80% of billed 34421 Y $1,955.65 35211 Y 80% of billed33881 Y 80% of billed 34451 Y 80% of billed 35216 Y 80% of billed33883 Y 80% of billed 34471 Y $537.59 35221 Y 80% of billed33884 Y 80% of billed 34490 Y $1,873.09 35226 Y $513.6333886 Y 80% of billed 34501 Y $3,350.35 35231 Y $1,955.6533889 Y 80% of billed 34502 Y 80% of billed 35236 Y $3,350.3533891 Y 80% of billed 34510 Y $3,350.35 35241 Y 80% of billed33910 Y 80% of billed 34520 Y $3,350.35 35246 Y 80% of billed33915 Y 80% of billed 34530 Y $1,955.65 35251 Y 80% of billed33916 Y 80% of billed 34701 Y 80% of billed 35256 Y $3,350.3533917 Y 80% of billed 34702 Y 80% of billed 35261 Y $1,955.6533920 Y 80% of billed 34703 Y 80% of billed 35266 Y $3,350.3533922 Y 80% of billed 34704 Y 80% of billed 35271 Y 80% of billed33924 Y 80% of billed 34705 Y 80% of billed 35276 Y 80% of billed33925 Y 80% of billed 34706 Y 80% of billed 35281 Y 80% of billed33926 Y 80% of billed 34707 Y 80% of billed 35286 Y $3,350.3533927 Y 80% of billed 34708 Y 80% of billed 35301 Y 80% of billed33928 Y 80% of billed 34709 Y 80% of billed 35302 Y 80% of billed33929 Y 80% of billed 34710 Y 80% of billed 35303 Y 80% of billed33930 Y 80% of billed 34711 Y 80% of billed 35304 Y 80% of billed33933 Y 80% of billed 34712 Y 80% of billed 35305 Y 80% of billed33935 Y 80% of billed 34713 N packaged 35306 Y 80% of billed33940 Y 80% of billed 34714 N packaged 35311 Y 80% of billed33944 Y 80% of billed 34715 N packaged 35321 Y $3,350.3533945 Y 80% of billed 34716 N packaged 35331 Y 80% of billed33946 Y 80% of billed 34717 Y 80% of billed 35341 Y 80% of billed33947 Y 80% of billed 34718 Y 80% of billed 35351 Y 80% of billed





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






35355 Y 80% of billed 35695 Y 80% of billed 36474 N packaged35361 Y 80% of billed 35697 Y 80% of billed 36475 Y $1,873.0935363 Y 80% of billed 35700 Y 80% of billed 36476 N packaged35371 Y 80% of billed 35701 Y 80% of billed 36478 Y $1,873.0935372 Y 80% of billed 35702 Y 80% of billed 36479 N packaged35390 Y 80% of billed 35703 Y 80% of billed 36481 N packaged35400 Y 80% of billed 35800 Y 80% of billed 36482 Y $2,595.8135500 N packaged 35820 Y 80% of billed 36483 N packaged35501 Y 80% of billed 35840 Y 80% of billed 36500 N packaged35506 Y 80% of billed 35860 Y $1,955.65 36510 N packaged35508 Y 80% of billed 35870 Y 80% of billed 36511 N $1,152.4835509 Y 80% of billed 35875 Y $3,349.38 36512 N $1,152.4835510 Y 80% of billed 35876 Y $3,349.38 36513 N $337.8635511 Y 80% of billed 35879 Y $3,350.35 36514 N $1,152.4835512 Y 80% of billed 35881 Y $3,350.35 36516 N $3,325.3435515 Y 80% of billed 35883 Y $3,350.35 36522 N $3,325.3435516 Y 80% of billed 35884 Y $3,350.35 36555 Y $842.7635518 Y 80% of billed 35901 Y 80% of billed 36556 Y $842.7635521 Y 80% of billed 35903 Y $1,955.65 36557 Y $3,349.3835522 Y 80% of billed 35905 Y 80% of billed 36558 Y $1,873.0935523 Y 80% of billed 35907 Y 80% of billed 36560 Y $1,873.0935525 Y 80% of billed 36000 N packaged 36561 Y $1,873.0935526 Y 80% of billed 36002 Y $537.57 36563 Y $3,349.3835531 Y 80% of billed 36005 N packaged 36565 Y $1,873.0935533 Y 80% of billed 36010 N packaged 36566 Y $3,349.3835535 Y 80% of billed 36011 N packaged 36568 Y $537.5735536 Y 80% of billed 36012 N packaged 36569 Y $842.7635537 Y 80% of billed 36013 N packaged 36570 Y $1,873.0935538 Y 80% of billed 36014 N packaged 36571 Y $1,873.0935539 Y 80% of billed 36015 N packaged 36572 Y $537.5735540 Y 80% of billed 36100 N packaged 36573 Y $842.7635556 Y 80% of billed 36140 N packaged 36575 Y $537.5735558 Y 80% of billed 36160 N packaged 36576 Y $842.7635560 Y 80% of billed 36200 N packaged 36578 Y $1,873.0935563 Y 80% of billed 36215 N packaged 36580 Y $842.7635565 Y 80% of billed 36216 N packaged 36581 Y $1,873.0935566 Y 80% of billed 36217 N packaged 36582 Y $1,873.0935570 Y 80% of billed 36218 N packaged 36583 Y $6,040.0235571 Y 80% of billed 36221 N packaged 36584 Y $842.7635572 N packaged 36222 N packaged 36585 Y $1,873.0935583 Y 80% of billed 36223 N packaged 36589 N $537.5735585 Y 80% of billed 36224 N packaged 36590 N $537.5735587 Y 80% of billed 36225 N packaged 36591 N packaged35600 Y 80% of billed 36226 N packaged 36592 N packaged35601 Y 80% of billed 36227 N packaged 36593 Y $54.1235606 Y 80% of billed 36228 N packaged 36595 Y $1,873.0935612 Y 80% of billed 36245 N packaged 36596 Y $842.7635616 Y 80% of billed 36246 N packaged 36597 Y $842.7635621 Y 80% of billed 36247 N packaged 36598 Y $159.9535623 Y 80% of billed 36248 N packaged 36600 N packaged35626 Y 80% of billed 36251 N packaged 36620 N packaged35631 Y 80% of billed 36252 N packaged 36625 N packaged35632 Y 80% of billed 36253 N packaged 36640 Y $1,873.0935633 Y 80% of billed 36254 N packaged 36660 Y 80% of billed35634 Y 80% of billed 36260 Y $3,349.38 36680 N packaged35636 Y 80% of billed 36261 Y $3,585.30 36800 Y $3,349.3835637 Y 80% of billed 36262 N $2,056.83 36810 Y $1,873.0935638 Y 80% of billed 36299 N packaged 36815 Y $3,349.3835642 Y 80% of billed 36400 N packaged 36818 Y $3,349.3835645 Y 80% of billed 36405 N packaged 36819 Y $3,349.3835646 Y 80% of billed 36406 N packaged 36820 Y $3,349.3835647 Y 80% of billed 36410 N packaged 36821 Y $1,873.0935650 Y 80% of billed 36415 Y 80% of billed 36823 Y 80% of billed35654 Y 80% of billed 36416 N packaged 36825 Y $3,349.3835656 Y 80% of billed 36420 N packaged 36830 Y $3,349.3835661 Y 80% of billed 36425 N packaged 36831 Y $3,349.3835663 Y 80% of billed 36430 N $60.33 36832 Y $3,349.3835665 Y 80% of billed 36440 N $337.86 36833 Y $3,349.3835666 Y 80% of billed 36450 N $337.86 36835 Y $2,792.6135671 Y 80% of billed 36455 N $337.86 36838 Y $3,350.3535681 Y 80% of billed 36456 Y $337.88 36860 Y $537.5735682 Y 80% of billed 36460 Y $337.88 36861 Y $3,349.3835683 Y 80% of billed 36465 Y $1,409.11 36901 Y $833.3935685 N packaged 36466 Y $1,409.11 36902 Y $2,637.3735686 N packaged 36468 N packaged 36903 Y $6,601.8135691 Y 80% of billed 36470 Y $138.06 36904 Y $3,540.6235693 Y 80% of billed 36471 Y $236.94 36905 Y $4,370.0935694 Y 80% of billed 36473 Y $1,827.04 36906 Y $8,619.40





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






36907 N packaged 37760 Y $1,873.09 39200 Y 80% of billed36908 N packaged 37761 Y $842.76 39220 Y 80% of billed36909 N packaged 37765 Y $346.26 39401 Y $3,995.4437140 Y 80% of billed 37766 Y $381.53 39402 Y $3,995.4437145 Y 80% of billed 37780 Y $842.76 39499 Y 80% of billed37160 Y 80% of billed 37785 Y $1,873.09 39501 Y 80% of billed37180 Y 80% of billed 37788 Y 80% of billed 39503 Y 80% of billed37181 Y 80% of billed 37790 Y $2,210.43 39540 Y 80% of billed37182 Y 80% of billed 37799 Y $537.59 39541 Y 80% of billed37183 Y $3,082.53 38100 Y 80% of billed 39545 Y 80% of billed37184 Y $6,717.34 38101 Y 80% of billed 39560 Y 80% of billed37185 N packaged 38102 Y 80% of billed 39561 Y 80% of billed37186 N packaged 38115 Y 80% of billed 39599 Y 80% of billed37187 Y $3,821.05 38120 Y $6,666.85 40490 Y $137.4437188 Y $1,873.09 38129 Y $3,995.44 40500 Y $1,791.3337191 Y $3,350.35 38200 N packaged 40510 Y $1,791.3337192 Y $1,955.65 38204 N packaged 40520 Y $1,791.3337193 Y $1,955.65 38205 Y 80% of billed 40525 Y $1,791.3337195 Y $269.61 38206 N $1,152.48 40527 Y $3,690.3937197 Y $1,873.09 38207 Y $337.88 40530 Y $1,791.3337200 Y $3,349.38 38208 Y $337.88 40650 Y $384.1737211 Y $3,349.38 38209 Y $337.88 40652 Y $384.1737212 Y $1,873.09 38210 Y $337.88 40654 Y $899.0537213 Y $1,197.81 38211 Y $337.88 40700 Y $3,690.3937214 Y $1,197.81 38212 Y $337.88 40701 Y $3,690.3937215 Y 80% of billed 38213 Y $337.88 40702 Y $3,690.3937216 Y 80% of billed 38214 Y $337.88 40720 Y $1,791.3337217 Y 80% of billed 38215 Y $337.88 40761 Y $3,690.3937218 Y 80% of billed 38220 Y $205.06 40799 Y $176.5237220 Y $2,637.37 38221 Y $187.53 40800 Y $277.2337221 Y $6,456.35 38222 Y $1,692.88 40801 Y $384.1737222 N packaged 38230 N $1,152.48 40804 N packaged37223 N packaged 38232 N $3,325.34 40805 Y $338.5737224 Y $3,841.96 38240 Y $32,600.13 40806 Y $154.0537225 Y $6,974.06 38241 N $1,152.48 40808 Y $209.9637226 Y $6,733.17 38242 N $1,152.48 40810 Y $275.1237227 Y $9,262.28 38243 N $1,152.48 40812 Y $336.2037228 Y $5,924.08 38300 Y $1,692.88 40814 Y $1,791.3337229 Y $8,707.87 38305 Y $1,692.88 40816 Y $1,791.3337230 Y $8,551.23 38308 Y $1,908.59 40818 Y $384.1737231 Y $9,014.94 38380 Y 80% of billed 40819 Y $899.0537232 N packaged 38381 Y 80% of billed 40820 Y $364.5837233 N packaged 38382 Y 80% of billed 40830 Y $176.5037234 N packaged 38500 Y $1,908.59 40831 Y $384.1737235 N packaged 38505 Y $966.11 40840 Y $3,690.3937236 Y $6,211.18 38510 Y $1,908.59 40842 Y $3,690.3937237 N packaged 38520 Y $1,908.59 40843 Y $3,690.3937238 Y $6,471.32 38525 Y $1,908.59 40844 Y $3,690.3937239 N packaged 38530 Y $1,908.59 40845 Y $3,690.3937241 Y $4,370.09 38531 Y $2,612.35 40899 Y $176.5237242 Y $6,369.49 38542 Y $3,589.05 41000 Y $188.8537243 Y $4,370.09 38550 Y $1,908.59 41005 Y $176.5037244 Y $5,230.82 38555 Y $3,684.91 41006 Y $899.0537246 Y $2,637.37 38562 Y 80% of billed 41007 Y $899.0537247 N packaged 38564 Y 80% of billed 41008 Y $1,791.3337248 Y $2,637.37 38570 Y $3,589.05 41009 Y $384.1737249 N packaged 38571 Y $5,627.72 41010 Y $899.0537252 N packaged 38572 Y $5,627.72 41015 Y $384.1737253 N packaged 38573 Y $5,627.72 41016 Y $3,690.3937500 Y $3,349.38 38589 Y $3,995.44 41017 Y $1,791.3337501 Y $537.59 38700 Y $3,684.91 41018 Y $899.0537565 Y $1,197.81 38720 Y $4,899.31 41019 Y $3,690.3937600 Y $1,955.65 38724 Y 80% of billed 41100 Y $211.2037605 Y $1,955.65 38740 Y $3,589.05 41105 Y $208.3337606 Y $1,955.65 38745 Y $3,589.05 41108 Y $193.5737607 Y $1,873.09 38746 Y 80% of billed 41110 Y $276.9537609 Y $966.11 38747 Y 80% of billed 41112 Y $1,791.3337615 Y $1,197.81 38760 Y $3,684.91 41113 Y $1,791.3337616 Y 80% of billed 38765 Y 80% of billed 41114 Y $1,791.3337617 Y 80% of billed 38770 Y 80% of billed 41115 Y $315.0337618 Y 80% of billed 38780 Y 80% of billed 41116 Y $1,791.3337619 Y $3,350.35 38790 N packaged 41120 Y $3,690.3937650 Y $1,873.09 38792 N packaged 41130 Y 80% of billed37660 Y 80% of billed 38794 N packaged 41135 Y 80% of billed37700 Y $1,873.09 38900 N packaged 41140 Y 80% of billed37718 Y $1,873.09 38999 Y $337.88 41145 Y 80% of billed37722 Y $1,873.09 39000 Y 80% of billed 41150 Y 80% of billed37735 Y $1,873.09 39010 Y 80% of billed 41153 Y 80% of billed





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






41155 Y 80% of billed 42699 Y $176.52 43217 Y $1,036.9841250 N packaged 42700 Y $176.50 43220 Y $1,036.9841251 Y $176.50 42720 Y $1,791.33 43226 Y $1,036.9841252 Y $176.50 42725 Y $3,690.39 43227 Y $1,036.9841510 Y $1,791.33 42800 Y $172.94 43229 Y $1,961.4241512 Y $3,690.39 42804 Y $1,791.33 43231 Y $1,036.9841520 Y $1,791.33 42806 Y $1,791.33 43232 Y $1,036.9841530 Y $1,417.89 42808 Y $1,791.33 43233 Y $1,036.9841599 Y $176.52 42809 N packaged 43235 Y $669.8741800 N packaged 42810 Y $1,791.33 43236 Y $669.8741805 Y $422.66 42815 Y $3,690.39 43237 Y $1,036.9841806 Y $507.31 42820 Y $3,690.39 43238 Y $1,036.9841820 Y $1,791.33 42821 Y $1,791.33 43239 Y $669.8741821 Y $899.05 42825 Y $3,690.39 43240 Y $2,954.6441822 Y $425.68 42826 Y $1,791.33 43241 Y $1,036.9841823 Y $600.55 42830 Y $1,791.33 43242 Y $1,036.9841825 Y $284.94 42831 Y $1,791.33 43243 Y $1,036.9841826 Y $386.03 42835 Y $1,791.33 43244 Y $1,036.9841827 Y $3,690.39 42836 Y $1,791.33 43245 Y $1,036.9841828 Y $379.12 42842 Y $4,026.25 43246 Y $1,036.9841830 Y $552.70 42844 Y $4,026.25 43247 Y $669.8741850 Y $899.05 42845 Y 80% of billed 43248 Y $669.8741870 Y $899.05 42860 Y $1,791.33 43249 Y $1,036.9841872 Y $568.63 42870 Y $3,690.39 43250 Y $1,036.9841874 Y $471.20 42890 Y $3,690.39 43251 Y $1,036.9841899 Y $176.52 42892 Y $3,690.39 43252 Y $1,961.4242000 Y $176.50 42894 Y 80% of billed 43253 Y $1,036.9842100 Y $163.25 42900 Y $899.05 43254 Y $1,036.9842104 Y $262.86 42950 Y $3,690.39 43255 Y $1,036.9842106 Y $321.09 42953 Y 80% of billed 43257 Y $1,961.4242107 Y $3,690.39 42955 Y $899.05 43259 Y $1,036.9842120 Y $3,690.39 42960 Y $384.17 43260 Y $1,961.4242140 Y $1,791.33 42961 Y 80% of billed 43261 Y $1,961.4242145 Y $3,690.39 42962 Y $1,791.33 43262 Y $1,961.4242160 Y $283.08 42970 Y $176.50 43263 Y $1,961.4242180 Y $384.17 42971 Y 80% of billed 43264 Y $1,961.4242182 Y $3,690.39 42972 Y $1,791.33 43265 Y $2,415.6342200 Y $3,690.39 42999 Y $176.52 43266 Y $3,899.9642205 Y $1,791.33 43020 Y $1,142.37 43270 Y $1,036.9842210 Y $3,690.39 43030 Y $3,690.39 43273 N packaged42215 Y $3,690.39 43045 Y 80% of billed 43274 Y $2,415.6342220 Y $3,690.39 43100 Y 80% of billed 43275 Y $1,961.4242225 Y $3,690.39 43101 Y 80% of billed 43276 Y $2,415.6342226 Y $3,690.39 43107 Y 80% of billed 43277 Y $1,961.4242227 Y $3,690.39 43108 Y 80% of billed 43278 Y $1,961.4242235 Y $3,690.39 43112 Y 80% of billed 43279 Y 80% of billed42260 Y $3,690.39 43113 Y 80% of billed 43280 Y $6,666.8542280 Y $208.72 43116 Y 80% of billed 43281 Y $6,666.8542281 Y $3,690.39 43117 Y 80% of billed 43282 Y $6,666.8542299 Y $176.52 43118 Y 80% of billed 43283 Y 80% of billed42300 Y $899.05 43121 Y 80% of billed 43284 Y $8,032.2642305 Y $1,791.33 43122 Y 80% of billed 43285 N $3,589.0542310 Y $384.17 43123 Y 80% of billed 43286 Y 80% of billed42320 Y $384.17 43124 Y 80% of billed 43287 Y 80% of billed42330 Y $249.38 43130 Y $3,690.39 43288 Y 80% of billed42335 Y $470.59 43135 Y 80% of billed 43289 Y $3,995.4442340 Y $1,791.33 43180 Y $3,690.39 43300 Y 80% of billed42400 Y $125.08 43191 Y $1,036.98 43305 Y 80% of billed42405 Y $899.05 43192 Y $1,036.98 43310 Y 80% of billed42408 Y $1,791.33 43193 Y $1,036.98 43312 Y 80% of billed42409 Y $1,791.33 43194 Y $1,036.98 43313 Y 80% of billed42410 Y $3,690.39 43195 Y $1,961.42 43314 Y 80% of billed42415 Y $3,690.39 43196 Y $1,961.42 43320 Y 80% of billed42420 Y $3,690.39 43197 Y $228.30 43325 Y 80% of billed42425 Y $3,690.39 43198 Y $243.51 43327 Y 80% of billed42426 Y 80% of billed 43200 Y $669.87 43328 Y 80% of billed42440 Y $3,690.39 43201 Y $1,036.98 43330 Y 80% of billed42450 Y $3,690.39 43202 Y $1,036.98 43331 Y 80% of billed42500 Y $3,690.39 43204 Y $1,036.98 43332 Y 80% of billed42505 Y $3,690.39 43205 Y $1,036.98 43333 Y 80% of billed42507 Y $3,690.39 43206 Y $1,036.98 43334 Y 80% of billed42509 Y $3,690.39 43210 Y $5,627.72 43335 Y 80% of billed42510 Y $1,791.33 43211 Y $1,036.98 43336 Y 80% of billed42550 N packaged 43212 Y $3,849.81 43337 Y 80% of billed42600 Y $1,791.33 43213 Y $1,036.98 43338 Y 80% of billed42650 Y $82.83 43214 Y $1,036.98 43340 Y 80% of billed42660 Y $129.84 43215 Y $1,036.98 43341 Y 80% of billed42665 Y $1,791.33 43216 Y $1,036.98 43351 Y 80% of billed





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






43352 Y 80% of billed 43887 N $1,409.11 44376 Y $1,036.9843360 Y 80% of billed 43888 Y $2,561.48 44377 Y $1,036.9843361 Y 80% of billed 43999 Y $669.89 44378 Y $1,036.9843400 Y 80% of billed 44005 Y 80% of billed 44379 Y $2,415.6343405 Y 80% of billed 44010 Y 80% of billed 44380 Y $669.8743410 Y 80% of billed 44015 Y 80% of billed 44381 Y $1,036.9843415 Y 80% of billed 44020 Y 80% of billed 44382 Y $669.8743420 Y $2,247.18 44021 Y 80% of billed 44384 Y $1,961.4243425 Y 80% of billed 44025 Y 80% of billed 44385 Y $664.6543450 Y $669.87 44050 Y 80% of billed 44386 Y $664.6543453 Y $1,036.98 44055 Y 80% of billed 44388 Y $664.6543460 Y 80% of billed 44100 Y $669.87 44389 Y $871.0543496 Y 80% of billed 44110 Y 80% of billed 44390 Y $664.6543499 Y $669.89 44111 Y 80% of billed 44391 Y $871.0543500 Y 80% of billed 44120 Y 80% of billed 44392 Y $871.0543501 Y 80% of billed 44121 Y 80% of billed 44394 Y $871.0543502 Y 80% of billed 44125 Y 80% of billed 44401 Y $871.0543510 Y $669.89 44126 Y 80% of billed 44402 Y $3,626.8043520 Y 80% of billed 44127 Y 80% of billed 44403 Y $871.0543605 Y 80% of billed 44128 Y 80% of billed 44404 Y $871.0543610 Y 80% of billed 44130 Y 80% of billed 44405 Y $871.0543611 Y 80% of billed 44132 Y 80% of billed 44406 Y $871.0543620 Y 80% of billed 44133 Y 80% of billed 44407 Y $871.0543621 Y 80% of billed 44135 Y 80% of billed 44408 Y $664.6543622 Y 80% of billed 44136 Y 80% of billed 44500 Y $669.8743631 Y 80% of billed 44137 Y 80% of billed 44602 Y 80% of billed43632 Y 80% of billed 44139 Y 80% of billed 44603 Y 80% of billed43633 Y 80% of billed 44140 Y 80% of billed 44604 Y 80% of billed43634 Y 80% of billed 44141 Y 80% of billed 44605 Y 80% of billed43635 Y 80% of billed 44143 Y 80% of billed 44615 Y 80% of billed43640 Y 80% of billed 44144 Y 80% of billed 44620 Y 80% of billed43641 Y 80% of billed 44145 Y 80% of billed 44625 Y 80% of billed43644 Y 80% of billed 44146 Y 80% of billed 44626 Y 80% of billed43645 Y 80% of billed 44147 Y 80% of billed 44640 Y 80% of billed43647 Y $2,525.82 44150 Y 80% of billed 44650 Y 80% of billed43648 Y $3,995.44 44151 Y 80% of billed 44660 Y 80% of billed43651 Y $3,995.44 44155 Y 80% of billed 44661 Y 80% of billed43652 Y $3,995.44 44156 Y 80% of billed 44680 Y 80% of billed43653 Y $3,589.05 44157 Y 80% of billed 44700 Y 80% of billed43659 Y $3,995.44 44158 Y 80% of billed 44701 N packaged43752 N $308.64 44160 Y 80% of billed 44705 Y 80% of billed43753 N packaged 44180 Y $3,995.44 44715 Y 80% of billed43754 N packaged 44186 Y $3,995.44 44720 Y 80% of billed43755 N $120.47 44187 Y 80% of billed 44721 Y 80% of billed43756 N $669.87 44188 Y 80% of billed 44799 Y $669.8943757 Y $669.87 44202 Y 80% of billed 44800 Y 80% of billed43761 Y $201.62 44203 Y 80% of billed 44820 Y 80% of billed43762 Y $201.62 44204 Y 80% of billed 44850 Y 80% of billed43763 Y $201.62 44205 Y 80% of billed 44899 Y 80% of billed43770 Y $6,666.85 44206 Y 80% of billed 44900 Y 80% of billed43771 Y 80% of billed 44207 Y 80% of billed 44950 Y $2,383.5243772 Y $2,275.75 44208 Y 80% of billed 44955 N packaged43773 Y $3,995.44 44210 Y 80% of billed 44960 Y 80% of billed43774 Y $2,275.75 44211 Y 80% of billed 44970 Y $3,995.4443775 Y 80% of billed 44212 Y 80% of billed 44979 Y $3,995.4443800 Y 80% of billed 44213 Y 80% of billed 45000 Y $871.0543810 Y 80% of billed 44227 Y 80% of billed 45005 Y $871.0543820 Y 80% of billed 44238 Y $3,995.44 45020 Y $1,864.1943825 Y 80% of billed 44300 Y 80% of billed 45100 Y $1,864.1943830 Y $1,230.75 44310 Y 80% of billed 45108 Y $1,864.1943831 Y $669.89 44312 Y $2,561.48 45110 Y 80% of billed43832 Y 80% of billed 44314 Y 80% of billed 45111 Y 80% of billed43840 Y 80% of billed 44316 Y 80% of billed 45112 Y 80% of billed43842 Y 80% of billed 44320 Y 80% of billed 45113 Y 80% of billed43843 Y 80% of billed 44322 Y 80% of billed 45114 Y 80% of billed43845 Y 80% of billed 44340 Y $2,561.48 45116 Y 80% of billed43846 Y 80% of billed 44345 Y 80% of billed 45119 Y 80% of billed43847 Y 80% of billed 44346 Y 80% of billed 45120 Y 80% of billed43848 Y 80% of billed 44360 Y $1,036.98 45121 Y 80% of billed43850 Y 80% of billed 44361 Y $1,036.98 45123 Y 80% of billed43855 Y 80% of billed 44363 Y $1,036.98 45126 Y 80% of billed43860 Y 80% of billed 44364 Y $1,036.98 45130 Y 80% of billed43865 Y 80% of billed 44365 Y $1,036.98 45135 Y 80% of billed43870 Y $1,961.42 44366 Y $1,036.98 45136 Y 80% of billed43880 Y 80% of billed 44369 Y $1,036.98 45150 Y $871.0543881 Y 80% of billed 44370 Y $3,903.98 45160 Y $1,864.1943882 Y 80% of billed 44372 Y $1,036.98 45171 Y $1,864.1943886 Y $2,561.48 44373 Y $1,036.98 45172 Y $1,864.19





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






45190 Y $1,864.19 46221 Y $320.67 47144 Y 80% of billed45300 Y $162.19 46230 Y $1,864.19 47145 Y 80% of billed45303 Y $871.05 46250 Y $1,864.19 47146 Y 80% of billed45305 Y $871.05 46255 Y $1,864.19 47147 Y 80% of billed45307 Y $1,864.19 46257 Y $1,864.19 47300 Y 80% of billed45308 Y $1,864.19 46258 Y $1,864.19 47350 Y 80% of billed45309 Y $871.05 46260 Y $1,864.19 47360 Y 80% of billed45315 Y $871.05 46261 Y $1,864.19 47361 Y 80% of billed45317 Y $871.05 46262 Y $1,864.19 47362 Y 80% of billed45320 Y $1,864.19 46270 Y $1,864.19 47370 Y $6,666.8545321 Y $1,864.19 46275 Y $1,864.19 47371 Y $6,666.8545327 Y $3,126.35 46280 Y $1,864.19 47379 Y $3,995.4445330 Y $250.45 46285 Y $1,864.19 47380 Y 80% of billed45331 Y $664.65 46288 Y $1,864.19 47381 Y 80% of billed45332 Y $871.05 46320 Y $231.08 47382 Y $3,589.0545333 Y $664.65 46500 Y $405.82 47383 Y $5,075.1245334 Y $871.05 46505 Y $871.05 47399 Y $513.6345335 Y $664.65 46600 N packaged 47400 Y 80% of billed45337 Y $664.65 46601 N packaged 47420 Y 80% of billed45338 Y $871.05 46604 Y $871.05 47425 Y 80% of billed45340 Y $871.05 46606 Y $366.76 47460 Y 80% of billed45341 Y $664.65 46607 Y $871.05 47480 Y 80% of billed45342 Y $871.05 46608 Y $664.65 47490 Y $2,383.5245346 Y $871.05 46610 Y $1,864.19 47531 N packaged45347 Y $4,000.95 46611 Y $664.65 47532 N packaged45349 Y $1,864.19 46612 Y $1,864.19 47533 Y $2,089.2845350 Y $871.05 46614 Y $189.56 47534 Y $2,089.2845378 Y $664.65 46615 Y $1,864.19 47535 Y $2,089.2845379 Y $871.05 46700 Y $1,864.19 47536 Y $2,089.2845380 Y $871.05 46705 Y 80% of billed 47537 N $669.8745381 Y $871.05 46706 Y $1,864.19 47538 Y $5,446.2045382 Y $871.05 46707 Y $1,864.19 47539 Y $3,589.0545384 Y $871.05 46710 Y 80% of billed 47540 Y $5,102.5345385 Y $871.05 46712 Y 80% of billed 47541 Y $2,089.2845386 Y $871.05 46715 Y 80% of billed 47542 N packaged45388 Y $871.05 46716 Y 80% of billed 47543 N packaged45389 Y $3,859.76 46730 Y 80% of billed 47544 N packaged45390 Y $1,864.19 46735 Y 80% of billed 47550 Y 80% of billed45391 Y $871.05 46740 Y 80% of billed 47552 Y $2,089.2845392 Y $871.05 46742 Y 80% of billed 47553 Y $2,089.2845393 Y $871.05 46744 Y 80% of billed 47554 Y $3,589.0545395 Y 80% of billed 46746 Y 80% of billed 47555 Y $2,089.2845397 Y 80% of billed 46748 Y 80% of billed 47556 Y $5,319.6845398 Y $871.05 46750 Y $1,864.19 47562 Y $3,589.0545399 Y $664.68 46751 Y 80% of billed 47563 Y $3,589.0545400 Y 80% of billed 46753 Y $1,864.19 47564 Y $3,589.0545402 Y 80% of billed 46754 Y $1,864.19 47570 Y 80% of billed45499 Y $3,995.44 46760 Y $1,864.19 47579 Y $3,995.4445500 Y $1,864.19 46761 Y $1,864.19 47600 Y 80% of billed45505 Y $1,864.19 46900 Y $278.21 47605 Y 80% of billed45520 N packaged 46910 Y $321.26 47610 Y 80% of billed45540 Y 80% of billed 46916 Y $152.17 47612 Y 80% of billed45541 Y $1,864.19 46917 Y $1,864.19 47620 Y 80% of billed45550 Y 80% of billed 46922 Y $1,864.19 47700 Y 80% of billed45560 Y $1,864.19 46924 Y $1,864.19 47701 Y 80% of billed45562 Y 80% of billed 46930 Y $265.77 47711 Y 80% of billed45563 Y 80% of billed 46940 Y $267.83 47712 Y 80% of billed45800 Y 80% of billed 46942 Y $271.58 47715 Y 80% of billed45805 Y 80% of billed 46945 Y $1,864.19 47720 Y 80% of billed45820 Y 80% of billed 46946 Y $1,864.19 47721 Y 80% of billed45825 Y 80% of billed 46947 Y $1,864.19 47740 Y 80% of billed45900 Y $664.65 46948 Y $1,864.19 47741 Y 80% of billed45905 Y $871.05 46999 Y $664.68 47760 Y 80% of billed45910 Y $871.05 47000 Y $966.11 47765 Y 80% of billed45915 Y $871.05 47001 N packaged 47780 Y 80% of billed45990 Y $1,864.19 47010 Y 80% of billed 47785 Y 80% of billed45999 Y $664.68 47015 Y 80% of billed 47800 Y 80% of billed46020 Y $1,864.19 47100 Y 80% of billed 47801 Y 80% of billed46030 Y $871.05 47120 Y 80% of billed 47802 Y 80% of billed46040 Y $871.05 47122 Y 80% of billed 47900 Y 80% of billed46045 Y $1,864.19 47125 Y 80% of billed 47999 Y $669.8946050 Y $664.65 47130 Y 80% of billed 48000 Y 80% of billed46060 Y $1,864.19 47133 Y 80% of billed 48001 Y 80% of billed46070 Y $1,864.19 47135 Y 80% of billed 48020 Y 80% of billed46080 Y $1,864.19 47140 Y 80% of billed 48100 Y 80% of billed46083 Y $201.62 47141 Y 80% of billed 48102 Y $966.1146200 Y $1,864.19 47142 Y 80% of billed 48105 Y 80% of billed46220 Y $871.05 47143 Y 80% of billed 48120 Y 80% of billed





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






48140 Y 80% of billed 49450 Y $669.87 50300 Y 80% of billed48145 Y 80% of billed 49451 Y $669.87 50320 Y 80% of billed48146 Y 80% of billed 49452 Y $669.87 50323 Y 80% of billed48148 Y 80% of billed 49460 Y $669.87 50325 Y 80% of billed48150 Y 80% of billed 49465 N $202.89 50327 Y 80% of billed48152 Y 80% of billed 49491 Y $3,995.44 50328 Y 80% of billed48153 Y 80% of billed 49492 Y $2,383.52 50329 Y 80% of billed48154 Y 80% of billed 49495 Y $2,089.28 50340 Y 80% of billed48155 Y 80% of billed 49496 Y $2,089.28 50360 Y 80% of billed48160 Y 80% of billed 49500 Y $2,089.28 50365 Y 80% of billed48400 Y 80% of billed 49501 Y $2,089.28 50370 Y 80% of billed48500 Y 80% of billed 49505 Y $2,089.28 50380 Y 80% of billed48510 Y 80% of billed 49507 Y $2,089.28 50382 Y $1,276.4348520 Y 80% of billed 49520 Y $2,089.28 50384 N $1,276.4348540 Y 80% of billed 49521 Y $2,089.28 50385 Y $1,276.4348545 Y 80% of billed 49525 Y $2,089.28 50386 N $1,033.6548547 Y 80% of billed 49540 Y $3,589.05 50387 Y $1,276.4348548 Y 80% of billed 49550 Y $2,089.28 50389 N $482.3948550 Y 80% of billed 49553 Y $2,089.28 50390 Y $513.6148551 Y 80% of billed 49555 Y $2,089.28 50391 Y $83.3748552 Y 80% of billed 49557 Y $2,089.28 50396 Y $482.3948554 Y 80% of billed 49560 Y $2,089.28 50400 Y 80% of billed48556 Y 80% of billed 49561 Y $2,089.28 50405 Y 80% of billed48999 Y $513.63 49565 Y $3,589.05 50430 N packaged49000 Y 80% of billed 49566 Y $3,589.05 50431 N packaged49002 Y 80% of billed 49568 N packaged 50432 Y $1,276.4349010 Y 80% of billed 49570 Y $2,089.28 50433 Y $2,210.4349013 Y 80% of billed 49572 Y $2,089.28 50434 Y $1,710.0949014 Y 80% of billed 49580 Y $2,089.28 50435 Y $1,276.4349020 Y 80% of billed 49582 Y $2,089.28 50436 Y $1,276.4349040 Y 80% of billed 49585 Y $2,089.28 50437 Y $2,210.4349060 Y 80% of billed 49587 Y $2,089.28 50500 Y 80% of billed49062 Y 80% of billed 49590 Y $2,089.28 50520 Y 80% of billed49082 Y $669.87 49600 Y $2,089.28 50525 Y 80% of billed49083 Y $669.87 49605 Y 80% of billed 50526 Y 80% of billed49084 Y $669.87 49606 Y 80% of billed 50540 Y 80% of billed49180 Y $966.11 49610 Y 80% of billed 50541 Y $3,995.4449185 Y $513.63 49611 Y 80% of billed 50542 Y $6,666.8549203 Y 80% of billed 49650 Y $3,589.05 50543 Y $6,666.8549204 Y 80% of billed 49651 Y $3,589.05 50544 Y $6,666.8549205 Y 80% of billed 49652 Y $3,589.05 50545 Y 80% of billed49215 Y 80% of billed 49653 Y $3,589.05 50546 Y 80% of billed49220 Y 80% of billed 49654 Y $5,627.72 50547 Y 80% of billed49250 Y $2,089.28 49655 Y $5,627.72 50548 Y 80% of billed49255 Y 80% of billed 49656 Y $5,627.72 50549 Y $3,995.4449320 Y $3,589.05 49657 Y $5,627.72 50551 Y $3,201.4549321 Y $3,589.05 49659 Y $3,995.44 50553 Y $3,201.4549322 Y $3,589.05 49900 Y 80% of billed 50555 Y $3,045.5849323 Y $3,995.44 49904 Y 80% of billed 50557 Y $3,045.5849324 Y $3,589.05 49905 Y 80% of billed 50561 Y $3,201.4549325 Y $3,589.05 49906 Y 80% of billed 50562 Y $3,045.5849326 N packaged 49999 Y $669.89 50570 Y $2,210.4349327 N packaged 50010 Y 80% of billed 50572 Y $482.3949329 Y $3,995.44 50020 Y $1,446.89 50574 Y $1,276.4349400 N packaged 50040 Y 80% of billed 50575 Y $3,201.4549402 Y $2,089.28 50045 Y 80% of billed 50576 Y $3,201.4549405 Y $1,162.54 50060 Y 80% of billed 50580 Y $3,201.4549406 Y $966.11 50065 Y 80% of billed 50590 Y $2,210.4349407 Y $966.11 50070 Y 80% of billed 50592 Y $3,589.0549411 N $621.62 50075 Y 80% of billed 50593 Y $7,710.4849412 Y 80% of billed 50080 Y $3,045.58 50600 Y 80% of billed49418 Y $2,089.28 50081 Y $3,045.58 50605 Y 80% of billed49419 Y $3,349.38 50100 Y 80% of billed 50606 N packaged49421 Y $2,089.28 50120 Y 80% of billed 50610 Y 80% of billed49422 N $1,873.09 50125 Y 80% of billed 50620 Y 80% of billed49423 Y $1,036.98 50130 Y 80% of billed 50630 Y 80% of billed49424 N packaged 50135 Y 80% of billed 50650 Y 80% of billed49425 Y 80% of billed 50200 Y $966.11 50660 Y 80% of billed49426 Y $2,089.28 50205 Y 80% of billed 50684 N packaged49427 N packaged 50220 Y 80% of billed 50686 N $120.4749428 Y 80% of billed 50225 Y 80% of billed 50688 Y $1,276.4349429 N $1,873.09 50230 Y 80% of billed 50690 N packaged49435 N packaged 50234 Y 80% of billed 50693 Y $2,210.4349436 Y $1,036.98 50236 Y 80% of billed 50694 Y $2,210.4349440 Y $1,036.98 50240 Y 80% of billed 50695 Y $2,210.4349441 Y $1,036.98 50250 Y 80% of billed 50700 Y 80% of billed49442 Y $871.05 50280 Y 80% of billed 50705 N packaged49446 Y $1,036.98 50290 Y 80% of billed 50706 N packaged





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






50715 Y 80% of billed 51725 Y $201.62 52400 Y $2,210.4350722 Y 80% of billed 51726 Y $201.62 52402 Y $2,210.4350725 Y 80% of billed 51727 Y $419.75 52441 Y 80% of billed50727 Y $2,210.43 51728 Y $430.88 52442 Y 80% of billed50728 Y 80% of billed 51729 Y $432.75 52450 Y $2,210.4350740 Y 80% of billed 51736 N packaged 52500 Y $2,210.4350750 Y 80% of billed 51741 N packaged 52601 Y $3,201.4550760 Y 80% of billed 51784 N $50.37 52630 Y $3,201.4550770 Y 80% of billed 51785 Y $201.62 52640 Y $2,210.4350780 Y 80% of billed 51792 N packaged 52647 Y $3,201.4550782 Y 80% of billed 51797 N packaged 52648 Y $3,201.4550783 Y 80% of billed 51798 N packaged 52649 Y $3,201.4550785 Y 80% of billed 51800 Y 80% of billed 52700 Y $2,210.4350800 Y 80% of billed 51820 Y 80% of billed 53000 Y $1,276.4350810 Y 80% of billed 51840 Y 80% of billed 53010 Y $3,201.4550815 Y 80% of billed 51841 Y 80% of billed 53020 Y $1,276.4350820 Y 80% of billed 51845 Y $3,153.87 53025 Y $1,276.4350825 Y 80% of billed 51860 Y $3,463.86 53040 Y $1,276.4350830 Y 80% of billed 51865 Y 80% of billed 53060 Y $132.4150840 Y 80% of billed 51880 Y $2,210.43 53080 Y $482.3950845 Y 80% of billed 51900 Y 80% of billed 53085 Y $1,276.4350860 Y 80% of billed 51920 Y 80% of billed 53200 Y $1,276.4350900 Y 80% of billed 51925 Y 80% of billed 53210 Y $2,210.4350920 Y 80% of billed 51940 Y 80% of billed 53215 Y $3,201.4550930 Y 80% of billed 51960 Y 80% of billed 53220 Y $2,210.4350940 Y 80% of billed 51980 Y 80% of billed 53230 Y $3,201.4550945 Y $3,995.44 51990 Y $3,995.44 53235 Y $3,201.4550947 Y $3,589.05 51992 Y $4,783.11 53240 Y $2,210.4350948 Y $5,627.72 51999 Y $3,995.44 53250 Y $2,210.4350949 Y $3,995.44 52000 Y $482.39 53260 Y $1,276.4350951 Y $2,210.43 52001 Y $2,210.43 53265 Y $1,276.4350953 Y $2,210.43 52005 Y $1,276.43 53270 Y $1,276.4350955 Y $3,201.45 52007 Y $2,210.43 53275 Y $1,276.4350957 Y $3,201.45 52010 Y $482.39 53400 Y $3,201.4550961 Y $3,201.45 52204 Y $1,276.43 53405 Y $3,201.4550970 Y $2,210.43 52214 Y $1,276.43 53410 Y $3,201.4550972 Y $2,210.43 52224 Y $1,276.43 53415 Y 80% of billed50974 Y $3,201.45 52234 Y $2,210.43 53420 Y $3,201.4550976 Y $3,201.45 52235 Y $2,210.43 53425 Y $3,201.4550980 Y $3,201.45 52240 Y $3,201.45 53430 Y $3,201.4551020 Y $2,210.43 52250 Y $2,210.43 53431 Y $3,201.4551030 Y $2,210.43 52260 Y $1,276.43 53440 Y $4,990.0551040 Y $1,276.43 52265 Y $439.24 53442 Y $3,201.4551045 Y $1,276.43 52270 Y $1,276.43 53444 Y $7,009.4651050 Y $3,201.45 52275 Y $1,276.43 53445 Y $7,641.8951060 Y $1,446.89 52276 Y $1,276.43 53446 N $3,201.4551065 Y $2,210.43 52277 Y $2,210.43 53447 Y $7,409.6851080 Y $1,692.88 52281 Y $1,276.43 53448 Y 80% of billed51100 Y $66.21 52282 Y $2,210.43 53449 Y $3,201.4551101 N $181.65 52283 Y $1,276.43 53450 Y $2,210.4351102 Y $1,276.43 52285 Y $482.39 53460 Y $2,210.4351500 Y $3,589.05 52287 Y $1,276.43 53500 Y $2,448.5351520 Y $2,210.43 52290 Y $1,276.43 53502 Y $2,210.4351525 Y 80% of billed 52300 Y $2,210.43 53505 Y $3,201.4551530 Y 80% of billed 52301 Y $2,210.43 53510 Y $3,201.4551535 Y $2,210.43 52305 Y $3,201.45 53515 Y $3,201.4551550 Y 80% of billed 52310 Y $1,276.43 53520 Y $3,201.4551555 Y 80% of billed 52315 Y $1,276.43 53600 Y $66.8251565 Y 80% of billed 52317 Y $2,210.43 53601 N packaged51570 Y 80% of billed 52318 Y $2,210.43 53605 Y $1,276.4351575 Y 80% of billed 52320 Y $2,210.43 53620 Y $149.8351580 Y 80% of billed 52325 Y $3,201.45 53621 Y $152.0351585 Y 80% of billed 52327 Y $4,354.29 53660 N $75.8751590 Y 80% of billed 52330 Y $2,210.43 53661 N packaged51595 Y 80% of billed 52332 Y $2,210.43 53665 Y $1,276.4351596 Y 80% of billed 52334 Y $2,210.43 53850 Y $2,210.4351597 Y 80% of billed 52341 Y $2,210.43 53852 Y $2,109.3951600 N packaged 52342 Y $2,210.43 53854 Y $1,276.4351605 N packaged 52343 Y $1,276.43 53855 Y $1,123.4951610 N packaged 52344 Y $2,210.43 53860 Y $1,276.4351700 Y $88.89 52345 Y $2,210.43 53899 Y $201.6351701 N packaged 52346 Y $3,201.45 54000 Y $2,210.4351702 N packaged 52351 Y $2,210.43 54001 Y $1,276.4351703 N $120.47 52352 Y $2,210.43 54015 Y $966.1151705 Y $104.22 52353 Y $3,201.45 54050 N packaged51710 Y $482.39 52354 Y $3,201.45 54055 Y $137.0851715 Y $2,931.53 52355 Y $3,201.45 54056 N packaged51720 Y $87.06 52356 Y $3,201.45 54057 Y $1,409.11





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






54060 Y $1,409.11 54680 Y $2,210.43 56632 Y 80% of billed54065 Y $1,409.11 54690 Y $3,589.05 56633 Y 80% of billed54100 Y $966.11 54692 Y $3,589.05 56634 Y 80% of billed54105 Y $1,692.88 54699 Y $3,995.44 56637 Y 80% of billed54110 Y $2,210.43 54700 Y $1,276.43 56640 Y 80% of billed54111 Y $3,201.45 54800 Y $966.11 56700 Y $2,099.5054112 Y $3,045.58 54830 Y $1,276.43 56740 Y $2,099.5054115 Y $1,692.88 54840 Y $1,276.43 56800 Y $2,099.5054120 Y $2,210.43 54860 Y $1,276.43 56805 Y $2,099.5054125 Y 80% of billed 54861 Y $2,210.43 56810 Y $2,099.5054130 Y 80% of billed 54865 Y $2,210.43 56820 Y $104.9754135 Y 80% of billed 54900 Y $1,276.43 56821 Y $136.7854150 Y $1,276.43 54901 Y $2,210.43 57000 Y $2,099.5054160 Y $482.39 55000 Y $107.05 57010 Y $2,099.5054161 Y $1,276.43 55040 Y $2,089.28 57020 Y $2,654.0554162 Y $1,276.43 55041 Y $2,089.28 57022 Y $1,692.8854163 Y $1,276.43 55060 Y $2,210.43 57023 Y $1,692.8854164 Y $1,276.43 55100 Y $966.11 57061 Y $155.8054200 Y $118.93 55110 Y $2,210.43 57065 Y $2,099.5054205 Y $3,201.45 55120 Y $1,276.43 57100 Y $85.7954220 Y $201.62 55150 Y $2,210.43 57105 Y $2,099.5054230 N packaged 55175 Y $2,210.43 57106 Y $2,145.3954231 Y $109.74 55180 Y $3,201.45 57107 Y $2,145.3954235 Y $74.18 55200 Y $2,210.43 57109 Y $2,145.3954240 N $65.29 55250 Y $1,276.43 57110 Y 80% of billed54250 Y $20.84 55300 N packaged 57111 Y 80% of billed54300 Y $2,210.43 55400 Y $2,210.43 57112 Y 80% of billed54304 Y $2,210.43 55500 Y $2,210.43 57120 Y $2,654.0554308 Y $3,201.45 55520 Y $2,210.43 57130 Y $2,099.5054312 Y $2,210.43 55530 Y $2,210.43 57135 Y $2,099.5054316 Y $3,201.45 55535 Y $2,089.28 57150 N packaged54318 Y $2,210.43 55540 Y $2,089.28 57155 Y $2,654.0554322 Y $2,210.43 55550 Y $3,589.05 57156 Y $235.6554324 Y $2,210.43 55559 Y $3,995.44 57160 Y $58.3854326 Y $1,276.43 55600 Y $1,276.43 57170 Y $60.8854328 Y $2,210.43 55605 Y 80% of billed 57180 Y $144.4054332 Y $2,448.53 55650 Y 80% of billed 57200 Y $2,099.5054336 Y $2,448.53 55680 Y $2,210.43 57210 Y $2,099.5054340 Y $2,210.43 55700 Y $1,276.43 57220 Y $2,654.0554344 Y $3,201.45 55705 Y $1,276.43 57230 Y $2,099.5054348 Y $3,201.45 55706 Y $2,210.43 57240 Y $2,654.0554352 Y $3,201.45 55720 Y $1,276.43 57250 Y $2,654.0554360 Y $2,210.43 55725 Y $2,210.43 57260 Y $2,654.0554380 Y $1,276.43 55801 Y 80% of billed 57265 Y $2,654.0554385 Y $1,276.43 55810 Y 80% of billed 57267 N packaged54390 Y 80% of billed 55812 Y 80% of billed 57268 Y $2,654.0554400 N $7,396.04 55815 Y 80% of billed 57270 Y 80% of billed54401 N $7,604.51 55821 Y 80% of billed 57280 Y 80% of billed54405 N $7,643.21 55831 Y 80% of billed 57282 Y $4,658.2254406 N $2,210.43 55840 Y 80% of billed 57283 Y $4,658.2254408 Y $3,201.45 55842 Y 80% of billed 57284 Y $3,153.8754410 N $7,535.47 55845 Y 80% of billed 57285 Y $4,658.2254411 Y $4,543.09 55860 Y $3,201.45 57287 N $2,099.5054415 N $2,210.43 55862 Y 80% of billed 57288 Y $3,582.4954416 N $7,487.52 55865 Y 80% of billed 57289 Y $3,754.6854417 Y $4,543.09 55866 Y $6,666.85 57291 Y $2,654.0554420 Y $1,276.43 55870 Y $133.67 57292 Y $3,153.8754430 Y 80% of billed 55873 Y $4,721.68 57295 Y $2,099.5054435 Y $2,210.43 55874 Y $3,201.45 57296 Y 80% of billed54437 Y $2,210.43 55875 N $3,201.45 57300 Y $2,099.5054438 Y 80% of billed 55876 N $139.16 57305 Y 80% of billed54440 Y $2,210.43 55899 Y $201.63 57307 Y 80% of billed54450 Y $201.62 55920 Y $2,654.05 57308 Y 80% of billed54500 Y $1,692.88 55970 Y $3,153.87 57310 Y $3,754.6854505 Y $2,210.43 55980 Y $2,448.53 57311 Y 80% of billed54512 Y $2,210.43 56405 Y $120.61 57320 Y $2,654.0554520 Y $2,210.43 56420 Y $144.40 57330 Y $4,658.2254522 Y $2,210.43 56440 Y $2,099.50 57335 Y $3,153.8754530 Y $2,089.28 56441 Y $2,099.50 57400 Y $2,099.5054535 Y $2,448.53 56442 Y $2,099.50 57410 Y $2,099.5054550 Y $2,089.28 56501 Y $178.01 57415 Y $2,099.5054560 Y $1,276.43 56515 Y $1,409.11 57420 Y $108.8154600 Y $2,210.43 56605 Y $82.07 57421 Y $143.6454620 Y $2,210.43 56606 N packaged 57423 Y $6,666.8554640 Y $2,089.28 56620 Y $2,099.50 57425 Y $6,666.8554650 Y $2,383.52 56625 Y $2,099.50 57426 Y $3,754.6854660 Y $4,442.07 56630 Y 80% of billed 57452 Y $106.2154670 Y $1,276.43 56631 Y 80% of billed 57454 Y $124.96





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






57455 Y $133.05 58562 Y $2,099.50 59320 Y $2,099.5057456 Y $126.82 58563 Y $2,654.05 59325 Y 80% of billed57460 Y $337.96 58565 Y $2,654.05 59350 Y 80% of billed57461 Y $360.66 58570 Y $5,627.72 59400 Y 80% of billed57500 Y $169.11 58571 Y $5,627.72 59409 Y $2,145.3957505 Y $144.26 58572 Y $5,627.72 59410 Y 80% of billed57510 Y $130.65 58573 Y $5,627.72 59412 Y $2,099.5057511 Y $170.35 58575 Y 80% of billed 59414 Y $2,099.5057513 Y $2,099.50 58578 Y $3,995.44 59425 Y 80% of billed57520 Y $2,099.50 58579 Y $144.41 59426 Y 80% of billed57522 Y $2,099.50 58600 Y $2,099.50 59430 Y 80% of billed57530 Y $2,654.05 58605 Y 80% of billed 59510 Y 80% of billed57531 Y 80% of billed 58611 Y 80% of billed 59514 Y 80% of billed57540 Y 80% of billed 58615 Y $2,099.50 59515 Y 80% of billed57545 Y 80% of billed 58660 Y $3,589.05 59525 Y 80% of billed57550 Y $2,654.05 58661 Y $3,589.05 59610 Y 80% of billed57555 Y $3,153.87 58662 Y $3,589.05 59612 Y $2,145.3957556 Y $2,654.05 58670 Y $3,589.05 59614 Y 80% of billed57558 Y $2,099.50 58671 Y $3,589.05 59618 Y 80% of billed57700 Y $2,099.50 58672 Y $3,589.05 59620 Y 80% of billed57720 Y $2,099.50 58673 Y $3,589.05 59622 Y 80% of billed57800 Y $68.70 58674 Y $5,627.72 59812 Y $2,099.5058100 Y $86.97 58679 Y $3,995.44 59820 Y $2,099.5058110 N packaged 58700 Y 80% of billed 59821 Y $2,099.5058120 Y $2,099.50 58720 Y 80% of billed 59830 Y 80% of billed58140 Y 80% of billed 58740 Y 80% of billed 59840 Y $2,099.5058145 Y $2,099.50 58750 Y 80% of billed 59841 Y $2,099.5058146 Y 80% of billed 58752 Y 80% of billed 59850 Y 80% of billed58150 Y 80% of billed 58760 Y 80% of billed 59851 Y 80% of billed58152 Y 80% of billed 58770 Y $2,145.39 59852 Y 80% of billed58180 Y 80% of billed 58800 Y $2,099.50 59855 Y 80% of billed58200 Y 80% of billed 58805 Y $2,099.50 59856 Y 80% of billed58210 Y 80% of billed 58820 Y $2,099.50 59857 Y 80% of billed58240 Y 80% of billed 58822 Y 80% of billed 59866 Y $235.6558260 Y $2,654.05 58825 Y 80% of billed 59870 Y $2,099.5058262 Y $2,654.05 58900 Y $2,099.50 59871 N $2,099.5058263 Y $3,153.87 58920 Y $4,658.22 59897 Y $144.4158267 Y 80% of billed 58925 Y $3,153.87 59898 Y $3,995.4458270 Y $3,153.87 58940 Y 80% of billed 59899 Y $144.4158275 Y 80% of billed 58943 Y 80% of billed 60000 Y $899.0558280 Y 80% of billed 58950 Y 80% of billed 60100 Y $89.6058285 Y 80% of billed 58951 Y 80% of billed 60200 Y $3,589.0558290 Y $4,658.22 58952 Y 80% of billed 60210 Y $3,589.0558291 Y $3,153.87 58953 Y 80% of billed 60212 Y $3,589.0558292 Y $4,658.22 58954 Y 80% of billed 60220 Y $3,589.0558293 Y 80% of billed 58956 Y 80% of billed 60225 Y $3,589.0558294 Y $3,153.87 58957 Y 80% of billed 60240 Y $3,589.0558300 Y 80% of billed 58958 Y 80% of billed 60252 Y $4,026.2558301 N $90.15 58960 Y 80% of billed 60254 Y 80% of billed58321 Y $75.23 58970 Y $555.81 60260 Y $4,026.2558322 Y $79.50 58974 Y $555.81 60270 Y 80% of billed58323 Y $10.57 58976 Y $235.65 60271 Y $4,026.2558340 N packaged 58999 Y $144.41 60280 Y $3,589.0558345 Y $2,099.50 59000 Y $113.16 60281 Y $3,589.0558346 Y $2,654.05 59001 Y $235.65 60300 Y $131.1058350 Y $2,654.05 59012 Y $235.65 60500 Y $3,690.3958353 Y $2,654.05 59015 Y $106.31 60502 Y $4,026.2558356 Y $2,352.98 59020 Y $57.14 60505 Y 80% of billed58400 Y 80% of billed 59025 Y $32.31 60512 N packaged58410 Y 80% of billed 59030 Y $235.66 60520 Y $4,026.2558520 Y 80% of billed 59050 Y 80% of billed 60521 Y 80% of billed58540 Y 80% of billed 59051 Y 80% of billed 60522 Y 80% of billed58541 Y $3,589.05 59070 Y $235.65 60540 Y 80% of billed58542 Y $5,627.72 59072 Y $329.40 60545 Y 80% of billed58543 Y $5,627.72 59074 Y $235.65 60600 Y 80% of billed58544 Y $5,627.72 59076 Y $235.65 60605 Y 80% of billed58545 Y $3,589.05 59100 Y $2,654.05 60650 Y 80% of billed58546 Y $5,627.72 59120 Y 80% of billed 60659 Y $3,995.4458548 Y 80% of billed 59121 Y 80% of billed 60699 Y $3,995.4458550 Y $3,589.05 59130 Y 80% of billed 61000 Y $543.3158552 Y $5,627.72 59135 Y 80% of billed 61001 Y $543.3158553 Y $5,627.72 59136 Y 80% of billed 61020 Y $705.5758554 Y $5,627.72 59140 Y 80% of billed 61026 Y $543.3158555 Y $2,099.50 59150 Y $3,589.05 61050 Y $227.8858558 Y $2,099.50 59151 Y $3,589.05 61055 Y $227.8858559 Y $2,654.05 59160 Y $2,099.50 61070 Y $543.3158560 Y $2,654.05 59200 Y $96.99 61105 Y 80% of billed58561 Y $2,654.05 59300 Y $190.15 61107 Y 80% of billed





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






61108 Y 80% of billed 61584 Y 80% of billed 62100 Y 80% of billed61120 Y 80% of billed 61585 Y 80% of billed 62115 Y 80% of billed61140 Y 80% of billed 61586 Y 80% of billed 62117 Y 80% of billed61150 Y 80% of billed 61590 Y 80% of billed 62120 Y 80% of billed61151 Y 80% of billed 61591 Y 80% of billed 62121 Y 80% of billed61154 Y 80% of billed 61592 Y 80% of billed 62140 Y 80% of billed61156 Y 80% of billed 61595 Y 80% of billed 62141 Y 80% of billed61210 Y 80% of billed 61596 Y 80% of billed 62142 Y 80% of billed61215 Y $2,707.26 61597 Y 80% of billed 62143 Y 80% of billed61250 Y 80% of billed 61598 Y 80% of billed 62145 Y 80% of billed61253 Y 80% of billed 61600 Y 80% of billed 62146 Y 80% of billed61304 Y 80% of billed 61601 Y 80% of billed 62147 Y 80% of billed61305 Y 80% of billed 61605 Y 80% of billed 62148 Y 80% of billed61312 Y 80% of billed 61606 Y 80% of billed 62160 N packaged61313 Y 80% of billed 61607 Y 80% of billed 62161 Y 80% of billed61314 Y 80% of billed 61608 Y 80% of billed 62162 Y 80% of billed61315 Y 80% of billed 61611 Y 80% of billed 62163 Y 80% of billed61316 Y 80% of billed 61613 Y 80% of billed 62164 Y 80% of billed61320 Y 80% of billed 61615 Y 80% of billed 62165 Y 80% of billed61321 Y 80% of billed 61616 Y 80% of billed 62180 Y 80% of billed61322 Y 80% of billed 61618 Y 80% of billed 62190 Y 80% of billed61323 Y 80% of billed 61619 Y 80% of billed 62192 Y 80% of billed61330 Y $1,791.33 61623 Y $5,230.82 62194 Y $1,366.5761333 Y 80% of billed 61624 Y 80% of billed 62200 Y 80% of billed61340 Y 80% of billed 61626 Y $5,230.82 62201 Y 80% of billed61343 Y 80% of billed 61630 Y 80% of billed 62220 Y 80% of billed61345 Y 80% of billed 61635 Y 80% of billed 62223 Y 80% of billed61450 Y 80% of billed 61640 Y 80% of billed 62225 Y $2,707.2661458 Y 80% of billed 61641 Y 80% of billed 62230 Y $2,707.2661460 Y 80% of billed 61642 Y 80% of billed 62252 N $60.3361500 Y 80% of billed 61645 Y 80% of billed 62256 Y 80% of billed61501 Y 80% of billed 61650 Y 80% of billed 62258 Y 80% of billed61510 Y 80% of billed 61651 Y 80% of billed 62263 Y $705.5761512 Y 80% of billed 61680 Y 80% of billed 62264 Y $705.5761514 Y 80% of billed 61682 Y 80% of billed 62267 Y $513.6161516 Y 80% of billed 61684 Y 80% of billed 62268 Y $705.5761517 Y 80% of billed 61686 Y 80% of billed 62269 Y $966.1161518 Y 80% of billed 61690 Y 80% of billed 62270 Y $543.3161519 Y 80% of billed 61692 Y 80% of billed 62272 Y $543.3161520 Y 80% of billed 61697 Y 80% of billed 62273 Y $543.3161521 Y 80% of billed 61698 Y 80% of billed 62280 Y $705.5761522 Y 80% of billed 61700 Y 80% of billed 62281 Y $705.5761524 Y 80% of billed 61702 Y 80% of billed 62282 Y $705.5761526 Y 80% of billed 61703 Y 80% of billed 62284 N packaged61530 Y 80% of billed 61705 Y 80% of billed 62287 Y $1,366.5761531 Y 80% of billed 61708 Y 80% of billed 62290 N packaged61533 Y 80% of billed 61710 Y 80% of billed 62291 N packaged61534 Y 80% of billed 61711 Y 80% of billed 62292 Y $1,366.5761535 Y 80% of billed 61720 Y $3,472.56 62294 Y $705.5761536 Y 80% of billed 61735 Y 80% of billed 62302 N packaged61537 Y 80% of billed 61750 Y 80% of billed 62303 N packaged61538 Y 80% of billed 61751 Y 80% of billed 62304 N packaged61539 Y 80% of billed 61760 Y 80% of billed 62305 N packaged61540 Y 80% of billed 61770 Y $2,707.26 62320 Y $543.3161541 Y 80% of billed 61781 N packaged 62321 Y $543.3161543 Y 80% of billed 61782 N packaged 62322 Y $543.3161544 Y 80% of billed 61783 N packaged 62323 Y $543.3161545 Y 80% of billed 61790 Y $1,366.57 62324 Y $705.5761546 Y 80% of billed 61791 Y $1,366.57 62325 Y $705.5761548 Y 80% of billed 61796 Y 80% of billed 62326 Y $705.5761550 Y 80% of billed 61797 Y 80% of billed 62327 Y $705.5761552 Y 80% of billed 61798 Y 80% of billed 62328 Y $543.3161556 Y 80% of billed 61799 Y 80% of billed 62329 Y $543.3161557 Y 80% of billed 61800 Y 80% of billed 62350 Y $3,615.0961558 Y 80% of billed 61850 Y 80% of billed 62351 Y $4,027.5561559 Y 80% of billed 61860 Y 80% of billed 62355 N $1,366.5761563 Y 80% of billed 61863 Y 80% of billed 62360 Y $6,005.2161564 Y 80% of billed 61864 Y 80% of billed 62361 Y $6,186.3661566 Y 80% of billed 61867 Y 80% of billed 62362 Y $5,936.9161567 Y 80% of billed 61868 Y 80% of billed 62365 N $2,707.2661570 Y 80% of billed 61870 Y 80% of billed 62367 N $23.6261571 Y 80% of billed 61880 N $2,699.51 62368 N $32.9761575 Y 80% of billed 61885 N $4,806.16 62369 N $122.5261576 Y 80% of billed 61886 N $6,782.56 62370 N $114.4261580 Y 80% of billed 61888 N $3,618.37 62380 Y $3,735.2761581 Y 80% of billed 62000 Y $2,247.18 63001 Y $3,735.2761582 Y 80% of billed 62005 Y 80% of billed 63003 Y $3,735.2761583 Y 80% of billed 62010 Y 80% of billed 63005 Y $3,735.27





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






63011 Y $4,027.55 63301 Y 80% of billed 64568 N $6,893.4863012 Y $4,027.55 63302 Y 80% of billed 64569 N $4,415.4563015 Y $4,027.55 63303 Y 80% of billed 64570 N $2,707.2663016 Y $4,027.55 63304 Y 80% of billed 64575 N $4,352.0863017 Y $4,027.55 63305 Y 80% of billed 64580 N $4,731.6363020 Y $3,735.27 63306 Y 80% of billed 64581 N $3,913.6563030 Y $3,735.27 63307 Y 80% of billed 64585 N $2,699.5163035 N packaged 63308 Y 80% of billed 64590 N $4,802.0863040 Y $4,027.55 63600 Y $1,366.57 64595 N $2,699.5163042 Y $3,735.27 63610 Y $2,019.64 64600 Y $705.5763043 N packaged 63620 Y 80% of billed 64605 Y $1,366.5763044 N packaged 63621 Y 80% of billed 64610 Y $1,366.5763045 Y $3,735.27 63650 N $3,647.57 64611 Y $129.9663046 Y $3,735.27 63655 N $4,427.38 64612 Y $133.0563047 Y $3,735.27 63661 N $1,366.57 64615 Y $117.5263048 N packaged 63662 N $2,699.51 64616 Y $112.5463050 Y 80% of billed 63663 N $3,565.67 64617 Y $152.9663051 Y 80% of billed 63664 N $4,033.03 64620 Y $705.5763055 Y $3,735.27 63685 N $6,755.55 64624 Y $546.5563056 Y $3,735.27 63688 N $2,699.51 64625 Y $1,366.5763057 N packaged 63700 Y 80% of billed 64630 Y $705.5763064 Y $4,027.55 63702 Y 80% of billed 64632 Y $73.3863066 N packaged 63704 Y 80% of billed 64633 Y $1,366.5763075 Y $4,027.55 63706 Y 80% of billed 64634 N packaged63076 N packaged 63707 Y 80% of billed 64635 Y $1,366.5763077 Y 80% of billed 63709 Y 80% of billed 64636 N packaged63078 Y 80% of billed 63710 Y 80% of billed 64640 Y $303.4763081 Y 80% of billed 63740 Y 80% of billed 64642 Y $135.9763082 Y 80% of billed 63741 Y $3,472.56 64643 N packaged63085 Y 80% of billed 63744 Y $2,707.26 64644 Y $167.6263086 Y 80% of billed 63746 N $1,366.57 64645 N packaged63087 Y 80% of billed 64400 Y $131.81 64646 Y $136.5963088 Y 80% of billed 64405 Y $57.20 64647 Y $150.2563090 Y 80% of billed 64408 Y $70.25 64650 Y $92.6463091 Y 80% of billed 64415 Y $705.57 64653 Y $106.9463101 Y 80% of billed 64416 Y $705.57 64680 Y $705.5763102 Y 80% of billed 64417 Y $705.57 64681 Y $705.5763103 Y 80% of billed 64418 Y $74.51 64702 Y $1,366.5763170 Y 80% of billed 64420 Y $543.31 64704 Y $1,366.5763172 Y 80% of billed 64421 Y $705.57 64708 Y $1,366.5763173 Y 80% of billed 64425 Y $129.13 64712 Y $1,366.5763180 Y 80% of billed 64430 Y $705.57 64713 Y $1,366.5763182 Y 80% of billed 64435 Y $76.36 64714 Y $1,366.5763185 Y 80% of billed 64445 Y $153.97 64716 Y $1,366.5763190 Y 80% of billed 64446 Y $705.57 64718 Y $1,366.5763191 Y 80% of billed 64447 Y $83.19 64719 Y $1,366.5763194 Y 80% of billed 64448 Y $705.57 64721 Y $1,366.5763195 Y 80% of billed 64449 Y $705.57 64722 Y $1,366.5763196 Y 80% of billed 64450 Y $83.19 64726 Y $1,366.5763197 Y 80% of billed 64451 Y $543.31 64727 N packaged63198 Y 80% of billed 64454 Y $271.92 64732 Y $1,366.5763199 Y 80% of billed 64455 Y $35.44 64734 Y $1,366.5763200 Y 80% of billed 64461 Y $543.31 64736 Y $1,366.5763250 Y 80% of billed 64462 N packaged 64738 Y $1,366.5763251 Y 80% of billed 64463 Y $543.31 64740 Y $1,366.5763252 Y 80% of billed 64479 Y $705.57 64742 Y $1,366.5763265 Y $4,027.55 64480 N packaged 64744 Y $1,366.5763266 Y $4,027.55 64483 Y $705.57 64746 Y $1,366.5763267 Y $4,027.55 64484 N packaged 64755 Y 80% of billed63268 Y $4,027.55 64486 N packaged 64760 Y 80% of billed63270 Y 80% of billed 64487 N packaged 64763 Y $1,366.5763271 Y 80% of billed 64488 N packaged 64766 Y $1,366.5763272 Y 80% of billed 64489 N packaged 64771 Y $1,366.5763273 Y 80% of billed 64490 Y $705.57 64772 Y $1,366.5763275 Y 80% of billed 64491 N packaged 64774 Y $1,366.5763276 Y 80% of billed 64492 N packaged 64776 Y $1,366.5763277 Y 80% of billed 64493 Y $705.57 64778 N packaged63278 Y 80% of billed 64494 N packaged 64782 Y $1,366.5763280 Y 80% of billed 64495 N packaged 64783 N packaged63281 Y 80% of billed 64505 Y $123.12 64784 Y $1,366.5763282 Y 80% of billed 64510 Y $705.57 64786 Y $2,707.2663283 Y 80% of billed 64517 Y $705.57 64787 N packaged63285 Y 80% of billed 64520 Y $705.57 64788 Y $1,366.5763286 Y 80% of billed 64530 Y $705.57 64790 Y $1,366.5763287 Y 80% of billed 64553 N $4,171.20 64792 Y $2,707.2663290 Y 80% of billed 64555 N $3,785.95 64795 Y $1,366.5763295 Y 80% of billed 64561 N $3,784.04 64802 Y $1,366.5763300 Y 80% of billed 64566 Y $180.31 64804 Y $1,490.06





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






64809 Y 80% of billed 65426 Y $1,415.66 66850 Y $1,516.4364818 Y 80% of billed 65430 N packaged 66852 Y $2,681.2464820 Y $1,366.57 65435 Y $80.00 66920 Y $1,516.4364821 Y $2,110.49 65436 Y $353.45 66930 Y $2,681.2464822 Y $2,110.49 65450 Y $234.87 66940 Y $1,516.4364823 Y $2,110.49 65600 Y $440.14 66982 Y $1,516.4364831 Y $1,366.57 65710 Y $2,681.24 66983 Y $1,516.4364832 N packaged 65730 Y $2,681.24 66984 Y $1,516.4364834 Y $2,707.26 65750 Y $2,681.24 66985 Y $1,516.4364835 Y $2,707.26 65755 Y $2,681.24 66986 Y $1,516.4364836 Y $2,707.26 65756 Y $2,681.24 66987 Y $3,495.0464837 N packaged 65757 N packaged 66988 Y $3,495.0464840 Y $2,707.26 65760 Y 80% of billed 66990 N packaged64856 Y $2,707.26 65765 Y 80% of billed 66999 Y $1,529.8264857 Y $2,707.26 65767 Y 80% of billed 67005 Y $1,516.4364858 Y $1,366.57 65770 Y $10,570.83 67010 Y $1,516.4364859 N packaged 65771 Y 80% of billed 67015 Y $1,516.4364861 Y $1,366.57 65772 Y $679.58 67025 Y $1,516.4364862 Y $2,707.26 65775 Y $1,415.66 67027 Y $2,678.6364864 Y $2,707.26 65778 N packaged 67028 N $81.4864865 Y $2,707.26 65779 N packaged 67030 Y $1,516.4364866 Y 80% of billed 65780 Y $2,184.12 67031 Y $441.4764868 Y 80% of billed 65781 Y $2,681.24 67036 Y $2,681.2464872 N packaged 65782 Y $2,184.12 67039 Y $2,681.2464874 N packaged 65785 Y $2,681.24 67040 Y $2,681.2464876 N packaged 65800 Y $1,516.43 67041 Y $2,681.2464885 Y $2,707.26 65810 Y $1,516.43 67042 Y $2,681.2464886 Y $2,707.26 65815 Y $1,516.43 67043 Y $2,681.2464890 Y $2,707.26 65820 Y $2,681.24 67101 Y $303.7064891 Y $3,528.94 65850 Y $1,516.43 67105 Y $295.4764892 Y $2,707.26 65855 Y $233.88 67107 Y $2,681.2464893 Y $2,707.26 65860 Y $305.41 67108 Y $2,681.2464895 Y $2,707.26 65865 Y $1,516.43 67110 Y $761.4264896 Y $2,707.26 65870 Y $1,516.43 67113 Y $2,681.2464897 Y $2,707.26 65875 Y $1,516.43 67115 Y $2,681.2464898 Y $2,707.26 65880 Y $2,681.24 67120 Y $1,516.4364901 N packaged 65900 Y $1,516.43 67121 Y $1,516.4364902 N packaged 65920 Y $1,516.43 67141 Y $234.8764905 Y $2,707.26 65930 Y $1,516.43 67145 Y $441.4764907 Y $2,707.26 66020 Y $1,516.43 67208 Y $234.8764910 Y $3,907.98 66030 Y $1,516.43 67210 Y $441.4764911 Y $3,472.56 66130 Y $1,415.66 67218 Y $2,184.1264912 Y $4,268.73 66150 Y $2,681.24 67220 Y $441.4764913 N packaged 66155 Y $2,681.24 67221 Y $263.7464999 Y $227.89 66160 Y $1,516.43 67225 N packaged65091 Y $2,184.12 66170 Y $1,516.43 67227 Y $265.1465093 Y $2,184.12 66172 Y $1,516.43 67228 Y $308.5165101 Y $2,184.12 66174 Y $2,681.24 67229 Y $441.4765103 Y $2,184.12 66175 Y $2,681.24 67250 Y $1,415.6665105 Y $2,184.12 66179 Y $2,681.24 67255 Y $1,516.4365110 Y $2,184.12 66180 Y $3,596.10 67299 Y $1,529.8265112 Y $2,184.12 66183 Y $3,785.63 67311 Y $1,415.6665114 Y $2,184.12 66184 Y $1,516.43 67312 Y $2,184.1265125 Y $1,415.66 66185 Y $1,516.43 67314 Y $1,415.6665130 Y $2,184.12 66225 Y $2,681.24 67316 Y $1,415.6665135 Y $2,184.12 66250 Y $1,415.66 67318 Y $1,415.6665140 Y $2,184.12 66500 Y $1,516.43 67320 N packaged65150 Y $2,184.12 66505 Y $1,516.43 67331 N packaged65155 Y $2,184.12 66600 Y $2,681.24 67332 N packaged65175 Y $2,184.12 66605 Y $1,516.43 67334 N packaged65205 N packaged 66625 Y $1,516.43 67335 N packaged65210 N packaged 66630 Y $1,516.43 67340 N packaged65220 N packaged 66635 Y $1,516.43 67343 Y $1,415.6665222 N packaged 66680 Y $1,516.43 67345 Y $217.0565235 Y $1,516.43 66682 Y $1,516.43 67346 Y $2,184.1265260 Y $1,516.43 66700 Y $1,516.43 67399 Y $234.8765265 Y $1,516.43 66710 Y $1,415.66 67400 Y $2,184.1265270 Y $1,415.66 66711 Y $1,516.43 67405 Y $1,415.6665272 Y $1,415.66 66720 Y $1,415.66 67412 Y $1,415.6665273 Y 80% of billed 66740 Y $1,415.66 67413 Y $1,415.6665275 Y $2,184.12 66761 Y $327.17 67414 Y $2,184.1265280 Y $2,681.24 66762 Y $441.47 67415 Y $1,415.6665285 Y $2,681.24 66770 Y $441.47 67420 Y $2,184.1265286 Y $692.79 66820 Y $1,516.43 67430 Y $2,184.1265290 Y $2,184.12 66821 Y $441.47 67440 Y $2,184.1265400 Y $679.58 66825 Y $1,516.43 67445 Y $2,184.1265410 Y $1,415.66 66830 Y $1,516.43 67450 Y $2,184.1265420 Y $1,415.66 66840 Y $1,516.43 67500 Y $234.87





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






67505 Y $66.98 68525 Y $1,415.66 69650 Y $1,791.3367515 Y $62.02 68530 Y $234.87 69660 Y $3,690.3967550 Y $2,184.12 68540 Y $1,415.66 69661 Y $3,690.3967560 Y $2,184.12 68550 Y $2,184.12 69662 Y $3,690.3967570 Y $2,184.12 68700 Y $1,415.66 69666 Y $1,791.3367599 Y $234.87 68705 Y $234.87 69667 Y $1,791.3367700 Y $234.87 68720 Y $2,184.12 69670 Y $3,690.3967710 Y $332.02 68745 Y $2,184.12 69676 Y $1,791.3367715 Y $1,415.66 68750 Y $2,184.12 69700 Y $899.0567800 Y $131.47 68760 Y $234.87 69710 Y 80% of billed67801 Y $154.58 68761 Y $167.43 69711 N $1,791.3367805 Y $204.02 68770 Y $1,415.66 69714 Y $8,707.0167808 Y $1,415.66 68801 N packaged 69715 Y $6,932.5467810 Y $234.87 68810 Y $234.87 69717 Y $5,829.6967820 N packaged 68811 Y $1,415.66 69718 Y $5,272.5867825 Y $138.30 68815 Y $1,415.66 69720 Y $3,690.3967830 Y $679.58 68816 Y $1,415.66 69725 Y $4,026.2567835 Y $1,415.66 68840 Y $143.26 69740 Y $3,690.3967840 Y $340.45 68850 N packaged 69745 Y $3,690.3967850 Y $255.63 68899 Y $234.87 69799 Y $176.5267875 Y $679.58 69000 Y $217.08 69801 Y $224.3367880 Y $1,415.66 69005 Y $224.42 69805 Y $3,690.3967882 Y $1,415.66 69020 Y $288.65 69806 Y $3,690.3967900 Y $1,415.66 69090 Y 80% of billed 69905 Y $3,690.3967901 Y $1,415.66 69100 Y $117.01 69910 Y $3,690.3967902 Y $2,184.12 69105 Y $183.82 69915 Y $1,791.3367903 Y $1,415.66 69110 Y $1,692.88 69930 Y $9,746.8167904 Y $1,415.66 69120 Y $3,690.39 69949 Y $176.5267906 Y $2,184.12 69140 Y $3,690.39 69950 Y 80% of billed67908 Y $1,415.66 69145 Y $1,692.88 69955 Y $4,026.2567909 Y $1,415.66 69150 Y $3,690.39 69960 Y $4,026.2567911 Y $1,415.66 69155 Y 80% of billed 69970 Y $4,026.2567912 Y $1,415.66 69200 N packaged 69979 Y $176.5267914 Y $1,415.66 69205 Y $966.11 69990 N packaged67915 Y $395.57 69209 N packaged 92920 Y $3,720.8767916 Y $1,415.66 69210 N packaged 92921 N packaged67917 Y $1,415.66 69220 N packaged 92928 Y $6,328.8467921 Y $1,415.66 69222 Y $270.85 92929 N packaged67922 Y $382.14 69300 Y $1,791.33 93451 Y $2,091.3567923 Y $1,415.66 69310 Y $3,690.39 93452 Y $2,091.3567924 Y $1,415.66 69320 Y $3,690.39 93453 Y $2,091.3567930 Y $398.00 69399 Y $176.52 93454 Y $2,091.3567935 Y $1,415.66 69420 Y $176.50 93455 Y $2,091.3567938 Y $234.87 69421 Y $1,791.33 93456 Y $2,091.3567950 Y $1,415.66 69424 N $162.99 93457 Y $2,091.3567961 Y $1,415.66 69433 Y $237.92 93458 Y $2,091.3567966 Y $1,415.66 69436 Y $899.05 93459 Y $2,091.3567971 Y $1,415.66 69440 Y $1,791.33 93460 Y $2,091.3567973 Y $1,415.66 69450 Y $1,791.33 93461 Y $2,091.3567974 Y $2,184.12 69501 Y $3,690.39 93462 N packaged67975 Y $1,415.66 69502 Y $3,690.39 93566 N packaged67999 Y $234.87 69505 Y $3,690.39 93567 N packaged68020 Y $114.28 69511 Y $3,690.39 93568 N packaged68040 Y $54.58 69530 Y $3,690.39 93571 N packaged68100 Y $219.75 69535 Y 80% of billed 93572 N packaged68110 Y $285.69 69540 Y $266.05 93985 N $202.8968115 Y $1,415.66 69550 Y $3,690.39 93986 N $97.6168130 Y $1,415.66 69552 Y $3,690.39 0100T Y $15,847.1768135 Y $148.95 69554 Y 80% of billed 0101T Y $2,110.4968200 N packaged 69601 Y $3,690.39 0102T Y $2,110.4968320 Y $1,415.66 69602 Y $3,690.39 0191T Y $3,969.1268325 Y $2,184.12 69603 Y $3,690.39 0200T Y $5,149.8468326 Y $2,184.12 69604 Y $3,690.39 0201T Y $3,735.2768328 Y $1,415.66 69605 Y $3,690.39 0213T Y $705.5768330 Y $1,516.43 69610 Y $342.24 0214T N packaged68335 Y $2,184.12 69620 Y $1,791.33 0215T N packaged68340 Y $1,415.66 69631 Y $3,690.39 0216T Y $705.5768360 Y $2,184.12 69632 Y $3,690.39 0217T N packaged68362 Y $1,415.66 69633 Y $3,690.39 0218T N packaged68371 Y $1,415.66 69635 Y $3,690.39 0228T Y $705.5768399 Y $234.87 69636 Y $3,690.39 0229T N packaged68400 Y $386.77 69637 Y $3,690.39 0230T Y $705.5768420 Y $415.71 69641 Y $3,690.39 0231T N packaged68440 Y $114.10 69642 Y $3,690.39 0232T N packaged68500 Y $2,184.12 69643 Y $3,690.39 0238T Y $8,694.3468505 Y $2,184.12 69644 Y $3,690.39 0253T Y $3,759.1168510 Y $1,415.66 69645 Y $3,690.39 0263T N $3,325.3468520 Y $2,184.12 69646 Y $3,690.39 0264T N $3,325.34





HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment



HCPCS

Code

Subject To

Multiple

Procedure

Discounting

Maximum Payment






0265T N $3,325.34 0493T N packaged0269T N $2,707.26 0502T N packaged0270T N $2,699.51 0503T N packaged0271T N $2,699.51 0510T N $2,110.490274T Y $3,735.27 0511T Y $4,868.970275T Y $3,735.27 0512T N $278.210278T N packaged 0513T N packaged0290T N packaged 0514T N packaged0308T Y $6,340.13 0523T N packaged0313T Y $5,052.85 0524T Y $1,873.090314T N $2,699.51 0525T Y $3,956.490315T N $2,699.51 0526T Y $2,250.400316T N $7,070.28 0527T Y $2,250.400330T N packaged 0530T N $2,056.830335T Y $5,668.77 0531T N $2,056.830338T N $2,637.37 0532T N $2,056.830339T N $2,637.37 0548T Y $3,969.950342T N $3,325.34 0549T Y $4,173.130347T N packaged 0550T Y $2,210.430348T N packaged 0551T Y $201.620349T N packaged 0566T Y $227.880350T N packaged 0587T Y $708.210351T N packaged 0588T Y $227.880353T N packaged C5271 Y $432.240356T N packaged C5272 N packaged0376T N packaged C5273 Y $1,409.110379T N packaged C5274 N packaged0396T N packaged C5275 Y $432.240397T N packaged C5276 N packaged0400T N packaged C5277 Y $432.240401T N packaged C5278 N packaged0402T Y $1,415.66 C9600 Y $6,466.190408T Y $8,156.91 C9601 N packaged0409T Y $6,534.34 C9725 Y $664.650410T Y $2,250.40 C9726 N packaged0411T Y $2,250.40 C9727 Y $899.050412T N $2,056.83 C9728 N $1,078.480413T N $2,056.83 C9739 Y $5,316.240414T Y $6,534.34 C9740 Y $5,266.160415T Y $537.57 C9745 Y $5,517.220416T Y $1,409.11 C9747 Y $3,201.450419T Y $432.24 C9749 Y $5,614.780420T Y $432.24 C9752 Y $6,872.880421T Y $3,045.58 C9753 N packaged0424T Y $6,362.67 C9754 Y $7,501.530425T Y $2,424.41 C9755 Y $7,501.530426T Y $2,606.99 C9757 Y $6,872.880427T Y $3,678.07 G0104 Y $250.450428T N $2,699.51 G0105 Y $664.650429T N $2,699.51 G0121 Y $664.650430T N $2,699.51 G0186 Y $441.470431T Y $6,854.22 G0260 Y $543.310432T Y $2,699.51 G0276 Y $3,735.270433T Y $2,699.51 G0429 Y $90.550434T N $98.74 G0516 N packaged0437T N packaged G0517 N packaged0439T N packaged G0518 N packaged0440T Y $1,366.570441T Y $1,366.570442T Y $4,006.320443T N packaged0444T N packaged0445T N packaged0446T Y $432.240447T N $152.170448T Y $432.240449T Y $4,121.900450T N packaged0465T Y $269.600466T N packaged0467T N $2,699.510468T N $2,699.510471T N packaged0479T Y $278.210480T N packaged0487T N packaged0491T Y $278.210492T N packaged



appendix c for administrative order no. 20-053 ambulatory ...note: listing of a payment amount does...

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