illinois department of healthcare and family services ... · national correct coding institute...
TRANSCRIPT
Please note the appearance of a code on this fee schedule does not guarantee payment. Services for which medical necessity is not clearly established are not covered by the Department's Medical Programs. See Chapter 100, Topic 104 and Chapter A-200, Section 204 for additional exclusions. Updates are based on periodic modifications to the HCPCS/cpt code setCPT codes and descriptions only are copyright 2015 by the American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. National Correct Coding Institute (NCCI) edits apply. *2.7% rate reductions shown in a separate column do not apply to: Physicians, Dentists, Advanced Practice Nurses, Community Mental Health Providers, FQHCs, RHCs, ERCs, LEAs, DORs Schools,School-based Clinics, Local Health Departments and Early Intervention.
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
00100 04 Y I 300102 04 Y M 300103 04 Y M 500104 04 04/01/15 N N 44.40 43.20 00120 04 Y M 400124 04 Y I 300126 04 Y I 300140 04 Y M 500142 04 Y M 500144 04 Y M 500145 04 Y M 500147 04 Y M 500148 04 Y I 300160 04 Y M 400162 04 Y M 400164 04 Y I 400170 04 Y I 500172 04 Y M 500174 04 Y M 400176 04 Y M 400190 04 Y M 400192 04 Y M 400210 04 Y M 900211 04 01/01/09 Y M 900212 04 Y M 400214 04 Y M 900215 04 Y M 900216 04 Y M 900218 04 Y M 900220 04 Y M 1100222 04 Y M 900300 04 Y M 300320 04 Y M 6
Rate reducedby 2.7%
Illinois Department of Healthcare and Family ServicesPractitioner Fee Schedule Effective 04/01/2017 Updated 04/18/2017
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
00322 04 Y M 300326 04 Y M 400350 04 Y M 1500352 04 Y M 500400 04 Y I 300402 04 Y M 400404 04 Y M 400406 04 Y M 400410 04 N I 112.40 109.37 00450 04 Y M 300454 04 Y I 300470 04 Y M 400472 04 Y M 700474 04 Y M 500500 04 Y M 900520 04 Y M 400522 04 Y I 400524 04 Y M 400528 04 Y M 400529 04 Y N 500530 04 Y M 500532 04 Y I 300534 04 Y M 500537 04 Y I 500539 04 Y M 1100540 04 Y M 1100541 04 Y M 1100542 04 Y M 1100546 04 Y M 700548 04 Y M 1100550 04 Y M 300560 04 Y M 2000561 04 Y M 2000562 04 Y M 2000563 04 Y M 2000566 04 Y M 2000567 04 01/01/09 Y M 2000580 04 Y M 2000600 04 Y M 800604 04 Y M 800620 04 Y M 8
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
00625 04 01/01/07 Y M 1000626 04 01/01/07 Y N 1000630 04 Y M 700632 04 Y M 400635 04 Y I 300640 04 Y M 800670 04 Y M 700700 04 Y M 400702 04 Y I 300730 04 Y M 400740 04 Y M 400750 04 Y M 300752 04 Y M 300754 04 Y M 300756 04 Y M 600770 04 Y M 1500790 04 Y M 600792 04 Y M 1200794 04 Y M 600796 04 Y M 1200797 04 Y M 500800 04 Y M 400802 04 Y M 300810 04 Y M 400820 04 Y M 400830 04 Y M 300832 04 Y M 300834 04 Y M 300836 04 Y M 300840 04 Y M 400842 04 Y I 400844 04 Y M 600846 04 Y M 500848 04 Y M 600851 04 01/01/12 Y M 400860 04 Y M 400862 04 Y M 500864 04 Y M 700865 04 Y M 600866 04 Y M 900868 04 Y M 5
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
00870 04 Y M 500872 04 Y M 300873 04 Y M 300880 04 Y M 400882 04 Y M 500902 04 Y M 400904 04 Y M 300906 04 Y M 300908 04 Y M 600910 04 Y M 300912 04 Y M 300914 04 Y M 500916 04 Y M 500918 04 Y M 300920 04 Y M 300921 04 Y M 300922 04 Y M 300924 04 Y M 400926 04 Y M 300928 04 Y M 400930 04 Y M 300932 04 Y M 300934 04 Y M 400936 04 Y M 400938 04 Y M 300940 04 Y I 300942 04 Y M 300944 04 Y M 500948 04 Y I 300950 04 Y I 300952 04 Y I 301112 04 Y I 301120 04 Y M 301130 04 Y I 301140 04 Y M 1101150 04 Y M 1101160 04 Y M 301170 04 Y M 301173 04 Y M 301180 04 Y M 301190 04 Y M 3
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
01200 04 Y M 501202 04 Y M 301210 04 Y M 301212 04 Y M 801214 04 Y M 301215 04 Y I 301220 04 Y M 301230 04 Y M 401232 04 Y M 301234 04 Y M 601250 04 Y M 301260 04 Y M 1001270 04 Y M 1001272 04 Y M 501274 04 Y M 501320 04 Y M 301340 04 Y M 301360 04 Y M 401380 04 Y M 301382 04 Y M 301390 04 Y M 401392 04 Y M 401400 04 Y M 301402 04 Y M 301404 04 Y M 301420 04 Y I 301430 04 Y M 501432 04 Y M 501440 04 Y M 501442 04 Y M 501444 04 Y M 501462 04 Y M 301464 04 Y M 301470 04 Y M 401472 04 Y M 301474 04 Y M 301480 04 Y M 301482 04 Y M 301484 04 Y M 301486 04 Y M 301490 04 Y I 3
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
01500 04 Y M 1001502 04 Y M 501520 04 Y M 1001522 04 Y M 501610 04 Y M 301620 04 Y M 301622 04 Y M 301630 04 Y M 301634 04 Y M 501636 04 Y M 1101638 04 Y M 301650 04 Y M 501652 04 Y M 1501654 04 Y M 1001656 04 Y M 1001670 04 Y M 1001680 04 Y I 301682 04 Y I 301710 04 Y M 301712 04 Y M 301714 04 Y M 301716 04 Y M 301730 04 Y M 301732 04 Y M 301740 04 Y M 301742 04 Y M 301744 04 Y M 301756 04 Y M 301758 04 Y M 301760 04 Y M 301770 04 Y M 501772 04 Y M 501780 04 Y M 501782 04 Y M 301810 04 Y M 301820 04 Y M 301829 04 Y M 3 #VALUE!01830 04 Y M 301832 04 Y M 301840 04 Y M 501842 04 Y M 5
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
01844 04 Y M 501850 04 Y M 1001852 04 Y M 301860 04 Y M 301916 04 Y I 301920 04 Y M 301922 04 Y I 301924 04 Y M 301925 04 Y M 301926 04 Y I 301930 04 Y M 501931 04 Y M 801932 04 Y M 601933 04 Y M 901935 04 01/01/08 Y M 501936 04 01/01/08 Y M 501951 04 Y I 301952 04 Y I 301953 04 Y I 301958 04 Y M 401960 09 Y M 401961 04 Y M 501962 04 Y M 501963 04 Y M 501965 04 Y M 301966 04 07/01/08 Y M 301967 04 Y M 301968 04 Y M 301969 04 Y M 301991 04 Y I 301992 04 Y I 301996 04 N I 14.25 13.87 01999 04 Y M 310021 04 N I 3 49.80 48.46 10022 04 N I 3 56.70 55.17 10030 04 01/01/14 N I 4 Y 95.05 92.48 10035 04 01/01/16 N I 3 Y 53.40 51.96 10036 A 04 01/01/16 N I 3 Y 23.93 23.28 10040 04 N I 3 35.20 34.25 10060 04 N I 3 36.00 35.03 10061 04 N I 3 66.50 64.70
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
10080 04 N I 3 70.65 68.74 10081 04 N I 4 131.80 128.24 10120 04 N I 3 39.05 38.00 10121 04 N I 3 77.60 75.50 10140 04 N I 3 41.50 40.38 10160 04 N I 3 35.95 34.98 10180 04 N I 3 Y 130.55 127.03 11000 04 N I 3 77.70 75.60 11001 04 N I 3 20.85 20.29 11004 04 N M 3 Y Y 154.43 150.26 11005 04 N M 3 Y Y 154.43 150.26 11006 04 N M 3 Y Y 154.43 150.26 11008 04 N M 3 Y Y 154.43 150.26 11010 04 N I 3 127.60 124.15 11011 04 N I 3 157.90 153.64 11012 04 N I 3 218.40 212.50 11042 04 01/01/10 N I 3 70.55 68.65 11043 04 07/01/12 N I 3 170.55 165.95 11044 04 07/01/12 N M 3 219.35 213.43 11045 04 01/01/11 Y I 3 11046 04 01/01/11 Y I 3 Y11047 04 01/01/11 Y I 3 Y11055 04 N I 3 22.15 21.55 11056 04 04/01/14 N I 3 13.93 13.55 11057 04 04/01/14 N I 3 18.21 17.72 11100 04 N I 3 50.20 17.00 48.84 11101 04 N I 3 22.15 21.55 11200 04 N I 3 35.65 17.00 34.69 11201 04 N I 3 15.20 14.79 11300 04 N I 3 21.10 20.53 11301 04 N I 3 29.20 28.41 11302 04 N I 3 37.50 36.49 11303 04 N I 3 45.70 44.47 11305 04 N I 3 22.25 21.65 11306 04 N I 3 31.25 30.41 11307 04 N I 3 37.50 36.49 11308 04 N I 3 45.70 44.47 11310 04 N I 3 32.40 31.53 11311 04 N I 3 40.55 39.46 11312 04 N I 3 48.80 47.48 11313 04 N I 3 57.10 55.56
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
11400 04 N I 3 39.05 17.00 38.00 11401 04 N I 3 50.20 17.00 48.84 11402 04 N I 3 64.80 17.00 63.05 11403 04 N I 3 77.90 17.00 75.80 11404 04 N I 3 92.40 17.00 89.91 11406 04 N I 3 108.00 17.00 105.08 11420 04 N I 3 38.30 17.00 37.27 11421 04 N I 3 50.85 17.00 49.48 11422 04 N I 3 64.80 17.00 63.05 11423 04 N I 3 77.90 17.00 75.80 11424 04 N I 3 92.40 17.00 89.91 11426 04 N I 3 127.48 17.00 124.04 11440 04 N I 3 54.15 17.00 52.69 11441 04 N I 3 75.30 17.00 73.27 11442 04 N I 3 96.40 17.00 93.80 11443 04 N I 3 111.00 17.00 108.00 11444 04 N I 3 117.55 17.00 114.38 11446 04 N I 3 146.37 17.00 142.42 11450 04 N M 3 Y 215.40 34.00 209.58 11451 04 N M 3 Y 244.10 34.00 237.51 11462 04 N M 3 Y 215.40 34.00 209.58 11463 04 N M 3 Y 232.20 225.93 11470 04 N M 3 Y 291.30 283.43 11471 04 N M 3 Y 297.00 288.98 11600 04 N I 3 54.15 17.00 52.69 11601 04 N I 3 75.30 17.00 73.27 11602 04 N I 3 96.40 17.00 93.80 11603 04 N I 3 117.55 17.00 114.38 11604 04 N I 3 138.75 17.00 135.00 11606 04 N M 3 185.52 17.00 180.51 11620 04 N I 3 54.15 17.00 52.69 11621 04 N I 3 75.30 17.00 73.27 11622 04 N I 3 96.40 17.00 93.80 11623 04 N I 3 117.55 17.00 114.38 11624 04 N I 3 138.75 17.00 135.00 11626 04 N M 3 185.52 17.00 180.51 11640 04 N I 3 107.00 17.00 104.11 11641 04 N I 3 149.25 17.00 145.22 11642 04 N M 3 192.95 17.00 187.74 11643 04 N M 3 235.20 17.00 228.85 11644 04 N M 3 278.80 17.00 271.27
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
11646 04 N M 3 294.77 17.00 286.81 11719 04 N I 3 15.90 15.47 11720 04 N I 15.90 15.47 11721 04 N I 18.10 17.61 11730 04 N I 3 34.30 17.00 33.37 11732 04 N I 3 14.45 14.06 11740 04 N I 3 36.00 35.03 11750 04 N I 3 61.85 34.00 60.18 11755 04 N I 3 38.80 37.75 11760 04 N I 3 60.80 17.00 59.16 11762 04 N I 3 87.75 17.00 85.38 11765 04 N I 3 38.40 37.36 11770 04 N M 4 215.40 34.00 209.58 11771 04 N M 4 Y 291.30 283.43 11772 04 N M 4 341.25 332.04 11900 04 N I 3 21.10 17.00 20.53 11901 04 09/01/14 N I 3 29.63 28.83 11920 04 09/01/14 N I 70.11 68.22 11921 04 N I 63.57 61.85 11922 04 N I 16.13 15.69 11950 09 Y M11951 09 Y M11952 09 Y M11954 09 Y M11960 04 N M 3 Y 350.05 340.60 11970 04 N M 3 475.70 462.86 11971 04 06/01/16 N M 3 Y 135.00 131.36 11976 04 N I 3 108.00 105.08 11980 04 N M 3 108.00 105.08 11981 04 10/01/14 N I 3 88.00 85.62 11982 04 10/01/14 N I 3 Y 99.00 96.33 11983 04 10/01/14 N I 3 Y 143.00 139.14 12001 04 01/01/10 N I 3 53.10 17.00 51.67 12002 04 N I 3 58.40 17.00 56.82 12004 04 N I 3 69.70 17.00 67.82 12005 04 N I 3 100.40 17.00 97.69 12006 04 N I 3 145.80 17.00 141.86 12007 04 N M 3 195.80 17.00 190.51 12011 04 N I 3 56.40 17.00 54.88 12013 04 N I 3 64.00 17.00 62.27 12014 04 N I 3 112.90 17.00 109.85
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
12015 04 N I 3 125.50 17.00 122.11 12016 04 N I 3 200.75 17.00 195.33 12017 04 N M 3 259.20 17.00 252.20 12018 04 N M 3 272.63 265.27 12020 04 N I 3 139.30 17.00 135.54 12021 04 N I 3 88.70 17.00 86.31 12031 04 N I 3 64.70 17.00 62.95 12032 04 N I 3 81.60 17.00 79.40 12034 04 N I 3 106.65 17.00 103.77 12035 04 N I 3 144.30 17.00 140.40 12036 04 N M 3 194.50 17.00 189.25 12037 04 N M 3 261.12 254.07 12041 04 N I 3 72.10 17.00 70.15 12042 04 N I 3 94.10 17.00 91.56 12044 04 N I 3 119.20 17.00 115.98 12045 04 N I 3 156.85 17.00 152.62 12046 04 N M 3 207.10 17.00 201.51 12047 04 N M 3 270.45 263.15 12051 04 N I 3 74.70 17.00 72.68 12052 04 N I 3 94.10 17.00 91.56 12053 04 N I 3 112.90 17.00 109.85 12054 04 N I 3 131.80 17.00 128.24 12055 04 N I 3 169.40 17.00 164.83 12056 04 N M 3 219.60 17.00 213.67 12057 04 N M 3 305.68 297.43 13100 04 N I 3 110.04 107.07 13101 04 N I 3 127.57 124.13 13102 04 Y I 313120 04 N I 3 114.98 111.88 13121 04 N I 3 138.55 134.81 13122 04 Y I 313131 04 N I 3 127.85 124.40 13132 04 N I 3 178.18 173.37 13133 04 Y I 313151 04 N I 3 160.83 156.49 13152 04 N I 3 205.55 200.00 13153 04 Y I 313160 04 N M 3 Y 295.88 287.89 14000 04 N M 3 224.25 218.20 14001 04 N M 3 291.69 283.81 14020 04 N M 3 Y 244.40 237.80
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
14021 04 N M 3 Y 328.07 319.21 14040 04 N M 3 Y 277.07 269.59 14041 04 N M 3 Y 375.10 364.97 14060 04 N M 3 Y 299.29 291.21 14061 04 N M 3 Y 405.20 394.26 14301 04 01/01/10 N M 3 Y 496.65 483.24 14302 04 01/01/10 Y M 3 Y14350 04 N M 3 270.20 262.90 15002 04 11/01/14 N I 3 Y 87.85 85.48 15003 04 01/01/07 Y M 3 Y15004 04 11/01/14 N I 3 Y 102.63 99.86 15005 04 01/01/07 Y M 3 Y15040 04 N M 3 71.01 69.09 15050 04 N M 3 Y 131.80 128.24 15100 04 11/01/14 N M 3 263.55 256.43 15101 04 Y M 315110 04 N M 3 71.01 69.09 15111 04 Y M 3 Y #VALUE!15115 04 Y M 3 Y #VALUE!15116 04 Y M 3 Y #VALUE!15120 04 11/01/14 N M 3 307.90 299.59 15121 04 Y M 3 Y15130 04 N M 3 Y 297.44 289.41 15131 04 Y M 3 Y #VALUE!15135 04 N M 3 Y 414.03 402.85 15136 04 Y M 3 Y #VALUE!15150 04 N M 3 330.87 321.94 15151 04 N M 3 66.75 64.95 15152 04 Y M 3 #VALUE!15155 04 N M 3 354.66 345.08 15156 04 Y M 3 #VALUE!15157 04 Y M 3 Y #VALUE!15200 04 N M 3 Y 318.60 310.00 15201 04 Y M 3 Y15220 04 N M 3 Y 307.90 299.59 15221 04 Y M 3 Y15240 04 N M 3 Y 308.96 300.62 15241 04 Y M 3 Y15260 04 N M 3 Y 332.72 323.74 15261 04 Y M 315271 04 07/01/12 N I 3 52.87 51.44
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
15272 04 07/01/12 Y I15273 04 07/01/12 N I 3 126.08 122.68 15274 04 07/01/12 Y I 315275 04 07/01/12 N I 3 61.61 59.95 15276 04 07/01/12 Y I 315277 04 07/01/12 N I 3 130.46 126.94 15278 04 09/01/14 N I 3 Y 33.62 32.71 15570 04 N M 3 Y 298.24 290.19 15572 04 N M 3 Y 292.34 284.45 15574 04 N M 3 Y 466.61 454.01 15576 04 N M 3 Y 296.30 288.30 15600 04 N M 3 Y 259.81 252.80 15610 04 N M 3 Y 97.47 94.84 15620 04 N M 3 Y 158.26 153.99 15630 04 N M 3 Y 310.61 302.22 15650 04 N M 3 Y 168.27 163.73 15731 04 01/01/07 N M 5 Y 168.27 163.73 15732 04 05/29/14 N M 3 Y 536.60 522.11 15734 04 N M 3 Y Y 569.25 553.88 15736 04 N M 3 Y 512.70 498.86 15738 04 N M 3 Y 520.25 506.20 15740 04 N M 3 Y 321.69 313.00 15750 04 N M 3 Y 339.54 330.37 15756 04 N M 3 Y Y 1,306.65 1,271.37 15757 04 N M 3 Y Y 1,306.65 1,271.37 15758 04 N M 3 Y Y 1,306.65 1,271.37 15760 04 N M 3 Y 300.05 291.95 15770 04 N M 3 Y 307.90 299.59 15775 09 Y M15776 09 Y M15777 04 01/01/12 N M 130.27 126.75 15780 09 Y M15781 09 Y M15782 09 Y M15783 09 Y M15786 09 Y I15787 09 Y M15819 04 N M 3 Y 274.36 266.95 15820 04 N M 3 651.10 633.52 15821 04 N M 3 651.10 633.52 15822 04 N M 3 651.10 633.52
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
15823 04 N M 3 651.10 633.52 15830 04 01/01/10 Y M 5 Y Y15832 04 N M 3 340.15 330.97 15833 04 N M 3 306.75 298.47 15834 04 N M 3 308.30 299.98 15835 04 N M 3 319.10 310.48 15836 04 N M 3 265.30 258.14 15837 04 N M 3 255.00 248.12 15838 04 N M 3 Y 219.35 213.43 15839 04 N M 3 Y 237.80 231.38 15840 04 N M 3 Y 891.10 867.04 15841 04 N M 3 Y 663.96 646.03 15842 04 N M 3 Y 1,063.03 1,034.33 15845 04 N M 3 Y 355.83 346.22 15847 04 01/01/07 Y M 10 Y15850 04 N I 3 31.40 30.55 15851 04 N I 3 48.60 47.29 15852 04 N I 3 Y 31.95 31.09 15860 04 N I 3 Y 55.50 54.00 15876 04 Y M 315877 04 Y M 315878 04 Y M 315879 04 Y M 315920 04 N M 4 Y 374.55 364.44 15922 04 N M 4 Y 449.50 437.36 15931 04 N M 3 Y Y 449.50 437.36 15933 04 N M 3 Y 674.20 656.00 15934 04 N M 3 Y Y 749.20 728.97 15935 04 N M 3 Y Y 749.20 728.97 15936 04 N M 3 Y 749.20 728.97 15937 04 N M 3 Y Y 749.20 728.97 15940 04 N M 3 Y 449.50 437.36 15941 04 N M 3 Y 524.40 510.24 15944 04 N M 3 Y 524.40 510.24 15945 04 N M 3 Y 600.00 583.80 15946 04 N M 3 Y 674.20 656.00 15950 04 N M 3 Y 449.50 437.36 15951 04 N M 3 Y 524.40 510.24 15952 04 N M 3 Y 524.40 510.24 15953 04 N M 3 Y 599.35 583.17 15956 04 N M 3 Y 727.40 707.76
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
15958 04 N M 3 Y 727.40 707.76 15999 04 Y M 3 Y Y16000 04 01/01/10 N I 45.80 44.56 16020 04 N I 24.90 17.00 24.23 16025 04 N I 49.50 34.00 48.16 16030 04 N I 61.65 34.00 59.99 16035 04 N M 3 92.79 34.00 90.28 16036 04 N M 3 36.74 35.75 17000 04 N I 52.70 51.28 17003 04 N I 3 8.85 13 115.05 8.61 111.94 17004 04 N I 3 86.59 84.25 17106 04 N I 3 125.35 121.97 17107 04 N M 3 238.80 232.35 17108 04 N M 3 372.30 362.25 17110 04 N I 3 74.90 72.88 17111 04 N I 3 43.05 41.89 17250 04 N I 3 18.90 18.39 17260 04 N I 3 40.60 39.50 17261 04 N I 3 60.70 59.06 17262 04 N I 3 80.85 78.67 17263 04 N I 3 100.90 98.18 17264 04 N I 3 117.55 114.38 17266 04 N M 3 162.00 157.63 17270 04 N I 3 45.25 44.03 17271 04 N I 3 64.50 62.76 17272 04 N I 3 85.60 83.29 17273 04 N I 3 106.75 103.87 17274 04 N I 3 117.20 114.04 17276 04 07/01/12 N I 3 162.00 157.63 17280 04 N I 3 96.20 93.60 17281 04 N I 3 127.70 124.25 17282 04 N M 3 171.30 166.67 17283 04 N M 3 213.60 207.83 17284 04 N M 3 257.10 250.16 17286 04 09/01/14 N I 3 170.96 166.34 17311 04 01/01/07 N M 3 216.00 210.17 17312 04 09/01/14 N I 3 121.19 5 605.95 117.92 589.59 17313 04 01/01/10 N M 3 191.09 185.93 17314 04 09/01/14 N I 3 112.46 5 562.30 109.42 547.12 17315 04 09/01/14 N I 3 31.73 5 158.65 30.87 154.37 17340 04 N I 3 26.20 25.49
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
17360 04 N I 3 38.65 37.61 17999 04 Y M 3 Y Y19000 04 N I 3 37.40 36.39 19001 04 N I 3 17.80 17.32 19020 04 N I 3 135.90 132.23 19030 04 N I 3 102.50 99.73 19081 04 01/01/14 N I 3 Y 114.67 111.57 19082 04 04/01/14 N I 3 Y 53.87 5 269.35 262.08 19083 04 01/01/14 N I 3 Y 107.27 104.37 19084 04 01/01/14 N I 3 Y 50.57 5 252.85 246.02 19085 04 01/01/14 N I 3 Y 125.10 121.72 19086 04 01/01/14 N I 3 Y 53.80 5 269.40 262.13 19100 04 N I 3 59.60 57.99 19101 04 N M 3 192.85 34.00 187.64 19105 04 09/01/14 N I 5 116.96 113.80 19110 04 N M 3 240.00 34.00 233.52 19112 04 N M 3 240.00 233.52 19120 04 N M 3 240.00 34.00 233.52 19125 04 N M 3 240.00 233.52 19126 04 N M 3 74.45 72.44 19260 04 N M 4 Y 430.64 419.01 19271 04 N M 4 Y 534.45 520.02 19272 04 N M 4 Y 598.34 582.18 19281 04 01/01/14 N I 3 Y 62.74 61.05 19282 04 03/01/14 N I 3 Y 29.56 8 236.48 230.10 19283 04 01/01/14 N I 3 Y 63.32 61.61 19284 04 03/01/14 N I 3 Y 29.75 5 148.75 144.73 19285 04 01/01/14 N I 3 Y 53.69 52.24 19286 04 03/01/14 N I 3 Y 25.55 5 127.75 124.30 19287 04 01/01/14 N I 3 Y 89.26 86.85 19288 04 03/01/14 N I 3 Y 38.20 5 191.00 185.84 19296 04 N I 3 109.01 106.07 19297 04 N I 3 109.01 106.07 19298 04 N I 3 109.01 106.07 19300 04 01/01/07 N M 3 Y 374.55 364.44 19301 04 01/01/07 N M 3 Y 310.80 302.41 19302 04 01/01/07 N M 5 Y 601.45 585.21 19303 04 01/01/07 N M 3 Y 461.95 449.48 19304 04 01/01/07 N M 3 Y 574.35 558.84 19305 04 01/01/07 N M 5 Y 787.95 766.68 19306 04 01/01/07 N M 4 Y 948.90 923.28 19307 04 01/01/07 N M 5 Y 738.10 718.17
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
19316 04 01/19/16 N M 3 Y Y 567.10 551.79 19318 04 N M 3 Y Y 374.60 364.49 19324 04 N M 3 Y 567.10 551.79 19325 04 N M 3 Y 567.10 551.79 19328 04 N M 3 Y 240.00 233.52 19330 04 N M 3 Y 240.00 233.52 19340 04 N M 3 Y 310.80 302.41 19342 04 03/14/16 N M 3 Y Y 354.20 344.64 19350 04 N M 3 Y 310.55 302.17 19355 04 N M 3 Y Y 275.00 267.58 19357 04 N M 3 Y 532.30 517.93 19361 04 N M 3 Y 609.80 593.34 19364 04 N M 3 Y 558.15 543.08 19366 04 N M 3 Y 558.15 543.08 19367 04 N M 3 Y Y 755.20 734.81 19368 04 N M 3 Y 1,306.65 1,271.37 19369 04 N M 3 Y 852.25 829.24 19370 04 N M 3 Y 242.70 236.15 19371 04 N M 3 Y 297.00 288.98 19380 04 N M 3 Y 280.40 272.83 19396 04 N M 3 136.88 133.18 19499 04 Y M 3 Y20005 04 N I 3 125.50 17.00 122.11 20100 04 N M 3 Y 372.65 362.59 20101 04 N M 3 Y 599.35 583.17 20102 04 N M 4 Y 480.00 467.04 20103 04 09/01/14 N I 3 Y 213.31 207.55 20150 04 09/01/14 N M 3 Y Y 562.01 546.84 20200 04 N I 3 113.60 17.00 110.53 20205 04 N M 3 252.35 17.00 245.54 20206 04 N I 3 53.50 17.00 52.06 20220 04 N I 90.10 87.67 20225 04 N I 3 187.30 34.00 182.24 20240 04 N M 3 220.55 214.60 20245 04 N M 3 289.90 282.07 20250 04 N M 3 163.05 158.65 20251 04 N M 3 277.50 270.01 20500 04 N I 3 61.40 59.74 20501 04 N I 3 105.90 103.04 20520 04 03/09/17 N I 3 107.00 17.00 104.11 20525 04 N M 3 167.80 163.27
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
20526 04 N I 31.35 30.50 20527 04 01/01/12 N I 35.65 34.69 20550 04 N I 3 31.75 30.89 20551 04 N I 3 31.75 30.89 20552 04 N I 3 31.75 30.89 20553 04 N I 3 31.75 30.89 20555 04 01/01/08 N I 3 176.10 171.35 20600 04 N I 3 30.40 17.00 29.58 20604 04 01/01/15 N I 3 28.22 27.46 20605 04 N I 3 33.00 17.00 32.11 20606 04 01/01/15 N I 3 32.29 31.42 20610 04 N I 3 31.80 17.00 30.94 20611 04 01/01/15 N I 3 38.11 37.08 20612 04 N I 31.80 30.94 20615 04 N I 3 73.35 71.37 20650 04 N I 3 Y 141.50 137.68 20660 04 N M 3 Y 192.85 187.64 20661 04 N M 3 192.85 187.64 20662 04 N I 3 203.85 198.35 20663 04 N I 3 170.05 165.46 20664 04 N M 3 Y 271.45 264.12 20665 04 N I 3 134.60 130.97 20670 04 N I 3 134.60 130.97 20680 04 N M 3 Y 233.00 226.71 20690 04 N I 3 Y Y 172.80 168.13 20692 04 N I 3 Y 297.00 288.98 20693 04 N I 3 Y 243.00 236.44 20694 04 N I 3 Y 152.95 148.82 20696 04 01/01/09 N M 3 Y 332.64 323.66 20697 04 12/08/14 N I 3 Y Y 349.27 339.84 20802 04 09/01/14 N M 5 Y Y 1,403.92 1,366.01 20805 04 09/01/14 N M 5 Y Y 1,892.05 1,840.96 20808 04 09/01/14 N M 5 Y Y 2,441.73 2,375.80 20816 04 09/01/14 N M 5 Y Y 1,205.49 1,172.94 20822 04 09/01/14 N M 3 Y Y 1,113.83 1,083.76 20824 04 09/01/14 N M 3 Y Y 1,307.75 1,272.44 20827 04 09/01/14 N M 3 Y Y 1,114.45 1,084.36 20838 04 09/01/14 N M 5 Y Y 1,565.50 1,523.23 20900 04 04/04/16 N I 3 Y Y 224.70 218.63 20902 04 N I 7 Y Y 374.55 364.44 20910 04 09/01/14 N M 7 Y 245.83 239.19
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
20912 04 09/08/14 N M 5 Y 290.49 282.65 20920 04 N M 3 Y Y 168.10 163.56 20922 04 N M 3 Y Y 231.10 224.86 20924 04 N M 4 Y Y 212.90 207.15 20926 04 09/08/14 N M 3 265.43 258.26 20930 09 Y M20931 09 Y M20936 09 Y M20937 09 Y M20938 09 Y M20950 04 N I 3 44.80 43.59 20955 04 09/08/14 N M 5 Y Y 1,543.48 1,501.81 20956 04 09/08/14 N M 5 Y Y 1,626.36 1,582.45 20957 04 09/08/14 N M 5 Y Y 1,432.31 1,393.64 20962 04 09/08/14 N M 5 Y Y 1,366.93 1,330.02 20969 04 09/08/14 N M 5 Y Y 1,706.77 1,660.69 20970 04 09/08/14 N M 5 Y Y 1,760.01 1,712.49 20972 04 09/08/14 N M 3 Y 1,347.30 1,310.92 20973 04 09/08/14 N M 3 Y Y 1,697.32 1,651.49 20974 09 Y M20975 04 N I 3 Y 82.90 80.66 20979 04 N I 176.70 171.93 20982 04 N I 4 Y 220.57 214.61 20983 04 03/23/15 N I 3 242.35 235.81 20985 04 01/01/08 N M 5 Y 83.23 80.98 20999 04 Y M 3 Y21010 04 N M 3 Y 374.55 364.44 21011 04 01/01/10 N M 3 Y 135.00 131.36 21012 04 01/01/10 N M 3 Y 186.15 181.12 21013 04 01/01/10 N M 3 Y 219.07 213.16 21014 04 01/01/10 N M 3 Y 287.92 280.15 21015 04 01/01/10 N M 4 Y 333.35 324.35 21016 04 01/01/10 N M 4 Y 583.64 567.88 21025 04 N M 4 Y Y 299.70 291.61 21026 04 N M 4 Y Y 299.70 291.61 21029 04 09/08/14 N M 4 Y 394.09 383.45 21030 04 N M 3 Y 299.70 291.61 21031 04 N M 3 Y 299.70 291.61 21032 04 N M 3 Y 299.70 291.61 21034 04 N M 4 Y Y 421.10 409.73 21040 04 N M 3 Y 299.70 291.61
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
21044 04 N M 4 Y 350.55 341.09 21045 04 N M 4 Y Y 1,678.65 1,633.33 21046 04 N M 5 Y Y 397.20 386.48 21047 04 09/08/14 N M 5 Y Y 792.69 771.29 21048 04 09/08/14 N M 5 Y Y 684.04 665.57 21049 04 09/08/14 N M 5 Y Y 740.52 720.53 21050 04 N M 5 Y 524.40 510.24 21060 04 N M 5 Y 524.40 510.24 21070 04 N M 4 Y 299.70 291.61 21073 04 01/01/08 N M 3 Y 188.93 183.83 21076 04 09/08/14 N I 3 Y 508.05 494.33 21077 04 09/08/14 N I 3 Y 1,284.83 1,250.14 21079 04 09/08/14 N M 3 847.88 824.99 21080 04 09/08/14 N M 3 947.01 921.44 21081 04 09/08/14 N M 3 Y 870.11 846.62 21082 04 09/08/14 N M 3 Y 817.64 795.56 21083 04 09/08/14 N M 3 Y 729.84 710.13 21084 04 09/08/14 N M 3 Y 877.57 853.88 21085 04 09/08/14 N I 3 Y 403.82 392.92 21086 04 09/08/14 N M 3 Y 947.78 922.19 21087 04 09/08/14 N M 3 Y 947.78 922.19 21088 04 Y I 321089 04 Y I 321100 04 N M 3 192.85 187.64 21110 04 N M 3 Y 176.70 171.93 21116 04 N I 3 73.20 71.22 21120 04 N M 5 Y Y 1,198.70 1,166.34 21121 04 N M 5 Y Y 1,198.70 1,166.34 21122 04 N M 5 Y Y 1,414.70 1,376.50 21123 04 N M 5 Y Y 1,522.70 1,481.59 21125 04 N M 5 Y Y 1,198.70 1,166.34 21127 04 N M 5 Y Y 1,306.65 1,271.37 21137 04 N M 5 Y Y 958.60 932.72 21138 04 N M 5 Y Y 1,198.70 1,166.34 21139 04 N M 7 Y Y 1,522.70 1,481.59 21141 04 N M 5 Y Y 1,198.70 1,166.34 21142 04 N M 5 Y Y 1,306.65 1,271.37 21143 04 N M 5 Y Y 1,414.70 1,376.50 21145 04 N M 5 Y Y 1,306.65 1,271.37 21146 04 N M 5 Y Y 1,522.70 1,481.59 21147 04 N M 5 Y Y 1,522.70 1,481.59
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
21150 04 N M 5 Y Y 1,306.65 1,271.37 21151 04 N M 5 Y Y 1,522.70 1,481.59 21154 04 N M 5 Y Y 1,306.65 1,271.37 21155 04 N M 5 Y Y 1,522.70 1,481.59 21159 04 N M 7 Y Y 1,522.70 1,481.59 21160 04 N M 7 Y Y 1,522.70 1,481.59 21172 04 N M 7 Y Y 1,522.70 1,481.59 21175 04 N M 7 Y Y 1,522.70 1,481.59 21179 04 N M 7 Y Y 1,414.70 1,376.50 21180 04 N M 7 Y Y 1,522.70 1,481.59 21181 04 N M 5 Y Y 958.60 932.72 21182 04 N M 7 Y Y 1,522.70 1,481.59 21183 04 N M 7 Y Y 1,522.70 1,481.59 21184 04 N M 7 Y Y 1,630.70 1,586.67 21188 04 N M 5 Y Y 1,306.65 1,271.37 21193 04 N M 5 Y Y 1,198.70 1,166.34 21194 04 N M 5 Y Y 1,414.70 1,376.50 21195 04 N M 5 Y Y 1,198.70 1,166.34 21196 04 N M 5 Y Y 1,198.70 1,166.34 21198 04 N M 5 Y Y 958.60 932.72 21199 04 N M 5 Y Y 700.70 681.78 21206 04 N M 4 Y 1,198.70 1,166.34 21208 04 N M 4 Y Y 1,198.70 1,166.34 21209 04 N M 4 Y Y 1,198.70 1,166.34 21210 04 N M 7 Y Y 636.80 619.61 21215 04 N M 7 Y Y 1,048.85 1,020.53 21230 04 N M 7 Y Y 957.25 931.40 21235 04 N M 7 Y Y 449.50 437.36 21240 04 N M 5 Y Y 599.35 583.17 21242 04 N M 5 Y Y 599.35 583.17 21243 04 N M 5 Y Y 1,198.70 1,166.34 21244 04 N M 5 Y Y 1,198.70 1,166.34 21245 04 N M 5 Y Y 1,198.70 1,166.34 21246 04 N M 5 Y Y 1,198.70 1,166.34 21247 04 N M 5 Y Y 1,306.65 1,271.37 21248 04 N M 5 Y Y 1,198.70 1,166.34 21249 04 N M 5 Y Y 1,198.70 1,166.34 21255 04 N M 5 Y Y 1,306.65 1,271.37 21256 04 N M 5 Y Y 1,306.65 1,271.37 21260 04 N M 7 Y Y 1,306.65 1,271.37 21261 04 N M 7 Y Y 1,522.70 1,481.59
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
21263 04 N M 7 Y Y 1,522.70 1,481.59 21267 04 N M 7 Y Y 1,306.65 1,271.37 21268 04 N M 7 Y Y 1,522.70 1,481.59 21270 04 N M 7 Y Y 1,048.85 1,020.53 21275 04 N M 5 Y Y 1,048.85 1,020.53 21280 04 N M 5 Y Y 359.30 349.60 21282 04 N M 5 Y Y 359.30 349.60 21295 04 N M 5 Y Y 449.50 437.36 21296 04 N M 5 Y Y 449.50 437.36 21299 04 Y M 7 Y Y21310 04 N I 4 138.75 135.00 21315 04 N M 4 176.20 171.44 21320 04 N M 4 280.25 272.68 21325 04 N M 4 Y 337.10 328.00 21330 04 N M 4 Y 424.45 412.99 21335 04 N M 4 Y 571.60 556.17 21336 04 N M 4 Y 337.10 328.00 21337 04 N M 4 Y Y 224.70 218.63 21338 04 N M 4 Y Y 334.40 325.37 21339 04 N M 4 Y Y 457.70 445.34 21340 04 N M 6 Y Y 749.20 728.97 21343 04 N M 4 Y 898.95 874.68 21344 04 N M 4 Y 1,048.85 1,020.53 21345 04 N M 4 Y Y 749.20 728.97 21346 04 N M 4 Y Y 749.20 728.97 21347 04 N M 4 Y Y 766.90 746.19 21348 04 N M 4 Y 954.20 928.44 21355 04 N M 4 Y 149.80 145.76 21356 04 N M 4 Y 539.65 525.08 21360 04 N M 4 Y 539.65 525.08 21365 04 N M 4 Y Y 689.50 670.88 21366 04 N M 4 Y Y 954.20 928.44 21385 04 N M 4 Y Y 599.35 583.17 21386 04 N M 5 Y Y 599.35 583.17 21387 04 N M 5 Y Y 749.20 728.97 21390 04 N M 5 Y Y 861.50 838.24 21395 04 N M 5 Y Y 861.50 838.24 21400 04 N I 149.80 145.76 21401 04 N M 5 Y 224.70 218.63 21406 04 N M 5 Y 599.35 583.17 21407 04 N M 5 Y 749.20 728.97
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
21408 04 N M 4 Y 749.20 728.97 21421 04 N M 4 Y 457.70 445.34 21422 04 N M 4 Y 678.40 660.08 21423 04 N M 4 Y 828.20 805.84 21431 04 N M 4 Y 524.40 510.24 21432 04 N M 4 Y 749.20 728.97 21433 04 N M 6 Y Y 898.95 874.68 21435 04 N M 6 Y Y 1,048.85 1,020.53 21436 04 N M 4 Y 1,048.85 1,020.53 21440 04 N M 4 374.55 364.44 21445 04 N M 4 Y 599.35 583.17 21450 04 N I 117.60 114.42 21451 04 N M 4 Y Y 498.10 484.65 21452 04 N I 4 Y Y 112.40 109.37 21453 04 N M 4 Y Y 498.10 484.65 21454 04 N M 4 Y Y 498.10 484.65 21461 04 N M 4 Y 706.15 687.08 21462 04 N M 4 Y 706.15 687.08 21465 04 N M 4 Y 498.10 484.65 21470 04 N M 4 Y 885.20 861.30 21480 04 N M 3 240.00 233.52 21485 04 N M 4 240.00 233.52 21490 04 N M 4 Y 749.20 728.97 21497 04 N M 4 149.80 145.76 21499 04 Y M Y21501 04 N I 3 115.30 17.00 112.19 21502 04 N M 3 224.70 218.63 21510 04 N M 3 224.70 218.63 21550 04 N I 3 99.10 17.00 96.42 21552 04 01/01/10 N M 3 Y 251.32 244.53 21554 04 01/01/10 N M 3 Y 413.28 402.12 21555 04 01/01/10 N M 3 124.00 17.00 120.65 21556 04 01/01/10 N M 3 270.27 262.97 21557 04 01/01/10 N M 3 Y Y 460.66 448.22 21558 04 01/01/10 N M 3 Y Y 778.24 757.23 21600 04 N M 3 Y 299.70 291.61 21610 04 N M 3 Y 399.50 388.71 21615 04 N M 4 Y 449.50 437.36 21616 04 N M 6 Y 599.35 583.17 21620 04 N M 3 Y 250.40 243.64 21627 04 09/08/14 N M 3 Y 331.00 322.06
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
21630 04 N M 6 Y Y 749.20 728.97 21632 04 N M 6 Y Y 749.20 728.97 21685 04 N M 4 Y 491.50 478.23 21700 04 N M 4 Y 374.55 364.44 21705 04 N M 4 Y 449.50 437.36 21720 04 N M 4 Y 577.10 561.52 21725 04 N M 4 Y 599.35 583.17 21740 04 N M 5 Y 898.95 874.68 21742 04 N M 5 Y 898.95 874.68 21743 04 N M 5 Y 898.95 874.68 21750 04 N M 3 Y 368.20 358.26 21811 04 03/23/15 N I 3 Y 379.33 369.09 21812 04 03/23/15 N I 3 Y 455.05 442.76 21813 04 03/23/15 N I 3 Y 618.97 602.26 21820 04 N I 3 74.90 72.88 21825 04 N M 3 374.55 364.44 21899 04 Y M21920 04 N I 3 113.50 17.00 110.44 21925 04 N M 3 180.20 17.00 175.33 21930 04 N M 3 149.80 145.76 21931 04 01/01/10 N M 3 Y 263.72 256.60 21932 04 01/01/10 N M 3 Y 378.77 368.54 21933 04 01/01/10 N M 3 Y 418.56 407.26 21935 04 01/01/10 N M 3 Y 581.85 566.14 21936 04 01/01/10 N M 3 Y 812.41 790.47 22010 04 N M 3 Y 453.30 441.06 22015 04 N M 3 Y 449.25 437.12 22100 04 N M 7 Y 311.40 302.99 22101 04 N M 7 Y 315.50 306.98 22102 04 N M 7 Y 299.70 291.61 22103 04 09/08/14 N M 7 Y Y 89.55 5 447.75 87.13 435.66 22110 04 N M 7 Y 718.70 699.30 22112 04 N M 7 Y 718.70 699.30 22114 04 N M 7 Y 718.70 699.30 22116 04 09/08/14 N M 7 Y Y 87.81 5 439.05 85.44 427.20 22206 04 01/01/08 N M 7 Y Y 1270.13 1,235.84 22207 04 01/01/08 N M 7 Y Y 1253.30 1,219.46 22208 04 01/01/08 N M 7 Y Y 325.80 317.00 22210 04 N M 7 Y Y 973.90 947.60 22212 04 N M 7 Y Y 973.90 947.60 22214 04 N M 7 Y Y 973.90 947.60
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
22216 04 09/08/14 N M 7 Y Y 227.91 5 1,139.55 221.76 1,108.78 22220 04 N M 7 Y Y 973.90 947.60 22222 04 N M 7 Y Y 973.90 947.60 22224 04 N M 7 Y Y 973.90 947.60 22226 04 09/08/14 N M 7 Y Y 229.27 5 1,146.35 223.08 1,115.40 22310 04 N I 98.80 96.13 22315 04 N M 3 276.20 268.74 22318 04 N M 7 Y Y 1,417.20 1,378.94 22319 04 N M 7 Y Y 1,558.90 1,516.81 22325 04 N M 3 Y 599.35 583.17 22326 04 N M 4 Y 627.30 610.36 22327 04 N M 3 Y 608.50 592.07 22328 04 09/08/14 N M 7 Y Y 178.43 5 892.15 173.61 868.06 22505 04 N I 3 149.80 145.76 22510 04 03/23/15 N I 7 279.51 271.96 22511 04 03/23/15 N I 7 262.43 255.34 22512 04 03/23/15 N I 7 131.73 5 658.65 128.17 640.87 22513 04 01/01/15 N I 3 336.16 327.08 22514 04 01/01/15 N I 3 312.97 304.52 22515 04 01/01/15 N I 3 143.05 5 715.25 139.19 695.94 22532 04 01/01/10 N M 7 Y Y 876.68 853.01 22533 04 01/01/10 N M 7 Y Y 816.43 794.39 22534 04 09/08/14 N M 7 Y Y 227.91 5 1,139.55 221.76 1,108.78 22548 04 N M 7 Y 1,642.15 1,597.81 22551 04 01/01/11 N M 7 Y Y 1,062.48 1,033.79 22552 04 09/08/14 N M 7 Y Y 248.18 5 1,240.90 241.48 1,207.40 22554 04 N M 7 Y Y 1,642.65 1,598.30 22556 04 N M 7 Y Y 1,642.65 1,598.30 22558 04 N M 7 Y Y 1,642.65 1,598.30 22585 04 09/08/14 N M 7 Y Y 211.55 5 1,057.75 205.84 1,029.19 22586 04 01/01/13 N M 7 Y Y 950.83 925.16 22590 04 N M 7 Y Y 1,198.70 1,166.34 22595 04 N M 7 Y Y 1,198.70 1,166.34 22600 04 N M 7 Y Y 1,198.70 1,166.34 22610 04 N M 7 Y Y 1,198.70 1,166.34 22612 04 N M 7 Y Y 1,198.70 1,166.34 22614 04 Y M 7 Y Y22630 04 N M 7 Y Y 1,198.70 1,166.34 22632 04 Y M 7 Y Y22633 04 01/01/12 N M 7 Y Y 1,132.79 1,102.20 22634 04 01/01/12 Y M 7 Y Y
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
22800 04 N M 7 Y Y 1,086.30 1,056.97 22802 04 N M 7 Y Y 1,086.30 1,056.97 22804 04 N M 7 Y Y 1,782.30 1,734.18 22808 04 N M 7 Y Y 1,086.30 1,056.97 22810 04 N M 7 Y Y 1,086.30 1,056.97 22812 04 N M 7 Y Y 1,086.30 1,056.97 22818 04 N M 7 Y Y 1,610.65 1,567.16 22819 04 N M 7 Y Y 1,610.65 1,567.16 22830 04 N M 7 Y Y 443.39 431.42 22840 04 N M 7 Y Y 1,872.90 1,822.33 22841 04 N M 7 Y Y 1,872.90 1,822.33 22842 04 N M 7 Y Y 1,872.90 1,822.33 22843 04 N M 7 Y Y 1,872.90 1,822.33 22844 04 N M 7 Y Y 1,872.90 1,822.33 22845 04 N M 7 Y Y 1,872.90 1,822.33 22846 04 N M 7 Y Y 1,872.90 1,822.33 22847 04 N M 7 Y Y 1,872.90 1,822.33 22848 04 N M 7 Y Y 351.00 341.52 22849 04 N M 7 Y Y 1,134.10 1,103.48 22850 04 N M 7 Y 449.50 437.36 22852 04 N M 7 Y Y 449.50 437.36 22853 04 01/01/17 N M 7 Y Y 167.52 5 837.60 163.00 814.98 22854 04 01/01/17 N M 7 Y Y 216.85 5 1,084.25 211.00 1,054.98 22855 04 N M 7 Y 449.50 437.36 22856 04 01/01/09 N M 8 Y Y 925.00 900.03 22857 04 01/01/10 N M 8 Y Y 938.71 913.36 22858 04 01/01/15 N M 8 Y Y 317.99 309.40 22859 04 01/01/17 N M 7 Y Y 216.85 5 1,084.25 211.00 1,054.98 22861 04 01/01/09 N M 8 Y Y 1,121.23 1,090.96 22862 04 01/01/10 N M 8 Y Y 1104.45 1,074.63 22864 04 01/01/10 N M 8 Y Y 1051.39 1,023.00 22865 04 01/01/10 N M 8 Y Y 1166.35 1,134.86 22867 04 01/01/17 N M 7 616.05 599.42 22868 04 01/01/17 N M 7 Y Y 156.26 152.04 22869 04 01/01/17 N M 7 335.39 326.33 22870 04 01/01/17 N M 7 Y Y 90.92 88.47 22899 04 Y M Y Y22900 04 01/01/10 N M 3 Y Y 224.70 218.63 22901 04 01/01/10 N M 3 Y Y 373.91 363.81 22902 04 01/01/10 N M 3 Y Y 185.37 180.37 22903 04 01/01/10 N M 3 Y Y 245.80 239.16
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
22904 04 01/01/10 N M 4 Y Y 588.58 572.69 22905 04 01/01/10 N M 4 Y Y 763.23 742.62 22999 04 Y M Y23000 04 N M 3 Y 359.30 349.60 23020 04 N M 3 Y 299.70 291.61 23030 04 N I 3 125.50 17.00 122.11 23031 04 N I 3 99.10 17.00 96.42 23035 04 N M 3 Y 317.40 308.83 23040 04 N M 3 Y 599.35 583.17 23044 04 N M 3 Y 599.35 583.17 23065 04 N I 3 113.60 17.00 110.53 23066 04 N I 3 149.25 17.00 145.22 23071 04 01/01/10 N M 3 Y 233.57 227.26 23073 04 01/01/10 N M 3 Y 387.83 377.36 23075 04 N M 3 224.70 218.63 23076 04 01/01/10 N M 3 449.50 437.36 23077 04 01/01/10 N M 7 Y Y 641.38 624.06 23078 04 01/01/10 N M 7 Y Y 794.53 773.08 23100 04 N M 3 Y 374.55 364.44 23101 04 N M 3 Y 599.35 583.17 23105 04 N M 3 Y 599.35 583.17 23106 04 N M 3 Y 599.35 583.17 23107 04 N M 3 Y Y 473.50 460.72 23120 04 N M 3 Y 362.00 352.23 23125 04 N M 3 Y 718.70 699.30 23130 04 N M 3 Y 362.00 352.23 23140 04 N M 3 Y 264.90 257.75 23145 04 N M 3 Y 480.00 467.04 23146 04 N M 3 Y 480.00 467.04 23150 04 N M 3 Y 275.80 268.35 23155 04 N M 3 Y 480.00 467.04 23156 04 N M 3 Y 480.00 467.04 23170 04 N M 3 Y 240.00 233.52 23172 04 N M 3 Y 240.00 233.52 23174 04 N M 3 Y 480.00 467.04 23180 04 N M 3 Y 299.70 291.61 23182 04 N M 3 Y 480.00 467.04 23184 04 N M 3 Y 480.00 467.04 23190 04 N M 3 Y 480.00 467.04 23195 04 N M 3 Y 599.35 583.17 23200 04 01/01/10 N M 6 Y Y 718.70 699.30
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
23210 04 01/01/10 N M 6 Y Y 718.70 699.30 23220 04 01/01/10 N M 6 Y Y 718.70 699.30 23330 04 N I 3 17.00 107.00 16.54 104.11 23333 04 01/01/14 N M 3 Y 275.21 267.78 23334 04 01/01/14 N M 3 654.38 636.71 23335 04 01/01/14 N M 3 Y 782.09 760.97 23350 04 N I 3 88.30 85.92 23395 04 N M 3 Y 501.35 487.81 23397 04 N M 3 Y 599.35 583.17 23400 04 N M 6 Y 839.35 816.69 23405 04 N M 3 Y 299.70 291.61 23406 04 N M 3 Y 449.50 437.36 23410 04 N M 3 Y 779.70 758.65 23412 04 N M 3 Y 779.70 758.65 23415 04 N M 3 Y 674.20 656.00 23420 04 N M 3 Y 674.20 656.00 23430 04 N M 3 Y 449.50 437.36 23440 04 N M 3 Y 449.50 437.36 23450 04 N M 3 Y 839.35 816.69 23455 04 N M 3 Y 839.35 816.69 23460 04 N M 3 Y 839.35 816.69 23462 04 N M 3 Y 839.35 816.69 23465 04 N M 3 Y 733.85 714.04 23466 04 N M 3 Y 584.40 568.62 23470 04 N M 3 Y 839.35 816.69 23472 04 N M 3 Y 1,498.30 1,457.85 23473 04 01/01/13 N M 3 Y Y 984.68 958.09 23474 04 01/01/13 N M 3 Y Y 1,064.97 1,036.22 23480 04 N M 3 Y 480.00 467.04 23485 04 N M 3 Y 486.90 473.75 23490 04 N M 3 Y Y 379.40 369.16 23491 04 N M 3 Y Y 464.45 451.91 23500 04 N I 3 112.40 109.37 23505 04 N M 3 187.30 182.24 23515 04 N M 3 Y 419.00 407.69 23520 04 N I 112.40 109.37 23525 04 N M 3 162.30 157.92 23530 04 N M 3 Y 720.00 700.56 23532 04 N I 3 Y 786.60 765.36 23540 04 N I 112.40 109.37 23545 04 N M 3 228.90 222.72 23550 04 N M 3 Y 503.60 490.00
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
23552 04 N M 3 Y Y 561.85 546.68 23570 04 N I 79.60 77.45 23575 04 N M 3 241.35 234.83 23585 04 N M 3 Y 449.50 437.36 23600 04 N M 194.20 188.96 23605 04 N M 3 277.50 270.01 23615 04 N M 3 Y 545.25 530.53 23616 04 N M 3 Y 975.25 948.92 23620 04 N I 111.00 108.00 23625 04 N M 3 163.70 159.28 23630 04 N M 3 Y 524.40 510.24 23650 04 N M 178.90 174.07 23655 04 N M 3 255.20 248.31 23660 04 N M 3 Y 419.00 407.69 23665 04 N M 3 206.70 201.12 23670 04 N M 3 Y 842.10 819.36 23675 04 N M 3 299.70 291.61 23680 04 N M 3 Y 599.35 583.17 23700 04 N M 3 194.20 188.96 23800 04 N M 3 Y 839.35 816.69 23802 04 N M 3 Y 839.35 816.69 23900 04 N M 11 Y 1198.70 1,166.34 23920 04 N M 5 Y 1048.85 1,020.53 23921 04 N M 3 Y 224.70 218.63 23929 04 Y M 3 Y23930 04 N M 3 179.70 17.00 174.85 23931 04 N I 3 141.30 17.00 137.48 23935 04 N M 3 Y 240.00 233.52 24000 04 N M 3 Y 299.70 291.61 24006 04 N M 3 Y 380.15 369.89 24065 04 N I 3 113.60 17.00 110.53 24066 04 N M 3 Y 264.25 17.00 257.12 24071 04 01/01/10 N M 3 Y 226.29 220.18 24073 04 01/01/10 N M 3 Y 389.59 379.07 24075 04 N M 3 149.80 145.76 24076 04 01/01/10 N M 3 224.70 218.63 24077 04 01/01/10 N M 7 Y 319.02 310.41 24079 04 01/01/10 N M 7 Y Y 731.94 712.18 24100 04 N M 3 Y 299.70 291.61 24101 04 N M 3 Y 480.00 467.04 24102 04 N M 3 Y 524.40 510.24
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
24105 04 N M 3 380.15 369.89 24110 04 N M 3 Y 527.20 512.97 24115 04 N M 3 Y 749.20 728.97 24116 04 N M 3 Y 749.20 728.97 24120 04 N M 3 Y 449.50 437.36 24125 04 N M 7 Y 749.20 728.97 24126 04 N M 7 Y 749.20 728.97 24130 04 N M 3 Y 492.55 479.25 24134 04 N M 3 Y 351.00 341.52 24136 04 N M 3 Y 262.80 255.70 24138 04 N M 3 Y 254.80 247.92 24140 04 N M 3 Y 480.00 467.04 24145 04 N M 3 Y 480.00 467.04 24147 04 N M 3 Y 480.00 467.04 24149 04 10/24/14 N M 6 Y Y 708.52 689.39 24150 04 01/01/10 N M 6 Y Y 1198.70 1,166.34 24152 04 01/01/10 N M 6 Y Y 958.60 932.72 24155 04 N M 3 Y 749.20 728.97 24160 04 N M 3 Y 299.70 291.61 24164 04 N M 3 492.55 479.25 24200 04 N M 3 169.30 164.73 24201 04 N M 3 Y 245.55 238.92 24220 04 N I 3 105.15 102.31 24300 04 N I 3 66.70 64.90 24301 04 N M 3 Y 453.70 441.45 24305 04 N M 3 Y 359.30 349.60 24310 04 N M 3 Y 188.70 183.61 24320 04 N M 3 Y 599.35 583.17 24330 04 N M 3 Y 599.35 583.17 24331 04 N M 3 Y 599.35 583.17 24332 04 N M 3 Y 326.30 317.49 24340 04 N M 3 Y 299.70 291.61 24341 04 N M 3 Y 274.20 266.80 24342 04 N M 3 Y 535.45 520.99 24343 04 N M 3 Y 430.15 418.54 24344 04 N M 3 Y 651.95 634.35 24345 04 N M 3 Y 430.15 418.54 24346 04 N M 3 Y 651.95 634.35 24357 04 01/01/08 N M 3 Y 233.94 227.62 24358 04 01/01/08 N M 3 Y 275.71 268.27 24359 04 01/01/08 N M 3 Y 341.04 331.83
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
24360 04 N M 3 Y 718.70 699.30 24361 04 N M 3 Y 1123.70 1,093.36 24362 04 N M 3 Y 1123.70 1,093.36 24363 04 N M 3 Y 1123.70 1,093.36 24365 04 N M 3 Y 1123.70 1,093.36 24366 04 N M 3 Y 1123.70 1,093.36 24370 04 01/01/13 N M 3 Y 928.46 903.39 24371 04 01/01/13 N M 3 Y 1,070.94 1,042.02 24400 04 N M 3 Y 541.05 526.44 24410 04 N M 3 Y 481.65 468.65 24420 04 N M 3 Y 898.95 874.68 24430 04 N M 3 Y 636.80 619.61 24435 04 N M 7 Y 958.60 932.72 24470 04 N M 3 Y 374.55 364.44 24495 04 N M 3 Y 299.70 291.61 24498 04 N M 3 Y Y 491.50 478.23 24500 04 N M 153.95 149.79 24505 04 N M 3 295.50 287.52 24515 04 N M 3 Y Y 624.30 607.44 24516 04 N M 3 Y 624.30 607.44 24530 04 N M 299.70 291.61 24535 04 N M 3 334.40 325.37 24538 04 05/27/15 N M 3 405.10 394.16 24545 04 N M 3 Y 718.70 699.30 24546 04 N M 3 Y 718.70 699.30 24560 04 N M 199.75 194.36 24565 04 N M 3 242.80 236.24 24566 04 N M 3 Y 257.30 250.35 24575 04 N M 3 Y 718.70 699.30 24576 04 N M 188.70 183.61 24577 04 N M 3 245.55 238.92 24579 04 N M 3 Y 718.70 699.30 24582 04 N M Y 405.10 394.16 24586 04 N M 3 Y 480.65 467.67 24587 04 N M 3 Y 1123.70 1,093.36 24600 04 N M 208.05 202.43 24605 04 N M 3 242.80 236.24 24615 04 N M 3 Y Y 419.00 407.69 24620 04 N M 3 259.40 252.40 24635 04 N M 3 Y 482.80 469.76 24640 04 06/23/15 N I 3 Y 180.30 175.43
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
24650 04 N I 3 142.90 139.04 24655 04 N M 3 Y 208.05 202.43 24665 04 N M 3 Y 400.90 390.08 24666 04 N M 3 Y 449.50 437.36 24670 04 N M 3 181.65 176.75 24675 04 N M 3 206.70 201.12 24685 04 N M 3 Y 556.35 541.33 24800 04 N M 3 Y 718.70 699.30 24802 04 N M 3 Y 839.35 816.69 24900 04 N M 3 Y 313.50 305.04 24920 04 N M 3 Y 595.20 579.13 24925 04 N M 3 Y 262.20 255.12 24930 04 N M 3 Y 595.20 579.13 24931 04 N M 3 Y 674.20 656.00 24935 04 N M 3 Y 599.35 583.17 24940 04 N M 3 Y 621.10 604.33 24999 04 Y M 0 Y25000 04 N M 3 351.00 341.52 25001 04 N M 3 Y 207.95 202.34 25020 04 N M 3 Y 388.50 378.01 25023 04 N M 3 Y 394.80 384.14 25024 04 N M 3 Y 458.20 445.83 25025 04 N M 3 Y 588.15 572.27 25028 04 N I 3 179.25 17.00 174.41 25031 04 N M 3 232.55 17.00 226.27 25035 04 N M 3 287.60 279.83 25040 04 N M 3 Y 480.00 467.04 25065 04 N I 3 113.60 17.00 110.53 25066 04 N I 3 149.25 17.00 145.22 25071 04 01/01/10 N M 3 Y 236.70 230.31 25073 04 01/01/10 N M 3 Y 293.97 286.03 25075 04 01/01/10 N M 3 149.80 145.76 25076 04 01/01/10 N M 3 262.20 255.12 25077 04 01/01/10 N M 7 467.49 454.87 25078 04 01/01/10 N M 3 Y 637.84 620.62 25085 04 N M 3 Y 262.20 255.12 25100 04 N M 3 Y 419.00 407.69 25101 04 N M 3 Y 480.00 467.04 25105 04 N M 3 Y 480.00 467.04 25107 04 N M 3 Y 480.00 467.04 25109 04 01/01/07 N M 3 Y 240.00 233.52
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
25110 04 N M 3 217.80 211.92 25111 04 N M 3 214.00 34.00 208.22 25112 04 N M 3 214.00 34.00 208.22 25115 04 N M 3 Y 599.35 583.17 25116 04 N M 3 Y 599.35 583.17 25118 04 N M 3 Y 480.00 467.04 25119 04 N M 3 Y 659.00 641.21 25120 04 N M 3 Y 599.35 583.17 25125 04 N M 7 Y 674.20 656.00 25126 04 N M 7 Y 674.20 656.00 25130 04 N M 3 Y 299.70 291.61 25135 04 N M 7 Y 449.50 437.36 25136 04 N M 7 Y 449.50 437.36 25145 04 N M 3 Y 359.30 349.60 25150 04 01/01/10 N M 3 Y 359.30 349.60 25151 04 01/01/10 N M 3 Y Y 359.30 349.60 25170 04 01/01/10 N M 3 Y Y 721.98 702.49 25210 04 N M 3 Y 480.00 467.04 25215 04 N M 3 Y 480.00 467.04 25230 04 N M 3 Y 299.70 291.61 25240 04 N M 3 Y 359.30 349.60 25246 04 N I 3 96.90 94.28 25248 04 N M 3 181.25 176.36 25250 04 N M 3 224.70 218.63 25251 04 N M 3 339.50 330.33 25259 04 N M 3 230.15 223.94 25260 04 N M 3 Y 283.50 275.85 25263 04 N M 3 Y 302.60 294.43 25265 04 N M 3 Y 484.20 471.13 25270 04 N M 3 Y 369.05 359.09 25272 04 N M 3 Y 256.85 249.92 25274 04 N M 3 Y 359.30 349.60 25275 04 N M 3 Y 442.50 430.55 25280 04 N M 3 Y 359.30 349.60 25290 04 N M 3 Y 302.40 294.24 25295 04 N M 3 Y 277.50 270.01 25300 04 N M 4 Y 359.30 349.60 25301 04 N M 4 Y 359.30 349.60 25310 04 N M 4 Y 480.00 467.04 25312 04 N M 4 Y 524.40 510.24 25315 04 N M 3 Y 480.00 467.04
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
25316 04 N M 3 Y 524.40 510.24 25320 04 N M 3 Y 449.50 437.36 25332 04 N M 3 Y 749.20 728.97 25335 04 N M 3 Y 749.20 728.97 25337 04 N M 3 Y 718.70 699.30 25350 04 N M 3 Y 374.55 364.44 25355 04 N M 3 Y 480.00 467.04 25360 04 N M 3 Y 316.10 307.57 25365 04 N M 3 Y 561.85 546.68 25370 04 N M 3 Y 480.00 467.04 25375 04 N M 3 Y 524.40 510.24 25390 04 N M 3 Y 599.35 583.17 25391 04 N M 7 Y 898.95 874.68 25392 04 N M 3 Y 898.95 874.68 25393 04 N M 7 Y 898.95 874.68 25394 04 N M 3 Y 514.80 500.90 25400 04 N M 3 Y 524.40 510.24 25405 04 N M 7 Y 599.35 583.17 25415 04 N M 3 Y 488.00 474.82 25420 04 N M 7 Y 839.35 816.69 25425 04 N M 7 Y 599.35 583.17 25426 04 N M 7 Y 749.20 728.97 25430 04 N M 3 Y 451.90 439.70 25431 04 N M 3 Y 449.10 436.97 25440 04 N M 3 Y 599.35 583.17 25441 04 N M 3 Y 659.00 641.21 25442 04 N M 3 Y 659.00 641.21 25443 04 N M 3 Y 749.20 728.97 25444 04 N M 3 Y 749.20 728.97 25445 04 N M 3 Y 749.20 728.97 25446 04 N M 3 Y 898.95 874.68 25447 04 01/01/12 N M 3 Y Y 494.84 481.48 25449 04 N M 3 Y 659.00 641.21 25450 04 N M 3 Y 299.70 291.61 25455 04 N M 3 Y 449.50 437.36 25490 04 N M 3 Y Y 356.50 346.87 25491 04 N M 3 Y Y 365.60 355.73 25492 04 N M 3 Y Y 459.05 446.66 25500 04 N I 3 112.40 109.37 25505 04 N M 3 210.90 205.21 25515 04 N M 3 Y 554.90 539.92
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
25520 04 N M 3 267.80 260.57 25525 04 N M 3 Y 443.95 431.96 25526 04 10/01/14 N M 3 Y Y 577.42 561.83 25530 04 N M 199.75 194.36 25535 04 N M 3 240.00 233.52 25545 04 N M 3 Y 538.20 523.67 25560 04 N M 3 176.20 171.44 25565 04 N M 3 292.60 284.70 25574 04 N M 3 Y 538.20 523.67 25575 04 11/24/14 N M 3 Y Y 592.40 576.41 25600 04 N M 155.35 151.16 25605 04 N M 3 294.10 286.16 25606 04 01/01/07 N M 3 301.00 292.87 25607 04 01/01/07 N M 3 443.95 431.96 25608 04 01/01/07 N M 3 Y 443.95 431.96 25609 04 01/01/07 N M Y 443.95 431.96 25622 04 N I 147.10 143.13 25624 04 N I 3 181.10 176.21 25628 04 N M 3 Y 335.70 326.64 25630 04 N M 201.10 195.67 25635 04 N I 3 174.60 169.89 25645 04 N M 3 Y 335.70 326.64 25650 04 N I 3 Y Y 126.90 123.47 25651 04 N M 3 Y 271.25 263.93 25652 04 N M 3 Y 374.00 363.90 25660 04 N I 3 139.00 135.25 25670 04 N M 3 Y 266.70 259.50 25671 04 N M 3 Y 205.30 199.76 25675 04 N I 3 168.25 163.71 25676 04 N M 3 Y 270.40 263.10 25680 04 N M 3 240.00 233.52 25685 04 N M 3 Y 449.50 437.36 25690 04 N I 3 188.65 183.56 25695 04 N M 3 Y 276.50 269.03 25800 04 N M 3 Y 718.70 699.30 25805 04 N M 3 Y 786.60 765.36 25810 04 N M 3 Y 839.35 816.69 25820 04 N M 3 Y 664.25 646.32 25825 04 N M 7 Y 718.70 699.30 25830 04 N M 3 Y 786.60 765.36 25900 04 N M 3 Y 359.30 349.60
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
25905 04 N M 3 Y 359.30 349.60 25907 04 N M 3 Y 290.30 282.46 25909 04 N M 3 Y 359.30 349.60 25915 04 N M 3 Y 1198.70 1,166.34 25920 04 N M 3 Y 359.30 349.60 25922 04 N M 3 Y 244.50 237.90 25924 04 N M 3 Y 359.30 349.60 25927 04 N M 3 Y 302.60 294.43 25929 04 N M 3 Y 236.30 229.92 25931 04 N M 3 Y 285.80 278.08 25999 04 Y M26010 04 N I 3 76.25 74.19 26011 04 N I 3 97.40 94.77 26020 04 N M 3 191.80 186.62 26025 04 N M 3 201.60 196.16 26030 04 N M 3 Y 237.15 230.75 26034 04 N M 3 Y 240.00 233.52 26035 04 N M 3 Y 321.65 312.97 26037 04 N M 3 Y 265.20 258.04 26040 04 N M 3 Y 264.90 257.75 26045 04 N M 3 Y 449.50 437.36 26055 04 N M 3 Y 235.80 229.43 26060 04 N I 3 Y 107.90 104.99 26070 04 N M 3 Y 224.70 218.63 26075 04 N M 3 Y 224.70 218.63 26080 04 N M 3 Y 187.30 182.24 26100 04 N M 3 Y 299.70 291.61 26105 04 N M 3 Y 262.20 255.12 26110 04 N M 3 Y 187.30 182.24 26111 04 01/01/10 N M 3 Y 228.07 221.91 26113 04 01/01/10 N M 3 Y 299.94 291.84 26115 04 01/01/10 N M 3 149.80 145.76 26116 04 01/01/10 N M 3 224.70 218.63 26117 04 01/01/10 N M 7 380.08 369.82 26118 04 01/01/10 N M 7 Y 592.39 576.40 26121 04 N M 3 Y 449.50 437.36 26123 04 N M 3 Y 524.40 510.24 26125 04 Y M 3 Y26130 04 N M 3 Y 374.55 364.44 26135 04 N M 3 Y 270.60 263.29 26140 04 N M 3 Y 245.35 238.73
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
26145 04 N M 3 Y 252.80 245.97 26160 04 02/02/15 N M 3 210.10 34.00 204.43 26170 04 N M 3 Y 240.00 233.52 26180 04 N M 3 Y 240.00 233.52 26185 04 N M 3 Y 327.22 318.39 26200 04 N M 3 Y 299.70 291.61 26205 04 N M 3 Y 374.55 364.44 26210 04 N M 3 224.70 218.63 26215 04 N M 3 Y 314.95 306.45 26230 04 N M 3 Y 299.70 291.61 26235 04 N M 3 Y 224.70 218.63 26236 04 N M 3 Y 204.05 198.54 26250 04 N M 3 Y 449.50 437.36 26260 04 N M 3 Y 374.55 364.44 26262 04 N M 3 Y 299.70 291.61 26320 04 N M 3 Y 233.00 226.71 26340 04 N I 3 139.70 135.93 26341 04 01/01/12 N I 43.57 42.39 26350 04 N M 3 Y 274.40 266.99 26352 04 N M 3 Y 480.00 467.04 26356 04 N M 3 Y 359.30 349.60 26357 04 N M 4 Y Y 359.30 349.60 26358 04 N M 3 Y 599.35 583.17 26370 04 N M 3 Y 307.20 298.91 26372 04 N M 3 Y 480.00 467.04 26373 04 N M 3 Y 480.00 467.04 26390 04 N M 3 Y 480.00 467.04 26392 04 N M 3 Y 480.00 467.04 26410 04 N M 4 Y 222.00 216.01 26412 04 N M 4 Y 299.70 291.61 26415 04 N M 3 Y Y 306.95 298.66 26416 04 N M 3 Y Y 414.90 403.70 26418 04 11/24/14 N M 4 201.65 196.21 26420 04 N M 4 Y 299.70 291.61 26426 04 N M 4 Y 480.00 467.04 26428 04 N M 4 Y 599.35 583.17 26432 04 N M 4 Y 359.30 349.60 26433 04 N M 4 Y 222.00 216.01 26434 04 N M 4 Y 359.30 349.60 26437 04 N M 4 Y 225.10 219.02 26440 04 N M 3 Y 417.60 406.32
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
26442 04 N M 3 Y 627.05 610.12 26445 04 02/02/15 N M 4 240.00 233.52 26449 04 N M 4 Y 359.30 349.60 26450 04 N M 3 Y 240.00 233.52 26455 04 N M 3 Y 240.00 233.52 26460 04 N M 4 Y 240.00 233.52 26471 04 N M 3 Y 299.70 291.61 26474 04 N M 3 Y 359.30 349.60 26476 04 N M 4 Y 359.30 349.60 26477 04 N M 4 Y 359.30 349.60 26478 04 N M 4 Y Y 359.30 349.60 26479 04 N M 4 Y Y 359.30 349.60 26480 04 N M 3 Y 480.00 467.04 26483 04 N M 3 Y 480.00 467.04 26485 04 N M 3 Y 480.00 467.04 26489 04 N M 3 Y 561.85 546.68 26490 04 N M 3 Y 356.60 346.97 26492 04 N M 3 Y 449.50 437.36 26494 04 N M 3 Y 356.60 346.97 26496 04 10/24/14 N M 3 Y 490.99 477.73 26497 04 N M 3 Y 374.55 364.44 26498 04 N M 3 Y 693.70 674.97 26499 04 N M 3 Y 374.55 364.44 26500 04 N M 3 Y 226.50 220.38 26502 04 N M 3 Y 419.00 407.69 26508 04 N M 3 Y 232.55 226.27 26510 04 N M 3 Y 442.90 430.94 26516 04 N M 3 Y 255.00 248.12 26517 04 N M 3 Y 374.55 364.44 26518 04 N M 3 Y 416.20 404.96 26520 04 N M 3 Y 262.20 255.12 26525 04 N M 3 Y 262.20 255.12 26530 04 N M 3 Y 289.30 281.49 26531 04 N M 3 Y 337.10 328.00 26535 04 N M 3 Y 524.40 510.24 26536 04 N M 3 Y 524.40 510.24 26540 04 N M 3 Y 346.75 337.39 26541 04 N M 3 Y 374.55 364.44 26542 04 N M 3 Y 374.55 364.44 26545 04 N M 3 Y 299.70 291.61 26546 04 10/24/14 N M 3 Y 577.06 561.48
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
26548 04 N M 3 Y Y 299.70 291.61 26550 04 N M 3 Y 680.50 662.13 26551 04 10/24/14 N M 3 Y 1,810.96 1,762.06 26553 04 10/24/14 N M 3 Y Y 1,826.29 1,776.98 26554 04 10/24/14 N M 3 Y Y 1,918.51 1,866.71 26555 04 N M 3 Y 571.10 555.68 26556 04 10/24/14 N M 3 Y Y 1,650.94 1,606.36 26560 04 N M 3 Y 584.05 568.28 26561 04 N M 3 Y 639.60 622.33 26562 04 N M 3 Y 898.95 874.68 26565 04 N M 3 Y 359.30 349.60 26567 04 N M 3 Y 359.30 349.60 26568 04 N M 3 Y 415.85 404.62 26580 04 N M 3 Y 579.05 563.42 26587 04 N M 3 Y Y 259.20 252.20 26590 04 N M 3 Y 587.40 571.54 26591 04 N M 3 Y 237.60 231.18 26593 04 N M 3 Y 259.20 252.20 26596 04 10/24/14 N M 3 Y 452.09 439.88 26600 04 N I 93.70 91.17 26605 04 N I 3 138.75 135.00 26607 04 N M 3 Y 299.70 291.61 26608 04 N M 3 Y 299.70 291.61 26615 04 N M 3 299.70 291.61 26641 04 N M 3 166.40 161.91 26645 04 12/09/14 N M 3 Y 166.40 161.91 26650 04 N M 3 Y 240.00 233.52 26665 04 N M 3 Y 374.55 364.44 26670 04 N I 134.25 130.63 26675 04 N I 3 181.55 176.65 26676 04 N M 3 Y 262.20 255.12 26685 04 N M 3 Y 233.30 227.00 26686 04 N M 3 Y 280.80 273.22 26700 04 N I 107.00 104.11 26705 04 N M 3 166.40 161.91 26706 04 N M 3 Y 237.85 231.43 26715 04 N M 3 Y 274.65 267.23 26720 04 N I 3 97.05 94.43 26725 04 N I 3 130.35 126.83 26727 04 N M 3 171.00 166.38 26735 04 N M 3 Y 263.55 256.43
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
26740 04 N I 3 97.05 94.43 26742 04 N I 3 150.50 146.44 26746 04 N M 3 263.55 256.43 26750 04 N I 97.05 94.43 26755 04 N I 3 104.10 101.29 26756 04 N M 3 Y 224.70 218.63 26765 04 N M 3 Y 285.80 278.08 26770 04 N I 92.50 90.00 26775 04 01/27/15 N M 3 132.45 128.87 26776 04 N M 3 Y 224.70 218.63 26785 04 N I 3 Y 148.60 144.59 26820 04 N M 3 Y 310.10 301.73 26841 04 N M 3 Y 299.70 291.61 26842 04 N M 3 Y 374.55 364.44 26843 04 N M 3 Y 299.70 291.61 26844 04 N M 3 Y 374.55 364.44 26850 04 N M 3 Y 262.20 255.12 26852 04 N M 3 Y 301.70 293.55 26860 04 N M 3 Y 200.65 195.23 26861 04 N M 3 Y 90.10 87.67 26862 04 N M 3 Y 274.60 267.19 26863 04 N M 3 Y 119.25 116.03 26910 04 N M 3 Y 271.90 264.56 26951 04 N M 3 Y 271.90 264.56 26952 04 N M 3 Y 259.40 252.40 26989 04 Y M Y26990 04 N I 3 262.45 17.00 255.36 26991 04 N I 3 215.80 17.00 209.97 26992 04 N M 3 Y 418.80 407.49 27000 04 N M 3 Y 197.00 191.68 27001 04 N M 3 Y 202.20 196.74 27003 04 N M 3 Y 299.70 291.61 27005 04 N M 3 Y 274.65 267.23 27006 04 N M 3 Y 289.20 281.39 27025 04 N M 3 Y 374.55 364.44 27027 04 01/01/09 N M 3 Y 367.57 357.65 27030 04 N M 3 Y 524.40 510.24 27033 04 N M 3 Y 599.35 583.17 27035 04 N M 3 Y 599.35 583.17 27036 04 10/24/14 N M 3 Y Y 614.33 597.74 27040 04 N I 3 113.60 17.00 110.53
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
27041 04 01/01/10 N M 3 258.20 17.00 251.23 27043 04 01/01/10 N M 3 263.34 256.23 27045 04 01/01/10 N M 4 Y Y 418.81 407.50 27047 04 N M 3 224.70 218.63 27048 04 01/01/10 N M 3 Y Y 374.55 364.44 27049 04 01/01/10 N M 3 Y Y 694.85 676.09 27050 04 01/01/10 N M 3 Y Y 524.40 510.24 27052 04 01/01/10 N M 3 Y Y 524.40 510.24 27054 04 01/01/10 N M 3 Y Y 749.20 728.97 27057 04 01/01/09 N M 3 Y 374.55 364.44 27059 04 01/01/10 N M 3 Y Y 1,032.19 1,004.32 27060 04 N M 3 Y 277.50 270.01 27062 04 N M 3 Y 374.55 364.44 27065 04 N M 3 Y 599.35 583.17 27066 04 N M 3 Y 674.20 656.00 27067 04 N M 3 Y 749.20 728.97 27070 04 N M 3 Y 419.00 407.69 27071 04 N M 3 Y 480.00 467.04 27075 04 01/01/10 N M 3 Y Y 599.35 583.17 27076 04 N M 3 Y Y 681.10 662.71 27077 04 01/01/10 N M 3 Y Y 723.20 703.67 27078 04 01/01/10 N M 3 Y Y 599.35 583.17 27080 04 N M 4 Y 359.30 349.60 27086 04 N I 3 107.00 17.00 104.11 27087 04 N M 3 Y 247.20 17.00 240.53 27090 04 N M 3 Y 412.00 400.88 27091 04 N M 5 Y 694.45 675.70 27093 04 N I 106.70 103.82 27095 04 N I 3 111.70 108.68 27096 04 N I 3 172.50 167.84 27097 04 N M 3 Y 290.25 282.41 27098 04 N M 3 Y 345.70 336.37 27100 04 N M 3 Y 561.85 546.68 27105 04 N M 3 Y 636.80 619.61 27110 04 N M 3 Y 674.20 656.00 27111 04 N M 3 Y 674.20 656.00 27120 04 N M 5 Y 898.95 874.68 27122 04 N M 5 Y 954.50 928.73 27125 04 N M 5 Y 1026.65 998.93 27130 04 N M 5 Y 1749.50 1,702.26 27132 04 N M 5 Y 1798.05 1,749.50
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
27134 04 N M 5 Y 1048.85 1,020.53 27137 04 N M 5 Y 1048.85 1,020.53 27138 04 N M 5 Y 1048.85 1,020.53 27140 04 N M 3 Y 718.70 699.30 27146 04 N M 3 Y 718.70 699.30 27147 04 N M 5 Y 839.35 816.69 27151 04 N M 5 Y 1011.40 984.09 27156 04 N M 5 Y 1123.70 1,093.36 27158 04 N M 3 Y 583.00 567.26 27161 04 N M 3 Y 749.20 728.97 27165 04 N M 5 Y 898.95 874.68 27170 04 N M 5 Y 898.95 874.68 27175 04 N M 3 Y 599.35 583.17 27176 04 N M 5 Y 599.35 583.17 27177 04 N M 5 Y 958.60 932.72 27178 04 N M 3 Y 958.60 932.72 27179 04 N M 5 Y 839.35 816.69 27181 04 N M 5 Y 958.60 932.72 27185 04 N M 5 Y 779.70 758.65 27187 04 N M 5 Y Y 950.50 924.84 27197 04 01/01/17 N I 70.20 68.30 27198 04 01/01/17 N I 3 Y Y 181.93 177.02 27200 04 N M 149.80 145.76 27202 04 N M 3 Y 374.55 364.44 27215 04 N M 3 Y 674.20 656.00 27216 04 N M 3 Y 550.90 536.03 27217 04 N M 3 Y 599.35 583.17 27218 04 N M 3 Y 599.35 583.17 27220 04 N M 412.00 400.88 27222 04 N M 3 Y 412.00 400.88 27226 04 N M 3 Y 930.90 905.77 27227 04 N M 3 Y 930.90 905.77 27228 04 N M 3 Y Y 1198.70 1,166.34 27230 04 N I 179.15 174.31 27232 04 N M 3 Y 449.50 437.36 27235 04 N M 5 Y 674.20 656.00 27236 04 N M 5 Y 1019.70 992.17 27238 04 N I 183.80 178.84 27240 04 N M 3 Y 449.50 437.36 27244 04 N M 5 Y 933.80 908.59 27245 04 N M 3 Y 933.80 908.59
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
27246 04 N I 167.00 162.49 27248 04 N M 5 Y 779.70 758.65 27250 04 N M 242.80 236.24 27252 04 N M 3 284.90 277.21 27253 04 N M 3 Y 599.35 583.17 27254 04 N M 3 Y 606.30 589.93 27256 04 N M 3 208.05 202.43 27257 04 N M 3 Y 277.50 270.01 27258 04 N M 5 Y 733.85 714.04 27259 04 N M 5 Y 958.60 932.72 27265 04 N M 242.80 236.24 27266 04 N M 3 Y 283.00 275.36 27267 04 01/01/08 N M Y Y 220.82 214.86 27268 04 01/01/08 N M 3 Y Y 273.08 265.71 27269 04 01/01/08 N M 5 Y Y 655.58 637.88 27275 04 N M 3 Y 240.00 233.52 27279 04 01/01/15 N M 3 Y Y 339.02 329.87 27280 04 N M 3 Y 958.60 932.72 27282 04 N M 3 Y 958.60 932.72 27284 04 N M 5 Y 898.95 874.68 27286 04 N M 5 Y 1033.50 1,005.60 27290 04 N M 11 Y Y 1678.65 1,633.33 27295 04 06/01/11 N M 8 Y Y 1198.70 1,166.34 27299 04 Y M 5 Y27301 04 N M 3 242.10 235.56 27303 04 N M 3 Y 298.20 290.15 27305 04 N M 3 Y 374.55 364.44 27306 04 N M 3 Y 374.55 364.44 27307 04 N M 3 Y 561.85 546.68 27310 04 N M 4 486.90 473.75 27323 04 N I 3 113.60 17.00 110.53 27324 04 N M 3 Y 264.25 17.00 257.12 27325 04 01/01/07 N M 4 Y 412.00 400.88 27326 04 01/01/07 N M 4 Y 412.00 400.88 27327 04 01/01/10 N I 3 156.30 152.08 27328 04 01/01/10 N M 3 295.50 287.52 27329 04 01/01/10 N M 3 Y Y 570.20 554.80 27330 04 N M 3 Y 374.55 364.44 27331 04 N M 3 Y 599.35 583.17 27332 04 N M 3 Y 621.50 604.72 27333 04 N M 3 Y 621.50 604.72
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
27334 04 N M 3 Y 621.50 604.72 27335 04 N M 3 Y 621.50 604.72 27337 04 01/01/10 N M 3 Y 233.88 227.57 27339 04 01/01/10 N M 3 Y 422.81 411.39 27340 04 N M 3 Y 240.00 233.52 27345 04 N M 4 Y 381.50 371.20 27347 04 N M 4 Y 381.50 371.20 27350 04 N M 3 Y 636.80 619.61 27355 04 N M 3 Y Y 599.35 583.17 27356 04 N M 3 Y 674.20 656.00 27357 04 N M 6 Y 674.20 656.00 27358 04 N M 6 Y 674.20 656.00 27360 04 01/01/10 N M 3 Y Y 480.00 467.04 27364 04 01/01/10 N M 6 Y Y 886.89 862.94 27365 04 01/01/10 N M 6 Y Y 898.95 874.68 27370 04 N I 3 101.10 98.37 27372 04 N M 3 Y 174.10 169.40 27380 04 N M 3 Y 412.00 400.88 27381 04 N M 3 Y 524.40 510.24 27385 04 N M 3 Y 419.00 407.69 27386 04 N M 3 Y 524.40 510.24 27390 04 N M 3 Y 359.30 349.60 27391 04 N M 3 Y 458.40 446.02 27392 04 N M 3 Y 661.15 643.30 27393 04 N M 3 Y 359.30 349.60 27394 04 N M 3 Y 458.40 446.02 27395 04 N M 3 Y 661.15 643.30 27396 04 N M 3 Y 599.35 583.17 27397 04 N M 3 Y 550.90 536.03 27400 04 N M 3 Y 599.35 583.17 27403 04 N M 3 Y Y 621.50 604.72 27405 04 N M 3 Y 524.40 510.24 27407 04 N M 3 Y 524.40 510.24 27409 04 N M 3 Y 674.20 656.00 27412 04 N M 3 621.50 604.72 27415 04 N M 3 621.50 604.72 27416 04 01/01/08 N M 3 Y 513.32 499.46 27418 04 N M 3 Y 486.10 472.98 27420 04 N M 3 Y 620.10 603.36 27422 04 N M 3 Y 620.10 603.36 27424 04 N M 3 Y 636.80 619.61
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
27425 04 N M 3 Y Y 561.85 546.68 27427 04 N M 3 Y Y 524.40 510.24 27428 04 N M 3 Y Y 621.10 604.33 27429 04 N M 3 Y Y 674.20 656.00 27430 04 N M 3 Y 561.85 546.68 27435 04 N M 3 Y 524.40 510.24 27437 04 N M 3 Y 599.35 583.17 27438 04 N M 3 Y 958.60 932.72 27440 04 N M 3 Y 599.35 583.17 27441 04 N M 3 Y 599.35 583.17 27442 04 N M 3 Y 881.00 857.21 27443 04 N M 3 Y 881.00 857.21 27445 04 N M 3 Y 1473.35 1,433.57 27446 04 N M 3 Y 1473.35 1,433.57 27447 04 N M 3 Y 1473.35 1,433.57 27448 04 N M 3 Y 599.35 583.17 27450 04 N M 4 Y 689.50 670.88 27454 04 N M 4 Y 749.20 728.97 27455 04 N M 3 Y 524.40 510.24 27457 04 N M 3 Y 524.40 510.24 27465 04 N M 3 Y 749.20 728.97 27466 04 N M 3 Y 898.95 874.68 27468 04 N M 3 Y 1198.70 1,166.34 27470 04 N M 4 Y 839.35 816.69 27472 04 N M 4 Y 958.60 932.72 27475 04 N M 3 Y 659.00 641.21 27477 04 N M 3 Y 659.00 641.21 27479 04 N M 3 Y 958.60 932.72 27485 04 N M 3 Y 561.85 546.68 27486 04 N M 3 Y 736.60 716.71 27487 04 N M 3 Y 1473.30 1,433.52 27488 04 N M 3 524.65 510.48 27495 04 10/24/14 N M 5 Y Y 688.44 669.85 27496 04 N M 3 Y 374.55 364.44 27497 04 N M 3 Y 374.55 364.44 27498 04 N M 3 Y 383.45 373.10 27499 04 N M 3 Y 383.45 373.10 27500 04 N M 3 257.40 250.45 27501 04 N M 3 263.20 256.09 27502 04 N M 3 Y 338.50 329.36 27503 04 N M 3 Y 338.50 329.36
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
27506 04 N M 4 Y Y 910.10 885.53 27507 04 N M 4 Y 910.10 885.53 27508 04 N M 209.00 203.36 27509 04 N M 3 Y 524.40 510.24 27510 04 N M 4 524.40 510.24 27511 04 N M 4 Y 836.55 813.96 27513 04 N M 4 Y 826.30 803.99 27514 04 N M 4 Y 836.55 813.96 27516 04 N M 3 599.35 583.17 27517 04 N M 3 599.35 583.17 27519 04 N M 3 Y 836.55 813.96 27520 04 N M 191.50 186.33 27524 04 N M 3 Y 629.90 612.89 27530 04 N M 288.50 280.71 27532 04 N M 3 321.90 313.21 27535 04 N M 4 Y 839.35 816.69 27536 04 N M 3 Y 839.35 816.69 27538 04 N M 3 213.65 207.88 27540 04 N M 3 Y Y 958.60 932.72 27550 04 N M 194.25 189.01 27552 04 N M 3 227.40 221.26 27556 04 N M 3 Y 656.20 638.48 27557 04 N M 3 Y 749.20 728.97 27558 04 N M 3 Y 749.20 728.97 27560 04 N I 149.80 145.76 27562 04 N M 3 187.80 182.73 27566 04 N M 3 Y 383.25 372.90 27570 04 N I 3 66.70 64.90 27580 04 N M 3 Y 1384.60 1,347.22 27590 04 N M 3 Y 649.25 631.72 27591 04 N M 3 Y 749.20 728.97 27592 04 N M 3 Y 574.35 558.84 27594 04 N M 3 Y 224.70 218.63 27596 04 N M 3 Y 574.35 558.84 27598 04 N M 3 Y 480.00 467.04 27599 04 Y M Y27600 04 N M 3 Y 189.80 184.68 27601 04 N M 3 Y 190.20 185.06 27602 04 N M 3 Y 262.20 255.12 27603 04 N M 3 Y 211.60 17.00 205.89 27604 04 N I 3 156.50 17.00 152.27
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
27605 04 07/01/12 N I Y 359.30 349.60 27606 04 07/01/12 N I 3 Y 359.30 349.60 27607 04 N M 3 Y 292.30 284.41 27610 04 N M 3 Y 480.00 467.04 27612 04 N M 3 Y 374.55 364.44 27613 04 N I 3 113.60 17.00 110.53 27614 04 07/01/12 N M 3 264.25 17.00 257.12 27615 04 N M 3 Y Y 521.56 507.48 27616 04 01/01/10 N M 3 Y Y 722.21 702.71 27618 04 01/01/10 N M 3 186.90 181.85 27619 04 01/01/10 N M 3 268.40 261.15 27620 04 01/01/10 N M 3 Y Y 480.00 467.04 27625 04 N M 3 Y 480.00 467.04 27626 04 N M 3 Y 480.00 467.04 27630 04 01/01/10 N M 3 188.65 183.56 27632 04 01/01/10 N M 3 Y 230.50 224.28 27634 04 01/01/10 N M 3 Y 376.84 366.67 27635 04 N M 3 Y 374.55 364.44 27637 04 N M 3 Y 599.35 583.17 27638 04 N M 3 Y 599.35 583.17 27640 04 01/01/10 N M 3 Y 407.80 396.79 27641 04 01/01/10 N M 3 Y 335.00 325.96 27645 04 01/01/10 N M 6 Y Y 599.35 583.17 27646 04 01/01/10 N M 6 Y Y 599.35 583.17 27647 04 N M 3 Y 449.50 437.36 27648 04 N I 3 82.75 80.52 27650 04 N M 3 Y 359.30 349.60 27652 04 N M 3 Y 480.00 467.04 27654 04 N M 3 Y 449.50 437.36 27656 04 N M 3 Y 299.70 291.61 27658 04 N M 3 Y 224.70 218.63 27659 04 N M 3 Y 416.20 404.96 27664 04 N M 3 Y 182.50 177.57 27665 04 N M 3 Y 302.40 294.24 27675 04 N M 3 Y 239.30 232.84 27676 04 N M 3 Y 313.20 304.74 27680 04 02/22/17 N M 3 Y 381.50 371.20 27681 04 N M 3 Y 231.00 224.76 27685 04 N M 3 Y 262.20 255.12 27686 04 N M 3 Y 257.00 250.06 27687 04 N M 3 Y Y 262.20 255.12
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
27690 04 N M 4 Y 299.70 291.61 27691 04 N M 4 Y 524.40 510.24 27692 04 N M 4 Y 149.80 145.76 27695 04 N M 3 Y 374.55 364.44 27696 04 N M 3 Y 561.85 546.68 27698 04 N M 3 Y 453.70 441.45 27700 04 N M 3 Y 718.70 699.30 27702 04 N M 3 Y 749.20 728.97 27703 04 07/01/12 N M 3 Y 681.29 662.90 27704 04 N M 3 Y 249.35 242.62 27705 04 N M 3 Y 412.00 400.88 27707 04 N M 3 Y 359.30 349.60 27709 04 N M 3 Y 524.40 510.24 27712 04 N M 3 Y 674.20 656.00 27715 04 N M 3 Y 749.20 728.97 27720 04 N M 3 Y 629.90 612.89 27722 04 N M 3 Y 733.85 714.04 27724 04 N M 3 Y 840.75 818.05 27725 04 N M 3 Y 840.75 818.05 27726 04 01/01/08 N M 3 Y 478.66 465.74 27727 04 N M 3 Y 648.10 630.60 27730 04 N M 3 Y 412.00 400.88 27732 04 N M 3 Y 314.95 306.45 27734 04 12/09/14 N M 3 599.35 583.17 27740 04 N M 3 Y 839.35 816.69 27742 04 N M 3 Y 839.35 816.69 27745 04 N M 3 Y Y 378.05 367.84 27750 04 N M 208.05 202.43 27752 04 N M 3 320.45 311.80 27756 04 N M 3 Y 738.10 718.17 27758 04 N M 3 Y 839.35 816.69 27759 04 N M 3 Y 839.35 816.69 27760 04 N M 3 166.40 161.91 27762 04 N M 3 235.80 229.43 27766 04 N M 3 Y 535.45 520.99 27767 04 01/01/08 N M 3 Y 131.63 128.08 27768 04 01/01/08 N M 3 Y 208.32 202.70 27769 04 01/01/08 N M 3 Y 362.81 353.01 27780 04 N M 152.60 148.48 27781 04 N M 3 217.80 211.92 27784 04 N M 3 Y 416.20 404.96
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
27786 04 N M 3 152.60 148.48 27788 04 N M 3 222.00 216.01 27792 04 N M 3 Y 299.70 291.61 27808 04 N M 3 208.05 202.43 27810 04 N M 3 305.15 296.91 27814 04 N M 3 Y Y 610.45 593.97 27816 04 N M 3 224.70 218.63 27818 04 N M 3 369.05 359.09 27822 04 09/01/11 N M 3 Y 599.35 583.17 27823 04 N M 3 Y 599.35 583.17 27824 04 N M 3 Y 232.20 225.93 27825 04 N M 3 Y 286.20 278.47 27826 04 N M 3 Y 515.70 501.78 27827 04 N M 3 Y 638.00 620.77 27828 04 11/24/14 N M 3 Y Y 696.90 678.08 27829 04 09/01/11 N M 3 Y Y 412.00 400.88 27830 04 N M 153.75 149.60 27831 04 N M 3 224.70 218.63 27832 04 N M 3 Y 599.35 583.17 27840 04 N M 138.20 134.47 27842 04 N M 3 208.05 202.43 27846 04 N M 3 Y 378.70 368.48 27848 04 N M 3 Y 481.90 468.89 27860 04 N I 3 77.10 75.02 27870 04 N M 3 Y 659.00 641.21 27871 04 N M 3 Y 659.00 641.21 27880 04 09/01/11 N M 3 Y 613.20 596.64 27881 04 N M 3 Y 674.20 656.00 27882 04 N M 3 Y 588.20 572.32 27884 04 N M 3 Y 252.65 245.83 27886 04 N M 3 Y 374.55 364.44 27888 04 N M 3 Y 599.35 583.17 27889 04 N M 3 Y 374.55 364.44 27892 04 N M 3 Y 220.40 214.45 27893 04 N M 3 Y 212.80 207.05 27894 04 N M 3 Y 293.20 285.28 27899 04 Y M Y28001 04 01/01/10 N I 3 136.05 17.00 132.38 28002 04 01/01/10 N I 3 143.95 140.06 28003 04 N M 3 246.85 240.19 28005 04 01/01/10 N M 3 270.50 263.20
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
28008 04 07/01/12 N M 3 147.95 143.96 28010 04 07/01/12 N M 3 123.35 120.02 28011 04 07/01/12 N M 3 173.55 168.86 28020 04 N M 3 Y 224.70 218.63 28022 04 N M 3 Y 153.65 149.50 28024 04 07/01/12 N M 3 146.15 142.20 28035 04 01/01/10 N M 4 Y Y 524.40 510.24 28039 04 01/01/10 N M 3 Y 189.10 183.99 28041 04 01/01/10 N M 3 Y 248.90 242.18 28043 04 01/01/10 N M 3 149.80 145.76 28045 04 N M 3 Y 224.70 218.63 28046 04 01/01/10 N M 3 Y 408.09 397.07 28047 04 01/01/10 N M 3 Y Y 527.94 513.69 28050 04 03/03/17 N M 3 Y 299.70 291.61 28052 04 03/03/17 N M 3 Y 299.70 291.61 28054 04 N M 3 Y 224.70 218.63 28055 04 01/01/07 N M 3 Y 302.40 294.24 28060 04 N M 3 Y 224.70 218.63 28062 04 07/01/12 N M 3 240.07 233.59 28070 04 03/03/17 N M 3 224.70 218.63 28072 04 03/03/17 N M 3 161.90 157.53 28080 04 N M 3 Y 180.30 175.43 28086 04 03/03/17 N M 3 Y Y 184.50 179.52 28088 04 N M 3 Y 184.50 179.52 28090 04 N M 3 Y 175.75 34.00 171.00 28092 04 N M 3 Y 211.35 34.00 205.64 28100 04 03/03/17 N M 3 Y Y 224.70 218.63 28102 04 N M 3 Y 718.70 699.30 28103 04 N M 3 Y 718.70 699.30 28104 04 03/03/17 N M 3 Y Y 259.40 252.40 28106 04 N M 3 Y 449.50 437.36 28107 04 N M 3 Y 449.50 437.36 28108 04 03/03/17 N M 3 259.40 252.40 28110 04 N M 3 Y 359.30 349.60 28111 04 03/03/17 N M 3 Y 359.30 349.60 28112 04 03/03/17 N M 3 Y 314.95 306.45 28113 04 N M 3 Y 314.95 306.45 28114 04 03/03/17 N M 3 Y Y 943.40 917.93 28116 04 N M 3 Y 346.75 337.39 28118 04 03/03/17 N M 3 Y Y 346.75 337.39 28119 04 N M 3 264.90 257.75
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
28120 04 03/03/17 N M 3 Y 259.40 252.40 28122 04 03/03/17 N M 3 Y Y 253.90 247.04 28124 04 03/03/17 N M 3 259.40 252.40 28126 04 03/03/17 N M 3 209.40 203.75 28130 04 N M 3 Y 412.00 400.88 28140 04 03/03/17 N M 3 Y 394.00 383.36 28150 04 03/03/17 N M 3 209.40 203.75 28153 04 03/03/17 N M 3 144.70 140.79 28160 04 N M 3 Y 224.70 218.63 28171 04 01/01/10 N M 3 Y 467.16 454.55 28173 04 01/01/10 N M 3 Y 418.51 407.21 28175 04 01/01/10 N M 3 Y 262.17 255.09 28190 04 N I 3 Y 107.00 17.00 104.11 28192 04 N M 3 Y 159.80 17.00 155.49 28193 04 N M 3 Y 180.30 175.43 28200 04 N M 3 Y 353.75 344.20 28202 04 08/30/16 N M 3 Y Y 480.00 467.04 28208 04 08/30/16 N M 3 Y 299.70 291.61 28210 04 N M 3 Y 378.05 367.84 28220 04 07/01/12 N M 3 212.30 206.57 28222 04 07/01/12 N M 3 248.39 241.68 28225 04 08/30/16 N M 3 Y 212.30 206.57 28226 04 07/01/12 N M 4 248.39 241.68 28230 04 08/30/16 N M 3 173.40 168.72 28232 04 07/01/12 N M 3 Y 121.10 117.83 28234 04 08/30/16 N M 4 121.05 117.78 28238 04 N M 3 Y Y 299.70 291.61 28240 04 08/30/16 N M 3 140.75 136.95 28250 04 08/30/16 N M 3 Y Y 359.30 349.60 28260 04 08/30/16 N M 3 Y Y 299.70 291.61 28261 04 N M 3 Y 363.45 353.64 28262 04 08/30/16 N M 3 Y Y 524.40 510.24 28264 04 N M 3 Y 449.50 437.36 28270 04 08/30/16 N M 3 299.70 291.61 28272 04 N M 3 Y 224.70 218.63 28280 04 N M 3 Y 162.35 157.97 28285 04 N M 3 Y 270.50 263.20 28286 04 08/30/16 N M 3 337.10 328.00 28288 04 08/30/16 N M 3 299.70 291.61 28289 04 08/01/16 N M 3 Y Y 359.30 349.60 28291 04 01/01/17 N M 3 Y Y 292.48 284.58
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
28292 04 08/30/16 N M 3 Y Y 359.30 349.60 28295 04 01/01/17 N M 3 Y Y 324.34 315.58 28296 04 03/03/17 N M 3 Y Y 419.00 407.69 28297 04 03/03/17 N M 3 Y Y 419.00 407.69 28298 04 03/03/17 N M 3 Y Y 359.30 349.60 28299 04 03/03/17 N M 3 Y Y 430.51 418.89 28300 04 10/01/16 N M 3 Y Y 374.55 364.44 28302 04 10/01/16 N M 3 Y Y 337.90 328.78 28304 04 03/03/17 N M 3 Y Y 283.60 275.94 28305 04 N M 3 Y 373.70 363.61 28306 04 03/03/17 N M 3 Y Y 262.20 255.12 28307 04 N M 3 Y 299.70 291.61 28308 04 03/03/17 N M 3 Y Y 202.50 197.03 28309 04 N M 3 Y 358.05 348.38 28310 04 03/03/17 N M 3 Y 262.20 255.12 28312 04 03/03/17 N M 3 Y 169.85 165.26 28313 04 03/03/17 N M 3 167.10 162.59 28315 04 03/03/17 N M 3 224.70 218.63 28320 04 10/01/16 N M 3 Y Y 378.05 367.84 28322 04 10/01/16 N M 3 Y Y 244.90 238.29 28340 04 03/03/17 N M 3 270.00 262.71 28341 04 03/03/17 N M 3 307.90 299.59 28344 04 03/03/17 N M 3 Y 172.80 168.13 28345 04 N M 3 Y 216.00 210.17 28360 04 10/01/14 N M 3 Y 552.23 537.32 28400 04 07/01/12 N M 114.20 111.12 28405 04 N M 3 Y 228.90 222.72 28406 04 N M 3 Y 231.65 225.40 28415 04 N M 3 Y 642.45 625.10 28420 04 N M 3 Y 671.85 653.71 28430 04 N M 109.00 106.06 28435 04 N M 3 Y 215.05 209.24 28436 04 N M 3 Y 318.60 310.00 28445 04 12/09/14 N M 3 Y Y 718.70 699.30 28446 04 01/01/08 N M 3 Y Y 626.74 609.82 28450 04 N M 98.00 95.35 28455 04 N M 3 277.50 270.01 28456 04 N M 3 Y 313.20 304.74 28465 04 N M 3 Y 599.35 583.17 28470 04 07/01/12 N M 97.05 94.43 28475 04 N M 3 173.40 168.72
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
28476 04 N M 3 Y 237.85 231.43 28485 04 N M 3 Y 301.00 292.87 28490 04 07/01/12 N M 55.40 53.90 28495 04 07/01/12 N M 3 69.30 67.43 28496 04 03/03/17 N M 3 113.60 110.53 28505 04 N M 3 Y 230.80 224.57 28510 04 07/01/12 N M 3 41.60 40.48 28515 04 07/01/12 N M 3 97.05 94.43 28525 04 07/01/12 N M 3 Y 202.90 197.42 28530 04 07/01/12 N M 3 57.30 55.75 28531 04 03/03/17 N M 3 Y 224.70 218.63 28540 04 07/01/12 N M 138.75 135.00 28545 04 07/01/12 N M 3 Y 152.60 148.48 28546 04 07/01/12 N M 3 Y 134.60 130.97 28555 04 03/03/17 N M 3 Y Y 480.00 467.04 28570 04 07/01/12 N M 113.65 110.58 28575 04 N M 3 151.15 147.07 28576 04 N M 3 Y 262.20 255.12 28585 04 03/03/17 N M 3 Y Y 427.20 415.67 28600 04 N M 299.70 291.61 28605 04 N M 3 299.70 291.61 28606 04 N M 3 Y 299.70 291.61 28615 04 N M 3 Y 368.45 358.50 28630 04 N I 112.40 109.37 28635 04 07/01/12 N I 3 262.20 255.12 28636 04 03/03/17 N I 3 Y 262.20 255.12 28645 04 03/03/17 N M 3 Y 240.00 233.52 28660 04 N I 104.10 101.29 28665 04 N I 3 117.85 114.67 28666 04 07/01/12 N I 3 Y 133.35 129.75 28675 04 N M 3 Y 241.35 234.83 28705 04 N M 3 Y 599.35 583.17 28715 04 N M 3 Y 599.35 583.17 28725 04 N M 3 Y 480.00 467.04 28730 04 N M 3 Y 480.00 467.04 28735 04 N M 3 Y 599.35 583.17 28737 04 N M 3 Y 599.35 583.17 28740 04 03/03/17 N M 3 Y Y 337.10 328.00 28750 04 N M 3 Y 262.20 255.12 28755 04 N M 3 Y 169.10 164.53 28760 04 03/03/17 N M 4 Y Y 239.10 232.64
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
28800 04 N M 3 Y 485.50 472.39 28805 04 N M 3 Y 482.80 469.76 28810 04 N M 3 Y 419.00 407.69 28820 04 03/03/17 N M 3 167.10 162.59 28825 04 03/03/17 N M 3 145.60 141.67 28890 04 N M 3 121.80 118.51 28899 04 Y M 3 Y29000 04 N I 3 156.80 152.57 29010 04 N I 3 141.50 137.68 29015 04 N I 3 188.70 183.61 29035 04 N I 3 152.60 148.48 29040 04 N I 3 181.65 176.75 29044 04 N I 3 173.40 168.72 29046 04 N I 3 187.30 182.24 29049 04 N I 3 66.10 34.00 64.32 29055 04 N I 3 115.80 34.00 112.67 29058 04 N I 3 79.30 34.00 77.16 29065 04 N I 3 59.45 34.00 57.84 29075 04 N I 3 59.45 34.00 57.84 29085 04 N I 3 49.30 17.00 47.97 29086 04 N I 3 30.70 29.87 29105 04 N I 3 42.10 17.00 40.96 29125 04 N I 3 32.15 17.00 31.28 29126 04 N I 3 39.30 17.00 38.24 29130 04 N I 23.00 17.00 22.38 29131 04 N I 23.50 17.00 22.87 29200 04 N I 24.25 23.60 29240 04 N I 37.40 36.39 29260 04 N I 19.95 19.41 29280 04 N I 19.30 18.78 29305 04 N I 3 166.40 161.91 29325 04 N I 3 194.20 188.96 29345 04 N I 3 79.30 34.00 77.16 29355 04 N I 3 92.40 34.00 89.91 29358 04 N I 3 174.40 34.00 169.69 29365 04 N I 3 79.30 34.00 77.16 29405 04 N I 3 70.00 34.00 68.11 29425 04 N I 3 75.30 34.00 73.27 29435 04 N I 3 79.30 34.00 77.16 29440 04 N I 29.80 29.00 29445 04 N I 3 91.65 34.00 89.18
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
29450 04 N I 3 43.50 17.00 42.33 29505 04 N I 3 43.50 17.00 42.33 29515 04 N I 3 35.85 17.00 34.88 29520 04 N I Y 21.40 20.82 29530 04 N I 3 21.80 21.21 29540 04 N I 3 15.40 14.98 29550 04 N I 14.20 13.82 29580 04 N I 27.00 17.00 26.27 29581 04 01/01/10 N I Y 18.63 18.13 29582 04 01/01/12 N I 9.09 8.84 29583 04 01/01/12 N I 6.68 6.50 29584 04 01/01/12 N I 9.09 8.84 29700 04 N I 3 24.15 23.50 29705 04 N I 25.60 24.91 29710 04 N I 56.80 55.27 29720 04 N I 59.60 57.99 29730 04 N I 36.00 35.03 29740 04 N I 46.55 45.29 29750 04 N I 44.30 43.10 29799 04 Y I29800 04 N M 4 Y 374.55 364.44 29804 04 N M 4 Y 355.80 346.19 29805 04 N M 3 Y 325.20 316.42 29806 04 N M 3 Y 673.30 655.12 29807 04 N M 3 Y 673.30 655.12 29819 04 N M 3 Y 480.00 467.04 29820 04 N M 3 Y 480.00 467.04 29821 04 N M 3 Y 480.00 467.04 29822 04 N M 3 Y 480.00 467.04 29823 04 N M 3 Y 480.00 467.04 29824 04 N M 3 Y 526.45 512.24 29825 04 N M 3 Y 480.00 467.04 29826 04 N M 3 Y Y 480.00 467.04 29827 04 N M 3 Y 674.20 656.00 29828 04 01/01/08 N M 3 Y 484.90 471.81 29830 04 N M 3 Y 394.50 383.85 29834 04 N M 3 Y 480.00 467.04 29835 04 N M 3 Y 480.00 467.04 29836 04 N M 3 Y 480.00 467.04 29837 04 N M 3 Y 480.00 467.04 29838 04 N M 3 Y 480.00 467.04
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
29840 04 N M 3 Y Y 356.10 346.49 29843 04 N M 3 Y Y 356.10 346.49 29844 04 N M 3 Y Y 480.00 467.04 29845 04 N M 3 Y Y 480.00 467.04 29846 04 N M 3 Y Y 356.10 346.49 29847 04 N M 3 Y Y 480.00 467.04 29848 04 N M 3 Y 456.00 443.69 29850 04 N M 3 Y 675.10 656.87 29851 04 N M 3 Y 958.60 932.72 29855 04 N M 3 Y 629.90 612.89 29856 04 N M 3 Y 839.35 816.69 29860 04 N M 3 Y 374.55 364.44 29861 04 N M 3 Y 486.90 473.75 29862 04 N M 3 Y 599.35 583.17 29863 04 N M 3 Y 599.35 583.17 29866 04 09/01/13 N M 3 Y 631.20 614.16 29867 04 09/01/13 N M 3 Y 769.56 748.78 29868 04 09/01/13 N M 3 Y 1,009.61 982.35 29870 04 N M 3 374.55 364.44 29871 04 N M 3 Y 374.55 364.44 29873 04 N M 3 Y 374.55 364.44 29874 04 N M 3 Y 486.90 473.75 29875 04 N M 3 Y 599.35 583.17 29876 04 N M 3 Y 599.35 583.17 29877 04 N M 3 Y 599.35 583.17 29879 04 N M 3 Y 599.35 583.17 29880 04 N M 3 Y Y 621.50 604.72 29881 04 N M 3 Y 621.50 604.72 29882 04 N M 3 Y 621.50 604.72 29883 04 N M 3 Y Y 599.35 583.17 29884 04 N M 3 Y 599.35 583.17 29885 04 N M 3 Y Y 621.50 604.72 29886 04 N M 3 Y 599.35 583.17 29887 04 N M 3 Y 599.35 583.17 29888 04 N M 3 Y Y 621.50 604.72 29889 04 N M 3 Y Y 621.50 604.72 29891 04 N M 3 Y 480.00 467.04 29892 04 N M 3 Y 480.00 467.04 29893 04 N M 3 171.90 167.26 29894 04 02/22/17 N M 3 Y Y 480.00 467.04 29895 04 02/22/17 N M 3 Y Y 480.00 467.04
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
29897 04 02/22/17 N M 3 Y 480.00 467.04 29898 04 08/10/15 N M 3 Y Y 480.00 467.04 29899 04 02/22/17 N M 3 Y Y 659.00 641.21 29900 04 N M 3 Y 288.60 280.81 29901 04 N M 3 Y 318.80 310.19 29902 04 N M 3 Y 342.55 333.30 29904 04 01/01/08 N M 3 Y 323.37 314.64 29905 04 01/01/08 N M 3 Y 347.96 338.57 29906 04 01/01/08 N M 3 Y 366.46 356.57 29907 04 01/01/08 N M 3 Y 451.20 439.02 29914 04 01/01/11 N M 3 Y Y 619.03 602.32 29915 04 01/01/11 N M 3 Y Y 630.63 613.60 29916 04 01/01/11 N M 3 Y Y 630.63 613.60 29999 04 Y M 3 Y30000 04 N I 3 46.70 17.00 45.44 30020 04 N I 3 47.80 17.00 46.51 30100 04 N I 3 55.40 17.00 53.90 30110 04 N I 3 57.10 17.00 55.56 30115 04 N M 4 156.80 152.57 30117 04 N I 4 109.30 106.35 30118 04 N I 4 299.35 291.27 30120 04 N M 4 Y 480.00 467.04 30124 04 N I 3 89.10 17.00 86.69 30125 04 N I 4 218.95 213.04 30130 04 N M 4 180.30 175.43 30140 04 N M 4 Y 180.30 175.43 30150 04 N M 4 Y 431.22 419.58 30160 04 N M 4 Y Y 424.33 412.87 30200 04 N I 3 24.90 24.23 30210 04 N I 3 34.80 33.86 30220 04 N I 4 Y Y 56.00 54.49 30300 04 N I 39.05 38.00 30310 04 N I 3 74.90 72.88 30320 04 N I 3 152.60 148.48 30400 04 N M 4 Y Y 749.20 728.97 30410 04 N M 4 Y 749.20 728.97 30420 04 N M 4 Y Y 980.85 954.37 30430 04 N M 4 Y 374.55 364.44 30435 04 10/24/14 N M 4 Y 657.77 640.01 30450 04 N M 4 Y 599.35 583.17 30460 04 N M 4 Y Y 599.35 583.17
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
30462 04 N M 4 Y Y 815.50 793.48 30465 04 N M 4 Y 547.60 532.81 30520 04 N M 4 Y 417.60 406.32 30540 04 N M 4 Y Y 524.40 510.24 30545 04 N M 4 Y Y 674.20 656.00 30560 04 N I 4 42.00 40.87 30580 04 N M 4 Y 374.55 364.44 30600 04 N M 4 Y 374.55 364.44 30620 04 N M 4 524.40 510.24 30630 04 N M 4 Y Y 524.40 510.24 30801 04 N I 4 50.05 48.70 30802 04 N I 4 71.15 69.23 30901 04 01/01/10 N I 4 74.90 72.88 30903 04 N I 4 Y Y 71.40 17.00 69.47 30905 04 N I 4 80.75 17.00 78.57 30906 04 N I 4 85.70 17.00 83.39 30915 04 N M 4 359.30 349.60 30920 04 N M 4 359.30 349.60 30930 04 N I 4 Y Y 90.10 87.67 30999 04 Y M Y31000 04 N I 4 39.35 38.29 31002 04 N I 4 51.50 50.11 31020 04 N M 4 180.30 175.43 31030 04 N M 4 480.00 467.04 31032 04 N M 4 Y Y 718.70 699.30 31040 04 N M 4 Y 359.30 349.60 31050 04 N M 4 Y 412.00 400.88 31051 04 N M 4 Y 412.00 400.88 31070 04 N M 4 180.30 175.43 31075 04 N M 4 Y 599.35 583.17 31080 04 N M 4 Y 898.95 874.68 31081 04 N M 4 Y 898.95 874.68 31084 04 N M 4 Y 898.95 874.68 31085 04 N M 5 Y 898.95 874.68 31086 04 N M 4 Y 898.95 874.68 31087 04 N M 4 Y 898.95 874.68 31090 04 N M 4 Y 718.70 699.30 31200 04 N M 4 Y 262.20 255.12 31201 04 N M 4 449.50 437.36 31205 04 N M 4 Y 449.50 437.36 31225 04 N M 5 Y 898.95 874.68
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
31230 04 N M 5 Y 1,198.70 1,166.34 31231 04 N I 3 107.00 104.11 31233 04 N I 4 112.40 109.37 31235 04 N I 4 107.00 104.11 31237 04 N I 4 102.55 99.78 31238 04 N I 4 113.10 110.05 31239 04 07/08/14 N I 4 Y 356.48 346.86 31240 04 N M 4 221.90 215.91 31254 04 N M 4 Y 262.20 255.12 31255 04 N M 4 Y 449.50 437.36 31256 04 N M 4 Y 180.30 175.43 31267 04 N M 4 Y 224.70 218.63 31276 04 N M 4 253.30 246.46 31287 04 N M 4 205.95 200.39 31288 04 N M 4 412.00 400.88 31290 04 07/08/14 N I 4 Y 638.46 621.22 31291 04 07/08/14 N I 4 Y 658.30 640.53 31292 04 N M 4 451.50 439.31 31293 04 N M 4 492.15 478.86 31294 04 N M 4 581.00 565.31 31295 04 01/01/11 N I 4 Y 104.61 101.79 31296 04 01/01/11 N I 4 Y 124.97 121.60 31297 04 01/01/11 N I 4 102.36 99.60 31299 04 Y M Y31300 04 N M 6 Y 524.40 510.24 31320 04 N M 4 299.70 291.61 31360 04 N M 6 Y Y 1,198.70 1,166.34 31365 04 N M 6 Y Y 1,537.15 1,495.65 31367 04 N M 6 Y Y 958.60 932.72 31368 04 N M 6 Y Y 1,537.15 1,495.65 31370 04 N M 6 Y Y 958.60 932.72 31375 04 N M 6 Y Y 958.60 932.72 31380 04 N M 6 Y 958.60 932.72 31382 04 N M 6 Y Y 958.60 932.72 31390 04 N M 6 Y Y 1,537.15 1,495.65 31395 04 N M 6 Y Y 1,728.25 1,681.59 31400 04 N M 6 Y 749.20 728.97 31420 04 N M 6 Y Y 524.40 510.24 31500 04 N I 55.50 54.00 31502 04 N I 3 Y 28.50 27.73 31505 04 N I 4 37.40 36.39
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
31510 04 N I 4 74.90 72.88 31511 04 N I 4 202.50 197.03 31512 04 N M 4 202.50 197.03 31513 04 N M 4 Y Y 235.80 229.43 31515 04 N I 4 107.00 17.00 104.11 31520 04 N I 4 112.40 109.37 31525 04 11/01/14 N I 4 98.34 17.00 95.68 31526 04 N I 4 192.95 17.00 187.74 31527 04 N M 4 Y Y 192.95 17.00 187.74 31528 04 N I 4 Y Y 192.95 17.00 187.74 31529 04 N I 4 Y Y 192.95 17.00 187.74 31530 04 N M 4 192.95 34.00 187.74 31531 04 N M 4 224.60 34.00 218.54 31535 04 N I 4 224.60 34.00 218.54 31536 04 N I 4 224.60 34.00 218.54 31540 04 N M 4 268.20 34.00 260.96 31541 04 N M 4 268.20 34.00 260.96 31545 04 N M 4 268.20 260.96 31546 04 N M 4 577.16 561.58 31551 04 01/01/17 N M 4 Y Y 861.36 838.10 31552 04 01/01/17 N M 4 Y Y 867.41 843.99 31553 04 01/01/17 N M 4 Y Y 944.84 919.33 31554 04 01/01/17 N M 4 Y Y 991.68 964.90 31560 04 N M 4 Y 499.45 34.00 485.96 31561 04 N M 4 499.45 34.00 485.96 31570 04 N M 4 224.60 34.00 218.54 31571 04 N M 4 224.60 34.00 218.54 31572 04 01/01/17 N I 4 Y 111.05 108.05 31573 04 01/01/17 N I 4 Y 91.52 89.05 31574 04 01/01/17 N I 4 4 91.52 89.05 31575 04 02/15/17 N I 4 107.00 34.00 104.11 31576 04 02/15/17 N I 4 224.60 34.00 218.54 31577 04 02/15/17 N I 4 Y 192.95 34.00 187.74 31578 04 02/15/17 N I 4 Y 268.20 34.00 260.96 31579 04 N I 4 192.95 187.74 31580 04 02/15/17 N M 4 Y Y 524.35 510.19 31584 04 02/15/17 N M 4 Y Y 591.60 575.63 31587 04 N M 4 Y Y 524.35 510.19 31590 04 N M 4 Y Y 839.35 816.69 31591 04 01/01/17 N M 4 Y Y 625.23 608.35 31592 04 01/01/17 N M 4 Y Y 1,019.84 992.30
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
31595 04 N M 4 Y Y 360.70 350.96 31599 04 Y M Y31600 04 N I 4 266.40 259.21 31601 04 N I 4 284.40 276.72 31603 04 N I 4 Y 266.40 259.21 31605 04 N I 4 266.40 259.21 31610 04 11/01/15 N M 4 289.40 281.59 31611 04 N M 11 Y Y 374.60 364.49 31612 04 N I 4 149.80 145.76 31613 04 N M 3 Y Y 208.05 202.43 31614 04 N M 3 334.78 325.74 31615 04 N I 4 107.00 17.00 104.11 31622 04 N I 3 235.20 56.70 228.85 31623 04 01/01/10 N I 3 235.20 56.70 228.85 31624 04 01/01/10 N I 3 270.50 56.70 263.20 31625 04 01/01/10 N I 3 235.20 56.70 228.85 31626 04 01/01/10 N I 3 Y 121.44 56.70 118.16 31627 04 01/01/10 N I 3 Y 59.02 57.43 31628 04 01/01/10 N I 4 246.95 56.70 240.28 31629 04 01/01/10 N I 4 235.20 56.70 228.85 31630 04 N M 4 251.10 244.32 31631 04 N M 4 Y 251.10 244.32 31632 04 N I 4 30.94 30.10 31633 04 N I 4 38.51 37.47 31634 04 01/01/11 N I 4 Y 123.68 120.34 31635 04 N M 4 239.15 56.70 232.69 31636 04 N M 4 Y 251.10 244.32 31637 04 N M 4 Y 251.10 244.32 31638 04 N M 4 Y 251.10 244.32 31640 04 N M 4 251.10 244.32 31641 04 N M 4 251.10 244.32 31643 04 N I 4 235.95 229.58 31645 04 N I 4 219.35 56.70 213.43 31646 04 N I 4 219.35 56.70 213.43 31647 04 01/01/13 N I 4 Y 136.36 132.68 31648 04 01/01/13 N M 4 141.46 137.64 31649 04 01/01/13 N M 4 44.00 42.81 31651 04 01/01/13 N M 4 46.76 45.50 31652 04 01/01/16 N I 3 144.20 140.31 31653 04 01/01/16 N I 3 159.22 154.92 31654 04 01/01/16 N I 3 41.78 40.65 31660 04 01/01/13 N M 4 136.27 132.59
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
31661 04 01/01/13 N M 4 144.04 140.15 31717 04 N I 4 230.25 224.03 31720 04 01/01/14 N I 4 31.46 30.61 31725 04 N I 4 224.70 218.63 31730 04 N I 4 Y 88.90 86.50 31750 04 N M 6 Y Y 713.50 694.24 31755 04 N M 6 Y 527.50 513.26 31760 04 N M 11 Y Y 1,123.70 1,093.36 31766 04 N M 4 Y Y 1,198.70 1,166.34 31770 04 N M 4 Y Y 1,048.85 1,020.53 31775 04 N M 4 Y Y 1,123.70 1,093.36 31780 04 N M 6 Y Y 749.20 728.97 31781 04 N M 11 Y Y 1,123.70 1,093.36 31785 04 N M 6 Y Y 1,198.70 1,166.34 31786 04 N M 11 Y Y 1,198.70 1,166.34 31800 04 N M 6 Y Y 524.40 510.24 31805 04 N M 11 Y Y 749.20 728.97 31820 04 N M 4 214.00 34.00 208.22 31825 04 N M 5 Y 374.55 364.44 31830 04 N M 3 Y 166.75 162.25 31899 04 Y M Y32035 04 N M 4 Y Y 524.40 510.24 32036 04 N M 4 Y Y 331.15 322.21 32096 04 01/01/12 N M 11 Y Y 503.81 490.21 32097 04 01/01/12 N M 11 Y Y 503.81 490.21 32098 04 01/01/12 N M 11 Y Y 473.32 460.54 32100 04 N M 11 Y Y 811.50 789.59 32110 04 N M 11 Y Y 811.50 789.59 32120 04 N M 11 Y Y 599.35 583.17 32124 04 N M 11 Y Y 599.35 583.17 32140 04 N M 11 Y Y 599.35 583.17 32141 04 N M 11 Y Y 599.35 583.17 32150 04 N M 11 Y Y 599.35 583.17 32151 04 N M 11 Y Y 599.35 583.17 32160 04 N M 11 Y Y 374.55 364.44 32200 04 N M 11 Y 480.00 467.04 32215 04 N M 11 Y 599.35 583.17 32220 04 N M 11 Y 749.20 728.97 32225 04 N M 11 Y 599.35 583.17 32310 04 N M 11 Y 958.60 932.72 32320 04 N M 11 Y 1,198.70 1,166.34 32400 04 N I 4 71.40 34.00 69.47
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
32405 04 N I 4 107.00 34.00 104.11 32440 04 N M 11 Y Y 1,198.70 1,166.34 32442 04 N M 11 Y Y 1,414.70 1,376.50 32445 04 N M 11 Y Y 1,198.70 1,166.34 32480 04 N M 11 Y Y 1,213.95 1,181.17 32482 04 N M 11 Y Y 1,213.95 1,181.17 32484 04 N M 11 Y Y 1,213.95 1,181.17 32486 04 N M 11 Y Y 1,350.15 1,313.70 32488 04 N M 11 Y Y 1,213.95 1,181.17 32491 04 N M 11 Y Y 1,213.95 1,181.17 32501 04 N M 4 Y Y 324.05 315.30 32503 04 N M 11 Y 1,050.34 1,021.98 32504 04 N M 11 Y 1,203.13 1,170.65 32505 04 01/01/12 N M 11 Y Y 579.99 564.33 32506 04 01/01/12 N M Y Y 99.39 96.71 32507 04 01/01/12 N M Y Y 99.39 96.71 32540 04 N M 11 Y Y 958.60 932.72 32550 04 05/14/14 N I 4 127.01 318.46 123.58 32551 04 01/01/08 N M 4 224.70 218.63 32552 04 01/01/10 N I 3 Y 92.88 90.37 32553 04 01/01/10 N I 3 Y 121.68 118.39 32554 04 01/01/13 N I 3 53.85 259.97 52.40 32555 04 01/01/13 N I 3 67.46 295.04 65.64 32556 04 01/01/13 N I 4 74.00 258.49 72.00 32557 04 01/01/13 N I 4 102.37 438.11 99.61 32560 04 01/01/10 N I 3 198.20 192.85 32561 04 01/01/10 N I 3 42.28 41.14 32562 04 01/01/10 N I 3 37.83 36.81 32601 04 N I 4 Y 167.20 162.69 32604 04 N I 4 Y 302.40 294.24 32606 04 N I 4 Y 314.95 306.45 32607 04 01/01/12 N I 4 Y 193.84 188.61 32608 04 01/01/12 N I 4 Y 238.48 232.04 32609 04 01/01/12 N I 4 Y 164.66 160.21 32650 04 N M 4 Y 349.85 340.40 32651 04 N M 11 Y 426.10 414.60 32652 04 N M 11 Y 591.40 575.43 32653 04 N M 11 Y 418.50 407.20 32654 04 N M 11 Y 400.80 389.98 32655 04 N M 11 Y 838.95 816.30 32656 04 N M 11 Y 523.85 509.71 32658 04 N M 11 Y 415.90 404.67
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
32659 04 N M 11 Y 415.55 404.33 32661 04 N M 11 Y 523.85 509.71 32662 04 N M 11 Y 598.40 582.24 32663 04 N M 11 Y Y 1,213.85 1,181.08 32664 04 N M 11 Y 749.20 728.97 32665 04 N M 11 Y Y 1,082.10 1,052.88 32666 04 01/01/12 N M 11 Y Y 542.15 527.51 32667 04 01/01/12 Y M Y Y32668 04 01/01/12 N M Y Y 100.12 97.42 32669 04 01/01/12 N M 11 Y Y 839.65 816.98 32670 04 01/01/12 N M 11 Y Y 1,003.13 976.05 32671 04 01/01/12 N M 11 Y Y 1,116.21 1,086.07 32672 04 01/01/12 N M 11 Y Y 953.46 927.72 32673 04 01/01/12 N M 11 Y Y 746.72 726.56 32674 04 01/01/12 N M Y Y 136.14 132.46 32701 09 01/01/13 Y M32810 04 N M 4 398.40 387.64 32815 04 N M 11 Y 813.26 791.30 32820 04 10/24/14 N M 11 Y Y 837.74 815.12 32850 04 N M Y 1,134.10 1,103.48 32851 04 N M 11 Y Y 2,106.30 2,049.43 32852 04 N M 11 Y Y 2,397.40 2,332.67 32853 04 N M 11 Y Y 3,402.50 3,310.63 32854 04 N M 11 Y Y 3,834.55 3,731.02 32900 04 N M 4 Y 564.90 549.65 32905 04 N M 7 Y 749.20 728.97 32906 04 N M 7 Y 772.90 752.03 32940 04 N M 6 Y Y 571.55 556.12 32960 04 N I 4 299.70 291.61 32997 04 N M 3 246.40 239.75 32998 04 01/01/07 N M 3 214.24 208.46 32999 04 Y M Y33010 04 N I 3 61.25 59.60 33011 04 N I 3 57.55 56.00 33015 04 N I 3 204.05 198.54 33020 04 N M 20 Y Y 733.85 714.04 33025 04 N M 20 Y Y 839.35 816.69 33030 04 N M 20 Y Y 839.35 816.69 33031 04 N M 20 Y Y 2,397.40 2,332.67 33050 04 N M 20 Y Y 1,048.85 1,020.53 33120 04 N M 20 Y Y 2,397.40 2,332.67
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
33130 04 N M 20 Y Y 749.20 728.97 33140 04 N M 11 Y 828.48 806.11 33141 04 N M 11 Y 86.29 83.96 33202 04 01/01/07 N M 11 Y 861.50 838.24 33203 04 01/01/07 N M 349.85 340.40 33206 04 01/01/12 N M Y 861.50 838.24 33207 04 01/01/12 N M Y 861.50 838.24 33208 04 01/01/12 N M Y 861.50 838.24 33210 04 01/01/12 N I 240.00 233.52 33211 04 01/01/12 N I 240.00 233.52 33212 04 01/01/12 N I 240.00 233.52 33213 04 01/01/12 N I 240.00 233.52 33214 04 01/01/12 N M Y 299.70 291.61 33215 04 01/01/12 N M 5 299.70 291.61 33216 04 01/01/10 N M 299.70 291.61 33217 04 01/01/10 N M 299.70 291.61 33218 04 01/01/12 N M 299.70 291.61 33220 04 01/01/12 N M 245.65 239.02 33221 04 01/01/12 N M 217.32 211.45 33222 04 01/01/10 N M 299.70 291.61 33223 04 N M Y 299.70 291.61 33224 04 01/01/10 N I 5 299.70 291.61 33225 04 N M 299.70 291.61 33226 04 N I 5 299.70 291.61 33227 04 01/01/12 N M 207.33 201.73 33228 04 01/01/12 N M 216.34 210.50 33229 04 01/01/12 N M 225.35 219.27 33230 04 01/01/12 N M 234.19 227.87 33231 04 01/01/12 N M 243.19 236.62 33233 04 01/01/12 N M 167.40 162.88 33234 04 01/01/12 N M 351.00 341.52 33235 04 01/01/12 N M 351.00 341.52 33236 04 N M 11 Y Y 419.00 407.69 33237 04 N M 11 Y Y 433.95 422.23 33238 04 N M 11 Y Y 452.80 440.57 33240 04 01/01/12 N M 278.44 270.92 33241 04 01/01/12 N M 138.57 134.83 33243 04 N M 11 Y Y 747.68 727.49 33244 04 01/01/12 N M Y 473.20 460.42 33249 04 01/01/12 N M 642.60 625.25 33250 04 N M 15 Y Y 1,798.10 1,749.55 33251 04 N M 20 Y Y 2,397.40 2,332.67
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
33254 04 01/01/07 N M 20 Y 2,397.40 2,332.67 33255 04 01/01/07 N M 20 Y 2,397.40 2,332.67 33256 04 01/01/07 N M 20 Y 2,397.40 2,332.67 33257 04 01/01/08 N M 20 Y 327.74 318.89 33258 04 01/01/08 N M 20 Y 371.27 361.25 33259 04 01/01/08 N M 20 489.48 476.26 33261 04 N M 20 Y Y 2,397.40 2,332.67 33262 04 01/01/12 N M 225.57 219.48 33263 04 01/01/12 N M 234.58 228.25 33264 04 01/01/12 N M 243.58 237.00 33265 04 01/01/07 N M 20 Y 2,397.40 2,332.67 33266 04 01/01/07 N M 20 Y 2,397.40 2,332.67 33270 04 01/01/15 N M 365.80 355.92 33271 04 01/01/15 N M 307.09 298.80 33272 04 01/01/15 N M 225.73 219.64 33273 04 01/01/15 N M 5 250.28 243.52 33282 04 N M 5 584.80 569.01 33284 04 N M 5 444.05 432.06 33300 04 N M 15 Y Y 629.90 612.89 33305 04 N M 20 Y Y 2,397.40 2,332.67 33310 04 N M 20 Y Y 1,048.85 1,020.53 33315 04 N M 20 Y Y 2,397.40 2,332.67 33320 04 N M 15 Y Y 749.20 728.97 33321 04 N M 15 Y Y 1,798.05 1,749.50 33322 04 N M 20 Y Y 2,397.40 2,332.67 33330 04 N M 20 Y Y 1,198.70 1,166.34 33335 04 N M 20 Y Y 2,397.40 2,332.67 33340 04 01/01/17 N I 3 Y Y 503.95 490.34 33361 04 09/06/16 N M 3 Y Y 833.19 810.69 33362 04 01/01/13 N M 5 Y Y 911.65 887.04 33363 04 01/01/13 N M 4 Y Y 943.96 918.47 33364 04 01/01/13 N M 10 Y Y 1,003.16 976.07 33365 04 01/01/13 N M 10 Y Y 1,105.59 1,075.74 33366 04 01/01/14 N I 10 Y Y 1,226.35 1,193.24 33367 04 01/01/13 N M 20 Y Y 389.18 378.67 33368 04 01/01/13 N M 20 Y Y 471.72 458.98 33369 04 01/01/13 N M 20 Y Y 622.73 605.92 33390 04 01/01/17 N M 20 Y Y 1,204.47 1,171.95 33391 04 01/01/17 N M 20 Y Y 1,427.26 1,388.72 33404 04 10/24/14 N M 20 Y Y 1,115.44 1,085.32 33405 04 N M 20 Y Y 2,397.40 2,332.67 33406 04 N M 20 Y Y 2,397.40 2,332.67 33410 04 N M 20 Y 2,397.40 2,332.67
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
33411 04 N M 20 Y Y 2,397.40 2,332.67 33412 04 N M 20 Y Y 2,397.40 2,332.67 33413 04 N M 20 Y Y 2,397.40 2,332.67 33414 04 10/24/14 N M 20 Y Y 1,381.46 1,344.16 33415 04 N M 20 Y Y 1,198.70 1,166.34 33416 04 N M 20 Y Y 2,397.40 2,332.67 33417 04 Y M 20 Y Y33418 04 01/01/15 N M 3 Y Y 1,168.16 1,136.62 33419 04 01/01/15 N M 3 Y Y 275.71 268.27 33420 04 N M 20 Y Y 1,048.85 1,020.53 33422 04 N M 20 Y Y 2,397.40 2,332.67 33425 04 N M 20 Y Y 2,397.40 2,332.67 33426 04 N M 20 Y Y 2,397.40 2,332.67 33427 04 N M 20 Y Y 2,397.40 2,332.67 33430 04 N M 20 Y Y 2,397.40 2,332.67 33460 04 N M 20 Y Y 2,397.40 2,332.67 33463 04 N M 20 Y Y 2,397.40 2,332.67 33464 04 N M 20 Y Y 2,397.40 2,332.67 33465 04 N M 20 Y Y 2,397.40 2,332.67 33468 04 N M 20 Y Y 2,397.40 2,332.67 33470 04 N M 20 Y Y 749.20 728.97 33471 04 N M 20 Y Y 1,198.70 1,166.34 33474 04 N M 20 Y Y 2,397.40 2,332.67 33475 04 N M 20 Y Y 2,397.40 2,332.67 33476 04 N M 20 Y Y 1,198.70 1,166.34 33477 04 01/01/16 N I 3 Y Y 810.31 788.43 33478 04 N M 20 Y Y 2,277.50 2,216.01 33496 04 N M 20 Y Y 2,397.40 2,332.67 33500 04 N M 20 Y Y 2,397.40 2,332.67 33501 04 N M 20 Y Y 1,198.70 1,166.34 33502 04 N M 20 Y Y 749.20 728.97 33503 04 N M 20 Y Y 2,397.40 2,332.67 33504 04 N M 20 Y Y 2,397.40 2,332.67 33505 04 Y M 20 Y Y33506 04 Y M 20 Y Y33507 04 N M 20 Y Y 1,014.99 987.59 33508 04 N M 5 Y Y 17.04 16.58 33510 04 N M 20 Y Y 2,397.40 2,332.67 33511 04 N M 20 Y Y 2,397.40 2,332.67 33512 04 N M 20 Y Y 2,397.40 2,332.67 33513 04 N M 20 Y Y 2,397.40 2,332.67
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
33514 04 N M 20 Y Y 2,397.40 2,332.67 33516 04 N M 20 Y Y 2,397.40 2,332.67 33517 04 N M 20 Y Y 2,397.40 2,332.67 33518 04 N M 20 Y Y 2,397.40 2,332.67 33519 04 N M 20 Y Y 2,397.40 2,332.67 33521 04 N M 20 Y Y 2,397.40 2,332.67 33522 04 N M 20 Y Y 2,397.40 2,332.67 33523 04 N M 20 Y Y 2,397.40 2,332.67 33530 04 N M 20 Y Y 2,397.40 2,332.67 33533 04 N M 20 Y Y 2,397.40 2,332.67 33534 04 N M 20 Y Y 2,397.40 2,332.67 33535 04 N M 20 Y Y 2,397.40 2,332.67 33536 04 N M 20 Y Y 2,397.40 2,332.67 33542 04 N M 20 Y Y 1,198.70 1,166.34 33545 04 N M 20 Y Y 2,397.40 2,332.67 33548 04 N M 20 Y 1,333.12 1,297.13 33572 04 N M 20 Y Y 2,397.40 2,332.67 33600 04 Y M 20 Y Y33602 04 Y M 20 Y Y33606 04 Y M 20 Y Y33608 04 Y M 20 Y Y33610 04 Y M 20 Y Y33611 04 Y M 20 Y Y33612 04 Y M 20 Y Y33615 04 N M 20 Y Y 2,397.40 2,332.67 33617 04 N M 20 Y Y 2,397.40 2,332.67 33619 04 N M 20 Y Y 2,397.40 2,332.67 33620 04 01/01/11 N M 20 Y Y 1,063.42 1,034.71 33621 04 01/01/11 N M 20 Y Y 569.26 553.89 33622 04 01/01/11 N M 20 Y Y 2,234.71 2,174.37 33641 04 N M 20 Y Y 2,397.40 2,332.67 33645 04 N M 20 Y Y 2,397.40 2,332.67 33647 04 N M 20 Y Y 2,397.40 2,332.67 33660 04 N M 20 Y Y 2,397.40 2,332.67 33665 04 N M 20 Y Y 2,397.40 2,332.67 33670 04 N M 20 Y Y 2,397.40 2,332.67 33675 04 01/01/07 N M 20 Y 2,397.40 2,332.67 33676 04 01/01/07 N M 20 Y 2,397.40 2,332.67 33677 04 01/01/07 N M 20 Y 2,397.40 2,332.67 33681 04 N M 20 Y Y 2,397.40 2,332.67 33684 04 N M 20 Y Y 2,397.40 2,332.67
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
33688 04 N M 20 Y Y 2,397.40 2,332.67 33690 04 N M 20 Y Y 958.60 932.72 33692 04 N M 20 Y Y 2,397.40 2,332.67 33694 04 N M 20 Y Y 2,397.40 2,332.67 33697 04 N M 20 Y Y 2,996.80 2,915.89 33702 04 N M 20 Y Y 2,397.40 2,332.67 33710 04 N M 20 Y Y 2,397.40 2,332.67 33720 04 N M 20 Y Y 2,397.40 2,332.67 33722 04 Y M 20 Y Y33724 04 01/01/07 N M 20 Y 2,397.40 2,332.67 33726 04 01/01/07 N M 20 2,721.45 2,647.97 33730 04 N M 20 Y Y 2,721.45 2,647.97 33732 04 N M 20 Y Y 2,397.40 2,332.67 33735 04 N M 20 Y Y 1,198.70 1,166.34 33736 04 N M 20 Y Y 2,397.40 2,332.67 33737 04 N M 20 Y Y 2,397.40 2,332.67 33750 04 N M 20 Y Y 1,079.30 1,050.16 33755 04 N M 20 Y Y 1,079.30 1,050.16 33762 04 N M 20 Y Y 1,079.30 1,050.16 33764 04 N M 20 Y Y 1,198.70 1,166.34 33766 04 N M 20 Y Y 1,079.30 1,050.16 33767 04 N M 20 Y Y 2,397.40 2,332.67 33768 04 N M 20 Y Y 255.00 248.12 33770 04 N M 20 Y Y 2,996.80 2,915.89 33771 04 N M 20 Y Y 2,996.80 2,915.89 33774 04 N M 20 Y Y 2,397.40 2,332.67 33775 04 N M 20 Y Y 2,397.40 2,332.67 33776 04 N M 20 Y Y 2,996.60 2,915.69 33777 04 N M 20 Y Y 2,996.60 2,915.69 33778 04 N M 20 Y Y 2,397.40 2,332.67 33779 04 N M 20 Y Y 2,397.40 2,332.67 33780 04 N M 20 Y Y 2,996.60 2,915.69 33781 04 N M 20 Y Y 2,996.60 2,915.69 33782 04 01/01/10 N M 20 Y Y 1,272.80 1,238.43 33783 04 01/01/10 N M 20 Y Y 1,927.20 1,875.17 33786 04 N M 20 Y Y 2,397.40 2,332.67 33788 04 N M 20 Y Y 2,057.80 2,002.24 33800 04 N M 20 Y Y 1,123.70 1,093.36 33802 04 N M 20 Y Y 1,123.70 1,093.36 33803 04 N M 20 Y Y 1,501.75 1,461.20 33813 04 N M 15 Y Y 1,797.95 1,749.41
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
33814 04 N M 20 Y Y 2,397.40 2,332.67 33820 04 N M 15 Y Y 839.35 816.69 33822 04 N M 15 Y Y 839.35 816.69 33824 04 N M 15 Y Y 1,079.30 1,050.16 33840 04 N M 20 Y Y 1,198.70 1,166.34 33845 04 N M 20 Y Y 1,198.70 1,166.34 33851 04 N M 20 Y Y 1,198.70 1,166.34 33852 04 N M 20 Y Y 2,397.40 2,332.67 33853 04 N M 20 Y Y 2,397.40 2,332.67 33860 04 N M 20 Y Y 2,397.40 2,332.67 33863 04 N M 20 Y Y 2,397.40 2,332.67 33864 04 01/01/08 N M 20 Y 1794.48 1,746.03 33870 04 N M 20 Y Y 2,397.40 2,332.67 33875 04 Y M 15 Y Y33877 04 Y M 20 Y Y33880 04 N M 20 Y Y 1,042.97 1,014.81 33881 04 N M 20 Y Y 894.71 870.55 33883 04 N M 20 Y Y 662.83 644.93 33884 04 N M 20 Y Y 249.09 242.36 33886 04 N M 20 Y Y 571.51 556.08 33889 04 N M 20 Y Y 499.99 486.49 33891 04 N M 20 Y Y 636.67 619.48 33910 04 N M 20 Y Y 2,397.40 2,332.67 33915 04 Y M 20 Y Y33916 04 N M 20 Y Y 2,397.40 2,332.67 33917 04 N M 20 Y Y 2,397.40 2,332.67 33920 04 N M 20 Y Y 2,397.40 2,332.67 33922 04 N M 20 Y Y 2,397.40 2,332.67 33924 04 N M 20 Y Y 324.05 315.30 33925 04 N M 20 Y Y 1,037.68 1,009.66 33926 04 N M 20 Y Y 1,407.80 1,369.79 33930 04 N M Y 1,306.65 1,271.37 33935 04 N M 20 Y Y 4,104.60 3,993.78 33940 04 N M Y 1,198.70 1,166.34 33945 04 N M 20 Y Y 2,894.30 2,816.15 33946 04 01/01/15 N I 3 195.36 190.09 33947 04 01/01/15 N I 5 215.81 209.98 33948 04 01/01/15 N I 153.89 149.73 33949 04 01/01/15 N I 149.78 145.74 33951 04 01/01/15 N I 5 Y 281.93 274.32 33952 04 01/01/15 N I 5 Y 274.40 266.99
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
33953 04 01/01/15 N I 5 Y 314.41 305.92 33954 04 01/01/15 N I 5 Y 306.64 298.36 33955 04 01/01/15 N I 5 Y Y 565.90 550.62 33956 04 01/01/15 N I 5 Y Y 538.60 524.06 33957 04 01/01/15 N I 5 Y 125.50 122.11 33958 04 01/01/15 N I 5 Y 121.79 118.50 33959 04 01/01/15 N I 5 Y 159.49 155.18 33962 04 01/01/15 N I 5 Y 150.71 146.64 33963 04 01/01/15 N I 11 Y Y 318.78 310.17 33964 04 01/01/15 N I 11 Y Y 327.61 318.76 33965 04 01/01/15 N I 5 Y 125.50 122.11 33966 04 01/01/15 N I 5 Y 151.82 147.72 33967 04 N I 3 230.20 223.98 33968 04 N I 3 162.00 157.63 33969 04 01/01/15 N I 5 Y 184.73 179.74 33970 04 N M 5 689.50 670.88 33971 04 N M 5 Y Y 334.80 325.76 33973 04 N M 5 Y Y 689.50 670.88 33974 04 N M 5 Y Y 419.25 407.93 33975 04 N M 5 Y Y 1,350.15 1,313.70 33976 04 N M 5 Y Y 1,674.20 1,629.00 33977 04 N M 5 Y Y 1,215.15 1,182.34 33978 04 N M 5 Y Y 1,458.20 1,418.83 33979 04 N M 5 Y Y 730.85 711.12 33980 04 N M 5 Y Y 787.90 766.63 33981 04 01/01/10 Y M 20 Y33982 04 01/01/10 Y M 20 Y33983 04 01/01/10 Y M 20 Y33984 04 01/01/15 N I 5 Y 182.52 177.59 33985 04 01/01/15 N I 5 Y Y 348.34 338.93 33986 04 01/01/15 N I 5 Y Y 333.17 324.17 33987 04 01/01/15 N I 5 Y Y 133.70 130.09 33988 04 01/01/15 N I 5 Y Y 496.72 483.31 33989 04 01/01/15 N I 5 Y Y 315.68 307.16 33990 04 01/01/13 N I 5 Y 270.94 263.62 33991 04 N I 5 Y 394.76 384.10 33992 04 N I 5 Y 129.31 125.82 33993 04 N I 5 Y 113.52 110.45 33999 04 Y M Y Y34001 04 N M 5 Y 718.70 699.30 34051 04 N M 5 Y 718.70 699.30
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
34101 04 N M 5 Y 718.70 699.30 34111 04 N M 5 Y 718.70 699.30 34151 04 N M 5 Y 718.70 699.30 34201 04 N M 5 Y 718.70 699.30 34203 04 N M 5 Y 718.70 699.30 34401 04 N M 5 Y 718.70 699.30 34421 04 N M 5 Y 718.70 699.30 34451 04 N M 5 Y 898.95 874.68 34471 04 N M 5 Y 599.35 583.17 34490 04 N M 5 Y 599.35 583.17 34501 04 N M 10 Y Y 480.00 467.04 34502 04 Y M 10 Y Y34510 04 N M 10 Y Y 480.00 467.04 34520 04 N M 10 Y Y 480.00 467.04 34530 04 N M 10 Y Y 599.35 583.17 34800 04 N M 11 Y 819.60 797.47 34802 04 N M 15 Y 904.75 880.32 34803 04 N M 8 Y Y 1,148.60 1,117.59 34804 04 N M 15 Y 904.75 880.32 34805 04 N M 11 Y Y 669.46 651.38 34806 04 10/01/09 N M 11 Y 64.68 62.93 34808 04 N M 5 Y Y 156.10 151.89 34812 04 N M 5 Y Y 255.70 248.80 34813 04 N M 5 Y Y 181.55 176.65 34820 04 N M 10 Y Y 369.05 359.09 34825 04 N M 10 Y Y 488.60 475.41 34826 04 01/01/10 N M 10 Y Y 156.10 151.89 34830 04 N M 10 Y Y 1,276.30 1,241.84 34831 04 N M 10 Y Y 1,379.95 1,342.69 34832 04 N M 10 Y Y 1,379.95 1,342.69 34833 04 N M 4 Y Y 488.60 475.41 34834 04 N M 4 Y Y 369.05 359.09 34841 04 01/01/14 N M 11 Y Y 975.70 949.36 34842 04 01/01/14 N M 11 Y Y 1,131.80 1,101.24 34843 04 01/01/14 N M 11 Y Y 1,287.90 1,253.13 34844 04 01/01/14 N M 11 Y Y 1,444.00 1,405.01 34845 04 01/01/14 N M 15 Y Y 1,060.85 1,032.21 34846 04 01/01/14 N M 15 Y Y 1,216.95 1,184.09 34847 04 01/01/14 N M 15 Y Y 1,373.05 1,335.98 34848 04 01/01/14 N M 15 Y Y 1,529.15 1,487.86 34900 04 N M 5 Y Y 488.60 475.41
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
35001 04 N M 15 Y 1,123.70 1,093.36 35002 04 N M 15 Y 1,306.65 1,271.37 35005 04 N M 15 Y 1,414.70 1,376.50 35011 04 N M 15 Y 898.95 874.68 35013 04 N M 15 Y 1,198.70 1,166.34 35021 04 N M 15 Y 1,198.70 1,166.34 35022 04 N M 15 Y 1,414.70 1,376.50 35045 04 N M 15 Y 599.35 583.17 35081 04 N M 15 Y 1,198.70 1,166.34 35082 04 N M 15 Y 1,630.70 1,586.67 35091 04 N M 15 Y 1,198.70 1,166.34 35092 04 N M 15 Y 1,630.70 1,586.67 35102 04 N M 15 Y 1,198.70 1,166.34 35103 04 N M 15 Y Y 1,630.70 1,586.67 35111 04 N M 15 Y 1,198.70 1,166.34 35112 04 N M 15 Y 1,630.70 1,586.67 35121 04 N M 15 Y 1198.70 1,166.34 35122 04 N M 15 Y 1630.70 1,586.67 35131 04 N M 10 Y 958.60 932.72 35132 04 N M 10 Y 1,198.70 1,166.34 35141 04 N M 10 Y 958.60 932.72 35142 04 N M 10 Y 1,198.70 1,166.34 35151 04 N M 10 Y 958.60 932.72 35152 04 N M 10 Y 1,198.70 1,166.34 35180 04 N M 10 Y 1,198.70 1,166.34 35182 04 N M 10 Y 952.10 926.39 35184 04 N M 10 Y 599.35 583.17 35188 04 N M 10 Y 1,198.70 1,166.34 35189 04 N M 10 Y 952.10 926.39 35190 04 N M 10 Y 599.35 583.17 35201 04 N M 10 Y 1,198.70 1,166.34 35206 04 N M 10 Y 599.35 583.17 35207 04 N M 10 Y 341.20 331.99 35211 04 N M 15 Y 1,498.30 1,457.85 35216 04 N M 15 Y 1,198.70 1,166.34 35221 04 N M 15 Y 1,198.70 1,166.34 35226 04 N M 10 Y 599.35 583.17 35231 04 N M 10 Y 599.35 583.17 35236 04 N M 10 Y 599.35 583.17 35241 04 N M 15 Y 1498.30 1,457.85 35246 04 N M 15 Y 1,198.70 1,166.34
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
35251 04 N M 15 Y 1198.70 1,166.34 35256 04 N M 10 Y 599.35 583.17 35261 04 N M 10 Y 599.35 583.17 35266 04 N M 10 Y 599.35 583.17 35271 04 N M 15 Y 1498.30 1,457.85 35276 04 N M 15 Y 1198.70 1,166.34 35281 04 N M 15 Y 1198.70 1,166.34 35286 04 N M 10 Y 599.35 583.17 35301 04 N M 15 Y 1101.60 1,071.86 35302 04 01/01/07 N M 10 Y 958.60 932.72 35303 04 01/01/07 N M 10 Y 958.60 932.72 35304 04 01/01/07 N M 10 Y 958.60 932.72 35305 04 01/01/07 N M 10 Y 958.60 932.72 35306 04 01/01/07 N M 10 Y 958.60 932.72 35311 04 N M 15 Y 749.20 728.97 35321 04 N M 15 Y 749.20 728.97 35331 04 N M 15 Y 1198.70 1,166.34 35341 04 N M 15 Y 958.60 932.72 35351 04 N M 10 Y 958.60 932.72 35355 04 N M 10 Y 958.60 932.72 35361 04 N M 15 Y 1,198.70 1,166.34 35363 04 N M 10 Y 1,198.70 1,166.34 35371 04 N M 10 Y 958.60 932.72 35372 04 N M 10 Y Y 1,021.15 993.58 35390 04 Y M 15 Y Y35400 04 N I Y Y 91.63 89.16 35500 04 N M 3 Y 209.75 204.09 35501 04 N M 10 Y 839.35 816.69 35506 04 N M 10 Y 958.60 932.72 35508 04 N M 10 Y 958.60 932.72 35509 04 N M 10 Y 958.60 932.72 35510 04 N M 10 Y Y 708.05 688.93 35511 04 N M 10 Y 958.60 932.72 35512 04 N M 10 Y Y 694.72 675.96 35515 04 N M 10 Y 958.60 932.72 35516 04 N M 10 Y 958.60 932.72 35518 04 N M 10 Y 958.60 932.72 35521 04 N M 10 Y 1,198.70 1,166.34 35522 04 N M 10 Y Y 674.99 656.77 35523 04 01/01/08 N M 10 Y Y 726.14 706.53 35525 04 N M 10 Y Y 644.91 627.50
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
35526 04 N M 10 Y 958.60 932.72 35531 04 N M 8 Y 958.60 932.72 35533 04 N M 10 Y 1,198.70 1,166.34 35535 04 01/01/09 N M 8 Y 1109.75 1,079.79 35536 04 N M 8 Y 958.60 932.72 35537 04 01/01/07 N M 10 Y 1,198.70 1,166.34 35538 04 01/01/07 N M 10 Y 1,198.70 1,166.34 35539 04 01/01/07 N M 10 Y 839.35 816.69 35540 04 01/01/07 N M 10 Y 839.35 816.69 35556 04 N M 10 Y Y 958.60 932.72 35558 04 N M 10 Y Y 1,079.30 1,050.16 35560 04 N M 10 Y 1,198.70 1,166.34 35563 04 N M 10 Y Y 1,198.70 1,166.34 35565 04 N M 10 Y Y 1,198.70 1,166.34 35566 04 N M 10 Y Y 958.60 932.72 35570 04 01/01/09 N M 10 Y Y 958.60 932.72 35571 04 N M 10 Y Y 958.60 932.72 35572 04 N M 5 Y Y 209.75 204.09 35583 04 N M 10 Y Y 958.60 932.72 35585 04 N M 10 Y Y 958.60 932.72 35587 04 N M 10 Y Y 958.60 932.72 35600 04 N M 3 Y Y 192.75 187.55 35601 04 N M 10 Y Y 839.35 816.69 35606 04 N M 10 Y Y 958.60 932.72 35612 04 N M 10 Y Y 958.60 932.72 35616 04 N M 10 Y 958.60 932.72 35621 04 N M 10 Y Y 1,198.70 1,166.34 35623 04 N M 10 Y Y 1,306.65 1,271.37 35626 04 N M 10 Y 958.60 932.72 35631 04 N M 8 Y Y 1,198.70 1,166.34 35632 04 01/01/09 N M 8 Y Y 1198.70 1,166.34 35633 04 01/01/09 N M 8 Y Y 1198.70 1,166.34 35634 04 01/01/09 N M 8 Y Y 1198.70 1,166.34 35636 04 N M 8 Y Y 1,079.30 1,050.16 35637 04 01/01/07 N M 10 Y 1,198.70 1,166.34 35638 04 01/01/07 N M 10 Y 1,198.70 1,166.34 35642 04 N M 10 Y 958.60 932.72 35645 04 N M 10 Y 958.60 932.72 35646 04 N M 10 Y Y 1,198.70 1,166.34 35647 04 N M 10 Y Y 1,053.80 1,025.35 35650 04 N M 10 Y 1,079.30 1,050.16
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
35654 04 N M 10 Y 1,198.70 1,166.34 35656 04 N M 10 Y Y 958.60 932.72 35661 04 N M 10 Y Y 1,079.30 1,050.16 35663 04 N M 10 Y Y 1,198.70 1,166.34 35665 04 N M 10 Y Y 1,198.70 1,166.34 35666 04 N M 10 Y Y 958.60 932.72 35671 04 N M 10 Y Y 958.60 932.72 35681 04 Y M 10 Y35682 04 N M 10 Y 314.60 306.11 35683 04 N M 10 Y 314.60 306.11 35685 04 N I 3 Y 146.50 142.54 35686 04 N I 3 129.25 125.76 35691 04 N M 10 Y Y 1,198.70 1,166.34 35693 04 N M 10 Y Y 1,198.70 1,166.34 35694 04 N M 10 Y Y 1,198.70 1,166.34 35695 04 N M 10 Y Y 1,198.70 1,166.34 35697 04 N M 10 Y Y 90.02 87.59 35700 04 Y M 10 Y Y35701 04 N M 5 Y Y 374.55 364.44 35721 04 N M 5 Y Y 299.70 291.61 35741 04 N M 5 Y Y 299.70 291.61 35761 04 Y M 535800 04 N M 5 Y Y 374.55 364.44 35820 04 N M 11 Y Y 524.40 510.24 35840 04 N M 4 Y 480.00 467.04 35860 04 N M 3 Y 449.50 437.36 35870 04 N M 5 Y Y 723.39 703.86 35875 04 N M 5 Y 449.50 437.36 35876 04 N M 10 Y Y 455.15 442.86 35879 04 N M 10 Y 599.35 583.17 35881 04 N M 10 Y 789.80 768.48 35883 04 01/01/07 N M 10 Y 599.35 583.17 35884 04 01/01/07 N M 10 Y 599.35 583.17 35901 04 N M 5 Y Y 599.35 583.17 35903 04 N M 5 Y Y 449.50 437.36 35905 04 N M 5 Y Y 811.50 789.59 35907 04 N M 5 Y Y 599.35 583.17 36000 09 Y I36002 04 N I 3 100.12 97.42 36005 04 N I 136.65 132.96 36010 04 N I 3 224.70 218.63
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
36011 04 N I 3 249.35 242.62 36012 04 N I 3 264.80 257.65 36013 04 N I 3 213.50 207.74 36014 04 N I 3 213.50 207.74 36015 04 N I 3 249.35 242.62 36100 04 N I 3 213.65 207.88 36120 04 N I 3 233.00 226.71 36140 04 N I 3 188.70 183.61 36160 04 N I 3 202.50 197.03 36200 04 N I 3 224.70 218.63 36215 04 N I 3 198.90 193.53 36216 04 N I 3 264.80 257.65 36217 04 N I 3 281.00 273.41 36218 04 N I 3 281.00 273.41 36221 04 01/01/13 N I 3 133.55 517.34 129.94 36222 04 01/01/13 N I 3 179.14 627.20 174.30 36223 04 01/01/13 N I 3 193.70 688.25 188.47 36224 04 01/01/13 N I 3 210.38 747.07 204.70 36225 04 01/01/13 N I 3 192.87 682.68 187.66 36226 04 01/01/13 N I 3 210.75 764.89 205.06 36227 04 01/01/13 N I 3 66.51 77.56 64.71 36228 04 01/01/13 N I 3 135.46 533.12 131.80 36245 04 N I 3 213.50 207.74 36246 04 N I 3 264.80 257.65 36247 04 N I 3 281.00 273.41 36248 04 N I 3 281.00 273.41 36251 04 01/01/12 N I 172.75 168.09 36252 04 01/01/12 N I 225.01 218.93 36253 04 01/01/12 N I 240.74 234.24 36254 04 01/01/12 N I 259.71 252.70 36260 04 N M 3 337.14 328.04 36261 04 N M 3 Y 193.74 188.51 36262 04 N M 3 144.98 141.07 36299 04 Y I 3 Y36400 04 N I 16.65 16.20 36405 04 N I 16.65 16.20 36406 04 N I 16.65 16.20 36410 04 02/01/11 Y I36415 J 04 N I 4.10 3.99 36416 J 04 05/01/07 N I 4.10 3.99 36420 04 N I 3 37.40 36.39 36425 04 N I 3 37.40 36.39
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
36430 04 N I 16.65 16.20 36440 04 N I 28.80 28.02 36450 04 N I 3 308.00 299.68 36455 04 N I 3 338.50 329.36 36456 04 01/01/17 N I 3 Y 66.29 64.50 36460 04 N I 3 176.90 172.12 36470 04 Y I 3 17.0036471 04 Y I 3 17.0036473 04 01/01/17 N I 3 108.91 105.97 36474 04 01/01/17 N I 3 54.50 2 109.10 53.03 106.15 36475 04 04/01/11 N M 3 213.52 269.34 207.75 36476 04 N M 3 104.57 101.75 36478 04 04/01/11 N M 3 213.52 269.34 207.75 36479 04 N M 3 104.57 101.75 36481 04 N I 3 264.80 257.65 36500 04 N I 3 71.05 69.13 36510 04 N I 25.20 24.52 36511 04 Y I 336512 04 Y I 336513 04 Y I 336514 04 Y I 336515 04 Y I 336516 04 Y I 336522 04 N M 5 Y Y 599.30 583.12 36555 04 N I 3 74.38 72.37 36556 04 N I 3 67.13 65.32 36557 04 03/14/16 N I 3 Y 166.18 161.69 36558 04 03/14/16 N I 3 Y 158.02 153.75 36560 04 03/14/16 N I 3 Y 196.66 191.35 36561 04 03/31/15 N I 3 Y 190.09 184.96 36563 04 03/14/16 N I 3 Y 197.81 192.47 36565 04 03/14/16 N I 3 Y 190.09 184.96 36566 04 03/14/16 N I 3 Y 203.24 197.75 36568 04 N I 3 55.01 53.52 36569 04 N I 3 51.61 50.22 36570 04 N I 3 171.97 167.33 36571 04 N I 3 171.37 166.74 36575 04 08/03/15 N I 3 Y 33.10 32.21 36576 04 N I 3 112.21 109.18 36578 04 N I 3 126.75 123.33 36580 04 N I 3 38.25 37.22
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
36581 04 N I 3 118.78 115.57 36582 04 N I 3 171.77 167.13 36583 04 N I 3 173.17 168.49 36584 04 N I 3 38.64 37.60 36585 04 N I 3 161.21 156.86 36589 04 N I 3 78.73 76.60 36590 04 N I 3 107.54 104.64 36593 04 01/01/08 N I 3 112.40 109.37 36595 04 N I 3 107.23 104.33 36596 04 N I 3 25.85 25.15 36597 04 N I 3 34.37 33.44 36598 04 N I 3 67.51 65.69 36600 09 Y I36620 04 N I 37.40 36.39 36625 04 N I 3 52.70 51.28 36640 04 N I 3 74.90 72.88 36660 04 N I 37.40 36.39 36680 04 N I 3 90.10 87.67 36800 04 N M 3 424.45 412.99 36810 04 N M 5 424.45 412.99 36815 04 N I 3 112.40 109.37 36818 04 N M 5 Y 850.30 827.34 36819 04 N M 5 Y 850.30 827.34 36820 04 N M 5 541.15 526.54 36821 04 N M 5 578.55 562.93 36823 04 N M 5 Y 578.55 562.93 36825 04 N M 5 578.55 562.93 36830 04 N M 5 578.55 562.93 36831 04 N M 5 578.55 562.93 36832 04 N M 5 578.55 562.93 36833 04 N M 5 Y 578.55 562.93 36835 04 N M 5 578.55 562.93 36838 04 N M 5 666.71 648.71 36860 04 N I 3 112.40 109.37 36861 04 N I 3 419.00 407.69 36901 04 01/01/17 N I 3 91.29 88.83 36902 04 01/01/17 N I 3 136.03 132.36 36903 04 01/01/17 N I 3 186.25 181.22 36904 04 01/01/17 N I 3 214.49 208.70 36905 04 01/01/17 N I 3 269.27 262.00 36906 04 01/01/17 N I 3 314.28 305.79
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
36907 04 01/01/17 N I 3 78.44 76.32 36908 04 01/01/17 N I 3 117.62 114.44 36909 04 01/01/17 N I 3 111.56 108.55 37140 04 N M 8 Y Y 1198.70 1,166.34 37145 04 N M 8 Y Y 1079.30 1,050.16 37160 04 N M 8 Y Y 1079.30 1,050.16 37180 04 N M 8 Y Y 1079.30 1,050.16 37181 04 N M 8 Y 1079.30 1,050.16 37182 04 N M 5 Y 910.70 886.11 37183 04 01/01/10 N M 5 Y 429.07 417.49 37184 04 N M 3 265.81 258.63 37185 04 N I 97.64 95.00 37186 04 N M 3 146.50 142.54 37187 04 N M 3 247.12 240.45 37188 04 N I 3 178.38 173.56 37191 04 01/01/12 N I 146.20 142.25 37192 04 01/01/12 N I 226.54 220.42 37193 04 01/01/12 N I 226.36 220.25 37195 04 N M 3 472.40 459.65 37197 04 01/01/13 N I 3 184.03 696.78 179.06 37200 04 N I 3 189.00 183.90 37211 04 01/01/13 N I 3 248.72 242.00 37212 04 01/01/13 N I 3 219.61 213.68 37213 04 01/01/13 N I 3 153.63 149.48 37214 04 01/01/13 N I 3 89.62 87.20 37215 04 N M 5 Y 910.70 886.11 37216 04 N M 3 Y 910.70 886.11 37217 04 01/01/14 N M 5 Y 709.27 690.12 37218 04 01/01/15 N M 5 Y 521.49 507.41 37220 04 01/01/11 N I 3 267.45 260.23 37221 04 01/01/11 N I 3 324.50 315.74 37222 04 01/01/11 N I 3 121.48 118.20 37223 04 01/01/11 N I 3 137.81 134.09 37224 04 01/01/11 N I 3 294.36 286.41 37225 04 01/01/11 N I 3 396.98 386.26 37226 04 01/01/11 N I 3 294.36 286.41 37227 04 01/01/11 N I 3 479.55 466.60 37228 04 01/01/11 N I 3 360.05 350.33 37229 04 01/01/11 N I 3 465.10 452.54 37230 04 01/01/11 N I 3 447.14 435.07 37231 04 01/01/11 N I 3 486.01 472.89 37232 04 01/01/11 N I 3 130.27 126.75
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
37233 04 01/01/11 N I 3 214.13 208.35 37234 04 01/01/11 N I 3 178.22 173.41 37235 04 01/01/11 N I 3 252.98 246.15 37236 04 01/01/14 N I 3 Y 294.02 286.08 37237 04 05/01/16 N I 3 Y 137.84 2 275.68 268.24 37238 04 01/01/14 N I 3 Y 205.92 200.36 37239 04 09/01/14 N I 3 Y 96.23 2 192.46 187.26 37241 04 01/01/14 N I 3 279.33 271.79 37242 04 01/01/14 N I 3 311.96 303.54 37243 04 01/01/14 N I 3 371.98 361.94 37244 04 01/01/14 N I 3 433.90 422.18 37246 04 01/01/17 N I 3 223.67 217.63 37247 04 01/01/17 N i 3 110.95 2 221.90 107.95 215.91 37248 04 01/01/17 N I 3 192.32 187.13 37249 04 01/01/17 N I 3 94.40 2 188.80 91.85 183.70 37251 04 N I 57.65 56.09 37252 04 01/01/16 N I Y Y 59.20 57.60 37253 A 04 01/01/16 N I Y Y 47.44 46.16 37500 04 N I 4 299.70 291.61 37501 04 Y I 337565 04 N M 5 Y 374.55 364.44 37600 04 N M 5 Y 374.55 364.44 37605 04 N M 5 Y 449.50 437.36 37606 04 N M 5 Y 449.50 437.36 37607 04 N M 3 Y Y 262.20 255.12 37609 04 N I 3 112.40 109.37 37615 04 N M 5 Y 374.55 364.44 37616 04 N M 11 Y 524.40 510.24 37617 04 N M 5 Y 524.40 510.24 37618 04 N M 5 Y 262.20 255.12 37619 04 01/01/12 N M 5 Y 1,021.58 994.00 37650 04 N M 3 Y 374.55 364.44 37660 04 N M 3 Y 449.50 437.36 37700 04 N M 3 Y 203.95 198.44 37718 04 N I 3 Y 227.39 221.25 37722 04 N I 3 Y 275.02 267.59 37735 04 N M 3 Y 419.00 407.69 37760 04 01/01/10 N M 3 Y 299.70 291.61 37761 04 01/01/10 N M 3 Y Y 331.99 323.03 37765 04 04/01/11 N M 3 245.90 253.05 239.26 37766 04 04/01/11 N M 3 298.81 226.60 290.74
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
37780 04 N M 3 149.80 145.76 37785 04 N I 3 131.25 127.71 37788 04 Y M 337790 04 Y M 3 Y37799 04 Y M 5 Y38100 04 N M 5 Y Y 770.00 749.21 38101 04 N M 5 Y 770.00 749.21 38102 04 Y M 5 Y Y38115 04 N M 5 Y 770.00 749.21 38120 04 N M 5 Y 770.00 749.21 38129 04 Y M 5 Y38200 04 N I 3 66.50 64.70 38204 09 Y I38205 04 Y I38206 04 Y I38207 09 Y I38208 09 Y I38209 09 Y I38210 09 Y I38211 09 Y I38212 09 Y I38213 09 Y I38214 09 Y I38215 09 Y I38220 04 N I 3 50.15 48.80 38221 04 N I 3 Y 78.45 76.33 38230 04 N M 3 Y 660.65 642.81 38232 04 01/01/12 N M 3 Y 113.02 109.97 38240 04 N I 3 Y 220.20 214.25 38241 04 N I 3 Y 220.20 214.25 38242 04 N I 3 Y 80.55 78.38 38243 04 01/01/13 N I 3 Y 68.47 66.62 38300 04 N I 3 71.40 17.00 69.47 38305 04 N I 3 156.95 17.00 152.71 38308 04 N M 3 246.47 239.82 38380 04 N M 4 Y 556.25 541.23 38381 04 N M 11 Y 811.60 789.69 38382 04 N M 11 Y 612.15 595.62 38500 04 N I 3 85.70 17.00 83.39 38505 04 N I 3 106.80 17.00 103.92 38510 04 N I 3 127.70 124.25
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
38520 04 N I 3 157.90 153.64 38525 04 N I 3 135.60 131.94 38530 04 N I 3 189.25 184.14 38542 04 N I 3 Y Y 185.45 180.44 38550 04 N M 3 224.70 218.63 38555 04 N M 3 Y 656.60 638.87 38562 04 N M 3 Y 480.00 467.04 38564 04 N M 4 Y 599.35 583.17 38570 04 N M 4 Y 302.40 294.24 38571 04 N M 4 Y 599.35 583.17 38572 04 N M 4 Y 599.35 583.17 38589 04 Y M 4 Y38700 04 N M 4 Y 786.60 765.36 38720 04 N M 4 Y 861.50 838.24 38724 04 N M 4 Y Y 645.45 628.02 38740 04 N M 4 Y 524.40 510.24 38745 04 N M 4 Y 524.40 510.24 38746 04 N M 11 Y Y 216.02 210.19 38747 04 N M 4 Y Y 158.57 154.29 38760 04 N M 3 299.70 291.61 38765 04 N M 3 Y 918.40 893.60 38770 04 N M 3 Y 918.40 893.60 38780 04 N M 4 Y 998.80 971.83 38790 04 N I 3 220.85 214.89 38792 04 N I 3 105.40 102.55 38794 04 Y M 338900 04 01/01/11 N I 3 Y 84.10 81.83 38999 04 Y M Y39000 04 N M 11 Y Y 718.70 699.30 39010 04 N M 11 Y Y 718.70 699.30 39200 04 N M 11 Y Y 749.20 728.97 39220 04 N M 11 Y 749.20 728.97 39401 04 01/01/16 N I 4 196.90 191.58 39402 04 01/01/16 N I 4 257.70 250.74 39499 04 Y M Y39501 04 N M 6 Y Y 648.60 631.09 39503 04 N M 6 Y Y 960.55 934.62 39540 04 N M 6 Y Y 682.60 664.17 39541 04 N M 6 Y Y 682.60 664.17 39545 04 N M 6 Y Y 682.60 664.17 39560 04 N M 6 Y Y 708.60 689.47
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
39561 04 N M 6 Y 803.05 781.37 39599 04 Y M Y40490 04 N I 4 46.25 17.00 45.00 40500 04 N M 4 165.10 160.64 40510 04 N I 4 170.45 165.85 40520 04 N M 4 Y Y 524.40 510.24 40525 04 N M 4 Y Y 629.90 612.89 40527 04 N M 5 Y Y 718.70 699.30 40530 04 N M 5 Y Y 524.35 510.19 40650 04 N M 5 Y Y 629.90 612.89 40652 04 N M 5 Y Y 629.90 612.89 40654 04 N M 5 Y Y 629.90 612.89 40700 04 N M 5 Y Y 718.70 699.30 40701 04 N M 5 Y Y 958.60 932.72 40702 04 N M 5 Y 958.60 932.72 40720 04 N M 5 Y Y 718.70 699.30 40761 04 N M 5 Y Y 802.00 780.35 40799 04 Y M Y40800 04 N I 4 39.90 17.00 38.82 40801 04 N I 5 76.15 74.09 40804 04 N I 4 44.10 17.00 42.91 40805 04 N I 5 89.10 86.69 40806 04 08/01/16 N I 4 Y 35.65 17.00 34.69 40808 04 N I 4 50.20 17.00 48.84 40810 04 N I 4 50.95 17.00 49.57 40812 04 N I 4 73.70 17.00 71.71 40814 04 N I 5 117.65 114.47 40816 04 N I 5 142.70 34.00 138.85 40818 04 N I 4 113.40 110.34 40819 04 N M 4 149.80 145.76 40820 04 N I 4 142.70 17.00 138.85 40830 04 N I 4 107.00 17.00 104.11 40831 04 N I 5 132.75 17.00 129.17 40840 04 N M 5 Y Y 252.00 245.20 40842 04 N M 5 Y Y 251.05 244.27 40843 04 N M 5 Y Y 347.20 337.83 40844 04 N M 5 Y Y 496.90 483.48 40845 04 N M 5 Y Y 629.10 612.11 40899 04 Y M Y41000 04 N I 4 44.65 17.00 43.44 41005 04 N I 4 41.70 17.00 40.57
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
41006 04 N I 4 93.60 91.07 41007 04 N I 4 102.95 17.00 100.17 41008 04 N I 4 92.70 17.00 90.20 41009 04 N I 4 116.50 113.35 41010 04 N I 4 42.45 17.00 41.30 41015 04 N I 4 106.45 17.00 103.58 41016 04 N I 4 130.40 17.00 126.88 41017 04 N I 4 113.10 17.00 110.05 41018 04 N I 4 154.95 150.77 41019 04 01/01/08 N I 4 Y 259.65 252.64 41100 04 N I 4 88.50 17.00 86.11 41105 04 N I 4 181.00 17.00 176.11 41108 04 N I 4 88.50 17.00 86.11 41110 04 N M 4 214.00 17.00 208.22 41112 04 N M 4 299.70 291.61 41113 04 N M 4 299.70 291.61 41114 04 N M 4 249.70 242.96 41115 04 N M 4 224.70 218.63 41116 04 N M 4 224.70 218.63 41120 04 N M 6 Y Y 524.40 510.24 41130 04 N M 6 Y Y 524.40 510.24 41135 04 N M 6 Y Y 861.50 838.24 41140 04 N M 6 Y Y 735.65 715.79 41145 04 N M 6 Y Y 1048.85 1,020.53 41150 04 N M 6 Y Y 1498.30 1,457.85 41153 04 N M 6 Y Y 1498.30 1,457.85 41155 04 N M 6 Y Y 1798.05 1,749.50 41250 04 N I 5 71.40 34.00 69.47 41251 04 N I 5 74.10 34.00 72.10 41252 04 N I 5 95.25 34.00 92.68 41500 04 N I 4 121.70 118.41 41510 04 N M 4 374.55 364.44 41512 04 01/01/09 N I 5 71.40 69.47 41520 04 N I 4 92.70 90.20 41530 04 01/01/09 N I 222.81 216.79 41599 04 Y M Y41800 04 N I 3 39.70 17.00 38.63 41805 04 N I 4 42.30 17.00 41.16 41806 04 N I 4 90.10 87.67 41820 04 N I 4 99.05 96.38 41821 04 N I 4 71.60 69.67
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
41822 04 N I 4 90.10 87.67 41823 04 N M 4 169.40 164.83 41825 04 N I 4 76.95 74.87 41826 04 N M 4 224.70 218.63 41827 04 N M 4 299.70 291.61 41828 04 N I 4 110.35 107.37 41830 04 N M 4 224.70 218.63 41850 04 N I 4 41.25 40.14 41870 04 N M 4 Y Y 169.40 164.83 41872 04 N M 4 169.40 164.83 41874 04 N M 4 169.40 164.83 41899 04 Y M 4 Y42000 04 N I 5 43.05 17.00 41.89 42100 04 N I 5 50.20 34.00 48.84 42104 04 N I 5 79.30 34.00 77.16 42106 04 N M 5 Y Y 480.00 467.04 42107 04 N M 5 Y Y 506.40 492.73 42120 04 N M 5 Y Y 647.90 630.41 42140 04 N M 5 184.50 179.52 42145 04 N M 5 Y 359.30 349.60 42160 04 N I 5 64.10 17.00 62.37 42180 04 N M 5 Y Y 149.80 145.76 42182 04 N M 5 Y Y 215.90 210.07 42200 04 N M 5 Y Y 718.70 699.30 42205 04 N M 5 Y Y 718.70 699.30 42210 04 N M 5 Y Y 850.80 827.83 42215 04 N M 5 Y Y 491.50 478.23 42220 04 N M 5 Y Y 718.70 699.30 42225 04 N M 5 Y Y 986.35 959.72 42226 04 N M 5 Y Y 784.75 763.56 42227 04 N M 5 Y Y 784.75 763.56 42235 04 N M 5 Y Y 374.55 364.44 42260 04 N M 5 Y Y 718.70 699.30 42280 04 N I 5 Y Y 53.85 52.40 42281 04 N I 5 Y 58.45 56.87 42299 04 Y M Y42300 04 N I 4 79.30 17.00 77.16 42305 04 N I 4 164.90 160.45 42310 04 N I 4 79.30 17.00 77.16 42320 04 N I 4 113.60 17.00 110.53 42330 04 N I 4 113.60 34.00 110.53
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
42335 04 N M 4 240.00 233.52 42340 04 N M 4 240.00 233.52 42381 04 01/01/1042400 04 N I 4 113.60 17.00 110.53 42405 04 N I 4 113.60 34.00 110.53 42408 04 N I 4 137.80 34.00 134.08 42409 04 N I 4 113.60 34.00 110.53 42410 04 N M 4 Y Y 749.20 728.97 42415 04 N M 4 Y Y 754.65 734.27 42420 04 N M 4 Y Y 867.10 843.69 42425 04 N M 4 Y Y 892.00 867.92 42426 04 N M 6 Y Y 1079.30 1,050.16 42440 04 N M 4 Y 480.00 467.04 42450 04 N M 4 Y Y 480.00 467.04 42500 04 N M 4 Y Y 359.30 349.60 42505 04 N M 4 Y Y 359.30 349.60 42507 04 N M 4 Y Y 767.60 746.87 42509 04 N M 4 Y Y 1079.30 1,050.16 42510 04 N M 4 Y Y 839.35 816.69 42550 04 N I 3 109.95 106.98 42600 04 N M 4 359.30 349.60 42650 04 N I 4 30.40 17.00 29.58 42660 04 N I 4 34.30 17.00 33.37 42665 04 N I 4 160.20 155.87 42699 04 Y M Y42700 04 N I 4 79.30 34.00 77.16 42720 04 N I 4 157.30 153.05 42725 04 N I 4 291.90 284.02 42800 04 N I 4 79.30 34.00 77.16 42804 04 N I 4 79.30 34.00 77.16 42806 04 N I 4 79.30 34.00 77.16 42808 04 N M 4 192.95 34.00 187.74 42809 04 N M 4 202.50 34.00 197.03 42810 04 N M 3 374.55 364.44 42815 04 N M 3 Y 431.40 419.75 42820 04 N M 3 194.20 188.96 42821 04 N M 4 202.50 197.03 42825 04 N M 3 194.20 188.96 42826 04 N M 4 202.50 197.03 42830 04 N M 3 142.90 139.04 42831 04 N M 3 142.90 139.04
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
42835 04 N M 3 142.90 139.04 42836 04 N M 3 142.90 139.04 42842 04 N M 4 Y 702.10 683.14 42844 04 N M 4 Y 810.10 788.23 42845 04 N M 4 Y 918.15 893.36 42860 04 N I 3 119.25 34.00 116.03 42870 04 N I 3 156.65 34.00 152.42 42890 04 N M 4 Y Y 958.60 932.72 42892 04 N M 4 Y Y 912.80 888.15 42894 04 N M 4 Y Y 1188.20 1,156.12 42900 04 Y M 4 Y Y 34.0042950 04 N M 4 Y Y 939.50 914.13 42953 04 Y M 11 Y Y42955 04 N M 4 266.40 259.21 42960 04 N I 3 74.90 34.00 72.88 42961 04 N M 3 150.80 146.73 42962 04 N M 3 220.10 214.16 42970 04 N I 3 131.20 34.00 127.66 42971 04 N M 3 173.40 168.72 42972 04 N M 4 206.40 200.83 42999 04 Y M Y43020 04 N M 6 Y Y 480.00 467.04 43030 04 N M 6 Y Y 819.10 796.98 43045 04 N M 11 Y Y 839.35 816.69 43100 04 N M 6 Y Y 749.20 728.97 43101 04 N M 11 Y Y 749.20 728.97 43107 04 N M 6 Y Y 1467.80 1,428.17 43108 04 N M 11 Y Y 1782.30 1,734.18 43112 04 N M 11 Y Y 1467.80 1,428.17 43113 04 N M 11 Y Y 1782.30 1,734.18 43116 04 N M 11 Y Y 2106.30 2,049.43 43117 04 N M 11 Y Y 1467.80 1,428.17 43118 04 N M 11 Y Y 1782.30 1,734.18 43121 04 N M 11 Y Y 1467.80 1,428.17 43122 04 N M 11 Y Y 1467.80 1,428.17 43123 04 N M 11 Y Y 1782.30 1,734.18 43124 04 Y M 11 Y Y43130 04 N M 6 Y Y 718.70 699.30 43135 04 N M 11 Y Y 718.70 699.30 43180 04 01/01/15 N M 6 344.66 335.35 43191 04 01/01/14 N I 4 76.77 74.70
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
43192 04 01/01/14 N I 4 91.74 89.26 43193 04 01/01/14 N I 4 109.53 106.57 43194 04 01/01/14 N I 4 100.15 97.45 43195 04 01/01/14 N I 4 109.73 106.77 43196 04 01/01/14 N I 4 120.91 117.65 43197 04 01/01/14 N I 4 49.27 47.94 43198 04 01/01/14 N I 4 58.70 57.12 43200 04 N I 4 186.20 56.70 181.17 43201 04 N I 4 113.55 110.48 43202 04 N I 4 199.50 56.70 194.11 43204 04 N M 4 Y Y 256.60 249.67 43205 04 N M 4 256.60 249.67 43206 04 01/01/13 Y I 343210 04 01/01/16 N I 4 264.61 257.47 43211 04 01/01/14 N I 4 150.90 146.83 43212 04 01/01/14 N I 4 120.00 116.76 43213 04 01/01/14 N I 4 168.18 163.64 43214 04 01/01/14 N I 4 121.57 118.29 43215 04 N I 4 244.50 56.70 237.90 43216 04 N I 4 244.50 237.90 43217 04 N I 4 244.50 56.70 237.90 43220 04 N I 4 142.70 56.70 138.85 43226 04 N M 4 224.60 56.70 218.54 43227 04 N I 4 235.20 56.70 228.85 43229 04 01/01/14 N I 4 128.63 125.16 43231 04 N I 3 Y 158.20 153.93 43232 04 N I 4 Y 183.70 178.74 43233 04 01/01/14 N I 4 144.34 140.44 43235 04 N I 4 239.15 56.70 232.69 43236 04 N I 4 239.15 232.69 43237 04 N I 4 117.67 114.49 43238 04 N I 4 145.34 141.42 43239 04 N I 4 249.70 56.70 242.96 43240 04 N I 4 Y 201.55 196.11 43241 04 N I 4 249.70 56.70 242.96 43242 04 N I 4 Y 201.55 196.11 43243 04 N M 4 256.60 249.67 43244 04 N M 4 256.60 249.67 43245 04 N I 4 249.70 56.70 242.96 43246 04 N I 4 Y 249.70 56.70 242.96 43247 04 N M 4 249.70 56.70 242.96 43248 04 N I 4 295.95 287.96 43249 04 N I 4 113.40 110.34
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
43250 04 N I 4 249.70 242.96 43251 04 N I 4 249.70 56.70 242.96 43252 04 01/01/13 Y I 443253 04 01/01/14 N I 4 167.41 162.89 43254 04 01/01/14 N I 4 174.08 169.38 43255 04 N I 4 249.70 56.70 242.96 43257 04 N I 4 170.53 165.93 43259 04 N I 4 240.30 233.81 43260 04 N I 4 264.25 56.70 257.12 43261 04 N I 4 264.25 257.12 43262 04 N M 4 390.10 56.70 379.57 43263 04 N I 4 Y Y 264.25 56.70 257.12 43264 04 N M 4 390.10 56.70 379.57 43265 04 N M 4 390.10 379.57 43266 04 N I 4 144.19 140.30 43270 04 01/01/14 N I 4 151.95 147.85 43273 04 01/01/09 N M 4 Y 117.03 113.87 43274 04 01/01/14 N I 4 298.31 290.26 43275 04 01/01/14 N I 4 245.92 239.28 43276 04 01/01/14 N I 4 310.29 301.91 43277 04 01/01/14 N I 4 247.37 240.69 43278 04 01/01/14 N I 4 281.34 273.74 43279 04 01/01/09 N M 11 Y 682.60 664.17 43280 04 N M 11 Y Y 682.60 664.17 43281 04 01/01/10 N M 7 Y Y 897.40 873.17 43282 04 01/01/10 N M 7 Y Y 1,009.78 982.52 43283 04 01/01/11 N I 11 Y 100.28 97.57 43284 04 01/01/17 N M 6 Y Y 404.95 394.02 43285 04 01/01/17 N M 6 Y Y 410.46 399.38 43289 04 Y M 11 Y43300 04 N M 11 Y Y 786.60 765.36 43305 04 N M 11 Y Y 1258.35 1,224.37 43310 04 N M 11 Y Y 839.35 816.69 43312 04 N M 11 Y Y 1258.35 1,224.37 43313 04 N M 11 Y Y 1188.50 1,156.41 43314 04 N M 11 Y Y 1564.90 1,522.65 43320 04 N M 11 Y Y 958.60 932.72 43325 04 N M 11 Y Y 749.20 728.97 43327 04 01/01/11 N M 11 Y Y 501.68 488.13 43328 04 01/01/11 N M 11 Y Y 742.78 722.72 43330 04 N M 11 Y Y 1082.10 1,052.88 43331 04 N M 11 Y Y 1082.10 1,052.88
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
43332 04 01/01/11 N M 11 Y Y 719.93 700.49 43333 04 01/01/11 N M 11 Y Y 782.01 760.90 43334 04 01/01/11 N M 11 Y Y 791.75 770.37 43335 04 01/01/11 N M 11 Y Y 853.27 830.23 43336 04 01/01/11 N M 11 Y Y 936.29 911.01 43337 04 01/01/11 N M 11 Y Y 1,020.59 993.03 43338 04 01/01/11 N I 11 Y N 82.97 80.73 43340 04 N M 11 Y Y 1198.70 1,166.34 43341 04 N M 11 Y Y 1082.10 1,052.88 43351 04 N M 11 Y Y 839.35 816.69 43352 04 N M 11 Y Y 839.35 816.69 43360 04 N M 11 Y Y 1467.80 1,428.17 43361 04 N M 11 Y Y 1782.30 1,734.18 43400 04 N M 7 Y Y 480.00 467.04 43401 04 N M 7 Y 822.80 800.58 43405 04 Y M 7 Y Y43410 04 N M 7 Y Y 480.00 467.04 43415 04 N M 11 Y Y 839.35 816.69 43420 04 N M 7 Y Y 480.00 467.04 43425 04 N M 11 Y Y 839.35 816.69 43450 04 N I 4 74.90 72.88 43453 04 N I 4 74.90 72.88 43460 04 N I 4 93.05 90.54 43496 04 N M 4 Y Y 1778.60 1,730.58 43499 04 Y M Y43500 04 N M 5 Y Y 599.35 583.17 43501 04 N M 5 Y Y 599.35 583.17 43502 04 N M 5 Y Y 658.90 641.11 43510 04 N M 5 Y Y 599.35 583.17 43520 04 N M 5 Y Y 599.35 583.17 43605 04 N M 5 Y Y 599.35 583.17 43610 04 N M 5 Y Y 718.70 699.30 43611 04 N M 5 Y Y 564.99 549.74 43620 04 N M 6 Y Y 1011.40 984.09 43621 04 N M 6 Y Y 1011.40 984.09 43622 04 N M 6 Y Y 1173.40 1,141.72 43631 04 N M 6 Y Y 915.65 890.93 43632 04 N M 6 Y Y 915.65 890.93 43633 04 N M 6 Y Y 915.65 890.93 43634 04 N M 6 Y Y 1077.70 1,048.60 43635 04 N M 6 Y Y 1026.65 998.93
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
43640 04 N M 5 Y Y 812.90 790.95 43641 04 N M 5 Y 812.90 790.95 43644 K 04 10/01/12 N M 5 Y 942.28 916.84 43645 K 04 10/01/12 N M 5 Y 1017.05 989.59 43647 04 01/01/07 N M 5 Y 399.59 388.80 43648 04 01/01/07 N M 5 399.50 388.71 43651 04 N M 5 Y 524.40 510.24 43652 04 N M 5 Y 524.40 510.24 43653 04 N M 5 Y 399.50 388.71 43659 04 10/01/12 Y M 5 Y43752 04 N I 4 Y 35.05 34.10 43753 04 01/01/11 N I 12.44 12.10 43754 04 01/01/11 N I 18.65 18.15 43755 04 01/01/11 N I 34.28 33.35 43756 04 01/01/11 N I 30.62 29.79 43757 04 01/01/11 N I 44.45 43.25 43760 04 N I 3 35.65 17.00 34.69 43761 04 N I 3 48.50 47.19 43770 K 04 10/01/12 N M Y Y 565.47 550.20 43771 04 10/01/12 N M Y Y 652.01 634.41 43772 04 10/01/12 N M Y Y 497.20 483.78 43773 K 04 10/01/12 N M Y Y 652.27 634.66 43774 04 10/01/12 N M Y Y 497.78 484.34 43775 K 04 10/01/12 N M Y Y 750.81 730.54 43800 04 N M 5 Y Y 699.20 680.32 43810 04 N M 5 Y Y 718.70 699.30 43820 04 N M 5 Y Y 718.70 699.30 43825 04 N M 5 Y Y 898.95 874.68 43830 04 N M 5 Y Y 399.50 388.71 43831 04 N M 5 Y Y 399.50 388.71 43832 04 N M 5 Y Y 399.50 388.71 43840 04 N M 5 Y Y 678.40 660.08 43842 K 04 10/01/12 N M 5 Y 718.70 699.30 43843 K 04 10/01/12 N M 5 Y 718.70 699.30 43845 K 04 10/01/12 N M 5 Y 982.18 955.66 43846 K 04 10/01/12 N M 5 Y Y 770.00 749.21 43847 K 04 10/01/12 N M 5 Y Y 986.00 959.38 43848 04 10/01/12 N M 5 Y Y 770.00 749.21 43850 04 N M 5 Y Y 718.70 699.30 43855 04 N M 5 Y Y 793.60 772.17 43860 04 N M 5 Y Y 718.70 699.30 43865 04 N M 5 Y Y 793.60 772.17
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
43870 04 N M 4 Y Y 240.00 233.52 43880 04 N M 4 Y Y 958.60 932.72 43881 04 01/01/07 N M 5 Y 599.35 583.17 43882 04 01/01/07 N M 5 Y 599.35 583.17 43886 04 10/01/12 N I 5 Y Y 152.73 148.61 43887 04 10/01/12 N I 5 Y Y 151.56 147.47 43888 04 10/01/12 N I 5 Y Y 215.38 209.56 43999 04 Y M Y44005 04 N M 4 Y Y 643.65 626.27 44010 04 N M 4 Y Y 599.35 583.17 44015 04 N M 4 Y Y 399.50 388.71 44020 04 N M 4 Y Y 599.35 583.17 44021 04 N M 4 Y Y 599.35 583.17 44025 04 N M 5 Y Y 599.35 583.17 44050 04 N M 5 Y Y 599.35 583.17 44055 04 N M 5 Y 599.35 583.17 44100 04 N I 3 108.20 105.28 44110 04 N M 4 Y Y 599.35 583.17 44111 04 N M 4 Y Y 599.35 583.17 44120 04 N M 4 Y Y 806.10 784.34 44121 04 N M 4 Y Y 403.05 392.17 44125 04 N M 4 Y Y 733.85 714.04 44126 04 N M 4 Y Y 1039.70 1,011.63 44127 04 N M 4 Y Y 1195.80 1,163.51 44128 04 N M 4 Y Y 175.20 170.47 44130 04 N M 4 Y Y 718.70 699.30 44132 04 N M Y Y 1039.70 1,011.63 44133 04 N M 12 Y Y 1039.70 1,011.63 44135 04 N M 12 Y Y 1180.95 1,149.06 44136 04 N M 12 Y Y 1180.95 1,149.06 44137 04 N M 5 Y 806.10 784.34 44139 04 N M 4 Y Y 108.00 105.08 44140 04 N M 5 Y Y 951.80 926.10 44141 04 N M 5 Y Y 951.80 926.10 44143 04 N M 6 Y Y 951.80 926.10 44144 04 N M 6 Y Y 951.80 926.10 44145 04 N M 6 Y Y 958.60 932.72 44146 04 N M 6 Y Y 951.80 926.10 44147 04 N M 5 Y Y 1198.70 1,166.34 44150 04 N M 6 Y Y 1079.30 1,050.16 44151 04 N M 6 Y Y 1079.10 1,049.96
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
44155 04 N M 6 Y Y 1198.70 1,166.34 44156 04 N M 6 Y Y 1198.70 1,166.34 44157 04 01/01/07 N M 6 Y 1198.70 1,166.34 44158 04 01/01/07 N M 6 Y 1198.70 1,166.34 44160 04 N M 6 Y Y 1198.70 1,166.34 44180 04 N I 4 Y 479.20 466.26 44186 04 03/01/11 N M 4 Y 335.80 326.73 44187 04 03/01/11 N M 4 Y 553.18 538.24 44188 04 03/01/11 N M 4 Y 607.88 591.47 44202 04 N M 4 Y 806.10 784.34 44203 04 N M 4 Y Y 191.80 186.62 44204 04 N M 5 Y Y 973.80 947.51 44205 04 N M 6 Y Y 861.80 838.53 44206 04 N M 6 Y Y 951.80 926.10 44207 04 N M 6 Y Y 958.60 932.72 44208 04 N M 6 Y Y 951.80 926.10 44210 04 N M 6 Y Y 1255.88 1,221.97 44211 04 N M 6 Y Y 1079.30 1,050.16 44212 04 N M 6 Y Y 1198.70 1,166.34 44213 04 03/01/11 N M 4 Y 110.46 107.48 44227 04 03/01/11 N M 4 Y 864.06 840.73 44238 04 Y M 4 Y Y44300 04 N M 5 Y Y 599.35 583.17 44310 04 N M 5 Y Y 629.90 612.89 44312 04 N M 5 Y Y 374.55 364.44 44314 04 N M 5 Y Y 599.35 583.17 44316 04 N M 5 Y Y 535.45 520.99 44320 04 N M 5 Y Y 535.45 520.99 44322 04 N M 5 Y Y 535.45 520.99 44340 04 N M 5 Y Y 299.70 291.61 44345 04 N M 5 Y Y 480.00 467.04 44346 04 N M 5 Y Y 951.80 926.10 44360 04 N I 4 264.25 56.70 257.12 44361 04 N I 4 285.40 56.70 277.69 44363 04 N M 4 Y 285.40 56.70 277.69 44364 04 N M 4 356.70 56.70 347.07 44365 04 N M 4 356.70 347.07 44366 04 N M 4 285.40 56.70 277.69 44369 04 N M 4 285.40 56.70 277.69 44370 04 N M 4 158.30 154.03 44372 04 N M 4 285.40 277.69
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
44373 04 N M 4 356.70 347.07 44376 04 N I 4 318.30 309.71 44377 04 N I 4 318.30 309.71 44378 04 N M 4 318.30 309.71 44379 04 N M 4 258.55 251.57 44380 04 N I 4 182.30 56.70 177.38 44381 04 01/01/16 N I 4 56.15 54.63 44382 04 N I 4 218.00 56.70 212.11 44384 04 01/01/16 N I 4 97.99 95.34 44385 04 N I 4 182.30 56.70 177.38 44386 04 N I 4 182.30 56.70 177.38 44388 04 N I 3 192.85 56.70 187.64 44389 04 N I 3 192.85 56.70 187.64 44390 04 N I 3 192.85 56.70 187.64 44391 04 N I 3 283.40 56.70 275.75 44392 04 N M 3 230.80 56.70 224.57 44394 04 N M 3 318.30 309.71 44401 04 01/01/16 N I 3 155.60 151.40 44402 04 01/01/16 N I 4 168.39 163.84 44403 04 01/01/16 N I 3 193.39 188.17 44404 04 01/01/16 N I 3 111.38 108.37 44405 04 01/01/16 N I 3 118.46 115.26 44406 04 01/01/16 N I 3 147.68 143.69 44407 04 01/01/16 N I 3 176.95 172.17 44408 04 01/01/16 N I 3 149.20 145.17 44500 04 N I 3 99.10 96.42 44602 04 N M 5 Y Y 599.35 583.17 44603 04 N M 5 Y Y 674.20 656.00 44604 04 N M 5 Y Y 599.35 583.17 44605 04 N M 5 Y Y 718.70 699.30 44615 04 N M 5 Y Y 599.35 583.17 44620 04 N M 5 Y Y 359.30 349.60 44625 04 N M 5 Y Y 729.70 710.00 44626 04 N M 5 Y Y 729.70 710.00 44640 04 N M 5 Y Y 480.00 467.04 44650 04 N M 5 Y Y 629.90 612.89 44660 04 N M 5 Y Y 958.60 932.72 44661 04 N M 5 Y Y 958.60 932.72 44680 04 N M 4 Y Y 599.35 583.17 44700 04 N M 3 Y Y 480.00 467.04 44701 04 N I 3 72.34 70.39
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
44799 04 Y M Y44800 04 N M 4 Y Y 480.00 467.04 44820 04 N M 4 Y Y 599.35 583.17 44850 04 N M 4 Y Y 480.00 467.04 44899 04 Y M Y44900 04 N M 4 Y 310.80 302.41 44950 04 N M 4 Y 374.55 364.44 44955 04 N M 4 Y 374.55 364.44 44960 04 N M 4 Y 480.00 467.04 44970 04 N M 3 Y 374.55 364.44 44979 04 Y M 4 Y45000 04 N M 3 170.65 166.04 45005 04 N I 3 107.00 34.00 104.11 45020 04 N I 3 134.00 130.38 45100 04 N I 3 118.00 114.81 45108 04 N M 4 Y 262.20 255.12 45110 04 N M 6 Y Y 1079.30 1,050.16 45111 04 N M 6 Y Y 1079.30 1,050.16 45112 04 N M 6 Y Y 1079.30 1,050.16 45113 04 N M 6 Y Y 1631.05 1,587.01 45114 04 N M 6 Y Y 1138.70 1,107.96 45116 04 N M 6 Y Y 1079.30 1,050.16 45119 04 N M 6 Y Y 1630.70 1,586.67 45120 04 N M 7 Y Y 1198.70 1,166.34 45121 04 N M 7 Y Y 1450.40 1,411.24 45123 04 N M 7 Y Y 540.00 525.42 45126 04 Y M 7 Y45130 04 N M 4 Y 383.70 373.34 45135 04 N M 4 Y 524.40 510.24 45136 04 N M 4 Y Y 1028.70 1,000.93 45150 04 Y I 4 Y45160 04 01/01/10 N M 4 Y Y 1138.70 1,107.96 45171 04 01/01/10 N M 4 Y Y 331.06 322.12 45172 04 01/01/10 N M 4 Y Y 457.49 445.14 45190 04 03/01/11 N M 4 Y 240.00 233.52 45300 04 N I 3 42.30 17.00 41.16 45303 04 N I 3 42.30 17.00 41.16 45305 04 N I 3 72.60 17.00 70.64 45307 04 N M 3 72.60 17.00 70.64 45308 04 N I 3 125.50 122.11 45309 04 N I 3 125.50 122.11
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
45315 04 N I 3 107.00 17.00 104.11 45317 04 N I 3 76.85 17.00 74.78 45320 04 N M 3 Y 201.30 56.70 195.86 45321 04 N I 3 125.50 17.00 122.11 45327 04 N I 3 61.65 59.99 45330 04 N I 3 107.00 34.00 104.11 45331 04 N I 3 142.70 34.00 138.85 45332 04 N I 3 125.50 34.00 122.11 45333 04 N M 3 161.20 34.00 156.85 45334 04 N I 3 142.70 34.00 138.85 45335 04 N I 3 68.14 66.30 45337 04 N I 3 125.50 34.00 122.11 45338 04 N M 3 161.20 156.85 45340 04 N I 3 42.30 41.16 45341 04 N I 3 137.30 133.59 45342 04 N I 3 158.60 154.32 45346 04 01/01/16 N I 3 103.55 100.75 45347 04 01/01/16 N I 3 99.91 97.21 45349 04 01/01/16 N I 3 127.57 124.13 45350 04 01/01/16 N I 3 65.93 64.15 45378 04 N I 3 214.00 56.70 208.22 45379 04 N M 3 214.00 56.70 208.22 45380 04 N I 3 214.00 56.70 208.22 45381 04 N I 3 184.28 179.30 45382 04 N M 3 283.40 56.70 275.75 45384 04 N M 3 285.40 277.69 45385 04 N M 3 285.40 56.70 277.69 45386 04 N I 3 108.86 105.92 45388 04 01/01/16 N I 3 173.35 168.67 45389 04 01/01/16 N I 3 185.41 180.40 45390 04 01/01/16 N I 3 212.17 206.44 45391 04 N M 5 Y 204.00 198.49 45392 04 N I 5 Y 214.00 208.22 45393 04 01/01/16 N I 3 162.46 158.07 45395 04 03/01/11 N M 4 Y 1015.28 987.87 45397 04 03/01/11 N M 4 Y 1103.45 1,073.66 45398 04 01/01/16 N I 3 151.15 147.07 45400 04 N I 4 Y 592.90 576.89 45402 04 N I 4 Y 805.75 783.99 45499 04 Y I 6 Y45500 04 N M 3 Y 419.00 407.69
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
45505 04 N M 3 Y 419.00 407.69 45520 04 N I 74.90 72.88 45540 04 N M 4 Y 599.35 583.17 45541 04 N M 3 Y 599.35 583.17 45550 04 N M 6 Y Y 749.20 728.97 45560 04 N M 3 Y 227.70 221.55 45562 04 N M 3 Y Y 496.12 482.72 45563 04 N M 5 Y Y 756.60 736.17 45800 04 N M 5 Y Y 599.35 583.17 45805 04 N M 5 Y Y 674.20 656.00 45820 04 N M 5 Y Y 599.35 583.17 45825 04 N M 5 Y Y 674.20 656.00 45900 04 N I 4 44.40 43.20 45905 04 N I 4 58.05 56.48 45910 04 N I 3 73.40 71.42 45915 04 N I 3 77.60 75.50 45990 04 N I 6 Y 58.42 56.84 45999 04 Y M Y46020 04 N I 3 140.75 136.95 46030 04 N I 3 71.40 34.00 69.47 46040 04 N M 4 149.80 145.76 46045 04 N M 3 149.80 145.76 46050 04 N I 3 71.40 34.00 69.47 46060 04 N M 3 471.70 458.96 46070 04 N I 3 81.20 79.01 46080 04 N I 3 119.25 116.03 46083 04 N I 3 64.10 17.00 62.37 46200 04 N M 3 262.20 255.12 46220 04 N I 3 71.40 17.00 69.47 46221 04 N I 3 107.00 17.00 104.11 46230 04 N I 3 84.65 17.00 82.36 46250 04 N M 3 248.30 34.00 241.60 46255 04 N M 3 342.65 333.40 46257 04 N M 3 417.60 406.32 46258 04 01/01/10 N M 3 Y 471.70 458.96 46260 04 N M 3 449.50 437.36 46261 04 N M 3 524.40 510.24 46262 04 N M 3 578.55 562.93 46270 04 N M 3 471.70 458.96 46275 04 N M 3 471.70 458.96 46280 04 01/01/10 N M 3 471.70 458.96
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
46285 04 N M 3 471.70 458.96 46288 04 01/01/10 N M 3 471.70 458.96 46320 04 01/01/10 N M 3 Y 62.90 17.00 61.20 46500 04 N I 51.50 17.00 50.11 46505 04 N I Y 102.99 100.21 46600 04 N I 3 19.80 17.00 19.27 46601 04 01/01/16 N I 3 56.74 55.21 46604 04 N I 34.10 17.00 33.18 46606 04 N I 3 24.20 17.00 23.55 46607 04 01/01/16 N I 3 76.93 74.85 46608 04 N I 3 49.85 17.00 48.50 46610 04 N I 3 71.40 17.00 69.47 46611 04 N I 3 71.40 69.47 46612 04 N I 3 89.85 17.00 87.42 46614 04 N I 3 62.00 17.00 60.33 46615 04 N I 3 91.06 88.60 46700 04 N M 3 Y 299.70 291.61 46705 04 N M 3 Y 299.70 291.61 46706 04 01/01/10 N I 3 62.32 60.64 46707 04 01/01/10 N M 5 Y 252.18 245.37 46710 04 N I 530.10 515.79 46712 04 N I 1118.22 1,088.03 46715 04 N M 3 Y 449.50 437.36 46716 04 N M 3 Y 449.50 437.36 46730 04 N M 3 Y 571.25 555.83 46735 04 N M 4 Y Y 1079.30 1,050.16 46740 04 N M 5 Y Y 788.65 767.36 46742 04 N M 5 Y Y 1079.30 1,050.16 46744 04 N M 5 Y Y 918.15 893.36 46746 04 N M 5 Y Y 1139.40 1,108.64 46748 04 N M 5 Y Y 1139.40 1,108.64 46750 04 N M 3 Y 419.00 407.69 46751 04 N M 3 Y 419.00 407.69 46753 04 N I 3 Y 187.90 182.83 46754 04 N I 3 134.60 130.97 46760 04 N M 3 Y 524.40 510.24 46761 04 N M 3 Y 524.40 510.24 46762 04 N M 3 Y 739.90 719.92 46900 04 N I 3 62.70 17.00 61.01 46910 04 N I 3 108.30 17.00 105.38 46916 04 N I 3 108.30 34.00 105.38
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
46917 04 N I 3 108.30 34.00 105.38 46922 04 N I 3 108.30 17.00 105.38 46924 04 N M 3 181.00 17.00 176.11 46930 04 01/01/09 N M 3 127.20 123.77 46940 04 N I 3 68.50 17.00 66.65 46942 04 01/01/10 N I 3 Y 61.15 17.00 59.50 46945 04 01/01/10 N M 3 72.45 17.00 70.49 46946 04 01/01/10 N M 3 112.40 109.37 46947 04 N M 3 342.65 333.40 46999 04 Y M Y47000 04 N I 3 106.80 103.92 47001 04 N I 3 65.90 64.12 47010 04 N M 4 Y 599.35 583.17 47015 04 N M 4 Y Y 480.00 467.04 47100 04 N M 4 Y 480.00 467.04 47120 04 N M 12 Y Y 682.60 664.17 47122 04 N M 12 Y Y 1048.85 1,020.53 47125 04 N M 12 Y Y 1048.85 1,020.53 47130 04 N M 12 Y Y 1048.85 1,020.53 47133 04 N M 12 Y Y 1048.85 1,020.53 47135 04 N M 12 Y Y 3299.30 3,210.22 47140 04 N M 12 Y Y 1660.18 1,615.36 47141 04 N M 12 Y Y 2001.23 1,947.20 47142 04 N M 12 Y Y 2201.17 2,141.74 47300 04 N M 6 Y 718.70 699.30 47350 04 N M 9 Y 659.00 641.21 47360 04 N M 9 Y 697.90 679.06 47361 04 N M 9 Y 810.10 788.23 47362 04 N M 9 Y 523.85 509.71 47370 04 N M 6 Y Y 761.10 740.55 47371 04 N M 6 Y Y 761.10 740.55 47379 04 Y M 9 Y Y47380 04 N M 6 Y Y 892.80 868.69 47381 04 N M 6 Y Y 892.80 868.69 47382 04 01/01/10 N I 3 474.20 461.40 47383 04 03/23/15 N M 6 295.09 287.12 47399 04 Y M Y47400 04 N M 6 Y 718.70 699.30 47420 04 N M 6 Y 647.90 630.41 47425 04 01/01/10 N M 6 Y 682.60 664.17 47460 04 N M 6 Y 463.80 451.28
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
47480 04 N M 6 Y 647.90 630.41 47490 04 N M 4 599.35 583.17 47531 04 01/01/16 N I 3 59.06 57.47 47532 04 01/01/16 N I 3 134.00 130.38 47533 04 01/01/16 N I 4 190.38 185.24 47534 04 01/01/16 N I 4 252.68 245.86 47535 04 01/01/16 N I 4 145.48 141.55 47536 04 01/01/16 N I 4 91.13 88.67 47537 04 01/01/16 N I 4 61.79 60.12 47538 04 01/01/16 N I 4 203.68 198.18 47539 04 01/01/16 N I 4 275.53 268.09 47540 04 01/01/16 N I 4 328.88 320.00 47541 04 01/01/16 N I 4 175.58 170.84 47542 04 01/01/16 N I 4 85.01 2 170.02 165.43 47543 04 01/01/16 N I 4 106.69 103.81 47544 04 01/01/16 N I 4 134.50 130.87 47550 04 N M 6 94.30 91.75 47552 04 N I 4 135.70 132.04 47553 04 N I 4 155.75 151.54 47554 04 N I 4 220.30 214.35 47555 04 N I 4 169.10 164.53 47556 04 N I 4 187.90 182.83 47562 04 N M 6 Y 647.90 630.41 47563 04 11/15/14 N M 6 Y Y 438.49 426.65 47564 04 N M 6 Y 801.90 780.25 47570 04 N M 6 Y 685.40 666.89 47579 04 Y M 6 Y47600 04 06/02/14 N M 6 Y Y 647.90 630.41 47605 04 N M 6 Y 699.20 680.32 47610 04 N M 6 Y 801.90 780.25 47612 04 N M 6 Y 801.90 780.25 47620 04 N M 6 Y 801.90 780.25 47700 04 N M 6 Y 449.50 437.36 47701 04 N M 6 Y Y 685.40 666.89 47711 04 N M 6 Y Y 801.90 780.25 47712 04 N M 6 Y Y 1198.70 1,166.34 47715 04 N M 6 Y Y 862.30 839.02 47720 04 N M 6 Y Y 685.40 666.89 47721 04 N M 6 Y Y 1044.70 1,016.49 47740 04 N M 6 Y Y 685.40 666.89 47741 04 N M 6 Y Y 1044.70 1,016.49
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
47760 04 N M 6 Y Y 685.40 666.89 47765 04 N M 6 Y Y 1438.70 1,399.86 47780 04 N M 6 Y Y 770.00 749.21 47785 04 N M 6 Y Y 1438.70 1,399.86 47800 04 N M 6 Y Y 770.00 749.21 47801 04 N M 6 Y 621.95 605.16 47802 04 N M 6 Y 948.90 923.28 47900 04 N M 6 Y Y 621.95 605.16 47999 04 Y M48000 04 N M 4 Y 718.70 699.30 48001 04 N M 4 Y Y 801.90 780.25 48020 04 N M 6 Y 839.35 816.69 48100 04 N M 6 Y 480.00 467.04 48102 04 N I 3 Y 154.90 150.72 48105 04 01/01/07 N M 7 Y 810.10 788.23 48120 04 N M 6 Y 599.35 583.17 48140 04 N M 6 Y Y 839.35 816.69 48145 04 N M 6 Y Y 1438.70 1,399.86 48146 04 N M 6 Y 1438.70 1,399.86 48148 04 N M 6 Y 859.00 835.81 48150 04 N M 6 Y Y 1438.70 1,399.86 48152 04 N M 6 Y Y 1438.70 1,399.86 48153 04 N M 6 Y Y 1438.70 1,399.86 48154 04 N M 6 Y Y 1438.70 1,399.86 48155 04 N M 6 Y Y 1438.70 1,399.86 48160 04 N M 6 Y Y 2397.40 2,332.67 48400 04 N I 3 47.30 46.02 48500 04 N M 6 Y 839.35 816.69 48510 04 N M 6 Y 839.35 816.69 48520 04 N M 6 Y Y 839.35 816.69 48540 04 N M 6 Y Y 839.35 816.69 48545 04 N M 6 Y Y 599.35 583.17 48547 04 N M 6 Y Y 718.70 699.30 48548 04 01/01/07 N M 7 Y 958.60 932.72 48550 04 N M 6 Y Y 599.35 583.17 48554 04 N M 6 Y Y 2397.40 2,332.67 48556 04 N M 6 Y 599.35 583.17 48999 04 Y M Y49000 04 N M 4 Y 480.00 467.04 49002 04 N M 4 Y 480.00 467.04 49010 04 N M 4 Y 480.00 467.04
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
49020 04 N M 4 Y 480.00 467.04 49040 04 N M 4 Y 480.00 467.04 49060 04 N M 4 Y 480.00 467.04 49062 04 N M 4 Y 480.00 467.04 49082 04 01/01/12 N I 3 41.32 34.00 40.20 49083 04 01/01/12 N I 3 63.95 34.00 62.22 49084 04 01/01/12 N I 0 58.94 57.35 49180 04 N I 3 106.80 103.92 49185 04 01/01/16 N I 4 76.08 74.03 49203 04 01/01/08 N M 4 Y 480.00 467.04 49204 04 01/01/08 N M 4 Y 704.75 685.72 49205 04 01/01/08 N M 4 Y 947.27 921.69 49215 04 N M 4 Y Y 766.90 746.19 49220 04 N M 5 Y 998.80 971.83 49250 04 N M 3 Y 374.55 364.44 49255 04 N M 3 Y 599.35 583.17 49320 04 N M 4 Y 302.40 294.24 49321 04 N M 4 Y 302.40 294.24 49322 04 07/08/14 N I 4 Y Y 302.40 294.24 49323 04 N M 4 Y 480.00 467.04 49324 04 01/01/07 N M 4 Y 480.00 467.04 49325 04 01/01/07 N M 4 Y 480.00 467.04 49326 04 01/01/07 N M 4 Y 480.00 467.04 49327 04 01/01/11 N I 4 80.74 78.56 49329 04 Y M 4 Y49400 04 N I 3 47.00 45.73 49402 04 01/01/10 N M 4 Y 406.05 395.09 49405 04 01/01/14 N I 4 131.54 127.99 49406 04 01/01/14 N I 4 131.74 128.18 49407 04 01/01/14 N I 4 140.29 136.50 49411 04 01/01/10 N I 3 Y 114.29 111.20 49412 04 01/01/11 N I 50.45 49.09 49418 04 01/01/11 N I Y 141.89 138.06 49419 04 01/01/10 N M 5 180.46 175.59 49421 04 N M 4 299.70 291.61 49422 04 N M 4 240.00 233.52 49423 04 N M 4 262.20 255.12 49424 04 N I 20.95 20.38 49425 04 N M 5 Y Y 718.70 699.30 49426 04 Y M 5 Y49427 04 N I 3 37.40 36.39
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
49428 04 Y M 4 Y Y49429 04 Y M 4 Y Y49435 04 01/01/07 N M 4 60.90 59.26 49436 04 01/01/07 N M 4 88.75 86.35 49440 04 01/01/08 N I 5 Y 133.76 465.96 130.15 49441 04 01/01/08 N I 5 Y 144.19 563.56 140.30 49442 04 01/01/08 N I 5 Y 119.66 457.55 116.43 49446 04 01/01/08 N I 5 Y 94.47 493.61 91.92 49450 04 01/01/08 Y I 5 Y49451 04 01/01/08 Y I 5 Y49452 04 01/01/08 Y I 5 Y49460 04 01/01/08 N I 5 Y 27.00 406.44 26.27 49465 04 01/01/08 N I 5 Y 17.80 73.55 17.32 49491 04 N M 3 Y Y 433.70 421.99 49492 04 N M 3 Y Y 535.00 520.56 49495 04 N M 3 Y 362.00 352.23 49496 04 N M 3 Y 362.00 352.23 49500 04 N M 3 Y 362.00 352.23 49501 04 N M 3 Y 387.05 376.60 49505 04 N M 3 Y 387.05 376.60 49507 04 N M 3 Y 387.05 376.60 49520 04 N M 3 Y 409.20 398.15 49521 04 N M 3 Y 387.05 376.60 49525 04 N M 3 Y 464.80 452.25 49540 04 N M 3 Y 337.10 328.00 49550 04 N M 3 Y 409.20 398.15 49553 04 N M 3 Y 409.20 398.15 49555 04 N M 3 Y 460.60 448.16 49557 04 N M 3 Y 460.60 448.16 49560 04 N M 3 Y 503.60 490.00 49561 04 N M 3 Y 503.60 490.00 49565 04 N M 3 Y 546.65 531.89 49566 04 N M 3 Y 572.50 557.04 49568 04 N M 3 Y 460.60 448.16 49570 04 N M 3 Y 345.50 336.17 49572 04 N M 3 Y 345.50 336.17 49580 04 N M 3 Y Y 342.65 333.40 49582 04 N M 3 Y 374.55 364.44 49585 04 N M 3 Y 374.55 364.44 49587 04 N M 3 Y 374.55 364.44 49590 04 N M 3 Y 374.55 364.44
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
49600 04 N M 3 Y 275.80 268.35 49605 04 N M 3 Y 573.10 557.63 49606 04 N M 3 Y 506.50 492.82 49610 04 N M 3 Y 599.35 583.17 49611 04 N M 3 Y 449.50 437.36 49650 04 N M 3 Y 387.05 376.60 49651 04 N M 3 Y 409.20 398.15 49652 04 08/10/15 N M 3 Y Y 387.05 376.60 49653 04 01/01/09 N M 3 Y 387.05 376.60 49654 04 01/01/09 N M Y 387.05 376.60 49655 04 01/01/09 N M 3 Y 387.05 376.60 49656 04 01/01/09 N M 3 Y 387.05 376.60 49657 04 01/01/09 N M Y 387.05 376.60 49659 04 Y M 3 Y49900 04 N M 4 Y 307.05 298.76 49904 04 N M 4 Y Y 617.40 600.73 49905 04 N M 5 Y Y 442.90 430.94 49906 04 N M 4 Y Y 1306.65 1,271.37 49999 04 Y M 4 Y50010 04 N M 5 Y 480.00 467.04 50020 04 N M 5 Y 398.35 387.59 50040 04 N M 5 Y 775.60 754.66 50045 04 N M 5 Y 718.70 699.30 50060 04 N M 5 Y 718.70 699.30 50065 04 N M 5 Y 599.35 583.17 50070 04 N M 5 Y 749.20 728.97 50075 04 N M 5 Y 749.20 728.97 50080 04 N M 5 434.20 422.48 50081 04 N M 5 600.55 584.34 50100 04 N M 5 Y 767.20 746.49 50120 04 N M 5 Y 839.35 816.69 50125 04 N M 5 Y 839.35 816.69 50130 04 N M 5 Y 837.90 815.28 50135 04 01/01/12 N M 5 Y Y 671.40 653.27 50200 04 N I 5 112.40 109.37 50205 04 01/01/10 N M 5 Y Y 480.00 467.04 50220 04 N M 5 Y Y 933.80 908.59 50225 04 N M 5 Y Y 933.80 908.59 50230 04 N M 5 Y Y 1057.20 1,028.66 50234 04 N M 5 Y Y 933.80 908.59 50236 04 Y M 5 Y Y
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
50240 04 09/26/16 N M 5 Y Y 749.20 728.97 50250 04 N M 6 Y 373.74 363.65 50280 04 N M 5 Y 718.70 699.30 50290 04 N M 5 Y 718.70 699.30 50300 04 Y M 5 Y50320 04 N M 5 Y Y 933.80 908.59 50323 09 Y M50328 09 Y M50340 04 N M 5 Y 933.80 908.59 50360 04 N M 5 Y Y 1366.60 1,329.70 50365 04 N M 5 Y Y 1833.45 1,783.95 50370 04 N M 5 Y Y 933.80 908.59 50380 04 Y M 5 Y Y50382 04 N I 3 163.58 159.16 50384 04 N I 3 148.92 144.90 50385 04 01/01/08 N M 3 Y 137.81 572.99 134.09 50386 04 01/01/08 N M 3 Y 104.23 356.14 101.42 50387 04 N I 3 59.20 57.60 50389 04 N I 3 32.75 31.87 50390 04 N I 5 119.25 116.03 50391 04 N I 3 117.95 114.77 50395 04 N I 3 119.25 116.03 50396 04 N I 3 50.20 34.00 48.84 50400 04 N M 5 Y Y 958.60 932.72 50405 04 N M 5 Y Y 958.60 932.72 50430 04 01/01/16 N I 3 Y 102.74 99.97 50431 04 01/01/16 N I 3 40.38 39.29 50432 04 01/01/16 N I 5 136.02 132.35 50433 04 01/01/16 N I 3 167.91 163.38 50434 04 01/01/16 N I 5 128.62 125.15 50435 04 01/01/16 N I 3 62.15 60.47 50500 04 N M 5 Y 718.70 699.30 50520 04 N M 5 Y 480.00 467.04 50525 04 N M 5 Y 674.20 656.00 50526 04 N M 5 Y 674.20 656.00 50540 04 N M 5 Y Y 1198.70 1,166.34 50541 04 N M 5 Y 718.70 699.30 50542 04 N M 6 Y Y 718.70 699.30 50543 04 N M 5 Y Y 749.20 728.97 50544 04 N M 5 Y 958.60 932.72 50545 04 N M 5 Y Y 906.40 881.93
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
50546 04 07/13/15 N M 5 Y Y 933.80 908.59 50547 04 N M 5 Y Y 933.80 908.59 50548 04 N M 5 Y 933.80 908.59 50549 04 Y M 4 Y50551 04 N I 3 151.00 56.70 146.92 50553 04 N I 3 245.35 56.70 238.73 50555 04 N I 3 250.35 56.70 243.59 50557 04 N I 3 294.80 56.70 286.84 50561 04 N I 3 301.85 56.70 293.70 50562 04 N M 3 301.95 293.80 50570 04 N I 3 204.70 199.17 50572 04 N I 3 268.20 260.96 50574 04 N I 3 281.05 273.46 50575 04 N I 3 365.15 355.29 50576 04 N I 3 294.80 286.84 50580 04 N I 3 269.70 262.42 50590 04 N M 3 Y Y 749.20 728.97 50592 04 N I 3 214.22 208.44 50593 04 01/01/08 N M 3 Y 267.81 2228.0 260.58 50600 04 N M 5 Y 718.70 699.30 50605 04 N M 5 Y 738.10 718.17 50606 04 01/01/16 N I 3 97.81 95.17 50610 04 N M 5 Y 738.10 718.17 50620 04 N M 5 Y 738.10 718.17 50630 04 N M 5 Y 738.10 718.17 50650 04 N M 5 Y 599.35 583.17 50660 04 N M 5 Y Y 599.35 583.17 50684 04 N I 3 120.00 17.00 116.76 50686 04 N I 3 64.10 34.00 62.37 50688 04 N I 3 37.40 34.00 36.39 50690 04 N I 3 129.70 17.00 126.20 50693 04 01/01/16 N I 3 134.57 130.94 50694 04 01/01/16 N I 3 174.11 169.41 50695 04 01/01/16 N I 3 221.06 215.09 50700 04 N M 5 Y 958.60 932.72 50705 04 01/01/16 N I 3 125.39 122.00 50706 04 01/01/16 N I 3 116.12 112.98 50715 04 N M 5 Y Y 749.20 728.97 50722 04 N M 5 Y 749.20 728.97 50725 04 N M 5 Y 958.60 932.72 50727 04 N M 5 Y Y 455.80 443.49
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
50728 04 N M 5 Y Y 567.10 551.79 50740 04 N M 5 Y 958.60 932.72 50750 04 N M 5 Y 958.60 932.72 50760 04 N M 5 Y 958.60 932.72 50770 04 N M 5 Y 958.60 932.72 50780 04 N M 5 Y 958.60 932.72 50782 04 N M 5 Y Y 945.15 919.63 50783 04 N M 5 Y Y 945.15 919.63 50785 04 N M 5 Y 958.60 932.72 50800 04 N M 5 Y 718.70 699.30 50810 04 N M 6 Y 718.70 699.30 50815 04 N M 6 Y 718.70 699.30 50820 04 N M 6 Y 718.70 699.30 50825 04 N M 6 Y Y 1438.70 1,399.86 50830 04 Y M 6 Y Y50840 04 N M 6 Y 718.70 699.30 50845 04 Y M 5 Y50860 04 N M 5 Y 958.60 932.72 50900 04 N M 5 Y Y 958.60 932.72 50920 04 N M 5 Y 480.00 467.04 50930 04 N M 5 Y 629.90 612.89 50940 04 N M 5 Y 934.70 909.46 50945 04 N M 5 Y 738.10 718.17 50947 04 N M 5 Y Y 973.55 947.26 50948 04 N M 5 Y 890.50 866.46 50949 04 Y M 5 Y Y50951 04 N I 3 152.60 56.70 148.48 50953 04 N I 3 251.25 56.70 244.47 50955 04 N I 3 235.50 56.70 229.14 50957 04 N I 3 236.20 56.70 229.82 50961 04 N M 3 297.95 56.70 289.91 50970 04 N I 3 187.70 182.63 50972 04 N I 3 152.10 147.99 50974 04 N I 3 243.40 236.83 50976 04 N I 3 236.20 229.82 50980 04 N M 3 262.20 255.12 51020 04 N M 5 Y 524.40 510.24 51030 04 N M 5 Y 524.40 510.24 51040 04 N M 5 Y 449.50 437.36 51045 04 N M 5 Y 449.50 437.36 51050 04 N M 5 Y 599.35 583.17
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
51060 04 N M 5 Y 738.10 718.17 51065 04 N M 5 Y 738.10 718.17 51080 04 N M 5 Y 599.35 583.17 51100 04 01/01/08 N I 5 22.55 13.02 21.94 51101 04 01/01/08 N I 5 30.11 41.49 29.30 51102 04 01/01/08 N I 5 141.08 47.69 137.27 51500 04 N M 3 Y 599.35 583.17 51520 04 N M 5 Y 480.00 467.04 51525 04 N M 5 Y 718.70 699.30 51530 04 N M 5 Y 599.35 583.17 51535 04 N M 5 Y 599.35 583.17 51550 04 N M 6 Y 599.35 583.17 51555 04 N M 6 Y 599.35 583.17 51565 04 N M 6 Y Y 958.60 932.72 51570 04 N M 7 Y Y 749.20 728.97 51575 04 N M 7 Y Y 1198.70 1,166.34 51580 04 N M 7 Y Y 1438.70 1,399.86 51585 04 N M 7 Y Y 1438.70 1,399.86 51590 04 N M 7 Y Y 1438.70 1,399.86 51595 04 N M 7 Y Y 1498.30 1,457.85 51596 04 N M 7 Y Y 1438.70 1,399.86 51597 04 N M 7 Y Y 1498.30 1,457.85 51600 04 N I 3 121.35 17.00 118.07 51605 04 N I 3 121.35 17.00 118.07 51610 04 N I 3 130.80 17.00 127.27 51700 04 N I 44.60 43.40 51701 04 N I 24.02 23.37 51702 04 N I 24.02 23.37 51703 04 N I 26.18 25.47 51705 04 N I 3 38.85 17.00 37.80 51710 04 N I 3 66.85 17.00 65.05 51715 04 N I 3 295.95 287.96 51720 04 N I 3 66.85 17.00 65.05 51725 C 04 01/01/10 N I 16.87 27.53 44.40 43.20 51726 C 04 01/01/10 N I 15.00 35.05 50.05 48.70 51727 C 04 01/01/10 N I 62.18 97.28 159.46 155.15 51728 C 04 01/01/10 N I 60.46 98.66 159.12 154.82 51729 C 04 01/01/10 N I 72.06 99.51 171.57 166.94 51736 C 04 01/01/10 N I 10.38 6.92 17.30 16.83 51741 C 04 01/01/10 N I 37.42 15.20 52.70 51.28 51784 04 N I 52.70 51.28
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
51785 04 N I 52.70 51.28 51792 04 N I 74.90 72.88 51797 C 04 01/01/10 N I 14.85 30.15 45.00 43.79 51798 A 04 N I 8.78 8.78 17.56 17.09 51800 04 N M 5 Y 599.35 583.17 51820 04 N M 5 Y 839.35 816.69 51840 04 N M 4 Y 631.25 614.21 51841 04 N M 4 Y 631.25 614.21 51845 04 N M 5 Y 631.25 614.21 51860 04 N M 5 Y Y 599.35 583.17 51865 04 N M 5 Y Y 599.35 583.17 51880 04 N M 5 216.65 210.80 51900 04 N M 5 Y 958.60 932.72 51920 04 N M 5 Y 958.60 932.72 51925 04 N M 5 Y 958.60 932.72 51940 04 N M 5 Y 839.35 816.69 51960 04 N M 5 Y 1105.80 1,075.94 51980 04 N M 5 Y 449.50 437.36 51990 04 N M 5 Y 631.25 614.21 51992 04 N M 4 Y 631.25 614.21 51999 04 Y M 352000 04 N I 3 85.90 56.70 83.58 52001 04 N I 3 90.40 87.96 52005 04 N I 3 118.90 56.70 115.69 52007 04 N M 3 154.60 56.70 150.43 52010 04 N I 3 118.90 56.70 115.69 52204 04 N I 3 163.90 56.70 159.47 52214 04 N M 3 178.30 56.70 173.49 52224 04 N M 3 295.95 56.70 287.96 52234 04 06/01/16 N I 3 374.55 364.44 52235 04 06/01/16 N I 3 374.55 364.44 52240 04 06/01/16 N I 3 524.40 510.24 52250 04 N I 3 141.30 56.70 137.48 52260 04 N I 3 149.80 145.76 52265 04 N I 142.70 56.70 138.85 52270 04 N M 3 180.30 175.43 52275 04 N M 3 194.20 188.96 52276 04 N M 3 209.40 203.75 52277 04 N M 3 180.30 175.43 52281 04 N I 3 134.80 56.70 131.16 52282 04 01/01/10 N I 3 204.10 198.59
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
52283 04 N I 3 149.80 145.76 52285 04 N I 3 135.70 132.04 52287 04 01/01/13 N I 3 99.37 96.69 52290 04 N M 3 184.50 179.52 52300 04 N M 3 240.00 233.52 52301 04 N M 3 240.00 233.52 52305 04 N M 3 297.00 288.98 52310 04 N I 3 180.30 56.70 175.43 52315 04 N M 3 239.00 56.70 232.55 52317 04 N M 3 Y Y 342.15 56.70 332.91 52318 04 N M 3 Y Y 339.25 56.70 330.09 52320 04 N M 3 249.70 56.70 242.96 52325 04 03/01/11 N I 3 379.40 369.16 52327 04 N I 3 295.95 287.96 52330 04 N M 3 260.80 56.70 253.76 52332 04 N I 3 138.90 135.15 52334 04 N M 3 308.35 300.02 52341 04 N M 3 224.45 218.39 52342 04 N M 3 242.90 236.34 52343 04 N M 3 269.10 261.83 52344 04 03/01/11 N I 3 287.60 279.83 52345 04 N M 3 306.60 298.32 52346 04 N M 3 344.90 335.59 52351 04 N I 3 178.30 173.49 52352 04 N M 3 293.75 285.82 52353 04 N M 3 262.20 255.12 52354 04 N M 3 249.70 242.96 52355 04 N M 3 337.00 327.90 52356 04 01/01/14 N I 3 252.92 246.09 52400 04 N M 3 398.85 388.08 52402 04 N M 3 537.15 522.65 52441 04 01/01/15 N I 3 140.15 136.37 52442 04 01/01/15 N I 3 37.50 3 112.50 109.46 52450 04 N M 3 249.00 242.28 52500 04 N M 3 480.00 467.04 52601 04 N M 5 775.60 754.66 52630 04 N M 5 599.35 583.17 52640 04 N M 3 486.90 473.75 52647 04 N M 5 599.35 583.17 52648 04 N M 5 599.35 583.17 52649 04 01/01/08 N M 5 Y 562.42 547.23
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
52700 04 N M 3 314.95 306.45 52920 04 Y 3 Y53000 04 N M 3 Y 240.00 233.52 53010 04 N M 3 314.95 306.45 53020 04 N I 3 67.80 17.00 65.97 53025 04 N I 3 58.60 17.00 57.02 53040 04 N I 3 197.80 17.00 192.46 53060 04 N I 3 95.30 17.00 92.73 53080 04 Y M 3 17.0053085 04 Y M 353200 04 N I 3 92.70 17.00 90.20 53210 04 N M 5 449.50 437.36 53215 04 N M 5 524.40 510.24 53220 04 N M 3 449.50 437.36 53230 04 N M 3 Y 599.35 583.17 53235 04 N M 3 Y 599.35 583.17 53240 04 N M 3 449.50 437.36 53250 04 Y M 3 34.0053260 04 N I 3 113.60 34.00 110.53 53265 04 N I 3 115.00 34.00 111.90 53270 04 N I 3 113.60 34.00 110.53 53275 04 N I 3 122.20 34.00 118.90 53400 04 N M 3 Y 599.35 583.17 53405 04 N M 3 Y 599.35 583.17 53410 04 N M 3 Y 599.35 583.17 53415 04 N M 3 Y 745.30 725.18 53420 04 N M 3 Y 599.35 583.17 53425 04 N M 3 Y 449.50 437.36 53430 04 N M 3 517.40 503.43 53431 04 N M 3 709.95 690.78 53440 04 N M 3 599.35 583.17 53442 04 N M 3 Y 449.50 437.36 53444 04 N M 3 540.40 525.81 53445 04 Y M 353446 04 N M 3 494.90 481.54 53447 04 N M 3 449.50 437.36 53448 04 N M 842.25 819.51 53449 04 Y M 353450 04 N M 3 164.30 159.86 53460 04 N M 3 224.70 218.63 53500 04 N M 5 Y Y 386.25 375.82
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
53502 04 07/01/12 N M 3 289.28 281.47 53505 04 07/01/12 N M 3 289.84 282.01 53510 04 07/01/12 N M 3 376.77 366.60 53515 04 07/01/12 N M 3 475.01 462.18 53520 04 N M 3 314.95 306.45 53600 04 N I 3 52.80 51.37 53601 04 N I 3 47.80 46.51 53605 04 N I 3 47.80 46.51 53620 04 N I 3 75.10 73.07 53621 04 N I 3 69.55 67.67 53660 04 N I 3 41.80 40.67 53661 04 N I 3 42.10 40.96 53665 04 N I 3 36.00 35.03 53850 04 N M 5 576.80 561.23 53852 04 N M 5 576.80 561.23 53855 04 01/01/10 N I 3 Y 47.81 46.52 53860 04 01/01/11 N M 3 141.37 137.55 53899 04 Y M Y54000 04 N I 3 74.90 17.00 72.88 54001 04 N I 3 87.85 17.00 85.48 54015 04 N I 3 156.75 17.00 152.52 54050 04 N I 52.70 17.00 51.28 54055 04 N I 3 72.10 17.00 70.15 54056 04 N I 3 71.40 17.00 69.47 54057 04 N I 3 71.40 17.00 69.47 54060 04 N I 3 88.50 17.00 86.11 54065 04 N I 3 107.00 34.00 104.11 54100 04 N I 3 88.50 17.00 86.11 54105 04 N I 3 114.25 17.00 111.17 54110 04 N M 3 321.45 312.77 54111 04 N M 3 585.75 569.93 54112 04 N M 3 717.90 698.52 54115 04 Y M 354120 04 N M 3 Y 285.10 277.40 54125 04 N M 3 Y 449.50 437.36 54130 04 N M 3 Y Y 749.20 728.97 54135 04 N M 4 Y Y 749.20 728.97 54150 04 N I 3 77.50 75.41 54160 04 N I 3 99.80 97.11 54161 04 N I 3 146.70 34.00 142.74 54162 04 N I 3 97.25 94.62
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
54163 04 N I 3 137.40 133.69 54164 04 N I 3 120.30 117.05 54200 04 N I 3 38.60 37.56 54205 04 Y I 354220 04 N M 3 299.70 291.61 54230 04 N I 3 38.20 37.17 54231 04 N I 3 118.80 115.59 54235 04 N I 3 37.40 36.39 54240 09 Y I54250 04 N I 54.55 53.08 54300 04 N M 3 Y Y 425.80 414.30 54304 04 N M 3 Y 670.10 652.01 54308 04 N M 3 Y 599.35 583.17 54312 04 N M 3 Y 670.10 652.01 54316 04 N M 3 Y 670.10 652.01 54318 04 N M 3 Y 670.10 652.01 54322 04 N M 3 Y 480.00 467.04 54324 04 N M 3 Y 538.00 523.47 54326 04 N M 3 Y 670.10 652.01 54328 04 N M 3 Y 958.60 932.72 54332 04 N M 3 Y Y 670.10 652.01 54336 04 N M 3 Y Y 958.60 932.72 54340 04 N M 3 Y 538.00 523.47 54344 04 N M 3 Y 670.10 652.01 54348 04 N M 3 Y 958.60 932.72 54352 04 Y M 3 Y Y54360 04 N M 3 Y Y 690.78 672.13 54380 04 N M 3 Y 386.30 375.87 54385 04 N M 3 Y 446.00 433.96 54390 04 N M 3 Y 600.70 584.48 54400 09 Y M54401 09 Y M54405 09 Y M54406 09 Y M54408 09 Y M54410 09 Y M54411 09 Y M54415 09 Y M54416 09 Y M54417 09 Y M54420 04 N M 3 Y 409.20 398.15
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
54430 04 N M 3 Y 409.20 398.15 54435 04 N M 3 405.10 394.16 54437 04 01/01/16 N M 3 Y Y 415.40 404.18 54438 04 01/01/16 N M 3 Y Y 843.41 820.64 54440 04 N M 3 Y 224.70 218.63 54450 04 N I 3 37.45 36.44 54500 04 N I 3 68.20 17.00 66.36 54505 04 N I 3 113.60 17.00 110.53 54512 04 N M 3 356.05 346.44 54520 04 N M 3 Y 351.00 341.52 54522 04 N M 3 404.20 393.29 54530 04 N M 3 Y 958.60 932.72 54535 04 N M 4 Y 958.60 932.72 54550 04 N M 3 Y 359.30 349.60 54560 04 N M 4 Y 480.00 467.04 54600 04 N M 3 Y 359.30 349.60 54620 04 N M 3 Y 299.70 291.61 54640 04 N M 3 Y 504.90 491.27 54650 04 N M 3 Y 480.00 467.04 54660 09 Y M54670 04 06/01/11 N M 3 228.72 222.54 54680 04 Y M 3 Y54690 04 N M 3 Y 351.00 341.52 54692 04 N M 3 504.90 491.27 54699 04 Y M 3 Y54700 04 N I 3 128.30 17.00 124.84 54800 04 N I 3 119.25 116.03 54830 04 N M 3 299.70 291.61 54840 04 N M 3 299.70 291.61 54860 04 N M 3 359.30 349.60 54861 04 N M 3 480.00 467.04 54865 04 01/01/07 N M 3 179.47 174.62 55000 04 N I 3 42.35 17.00 41.21 55040 04 N M 3 Y 299.70 291.61 55041 04 N M 3 449.50 437.36 55060 04 N M 3 Y 259.40 252.40 55100 04 N I 3 110.90 17.00 107.91 55110 04 Y M 355120 04 N I 3 129.30 17.00 125.81 55150 04 N I 3 206.10 200.54 55175 04 Y M 3
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
55180 04 Y M 3 Y55200 04 N M 3 147.95 56.70 143.96 55250 04 10/01/14 N M 3 408.00 396.98 55300 04 N I 3 112.40 109.37 55400 04 Y M 3 Y55450 04 N M 3 150.40 56.70 146.34 55500 04 N M 3 359.30 349.60 55520 04 N M 3 240.00 233.52 55530 04 N M 3 359.30 349.60 55535 04 N M 4 Y 359.30 349.60 55540 04 N M 3 Y 480.00 467.04 55550 04 N M 3 Y 359.30 349.60 55559 04 Y M 3 Y55600 04 N I 3 178.30 173.49 55605 04 N M 3 223.60 217.56 55650 04 N M 3 Y 958.60 932.72 55680 04 N I 3 Y 299.70 291.61 55700 04 N I 3 113.60 17.00 110.53 55705 04 N M 3 187.30 182.24 55706 04 01/01/09 N I 3 291.03 283.17 55720 04 N M 3 359.30 349.60 55725 04 N M 3 359.30 349.60 55801 04 N M 6 Y 839.35 816.69 55810 04 N M 6 Y 1198.70 1,166.34 55812 04 N M 6 Y 1678.65 1,633.33 55815 04 N M 6 Y 1809.25 1,760.40 55821 04 N M 6 Y 958.60 932.72 55831 04 N M 6 Y 958.60 932.72 55840 04 N M 6 Y Y 1198.70 1,166.34 55842 04 N M 6 Y 1285.40 1,250.69 55845 04 N M 6 Y Y 1438.70 1,399.86 55860 04 07/01/13 N M 3 Y 511.97 498.15 55862 04 07/01/13 N M 3 Y 641.36 624.04 55865 04 07/01/13 N M 6 Y Y 780.62 759.54 55866 04 05/01/12 N M 6 Y Y 990.55 963.81 55870 09 Y I55873 04 01/01/10 N M 3 739.15 719.19 55875 04 03/01/11 N M 3 Y 359.30 349.60 55876 04 01/01/10 N I 3 59.34 57.74 55899 04 Y M Y Y55920 04 01/01/08 N M 3 Y 246.06 239.42
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
56405 04 N I 3 95.05 92.48 56420 04 01/01/12 N I 3 103.05 17.00 100.27 56440 04 N M 3 202.50 197.03 56441 04 N I 3 127.90 124.45 56442 04 01/01/07 N I 3 68.65 66.80 56501 04 01/01/12 N I 3 Y 52.70 17.00 51.28 56515 04 01/01/12 N M 3 Y 181.00 34.00 176.11 56605 04 N I 3 Y 108.30 105.38 56606 04 10/01/14 N I 3 Y 18.35 5 91.75 17.85 89.27 56620 04 N M 3 Y 335.70 326.64 56625 04 N M 3 Y 480.00 467.04 56630 04 N M 3 Y 524.40 510.24 56631 04 N M 4 Y 511.20 497.40 56632 04 N M 4 Y 599.65 583.46 56633 04 N M 4 Y 524.40 510.24 56634 04 N M 4 Y 599.35 583.17 56637 04 N M 4 Y 749.20 728.97 56640 04 N M 3 Y 749.20 728.97 56700 04 N I 3 113.60 110.53 56740 04 N M 3 226.10 220.00 56800 04 N I 3 119.25 116.03 56805 04 N M 3 496.90 483.48 56810 04 N M 3 Y 190.00 184.87 56820 04 N I 3 37.40 36.39 56821 04 N I 3 50.20 48.84 57000 04 N M 3 202.55 197.08 57010 04 N M 3 224.70 218.63 57020 04 N I 3 79.30 17.00 77.16 57022 04 N I 3 109.50 106.54 57023 04 N I 3 109.50 106.54 57061 04 01/01/12 N I 3 45.40 17.00 44.17 57065 04 01/01/12 N I 3 91.35 88.88 57100 04 N I 3 107.00 17.00 104.11 57105 04 N I 3 107.00 17.00 104.11 57106 04 N M 3 Y 299.70 291.61 57107 04 N M 3 Y 544.50 529.80 57109 04 N M 3 Y 782.80 761.66 57110 04 N M 3 Y 374.30 364.19 57111 04 N M 3 Y 782.80 761.66 57112 04 N M 3 Y 1022.80 995.18 57120 04 N M 3 Y 299.70 291.61 57130 04 N M 3 180.30 175.43
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
57135 04 N I 3 121.55 17.00 118.27 57150 04 N I 18.25 17.76 57155 04 N I 257.40 250.45 57156 04 01/01/11 N I 61.27 59.62 57160 04 N I 27.65 26.90 57170 04 01/01/12 N I 28.60 27.83 57180 04 N I 3 48.75 17.00 47.43 57200 04 N M 3 188.90 34.00 183.80 57210 04 N M 3 206.05 34.00 200.49 57220 04 N M 3 355.10 345.51 57230 04 N M 3 517.40 503.43 57240 04 N M 3 Y 355.10 345.51 57250 04 N M 3 Y 314.95 306.45 57260 04 N M 3 Y 525.80 511.60 57265 04 N M 3 Y 532.80 518.41 57267 04 N M 3 167.79 163.26 57268 04 N M 3 Y 532.80 518.41 57270 04 N M 4 Y 480.00 467.04 57280 04 N M 4 Y Y 599.35 583.17 57282 04 N M 4 Y 480.00 467.04 57283 04 N M Y 599.35 583.17 57284 04 N M 3 532.80 518.41 57285 04 01/01/08 N M 3 Y Y 352.36 342.85 57287 04 N M 4 Y 467.50 454.88 57288 04 N M 4 Y Y 631.25 614.21 57289 04 N M 3 Y 674.20 656.00 57291 04 Y M 3 Y Y57292 04 Y M 3 Y Y57295 04 N M 3 269.31 262.04 57296 04 01/01/07 N M 481.19 468.20 57300 04 N M 3 Y 466.15 453.56 57305 04 N M 4 Y 1127.90 1,097.45 57307 04 N M 5 Y 1127.90 1,097.45 57308 04 N M 3 Y Y 728.35 708.68 57310 04 N M 5 Y 718.70 699.30 57311 04 N M 5 Y 799.70 778.11 57320 04 N M 5 Y 597.90 581.76 57330 04 N M 5 Y 524.40 510.24 57335 04 N M 3 466.15 453.56 57400 04 N I 3 111.00 108.00 57410 04 N I 3 53.30 51.86
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
57415 04 N I 3 Y 111.00 108.00 57420 04 N I 3 37.40 36.39 57421 04 N I 3 50.20 48.84 57423 04 01/01/08 N M 3 Y Y 497.75 484.31 57425 04 01/01/10 N M 4 Y Y 487.77 474.60 57426 04 01/01/10 N M 3 Y Y 491.98 478.70 57452 04 01/01/12 N I 3 37.40 36.39 57454 04 01/01/12 N I 3 50.20 34.00 48.84 57455 04 01/01/12 N I 3 50.20 48.84 57456 04 01/01/12 N I 3 50.20 48.84 57460 04 01/01/12 N I 3 Y 77.00 34.00 74.92 57461 04 01/01/12 N I 3 172.05 167.40 57500 04 01/01/12 N I 3 142.70 17.00 138.85 57505 04 01/01/12 N I 3 48.55 47.24 57510 04 N I 3 60.60 58.96 57511 04 01/01/12 N I 3 58.10 56.53 57513 04 N I 3 131.10 127.56 57520 04 N M 3 321.90 313.21 57522 04 01/01/12 N M 3 305.80 34.00 297.54 57530 04 N M 3 Y 308.00 299.68 57531 04 N M 5 Y Y 1030.80 1,002.97 57540 04 N M 4 Y 599.35 583.17 57545 04 N M 4 Y 599.35 583.17 57550 04 N M 3 Y 599.35 583.17 57555 04 N M 3 Y 674.20 656.00 57556 04 N M 3 Y 674.20 656.00 57558 04 01/01/07 N I 149.80 145.76 57700 04 N M 3 313.50 305.04 57720 04 N M 3 359.30 349.60 57800 04 N I 3 119.25 116.03 58100 04 01/01/12 N I 3 52.90 34.00 51.47 58110 04 01/01/12 N I 3 24.90 24.23 58120 04 N M 3 206.85 201.27 58140 04 N M 5 Y 718.70 699.30 58145 04 N M 5 Y 718.70 699.30 58146 04 N M 4 Y 718.70 699.30 58150 04 N M 5 Y 772.70 751.84 58152 04 N M 5 Y 1096.05 1,066.46 58180 04 N M 5 Y 652.05 634.44 58200 04 N M 5 Y 772.70 751.84 58210 04 N M 5 Y 1030.80 1,002.97 58240 04 N M 6 Y Y 1423.45 1,385.02 58260 04 N M 5 Y 725.60 706.01
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
58262 04 N M 5 Y 725.60 706.01 58263 04 N M 5 Y 725.60 706.01 58267 04 N M 5 Y 856.00 832.89 58270 04 N M 5 Y 856.00 832.89 58275 04 N M 5 Y 875.40 851.76 58280 04 N M 5 Y 800.50 778.89 58285 04 N M 5 Y 950.30 924.64 58290 04 N M 5 Y 725.60 706.01 58291 04 N M 5 Y 725.60 706.01 58292 04 N M 5 Y 725.60 706.01 58293 04 N M 5 Y 856.00 832.89 58294 04 N M 5 Y 856.00 832.89 58300 04 10/01/14 N I 88.00 85.62 58301 04 01/01/12 N I 37.40 36.39 58340 04 01/01/12 N I 3 93.40 90.88 58346 04 N I 3 274.00 266.60 58353 04 N I 3 Y 150.60 146.53 58356 04 N M 3 201.30 195.86 58400 04 N M 4 Y 449.50 437.36 58410 04 N M 4 Y 449.50 437.36 58520 04 N M 6 Y 480.00 467.04 58540 04 N M 5 Y 501.38 487.84 58541 04 01/01/07 N M 5 Y 433.94 422.22 58542 04 01/01/07 N M 5 Y 479.33 466.39 58543 04 01/01/07 N M 5 Y 487.55 474.39 58544 04 01/01/07 N M 5 Y 528.11 513.85 58545 04 N M 5 Y 480.00 467.04 58546 04 N M 4 Y 480.00 467.04 58548 04 01/01/07 N M 5 Y 924.56 899.60 58550 04 N M 5 Y 725.60 706.01 58552 04 N M 5 Y 725.00 705.43 58553 04 N M 5 Y 725.00 705.43 58554 04 N M 5 Y 725.00 705.43 58555 04 N I 3 95.75 93.16 58558 04 N I 3 145.80 141.86 58559 04 N I 4 160.80 156.46 58560 04 N I 4 160.80 156.46 58561 04 03/01/11 N I 4 361.85 352.08 58562 04 03/01/11 N I 5 361.85 352.08 58563 04 N I 3 300.43 292.32 58565 04 01/01/12 N M 4 327.45 34.00 318.61
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
58570 04 01/01/08 N M 5 Y Y 496.17 482.77 58571 04 01/01/08 N M 5 Y Y 542.05 527.41 58572 04 01/01/08 N M 5 Y Y 617.19 600.53 58573 04 01/01/08 N M 5 Y Y 693.59 674.86 58578 04 Y M 458579 04 Y M 358600 04 01/01/12 N M 4 Y 327.45 318.61 58605 04 N M 4 Y 327.45 318.61 58611 04 01/01/12 N M 4 Y 97.30 94.67 58615 04 01/01/12 N M 4 327.45 318.61 58660 04 N M 4 Y 302.40 294.24 58661 04 N M 4 Y 480.00 467.04 58662 04 N M 4 Y 302.40 294.24 58670 04 01/01/12 N M 4 363.45 353.64 58671 04 01/01/12 N M 4 363.45 353.64 58672 09 Y M 458673 04 N M 4 Y 480.00 467.04 58674 04 01/01/17 N M 4 Y Y 494.47 481.12 58679 04 Y M 458700 04 N M 4 Y 481.90 468.89 58720 04 N M 4 Y 525.85 511.65 58740 04 N M 4 Y 480.00 467.04 58752 09 Y M 458770 04 N M 4 Y 480.00 467.04 58800 04 03/29/17 N M 4 359.30 349.60 58805 04 N M 4 Y 480.00 467.04 58820 04 N M 4 Y 240.00 233.52 58822 04 N M 4 Y 480.00 467.04 58825 04 10/01/09 N M Y 542.40 527.76 58900 04 N M 4 Y 480.00 467.04 58920 04 N M 4 Y 529.95 515.64 58925 04 N M 4 Y 524.40 510.24 58940 04 N M 4 Y 554.90 539.92 58943 04 N M 4 Y Y 958.60 932.72 58950 04 N M 4 Y Y 704.70 685.67 58951 04 N M 5 Y Y 898.95 874.68 58952 04 N M 4 Y Y 958.60 932.72 58953 04 N M 5 Y Y 1241.75 1,208.22 58954 04 N M 5 Y Y 1350.35 1,313.89 58956 04 N M 5 Y Y 1241.75 1,208.22 58957 04 01/01/07 N M 4 Y 749.43 729.20 58958 04 01/01/07 N M 5 Y 830.11 807.70 58960 04 N M 4 Y Y 599.35 583.17
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
58999 04 Y M 3 Y59000 04 N I 4 58.35 34.00 56.77 59001 04 N B 4 Y 89.80 87.38 59012 04 N I 4 115.00 111.90 59015 04 N I 3 99.20 96.52 59020 C 04 N B 7.90 25.80 33.70 32.79 59025 C 04 N B 3 7.90 25.80 33.70 32.79 59030 04 N I 79.00 76.87 59050 04 N I 25.40 24.71 59051 09 Y N59070 04 N I 4 158.55 154.27 59074 04 N I 4 158.55 154.27 59076 04 03/01/11 N I 4 Y 257.88 250.92 59100 04 N M 5 Y 540.00 525.42 59120 04 N M 4 Y 540.00 525.42 59121 04 N M 4 Y 540.00 525.42 59130 04 N M 4 Y 540.00 525.42 59135 04 N M 5 Y 696.15 677.35 59136 04 N M 5 Y 540.00 525.42 59140 04 N M 5 Y 540.00 525.42 59150 04 N M 4 Y 540.00 525.42 59151 04 N M 4 Y 540.00 525.42 59160 04 N M 3 199.95 194.55 59200 04 N B 3 27.80 27.05 59300 04 N B 3 Y 74.95 72.93 59320 04 N M 3 282.45 274.82 59325 04 N M 5 Y 540.10 525.52 59350 04 N M 6 Y 540.00 525.42 59400 09 Y B 59409 Q 04 04/01/09 N B 924.45 899.49 59410 Q 04 04/01/09 N B 924.45 899.49 59412 04 N B 72.95 70.98 59414 04 N B 67.50 65.68 59430 04 N B 50.15 48.80 59510 09 Y N59514 Q 04 04/01/09 N B 5 Y Y 1070.45 1,041.55 59515 Q 04 04/01/09 N B 5 Y 1070.45 1,041.55 59525 04 N M 5 Y 299.30 291.22 59610 09 Y N59612 Q 04 04/01/09 N B 924.45 899.49 59614 Q 04 04/01/09 N B 924.45 899.49
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
59618 09 Y B59620 Q 04 04/01/09 N B 5 Y 1070.45 1,041.55 59622 Q 04 04/01/09 N B 5 Y 1070.45 1,041.55 59812 04 N M 4 298.70 290.64 59820 04 N M 3 199.95 194.55 59821 04 N M 4 Y 298.70 290.64 59830 04 N M 3 Y 223.70 217.66 59840 04 N M 3 Y 199.95 194.55 59841 04 N B 3 199.95 194.55 59850 04 N M Y 199.95 194.55 59851 04 N M 3 Y 199.95 194.55 59855 04 N M Y 199.95 194.55 59856 04 N M Y 199.95 194.55 59857 04 N M Y 199.95 194.55 59866 09 Y M59870 04 N M 4 Y 389.25 378.74 59871 04 01/01/10 N I 3 Y 66.95 65.14 59897 04 06/27/16 Y B 4 Y Y59898 04 Y B Y59899 04 Y B Y60000 04 N I 3 113.60 17.00 110.53 60100 04 N I 3 50.20 17.00 48.84 60200 04 11/01/15 N M 5 Y Y 360.70 350.96 60210 04 N M 5 Y Y 550.90 536.03 60212 04 N M 5 Y Y 718.70 699.30 60220 04 N M 5 Y Y 703.30 684.31 60225 04 N M 5 Y Y 703.30 684.31 60240 04 N M 5 Y Y 718.70 699.30 60252 04 N M 5 Y Y 1198.70 1,166.34 60254 04 N M 6 Y Y 1198.70 1,166.34 60260 04 N M 5 Y Y 718.70 699.30 60270 04 N M 5 Y Y 839.35 816.69 60271 04 N M 5 Y Y 749.20 728.97 60280 04 N M 5 Y Y 718.70 699.30 60281 04 N M 5 Y 718.70 699.30 60300 04 01/01/08 N I 3 27.75 27.00 60500 04 N M 5 Y Y 839.35 816.69 60502 04 N M 5 Y Y 839.35 816.69 60505 04 N M 11 Y Y 839.35 816.69 60512 04 N M 11 Y Y 135.00 131.36 60520 04 N M 5 Y Y 749.20 728.97
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
60521 04 N M 5 Y Y 839.35 816.69 60522 04 N M 5 Y Y 1198.70 1,166.34 60540 04 N M 9 Y Y 839.35 816.69 60545 04 N M 9 Y Y 958.60 932.72 60600 04 N M 9 Y Y 839.35 816.69 60605 04 N M 9 Y Y 839.35 816.69 60650 04 N M 9 Y 839.35 816.69 60659 04 Y M 5 Y60699 04 Y M Y61000 04 N I 4 112.40 109.37 61020 04 N I 4 112.40 109.37 61026 04 N M 4 62.15 60.47 61050 04 N I 3 112.40 109.37 61055 04 N M 4 157.50 153.25 61070 04 N I 4 112.40 109.37 61105 04 N M 9 Y Y 359.30 349.60 61107 04 N M 9 Y 359.30 349.60 61108 04 N M 9 Y 599.35 583.17 61120 04 N M 9 Y Y 359.30 349.60 61140 04 N M 9 Y Y 510.30 496.52 61150 04 N M 9 Y Y 958.60 932.72 61151 04 N I 9 Y Y 330.80 321.87 61154 04 N M 9 Y Y 599.35 583.17 61156 04 N M 9 Y Y 599.35 583.17 61210 04 03/01/11 N I 9 Y Y 449.50 437.36 61215 04 N M 9 Y 449.50 437.36 61250 04 N M 9 Y Y 449.50 437.36 61253 04 N M 9 Y Y 449.50 437.36 61304 04 N M 9 Y Y 749.20 728.97 61305 04 N M 9 Y Y 886.90 862.95 61312 04 N M 9 Y Y 861.50 838.24 61313 04 N M 9 Y Y 861.50 838.24 61314 04 N M 9 Y Y 861.50 838.24 61315 04 N M 9 Y Y 1198.70 1,166.34 61316 04 Y M Y Y61320 04 N M 9 Y Y 1123.70 1,093.36 61321 04 N M 9 Y Y 1123.70 1,093.36 61322 04 N M 9 Y Y 1123.70 1,093.36 61323 04 N M 9 Y Y 1123.70 1,093.36 61330 04 N M 9 Y Y 973.90 947.60 61332 04 N M 9 Y Y 973.90 947.60
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
61333 04 N M 9 Y Y 1198.70 1,166.34 61340 04 N M 9 Y Y 839.35 816.69 61343 04 N M 9 Y Y 1738.80 1,691.85 61345 04 N M 9 Y Y 1198.70 1,166.34 61450 04 N M 9 Y Y 839.35 816.69 61458 04 N M 9 Y Y 893.25 869.13 61460 04 N M 9 Y Y 891.30 867.23 61480 04 N M 9 Y Y 958.60 932.72 61500 04 N M 9 Y Y 1198.70 1,166.34 61501 04 N M 9 Y Y 1198.70 1,166.34 61510 04 N M 9 Y Y 1198.70 1,166.34 61512 04 N M 9 Y Y 1198.70 1,166.34 61514 04 N M 9 Y Y 1198.70 1,166.34 61516 04 N M 9 Y Y 1198.70 1,166.34 61517 04 N I 3 Y 49.85 48.50 61518 04 N M 9 Y Y 1198.70 1,166.34 61519 04 N M 9 Y Y 1271.10 1,236.78 61520 04 N M 9 Y Y 1604.85 1,561.52 61521 04 N M 9 Y Y 1351.20 1,314.72 61522 04 N M 9 Y Y 1198.70 1,166.34 61524 04 N M 9 Y Y 1198.70 1,166.34 61526 04 N M 9 Y Y 1499.10 1,458.62 61530 04 N M 9 Y Y 1327.00 1,291.17 61531 04 N M 9 Y 1138.70 1,107.96 61533 04 N M 9 Y Y 1138.70 1,107.96 61534 04 N M 9 Y Y 1198.70 1,166.34 61535 04 10/16/14 N M 9 Y Y 620.75 603.99 61536 04 N M 9 Y Y 1198.70 1,166.34 61537 04 N M 9 Y Y 939.13 913.77 61538 04 N M 9 Y Y 1198.70 1,166.34 61539 04 N M 9 Y Y 1198.70 1,166.34 61540 04 N M 9 Y Y 1134.13 1,103.51 61541 04 N M 9 Y Y 1701.95 1,656.00 61543 04 N M 9 Y Y 1198.70 1,166.34 61544 04 N M 9 Y Y 1198.70 1,166.34 61545 04 N M 9 Y Y 1283.15 1,248.50 61546 04 N M 9 Y Y 1198.70 1,166.34 61548 04 N M 9 Y Y 1198.70 1,166.34 61550 04 N M 9 Y Y 898.95 874.68 61552 04 N M 9 Y Y 1198.70 1,166.34 61556 04 N M 9 Y Y 1144.65 1,113.74
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
61557 04 N M 9 Y Y 1690.50 1,644.86 61558 04 N M 9 Y Y 1689.90 1,644.27 61559 04 N M 9 Y Y 1689.90 1,644.27 61563 04 Y M 9 Y Y61564 04 Y M 9 Y Y61566 04 N M 9 Y Y 1116.28 1,086.14 61567 04 N M 9 Y Y 1270.28 1,235.98 61570 04 N M 9 Y Y 1198.70 1,166.34 61571 04 N M 9 Y Y 1198.70 1,166.34 61575 04 N M 9 Y Y 1198.70 1,166.34 61576 04 N M 9 Y Y 1630.70 1,586.67 61580 04 N M 9 Y Y 1198.70 1,166.34 61581 04 N M 9 Y 1630.70 1,586.67 61582 04 N M 9 Y Y 1198.70 1,166.34 61583 04 N M 9 Y Y 1306.65 1,271.37 61584 04 N M 9 Y Y 1306.65 1,271.37 61585 04 N M 9 Y Y 1630.70 1,586.67 61586 04 N M 9 Y Y 1306.65 1,271.37 61590 04 N M 9 Y Y 1630.70 1,586.67 61591 04 N M 9 Y Y 1630.70 1,586.67 61592 04 N M 9 Y Y 1630.70 1,586.67 61595 04 N M 9 Y Y 1414.70 1,376.50 61596 04 N M 9 Y Y 1630.70 1,586.67 61597 04 N M 9 Y Y 1630.70 1,586.67 61598 04 N M 9 Y Y 1522.70 1,481.59 61600 04 N M 9 Y Y 1198.70 1,166.34 61601 04 N M 9 Y Y 1198.70 1,166.34 61605 04 N M 9 Y Y 1138.70 1,107.96 61606 04 N M 9 Y Y 1198.70 1,166.34 61607 04 N M 9 Y Y 1198.70 1,166.34 61608 04 N M 9 Y Y 1274.80 1,240.38 61610 04 N M 9 Y Y 1306.65 1,271.37 61611 04 N M 9 Y Y 1198.70 1,166.34 61612 04 N M 9 Y Y 1306.65 1,271.37 61613 04 N M 9 Y Y 1244.80 1,211.19 61615 04 N M 9 Y Y 1198.70 1,166.34 61616 04 N M 9 Y Y 1306.65 1,271.37 61618 04 N M 9 Y Y 958.60 932.72 61619 04 Y M 9 Y Y61623 04 N I 3 241.20 234.69 61624 04 03/01/11 N I 3 682.80 664.36
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
61626 04 03/01/11 N I 3 682.80 664.36 61630 04 01/01/10 N I 3 Y Y 731.40 711.65 61635 04 01/01/10 N I 3 Y Y 790.53 769.19 61640 04 Y M 361641 04 Y M 361642 04 Y M 361645 04 01/01/16 N I 3 Y 492.92 479.61 61650 04 01/01/16 N I 3 327.20 318.37 61651 04 01/01/16 N I 3 138.98 2 277.96 270.46 61680 04 N M 9 Y Y 1048.85 1,020.53 61682 04 N M 9 Y Y 1784.20 1,736.03 61684 04 N M 9 Y Y 1231.20 1,197.96 61686 04 N M 9 Y Y 1871.15 1,820.63 61690 04 N M 9 Y Y 973.90 947.60 61692 04 N M 9 Y Y 1480.90 1,440.92 61697 04 N M 9 Y Y 2267.10 2,205.89 61698 04 N M 9 Y 2182.15 2,123.23 61700 04 N M 9 Y Y 1498.85 1,458.38 61702 04 N M 9 Y Y 1481.20 1,441.21 61703 04 N M 9 Y Y 718.70 699.30 61705 04 N M 9 Y Y 1198.70 1,166.34 61708 04 N M 9 Y Y 1198.70 1,166.34 61710 04 N M 9 Y Y 787.40 766.14 61711 04 N M 9 Y Y 1158.10 1,126.83 61720 04 N M 9 Y Y 1198.70 1,166.34 61735 04 N M 9 Y Y 1198.70 1,166.34 61750 04 N M 9 Y Y 1306.65 1,271.37 61751 04 N M 9 Y Y 1198.70 1,166.34 61760 04 N M 9 Y Y 1138.70 1,107.96 61770 04 N M 9 Y Y 749.20 728.97 61781 04 01/01/11 N I 149.77 145.73 61782 04 01/01/11 N I 121.95 118.66 61783 04 01/01/11 N I 149.77 145.73 61790 04 N M 9 Y Y 749.20 728.97 61791 04 N M 9 Y Y 1198.70 1,166.34 61796 04 01/01/09 N M 9 Y 1198.70 1,166.34 61797 04 01/01/09 N M 9 Y 1198.70 1,166.34 61798 04 01/01/09 N N 9 1198.70 1,166.34 61799 04 01/01/09 N M 9 Y 1198.70 1,166.34 61800 04 01/01/09 N M 9 Y 1198.70 1,166.34 61850 04 N M 9 Y Y 749.20 728.97
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
61860 04 N M 9 Y Y 1198.70 1,166.34 61863 04 N M 9 Y Y 574.19 558.69 61867 04 N M 9 Y Y 843.83 821.05 61868 04 01/01/10 N I 9 Y Y 168.27 163.73 61870 04 N M 9 Y Y 958.60 932.72 61880 04 N M 3 Y Y 749.20 728.97 61885 04 10/01/14 N M 3 Y 749.20 728.97 61886 04 N M 3 Y Y 749.20 728.97 61888 04 N M 3 Y Y 749.20 728.97 62000 04 N M 9 Y Y 789.30 767.99 62005 04 N M 9 Y Y 1347.10 1,310.73 62010 04 N M 9 Y Y 1347.10 1,310.73 62100 04 N M 9 Y Y 1198.70 1,166.34 62115 04 N M 9 Y 1296.20 1,261.20 62117 04 N M 9 Y 1458.20 1,418.83 62120 04 N M 9 Y Y 698.40 679.54 62121 04 N M 9 Y Y 1198.70 1,166.34 62140 04 N M 9 Y Y 749.20 728.97 62141 04 N M 9 Y Y 1048.85 1,020.53 62142 04 N M 9 Y Y 749.20 728.97 62143 04 N M 9 Y Y 1048.85 1,020.53 62145 04 N M 9 Y Y 1198.70 1,166.34 62146 04 N M 9 Y Y 1350.15 1,313.70 62147 04 N M 9 Y Y 1458.20 1,418.83 62148 04 N M 9 Y Y 105.00 102.17 62160 04 N M 9 Y Y 156.52 152.29 62161 04 N M 9 Y Y 985.60 958.99 62162 04 N M 9 Y Y 1036.85 1,008.86 62163 04 N M 9 Y Y 861.50 838.24 62164 04 N M 9 Y Y 1198.70 1,166.34 62165 04 N M 9 Y Y 1198.70 1,166.34 62180 04 N M 11 Y Y 839.35 816.69 62190 04 N M 11 Y Y 839.35 816.69 62192 04 N M 11 Y Y 761.60 741.04 62194 04 N M 8 Y Y 599.35 583.17 62200 04 N M 11 Y Y 839.35 816.69 62201 04 N M 11 Y Y 1048.85 1,020.53 62220 04 N M 11 Y Y 839.35 816.69 62223 04 N M 11 Y Y 761.60 741.04 62225 04 N M 8 Y Y 374.55 364.44 62230 04 N M 8 Y Y 374.55 364.44
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
62252 04 N I 3 Y 54.20 52.74 62256 04 N M 8 Y Y 225.80 219.70 62258 04 N M 11 Y Y 599.35 583.17 62263 04 N M 3 193.60 188.37 62264 04 N M 3 193.60 188.37 62267 04 03/01/11 N I 3 481.80 468.79 62268 04 N M 3 449.50 437.36 62269 04 03/01/11 N I 3 449.50 437.36 62270 04 N I 3 53.70 52.25 62272 04 N I 3 59.10 57.50 62273 04 N I 3 74.90 72.88 62280 04 N I 4 158.20 153.93 62281 04 N I 4 81.10 78.91 62282 04 N I 4 158.20 153.93 62284 04 N I 4 158.20 153.93 62287 04 N M 4 481.80 468.79 62290 04 N I 4 158.20 153.93 62291 04 N I 4 158.20 153.93 62292 04 N M 4 Y 852.05 829.04 62294 04 N M 3 852.05 829.04 62302 04 01/01/15 N I 4 76.86 74.78 62303 04 01/01/15 N I 4 77.84 75.74 62304 04 01/01/15 N I 4 75.61 73.57 62305 04 01/01/15 N I 4 79.19 77.05 62320 04 01/01/17 N I 4 62.70 61.01 62321 04 01/01/17 N I 4 67.64 65.81 62322 04 01/01/17 N I 4 53.89 52.43 62323 04 01/01/17 N I 4 61.58 59.92 62324 04 01/01/17 N I 3 57.88 56.32 62325 04 01/01/17 N I 3 66.61 64.81 62326 04 01/01/17 N I 3 56.49 54.96 62327 04 01/01/17 N I 3 60.20 58.57 62350 04 N M 8 Y Y 545.10 530.38 62351 04 N M 8 Y Y 839.35 816.69 62355 04 N M 3 Y Y 180.30 175.43 62360 04 N M 8 Y Y 545.10 530.38 62361 04 N M 8 Y Y 545.10 530.38 62362 04 N M 8 Y Y 545.10 530.38 62365 04 N M 8 Y Y 162.00 157.63 62367 04 N I 27.55 26.81 62368 04 N I Y 40.45 39.36
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
62369 04 01/01/12 N I 20.72 20.16 62370 04 01/01/12 N I 27.82 27.07 63001 04 N M 8 Y Y 1102.95 1,073.17 63003 04 N M 8 Y Y 1102.95 1,073.17 63005 04 N M 7 Y Y 1102.95 1,073.17 63011 04 N M 7 Y Y 881.00 857.21 63012 04 N M 8 Y 1404.20 1,366.29 63015 04 N M 8 Y Y 1161.20 1,129.85 63016 04 N M 8 Y Y 1161.20 1,129.85 63017 04 N M 8 Y Y 1161.20 1,129.85 63020 04 Y M 7 Y Y63030 04 N M 7 Y Y 1129.30 1,098.81 63035 04 Y M 7 Y Y63040 04 N M 7 Y Y 1129.30 1,098.81 63042 04 N M 7 Y Y 1129.30 1,098.81 63043 04 01/01/10 Y M 7 Y Y63044 04 01/01/10 Y M 7 Y Y63045 04 N M 7 Y Y 1129.30 1,098.81 63046 04 N M 7 Y Y 1129.30 1,098.81 63047 04 N M 7 Y Y 1129.30 1,098.81 63048 04 Y M 7 Y Y63050 04 N M 8 Y Y 843.88 821.10 63051 04 N M 7 Y Y 947.11 921.54 63055 04 N M 7 Y Y 1291.70 1,256.82 63056 04 N M 7 Y Y 1291.70 1,256.82 63057 04 Y M 7 Y Y63064 04 N M 7 Y Y 1198.70 1,166.34 63066 04 Y M 7 Y Y63075 04 N M 7 Y Y 1198.70 1,166.34 63076 04 N M 7 Y Y 1198.70 1,166.34 63077 04 N M 7 Y Y 1198.70 1,166.34 63078 04 N M 7 Y Y 1198.70 1,166.34 63081 04 N M 7 Y Y 1291.70 1,256.82 63082 04 Y M 7 Y Y63085 04 N M 7 Y Y 1291.70 1,256.82 63086 04 Y M 7 Y Y63087 04 N M 7 Y Y 1291.70 1,256.82 63088 04 Y M 7 Y Y63090 04 N M 7 Y Y 1291.70 1,256.82 63091 04 Y M 7 Y Y63101 04 N M 7 Y Y 1153.57 1,122.42
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
63102 04 N M 7 Y Y 1153.57 1,122.42 63103 04 Y M 7 Y Y63170 04 N M 7 Y Y 1291.70 1,256.82 63172 04 N M 8 Y Y 1198.70 1,166.34 63173 04 N M 8 Y Y 1393.75 1,356.12 63180 04 N M 7 Y Y 1198.70 1,166.34 63182 04 N M 7 Y Y 1198.70 1,166.34 63185 04 N M 8 Y Y 839.35 816.69 63190 04 N M 8 Y Y 1079.30 1,050.16 63191 04 Y M 8 Y Y63194 04 N M 8 Y Y 958.60 932.72 63195 04 N M 8 Y Y 958.60 932.72 63196 04 N M 8 Y Y 958.60 932.72 63197 04 N M 8 Y Y 958.60 932.72 63198 04 N M 8 Y Y 1291.70 1,256.82 63199 04 Y M 8 Y Y63200 04 N M 7 Y Y 1198.70 1,166.34 63250 04 N M 8 Y Y 1198.70 1,166.34 63251 04 N M 8 Y Y 1198.70 1,166.34 63252 04 N M 8 Y Y 1224.30 1,191.24 63265 04 N M 8 Y Y 1198.70 1,166.34 63266 04 N M 8 Y Y 1198.70 1,166.34 63267 04 N M 8 Y Y 1198.70 1,166.34 63268 04 N M 8 Y Y 1198.70 1,166.34 63270 04 N M 8 Y Y 1198.70 1,166.34 63271 04 N M 8 Y Y 1198.70 1,166.34 63272 04 N M 8 Y Y 1198.70 1,166.34 63273 04 N M 8 Y Y 1198.70 1,166.34 63275 04 N M 8 Y Y 1198.70 1,166.34 63276 04 N M 8 Y Y 1198.70 1,166.34 63277 04 N M 8 Y Y 1198.70 1,166.34 63278 04 N M 8 Y Y 1198.70 1,166.34 63280 04 N M 8 Y Y 1198.70 1,166.34 63281 04 N M 8 Y Y 1198.70 1,166.34 63282 04 N M 8 Y Y 1198.70 1,166.34 63283 04 N M 8 Y Y 1198.70 1,166.34 63285 04 N M 8 Y Y 1198.70 1,166.34 63286 04 N M 8 Y Y 1198.70 1,166.34 63287 04 N M 8 Y Y 1198.70 1,166.34 63290 04 N M 8 Y Y 1198.70 1,166.34 63295 04 N M 7 Y Y 190.18 185.05
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
63300 04 N M 8 Y Y 1606.30 1,562.93 63301 04 N M 8 Y Y 1615.70 1,572.08 63302 04 N M 8 Y Y 1291.70 1,256.82 63303 04 N M 8 Y Y 1291.70 1,256.82 63304 04 N M 8 Y Y 1291.70 1,256.82 63305 04 N M 8 Y Y 1291.70 1,256.82 63306 04 N M 8 Y Y 1291.70 1,256.82 63307 04 N M 8 Y Y 1291.70 1,256.82 63308 04 Y M 8 Y63600 04 N M 8 Y Y 898.95 874.68 63610 04 N M 7 Y Y 599.35 583.17 63615 04 N M 3 Y Y 898.95 874.68 63620 04 01/01/09 N M 9 Y 629.27 612.28 63621 04 01/01/09 N M 9 Y 201.37 195.93 63650 04 05/04/16 N I 3 N N 524.40 510.24 63655 04 N M 7 Y Y 733.85 714.04 63661 04 01/01/10 N I 3 Y Y 168.27 163.73 63662 04 01/01/10 N M 3 Y Y 393.19 382.57 63663 04 01/01/10 N I 3 Y Y 265.27 258.11 63664 04 01/01/10 N M 7 Y Y 409.75 398.69 63685 04 N M 3 Y Y 599.35 583.17 63688 04 N M 3 Y Y 374.55 364.44 63700 04 N M 9 Y Y 599.35 583.17 63702 04 N M 9 Y 599.35 583.17 63704 04 N M 9 Y Y 630.10 613.09 63706 04 N M 9 Y Y 689.00 670.40 63707 04 N M 9 Y Y 1198.70 1,166.34 63709 04 N M 9 Y Y 1198.70 1,166.34 63710 04 N M 9 Y Y 1102.95 1,073.17 63740 04 N M 11 Y Y 839.35 816.69 63741 04 N M 8 Y Y 324.05 315.30 63744 04 N M 8 Y Y 374.55 364.44 63746 04 N M 8 Y Y 194.05 188.81 64400 04 N I 74.90 72.88 64402 04 N I 74.90 72.88 64405 04 N I 74.90 72.88 64408 04 N I 52.40 50.99 64410 04 N I 49.40 48.07 64413 04 N I 52.70 51.28 64415 04 N I 52.70 51.28 64416 04 N I 74.90 72.88
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
64417 04 N I 48.40 47.09 64418 04 N I 47.15 45.88 64420 04 N I 43.25 42.08 64421 04 N I 56.40 54.88 64425 04 N I 52.65 51.23 64430 04 N I 51.10 49.72 64435 04 N I 50.55 49.19 64445 04 N I 53.20 51.76 64446 04 N I 74.90 72.88 64447 04 N I 53.20 51.76 64448 04 N I 74.90 72.88 64449 04 N I 81.40 79.20 64450 04 N I 38.95 37.90 64455 04 03/01/11 N I 38.95 37.90 64461 04 01/01/16 N I 53.23 51.79 64462 04 01/01/16 N I 33.55 32.64 64463 04 01/01/16 N I 51.64 50.25 64479 04 N I 95.90 93.31 64480 04 N I 85.75 83.43 64483 04 N I 88.25 85.87 64484 04 N I 83.20 80.95 64486 04 01/01/15 N I 38.51 37.47 64487 04 01/01/15 N I 44.26 43.06 64488 04 01/01/15 N I 48.28 46.98 64489 04 01/01/15 N I 54.35 52.88 64490 04 01/01/10 N I 61.54 59.88 64491 04 01/01/10 N I 35.62 34.66 64492 04 01/01/13 N I 37.07 36.07 64493 04 01/01/10 N I 52.13 50.72 64494 04 01/01/10 N I 30.39 29.57 64495 04 01/01/13 N I 31.50 30.65 64505 04 N I 59.60 57.99 64508 04 N I 59.60 57.99 64510 04 N I 59.60 57.99 64517 04 N I 64.40 62.66 64520 04 N I 56.20 54.68 64530 04 N I 58.70 57.12 64553 04 N I 3 Y 149.80 145.76 64555 04 N I 3 60.80 59.16 64560 04 N I 3 97.20 94.58 64561 04 N M 3 171.50 166.87
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
64565 04 Y I 364566 04 01/01/11 N I 3 17.94 17.46 64568 04 01/01/11 N M 3 Y 381.68 371.37 64569 04 01/01/11 N M 3 Y 392.45 381.85 64570 04 01/01/11 N M 3 Y 348.13 338.73 64575 04 N M 3 599.35 583.17 64580 04 N M 3 Y 599.35 583.17 64581 04 N M 3 Y 332.00 323.04 64585 04 N I 3 149.80 145.76 64590 04 N M 3 Y 599.35 583.17 64595 04 N M 3 149.80 145.76 64600 04 N I 100.00 97.30 64605 04 N I 140.65 136.85 64610 04 N I 233.00 226.71 64611 04 01/01/11 N I 54.43 52.96 64612 04 N I 71.15 69.23 64615 04 01/01/13 N I 79.37 77.23 64616 04 01/01/14 N I 66.54 64.74 64617 04 01/01/14 N I 69.32 67.45 64620 04 N I 80.90 78.72 64630 04 N I 88.50 86.11 64632 04 01/01/09 N I 90.50 88.06 64633 04 01/01/12 N I 138.48 134.74 64634 04 04/01/17 N I 41.84 4 167.36 40.71 162.84 64635 04 01/01/12 N I 135.68 132.02 64636 04 08/01/16 N I 36.35 4 145.40 35.37 141.47 64640 04 N I 90.50 88.06 64642 04 01/01/14 N I 65.69 63.92 64643 04 01/01/14 N I 44.26 43.06 64644 04 01/01/14 N I 71.56 69.63 64645 04 01/01/14 N I 50.79 49.42 64646 04 01/01/14 N I 70.93 69.01 64647 04 01/01/14 N I 81.91 79.70 64650 04 N I 3 22.42 21.81 64653 04 N I 3 28.36 27.59 64680 04 N M 224.70 218.63 64681 04 N I 116.11 112.98 64702 04 N M 4 Y Y 524.40 510.24 64704 04 N M 4 Y Y 191.28 186.12 64708 04 N M 4 Y Y 524.40 510.24 64712 04 N M 4 Y Y 524.40 510.24 64713 04 N M 4 Y Y 647.90 630.41
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
64714 04 N M 4 Y Y 647.90 630.41 64716 04 Y M 4 Y Y64718 04 N M 4 Y Y 524.40 510.24 64719 04 N M 4 Y Y 524.40 510.24 64721 04 N M 4 Y Y 524.40 510.24 64722 04 N M 4 Y Y 524.40 510.24 64726 04 N M 4 Y Y 524.40 510.24 64727 04 N M 4 Y Y 524.40 510.24 64732 04 N I 9 Y Y 148.20 144.20 64734 04 N M 9 Y Y 158.30 154.03 64736 04 N M 9 224.70 218.63 64738 04 N M 9 Y Y 374.55 364.44 64740 04 N M 9 Y Y 224.70 218.63 64742 04 N M 9 Y Y 224.70 218.63 64744 04 N M 9 Y Y 607.60 591.19 64746 04 N I 4 Y Y 181.05 176.16 64755 04 N M 5 Y Y 524.40 510.24 64760 04 N M 5 Y Y 524.40 510.24 64763 04 N M 3 Y Y 224.70 218.63 64766 04 N M 4 Y Y 374.55 364.44 64771 04 N M 9 Y 374.55 364.44 64772 04 N M 8 Y Y 374.55 364.44 64774 04 05/04/16 N M 4 144.55 34.00 140.65 64776 04 N M 3 Y Y 180.30 175.43 64778 04 Y M 3 Y Y64782 04 N M 3 Y Y 240.00 233.52 64783 04 N M 3 Y Y 120.60 117.34 64784 04 05/04/16 N M 3 Y 359.30 349.60 64786 04 N M 3 Y Y 470.15 457.46 64787 04 N M 3 Y 124.70 121.33 64788 04 N I 4 Y 139.60 34.00 135.83 64790 04 N M 3 Y Y 359.30 349.60 64792 04 12/01/10 N M 3 Y Y 670.95 652.83 64795 04 N I 3 112.40 109.37 64802 04 N M 6 Y Y 480.00 467.04 64804 04 N M 11 Y Y 599.35 583.17 64809 04 N M 11 Y Y 749.20 728.97 64818 04 N M 4 Y Y 653.40 635.76 64820 04 Y M 4 Y Y64821 04 N M 4 Y 407.40 396.40 64822 04 N M 4 Y 407.40 396.40
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
64823 04 N M 4 Y 471.00 458.28 64831 04 N M 4 Y Y 252.45 245.63 64832 04 N M 4 Y Y 139.00 135.25 64834 04 N M 4 Y Y 299.70 291.61 64835 04 N M 4 Y Y 599.35 583.17 64836 04 N M 4 Y Y 599.35 583.17 64837 04 N M 4 Y Y 299.70 291.61 64840 04 N M 4 Y Y 449.50 437.36 64856 04 N M 4 Y Y 449.50 437.36 64857 04 N M 4 Y Y 449.50 437.36 64858 04 N M 4 Y Y 599.35 583.17 64859 04 N M 4 Y Y 229.70 223.50 64861 04 N M 4 Y Y 718.70 699.30 64862 04 N M 4 Y Y 718.70 699.30 64864 04 N M 4 Y Y 599.35 583.17 64865 04 N M 4 Y Y 861.50 838.24 64866 04 N M 4 Y Y 599.35 583.17 64868 04 N M 4 Y Y 599.35 583.17 64872 04 N M 4 Y Y 449.50 437.36 64874 04 N M 4 Y Y 749.20 728.97 64876 04 N M 4 Y Y 524.40 510.24 64885 04 N M 4 Y Y 507.15 493.46 64886 04 N M 4 Y Y 600.65 584.43 64890 04 N M 4 Y Y 455.90 443.59 64891 04 N M 4 Y Y 457.30 444.95 64892 04 N M 4 Y Y 557.45 542.40 64893 04 N M 4 Y Y 557.45 542.40 64895 04 N M 4 Y Y 551.10 536.22 64896 04 N M 4 Y Y 619.50 602.77 64897 04 N M 4 Y Y 665.50 647.53 64898 04 N M 4 Y Y 665.50 647.53 64901 04 N M 4 Y Y 316.55 308.00 64902 04 N M 4 Y Y 359.70 349.99 64905 04 09/01/13 N M 4 Y Y 627.62 610.67 64907 04 09/01/13 N M 4 Y Y 735.24 715.39 64910 04 01/01/07 Y M 464911 04 01/01/07 Y M64999 04 Y M Y Y65091 04 N M 5 359.30 349.60 65093 04 N M 5 480.00 467.04 65101 04 N M 5 359.30 349.60
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
65103 04 N M 5 480.00 467.04 65105 04 N M 5 599.35 583.17 65110 04 N M 5 898.95 874.68 65112 04 N M 5 973.90 947.60 65114 04 N M 5 1048.85 1,020.53 65125 04 Y M 565130 04 N M 5 749.20 728.97 65135 04 N M 5 449.50 437.36 65140 04 N M 5 599.35 583.17 65150 04 N M 5 524.40 510.24 65155 04 N M 5 475.25 462.42 65175 04 N M 5 236.70 230.31 65205 04 N I 3 58.15 56.58 65210 04 N I 5 62.60 60.91 65220 04 N I 3 73.50 71.52 65222 04 N I 3 64.60 62.86 65235 04 N M 5 480.00 467.04 65260 04 N M 5 480.00 467.04 65265 04 N M 5 480.00 467.04 65270 04 N M 5 107.00 17.00 104.11 65272 04 N M 5 142.70 17.00 138.85 65273 04 N M 5 224.70 218.63 65275 04 N M 5 359.30 349.60 65280 04 N M 5 599.35 583.17 65285 04 N M 5 599.35 583.17 65286 04 N M 5 359.30 349.60 65290 04 N M 5 449.50 437.36 65400 04 N M 5 323.30 314.57 65410 04 N I 5 51.40 17.00 50.01 65420 04 N M 5 Y 273.30 265.92 65426 04 N M 5 348.15 338.75 65430 04 N I 3 78.50 17.00 76.38 65435 04 N I 5 48.55 47.24 65436 04 N I 5 125.25 121.87 65450 04 N I 5 Y 135.40 131.74 65600 04 N M 5 240.00 233.52 65710 04 N M 5 839.25 816.59 65730 04 N M 5 Y 1317.95 1,282.37 65750 04 N M 5 1317.95 1,282.37 65755 04 N M 5 Y 1317.95 1,282.37 65756 04 01/01/09 N M 5 839.35 816.69
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
65760 04 N M 5 1560.80 1,518.66 65765 04 N M 5 1560.80 1,518.66 65767 04 N M 5 Y 1560.80 1,518.66 65770 04 04/01/14 N M 5 Y 839.35 816.69 65772 04 N M 5 Y 1252.00 1,218.20 65775 04 N M 5 Y 648.10 630.60 65778 04 01/01/11 N I 45.05 43.83 65779 04 01/01/11 N I Y 172.53 167.87 65780 04 N M 5 Y Y 403.90 392.99 65781 04 N M 5 Y Y 617.78 601.10 65782 04 N M 5 Y Y 532.61 518.23 65785 04 01/01/16 N M 5 Y 231.40 225.15 65800 04 N M 5 240.00 233.52 65810 04 N M 5 299.70 291.61 65815 04 N M 5 480.00 467.04 65820 04 N M 5 599.35 583.17 65850 04 N M 5 Y 599.35 583.17 65855 04 N M 5 599.35 583.17 65860 04 N M 5 Y 299.70 291.61 65865 04 N M 5 299.70 291.61 65870 04 N M 5 297.00 288.98 65875 04 N M 5 324.05 315.30 65880 04 N M 5 299.70 291.61 65900 04 N M 5 378.05 367.84 65920 04 04/01/14 N M 5 Y 343.65 334.37 65930 04 N M 5 480.00 467.04 66020 04 N M 5 180.30 175.43 66030 04 N M 5 180.30 175.43 66130 04 N M 5 273.30 265.92 66150 04 N M 5 718.70 699.30 66155 04 N M 5 718.70 699.30 66160 04 N M 5 718.70 699.30 66170 04 03/01/12 N M Y 718.70 699.30 66172 04 03/01/12 N M Y 810.10 788.23 66174 04 N M 5 Y 585.45 569.64 66175 04 N M 5 Y 678.24 659.93 66179 04 01/01/15 N M Y 629.24 612.25 66180 04 03/01/12 N M Y 799.70 778.11 66183 04 01/01/14 N M 638.49 621.25 66184 04 01/01/15 N M 5 Y 456.59 444.26 66185 04 N M 5 Y 351.00 341.52
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
66220 04 N M 5 550.90 536.03 66225 04 N M 5 675.10 656.87 66250 04 01/01/14 N M 5 243.75 237.17 66500 04 N M 5 149.80 145.76 66505 04 N M 5 240.00 233.52 66600 04 N M 5 581.30 565.60 66605 04 N M 5 581.30 565.60 66625 04 N M 5 581.30 565.60 66630 04 N M 5 581.30 565.60 66635 04 N M 5 581.30 565.60 66680 04 N M 5 471.70 458.96 66682 04 N M 5 Y Y 471.70 458.96 66700 04 N M 5 341.30 332.08 66710 04 N M 5 341.30 332.08 66711 04 N M 5 341.30 332.08 66720 04 N M 5 Y 341.30 332.08 66740 04 N M 5 569.30 553.93 66761 04 N M 5 449.50 437.36 66762 04 N M 5 449.50 437.36 66770 04 N M 5 374.55 364.44 66820 04 N M 5 Y 299.70 291.61 66821 04 N M 6 299.70 291.61 66825 04 N M 5 Y 299.70 291.61 66830 04 N M 5 Y 374.55 364.44 66840 04 N M 5 Y 751.90 731.60 66850 04 N M 5 Y 751.90 731.60 66852 04 N M 5 Y 751.90 731.60 66920 04 N M 5 Y 751.90 731.60 66930 04 N M 5 Y 751.90 731.60 66940 04 N M 5 Y 751.90 731.60 66982 04 N M 5 587.60 571.73 66983 04 N M 5 Y 1051.60 1,023.21 66984 04 N M 5 1051.60 1,023.21 66985 04 N M 5 574.75 559.23 66986 04 N M 5 546.00 531.26 66990 09 Y N66999 04 Y M Y67005 04 N M 5 Y 749.20 728.97 67010 04 N M 5 Y 749.20 728.97 67015 04 N M 5 Y 861.50 838.24 67025 04 N M 5 Y 818.45 796.35
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
67027 04 N M 5 Y 524.35 510.19 67028 04 N I 5 287.10 279.35 67030 04 N M 5 Y 818.45 796.35 67031 04 N M 5 818.45 796.35 67036 04 N M 5 Y 1086.30 1,056.97 67039 04 N M 5 Y 1086.30 1,056.97 67040 04 N M 5 Y Y 1086.30 1,056.97 67041 04 01/01/08 N M Y Y 613.65 597.08 67042 04 01/01/08 N M 5 Y Y 703.00 684.02 67043 04 01/01/08 N M 5 Y Y 737.55 717.64 67101 04 N M 6 434.30 422.57 67105 04 N M 6 457.20 444.86 67107 04 N M 6 Y 980.85 954.37 67108 04 N M 6 Y 1086.30 1,056.97 67110 04 N M 6 Y 434.30 422.57 67113 04 01/01/08 N M 6 Y Y 809.66 787.80 67115 04 N M 3 Y 735.60 715.74 67120 04 N M 5 958.60 932.72 67121 04 01/01/13 N M 5 Y 513.70 499.83 67141 04 N M 6 443.95 431.96 67145 04 N M 6 Y 443.95 431.96 67208 04 N M 6 Y 443.95 431.96 67210 04 N M 6 Y 443.95 431.96 67218 04 N M 6 486.10 472.98 67220 04 N M 6 Y 443.95 431.96 67221 04 N M 6 Y 225.30 219.22 67225 04 N I 3 42.55 41.40 67227 04 N M 6 Y 443.95 431.96 67228 04 N M 6 466.15 453.56 67229 04 01/01/08 N M 532.19 517.82 67250 04 N M 5 749.20 728.97 67255 04 N M 5 898.95 874.68 67299 04 Y M Y67311 04 N M 5 Y 511.90 498.08 67312 04 N M 5 Y 511.90 498.08 67314 04 N M 5 Y 511.90 498.08 67316 04 N M 5 Y 511.90 498.08 67318 04 N M 5 Y 550.90 536.03 67320 04 N M 5 Y 647.20 629.73 67331 04 N M 5 Y 374.55 364.44 67332 04 N M 5 Y 511.90 498.08
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
67334 04 N M 5 Y 511.90 498.08 67335 09 Y N67340 04 N M 5 Y 405.10 394.16 67343 04 N M 5 Y 399.60 388.81 67345 04 N M 5 Y 100.00 97.30 67346 04 01/01/07 N I 5 107.00 104.11 67399 04 Y M Y67400 04 N M 5 Y 681.10 662.71 67405 04 N M 5 Y 524.40 510.24 67412 04 N M 5 Y 839.35 816.69 67413 04 N M 5 Y 839.35 816.69 67414 04 N M 5 Y 797.40 775.87 67415 04 N I 5 56.80 17.00 55.27 67420 04 N M 5 Y 1079.30 1,050.16 67430 04 N M 5 1079.30 1,050.16 67440 04 N M 5 681.10 662.71 67445 04 N M 5 Y 1025.40 997.71 67450 04 N M 5 Y 681.10 662.71 67500 04 N I 5 78.20 76.09 67505 04 N M 5 74.90 72.88 67515 04 N I 5 74.90 72.88 67550 04 N M 5 415.85 404.62 67560 04 N M 5 340.90 331.70 67570 04 N M 5 Y 797.40 775.87 67599 04 Y M Y67700 04 N I 3 73.50 71.52 67710 04 N M 4 224.70 218.63 67715 04 N I 4 59.60 57.99 67800 04 N I 3 77.20 17.00 75.12 67801 04 N I 3 91.85 17.00 89.37 67805 04 N M 3 99.05 17.00 96.38 67808 04 N I 3 112.80 109.75 67810 04 N I 3 68.10 17.00 66.26 67820 04 N I 3 30.50 29.68 67825 04 N I 3 88.50 86.11 67830 04 N I 3 112.60 109.56 67835 04 N M 4 187.30 182.24 67840 04 N I 3 93.30 17.00 90.78 67850 04 N I 3 90.20 87.76 67875 04 N M 4 Y 187.30 182.24 67880 04 N M 4 187.30 182.24
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
67882 04 N M 4 Y 231.50 225.25 67900 04 N M Y 216.00 210.17 67901 04 N M 4 685.40 666.89 67902 04 N M 4 685.40 666.89 67903 04 N M 4 685.40 666.89 67904 04 N M 4 Y 685.40 666.89 67906 04 N M 4 749.20 728.97 67908 04 N M 4 749.20 728.97 67909 04 N M 4 749.20 728.97 67911 04 N M 4 749.20 728.97 67912 04 N M 4 Y 221.64 215.66 67914 04 N M 4 359.30 349.60 67915 04 N I 4 133.90 130.28 67916 04 N M 4 299.70 291.61 67917 04 N M 4 359.30 349.60 67921 04 N M 4 359.30 349.60 67922 04 N I 4 130.70 127.17 67923 04 N M 4 299.70 291.61 67924 04 N M 4 359.30 349.60 67930 04 N M 4 189.00 17.00 183.90 67935 04 N M 4 244.50 17.00 237.90 67938 04 N I 80.90 17.00 78.72 67950 04 N M 4 359.30 349.60 67961 04 N M 4 324.05 315.30 67966 04 N M 4 345.70 336.37 67971 04 N M 4 449.50 437.36 67973 04 N M 4 449.50 437.36 67974 04 N M 4 449.50 437.36 67975 04 N M 4 449.50 437.36 67999 04 Y M Y68020 04 N I 3 72.55 17.00 70.59 68040 04 N I 3 71.40 17.00 69.47 68100 04 N I 4 77.60 17.00 75.50 68110 04 N M 4 180.30 175.43 68115 04 N M 4 180.30 175.43 68130 04 N M 4 224.70 218.63 68135 04 N M 4 224.70 218.63 68200 04 N I 3 56.60 55.07 68320 04 N M 4 449.50 437.36 68325 04 N M 4 531.30 516.95 68326 04 N M 4 531.30 516.95
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
68328 04 N M 4 531.30 516.95 68330 04 N M 4 299.70 291.61 68335 04 N M 4 524.40 510.24 68340 04 N M 4 299.70 291.61 68360 04 N M 4 240.00 233.52 68362 04 N M 4 359.30 349.60 68371 04 N M 3 Y 191.25 186.09 68399 04 Y M Y Y68400 04 N I 4 103.60 17.00 100.80 68420 04 N I 4 117.70 17.00 114.52 68440 04 N I 4 66.90 17.00 65.09 68500 04 N M 4 599.35 583.17 68505 04 N M 5 336.45 327.37 68510 04 N I 4 191.40 17.00 186.23 68520 04 N M 4 599.35 583.17 68525 04 N I 4 124.50 17.00 121.14 68530 04 N I 4 174.60 17.00 169.89 68540 04 N M 4 599.35 583.17 68550 04 N M 4 648.10 630.60 68700 04 N M 4 359.30 349.60 68705 04 N I 4 93.60 91.07 68720 04 N M 4 Y Y 839.35 816.69 68745 04 N M 4 839.35 816.69 68750 04 N M 4 Y 858.70 835.52 68760 04 N I 4 84.10 81.83 68761 04 N I 4 75.50 73.46 68770 04 04/01/14 N M 4 Y 301.02 292.89 68801 04 N I 4 71.70 69.76 68810 04 N I 4 103.50 100.71 68811 04 N I 4 115.10 111.99 68815 04 N I 4 143.40 139.53 68816 04 01/01/08 N I 4 115.00 205.23 111.90 68840 04 N I 4 83.30 81.05 68850 04 N I 4 116.35 113.21 68899 04 Y M Y69000 04 N I 3 42.40 17.00 41.26 69005 04 N I 3 64.10 17.00 62.37 69020 04 N I 3 44.60 17.00 43.40 69100 04 N I 4 31.15 17.00 30.31 69105 04 N I 4 50.20 17.00 48.84 69110 04 N M 4 209.40 203.75
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
69120 04 N M 4 240.00 233.52 69140 04 N M 4 480.00 467.04 69145 04 N I 4 90.10 87.67 69150 04 N M 4 Y 718.70 699.30 69155 04 N M 5 Y 1198.70 1,166.34 69200 04 N I 26.60 25.88 69205 04 N I 4 74.90 72.88 69209 04 01/01/16 N I 3 7.10 6.91 69210 04 N I 3 21.40 20.82 69220 04 N I 3 Y Y 28.50 27.73 69222 04 N I 3 Y Y 57.30 55.75 69300 09 Y M69310 04 N M 3 694.40 675.65 69320 04 N M 3 958.60 932.72 69399 04 Y M Y69420 04 N I 3 43.80 17.00 42.62 69421 04 N I 3 56.60 55.07 69424 04 N I 3 30.35 29.53 69433 04 N I 76.60 34.00 74.53 69436 04 N I 3 80.50 78.33 69440 04 N M 4 599.35 583.17 69450 04 N I 4 191.10 185.94 69501 04 N M 4 Y Y 692.20 673.51 69502 04 N M 4 Y Y 692.20 673.51 69505 04 N M 4 Y Y 749.20 728.97 69511 04 N M 4 Y Y 839.35 816.69 69530 04 N M 4 Y Y 1198.70 1,166.34 69535 04 N M 4 Y Y 1198.70 1,166.34 69540 04 N I 4 Y 50.20 17.00 48.84 69550 04 N I 4 Y 363.60 17.00 353.78 69552 04 N M 4 Y 674.20 656.00 69554 04 N M 4 Y Y 954.95 929.17 69601 04 N M 4 Y Y 695.05 676.28 69602 04 N M 4 Y 695.05 676.28 69603 04 N M 4 Y Y 695.05 676.28 69604 04 N M 4 Y Y 695.05 676.28 69605 04 N M 4 Y Y 695.05 676.28 69610 04 N M 4 Y Y 160.75 156.41 69620 04 N M 4 Y Y 254.67 247.79 69631 04 N M 4 Y Y 749.20 728.97 69632 04 N M 4 Y Y 749.20 728.97
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
69633 04 N M 4 Y 861.50 838.24 69635 04 N M 4 Y Y 749.20 728.97 69636 04 N M 4 Y Y 749.20 728.97 69637 04 N M 4 Y 861.50 838.24 69641 04 N M 4 Y Y 1048.85 1,020.53 69642 04 N M 4 Y Y 1048.85 1,020.53 69643 04 N M 4 Y Y 1048.85 1,020.53 69644 04 N M 4 Y 1048.85 1,020.53 69645 04 N M 4 Y Y 1048.85 1,020.53 69646 04 N M 4 Y Y 1048.85 1,020.53 69650 04 N M 4 Y Y 743.65 723.57 69660 04 N M 4 Y Y 749.20 728.97 69661 04 N M 5 Y Y 749.20 728.97 69662 04 N M 4 Y Y 749.20 728.97 69666 04 N M 4 Y Y 749.20 728.97 69667 04 N M 4 Y Y 749.20 728.97 69670 04 N M 4 Y Y 1079.30 1,050.16 69676 04 N M 4 Y Y 834.50 811.97 69700 04 N M 4 Y Y 299.70 291.61 69710 04 N M 3 918.15 893.36 69711 04 N M 3 Y 550.90 536.03 69714 04 N M 3 Y 604.65 588.32 69715 04 N M 3 Y 765.85 745.17 69717 04 N M 3 Y 623.25 606.42 69718 04 N M 3 Y 775.20 754.27 69720 04 N M 4 Y Y 749.20 728.97 69725 04 N M 4 Y Y 749.20 728.97 69740 04 N M 4 Y Y 599.35 583.17 69745 04 N M 4 Y Y 947.20 921.63 69799 04 Y M Y69801 04 N I 5 Y Y 75.95 73.90 69805 04 N M 5 Y Y 749.20 728.97 69806 04 N M 5 Y Y 749.20 728.97 69820 04 N M 5 Y Y 749.20 728.97 69840 04 N M 5 Y Y 749.20 728.97 69905 04 N M 5 Y Y 1198.70 1,166.34 69910 04 N M 5 Y 1198.70 1,166.34 69915 04 N M 5 Y Y 1198.70 1,166.34 69930 04 N M 3 Y 1296.20 1,261.20 69949 04 Y M Y69950 04 N M 4 Y Y 1079.30 1,050.16
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
69955 04 N M 4 Y Y 1079.30 1,050.16 69960 04 N M 4 Y Y 1198.70 1,166.34 69970 04 N M 4 Y Y 1188.20 1,156.12 69979 04 Y M Y69990 09 Y N70010 04 N I 28.70 27.93 70015 04 N I 39.20 38.14 70030 A 04 N N 10.75 10.75 21.50 20.92 70100 A 04 N N 11.40 11.40 22.80 22.18 70110 A 04 N N 15.65 15.65 31.30 30.45 70120 A 04 N N 11.40 11.40 22.80 22.18 70130 A 04 N N 15.65 15.65 31.30 30.45 70134 A 04 N N 20.25 20.25 40.50 39.41 70140 A 04 N N 14.35 14.35 28.70 27.93 70150 A 04 N N 17.62 15.62 35.25 34.30 70160 A 04 N N 10.47 10.47 20.95 20.38 70170 04 N I 18.30 17.81 70190 A 04 N N 11.40 11.40 22.80 22.18 70200 A 04 N N 17.62 17.62 35.25 34.30 70210 A 04 N N 11.10 11.10 22.20 21.60 70220 A 04 N N 14.35 14.35 28.70 27.93 70240 A 04 N N 11.40 11.40 22.80 22.18 70250 A 04 N N 10.75 10.75 21.50 20.92 70260 A 04 N N 17.62 17.62 35.25 34.30 70300 A 04 N N 5.90 5.90 11.80 11.48 70310 A 04 N N 7.17 7.17 14.35 13.96 70320 A 04 N N 14.35 14.35 28.70 27.93 70328 A 04 N N 14.35 14.35 28.70 27.93 70330 A 04 N N 14.35 14.35 28.70 27.93 70332 04 N I 23.30 22.67 70336 B 04 03/01/11 N N 148.30 148.30 296.60 288.59 70350 A 04 N N 7.17 7.17 14.35 13.96 70355 B 04 01/01/12 N N 14.35 14.35 28.70 27.93 70360 A 04 N N 7.17 7.17 14.35 13.96 70370 A 04 N N 13.07 13.07 26.15 25.44 70371 A 04 N N 12.70 12.70 25.40 24.71 70380 A 04 N N 11.10 11.10 22.20 21.60 70390 04 N I 22.20 21.60 70450 C 04 01/01/14 N N 3 88.97 158.18 247.15 240.48 70460 C 04 01/01/14 N N 3 98.86 183.59 282.45 274.82 70470 B 04 N N 3 141.22 141.22 282.45 274.82
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
70480 B 04 N N 3 31.35 31.35 62.70 61.01 70481 B 04 N N 4 37.95 37.95 75.90 73.85 70482 B 04 N N 4 54.92 54.92 109.95 106.98 70486 B 04 N N 3 31.35 31.35 62.70 61.01 70487 B 04 N N 3 37.95 37.95 75.90 73.85 70488 B 04 N N 3 54.92 54.92 109.85 106.88 70490 B 04 N N 3 31.35 31.35 62.70 61.01 70491 B 04 N N 3 37.95 37.95 75.90 73.85 70492 B 04 N N 3 54.92 54.92 109.85 106.88 70496 B 04 03/01/11 N N 123.52 123.52 247.05 240.38 70498 B 04 03/01/11 N N 123.52 123.52 247.05 240.38 70540 B 04 N N 148.30 148.30 296.60 288.59 70542 B 04 N N 3 148.30 148.30 296.60 288.59 70543 B 04 N N 3 223.93 223.92 447.85 435.76 70544 C 04 02/01/14 N N 3 47.46 249.14 296.60 288.59 70545 B 04 N N 3 148.30 148.30 296.60 288.59 70546 B 04 N N 3 204.77 204.78 409.55 398.49 70547 B 04 N N 3 148.30 148.30 296.60 288.59 70548 B 04 N N 3 148.30 148.30 296.60 288.59 70549 B 04 N N 3 204.77 204.78 409.55 398.49 70551 C 04 01/01/14 N N 3 94.91 201.69 296.60 288.59 70552 C 04 01/01/14 N N 86.01 210.59 296.60 288.59 70553 C 04 01/01/14 N N 91.95 204.65 296.60 288.59 70554 C 04 01/01/07 N N 50.42 246.18 1 296.60 288.59 70555 04 01/01/07 N N 64.32 62.58 70557 04 N M 79.06 76.93 70558 04 N M 87.53 85.17 70559 04 N N 88.02 85.64 71010 A 04 N N 8.50 8.50 17.00 16.54 71015 A 04 N N 10.75 10.75 21.50 20.92 71020 A 04 N N 10.75 10.75 21.50 20.92 71021 A 04 N N 10.75 10.75 21.50 20.92 71022 A 04 N N 10.75 10.75 21.50 20.92 71023 A 04 N N 10.75 10.75 21.50 20.92 71030 A 04 N N 14.35 14.35 28.70 27.93 71034 A 04 N N 14.35 14.35 28.70 27.93 71035 A 04 N N 14.35 14.35 28.70 27.93 71100 A 04 N N 10.75 10.75 21.50 20.92 71101 A 04 N N 12.40 12.40 24.80 24.13 71110 A 04 N N 13.07 13.08 26.15 25.44 71111 A 04 N N 14.35 14.35 28.70 27.93
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
71120 A 04 N N 10.75 10.75 21.50 20.92 71130 A 04 N N 14.35 14.35 28.70 27.93 71250 B 04 N N 4 31.35 31.35 62.70 61.01 71260 B 04 N N 3 37.95 37.95 75.90 73.85 71270 B 04 N N 3 54.93 54.92 109.85 106.88 71275 B 04 03/01/11 N N 132.50 132.50 265.00 257.85 71550 B 04 N N 148.30 148.30 296.60 288.59 71551 B 04 N N 3 148.30 148.30 296.60 288.59 71552 B 04 N N 3 224.03 224.02 448.05 435.95 71555 B 04 N N 3 148.30 148.30 296.60 288.59 72020 A 04 N N 12.07 12.08 24.15 23.50 72040 A 04 N N 12.07 12.08 24.15 23.50 72050 A 04 N N 17.63 17.62 35.25 34.30 72052 A 04 N N 18.25 18.25 36.50 35.51 72070 A 04 N N 11.40 11.40 22.80 22.18 72072 A 04 N N 10.47 10.48 20.95 20.38 72074 A 04 N N 10.75 10.75 21.50 20.92 72080 A 04 N N 12.70 12.70 25.40 24.71 72081 C 04 01/01/16 N N 8.08 13.94 22.01 21.42 72082 C 04 01/01/16 N N 9.74 25.27 35.00 34.06 72083 C 04 01/01/16 N N 10.60 27.41 38.01 36.98 72084 C 04 01/01/16 N N 12.28 33.08 45.35 44.13 72100 A 04 N N 14.35 14.35 28.70 27.93 72110 A 04 N N 18.95 18.95 37.90 36.88 72114 C 04 01/01/12 N N 10.26 27.64 37.90 36.88 72120 C 04 01/01/12 N N 10.75 27.15 37.90 36.88 72125 B 04 N N 4 31.35 31.35 62.70 61.01 72126 B 04 N N 4 37.95 37.95 75.90 73.85 72127 B 04 N N 4 54.93 54.92 109.85 106.88 72128 B 04 N N 4 31.35 31.35 62.70 61.01 72129 B 04 N N 4 37.95 37.95 75.90 73.85 72130 B 04 N N 4 54.93 54.92 109.85 106.88 72131 B 04 N N 4 31.35 31.35 62.70 61.01 72132 B 04 N N 4 37.95 37.95 75.90 73.85 72133 B 04 N N 4 54.93 54.92 109.85 106.88 72141 C 04 01/01/14 N N 97.88 198.72 296.60 288.59 72142 C 04 01/01/14 N N 86.01 210.59 296.60 288.59 72146 C 04 01/01/14 N N 97.88 198.72 296.60 288.59 72147 C 04 01/01/14 N N 86.01 210.59 296.60 288.59 72148 C 04 01/01/14 N N 97.88 198.72 296.60 288.59 72149 C 04 01/01/14 N N 86.01 210.59 296.60 288.59
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
72156 C 04 01/01/14 N N 91.95 204.65 296.60 288.59 72157 C 04 01/01/14 N N 91.95 204.65 296.60 288.59 72158 C 04 01/01/14 N N 91.95 204.65 296.60 288.59 72159 B 04 N N 148.30 148.30 296.60 288.59 72170 A 04 N N 7.85 7.85 15.70 15.28 72190 A 04 N N 17.63 17.62 35.25 34.30 72191 C 04 01/01/14 N N 3 64.15 192.45 256.60 249.67 72192 B 04 N N 3 31.35 31.35 62.70 61.01 72193 B 04 N N 3 37.95 37.95 75.90 73.85 72194 B 04 N N 3 54.93 54.92 109.85 106.88 72195 B 04 N N 3 148.30 148.30 296.60 288.59 72196 B 04 N N 148.30 148.30 296.60 288.59 72197 B 04 N N 3 226.15 226.15 452.30 440.09 72198 B 04 N N 148.30 148.30 296.60 288.59 72200 A 04 N N 10.75 10.75 21.50 20.92 72202 A 04 N N 11.40 11.40 22.80 22.18 72220 A 04 N N 10.75 10.75 21.50 20.92 72240 04 N I 65.35 63.59 72255 04 N I 52.30 50.89 72265 04 N N 52.30 50.89 72270 04 N N 99.35 96.67 72275 04 N I 57.45 55.90 72285 04 N I 52.30 50.89 72295 04 N I 45.80 44.56 73000 A 04 N N 7.50 7.50 15.00 14.60 73010 A 04 N N 10.75 10.75 21.50 20.92 73020 A 04 N N 10.75 10.75 21.50 20.92 73030 A 04 N N 11.10 11.10 22.20 21.60 73040 C 04 N I 6.03 17.47 23.50 22.87 73050 A 04 N N 10.07 10.08 20.15 19.61 73060 A 04 N N 7.85 7.85 15.70 15.28 73070 A 04 N N 9.80 9.80 19.60 19.07 73080 B 04 03/01/11 N N 10.75 10.75 21.50 20.92 73085 04 N I 22.20 21.60 73090 A 04 N N 9.15 9.15 18.30 17.81 73092 A 04 N N 7.17 7.18 14.35 13.96 73100 A 04 N N 10.75 10.75 21.50 20.92 73110 A 04 N N 11.10 11.10 22.20 21.60 73115 C 04 09/01/09 N I 8.73 21.37 30.10 29.29 73120 A 04 N N 8.50 8.50 17.00 16.54 73130 A 04 N N 9.15 9.15 18.30 17.81
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
73140 A 04 N N 7.17 7.18 14.35 13.96 73200 B 04 N N 3 31.35 31.35 62.70 61.01 73201 B 04 N N 3 37.95 37.95 75.90 73.85 73202 B 04 N N 3 54.93 54.92 109.85 106.88 73206 B 04 N N 3 115.55 115.55 231.10 224.86 73218 B 04 N N 3 148.30 148.30 296.60 288.59 73219 B 04 N N 3 148.30 148.30 296.60 288.59 73220 B 04 N N 148.30 148.30 296.60 288.59 73221 B 04 N N 3 148.30 148.30 296.60 288.59 73222 B 04 N N 3 148.30 148.30 296.60 288.59 73223 B 04 N N 3 223.92 223.92 447.85 435.76 73225 B 04 N N 148.30 148.30 296.60 288.59 73501 C 04 01/01/16 N N 5.70 11.01 16.71 16.26 73502 C 04 01/01/16 N N 6.75 16.48 23.23 22.60 73503 C 04 01/01/16 N N 8.68 20.38 29.06 28.28 73521 C 04 01/01/16 N N 6.95 15.31 22.25 21.65 73522 C 04 01/01/16 N N 9.11 18.43 27.54 26.80 73523 C 04 01/01/16 N N 9.74 22.14 31.88 31.02 73525 C 04 N I 14.02 38.28 52.30 50.89 73551 C 04 01/01/16 N N 5.08 10.62 15.69 15.27 73552 C 04 01/01/16 N N 5.70 12.57 18.27 17.78 73560 A 04 N N 9.80 9.80 19.60 19.07 73562 A 04 N N 10.10 10.10 20.20 19.65 73564 A 04 N N 11.10 11.10 22.20 21.60 73565 A 04 N N 16.70 16.70 33.40 32.50 73580 04 N I 37.90 36.88 73590 A 04 N N 10.75 10.75 21.50 20.92 73592 A 04 N N 10.75 10.75 21.50 20.92 73600 A 04 N N 10.75 10.75 21.50 20.92 73610 A 04 N N 14.35 14.35 28.70 27.93 73615 C 04 N I 7.85 18.30 26.15 25.44 73620 A 04 N N 8.50 8.50 17.00 16.54 73630 A 04 N N 10.75 10.75 21.50 20.92 73650 A 04 N N 8.50 8.50 17.00 16.54 73660 A 04 N N 7.17 7.17 14.35 13.96 73700 B 04 N N 3 31.35 31.35 62.70 61.01 73701 B 04 N N 3 37.95 37.95 75.90 73.85 73702 B 04 N N 54.92 54.92 109.85 106.88 73706 B 04 N N 3 115.55 115.55 231.10 224.86 73718 B 04 N N 3 148.30 148.30 296.60 288.59 73719 B 04 N N 3 148.30 148.30 296.60 288.59
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
73720 B 04 N N 3 148.30 148.30 296.60 288.59 73721 B 04 N N 3 148.30 148.30 296.60 288.59 73722 B 04 N N 3 148.30 148.30 296.60 288.59 73723 B 04 N N 3 223.92 223.92 447.85 435.76 73725 B 04 N N 148.30 148.30 296.60 288.59 74000 A 04 N N 10.75 10.75 21.50 20.92 74010 A 04 N N 12.70 12.70 25.40 24.71 74020 A 04 N N 12.70 12.70 25.40 24.71 74022 A 04 N N 20.95 20.95 41.90 40.77 74150 B 04 N N 4 31.35 31.35 62.70 61.01 74160 B 04 N N 4 37.95 37.95 75.90 73.85 74170 B 04 N N 4 54.92 54.92 109.85 106.88 74174 C 04 01/01/12 N N 62.42 249.66 312.08 303.65 74175 C 04 01/01/12 N N 51.33 205.32 256.65 249.72 74176 C 04 01/01/11 N N 50.54 74.50 125.04 121.66 74177 C 04 01/01/11 N N 52.94 142.02 194.96 189.70 74178 C 04 01/01/11 N N 58.67 187.68 246.35 239.70 74181 B 04 N N 148.30 148.30 296.60 288.59 74182 B 04 N N 3 148.30 148.30 296.60 288.59 74183 B 04 N N 3 226.15 226.15 452.30 440.09 74185 B 04 N N 148.30 148.30 296.60 288.59 74190 04 N I 21.50 20.92 74210 A 04 N N 14.35 14.35 28.70 27.93 74220 A 04 N N 14.35 14.35 28.70 27.93 74230 A 04 N N 12.70 12.70 25.40 24.71 74235 04 N I 4 122.40 119.10 74240 B 04 N N 24.85 24.85 49.70 48.36 74241 B 04 N N 25.50 25.50 51.00 49.62 74245 B 04 N N 32.02 32.02 64.05 62.32 74246 B 04 N N 26.15 26.15 52.30 50.89 74247 B 04 N N 26.80 26.80 53.60 52.15 74249 B 04 N N 32.02 32.02 64.05 62.32 74250 B 04 N N 21.57 21.57 43.15 41.98 74251 B 04 N N 29.45 29.45 58.90 57.31 74260 B 04 N N 18.25 18.25 36.50 35.51 74261 C 04 01/01/11 N N 69.31 226.62 295.93 287.94 74262 C 04 01/01/11 N N 72.63 255.97 328.60 319.73 74270 B 04 N N 24.85 24.85 49.70 48.36 74280 B 04 N N 29.45 29.45 58.90 57.31 74283 B 04 N N 29.45 29.45 58.90 57.31 74290 B 04 N N 17.62 17.62 35.25 34.30
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
74300 B 04 08/01/09 N I 17.62 17.62 35.25 34.30 74301 04 Y I74328 04 N I 3 64.05 62.32 74329 04 N I 3 92.80 90.29 74330 04 N I 3 100.65 97.93 74340 04 N I 3 51.00 49.62 74355 04 03/01/11 N I 118.60 115.40 74360 04 03/01/11 N I 44.90 43.69 74363 04 03/01/11 N I 170.00 165.41 74400 B 04 N N 24.85 24.85 49.70 48.36 74410 B 04 N N 28.77 28.77 57.55 56.00 74415 B 04 N N 28.77 28.77 57.55 56.00 74420 B 04 03/09/17 N I 14.35 14.35 28.70 27.93 74425 04 N I 28.70 27.93 74430 C 04 03/01/12 N I 7.29 16.21 23.50 22.87 74440 04 N I 32.70 31.82 74445 04 N I 28.70 27.93 74450 04 N I 26.15 25.44 74455 C 04 03/01/12 N I 4.97 21.18 26.15 25.44 74470 04 N I 18.30 17.81 74485 04 03/01/11 N I 28.50 27.73 74710 B 04 N N 22.90 22.90 45.80 44.56 74712 C 04 01/01/16 N N 90.89 180.97 271.87 264.53 74713 C 04 01/01/16 N N 54.01 77.60 131.62 128.07 74740 C 04 N I 10.65 28.55 39.20 38.14 74742 04 03/01/11 N I 39.20 38.14 74775 04 N N 71.20 69.28 75557 C 04 01/01/10 N N 68.87 230.81 299.68 291.59 75559 C 04 01/01/10 N N 87.60 344.24 431.84 420.18 75561 C 04 01/01/10 N N 76.18 325.65 401.83 390.98 75563 C 04 01/01/10 N N 90.99 404.09 495.08 481.71 75565 C 04 01/01/10 N N 7.36 41.70 49.06 47.74 75571 R 04 01/01/10 N N 21.37 88.48 109.85 106.88 75572 R 04 01/01/10 N N 21.37 88.48 109.85 106.88 75573 R 04 01/01/10 N N 21.37 88.48 109.85 106.88 75574 R 04 01/01/10 N N 21.37 88.48 109.85 106.88 75600 C 04 01/01/17 N I 14.28 95.57 109.85 106.88 75605 C 04 01/01/17 N I 33.20 44.00 77.20 75.12 75625 C 04 01/01/17 N I 42.18 55.92 98.10 95.45 75630 C 04 01/01/17 N I 70.63 60.17 130.80 127.27 75635 C 04 N I 3 51.14 230.26 281.40 273.80
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
75658 04 N I 78.45 76.33 75705 04 N I 98.10 95.45 75710 04 N I 78.45 76.33 75716 04 N I 111.10 108.10 75726 04 N I 91.45 88.98 75731 04 N I 91.45 88.98 75733 04 N I 115.10 111.99 75736 04 N I 91.45 88.98 75741 04 N I 91.45 88.98 75743 04 N I 117.60 114.42 75746 04 N I 65.35 63.59 75756 04 N I 39.20 38.14 75774 04 N I 3 25.10 24.42 75801 04 N I 35.25 34.30 75803 04 N I 75.90 73.85 75805 04 N I 77.20 75.12 75807 04 N I 91.45 88.98 75809 04 N I 3 77.20 75.12 75810 04 N I 91.45 88.98 75820 04 N I 45.80 44.56 75822 04 N I 65.35 63.59 75825 04 N I 78.45 76.33 75827 04 N I 100.65 97.93 75831 04 N I 91.45 88.98 75833 04 N I 111.10 108.10 75840 04 N I 57.55 56.00 75842 04 N I 91.45 88.98 75860 04 N I 78.45 76.33 75870 04 N I 52.30 50.89 75872 04 N I 130.80 127.27 75880 04 N I 28.70 27.93 75885 04 N I 3 64.30 62.56 75887 04 03/01/11 N I 54.60 53.13 75889 04 N I 128.20 124.74 75891 04 N I 93.40 90.88 75893 04 01/01/11 Y75894 04 N I 3 64.05 62.32 75893 04 N I 64.05 62.32 75898 04 N I 3 56.20 54.68 75901 04 N I 3 66.60 64.80 75902 04 N I 3 66.60 64.80
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
75952 04 N I 3 162.85 158.45 75953 04 N I 3 68.30 66.46 75954 04 N I 3 83.00 80.76 75956 04 03/01/11 N M Y 221.10 215.13 75957 04 03/01/11 N M Y 189.42 184.31 75958 04 03/01/11 N M Y 126.26 122.85 75959 04 03/01/11 N M Y 110.52 107.54 75970 04 N I 3 78.90 76.77 75984 C 04 03/01/14 N I 3 18.22 35.38 53.60 52.15 75989 04 N I 3 84.90 82.61 76000 04 N I 32.70 31.82 76001 04 N I 56.45 54.93 76010 A 04 N N 16.20 16.20 32.40 31.53 76080 04 N I 26.15 25.44 76098 A 04 N N 6.20 6.20 12.40 12.07 76100 A 04 N N 24.85 24.85 49.70 48.36 76101 A 04 N N 17.62 17.62 35.25 34.30 76102 A 04 N N 24.85 24.85 49.70 48.36 76120 A 04 N N 10.47 10.47 20.95 20.38 76125 A 04 N N 24.85 24.85 49.70 48.36 76140 04 N N 19.60 19.07 76376 C 04 01/01/12 N I 6.18 66.99 73.17 71.19 76377 C 04 N I 24.33 72.94 1 97.27 94.64 76380 04 N N 59.55 57.94 76390 B 04 N I 148.30 148.30 296.60 288.59 76496 04 Y I76497 B 04 Y I76498 B 04 Y I76499 04 Y N 376506 B 04 N N 32.02 32.02 64.05 62.32 76510 A 04 N N 32.67 32.67 65.35 63.59 76511 A 04 N N 24.85 24.85 49.70 48.36 76512 A 04 06/01/16 N N 32.67 32.67 Y 65.35 63.59 76513 A 04 N N 32.67 32.67 65.35 63.59 76514 C 04 N N 5.20 1.37 1 6.57 6.39 76516 A 04 N N 24.85 24.85 49.70 48.36 76519 A 04 N N 24.90 24.90 49.80 48.46 76529 A 04 N N 32.67 32.67 65.35 63.59 76536 B 04 N N 34.00 34.00 68.00 66.16 76604 B 04 N N 31.35 31.35 62.70 61.01 76641 C 04 01/01/15 N N 22.27 39.27 1 61.54 59.88
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
76642 C 04 01/01/15 N N 20.81 30.10 1 50.91 49.54 76700 C 04 01/01/17 N N 26.56 49.34 75.90 73.85 76705 C 04 03/01/17 N N 21.32 41.38 62.70 61.01 76706 C 04 01/01/17 N N 16.78 36.87 53.65 52.20 76770 B 04 N N 37.95 37.95 75.90 73.85 76775 B 04 N N 31.35 31.35 62.70 61.01 76776 C 04 01/01/07 N N 53.13 22.77 75.90 73.85 76800 B 04 N N 37.95 37.95 75.90 73.85 76801 B 04 N N 35.95 35.95 71.90 69.96 76802 B 04 N N 22.52 22.52 45.05 43.83 76805 B 04 N N 35.95 35.95 71.90 69.96 76810 B 04 N N 22.52 22.52 45.05 43.83 76811 B 04 N N 35.95 35.95 71.90 69.96 76812 B 04 N N 22.52 22.52 45.05 43.83 76813 C 04 01/01/07 N N 32.36 39.54 71.90 69.96 76814 C 04 01/01/07 N N 25.23 19.82 45.05 43.83 76815 B 04 N N 35.95 35.95 71.90 69.96 76816 B 04 N N 35.95 35.95 71.90 69.96 76817 B 04 N N 35.95 35.95 71.90 69.96 76818 B 04 N N 31.97 31.97 63.95 62.22 76819 B 04 N N 15.55 15.55 31.10 30.26 76820 B 04 N N 35.95 35.95 71.90 69.96 76821 B 04 N N 35.95 35.95 71.90 69.96 76825 B 04 N N 35.95 35.95 71.90 69.96 76826 B 04 N N 35.95 35.95 71.90 69.96 76827 B 04 N N 35.95 35.95 71.90 69.96 76828 B 04 N N 35.95 35.95 71.90 69.96 76830 B 04 01/01/12 N N 35.95 35.95 71.90 69.96 76831 B 04 N N 35.95 35.90 71.90 69.96 76856 B 04 01/01/12 N N 35.95 35.95 71.90 69.96 76857 B 04 01/01/12 N N 35.95 35.95 71.90 69.96 76870 B 04 N N 24.85 24.85 49.70 48.36 76872 B 04 N N 35.95 35.95 71.90 69.96 76873 B 04 N N 71.35 71.35 142.70 138.85 76881 C 04 01/01/11 N N 17.29 48.79 66.08 64.30 76882 C 04 01/01/11 N N 12.02 5.82 17.84 17.36 76885 B 04 N N 35.95 35.95 71.90 69.96 76886 B 04 N N 35.95 35.95 71.90 69.96 76930 04 N I 56.20 54.68 76932 04 N I 65.35 63.59 76936 04 N I 56.20 54.68 76937 C 04 04/01/11 N I 9.21 9.60 18.81 18.30
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
76940 C 04 N I 55.84 35.48 91.32 88.85 76941 04 N I 56.20 54.68 76942 C 04 06/01/09 N I 12.02 48.08 60.10 58.48 76945 04 N I 49.70 48.36 76946 C 04 01/01/11 N I 27.80 23.20 51.00 49.62 76965 B 04 N N 24.85 24.85 49.70 48.36 76970 04 Y N76975 04 N I 51.00 49.62 76977 B 04 N N 17.25 17.25 34.50 33.57 76998 04 01/01/12 N N 33.37 32.47 76999 04 Y N77001 C 04 01/01/07 N N 8.75 29.29 38.04 37.01 77002 C 04 03/01/11 N I 13.27 24.63 37.90 36.88 77003 C 04 01/01/12 N I 25.21 27.09 52.30 50.89 77011 C 04 01/01/07 N N 7.31 48.89 56.20 54.68 77012 C 04 01/01/07 N N 10.12 46.08 56.20 54.68 77013 04 N N 233.70 227.39 77014 C 04 03/01/15 N N 14.05 42.15 56.20 54.68 77021 C 04 01/01/07 N N 53.61 281.44 335.05 326.00 77022 C 04 01/01/07 N N 53.61 281.44 335.05 326.00 77053 C 04 01/01/07 N N 9.18 41.82 51.00 49.62 77054 C 04 01/01/07 N N 11.44 60.06 71.50 69.57 77058 C 04 01/01/07 N N 29.66 266.94 296.60 288.59 77059 C 04 01/01/07 N N 23.73 272.87 296.60 288.59 77063 C 04 01/01/15 N N 17.97 14.11 32.08 31.21 77071 04 01/01/07 N N 15.53 15.11 77072 C 04 01/01/07 N N 8.81 12.69 21.50 20.92 77073 C 04 01/01/07 N N 9.18 19.52 28.70 27.93 77074 C 04 01/01/07 N N 20.72 36.83 57.55 56.00 77075 C 04 01/01/07 N N 30.41 67.69 98.10 95.45 77076 C 04 01/01/07 N N 16.92 18.33 35.25 34.30 77077 C 04 01/01/07 N N 12.57 29.33 41.90 40.77 77078 C 04 01/01/07 N N 3.20 32.40 35.60 34.64 77080 C 04 01/01/07 N N 9.81 88.29 98.10 95.45 77081 C 04 01/01/07 N N 28.45 69.65 98.10 95.45 77084 C 04 01/01/07 N N 48.83 238.43 287.26 279.50 77085 C 04 01/01/15 N N 9.04 22.50 31.54 30.69 77086 C 04 01/01/15 N N 5.28 14.70 19.98 19.44 77261 09 Y N77262 09 Y N77263 09 Y I
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
77280 09 Y N77285 09 Y N77290 09 Y N77293 09 01/01/14 Y N77295 09 Y N77299 09 Y N77300 09 Y N77301 09 Y N77306 09 01/01/15 Y N77307 09 01/01/15 Y N77316 09 01/01/15 Y N77317 09 01/01/15 Y N77318 09 01/01/15 Y N77321 09 Y N77331 09 Y N77332 09 Y N77333 09 Y N77334 09 Y N77336 09 Y N77338 09 01/01/10 Y N77370 09 Y N77371 04 01/01/07 N N 574.13 558.63 77372 04 01/01/07 N N 435.96 424.19 77373 04 01/01/07 N N 812.27 790.34 77399 09 Y N77401 B 04 N N 12.07 12.07 24.15 23.50 77417 09 Y N77422 04 N I 35.73 34.77 77423 04 N I 46.14 44.89 77424 04 01/01/12 Y77425 04 01/01/12 Y77427 04 N N 70.85 68.94 77431 04 N N 35.65 34.69 77432 04 N I 254.60 247.73 77435 04 01/01/07 N N 350.19 340.73 77469 04 01/01/12 N N 177.04 172.26 77470 C 04 01/01/12 N N 146.73 93.37 240.10 233.62 77499 04 Y N 377520 04 06/01/13 N N 1,161.00 1,129.65 77522 04 06/01/13 N N 1,161.00 1,129.65 77523 04 06/01/13 N N 1,389.00 1,351.50
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
77525 04 06/01/13 N I 1,389.00 1,351.50 77600 04 N N 21.30 20.72 77605 04 N N 28.45 27.68 77610 04 N N 58.80 57.21 77615 B 04 N N 35.30 35.30 70.60 68.69 77620 04 N N 74.10 72.10 77750 C 04 N N 105.98 35.32 141.30 137.48 77761 C 04 N I 3 143.53 112.77 256.30 249.38 77762 C 04 N I 3 158.90 97.40 256.30 249.38 77763 C 04 N I 3 169.15 87.15 256.30 249.38 77767 C 04 01/01/16 N N 32.50 94.15 126.64 123.22 77768 C 04 01/01/16 N N 43.01 154.84 197.85 192.51 77770 C 04 01/01/16 N N 60.06 121.56 181.62 176.72 77771 C 04 01/01/16 N N 116.99 221.38 338.36 329.22 77772 C 04 01/01/16 N N 166.13 350.04 516.17 502.23 77778 C 04 N I 146.47 62.78 209.25 203.60 77789 C 04 N N 55.12 41.58 96.70 94.09 77790 C 04 N N 22.65 13.30 35.95 34.98 77799 04 Y N78012 C 04 01/01/13 N N 5.45 40.36 45.80 44.56 78013 C 04 01/01/13 N 10.42 82.01 92.43 89.93 78014 C 04 01/01/13 N N 14.18 119.58 133.76 130.15 78015 B 04 N N 39.22 39.22 78.45 76.33 78016 B 04 N N 49.05 49.05 98.10 95.45 78018 04 N N 84.90 82.61 78020 04 N N 78.45 76.33 78070 B 04 N N 29.45 29.45 58.90 57.31 78071 C 04 01/01/13 N N 33.56 166.71 200.27 194.86 78072 C 04 01/01/16 N N 8.76 37.33 46.09 44.85 78075 B 04 N N 32.67 32.67 65.35 63.59 78099 04 Y N78102 B 04 04/01/11 N N 42.45 42.45 84.90 82.61 78103 B 04 N N 58.80 58.80 117.60 114.42 78104 B 04 N N 58.80 58.80 117.60 114.42 78110 B 04 N N 10.47 10.47 20.95 20.38 78111 B 04 N N 16.35 16.35 32.70 31.82 78120 B 04 N N 16.35 16.35 32.70 31.82 78121 B 04 N N 28.77 28.77 57.55 56.00 78122 A 04 N N 28.77 28.77 57.55 56.00 78130 B 04 N N 32.67 32.67 65.35 63.59 78135 B 04 N N 39.22 39.22 78.45 76.33 78140 B 04 N N 21.57 21.57 43.15 41.98
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
78185 B 04 N N 49.05 49.05 98.10 95.45 78190 04 Y N78191 04 N N 18.65 18.15 78195 B 04 N N 49.05 49.05 98.10 95.45 78199 04 Y N78201 B 04 N N 65.40 65.40 130.80 127.27 78202 B 04 N N 65.40 65.40 130.80 127.27 78205 B 04 N N 65.40 65.40 130.80 127.27 78206 B 04 N N 65.40 65.40 130.80 127.27 78215 B 04 N N 65.40 65.40 130.80 127.27 78216 B 04 N N 65.40 65.40 130.80 127.27 78226 C 04 01/01/12 N N 20.83 160.30 181.13 176.24 78227 C 04 01/01/12 N N 25.03 222.57 247.60 240.91 78230 B 04 N N 16.35 16.35 32.70 31.82 78231 04 N N 28.70 27.93 78232 04 N N 14.25 13.87 78258 B 04 N N 35.30 35.30 70.60 68.69 78261 04 N N 28.70 27.93 78262 04 N N 28.70 27.93 78264 04 N N 41.90 40.77 78265 C 04 01/01/16 N N 29.04 200.72 229.76 223.56 78266 C 04 01/01/16 N N 32.24 240.17 272.41 265.05 78267 04 Y N78268 B 04 N N 30.58 30.58 61.17 59.52 78270 B 04 N N 16.35 16.35 32.70 31.82 78271 B 04 N N 16.35 16.35 32.70 31.82 78272 B 04 N N 16.35 16.35 32.70 31.82 78278 C 04 N N 9.64 32.26 41.90 40.77 78282 B 04 N N 22.90 22.90 45.80 44.56 78290 B 04 N N 49.05 49.05 98.10 95.45 78291 B 04 N N 12.45 12.45 24.90 24.23 78299 04 Y N78300 B 04 N N 39.22 39.22 78.45 76.33 78305 B 04 N N 58.80 58.80 117.60 114.42 78306 B 04 N N 58.80 58.80 117.60 114.42 78315 B 04 N N 17.62 17.62 35.25 34.30 78320 B 04 N N 33.67 33.67 67.35 65.53 78350 B 04 N N 62.25 62.25 124.50 121.14 78351 B 04 N N 74.75 74.75 149.50 145.46 78399 04 Y N78414 04 N N 49.70 48.36
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
78428 04 N N 49.70 48.36 78445 B 04 N N 24.85 24.85 49.70 48.36 78451 C 04 01/01/10 N N 38.67 82.16 120.83 117.57 78452 C 04 01/01/10 N N 44.98 159.48 204.46 198.94 78453 C 04 01/01/10 N N 28.28 76.45 104.73 101.90 78454 C 04 01/01/10 N N 37.63 64.07 101.70 98.95 78456 B 04 N N 70.85 70.85 141.70 137.87 78457 C 04 01/01/10 N N 15.02 45.08 60.10 58.48 78458 C 04 01/01/10 N N 21.22 63.68 84.90 82.61 78459 B 04 N N 3 65.40 65.40 130.80 127.27 78466 B 04 N N 3 24.85 24.85 49.70 48.36 78468 B 04 N N 3 24.85 24.85 49.70 48.36 78469 B 04 N N 3 65.40 65.40 130.80 127.27 78472 B 04 04/01/11 N N 32.67 32.67 65.35 63.59 78473 B 04 N N 37.20 37.20 74.40 72.39 78481 B 04 04/01/11 N N 24.85 24.85 49.70 48.36 78483 B 04 N N 31.07 31.07 62.15 60.47 78491 B 04 04/01/11 N I 65.40 65.40 130.80 127.27 78492 B 04 04/01/11 N I 65.40 65.40 130.80 127.27 78494 B 04 N N 31.07 31.07 62.15 60.47 78496 B 04 N N 31.07 31.07 62.15 60.47 78499 04 Y N78579 C 04 01/01/12 N N 13.80 82.78 96.58 93.97 78580 C 04 01/01/12 N N 10.97 54.38 65.35 63.59 78582 C 04 01/01/12 N N 29.70 148.60 178.30 173.49 78597 C 04 01/01/12 N N 20.31 88.73 109.04 106.10 78598 C 04 01/01/12 N N 23.19 143.76 166.95 162.44 78599 04 Y N78600 B 04 N N 3 49.05 49.05 98.10 95.45 78601 B 04 N N 3 65.40 65.40 130.80 127.27 78605 B 04 N N 3 49.05 49.05 98.10 95.45 78606 B 04 N N 3 65.40 65.40 130.80 127.27 78607 B 04 N N 3 65.40 65.40 130.80 127.27 78608 B 04 N N 65.40 65.40 130.80 127.27 78609 B 04 N N 65.40 65.40 130.80 127.27 78610 B 04 N N 3 65.40 65.40 130.80 127.27 78630 B 04 N N 49.05 49.05 98.10 95.45 78635 B 04 N N 49.05 49.05 98.10 95.45 78645 B 04 N N 20.95 20.95 41.90 40.77 78647 B 04 N N 24.85 24.85 49.70 48.36 78650 B 04 N N 20.95 20.95 41.90 40.77
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
78660 B 04 N N 16.35 16.35 32.70 31.82 78699 04 Y N78700 B 04 N N 39.22 39.22 78.45 76.33 78701 B 04 N N 39.22 39.22 78.45 76.33 78707 B 04 N N 42.45 42.45 84.90 82.61 78708 B 04 N N 47.20 47.20 94.40 91.85 78709 B 04 N N 47.20 47.20 94.40 91.85 78710 B 04 N N 39.22 39.22 78.45 76.33 78725 B 04 N N 39.22 39.22 78.45 76.33 78730 C 04 01/01/12 N N 3.10 25.60 28.70 27.93 78740 B 04 N N 17.62 17.62 35.25 34.30 78761 B 04 N N 24.85 24.85 49.70 48.36 78799 04 Y N78800 B 04 N N 32.02 32.02 64.05 62.32 78801 B 04 N N 35.95 35.95 71.90 69.96 78802 B 04 N N 42.45 42.45 84.90 82.61 78803 B 04 N N 32.02 32.02 64.05 62.32 78804 C 04 N N 29.65 86.89 116.54 113.39 78805 B 04 N N 32.02 32.02 64.05 62.32 78806 B 04 N N 42.45 42.45 84.90 82.61 78807 B 04 N N 32.02 32.02 64.05 62.32 78808 09 01/01/09 Y78811 B 04 N N 3 65.40 65.40 130.80 127.27 78812 B 04 N N 3 65.40 65.40 130.80 127.27 78813 B 04 N N 3 65.40 65.40 130.80 127.27 78814 B 04 N N 3 65.40 65.40 130.80 127.27 78815 B 04 N N 3 65.40 65.40 130.80 127.27 78816 B 04 N N 3 65.40 65.40 130.80 127.27 78999 04 Y N79005 C 04 01/01/16 N N 34.65 17.85 52.50 51.08 79101 C 04 03/01/14 N N 38.96 18.34 57.30 55.75 79200 C 04 N N 61.51 56.11 117.62 114.44 79300 B 04 N N 70.60 70.60 141.20 137.39 79403 C 04 N N 65.05 82.93 147.98 143.98 79440 B 04 N N 52.95 52.95 105.90 103.04 79445 04 Y N79999 04 Y N80047 B 04 01/01/10 N N 4.14 4.14 8.28 8.06 80048 B 04 01/01/10 N N 4.14 4.14 8.28 8.06 80051 B 04 01/01/10 N N 3.43 3.43 6.86 6.67 80053 B 04 01/01/10 N N 5.18 5.18 10.36 10.08
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
80055 B 04 01/01/10 N N 15.71 15.71 31.42 30.57 80061 B 04 01/01/12 N N 3.11 3.11 6.22 6.05 80069 B 04 01/01/10 N N 4.26 4.26 8.52 8.29 80074 B 04 01/01/10 N N 19.24 19.24 38.48 37.44 80076 B 04 01/01/10 N N 3.99 3.99 7.98 7.76 80081 B 04 01/01/16 N N 30.59 30.59 61.18 59.53 80150 H 04 03/01/13 N N 2.70 2.70 5.40 2 10.80 5.25 10.51 80155 H 04 01/01/14 N N 8.05 8.05 16.10 2 32.20 15.67 31.33 80156 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 80157 H 04 03/01/13 N N 3.90 3.90 7.80 2 15.60 7.59 15.18 80158 H 04 03/01/13 N N 6.32 6.32 12.64 2 25.28 12.30 24.60 80159 H 04 01/01/14 N N 4.01 4.01 8.02 2 16.04 7.80 15.61 80162 H 04 03/01/13 N N 6.49 6.49 12.98 2 25.96 12.63 25.26 80163 H 04 01/01/15 N N 5.42 5.42 10.84 2 21.68 10.55 21.09 80164 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 80165 H 04 01/01/15 N N 5.53 5.53 11.06 2 22.12 10.76 21.52 80168 H 04 03/01/13 N N 5.66 5.66 11.32 2 22.64 11.01 22.03 80169 H 04 01/01/14 N N 12.00 12.00 24.00 2 48.00 23.35 46.70 80170 H 04 03/01/13 N N 2.94 2.94 5.88 2 11.76 5.72 11.44 80171 H 04 01/01/14 N N 6.70 6.70 13.40 2 26.80 13.04 26.08 80173 H 04 03/01/13 N N 5.70 5.70 11.40 2 22.80 11.09 22.18 80175 H 04 01/01/14 N N 6.70 6.70 13.40 2 26.80 13.04 26.08 80176 B 04 01/01/13 N N .86 .86 1.72 1.67 80177 H 04 01/01/14 N N 4.81 4.81 9.61 2 19.22 18.70 80178 H 04 03/01/13 N N 3.23 3.23 6.46 2 12.92 6.29 12.57 80180 H 04 01/01/14 N N 20.00 20.00 40.00 2 80.00 38.92 77.84 80183 H 04 01/01/14 N N 4.42 4.42 8.83 2 17.66 8.59 17.18 80184 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 80185 H 04 03/01/13 N N 6.49 6.49 12.98 2 25.96 12.63 25.26 80186 H 04 03/01/13 N N 6.75 6.75 13.50 2 27.00 13.14 26.27 80188 H 04 03/01/13 N N 5.48 5.48 10.96 2 21.92 10.66 21.33 80190 H 04 03/01/13 N N 4.61 4.61 9.22 2 18.44 8.97 17.94 80192 H 04 03/01/13 N N 4.61 4.61 9.22 2 18.44 8.97 17.94 80194 H 04 03/01/13 N N 5.25 5.25 10.50 2 21.00 10.22 20.43 80195 H 04 03/01/13 N N 4.31 4.31 8.62 2 17.24 8.39 16.77 80197 H 04 03/01/13 N N 5.25 5.25 10.50 2 21.00 10.22 20.43 80198 H 04 03/01/13 N N 4.61 4.61 9.22 2 18.44 8.97 17.94 80199 H 04 01/01/14 N N 6.70 6.70 13.40 2 26.80 13.04 26.08 80200 H 04 03/01/13 N N 4.39 4.39 8.78 2 17.56 8.54 17.09 80201 H 04 03/01/13 N N 5.66 5.66 11.32 2 22.64 11.01 22.03 80202 H 04 03/01/13 N N 6.64 6.64 13.28 2 26.56 12.92 25.84 80203 H 04 01/01/14 N N 4.01 4.01 8.01 2 16.02 7.79 15.59
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
80299 04 01/01/10 Y N80305 B 04 01/01/17 N N 4.49 4.49 8.98 8.74 80306 B 04 01/01/17 N N 5.99 5.99 11.97 11.65 80307 B 04 01/01/17 N N 23.95 23.95 47.89 46.60 80400 B 04 01/01/10 N N 13.48 13.48 26.96 26.23 80402 B 04 01/01/10 N N 22.29 22.29 44.58 43.38 80406 B 04 01/01/10 N N 22.73 22.73 45.46 44.23 80408 B 04 01/01/10 N N 61.43 61.43 122.86 119.54 80410 B 04 01/01/10 N N 12.60 12.60 25.20 24.52 80412 B 04 01/01/10 N N 80.89 80.89 161.78 157.41 80414 B 04 01/01/10 N N 25.28 25.28 50.56 49.19 80415 B 04 01/01/10 N N 10.20 10.20 20.40 19.85 80416 B 04 01/01/10 N N 64.61 64.61 129.22 125.73 80417 B 04 01/01/10 N N 21.54 21.54 43.08 41.92 80418 B 04 01/01/12 N N 245.65 245.65 491.31 478.04 80420 B 04 01/01/10 N N 29.51 29.51 59.02 57.43 80422 B 04 01/01/10 N N 19.99 19.99 39.98 38.90 80424 B 04 01/01/10 N N 15.15 15.15 30.30 29.48 80426 B 04 01/01/10 N N 60.11 60.11 120.22 116.97 80428 B 04 01/01/10 N N 17.64 17.64 35.28 34.33 80430 B 04 01/01/10 N N 24.39 24.39 48.78 47.46 80432 B 04 01/01/10 N N 47.72 47.72 95.44 92.86 80434 B 04 01/01/10 N N 44.86 44.86 89.92 87.49 80435 B 04 01/01/10 N N 33.30 33.30 66.60 64.80 80436 B 04 01/01/10 N N 29.03 29.03 58.06 56.49 80438 B 04 01/01/10 N N 24.68 24.68 49.36 48.03 80439 B 04 01/01/10 N N 32.89 32.89 65.78 64.00 80500 04 N N 12.40 12.07 80502 04 N N 49.80 48.46 81000 H 04 03/01/13 N N 1.31 1.31 2.62 2 5.24 2.55 5.10 81001 H 04 03/01/13 N N 1.43 1.43 2.86 2 5.72 2.78 5.57 81002 H 04 03/01/13 N N 1.30 1.30 2.60 2 5.20 2.53 5.06 81003 H 04 03/01/13 N N 1.09 1.09 2.18 2 4.36 2.12 4.24 81005 H 04 03/01/13 N N .86 .86 1.72 2 3.44 1.67 3.35 81007 B 04 01/01/13 N N 1.26 1.26 2.52 2.45 81015 B 04 01/01/13 N N 1.31 1.31 2.62 2.55 81020 B 04 01/01/13 N N 1.39 1.39 2.78 2.70 81025 B 04 01/01/13 N N 1.29 1.29 2.58 2.51 81050 H 04 03/01/13 N N 1.28 1.28 2.56 2 5.12 2.49 4.98 81099 04 10/01/08 Y N81161 04 01/01/14 N N 28.10 27.34 81162 04 01/01/16 N N 1,491.52 1,451.25 81170 04 01/01/16 N N 197.71 192.37
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
81200 04 01/01/13 N N 28.10 27.34 81201 04 01/01/13 N N 21.90 21.31 81202 04 01/01/13 N N 28.10 27.34 81203 04 01/01/13 N N 21.90 21.31 81205 04 01/01/13 N N 28.10 27.34 81206 04 01/01/14 N N 21.90 21.31 81207 04 01/01/13 N N 21.90 21.31 81208 04 01/01/13 N N 21.90 21.31 81209 04 01/01/13 N N 21.90 21.31 81210 04 01/01/13 N N 21.90 21.31 81211 04 06/01/14 N N 1,310.10 1,274.73 81212 04 04/01/12 N N 146.95 142.98 81214 04 01/01/14 N N 862.88 839.58 81215 04 04/01/12 N N 59.35 57.75 81216 04 01/01/13 Y N81217 04 04/01/12 N N 59.35 57.75 81218 04 01/01/15 N N 197.71 192.37 81219 04 01/01/16 N N 99.41 96.73 81220 04 01/01/13 N N 42.15 41.01 81221 04 01/01/13 N N 21.90 21.31 81222 04 01/01/13 N N 35.95 34.98 81223 04 01/01/13 N N 21.90 21.31 81224 04 01/01/13 N N 21.90 21.31 81225 04 01/01/13 N N 28.10 27.34 81226 04 01/01/13 N N 42.15 41.01 81227 04 01/01/13 N N 42.15 41.01 81228 04 01/01/13 N N 21.90 21.31 81229 04 01/01/13 N N 21.90 21.31 81235 04 01/01/13 N N 21.90 21.31 81240 04 01/01/13 N N 21.90 21.31 81241 04 01/01/13 N N 21.90 21.31 81242 04 01/01/13 N N 42.15 41.01 81243 04 01/01/13 N N 28.10 27.34 81244 04 01/01/13 N N 21.90 21.31 81245 04 01/01/13 N N 21.90 21.31 81246 04 01/01/15 N N 21.90 21.31 81250 04 01/01/13 N N 28.10 27.34 81251 04 01/01/13 N N 28.10 27.34 81252 04 01/01/13 N N 21.90 21.31 81253 04 01/01/13 N N 28.10 27.34 81254 04 01/01/13 N N 28.10 27.34 81255 04 01/01/13 N N 42.15 41.01 81256 04 01/01/13 N N 28.10 27.34 81257 04 01/01/13 N N 42.15 41.01 81260 04 01/01/13 N N 42.15 41.01 81261 04 01/01/13 N N 28.10 27.34 81262 04 01/01/13 N N 21.90 21.31
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
81263 04 01/01/13 N N 28.10 27.34 81264 04 01/01/13 N N 28.10 27.34 81265 04 01/01/13 N N 28.10 27.34 81266 04 01/01/13 N N 28.10 3 84.30 27.34 82.02 81267 04 01/01/13 N N 42.15 41.01 81268 A 04 01/01/13 N N 59.35 57.75 81270 04 01/01/13 N N 21.90 21.31 81272 04 01/01/16 N N 197.71 192.37 81273 04 01/01/16 N N 74.92 72.90 81275 04 01/01/13 N N 21.90 21.31 81276 04 01/01/16 N N 118.31 115.12 81287 04 01/01/14 N N 21.90 21.31 81288 04 01/01/15 N N 21.90 21.31 81290 04 01/01/13 N N 21.90 21.31 81291 04 01/01/13 N N 21.90 21.31 81292 04 01/01/13 N N 21.90 21.31 81293 04 01/01/13 N N 21.90 21.31 81294 04 01/01/13 N N 21.90 21.31 81295 04 01/01/13 N N 21.90 21.31 81296 04 01/01/13 N N 21.90 21.31 81297 04 01/01/13 N N 21.90 21.31 81298 04 01/01/13 N N 28.10 27.34 81299 04 01/01/13 N N 21.90 21.31 81300 04 01/01/13 N N 21.90 21.31 81301 04 01/01/13 N N 28.10 27.34 81302 04 01/01/13 N N 21.90 21.31 81303 04 01/01/13 N N 21.90 21.31 81304 04 01/01/13 N N 21.90 21.31 81310 04 01/01/13 N N 21.90 21.31 81311 04 01/01/16 N N 177.47 172.68 81313 04 01/01/15 N N 21.90 21.31 81314 04 01/01/16 N N 197.71 192.37 81315 04 01/01/13 N N 21.90 21.31 81316 04 01/01/13 N N 21.90 21.31 81317 04 01/01/13 N N 42.15 41.01 81318 04 01/01/13 N N 21.90 21.31 81319 04 01/01/13 N N 21.90 21.31 81321 04 01/01/13 N N 42.15 41.01 81322 04 01/01/13 N N 21.90 21.31 81323 04 01/01/13 N N 21.90 21.31 81324 04 01/01/13 N N 42.15 41.01 81325 04 01/01/13 N N 42.15 41.01 81326 04 01/01/13 N N 42.15 41.01 81330 04 01/01/13 N N 42.15 41.01 81331 04 01/01/13 N N 21.90 21.31 81332 04 01/01/13 N N 28.10 27.34 81340 04 01/01/13 N N 21.90 21.31 81341 04 01/01/13 N N 21.90 21.31
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
81342 04 01/01/13 N N 28.10 27.34 81350 04 01/01/13 N N 28.10 27.34 81355 04 01/01/13 N N 28.10 27.34 81370 04 01/01/13 N N 42.15 41.01 81371 04 01/01/13 N N 35.95 34.98 81372 04 01/01/13 N N 28.10 27.34 81373 04 01/01/13 N N 21.90 2 43.80 21.31 42.62 81374 04 01/01/13 N N 21.90 3 65.70 21.31 63.93 81375 04 01/01/13 N N 21.90 21.31 81376 04 01/01/13 N N 21.90 5 109.50 21.31 106.54 81377 04 01/01/13 N N 21.90 3 65.70 21.31 63.93 81378 04 01/01/13 N N 28.10 27.34 81379 04 01/01/13 N N 28.10 27.34 81380 04 01/01/13 N N 28.10 2 56.20 27.34 54.68 81381 04 01/01/13 N N 28.10 5 140.50 27.34 136.71 81382 04 01/01/13 N N 21.90 21.31 81383 04 01/01/13 N N 21.90 3 65.70 21.31 63.93 81400 A 04 01/01/13 N N 21.90 21.31 81401 A 04 01/01/14 N N 21.90 21.31 81402 A 04 01/01/13 N N 35.95 34.98 81403 A 04 01/01/13 N N 42.15 41.01 81404 A 04 01/01/13 N N 42.15 41.01 81405 A 04 01/01/13 N N 42.15 41.01 81406 A 04 01/01/13 N N 42.15 41.01 81407 A 04 01/01/13 N N 42.15 41.01 81408 A 04 01/01/13 N N 42.15 41.01 81410 A 04 01/01/15 N N 42.15 41.01 81411 A 04 01/01/15 N N 42.15 41.01 81415 A 04 01/01/15 N N 42.15 41.01 81416 A 04 01/01/15 N N 21.90 21.31 81417 A 04 01/01/15 N N 21.90 21.31 81420 04 01/01/15 N N 28.10 27.34 81430 A 04 01/01/15 N N 42.15 41.01 81435 04 01/01/15 N N 42.15 41.01 81440 A 04 01/01/15 N N 42.15 41.01 81445 A 04 01/01/15 N N 42.15 41.01 81450 A 04 01/01/15 N N 42.15 41.01 81455 A 04 01/01/15 N N 42.15 41.01 81460 04 01/01/15 N N 42.15 41.01 81465 A 04 01/01/15 N N 42.15 41.01 81470 A 04 01/01/15 N N 42.15 41.01 81471 A 04 01/01/15 N N 42.15 41.01 81479 04 01/01/13 Y N81500 04 01/01/13 Y N81503 04 01/01/13 N N 71.20 69.28 81506 04 01/01/13 Y N81507 04 01/01/14 N N 28.10 27.34 81508 04 01/01/13 N N 18.44 17.94
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
81509 04 01/01/13 N N 40.19 39.10 81510 04 01/01/13 N N 35.40 34.44 81511 04 01/01/13 N N 57.15 55.61 81512 04 01/01/13 N N 70.99 69.07 81519 04 01/01/16 N N 2,051.65 1,996.26 81528 04 01/01/16 N N 305.32 297.08 81535 04 01/01/16 N N 347.68 338.29 81536 04 01/01/16 N N 107.54 104.64 81599 04 01/01/13 Y N82009 B 04 01/01/13 N N .86 .86 1.72 1.67 82010 H 04 03/01/13 N N .86 .86 1.72 4 6.88 1.67 6.69 82013 B 04 01/01/13 N N 2.70 2.70 5.40 5.25 82016 B 04 02/01/13 N N 2.55 2.55 5.10 4.96 82017 B 04 01/01/13 N N 5.82 5.82 11.64 11.33 82024 A 04 10/01/08 N N 6.71 6.71 13.42 13.06 82030 B 04 10/01/08 N N 4.43 4.43 8.86 8.62 82040 B 04 01/01/13 N N 2.25 2.25 4.50 4.38 82042 H 04 03/01/13 N N 2.25 2.25 4.50 2 9.00 4.38 8.76 82043 B 04 01/01/13 N N 1.97 1.97 3.94 3.83 82044 B 04 01/01/13 N N 1.97 1.97 3.94 3.83 82045 B 04 01/01/13 N N 12.42 12.42 24.84 24.17 82075 H 04 03/01/13 N N 2.51 2.51 5.02 2 10.04 4.88 9.77 82085 B 04 10/01/08 N N 3.15 3.15 6.30 6.13 82088 A 04 10/01/08 N N 19.95 19.95 39.90 38.82 82103 B 04 10/01/08 N N 4.43 4.43 8.86 8.62 82104 B 04 10/01/08 N N 3.58 3.58 7.16 6.97 82105 B 04 10/01/08 N N 8.21 8.21 16.42 15.98 82106 B 04 10/01/08 N N 3.11 3.11 6.22 6.05 82107 B 04 10/01/08 N N 14.72 14.72 29.44 28.65 82108 B 04 01/01/13 N N 2.51 2.51 5.02 4.88 82120 B 04 01/01/13 N N 1.84 1.84 3.68 3.58 82127 H 04 03/01/13 N N 2.55 2.55 5.10 2 10.20 4.96 9.92 82128 H 04 03/01/13 N N 2.55 2.55 5.10 2 10.20 4.96 9.92 82131 H 04 03/01/13 N N 5.81 5.81 11.62 3 34.86 11.31 33.92 82135 B 04 10/01/08 N N 4.43 4.43 8.86 8.62 82136 H 04 03/01/13 N N 5.81 5.81 11.62 3 34.86 11.31 33.92 82139 H 04 03/01/13 N N 5.81 5.81 11.62 3 34.86 11.31 33.92 82140 H 04 03/01/13 N N 3.58 3.58 7.16 2 14.32 6.97 13.93 82143 H 04 03/01/13 N N 3.36 3.36 6.72 2 13.44 6.54 13.08 82150 H 04 03/01/13 N N 3.19 3.19 6.38 4 25.52 6.21 24.83 82154 B 04 10/01/08 N N 8.40 8.40 16.80 16.35 82157 B 04 10/01/08 N N 8.40 8.40 16.80 16.35 82160 B 04 01/01/13 N N 2.70 2.70 5.40 5.25
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
82163 B 04 10/01/08 N N 3.75 3.75 7.50 7.30 82164 B 04 10/01/08 N N 3.58 3.58 7.16 6.97 82172 H 04 03/01/13 N N 6.00 6.00 12.00 3 36.00 11.68 35.03 82175 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 82180 B 04 10/01/08 N N 2.51 2.51 5.02 4.88 82190 H 04 03/01/13 N N 7.31 7.31 14.62 4 58.48 14.23 56.90 82232 H 04 03/01/13 N N 3.96 3.96 7.92 2 15.84 7.71 15.41 82239 B 04 10/01/08 N N 8.38 8.38 16.76 16.31 82240 B 04 10/01/08 N N 6.38 6.38 12.76 12.42 82247 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 82248 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 82252 B 04 01/01/13 N N 1.31 1.31 2.62 2.55 82261 B 04 10/01/08 N N 8.25 8.25 16.50 16.05 82270 B 04 11/01/12 N N 1.24 1.24 2.48 2.41 82271 B 04 11/01/12 N N 1.02 1.02 2.04 1.98 82272 B 04 11/01/12 N N 1.02 1.02 2.04 1.98 82274 B 04 11/01/12 N N 5.00 5.00 10.00 9.73 82286 B 04 01/01/13 N N 2.01 2.01 4.02 3.91 82300 B 04 01/01/13 N N 3.34 3.34 6.68 6.50 82306 B 04 01/01/10 N N 4.43 4.43 8.86 8.62 82308 H 04 03/01/13 N N 3.15 3.15 6.30 3 18.90 6.13 18.39 82310 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 82330 H 04 03/01/13 N N 6.68 6.68 13.36 2 26.72 13.00 26.00 82331 B 04 01/01/13 N N 2.08 2.08 4.16 4.05 82340 B 04 01/01/13 N N 2.70 2.70 5.40 5.25 82355 H 04 03/01/13 N N 2.33 2.33 4.66 3 13.98 4.53 13.60 82360 H 04 03/01/13 N N 4.54 4.54 9.08 3 27.24 8.83 26.50 82365 H 04 03/01/13 N N 2.33 2.33 4.66 3 13.98 4.53 13.60 82370 H 04 03/01/13 N N 2.33 2.33 4.66 3 13.98 4.53 13.60 82373 B 04 01/01/13 N N 2.81 2.81 5.62 5.47 82374 H 04 03/01/13 N N 2.40 2.40 4.80 2 9.60 4.67 9.34 82375 B 04 01/01/13 N N 2.33 2.33 4.66 4.53 82376 B 04 02/01/13 N N 2.33 2.33 4.66 4.53 82378 H 04 03/01/13 N N 6.71 6.71 13.42 2 26.84 13.06 26.12 82379 B 04 01/01/13 N N 5.81 5.81 11.62 11.31 82380 B 04 01/01/13 N N 2.33 2.33 4.66 4.53 82382 B 04 10/01/08 N N 7.58 7.58 15.16 14.75 82383 B 04 10/01/08 N N 7.58 7.58 15.16 14.75 82384 H 04 03/01/13 N N 7.58 7.58 15.16 2 30.32 14.75 29.50 82387 B 04 10/01/08 N N 5.74 5.74 11.48 11.17 82390 B 04 10/01/08 N N 4.43 4.43 8.86 8.62
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
82397 A 04 10/01/08 N N 6.92 6.92 13.84 13.47 82415 B 04 01/01/13 N N 4.43 4.43 8.86 8.62 82435 H 04 03/01/13 N N 2.25 2.25 4.50 2 9.00 4.38 8.76 82436 B 04 01/01/13 N N 2.33 2.33 4.66 4.53 82438 B 04 01/01/13 N N 2.40 2.40 4.80 4.67 82441 B 04 01/01/13 N N 2.14 2.14 4.28 4.16 82465 B 04 01/01/13 N N 2.12 2.12 4.24 4.13 82480 H 04 03/01/13 N N 3.58 3.58 7.16 2 14.32 6.97 13.93 82482 B 04 01/01/13 N N 1.31 1.31 2.62 2.55 82485 B 04 01/01/13 N N 5.04 5.04 10.08 9.81 82495 B 04 01/01/13 N N 6.71 6.71 13.42 13.06 82507 B 04 01/01/13 N N 2.70 2.70 5.40 5.25 82523 09 Y N82525 H 04 03/01/13 N N 5.55 5.55 11.10 2 22.20 10.80 21.60 82528 B 04 10/01/08 N N 8.85 8.85 17.70 17.22 82530 H 04 03/01/13 N N 6.71 6.71 13.42 2 26.84 13.06 26.12 82533 A 04 10/01/08 N N 6.71 6.71 13.42 13.06 82540 B 04 01/01/13 N N 2.25 2.25 4.50 4.38 82542 B 04 10/01/08 N N 6.09 6.09 12.18 11.85 82550 H 04 03/01/13 N N 3.04 3.04 6.08 3 18.24 5.92 17.75 82552 H 04 03/01/13 N N 3.15 3.15 6.30 3 18.90 6.13 18.39 82553 H 04 03/01/13 N N 3.71 3.71 7.42 3 22.26 7.22 21.66 82554 B 04 10/01/08 N N 3.08 3.08 6.16 5.99 82565 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 82570 H 04 03/01/13 N N 2.33 2.33 4.66 3 13.98 4.53 13.60 82575 B 04 10/01/08 N N 4.61 4.61 9.22 8.97 82585 B 04 10/01/08 N N 4.20 4.20 8.40 8.17 82595 B 04 10/01/08 N N 2.33 2.33 4.66 4.53 82600 B 04 01/01/13 N N 3.34 3.34 6.68 6.50 82607 B 04 10/01/08 N N 6.00 6.00 12.00 11.68 82608 B 04 10/01/08 N N 6.01 6.01 12.02 11.70 82610 B 04 10/01/08 N N 4.28 4.28 8.56 8.33 82615 B 04 01/01/13 N N 3.15 3.15 6.30 6.13 82626 B 04 10/01/08 N N 4.43 4.43 8.86 8.62 82627 B 04 10/01/08 N N 3.48 3.48 7.96 7.75 82633 B 04 10/01/08 N N 5.04 5.04 10.08 9.81 82634 H 04 03/01/13 N N 7.76 7.76 15.52 2 31.04 15.10 30.20 82638 B 04 01/01/13 N N 3.58 3.58 7.16 6.97 82652 B 04 01/01/10 N N 8.03 8.03 16.06 15.63 82656 B 04 10/01/08 N N 3.63 3.63 7.26 7.06 82657 H 04 03/01/13 N N 6.09 6.09 12.18 3 36.54 11.85 35.55
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
82658 H 04 03/01/13 N N 6.09 6.09 12.18 2 24.36 11.85 23.70 82664 B 04 10/01/08 N N 13.53 13.53 27.06 26.33 82668 B 04 10/01/08 N N 5.21 5.21 10.42 10.14 82670 H 04 03/01/13 N N 5.06 5.06 10.12 2 20.24 9.85 19.69 82671 B 04 10/01/08 N N 8.85 8.85 17.70 17.22 82672 B 04 10/01/08 N N 8.85 8.85 17.70 17.22 82677 B 04 10/01/08 N N 5.06 5.06 10.12 9.85 82679 B 04 10/01/08 N N 5.06 5.06 10.12 9.85 82693 H 04 03/01/13 N N 7.31 7.31 14.62 2 29.24 14.23 28.45 82696 B 04 10/01/08 N N 5.04 5.04 10.08 9.81 82705 B 04 10/01/08 N N 1.28 1.28 2.56 2.49 82710 B 04 10/01/08 N N 1.54 1.54 3.08 3.00 82715 B 04 01/01/13 N N 1.61 1.61 3.22 3.13 82725 B 04 01/01/13 N N 1.31 1.31 2.62 2.55 82726 B 04 10/01/08 N N 6.09 6.09 12.18 11.85 82728 B 04 01/01/13 N N 3.58 3.58 7.16 6.97 82731 B 04 10/01/08 N N 18.39 18.39 36.78 35.79 82735 B 04 01/01/13 N N 3.58 3.58 7.16 6.97 82746 B 04 10/01/08 N N 5.73 5.73 11.46 11.15 82747 B 04 10/01/08 N N 6.64 6.64 13.28 12.92 82757 B 04 01/01/13 N N 3.98 3.98 7.96 7.75 82759 B 04 01/01/13 N N 2.33 2.33 4.66 4.53 82760 B 04 01/01/13 N N 2.33 2.33 4.66 4.53 82775 B 04 01/01/13 N N 6.71 6.71 13.42 13.06 82776 B 04 01/01/13 N N 2.51 2.51 5.02 4.88 82777 B 04 01/01/13 N N 5.34 5.34 10.68 10.39 82784 H 04 03/01/13 N N 4.54 4.54 9.08 6 54.48 8.83 53.01 82785 B 04 01/01/13 N N 3.58 3.58 7.16 6.97 82787 H 04 03/01/13 N N 3.94 3.94 7.88 4 31.52 7.67 30.67 82800 B 04 02/01/13 N N 2.33 2.33 4.66 4.53 82803 A 04 10/01/08 N N 5.44 5.44 10.88 10.59 82805 H 04 03/01/13 N N 5.44 5.44 10.88 2 21.76 10.59 21.17 82810 A 04 10/01/08 N N 2.85 2.85 5.70 5.55 82820 B 04 01/01/13 N N 4.89 4.89 9.78 9.52 82930 B 04 01/01/11 N N 2.30 2.30 4.60 4.48 82938 B 04 10/01/08 N N 8.40 8.40 16.80 16.35 82941 B 04 10/01/08 N N 3.96 3.96 7.92 7.71 82943 B 04 01/01/13 N N 3.51 3.51 7.02 6.83 82945 A 04 10/01/08 N N 1.54 1.54 3.08 3.00 82946 B 04 10/01/08 N N 5.25 5.25 10.50 10.22 82947 A 04 01/01/12 N N 1.91 1.91 3.82 3.72
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
82948 A 04 10/01/08 N N .86 .86 1.72 1.67 82950 A 04 10/01/08 N N 2.33 2.33 4.66 4.53 82951 B 04 10/01/08 N N 6.30 6.30 12.60 12.26 82952 H 04 03/01/13 N N 1.91 1.91 3.82 3 11.46 3.72 11.15 82955 B 04 10/01/08 N N 4.31 4.31 8.62 8.39 82960 B 04 10/01/08 N N 2.96 2.96 5.92 5.76 82962 A 04 10/01/08 N N .84 .84 1.68 1.63 82963 B 04 10/01/08 N N 6.32 6.32 12.64 12.30 82965 B 04 10/01/08 N N 3.58 3.58 7.16 6.97 82977 B 04 10/01/08 N N 2.70 2.70 5.40 5.25 82978 B 04 01/01/13 N N 4.80 4.80 9.60 9.34 82979 B 04 01/01/13 N N 1.76 1.76 3.52 3.42 82985 B 04 10/01/08 N N 6.71 6.71 13.42 13.06 83001 A 04 10/01/08 N N 9.09 9.09 18.18 17.69 83002 A 04 10/01/08 N N 4.43 4.43 8.86 8.62 83003 A 04 10/01/08 N N 4.43 4.43 8.86 8.62 83006 B 04 01/01/15 N N 8.98 8.98 17.96 17.48 83009 B 04 01/01/13 N N 21.18 21.18 42.36 41.22 83010 B 04 01/01/13 N N 4.43 4.43 8.86 8.62 83012 B 04 01/01/13 N N 3.34 3.34 6.68 6.50 83013 B 04 10/01/08 N N 4.31 4.31 8.62 8.39 83014 B 04 10/01/08 N N 3.83 3.83 7.66 7.45 83015 B 04 10/01/08 N N 9.23 9.23 18.46 17.96 83018 H 04 03/01/13 N N 2.33 2.33 4.66 7 32.62 4.53 31.74 83020 H 04 03/01/13 N N 4.31 4.31 8.62 2 17.24 8.39 16.77 83021 H 04 03/01/13 N N 6.09 6.09 12.18 2 24.36 11.85 23.70 83026 B 04 02/01/13 N N 1.14 1.14 2.28 2.22 83030 B 04 02/01/13 N N 1.61 1.61 3.22 3.13 83033 B 04 02/01/13 N N 2.93 2.93 5.86 5.70 83036 B 04 01/01/12 N N 3.15 3.15 6.30 6.13 83037 B 04 10/01/08 N N .74 .74 1.48 1.44 83045 B 04 02/01/13 N N 2.33 2.33 4.66 4.53 83050 B 04 02/01/13 N N 1.50 1.50 3.00 2.92 83051 B 04 02/01/13 N N 1.61 1.61 3.22 3.13 83060 B 04 02/01/13 N N 1.61 1.61 3.22 3.13 83065 B 04 02/01/13 N N 1.61 1.61 3.22 3.13 83068 B 04 02/01/13 N N 1.61 1.61 3.22 3.13 83069 B 04 02/01/13 N N .77 .77 1.54 1.50 83070 B 04 02/01/13 N N 1.31 1.31 2.62 2.55 83080 H 04 03/01/13 N N 5.81 5.81 11.62 2 23.24 11.31 22.61 83088 B 04 10/01/08 N N 8.85 8.85 17.70 17.22 83090 H 04 03/01/13 N N 6.60 6.60 13.20 2 26.40 12.84 25.69 83150 B 04 10/01/08 N N 5.48 5.48 10.96 10.66
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
83491 B 04 10/01/08 N N 3.58 3.58 7.16 6.97 83497 B 04 10/01/08 N N 6.32 6.32 12.64 12.30 83498 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 83499 B 04 10/01/08 N N 8.03 8.03 16.06 15.63 83500 B 04 10/01/08 N N 7.14 7.14 14.28 13.89 83505 B 04 10/01/08 N N 8.85 8.85 17.70 17.22 83516 A 04 10/01/08 N N 4.39 4.39 8.78 8.54 83518 H 04 03/01/13 N N 4.14 4.14 8.28 2 16.56 8.06 16.11 83519 A 04 10/01/08 N N 6.60 6.60 13.20 12.84 83520 A 04 10/01/08 N N 6.34 6.34 12.68 12.34 83525 A 04 10/01/08 N N 4.43 4.43 8.86 8.62 83527 B 04 02/01/13 N N 4.43 4.43 8.86 8.62 83528 B 04 02/01/13 N N 3.98 3.98 7.96 7.75 83540 H 04 03/01/13 N N 3.19 3.19 6.38 2 12.76 6.21 12.42 83550 B 04 02/01/13 N N 4.28 4.28 8.56 8.33 83570 B 04 02/01/13 N N 3.58 3.58 7.16 6.97 83582 B 04 10/01/08 N N 6.09 6.09 12.18 11.85 83586 B 04 10/01/08 N N 3.28 3.28 6.56 6.38 83593 B 04 10/01/08 N N 7.76 7.76 15.52 15.10 83605 H 04 03/01/13 N N 4.43 4.43 8.86 3 26.58 8.62 25.86 83615 H 04 03/01/13 N N 2.96 2.96 5.92 2 11.84 5.76 11.52 83625 B 04 10/01/08 N N 5.21 5.21 10.42 10.14 83630 B 04 10/01/08 N N 3.61 3.61 7.22 7.03 83631 B 04 10/01/08 N N 6.17 6.17 12.34 12.01 83632 B 04 10/01/08 N N 4.43 4.43 8.86 8.62 83633 B 04 02/01/13 N N 2.70 2.70 5.40 5.25 83655 B 04 03/01/13 N N 5.93 5.93 11.86 11.54 83661 H 04 03/01/13 N N 6.71 6.71 13.42 4 53.68 13.06 52.23 83662 H 04 03/01/13 N N 6.21 6.21 12.42 4 49.68 12.08 48.34 83663 H 04 03/01/13 N N 3.68 3.68 7.36 4 29.44 7.16 28.65 83664 H 04 03/01/13 N N 1.86 1.86 3.72 4 14.88 3.62 14.48 83670 B 04 10/01/08 N N 3.15 3.15 6.30 6.13 83690 H 04 03/01/13 N N 3.36 3.36 6.72 2 13.44 6.54 13.08 83695 B 04 10/01/08 N N 4.07 4.07 8.14 7.92 83698 B 04 10/01/08 N N 8.92 8.92 17.84 17.36 83700 B 04 10/01/08 N N 3.54 3.54 7.08 6.89 83701 B 04 10/01/08 N N 7.80 7.80 15.60 15.18 83704 B 04 10/01/08 N N 9.92 9.92 19.84 19.30 83718 B 04 10/01/08 N N 4.01 4.01 8.02 7.80 83719 B 04 10/01/08 N N 5.70 5.70 11.40 11.09 83721 B 04 10/01/08 N N 4.67 4.67 9.34 9.09 83727 B 04 02/01/13 N N 4.43 4.43 8.86 8.62
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
83735 H 04 03/01/13 N N 3.28 3.28 6.56 4 26.24 6.38 25.53 83775 B 04 02/01/13 N N 2.78 2.78 5.56 5.41 83785 B 04 02/01/13 N N .64 .64 1.28 1.25 83789 H 04 03/01/13 N N 3.58 3.58 7.16 2 14.32 6.97 13.93 83825 H 04 03/01/13 N N 3.96 3.96 7.92 2 15.84 7.71 15.41 83835 H 04 03/01/13 N N 6.71 6.71 13.42 2 26.84 13.06 26.12 83857 B 04 02/01/13 N N 1.31 1.31 2.62 2.55 83861 H 04 03/01/13 N N 14.40 2 28.80 14.01 28.02 83864 B 04 10/01/08 N N 5.25 5.25 10.50 10.22 83872 H 04 03/01/13 N N 1.31 1.31 2.62 2 5.24 2.55 5.10 83873 B 04 10/01/08 N N 4.82 4.82 9.64 9.38 83874 B 04 10/01/08 N N 6.32 6.32 12.64 12.30 83876 H 04 03/01/13 N N 5.68 5.68 11.36 2 22.72 11.05 22.11 83880 B 04 10/01/08 N N 7.43 7.43 14.86 14.46 83883 A 04 10/01/08 N N 5.22 5.22 10.44 10.16 83885 A 04 10/01/08 N N 3.96 3.96 7.92 7.71 83915 B 04 10/01/08 N N 2.70 2.70 5.40 5.25 83916 H 04 03/01/13 N N 3.34 3.34 6.68 2 13.36 6.50 13.00 83918 H 04 03/01/13 N N 8.06 8.06 16.12 2 32.24 15.68 31.37 83919 B 04 10/01/08 N N 8.06 8.06 16.12 15.68 83921 H 04 03/01/13 N N 6.45 6.45 12.90 2 25.80 12.55 25.10 83930 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 83935 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 83937 B 04 10/01/08 N N 6.71 6.71 13.42 13.06 83945 H 04 03/01/13 N N 1.54 1.54 3.08 2 6.16 3.00 5.99 83950 B 04 10/01/08 N N 22.41 22.41 44.82 43.61 83951 B 04 01/01/09 N N 20.50 20.50 41.00 39.89 83970 H 04 03/01/13 N N 15.56 15.56 31.12 2 62.24 30.28 60.56 83986 H 04 03/01/13 N N 1.76 1.76 3.52 2 7.04 3.42 6.85 83992 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 83993 B 04 10/01/08 N N 6.17 6.17 12.34 12.01 84030 B 04 02/01/13 N N 2.63 2.63 5.26 5.12 84035 B 04 02/01/13 N N .86 .86 1.72 1.67 84060 B 04 02/01/13 N N 3.58 3.58 7.16 6.97 84061 B 04 02/01/13 N N 3.15 3.15 6.30 6.13 84066 B 04 02/01/13 N N 1.54 1.54 3.08 3.00 84075 H 04 03/01/13 N N 2.51 2.51 5.02 2 10.04 4.88 9.77 84078 B 04 02/01/13 N N 3.58 3.58 7.16 6.97 84080 B 04 02/01/13 N N 4.43 4.43 8.86 8.62 84081 B 04 02/01/13 N N 1.26 1.26 2.52 2.45 84085 B 04 02/01/13 N N 1.76 1.76 3.52 3.42 84087 B 04 02/01/13 N N 2.78 2.78 5.56 5.41 84100 H 04 03/01/13 N N 2.33 2.33 4.66 3 13.98 4.53 13.60
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
84105 B 04 02/01/13 N N 1.13 1.13 2.26 2.20 84106 B 04 02/01/13 N N 2.10 2.10 4.20 4.09 84110 B 04 02/01/13 N N 2.33 2.33 4.66 4.53 84112 04 07/01/13 N N 38.60 37.56 84119 B 04 10/01/08 N N 4.22 4.22 8.44 8.21 84120 B 04 10/01/08 N N 6.71 6.71 13.42 13.06 84126 B 04 10/01/08 N N 10.95 10.95 21.90 21.31 84132 H 04 03/01/13 N N 2.25 2.25 4.50 3 13.98 4.38 13.60 84133 H 04 03/01/13 N N 2.10 2.10 4.20 2 8.40 4.09 8.17 84134 B 04 02/01/13 N N 2.79 2.79 5.58 5.43 84135 B 04 10/01/08 N N 3.96 3.96 7.92 7.71 84138 B 04 10/01/08 N N 4.43 4.43 8.86 8.62 84140 B 04 10/01/08 N N 4.43 4.43 8.86 8.62 84143 H 04 03/01/13 N N 4.61 4.61 9.22 2 18.44 8.97 17.94 84144 B 04 02/01/13 N N 4.61 4.61 9.22 8.97 84146 H 04 03/01/13 N N 6.71 6.71 13.42 3 40.26 13.06 39.17 84150 H 04 03/01/13 N N 1.76 1.76 3.52 2 7.04 3.42 6.85 84152 B 04 10/01/08 N N 7.20 7.20 14.40 14.01 84153 B 04 10/01/08 N N 6.60 6.60 13.20 12.84 84154 B 04 10/01/08 N N 6.60 6.60 13.20 12.84 84155 B 04 02/01/13 N N 1.80 1.80 3.60 3.50 84156 B 04 10/01/08 N N 1.15 1.15 2.30 2.24 84157 H 04 03/01/13 N N 1.15 1.15 2.30 3 6.90 2.24 6.71 84160 H 04 03/01/13 N N 1.31 1.31 2.62 2 5.24 2.55 5.10 84163 B 04 10/01/08 N N 4.79 4.79 9.58 9.32 84165 B 04 10/01/08 N N 5.25 5.25 10.50 10.22 84166 H 04 03/01/13 N N 5.61 5.61 11.22 2 22.44 10.92 21.83 84181 B 04 10/01/08 N N 8.33 8.33 16.66 16.21 84182 B 04 10/01/08 N N 8.80 8.80 17.60 17.12 84202 B 04 02/01/13 N N 1.76 1.76 3.52 3.42 84203 B 04 02/01/13 N N 1.31 1.31 2.62 2.55 84206 B 04 10/01/08 N N 3.58 3.58 7.16 6.97 84207 B 04 10/01/08 N N 6.00 6.00 12.00 11.68 84210 H 04 03/01/13 N N 3.58 3.58 7.16 2 14.32 6.97 13.93 84220 B 04 02/01/13 N N 2.33 2.33 4.66 4.53 84228 B 04 02/01/13 N N 5.25 5.25 10.50 10.22 84233 H 04 03/01/13 N N 16.50 16.50 33.00 2 66.00 32.11 64.22 84234 H 04 03/01/13 N N 2.70 2.70 5.40 2 10.80 5.25 10.51 84235 B 04 02/01/13 N N 2.70 2.70 5.40 5.25 84238 H 04 03/01/13 N N 10.01 10.01 20.02 3 60.06 19.48 58.44 84244 A 04 10/01/08 N N 10.76 10.76 21.52 20.94 84252 B 04 10/01/08 N N 1.31 1.31 2.62 2.55
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
84255 H 04 03/01/13 N N 2.40 2.40 4.80 2 9.60 4.67 9.34 84260 B 04 02/01/13 N N 2.51 2.51 5.02 4.88 84270 B 04 10/01/08 N N 8.19 8.19 16.38 15.94 84275 B 04 02/01/13 N N 1.76 1.76 3.52 3.42 84285 B 04 02/01/13 N N 1.80 1.80 3.60 3.50 84295 H 04 03/01/13 N N 2.33 2.33 4.66 3 13.98 4.53 13.60 84300 H 04 03/01/13 N N 2.12 2.12 4.24 2 8.48 4.13 8.25 84302 B 04 10/01/08 N N 1.28 1.28 2.56 2.49 84305 B 04 10/01/08 N N 7.54 7.54 15.08 14.67 84307 B 04 10/01/08 N N 7.54 7.54 15.08 14.67 84311 H 04 03/01/13 N N 3.44 3.44 6.88 2 13.76 6.69 13.39 84315 H 04 03/01/13 N N 1.22 1.22 2.44 2 4.88 2.37 4.75 84375 B 04 02/01/13 N N 2.33 2.33 4.66 4.53 84376 B 04 02/01/13 N N 2.70 2.70 5.40 5.25 84377 B 04 02/01/13 N N 2.70 2.70 5.40 5.25 84378 H 04 03/01/13 N N 2.96 2.96 5.92 2 11.84 5.76 11.52 84379 B 04 02/01/13 N N 2.96 2.96 5.92 5.76 84392 B 04 02/01/13 N N 2.33 2.33 4.66 4.53 84402 B 04 02/01/13 N N 9.17 9.17 18.34 17.84 84403 H 04 03/01/13 N N 12.64 12.64 25.28 2 50.56 24.60 49.19 84410 B 04 01/01/17 N N 21.77 21.77 43.53 42.35 84425 B 04 10/01/08 N N 6.41 6.41 12.82 12.47 84430 B 04 10/01/08 N N 3.58 3.58 7.16 6.97 84432 B 04 10/01/08 N N 7.86 7.86 15.72 15.30 84436 B 04 10/01/08 N N 3.36 3.36 6.72 6.54 84437 B 04 10/01/08 N N 3.19 3.19 6.38 6.21 84439 B 04 10/01/08 N N 4.43 4.43 8.86 8.62 84442 B 04 10/01/08 N N 4.43 4.43 8.86 8.62 84443 B 04 10/01/08 N N 8.21 8.21 16.42 15.98 84445 B 04 10/01/08 N N 13.48 13.48 26.96 26.23 84446 B 04 10/01/08 N N 4.43 4.43 8.86 8.62 84449 B 04 10/01/08 N N 6.71 6.71 13.42 13.06 84450 B 04 02/01/13 N N 2.51 2.51 5.02 4.88 84460 B 04 02/01/13 N N 2.59 2.59 5.18 5.04 84466 B 04 02/01/13 N N 4.39 4.39 8.78 8.54 84478 B 04 10/01/08 N N 2.70 2.70 5.40 5.25 84479 B 04 10/01/08 N N 3.19 3.19 6.38 6.21 84480 B 04 10/01/08 N N 4.78 4.78 9.56 9.30 84481 B 04 10/01/08 N N 5.06 5.06 10.12 9.85 84482 B 04 10/01/08 N N 3.41 3.41 6.82 6.64 84484 H 04 03/01/13 N N 3.71 3.71 7.42 2 14.84 7.22 14.44
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
84485 B 04 02/01/13 N N 2.70 2.70 5.40 5.25 84488 B 04 10/01/08 N N 2.70 2.70 5.40 5.25 84490 B 04 10/01/08 N N 2.70 2.70 5.40 5.25 84510 B 04 10/01/08 N N 5.10 5.10 10.20 9.92 84512 B 04 02/01/13 N N 3.71 3.71 7.42 7.22 84520 H 04 03/01/13 N N 1.93 1.93 3.86 4 15.44 3.76 15.02 84525 B 04 02/01/13 N N .86 .86 1.72 1.67 84540 H 04 03/01/13 N N 1.76 1.76 3.52 2 7.04 3.42 6.85 84545 B 04 02/01/13 N N 2.01 2.01 4.02 3.91 84550 B 04 02/01/13 N N 2.21 2.21 4.42 4.30 84560 H 04 03/01/13 N N 1.31 1.31 2.62 2 5.24 2.55 5.10 84577 B 04 02/01/13 N N 2.70 2.70 5.40 5.25 84578 B 04 02/01/13 N N .86 .86 1.72 1.67 84580 B 04 02/01/13 N N 2.01 2.01 4.02 3.91 84583 B 04 02/01/13 N N 1.31 1.31 2.62 2.55 84585 B 04 10/01/08 N N 7.58 7.58 15.16 14.75 84586 B 04 11/01/14 N N 14.46 14.46 28.92 28.14 84588 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 84590 B 04 10/01/08 N N 2.33 2.33 4.66 4.53 84591 B 04 10/01/08 N N 4.54 4.54 9.08 8.83 84597 B 04 10/01/08 N N 2.51 2.51 5.02 4.88 84600 H 04 03/01/13 N N 1.76 1.76 3.52 2 7.04 3.42 6.85 84620 B 04 02/01/13 N N 3.75 3.75 7.50 7.30 84630 H 04 03/01/13 N N 5.04 5.04 10.08 2 20.16 9.81 19.62 84681 B 04 10/01/08 N N 6.41 6.41 12.82 12.47 84702 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 84703 B 04 01/01/12 N N 3.58 3.58 7.16 6.97 84704 B 04 10/01/08 N N 4.73 4.73 9.46 9.20 84999 04 10/01/08 Y N85002 B 04 02/01/13 N N .86 .86 1.72 1.67 85004 H 04 03/01/13 N N 1.70 1.70 3.40 2 6.80 3.31 6.62 85007 B 04 02/01/13 N N 1.75 1.75 3.50 3.41 85008 B 04 02/01/13 N N 1.69 1.69 3.38 3.29 85009 B 04 02/01/13 N N 1.75 1.75 3.50 3.41 85013 H 04 03/01/13 N N 1.16 1.16 2.32 2 4.64 2.26 4.51 85014 H 04 03/01/13 N N 1.16 1.16 2.32 2 4.64 2.26 4.51 85018 H 04 03/01/13 N N 1.16 1.16 2.32 2 4.64 2.26 4.51 85025 H 04 03/01/13 N N 2.87 2.87 5.74 2 11.48 5.59 11.17 85027 H 04 02/01/17 N N 2.87 2.87 5.74 2 11.48 5.59 11.17 85032 H 04 03/01/13 N N 1.50 1.50 3.01 3 9.03 2.93 8.79 85041 H 04 03/01/13 N N .86 .86 1.72 2 3.44 1.67 3.35 85044 B 04 02/01/13 N N 1.75 1.75 3.50 3.41
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
85045 B 04 02/01/13 N N 1.31 1.31 2.62 2.55 85046 B 04 02/01/13 N N 2.74 2.74 5.48 5.33 85048 H 04 03/01/13 N N .86 .86 1.72 2 3.44 1.67 3.35 85049 H 04 03/01/13 N N 1.17 1.17 2.34 2 4.68 2.28 4.55 85055 B 04 02/01/13 N N 4.25 4.25 8.50 8.27 85060 04 N N 4.50 4.38 85097 04 03/01/13 N N 22.40 2 44.80 21.80 43.59 85130 H 04 03/01/13 N N 5.82 5.82 11.64 2 23.28 11.33 22.65 85170 B 04 02/01/13 N N 2.23 2.23 4.46 4.34 85175 B 04 02/01/13 N N 2.23 2.23 4.46 4.34 85210 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 85220 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 85230 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 85240 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 85244 H 04 03/01/13 N N 3.58 3.58 7.16 2 14.32 6.97 13.93 85245 H 04 03/01/13 N N 3.60 3.60 7.20 2 14.40 7.01 14.01 85246 H 04 03/01/13 N N 3.60 3.60 7.20 2 14.40 7.01 14.01 85247 H 04 03/01/13 N N 6.94 6.94 13.88 2 27.76 13.51 27.01 85250 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 85260 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 85270 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 85280 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 85290 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 85291 H 04 03/01/13 N N 4.35 4.35 8.70 2 17.40 8.47 16.93 85292 H 04 03/01/13 N N 5.63 5.63 11.26 2 22.52 10.96 21.91 85293 H 04 03/01/13 N N 5.63 5.63 11.26 2 22.52 10.96 21.91 85300 H 04 03/01/13 N N 4.43 4.43 8.86 2 17.72 8.62 17.24 85301 H 04 03/01/13 N N 5.29 5.29 10.58 2 21.16 10.29 20.59 85302 H 04 03/01/13 N N 5.89 5.89 11.78 2 23.56 11.46 22.92 85303 H 04 03/01/13 N N 5.85 5.85 11.70 2 23.40 11.38 22.77 85305 H 04 03/01/13 N N 5.66 5.66 11.32 2 22.64 11.01 22.03 85306 H 04 03/01/13 N N 5.85 5.85 11.70 2 23.40 11.38 22.77 85307 H 04 03/01/13 N N 6.00 6.00 12.00 2 24.00 11.68 23.35 85335 H 04 03/01/13 N N 5.29 5.29 10.58 2 21.16 10.29 20.59 85337 B 04 02/01/13 N N 5.10 5.10 10.20 9.92 85345 H 04 03/01/13 N N 1.50 1.50 3.00 2 6.00 2.92 5.84 85347 A 04 10/01/08 N N 1.31 1.31 2.62 2.55 85348 B 04 02/01/13 N N 1.84 1.84 3.68 3.58 85360 B 04 02/01/13 N N 2.96 2.96 5.92 5.76 85362 H 04 03/01/13 N N 1.31 1.31 2.62 2 5.24 2.55 5.10 85366 H 04 03/01/13 N N 2.74 2.74 5.48 2 10.96 5.33 10.66
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
85370 H 04 03/01/13 N N 2.74 2.74 5.48 2 10.96 5.33 10.66 85378 H 04 03/01/13 N N 3.49 3.49 6.98 2 13.96 6.79 13.58 85379 H 04 03/01/13 N N 3.75 3.75 7.50 2 15.00 7.30 14.60 85380 H 04 03/01/13 N N 2.67 2.67 5.34 2 10.68 5.20 10.39 85384 H 04 03/01/13 N N 2.63 2.63 5.26 2 10.52 5.12 10.24 85385 B 04 02/01/13 N N 2.63 2.63 5.26 5.12 85390 H 04 03/01/13 N N 1.62 1.62 3.25 3 9.75 3.16 9.49 85396 B 04 02/01/13 N N 5.84 5.84 11.69 11.37 85397 B 04 01/01/09 N N 6.21 6.21 12.42 12.08 85400 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 85410 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 85415 H 04 03/01/13 N N 4.31 4.31 8.62 2 17.24 8.39 16.77 85420 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 85421 H 04 03/01/13 N N 3.23 3.23 6.46 2 12.92 6.29 12.57 85441 B 04 02/01/13 N N 2.04 2.04 4.08 3.97 85445 B 04 02/01/13 N N .86 .86 1.72 1.67 85460 B 04 02/01/13 N N 1.61 1.61 3.22 3.13 85461 B 04 02/01/13 N N 1.58 1.58 3.16 3.07 85475 B 04 02/01/13 N N 4.35 4.35 8.70 8.47 85520 B 04 10/01/08 N N 3.15 3.15 6.30 6.13 85525 H 04 03/01/13 N N 5.38 5.38 10.76 2 21.52 10.47 20.94 85530 B 04 10/01/08 N N 3.15 3.15 6.30 6.13 85536 B 04 02/01/13 N N 2.53 2.53 5.06 4.92 85540 B 04 02/01/13 N N 1.76 1.76 3.52 3.42 85547 B 04 02/01/13 N N 1.14 1.14 2.28 2.22 85549 B 04 02/01/13 N N 3.58 3.58 7.16 6.97 85555 B 04 02/01/13 N N 2.33 2.33 4.66 4.53 85557 B 04 02/01/13 N N 2.33 2.33 4.66 4.53 85576 A 04 10/01/08 N N 2.55 2.55 5.10 4.96 85597 B 04 02/01/13 N N 2.74 2.74 5.48 5.33 85598 B 04 01/01/11 N N 7.59 7.59 15.18 14.77 85610 A 04 10/01/08 N N 1.91 1.91 3.82 3.72 85611 H 04 03/01/13 N N 1.93 1.93 3.86 2 7.72 3.76 7.51 85612 B 04 10/01/08 N N 2.78 2.78 5.56 5.41 85613 B 04 10/01/08 N N 3.51 3.51 7.02 6.83 85635 B 04 10/01/08 N N 1.31 1.31 2.62 2.55 85651 B 04 02/01/13 N N 2.30 2.30 4.60 4.48 85652 B 04 02/01/13 N N 1.31 1.31 2.62 2.55 85660 B 04 02/01/13 N N 2.33 2.33 4.66 4.53 85670 H 04 03/01/13 N N 2.33 2.33 4.66 2 9.32 4.53 9.07 85675 B 04 02/01/13 N N 3.19 3.19 6.38 6.21
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
85705 B 04 02/01/13 N N 4.35 4.35 8.70 8.47 85730 A 04 10/01/08 N N 2.94 2.94 5.88 5.72 85732 H 04 03/01/13 N N 3.19 3.19 6.38 4 25.52 6.21 24.83 85810 H 04 03/01/13 N N 2.70 2.70 5.40 2 10.80 5.25 10.51 85999 04 10/01/08 Y N86000 A 04 N N 3.70 3.70 7.40 7.20 86001 A 04 N N 2.72 2.72 5.45 5.30 86003 H 04 01/01/14 N N 0.57 0.57 1.15 51 58.65 1.12 57.07 86005 A 04 N N 5.20 5.20 10.40 10.12 86021 B 04 02/01/13 N N 3.10 3.10 6.20 6.03 86022 B 04 02/01/13 N N 9.52 9.52 19.05 18.54 86023 H 04 03/01/13 N N 4.70 4.70 9.40 2 18.80 9.15 18.29 86038 B 04 N N 7.90 7.90 15.80 15.37 86039 B 04 N N 5.35 5.35 10.70 10.41 86060 B 04 N N 4.30 4.30 8.60 8.37 86063 B 04 N N 3.77 3.77 7.55 7.35 86077 04 N N 39.30 38.24 86078 04 N N 16.85 16.40 86079 04 N N 20.35 19.80 86140 B 04 N N 2.35 2.35 4.70 4.57 86141 B 04 N N 8.45 8.45 16.90 16.44 86146 H 04 03/01/13 N N 13.30 13.30 26.60 3 79.80 25.88 77.65 86147 H 04 03/01/13 N N 6.35 6.35 12.70 4 50.80 12.36 49.43 86148 B 04 N N 6.35 6.35 12.70 12.36 86155 B 04 02/01/13 N N 4.30 4.30 8.60 8.37 86156 B 04 N N 2.62 2.62 5.25 5.11 86157 B 04 N N 3.30 3.30 6.60 6.42 86160 H 04 03/01/13 N N 4.62 4.62 9.25 4 37.00 9.00 36.00 86161 H 04 03/01/13 N N 5.15 5.15 10.30 3 30.90 10.02 30.07 86162 B 04 N N 8.95 8.95 17.90 17.42 86171 09 Y N86185 A 04 N N 4.20 4.20 8.40 8.17 86200 B 04 N N 5.42 5.42 10.85 10.56 86215 B 04 N N 5.90 5.90 11.80 11.48 86225 B 04 N N 5.90 5.90 11.80 11.48 86226 B 04 N N 6.67 6.67 13.35 12.99 86235 A 04 N N 5.90 5.90 11.80 11.48 86243 B 04 02/01/13 N N 5.90 5.90 11.80 11.48 86255 A 04 N N 3.60 3.60 7.20 7.01 86256 A 04 N N 5.90 5.90 11.80 11.48 86277 B 04 02/01/13 N N 10.27 10.27 20.55 20.00
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
86280 B 04 02/01/13 N N 4.10 4.10 8.20 7.98 86294 B 04 N N 10.85 10.85 21.70 21.11 86300 H 04 03/01/13 N N 10.85 10.85 21.70 2 43.40 21.11 42.23 86301 B 04 N N 10.85 10.85 21.70 21.11 86304 B 04 N N 10.85 10.85 21.70 21.11 86305 04 01/01/13 N N 17.17 16.71 86308 B 04 N N 2.40 2.40 4.80 4.67 86309 B 04 N N 4.25 4.25 8.50 8.27 86310 B 04 N N 4.82 4.82 9.65 9.39 86316 H 04 03/01/13 N N 5.05 5.05 10.10 3 30.30 9.83 29.48 86317 09 Y86318 A 04 N N 8.45 8.45 16.90 16.44 86320 B 04 N N 10.65 10.65 21.30 20.72 86325 H 04 03/01/13 N N 5.90 5.90 11.80 2 23.60 11.48 22.96 86327 B 04 N N 7.00 7.00 14.00 13.62 86329 A 04 N N 9.15 9.15 18.30 17.81 86331 A 04 N N 5.90 5.90 11.80 11.48 86332 B 04 N N 9.40 9.40 18.80 18.29 86334 B 04 N N 13.95 13.95 27.90 27.15 86335 H 04 03/01/13 N N 12.30 12.30 24.60 2 49.20 23.94 47.87 86336 B 04 N N 10.87 10.87 21.75 21.16 86337 B 04 N N 5.90 5.90 11.80 11.48 86340 B 04 02/01/13 N N 5.90 5.90 11.80 11.48 86341 B 04 N N 5.90 5.90 11.80 11.48 86343 B 04 N N 8.07 8.07 16.15 15.71 86344 B 04 02/01/13 N N 1.15 1.15 2.30 2.24 86352 B 04 01/01/10 N N 29.19 29.19 58.38 56.80 86353 B 04 N N 5.90 5.90 11.80 11.48 86355 B 04 N N 15.81 15.81 31.62 30.77 86356 04 01/01/08 N N 11.33 11.02 86357 B 04 N N 15.81 15.81 31.62 30.77 86359 B 04 N N 3.82 3.82 7.65 7.44 86360 B 04 N N 4.85 4.85 9.70 9.44 86361 B 04 N N 4.85 4.85 9.70 9.44 86367 B 04 N N 15.81 15.81 31.62 30.77 86376 H 04 03/01/13 N N 4.20 4.20 8.40 2 16.80 8.17 16.35 86378 B 04 N N 6.95 6.95 13.90 13.52 86382 H 04 03/01/13 N N 3.60 3.60 7.20 3 21.60 7.01 21.02 86384 B 04 02/01/13 N N 2.35 2.35 4.70 4.57 86403 A 04 N N 3.00 3.00 6.00 5.84 86406 H 04 03/01/13 N N 5.90 5.90 11.80 2 23.60 11.48 22.96
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
86430 H 04 03/01/13 N N 3.10 3.10 6.20 2 12.40 6.03 12.07 86431 H 04 03/01/13 N N 3.62 3.62 7.25 2 14.50 7.05 14.11 86480 B 04 N N 25.97 25.97 51.95 50.55 86481 B 04 01/01/11 N N 26.16 26.16 52.32 50.91 86485 B 04 N N 2.00 2.00 4.00 3.89 86486 04 01/01/08 Y N86490 B 04 N N 2.57 2.57 5.15 5.01 86510 B 04 N N 2.57 2.57 5.15 5.01 86580 04 N N 4.00 3.89 86590 B 04 N N 5.90 5.90 11.80 11.48 86592 H 04 03/01/13 N N 2.00 2.00 4.00 2 8.00 3.89 7.78 86593 H 04 03/01/13 N N 2.00 2.00 4.00 2 8.00 3.89 7.78 86602 H 04 03/01/13 N N 5.10 5.10 10.20 3 30.60 9.92 29.77 86603 H 04 03/01/13 N N 7.40 7.40 14.80 2 29.60 14.40 28.80 86606 B 04 N N 5.10 5.10 10.20 9.92 86609 B 04 N N 5.12 5.12 10.25 9.97 86611 B 04 N N 5.30 5.30 10.60 10.31 86612 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86615 B 04 N N 5.95 5.95 11.90 11.58 86617 H 04 03/01/13 N N 10.10 10.10 20.20 2 40.40 19.65 39.31 86618 H 04 03/01/13 N N 11.10 11.10 22.20 2 44.40 21.60 43.20 86619 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86622 B 04 N N 5.10 5.10 10.20 9.92 86625 H 04 03/01/13 N N 4.85 4.85 9.70 2 19.40 9.44 18.88 86628 H 04 03/01/13 N N 5.10 5.10 10.20 3 30.60 9.92 29.77 86631 B 04 01/01/12 N N 7.70 7.70 15.40 14.98 86632 H 04 03/01/13 N N 8.27 8.27 16.55 3 49.65 16.10 48.31 86635 B 04 N N 5.10 5.10 10.20 9.92 86638 B 04 N N 5.10 5.10 10.20 9.92 86641 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86644 B 04 N N 6.67 6.67 13.35 12.99 86645 B 04 N N 9.12 9.12 18.25 17.76 86648 H 04 03/01/13 N N 9.60 9.60 19.20 2 38.40 18.68 37.36 86651 H 04 03/01/13 N N 8.00 8.00 16.00 2 32.00 15.57 31.14 86652 H 04 03/01/13 N N 8.00 8.00 16.00 2 32.00 15.57 31.14 86653 H 04 03/01/13 N N 7.80 7.80 15.60 2 31.20 15.18 30.36 86654 H 04 03/01/13 N N 8.00 8.00 16.00 2 32.00 15.57 31.14 86658 B 04 N N 8.50 8.50 17.00 16.54 86663 H 04 03/01/13 N N 8.57 8.57 17.15 2 34.30 16.69 33.37 86664 H 04 03/01/13 N N 8.80 8.80 17.60 2 35.20 17.12 34.25 86665 H 04 03/01/13 N N 9.60 9.60 19.20 2 38.40 18.68 37.36 86666 B 04 N N 5.30 5.30 10.60 10.31
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
86668 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86671 B 04 N N 8.01 8.01 16.02 15.59 86674 H 04 03/01/13 N N 5.10 5.10 10.20 3 30.60 9.92 29.77 86677 H 04 03/01/13 N N 7.50 7.50 15.00 3 45.00 14.60 43.79 86682 B 04 05/01/08 N N 5.45 5.45 10.90 10.61 86684 H 04 03/01/13 N N 9.60 9.60 19.20 2 38.40 18.68 37.36 86687 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86688 H 04 03/01/13 N N 6.72 6.72 13.45 2 26.90 13.09 26.17 86689 H 04 03/01/13 N N 11.19 11.19 22.39 2 44.78 21.79 43.57 86692 H 04 03/01/13 N N 5.05 5.05 10.10 2 20.20 9.83 19.65 86694 H 04 03/01/13 N N 6.67 6.67 13.35 2 26.70 12.99 25.98 86695 H 04 03/01/13 N N 7.65 7.65 15.30 2 30.60 14.89 29.77 86696 H 04 03/01/13 N N 10.10 10.10 20.20 2 40.40 19.65 39.31 86698 H 04 03/01/13 N N 8.15 8.15 16.30 3 48.90 15.86 47.58 86701 H 04 03/01/13 N N 6.48 6.48 12.96 2 25.92 12.61 25.22 86702 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86703 B 04 01/01/12 N N 10.01 10.01 20.02 19.48 86704 B 04 N N 7.85 7.85 15.70 15.28 86705 B 04 N N 7.70 7.70 15.40 14.98 86706 H 04 03/01/13 N N 7.00 7.00 14.00 2 28.00 13.62 27.24 86707 H 04 03/01/13 N N 4.77 4.77 9.55 2 19.10 9.29 18.58 86708 B 04 N N 4.77 4.77 9.55 9.29 86709 B 04 N N 2.77 2.77 5.55 5.40 86710 B 04 N N 8.85 8.85 17.70 17.22 86711 H 04 01/01/14 N N 5.94 5.94 11.87 2 23.74 11.55 23.10 86713 H 04 03/01/13 N N 2.62 2.62 5.25 3 15.75 5.11 15.32 86717 B 04 N N 5.10 5.10 10.20 9.92 86720 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86723 H 04 03/01/13 N N 8.32 8.32 16.65 2 33.30 16.20 32.40 86727 H 04 03/01/13 N N 7.80 7.80 15.60 2 31.20 15.18 30.36 86729 B 04 N N 7.65 7.65 15.30 14.89 86732 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86735 B 04 N N 6.35 6.35 12.70 12.36 86738 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86741 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86744 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86747 H 04 03/01/13 N N 9.80 9.80 19.60 2 39.20 19.07 38.14 86750 H 04 03/01/13 N N 5.10 5.10 10.20 4 40.80 9.92 39.70 86753 H 04 03/01/13 N N 8.08 8.08 16.17 3 48.51 15.73 47.20 86756 H 04 03/01/13 N N 8.42 8.42 16.85 2 33.70 16.40 32.79 86757 B 04 N N 10.10 10.10 20.20 19.65 86759 H 04 03/01/13 N N 8.40 8.40 16.80 2 33.60 16.35 32.69
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
86762 H 04 03/01/13 N N 4.10 4.10 8.20 2 16.40 7.98 15.96 86765 B 04 N N 4.10 4.10 8.20 7.98 86768 H 04 03/01/13 N N 5.10 5.10 10.20 5 51.00 9.92 49.62 86771 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86774 H 04 03/01/13 N N 9.65 9.65 19.30 2 38.60 18.78 37.56 86777 H 04 03/01/13 N N 6.35 6.35 12.70 2 25.40 12.36 24.71 86778 H 04 03/01/13 N N 9.40 9.40 18.80 2 37.60 18.29 36.58 86780 H 04 03/01/13 N N 8.64 8.64 17.29 2 34.58 16.82 33.65 86784 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86787 H 04 03/01/13 N N 7.50 7.50 15.00 2 30.00 14.60 29.19 86788 H 04 03/01/13 N N 7.06 7.06 14.12 2 28.24 13.74 27.48 86789 H 04 03/01/13 N N 6.03 6.03 12.07 2 24.14 11.74 23.49 86790 B 04 N N 8.42 8.42 16.85 16.40 86793 H 04 03/01/13 N N 5.10 5.10 10.20 2 20.40 9.92 19.85 86800 B 04 N N 5.90 5.90 11.80 11.48 86803 H 04 03/01/13 N N 8.42 8.42 16.85 2 33.70 16.40 32.79 86804 B 04 N N 6.20 6.20 12.40 12.07 86805 B 04 N N 23.90 23.90 47.80 46.51 86806 B 04 N N 21.72 21.72 43.45 42.28 86807 H 04 03/01/13 N N 18.05 18.05 36.10 2 72.20 35.13 70.25 86808 B 04 N N 13.55 13.55 27.10 26.37 86812 B 04 N N 3.10 3.10 6.20 6.03 86813 B 04 N N 8.42 8.42 16.85 16.40 86816 B 04 N N 7.50 7.50 15.00 14.60 86817 B 04 N N 14.00 14.00 28.00 27.24 86821 H 04 03/01/13 N N 28.05 28.05 56.10 3 168.30 54.59 163.76 86822 H 04 03/01/13 N N 13.35 13.35 26.70 3 80.10 25.98 77.94 86825 B 04 01/01/10 N N 17.42 17.42 34.80 33.86 86826 A 04 01/01/10 N N 7.31 7.31 14.62 14.23 86828 B 04 01/01/13 N N 16.32 16.32 32.64 31.76 86829 B 04 01/01/13 N N 12.24 12.24 24.48 23.82 86830 B 04 01/01/13 N N 33.30 33.30 66.59 64.79 86831 B 04 01/01/13 N N 28.54 28.54 57.08 55.54 86832 B 04 01/01/13 N N 52.32 52.32 104.64 101.81 86833 B 04 01/01/13 N N 47.57 47.57 95.13 92.56 86834 B 04 01/01/13 N N 147.45 147.45 294.89 286.93 86835 B 04 01/01/13 N N 133.05 133.05 266.09 258.91 86849 04 Y N86850 H 04 03/01/13 N N 2.82 2.82 5.65 3 16.95 5.50 16.49 86860 H 04 03/01/13 N N 5.95 5.95 11.90 2 23.80 11.58 23.16 86870 A 04 N N 7.17 7.17 14.35 13.96 86880 A 04 N N 2.90 2.90 5.80 5.64
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
86885 H 04 03/01/13 N N 3.05 3.05 6.10 3 18.30 5.94 17.81 86886 H 04 03/01/13 N N 3.10 3.10 6.20 3 18.60 6.03 18.10 86890 04 N N 40.40 39.31 86891 04 N N 101.80 99.05 86900 A 04 N N 1.75 1.75 3.50 3.41 86901 A 04 N N 2.35 2.35 4.70 4.57 86902 A 04 01/01/11 N N 1.62 1.62 3.24 3.15 86904 H 04 03/01/13 N N 6.20 6.20 12.40 2 24.80 12.07 24.13 86905 A 04 N N 2.47 2.47 4.95 4.82 86906 B 04 02/01/13 N N 2.30 2.30 4.60 4.48 86910 A 04 N N 12.02 12.02 24.05 23.40 86911 A 04 N N 3.40 3.40 6.80 6.62 86920 A 04 N N 2.35 2.35 4.70 4.57 86921 H 04 03/01/13 N N 4.70 4.70 9.40 2 18.80 9.15 18.29 86922 A 04 N N 4.70 4.70 9.40 9.15 86927 09 Y N86930 09 Y N86931 09 Y N86932 09 Y N86940 A 04 N N 2.77 2.77 5.55 5.40 86941 A 04 N N 2.35 2.35 4.70 4.57 86945 H 04 03/01/13 N N 3.30 3.30 6.60 3 19.80 6.42 19.27 86950 04 N N 25.70 25.01 86965 04 N N 5.05 4.91 86970 04 N N 10.10 9.83 86971 04 N N 8.20 7.98 86972 04 N N 8.20 7.98 86975 H 04 03/01/13 N N 4.10 4.10 8.20 2 16.40 7.98 15.96 86976 H 04 03/01/13 N N 4.10 4.10 8.20 2 16.40 7.98 15.96 86977 H 04 03/01/13 N N 4.10 4.10 8.20 2 16.40 7.98 15.96 86978 04 N N 10.10 9.83 86985 B 04 02/01/13 N N 4.10 4.10 8.20 7.98 86999 04 Y N87003 B 04 N N 8.95 8.95 17.90 17.42 87015 A 04 N N 3.60 3.60 7.20 7.01 87040 H 04 03/01/13 N N 6.75 6.75 13.50 2 27.00 13.14 26.27 87045 H 04 03/01/13 N N 6.15 6.15 12.30 3 36.90 11.97 35.90 87046 B 04 N N 1.20 1.20 2.40 2.34 87070 H 04 N N 3.10 3.10 6.20 3 18.60 6.03 18.10 87071 09 Y N87073 09 Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
87075 B 04 N N 6.17 6.17 12.35 12.02 87076 09 Y N87077 09 Y N87081 B 04 N N 2.90 2.90 5.80 5.64 87084 H 04 03/01/13 N N 3.00 3.00 6.00 2 12.00 5.84 11.68 87086 H 04 03/01/13 N N 5.25 5.25 10.50 3 31.50 10.22 30.65 87088 B 04 N N 5.65 5.65 11.31 11.00 87101 B 04 N N 3.10 3.10 6.20 6.03 87102 B 04 N N 3.10 3.10 6.20 6.03 87103 H 04 03/01/13 N N 3.10 3.10 6.20 3 18.60 6.03 18.10 87106 09 Y N87107 09 Y N87109 H 04 03/01/13 N N 4.77 4.77 9.55 3 28.65 9.29 27.88 87110 H 04 03/01/13 N N 8.42 8.42 16.85 2 33.70 16.40 32.79 87116 H 04 03/01/13 N N 5.85 5.85 11.70 2 23.40 11.38 22.77 87118 09 Y N87140 B 04 N N 0.57 0.57 1.15 1.12 87143 H 04 03/01/13 N N 3.60 3.60 7.20 . 14.40 7.01 14.01 87147 B 04 N N 1.60 1.60 3.20 3.11 87149 09 Y N87150 09 01/01/10 Y N87152 09 Y N87153 09 01/01/10 N N87158 B 04 N N 0.57 0.57 1.15 1.12 87164 H 04 03/01/13 N N 14.00 2 28.00 13.62 27.24 87166 H 04 03/01/13 N N 14.75 2 29.50 14.35 28.70 87168 H 04 03/01/13 N N 2.25 2.25 4.50 2 9.00 4.38 8.76 87169 H 04 03/01/13 N N 2.25 2.25 4.50 2 9.00 4.38 8.76 87172 H 04 03/01/13 N N 2.25 2.25 4.50 2 9.00 4.38 8.76 87176 H 04 03/01/13 N N 3.85 3.85 7.70 2 15.40 7.49 14.98 87177 H 04 03/01/13 N N 3.60 3.60 7.20 3 21.60 7.01 21.02 87181 B 04 N N 3.10 3.10 6.20 6.03 87184 B 04 01/01/12 N N 4.50 4.50 9.00 8.76 87185 A 04 N N 2.47 2.47 4.95 4.82 87186 B 04 01/01/12 N N 5.65 5.65 11.30 10.99 87187 H 04 03/01/13 N N 4.30 4.30 8.60 3 25.80 8.37 25.10 87188 B 04 N N 4.32 4.32 8.65 8.42 87190 04 N N 7.40 7.20 87197 B 04 N N 6.40 6.40 12.80 12.45 87205 H 04 03/01/13 N N 1.75 1.75 3.50 3 10.50 3.41 10.22 87206 B 04 N N 2.10 2.10 4.20 4.09 87207 H 04 03/01/13 N N 1.75 1.75 3.50 3 10.50 3.41 10.22
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
87209 B 04 N N 7.53 7.53 15.06 14.65 87210 B 04 01/01/12 N N 2.35 2.35 4.70 4.57 87220 H 04 03/01/13 N N 2.35 2.35 4.70 3 14.10 4.57 13.72 87230 H 04 03/01/13 N N 7.50 7.50 15.00 3 45.00 14.60 43.79 87250 H 04 03/01/13 N N 12.80 3 38.40 12.45 37.36 87252 B 04 N N 6.40 6.40 12.80 12.45 87253 H 04 03/01/13 N N 7.50 7.50 15.00 2 30.00 14.60 29.19 87254 A 04 N N 3.20 3.20 6.40 6.23 87255 H 04 03/01/13 N N 11.83 11.83 23.66 2 47.32 23.02 46.04 87260 B 04 N N 7.85 7.85 15.70 15.28 87265 B 04 N N 7.85 7.85 15.70 15.28 87267 B 04 N N 4.19 4.19 8.38 8.15 87269 B 04 N N 5.02 5.02 10.05 9.78 87270 B 04 01/01/12 N N 7.85 7.85 15.70 15.28 87271 B 04 N N 4.19 4.19 8.38 8.15 87272 B 04 N N 7.85 7.85 15.70 15.28 87273 B 04 01/01/12 N N 6.25 6.25 12.50 12.16 87274 B 04 N N 7.85 7.85 15.70 15.28 87275 B 04 N N 6.25 6.25 12.50 12.16 87276 B 04 N N 7.85 7.85 15.70 15.28 87277 B 04 N N 6.25 6.25 12.50 12.16 87278 B 04 N N 7.85 7.85 15.70 15.28 87279 B 04 02/01/13 N N 6.25 6.25 12.50 12.16 87280 B 04 N N 7.85 7.85 15.70 15.28 87281 B 04 N N 6.25 6.25 12.50 12.16 87283 B 04 N N 6.25 6.25 12.50 12.16 87285 B 04 N N 7.85 7.85 15.70 15.28 87290 B 04 N N 7.85 7.85 15.70 15.28 87299 04 Y N87300 A 04 N N 3.10 3.10 6.20 6.03 87301 B 04 N N 7.85 7.85 15.70 15.28 87305 B 04 N N 7.85 7.85 15.70 15.28 87320 B 04 01/01/12 N N 7.85 7.85 15.70 15.28 87324 B 04 N N 7.85 7.85 15.70 15.28 87327 B 04 N N 6.25 6.25 12.50 12.16 87328 B 04 N N 7.85 7.85 15.70 15.28 87329 B 04 N N 5.02 5.02 10.05 9.78 87332 B 04 N N 7.85 7.85 15.70 15.28 87335 B 04 N N 7.85 7.85 15.70 15.28 87336 B 04 N N 6.25 6.25 12.50 12.16 87337 B 04 N N 6.25 6.25 12.50 12.16 87338 B 04 N N 9.40 9.40 18.80 18.29
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
87339 B 04 N N 6.25 6.25 12.50 12.16 87340 B 04 N N 6.75 6.75 13.50 13.14 87341 B 04 N N 5.40 5.40 10.80 10.51 87350 B 04 N N 7.52 7.52 15.05 14.64 87380 B 04 N N 10.70 10.70 21.40 20.82 87385 B 04 N N 7.85 7.85 15.70 15.28 87389 C 04 01/01/12 N N 54.53 27.27 81.80 79.59 87390 B 04 01/01/12 N N 11.50 11.50 23.00 22.38 87391 B 04 01/01/12 N N 11.50 11.50 23.00 22.38 87400 H 04 01/01/14 N N 3.10 3.10 6.20 2 12.40 6.03 12.07 87420 B 04 N N 7.85 7.85 15.70 15.28 87425 B 04 N N 7.85 7.85 15.70 15.28 87427 B 04 N N 6.25 6.25 12.50 12.16 87430 B 04 N N 7.85 7.85 15.70 15.28 87449 H 04 03/01/13 N N 7.84 7.84 15.68 3 47.04 15.26 45.77 87450 H 04 03/01/13 N N 4.12 4.12 8.23 2 16.46 8.01 16.02 87451 H 04 03/01/13 N N 5.00 5.00 10.00 2 20.00 9.73 19.46 87470 B 04 N N 13.10 13.10 26.20 25.49 87471 B 04 N N 22.90 22.90 45.80 44.56 87472 B 04 N N 27.95 27.95 55.91 54.40 87475 B 04 N N 13.10 13.10 26.20 25.49 87476 B 04 N N 22.90 22.90 45.80 44.56 87477 B 04 N N 27.95 27.95 55.91 54.40 87480 B 04 N N 13.10 13.10 26.20 25.49 87481 B 04 N N 22.90 22.90 45.80 44.56 87482 B 04 N N 27.25 27.25 54.50 53.03 87483 B 04 01/01/17 N N 171.52 171.52 343.03 333.77 87485 B 04 01/01/12 N N 13.10 13.10 26.20 25.49 87486 B 04 N N 22.90 22.90 45.80 44.56 87487 B 04 N N 27.95 27.95 55.91 54.40 87490 B 04 01/01/12 N N 13.10 13.10 26.20 25.49 87491 B 04 01/01/12 N N 22.90 22.90 45.80 44.56 87492 B 04 N N 22.81 22.81 45.63 44.40 87493 B 04 01/01/10 N N 22.91 22.91 45.82 44.58 87495 B 04 N N 13.10 13.10 26.20 25.49 87496 B 04 N N 22.90 22.90 45.80 44.56 87497 B 04 N N 22.81 22.81 45.63 44.40 87498 B 04 N N 22.91 22.91 45.83 44.59 87500 B 04 01/01/10 N N 14.71 14.71 29.42 28.63 87501 B 04 01/01/11 N N 21.67 21.67 43.34 42.17 87502 B 04 01/01/11 N N 35.93 35.93 71.86 69.92 87503 B 04 01/01/11 N N 8.75 8.75 17.50 17.03
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
87505 B 04 01/01/15 N N 52.87 52.87 105.75 102.89 87506 B 04 01/01/15 N N 87.13 87.13 174.27 169.56 87507 B 04 01/01/15 N N 170.15 170.15 340.31 331.12 87510 B 04 01/01/12 N N 13.10 13.10 26.20 25.49 87511 B 04 01/01/12 N N 22.90 22.90 45.80 44.56 87512 B 04 01/01/10 N N 17.93 17.93 35.86 34.89 87515 B 04 N N 13.10 13.10 26.20 25.49 87516 B 04 N N 22.90 22.90 45.80 44.56 87517 B 04 N N 27.95 27.95 55.90 54.39 87520 B 04 N N 13.10 13.10 26.20 25.49 87521 B 04 N N 22.90 22.90 45.80 44.56 87522 B 04 N N 27.95 27.95 55.90 54.39 87525 B 04 N N 13.10 13.10 26.20 25.49 87526 B 04 N N 22.90 22.90 45.80 44.56 87527 B 04 01/01/10 N N 17.93 17.93 35.86 34.89 87528 B 04 01/01/12 N N 13.10 13.10 26.20 25.49 87529 B 04 01/01/12 N N 22.90 22.90 45.80 44.56 87530 B 04 01/01/10 N N 18.40 18.40 36.80 35.81 87531 B 04 N N 13.10 13.10 26.20 25.49 87532 B 04 N N 22.90 22.90 45.80 44.56 87533 B 04 01/01/10 N N 17.93 17.93 35.86 34.89 87534 B 04 N N 13.10 13.10 26.20 25.49 87535 B 04 N N 22.90 22.90 45.80 44.56 87536 B 04 N N 43.45 43.45 86.90 84.55 87537 B 04 N N 13.10 13.10 26.20 25.49 87538 B 04 N N 22.90 22.90 45.80 44.56 87539 B 04 01/01/10 N N 18.41 18.41 36.72 35.73 87540 B 04 N N 13.10 13.10 26.20 25.49 87541 B 04 N N 22.90 22.90 45.80 44.56 87542 B 04 01/01/10 N N 17.93 17.93 35.86 34.89 87550 B 04 N N 13.10 13.10 26.20 25.49 87551 B 04 N N 22.90 22.90 45.80 44.56 87552 B 04 01/01/10 N N 18.41 18.41 36.82 35.83 87555 B 04 N N 13.10 13.10 26.20 25.49 87556 B 04 N N 22.90 22.90 45.80 44.56 87557 B 04 01/01/10 N N 18.41 18.41 36.82 35.83 87560 B 04 N N 13.10 13.10 26.20 25.49 87561 B 04 N N 22.90 22.90 45.80 44.56 87562 B 04 01/01/10 N N 18.41 18.41 36.82 35.83 87580 B 04 N N 13.10 13.10 26.20 25.49 87581 B 04 N N 22.90 22.90 45.80 44.56 87582 B 04 01/01/10 N N 17.93 17.93 35.86 34.89
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
87590 B 04 01/01/12 N N 13.10 13.10 26.20 25.49 87591 B 04 01/01/12 N N 22.90 22.90 45.80 44.56 87592 B 04 01/01/10 N N 18.41 18.41 36.82 35.83 87623 B 04 01/01/15 N N 14.33 14.33 28.66 27.89 87624 B 04 01/01/15 N N 14.33 14.33 28.66 27.89 87625 B 04 01/01/15 N N 14.33 14.33 28.66 27.89 87631 B 04 01/01/13 N N 52.90 52.90 105.80 102.94 87632 B 04 01/01/13 N N 88.01 88.01 176.02 171.27 87633 B 04 01/01/13 N N 171.88 171.88 343.75 334.47 87640 B 04 N N 22.91 22.91 45.83 44.59 87641 B 04 N N 22.91 22.91 45.83 44.59 87650 B 04 N N 13.10 13.10 26.20 25.49 87651 B 04 N N 22.90 22.90 45.80 44.56 87652 B 04 01/01/10 N N 17.93 17.93 35.86 34.89 87653 B 04 N N 22.91 22.92 45.83 44.59 87660 B 04 01/01/12 N N 8.40 8.40 16.81 16.36 87661 B 04 01/01/14 N N 14.36 14.36 28.72 27.94 87797 H 04 03/01/13 N N 13.10 13.10 26.20 3 78.60 25.49 76.48 87798 A 04 N N 22.91 22.91 45.83 44.59 87799 H 04 03/01/13 N N 25.94 25.94 51.89 3 155.67 50.49 151.47 87800 B 04 N N 10.47 10.47 20.95 20.38 87801 B 04 N N 18.30 18.30 36.60 35.61 87802 H 04 03/01/13 N N 7.82 7.82 15.65 2 31.30 15.23 30.45 87803 H 04 03/01/13 N N 7.82 7.82 15.65 3 46.95 15.23 45.68 87804 H 04 03/01/13 N N 7.82 7.82 15.65 2 31.30 15.23 30.45 87806 B 04 01/01/15 N N 9.83 9.83 19.66 19.13 87807 H 04 03/01/13 N N 5.03 5.03 10.06 2 20.12 9.79 19.58 87808 B 04 01/01/12 N N 7.82 7.82 15.65 15.23 87809 B 04 01/01/10 N N 5.03 5.03 10.06 9.79 87810 H 04 01/01/12 N N 7.85 7.85 15.70 2 31.40 15.28 30.55 87850 B 04 01/01/12 N N 7.85 7.85 15.70 15.28 87880 H 04 03/01/13 N N 7.85 7.85 15.70 2 31.40 15.28 30.55 87899 A 04 01/01/13 N N 4.94 4.94 9.89 9.62 87900 04 N N 162.20 157.82 87901 B 04 N N 84.02 84.02 168.05 163.51 87902 B 04 N N 84.02 84.02 168.05 163.51 87903 04 N N 682.72 664.29 87904 04 N N 32.44 9 291.96 31.56 284.08 87905 H 04 03/01/13 N N 5.27 5.27 10.54 2 21.08 10.26 20.51 87906 H 04 03/01/13 N N 54.34 54.34 108.68 2 217.36 105.75 211.49 87910 B 04 01/01/13 N N 106.17 106.17 212.33 206.60 87912 B 04 01/01/13 N N 106.17 106.17 212.33 206.60 87999 04 Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
88104 H 04 03/01/13 N N 5.90 5.90 11.80 4 47.20 11.48 45.93 88106 H 04 03/01/13 N N 5.90 5.90 11.80 3 35.40 11.48 34.44 88108 B 04 N N 4.45 4.45 8.90 8.66 88112 C 04 04/01/14 N N 26.72 36.89 63.61 61.89 88120 H 04 03/01/13 N N 31.19 228.29 259.48 2 518.96 252.47 504.95 88121 H 04 03/01/13 N N 27.69 191.32 219.01 2 438.02 213.10 426.19 88125 B 04 N N 1.67 1.67 3.35 3.26 88130 B 04 N N 7.00 7.00 14.00 13.62 88140 B 04 N N 4.77 4.77 9.55 9.29 88141 04 01/01/12 N N 3.50 3.41 88142 04 01/01/12 N N 3.35 3.26 88143 04 01/01/12 N N 3.50 3.41 88147 04 01/01/12 N N 3.50 3.41 88148 04 01/01/12 N N 3.50 3.41 88150 04 01/01/12 N N 3.50 3.41 88152 04 01/01/12 N N 3.50 3.41 88153 04 01/01/12 N N 3.50 3.41 88154 04 01/01/12 N N 3.50 3.41 88155 04 01/01/12 N N 4.10 3.99 88160 H 04 03/01/13 N N 5.90 5.90 11.80 4 47.20 11.48 45.93 88161 H 04 03/01/13 N N 5.62 5.62 11.25 4 45.00 10.95 43.79 88162 H 04 03/01/13 N N 11.80 11.80 23.60 23.60 22.96 22.96 88164 04 01/01/12 N N 3.50 3.41 88165 04 01/01/12 N N 3.50 3.41 88166 04 01/01/12 N N 3.50 3.41 88167 04 01/01/12 N N 3.50 3.41 88172 H 04 03/01/13 N N 8.43 8.43 16.85 3 50.55 16.40 49.19 88173 H 04 03/01/13 N N 14.00 14.00 28.00 3 84.00 27.24 81.73 88174 B 04 01/01/12 N N 7.46 7.46 14.93 14.53 88175 B 04 01/01/12 N N 9.20 9.20 18.41 17.91 88177 H 04 03/01/13 N N 12.66 3.71 16.37 2 32.74 15.93 31.86 88182 H 04 03/01/13 N N 15.25 15.25 30.50 2 61.00 29.68 59.35 88184 04 N N 2.10 2.04 88185 04 N N 1.05 24 25.20 1.02 24.52 88187 04 N N 40.11 39.03 88188 04 N N 50.00 48.65 88189 04 N N 65.85 64.07 88199 04 01/01/10 Y N88230 H 04 03/01/13 N N 45.40 45.40 90.80 2 181.60 88.35 176.70 88233 H 04 03/01/13 N N 58.77 58.77 117.55 3 352.65 114.38 343.13 88235 B 04 N N 66.80 66.80 133.60 129.99 88237 B 04 N N 53.47 53.47 106.95 104.06 88239 H 04 03/01/13 N N 66.80 66.80 133.60 3 400.80 129.99 389.98 88240 09 Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
88241 09 Y N88245 B 04 N N 43.82 43.82 87.65 85.28 88248 B 04 N N 44.12 44.12 88.25 85.87 88249 B 04 N N 43.77 43.77 87.55 85.19 88261 H 04 03/01/13 N N 58.90 58.90 117.80 2 235.60 114.62 229.24 88262 H 04 03/01/13 N N 81.37 81.37 162.75 2 325.50 158.36 316.71 88263 B 04 N N 94.37 94.37 188.75 183.65 88264 H 04 03/01/13 N N 81.37 81.37 162.75 2 325.50 158.36 316.71 88267 H 04 03/01/13 N N 44.30 44.30 88.60 2 177.20 86.21 172.42 88269 H 04 03/01/13 N N 38.17 38.17 76.35 2 152.70 74.29 148.58 88271 B 04 N N 9.45 9.45 18.90 18.39 88272 B 04 N N 16.52 16.52 33.05 32.16 88273 H 04 03/01/13 N N 20.95 20.95 41.90 3 125.70 40.77 122.31 88274 B 04 N N 22.70 22.70 45.40 44.17 88275 B 04 N N 26.20 26.20 52.40 50.99 88280 B 04 N N 16.35 16.35 32.70 31.82 88283 H 04 03/01/13 N N 12.27 12.27 24.55 2 49.10 23.89 47.77 88285 B 04 N N 12.40 12.40 24.80 24.13 88289 B 04 N N 8.55 8.55 17.10 16.64 88291 B 04 N N 2.62 2.62 5.25 5.11 88299 04 Y N88300 H 04 03/01/13 N N 6.52 6.52 13.05 2 26.10 12.70 25.40 88302 H 04 03/01/13 N N 10.47 10.47 20.95 2 41.90 20.38 40.77 88304 A 04 N N 18.67 18.67 37.35 36.34 88305 H 04 07/01/15 N N 22.60 18.50 41.10 8 328.80 39.99 319.92 88307 A 04 01/01/12 N N 21.80 21.80 43.60 42.42 88309 H 04 03/01/13 N N 23.70 23.70 47.40 3 142.20 46.12 138.36 88311 H 04 03/01/13 N N 5.75 5.75 11.50 4 46.00 11.19 44.76 88312 A 04 09/01/11 N N 5.90 5.90 11.80 11.48 88313 A 04 01/01/12 N N 3.35 3.35 6.70 6.52 88314 A 04 01/01/12 N N 3.10 3.10 6.20 6.03 88319 A 04 01/01/12 N N 11.20 11.20 22.40 21.80 88321 04 N N 6.20 6.03 88323 04 N N 17.90 17.42 88325 04 N N 19.90 19.36 88329 04 07/01/13 N N 48.55 4 194.20 47.24 188.96 88331 H 04 03/01/13 N N 24.28 24.28 48.55 11 534.05 47.24 519.63 88332 H 04 01/01/12 N N 14.13 5.77 19.90 2 39.80 19.36 38.73 88333 H 04 03/01/13 N N 25.43 24.43 50.86 4 203.44 49.49 197.95 88334 04 N N 26.40 25.69 88341 C 04 01/01/15 N N 12.79 35.03 37.82 36.80 88342 H 04 05/01/15 N N 5.65 7.80 13.45 3 40.35 13.09 39.26
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
88344 C 04 01/01/15 N N 23.42 42.00 65.42 63.65 88346 C 04 01/01/16 N N 7.25 9.60 16.85 16.40 88348 B 04 N N 23.60 23.60 47.20 45.93 88350 H 04 01/01/16 N N 16.79 23.82 40.61 4 162.44 39.51 158.05 88355 B 04 N N 54.30 54.30 108.60 105.67 88356 B 04 N N 54.30 54.30 108.60 105.67 88358 H 04 03/01/13 N N 54.30 54.30 108.60 2 217.20 105.67 211.34 88360 A 04 N N 30.91 30.91 61.83 60.16 88361 C 04 07/01/10 N N 29.08 43.62 72.70 70.74 88362 04 Y N88363 04 01/01/11 N N 10.24 9.96 88364 H 04 01/01/15 N N 15.93 38.29 54.22 3 162.66 52.76 158.27 88365 H 04 05/01/15 N N 12.24 28.57 40.81 2 81.62 39.71 79.42 88366 H 04 01/01/15 N N 36.81 47.27 84.08 81.81 88367 A 04 N N 57.57 57.57 115.15 112.04 88368 H 04 07/01/15 N N 42.08 63.12 105.2 2 210.40 102.36 204.72 88369 H 04 01/01/15 N N 14.76 26.59 41.35 3 124.05 40.23 120.70 88371 B 04 N N 14.22 14.22 28.45 27.68 88372 B 04 N N 14.85 14.85 29.70 28.90 88373 H 04 01/01/15 N N 12.42 21.52 33.94 3 101.82 33.02 99.07 88374 C 04 01/01/15 N N 26.46 87.05 113.51 110.45 88375 04 01/01/13 Y N88377 C 04 01/01/15 N N 38.50 81.00 119.50 116.27 88380 04 Y N88381 C 04 01/01/08 N N 31.82 83.72 115.54 112.42 88387 H 04 03/01/13 N N 17.75 4.43 22.18 3 66.54 21.58 64.74 88388 H 04 03/01/13 N N 11.30 2.15 13.45 3 40.35 13.09 39.26 88398 04 01/01/10 N N88399 04 03/01/11 Y N88720 B 04 01/01/09 N N 2.20 2.20 4.40 4.28 88738 B 04 01/01/10 N N 2.20 2.20 4.40 4.28 88740 B 04 01/01/09 N N 2.20 2.20 4.40 4.28 88741 B 04 01/01/09 N N 2.20 2.20 4.40 4.28 89049 B 04 N N 18.52 18.52 37.05 36.05 89050 H 04 03/01/13 N N 1.75 1.75 3.50 2 7.00 3.41 6.81 89051 H 04 03/01/13 N N 3.10 3.10 6.20 2 12.40 6.03 12.07 89055 H 04 03/01/13 N N 1.49 1.49 2.98 2 5.96 2.90 5.80 89060 H 04 03/01/13 N N 4.67 4.67 9.35 2 18.70 9.10 18.20 89125 H 04 03/01/13 N N 1.67 1.67 3.35 2 6.70 3.26 6.52 89160 B 04 N N 0.67 0.67 1.35 1.31 89190 B 04 N N 1.67 1.67 3.35 3.26 89240 04 Y N89310 04 01/01/08 N N 6.70 6.52
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
89321 B 04 01/01/08 N N 4.21 4.21 8.43 8.20 90371 T 04 04/01/17 N Y N 111.96 1 111.96 108.94 108.94 90375 T 04 04/01/17 N Y N 296.7058 17 5,044.00 288.69 4,907.81 90376 T 04 04/01/17 N Y N 296.338 17 5,037.75 288.34 4,901.73 90384 T 04 04/01/17 N Y N 79.40 1 79.40 77.26 77.26 90385 T 04 04/01/17 N Y N 28.95 1 28.95 28.17 28.17 90386 04 Y Y N90393 04 Y Y N90399 04 Y Y N90460 09 01/01/12 Y N90461 09 01/01/12 Y N90471 09 Y N90472 09 Y N90473 09 Y N90474 09 Y N90581 F 04 Y N90585 F 04 04/01/17 N N N 128.38 124.91 90586 F 04 04/01/17 N N N 128.38 124.91 90620 E , Y 04 04/01/17 N N 6.40 160.00 6.23 155.68 90621 E , Y 04 04/01/17 N N 6.40 121.90 6.23 118.61 90630 E , Y 04 04/01/17 N N 6.40 20.34 6.23 19.79 90632 E , Y 04 04/01/17 N N 6.40 49.66 6.23 48.32 90633 E , Y 04 04/01/17 N N 6.40 30.37 6.23 29.55 90636 E , Y 04 04/01/17 N N 6.40 93.73 6.23 91.20 90644 E , Y 04 04/01/17 N N 6.40 23.21 6.23 22.58 90647 E , Y 04 04/01/17 N N 6.40 24.50 6.23 23.84 90648 E , Y 04 04/01/17 N N 6.40 15.00 6.23 14.60 90649 M, Y 04 04/01/17 N N 6.40 160.94 6.23 156.59 90650 I , Y 04 04/01/17 N N 6.40 128.00 6.23 124.54 90651 M , Y 04 04/01/17 N N 6.40 192.88 6.23 187.67 90653 F 04 04/01/17 N N 37.38 36.37 90654 E, F 04 04/01/17 N N 17.22 16.76 90656 E , Y 04 04/01/17 N N 6.40 17.72 6.23 17.24 90658 E , Y 04 04/01/17 N N 6.40 14.92 6.23 14.52 90662 F 04 04/01/17 N N 42.72 41.57 90670 E , Y 04 04/01/17 N N 6.40 192.64 6.23 187.44 90673 E , Y 04 04/01/17 N N 6.40 40.61 6.23 39.51 90674 E , Y 04 04/01/17 N N 6.40 22.94 6.23 22.32 90675 F 04 04/01/17 N N 269.91 262.62 90680 E , Y 04 04/01/17 N N 6.40 80.53 6.23 78.36 90681 E , Y 04 04/01/17 N N 6.40 109.00 6.23 106.06 90685 E , Y 04 04/01/17 N N 6.40 26.27 6.23 25.56
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
90686 E , Y 04 04/01/17 N N 6.40 19.03 6.23 18.52 90687 E , Y 04 04/01/17 N N 6.40 9.40 6.23 9.15 90688 E , Y 04 04/01/17 N N 6.40 17.84 6.23 17.36 90690 09 Y N90691 09 Y N90696 E , Y 04 04/01/17 N N 6.40 46.35 6.23 45.10 90698 E , Y 04 04/01/17 N N 6.40 86.25 6.23 83.92 90700 E , Y 04 04/01/17 N N 6.40 26.95 6.23 26.22 90702 E , Y 04 04/01/17 N N 6.40 48.16 6.23 46.86 90707 E , Y 04 04/01/17 N N 6.40 64.78 6.23 63.03 90710 E , Y 04 04/01/17 N N 6.40 188.12 6.23 183.04 90713 E , Y 04 04/01/17 N N 6.40 30.31 6.23 29.49 90714 E , Y 04 04/01/17 N N 6.40 22.73 6.23 22.12 90715 E , Y 04 10/01/16 N N 6.40 31.85 6.23 30.99 90716 E , Y 04 04/01/17 N N 6.40 114.41 6.23 111.32 90717 09 Y N90723 E , Y 04 04/01/17 N N 6.40 68.98 6.23 67.12 90732 E , Y 04 04/01/17 N N 6.40 98.85 6.23 96.18 90733 F 04 04/01/17 N N 122.42 119.11 90734 E , Y 04 04/01/17 N N 6.40 119.00 6.23 115.79 90736 F 04 04/01/17 N N 212.67 206.93 90738 F 04 07/01/08 Y N90740 F 04 04/01/17 N N 122.96 119.64 90743 E , Y 04 04/01/17 N N 6.40 25.39 6.23 24.70 90744 E , Y 04 04/01/17 N N 6.40 25.39 6.23 24.70 90746 F 04 04/01/17 N N 61.48 59.82 90747 F 04 04/01/17 N N 122.96 119.64 90748 E , Y 04 04/01/17 N N 6.40 42.06 6.23 40.92 90749 F 04 Y N90791 04 01/01/13 N N 70.00 52.11 52.11 68.11 90792 04 01/01/13 N N 72.33 52.11 52.11 70.38 90832 04 01/01/13 N N 29.48 28.68 90833 04 01/01/13 N N 24.62 23.96 90834 04 01/01/17 N N 44.20 2 88.40 43.01 86.01 90836 04 01/01/13 N N 40.24 39.15 90837 04 01/01/17 N N 66.71 2 133.42 64.91 129.82 90838 04 01/01/13 N N 64.64 62.89 90839 04 01/01/13 N N 66.71 64.91 90845 D 04 N N90846 09 Y N90847 04 N N 61.20 59.55 90849 04 N N 61.20 59.55 90853 04 N N 33.70 32.79
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
90865 04 N N 63.40 61.69 90870 04 N I 44.40 43.20 90875 04 N N 28.70 27.93 90876 04 N N 47.50 46.22 90880 09 Y N90885 09 Y N90887 09 Y N90889 09 Y N90899 04 Y N90901 09 Y I90911 04 01/01/12 N I 26.69 26.69 53.38 51.94 90935 04 N I 35.75 34.78 90937 04 N I 61.70 60.03 90940 04 Y I90945 04 N I 36.50 35.51 90947 04 N N 60.90 59.26 90951 04 01/01/09 N I 252.35 245.54 90952 04 01/01/09 N I 252.35 245.54 90953 04 01/01/09 N I 252.35 245.54 90954 04 01/01/09 N I 213.65 207.88 90955 04 01/01/09 N I 213.65 207.88 90956 04 01/01/09 N I 213.65 207.88 90957 04 01/01/09 N I 213.65 207.88 90958 04 01/01/09 N I 213.65 207.88 90959 04 01/01/09 N I 213.65 207.88 90960 04 01/01/09 N I 213.65 207.88 90961 04 01/01/09 N I 213.65 207.88 90962 04 01/01/09 N I 213.65 207.88 90963 04 01/01/09 N I 252.35 245.54 90964 04 01/01/09 N I 213.65 207.88 90965 04 01/01/09 N I 213.65 207.88 90966 04 01/01/09 N I 213.65 207.88 90967 04 01/01/09 N I 8.30 8.08 90968 04 01/01/09 N I 7.10 6.91 90969 04 01/01/09 N I 7.10 6.91 90970 04 01/01/09 N I 7.10 6.91 90989 09 Y I90993 09 Y I90997 04 Y N90999 04 Y I91010 C 04 N I 20.19 32.51 Y 52.70 51.28
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
91013 C 04 01/01/11 N I 5.85 7.55 Y 13.40 13.04 91020 04 N I 74.90 72.88 91022 C 04 N N 3 42.72 75.37 118.09 114.90 91030 04 N I 3 74.90 72.88 91034 C 04 N I 3 31.17 99.11 130.28 126.76 91035 C 04 05/01/13 N I 3 76.69 178.93 255.62 248.72 91037 04 N I 3 84.00 81.73 91038 C 04 N I 3 32.73 40.00 72.73 70.77 91040 04 N I 3 248.27 241.57 91065 04 N I 29.65 28.85 91110 C 04 N I 140.95 563.92 704.90 685.87 91111 C 04 N N 28.37 343.76 372.13 362.08 91112 C 04 01/01/13 N I 65.74 586.46 652.19 634.58 91120 04 N I 3 245.00 238.39 91122 04 N I 3 57.20 55.66 91132 04 Y I91133 04 Y I91200 C 04 01/01/15 N I 8.66 11.77 20.43 19.88 91299 04 Y I92002 04 N N 27.55 26.81 92004 04 N N 46.45 45.20 92012 04 N N 23.30 22.67 92014 04 N N 44.45 43.25 92015 04 N I 18.45 17.95 92018 04 N I 3 152.60 148.48 92019 04 N I 3 152.60 148.48 92020 04 N I 19.50 18.97 92025 C 04 N I 9.04 6.29 15.33 14.92 92060 C 04 08/01/08 N I 16.68 8.22 24.90 24.23 92065 C 04 08/01/08 N I 9.75 12.40 22.15 21.55 92071 09 01/01/12 Y I92072 09 01/01/12 Y I92081 C 04 08/01/08 N I 8.18 12.27 20.45 19.90 92082 C 04 08/01/08 N I 11.29 19.21 30.50 29.68 92083 C 04 08/01/08 N I 13.84 23.56 37.40 36.39 92100 04 N I 23.80 23.16 92132 C 04 01/01/11 N I 12.52 8.70 21.22 20.65 92133 C 04 01/01/11 N I 17.30 8.70 26.00 25.30 92134 C 04 01/01/11 N I 17.30 8.70 26.00 25.30 92136 C 04 08/01/08 N I 19.02 31.03 50.05 48.70 92145 C 04 01/01/15 N I 5.28 3.78 9.06 8.82
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
92225 04 N I 30.50 29.68 92226 04 N I 30.50 29.68 92227 04 01/01/11 N I 6.59 6.41 92228 C 04 01/01/11 N I 10.22 7.16 17.38 16.91 92230 B 04 N I 22.20 22.20 44.40 43.20 92235 C 04 08/01/08 N I 20.03 32.67 52.70 51.28 92240 C 04 08/01/08 N I 15.82 40.68 56.50 54.97 92242 C 04 01/01/17 N I 32.80 95.13 127.93 124.48 92250 C 04 08/01/08 N I 15.98 28.42 44.40 43.20 92260 B 04 N I 26.35 26.35 52.70 51.28 92265 04 N I 74.90 72.88 92270 04 N I 52.70 51.28 92275 B 04 N I 26.35 26.35 52.70 51.28 92283 04 N I 22.15 21.55 92284 B 04 N I 7.60 7.60 15.20 14.79 92285 04 N I 30.50 29.68 92286 04 N I 52.70 51.28 92287 04 N I 69.30 67.43 92310 04 Y N92311 09 Y N92312 09 Y N92313 09 Y N92314 09 Y N92315 09 Y N92316 09 Y N92317 09 Y N92325 09 Y N92326 09 Y N92340 04 N N 30.09 29.28 92341 09 Y N92342 09 Y N92352 09 Y N92353 09 Y N92354 09 Y N92355 09 Y N92358 09 Y N92370 04 N N 4.76 4.63 92371 09 Y N92499 04 Y I92502 04 N I 4 52.70 51.28 92504 04 N I 3 37.40 36.39
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
92507 04 N I 19.85 19.31 92508 09 Y I92511 04 N I 3 112.40 109.37 92512 04 N I 20.05 19.51 92516 04 N I 15.90 15.47 92520 04 N I 30.50 29.68 92521 04 01/01/14 N I 37.40 36.39 92522 04 01/01/14 N I 37.40 36.39 92523 04 01/01/14 N I 37.40 36.39 92524 04 01/01/14 N I 37.40 36.39 92526 04 Y I92531 04 N I 30.50 29.68 92532 04 N I 30.50 29.68 92533 04 N I 22.15 21.55 92534 04 N I 22.15 21.55 92537 C 04 01/01/16 N I 18.90 4.76 23.66 23.02 92538 C 04 01/01/16 I 9.45 2.61 12.06 11.73 92540 C 04 01/01/10 N I 44.40 9.10 53.50 52.06 92541 C 04 10/01/09 N I 8.35 13.80 22.15 21.55 92542 C 04 10/01/09 N I 6.64 15.51 22.15 21.55 92544 C 04 10/01/09 N I 4.75 17.40 22.15 21.55 92545 C 04 10/01/09 N I 6.14 16.01 22.15 21.55 92546 C 04 10/01/09 N I 4.32 17.83 22.15 21.55 92547 04 01/01/10 N I 22.15 21.55 92548 C 04 01/01/10 N I 11.80 27.55 39.35 38.29 92550 04 01/01/10 N N 11.65 11.34 92551 04 N N 15.20 14.79 92552 04 N I 15.20 14.79 92553 04 N I 15.20 14.79 92555 04 N I 15.20 14.79 92556 04 N I 15.20 14.79 92557 04 N I 37.40 36.39 92558 04 01/01/15 N I 12.20 11.87 92559 09 Y N92560 04 N I 15.20 14.79 92561 04 N I 26.35 25.64 92562 04 N N 7.60 7.39 92563 04 N N 15.20 14.79 92564 04 N N 15.20 14.79 92565 04 N N 15.20 14.79 92567 04 N N 15.20 14.79 92568 04 N N 13.70 13.33
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
92570 04 01/01/10 N N 16.90 16.44 92571 04 N N 15.20 14.79 92572 04 N N 15.20 14.79 92575 04 N N 15.20 14.79 92576 04 N N 15.20 14.79 92577 04 N N 12.20 11.87 92579 04 N N 22.15 21.55 92582 04 N N 22.15 21.55 92583 04 N N 15.15 14.74 92584 04 N I 74.90 72.88 92585 04 N I 53.75 52.30 92586 04 N I 47.80 46.51 92587 04 01/01/15 Y I #VALUE!92588 C 04 01/01/15 N I 17.23 2.13 19.36 18.84 92590 04 N I 37.40 36.39 92591 04 N I 37.40 36.39 92592 04 N I 15.20 14.79 92593 04 N I 15.20 14.79 92594 04 N I 15.20 14.79 92595 04 N I 15.20 14.79 92596 04 N I 15.20 14.79 92597 04 N I 43.18 42.01 92601 04 N I 55.01 53.52 92602 04 N I 38.72 37.67 92603 04 N I 37.18 36.18 92604 04 N I 25.49 24.80 92606 04 N I 24.90 24.23 92607 04 N I 45.85 44.61 92608 04 N N 9.25 9.00 92609 04 N I 24.90 24.23 92610 04 N I 18.00 17.51 92611 04 N I 19.55 19.02 92612 04 N I 30.25 29.43 92613 04 N I 30.25 29.43 92614 04 N I 30.25 29.43 92615 04 N I 30.25 29.43 92616 04 N I 44.00 42.81 92617 04 N I 44.00 42.81 92620 04 N I 24.46 23.80 92621 04 N I 6.63 6.45 92625 04 N I 24.06 23.41
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
92626 09 Y N92627 09 Y N92630 09 Y N92633 09 Y N92640 04 N N 26.67 25.95 92700 04 Y I92920 04 01/01/13 N I 334.57 325.54 92921 04 01/01/13 Y I92924 04 01/01/13 N I 397.78 387.04 92925 04 01/01/13 Y I92928 04 01/01/13 N I 371.74 361.70 92929 04 01/01/13 Y I92933 04 01/01/13 N I 415.70 404.48 92934 04 01/01/13 Y I92937 04 01/01/13 N I 371.35 361.32 92938 04 01/01/13 Y I92941 04 01/01/13 N I 416.57 405.32 92943 04 01/01/13 N I 416.57 405.32 92944 04 01/01/13 Y I92950 04 N I Y Y 112.50 109.46 92953 04 N I Y Y 6.37 6.20 92960 04 N I 112.40 109.37 92961 04 N I 3 112.40 109.37 92970 04 01/01/12 N I 104.97 102.14 92971 04 01/01/12 N I 56.04 54.53 92973 04 N I 3 Y 156.50 152.27 92974 04 N I 3 183.90 178.93 92975 04 Y I 392977 04 Y I 392978 04 N I 120.70 117.44 92979 04 N I 74.20 72.20 92986 04 N M 3 Y 682.80 664.36 92987 04 N M 3 Y 682.80 664.36 92990 04 N M 3 Y 682.80 664.36 92992 04 N M 3 Y 898.75 874.48 92993 04 N M 3 Y 958.60 932.72 92997 04 N M 3 Y 718.70 699.30 92998 04 Y M 3 Y93000 04 01/01/17 N I 22.15 3 66.45 21.55 64.66 93005 04 01/01/17 N I 11.05 3 33.15 10.75 32.25 93010 04 04/01/16 N I 11.05 5 55.25 53.76 93015 04 N I 67.90 66.07 93016 04 N I 21.60 21.02
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
93017 04 N I 27.90 27.15 93018 04 N I 22.15 21.55 93024 04 N I 3 59.60 57.99 93025 04 N I 3 Y 168.20 163.66 93040 04 07/01/16 N I 7.60 3 22.80 7.39 22.18 93041 04 07/01/16 N I 3.80 2 7.60 3.70 7.39 93042 04 07/01/16 N I 4.20 3 12.60 4.09 12.26 93050 C 04 01/01/16 N N 5.09 4.96 10.05 9.78 93224 04 N I 180.30 175.43 93225 04 N I 135.90 132.23 93226 04 N I 44.40 43.20 93227 04 N I 44.40 43.20 93228 04 01/01/09 N I 21.60 21.02 93229 04 01/01/09 N I 39.50 38.43 93260 C 04 01/01/15 N I 26.45 12.36 38.81 37.76 93261 C 04 01/01/15 N I 23.12 12.36 35.48 34.52 93268 04 N I 73.70 71.71 93270 04 N I 21.60 21.02 93271 04 N I 39.50 38.43 93272 04 N I 21.60 21.02 93279 C 04 01/01/10 N I 20.88 10.77 31.65 30.80 93280 C 04 01/01/10 N I 24.99 12.22 37.21 36.21 93281 C 04 01/01/10 N I 29.15 14.38 43.53 42.35 93282 C 04 01/01/10 N I 27.37 13.05 40.42 39.33 93283 C 04 01/01/10 N I 34.44 14.76 49.20 47.87 93284 C 04 01/01/10 N I 40.86 16.67 57.53 55.98 93285 C 04 01/01/10 N I 17.11 10.19 27.30 26.56 93286 C 04 01/01/10 N I 8.92 6.62 15.54 15.12 93287 C 04 01/01/10 N I 12.86 7.72 20.58 20.02 93288 C 04 01/01/10 N I 13.95 10.38 24.33 23.67 93289 C 04 01/01/10 N I 25.21 12.22 37.43 36.42 93290 C 04 01/01/10 N I 12.50 6.00 18.50 18.00 93291 C 04 01/01/10 N I 14.21 9.17 23.38 22.75 93292 C 04 01/01/10 N I 13.95 7.33 21.28 20.71 93293 C 04 01/01/10 N I 9.93 23.46 33.39 32.49 93294 04 01/01/09 N I 21.33 20.75 93295 04 01/01/09 N I 38.37 37.33 93296 04 01/01/09 N I 19.30 18.78 93297 04 01/01/09 N I 15.02 14.61 93298 04 01/01/09 N I 17.11 16.65 93299 04 05/01/11 N I 22.72 22.11
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
93303 C 04 06/01/12 N I 32.37 65.73 98.10 95.45 93304 C 04 06/01/12 N I 15.37 37.63 53.00 51.57 93306 C 04 01/01/09 N I 27.30 63.70 91.00 88.54 93307 C 04 06/01/12 N I 32.76 58.24 91.00 88.54 93308 C 04 06/01/12 N I 14.23 38.47 52.70 51.28 93312 B 04 N I 81.85 81.85 163.70 159.28 93313 B 04 N I 55.50 55.50 111.00 108.00 93314 B 04 N I 47.15 47.15 94.30 91.75 93315 B 04 N I 81.85 81.85 163.70 159.28 93316 B 04 N I 55.50 55.50 111.00 108.00 93317 B 04 N I 53.13 53.12 106.25 103.38 93318 B 04 N I 81.85 81.85 163.70 159.28 93320 B 04 N I 19.90 19.90 39.80 38.73 93321 B 04 N I 12.95 12.95 25.90 25.20 93325 B 04 N I 25.17 25.17 50.35 48.99 93350 B 04 N I 81.85 81.85 163.70 159.28 93351 C 04 01/01/12 N I 81.50 132.95 214.45 208.66 93355 04 10/01/16 N I 136.85 133.16 93451 C 04 01/01/11 N I 91.10 347.42 438.52 426.68 93452 C 04 01/01/12 N I 159.85 331.88 491.73 478.45 93453 C 04 01/01/11 N I 209.41 433.99 643.40 626.03 93454 C 04 01/01/11 N I 161.05 345.69 506.74 493.06 93455 C 04 01/01/12 N I 185.80 405.22 591.02 575.06 93456 C 04 01/01/12 N I 205.96 428.43 634.39 617.26 93457 C 04 01/01/11 N I 231.02 487.72 718.74 699.33 93458 C 04 01/01/11 N I 196.50 415.20 611.70 595.18 93459 C 04 01/01/12 N I 220.98 454.72 675.70 657.46 93460 C 04 01/01/12 N I 246.19 477.74 723.93 704.38 93461 C 04 01/01/12 N I 271.72 557.03 828.75 806.37 93462 04 01/01/11 N I 125.02 121.64 93463 04 01/01/11 N I 66.05 64.27 93464 C 04 01/01/11 N I 58.25 88.69 146.94 142.97 93503 04 N I 3 149.80 145.76 93505 C 04 11/01/15 N I 51.08 103.72 154.80 150.62 93530 04 N I 399.90 389.10 93531 04 N I 3 1021.95 994.36 93532 04 N I 3 1050.75 1,022.38 93533 04 N I 3 940.30 914.91 93561 04 N I 109.20 106.25 93562 04 N I 149.80 145.76 93563 04 01/01/12 N I 33.67 32.76
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
93564 04 01/01/11 N I 34.33 33.40 93565 04 01/01/11 N I 25.94 25.24 93566 04 01/01/11 N I 25.94 25.24 93567 04 01/01/11 N I 29.14 28.35 93568 04 01/01/11 N I 26.54 25.82 93571 B 04 N I 57.82 57.82 115.65 112.53 93572 B 04 N I 52.75 52.75 105.50 102.65 93580 04 08/29/16 N I 3 Y 888.00 864.02 93581 04 Y M 3 Y93582 04 01/01/14 N I 3 Y 426.70 415.18 93583 04 01/01/14 N I 3 Y 474.99 462.17 93590 04 01/01/17 N I 3 Y Y 757.60 737.14 93591 04 01/01/17 N I 3 Y Y 628.70 611.73 93592 04 01/01/17 N I 3 Y Y 277.34 2 554.68 269.85 539.70 93600 04 N I 3 Y 224.70 218.63 93602 04 N I 3 Y 224.70 218.63 93603 04 N I 3 Y 224.70 218.63 93609 04 N I 3 Y 282.40 274.78 93610 04 N I 3 Y 224.70 218.63 93612 04 N I Y 224.70 218.63 93613 04 N I 3 Y 252.15 245.34 93615 04 03/31/15 N I 3 N 224.70 218.63 93616 04 N I 3 Y 374.60 364.49 93618 04 N I 3 Y 374.60 364.49 93619 04 N I 3 Y 343.70 334.42 93620 04 N I 3 Y 489.60 476.38 93621 04 N I 3 Y 374.60 364.49 93622 04 N I 3 Y 374.60 364.49 93623 04 N I 3 Y 374.60 364.49 93624 04 N I 3 Y 224.70 218.63 93631 04 N I 3 Y 310.95 302.55 93640 04 N I Y 222.35 216.35 93641 04 N I Y 293.55 285.62 93642 C 04 01/01/12 N I 99.65 162.60 Y 262.25 255.17 93644 C 04 01/01/15 N I 118.50 58.45 Y 176.95 172.17 93650 04 N I 5 Y 550.90 536.03 93653 04 01/01/13 N I 505.06 491.42 93654 04 01/01/13 N I 673.96 655.76 93655 04 01/01/13 N M 252.49 245.67 93656 04 01/01/13 N I 674.19 655.99 93657 04 01/01/13 N I 252.76 245.94 93660 C 04 06/01/12 N I 41.58 27.72 69.30 67.43
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
93662 04 N I 205.00 199.47 93668 04 N I 28.35 27.58 93701 04 N I 30.10 29.29 93702 04 01/01/15 N I 62.48 60.79 93724 04 N I 224.70 218.63 93740 04 N I 7.60 7.39 93745 04 N I 36.90 35.90 93750 04 01/01/10 N I 26.19 25.48 93770 04 N I 16.65 16.20 93784 04 N I 180.30 175.43 93786 04 N I 134.60 130.97 93788 04 N I 44.40 43.20 93790 04 N I 44.40 43.20 93797 04 N N 21.10 20.53 93798 04 N N 43.35 42.18 93799 04 Y I Y93880 C 04 01/01/14 N I 13.40 65.40 78.80 76.67 93882 C 04 01/01/14 N I 9.43 42.97 52.40 50.99 93886 A 04 N I 47.15 47.15 94.30 91.75 93888 A 04 N I 31.53 31.52 63.05 61.35 93890 A 04 N I 84.30 84.30 168.60 164.05 93892 A 04 N I 70.87 70.86 141.73 137.90 93893 A 04 N I 69.56 69.56 139.12 135.36 93922 A 04 N I 25.03 25.02 50.05 48.70 93923 A 04 N I 25.47 25.47 50.95 49.57 93924 A 04 N I 28.00 28.00 56.00 54.49 93925 A 04 N I 39.40 39.40 78.80 76.67 93926 A 04 N I 26.35 26.35 52.70 51.28 93930 A 04 N I 40.07 40.08 80.15 77.99 93931 A 04 N I 26.60 26.60 53.20 51.76 93970 C 04 N I 17.38 70.17 87.55 85.19 93971 C 04 N I 10.77 47.48 58.25 56.68 93975 C 04 02/01/15 N I 26.22 92.98 119.20 115.98 93976 C 04 02/01/15 N I 20.72 58.98 79.70 77.55 93978 C 04 02/01/15 N I 13.17 69.13 Y 82.30 80.08 93979 A 04 N I 27.40 27.40 54.80 53.32 93980 A 04 N I 45.83 45.82 91.65 89.18 93981 A 04 N I 33.65 33.65 67.30 65.48 93982 04 01/01/08 N I 22.25 21.65 93990 A 04 N I 40.93 40.92 81.85 79.64 93998 04 01/01/12 Y I94002 04 N I 46.34 45.09
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
94003 04 N I 33.61 32.70 94004 04 N I 24.47 23.81 94010 C 04 N I 7.65 29.75 37.40 36.39 94014 04 N I 52.90 51.47 94015 04 N I 29.90 29.09 94016 04 N I 23.00 22.38 94060 C 04 N I 12.50 40.20 52.70 51.28 94070 C 04 N I 15.25 37.45 52.70 51.28 94150 C 04 N I 1.60 6.00 7.60 7.39 94200 C 04 N I 1.55 15.10 16.65 16.20 94250 C 04 N I 3.20 4.40 7.60 7.39 94375 C 04 N I 7.70 36.70 44.40 43.20 94400 C 04 N I 4.45 17.70 22.15 21.55 94450 C 04 N I 4.45 17.70 22.15 21.55 94452 A 04 N I 14.29 14.28 28.57 27.80 94453 A 04 N I 20.21 20.21 40.42 39.33 94610 04 N N 35.06 34.11 94620 C 04 N I 12.30 29.80 42.10 40.96 94621 C 04 06/01/10 N I 17.76 41.24 59.00 57.41 94640 04 N I 14.50 14.11 94642 04 N N 22.05 21.45 94644 04 N I 17.87 17.39 94645 04 N N 6.92 6.73 94660 09 Y I94662 04 Y I94664 04 07/01/12 N I 15.20 14.79 94667 04 N N 15.20 14.79 94668 04 N N 8.20 7.98 94669 04 01/01/14 N N 19.43 18.91 94680 C 04 N I 7.65 29.75 37.40 36.39 94681 C 04 N I 7.70 36.70 44.40 43.20 94690 C 04 N I 4.50 26.00 30.50 29.68 94726 C 04 01/01/12 N I 7.27 22.81 30.08 29.27 94727 C 04 01/01/12 N I 7.26 16.42 23.68 23.04 94728 C 04 01/01/12 N I 7.26 16.42 23.68 23.04 94729 C 04 01/01/12 N I 4.86 24.78 29.64 28.84 94750 C 04 N I 4.45 17.70 22.15 21.55 94760 C 04 N I 1.50 2.90 4.40 4.28 94761 C 04 N I 4.45 10.75 15.20 14.79 94762 C 04 N I 7.55 14.60 22.15 21.55 94770 C 04 N I 1.60 13.60 15.20 14.79
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
94772 04 Y I94774 04 N I 52.90 51.47 94777 04 N N 23.00 22.38 94780 04 01/01/12 N I 13.96 13.58 94781 04 01/01/12 N I 4.86 4.73 94799 04 Y I95004 04 N N 1.70 65 110.50 1.65 107.52 95012 04 N I 9.31 9.06 95017 04 01/01/13 N N 2.26 80 180.80 2.20 175.92 95018 04 01/01/13 N N 4.24 65 275.60 4.13 268.16 95024 04 N N 2.50 40 100.00 2.43 97.30 95027 04 N N 4.10 40 164.00 3.99 159.57 95028 04 N N 3.85 40 154.00 3.75 149.84 95044 04 N N 3.40 65 221.00 3.31 215.03 95052 04 N N 4.10 200 820.00 3.99 797.86 95056 04 N N 2.90 2.82 95060 04 N N 7.20 7.01 95065 04 N N 7.20 7.01 95070 04 N N 105.40 102.55 95071 04 N N 59.04 57.45 95076 04 01/01/13 N N 42.38 41.24 95079 04 01/01/13 Y n95115 04 N I 6.50 6.32 95117 04 N I 8.30 8.08 95120 04 N I 6.50 6.32 95125 04 N I 8.30 8.08 95130 04 N I 4.20 4.09 95131 04 N I 8.60 8.37 95132 04 N I 12.75 12.41 95133 04 N I 17.00 16.54 95134 04 N I 21.30 20.72 95144 04 N I 14.30 13.91 95145 04 N I 21.60 21.02 95146 04 N I 32.40 31.53 95147 04 N I 37.80 36.78 95148 04 N I 43.25 42.08 95149 04 N I 48.60 47.29 95165 04 08/01/16 N I 3.60 40 144.00 140.11 95170 04 N I 12.30 11.97 95180 04 N N 47.50 46.22 95199 04 Y I95250 04 09/01/09 N N 67.87 66.04
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
95251 04 N N 15.40 14.98 95782 C 04 01/01/13 N I 75.29 502.12 577.40 561.81 95783 C 04 01/01/13 N I 82.39 534.20 616.59 599.94 95800 C 04 01/01/11 N I 34.34 83.32 117.66 114.48 95801 C 04 01/01/11 N I 30.44 25.76 56.20 54.68 95803 09 01/01/09 N N95805 B 04 N I 76.05 76.05 152.10 147.99 95806 B 04 N I 55.27 55.28 110.55 107.57 95807 B 04 N I 77.35 77.35 154.70 150.52 95808 B 04 N I 96.65 96.65 193.30 188.08 95810 C 04 06/01/14 N I 54.94 206.66 261.60 254.54 95811 C 04 07/01/12 N I 54.46 217.84 272.30 264.95 95812 C 04 06/01/11 N I 10.58 48.22 58.80 57.21 95813 C 04 06/01/11 N I 20.45 61.35 81.80 79.59 95816 C 04 06/01/11 N I 11.42 45.68 57.10 55.56 95819 C 04 06/01/11 N I 9.49 43.21 52.70 51.28 95822 C 04 06/01/11 N I 10.50 44.80 55.30 53.81 95824 04 06/01/11 N I 52.70 51.28 95827 C 04 06/01/11 N I 6.68 60.12 66.80 65.00 95829 04 N I 3 163.50 159.09 95830 04 01/19/16 N I 4 Y 79.10 76.96 95831 04 N I 25.60 24.91 95832 04 N I 22.15 21.55 95833 04 N I 52.70 51.28 95834 04 N I 52.70 51.28 95851 04 N I 30.50 29.68 95852 04 N I 30.50 29.68 95857 04 N I 25.60 24.91 95860 C 04 01/01/09 N I 23.56 13.84 37.40 36.39 95861 C 04 01/01/09 N I 39.19 17.61 56.80 55.27 95863 C 04 01/01/09 N I 45.33 20.37 65.70 63.93 95864 C 04 01/01/09 N I 54.59 30.71 85.30 83.00 95865 C 04 N I 50.72 13.65 64.37 62.63 95866 C 04 N I 39.54 4.56 44.10 42.91 95867 C 04 01/01/09 N I 18.11 12.59 30.70 29.87 95868 C 04 01/01/09 N I 29.63 16.67 46.30 45.05 95869 C 04 01/01/09 N I 23.19 29.51 52.70 51.28 95870 C 04 01/01/09 N I 23.71 28.99 52.70 51.28 95872 C 04 07/01/09 N I 48.28 8.52 56.80 55.27 95873 C 04 N I 11.58 4.30 15.88 15.45 95874 C 04 N N 11.76 4.30 16.06 15.63
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
95875 04 N I 36.60 35.61 95885 H 04 11/01/14 N I 10.39 20.88 31.27 4 125.08 30.43 121.70 95886 H 04 11/01/14 N I 27.78 21.99 49.77 4 199.08 48.43 193.70 95887 C 04 01/01/12 N I 21.77 22.36 44.13 42.94 95905 04 01/01/10 Y I95907 C 04 01/01/13 N I 30.32 23.64 53.96 52.50 95908 C 04 01/01/13 N I 38.11 28.46 66.58 64.78 95909 C 04 01/01/13 N I 45.44 34.39 79.84 77.68 95910 C 04 01/01/13 N I 60.83 44.32 105.15 102.31 95911 C 04 01/01/13 N I 75.95 51.54 127.49 124.05 95912 C 04 01/01/13 N I 91.16 58.31 149.47 145.43 95913 C 04 01/01/13 N I 108.06 65.35 173.41 168.73 95921 04 N I 44.50 43.30 95922 04 N I 44.50 43.30 95923 04 N I 44.80 43.59 95924 C 04 01/01/13 N I 51.23 33.30 84.53 82.25 95925 04 N I 74.90 72.88 95926 04 N I 74.90 72.88 95927 04 N I 74.90 72.88 95928 04 N I 97.05 94.43 95929 04 N I 100.85 98.13 95930 04 N I 52.70 51.28 95933 04 N I 30.50 29.68 95937 04 N I 37.40 36.39 95938 C 04 01/01/12 N I 25.71 137.82 163.53 159.11 95939 C 04 01/01/12 N I 67.71 190.25 257.96 251.00 95940 04 01/01/13 N I 18.82 28 526.96 18.31 512.73 95950 C 04 N I 61.31 118.99 180.30 175.43 95951 S 04 06/01/09 N I 71.18 284.72 355.90 346.29 95953 C 04 N I 77.53 102.77 180.30 175.43 95954 C 04 N I 119.09 106.61 224.70 218.63 95955 04 N I 4 62.05 60.37 95956 C 04 N I 100.41 294.32 394.73 384.07 95957 C 04 N I 65.03 37.30 102.33 99.57 95958 C 04 06/01/11 N I 68.18 73.87 142.05 138.21 95961 C 04 06/01/11 N I 111.79 68.51 180.30 175.43 95962 04 Y I95965 A 04 N I 138.25 138.25 276.50 269.03 95966 A 04 N I 93.83 93.82 187.65 182.58 95967 A 04 N I 82.35 82.35 164.70 160.25 95970 04 N I Y 41.90 40.77 95971 04 N I Y 41.90 40.77 95972 04 N I Y 41.90 40.77
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
95974 04 N I Y 68.50 66.65 95975 04 N I Y 41.90 40.77 95978 04 N I 110.51 107.53 95979 04 N I 53.28 51.84 95980 04 01/01/08 N I Y 22.92 22.30 95981 04 01/01/08 N I Y 8.89 6.41 8.65 95982 04 01/01/08 N I Y 18.00 5.81 17.51 95990 04 N I Y 29.41 28.62 95991 04 N I Y 29.41 28.62 95999 04 Y I Y96000 04 N I 82.00 79.79 96001 04 N N 97.80 95.16 96002 04 N I 19.20 18.68 96003 04 N I 17.90 17.42 96004 04 N I 67.50 65.68 96020 04 N I 85.31 83.01 96040 04 08/01/08 N N 40.20 39.11 96105 04 N I 52.70 51.28 96110 04 N N 16.07 2 32.14 15.64 31.27 96111 04 N N 16.07 2 32.14 15.64 31.27 96116 09 Y I96118 04 01/01/07 N N 64.64 62.89 96119 04 01/01/07 N N 41.34 40.22 96120 09 Y N96125 09 01/01/08 Y N96127 04 01/01/17 N N 14.60 2 29.20 14.21 28.41 96150 04 Y N96151 04 Y N96152 04 Y N96153 04 Y N96154 04 Y N96160 04 01/01/17 N N 14.60 14.21 96360 04 01/01/09 N N 19.11 18.59 96361 04 01/01/09 N N 19.11 8 152.90 18.59 148.77 96365 04 01/01/09 N I 19.11 18.59 96366 04 01/01/09 N I 19.11 8 152.90 18.59 148.77 96367 04 01/01/09 N I Y 19.11 18.59 96368 04 01/01/09 N I 19.11 18.59 96369 04 01/01/09 N I 84.51 82.23 96370 04 01/01/09 N M 9.15 8.90 96371 04 01/01/09 N I 36.95 35.95
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
96372 04 01/01/09 N I 9.81 9.55 96373 04 01/01/09 N I 10.26 9.98 96374 04 01/01/09 N I 29.55 28.75 96375 04 01/01/09 N I 13.99 2 27.98 13.61 27.22 96376 04 01/01/09 Y M96379 04 01/01/09 Y96401 04 N I 22.15 21.55 96402 04 N I 18.39 17.89 96405 04 N I 65.35 63.59 96406 04 N I 78.38 76.26 96409 04 N I 62.22 60.54 96411 04 N I 36.36 35.38 96413 04 N I 25.40 24.71 96415 04 N I 19.11 8 152.90 18.59 148.77 96416 04 N I 22.15 21.55 96417 04 N I 25.40 24.71 96420 04 N I 37.40 36.39 96422 04 N I 37.40 36.39 96423 04 N I 14.17 8 113.40 13.79 110.34 96425 04 N I 33.80 32.89 96440 04 N I 102.00 99.25 96446 04 01/01/11 N I 100.87 98.15 96450 04 N I 3 83.20 80.95 96521 04 N I 32.90 32.01 96522 04 N I 34.70 33.76 96523 09 Y N96542 04 N I Y 26.81 26.09 96549 04 Y I96567 04 Y I96570 04 01/01/10 N I 34.27 33.34 96571 04 Y I96900 04 N I 6.60 6.42 96902 04 N N 10.50 10.22 96910 04 N I 9.55 9.29 96912 04 N I 10.95 10.65 96913 04 N I 30.05 29.24 96920 04 Y I96921 04 Y I96922 04 Y I96999 04 Y I97010 04 N I 4.40 4.28
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
97012 04 N I 7.70 7.49 97014 04 N I 6.50 6.32 97016 04 N I 7.00 6.81 97018 04 N I 5.95 5.79 97022 04 N I 6.50 6.32 97024 04 N I 4.50 4.38 97026 04 N I 4.40 4.28 97028 04 N I 4.70 4.57 97032 04 N I 7.40 7.20 97033 04 N I 7.70 7.49 97034 04 N I 6.40 6.23 97035 04 N I 5.50 5.35 97036 04 N I 8.95 8.71 97039 04 Y I97110 04 N N 10.40 10.12 97112 04 N I 10.90 10.61 97113 04 N N 11.50 11.19 97116 04 N I 9.75 9.49 97124 04 N I 8.90 8.66 97139 04 Y I97140 04 N I 11.80 11.48 97150 04 N I 8.40 8.17 97530 04 N I 22.15 21.55 97532 09 Y I97533 04 N I 18.75 18.24 97535 04 N I 11.20 10.90 97537 04 N I 11.00 10.70 97542 04 N I 7.55 7.35 97545 04 N I 27.00 26.27 97546 09 Y I97597 04 N I 27.78 27.03 97598 04 03/12/12 Y I #VALUE!97602 04 N I 28.35 27.58 97605 04 07/01/13 N I 16.01 15.58 97606 04 07/01/12 N I 17.95 17.47 97750 04 N I 22.15 21.55 97760 09 Y N97761 09 Y N97762 09 Y N97799 04 Y I97802 09 Y N97803 09 Y N97804 09 Y N98925 04 N I 12.55 12.21 98926 04 N I 17.60 17.12 98927 04 N I 22.05 21.45
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
98928 04 N I 25.50 24.81 98929 04 N I 28.60 27.83 99000 09 Y N99001 09 Y N99002 09 Y N99056 04 N N 14.35 13.96 99058 04 N N 14.35 13.96 99070 X 04 Y N99071 09 Y N99075 09 Y N99078 09 Y N99082 04 Y N99090 09 Y N99091 09 Y N99100 09 Y N99116 09 Y N99135 09 Y N99140 09 Y N99151 04 01/01/17 N I 14.45 14.06 99152 04 01/01/17 N I 7.49 7.29 99153 04 01/01/17 N I 6.17 9 55.53 54.03 99155 04 01/01/17 N I 56.44 54.92 99156 04 01/01/17 N I 46.39 45.14 99157 04 01/01/17 N I 35.15 6 210.90 205.21 99170 04 N I 3 58.90 57.31 99172 04 Y I99173 04 N N 7.45 7.25 99174 04 07/01/14 Y N99175 09 Y N99183 04 N I 60.50 58.87 99184 04 01/01/15 Y N99190 04 Y I Y99191 04 Y I Y99192 04 Y I Y99195 04 N I 33.25 32.35 99199 04 Y I 99201 P 04 02/01/09 N N 27.95 1 27.95 1.60 1.60 27.20 27.20 99202 P 04 02/01/09 N N 32.00 1 32.00 1.60 1.60 31.14 31.14 99203 P 04 02/01/09 N N 41.60 1 41.60 1.95 1.95 40.48 40.48 99204 P 04 02/01/09 N N 66.40 1 66.40 3.25 3.25 64.61 64.61 99205 P 04 02/01/09 N N 70.85 1 70.85 3.25 3.25 68.94 68.94
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
99211 P 04 02/01/09 N N 12.30 1 12.30 .58 .58 11.97 11.97 99212 P 04 02/01/09 N N 24.25 1 24.25 1.40 1.40 23.60 23.60 99213 P 04 02/01/09 N N 28.35 1 28.35 18.21 18.21 27.58 27.58 99214 P 04 02/01/09 N N 42.50 1 42.50 30.47 30.47 41.35 41.35 99215 P 04 02/01/09 N N 48.00 1 48.00 1.95 1.95 46.70 46.70 99217 09 Y N99218 04 N N 69.55 67.67 99219 04 N N 69.55 67.67 99220 04 N N 69.55 67.67 99221 04 N N 33.90 32.98 99222 04 N N 51.40 50.01 99223 04 N N 69.00 67.14 99224 09 01/01/11 Y N99225 09 01/01/11 Y N99226 09 01/01/11 Y N99231 04 N N 16.40 15.96 99232 04 N N 24.90 24.23 99233 04 N N 35.05 34.10 99234 04 N N 69.55 67.67 99235 04 N N 76.65 74.58 99236 04 N N 94.20 91.66 99238 04 N N 29.65 28.85 99239 04 N N 39.05 38.00 99241 04 06/01/09 N N 32.15 7.04 7.04 31.28 99242 04 06/01/09 N N 40.20 32.71 32.71 39.11 99243 04 06/01/09 N N 51.30 48.56 48.56 49.91 99244 04 06/01/09 N N 71.40 75.84 75.84 69.47 99245 04 06/01/09 N N 92.80 90.02 90.02 90.29 99251 04 N N 32.15 31.28 99252 04 N N 33.95 33.03 99253 04 N N 46.45 45.20 99254 04 N N 66.40 64.61 99255 04 N N 87.10 84.75 99281 04 N N 14.35 13.96 99282 04 N N 24.20 23.55 99283 04 N N 32.20 31.33 99284 04 N N 44.00 42.81 99285 04 N N 69.25 67.38 99288 09 Y N99291 04 06/01/09 N N 84.90 55.20 55.20 82.61 99292 04 N N 42.35 41.21 99304 04 N N 27.55 26.81
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
99305 04 N N 36.10 35.13 99306 04 N N 47.70 46.41 99307 04 N N 14.80 14.40 99308 04 N N 18.91 18.40 99309 04 N N 23.40 22.77 99310 04 N N 32.05 31.18 99315 04 N N 26.55 25.83 99316 04 N N 34.00 33.08 99318 04 N N 23.10 22.48 99324 04 N N 18.60 18.10 99325 04 N N 26.70 25.98 99326 04 N N 34.85 33.91 99327 04 N N 42.95 41.79 99328 04 N N 51.05 49.67 99334 04 N N 16.00 15.57 99335 04 N N 21.00 20.43 99336 04 N N 26.05 25.35 99337 04 N N 31.05 30.21 99341 04 N N 27.95 8.86 8.86 27.20 99342 04 N N 37.40 16.23 16.23 36.39 99343 04 N N 54.90 31.38 31.38 53.42 99344 04 N N 70.55 42.78 42.78 68.65 99345 04 N N 85.55 50.85 50.85 83.24 99347 04 N N 24.25 11.56 11.56 23.60 99348 04 N N 31.30 22.82 22.82 30.45 99349 04 N N 47.50 31.43 31.43 46.22 99350 04 N N 68.85 41.29 41.29 66.99 99354 04 Y I99355 04 Y I99356 04 Y I99357 04 Y I99360 09 Y I99374 09 Y N99377 09 Y N99379 09 Y N99380 09 Y N99381 P 04 N N 32.15 59.75 31.28 99382 P 04 N N 32.15 66.50 31.28 99383 P 04 N N 32.15 64.45 31.28 99384 P 04 N N 32.15 72.81 31.28 99385 P 04 02/01/09 N N 66.40 72.81 38.56 64.61
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
99386 P 04 02/01/09 N N 66.40 38.56 64.61 99387 P 04 02/01/09 N N 66.40 38.56 64.61 99391 P 04 N N 32.15 37.37 31.28 99392 P 04 N N 32.15 45.72 31.28 99393 P 04 N N 32.15 44.69 31.28 99394 P 04 N N 32.15 52.47 31.28 99395 P 04 01/01/12 N N 42.50 53.50 43.15 41.36 99396 P 04 01/01/12 N N 42.50 43.15 41.35 99397 P 04 N N 42.50 43.15 41.35 99401 W 04 10/01/12 N N 30.00 29.19 99406 V 04 01/01/14 N N 7.19 7.00 99407 V 04 01/01/14 N N 15.29 14.88 99450 09 Y N99455 09 Y N99456 09 Y N99460 04 01/01/09 N N 38.75 37.70 99461 04 01/01/09 N N 16.40 15.96 99462 04 01/01/09 N N 16.40 15.96 99463 04 01/01/09 N N 42.55 41.40 99464 04 01/01/09 N N 83.70 81.44 99465 04 01/01/09 N N 94.50 91.95 99466 04 01/01/09 Y N99467 04 01/01/09 Y N99468 04 02/01/09 N N 586.70 570.86 99469 04 02/01/09 N N 251.69 244.89 99471 04 02/01/09 N N 510.67 496.88 99472 04 02/01/09 N N 249.51 242.77 99475 04 01/01/09 N N 84.90 82.61 99476 04 01/01/09 N N 42.35 41.21 99477 04 02/01/09 N N 220.73 214.77 99478 04 02/01/09 N N 88.85 86.45 99479 04 01/01/09 N N 81.22 79.03 99480 04 02/01/09 N N 79.04 76.91 99499 04 Y N99999 04 Y N Y Y0500F 04 N B 44.10 42.91 0502F 04 N B 44.10 42.91 0503F 04 N B 50.15 48.80 0042T B 04 N N 141.22 141.22 282.45 274.82 0051T 04 Y M 10 Y Y0052T 04 Y M 10 Y Y
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
0053T 04 Y M 20 Y Y0075T 04 N I 3 83.00 80.76 0076T 04 N I 3 83.00 80.76 0095T 04 Y M 8 Y0101T 04 Y M 30102T 04 Y M 30249T 04 12/01/15 N M 3 234.82 228.48 0274T 04 07/01/11 Y M 3 0275T 04 07/01/11 Y M 3 0298T 04 07/19/15 N I 15.77 15.34 A4264 04 08/01/10 N N 1,550.00 1,508.15 A4267 04 N N 0.45 30 13.62 0.44 13.25 A4268 04 N N 1.12 30 33.82 1.09 32.91 A4269 04 Y Y NA9502 09 Y NA9503 09 Y NA9507 09 Y NA9517 04 01/01/14 Y NA9526 09 Y NA9527 04 01/01/07 Y NA9528 09 Y NA9529 09 Y NA9530 09 Y NA9531 09 Y NA9532 09 Y NA9543 04 04/01/16 N Y N 42,430.83 1 42,430.83 41,285.20 41,285.20 A9563 04 Y NA9564 04 Y NA9604 04 01/01/10 Y N NA9606 04 01/01/15 Y NA9699 04 05/15/13 Y Y ND1206 04 08/01/11 N N 26.00 25.30 G0008 04 N N 6.40 6.23 G0009 04 N N 6.40 6.23 G0010 04 N N 6.40 6.23 G0101 04 N I 32.86 31.97 G0102 04 N I 28.35 27.58 G0103 B 04 N N 8.80 8.80 17.60 17.12 G0104 04 Y I 3G0105 04 N I 3 214.00 208.22 G0108 09 Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
G0109 09 Y NG0111 09 Y NG0117 04 Y IG0118 04 Y IG0121 04 N I 3 214.00 208.22 G0123 04 N N 3.50 3.41 G0124 04 N N 11.45 11.14 G0125 04 N N 4 920.70 895.84 G0127 04 07/01/12 N I 3 14.35 13.96 G0128 09 Y NG0130 B 04 N N 48.52 48.52 97.05 94.43 G0141 04 N N 11.45 11.14 G0143 04 N N 3.45 3.36 G0144 04 N N 3.45 3.36 G0145 04 N N 3.45 3.36 G0147 04 N N 3.45 3.36 G0148 04 N N 3.45 3.36 G0166 04 N I 66.70 64.90 G0168 04 N I 22.55 21.94 G0175 09 Y NG0186 04 Y IG0202 C 04 09/01/12 N N 17.98 53.92 71.90 69.96 G0204 C 04 09/01/12 N N 18.70 53.20 71.90 69.96 G0206 C 04 09/01/12 N N 10.20 29.00 39.20 38.14 G0219 B 04 N N 35.25 35.25 70.50 68.60 G0237 04 07/01/16 N I 5.76 5.60 G0238 04 07/01/16 N I 5.95 5.79 G0245 04 N N 25.09 24.41 G0248 09 Y NG0249 09 Y NG0250 09 Y NG0252 04 N N 35.25 35.25 70.50 68.60 G0255 04 Y IG0257 04 N I 35.75 34.78 G0259 04 N I 3 172.50 167.84 G0260 04 N I 31.80 30.94 G0265 09 Y NG0266 09 Y NG0268 04 N I 3 21.40 20.82 G0269 04 Y I 3G0270 09 Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
G0271 09 Y NG0278 04 N I 3 78.45 76.33 G0279 C 04 01/01/15 N N 18.24 14.11 1 32.35 31.48 G0281 04 Y IG0282 04 Y IG0283 04 Y IG0288 B 04 Y IG0289 04 Y M 3 YG0293 09 Y MG0294 09 Y IG0295 09 Y IG0297 C 04 01/01/16 N N 30.33 110.99 141.32 137.50 G0306 A 04 N N 2.69 2.69 5.39 5.24 G0307 B 04 02/01/17 N N 3.21 3.21 6.42 6.25 G0328 A 04 N N 6.66 6.66 13.33 12.97 G0329 04 N I 9.05 8.81 G0339 04 Y N 9 YG0340 04 Y N 9 YG0365 04 N I 25.03 25.02 50.05 48.70 G0377 04 01/01/07 N N 9.81 9.55 G0380 04 01/01/07 N N 14.35 13.96 G0381 04 01/01/07 N N 24.20 23.55 G0382 04 01/01/07 N N 32.20 31.33 G0383 04 01/01/07 N N 44.00 42.81 G0384 04 01/01/07 N N 69.25 67.38 G0394 04 01/01/07 N N 2.72 2.65 G0412 04 01/01/09 N N 3 Y 674.20 656.00 G0413 04 01/01/09 N N Y 550.90 536.03 G0414 04 01/01/09 N N Y 599.35 583.17 G0415 04 01/01/09 N M 3 Y 599.35 583.17 G0422 04 01/01/10 N N 43.35 42.18 G0423 04 01/01/10 N N 21.10 20.53 G0424 04 10/01/11 N I 5.66 5.51 G0432 B 04 04/01/10 N N 5.79 5.79 11.58 11.27 G0433 B 04 01/01/12 N N 5.79 5.79 11.58 11.27 G0435 B 04 01/01/12 N N 6.48 6.48 12.96 12.61 G0438 09 01/01/11 Y NG0453 04 01/01/13 N M 15.48 28 433.40 15.06 421.70 G0472 B 04 01/01/15 N N 8.42 8.42 16.85 16.40 G0480 B 04 01/01/16 N N 23.98 23.98 47.96 46.67 G0481 B 04 01/01/16 N N 36.90 36.90 73.79 71.80
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
G0482 B 04 01/01/16 N N 49.81 49.81 99.62 96.93 G0483 B 04 01/01/16 N N 64.57 64.57 129.14 125.65 G0659 B 04 01/01/16 N N 23.95 23.95 47.89 46.60 G6002 C 04 01/01/15 N I 12.24 29.91 41.93 40.80 G6003 04 01/01/15 N N 88.29 85.91 G6004 04 01/01/15 N N 68.33 66.49 G6005 04 04/12/17 N I 76.32 74.26 G6006 04 01/01/15 N N 75.93 73.88 G6007 04 01/01/15 N N 140.29 136.50 G6008 04 01/01/15 N N 94.46 91.91 G6009 04 01/01/15 N N 104.60 101.78 G6010 04 01/01/15 N N 104.60 101.78 G6011 04 03/06/17 N I 150.04 145.99 G6012 04 01/01/15 N N 124.29 120.93 G6013 04 01/01/15 N N 139.90 136.12 G6014 04 01/01/15 N N 139.90 136.12 G6015 04 01/01/15 N I 218.51 212.61 G6016 04 01/01/15 N N 217.70 211.82 G9001 09 Y NG9002 09 Y NG9003 09 Y NG9004 09 Y NG9005 09 Y NG9006 09 Y NG9007 09 Y NG9008 04 Y NG9009 09 Y NG9010 09 Y NG9011 09 Y NG9012 09 Y NG9016 09 Y NG9021 09 Y NG9022 09 Y NG9023 09 Y NG9024 09 Y NG9025 09 Y NG9026 09 Y NG9027 09 Y NG9028 09 Y NG9029 09 Y NG9030 09 Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
G9031 09 Y NG9032 09 Y NG9033 09 Y NG9034 09 Y NG9050 09 Y NG9051 09 Y NG9052 09 Y NG9053 09 Y NG9054 09 Y NG9055 09 Y NG9056 09 Y NG9057 09 Y NG9058 09 Y NG9059 09 Y NG9060 09 Y NG9061 09 Y NG9062 09 Y NG9063 09 Y NG9064 09 Y NG9065 09 Y NG9066 09 Y NG9067 09 Y NG9068 09 Y NG9069 09 Y NG9070 09 Y NG9071 09 Y NG9072 09 Y NG9073 09 Y NG9074 09 Y NG9075 09 Y NG9077 09 Y NG9078 09 Y NG9079 09 Y NG9080 09 Y NG9083 09 Y NG9084 09 Y NG9085 09 Y NG9086 09 Y NG9087 09 Y NG9088 09 Y NG9089 09 Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
G9090 09 Y NG9091 09 Y NG9092 09 Y NG9093 09 Y NG9094 09 Y NG9095 09 Y NG9096 09 Y NG9097 09 Y NG9098 09 Y NG9099 09 Y NG9100 09 Y NG9101 09 Y NG9102 09 Y NG9103 09 Y NG9104 09 Y NG9105 09 Y NG9106 09 Y NG9107 09 Y NG9108 09 Y NG9109 09 Y NG9110 09 Y NG9111 09 Y NG9112 09 Y NG9113 09 Y NG9114 09 Y NG9115 09 Y NG9116 09 Y NG9117 09 Y NG9123 09 Y NG9124 09 Y NG9125 09 Y NG9126 09 Y NG9128 09 Y NG9129 09 Y NG9130 09 Y NG9157 04 01/01/13 N I 60.18 58.56 H0033 04 N N 118.10 114.91 H1000 04 N N 14.60 14.21 J0129 T 04 04/01/17 N Y N 46.857 100 4,685.70 45.59 4,559.19 J0130 T 04 04/01/17 N Y N 1152.188 3 3,456.56 1,121.08 3,363.23 J0131 T 04 04/01/17 N Y N 0.3752 100 37.52 0.37 36.51
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J0132 T 04 04/01/17 N Y N 1.382 150 207.30 1.34 201.70 J0133 T 04 04/01/17 N Y N 0.072 500 36.00 0.07 35.03 J0153 T 04 04/01/17 N Y N 0.554 120 66.48 0.54 64.69 J0171 T 04 04/01/17 N Y N 0.401 10 4.01 0.39 3.90 J0178 T 04 04/01/17 N Y N 980.144 2 1,960.29 953.68 1,907.36 J0180 T 04 04/01/17 N Y N 166.058 125 20,757.25 161.57 20,196.80 J0190 T 04 Y Y NJ0200 T 04 Y Y NJ0202 T 04 04/01/17 N Y N 1753.02 12 21,036.24 1,705.69 20,468.26 J0207 T 04 04/01/17 N Y N 519.005 4 2,076.02 504.99 2,019.97 J0220 T 04 04/01/17 N Y N 206.70 250 51,675.00 201.12 50,279.78 J0221 T 04 04/01/17 N Y N 159.736 250 39,934.00 155.42 38,855.78 J0256 T 04 04/01/17 N Y N 4.817 750 3,612.75 4.69 3,515.21 J0257 T 04 04/01/17 N Y N 4.357 750 3,267.75 4.24 3,179.52 J0278 T 04 04/01/17 N Y N 1.697 15 25.46 1.65 24.77 J0280 T 04 04/01/17 N Y N 8.501 5 42.51 8.27 41.36 J0282 T 04 04/01/17 N Y N 0.28 30 8.40 0.27 8.17 J0285 T 04 04/01/17 N Y N 32.856 3 98.57 31.97 95.91 J0287 T 04 04/01/17 N Y N 13.182 75 988.65 12.83 961.96 J0289 T 04 04/01/17 N Y N 19.533 75 1,464.98 19.01 1,425.43 J0290 T 04 04/01/17 N Y N 1.157 4 4.63 1.13 4.50 J0295 T 04 04/01/17 N Y N 2.575 2 5.15 2.51 5.01 J0300 T 04 Y Y NJ0348 T 04 04/01/17 N Y N 0.521 200 104.20 0.51 101.39 J0350 T 04 Y Y NJ0360 T 04 04/01/17 N Y N 3.121 2 6.24 3.04 6.07 J0364 T 04 04/01/17 N Y N 33.60 6 201.60 32.69 196.16 J0456 T 04 04/01/17 N Y N 3.594 1 3.59 3.50 3.49 J0461 T 04 04/01/17 N Y N 0.051 400 20.40 0.05 19.85 J0470 T 04 04/01/17 N Y N 46.602 6 279.61 45.34 272.06 J0475 T 04 04/01/17 N Y N 168.687 8 1,349.50 164.13 1,313.06 J0476 T 04 04/01/17 N Y N 76.836 2 153.67 74.76 149.52 J0480 T 04 04/01/17 N Y N 3357.342 1 3,357.34 3,266.69 3,266.69 J0485 T 04 04/01/17 N Y N 3.826 1250 4,782.50 3.72 4,653.37 J0490 T 04 04/01/17 N Y N 42.581 125 5,322.63 41.43 5,178.92 J0500 T 04 04/01/17 N Y N 69.111 1 69.11 67.25 67.24 J0515 T 04 04/01/17 N Y N 25.368 6 152.21 24.68 148.10 J0558 T 04 04/01/17 N Y N 8.546 24 205.10 8.32 199.56 J0561 T 04 04/01/17 N Y N 10.746 24 257.90 10.46 250.94 J0570 T 04 04/01/17 N Y N 1260.592 4 5,042.37 1,226.56 4,906.23 J0583 T 04 04/01/17 N Y N 1.475 500 737.50 1.44 717.59 J0585 N , T 04 02/01/12 Y Y NJ0586 N , T 04 02/01/12 Y Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J0587 N , T 04 01/01/10 Y Y NJ0588 N , T 04 02/01/12 Y Y NJ0594 T 04 04/01/17 N Y N 36.501 60 2,190.06 35.52 2,130.93 J0595 T 04 04/01/17 N Y N 2.318 4 9.27 2.26 9.02 J0596 T 04 04/01/17 N Y N 27.18 420 11,415.60 26.45 11,107.38 J0597 T 04 04/01/17 N Y N 48.695 250 12,173.75 47.38 11,845.06 J0598 T 04 04/01/17 N Y N 55.53 100 5,553.00 54.03 5,403.07 J0600 T 04 04/01/17 N Y N 5594.422 2 11,188.84 5,443.37 10,886.74 J0610 T 04 04/01/17 N Y N 3.413 3 10.24 3.32 9.96 J0630 T 04 04/01/17 N Y N 2267.891 2 4,535.78 2,206.66 4,413.31 J0636 T 04 04/01/17 N Y N 0.604 40 24.60 0.59 23.94 J0637 T 04 04/01/17 N Y N 10.562 14 147.87 10.28 143.88 J0638 T 04 04/01/17 N Y N 92.506 150 13,875.90 90.01 13,501.25 J0640 T 04 04/01/17 N Y N 3.024 25 75.60 2.94 73.56 J0641 T 04 04/01/17 N Y N 0.707 1200 848.40 0.69 825.49 J0690 T 04 04/01/17 N Y N 0.827 4 3.31 0.80 3.22 J0692 T 04 04/01/17 N Y N 2.288 4 9.15 2.23 8.90 J0694 T 04 04/01/17 N Y N 4.638 3 13.91 4.51 13.53 J0695 T 04 04/01/17 N Y N 3.19 60 191.40 3.10 186.23 J0696 T 04 04/01/17 N Y N 0.664 16 10.62 0.65 10.33 J0697 T 04 04/01/17 N Y N 2.382 4 9.53 2.32 9.27 J0698 T 04 04/01/17 N Y N 2.20 2 4.40 2.14 4.28 J0702 T 04 04/01/17 N Y N 6.066 5 30.33 5.90 29.51 J0706 T 04 04/01/17 N Y N 0.6775 8 5.42 0.66 5.27 J0712 T 04 04/01/17 N Y N 2.465 60 147.90 2.40 143.91 J0713 T 04 04/01/17 N Y N 2.329 4 9.32 2.27 9.07 J0714 T 04 04/01/17 N Y N 74.81 12 897.72 72.79 873.48 J0716 T 04 04/01/17 N Y N 4292.47 3 12,877.41 4,176.57 12,529.72 J0720 T 04 04/01/17 N Y N 39.44 3 118.32 38.38 115.13 J0725 T 04 04/01/17 N Y N 21.842 5 109.21 21.25 106.26 J0735 T 04 04/01/17 N Y N 13.975 1 13.98 13.60 13.60 J0740 T 04 04/01/17 N Y N 522.116 2 1,044.23 508.02 1,016.04 J0743 T 04 04/01/17 N Y N 4.009 4 16.04 3.90 15.61 J0744 T 04 04/01/17 N Y N 1.379 2 2.76 1.34 2.69 J0770 T 04 04/01/17 N Y N 12.995 2 25.99 12.64 25.29 J0775 T 04 04/01/17 N Y N 40.692 58 2,360.14 39.59 2,296.42 J0780 T 04 04/01/17 N Y N 12.484 2 24.97 12.15 24.30 J0795 T 04 04/01/17 N Y N 8.121 100 812.10 7.90 790.17 J0833 T 04 04/01/17 N Y N 80.20 3 240.60 78.03 234.10 J0834 T 04 04/01/17 N Y N 45.856 3 137.57 44.62 133.86 J0840 T 04 04/01/17 N Y N 2869.924 6 17,219.54 2,792.44 16,754.61
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J0850 T 04 04/01/17 N Y N 1127.74 7 7,894.18 1,097.29 7,681.04 J0875 T 04 04/01/17 N Y N 14.728 300 4,418.40 14.33 4,299.10 J0878 T 04 04/01/17 N Y N 0.675 1000 675.00 0.66 656.78 J0881 T 04 04/01/17 N Y N 3.854 500 1,927.00 3.75 1,874.97 J0882 T 04 04/01/17 N Y N 3.854 500 1,927.00 3.75 1,874.97 J0883 T 04 04/01/17 N Y N 1.90 500 950.00 1.85 924.35 J0884 T 04 04/01/17 N Y N 1.90 500 950.00 1.85 924.35 J0885 T 04 04/01/17 N Y N 13.618 80 1,089.44 13.25 1,060.03 J0894 T 04 04/01/17 N Y N 17.958 50 897.90 17.47 873.66 J0895 T 04 04/01/17 N Y N 8.138 4 32.55 7.92 31.67 J0897 T 04 04/01/17 N Y N 16.629 120 1,995.48 16.18 1,941.60 J1000 T 04 04/01/17 N Y N 17.745 1 17.75 17.27 17.27 J1020 T 04 04/01/17 N Y N 4.99 8 39.92 4.86 38.84 J1030 T 04 04/01/17 N Y N 5.568 4 22.27 5.42 21.67 J1040 T 04 04/01/17 N Y N 10.614 2 21.23 10.33 20.66 J1050 U 04 04/01/17 N Y N 0.44 1000 440.00 0.43 428.12 J1071 T 04 04/01/17 N Y N 0.021 400 8.40 0.02 8.17 J1100 T 04 04/01/17 N Y N 0.107 40 4.28 0.10 4.16 J1110 T 04 04/01/17 N Y N 161.554 3 484.66 157.19 471.57 J1120 T 04 04/01/17 N Y N 24.682 1 24.68 24.02 24.01 J1130 T 04 04/01/17 N Y N .21 75 15.75 0.20 15.32 J1160 T 04 04/01/17 N Y N 5.816 2 11.63 5.66 11.32 J1162 T 04 04/01/17 N Y N 3267.538 20 65,350.76 3,179.31 63,586.29 J1165 T 04 04/01/17 N Y N 0.628 35 21.98 0.61 21.39 J1170 T 04 04/01/17 N Y N 1.91 1 1.91 1.86 1.86 J1180 T 04 Y Y NJ1190 T 04 04/01/17 N Y N 206.33 6 1,237.98 200.76 1,204.55 J1200 T 04 04/01/17 N Y N 0.717 2 1.43 0.70 1.39 J1205 T 04 04/01/17 N Y N 77.897 2 155.79 75.79 151.58 J1212 T 04 04/01/17 N Y N 533.72 1 533.72 519.31 519.31 J1240 T 04 04/01/17 N Y N 7.008 2 14.18 6.82 13.80 J1245 T 04 04/01/17 N Y N 0.784 6 4.70 0.76 4.57 J1250 T 04 04/01/17 N Y N 5.376 2 10.75 5.23 10.46 J1265 T 04 04/01/17 N Y N 0.63 10 6.30 0.61 6.13 J1267 T 04 04/01/17 N Y N 0.507 50 25.35 0.49 24.67 J1270 T 04 04/01/17 N Y N 0.572 6 3.43 0.56 3.34 J1290 T 04 04/01/17 N Y N 421.623 30 12,648.69 410.24 12,307.18 J1300 T 04 04/01/17 N Y N 223.628 120 27,195.36 217.59 26,461.09 J1322 T 04 04/01/17 N Y N 222.20 160 35,552.00 216.20 34,592.10 J1324 T 04 04/01/17 N Y N 0.664 90 59.76 0.65 58.15 J1325 T 04 04/01/17 N Y N 15.529 3 46.59 15.11 45.33
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J1327 T 04 04/01/17 N Y N 20.00 40 800.00 19.46 778.40 J1330 T 04 Y Y NJ1335 T 04 04/01/17 N Y N 48.248 2 96.50 46.95 93.89 J1364 T 04 04/01/17 N Y N 59.443 2 118.89 57.84 115.68 J1380 T 04 04/01/17 N Y N 7.376 3 22.13 7.18 21.53 J1410 T 04 04/01/17 N Y N 278.389 1 278.39 270.87 270.87 J1430 T 04 04/01/17 N Y N 422.372 10 4,223.72 410.97 4,109.68 J1436 T 04 Y Y NJ1439 T 04 04/01/17 N Y N 1.057 750 792.75 1.03 771.35 J1442 T 04 04/01/17 N Y N 1.009 960 968.64 0.98 942.49 J1447 T 04 04/01/17 N Y N 0.665 625 415.63 0.65 404.41 J1450 T 04 04/01/17 N Y N 4.211 4 16.84 4.10 16.39 J1451 T 04 04/01/17 N Y N 6.04 100 604.00 5.88 587.69 J1452 T 04 Y Y NJ1453 T 04 04/01/17 N Y N 1.94 150 291.00 1.89 283.14 J1455 T 04 04/01/17 N Y N 70.83 12 849.96 68.92 827.01 J1458 T 04 04/01/17 N Y N 369.418 125 46,177.25 359.44 44,930.46 J1459 T 04 04/01/17 N Y N 38.867 250 9,716.75 37.82 9,454.40 J1460 T 04 04/01/17 N Y N 35.738 10 357.38 34.77 347.73 J1556 T 04 04/01/17 N Y N 38.31 250 9,577.50 37.28 9,318.91 J1557 T 04 04/01/17 N Y N 41.616 250 10,404.00 40.49 10,123.09 J1559 T 04 04/01/17 N Y N 9.826 400 3,930.40 9.56 3,824.28 J1560 T 04 04/01/17 N Y N 357.381 8 2,859.05 347.73 2,781.86 J1561 T 04 04/01/17 N Y N 33.93 250 8,482.50 33.01 8,253.47 J1566 T 04 04/01/17 N Y N 32.638 250 8,159.50 31.76 7,939.19 J1568 T 04 04/01/17 N Y N 36.087 250 9,021.75 35.11 8,778.16 J1569 T 04 04/01/17 N Y N 40.431 250 10,107.75 39.34 9,834.84 J1570 T 04 04/01/17 N Y N 67.05 1 67.05 65.24 65.24 J1571 T 04 04/01/17 N Y N 58.645 15 879.68 57.06 855.93 J1572 T 04 04/01/17 N Y N 30.175 150 4,526.25 29.36 4,404.04 J1573 T 04 04/01/17 N Y N 69.94 68 4,755.92 68.05 4,627.51 J1575 T 04 04/01/17 N Y N 12.956 750 9,717.00 12.61 9,454.64 J1580 T 04 04/01/17 N Y N 1.536 8 12.29 1.49 11.96 J1595 T 04 Y Y NJ1599 T 04 01/01/11 Y Y NJ1610 T 04 04/01/17 N Y N 200.817 2 401.63 195.39 390.79 J1626 T 04 04/01/17 N Y N 0.389 20 7.78 0.38 7.57 J1630 T 04 04/01/17 N Y N 1.22 1 1.22 1.19 1.19 J1631 T 04 04/01/17 N Y N 17.867 6 107.20 17.38 104.31 J1640 T 04 04/01/17 N Y N 22.858 500 11,429.00 22.24 11,120.42 J1645 T 04 04/01/17 N Y N 15.342 4 61.37 14.93 59.71
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J1650 T 04 04/01/17 N Y N 0.932 18 16.78 0.91 16.33 J1652 T 04 04/01/17 N Y N 2.283 20 45.66 2.22 44.43 J1670 T 04 04/01/17 N Y N 365.15 1 365.15 355.29 355.29 J1675 T 04 04/01/17 N Y N 0.667 5000 3,335.00 0.65 3,244.96 J1700 T 04 Y Y NJ1720 T 04 04/01/17 N Y N 9.034 5 45.17 8.79 43.95 J1730 T 04 Y Y NJ1740 T 04 04/01/17 N Y N 78.291 3 234.87 76.18 228.53 J1741 T 04 04/01/17 N Y N 1.72 8 13.76 1.67 13.39 J1742 T 04 04/01/17 N Y N 192.50 2 385.00 187.30 374.61 J1743 T 04 04/01/17 N Y N 522.012 60 31,320.72 507.92 30,475.06 J1744 T 04 04/01/17 N Y N 324.13 30 9,723.90 315.38 9,461.35 J1745 N,T 04 01/01/17 Y Y NJ1750 T 04 04/01/17 N Y N 12.455 50 622.75 12.12 605.94 J1756 T 04 04/01/17 N Y N 0.252 500 126.00 0.25 122.60 J1786 T 04 04/01/17 N Y N 41.798 750 31,348.50 40.67 30,502.09 J1790 T 04 04/01/17 N Y N 1.51 1 1.51 1.47 1.47 J1800 T 04 04/01/17 N Y N 2.171 3 6.51 2.11 6.33 J1810 T 04 Y Y NJ1815 T 04 04/01/17 N Y N 0.809 20 16.18 0.79 15.74 J1817 T 04 04/01/17 N Y N 9.617 6 57.70 9.36 56.14 J1826 T 04 04/01/17 N Y N 1455.25 1 1,455.25 1,415.96 1,415.96 J1833 T 04 04/01/17 N Y N 0.73 1116 814.68 0.71 792.68 J1885 T 04 04/01/17 N Y N 0.689 4 2.76 0.67 2.69 J1890 T 04 Y Y NJ1930 T 04 04/01/17 N Y N 54.011 120 6,481.32 52.55 6,306.32 J1931 T 04 04/01/17 N Y N 30.611 200 6,122.20 29.78 5,956.90 J1940 T 04 04/01/17 N Y N 1.063 5 5.32 1.03 5.18 J1950 T 04 04/01/17 N Y N 1024.549 8 8,196.39 996.89 7,975.09 J1953 T 04 04/01/17 N Y N 0.158 150 23.70 0.15 23.06 J1955 T 04 04/01/17 N Y N 19.878 6 119.27 19.34 116.05 J1956 T 04 04/01/17 N Y N 1.554 3 4.66 1.51 4.53 J1980 T 04 04/01/17 N Y N 27.559 2 55.12 26.81 53.63 J2001 T 04 04/01/17 N Y N 0.019 30 0.57 0.02 0.55 J2010 T 04 04/01/17 N Y N 12.264 13 159.43 11.93 155.13 J2020 T 04 04/01/17 N Y N 16.639 3 49.92 16.19 48.57 J2060 T 04 04/01/17 N Y N 0.745 2 1.49 0.72 1.45 J2150 T 04 04/01/17 N Y N 1.782 8 14.26 1.73 13.87 J2175 T 04 04/01/17 N Y N 4.775 2 9.55 4.65 9.29 J2180 T 04 Y Y NJ2182 T 04 04/01/17 N Y N 26.78 100 2,678.00 26.06 2,605.69
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J2185 T 04 04/01/17 N Y N 1.11 20 22.20 1.08 21.60 J2210 T 04 04/01/17 N Y N 14.17 1 14.17 13.79 13.79 J2212 T 04 04/01/17 N Y N 0.83 120 99.60 0.81 96.91 J2248 T 04 04/01/17 N Y N 0.948 150 142.20 0.92 138.36 J2250 T 04 04/01/17 N Y N 0.12 40 4.80 0.12 4.67 J2260 T 04 04/01/17 N Y N 2.484 8 19.87 2.42 19.33 J2270 T 04 04/01/17 N Y N 1.588 2 3.18 1.55 3.09 J2274 T 04 04/01/17 N Y N 10.757 1 10.76 10.47 10.47 J2278 T 04 04/01/17 N Y N 7.328 20 146.56 7.13 142.60 J2280 T 04 04/01/17 N Y N 8.082 4 32.33 7.86 31.46 J2300 T 04 04/01/17 N Y N 2.525 2 5.05 2.46 4.91 J2310 T 04 04/01/17 N Y N 27.338 2 54.68 26.60 53.20 J2315 T 04 04/01/17 N Y N 3.248 380 1,234.24 3.16 1,200.92 J2323 T 04 04/01/17 N Y N 18.797 300 5,639.10 18.29 5,486.84 J2325 T 04 04/01/17 N Y N 70.5673 15 1,058.51 68.66 1,029.93 J2353 T 04 04/01/17 N Y N 175.55 40 7,022.00 170.81 6,832.41 J2354 T 04 04/01/17 N Y N 1.117 20 22.34 1.09 21.74 J2355 T 04 04/01/17 N Y N 467.22 1 467.22 454.61 454.61 J2357 N,T 04 01/01/17 Y Y NJ2358 T 04 04/01/17 N Y N 2.917 10 29.17 2.84 28.38 J2360 T 04 04/01/17 N Y N 5.22 1 5.22 5.08 5.08 J2370 T 04 04/01/17 N Y N 5.47 1 5.47 5.32 5.32 J2400 T 04 04/01/17 N Y N 29.227 2 58.45 28.44 56.87 J2405 T 04 04/01/17 N Y N 0.091 16 1.46 0.09 1.42 J2407 T 04 04/01/17 N Y N 24.562 120 2,947.44 23.90 2,867.86 J2410 T 04 04/01/17 N Y N 2.90 2 5.80 2.82 5.64 J2425 T 04 04/01/17 N Y N 17.679 150 2,651.85 17.20 2,580.25 J2426 T 04 04/01/17 N Y N 9.504 234 2,223.94 9.25 2,163.89 J2430 T 04 04/01/17 N Y N 10.223 3 30.67 9.95 29.84 J2440 T 04 04/01/17 N Y N 11.25 2 22.50 10.95 21.89 J2469 T 04 04/01/17 N Y N 22.627 10 226.27 22.02 220.16 J2501 T 04 04/01/17 N Y N 1.164 13 15.13 1.13 14.72
J2502 N , T 04Code eff
1/1/16 PA 3/1/16
Y Y N
J2503 T 04 04/01/17 N Y N 1054.70 1 1,054.70 1,026.22 1,026.22 J2504 T 04 04/01/17 N Y N 345.228 16 5,523.65 335.91 5,374.51 J2505 T 04 04/01/17 N Y N 4191.34 1 4,191.34 4,078.17 4,078.17 J2507 T 04 04/01/17 N Y N 1821.528 8 14,572.22 1,772.35 14,178.77 J2510 T 04 04/01/17 N Y N 26.768 4 107.07 26.05 104.18 J2515 T 04 04/01/17 N Y N 47.343 8 378.74 46.06 368.51
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J2540 T 04 04/01/17 N Y N 1.077 10 10.77 1.05 10.48 J2543 T 04 04/01/17 N Y N 2.808 4 11.23 2.73 10.93 J2545 T 04 04/01/17 N Y N 122.398 1 122.40 119.09 119.10 J2547 T 04 04/01/17 N Y N 1.5833 600 949.98 1.54 924.33 J2550 T 04 04/01/17 N Y N 2.19 1 2.19 2.13 2.13 J2560 T 04 04/01/17 N Y N 38.367 5 191.84 37.33 186.66 J2562 T 04 04/01/17 N Y N 312.098 40 12,483.92 303.67 12,146.85 J2590 T 04 04/01/17 N Y N 0.76 4 3.04 0.74 2.96 J2597 T 04 04/01/17 N Y N 13.154 4 52.62 12.80 51.20 J2650 T 04 Y Y NJ2670 T 04 Y Y NJ2675 T 04 04/01/17 N Y N 1.43 1 1.43 1.39 1.39 J2680 T 04 04/01/17 N Y N 21.335 4 85.34 20.76 83.04 J2690 T 04 04/01/17 N Y N 59.38 1 59.38 57.78 57.78 J2700 T 04 04/01/17 N Y N 0.42 8 3.36 0.41 3.27 J2704 T 04 04/01/17 N Y N 0.118 100 11.80 0.11 11.48 J2710 T 04 04/01/17 N Y N 6.55 10 65.50 6.37 63.73 J2720 T 04 04/01/17 N Y N 1.092 5 5.46 1.06 5.31 J2724 T 04 04/01/17 N Y N 15.197 1500 22,795.50 14.79 22,180.02 J2730 T 04 04/01/17 N Y N 86.70 2 173.40 84.36 168.72 J2760 T 04 04/01/17 N Y N 425.00 2 850.00 413.53 827.05 J2765 T 04 04/01/17 N Y N 0.887 25 22.18 0.86 21.58 J2770 T 04 04/01/17 N Y N 436.772 2 873.54 424.98 849.95 J2778 T 04 04/01/17 N Y N 375.205 5 1,876.03 365.07 1,825.38 J2780 T 04 04/01/17 N Y N 1.394 2 2.79 1.36 2.71 J2783 T 04 04/01/17 N Y N 259.153 50 12,957.65 252.16 12,607.79 J2785 T 04 04/01/17 N Y N 55.269 4 221.08 53.78 215.11 J2786 T 04 04/01/17 N Y N 8.35 400 3,340.00 8.12 3,249.82 J2788 T 04 04/01/17 N Y N 25.14 1 25.14 24.46 24.46 J2790 T 04 04/01/17 N Y N 78.44 1 78.44 76.32 76.32 J2791 T 04 04/01/17 N Y N 4.787 15 71.81 4.66 69.87 J2792 T 04 04/01/17 N Y N 22.699 75 1,702.43 22.09 1,656.46 J2793 T 04 04/01/17 N Y N 22.72 320 7,270.40 22.11 7,074.10 J2794 N,T 04 01/01/17 Y Y NJ2795 T 04 04/01/17 N Y N 0.075 150 11.25 0.07 10.95 J2796 T 04 04/01/17 N Y N 65.031 125 8,128.88 63.28 7,909.40 J2800 T 04 04/01/17 N Y N 38.924 2 77.85 37.87 75.75 J2810 T 04 04/01/17 N Y N 0.308 20 6.16 0.30 5.99 J2820 T 04 04/01/17 N Y N 37.085 25 927.13 36.08 902.10 J2840 T 04 04/01/17 N Y N 500.00 140 70,000.00 486.50 68,110.00 J2860 N , T 04 01/01/16 Y Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J2916 T 04 04/01/17 N Y N 2.314 10 23.14 2.25 22.52 J2920 T 04 04/01/17 N Y N 4.064 1 4.06 3.95 3.95 J2930 T 04 04/01/17 N Y N 5.568 30 167.04 5.42 162.53 J2941 T 04 04/01/17 N Y N 104.78 10 1,047.80 101.95 1,019.51 J2950 T 04 01/01/11 Y NJ2994 T 04 Y Y NJ2995 T 04 Y Y NJ2997 T 04 04/01/17 N Y N 81.351 2 162.70 79.15 158.31 J3000 T 04 04/01/17 N Y N 13.281 2 26.56 12.92 25.84 J3010 T 04 04/01/17 N Y N 0.509 2 1.02 0.50 0.99 J3030 T 04 04/01/17 N Y N 39.37 1 39.37 38.31 38.31 J3060 T 04 04/01/17 N Y N 40.40 900 36,360.00 39.31 35,378.28 J3070 T 04 04/01/17 N Y N 136.714 2 273.43 133.02 266.05 J3090 T 04 04/01/17 N Y N 1.27 20 25.40 1.24 24.71 J3095 T 04 04/01/17 N Y N 5.004 125 625.50 4.87 608.61 J3101 T 04 04/01/17 N Y N 102.418 50 5,120.90 99.65 4,982.64 J3105 T 04 04/01/17 N Y N 3.93 1 3.93 3.82 3.82 J3121 T 04 04/01/17 N Y N 0.035 400 14.00 0.03 13.62 J3145 T 04 04/01/17 N Y N 1.24 400 496.00 1.21 482.61 J3230 T 04 04/01/17 N Y N 26.885 8 215.08 26.16 209.27 J3240 T 04 04/01/17 N Y N 1566.93 1 1,566.93 1,524.62 1,524.62 J3243 T 04 04/01/17 N Y N 3.178 100 317.80 3.09 309.22 J3246 T 04 04/01/17 N Y N 10.36 100 1,036.00 10.08 1,008.03 J3250 T 04 04/01/17 N Y N 27.43 1 27.43 26.69 26.69 J3260 T 04 04/01/17 N Y N 2.735 8 21.88 2.66 21.29 J3262 T 04 04/01/17 N Y N 4.219 800 3,375.20 4.11 3,284.07 J3280 T 04 Y Y NJ3285 T 04 04/01/17 N Y N 61.237 200 12,247.40 59.58 11,916.72 J3300 T 04 04/01/17 N Y N 3.738 40 149.52 3.64 145.48 J3301 T 04 04/01/17 N Y N 1.776 16 28.42 1.73 27.65 J3303 T 04 04/01/17 N Y N 3.41 4 13.64 3.32 13.27 J3315 T 04 04/01/17 N Y N 365.44 6 2,192.64 355.57 2,133.44 J3350 T 04 Y Y NJ3357 T 04 04/01/17 N Y N 174.204 90 15,678.36 169.50 15,255.04 J3360 T 04 04/01/17 N Y N 9.337 4 37.35 9.08 36.34 J3370 T 04 04/01/17 N Y N 2.755 6 16.53 2.68 16.08 J3380 T 04 04/01/17 N Y N 18.127 300 5,438.10 17.64 5,291.27 J3385 T 04 04/01/17 N Y N 342.695 72 24,674.04 333.44 24,007.84 J3396 T 04 04/01/17 N Y N 10.758 150 1,613.70 10.47 1,570.13 J3410 T 04 04/01/17 N Y N 2.236 4 8.94 2.18 8.70 J3411 T 04 04/01/17 N Y N 3.10 1 3.10 3.02 3.02
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J3415 T 04 04/01/17 N Y N 11.193 6 67.16 10.89 65.35 J3420 T 04 04/01/17 N Y N 3.35 1 3.35 3.26 3.26 J3430 T 04 04/01/17 N Y N 3.549 25 88.73 3.45 86.33 J3465 T 04 04/01/17 N Y N 3.643 60 218.58 3.54 212.68 J3470 T 04 04/01/17 N Y N 55.80 2 111.60 54.29 108.59 J3471 T 04 04/01/17 N Y N 0.354 400 141.60 0.34 137.78 J3472 T 04 04/01/17 N Y N 372.13 1 372.13 362.08 362.08 J3473 T 04 04/01/17 N Y N 0.358 300 107.40 0.35 104.50 J3475 T 04 04/01/17 N Y N 0.447 20 8.94 0.43 8.70 J3480 T 04 04/01/17 N Y N 0.127 20 2.54 0.12 2.47 J3485 T 04 04/01/17 N Y N 1.512 20 30.24 1.47 29.42 J3489 T 04 04/01/17 N Y N 13.411 5 67.06 13.05 65.25 J3490 T, U* 04 Y Y NJ3530 T 04 Y NJ3590 T 04 Y Y NJ7121 T 04 04/01/17 N Y N .0019 3000 5.70 0.00 5.55 J7131 T 04 04/01/17 N Y N .0099 500 4.95 0.01 4.82 J7175 T 04 04/01/17 N Y N 6.00 9999 59,994.00 5.84 58,374.16 J7178 T 04 04/01/17 N Y N 1.17 9000 10,530.00 1.14 10,245.69 J7179 T 04 04/01/17 N Y N 1.45 9999 14,498.55 1.41 14,107.09 J7180 T 04 04/01/17 N Y N 8.192 5000 40,960.00 7.97 39,854.08 J7181 T 04 04/01/17 N Y N 10.24 4500 46,080.00 9.96 44,835.84 J7182 T 04 04/01/17 N Y N 1.287 6250 8,043.75 1.25 7,826.57 J7183 T 04 04/01/17 N Y N 1.01 7500 7,575.00 0.98 7,370.48 J7185 T 04 04/01/17 N Y N 1.222 6250 7,637.50 1.19 7,431.29 J7186 T 04 04/01/17 N Y N 0.986 6250 6,162.50 0.96 5,996.11 J7187 T 04 04/01/17 N Y N 1.086 9999 10,858.91 1.06 10,565.72 J7189 T 04 04/01/17 N Y N 1.925 9999 19,248.08 1.87 18,728.38 J7190 T 04 04/01/17 N Y N 1.012 6250 6,325.00 0.98 6,154.23 J7192 T 04 04/01/17 N Y N 1.199 6250 7,493.75 1.17 7,291.42 J7193 T 04 04/01/17 N Y N 1.157 6250 7,231.25 1.13 7,036.01 J7194 T 04 04/01/17 N Y N 1.339 9999 13,388.66 1.30 13,027.17 J7195 T 04 04/01/17 N Y N 1.506 9999 15,058.49 1.47 14,651.91 J7196 T 04 01/01/11 Y Y NJ7197 T 04 04/01/17 N Y N 3.222 6250 20,137.50 3.14 19,593.79 J7198 T 04 04/01/17 N Y N 1.932 9999 19,318.07 1.88 18,796.48 J7199 T 04 Y Y NJ7200 T 04 04/01/17 N Y N 1.25 6250 7,182.50 1.22 6,988.57 J7201 T 04 04/01/17 N Y N 2.926 6250 18,287.50 2.85 17,793.74 J7202 T 04 04/01/17 N Y N 3.84 9999 38,396.16 3.74 37,359.46 J7205 T 04 04/01/17 N Y N 1.977 8125 16,063.13 1.92 15,629.43
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J7207 T 04 04/01/17 N Y N 1.36 9999 13,598.64 1.32 13,231.48 J7209 T 04 04/01/17 N Y N 1.19 9999 11,898.81 1.16 11,577.54 J7297 U 04 04/01/17 N Y N 684.38 1 684.38 665.90 665.90 J7298 U 04 04/01/17 N Y N 858.33 1 858.33 835.16 835.16 J7300 U 04 04/01/17 N Y N 739.00 1 739.00 719.05 719.05 J7301 U 04 04/01/17 N Y N 714.70 1 714.70 695.40 695.40 J7303 U 04 04/01/17 N Y N 135.77 3 407.31 132.10 396.31 J7304 U 04 04/01/17 N Y N 35.31 9 317.79 34.36 309.21 J7307 U 04 04/01/17 N Y N 847.90 1 847.90 825.01 825.01 J7308 T 04 04/01/17 N Y N 367.81 1 367.81 357.88 357.88 J7311 T 04 04/01/17 N Y N 20110.39 1 20,110.39 19,567.41 19,567.41 J7312 T 04 04/01/17 N Y N 200.781 7 1,405.47 195.36 1,367.52 J7313 T 04 04/01/17 N Y N 490.947 19 9,327.99 477.69 9,076.13 J7316 T 04 04/01/17 N Y N 1046.75 4 4,187.00 1,018.49 4,073.95 J7320 T 04 04/01/17 N Y N 6.993 25 174.83 6.80 170.11 J7321 T 04 04/01/17 N N N 87.16 1 87.16 84.81 84.81 J7322 T 04 04/01/17 N Y N 16.6662 24 399.99 16.22 389.19 J7323 T 04 04/01/17 N N N 153.84 1 153.84 149.69 149.69 J7324 T 04 04/01/17 N N N 153.55 1 153.55 149.40 149.40 J7325 T 04 04/01/17 N N N 12.539 48 601.87 12.20 585.62 J7326 T 04 04/01/17 N N N 543.61 1 543.61 528.93 528.93 J7327 T 04 04/01/17 N N N 895.15 1 895.15 870.98 870.98 J7328 T 04 04/01/17 N N N 2.0535 168 344.99 2.00 335.68 J7336 T 04 04/01/17 N Y N 2.978 1120 3,335.36 2.90 3,245.31 J7342 T 04 04/01/17 N Y N 28.32 10 283.20 27.56 275.55 J7501 T 04 04/01/17 N Y N 250.00 6 1,500.00 243.25 1,459.50 J7504 T 04 04/01/17 N Y N 1478.80 15 22,182.00 1,438.87 21,583.09 J7510 T 04 04/01/17 N Y N 0.075 40 3.00 0.07 2.92 J7511 T 04 04/01/17 N Y N 687.769 7 4,814.38 669.20 4,684.39 J7516 T 04 04/01/17 N Y N 39.412 3 118.24 38.35 115.05 J7525 T 04 04/01/17 N Y N 170.85 1 170.85 166.24 166.24 J7599 T 04 Y Y NJ7604 T 04 07/01/15 Y Y NJ7605 T 04 04/01/17 N Y N 9.54 1 9.54 9.28 9.28 J7606 T 04 04/01/17 N Y N 10.54 1 10.54 10.26 10.26 J7607 T 04 01/01/07 Y Y NJ7608 T 04 04/01/17 N Y N 4.459 2 8.92 4.34 8.68 J7609 T 04 01/01/07 Y Y NJ7610 T 04 01/01/07 Y Y NJ7611 T 04 04/01/17 N Y N 0.127 5 0.64 0.12 0.62 J7612 T 04 04/01/17 N Y N 0.199 5 1.00 0.19 0.97 J7613 T 04 04/01/17 N Y N 0.049 5 0.25 0.05 0.24
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J7614 T 04 04/01/17 N Y N 0.068 5 0.34 0.07 0.33 J7615 T 04 04/01/15 Y Y NJ7620 T 04 04/01/17 N Y N 0.16 1 0.16 0.16 0.16 J7626 T 04 04/01/17 N Y N 3.46 2 6.92 3.37 6.73 J7627 T 04 07/01/15 Y Y NJ7628 T 04 Y Y NJ7629 T 04 Y Y NJ7631 T 04 04/01/17 N Y N 0.814 2 1.63 0.79 1.59 J7632 T 04 07/01/15 Y Y NJ7634 T 04 01/01/07 Y Y NJ7635 T 04 07/01/15 Y Y NJ7636 T 04 Y Y NJ7637 T 04 07/01/15 Y Y NJ7638 T 04 Y Y NJ7639 T 04 04/01/17 N Y N 42.50 3 127.50 41.35 124.06 J7640 T 04 07/01/15 Y Y NJ7642 T 04 Y Y NJ7643 T 04 Y Y NJ7644 T 04 04/01/17 N Y N 0.23 1 0.23 0.22 0.22 J7645 T 04 01/01/07 Y Y NJ7647 T 04 01/01/07 Y Y NJ7648 T 04 Y Y NJ7649 T 04 Y Y NJ7650 T 04 01/01/07 Y Y NJ7657 T 04 01/01/07 Y Y NJ7658 T 04 Y Y NJ7659 T 04 Y Y NJ7660 T 04 01/01/07 Y Y NJ7667 T 04 01/01/07 Y Y NJ7668 T 04 Y Y NJ7670 T 04 04/01/14 Y Y NJ7674 T 04 04/01/17 N Y N 0.531 200 106.20 0.52 103.33 J7676 T 04 07/01/15 Y Y NJ7680 T 04 Y Y NJ7681 T 04 Y Y NJ7682 T 04 04/01/17 N Y N 42.38 1 42.38 41.24 41.24 J7683 T 04 Y Y NJ7684 T 04 Y Y NJ7685 T 04 01/01/07 Y Y NJ7686 T 04 04/01/17 N Y N 531.30 1 531.30 516.95 516.95 J7699 T 04 Y Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J7799 T 04 Y Y NJ7999 T 04 01/01/16 Y Y NJ8499 T, U 04 06/01/16 Y Y NJ8501 T 04 04/01/17 N Y N 11.75 25 294.58 11.43 286.63 J8510 T 04 04/01/17 N Y N 23.672 32 757.50 23.03 737.05 J8520 T 04 04/01/17 N Y N 4.032 21 84.67 3.92 82.38 J8521 T 04 04/01/17 N Y N 11.247 6 67.48 10.94 65.66 J8530 T 04 04/01/17 N Y N 3.133 25 78.33 3.05 76.22 J8560 T 04 04/01/17 N Y N 74.254 10 742.54 72.25 722.49 J8565 T 04 04/01/17 N Y N 253.26 1 253.26 246.42 246.42 J8600 T 04 04/01/17 N Y N 11.698 12 140.38 11.38 136.59 J8610 T 04 04/01/17 N Y N 0.573 20 11.46 0.56 11.15 J8655 T 04 04/01/17 N Y N 444.91 1 444.91 432.90 432.90 J8700 T 04 04/01/17 N Y N 1.859 100 185.90 1.81 180.88 J8705 T 04 04/01/17 N Y N 103.786 23 2,387.08 100.98 2,322.63 J8999 T 04 Y Y NJ9000 T 04 04/01/17 N Y N 4.943 18 88.97 4.81 86.57 J9015 T 04 04/01/17 N Y N 2894.00 3 8,682.00 2,815.86 8,447.59 J9017 T 04 04/01/17 N Y N 64.925 30 1,947.75 63.17 1,895.16 J9019 T 04 04/01/17 N Y N 402.743 60 24,164.58 391.87 23,512.14 J9020 T 04 04/01/17 N Y N 3799.46 2 7,598.92 3,696.87 7,393.75 J9025 T 04 04/01/17 N Y N 2.112 200 422.40 2.05 411.00 J9027 T 04 04/01/17 N Y N 152.638 120 18,284.16 148.52 17,790.49 J9031 T 04 04/01/17 N Y N 128.38 1 128.38 124.91 124.91 J9032 T 04 04/01/17 N Y N 34.392 252 8,666.78 33.46 8,432.78 J9033 T 04 04/01/17 N Y N 27.969 300 8,390.70 27.21 8,164.15 J9034 T 04 04/01/17 N Y N 23.457 400 9,382.80 22.82 9,129.46 J9035 T 04 04/01/17 N Y N 73.604 190 13,984.76 71.62 13,607.17 J9039 T 04 04/01/17 N Y N 98.98 28 2,771.44 96.31 2,696.61 J9040 T 04 04/01/17 N Y N 45.803 4 183.21 44.57 178.26 J9041 T 04 04/01/17 N Y N 46.427 35 1,618.65 45.17 1,574.95 J9042 T 04 04/01/17 N Y N 134.154 200 26,830.80 130.53 26,106.37 J9043 T 04 04/01/17 N Y N 156.664 60 9,399.84 152.43 9,146.04 J9045 T 04 04/01/17 N Y N 3.53 18 63.54 3.43 61.82 J9047 T 04 04/01/17 N Y N 32.204 60 1,932.24 31.33 1,880.07 J9050 T 04 04/01/17 N Y N 3846.964 5 19,234.82 3,743.10 18,715.48 J9055 T 04 04/01/17 N Y N 56.385 100 5,638.50 54.86 5,486.26 J9060 T 04 04/01/17 N Y N 2.322 25 58.05 2.26 56.48 J9065 T 04 04/01/17 N Y N 20.032 10 200.32 19.49 194.91 J9070 T 04 04/01/17 N Y N 42.306 60 2,538.36 41.16 2,469.82 J9098 T 04 04/01/17 N Y N 593.988 5 2,969.94 577.95 2,889.75
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J9100 T 04 04/01/17 N Y N 0.849 75 63.68 0.83 61.96 J9120 T 04 04/01/17 N Y N 1276.378 5 6,381.89 1,241.92 6,209.58 J9130 T 04 04/01/17 N Y N 3.983 10 39.83 3.88 38.75 J9145 T 04 04/01/17 N Y N 48.105 200 9,621.00 46.81 9,361.23 J9150 T 04 04/01/17 N Y N 39.242 10 392.42 38.18 381.82 J9155 T 04 04/01/17 N Y N 3.634 240 872.16 3.54 848.61 J9165 T 04 Y Y NJ9171 T 04 04/01/17 N Y N 1.88 260 490.88 1.83 477.63 J9175 T 04 Y Y NJ9176 T 04 04/01/17 N Y N 6.21 1500 9,315.00 6.04 9,063.50 J9178 T 04 04/01/17 N Y N 1.385 150 207.75 1.35 202.14 J9179 T 04 04/01/17 N Y N 108.31 30 3,249.30 105.39 3,161.57 J9181 T 04 04/01/17 N Y N 0.584 25 14.60 0.57 14.21 J9185 T 04 04/01/17 N Y N 67.932 2 135.86 66.10 132.19 J9190 T 04 04/01/17 N Y N 1.84 2 3.68 1.79 3.58 J9200 T 04 04/01/17 N Y N 60.59 1 60.59 58.95 58.95 J9201 T 04 04/01/17 N Y N 6.287 15 94.31 6.12 91.76 J9202 T 04 04/01/17 N Y N 349.915 3 1,049.75 340.47 1,021.41 J9205 T 04 04/01/17 N Y N 39.482 215 8,488.63 38.42 8,259.44 J9206 T 04 04/01/17 N Y N 3.687 44 162.23 3.59 157.85 J9207 T 04 04/01/17 N Y N 75.364 90 6,782.76 73.33 6,599.63 J9208 T 04 04/01/17 N Y N 28.071 3 84.21 27.31 81.94 J9209 T 04 04/01/17 N Y N 2.058 15 30.87 2.77 30.04 J9211 T 04 04/01/17 N Y N 41.537 6 249.22 40.42 242.49 J9214 T 04 04/01/17 N Y N 28.522 75 2,139.15 27.75 2,081.39 J9215 T 04 04/01/17 N Y N 30.00 20 600.00 29.19 583.80 J9216 T 04 04/01/17 N Y N 5951.07 1 5,951.07 5,790.39 5,790.39 J9217 T 04 04/01/17 N Y N 216.008 6 1,296.05 210.18 1,261.06 J9218 T 04 04/01/17 N Y N 25.96 1 25.96 25.26 25.26 J9225 T 04 04/01/17 N Y N 3128.81 1 3,128.81 3,044.33 3,044.33 J9226 T 04 04/01/17 N Y N 27736.93 1 27,736.93 26,988.03 26,988.03 J9228 T 04 04/01/17 N Y N 144.659 350 50,630.65 140.75 49,263.62 J9230 T 04 04/01/17 N Y N 265.888 3 797.66 258.71 776.13 J9245 T 04 04/01/17 N Y N 1804.13 1 1,804.13 1,755.42 1,755.42 J9250 T 04 04/01/17 N Y N 0.263 24 6.31 0.26 6.14 J9260 T 04 04/01/17 N Y N 2.632 2 5.26 2.56 5.12 J9261 T 04 04/01/17 N Y N 152.029 75 11,402.18 147.92 11,094.32 J9262 T 04 04/01/17 Y Y N 2.73 700 1,911.00 2.66 1,859.40 J9263 T 04 04/01/17 N Y N 0.265 400 106.00 0.26 103.14 J9264 T 04 04/01/17 N Y N 10.447 600 6,268.20 10.16 6,098.96 J9266 T 04 04/01/17 N Y N 13912.195 2 27,824.39 13,536.57 27,073.13
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
J9267 T 04 04/01/17 N Y N 0.150 560 84.00 0.15 81.73 J9268 T 04 04/01/17 N Y N 1883.12 1 1,883.12 1,832.28 1,832.28
J9271 N , T 04Code eff
1/1/16 PA 3/1/16
Y Y N
J9280 T 04 04/01/17 N Y N 115.681 10 1,156.81 112.56 1,125.58 J9293 T 04 04/01/17 N Y N 32.849 6 197.09 31.96 191.77 J9295 T 04 04/01/17 N Y N 5.253 800 4,202.40 5.11 4,088.94
J9299 N , T 04Code eff
1/1/16 PA 3/1/16
Y Y N
J9301 T 04 04/01/17 N Y N 57.361 100 5,736.10 55.81 5,581.23 J9302 T 04 04/01/17 N Y N 53.387 200 10,677.40 51.95 10,389.11 J9303 T 04 04/01/17 N Y N 107.713 70 7,539.91 104.80 7,336.33 J9305 T 04 04/01/17 N Y N 64.041 120 7,684.92 62.31 7,477.43 J9306 T 04 04/01/17 N Y N 10.882 840 9,140.88 10.59 8,894.08 J9307 T 04 04/01/17 N Y N 238.679 60 14,320.74 232.23 13,934.08 J9308 T 04 04/01/17 N Y N 56.271 250 14,067.75 54.75 13,687.92 J9310 T 04 04/01/17 N Y N 818.308 12 9,819.70 796.21 9,554.57 J9315 T 04 04/01/17 N Y N 317.577 30 9,527.31 309.00 9,270.07 J9320 T 04 04/01/17 N Y N 320.212 4 1,280.85 311.57 1,246.27 J9325 T 04 04/01/17 N Y N 46.042 100 4,604.20 44.80 4,479.89 J9328 T 04 04/01/17 N Y N 8.947 500 4,473.50 8.71 4,352.72 J9330 T 04 04/01/17 N Y N 67.302 25 1,682.55 65.48 1,637.12 J9340 T 04 04/01/17 N Y N 1400.00 7 9,800.00 1,362.20 9,535.40 J9351 T 04 04/01/17 N Y N 1.259 40 50.36 1.23 49.00 J9352 T 04 04/01/17 N Y N 283.444 40 11,337.76 275.79 11,031.64 J9354 T 04 04/01/17 N Y N 29.524 400 11,809.60 28.73 11,490.74 J9355 T 04 04/01/17 N Y N 94.494 100 9,449.40 91.94 9,194.27 J9357 T 04 04/01/17 N Y N 1158.108 4 4,632.43 1,126.84 4,507.35 J9360 T 04 04/01/17 N Y N 3.576 46 164.50 3.48 160.06 J9370 T 04 04/01/17 N Y N 4.47 4 17.88 4.35 17.40 J9371 T 04 04/01/17 N Y N 2600.362 5 13,001.81 2,530.15 12,650.76 J9390 T 04 04/01/17 N Y N 7.706 8 61.65 7.50 59.99 J9395 T 04 04/01/17 N Y N 96.243 20 1,924.86 93.64 1,872.89 J9400 T 04 04/01/17 N Y N 8.122 500 4,061.00 7.90 3,951.35 J9600 T 04 04/01/17 N Y N 20427.00 3 61,281.00 19,875.47 59,626.41 J9999 N , T 04 03/01/15 Y Y NP3000 04 N N 3.55 3.45 P3001 04 N N 11.45 11.14 P7001 A 04 N N 6.40 6.40 12.80 12.45 P9041 09 Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
P9043 09 Y NP9045 09 Y NP9046 09 Y NP9047 09 Y NP9048 09 Y NP9050 04 Y NP9604 04 N N 2.90 2.82 P9612 09 Y NP9615 09 Y NQ0044 04 N N 7.60 7.39 Q0081 04 Y IQ0083 04 N I 19.00 18.49 Q0084 04 N I 19.00 18.49 Q0085 04 N I 19.00 18.49 Q0111 B 04 01/01/12 N N 2.40 2.40 4.80 4.67 Q0112 B 04 N N 2.40 2.40 4.80 4.67 Q0113 B 04 N N 2.40 2.40 4.80 4.67 Q0138 T 04 04/01/17 N Y N 0.892 510 454.92 0.87 442.64 Q0139 T 04 04/01/17 N Y N 0.892 510 454.92 0.87 442.64 Q0161 T 04 04/01/17 N Y N 1.32 10 13.20 1.28 12.84 Q0163 T 04 04/01/17 N Y N 0.251 2 0.50 0.24 0.49 Q0164 T 04 04/01/17 N Y N 0.039 10 0.39 0.04 0.38 Q0166 T 04 04/01/17 N Y N 2.443 2 4.89 2.38 4.76 Q0169 T 04 04/01/17 N Y N 0.032 4 0.13 0.03 0.13 Q0175 T 04 04/01/17 N Y N 1.1858 24 28.46 1.15 27.69 Q0177 T 04 04/01/17 N Y N 0.07 4 0.28 0.07 0.27 Q0180 T 04 04/01/17 N Y N 95.50 1 95.50 92.92 92.92 Q0181 04 Y Y NQ2004 04 Y Y NQ2009 T 04 04/01/17 N Y N 0.73 250 182.50 0.71 177.57 Q2017 T 04 04/01/17 N Y N 2495.95 13 32,447.35 2,428.56 31,571.27 Q2036 E , Y 04 04/01/17 N N 6.40 16.07 6.23 15.64 Q2037 E , Y 04 04/01/17 N N 6.40 16.28 6.23 15.84 Q2038 E , Y 04 04/01/17 N N 6.40 17.22 6.23 16.76 Q2049 T 04 04/01/17 N Y N 484.50 10 4,845.00 471.42 4,714.19 Q2050 T 04 04/01/17 N Y N 408.154 10 4,081.54 397.13 3,971.34 Q3014 04 01/29/10 N N 25.00 24.33 Q3027 T 04 04/01/17 N Y N 46.206 30 1,386.18 44.96 1,348.75 Q3028 T 04 04/01/17 N Y N 25.01 44 1,100.44 24.33 1,070.73 Q3031 04 Y NQ4001 09 Y NQ4002 09 Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
Q4003 09 Y NQ4004 09 Y NQ4005 09 Y NQ4010 09 Y NQ4011 09 Y NQ4012 09 Y NQ4013 09 Y NQ4014 09 Y NQ4015 09 Y NQ4016 09 Y NQ4018 09 Y NQ4019 09 Y NQ4020 09 Y NQ4024 09 Y NQ4025 09 Y NQ4026 09 Y NQ4027 09 Y NQ4028 09 Y NQ4029 09 Y NQ4031 09 Y NQ4033 09 Y NQ4035 09 Y NQ4036 09 Y NQ4037 09 Y NQ4038 09 Y NQ4041 09 Y NQ4044 09 Y NQ4045 09 Y NQ4046 09 Y NQ4047 09 Y NQ4048 09 Y NQ4049 09 Y NQ4050 09 Y NQ4051 09 Y NQ4074 T 04 04/01/17 N Y N 123.93 1 123.93 120.58 120.59 Q4081 T 04 04/01/17 N Y N 1.362 800 1,089.60 1.33 1,060.18 Q4100 04 01/01/09 Y N NQ4101 04 01/01/09 Y N NQ4102 04 01/01/09 Y N NQ4103 04 01/01/09 Y N NQ4104 04 01/01/09 Y N N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
Q4105 04 01/01/09 Y N NQ4106 04 01/01/09 Y N NQ4107 04 01/01/09 Y N NQ4108 04 01/01/09 Y N NQ4110 04 01/01/09 Y N NQ4111 04 01/01/09 Y N NQ4112 04 01/01/09 Y N NQ4113 04 01/01/09 Y N NQ4114 04 01/01/09 Y N NQ4115 04 01/01/10 Y N NQ4116 04 01/01/10 Y N NQ4121 04 05/01/12 Y NQ4122 04 01/01/12 Y N NQ4124 X 04 06/01/15 YQ4131 04 01/01/13 Y NQ4132 X 04 06/01/15 YQ4133 X 04 06/01/15 YQ5102 T 04 04/01/17 N Y N 100.306 200 20,061.20 97.60 19,519.55 R0070 04 N N 4.10 3.99 R0075 04 N N 4.10 3.99 R0076 09 Y NS0017 T 04 04/01/17 N Y N 6.00 3 18.00 5.84 17.51 S0021 04 Y Y NS0030 T 04 04/01/17 N Y N 0.90 1 0.90 0.88 0.88 S0032 T 04 04/01/17 N Y N 22.00 1 22.00 21.41 21.41 S0039 T 04 04/01/17 N Y N 9.29 3 27.87 9.04 27.12 S0073 T 04 04/01/17 N Y N 13.66 4 54.64 13.29 53.16 S0074 T 04 04/01/17 N Y N 9.615 6 57.69 9.36 56.13 S0077 T 04 04/01/17 N Y N .58 3 1.74 0.56 1.69 S0080 T 04 04/01/17 N Y N 166.89 1 166.89 162.38 162.38 S0088 T 04 04/01/17 N Y N 58.33 6 349.98 56.76 340.53 S0142 04 Y Y NS0145 04 Y Y NS0148 T 04 04/01/17 N Y N 250.47 15 3,757.05 243.71 3,655.61 S0155 04 Y Y NS0166 T 04 04/01/17 N Y N 8.25 4 33.00 8.03 32.11 S0169 T 04 04/01/17 N Y N 0.37 16 5.92 0.36 5.76 S0190 T 04 04/01/17 N Y N 1296.00 6 7,776.00 1,261.01 7,566.05 S0191 T 04 04/01/17 N Y N 1.62 4 6.48 1.58 6.31 S0630 04 N I 24.35 23.69 S1015 04 Y N
Add-On
Procedure Code Note Prog
Cov Eff Date HP NDC Ind
Surg Ind AV M1
(26)M2
(TC)Asst Surg
Co-Surg
Unitprice Max Qty State
Max Surg Child Adult Unitprice
StateMax
Rate reducedby 2.7%
S1016 04 Y NS2066 04 01/01/08 Y M S2067 04 01/01/08 Y M 3S2068 04 Y M YS2070 04 N I 3 198.98 193.61 S2079 04 Y M 11 Y YS2080 04 N M 5 Y 388.70 378.21 S2083 04 10/01/12 N N 10.00 9.73 S2118 04 01/01/10 Y MS2225 04 N I 3 43.80 17.00 42.62 S2325 04 Y M YS4981 04 Y I 3S4989 04 Y NS4990 09 Y NS4993 U 04 04/01/17 N Y N .45 91 40.95 0.44 39.84 S5190 D 04 N NS9123 09 Y NS9124 09 Y NS9125 09 Y NS9127 09 Y NS9460 09 Y NS9474 09 Y NT1015 D 04 02/01/12 N NT1029 04 N N Y 41.30 40.18
HOURS RATE1 - 60 MIN $74.95
Between 1-2 HRS $119.20Between 2-3 HRS $178.80Between 3-4 HRS $238.40Between 4-5 HRS $298.00Between 5-6 HRS $357.60Between 6-7 HRS $417.20Between 7-8 HRS $476.80Between 8-9 HRS $536.40
Between 9-10 HRS $596.00Between 10-11 HRS $655.60Between 11-12 HRS $715.20Between 12-13 HRS $774.80Between 13-14 HRS $834.40Between 14-15 HRS $894.00
*For time greater than 15 hours, add $59.60 for each additional hour
Please note:*Rates apply to procedure codes payable for surgical assistance as identified on the Practitioner Fee Schedule*Time entry on claims must be in minute format (e.g. for 1 hour, 10 min enter '0070')*When surgical assistance time billed is 8 hours or more (480 minutes or more), documentation is required as
ASSISTANT SURGERY RATES
indicated in the Practitioner Handbook
Procedure Code Modifier
StateMax
Base Add-On Child or
Adult
Psych Add-On Child or
Adult
90791 UB 70.00 52.11 30.0090792 UB 72.33 52.11 30.0090832 UB 29.48 N/A 12.0090833 UB 24.62 N/A 10.0090834 UB 44.20 N/A 15.0090836 UB 40.24 N/A 15.0090837 UB 66.71 N/A 25.0090838 UB 64.64 N/A 25.0090839 UB 66.71 N/A 12.0090847 UB 61.20 N/A 15.00
*In order to receive the Psychiatric add-on payments claims must be submitted with the applicable proc and designate the Community Mental Health Center as the billing provider/payee.
*The following psychiatric add-ons apply to participating physicians rendering psychiatric services to Me partnership with participating Community Mental Health Centers. *Psychiatric add-ons apply to the CPT codes listed below for services rendered on dates of service 07/01
cedure code, UB
edicaid participa
1/2016 - 06/30/