temporary appendix b for administrative order no. 16...

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Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040 Effective January 1, 2017 Link to Medical Fee and Payment Rules HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days 10021 $331.48 $189.42 N/A 11446 $1,055.07 $887.43 010 10022 $377.89 $178.05 N/A 11450 $908.83 $607.84 090 10030 $2,097.83 $462.18 N/A 11451 $1,162.86 $785.58 090 10035 $1,437.70 $236.77 000 11462 $887.87 $580.17 090 10036 $1,249.22 $119.33 ZZZ 11463 $1,177.11 $788.93 090 10040 $273.71 $238.67 010 11470 $987.64 $679.94 090 10060 $314.44 $262.35 010 11471 $1,223.23 $845.11 090 10061 $554.05 $484.92 010 11600 $514.28 $322.96 010 10080 $480.18 $278.45 010 11601 $611.83 $404.41 010 10081 $719.80 $459.34 010 11602 $664.86 $444.19 010 10120 $407.25 $279.39 010 11603 $761.47 $533.22 010 10121 $739.69 $505.75 010 11604 $847.65 $587.20 010 10140 $436.61 $320.12 010 11606 $1,217.02 $876.07 010 10160 $351.37 $260.45 010 11620 $519.96 $327.70 010 10180 $664.86 $486.81 010 11621 $616.56 $408.20 010 11000 $146.80 $77.66 000 11622 $688.54 $467.87 010 11001 $57.77 $38.83 ZZZ 11623 $809.77 $578.68 010 11004 $1,590.18 $1,590.18 000 11624 $913.00 $655.39 010 11005 $2,153.71 $2,153.71 000 11626 $1,104.32 $806.93 010 11006 $1,929.24 $1,929.24 000 11640 $537.01 $340.01 010 11008 $757.68 $757.68 ZZZ 11641 $638.35 $425.25 010 11010 $1,327.83 $762.42 010 11642 $730.21 $502.91 010 11011 $1,443.38 $818.29 000 11643 $861.86 $628.87 010 11012 $1,937.77 $1,171.56 000 11644 $1,065.49 $780.41 010 11042 $313.49 $167.64 000 11646 $1,396.03 $1,086.32 010 11043 $614.67 $424.30 000 11719 $37.88 $20.84 000 11044 $850.50 $632.66 000 11720 $86.19 $39.78 000 11045 $109.86 $71.03 ZZZ 11721 $120.28 $67.24 000 11046 $197.94 $153.43 ZZZ 11730 $266.14 $138.28 000 11047 $336.22 $272.76 ZZZ 11732 $95.66 $54.93 ZZZ 11055 $127.86 $43.57 000 11740 $133.54 $89.03 000 11056 $156.27 $61.56 000 11750 $483.02 $378.84 010 11057 $176.16 $80.50 000 11752 $871.33 $710.32 010 11100 $277.50 $132.59 000 11755 $358.00 $211.20 000 11101 $88.08 $68.19 ZZZ 11760 $524.69 $319.17 010 11200 $235.83 $197.94 010 11762 $756.73 $501.02 010 11201 $51.14 $45.46 ZZZ 11765 $448.93 $254.77 010 11300 $260.45 $95.66 000 11770 $747.26 $503.86 010 11301 $320.12 $145.85 000 11771 $1,369.95 $1,048.00 090 11302 $377.89 $171.43 000 11772 $1,660.87 $1,387.55 090 11303 $417.67 $203.63 000 11900 $148.69 $85.24 000 11305 $266.14 $107.02 000 11901 $187.53 $132.59 000 11306 $326.75 $142.06 000 11920 $461.24 $311.60 000 11307 $384.52 $181.84 000 11921 $537.95 $369.37 000 11308 $404.41 $200.79 000 11922 $166.69 $81.45 ZZZ 11310 $304.97 $128.81 000 11950 $197.94 $139.22 000 11311 $300.23 $179.95 000 11951 $262.35 $196.05 000 11312 $429.98 $213.10 000 11952 $352.32 $263.29 000 11313 $499.12 $274.66 000 11954 $428.09 $314.44 000 11400 $331.48 $217.83 010 11960 $2,286.32 $2,286.32 090 11401 $398.73 $281.29 010 11970 $1,480.61 $1,480.61 090 11402 $444.19 $309.70 010 11971 $1,131.00 $773.00 090 11403 $513.33 $399.68 010 11976 $383.58 $254.77 000 11404 $584.36 $441.35 010 11980 $251.93 $152.48 000 11406 $844.81 $671.49 010 11981 $378.84 $225.41 N/A 11420 $327.70 $219.73 010 11982 $429.98 $273.71 N/A 11421 $419.57 $298.34 010 11983 $597.62 $472.60 N/A 11422 $469.76 $367.47 010 12001 $238.67 $120.28 000 11423 $541.74 $426.19 010 12002 $290.76 $158.17 000 11424 $626.98 $488.70 010 12004 $342.85 $197.94 000 11426 $900.69 $750.10 010 12005 $432.82 $257.61 000 11440 $360.85 $279.39 010 12006 $513.33 $317.28 000 11441 $449.87 $356.11 010 12007 $600.46 $400.62 000 11442 $505.75 $395.89 010 12011 $292.65 $149.64 000 11443 $603.30 $483.97 010 12013 $305.91 $157.22 000 11444 $757.68 $617.51 010 12014 $358.00 $202.68 000 Temporary Appendix B for Administrative Order No. 16-059 Physician Fee Schedule CPT only copyright 2015/2016 American Medical Association. All rights reserved. *ZZZ means the code is related to another service that is always included in the global period of the other service Page 1 of 84

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Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days10021 $331.48 $189.42 N/A 11446 $1,055.07 $887.43 01010022 $377.89 $178.05 N/A 11450 $908.83 $607.84 09010030 $2,097.83 $462.18 N/A 11451 $1,162.86 $785.58 09010035 $1,437.70 $236.77 000 11462 $887.87 $580.17 09010036 $1,249.22 $119.33 ZZZ 11463 $1,177.11 $788.93 09010040 $273.71 $238.67 010 11470 $987.64 $679.94 09010060 $314.44 $262.35 010 11471 $1,223.23 $845.11 09010061 $554.05 $484.92 010 11600 $514.28 $322.96 01010080 $480.18 $278.45 010 11601 $611.83 $404.41 01010081 $719.80 $459.34 010 11602 $664.86 $444.19 01010120 $407.25 $279.39 010 11603 $761.47 $533.22 01010121 $739.69 $505.75 010 11604 $847.65 $587.20 01010140 $436.61 $320.12 010 11606 $1,217.02 $876.07 01010160 $351.37 $260.45 010 11620 $519.96 $327.70 01010180 $664.86 $486.81 010 11621 $616.56 $408.20 01011000 $146.80 $77.66 000 11622 $688.54 $467.87 01011001 $57.77 $38.83 ZZZ 11623 $809.77 $578.68 01011004 $1,590.18 $1,590.18 000 11624 $913.00 $655.39 01011005 $2,153.71 $2,153.71 000 11626 $1,104.32 $806.93 01011006 $1,929.24 $1,929.24 000 11640 $537.01 $340.01 01011008 $757.68 $757.68 ZZZ 11641 $638.35 $425.25 01011010 $1,327.83 $762.42 010 11642 $730.21 $502.91 01011011 $1,443.38 $818.29 000 11643 $861.86 $628.87 01011012 $1,937.77 $1,171.56 000 11644 $1,065.49 $780.41 01011042 $313.49 $167.64 000 11646 $1,396.03 $1,086.32 01011043 $614.67 $424.30 000 11719 $37.88 $20.84 00011044 $850.50 $632.66 000 11720 $86.19 $39.78 00011045 $109.86 $71.03 ZZZ 11721 $120.28 $67.24 00011046 $197.94 $153.43 ZZZ 11730 $266.14 $138.28 00011047 $336.22 $272.76 ZZZ 11732 $95.66 $54.93 ZZZ11055 $127.86 $43.57 000 11740 $133.54 $89.03 00011056 $156.27 $61.56 000 11750 $483.02 $378.84 01011057 $176.16 $80.50 000 11752 $871.33 $710.32 01011100 $277.50 $132.59 000 11755 $358.00 $211.20 00011101 $88.08 $68.19 ZZZ 11760 $524.69 $319.17 01011200 $235.83 $197.94 010 11762 $756.73 $501.02 01011201 $51.14 $45.46 ZZZ 11765 $448.93 $254.77 01011300 $260.45 $95.66 000 11770 $747.26 $503.86 01011301 $320.12 $145.85 000 11771 $1,369.95 $1,048.00 09011302 $377.89 $171.43 000 11772 $1,660.87 $1,387.55 09011303 $417.67 $203.63 000 11900 $148.69 $85.24 00011305 $266.14 $107.02 000 11901 $187.53 $132.59 00011306 $326.75 $142.06 000 11920 $461.24 $311.60 00011307 $384.52 $181.84 000 11921 $537.95 $369.37 00011308 $404.41 $200.79 000 11922 $166.69 $81.45 ZZZ11310 $304.97 $128.81 000 11950 $197.94 $139.22 00011311 $300.23 $179.95 000 11951 $262.35 $196.05 00011312 $429.98 $213.10 000 11952 $352.32 $263.29 00011313 $499.12 $274.66 000 11954 $428.09 $314.44 00011400 $331.48 $217.83 010 11960 $2,286.32 $2,286.32 09011401 $398.73 $281.29 010 11970 $1,480.61 $1,480.61 09011402 $444.19 $309.70 010 11971 $1,131.00 $773.00 09011403 $513.33 $399.68 010 11976 $383.58 $254.77 00011404 $584.36 $441.35 010 11980 $251.93 $152.48 00011406 $844.81 $671.49 010 11981 $378.84 $225.41 N/A11420 $327.70 $219.73 010 11982 $429.98 $273.71 N/A11421 $419.57 $298.34 010 11983 $597.62 $472.60 N/A11422 $469.76 $367.47 010 12001 $238.67 $120.28 00011423 $541.74 $426.19 010 12002 $290.76 $158.17 00011424 $626.98 $488.70 010 12004 $342.85 $197.94 00011426 $900.69 $750.10 010 12005 $432.82 $257.61 00011440 $360.85 $279.39 010 12006 $513.33 $317.28 00011441 $449.87 $356.11 010 12007 $600.46 $400.62 00011442 $505.75 $395.89 010 12011 $292.65 $149.64 00011443 $603.30 $483.97 010 12013 $305.91 $157.22 00011444 $757.68 $617.51 010 12014 $358.00 $202.68 000

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 1 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

12015 $433.77 $255.72 000 15136 $259.51 $242.46 ZZZ12016 $550.27 $348.53 000 15150 $1,676.80 $1,537.63 09012017 $417.67 $417.67 000 15151 $333.38 $307.81 ZZZ12018 $473.55 $473.55 000 15152 $408.20 $383.58 ZZZ12020 $781.36 $530.38 010 15155 $1,731.30 $1,603.86 09012021 $449.87 $384.52 010 15156 $430.93 $409.15 ZZZ12031 $636.45 $417.67 010 15157 $473.55 $442.30 ZZZ12032 $814.51 $531.32 010 15200 $1,996.23 $1,631.53 09012034 $838.18 $563.52 010 15201 $401.57 $216.89 ZZZ12035 $1,030.44 $655.39 010 15220 $1,849.51 $1,491.51 09012036 $1,138.41 $764.31 010 15221 $370.32 $196.05 ZZZ12037 $1,291.84 $895.96 010 15240 $2,242.72 $1,945.09 09012041 $636.45 $410.09 010 15241 $501.96 $306.86 ZZZ12042 $776.62 $546.48 010 15260 $2,425.49 $2,081.75 09012044 $966.04 $585.31 010 15261 $584.36 $386.42 ZZZ12045 $1,084.43 $735.90 010 15271 $378.84 $231.09 00012046 $1,288.06 $847.65 010 15272 $72.93 $47.35 ZZZ12047 $1,400.76 $944.26 010 15273 $800.30 $551.21 00012051 $695.17 $468.81 010 15274 $193.21 $125.96 ZZZ12052 $791.78 $555.95 010 15275 $400.62 $260.45 00012053 $929.11 $593.83 010 15276 $93.76 $69.14 ZZZ12054 $970.78 $608.04 010 15277 $871.33 $615.61 00012055 $1,261.54 $835.34 010 15278 $231.09 $157.22 ZZZ12056 $1,486.00 $1,040.86 010 15570 $2,204.15 $1,790.82 09012057 $1,523.88 $1,115.68 010 15572 $2,137.92 $1,814.30 09013100 $900.69 $563.52 010 15574 $2,197.45 $1,862.92 09013101 $1,065.49 $693.28 010 15576 $1,936.70 $1,627.33 09013102 $329.59 $204.57 ZZZ 15600 $776.36 $501.36 09013120 $943.31 $645.92 010 15610 $854.33 $585.20 09013121 $1,149.78 $732.11 010 15620 $1,057.22 $792.29 09013122 $359.90 $234.88 ZZZ 15630 $1,099.98 $838.40 09013131 $1,038.02 $683.81 010 15650 $1,206.46 $923.92 09013132 $1,283.32 $861.86 010 15731 $2,717.25 $2,448.13 09013133 $482.07 $360.85 ZZZ 15732 $3,097.05 $2,709.71 09013151 $1,138.41 $787.04 010 15734 $3,631.11 $3,206.04 09013152 $1,367.61 $955.62 010 15736 $3,196.82 $2,776.78 09013153 $524.69 $389.26 ZZZ 15738 $3,388.81 $2,994.76 09013160 $1,950.96 $1,950.96 090 15740 $2,448.97 $2,073.36 09014000 $1,492.35 $1,218.20 090 15750 $2,232.66 $2,232.66 09014001 $1,918.26 $1,586.25 090 15756 $5,659.20 $5,659.20 09014020 $1,669.25 $1,376.65 090 15757 $5,577.04 $5,577.04 09014021 $2,087.62 $1,742.20 090 15758 $5,585.42 $5,585.42 09014040 $1,826.04 $1,532.60 090 15760 $2,053.24 $1,722.07 09014041 $2,259.49 $1,885.56 090 15770 $1,630.69 $1,630.69 09014060 $1,862.09 $1,631.53 090 15775 $810.72 $608.99 00014061 $2,430.52 $2,018.03 090 15776 $1,352.46 $983.09 00014301 $2,588.98 $2,143.79 090 15777 $589.10 $589.10 ZZZ14302 $608.04 $608.04 ZZZ 15780 $2,003.78 $1,520.86 09014350 $1,677.64 $1,677.64 090 15781 $1,334.73 $1,051.35 09015002 $943.31 $623.19 000 15782 $1,535.95 $1,086.57 09015003 $205.52 $125.02 ZZZ 15783 $1,101.66 $861.04 09015004 $1,087.27 $741.58 000 15786 $657.29 $368.42 01015005 $339.06 $250.03 ZZZ 15787 $131.65 $47.35 ZZZ15040 $692.33 $350.43 000 15788 $1,099.14 $593.59 09015050 $1,344.79 $1,070.64 090 15789 $1,313.77 $998.53 09015100 $2,065.82 $1,738.00 090 15792 $1,056.38 $632.99 09015101 $504.80 $305.91 ZZZ 15793 $1,176.28 $884.51 09015110 $1,921.61 $1,678.48 090 15819 $1,782.44 $1,782.44 09015111 $315.38 $285.08 ZZZ 15820 $1,342.28 $1,211.49 09015115 $1,976.95 $1,729.62 090 15821 $1,448.76 $1,302.04 09015116 $416.72 $376.95 ZZZ 15822 $1,062.25 $934.82 09015120 $2,049.05 $1,696.08 090 15823 $1,446.24 $1,297.84 09015121 $565.42 $365.58 ZZZ 15824 80% of billed 80% of billed 00015130 $1,613.92 $1,364.08 090 15825 80% of billed 80% of billed 00015131 $272.76 $250.98 ZZZ 15826 80% of billed 80% of billed 00015135 $2,024.74 $1,779.92 090 15828 80% of billed 80% of billed 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 2 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

15829 80% of billed 80% of billed 000 17272 $500.07 $349.48 01015830 $2,849.72 $2,849.72 090 17273 $557.84 $393.99 01015832 $2,232.66 $2,232.66 090 17274 $659.18 $481.13 01015833 $2,095.16 $2,095.16 090 17276 $764.31 $577.73 01015834 $2,161.40 $2,161.40 090 17280 $377.89 $247.19 01015835 $2,257.81 $2,257.81 090 17281 $477.34 $340.01 01015836 $1,849.51 $1,849.51 090 17282 $549.32 $393.99 01015837 $1,939.22 $1,624.82 090 17283 $657.29 $490.60 01015838 $1,384.20 $1,384.20 090 17284 $752.00 $572.05 01015839 $2,125.34 $1,786.63 090 17286 $965.09 $767.15 01015840 $2,445.61 $2,445.61 090 17311 $1,780.55 $1,036.13 00015841 $3,923.71 $3,923.71 090 17312 $1,043.70 $551.21 ZZZ15842 $6,417.11 $6,417.11 090 17313 $1,664.05 $928.16 00015845 $2,419.62 $2,419.62 090 17314 $1,002.03 $510.49 ZZZ15847 80% of billed 80% of billed N/A 17315 $214.99 $144.91 ZZZ15850 $238.67 $112.70 N/A 17340 $138.28 $132.59 01015851 $265.19 $124.07 000 17360 $347.59 $268.03 01015852 $127.86 $127.86 000 17380 80% of billed 80% of billed 00015860 $304.02 $304.02 000 17999 80% of billed 80% of billed N/A15876 80% of billed 80% of billed 000 19000 $304.02 $119.33 00015877 80% of billed 80% of billed 000 19001 $72.93 $59.67 ZZZ15878 80% of billed 80% of billed 000 19020 $1,127.65 $736.12 09015879 80% of billed 80% of billed 000 19030 $442.30 $212.15 00015920 $1,465.52 $1,465.52 090 19081 $1,862.95 $463.13 00015922 $1,898.98 $1,898.98 090 19082 $1,539.04 $232.04 ZZZ15931 $1,659.19 $1,659.19 090 19083 $1,802.33 $435.67 00015933 $2,054.92 $2,054.92 090 19084 $1,480.32 $216.89 ZZZ15934 $2,246.07 $2,246.07 090 19085 $2,766.48 $510.49 00015935 $2,646.83 $2,646.83 090 19086 $2,190.64 $252.88 ZZZ15936 $2,157.20 $2,157.20 090 19100 $405.36 $191.31 00015937 $2,507.65 $2,507.65 090 19101 $921.53 $603.30 01015940 $1,697.76 $1,697.76 090 19105 $5,738.48 $530.38 00015941 $2,177.32 $2,177.32 090 19110 $1,161.18 $825.82 09015944 $2,144.63 $2,144.63 090 19112 $1,088.24 $748.69 09015945 $2,362.61 $2,362.61 090 19120 $1,185.50 $999.37 09015946 $3,978.21 $3,978.21 090 19125 $1,314.61 $1,110.04 09015950 $1,427.80 $1,427.80 090 19126 $445.14 $445.14 ZZZ15951 $2,135.40 $2,135.40 090 19260 $2,920.99 $2,920.99 09015952 $2,179.00 $2,179.00 090 19271 $3,956.41 $3,956.41 09015953 $2,417.95 $2,417.95 090 19272 $4,319.44 $4,319.44 09015956 $2,790.20 $2,790.20 090 19281 $642.13 $276.55 00015958 $2,844.69 $2,844.69 090 19282 $449.87 $139.22 ZZZ15999 80% of billed 80% of billed N/A 19283 $723.58 $279.39 00016000 $184.68 $125.02 000 19284 $545.53 $141.12 ZZZ16020 $218.78 $146.80 000 19285 $1,381.82 $236.77 00016025 $397.78 $303.07 000 19286 $1,213.24 $118.39 ZZZ16030 $501.02 $365.58 000 19287 $2,309.98 $356.11 00016035 $531.32 $531.32 000 19288 $1,862.00 $177.11 ZZZ16036 $221.62 $221.62 ZZZ 19296 $10,636.88 $578.68 00017000 $179.00 $143.96 010 19297 $260.45 $260.45 ZZZ17003 $15.15 $6.63 ZZZ 19298 $2,793.00 $890.27 00017004 $403.46 $270.87 010 19300 $1,255.92 $997.70 09017106 $814.09 $663.17 090 19301 $1,581.22 $1,581.22 09017107 $1,035.42 $835.88 090 19302 $2,174.81 $2,174.81 09017108 $1,526.73 $1,268.50 090 19303 $2,445.61 $2,445.61 09017110 $297.39 $189.42 010 19304 $1,385.88 $1,385.88 09017111 $352.32 $232.99 010 19305 $2,729.83 $2,729.83 09017250 $213.10 $100.39 000 19306 $2,902.54 $2,902.54 09017260 $254.77 $191.31 010 19307 $2,895.00 $2,895.00 09017261 $385.47 $249.09 010 19316 $1,865.44 $1,865.44 09017262 $469.76 $317.28 010 19318 $2,680.36 $2,680.36 09017263 $513.33 $352.32 010 19324 $1,182.14 $1,182.14 09017264 $551.21 $376.00 010 19325 $1,556.07 $1,556.07 09017266 $624.14 $440.40 010 19328 $1,205.62 $1,205.62 09017270 $403.46 $271.82 010 19330 $1,542.66 $1,542.66 09017271 $437.56 $301.18 010 19340 $2,443.10 $2,443.10 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 3 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

19342 $2,245.24 $2,245.24 090 20808 $9,790.00 $9,790.00 09019350 $1,993.72 $1,638.23 090 20816 $5,033.75 $5,033.75 09019355 $1,688.54 $1,383.36 090 20822 $4,376.45 $4,376.45 09019357 $3,662.13 $3,662.13 090 20824 $4,981.77 $4,981.77 09019361 $3,830.65 $3,830.65 090 20827 $4,443.52 $4,443.52 09019364 $6,718.10 $6,718.10 090 20838 $5,874.67 $5,874.67 09019366 $3,414.80 $3,414.80 090 20900 $1,130.84 $518.06 00019367 $4,355.49 $4,355.49 090 20902 $781.36 $781.36 00019368 $5,370.79 $5,370.79 090 20910 $990.99 $990.99 09019369 $4,970.87 $4,970.87 090 20912 $1,164.54 $1,164.54 09019370 $1,670.09 $1,670.09 090 20920 $948.23 $948.23 09019371 $1,908.20 $1,908.20 090 20922 $1,507.44 $1,242.51 09019380 $1,881.37 $1,881.37 090 20924 $1,216.52 $1,216.52 09019396 $754.84 $385.47 000 20926 $1,026.20 $1,026.20 09019499 80% of billed 80% of billed N/A 20930 80% of billed 80% of billed N/A20005 $837.24 $636.45 010 20931 $312.54 $312.54 ZZZ20100 $1,665.95 $1,665.95 010 20936 80% of billed 80% of billed N/A20101 $1,211.34 $572.05 010 20937 $453.66 $453.66 ZZZ20102 $1,329.73 $699.91 010 20938 $501.96 $501.96 ZZZ20103 $1,584.50 $954.68 010 20950 $683.81 $250.03 00020150 $2,191.58 $2,191.58 090 20955 $6,102.71 $6,102.71 09020200 $559.74 $262.35 000 20956 $6,458.19 $6,458.19 09020205 $782.30 $427.14 000 20957 $5,958.51 $5,958.51 09020206 $634.56 $161.95 000 20962 $5,133.52 $5,133.52 09020220 $452.71 $198.89 000 20969 $6,734.87 $6,734.87 09020225 $1,413.07 $297.39 000 20970 $7,119.69 $7,119.69 09020240 $424.30 $424.30 010 20972 $5,700.28 $5,700.28 09020245 $1,409.28 $1,409.28 010 20973 $6,393.64 $6,393.64 09020250 $1,073.06 $1,073.06 010 20974 $207.41 $137.33 00020251 $1,158.30 $1,158.30 010 20975 $482.07 $482.07 00020500 $280.34 $229.20 010 20979 $141.12 $88.08 00020501 $317.28 $104.18 000 20982 $8,128.96 $1,044.65 00020520 $549.32 $398.73 010 20983 $19,655.17 $1,118.53 00020525 $1,304.16 $680.02 010 20985 $404.41 $404.41 ZZZ20526 $209.31 $157.22 000 20999 80% of billed 80% of billed N/A20527 $229.20 $182.79 000 21010 $1,799.21 $1,799.21 09020550 $159.11 $113.65 000 21011 $838.40 $627.96 09020551 $163.85 $116.49 000 21012 $819.96 $819.96 09020552 $148.69 $103.23 000 21013 $1,252.57 $974.22 09020553 $171.43 $117.44 000 21014 $1,264.31 $1,264.31 09020555 $893.12 $893.12 000 21015 $1,725.43 $1,725.43 09020600 $128.81 $96.60 000 21016 $2,490.05 $2,490.05 09020604 $195.10 $125.02 000 21025 $2,177.32 $1,842.80 09020605 $135.44 $101.34 000 21026 $1,507.44 $1,221.55 09020606 $215.94 $143.96 000 21029 $1,865.44 $1,556.91 09020610 $162.90 $125.96 000 21030 $1,265.98 $1,024.52 09020611 $247.19 $167.64 000 21031 $962.48 $724.38 09020612 $163.85 $114.60 000 21032 $978.41 $716.83 09020615 $661.08 $445.14 010 21034 $3,196.82 $2,822.05 09020650 $564.47 $429.04 010 21040 $1,276.04 $1,026.20 09020660 $676.23 $676.23 000 21044 $2,135.40 $2,135.40 09020661 $1,237.48 $1,237.48 090 21045 $2,997.28 $2,997.28 09020662 $1,038.78 $1,038.78 090 21046 $2,741.57 $2,741.57 09020663 $1,135.19 $1,135.19 090 21047 $3,233.71 $3,233.71 09020664 $2,142.95 $2,142.95 090 21048 $2,810.32 $2,810.32 09020665 $284.13 $245.30 010 21049 $2,947.81 $2,947.81 09020670 $1,031.39 $402.52 010 21050 $2,050.73 $2,050.73 09020680 $1,488.16 $1,025.36 090 21060 $1,941.73 $1,941.73 09020690 $1,442.05 $1,442.05 090 21070 $1,482.29 $1,482.29 09020692 $2,708.03 $2,708.03 090 21073 $941.52 $619.58 09020693 $1,073.15 $1,073.15 090 21076 $2,769.32 $2,327.02 01020694 $1,017.82 $813.25 090 21077 $6,146.31 $5,171.25 09020696 $2,911.76 $2,911.76 090 21079 $4,138.34 $3,444.15 09020697 $5,367.22 $5,367.22 000 21080 $4,643.90 $3,833.16 09020802 $5,815.14 $5,815.14 090 21081 $4,288.42 $3,526.31 09020805 $8,036.90 $8,036.90 090 21082 $4,052.83 $3,308.33 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 4 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

21083 $3,859.16 $3,067.71 090 21263 $4,716.84 $4,716.84 09021084 $4,439.33 $3,561.52 090 21267 $3,791.24 $3,791.24 09021085 $2,098.77 $1,576.92 010 21268 $4,214.64 $4,214.64 09021086 $4,571.80 $3,832.33 090 21270 $2,321.53 $1,744.71 09021087 $4,564.25 $3,823.94 090 21275 $2,042.34 $2,042.34 09021088 80% of billed 80% of billed 090 21280 $1,364.92 $1,364.92 09021089 80% of billed 80% of billed N/A 21282 $917.21 $917.21 09021100 $2,496.76 $1,220.71 090 21295 $433.45 $433.45 09021110 $1,963.53 $1,648.29 090 21296 $1,047.16 $1,047.16 09021116 $393.99 $120.28 000 21299 80% of billed 80% of billed N/A21120 $1,598.83 $1,268.50 090 21310 $355.16 $73.87 00021121 $1,981.14 $1,655.84 090 21315 $752.94 $414.83 01021122 $1,596.31 $1,596.31 090 21320 $698.96 $370.32 01021123 $2,299.73 $2,299.73 090 21325 $1,150.28 $1,150.28 09021125 $7,367.02 $1,914.07 090 21330 $1,375.81 $1,375.81 09021127 $10,733.20 $2,191.58 090 21335 $1,763.99 $1,763.99 09021137 $1,847.00 $1,847.00 090 21336 $1,562.78 $1,562.78 09021138 $2,159.72 $2,159.72 090 21337 $976.74 $715.16 09021139 $2,304.76 $2,304.76 090 21338 $1,757.29 $1,757.29 09021141 $3,281.50 $3,281.50 090 21339 $1,865.44 $1,865.44 09021142 $3,444.99 $3,444.99 090 21340 $1,830.23 $1,830.23 09021143 $3,461.75 $3,461.75 090 21343 $2,943.62 $2,943.62 09021145 $3,854.96 $3,854.96 090 21344 $3,383.78 $3,383.78 09021146 $3,761.06 $3,761.06 090 21345 $1,966.89 $1,591.28 09021147 $4,275.00 $4,275.00 090 21346 $2,202.48 $2,202.48 09021150 $4,083.85 $4,083.85 090 21347 $2,781.81 $2,781.81 09021151 $4,956.62 $4,956.62 090 21348 $2,952.01 $2,952.01 09021154 $5,090.76 $5,090.76 090 21355 $1,168.72 $877.01 01021155 $5,250.90 $5,250.90 090 21356 $1,375.19 $1,041.81 01021159 $6,074.21 $6,074.21 090 21360 $1,310.42 $1,310.42 09021160 $7,792.09 $7,792.09 090 21365 $2,712.22 $2,712.22 09021172 $4,392.38 $4,392.38 090 21366 $2,801.09 $2,801.09 09021175 $5,261.80 $5,261.80 090 21385 $1,652.49 $1,652.49 09021179 $3,517.93 $3,517.93 090 21386 $1,696.08 $1,696.08 09021180 $3,742.62 $3,742.62 090 21387 $1,726.27 $1,726.27 09021181 $1,805.91 $1,805.91 090 21390 $1,927.48 $1,927.48 09021182 $4,708.45 $4,708.45 090 21395 $2,448.13 $2,448.13 09021183 $5,660.88 $5,660.88 090 21400 $463.64 $377.28 09021184 $5,178.80 $5,178.80 090 21401 $1,066.44 $693.36 09021188 $3,927.07 $3,927.07 090 21406 $1,258.44 $1,258.44 09021193 $2,969.61 $2,969.61 090 21407 $1,568.65 $1,568.65 09021194 $3,498.64 $3,498.64 090 21408 $2,139.60 $2,139.60 09021195 $3,263.05 $3,263.05 090 21421 $1,838.61 $1,551.88 09021196 $3,634.46 $3,634.46 090 21422 $1,644.10 $1,644.10 09021198 $2,868.17 $2,868.17 090 21423 $2,003.78 $2,003.78 09021199 $2,620.00 $2,620.00 090 21431 $1,805.08 $1,805.08 09021206 $2,881.58 $2,881.58 090 21432 $1,591.28 $1,591.28 09021208 $4,598.62 $2,045.70 090 21433 $4,239.79 $4,239.79 09021209 $1,965.21 $1,500.74 090 21435 $3,061.84 $3,061.84 09021210 $5,567.81 $2,124.51 090 21436 $5,088.25 $5,088.25 09021215 $9,901.50 $2,210.02 090 21440 $1,408.51 $1,144.42 09021230 $1,727.94 $1,727.94 090 21445 $1,883.05 $1,534.27 09021235 $1,758.96 $1,380.01 090 21450 $1,494.87 $1,202.27 09021240 $2,747.44 $2,747.44 090 21451 $1,862.09 $1,563.62 09021242 $2,518.55 $2,518.55 090 21452 $1,448.76 $853.49 09021243 $4,166.01 $4,166.01 090 21453 $2,235.17 $1,918.26 09021244 $2,614.13 $2,614.13 090 21454 $1,456.30 $1,456.30 09021245 $2,687.07 $2,153.01 090 21461 $5,230.78 $2,303.92 09021246 $2,120.31 $2,120.31 090 21462 $5,542.66 $2,562.99 09021247 $3,781.18 $3,781.18 090 21465 $2,351.71 $2,351.71 09021248 $2,713.06 $2,223.44 090 21470 $2,947.81 $2,947.81 09021249 $3,714.95 $3,159.09 090 21480 $268.98 $87.13 00021255 $3,393.00 $3,393.00 090 21485 $1,712.85 $1,433.66 09021256 $2,915.12 $2,915.12 090 21490 $2,239.37 $2,239.37 09021260 $3,399.71 $3,399.71 090 21495 $1,712.01 $1,712.01 09021261 $5,105.86 $5,105.86 090 21497 $1,801.72 $1,498.22 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 5 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

21499 80% of billed 80% of billed N/A 22318 $4,016.77 $4,016.77 09021501 $1,091.60 $778.04 090 22319 $4,488.79 $4,488.79 09021502 $1,289.46 $1,289.46 090 22325 $3,476.84 $3,476.84 09021510 $1,090.76 $1,090.76 090 22326 $3,633.63 $3,633.63 09021550 $712.22 $431.88 010 22327 $3,666.32 $3,666.32 09021552 $1,082.37 $1,082.37 090 22328 $759.57 $759.57 ZZZ21554 $1,775.73 $1,775.73 090 22505 $350.43 $350.43 01021555 $998.53 $741.15 090 22510 $4,768.65 $1,240.70 01021556 $1,286.11 $1,286.11 090 22511 $4,721.29 $1,164.93 01021557 $2,329.91 $2,329.91 090 22512 $2,646.20 $576.78 ZZZ21558 $3,278.98 $3,278.98 090 22513 $19,837.01 $1,482.21 01021600 $1,349.82 $1,349.82 090 22514 $19,815.23 $1,381.82 01021610 $2,924.34 $2,924.34 090 22515 $12,006.39 $626.03 ZZZ21615 $1,494.87 $1,494.87 090 22526 $6,430.81 $958.47 01021616 $1,826.87 $1,826.87 090 22527 $5,335.96 $435.67 ZZZ21620 $1,222.39 $1,222.39 090 22532 $4,318.60 $4,318.60 09021627 $1,304.55 $1,304.55 090 22533 $4,010.07 $4,010.07 09021630 $2,932.72 $2,932.72 090 22534 $972.67 $972.67 ZZZ21632 $2,948.65 $2,948.65 090 22548 $4,871.94 $4,871.94 09021685 $2,435.55 $2,435.55 090 22551 $4,181.10 $4,181.10 09021700 $905.47 $905.47 090 22552 $1,074.96 $1,074.96 ZZZ21705 $1,342.28 $1,342.28 090 22554 $3,040.04 $3,040.04 09021720 $1,099.98 $1,099.98 090 22556 $4,068.76 $4,068.76 09021725 $1,286.11 $1,286.11 090 22558 $3,754.36 $3,754.36 09021740 $2,492.56 $2,492.56 090 22585 $894.06 $894.06 ZZZ21742 80% of billed 80% of billed 090 22586 $4,408.31 $4,408.31 09021743 80% of billed 80% of billed 090 22590 $3,868.38 $3,868.38 09021750 $1,660.87 $1,660.87 090 22595 $3,688.96 $3,688.96 09021811 $1,681.10 $1,681.10 000 22600 $3,140.65 $3,140.65 09021812 $2,016.38 $2,016.38 000 22610 $3,071.06 $3,071.06 09021813 $2,636.73 $2,636.73 000 22612 $3,866.70 $3,866.70 09021820 $336.20 $344.58 090 22614 $1,060.75 $1,060.75 ZZZ21825 $1,313.77 $1,313.77 090 22630 $3,815.56 $3,815.56 09021899 80% of billed 80% of billed N/A 22632 $865.65 $865.65 ZZZ21920 $697.07 $438.51 010 22633 $4,501.37 $4,501.37 09021925 $1,062.25 $849.30 090 22634 $1,334.46 $1,334.46 ZZZ21930 $1,137.71 $884.51 090 22800 $3,275.63 $3,275.63 09021931 $1,139.39 $1,139.39 090 22802 $5,102.50 $5,102.50 09021932 $1,605.54 $1,605.54 090 22804 $5,909.04 $5,909.04 09021933 $1,788.31 $1,788.31 090 22808 $4,478.73 $4,478.73 09021935 $2,494.24 $2,494.24 090 22810 $4,937.34 $4,937.34 09021936 $3,433.25 $3,433.25 090 22812 $5,924.97 $5,924.97 09022010 $2,324.88 $2,324.88 090 22818 $5,299.53 $5,299.53 09022015 $2,275.42 $2,275.42 090 22819 $6,827.93 $6,827.93 09022100 $2,133.73 $2,133.73 090 22830 $1,969.40 $1,969.40 09022101 $2,080.07 $2,080.07 090 22840 $2,051.42 $2,051.42 ZZZ22102 $1,909.04 $1,909.04 090 22841 80% of billed 80% of billed N/A22103 $382.63 $382.63 ZZZ 22842 $2,060.89 $2,060.89 ZZZ22110 $2,544.54 $2,544.54 090 22843 $2,223.79 $2,223.79 ZZZ22112 $2,407.88 $2,407.88 090 22844 $2,691.66 $2,691.66 ZZZ22114 $2,417.95 $2,417.95 090 22845 $1,968.07 $1,968.07 ZZZ22116 $382.63 $382.63 ZZZ 22846 $2,041.00 $2,041.00 ZZZ22206 $5,943.42 $5,943.42 090 22847 $2,242.73 $2,242.73 ZZZ22207 $5,824.36 $5,824.36 090 22848 $979.30 $979.30 ZZZ22208 $1,565.56 $1,565.56 ZZZ 22849 $3,159.09 $3,159.09 09022210 $4,347.10 $4,347.10 090 22850 $1,756.45 $1,756.45 09022212 $3,594.22 $3,594.22 090 22851 $1,095.79 $1,095.79 ZZZ22214 $3,597.57 $3,597.57 090 22852 $1,684.35 $1,684.35 09022216 $984.04 $984.04 ZZZ 22853 $723.58 $723.58 ZZZ22220 $3,887.66 $3,887.66 090 22854 $936.68 $936.68 ZZZ22222 $3,792.08 $3,792.08 090 22855 $2,684.56 $2,684.56 09022224 $3,832.33 $3,832.33 090 22856 $3,951.38 $3,951.38 09022226 $978.35 $978.35 ZZZ 22857 $4,807.39 $4,807.39 09022305 $460.28 $418.36 090 22858 $1,397.92 $1,397.92 ZZZ22310 $743.66 $685.81 090 22859 $936.68 $936.68 ZZZ22315 $2,137.08 $1,872.99 090 22861 $4,892.90 $4,892.90 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 6 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

22862 $4,867.75 $4,867.75 090 23412 $2,056.60 $2,056.60 09022864 $5,071.48 $5,071.48 090 23415 $1,686.86 $1,686.86 09022865 $5,000.22 $5,000.22 090 23420 $2,340.81 $2,340.81 09022867 $2,393.63 $2,393.63 090 23430 $1,797.53 $1,797.53 09022868 $676.23 $676.23 ZZZ 23440 $1,821.84 $1,821.84 09022869 $1,316.29 $1,316.29 090 23450 $2,286.32 $2,286.32 09022870 $393.99 $393.99 ZZZ 23455 $2,417.95 $2,417.95 09022899 80% of billed 80% of billed N/A 23460 $2,645.99 $2,645.99 09022900 $1,368.27 $1,368.27 090 23462 $2,566.34 $2,566.34 09022901 $1,611.40 $1,611.40 090 23465 $2,682.88 $2,682.88 09022902 $1,055.55 $801.51 090 23466 $2,697.97 $2,697.97 09022903 $1,063.93 $1,063.93 090 23470 $2,912.60 $2,912.60 09022904 $2,548.74 $2,548.74 090 23472 $3,523.80 $3,523.80 09022905 $3,231.19 $3,231.19 090 23473 $3,913.65 $3,913.65 09022999 80% of billed 80% of billed N/A 23474 $4,229.73 $4,229.73 09023000 $1,405.16 $894.57 090 23480 $1,990.36 $1,990.36 09023020 $1,655.00 $1,655.00 090 23485 $2,308.95 $2,308.95 09023030 $1,200.92 $699.91 010 23490 $2,038.99 $2,038.99 09023031 $1,156.41 $598.57 010 23491 $2,456.51 $2,456.51 09023035 $1,635.72 $1,635.72 090 23500 $527.35 $535.74 09023040 $1,740.52 $1,740.52 090 23505 $850.98 $804.03 09023044 $1,371.62 $1,371.62 090 23515 $1,739.68 $1,739.68 09023065 $586.25 $456.50 010 23520 $537.41 $545.80 09023066 $1,333.06 $859.36 090 23525 $904.63 $836.72 09023071 $1,016.14 $1,016.14 090 23530 $1,328.86 $1,328.86 09023073 $1,679.32 $1,679.32 090 23532 $1,504.09 $1,504.09 09023075 $1,122.62 $788.10 090 23540 $544.12 $553.34 09023076 $1,307.90 $1,307.90 090 23545 $812.41 $738.63 09023077 $2,785.16 $2,785.16 090 23550 $1,354.85 $1,354.85 09023078 $3,491.10 $3,491.10 090 23552 $1,580.38 $1,580.38 09023100 $1,204.78 $1,204.78 090 23570 $557.54 $575.14 09023101 $1,097.47 $1,097.47 090 23575 $959.97 $900.44 09023105 $1,536.79 $1,536.79 090 23585 $2,373.51 $2,373.51 09023106 $1,189.69 $1,189.69 090 23600 $785.58 $741.15 09023107 $1,591.28 $1,591.28 090 23605 $1,119.26 $1,027.88 09023120 $1,406.00 $1,406.00 090 23615 $2,140.44 $2,140.44 09023125 $1,717.88 $1,717.88 090 23616 $3,007.34 $3,007.34 09023130 $1,475.58 $1,475.58 090 23620 $646.41 $616.22 09023140 $1,286.94 $1,286.94 090 23625 $914.69 $852.65 09023145 $1,683.51 $1,683.51 090 23630 $1,890.59 $1,890.59 09023146 $1,499.90 $1,499.90 090 23650 $747.01 $685.81 09023150 $1,582.06 $1,582.06 090 23655 $970.03 $970.03 09023155 $1,922.45 $1,922.45 090 23660 $1,401.80 $1,401.80 09023156 $1,635.72 $1,635.72 090 23665 $1,025.36 $956.61 09023170 $1,348.15 $1,348.15 090 23670 $2,116.96 $2,116.96 09023172 $1,371.62 $1,371.62 090 23675 $1,328.86 $1,212.33 09023174 $1,815.97 $1,815.97 090 23680 $2,246.07 $2,246.07 09023180 $1,605.54 $1,605.54 090 23700 $536.06 $536.06 01023182 $1,561.94 $1,561.94 090 23800 $2,489.21 $2,489.21 09023184 $1,776.57 $1,776.57 090 23802 $3,074.41 $3,074.41 09023190 $1,369.95 $1,369.95 090 23900 $3,376.24 $3,376.24 09023195 $1,824.36 $1,824.36 090 23920 $2,728.15 $2,728.15 09023200 $3,615.18 $3,615.18 090 23921 $1,132.68 $1,132.68 09023210 $4,311.89 $4,311.89 090 23929 80% of billed 80% of billed N/A23220 $4,708.45 $4,708.45 090 23930 $956.57 $588.15 01023330 $643.08 $409.15 010 23931 $777.57 $434.72 01023333 $1,097.47 $1,097.47 090 23935 $1,224.06 $1,224.06 09023334 $2,614.97 $2,614.97 090 24000 $1,152.80 $1,152.80 09023335 $3,111.30 $3,111.30 090 24006 $1,710.34 $1,710.34 09023350 $350.43 $139.22 000 24065 $693.28 $457.45 01023395 $3,105.43 $3,105.43 090 24066 $1,498.22 $1,003.56 09023397 $2,767.56 $2,767.56 090 24071 $982.60 $982.60 09023400 $2,356.74 $2,356.74 090 24073 $1,678.48 $1,678.48 09023405 $1,504.93 $1,504.93 090 24075 $1,178.79 $798.16 09023406 $1,852.03 $1,852.03 090 24076 $1,316.29 $1,316.29 09023410 $1,985.33 $1,985.33 090 24077 $2,517.72 $2,517.72 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 7 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

24079 $3,214.43 $3,214.43 090 24535 $1,483.13 $1,371.62 09024100 $1,011.11 $1,011.11 090 24538 $1,800.04 $1,800.04 09024101 $1,209.81 $1,209.81 090 24545 $2,247.75 $2,247.75 09024102 $1,491.51 $1,491.51 090 24546 $2,516.04 $2,516.04 09024105 $847.62 $847.62 090 24560 $770.49 $690.84 09024110 $1,403.48 $1,403.48 090 24565 $1,272.69 $1,171.24 09024115 $1,788.31 $1,788.31 090 24566 $1,736.33 $1,736.33 09024116 $2,090.97 $2,090.97 090 24575 $1,769.02 $1,769.02 09024120 $1,279.40 $1,279.40 090 24576 $817.44 $736.12 09024125 $1,483.13 $1,483.13 090 24577 $1,310.42 $1,202.27 09024126 $1,571.16 $1,571.16 090 24579 $2,023.06 $2,023.06 09024130 $1,232.45 $1,232.45 090 24582 $1,948.44 $1,948.44 09024134 $1,808.43 $1,808.43 090 24586 $2,625.03 $2,625.03 09024136 $1,532.60 $1,532.60 090 24587 $2,620.00 $2,620.00 09024138 $1,625.66 $1,625.66 090 24600 $872.77 $801.51 09024140 $1,695.24 $1,695.24 090 24605 $1,136.03 $1,136.03 09024145 $1,432.83 $1,432.83 090 24615 $1,725.43 $1,725.43 09024147 $1,504.93 $1,504.93 090 24620 $1,331.38 $1,331.38 09024149 $2,851.40 $2,851.40 090 24635 $1,628.17 $1,628.17 09024150 $3,787.05 $3,787.05 090 24640 $365.58 $250.98 01024152 $3,243.77 $3,243.77 090 24650 $627.96 $577.66 09024155 $2,045.70 $2,045.70 090 24655 $1,045.48 $954.10 09024160 $3,076.93 $3,076.93 090 24665 $1,574.52 $1,574.52 09024164 $1,771.54 $1,771.54 090 24666 $1,773.22 $1,773.22 09024200 $558.79 $379.79 010 24670 $700.06 $632.99 09024201 $1,308.74 $871.94 090 24675 $1,091.60 $997.70 09024220 $431.88 $188.47 000 24685 $1,581.22 $1,581.22 09024300 $1,007.76 $1,007.76 090 24800 $2,010.48 $2,010.48 09024301 $1,813.46 $1,813.46 090 24802 $2,374.35 $2,374.35 09024305 $1,398.45 $1,398.45 090 24900 $1,772.38 $1,772.38 09024310 $1,138.55 $1,138.55 090 24920 $1,771.54 $1,771.54 09024320 $1,893.95 $1,893.95 090 24925 $1,323.83 $1,323.83 09024330 $1,739.68 $1,739.68 090 24930 $1,862.92 $1,862.92 09024331 $1,906.52 $1,906.52 090 24931 $1,933.35 $1,933.35 09024332 $1,478.94 $1,478.94 090 24935 $2,688.75 $2,688.75 09024340 $1,474.75 $1,474.75 090 24940 80% of billed 80% of billed 09024341 $1,804.24 $1,804.24 090 24999 80% of billed 80% of billed N/A24342 $1,874.66 $1,874.66 090 25000 $814.92 $814.92 09024343 $1,706.14 $1,706.14 090 25001 $825.82 $825.82 09024344 $2,656.89 $2,656.89 090 25020 $1,395.10 $1,395.10 09024345 $1,700.28 $1,700.28 090 25023 $2,666.95 $2,666.95 09024346 $2,652.70 $2,652.70 090 25024 $1,877.18 $1,877.18 09024357 $1,032.91 $1,032.91 090 25025 $2,931.88 $2,931.88 09024358 $1,263.47 $1,263.47 090 25028 $1,265.15 $1,265.15 09024359 $1,597.15 $1,597.15 090 25031 $864.39 $864.39 09024360 $2,146.30 $2,146.30 090 25035 $1,400.97 $1,400.97 09024361 $2,420.46 $2,420.46 090 25040 $1,362.40 $1,362.40 09024362 $2,572.21 $2,572.21 090 25065 $686.65 $445.14 01024363 $3,534.69 $3,534.69 090 25066 $862.71 $862.71 09024365 $1,537.63 $1,537.63 090 25071 $1,031.23 $1,031.23 09024366 $1,644.94 $1,644.94 090 25073 $1,288.62 $1,288.62 09024370 $3,775.32 $3,775.32 090 25075 $1,148.61 $764.62 09024371 $4,324.47 $4,324.47 090 25076 $1,253.41 $1,253.41 09024400 $1,973.59 $1,973.59 090 25077 $2,149.66 $2,149.66 09024410 $2,565.50 $2,565.50 090 25078 $2,828.76 $2,828.76 09024420 $2,369.32 $2,369.32 090 25085 $1,086.57 $1,086.57 09024430 $2,557.96 $2,557.96 090 25100 $830.85 $830.85 09024435 $2,606.59 $2,606.59 090 25101 $973.38 $973.38 09024470 $1,364.92 $1,364.92 090 25105 $1,169.57 $1,169.57 09024495 $1,580.38 $1,580.38 090 25107 $1,490.68 $1,490.68 09024498 $2,096.00 $2,096.00 090 25109 $1,307.07 $1,307.07 09024500 $861.04 $785.58 090 25110 $826.66 $826.66 09024505 $1,203.94 $1,092.44 090 25111 $773.84 $773.84 09024515 $2,118.64 $2,118.64 090 25112 $935.65 $935.65 09024516 $2,081.75 $2,081.75 090 25115 $1,841.96 $1,841.96 09024530 $916.37 $831.69 090 25116 $1,452.95 $1,452.95 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 8 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

25118 $924.76 $924.76 090 25446 $2,843.01 $2,843.01 09025119 $1,198.07 $1,198.07 090 25447 $2,007.13 $2,007.13 09025120 $1,203.94 $1,203.94 090 25449 $2,507.65 $2,507.65 09025125 $1,397.61 $1,397.61 090 25450 $1,247.54 $1,247.54 09025126 $1,434.50 $1,434.50 090 25455 $1,477.26 $1,477.26 09025130 $1,081.54 $1,081.54 090 25490 $1,737.16 $1,737.16 09025135 $1,337.25 $1,337.25 090 25491 $1,791.66 $1,791.66 09025136 $1,188.85 $1,188.85 090 25492 $2,191.58 $2,191.58 09025145 $1,250.89 $1,250.89 090 25500 $654.79 $601.97 09025150 $1,373.30 $1,373.30 090 25505 $1,209.81 $1,110.88 09025151 $1,407.67 $1,407.67 090 25515 $1,618.11 $1,618.11 09025170 $3,596.74 $3,596.74 090 25520 $1,343.96 $1,276.88 09025210 $1,181.31 $1,181.31 090 25525 $1,899.81 $1,899.81 09025215 $1,495.71 $1,495.71 090 25526 $2,304.76 $2,304.76 09025230 $1,048.00 $1,048.00 090 25530 $629.64 $570.11 09025240 $1,035.42 $1,035.42 090 25535 $1,176.28 $1,090.76 09025246 $435.67 $205.52 000 25545 $1,506.60 $1,506.60 09025248 $1,003.56 $1,003.56 090 25560 $665.69 $602.81 09025250 $1,277.72 $1,277.72 090 25565 $1,254.25 $1,138.55 09025251 $1,735.49 $1,735.49 090 25574 $1,625.66 $1,625.66 09025259 $1,004.40 $1,004.40 090 25575 $2,180.68 $2,180.68 09025260 $1,527.56 $1,527.56 090 25600 $788.93 $747.85 09025263 $1,506.60 $1,506.60 090 25605 $1,324.67 $1,248.38 09025265 $1,810.11 $1,810.11 090 25606 $1,603.86 $1,603.86 09025270 $1,184.66 $1,184.66 090 25607 $1,778.25 $1,778.25 09025272 $1,337.25 $1,337.25 090 25608 $1,994.55 $1,994.55 09025274 $1,609.73 $1,609.73 090 25609 $2,532.81 $2,532.81 09025275 $1,629.85 $1,629.85 090 25622 $731.08 $667.37 09025280 $1,364.08 $1,364.08 090 25624 $1,141.90 $1,042.13 09025290 $1,058.90 $1,058.90 090 25628 $1,746.39 $1,746.39 09025295 $1,268.50 $1,268.50 090 25630 $735.28 $676.59 09025300 $1,651.65 $1,651.65 090 25635 $1,013.63 $907.15 09025301 $1,554.39 $1,554.39 090 25645 $1,370.78 $1,370.78 09025310 $1,499.06 $1,499.06 090 25650 $769.65 $723.54 09025312 $1,729.62 $1,729.62 090 25651 $1,164.54 $1,164.54 09025315 $1,867.96 $1,867.96 090 25652 $1,510.80 $1,510.80 09025316 $2,215.89 $2,215.89 090 25660 $982.60 $982.60 09025320 $2,393.63 $2,393.63 090 25670 $1,457.14 $1,457.14 09025332 $2,041.50 $2,041.50 090 25671 $1,282.75 $1,282.75 09025335 $1,945.09 $1,945.09 090 25675 $1,042.97 $953.26 09025337 $2,161.40 $2,161.40 090 25676 $1,509.12 $1,509.12 09025350 $1,634.04 $1,634.04 090 25680 $1,137.71 $1,137.71 09025355 $1,818.49 $1,818.49 090 25685 $1,776.57 $1,776.57 09025360 $1,580.38 $1,580.38 090 25690 $1,146.09 $1,146.09 09025365 $2,207.51 $2,207.51 090 25695 $1,532.60 $1,532.60 09025370 $2,445.61 $2,445.61 090 25800 $1,773.22 $1,773.22 09025375 $2,309.79 $2,309.79 090 25805 $2,047.37 $2,047.37 09025390 $1,864.60 $1,864.60 090 25810 $2,103.55 $2,103.55 09025391 $2,416.27 $2,416.27 090 25820 $1,489.00 $1,489.00 09025392 $2,097.68 $2,097.68 090 25825 $1,836.93 $1,836.93 09025393 $2,774.27 $2,774.27 090 25830 $2,290.51 $2,290.51 09025394 $1,887.24 $1,887.24 090 25900 $1,717.04 $1,717.04 09025400 $1,946.76 $1,946.76 090 25905 $1,563.62 $1,563.62 09025405 $2,512.68 $2,512.68 090 25907 $1,405.16 $1,405.16 09025415 $2,332.43 $2,332.43 090 25909 $1,658.36 $1,658.36 09025420 $2,830.44 $2,830.44 090 25915 $2,868.17 $2,868.17 09025425 $2,334.94 $2,334.94 090 25920 $1,678.48 $1,678.48 09025426 $2,728.15 $2,728.15 090 25922 $1,363.24 $1,363.24 09025430 $1,770.70 $1,770.70 090 25924 $1,465.52 $1,465.52 09025431 $1,903.17 $1,903.17 090 25927 $1,961.02 $1,961.02 09025440 $1,859.57 $1,859.57 090 25929 $1,426.96 $1,426.96 09025441 $2,287.16 $2,287.16 090 25931 $1,595.48 $1,595.48 09025442 $1,956.83 $1,956.83 090 25999 80% of billed 80% of billed N/A25443 $1,892.27 $1,892.27 090 26010 $711.27 $372.21 01025444 $2,002.10 $2,002.10 090 26011 $1,058.86 $504.80 01025445 $1,750.58 $1,750.58 090 26020 $1,052.19 $1,052.19 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 9 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

26025 $1,023.69 $1,023.69 090 26437 $1,489.84 $1,489.84 09026030 $1,190.53 $1,190.53 090 26440 $1,481.45 $1,481.45 09026034 $1,302.04 $1,302.04 090 26442 $2,308.12 $2,308.12 09026035 $2,078.39 $2,078.39 090 26445 $1,378.33 $1,378.33 09026037 $1,374.98 $1,374.98 090 26449 $1,684.35 $1,684.35 09026040 $755.40 $755.40 090 26450 $972.54 $972.54 09026045 $1,134.36 $1,134.36 090 26455 $956.61 $956.61 09026055 $1,344.79 $749.53 090 26460 $941.52 $941.52 09026060 $640.54 $640.54 090 26471 $1,466.36 $1,466.36 09026070 $748.69 $748.69 090 26474 $1,430.31 $1,430.31 09026075 $800.67 $800.67 090 26476 $1,394.26 $1,394.26 09026080 $944.88 $944.88 090 26477 $1,390.91 $1,390.91 09026100 $803.19 $803.19 090 26478 $1,481.45 $1,481.45 09026105 $804.86 $804.86 090 26479 $1,475.58 $1,475.58 09026110 $776.36 $776.36 090 26480 $1,793.34 $1,793.34 09026111 $1,013.63 $1,013.63 090 26483 $2,014.68 $2,014.68 09026113 $1,330.54 $1,330.54 090 26485 $1,928.32 $1,928.32 09026115 $1,216.52 $806.54 090 26489 $2,194.93 $2,194.93 09026116 $1,279.40 $1,279.40 090 26490 $1,883.05 $1,883.05 09026117 $1,821.00 $1,821.00 090 26492 $2,102.71 $2,102.71 09026118 $2,552.93 $2,552.93 090 26494 $1,882.21 $1,882.21 09026121 $1,447.92 $1,447.92 090 26496 $2,055.76 $2,055.76 09026123 $2,025.57 $2,025.57 090 26497 $2,067.49 $2,067.49 09026125 $755.79 $755.79 ZZZ 26498 $2,738.21 $2,738.21 09026130 $1,116.75 $1,116.75 090 26499 $1,981.14 $1,981.14 09026135 $1,330.54 $1,330.54 090 26500 $1,488.16 $1,488.16 09026140 $1,223.23 $1,223.23 090 26502 $1,677.64 $1,677.64 09026145 $1,239.99 $1,239.99 090 26508 $1,527.56 $1,527.56 09026160 $1,382.52 $807.38 090 26510 $1,415.22 $1,415.22 09026170 $980.93 $980.93 090 26516 $1,668.42 $1,668.42 09026180 $1,073.99 $1,073.99 090 26517 $1,962.69 $1,962.69 09026185 $1,327.19 $1,327.19 090 26518 $1,988.68 $1,988.68 09026200 $1,090.76 $1,090.76 090 26520 $1,555.23 $1,555.23 09026205 $1,456.30 $1,456.30 090 26525 $1,556.91 $1,556.91 09026210 $1,072.31 $1,072.31 090 26530 $1,297.00 $1,297.00 09026215 $1,361.56 $1,361.56 090 26531 $1,511.64 $1,511.64 09026230 $1,209.81 $1,209.81 090 26535 $1,021.17 $1,021.17 09026235 $1,198.07 $1,198.07 090 26536 $1,703.63 $1,703.63 09026236 $1,071.48 $1,071.48 090 26540 $1,570.32 $1,570.32 09026250 $2,625.03 $2,625.03 090 26541 $1,914.07 $1,914.07 09026260 $1,948.44 $1,948.44 090 26542 $1,618.95 $1,618.95 09026262 $1,528.40 $1,528.40 090 26545 $1,649.97 $1,649.97 09026320 $840.92 $840.92 090 26546 $2,374.35 $2,374.35 09026340 $808.22 $808.22 090 26548 $1,816.81 $1,816.81 09026341 $269.92 $205.52 010 26550 $3,715.79 $3,715.79 09026350 $1,701.95 $1,701.95 090 26551 $6,844.70 $6,844.70 09026352 $1,948.44 $1,948.44 090 26553 $7,921.20 $7,921.20 09026356 $2,095.16 $2,095.16 090 26554 $7,960.61 $7,960.61 09026357 $2,075.04 $2,075.04 090 26555 $3,237.06 $3,237.06 09026358 $2,303.92 $2,303.92 090 26556 $6,756.67 $6,756.67 09026370 $1,810.11 $1,810.11 090 26560 $1,339.76 $1,339.76 09026372 $2,092.65 $2,092.65 090 26561 $2,233.50 $2,233.50 09026373 $2,011.32 $2,011.32 090 26562 $3,220.29 $3,220.29 09026390 $1,997.07 $1,997.07 090 26565 $1,618.11 $1,618.11 09026392 $2,306.44 $2,306.44 090 26567 $1,628.17 $1,628.17 09026410 $1,350.66 $1,350.66 090 26568 $2,145.47 $2,145.47 09026412 $1,629.01 $1,629.01 090 26580 $3,531.34 $3,531.34 09026415 $1,821.00 $1,821.00 090 26587 $2,190.74 $2,190.74 09026416 $1,713.69 $1,713.69 090 26590 $3,236.22 $3,236.22 09026418 $1,379.17 $1,379.17 090 26591 $1,039.62 $1,039.62 09026420 $1,691.05 $1,691.05 090 26593 $1,437.02 $1,437.02 09026426 $1,214.84 $1,214.84 090 26596 $1,818.49 $1,818.49 09026428 $1,797.53 $1,797.53 090 26600 $707.61 $667.37 09026432 $1,190.53 $1,190.53 090 26605 $773.84 $705.93 09026433 $1,269.34 $1,269.34 090 26607 $1,099.14 $1,099.14 09026434 $1,537.63 $1,537.63 090 26608 $1,151.96 $1,151.96 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 10 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

26615 $1,396.77 $1,396.77 090 27052 $1,391.74 $1,391.74 09026641 $878.64 $804.03 090 27054 $1,649.13 $1,649.13 09026645 $1,012.79 $931.46 090 27057 $2,463.22 $2,463.22 09026650 $1,155.32 $1,155.32 090 27059 $4,419.21 $4,419.21 09026665 $1,527.56 $1,527.56 090 27060 $1,118.43 $1,118.43 09026670 $812.41 $738.63 090 27062 $1,105.01 $1,105.01 09026675 $1,083.21 $997.70 090 27065 $1,231.61 $1,231.61 09026676 $1,210.65 $1,210.65 090 27066 $1,952.63 $1,952.63 09026685 $1,398.45 $1,398.45 090 27067 $2,458.19 $2,458.19 09026686 $1,508.28 $1,508.28 090 27070 $2,049.89 $2,049.89 09026700 $770.49 $724.38 090 27071 $2,216.73 $2,216.73 09026705 $1,002.73 $919.72 090 27075 $5,094.12 $5,094.12 09026706 $1,065.61 $1,065.61 090 27076 $6,144.63 $6,144.63 09026715 $1,385.88 $1,385.88 090 27077 $6,919.31 $6,919.31 09026720 $475.37 $442.68 090 27078 $5,020.34 $5,020.34 09026725 $811.57 $733.60 090 27080 $1,245.02 $1,245.02 09026727 $1,135.19 $1,135.19 090 27086 $787.04 $452.71 01026735 $1,446.24 $1,446.24 090 27087 $1,514.99 $1,514.99 09026740 $553.34 $519.81 090 27090 $2,007.97 $2,007.97 09026742 $887.03 $806.54 090 27091 $3,870.89 $3,870.89 09026746 $1,800.88 $1,800.88 090 27093 $505.75 $192.26 00026750 $442.68 $444.35 090 27095 $653.50 $226.36 00026755 $756.24 $658.98 090 27096 $437.56 $231.09 00026756 $1,010.27 $1,010.27 090 27097 $1,622.30 $1,622.30 09026765 $1,213.16 $1,213.16 090 27098 $1,617.27 $1,617.27 09026770 $653.11 $606.16 090 27100 $1,972.76 $1,972.76 09026775 $918.89 $832.53 090 27105 $2,101.03 $2,101.03 09026776 $1,071.48 $1,071.48 090 27110 $2,345.84 $2,345.84 09026785 $1,327.19 $1,327.19 090 27111 $2,182.36 $2,182.36 09026820 $1,873.82 $1,873.82 090 27120 $3,160.77 $3,160.77 09026841 $1,731.30 $1,731.30 090 27122 $2,665.27 $2,665.27 09026842 $1,873.82 $1,873.82 090 27125 $2,750.79 $2,750.79 09026843 $1,761.48 $1,761.48 090 27130 $3,284.01 $3,284.01 09026844 $1,955.15 $1,955.15 090 27132 $4,055.34 $4,055.34 09026850 $1,653.32 $1,653.32 090 27134 $4,633.00 $4,633.00 09026852 $1,899.81 $1,899.81 090 27137 $3,561.52 $3,561.52 09026860 $1,348.99 $1,348.99 090 27138 $3,702.37 $3,702.37 09026861 $285.08 $285.08 ZZZ 27140 $2,158.88 $2,158.88 09026862 $1,736.33 $1,736.33 090 27146 $3,126.39 $3,126.39 09026863 $632.66 $632.66 ZZZ 27147 $3,577.45 $3,577.45 09026910 $1,722.07 $1,722.07 090 27151 $3,862.51 $3,862.51 09026951 $1,563.62 $1,563.62 090 27156 $4,176.91 $4,176.91 09026952 $1,544.33 $1,544.33 090 27158 $3,465.95 $3,465.95 09026989 80% of billed 80% of billed N/A 27161 $2,934.40 $2,934.40 09026990 $1,509.96 $1,509.96 090 27165 $3,328.45 $3,328.45 09026991 $1,691.05 $1,260.12 090 27170 $2,847.21 $2,847.21 09026992 $2,322.37 $2,322.37 090 27175 $1,617.27 $1,617.27 09027000 $972.54 $972.54 090 27176 $2,180.68 $2,180.68 09027001 $1,291.97 $1,291.97 090 27177 $2,706.36 $2,706.36 09027003 $1,439.53 $1,439.53 090 27178 $2,227.63 $2,227.63 09027005 $1,742.20 $1,742.20 090 27179 $2,370.16 $2,370.16 09027006 $1,775.73 $1,775.73 090 27181 $2,329.91 $2,329.91 09027025 $2,210.02 $2,210.02 090 27185 $1,468.88 $1,468.88 09027027 $2,183.19 $2,183.19 090 27187 $2,398.66 $2,398.66 09027030 $2,268.71 $2,268.71 090 27193 $1,137.71 $1,153.64 09027033 $2,352.55 $2,352.55 090 27194 $1,697.76 $1,697.76 09027035 $2,783.49 $2,783.49 090 27197 $317.28 $317.28 00027036 $2,436.39 $2,436.39 090 27198 $808.82 $808.82 00027040 $927.21 $544.58 010 27200 $435.13 $453.57 09027041 $1,652.49 $1,652.49 090 27202 $1,282.75 $1,282.75 09027043 $1,139.39 $1,139.39 090 27215 $1,506.60 $1,506.60 09027045 $1,812.62 $1,812.62 090 27216 $2,233.50 $2,233.50 09027047 $1,120.94 $875.29 090 27217 $2,095.16 $2,095.16 09027048 $1,474.75 $1,474.75 090 27218 $2,897.51 $2,897.51 09027049 $3,272.28 $3,272.28 090 27220 $1,282.75 $1,272.69 09027050 $916.37 $916.37 090 27222 $2,374.35 $2,374.35 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 11 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

27226 $2,559.64 $2,559.64 090 27365 $5,022.85 $5,022.85 09027227 $4,026.00 $4,026.00 090 27370 $416.72 $138.28 00027228 $4,583.53 $4,583.53 090 27372 $1,458.82 $975.90 09027230 $1,148.61 $1,141.06 090 27380 $1,431.99 $1,431.99 09027232 $1,835.26 $1,835.26 090 27381 $1,921.61 $1,921.61 09027235 $2,208.35 $2,208.35 090 27385 $1,386.71 $1,386.71 09027236 $2,903.38 $2,903.38 090 27386 $2,002.10 $2,002.10 09027238 $1,112.56 $1,112.56 090 27390 $1,082.37 $1,082.37 09027240 $2,327.40 $2,327.40 090 27391 $1,395.10 $1,395.10 09027244 $2,991.41 $2,991.41 090 27392 $1,717.88 $1,717.88 09027245 $2,990.57 $2,990.57 090 27393 $1,214.00 $1,214.00 09027246 $931.46 $935.65 090 27394 $1,528.40 $1,528.40 09027248 $1,800.04 $1,800.04 090 27395 $2,130.37 $2,130.37 09027250 $493.44 $493.44 000 27396 $1,490.68 $1,490.68 09027252 $1,844.48 $1,844.48 090 27397 $2,189.90 $2,189.90 09027253 $2,277.93 $2,277.93 090 27400 $1,681.83 $1,681.83 09027254 $3,071.90 $3,071.90 090 27403 $1,541.82 $1,541.82 09027256 $811.66 $638.35 010 27405 $1,626.50 $1,626.50 09027257 $996.35 $996.35 010 27407 $1,893.95 $1,893.95 09027258 $2,697.13 $2,697.13 090 27409 $2,308.95 $2,308.95 09027259 $3,778.67 $3,778.67 090 27412 $4,020.97 $4,020.97 09027265 $963.32 $963.32 090 27415 $3,330.12 $3,330.12 09027266 $1,407.67 $1,407.67 090 27416 $2,374.35 $2,374.35 09027267 $1,055.55 $1,055.55 090 27418 $2,002.94 $2,002.94 09027268 $1,286.11 $1,286.11 090 27420 $1,797.53 $1,797.53 09027269 $3,007.34 $3,007.34 090 27422 $1,789.98 $1,789.98 09027275 $497.23 $497.23 010 27424 $1,813.46 $1,813.46 09027279 $1,689.38 $1,689.38 090 27425 $1,084.05 $1,084.05 09027280 $3,311.68 $3,311.68 090 27427 $1,717.88 $1,717.88 09027282 $1,997.91 $1,997.91 090 27428 $2,693.78 $2,693.78 09027284 $3,774.48 $3,774.48 090 27429 $2,998.12 $2,998.12 09027286 $3,973.18 $3,973.18 090 27430 $1,781.60 $1,781.60 09027290 $3,913.65 $3,913.65 090 27435 $1,936.70 $1,936.70 09027295 $3,055.13 $3,055.13 090 27437 $1,595.48 $1,595.48 09027299 80% of billed 80% of billed N/A 27438 $2,033.12 $2,033.12 09027301 $1,618.95 $1,214.84 090 27440 $1,935.87 $1,935.87 09027303 $1,537.63 $1,537.63 090 27441 $1,995.39 $1,995.39 09027305 $1,159.51 $1,159.51 090 27442 $2,099.35 $2,099.35 09027306 $849.30 $849.30 090 27443 $1,954.31 $1,954.31 09027307 $1,111.72 $1,111.72 090 27445 $3,024.11 $3,024.11 09027310 $1,769.86 $1,769.86 090 27446 $2,803.61 $2,803.61 09027323 $734.00 $485.86 010 27447 $3,284.01 $3,284.01 09027324 $959.97 $959.97 090 27448 $1,852.03 $1,852.03 09027325 $1,326.35 $1,326.35 090 27450 $2,441.42 $2,441.42 09027326 $1,255.92 $1,255.92 090 27454 $3,159.93 $3,159.93 09027327 $1,105.01 $759.59 090 27455 $2,282.96 $2,282.96 09027328 $1,503.25 $1,503.25 090 27457 $2,282.12 $2,282.12 09027329 $2,515.20 $2,515.20 090 27465 $2,982.19 $2,982.19 09027330 $1,011.11 $1,011.11 090 27466 $2,837.98 $2,837.98 09027331 $1,146.93 $1,146.93 090 27468 $2,986.38 $2,986.38 09027332 $1,545.17 $1,545.17 090 27470 $2,846.37 $2,846.37 09027333 $1,417.73 $1,417.73 090 27472 $3,058.48 $3,058.48 09027334 $1,647.46 $1,647.46 090 27475 $1,602.18 $1,602.18 09027335 $1,840.29 $1,840.29 090 27477 $1,772.38 $1,772.38 09027337 $1,013.63 $1,013.63 090 27479 $1,904.01 $1,904.01 09027339 $1,826.87 $1,826.87 090 27485 $1,623.98 $1,623.98 09027340 $898.76 $898.76 090 27486 $3,403.07 $3,403.07 09027345 $1,156.99 $1,156.99 090 27487 $4,249.01 $4,249.01 09027347 $1,278.56 $1,278.56 090 27488 $2,908.41 $2,908.41 09027350 $1,570.32 $1,570.32 090 27495 $2,731.51 $2,731.51 09027355 $1,449.59 $1,449.59 090 27496 $1,309.58 $1,309.58 09027356 $1,778.25 $1,778.25 090 27497 $1,400.97 $1,400.97 09027357 $1,968.56 $1,968.56 090 27498 $1,561.10 $1,561.10 09027358 $766.20 $766.20 ZZZ 27499 $1,690.21 $1,690.21 09027360 $2,057.43 $2,057.43 090 27500 $1,255.08 $1,164.54 09027364 $3,797.11 $3,797.11 090 27501 $1,218.20 $1,208.97 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 12 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

27502 $1,874.66 $1,874.66 090 27646 $3,740.94 $3,740.94 09027503 $1,947.60 $1,947.60 090 27647 $2,474.12 $2,474.12 09027506 $3,245.45 $3,245.45 090 27648 $443.24 $143.96 00027507 $2,354.23 $2,354.23 090 27650 $1,593.80 $1,593.80 09027508 $1,271.01 $1,198.07 090 27652 $1,653.32 $1,653.32 09027509 $1,551.88 $1,551.88 090 27654 $1,705.31 $1,705.31 09027510 $1,671.77 $1,671.77 090 27656 $1,533.43 $959.97 09027511 $2,417.95 $2,417.95 090 27658 $898.76 $898.76 09027513 $3,009.86 $3,009.86 090 27659 $1,158.67 $1,158.67 09027514 $2,345.84 $2,345.84 090 27664 $871.10 $871.10 09027516 $1,226.58 $1,153.64 090 27665 $988.47 $988.47 09027517 $1,629.85 $1,629.85 090 27675 $1,172.92 $1,172.92 09027519 $2,166.43 $2,166.43 090 27676 $1,455.46 $1,455.46 09027520 $776.36 $710.12 090 27680 $1,029.56 $1,029.56 09027524 $1,821.00 $1,821.00 090 27681 $1,319.64 $1,319.64 09027530 $726.05 $674.91 090 27685 $1,594.64 $1,116.75 09027532 $1,483.97 $1,394.26 090 27686 $1,347.31 $1,347.31 09027535 $2,176.49 $2,176.49 090 27687 $1,094.95 $1,094.95 09027536 $2,884.10 $2,884.10 090 27690 $1,514.99 $1,514.99 09027538 $1,137.71 $1,067.28 090 27691 $1,811.78 $1,811.78 09027540 $1,958.50 $1,958.50 090 27692 $286.02 $286.02 ZZZ27550 $1,225.74 $1,140.22 090 27695 $1,132.68 $1,132.68 09027552 $1,513.31 $1,513.31 090 27696 $1,341.44 $1,341.44 09027556 $2,119.48 $2,119.48 090 27698 $1,542.66 $1,542.66 09027557 $2,547.90 $2,547.90 090 27700 $1,437.02 $1,437.02 09027558 $2,892.48 $2,892.48 090 27702 $2,338.30 $2,338.30 09027560 $873.61 $808.22 090 27703 $2,687.07 $2,687.07 09027562 $1,133.52 $1,133.52 090 27704 $1,398.45 $1,398.45 09027566 $2,159.72 $2,159.72 090 27705 $1,830.23 $1,830.23 09027570 $412.94 $412.94 010 27707 $976.74 $976.74 09027580 $3,479.36 $3,479.36 090 27709 $2,828.76 $2,828.76 09027590 $1,966.05 $1,966.05 090 27712 $2,673.66 $2,673.66 09027591 $2,340.81 $2,340.81 090 27715 $2,601.56 $2,601.56 09027592 $1,669.25 $1,669.25 090 27720 $2,116.96 $2,116.96 09027594 $1,237.48 $1,237.48 090 27722 $2,132.89 $2,132.89 09027596 $1,767.35 $1,767.35 090 27724 $3,063.51 $3,063.51 09027598 $1,764.83 $1,764.83 090 27725 $2,920.99 $2,920.99 09027599 80% of billed 80% of billed N/A 27726 $2,350.87 $2,350.87 09027600 $1,010.27 $1,010.27 090 27727 $2,517.72 $2,517.72 09027601 $1,065.61 $1,065.61 090 27730 $1,380.01 $1,380.01 09027602 $1,213.16 $1,213.16 090 27732 $980.93 $980.93 09027603 $1,277.72 $940.68 090 27734 $1,588.77 $1,588.77 09027604 $1,188.85 $835.05 090 27740 $1,716.20 $1,716.20 09027605 $928.16 $502.91 010 27742 $1,897.30 $1,897.30 09027606 $770.94 $770.94 010 27745 $1,826.04 $1,826.04 09027607 $1,469.72 $1,469.72 090 27750 $833.37 $766.30 09027610 $1,576.19 $1,576.19 090 27752 $1,300.36 $1,203.10 09027612 $1,343.12 $1,343.12 090 27756 $1,382.52 $1,382.52 09027613 $681.91 $443.24 010 27758 $2,155.53 $2,155.53 09027614 $1,385.88 $974.22 090 27759 $2,421.30 $2,421.30 09027615 $2,487.53 $2,487.53 090 27760 $802.35 $732.76 09027616 $3,094.53 $3,094.53 090 27762 $1,145.25 $1,047.16 09027618 $1,079.02 $742.82 090 27766 $1,477.26 $1,477.26 09027619 $1,136.87 $1,136.87 090 27767 $674.07 $677.43 09027620 $1,100.82 $1,100.82 090 27768 $1,063.09 $1,063.09 09027625 $1,413.54 $1,413.54 090 27769 $1,777.41 $1,777.41 09027626 $1,490.68 $1,490.68 090 27780 $736.12 $669.88 09027630 $1,351.50 $884.51 090 27781 $1,010.27 $938.17 09027632 $1,005.24 $1,005.24 090 27784 $1,733.81 $1,733.81 09027634 $1,665.90 $1,665.90 090 27786 $761.27 $690.00 09027635 $1,419.41 $1,419.41 090 27788 $1,015.30 $929.79 09027637 $1,804.24 $1,804.24 090 27792 $1,580.38 $1,580.38 09027638 $1,842.80 $1,842.80 090 27808 $804.03 $724.38 09027640 $2,020.54 $2,020.54 090 27810 $1,128.49 $1,027.88 09027641 $1,617.27 $1,617.27 090 27814 $1,870.47 $1,870.47 09027645 $4,315.24 $4,315.24 090 27816 $770.49 $691.68 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 13 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

27818 $1,167.89 $1,051.35 090 28108 $1,068.12 $695.87 09027822 $2,035.64 $2,035.64 090 28110 $1,121.78 $697.55 09027823 $2,312.31 $2,312.31 090 28111 $1,195.56 $788.93 09027824 $755.40 $734.44 090 28112 $1,177.11 $751.21 09027825 $1,307.90 $1,187.17 090 28113 $1,429.47 $1,024.52 09027826 $2,016.35 $2,016.35 090 28114 $2,609.10 $2,029.77 09027827 $2,617.48 $2,617.48 090 28116 $1,823.52 $1,374.98 09027828 $3,135.62 $3,135.62 090 28118 $1,436.18 $996.02 09027829 $1,653.32 $1,653.32 090 28119 $1,273.53 $871.10 09027830 $916.37 $854.33 090 28120 $1,629.85 $1,194.72 09027831 $948.23 $948.23 090 28122 $1,450.43 $1,062.25 09027832 $1,835.26 $1,835.26 090 28124 $1,155.32 $795.64 09027840 $882.84 $882.84 090 28126 $956.61 $598.62 09027842 $1,199.75 $1,199.75 090 28130 $1,546.85 $1,546.85 09027846 $1,755.61 $1,755.61 090 28140 $1,451.27 $1,068.12 09027848 $1,961.86 $1,961.86 090 28150 $1,036.26 $679.10 09027860 $475.44 $475.44 010 28153 $988.47 $631.32 09027870 $2,495.08 $2,495.08 090 28160 $1,017.82 $649.76 09027871 $1,649.13 $1,649.13 090 28171 $2,050.73 $2,050.73 09027880 $2,247.75 $2,247.75 090 28173 $1,848.67 $1,848.67 09027881 $2,128.70 $2,128.70 090 28175 $1,183.82 $1,183.82 09027882 $1,473.07 $1,473.07 090 28190 $702.75 $365.58 01027884 $1,411.87 $1,411.87 090 28192 $1,145.25 $760.43 09027886 $1,613.08 $1,613.08 090 28193 $1,286.11 $890.38 09027888 $1,664.22 $1,664.22 090 28200 $1,188.85 $776.36 09027889 $1,593.80 $1,593.80 090 28202 $1,449.59 $1,031.23 09027892 $1,339.76 $1,339.76 090 28208 $1,156.99 $757.08 09027893 $1,465.52 $1,465.52 090 28210 $1,386.71 $985.12 09027894 $2,084.26 $2,084.26 090 28220 $1,083.21 $723.54 09027899 80% of billed 80% of billed N/A 28222 $1,223.23 $839.24 09028001 $755.79 $462.18 010 28225 $978.41 $617.90 09028002 $1,208.50 $868.49 010 28226 $1,477.26 $949.91 09028003 $1,721.24 $1,375.81 090 28230 $1,041.29 $675.75 09028005 $1,400.97 $1,400.97 090 28232 $928.11 $580.17 09028008 $1,041.29 $705.09 090 28234 $970.87 $625.45 09028010 $555.86 $500.52 090 28238 $1,626.50 $1,176.28 09028011 $773.84 $690.84 090 28240 $1,060.58 $694.20 09028020 $1,307.07 $871.94 090 28250 $1,399.29 $973.38 09028022 $1,193.04 $791.45 090 28260 $1,659.19 $1,229.09 09028024 $1,120.94 $737.79 090 28261 $2,368.48 $1,869.63 09028035 $1,275.21 $856.01 090 28262 $3,574.94 $2,875.71 09028039 $1,239.16 $850.14 090 28264 $2,431.36 $1,851.19 09028041 $1,118.43 $1,118.43 090 28270 $1,180.47 $798.16 09028043 $967.51 $632.99 090 28272 $954.10 $612.03 09028045 $1,201.43 $839.24 090 28280 $1,255.92 $845.11 09028046 $1,763.99 $1,763.99 090 28285 $1,286.11 $904.63 09028047 $2,599.04 $2,599.04 090 28286 $1,097.47 $723.54 09028050 $1,029.56 $675.75 090 28288 $1,461.33 $1,034.59 09028052 $1,103.33 $699.23 090 28289 $1,777.41 $1,323.00 09028054 $956.61 $594.43 090 28290 $1,412.70 $946.55 09028055 $907.99 $907.99 090 28291 $1,772.38 $1,160.35 09028060 $1,254.25 $860.20 090 28292 $1,909.88 $1,450.43 09028062 $1,422.76 $984.28 090 28293 $2,543.71 $1,715.37 09028070 $1,282.75 $853.49 090 28294 $1,861.25 $1,321.32 09028072 $1,230.77 $803.19 090 28295 $2,272.06 $1,292.81 09028080 $1,273.53 $887.03 090 28296 $1,729.62 $1,259.28 09028086 $1,326.35 $871.10 090 28297 $1,968.56 $1,406.84 09028088 $1,082.37 $679.94 090 28298 $1,750.58 $1,223.23 09028090 $1,143.58 $745.34 090 28299 $2,175.65 $1,638.23 09028092 $1,026.20 $648.92 090 28300 $1,565.29 $1,565.29 09028100 $1,466.36 $994.34 090 28302 $1,734.65 $1,734.65 09028102 $1,463.85 $1,463.85 090 28304 $1,962.69 $1,439.53 09028103 $946.55 $946.55 090 28305 $1,592.96 $1,592.96 09028104 $1,283.59 $855.17 090 28306 $1,476.42 $967.51 09028106 $1,126.81 $1,126.81 090 28307 $1,653.32 $1,089.92 09028107 $1,367.43 $909.66 090 28308 $1,364.08 $905.47 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 14 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

28309 $2,197.45 $2,197.45 090 28750 $1,977.79 $1,432.83 09028310 $1,328.86 $865.23 090 28755 $1,233.29 $797.32 09028312 $1,230.77 $767.97 090 28760 $1,915.74 $1,396.77 09028313 $1,253.41 $848.46 090 28800 $1,317.96 $1,317.96 09028315 $1,165.38 $783.90 090 28805 $1,782.44 $1,782.44 09028320 $1,472.23 $1,472.23 090 28810 $1,053.03 $1,053.03 09028322 $1,919.94 $1,400.97 090 28820 $1,379.17 $963.32 09028340 $1,404.32 $998.53 090 28825 $1,313.77 $900.44 09028341 $1,629.01 $1,188.01 090 28890 $780.55 $541.61 09028344 $1,123.46 $751.21 090 28899 80% of billed 80% of billed N/A28345 $1,268.50 $881.16 090 29000 $802.19 $487.76 00028360 $2,226.79 $2,226.79 090 29010 $645.92 $402.52 00028400 $599.46 $548.31 090 29015 $775.67 $488.70 00028405 $944.04 $856.84 090 29035 $527.53 $326.75 00028406 $1,265.98 $1,265.98 090 29040 $611.83 $397.78 00028415 $2,678.69 $2,678.69 090 29044 $766.20 $416.72 00028420 $3,046.75 $3,046.75 090 29046 $658.23 $431.88 00028430 $570.95 $508.07 090 29049 $228.25 $169.53 00028435 $764.62 $683.30 090 29055 $607.09 $380.73 00028436 $1,087.40 $1,087.40 090 29058 $334.33 $254.77 00028445 $2,571.37 $2,571.37 090 29065 $263.29 $187.53 00028446 $2,941.11 $2,941.11 090 29075 $237.72 $171.43 00028450 $518.97 $461.96 090 29085 $261.40 $185.63 00028455 $695.03 $625.45 090 29086 $213.10 $140.17 00028456 $772.17 $772.17 090 29105 $238.67 $161.95 00028465 $1,498.22 $1,498.22 090 29125 $175.21 $107.02 00028470 $528.19 $493.82 090 29126 $208.36 $132.59 00028475 $618.74 $549.15 090 29130 $111.76 $77.66 00028476 $850.14 $850.14 090 29131 $138.28 $89.97 00028485 $1,265.98 $1,265.98 090 29200 $79.56 $49.25 00028490 $347.94 $300.99 090 29240 $77.66 $50.20 00028495 $426.75 $358.84 090 29260 $78.61 $53.04 00028496 $1,063.93 $565.08 090 29280 $79.56 $54.93 00028505 $1,621.47 $1,209.81 090 29305 $673.39 $437.56 00028510 $296.79 $288.41 090 29325 $739.69 $486.81 00028515 $386.50 $342.07 090 29345 $372.21 $276.55 00028525 $1,359.88 $954.10 090 29355 $383.58 $290.76 00028530 $279.19 $247.33 090 29358 $437.56 $285.08 00028531 $838.40 $444.35 090 29365 $334.33 $239.62 00028540 $497.17 $447.71 090 29405 $222.57 $163.85 00028545 $702.58 $622.93 090 29425 $213.10 $154.38 00028546 $1,345.63 $792.29 090 29435 $317.28 $226.36 00028555 $2,124.51 $1,609.73 090 29440 $118.39 $78.61 00028570 $537.41 $455.25 090 29445 $365.58 $283.18 00028575 $883.67 $799.00 090 29450 $389.26 $305.91 00028576 $935.65 $935.65 090 29505 $225.41 $135.44 00028585 $2,051.56 $1,607.21 090 29515 $194.16 $135.44 00028600 $524.00 $451.06 090 29520 $84.29 $50.20 00028605 $788.10 $709.29 090 29530 $77.66 $50.20 00028606 $949.07 $949.07 090 29540 $70.09 $49.25 00028615 $1,904.01 $1,904.01 090 29550 $51.14 $31.25 00028630 $425.25 $298.34 010 29580 $142.06 $96.60 00028635 $474.50 $358.00 010 29581 $165.74 $34.10 00028636 $773.78 $496.28 010 29582 $188.47 $42.62 00028645 $1,591.28 $1,171.24 090 29583 $117.44 $30.31 00028660 $316.33 $241.51 010 29584 $188.47 $42.62 00028665 $418.62 $356.11 010 29700 $169.53 $90.92 00028666 $512.38 $512.38 010 29705 $181.84 $128.81 00028675 $1,421.93 $998.53 090 29710 $332.43 $227.30 00028705 $3,033.33 $3,033.33 090 29720 $232.04 $121.23 00028715 $2,269.55 $2,269.55 090 29730 $176.16 $123.12 00028725 $1,880.53 $1,880.53 090 29740 $270.87 $193.21 00028730 $1,774.89 $1,774.89 090 29750 $242.46 $182.79 00028735 $1,890.59 $1,890.59 090 29799 80% of billed 80% of billed N/A28737 $1,657.52 $1,657.52 090 29800 $1,235.80 $1,235.80 09028740 $2,043.18 $1,499.90 090 29804 $1,568.65 $1,568.65 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 15 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

29805 $1,145.25 $1,145.25 090 29904 $1,548.52 $1,548.52 09029806 $2,578.08 $2,578.08 090 29905 $1,664.22 $1,664.22 09029807 $2,516.88 $2,516.88 090 29906 $1,747.23 $1,747.23 09029819 $1,421.09 $1,421.09 090 29907 $2,129.54 $2,129.54 09029820 $1,295.33 $1,295.33 090 29914 $2,416.27 $2,416.27 09029821 $1,413.54 $1,413.54 090 29915 $2,457.35 $2,457.35 09029822 $1,372.46 $1,372.46 090 29916 $2,459.87 $2,459.87 09029823 $1,498.22 $1,498.22 090 29999 80% of billed 80% of billed N/A29824 $1,618.11 $1,618.11 090 30000 $623.19 $321.07 01029825 $1,400.13 $1,400.13 090 30020 $632.66 $324.86 01029826 $1,577.28 $1,577.28 090 30100 $382.63 $187.53 00029827 $2,562.99 $2,562.99 090 30110 $625.09 $354.22 01029828 $2,216.73 $2,216.73 090 30115 $1,039.62 $1,039.62 09029830 $1,105.01 $1,105.01 090 30117 $2,107.74 $819.96 09029834 $1,178.79 $1,178.79 090 30118 $1,852.86 $1,852.86 09029835 $1,225.74 $1,225.74 090 30120 $1,254.25 $1,059.74 09029836 $1,378.33 $1,378.33 090 30124 $687.49 $687.49 09029837 $1,268.50 $1,268.50 090 30125 $1,463.85 $1,463.85 09029838 $1,421.93 $1,421.93 090 30130 $913.02 $913.02 09029840 $1,096.63 $1,096.63 090 30140 $1,059.74 $1,059.74 09029843 $1,174.60 $1,174.60 090 30150 $1,854.54 $1,854.54 09029844 $1,203.10 $1,203.10 090 30160 $1,857.89 $1,857.89 09029845 $1,397.61 $1,397.61 090 30200 $307.81 $161.95 00029846 $1,265.15 $1,265.15 090 30210 $406.31 $270.87 01029847 $1,294.49 $1,294.49 090 30220 $823.03 $340.96 01029848 $1,242.51 $1,242.51 090 30300 $502.91 $286.97 01029850 $1,494.87 $1,494.87 090 30310 $559.74 $559.74 01029851 $2,147.98 $2,147.98 090 30320 $1,064.77 $1,064.77 09029855 $1,890.59 $1,890.59 090 30400 $2,432.20 $2,432.20 09029856 $2,423.81 $2,423.81 090 30410 $2,843.85 $2,843.85 09029860 $1,599.67 $1,599.67 090 30420 $3,303.30 $3,303.30 09029861 $1,743.87 $1,743.87 090 30430 $2,337.46 $2,337.46 09029862 $1,955.99 $1,955.99 090 30435 $2,668.63 $2,668.63 09029863 $1,956.83 $1,956.83 090 30450 $3,595.90 $3,595.90 09029866 $2,531.13 $2,531.13 090 30460 $1,716.20 $1,716.20 09029867 $3,069.38 $3,069.38 090 30462 $3,789.57 $3,789.57 09029868 $3,901.91 $3,901.91 090 30465 $2,362.61 $2,362.61 09029870 $1,411.87 $1,000.21 090 30520 $1,499.90 $1,499.90 09029871 $1,249.22 $1,249.22 090 30540 $1,669.25 $1,669.25 09029873 $1,273.53 $1,273.53 090 30545 $2,114.44 $2,114.44 09029874 $1,302.87 $1,302.87 090 30560 $728.32 $372.21 01029875 $1,202.27 $1,202.27 090 30580 $1,582.90 $1,243.35 09029876 $1,596.31 $1,596.31 090 30600 $1,424.44 $1,080.70 09029877 $1,509.12 $1,509.12 090 30620 $1,503.25 $1,503.25 09029879 $1,607.21 $1,607.21 090 30630 $1,498.22 $1,498.22 09029880 $1,363.24 $1,363.24 090 30801 $621.30 $370.32 01029881 $1,313.77 $1,313.77 090 30802 $788.93 $516.17 01029882 $1,701.11 $1,701.11 090 30901 $257.61 $154.38 00029883 $2,043.18 $2,043.18 090 30903 $597.62 $219.73 00029884 $1,490.68 $1,490.68 090 30905 $733.06 $291.71 00029885 $1,825.20 $1,825.20 090 30906 $943.31 $375.05 00029886 $1,546.01 $1,546.01 090 30915 $1,385.88 $1,385.88 09029887 $1,812.62 $1,812.62 090 30920 $2,010.48 $2,010.48 09029888 $2,386.09 $2,386.09 090 30930 $335.27 $335.27 01029889 $2,966.26 $2,966.26 090 30999 80% of billed 80% of billed N/A29891 $1,637.40 $1,637.40 090 31000 $498.17 $287.92 01029892 $1,411.03 $1,411.03 090 31002 $524.69 $524.69 01029893 $1,480.61 $1,032.91 090 31020 $1,164.54 $864.39 09029894 $1,206.46 $1,206.46 090 31030 $1,667.58 $1,277.72 09029895 $1,152.80 $1,152.80 090 31032 $1,384.20 $1,384.20 09029897 $1,229.09 $1,229.09 090 31040 $1,833.58 $1,833.58 09029898 $1,365.75 $1,365.75 090 31050 $1,172.08 $1,172.08 09029899 $2,509.33 $2,509.33 090 31051 $1,552.72 $1,552.72 09029900 $1,102.50 $1,102.50 090 31070 $1,055.55 $1,055.55 09029901 $1,291.97 $1,291.97 090 31075 $1,890.59 $1,890.59 09029902 $1,375.81 $1,375.81 090 31080 $2,493.40 $2,493.40 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 16 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

31081 $3,566.55 $3,566.55 090 31540 $666.76 $666.76 00031084 $2,787.68 $2,787.68 090 31541 $726.43 $726.43 00031085 $3,807.17 $3,807.17 090 31545 $1,000.14 $1,000.14 00031086 $2,714.74 $2,714.74 090 31546 $1,521.99 $1,521.99 00031087 $2,609.10 $2,609.10 090 31551 $3,415.64 $3,415.64 09031090 $2,459.87 $2,459.87 090 31552 $3,453.37 $3,453.37 09031200 $1,359.88 $1,359.88 090 31553 $3,765.25 $3,765.25 09031201 $1,777.41 $1,777.41 090 31554 $3,964.79 $3,964.79 09031205 $2,149.66 $2,149.66 090 31560 $863.76 $863.76 00031225 $4,522.33 $4,522.33 090 31561 $946.15 $946.15 00031230 $5,019.50 $5,019.50 090 31570 $924.37 $632.66 00031231 $568.26 $178.05 000 31571 $688.54 $688.54 00031233 $713.17 $373.16 000 31572 $1,340.15 $493.44 00031235 $812.61 $442.30 000 31573 $713.17 $407.25 00031237 $701.80 $441.35 000 31574 $2,761.74 $407.25 00031238 $700.85 $462.18 000 31575 $309.70 $209.31 00031239 $1,672.58 $1,672.58 010 31576 $608.99 $339.06 00031240 $440.40 $440.40 000 31577 $657.29 $411.04 00031254 $746.31 $746.31 000 31578 $758.63 $472.60 00031255 $1,096.74 $1,096.74 000 31579 $571.10 $386.42 00031256 $541.74 $541.74 000 31580 $2,950.33 $2,950.33 09031267 $869.44 $869.44 000 31582 $4,579.34 $4,579.34 09031276 $1,382.77 $1,382.77 000 31584 $3,656.26 $3,656.26 09031287 $635.50 $635.50 000 31587 $2,421.30 $2,421.30 09031288 $734.95 $734.95 000 31588 $2,753.31 $2,753.31 09031290 $3,160.47 $3,160.47 010 31590 $2,162.23 $2,162.23 09031291 $3,375.46 $3,375.46 010 31591 $2,502.62 $2,502.62 09031292 $2,735.22 $2,735.22 010 31592 $4,049.47 $4,049.47 09031293 $2,968.21 $2,968.21 010 31595 $1,846.16 $1,846.16 09031294 $3,390.62 $3,390.62 010 31599 80% of billed 80% of billed N/A31295 $5,534.85 $448.93 000 31600 $1,092.01 $1,092.01 00031296 $5,641.87 $537.95 000 31601 $691.38 $691.38 00031297 $5,543.38 $439.45 000 31603 $615.61 $615.61 00031299 80% of billed 80% of billed N/A 31605 $501.96 $501.96 00031300 $3,159.93 $3,159.93 090 31610 $1,729.62 $1,729.62 09031320 $1,687.70 $1,687.70 090 31611 $1,304.55 $1,304.55 09031360 $5,124.30 $5,124.30 090 31612 $226.36 $132.59 00031365 $6,322.37 $6,322.37 090 31613 $1,098.30 $1,098.30 09031367 $5,428.64 $5,428.64 090 31614 $1,823.52 $1,823.52 09031368 $6,059.95 $6,059.95 090 31615 $493.44 $352.32 00031370 $5,114.24 $5,114.24 090 31622 $819.24 $393.05 00031375 $4,830.02 $4,830.02 090 31623 $892.17 $399.68 00031380 $4,779.72 $4,779.72 090 31624 $844.81 $403.46 00031382 $5,265.99 $5,265.99 090 31625 $1,066.43 $462.18 00031390 $7,053.46 $7,053.46 090 31626 $2,452.99 $577.73 00031395 $7,452.54 $7,452.54 090 31627 $3,806.39 $266.14 ZZZ31400 $2,360.93 $2,360.93 090 31628 $1,123.26 $514.28 00031420 $2,014.68 $2,014.68 090 31629 $1,341.09 $544.58 00031500 $300.23 $300.23 000 31630 $547.42 $547.42 00031502 $95.66 $95.66 000 31631 $629.82 $629.82 00031505 $225.41 $134.49 000 31632 $201.73 $134.49 ZZZ31510 $573.00 $332.43 000 31633 $249.09 $173.32 ZZZ31511 $574.89 $357.06 000 31634 $5,013.95 $564.47 00031512 $555.00 $354.22 000 31635 $942.36 $516.17 00031513 $361.79 $361.79 000 31636 $607.09 $607.09 00031515 $500.07 $286.97 000 31637 $202.68 $202.68 ZZZ31520 $429.04 $429.04 000 31638 $692.33 $692.33 00031525 $688.54 $440.40 000 31640 $696.12 $696.12 00031526 $432.82 $432.82 000 31641 $705.59 $705.59 00031527 $535.11 $535.11 000 31643 $483.02 $483.02 00031528 $397.78 $397.78 000 31645 $872.28 $440.40 00031529 $446.08 $446.08 000 31646 $783.25 $380.73 00031530 $544.58 $544.58 000 31647 $605.20 $605.20 00031531 $586.25 $586.25 000 31648 $559.74 $559.74 00031535 $522.80 $522.80 000 31649 $190.37 $190.37 ZZZ31536 $581.52 $581.52 000 31651 $216.89 $216.89 ZZZ

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 17 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

31652 $2,434.05 $639.29 000 32553 $1,591.13 $531.32 00031653 $2,586.53 $705.59 000 32554 $538.90 $245.30 00031654 $292.65 $184.68 ZZZ 32555 $779.46 $307.81 00031660 $573.00 $573.00 000 32556 $1,452.85 $338.11 00031661 $600.46 $600.46 000 32557 $1,387.50 $420.51 00031717 $701.80 $295.50 000 32560 $658.23 $213.10 00031720 $140.17 $140.17 000 32561 $250.98 $187.53 00031725 $246.25 $246.25 000 32562 $226.36 $169.53 00031730 $3,346.10 $407.25 000 32601 $853.34 $853.34 00031750 $3,419.00 $3,419.00 090 32604 $1,334.46 $1,334.46 00031755 $4,275.84 $4,275.84 090 32606 $1,278.58 $1,278.58 00031760 $3,405.58 $3,405.58 090 32607 $855.23 $855.23 00031766 $4,369.74 $4,369.74 090 32608 $1,047.49 $1,047.49 00031770 $3,279.82 $3,279.82 090 32609 $716.95 $716.95 00031775 $3,135.62 $3,135.62 090 32650 $1,623.14 $1,623.14 09031780 $2,872.36 $2,872.36 090 32651 $2,681.20 $2,681.20 09031781 $3,517.09 $3,517.09 090 32652 $4,061.21 $4,061.21 09031785 $2,640.96 $2,640.96 090 32653 $2,588.14 $2,588.14 09031786 $3,522.12 $3,522.12 090 32654 $2,879.07 $2,879.07 09031800 $1,780.76 $1,780.76 090 32655 $2,336.62 $2,336.62 09031805 $2,018.03 $2,018.03 090 32656 $1,958.50 $1,958.50 09031820 $1,047.16 $794.80 090 32658 $1,748.06 $1,748.06 09031825 $1,448.76 $1,161.18 090 32659 $1,784.12 $1,784.12 09031830 $1,070.64 $832.53 090 32661 $1,961.02 $1,961.02 09031899 80% of billed 80% of billed N/A 32662 $2,178.16 $2,178.16 09032035 $1,753.09 $1,753.09 090 32663 $3,419.00 $3,419.00 09032036 $1,891.43 $1,891.43 090 32664 $2,080.07 $2,080.07 09032096 $1,968.56 $1,968.56 090 32665 $2,998.12 $2,998.12 09032097 $1,965.21 $1,965.21 090 32666 $2,127.02 $2,127.02 09032098 $1,865.44 $1,865.44 090 32667 $429.04 $429.04 ZZZ32100 $1,974.43 $1,974.43 090 32668 $429.04 $429.04 ZZZ32110 $3,565.72 $3,565.72 090 32669 $3,291.56 $3,291.56 09032120 $2,125.34 $2,125.34 090 32670 $3,905.27 $3,905.27 09032124 $2,256.13 $2,256.13 090 32671 $4,337.88 $4,337.88 09032140 $2,439.74 $2,439.74 090 32672 $3,723.33 $3,723.33 09032141 $3,729.20 $3,729.20 090 32673 $2,978.00 $2,978.00 09032150 $2,454.84 $2,454.84 090 32674 $590.04 $590.04 ZZZ32151 $2,454.84 $2,454.84 090 32701 $602.36 $602.36 N/A32160 $1,927.48 $1,927.48 090 32800 $2,313.98 $2,313.98 09032200 $2,770.91 $2,770.91 090 32810 $2,206.67 $2,206.67 09032215 $1,939.22 $1,939.22 090 32815 $6,852.24 $6,852.24 09032220 $3,861.67 $3,861.67 090 32820 $3,269.76 $3,269.76 09032225 $2,424.65 $2,424.65 090 32850 80% of billed 80% of billed N/A32310 $2,213.38 $2,213.38 090 32851 $8,072.11 $8,072.11 09032320 $3,900.24 $3,900.24 090 32852 $8,838.41 $8,838.41 09032400 $407.25 $238.67 000 32853 $11,246.30 $11,246.30 09032405 $1,209.45 $284.13 000 32854 $11,957.26 $11,957.26 09032440 $3,823.94 $3,823.94 090 32855 80% of billed 80% of billed N/A32442 $7,823.11 $7,823.11 090 32856 80% of billed 80% of billed N/A32445 $8,680.79 $8,680.79 090 32900 $3,410.61 $3,410.61 09032480 $3,605.96 $3,605.96 090 32905 $3,285.69 $3,285.69 09032482 $3,858.32 $3,858.32 090 32906 $4,058.69 $4,058.69 09032484 $3,511.22 $3,511.22 090 32940 $3,021.59 $3,021.59 09032486 $5,749.75 $5,749.75 090 32960 $384.52 $273.71 00032488 $5,847.84 $5,847.84 090 32997 $938.58 $938.58 00032491 $3,608.47 $3,608.47 090 32998 $6,433.65 $779.46 00032501 $673.39 $673.39 ZZZ 32999 80% of billed 80% of billed N/A32503 $4,407.47 $4,407.47 090 33010 $330.54 $330.54 00032504 $5,042.14 $5,042.14 090 33011 $331.48 $331.48 00032505 $2,276.26 $2,276.26 090 33015 $1,236.64 $1,236.64 09032506 $429.04 $429.04 ZZZ 33020 $2,149.66 $2,149.66 09032507 $425.25 $425.25 ZZZ 33025 $1,953.47 $1,953.47 09032540 $4,247.33 $4,247.33 090 33030 $4,897.09 $4,897.09 09032550 $2,109.19 $609.93 000 33031 $6,039.83 $6,039.83 09032551 $465.03 $465.03 000 33050 $2,436.39 $2,436.39 09032552 $502.91 $436.61 010 33120 $5,117.59 $5,117.59 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 18 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

33130 $3,380.43 $3,380.43 090 33322 $3,393.00 $3,393.00 09033140 $3,857.48 $3,857.48 090 33330 $3,490.26 $3,490.26 09033141 $358.95 $358.95 ZZZ 33335 $4,556.70 $4,556.70 09033202 $1,898.98 $1,898.98 090 33340 $2,199.17 $2,199.17 00033203 $1,970.24 $1,970.24 090 33361 $3,755.25 $3,755.25 00033206 $1,121.78 $1,121.78 090 33362 $4,106.63 $4,106.63 00033207 $1,196.40 $1,196.40 090 33363 $4,265.74 $4,265.74 00033208 $1,296.17 $1,296.17 090 33364 $4,472.21 $4,472.21 00033210 $493.44 $493.44 000 33365 $4,923.03 $4,923.03 00033211 $503.86 $503.86 000 33366 $5,326.49 $5,326.49 00033212 $810.73 $810.73 090 33367 $1,730.35 $1,730.35 ZZZ33213 $845.95 $845.95 090 33368 $2,075.10 $2,075.10 ZZZ33214 $1,189.69 $1,189.69 090 33369 $2,741.85 $2,741.85 ZZZ33215 $752.88 $752.88 090 33390 $4,642.22 $4,642.22 09033216 $929.79 $929.79 090 33391 $5,500.74 $5,500.74 09033217 $912.18 $912.18 090 33400 $5,554.40 $5,554.40 09033218 $973.38 $973.38 090 33401 $3,587.51 $3,587.51 09033220 $975.06 $975.06 090 33403 $3,639.49 $3,639.49 09033221 $906.31 $906.31 090 33404 $4,321.11 $4,321.11 09033222 $847.62 $847.62 090 33405 $5,541.82 $5,541.82 09033223 $1,021.17 $1,021.17 090 33406 $7,015.73 $7,015.73 09033224 $1,416.86 $1,416.86 000 33410 $6,180.68 $6,180.68 09033225 $1,287.11 $1,287.11 ZZZ 33411 $8,197.04 $8,197.04 09033226 $1,358.14 $1,358.14 000 33412 $7,780.35 $7,780.35 09033227 $852.65 $852.65 090 33413 $7,981.57 $7,981.57 09033228 $888.70 $888.70 090 33414 $5,274.37 $5,274.37 09033229 $936.49 $936.49 090 33415 $4,935.66 $4,935.66 09033230 $965.00 $965.00 090 33416 $4,950.75 $4,950.75 09033231 $1,004.40 $1,004.40 090 33417 $4,094.75 $4,094.75 09033233 $588.56 $588.56 090 33418 $4,384.83 $4,384.83 09033234 $1,207.30 $1,207.30 090 33419 $1,165.88 $1,165.88 ZZZ33235 $1,574.52 $1,574.52 090 33420 $3,808.01 $3,808.01 09033236 $1,919.10 $1,919.10 090 33422 $4,092.23 $4,092.23 09033237 $2,059.95 $2,059.95 090 33425 $6,679.53 $6,679.53 09033238 $2,279.61 $2,279.61 090 33426 $5,813.47 $5,813.47 09033240 $918.89 $918.89 090 33427 $5,963.54 $5,963.54 09033241 $553.34 $553.34 090 33430 $6,837.99 $6,837.99 09033243 $3,337.67 $3,337.67 090 33460 $5,989.53 $5,989.53 09033244 $2,115.28 $2,115.28 090 33463 $7,563.21 $7,563.21 09033249 $2,254.46 $2,254.46 090 33464 $5,963.54 $5,963.54 09033250 $3,595.06 $3,595.06 090 33465 $6,746.60 $6,746.60 09033251 $3,961.44 $3,961.44 090 33468 $6,014.68 $6,014.68 09033254 $3,361.98 $3,361.98 090 33470 $3,170.83 $3,170.83 09033255 $3,950.54 $3,950.54 090 33471 $3,388.81 $3,388.81 09033256 $4,788.94 $4,788.94 090 33474 $5,363.24 $5,363.24 09033257 $1,610.07 $1,610.07 ZZZ 33475 $5,697.77 $5,697.77 09033258 $1,802.33 $1,802.33 ZZZ 33476 $3,755.19 $3,755.19 09033259 $2,329.87 $2,329.87 ZZZ 33477 $3,560.15 $3,560.15 00033261 $3,995.81 $3,995.81 090 33478 $3,844.90 $3,844.90 09033262 $935.65 $935.65 090 33496 $4,101.45 $4,101.45 09033263 $972.54 $972.54 090 33500 $3,835.68 $3,835.68 09033264 $1,013.63 $1,013.63 090 33501 $2,780.13 $2,780.13 09033265 $3,314.20 $3,314.20 090 33502 $3,123.04 $3,123.04 09033266 $4,508.92 $4,508.92 090 33503 $3,271.44 $3,271.44 09033270 $1,437.86 $1,437.86 090 33504 $3,640.33 $3,640.33 09033271 $1,210.65 $1,210.65 090 33505 $5,091.60 $5,091.60 09033272 $854.33 $854.33 090 33506 $5,146.94 $5,146.94 09033273 $979.25 $979.25 090 33507 $4,217.99 $4,217.99 09033282 $578.50 $578.50 090 33508 $43.57 $43.57 ZZZ33284 $512.26 $512.26 090 33510 $4,701.75 $4,701.75 09033300 $6,002.11 $6,002.11 090 33511 $5,177.96 $5,177.96 09033305 $10,042.35 $10,042.35 090 33512 $5,893.95 $5,893.95 09033310 $2,885.77 $2,885.77 090 33513 $6,065.82 $6,065.82 09033315 $4,660.67 $4,660.67 090 33514 $6,387.77 $6,387.77 09033320 $2,594.01 $2,594.01 090 33516 $6,697.14 $6,697.14 09033321 $3,013.21 $3,013.21 090 33517 $515.22 $515.22 ZZZ

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 19 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

33518 $1,130.84 $1,130.84 ZZZ 33777 $4,882.84 $4,882.84 09033519 $1,491.68 $1,491.68 ZZZ 33778 $6,074.21 $6,074.21 09033521 $1,785.28 $1,785.28 ZZZ 33779 $6,041.51 $6,041.51 09033522 $2,005.96 $2,005.96 ZZZ 33780 $5,850.35 $5,850.35 09033523 $2,291.98 $2,291.98 ZZZ 33781 $6,014.68 $6,014.68 09033530 $1,441.49 $1,441.49 ZZZ 33782 $7,974.86 $7,974.86 09033533 $4,566.76 $4,566.76 090 33783 $9,068.97 $9,068.97 09033534 $5,364.92 $5,364.92 090 33786 $5,618.12 $5,618.12 09033535 $5,973.60 $5,973.60 090 33788 $3,948.86 $3,948.86 09033536 $6,432.20 $6,432.20 090 33800 $2,329.08 $2,329.08 09033542 $6,422.98 $6,422.98 090 33802 $2,645.15 $2,645.15 09033545 $7,588.36 $7,588.36 090 33803 $2,821.22 $2,821.22 09033548 $7,247.13 $7,247.13 090 33813 $3,171.67 $3,171.67 09033572 $626.03 $626.03 ZZZ 33814 $3,931.26 $3,931.26 09033600 $4,203.74 $4,203.74 090 33820 $2,387.76 $2,387.76 09033602 $4,148.40 $4,148.40 090 33822 $2,616.65 $2,616.65 09033606 $4,572.63 $4,572.63 090 33824 $2,984.70 $2,984.70 09033608 $4,411.66 $4,411.66 090 33840 $3,160.77 $3,160.77 09033610 $4,667.37 $4,667.37 090 33845 $3,267.24 $3,267.24 09033611 $5,049.68 $5,049.68 090 33851 $2,837.98 $2,837.98 09033612 $4,944.88 $4,944.88 090 33852 $3,450.02 $3,450.02 09033615 $5,006.09 $5,006.09 090 33853 $4,522.33 $4,522.33 09033617 $5,304.56 $5,304.56 090 33860 $7,841.55 $7,841.55 09033619 $6,726.48 $6,726.48 090 33863 $7,692.32 $7,692.32 09033620 $3,783.70 $3,783.70 090 33864 $7,865.87 $7,865.87 09033621 $2,296.38 $2,296.38 090 33870 $6,147.15 $6,147.15 09033622 $8,922.25 $8,922.25 090 33875 $6,737.38 $6,737.38 09033641 $4,037.73 $4,037.73 090 33877 $8,933.99 $8,933.99 09033645 $4,249.01 $4,249.01 090 33880 $4,441.00 $4,441.00 09033647 $4,503.88 $4,503.88 090 33881 $3,813.04 $3,813.04 09033660 $4,261.59 $4,261.59 090 33883 $2,758.34 $2,758.34 09033665 $4,695.88 $4,695.88 090 33884 $1,138.41 $1,138.41 ZZZ33670 $4,866.91 $4,866.91 090 33886 $2,383.57 $2,383.57 09033675 $4,844.27 $4,844.27 090 33889 $2,201.06 $2,201.06 00033676 $5,239.16 $5,239.16 090 33891 $2,705.86 $2,705.86 00033677 $5,443.73 $5,443.73 090 33910 $6,443.10 $6,443.10 09033681 $4,519.81 $4,519.81 090 33915 $3,098.73 $3,098.73 09033684 $4,885.36 $4,885.36 090 33916 $10,342.50 $10,342.50 09033688 $4,631.32 $4,631.32 090 33917 $3,554.82 $3,554.82 09033690 $2,723.12 $2,723.12 090 33920 $4,673.24 $4,673.24 09033692 $5,077.35 $5,077.35 090 33922 $3,421.51 $3,421.51 09033694 $5,049.68 $5,049.68 090 33924 $794.62 $794.62 ZZZ33697 $5,129.33 $5,129.33 090 33925 $4,242.30 $4,242.30 09033702 $3,790.41 $3,790.41 090 33926 $6,272.91 $6,272.91 09033710 $5,312.10 $5,312.10 090 33930 80% of billed 80% of billed N/A33720 $3,816.40 $3,816.40 090 33933 80% of billed 80% of billed N/A33722 $4,164.33 $4,164.33 090 33935 $12,269.15 $12,269.15 09033724 $3,790.41 $3,790.41 090 33940 80% of billed 80% of billed N/A33726 $4,913.86 $4,913.86 090 33944 80% of billed 80% of billed N/A33730 $5,040.46 $5,040.46 090 33945 $11,921.21 $11,921.21 09033732 $4,065.40 $4,065.40 090 33946 $848.60 $848.60 N/A33735 $3,157.41 $3,157.41 090 33947 $938.58 $938.58 N/A33736 $3,444.99 $3,444.99 090 33948 $668.65 $668.65 N/A33737 $3,322.58 $3,322.58 090 33949 $650.66 $650.66 N/A33750 $3,096.21 $3,096.21 090 33951 $1,151.67 $1,151.67 00033755 $3,225.32 $3,225.32 090 33952 $1,191.45 $1,191.45 00033762 $3,293.24 $3,293.24 090 33953 $1,286.16 $1,286.16 00033764 $3,247.12 $3,247.12 090 33954 $1,331.62 $1,331.62 00033766 $3,255.51 $3,255.51 090 33955 $2,313.77 $2,313.77 00033767 $3,510.38 $3,510.38 090 33956 $2,326.08 $2,326.08 00033768 $1,156.41 $1,156.41 ZZZ 33957 $513.33 $513.33 00033770 $5,490.68 $5,490.68 090 33958 $506.70 $506.70 00033771 $5,661.71 $5,661.71 090 33959 $651.60 $651.60 00033774 $4,439.33 $4,439.33 090 33962 $662.97 $662.97 00033775 $4,770.50 $4,770.50 090 33963 $1,305.10 $1,305.10 00033776 $5,038.78 $5,038.78 090 33964 $1,358.14 $1,358.14 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 20 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

33965 $513.33 $513.33 000 34843 80% of billed 80% of billed N/A33966 $654.45 $654.45 000 34844 80% of billed 80% of billed N/A33967 $716.95 $716.95 000 34845 80% of billed 80% of billed N/A33968 $92.82 $92.82 000 34846 80% of billed 80% of billed N/A33969 $760.52 $760.52 000 34847 80% of billed 80% of billed N/A33970 $983.09 $983.09 000 34848 80% of billed 80% of billed N/A33971 $1,738.84 $1,738.84 090 34900 $2,217.57 $2,217.57 09033973 $1,422.54 $1,422.54 000 35001 $2,770.91 $2,770.91 09033974 $2,168.94 $2,168.94 090 35002 $2,815.35 $2,815.35 09033975 $3,640.65 $3,640.65 N/A 35005 $2,679.53 $2,679.53 09033976 $4,432.43 $4,432.43 N/A 35011 $2,483.34 $2,483.34 09033977 $3,122.59 $3,122.59 N/A 35013 $3,110.46 $3,110.46 09033978 $3,714.53 $3,714.53 N/A 35021 $3,102.08 $3,102.08 09033979 $5,397.52 $5,397.52 N/A 35022 $3,435.76 $3,435.76 09033980 $4,942.91 $4,942.91 N/A 35045 $2,459.03 $2,459.03 09033981 $2,325.13 $2,325.13 N/A 35081 $4,332.85 $4,332.85 09033982 $5,497.92 $5,497.92 N/A 35082 $5,449.60 $5,449.60 09033983 $6,411.87 $6,411.87 N/A 35091 $4,450.23 $4,450.23 09033984 $792.72 $792.72 000 35092 $6,452.33 $6,452.33 09033985 $1,432.96 $1,432.96 000 35102 $4,687.49 $4,687.49 09033986 $1,470.85 $1,470.85 000 35103 $5,577.04 $5,577.04 09033987 $578.68 $578.68 ZZZ 35111 $3,771.12 $3,771.12 09033988 $2,158.44 $2,158.44 000 35112 $4,558.38 $4,558.38 09033989 $1,395.08 $1,395.08 000 35121 $4,077.98 $4,077.98 09033990 $1,213.24 $1,213.24 N/A 35122 $5,316.29 $5,316.29 09033991 $1,767.29 $1,767.29 N/A 35131 $3,442.47 $3,442.47 09033992 $575.84 $575.84 N/A 35132 $4,043.60 $4,043.60 09033993 $504.80 $504.80 N/A 35141 $2,744.92 $2,744.92 09033999 80% of billed 80% of billed N/A 35142 $3,281.50 $3,281.50 09034001 $2,418.78 $2,418.78 090 35151 $3,081.12 $3,081.12 09034051 $2,435.55 $2,435.55 090 35152 $3,474.33 $3,474.33 09034101 $1,490.68 $1,490.68 090 35180 $2,305.60 $2,305.60 09034111 $1,487.32 $1,487.32 090 35182 $4,301.83 $4,301.83 09034151 $3,466.78 $3,466.78 090 35184 $2,582.27 $2,582.27 09034201 $2,554.60 $2,554.60 090 35188 $2,862.30 $2,862.30 09034203 $2,366.80 $2,366.80 090 35189 $3,792.92 $3,792.92 09034401 $3,573.26 $3,573.26 090 35190 $1,883.05 $1,883.05 09034421 $1,809.27 $1,809.27 090 35201 $2,347.52 $2,347.52 09034451 $3,575.78 $3,575.78 090 35206 $1,914.07 $1,914.07 09034471 $2,675.33 $2,675.33 090 35207 $1,854.54 $1,854.54 09034490 $1,521.70 $1,521.70 090 35211 $3,369.53 $3,369.53 09034501 $2,421.30 $2,421.30 090 35216 $5,037.95 $5,037.95 09034502 $3,779.51 $3,779.51 090 35221 $3,574.94 $3,574.94 09034510 $2,934.40 $2,934.40 090 35226 $2,060.79 $2,060.79 09034520 $2,485.02 $2,485.02 090 35231 $2,970.45 $2,970.45 09034530 $2,694.62 $2,694.62 090 35236 $2,419.62 $2,419.62 09034800 $2,798.58 $2,798.58 090 35241 $3,356.12 $3,356.12 09034802 $3,084.47 $3,084.47 090 35246 $3,883.47 $3,883.47 09034803 $3,185.08 $3,185.08 090 35251 $4,195.35 $4,195.35 09034804 $3,081.96 $3,081.96 090 35256 $2,525.26 $2,525.26 09034805 $2,952.01 $2,952.01 090 35261 $2,599.88 $2,599.88 09034806 $279.39 $279.39 ZZZ 35266 $2,159.72 $2,159.72 09034808 $578.68 $578.68 ZZZ 35271 $3,356.95 $3,356.95 09034812 $944.26 $944.26 000 35276 $3,591.71 $3,591.71 09034813 $661.08 $661.08 ZZZ 35281 $3,993.30 $3,993.30 09034820 $1,377.08 $1,377.08 000 35286 $2,320.69 $2,320.69 09034825 $1,717.04 $1,717.04 090 35301 $2,803.61 $2,803.61 09034826 $571.10 $571.10 ZZZ 35302 $2,789.36 $2,789.36 09034830 $4,373.93 $4,373.93 090 35303 $3,087.83 $3,087.83 09034831 $4,713.48 $4,713.48 090 35304 $3,177.54 $3,177.54 09034832 $4,676.59 $4,676.59 090 35305 $3,045.07 $3,045.07 09034833 $1,703.83 $1,703.83 000 35306 $1,271.01 $1,271.01 ZZZ34834 $764.31 $764.31 000 35311 $3,614.34 $3,614.34 09034839 80% of billed 80% of billed N/A 35321 $2,208.35 $2,208.35 09034841 80% of billed 80% of billed N/A 35331 $3,590.87 $3,590.87 09034842 80% of billed 80% of billed N/A 35341 $3,387.97 $3,387.97 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 21 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

35351 $3,174.18 $3,174.18 090 35638 $4,381.48 $4,381.48 09035355 $2,569.70 $2,569.70 090 35642 $2,446.45 $2,446.45 09035361 $3,814.72 $3,814.72 090 35645 $2,539.51 $2,539.51 09035363 $4,350.46 $4,350.46 090 35646 $4,264.94 $4,264.94 09035371 $2,030.60 $2,030.60 090 35647 $3,874.25 $3,874.25 09035372 $2,433.04 $2,433.04 090 35650 $2,673.66 $2,673.66 09035390 $441.35 $441.35 ZZZ 35654 $3,403.07 $3,403.07 09035400 $417.67 $417.67 ZZZ 35656 $2,692.94 $2,692.94 09035450 $1,415.91 $1,415.91 000 35661 $2,696.29 $2,696.29 09035452 $954.68 $954.68 000 35663 $3,124.72 $3,124.72 09035458 $1,380.87 $1,380.87 000 35665 $2,914.28 $2,914.28 09035460 $879.86 $879.86 000 35666 $3,149.87 $3,149.87 09035471 $6,882.58 $1,451.90 000 35671 $2,775.94 $2,775.94 09035472 $4,960.91 $989.72 000 35681 $220.67 $220.67 ZZZ35475 $4,191.86 $922.48 000 35682 $991.61 $991.61 ZZZ35476 $3,842.38 $745.37 000 35683 $1,155.46 $1,155.46 ZZZ35500 $887.43 $887.43 ZZZ 35685 $555.00 $555.00 ZZZ35501 $3,710.76 $3,710.76 090 35686 $452.71 $452.71 ZZZ35506 $3,163.28 $3,163.28 090 35691 $2,386.92 $2,386.92 09035508 $3,360.31 $3,360.31 090 35693 $2,019.71 $2,019.71 09035509 $3,501.16 $3,501.16 090 35694 $2,458.19 $2,458.19 09035510 $3,055.13 $3,055.13 090 35695 $2,608.26 $2,608.26 09035511 $2,782.65 $2,782.65 090 35697 $411.04 $411.04 ZZZ35512 $3,027.46 $3,027.46 090 35700 $425.25 $425.25 ZZZ35515 $3,560.68 $3,560.68 090 35701 $1,386.71 $1,386.71 09035516 $3,029.14 $3,029.14 090 35721 $1,121.78 $1,121.78 09035518 $2,880.74 $2,880.74 090 35741 $1,266.82 $1,266.82 09035521 $3,066.03 $3,066.03 090 35761 $955.78 $955.78 09035522 $2,996.44 $2,996.44 090 35800 $1,759.80 $1,759.80 09035523 $3,181.73 $3,181.73 090 35820 $4,933.15 $4,933.15 09035525 $2,839.66 $2,839.66 090 35840 $2,920.99 $2,920.99 09035526 $4,218.83 $4,218.83 090 35860 $2,084.26 $2,084.26 09035531 $5,025.37 $5,025.37 090 35870 $3,086.99 $3,086.99 09035533 $3,716.63 $3,716.63 090 35875 $1,478.94 $1,478.94 09035535 $4,755.40 $4,755.40 090 35876 $2,343.33 $2,343.33 09035536 $4,194.52 $4,194.52 090 35879 $2,289.67 $2,289.67 09035537 $5,425.29 $5,425.29 090 35881 $2,530.29 $2,530.29 09035538 $5,822.69 $5,822.69 090 35883 $2,998.12 $2,998.12 09035539 $5,449.60 $5,449.60 090 35884 $3,073.57 $3,073.57 09035540 $6,090.14 $6,090.14 090 35901 $1,171.24 $1,171.24 09035556 $3,472.65 $3,472.65 090 35903 $1,400.13 $1,400.13 09035558 $3,063.51 $3,063.51 090 35905 $4,179.42 $4,179.42 09035560 $4,259.07 $4,259.07 090 35907 $4,750.37 $4,750.37 09035563 $3,287.37 $3,287.37 090 36000 $69.14 $25.57 N/A35565 $3,289.04 $3,289.04 090 36002 $438.51 $292.65 00035566 $4,145.89 $4,145.89 090 36005 $878.91 $132.59 00035570 $3,774.48 $3,774.48 090 36010 $1,339.20 $337.17 N/A35571 $3,299.94 $3,299.94 090 36011 $2,230.42 $432.82 N/A35572 $965.09 $965.09 ZZZ 36012 $2,317.55 $482.07 N/A35583 $3,590.87 $3,590.87 090 36013 $2,134.76 $350.43 N/A35585 $4,165.17 $4,165.17 090 36014 $2,185.91 $412.94 N/A35587 $3,389.65 $3,389.65 090 36015 $2,338.39 $472.60 N/A35600 $697.07 $697.07 ZZZ 36100 $1,313.63 $427.14 N/A35601 $3,481.88 $3,481.88 090 36120 $1,133.68 $277.50 N/A35606 $2,912.60 $2,912.60 090 36140 $1,167.77 $284.13 N/A35612 $2,668.63 $2,668.63 090 36147 $2,254.10 $513.33 N/A35616 $2,739.05 $2,739.05 090 36148 $704.64 $135.44 ZZZ35621 $2,730.67 $2,730.67 090 36160 $1,326.89 $340.01 N/A35623 $3,263.05 $3,263.05 090 36200 $1,679.21 $424.30 00035626 $3,897.72 $3,897.72 090 36215 $3,028.83 $648.76 N/A35631 $4,594.43 $4,594.43 090 36216 $3,240.03 $767.15 N/A35632 $4,471.19 $4,471.19 090 36217 $5,411.73 $913.95 N/A35633 $4,978.42 $4,978.42 090 36218 $519.01 $146.80 ZZZ35634 $4,381.48 $4,381.48 090 36221 $2,954.00 $595.73 00035636 $3,996.65 $3,996.65 090 36222 $3,545.00 $817.35 00035637 $4,288.42 $4,288.42 090 36223 $4,147.35 $893.12 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 22 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

36224 $4,891.77 $993.51 000 36580 $578.68 $183.74 00036225 $4,050.75 $879.86 000 36581 $2,066.57 $538.90 01036226 $4,965.65 $997.30 000 36582 $2,973.89 $842.92 01036227 $680.02 $314.44 ZZZ 36583 $3,693.69 $934.79 01036228 $3,282.65 $644.98 ZZZ 36584 $551.21 $181.84 00036245 $3,691.80 $697.07 N/A 36585 $3,105.54 $781.36 01036246 $2,400.90 $744.42 000 36589 $447.98 $377.89 01036247 $4,246.80 $881.75 000 36590 $795.56 $563.52 01036248 $411.99 $136.38 ZZZ 36591 $62.51 $62.51 N/A36251 $3,840.49 $777.57 000 36592 $70.09 $70.09 N/A36252 $4,165.35 $1,037.07 000 36593 $83.34 $83.34 N/A36253 $6,093.64 $1,043.70 000 36595 $1,575.97 $505.75 00036254 $5,933.58 $1,204.71 000 36596 $359.90 $123.12 00036260 $1,538.46 $1,538.46 090 36597 $343.80 $168.58 00036261 $893.73 $893.73 090 36598 $297.39 $101.34 00036262 $744.50 $744.50 090 36600 $85.24 $42.62 N/A36299 80% of billed 80% of billed N/A 36620 $141.12 $141.12 00036400 $80.50 $54.93 N/A 36625 $286.97 $286.97 00036405 $70.09 $44.51 N/A 36640 $323.91 $323.91 00036406 $45.46 $22.73 N/A 36660 $176.16 $176.16 00036410 $45.46 $25.57 N/A 36680 $160.06 $160.06 00036415 80% of billed 80% of billed N/A 36800 $339.06 $339.06 00036416 80% of billed 80% of billed N/A 36810 $600.46 $600.46 00036420 $143.01 $143.01 N/A 36815 $404.41 $404.41 00036425 $108.92 $108.92 N/A 36818 $1,716.20 $1,716.20 09036430 $92.82 $92.82 N/A 36819 $1,813.46 $1,813.46 09036440 $156.27 $156.27 N/A 36820 $1,810.11 $1,810.11 09036450 $319.17 $319.17 N/A 36821 $1,644.10 $1,644.10 09036455 $346.64 $346.64 N/A 36823 $3,300.78 $3,300.78 09036456 $292.65 $292.65 N/A 36825 $1,984.49 $1,984.49 09036460 $946.15 $946.15 N/A 36830 $1,649.97 $1,649.97 09036468 80% of billed 80% of billed 000 36831 $1,529.24 $1,529.24 09036470 $402.52 $229.20 010 36832 $1,874.66 $1,874.66 09036471 $471.66 $275.61 010 36833 $2,008.81 $2,008.81 09036473 $4,017.60 $474.50 000 36835 $1,217.36 $1,217.36 09036474 $735.90 $237.72 ZZZ 36838 $2,832.12 $2,832.12 09036475 $4,142.62 $778.52 000 36860 $560.68 $302.12 00036476 $804.09 $376.00 ZZZ 36861 $364.63 $364.63 00036478 $3,254.24 $774.73 000 36870 $4,368.90 $730.25 09036479 $836.29 $377.89 ZZZ 36901 $1,532.41 $398.73 00036481 $5,483.71 $958.47 000 36902 $3,258.97 $593.83 00036500 $502.91 $502.91 000 36903 $14,945.24 $812.61 00036510 $244.35 $151.54 000 36904 $4,751.60 $935.73 00036511 $254.77 $254.77 000 36905 $6,080.38 $1,174.40 00036512 $256.66 $256.66 000 36906 $18,122.76 $1,370.45 00036513 $264.24 $264.24 000 36907 $1,950.08 $341.90 ZZZ36514 $1,445.27 $252.88 000 36908 $7,182.81 $512.38 ZZZ36515 $5,527.28 $238.67 000 36909 $5,239.36 $486.81 ZZZ36516 $5,586.94 $190.37 000 37140 $5,595.48 $5,595.48 09036522 $3,762.83 $277.50 000 37145 $5,251.74 $5,251.74 09036555 $721.69 $328.64 000 37160 $5,393.43 $5,393.43 09036556 $636.45 $332.43 000 37180 $4,968.36 $4,968.36 09036557 $2,722.91 $905.43 010 37181 $5,674.29 $5,674.29 09036558 $2,107.30 $758.63 010 37182 $2,294.82 $2,294.82 00036560 $3,633.08 $1,073.06 010 37183 $15,909.39 $1,082.54 00036561 $3,173.73 $975.51 010 37184 $6,120.16 $1,274.80 00036563 $3,598.03 $1,054.12 010 37185 $1,947.24 $465.97 ZZZ36565 $2,632.94 $964.15 010 37186 $3,715.47 $693.28 ZZZ36566 $14,715.09 $1,062.65 010 37187 $5,545.27 $1,128.00 00036568 $813.56 $266.14 000 37188 $4,788.54 $810.72 00036569 $673.39 $250.98 000 37191 $7,087.15 $660.13 00036570 $3,123.54 $853.34 010 37192 $4,174.82 $1,017.19 00036571 $3,527.00 $891.22 010 37193 $4,312.15 $1,012.45 00036575 $447.98 $96.60 000 37195 80% of billed 80% of billed N/A36576 $1,052.23 $544.58 010 37197 $4,098.10 $875.12 00036578 $1,405.50 $595.73 010 37200 $605.20 $605.20 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 23 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

37211 $1,107.16 $1,107.16 000 38100 $2,812.83 $2,812.83 09037212 $973.62 $973.62 000 38101 $2,819.54 $2,819.54 09037213 $683.81 $683.81 000 38102 $721.69 $721.69 ZZZ37214 $374.10 $374.10 000 38115 $3,085.31 $3,085.31 09037215 $2,465.73 $2,465.73 090 38120 $2,562.99 $2,562.99 09037216 80% of billed 80% of billed 090 38129 80% of billed 80% of billed N/A37217 $2,690.43 $2,690.43 090 38200 $318.23 $318.23 00037218 $2,018.03 $2,018.03 090 38204 $287.92 $287.92 N/A37220 $8,510.64 $1,157.36 000 38205 $224.46 $224.46 00037221 $12,541.50 $1,421.60 000 38206 $226.36 $226.36 00037222 $2,390.48 $521.85 ZZZ 38207 $127.86 $127.86 N/A37223 $6,974.44 $598.57 ZZZ 38208 $80.50 $80.50 N/A37224 $10,323.39 $1,272.90 000 38209 $34.10 $34.10 N/A37225 $29,658.44 $1,726.56 000 38210 $225.41 $225.41 N/A37226 $24,383.09 $1,496.42 000 38211 $203.63 $203.63 N/A37227 $40,050.96 $2,077.94 000 38212 $135.44 $135.44 N/A37228 $14,666.79 $1,556.09 000 38213 $34.10 $34.10 N/A37229 $29,222.77 $2,013.53 000 38214 $116.49 $116.49 N/A37230 $22,353.45 $1,984.17 000 38215 $135.44 $135.44 N/A37231 $35,961.39 $2,156.55 000 38220 $443.24 $167.64 N/A37232 $3,268.44 $565.42 ZZZ 38221 $449.87 $203.63 N/A37233 $3,948.46 $920.58 ZZZ 38230 $542.69 $542.69 00037234 $10,442.72 $793.67 ZZZ 38232 $540.79 $540.79 00037235 $10,994.88 $1,127.05 ZZZ 38240 $608.04 $608.04 N/A37236 $11,077.28 $1,259.64 000 38241 $455.56 $455.56 N/A37237 $6,622.12 $593.83 ZZZ 38242 $320.12 $320.12 00037238 $11,289.43 $872.28 000 38243 $319.17 $319.17 00037239 $5,464.77 $415.78 ZZZ 38300 $745.37 $501.96 01037241 $12,876.77 $1,250.17 000 38305 $1,155.32 $1,155.32 09037242 $20,634.47 $1,365.72 000 38308 $1,071.48 $1,071.48 09037243 $26,202.47 $1,611.02 000 38380 $1,380.84 $1,380.84 09037244 $18,259.14 $1,887.57 000 38381 $1,955.99 $1,955.99 09037246 $5,739.43 $974.57 000 38382 $1,499.06 $1,499.06 09037247 $2,322.29 $483.02 ZZZ 38500 $904.48 $698.01 01037248 $3,975.93 $838.18 000 38505 $341.90 $195.10 00037249 $1,703.83 $411.04 ZZZ 38510 $1,419.70 $1,155.46 01037252 $3,759.99 $255.72 ZZZ 38520 $1,127.65 $1,127.65 09037253 $584.36 $204.57 ZZZ 38525 $1,062.25 $1,062.25 09037500 $1,867.96 $1,867.96 090 38530 $1,337.25 $1,337.25 09037501 80% of billed 80% of billed N/A 38542 $1,260.12 $1,260.12 09037565 $1,772.38 $1,772.38 090 38550 $1,228.26 $1,228.26 09037600 $1,740.52 $1,740.52 090 38555 $2,442.26 $2,442.26 09037605 $1,979.46 $1,979.46 090 38562 $1,702.79 $1,702.79 09037606 $1,425.28 $1,425.28 090 38564 $1,713.69 $1,713.69 09037607 $928.11 $928.11 090 38570 $1,378.98 $1,378.98 01037609 $843.87 $571.10 010 38571 $1,818.43 $1,818.43 01037615 $1,248.38 $1,248.38 090 38572 $2,538.23 $2,538.23 01037616 $2,699.65 $2,699.65 090 38589 80% of billed 80% of billed N/A37617 $3,279.82 $3,279.82 090 38700 $1,960.18 $1,960.18 09037618 $944.04 $944.04 090 38720 $3,275.63 $3,275.63 09037619 $4,020.13 $4,020.13 090 38724 $3,539.72 $3,539.72 09037650 $1,255.08 $1,255.08 090 38740 $1,687.70 $1,687.70 09037660 $2,859.78 $2,859.78 090 38745 $2,129.54 $2,129.54 09037700 $614.55 $614.55 090 38746 $587.20 $587.20 ZZZ37718 $1,080.70 $1,080.70 090 38747 $733.06 $733.06 ZZZ37722 $1,183.82 $1,183.82 090 38760 $2,044.86 $2,044.86 09037735 $1,692.73 $1,692.73 090 38765 $3,143.16 $3,143.16 09037760 $1,525.05 $1,525.05 090 38770 $1,955.15 $1,955.15 09037761 $1,359.88 $1,359.88 090 38780 $2,481.66 $2,481.66 09037765 $1,583.74 $1,107.53 090 38790 $228.25 $228.25 00037766 $1,882.21 $1,351.50 090 38792 $107.02 $107.02 00037780 $626.28 $626.28 090 38794 $720.19 $720.19 09037785 $865.23 $645.57 090 38900 $379.79 $379.79 ZZZ37788 $3,123.88 $3,123.88 090 38999 80% of billed 80% of billed N/A37790 $1,219.87 $1,219.87 090 39000 $1,212.33 $1,212.33 09037799 80% of billed 80% of billed N/A 39010 $1,922.45 $1,922.45 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 24 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

39200 $2,158.88 $2,158.88 090 41112 $824.15 $626.28 09039220 $2,777.62 $2,777.62 090 41113 $902.12 $694.20 09039401 $861.86 $861.86 000 41114 $1,565.29 $1,565.29 09039402 $1,124.21 $1,124.21 000 41115 $687.59 $426.19 01039499 80% of billed 80% of billed N/A 41116 $815.76 $544.96 09039501 $2,060.79 $2,060.79 090 41120 $2,667.79 $2,667.79 09039503 $15,004.84 $15,004.84 090 41130 $3,282.34 $3,282.34 09039540 $2,106.06 $2,106.06 090 41135 $5,378.34 $5,378.34 09039541 $2,297.22 $2,297.22 090 41140 $5,424.45 $5,424.45 09039545 $2,183.19 $2,183.19 090 41145 $6,893.32 $6,893.32 09039560 $1,935.87 $1,935.87 090 41150 $5,458.82 $5,458.82 09039561 $3,024.11 $3,024.11 090 41153 $5,948.45 $5,948.45 09039599 80% of billed 80% of billed N/A 41155 $7,455.89 $7,455.89 09040490 $349.48 $200.79 000 41250 $736.84 $425.25 01040500 $1,229.09 $890.38 090 41251 $803.14 $504.80 01040510 $1,178.79 $872.77 090 41252 $871.33 $582.47 01040520 $1,192.20 $878.64 090 41500 $1,013.63 $1,013.63 09040525 $1,351.50 $1,351.50 090 41510 $1,037.94 $1,037.94 09040527 $1,506.60 $1,506.60 090 41512 $1,634.88 $1,634.88 09040530 $1,314.61 $987.64 090 41520 $871.10 $639.70 09040650 $1,071.48 $729.41 090 41530 $2,713.44 $1,046.55 00040652 $1,186.34 $861.04 090 41599 80% of billed 80% of billed N/A40654 $1,390.91 $1,043.81 090 41800 $751.05 $408.20 01040700 $2,203.32 $2,203.32 090 41805 $717.90 $488.70 01040701 $2,469.93 $2,469.93 090 41806 $986.88 $730.21 01040702 $2,070.85 $2,070.85 090 41820 80% of billed 80% of billed 00040720 $2,506.82 $2,506.82 090 41821 80% of billed 80% of billed 00040761 $2,652.70 $2,652.70 090 41822 $816.40 $511.43 01040799 80% of billed 80% of billed N/A 41823 $1,055.55 $803.19 09040800 $590.04 $367.47 010 41825 $590.04 $343.80 01040801 $877.96 $622.24 010 41826 $879.86 $597.62 01040804 $527.53 $325.80 010 41827 $1,088.24 $763.78 09040805 $1,009.61 $615.61 010 41828 $860.91 $595.73 01040806 $309.70 $89.03 000 41830 $1,098.64 $800.30 01040808 $518.06 $303.07 010 41850 80% of billed 80% of billed 00040810 $572.05 $357.06 010 41870 80% of billed 80% of billed 00040812 $803.14 $553.11 010 41872 $902.96 $637.18 09040814 $949.07 $757.08 090 41874 $930.62 $637.18 09040816 $990.99 $784.74 090 41899 80% of billed 80% of billed N/A40818 $878.64 $672.40 090 42000 $439.45 $288.87 01040819 $781.39 $596.10 090 42100 $415.78 $305.91 01040820 $736.84 $480.18 010 42104 $597.62 $388.31 01040830 $734.95 $459.34 010 42106 $762.42 $500.07 01040831 $937.63 $625.09 010 42107 $1,136.03 $857.68 09040840 $1,991.20 $1,547.69 090 42120 $2,514.36 $2,514.36 09040842 $1,906.52 $1,478.10 090 42140 $618.74 $379.80 09040843 $2,652.70 $2,090.97 090 42145 $1,722.91 $1,722.91 09040844 $3,176.70 $2,572.21 090 42160 $642.13 $409.15 01040845 $3,577.45 $3,009.86 090 42180 $673.39 $509.54 01040899 80% of billed 80% of billed N/A 42182 $883.64 $707.48 01041000 $449.87 $313.49 010 42200 $2,084.26 $2,084.26 09041005 $628.87 $348.53 010 42205 $2,166.43 $2,166.43 09041006 $876.97 $619.58 090 42210 $2,426.33 $2,426.33 09041007 $856.84 $596.94 090 42215 $1,612.24 $1,612.24 09041008 $933.14 $668.20 090 42220 $1,216.52 $1,216.52 09041009 $990.99 $724.38 090 42225 $2,149.66 $2,149.66 09041010 $559.74 $301.18 010 42226 $2,199.96 $2,199.96 09041015 $1,118.43 $871.10 090 42227 $2,083.42 $2,083.42 09041016 $1,086.57 $871.94 090 42235 $1,797.53 $1,797.53 09041017 $1,097.47 $877.80 090 42260 $1,992.04 $1,628.17 09041018 $1,250.05 $1,026.20 090 42280 $459.34 $307.81 01041019 $1,280.48 $1,280.48 000 42281 $565.42 $418.62 01041100 $465.03 $300.23 010 42299 80% of billed 80% of billed N/A41105 $473.55 $311.60 010 42300 $577.73 $423.35 01041108 $409.15 $251.93 010 42305 $1,056.38 $1,056.38 09041110 $587.20 $366.53 010 42310 $443.24 $342.85 010

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 25 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

42320 $688.54 $484.92 010 43100 $1,522.53 $1,522.53 09042330 $641.19 $456.50 010 43101 $2,495.92 $2,495.92 09042335 $917.21 $632.99 090 43107 $6,253.63 $6,253.63 09042340 $1,132.68 $822.47 090 43108 $11,211.92 $11,211.92 09042400 $290.76 $151.54 000 43112 $6,603.24 $6,603.24 09042405 $822.08 $624.14 010 43113 $11,089.52 $11,089.52 09042408 $1,101.66 $796.48 090 43116 $12,383.17 $12,383.17 09042409 $811.57 $541.61 090 43117 $6,042.35 $6,042.35 09042410 $1,519.18 $1,519.18 090 43118 $9,046.34 $9,046.34 09042415 $2,577.24 $2,577.24 090 43121 $7,050.11 $7,050.11 09042420 $2,895.00 $2,895.00 090 43122 $6,280.45 $6,280.45 09042425 $2,039.83 $2,039.83 090 43123 $11,571.60 $11,571.60 09042426 $3,291.56 $3,291.56 090 43124 $9,395.95 $9,395.95 09042440 $1,006.92 $1,006.92 090 43130 $1,921.61 $1,921.61 09042450 $1,103.33 $877.80 090 43135 $3,635.30 $3,635.30 09042500 $1,059.74 $839.24 090 43180 $1,342.28 $1,342.28 09042505 $1,359.05 $1,112.56 090 43191 $425.25 $425.25 00042507 $1,261.79 $1,261.79 090 43192 $468.81 $468.81 00042509 $2,065.82 $2,065.82 090 43193 $467.87 $467.87 00042510 $1,575.35 $1,575.35 090 43194 $532.27 $532.27 00042550 $364.63 $173.32 000 43195 $508.59 $508.59 00042600 $1,167.89 $850.98 090 43196 $544.58 $544.58 00042650 $231.09 $162.90 000 43197 $512.38 $228.25 00042660 $352.32 $247.19 000 43198 $569.21 $273.71 00042665 $751.21 $498.85 090 43200 $734.00 $258.56 00042699 80% of billed 80% of billed N/A 43201 $746.31 $302.12 00042700 $521.85 $375.05 010 43202 $977.41 $302.12 00042720 $1,253.01 $1,084.43 010 43204 $390.21 $390.21 00042725 $1,998.75 $1,998.75 090 43205 $407.25 $407.25 00042800 $435.67 $309.70 010 43206 $890.27 $390.21 00042804 $537.95 $313.49 010 43210 $1,177.25 $1,177.25 N/A42806 $604.25 $365.58 010 43211 $670.55 $670.55 00042808 $625.09 $447.98 010 43212 $543.64 $543.64 00042809 $555.95 $337.17 010 43213 $3,296.86 $732.11 00042810 $944.04 $706.77 090 43214 $548.37 $548.37 00042815 $1,366.59 $1,366.59 090 43215 $1,129.89 $409.15 00042820 $708.45 $708.45 090 43216 $1,115.68 $387.36 00042821 $735.28 $735.28 090 43217 $1,204.71 $462.18 00042825 $639.70 $639.70 090 43220 $3,052.50 $342.85 00042826 $613.71 $613.71 090 43226 $1,026.66 $378.84 00042830 $505.56 $505.56 090 43227 $1,872.42 $474.50 00042831 $546.64 $546.64 090 43229 $1,945.34 $564.47 00042835 $469.50 $469.50 090 43231 $1,079.69 $460.29 00042836 $587.72 $587.72 090 43232 $1,289.00 $566.37 00042842 $2,508.49 $2,508.49 090 43233 $648.76 $648.76 00042844 $3,435.76 $3,435.76 090 43235 $838.18 $356.11 00042845 $5,533.44 $5,533.44 090 43236 $1,042.76 $400.62 00042860 $459.44 $459.44 090 43237 $559.74 $559.74 00042870 $1,478.94 $1,478.94 090 43238 $662.97 $662.97 00042890 $3,544.76 $3,544.76 090 43239 $1,069.28 $399.68 00042892 $4,678.27 $4,678.27 090 43240 $1,109.05 $1,109.05 00042894 $5,882.21 $5,882.21 090 43241 $411.04 $411.04 00042900 $931.00 $931.00 010 43242 $747.26 $747.26 00042950 $2,024.74 $2,024.74 090 43243 $675.28 $675.28 00042953 $2,438.91 $2,438.91 090 43244 $698.96 $698.96 00042955 $1,909.04 $1,909.04 090 43245 $1,652.69 $503.86 00042960 $469.76 $469.76 010 43246 $572.05 $572.05 00042961 $1,036.26 $1,036.26 090 43247 $1,120.42 $508.59 00042962 $1,269.34 $1,269.34 090 43248 $1,099.58 $477.34 00042970 $983.44 $983.44 090 43249 $2,890.55 $442.30 00042971 $1,116.75 $1,116.75 090 43250 $1,227.44 $487.76 00042972 $1,250.05 $1,250.05 090 43251 $1,343.93 $561.63 00042999 80% of billed 80% of billed N/A 43252 $989.72 $483.02 00043020 $1,292.81 $1,292.81 090 43253 $745.37 $745.37 00043030 $1,266.82 $1,266.82 090 43254 $768.10 $768.10 00043045 $3,200.17 $3,200.17 090 43255 $1,964.29 $573.94 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 26 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

43257 $663.92 $663.92 000 43605 $2,038.99 $2,038.99 09043259 $644.98 $644.98 000 43610 $2,386.09 $2,386.09 09043260 $913.00 $913.00 000 43611 $2,983.87 $2,983.87 09043261 $959.41 $959.41 000 43620 $4,773.85 $4,773.85 09043262 $1,010.56 $1,010.56 000 43621 $5,543.50 $5,543.50 09043263 $1,012.45 $1,012.45 000 43622 $5,650.82 $5,650.82 09043264 $1,029.50 $1,029.50 000 43631 $3,531.34 $3,531.34 09043265 $1,223.65 $1,223.65 000 43632 $4,953.27 $4,953.27 09043266 $644.98 $644.98 000 43633 $4,679.95 $4,679.95 09043270 $2,023.01 $662.97 000 43634 $5,162.03 $5,162.03 09043273 $333.38 $333.38 ZZZ 43635 $308.75 $308.75 ZZZ43274 $1,306.05 $1,306.05 000 43640 $2,869.84 $2,869.84 09043275 $1,064.54 $1,064.54 000 43641 $2,890.80 $2,890.80 09043276 $1,359.09 $1,359.09 000 43644 $4,209.61 $4,209.61 09043277 $1,070.22 $1,070.22 000 43645 $4,496.34 $4,496.34 09043278 $1,222.71 $1,222.71 000 43647 80% of billed 80% of billed N/A43279 $3,153.22 $3,153.22 090 43648 80% of billed 80% of billed N/A43280 $2,631.74 $2,631.74 090 43651 $1,588.77 $1,588.77 09043281 $3,757.71 $3,757.71 090 43652 $1,863.76 $1,863.76 09043282 $4,223.02 $4,223.02 090 43653 $1,391.74 $1,391.74 09043283 $435.67 $435.67 ZZZ 43659 80% of billed 80% of billed N/A43284 $1,575.35 $1,575.35 090 43752 $111.76 $111.76 00043285 $1,593.80 $1,593.80 090 43753 $59.67 $59.67 00043289 80% of billed 80% of billed N/A 43754 $286.02 $89.97 00043300 $1,504.09 $1,504.09 090 43755 $380.73 $168.58 00043305 $2,680.36 $2,680.36 090 43756 $554.05 $141.12 00043310 $3,650.39 $3,650.39 090 43757 $782.30 $213.10 00043312 $3,958.92 $3,958.92 090 43760 $1,313.63 $128.81 00043313 $6,599.05 $6,599.05 090 43761 $316.33 $281.29 00043314 $7,543.92 $7,543.92 090 43770 $2,722.28 $2,722.28 09043320 $3,396.36 $3,396.36 090 43771 $3,098.73 $3,098.73 09043325 $3,265.57 $3,265.57 090 43772 $2,306.44 $2,306.44 09043327 $1,998.75 $1,998.75 090 43773 $3,087.83 $3,087.83 09043328 $2,774.27 $2,774.27 090 43774 $2,331.59 $2,331.59 09043330 $3,242.09 $3,242.09 090 43775 $2,981.35 $2,981.35 09043331 $3,298.27 $3,298.27 090 43800 $2,262.00 $2,262.00 09043332 $2,829.60 $2,829.60 090 43810 $2,476.63 $2,476.63 09043333 $3,086.15 $3,086.15 090 43820 $3,268.92 $3,268.92 09043334 $3,069.38 $3,069.38 090 43825 $3,181.73 $3,181.73 09043335 $3,294.91 $3,294.91 090 43830 $1,701.95 $1,701.95 09043336 $3,693.15 $3,693.15 090 43831 $1,417.73 $1,417.73 09043337 $3,983.24 $3,983.24 090 43832 $2,530.29 $2,530.29 09043338 $321.07 $321.07 ZZZ 43840 $3,311.68 $3,311.68 09043340 $3,323.42 $3,323.42 090 43842 $2,894.16 $2,894.16 09043341 $3,610.15 $3,610.15 090 43843 $3,114.66 $3,114.66 09043351 $3,150.71 $3,150.71 090 43845 $4,778.04 $4,778.04 09043352 $2,623.35 $2,623.35 090 43846 $3,924.55 $3,924.55 09043360 $5,779.93 $5,779.93 090 43847 $4,325.31 $4,325.31 09043361 $6,268.72 $6,268.72 090 43848 $4,688.33 $4,688.33 09043400 $3,621.05 $3,621.05 090 43850 $3,953.06 $3,953.06 09043401 $3,823.94 $3,823.94 090 43855 $4,000.01 $4,000.01 09043405 $3,581.64 $3,581.64 090 43860 $3,983.24 $3,983.24 09043410 $2,564.67 $2,564.67 090 43865 $4,150.92 $4,150.92 09043415 $6,301.41 $6,301.41 090 43870 $1,731.30 $1,731.30 09043420 $2,479.15 $2,479.15 090 43880 $3,894.37 $3,894.37 09043425 $3,527.15 $3,527.15 090 43881 80% of billed 80% of billed N/A43450 $570.15 $234.88 000 43882 80% of billed 80% of billed N/A43453 $2,599.79 $252.88 000 43886 $877.80 $877.80 09043460 $592.88 $592.88 000 43887 $785.58 $785.58 09043496 80% of billed 80% of billed 090 43888 $1,112.56 $1,112.56 09043499 80% of billed 80% of billed N/A 43999 80% of billed 80% of billed N/A43500 $1,907.36 $1,907.36 090 44005 $2,664.44 $2,664.44 09043501 $3,275.63 $3,275.63 090 44010 $2,099.35 $2,099.35 09043502 $3,710.76 $3,710.76 090 44015 $392.10 $392.10 ZZZ43510 $2,301.41 $2,301.41 090 44020 $2,373.51 $2,373.51 09043520 $1,677.64 $1,677.64 090 44021 $2,372.67 $2,372.67 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 27 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

44025 $2,402.02 $2,402.02 090 44369 $699.91 $699.91 00044050 $2,279.61 $2,279.61 090 44370 $757.68 $757.68 00044055 $3,635.30 $3,635.30 090 44372 $683.81 $683.81 00044100 $299.28 $299.28 000 44373 $549.32 $549.32 00044110 $2,074.20 $2,074.20 090 44376 $805.98 $805.98 00044111 $2,398.66 $2,398.66 090 44377 $850.50 $850.50 00044120 $2,982.19 $2,982.19 090 44378 $1,087.27 $1,087.27 00044121 $666.76 $666.76 ZZZ 44379 $1,158.30 $1,158.30 00044125 $2,877.39 $2,877.39 090 44380 $592.88 $171.43 00044126 $6,014.68 $6,014.68 090 44381 $2,690.71 $250.98 00044127 $6,904.22 $6,904.22 090 44382 $860.91 $217.83 00044128 $677.18 $677.18 ZZZ 44384 $434.72 $434.72 00044130 $3,199.33 $3,199.33 090 44385 $654.45 $212.15 00044132 80% of billed 80% of billed N/A 44386 $921.53 $262.35 00044133 80% of billed 80% of billed N/A 44388 $950.89 $449.87 00044135 80% of billed 80% of billed N/A 44388 53 $471.66 $221.62 00044136 80% of billed 80% of billed N/A 44389 $1,199.03 $493.44 00044137 80% of billed 80% of billed N/A 44390 $1,197.13 $601.41 00044139 $332.43 $332.43 ZZZ 44391 $2,064.68 $657.29 00044140 $3,267.24 $3,267.24 090 44392 $1,126.10 $566.37 00044141 $4,448.55 $4,448.55 090 44394 $1,269.11 $643.08 00044143 $4,056.18 $4,056.18 090 44401 $8,764.46 $689.49 00044144 $4,316.08 $4,316.08 090 44402 $747.26 $747.26 00044145 $4,038.57 $4,038.57 090 44403 $857.13 $857.13 00044146 $5,157.84 $5,157.84 090 44404 $1,148.83 $494.39 00044147 $4,736.12 $4,736.12 090 44405 $1,647.01 $525.64 00044150 $4,555.03 $4,555.03 090 44406 $654.45 $654.45 00044151 $5,213.17 $5,213.17 090 44407 $783.25 $783.25 00044155 $5,072.32 $5,072.32 090 44408 $661.08 $661.08 00044156 $5,600.51 $5,600.51 090 44500 $67.24 $67.24 00044157 $5,250.06 $5,250.06 090 44602 $3,444.99 $3,444.99 09044158 $5,189.70 $5,189.70 090 44603 $3,948.03 $3,948.03 09044160 $3,025.79 $3,025.79 090 44604 $2,575.56 $2,575.56 09044180 $2,234.34 $2,234.34 090 44605 $3,182.57 $3,182.57 09044186 $1,589.61 $1,589.61 090 44615 $2,621.68 $2,621.68 09044187 $2,696.29 $2,696.29 090 44620 $2,112.77 $2,112.77 09044188 $2,983.87 $2,983.87 090 44625 $2,477.47 $2,477.47 09044202 $3,375.40 $3,375.40 090 44626 $3,907.78 $3,907.78 09044203 $665.81 $665.81 ZZZ 44640 $3,419.00 $3,419.00 09044204 $3,743.46 $3,743.46 090 44650 $3,536.37 $3,536.37 09044205 $3,257.18 $3,257.18 090 44660 $3,221.13 $3,221.13 09044206 $4,271.65 $4,271.65 090 44661 $3,777.83 $3,777.83 09044207 $4,433.46 $4,433.46 090 44680 $2,594.85 $2,594.85 09044208 $4,840.08 $4,840.08 090 44700 $2,483.34 $2,483.34 09044210 $4,337.88 $4,337.88 090 44701 $462.18 $462.18 ZZZ44211 $5,316.29 $5,316.29 090 44705 80% of billed 80% of billed N/A44212 $4,987.64 $4,987.64 090 44715 80% of billed 80% of billed N/A44213 $517.12 $517.12 ZZZ 44720 $760.52 $760.52 N/A44227 $4,063.72 $4,063.72 090 44721 $1,062.65 $1,062.65 N/A44238 80% of billed 80% of billed N/A 44799 80% of billed 80% of billed N/A44300 $2,049.89 $2,049.89 090 44800 $1,854.54 $1,854.54 09044310 $2,544.54 $2,544.54 090 44820 $2,043.18 $2,043.18 09044312 $1,430.31 $1,430.31 090 44850 $1,827.71 $1,827.71 09044314 $2,439.74 $2,439.74 090 44899 80% of billed 80% of billed N/A44316 $3,452.53 $3,452.53 090 44900 $1,877.18 $1,877.18 09044320 $2,926.02 $2,926.02 090 44950 $1,563.62 $1,563.62 09044322 $2,428.84 $2,428.84 090 44955 $230.15 $230.15 ZZZ44340 $1,521.70 $1,521.70 090 44960 $2,130.37 $2,130.37 09044345 $2,561.31 $2,561.31 090 44970 $1,462.17 $1,462.17 09044346 $2,879.90 $2,879.90 090 44979 80% of billed 80% of billed N/A44360 $414.83 $414.83 000 45000 $1,025.36 $1,025.36 09044361 $457.45 $457.45 000 45005 $743.47 $441.35 01044363 $548.37 $548.37 000 45020 $1,386.71 $1,386.71 09044364 $583.41 $583.41 000 45100 $726.05 $726.05 09044365 $513.33 $513.33 000 45108 $888.70 $888.70 09044366 $683.81 $683.81 000 45110 $4,498.02 $4,498.02 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 28 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

45111 $2,645.15 $2,645.15 090 45500 $1,264.31 $1,264.31 09045112 $4,574.31 $4,574.31 090 45505 $1,437.86 $1,437.86 09045113 $4,610.36 $4,610.36 090 45520 $423.35 $110.81 00045114 $4,430.94 $4,430.94 090 45540 $2,574.73 $2,574.73 09045116 $4,009.23 $4,009.23 090 45541 $2,293.86 $2,293.86 09045119 $4,740.31 $4,740.31 090 45550 $3,548.11 $3,548.11 09045120 $3,658.78 $3,658.78 090 45560 $1,665.06 $1,665.06 09045121 $4,233.08 $4,233.08 090 45562 $2,729.83 $2,729.83 09045123 $2,725.64 $2,725.64 090 45563 $4,015.94 $4,015.94 09045126 $6,812.00 $6,812.00 090 45800 $2,900.03 $2,900.03 09045130 $2,645.99 $2,645.99 090 45805 $3,564.88 $3,564.88 09045135 $3,334.32 $3,334.32 090 45820 $2,895.83 $2,895.83 09045136 $4,403.28 $4,403.28 090 45825 $3,360.31 $3,360.31 09045150 $947.39 $947.39 090 45900 $556.89 $556.89 01045160 $2,487.53 $2,487.53 090 45905 $465.03 $465.03 01045171 $1,457.98 $1,457.98 090 45910 $532.27 $532.27 01045172 $1,965.21 $1,965.21 090 45915 $896.90 $617.51 01045190 $1,682.67 $1,682.67 090 45990 $296.44 $296.44 00045300 $331.48 $147.75 000 45999 80% of billed 80% of billed N/A45303 $2,588.42 $253.82 000 46020 $751.05 $640.24 01045305 $525.64 $214.99 000 46030 $376.95 $246.25 01045307 $630.77 $291.71 000 46040 $1,287.78 $1,003.56 09045308 $581.52 $244.35 000 46045 $1,050.52 $1,050.52 09045309 $609.93 $260.45 000 46050 $543.64 $265.19 01045315 $608.99 $286.97 000 46060 $1,154.48 $1,154.48 09045317 $657.29 $322.96 000 46070 $547.48 $547.48 09045320 $657.29 $303.07 000 46080 $671.49 $435.67 01045321 $294.55 $294.55 000 46083 $474.50 $289.81 01045327 $335.27 $335.27 000 46200 $1,065.61 $783.90 09045330 $448.93 $154.38 000 46220 $557.84 $324.86 01045331 $689.49 $199.84 000 46221 $725.48 $518.06 01045332 $836.29 $307.81 000 46230 $738.74 $471.66 01045333 $938.58 $275.61 000 46250 $1,114.23 $763.78 09045334 $1,640.38 $341.90 000 46255 $1,218.20 $857.68 09045335 $777.57 $198.89 000 46257 $1,021.17 $1,021.17 09045337 $335.27 $335.27 000 46258 $1,131.00 $1,131.00 09045338 $873.23 $349.48 000 46260 $1,152.80 $1,152.80 09045340 $1,318.36 $231.09 000 46261 $1,265.15 $1,265.15 09045341 $359.90 $359.90 000 46262 $1,335.57 $1,335.57 09045342 $487.76 $487.76 000 46270 $1,223.23 $949.91 09045346 $8,395.09 $460.29 000 46275 $1,293.65 $1,001.05 09045347 $444.19 $444.19 000 46280 $1,136.03 $1,136.03 09045349 $566.37 $566.37 000 46285 $1,281.91 $998.53 09045350 $1,570.29 $293.60 000 46288 $1,332.22 $1,332.22 09045378 $1,020.97 $529.43 000 46320 $495.33 $303.07 01045378 53 $509.54 $264.24 000 46500 $524.69 $336.22 01045379 $1,288.06 $680.96 000 46505 $773.78 $651.60 01045380 $1,262.48 $573.94 000 46600 $238.67 $111.76 00045381 $1,214.18 $573.00 000 46601 $369.37 $255.72 00045382 $2,135.71 $736.84 000 46604 $1,668.79 $181.84 00045384 $1,385.61 $650.66 000 46606 $608.99 $208.36 00045385 $1,324.05 $724.53 000 46607 $515.22 $344.74 00045386 $1,764.45 $605.20 000 46608 $626.03 $221.62 00045388 $8,817.50 $769.05 000 46610 $608.99 $221.62 00045389 $823.03 $823.03 000 46611 $473.55 $222.57 00045390 $939.52 $939.52 000 46612 $694.22 $255.72 00045391 $732.11 $732.11 000 46614 $345.69 $177.11 00045392 $862.81 $862.81 000 46615 $389.26 $253.82 00045393 $718.85 $718.85 000 46700 $1,582.90 $1,582.90 09045395 $4,814.93 $4,814.93 090 46705 $1,213.16 $1,213.16 09045397 $5,243.35 $5,243.35 090 46706 $453.66 $453.66 01045398 $1,971.86 $669.60 000 46707 $1,154.48 $1,154.48 09045399 80% of billed 80% of billed N/A 46710 $2,554.60 $2,554.60 09045400 $2,773.43 $2,773.43 090 46712 $5,194.73 $5,194.73 09045402 $3,697.34 $3,697.34 090 46715 $1,314.61 $1,314.61 09045499 80% of billed 80% of billed N/A 46716 $2,685.40 $2,685.40 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 29 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

46730 $4,417.53 $4,417.53 090 47532 $2,200.11 $592.88 00046735 $5,120.11 $5,120.11 090 47533 $3,591.40 $841.02 00046740 $5,224.07 $5,224.07 090 47534 $4,425.80 $1,114.74 00046742 $5,908.20 $5,908.20 090 47535 $2,968.21 $640.24 00046744 $8,591.08 $8,591.08 090 47536 $2,189.70 $405.36 00046746 $8,866.08 $8,866.08 090 47537 $1,083.48 $273.71 00046748 $9,629.02 $9,629.02 090 47538 $12,081.21 $902.59 00046750 $1,827.71 $1,827.71 090 47539 $13,205.42 $1,220.81 00046751 $1,444.56 $1,444.56 090 47540 $13,732.00 $1,458.53 00046753 $1,483.13 $1,483.13 090 47541 $3,170.89 $776.62 00046754 $790.83 $618.46 010 47542 $1,387.50 $366.53 ZZZ46760 $2,646.83 $2,646.83 090 47543 $3,569.62 $463.13 ZZZ46761 $2,225.11 $2,225.11 090 47544 $2,180.22 $579.63 ZZZ46762 $2,246.07 $2,246.07 090 47550 $456.50 $456.50 ZZZ46900 $655.39 $375.05 010 47552 $853.34 $853.34 00046910 $693.28 $366.53 010 47553 $842.92 $842.92 00046916 $621.30 $391.15 010 47554 $1,314.57 $1,314.57 00046917 $1,217.02 $359.90 010 47555 $1,008.66 $1,008.66 00046922 $721.69 $370.32 010 47556 $1,148.83 $1,148.83 00046924 $1,439.59 $501.96 010 47562 $1,597.99 $1,597.99 09046930 $491.30 $352.97 090 47563 $1,735.49 $1,735.49 09046940 $618.46 $399.68 010 47564 $2,708.03 $2,708.03 09046942 $584.36 $358.95 010 47570 $1,864.60 $1,864.60 09046945 $740.31 $544.12 090 47579 80% of billed 80% of billed N/A46946 $751.21 $543.28 090 47600 $2,597.36 $2,597.36 09046947 $927.27 $927.27 090 47605 $2,735.70 $2,735.70 09046999 80% of billed 80% of billed N/A 47610 $3,055.97 $3,055.97 09047000 $975.51 $282.24 000 47612 $3,093.70 $3,093.70 09047001 $286.02 $286.02 ZZZ 47620 $3,353.60 $3,353.60 09047010 $2,929.37 $2,929.37 090 47700 $2,520.23 $2,520.23 09047015 $2,781.81 $2,781.81 090 47701 $4,128.28 $4,128.28 09047100 $2,053.24 $2,053.24 090 47711 $3,789.57 $3,789.57 09047120 $5,681.00 $5,681.00 090 47712 $4,840.08 $4,840.08 09047122 $8,385.68 $8,385.68 090 47715 $3,244.61 $3,244.61 09047125 $7,494.46 $7,494.46 090 47720 $2,798.58 $2,798.58 09047130 $8,053.67 $8,053.67 090 47721 $3,304.13 $3,304.13 09047133 80% of billed 80% of billed N/A 47740 $3,167.48 $3,167.48 09047135 $13,083.23 $13,083.23 090 47741 $3,574.10 $3,574.10 09047140 $8,709.30 $8,709.30 090 47760 $5,504.93 $5,504.93 09047141 $10,409.57 $10,409.57 090 47765 $7,393.85 $7,393.85 09047142 $11,476.86 $11,476.86 090 47780 $6,025.58 $6,025.58 09047143 80% of billed 80% of billed N/A 47785 $7,914.50 $7,914.50 09047144 80% of billed 80% of billed 090 47800 $3,834.00 $3,834.00 09047145 80% of billed 80% of billed N/A 47801 $2,399.50 $2,399.50 09047146 $910.16 $910.16 N/A 47802 $3,653.75 $3,653.75 09047147 $1,057.91 $1,057.91 N/A 47900 $3,335.99 $3,335.99 09047300 $2,757.50 $2,757.50 090 47999 80% of billed 80% of billed N/A47350 $3,336.83 $3,336.83 090 48000 $4,562.57 $4,562.57 09047360 $4,529.88 $4,529.88 090 48001 $5,577.04 $5,577.04 09047361 $7,363.67 $7,363.67 090 48020 $2,848.88 $2,848.88 09047362 $3,530.50 $3,530.50 090 48100 $2,150.50 $2,150.50 09047370 $3,038.36 $3,038.36 090 48102 $1,437.70 $664.86 01047371 $2,739.05 $2,739.05 090 48105 $6,950.34 $6,950.34 09047379 80% of billed 80% of billed N/A 48120 $2,699.65 $2,699.65 09047380 $3,515.41 $3,515.41 090 48140 $3,812.20 $3,812.20 09047381 $3,239.58 $3,239.58 090 48145 $3,964.79 $3,964.79 09047382 $13,467.76 $2,114.87 010 48146 $4,572.63 $4,572.63 09047383 $20,272.68 $1,345.83 010 48148 $3,033.33 $3,033.33 09047399 80% of billed 80% of billed N/A 48150 $7,594.23 $7,594.23 09047400 $5,240.00 $5,240.00 090 48152 $6,995.61 $6,995.61 09047420 $3,268.08 $3,268.08 090 48153 $7,546.44 $7,546.44 09047425 $3,297.43 $3,297.43 090 48154 $7,080.29 $7,080.29 09047460 $3,050.94 $3,050.94 090 48155 $4,435.14 $4,435.14 09047480 $2,127.02 $2,127.02 090 48160 80% of billed 80% of billed N/A47490 $907.32 $907.32 010 48400 $290.76 $290.76 ZZZ47531 $1,000.14 $263.29 000 48500 $2,733.18 $2,733.18 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 30 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

48510 $2,650.18 $2,650.18 090 49452 $2,420.79 $384.52 00048520 $2,663.60 $2,663.60 090 49460 $1,973.76 $132.59 00048540 $3,164.12 $3,164.12 090 49465 $438.51 $85.24 00048545 $3,247.12 $3,247.12 090 49491 $1,781.60 $1,781.60 09048547 $4,359.68 $4,359.68 090 49492 $2,330.75 $2,330.75 09048548 $4,056.18 $4,056.18 090 49495 $925.59 $925.59 09048550 80% of billed 80% of billed N/A 49496 $1,494.87 $1,494.87 09048551 80% of billed 80% of billed N/A 49500 $871.94 $871.94 09048552 $649.71 $649.71 N/A 49501 $1,415.22 $1,415.22 09048554 $6,219.25 $6,219.25 090 49505 $1,262.63 $1,262.63 09048556 $3,086.99 $3,086.99 090 49507 $1,421.93 $1,421.93 09048999 80% of billed 80% of billed N/A 49520 $1,535.11 $1,535.11 09049000 $1,874.66 $1,874.66 090 49521 $1,738.84 $1,738.84 09049002 $2,547.90 $2,547.90 090 49525 $1,391.74 $1,391.74 09049010 $2,272.90 $2,272.90 090 49540 $1,630.69 $1,630.69 09049020 $3,875.08 $3,875.08 090 49550 $1,397.61 $1,397.61 09049040 $2,432.20 $2,432.20 090 49553 $1,533.43 $1,533.43 09049060 $2,673.66 $2,673.66 090 49555 $1,452.11 $1,452.11 09049062 $1,783.28 $1,783.28 090 49557 $1,758.96 $1,758.96 09049082 $517.12 $203.63 000 49560 $1,789.98 $1,789.98 09049083 $788.93 $298.34 000 49561 $2,260.33 $2,260.33 09049084 $297.39 $297.39 000 49565 $1,865.44 $1,865.44 09049180 $440.40 $234.88 000 49566 $2,280.45 $2,280.45 09049185 $2,673.66 $338.11 000 49568 $734.95 $734.95 ZZZ49203 $2,911.76 $2,911.76 090 49570 $1,010.27 $1,010.27 09049204 $3,726.69 $3,726.69 090 49572 $1,253.41 $1,253.41 09049205 $4,280.87 $4,280.87 090 49580 $806.54 $806.54 09049215 $5,400.97 $5,400.97 090 49582 $1,173.76 $1,173.76 09049220 $2,159.72 $2,159.72 090 49585 $1,079.86 $1,079.86 09049250 $1,431.15 $1,431.15 090 49587 $1,153.64 $1,153.64 09049255 $1,922.45 $1,922.45 090 49590 $1,389.23 $1,389.23 09049320 $892.17 $892.17 010 49600 $1,705.31 $1,705.31 09049321 $947.10 $947.10 010 49605 $12,064.58 $12,064.58 09049322 $1,008.66 $1,008.66 010 49606 $2,718.93 $2,718.93 09049323 $1,543.49 $1,543.49 090 49610 $1,674.28 $1,674.28 09049324 $1,071.17 $1,071.17 010 49611 $1,473.91 $1,473.91 09049325 $1,143.15 $1,143.15 010 49650 $1,037.94 $1,037.94 09049326 $519.96 $519.96 ZZZ 49651 $1,348.15 $1,348.15 09049327 $360.85 $360.85 ZZZ 49652 $1,806.75 $1,806.75 09049329 80% of billed 80% of billed N/A 49653 $2,253.62 $2,253.62 09049400 $367.47 $257.61 000 49654 $2,051.56 $2,051.56 09049402 $2,083.42 $2,083.42 090 49655 $2,505.14 $2,505.14 09049405 $2,351.65 $580.57 000 49656 $2,232.66 $2,232.66 09049406 $2,353.54 $581.52 000 49657 $3,208.56 $3,208.56 09049407 $1,966.18 $624.14 000 49659 80% of billed 80% of billed N/A49411 $1,474.63 $541.74 000 49900 $1,979.46 $1,979.46 09049412 $228.25 $228.25 ZZZ 49904 $3,500.32 $3,500.32 09049418 $3,856.59 $598.57 000 49905 $970.78 $970.78 ZZZ49419 $1,073.15 $1,073.15 090 49906 80% of billed 80% of billed 09049421 $635.50 $635.50 000 49999 80% of billed 80% of billed N/A49422 $1,046.55 $1,046.55 010 50010 $1,785.79 $1,785.79 09049423 $1,476.53 $197.94 000 50020 $2,456.51 $2,456.51 09049424 $393.99 $105.13 000 50040 $2,230.14 $2,230.14 09049425 $1,775.73 $1,775.73 090 50045 $2,329.08 $2,329.08 09049426 $1,486.48 $1,486.48 090 50060 $2,755.82 $2,755.82 09049427 $126.91 $126.91 000 50065 $2,914.28 $2,914.28 09049428 $1,184.82 $1,184.82 010 50070 $2,857.27 $2,857.27 09049429 $1,259.64 $1,259.64 010 50075 $3,514.57 $3,514.57 09049435 $329.59 $329.59 ZZZ 50080 $2,095.16 $2,095.16 09049436 $512.38 $512.38 010 50081 $3,076.93 $3,076.93 09049440 $2,794.89 $608.04 010 50100 $2,552.93 $2,552.93 09049441 $3,147.21 $703.70 010 50120 $2,287.16 $2,287.16 09049442 $2,602.63 $608.99 010 50125 $2,491.72 $2,491.72 09049446 $2,690.71 $446.08 000 50130 $2,489.21 $2,489.21 09049450 $1,794.75 $183.74 000 50135 $2,746.60 $2,746.60 09049451 $1,957.66 $250.03 000 50200 $1,650.80 $389.26 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 31 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

50205 $1,820.17 $1,820.17 090 50590 $1,721.24 $1,368.27 09050220 $2,524.42 $2,524.42 090 50592 $6,841.85 $987.83 01050225 $2,905.06 $2,905.06 090 50593 $12,449.63 $1,312.68 01050230 $3,093.70 $3,093.70 090 50600 $2,276.26 $2,276.26 09050234 $3,135.62 $3,135.62 090 50605 $2,359.26 $2,359.26 09050236 $3,541.40 $3,541.40 090 50606 $1,419.70 $431.88 ZZZ50240 $3,191.79 $3,191.79 090 50610 $2,369.32 $2,369.32 09050250 $2,932.72 $2,932.72 090 50620 $2,185.71 $2,185.71 09050280 $2,301.41 $2,301.41 090 50630 $2,147.14 $2,147.14 09050290 $2,163.91 $2,163.91 090 50650 $2,498.43 $2,498.43 09050300 80% of billed 80% of billed N/A 50660 $2,771.75 $2,771.75 09050320 $3,520.44 $3,520.44 090 50684 $286.02 $137.33 00050323 80% of billed 80% of billed N/A 50686 $389.26 $244.35 00050325 80% of billed 80% of billed N/A 50688 $216.89 $216.89 01050327 $598.57 $598.57 N/A 50690 $266.14 $192.26 00050328 $524.69 $524.69 N/A 50693 $2,842.25 $598.57 00050329 $490.60 $490.60 N/A 50694 $3,130.17 $773.78 00050340 $2,274.58 $2,274.58 090 50695 $3,816.81 $980.25 00050360 $5,886.41 $5,886.41 090 50700 $2,243.56 $2,243.56 09050365 $6,879.07 $6,879.07 090 50705 $4,580.18 $553.11 ZZZ50370 $2,915.12 $2,915.12 090 50706 $2,054.26 $513.33 ZZZ50380 $4,832.54 $4,832.54 090 50715 $2,952.01 $2,952.01 09050382 $3,192.67 $741.58 000 50722 $2,467.41 $2,467.41 09050384 $2,545.80 $673.39 000 50725 $2,726.48 $2,726.48 09050385 $3,072.39 $634.56 000 50727 $1,222.39 $1,222.39 09050386 $2,003.12 $482.07 000 50728 $1,689.38 $1,689.38 09050387 $1,464.22 $266.14 000 50740 $2,978.00 $2,978.00 09050389 $797.46 $148.69 000 50750 $2,780.13 $2,780.13 09050390 $264.24 $264.24 000 50760 $2,725.64 $2,725.64 09050391 $329.59 $267.08 000 50770 $2,775.94 $2,775.94 09050395 $488.70 $488.70 000 50780 $2,673.66 $2,673.66 09050396 $322.01 $322.01 000 50782 $2,544.54 $2,544.54 09050400 $2,792.71 $2,792.71 090 50783 $2,730.67 $2,730.67 09050405 $3,369.53 $3,369.53 090 50785 $2,926.02 $2,926.02 09050430 $1,399.81 $457.45 000 50800 $2,227.63 $2,227.63 09050431 $434.72 $181.84 000 50810 $3,046.75 $3,046.75 09050432 $2,268.30 $604.25 000 50815 $2,952.01 $2,952.01 09050433 $3,053.45 $746.31 000 50820 $3,171.67 $3,171.67 09050434 $2,417.00 $572.05 000 50825 $3,996.65 $3,996.65 09050435 $1,268.17 $277.50 000 50830 $4,368.90 $4,368.90 09050500 $3,097.05 $3,097.05 090 50840 $2,969.61 $2,969.61 09050520 $2,733.18 $2,733.18 090 50845 $3,013.21 $3,013.21 09050525 $3,460.92 $3,460.92 090 50860 $2,276.26 $2,276.26 09050526 $3,589.19 $3,589.19 090 50900 $2,068.33 $2,068.33 09050540 $2,774.27 $2,774.27 090 50920 $2,126.18 $2,126.18 09050541 $2,216.73 $2,216.73 090 50930 $2,852.24 $2,852.24 09050542 $2,812.83 $2,812.83 090 50940 $2,133.73 $2,133.73 09050543 $3,585.00 $3,585.00 090 50945 $2,344.17 $2,344.17 09050544 $3,000.63 $3,000.63 090 50947 $3,350.25 $3,350.25 09050545 $3,232.03 $3,232.03 090 50948 $3,079.44 $3,079.44 09050546 $2,901.70 $2,901.70 090 50949 80% of billed 80% of billed N/A50547 $3,908.62 $3,908.62 090 50951 $1,017.19 $837.24 00050548 $3,250.48 $3,250.48 090 50953 $1,074.01 $886.49 00050549 80% of billed 80% of billed N/A 50955 $1,151.67 $962.25 00050551 $974.57 $804.09 000 50957 $1,163.04 $966.99 00050553 $1,035.18 $848.60 000 50961 $1,047.49 $864.70 00050555 $1,112.84 $927.21 000 50970 $1,015.29 $1,015.29 00050557 $1,137.47 $945.21 000 50972 $987.83 $987.83 00050561 $1,289.95 $1,077.80 000 50974 $1,291.84 $1,291.84 00050562 $1,402.64 $1,402.64 090 50976 $1,271.01 $1,271.01 00050570 $1,342.04 $1,342.04 000 50980 $966.04 $966.04 00050572 $1,451.90 $1,451.90 000 51020 $1,129.32 $1,129.32 09050574 $1,543.77 $1,543.77 000 51030 $1,147.77 $1,147.77 09050575 $1,950.08 $1,950.08 000 51040 $695.03 $695.03 09050576 $1,542.83 $1,542.83 000 51045 $1,167.89 $1,167.89 09050580 $1,662.16 $1,662.16 000 51050 $1,136.03 $1,136.03 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 32 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

51060 $1,406.84 $1,406.84 090 51798 $51.14 $51.14 N/A51065 $1,392.58 $1,392.58 090 51800 $2,511.85 $2,511.85 09051080 $987.64 $987.64 090 51820 $2,687.07 $2,687.07 09051100 $164.80 $107.02 000 51840 $1,582.90 $1,582.90 09051101 $334.33 $142.06 000 51841 $1,875.50 $1,875.50 09051102 $610.88 $393.99 000 51845 $1,410.19 $1,410.19 09051500 $1,538.46 $1,538.46 090 51860 $1,784.95 $1,784.95 09051520 $1,442.05 $1,442.05 090 51865 $2,153.85 $2,153.85 09051525 $2,068.33 $2,068.33 090 51880 $1,125.13 $1,125.13 09051530 $1,904.01 $1,904.01 090 51900 $2,009.64 $2,009.64 09051535 $1,878.02 $1,878.02 090 51920 $2,094.32 $2,094.32 09051550 $2,314.82 $2,314.82 090 51925 $2,654.37 $2,654.37 09051555 $3,056.81 $3,056.81 090 51940 $3,985.75 $3,985.75 09051565 $3,136.45 $3,136.45 090 51960 $3,357.79 $3,357.79 09051570 $3,564.88 $3,564.88 090 51980 $1,717.04 $1,717.04 09051575 $4,397.41 $4,397.41 090 51990 $1,806.75 $1,806.75 09051580 $4,570.12 $4,570.12 090 51992 $2,025.57 $2,025.57 09051585 $5,087.41 $5,087.41 090 51999 80% of billed 80% of billed N/A51590 $4,666.53 $4,666.53 090 52000 $548.37 $342.85 00051595 $5,277.73 $5,277.73 090 52001 $1,002.03 $784.20 00051596 $5,671.78 $5,671.78 090 52005 $712.22 $362.74 00051597 $5,540.99 $5,540.99 090 52007 $1,186.72 $451.77 00051600 $491.54 $120.28 000 52010 $997.30 $455.56 00051605 $104.18 $104.18 000 52204 $985.93 $386.42 00051610 $286.97 $175.21 000 52214 $1,763.50 $480.18 00051700 $223.52 $122.18 000 52224 $1,845.90 $555.95 00051701 $146.80 $75.77 000 52234 $671.49 $671.49 00051702 $189.42 $82.40 000 52235 $787.04 $787.04 00051703 $348.53 $221.62 000 52240 $1,070.22 $1,070.22 00051705 $244.35 $141.12 000 52250 $654.45 $654.45 00051710 $345.69 $217.83 000 52260 $573.94 $573.94 00051715 $782.30 $544.58 000 52265 $980.25 $444.19 00051720 $292.65 $217.83 000 52270 $952.78 $495.33 00051725 $501.02 $501.02 000 52275 $1,285.21 $678.12 00051725 TC $293.60 $293.60 000 52276 $721.69 $721.69 00051725 26 $207.41 $207.41 000 52277 $882.70 $882.70 00051726 $703.70 $703.70 000 52281 $730.21 $414.83 00051726 TC $471.66 $471.66 000 52282 $917.74 $917.74 00051726 26 $232.04 $232.04 000 52283 $744.42 $549.32 00051727 $835.34 $835.34 000 52285 $751.05 $534.16 00051727 TC $544.58 $544.58 000 52287 $835.34 $461.24 00051727 26 $290.76 $290.76 000 52290 $665.81 $665.81 00051728 $841.02 $841.02 000 52300 $765.26 $765.26 00051728 TC $556.89 $556.89 000 52301 $791.78 $791.78 00051728 26 $284.13 $284.13 000 52305 $761.47 $761.47 00051729 $910.16 $910.16 000 52310 $653.50 $412.94 00051729 TC $566.37 $566.37 000 52315 $1,110.00 $748.21 00051729 26 $343.80 $343.80 000 52317 $2,152.76 $948.05 00051736 $41.67 $41.67 N/A 52318 $1,293.74 $1,293.74 00051736 TC $18.94 $18.94 N/A 52320 $672.44 $672.44 00051736 26 $22.73 $22.73 N/A 52325 $877.01 $877.01 00051741 $42.62 $42.62 N/A 52327 $715.06 $715.06 00051741 TC $19.89 $19.89 N/A 52330 $1,323.10 $719.80 00051741 26 $22.73 $22.73 N/A 52332 $1,307.00 $424.30 00051784 $514.28 $514.28 000 52334 $698.96 $698.96 00051784 TC $305.91 $305.91 000 52341 $774.73 $774.73 00051784 26 $208.36 $208.36 000 52342 $841.97 $841.97 00051785 $686.65 $686.65 000 52343 $939.52 $939.52 00051785 TC $449.87 $449.87 000 52344 $1,008.66 $1,008.66 00051785 26 $236.77 $236.77 000 52345 $1,077.80 $1,077.80 00051792 $565.42 $565.42 000 52346 $1,218.92 $1,218.92 00051792 TC $414.83 $414.83 000 52351 $825.87 $825.87 00051792 26 $150.59 $150.59 000 52352 $966.04 $966.04 00051797 $299.28 $299.28 ZZZ 52353 $1,070.22 $1,070.22 00051797 TC $190.37 $190.37 ZZZ 52354 $1,138.41 $1,138.41 00051797 26 $108.92 $108.92 ZZZ 52355 $1,276.69 $1,276.69 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 33 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

52356 $1,134.63 $1,134.63 000 53850 $4,904.64 $1,461.33 09052400 $1,153.64 $1,153.64 090 53852 $4,521.49 $1,499.06 09052402 $728.32 $728.32 000 53855 $2,071.31 $224.46 00052441 $3,325.27 $623.19 000 53860 $3,658.78 $545.80 09052442 $2,542.02 $165.74 ZZZ 53899 80% of billed 80% of billed N/A52450 $1,131.00 $1,131.00 090 54000 $397.78 $293.60 01052500 $1,174.60 $1,174.60 090 54001 $495.33 $376.00 01052601 $2,037.31 $2,037.31 090 54015 $842.92 $842.92 01052630 $962.48 $962.48 090 54050 $355.16 $285.08 01052640 $757.08 $757.08 090 54055 $320.12 $251.93 01052647 $4,216.31 $1,559.42 090 54056 $382.63 $302.12 01052648 $4,340.40 $1,663.39 090 54057 $364.63 $257.61 01052649 $1,981.14 $1,981.14 090 54060 $482.07 $354.22 01052700 $1,061.41 $1,061.41 090 54065 $590.99 $471.66 01053000 $401.57 $401.57 010 54100 $537.01 $344.74 00053010 $710.12 $710.12 090 54105 $712.22 $579.63 01053020 $264.24 $264.24 000 54110 $1,524.21 $1,524.21 09053025 $196.05 $196.05 000 54111 $1,929.16 $1,929.16 09053040 $944.04 $944.04 090 54112 $2,262.84 $2,262.84 09053060 $496.28 $447.03 010 54115 $1,085.73 $1,022.85 09053080 $1,011.11 $1,011.11 090 54120 $1,521.70 $1,521.70 09053085 $1,602.18 $1,602.18 090 54125 $1,956.83 $1,956.83 09053200 $423.35 $387.36 000 54130 $2,869.84 $2,869.84 09053210 $1,854.54 $1,854.54 090 54135 $3,615.18 $3,615.18 09053215 $2,239.37 $2,239.37 090 54150 $414.83 $266.14 00053220 $1,092.44 $1,092.44 090 54160 $599.51 $396.83 01053230 $1,458.82 $1,458.82 090 54161 $535.11 $535.11 01053235 $1,523.37 $1,523.37 090 54162 $692.33 $541.74 01053240 $1,028.72 $1,028.72 090 54163 $592.88 $592.88 01053250 $995.18 $995.18 090 54164 $523.75 $523.75 01053260 $544.58 $490.60 010 54200 $287.92 $227.30 01053265 $588.15 $505.75 010 54205 $1,281.91 $1,281.91 09053270 $562.58 $505.75 010 54220 $549.32 $365.58 00053275 $713.17 $713.17 010 54230 $260.45 $216.89 00053400 $1,930.00 $1,930.00 090 54231 $378.84 $316.33 00053405 $2,102.71 $2,102.71 090 54235 $243.40 $199.84 00053410 $2,355.90 $2,355.90 090 54240 $275.61 $275.61 00053415 $2,724.80 $2,724.80 090 54240 TC $93.76 $93.76 00053420 $2,056.60 $2,056.60 090 54240 26 $181.84 $181.84 00053425 $2,256.13 $2,256.13 090 54250 $327.70 $327.70 00053430 $2,322.37 $2,322.37 090 54250 TC $29.36 $29.36 00053431 $2,791.87 $2,791.87 090 54250 26 $298.34 $298.34 00053440 $1,812.62 $1,812.62 090 54300 $1,543.49 $1,543.49 09053442 $1,883.88 $1,883.88 090 54304 $1,806.75 $1,806.75 09053444 $1,909.04 $1,909.04 090 54308 $1,722.91 $1,722.91 09053445 $1,811.78 $1,811.78 090 54312 $2,075.88 $2,075.88 09053446 $1,546.01 $1,546.01 090 54316 $2,531.13 $2,531.13 09053447 $1,945.93 $1,945.93 090 54318 $1,803.40 $1,803.40 09053448 $3,100.40 $3,100.40 090 54322 $1,857.89 $1,857.89 09053449 $1,471.39 $1,471.39 090 54324 $2,403.69 $2,403.69 09053450 $983.44 $983.44 090 54326 $2,277.93 $2,277.93 09053460 $1,101.66 $1,101.66 090 54328 $2,262.84 $2,262.84 09053500 $1,802.56 $1,802.56 090 54332 $2,584.79 $2,584.79 09053502 $1,171.24 $1,171.24 090 54336 $3,017.40 $3,017.40 09053505 $1,175.44 $1,175.44 090 54340 $1,372.46 $1,372.46 09053510 $1,520.86 $1,520.86 090 54344 $2,511.01 $2,511.01 09053515 $1,915.74 $1,915.74 090 54348 $2,443.94 $2,443.94 09053520 $1,340.60 $1,340.60 090 54352 $3,415.64 $3,415.64 09053600 $223.52 $173.32 000 54360 $1,735.49 $1,735.49 09053601 $217.83 $145.85 000 54380 $1,924.13 $1,924.13 09053605 $176.16 $176.16 000 54385 $2,354.23 $2,354.23 09053620 $312.54 $237.72 000 54390 $3,146.52 $3,146.52 09053621 $294.55 $196.05 000 54400 $1,276.04 $1,276.04 09053660 $189.42 $113.65 000 54401 $1,579.55 $1,579.55 09053661 $185.63 $109.86 000 54405 $1,947.60 $1,947.60 09053665 $105.13 $105.13 000 54406 $1,759.80 $1,759.80 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 34 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

54408 $1,901.49 $1,901.49 090 55680 $856.01 $856.01 09054410 $2,068.33 $2,068.33 090 55700 $585.31 $379.79 00054411 $2,470.76 $2,470.76 090 55705 $722.64 $722.64 01054415 $1,271.85 $1,271.85 090 55706 $1,015.29 $1,015.29 01054416 $1,708.66 $1,708.66 090 55720 $1,090.76 $1,090.76 09054417 $2,163.07 $2,163.07 090 55725 $1,428.63 $1,428.63 09054420 $1,697.76 $1,697.76 090 55801 $2,655.21 $2,655.21 09054430 $1,541.82 $1,541.82 090 55810 $3,180.89 $3,180.89 09054435 $1,000.21 $1,000.21 090 55812 $3,879.28 $3,879.28 09054437 $1,642.43 $1,642.43 090 55815 $4,270.81 $4,270.81 09054438 $3,313.36 $3,313.36 090 55821 $2,105.22 $2,105.22 09054440 80% of billed 80% of billed 090 55831 $2,277.93 $2,277.93 09054450 $189.42 $157.22 000 55840 $2,827.08 $2,827.08 09054500 $202.68 $202.68 000 55842 $2,824.57 $2,824.57 09054505 $572.05 $572.05 010 55845 $3,292.40 $3,292.40 09054512 $1,301.20 $1,301.20 090 55860 $2,108.58 $2,108.58 09054520 $781.39 $781.39 090 55862 $2,780.97 $2,780.97 09054522 $1,493.19 $1,493.19 090 55865 $3,216.10 $3,216.10 09054530 $1,216.52 $1,216.52 090 55866 $3,377.08 $3,377.08 09054535 $1,790.82 $1,790.82 090 55870 $474.50 $387.36 00054550 $1,189.69 $1,189.69 090 55873 $16,793.15 $1,850.35 09054560 $1,655.00 $1,655.00 090 55875 $1,837.77 $1,837.77 09054600 $1,096.63 $1,096.63 090 55876 $365.58 $273.71 00054620 $819.24 $819.24 010 55899 80% of billed 80% of billed N/A54640 $1,154.48 $1,154.48 090 55920 $1,220.81 $1,220.81 00054650 $1,709.50 $1,709.50 090 55970 80% of billed 80% of billed N/A54660 $859.36 $859.36 090 55980 80% of billed 80% of billed N/A54670 $973.38 $973.38 090 56405 $293.60 $291.71 01054680 $1,907.36 $1,907.36 090 56420 $326.75 $245.30 01054690 $1,789.98 $1,789.98 090 56440 $490.60 $490.60 01054692 $2,070.01 $2,070.01 090 56441 $387.36 $373.16 01054699 80% of billed 80% of billed N/A 56442 $128.81 $128.81 00054700 $582.47 $582.47 010 56501 $351.37 $309.70 01054800 $347.59 $347.59 000 56515 $608.99 $544.58 01054830 $897.09 $897.09 090 56605 $220.67 $162.90 00054840 $771.33 $771.33 090 56606 $102.29 $80.50 ZZZ54860 $1,008.60 $1,008.60 090 56620 $1,250.05 $1,250.05 09054861 $1,364.92 $1,364.92 090 56625 $1,512.47 $1,512.47 09054865 $862.71 $862.71 090 56630 $2,240.20 $2,240.20 09054900 $2,029.77 $2,029.77 090 56631 $2,858.94 $2,858.94 09054901 $2,678.69 $2,678.69 090 56632 $3,318.39 $3,318.39 09055000 $316.33 $231.09 000 56633 $2,927.69 $2,927.69 09055040 $812.41 $812.41 090 56634 $3,169.15 $3,169.15 09055041 $1,228.26 $1,228.26 090 56637 $3,641.17 $3,641.17 09055060 $916.37 $916.37 090 56640 $3,675.55 $3,675.55 09055100 $582.47 $452.71 010 56700 $501.02 $501.02 01055110 $933.98 $933.98 090 56740 $811.66 $811.66 01055120 $859.36 $859.36 090 56800 $647.82 $647.82 01055150 $1,184.66 $1,184.66 090 56805 $2,780.97 $2,780.97 09055175 $871.94 $871.94 090 56810 $699.91 $699.91 01055180 $1,670.93 $1,670.93 090 56820 $303.07 $234.88 00055200 $1,037.10 $669.04 090 56821 $398.73 $313.49 00055250 $913.02 $545.80 090 57000 $506.70 $506.70 01055300 $510.49 $510.49 000 57010 $1,032.91 $1,032.91 09055400 $1,229.09 $1,229.09 090 57020 $250.03 $217.83 00055450 $966.04 $698.96 010 57022 $456.50 $456.50 01055500 $951.58 $951.58 090 57023 $832.50 $832.50 01055520 $1,091.60 $1,091.60 090 57061 $304.97 $264.24 01055530 $845.11 $845.11 090 57065 $524.69 $471.66 01055535 $1,036.26 $1,036.26 090 57100 $239.62 $180.90 00055540 $1,312.10 $1,312.10 090 57105 $367.47 $340.96 01055550 $1,034.59 $1,034.59 090 57106 $1,191.37 $1,191.37 09055559 80% of billed 80% of billed N/A 57107 $3,497.80 $3,497.80 09055600 $1,014.46 $1,014.46 090 57109 $4,194.52 $4,194.52 09055605 $1,323.83 $1,323.83 090 57110 $2,126.18 $2,126.18 09055650 $1,731.30 $1,731.30 090 57111 $3,844.90 $3,844.90 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 35 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

57112 $4,477.89 $4,477.89 090 57545 $2,018.03 $2,018.03 09057120 $1,213.16 $1,213.16 090 57550 $968.35 $968.35 09057130 $474.50 $427.14 010 57555 $1,426.96 $1,426.96 09057135 $515.22 $466.92 010 57556 $1,353.18 $1,353.18 09057150 $121.23 $77.66 000 57558 $334.33 $304.97 01057155 $1,159.25 $787.04 000 57700 $757.08 $757.08 09057156 $531.32 $395.89 000 57720 $729.41 $729.41 09057160 $204.57 $126.91 000 57800 $161.95 $131.65 00057170 $162.90 $130.70 000 58100 $292.65 $235.83 00057180 $376.95 $284.13 010 58110 $128.81 $110.81 ZZZ57200 $716.83 $716.83 090 58120 $693.28 $590.04 01057210 $876.13 $876.13 090 58140 $2,198.28 $2,198.28 09057220 $758.75 $758.75 090 58145 $1,308.74 $1,308.74 09057230 $940.68 $940.68 090 58146 $2,736.54 $2,736.54 09057240 $1,599.67 $1,599.67 090 58150 $2,422.98 $2,422.98 09057250 $1,609.73 $1,609.73 090 58152 $2,978.00 $2,978.00 09057260 $1,981.14 $1,981.14 090 58180 $2,298.05 $2,298.05 09057265 $2,170.62 $2,170.62 090 58200 $3,293.24 $3,293.24 09057267 $691.38 $691.38 ZZZ 58210 $4,442.68 $4,442.68 09057268 $1,152.80 $1,152.80 090 58240 $7,014.89 $7,014.89 09057270 $1,900.65 $1,900.65 090 58260 $1,964.37 $1,964.37 09057280 $2,270.39 $2,270.39 090 58262 $2,193.25 $2,193.25 09057282 $1,193.04 $1,193.04 090 58263 $2,352.55 $2,352.55 09057283 $1,639.91 $1,639.91 090 58267 $2,508.49 $2,508.49 09057284 $1,941.73 $1,941.73 090 58270 $2,096.00 $2,096.00 09057285 $1,600.51 $1,600.51 090 58275 $2,341.65 $2,341.65 09057287 $1,623.14 $1,623.14 090 58280 $2,495.08 $2,495.08 09057288 $1,704.47 $1,704.47 090 58285 $3,213.59 $3,213.59 09057289 $1,753.09 $1,753.09 090 58290 $2,737.38 $2,737.38 09057291 $1,469.72 $1,469.72 090 58291 $2,953.68 $2,953.68 09057292 $1,964.37 $1,964.37 090 58292 $3,119.69 $3,119.69 09057295 $1,137.71 $1,137.71 090 58293 $3,242.93 $3,242.93 09057296 $2,256.13 $2,256.13 090 58294 $2,900.86 $2,900.86 09057300 $1,345.63 $1,345.63 090 58300 $195.10 $145.85 N/A57305 $2,238.53 $2,238.53 090 58301 $253.82 $181.84 00057307 $2,602.39 $2,602.39 090 58321 $206.47 $131.65 00057308 $1,577.87 $1,577.87 090 58322 $230.15 $157.22 00057310 $1,107.53 $1,107.53 090 58323 $40.73 $32.20 00057311 $1,267.66 $1,267.66 090 58340 $318.23 $157.22 00057320 $1,281.91 $1,281.91 090 58345 $730.21 $730.21 01057330 $1,777.41 $1,777.41 090 58346 $1,064.77 $1,064.77 09057335 $2,703.84 $2,703.84 090 58350 $257.61 $210.26 01057400 $365.58 $365.58 000 58353 $2,689.76 $588.15 01057410 $291.71 $291.71 000 58356 $5,031.94 $930.05 01057415 $430.93 $430.93 010 58400 $1,051.35 $1,051.35 09057420 $317.28 $249.09 000 58410 $1,954.31 $1,954.31 09057421 $425.25 $337.17 000 58520 $2,035.64 $2,035.64 09057423 $2,170.62 $2,170.62 090 58540 $2,154.69 $2,154.69 09057425 $2,307.28 $2,307.28 090 58541 $1,705.31 $1,705.31 09057426 $2,009.64 $2,009.64 090 58542 $1,950.12 $1,950.12 09057452 $293.60 $249.09 000 58543 $1,971.08 $1,971.08 09057454 $411.04 $366.53 000 58544 $2,152.17 $2,152.17 09057455 $383.58 $299.28 000 58545 $2,152.17 $2,152.17 09057456 $361.79 $278.45 000 58546 $2,669.47 $2,669.47 09057460 $757.68 $438.51 000 58548 $4,573.47 $4,573.47 09057461 $857.13 $505.75 000 58550 $2,096.84 $2,096.84 09057500 $342.85 $204.57 000 58552 $2,355.90 $2,355.90 09057505 $274.66 $248.14 010 58553 $2,705.52 $2,705.52 09057510 $352.32 $310.65 010 58554 $3,168.31 $3,168.31 09057511 $388.31 $355.16 010 58555 $834.40 $509.54 00057513 $389.26 $359.90 010 58558 $1,085.38 $717.90 00057520 $731.08 $656.47 090 58559 $918.69 $918.69 00057522 $624.61 $578.50 090 58560 $1,035.18 $1,035.18 00057530 $829.18 $829.18 090 58561 $1,469.90 $1,469.90 00057531 $4,421.72 $4,421.72 090 58562 $1,122.31 $777.57 00057540 $1,867.96 $1,867.96 090 58563 $4,461.79 $917.74 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 36 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

58565 $4,420.04 $1,028.72 090 59076 $1,278.58 $1,278.58 00058570 $1,853.70 $1,853.70 090 59100 $1,913.23 $1,913.23 09058571 $2,144.63 $2,144.63 090 59120 $1,924.97 $1,924.97 09058572 $2,431.36 $2,431.36 090 59121 $1,931.67 $1,931.67 09058573 $2,902.54 $2,902.54 090 59130 $2,256.13 $2,256.13 09058578 80% of billed 80% of billed N/A 59135 $2,004.61 $2,004.61 09058579 80% of billed 80% of billed N/A 59136 $2,055.76 $2,055.76 09058600 $864.39 $864.39 090 59140 $964.16 $964.16 09058605 $780.55 $780.55 090 59150 $1,869.63 $1,869.63 09058611 $207.41 $207.41 ZZZ 59151 $1,814.30 $1,814.30 09058615 $651.60 $651.60 010 59160 $555.95 $475.44 01058660 $1,607.21 $1,607.21 090 59200 $195.10 $122.18 00058661 $1,752.13 $1,752.13 010 59300 $525.64 $408.20 00058662 $1,691.05 $1,691.05 090 59320 $418.62 $418.62 00058670 $867.74 $867.74 090 59325 $668.65 $668.65 00058671 $866.91 $866.91 090 59350 $712.22 $712.22 00058672 $1,744.71 $1,744.71 090 59400 $5,711.96 $5,711.96 N/A58673 $1,895.62 $1,895.62 090 59409 $2,237.05 $2,237.05 N/A58674 $1,947.60 $1,947.60 090 59410 $2,849.82 $2,849.82 N/A58679 80% of billed 80% of billed N/A 59412 $284.13 $284.13 N/A58700 $1,855.38 $1,855.38 090 59414 $252.88 $252.88 N/A58720 $1,760.64 $1,760.64 090 59425 $1,238.81 $976.46 N/A58740 $2,107.74 $2,107.74 090 59426 $2,215.27 $1,719.93 N/A58750 $2,333.27 $2,333.27 090 59430 $501.96 $380.73 N/A58752 $2,204.99 $2,204.99 090 59510 $6,342.73 $6,342.73 N/A58760 $1,959.34 $1,959.34 090 59514 $2,522.13 $2,522.13 N/A58770 $2,212.54 $2,212.54 090 59515 $3,467.33 $3,467.33 N/A58800 $752.88 $706.77 090 59525 $1,329.73 $1,329.73 ZZZ58805 $959.13 $959.13 090 59610 $6,014.08 $6,014.08 N/A58820 $740.31 $740.31 090 59612 $2,523.07 $2,523.07 N/A58822 $1,792.50 $1,792.50 090 59614 $3,137.74 $3,137.74 N/A58825 $1,662.55 $1,662.55 090 59618 $6,427.97 $6,427.97 N/A58900 $1,089.08 $1,089.08 090 59620 $2,584.64 $2,584.64 N/A58920 $1,825.20 $1,825.20 090 59622 $3,562.99 $3,562.99 N/A58925 $1,780.76 $1,780.76 090 59812 $769.65 $715.99 09058940 $1,251.73 $1,251.73 090 59820 $915.53 $861.88 09058943 $2,831.28 $2,831.28 090 59821 $923.92 $865.23 09058950 $2,722.28 $2,722.28 090 59830 $1,058.06 $1,058.06 09058951 $3,499.48 $3,499.48 090 59840 $592.88 $570.15 01058952 $3,955.57 $3,955.57 090 59841 $1,045.60 $988.77 01058953 $4,894.58 $4,894.58 090 59850 $839.24 $839.24 09058954 $5,312.10 $5,312.10 090 59851 $890.38 $890.38 09058956 $3,325.93 $3,325.93 090 59852 $1,214.00 $1,214.00 09058957 $3,828.13 $3,828.13 090 59855 $1,006.92 $1,006.92 09058958 $4,202.90 $4,202.90 090 59856 $1,183.82 $1,183.82 09058960 $2,345.84 $2,345.84 090 59857 $1,248.38 $1,248.38 09058970 $596.67 $538.90 000 59866 $590.04 $590.04 00058974 80% of billed 80% of billed 000 59870 $1,142.74 $1,142.74 09058976 $680.02 $590.04 000 59871 $365.58 $365.58 00058999 80% of billed 80% of billed N/A 59897 80% of billed 80% of billed N/A59000 $340.96 $221.62 000 59898 80% of billed 80% of billed N/A59001 $495.33 $495.33 000 59899 80% of billed 80% of billed N/A59012 $558.79 $558.79 000 60000 $464.08 $417.67 01059015 $425.25 $362.74 000 60100 $304.97 $215.94 00059020 $192.26 $192.26 000 60200 $1,600.51 $1,600.51 09059020 TC $90.92 $90.92 000 60210 $1,716.20 $1,716.20 09059020 26 $101.34 $101.34 000 60212 $2,441.42 $2,441.42 09059025 $130.70 $130.70 000 60220 $1,716.20 $1,716.20 09059025 TC $49.25 $49.25 000 60225 $2,262.84 $2,262.84 09059025 26 $81.45 $81.45 000 60240 $2,231.82 $2,231.82 09059030 $273.71 $273.71 000 60252 $3,209.40 $3,209.40 09059050 $139.22 $139.22 N/A 60254 $4,072.11 $4,072.11 09059051 $115.55 $115.55 N/A 60260 $2,656.89 $2,656.89 09059070 $1,085.38 $827.77 000 60270 $3,326.77 $3,326.77 09059072 $1,278.58 $1,278.58 000 60271 $2,569.70 $2,569.70 09059074 $1,038.97 $818.29 000 60280 $1,076.51 $1,076.51 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 37 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

60281 $1,426.12 $1,426.12 090 61520 $9,294.50 $9,294.50 09060300 $319.17 $136.38 000 61521 $7,816.40 $7,816.40 09060500 $2,342.49 $2,342.49 090 61522 $5,374.98 $5,374.98 09060502 $3,124.72 $3,124.72 090 61524 $5,130.17 $5,130.17 09060505 $3,367.85 $3,367.85 090 61526 $9,105.02 $9,105.02 09060512 $667.71 $667.71 ZZZ 61530 $7,674.71 $7,674.71 09060520 $2,537.00 $2,537.00 090 61531 $3,019.08 $3,019.08 09060521 $2,731.51 $2,731.51 090 61533 $3,755.19 $3,755.19 09060522 $3,310.00 $3,310.00 090 61534 $4,018.45 $4,018.45 09060540 $2,572.21 $2,572.21 090 61535 $2,462.38 $2,462.38 09060545 $2,952.01 $2,952.01 090 61536 $6,429.69 $6,429.69 09060600 $3,392.17 $3,392.17 090 61537 $6,084.27 $6,084.27 09060605 $4,188.65 $4,188.65 090 61538 $6,642.64 $6,642.64 09060650 $2,895.00 $2,895.00 090 61539 $5,817.66 $5,817.66 09060659 80% of billed 80% of billed N/A 61540 $5,439.54 $5,439.54 09060699 80% of billed 80% of billed N/A 61541 $5,354.86 $5,354.86 09061000 $287.92 $287.92 000 61543 $5,229.10 $5,229.10 09061001 $232.04 $232.04 000 61544 $4,738.64 $4,738.64 09061020 $278.45 $278.45 000 61545 $7,938.81 $7,938.81 09061026 $282.24 $282.24 000 61546 $5,750.59 $5,750.59 09061050 $233.93 $233.93 000 61548 $3,889.34 $3,889.34 09061055 $330.54 $330.54 000 61550 $2,344.17 $2,344.17 09061070 $158.17 $158.17 000 61552 $2,817.02 $2,817.02 09061105 $1,120.94 $1,120.94 090 61556 $3,761.06 $3,761.06 09061107 $886.49 $886.49 000 61557 $3,949.70 $3,949.70 09061108 $2,240.20 $2,240.20 090 61558 $4,316.08 $4,316.08 09061120 $1,836.10 $1,836.10 090 61559 $5,089.93 $5,089.93 09061140 $3,123.88 $3,123.88 090 61563 $4,721.03 $4,721.03 09061150 $3,318.39 $3,318.39 090 61564 $5,670.10 $5,670.10 09061151 $2,472.44 $2,472.44 090 61566 $5,572.01 $5,572.01 09061154 $3,143.16 $3,143.16 090 61567 $6,385.25 $6,385.25 09061156 $3,080.28 $3,080.28 090 61570 $4,623.78 $4,623.78 09061210 $1,038.97 $1,038.97 000 61571 $4,928.11 $4,928.11 09061215 $1,249.22 $1,249.22 090 61575 $5,238.32 $5,238.32 09061250 $1,996.23 $1,996.23 090 61576 $8,859.37 $8,859.37 09061253 $1,987.01 $1,987.01 090 61580 $6,106.07 $6,106.07 09061304 $4,058.69 $4,058.69 090 61581 $6,470.77 $6,470.77 09061305 $4,965.84 $4,965.84 090 61582 $7,117.18 $7,117.18 09061312 $5,143.58 $5,143.58 090 61583 $7,136.46 $7,136.46 09061313 $4,903.80 $4,903.80 090 61584 $7,039.21 $7,039.21 09061314 $4,489.63 $4,489.63 090 61585 $7,988.27 $7,988.27 09061315 $5,099.15 $5,099.15 090 61586 $5,913.23 $5,913.23 09061316 $247.19 $247.19 ZZZ 61590 $7,398.04 $7,398.04 09061320 $4,686.66 $4,686.66 090 61591 $7,569.91 $7,569.91 09061321 $5,204.79 $5,204.79 090 61592 $7,787.90 $7,787.90 09061322 $5,891.44 $5,891.44 090 61595 $5,702.80 $5,702.80 09061323 $5,969.41 $5,969.41 090 61596 $5,930.00 $5,930.00 09061330 $3,937.96 $3,937.96 090 61597 $6,832.12 $6,832.12 09061332 $4,321.11 $4,321.11 090 61598 $7,012.38 $7,012.38 09061333 $4,468.67 $4,468.67 090 61600 $5,158.67 $5,158.67 09061340 $3,508.70 $3,508.70 090 61601 $5,911.56 $5,911.56 09061343 $5,405.16 $5,405.16 090 61605 $5,291.98 $5,291.98 09061345 $5,037.95 $5,037.95 090 61606 $7,304.98 $7,304.98 09061450 $4,767.98 $4,767.98 090 61607 $6,616.65 $6,616.65 09061458 $4,941.53 $4,941.53 090 61608 $8,042.77 $8,042.77 09061460 $5,243.35 $5,243.35 090 61610 $4,267.63 $4,267.63 ZZZ61480 $3,918.68 $3,918.68 090 61611 $1,067.38 $1,067.38 ZZZ61500 $3,241.25 $3,241.25 090 61612 $4,010.97 $4,010.97 ZZZ61501 $2,837.98 $2,837.98 090 61613 $7,970.67 $7,970.67 09061510 $5,379.17 $5,379.17 090 61615 $5,555.24 $5,555.24 09061512 $6,265.36 $6,265.36 090 61616 $8,224.70 $8,224.70 09061514 $4,677.43 $4,677.43 090 61618 $3,143.16 $3,143.16 09061516 $4,565.93 $4,565.93 090 61619 $3,487.74 $3,487.74 09061517 $246.25 $246.25 ZZZ 61623 $1,570.29 $1,570.29 00061518 $6,788.52 $6,788.52 090 61624 $3,157.63 $3,157.63 00061519 $7,210.24 $7,210.24 090 61626 $2,366.80 $2,366.80 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 38 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

61630 $3,673.80 $3,673.80 N/A 62160 $537.01 $537.01 ZZZ61635 $3,938.04 $3,938.04 N/A 62161 $3,762.74 $3,762.74 09061640 $1,774.87 $1,774.87 000 62162 $4,683.30 $4,683.30 09061641 $623.19 $623.19 ZZZ 62163 $2,722.28 $2,722.28 09061642 $1,247.33 $1,247.33 ZZZ 62164 $5,148.61 $5,148.61 09061645 $2,139.50 $2,139.50 000 62165 $3,813.88 $3,813.88 09061650 $1,465.16 $1,465.16 ZZZ 62180 $3,952.22 $3,952.22 09061651 $624.14 $624.14 ZZZ 62190 $2,166.43 $2,166.43 09061680 $5,522.54 $5,522.54 090 62192 $2,402.02 $2,402.02 09061682 $10,278.78 $10,278.78 090 62194 $1,285.21 $1,285.21 01061684 $7,092.86 $7,092.86 090 62200 $3,412.29 $3,412.29 09061686 $11,138.14 $11,138.14 090 62201 $2,990.57 $2,990.57 09061690 $5,377.50 $5,377.50 090 62220 $2,540.35 $2,540.35 09061692 $9,044.66 $9,044.66 090 62223 $2,592.33 $2,592.33 09061697 $10,469.94 $10,469.94 090 62225 $1,294.49 $1,294.49 09061698 $11,507.88 $11,507.88 090 62230 $2,079.23 $2,079.23 09061700 $8,417.54 $8,417.54 090 62252 $233.93 $233.93 N/A61702 $9,964.38 $9,964.38 090 62252 TC $104.18 $104.18 N/A61703 $3,380.43 $3,380.43 090 62252 26 $129.75 $129.75 N/A61705 $6,356.75 $6,356.75 090 62256 $1,473.91 $1,473.91 09061708 $5,143.58 $5,143.58 090 62258 $2,775.94 $2,775.94 09061710 $5,362.41 $5,362.41 090 62263 $1,771.08 $929.11 01061711 $6,424.66 $6,424.66 090 62264 $1,155.46 $657.29 01061720 $3,159.93 $3,159.93 090 62267 $671.49 $435.67 00061735 $3,906.94 $3,906.94 090 62268 $711.27 $711.27 00061750 $3,486.91 $3,486.91 090 62269 $740.63 $740.63 00061751 $3,425.70 $3,425.70 090 62270 $429.04 $213.10 00061760 $3,936.29 $3,936.29 090 62272 $548.37 $230.15 00061770 $4,015.10 $4,015.10 090 62273 $473.55 $313.49 00061781 $662.97 $662.97 ZZZ 62280 $833.45 $444.19 01061782 $483.97 $483.97 ZZZ 62281 $657.29 $431.88 01061783 $652.55 $652.55 ZZZ 62282 $794.62 $398.73 01061790 $2,184.03 $2,184.03 090 62284 $491.54 $234.88 00061791 $2,640.96 $2,640.96 090 62287 $1,378.33 $1,378.33 09061796 $2,516.04 $2,516.04 090 62290 $907.32 $473.55 00061797 $621.30 $621.30 ZZZ 62291 $897.85 $467.87 00061798 $3,427.38 $3,427.38 090 62292 $1,407.67 $1,407.67 09061799 $852.39 $852.39 ZZZ 62294 $1,901.49 $1,901.49 09061800 $433.77 $433.77 ZZZ 62302 $650.66 $335.27 00061850 $2,441.42 $2,441.42 090 62303 $676.23 $340.01 00061860 $3,896.88 $3,896.88 090 62304 $644.03 $330.54 00061863 $3,710.76 $3,710.76 090 62305 $700.85 $344.74 00061864 $796.51 $796.51 ZZZ 62310 $655.39 $299.28 00061867 $5,609.73 $5,609.73 090 62311 $605.20 $246.25 00061868 $1,386.55 $1,386.55 ZZZ 62318 $644.98 $276.55 00061870 $2,833.79 $2,833.79 090 62319 $465.03 $266.14 00061880 $1,404.32 $1,404.32 090 62320 $449.87 $278.45 00061885 $1,268.50 $1,268.50 090 62321 $668.65 $300.23 00061886 $2,083.42 $2,083.42 090 62322 $419.57 $239.62 00061888 $1,102.42 $1,102.42 010 62323 $656.34 $273.71 00062000 $2,561.31 $2,561.31 090 62324 $393.05 $253.82 00062005 $3,068.54 $3,068.54 090 62325 $592.88 $291.71 00062010 $3,786.21 $3,786.21 090 62326 $412.94 $249.09 00062100 $3,926.23 $3,926.23 090 62327 $604.25 $265.19 00062115 $3,176.70 $3,176.70 090 62350 $1,108.11 $1,108.11 01062117 $3,962.28 $3,962.28 090 62351 $2,135.40 $2,135.40 09062120 $4,059.53 $4,059.53 090 62355 $728.32 $728.32 01062121 $3,906.94 $3,906.94 090 62360 $864.70 $864.70 01062140 $2,535.32 $2,535.32 090 62361 $998.24 $998.24 01062141 $2,794.39 $2,794.39 090 62362 $1,071.17 $1,071.17 01062142 $2,184.87 $2,184.87 090 62365 $820.19 $820.19 01062143 $2,551.25 $2,551.25 090 62367 $112.70 $70.09 N/A62145 $3,434.09 $3,434.09 090 62368 $154.38 $96.60 N/A62146 $3,070.22 $3,070.22 090 62369 $326.75 $98.50 N/A62147 $3,498.64 $3,498.64 090 62370 $344.74 $128.81 N/A62148 $358.00 $358.00 ZZZ 62380 80% of billed 80% of billed 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 39 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

63001 $3,047.58 $3,047.58 090 63273 $4,616.23 $4,616.23 09063003 $3,028.30 $3,028.30 090 63275 $4,419.21 $4,419.21 09063005 $2,881.58 $2,881.58 090 63276 $4,377.29 $4,377.29 09063011 $2,648.51 $2,648.51 090 63277 $3,782.02 $3,782.02 09063012 $2,886.61 $2,886.61 090 63278 $3,953.89 $3,953.89 09063015 $3,640.33 $3,640.33 090 63280 $5,185.50 $5,185.50 09063016 $3,735.07 $3,735.07 090 63281 $5,121.79 $5,121.79 09063017 $3,060.16 $3,060.16 090 63282 $4,808.22 $4,808.22 09063020 $2,840.50 $2,840.50 090 63283 $4,679.95 $4,679.95 09063030 $2,365.13 $2,365.13 090 63285 $6,505.15 $6,505.15 09063035 $519.01 $519.01 ZZZ 63286 $6,345.85 $6,345.85 09063040 $3,398.04 $3,398.04 090 63287 $6,844.70 $6,844.70 09063042 $3,159.93 $3,159.93 090 63290 $6,806.13 $6,806.13 09063043 80% of billed 80% of billed ZZZ 63295 $936.68 $936.68 ZZZ63044 80% of billed 80% of billed ZZZ 63300 $4,511.43 $4,511.43 09063045 $3,146.52 $3,146.52 090 63301 $5,468.04 $5,468.04 09063046 $2,978.00 $2,978.00 090 63302 $5,374.98 $5,374.98 09063047 $2,692.10 $2,692.10 090 63303 $5,727.11 $5,727.11 09063048 $571.10 $571.10 ZZZ 63304 $5,779.93 $5,779.93 09063050 $3,645.36 $3,645.36 090 63305 $6,011.33 $6,011.33 09063051 $4,170.20 $4,170.20 090 63306 $5,678.48 $5,678.48 09063055 $3,980.72 $3,980.72 090 63307 $5,692.74 $5,692.74 09063056 $3,603.44 $3,603.44 090 63308 $908.27 $908.27 ZZZ63057 $859.97 $859.97 ZZZ 63600 $2,199.96 $2,199.96 09063064 $4,322.79 $4,322.79 090 63610 $1,189.56 $1,189.56 00063066 $585.31 $585.31 ZZZ 63615 $2,369.32 $2,369.32 09063075 $3,314.20 $3,314.20 090 63620 $2,770.91 $2,770.91 09063076 $670.55 $670.55 ZZZ 63621 $714.11 $714.11 ZZZ63077 $3,638.66 $3,638.66 090 63650 $3,622.66 $1,136.52 01063078 $520.90 $520.90 ZZZ 63655 $2,012.16 $2,012.16 09063081 $4,291.77 $4,291.77 090 63661 $1,575.97 $880.80 01063082 $717.90 $717.90 ZZZ 63662 $2,040.67 $2,040.67 09063085 $4,696.72 $4,696.72 090 63663 $2,163.18 $1,247.33 01063086 $521.85 $521.85 ZZZ 63664 $2,097.68 $2,097.68 09063087 $5,898.14 $5,898.14 090 63685 $1,007.71 $1,007.71 01063088 $710.32 $710.32 ZZZ 63688 $1,013.40 $1,013.40 01063090 $4,762.95 $4,762.95 090 63700 $2,847.21 $2,847.21 09063091 $475.44 $475.44 ZZZ 63702 $3,105.43 $3,105.43 09063101 $5,678.48 $5,678.48 090 63704 $4,099.78 $4,099.78 09063102 $5,542.66 $5,542.66 090 63706 $4,162.66 $4,162.66 09063103 $795.56 $795.56 ZZZ 63707 $2,250.27 $2,250.27 09063170 $3,964.79 $3,964.79 090 63709 $2,691.26 $2,691.26 09063172 $3,408.10 $3,408.10 090 63710 $2,637.61 $2,637.61 09063173 $4,243.14 $4,243.14 090 63740 $2,317.34 $2,317.34 09063180 $3,697.34 $3,697.34 090 63741 $1,659.19 $1,659.19 09063182 $3,357.79 $3,357.79 090 63744 $1,650.81 $1,650.81 09063185 $2,767.56 $2,767.56 090 63746 $1,486.48 $1,486.48 09063190 $3,055.97 $3,055.97 090 64400 $345.69 $194.16 00063191 $3,349.41 $3,349.41 090 64402 $353.27 $214.99 00063194 $3,976.53 $3,976.53 090 64405 $273.71 $172.37 00063195 $3,827.30 $3,827.30 090 64408 $284.13 $207.41 00063196 $3,430.73 $3,430.73 090 64410 $340.96 $193.21 00063197 $4,259.91 $4,259.91 090 64413 $344.74 $221.62 00063198 $4,039.41 $4,039.41 090 64415 $329.59 $179.95 00063199 $4,240.63 $4,240.63 090 64416 $218.78 $218.78 00063200 $3,777.83 $3,777.83 090 64417 $360.85 $197.00 00063250 $6,942.79 $6,942.79 090 64418 $393.99 $209.31 00063251 $7,544.76 $7,544.76 090 64420 $305.91 $186.58 00063252 $7,535.54 $7,535.54 090 64421 $410.09 $251.93 00063265 $4,097.26 $4,097.26 090 64425 $360.85 $256.66 00063266 $4,219.67 $4,219.67 090 64430 $375.05 $224.46 00063267 $3,335.99 $3,335.99 090 64435 $367.47 $226.36 00063268 $3,539.72 $3,539.72 090 64445 $372.21 $198.89 00063270 $5,161.19 $5,161.19 090 64446 $218.78 $218.78 00063271 $5,079.87 $5,079.87 090 64447 $334.33 $182.79 00063272 $4,629.64 $4,629.64 090 64448 $197.00 $197.00 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 40 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

64449 $232.04 $232.04 000 64681 $961.31 $531.32 01064450 $215.94 $125.02 000 64702 $1,206.46 $1,206.46 09064455 $128.81 $94.71 000 64704 $765.46 $765.46 09064461 $402.52 $236.77 000 64708 $1,203.94 $1,203.94 09064462 $227.30 $148.69 ZZZ 64712 $1,385.04 $1,385.04 09064463 $444.19 $232.04 000 64713 $1,762.32 $1,762.32 09064479 $640.24 $362.74 000 64714 $1,559.42 $1,559.42 09064480 $306.86 $173.32 ZZZ 64716 $1,303.71 $1,303.71 09064483 $595.73 $308.75 000 64718 $1,437.02 $1,437.02 09064484 $238.67 $143.01 ZZZ 64719 $973.38 $973.38 09064486 $337.17 $172.37 000 64721 $1,042.13 $1,036.26 09064487 $417.67 $203.63 000 64722 $891.22 $891.22 09064488 $415.78 $218.78 000 64726 $656.47 $656.47 09064489 $584.36 $247.19 000 64727 $508.59 $508.59 ZZZ64490 $517.12 $292.65 000 64732 $909.66 $909.66 09064491 $254.77 $165.74 ZZZ 64734 $995.18 $995.18 09064492 $256.66 $167.64 ZZZ 64736 $962.48 $962.48 09064493 $469.76 $250.98 000 64738 $1,022.01 $1,022.01 09064494 $235.83 $143.01 ZZZ 64740 $1,105.85 $1,105.85 09064495 $236.77 $144.91 ZZZ 64742 $1,169.57 $1,169.57 09064505 $283.18 $237.72 000 64744 $1,203.10 $1,203.10 09064508 $168.58 $199.84 000 64746 $1,114.23 $1,114.23 09064510 $347.59 $202.68 000 64755 $2,240.20 $2,240.20 09064517 $497.23 $337.17 000 64760 $1,215.68 $1,215.68 09064520 $507.65 $222.57 000 64763 $1,222.39 $1,222.39 09064530 $519.96 $253.82 000 64766 $1,464.68 $1,464.68 09064550 $42.62 $24.62 000 64771 $1,459.65 $1,459.65 09064553 $567.31 $427.14 010 64772 $1,359.05 $1,359.05 09064555 $570.15 $417.67 010 64774 $1,011.11 $1,011.11 09064561 $2,198.22 $822.08 010 64776 $946.55 $946.55 09064565 $508.59 $357.06 010 64778 $391.15 $391.15 ZZZ64566 $340.01 $83.34 000 64782 $1,089.08 $1,089.08 09064568 $1,606.37 $1,606.37 090 64783 $613.72 $613.72 ZZZ64569 $1,921.61 $1,921.61 090 64784 $1,778.25 $1,778.25 09064570 $1,592.96 $1,592.96 090 64786 $2,607.42 $2,607.42 09064575 $778.87 $778.87 090 64787 $670.55 $670.55 ZZZ64580 $731.92 $731.92 090 64788 $970.87 $970.87 09064581 $1,597.99 $1,597.99 090 64790 $2,045.70 $2,045.70 09064585 $659.18 $390.21 010 64792 $2,947.81 $2,947.81 09064590 $713.17 $437.56 010 64795 $532.27 $532.27 00064595 $661.08 $343.80 010 64802 $1,613.08 $1,613.08 09064600 $1,067.38 $604.25 010 64804 $2,445.61 $2,445.61 09064605 $2,043.84 $1,136.52 010 64809 $2,483.34 $2,483.34 09064610 $2,035.32 $1,354.35 010 64818 $1,499.06 $1,499.06 09064611 $316.33 $277.50 010 64820 $1,756.45 $1,756.45 09064612 $357.06 $320.12 010 64821 $1,687.70 $1,687.70 09064615 $392.10 $340.96 010 64822 $1,687.70 $1,687.70 09064616 $342.85 $298.34 010 64823 $1,919.10 $1,919.10 09064617 $529.43 $340.01 010 64831 $1,670.09 $1,670.09 09064620 $557.84 $471.66 010 64832 $934.79 $934.79 ZZZ64630 $631.72 $527.53 010 64834 $1,805.08 $1,805.08 09064632 $231.09 $186.58 010 64835 $1,960.18 $1,960.18 09064633 $1,149.78 $622.24 010 64836 $1,966.05 $1,966.05 09064634 $517.12 $188.47 ZZZ 64837 $1,035.18 $1,035.18 ZZZ64635 $1,136.52 $613.72 010 64840 $2,470.76 $2,470.76 09064636 $469.76 $164.80 ZZZ 64856 $2,475.80 $2,475.80 09064640 $359.90 $253.82 010 64857 $2,572.21 $2,572.21 09064642 $384.52 $297.39 000 64858 $2,750.79 $2,750.79 09064643 $251.93 $197.94 ZZZ 64859 $702.75 $702.75 ZZZ64644 $441.35 $325.80 000 64861 $3,215.26 $3,215.26 09064645 $310.65 $228.25 ZZZ 64862 $3,785.38 $3,785.38 09064646 $408.20 $320.12 000 64864 $2,148.82 $2,148.82 09064647 $481.13 $374.10 000 64865 $2,737.38 $2,737.38 09064650 $209.31 $115.55 000 64866 $2,793.55 $2,793.55 09064653 $261.40 $148.69 000 64868 $2,464.06 $2,464.06 09064680 $840.08 $454.61 010 64872 $335.27 $335.27 ZZZ

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 41 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

64874 $471.66 $471.66 ZZZ 65767 80% of billed 80% of billed N/A64876 $484.92 $484.92 ZZZ 65770 $3,343.54 $3,343.54 09064885 $2,805.29 $2,805.29 090 65771 80% of billed 80% of billed N/A64886 $3,172.51 $3,172.51 090 65772 $1,071.48 $968.35 09064890 $2,666.95 $2,666.95 090 65775 $1,312.10 $1,312.10 09064891 $2,851.40 $2,851.40 090 65778 $3,844.28 $158.17 00064892 $2,542.87 $2,542.87 090 65779 $3,228.66 $410.09 00064893 $2,772.59 $2,772.59 090 65780 $1,705.31 $1,705.31 09064895 $3,280.66 $3,280.66 090 65781 $3,175.86 $3,175.86 09064896 $3,531.34 $3,531.34 090 65782 $2,739.89 $2,739.89 09064897 $3,036.68 $3,036.68 090 65785 $5,025.37 $926.43 09064898 $3,324.26 $3,324.26 090 65800 $320.12 $246.25 00064901 $1,536.20 $1,536.20 ZZZ 65810 $1,108.36 $1,108.36 09064902 $1,809.91 $1,809.91 ZZZ 65815 $1,515.83 $1,136.87 09064905 $2,516.04 $2,516.04 090 65820 $1,781.60 $1,781.60 09064907 $3,358.63 $3,358.63 090 65850 $1,998.75 $1,998.75 09064910 $2,010.48 $2,010.48 090 65855 $732.11 $644.03 01064911 $2,471.60 $2,471.60 090 65860 $733.60 $602.81 09064999 80% of billed 80% of billed N/A 65865 $1,125.13 $1,125.13 09065091 $1,509.12 $1,509.12 090 65870 $1,406.84 $1,406.84 09065093 $1,492.35 $1,492.35 090 65875 $1,499.90 $1,499.90 09065101 $1,752.26 $1,752.26 090 65880 $1,576.19 $1,576.19 09065103 $1,829.39 $1,829.39 090 65900 $2,283.80 $2,283.80 09065105 $2,018.87 $2,018.87 090 65920 $1,878.02 $1,878.02 09065110 $2,909.25 $2,909.25 090 65930 $1,517.50 $1,517.50 09065112 $3,383.78 $3,383.78 090 66020 $500.07 $354.22 01065114 $3,552.30 $3,552.30 090 66030 $444.19 $298.34 01065125 $1,086.57 $695.87 090 66130 $1,653.32 $1,353.18 09065130 $1,738.84 $1,738.84 090 66150 $2,085.94 $2,085.94 09065135 $1,763.99 $1,763.99 090 66155 $2,085.10 $2,085.10 09065140 $1,919.10 $1,919.10 090 66160 $2,351.71 $2,351.71 09065150 $1,353.18 $1,353.18 090 66170 $2,302.25 $2,302.25 09065155 $2,010.48 $2,010.48 090 66172 $2,902.54 $2,902.54 09065175 $1,562.78 $1,562.78 090 66174 $2,256.13 $2,256.13 09065205 $149.64 $118.39 000 66175 $2,364.29 $2,364.29 09065210 $182.79 $142.06 000 66179 $2,566.34 $2,566.34 09065220 $154.38 $113.65 000 66180 $2,708.87 $2,708.87 09065222 $178.05 $139.22 000 66183 $2,453.16 $2,453.16 09065235 $1,691.89 $1,691.89 090 66184 $1,868.79 $1,868.79 09065260 $2,286.32 $2,286.32 090 66185 $2,012.16 $2,012.16 09065265 $2,577.24 $2,577.24 090 66220 $1,776.57 $1,776.57 09065270 $714.11 $378.84 010 66225 $2,216.73 $2,216.73 09065272 $1,193.04 $835.88 090 66250 $1,779.08 $1,327.19 09065273 $907.15 $907.15 090 66500 $840.92 $840.92 09065275 $1,374.14 $1,100.82 090 66505 $923.08 $923.08 09065280 $1,598.83 $1,598.83 090 66600 $1,978.62 $1,978.62 09065285 $2,640.96 $2,640.96 090 66605 $2,516.04 $2,516.04 09065286 $1,671.77 $1,180.47 090 66625 $1,022.01 $1,022.01 09065290 $1,162.86 $1,162.86 090 66630 $1,354.85 $1,354.85 09065400 $1,615.60 $1,436.18 090 66635 $1,368.27 $1,368.27 09065410 $382.63 $281.29 000 66680 $1,230.77 $1,230.77 09065420 $1,225.74 $898.76 090 66682 $1,516.67 $1,516.67 09065426 $1,547.69 $1,138.55 090 66700 $1,068.96 $936.49 09065430 $306.86 $278.45 000 66710 $1,045.48 $935.65 09065435 $213.10 $186.58 000 66711 $1,525.05 $1,525.05 09065436 $921.40 $885.35 090 66720 $1,125.97 $1,007.76 09065450 $772.17 $764.62 090 66740 $1,039.62 $936.49 09065600 $936.49 $819.12 090 66761 $794.62 $633.61 01065710 $2,635.93 $2,635.93 090 66762 $1,128.49 $1,015.30 09065730 $2,921.82 $2,921.82 090 66770 $1,254.25 $1,150.28 09065750 $2,937.75 $2,937.75 090 66820 $927.27 $927.27 09065755 $2,921.82 $2,921.82 090 66821 $781.39 $738.63 09065756 $2,822.89 $2,822.89 090 66825 $1,806.75 $1,806.75 09065757 80% of billed 80% of billed ZZZ 66830 $1,683.51 $1,683.51 09065760 80% of billed 80% of billed N/A 66840 $1,658.36 $1,658.36 09065765 80% of billed 80% of billed N/A 66850 $1,886.40 $1,886.40 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 42 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

66852 $2,011.32 $2,011.32 090 67413 $2,038.15 $2,038.15 09066920 $1,795.85 $1,795.85 090 67414 $3,154.90 $3,154.90 09066930 $2,040.67 $2,040.67 090 67415 $282.24 $282.24 00066940 $1,863.76 $1,863.76 090 67420 $3,853.29 $3,853.29 09066982 $1,884.72 $1,884.72 090 67430 $2,949.49 $2,949.49 09066983 $1,668.42 $1,668.42 090 67440 $2,864.81 $2,864.81 09066984 $1,501.57 $1,501.57 090 67445 $3,336.83 $3,336.83 09066985 $1,823.52 $1,823.52 090 67450 $2,988.06 $2,988.06 09066986 $2,162.23 $2,162.23 090 67500 $213.10 $196.05 00066990 $243.40 $243.40 ZZZ 67505 $239.62 $218.78 00066999 80% of billed 80% of billed N/A 67515 $260.45 $240.56 00067005 $1,123.46 $1,123.46 090 67550 $2,295.54 $2,295.54 09067010 $1,291.14 $1,291.14 090 67560 $2,353.39 $2,353.39 09067015 $1,380.01 $1,380.01 090 67570 $2,762.53 $2,762.53 09067025 $1,726.27 $1,505.77 090 67599 80% of billed 80% of billed N/A67027 $2,030.60 $2,030.60 090 67700 $717.90 $313.49 01067028 $273.71 $269.92 000 67710 $598.57 $262.35 01067030 $1,266.82 $1,266.82 090 67715 $641.19 $291.71 01067031 $923.92 $849.30 090 67800 $340.96 $278.45 01067036 $2,147.14 $2,147.14 090 67801 $433.77 $359.90 01067039 $2,300.57 $2,300.57 090 67805 $540.79 $444.19 01067040 $2,485.86 $2,485.86 090 67808 $879.48 $879.48 09067041 $2,746.60 $2,746.60 090 67810 $461.24 $194.16 00067042 $2,746.60 $2,746.60 090 67820 $133.54 $142.06 00067043 $2,900.03 $2,900.03 090 67825 $344.74 $326.75 01067101 $1,862.92 $1,605.54 090 67830 $714.11 $372.21 01067105 $1,710.34 $1,533.43 090 67835 $1,042.97 $1,042.97 09067107 $2,422.98 $2,422.98 090 67840 $736.84 $426.19 01067108 $2,584.79 $2,584.79 090 67850 $574.89 $366.53 01067110 $1,807.59 $1,659.19 090 67875 $459.34 $262.35 00067113 $3,193.47 $3,193.47 090 67880 $1,088.24 $877.80 09067115 $1,188.85 $1,188.85 090 67882 $1,338.92 $1,124.29 09067120 $1,561.94 $1,328.03 090 67900 $1,522.53 $1,215.68 09067121 $2,163.91 $2,163.91 090 67901 $1,796.69 $1,374.14 09067141 $1,245.02 $1,161.18 090 67902 $1,725.43 $1,725.43 09067145 $1,252.57 $1,184.66 090 67903 $1,409.35 $1,152.80 09067208 $1,426.12 $1,376.65 090 67904 $1,739.68 $1,423.60 09067210 $1,231.61 $1,190.53 090 67906 $1,207.30 $1,207.30 09067218 $3,296.59 $3,296.59 090 67908 $1,171.24 $1,011.11 09067220 $1,270.18 $1,190.53 090 67909 $1,273.53 $1,045.48 09067221 $769.99 $574.89 000 67911 $1,339.76 $1,339.76 09067225 $79.56 $75.77 ZZZ 67912 $2,097.68 $1,172.92 09067227 $688.33 $611.19 090 67914 $1,114.23 $779.71 09067228 $810.73 $731.08 090 67915 $694.20 $471.18 09067229 $2,660.24 $2,660.24 090 67916 $1,405.16 $1,027.04 09067250 $1,857.89 $1,857.89 090 67917 $1,431.15 $1,091.60 09067255 $1,626.50 $1,626.50 090 67921 $1,091.60 $739.47 09067299 80% of billed 80% of billed N/A 67922 $687.49 $470.34 09067311 $1,424.44 $1,424.44 090 67923 $1,403.48 $1,026.20 09067312 $1,696.92 $1,696.92 090 67924 $1,496.54 $1,091.60 09067314 $1,603.02 $1,603.02 090 67930 $974.57 $645.92 01067316 $1,909.04 $1,909.04 090 67935 $1,411.87 $1,055.55 09067318 $1,675.96 $1,675.96 090 67938 $643.08 $308.75 01067320 $869.44 $869.44 ZZZ 67950 $1,359.88 $1,105.01 09067331 $824.92 $824.92 ZZZ 67961 $1,364.92 $1,084.05 09067332 $895.96 $895.96 ZZZ 67966 $1,827.71 $1,568.65 09067334 $813.56 $813.56 ZZZ 67971 $1,725.43 $1,725.43 09067335 $401.57 $401.57 ZZZ 67973 $2,219.24 $2,219.24 09067340 $966.99 $966.99 ZZZ 67974 $2,214.21 $2,214.21 09067343 $1,557.75 $1,557.75 090 67975 $1,632.36 $1,632.36 09067345 $653.50 $589.10 010 67999 80% of billed 80% of billed N/A67346 $520.90 $520.90 000 68020 $320.12 $297.39 01067399 80% of billed 80% of billed N/A 68040 $167.64 $136.38 00067400 $2,213.38 $2,213.38 090 68100 $454.61 $262.35 00067405 $1,891.43 $1,891.43 090 68110 $603.30 $400.62 01067412 $2,025.57 $2,025.57 090 68115 $834.40 $495.33 010

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 43 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

68130 $1,278.56 $981.77 090 69433 $551.21 $362.74 01068135 $419.57 $406.31 010 69436 $439.45 $439.45 01068200 $110.81 $93.76 000 69440 $1,673.45 $1,673.45 09068320 $1,719.56 $1,283.59 090 69450 $1,322.16 $1,322.16 09068325 $1,571.16 $1,571.16 090 69501 $1,781.60 $1,781.60 09068326 $1,538.46 $1,538.46 090 69502 $2,358.42 $2,358.42 09068328 $1,688.54 $1,688.54 090 69505 $2,916.79 $2,916.79 09068330 $1,434.50 $1,099.14 090 69511 $2,980.51 $2,980.51 09068335 $1,542.66 $1,542.66 090 69530 $4,020.13 $4,020.13 09068340 $1,293.65 $951.58 090 69535 $6,516.88 $6,516.88 09068360 $1,265.15 $984.28 090 69540 $568.26 $347.59 01068362 $1,563.62 $1,563.62 090 69550 $2,526.10 $2,526.10 09068371 $1,110.95 $1,110.95 010 69552 $3,793.76 $3,793.76 09068399 80% of billed 80% of billed N/A 69554 $5,907.37 $5,907.37 09068400 $759.57 $355.16 010 69601 $2,538.68 $2,538.68 09068420 $861.86 $454.61 010 69602 $2,640.96 $2,640.96 09068440 $274.66 $267.08 010 69603 $3,089.50 $3,089.50 09068500 $2,323.21 $2,323.21 090 69604 $2,700.49 $2,700.49 09068505 $2,309.79 $2,309.79 090 69605 $3,787.05 $3,787.05 09068510 $1,193.35 $787.04 000 69610 $1,047.49 $796.51 01068520 $1,640.75 $1,640.75 090 69620 $1,676.80 $1,186.34 09068525 $711.27 $711.27 000 69631 $2,145.47 $2,145.47 09068530 $1,145.04 $693.28 010 69632 $2,611.62 $2,611.62 09068540 $2,217.57 $2,217.57 090 69633 $2,535.32 $2,535.32 09068550 $2,636.77 $2,636.77 090 69635 $3,000.63 $3,000.63 09068700 $1,437.86 $1,437.86 090 69636 $3,353.60 $3,353.60 09068705 $633.61 $447.03 010 69637 $3,335.16 $3,335.16 09068720 $1,802.56 $1,802.56 090 69641 $2,527.78 $2,527.78 09068745 $1,810.11 $1,810.11 090 69642 $3,242.09 $3,242.09 09068750 $1,873.82 $1,873.82 090 69643 $2,971.29 $2,971.29 09068760 $538.90 $393.99 010 69644 $3,585.84 $3,585.84 09068761 $393.05 $319.17 010 69645 $3,527.15 $3,527.15 09068770 $1,496.54 $1,496.54 090 69646 $3,747.65 $3,747.65 09068801 $268.98 $232.99 010 69650 $1,956.83 $1,956.83 09068810 $521.85 $407.25 010 69660 $2,251.10 $2,251.10 09068811 $447.03 $447.03 010 69661 $2,934.40 $2,934.40 09068815 $1,063.59 $595.73 010 69662 $2,814.51 $2,814.51 09068816 $1,729.40 $542.69 010 69666 $1,961.86 $1,961.86 09068840 $342.85 $314.44 010 69667 $1,963.53 $1,963.53 09068850 $163.85 $150.59 000 69670 $2,300.57 $2,300.57 09068899 80% of billed 80% of billed N/A 69676 $2,016.35 $2,016.35 09069000 $505.75 $323.91 010 69700 $1,663.39 $1,663.39 09069005 $583.41 $429.04 010 69710 80% of billed 80% of billed N/A69020 $631.72 $389.26 010 69711 $2,096.84 $2,096.84 09069090 80% of billed 80% of billed N/A 69714 $2,615.81 $2,615.81 09069100 $270.87 $133.54 000 69715 $3,227.00 $3,227.00 09069105 $380.73 $174.27 000 69717 $2,749.11 $2,749.11 09069110 $1,104.17 $785.58 090 69718 $3,260.54 $3,260.54 09069120 $980.93 $980.93 090 69720 $2,957.04 $2,957.04 09069140 $2,125.34 $2,125.34 090 69725 $4,567.60 $4,567.60 09069145 $956.61 $604.49 090 69740 $2,834.63 $2,834.63 09069150 $2,543.71 $2,543.71 090 69745 $3,429.89 $3,429.89 09069155 $4,045.28 $4,045.28 090 69799 80% of billed 80% of billed N/A69200 $268.03 $128.81 000 69801 $533.22 $345.69 00069205 $277.50 $277.50 010 69805 $2,561.31 $2,561.31 09069209 $34.10 $34.10 000 69806 $2,294.70 $2,294.70 09069210 $132.59 $89.03 000 69820 $2,079.23 $2,079.23 09069220 $299.28 $142.06 000 69840 $2,210.02 $2,210.02 09069222 $597.62 $374.10 010 69905 $2,226.79 $2,226.79 09069300 $2,003.12 $1,307.00 N/A 69910 $2,469.09 $2,469.09 09069310 $2,645.15 $2,645.15 090 69915 $3,737.59 $3,737.59 09069320 $3,747.65 $3,747.65 090 69930 $2,974.64 $2,974.64 09069399 80% of billed 80% of billed N/A 69949 80% of billed 80% of billed N/A69420 $520.90 $330.54 010 69950 $4,332.01 $4,332.01 09069421 $408.20 $408.20 010 69955 $4,847.63 $4,847.63 09069424 $345.69 $170.48 000 69960 $4,660.67 $4,660.67 090

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 44 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

69970 $5,213.17 $5,213.17 090 70320 26 $25.94 $25.94 N/A69979 80% of billed 80% of billed N/A 70328 $65.60 $65.60 N/A69990 $603.30 $603.30 ZZZ 70328 TC $45.77 $45.77 N/A70010 $133.49 $133.49 N/A 70328 26 $19.83 $19.83 N/A70015 $328.77 $328.77 N/A 70330 $100.69 $100.69 N/A70015 TC $193.75 $193.75 N/A 70330 TC $73.23 $73.23 N/A70015 26 $135.02 $135.02 N/A 70330 26 $27.46 $27.46 N/A70030 $59.50 $59.50 N/A 70332 $174.68 $174.68 N/A70030 TC $41.19 $41.19 N/A 70332 TC $106.79 $106.79 N/A70030 26 $18.31 $18.31 N/A 70332 26 $67.89 $67.89 N/A70100 $70.18 $70.18 N/A 70336 $685.76 $685.76 N/A70100 TC $50.34 $50.34 N/A 70336 TC $526.33 $526.33 N/A70100 26 $19.83 $19.83 N/A 70336 26 $159.43 $159.43 N/A70110 $80.86 $80.86 N/A 70350 $42.72 $42.72 N/A70110 TC $53.40 $53.40 N/A 70350 TC $20.60 $20.60 N/A70110 26 $27.46 $27.46 N/A 70350 26 $22.12 $22.12 N/A70120 $72.47 $72.47 N/A 70355 $44.24 $44.24 N/A70120 TC $52.63 $52.63 N/A 70355 TC $19.83 $19.83 N/A70120 26 $19.83 $19.83 N/A 70355 26 $24.41 $24.41 N/A70130 $116.71 $116.71 N/A 70360 $60.26 $60.26 N/A70130 TC $79.33 $79.33 N/A 70360 TC $41.95 $41.95 N/A70130 26 $37.38 $37.38 N/A 70360 26 $18.31 $18.31 N/A70134 $109.84 $109.84 N/A 70370 $167.82 $167.82 N/A70134 TC $71.70 $71.70 N/A 70370 TC $132.73 $132.73 N/A70134 26 $38.14 $38.14 N/A 70370 26 $35.09 $35.09 N/A70140 $63.31 $63.31 N/A 70371 $196.04 $196.04 N/A70140 TC $40.43 $40.43 N/A 70371 TC $102.98 $102.98 N/A70140 26 $22.88 $22.88 N/A 70371 26 $93.06 $93.06 N/A70150 $88.48 $88.48 N/A 70380 $77.04 $77.04 N/A70150 TC $59.50 $59.50 N/A 70380 TC $57.21 $57.21 N/A70150 26 $28.99 $28.99 N/A 70380 26 $19.83 $19.83 N/A70160 $69.41 $69.41 N/A 70390 $201.38 $201.38 N/A70160 TC $50.34 $50.34 N/A 70390 TC $160.19 $160.19 N/A70160 26 $19.07 $19.07 N/A 70390 26 $41.19 $41.19 N/A70170 80% of billed 80% of billed N/A 70450 $247.91 $247.91 N/A70170 TC 80% of billed 80% of billed N/A 70450 TC $155.61 $155.61 N/A70170 26 $32.80 $32.80 N/A 70450 26 $92.30 $92.30 N/A70190 $76.28 $76.28 N/A 70460 $346.31 $346.31 N/A70190 TC $51.87 $51.87 N/A 70460 TC $223.50 $223.50 N/A70190 26 $24.41 $24.41 N/A 70460 26 $122.81 $122.81 N/A70200 $90.01 $90.01 N/A 70470 $409.62 $409.62 N/A70200 TC $59.50 $59.50 N/A 70470 TC $271.56 $271.56 N/A70200 26 $30.51 $30.51 N/A 70470 26 $138.07 $138.07 N/A70210 $63.31 $63.31 N/A 70480 $499.63 $499.63 N/A70210 TC $44.24 $44.24 N/A 70480 TC $360.04 $360.04 N/A70210 26 $19.07 $19.07 N/A 70480 26 $139.59 $139.59 N/A70220 $80.09 $80.09 N/A 70481 $591.17 $591.17 N/A70220 TC $52.63 $52.63 N/A 70481 TC $440.90 $440.90 N/A70220 26 $27.46 $27.46 N/A 70481 26 $150.27 $150.27 N/A70240 $64.08 $64.08 N/A 70482 $645.33 $645.33 N/A70240 TC $42.72 $42.72 N/A 70482 TC $488.19 $488.19 N/A70240 26 $21.36 $21.36 N/A 70482 26 $157.14 $157.14 N/A70250 $77.04 $77.04 N/A 70486 $299.78 $299.78 N/A70250 TC $49.58 $49.58 N/A 70486 TC $206.72 $206.72 N/A70250 26 $27.46 $27.46 N/A 70486 26 $93.06 $93.06 N/A70260 $97.64 $97.64 N/A 70487 $360.04 $360.04 N/A70260 TC $59.50 $59.50 N/A 70487 TC $237.23 $237.23 N/A70260 26 $38.14 $38.14 N/A 70487 26 $122.81 $122.81 N/A70300 $32.04 $32.04 N/A 70488 $439.37 $439.37 N/A70300 TC $19.07 $19.07 N/A 70488 TC $301.31 $301.31 N/A70300 26 $12.97 $12.97 N/A 70488 26 $138.07 $138.07 N/A70310 $78.57 $78.57 N/A 70490 $413.44 $413.44 N/A70310 TC $61.02 $61.02 N/A 70490 TC $273.85 $273.85 N/A70310 26 $17.54 $17.54 N/A 70490 26 $139.59 $139.59 N/A70320 $112.13 $112.13 N/A 70491 $504.97 $504.97 N/A70320 TC $86.20 $86.20 N/A 70491 TC $353.94 $353.94 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 45 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

70491 26 $151.03 $151.03 N/A 71015 26 $23.65 $23.65 N/A70492 $594.22 $594.22 N/A 71020 $59.50 $59.50 N/A70492 TC $437.08 $437.08 N/A 71020 TC $35.85 $35.85 N/A70492 26 $157.14 $157.14 N/A 71020 26 $23.65 $23.65 N/A70496 $630.84 $630.84 N/A 71021 $72.47 $72.47 N/A70496 TC $440.90 $440.90 N/A 71021 TC $42.72 $42.72 N/A70496 26 $189.94 $189.94 N/A 71021 26 $29.75 $29.75 N/A70498 $627.78 $627.78 N/A 71022 $89.25 $89.25 N/A70498 TC $437.85 $437.85 N/A 71022 TC $53.40 $53.40 N/A70498 26 $189.94 $189.94 N/A 71022 26 $35.85 $35.85 N/A70540 $768.14 $768.14 N/A 71023 $135.78 $135.78 N/A70540 TC $621.68 $621.68 N/A 71023 TC $94.59 $94.59 N/A70540 26 $146.46 $146.46 N/A 71023 26 $41.19 $41.19 N/A70542 $860.44 $860.44 N/A 71030 $89.25 $89.25 N/A70542 TC $684.23 $684.23 N/A 71030 TC $54.92 $54.92 N/A70542 26 $176.21 $176.21 N/A 71030 26 $34.33 $34.33 N/A70543 $1,052.66 $1,052.66 N/A 71034 $177.73 $177.73 N/A70543 TC $820.01 $820.01 N/A 71034 TC $127.39 $127.39 N/A70543 26 $232.65 $232.65 N/A 71034 26 $50.34 $50.34 N/A70544 $838.32 $838.32 N/A 71035 $70.18 $70.18 N/A70544 TC $707.88 $707.88 N/A 71035 TC $50.34 $50.34 N/A70544 26 $130.44 $130.44 N/A 71035 26 $19.83 $19.83 N/A70545 $828.40 $828.40 N/A 71100 $70.18 $70.18 N/A70545 TC $697.96 $697.96 N/A 71100 TC $45.77 $45.77 N/A70545 26 $130.44 $130.44 N/A 71100 26 $24.41 $24.41 N/A70546 $1,279.98 $1,279.98 N/A 71101 $77.81 $77.81 N/A70546 TC $1,084.70 $1,084.70 N/A 71101 TC $48.06 $48.06 N/A70546 26 $195.28 $195.28 N/A 71101 26 $29.75 $29.75 N/A70547 $842.13 $842.13 N/A 71110 $80.09 $80.09 N/A70547 TC $710.93 $710.93 N/A 71110 TC $50.34 $50.34 N/A70547 26 $131.20 $131.20 N/A 71110 26 $29.75 $29.75 N/A70548 $883.32 $883.32 N/A 71111 $102.22 $102.22 N/A70548 TC $752.88 $752.88 N/A 71111 TC $66.36 $66.36 N/A70548 26 $130.44 $130.44 N/A 71111 26 $35.85 $35.85 N/A70549 $1,288.37 $1,288.37 N/A 71120 $63.31 $63.31 N/A70549 TC $1,093.09 $1,093.09 N/A 71120 TC $41.19 $41.19 N/A70549 26 $195.28 $195.28 N/A 71120 26 $22.12 $22.12 N/A70551 $493.53 $493.53 N/A 71130 $77.04 $77.04 N/A70551 TC $332.58 $332.58 N/A 71130 TC $52.63 $52.63 N/A70551 26 $160.95 $160.95 N/A 71130 26 $24.41 $24.41 N/A70552 $684.23 $684.23 N/A 71250 $385.98 $385.98 N/A70552 TC $490.48 $490.48 N/A 71250 TC $274.61 $274.61 N/A70552 26 $193.75 $193.75 N/A 71250 26 $111.37 $111.37 N/A70553 $808.57 $808.57 N/A 71260 $491.24 $491.24 N/A70553 TC $559.13 $559.13 N/A 71260 TC $355.46 $355.46 N/A70553 26 $249.44 $249.44 N/A 71260 26 $135.78 $135.78 N/A70554 $965.70 $965.70 N/A 71270 $588.88 $588.88 N/A70554 TC $734.58 $734.58 N/A 71270 TC $438.61 $438.61 N/A70554 26 $231.13 $231.13 N/A 71270 26 $150.27 $150.27 N/A70555 80% of billed 80% of billed N/A 71275 $641.51 $641.51 N/A70555 TC 80% of billed 80% of billed N/A 71275 TC $443.95 $443.95 N/A70555 26 $274.61 $274.61 N/A 71275 26 $197.57 $197.57 N/A70557 80% of billed 80% of billed N/A 71550 $886.37 $886.37 N/A70557 TC 80% of billed 80% of billed N/A 71550 TC $727.71 $727.71 N/A70557 26 $317.32 $317.32 N/A 71550 26 $158.66 $158.66 N/A70558 80% of billed 80% of billed N/A 71551 $980.96 $980.96 N/A70558 TC 80% of billed 80% of billed N/A 71551 TC $793.31 $793.31 N/A70558 26 $349.36 $349.36 N/A 71551 26 $187.65 $187.65 N/A70559 80% of billed 80% of billed N/A 71552 $1,239.55 $1,239.55 N/A70559 TC 80% of billed 80% of billed N/A 71552 TC $993.93 $993.93 N/A70559 26 $351.65 $351.65 N/A 71552 26 $245.62 $245.62 N/A71010 $48.06 $48.06 N/A 71555 $850.52 $850.52 N/A71010 TC $28.22 $28.22 N/A 71555 TC $656.01 $656.01 N/A71010 26 $19.83 $19.83 N/A 71555 26 $194.51 $194.51 N/A71015 $59.50 $59.50 N/A 72020 $47.29 $47.29 N/A71015 TC $35.85 $35.85 N/A 72020 TC $30.51 $30.51 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 46 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

72020 26 $16.78 $16.78 N/A 72131 26 $109.08 $109.08 N/A72040 $70.94 $70.94 N/A 72132 $488.95 $488.95 N/A72040 TC $46.53 $46.53 N/A 72132 TC $356.23 $356.23 N/A72040 26 $24.41 $24.41 N/A 72132 26 $132.73 $132.73 N/A72050 $96.11 $96.11 N/A 72133 $578.97 $578.97 N/A72050 TC $61.79 $61.79 N/A 72133 TC $440.90 $440.90 N/A72050 26 $34.33 $34.33 N/A 72133 26 $138.07 $138.07 N/A72052 $120.52 $120.52 N/A 72141 $852.63 $852.63 N/A72052 TC $80.86 $80.86 N/A 72141 TC $690.92 $690.92 N/A72052 26 $39.67 $39.67 N/A 72141 26 $161.71 $161.71 N/A72070 $72.47 $72.47 N/A 72142 $695.67 $695.67 N/A72070 TC $48.06 $48.06 N/A 72142 TC $500.40 $500.40 N/A72070 26 $24.41 $24.41 N/A 72142 26 $195.28 $195.28 N/A72072 $73.99 $73.99 N/A 72146 $479.80 $479.80 N/A72072 TC $50.34 $50.34 N/A 72146 TC $318.09 $318.09 N/A72072 26 $23.65 $23.65 N/A 72146 26 $161.71 $161.71 N/A72074 $83.91 $83.91 N/A 72147 $688.05 $688.05 N/A72074 TC $60.26 $60.26 N/A 72147 TC $494.29 $494.29 N/A72074 26 $23.65 $23.65 N/A 72147 26 $193.75 $193.75 N/A72080 $65.60 $65.60 N/A 72148 $858.58 $858.58 N/A72080 TC $41.95 $41.95 N/A 72148 TC $696.87 $696.87 N/A72080 26 $23.65 $23.65 N/A 72148 26 $161.71 $161.71 N/A72081 $83.15 $83.15 N/A 72149 $686.52 $686.52 N/A72081 TC $54.16 $54.16 N/A 72149 TC $492.01 $492.01 N/A72081 26 $28.99 $28.99 N/A 72149 26 $194.51 $194.51 N/A72082 $133.49 $133.49 N/A 72156 $812.38 $812.38 N/A72082 TC $98.40 $98.40 N/A 72156 TC $562.95 $562.95 N/A72082 26 $35.09 $35.09 N/A 72156 26 $249.44 $249.44 N/A72083 $144.93 $144.93 N/A 72157 $813.14 $813.14 N/A72083 TC $106.79 $106.79 N/A 72157 TC $563.71 $563.71 N/A72083 26 $38.14 $38.14 N/A 72157 26 $249.44 $249.44 N/A72084 $172.39 $172.39 N/A 72158 $810.09 $810.09 N/A72084 TC $128.15 $128.15 N/A 72158 TC $560.66 $560.66 N/A72084 26 $44.24 $44.24 N/A 72158 26 $249.44 $249.44 N/A72100 $74.75 $74.75 N/A 72159 $891.71 $891.71 N/A72100 TC $50.34 $50.34 N/A 72159 TC $695.67 $695.67 N/A72100 26 $24.41 $24.41 N/A 72159 26 $196.04 $196.04 N/A72110 $104.50 $104.50 N/A 72170 $67.89 $67.89 N/A72110 TC $70.18 $70.18 N/A 72170 TC $48.82 $48.82 N/A72110 26 $34.33 $34.33 N/A 72170 26 $19.07 $19.07 N/A72114 $133.49 $133.49 N/A 72190 $81.62 $81.62 N/A72114 TC $97.64 $97.64 N/A 72190 TC $57.97 $57.97 N/A72114 26 $35.85 $35.85 N/A 72190 26 $23.65 $23.65 N/A72120 $86.20 $86.20 N/A 72191 $653.72 $653.72 N/A72120 TC $61.79 $61.79 N/A 72191 TC $457.68 $457.68 N/A72120 26 $24.41 $24.41 N/A 72191 26 $196.04 $196.04 N/A72125 $395.13 $395.13 N/A 72192 $311.99 $311.99 N/A72125 TC $278.42 $278.42 N/A 72192 TC $193.75 $193.75 N/A72125 26 $116.71 $116.71 N/A 72192 26 $118.23 $118.23 N/A72126 $490.48 $490.48 N/A 72193 $483.62 $483.62 N/A72126 TC $357.75 $357.75 N/A 72193 TC $356.99 $356.99 N/A72126 26 $132.73 $132.73 N/A 72193 26 $126.62 $126.62 N/A72127 $579.73 $579.73 N/A 72194 $556.84 $556.84 N/A72127 TC $441.66 $441.66 N/A 72194 TC $424.88 $424.88 N/A72127 26 $138.07 $138.07 N/A 72194 26 $131.96 $131.96 N/A72128 $385.98 $385.98 N/A 72195 $801.70 $801.70 N/A72128 TC $276.90 $276.90 N/A 72195 TC $643.04 $643.04 N/A72128 26 $109.08 $109.08 N/A 72195 26 $158.66 $158.66 N/A72129 $491.24 $491.24 N/A 72196 $880.27 $880.27 N/A72129 TC $358.52 $358.52 N/A 72196 TC $691.86 $691.86 N/A72129 26 $132.73 $132.73 N/A 72196 26 $188.41 $188.41 N/A72130 $583.54 $583.54 N/A 72197 $1,081.65 $1,081.65 N/A72130 TC $445.48 $445.48 N/A 72197 TC $836.03 $836.03 N/A72130 26 $138.07 $138.07 N/A 72197 26 $245.62 $245.62 N/A72131 $384.45 $384.45 N/A 72198 $856.62 $856.62 N/A72131 TC $275.37 $275.37 N/A 72198 TC $662.87 $662.87 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 47 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

72198 26 $193.75 $193.75 N/A 73092 26 $17.54 $17.54 N/A72200 $61.02 $61.02 N/A 73100 $62.55 $62.55 N/A72200 TC $41.95 $41.95 N/A 73100 TC $44.24 $44.24 N/A72200 26 $19.07 $19.07 N/A 73100 26 $18.31 $18.31 N/A72202 $70.18 $70.18 N/A 73110 $75.52 $75.52 N/A72202 TC $49.58 $49.58 N/A 73110 TC $56.45 $56.45 N/A72202 26 $20.60 $20.60 N/A 73110 26 $19.07 $19.07 N/A72220 $60.26 $60.26 N/A 73115 $228.84 $228.84 N/A72220 TC $41.19 $41.19 N/A 73115 TC $167.05 $167.05 N/A72220 26 $19.07 $19.07 N/A 73115 26 $61.79 $61.79 N/A72240 $209.77 $209.77 N/A 73120 $55.68 $55.68 N/A72240 TC $110.61 $110.61 N/A 73120 TC $37.38 $37.38 N/A72240 26 $99.16 $99.16 N/A 73120 26 $18.31 $18.31 N/A72255 $209.01 $209.01 N/A 73130 $65.60 $65.60 N/A72255 TC $108.32 $108.32 N/A 73130 TC $46.53 $46.53 N/A72255 26 $100.69 $100.69 N/A 73130 26 $19.07 $19.07 N/A72265 $197.57 $197.57 N/A 73140 $67.13 $67.13 N/A72265 TC $106.79 $106.79 N/A 73140 TC $51.87 $51.87 N/A72265 26 $90.77 $90.77 N/A 73140 26 $15.26 $15.26 N/A72270 $273.08 $273.08 N/A 73200 $382.93 $382.93 N/A72270 TC $127.39 $127.39 N/A 73200 TC $273.85 $273.85 N/A72270 26 $145.69 $145.69 N/A 73200 26 $109.08 $109.08 N/A72275 $248.67 $248.67 N/A 73201 $476.75 $476.75 N/A72275 TC $163.24 $163.24 N/A 73201 TC $350.13 $350.13 N/A72275 26 $85.43 $85.43 N/A 73201 26 $126.62 $126.62 N/A72285 $246.38 $246.38 N/A 73202 $594.22 $594.22 N/A72285 TC $113.66 $113.66 N/A 73202 TC $461.49 $461.49 N/A72285 26 $132.73 $132.73 N/A 73202 26 $132.73 $132.73 N/A72295 $212.82 $212.82 N/A 73206 $701.01 $701.01 N/A72295 TC $118.23 $118.23 N/A 73206 TC $505.74 $505.74 N/A72295 26 $94.59 $94.59 N/A 73206 26 $195.28 $195.28 N/A73000 $58.74 $58.74 N/A 73218 $781.11 $781.11 N/A73000 TC $40.43 $40.43 N/A 73218 TC $633.89 $633.89 N/A73000 26 $18.31 $18.31 N/A 73218 26 $147.22 $147.22 N/A73010 $64.08 $64.08 N/A 73219 $865.02 $865.02 N/A73010 TC $44.24 $44.24 N/A 73219 TC $688.81 $688.81 N/A73010 26 $19.83 $19.83 N/A 73219 26 $176.21 $176.21 N/A73020 $48.82 $48.82 N/A 73220 $1,070.21 $1,070.21 N/A73020 TC $32.04 $32.04 N/A 73220 TC $836.03 $836.03 N/A73020 26 $16.78 $16.78 N/A 73220 26 $234.18 $234.18 N/A73030 $61.79 $61.79 N/A 73221 $901.65 $901.65 N/A73030 TC $41.19 $41.19 N/A 73221 TC $753.67 $753.67 N/A73030 26 $20.60 $20.60 N/A 73221 26 $147.98 $147.98 N/A73040 $214.35 $214.35 N/A 73222 $809.33 $809.33 N/A73040 TC $154.85 $154.85 N/A 73222 TC $632.36 $632.36 N/A73040 26 $59.50 $59.50 N/A 73222 26 $176.97 $176.97 N/A73050 $76.28 $76.28 N/A 73223 $1,004.61 $1,004.61 N/A73050 TC $53.40 $53.40 N/A 73223 TC $770.43 $770.43 N/A73050 26 $22.88 $22.88 N/A 73223 26 $234.18 $234.18 N/A73060 $61.79 $61.79 N/A 73225 $867.30 $867.30 N/A73060 TC $43.48 $43.48 000 73225 TC $681.18 $681.18 N/A73060 26 $18.31 $18.31 000 73225 26 $186.12 $186.12 N/A73070 $58.74 $58.74 N/A 73501 $64.08 $64.08 N/A73070 TC $41.19 $41.19 N/A 73501 TC $43.48 $43.48 N/A73070 26 $17.54 $17.54 N/A 73501 26 $20.60 $20.60 N/A73080 $66.36 $66.36 N/A 73502 $88.48 $88.48 N/A73080 TC $47.29 $47.29 N/A 73502 TC $64.08 $64.08 N/A73080 26 $19.07 $19.07 N/A 73502 26 $24.41 $24.41 N/A73085 $209.01 $209.01 N/A 73503 $110.61 $110.61 N/A73085 TC $146.46 $146.46 N/A 73503 TC $79.33 $79.33 N/A73085 26 $62.55 $62.55 N/A 73503 26 $31.27 $31.27 N/A73090 $54.92 $54.92 N/A 73521 $85.43 $85.43 N/A73090 TC $36.61 $36.61 N/A 73521 TC $60.26 $60.26 N/A73090 26 $18.31 $18.31 N/A 73521 26 $25.17 $25.17 N/A73092 $57.97 $57.97 N/A 73522 $104.50 $104.50 N/A73092 TC $40.43 $40.43 N/A 73522 TC $71.70 $71.70 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 48 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

73522 26 $32.80 $32.80 N/A 73706 26 $205.19 $205.19 N/A73523 $121.29 $121.29 N/A 73718 $781.11 $781.11 N/A73523 TC $86.20 $86.20 N/A 73718 TC $633.89 $633.89 N/A73523 26 $35.09 $35.09 N/A 73718 26 $147.22 $147.22 N/A73525 $218.16 $218.16 N/A 73719 $865.02 $865.02 N/A73525 TC $155.61 $155.61 N/A 73719 TC $688.81 $688.81 N/A73525 26 $62.55 $62.55 N/A 73719 26 $176.21 $176.21 N/A73551 $59.50 $59.50 N/A 73720 $1,075.55 $1,075.55 N/A73551 TC $41.19 $41.19 N/A 73720 TC $842.13 $842.13 N/A73551 26 $18.31 $18.31 N/A 73720 26 $233.42 $233.42 N/A73552 $69.41 $69.41 N/A 73721 $920.81 $920.81 N/A73552 TC $48.82 $48.82 N/A 73721 TC $772.83 $772.83 N/A73552 26 $20.60 $20.60 N/A 73721 26 $147.98 $147.98 N/A73560 $66.36 $66.36 N/A 73722 $817.72 $817.72 N/A73560 TC $48.06 $48.06 N/A 73722 TC $640.75 $640.75 N/A73560 26 $18.31 $18.31 000 73722 26 $176.97 $176.97 N/A73562 $76.28 $76.28 N/A 73723 $1,006.90 $1,006.90 N/A73562 TC $55.68 $55.68 N/A 73723 TC $773.48 $773.48 N/A73562 26 $20.60 $20.60 N/A 73723 26 $233.42 $233.42 N/A73564 $84.67 $84.67 N/A 73725 $858.91 $858.91 N/A73564 TC $60.26 $60.26 N/A 73725 TC $663.64 $663.64 N/A73564 26 $24.41 $24.41 N/A 73725 26 $195.28 $195.28 N/A73565 $77.04 $77.04 N/A 74000 $50.34 $50.34 N/A73565 TC $57.97 $57.97 N/A 74000 TC $30.51 $30.51 N/A73565 26 $19.07 $19.07 N/A 74000 26 $19.83 $19.83 N/A73580 $247.15 $247.15 N/A 74010 $75.52 $75.52 N/A73580 TC $185.36 $185.36 N/A 74010 TC $50.34 $50.34 N/A73580 26 $61.79 $61.79 N/A 74010 26 $25.17 $25.17 N/A73590 $61.02 $61.02 N/A 74020 $80.09 $80.09 N/A73590 TC $42.72 $42.72 N/A 74020 TC $50.34 $50.34 N/A73590 26 $18.31 $18.31 N/A 74020 26 $29.75 $29.75 N/A73592 $59.50 $59.50 N/A 74022 $95.35 $95.35 N/A73592 TC $41.95 $41.95 N/A 74022 TC $60.26 $60.26 N/A73592 26 $17.54 $17.54 N/A 74022 26 $35.09 $35.09 N/A73600 $64.08 $64.08 N/A 74150 $320.38 $320.38 N/A73600 TC $45.77 $45.77 N/A 74150 TC $190.70 $190.70 N/A73600 26 $18.31 $18.31 N/A 74150 26 $129.68 $129.68 N/A73610 $67.13 $67.13 N/A 74160 $493.53 $493.53 N/A73610 TC $48.06 $48.06 N/A 74160 TC $355.46 $355.46 N/A73610 26 $19.07 $19.07 N/A 74160 26 $138.07 $138.07 N/A73615 $225.79 $225.79 N/A 74170 $561.42 $561.42 N/A73615 TC $163.24 $163.24 N/A 74170 TC $408.86 $408.86 N/A73615 26 $62.55 $62.55 N/A 74170 26 $152.56 $152.56 N/A73620 $55.68 $55.68 N/A 74174 $831.45 $831.45 N/A73620 TC $38.90 $38.90 N/A 74174 TC $593.46 $593.46 N/A73620 26 $16.78 $16.78 N/A 74174 26 $237.99 $237.99 N/A73630 $62.55 $62.55 N/A 74175 $656.77 $656.77 N/A73630 TC $44.24 $44.24 N/A 74175 TC $459.97 $459.97 N/A73630 26 $18.31 $18.31 N/A 74175 26 $196.80 $196.80 N/A73650 $57.97 $57.97 N/A 74176 $427.93 $427.93 N/A73650 TC $40.43 $40.43 N/A 74176 TC $238.76 $238.76 N/A73650 26 $17.54 $17.54 N/A 74176 26 $189.17 $189.17 N/A73660 $60.26 $60.26 N/A 74177 $666.69 $666.69 N/A73660 TC $45.77 $45.77 N/A 74177 TC $468.36 $468.36 N/A73660 26 $14.49 $14.49 N/A 74177 26 $198.33 $198.33 N/A73700 $383.69 $383.69 N/A 74178 $755.17 $755.17 N/A73700 TC $274.61 $274.61 N/A 74178 TC $537.01 $537.01 N/A73700 26 $109.08 $109.08 N/A 74178 26 $218.16 $218.16 N/A73701 $484.38 $484.38 N/A 74181 $712.46 $712.46 N/A73701 TC $357.75 $357.75 N/A 74181 TC $553.79 $553.79 N/A73701 26 $126.62 $126.62 N/A 74181 26 $158.66 $158.66 N/A73702 $588.12 $588.12 N/A 74182 $971.81 $971.81 N/A73702 TC $456.15 $456.15 N/A 74182 TC $783.40 $783.40 N/A73702 26 $131.96 $131.96 N/A 74182 26 $188.41 $188.41 N/A73706 $752.88 $752.88 N/A 74183 $1,083.94 $1,083.94 N/A73706 TC $547.69 $547.69 N/A 74183 TC $838.32 $838.32 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 49 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

74183 26 $245.62 $245.62 N/A 74290 26 $35.09 $35.09 N/A74185 $862.73 $862.73 N/A 74300 80% of billed 80% of billed N/A74185 TC $668.21 $668.21 N/A 74300 TC 80% of billed 80% of billed N/A74185 26 $194.51 $194.51 N/A 74300 26 $39.67 $39.67 N/A74190 80% of billed 80% of billed N/A 74301 80% of billed 80% of billed ZZZ74190 TC 80% of billed 80% of billed N/A 74301 TC 80% of billed 80% of billed ZZZ74190 26 $51.11 $51.11 N/A 74301 26 $22.88 $22.88 ZZZ74210 $166.29 $166.29 N/A 74328 80% of billed 80% of billed N/A74210 TC $127.39 $127.39 N/A 74328 TC 80% of billed 80% of billed N/A74210 26 $38.90 $38.90 N/A 74328 26 $77.04 $77.04 N/A74220 $189.94 $189.94 N/A 74329 80% of billed 80% of billed N/A74220 TC $139.59 $139.59 N/A 74329 TC 80% of billed 80% of billed N/A74220 26 $50.34 $50.34 N/A 74329 26 $77.81 $77.81 N/A74230 $273.08 $273.08 N/A 74330 80% of billed 80% of billed N/A74230 TC $215.11 $215.11 N/A 74330 TC 80% of billed 80% of billed N/A74230 26 $57.97 $57.97 N/A 74330 26 $98.40 $98.40 N/A74235 80% of billed 80% of billed N/A 74340 80% of billed 80% of billed N/A74235 TC 80% of billed 80% of billed N/A 74340 TC 80% of billed 80% of billed N/A74235 26 $135.78 $135.78 N/A 74340 26 $58.74 $58.74 N/A74240 $242.57 $242.57 N/A 74355 80% of billed 80% of billed N/A74240 TC $167.05 $167.05 N/A 74355 TC 80% of billed 80% of billed N/A74240 26 $75.52 $75.52 N/A 74355 26 $83.91 $83.91 N/A74241 $252.49 $252.49 N/A 74360 80% of billed 80% of billed N/A74241 TC $176.97 $176.97 N/A 74360 TC 80% of billed 80% of billed N/A74241 26 $75.52 $75.52 N/A 74360 26 $61.79 $61.79 N/A74245 $366.91 $366.91 N/A 74363 80% of billed 80% of billed N/A74245 TC $267.74 $267.74 N/A 74363 TC 80% of billed 80% of billed N/A74245 26 $99.16 $99.16 N/A 74363 26 $93.06 $93.06 N/A74246 $271.56 $271.56 N/A 74400 $234.18 $234.18 N/A74246 TC $196.80 $196.80 N/A 74400 TC $180.78 $180.78 N/A74246 26 $74.75 $74.75 N/A 74400 26 $53.40 $53.40 N/A74247 $301.31 $301.31 N/A 74410 $231.13 $231.13 N/A74247 TC $225.79 $225.79 N/A 74410 TC $178.50 $178.50 N/A74247 26 $75.52 $75.52 N/A 74410 26 $52.63 $52.63 N/A74249 $393.60 $393.60 N/A 74415 $292.15 $292.15 N/A74249 TC $294.44 $294.44 N/A 74415 TC $238.76 $238.76 N/A74249 26 $99.16 $99.16 N/A 74415 26 $53.40 $53.40 N/A74250 $221.97 $221.97 N/A 74420 80% of billed 80% of billed N/A74250 TC $170.87 $170.87 N/A 74420 TC 80% of billed 80% of billed N/A74250 26 $51.11 $51.11 N/A 74420 26 $38.14 $38.14 N/A74251 $895.53 $895.53 N/A 74425 80% of billed 80% of billed N/A74251 TC $820.01 $820.01 N/A 74425 TC 80% of billed 80% of billed N/A74251 26 $75.52 $75.52 N/A 74425 26 $38.14 $38.14 N/A74260 $754.41 $754.41 N/A 74430 $80.09 $80.09 N/A74260 TC $700.25 $700.25 N/A 74430 TC $45.77 $45.77 N/A74260 26 $54.16 $54.16 N/A 74430 26 $34.33 $34.33 N/A74261 $1,039.70 $1,039.70 N/A 74440 $173.92 $173.92 N/A74261 TC $778.06 $778.06 N/A 74440 TC $134.25 $134.25 N/A74261 26 $261.64 $261.64 N/A 74440 26 $39.67 $39.67 N/A74262 $1,157.17 $1,157.17 N/A 74445 80% of billed 80% of billed N/A74262 TC $884.85 $884.85 N/A 74445 TC 80% of billed 80% of billed N/A74262 26 $272.32 $272.32 N/A 74445 26 $117.47 $117.47 N/A74263 $1,618.66 $1,618.66 N/A 74450 80% of billed 80% of billed N/A74263 TC $1,373.04 $1,373.04 N/A 74450 TC 80% of billed 80% of billed N/A74263 26 $245.62 $245.62 N/A 74450 26 $35.85 $35.85 N/A74270 $321.14 $321.14 N/A 74455 $174.68 $174.68 N/A74270 TC $245.62 $245.62 N/A 74455 TC $138.83 $138.83 N/A74270 26 $75.52 $75.52 N/A 74455 26 $35.85 $35.85 N/A74280 $455.39 $455.39 N/A 74470 80% of billed 80% of billed N/A74280 TC $347.07 $347.07 N/A 74470 TC 80% of billed 80% of billed N/A74280 26 $108.32 $108.32 N/A 74470 26 $57.21 $57.21 N/A74283 $440.14 $440.14 N/A 74485 $197.57 $197.57 N/A74283 TC $218.16 $218.16 N/A 74485 TC $141.12 $141.12 N/A74283 26 $221.97 $221.97 N/A 74485 26 $56.45 $56.45 N/A74290 $150.27 $150.27 N/A 74710 $78.57 $78.57 N/A74290 TC $115.18 $115.18 N/A 74710 TC $41.19 $41.19 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 50 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

74710 26 $37.38 $37.38 N/A 75710 26 $122.05 $122.05 N/A74712 $1,032.07 $1,032.07 N/A 75716 $402.76 $402.76 N/A74712 TC $704.83 $704.83 N/A 75716 TC $263.17 $263.17 N/A74712 26 $327.24 $327.24 N/A 75716 26 $139.59 $139.59 N/A74713 $495.82 $495.82 ZZZ 75726 $321.14 $321.14 N/A74713 TC $302.07 $302.07 ZZZ 75726 TC $200.62 $200.62 N/A74713 26 $193.75 $193.75 ZZZ 75726 26 $120.52 $120.52 N/A74740 $160.19 $160.19 N/A 75731 $370.72 $370.72 N/A74740 TC $119.00 $119.00 N/A 75731 TC $246.38 $246.38 N/A74740 26 $41.19 $41.19 N/A 75731 26 $124.34 $124.34 N/A74742 80% of billed 80% of billed N/A 75733 $395.13 $395.13 N/A74742 TC 80% of billed 80% of billed N/A 75733 TC $257.83 $257.83 N/A74742 26 $64.08 $64.08 N/A 75733 26 $137.30 $137.30 N/A74775 80% of billed 80% of billed N/A 75736 $344.02 $344.02 N/A74775 TC 80% of billed 80% of billed N/A 75736 TC $224.26 $224.26 N/A74775 26 $67.89 $67.89 N/A 75736 26 $119.76 $119.76 N/A75557 $681.18 $681.18 N/A 75741 $324.95 $324.95 N/A75557 TC $430.22 $430.22 N/A 75741 TC $186.89 $186.89 N/A75557 26 $250.96 $250.96 N/A 75741 26 $138.07 $138.07 N/A75559 $932.14 $932.14 N/A 75743 $363.86 $363.86 N/A75559 TC $622.44 $622.44 N/A 75743 TC $189.17 $189.17 N/A75559 26 $309.70 $309.70 N/A 75743 26 $174.68 $174.68 N/A75561 $904.68 $904.68 N/A 75746 $327.24 $327.24 N/A75561 TC $627.78 $627.78 N/A 75746 TC $205.19 $205.19 N/A75561 26 $276.90 $276.90 N/A 75746 26 $122.05 $122.05 N/A75563 $1,074.02 $1,074.02 N/A 75756 $357.75 $357.75 N/A75563 TC $756.70 $756.70 N/A 75756 TC $235.71 $235.71 N/A75563 26 $317.32 $317.32 N/A 75756 26 $122.05 $122.05 N/A75565 $117.47 $117.47 ZZZ 75774 $188.41 $188.41 ZZZ75565 TC $90.77 $90.77 ZZZ 75774 TC $150.27 $150.27 ZZZ75565 26 $26.70 $26.70 ZZZ 75774 26 $38.14 $38.14 ZZZ75571 $215.11 $215.11 N/A 75791 $697.20 $697.20 N/A75571 TC $152.56 $152.56 N/A 75791 TC $510.31 $510.31 N/A75571 26 $62.55 $62.55 N/A 75791 26 $186.89 $186.89 N/A75572 $607.19 $607.19 N/A 75801 80% of billed 80% of billed N/A75572 TC $419.54 $419.54 N/A 75801 TC 80% of billed 80% of billed N/A75572 26 $187.65 $187.65 N/A 75801 26 $96.88 $96.88 N/A75573 $836.03 $836.03 N/A 75803 80% of billed 80% of billed N/A75573 TC $562.95 $562.95 N/A 75803 TC 80% of billed 80% of billed N/A75573 26 $273.08 $273.08 N/A 75803 26 $127.39 $127.39 N/A75574 $896.29 $896.29 N/A 75805 80% of billed 80% of billed N/A75574 TC $639.99 $639.99 N/A 75805 TC 80% of billed 80% of billed N/A75574 26 $256.30 $256.30 N/A 75805 26 $88.48 $88.48 N/A75600 $424.12 $424.12 N/A 75807 80% of billed 80% of billed N/A75600 TC $371.48 $371.48 N/A 75807 TC 80% of billed 80% of billed N/A75600 26 $52.63 $52.63 N/A 75807 26 $128.15 $128.15 N/A75605 $299.02 $299.02 N/A 75809 $213.58 $213.58 N/A75605 TC $177.73 $177.73 N/A 75809 TC $161.71 $161.71 N/A75605 26 $121.29 $121.29 N/A 75809 26 $51.87 $51.87 N/A75625 $297.49 $297.49 N/A 75810 80% of billed 80% of billed N/A75625 TC $176.21 $176.21 N/A 75810 TC 80% of billed 80% of billed N/A75625 26 $121.29 $121.29 N/A 75810 26 $124.34 $124.34 N/A75630 $367.67 $367.67 N/A 75820 $248.67 $248.67 N/A75630 TC $176.21 $176.21 N/A 75820 TC $173.16 $173.16 N/A75630 26 $191.46 $191.46 N/A 75820 26 $75.52 $75.52 N/A75635 $813.91 $813.91 N/A 75822 $295.97 $295.97 N/A75635 TC $555.32 $555.32 N/A 75822 TC $182.31 $182.31 N/A75635 26 $258.59 $258.59 N/A 75822 26 $113.66 $113.66 N/A75658 $356.99 $356.99 N/A 75825 $294.44 $294.44 N/A75658 TC $218.92 $218.92 N/A 75825 TC $171.63 $171.63 N/A75658 26 $138.07 $138.07 N/A 75825 26 $122.81 $122.81 N/A75705 $524.81 $524.81 N/A 75827 $298.25 $298.25 N/A75705 TC $276.90 $276.90 N/A 75827 TC $176.21 $176.21 N/A75705 26 $247.91 $247.91 N/A 75827 26 $122.05 $122.05 N/A75710 $351.65 $351.65 N/A 75831 $302.07 $302.07 N/A75710 TC $229.60 $229.60 N/A 75831 TC $182.31 $182.31 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 51 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

75831 26 $119.76 $119.76 N/A 75958 26 $434.80 $434.80 N/A75833 $353.94 $353.94 N/A 75959 80% of billed 80% of billed N/A75833 TC $196.80 $196.80 N/A 75959 TC 80% of billed 80% of billed N/A75833 26 $157.14 $157.14 N/A 75959 26 $379.11 $379.11 N/A75840 $319.61 $319.61 N/A 75962 $301.31 $301.31 N/A75840 TC $195.28 $195.28 N/A 75962 TC $243.33 $243.33 N/A75840 26 $124.34 $124.34 N/A 75962 26 $57.97 $57.97 N/A75842 $388.27 $388.27 N/A 75964 $189.94 $189.94 ZZZ75842 TC $226.55 $226.55 N/A 75964 TC $151.03 $151.03 ZZZ75842 26 $161.71 $161.71 N/A 75964 26 $38.90 $38.90 ZZZ75860 $308.17 $308.17 N/A 75966 $368.43 $368.43 N/A75860 TC $186.89 $186.89 N/A 75966 TC $228.84 $228.84 N/A75860 26 $121.29 $121.29 N/A 75966 26 $139.59 $139.59 N/A75870 $318.09 $318.09 N/A 75968 $188.41 $188.41 ZZZ75870 TC $193.75 $193.75 N/A 75968 TC $149.51 $149.51 ZZZ75870 26 $124.34 $124.34 N/A 75968 26 $38.90 $38.90 ZZZ75872 $302.07 $302.07 N/A 75970 80% of billed 80% of billed N/A75872 TC $186.12 $186.12 N/A 75970 TC 80% of billed 80% of billed N/A75872 26 $115.95 $115.95 N/A 75970 26 $86.96 $86.96 N/A75880 $307.41 $307.41 N/A 75978 $297.49 $297.49 N/A75880 TC $228.84 $228.84 N/A 75978 TC $239.52 $239.52 N/A75880 26 $78.57 $78.57 N/A 75978 26 $57.97 $57.97 N/A75885 $340.21 $340.21 N/A 75984 $228.84 $228.84 N/A75885 TC $189.94 $189.94 N/A 75984 TC $152.56 $152.56 N/A75885 26 $150.27 $150.27 N/A 75984 26 $76.28 $76.28 N/A75887 $341.73 $341.73 N/A 75989 $259.35 $259.35 N/A75887 TC $190.70 $190.70 N/A 75989 TC $132.73 $132.73 N/A75887 26 $151.03 $151.03 N/A 75989 26 $126.62 $126.62 N/A75889 $309.70 $309.70 N/A 76000 $101.45 $101.45 N/A75889 TC $189.94 $189.94 N/A 76000 TC $82.38 $82.38 N/A75889 26 $119.76 $119.76 N/A 76000 26 $19.07 $19.07 N/A75891 $312.75 $312.75 N/A 76001 80% of billed 80% of billed N/A75891 TC $191.46 $191.46 N/A 76001 TC 80% of billed 80% of billed N/A75891 26 $121.29 $121.29 N/A 76001 26 $78.57 $78.57 N/A75893 $254.01 $254.01 N/A 76010 $55.68 $55.68 N/A75893 TC $195.28 $195.28 N/A 76010 TC $35.85 $35.85 N/A75893 26 $58.74 $58.74 N/A 76010 26 $19.83 $19.83 N/A75894 80% of billed 80% of billed N/A 76080 $118.23 $118.23 N/A75894 TC 80% of billed 80% of billed N/A 76080 TC $61.02 $61.02 N/A75894 26 $144.17 $144.17 N/A 76080 26 $57.21 $57.21 N/A75898 80% of billed 80% of billed N/A 76098 $35.85 $35.85 N/A75898 TC 80% of billed 80% of billed N/A 76098 TC $18.31 $18.31 N/A75898 26 $182.31 $182.31 N/A 76098 26 $17.54 $17.54 N/A75901 $379.87 $379.87 N/A 76100 $199.09 $199.09 N/A75901 TC $328.00 $328.00 N/A 76100 TC $129.68 $129.68 N/A75901 26 $51.87 $51.87 N/A 76100 26 $69.41 $69.41 N/A75902 $154.09 $154.09 N/A 76101 $283.00 $283.00 N/A75902 TC $112.89 $112.89 N/A 76101 TC $209.77 $209.77 N/A75902 26 $41.19 $41.19 N/A 76101 26 $73.23 $73.23 N/A75952 80% of billed 80% of billed N/A 76102 $376.06 $376.06 N/A75952 TC 80% of billed 80% of billed N/A 76102 TC $301.31 $301.31 N/A75952 26 $488.95 $488.95 N/A 76102 26 $74.75 $74.75 N/A75953 80% of billed 80% of billed N/A 76120 $179.26 $179.26 N/A75953 TC 80% of billed 80% of billed N/A 76120 TC $137.30 $137.30 N/A75953 26 $147.98 $147.98 N/A 76120 26 $41.95 $41.95 N/A75954 80% of billed 80% of billed N/A 76125 80% of billed 80% of billed ZZZ75954 TC 80% of billed 80% of billed N/A 76125 TC 80% of billed 80% of billed ZZZ75954 26 $247.15 $247.15 N/A 76125 26 $31.27 $31.27 ZZZ75956 80% of billed 80% of billed N/A 76140 80% of billed 80% of billed N/A75956 TC 80% of billed 80% of billed N/A 76376 $49.58 $49.58 N/A75956 26 $763.56 $763.56 N/A 76376 TC $28.22 $28.22 N/A75957 80% of billed 80% of billed N/A 76376 26 $21.36 $21.36 N/A75957 TC 80% of billed 80% of billed N/A 76377 $138.83 $138.83 N/A75957 26 $655.25 $655.25 N/A 76377 TC $52.63 $52.63 N/A75958 80% of billed 80% of billed N/A 76377 26 $86.20 $86.20 N/A75958 TC 80% of billed 80% of billed N/A 76380 $312.75 $312.75 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 52 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

76380 TC $205.96 $205.96 N/A 76770 TC $164.00 $164.00 N/A76380 26 $106.79 $106.79 N/A 76770 26 $80.09 $80.09 N/A76390 $954.26 $954.26 N/A 76775 $125.10 $125.10 N/A76390 TC $803.23 $803.23 N/A 76775 TC $62.55 $62.55 N/A76390 26 $151.03 $151.03 N/A 76775 26 $62.55 $62.55 N/A76496 80% of billed 80% of billed N/A 76776 $337.92 $337.92 N/A76496 TC 80% of billed 80% of billed N/A 76776 TC $255.54 $255.54 N/A76496 26 80% of billed 80% of billed N/A 76776 26 $82.38 $82.38 N/A76497 80% of billed 80% of billed N/A 76800 $305.88 $305.88 N/A76497 TC 80% of billed 80% of billed N/A 76800 TC $174.68 $174.68 N/A76497 26 80% of billed 80% of billed N/A 76800 26 $131.20 $131.20 N/A76498 80% of billed 80% of billed N/A 76801 $266.98 $266.98 N/A76498 TC 80% of billed 80% of billed N/A 76801 TC $157.90 $157.90 N/A76498 26 80% of billed 80% of billed N/A 76801 26 $109.08 $109.08 N/A76499 80% of billed 80% of billed N/A 76802 $140.36 $140.36 ZZZ76499 TC 80% of billed 80% of billed N/A 76802 TC $48.06 $48.06 ZZZ76499 26 80% of billed 80% of billed N/A 76802 26 $92.30 $92.30 ZZZ76506 $254.78 $254.78 N/A 76805 $306.65 $306.65 N/A76506 TC $184.60 $184.60 N/A 76805 TC $196.80 $196.80 N/A76506 26 $70.18 $70.18 N/A 76805 26 $109.84 $109.84 N/A76510 $367.67 $367.67 N/A 76810 $202.90 $202.90 ZZZ76510 TC $175.44 $175.44 N/A 76810 TC $93.82 $93.82 ZZZ76510 26 $192.23 $192.23 N/A 76810 26 $109.08 $109.08 ZZZ76511 $218.16 $218.16 N/A 76811 $395.13 $395.13 N/A76511 TC $103.74 $103.74 N/A 76811 TC $181.55 $181.55 N/A76511 26 $114.42 $114.42 N/A 76811 26 $213.58 $213.58 N/A76512 $199.85 $199.85 N/A 76812 $447.76 $447.76 ZZZ76512 TC $85.43 $85.43 N/A 76812 TC $247.15 $247.15 ZZZ76512 26 $114.42 $114.42 N/A 76812 26 $200.62 $200.62 ZZZ76513 $204.43 $204.43 N/A 76813 $263.17 $263.17 N/A76513 TC $127.39 $127.39 N/A 76813 TC $130.44 $130.44 N/A76513 26 $77.04 $77.04 N/A 76813 26 $132.73 $132.73 N/A76514 $32.80 $32.80 N/A 76814 $176.97 $176.97 N/A76514 TC $11.44 $11.44 N/A 76814 TC $64.84 $64.84 N/A76514 26 $21.36 $21.36 N/A 76814 26 $112.13 $112.13 N/A76516 $170.10 $170.10 N/A 76815 $182.31 $182.31 N/A76516 TC $102.98 $102.98 N/A 76815 TC $111.37 $111.37 N/A76516 26 $67.13 $67.13 N/A 76815 26 $70.94 $70.94 N/A76519 $182.31 $182.31 N/A 76816 $249.44 $249.44 N/A76519 TC $114.42 $114.42 N/A 76816 TC $154.09 $154.09 N/A76519 26 $67.89 $67.89 N/A 76816 26 $95.35 $95.35 N/A76529 $170.87 $170.87 N/A 76817 $210.53 $210.53 N/A76529 TC $100.69 $100.69 N/A 76817 TC $127.39 $127.39 N/A76529 26 $70.18 $70.18 N/A 76817 26 $83.15 $83.15 N/A76536 $250.20 $250.20 N/A 76818 $263.93 $263.93 N/A76536 TC $189.17 $189.17 N/A 76818 TC $145.69 $145.69 N/A76536 26 $61.02 $61.02 N/A 76818 26 $118.23 $118.23 N/A76604 $189.94 $189.94 N/A 76819 $192.99 $192.99 N/A76604 TC $131.20 $131.20 N/A 76819 TC $106.79 $106.79 N/A76604 26 $58.74 $58.74 N/A 76819 26 $86.20 $86.20 N/A76641 $231.89 $231.89 N/A 76820 $103.74 $103.74 N/A76641 TC $152.56 $152.56 N/A 76820 TC $47.29 $47.29 N/A76641 26 $79.33 $79.33 N/A 76820 26 $56.45 $56.45 N/A76642 $190.70 $190.70 N/A 76821 $201.38 $201.38 N/A76642 TC $116.71 $116.71 N/A 76821 TC $122.81 $122.81 N/A76642 26 $73.99 $73.99 N/A 76821 26 $78.57 $78.57 N/A76700 $264.69 $264.69 N/A 76825 $598.04 $598.04 N/A76700 TC $176.97 $176.97 N/A 76825 TC $415.73 $415.73 N/A76700 26 $87.72 $87.72 N/A 76825 26 $182.31 $182.31 N/A76705 $196.80 $196.80 N/A 76826 $353.18 $353.18 N/A76705 TC $132.73 $132.73 N/A 76826 TC $263.17 $263.17 N/A76705 26 $64.08 $64.08 N/A 76826 26 $90.01 $90.01 N/A76706 $202.90 $202.90 N/A 76827 $164.00 $164.00 N/A76706 TC $142.64 $142.64 N/A 76827 TC $101.45 $101.45 N/A76706 26 $60.26 $60.26 N/A 76827 26 $62.55 $62.55 N/A76770 $244.10 $244.10 N/A 76828 $115.95 $115.95 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 53 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

76828 TC $54.16 $54.16 N/A 76965 TC $51.11 $51.11 N/A76828 26 $61.79 $61.79 N/A 76965 26 $143.41 $143.41 N/A76830 $263.17 $263.17 N/A 76970 $201.38 $201.38 N/A76830 TC $187.65 $187.65 N/A 76970 TC $159.43 $159.43 N/A76830 26 $75.52 $75.52 N/A 76970 26 $41.95 $41.95 N/A76831 $257.06 $257.06 N/A 76975 80% of billed 80% of billed N/A76831 TC $176.97 $176.97 N/A 76975 TC 80% of billed 80% of billed N/A76831 26 $80.09 $80.09 N/A 76975 26 $92.30 $92.30 N/A76856 $237.23 $237.23 N/A 76977 $15.26 $15.26 N/A76856 TC $162.48 $162.48 N/A 76977 TC $9.15 $9.15 N/A76856 26 $74.75 $74.75 N/A 76977 26 $6.10 $6.10 N/A76857 $102.22 $102.22 N/A 76998 80% of billed 80% of billed N/A76857 TC $48.82 $48.82 N/A 76998 TC 80% of billed 80% of billed N/A76857 26 $53.40 $53.40 N/A 76998 26 $138.07 $138.07 N/A76870 $145.69 $145.69 N/A 76999 80% of billed 80% of billed N/A76870 TC $76.28 $76.28 N/A 76999 TC 80% of billed 80% of billed N/A76870 26 $69.41 $69.41 N/A 76999 26 80% of billed 80% of billed N/A76872 $202.90 $202.90 N/A 77001 $151.03 $151.03 ZZZ76872 TC $130.44 $130.44 N/A 77001 TC $109.84 $109.84 ZZZ76872 26 $72.47 $72.47 N/A 77001 26 $41.19 $41.19 ZZZ76873 $361.57 $361.57 N/A 77002 $199.85 $199.85 N/A76873 TC $192.99 $192.99 N/A 77002 TC $138.83 $138.83 N/A76873 26 $168.58 $168.58 N/A 77002 26 $61.02 $61.02 N/A76881 $248.67 $248.67 N/A 77003 $185.36 $185.36 N/A76881 TC $180.02 $180.02 N/A 77003 TC $119.76 $119.76 N/A76881 26 $68.65 $68.65 N/A 77003 26 $65.60 $65.60 N/A76882 $77.81 $77.81 N/A 77011 $478.28 $478.28 N/A76882 TC $24.41 $24.41 N/A 77011 TC $342.50 $342.50 N/A76882 26 $53.40 $53.40 N/A 77011 26 $135.78 $135.78 N/A76885 $314.27 $314.27 N/A 77012 $266.98 $266.98 N/A76885 TC $233.42 $233.42 N/A 77012 TC $142.64 $142.64 N/A76885 26 $80.86 $80.86 N/A 77012 26 $124.34 $124.34 N/A76886 $228.84 $228.84 N/A 77013 80% of billed 80% of billed N/A76886 TC $162.48 $162.48 N/A 77013 TC 80% of billed 80% of billed N/A76886 26 $66.36 $66.36 N/A 77013 26 $424.12 $424.12 N/A76930 80% of billed 80% of billed N/A 77014 $253.25 $253.25 N/A76930 TC 80% of billed 80% of billed N/A 77014 TC $158.66 $158.66 N/A76930 26 $70.94 $70.94 N/A 77014 26 $94.59 $94.59 N/A76932 80% of billed 80% of billed N/A 77021 $863.49 $863.49 N/A76932 TC 80% of billed 80% of billed N/A 77021 TC $701.01 $701.01 N/A76932 26 $70.18 $70.18 N/A 77021 26 $162.48 $162.48 N/A76936 $585.83 $585.83 N/A 77022 80% of billed 80% of billed N/A76936 TC $372.25 $372.25 N/A 77022 TC 80% of billed 80% of billed N/A76936 26 $213.58 $213.58 N/A 77022 26 $460.73 $460.73 N/A76937 $67.89 $67.89 ZZZ 77051 $17.54 $17.54 ZZZ76937 TC $36.61 $36.61 ZZZ 77051 TC $11.44 $11.44 ZZZ76937 26 $31.27 $31.27 ZZZ 77051 26 $6.10 $6.10 ZZZ76940 80% of billed 80% of billed N/A 77052 $17.54 $17.54 ZZZ76940 TC 80% of billed 80% of billed N/A 77052 TC $11.44 $11.44 ZZZ76940 26 $224.26 $224.26 N/A 77052 26 $6.10 $6.10 ZZZ76941 80% of billed 80% of billed N/A 77053 $125.10 $125.10 N/A76941 TC 80% of billed 80% of billed N/A 77053 TC $86.20 $86.20 N/A76941 26 $148.75 $148.75 N/A 77053 26 $38.90 $38.90 N/A76942 $131.96 $131.96 N/A 77054 $164.76 $164.76 N/A76942 TC $59.50 $59.50 N/A 77054 TC $115.18 $115.18 N/A76942 26 $72.47 $72.47 N/A 77054 26 $49.58 $49.58 N/A76945 80% of billed 80% of billed N/A 77055 $192.99 $192.99 N/A76945 TC 80% of billed 80% of billed N/A 77055 TC $116.71 $116.71 N/A76945 26 $75.52 $75.52 N/A 77055 26 $76.28 $76.28 N/A76946 $70.94 $70.94 N/A 77056 $247.91 $247.91 N/A76946 TC $28.22 $28.22 N/A 77056 TC $153.32 $153.32 N/A76946 26 $42.72 $42.72 N/A 77056 26 $94.59 $94.59 N/A76948 $160.19 $160.19 N/A 77057 $176.97 $176.97 N/A76948 TC $85.43 $85.43 N/A 77057 TC $100.69 $100.69 N/A76948 26 $74.75 $74.75 N/A 77057 26 $76.28 $76.28 N/A76965 $194.51 $194.51 N/A 77058 $1,151.83 $1,151.83 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 54 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

77058 TC $974.86 $974.86 N/A 77285 $927.56 $927.56 N/A77058 26 $176.97 $176.97 N/A 77285 TC $810.09 $810.09 N/A77059 $1,146.49 $1,146.49 N/A 77285 26 $117.47 $117.47 N/A77059 TC $969.52 $969.52 N/A 77290 $1,107.59 $1,107.59 N/A77059 26 $176.97 $176.97 N/A 77290 TC $933.67 $933.67 N/A77061 80% of billed 80% of billed N/A 77290 26 $173.92 $173.92 N/A77061 TC 80% of billed 80% of billed N/A 77293 $1,002.32 $1,002.32 ZZZ77061 26 80% of billed 80% of billed N/A 77293 TC $779.58 $779.58 ZZZ77062 80% of billed 80% of billed N/A 77293 26 $222.74 $222.74 ZZZ77062 TC 80% of billed 80% of billed N/A 77295 $1,054.95 $1,054.95 N/A77062 26 80% of billed 80% of billed N/A 77295 TC $577.44 $577.44 N/A77063 $119.76 $119.76 ZZZ 77295 26 $477.51 $477.51 N/A77063 TC $54.92 $54.92 ZZZ 77299 80% of billed 80% of billed N/A77063 26 $64.84 $64.84 ZZZ 77299 TC 80% of billed 80% of billed N/A77065 80% of billed 80% of billed N/A 77299 26 80% of billed 80% of billed N/A77065 TC 80% of billed 80% of billed N/A 77300 $143.41 $143.41 N/A77065 26 80% of billed 80% of billed N/A 77300 TC $73.99 $73.99 N/A77066 80% of billed 80% of billed N/A 77300 26 $69.41 $69.41 N/A77066 TC 80% of billed 80% of billed N/A 77301 $4,202.27 $4,202.27 N/A77066 26 80% of billed 80% of billed N/A 77301 TC $3,313.60 $3,313.60 N/A77067 80% of billed 80% of billed N/A 77301 26 $888.66 $888.66 N/A77067 TC 80% of billed 80% of billed N/A 77306 $321.14 $321.14 N/A77067 26 80% of billed 80% of billed N/A 77306 TC $165.53 $165.53 N/A77071 $104.50 $104.50 N/A 77306 26 $155.61 $155.61 N/A77072 $49.58 $49.58 N/A 77307 $620.92 $620.92 N/A77072 TC $28.99 $28.99 N/A 77307 TC $298.25 $298.25 N/A77072 26 $20.60 $20.60 N/A 77307 26 $322.66 $322.66 N/A77073 $77.81 $77.81 N/A 77316 $405.81 $405.81 N/A77073 TC $46.53 $46.53 N/A 77316 TC $249.44 $249.44 N/A77073 26 $31.27 $31.27 N/A 77316 26 $156.37 $156.37 N/A77074 $138.07 $138.07 N/A 77317 $527.86 $527.86 N/A77074 TC $88.48 $88.48 N/A 77317 TC $324.19 $324.19 N/A77074 26 $49.58 $49.58 N/A 77317 26 $203.67 $203.67 N/A77075 $187.65 $187.65 N/A 77318 $762.80 $762.80 N/A77075 TC $128.91 $128.91 N/A 77318 TC $440.14 $440.14 N/A77075 26 $58.74 $58.74 N/A 77318 26 $322.66 $322.66 N/A77076 $205.96 $205.96 N/A 77321 $199.85 $199.85 N/A77076 TC $129.68 $129.68 N/A 77321 TC $93.82 $93.82 N/A77076 26 $76.28 $76.28 N/A 77321 26 $106.03 $106.03 N/A77077 $80.09 $80.09 N/A 77331 $137.30 $137.30 N/A77077 TC $45.01 $45.01 N/A 77331 TC $40.43 $40.43 N/A77077 26 $35.09 $35.09 N/A 77331 26 $96.88 $96.88 N/A77078 $242.57 $242.57 N/A 77332 $179.26 $179.26 N/A77078 TC $215.87 $215.87 N/A 77332 TC $118.23 $118.23 N/A77078 26 $26.70 $26.70 N/A 77332 26 $61.02 $61.02 N/A77080 $88.48 $88.48 N/A 77333 $114.42 $114.42 N/A77080 TC $66.36 $66.36 N/A 77333 TC $20.60 $20.60 N/A77080 26 $22.12 $22.12 N/A 77333 26 $93.82 $93.82 N/A77081 $60.26 $60.26 N/A 77334 $328.00 $328.00 N/A77081 TC $36.61 $36.61 N/A 77334 TC $189.94 $189.94 N/A77081 26 $23.65 $23.65 N/A 77334 26 $138.07 $138.07 N/A77084 $836.03 $836.03 N/A 77336 $170.87 $170.87 N/A77084 TC $661.35 $661.35 N/A 77338 $1,092.33 $1,092.33 N/A77084 26 $174.68 $174.68 N/A 77338 TC $614.82 $614.82 N/A77085 $119.76 $119.76 N/A 77338 26 $477.51 $477.51 N/A77085 TC $86.96 $86.96 N/A 77370 $261.64 $261.64 N/A77085 26 $32.80 $32.80 N/A 77371 80% of billed 80% of billed N/A77086 $76.28 $76.28 N/A 77372 $2,307.47 $2,307.47 N/A77086 TC $57.21 $57.21 N/A 77373 $2,932.20 $2,932.20 N/A77086 26 $19.07 $19.07 N/A 77385 80% of billed 80% of billed N/A77261 $163.24 $163.24 N/A 77386 80% of billed 80% of billed N/A77262 $244.10 $244.10 N/A 77387 80% of billed 80% of billed N/A77263 $356.99 $356.99 N/A 77399 80% of billed 80% of billed N/A77280 $588.12 $588.12 N/A 77399 TC 80% of billed 80% of billed N/A77280 TC $510.31 $510.31 N/A 77399 26 80% of billed 80% of billed N/A77280 26 $77.81 $77.81 N/A 77401 $52.63 $52.63 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 55 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

77402 80% of billed 80% of billed N/A 77778 TC $791.79 $791.79 00077407 80% of billed 80% of billed N/A 77778 26 $887.14 $887.14 00077412 80% of billed 80% of billed N/A 77789 $258.59 $258.59 00077417 $23.65 $23.65 N/A 77789 TC $130.44 $130.44 00077422 80% of billed 80% of billed N/A 77789 26 $128.15 $128.15 00077423 80% of billed 80% of billed N/A 77790 $32.04 $32.04 N/A77424 80% of billed 80% of billed N/A 77799 80% of billed 80% of billed N/A77425 80% of billed 80% of billed N/A 77799 TC 80% of billed 80% of billed N/A77427 $399.71 $399.71 N/A 77799 26 80% of billed 80% of billed N/A77431 $219.69 $219.69 N/A 78012 $175.44 $175.44 N/A77432 $899.34 $899.34 N/A 78012 TC $154.85 $154.85 N/A77435 $1,357.02 $1,357.02 N/A 78012 26 $20.60 $20.60 N/A77469 $693.39 $693.39 N/A 78013 $422.59 $422.59 N/A77470 $336.39 $336.39 N/A 78013 TC $382.93 $382.93 N/A77470 TC $103.74 $103.74 N/A 78013 26 $39.67 $39.67 N/A77470 26 $232.65 $232.65 N/A 78014 $535.49 $535.49 N/A77499 80% of billed 80% of billed N/A 78014 TC $482.09 $482.09 N/A77499 TC 80% of billed 80% of billed N/A 78014 26 $53.40 $53.40 N/A77499 26 80% of billed 80% of billed N/A 78015 $488.19 $488.19 N/A77520 80% of billed 80% of billed N/A 78015 TC $417.25 $417.25 N/A77522 80% of billed 80% of billed N/A 78015 26 $70.94 $70.94 N/A77523 80% of billed 80% of billed N/A 78016 $617.87 $617.87 N/A77525 80% of billed 80% of billed N/A 78016 TC $543.88 $543.88 N/A77600 $906.21 $906.21 N/A 78016 26 $73.99 $73.99 N/A77600 TC $729.24 $729.24 N/A 78018 $691.86 $691.86 N/A77600 26 $176.97 $176.97 N/A 78018 TC $602.61 $602.61 N/A77605 $1,722.40 $1,722.40 N/A 78018 26 $89.25 $89.25 N/A77605 TC $1,471.44 $1,471.44 N/A 78020 $184.60 $184.60 ZZZ77605 26 $250.96 $250.96 N/A 78020 TC $124.34 $124.34 ZZZ77610 $2,139.65 $2,139.65 N/A 78020 26 $60.26 $60.26 ZZZ77610 TC $1,953.53 $1,953.53 N/A 78070 $663.64 $663.64 N/A77610 26 $186.12 $186.12 N/A 78070 TC $578.97 $578.97 N/A77615 $2,286.87 $2,286.87 N/A 78070 26 $84.67 $84.67 N/A77615 TC $2,054.98 $2,054.98 N/A 78071 $793.31 $793.31 N/A77615 26 $231.89 $231.89 N/A 78071 TC $666.69 $666.69 N/A77620 $825.35 $825.35 N/A 78071 26 $126.62 $126.62 N/A77620 TC $651.43 $651.43 N/A 78072 $916.12 $916.12 N/A77620 26 $173.92 $173.92 N/A 78072 TC $749.83 $749.83 N/A77750 $798.65 $798.65 090 78072 26 $166.29 $166.29 N/A77750 TC $243.33 $243.33 090 78075 $948.16 $948.16 N/A77750 26 $555.32 $555.32 090 78075 TC $871.88 $871.88 N/A77761 $837.55 $837.55 090 78075 26 $76.28 $76.28 N/A77761 TC $414.20 $414.20 090 78099 80% of billed 80% of billed N/A77761 26 $423.35 $423.35 090 78099 TC 80% of billed 80% of billed N/A77762 $1,114.45 $1,114.45 090 78099 26 80% of billed 80% of billed N/A77762 TC $475.22 $475.22 090 78102 $375.30 $375.30 N/A77762 26 $639.23 $639.23 090 78102 TC $318.09 $318.09 N/A77763 $1,578.23 $1,578.23 090 78102 26 $57.21 $57.21 N/A77763 TC $614.82 $614.82 090 78103 $492.77 $492.77 N/A77763 26 $963.42 $963.42 090 78103 TC $414.20 $414.20 N/A77767 $483.62 $483.62 N/A 78103 26 $78.57 $78.57 N/A77767 TC $366.14 $366.14 N/A 78104 $543.11 $543.11 N/A77767 26 $117.47 $117.47 N/A 78104 TC $459.97 $459.97 N/A77768 $757.46 $757.46 N/A 78104 26 $83.15 $83.15 N/A77768 TC $601.85 $601.85 N/A 78110 $207.48 $207.48 N/A77768 26 $155.61 $155.61 N/A 78110 TC $186.89 $186.89 N/A77770 $690.33 $690.33 N/A 78110 26 $20.60 $20.60 N/A77770 TC $473.70 $473.70 N/A 78111 $212.82 $212.82 N/A77770 26 $216.64 $216.64 N/A 78111 TC $189.17 $189.17 N/A77771 $1,286.08 $1,286.08 N/A 78111 26 $23.65 $23.65 N/A77771 TC $862.73 $862.73 N/A 78120 $207.48 $207.48 N/A77771 26 $423.35 $423.35 N/A 78120 TC $182.31 $182.31 N/A77772 $1,961.92 $1,961.92 N/A 78120 26 $25.17 $25.17 N/A77772 TC $1,361.60 $1,361.60 N/A 78121 $225.79 $225.79 N/A77772 26 $600.32 $600.32 N/A 78121 TC $190.70 $190.70 N/A77778 $1,678.92 $1,678.92 000 78121 26 $35.09 $35.09 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 56 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

78122 $216.64 $216.64 N/A 78262 $541.59 $541.59 N/A78122 TC $170.10 $170.10 N/A 78262 TC $469.88 $469.88 N/A78122 26 $46.53 $46.53 N/A 78262 26 $71.70 $71.70 N/A78130 $373.01 $373.01 N/A 78264 $742.20 $742.20 N/A78130 TC $307.41 $307.41 N/A 78264 TC $662.87 $662.87 N/A78130 26 $65.60 $65.60 N/A 78264 26 $79.33 $79.33 N/A78135 $781.87 $781.87 N/A 78265 $884.85 $884.85 N/A78135 TC $712.46 $712.46 N/A 78265 TC $780.34 $780.34 N/A78135 26 $69.41 $69.41 N/A 78265 26 $104.50 $104.50 N/A78140 $301.31 $301.31 N/A 78266 $1,049.61 $1,049.61 N/A78140 TC $234.94 $234.94 N/A 78266 TC $933.67 $933.67 N/A78140 26 $66.36 $66.36 N/A 78266 26 $115.95 $115.95 N/A78185 $469.12 $469.12 N/A 78267 80% of billed 80% of billed N/A78185 TC $425.64 $425.64 N/A 78268 80% of billed 80% of billed N/A78185 26 $43.48 $43.48 N/A 78270 $223.50 $223.50 N/A78190 $873.41 $873.41 N/A 78270 TC $200.62 $200.62 N/A78190 TC $755.93 $755.93 N/A 78270 26 $22.88 $22.88 N/A78190 26 $117.47 $117.47 N/A 78271 $200.62 $200.62 N/A78191 $373.01 $373.01 N/A 78271 TC $178.50 $178.50 N/A78191 TC $307.41 $307.41 N/A 78271 26 $22.12 $22.12 N/A78191 26 $65.60 $65.60 N/A 78272 $214.35 $214.35 N/A78195 $788.74 $788.74 N/A 78272 TC $185.36 $185.36 N/A78195 TC $661.35 $661.35 N/A 78272 26 $28.99 $28.99 N/A78195 26 $127.39 $127.39 N/A 78278 $773.48 $773.48 N/A78199 80% of billed 80% of billed N/A 78278 TC $667.45 $667.45 N/A78199 TC 80% of billed 80% of billed N/A 78278 26 $106.03 $106.03 N/A78199 26 80% of billed 80% of billed N/A 78282 80% of billed 80% of billed N/A78201 $415.73 $415.73 N/A 78282 TC 80% of billed 80% of billed N/A78201 TC $369.96 $369.96 N/A 78282 26 $41.19 $41.19 N/A78201 26 $45.77 $45.77 N/A 78290 $739.92 $739.92 N/A78202 $447.00 $447.00 N/A 78290 TC $666.69 $666.69 N/A78202 TC $395.13 $395.13 N/A 78290 26 $73.23 $73.23 N/A78202 26 $51.87 $51.87 N/A 78291 $558.37 $558.37 N/A78205 $469.12 $469.12 N/A 78291 TC $466.83 $466.83 N/A78205 TC $395.89 $395.89 N/A 78291 26 $91.54 $91.54 N/A78205 26 $73.23 $73.23 N/A 78299 80% of billed 80% of billed N/A78206 $759.75 $759.75 N/A 78299 TC 80% of billed 80% of billed N/A78206 TC $658.30 $658.30 N/A 78299 26 80% of billed 80% of billed N/A78206 26 $101.45 $101.45 N/A 78300 $401.23 $401.23 N/A78215 $431.74 $431.74 N/A 78300 TC $333.34 $333.34 N/A78215 TC $379.11 $379.11 N/A 78300 26 $67.89 $67.89 N/A78215 26 $52.63 $52.63 N/A 78305 $512.60 $512.60 N/A78216 $277.66 $277.66 N/A 78305 TC $423.35 $423.35 N/A78216 TC $218.16 $218.16 N/A 78305 26 $89.25 $89.25 N/A78216 26 $59.50 $59.50 N/A 78306 $559.90 $559.90 N/A78226 $735.34 $735.34 N/A 78306 TC $467.60 $467.60 N/A78226 TC $656.01 $656.01 N/A 78306 26 $92.30 $92.30 N/A78226 26 $79.33 $79.33 N/A 78315 $768.90 $768.90 N/A78227 $999.27 $999.27 N/A 78315 TC $660.58 $660.58 N/A78227 TC $902.39 $902.39 N/A 78315 26 $108.32 $108.32 N/A78227 26 $96.88 $96.88 N/A 78320 $504.21 $504.21 N/A78230 $311.99 $311.99 N/A 78320 TC $395.13 $395.13 N/A78230 TC $270.79 $270.79 N/A 78320 26 $109.08 $109.08 N/A78230 26 $41.19 $41.19 N/A 78350 $70.94 $70.94 N/A78231 $287.58 $287.58 N/A 78350 TC $47.29 $47.29 N/A78231 TC $231.13 $231.13 N/A 78350 26 $23.65 $23.65 N/A78231 26 $56.45 $56.45 N/A 78351 $32.80 $32.80 N/A78232 $218.16 $218.16 N/A 78399 80% of billed 80% of billed N/A78232 TC $175.44 $175.44 N/A 78399 TC 80% of billed 80% of billed N/A78232 26 $42.72 $42.72 N/A 78399 26 80% of billed 80% of billed N/A78258 $491.24 $491.24 N/A 78414 80% of billed 80% of billed N/A78258 TC $411.91 $411.91 N/A 78414 TC 80% of billed 80% of billed N/A78258 26 $79.33 $79.33 N/A 78414 26 $48.06 $48.06 N/A78261 $550.74 $550.74 N/A 78428 $398.94 $398.94 N/A78261 TC $476.75 $476.75 N/A 78428 TC $317.32 $317.32 N/A78261 26 $73.99 $73.99 N/A 78428 26 $81.62 $81.62 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 57 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

78445 $387.50 $387.50 N/A 78580 $530.91 $530.91 N/A78445 TC $337.16 $337.16 N/A 78580 TC $451.58 $451.58 N/A78445 26 $50.34 $50.34 N/A 78580 26 $79.33 $79.33 N/A78451 $755.17 $755.17 N/A 78582 $742.97 $742.97 N/A78451 TC $610.24 $610.24 N/A 78582 TC $628.55 $628.55 N/A78451 26 $144.93 $144.93 N/A 78582 26 $114.42 $114.42 N/A78452 $1,048.09 $1,048.09 N/A 78597 $447.76 $447.76 N/A78452 TC $877.22 $877.22 N/A 78597 TC $370.72 $370.72 N/A78452 26 $170.87 $170.87 N/A 78597 26 $77.04 $77.04 N/A78453 $673.55 $673.55 N/A 78598 $680.42 $680.42 N/A78453 TC $566.76 $566.76 N/A 78598 TC $590.41 $590.41 N/A78453 26 $106.79 $106.79 N/A 78598 26 $90.01 $90.01 N/A78454 $968.76 $968.76 N/A 78599 80% of billed 80% of billed N/A78454 TC $824.59 $824.59 N/A 78599 TC 80% of billed 80% of billed N/A78454 26 $144.17 $144.17 N/A 78599 26 80% of billed 80% of billed N/A78456 $700.25 $700.25 N/A 78600 $409.62 $409.62 N/A78456 TC $594.98 $594.98 N/A 78600 TC $361.57 $361.57 N/A78456 26 $105.27 $105.27 N/A 78600 26 $48.06 $48.06 N/A78457 $416.49 $416.49 N/A 78601 $474.46 $474.46 N/A78457 TC $333.34 $333.34 N/A 78601 TC $420.30 $420.30 N/A78457 26 $83.15 $83.15 N/A 78601 26 $54.16 $54.16 N/A78458 $369.96 $369.96 N/A 78605 $441.66 $441.66 N/A78458 TC $288.34 $288.34 N/A 78605 TC $383.69 $383.69 N/A78458 26 $81.62 $81.62 N/A 78605 26 $57.97 $57.97 N/A78459 80% of billed 80% of billed N/A 78606 $733.81 $733.81 N/A78459 TC 80% of billed 80% of billed N/A 78606 TC $665.92 $665.92 N/A78459 26 $152.56 $152.56 N/A 78606 26 $67.89 $67.89 N/A78466 $427.93 $427.93 N/A 78607 $778.06 $778.06 N/A78466 TC $352.41 $352.41 N/A 78607 TC $649.91 $649.91 N/A78466 26 $75.52 $75.52 N/A 78607 26 $128.15 $128.15 N/A78468 $437.85 $437.85 N/A 78608 80% of billed 80% of billed N/A78468 TC $353.18 $353.18 N/A 78608 TC 80% of billed 80% of billed N/A78468 26 $84.67 $84.67 N/A 78608 26 $155.61 $155.61 N/A78469 $503.45 $503.45 N/A 78609 $160.95 $160.95 N/A78469 TC $405.05 $405.05 N/A 78609 TC 80% of billed 80% of billed N/A78469 26 $98.40 $98.40 N/A 78609 26 $160.95 $160.95 N/A78472 $508.79 $508.79 N/A 78610 $387.50 $387.50 N/A78472 TC $405.05 $405.05 N/A 78610 TC $354.70 $354.70 N/A78472 26 $103.74 $103.74 N/A 78610 26 $32.80 $32.80 N/A78473 $639.99 $639.99 N/A 78630 $751.36 $751.36 N/A78473 TC $485.90 $485.90 N/A 78630 TC $678.13 $678.13 N/A78473 26 $154.09 $154.09 N/A 78630 26 $73.23 $73.23 N/A78481 $385.21 $385.21 N/A 78635 $752.12 $752.12 N/A78481 TC $282.24 $282.24 N/A 78635 TC $685.76 $685.76 N/A78481 26 $102.98 $102.98 N/A 78635 26 $66.36 $66.36 N/A78483 $533.96 $533.96 N/A 78645 $716.27 $716.27 N/A78483 TC $379.87 $379.87 N/A 78645 TC $656.01 $656.01 N/A78483 26 $154.09 $154.09 N/A 78645 26 $60.26 $60.26 N/A78491 80% of billed 80% of billed N/A 78647 $776.53 $776.53 N/A78491 TC 80% of billed 80% of billed N/A 78647 TC $678.89 $678.89 N/A78491 26 $154.09 $154.09 N/A 78647 26 $97.64 $97.64 N/A78492 80% of billed 80% of billed N/A 78650 $730.76 $730.76 N/A78492 TC 80% of billed 80% of billed N/A 78650 TC $665.92 $665.92 N/A78492 26 $193.75 $193.75 N/A 78650 26 $64.84 $64.84 N/A78494 $496.58 $496.58 N/A 78660 $399.71 $399.71 N/A78494 TC $371.48 $371.48 N/A 78660 TC $341.73 $341.73 N/A78494 26 $125.10 $125.10 N/A 78660 26 $57.97 $57.97 N/A78496 $96.88 $96.88 ZZZ 78699 80% of billed 80% of billed N/A78496 TC $44.24 $44.24 ZZZ 78699 TC 80% of billed 80% of billed N/A78496 26 $52.63 $52.63 ZZZ 78699 26 80% of billed 80% of billed N/A78499 80% of billed 80% of billed N/A 78700 $381.40 $381.40 N/A78499 TC 80% of billed 80% of billed N/A 78700 TC $333.34 $333.34 N/A78499 26 80% of billed 80% of billed N/A 78700 26 $48.06 $48.06 N/A78579 $413.44 $413.44 N/A 78701 $467.60 $467.60 N/A78579 TC $362.33 $362.33 N/A 78701 TC $416.49 $416.49 N/A78579 26 $51.11 $51.11 N/A 78701 26 $51.11 $51.11 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 58 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

78707 $514.89 $514.89 N/A 78815 26 $258.59 $258.59 N/A78707 TC $413.44 $413.44 N/A 78816 80% of billed 80% of billed N/A78707 26 $101.45 $101.45 N/A 78816 TC 80% of billed 80% of billed N/A78708 $384.45 $384.45 N/A 78816 26 $260.88 $260.88 N/A78708 TC $256.30 $256.30 N/A 78999 80% of billed 80% of billed N/A78708 26 $128.15 $128.15 N/A 78999 TC 80% of billed 80% of billed N/A78709 $805.52 $805.52 N/A 78999 26 80% of billed 80% of billed N/A78709 TC $657.53 $657.53 N/A 79005 $295.97 $295.97 N/A78709 26 $147.98 $147.98 N/A 79005 TC $106.03 $106.03 N/A78710 $443.19 $443.19 N/A 79005 26 $189.94 $189.94 N/A78710 TC $376.82 $376.82 N/A 79101 $308.93 $308.93 N/A78710 26 $66.36 $66.36 N/A 79101 TC $102.98 $102.98 N/A78725 $238.76 $238.76 N/A 79101 26 $205.96 $205.96 N/A78725 TC $199.09 $199.09 N/A 79200 $346.31 $346.31 N/A78725 26 $39.67 $39.67 N/A 79200 TC $125.86 $125.86 N/A78730 $169.34 $169.34 ZZZ 79200 26 $220.45 $220.45 N/A78730 TC $152.56 $152.56 ZZZ 79300 80% of billed 80% of billed N/A78730 26 $16.78 $16.78 ZZZ 79300 TC 80% of billed 80% of billed N/A78740 $482.85 $482.85 N/A 79300 26 $172.39 $172.39 N/A78740 TC $423.35 $423.35 N/A 79403 $417.25 $417.25 N/A78740 26 $59.50 $59.50 N/A 79403 TC $176.97 $176.97 N/A78761 $462.26 $462.26 N/A 79403 26 $240.28 $240.28 N/A78761 TC $385.21 $385.21 N/A 79440 $313.51 $313.51 N/A78761 26 $77.04 $77.04 N/A 79440 TC $108.32 $108.32 N/A78799 80% of billed 80% of billed N/A 79440 26 $205.19 $205.19 N/A78799 TC 80% of billed 80% of billed N/A 79445 80% of billed 80% of billed N/A78799 26 80% of billed 80% of billed N/A 79445 TC 80% of billed 80% of billed N/A78800 $424.12 $424.12 N/A 79445 26 $249.44 $249.44 N/A78800 TC $350.89 $350.89 N/A 79999 80% of billed 80% of billed N/A78800 26 $73.23 $73.23 N/A 79999 TC 80% of billed 80% of billed N/A78801 $578.97 $578.97 N/A 79999 26 80% of billed 80% of billed N/A78801 TC $492.01 $492.01 N/A 80047 80% of billed 80% of billed N/A78801 26 $86.96 $86.96 N/A 80048 80% of billed 80% of billed N/A78802 $720.85 $720.85 N/A 80050 80% of billed 80% of billed N/A78802 TC $630.07 $630.07 N/A 80051 80% of billed 80% of billed N/A78802 26 $90.77 $90.77 N/A 80053 80% of billed 80% of billed N/A78803 $754.41 $754.41 N/A 80055 80% of billed 80% of billed N/A78803 TC $642.28 $642.28 N/A 80061 80% of billed 80% of billed N/A78803 26 $112.13 $112.13 N/A 80069 80% of billed 80% of billed N/A78804 $1,257.09 $1,257.09 N/A 80074 80% of billed 80% of billed N/A78804 TC $1,144.96 $1,144.96 N/A 80076 80% of billed 80% of billed N/A78804 26 $112.13 $112.13 N/A 80081 80% of billed 80% of billed N/A78805 $403.52 $403.52 N/A 80150 80% of billed 80% of billed N/A78805 TC $325.72 $325.72 N/A 80155 80% of billed 80% of billed N/A78805 26 $77.81 $77.81 N/A 80156 80% of billed 80% of billed N/A78806 $737.63 $737.63 N/A 80157 80% of billed 80% of billed N/A78806 TC $646.85 $646.85 N/A 80158 80% of billed 80% of billed N/A78806 26 $90.77 $90.77 N/A 80159 80% of billed 80% of billed N/A78807 $753.65 $753.65 N/A 80162 80% of billed 80% of billed N/A78807 TC $641.51 $641.51 N/A 80163 80% of billed 80% of billed N/A78807 26 $112.13 $112.13 N/A 80164 80% of billed 80% of billed N/A78808 $99.93 $99.93 N/A 80165 80% of billed 80% of billed N/A78811 80% of billed 80% of billed N/A 80168 80% of billed 80% of billed N/A78811 TC 80% of billed 80% of billed N/A 80169 80% of billed 80% of billed N/A78811 26 $167.05 $167.05 N/A 80170 80% of billed 80% of billed N/A78812 80% of billed 80% of billed N/A 80171 80% of billed 80% of billed N/A78812 TC 80% of billed 80% of billed N/A 80173 80% of billed 80% of billed N/A78812 26 $203.67 $203.67 N/A 80175 80% of billed 80% of billed N/A78813 80% of billed 80% of billed N/A 80176 80% of billed 80% of billed N/A78813 TC 80% of billed 80% of billed N/A 80177 80% of billed 80% of billed N/A78813 26 $212.06 $212.06 N/A 80178 80% of billed 80% of billed N/A78814 80% of billed 80% of billed N/A 80180 80% of billed 80% of billed N/A78814 TC 80% of billed 80% of billed N/A 80183 80% of billed 80% of billed N/A78814 26 $234.94 $234.94 N/A 80184 80% of billed 80% of billed N/A78815 80% of billed 80% of billed N/A 80185 80% of billed 80% of billed N/A78815 TC 80% of billed 80% of billed N/A 80186 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 59 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

80188 80% of billed 80% of billed N/A 80365 80% of billed 80% of billed N/A80190 80% of billed 80% of billed N/A 80366 80% of billed 80% of billed N/A80192 80% of billed 80% of billed N/A 80367 80% of billed 80% of billed N/A80194 80% of billed 80% of billed N/A 80368 80% of billed 80% of billed N/A80195 80% of billed 80% of billed N/A 80369 80% of billed 80% of billed N/A80197 80% of billed 80% of billed N/A 80370 80% of billed 80% of billed N/A80198 80% of billed 80% of billed N/A 80371 80% of billed 80% of billed N/A80199 80% of billed 80% of billed N/A 80372 80% of billed 80% of billed N/A80200 80% of billed 80% of billed N/A 80373 80% of billed 80% of billed N/A80201 80% of billed 80% of billed N/A 80374 80% of billed 80% of billed N/A80202 80% of billed 80% of billed N/A 80375 80% of billed 80% of billed N/A80203 80% of billed 80% of billed N/A 80376 80% of billed 80% of billed N/A80299 $50.47 $50.47 N/A 80377 80% of billed 80% of billed N/A80300 $45.32 $45.32 N/A 80400 80% of billed 80% of billed N/A80301 $26.78 $26.78 N/A 80402 80% of billed 80% of billed N/A80302 80% of billed 80% of billed N/A 80406 80% of billed 80% of billed N/A80303 80% of billed 80% of billed N/A 80408 80% of billed 80% of billed N/A80304 80% of billed 80% of billed N/A 80410 80% of billed 80% of billed N/A80305 80% of billed 80% of billed N/A 80412 80% of billed 80% of billed N/A80306 80% of billed 80% of billed N/A 80414 80% of billed 80% of billed N/A80307 80% of billed 80% of billed N/A 80415 80% of billed 80% of billed N/A80320 $46.35 $46.35 N/A 80416 80% of billed 80% of billed N/A80321 80% of billed 80% of billed N/A 80417 80% of billed 80% of billed N/A80322 80% of billed 80% of billed N/A 80418 80% of billed 80% of billed N/A80323 80% of billed 80% of billed N/A 80420 80% of billed 80% of billed N/A80324 $45.32 $45.32 N/A 80422 80% of billed 80% of billed N/A80325 80% of billed 80% of billed N/A 80424 80% of billed 80% of billed N/A80326 80% of billed 80% of billed N/A 80426 80% of billed 80% of billed N/A80327 80% of billed 80% of billed N/A 80428 80% of billed 80% of billed N/A80328 80% of billed 80% of billed N/A 80430 80% of billed 80% of billed N/A80329 80% of billed 80% of billed N/A 80432 80% of billed 80% of billed N/A80330 80% of billed 80% of billed N/A 80434 80% of billed 80% of billed N/A80331 80% of billed 80% of billed N/A 80435 80% of billed 80% of billed N/A80332 80% of billed 80% of billed N/A 80436 80% of billed 80% of billed N/A80333 80% of billed 80% of billed N/A 80438 80% of billed 80% of billed N/A80334 80% of billed 80% of billed N/A 80439 80% of billed 80% of billed N/A80335 80% of billed 80% of billed N/A 80500 $35.49 $31.49 N/A80336 80% of billed 80% of billed N/A 80502 $115.64 $111.06 N/A80337 80% of billed 80% of billed N/A 81000 80% of billed 80% of billed N/A80338 80% of billed 80% of billed N/A 81001 80% of billed 80% of billed N/A80339 80% of billed 80% of billed N/A 81002 80% of billed 80% of billed N/A80340 80% of billed 80% of billed N/A 81003 $15.45 $15.45 N/A80341 80% of billed 80% of billed N/A 81005 $6.18 $6.18 N/A80342 80% of billed 80% of billed N/A 81007 80% of billed 80% of billed N/A80343 80% of billed 80% of billed N/A 81015 80% of billed 80% of billed N/A80344 80% of billed 80% of billed N/A 81020 80% of billed 80% of billed N/A80345 80% of billed 80% of billed N/A 81025 80% of billed 80% of billed N/A80346 $54.59 $54.59 N/A 81050 80% of billed 80% of billed N/A80347 80% of billed 80% of billed N/A 81099 80% of billed 80% of billed N/A80348 80% of billed 80% of billed N/A 81161 80% of billed 80% of billed N/A80349 80% of billed 80% of billed N/A 81162 80% of billed 80% of billed N/A80350 80% of billed 80% of billed N/A 81170 80% of billed 80% of billed N/A80351 80% of billed 80% of billed N/A 81200 80% of billed 80% of billed N/A80352 80% of billed 80% of billed N/A 81201 80% of billed 80% of billed N/A80353 $44.29 $44.29 N/A 81202 80% of billed 80% of billed N/A80354 80% of billed 80% of billed N/A 81203 80% of billed 80% of billed N/A80355 80% of billed 80% of billed N/A 81205 80% of billed 80% of billed N/A80356 80% of billed 80% of billed N/A 81206 80% of billed 80% of billed N/A80357 80% of billed 80% of billed N/A 81207 80% of billed 80% of billed N/A80358 $56.65 $56.65 N/A 81208 80% of billed 80% of billed N/A80359 80% of billed 80% of billed N/A 81209 80% of billed 80% of billed N/A80360 80% of billed 80% of billed N/A 81210 80% of billed 80% of billed N/A80361 80% of billed 80% of billed N/A 81211 80% of billed 80% of billed N/A80362 80% of billed 80% of billed N/A 81212 80% of billed 80% of billed N/A80363 80% of billed 80% of billed N/A 81213 80% of billed 80% of billed N/A80364 80% of billed 80% of billed N/A 81214 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 60 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

81215 80% of billed 80% of billed N/A 81311 80% of billed 80% of billed N/A81216 80% of billed 80% of billed N/A 81313 80% of billed 80% of billed N/A81217 80% of billed 80% of billed N/A 81314 80% of billed 80% of billed N/A81218 80% of billed 80% of billed N/A 81315 80% of billed 80% of billed N/A81219 80% of billed 80% of billed N/A 81316 80% of billed 80% of billed N/A81220 80% of billed 80% of billed N/A 81317 80% of billed 80% of billed N/A81221 80% of billed 80% of billed N/A 81318 80% of billed 80% of billed N/A81222 80% of billed 80% of billed N/A 81319 80% of billed 80% of billed N/A81223 80% of billed 80% of billed N/A 81321 80% of billed 80% of billed N/A81224 80% of billed 80% of billed N/A 81322 80% of billed 80% of billed N/A81225 80% of billed 80% of billed N/A 81323 80% of billed 80% of billed N/A81226 80% of billed 80% of billed N/A 81324 80% of billed 80% of billed N/A81227 80% of billed 80% of billed N/A 81325 80% of billed 80% of billed N/A81228 80% of billed 80% of billed N/A 81326 80% of billed 80% of billed N/A81229 80% of billed 80% of billed N/A 81327 80% of billed 80% of billed N/A81235 80% of billed 80% of billed N/A 81330 80% of billed 80% of billed N/A81240 80% of billed 80% of billed N/A 81331 80% of billed 80% of billed N/A81241 80% of billed 80% of billed N/A 81332 80% of billed 80% of billed N/A81242 80% of billed 80% of billed N/A 81340 80% of billed 80% of billed N/A81243 80% of billed 80% of billed N/A 81341 80% of billed 80% of billed N/A81244 80% of billed 80% of billed N/A 81342 80% of billed 80% of billed N/A81245 80% of billed 80% of billed N/A 81350 80% of billed 80% of billed N/A81246 80% of billed 80% of billed N/A 81355 80% of billed 80% of billed N/A81250 80% of billed 80% of billed N/A 81370 80% of billed 80% of billed N/A81251 80% of billed 80% of billed N/A 81371 80% of billed 80% of billed N/A81252 80% of billed 80% of billed N/A 81372 80% of billed 80% of billed N/A81253 80% of billed 80% of billed N/A 81373 80% of billed 80% of billed N/A81254 80% of billed 80% of billed N/A 81374 80% of billed 80% of billed N/A81255 80% of billed 80% of billed N/A 81375 80% of billed 80% of billed N/A81256 80% of billed 80% of billed N/A 81376 80% of billed 80% of billed N/A81257 80% of billed 80% of billed N/A 81377 80% of billed 80% of billed N/A81260 80% of billed 80% of billed N/A 81378 80% of billed 80% of billed N/A81261 80% of billed 80% of billed N/A 81379 80% of billed 80% of billed N/A81262 80% of billed 80% of billed N/A 81380 80% of billed 80% of billed N/A81263 80% of billed 80% of billed N/A 81381 80% of billed 80% of billed N/A81264 80% of billed 80% of billed N/A 81382 80% of billed 80% of billed N/A81265 80% of billed 80% of billed N/A 81383 80% of billed 80% of billed N/A81266 80% of billed 80% of billed N/A 81400 80% of billed 80% of billed N/A81267 80% of billed 80% of billed N/A 81401 80% of billed 80% of billed N/A81268 80% of billed 80% of billed N/A 81402 80% of billed 80% of billed N/A81270 80% of billed 80% of billed N/A 81403 80% of billed 80% of billed N/A81272 80% of billed 80% of billed N/A 81404 80% of billed 80% of billed N/A81273 80% of billed 80% of billed N/A 81405 80% of billed 80% of billed N/A81275 80% of billed 80% of billed N/A 81406 80% of billed 80% of billed N/A81276 80% of billed 80% of billed N/A 81407 80% of billed 80% of billed N/A81280 80% of billed 80% of billed N/A 81408 80% of billed 80% of billed N/A81281 80% of billed 80% of billed N/A 81410 80% of billed 80% of billed N/A81282 80% of billed 80% of billed N/A 81411 80% of billed 80% of billed N/A81287 80% of billed 80% of billed N/A 81412 80% of billed 80% of billed N/A81288 80% of billed 80% of billed N/A 81413 80% of billed 80% of billed N/A81290 80% of billed 80% of billed N/A 81414 80% of billed 80% of billed N/A81291 80% of billed 80% of billed N/A 81415 80% of billed 80% of billed N/A81292 80% of billed 80% of billed N/A 81416 80% of billed 80% of billed N/A81293 80% of billed 80% of billed N/A 81417 80% of billed 80% of billed N/A81294 80% of billed 80% of billed N/A 81420 80% of billed 80% of billed N/A81295 80% of billed 80% of billed N/A 81422 80% of billed 80% of billed N/A81296 80% of billed 80% of billed N/A 81425 80% of billed 80% of billed N/A81297 80% of billed 80% of billed N/A 81426 80% of billed 80% of billed N/A81298 80% of billed 80% of billed N/A 81427 80% of billed 80% of billed N/A81299 80% of billed 80% of billed N/A 81430 80% of billed 80% of billed N/A81300 80% of billed 80% of billed N/A 81431 80% of billed 80% of billed N/A81301 80% of billed 80% of billed N/A 81432 80% of billed 80% of billed N/A81302 80% of billed 80% of billed N/A 81433 80% of billed 80% of billed N/A81303 80% of billed 80% of billed N/A 81434 80% of billed 80% of billed N/A81304 80% of billed 80% of billed N/A 81435 80% of billed 80% of billed N/A81310 80% of billed 80% of billed N/A 81436 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 61 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

81437 80% of billed 80% of billed N/A 82150 80% of billed 80% of billed N/A81438 80% of billed 80% of billed N/A 82154 80% of billed 80% of billed N/A81439 80% of billed 80% of billed N/A 82157 80% of billed 80% of billed N/A81440 80% of billed 80% of billed N/A 82160 80% of billed 80% of billed N/A81442 80% of billed 80% of billed N/A 82163 80% of billed 80% of billed N/A81445 80% of billed 80% of billed N/A 82164 80% of billed 80% of billed N/A81450 80% of billed 80% of billed N/A 82172 80% of billed 80% of billed N/A81455 80% of billed 80% of billed N/A 82175 80% of billed 80% of billed N/A81460 80% of billed 80% of billed N/A 82180 80% of billed 80% of billed N/A81465 80% of billed 80% of billed N/A 82190 80% of billed 80% of billed N/A81470 80% of billed 80% of billed N/A 82232 80% of billed 80% of billed N/A81471 80% of billed 80% of billed N/A 82239 80% of billed 80% of billed N/A81479 80% of billed 80% of billed N/A 82240 80% of billed 80% of billed N/A81490 80% of billed 80% of billed N/A 82247 80% of billed 80% of billed N/A81493 80% of billed 80% of billed N/A 82248 80% of billed 80% of billed N/A81500 80% of billed 80% of billed N/A 82252 80% of billed 80% of billed N/A81503 80% of billed 80% of billed N/A 82261 80% of billed 80% of billed N/A81504 80% of billed 80% of billed N/A 82270 80% of billed 80% of billed N/A81506 80% of billed 80% of billed N/A 82271 80% of billed 80% of billed N/A81507 80% of billed 80% of billed N/A 82272 80% of billed 80% of billed N/A81508 80% of billed 80% of billed N/A 82274 80% of billed 80% of billed N/A81509 80% of billed 80% of billed N/A 82286 80% of billed 80% of billed N/A81510 80% of billed 80% of billed N/A 82300 80% of billed 80% of billed N/A81511 80% of billed 80% of billed N/A 82306 80% of billed 80% of billed N/A81512 80% of billed 80% of billed N/A 82308 80% of billed 80% of billed N/A81519 80% of billed 80% of billed N/A 82310 80% of billed 80% of billed N/A81525 80% of billed 80% of billed N/A 82330 80% of billed 80% of billed N/A81528 80% of billed 80% of billed N/A 82331 80% of billed 80% of billed N/A81535 80% of billed 80% of billed N/A 82340 80% of billed 80% of billed N/A81536 80% of billed 80% of billed N/A 82355 80% of billed 80% of billed N/A81538 80% of billed 80% of billed N/A 82360 80% of billed 80% of billed N/A81539 80% of billed 80% of billed N/A 82365 80% of billed 80% of billed N/A81540 80% of billed 80% of billed N/A 82370 80% of billed 80% of billed N/A81545 80% of billed 80% of billed N/A 82373 80% of billed 80% of billed N/A81595 80% of billed 80% of billed N/A 82374 80% of billed 80% of billed N/A81599 80% of billed 80% of billed N/A 82375 80% of billed 80% of billed N/A82009 80% of billed 80% of billed N/A 82376 80% of billed 80% of billed N/A82010 80% of billed 80% of billed N/A 82378 80% of billed 80% of billed N/A82013 80% of billed 80% of billed N/A 82379 80% of billed 80% of billed N/A82016 80% of billed 80% of billed N/A 82380 80% of billed 80% of billed N/A82017 80% of billed 80% of billed N/A 82382 80% of billed 80% of billed N/A82024 80% of billed 80% of billed N/A 82383 80% of billed 80% of billed N/A82030 80% of billed 80% of billed N/A 82384 80% of billed 80% of billed N/A82040 80% of billed 80% of billed N/A 82387 80% of billed 80% of billed N/A82042 80% of billed 80% of billed N/A 82390 80% of billed 80% of billed N/A82043 80% of billed 80% of billed N/A 82397 80% of billed 80% of billed N/A82044 80% of billed 80% of billed N/A 82415 80% of billed 80% of billed N/A82045 80% of billed 80% of billed N/A 82435 80% of billed 80% of billed N/A82075 80% of billed 80% of billed N/A 82436 80% of billed 80% of billed N/A82085 80% of billed 80% of billed N/A 82438 80% of billed 80% of billed N/A82088 80% of billed 80% of billed N/A 82441 80% of billed 80% of billed N/A82103 80% of billed 80% of billed N/A 82465 80% of billed 80% of billed N/A82104 80% of billed 80% of billed N/A 82480 80% of billed 80% of billed N/A82105 80% of billed 80% of billed N/A 82482 80% of billed 80% of billed N/A82106 80% of billed 80% of billed N/A 82485 80% of billed 80% of billed N/A82107 80% of billed 80% of billed N/A 82495 80% of billed 80% of billed N/A82108 80% of billed 80% of billed N/A 82507 80% of billed 80% of billed N/A82120 80% of billed 80% of billed N/A 82523 80% of billed 80% of billed N/A82127 80% of billed 80% of billed N/A 82525 80% of billed 80% of billed N/A82128 80% of billed 80% of billed N/A 82528 80% of billed 80% of billed N/A82131 80% of billed 80% of billed N/A 82530 80% of billed 80% of billed N/A82135 80% of billed 80% of billed N/A 82533 80% of billed 80% of billed N/A82136 80% of billed 80% of billed N/A 82540 80% of billed 80% of billed N/A82139 80% of billed 80% of billed N/A 82542 80% of billed 80% of billed N/A82140 80% of billed 80% of billed N/A 82550 80% of billed 80% of billed N/A82143 80% of billed 80% of billed N/A 82552 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 62 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

82553 80% of billed 80% of billed N/A 82960 80% of billed 80% of billed N/A82554 80% of billed 80% of billed N/A 82962 80% of billed 80% of billed N/A82565 80% of billed 80% of billed N/A 82963 80% of billed 80% of billed N/A82570 $19.57 $19.57 N/A 82965 80% of billed 80% of billed N/A82575 80% of billed 80% of billed N/A 82977 80% of billed 80% of billed N/A82585 80% of billed 80% of billed N/A 82978 80% of billed 80% of billed N/A82595 80% of billed 80% of billed N/A 82979 80% of billed 80% of billed N/A82600 80% of billed 80% of billed N/A 82985 80% of billed 80% of billed N/A82607 80% of billed 80% of billed N/A 83001 80% of billed 80% of billed N/A82608 80% of billed 80% of billed N/A 83002 80% of billed 80% of billed N/A82610 80% of billed 80% of billed N/A 83003 80% of billed 80% of billed N/A82615 80% of billed 80% of billed N/A 83006 80% of billed 80% of billed N/A82626 80% of billed 80% of billed N/A 83009 80% of billed 80% of billed N/A82627 80% of billed 80% of billed N/A 83010 80% of billed 80% of billed N/A82633 80% of billed 80% of billed N/A 83012 80% of billed 80% of billed N/A82634 80% of billed 80% of billed N/A 83013 80% of billed 80% of billed N/A82638 80% of billed 80% of billed N/A 83014 80% of billed 80% of billed N/A82652 80% of billed 80% of billed N/A 83015 80% of billed 80% of billed N/A82656 80% of billed 80% of billed N/A 83018 80% of billed 80% of billed N/A82657 80% of billed 80% of billed N/A 83020 80% of billed 80% of billed N/A82658 80% of billed 80% of billed N/A 83020 26 $29.77 $29.77 N/A82664 80% of billed 80% of billed N/A 83021 80% of billed 80% of billed N/A82668 80% of billed 80% of billed N/A 83026 80% of billed 80% of billed N/A82670 80% of billed 80% of billed N/A 83030 80% of billed 80% of billed N/A82671 80% of billed 80% of billed N/A 83033 80% of billed 80% of billed N/A82672 80% of billed 80% of billed N/A 83036 80% of billed 80% of billed N/A82677 80% of billed 80% of billed N/A 83037 80% of billed 80% of billed N/A82679 80% of billed 80% of billed N/A 83045 80% of billed 80% of billed N/A82693 80% of billed 80% of billed N/A 83050 80% of billed 80% of billed N/A82696 80% of billed 80% of billed N/A 83051 80% of billed 80% of billed N/A82705 80% of billed 80% of billed N/A 83060 80% of billed 80% of billed N/A82710 80% of billed 80% of billed N/A 83065 80% of billed 80% of billed N/A82715 80% of billed 80% of billed N/A 83068 80% of billed 80% of billed N/A82725 80% of billed 80% of billed N/A 83069 80% of billed 80% of billed N/A82726 80% of billed 80% of billed N/A 83070 80% of billed 80% of billed N/A82728 80% of billed 80% of billed N/A 83080 80% of billed 80% of billed N/A82731 80% of billed 80% of billed N/A 83088 80% of billed 80% of billed N/A82735 80% of billed 80% of billed N/A 83090 80% of billed 80% of billed N/A82746 80% of billed 80% of billed N/A 83150 80% of billed 80% of billed N/A82747 80% of billed 80% of billed N/A 83491 80% of billed 80% of billed N/A82757 80% of billed 80% of billed N/A 83497 80% of billed 80% of billed N/A82759 80% of billed 80% of billed N/A 83498 80% of billed 80% of billed N/A82760 80% of billed 80% of billed N/A 83499 80% of billed 80% of billed N/A82775 80% of billed 80% of billed N/A 83500 80% of billed 80% of billed N/A82776 80% of billed 80% of billed N/A 83505 80% of billed 80% of billed N/A82777 80% of billed 80% of billed N/A 83516 80% of billed 80% of billed N/A82784 80% of billed 80% of billed N/A 83518 80% of billed 80% of billed N/A82785 80% of billed 80% of billed N/A 83519 80% of billed 80% of billed N/A82787 80% of billed 80% of billed N/A 83520 80% of billed 80% of billed N/A82800 80% of billed 80% of billed N/A 83525 80% of billed 80% of billed N/A82803 80% of billed 80% of billed N/A 83527 80% of billed 80% of billed N/A82805 80% of billed 80% of billed N/A 83528 80% of billed 80% of billed N/A82810 80% of billed 80% of billed N/A 83540 80% of billed 80% of billed N/A82820 80% of billed 80% of billed N/A 83550 80% of billed 80% of billed N/A82930 80% of billed 80% of billed N/A 83570 80% of billed 80% of billed N/A82938 80% of billed 80% of billed N/A 83582 80% of billed 80% of billed N/A82941 80% of billed 80% of billed N/A 83586 80% of billed 80% of billed N/A82943 80% of billed 80% of billed N/A 83593 80% of billed 80% of billed N/A82945 80% of billed 80% of billed N/A 83605 80% of billed 80% of billed N/A82946 80% of billed 80% of billed N/A 83615 80% of billed 80% of billed N/A82947 80% of billed 80% of billed N/A 83625 80% of billed 80% of billed N/A82948 80% of billed 80% of billed N/A 83630 80% of billed 80% of billed N/A82950 80% of billed 80% of billed N/A 83631 80% of billed 80% of billed N/A82951 80% of billed 80% of billed N/A 83632 80% of billed 80% of billed N/A82952 80% of billed 80% of billed N/A 83633 80% of billed 80% of billed N/A82955 80% of billed 80% of billed N/A 83655 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 63 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

83661 80% of billed 80% of billed N/A 84132 80% of billed 80% of billed N/A83662 80% of billed 80% of billed N/A 84133 80% of billed 80% of billed N/A83663 80% of billed 80% of billed N/A 84134 80% of billed 80% of billed N/A83664 80% of billed 80% of billed N/A 84135 80% of billed 80% of billed N/A83670 80% of billed 80% of billed N/A 84138 80% of billed 80% of billed N/A83690 80% of billed 80% of billed N/A 84140 80% of billed 80% of billed N/A83695 80% of billed 80% of billed N/A 84143 80% of billed 80% of billed N/A83698 80% of billed 80% of billed N/A 84144 80% of billed 80% of billed N/A83700 80% of billed 80% of billed N/A 84145 80% of billed 80% of billed N/A83701 80% of billed 80% of billed N/A 84146 80% of billed 80% of billed N/A83704 80% of billed 80% of billed N/A 84150 80% of billed 80% of billed N/A83718 80% of billed 80% of billed N/A 84152 80% of billed 80% of billed N/A83719 80% of billed 80% of billed N/A 84153 80% of billed 80% of billed N/A83721 80% of billed 80% of billed N/A 84154 80% of billed 80% of billed N/A83727 80% of billed 80% of billed N/A 84155 80% of billed 80% of billed N/A83735 80% of billed 80% of billed N/A 84156 80% of billed 80% of billed N/A83775 80% of billed 80% of billed N/A 84157 80% of billed 80% of billed N/A83785 80% of billed 80% of billed N/A 84160 80% of billed 80% of billed N/A83789 80% of billed 80% of billed N/A 84163 80% of billed 80% of billed N/A83825 80% of billed 80% of billed N/A 84165 80% of billed 80% of billed N/A83835 80% of billed 80% of billed N/A 84165 26 $29.77 $29.77 N/A83857 80% of billed 80% of billed N/A 84166 80% of billed 80% of billed N/A83861 80% of billed 80% of billed N/A 84166 26 $29.77 $29.77 N/A83864 80% of billed 80% of billed N/A 84181 80% of billed 80% of billed N/A83872 80% of billed 80% of billed N/A 84181 26 $29.77 $29.77 N/A83873 80% of billed 80% of billed N/A 84182 80% of billed 80% of billed N/A83874 80% of billed 80% of billed N/A 84182 26 $29.77 $29.77 N/A83876 80% of billed 80% of billed N/A 84202 80% of billed 80% of billed N/A83880 80% of billed 80% of billed N/A 84203 80% of billed 80% of billed N/A83883 80% of billed 80% of billed N/A 84206 80% of billed 80% of billed N/A83885 80% of billed 80% of billed N/A 84207 80% of billed 80% of billed N/A83915 80% of billed 80% of billed N/A 84210 80% of billed 80% of billed N/A83916 80% of billed 80% of billed N/A 84220 80% of billed 80% of billed N/A83918 80% of billed 80% of billed N/A 84228 80% of billed 80% of billed N/A83919 80% of billed 80% of billed N/A 84233 80% of billed 80% of billed N/A83921 80% of billed 80% of billed N/A 84234 80% of billed 80% of billed N/A83930 80% of billed 80% of billed N/A 84235 80% of billed 80% of billed N/A83935 80% of billed 80% of billed N/A 84238 80% of billed 80% of billed N/A83937 80% of billed 80% of billed N/A 84244 80% of billed 80% of billed N/A83945 80% of billed 80% of billed N/A 84252 80% of billed 80% of billed N/A83950 80% of billed 80% of billed N/A 84255 80% of billed 80% of billed N/A83951 80% of billed 80% of billed N/A 84260 80% of billed 80% of billed N/A83970 80% of billed 80% of billed N/A 84270 80% of billed 80% of billed N/A83986 80% of billed 80% of billed N/A 84275 80% of billed 80% of billed N/A83987 80% of billed 80% of billed N/A 84285 80% of billed 80% of billed N/A83992 $37.08 $37.08 N/A 84295 80% of billed 80% of billed N/A83993 80% of billed 80% of billed N/A 84300 80% of billed 80% of billed N/A84030 80% of billed 80% of billed N/A 84302 80% of billed 80% of billed N/A84035 80% of billed 80% of billed N/A 84305 80% of billed 80% of billed N/A84060 80% of billed 80% of billed N/A 84307 80% of billed 80% of billed N/A84061 80% of billed 80% of billed N/A 84311 80% of billed 80% of billed N/A84066 80% of billed 80% of billed N/A 84315 80% of billed 80% of billed N/A84075 80% of billed 80% of billed N/A 84375 80% of billed 80% of billed N/A84078 80% of billed 80% of billed N/A 84376 80% of billed 80% of billed N/A84080 80% of billed 80% of billed N/A 84377 80% of billed 80% of billed N/A84081 80% of billed 80% of billed N/A 84378 80% of billed 80% of billed N/A84085 80% of billed 80% of billed N/A 84379 80% of billed 80% of billed N/A84087 80% of billed 80% of billed N/A 84392 80% of billed 80% of billed N/A84100 80% of billed 80% of billed N/A 84402 80% of billed 80% of billed N/A84105 80% of billed 80% of billed N/A 84403 80% of billed 80% of billed N/A84106 80% of billed 80% of billed N/A 84410 80% of billed 80% of billed N/A84110 80% of billed 80% of billed N/A 84425 80% of billed 80% of billed N/A84112 80% of billed 80% of billed N/A 84430 80% of billed 80% of billed N/A84119 80% of billed 80% of billed N/A 84431 80% of billed 80% of billed N/A84120 80% of billed 80% of billed N/A 84432 80% of billed 80% of billed N/A84126 80% of billed 80% of billed N/A 84436 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 64 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

84437 80% of billed 80% of billed N/A 85130 80% of billed 80% of billed N/A84439 80% of billed 80% of billed N/A 85170 80% of billed 80% of billed N/A84442 80% of billed 80% of billed N/A 85175 80% of billed 80% of billed N/A84443 80% of billed 80% of billed N/A 85210 80% of billed 80% of billed N/A84445 80% of billed 80% of billed N/A 85220 80% of billed 80% of billed N/A84446 80% of billed 80% of billed N/A 85230 80% of billed 80% of billed N/A84449 80% of billed 80% of billed N/A 85240 80% of billed 80% of billed N/A84450 80% of billed 80% of billed N/A 85244 80% of billed 80% of billed N/A84460 80% of billed 80% of billed N/A 85245 80% of billed 80% of billed N/A84466 80% of billed 80% of billed N/A 85246 80% of billed 80% of billed N/A84478 80% of billed 80% of billed N/A 85247 80% of billed 80% of billed N/A84479 80% of billed 80% of billed N/A 85250 80% of billed 80% of billed N/A84480 80% of billed 80% of billed N/A 85260 80% of billed 80% of billed N/A84481 80% of billed 80% of billed N/A 85270 80% of billed 80% of billed N/A84482 80% of billed 80% of billed N/A 85280 80% of billed 80% of billed N/A84484 80% of billed 80% of billed N/A 85290 80% of billed 80% of billed N/A84485 80% of billed 80% of billed N/A 85291 80% of billed 80% of billed N/A84488 80% of billed 80% of billed N/A 85292 80% of billed 80% of billed N/A84490 80% of billed 80% of billed N/A 85293 80% of billed 80% of billed N/A84510 80% of billed 80% of billed N/A 85300 80% of billed 80% of billed N/A84512 80% of billed 80% of billed N/A 85301 80% of billed 80% of billed N/A84520 80% of billed 80% of billed N/A 85302 80% of billed 80% of billed N/A84525 80% of billed 80% of billed N/A 85303 80% of billed 80% of billed N/A84540 80% of billed 80% of billed N/A 85305 80% of billed 80% of billed N/A84545 80% of billed 80% of billed N/A 85306 80% of billed 80% of billed N/A84550 80% of billed 80% of billed N/A 85307 80% of billed 80% of billed N/A84560 80% of billed 80% of billed N/A 85335 80% of billed 80% of billed N/A84577 80% of billed 80% of billed N/A 85337 80% of billed 80% of billed N/A84578 80% of billed 80% of billed N/A 85345 80% of billed 80% of billed N/A84580 80% of billed 80% of billed N/A 85347 80% of billed 80% of billed N/A84583 80% of billed 80% of billed N/A 85348 80% of billed 80% of billed N/A84585 80% of billed 80% of billed N/A 85360 80% of billed 80% of billed N/A84586 80% of billed 80% of billed N/A 85362 80% of billed 80% of billed N/A84588 80% of billed 80% of billed N/A 85366 80% of billed 80% of billed N/A84590 80% of billed 80% of billed N/A 85370 80% of billed 80% of billed N/A84591 80% of billed 80% of billed N/A 85378 80% of billed 80% of billed N/A84597 80% of billed 80% of billed N/A 85379 80% of billed 80% of billed N/A84600 80% of billed 80% of billed N/A 85380 80% of billed 80% of billed N/A84620 80% of billed 80% of billed N/A 85384 80% of billed 80% of billed N/A84630 80% of billed 80% of billed N/A 85385 80% of billed 80% of billed N/A84681 80% of billed 80% of billed N/A 85390 80% of billed 80% of billed N/A84702 80% of billed 80% of billed N/A 85390 26 $29.77 $29.77 N/A84703 80% of billed 80% of billed N/A 85396 $33.78 $33.78 N/A84704 80% of billed 80% of billed N/A 85397 80% of billed 80% of billed N/A84830 80% of billed 80% of billed N/A 85400 80% of billed 80% of billed N/A84999 80% of billed 80% of billed N/A 85410 80% of billed 80% of billed N/A85002 80% of billed 80% of billed N/A 85415 80% of billed 80% of billed N/A85004 80% of billed 80% of billed N/A 85420 80% of billed 80% of billed N/A85007 80% of billed 80% of billed N/A 85421 80% of billed 80% of billed N/A85008 80% of billed 80% of billed N/A 85441 80% of billed 80% of billed N/A85009 80% of billed 80% of billed N/A 85445 80% of billed 80% of billed N/A85013 80% of billed 80% of billed N/A 85460 80% of billed 80% of billed N/A85014 80% of billed 80% of billed N/A 85461 80% of billed 80% of billed N/A85018 80% of billed 80% of billed N/A 85475 80% of billed 80% of billed N/A85025 80% of billed 80% of billed N/A 85520 80% of billed 80% of billed N/A85027 80% of billed 80% of billed N/A 85525 80% of billed 80% of billed N/A85032 80% of billed 80% of billed N/A 85530 80% of billed 80% of billed N/A85041 80% of billed 80% of billed N/A 85536 80% of billed 80% of billed N/A85044 80% of billed 80% of billed N/A 85540 80% of billed 80% of billed N/A85045 80% of billed 80% of billed N/A 85547 80% of billed 80% of billed N/A85046 80% of billed 80% of billed N/A 85549 80% of billed 80% of billed N/A85048 80% of billed 80% of billed N/A 85555 80% of billed 80% of billed N/A85049 80% of billed 80% of billed N/A 85557 80% of billed 80% of billed N/A85055 80% of billed 80% of billed N/A 85576 80% of billed 80% of billed N/A85060 $40.07 $40.07 N/A 85576 26 $29.77 $29.77 N/A85097 $145.42 $81.30 N/A 85597 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 65 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

85598 80% of billed 80% of billed N/A 86317 80% of billed 80% of billed N/A85610 80% of billed 80% of billed N/A 86318 80% of billed 80% of billed N/A85611 80% of billed 80% of billed N/A 86320 80% of billed 80% of billed N/A85612 80% of billed 80% of billed N/A 86320 26 $29.77 $29.77 N/A85613 80% of billed 80% of billed N/A 86325 80% of billed 80% of billed N/A85635 80% of billed 80% of billed N/A 86325 26 $29.77 $29.77 N/A85651 80% of billed 80% of billed N/A 86327 80% of billed 80% of billed N/A85652 80% of billed 80% of billed N/A 86327 26 $33.78 $33.78 N/A85660 80% of billed 80% of billed N/A 86329 80% of billed 80% of billed N/A85670 80% of billed 80% of billed N/A 86331 80% of billed 80% of billed N/A85675 80% of billed 80% of billed N/A 86332 80% of billed 80% of billed N/A85705 80% of billed 80% of billed N/A 86334 80% of billed 80% of billed N/A85730 80% of billed 80% of billed N/A 86334 26 $29.77 $29.77 N/A85732 80% of billed 80% of billed N/A 86335 80% of billed 80% of billed N/A85810 80% of billed 80% of billed N/A 86335 26 $29.77 $29.77 N/A85999 80% of billed 80% of billed N/A 86336 80% of billed 80% of billed N/A86000 80% of billed 80% of billed N/A 86337 80% of billed 80% of billed N/A86001 80% of billed 80% of billed N/A 86340 80% of billed 80% of billed N/A86003 80% of billed 80% of billed N/A 86341 80% of billed 80% of billed N/A86005 80% of billed 80% of billed N/A 86343 80% of billed 80% of billed N/A86021 80% of billed 80% of billed N/A 86344 80% of billed 80% of billed N/A86022 80% of billed 80% of billed N/A 86352 80% of billed 80% of billed N/A86023 80% of billed 80% of billed N/A 86353 80% of billed 80% of billed N/A86038 80% of billed 80% of billed N/A 86355 80% of billed 80% of billed N/A86039 80% of billed 80% of billed N/A 86356 80% of billed 80% of billed N/A86060 80% of billed 80% of billed N/A 86357 80% of billed 80% of billed N/A86063 80% of billed 80% of billed N/A 86359 80% of billed 80% of billed N/A86077 $91.03 $84.73 N/A 86360 80% of billed 80% of billed N/A86078 $91.03 $84.73 N/A 86361 80% of billed 80% of billed N/A86079 $89.88 $83.58 N/A 86367 80% of billed 80% of billed N/A86140 80% of billed 80% of billed N/A 86376 80% of billed 80% of billed N/A86141 80% of billed 80% of billed N/A 86378 80% of billed 80% of billed N/A86146 80% of billed 80% of billed N/A 86382 80% of billed 80% of billed N/A86147 80% of billed 80% of billed N/A 86384 80% of billed 80% of billed N/A86148 80% of billed 80% of billed N/A 86386 80% of billed 80% of billed N/A86152 80% of billed 80% of billed N/A 86403 80% of billed 80% of billed N/A86153 26 $55.53 $55.53 N/A 86406 80% of billed 80% of billed N/A86155 80% of billed 80% of billed N/A 86430 80% of billed 80% of billed N/A86156 80% of billed 80% of billed N/A 86431 80% of billed 80% of billed N/A86157 80% of billed 80% of billed N/A 86480 80% of billed 80% of billed N/A86160 80% of billed 80% of billed N/A 86481 80% of billed 80% of billed N/A86161 80% of billed 80% of billed N/A 86485 80% of billed 80% of billed N/A86162 80% of billed 80% of billed N/A 86486 $8.02 $8.02 N/A86171 80% of billed 80% of billed N/A 86490 $112.78 $112.78 N/A86185 80% of billed 80% of billed N/A 86510 $9.73 $9.73 N/A86200 80% of billed 80% of billed N/A 86580 $12.60 $12.60 N/A86215 80% of billed 80% of billed N/A 86590 80% of billed 80% of billed N/A86225 80% of billed 80% of billed N/A 86592 80% of billed 80% of billed N/A86226 80% of billed 80% of billed N/A 86593 80% of billed 80% of billed N/A86235 80% of billed 80% of billed N/A 86602 80% of billed 80% of billed N/A86243 80% of billed 80% of billed N/A 86603 80% of billed 80% of billed N/A86255 80% of billed 80% of billed N/A 86606 80% of billed 80% of billed N/A86255 26 $29.77 $29.77 N/A 86609 80% of billed 80% of billed N/A86256 80% of billed 80% of billed N/A 86611 80% of billed 80% of billed N/A86256 26 $29.77 $29.77 N/A 86612 80% of billed 80% of billed N/A86277 80% of billed 80% of billed N/A 86615 80% of billed 80% of billed N/A86280 80% of billed 80% of billed N/A 86617 80% of billed 80% of billed N/A86294 80% of billed 80% of billed N/A 86618 80% of billed 80% of billed N/A86300 80% of billed 80% of billed N/A 86619 80% of billed 80% of billed N/A86301 80% of billed 80% of billed N/A 86622 80% of billed 80% of billed N/A86304 80% of billed 80% of billed N/A 86625 80% of billed 80% of billed N/A86305 80% of billed 80% of billed N/A 86628 80% of billed 80% of billed N/A86308 80% of billed 80% of billed N/A 86631 80% of billed 80% of billed N/A86309 80% of billed 80% of billed N/A 86632 80% of billed 80% of billed N/A86310 80% of billed 80% of billed N/A 86635 80% of billed 80% of billed N/A86316 80% of billed 80% of billed N/A 86638 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 66 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

86641 80% of billed 80% of billed N/A 86789 80% of billed 80% of billed N/A86644 80% of billed 80% of billed N/A 86790 80% of billed 80% of billed N/A86645 80% of billed 80% of billed N/A 86793 80% of billed 80% of billed N/A86648 80% of billed 80% of billed N/A 86800 80% of billed 80% of billed N/A86651 80% of billed 80% of billed N/A 86803 80% of billed 80% of billed N/A86652 80% of billed 80% of billed N/A 86804 80% of billed 80% of billed N/A86653 80% of billed 80% of billed N/A 86805 80% of billed 80% of billed N/A86654 80% of billed 80% of billed N/A 86806 80% of billed 80% of billed N/A86658 80% of billed 80% of billed N/A 86807 80% of billed 80% of billed N/A86663 80% of billed 80% of billed N/A 86808 80% of billed 80% of billed N/A86664 80% of billed 80% of billed N/A 86812 80% of billed 80% of billed N/A86665 80% of billed 80% of billed N/A 86813 80% of billed 80% of billed N/A86666 80% of billed 80% of billed N/A 86816 80% of billed 80% of billed N/A86668 80% of billed 80% of billed N/A 86817 80% of billed 80% of billed N/A86671 80% of billed 80% of billed N/A 86821 80% of billed 80% of billed N/A86674 80% of billed 80% of billed N/A 86822 80% of billed 80% of billed N/A86677 80% of billed 80% of billed N/A 86825 80% of billed 80% of billed N/A86682 80% of billed 80% of billed N/A 86826 80% of billed 80% of billed N/A86684 80% of billed 80% of billed N/A 86828 80% of billed 80% of billed N/A86687 80% of billed 80% of billed N/A 86829 80% of billed 80% of billed N/A86688 80% of billed 80% of billed N/A 86830 80% of billed 80% of billed N/A86689 80% of billed 80% of billed N/A 86831 80% of billed 80% of billed N/A86692 80% of billed 80% of billed N/A 86832 80% of billed 80% of billed N/A86694 80% of billed 80% of billed N/A 86833 80% of billed 80% of billed N/A86695 80% of billed 80% of billed N/A 86834 80% of billed 80% of billed N/A86696 80% of billed 80% of billed N/A 86835 80% of billed 80% of billed N/A86698 80% of billed 80% of billed N/A 86849 80% of billed 80% of billed N/A86701 80% of billed 80% of billed N/A 86850 80% of billed 80% of billed N/A86702 80% of billed 80% of billed N/A 86860 80% of billed 80% of billed N/A86703 80% of billed 80% of billed N/A 86870 80% of billed 80% of billed N/A86704 80% of billed 80% of billed N/A 86880 80% of billed 80% of billed N/A86705 80% of billed 80% of billed N/A 86885 80% of billed 80% of billed N/A86706 80% of billed 80% of billed N/A 86886 80% of billed 80% of billed N/A86707 80% of billed 80% of billed N/A 86890 80% of billed 80% of billed N/A86708 80% of billed 80% of billed N/A 86891 80% of billed 80% of billed N/A86709 80% of billed 80% of billed N/A 86900 80% of billed 80% of billed N/A86710 80% of billed 80% of billed N/A 86901 80% of billed 80% of billed N/A86711 80% of billed 80% of billed N/A 86902 80% of billed 80% of billed N/A86713 80% of billed 80% of billed N/A 86904 80% of billed 80% of billed N/A86717 80% of billed 80% of billed N/A 86905 80% of billed 80% of billed N/A86720 80% of billed 80% of billed N/A 86906 80% of billed 80% of billed N/A86723 80% of billed 80% of billed N/A 86910 80% of billed 80% of billed N/A86727 80% of billed 80% of billed N/A 86911 80% of billed 80% of billed N/A86729 80% of billed 80% of billed N/A 86920 80% of billed 80% of billed N/A86732 80% of billed 80% of billed N/A 86921 80% of billed 80% of billed N/A86735 80% of billed 80% of billed N/A 86922 80% of billed 80% of billed N/A86738 80% of billed 80% of billed N/A 86923 80% of billed 80% of billed N/A86741 80% of billed 80% of billed N/A 86927 80% of billed 80% of billed N/A86744 80% of billed 80% of billed N/A 86930 80% of billed 80% of billed N/A86747 80% of billed 80% of billed N/A 86931 80% of billed 80% of billed N/A86750 80% of billed 80% of billed N/A 86932 80% of billed 80% of billed N/A86753 80% of billed 80% of billed N/A 86940 80% of billed 80% of billed N/A86756 80% of billed 80% of billed N/A 86941 80% of billed 80% of billed N/A86757 80% of billed 80% of billed N/A 86945 80% of billed 80% of billed N/A86759 80% of billed 80% of billed N/A 86950 80% of billed 80% of billed N/A86762 80% of billed 80% of billed N/A 86960 80% of billed 80% of billed N/A86765 80% of billed 80% of billed N/A 86965 80% of billed 80% of billed N/A86768 80% of billed 80% of billed N/A 86970 80% of billed 80% of billed N/A86771 80% of billed 80% of billed N/A 86971 80% of billed 80% of billed N/A86774 80% of billed 80% of billed N/A 86972 80% of billed 80% of billed N/A86777 80% of billed 80% of billed N/A 86975 80% of billed 80% of billed N/A86778 80% of billed 80% of billed N/A 86976 80% of billed 80% of billed N/A86780 80% of billed 80% of billed N/A 86977 80% of billed 80% of billed N/A86784 80% of billed 80% of billed N/A 86978 80% of billed 80% of billed N/A86787 80% of billed 80% of billed N/A 86985 80% of billed 80% of billed N/A86788 80% of billed 80% of billed N/A 86999 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 67 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

87003 80% of billed 80% of billed N/A 87271 80% of billed 80% of billed N/A87015 80% of billed 80% of billed N/A 87272 80% of billed 80% of billed N/A87040 80% of billed 80% of billed N/A 87273 80% of billed 80% of billed N/A87045 80% of billed 80% of billed N/A 87274 80% of billed 80% of billed N/A87046 80% of billed 80% of billed N/A 87275 80% of billed 80% of billed N/A87070 80% of billed 80% of billed N/A 87276 80% of billed 80% of billed N/A87071 80% of billed 80% of billed N/A 87277 80% of billed 80% of billed N/A87073 80% of billed 80% of billed N/A 87278 80% of billed 80% of billed N/A87075 80% of billed 80% of billed N/A 87279 80% of billed 80% of billed N/A87076 80% of billed 80% of billed N/A 87280 80% of billed 80% of billed N/A87077 80% of billed 80% of billed N/A 87281 80% of billed 80% of billed N/A87081 80% of billed 80% of billed N/A 87283 80% of billed 80% of billed N/A87084 80% of billed 80% of billed N/A 87285 80% of billed 80% of billed N/A87086 80% of billed 80% of billed N/A 87290 80% of billed 80% of billed N/A87088 80% of billed 80% of billed N/A 87299 80% of billed 80% of billed N/A87101 80% of billed 80% of billed N/A 87300 80% of billed 80% of billed N/A87102 80% of billed 80% of billed N/A 87301 80% of billed 80% of billed N/A87103 80% of billed 80% of billed N/A 87305 80% of billed 80% of billed N/A87106 80% of billed 80% of billed N/A 87320 80% of billed 80% of billed N/A87107 80% of billed 80% of billed N/A 87324 80% of billed 80% of billed N/A87109 80% of billed 80% of billed N/A 87327 80% of billed 80% of billed N/A87110 80% of billed 80% of billed N/A 87328 80% of billed 80% of billed N/A87116 80% of billed 80% of billed N/A 87329 80% of billed 80% of billed N/A87118 80% of billed 80% of billed N/A 87332 80% of billed 80% of billed N/A87140 80% of billed 80% of billed N/A 87335 80% of billed 80% of billed N/A87143 80% of billed 80% of billed N/A 87336 80% of billed 80% of billed N/A87147 80% of billed 80% of billed N/A 87337 80% of billed 80% of billed N/A87149 80% of billed 80% of billed N/A 87338 80% of billed 80% of billed N/A87150 80% of billed 80% of billed N/A 87339 80% of billed 80% of billed N/A87152 80% of billed 80% of billed N/A 87340 80% of billed 80% of billed N/A87153 80% of billed 80% of billed N/A 87341 80% of billed 80% of billed N/A87158 80% of billed 80% of billed N/A 87350 80% of billed 80% of billed N/A87164 80% of billed 80% of billed N/A 87380 80% of billed 80% of billed N/A87164 26 $29.77 $29.77 N/A 87385 80% of billed 80% of billed N/A87166 80% of billed 80% of billed N/A 87389 80% of billed 80% of billed N/A87168 80% of billed 80% of billed N/A 87390 80% of billed 80% of billed N/A87169 80% of billed 80% of billed N/A 87391 80% of billed 80% of billed N/A87172 80% of billed 80% of billed N/A 87400 80% of billed 80% of billed N/A87176 80% of billed 80% of billed N/A 87420 80% of billed 80% of billed N/A87177 80% of billed 80% of billed N/A 87425 80% of billed 80% of billed N/A87181 80% of billed 80% of billed N/A 87427 80% of billed 80% of billed N/A87184 80% of billed 80% of billed N/A 87430 80% of billed 80% of billed N/A87185 80% of billed 80% of billed N/A 87449 80% of billed 80% of billed N/A87186 80% of billed 80% of billed N/A 87450 80% of billed 80% of billed N/A87187 80% of billed 80% of billed N/A 87451 80% of billed 80% of billed N/A87188 80% of billed 80% of billed N/A 87470 80% of billed 80% of billed N/A87190 80% of billed 80% of billed N/A 87471 80% of billed 80% of billed N/A87197 80% of billed 80% of billed N/A 87472 80% of billed 80% of billed N/A87205 80% of billed 80% of billed N/A 87475 80% of billed 80% of billed N/A87206 80% of billed 80% of billed N/A 87476 80% of billed 80% of billed N/A87207 80% of billed 80% of billed N/A 87477 80% of billed 80% of billed N/A87207 26 $29.77 $29.77 N/A 87480 80% of billed 80% of billed N/A87209 80% of billed 80% of billed N/A 87481 80% of billed 80% of billed N/A87210 80% of billed 80% of billed N/A 87482 80% of billed 80% of billed N/A87220 80% of billed 80% of billed N/A 87483 80% of billed 80% of billed N/A87230 80% of billed 80% of billed N/A 87485 80% of billed 80% of billed N/A87250 80% of billed 80% of billed N/A 87486 80% of billed 80% of billed N/A87252 80% of billed 80% of billed N/A 87487 80% of billed 80% of billed N/A87253 80% of billed 80% of billed N/A 87490 80% of billed 80% of billed N/A87254 80% of billed 80% of billed N/A 87491 80% of billed 80% of billed N/A87255 80% of billed 80% of billed N/A 87492 80% of billed 80% of billed N/A87260 80% of billed 80% of billed N/A 87493 80% of billed 80% of billed N/A87265 80% of billed 80% of billed N/A 87495 80% of billed 80% of billed N/A87267 80% of billed 80% of billed N/A 87496 80% of billed 80% of billed N/A87269 80% of billed 80% of billed N/A 87497 80% of billed 80% of billed N/A87270 80% of billed 80% of billed N/A 87498 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 68 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

87500 80% of billed 80% of billed N/A 87800 80% of billed 80% of billed N/A87501 80% of billed 80% of billed N/A 87801 80% of billed 80% of billed N/A87502 80% of billed 80% of billed N/A 87802 80% of billed 80% of billed N/A87503 80% of billed 80% of billed N/A 87803 80% of billed 80% of billed N/A87505 80% of billed 80% of billed N/A 87804 80% of billed 80% of billed N/A87506 80% of billed 80% of billed N/A 87806 80% of billed 80% of billed N/A87507 80% of billed 80% of billed N/A 87807 80% of billed 80% of billed N/A87510 80% of billed 80% of billed N/A 87808 80% of billed 80% of billed N/A87511 80% of billed 80% of billed N/A 87809 80% of billed 80% of billed N/A87512 80% of billed 80% of billed N/A 87810 80% of billed 80% of billed N/A87515 80% of billed 80% of billed N/A 87850 80% of billed 80% of billed N/A87516 80% of billed 80% of billed N/A 87880 80% of billed 80% of billed N/A87517 80% of billed 80% of billed N/A 87899 80% of billed 80% of billed N/A87520 80% of billed 80% of billed N/A 87900 80% of billed 80% of billed N/A87521 80% of billed 80% of billed N/A 87901 80% of billed 80% of billed N/A87522 80% of billed 80% of billed N/A 87902 80% of billed 80% of billed N/A87525 80% of billed 80% of billed N/A 87903 80% of billed 80% of billed N/A87526 80% of billed 80% of billed N/A 87904 80% of billed 80% of billed N/A87527 80% of billed 80% of billed N/A 87905 80% of billed 80% of billed N/A87528 80% of billed 80% of billed N/A 87906 80% of billed 80% of billed N/A87529 80% of billed 80% of billed N/A 87910 80% of billed 80% of billed N/A87530 80% of billed 80% of billed N/A 87912 80% of billed 80% of billed N/A87531 80% of billed 80% of billed N/A 87999 80% of billed 80% of billed N/A87532 80% of billed 80% of billed N/A 88000 80% of billed 80% of billed N/A87533 80% of billed 80% of billed N/A 88005 80% of billed 80% of billed N/A87534 80% of billed 80% of billed N/A 88007 80% of billed 80% of billed N/A87535 80% of billed 80% of billed N/A 88012 80% of billed 80% of billed N/A87536 80% of billed 80% of billed N/A 88014 80% of billed 80% of billed N/A87537 80% of billed 80% of billed N/A 88016 80% of billed 80% of billed N/A87538 80% of billed 80% of billed N/A 88020 80% of billed 80% of billed N/A87539 80% of billed 80% of billed N/A 88025 80% of billed 80% of billed N/A87540 80% of billed 80% of billed N/A 88027 80% of billed 80% of billed N/A87541 80% of billed 80% of billed N/A 88028 80% of billed 80% of billed N/A87542 80% of billed 80% of billed N/A 88029 80% of billed 80% of billed N/A87550 80% of billed 80% of billed N/A 88036 80% of billed 80% of billed N/A87551 80% of billed 80% of billed N/A 88037 80% of billed 80% of billed N/A87552 80% of billed 80% of billed N/A 88040 80% of billed 80% of billed N/A87555 80% of billed 80% of billed N/A 88045 80% of billed 80% of billed N/A87556 80% of billed 80% of billed N/A 88099 80% of billed 80% of billed N/A87557 80% of billed 80% of billed N/A 88104 $122.52 $122.52 N/A87560 80% of billed 80% of billed N/A 88104 TC $74.42 $74.42 N/A87561 80% of billed 80% of billed N/A 88104 26 $48.09 $48.09 N/A87562 80% of billed 80% of billed N/A 88106 $120.80 $120.80 N/A87580 80% of billed 80% of billed N/A 88106 TC $88.16 $88.16 N/A87581 80% of billed 80% of billed N/A 88106 26 $32.63 $32.63 N/A87582 80% of billed 80% of billed N/A 88108 $116.79 $116.79 N/A87590 80% of billed 80% of billed N/A 88108 TC $79.00 $79.00 N/A87591 80% of billed 80% of billed N/A 88108 26 $37.79 $37.79 N/A87592 80% of billed 80% of billed N/A 88112 $115.64 $115.64 N/A87623 80% of billed 80% of billed N/A 88112 TC $69.27 $69.27 N/A87624 80% of billed 80% of billed N/A 88112 26 $46.37 $46.37 N/A87625 80% of billed 80% of billed N/A 88120 $1,022.48 $1,022.48 N/A87631 80% of billed 80% of billed N/A 88120 TC $926.30 $926.30 N/A87632 80% of billed 80% of billed N/A 88120 26 $96.18 $96.18 N/A87633 80% of billed 80% of billed N/A 88121 $891.96 $891.96 N/A87640 80% of billed 80% of billed N/A 88121 TC $808.94 $808.94 N/A87641 80% of billed 80% of billed N/A 88121 26 $83.01 $83.01 N/A87650 80% of billed 80% of billed N/A 88125 $37.79 $37.79 N/A87651 80% of billed 80% of billed N/A 88125 TC $15.46 $15.46 N/A87652 80% of billed 80% of billed N/A 88125 26 $22.33 $22.33 N/A87653 80% of billed 80% of billed N/A 88130 80% of billed 80% of billed N/A87660 80% of billed 80% of billed N/A 88140 80% of billed 80% of billed N/A87661 80% of billed 80% of billed N/A 88141 $52.10 $52.10 N/A87797 80% of billed 80% of billed N/A 88142 80% of billed 80% of billed N/A87798 80% of billed 80% of billed N/A 88143 80% of billed 80% of billed N/A87799 80% of billed 80% of billed N/A 88147 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 69 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

88148 80% of billed 80% of billed N/A 88291 $51.52 $51.52 N/A88150 80% of billed 80% of billed N/A 88299 80% of billed 80% of billed N/A88152 80% of billed 80% of billed N/A 88300 $24.62 $24.62 N/A88153 80% of billed 80% of billed N/A 88300 TC $17.18 $17.18 N/A88154 80% of billed 80% of billed N/A 88300 26 $7.44 $7.44 N/A88155 80% of billed 80% of billed N/A 88302 $52.67 $52.67 N/A88160 $116.79 $116.79 N/A 88302 TC $40.65 $40.65 N/A88160 TC $73.28 $73.28 N/A 88302 26 $12.02 $12.02 N/A88160 26 $43.51 $43.51 N/A 88304 $73.85 $73.85 N/A88161 $104.77 $104.77 N/A 88304 TC $54.96 $54.96 N/A88161 TC $62.98 $62.98 N/A 88304 26 $18.89 $18.89 N/A88161 26 $41.79 $41.79 N/A 88305 $118.51 $118.51 N/A88162 $168.89 $168.89 N/A 88305 TC $54.96 $54.96 N/A88162 TC $103.05 $103.05 N/A 88305 26 $63.55 $63.55 N/A88162 26 $65.84 $65.84 N/A 88307 $498.65 $498.65 N/A88164 80% of billed 80% of billed N/A 88307 TC $358.96 $358.96 N/A88165 80% of billed 80% of billed N/A 88307 26 $139.69 $139.69 N/A88166 80% of billed 80% of billed N/A 88309 $756.27 $756.27 N/A88167 80% of billed 80% of billed N/A 88309 TC $509.52 $509.52 N/A88172 $92.74 $92.74 N/A 88309 26 $246.75 $246.75 N/A88172 TC $32.06 $32.06 N/A 88311 $34.92 $34.92 N/A88172 26 $60.68 $60.68 N/A 88311 TC $13.74 $13.74 N/A88173 $248.46 $248.46 N/A 88311 26 $21.18 $21.18 N/A88173 TC $129.96 $129.96 N/A 88312 $158.01 $158.01 N/A88173 26 $118.51 $118.51 N/A 88312 TC $112.78 $112.78 N/A88174 80% of billed 80% of billed N/A 88312 26 $45.23 $45.23 N/A88175 80% of billed 80% of billed N/A 88313 $110.49 $110.49 N/A88177 $48.66 $48.66 ZZZ 88313 TC $90.46 $90.46 N/A88177 TC $12.02 $12.02 ZZZ 88313 26 $20.04 $20.04 N/A88177 26 $36.64 $36.64 ZZZ 88314 $124.80 $124.80 N/A88182 $181.48 $181.48 N/A 88314 TC $87.59 $87.59 N/A88182 TC $121.37 $121.37 N/A 88314 26 $37.21 $37.21 N/A88182 26 $60.11 $60.11 N/A 88319 $142.55 $142.55 N/A88184 $121.94 $121.94 N/A 88319 TC $97.90 $97.90 N/A88185 $73.85 $73.85 ZZZ 88319 26 $44.66 $44.66 N/A88187 $116.79 $116.79 N/A 88321 $165.45 $140.26 N/A88188 $148.28 $148.28 N/A 88323 $224.99 $224.99 N/A88189 $182.63 $182.63 N/A 88323 TC $81.30 $81.30 N/A88199 80% of billed 80% of billed N/A 88323 26 $143.70 $143.70 N/A88199 TC 80% of billed 80% of billed N/A 88325 $279.38 $220.98 N/A88199 26 80% of billed 80% of billed N/A 88329 $81.30 $60.68 N/A88230 80% of billed 80% of billed N/A 88331 $155.15 $155.15 N/A88233 80% of billed 80% of billed N/A 88331 TC $50.38 $50.38 N/A88235 80% of billed 80% of billed N/A 88331 26 $104.77 $104.77 N/A88237 80% of billed 80% of billed N/A 88332 $81.87 $81.87 N/A88239 80% of billed 80% of billed N/A 88332 TC $30.34 $30.34 N/A88240 80% of billed 80% of billed N/A 88332 26 $51.52 $51.52 N/A88241 80% of billed 80% of billed N/A 88333 $162.59 $162.59 N/A88245 80% of billed 80% of billed N/A 88333 TC $57.25 $57.25 N/A88248 80% of billed 80% of billed N/A 88333 26 $105.34 $105.34 N/A88249 80% of billed 80% of billed N/A 88334 $99.62 $99.62 N/A88261 80% of billed 80% of billed N/A 88334 TC $34.92 $34.92 N/A88262 80% of billed 80% of billed N/A 88334 26 $64.69 $64.69 N/A88263 80% of billed 80% of billed N/A 88341 $144.84 $144.84 ZZZ88264 80% of billed 80% of billed N/A 88341 TC $100.19 $100.19 ZZZ88267 80% of billed 80% of billed N/A 88341 26 $44.66 $44.66 ZZZ88269 80% of billed 80% of billed N/A 88342 $171.75 $171.75 N/A88271 80% of billed 80% of billed N/A 88342 TC $112.21 $112.21 N/A88272 80% of billed 80% of billed N/A 88342 26 $59.54 $59.54 N/A88273 80% of billed 80% of billed N/A 88344 $277.66 $277.66 N/A88274 80% of billed 80% of billed N/A 88344 TC $212.40 $212.40 N/A88275 80% of billed 80% of billed N/A 88344 26 $65.26 $65.26 N/A88280 80% of billed 80% of billed N/A 88346 $150.00 $150.00 N/A88283 80% of billed 80% of billed N/A 88346 TC $88.74 $88.74 N/A88285 80% of billed 80% of billed N/A 88346 26 $61.26 $61.26 N/A88289 80% of billed 80% of billed N/A 88348 $556.47 $556.47 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 70 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

88348 TC $429.95 $429.95 N/A 88388 TC $16.03 $16.03 N/A88348 26 $126.52 $126.52 N/A 88388 26 $40.07 $40.07 N/A88350 $115.64 $115.64 ZZZ 88399 80% of billed 80% of billed N/A88350 TC $69.84 $69.84 ZZZ 88399 TC 80% of billed 80% of billed N/A88350 26 $45.80 $45.80 ZZZ 88399 26 80% of billed 80% of billed N/A88355 $253.04 $253.04 N/A 88720 80% of billed 80% of billed N/A88355 TC $118.51 $118.51 N/A 88738 80% of billed 80% of billed N/A88355 26 $134.54 $134.54 N/A 88740 80% of billed 80% of billed N/A88356 $331.48 $331.48 N/A 88741 80% of billed 80% of billed N/A88356 TC $133.96 $133.96 N/A 88749 80% of billed 80% of billed N/A88356 26 $197.51 $197.51 N/A 89049 $432.81 $107.63 N/A88358 $137.40 $137.40 N/A 89050 80% of billed 80% of billed N/A88358 TC $63.55 $63.55 N/A 89051 80% of billed 80% of billed N/A88358 26 $73.85 $73.85 N/A 89055 80% of billed 80% of billed N/A88360 $194.65 $194.65 N/A 89060 80% of billed 80% of billed N/A88360 TC $104.20 $104.20 N/A 89060 26 $29.77 $29.77 N/A88360 26 $90.46 $90.46 N/A 89125 80% of billed 80% of billed N/A88361 $238.73 $238.73 N/A 89160 80% of billed 80% of billed N/A88361 TC $141.41 $141.41 N/A 89190 80% of billed 80% of billed N/A88361 26 $97.32 $97.32 N/A 89220 $26.34 $26.34 N/A88362 $417.92 $417.92 N/A 89230 $8.59 $8.59 N/A88362 TC $237.59 $237.59 N/A 89240 80% of billed 80% of billed N/A88362 26 $180.34 $180.34 N/A 89250 80% of billed 80% of billed N/A88363 $37.21 $32.06 N/A 89251 80% of billed 80% of billed N/A88364 $215.83 $215.83 ZZZ 89253 80% of billed 80% of billed N/A88364 TC $159.73 $159.73 ZZZ 89254 80% of billed 80% of billed N/A88364 26 $56.10 $56.10 ZZZ 89255 80% of billed 80% of billed N/A88365 $285.10 $285.10 N/A 89257 80% of billed 80% of billed N/A88365 TC $211.82 $211.82 N/A 89258 80% of billed 80% of billed N/A88365 26 $73.28 $73.28 N/A 89259 80% of billed 80% of billed N/A88366 $419.64 $419.64 N/A 89260 80% of billed 80% of billed N/A88366 TC $316.59 $316.59 N/A 89261 80% of billed 80% of billed N/A88366 26 $103.05 $103.05 N/A 89264 80% of billed 80% of billed N/A88367 $171.75 $171.75 N/A 89268 80% of billed 80% of billed N/A88367 TC $114.50 $114.50 N/A 89272 80% of billed 80% of billed N/A88367 26 $57.25 $57.25 N/A 89280 80% of billed 80% of billed N/A88368 $183.77 $183.77 N/A 89281 80% of billed 80% of billed N/A88368 TC $117.94 $117.94 N/A 89290 80% of billed 80% of billed N/A88368 26 $65.84 $65.84 N/A 89291 80% of billed 80% of billed N/A88369 $173.47 $173.47 ZZZ 89300 80% of billed 80% of billed N/A88369 TC $122.52 $122.52 ZZZ 89310 80% of billed 80% of billed N/A88369 26 $50.95 $50.95 ZZZ 89320 80% of billed 80% of billed N/A88371 80% of billed 80% of billed N/A 89321 80% of billed 80% of billed N/A88371 26 $29.77 $29.77 N/A 89322 80% of billed 80% of billed N/A88372 80% of billed 80% of billed N/A 89325 80% of billed 80% of billed N/A88372 26 $29.77 $29.77 N/A 89329 80% of billed 80% of billed N/A88373 $120.22 $120.22 ZZZ 89330 80% of billed 80% of billed N/A88373 TC $85.88 $85.88 ZZZ 89331 80% of billed 80% of billed N/A88373 26 $34.35 $34.35 ZZZ 89335 80% of billed 80% of billed N/A88374 $553.04 $553.04 N/A 89337 80% of billed 80% of billed N/A88374 TC $479.18 $479.18 N/A 89342 80% of billed 80% of billed N/A88374 26 $73.85 $73.85 N/A 89343 80% of billed 80% of billed N/A88375 $80.15 $80.15 N/A 89344 80% of billed 80% of billed N/A88377 $658.38 $658.38 N/A 89346 80% of billed 80% of billed N/A88377 TC $552.46 $552.46 N/A 89352 80% of billed 80% of billed N/A88377 26 $105.91 $105.91 N/A 89353 80% of billed 80% of billed N/A88380 $232.43 $232.43 N/A 89354 80% of billed 80% of billed N/A88380 TC $138.54 $138.54 N/A 89356 80% of billed 80% of billed N/A88380 26 $93.89 $93.89 N/A 89398 80% of billed 80% of billed N/A88381 $188.35 $188.35 N/A 90281 80% of billed 80% of billed N/A88381 TC $147.13 $147.13 N/A 90283 80% of billed 80% of billed N/A88381 26 $41.22 $41.22 N/A 90284 80% of billed 80% of billed N/A88387 $68.13 $68.13 N/A 90287 80% of billed 80% of billed N/A88387 TC $14.88 $14.88 N/A 90288 80% of billed 80% of billed N/A88387 26 $53.24 $53.24 N/A 90291 80% of billed 80% of billed N/A88388 $56.10 $56.10 N/A 90296 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 71 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

90371 80% of billed 80% of billed N/A 90698 80% of billed 80% of billed N/A90375 80% of billed 80% of billed N/A 90700 80% of billed 80% of billed N/A90376 80% of billed 80% of billed N/A 90702 80% of billed 80% of billed N/A90378 80% of billed 80% of billed N/A 90707 80% of billed 80% of billed N/A90384 80% of billed 80% of billed N/A 90710 80% of billed 80% of billed N/A90385 80% of billed 80% of billed N/A 90713 80% of billed 80% of billed N/A90386 80% of billed 80% of billed N/A 90714 80% of billed 80% of billed N/A90389 80% of billed 80% of billed N/A 90715 80% of billed 80% of billed N/A90393 80% of billed 80% of billed N/A 90716 80% of billed 80% of billed N/A90396 80% of billed 80% of billed N/A 90717 80% of billed 80% of billed N/A90399 80% of billed 80% of billed N/A 90723 80% of billed 80% of billed N/A90460 $47.38 $47.38 N/A 90732 80% of billed 80% of billed N/A90461 $23.36 $23.36 ZZZ 90733 80% of billed 80% of billed N/A90471 $47.38 $47.38 N/A 90734 80% of billed 80% of billed N/A90472 $23.36 $23.36 ZZZ 90736 80% of billed 80% of billed N/A90473 $47.38 $47.38 N/A 90738 80% of billed 80% of billed N/A90474 $23.36 $23.36 ZZZ 90739 80% of billed 80% of billed N/A90476 80% of billed 80% of billed N/A 90740 80% of billed 80% of billed N/A90477 80% of billed 80% of billed N/A 90743 80% of billed 80% of billed N/A90581 80% of billed 80% of billed N/A 90744 80% of billed 80% of billed N/A90585 80% of billed 80% of billed N/A 90746 80% of billed 80% of billed N/A90586 80% of billed 80% of billed N/A 90747 80% of billed 80% of billed N/A90620 80% of billed 80% of billed N/A 90748 80% of billed 80% of billed N/A90621 80% of billed 80% of billed N/A 90749 80% of billed 80% of billed N/A90625 80% of billed 80% of billed N/A 90750 80% of billed 80% of billed N/A90630 80% of billed 80% of billed N/A 90785 $26.02 $26.02 ZZZ90632 80% of billed 80% of billed N/A 90791 $246.23 $238.89 N/A90633 80% of billed 80% of billed N/A 90792 $272.93 $264.92 N/A90634 80% of billed 80% of billed N/A 90832 $119.45 $118.11 N/A90636 80% of billed 80% of billed N/A 90833 $123.45 $122.12 ZZZ90644 80% of billed 80% of billed N/A 90834 $158.82 $157.48 N/A90647 80% of billed 80% of billed N/A 90836 $156.82 $155.48 ZZZ90648 80% of billed 80% of billed N/A 90837 $238.23 $236.89 N/A90649 80% of billed 80% of billed N/A 90838 $206.86 $205.53 ZZZ90650 80% of billed 80% of billed N/A 90839 $248.90 $246.90 N/A90651 80% of billed 80% of billed N/A 90840 $118.78 $118.11 ZZZ90653 80% of billed 80% of billed N/A 90845 $171.50 $170.83 N/A90654 80% of billed 80% of billed N/A 90846 $192.85 $191.52 N/A90655 80% of billed 80% of billed N/A 90847 $199.52 $198.19 N/A90656 80% of billed 80% of billed N/A 90849 $64.06 $57.39 N/A90657 80% of billed 80% of billed N/A 90853 $48.05 $47.38 N/A90658 80% of billed 80% of billed N/A 90863 80% of billed 80% of billed N/A90660 80% of billed 80% of billed N/A 90865 $312.96 $242.23 N/A90661 80% of billed 80% of billed N/A 90867 80% of billed 80% of billed 00090662 80% of billed 80% of billed N/A 90868 80% of billed 80% of billed 00090664 80% of billed 80% of billed N/A 90869 80% of billed 80% of billed 00090666 80% of billed 80% of billed N/A 90870 $332.98 $208.20 00090667 80% of billed 80% of billed N/A 90875 $115.44 $115.44 N/A90668 80% of billed 80% of billed N/A 90876 $203.53 $182.84 N/A90670 80% of billed 80% of billed N/A 90880 $190.18 $176.17 N/A90672 80% of billed 80% of billed N/A 90882 80% of billed 80% of billed N/A90673 80% of billed 80% of billed N/A 90885 $93.42 $93.42 N/A90674 80% of billed 80% of billed N/A 90887 $166.16 $142.80 N/A90675 80% of billed 80% of billed N/A 90889 80% of billed 80% of billed N/A90676 80% of billed 80% of billed N/A 90899 80% of billed 80% of billed N/A90680 80% of billed 80% of billed N/A 90901 $72.07 $37.37 00090681 80% of billed 80% of billed N/A 90911 $158.15 $84.08 00090682 80% of billed 80% of billed N/A 90935 $136.13 $136.13 00090685 80% of billed 80% of billed N/A 90937 $195.52 $195.52 00090686 80% of billed 80% of billed N/A 90940 80% of billed 80% of billed N/A90687 80% of billed 80% of billed N/A 90945 $161.49 $161.49 00090688 80% of billed 80% of billed N/A 90947 $233.56 $233.56 00090690 80% of billed 80% of billed N/A 90951 $1,776.35 $1,776.35 N/A90691 80% of billed 80% of billed N/A 90952 80% of billed 80% of billed N/A90696 80% of billed 80% of billed N/A 90953 80% of billed 80% of billed N/A90697 80% of billed 80% of billed N/A 90954 $1,535.46 $1,535.46 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 72 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

90955 $859.48 $859.48 N/A 91122 $427.74 $427.74 00090956 $599.24 $599.24 N/A 91122 TC $256.24 $256.24 00090957 $1,213.82 $1,213.82 N/A 91122 26 $171.50 $171.50 00090958 $819.44 $819.44 N/A 91132 $290.94 $290.94 N/A90959 $556.53 $556.53 N/A 91132 TC $237.56 $237.56 N/A90960 $533.17 $533.17 N/A 91132 26 $53.38 $53.38 N/A90961 $448.43 $448.43 N/A 91133 $323.64 $323.64 N/A90962 $345.66 $345.66 N/A 91133 TC $258.25 $258.25 N/A90963 $1,023.64 $1,023.64 N/A 91133 26 $65.40 $65.40 N/A90964 $894.85 $894.85 N/A 91200 $53.38 $53.38 N/A90965 $851.47 $851.47 N/A 91200 TC $28.69 $28.69 N/A90966 $447.09 $447.09 N/A 91200 26 $24.69 $24.69 N/A90967 $34.03 $34.03 N/A 91299 80% of billed 80% of billed N/A90968 $29.36 $29.36 N/A 91299 TC 80% of billed 80% of billed N/A90969 $28.69 $28.69 N/A 91299 26 80% of billed 80% of billed N/A90970 $14.68 $14.68 N/A 92002 $151.48 $90.09 N/A90989 80% of billed 80% of billed N/A 92004 $277.60 $186.84 N/A90993 80% of billed 80% of billed N/A 92012 $160.15 $99.43 N/A90997 $176.17 $176.17 000 92014 $232.22 $150.81 N/A90999 80% of billed 80% of billed N/A 92015 $37.37 $36.70 N/A91010 $331.65 $331.65 000 92018 $274.93 $274.93 N/A91010 TC $204.19 $204.19 000 92019 $135.46 $135.46 N/A91010 26 $127.45 $127.45 000 92020 $50.05 $39.37 N/A91013 $44.04 $44.04 ZZZ 92025 $71.40 $71.40 N/A91013 TC $26.02 $26.02 ZZZ 92025 TC $33.37 $33.37 N/A91013 26 $18.02 $18.02 ZZZ 92025 26 $38.04 $38.04 N/A91020 $441.09 $441.09 000 92060 $122.12 $122.12 N/A91020 TC $298.28 $298.28 000 92060 TC $50.05 $50.05 N/A91020 26 $142.80 $142.80 000 92060 26 $72.07 $72.07 N/A91022 $315.63 $315.63 000 92065 $97.43 $97.43 N/A91022 TC $172.83 $172.83 000 92065 TC $64.06 $64.06 N/A91022 26 $142.80 $142.80 000 92065 26 $33.37 $33.37 N/A91030 $256.24 $256.24 000 92071 $70.73 $63.39 N/A91030 TC $166.83 $166.83 000 92072 $251.57 $193.52 N/A91030 26 $89.42 $89.42 000 92081 $63.39 $63.39 N/A91034 $357.01 $357.01 000 92081 TC $32.70 $32.70 N/A91034 TC $259.58 $259.58 000 92081 26 $30.70 $30.70 N/A91034 26 $97.43 $97.43 000 92082 $89.42 $89.42 N/A91035 $905.53 $905.53 000 92082 TC $48.71 $48.71 N/A91035 TC $746.04 $746.04 000 92082 26 $40.71 $40.71 N/A91035 26 $159.48 $159.48 000 92083 $120.78 $120.78 N/A91037 $301.62 $301.62 000 92083 TC $68.06 $68.06 N/A91037 TC $205.53 $205.53 000 92083 26 $52.72 $52.72 N/A91037 26 $96.09 $96.09 000 92100 $150.14 $64.06 N/A91038 $847.47 $847.47 000 92132 $65.40 $65.40 N/A91038 TC $738.03 $738.03 000 92132 TC $29.36 $29.36 N/A91038 26 $109.44 $109.44 000 92132 26 $36.03 $36.03 N/A91040 $817.44 $817.44 000 92133 $82.75 $82.75 N/A91040 TC $722.69 $722.69 000 92133 TC $30.03 $30.03 N/A91040 26 $94.76 $94.76 000 92133 26 $52.72 $52.72 N/A91065 $147.47 $147.47 000 92134 $84.75 $84.75 N/A91065 TC $128.12 $128.12 000 92134 TC $30.70 $30.70 N/A91065 26 $19.35 $19.35 000 92134 26 $54.05 $54.05 N/A91110 $1,662.91 $1,662.91 N/A 92136 $170.16 $170.16 N/A91110 TC $1,301.90 $1,301.90 N/A 92136 TC $110.77 $110.77 N/A91110 26 $361.01 $361.01 N/A 92136 26 $59.39 $59.39 N/A91111 $1,364.63 $1,364.63 N/A 92140 $118.78 $50.71 N/A91111 TC $1,265.20 $1,265.20 N/A 92145 $29.36 $29.36 N/A91111 26 $99.43 $99.43 N/A 92145 TC $12.68 $12.68 N/A91112 $2,035.93 $2,035.93 N/A 92145 26 $16.68 $16.68 N/A91112 TC $1,827.73 $1,827.73 N/A 92225 $50.71 $40.04 N/A91112 26 $208.20 $208.20 N/A 92226 $46.71 $36.03 N/A91117 $262.92 $262.92 000 92227 $27.36 $27.36 N/A91120 $801.43 $801.43 N/A 92228 $64.73 $64.73 N/A91120 TC $706.00 $706.00 N/A 92228 TC $25.36 $25.36 N/A91120 26 $95.42 $95.42 N/A 92228 26 $39.37 $39.37 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 73 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

92230 $109.44 $63.39 N/A 92512 $115.44 $54.72 N/A92235 $206.86 $206.86 N/A 92516 $133.46 $44.04 N/A92235 TC $118.11 $118.11 N/A 92520 $142.80 $79.41 N/A92235 26 $88.75 $88.75 N/A 92521 $208.86 $208.86 N/A92240 $481.12 $481.12 N/A 92522 $174.17 $174.17 N/A92240 TC $360.34 $360.34 N/A 92523 $365.01 $365.01 N/A92240 26 $120.78 $120.78 N/A 92524 $168.16 $168.16 N/A92242 $427.07 $427.07 N/A 92526 $161.49 $161.49 N/A92242 TC $322.31 $322.31 N/A 92531 80% of billed 80% of billed N/A92242 26 $104.77 $104.77 N/A 92532 80% of billed 80% of billed N/A92250 $146.81 $146.81 N/A 92533 80% of billed 80% of billed N/A92250 TC $102.10 $102.10 N/A 92534 80% of billed 80% of billed N/A92250 26 $44.71 $44.71 N/A 92537 $76.07 $76.07 N/A92260 $34.70 $20.69 N/A 92537 TC $16.02 $16.02 N/A92265 $147.47 $147.47 N/A 92537 26 $60.06 $60.06 N/A92265 TC $66.73 $66.73 N/A 92538 $38.70 $38.70 N/A92265 26 $80.74 $80.74 N/A 92538 TC $8.67 $8.67 N/A92270 $172.16 $172.16 N/A 92538 26 $30.03 $30.03 N/A92270 TC $94.09 $94.09 N/A 92540 $191.52 $191.52 N/A92270 26 $78.07 $78.07 N/A 92540 TC $41.37 $41.37 N/A92275 $276.26 $276.26 N/A 92540 26 $150.14 $150.14 N/A92275 TC $174.83 $174.83 N/A 92541 $45.38 $45.38 N/A92275 26 $101.43 $101.43 N/A 92541 TC $6.01 $6.01 N/A92283 $103.43 $103.43 N/A 92541 26 $39.37 $39.37 N/A92283 TC $86.08 $86.08 N/A 92542 $52.72 $52.72 N/A92283 26 $17.35 $17.35 N/A 92542 TC $5.34 $5.34 N/A92284 $113.44 $113.44 N/A 92542 26 $47.38 $47.38 N/A92284 TC $90.09 $90.09 N/A 92544 $31.36 $31.36 N/A92284 26 $23.36 $23.36 N/A 92544 TC $4.67 $4.67 N/A92285 $38.70 $38.70 N/A 92544 26 $26.69 $26.69 N/A92285 TC $32.70 $32.70 N/A 92545 $28.69 $28.69 N/A92285 26 $6.01 $6.01 N/A 92545 TC $4.00 $4.00 N/A92286 $71.40 $71.40 N/A 92545 26 $24.69 $24.69 N/A92286 TC $30.03 $30.03 N/A 92546 $193.52 $193.52 N/A92286 26 $41.37 $41.37 N/A 92546 TC $165.49 $165.49 N/A92287 $260.25 $260.25 N/A 92546 26 $28.03 $28.03 N/A92287 TC $171.50 $171.50 N/A 92547 $11.34 $11.34 ZZZ92287 26 $88.75 $88.75 N/A 92548 $192.18 $192.18 N/A92310 $180.84 $112.77 N/A 92548 TC $142.80 $142.80 N/A92311 $188.18 $104.10 N/A 92548 26 $49.38 $49.38 N/A92312 $215.54 $118.78 N/A 92550 $40.04 $40.04 N/A92313 $179.50 $88.75 N/A 92551 $22.69 $22.69 N/A92314 $150.14 $66.06 N/A 92552 $58.72 $58.72 N/A92315 $133.46 $40.71 N/A 92553 $70.07 $70.07 N/A92316 $167.49 $61.39 N/A 92555 $43.37 $43.37 N/A92317 $140.80 $41.37 N/A 92556 $70.07 $70.07 N/A92325 $78.07 $78.07 N/A 92557 $70.73 $61.39 N/A92326 $66.06 $66.06 N/A 92558 80% of billed 80% of billed N/A92340 $66.73 $35.37 N/A 92559 80% of billed 80% of billed N/A92341 $76.74 $45.38 N/A 92560 80% of billed 80% of billed N/A92342 $82.08 $50.71 N/A 92561 $71.40 $71.40 N/A92352 $76.07 $35.37 N/A 92562 $87.42 $87.42 N/A92353 $88.75 $48.05 N/A 92563 $58.06 $58.06 N/A92354 $25.36 $25.36 N/A 92564 $52.72 $52.72 N/A92355 $39.37 $39.37 N/A 92565 $30.03 $30.03 N/A92358 $21.35 $21.35 N/A 92567 $27.36 $20.69 N/A92370 $58.06 $30.70 N/A 92568 $30.03 $29.36 N/A92371 $22.02 $22.02 N/A 92570 $60.72 $56.72 N/A92499 80% of billed 80% of billed N/A 92571 $50.71 $50.71 N/A92499 TC 80% of billed 80% of billed N/A 92572 $67.40 $67.40 N/A92499 26 80% of billed 80% of billed N/A 92575 $136.13 $136.13 N/A92502 $184.84 $184.84 000 92576 $67.40 $67.40 N/A92504 $56.72 $18.02 N/A 92577 $31.36 $31.36 N/A92507 $148.81 $148.81 N/A 92579 $79.41 $71.40 N/A92508 $43.37 $43.37 N/A 92582 $127.45 $127.45 N/A92511 $212.20 $74.74 000 92583 $98.09 $98.09 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 74 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

92584 $138.13 $138.13 N/A 92974 $314.30 $314.30 ZZZ92585 $254.91 $254.91 N/A 92975 $757.39 $757.39 00092585 TC $204.19 $204.19 N/A 92977 $116.78 $116.78 N/A92585 26 $50.71 $50.71 N/A 92978 80% of billed 80% of billed ZZZ92586 $160.15 $160.15 N/A 92978 TC 80% of billed 80% of billed ZZZ92587 $40.71 $40.71 N/A 92978 26 $184.84 $184.84 ZZZ92587 TC $6.01 $6.01 N/A 92979 80% of billed 80% of billed ZZZ92587 26 $34.70 $34.70 N/A 92979 TC 80% of billed 80% of billed ZZZ92588 $62.06 $62.06 N/A 92979 26 $148.14 $148.14 ZZZ92588 TC $7.34 $7.34 N/A 92986 $2,583.79 $2,583.79 09092588 26 $54.72 $54.72 N/A 92987 $2,663.86 $2,663.86 09092590 80% of billed 80% of billed N/A 92990 $2,102.66 $2,102.66 09092591 80% of billed 80% of billed N/A 92992 80% of billed 80% of billed 09092592 80% of billed 80% of billed N/A 92993 80% of billed 80% of billed 09092593 80% of billed 80% of billed N/A 92997 $1,271.87 $1,271.87 00092594 80% of billed 80% of billed N/A 92998 $626.59 $626.59 ZZZ92595 80% of billed 80% of billed N/A 93000 $32.03 $32.03 N/A92596 $79.41 $79.41 N/A 93005 $16.02 $16.02 N/A92597 $136.13 $136.13 N/A 93010 $16.02 $16.02 N/A92601 $266.92 $226.88 N/A 93015 $142.13 $142.13 N/A92602 $168.83 $131.46 N/A 93016 $41.37 $41.37 N/A92603 $285.60 $231.55 N/A 93017 $73.40 $73.40 N/A92604 $168.16 $128.12 N/A 93018 $27.36 $27.36 N/A92605 $176.17 $168.16 N/A 93024 $210.20 $210.20 N/A92606 $156.82 $134.79 N/A 93024 TC $102.76 $102.76 N/A92607 $237.56 $237.56 N/A 93024 26 $107.44 $107.44 N/A92608 $99.43 $99.43 ZZZ 93025 $299.62 $299.62 N/A92609 $208.20 $208.20 N/A 93025 TC $230.22 $230.22 N/A92610 $160.82 $137.46 N/A 93025 26 $69.40 $69.40 N/A92611 $164.16 $164.16 N/A 93040 $24.02 $24.02 N/A92612 $351.67 $129.46 N/A 93041 $10.68 $10.68 N/A92613 $72.74 $72.74 N/A 93042 $13.35 $13.35 N/A92614 $275.59 $128.79 N/A 93050 $33.37 $33.37 N/A92615 $64.06 $63.39 N/A 93050 TC $16.68 $16.68 N/A92616 $393.71 $192.18 N/A 93050 26 $16.68 $16.68 N/A92617 $79.41 $79.41 N/A 93224 $171.50 $171.50 N/A92618 $64.06 $62.73 ZZZ 93225 $50.05 $50.05 N/A92620 $177.50 $156.15 N/A 93226 $71.40 $71.40 N/A92621 $42.04 $36.03 ZZZ 93227 $50.05 $50.05 N/A92625 $132.13 $118.11 N/A 93228 $49.38 $49.38 N/A92626 $168.83 $144.14 N/A 93229 $1,364.63 $1,364.63 N/A92627 $41.37 $34.03 ZZZ 93260 $126.12 $126.12 N/A92630 80% of billed 80% of billed N/A 93260 TC $41.37 $41.37 N/A92633 80% of billed 80% of billed N/A 93260 26 $84.75 $84.75 N/A92640 $213.54 $180.84 N/A 93261 $114.11 $114.11 N/A92700 80% of billed 80% of billed N/A 93261 TC $41.37 $41.37 N/A92920 $1,059.01 $1,059.01 000 93261 26 $72.74 $72.74 N/A92921 80% of billed 80% of billed ZZZ 93268 $385.03 $385.03 N/A92924 $1,257.19 $1,257.19 000 93270 $17.35 $17.35 N/A92925 80% of billed 80% of billed ZZZ 93271 $319.64 $319.64 N/A92928 $1,175.78 $1,175.78 000 93272 $48.05 $48.05 N/A92929 80% of billed 80% of billed ZZZ 93278 $56.72 $56.72 N/A92933 $1,315.25 $1,315.25 000 93278 TC $33.37 $33.37 N/A92934 80% of billed 80% of billed ZZZ 93278 26 $23.36 $23.36 N/A92937 $1,174.45 $1,174.45 000 93279 $93.42 $93.42 N/A92938 80% of billed 80% of billed ZZZ 93279 TC $32.70 $32.70 N/A92941 $1,317.92 $1,317.92 000 93279 26 $60.72 $60.72 N/A92943 $1,317.25 $1,317.25 000 93280 $108.77 $108.77 N/A92944 80% of billed 80% of billed ZZZ 93280 TC $36.70 $36.70 N/A92950 $573.88 $355.67 000 93280 26 $72.07 $72.07 N/A92953 $21.35 $21.35 000 93281 $128.12 $128.12 N/A92960 $387.70 $231.55 000 93281 TC $43.37 $43.37 N/A92961 $504.48 $504.48 000 93281 26 $84.75 $84.75 N/A92970 $360.34 $360.34 000 93282 $118.11 $118.11 N/A92971 $194.85 $194.85 000 93282 TC $38.04 $38.04 N/A92973 $343.66 $343.66 ZZZ 93282 26 $80.08 $80.08 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 75 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

93283 $153.48 $153.48 N/A 93317 TC 80% of billed 80% of billed N/A93283 TC $44.71 $44.71 N/A 93317 26 $200.86 $200.86 N/A93283 26 $108.77 $108.77 N/A 93318 80% of billed 80% of billed N/A93284 $169.49 $169.49 N/A 93318 TC 80% of billed 80% of billed N/A93284 TC $50.71 $50.71 N/A 93318 26 $221.54 $221.54 N/A93284 26 $118.78 $118.78 N/A 93320 $102.10 $102.10 ZZZ93285 $79.41 $79.41 N/A 93320 TC $67.40 $67.40 ZZZ93285 TC $30.03 $30.03 N/A 93320 26 $34.70 $34.70 ZZZ93285 26 $49.38 $49.38 N/A 93321 $51.38 $51.38 ZZZ93286 $51.38 $51.38 N/A 93321 TC $37.37 $37.37 ZZZ93286 TC $22.69 $22.69 N/A 93321 26 $14.01 $14.01 ZZZ93286 26 $28.69 $28.69 N/A 93325 $48.05 $48.05 ZZZ93287 $68.06 $68.06 N/A 93325 TC $42.04 $42.04 ZZZ93287 TC $24.69 $24.69 N/A 93325 26 $6.01 $6.01 ZZZ93287 26 $43.37 $43.37 N/A 93350 $452.43 $452.43 N/A93288 $69.40 $69.40 N/A 93350 TC $318.30 $318.30 N/A93288 TC $29.36 $29.36 N/A 93350 26 $134.13 $134.13 N/A93288 26 $40.04 $40.04 N/A 93351 $509.15 $509.15 N/A93289 $122.78 $122.78 N/A 93351 TC $348.33 $348.33 N/A93289 TC $36.70 $36.70 N/A 93351 26 $160.82 $160.82 N/A93289 26 $86.08 $86.08 N/A 93352 $64.06 $64.06 ZZZ93290 $58.72 $58.72 N/A 93355 $429.74 $429.74 N/A93290 TC $18.02 $18.02 N/A 93451 $1,478.07 $1,478.07 00093290 26 $40.71 $40.71 N/A 93451 TC $1,200.47 $1,200.47 00093291 $68.06 $68.06 N/A 93451 26 $277.60 $277.60 00093291 TC $27.36 $27.36 N/A 93452 $1,669.58 $1,669.58 00093291 26 $40.71 $40.71 N/A 93452 TC $1,182.46 $1,182.46 00093292 $60.72 $60.72 N/A 93452 26 $487.13 $487.13 00093292 TC $20.69 $20.69 N/A 93453 $2,150.04 $2,150.04 00093292 26 $40.04 $40.04 N/A 93453 TC $1,506.76 $1,506.76 00093293 $100.10 $100.10 N/A 93453 26 $643.28 $643.28 00093293 TC $70.73 $70.73 N/A 93454 $1,692.27 $1,692.27 00093293 26 $29.36 $29.36 N/A 93454 TC $1,198.47 $1,198.47 00093294 $64.06 $64.06 N/A 93454 26 $493.80 $493.80 00093295 $126.79 $126.79 N/A 93455 $1,971.20 $1,971.20 00093296 $48.71 $48.71 N/A 93455 TC $1,400.66 $1,400.66 00093297 $50.05 $50.05 N/A 93455 26 $570.54 $570.54 00093298 $50.05 $50.05 N/A 93456 $2,120.68 $2,120.68 00093299 80% of billed 80% of billed N/A 93456 TC $1,487.41 $1,487.41 00093303 $448.43 $448.43 N/A 93456 26 $633.27 $633.27 00093303 TC $327.64 $327.64 N/A 93457 $2,398.28 $2,398.28 00093303 26 $120.78 $120.78 N/A 93457 TC $1,688.27 $1,688.27 00093304 $292.94 $292.94 N/A 93457 26 $710.01 $710.01 00093304 TC $223.55 $223.55 N/A 93458 $2,031.26 $2,031.26 00093304 26 $69.40 $69.40 N/A 93458 TC $1,428.02 $1,428.02 00093306 $428.41 $428.41 N/A 93458 26 $603.24 $603.24 00093306 TC $308.29 $308.29 N/A 93459 $2,244.13 $2,244.13 00093306 26 $120.11 $120.11 N/A 93459 TC $1,564.15 $1,564.15 00093307 $244.90 $244.90 N/A 93459 26 $679.98 $679.98 00093307 TC $159.48 $159.48 N/A 93460 $2,406.95 $2,406.95 00093307 26 $85.41 $85.41 N/A 93460 TC $1,650.23 $1,650.23 00093308 $234.22 $234.22 N/A 93460 26 $756.72 $756.72 00093308 TC $185.51 $185.51 N/A 93461 $2,752.61 $2,752.61 00093308 26 $48.71 $48.71 N/A 93461 TC $1,918.49 $1,918.49 00093312 $578.55 $578.55 N/A 93461 26 $834.13 $834.13 00093312 TC $348.33 $348.33 N/A 93462 $405.05 $405.05 ZZZ93312 26 $230.22 $230.22 N/A 93463 $187.51 $187.51 ZZZ93313 $43.37 $43.37 N/A 93464 $516.49 $516.49 ZZZ93314 $565.20 $565.20 N/A 93464 TC $351.00 $351.00 ZZZ93314 TC $368.35 $368.35 N/A 93464 26 $165.49 $165.49 ZZZ93314 26 $196.85 $196.85 N/A 93503 $250.90 $250.90 00093315 80% of billed 80% of billed N/A 93505 $1,442.70 $1,442.70 00093315 TC 80% of billed 80% of billed N/A 93505 TC $992.94 $992.94 00093315 26 $268.92 $268.92 N/A 93505 26 $449.76 $449.76 00093316 $73.40 $73.40 N/A 93530 80% of billed 80% of billed 00093317 80% of billed 80% of billed N/A 93530 TC 80% of billed 80% of billed 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 76 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

93530 26 $425.07 $425.07 000 93620 80% of billed 80% of billed 00093531 80% of billed 80% of billed 000 93620 TC 80% of billed 80% of billed 00093531 TC 80% of billed 80% of billed 000 93620 26 $1,237.17 $1,237.17 00093531 26 $830.12 $830.12 000 93621 80% of billed 80% of billed ZZZ93532 80% of billed 80% of billed 000 93621 TC 80% of billed 80% of billed ZZZ93532 TC 80% of billed 80% of billed 000 93621 26 $225.55 $225.55 ZZZ93532 26 $1,030.31 $1,030.31 000 93622 80% of billed 80% of billed ZZZ93533 80% of billed 80% of billed 000 93622 TC 80% of billed 80% of billed ZZZ93533 TC 80% of billed 80% of billed 000 93622 26 $329.65 $329.65 ZZZ93533 26 $687.99 $687.99 000 93623 80% of billed 80% of billed ZZZ93561 80% of billed 80% of billed 000 93623 TC 80% of billed 80% of billed ZZZ93561 TC 80% of billed 80% of billed 000 93623 26 $306.29 $306.29 ZZZ93561 26 $48.71 $48.71 000 93624 80% of billed 80% of billed 00093562 80% of billed 80% of billed 000 93624 TC 80% of billed 80% of billed 00093562 TC 80% of billed 80% of billed 000 93624 26 $507.15 $507.15 00093562 26 $15.35 $15.35 000 93631 80% of billed 80% of billed 00093563 $112.77 $112.77 ZZZ 93631 TC 80% of billed 80% of billed 00093564 $118.78 $118.78 ZZZ 93631 26 $772.07 $772.07 00093565 $88.75 $88.75 ZZZ 93640 80% of billed 80% of billed 00093566 $322.97 $89.42 ZZZ 93640 TC 80% of billed 80% of billed 00093567 $266.92 $101.43 ZZZ 93640 26 $371.02 $371.02 00093568 $290.28 $91.42 ZZZ 93641 80% of billed 80% of billed 00093571 80% of billed 80% of billed ZZZ 93641 TC 80% of billed 80% of billed 00093571 TC 80% of billed 80% of billed ZZZ 93641 26 $630.60 $630.60 00093571 26 $184.84 $184.84 ZZZ 93642 $810.10 $810.10 00093572 80% of billed 80% of billed ZZZ 93642 TC $286.27 $286.27 00093572 TC 80% of billed 80% of billed ZZZ 93642 26 $523.83 $523.83 00093572 26 $148.14 $148.14 ZZZ 93644 $525.83 $525.83 00093580 $1,895.80 $1,895.80 000 93644 TC $198.19 $198.19 00093581 $2,585.79 $2,585.79 000 93644 26 $327.64 $327.64 00093582 $1,295.23 $1,295.23 000 93650 $1,168.44 $1,168.44 00093583 $1,464.06 $1,464.06 000 93653 $1,644.23 $1,644.23 00093590 $2,315.53 $2,315.53 000 93654 $2,189.41 $2,189.41 00093591 $1,921.82 $1,921.82 000 93655 $822.11 $822.11 ZZZ93592 $846.80 $846.80 ZZZ 93656 $2,190.75 $2,190.75 00093600 80% of billed 80% of billed 000 93657 $821.45 $821.45 ZZZ93600 TC 80% of billed 80% of billed 000 93660 $297.62 $297.62 00093600 26 $228.22 $228.22 000 93660 TC $119.45 $119.45 00093602 80% of billed 80% of billed 000 93660 26 $178.17 $178.17 00093602 TC 80% of billed 80% of billed 000 93662 80% of billed 80% of billed ZZZ93602 26 $223.55 $223.55 000 93662 TC 80% of billed 80% of billed ZZZ93603 80% of billed 80% of billed 000 93662 26 $270.26 $270.26 ZZZ93603 TC 80% of billed 80% of billed 000 93668 $36.03 $36.03 N/A93603 26 $223.55 $223.55 000 93701 $45.38 $45.38 N/A93609 80% of billed 80% of billed ZZZ 93702 $203.53 $203.53 N/A93609 TC 80% of billed 80% of billed ZZZ 93724 $510.48 $510.48 00093609 26 $535.17 $535.17 ZZZ 93724 TC $52.72 $52.72 00093610 80% of billed 80% of billed 000 93724 26 $457.77 $457.77 00093610 TC 80% of billed 80% of billed 000 93740 $15.35 $15.35 N/A93610 26 $316.97 $316.97 000 93745 80% of billed 80% of billed N/A93612 80% of billed 80% of billed 000 93745 TC 80% of billed 80% of billed N/A93612 TC 80% of billed 80% of billed 000 93745 26 80% of billed 80% of billed N/A93612 26 $314.97 $314.97 000 93750 $105.43 $88.08 N/A93613 $770.73 $770.73 ZZZ 93770 $15.35 $15.35 N/A93615 80% of billed 80% of billed 000 93784 $101.43 $101.43 N/A93615 TC 80% of billed 80% of billed 000 93786 $56.05 $56.05 N/A93615 26 $99.43 $99.43 000 93788 $10.01 $10.01 N/A93616 80% of billed 80% of billed 000 93790 $35.37 $35.37 N/A93616 TC 80% of billed 80% of billed 000 93797 $30.70 $16.68 00093616 26 $124.12 $124.12 000 93798 $47.38 $26.69 00093618 80% of billed 80% of billed 000 93799 80% of billed 80% of billed N/A93618 TC 80% of billed 80% of billed 000 93799 TC 80% of billed 80% of billed N/A93618 26 $456.43 $456.43 000 93799 26 80% of billed 80% of billed N/A93619 80% of billed 80% of billed 000 93880 $383.03 $383.03 N/A93619 TC 80% of billed 80% of billed 000 93880 TC $306.96 $306.96 N/A93619 26 $779.41 $779.41 000 93880 26 $76.07 $76.07 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 77 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

93882 $244.90 $244.90 N/A 93981 $138.80 $138.80 N/A93882 TC $196.85 $196.85 N/A 93981 TC $96.76 $96.76 N/A93882 26 $48.05 $48.05 N/A 93981 26 $42.04 $42.04 N/A93886 $532.51 $532.51 N/A 93982 $81.41 $81.41 N/A93886 TC $442.42 $442.42 N/A 93990 $306.29 $306.29 N/A93886 26 $90.09 $90.09 N/A 93990 TC $258.91 $258.91 N/A93888 $278.26 $278.26 N/A 93990 26 $47.38 $47.38 N/A93888 TC $229.55 $229.55 N/A 93998 80% of billed 80% of billed N/A93888 26 $48.71 $48.71 N/A 94002 $177.50 $177.50 N/A93890 $545.85 $545.85 N/A 94003 $126.79 $126.79 N/A93890 TC $447.76 $447.76 N/A 94004 $92.75 $92.75 N/A93890 26 $98.09 $98.09 N/A 94005 $175.50 $175.50 N/A93892 $631.27 $631.27 N/A 94010 $67.40 $67.40 N/A93892 TC $515.16 $515.16 N/A 94010 TC $51.38 $51.38 N/A93892 26 $116.11 $116.11 N/A 94010 26 $16.02 $16.02 N/A93893 $655.29 $655.29 N/A 94011 $194.18 $194.18 N/A93893 TC $541.85 $541.85 N/A 94012 $296.95 $296.95 N/A93893 26 $113.44 $113.44 N/A 94013 $65.40 $65.40 N/A93895 80% of billed 80% of billed N/A 94014 $106.10 $106.10 N/A93895 TC 80% of billed 80% of billed N/A 94015 $58.06 $58.06 N/A93895 26 80% of billed 80% of billed N/A 94016 $48.05 $48.05 N/A93922 $168.16 $168.16 N/A 94060 $114.78 $114.78 N/A93922 TC $144.14 $144.14 N/A 94060 TC $90.09 $90.09 N/A93922 26 $24.02 $24.02 N/A 94060 26 $24.69 $24.69 N/A93923 $261.58 $261.58 N/A 94070 $112.77 $112.77 N/A93923 TC $218.87 $218.87 N/A 94070 TC $58.06 $58.06 N/A93923 26 $42.71 $42.71 N/A 94070 26 $54.72 $54.72 N/A93924 $328.31 $328.31 N/A 94150 $48.05 $48.05 N/A93924 TC $280.93 $280.93 N/A 94150 TC $40.71 $40.71 N/A93924 26 $47.38 $47.38 N/A 94150 26 $7.34 $7.34 N/A93925 $492.47 $492.47 N/A 94200 $47.38 $47.38 N/A93925 TC $417.73 $417.73 N/A 94200 TC $36.70 $36.70 N/A93925 26 $74.74 $74.74 N/A 94200 26 $10.68 $10.68 N/A93926 $289.61 $289.61 N/A 94250 $49.38 $49.38 N/A93926 TC $243.56 $243.56 N/A 94250 TC $39.37 $39.37 N/A93926 26 $46.04 $46.04 N/A 94250 26 $10.01 $10.01 N/A93930 $396.38 $396.38 N/A 94375 $74.07 $74.07 N/A93930 TC $320.30 $320.30 N/A 94375 TC $46.04 $46.04 N/A93930 26 $76.07 $76.07 N/A 94375 26 $28.03 $28.03 N/A93931 $242.90 $242.90 N/A 94400 $105.43 $105.43 N/A93931 TC $196.19 $196.19 N/A 94400 TC $68.06 $68.06 N/A93931 26 $46.71 $46.71 N/A 94400 26 $37.37 $37.37 N/A93965 $225.55 $225.55 N/A 94450 $128.79 $128.79 N/A93965 TC $192.85 $192.85 N/A 94450 TC $90.75 $90.75 N/A93965 26 $32.70 $32.70 N/A 94450 26 $38.04 $38.04 N/A93970 $373.02 $373.02 N/A 94452 $108.77 $108.77 N/A93970 TC $306.96 $306.96 N/A 94452 TC $81.41 $81.41 N/A93970 26 $66.06 $66.06 N/A 94452 26 $27.36 $27.36 N/A93971 $227.55 $227.55 N/A 94453 $150.81 $150.81 N/A93971 TC $184.84 $184.84 N/A 94453 TC $114.78 $114.78 N/A93971 26 $42.71 $42.71 N/A 94453 26 $36.03 $36.03 N/A93975 $535.17 $535.17 N/A 94610 $112.77 $112.77 N/A93975 TC $425.07 $425.07 N/A 94620 $105.43 $105.43 N/A93975 26 $110.10 $110.10 N/A 94620 TC $47.38 $47.38 N/A93976 $308.29 $308.29 N/A 94620 26 $58.06 $58.06 N/A93976 TC $232.89 $232.89 N/A 94621 $306.96 $306.96 N/A93976 26 $75.40 $75.40 N/A 94621 TC $176.83 $176.83 N/A93978 $362.34 $362.34 N/A 94621 26 $130.12 $130.12 N/A93978 TC $286.94 $286.94 N/A 94640 $34.70 $34.70 N/A93978 26 $75.40 $75.40 N/A 94642 80% of billed 80% of billed N/A93979 $226.88 $226.88 N/A 94644 $82.75 $82.75 N/A93979 TC $179.50 $179.50 N/A 94645 $26.69 $26.69 N/A93979 26 $47.38 $47.38 N/A 94660 $119.45 $72.07 N/A93980 $228.22 $228.22 N/A 94662 $70.73 $70.73 N/A93980 TC $112.11 $112.11 N/A 94664 $32.70 $32.70 N/A93980 26 $116.11 $116.11 N/A 94667 $48.71 $48.71 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 78 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

94668 $54.05 $54.05 N/A 95134 80% of billed 80% of billed N/A94669 $62.06 $62.06 N/A 95144 $23.36 $6.01 N/A94680 $108.10 $108.10 N/A 95145 $40.71 $6.01 N/A94680 TC $84.08 $84.08 N/A 95146 $73.40 $6.01 N/A94680 26 $24.02 $24.02 N/A 95147 $66.06 $6.01 N/A94681 $99.43 $99.43 N/A 95148 $98.09 $6.01 N/A94681 TC $80.74 $80.74 N/A 95149 $132.13 $6.01 N/A94681 26 $18.68 $18.68 N/A 95165 $24.02 $6.01 N/A94690 $94.09 $94.09 N/A 95170 $18.02 $6.01 N/A94690 TC $86.75 $86.75 N/A 95180 $252.24 $191.52 N/A94690 26 $7.34 $7.34 N/A 95199 80% of billed 80% of billed N/A94726 $99.43 $99.43 N/A 95250 $296.95 $296.95 N/A94726 TC $76.07 $76.07 N/A 95251 $82.08 $82.08 N/A94726 26 $23.36 $23.36 N/A 95782 $1,933.84 $1,933.84 N/A94727 $79.41 $79.41 N/A 95782 TC $1,694.27 $1,694.27 N/A94727 TC $56.05 $56.05 N/A 95782 26 $239.56 $239.56 N/A94727 26 $23.36 $23.36 N/A 95783 $2,032.60 $2,032.60 N/A94728 $76.07 $76.07 N/A 95783 TC $1,767.01 $1,767.01 N/A94728 TC $52.05 $52.05 N/A 95783 26 $265.59 $265.59 N/A94728 26 $24.02 $24.02 N/A 95800 $334.98 $334.98 N/A94729 $102.76 $102.76 ZZZ 95800 TC $236.89 $236.89 N/A94729 TC $85.41 $85.41 ZZZ 95800 26 $98.09 $98.09 N/A94729 26 $17.35 $17.35 ZZZ 95801 $170.83 $170.83 N/A94750 $151.48 $151.48 N/A 95801 TC $77.41 $77.41 N/A94750 TC $130.12 $130.12 N/A 95801 26 $93.42 $93.42 N/A94750 26 $21.35 $21.35 N/A 95803 $266.25 $266.25 N/A94760 $6.01 $6.01 N/A 95803 TC $183.51 $183.51 N/A94761 $9.34 $9.34 N/A 95803 26 $82.75 $82.75 N/A94762 $46.04 $46.04 N/A 95805 $804.76 $804.76 N/A94770 $14.01 $14.01 N/A 95805 TC $692.66 $692.66 N/A94772 80% of billed 80% of billed N/A 95805 26 $112.11 $112.11 N/A94772 TC 80% of billed 80% of billed N/A 95806 $316.97 $316.97 N/A94772 26 80% of billed 80% of billed N/A 95806 TC $201.52 $201.52 N/A94774 80% of billed 80% of billed N/A 95806 26 $115.44 $115.44 N/A94775 80% of billed 80% of billed N/A 95807 $901.52 $901.52 N/A94776 80% of billed 80% of billed N/A 95807 TC $783.41 $783.41 N/A94777 80% of billed 80% of billed N/A 95807 26 $118.11 $118.11 N/A94780 $106.10 $43.37 N/A 95808 $1,187.13 $1,187.13 N/A94781 $43.37 $16.68 ZZZ 95808 TC $1,020.97 $1,020.97 N/A94799 80% of billed 80% of billed N/A 95808 26 $166.16 $166.16 N/A94799 TC 80% of billed 80% of billed N/A 95810 $1,174.45 $1,174.45 N/A94799 26 80% of billed 80% of billed N/A 95810 TC $943.56 $943.56 N/A95004 $12.68 $12.68 N/A 95810 26 $230.89 $230.89 N/A95012 $36.03 $36.03 N/A 95811 $1,233.84 $1,233.84 N/A95017 $14.68 $6.67 N/A 95811 TC $993.61 $993.61 N/A95018 $38.70 $13.35 N/A 95811 26 $240.23 $240.23 N/A95024 $14.68 $2.00 N/A 95812 $657.29 $657.29 N/A95027 $8.67 $8.67 N/A 95812 TC $547.85 $547.85 N/A95028 $25.36 $25.36 N/A 95812 26 $109.44 $109.44 N/A95044 $10.68 $10.68 N/A 95813 $794.09 $794.09 N/A95052 $12.68 $12.68 N/A 95813 TC $619.92 $619.92 N/A95056 $84.08 $84.08 N/A 95813 26 $174.17 $174.17 N/A95060 $66.06 $66.06 N/A 95816 $680.65 $680.65 N/A95065 $48.05 $48.05 N/A 95816 TC $571.21 $571.21 N/A95070 $57.39 $57.39 N/A 95816 26 $109.44 $109.44 N/A95071 $66.06 $66.06 N/A 95819 $778.74 $778.74 N/A95076 $219.54 $138.13 N/A 95819 TC $669.30 $669.30 N/A95079 $156.15 $126.79 ZZZ 95819 26 $109.44 $109.44 N/A95115 $16.68 $16.68 N/A 95822 $701.33 $701.33 N/A95117 $19.35 $19.35 N/A 95822 TC $591.90 $591.90 N/A95120 80% of billed 80% of billed N/A 95822 26 $109.44 $109.44 N/A95125 80% of billed 80% of billed N/A 95824 80% of billed 80% of billed N/A95130 80% of billed 80% of billed N/A 95824 TC 80% of billed 80% of billed N/A95131 80% of billed 80% of billed N/A 95824 26 $74.74 $74.74 N/A95132 80% of billed 80% of billed N/A 95827 $1,311.24 $1,311.24 N/A95133 80% of billed 80% of billed N/A 95827 TC $1,203.14 $1,203.14 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 79 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

95827 26 $108.10 $108.10 N/A 95907 $180.17 $180.17 N/A95829 $3,542.70 $3,542.70 N/A 95907 TC $78.74 $78.74 N/A95829 TC $2,904.09 $2,904.09 N/A 95907 26 $101.43 $101.43 N/A95829 26 $638.61 $638.61 N/A 95908 $222.88 $222.88 N/A95830 $462.44 $174.83 N/A 95908 TC $96.76 $96.76 N/A95831 $57.39 $28.69 N/A 95908 26 $126.12 $126.12 N/A95832 $56.05 $30.03 N/A 95909 $272.26 $272.26 N/A95833 $70.07 $40.71 N/A 95909 TC $120.11 $120.11 N/A95834 $96.09 $59.39 N/A 95909 26 $152.14 $152.14 N/A95851 $34.70 $14.68 N/A 95910 $361.68 $361.68 N/A95852 $30.70 $11.34 N/A 95910 TC $158.15 $158.15 N/A95857 $102.10 $56.05 N/A 95910 26 $203.53 $203.53 N/A95860 $230.22 $230.22 N/A 95911 $437.08 $437.08 N/A95860 TC $132.13 $132.13 N/A 95911 TC $182.84 $182.84 N/A95860 26 $98.09 $98.09 N/A 95911 26 $254.24 $254.24 N/A95861 $322.97 $322.97 N/A 95912 $489.80 $489.80 N/A95861 TC $165.49 $165.49 N/A 95912 TC $188.18 $188.18 N/A95861 26 $157.48 $157.48 N/A 95912 26 $301.62 $301.62 N/A95863 $401.05 $401.05 N/A 95913 $559.86 $559.86 N/A95863 TC $211.53 $211.53 N/A 95913 TC $202.86 $202.86 N/A95863 26 $189.51 $189.51 N/A 95913 26 $357.01 $357.01 N/A95864 $452.43 $452.43 N/A 95921 $162.15 $162.15 N/A95864 TC $247.57 $247.57 N/A 95921 TC $76.07 $76.07 N/A95864 26 $204.86 $204.86 N/A 95921 26 $86.08 $86.08 N/A95865 $272.26 $272.26 N/A 95922 $190.18 $190.18 N/A95865 TC $111.44 $111.44 N/A 95922 TC $98.09 $98.09 N/A95865 26 $160.82 $160.82 N/A 95922 26 $92.09 $92.09 N/A95866 $251.57 $251.57 N/A 95923 $308.96 $308.96 N/A95866 TC $124.12 $124.12 N/A 95923 TC $220.88 $220.88 N/A95866 26 $127.45 $127.45 N/A 95923 26 $88.08 $88.08 N/A95867 $178.17 $178.17 N/A 95924 $280.93 $280.93 N/A95867 TC $98.76 $98.76 N/A 95924 TC $111.44 $111.44 N/A95867 26 $79.41 $79.41 N/A 95924 26 $169.49 $169.49 N/A95868 $250.24 $250.24 N/A 95925 $292.94 $292.94 N/A95868 TC $130.12 $130.12 N/A 95925 TC $239.56 $239.56 N/A95868 26 $120.11 $120.11 N/A 95925 26 $53.38 $53.38 N/A95869 $175.50 $175.50 N/A 95926 $258.91 $258.91 N/A95869 TC $137.46 $137.46 N/A 95926 TC $206.86 $206.86 N/A95869 26 $38.04 $38.04 N/A 95926 26 $52.05 $52.05 N/A95870 $174.83 $174.83 N/A 95927 $267.59 $267.59 N/A95870 TC $137.46 $137.46 N/A 95927 TC $215.54 $215.54 N/A95870 26 $37.37 $37.37 N/A 95927 26 $52.05 $52.05 N/A95872 $370.35 $370.35 N/A 95928 $423.74 $423.74 N/A95872 TC $78.74 $78.74 N/A 95928 TC $271.59 $271.59 N/A95872 26 $291.61 $291.61 N/A 95928 26 $152.14 $152.14 N/A95873 $138.80 $138.80 ZZZ 95929 $426.40 $426.40 N/A95873 TC $100.76 $100.76 ZZZ 95929 TC $273.59 $273.59 N/A95873 26 $38.04 $38.04 ZZZ 95929 26 $152.81 $152.81 N/A95874 $137.46 $137.46 ZZZ 95930 $240.90 $240.90 N/A95874 TC $99.43 $99.43 ZZZ 95930 TC $206.20 $206.20 N/A95874 26 $38.04 $38.04 ZZZ 95930 26 $34.70 $34.70 N/A95875 $235.56 $235.56 N/A 95933 $141.47 $141.47 N/A95875 TC $123.45 $123.45 N/A 95933 TC $82.08 $82.08 N/A95875 26 $112.11 $112.11 N/A 95933 26 $59.39 $59.39 N/A95885 $110.10 $110.10 ZZZ 95937 $153.48 $153.48 N/A95885 TC $74.07 $74.07 ZZZ 95937 TC $88.08 $88.08 N/A95885 26 $36.03 $36.03 ZZZ 95937 26 $65.40 $65.40 N/A95886 $171.50 $171.50 ZZZ 95938 $642.61 $642.61 N/A95886 TC $84.08 $84.08 ZZZ 95938 TC $555.19 $555.19 N/A95886 26 $87.42 $87.42 ZZZ 95938 26 $87.42 $87.42 N/A95887 $152.81 $152.81 ZZZ 95939 $942.23 $942.23 N/A95887 TC $80.74 $80.74 ZZZ 95939 TC $715.35 $715.35 N/A95887 26 $72.07 $72.07 ZZZ 95939 26 $226.88 $226.88 N/A95905 $132.79 $132.79 N/A 95940 $62.06 $62.06 N/A95905 TC $127.45 $127.45 N/A 95941 80% of billed 80% of billed N/A95905 26 $5.34 $5.34 N/A 95943 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 80 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

95943 TC 80% of billed 80% of billed N/A 96103 $52.72 $50.71 N/A95943 26 80% of billed 80% of billed N/A 96105 $202.19 $202.19 N/A95950 $621.92 $621.92 N/A 96110 $16.68 $16.68 N/A95950 TC $470.45 $470.45 N/A 96111 $243.56 $231.55 N/A95950 26 $151.48 $151.48 N/A 96116 $174.83 $164.16 N/A95951 80% of billed 80% of billed N/A 96118 $184.17 $148.14 N/A95951 TC 80% of billed 80% of billed N/A 96119 $150.81 $44.71 N/A95951 26 $605.91 $605.91 N/A 96120 $90.75 $49.38 N/A95953 $793.42 $793.42 N/A 96125 $220.88 $220.88 N/A95953 TC $482.46 $482.46 N/A 96127 $10.01 $10.01 N/A95953 26 $310.96 $310.96 N/A 96150 $40.71 $40.04 N/A95954 $856.15 $856.15 N/A 96151 $38.70 $38.04 N/A95954 TC $618.59 $618.59 N/A 96152 $37.37 $36.70 N/A95954 26 $237.56 $237.56 N/A 96153 $8.67 $8.67 N/A95955 $406.39 $406.39 N/A 96154 $36.70 $36.03 N/A95955 TC $303.62 $303.62 N/A 96155 $42.71 $42.71 N/A95955 26 $102.76 $102.76 N/A 96160 $8.67 $8.67 ZZZ95956 $3,085.60 $3,085.60 N/A 96161 $8.67 $8.67 ZZZ95956 TC $2,722.58 $2,722.58 N/A 96360 $107.44 $107.44 N/A95956 26 $363.01 $363.01 N/A 96361 $28.69 $28.69 ZZZ95957 $592.56 $592.56 N/A 96365 $130.12 $130.12 N/A95957 TC $393.04 $393.04 N/A 96366 $35.37 $35.37 ZZZ95957 26 $199.52 $199.52 N/A 96367 $57.39 $57.39 ZZZ95958 $1,077.69 $1,077.69 N/A 96368 $38.70 $38.70 ZZZ95958 TC $648.62 $648.62 N/A 96369 $361.01 $361.01 N/A95958 26 $429.07 $429.07 N/A 96370 $28.03 $28.03 ZZZ95961 $555.19 $555.19 N/A 96371 $136.13 $136.13 ZZZ95961 TC $246.90 $246.90 N/A 96372 $47.38 $47.38 N/A95961 26 $308.29 $308.29 N/A 96373 $36.03 $36.03 N/A95962 $493.80 $493.80 ZZZ 96374 $106.77 $106.77 N/A95962 TC $164.82 $164.82 ZZZ 96375 $42.04 $42.04 ZZZ95962 26 $328.98 $328.98 ZZZ 96376 80% of billed 80% of billed ZZZ95965 80% of billed 80% of billed N/A 96379 80% of billed 80% of billed N/A95965 TC 80% of billed 80% of billed N/A 96401 $140.13 $140.13 N/A95965 26 $796.09 $796.09 N/A 96402 $60.72 $60.72 N/A95966 80% of billed 80% of billed N/A 96405 $154.81 $57.39 00095966 TC 80% of billed 80% of billed N/A 96406 $219.54 $88.08 00095966 26 $403.72 $403.72 N/A 96409 $207.53 $207.53 N/A95967 80% of billed 80% of billed ZZZ 96411 $116.78 $116.78 ZZZ95967 TC 80% of billed 80% of billed ZZZ 96413 $253.57 $253.57 N/A95967 26 $351.67 $351.67 ZZZ 96415 $53.38 $53.38 ZZZ95970 $128.79 $46.04 N/A 96416 $263.58 $263.58 N/A95971 $94.76 $77.41 N/A 96417 $117.44 $117.44 ZZZ95972 $110.77 $79.41 N/A 96420 $194.18 $194.18 N/A95974 $391.71 $310.96 N/A 96422 $318.30 $318.30 N/A95975 $210.87 $176.17 ZZZ 96423 $147.47 $147.47 ZZZ95978 $470.45 $365.68 N/A 96425 $340.32 $340.32 N/A95979 $204.19 $170.16 ZZZ 96440 $1,606.86 $268.92 00095980 $88.08 $88.08 N/A 96446 $377.69 $54.72 N/A95981 $60.06 $34.03 N/A 96450 $342.32 $153.48 00095982 $99.43 $69.40 N/A 96521 $258.25 $258.25 N/A95990 $173.50 $173.50 N/A 96522 $212.20 $212.20 N/A95991 $230.89 $76.07 N/A 96523 $46.71 $46.71 N/A95992 $81.41 $70.73 N/A 96542 $226.88 $80.08 N/A95999 80% of billed 80% of billed N/A 96549 80% of billed 80% of billed N/A96000 $180.17 $180.17 N/A 96567 $254.91 $254.91 N/A96001 $202.86 $202.86 N/A 96570 $110.10 $110.10 ZZZ96002 $40.71 $40.71 N/A 96571 $51.38 $51.38 ZZZ96003 $34.03 $34.03 N/A 96900 $38.70 $38.70 N/A96004 $221.54 $221.54 N/A 96902 $40.71 $39.37 N/A96020 80% of billed 80% of billed N/A 96904 $118.78 $118.78 N/A96020 TC 80% of billed 80% of billed N/A 96910 $134.79 $134.79 N/A96020 26 $309.63 $309.63 N/A 96912 $172.16 $172.16 N/A96040 $88.75 $88.75 N/A 96913 $246.90 $246.90 N/A96101 $150.14 $148.81 N/A 96920 $292.94 $127.45 00096102 $119.45 $44.04 N/A 96921 $322.97 $143.47 000

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 81 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

96922 $447.76 $232.22 000 97647 $32.22 $32.22 N/A96931 80% of billed 80% of billed N/A 97648 $105.06 $105.06 N/A96932 80% of billed 80% of billed N/A 97649 $52.53 $52.53 N/A96933 80% of billed 80% of billed N/A 97650 $56.73 $56.73 N/A96934 80% of billed 80% of billed N/A 97651 $28.72 $28.72 N/A96935 80% of billed 80% of billed N/A 97652 $37.82 $37.82 N/A96936 80% of billed 80% of billed N/A 97653 $19.61 $19.61 N/A96999 80% of billed 80% of billed N/A 97654 $28.72 $28.72 N/A97001 $125.29 $125.29 N/A 97655 $27.32 $27.32 N/A97002 $70.07 $70.07 N/A 97656 $54.63 $54.63 N/A97003 $141.92 $141.92 N/A 97657 $94.55 $94.55 N/A97004 $87.88 $87.88 N/A 97658 $47.63 $47.63 N/A97005 80% of billed 80% of billed N/A 97659 $120.47 $120.47 N/A97006 80% of billed 80% of billed N/A 97660 $60.23 $60.23 N/A97010 $10.09 $10.09 N/A 97661 $162.49 $162.49 N/A97012 $26.72 $26.72 N/A 97662 $65.84 $65.84 N/A97014 $26.72 $26.72 N/A 97663 $32.92 $32.92 N/A97016 $32.07 $32.07 N/A 97664 $88.98 $88.98 N/A97018 $18.41 $18.41 N/A 97665 $44.13 $44.13 N/A97022 $39.19 $39.19 N/A 97666 $71.44 $71.44 N/A97024 $10.69 $10.69 N/A 97667 $36.42 $36.42 N/A97026 $10.09 $10.09 N/A 97668 $74.94 $74.94 N/A97028 $12.47 $12.47 N/A 97669 $37.82 $37.82 N/A97032 $32.07 $32.07 N/A 97670 $468.65 $468.65 N/A97033 $43.94 $43.94 N/A 97671 $529.50 $529.50 N/A97034 $30.28 $30.28 N/A 97750 $55.22 $55.22 N/A97035 $20.78 $20.78 N/A 97755 $59.97 $59.97 N/A97036 $55.22 $55.22 N/A 97760 $63.54 $63.54 N/A97039 80% of billed 80% of billed N/A 97761 $55.22 $55.22 N/A97110 $54.04 $54.04 N/A 97762 $79.57 $79.57 N/A97112 $56.41 $56.41 N/A 97799 80% of billed 80% of billed N/A97113 $71.85 $71.85 N/A 97802 $65.40 $61.39 N/A97116 $47.50 $47.50 N/A 97803 $56.72 $52.05 N/A97124 $43.94 $43.94 N/A 97804 $29.36 $28.69 N/A97139 80% of billed 80% of billed N/A 97810 $68.73 $58.06 N/A97140 $49.88 $49.88 N/A 97811 $51.38 $48.05 ZZZ97150 $29.10 $29.10 N/A 97813 $73.40 $62.73 N/A97161 $135.39 $135.39 N/A 97814 $58.06 $52.72 ZZZ97162 $135.39 $135.39 N/A 98925 $59.39 $44.71 00097163 $135.39 $135.39 N/A 98926 $86.08 $68.06 00097164 $92.04 $92.04 N/A 98927 $111.44 $89.42 00097165 $131.23 $131.23 N/A 98928 $136.80 $112.77 00097166 $131.23 $131.23 N/A 98929 $163.49 $135.46 00097167 $131.23 $131.23 N/A 98940 $56.84 $56.84 00097168 $86.69 $86.69 N/A 98941 $79.58 $79.58 00097530 $58.19 $58.19 N/A 98942 $101.56 $101.56 00097532 $44.54 $44.54 N/A 98943 $53.82 $53.82 N/A97533 $48.69 $48.69 N/A 98960 $52.72 $52.72 N/A97535 $58.79 $58.79 N/A 98961 $25.36 $25.36 N/A97537 $50.47 $50.47 N/A 98962 $18.68 $18.68 N/A97542 $51.66 $51.66 N/A 98966 $26.02 $24.02 N/A97545 80% of billed 80% of billed N/A 98967 $50.71 $48.05 N/A97546 80% of billed 80% of billed ZZZ 98968 $74.74 $72.07 N/A97597 $125.89 $39.19 000 98969 80% of billed 80% of billed N/A97598 $40.97 $18.41 ZZZ 99000 80% of billed 80% of billed N/A97602 80% of billed 80% of billed N/A 99001 80% of billed 80% of billed N/A97605 $68.88 $42.16 N/A 99002 80% of billed 80% of billed N/A97606 $81.35 $45.72 N/A 99024 80% of billed 80% of billed N/A97607 80% of billed 80% of billed N/A 99026 80% of billed 80% of billed N/A97608 80% of billed 80% of billed N/A 99027 80% of billed 80% of billed N/A97610 $198.92 $26.72 N/A 99050 80% of billed 80% of billed N/A97642 $63.74 $63.74 N/A 99051 80% of billed 80% of billed N/A97643 $32.22 $32.22 N/A 99053 80% of billed 80% of billed N/A97644 $101.56 $101.56 N/A 99056 80% of billed 80% of billed N/A97645 $51.13 $51.13 N/A 99058 80% of billed 80% of billed N/A97646 $63.74 $63.74 N/A 99060 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 82 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

99070 80% of billed 80% of billed N/A 99235 $337.82 $337.82 N/A99071 80% of billed 80% of billed N/A 99236 $435.05 $435.05 N/A99075 80% of billed 80% of billed N/A 99238 $144.78 $144.78 N/A99078 80% of billed 80% of billed N/A 99239 $214.33 $214.33 N/A99080 80% of billed 80% of billed N/A 99241 $95.10 $65.29 N/A99082 80% of billed 80% of billed N/A 99242 $178.84 $136.97 N/A99090 80% of billed 80% of billed N/A 99243 $244.85 $191.62 N/A99091 $106.10 $106.10 N/A 99244 $366.21 $308.01 N/A99100 80% of billed 80% of billed ZZZ 99245 $446.40 $381.11 N/A99116 80% of billed 80% of billed ZZZ 99251 $97.94 $97.94 N/A99135 80% of billed 80% of billed ZZZ 99252 $149.75 $149.75 N/A99140 80% of billed 80% of billed ZZZ 99253 $229.94 $229.94 N/A99143 80% of billed 80% of billed N/A 99254 $334.98 $334.98 N/A99144 80% of billed 80% of billed N/A 99255 $403.11 $403.11 N/A99145 80% of billed 80% of billed ZZZ 99281 $42.58 $42.58 N/A99148 80% of billed 80% of billed N/A 99282 $83.03 $83.03 N/A99149 80% of billed 80% of billed N/A 99283 $124.20 $124.20 N/A99150 80% of billed 80% of billed ZZZ 99284 $235.62 $235.62 N/A99151 $145.47 $44.71 N/A 99285 $347.75 $347.75 N/A99152 $96.76 $23.36 N/A 99288 80% of billed 80% of billed N/A99153 $20.69 $20.69 ZZZ 99291 $549.31 $447.82 N/A99155 $175.50 $175.50 N/A 99292 $245.56 $224.27 ZZZ99156 $143.47 $143.47 N/A 99304 $183.10 $183.10 N/A99157 $108.77 $108.77 ZZZ 99305 $260.46 $260.46 N/A99170 $326.98 $168.83 000 99306 $332.14 $332.14 N/A99172 80% of billed 80% of billed N/A 99307 $89.42 $89.42 N/A99173 $6.01 $6.01 N/A 99308 $137.68 $137.68 N/A99174 80% of billed 80% of billed N/A 99309 $181.68 $181.68 N/A99175 $32.03 $32.03 N/A 99310 $271.11 $271.11 N/A99177 80% of billed 80% of billed N/A 99315 $145.49 $145.49 N/A99183 $208.86 $208.86 N/A 99316 $211.49 $211.49 N/A99184 $433.08 $433.08 N/A 99318 $191.62 $191.62 N/A99188 80% of billed 80% of billed N/A 99324 $110.71 $110.71 N/A99190 80% of billed 80% of billed N/A 99325 $161.10 $161.10 N/A99191 80% of billed 80% of billed N/A 99326 $278.20 $278.20 N/A99192 80% of billed 80% of billed N/A 99327 $370.46 $370.46 N/A99193 $56.03 $56.03 N/A 99328 $432.92 $432.92 N/A99195 $187.51 $187.51 N/A 99334 $120.65 $120.65 N/A99196 $168.10 $168.10 N/A 99335 $189.49 $189.49 N/A99197 $560.32 $560.32 N/A 99336 $268.98 $268.98 N/A99198 $1,120.64 $1,120.64 N/A 99337 $383.95 $383.95 N/A99199 80% of billed 80% of billed N/A 99339 $154.71 $154.71 N/A99201 $88.00 $53.94 N/A 99340 $217.17 $217.17 N/A99202 $149.75 $100.78 N/A 99341 $110.71 $110.71 N/A99203 $216.46 $154.00 N/A 99342 $158.97 $158.97 N/A99204 $329.30 $260.46 N/A 99343 $259.75 $259.75 N/A99205 $413.05 $338.53 N/A 99344 $363.37 $363.37 N/A99211 $39.74 $18.45 N/A 99345 $440.72 $440.72 N/A99212 $87.29 $51.10 N/A 99347 $111.42 $111.42 N/A99213 $145.49 $102.20 N/A 99348 $168.91 $168.91 N/A99214 $214.33 $156.84 N/A 99349 $256.20 $256.20 N/A99215 $288.85 $221.43 N/A 99350 $354.85 $354.85 N/A99217 $145.49 $145.49 N/A 99354 $200.14 $185.94 ZZZ99218 $199.43 $199.43 N/A 99355 $194.46 $180.26 ZZZ99219 $270.40 $270.40 N/A 99356 $183.10 $183.10 ZZZ99220 $370.46 $370.46 N/A 99357 $182.39 $182.39 ZZZ99221 $202.97 $202.97 N/A 99358 $217.17 $217.17 N/A99222 $273.94 $273.94 N/A 99359 $105.04 $105.04 ZZZ99223 $404.53 $404.53 N/A 99360 $122.78 $122.78 N/A99224 $79.49 $79.49 N/A 99363 $254.78 $168.91 N/A99225 $145.49 $145.49 N/A 99364 $86.58 $64.58 N/A99226 $209.36 $209.36 N/A 99366 $85.87 $83.74 N/A99231 $78.78 $78.78 N/A 99367 $112.84 $112.84 N/A99232 $144.07 $144.07 N/A 99368 $73.81 $73.81 N/A99233 $207.94 $207.94 N/A 99374 $140.52 $112.84 N/A99234 $266.85 $266.85 N/A 99375 $209.36 $176.72 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 83 of 84

Note: Listing of a payment amount does not guarantee payment See OAR 436-009-0040

Effective January 1, 2017 Link to Medical Fee and Payment Rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Temporary Appendix B for Administrative Order No. 16-059

Physician Fee Schedule

CPT only copyright 2015/2016 American Medical Association. All rights reserved.

99377 $140.52 $112.84 N/A 99495 $326.46 $220.72 N/A99378 $209.36 $176.72 N/A 99496 $460.60 $319.37 N/A99379 $140.52 $112.84 N/A 99497 $170.33 $157.55 N/A99380 $209.36 $176.72 N/A 99498 $148.33 $147.62 ZZZ99381 $220.72 $153.30 N/A 99499 80% of billed 80% of billed N/A99382 $230.65 $163.23 N/A 99500 80% of billed 80% of billed N/A99383 $239.88 $173.88 N/A 99501 80% of billed 80% of billed N/A99384 $271.11 $205.10 N/A 99502 80% of billed 80% of billed N/A99385 $262.59 $196.59 N/A 99503 80% of billed 80% of billed N/A99386 $305.17 $238.46 N/A 99504 80% of billed 80% of billed N/A99387 $330.72 $256.20 N/A 99505 80% of billed 80% of billed N/A99391 $198.01 $139.81 N/A 99506 80% of billed 80% of billed N/A99392 $211.49 $153.30 N/A 99507 80% of billed 80% of billed N/A99393 $210.78 $153.30 N/A 99509 80% of billed 80% of billed N/A99394 $231.36 $173.88 N/A 99510 80% of billed 80% of billed N/A99395 $236.33 $178.84 N/A 99511 80% of billed 80% of billed N/A99396 $251.94 $194.46 N/A 99512 80% of billed 80% of billed N/A99397 $271.82 $205.10 N/A 99600 80% of billed 80% of billed N/A99401 $72.39 $48.97 N/A 99601 80% of billed 80% of billed N/A99402 $123.49 $100.78 N/A 99602 80% of billed 80% of billed N/A99403 $173.17 $149.75 N/A 99605 80% of billed 80% of billed N/A99404 $222.85 $200.14 N/A 99606 80% of billed 80% of billed N/A99406 $28.39 $24.84 N/A 99607 80% of billed 80% of billed N/A99407 $55.36 $51.81 N/A AR001 $358.60 $358.60 N/A99408 $70.26 $66.71 N/A AR002 $477.67 $477.67 N/A99409 $136.97 $133.42 N/A AR003 $597.44 $597.44 N/A99411 $32.65 $15.61 N/A AR004 $179.30 $179.30 N/A99412 $42.58 $25.55 N/A AR011 $61.64 $61.64 N/A99415 $17.74 $17.74 N/A AR012 $92.45 $92.45 N/A99416 $1.42 $1.42 N/A AR013 $123.97 $123.97 N/A99420 $22.00 $22.00 N/A AR021 $61.64 $61.64 N/A99429 80% of billed 80% of billed N/A AR022 $154.79 $154.79 N/A99441 $27.68 $25.55 N/A AR023 $371.21 $371.21 N/A99442 $53.94 $51.10 N/A AR024 $716.51 $716.51 N/A99443 $79.49 $76.65 N/A AR025 $956.05 $956.05 N/A99444 80% of billed 80% of billed N/A AR031 $61.64 $61.64 N/A99446 80% of billed 80% of billed N/A AR032 $123.97 $123.97 N/A99447 80% of billed 80% of billed N/A CE001 80% of billed 80% of billed N/A99448 80% of billed 80% of billed N/A CR001 80% of billed 80% of billed N/A99449 80% of billed 80% of billed N/A D0001 as billed as billed N/A99450 80% of billed 80% of billed N/A D0002 as billed as billed N/A99455 80% of billed 80% of billed N/A D0003 as billed as billed N/A99456 80% of billed 80% of billed N/A D0019 as billed as billed N/A99460 $193.04 $193.04 N/A D0030 as billed as billed N/A99461 $198.01 $132.00 N/A G0477 $21.75 $21.75 N/A99462 $83.74 $83.74 N/A G0478 $29.00 $29.00 N/A99463 $238.46 $238.46 N/A G0479 $116.00 $116.00 N/A99464 $143.36 $143.36 N/A G0480 $127.75 $127.75 N/A99465 $305.88 $305.88 N/A G0481 $196.53 $196.53 N/A99466 $460.60 $460.60 N/A G0482 $265.32 $265.32 N/A99467 $232.78 $232.78 ZZZ G0483 $343.93 $343.93 N/A99468 $1,889.93 $1,889.93 N/A N0001 $119.77 $119.77 N/A99469 $796.28 $796.28 N/A N0002 $238.84 $238.84 N/A99471 $1,757.22 $1,757.22 N/A P0001 $299.07 $299.07 N/A99472 $820.41 $820.41 N/A P0002 $299.07 $299.07 N/A99475 $1,155.39 $1,155.39 N/A P0003 $299.07 $299.07 N/A99476 $694.09 $694.09 N/A P0004 $358.60 $358.60 N/A99477 $715.38 $715.38 N/A P0005 $151.99 $151.99 N/A99478 $273.94 $273.94 N/A R0001 $10.00 1st pg $10.00 1st pg N/A99479 $249.10 $249.10 N/A 99480 $239.17 $239.17 N/A R0002 $35.00 $35.00 N/A99485 $153.30 $153.30 N/A W0001 as billed as billed N/A99486 $133.42 $133.42 N/A99487 80% of billed 80% of billed N/A99489 80% of billed 80% of billed ZZZ99490 $80.91 $62.45 N/A

$.50 for each page thereafter

*ZZZ means the code is related to another service that is always included in the global period of the other service Page 84 of 84