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January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99 FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC*** G0101 $41.22 $39.16 $45.03 $44.36 # G0101 $28.96 $27.51 $31.64 $31.17 G0102 $21.97 $20.87 $24.00 $23.64 # G0102 $8.94 $8.49 $9.76 $9.61 G0104 $159.77 $151.78 $174.55 $171.93 # G0104 $69.74 $66.25 $76.19 $75.05 G0105 $447.59 $425.21 $488.99 $481.65 # G0105 $233.44 $221.77 $255.04 $251.21 G0105 53 $159.77 $151.78 $174.55 $171.93 # G0105 53 $69.74 $66.25 $76.19 $75.05 G0106 $250.35 $237.83 $273.50 $269.40 G0106 TC $201.10 $191.05 $219.71 $216.41 G0106 26 $49.25 $46.79 $53.81 $53.00 G0108 $55.26 $52.50 $60.38 $59.47 G0109 $14.79 $14.05 $16.16 $15.92 G0117 $60.75 $57.71 $66.37 $65.37 G0118 $43.80 $41.61 $47.85 $47.14 G0120 $250.35 $237.83 $273.50 $269.40 G0120 TC $201.10 $191.05 $219.71 $216.41 G0120 26 $49.25 $46.79 $53.81 $53.00 G0121 $447.59 $425.21 $488.99 $481.65 # G0121 $233.44 $221.77 $255.04 $251.21 G0121 53 $159.77 $151.78 $174.55 $171.93 # G0121 53 $69.74 $66.25 $76.19 $75.05 G0124 $34.05 $32.35 $37.20 $36.64 G0127 $25.80 $24.51 $28.19 $27.76 # G0127 $7.79 $7.40 $8.51 $8.38 G0128 $9.17 $8.71 $10.02 $9.87 G0130 $38.24 $36.33 $41.78 $41.16 G0130 TC $26.79 $25.45 $29.27 $28.83 G0130 26 $11.45 $10.88 $12.51 $12.33 G0141 $34.05 $32.35 $37.20 $36.64 G0166 $161.72 $153.63 $176.67 $174.03 G0168 $117.84 $111.95 $128.74 $126.81 # G0168 $28.96 $27.51 $31.64 $31.17 G0179 $45.05 $42.80 $49.22 $48.48 G0180 $57.26 $54.40 $62.56 $61.62 G0181 $112.69 $107.06 $123.12 $121.27 G0182 $113.45 $107.78 $123.95 $122.08 G0186 $1,114.73 $1,058.99 $1,217.84 $1,199.58 G0202 $153.67 $145.99 $167.89 $165.37 G0202 TC $117.20 $111.34 $128.04 $126.12 G0202 26 $36.47 $34.65 $39.85 $39.25 G0204 $187.13 $177.77 $204.44 $201.37 G0204 TC $141.72 $134.63 $154.82 $152.50 G0204 26 $45.41 $43.14 $49.61 $48.86 ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE AMERICAN MEDICAL ASSOCIATION

Transcript of New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

Page 1: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

G0101 $41.22 $39.16 $45.03 $44.36

# G0101 $28.96 $27.51 $31.64 $31.17

G0102 $21.97 $20.87 $24.00 $23.64

# G0102 $8.94 $8.49 $9.76 $9.61

G0104 $159.77 $151.78 $174.55 $171.93

# G0104 $69.74 $66.25 $76.19 $75.05

G0105 $447.59 $425.21 $488.99 $481.65

# G0105 $233.44 $221.77 $255.04 $251.21

G0105 53 $159.77 $151.78 $174.55 $171.93

# G0105 53 $69.74 $66.25 $76.19 $75.05

G0106 $250.35 $237.83 $273.50 $269.40

G0106 TC $201.10 $191.05 $219.71 $216.41

G0106 26 $49.25 $46.79 $53.81 $53.00

G0108 $55.26 $52.50 $60.38 $59.47

G0109 $14.79 $14.05 $16.16 $15.92

G0117 $60.75 $57.71 $66.37 $65.37

G0118 $43.80 $41.61 $47.85 $47.14

G0120 $250.35 $237.83 $273.50 $269.40

G0120 TC $201.10 $191.05 $219.71 $216.41

G0120 26 $49.25 $46.79 $53.81 $53.00

G0121 $447.59 $425.21 $488.99 $481.65

# G0121 $233.44 $221.77 $255.04 $251.21

G0121 53 $159.77 $151.78 $174.55 $171.93

# G0121 53 $69.74 $66.25 $76.19 $75.05

G0124 $34.05 $32.35 $37.20 $36.64

G0127 $25.80 $24.51 $28.19 $27.76

# G0127 $7.79 $7.40 $8.51 $8.38

G0128 $9.17 $8.71 $10.02 $9.87

G0130 $38.24 $36.33 $41.78 $41.16

G0130 TC $26.79 $25.45 $29.27 $28.83

G0130 26 $11.45 $10.88 $12.51 $12.33

G0141 $34.05 $32.35 $37.20 $36.64

G0166 $161.72 $153.63 $176.67 $174.03

G0168 $117.84 $111.95 $128.74 $126.81

# G0168 $28.96 $27.51 $31.64 $31.17

G0179 $45.05 $42.80 $49.22 $48.48

G0180 $57.26 $54.40 $62.56 $61.62

G0181 $112.69 $107.06 $123.12 $121.27

G0182 $113.45 $107.78 $123.95 $122.08

G0186 $1,114.73 $1,058.99 $1,217.84 $1,199.58

G0202 $153.67 $145.99 $167.89 $165.37

G0202 TC $117.20 $111.34 $128.04 $126.12

G0202 26 $36.47 $34.65 $39.85 $39.25

G0204 $187.13 $177.77 $204.44 $201.37

G0204 TC $141.72 $134.63 $154.82 $152.50

G0204 26 $45.41 $43.14 $49.61 $48.86

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

G0206 $147.54 $140.16 $161.18 $158.77

G0206 TC $111.07 $105.52 $121.35 $119.53

G0206 26 $36.47 $34.65 $39.85 $39.25

G0237 $12.23 $11.62 $13.36 $13.17

G0238 $13.00 $12.35 $14.20 $13.98

G0239 $14.53 $13.80 $15.87 $15.63

G0245 $69.89 $66.40 $76.36 $75.21

# G0245 $43.84 $41.65 $47.90 $47.18

G0246 $41.22 $39.16 $45.03 $44.36

# G0246 $21.68 $20.60 $23.69 $23.33

G0247 $82.39 $78.27 $90.01 $88.67

# G0247 $24.15 $22.94 $26.38 $25.99

G0248 $128.31 $121.89 $140.17 $138.07

G0249 $126.40 $120.08 $138.09 $136.02

G0250 $9.29 $8.83 $10.15 $10.01

G0268 $57.12 $54.26 $62.40 $61.47

# G0268 $33.75 $32.06 $36.87 $36.32

G0270 $32.79 $31.15 $35.82 $35.28

# G0270 $29.72 $28.23 $32.46 $31.98

G0271 $16.70 $15.87 $18.25 $17.97

# G0271 $16.32 $15.50 $17.83 $17.56

G0275 $12.49 $11.87 $13.65 $13.44

G0278 $12.49 $11.87 $13.65 $13.44

G0281 $14.65 $13.92 $16.01 $15.77

G0283 $14.65 $13.92 $16.01 $15.77

G0288 $44.03 $41.83 $48.10 $47.38

G0289 $91.99 $87.39 $100.50 $98.99

G0329 $11.25 $10.69 $12.29 $12.11

G0339 $2,992.29 $2,842.68 $3,269.08 $3,220.05

G0340 $2,250.46 $2,137.94 $2,458.63 $2,421.75

G0341 $2,553.89 $2,426.20 $2,790.13 $2,748.28

# G0341 $377.50 $358.63 $412.42 $406.24

G0342 $715.17 $679.41 $781.32 $769.60

G0343 $1,188.69 $1,129.26 $1,298.65 $1,279.17

G0364 $13.19 $12.53 $14.41 $14.19

# G0364 $8.98 $8.53 $9.81 $9.66

C G0365 $187.10 $177.75 $204.41 $201.34

C G0365 TC $174.28 $165.57 $190.41 $187.55

G0365 26 $12.82 $12.18 $14.01 $13.80

G0372 $9.33 $8.86 $10.19 $10.04

G0389 $122.71 $116.57 $134.06 $132.04

G0389 TC $93.45 $88.78 $102.10 $100.57

G0389 26 $29.26 $27.80 $31.97 $31.49

G0396 $38.56 $36.63 $42.12 $41.49

# G0396 $35.88 $34.09 $39.20 $38.62

G0397 $72.90 $69.26 $79.65 $78.45

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# G0397 $70.22 $66.71 $76.72 $75.57

G0398 $202.07 $191.97 $220.77 $217.45

G0398 TC $126.30 $119.99 $137.99 $135.92

G0398 26 $75.78 $71.99 $82.79 $81.55

G0399 $225.03 $213.78 $245.85 $242.16

G0399 TC $137.78 $130.89 $150.52 $148.27

G0399 26 $87.26 $82.90 $95.34 $93.91

G0400 $236.51 $224.68 $258.38 $254.51

G0400 TC $146.96 $139.61 $160.55 $158.15

G0400 26 $89.56 $85.08 $97.84 $96.37

G0402 $175.26 $166.50 $191.48 $188.60

# G0402 $129.29 $122.83 $141.25 $139.14

G0403 $20.02 $19.02 $21.87 $21.54

G0404 $11.47 $10.90 $12.54 $12.35

G0405 $8.56 $8.13 $9.35 $9.21

G0406 $40.05 $38.05 $43.76 $43.10

G0407 $73.73 $70.04 $80.55 $79.34

G0408 $106.30 $100.99 $116.14 $114.40

G0409 $21.43 $20.36 $23.41 $23.06

G0412 $781.09 $742.04 $853.35 $840.55

G0413 $1,145.58 $1,088.30 $1,251.55 $1,232.78

G0414 $1,072.61 $1,018.98 $1,171.83 $1,154.26

G0415 $1,469.39 $1,395.92 $1,605.31 $1,581.23

G0416 $744.10 $706.90 $812.94 $800.75

G0416 TC $550.49 $522.97 $601.42 $592.40

G0416 26 $193.62 $183.94 $211.53 $208.36

G0417 $1,447.94 $1,375.54 $1,581.87 $1,558.15

G0417 TC $1,074.95 $1,021.20 $1,174.38 $1,156.76

G0417 26 $373.00 $354.35 $407.50 $401.38

G0418 $2,482.45 $2,358.33 $2,712.08 $2,671.40

G0418 TC $1,835.40 $1,743.63 $2,005.17 $1,975.10

G0418 26 $647.06 $614.71 $706.92 $696.31

G0419 $2,951.18 $2,803.62 $3,224.16 $3,175.81

G0419 TC $2,202.79 $2,092.65 $2,406.55 $2,370.45

G0419 26 $748.38 $710.96 $817.60 $805.35

G0420 $112.03 $106.43 $122.39 $120.55

G0421 $26.10 $24.80 $28.52 $28.09

G0422 $85.55 $81.27 $93.46 $92.06

G0423 $90.15 $85.64 $98.49 $97.01

G0424 $33.78 $32.09 $36.90 $36.35

# G0424 $14.62 $13.89 $15.97 $15.73

G0425 $104.51 $99.28 $114.17 $112.46

G0426 $141.78 $134.69 $154.89 $152.57

G0427 $208.37 $197.95 $227.64 $224.23

G0429 $108.10 $102.70 $118.11 $116.33

# G0429 $76.30 $72.49 $83.36 $82.11

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

G0436 $14.82 $14.08 $16.19 $15.95

# G0436 $12.52 $11.89 $13.67 $13.47

G0437 $28.78 $27.34 $31.44 $30.97

# G0437 $26.48 $25.16 $28.93 $28.50

G0438 $181.77 $172.68 $198.58 $195.60

G0439 $120.60 $114.57 $131.76 $129.78

G0442 $20.02 $19.02 $21.87 $21.54

# G0442 $9.67 $9.19 $10.57 $10.41

G0443 $27.04 $25.69 $29.54 $29.10

# G0443 $24.36 $23.14 $26.61 $26.21

G0444 $20.02 $19.02 $21.87 $21.54

# G0444 $9.67 $9.19 $10.57 $10.41

G0445 $27.81 $26.42 $30.38 $29.92

# G0445 $23.98 $22.78 $26.20 $25.81

G0446 $27.04 $25.69 $29.54 $29.10

# G0446 $24.36 $23.14 $26.61 $26.21

G0447 $27.04 $25.69 $29.54 $29.10

# G0447 $24.74 $23.50 $27.03 $26.62

G0451 $10.32 $9.80 $11.27 $11.10

G0452 26 $19.67 $18.69 $21.49 $21.17

G0453 $27.63 $26.25 $30.19 $29.74

G0454 $9.29 $8.83 $10.15 $10.01

G0455 $122.68 $116.55 $134.03 $132.02

# G0455 $55.26 $52.50 $60.38 $59.47

M0064 $62.63 $59.50 $68.43 $67.40

# M0064 $15.89 $15.10 $17.37 $17.10

P3001 $34.05 $32.35 $37.20 $36.64

Q0035 $23.47 $22.30 $25.65 $25.27

Q0035 TC $14.15 $13.44 $15.46 $15.23

Q0035 26 $9.33 $8.86 $10.19 $10.04

Q0091 $50.31 $47.79 $54.96 $54.13

# Q0091 $20.05 $19.05 $21.91 $21.57

Q0092 $28.32 $26.90 $30.94 $30.48

0042T $399.93 $379.93 $436.92 $430.36

0051T $3,938.24 $3,741.33 $4,302.53 $4,237.99

0054T $326.30 $309.99 $356.49 $351.14

0055T $436.29 $414.48 $476.65 $469.50

0073T $456.63 $433.80 $498.87 $491.38

0075T $1,303.60 $1,238.42 $1,424.18 $1,402.82

0075T TC $1,036.90 $985.06 $1,132.82 $1,115.82

0075T 26 $266.69 $253.36 $291.36 $286.99

0078T $2,318.15 $2,202.24 $2,532.58 $2,494.59

0079T $206.67 $196.34 $225.79 $222.40

0081T $206.67 $196.34 $225.79 $222.40

0159T $9.20 $8.74 $10.05 $9.90

0159T TC $5.68 $5.40 $6.21 $6.12

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

0159T 26 $3.51 $3.33 $3.83 $3.77

0171T $1,371.87 $1,303.28 $1,498.77 $1,476.29

0172T $898.26 $853.35 $981.35 $966.63

0179T $12.02 $11.42 $13.13 $12.94

0182T $1,080.00 $1,026.00 $1,179.90 $1,162.20

0182T TC $702.00 $666.90 $766.94 $755.44

0182T 26 $378.00 $359.10 $412.97 $406.77

0183T $20.89 $19.85 $22.83 $22.48

0184T $761.90 $723.81 $832.38 $819.89

0192T $1,107.46 $1,052.09 $1,209.90 $1,191.76

0195T $1,492.83 $1,418.19 $1,630.92 $1,606.46

0196T $95.81 $91.02 $104.67 $103.10

0197T $68.89 $65.45 $75.27 $74.14

0198T $55.11 $52.35 $60.20 $59.29

0200T $500.02 $475.02 $546.27 $538.07

0201T $610.47 $579.95 $666.94 $656.94

0202T $1,286.38 $1,222.06 $1,405.37 $1,384.29

0205T $91.00 $86.45 $99.42 $97.92

0206T $202.00 $191.90 $220.69 $217.37

0207T $20.99 $19.94 $22.93 $22.59

0208T $28.65 $27.22 $31.30 $30.83

0212T $44.64 $42.41 $48.77 $48.04

0213T $199.21 $189.25 $217.64 $214.37

0214T $99.65 $94.67 $108.87 $107.24

0215T $100.87 $95.83 $110.20 $108.55

0216T $178.60 $169.67 $195.12 $192.19

0217T $90.80 $86.26 $99.20 $97.72

0218T $92.02 $87.42 $100.53 $99.03

0226T $108.73 $103.29 $118.78 $117.00

# 0226T $50.03 $47.53 $54.66 $53.84

0227T $281.63 $267.55 $307.68 $303.07

# 0227T $96.32 $91.50 $105.23 $103.65

0228T $232.62 $220.99 $254.14 $250.33

# 0228T $111.83 $106.24 $122.18 $120.35

0229T $110.46 $104.94 $120.68 $118.88

# 0229T $56.94 $54.09 $62.20 $61.27

0230T $211.53 $200.95 $231.09 $227.63

# 0230T $87.68 $83.30 $95.80 $94.36

0231T $93.06 $88.41 $101.67 $100.14

# 0231T $45.04 $42.79 $49.21 $48.47

0232T $45.69 $43.41 $49.92 $49.17

0237T $513.39 $487.72 $560.88 $552.46

0238T $784.40 $745.18 $856.96 $844.10

0249T $322.28 $306.17 $352.10 $346.82

# 0249T $235.13 $223.37 $256.88 $253.02

10021 $168.40 $159.98 $183.98 $181.22

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 10021 $74.54 $70.81 $81.43 $80.21

10022 $154.06 $146.36 $168.31 $165.78

# 10022 $67.87 $64.48 $74.15 $73.04

10040 $111.26 $105.70 $121.56 $119.73

# 10040 $95.94 $91.14 $104.81 $103.24

10060 $128.25 $121.84 $140.12 $138.01

# 10060 $105.26 $100.00 $115.00 $113.28

10061 $224.88 $213.64 $245.69 $242.01

# 10061 $194.61 $184.88 $212.61 $209.43

10080 $203.88 $193.69 $222.74 $219.40

# 10080 $113.85 $108.16 $124.38 $122.52

10081 $305.50 $290.23 $333.76 $328.76

# 10081 $187.12 $177.76 $204.42 $201.35

10120 $171.04 $162.49 $186.86 $184.06

# 10120 $113.96 $108.26 $124.50 $122.64

10121 $307.05 $291.70 $335.46 $330.42

# 10121 $201.70 $191.62 $220.36 $217.06

10140 $181.14 $172.08 $197.89 $194.93

# 10140 $129.04 $122.59 $140.98 $138.86

10160 $144.89 $137.65 $158.30 $155.93

# 10160 $104.66 $99.43 $114.34 $112.63

10180 $275.49 $261.72 $300.98 $296.46

# 10180 $195.42 $185.65 $213.50 $210.30

11000 $59.78 $56.79 $65.31 $64.33

# 11000 $29.52 $28.04 $32.25 $31.76

11001 $22.98 $21.83 $25.10 $24.73

# 11001 $14.94 $14.19 $16.32 $16.08

11004 $605.18 $574.92 $661.16 $651.25

11005 $820.92 $779.87 $896.85 $883.40

11006 $737.85 $700.96 $806.10 $794.02

11008 $288.41 $273.99 $315.09 $310.36

11010 $554.52 $526.79 $605.81 $596.72

# 11010 $301.29 $286.23 $329.16 $324.23

11011 $598.74 $568.80 $654.12 $644.31

# 11011 $318.31 $302.39 $347.75 $342.53

11012 $789.00 $749.55 $861.98 $849.06

# 11012 $450.34 $427.82 $491.99 $484.61

11042 $131.27 $124.71 $143.42 $141.27

# 11042 $66.14 $62.83 $72.25 $71.17

11043 $253.07 $240.42 $276.48 $272.33

# 11043 $166.87 $158.53 $182.31 $179.57

11044 $346.55 $329.22 $378.60 $372.92

# 11044 $247.71 $235.32 $270.62 $266.56

11045 $46.18 $43.87 $50.45 $49.69

# 11045 $28.94 $27.49 $31.61 $31.14

11046 $79.34 $75.37 $86.68 $85.38

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 11046 $59.04 $56.09 $64.50 $63.54

11047 $133.64 $126.96 $146.00 $143.82

# 11047 $104.53 $99.30 $114.20 $112.48

11055 $53.09 $50.44 $58.01 $57.13

# 11055 $16.32 $15.50 $17.83 $17.56

11056 $64.41 $61.19 $70.37 $69.31

# 11056 $23.42 $22.25 $25.59 $25.21

11057 $71.89 $68.30 $78.55 $77.37

# 11057 $30.51 $28.98 $33.33 $32.83

11100 $116.71 $110.87 $127.50 $125.59

# 11100 $51.97 $49.37 $56.78 $55.92

11101 $35.18 $33.42 $38.43 $37.86

# 11101 $26.36 $25.04 $28.80 $28.36

11200 $97.52 $92.64 $106.54 $104.94

# 11200 $80.67 $76.64 $88.14 $86.81

11201 $20.31 $19.29 $22.18 $21.85

# 11201 $17.63 $16.75 $19.26 $18.98

11300 $110.65 $105.12 $120.89 $119.07

# 11300 $37.10 $35.25 $40.54 $39.93

11301 $135.14 $128.38 $147.64 $145.42

# 11301 $56.98 $54.13 $62.25 $61.32

11302 $159.45 $151.48 $174.20 $171.59

# 11302 $66.74 $63.40 $72.91 $71.82

11303 $175.09 $166.34 $191.29 $188.42

# 11303 $79.32 $75.35 $86.65 $85.35

11305 $109.99 $104.49 $120.16 $118.36

# 11305 $40.27 $38.26 $44.00 $43.34

11306 $136.10 $129.30 $148.70 $146.46

# 11306 $54.12 $51.41 $59.12 $58.24

11307 $160.80 $152.76 $175.67 $173.04

# 11307 $70.39 $66.87 $76.90 $75.75

11308 $169.47 $161.00 $185.15 $182.38

# 11308 $77.91 $74.01 $85.11 $83.84

11310 $128.24 $121.83 $140.10 $138.00

# 11310 $50.09 $47.59 $54.73 $53.91

11311 $123.61 $117.43 $135.04 $133.02

# 11311 $69.98 $66.48 $76.45 $75.30

11312 $180.99 $171.94 $197.73 $194.76

# 11312 $83.68 $79.50 $91.43 $90.06

11313 $207.46 $197.09 $226.65 $223.25

# 11313 $107.09 $101.74 $117.00 $115.24

11400 $139.35 $132.38 $152.24 $149.95

# 11400 $88.01 $83.61 $96.15 $94.71

11401 $166.89 $158.55 $182.33 $179.60

# 11401 $114.02 $108.32 $124.57 $122.71

11402 $185.32 $176.05 $202.46 $199.42

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 8: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 11402 $124.80 $118.56 $136.34 $134.30

11403 $212.85 $202.21 $232.54 $229.06

# 11403 $161.14 $153.08 $176.04 $173.40

11404 $241.22 $229.16 $263.53 $259.58

# 11404 $176.86 $168.02 $193.22 $190.33

11406 $343.01 $325.86 $374.74 $369.12

# 11406 $265.24 $251.98 $289.78 $285.43

11420 $137.74 $130.85 $150.48 $148.22

# 11420 $89.47 $85.00 $97.75 $96.29

11421 $175.73 $166.94 $191.98 $189.11

# 11421 $120.95 $114.90 $132.14 $130.16

11422 $195.17 $185.41 $213.22 $210.02

# 11422 $149.20 $141.74 $163.00 $160.55

11423 $224.27 $213.06 $245.02 $241.34

# 11423 $172.17 $163.56 $188.09 $185.28

11424 $257.03 $244.18 $280.81 $276.60

# 11424 $194.97 $185.22 $213.00 $209.81

11426 $361.93 $343.83 $395.40 $389.47

# 11426 $294.51 $279.78 $321.75 $316.92

11440 $152.50 $144.88 $166.61 $164.12

# 11440 $115.72 $109.93 $126.42 $124.52

11441 $187.72 $178.33 $205.08 $202.01

# 11441 $145.20 $137.94 $158.63 $156.25

11442 $209.33 $198.86 $228.69 $225.26

# 11442 $160.29 $152.28 $175.12 $172.50

11443 $247.65 $235.27 $270.56 $266.50

# 11443 $194.79 $185.05 $212.81 $209.61

11444 $308.59 $293.16 $337.13 $332.07

# 11444 $245.76 $233.47 $268.49 $264.47

11446 $423.89 $402.70 $463.11 $456.16

# 11446 $349.19 $331.73 $381.49 $375.76

11450 $426.50 $405.18 $465.96 $458.97

# 11450 $274.80 $261.06 $300.22 $295.71

11451 $541.78 $514.69 $591.89 $583.02

# 11451 $351.00 $333.45 $383.47 $377.72

11462 $418.62 $397.69 $457.34 $450.48

# 11462 $263.46 $250.29 $287.83 $283.52

11463 $540.69 $513.66 $590.71 $581.85

# 11463 $350.67 $333.14 $383.11 $377.36

11470 $462.79 $439.65 $505.60 $498.02

# 11470 $306.87 $291.53 $335.26 $330.23

11471 $574.59 $545.86 $627.74 $618.32

# 11471 $379.21 $360.25 $414.29 $408.08

11600 $215.66 $204.88 $235.61 $232.08

# 11600 $130.23 $123.72 $142.28 $140.14

11601 $254.94 $242.19 $278.52 $274.34

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 9: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 11601 $161.85 $153.76 $176.82 $174.17

11602 $276.75 $262.91 $302.35 $297.82

# 11602 $177.91 $169.01 $194.36 $191.44

11603 $313.25 $297.59 $342.23 $337.10

# 11603 $210.97 $200.42 $230.48 $227.02

11604 $348.89 $331.45 $381.17 $375.45

# 11604 $232.43 $220.81 $253.93 $250.13

11606 $495.29 $470.53 $541.11 $532.99

# 11606 $342.44 $325.32 $374.12 $368.51

11620 $218.69 $207.76 $238.92 $235.34

# 11620 $132.49 $125.87 $144.75 $142.58

11621 $256.82 $243.98 $280.58 $276.37

# 11621 $162.96 $154.81 $178.03 $175.36

11622 $285.74 $271.45 $312.17 $307.49

# 11622 $186.52 $177.19 $203.77 $200.71

11623 $332.71 $316.07 $363.48 $358.03

# 11623 $229.66 $218.18 $250.91 $247.15

11624 $373.49 $354.82 $408.04 $401.93

# 11624 $258.95 $246.00 $282.90 $278.66

11626 $449.09 $426.64 $490.64 $483.28

# 11626 $316.15 $300.34 $345.39 $340.20

11640 $225.48 $214.21 $246.34 $242.65

# 11640 $136.98 $130.13 $149.65 $147.41

11641 $265.64 $252.36 $290.21 $285.86

# 11641 $170.25 $161.74 $186.00 $183.21

11642 $301.79 $286.70 $329.71 $324.76

# 11642 $199.50 $189.53 $217.96 $214.69

11643 $353.69 $336.01 $386.41 $380.62

# 11643 $249.48 $237.01 $272.56 $268.47

11644 $434.98 $413.23 $475.21 $468.08

# 11644 $307.79 $292.40 $336.26 $331.21

11646 $562.80 $534.66 $614.86 $605.64

# 11646 $424.50 $403.28 $463.77 $456.81

11719 $12.39 $11.77 $13.54 $13.33

# 11719 $7.79 $7.40 $8.51 $8.38

11720 $35.55 $33.77 $38.84 $38.25

# 11720 $15.25 $14.49 $16.66 $16.41

11721 $48.53 $46.10 $53.02 $52.22

# 11721 $25.54 $24.26 $27.90 $27.49

11730 $108.10 $102.70 $118.11 $116.33

# 11730 $52.17 $49.56 $56.99 $56.14

11732 $38.57 $36.64 $42.14 $41.50

# 11732 $20.95 $19.90 $22.89 $22.54

11740 $55.29 $52.53 $60.41 $59.50

# 11740 $35.76 $33.97 $39.07 $38.48

11750 $245.61 $233.33 $268.33 $264.30

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 10: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 11750 $187.76 $178.37 $205.13 $202.04

11752 $353.73 $336.04 $386.45 $380.65

# 11752 $283.24 $269.08 $309.44 $304.80

11755 $149.41 $141.94 $163.23 $160.78

# 11755 $83.90 $79.71 $91.67 $90.29

11760 $264.31 $251.09 $288.75 $284.42

# 11760 $147.08 $139.73 $160.69 $158.27

11762 $315.43 $299.66 $344.61 $339.45

# 11762 $200.50 $190.48 $219.05 $215.76

11765 $186.97 $177.62 $204.26 $201.20

# 11765 $101.54 $96.46 $110.93 $109.26

11770 $309.72 $294.23 $338.36 $333.29

# 11770 $199.39 $189.42 $217.83 $214.57

11771 $631.08 $599.53 $689.46 $679.12

# 11771 $467.88 $444.49 $511.16 $503.49

11772 $768.45 $730.03 $839.53 $826.94

# 11772 $629.00 $597.55 $687.18 $676.88

11900 $61.93 $58.83 $67.65 $66.64

# 11900 $33.58 $31.90 $36.69 $36.13

11901 $76.52 $72.69 $83.59 $82.34

# 11901 $52.01 $49.41 $56.82 $55.97

11920 $192.22 $182.61 $210.00 $206.85

# 11920 $125.56 $119.28 $137.17 $135.11

11921 $221.56 $210.48 $242.05 $238.42

# 11921 $147.24 $139.88 $160.86 $158.45

11922 $69.29 $65.83 $75.70 $74.57

# 11922 $31.74 $30.15 $34.67 $34.16

11950 $79.09 $75.14 $86.41 $85.11

# 11950 $52.66 $50.03 $57.53 $56.67

11951 $116.53 $110.70 $127.31 $125.40

# 11951 $80.90 $76.86 $88.39 $87.07

11952 $152.29 $144.68 $166.38 $163.89

# 11952 $112.06 $106.46 $122.43 $120.59

11954 $174.02 $165.32 $190.12 $187.27

# 11954 $123.45 $117.28 $134.87 $132.85

11960 $1,018.13 $967.22 $1,112.30 $1,095.62

11970 $668.51 $635.08 $730.34 $719.38

11971 $535.80 $509.01 $585.36 $576.58

# 11971 $356.89 $339.05 $389.91 $384.05

11976 $158.31 $150.39 $172.95 $170.35

# 11976 $101.61 $96.53 $111.01 $109.34

11980 $110.92 $105.37 $121.18 $119.36

# 11980 $84.11 $79.90 $91.89 $90.51

11981 $149.97 $142.47 $163.84 $161.38

# 11981 $84.85 $80.61 $92.70 $91.31

11982 $168.82 $160.38 $184.44 $181.67

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 11: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 11982 $101.40 $96.33 $110.78 $109.12

11983 $226.68 $215.35 $247.65 $243.94

# 11983 $174.58 $165.85 $190.73 $187.86

12001 $100.82 $95.78 $110.15 $108.49

# 12001 $47.18 $44.82 $51.54 $50.77

12002 $121.44 $115.37 $132.68 $130.69

# 12002 $62.45 $59.33 $68.23 $67.21

12004 $142.07 $134.97 $155.22 $152.89

# 12004 $77.71 $73.82 $84.89 $83.62

12005 $183.22 $174.06 $200.17 $197.17

# 12005 $104.68 $99.45 $114.37 $112.65

12006 $221.34 $210.27 $241.81 $238.19

# 12006 $127.48 $121.11 $139.28 $137.18

12007 $251.07 $238.52 $274.30 $270.18

# 12007 $160.27 $152.26 $175.10 $172.48

12011 $122.84 $116.70 $134.21 $132.19

# 12011 $59.25 $56.29 $64.73 $63.77

12013 $134.16 $127.45 $146.57 $144.37

# 12013 $65.58 $62.30 $71.65 $70.58

12014 $156.11 $148.30 $170.55 $167.99

# 12014 $83.32 $79.15 $91.02 $89.65

12015 $190.08 $180.58 $207.67 $204.55

# 12015 $103.88 $98.69 $113.49 $111.79

12016 $235.11 $223.35 $256.85 $253.00

# 12016 $140.10 $133.10 $153.07 $150.77

12017 $160.26 $152.25 $175.09 $172.47

12018 $214.82 $204.08 $234.69 $231.17

12020 $313.79 $298.10 $342.82 $337.67

# 12020 $204.99 $194.74 $223.95 $220.59

12021 $188.54 $179.11 $205.98 $202.88

# 12021 $157.51 $149.63 $172.07 $169.50

12031 $267.04 $253.69 $291.74 $287.36

# 12031 $168.20 $159.79 $183.76 $181.00

12032 $341.25 $324.19 $372.82 $367.23

# 12032 $214.06 $203.36 $233.86 $230.36

12034 $347.74 $330.35 $379.90 $374.20

# 12034 $224.38 $213.16 $245.13 $241.45

12035 $433.55 $411.87 $473.65 $466.54

# 12035 $263.07 $249.92 $287.41 $283.10

12036 $470.72 $447.18 $514.26 $506.54

# 12036 $302.54 $287.41 $330.52 $325.57

12037 $516.21 $490.40 $563.96 $555.50

# 12037 $348.80 $331.36 $381.06 $375.35

12041 $270.90 $257.36 $295.96 $291.53

# 12041 $170.91 $162.36 $186.71 $183.91

12042 $321.05 $305.00 $350.75 $345.49

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 12: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 12042 $218.00 $207.10 $238.17 $234.59

12044 $402.45 $382.33 $439.68 $433.09

# 12044 $232.35 $220.73 $253.84 $250.03

12045 $448.77 $426.33 $490.28 $482.93

# 12045 $295.92 $281.12 $323.29 $318.44

12046 $600.65 $570.62 $656.21 $646.37

# 12046 $370.79 $352.25 $405.09 $399.02

12047 $657.76 $624.87 $718.60 $707.83

# 12047 $411.04 $390.49 $449.06 $442.32

12051 $289.12 $274.66 $315.86 $311.12

# 12051 $187.60 $178.22 $204.95 $201.88

12052 $326.87 $310.53 $357.11 $351.75

# 12052 $221.51 $210.43 $241.99 $238.36

12053 $386.87 $367.53 $422.66 $416.32

# 12053 $235.55 $223.77 $257.34 $253.47

12054 $412.26 $391.65 $450.40 $443.65

# 12054 $247.53 $235.15 $270.42 $266.36

12055 $526.68 $500.35 $575.40 $566.77

# 12055 $325.17 $308.91 $355.25 $349.92

12056 $608.65 $578.22 $664.95 $654.98

# 12056 $409.06 $388.61 $446.90 $440.20

12057 $611.65 $581.07 $668.23 $658.20

# 12057 $404.39 $384.17 $441.80 $435.17

13100 $373.00 $354.35 $407.50 $401.38

# 13100 $222.83 $211.69 $243.44 $239.79

13101 $443.43 $421.26 $484.45 $477.18

# 13101 $277.16 $263.30 $302.80 $298.25

13102 $135.15 $128.39 $147.65 $145.43

# 13102 $79.22 $75.26 $86.55 $85.25

13120 $390.49 $370.97 $426.62 $420.22

# 13120 $257.93 $245.03 $281.78 $277.55

13121 $476.31 $452.49 $520.36 $512.56

# 13121 $289.36 $274.89 $316.12 $311.39

13122 $147.76 $140.37 $161.43 $159.00

# 13122 $91.45 $86.88 $99.91 $98.42

13131 $428.73 $407.29 $468.38 $461.36

# 13131 $270.90 $257.36 $295.96 $291.53

13132 $528.42 $502.00 $577.30 $568.64

# 13132 $339.93 $322.93 $371.37 $365.80

13133 $194.66 $184.93 $212.67 $209.48

# 13133 $139.88 $132.89 $152.82 $150.54

13150 $416.24 $395.43 $454.74 $447.93

# 13150 $239.63 $227.65 $261.80 $257.88

13151 $467.32 $443.95 $510.54 $502.88

# 13151 $311.02 $295.47 $339.79 $334.70

13152 $530.61 $504.08 $579.69 $571.00

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 13152 $346.73 $329.39 $378.80 $373.12

13153 $211.50 $200.93 $231.07 $227.61

# 13153 $150.59 $143.06 $164.52 $162.05

13160 $872.96 $829.31 $953.71 $939.40

14000 $692.82 $658.18 $756.91 $745.56

# 14000 $554.52 $526.79 $605.81 $596.72

14001 $884.21 $840.00 $966.00 $951.51

# 14001 $716.41 $680.59 $782.68 $770.94

14020 $774.61 $735.88 $846.26 $833.57

# 14020 $626.74 $595.40 $684.71 $674.44

14021 $962.04 $913.94 $1,051.03 $1,035.26

# 14021 $787.73 $748.34 $860.59 $847.68

14040 $842.55 $800.42 $920.48 $906.67

# 14040 $694.68 $659.95 $758.94 $747.56

14041 $1,037.95 $986.05 $1,133.96 $1,116.95

# 14041 $849.47 $807.00 $928.05 $914.14

14060 $854.20 $811.49 $933.21 $919.22

# 14060 $738.12 $701.21 $806.39 $794.29

14061 $1,116.22 $1,060.41 $1,219.47 $1,201.18

# 14061 $908.19 $862.78 $992.20 $977.32

14301 $1,185.55 $1,126.27 $1,295.21 $1,275.79

# 14301 $961.83 $913.74 $1,050.80 $1,035.03

14302 $233.19 $221.53 $254.76 $250.94

14350 $763.06 $724.91 $833.65 $821.15

15002 $386.27 $366.96 $422.00 $415.68

# 15002 $244.91 $232.66 $267.56 $263.55

15003 $84.43 $80.21 $92.24 $90.86

# 15003 $48.42 $46.00 $52.90 $52.11

15004 $442.66 $420.53 $483.61 $476.35

# 15004 $290.57 $276.04 $317.45 $312.69

15005 $135.94 $129.14 $148.51 $146.28

# 15005 $96.87 $92.03 $105.83 $104.25

15040 $290.65 $276.12 $317.54 $312.78

# 15040 $137.41 $130.54 $150.12 $147.87

15050 $635.79 $604.00 $694.60 $684.18

# 15050 $492.12 $467.51 $537.64 $529.58

15100 $946.89 $899.55 $1,034.48 $1,018.97

# 15100 $781.77 $742.68 $854.08 $841.27

15101 $208.60 $198.17 $227.90 $224.48

# 15101 $118.96 $113.01 $129.96 $128.01

15110 $951.33 $903.76 $1,039.32 $1,023.73

# 15110 $821.07 $780.02 $897.02 $883.57

15111 $122.21 $116.10 $133.52 $131.51

# 15111 $108.42 $103.00 $118.45 $116.68

15115 $946.45 $899.13 $1,034.00 $1,018.49

# 15115 $818.49 $777.57 $894.21 $880.80

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

15116 $160.96 $152.91 $175.85 $173.21

# 15116 $142.19 $135.08 $155.34 $153.01

15120 $935.41 $888.64 $1,021.94 $1,006.61

# 15120 $757.27 $719.41 $827.32 $814.91

15121 $231.66 $220.08 $253.09 $249.30

# 15121 $142.39 $135.27 $155.56 $153.23

15130 $745.18 $707.92 $814.11 $801.90

# 15130 $616.84 $586.00 $673.90 $663.79

15131 $95.69 $90.91 $104.55 $102.98

# 15131 $85.73 $81.44 $93.66 $92.25

15135 $960.28 $912.27 $1,049.11 $1,033.38

# 15135 $833.10 $791.45 $910.17 $896.52

15136 $97.80 $92.91 $106.85 $105.25

# 15136 $90.14 $85.63 $98.47 $97.00

15150 $752.07 $714.47 $821.64 $809.31

# 15150 $680.05 $646.05 $742.96 $731.81

15151 $126.17 $119.86 $137.84 $135.77

# 15151 $114.67 $108.94 $125.28 $123.41

15152 $165.56 $157.28 $180.87 $178.16

# 15152 $154.07 $146.37 $168.33 $165.80

15155 $834.76 $793.02 $911.97 $898.29

# 15155 $761.59 $723.51 $832.04 $819.56

15156 $169.37 $160.90 $185.04 $182.26

# 15156 $158.26 $150.35 $172.90 $170.30

15157 $197.47 $187.60 $215.74 $212.51

# 15157 $181.38 $172.31 $198.16 $195.19

15200 $917.83 $871.94 $1,002.73 $987.69

# 15200 $734.33 $697.61 $802.25 $790.22

15201 $166.58 $158.25 $181.99 $179.26

# 15201 $84.60 $80.37 $92.43 $91.03

15220 $856.44 $813.62 $935.66 $921.63

# 15220 $676.00 $642.20 $738.53 $727.46

15221 $154.48 $146.76 $168.77 $166.24

# 15221 $76.33 $72.51 $83.39 $82.13

15240 $1,031.95 $980.35 $1,127.40 $1,110.49

# 15240 $882.16 $838.05 $963.76 $949.30

15241 $205.83 $195.54 $224.87 $221.50

# 15241 $119.25 $113.29 $130.28 $128.33

15260 $1,117.78 $1,061.89 $1,221.17 $1,202.85

# 15260 $943.85 $896.66 $1,031.16 $1,015.69

15261 $240.41 $228.39 $262.65 $258.70

# 15261 $151.92 $144.32 $165.97 $163.48

15271 $148.34 $140.92 $162.06 $159.63

# 15271 $91.64 $87.06 $100.12 $98.61

15272 $27.44 $26.07 $29.98 $29.53

# 15272 $17.87 $16.98 $19.53 $19.24

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

15273 $294.95 $280.20 $322.23 $317.40

# 15273 $205.30 $195.04 $224.30 $220.93

15274 $66.59 $63.26 $72.75 $71.66

# 15274 $43.60 $41.42 $47.63 $46.92

15275 $166.92 $158.57 $182.36 $179.62

# 15275 $110.60 $105.07 $120.83 $119.01

15276 $36.74 $34.90 $40.14 $39.54

# 15276 $27.16 $25.80 $29.67 $29.22

15277 $321.59 $305.51 $351.34 $346.07

# 15277 $229.27 $217.81 $250.48 $246.72

15278 $79.97 $75.97 $87.37 $86.05

# 15278 $55.07 $52.32 $60.17 $59.27

15570 $1,010.96 $960.41 $1,104.47 $1,087.90

# 15570 $805.62 $765.34 $880.14 $866.94

15572 $967.91 $919.51 $1,057.44 $1,041.58

# 15572 $806.25 $765.94 $880.83 $867.62

15574 $1,005.30 $955.04 $1,098.30 $1,081.82

# 15574 $835.97 $794.17 $913.30 $899.60

15576 $894.75 $850.01 $977.51 $962.85

# 15576 $738.06 $701.16 $806.33 $794.24

15600 $369.89 $351.40 $404.11 $398.05

# 15600 $232.74 $221.10 $254.27 $250.45

15610 $402.35 $382.23 $439.56 $432.98

# 15610 $269.04 $255.59 $293.93 $289.52

15620 $494.83 $470.09 $540.60 $532.50

# 15620 $361.89 $343.80 $395.37 $389.44

15630 $517.67 $491.79 $565.56 $557.07

# 15630 $385.50 $366.23 $421.16 $414.85

15650 $565.04 $536.79 $617.31 $608.05

# 15650 $422.91 $401.76 $462.02 $455.09

15731 $1,239.93 $1,177.93 $1,354.62 $1,334.30

# 15731 $1,104.31 $1,049.09 $1,206.45 $1,188.35

15732 $1,421.42 $1,350.35 $1,552.90 $1,529.60

# 15732 $1,234.09 $1,172.39 $1,348.25 $1,328.02

15734 $1,635.11 $1,553.35 $1,786.35 $1,759.56

# 15734 $1,429.00 $1,357.55 $1,561.18 $1,537.77

15736 $1,447.32 $1,374.95 $1,581.19 $1,557.48

# 15736 $1,244.28 $1,182.07 $1,359.38 $1,338.99

15738 $1,532.80 $1,456.16 $1,674.58 $1,649.47

# 15738 $1,341.25 $1,274.19 $1,465.32 $1,443.34

15740 $1,117.97 $1,062.07 $1,221.38 $1,203.06

# 15740 $930.64 $884.11 $1,016.73 $1,001.48

15750 $992.10 $942.50 $1,083.88 $1,067.61

15756 $2,514.19 $2,388.48 $2,746.75 $2,705.55

15757 $2,480.56 $2,356.53 $2,710.01 $2,669.36

15758 $2,478.39 $2,354.47 $2,707.64 $2,667.02

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

15760 $946.14 $898.83 $1,033.65 $1,018.15

# 15760 $779.10 $740.15 $851.17 $838.41

15770 $740.81 $703.77 $809.34 $797.19

15775 $316.09 $300.29 $345.33 $340.16

# 15775 $226.44 $215.12 $247.39 $243.67

15776 $521.67 $495.59 $569.93 $561.38

# 15776 $369.19 $350.73 $403.34 $397.29

15777 $210.87 $200.33 $230.38 $226.93

15780 $1,021.71 $970.62 $1,116.21 $1,099.47

# 15780 $722.89 $686.75 $789.76 $777.92

15781 $620.51 $589.48 $677.90 $667.74

# 15781 $480.68 $456.65 $525.15 $517.27

15782 $638.27 $606.36 $697.31 $686.85

# 15782 $442.12 $420.01 $483.01 $475.77

15783 $543.75 $516.56 $594.04 $585.13

# 15783 $414.65 $393.92 $453.01 $446.21

15786 $278.60 $264.67 $304.37 $299.81

# 15786 $149.11 $141.65 $162.90 $160.46

15787 $56.56 $53.73 $61.79 $60.86

# 15787 $18.63 $17.70 $20.36 $20.04

15788 $542.47 $515.35 $592.65 $583.76

# 15788 $288.47 $274.05 $315.16 $310.43

15789 $615.76 $584.97 $672.72 $662.63

# 15789 $460.99 $437.94 $503.63 $496.08

15792 $509.71 $484.22 $556.85 $548.50

# 15792 $301.69 $286.61 $329.60 $324.66

15793 $557.04 $529.19 $608.57 $599.44

# 15793 $409.17 $388.71 $447.02 $440.31

15819 $795.54 $755.76 $869.12 $856.08

15820 $648.44 $616.02 $708.42 $697.80

# 15820 $582.93 $553.78 $636.85 $627.29

15821 $685.61 $651.33 $749.03 $737.79

# 15821 $613.21 $582.55 $669.93 $659.88

15822 $504.93 $479.68 $551.63 $543.35

# 15822 $440.57 $418.54 $481.32 $474.10

15823 $692.40 $657.78 $756.45 $745.10

# 15823 $618.08 $587.18 $675.26 $665.13

15830 $1,267.32 $1,203.95 $1,384.54 $1,363.77

15832 $1,019.31 $968.34 $1,113.59 $1,096.88

15833 $954.79 $907.05 $1,043.11 $1,027.46

15834 $973.17 $924.51 $1,063.19 $1,047.24

15835 $1,026.11 $974.80 $1,121.02 $1,104.21

15836 $865.84 $822.55 $945.93 $931.74

15837 $982.07 $932.97 $1,072.92 $1,056.83

# 15837 $788.22 $748.81 $861.13 $848.22

15838 $621.56 $590.48 $679.05 $668.86

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 17: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

15839 $958.21 $910.30 $1,046.85 $1,031.15

# 15839 $793.09 $753.44 $866.46 $853.46

15840 $1,104.84 $1,049.60 $1,207.04 $1,188.94

15841 $1,721.44 $1,635.37 $1,880.68 $1,852.47

15842 $2,852.02 $2,709.42 $3,115.83 $3,069.10

15845 $1,109.54 $1,054.06 $1,212.17 $1,193.99

15847 $393.72 $374.03 $430.13 $423.68

15851 $111.53 $105.95 $121.84 $120.01

# 15851 $49.08 $46.63 $53.62 $52.82

15852 $49.03 $46.58 $53.57 $52.76

15860 $118.41 $112.49 $129.36 $127.42

15920 $663.30 $630.14 $724.66 $713.79

15922 $857.61 $814.73 $936.94 $922.89

15931 $736.40 $699.58 $804.52 $792.45

15933 $923.62 $877.44 $1,009.06 $993.92

15934 $998.14 $948.23 $1,090.46 $1,074.11

15935 $1,198.71 $1,138.77 $1,309.59 $1,289.94

15936 $968.12 $919.71 $1,057.67 $1,041.80

15937 $1,126.24 $1,069.93 $1,230.42 $1,211.96

15940 $753.17 $715.51 $822.84 $810.50

15941 $990.86 $941.32 $1,082.52 $1,066.28

15944 $984.19 $934.98 $1,075.23 $1,059.10

15945 $1,078.45 $1,024.53 $1,178.21 $1,160.53

15946 $1,773.14 $1,684.48 $1,937.15 $1,908.09

15950 $635.82 $604.03 $694.63 $684.22

15951 $866.07 $822.77 $946.19 $931.99

15952 $997.32 $947.45 $1,089.57 $1,073.23

15953 $1,089.63 $1,035.15 $1,190.42 $1,172.56

15956 $1,252.29 $1,189.68 $1,368.13 $1,347.60

15958 $1,278.18 $1,214.27 $1,396.41 $1,375.47

16000 $75.03 $71.28 $81.97 $80.74

# 16000 $48.59 $46.16 $53.08 $52.29

16020 $91.05 $86.50 $99.48 $97.98

# 16020 $59.25 $56.29 $64.73 $63.77

16025 $161.93 $153.83 $176.90 $174.25

# 16025 $120.17 $114.16 $131.28 $129.32

16030 $202.25 $192.14 $220.96 $217.65

# 16030 $143.26 $136.10 $156.52 $154.17

16035 $209.78 $199.29 $229.18 $225.75

16036 $85.07 $80.82 $92.94 $91.55

17000 $91.32 $86.75 $99.76 $98.27

# 17000 $61.82 $58.73 $67.54 $66.53

17003 $7.38 $7.01 $8.06 $7.94

# 17003 $4.70 $4.47 $5.14 $5.06

17004 $187.26 $177.90 $204.59 $201.51

# 17004 $141.29 $134.23 $154.36 $152.05

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 18: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

17106 $371.90 $353.31 $406.31 $400.21

# 17106 $296.82 $281.98 $324.28 $319.41

17107 $483.89 $459.70 $528.66 $520.72

# 17107 $383.13 $363.97 $418.57 $412.29

17108 $703.27 $668.11 $768.33 $756.80

# 17108 $570.33 $541.81 $623.08 $613.73

17110 $126.00 $119.70 $137.66 $135.59

# 17110 $77.73 $73.84 $84.92 $83.64

17111 $148.68 $141.25 $162.44 $160.00

# 17111 $94.66 $89.93 $103.42 $101.87

17250 $90.73 $86.19 $99.12 $97.64

# 17250 $40.16 $38.15 $43.87 $43.22

17260 $104.27 $99.06 $113.92 $112.21

# 17260 $75.92 $72.12 $82.94 $81.70

17261 $161.41 $153.34 $176.34 $173.70

# 17261 $100.11 $95.10 $109.37 $107.72

17262 $195.05 $185.30 $213.10 $209.90

# 17262 $126.48 $120.16 $138.18 $136.11

17263 $212.61 $201.98 $232.28 $228.79

# 17263 $139.82 $132.83 $152.75 $150.47

17264 $228.08 $216.68 $249.18 $245.44

# 17264 $149.55 $142.07 $163.38 $160.93

17266 $257.16 $244.30 $280.95 $276.74

# 17266 $174.03 $165.33 $190.13 $187.28

17270 $168.48 $160.06 $184.07 $181.31

# 17270 $109.10 $103.65 $119.20 $117.42

17271 $182.35 $173.23 $199.21 $196.22

# 17271 $121.05 $115.00 $132.25 $130.27

17272 $206.93 $196.58 $226.07 $222.67

# 17272 $138.74 $131.80 $151.57 $149.29

17273 $230.34 $218.82 $251.64 $247.87

# 17273 $156.79 $148.95 $171.29 $168.73

17274 $270.74 $257.20 $295.78 $291.34

# 17274 $190.68 $181.15 $208.32 $205.19

17276 $312.70 $297.07 $341.63 $336.50

# 17276 $229.19 $217.73 $250.39 $246.63

17280 $157.96 $150.06 $172.57 $169.98

# 17280 $99.35 $94.38 $108.54 $106.90

17281 $197.54 $187.66 $215.81 $212.58

# 17281 $135.86 $129.07 $148.43 $146.20

17282 $226.16 $214.85 $247.08 $243.37

# 17282 $156.06 $148.26 $170.50 $167.95

17283 $269.39 $255.92 $294.31 $289.89

# 17283 $194.30 $184.59 $212.28 $209.09

17284 $305.71 $290.42 $333.98 $328.97

# 17284 $225.26 $214.00 $246.10 $242.41

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 19: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

17286 $393.98 $374.28 $430.42 $423.97

# 17286 $307.02 $291.67 $335.42 $330.38

17311 $723.65 $687.47 $790.59 $778.73

# 17311 $402.99 $382.84 $440.27 $433.67

17312 $434.81 $413.07 $475.03 $467.90

# 17312 $213.77 $203.08 $233.54 $230.03

17313 $660.67 $627.64 $721.79 $710.96

# 17313 $361.47 $343.40 $394.91 $388.99

17314 $403.19 $383.03 $440.48 $433.87

# 17314 $198.62 $188.69 $216.99 $213.74

17315 $85.47 $81.20 $93.38 $91.98

# 17315 $55.97 $53.17 $61.15 $60.23

17340 $55.20 $52.44 $60.31 $59.40

# 17340 $52.14 $49.53 $56.96 $56.11

17360 $142.44 $135.32 $155.62 $153.28

# 17360 $106.81 $101.47 $116.69 $114.94

19000 $125.03 $118.78 $136.60 $134.55

# 19000 $44.97 $42.72 $49.13 $48.39

19001 $28.24 $26.83 $30.85 $30.39

# 19001 $22.50 $21.38 $24.59 $24.22

19020 $535.06 $508.31 $584.56 $575.79

# 19020 $334.70 $317.97 $365.67 $360.18

19030 $176.89 $168.05 $193.26 $190.36

# 19030 $79.58 $75.60 $86.94 $85.64

19100 $169.82 $161.33 $185.53 $182.75

# 19100 $72.52 $68.89 $79.22 $78.04

19101 $382.36 $363.24 $417.73 $411.46

# 19101 $237.93 $226.03 $259.93 $256.04

19102 $237.05 $225.20 $258.98 $255.09

# 19102 $105.26 $100.00 $115.00 $113.28

19103 $622.21 $591.10 $679.77 $669.56

# 19103 $197.35 $187.48 $215.60 $212.37

19105 $2,265.95 $2,152.65 $2,475.55 $2,438.41

# 19105 $199.90 $189.91 $218.40 $215.12

19110 $548.95 $521.50 $599.73 $590.73

# 19110 $373.87 $355.18 $408.46 $402.33

19112 $523.97 $497.77 $572.44 $563.85

# 19112 $343.91 $326.71 $375.72 $370.08

19120 $540.09 $513.09 $590.05 $581.20

# 19120 $444.70 $422.47 $485.84 $478.55

19125 $598.94 $568.99 $654.34 $644.53

# 19125 $493.20 $468.54 $538.82 $530.74

19126 $168.62 $160.19 $184.22 $181.46

19260 $1,313.54 $1,247.86 $1,435.04 $1,413.51

19271 $1,780.55 $1,691.52 $1,945.25 $1,916.07

19272 $1,966.22 $1,867.91 $2,148.10 $2,115.87

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

19290 $175.19 $166.43 $191.39 $188.52

# 19290 $66.01 $62.71 $72.12 $71.04

19291 $74.61 $70.88 $81.51 $80.29

# 19291 $32.47 $30.85 $35.48 $34.95

19295 $107.62 $102.24 $117.58 $115.82

19296 $4,846.16 $4,603.85 $5,294.43 $5,215.01

# 19296 $220.63 $209.60 $241.04 $237.43

19297 $98.24 $93.33 $107.33 $105.72

19298 $1,293.18 $1,228.52 $1,412.80 $1,391.60

# 19298 $337.73 $320.84 $368.97 $363.43

19300 $578.62 $549.69 $632.14 $622.66

# 19300 $447.60 $425.22 $489.00 $481.67

19301 $695.73 $660.94 $760.08 $748.68

19302 $958.55 $910.62 $1,047.21 $1,031.50

19303 $1,076.46 $1,022.64 $1,176.04 $1,158.40

19304 $622.48 $591.36 $680.06 $669.86

19305 $1,206.90 $1,146.56 $1,318.54 $1,298.76

19306 $1,285.33 $1,221.06 $1,404.22 $1,383.15

19307 $1,279.23 $1,215.27 $1,397.56 $1,376.60

19316 $833.94 $792.24 $911.08 $897.41

19318 $1,202.85 $1,142.71 $1,314.12 $1,294.41

19324 $531.39 $504.82 $580.54 $571.84

19325 $707.69 $672.31 $773.16 $761.56

19328 $544.14 $516.93 $594.47 $585.56

19330 $693.19 $658.53 $757.31 $745.95

19340 $1,097.87 $1,042.98 $1,199.43 $1,181.44

19342 $1,010.87 $960.33 $1,104.38 $1,087.82

19350 $914.55 $868.82 $999.14 $984.16

# 19350 $738.33 $701.41 $806.62 $794.52

19355 $770.20 $731.69 $841.44 $828.82

# 19355 $612.37 $581.75 $669.01 $658.97

19357 $1,666.65 $1,583.32 $1,820.82 $1,793.51

19361 $1,717.08 $1,631.23 $1,875.91 $1,847.77

19364 $2,986.48 $2,837.16 $3,262.73 $3,213.79

19366 $1,498.40 $1,423.48 $1,637.00 $1,612.45

19367 $1,946.21 $1,848.90 $2,126.24 $2,094.35

19368 $2,389.35 $2,269.88 $2,610.36 $2,571.20

19369 $2,218.45 $2,107.53 $2,423.66 $2,387.31

19370 $752.23 $714.62 $821.81 $809.49

19371 $860.09 $817.09 $939.65 $925.55

19380 $847.92 $805.52 $926.35 $912.46

19396 $333.50 $316.83 $364.35 $358.89

# 19396 $159.95 $151.95 $174.74 $172.12

20005 $342.25 $325.14 $373.91 $368.30

# 20005 $252.99 $240.34 $276.39 $272.24

20100 $637.52 $605.64 $696.49 $686.04

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

20101 $519.45 $493.48 $567.50 $558.99

# 20101 $223.31 $212.14 $243.96 $240.30

20102 $555.93 $528.13 $607.35 $598.24

# 20102 $272.05 $258.45 $297.22 $292.76

20103 $653.60 $620.92 $714.06 $703.35

# 20103 $374.70 $355.97 $409.37 $403.22

20150 $1,083.55 $1,029.37 $1,183.78 $1,166.02

20200 $234.84 $223.10 $256.57 $252.71

# 20200 $101.53 $96.45 $110.92 $109.25

20205 $326.42 $310.10 $356.62 $351.27

# 20205 $165.52 $157.24 $180.83 $178.11

20206 $267.04 $253.69 $291.74 $287.36

# 20206 $62.46 $59.34 $68.24 $67.22

20220 $186.71 $177.37 $203.98 $200.92

# 20220 $76.38 $72.56 $83.44 $82.19

20225 $608.33 $577.91 $664.60 $654.63

# 20225 $116.81 $110.97 $127.62 $125.71

20240 $239.69 $227.71 $261.87 $257.93

20245 $674.89 $641.15 $737.32 $726.26

20250 $420.96 $399.91 $459.90 $453.00

20251 $453.27 $430.61 $495.20 $487.77

20500 $115.77 $109.98 $126.48 $124.58

# 20500 $92.02 $87.42 $100.53 $99.03

20501 $130.41 $123.89 $142.47 $140.33

# 20501 $39.23 $37.27 $42.86 $42.22

20520 $226.84 $215.50 $247.83 $244.11

# 20520 $159.80 $151.81 $174.58 $171.96

20525 $547.60 $520.22 $598.25 $589.28

# 20525 $269.85 $256.36 $294.81 $290.39

20526 $82.45 $78.33 $90.08 $88.73

# 20526 $60.23 $57.22 $65.80 $64.81

20527 $82.21 $78.10 $89.82 $88.47

# 20527 $64.21 $61.00 $70.15 $69.10

20550 $62.99 $59.84 $68.82 $67.78

# 20550 $43.46 $41.29 $47.48 $46.77

20551 $65.29 $62.03 $71.33 $70.27

# 20551 $44.99 $42.74 $49.15 $48.42

20552 $60.28 $57.27 $65.86 $64.87

# 20552 $40.36 $38.34 $44.09 $43.42

20553 $70.30 $66.79 $76.81 $75.66

# 20553 $45.40 $43.13 $49.60 $48.85

20555 $349.72 $332.23 $382.06 $376.34

20600 $50.70 $48.17 $55.40 $54.57

# 20600 $36.91 $35.06 $40.32 $39.71

20605 $70.11 $66.60 $76.59 $75.44

# 20605 $55.55 $52.77 $60.69 $59.78

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

20610 $65.04 $61.79 $71.06 $69.99

# 20610 $48.57 $46.14 $53.06 $52.27

20612 $65.85 $62.56 $71.94 $70.86

# 20612 $44.02 $41.82 $48.09 $47.37

20615 $269.39 $255.92 $294.31 $289.89

# 20615 $175.15 $166.39 $191.35 $188.47

20650 $227.04 $215.69 $248.04 $244.32

# 20650 $167.66 $159.28 $183.17 $180.42

20660 $256.59 $243.76 $280.32 $276.12

20661 $559.36 $531.39 $611.10 $601.93

20662 $457.85 $434.96 $500.20 $492.71

20663 $512.31 $486.69 $559.69 $551.30

20664 $953.62 $905.94 $1,041.83 $1,026.20

20665 $112.07 $106.47 $122.44 $120.60

# 20665 $95.21 $90.45 $104.02 $102.45

20670 $441.77 $419.68 $482.63 $475.39

# 20670 $162.87 $154.73 $177.94 $175.27

20680 $695.63 $660.85 $759.98 $748.58

# 20680 $462.32 $439.20 $505.08 $497.50

20690 $634.98 $603.23 $693.71 $683.31

20692 $1,205.28 $1,145.02 $1,316.77 $1,297.02

20693 $494.47 $469.75 $540.21 $532.11

20694 $471.45 $447.88 $515.06 $507.33

# 20694 $368.78 $350.34 $402.89 $396.84

20696 $1,238.66 $1,176.73 $1,353.24 $1,332.94

20697 $2,473.26 $2,349.60 $2,702.04 $2,661.51

20802 $2,440.20 $2,318.19 $2,665.92 $2,625.93

20805 $3,267.52 $3,104.14 $3,569.76 $3,516.22

20808 $3,847.57 $3,655.19 $4,203.47 $4,140.41

20816 $2,122.12 $2,016.01 $2,318.41 $2,283.64

20822 $1,964.33 $1,866.11 $2,146.03 $2,113.84

20824 $2,294.69 $2,179.96 $2,506.95 $2,469.35

20827 $2,018.07 $1,917.17 $2,204.75 $2,171.67

20838 $2,785.95 $2,646.65 $3,043.65 $2,997.99

20900 $479.26 $455.30 $523.60 $515.74

# 20900 $227.94 $216.54 $249.02 $245.28

20902 $329.48 $313.01 $359.96 $354.56

20910 $494.71 $469.97 $540.47 $532.36

20912 $527.49 $501.12 $576.29 $567.64

20920 $431.62 $410.04 $471.55 $464.47

20922 $675.47 $641.70 $737.96 $726.88

# 20922 $541.77 $514.68 $591.88 $583.00

20924 $549.39 $521.92 $600.21 $591.20

20926 $480.25 $456.24 $524.68 $516.81

20931 $118.41 $112.49 $129.36 $127.42

20937 $177.03 $168.18 $193.41 $190.51

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

20938 $194.56 $184.83 $212.55 $209.37

20950 $294.07 $279.37 $321.28 $316.46

# 20950 $99.83 $94.84 $109.07 $107.43

20955 $2,691.88 $2,557.29 $2,940.88 $2,896.77

20956 $2,827.47 $2,686.10 $3,089.02 $3,042.68

20957 $2,389.45 $2,269.98 $2,610.48 $2,571.32

20962 $2,305.01 $2,189.76 $2,518.22 $2,480.45

20969 $2,995.21 $2,845.45 $3,272.27 $3,223.19

20970 $2,927.61 $2,781.23 $3,198.41 $3,150.44

20972 $2,291.42 $2,176.85 $2,503.38 $2,465.83

20973 $3,009.20 $2,858.74 $3,287.55 $3,238.24

20974 $85.57 $81.29 $93.48 $92.08

# 20974 $54.54 $51.81 $59.58 $58.68

20975 $189.83 $180.34 $207.39 $204.27

20979 $57.71 $54.82 $63.04 $62.10

# 20979 $33.96 $32.26 $37.10 $36.55

20982 $4,052.59 $3,849.96 $4,427.45 $4,361.04

# 20982 $393.23 $373.57 $429.61 $423.17

20985 $155.60 $147.82 $169.99 $167.44

21010 $826.66 $785.33 $903.13 $889.58

21011 $391.10 $371.55 $427.28 $420.88

# 21011 $284.98 $270.73 $311.34 $306.67

21012 $365.98 $347.68 $399.83 $393.83

21013 $576.40 $547.58 $629.72 $620.28

# 21013 $434.65 $412.92 $474.86 $467.74

21014 $564.37 $536.15 $616.57 $607.33

21015 $769.41 $730.94 $840.58 $827.98

21016 $1,115.88 $1,060.09 $1,219.10 $1,200.82

21025 $983.07 $933.92 $1,074.01 $1,057.90

# 21025 $818.34 $777.42 $894.03 $880.62

21026 $695.66 $660.88 $760.01 $748.62

# 21026 $553.53 $525.85 $604.73 $595.65

21029 $867.68 $824.30 $947.95 $933.73

# 21029 $711.76 $676.17 $777.60 $765.93

21030 $581.83 $552.74 $635.65 $626.12

# 21030 $461.54 $438.46 $504.23 $496.66

21031 $440.67 $418.64 $481.44 $474.21

# 21031 $323.83 $307.64 $353.79 $348.48

21032 $450.08 $427.58 $491.72 $484.35

# 21032 $320.59 $304.56 $350.24 $344.99

21034 $1,451.32 $1,378.75 $1,585.56 $1,561.78

# 21034 $1,262.46 $1,199.34 $1,379.24 $1,358.55

21040 $585.31 $556.04 $639.45 $629.86

# 21040 $461.95 $438.85 $504.68 $497.11

21044 $961.13 $913.07 $1,050.03 $1,034.28

21045 $1,326.12 $1,259.81 $1,448.78 $1,427.05

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 24: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

21046 $1,211.89 $1,151.30 $1,324.00 $1,304.13

21047 $1,401.08 $1,331.03 $1,530.68 $1,507.72

21048 $1,242.86 $1,180.72 $1,357.83 $1,337.46

21049 $1,312.94 $1,247.29 $1,434.38 $1,412.87

21050 $946.17 $898.86 $1,033.69 $1,018.19

21060 $897.96 $853.06 $981.02 $966.30

21070 $699.43 $664.46 $764.13 $752.66

21073 $438.24 $416.33 $478.78 $471.60

# 21073 $279.26 $265.30 $305.10 $300.52

21076 $1,076.82 $1,022.98 $1,176.43 $1,158.79

# 21076 $882.59 $838.46 $964.23 $949.76

21077 $2,700.69 $2,565.66 $2,950.51 $2,906.26

# 21077 $2,232.16 $2,120.55 $2,438.63 $2,402.05

21079 $1,825.97 $1,734.67 $1,994.87 $1,964.95

# 21079 $1,482.71 $1,408.57 $1,619.86 $1,595.56

21080 $2,049.99 $1,947.49 $2,239.61 $2,206.02

# 21080 $1,646.97 $1,564.62 $1,799.31 $1,772.32

21081 $1,892.01 $1,797.41 $2,067.02 $2,036.02

# 21081 $1,512.74 $1,437.10 $1,652.67 $1,627.87

21082 $1,800.74 $1,710.70 $1,967.31 $1,937.80

# 21082 $1,430.28 $1,358.77 $1,562.59 $1,539.15

21083 $1,682.74 $1,598.60 $1,838.39 $1,810.81

# 21083 $1,290.07 $1,225.57 $1,409.41 $1,388.27

21084 $1,960.90 $1,862.86 $2,142.29 $2,110.16

# 21084 $1,536.42 $1,459.60 $1,678.54 $1,653.37

21085 $911.04 $865.49 $995.31 $980.39

# 21085 $681.94 $647.84 $745.02 $733.84

21086 $2,013.56 $1,912.88 $2,199.81 $2,166.82

# 21086 $1,646.17 $1,563.86 $1,798.44 $1,771.46

21087 $1,992.87 $1,893.23 $2,177.21 $2,144.55

# 21087 $1,611.30 $1,530.74 $1,760.35 $1,733.95

21088 $1,785.14 $1,695.88 $1,950.26 $1,921.01

21100 $683.56 $649.38 $746.79 $735.59

# 21100 $374.78 $356.04 $409.45 $403.31

21110 $911.27 $865.71 $995.57 $980.63

# 21110 $756.11 $718.30 $826.05 $813.66

21116 $173.19 $164.53 $189.21 $186.37

# 21116 $45.24 $42.98 $49.43 $48.69

21120 $707.65 $672.27 $773.11 $761.52

# 21120 $557.09 $529.24 $608.63 $599.50

21121 $858.63 $815.70 $938.06 $923.98

# 21121 $701.95 $666.85 $766.88 $755.38

21122 $769.03 $730.58 $840.17 $827.56

21123 $956.41 $908.59 $1,044.88 $1,029.20

21125 $4,010.62 $3,810.09 $4,381.60 $4,315.88

# 21125 $850.44 $807.92 $929.11 $915.17

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 25: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

21127 $4,538.02 $4,311.12 $4,957.79 $4,883.42

# 21127 $970.99 $922.44 $1,060.81 $1,044.89

21137 $757.05 $719.20 $827.08 $814.67

21138 $899.09 $854.14 $982.26 $967.53

21139 $1,069.35 $1,015.88 $1,168.26 $1,150.74

21141 $1,473.71 $1,400.02 $1,610.02 $1,585.87

21142 $1,514.05 $1,438.35 $1,654.10 $1,629.29

21143 $1,603.04 $1,522.89 $1,751.32 $1,725.06

21145 $1,615.38 $1,534.61 $1,764.80 $1,738.33

21146 $1,734.23 $1,647.52 $1,894.65 $1,866.23

21147 $1,872.45 $1,778.83 $2,045.65 $2,014.97

21150 $1,640.69 $1,558.66 $1,792.46 $1,765.57

21151 $2,006.86 $1,906.52 $2,192.50 $2,159.61

21154 $2,156.22 $2,048.41 $2,355.67 $2,320.33

21155 $2,314.53 $2,198.80 $2,528.62 $2,490.69

21159 $2,749.09 $2,611.64 $3,003.39 $2,958.34

21160 $2,776.62 $2,637.79 $3,033.46 $2,987.95

21172 $2,018.16 $1,917.25 $2,204.84 $2,171.76

21175 $2,600.29 $2,470.28 $2,840.82 $2,798.21

21179 $1,521.94 $1,445.84 $1,662.72 $1,637.77

21180 $1,641.88 $1,559.79 $1,793.76 $1,766.85

21181 $719.35 $683.38 $785.89 $774.10

21182 $2,271.44 $2,157.87 $2,481.55 $2,444.33

21183 $2,561.25 $2,433.19 $2,798.17 $2,756.19

21184 $2,338.46 $2,221.54 $2,554.77 $2,516.45

21188 $1,711.18 $1,625.62 $1,869.46 $1,841.43

21193 $1,343.03 $1,275.88 $1,467.26 $1,445.25

21194 $1,471.63 $1,398.05 $1,607.76 $1,583.64

21195 $1,458.73 $1,385.79 $1,593.66 $1,569.75

21196 $1,602.71 $1,522.57 $1,750.96 $1,724.69

21198 $1,267.99 $1,204.59 $1,385.28 $1,364.50

21199 $1,080.16 $1,026.15 $1,180.07 $1,162.37

21206 $1,380.84 $1,311.80 $1,508.57 $1,485.94

21208 $2,212.14 $2,101.53 $2,416.76 $2,380.51

# 21208 $942.16 $895.05 $1,029.31 $1,013.86

21209 $943.57 $896.39 $1,030.85 $1,015.38

# 21209 $706.05 $670.75 $771.36 $759.79

21210 $2,647.26 $2,514.90 $2,892.14 $2,848.76

# 21210 $934.43 $887.71 $1,020.87 $1,005.55

21215 $4,777.89 $4,539.00 $5,219.85 $5,141.56

# 21215 $999.00 $949.05 $1,091.41 $1,075.03

21230 $795.73 $755.94 $869.33 $856.29

21235 $819.89 $778.90 $895.74 $882.30

# 21235 $627.57 $596.19 $685.62 $675.34

21240 $1,192.77 $1,133.13 $1,303.10 $1,283.55

21242 $1,091.23 $1,036.67 $1,192.17 $1,174.29

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 26: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

21243 $1,804.60 $1,714.37 $1,971.53 $1,941.95

21244 $1,175.01 $1,116.26 $1,283.70 $1,264.45

21245 $1,239.95 $1,177.95 $1,354.64 $1,334.32

# 21245 $966.80 $918.46 $1,056.23 $1,040.38

21246 $887.51 $843.13 $969.60 $955.05

21247 $1,709.03 $1,623.58 $1,867.12 $1,839.11

21248 $1,218.05 $1,157.15 $1,330.72 $1,310.76

# 21248 $976.32 $927.50 $1,066.63 $1,050.63

21249 $1,653.34 $1,570.67 $1,806.27 $1,779.18

# 21249 $1,329.24 $1,262.78 $1,452.20 $1,430.42

21255 $1,450.78 $1,378.24 $1,584.98 $1,561.21

21256 $1,333.59 $1,266.91 $1,456.95 $1,435.10

21260 $1,343.12 $1,275.96 $1,467.35 $1,445.34

21261 $2,328.84 $2,212.40 $2,544.26 $2,506.09

21263 $2,014.34 $1,913.62 $2,200.66 $2,167.66

21267 $1,827.27 $1,735.91 $1,996.30 $1,966.35

21268 $1,928.20 $1,831.79 $2,106.56 $2,074.96

21270 $1,088.01 $1,033.61 $1,188.65 $1,170.83

# 21270 $804.51 $764.28 $878.92 $865.74

21275 $917.44 $871.57 $1,002.31 $987.28

21280 $649.14 $616.68 $709.18 $698.54

21282 $431.59 $410.01 $471.51 $464.44

21295 $219.37 $208.40 $239.66 $236.06

21296 $492.68 $468.05 $538.26 $530.18

21310 $154.72 $146.98 $169.03 $166.50

# 21310 $28.68 $27.25 $31.34 $30.87

21315 $324.81 $308.57 $354.86 $349.53

# 21315 $170.04 $161.54 $185.77 $182.99

21320 $295.95 $281.15 $323.32 $318.47

# 21320 $148.08 $140.68 $161.78 $159.36

21325 $529.52 $503.04 $578.50 $569.81

21330 $633.94 $602.24 $692.58 $682.19

21335 $803.78 $763.59 $878.13 $864.96

21336 $724.18 $687.97 $791.17 $779.30

21337 $463.41 $440.24 $506.28 $498.69

# 21337 $330.48 $313.96 $361.05 $355.64

21338 $848.24 $805.83 $926.70 $912.80

21339 $954.60 $906.87 $1,042.90 $1,027.26

21340 $895.00 $850.25 $977.79 $963.13

21343 $1,352.76 $1,285.12 $1,477.89 $1,455.72

21344 $1,680.34 $1,596.32 $1,835.77 $1,808.24

21345 $934.03 $887.33 $1,020.43 $1,005.12

# 21345 $731.76 $695.17 $799.45 $787.45

21346 $1,007.39 $957.02 $1,100.57 $1,084.06

21347 $1,224.97 $1,163.72 $1,338.28 $1,318.20

21348 $1,279.34 $1,215.37 $1,397.68 $1,376.71

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

21355 $485.19 $460.93 $530.07 $522.12

# 21355 $352.63 $335.00 $385.25 $379.48

21356 $564.63 $536.40 $616.86 $607.60

# 21356 $416.37 $395.55 $454.88 $448.06

21360 $582.85 $553.71 $636.77 $627.21

21365 $1,205.41 $1,145.14 $1,316.91 $1,297.15

21366 $1,393.77 $1,324.08 $1,522.69 $1,499.85

21385 $748.95 $711.50 $818.23 $805.95

21386 $765.14 $726.88 $835.91 $823.38

21387 $804.34 $764.12 $878.74 $865.56

21390 $879.86 $835.87 $961.25 $946.83

21395 $1,066.32 $1,013.00 $1,164.95 $1,147.48

21400 $221.46 $210.39 $241.95 $238.31

# 21400 $177.78 $168.89 $194.22 $191.31

21401 $533.47 $506.80 $582.82 $574.08

# 21401 $326.21 $309.90 $356.39 $351.04

21406 $614.86 $584.12 $671.74 $661.66

21407 $716.18 $680.37 $782.43 $770.68

21408 $969.89 $921.40 $1,059.61 $1,043.72

21421 $918.81 $872.87 $1,003.80 $988.75

# 21421 $753.70 $716.02 $823.42 $811.07

21422 $729.21 $692.75 $796.66 $784.71

21423 $910.02 $864.52 $994.20 $979.28

21431 $826.41 $785.09 $902.85 $889.31

21432 $790.89 $751.35 $864.05 $851.09

21433 $1,897.30 $1,802.44 $2,072.81 $2,041.71

21435 $1,488.10 $1,413.70 $1,625.76 $1,601.36

21436 $1,913.77 $1,818.08 $2,090.79 $2,059.43

21440 $670.85 $637.31 $732.91 $721.91

# 21440 $540.21 $513.20 $590.18 $581.33

21445 $869.20 $825.74 $949.60 $935.35

# 21445 $697.19 $662.33 $761.68 $750.26

21450 $709.40 $673.93 $775.02 $763.39

# 21450 $563.82 $535.63 $615.97 $606.74

21451 $867.39 $824.02 $947.62 $933.41

# 21451 $719.89 $683.90 $786.49 $774.69

21452 $655.16 $622.40 $715.76 $705.02

# 21452 $390.82 $371.28 $426.97 $420.57

21453 $1,047.21 $994.85 $1,144.08 $1,126.92

# 21453 $889.76 $845.27 $972.06 $957.48

21454 $592.15 $562.54 $646.92 $637.22

21461 $2,503.98 $2,378.78 $2,735.60 $2,694.57

# 21461 $1,060.84 $1,007.80 $1,158.97 $1,141.58

21462 $2,627.34 $2,495.97 $2,870.37 $2,827.31

# 21462 $1,163.13 $1,104.97 $1,270.72 $1,251.66

21465 $1,023.65 $972.47 $1,118.34 $1,101.56

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 28: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

21470 $1,310.04 $1,244.54 $1,431.22 $1,409.75

21480 $112.86 $107.22 $123.30 $121.45

# 21480 $33.94 $32.24 $37.08 $36.52

21485 $801.88 $761.79 $876.06 $862.91

# 21485 $663.58 $630.40 $724.96 $714.08

21490 $1,010.55 $960.02 $1,104.02 $1,087.46

21495 $807.76 $767.37 $882.48 $869.24

21497 $856.32 $813.50 $935.53 $921.50

# 21497 $705.38 $670.11 $770.63 $759.07

21501 $516.61 $490.78 $564.40 $555.93

# 21501 $356.09 $338.29 $389.03 $383.20

21502 $543.62 $516.44 $593.91 $584.99

21510 $486.03 $461.73 $530.99 $523.02

21550 $296.20 $281.39 $323.60 $318.75

# 21550 $172.08 $163.48 $188.00 $185.18

21552 $481.66 $457.58 $526.22 $518.33

21554 $783.53 $744.35 $856.00 $843.16

21555 $468.71 $445.27 $512.06 $504.38

# 21555 $336.92 $320.07 $368.08 $362.56

21556 $578.94 $549.99 $632.49 $623.00

21557 $1,033.75 $982.06 $1,129.37 $1,112.43

21558 $1,434.48 $1,362.76 $1,567.17 $1,543.67

21600 $618.32 $587.40 $675.51 $665.38

21610 $1,219.98 $1,158.98 $1,332.83 $1,312.84

21615 $689.14 $654.68 $752.88 $741.59

21616 $904.80 $859.56 $988.49 $973.67

21620 $557.20 $529.34 $608.74 $599.61

21627 $597.66 $567.78 $652.95 $643.15

21630 $1,316.36 $1,250.54 $1,438.12 $1,416.55

21632 $1,312.48 $1,246.86 $1,433.89 $1,412.38

21685 $1,081.72 $1,027.63 $1,181.77 $1,164.05

21700 $399.71 $379.72 $436.68 $430.12

21705 $592.14 $562.53 $646.91 $637.20

21720 $575.81 $547.02 $629.07 $619.63

21725 $530.87 $504.33 $579.98 $571.29

21740 $1,310.66 $1,245.13 $1,431.90 $1,410.42

21742 $1,127.10 $1,070.75 $1,231.36 $1,212.89

21750 $740.22 $703.21 $808.69 $796.56

21800 $128.06 $121.66 $139.91 $137.82

# 21800 $132.66 $126.03 $144.93 $142.76

21805 $297.79 $282.90 $325.34 $320.46

21810 $568.03 $539.63 $620.57 $611.27

21820 $159.54 $151.56 $174.29 $171.68

# 21820 $163.75 $155.56 $178.89 $176.21

21825 $596.31 $566.49 $651.46 $641.69

21920 $294.94 $280.19 $322.22 $317.39

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 29: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 21920 $178.09 $169.19 $194.57 $191.65

21925 $499.61 $474.63 $545.82 $537.64

# 21925 $388.51 $369.08 $424.44 $418.07

21930 $528.52 $502.09 $577.40 $568.74

# 21930 $398.65 $378.72 $435.53 $429.00

21931 $507.46 $482.09 $554.40 $546.09

21932 $711.59 $676.01 $777.41 $765.75

21933 $792.37 $752.75 $865.66 $852.68

21935 $1,108.04 $1,052.64 $1,210.54 $1,192.38

21936 $1,505.05 $1,429.80 $1,644.27 $1,619.60

22010 $1,025.72 $974.43 $1,120.59 $1,103.78

22015 $974.59 $925.86 $1,064.74 $1,048.77

22100 $1,011.74 $961.15 $1,105.32 $1,088.74

22101 $950.51 $902.98 $1,038.43 $1,022.86

22102 $871.35 $827.78 $951.95 $937.66

22103 $149.25 $141.79 $163.06 $160.61

22110 $1,166.23 $1,107.92 $1,274.11 $1,255.00

22112 $1,154.07 $1,096.37 $1,260.83 $1,241.91

22114 $1,079.11 $1,025.15 $1,178.92 $1,161.24

22116 $147.13 $139.77 $160.74 $158.32

22206 $2,519.12 $2,393.16 $2,752.13 $2,710.85

22207 $2,552.50 $2,424.88 $2,788.61 $2,746.79

22208 $622.26 $591.15 $679.82 $669.62

22210 $1,904.68 $1,809.45 $2,080.87 $2,049.66

22212 $1,588.53 $1,509.10 $1,735.47 $1,709.43

22214 $1,596.43 $1,516.61 $1,744.10 $1,717.94

22216 $384.98 $365.73 $420.59 $414.28

22220 $1,750.72 $1,663.18 $1,912.66 $1,883.96

22222 $1,549.23 $1,471.77 $1,692.54 $1,667.14

22224 $1,707.47 $1,622.10 $1,865.42 $1,837.44

22226 $385.55 $366.27 $421.21 $414.90

22305 $212.31 $201.69 $231.94 $228.46

# 22305 $191.24 $181.68 $208.93 $205.79

22310 $334.11 $317.40 $365.01 $359.54

# 22310 $305.37 $290.10 $333.62 $328.61

22315 $967.85 $919.46 $1,057.38 $1,041.52

# 22315 $837.98 $796.08 $915.49 $901.76

22318 $1,757.62 $1,669.74 $1,920.20 $1,891.39

22319 $1,961.18 $1,863.12 $2,142.59 $2,110.45

22325 $1,555.68 $1,477.90 $1,699.59 $1,674.09

22326 $1,602.64 $1,522.51 $1,750.89 $1,724.62

22327 $1,603.61 $1,523.43 $1,751.94 $1,725.67

22328 $299.32 $284.35 $327.00 $322.09

22505 $132.35 $125.73 $144.59 $142.42

22520 $2,595.65 $2,465.87 $2,835.75 $2,793.21

# 22520 $534.19 $507.48 $583.60 $574.85

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 30: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

22521 $2,600.50 $2,470.48 $2,841.05 $2,798.43

# 22521 $510.70 $485.17 $557.95 $549.57

22522 $234.85 $223.11 $256.58 $252.72

22523 $8,964.09 $8,515.89 $9,793.27 $9,646.37

# 22523 $600.28 $570.27 $655.81 $645.98

22524 $8,912.52 $8,466.89 $9,736.92 $9,590.87

# 22524 $570.54 $542.01 $623.31 $613.96

22525 $5,523.32 $5,247.15 $6,034.22 $5,943.71

# 22525 $270.65 $257.12 $295.69 $291.25

22532 $1,915.18 $1,819.42 $2,092.33 $2,060.95

22533 $1,799.77 $1,709.78 $1,966.25 $1,936.75

22534 $384.14 $364.93 $419.67 $413.38

22548 $2,108.48 $2,003.06 $2,303.52 $2,268.96

22551 $1,841.72 $1,749.63 $2,012.07 $1,981.90

22552 $417.42 $396.55 $456.03 $449.19

22554 $1,369.84 $1,301.35 $1,496.55 $1,474.10

22556 $1,787.15 $1,697.79 $1,952.46 $1,923.17

22558 $1,653.02 $1,570.37 $1,805.93 $1,778.83

22585 $354.40 $336.68 $387.18 $381.37

22586 $1,614.44 $1,533.72 $1,763.78 $1,737.32

22590 $1,703.02 $1,617.87 $1,860.55 $1,832.64

22595 $1,622.91 $1,541.76 $1,773.02 $1,746.42

22600 $1,395.81 $1,326.02 $1,524.92 $1,502.05

22610 $1,364.56 $1,296.33 $1,490.78 $1,468.42

22612 $1,713.13 $1,627.47 $1,871.59 $1,843.52

22614 $414.25 $393.54 $452.57 $445.79

22630 $1,663.38 $1,580.21 $1,817.24 $1,789.99

22632 $338.48 $321.56 $369.79 $364.25

22633 $1,970.41 $1,871.89 $2,152.67 $2,120.38

22634 $525.51 $499.23 $574.11 $565.50

22800 $1,461.11 $1,388.05 $1,596.26 $1,572.31

22802 $2,244.40 $2,132.18 $2,452.01 $2,415.23

22804 $2,579.77 $2,450.78 $2,818.40 $2,776.12

22808 $1,956.55 $1,858.72 $2,137.53 $2,105.47

22810 $2,172.64 $2,064.01 $2,373.61 $2,338.01

22812 $2,366.43 $2,248.11 $2,585.33 $2,546.55

22818 $2,351.94 $2,234.34 $2,569.49 $2,530.94

22819 $2,934.15 $2,787.44 $3,205.56 $3,157.47

22830 $878.64 $834.71 $959.92 $945.52

22840 $808.04 $767.64 $882.79 $869.55

22842 $808.77 $768.33 $883.58 $870.33

22843 $860.25 $817.24 $939.83 $925.73

22844 $1,035.26 $983.50 $1,131.03 $1,114.06

22845 $780.50 $741.48 $852.70 $839.91

22846 $809.58 $769.10 $884.47 $871.19

22847 $923.23 $877.07 $1,008.63 $993.50

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

22848 $378.56 $359.63 $413.57 $407.38

22849 $1,396.50 $1,326.68 $1,525.68 $1,502.80

22850 $783.69 $744.51 $856.19 $843.34

22851 $432.87 $411.23 $472.91 $465.82

22852 $750.60 $713.07 $820.03 $807.73

22855 $1,206.74 $1,146.40 $1,318.36 $1,298.58

22856 $1,791.51 $1,701.93 $1,957.22 $1,927.86

22857 $1,508.04 $1,432.64 $1,647.54 $1,622.82

22861 $2,386.44 $2,267.12 $2,607.19 $2,568.08

22862 $2,009.94 $1,909.44 $2,195.86 $2,162.92

22864 $2,133.10 $2,026.45 $2,330.42 $2,295.46

22865 $2,242.65 $2,130.52 $2,450.10 $2,413.34

22900 $606.11 $575.80 $662.17 $652.23

22901 $712.03 $676.43 $777.89 $766.22

22902 $482.96 $458.81 $527.63 $519.72

# 22902 $353.48 $335.81 $386.18 $380.39

22903 $469.18 $445.72 $512.58 $504.88

22904 $1,125.10 $1,068.85 $1,229.18 $1,210.74

22905 $1,418.49 $1,347.57 $1,549.71 $1,526.46

23000 $663.92 $630.72 $725.33 $714.45

# 23000 $406.87 $386.53 $444.51 $437.84

23020 $746.19 $708.88 $815.21 $802.99

23030 $501.00 $475.95 $547.34 $539.13

# 23030 $277.65 $263.77 $303.34 $298.78

23031 $482.77 $458.63 $527.42 $519.51

# 23031 $238.35 $226.43 $260.39 $256.48

23035 $737.33 $700.46 $805.53 $793.44

23040 $778.97 $740.02 $851.02 $838.26

23044 $616.57 $585.74 $673.60 $663.49

23065 $243.20 $231.04 $265.70 $261.71

# 23065 $184.58 $175.35 $201.65 $198.63

23066 $620.57 $589.54 $677.97 $667.81

# 23066 $385.73 $366.44 $421.41 $415.08

23071 $453.66 $430.98 $495.63 $488.20

23073 $744.31 $707.09 $813.15 $800.95

23075 $528.12 $501.71 $576.97 $568.31

# 23075 $357.26 $339.40 $390.31 $384.46

23076 $583.47 $554.30 $637.45 $627.89

23077 $1,218.83 $1,157.89 $1,331.57 $1,311.60

23078 $1,537.39 $1,460.52 $1,679.60 $1,654.40

23100 $545.69 $518.41 $596.17 $587.22

23101 $484.06 $459.86 $528.84 $520.90

23105 $692.64 $658.01 $756.71 $745.36

23106 $541.37 $514.30 $591.45 $582.58

23107 $716.77 $680.93 $783.07 $771.33

23120 $638.85 $606.91 $697.95 $687.48

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 32: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

23125 $765.63 $727.35 $836.45 $823.91

23130 $662.61 $629.48 $723.90 $713.05

23140 $575.95 $547.15 $629.22 $619.78

23145 $750.89 $713.35 $820.35 $808.05

23146 $673.57 $639.89 $735.87 $724.83

23150 $715.48 $679.71 $781.67 $769.94

23155 $856.35 $813.53 $935.56 $921.53

23156 $733.29 $696.63 $801.12 $789.11

23170 $608.57 $578.14 $664.86 $654.89

23172 $615.38 $584.61 $672.30 $662.22

23174 $821.41 $780.34 $897.39 $883.92

23180 $724.88 $688.64 $791.94 $780.06

23182 $719.29 $683.33 $785.83 $774.04

23184 $795.29 $755.53 $868.86 $855.83

23190 $618.21 $587.30 $675.40 $665.26

23195 $815.54 $774.76 $890.97 $877.61

23200 $1,624.72 $1,543.48 $1,775.00 $1,748.38

23210 $1,904.66 $1,809.43 $2,080.84 $2,049.63

23220 $2,090.35 $1,985.83 $2,283.70 $2,249.45

23330 $307.92 $292.52 $336.40 $331.35

# 23330 $182.65 $173.52 $199.55 $196.56

23331 $643.25 $611.09 $702.75 $692.21

23332 $952.91 $905.26 $1,041.05 $1,025.43

23350 $143.26 $136.10 $156.52 $154.17

# 23350 $52.85 $50.21 $57.74 $56.88

23395 $1,386.16 $1,316.85 $1,514.38 $1,491.67

23397 $1,224.35 $1,163.13 $1,337.60 $1,317.53

23400 $1,044.31 $992.09 $1,140.90 $1,123.79

23405 $679.40 $645.43 $742.24 $731.11

23406 $831.63 $790.05 $908.56 $894.93

23410 $888.72 $844.28 $970.92 $956.36

23412 $921.40 $875.33 $1,006.63 $991.53

23415 $755.05 $717.30 $824.90 $812.52

23420 $1,047.65 $995.27 $1,144.56 $1,127.39

23430 $811.78 $771.19 $886.87 $873.56

23440 $815.96 $775.16 $891.43 $878.06

23450 $1,019.71 $968.72 $1,114.03 $1,097.32

23455 $1,077.90 $1,024.01 $1,177.61 $1,159.95

23460 $1,170.74 $1,112.20 $1,279.03 $1,259.85

23462 $1,146.60 $1,089.27 $1,252.66 $1,233.87

23465 $1,201.75 $1,141.66 $1,312.91 $1,293.22

23466 $1,212.98 $1,152.33 $1,325.18 $1,305.31

23470 $1,295.61 $1,230.83 $1,415.45 $1,394.23

23472 $1,569.39 $1,490.92 $1,714.56 $1,688.84

23473 $1,746.46 $1,659.14 $1,908.01 $1,879.39

23474 $1,885.88 $1,791.59 $2,060.33 $2,029.43

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 33: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

23480 $883.86 $839.67 $965.62 $951.13

23485 $1,030.81 $979.27 $1,126.16 $1,109.27

23490 $928.38 $881.96 $1,014.25 $999.04

23491 $1,090.98 $1,036.43 $1,191.89 $1,174.01

23500 $243.82 $231.63 $266.37 $262.38

# 23500 $248.03 $235.63 $270.97 $266.92

23505 $389.27 $369.81 $425.28 $418.90

# 23505 $365.90 $347.61 $399.75 $393.76

23515 $782.31 $743.19 $854.67 $841.85

23520 $255.71 $242.92 $279.36 $275.17

# 23520 $260.31 $247.29 $284.38 $280.12

23525 $418.12 $397.21 $456.79 $449.94

# 23525 $385.17 $365.91 $420.80 $414.48

23530 $620.85 $589.81 $678.28 $668.10

23532 $676.15 $642.34 $738.69 $727.61

23540 $249.00 $236.55 $272.03 $267.95

# 23540 $253.60 $240.92 $277.06 $272.91

23545 $387.58 $368.20 $423.43 $417.08

# 23545 $349.27 $331.81 $381.58 $375.85

23550 $618.19 $587.28 $675.37 $665.24

23552 $712.38 $676.76 $778.27 $766.60

23570 $257.38 $244.51 $281.19 $276.97

# 23570 $266.19 $252.88 $290.81 $286.45

23575 $441.94 $419.84 $482.82 $475.57

# 23575 $412.06 $391.46 $450.18 $443.43

23585 $1,059.06 $1,006.11 $1,157.03 $1,139.67

23600 $366.19 $347.88 $400.06 $394.06

# 23600 $343.58 $326.40 $375.36 $369.73

23605 $513.26 $487.60 $560.74 $552.33

# 23605 $466.91 $443.56 $510.09 $502.45

23615 $957.76 $909.87 $1,046.35 $1,030.65

23616 $1,335.08 $1,268.33 $1,458.58 $1,436.71

23620 $301.38 $286.31 $329.26 $324.32

# 23620 $286.06 $271.76 $312.52 $307.83

23625 $420.32 $399.30 $459.20 $452.31

# 23625 $389.29 $369.83 $425.30 $418.92

23630 $849.54 $807.06 $928.12 $914.19

23650 $348.89 $331.45 $381.17 $375.45

# 23650 $318.24 $302.33 $347.68 $342.47

23655 $438.37 $416.45 $478.92 $471.73

23660 $634.33 $602.61 $693.00 $682.61

23665 $469.00 $445.55 $512.38 $504.70

# 23665 $434.52 $412.79 $474.71 $467.59

23670 $949.41 $901.94 $1,037.23 $1,021.67

23675 $602.96 $572.81 $658.73 $648.85

# 23675 $545.11 $517.85 $595.53 $586.59

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 34: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

23680 $1,002.53 $952.40 $1,095.26 $1,078.83

23700 $212.43 $201.81 $232.08 $228.60

23800 $1,103.16 $1,048.00 $1,205.20 $1,187.12

23802 $1,381.15 $1,312.09 $1,508.90 $1,486.27

23900 $1,487.30 $1,412.94 $1,624.88 $1,600.51

23920 $1,211.99 $1,151.39 $1,324.10 $1,304.24

23921 $519.05 $493.10 $567.07 $558.56

23930 $400.24 $380.23 $437.26 $430.71

# 23930 $234.74 $223.00 $256.45 $252.61

23931 $326.17 $309.86 $356.34 $350.99

# 23931 $175.61 $166.83 $191.85 $188.98

23935 $553.42 $525.75 $604.61 $595.54

24000 $518.29 $492.38 $566.24 $557.74

24006 $769.68 $731.20 $840.88 $828.26

24065 $291.42 $276.85 $318.38 $313.61

# 24065 $184.54 $175.31 $201.61 $198.58

24066 $700.82 $665.78 $765.65 $754.16

# 24066 $450.66 $428.13 $492.35 $484.97

24071 $439.22 $417.26 $479.85 $472.65

24073 $741.71 $704.62 $810.31 $798.16

24075 $554.89 $527.15 $606.22 $597.13

# 24075 $361.04 $342.99 $394.44 $388.53

24076 $588.54 $559.11 $642.98 $633.33

24077 $1,114.26 $1,058.55 $1,217.33 $1,199.07

24079 $1,417.97 $1,347.07 $1,549.13 $1,525.89

24100 $456.45 $433.63 $498.67 $491.20

24101 $544.21 $517.00 $594.55 $585.64

24102 $666.14 $632.83 $727.75 $716.84

24105 $386.38 $367.06 $422.12 $415.78

24110 $638.06 $606.16 $697.08 $686.63

24115 $795.82 $756.03 $869.43 $856.39

24116 $927.34 $880.97 $1,013.12 $997.92

24120 $575.08 $546.33 $628.28 $618.86

24125 $672.21 $638.60 $734.39 $723.37

24126 $702.40 $667.28 $767.37 $755.86

24130 $551.47 $523.90 $602.49 $593.45

24134 $806.54 $766.21 $881.14 $867.93

24136 $682.61 $648.48 $745.75 $734.56

24138 $734.32 $697.60 $802.24 $790.21

24140 $758.21 $720.30 $828.35 $815.93

24145 $640.96 $608.91 $700.25 $689.75

24147 $676.56 $642.73 $739.14 $728.05

24149 $1,264.73 $1,201.49 $1,381.71 $1,360.99

24150 $1,666.45 $1,583.13 $1,820.60 $1,793.29

24152 $1,449.77 $1,377.28 $1,583.87 $1,560.11

24155 $918.34 $872.42 $1,003.28 $988.23

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 35: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

24160 $656.10 $623.30 $716.80 $706.04

24164 $540.13 $513.12 $590.09 $581.23

24200 $229.82 $218.33 $251.08 $247.32

# 24200 $152.43 $144.81 $166.53 $164.04

24201 $628.85 $597.41 $687.02 $676.72

# 24201 $398.22 $378.31 $435.06 $428.54

24220 $178.88 $169.94 $195.43 $192.50

# 24220 $71.23 $67.67 $77.82 $76.65

24300 $460.16 $437.15 $502.72 $495.18

24301 $805.89 $765.60 $880.44 $867.24

24305 $624.90 $593.66 $682.71 $672.47

24310 $519.27 $493.31 $567.31 $558.80

24320 $841.80 $799.71 $919.67 $905.87

24330 $774.97 $736.22 $846.65 $833.96

24331 $847.55 $805.17 $925.95 $912.05

24332 $664.71 $631.47 $726.19 $715.30

24340 $667.47 $634.10 $729.22 $718.28

24341 $815.69 $774.91 $891.15 $877.78

24342 $838.93 $796.98 $916.53 $902.78

24343 $765.65 $727.37 $836.48 $823.93

24344 $1,184.36 $1,125.14 $1,293.91 $1,274.50

24345 $761.44 $723.37 $831.88 $819.40

24346 $1,185.89 $1,126.60 $1,295.59 $1,276.16

24357 $480.74 $456.70 $525.21 $517.33

24358 $569.25 $540.79 $621.91 $612.58

24359 $712.66 $677.03 $778.58 $766.90

24360 $967.71 $919.32 $1,057.22 $1,041.36

24361 $1,081.56 $1,027.48 $1,181.60 $1,163.88

24362 $1,139.06 $1,082.11 $1,244.43 $1,225.76

24363 $1,559.76 $1,481.77 $1,704.04 $1,678.47

24365 $690.52 $655.99 $754.39 $743.07

24366 $733.63 $696.95 $801.49 $789.48

24370 $1,651.50 $1,568.93 $1,804.27 $1,777.21

24371 $1,901.24 $1,806.18 $2,077.11 $2,045.95

24400 $888.25 $843.84 $970.42 $955.86

24410 $1,165.23 $1,106.97 $1,273.02 $1,253.93

24420 $1,071.71 $1,018.12 $1,170.84 $1,153.28

24430 $1,139.17 $1,082.21 $1,244.54 $1,225.88

24435 $1,163.53 $1,105.35 $1,271.15 $1,252.09

24470 $624.45 $593.23 $682.21 $671.98

24495 $699.40 $664.43 $764.09 $752.63

24498 $934.82 $888.08 $1,021.29 $1,005.97

24500 $399.04 $379.09 $435.95 $429.41

# 24500 $361.11 $343.05 $394.51 $388.59

24505 $553.27 $525.61 $604.45 $595.39

# 24505 $496.57 $471.74 $542.50 $534.36

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 36: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

24515 $947.46 $900.09 $1,035.10 $1,019.58

24516 $927.56 $881.18 $1,013.36 $998.15

24530 $422.80 $401.66 $461.91 $454.99

# 24530 $380.27 $361.26 $415.45 $409.22

24535 $674.96 $641.21 $737.39 $726.33

# 24535 $619.79 $588.80 $677.12 $666.97

24538 $807.22 $766.86 $881.89 $868.66

24545 $1,002.55 $952.42 $1,095.28 $1,078.85

24546 $1,120.99 $1,064.94 $1,224.68 $1,206.32

24560 $360.57 $342.54 $393.92 $388.01

# 24560 $320.34 $304.32 $349.97 $344.72

24565 $586.49 $557.17 $640.75 $631.13

# 24565 $534.38 $507.66 $583.81 $575.06

24566 $781.36 $742.29 $853.63 $840.83

24575 $796.44 $756.62 $870.11 $857.06

24576 $381.65 $362.57 $416.96 $410.70

# 24576 $340.28 $323.27 $371.76 $366.18

24577 $603.18 $573.02 $658.97 $649.08

# 24577 $548.39 $520.97 $599.12 $590.13

24579 $904.30 $859.09 $987.95 $973.13

24582 $880.79 $836.75 $962.26 $947.83

24586 $1,163.05 $1,104.90 $1,270.64 $1,251.58

24587 $1,165.26 $1,107.00 $1,273.05 $1,253.96

24600 $403.70 $383.52 $441.05 $434.44

# 24600 $366.93 $348.58 $400.87 $394.85

24605 $514.34 $488.62 $561.91 $553.48

24615 $768.92 $730.47 $840.04 $827.44

24620 $602.19 $572.08 $657.89 $648.03

24635 $730.16 $693.65 $797.70 $785.74

24640 $160.02 $152.02 $174.82 $172.20

# 24640 $104.85 $99.61 $114.55 $112.84

24650 $293.62 $278.94 $320.78 $315.97

# 24650 $267.95 $254.55 $292.73 $288.34

24655 $485.67 $461.39 $530.60 $522.64

# 24655 $439.31 $417.34 $479.94 $472.74

24665 $708.58 $673.15 $774.12 $762.51

24666 $793.66 $753.98 $867.08 $854.07

24670 $325.76 $309.47 $355.89 $350.55

# 24670 $292.04 $277.44 $319.06 $314.27

24675 $504.36 $479.14 $551.01 $542.74

# 24675 $456.85 $434.01 $499.11 $491.63

24685 $712.68 $677.05 $778.61 $766.92

24800 $895.08 $850.33 $977.88 $963.22

24802 $1,076.93 $1,023.08 $1,176.54 $1,158.89

24900 $792.10 $752.50 $865.38 $852.39

24920 $716.86 $681.02 $783.17 $771.42

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 37: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

24925 $613.94 $583.24 $670.73 $660.66

24930 $833.86 $792.17 $911.00 $897.33

24931 $818.62 $777.69 $894.34 $880.92

24935 $1,125.66 $1,069.38 $1,229.79 $1,211.34

25000 $370.57 $352.04 $404.85 $398.77

25001 $378.06 $359.16 $413.03 $406.84

25020 $634.74 $603.00 $693.45 $683.05

25023 $1,211.48 $1,150.91 $1,323.55 $1,303.70

25024 $850.15 $807.64 $928.79 $914.86

25025 $1,316.04 $1,250.24 $1,437.78 $1,416.21

25028 $581.29 $552.23 $635.06 $625.54

25031 $380.53 $361.50 $415.73 $409.49

25035 $632.89 $601.25 $691.44 $681.06

25040 $607.70 $577.32 $663.92 $653.96

25065 $289.47 $275.00 $316.25 $311.51

# 25065 $181.05 $172.00 $197.80 $194.83

25066 $390.92 $371.37 $427.08 $420.67

25071 $460.67 $437.64 $503.29 $495.74

25073 $575.69 $546.91 $628.95 $619.52

25075 $541.93 $514.83 $592.05 $583.18

# 25075 $346.94 $329.59 $379.03 $373.35

25076 $560.07 $532.07 $611.88 $602.70

25077 $950.72 $903.18 $1,038.66 $1,023.07

25078 $1,254.21 $1,191.50 $1,370.23 $1,349.67

25085 $490.56 $466.03 $535.93 $527.90

25100 $378.85 $359.91 $413.90 $407.69

25101 $441.90 $419.81 $482.78 $475.54

25105 $525.21 $498.95 $573.79 $565.19

25107 $668.28 $634.87 $730.10 $719.15

25109 $582.07 $552.97 $635.92 $626.38

25110 $371.20 $352.64 $405.54 $399.45

25111 $351.79 $334.20 $384.33 $378.57

25112 $421.87 $400.78 $460.90 $453.99

25115 $819.05 $778.10 $894.82 $881.39

25116 $652.39 $619.77 $712.74 $702.04

25118 $415.73 $394.94 $454.18 $447.37

25119 $539.91 $512.91 $589.85 $581.00

25120 $540.98 $513.93 $591.02 $582.15

25125 $646.14 $613.83 $705.90 $695.31

25126 $647.40 $615.03 $707.28 $696.67

25130 $487.40 $463.03 $532.48 $524.49

25135 $606.05 $575.75 $662.11 $652.18

25136 $536.74 $509.90 $586.39 $577.59

25145 $561.55 $533.47 $613.49 $604.29

25150 $611.58 $581.00 $668.15 $658.13

25151 $633.85 $602.16 $692.48 $682.10

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 38: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

25170 $1,583.52 $1,504.34 $1,729.99 $1,704.04

25210 $530.27 $503.76 $579.32 $570.63

25215 $665.45 $632.18 $727.01 $716.11

25230 $467.55 $444.17 $510.80 $503.14

25240 $465.44 $442.17 $508.50 $500.87

25246 $177.56 $168.68 $193.98 $191.07

# 25246 $77.57 $73.69 $84.74 $83.47

25248 $448.58 $426.15 $490.07 $482.72

25250 $575.17 $546.41 $628.37 $618.94

25251 $776.37 $737.55 $848.18 $835.46

25259 $460.54 $437.51 $503.14 $495.59

25260 $684.74 $650.50 $748.08 $736.85

25263 $683.32 $649.15 $746.52 $735.32

25265 $808.20 $767.79 $882.96 $869.71

25270 $532.94 $506.29 $582.23 $573.51

25272 $600.42 $570.40 $655.96 $646.12

25274 $722.87 $686.73 $789.74 $777.89

25275 $730.84 $694.30 $798.45 $786.47

25280 $610.23 $579.72 $666.68 $656.67

25290 $474.01 $450.31 $517.86 $510.09

25295 $565.40 $537.13 $617.70 $608.43

25300 $746.31 $708.99 $815.34 $803.11

25301 $695.17 $660.41 $759.47 $748.08

25310 $668.76 $635.32 $730.62 $719.66

25312 $775.25 $736.49 $846.96 $834.26

25315 $830.29 $788.78 $907.10 $893.49

25316 $962.78 $914.64 $1,051.84 $1,036.06

25320 $1,070.70 $1,017.17 $1,169.75 $1,152.20

25332 $909.80 $864.31 $993.96 $979.05

25335 $977.78 $928.89 $1,068.22 $1,052.20

25337 $961.26 $913.20 $1,050.18 $1,034.43

25350 $726.61 $690.28 $793.82 $781.92

25355 $826.31 $784.99 $902.74 $889.20

25360 $707.83 $672.44 $773.31 $761.70

25365 $984.28 $935.07 $1,075.33 $1,059.20

25370 $1,083.60 $1,029.42 $1,183.83 $1,166.08

25375 $976.83 $927.99 $1,067.19 $1,051.18

25390 $827.00 $785.65 $903.50 $889.95

25391 $1,070.18 $1,016.67 $1,169.17 $1,151.63

25392 $1,089.22 $1,034.76 $1,189.97 $1,172.13

25393 $1,212.12 $1,151.51 $1,324.24 $1,304.38

25394 $844.90 $802.66 $923.06 $909.21

25400 $863.86 $820.67 $943.77 $929.61

25405 $1,111.11 $1,055.55 $1,213.88 $1,195.68

25415 $1,039.63 $987.65 $1,135.80 $1,118.77

25420 $1,253.42 $1,190.75 $1,369.36 $1,348.82

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 39: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

25425 $1,034.97 $983.22 $1,130.70 $1,113.74

25426 $1,204.58 $1,144.35 $1,316.00 $1,296.26

25430 $766.87 $728.53 $837.81 $825.24

25431 $850.86 $808.32 $929.57 $915.63

25440 $827.04 $785.69 $903.54 $889.99

25441 $985.79 $936.50 $1,076.98 $1,060.82

25442 $846.38 $804.06 $924.67 $910.80

25443 $843.00 $800.85 $920.98 $907.17

25444 $848.47 $806.05 $926.96 $913.05

25445 $776.51 $737.68 $848.33 $835.60

25446 $1,247.54 $1,185.16 $1,362.93 $1,342.49

25447 $892.25 $847.64 $974.79 $960.17

25449 $1,117.29 $1,061.43 $1,220.64 $1,202.34

25450 $667.16 $633.80 $728.87 $717.93

25455 $631.18 $599.62 $689.56 $679.22

25490 $752.89 $715.25 $822.54 $810.20

25491 $797.63 $757.75 $871.41 $858.34

25492 $846.69 $804.36 $925.01 $911.13

25500 $303.23 $288.07 $331.28 $326.31

# 25500 $276.80 $262.96 $302.40 $297.87

25505 $555.79 $528.00 $607.20 $598.09

# 25505 $505.60 $480.32 $552.37 $544.09

25515 $726.33 $690.01 $793.51 $781.61

25520 $621.46 $590.39 $678.95 $668.76

# 25520 $586.98 $557.63 $641.27 $631.66

25525 $845.56 $803.28 $923.77 $909.91

25526 $1,030.79 $979.25 $1,126.14 $1,109.24

25530 $294.28 $279.57 $321.51 $316.69

# 25530 $264.40 $251.18 $288.86 $284.52

25535 $540.05 $513.05 $590.01 $581.15

# 25535 $497.14 $472.28 $543.12 $534.98

25545 $677.36 $643.49 $740.01 $728.92

25560 $311.61 $296.03 $340.43 $335.33

# 25560 $279.81 $265.82 $305.69 $301.10

25565 $575.24 $546.48 $628.45 $619.02

# 25565 $517.01 $491.16 $564.83 $556.36

25574 $731.61 $695.03 $799.28 $787.29

25575 $972.90 $924.26 $1,062.90 $1,046.96

25600 $368.67 $350.24 $402.78 $396.74

# 25600 $347.98 $330.58 $380.17 $374.46

25605 $604.56 $574.33 $660.48 $650.58

# 25605 $565.87 $537.58 $618.22 $608.95

25606 $720.58 $684.55 $787.23 $775.42

25607 $797.90 $758.01 $871.71 $858.64

25608 $890.66 $846.13 $973.05 $958.46

25609 $1,129.97 $1,073.47 $1,234.49 $1,215.98

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 40: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

25622 $341.05 $324.00 $372.60 $367.01

# 25622 $308.87 $293.43 $337.44 $332.38

25624 $527.60 $501.22 $576.40 $567.76

# 25624 $477.03 $453.18 $521.16 $513.34

25628 $776.28 $737.47 $848.09 $835.37

25630 $339.32 $322.35 $370.70 $365.14

# 25630 $309.82 $294.33 $338.48 $333.41

25635 $502.83 $477.69 $549.34 $541.10

# 25635 $442.69 $420.56 $483.64 $476.39

25645 $616.88 $586.04 $673.95 $663.84

25650 $356.50 $338.68 $389.48 $383.64

# 25650 $332.75 $316.11 $363.53 $358.08

25651 $528.99 $502.54 $577.92 $569.25

25652 $673.97 $640.27 $736.31 $725.27

25660 $449.03 $426.58 $490.57 $483.21

25670 $652.33 $619.71 $712.67 $701.97

25671 $579.48 $550.51 $633.09 $623.59

25675 $489.65 $465.17 $534.95 $526.92

# 25675 $444.45 $422.23 $485.56 $478.29

25676 $682.15 $648.04 $745.25 $734.07

25680 $521.83 $495.74 $570.10 $561.55

25685 $793.30 $753.64 $866.69 $853.69

25690 $525.79 $499.50 $574.43 $565.81

25695 $683.72 $649.53 $746.96 $735.76

25800 $788.45 $749.03 $861.38 $848.46

25805 $909.89 $864.40 $994.06 $979.14

25810 $934.50 $887.78 $1,020.95 $1,005.63

25820 $669.62 $636.14 $731.56 $720.59

25825 $820.40 $779.38 $896.29 $882.84

25830 $1,048.19 $995.78 $1,145.15 $1,127.97

25900 $767.08 $728.73 $838.04 $825.47

25905 $756.61 $718.78 $826.60 $814.20

25907 $663.19 $630.03 $724.53 $713.67

25909 $739.36 $702.39 $807.75 $795.63

25915 $1,098.09 $1,043.19 $1,199.67 $1,181.67

25920 $755.85 $718.06 $825.77 $813.38

25922 $630.52 $598.99 $688.84 $678.51

25924 $742.65 $705.52 $811.35 $799.18

25927 $892.73 $848.09 $975.30 $960.68

25929 $646.29 $613.98 $706.08 $695.49

25931 $810.94 $770.39 $885.95 $872.65

26010 $302.74 $287.60 $330.74 $325.78

# 26010 $152.94 $145.29 $167.08 $164.58

26011 $445.28 $423.02 $486.47 $479.17

# 26011 $202.01 $191.91 $220.70 $217.38

26020 $475.02 $451.27 $518.96 $511.18

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 41: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

26025 $461.28 $438.22 $503.95 $496.40

26030 $534.57 $507.84 $584.02 $575.25

26034 $587.06 $557.71 $641.37 $631.74

26035 $928.61 $882.18 $1,014.51 $999.29

26037 $617.57 $586.69 $674.69 $664.57

26040 $339.70 $322.72 $371.13 $365.56

26045 $509.80 $484.31 $556.96 $548.61

26055 $639.00 $607.05 $698.11 $687.63

# 26055 $343.25 $326.09 $375.00 $369.38

26060 $291.91 $277.31 $318.91 $314.12

26070 $337.05 $320.20 $368.23 $362.71

26075 $357.32 $339.45 $390.37 $384.51

26080 $426.66 $405.33 $466.13 $459.14

26100 $367.16 $348.80 $401.12 $395.11

26105 $370.03 $351.53 $404.26 $398.20

26110 $351.82 $334.23 $384.36 $378.60

26111 $452.57 $429.94 $494.43 $487.01

26113 $592.47 $562.85 $647.28 $637.57

26115 $566.59 $538.26 $619.00 $609.72

# 26115 $362.78 $344.64 $396.34 $390.39

26116 $570.63 $542.10 $623.42 $614.07

26117 $809.58 $769.10 $884.47 $871.19

26118 $1,144.99 $1,087.74 $1,250.90 $1,232.13

26121 $645.85 $613.56 $705.59 $695.01

26123 $900.95 $855.90 $984.29 $969.52

26125 $288.55 $274.12 $315.24 $310.51

26130 $498.12 $473.21 $544.19 $536.03

26135 $595.48 $565.71 $650.57 $640.80

26140 $547.33 $519.96 $597.95 $588.98

26145 $554.72 $526.98 $606.03 $596.94

26160 $652.81 $620.17 $713.20 $702.50

# 26160 $367.40 $349.03 $401.38 $395.36

26170 $441.34 $419.27 $482.16 $474.93

26180 $482.18 $458.07 $526.78 $518.88

26185 $600.70 $570.67 $656.27 $646.43

26200 $488.41 $463.99 $533.59 $525.58

26205 $651.94 $619.34 $712.24 $701.56

26210 $481.00 $456.95 $525.49 $517.62

26215 $613.67 $582.99 $670.44 $660.39

26230 $540.38 $513.36 $590.36 $581.51

26235 $532.53 $505.90 $581.79 $573.06

26236 $478.89 $454.95 $523.19 $515.35

26250 $1,152.94 $1,095.29 $1,259.58 $1,240.69

26260 $866.26 $822.95 $946.39 $932.20

26262 $687.30 $652.94 $750.88 $739.62

26320 $377.22 $358.36 $412.11 $405.93

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 42: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

26340 $375.49 $356.72 $410.23 $404.08

26341 $108.99 $103.54 $119.07 $117.29

# 26341 $80.65 $76.62 $88.11 $86.79

26350 $787.25 $747.89 $860.07 $847.17

26352 $898.93 $853.98 $982.08 $967.35

26356 $1,201.84 $1,141.75 $1,313.01 $1,293.31

26357 $954.27 $906.56 $1,042.54 $1,026.90

26358 $1,006.17 $955.86 $1,099.24 $1,082.75

26370 $831.83 $790.24 $908.78 $895.15

26372 $970.07 $921.57 $1,059.81 $1,043.91

26373 $932.35 $885.73 $1,018.59 $1,003.31

26390 $903.23 $858.07 $986.78 $971.98

26392 $1,052.45 $999.83 $1,149.80 $1,132.55

26410 $624.93 $593.68 $682.73 $672.49

26412 $759.01 $721.06 $829.22 $816.78

26415 $871.64 $828.06 $952.27 $937.99

26416 $816.89 $776.05 $892.46 $879.07

26418 $644.15 $611.94 $703.73 $693.17

26420 $777.47 $738.60 $849.39 $836.65

26426 $543.57 $516.39 $593.85 $584.94

26428 $818.08 $777.18 $893.76 $880.35

26432 $552.41 $524.79 $603.51 $594.46

26433 $585.75 $556.46 $639.93 $630.33

26434 $711.30 $675.74 $777.10 $765.44

26437 $681.05 $647.00 $744.05 $732.90

26440 $682.84 $648.70 $746.01 $734.82

26442 $1,054.50 $1,001.78 $1,152.05 $1,134.76

26445 $640.12 $608.11 $699.33 $688.84

26449 $755.48 $717.71 $825.37 $812.98

26450 $440.86 $418.82 $481.64 $474.42

26455 $446.30 $423.99 $487.59 $480.27

26460 $433.32 $411.65 $473.40 $466.30

26471 $673.32 $639.65 $735.60 $724.57

26474 $649.37 $616.90 $709.44 $698.80

26476 $640.73 $608.69 $699.99 $689.49

26477 $638.26 $606.35 $697.30 $686.84

26478 $681.72 $647.63 $744.77 $733.61

26479 $676.73 $642.89 $739.32 $728.24

26480 $828.24 $786.83 $904.85 $891.28

26483 $921.21 $875.15 $1,006.42 $991.32

26485 $883.95 $839.75 $965.71 $951.22

26489 $1,022.56 $971.43 $1,117.14 $1,100.39

26490 $861.84 $818.75 $941.56 $927.44

26492 $959.42 $911.45 $1,048.17 $1,032.45

26494 $871.20 $827.64 $951.79 $937.51

26496 $925.92 $879.62 $1,011.56 $996.39

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 43: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

26497 $934.45 $887.73 $1,020.89 $1,005.57

26498 $1,231.80 $1,170.21 $1,345.74 $1,325.56

26499 $896.63 $851.80 $979.57 $964.87

26500 $684.08 $649.88 $747.36 $736.15

26502 $777.43 $738.56 $849.34 $836.60

26508 $702.01 $666.91 $766.95 $755.45

26510 $654.61 $621.88 $715.16 $704.43

26516 $763.31 $725.14 $833.91 $821.40

26517 $891.23 $846.67 $973.67 $959.07

26518 $909.65 $864.17 $993.80 $978.89

26520 $719.41 $683.44 $785.96 $774.17

26525 $720.18 $684.17 $786.80 $775.00

26530 $580.42 $551.40 $634.11 $624.60

26531 $672.79 $639.15 $735.02 $723.99

26535 $453.05 $430.40 $494.96 $487.53

26536 $783.32 $744.15 $855.77 $842.94

26540 $719.06 $683.11 $785.58 $773.79

26541 $867.30 $823.94 $947.53 $933.32

26542 $741.37 $704.30 $809.95 $797.80

26545 $770.63 $732.10 $841.92 $829.29

26546 $1,080.99 $1,026.94 $1,180.98 $1,163.27

26548 $829.24 $787.78 $905.95 $892.35

26550 $1,778.42 $1,689.50 $1,942.93 $1,913.78

26551 $3,106.25 $2,950.94 $3,393.58 $3,342.68

26553 $2,869.85 $2,726.36 $3,135.31 $3,088.28

26554 $3,353.33 $3,185.66 $3,663.51 $3,608.56

26555 $1,480.84 $1,406.80 $1,617.82 $1,593.56

26556 $3,096.05 $2,941.25 $3,382.44 $3,331.70

26560 $650.76 $618.22 $710.95 $700.29

26561 $1,023.87 $972.68 $1,118.58 $1,101.80

26562 $1,374.55 $1,305.82 $1,501.69 $1,479.16

26565 $743.51 $706.33 $812.28 $800.10

26567 $741.64 $704.56 $810.24 $798.09

26568 $985.89 $936.60 $1,077.09 $1,060.93

26580 $1,626.20 $1,544.89 $1,776.62 $1,749.98

26587 $1,127.26 $1,070.90 $1,231.54 $1,213.07

26590 $1,370.84 $1,302.30 $1,497.65 $1,475.19

26591 $486.95 $462.60 $531.99 $524.01

26593 $656.64 $623.81 $717.38 $706.62

26596 $824.72 $783.48 $901.00 $887.49

26600 $329.96 $313.46 $360.48 $355.07

# 26600 $309.66 $294.18 $338.31 $333.24

26605 $358.86 $340.92 $392.06 $386.18

# 26605 $325.14 $308.88 $355.21 $349.89

26607 $498.13 $473.22 $544.20 $536.04

26608 $521.72 $495.63 $569.97 $561.43

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 44: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

26615 $627.44 $596.07 $685.48 $675.20

26641 $405.82 $385.53 $443.36 $436.71

# 26641 $367.89 $349.50 $401.93 $395.90

26645 $469.66 $446.18 $513.11 $505.41

# 26645 $428.29 $406.88 $467.91 $460.90

26650 $523.23 $497.07 $571.63 $563.05

26665 $683.98 $649.78 $747.25 $736.03

26670 $364.12 $345.91 $397.80 $391.83

# 26670 $328.49 $312.07 $358.88 $353.50

26675 $500.38 $475.36 $546.66 $538.46

# 26675 $457.09 $434.24 $499.38 $491.89

26676 $548.54 $521.11 $599.28 $590.28

26685 $631.76 $600.17 $690.20 $679.85

26686 $675.49 $641.72 $737.98 $726.90

26700 $357.66 $339.78 $390.75 $384.88

# 26700 $333.91 $317.21 $364.79 $359.32

26705 $457.14 $434.28 $499.42 $491.94

# 26705 $416.53 $395.70 $455.06 $448.22

26706 $480.66 $456.63 $525.12 $517.25

26715 $625.99 $594.69 $683.89 $673.64

26720 $222.66 $211.53 $243.26 $239.61

# 26720 $206.57 $196.24 $225.68 $222.30

26725 $373.88 $355.19 $408.47 $402.34

# 26725 $334.81 $318.07 $365.78 $360.30

26727 $512.72 $487.08 $560.14 $551.74

26735 $649.33 $616.86 $709.39 $698.75

26740 $255.21 $242.45 $278.82 $274.63

# 26740 $238.74 $226.80 $260.82 $256.91

26742 $404.79 $384.55 $442.23 $435.60

# 26742 $364.18 $345.97 $397.87 $391.90

26746 $800.99 $760.94 $875.08 $861.96

26750 $205.66 $195.38 $224.69 $221.32

# 26750 $206.43 $196.11 $225.53 $222.15

26755 $349.63 $332.15 $381.97 $376.25

# 26755 $301.36 $286.29 $329.23 $324.30

26756 $459.84 $436.85 $502.38 $494.85

26765 $548.79 $521.35 $599.55 $590.56

26770 $306.38 $291.06 $334.72 $329.69

# 26770 $282.24 $268.13 $308.35 $303.73

26775 $427.03 $405.68 $466.53 $459.53

# 26775 $383.74 $364.55 $419.23 $412.94

26776 $484.59 $460.36 $529.41 $521.47

26785 $596.39 $566.57 $651.56 $641.78

26820 $858.63 $815.70 $938.06 $923.98

26841 $797.41 $757.54 $871.17 $858.11

26842 $855.80 $813.01 $934.96 $920.93

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 45: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

26843 $806.18 $765.87 $880.75 $867.54

26844 $884.75 $840.51 $966.59 $952.09

26850 $752.98 $715.33 $822.63 $810.29

26852 $859.75 $816.76 $939.27 $925.19

26860 $621.18 $590.12 $678.64 $668.46

26861 $109.01 $103.56 $119.09 $117.31

26862 $788.45 $749.03 $861.38 $848.46

26863 $249.91 $237.41 $273.02 $268.93

26910 $778.29 $739.38 $850.29 $837.53

26951 $718.49 $682.57 $784.96 $773.18

26952 $704.85 $669.61 $770.05 $758.51

26990 $681.34 $647.27 $744.36 $733.19

26991 $786.57 $747.24 $859.33 $846.43

# 26991 $568.58 $540.15 $621.17 $611.86

26992 $1,037.85 $985.96 $1,133.85 $1,116.85

27000 $459.22 $436.26 $501.70 $494.18

27001 $589.34 $559.87 $643.85 $634.19

27003 $645.94 $613.64 $705.69 $695.11

27005 $784.56 $745.33 $857.13 $844.27

27006 $798.23 $758.32 $872.07 $858.99

27025 $995.03 $945.28 $1,087.07 $1,070.77

27027 $912.10 $866.50 $996.48 $981.53

27030 $970.58 $922.05 $1,060.36 $1,044.45

27033 $1,046.79 $994.45 $1,143.62 $1,126.46

27035 $1,066.30 $1,012.99 $1,164.94 $1,147.47

27036 $1,087.94 $1,033.54 $1,188.57 $1,170.75

27040 $379.77 $360.78 $414.90 $408.68

# 27040 $212.36 $201.74 $232.00 $228.52

27041 $734.80 $698.06 $802.77 $790.73

27043 $507.85 $482.46 $554.83 $546.50

27045 $800.28 $760.27 $874.31 $861.20

27047 $520.48 $494.46 $568.63 $560.10

# 27047 $394.44 $374.72 $430.93 $424.47

27048 $657.57 $624.69 $718.39 $707.62

27049 $1,448.07 $1,375.67 $1,582.02 $1,558.28

27050 $440.22 $418.21 $480.94 $473.73

27052 $630.29 $598.78 $688.60 $678.27

27054 $743.25 $706.09 $812.00 $799.83

27057 $1,020.71 $969.67 $1,115.12 $1,098.39

27059 $1,920.37 $1,824.35 $2,098.00 $2,066.53

27060 $506.40 $481.08 $553.24 $544.94

27062 $497.36 $472.49 $543.36 $535.21

27065 $562.66 $534.53 $614.71 $605.49

27066 $877.58 $833.70 $958.76 $944.37

27067 $1,113.21 $1,057.55 $1,216.18 $1,197.94

27070 $917.86 $871.97 $1,002.77 $987.72

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 46: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

27071 $993.72 $944.03 $1,085.63 $1,069.35

27075 $2,242.14 $2,130.03 $2,449.53 $2,412.79

27076 $2,710.04 $2,574.54 $2,960.72 $2,916.31

27077 $3,021.24 $2,870.18 $3,300.71 $3,251.20

27078 $2,211.26 $2,100.70 $2,415.81 $2,379.57

27080 $558.00 $530.10 $609.62 $600.47

27086 $291.49 $276.92 $318.46 $313.69

# 27086 $165.83 $157.54 $181.17 $178.46

27087 $679.78 $645.79 $742.66 $731.52

27090 $896.27 $851.46 $979.18 $964.49

27091 $1,714.52 $1,628.79 $1,873.11 $1,845.01

27093 $215.25 $204.49 $235.16 $231.63

# 27093 $73.89 $70.20 $80.73 $79.52

27095 $270.36 $256.84 $295.37 $290.94

# 27095 $86.47 $82.15 $94.47 $93.06

27096 $186.67 $177.34 $203.94 $200.88

# 27096 $91.28 $86.72 $99.73 $98.23

27097 $732.66 $696.03 $800.43 $788.43

27098 $750.82 $713.28 $820.27 $807.97

27100 $891.13 $846.57 $973.56 $958.95

27105 $933.54 $886.86 $1,019.89 $1,004.59

27110 $1,042.42 $990.30 $1,138.85 $1,121.77

27111 $968.40 $919.98 $1,057.98 $1,042.11

27120 $1,384.96 $1,315.71 $1,513.07 $1,490.37

27122 $1,183.10 $1,123.95 $1,292.54 $1,273.15

27125 $1,219.49 $1,158.52 $1,332.30 $1,312.31

27130 $1,548.08 $1,470.68 $1,691.28 $1,665.91

27132 $1,798.28 $1,708.37 $1,964.63 $1,935.15

27134 $2,050.26 $1,947.75 $2,239.91 $2,206.31

27137 $1,579.99 $1,500.99 $1,726.14 $1,700.25

27138 $1,642.12 $1,560.01 $1,794.01 $1,767.10

27140 $966.44 $918.12 $1,055.84 $1,040.00

27146 $1,379.79 $1,310.80 $1,507.42 $1,484.81

27147 $1,575.29 $1,496.53 $1,721.01 $1,695.19

27151 $1,703.58 $1,618.40 $1,861.16 $1,833.24

27156 $1,834.39 $1,742.67 $2,004.07 $1,974.01

27158 $1,353.09 $1,285.44 $1,478.26 $1,456.08

27161 $1,305.57 $1,240.29 $1,426.33 $1,404.94

27165 $1,478.80 $1,404.86 $1,615.59 $1,591.36

27170 $1,263.78 $1,200.59 $1,380.68 $1,359.97

27175 $718.40 $682.48 $784.85 $773.08

27176 $989.58 $940.10 $1,081.12 $1,064.90

27177 $1,197.63 $1,137.75 $1,308.41 $1,288.78

27178 $989.58 $940.10 $1,081.12 $1,064.90

27179 $1,049.67 $997.19 $1,146.77 $1,129.56

27181 $1,209.10 $1,148.65 $1,320.95 $1,301.13

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 47: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

27185 $731.24 $694.68 $798.88 $786.90

27187 $1,069.29 $1,015.83 $1,168.20 $1,150.68

27193 $512.42 $486.80 $559.82 $551.43

# 27193 $520.47 $494.45 $568.62 $560.08

27194 $763.88 $725.69 $834.54 $822.02

27200 $199.05 $189.10 $217.47 $214.20

# 27200 $207.86 $197.47 $227.09 $223.69

27202 $575.92 $547.12 $629.19 $619.75

27220 $576.85 $548.01 $630.21 $620.76

# 27220 $571.49 $542.92 $624.36 $615.00

27222 $1,039.95 $987.95 $1,136.14 $1,119.10

27226 $1,135.76 $1,078.97 $1,240.82 $1,222.21

27227 $1,778.73 $1,689.79 $1,943.26 $1,914.11

27228 $2,021.58 $1,920.50 $2,208.58 $2,175.44

27230 $520.49 $494.47 $568.64 $560.11

# 27230 $516.66 $490.83 $564.45 $555.99

27232 $816.97 $776.12 $892.54 $879.15

27235 $979.34 $930.37 $1,069.93 $1,053.87

27236 $1,288.29 $1,223.88 $1,407.46 $1,386.35

27238 $503.87 $478.68 $550.48 $542.23

27240 $1,035.85 $984.06 $1,131.67 $1,114.70

27244 $1,323.91 $1,257.71 $1,446.37 $1,424.67

27245 $1,324.29 $1,258.08 $1,446.79 $1,425.09

27246 $419.60 $398.62 $458.41 $451.54

# 27246 $421.90 $400.81 $460.93 $454.02

27248 $800.00 $760.00 $874.00 $860.89

27250 $190.23 $180.72 $207.83 $204.71

27252 $818.20 $777.29 $893.88 $880.47

27253 $1,014.51 $963.78 $1,108.35 $1,091.72

27254 $1,353.32 $1,285.65 $1,478.50 $1,456.33

27256 $333.18 $316.52 $364.00 $358.54

# 27256 $251.20 $238.64 $274.44 $270.32

27257 $357.35 $339.48 $390.40 $384.55

27258 $1,190.71 $1,131.17 $1,300.85 $1,281.33

27259 $1,663.50 $1,580.33 $1,817.38 $1,790.12

27265 $440.73 $418.69 $481.49 $474.27

27266 $630.01 $598.51 $688.29 $677.96

27267 $477.68 $453.80 $521.87 $514.04

27268 $582.90 $553.76 $636.82 $627.27

27269 $1,331.74 $1,265.15 $1,454.92 $1,433.10

27275 $199.81 $189.82 $218.29 $215.02

27280 $1,125.01 $1,068.76 $1,229.07 $1,210.64

27282 $921.69 $875.61 $1,006.95 $991.85

27284 $1,729.20 $1,642.74 $1,889.15 $1,860.82

27286 $1,768.97 $1,680.52 $1,932.60 $1,903.61

27290 $1,739.72 $1,652.73 $1,900.64 $1,872.13

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 48: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

27295 $1,350.74 $1,283.20 $1,475.68 $1,453.54

27301 $748.16 $710.75 $817.36 $805.10

# 27301 $544.35 $517.13 $594.70 $585.78

27303 $691.63 $657.05 $755.61 $744.27

27305 $526.22 $499.91 $574.90 $566.27

27306 $395.40 $375.63 $431.97 $425.50

27307 $522.49 $496.37 $570.83 $562.26

27310 $791.35 $751.78 $864.55 $851.58

27323 $307.75 $292.36 $336.21 $331.17

# 27323 $195.89 $186.10 $214.02 $210.81

27324 $430.01 $408.51 $469.79 $462.74

27325 $604.78 $574.54 $660.72 $650.81

27326 $559.14 $531.18 $610.86 $601.69

27327 $518.45 $492.53 $566.41 $557.91

# 27327 $342.61 $325.48 $374.30 $368.69

27328 $672.90 $639.26 $735.15 $724.12

27329 $1,109.28 $1,053.82 $1,211.89 $1,193.71

27330 $451.49 $428.92 $493.26 $485.86

27331 $519.24 $493.28 $567.27 $558.76

27332 $695.42 $660.65 $759.75 $748.35

27333 $636.25 $604.44 $695.11 $684.68

27334 $742.17 $705.06 $810.82 $798.65

27335 $826.62 $785.29 $903.08 $889.54

27337 $454.04 $431.34 $496.04 $488.60

27339 $808.32 $767.90 $883.09 $869.84

27340 $407.88 $387.49 $445.61 $438.93

27345 $523.53 $497.35 $571.95 $563.37

27347 $576.08 $547.28 $629.37 $619.93

27350 $708.38 $672.96 $773.90 $762.30

27355 $653.96 $621.26 $714.45 $703.73

27356 $798.28 $758.37 $872.13 $859.04

27357 $879.64 $835.66 $961.01 $946.60

27358 $293.97 $279.27 $321.16 $316.34

27360 $925.52 $879.24 $1,011.13 $995.96

27364 $1,663.37 $1,580.20 $1,817.23 $1,789.98

27365 $2,211.97 $2,101.37 $2,416.58 $2,380.33

27370 $187.02 $177.67 $204.32 $201.25

# 27370 $54.85 $52.11 $59.93 $59.03

27372 $682.69 $648.56 $745.84 $734.65

# 27372 $440.57 $418.54 $481.32 $474.10

27380 $648.95 $616.50 $708.98 $698.34

27381 $865.20 $821.94 $945.23 $931.05

27385 $631.57 $599.99 $689.99 $679.64

27386 $904.29 $859.08 $987.94 $973.12

27390 $489.06 $464.61 $534.30 $526.29

27391 $625.80 $594.51 $683.69 $673.43

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 49: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

27392 $769.88 $731.39 $841.10 $828.48

27393 $554.06 $526.36 $605.31 $596.23

27394 $705.59 $670.31 $770.86 $759.30

27395 $946.84 $899.50 $1,034.43 $1,018.91

27396 $666.75 $633.41 $728.42 $717.50

27397 $988.82 $939.38 $1,080.29 $1,064.08

27400 $751.17 $713.61 $820.65 $808.35

27403 $694.02 $659.32 $758.22 $746.84

27405 $734.93 $698.18 $802.91 $790.87

27407 $855.62 $812.84 $934.77 $920.75

27409 $1,038.83 $986.89 $1,134.92 $1,117.90

27412 $1,773.79 $1,685.10 $1,937.87 $1,908.79

27415 $1,477.32 $1,403.45 $1,613.97 $1,589.76

27416 $1,053.86 $1,001.17 $1,151.35 $1,134.07

27418 $899.35 $854.38 $982.54 $967.79

27420 $786.10 $746.80 $858.82 $845.94

27422 $804.69 $764.46 $879.13 $865.94

27424 $807.24 $766.88 $881.91 $868.69

27425 $490.03 $465.53 $535.36 $527.33

27427 $776.12 $737.31 $847.91 $835.19

27428 $1,202.73 $1,142.59 $1,313.98 $1,294.27

27429 $1,347.92 $1,280.52 $1,472.60 $1,450.51

27430 $802.19 $762.08 $876.39 $863.25

27435 $878.48 $834.56 $959.74 $945.35

27437 $714.48 $678.76 $780.57 $768.87

27438 $908.85 $863.41 $992.92 $978.03

27440 $860.40 $817.38 $939.99 $925.89

27441 $888.07 $843.67 $970.22 $955.66

27442 $937.92 $891.02 $1,024.67 $1,009.30

27443 $880.52 $836.49 $961.96 $947.53

27445 $1,346.35 $1,279.03 $1,470.88 $1,448.82

27446 $1,188.76 $1,129.32 $1,298.72 $1,279.24

27447 $1,652.81 $1,570.17 $1,805.70 $1,778.61

27448 $887.78 $843.39 $969.90 $955.35

27450 $1,095.24 $1,040.48 $1,196.55 $1,178.60

27454 $1,394.88 $1,325.14 $1,523.91 $1,501.05

27455 $1,014.25 $963.54 $1,108.07 $1,091.45

27457 $1,032.96 $981.31 $1,128.51 $1,111.58

27465 $1,342.38 $1,275.26 $1,466.55 $1,444.55

27466 $1,268.92 $1,205.47 $1,386.29 $1,365.50

27468 $1,439.11 $1,367.15 $1,572.22 $1,548.64

27470 $1,267.97 $1,204.57 $1,385.26 $1,364.48

27472 $1,360.70 $1,292.67 $1,486.57 $1,464.27

27475 $715.63 $679.85 $781.83 $770.10

27477 $790.38 $750.86 $863.49 $850.54

27479 $930.77 $884.23 $1,016.86 $1,001.62

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 50: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

27485 $724.76 $688.52 $791.80 $779.92

27486 $1,513.32 $1,437.65 $1,653.30 $1,628.50

27487 $1,886.30 $1,791.99 $2,060.79 $2,029.88

27488 $1,294.84 $1,230.10 $1,414.62 $1,393.40

27495 $1,214.19 $1,153.48 $1,326.50 $1,306.61

27496 $592.35 $562.73 $647.14 $637.43

27497 $630.30 $598.79 $688.61 $678.28

27498 $708.77 $673.33 $774.33 $762.71

27499 $757.65 $719.77 $827.74 $815.32

27500 $564.87 $536.63 $617.12 $607.87

# 27500 $519.28 $493.32 $567.32 $558.81

27501 $548.11 $520.70 $598.81 $589.82

# 27501 $543.51 $516.33 $593.78 $584.88

27502 $830.30 $788.79 $907.11 $893.50

27503 $867.75 $824.36 $948.01 $933.79

27506 $1,440.81 $1,368.77 $1,574.09 $1,550.48

27507 $1,045.63 $993.35 $1,142.35 $1,125.22

27508 $577.92 $549.02 $631.37 $621.90

# 27508 $540.76 $513.72 $590.78 $581.91

27509 $704.39 $669.17 $769.55 $758.00

27510 $741.33 $704.26 $809.90 $797.76

27511 $1,069.48 $1,016.01 $1,168.41 $1,150.89

27513 $1,327.88 $1,261.49 $1,450.71 $1,428.96

27514 $1,037.90 $986.01 $1,133.91 $1,116.90

27516 $559.69 $531.71 $611.47 $602.29

# 27516 $522.53 $496.40 $570.86 $562.29

27517 $742.45 $705.33 $811.13 $798.96

27519 $954.94 $907.19 $1,043.27 $1,027.62

27520 $362.57 $344.44 $396.11 $390.16

# 27520 $328.86 $312.42 $359.28 $353.89

27524 $815.12 $774.36 $890.51 $877.15

27530 $339.28 $322.32 $370.67 $365.11

# 27530 $313.61 $297.93 $342.62 $337.48

27532 $672.70 $639.07 $734.93 $723.90

# 27532 $627.11 $595.75 $685.11 $674.83

27535 $963.51 $915.33 $1,052.63 $1,036.84

27536 $1,281.91 $1,217.81 $1,400.48 $1,379.47

27538 $523.85 $497.66 $572.31 $563.73

# 27538 $487.84 $463.45 $532.97 $524.98

27540 $876.78 $832.94 $957.88 $943.52

27550 $547.96 $520.56 $598.64 $589.66

# 27550 $504.28 $479.07 $550.93 $542.66

27552 $681.20 $647.14 $744.21 $733.04

27556 $939.85 $892.86 $1,026.79 $1,011.39

27557 $1,120.62 $1,064.59 $1,224.28 $1,205.91

27558 $1,275.13 $1,211.37 $1,393.08 $1,372.18

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 51: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

27560 $405.06 $384.81 $442.53 $435.90

# 27560 $372.11 $353.50 $406.53 $400.43

27562 $527.05 $500.70 $575.81 $567.17

27566 $962.15 $914.04 $1,051.15 $1,035.38

27570 $165.06 $156.81 $180.33 $177.63

27580 $1,549.40 $1,471.93 $1,692.72 $1,667.33

27590 $874.68 $830.95 $955.59 $941.26

27591 $1,044.74 $992.50 $1,141.38 $1,124.25

27592 $750.41 $712.89 $819.82 $807.53

27594 $554.29 $526.58 $605.57 $596.48

27596 $792.81 $753.17 $866.15 $853.15

27598 $794.78 $755.04 $868.30 $855.27

27600 $452.30 $429.69 $494.14 $486.73

27601 $482.88 $458.74 $527.55 $519.64

27602 $541.53 $514.45 $591.62 $582.74

27603 $602.60 $572.47 $658.34 $648.46

# 27603 $428.29 $406.88 $467.91 $460.90

27604 $542.69 $515.56 $592.89 $584.00

# 27604 $369.92 $351.42 $404.13 $398.07

27605 $387.44 $368.07 $423.28 $416.93

# 27605 $200.10 $190.10 $218.62 $215.34

27606 $309.10 $293.65 $337.70 $332.64

27607 $658.64 $625.71 $719.57 $708.77

27610 $704.19 $668.98 $769.33 $757.79

27612 $604.40 $574.18 $660.31 $650.41

27613 $288.12 $273.71 $314.77 $310.04

# 27613 $180.08 $171.08 $196.74 $193.79

27614 $653.76 $621.07 $714.23 $703.51

# 27614 $444.21 $422.00 $485.30 $478.02

27615 $1,100.19 $1,045.18 $1,201.96 $1,183.93

27616 $1,347.29 $1,279.93 $1,471.92 $1,449.84

27618 $501.41 $476.34 $547.79 $539.57

# 27618 $333.23 $316.57 $364.06 $358.59

27619 $517.49 $491.62 $565.36 $556.89

27620 $493.09 $468.44 $538.71 $530.62

27625 $625.10 $593.85 $682.93 $672.68

27626 $672.42 $638.80 $734.62 $723.60

27630 $631.85 $600.26 $690.30 $679.95

# 27630 $398.55 $378.62 $435.41 $428.88

27632 $451.20 $428.64 $492.94 $485.54

27634 $735.78 $698.99 $803.84 $791.79

27635 $639.90 $607.91 $699.10 $688.61

27637 $822.67 $781.54 $898.77 $885.29

27638 $838.98 $797.03 $916.58 $902.83

27640 $901.06 $856.01 $984.41 $969.65

27641 $716.48 $680.66 $782.76 $771.02

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 52: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

27645 $1,904.66 $1,809.43 $2,080.84 $2,049.63

27646 $1,655.25 $1,572.49 $1,808.36 $1,781.24

27647 $1,092.78 $1,038.14 $1,193.86 $1,175.96

27648 $186.64 $177.31 $203.91 $200.85

# 27648 $55.24 $52.48 $60.35 $59.44

27650 $723.77 $687.58 $790.72 $778.86

27652 $733.49 $696.82 $801.34 $789.33

27654 $762.73 $724.59 $833.28 $820.78

27656 $721.20 $685.14 $787.91 $776.09

# 27656 $433.87 $412.18 $474.01 $466.90

27658 $412.08 $391.48 $450.20 $443.45

27659 $527.78 $501.39 $576.60 $567.95

27664 $398.23 $378.32 $435.07 $428.55

27665 $453.49 $430.82 $495.44 $488.01

27675 $530.64 $504.11 $579.73 $571.03

27676 $675.93 $642.13 $738.45 $727.38

27680 $472.02 $448.42 $515.68 $507.94

27681 $593.90 $564.21 $648.84 $639.11

27685 $742.86 $705.72 $811.58 $799.40

# 27685 $503.42 $478.25 $549.99 $541.74

27686 $598.19 $568.28 $653.52 $643.72

27687 $497.69 $472.81 $543.73 $535.58

27690 $685.36 $651.09 $748.75 $737.52

27691 $817.18 $776.32 $892.77 $879.38

27692 $112.68 $107.05 $123.11 $121.26

27695 $523.60 $497.42 $572.03 $563.45

27696 $605.16 $574.90 $661.14 $651.22

27698 $695.14 $660.38 $759.44 $748.04

27700 $635.29 $603.53 $694.06 $683.65

27702 $1,048.72 $996.28 $1,145.72 $1,128.54

27703 $1,218.32 $1,157.40 $1,331.01 $1,311.05

27704 $637.46 $605.59 $696.43 $685.99

27705 $820.70 $779.67 $896.62 $883.17

27707 $444.76 $422.52 $485.90 $478.61

27709 $1,257.98 $1,195.08 $1,374.34 $1,353.72

27712 $1,190.07 $1,130.57 $1,300.16 $1,280.65

27715 $1,144.43 $1,087.21 $1,250.29 $1,231.54

27720 $949.50 $902.03 $1,037.33 $1,021.78

27722 $959.80 $911.81 $1,048.58 $1,032.85

27724 $1,360.23 $1,292.22 $1,486.05 $1,463.77

27725 $1,314.76 $1,249.02 $1,436.37 $1,414.82

27726 $1,050.56 $998.03 $1,147.73 $1,130.52

27727 $1,115.76 $1,059.97 $1,218.97 $1,200.68

27730 $635.28 $603.52 $694.05 $683.64

27732 $488.57 $464.14 $533.76 $525.76

27734 $670.09 $636.59 $732.08 $721.10

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 53: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

27740 $660.77 $627.73 $721.89 $711.06

27742 $726.71 $690.37 $793.93 $782.01

27745 $820.41 $779.39 $896.30 $882.86

27750 $386.54 $367.21 $422.29 $415.96

# 27750 $352.82 $335.18 $385.46 $379.67

27752 $591.44 $561.87 $646.15 $636.46

# 27752 $542.02 $514.92 $592.16 $583.28

27756 $630.59 $599.06 $688.92 $678.58

27758 $963.28 $915.12 $1,052.39 $1,036.60

27759 $1,076.06 $1,022.26 $1,175.60 $1,157.97

27760 $374.99 $356.24 $409.68 $403.54

# 27760 $339.74 $322.75 $371.16 $365.60

27762 $526.27 $499.96 $574.95 $566.33

# 27762 $476.47 $452.65 $520.55 $512.74

27766 $665.28 $632.02 $726.82 $715.92

27767 $315.59 $299.81 $344.78 $339.61

# 27767 $317.51 $301.63 $346.87 $341.68

27768 $482.99 $458.84 $527.67 $519.75

27769 $794.21 $754.50 $867.68 $854.66

27780 $344.33 $327.11 $376.18 $370.53

# 27780 $311.38 $295.81 $340.18 $335.08

27781 $461.99 $438.89 $504.72 $497.16

# 27781 $425.98 $404.68 $465.38 $458.40

27784 $777.42 $738.55 $849.33 $836.59

27786 $355.12 $337.36 $387.96 $382.15

# 27786 $319.10 $303.15 $348.62 $343.39

27788 $468.03 $444.63 $511.32 $503.65

# 27788 $424.74 $403.50 $464.03 $457.07

27792 $712.74 $677.10 $778.67 $766.98

27808 $376.09 $357.29 $410.88 $404.72

# 27808 $335.87 $319.08 $366.94 $361.43

27810 $520.68 $494.65 $568.85 $560.31

# 27810 $469.34 $445.87 $512.75 $505.06

27814 $838.33 $796.41 $915.87 $902.13

27816 $356.47 $338.65 $389.45 $383.61

# 27816 $317.01 $301.16 $346.33 $341.14

27818 $535.34 $508.57 $584.86 $576.08

# 27818 $476.34 $452.52 $520.40 $512.59

27822 $916.35 $870.53 $1,001.11 $986.09

27823 $1,035.49 $983.72 $1,131.28 $1,114.30

27824 $346.61 $329.28 $378.67 $372.99

# 27824 $336.26 $319.45 $367.37 $361.86

27825 $595.11 $565.35 $650.15 $640.40

# 27825 $534.96 $508.21 $584.44 $575.68

27826 $912.20 $866.59 $996.58 $981.63

27827 $1,177.73 $1,118.84 $1,286.67 $1,267.37

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 54: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

27828 $1,400.35 $1,330.33 $1,529.88 $1,506.94

27829 $748.88 $711.44 $818.16 $805.89

27830 $420.87 $399.83 $459.80 $452.90

# 27830 $389.84 $370.35 $425.90 $419.51

27831 $437.25 $415.39 $477.70 $470.53

27832 $818.62 $777.69 $894.34 $880.92

27840 $410.51 $389.98 $448.48 $441.75

27842 $540.57 $513.54 $590.57 $581.72

27846 $793.06 $753.41 $866.42 $853.43

27848 $873.81 $830.12 $954.64 $940.32

27860 $194.96 $185.21 $212.99 $209.79

27870 $1,117.18 $1,061.32 $1,220.52 $1,202.21

27871 $746.17 $708.86 $815.19 $802.96

27880 $993.30 $943.64 $1,085.19 $1,068.91

27881 $961.67 $913.59 $1,050.63 $1,034.87

27882 $664.00 $630.80 $725.42 $714.54

27884 $633.24 $601.58 $691.82 $681.44

27886 $723.74 $687.55 $790.68 $778.83

27888 $734.56 $697.83 $802.50 $790.46

27889 $705.44 $670.17 $770.70 $759.14

27892 $597.72 $567.83 $653.00 $643.21

27893 $666.33 $633.01 $727.96 $717.04

27894 $944.20 $896.99 $1,031.54 $1,016.07

28001 $307.79 $292.40 $336.26 $331.21

# 28001 $180.22 $171.21 $196.89 $193.94

28002 $497.22 $472.36 $543.21 $535.06

# 28002 $345.90 $328.61 $377.90 $372.23

28003 $808.30 $767.89 $883.07 $869.83

# 28003 $628.24 $596.83 $686.35 $676.06

28005 $623.16 $592.00 $680.80 $670.59

28008 $482.80 $458.66 $527.46 $519.55

# 28008 $315.77 $299.98 $344.98 $339.80

28010 $256.05 $243.25 $279.74 $275.54

# 28010 $228.47 $217.05 $249.61 $245.86

28011 $358.03 $340.13 $391.15 $385.28

# 28011 $316.27 $300.46 $345.53 $340.34

28020 $611.49 $580.92 $668.06 $658.04

# 28020 $393.50 $373.83 $429.90 $423.45

28022 $553.82 $526.13 $605.05 $595.98

# 28022 $353.46 $335.79 $386.16 $380.36

28024 $519.80 $493.81 $567.88 $559.36

# 28024 $330.17 $313.66 $360.71 $355.30

28035 $593.63 $563.95 $648.54 $638.81

# 28035 $385.23 $365.97 $420.87 $414.55

28039 $583.30 $554.14 $637.26 $627.70

# 28039 $383.32 $364.15 $418.77 $412.49

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 55: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

28041 $500.04 $475.04 $546.30 $538.10

28043 $453.31 $430.64 $495.24 $487.81

# 28043 $285.89 $271.60 $312.34 $307.66

28045 $557.47 $529.60 $609.04 $599.91

# 28045 $377.41 $358.54 $412.32 $406.13

28046 $786.74 $747.40 $859.51 $846.62

28047 $1,087.12 $1,032.76 $1,187.67 $1,169.86

28050 $478.97 $455.02 $523.27 $515.42

# 28050 $304.28 $289.07 $332.43 $327.44

28052 $501.71 $476.62 $548.11 $539.89

# 28052 $307.86 $292.47 $336.34 $331.29

28054 $424.00 $402.80 $463.22 $456.27

# 28054 $255.05 $242.30 $278.65 $274.47

28055 $403.22 $383.06 $440.52 $433.91

28060 $582.60 $553.47 $636.49 $626.95

# 28060 $385.69 $366.41 $421.37 $415.05

28062 $653.30 $620.64 $713.74 $703.03

# 28062 $436.85 $415.01 $477.26 $470.10

28070 $601.89 $571.80 $657.57 $647.70

# 28070 $385.06 $365.81 $420.68 $414.37

28072 $577.09 $548.24 $630.48 $621.02

# 28072 $363.71 $345.52 $397.35 $391.39

28080 $596.96 $567.11 $652.18 $642.39

# 28080 $404.26 $384.05 $441.66 $435.03

28086 $621.36 $590.29 $678.83 $668.66

# 28086 $394.19 $374.48 $430.65 $424.19

28088 $554.34 $526.62 $605.61 $596.53

# 28088 $332.53 $315.90 $363.29 $357.83

28090 $532.94 $506.29 $582.23 $573.51

# 28090 $335.26 $318.50 $366.28 $360.78

28092 $484.98 $460.73 $529.84 $521.89

# 28092 $295.73 $280.94 $323.08 $318.24

28100 $692.32 $657.70 $756.36 $745.00

# 28100 $450.21 $427.70 $491.86 $484.47

28102 $624.74 $593.50 $682.53 $672.29

28103 $418.81 $397.87 $457.55 $450.69

28104 $585.02 $555.77 $639.14 $629.54

# 28104 $376.23 $357.42 $411.03 $404.87

28106 $488.62 $464.19 $533.82 $525.81

28107 $576.39 $547.57 $629.71 $620.26

# 28107 $374.11 $355.40 $408.71 $402.58

28108 $495.79 $471.00 $541.65 $533.53

# 28108 $311.91 $296.31 $340.76 $335.65

28110 $526.26 $499.95 $574.94 $566.32

# 28110 $314.41 $298.69 $343.49 $338.34

28111 $569.15 $540.69 $621.79 $612.47

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 56: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 28111 $359.22 $341.26 $392.45 $386.56

28112 $559.74 $531.75 $611.51 $602.34

# 28112 $342.91 $325.76 $374.62 $369.00

28113 $668.31 $634.89 $730.12 $719.18

# 28113 $465.27 $442.01 $508.31 $500.69

28114 $1,199.19 $1,139.23 $1,310.11 $1,290.46

# 28114 $910.71 $865.17 $994.95 $980.02

28116 $854.29 $811.58 $933.32 $919.32

# 28116 $622.13 $591.02 $679.67 $669.47

28118 $670.21 $636.70 $732.21 $721.22

# 28118 $448.78 $426.34 $490.29 $482.93

28119 $591.25 $561.69 $645.94 $636.25

# 28119 $390.51 $370.98 $426.63 $420.23

28120 $762.58 $724.45 $833.12 $820.62

# 28120 $542.69 $515.56 $592.89 $584.00

28122 $672.26 $638.65 $734.45 $723.43

# 28122 $477.64 $453.76 $521.82 $513.99

28124 $534.94 $508.19 $584.42 $575.66

# 28124 $357.18 $339.32 $390.22 $384.36

28126 $449.23 $426.77 $490.79 $483.43

# 28126 $270.32 $256.80 $295.32 $290.89

28130 $791.88 $752.29 $865.13 $852.16

28140 $669.25 $635.79 $731.16 $720.19

# 28140 $475.40 $451.63 $519.37 $511.59

28150 $484.06 $459.86 $528.84 $520.90

# 28150 $305.53 $290.25 $333.79 $328.79

28153 $471.56 $447.98 $515.18 $507.45

# 28153 $289.97 $275.47 $316.79 $312.04

28160 $476.61 $452.78 $520.70 $512.89

# 28160 $293.49 $278.82 $320.64 $315.84

28171 $893.76 $849.07 $976.43 $961.78

28173 $822.77 $781.63 $898.87 $885.40

28175 $525.59 $499.31 $574.21 $565.59

28190 $293.77 $279.08 $320.94 $316.12

# 28190 $145.51 $138.23 $158.96 $156.58

28192 $534.39 $507.67 $583.82 $575.06

# 28192 $342.45 $325.33 $374.13 $368.52

28193 $599.92 $569.92 $655.41 $645.58

# 28193 $400.70 $380.67 $437.77 $431.20

28200 $547.28 $519.92 $597.91 $588.94

# 28200 $344.24 $327.03 $376.08 $370.44

28202 $661.03 $627.98 $722.18 $711.34

# 28202 $454.92 $432.17 $497.00 $489.54

28208 $529.60 $503.12 $578.59 $569.91

# 28208 $334.99 $318.24 $365.98 $360.49

28210 $647.67 $615.29 $707.58 $696.97

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 28210 $443.86 $421.67 $484.92 $477.64

28220 $503.58 $478.40 $550.16 $541.90

# 28220 $325.06 $308.81 $355.13 $349.81

28222 $571.08 $542.53 $623.91 $614.55

# 28222 $377.62 $358.74 $412.55 $406.36

28225 $467.09 $443.74 $510.30 $502.64

# 28225 $282.82 $268.68 $308.98 $304.35

28226 $678.06 $644.16 $740.78 $729.68

# 28226 $411.81 $391.22 $449.90 $443.15

28230 $485.59 $461.31 $530.51 $522.55

# 28230 $304.00 $288.80 $332.12 $327.14

28232 $443.56 $421.38 $484.59 $477.32

# 28232 $266.95 $253.60 $291.64 $287.27

28234 $467.94 $444.54 $511.22 $503.55

# 28234 $290.95 $276.40 $317.86 $313.09

28238 $741.90 $704.81 $810.53 $798.38

# 28238 $520.09 $494.09 $568.20 $559.68

28240 $491.16 $466.60 $536.59 $528.54

# 28240 $310.72 $295.18 $339.46 $334.36

28250 $650.13 $617.62 $710.26 $699.61

# 28250 $436.36 $414.54 $476.72 $469.57

28260 $750.57 $713.04 $820.00 $807.69

# 28260 $541.79 $514.70 $591.91 $583.03

28261 $1,058.33 $1,005.41 $1,156.22 $1,138.88

# 28261 $813.91 $773.21 $889.19 $875.85

28262 $1,610.11 $1,529.60 $1,759.04 $1,732.66

# 28262 $1,259.19 $1,196.23 $1,375.66 $1,355.03

28264 $1,079.11 $1,025.15 $1,178.92 $1,161.24

# 28264 $784.89 $745.65 $857.50 $844.64

28270 $556.42 $528.60 $607.89 $598.77

# 28270 $363.34 $345.17 $396.95 $390.99

28272 $443.33 $421.16 $484.33 $477.07

# 28272 $274.38 $260.66 $299.76 $295.26

28280 $588.05 $558.65 $642.45 $632.81

# 28280 $381.94 $362.84 $417.27 $411.01

28285 $598.70 $568.77 $654.09 $644.28

# 28285 $407.92 $387.52 $445.65 $438.97

28286 $509.66 $484.18 $556.81 $548.46

# 28286 $323.86 $307.67 $353.82 $348.51

28288 $681.93 $647.83 $745.00 $733.83

# 28288 $468.93 $445.48 $512.30 $504.62

28289 $824.52 $783.29 $900.78 $887.27

# 28289 $595.81 $566.02 $650.92 $641.16

28290 $663.78 $630.59 $725.18 $714.30

# 28290 $428.18 $406.77 $467.79 $460.77

28292 $880.50 $836.48 $961.95 $947.52

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 58: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 28292 $652.17 $619.56 $712.49 $701.81

28293 $1,166.20 $1,107.89 $1,274.07 $1,254.96

# 28293 $762.79 $724.65 $833.35 $820.85

28294 $831.98 $790.38 $908.94 $895.30

# 28294 $571.86 $543.27 $624.76 $615.39

28296 $792.50 $752.88 $865.81 $852.83

# 28296 $559.96 $531.96 $611.75 $602.58

28297 $913.15 $867.49 $997.61 $982.65

# 28297 $630.42 $598.90 $688.74 $678.41

28298 $806.78 $766.44 $881.41 $868.18

# 28298 $543.59 $516.41 $593.87 $584.96

28299 $984.91 $935.66 $1,076.01 $1,059.87

# 28299 $719.81 $683.82 $786.39 $774.59

28300 $711.68 $676.10 $777.52 $765.85

28302 $773.62 $734.94 $845.18 $832.51

28304 $903.94 $858.74 $987.55 $972.74

# 28304 $641.52 $609.44 $700.86 $690.35

28305 $699.80 $664.81 $764.53 $753.07

28306 $697.27 $662.41 $761.77 $750.34

# 28306 $440.21 $418.20 $480.93 $473.72

28307 $796.91 $757.06 $870.62 $857.56

# 28307 $506.91 $481.56 $553.79 $545.49

28308 $635.76 $603.97 $694.57 $684.15

# 28308 $407.43 $387.06 $445.12 $438.44

28309 $959.61 $911.63 $1,048.37 $1,032.65

28310 $612.64 $582.01 $669.31 $659.27

# 28310 $383.93 $364.73 $419.44 $413.15

28312 $579.50 $550.53 $633.11 $623.61

# 28312 $347.34 $329.97 $379.47 $373.77

28313 $592.66 $563.03 $647.48 $637.77

# 28313 $387.32 $367.95 $423.14 $416.79

28315 $541.64 $514.56 $591.74 $582.87

# 28315 $351.63 $334.05 $384.16 $378.40

28320 $663.00 $629.85 $724.33 $713.46

28322 $883.44 $839.27 $965.16 $950.68

# 28322 $626.00 $594.70 $683.91 $673.65

28340 $642.24 $610.13 $701.65 $691.13

# 28340 $441.50 $419.43 $482.34 $475.11

28341 $742.01 $704.91 $810.65 $798.49

# 28341 $524.41 $498.19 $572.92 $564.33

28344 $480.99 $456.94 $525.48 $517.60

# 28344 $302.85 $287.71 $330.87 $325.90

28345 $581.92 $552.82 $635.74 $626.21

# 28345 $391.13 $371.57 $427.31 $420.90

28360 $1,181.48 $1,122.41 $1,290.77 $1,271.41

28400 $282.65 $268.52 $308.80 $304.16

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 59: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 28400 $256.60 $243.77 $280.34 $276.13

28405 $417.63 $396.75 $456.26 $449.42

# 28405 $376.25 $357.44 $411.06 $404.89

28406 $577.10 $548.25 $630.49 $621.03

28415 $1,201.65 $1,141.57 $1,312.81 $1,293.12

28420 $1,354.92 $1,287.17 $1,480.25 $1,458.04

28430 $265.40 $252.13 $289.95 $285.60

# 28430 $233.99 $222.29 $255.63 $251.80

28435 $401.11 $381.05 $438.21 $431.63

# 28435 $355.53 $337.75 $388.41 $382.58

28436 $497.36 $472.49 $543.36 $535.21

28445 $1,150.08 $1,092.58 $1,256.47 $1,237.62

28446 $1,317.35 $1,251.48 $1,439.20 $1,417.62

28450 $243.62 $231.44 $266.16 $262.17

# 28450 $214.88 $204.14 $234.76 $231.24

28455 $287.56 $273.18 $314.16 $309.44

# 28455 $258.06 $245.16 $281.93 $277.70

28456 $358.70 $340.77 $391.89 $386.01

28465 $658.47 $625.55 $719.38 $708.60

28470 $248.90 $236.46 $271.93 $267.85

# 28470 $231.28 $219.72 $252.68 $248.88

28475 $281.65 $267.57 $307.71 $303.09

# 28475 $247.56 $235.18 $270.46 $266.40

28476 $385.25 $365.99 $420.89 $414.58

28485 $573.03 $544.38 $626.04 $616.64

28490 $166.24 $157.93 $181.62 $178.89

# 28490 $141.72 $134.63 $154.82 $152.50

28495 $200.70 $190.67 $219.27 $215.98

# 28495 $166.99 $158.64 $182.44 $179.70

28496 $521.53 $495.45 $569.77 $561.22

# 28496 $265.62 $252.34 $290.19 $285.83

28505 $745.48 $708.21 $814.44 $802.23

# 28505 $540.91 $513.86 $590.94 $582.07

28510 $139.10 $132.15 $151.97 $149.70

# 28510 $135.27 $128.51 $147.79 $145.57

28515 $181.65 $172.57 $198.46 $195.48

# 28515 $159.05 $151.10 $173.77 $171.15

28525 $641.49 $609.42 $700.83 $690.32

# 28525 $436.92 $415.07 $477.33 $470.17

28530 $128.67 $122.24 $140.58 $138.47

# 28530 $113.34 $107.67 $123.82 $121.96

28531 $403.19 $383.03 $440.48 $433.87

# 28531 $209.72 $199.23 $229.11 $225.68

28540 $215.30 $204.54 $235.22 $231.69

# 28540 $193.08 $183.43 $210.94 $207.78

28545 $332.59 $315.96 $363.35 $357.90

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 28545 $291.98 $277.38 $318.99 $314.20

28546 $660.26 $627.25 $721.34 $710.52

# 28546 $374.85 $356.11 $409.53 $403.39

28555 $984.73 $935.49 $1,075.81 $1,059.68

# 28555 $726.14 $689.83 $793.30 $781.40

28570 $180.72 $171.68 $197.43 $194.47

# 28570 $153.13 $145.47 $167.29 $164.78

28575 $407.83 $387.44 $445.56 $438.87

# 28575 $365.69 $347.41 $399.52 $393.53

28576 $435.06 $413.31 $475.31 $468.18

28585 $969.75 $921.26 $1,059.45 $1,043.56

# 28585 $742.58 $705.45 $811.27 $799.10

28600 $208.82 $198.38 $228.14 $224.71

# 28600 $179.70 $170.72 $196.33 $193.38

28605 $367.78 $349.39 $401.80 $395.77

# 28605 $328.32 $311.90 $358.69 $353.30

28606 $433.86 $412.17 $474.00 $466.89

28615 $860.24 $817.23 $939.81 $925.72

28630 $175.47 $166.70 $191.71 $188.83

# 28630 $118.39 $112.47 $129.34 $127.40

28635 $192.75 $183.11 $210.58 $207.41

# 28635 $141.42 $134.35 $154.50 $152.18

28636 $339.95 $322.95 $371.39 $365.83

# 28636 $211.99 $201.39 $231.60 $228.13

28645 $735.12 $698.36 $803.11 $791.06

# 28645 $524.79 $498.55 $573.33 $564.73

28660 $130.49 $123.97 $142.57 $140.43

# 28660 $97.16 $92.30 $106.15 $104.56

28665 $171.59 $163.01 $187.46 $184.64

# 28665 $144.01 $136.81 $157.33 $154.97

28666 $210.88 $200.34 $230.39 $226.93

28675 $652.88 $620.24 $713.28 $702.58

# 28675 $446.00 $423.70 $487.26 $479.94

28705 $1,381.28 $1,312.22 $1,509.05 $1,486.42

28715 $1,013.47 $962.80 $1,107.22 $1,090.61

28725 $840.49 $798.47 $918.24 $904.46

28730 $796.21 $756.40 $869.86 $856.81

28735 $843.64 $801.46 $921.68 $907.86

28737 $743.95 $706.75 $812.76 $800.57

28740 $950.31 $902.79 $1,038.21 $1,022.64

# 28740 $677.54 $643.66 $740.21 $729.11

28750 $924.29 $878.08 $1,009.79 $994.65

# 28750 $649.61 $617.13 $709.70 $699.05

28755 $574.55 $545.82 $627.69 $618.27

# 28755 $358.10 $340.20 $391.23 $385.37

28760 $870.87 $827.33 $951.43 $937.16

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 28760 $616.87 $586.03 $673.93 $663.83

28800 $594.04 $564.34 $648.99 $639.25

28805 $798.79 $758.85 $872.68 $859.59

28810 $476.42 $452.60 $520.49 $512.68

28820 $647.29 $614.93 $707.17 $696.57

# 28820 $437.73 $415.84 $478.22 $471.04

28825 $615.84 $585.05 $672.81 $662.71

# 28825 $408.97 $388.52 $446.80 $440.09

28890 $365.98 $347.68 $399.83 $393.83

# 28890 $245.69 $233.41 $268.42 $264.40

29000 $312.89 $297.25 $341.84 $336.71

# 29000 $178.80 $169.86 $195.34 $192.41

29010 $268.93 $255.48 $293.80 $289.40

# 29010 $160.90 $152.86 $175.79 $173.16

29015 $330.07 $313.57 $360.61 $355.20

# 29015 $195.60 $185.82 $213.69 $210.48

29020 $229.38 $217.91 $250.60 $246.84

# 29020 $140.50 $133.48 $153.50 $151.20

29025 $331.44 $314.87 $362.10 $356.67

# 29025 $197.74 $187.85 $216.03 $212.78

29035 $251.71 $239.12 $274.99 $270.86

# 29035 $144.06 $136.86 $157.39 $155.03

29040 $255.63 $242.85 $279.28 $275.09

# 29040 $161.01 $152.96 $175.90 $173.27

29044 $326.51 $310.18 $356.71 $351.36

# 29044 $184.00 $174.80 $201.02 $198.01

29046 $298.08 $283.18 $325.66 $320.77

# 29046 $184.68 $175.45 $201.77 $198.74

29049 $111.25 $105.69 $121.54 $119.72

# 29049 $76.78 $72.94 $83.88 $82.63

29055 $252.03 $239.43 $275.34 $271.22

# 29055 $151.28 $143.72 $165.28 $162.79

29058 $136.43 $129.61 $149.05 $146.82

# 29058 $101.57 $96.49 $110.96 $109.30

29065 $108.32 $102.90 $118.34 $116.56

# 29065 $74.99 $71.24 $81.93 $80.70

29075 $97.62 $92.74 $106.65 $105.05

# 29075 $68.50 $65.08 $74.84 $73.72

29085 $106.84 $101.50 $116.73 $114.98

# 29085 $73.51 $69.83 $80.30 $79.10

29086 $89.13 $84.67 $97.37 $95.91

# 29086 $56.94 $54.09 $62.20 $61.27

29105 $98.41 $93.49 $107.51 $105.90

# 29105 $64.70 $61.47 $70.69 $69.63

29125 $73.85 $70.16 $80.68 $79.48

# 29125 $43.58 $41.40 $47.61 $46.90

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

29126 $86.94 $82.59 $94.98 $93.55

# 29126 $53.23 $50.57 $58.16 $57.28

29130 $45.14 $42.88 $49.31 $48.58

# 29130 $30.20 $28.69 $32.99 $32.50

29131 $57.96 $55.06 $63.32 $62.36

# 29131 $36.12 $34.31 $39.46 $38.87

29200 $58.45 $55.53 $63.86 $62.91

# 29200 $42.75 $40.61 $46.70 $46.00

29240 $63.22 $60.06 $69.07 $68.03

# 29240 $47.13 $44.77 $51.49 $50.72

29260 $57.66 $54.78 $63.00 $62.05

# 29260 $40.80 $38.76 $44.57 $43.91

29280 $56.68 $53.85 $61.93 $61.00

# 29280 $39.44 $37.47 $43.09 $42.45

29305 $279.38 $265.41 $305.22 $300.64

# 29305 $174.03 $165.33 $190.13 $187.28

29325 $308.44 $293.02 $336.97 $331.91

# 29325 $194.66 $184.93 $212.67 $209.48

29345 $152.47 $144.85 $166.58 $164.08

# 29345 $109.95 $104.45 $120.12 $118.31

29355 $158.08 $150.18 $172.71 $170.12

# 29355 $116.33 $110.51 $127.09 $125.18

29358 $180.66 $171.63 $197.37 $194.42

# 29358 $112.85 $107.21 $123.29 $121.44

29365 $138.43 $131.51 $151.24 $148.97

# 29365 $95.91 $91.11 $104.78 $103.20

29405 $91.46 $86.89 $99.92 $98.43

# 29405 $65.41 $62.14 $71.46 $70.39

29425 $87.66 $83.28 $95.77 $94.33

# 29425 $61.61 $58.53 $67.31 $66.30

29435 $134.22 $127.51 $146.64 $144.44

# 29435 $92.46 $87.84 $101.02 $99.50

29440 $49.08 $46.63 $53.62 $52.82

# 29440 $31.46 $29.89 $34.37 $33.86

29445 $150.05 $142.55 $163.93 $161.47

# 29445 $112.89 $107.25 $123.34 $121.49

29450 $157.46 $149.59 $172.03 $169.45

# 29450 $120.68 $114.65 $131.85 $129.87

29505 $94.54 $89.81 $103.28 $101.73

# 29505 $54.70 $51.97 $59.77 $58.87

29515 $80.63 $76.60 $88.09 $86.77

# 29515 $54.20 $51.49 $59.21 $58.33

29520 $53.89 $51.20 $58.88 $57.99

# 29520 $38.19 $36.28 $41.72 $41.10

29530 $58.36 $55.44 $63.76 $62.80

# 29530 $41.12 $39.06 $44.92 $44.24

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

29540 $41.05 $39.00 $44.85 $44.18

# 29540 $28.02 $26.62 $30.61 $30.15

29550 $35.47 $33.70 $38.76 $38.17

# 29550 $21.30 $20.24 $23.28 $22.93

29580 $58.75 $55.81 $64.18 $63.22

# 29580 $38.45 $36.53 $42.01 $41.38

29581 $71.49 $67.92 $78.11 $76.94

# 29581 $13.25 $12.59 $14.48 $14.26

29582 $80.71 $76.67 $88.17 $86.85

# 29582 $15.96 $15.16 $17.43 $17.17

29583 $50.03 $47.53 $54.66 $53.84

# 29583 $11.72 $11.13 $12.80 $12.60

29584 $80.71 $76.67 $88.17 $86.85

# 29584 $15.96 $15.16 $17.43 $17.17

29700 $74.31 $70.59 $81.18 $79.96

# 29700 $36.00 $34.20 $39.33 $38.74

29705 $73.57 $69.89 $80.37 $79.17

# 29705 $49.82 $47.33 $54.43 $53.61

29710 $136.98 $130.13 $149.65 $147.41

# 29710 $89.09 $84.64 $97.34 $95.88

29715 $89.02 $84.57 $97.26 $95.80

# 29715 $55.69 $52.91 $60.85 $59.94

29720 $94.16 $89.45 $102.87 $101.33

# 29720 $46.28 $43.97 $50.57 $49.81

29730 $72.10 $68.50 $78.78 $77.59

# 29730 $47.97 $45.57 $52.41 $51.62

29740 $103.15 $97.99 $112.69 $111.00

# 29740 $70.21 $66.70 $76.71 $75.56

29750 $118.52 $112.59 $129.48 $127.54

# 29750 $83.66 $79.48 $91.40 $90.03

29800 $558.42 $530.50 $610.08 $600.92

29804 $706.35 $671.03 $771.68 $760.10

29805 $514.99 $489.24 $562.63 $554.19

29806 $1,146.00 $1,088.70 $1,252.01 $1,233.23

29807 $1,117.71 $1,061.82 $1,221.09 $1,202.77

29819 $637.64 $605.76 $696.62 $686.17

29820 $587.17 $557.81 $641.48 $631.86

29821 $640.26 $608.25 $699.49 $689.00

29822 $626.11 $594.80 $684.02 $673.76

29823 $682.80 $648.66 $745.96 $734.77

29824 $737.67 $700.79 $805.91 $793.82

29825 $637.26 $605.40 $696.21 $685.77

29826 $186.49 $177.17 $203.75 $200.69

29827 $1,159.05 $1,101.10 $1,266.27 $1,247.27

29828 $998.61 $948.68 $1,090.98 $1,074.62

29830 $494.87 $470.13 $540.65 $532.54

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 64: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

29834 $534.18 $507.47 $583.59 $574.84

29835 $551.66 $524.08 $602.69 $593.65

29836 $625.25 $593.99 $683.09 $672.84

29837 $575.74 $546.95 $628.99 $619.56

29838 $641.20 $609.14 $700.51 $690.00

29840 $493.78 $469.09 $539.45 $531.36

29843 $527.51 $501.13 $576.30 $567.65

29844 $540.86 $513.82 $590.89 $582.03

29845 $628.07 $596.67 $686.17 $675.88

29846 $564.29 $536.08 $616.49 $607.25

29847 $589.76 $560.27 $644.31 $634.65

29848 $556.26 $528.45 $607.72 $598.60

29850 $677.02 $643.17 $739.65 $728.55

29851 $1,004.71 $954.47 $1,097.64 $1,081.17

29855 $852.55 $809.92 $931.41 $917.44

29856 $1,073.63 $1,019.95 $1,172.94 $1,155.35

29860 $723.39 $687.22 $790.30 $778.45

29861 $787.52 $748.14 $860.36 $847.46

29862 $888.06 $843.66 $970.21 $955.66

29863 $888.79 $844.35 $971.00 $956.43

29866 $1,134.08 $1,077.38 $1,238.99 $1,220.40

29867 $1,377.42 $1,308.55 $1,504.83 $1,482.26

29868 $1,795.71 $1,705.92 $1,961.81 $1,932.38

29870 $657.88 $624.99 $718.74 $707.96

# 29870 $451.01 $428.46 $492.73 $485.33

29871 $560.16 $532.15 $611.97 $602.80

29873 $576.19 $547.38 $629.49 $620.05

29874 $585.33 $556.06 $639.47 $629.88

29875 $540.44 $513.42 $590.43 $581.58

29876 $713.24 $677.58 $779.22 $767.53

29877 $678.07 $644.17 $740.80 $729.69

29879 $721.16 $685.10 $787.87 $776.04

29880 $614.74 $584.00 $671.60 $661.53

29881 $592.11 $562.50 $646.88 $637.17

29882 $759.64 $721.66 $829.91 $817.47

29883 $909.36 $863.89 $993.47 $978.57

29884 $675.84 $642.05 $738.36 $727.28

29885 $815.39 $774.62 $890.81 $877.45

29886 $690.30 $655.79 $754.16 $742.84

29887 $812.53 $771.90 $887.69 $874.37

29888 $1,067.51 $1,014.13 $1,166.25 $1,148.76

29889 $1,318.26 $1,252.35 $1,440.20 $1,418.59

29891 $737.45 $700.58 $805.67 $793.58

29892 $659.99 $626.99 $721.04 $710.23

29893 $685.93 $651.63 $749.37 $738.14

# 29893 $464.50 $441.28 $507.47 $499.86

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

29894 $563.42 $535.25 $615.54 $606.30

29895 $521.54 $495.46 $569.78 $561.23

29897 $557.72 $529.83 $609.30 $600.16

29898 $612.40 $581.78 $669.05 $659.01

29899 $1,134.22 $1,077.51 $1,239.14 $1,220.55

29900 $491.22 $466.66 $536.66 $528.61

29901 $582.80 $553.66 $636.71 $627.16

29902 $659.60 $626.62 $720.61 $709.80

29904 $690.80 $656.26 $754.70 $743.38

29905 $749.87 $712.38 $819.24 $806.94

29906 $765.97 $727.67 $836.82 $824.26

29907 $947.08 $899.73 $1,034.69 $1,019.16

29914 $1,090.02 $1,035.52 $1,190.85 $1,172.99

29915 $1,111.72 $1,056.13 $1,214.55 $1,196.33

29916 $1,112.87 $1,057.23 $1,215.81 $1,197.58

30000 $268.02 $254.62 $292.81 $288.42

# 30000 $131.64 $125.06 $143.82 $141.66

30020 $272.29 $258.68 $297.48 $293.02

# 30020 $132.08 $125.48 $144.30 $142.14

30100 $164.52 $156.29 $179.73 $177.04

# 30100 $76.02 $72.22 $83.05 $81.81

30110 $266.51 $253.18 $291.16 $286.79

# 30110 $143.92 $136.72 $157.23 $154.87

30115 $483.69 $459.51 $528.44 $520.51

30117 $1,038.83 $986.89 $1,134.92 $1,117.90

# 30117 $381.43 $362.36 $416.71 $410.46

30118 $839.01 $797.06 $916.62 $902.87

30120 $582.19 $553.08 $636.04 $626.50

# 30120 $484.50 $460.28 $529.32 $521.39

30124 $319.20 $303.24 $348.73 $343.49

30125 $673.96 $640.26 $736.30 $725.26

30130 $429.64 $408.16 $469.38 $462.35

30140 $503.57 $478.39 $550.15 $541.89

30150 $846.55 $804.22 $924.85 $910.98

30160 $851.11 $808.55 $929.83 $915.88

30200 $132.55 $125.92 $144.81 $142.63

# 30200 $65.90 $62.61 $72.00 $70.92

30210 $172.95 $164.30 $188.95 $186.12

# 30210 $111.27 $105.71 $121.57 $119.74

30220 $358.04 $340.14 $391.16 $385.30

# 30220 $138.91 $131.96 $151.75 $149.48

30300 $273.47 $259.80 $298.77 $294.29

# 30300 $145.13 $137.87 $158.55 $156.17

30310 $233.07 $221.42 $254.63 $250.82

30320 $507.38 $482.01 $554.31 $546.00

30400 $1,128.89 $1,072.45 $1,233.32 $1,214.81

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

30410 $1,312.69 $1,247.06 $1,434.12 $1,412.60

30420 $1,514.06 $1,438.36 $1,654.11 $1,629.30

30430 $995.87 $946.08 $1,087.99 $1,071.67

30435 $1,238.01 $1,176.11 $1,352.53 $1,332.24

30450 $1,642.94 $1,560.79 $1,794.91 $1,767.99

30460 $895.42 $850.65 $978.25 $963.57

30462 $1,568.83 $1,490.39 $1,713.95 $1,688.23

30465 $1,083.11 $1,028.95 $1,183.29 $1,165.55

30520 $696.92 $662.07 $761.38 $749.96

30540 $764.59 $726.36 $835.31 $822.78

30545 $926.62 $880.29 $1,012.33 $997.15

30560 $317.39 $301.52 $346.75 $341.55

# 30560 $156.11 $148.30 $170.55 $167.99

30580 $715.09 $679.34 $781.24 $769.52

# 30580 $547.29 $519.93 $597.92 $588.95

30600 $640.52 $608.49 $699.76 $689.26

# 30600 $465.83 $442.54 $508.92 $501.29

30620 $708.05 $672.65 $773.55 $761.94

30630 $696.82 $661.98 $761.28 $749.86

30801 $269.07 $255.62 $293.96 $289.56

# 30801 $157.59 $149.71 $172.17 $169.58

30802 $334.32 $317.60 $365.24 $359.77

# 30802 $213.26 $202.60 $232.99 $229.49

30901 $106.35 $101.03 $116.18 $114.44

# 30901 $59.22 $56.26 $64.70 $63.73

30903 $237.52 $225.64 $259.49 $255.60

# 30903 $83.89 $79.70 $91.66 $90.28

30905 $295.17 $280.41 $322.47 $317.63

# 30905 $105.92 $100.62 $115.71 $113.98

30906 $321.34 $305.27 $351.06 $345.79

# 30906 $138.21 $131.30 $151.00 $148.73

30915 $635.37 $603.60 $694.14 $683.73

30920 $916.61 $870.78 $1,001.40 $986.38

30930 $139.25 $132.29 $152.13 $149.86

31000 $209.86 $199.37 $229.28 $225.84

# 31000 $116.39 $110.57 $127.16 $125.25

31002 $226.36 $215.04 $247.30 $243.58

31020 $558.78 $530.84 $610.47 $601.31

# 31020 $407.83 $387.44 $445.56 $438.87

31030 $777.52 $738.64 $849.44 $836.69

# 31030 $580.61 $551.58 $634.32 $624.81

31032 $634.17 $602.46 $692.83 $682.43

31040 $834.35 $792.63 $911.52 $897.85

31050 $539.42 $512.45 $589.32 $580.47

31051 $717.87 $681.98 $784.28 $772.51

31070 $494.86 $470.12 $540.64 $532.53

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

31075 $863.33 $820.16 $943.18 $929.04

31080 $1,136.45 $1,079.63 $1,241.57 $1,222.96

31081 $1,668.42 $1,585.00 $1,822.75 $1,795.41

31084 $1,265.67 $1,202.39 $1,382.75 $1,362.00

31085 $1,765.98 $1,677.68 $1,929.33 $1,900.39

31086 $1,231.58 $1,170.00 $1,345.50 $1,325.32

31087 $1,181.00 $1,121.95 $1,290.24 $1,270.89

31090 $1,140.97 $1,083.92 $1,246.51 $1,227.81

31200 $646.60 $614.27 $706.41 $695.82

31201 $825.43 $784.16 $901.78 $888.26

31205 $1,004.45 $954.23 $1,097.36 $1,080.91

31225 $2,034.06 $1,932.36 $2,222.21 $2,188.88

31230 $2,246.54 $2,134.21 $2,454.34 $2,417.53

31231 $242.07 $229.97 $264.47 $260.50

# 31231 $68.91 $65.46 $75.28 $74.15

31233 $302.11 $287.00 $330.05 $325.11

# 31233 $147.72 $140.33 $161.38 $158.96

31235 $341.34 $324.27 $372.91 $367.32

# 31235 $173.55 $164.87 $189.60 $186.76

31237 $366.81 $348.47 $400.74 $394.73

# 31237 $194.41 $184.69 $212.39 $209.21

31238 $374.15 $355.44 $408.76 $402.63

# 31238 $210.57 $200.04 $230.05 $226.60

31239 $756.65 $718.82 $826.64 $814.25

31240 $173.24 $164.58 $189.27 $186.43

31254 $291.70 $277.12 $318.69 $313.90

31255 $425.95 $404.65 $465.35 $458.37

31256 $212.00 $201.40 $231.61 $228.14

31267 $338.36 $321.44 $369.66 $364.11

31276 $536.86 $510.02 $586.52 $577.73

31287 $248.61 $236.18 $271.61 $267.54

31288 $287.73 $273.34 $314.34 $309.63

31290 $1,242.19 $1,180.08 $1,357.09 $1,336.74

31291 $1,320.55 $1,254.52 $1,442.70 $1,421.06

31292 $1,074.23 $1,020.52 $1,173.60 $1,155.99

31293 $1,165.02 $1,106.77 $1,272.79 $1,253.70

31294 $1,331.20 $1,264.64 $1,454.34 $1,432.52

31295 $2,500.22 $2,375.21 $2,731.49 $2,690.52

# 31295 $180.17 $171.16 $196.83 $193.88

31296 $2,535.85 $2,409.06 $2,770.42 $2,728.86

# 31296 $215.03 $204.28 $234.92 $231.40

31297 $2,504.29 $2,379.08 $2,735.94 $2,694.90

# 31297 $177.35 $168.48 $193.75 $190.84

31300 $1,386.45 $1,317.13 $1,514.70 $1,491.98

31320 $746.81 $709.47 $815.89 $803.65

31360 $2,260.62 $2,147.59 $2,469.73 $2,432.69

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

31365 $2,786.49 $2,647.17 $3,044.25 $2,998.58

31367 $2,409.07 $2,288.62 $2,631.91 $2,592.43

31368 $2,663.94 $2,530.74 $2,910.35 $2,866.70

31370 $2,270.80 $2,157.26 $2,480.85 $2,443.64

31375 $2,156.74 $2,048.90 $2,356.24 $2,320.90

31380 $2,127.69 $2,021.31 $2,324.51 $2,289.64

31382 $2,330.02 $2,213.52 $2,545.55 $2,507.37

31390 $3,101.41 $2,946.34 $3,388.29 $3,337.46

31395 $3,264.41 $3,101.19 $3,566.37 $3,512.87

31400 $1,106.40 $1,051.08 $1,208.74 $1,190.61

31420 $913.25 $867.59 $997.73 $982.77

31500 $114.56 $108.83 $125.15 $123.28

31502 $36.94 $35.09 $40.35 $39.74

31505 $95.70 $90.92 $104.56 $102.99

# 31505 $54.71 $51.97 $59.77 $58.87

31510 $240.67 $228.64 $262.94 $258.99

# 31510 $131.49 $124.92 $143.66 $141.51

31511 $242.36 $230.24 $264.78 $260.81

# 31511 $139.69 $132.71 $152.62 $150.33

31512 $234.75 $223.01 $256.46 $252.61

# 31512 $141.27 $134.21 $154.34 $152.03

31513 $143.08 $135.93 $156.32 $153.97

31515 $237.33 $225.46 $259.28 $255.39

# 31515 $119.71 $113.72 $130.78 $128.81

31520 $170.00 $161.50 $185.73 $182.94

31525 $282.74 $268.60 $308.89 $304.26

# 31525 $172.02 $163.42 $187.93 $185.12

31526 $170.35 $161.83 $186.10 $183.31

31527 $210.92 $200.37 $230.43 $226.96

31528 $156.56 $148.73 $171.04 $168.48

31529 $174.91 $166.16 $191.08 $188.22

31530 $211.97 $201.37 $231.58 $228.10

31531 $228.47 $217.05 $249.61 $245.86

31535 $204.80 $194.56 $223.74 $220.39

31536 $227.43 $216.06 $248.47 $244.74

31540 $260.80 $247.76 $284.92 $280.65

31541 $284.49 $270.27 $310.81 $306.15

31545 $389.80 $370.31 $425.86 $419.47

31546 $590.46 $560.94 $645.08 $635.41

31560 $336.44 $319.62 $367.56 $362.05

31561 $367.65 $349.27 $401.66 $395.63

31570 $380.11 $361.10 $415.27 $409.03

# 31570 $247.17 $234.81 $270.03 $265.98

31571 $268.32 $254.90 $293.14 $288.74

31575 $128.67 $122.24 $140.58 $138.47

# 31575 $83.09 $78.94 $90.78 $89.42

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

31576 $254.34 $241.62 $277.86 $273.70

# 31576 $133.28 $126.62 $145.61 $143.43

31577 $275.29 $261.53 $300.76 $296.25

# 31577 $161.51 $153.43 $176.44 $173.80

31578 $316.06 $300.26 $345.30 $340.12

# 31578 $185.80 $176.51 $202.99 $199.94

31579 $236.67 $224.84 $258.57 $254.69

# 31579 $152.77 $145.13 $166.90 $164.39

31580 $1,351.87 $1,284.28 $1,476.92 $1,454.77

31582 $2,092.09 $1,987.49 $2,285.61 $2,251.33

31584 $1,650.47 $1,567.95 $1,803.14 $1,776.09

31587 $1,084.39 $1,030.17 $1,184.70 $1,166.93

31588 $1,255.16 $1,192.40 $1,371.26 $1,350.69

31590 $1,008.88 $958.44 $1,102.21 $1,085.67

31595 $848.32 $805.90 $926.79 $912.88

31600 $421.03 $399.98 $459.98 $453.08

31601 $277.58 $263.70 $303.26 $298.70

31603 $236.15 $224.34 $257.99 $254.12

31605 $193.15 $183.49 $211.01 $207.85

31610 $787.67 $748.29 $860.53 $847.63

31611 $603.99 $573.79 $659.86 $649.96

31612 $94.14 $89.43 $102.84 $101.30

# 31612 $50.85 $48.31 $55.56 $54.73

31613 $512.16 $486.55 $559.53 $551.14

31614 $846.28 $803.97 $924.57 $910.70

31615 $202.90 $192.76 $221.67 $218.35

# 31615 $138.54 $131.61 $151.35 $149.09

31620 $326.81 $310.47 $357.04 $351.68

# 31620 $71.29 $67.73 $77.89 $76.72

31622 $356.91 $339.06 $389.92 $384.07

# 31622 $156.16 $148.35 $170.60 $168.04

31623 $378.22 $359.31 $413.21 $407.01

# 31623 $156.41 $148.59 $170.88 $168.31

31624 $355.24 $337.48 $388.10 $382.28

# 31624 $157.56 $149.68 $172.13 $169.54

31625 $379.05 $360.10 $414.12 $407.91

# 31625 $181.37 $172.30 $198.15 $195.18

31626 $507.21 $481.85 $554.13 $545.81

# 31626 $218.74 $207.80 $238.97 $235.38

31627 $1,576.97 $1,498.12 $1,722.84 $1,697.00

# 31627 $100.12 $95.11 $109.38 $107.73

31628 $427.31 $405.94 $466.83 $459.83

# 31628 $201.67 $191.59 $220.33 $217.03

31629 $698.17 $663.26 $762.75 $751.31

# 31629 $216.99 $206.14 $237.06 $233.51

31630 $214.13 $203.42 $233.93 $230.43

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

31631 $243.66 $231.48 $266.20 $262.21

31632 $78.49 $74.57 $85.76 $84.47

# 31632 $51.68 $49.10 $56.47 $55.61

31633 $96.15 $91.34 $105.04 $103.47

# 31633 $66.65 $63.32 $72.82 $71.73

31634 $2,306.38 $2,191.06 $2,519.72 $2,481.92

# 31634 $212.74 $202.10 $232.42 $228.93

31635 $390.75 $371.21 $426.89 $420.49

# 31635 $200.35 $190.33 $218.88 $215.60

31636 $236.71 $224.87 $258.60 $254.73

31637 $77.95 $74.05 $85.16 $83.88

31638 $270.78 $257.24 $295.83 $291.39

31640 $273.69 $260.01 $299.01 $294.53

31641 $274.28 $260.57 $299.66 $295.16

31643 $187.48 $178.11 $204.83 $201.76

31645 $360.67 $342.64 $394.04 $388.13

# 31645 $171.80 $163.21 $187.69 $184.87

31646 $327.46 $311.09 $357.75 $352.38

# 31646 $149.70 $142.22 $163.55 $161.10

31647 $237.09 $225.24 $259.03 $255.14

31648 $249.32 $236.85 $272.38 $268.30

31649 $78.10 $74.20 $85.33 $84.05

31651 $82.55 $78.42 $90.18 $88.83

31660 $238.45 $226.53 $260.51 $256.60

31661 $251.59 $239.01 $274.86 $270.73

31717 $303.06 $287.91 $331.10 $326.13

# 31717 $116.49 $110.67 $127.27 $125.36

31720 $52.31 $49.69 $57.14 $56.28

31725 $96.65 $91.82 $105.59 $104.01

31730 $1,444.35 $1,372.13 $1,577.95 $1,554.28

# 31730 $154.46 $146.74 $168.75 $166.22

31750 $1,534.76 $1,458.02 $1,676.72 $1,651.57

31755 $1,940.11 $1,843.10 $2,119.57 $2,087.77

31760 $1,470.96 $1,397.41 $1,607.02 $1,582.92

31766 $1,896.89 $1,802.05 $2,072.36 $2,041.27

31770 $1,422.42 $1,351.30 $1,554.00 $1,530.68

31775 $1,459.71 $1,386.72 $1,594.73 $1,570.81

31780 $1,269.88 $1,206.39 $1,387.35 $1,366.53

31781 $1,644.83 $1,562.59 $1,796.98 $1,770.02

31785 $1,157.77 $1,099.88 $1,264.86 $1,245.89

31786 $1,541.24 $1,464.18 $1,683.81 $1,658.55

31800 $812.62 $771.99 $887.79 $874.47

31805 $879.64 $835.66 $961.01 $946.60

31820 $491.87 $467.28 $537.37 $529.31

# 31820 $361.23 $343.17 $394.65 $388.72

31825 $673.09 $639.44 $735.36 $724.33

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 31825 $524.44 $498.22 $572.95 $564.36

31830 $502.55 $477.42 $549.03 $540.80

# 31830 $379.20 $360.24 $414.28 $408.07

32035 $785.44 $746.17 $858.10 $845.23

32036 $844.52 $802.29 $922.63 $908.80

32096 $871.79 $828.20 $952.43 $938.15

32097 $871.79 $828.20 $952.43 $938.15

32098 $847.02 $804.67 $925.37 $911.49

32100 $879.23 $835.27 $960.56 $946.15

32110 $1,572.23 $1,493.62 $1,717.66 $1,691.90

32120 $942.18 $895.07 $1,029.33 $1,013.89

32124 $1,003.16 $953.00 $1,095.95 $1,079.52

32140 $1,067.95 $1,014.55 $1,166.73 $1,149.23

32141 $1,632.20 $1,550.59 $1,783.18 $1,756.43

32150 $1,082.21 $1,028.10 $1,182.32 $1,164.58

32151 $1,083.97 $1,029.77 $1,184.24 $1,166.47

32160 $851.76 $809.17 $930.55 $916.58

32200 $1,222.07 $1,160.97 $1,335.12 $1,315.09

32201 $1,038.99 $987.04 $1,135.10 $1,118.06

# 32201 $205.75 $195.46 $224.78 $221.41

32215 $866.33 $823.01 $946.46 $932.26

32220 $1,713.28 $1,627.62 $1,871.76 $1,843.69

32225 $1,072.91 $1,019.26 $1,172.15 $1,154.57

32310 $989.34 $939.87 $1,080.85 $1,064.64

32320 $1,720.25 $1,634.24 $1,879.38 $1,851.19

32400 $164.46 $156.24 $179.68 $176.99

# 32400 $90.91 $86.36 $99.31 $97.82

32405 $513.24 $487.58 $560.72 $552.31

# 32405 $108.69 $103.26 $118.75 $116.97

32440 $1,679.07 $1,595.12 $1,834.39 $1,806.87

32442 $3,255.34 $3,092.57 $3,556.46 $3,503.11

32445 $3,766.33 $3,578.01 $4,114.71 $4,052.99

32480 $1,588.19 $1,508.78 $1,735.10 $1,709.07

32482 $1,700.94 $1,615.89 $1,858.27 $1,830.40

32484 $1,538.84 $1,461.90 $1,681.19 $1,655.97

32486 $2,506.31 $2,380.99 $2,738.14 $2,697.07

32488 $2,543.93 $2,416.73 $2,779.24 $2,737.55

32491 $1,579.65 $1,500.67 $1,725.77 $1,699.88

32501 $258.79 $245.85 $282.73 $278.48

32503 $1,937.74 $1,840.85 $2,116.98 $2,085.23

32504 $2,185.57 $2,076.29 $2,387.73 $2,351.92

32505 $1,033.66 $981.98 $1,129.28 $1,112.34

32506 $176.19 $167.38 $192.49 $189.60

32507 $176.19 $167.38 $192.49 $189.60

32540 $1,849.18 $1,756.72 $2,020.23 $1,989.93

32550 $915.28 $869.52 $999.95 $984.95

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 32550 $237.20 $225.34 $259.14 $255.25

32551 $186.60 $177.27 $203.86 $200.80

32552 $210.74 $200.20 $230.23 $226.78

# 32552 $180.47 $171.45 $197.17 $194.21

32553 $657.87 $624.98 $718.73 $707.95

# 32553 $221.14 $210.08 $241.59 $237.97

32554 $630.89 $599.35 $689.25 $678.91

# 32554 $94.17 $89.46 $102.88 $101.34

32555 $726.81 $690.47 $794.04 $782.13

# 32555 $117.68 $111.80 $128.57 $126.64

32556 $662.72 $629.58 $724.02 $713.16

# 32556 $129.06 $122.61 $141.00 $138.89

32557 $1,078.40 $1,024.48 $1,178.15 $1,160.48

# 32557 $173.90 $165.21 $189.99 $187.14

32560 $284.53 $270.30 $310.85 $306.19

# 32560 $83.02 $78.87 $90.70 $89.34

32561 $103.17 $98.01 $112.71 $111.02

# 32561 $74.82 $71.08 $81.74 $80.51

32562 $93.39 $88.72 $102.03 $100.50

# 32562 $66.96 $63.61 $73.15 $72.06

32601 $330.81 $314.27 $361.41 $355.99

32604 $512.41 $486.79 $559.81 $551.41

32606 $493.77 $469.08 $539.44 $531.35

32607 $343.83 $326.64 $375.64 $370.00

32608 $422.83 $401.69 $461.94 $455.01

32609 $291.66 $277.08 $318.64 $313.86

32650 $721.82 $685.73 $788.59 $776.76

32651 $1,176.83 $1,117.99 $1,285.69 $1,266.40

32652 $1,779.12 $1,690.16 $1,943.68 $1,914.53

32653 $1,134.33 $1,077.61 $1,239.25 $1,220.67

32654 $1,264.30 $1,201.09 $1,381.25 $1,360.53

32655 $1,032.10 $980.50 $1,127.58 $1,110.66

32656 $860.71 $817.67 $940.32 $926.21

32658 $770.80 $732.26 $842.10 $829.47

32659 $787.08 $747.73 $859.89 $846.99

32661 $860.51 $817.48 $940.10 $926.00

32662 $959.30 $911.34 $1,048.04 $1,032.32

32663 $1,499.81 $1,424.82 $1,638.54 $1,613.97

32664 $913.18 $867.52 $997.65 $982.69

32665 $1,304.89 $1,239.65 $1,425.60 $1,404.22

32666 $962.88 $914.74 $1,051.95 $1,036.17

32667 $176.19 $167.38 $192.49 $189.60

32668 $176.90 $168.06 $193.27 $190.37

32669 $1,440.51 $1,368.48 $1,573.75 $1,550.14

32670 $1,715.79 $1,630.00 $1,874.50 $1,846.38

32671 $1,899.83 $1,804.84 $2,075.57 $2,044.44

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

32672 $1,627.59 $1,546.21 $1,778.14 $1,751.47

32673 $1,283.96 $1,219.76 $1,402.72 $1,381.68

32674 $228.59 $217.16 $249.73 $245.99

32701 $233.10 $221.45 $254.67 $250.85

32800 $1,016.73 $965.89 $1,110.77 $1,094.11

32810 $972.44 $923.82 $1,062.39 $1,046.45

32815 $3,001.53 $2,851.45 $3,279.17 $3,229.98

32820 $1,521.33 $1,445.26 $1,662.05 $1,637.12

32851 $3,502.59 $3,327.46 $3,826.58 $3,769.18

32852 $3,824.78 $3,633.54 $4,178.57 $4,115.90

32853 $4,888.86 $4,644.42 $5,341.08 $5,260.96

32854 $5,195.27 $4,935.51 $5,675.84 $5,590.70

32855 $437.48 $415.61 $477.95 $470.79

32856 $535.08 $508.33 $584.58 $575.82

32900 $1,492.76 $1,418.12 $1,630.84 $1,606.38

32905 $1,431.52 $1,359.94 $1,563.93 $1,540.47

32906 $1,763.92 $1,675.72 $1,927.08 $1,898.17

32940 $1,324.74 $1,258.50 $1,447.28 $1,425.56

32960 $166.58 $158.25 $181.99 $179.26

# 32960 $109.88 $104.39 $120.05 $118.24

32997 $374.78 $356.04 $409.45 $403.31

32998 $3,455.44 $3,282.67 $3,775.07 $3,718.44

# 32998 $301.01 $285.96 $328.85 $323.92

33010 $124.46 $118.24 $135.98 $133.94

33011 $126.26 $119.95 $137.94 $135.87

33015 $540.76 $513.72 $590.78 $581.91

33020 $942.55 $895.42 $1,029.73 $1,014.29

33025 $861.92 $818.82 $941.64 $927.52

33030 $2,144.13 $2,036.92 $2,342.46 $2,307.33

33031 $2,655.82 $2,523.03 $2,901.48 $2,857.96

33050 $1,078.12 $1,024.21 $1,177.84 $1,160.18

33120 $2,248.13 $2,135.72 $2,456.08 $2,419.23

33130 $1,494.15 $1,419.44 $1,632.36 $1,607.87

33140 $1,698.58 $1,613.65 $1,855.70 $1,827.87

33141 $140.57 $133.54 $153.57 $151.27

33202 $836.37 $794.55 $913.73 $900.02

33203 $863.17 $820.01 $943.01 $928.87

33206 $486.32 $462.00 $531.30 $523.33

33207 $514.20 $488.49 $561.76 $553.33

33208 $555.27 $527.51 $606.64 $597.54

33210 $186.62 $177.29 $203.88 $200.82

33211 $190.40 $180.88 $208.01 $204.90

33212 $354.63 $336.90 $387.44 $381.63

33213 $369.94 $351.44 $404.16 $398.10

33214 $513.61 $487.93 $561.12 $552.70

33215 $323.47 $307.30 $353.40 $348.09

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

33216 $399.98 $379.98 $436.98 $430.42

33217 $397.78 $377.89 $434.57 $428.05

33218 $419.84 $398.85 $458.68 $451.80

33220 $422.97 $401.82 $462.09 $455.16

33221 $385.64 $366.36 $421.31 $414.99

33222 $371.32 $352.75 $405.66 $399.58

33223 $441.49 $419.42 $482.33 $475.10

33224 $533.04 $506.39 $582.35 $573.61

33225 $478.96 $455.01 $523.26 $515.41

33226 $512.71 $487.07 $560.13 $551.72

33227 $368.87 $350.43 $402.99 $396.95

33228 $384.60 $365.37 $420.18 $413.87

33229 $399.94 $379.94 $436.93 $430.38

33230 $417.17 $396.31 $455.76 $448.93

33231 $432.51 $410.88 $472.51 $465.43

33233 $254.81 $242.07 $278.38 $274.21

33234 $517.84 $491.95 $565.74 $557.26

33235 $677.38 $643.51 $740.04 $728.94

33236 $858.68 $815.75 $938.11 $924.04

33237 $912.40 $866.78 $996.80 $981.85

33238 $1,017.45 $966.58 $1,111.57 $1,094.89

33240 $401.44 $381.37 $438.58 $432.00

33241 $239.14 $227.18 $261.26 $257.34

33243 $1,468.47 $1,395.05 $1,604.31 $1,580.24

33244 $907.27 $861.91 $991.20 $976.33

33249 $960.30 $912.29 $1,049.13 $1,033.40

33250 $1,588.33 $1,508.91 $1,735.25 $1,709.22

33251 $1,749.19 $1,661.73 $1,910.99 $1,882.32

33254 $1,479.27 $1,405.31 $1,616.11 $1,591.86

33255 $1,774.15 $1,685.44 $1,938.26 $1,909.18

33256 $2,103.06 $1,997.91 $2,297.60 $2,263.13

33257 $634.64 $602.91 $693.35 $682.95

33258 $713.52 $677.84 $779.52 $767.82

33259 $920.38 $874.36 $1,005.51 $990.43

33261 $1,757.01 $1,669.16 $1,919.53 $1,890.74

33262 $402.17 $382.06 $439.37 $432.78

33263 $417.90 $397.01 $456.56 $449.71

33264 $433.24 $411.58 $473.32 $466.22

33265 $1,465.45 $1,392.18 $1,601.01 $1,577.00

33266 $1,994.99 $1,895.24 $2,179.53 $2,146.83

33282 $343.14 $325.98 $374.88 $369.25

33284 $248.57 $236.14 $271.56 $267.49

33300 $2,622.46 $2,491.34 $2,865.04 $2,822.07

33305 $4,380.37 $4,161.35 $4,785.55 $4,713.77

33310 $1,259.64 $1,196.66 $1,376.16 $1,355.52

33315 $2,058.06 $1,955.16 $2,248.43 $2,214.70

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

33320 $1,134.43 $1,077.71 $1,239.37 $1,220.77

33321 $1,288.33 $1,223.91 $1,407.50 $1,386.38

33322 $1,502.15 $1,427.04 $1,641.10 $1,616.47

33330 $1,650.63 $1,568.10 $1,803.32 $1,776.27

33332 $1,508.24 $1,432.83 $1,647.75 $1,623.04

33335 $2,023.51 $1,922.33 $2,210.68 $2,177.53

33361 $1,417.58 $1,346.70 $1,548.71 $1,525.48

33362 $1,550.86 $1,473.32 $1,694.32 $1,668.90

33363 $1,605.75 $1,525.46 $1,754.28 $1,727.97

33364 $1,709.79 $1,624.30 $1,867.95 $1,839.93

33365 $1,872.63 $1,779.00 $2,045.85 $2,015.17

33367 $656.55 $623.72 $717.28 $706.51

33368 $795.69 $755.91 $869.30 $856.26

33369 $1,050.49 $997.97 $1,147.67 $1,130.45

33400 $2,451.40 $2,328.83 $2,678.15 $2,637.99

33401 $1,534.17 $1,457.46 $1,676.08 $1,650.94

33403 $1,616.35 $1,535.53 $1,765.86 $1,739.38

33404 $1,889.70 $1,795.22 $2,064.50 $2,033.53

33405 $2,430.89 $2,309.35 $2,655.75 $2,615.92

33406 $3,094.63 $2,939.90 $3,380.89 $3,330.17

33410 $2,731.88 $2,595.29 $2,984.58 $2,939.81

33411 $3,605.27 $3,425.01 $3,938.76 $3,879.67

33412 $3,419.76 $3,248.77 $3,736.09 $3,680.05

33413 $3,468.14 $3,294.73 $3,788.94 $3,732.11

33414 $2,314.72 $2,198.98 $2,528.83 $2,490.90

33415 $2,193.69 $2,084.01 $2,396.61 $2,360.66

33416 $2,190.45 $2,080.93 $2,393.07 $2,357.18

33417 $1,794.76 $1,705.02 $1,960.77 $1,931.36

33420 $1,548.12 $1,470.71 $1,691.32 $1,665.95

33422 $1,818.72 $1,727.78 $1,986.95 $1,957.14

33425 $2,944.07 $2,796.87 $3,216.40 $3,168.16

33426 $2,566.96 $2,438.61 $2,804.40 $2,762.33

33427 $2,628.22 $2,496.81 $2,871.33 $2,828.26

33430 $2,998.85 $2,848.91 $3,276.25 $3,227.11

33460 $2,609.22 $2,478.76 $2,850.57 $2,807.82

33463 $3,316.31 $3,150.49 $3,623.06 $3,568.71

33464 $2,632.91 $2,501.26 $2,876.45 $2,833.30

33465 $2,965.81 $2,817.52 $3,240.15 $3,191.55

33468 $2,637.20 $2,505.34 $2,881.14 $2,837.92

33470 $1,409.35 $1,338.88 $1,539.71 $1,516.62

33471 $1,489.28 $1,414.82 $1,627.04 $1,602.64

33472 $1,411.81 $1,341.22 $1,542.40 $1,519.27

33474 $2,326.25 $2,209.94 $2,541.43 $2,503.31

33475 $2,530.51 $2,403.98 $2,764.58 $2,723.11

33476 $1,649.04 $1,566.59 $1,801.58 $1,774.55

33478 $1,703.11 $1,617.95 $1,860.64 $1,832.73

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

33496 $1,800.77 $1,710.73 $1,967.34 $1,937.83

33500 $1,702.20 $1,617.09 $1,859.65 $1,831.75

33501 $1,220.89 $1,159.85 $1,333.83 $1,313.82

33502 $1,387.96 $1,318.56 $1,516.34 $1,493.60

33503 $1,419.62 $1,348.64 $1,550.94 $1,527.67

33504 $1,589.03 $1,509.58 $1,736.02 $1,709.98

33505 $2,218.09 $2,107.19 $2,423.27 $2,386.92

33506 $2,191.03 $2,081.48 $2,393.70 $2,357.80

33507 $1,839.38 $1,747.41 $2,009.52 $1,979.38

33508 $17.09 $16.24 $18.68 $18.40

33510 $2,084.94 $1,980.69 $2,277.79 $2,243.63

33511 $2,289.37 $2,174.90 $2,501.14 $2,463.62

33512 $2,599.57 $2,469.59 $2,840.03 $2,797.43

33513 $2,673.27 $2,539.61 $2,920.55 $2,876.75

33514 $2,817.94 $2,677.04 $3,078.60 $3,032.41

33516 $2,939.35 $2,792.38 $3,211.24 $3,163.06

33517 $200.04 $190.04 $218.55 $215.27

33518 $439.92 $417.92 $480.61 $473.40

33519 $581.56 $552.48 $635.35 $625.82

33521 $699.02 $664.07 $763.68 $752.23

33522 $784.77 $745.53 $857.36 $844.50

33523 $891.55 $846.97 $974.02 $959.41

33530 $561.29 $533.23 $613.21 $604.01

33533 $2,003.53 $1,903.35 $2,188.85 $2,156.02

33534 $2,368.78 $2,250.34 $2,587.89 $2,549.07

33535 $2,637.78 $2,505.89 $2,881.77 $2,838.55

33536 $2,821.99 $2,680.89 $3,083.02 $3,036.78

33542 $2,827.92 $2,686.52 $3,089.50 $3,043.15

33545 $3,315.15 $3,149.39 $3,621.80 $3,567.47

33548 $3,191.92 $3,032.32 $3,487.17 $3,434.87

33572 $246.65 $234.32 $269.47 $265.43

33600 $1,843.64 $1,751.46 $2,014.18 $1,983.97

33602 $1,768.94 $1,680.49 $1,932.56 $1,903.57

33606 $1,880.88 $1,786.84 $2,054.87 $2,024.05

33608 $1,930.84 $1,834.30 $2,109.45 $2,077.81

33610 $1,982.66 $1,883.53 $2,166.06 $2,133.57

33611 $2,103.32 $1,998.15 $2,297.87 $2,263.41

33612 $2,117.61 $2,011.73 $2,313.49 $2,278.78

33615 $2,134.94 $2,028.19 $2,332.42 $2,297.44

33617 $2,311.08 $2,195.53 $2,524.86 $2,486.99

33619 $2,916.59 $2,770.76 $3,186.37 $3,138.58

33620 $1,537.49 $1,460.62 $1,679.71 $1,654.52

33621 $929.81 $883.32 $1,015.82 $1,000.58

33622 $3,654.93 $3,472.18 $3,993.01 $3,933.12

33641 $1,762.23 $1,674.12 $1,925.24 $1,896.36

33645 $1,868.71 $1,775.27 $2,041.56 $2,010.94

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

33647 $1,959.91 $1,861.91 $2,141.20 $2,109.08

33660 $1,895.16 $1,800.40 $2,070.46 $2,039.40

33665 $2,064.19 $1,960.98 $2,255.13 $2,221.31

33670 $2,123.69 $2,017.51 $2,320.14 $2,285.34

33675 $2,125.50 $2,019.23 $2,322.11 $2,287.28

33676 $2,293.65 $2,178.97 $2,505.82 $2,468.23

33677 $2,272.28 $2,158.67 $2,482.47 $2,445.23

33681 $1,981.51 $1,882.43 $2,164.79 $2,132.32

33684 $2,038.71 $1,936.77 $2,227.29 $2,193.88

33688 $2,029.80 $1,928.31 $2,217.56 $2,184.30

33690 $1,293.69 $1,229.01 $1,413.36 $1,392.16

33692 $2,217.90 $2,107.01 $2,423.06 $2,386.71

33694 $2,206.38 $2,096.06 $2,410.47 $2,374.31

33697 $2,198.89 $2,088.95 $2,402.29 $2,366.26

33702 $1,675.29 $1,591.53 $1,830.26 $1,802.81

33710 $2,299.42 $2,184.45 $2,512.12 $2,474.43

33720 $1,660.70 $1,577.67 $1,814.32 $1,787.10

33722 $1,754.66 $1,666.93 $1,916.97 $1,888.22

33724 $1,646.54 $1,564.21 $1,798.84 $1,771.86

33726 $2,299.40 $2,184.43 $2,512.09 $2,474.41

33730 $2,164.08 $2,055.88 $2,364.26 $2,328.80

33732 $1,786.34 $1,697.02 $1,951.57 $1,922.29

33735 $1,389.85 $1,320.36 $1,518.41 $1,495.63

33736 $1,525.33 $1,449.06 $1,666.42 $1,641.42

33737 $1,447.56 $1,375.18 $1,581.46 $1,557.73

33750 $1,535.99 $1,459.19 $1,678.07 $1,652.90

33755 $1,454.90 $1,382.16 $1,589.48 $1,565.64

33762 $1,446.98 $1,374.63 $1,580.82 $1,557.11

33764 $1,400.80 $1,330.76 $1,530.37 $1,507.42

33766 $1,474.28 $1,400.57 $1,610.66 $1,586.49

33767 $1,537.58 $1,460.70 $1,679.81 $1,654.61

33768 $470.09 $446.59 $513.58 $505.87

33770 $2,374.75 $2,256.01 $2,594.41 $2,555.50

33771 $2,473.63 $2,349.95 $2,702.44 $2,661.91

33774 $1,949.23 $1,851.77 $2,129.54 $2,097.59

33775 $2,091.62 $1,987.04 $2,285.10 $2,250.81

33776 $2,210.18 $2,099.67 $2,414.62 $2,378.40

33777 $2,138.24 $2,031.33 $2,336.03 $2,300.99

33778 $2,540.06 $2,413.06 $2,775.02 $2,733.39

33779 $2,640.63 $2,508.60 $2,884.89 $2,841.62

33780 $2,687.63 $2,553.25 $2,936.24 $2,892.19

33781 $2,627.30 $2,495.94 $2,870.33 $2,827.28

33782 $3,435.45 $3,263.68 $3,753.23 $3,696.93

33783 $3,710.89 $3,525.35 $4,054.15 $3,993.34

33786 $2,453.48 $2,330.81 $2,680.43 $2,640.23

33788 $1,756.08 $1,668.28 $1,918.52 $1,889.75

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

33800 $982.59 $933.46 $1,073.48 $1,057.38

33802 $1,254.88 $1,192.14 $1,370.96 $1,350.40

33803 $1,244.71 $1,182.47 $1,359.84 $1,339.44

33813 $1,382.52 $1,313.39 $1,510.40 $1,487.74

33814 $1,652.87 $1,570.23 $1,805.76 $1,778.68

33820 $1,052.49 $999.87 $1,149.85 $1,132.60

33822 $1,150.77 $1,093.23 $1,257.21 $1,238.35

33824 $1,270.07 $1,206.57 $1,387.56 $1,366.74

33840 $1,344.90 $1,277.66 $1,469.31 $1,447.28

33845 $1,448.48 $1,376.06 $1,582.47 $1,558.73

33851 $1,381.69 $1,312.61 $1,509.50 $1,486.86

33852 $1,515.73 $1,439.94 $1,655.93 $1,631.09

33853 $1,982.26 $1,883.15 $2,165.62 $2,133.14

33860 $3,449.05 $3,276.60 $3,768.09 $3,711.57

33863 $3,374.94 $3,206.19 $3,687.12 $3,631.82

33864 $3,447.02 $3,274.67 $3,765.87 $3,709.38

33870 $2,706.73 $2,571.39 $2,957.10 $2,912.74

33875 $2,950.95 $2,803.40 $3,223.91 $3,175.55

33877 $3,912.08 $3,716.48 $4,273.95 $4,209.84

33880 $1,947.68 $1,850.30 $2,127.85 $2,095.93

33881 $1,672.49 $1,588.87 $1,827.20 $1,799.80

33883 $1,212.71 $1,152.07 $1,324.88 $1,305.01

33884 $439.91 $417.91 $480.60 $473.39

33886 $1,057.50 $1,004.63 $1,155.32 $1,137.99

33889 $853.68 $811.00 $932.65 $918.67

33891 $1,048.29 $995.88 $1,145.26 $1,128.08

33910 $2,838.70 $2,696.77 $3,101.29 $3,054.77

33915 $1,472.71 $1,399.07 $1,608.93 $1,584.79

33916 $4,503.12 $4,277.96 $4,919.65 $4,845.86

33917 $1,567.83 $1,489.44 $1,712.86 $1,687.17

33920 $1,951.45 $1,853.88 $2,131.96 $2,099.98

33922 $1,506.94 $1,431.59 $1,646.33 $1,621.64

33924 $302.49 $287.37 $330.48 $325.52

33925 $1,835.61 $1,743.83 $2,005.40 $1,975.32

33926 $2,598.77 $2,468.83 $2,839.15 $2,796.57

33935 $5,359.60 $5,091.62 $5,855.36 $5,767.54

33944 $495.80 $471.01 $541.66 $533.53

33945 $5,201.30 $4,941.24 $5,682.43 $5,597.19

33960 $1,053.62 $1,000.94 $1,151.08 $1,133.82

33961 $586.26 $556.95 $640.49 $630.89

33967 $273.19 $259.53 $298.46 $293.99

33968 $35.64 $33.86 $38.94 $38.35

33970 $376.53 $357.70 $411.36 $405.18

33971 $771.20 $732.64 $842.54 $829.90

33973 $547.76 $520.37 $598.43 $589.44

33974 $978.33 $929.41 $1,068.82 $1,052.79

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

33975 $1,410.60 $1,340.07 $1,541.08 $1,517.97

33976 $1,711.69 $1,626.11 $1,870.03 $1,841.98

33977 $1,210.90 $1,150.36 $1,322.91 $1,303.07

33978 $1,444.99 $1,372.74 $1,578.65 $1,554.97

33979 $2,081.65 $1,977.57 $2,274.21 $2,240.10

33980 $1,911.47 $1,815.90 $2,088.29 $2,056.96

33981 $897.55 $852.67 $980.57 $965.86

33982 $2,211.52 $2,100.94 $2,416.08 $2,379.84

33983 $2,462.91 $2,339.76 $2,690.72 $2,650.36

33990 $461.22 $438.16 $503.88 $496.33

33991 $672.02 $638.42 $734.18 $723.17

33992 $218.86 $207.92 $239.11 $235.52

33993 $192.18 $182.57 $209.96 $206.80

34001 $1,059.26 $1,006.30 $1,157.25 $1,139.89

34051 $1,084.17 $1,029.96 $1,184.45 $1,166.69

34101 $660.99 $627.94 $722.13 $711.30

34111 $661.43 $628.36 $722.61 $711.77

34151 $1,532.30 $1,455.69 $1,674.04 $1,648.93

34201 $1,132.10 $1,075.50 $1,236.83 $1,218.28

34203 $1,051.18 $998.62 $1,148.41 $1,131.19

34401 $1,574.15 $1,495.44 $1,719.76 $1,693.96

34421 $800.28 $760.27 $874.31 $861.20

34451 $1,796.07 $1,706.27 $1,962.21 $1,932.78

34471 $1,164.54 $1,106.31 $1,272.26 $1,253.18

34490 $679.95 $645.95 $742.84 $731.70

34501 $984.99 $935.74 $1,076.10 $1,059.96

34502 $1,655.32 $1,572.55 $1,808.43 $1,781.30

34510 $1,276.45 $1,212.63 $1,394.52 $1,373.61

34520 $1,085.86 $1,031.57 $1,186.31 $1,168.52

34530 $1,017.63 $966.75 $1,111.76 $1,095.09

34800 $1,220.65 $1,159.62 $1,333.56 $1,313.56

34802 $1,351.78 $1,284.19 $1,476.82 $1,454.67

34803 $1,394.92 $1,325.17 $1,523.95 $1,501.08

34804 $1,352.41 $1,284.79 $1,477.51 $1,455.35

34805 $1,295.39 $1,230.62 $1,415.21 $1,393.98

34806 $109.78 $104.29 $119.93 $118.14

34808 $222.24 $211.13 $242.80 $239.15

34812 $363.94 $345.74 $397.60 $391.63

34813 $256.45 $243.63 $280.17 $275.98

34820 $528.87 $502.43 $577.79 $569.12

34825 $761.16 $723.10 $831.57 $819.09

34826 $220.38 $209.36 $240.76 $237.15

34830 $1,926.35 $1,830.03 $2,104.53 $2,072.97

34831 $2,070.63 $1,967.10 $2,262.17 $2,228.23

34832 $2,070.63 $1,967.10 $2,262.17 $2,228.23

34833 $659.40 $626.43 $720.39 $709.58

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

34834 $298.16 $283.25 $325.74 $320.85

34900 $970.44 $921.92 $1,060.21 $1,044.30

35001 $1,245.18 $1,182.92 $1,360.36 $1,339.96

35002 $1,226.12 $1,164.81 $1,339.53 $1,319.44

35005 $1,262.79 $1,199.65 $1,379.60 $1,358.91

35011 $1,091.98 $1,037.38 $1,192.99 $1,175.09

35013 $1,366.28 $1,297.97 $1,492.67 $1,470.28

35021 $1,361.86 $1,293.77 $1,487.84 $1,465.51

35022 $1,554.63 $1,476.90 $1,698.44 $1,672.96

35045 $1,081.21 $1,027.15 $1,181.22 $1,163.50

35081 $1,917.96 $1,822.06 $2,095.37 $2,063.94

35082 $2,387.86 $2,268.47 $2,608.74 $2,569.61

35091 $1,952.06 $1,854.46 $2,132.63 $2,100.64

35092 $2,836.42 $2,694.60 $3,098.79 $3,052.31

35102 $2,070.49 $1,966.97 $2,262.02 $2,228.09

35103 $2,448.91 $2,326.46 $2,675.43 $2,635.29

35111 $1,431.48 $1,359.91 $1,563.90 $1,540.44

35112 $2,010.64 $1,910.11 $2,196.63 $2,163.68

35121 $1,794.41 $1,704.69 $1,960.39 $1,930.99

35122 $2,316.43 $2,200.61 $2,530.70 $2,492.74

35131 $1,517.05 $1,441.20 $1,657.38 $1,632.52

35132 $1,776.72 $1,687.88 $1,941.06 $1,911.94

35141 $1,217.59 $1,156.71 $1,330.22 $1,310.26

35142 $1,451.49 $1,378.92 $1,585.76 $1,561.98

35151 $1,364.39 $1,296.17 $1,490.60 $1,468.24

35152 $1,529.64 $1,453.16 $1,671.13 $1,646.06

35180 $1,001.97 $951.87 $1,094.65 $1,078.23

35182 $1,889.70 $1,795.22 $2,064.50 $2,033.53

35184 $1,144.95 $1,087.70 $1,250.86 $1,232.09

35188 $992.02 $942.42 $1,083.78 $1,067.52

35189 $1,665.13 $1,581.87 $1,819.15 $1,791.86

35190 $832.41 $790.79 $909.41 $895.77

35201 $1,030.95 $979.40 $1,126.31 $1,109.42

35206 $850.45 $807.93 $929.12 $915.18

35207 $814.89 $774.15 $890.27 $876.92

35211 $1,489.59 $1,415.11 $1,627.38 $1,602.96

35216 $2,203.76 $2,093.57 $2,407.61 $2,371.50

35221 $1,562.21 $1,484.10 $1,706.72 $1,681.12

35226 $916.37 $870.55 $1,001.13 $986.11

35231 $1,307.42 $1,242.05 $1,428.36 $1,406.93

35236 $1,076.22 $1,022.41 $1,175.77 $1,158.13

35241 $1,559.27 $1,481.31 $1,703.51 $1,677.95

35246 $1,564.41 $1,486.19 $1,709.12 $1,683.49

35251 $1,837.76 $1,745.87 $2,007.75 $1,977.63

35256 $1,116.31 $1,060.49 $1,219.56 $1,201.27

35261 $1,147.31 $1,089.94 $1,253.43 $1,234.63

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

35266 $940.64 $893.61 $1,027.65 $1,012.24

35271 $1,501.60 $1,426.52 $1,640.50 $1,615.89

35276 $1,574.80 $1,496.06 $1,720.47 $1,694.66

35281 $1,772.92 $1,684.27 $1,936.91 $1,907.86

35286 $1,023.34 $972.17 $1,118.00 $1,101.23

35301 $1,151.72 $1,094.13 $1,258.25 $1,239.38

35302 $1,237.58 $1,175.70 $1,352.06 $1,331.77

35303 $1,365.70 $1,297.42 $1,492.03 $1,469.65

35304 $1,405.57 $1,335.29 $1,535.58 $1,512.55

35305 $1,351.14 $1,283.58 $1,476.12 $1,453.98

35306 $484.62 $460.39 $529.45 $521.50

35311 $1,675.33 $1,591.56 $1,830.29 $1,802.84

35321 $975.44 $926.67 $1,065.67 $1,049.69

35331 $1,596.83 $1,516.99 $1,744.54 $1,718.38

35341 $1,507.11 $1,431.75 $1,646.51 $1,621.81

35351 $1,402.86 $1,332.72 $1,532.63 $1,509.64

35355 $1,135.89 $1,079.10 $1,240.97 $1,222.35

35361 $1,665.44 $1,582.17 $1,819.50 $1,792.21

35363 $1,881.35 $1,787.28 $2,055.37 $2,024.54

35371 $902.16 $857.05 $985.61 $970.82

35372 $1,076.54 $1,022.71 $1,176.12 $1,158.48

35390 $172.78 $164.14 $188.76 $185.93

35400 $161.34 $153.27 $176.26 $173.62

35450 $554.00 $526.30 $605.25 $596.17

35452 $388.57 $369.14 $424.51 $418.14

35458 $532.59 $505.96 $581.85 $573.13

35460 $341.06 $324.01 $372.61 $367.02

35471 $2,951.38 $2,803.81 $3,224.38 $3,176.01

# 35471 $558.93 $530.98 $610.63 $601.47

35472 $2,232.82 $2,121.18 $2,439.36 $2,402.76

# 35472 $385.13 $365.87 $420.75 $414.44

35475 $1,821.16 $1,730.10 $1,989.62 $1,959.77

# 35475 $317.50 $301.63 $346.87 $341.68

35476 $1,683.11 $1,598.95 $1,838.79 $1,811.22

# 35476 $270.24 $256.73 $295.24 $290.81

35500 $347.53 $330.15 $379.67 $373.98

35501 $1,649.06 $1,566.61 $1,801.60 $1,774.58

35506 $1,467.46 $1,394.09 $1,603.20 $1,579.16

35508 $1,469.11 $1,395.65 $1,605.00 $1,580.93

35509 $1,548.13 $1,470.72 $1,691.33 $1,665.96

35510 $1,346.97 $1,279.62 $1,471.56 $1,449.49

35511 $1,405.97 $1,335.67 $1,536.02 $1,512.97

35512 $1,321.45 $1,255.38 $1,443.69 $1,422.03

35515 $1,457.38 $1,384.51 $1,592.19 $1,568.30

35516 $1,336.23 $1,269.42 $1,459.83 $1,437.94

35518 $1,431.67 $1,360.09 $1,564.10 $1,540.64

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

35521 $1,546.48 $1,469.16 $1,689.53 $1,664.19

35522 $1,362.57 $1,294.44 $1,488.61 $1,466.27

35523 $1,400.06 $1,330.06 $1,529.57 $1,506.63

35525 $1,250.05 $1,187.55 $1,365.68 $1,345.20

35526 $1,884.86 $1,790.62 $2,059.21 $2,028.32

35531 $2,209.41 $2,098.94 $2,413.78 $2,377.58

35533 $1,648.06 $1,565.66 $1,800.51 $1,773.51

35535 $1,854.56 $1,761.83 $2,026.10 $1,995.71

35536 $2,221.12 $2,110.06 $2,426.57 $2,390.17

35537 $2,277.89 $2,164.00 $2,488.60 $2,451.27

35538 $2,549.20 $2,421.74 $2,785.00 $2,743.22

35539 $2,395.24 $2,275.48 $2,616.80 $2,577.55

35540 $2,804.03 $2,663.83 $3,063.40 $3,017.45

35556 $1,540.97 $1,463.92 $1,683.51 $1,658.25

35558 $1,362.26 $1,294.15 $1,488.27 $1,465.95

35560 $1,863.60 $1,770.42 $2,035.98 $2,005.44

35563 $1,448.84 $1,376.40 $1,582.86 $1,559.11

35565 $1,445.19 $1,372.93 $1,578.87 $1,555.19

35566 $1,835.19 $1,743.43 $2,004.94 $1,974.87

35570 $1,492.28 $1,417.67 $1,630.32 $1,605.86

35571 $1,458.33 $1,385.41 $1,593.22 $1,569.32

35572 $374.31 $355.59 $408.93 $402.80

35583 $1,583.91 $1,504.71 $1,730.42 $1,704.46

35585 $1,841.21 $1,749.15 $2,011.52 $1,981.35

35587 $1,498.74 $1,423.80 $1,637.37 $1,612.81

35600 $274.80 $261.06 $300.22 $295.71

35601 $1,547.25 $1,469.89 $1,690.37 $1,665.02

35606 $1,290.96 $1,226.41 $1,410.37 $1,389.21

35612 $1,146.78 $1,089.44 $1,252.86 $1,234.07

35616 $1,188.40 $1,128.98 $1,298.33 $1,278.86

35621 $1,206.71 $1,146.37 $1,318.33 $1,298.55

35623 $1,438.20 $1,366.29 $1,571.23 $1,547.67

35626 $1,714.01 $1,628.31 $1,872.56 $1,844.47

35631 $2,016.42 $1,915.60 $2,202.94 $2,169.90

35632 $1,761.72 $1,673.63 $1,924.67 $1,895.81

35633 $1,967.33 $1,868.96 $2,149.30 $2,117.07

35634 $1,724.16 $1,637.95 $1,883.64 $1,855.39

35636 $1,744.13 $1,656.92 $1,905.46 $1,876.88

35637 $1,899.32 $1,804.35 $2,075.00 $2,043.87

35638 $1,934.78 $1,838.04 $2,113.75 $2,082.04

35642 $1,085.35 $1,031.08 $1,185.74 $1,167.95

35645 $1,209.05 $1,148.60 $1,320.89 $1,301.08

35646 $1,881.35 $1,787.28 $2,055.37 $2,024.54

35647 $1,709.05 $1,623.60 $1,867.14 $1,839.14

35650 $1,168.04 $1,109.64 $1,276.09 $1,256.95

35654 $1,496.87 $1,422.03 $1,635.33 $1,610.81

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

35656 $1,191.53 $1,131.95 $1,301.74 $1,282.22

35661 $1,196.58 $1,136.75 $1,307.26 $1,287.66

35663 $1,383.56 $1,314.38 $1,511.54 $1,488.86

35665 $1,291.33 $1,226.76 $1,410.77 $1,389.61

35666 $1,401.47 $1,331.40 $1,531.11 $1,508.14

35671 $1,238.92 $1,176.97 $1,353.52 $1,333.22

35681 $86.74 $82.40 $94.76 $93.33

35682 $382.72 $363.58 $418.12 $411.85

35683 $444.18 $421.97 $485.27 $477.99

35685 $216.69 $205.86 $236.74 $233.19

35686 $179.08 $170.13 $195.65 $192.72

35691 $1,037.39 $985.52 $1,133.35 $1,116.35

35693 $921.13 $875.07 $1,006.33 $991.23

35694 $1,082.77 $1,028.63 $1,182.92 $1,165.18

35695 $1,123.90 $1,067.71 $1,227.87 $1,209.44

35697 $160.54 $152.51 $175.39 $172.75

35700 $166.33 $158.01 $181.71 $178.99

35701 $623.82 $592.63 $681.52 $671.30

35721 $501.67 $476.59 $548.08 $539.86

35741 $564.34 $536.12 $616.54 $607.29

35761 $431.15 $409.59 $471.03 $463.97

35800 $782.63 $743.50 $855.03 $842.20

35820 $2,161.63 $2,053.55 $2,361.58 $2,326.16

35840 $1,277.82 $1,213.93 $1,396.02 $1,375.08

35860 $922.41 $876.29 $1,007.73 $992.62

35870 $1,363.73 $1,295.54 $1,489.87 $1,467.53

35875 $658.35 $625.43 $719.24 $708.46

35876 $1,040.68 $988.65 $1,136.95 $1,119.89

35879 $1,020.88 $969.84 $1,115.32 $1,098.58

35881 $1,124.88 $1,068.64 $1,228.94 $1,210.50

35883 $1,328.09 $1,261.69 $1,450.94 $1,429.17

35884 $1,357.75 $1,289.86 $1,483.34 $1,461.09

35901 $553.62 $525.94 $604.83 $595.76

35903 $630.45 $598.93 $688.77 $678.44

35905 $1,837.02 $1,745.17 $2,006.95 $1,976.84

35907 $2,091.97 $1,987.37 $2,285.48 $2,251.19

36002 $178.74 $169.80 $195.27 $192.34

# 36002 $114.00 $108.30 $124.55 $122.68

36005 $376.25 $357.44 $411.06 $404.89

# 36005 $50.62 $48.09 $55.30 $54.48

36010 $580.33 $551.31 $634.01 $624.50

# 36010 $127.89 $121.50 $139.73 $137.63

36011 $982.48 $933.36 $1,073.36 $1,057.26

# 36011 $166.09 $157.79 $181.46 $178.73

36012 $1,005.45 $955.18 $1,098.46 $1,081.98

# 36012 $186.77 $177.43 $204.04 $200.99

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

36013 $947.89 $900.50 $1,035.58 $1,020.04

# 36013 $139.55 $132.57 $152.46 $150.17

36014 $947.58 $900.20 $1,035.23 $1,019.71

# 36014 $157.25 $149.39 $171.80 $169.22

36015 $1,018.51 $967.58 $1,112.72 $1,096.03

# 36015 $182.59 $173.46 $199.48 $196.49

36100 $593.43 $563.76 $648.32 $638.60

# 36100 $170.87 $162.33 $186.68 $183.89

36120 $505.65 $480.37 $552.43 $544.13

# 36120 $105.69 $100.41 $115.47 $113.74

36140 $513.53 $487.85 $561.03 $552.61

# 36140 $108.97 $103.52 $119.05 $117.27

36147 $980.62 $931.59 $1,071.33 $1,055.26

# 36147 $197.95 $188.05 $216.26 $213.01

36148 $306.41 $291.09 $334.75 $329.73

# 36148 $52.03 $49.43 $56.84 $55.99

36160 $593.71 $564.02 $648.62 $638.89

# 36160 $135.53 $128.75 $148.06 $145.84

36200 $734.98 $698.23 $802.96 $790.92

# 36200 $161.87 $153.78 $176.85 $174.19

36215 $1,282.06 $1,217.96 $1,400.65 $1,379.64

# 36215 $256.51 $243.68 $280.23 $276.02

36216 $1,428.26 $1,356.85 $1,560.38 $1,536.98

# 36216 $291.99 $277.39 $319.00 $314.21

36217 $2,468.97 $2,345.52 $2,697.35 $2,656.89

# 36217 $349.66 $332.18 $382.01 $376.28

36218 $226.58 $215.25 $247.54 $243.82

# 36218 $55.71 $52.92 $60.86 $59.95

36221 $1,295.70 $1,230.92 $1,415.56 $1,394.33

# 36221 $227.62 $216.24 $248.68 $244.95

36222 $1,603.42 $1,523.25 $1,751.74 $1,725.46

# 36222 $308.54 $293.11 $337.08 $332.02

36223 $1,754.37 $1,666.65 $1,916.65 $1,887.90

# 36223 $333.46 $316.79 $364.31 $358.85

36224 $1,905.72 $1,810.43 $2,081.99 $2,050.76

# 36224 $363.36 $345.19 $396.97 $391.01

36225 $1,741.38 $1,654.31 $1,902.46 $1,873.93

# 36225 $331.95 $315.35 $362.65 $357.21

36226 $1,943.26 $1,846.10 $2,123.02 $2,091.17

# 36226 $364.13 $345.92 $397.81 $391.84

36227 $275.12 $261.36 $300.56 $296.06

# 36227 $114.98 $109.23 $125.61 $123.73

36228 $1,334.93 $1,268.18 $1,458.41 $1,436.53

# 36228 $234.28 $222.57 $255.96 $252.11

36245 $1,153.20 $1,095.54 $1,259.87 $1,240.98

# 36245 $256.37 $243.55 $280.08 $275.89

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

36246 $1,030.85 $979.31 $1,126.21 $1,109.31

# 36246 $284.19 $269.98 $310.48 $305.82

36247 $1,853.38 $1,760.71 $2,024.82 $1,994.45

# 36247 $339.75 $322.76 $371.17 $365.61

36248 $175.62 $166.84 $191.87 $188.99

# 36248 $53.80 $51.11 $58.78 $57.89

36251 $1,690.58 $1,606.05 $1,846.96 $1,819.25

# 36251 $296.10 $281.30 $323.50 $318.64

36252 $1,844.03 $1,751.83 $2,014.60 $1,984.38

# 36252 $385.19 $365.93 $420.82 $414.51

36253 $2,580.35 $2,451.33 $2,819.03 $2,776.74

# 36253 $410.09 $389.59 $448.03 $441.31

36254 $2,678.27 $2,544.36 $2,926.01 $2,882.12

# 36254 $442.50 $420.38 $483.44 $476.18

36260 $695.84 $661.05 $760.21 $748.80

36261 $440.15 $418.14 $480.86 $473.65

36262 $335.75 $318.96 $366.80 $361.31

36400 $31.83 $30.24 $34.78 $34.26

# 36400 $20.72 $19.68 $22.63 $22.29

36405 $29.02 $27.57 $31.71 $31.23

# 36405 $17.53 $16.65 $19.15 $18.86

36406 $21.88 $20.79 $23.91 $23.55

# 36406 $10.38 $9.86 $11.34 $11.17

36410 $18.81 $17.87 $20.55 $20.24

# 36410 $10.00 $9.50 $10.93 $10.76

36420 $55.06 $52.31 $60.16 $59.26

36425 $42.19 $40.08 $46.09 $45.40

36430 $39.05 $37.10 $42.67 $42.02

36440 $62.32 $59.20 $68.08 $67.06

36450 $112.41 $106.79 $122.81 $120.97

36455 $118.51 $112.58 $129.47 $127.52

36460 $386.00 $366.70 $421.71 $415.38

36470 $174.75 $166.01 $190.91 $188.05

# 36470 $94.69 $89.96 $103.45 $101.90

36471 $197.39 $187.52 $215.65 $212.42

# 36471 $109.66 $104.18 $119.81 $118.01

36475 $2,012.85 $1,912.21 $2,199.04 $2,166.06

# 36475 $378.55 $359.62 $413.56 $407.36

36476 $439.53 $417.55 $480.18 $472.98

# 36476 $185.54 $176.26 $202.70 $199.66

36478 $1,570.64 $1,492.11 $1,715.93 $1,690.19

# 36478 $374.99 $356.24 $409.68 $403.54

36479 $446.62 $424.29 $487.93 $480.62

# 36479 $184.58 $175.35 $201.65 $198.63

36481 $2,440.18 $2,318.17 $2,665.90 $2,625.91

# 36481 $378.34 $359.42 $413.33 $407.13

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

36500 $189.43 $179.96 $206.95 $203.85

36510 $105.39 $100.12 $115.14 $113.41

# 36510 $64.02 $60.82 $69.94 $68.90

36511 $101.84 $96.75 $111.26 $109.60

36512 $98.31 $93.39 $107.40 $105.79

36513 $104.71 $99.47 $114.39 $112.68

36514 $614.43 $583.71 $671.27 $661.19

# 36514 $99.54 $94.56 $108.74 $107.11

36515 $2,506.25 $2,380.94 $2,738.08 $2,697.01

# 36515 $91.96 $87.36 $100.46 $98.96

36516 $2,445.74 $2,323.45 $2,671.97 $2,631.89

# 36516 $75.13 $71.37 $82.08 $80.85

36522 $1,633.64 $1,551.96 $1,784.75 $1,757.98

# 36522 $110.06 $104.56 $120.24 $118.44

36555 $288.25 $273.84 $314.92 $310.19

# 36555 $122.37 $116.25 $133.69 $131.69

36556 $261.45 $248.38 $285.64 $281.35

# 36556 $126.98 $120.63 $138.72 $136.64

36557 $886.20 $841.89 $968.17 $953.65

# 36557 $328.40 $311.98 $358.78 $353.40

36558 $903.23 $858.07 $986.78 $971.98

# 36558 $299.46 $284.49 $327.16 $322.25

36560 $1,601.78 $1,521.69 $1,749.94 $1,723.69

# 36560 $394.25 $374.54 $430.72 $424.26

36561 $1,385.58 $1,316.30 $1,513.75 $1,491.04

# 36561 $383.77 $364.58 $419.27 $412.98

36563 $1,578.90 $1,499.96 $1,724.95 $1,699.08

# 36563 $410.45 $389.93 $448.42 $441.69

36565 $1,163.62 $1,105.44 $1,271.26 $1,252.19

# 36565 $379.04 $360.09 $414.10 $407.89

36566 $6,611.48 $6,280.91 $7,223.05 $7,114.71

# 36566 $414.08 $393.38 $452.39 $445.60

36568 $332.07 $315.47 $362.79 $357.35

# 36568 $101.45 $96.38 $110.84 $109.17

36569 $278.03 $264.13 $303.75 $299.20

# 36569 $95.67 $90.89 $104.52 $102.96

36570 $1,378.20 $1,309.29 $1,505.68 $1,483.10

# 36570 $331.57 $314.99 $362.24 $356.81

36571 $1,528.90 $1,452.46 $1,670.33 $1,645.27

# 36571 $348.57 $331.14 $380.81 $375.10

36575 $196.54 $186.71 $214.72 $211.50

# 36575 $37.56 $35.68 $41.03 $40.41

36576 $439.71 $417.72 $480.38 $473.17

# 36576 $211.76 $201.17 $231.35 $227.87

36578 $599.62 $569.64 $655.09 $645.27

# 36578 $234.52 $222.79 $256.21 $252.37

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

36580 $245.43 $233.16 $268.13 $264.11

# 36580 $70.73 $67.19 $77.27 $76.11

36581 $891.24 $846.68 $973.68 $959.08

# 36581 $211.62 $201.04 $231.20 $227.72

36582 $1,290.97 $1,226.42 $1,410.38 $1,389.22

# 36582 $329.77 $313.28 $360.27 $354.87

36583 $1,625.67 $1,544.39 $1,776.05 $1,749.40

# 36583 $364.51 $346.28 $398.22 $392.25

36584 $230.25 $218.74 $251.55 $247.78

# 36584 $70.11 $66.60 $76.59 $75.44

36585 $1,415.57 $1,344.79 $1,546.51 $1,523.31

# 36585 $308.41 $292.99 $336.94 $331.89

36589 $182.38 $173.26 $199.25 $196.26

# 36589 $151.35 $143.78 $165.35 $162.86

36590 $328.02 $311.62 $358.36 $352.99

# 36590 $222.67 $211.54 $243.27 $239.63

36591 $26.79 $25.45 $29.27 $28.83

36592 $31.00 $29.45 $33.87 $33.36

36593 $35.60 $33.82 $38.89 $38.31

36595 $647.33 $614.96 $707.20 $696.60

# 36595 $195.27 $185.51 $213.34 $210.14

36596 $153.73 $146.04 $167.95 $165.43

# 36596 $48.38 $45.96 $52.85 $52.06

36597 $139.80 $132.81 $152.73 $150.44

# 36597 $63.95 $60.75 $69.86 $68.82

36598 $123.97 $117.77 $135.44 $133.40

# 36598 $38.16 $36.25 $41.69 $41.07

36600 $34.79 $33.05 $38.01 $37.43

# 36600 $16.40 $15.58 $17.92 $17.65

36620 $52.70 $50.07 $57.58 $56.72

36625 $111.60 $106.02 $121.92 $120.09

36640 $141.13 $134.07 $154.18 $151.87

36660 $77.58 $73.70 $84.76 $83.48

36680 $62.53 $59.40 $68.31 $67.29

36800 $179.41 $170.44 $196.01 $193.06

36810 $229.41 $217.94 $250.63 $246.87

36815 $161.49 $153.42 $176.43 $173.79

36818 $733.66 $696.98 $801.53 $789.51

36819 $804.75 $764.51 $879.19 $866.00

36820 $881.04 $836.99 $962.54 $948.11

36821 $759.52 $721.54 $829.77 $817.33

36822 $425.92 $404.62 $465.31 $458.33

36823 $1,437.26 $1,365.40 $1,570.21 $1,546.66

36825 $869.66 $826.18 $950.11 $935.86

36830 $714.99 $679.24 $781.13 $769.41

36831 $498.06 $473.16 $544.13 $535.97

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

36832 $631.34 $599.77 $689.74 $679.39

36833 $713.31 $677.64 $779.29 $767.60

36835 $460.93 $437.88 $503.56 $496.01

36838 $1,252.05 $1,189.45 $1,367.87 $1,347.35

36860 $233.07 $221.42 $254.63 $250.82

# 36860 $118.53 $112.60 $129.49 $127.55

36861 $172.80 $164.16 $188.78 $185.96

36870 $2,173.17 $2,064.51 $2,374.19 $2,338.57

# 36870 $325.87 $309.58 $356.02 $350.68

37140 $2,445.56 $2,323.28 $2,671.77 $2,631.69

37145 $2,275.58 $2,161.80 $2,486.07 $2,448.78

37160 $2,331.60 $2,215.02 $2,547.27 $2,509.06

37180 $2,243.63 $2,131.45 $2,451.17 $2,414.40

37181 $2,445.21 $2,322.95 $2,671.39 $2,631.33

37182 $880.40 $836.38 $961.84 $947.40

37183 $6,912.73 $6,567.09 $7,552.15 $7,438.87

# 37183 $414.22 $393.51 $452.54 $445.75

37184 $2,668.81 $2,535.37 $2,915.68 $2,871.94

# 37184 $484.38 $460.16 $529.18 $521.25

37185 $848.19 $805.78 $926.65 $912.74

# 37185 $177.00 $168.15 $193.37 $190.47

37186 $1,643.60 $1,561.42 $1,795.63 $1,768.70

# 37186 $268.28 $254.87 $293.10 $288.71

37187 $2,467.15 $2,343.79 $2,695.36 $2,654.92

# 37187 $431.75 $410.16 $471.68 $464.61

37188 $2,073.63 $1,969.95 $2,265.44 $2,231.46

# 37188 $307.17 $291.81 $335.58 $330.54

37191 $3,129.58 $2,973.10 $3,419.07 $3,367.78

# 37191 $252.51 $239.88 $275.86 $271.72

37192 $2,023.79 $1,922.60 $2,210.99 $2,177.82

# 37192 $387.96 $368.56 $423.84 $417.48

37193 $1,931.08 $1,834.53 $2,109.71 $2,078.06

# 37193 $388.73 $369.29 $424.68 $418.31

37195 $388.90 $369.46 $424.88 $418.51

37197 $1,760.05 $1,672.05 $1,922.86 $1,894.02

# 37197 $321.51 $305.43 $351.24 $345.98

37200 $232.37 $220.75 $253.86 $250.06

37202 $351.55 $333.97 $384.07 $378.30

37204 $939.80 $892.81 $1,026.73 $1,011.33

37205 $5,104.64 $4,849.41 $5,576.82 $5,493.17

# 37205 $450.37 $427.85 $492.03 $484.64

37206 $3,021.76 $2,870.67 $3,301.27 $3,251.75

# 37206 $223.99 $212.79 $244.71 $241.04

37207 $461.06 $438.01 $503.71 $496.16

37208 $220.24 $209.23 $240.61 $237.00

37210 $4,223.60 $4,012.42 $4,614.28 $4,545.06

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 37210 $551.98 $524.38 $603.04 $593.99

37211 $425.39 $404.12 $464.74 $457.77

37212 $375.56 $356.78 $410.30 $404.14

37213 $262.08 $248.98 $286.33 $282.04

37214 $154.77 $147.03 $169.08 $166.54

37215 $1,155.17 $1,097.41 $1,262.02 $1,243.09

37220 $3,822.94 $3,631.79 $4,176.56 $4,113.91

# 37220 $444.01 $421.81 $485.08 $477.80

37221 $5,600.20 $5,320.19 $6,118.22 $6,026.45

# 37221 $540.61 $513.58 $590.62 $581.76

37222 $1,069.52 $1,016.04 $1,168.45 $1,150.92

# 37222 $199.88 $189.89 $218.37 $215.10

37223 $3,130.43 $2,973.91 $3,420.00 $3,368.70

# 37223 $228.83 $217.39 $250.00 $246.25

37224 $4,607.94 $4,377.54 $5,034.17 $4,958.66

# 37224 $490.00 $465.50 $535.33 $527.30

37225 $13,286.24 $12,621.93 $14,515.22 $14,297.49

# 37225 $662.37 $629.25 $723.64 $712.78

37226 $10,918.67 $10,372.74 $11,928.65 $11,749.72

# 37226 $542.43 $515.31 $592.61 $583.72

37227 $17,958.09 $17,060.19 $19,619.22 $19,324.93

# 37227 $798.70 $758.77 $872.59 $859.50

37228 $6,578.26 $6,249.35 $7,186.75 $7,078.95

# 37228 $598.08 $568.18 $653.41 $643.61

37229 $13,076.53 $12,422.70 $14,286.11 $14,071.81

# 37229 $772.92 $734.27 $844.41 $831.75

37230 $9,955.42 $9,457.65 $10,876.30 $10,713.16

# 37230 $748.78 $711.34 $818.04 $805.77

37231 $15,921.86 $15,125.77 $17,394.64 $17,133.71

# 37231 $814.35 $773.63 $889.67 $876.33

37232 $1,453.02 $1,380.37 $1,587.43 $1,563.61

# 37232 $216.76 $205.92 $236.81 $233.25

37233 $1,730.66 $1,644.13 $1,890.75 $1,862.39

# 37233 $353.80 $336.11 $386.53 $380.73

37234 $4,732.76 $4,496.12 $5,170.54 $5,092.98

# 37234 $299.15 $284.19 $326.82 $321.92

37235 $4,817.90 $4,577.01 $5,263.56 $5,184.60

# 37235 $412.64 $392.01 $450.81 $444.05

37250 $113.85 $108.16 $124.38 $122.52

37251 $85.26 $81.00 $93.15 $91.76

37500 $701.17 $666.11 $766.03 $754.54

37565 $835.21 $793.45 $912.47 $898.78

37600 $766.14 $727.83 $837.00 $824.45

37605 $880.15 $836.14 $961.56 $947.14

37606 $627.64 $596.26 $685.70 $675.42

37607 $416.38 $395.56 $454.89 $448.07

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

37609 $356.26 $338.45 $389.22 $383.38

# 37609 $230.23 $218.72 $251.53 $247.76

37615 $564.07 $535.87 $616.25 $607.00

37616 $1,175.69 $1,116.91 $1,284.45 $1,265.18

37617 $1,440.85 $1,368.81 $1,574.13 $1,550.52

37618 $426.88 $405.54 $466.37 $459.38

37619 $1,821.51 $1,730.43 $1,989.99 $1,960.14

37650 $503.89 $478.70 $550.51 $542.25

37660 $1,212.53 $1,151.90 $1,324.69 $1,304.81

37700 $279.41 $265.44 $305.26 $300.68

37718 $485.09 $460.84 $529.97 $522.02

37722 $529.78 $503.29 $578.78 $570.10

37735 $701.87 $666.78 $766.80 $755.30

37760 $662.76 $629.62 $724.06 $713.21

37761 $602.52 $572.39 $658.25 $648.37

37765 $742.76 $705.62 $811.46 $799.30

# 37765 $492.59 $467.96 $538.15 $530.08

37766 $880.92 $836.87 $962.40 $947.97

# 37766 $605.09 $574.84 $661.07 $651.15

37780 $281.64 $267.56 $307.69 $303.08

37785 $405.77 $385.48 $443.30 $436.66

# 37785 $291.99 $277.39 $319.00 $314.21

37788 $1,492.79 $1,418.15 $1,630.87 $1,606.41

37790 $508.18 $482.77 $555.19 $546.86

38100 $1,221.83 $1,160.74 $1,334.85 $1,314.83

38101 $1,234.26 $1,172.55 $1,348.43 $1,328.20

38102 $274.00 $260.30 $299.35 $294.86

38115 $1,345.87 $1,278.58 $1,470.37 $1,448.31

38120 $1,122.42 $1,066.30 $1,226.25 $1,207.86

38200 $150.88 $143.34 $164.84 $162.37

38205 $84.83 $80.59 $92.68 $91.29

38206 $86.67 $82.34 $94.69 $93.27

38220 $181.64 $172.56 $198.44 $195.47

# 38220 $63.26 $60.10 $69.12 $68.08

38221 $183.75 $174.56 $200.74 $197.73

# 38221 $78.02 $74.12 $85.24 $83.96

38230 $219.78 $208.79 $240.11 $236.51

38232 $219.78 $208.79 $240.11 $236.51

38240 $174.89 $166.15 $191.07 $188.21

38241 $173.80 $165.11 $189.88 $187.02

38242 $121.62 $115.54 $132.87 $130.88

38243 $123.08 $116.93 $134.47 $132.46

38300 $320.29 $304.28 $349.92 $344.68

# 38300 $205.36 $195.09 $224.35 $220.98

38305 $503.06 $477.91 $549.60 $541.35

38308 $488.07 $463.67 $533.22 $525.22

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

38380 $623.79 $592.60 $681.49 $671.27

38381 $861.84 $818.75 $941.56 $927.44

38382 $722.69 $686.56 $789.54 $777.70

38500 $367.41 $349.04 $401.40 $395.37

# 38500 $273.93 $260.23 $299.26 $294.78

38505 $140.79 $133.75 $153.81 $151.50

# 38505 $76.81 $72.97 $83.92 $82.66

38510 $572.14 $543.53 $625.06 $615.69

# 38510 $451.84 $429.25 $493.64 $486.23

38520 $502.71 $477.57 $549.21 $540.97

38525 $470.93 $447.38 $514.49 $506.77

38530 $593.86 $564.17 $648.80 $639.07

38542 $561.35 $533.28 $613.27 $604.07

38550 $552.72 $525.08 $603.84 $594.78

38555 $1,013.11 $962.45 $1,106.82 $1,090.21

38562 $748.10 $710.70 $817.31 $805.05

38564 $746.16 $708.85 $815.18 $802.95

38570 $560.11 $532.10 $611.92 $602.74

38571 $817.04 $776.19 $892.62 $879.23

38572 $1,004.78 $954.54 $1,097.72 $1,081.25

38700 $872.63 $829.00 $953.35 $939.06

38720 $1,448.09 $1,375.69 $1,582.04 $1,558.31

38724 $1,566.33 $1,488.01 $1,711.21 $1,685.54

38740 $742.05 $704.95 $810.69 $798.54

38745 $936.85 $890.01 $1,023.51 $1,008.16

38746 $228.59 $217.16 $249.73 $245.99

38747 $278.93 $264.98 $304.73 $300.16

38760 $897.95 $853.05 $981.01 $966.29

38765 $1,363.17 $1,295.01 $1,489.26 $1,466.92

38770 $841.35 $799.28 $919.17 $905.38

38780 $1,079.78 $1,025.79 $1,179.66 $1,161.96

38790 $89.36 $84.89 $97.62 $96.16

38792 $44.28 $42.07 $48.38 $47.66

38794 $315.63 $299.85 $344.83 $339.65

38900 $144.00 $136.80 $157.32 $154.96

39000 $544.15 $516.94 $594.48 $585.57

39010 $854.50 $811.78 $933.55 $919.54

39200 $939.29 $892.33 $1,026.18 $1,010.79

39220 $1,226.59 $1,165.26 $1,340.05 $1,319.95

39400 $551.05 $523.50 $602.03 $593.00

39501 $909.25 $863.79 $993.36 $978.45

39503 $6,462.61 $6,139.48 $7,060.40 $6,954.50

39540 $924.30 $878.09 $1,009.80 $994.66

39541 $1,003.59 $953.41 $1,096.42 $1,079.98

39545 $964.87 $916.63 $1,054.12 $1,038.31

39560 $845.17 $802.91 $923.35 $909.50

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

39561 $1,340.11 $1,273.10 $1,464.07 $1,442.10

40490 $145.32 $138.05 $158.76 $156.38

# 40490 $79.04 $75.09 $86.35 $85.05

40500 $578.29 $549.38 $631.79 $622.31

# 40500 $406.66 $386.33 $444.28 $437.62

40510 $545.51 $518.23 $595.96 $587.03

# 40510 $392.27 $372.66 $428.56 $422.13

40520 $555.09 $527.34 $606.44 $597.34

# 40520 $397.25 $377.39 $434.00 $427.49

40525 $609.85 $579.36 $666.26 $656.27

40527 $676.73 $642.89 $739.32 $728.24

40530 $609.57 $579.09 $665.95 $655.96

# 40530 $446.37 $424.05 $487.66 $480.34

40650 $507.25 $481.89 $554.17 $545.86

# 40650 $336.39 $319.57 $367.51 $362.00

40652 $561.33 $533.26 $613.25 $604.05

# 40652 $392.76 $373.12 $429.09 $422.65

40654 $645.60 $613.32 $705.32 $694.74

# 40654 $472.06 $448.46 $515.73 $507.99

40700 $1,076.42 $1,022.60 $1,175.99 $1,158.35

40701 $1,167.11 $1,108.75 $1,275.06 $1,255.94

40702 $1,039.58 $987.60 $1,135.74 $1,118.71

40720 $1,133.51 $1,076.83 $1,238.35 $1,219.78

40761 $1,193.27 $1,133.61 $1,303.65 $1,284.10

40800 $247.96 $235.56 $270.89 $266.83

# 40800 $151.03 $143.48 $165.00 $162.53

40801 $361.19 $343.13 $394.60 $388.68

# 40801 $248.56 $236.13 $271.55 $267.48

40804 $253.89 $241.20 $277.38 $273.22

# 40804 $152.37 $144.75 $166.46 $163.97

40805 $457.60 $434.72 $499.93 $492.43

# 40805 $269.11 $255.65 $294.00 $289.59

40806 $135.93 $129.13 $148.50 $146.27

# 40806 $35.56 $33.78 $38.85 $38.26

40808 $220.17 $209.16 $240.53 $236.92

# 40808 $124.02 $117.82 $135.49 $133.46

40810 $241.74 $229.65 $264.10 $260.14

# 40810 $145.59 $138.31 $159.06 $156.68

40812 $330.87 $314.33 $361.48 $356.06

# 40812 $220.54 $209.51 $240.94 $237.33

40814 $439.69 $417.71 $480.37 $473.16

# 40814 $343.15 $325.99 $374.89 $369.27

40816 $460.14 $437.13 $502.70 $495.16

# 40816 $356.70 $338.87 $389.70 $383.86

40818 $404.15 $383.94 $441.53 $434.91

# 40818 $303.78 $288.59 $331.88 $326.90

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

40819 $356.37 $338.55 $389.33 $383.49

# 40819 $266.72 $253.38 $291.39 $287.02

40820 $315.75 $299.96 $344.95 $339.78

# 40820 $201.59 $191.51 $220.24 $216.94

40830 $311.38 $295.81 $340.18 $335.08

# 40830 $190.32 $180.80 $207.92 $204.80

40831 $393.06 $373.41 $429.42 $422.98

# 40831 $255.15 $242.39 $278.75 $274.56

40840 $905.33 $860.06 $989.07 $974.23

# 40840 $685.82 $651.53 $749.26 $738.02

40842 $901.89 $856.80 $985.32 $970.54

# 40842 $702.68 $667.55 $767.68 $756.17

40843 $1,222.32 $1,161.20 $1,335.38 $1,315.35

# 40843 $950.70 $903.17 $1,038.65 $1,023.06

40844 $1,489.28 $1,414.82 $1,627.04 $1,602.64

# 40844 $1,189.70 $1,130.22 $1,299.75 $1,280.26

40845 $1,616.53 $1,535.70 $1,766.06 $1,739.56

# 40845 $1,329.21 $1,262.75 $1,452.16 $1,430.38

41000 $186.23 $176.92 $203.46 $200.41

# 41000 $125.32 $119.05 $136.91 $134.85

41005 $271.48 $257.91 $296.60 $292.15

# 41005 $144.29 $137.08 $157.64 $155.27

41006 $411.77 $391.18 $449.86 $443.11

# 41006 $293.77 $279.08 $320.94 $316.12

41007 $406.55 $386.22 $444.15 $437.49

# 41007 $274.00 $260.30 $299.35 $294.86

41008 $429.29 $407.83 $469.00 $461.97

# 41008 $297.50 $282.63 $325.02 $320.15

41009 $455.49 $432.72 $497.63 $490.16

# 41009 $324.47 $308.25 $354.49 $349.17

41010 $242.75 $230.61 $265.20 $261.22

# 41010 $125.14 $118.88 $136.71 $134.67

41015 $509.22 $483.76 $556.32 $547.98

# 41015 $387.39 $368.02 $423.22 $416.88

41016 $491.18 $466.62 $536.61 $528.56

# 41016 $393.49 $373.82 $429.89 $423.44

41017 $501.52 $476.44 $547.91 $539.68

# 41017 $392.72 $373.08 $429.04 $422.60

41018 $579.44 $550.47 $633.04 $623.54

# 41018 $460.29 $437.28 $502.87 $495.33

41019 $482.85 $458.71 $527.52 $519.60

41100 $194.35 $184.63 $212.32 $209.14

# 41100 $120.42 $114.40 $131.56 $129.58

41105 $196.86 $187.02 $215.07 $211.84

# 41105 $124.45 $118.23 $135.96 $133.93

41108 $172.29 $163.68 $188.23 $185.40

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 41108 $101.80 $96.71 $111.22 $109.55

41110 $248.96 $236.51 $271.99 $267.90

# 41110 $149.74 $142.25 $163.59 $161.14

41112 $384.99 $365.74 $420.60 $414.29

# 41112 $286.16 $271.85 $312.63 $307.94

41113 $418.08 $397.18 $456.76 $449.90

# 41113 $314.64 $298.91 $343.75 $338.59

41114 $698.90 $663.96 $763.55 $752.10

41115 $291.41 $276.84 $318.37 $313.59

# 41115 $164.98 $156.73 $180.24 $177.54

41116 $385.04 $365.79 $420.66 $414.35

# 41116 $249.80 $237.31 $272.91 $268.81

41120 $1,186.26 $1,126.95 $1,295.99 $1,276.56

41130 $1,453.96 $1,381.26 $1,588.45 $1,564.62

41135 $2,365.97 $2,247.67 $2,584.82 $2,546.04

41140 $2,408.98 $2,288.53 $2,631.81 $2,592.33

41145 $3,036.55 $2,884.72 $3,317.43 $3,267.67

41150 $2,411.25 $2,290.69 $2,634.29 $2,594.78

41153 $2,609.69 $2,479.21 $2,851.09 $2,808.32

41155 $3,263.36 $3,100.19 $3,565.22 $3,511.74

41250 $312.74 $297.10 $341.67 $336.54

# 41250 $175.21 $166.45 $191.42 $188.54

41251 $342.19 $325.08 $373.84 $368.23

# 41251 $205.80 $195.51 $224.84 $221.47

41252 $362.18 $344.07 $395.68 $389.75

# 41252 $233.45 $221.78 $255.05 $251.22

41500 $530.22 $503.71 $579.27 $570.57

41510 $504.58 $479.35 $551.25 $542.98

41512 $707.39 $672.02 $772.82 $761.23

41520 $403.06 $382.91 $440.35 $433.75

# 41520 $288.13 $273.72 $314.78 $310.05

41530 $3,948.87 $3,751.43 $4,314.14 $4,249.43

# 41530 $459.99 $436.99 $502.54 $495.01

41800 $324.32 $308.10 $354.32 $349.00

# 41800 $171.85 $163.26 $187.75 $184.93

41805 $289.32 $274.85 $316.08 $311.34

# 41805 $196.99 $187.14 $215.21 $211.98

41806 $411.87 $391.28 $449.97 $443.22

# 41806 $298.85 $283.91 $326.50 $321.60

41822 $332.26 $315.65 $363.00 $357.56

# 41822 $202.01 $191.91 $220.70 $217.38

41823 $486.69 $462.36 $531.71 $523.73

# 41823 $361.80 $343.71 $395.27 $389.33

41825 $247.26 $234.90 $270.14 $266.09

# 41825 $137.69 $130.81 $150.43 $148.18

41826 $361.76 $343.67 $395.22 $389.29

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 41826 $238.40 $226.48 $260.45 $256.54

41827 $503.68 $478.50 $550.28 $542.02

# 41827 $342.02 $324.92 $373.66 $368.06

41828 $343.99 $326.79 $375.81 $370.17

# 41828 $231.74 $220.15 $253.17 $249.38

41830 $446.56 $424.23 $487.86 $480.55

# 41830 $315.93 $300.13 $345.15 $339.97

41872 $438.50 $416.58 $479.07 $471.88

# 41872 $301.73 $286.64 $329.64 $324.69

41874 $425.03 $403.78 $464.35 $457.38

# 41874 $282.90 $268.76 $309.07 $304.44

42000 $234.81 $223.07 $256.53 $252.68

# 42000 $129.84 $123.35 $141.85 $139.73

42100 $172.40 $163.78 $188.35 $185.52

# 42100 $122.98 $116.83 $134.35 $132.34

42104 $250.77 $238.23 $273.96 $269.86

# 42104 $157.30 $149.44 $171.86 $169.28

42106 $315.24 $299.48 $344.40 $339.24

# 42106 $199.93 $189.93 $218.42 $215.14

42107 $526.85 $500.51 $575.59 $566.95

# 42107 $385.87 $366.58 $421.57 $415.24

42120 $1,116.39 $1,060.57 $1,219.66 $1,201.36

42140 $300.16 $285.15 $327.92 $323.00

# 42140 $177.95 $169.05 $194.41 $191.49

42145 $782.60 $743.47 $854.99 $842.17

42160 $269.33 $255.86 $294.24 $289.82

# 42160 $165.12 $156.86 $180.39 $177.69

42180 $279.22 $265.26 $305.05 $300.47

# 42180 $204.52 $194.29 $223.43 $220.09

42182 $360.64 $342.61 $394.00 $388.09

# 42182 $281.34 $267.27 $307.36 $302.75

42200 $936.13 $889.32 $1,022.72 $1,007.38

42205 $971.88 $923.29 $1,061.78 $1,045.86

42210 $1,119.98 $1,063.98 $1,223.58 $1,205.22

42215 $807.71 $767.32 $882.42 $869.18

42220 $576.81 $547.97 $630.17 $620.71

42225 $992.96 $943.31 $1,084.81 $1,068.53

42226 $1,006.01 $955.71 $1,099.07 $1,082.58

42227 $942.25 $895.14 $1,029.41 $1,013.97

42235 $832.05 $790.45 $909.02 $895.38

42260 $941.00 $893.95 $1,028.04 $1,012.62

# 42260 $771.28 $732.72 $842.63 $829.99

42280 $189.53 $180.05 $207.06 $203.95

# 42280 $123.64 $117.46 $135.08 $133.06

42281 $236.63 $224.80 $258.52 $254.64

# 42281 $169.58 $161.10 $185.27 $182.48

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

42300 $240.81 $228.77 $263.09 $259.14

# 42300 $171.09 $162.54 $186.92 $184.12

42305 $471.20 $447.64 $514.79 $507.07

42310 $187.49 $178.12 $204.84 $201.77

# 42310 $141.90 $134.81 $155.03 $152.71

42320 $287.86 $273.47 $314.49 $309.78

# 42320 $195.91 $186.11 $214.03 $210.82

42330 $266.55 $253.22 $291.20 $286.83

# 42330 $183.42 $174.25 $200.39 $197.39

42335 $431.82 $410.23 $471.76 $464.69

# 42335 $287.39 $273.02 $313.97 $309.26

42340 $532.74 $506.10 $582.02 $573.29

# 42340 $372.98 $354.33 $407.48 $401.37

42400 $123.03 $116.88 $134.41 $132.40

# 42400 $60.59 $57.56 $66.19 $65.21

42405 $336.30 $319.49 $367.41 $361.91

# 42405 $247.80 $235.41 $270.72 $266.66

42408 $518.04 $492.14 $565.96 $557.47

# 42408 $361.35 $343.28 $394.77 $388.85

42409 $387.39 $368.02 $423.22 $416.88

# 42409 $249.09 $236.64 $272.14 $268.05

42410 $680.54 $646.51 $743.49 $732.33

42415 $1,145.66 $1,088.38 $1,251.64 $1,232.86

42420 $1,284.13 $1,219.92 $1,402.91 $1,381.86

42425 $909.33 $863.86 $993.44 $978.54

42426 $1,457.79 $1,384.90 $1,592.64 $1,568.75

42440 $452.76 $430.12 $494.64 $487.22

42450 $516.88 $491.04 $564.70 $556.22

# 42450 $400.80 $380.76 $437.87 $431.31

42500 $495.53 $470.75 $541.36 $533.24

# 42500 $384.04 $364.84 $419.57 $413.28

42505 $629.55 $598.07 $687.78 $677.47

# 42505 $503.89 $478.70 $550.51 $542.25

42507 $578.47 $549.55 $631.98 $622.51

42508 $796.60 $756.77 $870.29 $857.23

42509 $891.39 $846.82 $973.84 $959.24

42510 $701.59 $666.51 $766.49 $754.99

42550 $147.32 $139.95 $160.94 $158.53

# 42550 $64.96 $61.71 $70.97 $69.90

42600 $548.72 $521.28 $599.47 $590.48

# 42600 $385.91 $366.61 $421.60 $415.28

42650 $96.20 $91.39 $105.10 $103.52

# 42650 $65.93 $62.63 $72.02 $70.94

42660 $139.62 $132.64 $152.54 $150.25

# 42660 $92.12 $87.51 $100.64 $99.13

42665 $365.87 $347.58 $399.72 $393.73

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 42665 $232.94 $221.29 $254.48 $250.67

42700 $219.81 $208.82 $240.14 $236.54

# 42700 $153.54 $145.86 $167.74 $165.22

42720 $503.08 $477.93 $549.62 $541.37

# 42720 $427.23 $405.87 $466.75 $459.75

42725 $885.66 $841.38 $967.59 $953.07

42800 $183.94 $174.74 $200.95 $197.94

# 42800 $126.09 $119.79 $137.76 $135.69

42802 $271.08 $257.53 $296.16 $291.72

# 42802 $150.78 $143.24 $164.73 $162.25

42804 $230.94 $219.39 $252.30 $248.52

# 42804 $128.27 $121.86 $140.14 $138.03

42806 $257.53 $244.65 $281.35 $277.13

# 42806 $148.73 $141.29 $162.48 $160.05

42808 $259.71 $246.72 $283.73 $279.47

# 42808 $179.26 $170.30 $195.85 $192.91

42809 $196.42 $186.60 $214.59 $211.37

# 42809 $147.77 $140.38 $161.44 $159.01

42810 $450.70 $428.17 $492.40 $485.01

# 42810 $328.11 $311.70 $358.46 $353.07

42815 $624.29 $593.08 $682.04 $671.81

42820 $319.82 $303.83 $349.40 $344.16

42821 $332.65 $316.02 $363.42 $357.97

42825 $291.96 $277.36 $318.96 $314.18

42826 $279.15 $265.19 $304.97 $300.39

42830 $232.86 $221.22 $254.40 $250.59

42831 $251.04 $238.49 $274.26 $270.15

42835 $216.70 $205.87 $236.75 $233.20

42836 $268.04 $254.64 $292.84 $288.44

42842 $1,114.66 $1,058.93 $1,217.77 $1,199.51

42844 $1,520.47 $1,444.45 $1,661.12 $1,636.20

42845 $2,431.65 $2,310.07 $2,656.58 $2,616.73

42860 $212.39 $201.77 $232.04 $228.55

42870 $664.07 $630.87 $725.50 $714.62

42890 $1,565.14 $1,486.88 $1,709.91 $1,684.27

42892 $2,071.67 $1,968.09 $2,263.30 $2,229.36

42894 $2,602.35 $2,472.23 $2,843.06 $2,800.42

42900 $370.37 $351.85 $404.63 $398.56

42950 $900.93 $855.88 $984.26 $969.50

42953 $1,080.51 $1,026.48 $1,180.45 $1,162.74

42955 $854.65 $811.92 $933.71 $919.70

42960 $188.32 $178.90 $205.74 $202.65

42961 $470.04 $446.54 $513.52 $505.82

42962 $572.79 $544.15 $625.77 $616.39

42970 $452.70 $430.07 $494.58 $487.16

42971 $505.08 $479.83 $551.80 $543.52

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

42972 $563.60 $535.42 $615.73 $606.50

43020 $576.42 $547.60 $629.74 $620.30

43030 $567.78 $539.39 $620.30 $611.00

43045 $1,401.81 $1,331.72 $1,531.48 $1,508.50

43100 $685.75 $651.46 $749.18 $737.94

43101 $1,082.66 $1,028.53 $1,182.81 $1,165.07

43107 $2,713.50 $2,577.83 $2,964.50 $2,920.03

43108 $4,945.47 $4,698.20 $5,402.93 $5,321.89

43112 $2,856.30 $2,713.49 $3,120.51 $3,073.71

43113 $4,575.19 $4,346.43 $4,998.39 $4,923.41

43116 $5,589.02 $5,309.57 $6,106.01 $6,014.42

43117 $2,621.53 $2,490.45 $2,864.02 $2,821.05

43118 $4,037.37 $3,835.50 $4,410.83 $4,344.67

43121 $3,052.87 $2,900.23 $3,335.26 $3,285.24

43122 $2,723.71 $2,587.52 $2,975.65 $2,931.02

43123 $4,741.04 $4,503.99 $5,179.59 $5,101.89

43124 $4,063.66 $3,860.48 $4,439.55 $4,372.96

43130 $854.63 $811.90 $933.69 $919.68

43135 $1,588.34 $1,508.92 $1,735.26 $1,709.23

43200 $246.15 $233.84 $268.92 $264.88

# 43200 $113.98 $108.28 $124.52 $122.66

43201 $359.87 $341.88 $393.16 $387.26

# 43201 $138.05 $131.15 $150.82 $148.56

43202 $331.87 $315.28 $362.57 $357.13

# 43202 $125.38 $119.11 $136.98 $134.92

43204 $242.38 $230.26 $264.80 $260.83

43205 $240.86 $228.82 $263.14 $259.20

43215 $166.19 $157.88 $181.56 $178.84

43216 $251.35 $238.78 $274.60 $270.48

# 43216 $160.94 $152.89 $175.82 $173.19

43217 $440.73 $418.69 $481.49 $474.27

# 43217 $185.97 $176.67 $203.17 $200.12

43219 $184.05 $174.85 $201.08 $198.06

43220 $137.22 $130.36 $149.91 $147.66

43226 $151.91 $144.31 $165.96 $163.47

43227 $228.57 $217.14 $249.71 $245.96

43228 $239.70 $227.72 $261.88 $257.95

43231 $204.50 $194.28 $223.42 $220.08

43232 $279.41 $265.44 $305.26 $300.68

43235 $341.36 $324.29 $372.93 $367.34

# 43235 $157.09 $149.24 $171.63 $169.05

43236 $438.17 $416.26 $478.70 $471.52

# 43236 $188.77 $179.33 $206.23 $203.14

43237 $251.15 $238.59 $274.38 $270.26

43238 $311.76 $296.17 $340.60 $335.49

43239 $393.14 $373.48 $429.50 $423.06

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 43239 $185.12 $175.86 $202.24 $199.20

43240 $424.36 $403.14 $463.61 $456.65

43241 $168.20 $159.79 $183.76 $181.00

43242 $452.88 $430.24 $494.78 $487.36

43243 $286.78 $272.44 $313.31 $308.60

43244 $315.96 $300.16 $345.18 $340.01

43245 $202.18 $192.07 $220.88 $217.57

43246 $269.99 $256.49 $294.96 $290.54

43247 $215.59 $204.81 $235.53 $232.00

43248 $202.43 $192.31 $221.16 $217.84

43249 $186.93 $177.58 $204.22 $201.16

43250 $203.59 $193.41 $222.42 $219.09

43251 $234.67 $222.94 $256.38 $252.54

43255 $302.66 $287.53 $330.66 $325.70

43256 $272.63 $259.00 $297.85 $293.39

43257 $347.45 $330.08 $379.59 $373.90

43258 $286.47 $272.15 $312.97 $308.28

43259 $325.33 $309.06 $355.42 $350.08

43260 $370.56 $352.03 $404.83 $398.76

43261 $389.26 $369.80 $425.27 $418.89

43262 $457.17 $434.31 $499.46 $491.97

43263 $452.19 $429.58 $494.02 $486.61

43264 $547.71 $520.32 $598.37 $589.40

43265 $614.53 $583.80 $671.37 $661.30

43267 $453.34 $430.67 $495.27 $487.84

43268 $464.45 $441.23 $507.41 $499.80

43269 $506.01 $480.71 $552.82 $544.53

43271 $456.78 $433.94 $499.03 $491.54

43272 $457.93 $435.03 $500.28 $492.78

43273 $134.37 $127.65 $146.80 $144.60

43279 $1,369.59 $1,301.11 $1,496.28 $1,473.83

43280 $1,150.26 $1,092.75 $1,256.66 $1,237.81

43281 $1,635.54 $1,553.76 $1,786.82 $1,760.02

43282 $1,837.12 $1,745.26 $2,007.05 $1,976.94

43283 $164.80 $156.56 $180.04 $177.34

43300 $674.39 $640.67 $736.77 $725.72

43305 $1,180.17 $1,121.16 $1,289.33 $1,269.99

43310 $1,587.16 $1,507.80 $1,733.97 $1,707.96

43312 $1,700.54 $1,615.51 $1,857.84 $1,829.97

43313 $3,326.28 $3,159.97 $3,633.97 $3,579.46

43314 $3,085.99 $2,931.69 $3,371.44 $3,320.87

43320 $1,481.75 $1,407.66 $1,618.81 $1,594.53

43325 $1,426.47 $1,355.15 $1,558.42 $1,535.04

43327 $869.67 $826.19 $950.12 $935.87

43328 $1,236.46 $1,174.64 $1,350.84 $1,330.57

43330 $1,418.88 $1,347.94 $1,550.13 $1,526.88

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

43331 $1,440.88 $1,368.84 $1,574.17 $1,550.56

43332 $1,235.48 $1,173.71 $1,349.77 $1,329.52

43333 $1,342.44 $1,275.32 $1,466.62 $1,444.62

43334 $1,327.38 $1,261.01 $1,450.16 $1,428.40

43335 $1,413.23 $1,342.57 $1,543.96 $1,520.79

43336 $1,621.75 $1,540.66 $1,771.76 $1,745.18

43337 $1,747.72 $1,660.33 $1,909.38 $1,880.74

43338 $122.51 $116.38 $133.84 $131.82

43340 $1,462.81 $1,389.67 $1,598.12 $1,574.14

43341 $1,598.75 $1,518.81 $1,746.63 $1,720.43

43350 $1,290.05 $1,225.55 $1,409.38 $1,388.25

43351 $1,417.57 $1,346.69 $1,548.69 $1,525.46

43352 $1,150.83 $1,093.29 $1,257.28 $1,238.42

43360 $2,412.13 $2,291.52 $2,635.25 $2,595.72

43361 $2,688.96 $2,554.51 $2,937.69 $2,893.62

43400 $1,672.29 $1,588.68 $1,826.98 $1,799.58

43401 $1,664.31 $1,581.09 $1,818.25 $1,790.98

43405 $1,549.03 $1,471.58 $1,692.32 $1,666.94

43410 $1,182.00 $1,122.90 $1,291.34 $1,271.97

43415 $2,749.03 $2,611.58 $3,003.32 $2,958.27

43420 $1,101.82 $1,046.73 $1,203.74 $1,185.68

43425 $1,532.02 $1,455.42 $1,673.73 $1,648.63

43450 $176.05 $167.25 $192.34 $189.45

# 43450 $97.13 $92.27 $106.11 $104.52

43453 $344.51 $327.28 $376.37 $370.73

# 43453 $104.30 $99.09 $113.95 $112.24

43456 $702.34 $667.22 $767.30 $755.79

# 43456 $167.15 $158.79 $182.61 $179.87

43458 $442.95 $420.80 $483.92 $476.66

# 43458 $194.70 $184.97 $212.72 $209.53

43460 $241.27 $229.21 $263.59 $259.64

43496 $1,591.96 $1,512.36 $1,739.21 $1,713.12

43500 $838.69 $796.76 $916.27 $902.53

43501 $1,429.29 $1,357.83 $1,561.50 $1,538.08

43502 $1,615.56 $1,534.78 $1,765.00 $1,738.52

43510 $973.78 $925.09 $1,063.85 $1,047.89

43520 $733.53 $696.85 $801.38 $789.36

43605 $890.48 $845.96 $972.85 $958.26

43610 $1,042.31 $990.19 $1,138.72 $1,121.64

43611 $1,297.18 $1,232.32 $1,417.17 $1,395.92

43620 $2,070.81 $1,967.27 $2,262.36 $2,228.42

43621 $2,389.73 $2,270.24 $2,610.78 $2,571.62

43622 $2,423.18 $2,302.02 $2,647.32 $2,607.61

43631 $1,538.92 $1,461.97 $1,681.27 $1,656.05

43632 $2,144.57 $2,037.34 $2,342.94 $2,307.80

43633 $2,030.66 $1,929.13 $2,218.50 $2,185.22

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

43634 $2,245.02 $2,132.77 $2,452.69 $2,415.90

43635 $117.52 $111.64 $128.39 $126.47

43640 $1,253.49 $1,190.82 $1,369.44 $1,348.90

43641 $1,277.60 $1,213.72 $1,395.78 $1,374.84

43644 $1,835.85 $1,744.06 $2,005.67 $1,975.59

43645 $1,957.06 $1,859.21 $2,138.09 $2,106.02

43647 $766.06 $727.76 $836.92 $824.37

43648 $955.60 $907.82 $1,043.99 $1,028.33

43651 $702.60 $667.47 $767.59 $756.08

43652 $817.63 $776.75 $893.26 $879.87

43653 $620.20 $589.19 $677.57 $667.40

43752 $42.47 $40.35 $46.40 $45.70

43753 $21.30 $20.24 $23.28 $22.93

43754 $110.53 $105.00 $120.75 $118.94

# 43754 $36.98 $35.13 $40.40 $39.79

43755 $165.75 $157.46 $181.08 $178.37

# 43755 $63.08 $59.93 $68.92 $67.88

43756 $257.62 $244.74 $281.45 $277.23

# 43756 $56.49 $53.67 $61.72 $60.79

43757 $360.75 $342.71 $394.12 $388.21

# 43757 $84.54 $80.31 $92.36 $90.98

43760 $595.18 $565.42 $650.23 $640.48

# 43760 $51.18 $48.62 $55.91 $55.07

43761 $123.56 $117.38 $134.99 $132.96

# 43761 $108.24 $102.83 $118.25 $116.48

43770 $1,194.40 $1,134.68 $1,304.88 $1,285.31

43771 $1,354.71 $1,286.97 $1,480.02 $1,457.82

43772 $1,014.61 $963.88 $1,108.46 $1,091.83

43773 $1,353.18 $1,285.52 $1,478.35 $1,456.18

43774 $1,023.21 $972.05 $1,117.86 $1,101.09

43775 $1,356.50 $1,288.68 $1,481.98 $1,459.75

43800 $989.28 $939.82 $1,080.79 $1,064.58

43810 $1,080.63 $1,026.60 $1,180.59 $1,162.88

43820 $1,422.32 $1,351.20 $1,553.88 $1,530.57

43825 $1,371.38 $1,302.81 $1,498.23 $1,475.76

43830 $750.79 $713.25 $820.24 $807.93

43831 $646.22 $613.91 $706.00 $695.41

43832 $1,112.73 $1,057.09 $1,215.65 $1,197.41

43840 $1,442.15 $1,370.04 $1,575.55 $1,551.91

43843 $1,360.27 $1,292.26 $1,486.10 $1,463.81

43845 $2,081.64 $1,977.56 $2,274.19 $2,240.09

43846 $1,724.97 $1,638.72 $1,884.53 $1,856.26

43847 $1,910.61 $1,815.08 $2,087.34 $2,056.03

43848 $2,042.56 $1,940.43 $2,231.49 $2,198.02

43850 $1,724.53 $1,638.30 $1,884.05 $1,855.79

43855 $1,788.12 $1,698.71 $1,953.52 $1,924.21

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

43860 $1,730.31 $1,643.79 $1,890.36 $1,862.00

43865 $1,808.83 $1,718.39 $1,976.15 $1,946.50

43870 $762.14 $724.03 $832.63 $820.15

43880 $1,688.52 $1,604.09 $1,844.70 $1,817.03

43881 $900.85 $855.81 $984.18 $969.42

43886 $399.42 $379.45 $436.37 $429.82

43887 $358.65 $340.72 $391.83 $385.95

43888 $499.60 $474.62 $545.81 $537.63

44005 $1,161.65 $1,103.57 $1,269.11 $1,250.07

44010 $927.63 $881.25 $1,013.44 $998.23

44015 $149.23 $141.77 $163.04 $160.59

44020 $1,036.01 $984.21 $1,131.84 $1,114.87

44021 $1,038.26 $986.35 $1,134.30 $1,117.28

44025 $1,053.28 $1,000.62 $1,150.71 $1,133.45

44050 $995.28 $945.52 $1,087.35 $1,071.04

44055 $1,586.03 $1,506.73 $1,732.74 $1,706.75

44100 $120.69 $114.66 $131.86 $129.88

44110 $906.11 $860.80 $989.92 $975.07

44111 $1,049.39 $996.92 $1,146.46 $1,129.27

44120 $1,297.06 $1,232.21 $1,417.04 $1,395.79

44121 $253.28 $240.62 $276.71 $272.56

44125 $1,255.39 $1,192.62 $1,371.51 $1,350.94

44126 $2,607.17 $2,476.81 $2,848.33 $2,805.61

44127 $3,009.50 $2,859.03 $3,287.88 $3,238.56

44128 $254.73 $241.99 $278.29 $274.11

44130 $1,396.79 $1,326.95 $1,525.99 $1,503.11

44137 $1,715.94 $1,630.14 $1,874.66 $1,846.54

44139 $126.82 $120.48 $138.55 $136.47

44140 $1,425.50 $1,354.23 $1,557.36 $1,534.01

44141 $1,950.22 $1,852.71 $2,130.62 $2,098.66

44143 $1,773.58 $1,684.90 $1,937.64 $1,908.57

44144 $1,885.09 $1,790.84 $2,059.47 $2,028.58

44145 $1,761.79 $1,673.70 $1,924.76 $1,895.88

44146 $2,262.74 $2,149.60 $2,472.04 $2,434.96

44147 $2,058.42 $1,955.50 $2,248.83 $2,215.10

44150 $2,008.03 $1,907.63 $2,193.77 $2,160.87

44151 $2,293.56 $2,178.88 $2,505.71 $2,468.13

44155 $2,228.70 $2,117.27 $2,434.86 $2,398.34

44156 $2,470.44 $2,346.92 $2,698.96 $2,658.48

44157 $2,320.15 $2,204.14 $2,534.76 $2,496.74

44158 $2,381.51 $2,262.43 $2,601.79 $2,562.76

44160 $1,321.14 $1,255.08 $1,443.34 $1,421.69

44180 $978.36 $929.44 $1,068.86 $1,052.83

44186 $698.48 $663.56 $763.09 $751.65

44187 $1,197.54 $1,137.66 $1,308.31 $1,288.69

44188 $1,322.82 $1,256.68 $1,445.18 $1,423.50

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

44202 $1,474.16 $1,400.45 $1,610.52 $1,586.36

44203 $253.58 $240.90 $277.04 $272.88

44204 $1,638.13 $1,556.22 $1,789.65 $1,762.81

44205 $1,426.13 $1,354.82 $1,558.04 $1,534.68

44206 $1,871.67 $1,778.09 $2,044.80 $2,014.13

44207 $1,942.27 $1,845.16 $2,121.93 $2,090.10

44208 $2,125.82 $2,019.53 $2,322.46 $2,287.63

44210 $1,922.63 $1,826.50 $2,100.48 $2,068.97

44211 $2,396.38 $2,276.56 $2,618.04 $2,578.77

44212 $2,215.35 $2,104.58 $2,420.27 $2,383.96

44213 $198.65 $188.72 $217.03 $213.77

44227 $1,775.32 $1,686.55 $1,939.53 $1,910.44

44300 $900.22 $855.21 $983.49 $968.74

44310 $1,113.32 $1,057.65 $1,216.30 $1,198.06

44312 $633.56 $601.88 $692.16 $681.78

44314 $1,076.57 $1,022.74 $1,176.15 $1,158.51

44316 $1,500.89 $1,425.85 $1,639.73 $1,615.13

44320 $1,284.17 $1,219.96 $1,402.95 $1,381.91

44322 $1,098.87 $1,043.93 $1,200.52 $1,182.51

44340 $677.30 $643.44 $739.96 $728.86

44345 $1,127.72 $1,071.33 $1,232.03 $1,213.55

44346 $1,266.16 $1,202.85 $1,383.28 $1,362.53

44360 $169.37 $160.90 $185.04 $182.26

44361 $185.91 $176.61 $203.10 $200.05

44363 $221.71 $210.62 $242.21 $238.58

44364 $236.50 $224.68 $258.38 $254.51

44365 $210.94 $200.39 $230.45 $226.99

44366 $278.65 $264.72 $304.43 $299.86

44369 $284.75 $270.51 $311.09 $306.42

44370 $308.54 $293.11 $337.08 $332.02

44372 $276.22 $262.41 $301.77 $297.24

44373 $221.29 $210.23 $241.76 $238.14

44376 $324.54 $308.31 $354.56 $349.24

44377 $343.88 $326.69 $375.69 $370.06

44378 $440.97 $418.92 $481.76 $474.54

44379 $470.67 $447.14 $514.21 $506.49

44380 $73.63 $69.95 $80.44 $79.24

44382 $88.39 $83.97 $96.57 $95.12

44383 $171.71 $163.12 $187.59 $184.77

44385 $304.62 $289.39 $332.80 $327.81

# 44385 $114.99 $109.24 $125.63 $123.74

44386 $417.14 $396.28 $455.72 $448.89

# 44386 $138.24 $131.33 $151.03 $148.76

44388 $408.56 $388.13 $446.35 $439.66

# 44388 $179.47 $170.50 $196.08 $193.13

44389 $461.74 $438.65 $504.45 $496.88

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 44389 $199.70 $189.72 $218.18 $214.90

44390 $543.75 $516.56 $594.04 $585.13

# 44390 $244.55 $232.32 $267.17 $263.17

44391 $578.53 $549.60 $632.04 $622.56

# 44391 $270.90 $257.36 $295.96 $291.53

44392 $509.50 $484.03 $556.63 $548.29

# 44392 $237.50 $225.63 $259.47 $255.59

44393 $581.35 $552.28 $635.12 $625.60

# 44393 $298.24 $283.33 $325.83 $320.94

44394 $573.81 $545.12 $626.89 $617.48

# 44394 $275.38 $261.61 $300.85 $296.34

44397 $295.86 $281.07 $323.23 $318.38

44500 $25.34 $24.07 $27.68 $27.27

44602 $1,489.79 $1,415.30 $1,627.60 $1,603.18

44603 $1,713.21 $1,627.55 $1,871.68 $1,843.61

44604 $1,120.14 $1,064.13 $1,223.75 $1,205.40

44605 $1,385.40 $1,316.13 $1,513.55 $1,490.85

44615 $1,143.87 $1,086.68 $1,249.68 $1,230.94

44620 $926.75 $880.41 $1,012.47 $997.28

44625 $1,088.65 $1,034.22 $1,189.35 $1,171.52

44626 $1,700.89 $1,615.85 $1,858.23 $1,830.35

44640 $1,488.40 $1,413.98 $1,626.08 $1,601.69

44650 $1,540.19 $1,463.18 $1,682.66 $1,657.41

44660 $1,405.34 $1,335.07 $1,535.33 $1,512.30

44661 $1,639.38 $1,557.41 $1,791.02 $1,764.16

44680 $1,137.38 $1,080.51 $1,242.59 $1,223.95

44700 $1,087.67 $1,033.29 $1,188.28 $1,170.46

44701 $175.78 $166.99 $192.04 $189.16

44715 $437.48 $415.61 $477.95 $470.79

44720 $263.90 $250.71 $288.32 $283.99

44721 $402.61 $382.48 $439.85 $433.25

44800 $819.10 $778.15 $894.87 $881.45

44820 $896.30 $851.49 $979.21 $964.53

44850 $805.25 $764.99 $879.74 $866.55

44900 $827.41 $786.04 $903.95 $890.39

44901 $1,020.21 $969.20 $1,114.58 $1,097.86

# 44901 $175.10 $166.35 $191.30 $188.43

44950 $683.11 $648.95 $746.29 $735.10

44955 $87.92 $83.52 $96.05 $94.61

44960 $928.87 $882.43 $1,014.79 $999.57

44970 $643.49 $611.32 $703.02 $692.47

45000 $459.49 $436.52 $502.00 $494.47

45005 $310.86 $295.32 $339.62 $334.52

# 45005 $174.86 $166.12 $191.04 $188.17

45020 $616.99 $586.14 $674.06 $663.95

45100 $329.90 $313.41 $360.42 $355.02

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

45108 $402.41 $382.29 $439.63 $433.04

45110 $1,985.69 $1,886.41 $2,169.37 $2,136.83

45111 $1,165.97 $1,107.67 $1,273.82 $1,254.71

45112 $2,008.53 $1,908.10 $2,194.32 $2,161.40

45113 $2,127.08 $2,020.73 $2,323.84 $2,288.98

45114 $1,924.54 $1,828.31 $2,102.56 $2,071.02

45116 $1,677.98 $1,594.08 $1,833.19 $1,805.70

45119 $2,087.34 $1,982.97 $2,280.42 $2,246.21

45120 $1,684.23 $1,600.02 $1,840.02 $1,812.42

45121 $1,843.59 $1,751.41 $2,014.12 $1,983.91

45123 $1,203.06 $1,142.91 $1,314.35 $1,294.64

45126 $3,038.67 $2,886.74 $3,319.75 $3,269.96

45130 $1,171.51 $1,112.93 $1,279.87 $1,260.68

45135 $1,460.47 $1,387.45 $1,595.57 $1,571.64

45136 $1,954.91 $1,857.16 $2,135.73 $2,103.70

45150 $428.87 $407.43 $468.54 $461.52

45160 $1,092.48 $1,037.86 $1,193.54 $1,175.63

45171 $659.82 $626.83 $720.85 $710.04

45172 $883.75 $839.56 $965.49 $951.02

45190 $746.83 $709.49 $815.91 $803.68

45300 $142.77 $135.63 $155.97 $153.64

# 45300 $59.26 $56.30 $64.75 $63.78

45303 $1,152.42 $1,094.80 $1,259.02 $1,240.14

# 45303 $99.66 $94.68 $108.88 $107.25

45305 $228.97 $217.52 $250.15 $246.40

# 45305 $86.46 $82.14 $94.46 $93.05

45307 $267.70 $254.32 $292.47 $288.09

# 45307 $112.16 $106.55 $122.53 $120.69

45308 $245.60 $233.32 $268.32 $264.29

# 45308 $95.04 $90.29 $103.83 $102.28

45309 $251.34 $238.77 $274.59 $270.47

# 45309 $100.78 $95.74 $110.10 $108.45

45315 $264.28 $251.07 $288.73 $284.40

# 45315 $118.70 $112.77 $129.69 $127.74

45317 $280.80 $266.76 $306.77 $302.17

# 45317 $127.95 $121.55 $139.78 $137.69

45320 $280.49 $266.47 $306.44 $301.84

# 45320 $115.38 $109.61 $126.05 $124.17

45321 $116.96 $111.11 $127.78 $125.86

45327 $139.19 $132.23 $152.06 $149.79

45330 $159.77 $151.78 $174.55 $171.93

# 45330 $69.74 $66.25 $76.19 $75.05

45331 $192.31 $182.69 $210.09 $206.94

# 45331 $83.13 $78.97 $90.82 $89.46

45332 $345.64 $328.36 $377.61 $371.94

# 45332 $120.76 $114.72 $131.93 $129.95

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

45333 $350.62 $333.09 $383.05 $377.30

# 45333 $119.61 $113.63 $130.67 $128.72

45334 $176.51 $167.68 $192.83 $189.93

45335 $327.83 $311.44 $358.16 $352.79

# 45335 $100.65 $95.62 $109.96 $108.32

45337 $154.49 $146.77 $168.79 $166.26

45338 $373.77 $355.08 $408.34 $402.21

# 45338 $152.34 $144.72 $166.43 $163.93

45339 $394.69 $374.96 $431.20 $424.74

# 45339 $200.85 $190.81 $219.43 $216.14

45340 $589.29 $559.83 $643.80 $634.14

# 45340 $126.12 $119.81 $137.78 $135.71

45341 $169.34 $160.87 $185.00 $182.23

45342 $257.03 $244.18 $280.81 $276.60

45345 $188.33 $178.91 $205.75 $202.66

45355 $220.67 $209.64 $241.09 $237.48

45378 $447.59 $425.21 $488.99 $481.65

# 45378 $233.44 $221.77 $255.04 $251.21

45378 53 $159.77 $151.78 $174.55 $171.93

# 45378 53 $69.74 $66.25 $76.19 $75.05

45379 $575.87 $547.08 $629.14 $619.70

# 45379 $291.99 $277.39 $319.00 $314.21

45380 $533.22 $506.56 $582.54 $573.80

# 45380 $278.46 $264.54 $304.22 $299.66

45381 $538.41 $511.49 $588.21 $579.39

# 45381 $264.49 $251.27 $288.96 $284.63

45382 $694.94 $660.19 $759.22 $747.83

# 45382 $353.98 $336.28 $386.72 $380.93

45383 $641.62 $609.54 $700.97 $690.46

# 45383 $360.81 $342.77 $394.19 $388.27

45384 $529.07 $502.62 $578.01 $569.34

# 45384 $290.39 $275.87 $317.25 $312.49

45385 $598.72 $568.78 $654.10 $644.29

# 45385 $330.16 $313.65 $360.70 $355.29

45386 $785.81 $746.52 $858.50 $845.62

# 45386 $286.25 $271.94 $312.73 $308.04

45387 $370.71 $352.17 $405.00 $398.92

45391 $317.31 $301.44 $346.66 $341.46

45392 $406.73 $386.39 $444.35 $437.68

45395 $2,131.25 $2,024.69 $2,328.39 $2,293.47

45397 $2,309.06 $2,193.61 $2,522.65 $2,484.82

45400 $1,237.43 $1,175.56 $1,351.89 $1,331.62

45402 $1,634.73 $1,552.99 $1,785.94 $1,759.16

45500 $575.88 $547.09 $629.15 $619.71

45505 $647.51 $615.13 $707.40 $696.79

45520 $186.71 $177.37 $203.98 $200.92

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 45520 $44.58 $42.35 $48.70 $47.97

45540 $1,132.28 $1,075.67 $1,237.02 $1,218.46

45541 $1,001.38 $951.31 $1,094.01 $1,077.60

45550 $1,567.84 $1,489.45 $1,712.87 $1,687.18

45560 $746.97 $709.62 $816.06 $803.83

45562 $1,197.96 $1,138.06 $1,308.77 $1,289.14

45563 $1,759.00 $1,671.05 $1,921.71 $1,892.88

45800 $1,268.53 $1,205.10 $1,385.87 $1,365.07

45805 $1,561.02 $1,482.97 $1,705.42 $1,679.84

45820 $1,168.43 $1,110.01 $1,276.51 $1,257.36

45825 $1,571.37 $1,492.80 $1,716.72 $1,690.97

45900 $221.47 $210.40 $241.96 $238.33

45905 $184.71 $175.47 $201.79 $198.77

45910 $212.99 $202.34 $232.69 $229.20

45915 $371.04 $352.49 $405.36 $399.28

# 45915 $246.91 $234.56 $269.74 $265.70

45990 $114.16 $108.45 $124.72 $122.84

46020 $309.60 $294.12 $338.24 $333.17

# 46020 $259.41 $246.44 $283.41 $279.15

46030 $158.83 $150.89 $173.52 $170.92

# 46030 $99.45 $94.48 $108.65 $107.02

46040 $597.39 $567.52 $652.65 $642.86

# 46040 $454.11 $431.40 $496.11 $488.67

46045 $474.60 $450.87 $518.50 $510.73

46050 $234.73 $222.99 $256.44 $252.60

# 46050 $108.69 $103.26 $118.75 $116.97

46060 $522.59 $496.46 $570.93 $562.36

46070 $240.79 $228.75 $263.06 $259.12

46080 $280.04 $266.04 $305.95 $301.36

# 46080 $171.62 $163.04 $187.50 $184.68

46083 $200.65 $190.62 $219.21 $215.92

# 46083 $116.75 $110.91 $127.55 $125.64

46200 $505.69 $480.41 $552.47 $544.18

# 46200 $363.17 $345.01 $396.76 $390.80

46220 $236.31 $224.49 $258.16 $254.29

# 46220 $130.57 $124.04 $142.65 $140.51

46221 $306.88 $291.54 $335.27 $330.25

# 46221 $213.40 $202.73 $233.14 $229.64

46230 $309.59 $294.11 $338.23 $333.16

# 46230 $187.76 $178.37 $205.13 $202.04

46250 $521.19 $495.13 $569.40 $560.86

# 46250 $343.82 $326.63 $375.62 $369.99

46255 $568.49 $540.07 $621.08 $611.77

# 46255 $384.98 $365.73 $420.59 $414.28

46257 $460.68 $437.65 $503.30 $495.75

46258 $507.37 $482.00 $554.30 $545.99

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

46260 $517.22 $491.36 $565.06 $556.59

46261 $569.91 $541.41 $622.62 $613.28

46262 $605.25 $574.99 $661.24 $651.33

46270 $567.78 $539.39 $620.30 $611.00

# 46270 $431.01 $409.46 $470.88 $463.82

46275 $603.54 $573.36 $659.36 $649.47

# 46275 $456.04 $433.24 $498.23 $490.75

46280 $515.38 $489.61 $563.05 $554.61

46285 $600.67 $570.64 $656.24 $646.39

# 46285 $455.47 $432.70 $497.61 $490.14

46288 $596.33 $566.51 $651.49 $641.71

46320 $208.23 $197.82 $227.49 $224.08

# 46320 $120.89 $114.85 $132.08 $130.10

46500 $273.97 $260.27 $299.31 $294.83

# 46500 $143.34 $136.17 $156.60 $154.25

46505 $321.46 $305.39 $351.20 $345.93

# 46505 $265.91 $252.61 $290.50 $286.14

46600 $102.40 $97.28 $111.87 $110.19

# 46600 $44.94 $42.69 $49.09 $48.36

46604 $749.05 $711.60 $818.34 $806.07

# 46604 $72.12 $68.51 $78.79 $77.60

46606 $264.40 $251.18 $288.86 $284.52

# 46606 $83.19 $79.03 $90.88 $89.52

46608 $271.29 $257.73 $296.39 $291.94

# 46608 $87.79 $83.40 $95.91 $94.47

46610 $265.23 $251.97 $289.77 $285.42

# 46610 $87.86 $83.47 $95.99 $94.55

46611 $200.45 $190.43 $218.99 $215.71

# 46611 $88.58 $84.15 $96.77 $95.32

46612 $322.49 $306.37 $352.33 $347.04

# 46612 $101.44 $96.37 $110.83 $109.16

46614 $146.22 $138.91 $159.75 $157.35

# 46614 $69.98 $66.48 $76.45 $75.30

46615 $162.41 $154.29 $177.43 $174.78

# 46615 $100.34 $95.32 $109.62 $107.97

46700 $710.19 $674.68 $775.88 $764.24

46705 $562.38 $534.26 $614.40 $605.19

46706 $184.74 $175.50 $201.83 $198.80

46707 $506.43 $481.11 $553.28 $544.97

46710 $1,184.45 $1,125.23 $1,294.01 $1,274.60

46712 $2,175.80 $2,067.01 $2,377.06 $2,341.40

46715 $537.54 $510.66 $587.26 $578.45

46716 $1,198.53 $1,138.60 $1,309.39 $1,289.75

46730 $1,943.65 $1,846.47 $2,123.44 $2,091.59

46735 $2,159.34 $2,051.37 $2,359.08 $2,323.69

46740 $2,120.40 $2,014.38 $2,316.54 $2,281.78

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

46742 $2,573.70 $2,445.02 $2,811.77 $2,769.59

46744 $3,581.14 $3,402.08 $3,912.39 $3,853.71

46746 $3,711.61 $3,526.03 $4,054.93 $3,994.11

46748 $4,082.48 $3,878.36 $4,460.11 $4,393.21

46750 $821.57 $780.49 $897.56 $884.10

46751 $649.35 $616.88 $709.41 $698.77

46753 $637.57 $605.69 $696.54 $686.09

46754 $337.48 $320.61 $368.70 $363.17

# 46754 $257.41 $244.54 $281.22 $277.00

46760 $1,184.33 $1,125.11 $1,293.88 $1,274.46

46761 $997.98 $948.08 $1,090.29 $1,073.94

46762 $998.57 $948.64 $1,090.94 $1,074.57

46900 $275.46 $261.69 $300.94 $296.42

# 46900 $151.72 $144.13 $165.75 $163.27

46910 $291.82 $277.23 $318.81 $314.03

# 46910 $147.39 $140.02 $161.02 $158.61

46916 $260.60 $247.57 $284.71 $280.44

# 46916 $157.93 $150.03 $172.53 $169.95

46917 $532.05 $505.45 $581.27 $572.55

# 46917 $146.27 $138.96 $159.80 $157.41

46922 $307.50 $292.13 $335.95 $330.91

# 46922 $148.13 $140.72 $161.83 $159.40

46924 $623.52 $592.34 $681.19 $670.97

# 46924 $200.58 $190.55 $219.13 $215.84

46930 $233.73 $222.04 $255.35 $251.52

# 46930 $165.54 $157.26 $180.85 $178.14

46940 $258.37 $245.45 $282.27 $278.04

# 46940 $158.38 $150.46 $173.03 $170.43

46942 $245.31 $233.04 $268.00 $263.97

# 46942 $143.02 $135.87 $156.25 $153.90

46945 $353.09 $335.44 $385.76 $379.97

# 46945 $255.01 $242.26 $278.60 $274.42

46946 $355.63 $337.85 $388.53 $382.70

# 46946 $250.28 $237.77 $273.44 $269.33

46947 $415.75 $394.96 $454.20 $447.40

47000 $415.22 $394.46 $453.63 $446.82

# 47000 $109.51 $104.03 $119.63 $117.84

47001 $107.86 $102.47 $117.84 $116.07

47010 $1,283.61 $1,219.43 $1,402.34 $1,381.31

47011 $190.04 $180.54 $207.62 $204.50

47015 $1,242.09 $1,179.99 $1,356.99 $1,336.63

47100 $908.43 $863.01 $992.46 $977.57

47120 $2,467.08 $2,343.73 $2,695.29 $2,654.86

47122 $3,608.19 $3,427.78 $3,941.95 $3,882.81

47125 $3,243.25 $3,081.09 $3,543.25 $3,490.10

47130 $3,473.21 $3,299.55 $3,794.48 $3,737.57

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

47135 $5,176.68 $4,917.85 $5,655.53 $5,570.69

47136 $4,444.64 $4,222.41 $4,855.77 $4,782.93

47140 $3,787.30 $3,597.94 $4,137.63 $4,075.57

47141 $4,159.20 $3,951.24 $4,543.93 $4,475.77

47142 $4,976.62 $4,727.79 $5,436.96 $5,355.40

47143 $453.62 $430.94 $495.58 $488.15

47144 $524.95 $498.70 $573.51 $564.90

47146 $344.73 $327.49 $376.61 $370.97

47147 $402.28 $382.17 $439.50 $432.91

47300 $1,211.06 $1,150.51 $1,323.09 $1,303.24

47350 $1,459.02 $1,386.07 $1,593.98 $1,570.07

47360 $1,991.37 $1,891.80 $2,175.57 $2,142.93

47361 $3,192.18 $3,032.57 $3,487.46 $3,435.14

47362 $1,542.34 $1,465.22 $1,685.00 $1,659.73

47370 $1,314.29 $1,248.58 $1,435.87 $1,414.33

47371 $1,334.37 $1,267.65 $1,457.80 $1,435.94

47380 $1,519.89 $1,443.90 $1,660.49 $1,635.58

47381 $1,569.09 $1,490.64 $1,714.24 $1,688.52

47382 $5,785.72 $5,496.43 $6,320.89 $6,226.08

# 47382 $810.80 $770.26 $885.80 $872.52

47400 $2,281.46 $2,167.39 $2,492.50 $2,455.11

47420 $1,433.16 $1,361.50 $1,565.73 $1,542.24

47425 $1,455.28 $1,382.52 $1,589.90 $1,566.05

47460 $1,352.04 $1,284.44 $1,477.11 $1,454.95

47480 $943.83 $896.64 $1,031.14 $1,015.67

47490 $358.75 $340.81 $391.93 $386.06

47500 $101.25 $96.19 $110.62 $108.96

47505 $38.85 $36.91 $42.45 $41.81

47510 $499.70 $474.72 $545.93 $537.74

47511 $608.45 $578.03 $664.73 $654.76

47525 $569.91 $541.41 $622.62 $613.28

# 47525 $89.50 $85.03 $97.78 $96.31

47530 $1,583.42 $1,504.25 $1,729.89 $1,703.94

# 47530 $374.36 $355.64 $408.99 $402.86

47550 $173.28 $164.62 $189.31 $186.47

47552 $328.79 $312.35 $359.20 $353.81

47553 $326.92 $310.57 $357.16 $351.80

47554 $514.02 $488.32 $561.57 $553.15

47555 $386.73 $367.39 $422.50 $416.16

47556 $439.61 $417.63 $480.27 $473.08

47560 $280.79 $266.75 $306.76 $302.16

47561 $309.88 $294.39 $338.55 $333.47

47562 $703.17 $668.01 $768.21 $756.69

47563 $762.97 $724.82 $833.54 $821.04

47564 $1,188.19 $1,128.78 $1,298.10 $1,278.63

47570 $825.84 $784.55 $902.23 $888.70

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

47600 $1,137.95 $1,081.05 $1,243.21 $1,224.55

47605 $1,196.96 $1,137.11 $1,307.68 $1,288.06

47610 $1,332.77 $1,266.13 $1,456.05 $1,434.21

47612 $1,345.00 $1,277.75 $1,469.41 $1,447.37

47620 $1,462.80 $1,389.66 $1,598.11 $1,574.14

47630 $581.28 $552.22 $635.05 $625.53

47700 $1,127.01 $1,070.66 $1,231.26 $1,212.79

47701 $1,841.99 $1,749.89 $2,012.37 $1,982.19

47711 $1,645.82 $1,563.53 $1,798.06 $1,771.09

47712 $2,118.06 $2,012.16 $2,313.98 $2,279.28

47715 $1,418.22 $1,347.31 $1,549.41 $1,526.17

47720 $1,232.46 $1,170.84 $1,346.47 $1,326.27

47721 $1,443.57 $1,371.39 $1,577.10 $1,553.44

47740 $1,399.27 $1,329.31 $1,528.71 $1,505.78

47741 $1,570.75 $1,492.21 $1,716.04 $1,690.30

47760 $2,383.77 $2,264.58 $2,604.27 $2,565.20

47765 $3,210.85 $3,050.31 $3,507.86 $3,455.24

47780 $2,613.03 $2,482.38 $2,854.74 $2,811.91

47785 $3,419.84 $3,248.85 $3,736.18 $3,680.14

47800 $1,680.94 $1,596.89 $1,836.42 $1,808.88

47801 $1,079.70 $1,025.72 $1,179.58 $1,161.88

47802 $1,625.20 $1,543.94 $1,775.53 $1,748.90

47900 $1,465.27 $1,392.01 $1,600.81 $1,576.80

48000 $1,959.78 $1,861.79 $2,141.06 $2,108.94

48001 $2,439.53 $2,317.55 $2,665.18 $2,625.21

48020 $1,255.28 $1,192.52 $1,371.40 $1,350.82

48100 $944.21 $897.00 $1,031.55 $1,016.08

48102 $586.91 $557.56 $641.19 $631.58

# 48102 $253.23 $240.57 $276.66 $272.50

48105 $3,012.90 $2,862.26 $3,291.60 $3,242.23

48120 $1,179.64 $1,120.66 $1,288.76 $1,269.43

48140 $1,654.38 $1,571.66 $1,807.41 $1,780.30

48145 $1,731.47 $1,644.90 $1,891.64 $1,863.26

48146 $1,986.27 $1,886.96 $2,170.00 $2,137.46

48148 $1,329.22 $1,262.76 $1,452.17 $1,430.39

48150 $3,282.58 $3,118.45 $3,586.22 $3,532.42

48152 $3,058.92 $2,905.97 $3,341.87 $3,291.74

48153 $3,270.17 $3,106.66 $3,572.66 $3,519.07

48154 $3,072.13 $2,918.52 $3,356.30 $3,305.95

48155 $1,936.29 $1,839.48 $2,115.40 $2,083.67

48400 $117.51 $111.63 $128.37 $126.45

48500 $1,231.98 $1,170.38 $1,345.94 $1,325.74

48510 $1,157.30 $1,099.44 $1,264.36 $1,245.39

48511 $1,057.76 $1,004.87 $1,155.60 $1,138.27

# 48511 $205.36 $195.09 $224.35 $220.98

48520 $1,162.75 $1,104.61 $1,270.30 $1,251.25

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

48540 $1,389.81 $1,320.32 $1,518.37 $1,495.60

48545 $1,430.31 $1,358.79 $1,562.61 $1,539.17

48547 $1,897.58 $1,802.70 $2,073.11 $2,042.01

48548 $1,762.30 $1,674.19 $1,925.32 $1,896.44

48551 $327.84 $311.45 $358.17 $352.80

48552 $246.50 $234.18 $269.31 $265.27

48554 $2,765.88 $2,627.59 $3,021.73 $2,976.41

48556 $1,370.57 $1,302.04 $1,497.35 $1,474.89

49000 $821.59 $780.51 $897.59 $884.12

49002 $1,110.32 $1,054.80 $1,213.02 $1,194.83

49010 $992.69 $943.06 $1,084.52 $1,068.25

49020 $1,689.20 $1,604.74 $1,845.45 $1,817.77

49021 $1,001.55 $951.47 $1,094.19 $1,077.78

# 49021 $173.29 $164.63 $189.32 $186.48

49040 $1,069.83 $1,016.34 $1,168.79 $1,151.25

49041 $1,041.67 $989.59 $1,138.03 $1,120.96

# 49041 $205.75 $195.46 $224.78 $221.41

49060 $1,166.79 $1,108.45 $1,274.72 $1,255.59

49061 $1,018.33 $967.41 $1,112.52 $1,095.84

# 49061 $189.69 $180.21 $207.24 $204.14

49062 $786.25 $746.94 $858.98 $846.10

49082 $198.69 $188.76 $217.07 $213.82

# 49082 $76.87 $73.03 $83.98 $82.72

49083 $358.98 $341.03 $392.18 $386.30

# 49083 $118.40 $112.48 $129.35 $127.41

49084 $106.91 $101.56 $116.79 $115.05

49180 $178.03 $169.13 $194.50 $191.58

# 49180 $89.15 $84.69 $97.39 $95.93

49203 $1,265.38 $1,202.11 $1,382.43 $1,361.69

49204 $1,611.62 $1,531.04 $1,760.70 $1,734.28

49205 $1,849.85 $1,757.36 $2,020.96 $1,990.65

49215 $2,335.82 $2,219.03 $2,551.88 $2,513.60

49220 $1,009.61 $959.13 $1,103.00 $1,086.45

49250 $627.42 $596.05 $685.46 $675.18

49255 $848.39 $805.97 $926.87 $912.96

49320 $351.55 $333.97 $384.07 $378.30

49321 $372.43 $353.81 $406.88 $400.78

49322 $397.12 $377.26 $433.85 $427.34

49323 $693.87 $659.18 $758.06 $746.68

49324 $421.60 $400.52 $460.60 $453.69

49325 $449.69 $427.21 $491.29 $483.92

49326 $197.72 $187.83 $216.00 $212.76

49327 $135.75 $128.96 $148.30 $146.08

49400 $147.01 $139.66 $160.61 $158.21

# 49400 $99.12 $94.16 $108.28 $106.66

49402 $910.91 $865.36 $995.16 $980.24

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

49411 $607.54 $577.16 $663.73 $653.78

# 49411 $205.67 $195.39 $224.70 $221.33

49412 $85.38 $81.11 $93.28 $91.87

49418 $1,674.22 $1,590.51 $1,829.09 $1,801.65

# 49418 $237.22 $225.36 $259.16 $255.28

49419 $467.46 $444.09 $510.70 $503.04

49421 $242.03 $229.93 $264.42 $260.45

49422 $407.64 $387.26 $445.35 $438.67

49423 $635.76 $603.97 $694.57 $684.15

# 49423 $75.67 $71.89 $82.67 $81.43

49424 $166.42 $158.10 $181.82 $179.09

# 49424 $40.38 $38.36 $44.11 $43.45

49425 $804.45 $764.23 $878.86 $865.69

49426 $668.52 $635.09 $730.35 $719.39

49427 $47.11 $44.75 $51.46 $50.69

49428 $461.77 $438.68 $504.48 $496.92

49429 $470.52 $446.99 $514.04 $506.33

49435 $125.19 $118.93 $136.77 $134.72

49436 $203.19 $193.03 $221.98 $218.65

49440 $1,212.73 $1,152.09 $1,324.90 $1,305.03

# 49440 $237.74 $225.85 $259.73 $255.83

49441 $1,361.78 $1,293.69 $1,487.74 $1,465.42

# 49441 $270.71 $257.17 $295.75 $291.31

49442 $1,081.50 $1,027.43 $1,181.54 $1,163.82

# 49442 $231.02 $219.47 $252.39 $248.61

49446 $1,154.24 $1,096.53 $1,261.01 $1,242.09

# 49446 $170.44 $161.92 $186.21 $183.41

49450 $780.93 $741.88 $853.16 $840.36

# 49450 $69.90 $66.41 $76.37 $75.22

49451 $850.25 $807.74 $928.90 $914.96

# 49451 $95.93 $91.13 $104.80 $103.22

49452 $1,041.79 $989.70 $1,138.16 $1,121.08

# 49452 $147.26 $139.90 $160.89 $158.47

49460 $863.25 $820.09 $943.10 $928.96

# 49460 $50.31 $47.79 $54.96 $54.13

49465 $190.73 $181.19 $208.37 $205.24

# 49465 $31.74 $30.15 $34.67 $34.16

49491 $848.16 $805.75 $926.61 $912.71

49492 $991.25 $941.69 $1,082.94 $1,066.69

49495 $422.06 $400.96 $461.10 $454.19

49496 $609.25 $578.79 $665.61 $655.63

49500 $400.58 $380.55 $437.63 $431.07

49501 $648.74 $616.30 $708.75 $698.12

49505 $558.88 $530.94 $610.58 $601.43

49507 $627.68 $596.30 $685.75 $675.46

49520 $675.30 $641.54 $737.77 $726.71

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

49521 $763.75 $725.56 $834.39 $821.88

49525 $613.09 $582.44 $669.81 $659.76

49540 $721.99 $685.89 $788.77 $776.94

49550 $617.01 $586.16 $674.08 $663.98

49553 $675.17 $641.41 $737.62 $726.56

49555 $638.34 $606.42 $697.38 $686.92

49557 $770.42 $731.90 $841.69 $829.06

49560 $785.74 $746.45 $858.42 $845.54

49561 $988.50 $939.08 $1,079.94 $1,063.74

49565 $819.04 $778.09 $894.80 $881.38

49566 $998.94 $948.99 $1,091.34 $1,074.97

49568 $280.08 $266.08 $305.99 $301.40

49570 $451.05 $428.50 $492.78 $485.38

49572 $554.25 $526.54 $605.52 $596.44

49580 $363.36 $345.19 $396.97 $391.01

49582 $520.85 $494.81 $569.03 $560.50

49585 $479.14 $455.18 $523.46 $515.60

49587 $512.69 $487.06 $560.12 $551.71

49590 $613.91 $583.21 $670.69 $660.63

49600 $780.25 $741.24 $852.43 $839.64

49605 $5,188.78 $4,929.34 $5,668.74 $5,583.71

49606 $1,199.72 $1,139.73 $1,310.69 $1,291.02

49610 $655.73 $622.94 $716.38 $705.64

49611 $549.07 $521.62 $599.86 $590.87

49650 $461.68 $438.60 $504.39 $496.82

49651 $600.34 $570.32 $655.87 $646.04

49652 $735.12 $698.36 $803.11 $791.06

49653 $916.37 $870.55 $1,001.13 $986.11

49654 $832.36 $790.74 $909.35 $895.71

49655 $1,015.37 $964.60 $1,109.29 $1,092.65

49656 $901.67 $856.59 $985.08 $970.30

49657 $1,292.01 $1,227.41 $1,411.52 $1,390.35

49900 $878.04 $834.14 $959.26 $944.87

49904 $1,562.82 $1,484.68 $1,707.38 $1,681.77

49905 $369.34 $350.87 $403.50 $397.45

49906 $1,522.68 $1,446.55 $1,663.53 $1,638.58

50010 $775.98 $737.18 $847.76 $835.04

50020 $1,122.12 $1,066.01 $1,225.91 $1,207.52

50021 $1,065.53 $1,012.25 $1,164.09 $1,146.63

# 50021 $172.91 $164.26 $188.90 $186.07

50040 $962.08 $913.98 $1,051.08 $1,035.31

50045 $966.37 $918.05 $1,055.76 $1,039.92

50060 $1,178.86 $1,119.92 $1,287.91 $1,268.59

50065 $1,250.18 $1,187.67 $1,365.82 $1,345.33

50070 $1,226.30 $1,164.99 $1,339.74 $1,319.65

50075 $1,506.14 $1,430.83 $1,645.45 $1,620.78

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

50080 $902.23 $857.12 $985.69 $970.90

50081 $1,322.17 $1,256.06 $1,444.47 $1,422.80

50100 $1,071.70 $1,018.12 $1,170.84 $1,153.28

50120 $983.64 $934.46 $1,074.63 $1,058.51

50125 $1,095.86 $1,041.07 $1,197.23 $1,179.27

50130 $1,069.77 $1,016.28 $1,168.72 $1,151.20

50135 $1,161.05 $1,103.00 $1,268.45 $1,249.43

50200 $673.20 $639.54 $735.47 $724.44

# 50200 $151.42 $143.85 $165.43 $162.94

50205 $799.19 $759.23 $873.11 $860.02

50220 $1,088.24 $1,033.83 $1,188.90 $1,171.07

50225 $1,244.25 $1,182.04 $1,359.35 $1,338.96

50230 $1,324.51 $1,258.28 $1,447.02 $1,425.32

50234 $1,345.51 $1,278.23 $1,469.96 $1,447.92

50236 $1,516.99 $1,441.14 $1,657.31 $1,632.45

50240 $1,371.43 $1,302.86 $1,498.29 $1,475.82

50250 $1,263.12 $1,199.96 $1,379.95 $1,359.25

50280 $995.39 $945.62 $1,087.46 $1,071.16

50290 $932.12 $885.51 $1,018.34 $1,003.06

50320 $1,541.18 $1,464.12 $1,683.74 $1,658.48

50323 $394.15 $374.44 $430.61 $424.14

50325 $269.98 $256.48 $294.95 $290.52

50327 $225.68 $214.40 $246.56 $242.86

50328 $197.12 $187.26 $215.35 $212.12

50329 $181.74 $172.65 $198.55 $195.57

50340 $1,023.42 $972.25 $1,118.09 $1,101.32

50360 $2,745.25 $2,607.99 $2,999.19 $2,954.20

50365 $3,045.27 $2,893.01 $3,326.96 $3,277.05

50370 $1,283.34 $1,219.17 $1,402.05 $1,381.01

50380 $2,155.36 $2,047.59 $2,354.73 $2,319.41

50382 $1,355.78 $1,287.99 $1,481.19 $1,458.97

# 50382 $283.87 $269.68 $310.13 $305.47

50384 $1,083.37 $1,029.20 $1,183.58 $1,165.82

# 50384 $258.18 $245.27 $282.06 $277.83

50385 $1,309.27 $1,243.81 $1,430.38 $1,408.92

# 50385 $241.19 $229.13 $263.50 $259.54

50386 $845.88 $803.59 $924.13 $910.27

# 50386 $182.74 $173.60 $199.64 $196.65

50387 $635.14 $603.38 $693.89 $683.48

# 50387 $102.64 $97.51 $112.14 $110.46

50389 $344.03 $326.83 $375.85 $370.22

# 50389 $56.71 $53.87 $61.95 $61.02

50390 $100.54 $95.51 $109.84 $108.19

50391 $128.45 $122.03 $140.33 $138.23

# 50391 $101.63 $96.55 $111.03 $109.37

50392 $187.47 $178.10 $204.82 $201.74

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

50393 $227.40 $216.03 $248.43 $244.71

50394 $113.94 $108.24 $124.48 $122.61

# 50394 $53.41 $50.74 $58.35 $57.48

50395 $187.80 $178.41 $205.17 $202.09

50396 $117.64 $111.76 $128.52 $126.59

50398 $573.70 $545.02 $626.77 $617.37

# 50398 $75.67 $71.89 $82.67 $81.43

50400 $1,199.31 $1,139.34 $1,310.24 $1,290.59

50405 $1,442.70 $1,370.57 $1,576.16 $1,552.51

50500 $1,340.70 $1,273.67 $1,464.72 $1,442.74

50520 $1,073.33 $1,019.66 $1,172.61 $1,155.03

50525 $1,557.36 $1,479.49 $1,701.41 $1,675.90

50526 $1,504.92 $1,429.67 $1,644.12 $1,619.45

50540 $1,187.09 $1,127.74 $1,296.90 $1,277.44

50541 $952.98 $905.33 $1,041.13 $1,025.51

50542 $1,208.18 $1,147.77 $1,319.94 $1,300.13

50543 $1,541.91 $1,464.81 $1,684.53 $1,659.27

50544 $1,287.77 $1,223.38 $1,406.89 $1,385.78

50545 $1,386.81 $1,317.47 $1,515.09 $1,492.37

50546 $1,246.80 $1,184.46 $1,362.13 $1,341.69

50547 $1,705.42 $1,620.15 $1,863.17 $1,835.23

50548 $1,390.47 $1,320.95 $1,519.09 $1,496.31

50551 $376.96 $358.11 $411.83 $405.65

# 50551 $304.56 $289.33 $332.73 $327.74

50553 $406.30 $385.99 $443.89 $437.23

# 50553 $326.23 $309.92 $356.41 $351.06

50555 $431.24 $409.68 $471.13 $464.06

# 50555 $352.71 $335.07 $385.33 $379.55

50557 $438.94 $416.99 $479.54 $472.35

# 50557 $357.34 $339.47 $390.39 $384.54

50561 $497.62 $472.74 $543.65 $535.50

# 50561 $407.20 $386.84 $444.87 $438.20

50562 $600.98 $570.93 $656.57 $646.73

50570 $505.53 $480.25 $552.29 $544.01

50572 $547.60 $520.22 $598.25 $589.28

50574 $582.56 $553.43 $636.44 $626.90

50575 $735.18 $698.42 $803.18 $791.13

50576 $580.43 $551.41 $634.12 $624.61

50580 $625.70 $594.42 $683.58 $673.33

50590 $766.60 $728.27 $837.51 $824.95

# 50590 $592.68 $563.05 $647.51 $637.79

50592 $3,598.44 $3,418.52 $3,931.30 $3,872.33

# 50592 $378.88 $359.94 $413.93 $407.72

50593 $5,322.27 $5,056.16 $5,814.58 $5,727.37

# 50593 $505.18 $479.92 $551.91 $543.63

50600 $971.90 $923.31 $1,061.81 $1,045.88

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

50605 $1,029.15 $977.69 $1,124.34 $1,107.47

50610 $978.90 $929.96 $1,069.45 $1,053.41

50620 $936.81 $889.97 $1,023.47 $1,008.11

50630 $925.39 $879.12 $1,010.99 $995.82

50650 $1,074.56 $1,020.83 $1,173.95 $1,156.35

50660 $1,183.16 $1,124.00 $1,292.60 $1,273.21

50684 $117.77 $111.88 $128.66 $126.73

# 50684 $53.41 $50.74 $58.35 $57.48

50686 $163.71 $155.52 $178.85 $176.17

# 50686 $99.35 $94.38 $108.54 $106.90

50688 $85.44 $81.17 $93.35 $91.94

50690 $105.53 $100.25 $115.29 $113.56

# 50690 $74.12 $70.41 $80.97 $79.75

50700 $959.94 $911.94 $1,048.73 $1,033.00

50715 $1,264.18 $1,200.97 $1,381.12 $1,360.40

50722 $1,120.44 $1,064.42 $1,224.08 $1,205.72

50725 $1,140.72 $1,083.68 $1,246.23 $1,227.53

50727 $531.26 $504.70 $580.41 $571.70

50728 $727.10 $690.75 $794.36 $782.45

50740 $1,299.85 $1,234.86 $1,420.09 $1,398.79

50750 $1,193.14 $1,133.48 $1,303.50 $1,283.95

50760 $1,180.19 $1,121.18 $1,289.36 $1,270.01

50770 $1,193.14 $1,133.48 $1,303.50 $1,283.95

50780 $1,151.73 $1,094.14 $1,258.26 $1,239.39

50782 $1,275.54 $1,211.76 $1,393.52 $1,372.62

50783 $1,166.76 $1,108.42 $1,274.68 $1,255.56

50785 $1,253.32 $1,190.65 $1,369.25 $1,348.71

50800 $967.12 $918.76 $1,056.57 $1,040.73

50810 $1,388.13 $1,318.72 $1,516.53 $1,493.78

50815 $1,266.48 $1,203.16 $1,383.63 $1,362.88

50820 $1,368.61 $1,300.18 $1,495.21 $1,472.78

50825 $1,717.86 $1,631.97 $1,876.77 $1,848.61

50830 $1,860.88 $1,767.84 $2,033.02 $2,002.52

50840 $1,273.62 $1,209.94 $1,391.43 $1,370.56

50845 $1,300.57 $1,235.54 $1,420.87 $1,399.56

50860 $979.91 $930.91 $1,070.55 $1,054.49

50900 $885.03 $840.78 $966.90 $952.40

50920 $914.65 $868.92 $999.26 $984.27

50930 $1,223.92 $1,162.72 $1,337.13 $1,317.07

50940 $921.09 $875.04 $1,006.30 $991.20

50945 $1,006.75 $956.41 $1,099.87 $1,083.37

50947 $1,431.88 $1,360.29 $1,564.33 $1,540.87

50948 $1,316.84 $1,251.00 $1,438.65 $1,417.08

50951 $393.29 $373.63 $429.67 $423.23

# 50951 $316.67 $300.84 $345.97 $340.78

50953 $417.39 $396.52 $456.00 $449.16

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 50953 $352.27 $334.66 $384.86 $379.09

50955 $444.96 $422.71 $486.12 $478.83

# 50955 $378.30 $359.39 $413.30 $407.10

50957 $449.03 $426.58 $490.57 $483.21

# 50957 $365.90 $347.61 $399.75 $393.76

50961 $404.72 $384.48 $442.15 $435.52

# 50961 $327.72 $311.33 $358.03 $352.66

50970 $381.80 $362.71 $417.12 $410.86

50972 $369.70 $351.22 $403.90 $397.84

50974 $487.02 $462.67 $532.07 $524.09

50976 $480.23 $456.22 $524.65 $516.79

50980 $366.83 $348.49 $400.76 $394.75

51020 $492.54 $467.91 $538.10 $530.02

51030 $492.58 $467.95 $538.14 $530.07

51040 $305.32 $290.05 $333.56 $328.56

51045 $518.54 $492.61 $566.50 $558.00

51050 $493.84 $469.15 $539.52 $531.43

51060 $606.89 $576.55 $663.03 $653.09

51065 $603.83 $573.64 $659.69 $649.80

51080 $428.59 $407.16 $468.23 $461.21

51100 $66.72 $63.38 $72.89 $71.79

# 51100 $39.90 $37.91 $43.60 $42.94

51101 $139.30 $132.34 $152.19 $149.90

# 51101 $54.64 $51.91 $59.70 $58.80

51102 $245.85 $233.56 $268.59 $264.57

# 51102 $151.22 $143.66 $165.21 $162.74

51500 $663.22 $630.06 $724.57 $713.70

51520 $619.73 $588.74 $677.05 $666.90

51525 $893.35 $848.68 $975.98 $961.34

51530 $826.45 $785.13 $902.90 $889.35

51535 $808.65 $768.22 $883.45 $870.21

51550 $1,009.44 $958.97 $1,102.82 $1,086.28

51555 $1,320.21 $1,254.20 $1,442.33 $1,420.70

51565 $1,344.21 $1,277.00 $1,468.55 $1,446.53

51570 $1,529.63 $1,453.15 $1,671.12 $1,646.05

51575 $1,878.78 $1,784.84 $2,052.57 $2,021.78

51580 $1,958.18 $1,860.27 $2,139.31 $2,107.23

51585 $2,178.55 $2,069.62 $2,380.06 $2,344.37

51590 $1,995.49 $1,895.72 $2,180.08 $2,147.37

51595 $2,259.95 $2,146.95 $2,468.99 $2,431.96

51596 $2,428.87 $2,307.43 $2,653.54 $2,613.74

51597 $2,371.28 $2,252.72 $2,590.63 $2,551.77

51600 $204.66 $194.43 $223.59 $220.24

# 51600 $45.29 $43.03 $49.48 $48.74

51605 $40.10 $38.10 $43.82 $43.16

51610 $115.88 $110.09 $126.60 $124.71

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 51610 $67.61 $64.23 $73.86 $72.76

51700 $90.11 $85.60 $98.44 $96.97

# 51700 $45.67 $43.39 $49.90 $49.15

51701 $60.14 $57.13 $65.70 $64.71

# 51701 $28.72 $27.28 $31.37 $30.90

51702 $78.53 $74.60 $85.79 $84.50

# 51702 $31.79 $30.20 $34.73 $34.21

51703 $139.94 $132.94 $152.88 $150.59

# 51703 $84.39 $80.17 $92.20 $90.82

51705 $99.21 $94.25 $108.39 $106.77

# 51705 $54.38 $51.66 $59.41 $58.52

51710 $99.43 $94.46 $108.63 $107.00

# 51710 $83.73 $79.54 $91.47 $90.10

51715 $310.08 $294.58 $338.77 $333.68

# 51715 $207.80 $197.41 $227.02 $223.62

51720 $115.31 $109.54 $125.97 $124.09

# 51720 $82.75 $78.61 $90.40 $89.04

51725 $208.40 $197.98 $227.68 $224.26

51725 TC $129.46 $122.99 $141.44 $139.32

51725 26 $78.94 $74.99 $86.24 $84.95

51726 $295.30 $280.54 $322.62 $317.78

51726 TC $207.17 $196.81 $226.33 $222.94

51726 26 $88.13 $83.72 $96.28 $94.83

51727 $353.09 $335.44 $385.76 $379.97

51727 TC $240.56 $228.53 $262.81 $258.87

51727 26 $112.53 $106.90 $122.94 $121.10

51728 $351.29 $333.73 $383.79 $378.03

51728 TC $242.86 $230.72 $265.33 $261.35

51728 26 $108.43 $103.01 $118.46 $116.68

51729 $381.49 $362.42 $416.78 $410.53

51729 TC $248.99 $236.54 $272.02 $267.94

51729 26 $132.50 $125.88 $144.76 $142.59

51736 $16.58 $15.75 $18.11 $17.84

51736 TC $8.02 $7.62 $8.76 $8.64

51736 26 $8.56 $8.13 $9.35 $9.21

51741 $16.96 $16.11 $18.53 $18.25

51741 TC $8.40 $7.98 $9.18 $9.04

51741 26 $8.56 $8.13 $9.35 $9.21

51784 $213.31 $202.64 $233.04 $229.54

51784 TC $134.06 $127.36 $146.46 $144.27

51784 26 $79.25 $75.29 $86.58 $85.28

51785 $286.48 $272.16 $312.98 $308.29

51785 TC $203.78 $193.59 $222.63 $219.29

51785 26 $82.70 $78.57 $90.36 $89.00

51792 $239.04 $227.09 $261.15 $257.23

51792 TC $181.56 $172.48 $198.35 $195.37

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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January 2013 Medicare Physician's Fee Schedule - New Jersey Locality 99

FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

51792 26 $57.47 $54.60 $62.79 $61.85

51797 $124.93 $118.68 $136.48 $134.44

51797 TC $83.87 $79.68 $91.63 $90.25

51797 26 $41.06 $39.01 $44.86 $44.18

51798 $22.19 $21.08 $24.24 $23.87

51800 $1,084.10 $1,029.90 $1,184.39 $1,166.62

51820 $1,122.76 $1,066.62 $1,226.61 $1,208.21

51840 $699.64 $664.66 $764.36 $752.89

51841 $830.63 $789.10 $907.47 $893.85

51845 $617.06 $586.21 $674.14 $664.03

51860 $788.49 $749.07 $861.43 $848.50

51865 $938.92 $891.97 $1,025.77 $1,010.38

51880 $493.24 $468.58 $538.87 $530.78

51900 $865.56 $822.28 $945.62 $931.44

51920 $865.29 $822.03 $945.33 $931.16

51925 $1,116.03 $1,060.23 $1,219.26 $1,200.98

51940 $1,699.68 $1,614.70 $1,856.91 $1,829.05

51960 $1,443.55 $1,371.37 $1,577.08 $1,553.42

51980 $741.30 $704.24 $809.88 $797.73

51990 $800.17 $760.16 $874.18 $861.07

51992 $909.21 $863.75 $993.31 $978.41

52000 $219.34 $208.37 $239.63 $236.03

# 52000 $131.61 $125.03 $143.78 $141.62

52001 $390.17 $370.66 $426.26 $419.87

# 52001 $296.69 $281.86 $324.14 $319.27

52005 $288.92 $274.47 $315.64 $310.90

# 52005 $138.75 $131.81 $151.58 $149.30

52007 $491.01 $466.46 $536.43 $528.38

# 52007 $172.27 $163.66 $188.21 $185.39

52010 $401.37 $381.30 $438.50 $431.92

# 52010 $171.89 $163.30 $187.80 $184.98

52204 $406.84 $386.50 $444.48 $437.81

# 52204 $147.10 $139.75 $160.71 $158.30

52214 $736.69 $699.86 $804.84 $792.76

# 52214 $180.44 $171.42 $197.13 $194.18

52224 $767.87 $729.48 $838.90 $826.32

# 52224 $209.31 $198.84 $228.67 $225.24

52234 $253.90 $241.21 $277.39 $273.23

52235 $298.23 $283.32 $325.82 $320.93

52240 $404.48 $384.26 $441.90 $435.28

52250 $251.66 $239.08 $274.94 $270.81

52260 $218.26 $207.35 $238.45 $234.88

52265 $404.58 $384.35 $442.00 $435.37

# 52265 $171.65 $163.07 $187.53 $184.71

52270 $385.51 $366.23 $421.16 $414.85

# 52270 $188.60 $179.17 $206.05 $202.95

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

52275 $519.49 $493.52 $567.55 $559.04

# 52275 $256.69 $243.86 $280.44 $276.23

52276 $274.66 $260.93 $300.07 $295.57

52277 $337.22 $320.36 $368.41 $362.88

52281 $294.32 $279.60 $321.54 $316.72

# 52281 $158.71 $150.77 $173.39 $170.79

52282 $348.14 $330.73 $380.34 $374.64

52283 $292.13 $277.52 $319.15 $314.36

# 52283 $209.00 $198.55 $228.33 $224.91

52285 $297.20 $282.34 $324.69 $319.82

# 52285 $204.10 $193.90 $222.99 $219.64

52287 $335.90 $319.11 $366.98 $361.47

# 52287 $174.61 $165.88 $190.76 $187.90

52290 $252.89 $240.25 $276.29 $272.15

52300 $295.96 $281.16 $323.33 $318.48

52301 $302.61 $287.48 $330.60 $325.65

52305 $287.64 $273.26 $314.25 $309.53

52310 $260.01 $247.01 $284.06 $279.80

# 52310 $157.34 $149.47 $171.89 $169.31

52315 $438.61 $416.68 $479.18 $471.99

# 52315 $283.08 $268.93 $309.27 $304.64

52317 $880.27 $836.26 $961.70 $947.28

# 52317 $357.72 $339.83 $390.80 $384.94

52318 $487.33 $462.96 $532.40 $524.42

52320 $254.39 $241.67 $277.92 $273.75

52325 $331.13 $314.57 $361.76 $356.33

52327 $270.07 $256.57 $295.06 $290.63

52330 $533.49 $506.82 $582.84 $574.10

# 52330 $272.22 $258.61 $297.40 $292.94

52332 $566.48 $538.16 $618.88 $609.60

# 52332 $161.55 $153.47 $176.49 $173.85

52334 $265.72 $252.43 $290.29 $285.94

52341 $299.34 $284.37 $327.03 $322.12

52342 $325.03 $308.78 $355.10 $349.77

52343 $361.38 $343.31 $394.81 $388.88

52344 $393.20 $373.54 $429.57 $423.13

52345 $418.89 $397.95 $457.64 $450.78

52346 $473.14 $449.48 $516.90 $509.15

52351 $319.67 $303.69 $349.24 $344.00

52352 $375.56 $356.78 $410.30 $404.14

52353 $413.70 $393.02 $451.97 $445.19

52354 $439.74 $417.75 $480.41 $473.20

52355 $491.80 $467.21 $537.29 $529.23

52400 $495.70 $470.92 $541.56 $533.44

52402 $273.63 $259.95 $298.94 $294.46

52450 $492.30 $467.69 $537.84 $529.77

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

52500 $510.47 $484.95 $557.69 $549.33

52601 $877.26 $833.40 $958.41 $944.04

52630 $420.00 $399.00 $458.85 $451.97

52640 $332.95 $316.30 $363.75 $358.29

52647 $1,978.98 $1,880.03 $2,162.03 $2,129.60

# 52647 $674.14 $640.43 $736.49 $725.44

52648 $2,034.66 $1,932.93 $2,222.87 $2,189.53

# 52648 $718.72 $682.78 $785.20 $773.42

52649 $846.68 $804.35 $925.00 $911.12

52700 $460.09 $437.09 $502.65 $495.11

53000 $156.51 $148.68 $170.98 $168.42

53010 $310.88 $295.34 $339.64 $334.55

53020 $100.83 $95.79 $110.16 $108.50

53025 $78.90 $74.96 $86.20 $84.92

53040 $411.19 $390.63 $449.22 $442.49

53060 $197.24 $187.38 $215.49 $212.26

# 53060 $174.25 $165.54 $190.37 $187.52

53080 $440.43 $418.41 $481.17 $473.95

53085 $690.05 $655.55 $753.88 $742.58

53200 $163.16 $155.00 $178.25 $175.58

# 53200 $147.46 $140.09 $161.10 $158.69

53210 $808.17 $767.76 $882.92 $869.68

53215 $960.87 $912.83 $1,049.75 $1,034.01

53220 $475.66 $451.88 $519.66 $511.87

53230 $637.95 $606.05 $696.96 $686.50

53235 $658.89 $625.95 $719.84 $709.04

53240 $444.43 $422.21 $485.54 $478.26

53250 $442.86 $420.72 $483.83 $476.57

53260 $214.62 $203.89 $234.47 $230.95

# 53260 $190.49 $180.97 $208.12 $205.00

53265 $231.77 $220.18 $253.21 $249.41

# 53265 $195.38 $185.61 $213.45 $210.25

53270 $224.46 $213.24 $245.23 $241.55

# 53270 $199.56 $189.58 $218.02 $214.75

53275 $273.97 $260.27 $299.31 $294.83

53400 $837.85 $795.96 $915.35 $901.62

53405 $906.43 $861.11 $990.28 $975.42

53410 $1,016.68 $965.85 $1,110.73 $1,094.06

53415 $1,170.86 $1,112.32 $1,279.17 $1,259.99

53420 $872.28 $828.67 $952.97 $938.68

53425 $969.99 $921.49 $1,059.71 $1,043.82

53430 $1,009.96 $959.46 $1,103.38 $1,086.83

53431 $1,194.05 $1,134.35 $1,304.50 $1,284.93

53440 $783.05 $743.90 $855.49 $842.65

53442 $816.30 $775.49 $891.81 $878.44

53444 $823.59 $782.41 $899.77 $886.27

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

53445 $785.19 $745.93 $857.82 $844.95

53446 $670.58 $637.05 $732.61 $721.61

53447 $840.81 $798.77 $918.59 $904.81

53448 $1,325.20 $1,258.94 $1,447.78 $1,426.07

53449 $637.85 $605.96 $696.85 $686.40

53450 $427.23 $405.87 $466.75 $459.75

53460 $477.53 $453.65 $521.70 $513.88

53500 $787.26 $747.90 $860.09 $847.18

53502 $508.07 $482.67 $555.07 $546.74

53505 $507.69 $482.31 $554.66 $546.34

53510 $657.46 $624.59 $718.28 $707.50

53515 $825.40 $784.13 $901.75 $888.23

53520 $580.80 $551.76 $634.52 $625.00

53600 $87.70 $83.32 $95.82 $94.38

# 53600 $65.48 $62.21 $71.54 $70.47

53601 $86.31 $81.99 $94.29 $92.87

# 53601 $54.89 $52.15 $59.97 $59.08

53605 $65.97 $62.67 $72.07 $70.99

53620 $122.88 $116.74 $134.25 $132.24

# 53620 $90.31 $85.79 $98.66 $97.18

53621 $116.67 $110.84 $127.47 $125.56

# 53621 $74.15 $70.44 $81.01 $79.79

53660 $76.57 $72.74 $83.65 $82.40

# 53660 $43.63 $41.45 $47.67 $46.95

53661 $75.00 $71.25 $81.94 $80.71

# 53661 $42.06 $39.96 $45.95 $45.26

53665 $39.97 $37.97 $43.67 $43.01

53850 $2,327.66 $2,211.28 $2,542.97 $2,504.83

# 53850 $636.28 $604.47 $695.14 $684.71

53852 $2,134.39 $2,027.67 $2,331.82 $2,296.84

# 53852 $648.73 $616.29 $708.73 $698.11

53855 $888.62 $844.19 $970.82 $956.26

# 53855 $84.88 $80.64 $92.74 $91.34

53860 $1,799.07 $1,709.12 $1,965.49 $1,936.00

# 53860 $246.75 $234.41 $269.57 $265.52

54000 $159.82 $151.83 $174.60 $171.98

# 54000 $114.23 $108.52 $124.80 $122.92

54001 $198.62 $188.69 $216.99 $213.74

# 54001 $146.14 $138.83 $159.65 $157.26

54015 $322.18 $306.07 $351.98 $346.70

54050 $146.27 $138.96 $159.80 $157.41

# 54050 $114.86 $109.12 $125.49 $123.60

54055 $130.38 $123.86 $142.44 $140.30

# 54055 $100.12 $95.11 $109.38 $107.73

54056 $159.24 $151.28 $173.97 $171.36

# 54056 $122.85 $116.71 $134.22 $132.20

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

54057 $148.30 $140.89 $162.02 $159.60

# 54057 $101.18 $96.12 $110.54 $108.88

54060 $194.21 $184.50 $212.18 $208.99

# 54060 $138.28 $131.37 $151.08 $148.81

54065 $240.87 $228.83 $263.15 $259.21

# 54065 $187.62 $178.24 $204.98 $201.91

54100 $218.58 $207.65 $238.80 $235.22

# 54100 $135.83 $129.04 $148.40 $146.17

54105 $279.84 $265.85 $305.73 $301.14

# 54105 $221.99 $210.89 $242.52 $238.89

54110 $649.94 $617.44 $710.06 $699.41

54111 $830.35 $788.83 $907.15 $893.55

54112 $971.51 $922.93 $1,061.37 $1,045.45

54115 $475.95 $452.15 $519.97 $512.18

# 54115 $444.92 $422.67 $486.07 $478.78

54120 $658.35 $625.43 $719.24 $708.46

54125 $844.57 $802.34 $922.69 $908.85

54130 $1,235.53 $1,173.75 $1,349.81 $1,329.56

54135 $1,562.13 $1,484.02 $1,706.62 $1,681.02

54150 $166.89 $158.55 $182.33 $179.60

# 54150 $101.76 $96.67 $111.17 $109.50

54160 $236.25 $224.44 $258.11 $254.23

# 54160 $149.67 $142.19 $163.52 $161.07

54161 $206.34 $196.02 $225.42 $222.04

54162 $275.32 $261.55 $300.78 $296.27

# 54162 $209.04 $198.59 $228.38 $224.95

54163 $230.88 $219.34 $252.24 $248.46

54164 $205.58 $195.30 $224.60 $221.23

54200 $116.44 $110.62 $127.21 $125.30

# 54200 $89.62 $85.14 $97.91 $96.44

54205 $556.32 $528.50 $607.78 $598.66

54220 $218.58 $207.65 $238.80 $235.22

# 54220 $140.43 $133.41 $153.42 $151.12

54230 $102.15 $97.04 $111.60 $109.92

# 54230 $83.38 $79.21 $91.09 $89.72

54231 $148.08 $140.68 $161.78 $159.36

# 54231 $121.27 $115.21 $132.49 $130.50

54235 $96.20 $91.39 $105.10 $103.52

# 54235 $77.43 $73.56 $84.59 $83.33

54240 $106.55 $101.22 $116.40 $114.66

54240 TC $40.58 $38.55 $44.33 $43.67

54240 26 $65.97 $62.67 $72.07 $70.99

54250 $124.59 $118.36 $136.11 $134.07

54250 TC $12.61 $11.98 $13.78 $13.57

54250 26 $111.98 $106.38 $122.34 $120.50

54300 $667.63 $634.25 $729.39 $718.45

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

54304 $779.21 $740.25 $851.29 $838.52

54308 $743.80 $706.61 $812.60 $800.41

54312 $850.34 $807.82 $928.99 $915.06

54316 $1,034.43 $982.71 $1,130.12 $1,113.17

54318 $728.21 $691.80 $795.57 $783.63

54322 $810.58 $770.05 $885.56 $872.28

54324 $1,003.79 $953.60 $1,096.64 $1,080.20

54326 $981.28 $932.22 $1,072.05 $1,055.98

54328 $974.52 $925.79 $1,064.66 $1,048.69

54332 $1,051.18 $998.62 $1,148.41 $1,131.19

54336 $1,290.39 $1,225.87 $1,409.75 $1,388.60

54340 $594.86 $565.12 $649.89 $640.14

54344 $983.43 $934.26 $1,074.40 $1,058.29

54348 $1,034.32 $982.60 $1,129.99 $1,113.04

54352 $1,466.12 $1,392.81 $1,601.73 $1,577.71

54360 $749.31 $711.84 $818.62 $806.33

54380 $962.70 $914.57 $1,051.76 $1,035.98

54385 $1,039.03 $987.08 $1,135.14 $1,118.11

54390 $1,343.47 $1,276.30 $1,467.75 $1,445.73

54400 $551.72 $524.13 $602.75 $593.71

54401 $690.44 $655.92 $754.31 $742.99

54405 $839.13 $797.17 $916.75 $902.99

54406 $759.23 $721.27 $829.46 $817.02

54408 $822.30 $781.19 $898.37 $884.89

54410 $893.69 $849.01 $976.36 $961.71

54411 $1,065.43 $1,012.16 $1,163.98 $1,146.53

54415 $552.81 $525.17 $603.95 $594.88

54416 $743.16 $706.00 $811.90 $799.72

54417 $933.45 $886.78 $1,019.80 $1,004.50

54420 $733.54 $696.86 $801.39 $789.37

54430 $667.78 $634.39 $729.55 $718.60

54435 $437.05 $415.20 $477.48 $470.32

54440 $1,120.89 $1,064.85 $1,224.58 $1,206.21

54450 $72.73 $69.09 $79.45 $78.26

# 54450 $58.93 $55.98 $64.38 $63.41

54500 $77.36 $73.49 $84.51 $83.25

54505 $219.87 $208.88 $240.21 $236.61

54512 $562.51 $534.38 $614.54 $605.31

54520 $344.48 $327.26 $376.35 $370.70

54522 $631.41 $599.84 $689.82 $679.47

54530 $530.15 $503.64 $579.19 $570.50

54535 $773.40 $734.73 $844.94 $832.27

54550 $514.00 $488.30 $561.55 $553.13

54560 $714.36 $678.64 $780.44 $768.73

54600 $473.32 $449.65 $517.10 $509.35

54620 $312.16 $296.55 $341.03 $335.92

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

54640 $507.48 $482.11 $554.43 $546.11

54650 $741.59 $704.51 $810.19 $798.03

54660 $375.28 $356.52 $410.00 $403.85

54670 $425.00 $403.75 $464.31 $457.34

54680 $817.65 $776.77 $893.29 $879.89

54690 $789.21 $749.75 $862.21 $849.28

54692 $847.94 $805.54 $926.37 $912.48

54700 $225.97 $214.67 $246.87 $243.17

54800 $134.05 $127.35 $146.45 $144.26

54830 $393.22 $373.56 $429.59 $423.15

54840 $337.17 $320.31 $368.36 $362.84

54860 $439.15 $417.19 $479.77 $472.57

54861 $590.30 $560.79 $644.91 $635.24

54865 $377.42 $358.55 $412.33 $406.15

54900 $819.16 $778.20 $894.93 $881.51

54901 $1,077.70 $1,023.82 $1,177.39 $1,159.73

55000 $125.91 $119.61 $137.55 $135.49

# 55000 $89.13 $84.67 $97.37 $95.91

55040 $357.73 $339.84 $390.82 $384.95

55041 $535.53 $508.75 $585.06 $576.29

55060 $401.81 $381.72 $438.98 $432.39

55100 $235.22 $223.46 $256.98 $253.13

# 55100 $178.52 $169.59 $195.03 $192.11

55110 $408.41 $387.99 $446.19 $439.50

55120 $379.76 $360.77 $414.89 $408.66

55150 $516.77 $490.93 $564.57 $556.11

55175 $382.70 $363.57 $418.11 $411.84

55180 $722.86 $686.72 $789.73 $777.88

55200 $473.28 $449.62 $517.06 $509.31

# 55200 $292.08 $277.48 $319.10 $314.32

55250 $421.49 $400.42 $460.48 $453.57

# 55250 $241.05 $229.00 $263.35 $259.41

55300 $193.82 $184.13 $211.75 $208.58

55400 $519.38 $493.41 $567.42 $558.91

55450 $384.12 $364.91 $419.65 $413.36

# 55450 $268.04 $254.64 $292.84 $288.44

55500 $422.81 $401.67 $461.92 $454.99

55520 $489.26 $464.80 $534.52 $526.50

55530 $371.55 $352.97 $405.92 $399.83

55535 $450.52 $427.99 $492.19 $484.81

55540 $578.38 $549.46 $631.88 $622.40

55550 $448.19 $425.78 $489.65 $482.30

55600 $441.61 $419.53 $482.46 $475.23

55605 $544.87 $517.63 $595.27 $586.35

55650 $747.53 $710.15 $816.67 $804.43

55680 $362.89 $344.75 $396.46 $390.52

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

55700 $234.10 $222.40 $255.76 $251.92

# 55700 $144.46 $137.24 $157.83 $155.46

55705 $277.66 $263.78 $303.35 $298.79

55706 $383.59 $364.41 $419.07 $412.78

55720 $471.47 $447.90 $515.09 $507.36

55725 $620.33 $589.31 $677.71 $667.54

55801 $1,133.80 $1,077.11 $1,238.68 $1,220.09

55810 $1,364.08 $1,295.88 $1,490.26 $1,467.91

55812 $1,663.55 $1,580.37 $1,817.43 $1,790.16

55815 $1,821.15 $1,730.09 $1,989.60 $1,959.76

55821 $906.75 $861.41 $990.62 $975.76

55831 $979.49 $930.52 $1,070.10 $1,054.04

55840 $1,384.13 $1,314.92 $1,512.16 $1,489.48

55842 $1,481.93 $1,407.83 $1,619.00 $1,594.72

55845 $1,688.75 $1,604.31 $1,844.96 $1,817.29

55860 $908.08 $862.68 $992.08 $977.20

55862 $1,135.60 $1,078.82 $1,240.64 $1,222.04

55865 $1,380.21 $1,311.20 $1,507.88 $1,485.26

55866 $1,796.80 $1,706.96 $1,963.00 $1,933.56

55870 $185.83 $176.54 $203.02 $199.97

# 55870 $147.90 $140.51 $161.59 $159.16

55873 $7,881.26 $7,487.20 $8,610.28 $8,481.12

# 55873 $795.47 $755.70 $869.06 $856.01

55875 $793.09 $753.44 $866.46 $853.46

55876 $144.70 $137.47 $158.09 $155.72

# 55876 $104.86 $99.62 $114.56 $112.85

55920 $461.92 $438.82 $504.64 $497.08

56405 $120.38 $114.36 $131.51 $129.54

# 56405 $119.62 $113.64 $130.69 $128.73

56420 $135.17 $128.41 $147.67 $145.45

# 56420 $99.55 $94.57 $108.76 $107.12

56440 $198.26 $188.35 $216.60 $213.35

56441 $155.95 $148.15 $170.37 $167.82

# 56441 $149.82 $142.33 $163.68 $161.23

56442 $52.43 $49.81 $57.28 $56.42

56501 $144.55 $137.32 $157.92 $155.55

# 56501 $126.16 $119.85 $137.83 $135.76

56515 $245.06 $232.81 $267.73 $263.72

# 56515 $216.33 $205.51 $236.34 $232.79

56605 $90.20 $85.69 $98.54 $97.06

# 56605 $64.53 $61.30 $70.50 $69.44

56606 $40.34 $38.32 $44.07 $43.41

# 56606 $31.14 $29.58 $34.02 $33.51

56620 $553.83 $526.14 $605.06 $595.99

56625 $658.96 $626.01 $719.91 $709.11

56630 $965.25 $916.99 $1,054.54 $1,038.73

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

56631 $1,223.55 $1,162.37 $1,336.73 $1,316.67

56632 $1,428.02 $1,356.62 $1,560.11 $1,536.71

56633 $1,252.79 $1,190.15 $1,368.67 $1,348.15

56634 $1,332.10 $1,265.50 $1,455.33 $1,433.50

56637 $1,548.92 $1,471.47 $1,692.19 $1,666.81

56640 $1,508.59 $1,433.16 $1,648.13 $1,623.41

56700 $204.22 $194.01 $223.11 $219.77

56740 $322.39 $306.27 $352.21 $346.93

56800 $259.26 $246.30 $283.25 $279.00

56805 $1,234.46 $1,172.74 $1,348.65 $1,328.42

56810 $280.06 $266.06 $305.97 $301.38

56820 $121.50 $115.43 $132.74 $130.76

# 56820 $92.00 $87.40 $100.51 $99.00

56821 $160.30 $152.29 $175.13 $172.51

# 56821 $122.76 $116.62 $134.11 $132.10

57000 $205.43 $195.16 $224.43 $221.06

57010 $472.70 $449.07 $516.43 $508.68

57020 $101.58 $96.50 $110.98 $109.31

# 57020 $87.40 $83.03 $95.48 $94.05

57022 $182.09 $172.99 $198.94 $195.96

57023 $336.15 $319.34 $367.24 $361.73

57061 $126.15 $119.84 $137.82 $135.75

# 57061 $108.15 $102.74 $118.15 $116.38

57065 $210.72 $200.18 $230.21 $226.76

# 57065 $186.58 $177.25 $203.84 $200.78

57100 $96.30 $91.49 $105.21 $103.64

# 57100 $70.63 $67.10 $77.17 $76.00

57105 $148.91 $141.46 $162.68 $160.24

# 57105 $137.41 $130.54 $150.12 $147.87

57106 $525.75 $499.46 $574.38 $565.77

57107 $1,514.44 $1,438.72 $1,654.53 $1,629.71

57109 $1,774.76 $1,686.02 $1,938.92 $1,909.84

57110 $965.80 $917.51 $1,055.14 $1,039.31

57111 $1,724.96 $1,638.71 $1,884.52 $1,856.25

57112 $1,748.84 $1,661.40 $1,910.61 $1,881.95

57120 $552.05 $524.45 $603.12 $594.07

57130 $194.27 $184.56 $212.24 $209.06

# 57130 $173.20 $164.54 $189.22 $186.38

57135 $209.04 $198.59 $228.38 $224.95

# 57135 $186.82 $177.48 $204.10 $201.04

57150 $49.92 $47.42 $54.53 $53.72

# 57150 $30.76 $29.22 $33.60 $33.10

57155 $479.71 $455.72 $524.08 $516.21

# 57155 $296.98 $282.13 $324.45 $319.59

57156 $208.12 $197.71 $227.37 $223.95

# 57156 $150.27 $142.76 $164.17 $161.71

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

57160 $84.55 $80.32 $92.37 $90.99

# 57160 $50.07 $47.57 $54.71 $53.89

57170 $65.70 $62.42 $71.78 $70.70

# 57170 $51.53 $48.95 $56.29 $55.45

57180 $156.25 $148.44 $170.71 $168.14

# 57180 $114.49 $108.77 $125.09 $123.21

57200 $325.89 $309.60 $356.04 $350.70

57210 $396.97 $377.12 $433.69 $427.18

57220 $348.24 $330.83 $380.45 $374.75

57230 $429.31 $407.84 $469.02 $461.98

57240 $712.96 $677.31 $778.91 $767.22

57250 $728.03 $691.63 $795.37 $783.45

57260 $894.35 $849.63 $977.07 $962.42

57265 $978.77 $929.83 $1,069.30 $1,053.26

57267 $270.97 $257.42 $296.03 $291.59

57268 $523.17 $497.01 $571.56 $562.98

57270 $859.42 $816.45 $938.92 $924.83

57280 $1,019.19 $968.23 $1,113.46 $1,096.77

57282 $540.46 $513.44 $590.46 $581.60

57283 $742.62 $705.49 $811.31 $799.15

57284 $869.95 $826.45 $950.42 $936.16

57285 $721.33 $685.26 $788.05 $776.23

57287 $723.85 $687.66 $790.81 $778.95

57288 $756.79 $718.95 $826.79 $814.40

57289 $758.05 $720.15 $828.17 $815.75

57291 $575.36 $546.59 $628.58 $619.15

57292 $880.56 $836.53 $962.01 $947.58

57295 $513.91 $488.21 $561.44 $553.02

57296 $1,021.92 $970.82 $1,116.44 $1,099.70

57300 $605.24 $574.98 $661.23 $651.31

57305 $1,000.84 $950.80 $1,093.42 $1,077.02

57307 $1,142.21 $1,085.10 $1,247.87 $1,229.14

57308 $693.14 $658.48 $757.25 $745.89

57310 $481.71 $457.62 $526.26 $518.37

57311 $546.96 $519.61 $597.55 $588.59

57320 $559.95 $531.95 $611.74 $602.57

57330 $767.20 $728.84 $838.17 $825.60

57335 $1,246.96 $1,184.61 $1,362.30 $1,341.87

57400 $142.93 $135.78 $156.15 $153.80

57410 $115.92 $110.12 $126.64 $124.74

57415 $172.44 $163.82 $188.39 $185.56

57420 $126.89 $120.55 $138.63 $136.55

# 57420 $96.62 $91.79 $105.56 $103.97

57421 $170.41 $161.89 $186.17 $183.38

# 57421 $131.72 $125.13 $143.90 $141.74

57423 $985.13 $935.87 $1,076.25 $1,060.10

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

57425 $1,038.58 $986.65 $1,134.65 $1,117.63

57426 $913.81 $868.12 $998.34 $983.37

57452 $118.87 $112.93 $129.87 $127.93

# 57452 $99.33 $94.36 $108.51 $106.88

57454 $166.47 $158.15 $181.87 $179.15

# 57454 $146.55 $139.22 $160.10 $157.70

57455 $156.33 $148.51 $170.79 $168.22

# 57455 $118.79 $112.85 $129.78 $127.83

57456 $147.69 $140.31 $161.36 $158.94

# 57456 $110.91 $105.36 $121.16 $119.35

57460 $317.65 $301.77 $347.04 $341.83

# 57460 $175.90 $167.11 $192.18 $189.29

57461 $357.34 $339.47 $390.39 $384.54

# 57461 $201.81 $191.72 $220.48 $217.17

57500 $143.80 $136.61 $157.10 $154.74

# 57500 $82.51 $78.38 $90.14 $88.78

57505 $113.19 $107.53 $123.66 $121.81

# 57505 $101.70 $96.62 $111.11 $109.45

57510 $143.30 $136.14 $156.56 $154.22

# 57510 $125.29 $119.03 $136.88 $134.83

57511 $159.92 $151.92 $174.71 $172.09

# 57511 $144.98 $137.73 $158.39 $156.01

57513 $158.01 $150.11 $172.63 $170.04

# 57513 $145.36 $138.09 $158.80 $156.42

57520 $334.36 $317.64 $365.29 $359.81

# 57520 $297.20 $282.34 $324.69 $319.82

57522 $288.57 $274.14 $315.26 $310.53

# 57522 $265.58 $252.30 $290.15 $285.80

57530 $374.90 $356.16 $409.58 $403.44

57531 $1,874.24 $1,780.53 $2,047.61 $2,016.89

57540 $840.53 $798.50 $918.28 $904.50

57545 $885.96 $841.66 $967.91 $953.40

57550 $444.05 $421.85 $485.13 $477.85

57555 $650.26 $617.75 $710.41 $699.75

57556 $609.98 $579.48 $666.40 $656.41

57558 $137.10 $130.25 $149.79 $147.55

# 57558 $124.08 $117.88 $135.56 $133.53

57700 $341.44 $324.37 $373.03 $367.43

57720 $335.42 $318.65 $366.45 $360.95

57800 $66.26 $62.95 $72.39 $71.31

# 57800 $52.47 $49.85 $57.33 $56.47

58100 $119.47 $113.50 $130.53 $128.57

# 58100 $94.57 $89.84 $103.32 $101.76

58110 $51.70 $49.12 $56.49 $55.64

# 58110 $43.66 $41.48 $47.70 $46.99

58120 $282.40 $268.28 $308.52 $303.90

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 58120 $236.04 $224.24 $257.88 $254.01

58140 $989.78 $940.29 $1,081.33 $1,065.12

58145 $588.87 $559.43 $643.34 $633.70

58146 $1,240.70 $1,178.67 $1,355.47 $1,335.14

58150 $1,075.14 $1,021.38 $1,174.59 $1,156.97

58152 $1,339.41 $1,272.44 $1,463.31 $1,441.35

58180 $1,030.94 $979.39 $1,126.30 $1,109.41

58200 $1,421.15 $1,350.09 $1,552.60 $1,529.32

58210 $1,904.33 $1,809.11 $2,080.48 $2,049.27

58240 $3,027.28 $2,875.92 $3,307.31 $3,257.70

58260 $891.44 $846.87 $973.90 $959.30

58262 $993.00 $943.35 $1,084.85 $1,068.58

58263 $1,065.55 $1,012.27 $1,164.11 $1,146.65

58267 $1,134.87 $1,078.13 $1,239.85 $1,221.25

58270 $948.11 $900.70 $1,035.81 $1,020.27

58275 $1,059.78 $1,006.79 $1,157.81 $1,140.44

58280 $1,134.32 $1,077.60 $1,239.24 $1,220.66

58285 $1,407.01 $1,336.66 $1,537.16 $1,514.10

58290 $1,231.40 $1,169.83 $1,345.30 $1,325.12

58291 $1,339.49 $1,272.52 $1,463.40 $1,441.44

58292 $1,411.72 $1,341.13 $1,542.30 $1,519.16

58293 $1,468.25 $1,394.84 $1,604.07 $1,580.01

58294 $1,310.09 $1,244.59 $1,431.28 $1,409.81

58301 $104.81 $99.57 $114.51 $112.79

# 58301 $72.63 $69.00 $79.35 $78.17

58321 $81.62 $77.54 $89.17 $87.84

# 58321 $48.68 $46.25 $53.19 $52.39

58322 $94.41 $89.69 $103.14 $101.59

# 58322 $62.62 $59.49 $68.41 $67.39

58323 $17.07 $16.22 $18.65 $18.38

# 58323 $13.24 $12.58 $14.47 $14.25

58340 $133.68 $127.00 $146.05 $143.87

# 58340 $62.80 $59.66 $68.61 $67.59

58345 $300.95 $285.90 $328.79 $323.85

58346 $461.24 $438.18 $503.91 $496.35

58350 $107.58 $102.20 $117.53 $115.77

# 58350 $86.89 $82.55 $94.93 $93.51

58353 $1,171.15 $1,112.59 $1,279.48 $1,260.29

# 58353 $237.54 $225.66 $259.51 $255.62

58356 $2,187.67 $2,078.29 $2,390.03 $2,354.19

# 58356 $369.87 $351.38 $404.09 $398.03

58400 $472.61 $448.98 $516.33 $508.59

58410 $866.45 $823.13 $946.60 $932.40

58520 $870.95 $827.40 $951.51 $937.24

58540 $978.99 $930.04 $1,069.55 $1,053.50

58541 $932.17 $885.56 $1,018.39 $1,003.12

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

58542 $1,040.66 $988.63 $1,136.92 $1,119.87

58543 $1,057.01 $1,004.16 $1,154.78 $1,137.47

58544 $1,144.41 $1,087.19 $1,250.27 $1,231.51

58545 $963.41 $915.24 $1,052.53 $1,036.74

58546 $1,210.47 $1,149.95 $1,322.44 $1,302.61

58548 $1,957.55 $1,859.67 $2,138.62 $2,106.54

58550 $951.53 $903.95 $1,039.54 $1,023.95

58552 $1,056.84 $1,004.00 $1,154.60 $1,137.28

58553 $1,219.59 $1,158.61 $1,332.40 $1,312.41

58554 $1,415.25 $1,344.49 $1,546.16 $1,522.97

58555 $337.10 $320.25 $368.29 $362.77

# 58555 $204.16 $193.95 $223.04 $219.70

58558 $437.90 $416.01 $478.41 $471.24

# 58558 $286.19 $271.88 $312.66 $307.97

58559 $367.78 $349.39 $401.80 $395.77

58560 $414.64 $393.91 $453.00 $446.20

58561 $585.69 $556.41 $639.87 $630.27

58562 $451.77 $429.18 $493.56 $486.15

# 58562 $310.79 $295.25 $339.54 $334.44

58563 $1,929.29 $1,832.83 $2,107.75 $2,076.14

# 58563 $367.39 $349.02 $401.37 $395.35

58565 $2,182.89 $2,073.75 $2,384.81 $2,349.04

# 58565 $470.05 $446.55 $513.53 $505.83

58570 $1,002.02 $951.92 $1,094.71 $1,078.29

58571 $1,118.03 $1,062.13 $1,221.45 $1,203.13

58572 $1,245.15 $1,182.89 $1,360.32 $1,339.92

58573 $1,428.77 $1,357.33 $1,560.93 $1,537.52

58600 $395.60 $375.82 $432.19 $425.71

58605 $357.21 $339.35 $390.25 $384.40

58611 $82.65 $78.52 $90.30 $88.94

58615 $264.51 $251.28 $288.97 $284.64

58660 $723.77 $687.58 $790.72 $778.86

58661 $690.83 $656.29 $754.73 $743.42

58662 $759.23 $721.27 $829.46 $817.02

58670 $396.36 $376.54 $433.02 $426.52

58671 $396.36 $376.54 $433.02 $426.52

58672 $791.07 $751.52 $864.25 $851.29

58673 $859.36 $816.39 $938.85 $924.76

58700 $838.95 $797.00 $916.55 $902.81

58720 $781.58 $742.50 $853.88 $841.06

58740 $946.28 $898.97 $1,033.82 $1,018.31

58750 $993.44 $943.77 $1,085.34 $1,069.05

58752 $911.10 $865.55 $995.38 $980.46

58760 $872.42 $828.80 $953.12 $938.83

58770 $917.69 $871.81 $1,002.58 $987.54

58800 $347.26 $329.90 $379.39 $373.69

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 58800 $324.27 $308.06 $354.27 $348.96

58805 $437.61 $415.73 $478.09 $470.91

58820 $340.79 $323.75 $372.31 $366.72

58822 $805.18 $764.92 $879.66 $866.47

58823 $1,024.35 $973.13 $1,119.10 $1,102.31

# 58823 $176.16 $167.35 $192.45 $189.57

58825 $749.33 $711.86 $818.64 $806.36

58900 $459.52 $436.54 $502.02 $494.49

58920 $754.77 $717.03 $824.58 $812.21

58925 $799.16 $759.20 $873.08 $859.98

58940 $564.03 $535.83 $616.20 $606.96

58943 $1,222.34 $1,161.22 $1,335.40 $1,315.37

58950 $1,174.32 $1,115.60 $1,282.94 $1,263.70

58951 $1,502.78 $1,427.64 $1,641.79 $1,617.16

58952 $1,697.29 $1,612.43 $1,854.29 $1,826.48

58953 $2,098.78 $1,993.84 $2,292.92 $2,258.52

58954 $2,273.31 $2,159.64 $2,483.59 $2,446.34

58956 $1,434.59 $1,362.86 $1,567.29 $1,543.78

58957 $1,645.40 $1,563.13 $1,797.60 $1,770.63

58958 $1,803.62 $1,713.44 $1,970.46 $1,940.90

58960 $1,009.05 $958.60 $1,102.39 $1,085.85

58970 $229.59 $218.11 $250.83 $247.07

# 58970 $204.31 $194.09 $223.20 $219.86

58976 $259.53 $246.55 $283.53 $279.28

# 58976 $219.30 $208.34 $239.59 $235.99

59000 $140.68 $133.65 $153.70 $151.40

# 59000 $87.81 $83.42 $95.93 $94.50

59001 $194.55 $184.82 $212.54 $209.36

59012 $219.44 $208.47 $239.74 $236.14

59015 $170.84 $162.30 $186.65 $183.85

# 59015 $143.26 $136.10 $156.52 $154.17

59020 $79.54 $75.56 $86.89 $85.59

59020 TC $40.20 $38.19 $43.92 $43.26

59020 26 $39.34 $37.37 $42.98 $42.33

59025 $53.30 $50.64 $58.24 $57.36

59025 TC $21.81 $20.72 $23.83 $23.47

59025 26 $31.49 $29.92 $34.41 $33.89

59030 $114.00 $108.30 $124.55 $122.68

59050 $54.72 $51.98 $59.78 $58.88

59051 $45.79 $43.50 $50.03 $49.28

59070 $452.93 $430.28 $494.82 $487.40

# 59070 $335.70 $318.92 $366.76 $361.26

59072 $561.45 $533.38 $613.39 $604.19

59074 $441.44 $419.37 $482.28 $475.04

# 59074 $334.55 $317.82 $365.49 $360.01

59076 $561.45 $533.38 $613.39 $604.19

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

59100 $907.45 $862.08 $991.39 $976.52

59120 $863.32 $820.15 $943.17 $929.03

59121 $863.43 $820.26 $943.30 $929.15

59130 $890.94 $846.39 $973.35 $958.74

59135 $878.54 $834.61 $959.80 $945.40

59136 $993.61 $943.93 $1,085.52 $1,069.24

59140 $392.16 $372.55 $428.43 $422.00

59150 $835.90 $794.11 $913.23 $899.53

59151 $811.42 $770.85 $886.48 $873.18

59160 $223.60 $212.42 $244.28 $240.61

# 59160 $187.59 $178.21 $204.94 $201.87

59200 $80.44 $76.42 $87.88 $86.56

# 59200 $48.65 $46.22 $53.15 $52.36

59300 $213.63 $202.95 $233.39 $229.90

# 59300 $161.14 $153.08 $176.04 $173.40

59320 $165.08 $156.83 $180.35 $177.65

59325 $231.80 $220.21 $253.24 $249.45

59350 $302.92 $287.77 $330.94 $325.97

59400 $2,281.99 $2,167.89 $2,493.07 $2,455.68

59409 $879.35 $835.38 $960.69 $946.28

59410 $1,122.54 $1,066.41 $1,226.37 $1,207.97

59412 $112.07 $106.47 $122.44 $120.60

59414 $98.72 $93.78 $107.85 $106.23

59425 $501.34 $476.27 $547.71 $539.50

# 59425 $384.49 $365.27 $420.06 $413.76

59426 $897.71 $852.82 $980.74 $966.03

# 59426 $677.81 $643.92 $740.51 $729.40

59430 $203.87 $193.68 $222.73 $219.39

# 59430 $150.23 $142.72 $164.13 $161.67

59510 $2,521.42 $2,395.35 $2,754.65 $2,713.33

59514 $989.43 $939.96 $1,080.95 $1,064.74

59515 $1,362.68 $1,294.55 $1,488.73 $1,466.40

59525 $522.89 $496.75 $571.26 $562.70

59610 $2,390.16 $2,270.65 $2,611.25 $2,572.08

59612 $986.76 $937.42 $1,078.03 $1,061.86

59614 $1,229.10 $1,167.65 $1,342.80 $1,322.66

59618 $2,554.88 $2,427.14 $2,791.21 $2,749.34

59620 $1,021.80 $970.71 $1,116.32 $1,099.57

59622 $1,399.96 $1,329.96 $1,529.45 $1,506.51

59812 $348.85 $331.41 $381.12 $375.41

# 59812 $322.03 $305.93 $351.82 $346.54

59820 $419.83 $398.84 $458.67 $451.79

# 59820 $392.63 $373.00 $428.95 $422.52

59821 $421.39 $400.32 $460.37 $453.47

# 59821 $391.90 $372.31 $428.16 $421.74

59830 $476.17 $452.36 $520.21 $512.41

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

59840 $236.82 $224.98 $258.73 $254.85

# 59840 $226.10 $214.80 $247.02 $243.32

59841 $417.45 $396.58 $456.07 $449.22

# 59841 $392.16 $372.55 $428.43 $422.00

59850 $367.79 $349.40 $401.81 $395.78

59851 $435.45 $413.68 $475.73 $468.59

59852 $539.41 $512.44 $589.31 $580.46

59855 $452.34 $429.72 $494.18 $486.76

59856 $529.18 $502.72 $578.13 $569.46

59857 $546.42 $519.10 $596.97 $588.01

59866 $228.60 $217.17 $249.75 $246.00

59870 $518.77 $492.83 $566.75 $558.26

59871 $145.86 $138.57 $159.36 $156.96

60000 $194.00 $184.30 $211.95 $208.77

# 60000 $172.55 $163.92 $188.51 $185.68

60100 $120.41 $114.39 $131.55 $129.57

# 60100 $82.10 $78.00 $89.70 $88.35

60200 $715.37 $679.60 $781.54 $769.82

60210 $762.90 $724.76 $833.47 $820.97

60212 $1,082.55 $1,028.42 $1,182.68 $1,164.94

60220 $763.02 $724.87 $833.60 $821.10

60225 $1,002.99 $952.84 $1,095.77 $1,079.33

60240 $985.35 $936.08 $1,076.49 $1,060.35

60252 $1,410.51 $1,339.98 $1,540.98 $1,517.86

60254 $1,782.33 $1,693.21 $1,947.19 $1,917.98

60260 $1,168.53 $1,110.10 $1,276.62 $1,257.47

60270 $1,463.88 $1,390.69 $1,599.29 $1,575.30

60271 $1,130.16 $1,073.65 $1,234.70 $1,216.18

60280 $486.73 $462.39 $531.75 $523.77

60281 $641.90 $609.81 $701.28 $690.76

60300 $131.85 $125.26 $144.05 $141.89

# 60300 $51.78 $49.19 $56.57 $55.72

60500 $1,034.70 $982.97 $1,130.42 $1,113.46

60502 $1,376.44 $1,307.62 $1,503.76 $1,481.21

60505 $1,495.55 $1,420.77 $1,633.89 $1,609.38

60512 $255.77 $242.98 $279.43 $275.24

60520 $1,109.08 $1,053.63 $1,211.67 $1,193.50

60521 $1,205.83 $1,145.54 $1,317.37 $1,297.61

60522 $1,467.56 $1,394.18 $1,603.31 $1,579.26

60540 $1,117.54 $1,061.66 $1,220.91 $1,202.60

60545 $1,281.96 $1,217.86 $1,400.54 $1,379.53

60600 $1,477.17 $1,403.31 $1,613.81 $1,589.60

60605 $1,952.43 $1,854.81 $2,133.03 $2,101.04

60650 $1,255.33 $1,192.56 $1,371.44 $1,350.87

61000 $126.52 $120.19 $138.22 $136.15

61001 $121.17 $115.11 $132.38 $130.39

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

61020 $153.36 $145.69 $167.54 $165.03

61026 $141.56 $134.48 $154.65 $152.33

61050 $116.87 $111.03 $127.68 $125.76

61055 $146.85 $139.51 $160.44 $158.03

61070 $95.49 $90.72 $104.33 $102.76

61105 $509.28 $483.82 $556.39 $548.04

61107 $333.17 $316.51 $363.99 $358.52

61108 $989.80 $940.31 $1,081.36 $1,065.14

61120 $813.55 $772.87 $888.80 $875.47

61140 $1,364.36 $1,296.14 $1,490.56 $1,468.21

61150 $1,456.92 $1,384.07 $1,591.68 $1,567.81

61151 $1,073.95 $1,020.25 $1,173.29 $1,155.69

61154 $1,375.69 $1,306.91 $1,502.95 $1,480.41

61156 $1,337.49 $1,270.62 $1,461.21 $1,439.29

61210 $389.49 $370.02 $425.52 $419.14

61215 $556.09 $528.29 $607.53 $598.43

61250 $939.44 $892.47 $1,026.34 $1,010.94

61253 $785.70 $746.42 $858.38 $845.50

61304 $1,759.98 $1,671.98 $1,922.78 $1,893.94

61305 $2,154.16 $2,046.45 $2,353.42 $2,318.11

61312 $2,226.59 $2,115.26 $2,432.55 $2,396.06

61313 $2,133.06 $2,026.41 $2,330.37 $2,295.41

61314 $1,962.54 $1,864.41 $2,144.07 $2,111.91

61315 $2,218.08 $2,107.18 $2,423.26 $2,386.91

61316 $92.91 $88.26 $101.50 $99.98

61320 $2,038.70 $1,936.77 $2,227.29 $2,193.88

61321 $2,281.12 $2,167.06 $2,492.12 $2,454.73

61322 $2,545.11 $2,417.85 $2,780.53 $2,738.82

61323 $2,547.03 $2,419.68 $2,782.63 $2,740.89

61330 $1,986.25 $1,886.94 $2,169.98 $2,137.44

61332 $2,018.74 $1,917.80 $2,205.47 $2,172.38

61333 $2,262.76 $2,149.62 $2,472.06 $2,434.99

61334 $1,284.43 $1,220.21 $1,403.24 $1,382.20

61340 $1,555.56 $1,477.78 $1,699.45 $1,673.95

61343 $2,353.09 $2,235.44 $2,570.76 $2,532.20

61345 $2,184.80 $2,075.56 $2,386.89 $2,351.09

61440 $1,939.55 $1,842.57 $2,118.96 $2,087.17

61450 $2,058.12 $1,955.21 $2,248.49 $2,214.76

61458 $2,151.99 $2,044.39 $2,351.05 $2,315.78

61460 $2,252.61 $2,139.98 $2,460.98 $2,424.06

61470 $1,837.02 $1,745.17 $2,006.95 $1,976.84

61480 $1,787.26 $1,697.90 $1,952.59 $1,923.29

61490 $2,027.26 $1,925.90 $2,214.79 $2,181.56

61500 $1,434.54 $1,362.81 $1,567.23 $1,543.73

61501 $1,237.39 $1,175.52 $1,351.85 $1,331.57

61510 $2,349.66 $2,232.18 $2,567.01 $2,528.51

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

61512 $2,729.63 $2,593.15 $2,982.12 $2,937.39

61514 $2,045.04 $1,942.79 $2,234.21 $2,200.70

61516 $1,990.10 $1,890.60 $2,174.19 $2,141.58

61517 $92.18 $87.57 $100.71 $99.20

61518 $2,958.35 $2,810.43 $3,231.99 $3,183.51

61519 $3,148.15 $2,990.74 $3,439.35 $3,387.76

61520 $3,986.67 $3,787.34 $4,355.44 $4,290.11

61521 $3,394.84 $3,225.10 $3,708.87 $3,653.23

61522 $2,339.76 $2,222.77 $2,556.19 $2,517.84

61524 $2,229.64 $2,118.16 $2,435.88 $2,399.35

61526 $3,889.25 $3,694.79 $4,249.01 $4,185.28

61530 $3,279.48 $3,115.51 $3,582.84 $3,529.10

61531 $1,321.54 $1,255.46 $1,443.78 $1,422.12

61533 $1,639.50 $1,557.53 $1,791.16 $1,764.30

61534 $1,768.39 $1,679.97 $1,931.97 $1,902.99

61535 $1,083.95 $1,029.75 $1,184.21 $1,166.45

61536 $2,753.66 $2,615.98 $3,008.38 $2,963.25

61537 $2,631.70 $2,500.12 $2,875.14 $2,832.01

61538 $2,845.32 $2,703.05 $3,108.51 $3,061.88

61539 $2,523.03 $2,396.88 $2,756.41 $2,715.07

61540 $2,336.05 $2,219.25 $2,552.14 $2,513.85

61541 $2,299.58 $2,184.60 $2,512.29 $2,474.60

61542 $2,194.08 $2,084.38 $2,397.04 $2,361.08

61543 $2,323.97 $2,207.77 $2,538.94 $2,500.85

61544 $1,820.93 $1,729.88 $1,989.36 $1,959.52

61545 $3,401.61 $3,231.53 $3,716.26 $3,660.52

61546 $2,466.36 $2,343.04 $2,694.50 $2,654.07

61548 $1,665.75 $1,582.46 $1,819.83 $1,792.53

61550 $1,010.12 $959.61 $1,103.55 $1,087.00

61552 $1,124.88 $1,068.64 $1,228.94 $1,210.50

61556 $1,828.56 $1,737.13 $1,997.70 $1,967.73

61557 $1,808.77 $1,718.33 $1,976.08 $1,946.44

61558 $1,700.76 $1,615.72 $1,858.08 $1,830.20

61559 $1,930.60 $1,834.07 $2,109.18 $2,077.54

61563 $2,119.82 $2,013.83 $2,315.90 $2,281.16

61564 $2,306.06 $2,190.76 $2,519.37 $2,481.59

61566 $2,404.20 $2,283.99 $2,626.59 $2,587.19

61567 $2,741.95 $2,604.85 $2,995.58 $2,950.65

61570 $2,002.60 $1,902.47 $2,187.84 $2,155.02

61571 $2,130.29 $2,023.78 $2,327.35 $2,292.43

61575 $2,675.83 $2,542.04 $2,923.35 $2,879.50

61576 $3,693.52 $3,508.84 $4,035.17 $3,974.64

61580 $2,701.55 $2,566.47 $2,951.44 $2,907.17

61581 $2,928.74 $2,782.30 $3,199.65 $3,151.66

61582 $3,361.52 $3,193.44 $3,672.46 $3,617.37

61583 $3,145.59 $2,988.31 $3,436.56 $3,385.01

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

61584 $3,097.39 $2,942.52 $3,383.90 $3,333.14

61585 $3,511.15 $3,335.59 $3,835.93 $3,778.39

61586 $2,707.65 $2,572.27 $2,958.11 $2,913.74

61590 $3,300.23 $3,135.22 $3,605.50 $3,551.42

61591 $3,344.64 $3,177.41 $3,654.02 $3,599.21

61592 $3,437.89 $3,266.00 $3,755.90 $3,699.56

61595 $2,574.02 $2,445.32 $2,812.12 $2,769.94

61596 $2,651.40 $2,518.83 $2,896.65 $2,853.21

61597 $3,114.17 $2,958.46 $3,402.23 $3,351.19

61598 $3,083.97 $2,929.77 $3,369.24 $3,318.69

61600 $2,328.63 $2,212.20 $2,544.03 $2,505.87

61601 $2,606.40 $2,476.08 $2,847.49 $2,804.78

61605 $2,365.13 $2,246.87 $2,583.90 $2,545.15

61606 $3,227.79 $3,066.40 $3,526.36 $3,473.46

61607 $3,098.75 $2,943.81 $3,385.38 $3,334.60

61608 $3,501.03 $3,325.98 $3,824.88 $3,767.50

61609 $658.29 $625.38 $719.19 $708.40

61610 $1,984.90 $1,885.66 $2,168.51 $2,135.99

61611 $390.82 $371.28 $426.97 $420.57

61612 $1,468.91 $1,395.46 $1,604.78 $1,580.71

61613 $3,539.36 $3,362.39 $3,866.75 $3,808.74

61615 $2,444.31 $2,322.09 $2,670.40 $2,630.35

61616 $3,584.46 $3,405.24 $3,916.03 $3,857.28

61618 $1,406.46 $1,336.14 $1,536.56 $1,513.52

61619 $1,580.81 $1,501.77 $1,727.04 $1,701.13

61623 $579.98 $550.98 $633.63 $624.13

61624 $1,155.14 $1,097.38 $1,261.99 $1,243.06

61626 $886.42 $842.10 $968.42 $953.89

61630 $1,339.75 $1,272.76 $1,463.67 $1,441.72

61635 $1,455.89 $1,383.10 $1,590.57 $1,566.70

61680 $2,423.66 $2,302.48 $2,647.85 $2,608.13

61682 $4,447.77 $4,225.38 $4,859.19 $4,786.30

61684 $3,036.53 $2,884.70 $3,317.41 $3,267.64

61686 $4,788.43 $4,549.01 $5,231.36 $5,152.89

61690 $2,341.41 $2,224.34 $2,557.99 $2,519.62

61692 $3,898.40 $3,703.48 $4,259.00 $4,195.12

61697 $4,496.74 $4,271.90 $4,912.69 $4,838.99

61698 $4,930.46 $4,683.94 $5,386.53 $5,305.73

61700 $3,643.29 $3,461.13 $3,980.30 $3,920.59

61702 $4,288.09 $4,073.69 $4,684.74 $4,614.47

61703 $1,462.72 $1,389.58 $1,598.02 $1,574.05

61705 $2,779.12 $2,640.16 $3,036.18 $2,990.64

61708 $2,316.96 $2,201.11 $2,531.28 $2,493.30

61710 $1,741.31 $1,654.24 $1,902.38 $1,873.84

61711 $2,787.74 $2,648.35 $3,045.60 $2,999.91

61720 $1,366.96 $1,298.61 $1,493.40 $1,471.00

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

61735 $1,707.05 $1,621.70 $1,864.96 $1,836.98

61750 $1,510.29 $1,434.78 $1,650.00 $1,625.25

61751 $1,482.43 $1,408.31 $1,619.56 $1,595.27

61760 $1,695.00 $1,610.25 $1,851.79 $1,824.02

61770 $1,734.99 $1,648.24 $1,895.48 $1,867.05

61781 $247.50 $235.13 $270.40 $266.34

61782 $202.31 $192.19 $221.02 $217.71

61783 $247.88 $235.49 $270.81 $266.75

61790 $944.17 $896.96 $1,031.50 $1,016.04

61791 $1,200.21 $1,140.20 $1,311.23 $1,291.57

61796 $1,082.18 $1,028.07 $1,182.28 $1,164.55

61797 $229.94 $218.44 $251.21 $247.43

61798 $1,471.26 $1,397.70 $1,607.36 $1,583.24

61799 $317.48 $301.61 $346.85 $341.65

61800 $162.73 $154.59 $177.78 $175.11

61850 $1,060.06 $1,007.06 $1,158.12 $1,140.74

61860 $1,677.57 $1,593.69 $1,832.74 $1,805.25

61863 $1,619.61 $1,538.63 $1,769.42 $1,742.88

61864 $300.56 $285.53 $328.36 $323.44

61867 $2,441.45 $2,319.38 $2,667.29 $2,627.28

61868 $528.99 $502.54 $577.92 $569.25

61870 $1,274.34 $1,210.62 $1,392.21 $1,371.33

61875 $1,025.97 $974.67 $1,120.87 $1,104.06

61880 $625.79 $594.50 $683.68 $673.42

61885 $571.47 $542.90 $624.34 $614.97

61886 $932.49 $885.87 $1,018.75 $1,003.47

61888 $424.83 $403.59 $464.13 $457.17

62000 $1,112.93 $1,057.28 $1,215.87 $1,197.63

62005 $1,367.30 $1,298.94 $1,493.78 $1,471.38

62010 $1,645.73 $1,563.44 $1,797.96 $1,770.99

62100 $1,713.43 $1,627.76 $1,871.92 $1,843.84

62115 $1,336.14 $1,269.33 $1,459.73 $1,437.83

62116 $1,903.27 $1,808.11 $2,079.33 $2,048.14

62117 $1,671.58 $1,588.00 $1,826.20 $1,798.81

62120 $1,822.74 $1,731.60 $1,991.34 $1,961.47

62121 $1,785.53 $1,696.25 $1,950.69 $1,921.43

62140 $1,119.09 $1,063.14 $1,222.61 $1,204.27

62141 $1,233.56 $1,171.88 $1,347.66 $1,327.45

62142 $961.32 $913.25 $1,050.24 $1,034.48

62143 $1,128.61 $1,072.18 $1,233.01 $1,214.52

62145 $1,523.89 $1,447.70 $1,664.86 $1,639.88

62146 $1,343.98 $1,276.78 $1,468.30 $1,446.27

62147 $1,563.43 $1,485.26 $1,708.05 $1,682.43

62148 $133.79 $127.10 $146.17 $143.97

62160 $200.84 $190.80 $219.42 $216.13

62161 $1,632.08 $1,550.48 $1,783.05 $1,756.30

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

62162 $2,026.96 $1,925.61 $2,214.45 $2,181.24

62163 $1,322.18 $1,256.07 $1,444.48 $1,422.81

62164 $2,243.63 $2,131.45 $2,451.17 $2,414.40

62165 $1,658.27 $1,575.36 $1,811.66 $1,784.49

62180 $1,718.24 $1,632.33 $1,877.18 $1,849.03

62190 $1,001.45 $951.38 $1,094.09 $1,077.68

62192 $1,053.60 $1,000.92 $1,151.06 $1,133.80

62194 $404.88 $384.64 $442.34 $435.70

62200 $1,478.86 $1,404.92 $1,615.66 $1,591.43

62201 $1,301.47 $1,236.40 $1,421.86 $1,400.53

62220 $1,113.20 $1,057.54 $1,216.17 $1,197.93

62223 $1,144.74 $1,087.50 $1,250.63 $1,231.87

62225 $578.27 $549.36 $631.76 $622.29

62230 $914.79 $869.05 $999.41 $984.41

62252 $96.27 $91.46 $105.18 $103.60

62252 TC $47.86 $45.47 $52.29 $51.51

62252 26 $48.41 $45.99 $52.89 $52.10

62256 $655.97 $623.17 $716.65 $705.89

62258 $1,214.46 $1,153.74 $1,326.80 $1,306.89

62263 $797.04 $757.19 $870.77 $857.70

# 62263 $384.44 $365.22 $420.00 $413.70

62264 $482.04 $457.94 $526.63 $518.73

# 62264 $256.01 $243.21 $279.69 $275.49

62267 $268.88 $255.44 $293.76 $289.35

# 62267 $166.98 $158.63 $182.42 $179.69

62268 $278.76 $264.82 $304.54 $299.98

62269 $279.76 $265.77 $305.64 $301.05

62270 $178.74 $169.80 $195.27 $192.34

# 62270 $83.35 $79.18 $91.06 $89.69

62272 $231.02 $219.47 $252.39 $248.61

# 62272 $90.43 $85.91 $98.80 $97.31

62273 $192.90 $183.26 $210.75 $207.59

# 62273 $121.26 $115.20 $132.48 $130.49

62280 $378.07 $359.17 $413.05 $406.85

# 62280 $189.20 $179.74 $206.70 $203.60

62281 $272.10 $258.50 $297.28 $292.81

# 62281 $171.73 $163.14 $187.61 $184.79

62282 $322.64 $306.51 $352.49 $347.20

# 62282 $155.99 $148.19 $170.42 $167.87

62284 $214.67 $203.94 $234.53 $231.01

# 62284 $90.16 $85.65 $98.50 $97.03

62287 $607.94 $577.54 $664.17 $654.21

62290 $381.13 $362.07 $416.38 $410.14

# 62290 $186.90 $177.56 $204.19 $201.14

62291 $358.55 $340.62 $391.71 $385.84

# 62291 $179.64 $170.66 $196.26 $193.32

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

62292 $643.01 $610.86 $702.49 $691.96

62294 $730.05 $693.55 $797.58 $785.62

62310 $277.76 $263.87 $303.45 $298.90

# 62310 $117.24 $111.38 $128.09 $126.17

62311 $234.37 $222.65 $256.05 $252.21

# 62311 $95.69 $90.91 $104.55 $102.98

62318 $267.72 $254.33 $292.48 $288.10

# 62318 $106.05 $100.75 $115.86 $114.13

62319 $190.94 $181.39 $208.60 $205.47

# 62319 $102.83 $97.69 $112.34 $110.65

62350 $436.36 $414.54 $476.72 $469.57

62351 $956.55 $908.72 $1,045.03 $1,029.35

62355 $287.93 $273.53 $314.56 $309.84

62360 $339.18 $322.22 $370.55 $365.00

62361 $357.20 $339.34 $390.24 $384.39

62362 $422.07 $400.97 $461.12 $454.20

62365 $321.05 $305.00 $350.75 $345.49

62367 $46.42 $44.10 $50.72 $49.96

# 62367 $26.88 $25.54 $29.37 $28.93

62368 $62.24 $59.13 $68.00 $66.98

# 62368 $36.57 $34.74 $39.95 $39.35

62369 $142.69 $135.56 $155.89 $153.56

# 62369 $36.57 $34.74 $39.95 $39.35

62370 $147.94 $140.54 $161.62 $159.19

# 62370 $49.49 $47.02 $54.07 $53.26

63001 $1,332.36 $1,265.74 $1,455.60 $1,433.76

63003 $1,332.06 $1,265.46 $1,455.28 $1,433.45

63005 $1,273.90 $1,210.21 $1,391.74 $1,370.87

63011 $1,177.18 $1,118.32 $1,286.07 $1,266.78

63012 $1,285.75 $1,221.46 $1,404.68 $1,383.61

63015 $1,599.11 $1,519.15 $1,747.02 $1,720.81

63016 $1,627.33 $1,545.96 $1,777.85 $1,751.19

63017 $1,353.61 $1,285.93 $1,478.82 $1,456.64

63020 $1,263.67 $1,200.49 $1,380.56 $1,359.85

63030 $1,046.34 $994.02 $1,143.12 $1,125.98

63035 $203.16 $193.00 $221.95 $218.63

63040 $1,507.69 $1,432.31 $1,647.16 $1,622.45

63042 $1,401.63 $1,331.55 $1,531.28 $1,508.32

63043 $323.61 $307.43 $353.54 $348.24

63044 $325.53 $309.25 $355.64 $350.30

63045 $1,372.80 $1,304.16 $1,499.78 $1,477.29

63046 $1,305.67 $1,240.39 $1,426.45 $1,405.05

63047 $1,193.33 $1,133.66 $1,303.71 $1,284.16

63048 $225.41 $214.14 $246.26 $242.57

63050 $1,670.26 $1,586.75 $1,824.76 $1,797.39

63051 $1,839.66 $1,747.68 $2,009.83 $1,979.68

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

63055 $1,745.51 $1,658.23 $1,906.96 $1,878.36

63056 $1,591.63 $1,512.05 $1,738.86 $1,712.78

63057 $340.64 $323.61 $372.15 $366.57

63064 $1,894.16 $1,799.45 $2,069.37 $2,038.33

63066 $218.44 $207.52 $238.65 $235.07

63075 $1,474.65 $1,400.92 $1,611.06 $1,586.90

63076 $264.47 $251.25 $288.94 $284.60

63077 $1,587.72 $1,508.33 $1,734.58 $1,708.57

63078 $203.82 $193.63 $222.67 $219.34

63081 $1,899.35 $1,804.38 $2,075.04 $2,043.91

63082 $284.23 $270.02 $310.52 $305.87

63085 $2,021.29 $1,920.23 $2,208.26 $2,175.14

63086 $200.74 $190.70 $219.31 $216.02

63087 $2,548.01 $2,420.61 $2,783.70 $2,741.95

63088 $272.42 $258.80 $297.62 $293.16

63090 $2,101.21 $1,996.15 $2,295.57 $2,261.14

63091 $188.43 $179.01 $205.86 $202.77

63101 $2,485.37 $2,361.10 $2,715.27 $2,674.53

63102 $2,398.64 $2,278.71 $2,620.52 $2,581.21

63103 $308.31 $292.89 $336.82 $331.78

63170 $1,713.02 $1,627.37 $1,871.48 $1,843.40

63172 $1,510.49 $1,434.97 $1,650.22 $1,625.47

63173 $1,853.96 $1,761.26 $2,025.45 $1,995.07

63180 $1,599.67 $1,519.69 $1,747.64 $1,721.42

63182 $1,753.55 $1,665.87 $1,915.75 $1,887.01

63185 $1,284.78 $1,220.54 $1,403.62 $1,382.56

63190 $1,349.65 $1,282.17 $1,474.50 $1,452.38

63191 $1,377.11 $1,308.25 $1,504.49 $1,481.92

63194 $1,325.33 $1,259.06 $1,447.92 $1,426.20

63195 $1,650.51 $1,567.98 $1,803.18 $1,776.13

63196 $1,437.54 $1,365.66 $1,570.51 $1,546.96

63197 $1,838.55 $1,746.62 $2,008.61 $1,978.48

63198 $1,691.36 $1,606.79 $1,847.81 $1,820.09

63199 $2,024.10 $1,922.90 $2,211.34 $2,178.17

63200 $1,652.51 $1,569.88 $1,805.36 $1,778.28

63250 $3,165.05 $3,006.80 $3,457.82 $3,405.96

63251 $3,237.73 $3,075.84 $3,537.22 $3,484.16

63252 $3,237.38 $3,075.51 $3,536.84 $3,483.79

63265 $1,797.41 $1,707.54 $1,963.67 $1,934.22

63266 $1,849.77 $1,757.28 $2,020.87 $1,990.56

63267 $1,485.50 $1,411.23 $1,622.91 $1,598.57

63268 $1,568.25 $1,489.84 $1,713.32 $1,687.61

63270 $2,223.53 $2,112.35 $2,429.20 $2,392.76

63271 $2,212.76 $2,102.12 $2,417.44 $2,381.18

63272 $2,048.21 $1,945.80 $2,237.67 $2,204.10

63273 $2,000.09 $1,900.09 $2,185.10 $2,152.33

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

63275 $1,934.04 $1,837.34 $2,112.94 $2,081.25

63276 $1,917.71 $1,821.82 $2,095.09 $2,063.66

63277 $1,672.56 $1,588.93 $1,827.27 $1,799.87

63278 $1,709.21 $1,623.75 $1,867.31 $1,839.30

63280 $2,270.49 $2,156.97 $2,480.52 $2,443.31

63281 $2,245.95 $2,133.65 $2,453.70 $2,416.90

63282 $2,117.36 $2,011.49 $2,313.21 $2,278.52

63283 $2,039.77 $1,937.78 $2,228.45 $2,195.02

63285 $2,796.21 $2,656.40 $3,054.86 $3,009.03

63286 $2,749.59 $2,612.11 $3,003.93 $2,958.87

63287 $2,932.49 $2,785.87 $3,203.75 $3,155.69

63290 $2,982.00 $2,832.90 $3,257.84 $3,208.97

63295 $351.50 $333.93 $384.02 $378.26

63300 $1,967.08 $1,868.73 $2,149.04 $2,116.81

63301 $2,287.88 $2,173.49 $2,499.51 $2,462.02

63302 $2,333.52 $2,216.84 $2,549.37 $2,511.13

63303 $2,473.90 $2,350.21 $2,702.74 $2,662.20

63304 $2,514.29 $2,388.58 $2,746.87 $2,705.66

63305 $2,427.88 $2,306.49 $2,652.46 $2,612.67

63306 $2,275.08 $2,161.33 $2,485.53 $2,448.25

63307 $2,572.76 $2,444.12 $2,810.74 $2,768.58

63308 $339.75 $322.76 $371.17 $365.61

63600 $995.54 $945.76 $1,087.62 $1,071.31

63610 $463.85 $440.66 $506.76 $499.16

63615 $1,329.28 $1,262.82 $1,452.24 $1,430.46

63620 $1,191.13 $1,131.57 $1,301.31 $1,281.79

63621 $263.65 $250.47 $288.04 $283.72

63650 $466.89 $443.55 $510.08 $502.44

63655 $900.12 $855.11 $983.38 $968.62

63661 $654.92 $622.17 $715.50 $704.77

# 63661 $348.05 $330.65 $380.25 $374.54

63662 $843.31 $801.14 $921.31 $907.49

63663 $917.48 $871.61 $1,002.35 $987.32

# 63663 $502.97 $477.82 $549.49 $541.25

63664 $862.35 $819.23 $942.11 $927.98

63685 $396.45 $376.63 $433.12 $426.63

63688 $400.84 $380.80 $437.92 $431.35

63700 $1,355.43 $1,287.66 $1,480.81 $1,458.60

63702 $1,533.11 $1,456.45 $1,674.92 $1,649.79

63704 $1,779.11 $1,690.15 $1,943.67 $1,914.52

63706 $1,975.64 $1,876.86 $2,158.39 $2,126.02

63707 $991.41 $941.84 $1,083.12 $1,066.87

63709 $1,190.94 $1,131.39 $1,301.10 $1,281.58

63710 $1,190.45 $1,130.93 $1,300.57 $1,281.07

63740 $1,031.91 $980.31 $1,127.36 $1,110.45

63741 $700.00 $665.00 $764.75 $753.28

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

63744 $743.83 $706.64 $812.64 $800.45

63746 $656.91 $624.06 $717.67 $706.91

64400 $137.67 $130.79 $150.41 $148.15

# 64400 $74.46 $70.74 $81.35 $80.13

64402 $135.64 $128.86 $148.19 $145.97

# 64402 $81.24 $77.18 $88.76 $87.42

64405 $112.96 $107.31 $123.41 $121.56

# 64405 $68.14 $64.73 $74.44 $73.32

64408 $108.69 $103.26 $118.75 $116.97

# 64408 $78.04 $74.14 $85.26 $83.98

64410 $141.86 $134.77 $154.99 $152.66

# 64410 $79.80 $75.81 $87.18 $85.87

64412 $156.52 $148.69 $170.99 $168.43

# 64412 $77.98 $74.08 $85.19 $83.92

64413 $139.26 $132.30 $152.15 $149.87

# 64413 $86.77 $82.43 $94.79 $93.37

64415 $130.79 $124.25 $142.89 $140.75

# 64415 $66.82 $63.48 $73.00 $71.91

64416 $81.26 $77.20 $88.78 $87.45

64417 $143.58 $136.40 $156.86 $154.50

# 64417 $73.85 $70.16 $80.68 $79.48

64418 $158.54 $150.61 $173.20 $170.60

# 64418 $80.38 $76.36 $87.81 $86.49

64420 $127.62 $121.24 $139.43 $137.33

# 64420 $74.37 $70.65 $81.25 $80.03

64421 $172.74 $164.10 $188.72 $185.89

# 64421 $101.48 $96.41 $110.87 $109.20

64425 $149.12 $141.66 $162.91 $160.47

# 64425 $101.61 $96.53 $111.01 $109.34

64430 $151.85 $144.26 $165.90 $163.42

# 64430 $86.73 $82.39 $94.75 $93.32

64435 $150.85 $143.31 $164.81 $162.33

# 64435 $89.93 $85.43 $98.24 $96.77

64445 $150.96 $143.41 $164.92 $162.45

# 64445 $75.49 $71.72 $82.48 $81.24

64446 $81.64 $77.56 $89.19 $87.86

64447 $131.10 $124.55 $143.23 $141.08

# 64447 $67.51 $64.13 $73.75 $72.65

64448 $73.15 $69.49 $79.91 $78.72

64449 $85.86 $81.57 $93.81 $92.40

64450 $88.72 $84.28 $96.92 $95.47

# 64450 $48.11 $45.70 $52.56 $51.76

64455 $51.50 $48.93 $56.27 $55.43

# 64455 $36.56 $34.73 $39.94 $39.34

64479 $271.89 $258.30 $297.05 $292.59

# 64479 $145.08 $137.83 $158.50 $156.12

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

64480 $128.15 $121.74 $140.00 $137.90

# 64480 $69.54 $66.06 $75.97 $74.83

64483 $255.58 $242.80 $279.22 $275.03

# 64483 $122.64 $116.51 $133.99 $131.97

64484 $98.88 $93.94 $108.03 $106.41

# 64484 $55.59 $52.81 $60.73 $59.82

64490 $221.27 $210.21 $241.74 $238.12

# 64490 $117.45 $111.58 $128.32 $126.40

64491 $105.89 $100.60 $115.69 $113.95

# 64491 $64.89 $61.65 $70.90 $69.84

64492 $106.27 $100.96 $116.10 $114.37

# 64492 $65.66 $62.38 $71.74 $70.66

64493 $200.67 $190.64 $219.24 $215.95

# 64493 $99.54 $94.56 $108.74 $107.11

64494 $97.35 $92.48 $106.35 $104.75

# 64494 $55.20 $52.44 $60.31 $59.40

64495 $97.73 $92.84 $106.77 $105.17

# 64495 $55.97 $53.17 $61.15 $60.23

64505 $113.24 $107.58 $123.72 $121.87

# 64505 $92.94 $88.29 $101.53 $100.02

64508 $69.28 $65.82 $75.69 $74.55

# 64508 $83.83 $79.64 $91.59 $90.22

64510 $145.16 $137.90 $158.59 $156.20

# 64510 $80.03 $76.03 $87.43 $86.12

64517 $200.43 $190.41 $218.97 $215.68

# 64517 $131.48 $124.91 $143.65 $141.50

64520 $214.39 $203.67 $234.22 $230.70

# 64520 $86.82 $82.48 $94.85 $93.43

64530 $221.15 $210.09 $241.60 $237.98

# 64530 $101.24 $96.18 $110.61 $108.95

64550 $17.34 $16.47 $18.94 $18.65

# 64550 $9.29 $8.83 $10.15 $10.01

64553 $254.86 $242.12 $278.44 $274.26

# 64553 $183.22 $174.06 $200.17 $197.17

64555 $220.47 $209.45 $240.87 $237.26

# 64555 $159.94 $151.94 $174.73 $172.11

64561 $888.30 $843.89 $970.47 $955.91

# 64561 $417.85 $396.96 $456.50 $449.66

64565 $198.60 $188.67 $216.97 $213.72

# 64565 $138.07 $131.17 $150.85 $148.58

64566 $137.17 $130.31 $149.86 $147.61

# 64566 $31.05 $29.50 $33.93 $33.42

64568 $663.94 $630.74 $725.35 $714.47

64569 $840.40 $798.38 $918.14 $904.36

64570 $742.68 $705.55 $811.38 $799.22

64575 $342.73 $325.59 $374.43 $368.82

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

64580 $331.99 $315.39 $362.70 $357.26

64581 $697.96 $663.06 $762.52 $751.08

64585 $277.13 $263.27 $302.76 $298.22

# 64585 $156.45 $148.63 $170.92 $168.36

64590 $291.56 $276.98 $318.53 $313.75

# 64590 $171.27 $162.71 $187.12 $184.31

64595 $278.44 $264.52 $304.20 $299.63

# 64595 $137.08 $130.23 $149.76 $147.52

64600 $440.81 $418.77 $481.59 $474.36

# 64600 $233.94 $222.24 $255.58 $251.75

64605 $610.33 $579.81 $666.78 $656.78

# 64605 $360.55 $342.52 $393.90 $387.99

64610 $823.05 $781.90 $899.19 $885.70

# 64610 $519.25 $493.29 $567.28 $558.77

64611 $124.63 $118.40 $136.16 $134.11

# 64611 $107.77 $102.38 $117.74 $115.97

64612 $151.15 $143.59 $165.13 $162.66

# 64612 $134.29 $127.58 $146.72 $144.52

64613 $188.49 $179.07 $205.93 $202.84

# 64613 $171.25 $162.69 $187.09 $184.29

64614 $202.84 $192.70 $221.61 $218.28

# 64614 $178.70 $169.77 $195.24 $192.30

64615 $153.79 $146.10 $168.02 $165.50

# 64615 $137.70 $130.82 $150.44 $148.19

64620 $228.70 $217.27 $249.86 $246.11

# 64620 $189.24 $179.78 $206.75 $203.64

64630 $228.37 $216.95 $249.49 $245.76

# 64630 $190.83 $181.29 $208.48 $205.36

64632 $92.25 $87.64 $100.79 $99.28

# 64632 $73.10 $69.45 $79.87 $78.67

64633 $454.29 $431.58 $496.32 $488.88

# 64633 $235.54 $223.76 $257.32 $253.46

64634 $207.22 $196.86 $226.39 $223.00

# 64634 $70.07 $66.57 $76.56 $75.41

64635 $446.10 $423.80 $487.37 $480.06

# 64635 $231.95 $220.35 $253.40 $249.60

64636 $186.77 $177.43 $204.04 $200.99

# 64636 $61.50 $58.43 $67.19 $66.18

64640 $151.22 $143.66 $165.21 $162.74

# 64640 $103.34 $98.17 $112.90 $111.21

64650 $140.86 $133.82 $153.89 $151.58

# 64650 $43.55 $41.37 $47.58 $46.86

64653 $169.36 $160.89 $185.02 $182.25

# 64653 $56.34 $53.52 $61.55 $60.63

64680 $357.41 $339.54 $390.47 $384.62

# 64680 $182.72 $173.58 $199.62 $196.63

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

64681 $404.40 $384.18 $441.81 $435.18

# 64681 $210.93 $200.38 $230.44 $226.98

64702 $546.68 $519.35 $597.25 $588.29

64704 $342.64 $325.51 $374.34 $368.72

64708 $543.75 $516.56 $594.04 $585.13

64712 $614.18 $583.47 $670.99 $660.93

64713 $793.34 $753.67 $866.72 $853.71

64714 $685.49 $651.22 $748.90 $737.67

64716 $586.79 $557.45 $641.07 $631.45

64718 $648.84 $616.40 $708.86 $698.22

64719 $434.80 $413.06 $475.02 $467.89

64721 $470.68 $447.15 $514.22 $506.51

# 64721 $467.61 $444.23 $510.86 $503.21

64722 $396.51 $376.68 $433.18 $426.68

64726 $294.36 $279.64 $321.59 $316.77

64727 $194.15 $184.44 $212.11 $208.92

64732 $487.17 $462.81 $532.23 $524.25

64734 $422.23 $401.12 $461.29 $454.37

64736 $468.80 $445.36 $512.16 $504.48

64738 $539.54 $512.56 $589.44 $580.60

64740 $503.10 $477.95 $549.64 $541.40

64742 $547.78 $520.39 $598.45 $589.47

64744 $542.08 $514.98 $592.23 $583.35

64746 $468.43 $445.01 $511.76 $504.08

64752 $530.31 $503.79 $579.36 $570.66

64755 $976.74 $927.90 $1,067.09 $1,051.08

64760 $554.21 $526.50 $605.48 $596.39

64761 $501.13 $476.07 $547.48 $539.27

64763 $604.12 $573.91 $660.00 $650.10

64766 $634.08 $602.38 $692.74 $682.34

64771 $625.01 $593.76 $682.82 $672.58

64772 $626.32 $595.00 $684.25 $673.99

64774 $456.03 $433.23 $498.21 $490.74

64776 $419.01 $398.06 $457.77 $450.90

64778 $160.37 $152.35 $175.20 $172.57

64782 $485.19 $460.93 $530.07 $522.12

64783 $228.77 $217.33 $249.93 $246.18

64784 $796.30 $756.49 $869.96 $856.91

64786 $1,158.64 $1,100.71 $1,265.82 $1,246.83

64787 $257.10 $244.25 $280.89 $276.68

64788 $438.02 $416.12 $478.54 $471.36

64790 $888.94 $844.49 $971.16 $956.59

64792 $1,286.13 $1,221.82 $1,405.09 $1,384.01

64795 $208.04 $197.64 $227.29 $223.88

64802 $551.82 $524.23 $602.86 $593.83

64804 $910.44 $864.92 $994.66 $979.74

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

64809 $756.78 $718.94 $826.78 $814.38

64818 $683.59 $649.41 $746.82 $735.62

64820 $807.23 $766.87 $881.90 $868.68

64821 $756.15 $718.34 $826.09 $813.69

64822 $756.15 $718.34 $826.09 $813.69

64823 $859.49 $816.52 $939.00 $924.91

64831 $743.16 $706.00 $811.90 $799.72

64832 $357.83 $339.94 $390.93 $385.07

64834 $800.25 $760.24 $874.28 $861.17

64835 $876.17 $832.36 $957.21 $942.85

64836 $898.78 $853.84 $981.92 $967.18

64837 $395.45 $375.68 $432.03 $425.55

64840 $1,000.08 $950.08 $1,092.59 $1,076.20

64856 $1,090.32 $1,035.80 $1,191.17 $1,173.30

64857 $1,131.50 $1,074.93 $1,236.17 $1,217.63

64858 $1,301.23 $1,236.17 $1,421.60 $1,400.27

64859 $273.30 $259.64 $298.59 $294.11

64861 $1,397.38 $1,327.51 $1,526.64 $1,503.74

64862 $1,463.39 $1,390.22 $1,598.75 $1,574.78

64864 $945.76 $898.47 $1,033.24 $1,017.74

64865 $1,216.07 $1,155.27 $1,328.56 $1,308.63

64866 $1,260.21 $1,197.20 $1,376.78 $1,356.13

64868 $1,112.64 $1,057.01 $1,215.56 $1,197.32

64870 $1,173.03 $1,114.38 $1,281.54 $1,262.31

64872 $123.19 $117.03 $134.58 $132.56

64874 $188.70 $179.27 $206.16 $203.07

64876 $192.28 $182.67 $210.07 $206.92

64885 $1,223.12 $1,161.96 $1,336.25 $1,316.21

64886 $1,399.71 $1,329.72 $1,529.18 $1,506.24

64890 $1,157.55 $1,099.67 $1,264.62 $1,245.65

64891 $1,274.39 $1,210.67 $1,392.27 $1,371.39

64892 $1,164.15 $1,105.94 $1,271.83 $1,252.75

64893 $1,202.39 $1,142.27 $1,313.61 $1,293.91

64895 $1,450.80 $1,378.26 $1,585.00 $1,561.23

64896 $1,588.89 $1,509.45 $1,735.87 $1,709.83

64897 $1,386.36 $1,317.04 $1,514.60 $1,491.87

64898 $1,525.37 $1,449.10 $1,666.47 $1,641.46

64901 $672.15 $638.54 $734.32 $723.30

64902 $718.02 $682.12 $784.44 $772.67

64905 $1,121.97 $1,065.87 $1,225.75 $1,207.36

64907 $1,340.08 $1,273.08 $1,464.04 $1,442.08

64910 $889.41 $844.94 $971.68 $957.11

64911 $1,115.73 $1,059.94 $1,218.93 $1,200.65

65091 $728.25 $691.84 $795.62 $783.68

65093 $719.98 $683.98 $786.58 $774.78

65101 $846.22 $803.91 $924.50 $910.63

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

65103 $882.68 $838.55 $964.33 $949.87

65105 $971.68 $923.10 $1,061.57 $1,045.64

65110 $1,354.34 $1,286.62 $1,479.61 $1,457.42

65112 $1,568.21 $1,489.80 $1,713.27 $1,687.57

65114 $1,643.35 $1,561.18 $1,795.36 $1,768.42

65125 $531.70 $505.12 $580.89 $572.17

# 65125 $335.94 $319.14 $367.01 $361.50

65130 $838.07 $796.17 $915.60 $901.86

65135 $849.63 $807.15 $928.22 $914.30

65140 $901.44 $856.37 $984.83 $970.05

65150 $633.57 $601.89 $692.17 $681.79

65155 $966.81 $918.47 $1,056.24 $1,040.39

65175 $734.46 $697.74 $802.40 $790.36

65205 $62.31 $59.19 $68.07 $67.05

# 65205 $48.52 $46.09 $53.00 $52.21

65210 $77.12 $73.26 $84.25 $82.98

# 65210 $58.73 $55.79 $64.16 $63.19

65220 $64.20 $60.99 $70.14 $69.09

# 65220 $45.81 $43.52 $50.05 $49.30

65222 $75.56 $71.78 $82.55 $81.31

# 65222 $58.32 $55.40 $63.71 $62.76

65235 $793.80 $754.11 $867.23 $854.22

65260 $1,036.18 $984.37 $1,132.03 $1,115.04

65265 $1,238.99 $1,177.04 $1,353.60 $1,333.29

65270 $306.43 $291.11 $334.78 $329.75

# 65270 $156.64 $148.81 $171.13 $168.57

65272 $559.53 $531.55 $611.28 $602.12

# 65272 $379.86 $360.87 $415.00 $408.78

65273 $411.15 $390.59 $449.18 $442.44

65275 $631.79 $600.20 $690.23 $679.88

# 65275 $496.94 $472.09 $542.90 $534.76

65280 $765.12 $726.86 $835.89 $823.35

65285 $1,250.16 $1,187.65 $1,365.80 $1,345.32

65286 $798.26 $758.35 $872.10 $859.02

# 65286 $550.78 $523.24 $601.73 $592.70

65290 $558.90 $530.96 $610.60 $601.45

65400 $764.53 $726.30 $835.25 $822.72

# 65400 $674.12 $640.41 $736.47 $725.42

65410 $164.76 $156.52 $180.00 $177.30

# 65410 $119.17 $113.21 $130.19 $128.24

65420 $583.20 $554.04 $637.15 $627.59

# 65420 $420.00 $399.00 $458.85 $451.97

65426 $740.38 $703.36 $808.86 $796.73

# 65426 $534.27 $507.56 $583.69 $574.94

65430 $128.61 $122.18 $140.51 $138.40

# 65430 $115.58 $109.80 $126.27 $124.37

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

65435 $90.90 $86.36 $99.31 $97.82

# 65435 $79.02 $75.07 $86.33 $85.03

65436 $439.04 $417.09 $479.65 $472.45

# 65436 $420.65 $399.62 $459.56 $452.67

65450 $366.70 $348.37 $400.63 $394.61

# 65450 $362.87 $344.73 $396.44 $390.49

65600 $445.74 $423.45 $486.97 $479.67

# 65600 $386.75 $367.41 $422.52 $416.19

65710 $1,231.31 $1,169.74 $1,345.20 $1,325.02

65730 $1,363.64 $1,295.46 $1,489.78 $1,467.43

65750 $1,362.63 $1,294.50 $1,488.68 $1,466.34

65755 $1,361.14 $1,293.08 $1,487.04 $1,464.73

65756 $1,270.87 $1,207.33 $1,388.43 $1,367.60

65757 $321.48 $305.41 $351.22 $345.95

65770 $1,713.60 $1,627.92 $1,872.11 $1,844.03

65772 $505.25 $479.99 $551.99 $543.71

# 65772 $452.77 $430.13 $494.65 $487.23

65775 $599.56 $569.58 $655.02 $645.20

65778 $1,649.86 $1,567.37 $1,802.48 $1,775.44

# 65778 $78.39 $74.47 $85.64 $84.35

65779 $1,439.08 $1,367.13 $1,572.20 $1,548.61

# 65779 $315.45 $299.68 $344.63 $339.46

65780 $992.20 $942.59 $1,083.98 $1,067.72

65781 $1,437.25 $1,365.39 $1,570.20 $1,546.65

65782 $1,312.54 $1,246.91 $1,433.95 $1,412.44

65800 $132.99 $126.34 $145.29 $143.11

# 65800 $100.43 $95.41 $109.72 $108.08

65810 $520.51 $494.48 $568.65 $560.12

65815 $732.26 $695.65 $800.00 $788.00

# 65815 $541.86 $514.77 $591.99 $583.11

65820 $818.45 $777.53 $894.16 $880.75

65850 $947.58 $900.20 $1,035.23 $1,019.71

65855 $381.67 $362.59 $416.98 $410.72

# 65855 $333.78 $317.09 $364.65 $359.18

65860 $375.45 $356.68 $410.18 $404.03

# 65860 $309.94 $294.44 $338.61 $333.52

65865 $514.65 $488.92 $562.26 $553.83

65870 $670.35 $636.83 $732.35 $721.37

65875 $704.29 $669.08 $769.44 $757.90

65880 $720.89 $684.85 $787.58 $775.77

65900 $1,043.18 $991.02 $1,139.67 $1,122.57

65920 $876.75 $832.91 $957.85 $943.48

65930 $721.04 $684.99 $787.74 $775.93

66020 $207.99 $197.59 $227.23 $223.82

# 66020 $142.86 $135.72 $156.08 $153.73

66030 $189.47 $180.00 $207.00 $203.90

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 66030 $124.35 $118.13 $135.85 $133.81

66130 $802.23 $762.12 $876.44 $863.29

# 66130 $651.67 $619.09 $711.95 $701.27

66150 $956.04 $908.24 $1,044.48 $1,028.81

66155 $955.31 $907.54 $1,043.67 $1,028.02

66160 $1,073.52 $1,019.84 $1,172.82 $1,155.22

66165 $937.95 $891.05 $1,024.71 $1,009.33

66170 $1,335.53 $1,268.75 $1,459.06 $1,437.18

66172 $1,685.94 $1,601.64 $1,841.89 $1,814.26

66174 $1,070.32 $1,016.80 $1,169.32 $1,151.78

66175 $1,207.97 $1,147.57 $1,319.71 $1,299.91

66180 $1,286.73 $1,222.39 $1,405.75 $1,384.66

66185 $849.20 $806.74 $927.75 $913.84

66220 $832.08 $790.48 $909.05 $895.41

66225 $1,061.33 $1,008.26 $1,159.50 $1,142.11

66250 $864.55 $821.32 $944.52 $930.35

# 66250 $636.99 $605.14 $695.91 $685.47

66500 $390.13 $370.62 $426.21 $419.82

66505 $426.96 $405.61 $466.45 $459.46

66600 $909.16 $863.70 $993.26 $978.35

66605 $1,140.13 $1,083.12 $1,245.59 $1,226.90

66625 $479.79 $455.80 $524.17 $516.30

66630 $642.97 $610.82 $702.44 $691.91

66635 $623.51 $592.33 $681.18 $670.97

66680 $595.58 $565.80 $650.67 $640.91

66682 $731.77 $695.18 $799.46 $787.46

66700 $497.47 $472.60 $543.49 $535.34

# 66700 $430.43 $408.91 $470.25 $463.20

66710 $504.44 $479.22 $551.10 $542.83

# 66710 $448.89 $426.45 $490.42 $483.06

66711 $698.78 $663.84 $763.42 $751.96

66720 $533.08 $506.43 $582.39 $573.65

# 66720 $473.31 $449.64 $517.09 $509.34

66740 $477.55 $453.67 $521.72 $513.89

# 66740 $425.45 $404.18 $464.81 $457.84

66761 $336.28 $319.47 $367.39 $361.88

# 66761 $264.64 $251.41 $289.12 $284.79

66762 $530.95 $504.40 $580.06 $571.35

# 66762 $473.49 $449.82 $517.29 $509.53

66770 $576.88 $548.04 $630.25 $620.79

# 66770 $525.16 $498.90 $573.74 $565.13

66820 $448.53 $426.10 $490.02 $482.67

66821 $374.78 $356.04 $409.45 $403.31

# 66821 $352.56 $334.93 $385.17 $379.40

66825 $848.78 $806.34 $927.29 $913.38

66830 $769.98 $731.48 $841.20 $828.59

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

66840 $795.07 $755.32 $868.62 $855.59

66850 $881.94 $837.84 $963.52 $949.06

66852 $953.23 $905.57 $1,041.41 $1,025.79

66920 $813.87 $773.18 $889.16 $875.82

66930 $923.97 $877.77 $1,009.44 $994.29

66940 $880.66 $836.63 $962.12 $947.69

66982 $888.52 $844.09 $970.70 $956.14

66983 $811.32 $770.75 $886.36 $873.07

66984 $717.89 $682.00 $784.30 $772.54

66985 $856.48 $813.66 $935.71 $921.68

66986 $1,005.40 $955.13 $1,098.40 $1,081.92

66990 $94.70 $89.97 $103.47 $101.91

67005 $543.65 $516.47 $593.94 $585.03

67010 $604.57 $574.34 $660.49 $650.58

67015 $649.08 $616.63 $709.12 $698.49

67025 $827.88 $786.49 $904.46 $890.89

# 67025 $717.17 $681.31 $783.51 $771.75

67027 $961.21 $913.15 $1,050.12 $1,034.37

67028 $112.68 $107.05 $123.11 $121.26

# 67028 $110.77 $105.23 $121.01 $119.20

67030 $582.69 $553.56 $636.59 $627.05

67031 $434.85 $413.11 $475.08 $467.95

# 67031 $397.68 $377.80 $434.47 $427.95

67036 $1,062.60 $1,009.47 $1,160.89 $1,143.48

67039 $1,393.54 $1,323.86 $1,522.44 $1,499.60

67040 $1,573.31 $1,494.64 $1,718.84 $1,693.05

67041 $1,462.48 $1,389.36 $1,597.76 $1,573.80

67042 $1,668.04 $1,584.64 $1,822.34 $1,795.00

67043 $1,788.61 $1,699.18 $1,954.06 $1,924.74

67101 $892.54 $847.91 $975.10 $960.47

# 67101 $763.05 $724.90 $833.64 $821.13

67105 $805.67 $765.39 $880.20 $867.00

# 67105 $716.79 $680.95 $783.09 $771.35

67107 $1,371.09 $1,302.54 $1,497.92 $1,475.45

67108 $1,774.88 $1,686.14 $1,939.06 $1,909.98

67110 $970.00 $921.50 $1,059.73 $1,043.83

# 67110 $858.52 $815.59 $937.93 $923.86

67112 $1,467.52 $1,394.14 $1,603.26 $1,579.21

67113 $1,926.44 $1,830.12 $2,104.64 $2,073.07

67115 $556.42 $528.60 $607.89 $598.77

67120 $756.13 $718.32 $826.07 $813.68

# 67120 $638.52 $606.59 $697.58 $687.11

67121 $1,026.41 $975.09 $1,121.35 $1,104.53

67141 $595.65 $565.87 $650.75 $640.99

# 67141 $553.12 $525.46 $604.28 $595.22

67145 $589.16 $559.70 $643.66 $634.00

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 67145 $555.45 $527.68 $606.83 $597.72

67208 $649.68 $617.20 $709.78 $699.13

# 67208 $624.78 $593.54 $682.57 $672.34

67210 $581.52 $552.44 $635.31 $625.77

# 67210 $560.83 $532.79 $612.71 $603.52

67218 $1,478.24 $1,404.33 $1,614.98 $1,590.76

67220 $607.43 $577.06 $663.62 $653.66

# 67220 $567.59 $539.21 $620.09 $610.79

67221 $321.18 $305.12 $350.89 $345.62

# 67221 $234.22 $222.51 $255.89 $252.05

67225 $31.57 $29.99 $34.49 $33.97

# 67225 $29.65 $28.17 $32.40 $31.91

67227 $664.28 $631.07 $725.73 $714.84

# 67227 $617.54 $586.66 $674.66 $664.54

67228 $1,115.21 $1,059.45 $1,218.37 $1,200.09

# 67228 $1,053.15 $1,000.49 $1,150.56 $1,133.30

67229 $1,253.72 $1,191.03 $1,369.68 $1,349.13

67250 $883.71 $839.52 $965.45 $950.97

67255 $963.44 $915.27 $1,052.56 $1,036.77

67311 $674.68 $640.95 $737.09 $726.04

67312 $810.71 $770.17 $885.70 $872.41

67314 $759.83 $721.84 $830.12 $817.66

67316 $912.78 $867.14 $997.21 $982.25

67318 $762.12 $724.01 $832.61 $820.12

67320 $339.77 $322.78 $371.20 $365.63

67331 $339.42 $322.45 $370.82 $365.25

67332 $369.10 $350.65 $403.25 $397.20

67334 $317.74 $301.85 $347.13 $341.92

67335 $165.05 $156.80 $180.32 $177.62

67340 $377.75 $358.86 $412.69 $406.50

67343 $744.01 $706.81 $812.83 $800.64

67345 $277.05 $263.20 $302.68 $298.14

# 67345 $248.70 $236.27 $271.71 $267.64

67346 $229.80 $218.31 $251.06 $247.30

67400 $1,057.99 $1,005.09 $1,155.85 $1,138.51

67405 $881.79 $837.70 $963.36 $948.90

67412 $966.01 $917.71 $1,055.37 $1,039.53

67413 $975.80 $927.01 $1,066.06 $1,050.07

67414 $1,463.91 $1,390.71 $1,599.32 $1,575.33

67415 $114.11 $108.40 $124.66 $122.79

67420 $1,827.79 $1,736.40 $1,996.86 $1,966.90

67430 $1,357.54 $1,289.66 $1,483.11 $1,460.87

67440 $1,342.71 $1,275.57 $1,466.91 $1,444.91

67445 $1,593.15 $1,513.49 $1,740.51 $1,714.41

67450 $1,396.06 $1,326.26 $1,525.20 $1,502.33

67500 $84.20 $79.99 $91.99 $90.61

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 67500 $76.54 $72.71 $83.62 $82.36

67505 $101.63 $96.55 $111.03 $109.37

# 67505 $92.44 $87.82 $100.99 $99.48

67515 $109.59 $104.11 $119.73 $117.93

# 67515 $100.40 $95.38 $109.69 $108.04

67550 $1,098.23 $1,043.32 $1,199.82 $1,181.82

67560 $1,098.78 $1,043.84 $1,200.42 $1,182.41

67570 $1,387.05 $1,317.70 $1,515.36 $1,492.62

67700 $310.80 $295.26 $339.55 $334.45

# 67700 $131.13 $124.57 $143.26 $141.11

67710 $262.21 $249.10 $286.47 $282.16

# 67710 $112.03 $106.43 $122.39 $120.55

67715 $277.47 $263.60 $303.14 $298.60

# 67715 $124.62 $118.39 $136.15 $134.10

67800 $144.09 $136.89 $157.42 $155.07

# 67800 $116.51 $110.68 $127.28 $125.37

67801 $185.24 $175.98 $202.38 $199.34

# 67801 $151.53 $143.95 $165.54 $163.06

67805 $230.88 $219.34 $252.24 $248.46

# 67805 $187.21 $177.85 $204.53 $201.46

67808 $420.88 $399.84 $459.82 $452.92

67810 $196.42 $186.60 $214.59 $211.37

# 67810 $77.27 $73.41 $84.42 $83.16

67820 $56.16 $53.35 $61.35 $60.43

# 67820 $60.37 $57.35 $65.95 $64.96

67825 $147.00 $139.65 $160.60 $158.19

# 67825 $138.96 $132.01 $151.81 $149.53

67830 $309.63 $294.15 $338.27 $333.20

# 67830 $157.54 $149.66 $172.11 $169.53

67835 $501.37 $476.30 $547.75 $539.53

67840 $316.46 $300.64 $345.74 $340.55

# 67840 $177.78 $168.89 $194.22 $191.31

67850 $243.29 $231.13 $265.80 $261.81

# 67850 $149.81 $142.32 $163.67 $161.22

67875 $197.56 $187.68 $215.83 $212.59

# 67875 $109.83 $104.34 $119.99 $118.19

67880 $524.54 $498.31 $573.06 $564.47

# 67880 $418.42 $397.50 $457.13 $450.27

67882 $647.20 $614.84 $707.07 $696.46

# 67882 $539.55 $512.57 $589.46 $580.61

67900 $727.75 $691.36 $795.06 $783.14

# 67900 $573.36 $544.69 $626.39 $617.00

67901 $869.03 $825.58 $949.42 $935.18

# 67901 $656.41 $623.59 $717.13 $706.38

67902 $820.81 $779.77 $896.74 $883.28

67903 $678.91 $644.96 $741.70 $730.58

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 67903 $549.81 $522.32 $600.67 $591.66

67904 $836.97 $795.12 $914.39 $900.67

# 67904 $677.99 $644.09 $740.70 $729.59

67906 $548.16 $520.75 $598.86 $589.88

67908 $566.61 $538.28 $619.02 $609.74

# 67908 $485.40 $461.13 $530.30 $522.34

67909 $614.16 $583.45 $670.97 $660.91

# 67909 $499.62 $474.64 $545.84 $537.65

67911 $637.47 $605.60 $696.44 $686.00

67912 $1,012.15 $961.54 $1,105.77 $1,089.19

# 67912 $545.15 $517.89 $595.57 $586.64

67914 $444.07 $421.87 $485.15 $477.87

# 67914 $326.45 $310.13 $356.65 $351.30

67915 $398.56 $378.63 $435.42 $428.89

# 67915 $288.61 $274.18 $315.31 $310.58

67916 $613.75 $583.06 $670.52 $660.46

# 67916 $488.48 $464.06 $533.67 $525.67

67917 $669.63 $636.15 $731.57 $720.60

# 67917 $538.99 $512.04 $588.85 $580.01

67921 $427.44 $406.07 $466.98 $459.98

# 67921 $309.83 $294.34 $338.49 $333.41

67922 $388.73 $369.29 $424.68 $418.31

# 67922 $280.70 $266.67 $306.67 $302.07

67923 $649.53 $617.05 $709.61 $698.96

# 67923 $529.62 $503.14 $578.61 $569.93

67924 $672.18 $638.57 $734.36 $723.34

# 67924 $510.12 $484.61 $557.30 $548.94

67930 $418.67 $397.74 $457.40 $450.54

# 67930 $271.95 $258.35 $297.10 $292.64

67935 $678.74 $644.80 $741.52 $730.40

# 67935 $499.45 $474.48 $545.65 $537.46

67938 $280.26 $266.25 $306.19 $301.60

# 67938 $130.85 $124.31 $142.96 $140.82

67950 $652.89 $620.25 $713.29 $702.59

# 67950 $524.17 $497.96 $572.65 $564.06

67961 $658.33 $625.41 $719.22 $708.43

# 67961 $516.59 $490.76 $564.37 $555.91

67966 $875.05 $831.30 $956.00 $941.65

# 67966 $744.79 $707.55 $813.68 $801.48

67971 $821.96 $780.86 $897.99 $884.52

67973 $1,056.94 $1,004.09 $1,154.70 $1,137.38

67974 $1,055.52 $1,002.74 $1,153.15 $1,135.86

67975 $778.29 $739.38 $850.29 $837.53

68020 $134.21 $127.50 $146.63 $144.43

# 68020 $123.86 $117.67 $135.32 $133.29

68040 $73.14 $69.48 $79.90 $78.71

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 68040 $59.35 $56.38 $64.84 $63.86

68100 $194.22 $184.51 $212.19 $209.00

# 68100 $109.56 $104.08 $119.69 $117.90

68110 $260.70 $247.67 $284.82 $280.54

# 68110 $170.29 $161.78 $186.05 $183.25

68115 $354.86 $337.12 $387.69 $381.87

# 68115 $204.31 $194.09 $223.20 $219.86

68130 $597.99 $568.09 $653.30 $643.51

# 68130 $448.58 $426.15 $490.07 $482.72

68135 $174.89 $166.15 $191.07 $188.21

# 68135 $168.76 $160.32 $184.37 $181.61

68200 $46.30 $43.99 $50.59 $49.83

# 68200 $39.02 $37.07 $42.63 $41.99

68320 $835.08 $793.33 $912.33 $898.64

# 68320 $615.95 $585.15 $672.92 $662.83

68325 $749.87 $712.38 $819.24 $806.94

68326 $736.55 $699.72 $804.68 $792.60

68328 $806.23 $765.92 $880.81 $867.59

68330 $696.05 $661.25 $760.44 $749.03

# 68330 $527.49 $501.12 $576.29 $567.64

68335 $739.45 $702.48 $807.85 $795.73

68340 $629.25 $597.79 $687.46 $677.14

# 68340 $457.24 $434.38 $499.54 $492.04

68360 $611.60 $581.02 $668.17 $658.15

# 68360 $470.62 $447.09 $514.15 $506.44

68362 $749.55 $712.07 $818.88 $806.60

68371 $449.77 $427.28 $491.37 $484.00

68400 $331.51 $314.93 $362.17 $356.74

# 68400 $150.30 $142.79 $164.21 $161.75

68420 $366.60 $348.27 $400.51 $394.51

# 68420 $185.78 $176.49 $202.96 $199.92

68440 $118.12 $112.21 $129.04 $127.11

# 68440 $114.67 $108.94 $125.28 $123.41

68500 $1,129.92 $1,073.42 $1,234.43 $1,215.92

68505 $1,106.71 $1,051.37 $1,209.08 $1,190.94

68510 $513.59 $487.91 $561.10 $552.68

# 68510 $332.01 $315.41 $362.72 $357.28

68520 $763.49 $725.32 $834.12 $821.61

68525 $296.75 $281.91 $324.20 $319.33

68530 $492.40 $467.78 $537.95 $529.87

# 68530 $291.28 $276.72 $318.23 $313.46

68540 $1,030.58 $979.05 $1,125.91 $1,109.01

68550 $1,261.07 $1,198.02 $1,377.72 $1,357.06

68700 $688.63 $654.20 $752.33 $741.05

68705 $272.53 $258.90 $297.74 $293.27

# 68705 $189.78 $180.29 $207.33 $204.23

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

68720 $850.55 $808.02 $929.22 $915.29

68745 $867.59 $824.21 $947.84 $933.63

68750 $895.55 $850.77 $978.39 $963.71

68760 $232.14 $220.53 $253.61 $249.80

# 68760 $167.01 $158.66 $182.46 $179.72

68761 $168.67 $160.24 $184.28 $181.52

# 68761 $134.95 $128.20 $147.43 $145.22

68770 $717.18 $681.32 $783.52 $771.77

68801 $143.48 $136.31 $156.76 $154.41

# 68801 $123.56 $117.38 $134.99 $132.96

68810 $278.57 $264.64 $304.34 $299.77

# 68810 $214.21 $203.50 $234.03 $230.52

68811 $236.26 $224.45 $258.12 $254.24

68815 $518.71 $492.77 $566.69 $558.19

# 68815 $291.53 $276.95 $318.49 $313.72

68816 $871.61 $828.03 $952.23 $937.95

# 68816 $286.62 $272.29 $313.13 $308.44

68840 $147.17 $139.81 $160.78 $158.37

# 68840 $134.14 $127.43 $146.54 $144.35

68850 $63.99 $60.79 $69.91 $68.86

# 68850 $58.63 $55.70 $64.06 $63.09

69000 $215.47 $204.70 $235.41 $231.87

# 69000 $133.48 $126.81 $145.83 $143.65

69005 $243.56 $231.38 $266.09 $262.10

# 69005 $173.46 $164.79 $189.51 $186.67

69020 $271.35 $257.78 $296.45 $292.00

# 69020 $161.01 $152.96 $175.90 $173.27

69100 $113.65 $107.97 $124.17 $122.30

# 69100 $52.35 $49.73 $57.19 $56.33

69105 $164.10 $155.90 $179.29 $176.59

# 69105 $70.24 $66.73 $76.74 $75.59

69110 $527.25 $500.89 $576.02 $567.39

# 69110 $364.81 $346.57 $398.56 $392.58

69120 $462.81 $439.67 $505.62 $498.03

69140 $997.03 $947.18 $1,089.26 $1,072.92

69145 $462.90 $439.76 $505.72 $498.13

# 69145 $282.46 $268.34 $308.59 $303.96

69150 $1,154.30 $1,096.59 $1,261.08 $1,242.16

69155 $1,832.98 $1,741.33 $2,002.53 $1,972.49

69200 $142.93 $135.78 $156.15 $153.80

# 69200 $64.02 $60.82 $69.94 $68.90

69205 $113.23 $107.57 $123.71 $121.85

69210 $57.39 $54.52 $62.70 $61.76

# 69210 $34.41 $32.69 $37.59 $37.03

69220 $161.11 $153.05 $176.01 $173.36

# 69220 $68.40 $64.98 $74.73 $73.61

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

69222 $256.36 $243.54 $280.07 $275.87

# 69222 $154.84 $147.10 $169.17 $166.62

69300 $836.09 $794.29 $913.43 $899.74

# 69300 $522.71 $496.57 $571.06 $562.49

69310 $1,235.63 $1,173.85 $1,349.93 $1,329.68

69320 $1,712.82 $1,627.18 $1,871.26 $1,843.19

69400 $174.52 $165.79 $190.66 $187.80

# 69400 $68.40 $64.98 $74.73 $73.61

69401 $102.53 $97.40 $112.01 $110.33

# 69401 $55.40 $52.63 $60.52 $59.62

69405 $295.97 $281.17 $323.35 $318.49

# 69405 $211.69 $201.11 $231.28 $227.80

69420 $222.13 $211.02 $242.67 $239.03

# 69420 $135.94 $129.14 $148.51 $146.28

69421 $166.55 $158.22 $181.95 $179.23

69424 $149.16 $141.70 $162.96 $160.51

# 69424 $68.71 $65.27 $75.06 $73.93

69433 $234.75 $223.01 $256.46 $252.61

# 69433 $148.94 $141.49 $162.71 $160.28

69436 $178.67 $169.74 $195.20 $192.27

69440 $778.83 $739.89 $850.87 $838.11

69450 $618.61 $587.68 $675.83 $665.69

69501 $815.86 $775.07 $891.33 $877.96

69502 $1,080.62 $1,026.59 $1,180.58 $1,162.87

69505 $1,353.09 $1,285.44 $1,478.26 $1,456.08

69511 $1,384.33 $1,315.11 $1,512.38 $1,489.69

69530 $1,837.41 $1,745.54 $2,007.37 $1,977.26

69535 $2,933.56 $2,786.88 $3,204.91 $3,156.84

69540 $244.87 $232.63 $267.52 $263.51

# 69540 $144.89 $137.65 $158.30 $155.93

69550 $1,172.92 $1,114.27 $1,281.41 $1,262.19

69552 $1,741.16 $1,654.10 $1,902.22 $1,873.68

69554 $2,759.62 $2,621.64 $3,014.89 $2,969.67

69601 $1,163.58 $1,105.40 $1,271.21 $1,252.14

69602 $1,213.26 $1,152.60 $1,325.49 $1,305.61

69603 $1,413.06 $1,342.41 $1,543.77 $1,520.61

69604 $1,238.75 $1,176.81 $1,353.33 $1,333.03

69605 $1,738.68 $1,651.75 $1,899.51 $1,871.02

69610 $430.25 $408.74 $470.05 $463.00

# 69610 $316.85 $301.01 $346.16 $340.96

69620 $793.13 $753.47 $866.49 $853.50

# 69620 $544.12 $516.91 $594.45 $585.53

69631 $996.82 $946.98 $1,089.03 $1,072.70

69632 $1,207.61 $1,147.23 $1,319.31 $1,299.52

69633 $1,169.90 $1,111.41 $1,278.12 $1,258.95

69635 $1,380.88 $1,311.84 $1,508.62 $1,485.98

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

69636 $1,548.08 $1,470.68 $1,691.28 $1,665.91

69637 $1,552.22 $1,474.61 $1,695.80 $1,670.36

69641 $1,163.01 $1,104.86 $1,270.59 $1,251.53

69642 $1,489.17 $1,414.71 $1,626.92 $1,602.51

69643 $1,362.01 $1,293.91 $1,488.00 $1,465.68

69644 $1,653.59 $1,570.91 $1,806.55 $1,779.45

69645 $1,622.61 $1,541.48 $1,772.70 $1,746.11

69646 $1,719.65 $1,633.67 $1,878.72 $1,850.53

69650 $899.37 $854.40 $982.56 $967.82

69660 $1,029.64 $978.16 $1,124.88 $1,108.01

69661 $1,340.14 $1,273.13 $1,464.10 $1,442.13

69662 $1,281.52 $1,217.44 $1,400.06 $1,379.06

69666 $903.95 $858.75 $987.56 $972.75

69667 $904.68 $859.45 $988.37 $973.54

69670 $1,053.81 $1,001.12 $1,151.29 $1,134.02

69676 $934.65 $887.92 $1,021.11 $1,005.79

69700 $767.03 $728.68 $837.98 $825.41

69711 $964.33 $916.11 $1,053.53 $1,037.73

69714 $1,192.16 $1,132.55 $1,302.43 $1,282.89

69715 $1,459.91 $1,386.91 $1,594.95 $1,571.03

69717 $1,247.73 $1,185.34 $1,363.14 $1,342.69

69718 $1,474.64 $1,400.91 $1,611.05 $1,586.89

69720 $1,329.44 $1,262.97 $1,452.42 $1,430.63

69725 $2,059.05 $1,956.10 $2,249.52 $2,215.77

69740 $1,286.57 $1,222.24 $1,405.58 $1,384.50

69745 $1,371.73 $1,303.14 $1,498.61 $1,476.13

69801 $221.37 $210.30 $241.85 $238.22

# 69801 $135.94 $129.14 $148.51 $146.28

69805 $1,162.03 $1,103.93 $1,269.52 $1,250.48

69806 $1,045.67 $993.39 $1,142.40 $1,125.26

69820 $958.94 $910.99 $1,047.64 $1,031.93

69840 $929.93 $883.43 $1,015.94 $1,000.71

69905 $1,026.90 $975.56 $1,121.89 $1,105.07

69910 $1,124.53 $1,068.30 $1,228.55 $1,210.12

69915 $1,684.99 $1,600.74 $1,840.85 $1,813.24

69930 $1,343.27 $1,276.11 $1,467.53 $1,445.52

69950 $1,938.03 $1,841.13 $2,117.30 $2,085.54

69955 $2,163.54 $2,055.36 $2,363.66 $2,328.21

69960 $2,097.26 $1,992.40 $2,291.26 $2,256.89

69970 $2,337.61 $2,220.73 $2,553.84 $2,515.53

69990 $228.48 $217.06 $249.62 $245.87

70010 $65.63 $62.35 $71.70 $70.62

70015 $172.90 $164.26 $188.90 $186.07

70015 TC $111.84 $106.25 $122.19 $120.36

70015 26 $61.07 $58.02 $66.72 $65.72

70030 $33.05 $31.40 $36.11 $35.57

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

70030 TC $24.49 $23.27 $26.76 $26.36

70030 26 $8.56 $8.13 $9.35 $9.21

70100 $39.53 $37.55 $43.18 $42.54

70100 TC $30.24 $28.73 $33.04 $32.55

70100 26 $9.29 $8.83 $10.15 $10.01

70110 $45.02 $42.77 $49.19 $48.45

70110 TC $32.15 $30.54 $35.12 $34.59

70110 26 $12.87 $12.23 $14.06 $13.86

70120 $41.06 $39.01 $44.86 $44.18

70120 TC $31.77 $30.18 $34.71 $34.19

70120 26 $9.29 $8.83 $10.15 $10.01

70130 $66.92 $63.57 $73.11 $72.01

70130 TC $49.39 $46.92 $53.96 $53.15

70130 26 $17.53 $16.65 $19.15 $18.86

70134 $51.98 $49.38 $56.79 $55.94

70134 TC $35.22 $33.46 $38.48 $37.90

70134 26 $16.76 $15.92 $18.31 $18.03

70140 $34.13 $32.42 $37.28 $36.72

70140 TC $23.72 $22.53 $25.91 $25.52

70140 26 $10.40 $9.88 $11.36 $11.19

70150 $48.44 $46.02 $52.92 $52.13

70150 TC $35.22 $33.46 $38.48 $37.90

70150 26 $13.22 $12.56 $14.44 $14.23

70160 $38.41 $36.49 $41.96 $41.33

70160 TC $29.47 $28.00 $32.20 $31.72

70160 26 $8.94 $8.49 $9.76 $9.61

70170 $63.34 $60.17 $69.20 $68.16

70170 TC $47.64 $45.26 $52.05 $51.27

70170 26 $15.70 $14.92 $17.16 $16.91

70190 $41.34 $39.27 $45.16 $44.48

70190 TC $30.24 $28.73 $33.04 $32.55

70190 26 $11.10 $10.55 $12.13 $11.95

70200 $49.51 $47.03 $54.08 $53.27

70200 TC $35.22 $33.46 $38.48 $37.90

70200 26 $14.30 $13.59 $15.63 $15.40

70210 $35.35 $33.58 $38.62 $38.04

70210 TC $26.41 $25.09 $28.85 $28.42

70210 26 $8.94 $8.49 $9.76 $9.61

70220 $44.26 $42.05 $48.36 $47.63

70220 TC $31.39 $29.82 $34.29 $33.78

70220 26 $12.87 $12.23 $14.06 $13.86

70240 $34.13 $32.42 $37.28 $36.72

70240 TC $24.11 $22.90 $26.34 $25.94

70240 26 $10.02 $9.52 $10.95 $10.79

70250 $42.38 $40.26 $46.30 $45.61

70250 TC $29.47 $28.00 $32.20 $31.72

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

70250 26 $12.91 $12.26 $14.10 $13.89

70260 $53.13 $50.47 $58.04 $57.17

70260 TC $35.60 $33.82 $38.89 $38.31

70260 26 $17.53 $16.65 $19.15 $18.86

70300 $16.83 $15.99 $18.39 $18.11

70300 TC $10.70 $10.17 $11.70 $11.52

70300 26 $6.13 $5.82 $6.69 $6.59

70310 $44.20 $41.99 $48.29 $47.56

70310 TC $35.98 $34.18 $39.31 $38.72

70310 26 $8.21 $7.80 $8.97 $8.83

C 70320 $52.79 $50.15 $57.67 $56.81

C 70320 TC $40.58 $38.55 $44.33 $43.67

70320 26 $12.21 $11.60 $13.34 $13.14

70328 $36.46 $34.64 $39.84 $39.24

70328 TC $26.79 $25.45 $29.27 $28.83

70328 26 $9.67 $9.19 $10.57 $10.41

70330 $55.40 $52.63 $60.52 $59.62

70330 TC $42.50 $40.38 $46.44 $45.74

70330 26 $12.91 $12.26 $14.10 $13.89

70332 $79.94 $75.94 $87.33 $86.02

70332 TC $52.46 $49.84 $57.32 $56.45

70332 26 $27.49 $26.12 $30.04 $29.59

70336 $407.06 $386.71 $444.72 $438.05

70336 TC $332.89 $316.25 $363.69 $358.24

70336 26 $74.18 $70.47 $81.04 $79.82

70350 $24.24 $23.03 $26.48 $26.08

70350 TC $13.76 $13.07 $15.03 $14.80

70350 26 $10.48 $9.96 $11.45 $11.28

70355 $23.37 $22.20 $25.53 $25.15

70355 TC $11.85 $11.26 $12.95 $12.75

70355 26 $11.52 $10.94 $12.58 $12.40

70360 $31.52 $29.94 $34.43 $33.91

70360 TC $22.96 $21.81 $25.08 $24.70

70360 26 $8.56 $8.13 $9.35 $9.21

70370 $93.04 $88.39 $101.65 $100.12

70370 TC $76.98 $73.13 $84.10 $82.83

70370 26 $16.07 $15.27 $17.56 $17.30

70371 $102.24 $97.13 $111.70 $110.02

70371 TC $59.35 $56.38 $64.84 $63.86

70371 26 $42.89 $40.75 $46.86 $46.16

70373 $90.32 $85.80 $98.67 $97.19

70373 TC $68.16 $64.75 $74.46 $73.35

70373 26 $22.15 $21.04 $24.20 $23.83

70380 $44.93 $42.68 $49.08 $48.35

70380 TC $35.22 $33.46 $38.48 $37.90

70380 26 $9.71 $9.22 $10.60 $10.44

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

70390 $116.14 $110.33 $126.88 $124.98

70390 TC $96.51 $91.68 $105.43 $103.85

70390 26 $19.63 $18.65 $21.45 $21.13

70450 $185.31 $176.04 $202.45 $199.41

70450 TC $142.49 $135.37 $155.68 $153.34

70450 26 $42.83 $40.69 $46.79 $46.09

70460 $242.90 $230.76 $265.37 $261.40

70460 TC $186.16 $176.85 $203.38 $200.33

70460 26 $56.74 $53.90 $61.99 $61.05

70470 $245.02 $232.77 $267.69 $263.67

70470 TC $180.80 $171.76 $197.52 $194.56

70470 26 $64.23 $61.02 $70.17 $69.12

C 70480 $260.31 $247.29 $284.38 $280.12

C 70480 TC $195.35 $185.58 $213.42 $210.22

70480 26 $64.96 $61.71 $70.97 $69.90

70481 $361.83 $343.74 $395.30 $389.37

70481 TC $291.89 $277.30 $318.90 $314.11

70481 26 $69.94 $66.44 $76.41 $75.26

70482 $401.04 $380.99 $438.14 $431.57

70482 TC $327.91 $311.51 $358.24 $352.87

70482 26 $73.13 $69.47 $79.89 $78.69

C 70486 $253.20 $240.54 $276.62 $272.47

C 70486 TC $195.35 $185.58 $213.42 $210.22

70486 26 $57.85 $54.96 $63.20 $62.26

70487 $308.89 $293.45 $337.47 $332.41

70487 TC $243.24 $231.08 $265.74 $261.75

70487 26 $65.65 $62.37 $71.73 $70.64

70488 $372.41 $353.79 $406.86 $400.75

70488 TC $300.71 $285.67 $328.52 $323.59

70488 26 $71.71 $68.12 $78.34 $77.17

70490 $249.20 $236.74 $272.25 $268.17

70490 TC $184.24 $175.03 $201.28 $198.26

70490 26 $64.96 $61.71 $70.97 $69.90

70491 $300.95 $285.90 $328.79 $323.85

70491 TC $230.98 $219.43 $252.34 $248.56

70491 26 $69.96 $66.46 $76.43 $75.28

70492 $360.05 $342.05 $393.36 $387.46

70492 TC $286.91 $272.56 $313.44 $308.74

70492 26 $73.13 $69.47 $79.89 $78.69

C 70496 $470.40 $446.88 $513.91 $506.21

C 70496 TC $381.92 $362.82 $417.24 $410.99

70496 26 $88.48 $84.06 $96.67 $95.22

C 70498 $470.40 $446.88 $513.91 $506.21

C 70498 TC $381.92 $362.82 $417.24 $410.99

70498 26 $88.48 $84.06 $96.67 $95.22

C 70540 $449.28 $426.82 $490.84 $483.48

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

C 70540 TC $381.16 $362.10 $416.42 $410.17

70540 26 $68.13 $64.72 $74.43 $73.31

70542 $519.14 $493.18 $567.16 $558.65

70542 TC $436.71 $414.87 $477.10 $469.95

70542 26 $82.43 $78.31 $90.06 $88.71

70543 $636.72 $604.88 $695.61 $685.18

70543 TC $528.27 $501.86 $577.14 $568.48

70543 26 $108.45 $103.03 $118.48 $116.70

C 70544 $441.80 $419.71 $482.67 $475.42

C 70544 TC $381.16 $362.10 $416.42 $410.17

70544 26 $60.65 $57.62 $66.26 $65.27

70545 $512.29 $486.68 $559.68 $551.29

70545 TC $451.65 $429.07 $493.43 $486.02

70545 26 $60.65 $57.62 $66.26 $65.27

C 70546 $710.02 $674.52 $775.70 $764.06

C 70546 TC $618.68 $587.75 $675.91 $665.77

70546 26 $91.34 $86.77 $99.79 $98.29

C 70547 $442.19 $420.08 $483.09 $475.85

C 70547 TC $381.16 $362.10 $416.42 $410.17

70547 26 $61.03 $57.98 $66.68 $65.68

70548 $551.75 $524.16 $602.78 $593.75

70548 TC $490.72 $466.18 $536.11 $528.07

70548 26 $61.03 $57.98 $66.68 $65.68

C 70549 $709.66 $674.18 $775.31 $763.68

C 70549 TC $618.68 $587.75 $675.91 $665.77

70549 26 $90.98 $86.43 $99.39 $97.90

C 70551 $456.10 $433.30 $498.30 $490.82

C 70551 TC $381.16 $362.10 $416.42 $410.17

70551 26 $74.94 $71.19 $81.87 $80.64

70552 $543.06 $515.91 $593.30 $584.40

70552 TC $452.41 $429.79 $494.26 $486.84

70552 26 $90.65 $86.12 $99.04 $97.55

70553 $635.15 $603.39 $693.90 $683.49

70553 TC $515.62 $489.84 $563.32 $554.86

70553 26 $119.52 $113.54 $130.57 $128.62

70554 $552.19 $524.58 $603.27 $594.22

70554 TC $444.75 $422.51 $485.89 $478.60

70554 26 $107.44 $102.07 $117.38 $115.62

70555 26 $132.39 $125.77 $144.64 $142.46

70557 26 $178.30 $169.39 $194.80 $191.88

70558 26 $166.65 $158.32 $182.07 $179.34

70559 26 $167.03 $158.68 $182.48 $179.75

71010 $26.12 $24.81 $28.53 $28.11

71010 TC $16.83 $15.99 $18.39 $18.11

71010 26 $9.29 $8.83 $10.15 $10.01

71015 $34.44 $32.72 $37.63 $37.06

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

71015 TC $23.72 $22.53 $25.91 $25.52

71015 26 $10.72 $10.18 $11.71 $11.53

71020 $34.02 $32.32 $37.17 $36.62

71020 TC $22.96 $21.81 $25.08 $24.70

71020 26 $11.06 $10.51 $12.09 $11.90

71021 $42.27 $40.16 $46.18 $45.49

71021 TC $28.32 $26.90 $30.94 $30.48

71021 26 $13.95 $13.25 $15.24 $15.01

71022 $54.00 $51.30 $59.00 $58.11

71022 TC $37.90 $36.01 $41.41 $40.79

71022 26 $16.10 $15.30 $17.60 $17.33

71023 $74.44 $70.72 $81.33 $80.11

71023 TC $55.52 $52.74 $60.65 $59.74

71023 26 $18.92 $17.97 $20.67 $20.36

71030 $51.71 $49.12 $56.49 $55.64

71030 TC $36.37 $34.55 $39.73 $39.13

71030 26 $15.34 $14.57 $16.76 $16.50

71034 $97.14 $92.28 $106.12 $104.54

71034 TC $74.29 $70.58 $81.17 $79.95

71034 26 $22.85 $21.71 $24.97 $24.59

71035 $40.68 $38.65 $44.45 $43.78

71035 TC $31.77 $30.18 $34.71 $34.19

71035 26 $8.91 $8.46 $9.73 $9.58

71100 $36.70 $34.87 $40.10 $39.50

71100 TC $25.26 $24.00 $27.60 $27.19

71100 26 $11.45 $10.88 $12.51 $12.33

71101 $44.57 $42.34 $48.69 $47.96

71101 TC $31.00 $29.45 $33.87 $33.36

71101 26 $13.57 $12.89 $14.82 $14.61

71110 $46.10 $43.80 $50.37 $49.61

71110 TC $32.15 $30.54 $35.12 $34.59

71110 26 $13.95 $13.25 $15.24 $15.01

71111 $60.48 $57.46 $66.08 $65.09

71111 TC $44.03 $41.83 $48.10 $47.38

71111 26 $16.45 $15.63 $17.97 $17.71

71120 $35.62 $33.84 $38.92 $38.33

71120 TC $25.64 $24.36 $28.01 $27.59

71120 26 $9.98 $9.48 $10.90 $10.74

71130 $42.45 $40.33 $46.38 $45.69

71130 TC $31.00 $29.45 $33.87 $33.36

71130 26 $11.45 $10.88 $12.51 $12.33

71250 $236.01 $224.21 $257.84 $253.98

71250 TC $184.63 $175.40 $201.71 $198.69

71250 26 $51.38 $48.81 $56.13 $55.29

71260 $295.32 $280.55 $322.63 $317.79

71260 TC $232.13 $220.52 $253.60 $249.79

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

71260 26 $63.19 $60.03 $69.03 $68.00

71270 $358.41 $340.49 $391.56 $385.69

71270 TC $288.83 $274.39 $315.55 $310.81

71270 26 $69.58 $66.10 $76.02 $74.88

71275 $454.06 $431.36 $496.06 $488.62

71275 TC $357.02 $339.17 $390.05 $384.19

71275 26 $97.04 $92.19 $106.02 $104.43

C 71550 $454.64 $431.91 $496.70 $489.24

C 71550 TC $381.16 $362.10 $416.42 $410.17

71550 26 $73.48 $69.81 $80.28 $79.07

71551 $591.15 $561.59 $645.83 $636.15

71551 TC $503.75 $478.56 $550.34 $542.09

71551 26 $87.40 $83.03 $95.48 $94.05

C 71552 $732.48 $695.86 $800.24 $788.23

C 71552 TC $618.68 $587.75 $675.91 $665.77

71552 26 $113.80 $108.11 $124.33 $122.46

71555 $523.44 $497.27 $571.86 $563.28

71555 TC $432.11 $410.50 $472.08 $464.99

71555 26 $91.33 $86.76 $99.77 $98.28

72010 $90.23 $85.72 $98.58 $97.09

72010 TC $66.25 $62.94 $72.38 $71.30

72010 26 $23.98 $22.78 $26.20 $25.81

72020 $26.61 $25.28 $29.07 $28.64

72020 TC $18.74 $17.80 $20.47 $20.16

72020 26 $7.86 $7.47 $8.59 $8.46

72040 $40.48 $38.46 $44.23 $43.56

72040 TC $28.32 $26.90 $30.94 $30.48

72040 26 $12.16 $11.55 $13.28 $13.09

72050 $54.71 $51.97 $59.77 $58.87

72050 TC $38.28 $36.37 $41.83 $41.19

72050 26 $16.43 $15.61 $17.95 $17.69

72052 $70.63 $67.10 $77.17 $76.00

72052 TC $51.69 $49.11 $56.48 $55.63

72052 26 $18.94 $17.99 $20.69 $20.38

72069 $43.93 $41.73 $47.99 $47.27

72069 TC $31.77 $30.18 $34.71 $34.19

72069 26 $12.16 $11.55 $13.28 $13.09

72070 $38.24 $36.33 $41.78 $41.16

72070 TC $26.79 $25.45 $29.27 $28.83

72070 26 $11.45 $10.88 $12.51 $12.33

72072 $42.07 $39.97 $45.97 $45.28

72072 TC $31.00 $29.45 $33.87 $33.36

72072 26 $11.06 $10.51 $12.09 $11.90

72074 $50.49 $47.97 $55.17 $54.34

72074 TC $39.43 $37.46 $43.08 $42.44

72074 26 $11.06 $10.51 $12.09 $11.90

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

72080 $41.63 $39.55 $45.48 $44.80

72080 TC $29.47 $28.00 $32.20 $31.72

72080 26 $12.16 $11.55 $13.28 $13.09

72090 $59.39 $56.42 $64.88 $63.91

72090 TC $43.65 $41.47 $47.69 $46.98

72090 26 $15.75 $14.96 $17.20 $16.95

72100 $40.86 $38.82 $44.64 $43.98

72100 TC $28.70 $27.27 $31.36 $30.89

72100 26 $12.16 $11.55 $13.28 $13.09

72110 $55.48 $52.71 $60.62 $59.71

72110 TC $39.05 $37.10 $42.67 $42.02

72110 26 $16.43 $15.61 $17.95 $17.69

72114 $73.04 $69.39 $79.80 $78.60

72114 TC $55.52 $52.74 $60.65 $59.74

72114 26 $17.52 $16.64 $19.14 $18.85

72120 $48.52 $46.09 $53.00 $52.21

72120 TC $35.98 $34.18 $39.31 $38.72

72120 26 $12.54 $11.91 $13.70 $13.49

72125 $241.20 $229.14 $263.51 $259.56

72125 TC $187.31 $177.94 $204.63 $201.56

72125 26 $53.89 $51.20 $58.88 $57.99

72126 $295.00 $280.25 $322.29 $317.46

72126 TC $233.28 $221.62 $254.86 $251.05

72126 26 $61.72 $58.63 $67.42 $66.41

72127 $353.82 $336.13 $386.55 $380.75

72127 TC $289.60 $275.12 $316.39 $311.64

72127 26 $64.23 $61.02 $70.17 $69.12

72128 $236.47 $224.65 $258.35 $254.47

72128 TC $186.16 $176.85 $203.38 $200.33

72128 26 $50.31 $47.79 $54.96 $54.13

72129 $296.15 $281.34 $323.54 $318.69

72129 TC $234.43 $222.71 $256.12 $252.28

72129 26 $61.72 $58.63 $67.42 $66.41

72130 $355.74 $337.95 $388.64 $382.81

72130 TC $291.51 $276.93 $318.47 $313.70

72130 26 $64.23 $61.02 $70.17 $69.12

72131 $235.70 $223.92 $257.51 $253.64

72131 TC $185.39 $176.12 $202.54 $199.50

72131 26 $50.31 $47.79 $54.96 $54.13

72132 $295.39 $280.62 $322.71 $317.87

72132 TC $233.66 $221.98 $255.28 $251.45

72132 26 $61.72 $58.63 $67.42 $66.41

72133 $353.82 $336.13 $386.55 $380.75

72133 TC $289.98 $275.48 $316.80 $312.05

72133 26 $63.84 $60.65 $69.75 $68.70

72141 $429.95 $408.45 $469.72 $462.67

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

72141 TC $348.59 $331.16 $380.83 $375.12

72141 26 $81.36 $77.29 $88.88 $87.55

72142 $553.67 $525.99 $604.89 $595.82

72142 TC $455.86 $433.07 $498.03 $490.56

72142 26 $97.81 $92.92 $106.86 $105.26

72146 $430.71 $409.17 $470.55 $463.48

72146 TC $349.36 $331.89 $381.67 $375.95

72146 26 $81.36 $77.29 $88.88 $87.55

72147 $488.16 $463.75 $533.31 $525.31

72147 TC $390.73 $371.19 $426.87 $420.46

72147 26 $97.42 $92.55 $106.43 $104.83

72148 $424.63 $403.40 $463.91 $456.95

72148 TC $348.98 $331.53 $381.26 $375.54

72148 26 $75.65 $71.87 $82.65 $81.41

72149 $535.40 $508.63 $584.92 $576.15

72149 TC $444.75 $422.51 $485.89 $478.60

72149 26 $90.65 $86.12 $99.04 $97.55

72156 $634.72 $602.98 $693.43 $683.03

72156 TC $504.13 $478.92 $550.76 $542.50

72156 26 $130.59 $124.06 $142.67 $140.53

72157 $589.13 $559.67 $643.62 $633.96

72157 TC $458.54 $435.61 $500.95 $493.44

72157 26 $130.59 $124.06 $142.67 $140.53

72158 $621.68 $590.60 $679.19 $669.00

72158 TC $501.07 $476.02 $547.42 $539.21

72158 26 $120.62 $114.59 $131.78 $129.80

72159 $535.82 $509.03 $585.38 $576.60

72159 TC $445.90 $423.61 $487.15 $479.85

72159 26 $89.92 $85.42 $98.23 $96.76

72170 $33.00 $31.35 $36.05 $35.51

72170 TC $23.34 $22.17 $25.50 $25.12

72170 26 $9.65 $9.17 $10.55 $10.38

72190 $49.71 $47.22 $54.30 $53.49

72190 TC $37.90 $36.01 $41.41 $40.79

72190 26 $11.81 $11.22 $12.90 $12.71

72191 $451.36 $428.79 $493.11 $485.71

72191 TC $359.70 $341.72 $392.98 $387.08

72191 26 $91.66 $87.08 $100.14 $98.64

72192 $194.39 $184.67 $212.37 $209.19

72192 TC $139.80 $132.81 $152.73 $150.44

72192 26 $54.58 $51.85 $59.63 $58.73

72193 $308.63 $293.20 $337.18 $332.12

72193 TC $249.75 $237.26 $272.85 $268.76

72193 26 $58.87 $55.93 $64.32 $63.35

72194 $346.34 $329.02 $378.37 $372.69

72194 TC $284.61 $270.38 $310.94 $306.27

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

72194 26 $61.72 $58.63 $67.42 $66.41

C 72195 $455.73 $432.94 $497.88 $490.42

C 72195 TC $381.16 $362.10 $416.42 $410.17

72195 26 $74.58 $70.85 $81.48 $80.26

72196 $534.07 $507.37 $583.48 $574.72

72196 TC $446.28 $423.97 $487.57 $480.25

72196 26 $87.79 $83.40 $95.91 $94.47

72197 $651.26 $618.70 $711.51 $700.83

72197 TC $537.46 $510.59 $587.18 $578.37

72197 26 $113.80 $108.11 $124.33 $122.46

72198 $528.07 $501.67 $576.92 $568.26

72198 TC $437.47 $415.60 $477.94 $470.78

72198 26 $90.60 $86.07 $98.98 $97.50

72200 $33.82 $32.13 $36.95 $36.40

72200 TC $24.87 $23.63 $27.17 $26.77

72200 26 $8.94 $8.49 $9.76 $9.61

72202 $39.49 $37.52 $43.15 $42.50

72202 TC $29.85 $28.36 $32.61 $32.12

72202 26 $9.64 $9.16 $10.53 $10.37

72220 $33.05 $31.40 $36.11 $35.57

72220 TC $24.11 $22.90 $26.34 $25.94

72220 26 $8.94 $8.49 $9.76 $9.61

72240 $144.46 $137.24 $157.83 $155.46

72240 TC $98.43 $93.51 $107.54 $105.93

72240 26 $46.03 $43.73 $50.29 $49.53

72255 $137.59 $130.71 $150.32 $148.06

72255 TC $91.15 $86.59 $99.58 $98.08

72255 26 $46.44 $44.12 $50.74 $49.98

72265 $142.09 $134.99 $155.24 $152.92

72265 TC $99.96 $94.96 $109.20 $107.57

72265 26 $42.13 $40.02 $46.02 $45.33

72270 $221.06 $210.01 $241.51 $237.89

72270 TC $153.60 $145.92 $167.81 $165.29

72270 26 $67.46 $64.09 $73.70 $72.60

72275 $135.83 $129.04 $148.40 $146.17

72275 TC $94.60 $89.87 $103.35 $101.80

72275 26 $41.23 $39.17 $45.05 $44.37

72285 $129.78 $123.29 $141.78 $139.66

72285 TC $67.01 $63.66 $73.21 $72.12

72285 26 $62.76 $59.62 $68.56 $67.54

72291 $184.68 $175.45 $201.77 $198.74

72291 TC $109.90 $104.41 $120.07 $118.27

72291 26 $74.78 $71.04 $81.70 $80.47

72292 $409.26 $388.80 $447.12 $440.42

72292 TC $333.14 $316.48 $363.95 $358.49

72292 26 $76.12 $72.31 $83.16 $81.91

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

72295 $114.51 $108.78 $125.10 $123.22

72295 TC $69.31 $65.84 $75.72 $74.58

72295 26 $45.20 $42.94 $49.38 $48.65

73000 $33.09 $31.44 $36.16 $35.62

73000 TC $24.49 $23.27 $26.76 $26.36

73000 26 $8.60 $8.17 $9.40 $9.26

73010 $36.83 $34.99 $40.24 $39.64

73010 TC $26.79 $25.45 $29.27 $28.83

73010 26 $10.04 $9.54 $10.97 $10.81

73020 $26.99 $25.64 $29.49 $29.05

73020 TC $19.13 $18.17 $20.90 $20.59

73020 26 $7.86 $7.47 $8.59 $8.46

73030 $35.26 $33.50 $38.53 $37.95

73030 TC $24.87 $23.63 $27.17 $26.77

73030 26 $10.38 $9.86 $11.34 $11.17

73040 $120.91 $114.86 $132.09 $130.11

73040 TC $92.68 $88.05 $101.26 $99.74

73040 26 $28.23 $26.82 $30.84 $30.38

73050 $46.30 $43.99 $50.59 $49.83

73050 TC $34.83 $33.09 $38.05 $37.48

73050 26 $11.46 $10.89 $12.52 $12.34

73060 $33.05 $31.40 $36.11 $35.57

73060 TC $24.11 $22.90 $26.34 $25.94

73060 26 $8.94 $8.49 $9.76 $9.61

73070 $32.74 $31.10 $35.77 $35.22

73070 TC $24.49 $23.27 $26.76 $26.36

73070 26 $8.25 $7.84 $9.02 $8.88

73080 $38.41 $36.49 $41.96 $41.33

73080 TC $29.47 $28.00 $32.20 $31.72

73080 26 $8.94 $8.49 $9.76 $9.61

73085 $116.34 $110.52 $127.10 $125.19

73085 TC $86.55 $82.22 $94.55 $93.14

73085 26 $29.79 $28.30 $32.55 $32.06

73090 $31.94 $30.34 $34.89 $34.36

73090 TC $23.34 $22.17 $25.50 $25.12

73090 26 $8.60 $8.17 $9.40 $9.26

73092 $37.30 $35.44 $40.76 $40.15

73092 TC $28.70 $27.27 $31.36 $30.89

73092 26 $8.60 $8.17 $9.40 $9.26

73100 $36.86 $35.02 $40.27 $39.66

73100 TC $27.17 $25.81 $29.68 $29.23

73100 26 $9.69 $9.21 $10.59 $10.43

73110 $43.39 $41.22 $47.40 $46.69

73110 TC $34.45 $32.73 $37.64 $37.08

73110 26 $8.94 $8.49 $9.76 $9.61

73115 $127.42 $121.05 $139.21 $137.11

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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73115 TC $98.43 $93.51 $107.54 $105.93

73115 26 $28.99 $27.54 $31.67 $31.20

73120 $31.55 $29.97 $34.47 $33.95

73120 TC $22.96 $21.81 $25.08 $24.70

73120 26 $8.60 $8.17 $9.40 $9.26

73130 $37.26 $35.40 $40.71 $40.10

73130 TC $28.32 $26.90 $30.94 $30.48

73130 26 $8.94 $8.49 $9.76 $9.61

73140 $38.94 $36.99 $42.54 $41.91

73140 TC $31.77 $30.18 $34.71 $34.19

73140 26 $7.17 $6.81 $7.83 $7.72

73200 $234.88 $223.14 $256.61 $252.76

73200 TC $183.86 $174.67 $200.87 $197.86

73200 26 $51.02 $48.47 $55.74 $54.90

73201 $288.71 $274.27 $315.41 $310.68

73201 TC $229.83 $218.34 $251.09 $247.32

73201 26 $58.87 $55.93 $64.32 $63.35

73202 $368.56 $350.13 $402.65 $396.61

73202 TC $306.83 $291.49 $335.21 $330.19

73202 26 $61.72 $58.63 $67.42 $66.41

73206 $411.63 $391.05 $449.71 $442.96

73206 TC $321.01 $304.96 $350.70 $345.45

73206 26 $90.62 $86.09 $99.00 $97.52

C 73218 $449.70 $427.22 $491.30 $483.93

C 73218 TC $381.16 $362.10 $416.42 $410.17

73218 26 $68.54 $65.11 $74.88 $73.75

73219 $524.88 $498.64 $573.44 $564.83

73219 TC $442.45 $420.33 $483.38 $476.13

73219 26 $82.43 $78.31 $90.06 $88.71

73220 $646.68 $614.35 $706.50 $695.90

73220 TC $537.84 $510.95 $587.59 $578.78

73220 26 $108.83 $103.39 $118.90 $117.12

73221 $312.46 $296.84 $341.37 $336.25

73221 TC $242.47 $230.35 $264.90 $260.92

73221 26 $69.99 $66.49 $76.46 $75.31

73222 $492.32 $467.70 $537.86 $529.78

73222 TC $409.89 $389.40 $447.81 $441.09

73222 26 $82.43 $78.31 $90.06 $88.71

73223 $609.13 $578.67 $665.47 $655.49

73223 TC $500.30 $475.29 $546.58 $538.38

73223 26 $108.83 $103.39 $118.90 $117.12

73225 $536.83 $509.99 $586.49 $577.69

73225 TC $450.88 $428.34 $492.59 $485.20

73225 26 $85.95 $81.65 $93.90 $92.49

73500 $31.46 $29.89 $34.37 $33.86

73500 TC $21.43 $20.36 $23.41 $23.06

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

73500 26 $10.04 $9.54 $10.97 $10.81

73510 $45.11 $42.85 $49.28 $48.54

73510 TC $33.30 $31.64 $36.39 $35.85

73510 26 $11.81 $11.22 $12.90 $12.71

73520 $46.85 $44.51 $51.19 $50.42

73520 TC $32.54 $30.91 $35.55 $35.02

73520 26 $14.31 $13.59 $15.63 $15.40

73525 $120.52 $114.49 $131.66 $129.69

73525 TC $90.38 $85.86 $98.74 $97.26

73525 26 $30.14 $28.63 $32.92 $32.43

73530 $40.46 $38.44 $44.21 $43.54

73530 TC $25.49 $24.22 $27.85 $27.44

73530 26 $14.97 $14.22 $16.35 $16.11

73540 $51.66 $49.08 $56.44 $55.59

73540 TC $40.20 $38.19 $43.92 $43.26

73540 26 $11.46 $10.89 $12.52 $12.34

73550 $32.61 $30.98 $35.63 $35.10

73550 TC $22.96 $21.81 $25.08 $24.70

73550 26 $9.65 $9.17 $10.55 $10.38

73560 $35.68 $33.90 $38.99 $38.40

73560 TC $25.64 $24.36 $28.01 $27.59

73560 26 $10.04 $9.54 $10.97 $10.81

73562 $43.30 $41.14 $47.31 $46.60

73562 TC $32.92 $31.27 $35.96 $35.42

73562 26 $10.38 $9.86 $11.34 $11.17

73564 $50.44 $47.92 $55.11 $54.28

73564 TC $37.90 $36.01 $41.41 $40.79

73564 26 $12.54 $11.91 $13.70 $13.49

73565 $41.42 $39.35 $45.25 $44.57

73565 TC $31.00 $29.45 $33.87 $33.36

73565 26 $10.42 $9.90 $11.39 $11.21

73580 $150.00 $142.50 $163.88 $161.41

73580 TC $119.88 $113.89 $130.97 $129.01

73580 26 $30.11 $28.60 $32.89 $32.40

73590 $31.52 $29.94 $34.43 $33.91

73590 TC $22.58 $21.45 $24.67 $24.30

73590 26 $8.94 $8.49 $9.76 $9.61

73592 $31.94 $30.34 $34.89 $34.36

73592 TC $23.72 $22.53 $25.91 $25.52

73592 26 $8.21 $7.80 $8.97 $8.83

73600 $33.09 $31.44 $36.16 $35.62

73600 TC $24.49 $23.27 $26.76 $26.36

73600 26 $8.60 $8.17 $9.40 $9.26

73610 $38.41 $36.49 $41.96 $41.33

73610 TC $29.47 $28.00 $32.20 $31.72

73610 26 $8.94 $8.49 $9.76 $9.61

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

73615 $120.52 $114.49 $131.66 $129.69

73615 TC $90.77 $86.23 $99.16 $97.68

73615 26 $29.76 $28.27 $32.51 $32.03

73620 $31.55 $29.97 $34.47 $33.95

73620 TC $23.72 $22.53 $25.91 $25.52

73620 26 $7.83 $7.44 $8.56 $8.43

73630 $36.12 $34.31 $39.46 $38.87

73630 TC $27.56 $26.18 $30.11 $29.66

73630 26 $8.56 $8.13 $9.35 $9.21

73650 $32.70 $31.07 $35.73 $35.19

73650 TC $24.49 $23.27 $26.76 $26.36

73650 26 $8.21 $7.80 $8.97 $8.83

73660 $35.11 $33.35 $38.35 $37.78

73660 TC $28.32 $26.90 $30.94 $30.48

73660 26 $6.79 $6.45 $7.42 $7.30

73700 $235.64 $223.86 $257.44 $253.58

73700 TC $184.63 $175.40 $201.71 $198.69

73700 26 $51.02 $48.47 $55.74 $54.90

73701 $292.92 $278.27 $320.01 $315.22

73701 TC $234.05 $222.35 $255.70 $251.86

73701 26 $58.87 $55.93 $64.32 $63.35

73702 $367.79 $349.40 $401.81 $395.78

73702 TC $306.07 $290.77 $334.39 $329.37

73702 26 $61.72 $58.63 $67.42 $66.41

73706 $456.05 $433.25 $498.24 $490.76

73706 TC $360.09 $342.09 $393.40 $387.50

73706 26 $95.96 $91.16 $104.83 $103.26

C 73718 $449.67 $427.19 $491.27 $483.90

C 73718 TC $381.16 $362.10 $416.42 $410.17

73718 26 $68.51 $65.08 $74.84 $73.72

73719 $533.70 $507.02 $583.07 $574.32

73719 TC $451.26 $428.70 $493.01 $485.61

73719 26 $82.43 $78.31 $90.06 $88.71

73720 $650.89 $618.35 $711.10 $700.43

73720 TC $542.44 $515.32 $592.62 $583.73

73720 26 $108.45 $103.03 $118.48 $116.70

73721 $312.46 $296.84 $341.37 $336.25

73721 TC $242.47 $230.35 $264.90 $260.92

73721 26 $69.99 $66.49 $76.46 $75.31

73722 $499.57 $474.59 $545.78 $537.59

73722 TC $416.40 $395.58 $454.92 $448.10

73722 26 $83.17 $79.01 $90.86 $89.49

73723 $608.75 $578.31 $665.06 $655.09

73723 TC $499.92 $474.92 $546.16 $537.97

73723 26 $108.83 $103.39 $118.90 $117.12

73725 $531.07 $504.52 $580.20 $571.49

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

73725 TC $439.77 $417.78 $480.45 $473.24

73725 26 $91.30 $86.74 $99.75 $98.26

74000 $27.27 $25.91 $29.80 $29.35

74000 TC $17.98 $17.08 $19.64 $19.34

74000 26 $9.29 $8.83 $10.15 $10.01

74010 $43.95 $41.75 $48.01 $47.29

74010 TC $32.15 $30.54 $35.12 $34.59

74010 26 $11.79 $11.20 $12.88 $12.68

74020 $45.72 $43.43 $49.94 $49.20

74020 TC $32.15 $30.54 $35.12 $34.59

74020 26 $13.57 $12.89 $14.82 $14.61

74022 $55.12 $52.36 $60.21 $59.31

74022 TC $39.05 $37.10 $42.67 $42.02

74022 26 $16.07 $15.27 $17.56 $17.30

74150 $198.19 $188.28 $216.52 $213.28

74150 TC $137.89 $131.00 $150.65 $148.40

74150 26 $60.30 $57.29 $65.88 $64.89

74160 $313.60 $297.92 $342.61 $337.47

74160 TC $248.99 $236.54 $272.02 $267.94

74160 26 $64.61 $61.38 $70.59 $69.53

74170 $361.38 $343.31 $394.81 $388.88

74170 TC $290.36 $275.84 $317.22 $312.46

74170 26 $71.01 $67.46 $77.58 $76.42

74174 $562.54 $534.41 $614.57 $605.35

74174 TC $451.26 $428.70 $493.01 $485.61

74174 26 $111.28 $105.72 $121.58 $119.75

74175 $456.79 $433.95 $499.04 $491.56

74175 TC $360.47 $342.45 $393.82 $387.91

74175 26 $96.32 $91.50 $105.23 $103.65

74176 $255.14 $242.38 $278.74 $274.55

74176 TC $167.00 $158.65 $182.45 $179.71

74176 26 $88.13 $83.72 $96.28 $94.83

74177 $387.02 $367.67 $422.82 $416.47

74177 TC $294.96 $280.21 $322.24 $317.41

74177 26 $92.06 $87.46 $100.58 $99.07

74178 $453.71 $431.02 $495.67 $488.23

74178 TC $351.66 $334.08 $384.19 $378.43

74178 26 $102.06 $96.96 $111.50 $109.84

74181 $425.14 $403.88 $464.46 $457.49

74181 TC $351.66 $334.08 $384.19 $378.43

74181 26 $73.48 $69.81 $80.28 $79.07

74182 $588.09 $558.69 $642.49 $632.86

74182 TC $500.68 $475.65 $547.00 $538.80

74182 26 $87.40 $83.03 $95.48 $94.05

74183 $653.56 $620.88 $714.01 $703.31

74183 TC $539.76 $512.77 $589.69 $580.84

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

74183 26 $113.80 $108.11 $124.33 $122.46

74185 $527.69 $501.31 $576.51 $567.86

74185 TC $437.09 $415.24 $477.53 $470.36

74185 26 $90.60 $86.07 $98.98 $97.50

74190 $81.80 $77.71 $89.37 $88.02

74190 TC $57.19 $54.33 $62.48 $61.55

74190 26 $24.61 $23.38 $26.89 $26.48

74210 $89.07 $84.62 $97.31 $95.85

74210 TC $71.23 $67.67 $77.82 $76.65

74210 26 $17.84 $16.95 $19.49 $19.21

74220 $103.98 $98.78 $113.60 $111.90

74220 TC $80.42 $76.40 $87.86 $86.54

74220 26 $23.56 $22.38 $25.74 $25.35

74230 $102.97 $97.82 $112.49 $110.80

74230 TC $76.21 $72.40 $83.26 $82.01

74230 26 $26.76 $25.42 $29.23 $28.80

74235 26 $69.03 $65.58 $75.42 $74.29

74240 $129.18 $122.72 $141.13 $139.01

74240 TC $93.83 $89.14 $102.51 $100.97

74240 26 $35.35 $33.58 $38.62 $38.04

74241 $135.34 $128.57 $147.86 $145.64

74241 TC $100.73 $95.69 $110.04 $108.39

74241 26 $34.61 $32.88 $37.81 $37.25

C 74245 $184.30 $175.09 $201.35 $198.33

C 74245 TC $138.27 $131.36 $151.06 $148.80

74245 26 $46.03 $43.73 $50.29 $49.53

74246 $146.04 $138.74 $159.55 $157.16

74246 TC $111.07 $105.52 $121.35 $119.53

74246 26 $34.97 $33.22 $38.20 $37.63

74247 $162.90 $154.76 $177.97 $175.31

74247 TC $127.93 $121.53 $139.76 $137.67

74247 26 $34.97 $33.22 $38.20 $37.63

C 74249 $184.30 $175.09 $201.35 $198.33

C 74249 TC $138.27 $131.36 $151.06 $148.80

74249 26 $46.03 $43.73 $50.29 $49.53

C 74250 $116.97 $111.12 $127.79 $125.87

C 74250 TC $93.07 $88.42 $101.68 $100.15

74250 26 $23.91 $22.71 $26.12 $25.73

C 74251 $173.27 $164.61 $189.30 $186.46

C 74251 TC $138.30 $131.39 $151.10 $148.83

74251 26 $34.97 $33.22 $38.20 $37.63

C 74260 $118.42 $112.50 $129.38 $127.43

C 74260 TC $93.09 $88.44 $101.71 $100.18

74260 26 $25.33 $24.06 $27.67 $27.26

C 74261 $316.73 $300.89 $346.02 $340.84

C 74261 TC $195.38 $185.61 $213.45 $210.25

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

74261 26 $121.35 $115.28 $132.57 $130.58

C 74262 $460.72 $437.68 $503.33 $495.78

C 74262 TC $334.80 $318.06 $365.77 $360.28

74262 26 $125.92 $119.62 $137.56 $135.50

C 74270 $173.24 $164.58 $189.27 $186.43

C 74270 TC $138.27 $131.36 $151.06 $148.80

74270 26 $34.97 $33.22 $38.20 $37.63

C 74280 $188.23 $178.82 $205.64 $202.56

C 74280 TC $138.27 $131.36 $151.06 $148.80

74280 26 $49.96 $47.46 $54.58 $53.76

74283 $222.86 $211.72 $243.48 $239.82

74283 TC $122.56 $116.43 $133.89 $131.88

74283 26 $100.30 $95.29 $109.58 $107.94

74290 $79.64 $75.66 $87.01 $85.71

74290 TC $63.57 $60.39 $69.45 $68.40

74290 26 $16.07 $15.27 $17.56 $17.30

74291 $78.53 $74.60 $85.79 $84.50

74291 TC $68.16 $64.75 $74.46 $73.35

74291 26 $10.37 $9.85 $11.33 $11.16

74300 $55.60 $52.82 $60.74 $59.83

74300 TC $37.05 $35.20 $40.48 $39.87

74300 26 $18.55 $17.62 $20.26 $19.96

74301 26 $11.04 $10.49 $12.06 $11.88

74305 $60.96 $57.91 $66.60 $65.60

74305 TC $39.20 $37.24 $42.83 $42.18

74305 26 $21.76 $20.67 $23.77 $23.41

74320 $111.36 $105.79 $121.66 $119.83

74320 TC $84.25 $80.04 $92.05 $90.67

74320 26 $27.10 $25.75 $29.61 $29.16

74327 $159.19 $151.23 $173.91 $171.30

74327 TC $121.03 $114.98 $132.23 $130.25

74327 26 $38.16 $36.25 $41.69 $41.07

74328 $192.90 $183.26 $210.75 $207.59

74328 TC $156.08 $148.28 $170.52 $167.97

74328 26 $36.82 $34.98 $40.23 $39.63

74329 26 $37.20 $35.34 $40.64 $40.03

74330 $203.57 $193.39 $222.40 $219.06

74330 TC $156.41 $148.59 $170.88 $168.31

74330 26 $47.16 $44.80 $51.52 $50.75

74340 $139.75 $132.76 $152.67 $150.39

74340 TC $111.91 $106.31 $122.26 $120.43

74340 26 $27.84 $26.45 $30.42 $29.96

74355 26 $39.62 $37.64 $43.29 $42.64

74360 $163.45 $155.28 $178.57 $175.89

74360 TC $133.69 $127.01 $146.06 $143.87

74360 26 $29.76 $28.27 $32.51 $32.03

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

74363 26 $44.91 $42.66 $49.06 $48.32

74400 $128.78 $122.34 $140.69 $138.58

74400 TC $103.79 $98.60 $113.39 $111.69

74400 26 $24.98 $23.73 $27.29 $26.88

74410 $127.24 $120.88 $139.01 $136.93

74410 TC $102.64 $97.51 $112.14 $110.46

74410 26 $24.60 $23.37 $26.88 $26.47

74415 $158.27 $150.36 $172.91 $170.32

74415 TC $133.29 $126.63 $145.62 $143.44

74415 26 $24.98 $23.73 $27.29 $26.88

74420 $148.17 $140.76 $161.87 $159.45

74420 TC $129.62 $123.14 $141.61 $139.48

74420 26 $18.55 $17.62 $20.26 $19.96

74425 $82.89 $78.75 $90.56 $89.21

74425 TC $64.72 $61.48 $70.70 $69.64

74425 26 $18.17 $17.26 $19.85 $19.55

74430 $45.54 $43.26 $49.75 $49.00

74430 TC $29.85 $28.36 $32.61 $32.12

74430 26 $15.69 $14.91 $17.15 $16.89

74440 $95.46 $90.69 $104.29 $102.73

74440 TC $75.83 $72.04 $82.85 $81.60

74440 26 $19.63 $18.65 $21.45 $21.13

74445 $109.64 $104.16 $119.78 $117.99

74445 TC $51.16 $48.60 $55.89 $55.05

74445 26 $58.48 $55.56 $63.89 $62.94

74450 $89.33 $84.86 $97.59 $96.13

74450 TC $72.20 $68.59 $78.88 $77.69

74450 26 $17.13 $16.27 $18.71 $18.43

74455 $96.46 $91.64 $105.39 $103.81

74455 TC $80.04 $76.04 $87.45 $86.14

74455 26 $16.42 $15.60 $17.94 $17.68

74470 $82.25 $78.14 $89.86 $88.52

74470 TC $54.79 $52.05 $59.86 $58.96

74470 26 $27.46 $26.09 $30.00 $29.56

74475 $109.83 $104.34 $119.99 $118.19

74475 TC $82.72 $78.58 $90.37 $89.01

74475 26 $27.10 $25.75 $29.61 $29.16

74480 $109.83 $104.34 $119.99 $118.19

74480 TC $82.72 $78.58 $90.37 $89.01

74480 26 $27.10 $25.75 $29.61 $29.16

74485 $110.21 $104.70 $120.41 $118.60

74485 TC $83.10 $78.95 $90.79 $89.44

74485 26 $27.10 $25.75 $29.61 $29.16

74710 $36.66 $34.83 $40.05 $39.46

74710 TC $21.04 $19.99 $22.99 $22.64

74710 26 $15.61 $14.83 $17.05 $16.80

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

74740 $87.85 $83.46 $95.98 $94.54

74740 TC $68.93 $65.48 $75.30 $74.18

74740 26 $18.92 $17.97 $20.67 $20.36

74742 $165.73 $157.44 $181.06 $178.34

74742 TC $133.95 $127.25 $146.34 $144.14

74742 26 $31.78 $30.19 $34.72 $34.20

74775 $103.62 $98.44 $113.21 $111.50

74775 TC $71.49 $67.92 $78.11 $76.94

74775 26 $32.13 $30.52 $35.10 $34.57

75557 $404.28 $384.07 $441.68 $435.06

75557 TC $286.15 $271.84 $312.62 $307.92

75557 26 $118.14 $112.23 $129.06 $127.13

C 75559 $528.89 $502.45 $577.82 $569.15

C 75559 TC $381.16 $362.10 $416.42 $410.17

75559 26 $147.73 $140.34 $161.39 $158.96

75561 $541.66 $514.58 $591.77 $582.89

75561 TC $411.42 $390.85 $449.48 $442.74

75561 26 $130.24 $123.73 $142.29 $140.15

75563 $640.22 $608.21 $699.44 $688.95

75563 TC $490.34 $465.82 $535.69 $527.65

75563 26 $149.88 $142.39 $163.75 $161.29

75565 $71.07 $67.52 $77.65 $76.49

75565 TC $58.59 $55.66 $64.01 $63.05

75565 26 $12.49 $11.87 $13.65 $13.44

C 75571 $84.45 $80.23 $92.26 $90.88

C 75571 TC $55.90 $53.11 $61.08 $60.16

75571 26 $28.55 $27.12 $31.19 $30.72

75572 $346.80 $329.46 $378.88 $373.20

75572 TC $259.71 $246.72 $283.73 $279.47

75572 26 $87.09 $82.74 $95.15 $93.73

C 75573 $427.38 $406.01 $466.91 $459.91

C 75573 TC $300.71 $285.67 $328.52 $323.59

75573 26 $126.67 $120.34 $138.39 $136.31

C 75574 $420.63 $399.60 $459.54 $452.65

C 75574 TC $301.09 $286.04 $328.95 $324.01

75574 26 $119.54 $113.56 $130.59 $128.64

75600 $242.56 $230.43 $264.99 $261.02

75600 TC $217.96 $207.06 $238.12 $234.54

75600 26 $24.60 $23.37 $26.88 $26.47

75605 $172.32 $163.70 $188.26 $185.43

75605 TC $115.29 $109.53 $125.96 $124.07

75605 26 $57.03 $54.18 $62.31 $61.38

75625 $172.62 $163.99 $188.59 $185.76

75625 TC $115.67 $109.89 $126.37 $124.48

75625 26 $56.95 $54.10 $62.22 $61.28

75630 $203.24 $193.08 $222.04 $218.71

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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75630 TC $114.52 $108.79 $125.11 $123.23

75630 26 $88.72 $84.28 $96.92 $95.47

C 75635 $502.45 $477.33 $548.93 $540.70

C 75635 TC $381.87 $362.78 $417.20 $410.94

75635 26 $120.58 $114.55 $131.73 $129.75

75658 $204.24 $194.03 $223.13 $219.79

75658 TC $140.19 $133.18 $153.16 $150.86

75658 26 $64.06 $60.86 $69.99 $68.94

75705 $273.19 $259.53 $298.46 $293.99

75705 TC $163.17 $155.01 $178.26 $175.58

75705 26 $110.01 $104.51 $120.19 $118.38

75710 $201.10 $191.05 $219.71 $216.41

75710 TC $145.17 $137.91 $158.60 $156.22

75710 26 $55.94 $53.14 $61.11 $60.19

75716 $240.91 $228.86 $263.19 $259.24

75716 TC $175.38 $166.61 $191.60 $188.73

75716 26 $65.53 $62.25 $71.59 $70.52

75726 $201.79 $191.70 $220.46 $217.14

75726 TC $144.40 $137.18 $157.76 $155.39

75726 26 $57.39 $54.52 $62.70 $61.76

75731 $186.57 $177.24 $203.83 $200.77

75731 TC $129.46 $122.99 $141.44 $139.32

75731 26 $57.11 $54.25 $62.39 $61.46

75733 $232.27 $220.66 $253.76 $249.95

75733 TC $166.95 $158.60 $182.39 $179.65

75733 26 $65.32 $62.05 $71.36 $70.29

75736 $194.97 $185.22 $213.00 $209.81

75736 TC $139.42 $132.45 $152.32 $150.03

75736 26 $55.55 $52.77 $60.69 $59.78

75741 $180.49 $171.47 $197.19 $194.24

75741 TC $114.90 $109.16 $125.53 $123.65

75741 26 $65.59 $62.31 $71.66 $70.59

75743 $209.45 $198.98 $228.83 $225.40

75743 TC $126.78 $120.44 $138.51 $136.42

75743 26 $82.67 $78.54 $90.32 $88.96

75746 $189.56 $180.08 $207.09 $203.99

75746 TC $131.76 $125.17 $143.95 $141.78

75746 26 $57.80 $54.91 $63.15 $62.20

75756 $213.28 $202.62 $233.01 $229.52

75756 TC $151.68 $144.10 $165.72 $163.23

75756 26 $61.60 $58.52 $67.30 $66.29

75774 $114.30 $108.59 $124.88 $123.00

75774 TC $96.13 $91.32 $105.02 $103.44

75774 26 $18.17 $17.26 $19.85 $19.55

75791 $378.60 $359.67 $413.62 $407.41

75791 TC $294.19 $279.48 $321.40 $316.58

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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75791 26 $84.41 $80.19 $92.22 $90.84

75801 26 $46.80 $44.46 $51.13 $50.36

75803 26 $60.67 $57.64 $66.29 $65.30

75805 26 $42.12 $40.01 $46.01 $45.32

75807 26 $60.67 $57.64 $66.29 $65.30

C 75809 $103.95 $98.75 $113.56 $111.86

C 75809 TC $79.66 $75.68 $87.03 $85.72

75809 26 $24.29 $23.08 $26.54 $26.14

75810 26 $58.86 $55.92 $64.31 $63.34

75820 $142.17 $135.06 $155.32 $152.98

75820 TC $106.86 $101.52 $116.75 $115.00

75820 26 $35.32 $33.55 $38.58 $38.01

75822 $176.05 $167.25 $192.34 $189.45

75822 TC $122.95 $116.80 $134.32 $132.31

75822 26 $53.10 $50.45 $58.02 $57.14

75825 $166.16 $157.85 $181.53 $178.80

75825 TC $109.54 $104.06 $119.67 $117.88

75825 26 $56.62 $53.79 $61.86 $60.93

75827 $170.02 $161.52 $185.75 $182.97

75827 TC $113.75 $108.06 $124.27 $122.41

75827 26 $56.26 $53.45 $61.47 $60.55

75831 $178.74 $169.80 $195.27 $192.34

75831 TC $116.05 $110.25 $126.79 $124.89

75831 26 $62.69 $59.56 $68.49 $67.47

75833 $207.43 $197.06 $226.62 $223.22

75833 TC $135.21 $128.45 $147.72 $145.50

75833 26 $72.23 $68.62 $78.91 $77.73

75840 $179.13 $170.17 $195.70 $192.76

75840 TC $114.90 $109.16 $125.53 $123.65

75840 26 $64.22 $61.01 $70.16 $69.10

75842 $213.56 $202.88 $233.31 $229.82

75842 TC $137.89 $131.00 $150.65 $148.40

75842 26 $75.67 $71.89 $82.67 $81.43

75860 $172.67 $164.04 $188.65 $185.82

75860 TC $115.29 $109.53 $125.96 $124.07

75860 26 $57.39 $54.52 $62.70 $61.76

75870 $172.32 $163.70 $188.26 $185.43

75870 TC $114.52 $108.79 $125.11 $123.23

75870 26 $57.80 $54.91 $63.15 $62.20

75872 $172.32 $163.70 $188.26 $185.43

75872 TC $114.52 $108.79 $125.11 $123.23

75872 26 $57.80 $54.91 $63.15 $62.20

75880 $269.36 $255.89 $294.27 $289.86

75880 TC $230.60 $219.07 $251.93 $248.15

75880 26 $38.76 $36.82 $42.34 $41.71

75885 $188.07 $178.67 $205.47 $202.39

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

75885 TC $116.05 $110.25 $126.79 $124.89

75885 26 $72.02 $68.42 $78.68 $77.50

75887 $186.24 $176.93 $203.47 $200.42

75887 TC $115.29 $109.53 $125.96 $124.07

75887 26 $70.95 $67.40 $77.51 $76.35

75889 $173.85 $165.16 $189.93 $187.08

75889 TC $116.82 $110.98 $127.63 $125.72

75889 26 $57.03 $54.18 $62.31 $61.38

75891 $173.85 $165.16 $189.93 $187.08

75891 TC $116.43 $110.61 $127.20 $125.29

75891 26 $57.41 $54.54 $62.72 $61.78

75893 $142.83 $135.69 $156.04 $153.70

75893 TC $116.43 $110.61 $127.20 $125.29

75893 26 $26.39 $25.07 $28.83 $28.39

75894 $1,258.93 $1,195.98 $1,375.38 $1,354.75

75894 TC $1,190.50 $1,130.98 $1,300.63 $1,281.12

75894 26 $68.43 $65.01 $74.76 $73.63

75896 $1,103.37 $1,048.20 $1,205.43 $1,187.35

75896 TC $1,035.32 $983.55 $1,131.08 $1,114.12

75896 26 $68.05 $64.65 $74.35 $73.23

75898 $140.53 $133.50 $153.53 $151.23

75898 TC $53.50 $50.83 $58.45 $57.58

75898 26 $87.03 $82.68 $95.08 $93.66

75901 $199.27 $189.31 $217.71 $214.44

75901 TC $174.67 $165.94 $190.83 $187.97

75901 26 $24.60 $23.37 $26.88 $26.47

75902 $85.43 $81.16 $93.33 $91.93

75902 TC $65.48 $62.21 $71.54 $70.47

75902 26 $19.95 $18.95 $21.79 $21.47

75945 $212.97 $202.32 $232.67 $229.18

C 75945 TC $174.28 $165.57 $190.41 $187.55

75945 26 $20.27 $19.26 $22.15 $21.82

75946 $113.91 $108.21 $124.44 $122.58

75946 TC $93.31 $88.64 $101.94 $100.41

75946 26 $20.60 $19.57 $22.51 $22.17

75952 26 $237.12 $225.26 $259.05 $255.16

75953 26 $72.17 $68.56 $78.84 $77.66

75954 26 $118.40 $112.48 $129.35 $127.41

75956 26 $372.51 $353.88 $406.96 $400.86

75957 26 $317.72 $301.83 $347.10 $341.90

75958 26 $211.78 $201.19 $231.37 $227.90

75959 26 $183.65 $174.47 $200.64 $197.63

75960 $139.80 $132.81 $152.73 $150.44

75960 TC $99.20 $94.24 $108.38 $106.75

75960 26 $40.61 $38.58 $44.37 $43.70

75962 $170.36 $161.84 $186.12 $183.32

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

75962 TC $143.63 $136.45 $156.92 $154.56

75962 26 $26.72 $25.38 $29.19 $28.75

75964 $110.06 $104.56 $120.24 $118.44

75964 TC $91.53 $86.95 $99.99 $98.50

75964 26 $18.52 $17.59 $20.23 $19.93

75966 $197.38 $187.51 $215.64 $212.41

75966 TC $132.91 $126.26 $145.20 $143.03

75966 26 $64.47 $61.25 $70.44 $69.38

75968 $99.80 $94.81 $109.03 $107.40

75968 TC $82.34 $78.22 $89.95 $88.61

75968 26 $17.46 $16.59 $19.08 $18.79

75970 $587.91 $558.51 $642.29 $632.65

75970 TC $545.86 $518.57 $596.36 $587.41

75970 26 $42.05 $39.95 $45.94 $45.25

75978 $168.82 $160.38 $184.44 $181.67

75978 TC $142.10 $135.00 $155.25 $152.93

75978 26 $26.72 $25.38 $29.19 $28.75

75980 $306.01 $290.71 $334.32 $329.30

75980 TC $232.57 $220.94 $254.08 $250.27

75980 26 $73.44 $69.77 $80.24 $79.03

75982 26 $73.44 $69.77 $80.24 $79.03

75984 $125.25 $118.99 $136.84 $134.79

75984 TC $89.23 $84.77 $97.49 $96.03

75984 26 $36.01 $34.21 $39.34 $38.76

75989 $138.10 $131.20 $150.88 $148.61

75989 TC $78.89 $74.95 $86.19 $84.90

75989 26 $59.21 $56.25 $64.69 $63.72

76000 $59.10 $56.15 $64.57 $63.61

76000 TC $50.16 $47.65 $54.80 $53.98

76000 26 $8.94 $8.49 $9.76 $9.61

76001 $170.27 $161.76 $186.02 $183.23

76001 TC $133.42 $126.75 $145.76 $143.58

76001 26 $36.85 $35.01 $40.26 $39.65

76010 $30.33 $28.81 $33.13 $32.64

76010 TC $21.04 $19.99 $22.99 $22.64

76010 26 $9.29 $8.83 $10.15 $10.01

76080 $67.30 $63.94 $73.53 $72.43

76080 TC $40.20 $38.19 $43.92 $43.26

76080 26 $27.10 $25.75 $29.61 $29.16

76098 $20.83 $19.79 $22.76 $22.41

76098 TC $12.61 $11.98 $13.78 $13.57

76098 26 $8.21 $7.80 $8.97 $8.83

C 76100 $112.31 $106.69 $122.69 $120.85

C 76100 TC $79.66 $75.68 $87.03 $85.72

76100 26 $32.65 $31.02 $35.67 $35.13

76101 $173.91 $165.21 $189.99 $187.14

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

76101 TC $136.74 $129.90 $149.39 $147.14

76101 26 $37.17 $35.31 $40.61 $40.00

76102 $233.23 $221.57 $254.81 $250.99

76102 TC $195.35 $185.58 $213.42 $210.22

76102 26 $37.88 $35.99 $41.39 $40.77

76120 $85.50 $81.23 $93.41 $92.01

76120 TC $65.87 $62.58 $71.97 $70.89

76120 26 $19.63 $18.65 $21.45 $21.13

76125 $45.82 $43.53 $50.06 $49.31

76125 TC $31.16 $29.60 $34.04 $33.53

76125 26 $14.66 $13.93 $16.02 $15.78

76376 $67.04 $63.69 $73.24 $72.14

76376 TC $57.05 $54.20 $62.33 $61.40

76376 26 $9.98 $9.48 $10.90 $10.74

76377 $90.13 $85.62 $98.46 $96.99

76377 TC $50.16 $47.65 $54.80 $53.98

76377 26 $39.97 $37.97 $43.67 $43.01

C 76380 $160.71 $152.67 $175.57 $172.94

C 76380 TC $111.45 $105.88 $121.76 $119.93

76380 26 $49.26 $46.80 $53.82 $53.02

C 76506 $105.26 $100.00 $115.00 $113.28

C 76506 TC $72.76 $69.12 $79.49 $78.29

76506 26 $32.50 $30.88 $35.51 $34.98

76510 $199.06 $189.11 $217.48 $214.21

76510 TC $96.90 $92.06 $105.87 $104.28

76510 26 $102.16 $97.05 $111.61 $109.93

76511 $113.05 $107.40 $123.51 $121.66

76511 TC $57.44 $54.57 $62.76 $61.81

76511 26 $55.61 $52.83 $60.75 $59.85

76512 $104.54 $99.31 $114.21 $112.49

76512 TC $47.48 $45.11 $51.88 $51.09

76512 26 $57.06 $54.21 $62.34 $61.41

76513 $109.84 $104.35 $120.00 $118.20

76513 TC $72.00 $68.40 $78.66 $77.48

76513 26 $37.84 $35.95 $41.34 $40.72

76514 $16.58 $15.75 $18.11 $17.84

76514 TC $6.49 $6.17 $7.10 $6.99

76514 26 $10.09 $9.59 $11.03 $10.87

76516 $89.19 $84.73 $97.44 $95.98

76516 TC $56.67 $53.84 $61.92 $60.98

76516 26 $32.52 $30.89 $35.52 $34.99

76519 $96.80 $91.96 $105.75 $104.17

76519 TC $63.18 $60.02 $69.02 $67.99

76519 26 $33.62 $31.94 $36.73 $36.18

76529 $90.56 $86.03 $98.93 $97.45

76529 TC $55.52 $52.74 $60.65 $59.74

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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76529 26 $35.04 $33.29 $38.28 $37.71

76536 $138.49 $131.57 $151.31 $149.04

76536 TC $109.92 $104.42 $120.08 $118.28

76536 26 $28.56 $27.13 $31.20 $30.73

76604 $99.06 $94.11 $108.23 $106.61

76604 TC $71.23 $67.67 $77.82 $76.65

76604 26 $27.83 $26.44 $30.41 $29.95

C 76645 $100.60 $95.57 $109.91 $108.26

C 76645 TC $72.76 $69.12 $79.49 $78.29

76645 26 $27.84 $26.45 $30.42 $29.96

C 76700 $152.89 $145.25 $167.04 $164.53

C 76700 TC $111.84 $106.25 $122.19 $120.36

76700 26 $41.05 $39.00 $44.85 $44.18

76705 $121.91 $115.81 $133.18 $131.18

76705 TC $92.30 $87.69 $100.84 $99.33

76705 26 $29.61 $28.13 $32.35 $31.87

C 76770 $149.31 $141.84 $163.12 $160.67

C 76770 TC $111.84 $106.25 $122.19 $120.36

76770 26 $37.47 $35.60 $40.94 $40.33

76775 $122.71 $116.57 $134.06 $132.04

76775 TC $93.45 $88.78 $102.10 $100.57

76775 26 $29.26 $27.80 $31.97 $31.49

76776 $173.37 $164.70 $189.41 $186.56

76776 TC $135.21 $128.45 $147.72 $145.50

76776 26 $38.17 $36.26 $41.70 $41.08

76800 $146.00 $138.70 $159.51 $157.11

76800 TC $88.85 $84.41 $97.07 $95.61

76800 26 $57.15 $54.29 $62.43 $61.50

76801 $141.55 $134.47 $154.64 $152.32

76801 TC $91.15 $86.59 $99.58 $98.08

76801 26 $50.40 $47.88 $55.06 $54.23

76802 $72.40 $68.78 $79.10 $77.91

76802 TC $29.85 $28.36 $32.61 $32.12

76802 26 $42.54 $40.41 $46.47 $45.77

C 76805 $162.62 $154.49 $177.66 $175.00

C 76805 TC $111.84 $106.25 $122.19 $120.36

76805 26 $50.78 $48.24 $55.48 $54.65

76810 $107.10 $101.75 $117.01 $115.25

76810 TC $57.05 $54.20 $62.33 $61.40

76810 26 $50.05 $47.55 $54.68 $53.87

76811 $206.43 $196.11 $225.53 $222.15

76811 TC $108.01 $102.61 $118.00 $116.23

76811 26 $98.43 $93.51 $107.54 $105.93

C 76812 $165.49 $157.22 $180.80 $178.09

C 76812 TC $72.76 $69.12 $79.49 $78.29

76812 26 $92.73 $88.09 $101.30 $99.79

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

76813 $135.48 $128.71 $148.02 $145.80

76813 TC $74.29 $70.58 $81.17 $79.95

76813 26 $61.18 $58.12 $66.84 $65.84

76814 $87.15 $82.79 $95.21 $93.78

76814 TC $35.60 $33.82 $38.89 $38.31

76814 26 $51.55 $48.97 $56.32 $55.48

76815 $101.06 $96.01 $110.41 $108.76

76815 TC $68.55 $65.12 $74.89 $73.76

76815 26 $32.51 $30.88 $35.51 $34.98

C 76816 $116.76 $110.92 $127.56 $125.65

C 76816 TC $72.76 $69.12 $79.49 $78.29

76816 26 $44.00 $41.80 $48.07 $47.35

C 76817 $111.37 $105.80 $121.67 $119.84

C 76817 TC $72.76 $69.12 $79.49 $78.29

76817 26 $38.61 $36.68 $42.18 $41.55

76818 $137.89 $131.00 $150.65 $148.40

76818 TC $83.49 $79.32 $91.22 $89.85

76818 26 $54.40 $51.68 $59.43 $58.54

76819 $100.19 $95.18 $109.46 $107.81

76819 TC $60.50 $57.48 $66.10 $65.11

76819 26 $39.69 $37.71 $43.37 $42.71

76820 $44.13 $41.92 $48.21 $47.48

76820 TC $18.36 $17.44 $20.06 $19.76

76820 26 $25.77 $24.48 $28.15 $27.73

76821 $106.57 $101.24 $116.43 $114.68

76821 TC $70.08 $66.58 $76.57 $75.42

76821 26 $36.49 $34.67 $39.87 $39.27

76825 $243.68 $231.50 $266.23 $262.23

76825 TC $158.58 $150.65 $173.25 $170.65

76825 26 $85.10 $80.85 $92.98 $91.59

76826 $147.48 $140.11 $161.13 $158.71

76826 TC $104.94 $99.69 $114.64 $112.92

76826 26 $42.54 $40.41 $46.47 $45.77

76827 $66.06 $62.76 $72.17 $71.09

76827 TC $36.75 $34.91 $40.15 $39.55

76827 26 $29.31 $27.84 $32.02 $31.53

76828 $48.51 $46.08 $52.99 $52.20

76828 TC $19.89 $18.90 $21.74 $21.41

76828 26 $28.62 $27.19 $31.27 $30.80

76830 $83.24 $79.08 $90.94 $89.57

76830 TC $47.86 $45.47 $52.29 $51.51

76830 26 $35.38 $33.61 $38.65 $38.08

76831 $142.51 $135.38 $155.69 $153.35

76831 TC $104.94 $99.69 $114.64 $112.92

76831 26 $37.57 $35.69 $41.04 $40.42

76856 $140.32 $133.30 $153.30 $151.00

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

76856 TC $105.71 $100.42 $115.48 $113.75

76856 26 $34.61 $32.88 $37.81 $37.25

C 76857 $92.39 $87.77 $100.94 $99.42

C 76857 TC $72.76 $69.12 $79.49 $78.29

76857 26 $19.63 $18.65 $21.45 $21.13

76870 $140.47 $133.45 $153.47 $151.17

76870 TC $108.01 $102.61 $118.00 $116.23

76870 26 $32.47 $30.85 $35.48 $34.95

76872 $80.15 $76.14 $87.56 $86.25

76872 TC $45.56 $43.28 $49.77 $49.02

76872 26 $34.59 $32.86 $37.79 $37.23

76873 $189.21 $179.75 $206.71 $203.61

76873 TC $109.54 $104.06 $119.67 $117.88

76873 26 $79.67 $75.69 $87.04 $85.73

76881 $137.83 $130.94 $150.58 $148.33

76881 TC $105.32 $100.05 $115.06 $113.33

76881 26 $32.50 $30.88 $35.51 $34.98

76882 $37.95 $36.05 $41.46 $40.84

76882 TC $13.00 $12.35 $14.20 $13.98

76882 26 $24.96 $23.71 $27.27 $26.85

C 76885 $110.23 $104.72 $120.43 $118.62

C 76885 TC $72.76 $69.12 $79.49 $78.29

76885 26 $37.47 $35.60 $40.94 $40.33

C 76886 $103.47 $98.30 $113.05 $111.35

C 76886 TC $72.76 $69.12 $79.49 $78.29

76886 26 $30.70 $29.17 $33.55 $33.04

76930 $94.09 $89.39 $102.80 $101.26

76930 TC $61.27 $58.21 $66.94 $65.94

76930 26 $32.82 $31.18 $35.86 $35.32

76932 $104.48 $99.26 $114.15 $112.44

76932 26 $33.89 $32.20 $37.03 $36.48

C 76936 $223.62 $212.44 $244.31 $240.64

C 76936 TC $122.56 $116.43 $133.89 $131.88

76936 26 $101.06 $96.01 $110.41 $108.76

76937 $39.81 $37.82 $43.49 $42.84

76937 TC $24.49 $23.27 $26.76 $26.36

76937 26 $15.32 $14.55 $16.73 $16.48

76940 $198.13 $188.22 $216.45 $213.21

76940 TC $90.38 $85.86 $98.74 $97.26

76940 26 $107.75 $102.36 $117.71 $115.94

76941 $144.20 $136.99 $157.54 $155.18

76941 TC $71.90 $68.31 $78.56 $77.38

76941 26 $72.30 $68.69 $78.99 $77.81

76942 $232.31 $220.69 $253.79 $249.99

76942 TC $198.03 $188.13 $216.35 $213.11

76942 26 $34.27 $32.56 $37.44 $36.88

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

76945 $111.92 $106.32 $122.27 $120.44

76945 TC $76.11 $72.30 $83.15 $81.90

76945 26 $35.81 $34.02 $39.12 $38.54

76946 $35.36 $33.59 $38.63 $38.05

76946 TC $15.68 $14.90 $17.14 $16.88

76946 26 $19.69 $18.71 $21.52 $21.19

76948 $36.46 $34.64 $39.84 $39.24

76948 TC $16.06 $15.26 $17.55 $17.28

76948 26 $20.40 $19.38 $22.29 $21.95

76950 $55.28 $52.52 $60.40 $59.49

76950 TC $24.87 $23.63 $27.17 $26.77

76950 26 $30.41 $28.89 $33.22 $32.73

76965 $96.10 $91.30 $105.00 $103.42

76965 TC $27.56 $26.18 $30.11 $29.66

76965 26 $68.55 $65.12 $74.89 $73.76

C 76970 $93.82 $89.13 $102.50 $100.96

C 76970 TC $72.76 $69.12 $79.49 $78.29

76970 26 $21.06 $20.01 $23.01 $22.67

76975 $122.20 $116.09 $133.50 $131.50

76975 TC $76.66 $72.83 $83.75 $82.50

76975 26 $45.54 $43.26 $49.75 $49.00

76977 $7.81 $7.42 $8.53 $8.41

76977 TC $4.95 $4.70 $5.41 $5.32

76977 26 $2.86 $2.72 $3.13 $3.08

76998 $201.07 $191.02 $219.67 $216.37

76998 TC $134.05 $127.35 $146.45 $144.26

76998 26 $67.02 $63.67 $73.22 $72.12

77001 $134.92 $128.17 $147.40 $145.19

77001 TC $115.67 $109.89 $126.37 $124.48

77001 26 $19.25 $18.29 $21.03 $20.72

77002 $87.99 $83.59 $96.13 $94.69

77002 TC $59.35 $56.38 $64.84 $63.86

77002 26 $28.64 $27.21 $31.29 $30.82

77003 $105.78 $100.49 $115.56 $113.83

77003 TC $73.91 $70.21 $80.74 $79.53

77003 26 $31.87 $30.28 $34.82 $34.30

77011 $250.68 $238.15 $273.87 $269.77

77011 TC $187.69 $178.31 $205.06 $201.99

77011 26 $62.99 $59.84 $68.82 $67.78

77012 $140.53 $133.50 $153.53 $151.23

77012 TC $83.10 $78.95 $90.79 $89.44

77012 26 $57.42 $54.55 $62.73 $61.79

77013 26 $204.63 $194.40 $223.56 $220.20

77014 $137.04 $130.19 $149.72 $147.48

77014 TC $93.07 $88.42 $101.68 $100.15

77014 26 $43.97 $41.77 $48.04 $47.31

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

77021 $434.85 $413.11 $475.08 $467.95

77021 TC $358.17 $340.26 $391.30 $385.43

77021 26 $76.68 $72.85 $83.78 $82.52

77022 26 $216.35 $205.53 $236.36 $232.82

77031 $140.31 $133.29 $153.28 $150.98

77031 TC $58.59 $55.66 $64.01 $63.05

77031 26 $81.72 $77.63 $89.27 $87.94

77032 $56.89 $54.05 $62.16 $61.23

77032 TC $28.70 $27.27 $31.36 $30.89

77032 26 $28.18 $26.77 $30.79 $30.33

77051 $11.22 $10.66 $12.26 $12.08

77051 TC $8.02 $7.62 $8.76 $8.64

77051 26 $3.21 $3.05 $3.51 $3.45

77052 $11.22 $10.66 $12.26 $12.08

77052 TC $8.02 $7.62 $8.76 $8.64

77052 26 $3.21 $3.05 $3.51 $3.45

77053 $66.08 $62.78 $72.20 $71.12

77053 TC $48.24 $45.83 $52.70 $51.91

77053 26 $17.84 $16.95 $19.49 $19.21

77054 $89.08 $84.63 $97.32 $95.86

77054 TC $66.25 $62.94 $72.38 $71.30

77054 26 $22.83 $21.69 $24.94 $24.56

77055 $97.73 $92.84 $106.77 $105.17

77055 TC $62.42 $59.30 $68.20 $67.17

77055 26 $35.32 $33.55 $38.58 $38.01

77056 $125.83 $119.54 $137.47 $135.41

77056 TC $81.57 $77.49 $89.11 $87.78

77056 26 $44.26 $42.05 $48.36 $47.63

77057 $89.31 $84.84 $97.57 $96.11

77057 TC $53.61 $50.93 $58.57 $57.70

77057 26 $35.70 $33.92 $39.01 $38.42

C 77058 $701.07 $666.02 $765.92 $754.43

C 77058 TC $618.68 $587.75 $675.91 $665.77

77058 26 $82.40 $78.28 $90.02 $88.68

77059 $698.78 $663.84 $763.42 $751.96

77059 TC $616.38 $585.56 $673.39 $663.30

77059 26 $82.40 $78.28 $90.02 $88.68

77071 $57.34 $54.47 $62.64 $61.70

77072 $26.08 $24.78 $28.50 $28.07

77072 TC $16.45 $15.63 $17.97 $17.71

77072 26 $9.64 $9.16 $10.53 $10.37

77073 $43.34 $41.17 $47.35 $46.63

77073 TC $27.94 $26.54 $30.52 $30.06

77073 26 $15.40 $14.63 $16.82 $16.57

77074 $78.73 $74.79 $86.01 $84.72

77074 TC $55.90 $53.11 $61.08 $60.16

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

77074 26 $22.83 $21.69 $24.94 $24.56

C 77075 $107.14 $101.78 $117.05 $115.29

C 77075 TC $79.66 $75.68 $87.03 $85.72

77075 26 $27.49 $26.12 $30.04 $29.59

C 77076 $114.97 $109.22 $125.60 $123.72

C 77076 TC $79.66 $75.68 $87.03 $85.72

77076 26 $35.32 $33.55 $38.58 $38.01

77077 $45.49 $43.22 $49.70 $48.96

77077 TC $27.94 $26.54 $30.52 $30.06

77077 26 $17.55 $16.67 $19.17 $18.88

C 77078 $95.98 $91.18 $104.86 $103.28

C 77078 TC $83.49 $79.32 $91.22 $89.85

77078 26 $12.49 $11.87 $13.65 $13.44

77080 $55.93 $53.13 $61.10 $60.18

77080 TC $45.56 $43.28 $49.77 $49.02

77080 26 $10.37 $9.85 $11.33 $11.16

77081 $31.34 $29.77 $34.24 $33.72

77081 TC $19.89 $18.90 $21.74 $21.41

77081 26 $11.45 $10.88 $12.51 $12.33

77082 $31.52 $29.94 $34.43 $33.91

77082 TC $22.58 $21.45 $24.67 $24.30

77082 26 $8.94 $8.49 $9.76 $9.61

C 77084 $462.51 $439.38 $505.29 $497.71

C 77084 TC $381.16 $362.10 $416.42 $410.17

77084 26 $81.36 $77.29 $88.88 $87.55

77261 $75.21 $71.45 $82.17 $80.94

77262 $113.03 $107.38 $123.49 $121.64

77263 $166.97 $158.62 $182.41 $179.68

77280 $201.20 $191.14 $219.81 $216.51

77280 TC $165.09 $156.84 $180.37 $177.66

77280 26 $36.11 $34.30 $39.45 $38.86

77285 $356.58 $338.75 $389.56 $383.72

77285 TC $302.24 $287.13 $330.20 $325.24

77285 26 $54.34 $51.62 $59.36 $58.48

77290 $592.61 $562.98 $647.43 $637.72

77290 TC $511.79 $486.20 $559.13 $550.75

77290 26 $80.81 $76.77 $88.29 $86.96

77295 $484.41 $460.19 $529.22 $521.28

77295 TC $246.61 $234.28 $269.42 $265.39

77295 26 $237.81 $225.92 $259.81 $255.91

77300 $72.76 $69.12 $79.49 $78.29

77300 TC $40.58 $38.55 $44.33 $43.67

77300 26 $32.18 $30.57 $35.16 $34.63

77301 $2,210.85 $2,100.31 $2,415.36 $2,379.13

77301 TC $1,794.60 $1,704.87 $1,960.60 $1,931.20

77301 26 $416.25 $395.44 $454.76 $447.94

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

77305 $63.28 $60.12 $69.14 $68.10

77305 TC $27.17 $25.81 $29.68 $29.23

77305 26 $36.11 $34.30 $39.45 $38.86

77310 $91.09 $86.54 $99.52 $98.03

77310 TC $36.75 $34.91 $40.15 $39.55

77310 26 $54.34 $51.62 $59.36 $58.48

77315 $144.76 $137.52 $158.15 $155.78

77315 TC $63.95 $60.75 $69.86 $68.82

77315 26 $80.81 $76.77 $88.29 $86.96

77321 $98.76 $93.82 $107.89 $106.27

77321 TC $49.39 $46.92 $53.96 $53.15

77321 26 $49.36 $46.89 $53.92 $53.12

77326 $161.22 $153.16 $176.13 $173.49

77326 TC $112.93 $107.28 $123.37 $121.52

77326 26 $48.29 $45.88 $52.76 $51.97

77327 $224.24 $213.03 $244.98 $241.30

77327 TC $152.01 $144.41 $166.07 $163.58

77327 26 $72.23 $68.62 $78.91 $77.73

77328 $299.01 $284.06 $326.67 $321.77

77328 TC $190.29 $180.78 $207.90 $204.78

77328 26 $108.72 $103.28 $118.77 $116.99

77331 $66.48 $63.16 $72.63 $71.54

77331 TC $21.43 $20.36 $23.41 $23.06

77331 26 $45.05 $42.80 $49.22 $48.48

77332 $88.37 $83.95 $96.54 $95.09

77332 TC $60.12 $57.11 $65.68 $64.69

77332 26 $28.25 $26.84 $30.87 $30.41

77333 $54.33 $51.61 $59.35 $58.47

77333 TC $10.70 $10.17 $11.70 $11.52

77333 26 $43.63 $41.45 $47.67 $46.95

77334 $164.35 $156.13 $179.55 $176.86

77334 TC $100.34 $95.32 $109.62 $107.97

77334 26 $64.01 $60.81 $69.93 $68.89

77336 $49.39 $46.92 $53.96 $53.15

77338 $548.24 $520.83 $598.95 $589.97

77338 TC $324.37 $308.15 $354.37 $349.06

77338 26 $223.86 $212.67 $244.57 $240.90

77370 $132.83 $126.19 $145.12 $142.95

77371 $1,337.16 $1,270.30 $1,460.85 $1,438.94

77372 $883.67 $839.49 $965.41 $950.94

77373 $1,428.38 $1,356.96 $1,560.50 $1,537.10

77401 $23.34 $22.17 $25.50 $25.12

77402 $174.67 $165.94 $190.83 $187.97

77403 $144.02 $136.82 $157.34 $154.99

77404 $160.11 $152.10 $174.92 $172.29

77406 $160.11 $152.10 $174.92 $172.29

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

77407 $254.35 $241.63 $277.87 $273.71

77408 $198.42 $188.50 $216.78 $213.52

77409 $221.02 $209.97 $241.47 $237.84

77411 $222.17 $211.06 $242.72 $239.07

77412 $270.44 $256.92 $295.46 $291.03

77413 $260.48 $247.46 $284.58 $280.31

77414 $293.04 $278.39 $320.15 $315.34

77416 $292.66 $278.03 $319.73 $314.94

77417 $16.06 $15.26 $17.55 $17.28

77418 $456.63 $433.80 $498.87 $491.38

77421 $82.45 $78.33 $90.08 $88.73

77421 TC $62.42 $59.30 $68.20 $67.17

77421 26 $20.03 $19.03 $21.88 $21.55

77422 $318.33 $302.41 $347.77 $342.55

77423 $324.46 $308.24 $354.48 $349.16

77427 $187.96 $178.56 $205.34 $202.26

77431 $103.48 $98.31 $113.06 $111.37

77432 $421.59 $400.51 $460.59 $453.68

77435 $636.78 $604.94 $695.68 $685.25

77469 $317.21 $301.35 $346.55 $341.35

77470 $162.71 $154.57 $177.76 $175.09

77470 TC $53.99 $51.29 $58.98 $58.10

77470 26 $108.72 $103.28 $118.77 $116.99

77520 $944.76 $897.52 $1,032.15 $1,016.67

77522 $944.76 $897.52 $1,032.15 $1,016.67

77523 $1,084.82 $1,030.58 $1,185.17 $1,167.39

77525 $1,224.87 $1,163.63 $1,338.17 $1,318.11

77600 $479.92 $455.92 $524.31 $516.44

77600 TC $399.11 $379.15 $436.02 $429.48

77600 26 $80.81 $76.77 $88.29 $86.96

77605 $1,298.92 $1,233.97 $1,419.07 $1,397.78

77605 TC $1,181.01 $1,121.96 $1,290.25 $1,270.90

77605 26 $117.91 $112.01 $128.81 $126.88

77610 $1,226.58 $1,165.25 $1,340.04 $1,319.94

77610 TC $1,146.15 $1,088.84 $1,252.17 $1,233.39

77610 26 $80.43 $76.41 $87.87 $86.55

77615 $1,139.45 $1,082.48 $1,244.85 $1,226.18

77615 TC $1,030.73 $979.19 $1,126.07 $1,109.18

77615 26 $108.72 $103.28 $118.77 $116.99

77620 $655.82 $623.03 $716.48 $705.73

77620 TC $576.45 $547.63 $629.77 $620.33

77620 26 $79.36 $75.39 $86.70 $85.40

77750 $387.42 $368.05 $423.26 $416.91

77750 TC $127.11 $120.75 $138.86 $136.78

77750 26 $260.32 $247.30 $284.40 $280.13

77761 $417.34 $396.47 $455.94 $449.10

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

77761 TC $217.87 $206.98 $238.03 $234.46

77761 26 $199.46 $189.49 $217.91 $214.65

77762 $549.66 $522.18 $600.51 $591.50

77762 TC $250.41 $237.89 $273.57 $269.47

77762 26 $299.25 $284.29 $326.93 $322.03

77763 $773.31 $734.64 $844.84 $832.16

77763 TC $322.76 $306.62 $352.61 $347.32

77763 26 $450.56 $428.03 $492.23 $484.85

77776 $466.07 $442.77 $509.19 $501.55

77776 TC $218.61 $207.68 $238.83 $235.24

77776 26 $247.46 $235.09 $270.35 $266.29

77777 $626.75 $595.41 $684.72 $674.45

77777 TC $233.94 $222.24 $255.58 $251.75

77777 26 $392.81 $373.17 $429.15 $422.71

77778 $918.88 $872.94 $1,003.88 $988.83

77778 TC $330.01 $313.51 $360.54 $355.13

77778 26 $588.87 $559.43 $643.34 $633.70

77785 $277.00 $263.15 $302.62 $298.08

77785 TC $202.96 $192.81 $221.73 $218.41

77785 26 $74.04 $70.34 $80.89 $79.67

77786 $614.94 $584.19 $671.82 $661.74

77786 TC $445.79 $423.50 $487.03 $479.72

77786 26 $169.15 $160.69 $184.79 $182.02

77787 $1,057.72 $1,004.83 $1,155.55 $1,138.22

77787 TC $802.37 $762.25 $876.59 $863.44

77787 26 $255.35 $242.58 $278.97 $274.78

77789 $128.70 $122.27 $140.61 $138.51

77789 TC $68.93 $65.48 $75.30 $74.18

77789 26 $59.77 $56.78 $65.30 $64.32

77790 $102.61 $97.48 $112.10 $110.42

77790 TC $48.63 $46.20 $53.13 $52.34

77790 26 $53.99 $51.29 $58.98 $58.10

78012 $92.74 $88.10 $101.32 $99.80

78012 TC $83.10 $78.95 $90.79 $89.44

78012 26 $9.64 $9.16 $10.53 $10.37

C 78013 $187.46 $178.09 $204.80 $201.73

C 78013 TC $168.89 $160.45 $184.52 $181.75

78013 26 $18.57 $17.64 $20.29 $19.99

78014 $271.20 $257.64 $296.29 $291.85

78014 TC $246.25 $233.94 $269.03 $264.99

78014 26 $24.95 $23.70 $27.26 $26.84

78015 $248.34 $235.92 $271.31 $267.24

78015 TC $215.60 $204.82 $235.54 $232.01

78015 26 $32.74 $31.10 $35.77 $35.22

78016 $322.54 $306.41 $352.37 $347.08

78016 TC $287.62 $273.24 $314.23 $309.51

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

78016 26 $34.91 $33.16 $38.13 $37.56

78018 $359.53 $341.55 $392.78 $386.89

78018 TC $317.89 $302.00 $347.30 $342.09

78018 26 $41.64 $39.56 $45.49 $44.82

78020 $93.14 $88.48 $101.75 $100.22

78020 TC $65.10 $61.85 $71.13 $70.06

78020 26 $28.04 $26.64 $30.64 $30.18

C 78070 $301.51 $286.43 $329.39 $324.45

C 78070 TC $262.34 $249.22 $286.60 $282.30

78070 26 $39.17 $37.21 $42.79 $42.15

78071 $402.70 $382.57 $439.96 $433.35

78071 TC $343.56 $326.38 $375.34 $369.70

78071 26 $59.14 $56.18 $64.61 $63.64

78072 26 $82.26 $78.15 $89.87 $88.53

78075 $494.02 $469.32 $539.72 $531.62

78075 TC $458.84 $435.90 $501.29 $493.76

78075 26 $35.17 $33.41 $38.42 $37.85

78102 $194.40 $184.68 $212.38 $209.20

78102 TC $167.71 $159.32 $183.22 $180.47

78102 26 $26.68 $25.35 $29.15 $28.72

78103 $248.06 $235.66 $271.01 $266.95

78103 TC $212.15 $201.54 $231.77 $228.30

78103 26 $35.90 $34.11 $39.23 $38.64

78104 $284.66 $270.43 $310.99 $306.33

78104 TC $245.48 $233.21 $268.19 $264.17

78104 26 $39.17 $37.21 $42.79 $42.15

78110 $106.10 $100.80 $115.92 $114.18

78110 TC $96.46 $91.64 $105.39 $103.81

78110 26 $9.64 $9.16 $10.53 $10.37

78111 $96.79 $91.95 $105.74 $104.16

78111 TC $86.88 $82.54 $94.92 $93.50

78111 26 $9.91 $9.41 $10.82 $10.66

78120 $104.42 $99.20 $114.08 $112.37

78120 TC $93.01 $88.36 $101.61 $100.08

78120 26 $11.41 $10.84 $12.47 $12.28

78121 $88.01 $83.61 $96.15 $94.71

78121 TC $74.62 $70.89 $81.52 $80.30

78121 26 $13.39 $12.72 $14.63 $14.41

78122 $112.06 $106.46 $122.43 $120.59

78122 TC $90.71 $86.17 $99.10 $97.61

78122 26 $21.35 $20.28 $23.32 $22.98

78130 $183.40 $174.23 $200.36 $197.36

78130 TC $151.98 $144.38 $166.04 $163.54

78130 26 $31.42 $29.85 $34.33 $33.81

78135 $411.65 $391.07 $449.73 $442.98

78135 TC $378.80 $359.86 $413.84 $407.63

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

78135 26 $32.85 $31.21 $35.89 $35.35

78140 $153.55 $145.87 $167.75 $165.23

78140 TC $122.51 $116.38 $133.84 $131.82

78140 26 $31.04 $29.49 $33.91 $33.41

78185 $244.41 $232.19 $267.02 $263.02

78185 TC $224.41 $213.19 $245.17 $241.49

78185 26 $20.00 $19.00 $21.85 $21.53

C 78190 $277.52 $263.64 $303.19 $298.64

C 78190 TC $221.38 $210.31 $241.86 $238.23

78190 26 $56.14 $53.33 $61.33 $60.41

78191 $183.79 $174.60 $200.79 $197.78

78191 TC $152.36 $144.74 $166.45 $163.96

78191 26 $31.42 $29.85 $34.33 $33.81

C 78195 $374.71 $355.97 $409.37 $403.22

C 78195 TC $315.21 $299.45 $344.37 $339.20

78195 26 $59.50 $56.53 $65.01 $64.03

78201 $214.30 $203.59 $234.13 $230.62

78201 TC $192.62 $182.99 $210.44 $207.29

78201 26 $21.69 $20.61 $23.70 $23.35

78202 $235.21 $223.45 $256.97 $253.12

78202 TC $211.39 $200.82 $230.94 $227.48

78202 26 $23.82 $22.63 $26.02 $25.63

78205 $243.60 $231.42 $266.13 $262.14

78205 TC $209.09 $198.64 $228.44 $225.01

78205 26 $34.51 $32.78 $37.70 $37.13

78206 $389.82 $370.33 $425.88 $419.50

78206 TC $343.17 $326.01 $374.91 $369.29

78206 26 $46.65 $44.32 $50.97 $50.21

78215 $224.50 $213.28 $245.27 $241.59

78215 TC $199.89 $189.90 $218.39 $215.11

78215 26 $24.60 $23.37 $26.88 $26.47

78216 $140.31 $133.29 $153.28 $150.98

78216 TC $112.93 $107.28 $123.37 $121.52

78216 26 $27.38 $26.01 $29.91 $29.46

C 78226 $392.52 $372.89 $428.82 $422.40

C 78226 TC $353.90 $336.21 $386.64 $380.85

78226 26 $38.62 $36.69 $42.19 $41.56

C 78227 $400.38 $380.36 $437.41 $430.85

C 78227 TC $353.90 $336.21 $386.64 $380.85

78227 26 $46.48 $44.16 $50.78 $50.03

78230 $198.97 $189.02 $217.37 $214.11

78230 TC $176.14 $167.33 $192.43 $189.54

78230 26 $22.83 $21.69 $24.94 $24.56

78231 $147.06 $139.71 $160.67 $158.25

78231 TC $121.36 $115.29 $132.58 $130.59

78231 26 $25.70 $24.42 $28.08 $27.66

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

78232 $110.40 $104.88 $120.61 $118.81

78232 TC $90.33 $85.81 $98.68 $97.20

78232 26 $20.07 $19.07 $21.93 $21.60

78258 $257.32 $244.45 $281.12 $276.90

78258 TC $220.97 $209.92 $241.41 $237.79

78258 26 $36.35 $34.53 $39.71 $39.11

78261 $290.41 $275.89 $317.27 $312.51

78261 TC $255.44 $242.67 $279.07 $274.88

78261 26 $34.97 $33.22 $38.20 $37.63

78262 $288.23 $273.82 $314.89 $310.17

78262 TC $254.68 $241.95 $278.24 $274.07

78262 26 $33.55 $31.87 $36.65 $36.10

C 78264 $328.71 $312.27 $359.11 $353.73

C 78264 TC $289.16 $274.70 $315.91 $311.17

78264 26 $39.56 $37.58 $43.22 $42.57

78270 $98.07 $93.17 $107.15 $105.54

78270 TC $88.09 $83.69 $96.24 $94.79

78270 26 $9.98 $9.48 $10.90 $10.74

78271 $107.26 $101.90 $117.19 $115.43

78271 TC $96.90 $92.06 $105.87 $104.28

78271 26 $10.37 $9.85 $11.33 $11.16

78272 $107.73 $102.34 $117.69 $115.92

78272 TC $94.16 $89.45 $102.87 $101.33

78272 26 $13.57 $12.89 $14.82 $14.61

C 78278 $337.99 $321.09 $369.25 $363.71

C 78278 TC $288.80 $274.36 $315.51 $310.78

78278 26 $49.19 $46.73 $53.74 $52.93

78282 26 $19.63 $18.65 $21.45 $21.13

C 78290 $322.66 $306.53 $352.51 $347.22

C 78290 TC $288.80 $274.36 $315.51 $310.78

78290 26 $33.85 $32.16 $36.98 $36.43

78291 $293.15 $278.49 $320.26 $315.46

78291 TC $249.70 $237.22 $272.80 $268.71

78291 26 $43.46 $41.29 $47.48 $46.77

78300 $206.41 $196.09 $225.50 $222.12

78300 TC $175.38 $166.61 $191.60 $188.73

78300 26 $31.03 $29.48 $33.90 $33.40

78305 $271.52 $257.94 $296.63 $292.18

78305 TC $230.16 $218.65 $251.45 $247.68

78305 26 $41.36 $39.29 $45.18 $44.51

78306 $287.51 $273.13 $314.10 $309.38

78306 TC $245.10 $232.85 $267.78 $263.76

78306 26 $42.41 $40.29 $46.33 $45.64

C 78315 $345.52 $328.24 $377.48 $371.82

C 78315 TC $294.90 $280.16 $322.18 $317.35

78315 26 $50.62 $48.09 $55.30 $54.48

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

78320 $258.49 $245.57 $282.41 $278.17

78320 TC $207.94 $197.54 $227.17 $223.77

78320 26 $50.55 $48.02 $55.22 $54.40

78414 $112.54 $106.91 $122.95 $121.11

78414 TC $88.95 $84.50 $97.18 $95.71

78414 26 $23.59 $22.41 $25.77 $25.38

78428 $210.43 $199.91 $229.90 $226.45

78428 TC $172.31 $163.69 $188.24 $185.41

78428 26 $38.12 $36.21 $41.64 $41.02

78445 $198.12 $188.21 $216.44 $213.20

78445 TC $174.99 $166.24 $191.18 $188.31

78445 26 $23.12 $21.96 $25.25 $24.87

78451 $400.55 $380.52 $437.60 $431.03

78451 TC $332.06 $315.46 $362.78 $357.34

78451 26 $68.49 $65.07 $74.83 $73.70

78452 $559.42 $531.45 $611.17 $602.00

78452 TC $479.15 $455.19 $523.47 $515.61

78452 26 $80.27 $76.26 $87.70 $86.39

78453 $348.66 $331.23 $380.91 $375.20

78453 TC $298.73 $283.79 $326.36 $321.46

78453 26 $49.92 $47.42 $54.53 $53.72

78454 $501.80 $476.71 $548.22 $539.99

78454 TC $435.09 $413.34 $475.34 $468.21

78454 26 $66.71 $63.37 $72.88 $71.78

78456 $407.71 $387.32 $445.42 $438.74

78456 TC $358.11 $340.20 $391.23 $385.37

78456 26 $49.60 $47.12 $54.19 $53.37

78457 $233.43 $221.76 $255.02 $251.19

78457 TC $194.91 $185.16 $212.93 $209.74

78457 26 $38.51 $36.58 $42.07 $41.43

78458 $213.40 $202.73 $233.14 $229.64

78458 TC $171.55 $162.97 $187.42 $184.61

78458 26 $41.85 $39.76 $45.72 $45.03

78459 $1,937.02 $1,840.17 $2,116.20 $2,084.46

C 78459 TC $1,189.11 $1,129.65 $1,299.10 $1,279.62

78459 26 $73.28 $69.62 $80.06 $78.87

78466 $225.31 $214.04 $246.15 $242.45

78466 TC $189.55 $180.07 $207.08 $203.98

78466 26 $35.76 $33.97 $39.07 $38.48

78468 $228.75 $217.31 $249.91 $246.16

78468 TC $188.79 $179.35 $206.25 $203.16

78468 26 $39.97 $37.97 $43.67 $43.01

78469 $259.74 $246.75 $283.76 $279.51

78469 TC $213.30 $202.64 $233.04 $229.54

78469 26 $46.43 $44.11 $50.73 $49.97

78472 $264.86 $251.62 $289.36 $285.03

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

78472 TC $216.37 $205.55 $236.38 $232.84

78472 26 $48.49 $46.07 $52.98 $52.19

78473 $335.10 $318.35 $366.10 $360.61

78473 TC $262.34 $249.22 $286.60 $282.30

78473 26 $72.76 $69.12 $79.49 $78.29

78481 $207.86 $197.47 $227.09 $223.69

78481 TC $159.34 $151.37 $174.08 $171.47

78481 26 $48.52 $46.09 $53.00 $52.21

78483 $276.87 $263.03 $302.48 $297.94

78483 TC $203.73 $193.54 $222.57 $219.24

78483 26 $73.15 $69.49 $79.91 $78.72

78491 $1,495.70 $1,420.92 $1,634.06 $1,609.55

C 78491 TC $1,189.11 $1,129.65 $1,299.10 $1,279.62

78491 26 $74.82 $71.08 $81.74 $80.51

78492 $1,704.45 $1,619.23 $1,862.11 $1,834.18

C 78492 TC $1,189.11 $1,129.65 $1,299.10 $1,279.62

78492 26 $92.98 $88.33 $101.58 $100.06

78494 $261.81 $248.72 $286.03 $281.74

78494 TC $202.96 $192.81 $221.73 $218.41

78494 26 $58.85 $55.91 $64.30 $63.33

78496 $49.11 $46.65 $53.65 $52.84

78496 TC $24.49 $23.27 $26.76 $26.36

78496 26 $24.62 $23.39 $26.90 $26.50

78579 $249.04 $236.59 $272.08 $268.00

78579 TC $223.29 $212.13 $243.95 $240.29

78579 26 $25.75 $24.46 $28.13 $27.70

78580 $272.64 $259.01 $297.86 $293.39

78580 TC $236.29 $224.48 $258.15 $254.28

78580 26 $36.35 $34.53 $39.71 $39.11

C 78582 $434.22 $412.51 $474.39 $467.27

C 78582 TC $378.80 $359.86 $413.84 $407.63

78582 26 $55.42 $52.65 $60.55 $59.64

78597 $271.89 $258.30 $297.05 $292.59

78597 TC $233.64 $221.96 $255.25 $251.42

78597 26 $38.26 $36.35 $41.80 $41.17

78598 $406.71 $386.37 $444.33 $437.66

78598 TC $363.10 $344.95 $396.69 $390.75

78598 26 $43.62 $41.44 $47.66 $46.94

78600 $210.94 $200.39 $230.45 $226.99

78600 TC $189.17 $179.71 $206.67 $203.56

78600 26 $21.77 $20.68 $23.78 $23.43

78601 $248.94 $236.49 $271.96 $267.88

78601 TC $223.65 $212.47 $244.34 $240.67

78601 26 $25.30 $24.04 $27.65 $27.23

78605 $227.03 $215.68 $248.03 $244.31

78605 TC $200.28 $190.27 $218.81 $215.53

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

78605 26 $26.76 $25.42 $29.23 $28.80

78606 $383.38 $364.21 $418.84 $412.56

78606 TC $352.37 $334.75 $384.96 $379.19

78606 26 $31.02 $29.47 $33.89 $33.38

78607 $403.00 $382.85 $440.28 $433.68

78607 TC $344.32 $327.10 $376.17 $370.52

78607 26 $58.68 $55.75 $64.11 $63.15

78608 $1,746.00 $1,658.70 $1,907.51 $1,878.89

C 78608 TC $1,189.11 $1,129.65 $1,299.10 $1,279.62

78608 26 $73.64 $69.96 $80.45 $79.25

78610 $203.78 $193.59 $222.63 $219.29

78610 TC $188.79 $179.35 $206.25 $203.16

78610 26 $14.99 $14.24 $16.38 $16.13

78630 $398.13 $378.22 $434.95 $428.43

78630 TC $364.24 $346.03 $397.93 $391.97

78630 26 $33.88 $32.19 $37.02 $36.47

78635 $390.39 $370.87 $426.50 $420.11

78635 TC $360.41 $342.39 $393.75 $387.84

78635 26 $29.97 $28.47 $32.74 $32.25

C 78645 $325.35 $309.08 $355.44 $350.11

C 78645 TC $297.59 $282.71 $325.12 $320.24

78645 26 $27.76 $26.37 $30.33 $29.87

78647 $421.42 $400.35 $460.40 $453.49

78647 TC $376.89 $358.05 $411.76 $405.58

78647 26 $44.53 $42.30 $48.65 $47.92

78650 $384.94 $365.69 $420.54 $414.23

78650 TC $354.67 $336.94 $387.48 $381.67

78650 26 $30.27 $28.76 $33.07 $32.58

78660 $217.07 $206.22 $237.15 $233.60

78660 TC $189.17 $179.71 $206.67 $203.56

78660 26 $27.91 $26.51 $30.49 $30.03

78700 $203.57 $193.39 $222.40 $219.06

78700 TC $180.74 $171.70 $197.46 $194.49

78700 26 $22.83 $21.69 $24.94 $24.56

78701 $245.57 $233.29 $268.28 $264.26

78701 TC $220.97 $209.92 $241.41 $237.79

78701 26 $24.60 $23.37 $26.88 $26.47

78707 $263.40 $250.23 $287.76 $283.45

78707 TC $216.75 $205.91 $236.80 $233.24

78707 26 $46.65 $44.32 $50.97 $50.21

78708 $192.75 $183.11 $210.58 $207.41

78708 TC $133.62 $126.94 $145.98 $143.80

78708 26 $59.13 $56.17 $64.60 $63.63

78709 $420.69 $399.66 $459.61 $452.72

78709 TC $351.60 $334.02 $384.12 $378.36

78709 26 $69.09 $65.64 $75.49 $74.36

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

78710 $234.29 $222.58 $255.97 $252.13

78710 TC $204.11 $193.90 $222.99 $219.64

78710 26 $30.18 $28.67 $32.97 $32.48

78725 $126.87 $120.53 $138.61 $136.53

78725 TC $108.33 $102.91 $118.35 $116.58

78725 26 $18.54 $17.61 $20.25 $19.95

78730 $76.03 $72.23 $83.06 $81.82

78730 TC $68.55 $65.12 $74.89 $73.76

78730 26 $7.48 $7.11 $8.18 $8.05

78740 $266.35 $253.03 $290.98 $286.61

78740 TC $237.44 $225.57 $259.41 $255.52

78740 26 $28.91 $27.46 $31.58 $31.11

78761 $247.43 $235.06 $270.32 $266.26

78761 TC $211.77 $201.18 $231.36 $227.88

78761 26 $35.66 $33.88 $38.96 $38.38

78800 $217.35 $206.48 $237.45 $233.89

78800 TC $183.80 $174.61 $200.80 $197.79

78800 26 $33.54 $31.86 $36.64 $36.09

78801 $279.33 $265.36 $305.16 $300.59

78801 TC $240.12 $228.11 $262.33 $258.39

78801 26 $39.21 $37.25 $42.84 $42.19

78802 $371.41 $352.84 $405.77 $399.68

78802 TC $329.38 $312.91 $359.85 $354.45

78802 26 $42.02 $39.92 $45.91 $45.22

78803 $390.48 $370.96 $426.60 $420.21

78803 TC $338.19 $321.28 $369.47 $363.93

78803 26 $52.28 $49.67 $57.12 $56.26

78804 $655.98 $623.18 $716.66 $705.90

78804 TC $603.63 $573.45 $659.47 $649.58

78804 26 $52.36 $49.74 $57.20 $56.34

78805 $208.67 $198.24 $227.98 $224.56

78805 TC $172.31 $163.69 $188.24 $185.41

78805 26 $36.36 $34.54 $39.72 $39.12

78806 $380.98 $361.93 $416.22 $409.98

78806 TC $338.96 $322.01 $370.31 $364.76

78806 26 $42.02 $39.92 $45.91 $45.22

78807 $387.06 $367.71 $422.87 $416.52

78807 TC $335.51 $318.73 $366.54 $361.04

78807 26 $51.55 $48.97 $56.32 $55.48

78808 $50.99 $48.44 $55.71 $54.87

78811 $1,946.53 $1,849.20 $2,126.58 $2,094.68

C 78811 TC $1,189.11 $1,129.65 $1,299.10 $1,279.62

78811 26 $80.20 $76.19 $87.62 $86.31

78812 $2,184.16 $2,074.95 $2,386.19 $2,350.40

C 78812 TC $1,189.11 $1,129.65 $1,299.10 $1,279.62

78812 26 $97.25 $92.39 $106.25 $104.65

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

78813 $2,292.42 $2,177.80 $2,504.47 $2,466.90

C 78813 TC $1,189.11 $1,129.65 $1,299.10 $1,279.62

78813 26 $101.16 $96.10 $110.52 $108.86

78814 $2,372.71 $2,254.07 $2,592.18 $2,553.30

C 78814 TC $1,189.11 $1,129.65 $1,299.10 $1,279.62

78814 26 $111.88 $106.29 $122.23 $120.41

78815 $2,745.05 $2,607.80 $2,998.97 $2,953.98

C 78815 TC $1,189.11 $1,129.65 $1,299.10 $1,279.62

78815 26 $123.61 $117.43 $135.04 $133.02

78816 $2,939.82 $2,792.83 $3,211.75 $3,163.58

C 78816 TC $1,189.11 $1,129.65 $1,299.10 $1,279.62

78816 26 $124.55 $118.32 $136.07 $134.03

79005 $144.29 $137.08 $157.64 $155.27

79005 TC $55.90 $53.11 $61.08 $60.16

79005 26 $88.39 $83.97 $96.57 $95.12

79101 $153.68 $146.00 $167.90 $165.38

79101 TC $57.82 $54.93 $63.17 $62.23

79101 26 $95.86 $91.07 $104.73 $103.16

79200 $168.02 $159.62 $183.56 $180.81

79200 TC $63.95 $60.75 $69.86 $68.82

79200 26 $104.07 $98.87 $113.70 $112.00

79300 26 $83.16 $79.00 $90.85 $89.49

79403 $205.35 $195.08 $224.34 $220.97

79403 TC $92.24 $87.63 $100.77 $99.27

79403 26 $113.10 $107.45 $123.57 $121.72

79440 $153.63 $145.95 $167.84 $165.32

79440 TC $54.37 $51.65 $59.40 $58.51

79440 26 $99.25 $94.29 $108.43 $106.81

79445 26 $118.06 $112.16 $128.98 $127.05

80500 $21.58 $20.50 $23.58 $23.22

# 80500 $18.90 $17.96 $20.65 $20.34

80502 $68.61 $65.18 $74.96 $73.83

# 80502 $65.93 $62.63 $72.02 $70.94

83020 26 $21.20 $20.14 $23.16 $22.82

84165 26 $21.20 $20.14 $23.16 $22.82

84166 26 $21.20 $20.14 $23.16 $22.82

84181 26 $21.20 $20.14 $23.16 $22.82

84182 26 $19.28 $18.32 $21.07 $20.76

85060 $25.51 $24.23 $27.86 $27.45

85097 $93.43 $88.76 $102.07 $100.54

# 85097 $50.14 $47.63 $54.77 $53.96

85390 26 $21.20 $20.14 $23.16 $22.82

85396 $21.20 $20.14 $23.16 $22.82

85576 26 $21.20 $20.14 $23.16 $22.82

86077 $56.65 $53.82 $61.89 $60.96

# 86077 $52.44 $49.82 $57.29 $56.43

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

86078 $57.03 $54.18 $62.31 $61.38

# 86078 $52.44 $49.82 $57.29 $56.43

86079 $56.65 $53.82 $61.89 $60.96

# 86079 $52.44 $49.82 $57.29 $56.43

86153 26 $35.41 $33.64 $38.69 $38.11

86255 26 $21.20 $20.14 $23.16 $22.82

86256 26 $20.10 $19.10 $21.97 $21.63

86320 26 $19.34 $18.37 $21.13 $20.80

86325 26 $19.72 $18.73 $21.54 $21.22

86327 26 $24.08 $22.88 $26.31 $25.92

86334 26 $20.82 $19.78 $22.75 $22.40

86335 26 $21.20 $20.14 $23.16 $22.82

86485 $5.64 $5.36 $6.16 $6.07

86486 $6.49 $6.17 $7.10 $6.99

86490 $5.72 $5.43 $6.24 $6.15

86510 $7.25 $6.89 $7.92 $7.81

86580 $9.17 $8.71 $10.02 $9.87

87164 26 $20.05 $19.05 $21.91 $21.57

87207 26 $21.20 $20.14 $23.16 $22.82

88104 $83.76 $79.57 $91.51 $90.14

88104 TC $53.61 $50.93 $58.57 $57.70

88104 26 $30.15 $28.64 $32.94 $32.44

88106 $94.78 $90.04 $103.55 $101.99

88106 TC $74.68 $70.95 $81.59 $80.37

88106 26 $20.10 $19.10 $21.97 $21.63

88108 $87.25 $82.89 $95.32 $93.90

88108 TC $63.95 $60.75 $69.86 $68.82

88108 26 $23.30 $22.14 $25.46 $25.08

88112 $119.00 $113.05 $130.01 $128.05

88112 TC $57.82 $54.93 $63.17 $62.23

88112 26 $61.18 $58.12 $66.84 $65.84

88120 $694.70 $659.97 $758.97 $747.58

88120 TC $635.48 $603.71 $694.27 $683.85

88120 26 $59.22 $56.26 $64.70 $63.73

88121 $624.60 $593.37 $682.38 $672.14

88121 TC $572.71 $544.07 $625.68 $616.30

88121 26 $51.89 $49.30 $56.70 $55.84

88125 $24.30 $23.09 $26.55 $26.15

88125 TC $10.70 $10.17 $11.70 $11.52

88125 26 $13.60 $12.92 $14.86 $14.64

88141 $34.05 $32.35 $37.20 $36.64

88160 $69.80 $66.31 $76.26 $75.12

88160 TC $42.88 $40.74 $46.85 $46.15

88160 26 $26.92 $25.57 $29.41 $28.97

88161 $66.35 $63.03 $72.48 $71.39

88161 TC $40.58 $38.55 $44.33 $43.67

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

88161 26 $25.77 $24.48 $28.15 $27.73

88162 $105.59 $100.31 $115.36 $113.63

88162 TC $64.33 $61.11 $70.28 $69.22

88162 26 $41.26 $39.20 $45.08 $44.40

88172 $59.16 $56.20 $64.63 $63.66

88172 TC $21.81 $20.72 $23.83 $23.47

88172 26 $37.35 $35.48 $40.80 $40.19

88173 $163.84 $155.65 $179.00 $176.32

88173 TC $90.00 $85.50 $98.33 $96.85

88173 26 $73.84 $70.15 $80.67 $79.47

88177 $31.77 $30.18 $34.71 $34.19

88177 TC $8.78 $8.34 $9.59 $9.44

88177 26 $22.99 $21.84 $25.12 $24.74

88182 $120.06 $114.06 $131.17 $129.20

88182 TC $83.43 $79.26 $91.15 $89.78

88182 26 $36.63 $34.80 $40.02 $39.42

88184 $99.96 $94.96 $109.20 $107.57

88185 $60.89 $57.85 $66.53 $65.53

88187 $72.31 $68.69 $78.99 $77.81

88188 $92.53 $87.90 $101.09 $99.57

88189 $111.61 $106.03 $121.93 $120.11

88291 $32.54 $30.91 $35.55 $35.02

88300 $16.13 $15.32 $17.62 $17.35

88300 TC $11.47 $10.90 $12.54 $12.35

88300 26 $4.67 $4.44 $5.11 $5.03

88302 $34.34 $32.62 $37.51 $36.95

88302 TC $27.17 $25.81 $29.68 $29.23

88302 26 $7.17 $6.81 $7.83 $7.72

88304 $49.34 $46.87 $53.90 $53.10

88304 TC $37.52 $35.64 $40.99 $40.38

88304 26 $11.83 $11.24 $12.93 $12.73

88305 $76.18 $72.37 $83.23 $81.97

88305 TC $37.52 $35.64 $40.99 $40.38

88305 26 $38.67 $36.74 $42.25 $41.62

88307 $329.01 $312.56 $359.44 $354.05

88307 TC $242.47 $230.35 $264.90 $260.92

88307 26 $86.54 $82.21 $94.54 $93.13

88309 $495.77 $470.98 $541.63 $533.51

88309 TC $342.79 $325.65 $374.50 $368.89

88309 26 $152.98 $145.33 $167.13 $164.62

88311 $22.07 $20.97 $24.12 $23.76

88311 TC $9.17 $8.71 $10.02 $9.87

88311 26 $12.91 $12.26 $14.10 $13.89

88312 $107.97 $102.57 $117.96 $116.18

88312 TC $80.04 $76.04 $87.45 $86.14

88312 26 $27.93 $26.53 $30.51 $30.05

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

88313 $75.32 $71.55 $82.28 $81.05

88313 TC $62.80 $59.66 $68.61 $67.59

88313 26 $12.52 $11.89 $13.67 $13.47

88314 $89.51 $85.03 $97.78 $96.31

88314 TC $65.87 $62.58 $71.97 $70.89

88314 26 $23.65 $22.47 $25.84 $25.45

88319 $96.45 $91.63 $105.37 $103.80

88319 TC $67.78 $64.39 $74.05 $72.93

88319 26 $28.67 $27.24 $31.33 $30.85

88321 $98.87 $93.93 $108.02 $106.40

# 88321 $87.76 $83.37 $95.88 $94.44

88323 $152.69 $145.06 $166.82 $164.31

88323 TC $65.87 $62.58 $71.97 $70.89

88323 26 $86.83 $82.49 $94.86 $93.44

88325 $227.49 $216.12 $248.54 $244.81

# 88325 $135.93 $129.13 $148.50 $146.27

88329 $62.24 $59.13 $68.00 $66.98

# 88329 $37.72 $35.83 $41.20 $40.58

88331 $107.94 $102.54 $117.92 $116.15

88331 TC $43.26 $41.10 $47.27 $46.55

88331 26 $64.68 $61.45 $70.67 $69.61

88332 $46.87 $44.53 $51.21 $50.44

88332 TC $14.91 $14.16 $16.28 $16.04

88332 26 $31.96 $30.36 $34.91 $34.39

88333 $113.95 $108.25 $124.49 $122.62

88333 TC $48.24 $45.83 $52.70 $51.91

88333 26 $65.71 $62.42 $71.78 $70.70

88334 $71.22 $67.66 $77.81 $76.65

88334 TC $30.62 $29.09 $33.45 $32.95

88334 26 $40.60 $38.57 $44.36 $43.69

88342 $126.72 $120.38 $138.44 $136.36

88342 TC $82.34 $78.22 $89.95 $88.61

88342 26 $44.39 $42.17 $48.50 $47.77

88346 $119.85 $113.86 $130.94 $128.97

88346 TC $75.83 $72.04 $82.85 $81.60

88346 26 $44.02 $41.82 $48.09 $47.37

88347 $86.13 $81.82 $94.09 $92.68

88347 TC $46.33 $44.01 $50.61 $49.85

88347 26 $39.81 $37.82 $43.49 $42.84

88348 $811.04 $770.49 $886.06 $872.77

88348 TC $733.03 $696.38 $800.84 $788.82

88348 26 $78.01 $74.11 $85.23 $83.95

88349 $489.76 $465.27 $535.06 $527.03

88349 TC $447.35 $424.98 $488.73 $481.40

88349 26 $42.41 $40.29 $46.33 $45.64

88355 $198.95 $189.00 $217.35 $214.10

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

88355 TC $112.60 $106.97 $123.02 $121.18

88355 26 $86.35 $82.03 $94.33 $92.92

88356 $301.32 $286.25 $329.19 $324.25

88356 TC $168.45 $160.03 $184.03 $181.27

88356 26 $132.87 $126.23 $145.16 $142.99

88358 $88.82 $84.38 $97.04 $95.58

88358 TC $43.26 $41.10 $47.27 $46.55

88358 26 $45.56 $43.28 $49.77 $49.02

88360 $139.24 $132.28 $152.12 $149.85

88360 TC $84.25 $80.04 $92.05 $90.67

88360 26 $54.98 $52.23 $60.06 $59.17

88361 $171.87 $163.28 $187.77 $184.95

88361 TC $111.84 $106.25 $122.19 $120.36

88361 26 $60.03 $57.03 $65.58 $64.60

88362 $343.16 $326.00 $374.90 $369.28

88362 TC $228.22 $216.81 $249.33 $245.59

88362 26 $114.95 $109.20 $125.58 $123.69

88363 $62.57 $59.44 $68.36 $67.33

# 88363 $20.43 $19.41 $22.32 $21.99

88365 $196.73 $186.89 $214.92 $211.70

88365 TC $135.59 $128.81 $148.13 $145.91

88365 26 $61.14 $58.08 $66.79 $65.79

88367 $285.96 $271.66 $312.41 $307.73

88367 TC $223.32 $212.15 $243.97 $240.32

88367 26 $62.64 $59.51 $68.44 $67.41

88368 $256.13 $243.32 $279.82 $275.62

88368 TC $191.91 $182.31 $209.66 $206.52

88368 26 $64.23 $61.02 $70.17 $69.12

88371 26 $20.43 $19.41 $22.32 $21.99

88372 26 $16.60 $15.77 $18.14 $17.86

88380 $172.05 $163.45 $187.97 $185.15

88380 TC $96.90 $92.06 $105.87 $104.28

88380 26 $75.15 $71.39 $82.10 $80.87

88381 $168.07 $159.67 $183.62 $180.86

88381 TC $114.90 $109.16 $125.53 $123.65

88381 26 $53.17 $50.51 $58.09 $57.21

88387 $35.66 $33.88 $38.96 $38.38

88387 TC $6.87 $6.53 $7.51 $7.39

88387 26 $28.79 $27.35 $31.45 $30.98

88388 $35.50 $33.73 $38.79 $38.20

88388 TC $10.70 $10.17 $11.70 $11.52

88388 26 $24.80 $23.56 $27.09 $26.69

89049 $305.80 $290.51 $334.09 $329.07

# 89049 $68.28 $64.87 $74.60 $73.49

89060 26 $20.82 $19.78 $22.75 $22.40

89220 $19.89 $18.90 $21.74 $21.41

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

89230 $2.65 $2.52 $2.90 $2.85

90460 $28.48 $27.06 $31.12 $30.65

90461 $13.61 $12.93 $14.87 $14.65

90471 $28.48 $27.06 $31.12 $30.65

90472 $13.61 $12.93 $14.87 $14.65

90473 $28.48 $27.06 $31.12 $30.65

90474 $13.61 $12.93 $14.87 $14.65

90785 $4.94 $4.69 $5.39 $5.31

90791 $159.41 $151.44 $174.16 $171.55

# 90791 $121.48 $115.41 $132.72 $130.73

90792 $128.95 $122.50 $140.88 $138.76

# 90792 $125.12 $118.86 $136.69 $134.64

90832 $65.89 $62.60 $71.99 $70.91

# 90832 $50.56 $48.03 $55.23 $54.41

90833 $43.13 $40.97 $47.12 $46.41

# 90833 $42.74 $40.60 $46.69 $45.99

90834 $83.85 $79.66 $91.61 $90.24

# 90834 $75.80 $72.01 $82.81 $81.57

90836 $69.97 $66.47 $76.44 $75.29

90837 $122.52 $116.39 $133.85 $131.84

# 90837 $114.48 $108.76 $125.07 $123.20

90838 $113.17 $107.51 $123.64 $121.79

# 90838 $112.40 $106.78 $122.80 $120.96

90845 $78.08 $74.18 $85.31 $84.03

# 90845 $77.31 $73.44 $84.46 $83.19

90846 $76.40 $72.58 $83.47 $82.21

# 90846 $81.38 $77.31 $88.91 $87.57

90847 $91.49 $86.92 $99.96 $98.46

# 90847 $95.70 $90.92 $104.56 $102.99

90849 $36.12 $34.31 $39.46 $38.87

# 90849 $29.99 $28.49 $32.76 $32.27

90853 $25.39 $24.12 $27.74 $27.32

90865 $178.80 $169.86 $195.34 $192.41

# 90865 $129.77 $123.28 $141.77 $139.64

90870 $192.28 $182.67 $210.07 $206.92

# 90870 $112.59 $106.96 $123.00 $121.16

90880 $99.99 $94.99 $109.24 $107.61

# 90880 $92.33 $87.71 $100.87 $99.35

90901 $43.33 $41.16 $47.33 $46.62

# 90901 $21.11 $20.05 $23.06 $22.71

90911 $92.40 $87.78 $100.95 $99.43

# 90911 $46.05 $43.75 $50.31 $49.55

90935 $74.56 $70.83 $81.45 $80.24

90937 $106.71 $101.37 $116.58 $114.83

90945 $89.60 $85.12 $97.89 $96.42

90947 $127.73 $121.34 $139.54 $137.45

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

90951 $960.63 $912.60 $1,049.49 $1,033.75

90952 $515.36 $489.59 $563.03 $554.59

90953 $355.19 $337.43 $388.04 $382.23

90954 $835.73 $793.94 $913.03 $899.33

90955 $472.56 $448.93 $516.27 $508.53

90956 $329.49 $313.02 $359.97 $354.57

90957 $666.62 $633.29 $728.28 $717.36

90958 $453.89 $431.20 $495.88 $488.44

90959 $308.58 $293.15 $337.12 $332.06

90960 $297.85 $282.96 $325.40 $320.53

90961 $251.47 $238.90 $274.74 $270.62

90962 $195.45 $185.68 $213.53 $210.32

90963 $565.54 $537.26 $617.85 $608.58

90964 $493.44 $468.77 $539.09 $531.00

90965 $469.08 $445.63 $512.47 $504.79

90966 $251.08 $238.53 $274.31 $270.19

90967 $18.26 $17.35 $19.95 $19.65

90968 $15.76 $14.97 $17.22 $16.96

90969 $15.41 $14.64 $16.84 $16.58

90970 $8.28 $7.87 $9.05 $8.91

90997 $92.76 $88.12 $101.34 $99.82

91010 $206.68 $196.35 $225.80 $222.41

91010 TC $134.82 $128.08 $147.29 $145.08

91010 26 $71.85 $68.26 $78.50 $77.33

91013 $27.65 $26.27 $30.21 $29.76

91013 TC $17.59 $16.71 $19.22 $18.93

91013 26 $10.06 $9.56 $10.99 $10.83

91020 $278.89 $264.95 $304.69 $300.13

91020 TC $197.65 $187.77 $215.94 $212.69

91020 26 $81.24 $77.18 $88.76 $87.42

91022 $199.27 $189.31 $217.71 $214.44

91022 TC $118.35 $112.43 $129.29 $127.35

91022 26 $80.92 $76.87 $88.40 $87.08

91030 $164.03 $155.83 $179.20 $176.51

91030 TC $112.60 $106.97 $123.02 $121.18

91030 26 $51.42 $48.85 $56.18 $55.34

91034 $223.57 $212.39 $244.25 $240.58

91034 TC $170.07 $161.57 $185.81 $183.02

91034 26 $53.51 $50.83 $58.45 $57.58

91035 $585.99 $556.69 $640.19 $630.59

91035 TC $497.62 $472.74 $543.65 $535.50

91035 26 $88.37 $83.95 $96.54 $95.09

91037 $190.55 $181.02 $208.17 $205.05

91037 TC $135.59 $128.81 $148.13 $145.91

91037 26 $54.96 $52.21 $60.04 $59.14

91038 $551.40 $523.83 $602.40 $593.37

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

91038 TC $489.96 $465.46 $535.28 $527.25

91038 26 $61.44 $58.37 $67.13 $66.11

91040 $341.60 $324.52 $373.20 $367.60

91040 TC $293.43 $278.76 $320.57 $315.77

91040 26 $48.17 $45.76 $52.62 $51.83

91065 $112.24 $106.63 $122.62 $120.78

91065 TC $101.11 $96.05 $110.46 $108.80

91065 26 $11.13 $10.57 $12.16 $11.97

C 91110 $1,050.01 $997.51 $1,147.14 $1,129.93

C 91110 TC $845.09 $802.84 $923.27 $909.42

91110 26 $204.92 $194.67 $223.87 $220.51

91111 $909.21 $863.75 $993.31 $978.41

91111 TC $853.13 $810.47 $932.04 $918.06

91111 26 $56.08 $53.28 $61.27 $60.35

91112 $1,328.85 $1,262.41 $1,451.77 $1,429.99

91112 TC $1,210.57 $1,150.04 $1,322.55 $1,302.71

91112 26 $118.29 $112.38 $129.24 $127.29

91117 $171.02 $162.47 $186.84 $184.03

91120 $477.84 $453.95 $522.04 $514.21

91120 TC $424.83 $403.59 $464.13 $457.17

91120 26 $53.01 $50.36 $57.91 $57.04

91122 $250.82 $238.28 $274.02 $269.92

91122 TC $157.81 $149.92 $172.41 $169.82

91122 26 $93.01 $88.36 $101.61 $100.08

91132 $188.43 $179.01 $205.86 $202.77

91132 TC $158.96 $151.01 $173.66 $171.05

91132 26 $29.47 $28.00 $32.20 $31.72

91133 $217.02 $206.17 $237.10 $233.54

91133 TC $179.26 $170.30 $195.85 $192.91

91133 26 $37.76 $35.87 $41.25 $40.63

92002 $90.14 $85.63 $98.47 $97.00

# 92002 $51.06 $48.51 $55.79 $54.95

92004 $163.65 $155.47 $178.79 $176.11

# 92004 $105.80 $100.51 $115.59 $113.85

92012 $94.98 $90.23 $103.76 $102.21

# 92012 $56.28 $53.47 $61.49 $60.57

92014 $136.78 $129.94 $149.43 $147.19

# 92014 $85.06 $80.81 $92.93 $91.54

92018 $152.30 $144.69 $166.39 $163.90

92019 $73.66 $69.98 $80.48 $79.27

92020 $29.63 $28.15 $32.37 $31.89

# 92020 $22.73 $21.59 $24.83 $24.46

92025 $41.98 $39.88 $45.86 $45.17

92025 TC $21.04 $19.99 $22.99 $22.64

92025 26 $20.94 $19.89 $22.87 $22.53

92060 $72.51 $68.88 $79.21 $78.03

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

92060 TC $31.77 $30.18 $34.71 $34.19

92060 26 $40.74 $38.70 $44.51 $43.84

92065 $61.07 $58.02 $66.72 $65.72

92065 TC $42.50 $40.38 $46.44 $45.74

92065 26 $18.57 $17.64 $20.29 $19.99

92071 $36.05 $34.25 $39.39 $38.80

# 92071 $31.83 $30.24 $34.78 $34.26

92072 $136.70 $129.87 $149.35 $147.11

# 92072 $102.99 $97.84 $112.52 $110.83

92081 $38.28 $36.37 $41.83 $41.19

92081 TC $20.66 $19.63 $22.57 $22.24

92081 26 $17.62 $16.74 $19.25 $18.96

92082 $55.13 $52.37 $60.23 $59.32

92082 TC $31.39 $29.82 $34.29 $33.78

92082 26 $23.75 $22.56 $25.94 $25.55

92083 $73.19 $69.53 $79.96 $78.76

92083 TC $43.26 $41.10 $47.27 $46.55

92083 26 $29.93 $28.43 $32.69 $32.20

92100 $90.07 $85.57 $98.41 $96.93

# 92100 $35.66 $33.88 $38.96 $38.38

92132 $39.63 $37.65 $43.30 $42.65

92132 TC $18.74 $17.80 $20.47 $20.16

92132 26 $20.89 $19.85 $22.83 $22.48

92133 $49.06 $46.61 $53.60 $52.80

92133 TC $19.13 $18.17 $20.90 $20.59

92133 26 $29.93 $28.43 $32.69 $32.20

92134 $50.21 $47.70 $54.86 $54.03

92134 TC $19.51 $18.53 $21.31 $20.99

92134 26 $30.69 $29.16 $33.53 $33.03

92136 $102.98 $97.83 $112.50 $110.81

92136 TC $70.08 $66.58 $76.57 $75.42

92136 26 $32.91 $31.26 $35.95 $35.41

92140 $71.30 $67.74 $77.90 $76.73

# 92140 $28.01 $26.61 $30.60 $30.14

92225 $29.59 $28.11 $32.33 $31.84

# 92225 $23.08 $21.93 $25.22 $24.84

92226 $26.76 $25.42 $29.23 $28.80

# 92226 $20.25 $19.24 $22.13 $21.79

92227 $15.68 $14.90 $17.14 $16.88

92228 $39.23 $37.27 $42.86 $42.22

92228 TC $16.45 $15.63 $17.97 $17.71

92228 26 $22.79 $21.65 $24.90 $24.53

92230 $65.17 $61.91 $71.20 $70.13

# 92230 $36.06 $34.26 $39.40 $38.81

92235 $124.57 $118.34 $136.09 $134.04

92235 TC $74.68 $70.95 $81.59 $80.37

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

92235 26 $49.89 $47.40 $54.51 $53.69

C 92240 $230.80 $219.26 $252.15 $248.37

C 92240 TC $163.17 $155.01 $178.26 $175.58

92240 26 $67.63 $64.25 $73.89 $72.78

C 92250 $79.21 $75.25 $86.54 $85.24

C 92250 TC $54.37 $51.65 $59.40 $58.51

92250 26 $24.83 $23.59 $27.13 $26.73

92260 $21.09 $20.04 $23.05 $22.70

# 92260 $11.90 $11.31 $13.01 $12.81

92265 $88.61 $84.18 $96.81 $95.36

92265 TC $43.65 $41.47 $47.69 $46.98

92265 26 $44.97 $42.72 $49.13 $48.39

92270 $102.73 $97.59 $112.23 $110.55

92270 TC $59.74 $56.75 $65.26 $64.29

92270 26 $43.00 $40.85 $46.98 $46.28

92275 $182.44 $173.32 $199.32 $196.33

92275 TC $120.27 $114.26 $131.40 $129.43

92275 26 $62.17 $59.06 $67.92 $66.90

92283 $64.08 $60.88 $70.01 $68.97

92283 TC $54.37 $51.65 $59.40 $58.51

92283 26 $9.71 $9.22 $10.60 $10.44

92284 $71.11 $67.55 $77.68 $76.52

92284 TC $58.20 $55.29 $63.58 $62.63

92284 26 $12.91 $12.26 $14.10 $13.89

92285 $23.90 $22.71 $26.12 $25.73

92285 TC $20.66 $19.63 $22.57 $22.24

92285 26 $3.24 $3.08 $3.54 $3.48

92286 $42.19 $40.08 $46.09 $45.40

92286 TC $19.13 $18.17 $20.90 $20.59

92286 26 $23.06 $21.91 $25.20 $24.82

C 92287 $133.38 $126.71 $145.72 $143.53

C 92287 TC $83.49 $79.32 $91.22 $89.85

92287 26 $49.89 $47.40 $54.51 $53.69

92311 $114.68 $108.95 $125.29 $123.42

# 92311 $59.90 $56.91 $65.45 $64.47

92312 $128.68 $122.25 $140.59 $138.48

# 92312 $66.62 $63.29 $72.78 $71.69

92313 $113.80 $108.11 $124.33 $122.46

# 92313 $52.89 $50.25 $57.79 $56.93

92315 $93.67 $88.99 $102.34 $100.81

# 92315 $26.25 $24.94 $28.68 $28.26

92316 $123.50 $117.33 $134.93 $132.91

# 92316 $42.67 $40.54 $46.62 $45.92

92317 $86.86 $82.52 $94.90 $93.47

# 92317 $22.50 $21.38 $24.59 $24.22

92325 $48.63 $46.20 $53.13 $52.34

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

92326 $41.35 $39.28 $45.17 $44.49

92502 $103.98 $98.78 $113.60 $111.90

92504 $34.96 $33.21 $38.19 $37.62

# 92504 $10.06 $9.56 $10.99 $10.83

92506 $241.59 $229.51 $263.94 $259.98

92507 $75.23 $71.47 $82.19 $80.96

92508 $22.16 $21.05 $24.21 $23.84

92511 $159.79 $151.80 $174.57 $171.95

# 92511 $53.29 $50.63 $58.22 $57.35

92512 $68.83 $65.39 $75.20 $74.07

# 92512 $29.75 $28.26 $32.50 $32.02

92516 $79.98 $75.98 $87.38 $86.07

# 92516 $24.05 $22.85 $26.28 $25.89

92520 $81.88 $77.79 $89.46 $88.11

# 92520 $42.80 $40.66 $46.76 $46.06

92526 $81.98 $77.88 $89.56 $88.22

92540 $107.90 $102.51 $117.89 $116.12

92540 TC $25.64 $24.36 $28.01 $27.59

92540 26 $82.26 $78.15 $89.87 $88.53

92541 $32.61 $30.98 $35.63 $35.10

92541 TC $11.08 $10.53 $12.11 $11.93

92541 26 $21.53 $20.45 $23.52 $23.16

92542 $29.03 $27.58 $31.72 $31.25

92542 TC $11.08 $10.53 $12.11 $11.93

92542 26 $17.95 $17.05 $19.61 $19.31

92543 $17.98 $17.08 $19.64 $19.34

92543 TC $12.23 $11.62 $13.36 $13.17

92543 26 $5.74 $5.45 $6.27 $6.18

92544 $25.45 $24.18 $27.81 $27.39

92544 TC $11.08 $10.53 $12.11 $11.93

92544 26 $14.37 $13.65 $15.70 $15.47

92545 $22.88 $21.74 $25.00 $24.62

92545 TC $10.32 $9.80 $11.27 $11.10

92545 26 $12.56 $11.93 $13.72 $13.51

92546 $119.20 $113.24 $130.23 $128.27

92546 TC $103.79 $98.60 $113.39 $111.69

92546 26 $15.41 $14.64 $16.84 $16.58

92547 $7.25 $6.89 $7.92 $7.81

92548 $118.45 $112.53 $129.41 $127.47

92548 TC $91.92 $87.32 $100.42 $98.91

92548 26 $26.54 $25.21 $28.99 $28.55

92550 $22.09 $20.99 $24.14 $23.78

92552 $36.37 $34.55 $39.73 $39.13

92553 $44.03 $41.83 $48.10 $47.38

92555 $27.56 $26.18 $30.11 $29.66

92556 $43.26 $41.10 $47.27 $46.55

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

92557 $39.91 $37.91 $43.60 $42.94

# 92557 $33.79 $32.10 $36.92 $36.36

92561 $44.41 $42.19 $48.52 $47.79

92562 $55.14 $52.38 $60.24 $59.33

92563 $37.13 $35.27 $40.56 $39.95

92564 $33.69 $32.01 $36.81 $36.26

92565 $19.89 $18.90 $21.74 $21.41

92567 $15.35 $14.58 $16.77 $16.51

# 92567 $11.13 $10.57 $12.16 $11.97

92568 $16.18 $15.37 $17.68 $17.41

92570 $33.96 $32.26 $37.10 $36.55

# 92570 $31.28 $29.72 $34.18 $33.66

92571 $32.15 $30.54 $35.12 $34.59

92572 $62.03 $58.93 $67.77 $66.76

92575 $89.23 $84.77 $97.49 $96.03

92576 $40.20 $38.19 $43.92 $43.26

92577 $21.81 $20.72 $23.83 $23.47

92579 $44.15 $41.94 $48.23 $47.51

# 92579 $38.79 $36.85 $42.38 $41.75

92582 $84.64 $80.41 $92.47 $91.08

92583 $60.89 $57.85 $66.53 $65.53

92584 $82.34 $78.22 $89.95 $88.61

92585 $145.65 $138.37 $159.13 $156.73

92585 TC $118.35 $112.43 $129.29 $127.35

92585 26 $27.30 $25.94 $29.83 $29.38

92586 $100.73 $95.69 $110.04 $108.39

92587 $23.16 $22.00 $25.30 $24.92

92587 TC $3.42 $3.25 $3.74 $3.68

92587 26 $19.74 $18.75 $21.56 $21.24

92588 $35.11 $33.35 $38.35 $37.78

92588 TC $4.57 $4.34 $4.99 $4.91

92588 26 $30.54 $29.01 $33.36 $32.86

92596 $50.92 $48.37 $55.63 $54.79

92597 $73.46 $69.79 $80.26 $79.05

92601 $140.89 $133.85 $153.93 $151.62

# 92601 $119.44 $113.47 $130.49 $128.54

92602 $96.30 $91.49 $105.21 $103.64

# 92602 $71.02 $67.47 $77.59 $76.43

92603 $157.16 $149.30 $171.70 $169.12

# 92603 $127.66 $121.28 $139.47 $137.38

92604 $95.00 $90.25 $103.79 $102.24

# 92604 $70.48 $66.96 $77.00 $75.85

92607 $127.58 $121.20 $139.38 $137.29

92608 $51.41 $48.84 $56.17 $55.33

92609 $105.16 $99.90 $114.89 $113.16

92610 $82.89 $78.75 $90.56 $89.21

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 92610 $70.63 $67.10 $77.17 $76.00

92611 $93.45 $88.78 $102.10 $100.57

92612 $197.93 $188.03 $216.23 $212.99

# 92612 $69.97 $66.47 $76.44 $75.29

92613 $40.26 $38.25 $43.99 $43.33

92614 $169.58 $161.10 $185.27 $182.48

# 92614 $70.74 $67.20 $77.28 $76.12

92615 $35.21 $33.45 $38.47 $37.89

# 92615 $34.83 $33.09 $38.05 $37.48

92616 $232.06 $220.46 $253.53 $249.72

# 92616 $104.11 $98.90 $113.74 $112.03

92617 $43.81 $41.62 $47.86 $47.15

# 92617 $43.42 $41.25 $47.44 $46.72

92620 $98.65 $93.72 $107.78 $106.16

# 92620 $87.16 $82.80 $95.22 $93.79

92621 $23.62 $22.44 $25.81 $25.42

# 92621 $19.79 $18.80 $21.62 $21.30

92625 $73.14 $69.48 $79.90 $78.71

# 92625 $64.71 $61.47 $70.69 $69.63

92626 $95.56 $90.78 $104.40 $102.83

# 92626 $79.85 $75.86 $87.24 $85.93

92627 $22.93 $21.78 $25.05 $24.67

# 92627 $18.33 $17.41 $20.02 $19.72

92640 $131.37 $124.80 $143.52 $141.37

# 92640 $110.69 $105.16 $120.93 $119.12

92920 $570.46 $541.94 $623.23 $613.88

92924 $678.25 $644.34 $740.99 $729.87

92928 $633.59 $601.91 $692.20 $681.81

92933 $708.49 $673.07 $774.03 $762.42

92937 $632.85 $601.21 $691.39 $681.02

92941 $709.92 $674.42 $775.58 $763.95

92943 $709.92 $674.42 $775.58 $763.95

92950 $331.53 $314.95 $362.19 $356.76

# 92950 $191.32 $181.75 $209.01 $205.87

92953 $11.03 $10.48 $12.05 $11.87

92960 $222.97 $211.82 $243.59 $239.94

# 92960 $126.43 $120.11 $138.13 $136.06

92961 $251.71 $239.12 $274.99 $270.86

92970 $183.71 $174.52 $200.70 $197.69

92971 $96.43 $91.61 $105.35 $103.78

92973 $185.15 $175.89 $202.27 $199.24

92974 $169.08 $160.63 $184.72 $181.95

92975 $409.20 $388.74 $447.05 $440.35

92977 $63.89 $60.70 $69.81 $68.76

92978 $321.49 $305.42 $351.23 $345.97

92978 TC $229.41 $217.94 $250.63 $246.87

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

92978 26 $92.08 $87.48 $100.60 $99.10

92979 26 $73.88 $70.19 $80.72 $79.51

92986 $1,411.37 $1,340.80 $1,541.92 $1,518.79

92987 $1,460.63 $1,387.60 $1,595.74 $1,571.81

92990 $1,146.59 $1,089.26 $1,252.65 $1,233.86

92992 $657.28 $624.42 $718.08 $707.31

92997 $683.26 $649.10 $746.47 $735.26

92998 $337.79 $320.90 $369.04 $363.50

93000 $20.02 $19.02 $21.87 $21.54

93005 $11.47 $10.90 $12.54 $12.35

93010 $8.56 $8.13 $9.35 $9.21

93015 $86.88 $82.54 $94.92 $93.50

93016 $22.50 $21.38 $24.59 $24.22

93017 $49.39 $46.92 $53.96 $53.15

93018 $14.99 $14.24 $16.38 $16.13

93024 $122.49 $116.37 $133.83 $131.81

93024 TC $63.95 $60.75 $69.86 $68.82

93024 26 $58.54 $55.61 $63.95 $63.00

93025 $189.91 $180.41 $207.47 $204.36

93025 TC $151.68 $144.10 $165.72 $163.23

93025 26 $38.23 $36.32 $41.77 $41.15

93040 $14.35 $13.63 $15.67 $15.44

93041 $6.87 $6.53 $7.51 $7.39

93042 $7.48 $7.11 $8.18 $8.05

93224 $103.79 $98.60 $113.39 $111.69

93225 $31.77 $30.18 $34.71 $34.19

93226 $44.80 $42.56 $48.94 $48.21

93227 $27.23 $25.87 $29.75 $29.30

93228 $26.41 $25.09 $28.85 $28.42

93229 $828.62 $787.19 $905.27 $891.69

93268 $247.07 $234.72 $269.93 $265.88

93270 $10.70 $10.17 $11.70 $11.52

93271 $211.06 $200.51 $230.59 $227.13

93272 $25.31 $24.04 $27.65 $27.23

93278 $33.91 $32.21 $37.04 $36.49

93278 TC $21.04 $19.99 $22.99 $22.64

93278 26 $12.87 $12.23 $14.06 $13.86

93279 $53.50 $50.83 $58.45 $57.58

93279 TC $20.28 $19.27 $22.16 $21.83

93279 26 $33.22 $31.56 $36.29 $35.75

93280 $61.50 $58.43 $67.19 $66.18

93280 TC $22.58 $21.45 $24.67 $24.30

93280 26 $38.92 $36.97 $42.52 $41.88

93281 $71.76 $68.17 $78.40 $77.22

93281 TC $26.41 $25.09 $28.85 $28.42

93281 26 $45.36 $43.09 $49.55 $48.81

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

93282 $66.58 $63.25 $72.74 $71.65

93282 TC $23.34 $22.17 $25.50 $25.12

93282 26 $43.24 $41.08 $47.24 $46.53

93283 $85.40 $81.13 $93.30 $91.90

93283 TC $27.17 $25.81 $29.68 $29.23

93283 26 $58.23 $55.32 $63.62 $62.66

93284 $94.24 $89.53 $102.96 $101.42

93284 TC $31.00 $29.45 $33.87 $33.36

93284 26 $63.23 $60.07 $69.08 $68.05

93285 $44.06 $41.86 $48.14 $47.41

93285 TC $17.98 $17.08 $19.64 $19.34

93285 26 $26.08 $24.78 $28.50 $28.07

93286 $28.75 $27.31 $31.41 $30.94

93286 TC $13.38 $12.71 $14.62 $14.40

93286 26 $15.37 $14.60 $16.79 $16.54

93287 $37.41 $35.54 $40.87 $40.26

93287 TC $14.91 $14.16 $16.28 $16.04

93287 26 $22.50 $21.38 $24.59 $24.22

93288 $39.78 $37.79 $43.46 $42.80

93288 TC $18.36 $17.44 $20.06 $19.76

93288 26 $21.42 $20.35 $23.40 $23.05

93289 $69.01 $65.56 $75.39 $74.27

93289 TC $22.58 $21.45 $24.67 $24.30

93289 26 $46.43 $44.11 $50.73 $49.97

93290 $32.50 $30.88 $35.51 $34.98

93290 TC $11.08 $10.53 $12.11 $11.93

93290 26 $21.42 $20.35 $23.40 $23.05

93291 $38.25 $36.34 $41.79 $41.16

93291 TC $16.83 $15.99 $18.39 $18.11

93291 26 $21.42 $20.35 $23.40 $23.05

93292 $34.42 $32.70 $37.61 $37.04

93292 TC $13.00 $12.35 $14.20 $13.98

93292 26 $21.42 $20.35 $23.40 $23.05

93293 $58.57 $55.64 $63.99 $63.03

93293 TC $42.88 $40.74 $46.85 $46.15

93293 26 $15.69 $14.91 $17.15 $16.89

93294 $34.35 $32.63 $37.52 $36.96

93295 $67.58 $64.20 $73.83 $72.73

93296 $29.47 $28.00 $32.20 $31.72

93297 $26.79 $25.45 $29.27 $28.83

93298 $26.79 $25.45 $29.27 $28.83

93299 $48.45 $46.03 $52.93 $52.14

93303 $217.80 $206.91 $237.95 $234.38

93303 TC $152.45 $144.83 $166.55 $164.06

93303 26 $65.35 $62.08 $71.39 $70.32

93304 $145.09 $137.84 $158.52 $156.14

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

93304 TC $107.24 $101.88 $117.16 $115.40

93304 26 $37.85 $35.96 $41.35 $40.73

93306 $208.60 $198.17 $227.90 $224.48

93306 TC $143.63 $136.45 $156.92 $154.56

93306 26 $64.97 $61.72 $70.98 $69.91

93307 $125.32 $119.05 $136.91 $134.85

93307 TC $78.89 $74.95 $86.19 $84.90

93307 26 $46.43 $44.11 $50.73 $49.97

93308 $111.07 $105.52 $121.35 $119.53

93308 TC $85.02 $80.77 $92.89 $91.49

93308 26 $26.05 $24.75 $28.46 $28.04

93312 $336.27 $319.46 $367.38 $361.87

93312 TC $229.39 $217.92 $250.61 $246.85

93312 26 $106.88 $101.54 $116.77 $115.02

93313 $42.77 $40.63 $46.72 $46.02

93314 $316.38 $300.56 $345.64 $340.46

93314 TC $255.06 $242.31 $278.66 $274.48

93314 26 $61.32 $58.25 $66.99 $65.99

93315 $379.29 $360.33 $414.38 $408.17

93315 TC $237.00 $225.15 $258.92 $255.04

93315 26 $142.29 $135.18 $155.46 $153.12

93316 $43.53 $41.35 $47.55 $46.84

93317 $336.72 $319.88 $367.86 $362.34

93317 TC $240.84 $228.80 $263.12 $259.18

93317 26 $95.88 $91.09 $104.75 $103.18

93318 $454.81 $432.07 $496.88 $489.43

93318 TC $340.17 $323.16 $371.63 $366.06

93318 26 $114.64 $108.91 $125.25 $123.37

93320 $49.16 $46.70 $53.71 $52.90

93320 TC $30.24 $28.73 $33.04 $32.55

93320 26 $18.92 $17.97 $20.67 $20.36

93321 $26.23 $24.92 $28.66 $28.23

93321 TC $18.74 $17.80 $20.47 $20.16

93321 26 $7.48 $7.11 $8.18 $8.05

93325 $22.30 $21.19 $24.37 $24.00

93325 TC $18.36 $17.44 $20.06 $19.76

93325 26 $3.94 $3.74 $4.30 $4.23

93350 $220.26 $209.25 $240.64 $237.03

93350 TC $147.08 $139.73 $160.69 $158.27

93350 26 $73.18 $69.52 $79.95 $78.75

93351 $257.48 $244.61 $281.30 $277.08

93351 TC $170.01 $161.51 $185.74 $182.95

93351 26 $87.47 $83.10 $95.57 $94.13

93352 $38.37 $36.45 $41.92 $41.29

93451 $910.31 $864.79 $994.51 $979.59

93451 TC $756.54 $718.71 $826.52 $814.12

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

93451 26 $153.77 $146.08 $167.99 $165.47

93452 $1,000.60 $950.57 $1,093.16 $1,076.76

93452 TC $731.25 $694.69 $798.89 $786.91

93452 26 $269.35 $255.88 $294.26 $289.85

93453 $1,304.71 $1,239.47 $1,425.39 $1,404.01

93453 TC $951.12 $903.56 $1,039.09 $1,023.51

93453 26 $353.58 $335.90 $386.29 $380.49

93454 $1,024.98 $973.73 $1,119.79 $1,102.99

93454 TC $753.86 $716.17 $823.60 $811.24

93454 26 $271.12 $257.56 $296.19 $291.76

93455 $1,191.19 $1,131.63 $1,301.37 $1,281.86

93455 TC $878.34 $834.42 $959.58 $945.19

93455 26 $312.85 $297.21 $341.79 $336.66

93456 $1,284.07 $1,219.87 $1,402.85 $1,381.81

93456 TC $936.95 $890.10 $1,023.62 $1,008.26

93456 26 $347.12 $329.76 $379.22 $373.53

93457 $1,449.52 $1,377.04 $1,583.60 $1,559.84

93457 TC $1,060.31 $1,007.29 $1,158.38 $1,141.01

93457 26 $389.21 $369.75 $425.21 $418.83

93458 $1,227.02 $1,165.67 $1,340.52 $1,320.41

93458 TC $895.96 $851.16 $978.83 $964.15

93458 26 $331.06 $314.51 $361.69 $356.26

93459 $1,354.21 $1,286.50 $1,479.48 $1,457.28

93459 TC $981.77 $932.68 $1,072.58 $1,056.49

93459 26 $372.44 $353.82 $406.89 $400.79

93460 $1,449.93 $1,377.43 $1,584.04 $1,560.29

93460 TC $1,035.02 $983.27 $1,130.76 $1,113.80

93460 26 $414.91 $394.16 $453.28 $446.49

93461 $1,662.41 $1,579.29 $1,816.18 $1,788.94

93461 TC $1,204.33 $1,144.11 $1,315.73 $1,295.99

93461 26 $458.08 $435.18 $500.46 $492.95

93462 $214.33 $203.61 $234.15 $230.64

93463 $110.92 $105.37 $121.18 $119.36

93464 $320.51 $304.48 $350.15 $344.90

93464 TC $220.25 $209.24 $240.63 $237.02

93464 26 $100.26 $95.25 $109.54 $107.89

93503 $133.67 $126.99 $146.04 $143.85

93505 $864.30 $821.09 $944.25 $930.09

93505 TC $622.07 $590.97 $679.62 $669.43

93505 26 $242.23 $230.12 $264.64 $260.67

93530 26 $237.94 $226.04 $259.95 $256.05

93531 26 $470.88 $447.34 $514.44 $506.72

93532 26 $563.60 $535.42 $615.73 $606.50

93533 26 $377.75 $358.86 $412.69 $406.50

93561 $52.89 $50.25 $57.79 $56.93

93561 TC $27.97 $26.57 $30.56 $30.10

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

93561 26 $24.92 $23.67 $27.22 $26.81

93562 26 $7.83 $7.44 $8.56 $8.43

93563 $57.44 $54.57 $62.76 $61.81

93564 $58.87 $55.93 $64.32 $63.35

93565 $44.59 $42.36 $48.71 $47.98

93566 $195.92 $186.12 $214.04 $210.83

# 93566 $44.59 $42.36 $48.71 $47.98

93567 $159.51 $151.53 $174.26 $171.65

# 93567 $50.33 $47.81 $54.98 $54.15

93568 $174.78 $166.04 $190.95 $188.08

# 93568 $45.67 $43.39 $49.90 $49.15

93571 $308.65 $293.22 $337.20 $332.14

93571 TC $216.93 $206.08 $236.99 $233.44

93571 26 $91.72 $87.13 $100.20 $98.69

93572 $174.44 $165.72 $190.58 $187.71

93572 TC $100.20 $95.19 $109.47 $107.82

93572 26 $74.24 $70.53 $81.11 $79.89

93580 $1,032.16 $980.55 $1,127.63 $1,110.72

93581 $1,391.53 $1,321.95 $1,520.24 $1,497.44

93600 $209.04 $198.59 $228.38 $224.95

93600 TC $87.22 $82.86 $95.29 $93.86

93600 26 $121.82 $115.73 $133.09 $131.09

93602 26 $121.44 $115.37 $132.68 $130.69

93603 26 $121.06 $115.01 $132.26 $130.27

93609 26 $286.80 $272.46 $313.33 $308.63

93610 $233.51 $221.83 $255.10 $251.28

93610 TC $61.05 $58.00 $66.70 $65.70

93610 26 $172.46 $163.84 $188.42 $185.59

93612 26 $171.31 $162.74 $187.15 $184.35

93613 $402.98 $382.83 $440.25 $433.65

93615 26 $49.96 $47.46 $54.58 $53.76

93616 26 $66.78 $63.44 $72.96 $71.86

93618 $419.01 $398.06 $457.77 $450.90

93618 TC $174.66 $165.93 $190.82 $187.96

93618 26 $244.35 $232.13 $266.95 $262.95

93619 26 $419.65 $398.67 $458.47 $451.59

93620 $1,214.95 $1,154.20 $1,327.33 $1,307.42

93620 TC $549.51 $522.03 $600.33 $591.33

93620 26 $665.44 $632.17 $727.00 $716.09

93621 26 $120.75 $114.71 $131.92 $129.94

93622 26 $178.25 $169.34 $194.74 $191.82

93623 26 $164.31 $156.09 $179.50 $176.81

93624 $371.82 $353.23 $406.21 $400.12

93624 TC $98.02 $93.12 $107.09 $105.48

93624 26 $273.80 $260.11 $299.13 $294.64

93631 26 $423.02 $401.87 $462.15 $455.22

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

93640 $340.87 $323.83 $372.40 $366.82

93640 TC $140.97 $133.92 $154.01 $151.70

93640 26 $199.90 $189.91 $218.40 $215.12

93641 $515.45 $489.68 $563.13 $554.68

93641 TC $176.21 $167.40 $192.51 $189.62

93641 26 $339.24 $322.28 $370.62 $365.07

93642 $422.17 $401.06 $461.22 $454.30

93642 TC $173.08 $164.43 $189.09 $186.25

93642 26 $249.09 $236.64 $272.14 $268.05

93650 $615.58 $584.80 $672.52 $662.43

93653 $863.74 $820.55 $943.63 $929.48

93654 $1,152.80 $1,095.16 $1,259.43 $1,240.54

93655 $431.88 $410.29 $471.83 $464.76

93656 $1,153.11 $1,095.45 $1,259.77 $1,240.87

93657 $432.24 $410.63 $472.22 $465.14

93660 $168.87 $160.43 $184.49 $181.72

93660 TC $72.76 $69.12 $79.49 $78.29

93660 26 $96.11 $91.30 $105.00 $103.42

93662 $321.37 $305.30 $351.10 $345.83

93662 TC $174.85 $166.11 $191.03 $188.16

93662 26 $146.52 $139.19 $160.07 $157.67

93701 $28.32 $26.90 $30.94 $30.48

93724 $279.71 $265.72 $305.58 $300.99

93724 TC $32.54 $30.91 $35.55 $35.02

93724 26 $247.18 $234.82 $270.04 $266.00

93745 $92.87 $88.23 $101.46 $99.95

93745 TC $69.65 $66.17 $76.10 $74.96

93745 26 $23.22 $22.06 $25.37 $24.99

93750 $57.11 $54.25 $62.39 $61.46

# 93750 $46.00 $43.70 $50.26 $49.50

93784 $61.39 $58.32 $67.07 $66.07

93786 $35.60 $33.82 $38.89 $38.31

93788 $6.49 $6.17 $7.10 $6.99

93790 $19.30 $18.34 $21.09 $20.77

93797 $18.10 $17.20 $19.78 $19.48

# 93797 $9.29 $8.83 $10.15 $10.01

93798 $26.94 $25.59 $29.43 $28.99

# 93798 $14.30 $13.59 $15.63 $15.40

C 93880 $204.59 $194.36 $223.51 $220.16

C 93880 TC $174.28 $165.57 $190.41 $187.55

93880 26 $30.31 $28.79 $33.11 $32.61

C 93882 $194.94 $185.19 $212.97 $209.77

C 93882 TC $174.28 $165.57 $190.41 $187.55

93882 26 $20.65 $19.62 $22.56 $22.23

C 93886 $223.71 $212.52 $244.40 $240.73

C 93886 TC $173.93 $165.23 $190.01 $187.16

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

93886 26 $49.78 $47.29 $54.38 $53.57

C 93888 $104.94 $99.69 $114.64 $112.92

C 93888 TC $72.41 $68.79 $79.11 $77.92

93888 26 $32.54 $30.91 $35.55 $35.02

C 93890 $163.73 $155.54 $178.87 $176.19

C 93890 TC $111.86 $106.27 $122.21 $120.38

93890 26 $51.87 $49.28 $56.67 $55.82

C 93892 $171.98 $163.38 $187.89 $185.07

C 93892 TC $111.86 $106.27 $122.21 $120.38

93892 26 $60.11 $57.10 $65.67 $64.68

C 93893 $172.75 $164.11 $188.73 $185.90

C 93893 TC $111.86 $106.27 $122.21 $120.38

93893 26 $60.88 $57.84 $66.52 $65.52

93922 $105.17 $99.91 $114.90 $113.17

93922 TC $92.68 $88.05 $101.26 $99.74

93922 26 $12.49 $11.87 $13.65 $13.44

93923 $162.99 $154.84 $178.07 $175.40

93923 TC $140.19 $133.18 $153.16 $150.86

93923 26 $22.80 $21.66 $24.91 $24.54

93924 $204.57 $194.34 $223.49 $220.13

93924 TC $179.26 $170.30 $195.85 $192.91

93924 26 $25.30 $24.04 $27.65 $27.23

C 93925 $214.90 $204.16 $234.78 $231.27

C 93925 TC $174.25 $165.54 $190.37 $187.52

93925 26 $40.65 $38.62 $44.41 $43.75

C 93926 $137.47 $130.60 $150.19 $147.94

C 93926 TC $111.84 $106.25 $122.19 $120.36

93926 26 $25.63 $24.35 $28.00 $27.58

C 93930 $197.81 $187.92 $216.11 $212.87

C 93930 TC $174.28 $165.57 $190.41 $187.55

93930 26 $23.53 $22.35 $25.70 $25.31

C 93931 $127.50 $121.13 $139.30 $137.21

C 93931 TC $111.84 $106.25 $122.19 $120.36

93931 26 $15.67 $14.89 $17.12 $16.87

93965 $140.39 $133.37 $153.38 $151.08

93965 TC $122.56 $116.43 $133.89 $131.88

93965 26 $17.82 $16.93 $19.47 $19.18

C 93970 $210.28 $199.77 $229.74 $226.29

C 93970 TC $174.28 $165.57 $190.41 $187.55

93970 26 $36.00 $34.20 $39.33 $38.74

93971 $130.04 $123.54 $142.07 $139.94

93971 TC $107.24 $101.88 $117.16 $115.40

93971 26 $22.80 $21.66 $24.91 $24.54

C 93975 $265.90 $252.61 $290.50 $286.14

C 93975 TC $174.25 $165.54 $190.37 $187.52

93975 26 $91.64 $87.06 $100.12 $98.61

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

C 93976 $235.63 $223.85 $257.43 $253.56

C 93976 TC $174.28 $165.57 $190.41 $187.55

93976 26 $61.35 $58.28 $67.02 $66.02

C 93978 $207.78 $197.39 $227.00 $223.59

C 93978 TC $174.28 $165.57 $190.41 $187.55

93978 26 $33.50 $31.83 $36.60 $36.05

C 93979 $133.91 $127.21 $146.29 $144.10

C 93979 TC $111.84 $106.25 $122.19 $120.36

93979 26 $22.07 $20.97 $24.12 $23.76

93980 $180.35 $171.33 $197.03 $194.07

93980 TC $117.20 $111.34 $128.04 $126.12

93980 26 $63.15 $59.99 $68.99 $67.95

93981 $125.12 $118.86 $136.69 $134.64

93981 TC $103.03 $97.88 $112.56 $110.87

93981 26 $22.10 $21.00 $24.15 $23.79

93982 $48.59 $46.16 $53.08 $52.29

C 93990 $124.63 $118.40 $136.16 $134.11

C 93990 TC $111.84 $106.25 $122.19 $120.36

93990 26 $12.79 $12.15 $13.97 $13.77

94002 $95.50 $90.73 $104.34 $102.78

94003 $69.53 $66.05 $75.96 $74.82

94004 $51.02 $48.47 $55.74 $54.90

94010 $41.48 $39.41 $45.32 $44.64

94010 TC $32.92 $31.27 $35.96 $35.42

94010 26 $8.56 $8.13 $9.35 $9.21

94011 $103.95 $98.75 $113.56 $111.86

94012 $164.13 $155.92 $179.31 $176.62

94013 $36.99 $35.14 $40.41 $39.80

94014 $54.02 $51.32 $59.02 $58.13

94015 $28.70 $27.27 $31.36 $30.89

94016 $25.31 $24.04 $27.65 $27.23

94060 $71.39 $67.82 $77.99 $76.82

94060 TC $57.82 $54.93 $63.17 $62.23

94060 26 $13.57 $12.89 $14.82 $14.61

94070 $66.70 $63.37 $72.88 $71.78

94070 TC $36.75 $34.91 $40.15 $39.55

94070 26 $29.95 $28.45 $32.72 $32.22

94200 $29.05 $27.60 $31.74 $31.27

94200 TC $23.34 $22.17 $25.50 $25.12

94200 26 $5.71 $5.42 $6.23 $6.14

94250 $29.43 $27.96 $32.15 $31.67

94250 TC $23.72 $22.53 $25.91 $25.52

94250 26 $5.71 $5.42 $6.23 $6.14

94375 $44.43 $42.21 $48.54 $47.82

94375 TC $29.09 $27.64 $31.79 $31.31

94375 26 $15.34 $14.57 $16.76 $16.50

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

94400 $65.94 $62.64 $72.04 $70.96

94400 TC $46.33 $44.01 $50.61 $49.85

94400 26 $19.61 $18.63 $21.42 $21.10

94450 $77.82 $73.93 $85.02 $83.74

94450 TC $57.44 $54.57 $62.76 $61.81

94450 26 $20.38 $19.36 $22.26 $21.93

94452 $68.18 $64.77 $74.49 $73.37

94452 TC $52.84 $50.20 $57.73 $56.87

94452 26 $15.34 $14.57 $16.76 $16.50

94453 $95.82 $91.03 $104.68 $103.11

94453 TC $76.21 $72.40 $83.26 $82.01

94453 26 $19.61 $18.63 $21.42 $21.10

94610 $63.09 $59.94 $68.93 $67.90

94620 $61.96 $58.86 $67.69 $66.68

94620 TC $30.24 $28.73 $33.04 $32.55

94620 26 $31.73 $30.14 $34.66 $34.14

94621 $183.25 $174.09 $200.20 $197.20

94621 TC $112.22 $106.61 $122.60 $120.76

94621 26 $71.03 $67.48 $77.60 $76.44

94640 $21.81 $20.72 $23.83 $23.47

94642 $33.81 $32.12 $36.94 $36.39

94644 $52.84 $50.20 $57.73 $56.87

94645 $16.83 $15.99 $18.39 $18.11

94660 $69.17 $65.71 $75.57 $74.43

# 94660 $39.29 $37.33 $42.93 $42.29

94662 $37.37 $35.50 $40.83 $40.22

94664 $21.04 $19.99 $22.99 $22.64

94667 $29.47 $28.00 $32.20 $31.72

94668 $30.62 $29.09 $33.45 $32.95

94680 $67.97 $64.57 $74.26 $73.14

94680 TC $54.76 $52.02 $59.82 $58.93

94680 26 $13.22 $12.56 $14.44 $14.23

94681 $61.29 $58.23 $66.96 $65.96

94681 TC $50.92 $48.37 $55.63 $54.79

94681 26 $10.37 $9.85 $11.33 $11.16

94690 $57.93 $55.03 $63.28 $62.33

94690 TC $53.99 $51.29 $58.98 $58.10

94690 26 $3.94 $3.74 $4.30 $4.23

94726 $67.56 $64.18 $73.81 $72.70

94726 TC $53.96 $51.26 $58.95 $58.06

94726 26 $13.60 $12.92 $14.86 $14.64

94727 $52.65 $50.02 $57.52 $56.66

94727 TC $39.05 $37.10 $42.67 $42.02

94727 26 $13.60 $12.92 $14.86 $14.64

94728 $50.73 $48.19 $55.42 $54.59

94728 TC $37.13 $35.27 $40.56 $39.95

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

94728 26 $13.60 $12.92 $14.86 $14.64

94729 $69.76 $66.27 $76.21 $75.07

94729 TC $59.74 $56.75 $65.26 $64.29

94729 26 $10.02 $9.52 $10.95 $10.79

94750 $97.20 $92.34 $106.19 $104.59

94750 TC $85.79 $81.50 $93.73 $92.32

94750 26 $11.41 $10.84 $12.47 $12.28

94760 $3.80 $3.61 $4.15 $4.09

94761 $5.72 $5.43 $6.24 $6.15

94762 $28.32 $26.90 $30.94 $30.48

94770 $8.58 $8.15 $9.37 $9.23

94780 $57.20 $54.34 $62.49 $61.55

# 94780 $24.25 $23.04 $26.50 $26.09

94781 $22.73 $21.59 $24.83 $24.46

# 94781 $8.56 $8.13 $9.35 $9.21

95004 $7.60 $7.22 $8.30 $8.18

95012 $23.34 $22.17 $25.50 $25.12

95017 $9.68 $9.20 $10.58 $10.42

# 95017 $3.94 $3.74 $4.30 $4.23

95018 $23.99 $22.79 $26.21 $25.82

# 95018 $7.52 $7.14 $8.21 $8.08

95024 $9.13 $8.67 $9.97 $9.82

# 95024 $1.09 $1.04 $1.20 $1.17

95027 $5.68 $5.40 $6.21 $6.12

95028 $16.45 $15.63 $17.97 $17.71

95044 $6.49 $6.17 $7.10 $6.99

95052 $8.02 $7.62 $8.76 $8.64

95056 $53.22 $50.56 $58.14 $57.27

95060 $39.81 $37.82 $43.49 $42.84

95065 $31.00 $29.45 $33.87 $33.36

95070 $35.60 $33.82 $38.89 $38.31

95071 $40.58 $38.55 $44.33 $43.67

95076 $126.29 $119.98 $137.98 $135.91

# 95076 $75.34 $71.57 $82.31 $81.08

95079 $87.64 $83.26 $95.75 $94.31

# 95079 $69.25 $65.79 $75.66 $74.52

95115 $10.70 $10.17 $11.70 $11.52

95117 $12.23 $11.62 $13.36 $13.17

95144 $14.32 $13.60 $15.64 $15.41

# 95144 $3.21 $3.05 $3.51 $3.45

95145 $25.43 $24.16 $27.78 $27.37

# 95145 $3.21 $3.05 $3.51 $3.45

95146 $45.35 $43.08 $49.54 $48.79

# 95146 $3.21 $3.05 $3.51 $3.45

95147 $41.13 $39.07 $44.93 $44.25

# 95147 $3.21 $3.05 $3.51 $3.45

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

95148 $61.44 $58.37 $67.13 $66.11

# 95148 $3.21 $3.05 $3.51 $3.45

95149 $82.89 $78.75 $90.56 $89.21

# 95149 $3.21 $3.05 $3.51 $3.45

95165 $14.70 $13.97 $16.07 $15.82

# 95165 $3.59 $3.41 $3.92 $3.86

95170 $10.87 $10.33 $11.88 $11.71

# 95170 $3.21 $3.05 $3.51 $3.45

95180 $142.42 $135.30 $155.60 $153.26

# 95180 $104.49 $99.27 $114.16 $112.45

95250 $187.31 $177.94 $204.63 $201.56

95251 $44.74 $42.50 $48.88 $48.14

95782 $1,166.79 $1,108.45 $1,274.72 $1,255.59

95782 TC $1,032.69 $981.06 $1,128.22 $1,111.29

95782 26 $134.10 $127.40 $146.51 $144.31

95783 $1,245.16 $1,182.90 $1,360.34 $1,339.93

95783 TC $1,098.53 $1,043.60 $1,200.14 $1,182.14

95783 26 $146.63 $139.30 $160.20 $157.79

95800 $201.45 $191.38 $220.09 $216.79

95800 TC $147.85 $140.46 $161.53 $159.10

95800 26 $53.60 $50.92 $58.56 $57.68

95801 $103.56 $98.38 $113.14 $111.44

95801 TC $53.61 $50.93 $58.57 $57.70

95801 26 $49.95 $47.45 $54.57 $53.75

95803 $168.28 $159.87 $183.85 $181.09

95803 TC $122.18 $116.07 $133.48 $131.48

95803 26 $46.09 $43.79 $50.36 $49.60

95805 $478.96 $455.01 $523.26 $515.41

95805 TC $418.62 $397.69 $457.34 $450.48

95805 26 $60.35 $57.33 $65.93 $64.94

95806 $201.80 $191.71 $220.47 $217.15

95806 TC $137.83 $130.94 $150.58 $148.33

95806 26 $63.97 $60.77 $69.89 $68.84

95807 $557.79 $529.90 $609.39 $600.24

95807 TC $493.92 $469.22 $539.60 $531.51

95807 26 $63.86 $60.67 $69.77 $68.72

95808 $730.40 $693.88 $797.96 $785.99

95808 TC $641.03 $608.98 $700.33 $689.83

95808 26 $89.37 $84.90 $97.64 $96.17

95810 $717.61 $681.73 $783.99 $772.23

95810 TC $591.97 $562.37 $646.73 $637.02

95810 26 $125.64 $119.36 $137.26 $135.21

95811 $752.83 $715.19 $822.47 $810.13

95811 TC $622.21 $591.10 $679.77 $669.56

95811 26 $130.62 $124.09 $142.70 $140.56

95812 $506.24 $480.93 $553.07 $544.78

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

95812 TC $447.38 $425.01 $488.76 $481.42

95812 26 $58.86 $55.92 $64.31 $63.34

95813 $580.04 $551.04 $633.70 $624.19

95813 TC $485.66 $461.38 $530.59 $522.63

95813 26 $94.38 $89.66 $103.11 $101.57

95816 $464.07 $440.87 $507.00 $499.40

95816 TC $404.47 $384.25 $441.89 $435.26

95816 26 $59.60 $56.62 $65.11 $64.14

95819 $533.82 $507.13 $583.20 $574.45

95819 TC $474.58 $450.85 $518.48 $510.70

95819 26 $59.24 $56.28 $64.72 $63.76

95822 $476.74 $452.90 $520.84 $513.03

95822 TC $417.50 $396.63 $456.12 $449.28

95822 26 $59.24 $56.28 $64.72 $63.76

95824 26 $41.28 $39.22 $45.10 $44.42

95827 $910.62 $865.09 $994.85 $979.93

95827 TC $851.41 $808.84 $930.17 $916.22

95827 26 $59.22 $56.26 $64.70 $63.73

95829 $2,198.48 $2,088.56 $2,401.84 $2,365.81

95829 TC $1,862.11 $1,769.00 $2,034.35 $2,003.84

95829 26 $336.37 $319.55 $367.48 $361.97

95830 $296.19 $281.38 $323.59 $318.73

# 95830 $96.21 $91.40 $105.11 $103.53

95831 $31.48 $29.91 $34.40 $33.88

# 95831 $15.01 $14.26 $16.40 $16.16

95832 $29.91 $28.41 $32.67 $32.18

# 95832 $15.74 $14.95 $17.19 $16.94

95833 $40.43 $38.41 $44.17 $43.50

# 95833 $21.66 $20.58 $23.67 $23.31

95834 $56.39 $53.57 $61.61 $60.69

# 95834 $31.87 $30.28 $34.82 $34.30

95851 $20.09 $19.09 $21.95 $21.62

# 95851 $7.83 $7.44 $8.56 $8.43

95852 $18.73 $17.79 $20.46 $20.15

# 95852 $6.09 $5.79 $6.66 $6.56

95857 $58.53 $55.60 $63.94 $62.99

# 95857 $30.94 $29.39 $33.80 $33.29

95860 $139.74 $132.75 $152.66 $150.37

95860 TC $86.17 $81.86 $94.14 $92.72

95860 26 $53.57 $50.89 $58.52 $57.65

95861 $190.86 $181.32 $208.52 $205.39

95861 TC $105.32 $100.05 $115.06 $113.33

95861 26 $85.54 $81.26 $93.45 $92.05

95863 $233.30 $221.64 $254.89 $251.07

95863 TC $130.23 $123.72 $142.28 $140.14

95863 26 $103.08 $97.93 $112.62 $110.93

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

95864 $268.12 $254.71 $292.92 $288.52

95864 TC $158.19 $150.28 $172.82 $170.23

95864 26 $109.93 $104.43 $120.09 $118.29

95865 $147.88 $140.49 $161.56 $159.14

95865 TC $62.80 $59.66 $68.61 $67.59

95865 26 $85.08 $80.83 $92.95 $91.56

95866 $152.44 $144.82 $166.54 $164.05

95866 TC $82.72 $78.58 $90.37 $89.01

95866 26 $69.72 $66.23 $76.16 $75.03

95867 $126.94 $120.59 $138.68 $136.60

95867 TC $83.49 $79.32 $91.22 $89.85

95867 26 $43.45 $41.28 $47.47 $46.76

95868 $158.46 $150.54 $173.12 $170.52

95868 TC $93.83 $89.14 $102.51 $100.97

95868 26 $64.63 $61.40 $70.61 $69.55

95869 $96.70 $91.87 $105.65 $104.06

95869 TC $76.59 $72.76 $83.67 $82.42

95869 26 $20.10 $19.10 $21.97 $21.63

95870 $101.68 $96.60 $111.09 $109.42

95870 TC $81.19 $77.13 $88.70 $87.37

95870 26 $20.49 $19.47 $22.39 $22.06

95872 $218.09 $207.19 $238.27 $234.69

95872 TC $59.35 $56.38 $64.84 $63.86

95872 26 $158.74 $150.80 $173.42 $170.82

95873 $86.74 $82.40 $94.76 $93.33

95873 TC $65.48 $62.21 $71.54 $70.47

95873 26 $21.25 $20.19 $23.22 $22.87

95874 $83.29 $79.13 $91.00 $89.63

95874 TC $62.80 $59.66 $68.61 $67.59

95874 26 $20.49 $19.47 $22.39 $22.06

95875 $140.33 $133.31 $153.31 $151.01

95875 TC $79.66 $75.68 $87.03 $85.72

95875 26 $60.68 $57.65 $66.30 $65.31

95885 $67.65 $64.27 $73.91 $72.81

95885 TC $48.24 $45.83 $52.70 $51.91

95885 26 $19.41 $18.44 $21.21 $20.88

95886 $92.81 $88.17 $101.40 $99.88

95886 TC $53.99 $51.29 $58.98 $58.10

95886 26 $38.82 $36.88 $42.41 $41.78

95887 $78.72 $74.78 $86.00 $84.71

95887 TC $52.84 $50.20 $57.73 $56.87

95887 26 $25.88 $24.59 $28.28 $27.85

95905 $79.83 $75.84 $87.22 $85.91

95905 TC $76.98 $73.13 $84.10 $82.83

95905 26 $2.86 $2.72 $3.13 $3.08

95907 $102.76 $97.62 $112.26 $110.58

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

95907 TC $48.19 $45.78 $52.65 $51.85

95907 26 $54.58 $51.85 $59.63 $58.73

95908 $126.74 $120.40 $138.46 $136.38

95908 TC $58.15 $55.24 $63.53 $62.57

95908 26 $68.60 $65.17 $74.95 $73.82

95909 $151.85 $144.26 $165.90 $163.42

95909 TC $69.97 $66.47 $76.44 $75.29

95909 26 $81.88 $77.79 $89.46 $88.11

95910 $199.78 $189.79 $218.26 $214.98

95910 TC $90.25 $85.74 $98.60 $97.12

95910 26 $109.54 $104.06 $119.67 $117.88

95911 $241.59 $229.51 $263.94 $259.98

95911 TC $104.75 $99.51 $114.44 $112.72

95911 26 $136.84 $130.00 $149.50 $147.26

95912 $282.62 $268.49 $308.76 $304.13

95912 TC $118.51 $112.58 $129.47 $127.52

95912 26 $164.11 $155.90 $179.29 $176.59

95913 $327.28 $310.92 $357.56 $352.20

95913 TC $132.63 $126.00 $144.90 $142.73

95913 26 $194.65 $184.92 $212.66 $209.47

95921 $98.55 $93.62 $107.66 $106.05

95921 TC $51.31 $48.74 $56.05 $55.21

95921 26 $47.24 $44.88 $51.61 $50.84

95922 $119.02 $113.07 $130.03 $128.08

95922 TC $68.16 $64.75 $74.46 $73.35

95922 26 $50.86 $48.32 $55.57 $54.74

95923 $292.78 $278.14 $319.86 $315.07

95923 TC $243.62 $231.44 $266.16 $262.17

95923 26 $49.16 $46.70 $53.71 $52.90

95924 $159.84 $151.85 $174.63 $172.01

95924 TC $68.55 $65.12 $74.89 $73.76

95924 26 $91.29 $86.73 $99.74 $98.24

95925 $219.83 $208.84 $240.17 $236.57

95925 TC $190.76 $181.22 $208.40 $205.28

95925 26 $29.07 $27.62 $31.76 $31.29

95926 $212.50 $201.88 $232.16 $228.68

95926 TC $182.71 $173.57 $199.61 $196.62

95926 26 $29.79 $28.30 $32.55 $32.06

95927 $192.63 $183.00 $210.45 $207.30

95927 TC $163.94 $155.74 $179.10 $176.41

95927 26 $28.69 $27.26 $31.35 $30.88

95928 $328.05 $311.65 $358.40 $353.03

95928 TC $245.48 $233.21 $268.19 $264.17

95928 26 $82.56 $78.43 $90.19 $88.84

95929 $329.96 $313.46 $360.48 $355.07

95929 TC $247.40 $235.03 $270.28 $266.23

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

95929 26 $82.56 $78.43 $90.19 $88.84

95930 $183.73 $174.54 $200.72 $197.71

95930 TC $164.71 $156.47 $179.94 $177.24

95930 26 $19.03 $18.08 $20.79 $20.48

95933 $101.60 $96.52 $111.00 $109.33

95933 TC $68.93 $65.48 $75.30 $74.18

95933 26 $32.67 $31.04 $35.70 $35.16

95937 $86.80 $82.46 $94.83 $93.40

95937 TC $51.31 $48.74 $56.05 $55.21

95937 26 $35.49 $33.72 $38.78 $38.19

95938 $372.55 $353.92 $407.01 $400.90

95938 TC $325.17 $308.91 $355.25 $349.92

95938 26 $47.39 $45.02 $51.77 $50.99

95939 $565.81 $537.52 $618.15 $608.88

95939 TC $441.60 $419.52 $482.45 $475.21

95939 26 $124.21 $118.00 $135.70 $133.66

95940 $33.79 $32.10 $36.92 $36.36

95950 $388.16 $368.75 $424.06 $417.70

95950 TC $305.25 $289.99 $333.49 $328.49

95950 26 $82.91 $78.76 $90.57 $89.22

95951 $2,103.19 $1,998.03 $2,297.73 $2,263.27

95951 TC $1,765.42 $1,677.15 $1,928.72 $1,899.79

95951 26 $337.77 $320.88 $369.01 $363.48

95953 $487.68 $463.30 $532.80 $524.80

95953 TC $318.66 $302.73 $348.14 $342.92

95953 26 $169.02 $160.57 $184.66 $181.88

95954 $530.24 $503.73 $579.29 $570.60

95954 TC $402.53 $382.40 $439.76 $433.16

95954 26 $127.71 $121.32 $139.52 $137.43

95955 $265.57 $252.29 $290.13 $285.79

95955 TC $209.91 $199.41 $229.32 $225.88

95955 26 $55.66 $52.88 $60.81 $59.90

95956 $1,946.54 $1,849.21 $2,126.59 $2,094.69

95956 TC $1,749.17 $1,661.71 $1,910.97 $1,882.30

95956 26 $197.37 $187.50 $215.63 $212.39

95957 $517.09 $491.24 $564.93 $556.45

95957 TC $408.36 $387.94 $446.13 $439.44

95957 26 $108.73 $103.29 $118.78 $117.00

95958 $644.98 $612.73 $704.64 $694.07

95958 TC $414.40 $393.68 $452.73 $445.94

95958 26 $230.58 $219.05 $251.91 $248.12

95961 $312.70 $297.07 $341.63 $336.50

95961 TC $149.76 $142.27 $163.61 $161.16

95961 26 $162.93 $154.78 $178.00 $175.33

95962 $268.55 $255.12 $293.39 $288.98

95962 TC $93.07 $88.42 $101.68 $100.15

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

95962 26 $175.48 $166.71 $191.72 $188.84

95965 26 $451.25 $428.69 $492.99 $485.60

95966 26 $205.17 $194.91 $224.15 $220.79

95967 26 $180.20 $171.19 $196.87 $193.91

95970 $79.12 $75.16 $86.43 $85.13

# 95970 $25.10 $23.85 $27.43 $27.01

95971 $64.83 $61.59 $70.83 $69.77

# 95971 $41.84 $39.75 $45.71 $45.02

95972 $118.00 $112.10 $128.92 $126.98

# 95972 $81.60 $77.52 $89.15 $87.81

95973 $67.75 $64.36 $74.01 $72.90

# 95973 $50.51 $47.98 $55.18 $54.35

95974 $220.34 $209.32 $240.72 $237.11

# 95974 $168.24 $159.83 $183.80 $181.04

95975 $117.34 $111.47 $128.19 $126.27

# 95975 $95.50 $90.73 $104.34 $102.78

95978 $268.03 $254.63 $292.82 $288.43

# 95978 $200.98 $190.93 $219.57 $216.28

95979 $114.43 $108.71 $125.02 $123.14

# 95979 $92.98 $88.33 $101.58 $100.06

95980 $48.80 $46.36 $53.31 $52.51

95981 $36.77 $34.93 $40.17 $39.57

# 95981 $18.77 $17.83 $20.50 $20.19

95982 $57.30 $54.44 $62.61 $61.66

# 95982 $37.77 $35.88 $41.26 $40.64

95990 $108.72 $103.28 $118.77 $116.99

95991 $141.54 $134.46 $154.63 $152.31

# 95991 $41.55 $39.47 $45.39 $44.71

95992 $45.84 $43.55 $50.08 $49.34

# 95992 $38.94 $36.99 $42.54 $41.91

96000 $103.22 $98.06 $112.77 $111.08

96001 $100.41 $95.39 $109.70 $108.05

96002 $22.59 $21.46 $24.68 $24.31

96003 $17.37 $16.50 $18.98 $18.69

96004 $118.01 $112.11 $128.93 $126.99

96020 $378.60 $359.67 $413.62 $407.41

96020 TC $206.67 $196.34 $225.79 $222.40

96020 26 $171.93 $163.33 $187.83 $185.01

96101 $86.26 $81.95 $94.24 $92.83

# 96101 $77.06 $73.21 $84.19 $82.93

96102 $95.44 $90.67 $104.27 $102.71

# 96102 $23.42 $22.25 $25.59 $25.21

96103 $77.01 $73.16 $84.13 $82.87

# 96103 $26.83 $25.49 $29.31 $28.88

96105 $99.76 $94.77 $108.99 $107.35

96111 $133.17 $126.51 $145.49 $143.30

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 96111 $125.12 $118.86 $136.69 $134.64

96116 $93.45 $88.78 $102.10 $100.57

# 96116 $86.56 $82.23 $94.56 $93.15

96118 $96.60 $91.77 $105.54 $103.95

# 96118 $76.68 $72.85 $83.78 $82.52

96119 $81.52 $77.44 $89.06 $87.72

# 96119 $22.91 $21.76 $25.02 $24.64

96120 $113.79 $108.10 $124.32 $122.45

# 96120 $26.06 $24.76 $28.47 $28.05

96125 $115.18 $109.42 $125.83 $123.95

96150 $20.79 $19.75 $22.71 $22.37

# 96150 $20.41 $19.39 $22.30 $21.97

96151 $20.09 $19.09 $21.95 $21.62

# 96151 $19.71 $18.72 $21.53 $21.21

96152 $19.02 $18.07 $20.78 $20.47

# 96152 $18.63 $17.70 $20.36 $20.04

96153 $4.60 $4.37 $5.03 $4.95

# 96153 $4.21 $4.00 $4.60 $4.53

96154 $18.67 $17.74 $20.40 $20.09

# 96154 $18.29 $17.38 $19.99 $19.69

96360 $65.20 $61.94 $71.23 $70.16

96361 $16.89 $16.05 $18.46 $18.18

96365 $84.22 $80.01 $92.01 $90.63

96366 $23.85 $22.66 $26.06 $25.67

96367 $35.30 $33.54 $38.57 $38.00

96368 $20.44 $19.42 $22.33 $22.00

96369 $238.22 $226.31 $260.26 $256.36

96370 $18.87 $17.93 $20.62 $20.31

96371 $114.14 $108.43 $124.69 $122.82

96372 $28.48 $27.06 $31.12 $30.65

96373 $21.97 $20.87 $24.00 $23.64

96374 $64.02 $60.82 $69.94 $68.90

96375 $24.90 $23.66 $27.21 $26.81

96401 $84.57 $80.34 $92.39 $91.00

96402 $36.07 $34.27 $39.41 $38.82

96405 $92.69 $88.06 $101.27 $99.75

# 96405 $31.77 $30.18 $34.71 $34.19

96406 $130.35 $123.83 $142.40 $140.27

# 96406 $47.98 $45.58 $52.42 $51.64

96409 $125.04 $118.79 $136.61 $134.56

96411 $69.69 $66.21 $76.14 $75.00

96413 $160.15 $152.14 $174.96 $172.34

96415 $33.77 $32.08 $36.89 $36.34

96416 $159.58 $151.60 $174.34 $171.73

96417 $79.23 $75.27 $86.56 $85.26

96420 $120.23 $114.22 $131.35 $129.39

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

96422 $193.40 $183.73 $211.29 $208.12

96423 $88.93 $84.48 $97.15 $95.69

96425 $207.91 $197.51 $227.14 $223.73

96440 $1,009.47 $959.00 $1,102.85 $1,086.31

# 96440 $146.73 $139.39 $160.30 $157.90

96446 $223.75 $212.56 $244.44 $240.78

# 96446 $22.62 $21.49 $24.71 $24.35

96450 $197.66 $187.78 $215.95 $212.70

# 96450 $82.34 $78.22 $89.95 $88.61

96521 $157.71 $149.82 $172.29 $169.71

96522 $127.83 $121.44 $139.66 $137.56

96523 $28.18 $26.77 $30.79 $30.33

96542 $134.36 $127.64 $146.79 $144.59

# 96542 $43.18 $41.02 $47.17 $46.46

96567 $162.02 $153.92 $177.01 $174.35

96570 $59.55 $56.57 $65.06 $64.08

96571 $27.42 $26.05 $29.96 $29.51

96900 $24.87 $23.63 $27.17 $26.77

96904 $81.96 $77.86 $89.54 $88.19

96910 $85.79 $81.50 $93.73 $92.32

96912 $109.92 $104.42 $120.08 $118.28

96913 $154.74 $147.00 $169.05 $166.52

96920 $174.31 $165.59 $190.43 $187.58

# 96920 $70.49 $66.97 $77.02 $75.87

96921 $191.78 $182.19 $209.52 $206.38

# 96921 $79.14 $75.18 $86.46 $85.16

96922 $264.66 $251.43 $289.14 $284.81

# 96922 $129.04 $122.59 $140.98 $138.86

97001 $79.86 $75.87 $87.25 $85.94

97002 $45.28 $43.02 $49.47 $48.73

97003 $90.97 $86.42 $99.38 $97.89

97004 $57.92 $55.02 $63.27 $62.32

97012 $17.08 $16.23 $18.66 $18.39

97016 $21.55 $20.47 $23.54 $23.18

97018 $12.40 $11.78 $13.55 $13.34

97022 $26.18 $24.87 $28.60 $28.18

97024 $7.04 $6.69 $7.69 $7.58

97026 $6.65 $6.32 $7.27 $7.16

97028 $8.11 $7.70 $8.86 $8.72

97032 $20.53 $19.50 $22.43 $22.09

97033 $36.20 $34.39 $39.55 $38.95

97034 $19.53 $18.55 $21.33 $21.01

97035 $13.40 $12.73 $14.64 $14.42

97036 $36.52 $34.69 $39.89 $39.30

97039 $13.87 $13.18 $15.16 $14.93

97110 $34.38 $32.66 $37.56 $37.00

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

97112 $35.91 $34.11 $39.23 $38.64

97113 $47.44 $45.07 $51.83 $51.05

97116 $30.34 $28.82 $33.14 $32.65

97124 $28.22 $26.81 $30.83 $30.37

97139 $18.77 $17.83 $20.50 $20.19

97140 $32.15 $30.54 $35.12 $34.59

97150 $18.47 $17.55 $20.18 $19.88

97530 $37.86 $35.97 $41.37 $40.74

97532 $27.90 $26.51 $30.49 $30.03

97533 $30.96 $29.41 $33.82 $33.32

97535 $37.44 $35.57 $40.91 $40.30

97537 $32.08 $30.48 $35.05 $34.52

97542 $32.46 $30.84 $35.47 $34.94

97597 $86.15 $81.84 $94.12 $92.70

# 97597 $24.47 $23.25 $26.74 $26.34

97598 $27.79 $26.40 $30.36 $29.90

# 97598 $11.70 $11.12 $12.79 $12.59

97605 $45.70 $43.42 $49.93 $49.19

# 97605 $27.31 $25.94 $29.83 $29.38

97606 $48.53 $46.10 $53.02 $52.22

# 97606 $30.53 $29.00 $33.35 $32.86

97750 $35.85 $34.06 $39.17 $38.58

97755 $37.93 $36.03 $41.43 $40.81

97760 $41.60 $39.52 $45.45 $44.77

97761 $35.85 $34.06 $39.17 $38.58

97762 $54.25 $51.54 $59.27 $58.39

97802 $37.87 $35.98 $41.38 $40.76

# 97802 $34.80 $33.06 $38.02 $37.44

97803 $32.79 $31.15 $35.82 $35.28

# 97803 $29.72 $28.23 $32.46 $31.98

97804 $16.70 $15.87 $18.25 $17.97

# 97804 $16.32 $15.50 $17.83 $17.56

98925 $33.52 $31.84 $36.62 $36.06

# 98925 $24.32 $23.10 $26.57 $26.16

98926 $47.57 $45.19 $51.97 $51.19

# 98926 $36.46 $34.64 $39.84 $39.24

98927 $62.35 $59.23 $68.11 $67.09

# 98927 $48.56 $46.13 $53.05 $52.26

98928 $76.73 $72.89 $83.82 $82.57

# 98928 $61.79 $58.70 $67.51 $66.49

98929 $91.46 $86.89 $99.92 $98.43

# 98929 $73.84 $70.15 $80.67 $79.47

98940 $27.30 $25.94 $29.83 $29.38

# 98940 $21.30 $20.24 $23.28 $22.93

98941 $37.82 $35.93 $41.32 $40.70

# 98941 $31.43 $29.86 $34.34 $33.82

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

98942 $48.30 $45.89 $52.77 $51.98

# 98942 $41.55 $39.47 $45.39 $44.71

99143 $30.75 $29.21 $33.59 $33.09

99144 $43.80 $41.61 $47.85 $47.14

99145 $15.09 $14.34 $16.49 $16.24

99148 $55.61 $52.83 $60.75 $59.85

99149 $55.61 $52.83 $60.75 $59.85

99150 $20.90 $19.86 $22.84 $22.49

99170 $135.16 $128.40 $147.66 $145.44

# 99170 $91.49 $86.92 $99.96 $98.46

99175 $19.13 $18.17 $20.90 $20.59

99183 $236.49 $224.67 $258.37 $254.50

# 99183 $125.77 $119.48 $137.40 $135.34

99195 $115.56 $109.78 $126.25 $124.35

99201 $47.59 $45.21 $51.99 $51.21

# 99201 $27.29 $25.93 $29.82 $29.37

99202 $80.38 $76.36 $87.81 $86.49

# 99202 $51.65 $49.07 $56.43 $55.58

99203 $116.37 $110.55 $127.13 $125.22

# 99203 $79.21 $75.25 $86.54 $85.24

99204 $176.11 $167.30 $192.40 $189.51

# 99204 $135.11 $128.35 $147.60 $145.38

99205 $217.41 $206.54 $237.52 $233.96

# 99205 $173.35 $164.68 $189.38 $186.54

99211 $22.32 $21.20 $24.38 $24.01

# 99211 $9.29 $8.83 $10.15 $10.01

99212 $47.59 $45.21 $51.99 $51.21

# 99212 $25.76 $24.47 $28.14 $27.72

99213 $78.33 $74.41 $85.57 $84.28

# 99213 $52.27 $49.66 $57.11 $56.26

99214 $114.66 $108.93 $125.27 $123.40

# 99214 $80.56 $76.53 $88.01 $86.69

99215 $152.98 $145.33 $167.13 $164.62

# 99215 $113.52 $107.84 $124.02 $122.15

99217 $74.89 $71.15 $81.82 $80.59

99218 $101.61 $96.53 $111.01 $109.34

99219 $138.50 $131.58 $151.32 $149.05

99220 $190.05 $180.55 $207.63 $204.52

99221 $104.51 $99.28 $114.17 $112.46

99222 $141.78 $134.69 $154.89 $152.57

99223 $208.37 $197.95 $227.64 $224.23

99224 $40.79 $38.75 $44.56 $43.90

99225 $73.76 $70.07 $80.58 $79.37

99226 $106.72 $101.38 $116.59 $114.84

99231 $40.05 $38.05 $43.76 $43.10

99232 $73.73 $70.04 $80.55 $79.34

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

99233 $106.30 $100.99 $116.14 $114.40

99234 $138.12 $131.21 $150.89 $148.63

99235 $172.86 $164.22 $188.85 $186.02

99236 $223.25 $212.09 $243.90 $240.25

99238 $74.92 $71.17 $81.85 $80.62

99239 $110.90 $105.36 $121.16 $119.35

99281 $21.30 $20.24 $23.28 $22.93

99282 $41.87 $39.78 $45.75 $45.06

99283 $62.36 $59.24 $68.13 $67.10

99284 $119.35 $113.38 $130.39 $128.43

99285 $174.47 $165.75 $190.61 $187.75

99291 $289.47 $275.00 $316.25 $311.51

# 99291 $228.17 $216.76 $249.27 $245.54

99292 $127.47 $121.10 $139.27 $137.17

# 99292 $114.82 $109.08 $125.44 $123.56

99304 $96.81 $91.97 $105.77 $104.18

99305 $137.40 $130.53 $150.11 $147.86

99306 $173.47 $164.80 $189.52 $186.68

99307 $46.21 $43.90 $50.49 $49.73

99308 $71.90 $68.31 $78.56 $77.38

99309 $94.23 $89.52 $102.95 $101.41

99310 $140.24 $133.23 $153.21 $150.91

99315 $75.66 $71.88 $82.66 $81.42

99316 $108.25 $102.84 $118.27 $116.50

99318 $98.97 $94.02 $108.12 $106.50

99324 $57.49 $54.62 $62.81 $61.87

99325 $82.79 $78.65 $90.45 $89.09

99326 $143.40 $136.23 $156.66 $154.32

99327 $191.61 $182.03 $209.33 $206.20

99328 $222.25 $211.14 $242.81 $239.17

99334 $62.64 $59.51 $68.44 $67.41

99335 $97.78 $92.89 $106.82 $105.23

99336 $138.70 $131.77 $151.54 $149.26

99337 $198.43 $188.51 $216.79 $213.53

99341 $57.11 $54.25 $62.39 $61.46

99342 $82.00 $77.90 $89.59 $88.24

99343 $134.51 $127.78 $146.95 $144.74

99344 $187.68 $178.30 $205.05 $201.97

99345 $226.02 $214.72 $246.93 $243.23

99347 $57.53 $54.65 $62.85 $61.90

99348 $86.86 $82.52 $94.90 $93.47

99349 $131.89 $125.30 $144.10 $141.93

99350 $183.06 $173.91 $200.00 $197.00

99354 $102.94 $97.79 $112.46 $110.77

# 99354 $94.89 $90.15 $103.67 $102.12

99355 $100.64 $95.61 $109.95 $108.31

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION

Page 233: New Jersey (NJ) IHS and VA Part B Fee Schedule (Effective January

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FAC IND OPPS CAP IND PROC CODE MODIFIER PAR FEE NON PAR FEE LC eRX LC***

# 99355 $91.83 $87.24 $100.33 $98.82

99356 $94.34 $89.62 $103.06 $101.52

99357 $93.96 $89.26 $102.65 $101.11

99406 $14.82 $14.08 $16.19 $15.95

# 99406 $12.52 $11.89 $13.67 $13.47

99407 $28.40 $26.98 $31.03 $30.57

# 99407 $26.10 $24.80 $28.52 $28.09

99460 $92.91 $88.26 $101.50 $99.98

99461 $107.53 $102.15 $117.47 $115.71

# 99461 $66.53 $63.20 $72.68 $71.59

99462 $42.45 $40.33 $46.38 $45.69

99463 $118.89 $112.95 $129.89 $127.95

99464 $78.35 $74.43 $85.59 $84.31

99465 $150.21 $142.70 $164.11 $161.64

99466 $276.98 $263.13 $302.60 $298.06

99467 $125.51 $119.23 $137.11 $135.06

99468 $981.85 $932.76 $1,072.67 $1,056.59

99469 $403.58 $383.40 $440.91 $434.30

99471 $880.26 $836.25 $961.69 $947.27

99472 $416.83 $395.99 $455.39 $448.56

99475 $577.68 $548.80 $631.12 $621.66

99476 $358.70 $340.77 $391.89 $386.01

99477 $359.34 $341.37 $392.58 $386.69

99478 $144.45 $137.23 $157.81 $155.45

99479 $131.23 $124.67 $143.37 $141.22

99480 $122.39 $116.27 $133.71 $131.71

99495 $176.73 $167.89 $193.07 $190.18

# 99495 $143.78 $136.59 $157.08 $154.72

99496 $249.06 $236.61 $272.10 $268.02

# 99496 $211.13 $200.57 $230.66 $227.19

# - THESE AMOUNTS APPLY WHEN SERVICE IS PERFORMED IN A FACILITY SETTING.

C - THE PAYMENT FOR THE TECHNICAL COMPONENT IS CAPPED AT THE OPPS AMOUNT.

LIMITING CHARGE APPLIES TO UNASSIGNED CLAIMS BY NON-PARTICIPATING PROVIDERS.

***-LIMITING CHARGE REDUCED BASED ON STATUS AS AN UNSUCCESSFUL E-PRESCRIBING (ERX)

INCENTIVE PROGRAM.

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE

COPYRIGHTED 2012 BY THE AMERICAN MEDICAL ASSOCIATION.

ALL CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES AND DESCRIPTORS ARE COPYRIGHTED 2012 BY THE

AMERICAN MEDICAL ASSOCIATION