Effective April 1, 2012
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
0042T packaged 70548 $402.50 72157 $492.91 73600 $24.480073T $422.56 70549 $492.91 72158 $492.91 73610 $29.220174T packaged 70551 $312.35 72170 $20.53 73615 packaged0175T packaged 70552 $402.50 72190 $37.50 73620 $23.300182T $643.60 70553 $492.91 72191 $312.32 73630 $27.630185T packaged 70554 $312.35 72192 $177.14 73650 $24.080286T packaged 70555 $312.35 72193 $255.01 73660 $27.630287T packaged 70557 $312.35 72194 $308.38 73700 $177.140291T packaged 70558 $402.50 72195 $312.35 73701 $267.230292T packaged 70559 $492.91 72196 $402.50 73702 $308.3870010 packaged 71010 $16.98 72197 $492.91 73706 $312.3270015 packaged 71015 $23.68 72200 $25.26 73718 $312.3570030 $24.08 71020 $23.30 72202 $30.00 73719 $402.5070100 $30.00 71021 $28.82 72220 $24.08 73720 $492.9170110 $32.37 71022 $37.89 72240 packaged 73721 $312.3570120 $31.97 71023 $58.42 72255 packaged 73722 $402.5070130 $41.38 71030 $36.70 72265 packaged 73723 $492.9170134 $45.39 71034 $76.58 72270 packaged 74000 $18.5670140 $24.08 71035 $31.58 72275 packaged 74010 $31.9770150 $35.52 71040 packaged 72285 packaged 74020 $31.9770160 $29.22 71060 packaged 72291 packaged 74022 $38.6970170 packaged 71100 $25.66 72292 packaged 74150 $177.1470190 $30.00 71101 $31.18 72295 packaged 74160 $277.1570200 $35.52 71110 $32.37 73000 $24.48 74170 $308.3870210 $26.45 71111 $44.21 73010 $26.05 74174 $528.9470220 $31.97 71120 $25.66 73020 $19.34 74175 $312.3270240 $24.08 71130 $31.18 73030 $24.86 74176 $165.0170250 $29.60 71250 $177.14 73040 packaged 74177 $535.7870260 $36.32 71260 $268.82 73050 $34.34 74178 $414.4870300 $10.26 71270 $308.38 73060 $24.48 74181 $312.3570310 $29.95 71275 $312.32 73070 $24.48 74182 $402.5070320 $29.95 71550 $312.35 73080 $30.00 74183 $492.9170328 $26.05 71551 $402.50 73085 packaged 74190 packaged70330 $41.38 71552 $492.91 73090 $23.30 74210 $78.6770332 packaged 72010 $64.74 73092 $23.68 74220 $78.6770336 $312.35 72020 $18.94 73100 $26.85 74230 $78.5670350 $13.81 72040 $33.15 73110 $33.95 74235 packaged70355 $12.24 72050 $44.61 73115 packaged 74240 $78.6770360 $22.11 72052 $59.22 73120 $23.30 74241 $78.6770370 $78.58 72069 $31.18 73130 $28.03 74245 $131.3170371 $62.77 72070 $26.85 73140 $30.78 74246 $78.6770373 packaged 72072 $31.58 73200 $177.14 74247 $78.6770380 $36.70 72074 $39.87 73201 $263.68 74249 $131.3170390 packaged 72080 $29.60 73202 $308.38 74250 $78.6770450 $165.79 72090 $42.24 73206 $312.32 74251 $131.3170460 $215.52 72100 $30.00 73218 $312.35 74260 $78.6770470 $226.58 72110 $41.06 73219 $402.50 74261 $177.1470480 $177.14 72114 $58.03 73220 $492.91 74262 $277.1570481 $277.15 72120 $37.89 73221 $312.35 74270 $78.6770482 $308.38 72125 $177.14 73222 $402.50 74280 $131.3170486 $177.14 72126 $270.40 73223 $492.91 74283 $78.6770487 $276.32 72127 $308.38 73500 $21.31 74290 $78.6770488 $308.38 72128 $177.14 73510 $33.15 74291 $78.6770490 $177.14 72129 $270.40 73520 $32.77 74300 packaged70491 $263.68 72130 $308.38 73525 packaged 74301 packaged70492 $308.38 72131 $177.14 73530 packaged 74305 packaged70496 $312.32 72132 $269.60 73540 $39.07 74320 packaged70498 $312.32 72133 $308.38 73550 $22.90 74327 packaged70540 $312.35 72141 $312.35 73560 $25.66 74328 packaged70542 $402.50 72142 $402.50 73562 $32.37 74329 packaged70543 $492.91 72146 $312.35 73564 $37.50 74330 packaged70544 $312.35 72147 $402.50 73565 $30.40 74340 packaged70545 $402.50 72148 $312.35 73580 packaged 74355 packaged70546 $492.91 72149 $402.50 73590 $22.50 74360 packaged70547 $312.35 72156 $492.91 73592 $28.42 74363 packaged
Appendix D for Administrative Order No. 12-050
Ambulatory Surgery Center Fee Schedule Amounts for Ancillary ServicesNote: Listing of a payment amount does not guarantee payment.
CPT only copyright 2011 American Medical Association. All rights reserved
Effective 4/1/2012 Page 1 of 6 Appendix D
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
74400 $169.12 75885 packaged 76820 $22.50 77328 $194.2174410 $169.12 75887 packaged 76821 $58.05 77331 $21.7174415 $169.12 75889 packaged 76825 $164.61 77332 $58.4274420 $169.12 75891 packaged 76826 $105.01 77333 $15.0174425 packaged 75893 packaged 76827 $42.24 77334 $101.4474430 packaged 75894 packaged 76828 $22.90 77336 $53.6874440 packaged 75896 packaged 76830 $88.98 77338 $243.2874445 packaged 75898 packaged 76831 $109.34 77370 $98.9674450 packaged 75901 packaged 76856 $88.98 77371 $6,878.6974455 packaged 75902 packaged 76857 $58.05 77399 $98.9674470 packaged 75945 packaged 76870 $88.98 77401 $25.2674475 packaged 75946 packaged 76872 $88.98 77402 $92.0274480 packaged 75960 packaged 76873 $88.98 77403 $92.0274485 packaged 75961 packaged 76881 $88.98 77404 $92.0274710 $25.26 75962 packaged 76882 $12.24 77406 $92.0274740 packaged 75964 packaged 76885 $58.05 77407 $92.0274742 packaged 75966 packaged 76886 $58.05 77408 $155.9074775 $169.12 75968 packaged 76930 packaged 77409 $155.9075557 $312.35 75970 packaged 76932 packaged 77411 $155.9075559 $312.35 75978 packaged 76936 $98.45 77412 $155.9075561 $492.91 75980 packaged 76937 packaged 77413 $155.9075563 $492.91 75982 packaged 76940 packaged 77414 $155.9075565 packaged 75984 packaged 76941 packaged 77416 $155.9075571 $41.95 75989 packaged 76942 packaged 77417 packaged75572 $241.57 76000 packaged 76945 packaged 77418 $422.5675573 $241.57 76001 packaged 76946 packaged 77421 packaged75574 $241.57 76010 $21.31 76948 packaged 77422 $155.9075600 packaged 76080 packaged 76950 packaged 77423 $155.9075605 packaged 76098 packaged 76965 packaged 77424 packaged75625 packaged 76100 $69.66 76970 $58.05 77425 packaged75630 packaged 76101 $153.95 76975 packaged 77435 packaged75635 packaged 76102 $217.20 76977 $6.70 77469 packaged75650 packaged 76120 $68.29 76998 packaged 77470 $81.7175658 packaged 76125 packaged 76999 $58.05 77520 $1,091.7375660 packaged 76376 packaged 77001 packaged 77522 $1,091.7375662 packaged 76377 packaged 77002 packaged 77523 $1,428.1475665 packaged 76380 $98.46 77003 packaged 77525 $1,428.1475671 packaged 76496 $78.58 77011 packaged 77600 $364.0375676 packaged 76497 $98.46 77012 packaged 77605 $364.0375680 packaged 76498 $312.35 77013 packaged 77610 $364.0375685 packaged 76499 $41.38 77014 packaged 77615 $364.0375705 packaged 76506 $58.05 77021 packaged 77620 $364.0375710 packaged 76510 $91.18 77022 packaged 77750 $119.2275716 packaged 76511 $57.23 77031 packaged 77761 $206.4575726 packaged 76512 $46.58 77032 packaged 77762 $238.0375731 packaged 76513 $66.32 77053 packaged 77763 $309.0975733 packaged 76514 $5.52 77054 packaged 77776 $210.7875736 packaged 76516 $52.90 77071 $39.47 77777 $219.4775741 packaged 76519 $58.82 77072 $16.19 77778 $316.1975743 packaged 76529 $51.71 77073 $28.42 77785 $188.2975746 packaged 76536 $88.98 77074 $56.05 77786 $464.6175756 packaged 76604 $58.05 77075 $69.66 77787 $643.6075774 packaged 76645 $58.05 77076 $69.66 77789 $63.9575791 packaged 76700 $88.98 77077 $29.60 77790 packaged75801 packaged 76705 $88.98 77078 $65.97 77799 $348.9175803 packaged 76770 $88.98 77080 $54.08 78000 $100.5175805 packaged 76775 $88.98 77081 $20.53 78001 $100.5175807 packaged 76776 $88.98 77082 $23.30 78003 $100.5175809 packaged 76800 $88.98 77084 $312.35 78006 $204.0875810 packaged 76801 $88.98 77280 $98.96 78007 $204.0875820 packaged 76802 $33.15 77285 $243.28 78010 $122.3075822 packaged 76805 $88.98 77290 $243.28 78011 $122.3075825 packaged 76810 $59.60 77295 $317.38 78015 $258.5975827 packaged 76811 $114.86 77299 $98.96 78016 $258.5975831 packaged 76812 $58.05 77300 $42.62 78018 $258.5975833 packaged 76813 $58.05 77301 $880.18 78020 packaged75840 packaged 76814 $38.29 77305 $31.97 78070 $204.0875842 packaged 76815 $58.05 77310 $42.62 78075 $882.8875860 packaged 76816 $58.05 77315 $70.26 78099 $122.3075870 packaged 76817 $58.05 77321 $59.60 78102 $236.1675872 packaged 76818 $84.86 77326 $98.96 78103 $236.1675880 packaged 76819 $63.15 77327 $154.34 78104 $236.16
Effective 4/1/2012 Page 2 of 6 Appendix D
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
78110 $446.74 78601 $560.34 90670 packaged A9529 packaged78111 $446.74 78605 $222.14 90675 $328.77 A9531 packaged78120 $446.74 78606 $560.34 90676 $223.50 A9532 packaged78121 $446.74 78607 $560.34 90680 packaged A9536 packaged78122 $446.74 78608 $957.18 90681 $170.56 A9537 packaged78130 $446.74 78610 $222.14 90690 packaged A9538 packaged78135 $446.74 78630 $560.34 90691 packaged A9539 packaged78140 $446.74 78635 $560.34 90692 packaged A9540 packaged78185 $236.16 78645 $222.14 90696 packaged A9541 packaged78190 $147.79 78647 $560.34 90698 packaged A9542 packaged78191 $147.79 78650 $560.34 90700 packaged A9544 packaged78195 $236.16 78660 $222.14 90701 packaged A9546 packaged78199 $236.16 78699 $222.14 90702 packaged A9547 packaged78201 $270.58 78700 $293.98 90703 packaged A9548 packaged78202 $270.58 78701 $293.98 90704 packaged A9550 packaged78205 $270.58 78707 $293.98 90705 packaged A9551 packaged78206 $270.58 78708 $293.98 90706 packaged A9552 packaged78215 $270.58 78709 $293.98 90707 packaged A9553 packaged78216 $270.58 78710 $293.98 90708 packaged A9554 packaged78226 $270.58 78725 $147.79 90710 packaged A9555 packaged78227 $270.58 78730 $100.51 90712 packaged A9556 packaged78230 $224.93 78740 $293.98 90713 packaged A9557 packaged78231 $224.93 78761 $293.98 90714 packaged A9558 packaged78232 $224.93 78799 $293.98 90715 packaged A9559 packaged78258 $224.93 78800 $258.59 90717 packaged A9560 packaged78261 $224.93 78801 $456.22 90718 packaged A9561 packaged78262 $224.93 78802 $456.22 90719 packaged A9562 packaged78264 $224.93 78803 $456.22 90720 packaged A9566 packaged78270 $147.79 78804 $882.88 90721 packaged A9567 packaged78271 $147.79 78805 $456.22 90732 packaged A9568 packaged78272 $147.79 78806 $456.22 90733 $177.20 A9569 packaged78278 $224.93 78807 $456.22 90734 $148.67 A9570 packaged78282 $224.93 78808 packaged 90735 $160.24 A9571 packaged78290 $224.93 78811 $957.18 90740 80% of billed A9572 packaged78291 $224.93 78812 $957.18 90743 80% of billed A9576 packaged78299 $224.93 78813 $957.18 90744 80% of billed A9577 packaged78300 $227.94 78814 $957.18 90746 80% of billed A9578 packaged78305 $227.94 78815 $957.18 90747 80% of billed A9579 packaged78306 $227.94 78816 $957.18 90749 packaged A9580 packaged78315 $227.94 78999 $100.51 92071 packaged A9581 packaged78320 $227.94 79005 $59.22 92072 packaged A9582 packaged78399 $227.94 79101 $63.95 A4218 packaged A9583 packaged78414 $274.69 79200 $76.58 A4220 packaged A9584 $3,052.8078428 $274.69 79300 $212.67 A4248 packaged A9585 packaged78445 $135.46 79403 $97.50 A4262 packaged A9698 packaged78451 $619.90 79440 $65.92 A4263 packaged C1713 packaged78452 $619.90 79445 $212.67 A4270 packaged C1714 packaged78453 $619.90 79999 $212.67 A4300 packaged C1715 packaged78454 $619.90 90371 $181.60 A4301 packaged C1716 $56.0678456 $135.46 90375 $297.18 A4305 packaged C1717 $372.1978457 $135.46 90376 $284.50 A4306 packaged C1719 $50.9178458 $135.46 90378 $1,854.16 A4641 packaged C1721 packaged78459 $957.18 90385 packaged A4642 packaged C1722 packaged78466 $274.69 90396 $150.85 A4648 packaged C1724 packaged78468 $274.69 90476 packaged A4650 packaged C1725 packaged78469 $274.69 90585 $179.57 A9500 packaged C1726 packaged78472 $274.69 90632 packaged A9501 packaged C1727 packaged78473 $274.69 90633 packaged A9502 packaged C1728 packaged78481 $274.69 90634 packaged A9503 packaged C1729 packaged78483 $274.69 90636 packaged A9504 packaged C1730 packaged78491 $957.18 90645 packaged A9505 packaged C1731 packaged78492 $957.18 90646 packaged A9507 packaged C1732 packaged78494 $274.69 90647 packaged A9508 packaged C1733 packaged78496 packaged 90648 packaged A9509 packaged C1749 80% of billed78499 $274.69 90654 packaged A9510 packaged C1750 packaged78579 $186.67 90655 packaged A9512 packaged C1751 packaged78580 $186.67 90656 packaged A9516 packaged C1752 packaged78582 $291.76 90657 packaged A9521 packaged C1753 packaged78597 $186.67 90660 packaged A9524 packaged C1754 packaged78598 $291.76 90662 packaged A9526 packaged C1755 packaged78599 $186.67 90665 packaged A9527 $26.93 C1756 packaged78600 $222.14 90669 packaged A9528 packaged C1757 packaged
Effective 4/1/2012 Page 3 of 6 Appendix D
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
C1758 packaged C2622 packaged E0783 packaged J0630 packagedC1759 packaged C2625 packaged E0785 packaged J0636 packagedC1760 packaged C2626 packaged E0786 packaged J0637 $21.31C1762 packaged C2627 packaged G0130 $26.45 J0638 $142.35C1763 packaged C2628 packaged G0173 $3,110.77 J0640 packagedC1764 packaged C2629 packaged G0251 $832.21 J0641 $2.53C1765 packaged C2630 packaged G0288 packaged J0670 packagedC1766 packaged C2631 packaged G0339 $3,110.77 J0690 packagedC1767 packaged C2634 $100.19 G0340 $2,323.95 J0692 packagedC1768 packaged C2635 $43.18 J0120 packaged J0694 packagedC1769 packaged C2636 $59.31 J0129 $33.15 J0696 packagedC1770 packaged C2638 $72.80 J0130 $878.32 J0697 packagedC1771 packaged C2639 $56.88 J0131 $0.18 J0698 packagedC1772 packaged C2640 $128.08 J0132 $4.38 J0702 packagedC1773 packaged C2641 $102.83 J0133 packaged J0706 packagedC1776 packaged C2642 $194.69 J0135 $657.52 J0710 packagedC1777 packaged C2643 $123.73 J0150 packaged J0712 $1.18C1778 packaged C2698 $72.80 J0152 $151.07 J0713 packagedC1779 packaged C2699 $43.18 J0171 packaged J0715 packagedC1780 packaged C8900 $402.50 J0180 $221.65 J0718 $6.59C1781 packaged C8901 $312.35 J0200 packaged J0720 packagedC1782 packaged C8902 $492.91 J0205 $65.98 J0725 packagedC1783 packaged C8903 $402.50 J0207 $505.50 J0735 packagedC1784 packaged C8904 $312.35 J0210 $62.66 J0740 $1,188.26C1785 packaged C8905 $492.91 J0215 $61.95 J0743 packagedC1786 packaged C8906 $402.50 J0220 $249.34 J0744 packagedC1787 packaged C8907 $312.35 J0221 $237.28 J0745 packagedC1788 packaged C8908 $492.91 J0256 $6.13 J0760 packagedC1789 packaged C8909 $402.50 J0257 $6.10 J0770 packagedC1813 packaged C8910 $312.35 J0278 packaged J0775 $60.02C1814 packaged C8911 $492.91 J0280 packaged J0780 packagedC1815 packaged C8912 $402.50 J0282 packaged J0795 $8.93C1816 packaged C8913 $312.35 J0285 packaged J0800 $4,025.95C1817 packaged C8914 $492.91 J0287 $13.47 J0833 $159.62C1818 packaged C8918 $402.50 J0288 $23.30 J0834 packagedC1819 packaged C8919 $312.35 J0289 $22.80 J0840 $3,378.18C1820 packaged C8920 $492.91 J0290 packaged J0850 $1,516.58C1821 packaged C8931 $402.50 J0295 packaged J0878 $0.77C1830 80% of billed C8932 $312.35 J0300 $180.93 J0881 $5.02C1840 80% of billed C8933 $492.91 J0330 packaged J0885 $15.52C1874 packaged C8934 $402.50 J0348 $1.92 J0894 $51.10C1875 packaged C8935 $312.35 J0360 packaged J0895 packagedC1876 packaged C8936 $492.91 J0364 $8.19 J0897 $23.15C1877 packaged C9113 packaged J0365 packaged J0900 packagedC1878 packaged C9121 $32.26 J0380 packaged J0945 packagedC1879 packaged C9248 $4.26 J0390 packaged J1000 packagedC1880 packaged C9250 $207.55 J0400 packaged J1020 packagedC1881 packaged C9254 $0.24 J0456 packaged J1030 packagedC1882 packaged C9257 $2.40 J0461 packaged J1040 packagedC1883 packaged C9275 $997.25 J0470 packaged J1051 packagedC1884 packaged C9279 $2.59 J0475 $299.94 J1060 packagedC1885 packaged C9285 $21.71 J0476 $122.22 J1070 packagedC1887 packaged C9286 $6.26 J0480 $3,504.93 J1080 packagedC1888 packaged C9287 $152.64 J0490 $61.78 J1094 packagedC1891 packaged C9352 packaged J0500 packaged J1100 packagedC1892 packaged C9353 packaged J0515 packaged J1110 packagedC1893 packaged C9354 packaged J0520 packaged J1120 packagedC1894 packaged C9355 packaged J0558 packaged J1160 packagedC1895 packaged C9356 packaged J0561 packaged J1162 $1,002.74C1896 packaged C9358 $17.46 J0583 $4.34 J1165 packagedC1897 packaged C9359 packaged J0585 $8.61 J1170 packagedC1898 packaged C9360 $17.97 J0586 $11.66 J1180 packagedC1899 packaged C9361 packaged J0587 $17.25 J1190 $332.67C1900 packaged C9362 packaged J0588 $8.85 J1200 packagedC2614 packaged C9363 $32.96 J0592 packaged J1205 $431.78C2615 packaged C9364 packaged J0594 $29.95 J1212 $151.01C2616 $25,172.75 C9366 $284.43 J0595 packaged J1230 packagedC2617 packaged C9367 $6.96 J0597 $48.37 J1240 packagedC2618 packaged C9399 80% of billed J0598 $69.39 J1245 packagedC2619 packaged E0616 packaged J0600 $303.15 J1250 packagedC2620 packaged E0749 packaged J0610 packaged J1260 packagedC2621 packaged E0782 packaged J0620 packaged J1265 packaged
Effective 4/1/2012 Page 4 of 6 Appendix D
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
J1267 packaged J1817 packaged J2670 packaged J3370 packagedJ1270 packaged J1830 $338.54 J2675 packaged J3385 $559.22J1290 $462.51 J1835 $596.08 J2680 packaged J3396 $15.62J1300 $298.19 J1840 packaged J2690 packaged J3410 packagedJ1320 packaged J1850 packaged J2700 $4.02 J3411 packagedJ1324 $0.82 J1885 packaged J2710 packaged J3415 packagedJ1325 packaged J1890 packaged J2720 packaged J3420 packagedJ1327 $35.23 J1930 $49.57 J2724 $20.64 J3430 packagedJ1330 packaged J1931 $42.13 J2725 $43.25 J3465 $9.71J1335 packaged J1940 packaged J2730 $141.62 J3470 packagedJ1364 packaged J1945 $553.90 J2760 $86.02 J3471 packagedJ1380 packaged J1950 $945.14 J2765 packaged J3472 packagedJ1410 $165.66 J1953 packaged J2770 $274.37 J3473 packagedJ1430 $470.85 J1956 packaged J2778 $632.85 J3475 packagedJ1436 packaged J1960 packaged J2780 packaged J3480 packagedJ1438 $326.90 J1980 packaged J2783 $302.37 J3485 packagedJ1440 $394.88 J1990 packaged J2785 $81.95 J3486 packagedJ1441 $624.11 J2001 packaged J2788 $34.43 J3487 $352.48J1450 packaged J2010 packaged J2790 $131.42 J3488 $349.50J1451 $11.06 J2020 $55.17 J2791 $8.14 J3490 packagedJ1453 $2.70 J2060 packaged J2792 $27.54 J3530 packagedJ1455 $22.99 J2150 packaged J2793 $37.82 J3590 packagedJ1457 packaged J2170 $41.04 J2794 $8.11 J7030 packagedJ1458 $546.24 J2175 packaged J2795 packaged J7040 packagedJ1459 $55.07 J2180 packaged J2796 $73.39 J7042 packagedJ1460 $32.99 J2185 packaged J2800 packaged J7050 packagedJ1557 $59.66 J2210 packaged J2805 packaged J7060 packagedJ1559 $11.44 J2248 $1.57 J2810 packaged J7070 packagedJ1560 $329.86 J2250 packaged J2820 $38.75 J7100 packagedJ1561 $58.85 J2260 packaged J2850 $43.17 J7110 packagedJ1562 $19.97 J2270 packaged J2910 packaged J7120 packagedJ1566 $48.74 J2271 packaged J2916 packaged J7131 packagedJ1568 $89.28 J2275 packaged J2920 packaged J7180 $13.25J1569 $59.33 J2278 $10.37 J2930 packaged J7183 $1.39J1570 $106.53 J2280 packaged J2941 $98.90 J7185 $1.71J1571 $83.38 J2300 packaged J2950 packaged J7186 $1.44J1572 $56.24 J2310 packaged J2993 $2,597.74 J7187 $1.41J1573 $83.38 J2315 $4.45 J2995 $31.65 J7189 $2.43J1580 packaged J2320 packaged J2997 $67.58 J7190 $1.36J1590 packaged J2323 $16.51 J3000 packaged J7191 $14.59J1595 $174.88 J2325 $74.18 J3010 packaged J7192 $1.74J1599 packaged J2353 $187.38 J3030 $122.74 J7193 $1.42J1600 packaged J2354 packaged J3070 packaged J7194 $1.46J1610 $162.08 J2355 $383.84 J3095 $3.36 J7195 $1.82J1620 $267.60 J2357 $34.14 J3101 $91.44 J7196 $162.24J1626 packaged J2358 $4.32 J3105 packaged J7197 $4.34J1630 packaged J2360 packaged J3120 packaged J7198 $2.56J1631 packaged J2370 packaged J3130 packaged J7308 $236.48J1640 $16.66 J2400 packaged J3140 packaged J7309 $119.23J1642 $0.29 J2405 packaged J3150 packaged J7310 $26,624.00J1644 $0.43 J2410 packaged J3230 packaged J7311 $30,368.00J1645 packaged J2425 $18.32 J3240 $1,651.60 J7312 $307.62J1650 packaged J2426 $10.50 J3243 $2.08 J7321 $140.80J1652 packaged J2430 packaged J3246 $14.27 J7323 $233.76J1655 packaged J2440 packaged J3250 packaged J7324 $265.82J1670 $392.03 J2469 $30.13 J3260 packaged J7325 $19.09J1680 $114.51 J2501 packaged J3262 $5.55 J7326 $1,622.40J1700 packaged J2503 $1,602.14 J3265 packaged J7335 $40.88J1710 packaged J2504 $397.70 J3280 packaged J7500 packagedJ1720 packaged J2505 $4,282.38 J3285 $96.13 J7501 $196.05J1725 $4.03 J2507 $482.80 J3300 $5.46 J7502 packagedJ1730 packaged J2510 packaged J3301 packaged J7504 $890.42J1740 $236.83 J2513 $21.17 J3302 packaged J7505 $1,778.54J1742 $214.08 J2515 packaged J3303 packaged J7506 packagedJ1743 $714.30 J2540 packaged J3310 $31.26 J7507 packagedJ1745 $99.22 J2543 packaged J3315 $281.89 J7509 packagedJ1750 $18.45 J2550 packaged J3350 $115.20 J7510 packagedJ1756 $0.51 J2560 packaged J3355 $105.06 J7511 $691.52J1786 $65.92 J2562 $441.28 J3357 $188.10 J7513 $826.26J1790 packaged J2590 packaged J3360 packaged J7515 packagedJ1800 packaged J2597 packaged J3364 packaged J7516 packagedJ1815 packaged J2650 packaged J3365 $718.54 J7517 packaged
Effective 4/1/2012 Page 5 of 6 Appendix D
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
HCPCS
Code
Maximum
Payment
J7518 packaged J9226 $24,669.57 Q2009 packagedJ7520 packaged J9228 $203.52 Q2017 $506.10J7525 $218.98 J9230 $247.81 Q2035 packagedJ7599 packaged J9245 $2,420.34 Q2036 packagedJ7674 packaged J9250 packaged Q2037 packagedJ7799 packaged J9260 packaged Q2038 packagedJ8501 $9.70 J9261 $182.38 Q2039 packagedJ8510 $6.03 J9263 $15.94 Q2043 $52,576.00J8520 $11.71 J9264 $14.93 Q3025 $381.28J8521 $39.41 J9265 packaged Q4100 packagedJ8530 packaged J9266 $4,280.64 Q4101 $57.41J8540 packaged J9268 $1,734.56 Q4102 $9.18J8560 $60.06 J9270 packaged Q4103 $9.18J8561 $9.09 J9280 $31.28 Q4104 $26.02J8562 $124.69 J9293 $59.78 Q4105 $15.39J8597 packaged J9300 $4,305.34 Q4106 $64.82J8600 packaged J9302 $72.66 Q4107 $151.92J8610 packaged J9303 $136.94 Q4108 $34.77J8700 $15.17 J9305 $84.42 Q4110 $50.27J8705 $124.67 J9307 $265.01 Q4111 $10.85J9000 packaged J9310 $984.35 Q4112 $531.60J9001 $840.56 J9315 $359.66 Q4113 $531.60J9010 $920.29 J9320 $425.10 Q4114 $1,631.82J9015 $1,551.36 J9328 $7.60 Q4115 $13.22J9017 $64.16 J9330 $80.91 Q4116 $50.75J9020 $99.33 J9340 $209.89 Q4118 $4.70J9025 $8.24 J9351 $15.76 Q4119 $7.23J9027 $191.49 J9355 $113.73 Q4121 $52.54J9031 $187.74 J9357 $1,534.51 Q4122 $50.43J9033 $29.55 J9360 packaged Q4124 $16.62J9035 $95.97 J9370 packaged Q4130 packagedJ9040 packaged J9390 $27.92 Q9951 packagedJ9041 $65.07 J9395 $133.81 Q9953 packagedJ9043 $216.91 J9600 $30,956.98 Q9954 packagedJ9045 packaged J9999 packaged Q9955 packagedJ9050 $276.05 L8600 packaged Q9956 packagedJ9055 $79.25 L8603 packaged Q9957 packagedJ9060 packaged L8604 packaged Q9958 packagedJ9065 $38.30 L8606 packaged Q9959 packagedJ9070 $21.49 L8609 packaged Q9960 packagedJ9098 $805.57 L8610 packaged Q9961 packagedJ9100 packaged L8612 packaged Q9962 packagedJ9120 $907.65 L8613 packaged Q9963 packagedJ9130 packaged L8614 packaged Q9964 packagedJ9150 $24.96 L8630 packaged Q9965 packagedJ9151 $90.53 L8631 packaged Q9966 packagedJ9155 $4.34 L8641 packaged Q9967 packagedJ9160 $2,564.82 L8642 packaged Q9968 packagedJ9171 $25.20 L8658 packaged V2630 packagedJ9175 packaged L8659 packaged V2631 packagedJ9178 $2.99 L8670 packaged V2632 packagedJ9179 $144.10 L8682 packaged V2785 80% of billedJ9181 packaged L8690 packaged V2790 packagedJ9185 $162.94 L8699 packagedJ9190 packaged P9041 $34.11J9200 $97.31 P9045 $99.10J9201 $143.42 P9046 $42.94J9202 $298.29 P9047 $108.85J9206 $10.27 Q0138 $1.04J9207 $101.55 Q0162 packagedJ9208 $51.25 Q0163 packagedJ9209 packaged Q0164 packagedJ9211 $93.31 Q0166 packagedJ9212 packaged Q0167 packagedJ9213 packaged Q0169 packagedJ9214 $26.91 Q0171 packagedJ9215 $49.92 Q0173 packagedJ9216 $932.14 Q0175 packagedJ9217 $347.04 Q0177 packagedJ9218 $7.07 Q0180 packagedJ9219 $7,566.21 Q0515 $2.83J9225 $6,107.17 Q2004 packaged
Effective 4/1/2012 Page 6 of 6 Appendix D
