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Practitioner Fee Schedule 2019 Finalahca.myflorida.com/medicaid/review/Reimbursement/2019-01... ·...

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Note Number Title Details • Procedure: indicates the service level code reimbursed in the fee-for-service delivery system within the practitioner’s scope of practice. • Modifier (Mod): indicates pricing modifiers that have altered the code by some circumstance without significantly changing the base definition. These include: EP: Well child visit for a recipient between the age of 18-20 years FP: Family planning program service TG: Healthy Start Prenatal Risk Screening completed during the first trimester TH: Obstetrical treatment/services, prenatal or postpartum • Fee Schedule Increase (FSI): indicates the base Florida Medicaid rate with a 4% increase included for all ages and certain provider types (independent of increases detailed below). Provider types include (25, 26, 27, 28, 29, 30, 35, and 62 . • Facility: indicates the reimbursement rate for a practitioner if a procedure is performed in one of the following places of service: inpatient hospital (21), outpatient hospital (22), emergency room hospital (23), or ambulatory surgical center (24), according to Medicare’s designation. • PCI: indicates the professional component increase for physician work portion of a test. • TCI: indicates the technical component increase for the technical portion (i.e. staff and equipment costs) of a test. • PA: indicates the need for a prior authorization of the service through the Agency’s Quality Improvement Organization vendor. • Asterisk (*): Indicates reimbursement for a high risk delivery when associated with a high risk diagnosis code. • 4% increase for all FSI, Facility, PCI, and TCI rates for all services. Example: For code 99201, the rate is $29.53 X 1.04 = $30.71 (FSI, Facility, PCI, or TCI) X 1.04 = rate with a 4% pediatric increase. • For codes 99381-99384, 99385 EP, 99391-99394, and 99395 EP the base fee includes the 4% pediatric increase. • 24% increase for all FSI, Facility, PCI, and TCI rates for all services with physician specialty types: 02, 03, 04, 05, 08, 10, 14, 15, 17, 21, 22, 23, 29, 30, 31, 36, 37, 38, 39, 43, 46, 51, 53, 55, 57, 58, 60, and 62. Example: For code 99201, the rate is $29.53 x 1.04 X 1.24 = $38.08 (specialty rate) (FSI, Facility, PCI, or TCI) x 1.04 X 1.24 = pediatric rate with a 24% increase. • A 10.2% increase for all FSI and Facility rates for specific services (CPT codes 99201-99496) with physician specialty types: 01, 19, 23, 35, 36, 37, 38, 39, 43, 49, 59, 101, and 102. Example: For code 99201, the rate is $29.53 x 1.102 = $32.54 (FSI, Facility, PCI, or TCI) x 1.04 X 1.102 = pediatric rate with a 10.2% increase. • When all criteria above are met, the 4%, 24%, and 10.2% increases are applicable. To calculate the rate with all applicable increases, multiply the FSI, Facility, PCI, or TCI rate by 1.04, then multiply by 1.24, and then multiply by 1.102. Example: For code 99201 the rate is $29.53 x 1.04 x 1.24 x 1.102 = $41.97 (FSI, Facility, PCI, or TCI) X 1.04 x 1.24 x 1.102 = rate with 4%, 24%, and 10.2% increases. 5 Primary Care Evaluation and Management (E&M) Rate Increase • Specific E&M services (99212 – 99214) provided to recipients ages 0-19 by provider types 25 and 26 are reimbursed at set rates, and receive the 10.2% increase for the following specialties: 01, 19, 23, 35, 36, 37, 38, 39, 43, 49, 59, 101, and 102. These set rates are: 99212= 1 unit at $26.45, 99213 = 1 unit at $32.56, and 99214 = 1 unit at $48.27. 6 Services not Eligible for Rate Increases • Reimbursement increases detailed above do not apply to the following services: regional perinatal intensive care center services, injectable medications/ immunization/vaccinations, supplies, devices, and laboratory/pathology services. • When the assistant at surgery is a physician, the assistant physician is reimbursed at 16%. • If not a physician, the assistant at surgery is reimbursed at 12.8%. • Services provided by an APRN or a PA within their scope of practice may be billed under a physician’s Medicaid provider number when the physician is in the building and able to render assistance as needed. These services are reimbursed at the physician allowable amount. • Services provided within the APRN’s and PA’s scope of practice that are performed when the physician is not in the building, must be billed under the rendering APRN’s or PA’s Medicaid provider number and are reimbursed at 80% of the allowable amount. Practitioner Fee Schedule 1 Legend 2 Pediatric Rate Increases for Recipients (ages 0-20 years) 8 Advanced Practice Registered Nurse (APRN) and Physician Assistant (PA) Reimbursement Rates 3 Rate Increase for Pediatric Physicians 4 Calculating All Rate Increases 7 Assistant at Surgery Reimbursement Rates Page 1 Practitioner_Notes
Transcript
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Note Number

Title Details

• Procedure: indicates the service level code reimbursed in the fee-for-service delivery system within the practitioner’s scope of practice.• Modifier (Mod): indicates pricing modifiers that have altered the code by some circumstance without significantly changing the base definition. These include: EP: Well child visit for a recipient between the age of 18-20 years FP: Family planning program service TG: Healthy Start Prenatal Risk Screening completed during the first trimester TH: Obstetrical treatment/services, prenatal or postpartum• Fee Schedule Increase (FSI): indicates the base Florida Medicaid rate with a 4% increase included for all ages and certain provider types (independent of increases detailed below). Provider types include (25, 26, 27, 28, 29, 30, 35, and 62 .

• Facility: indicates the reimbursement rate for a practitioner if a procedure is performed in one of the following places of service: inpatient hospital (21), outpatient hospital (22), emergency room hospital (23), or ambulatory surgical center (24), according to Medicare’s designation.

• PCI: indicates the professional component increase for physician work portion of a test.• TCI: indicates the technical component increase for the technical portion (i.e. staff and equipment costs) of a test.• PA: indicates the need for a prior authorization of the service through the Agency’s Quality Improvement Organization vendor.• Asterisk (*): Indicates reimbursement for a high risk delivery when associated with a high risk diagnosis code.• 4% increase for all FSI, Facility, PCI, and TCI rates for all services.Example: For code 99201, the rate is $29.53 X 1.04 = $30.71 (FSI, Facility, PCI, or TCI) X 1.04 = rate with a 4% pediatric increase.• For codes 99381-99384, 99385 EP, 99391-99394, and 99395 EP the base fee includes the 4% pediatric increase.• 24% increase for all FSI, Facility, PCI, and TCI rates for all services with physician specialty types: 02, 03, 04, 05, 08, 10, 14, 15, 17, 21, 22, 23, 29, 30, 31, 36, 37, 38, 39, 43, 46, 51, 53, 55, 57, 58, 60, and 62.Example: For code 99201, the rate is $29.53 x 1.04 X 1.24 = $38.08 (specialty rate) (FSI, Facility, PCI, or TCI) x 1.04 X 1.24 = pediatric rate with a 24% increase.

• A 10.2% increase for all FSI and Facility rates for specific services (CPT codes 99201-99496) with physician specialty types: 01, 19, 23, 35, 36, 37, 38, 39, 43, 49, 59, 101, and 102.

Example: For code 99201, the rate is $29.53 x 1.102 = $32.54 (FSI, Facility, PCI, or TCI) x 1.04 X 1.102 = pediatric rate with a 10.2% increase.• When all criteria above are met, the 4%, 24%, and 10.2% increases are applicable.To calculate the rate with all applicable increases, multiply the FSI, Facility, PCI, or TCI rate by 1.04, then multiply by 1.24, and then multiply by 1.102.

Example: For code 99201 the rate is $29.53 x 1.04 x 1.24 x 1.102 = $41.97(FSI, Facility, PCI, or TCI) X 1.04 x 1.24 x 1.102 = rate with 4%, 24%, and 10.2% increases.

5

Primary Care Evaluation and Management (E&M) Rate Increase

• Specific E&M services (99212 – 99214) provided to recipients ages 0-19 by provider types 25 and 26 are reimbursed at set rates, and receive the 10.2% increase for the following specialties: 01, 19, 23, 35, 36, 37, 38, 39, 43, 49, 59, 101, and 102. These set rates are: 99212= 1 unit at $26.45, 99213 = 1 unit at $32.56, and 99214 = 1 unit at $48.27.

6Services not Eligible for Rate Increases

• Reimbursement increases detailed above do not apply to the following services: regional perinatal intensive care center services, injectable medications/ immunization/vaccinations, supplies, devices, and laboratory/pathology services.

• When the assistant at surgery is a physician, the assistant physician is reimbursed at 16%.

• If not a physician, the assistant at surgery is reimbursed at 12.8%.

• Services provided by an APRN or a PA within their scope of practice may be billed under a physician’s Medicaid provider number when the physician is in the building and able to render assistance as needed. These services are reimbursed at the physician allowable amount.

• Services provided within the APRN’s and PA’s scope of practice that are performed when the physician is not in the building, must be billed under the rendering APRN’s or PA’s Medicaid provider number and are reimbursed at 80% of the allowable amount.

Practitioner Fee Schedule

1 Legend

2

Pediatric Rate Increases for Recipients (ages 0-20 years)

8

Advanced Practice Registered Nurse (APRN) and Physician Assistant (PA) Reimbursement Rates

3Rate Increase for Pediatric Physicians

4Calculating All Rate Increases

7Assistant at Surgery Reimbursement Rates

Page 1 Practitioner_Notes

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Note Number

Title Details

Practitioner Fee Schedule

• Anesthesia time is reported in total minutes and reimbursed through the below calculation. Qualified non-physician providers, within their scope of practice, are reimbursed at 80%.

(Anesthesia FSI, Facility, PCI, or TCI rate) + (time/15 x $14.50) = reimbursement rate.

10Reproductive Services Information

Coding:• 59410 TH: Professional services for vaginal delivery which include immediate post-partum care and recovery services in the home setting.• 99211 - 99215 TH: Professional evaluation and management primary code for labor management when recipient transferred from birth center to hospital for delivery.• 99347 - 99350 TH: Professional evaluation and management primary code for labor management when recipient transferred from home to hospital for delivery.• 99354 - 99355 TH: Prolonged services add-on codes for labor management when recipient transferred from birth center or home to hospital for delivery.• 59400 and 59510 Third-party liability delivery only.• 59820 or 59821: Deliveries less than 20 full weeks of gestation.• 99401 and 99402: HIV preventive counseling visits.• H1000 Prenatal visit(s).• H1001 Prenatal visit with completion of Healthy Start Prenatal Risk screening.• H1001 TG: Used when Healthy Start Prenatal Risk Screening is completed during the first trimester of the pregnancy.

9Anesthesia Reimbursement Rates

Page 2 Practitioner_Notes

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Procedure Mod FSI Facility PCI TCI PA

00100 72.49 00102 86.99 00103 72.49 00104 57.99 00120 72.49 00124 57.99 00126 57.99 00140 72.49 00142 86.99 00144 86.99 00145 86.99 00148 57.99 00160 72.49 00162 101.48 00164 57.99 00170 72.49 00172 86.99 00174 86.99 00176 101.48 00190 72.49 00192 101.48 00210 159.47 00211 130.48 00212 72.49 00214 130.48 00215 130.48 00216 217.46 00218 188.47 00220 144.98 00222 86.99 00300 72.49 00320 86.99 00322 43.49 00326 116.00 00350 144.98 00352 72.49 00400 43.49 00402 72.49 00404 72.49 00406 188.47 00410 57.99 00450 72.49 00454 43.49 00470 86.99 00472 144.98 00474 188.47 00500 217.46 00520 86.99 00522 57.99

Practitioner Fee Schedule2019

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Procedure Mod FSI Facility PCI TCI PA

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00524 57.99 00528 115.98 00529 159.50 00530 57.99 00532 57.99 00534 101.48 00537 144.98 00539 261.00 00540 174.00 00541 217.50 00542 217.50 00546 217.50 00548 246.50 00550 144.98 00560 217.46 00561 217.46 00562 289.95 00563 362.44 00566 362.44 00567 362.44 00580 289.95 00600 144.98 00604 188.47 00620 144.98 00625 144.98 00626 144.98 00630 115.98 00632 101.48 00635 58.00 00640 43.50 00670 188.47 00700 58.00 00702 57.99 00730 72.49 00731 72.49 00732 72.50 00750 57.99 00752 86.99 00754 101.48 00756 101.48 00770 217.46 00790 101.48 00792 188.47 00794 115.98 00796 434.93 00797 145.00 00800 58.00 00802 72.49 00811 72.50

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

00812 72.50 00813 72.49 00820 72.49 00830 57.99 00832 86.99 00834 72.50 00836 87.00 00840 86.99 00842 57.99 00844 101.48 00846 115.98 00848 115.98 00851 87.00 00860 86.99 00862 101.48 00864 115.98 00865 101.48 00866 144.98 00868 144.98 00870 72.49 00872 101.48 00873 72.49 00880 217.46 00882 144.98 00902 72.50 00904 101.48 00906 57.99 00908 86.99 00910 43.49 00912 72.49 00914 72.49 00916 72.49 00918 72.49 00920 43.49 00921 43.50 00922 86.99 00924 57.99 00926 57.99 00928 86.99 00930 57.99 00932 57.99 00934 86.99 00936 115.98 00940 43.49 00942 57.99 00944 86.99 00948 57.99 00950 72.49 00952 57.99

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01112 72.49 01120 86.99 01130 43.49 01140 217.46 01150 145.00 01160 57.99 01170 115.98 01173 174.00 01200 57.99 01202 57.99 01210 86.99 01212 144.98 01214 116.00 01215 144.98 01220 57.99 01230 86.99 01232 72.49 01234 115.98 01250 57.99 01260 115.98 01270 116.48 01272 57.99 01274 86.99 01320 57.99 01340 57.99 01360 72.49 01380 43.49 01382 43.49 01390 43.49 01392 57.99 01400 57.99 01402 101.48 01404 72.49 01420 43.49 01430 43.49 01432 87.00 01440 116.00 01442 115.98 01444 115.98 01462 43.49 01464 43.49 01470 43.49 01472 72.49 01474 72.49 01480 43.49 01482 57.99 01484 57.99 01486 101.48 01490 43.49

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01500 115.98 01502 86.99 01520 43.49 01522 72.49 01610 72.49 01620 57.99 01622 57.99 01630 72.49 01634 130.48 01636 217.46 01638 144.98 01650 86.99 01652 144.98 01654 115.98 01656 144.98 01670 57.99 01680 43.49 01710 43.49 01712 72.49 01714 72.49 01716 72.49 01730 43.49 01732 43.49 01740 57.99 01742 72.49 01744 72.49 01756 86.99 01758 72.49 01760 101.48 01770 87.00 01772 86.99 01780 43.49 01782 57.99 01810 43.49 01820 43.49 01829 43.50 01830 43.49 01832 86.99 01840 86.99 01842 86.99 01844 86.99 01850 43.49 01852 57.99 01860 43.49 01916 72.49 01920 101.48 01922 101.48 01924 87.00 01925 116.00

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

01926 145.00 01930 72.50 01931 101.50 01932 101.50 01933 116.00 01935 101.50 01936 101.50 01951 43.49 01952 72.49 01953 14.50 01958 72.50 01960 72.50 01961 101.50 01962 116.00 01963 145.00 01965 58.00 01966 58.00 01967 101.38 01968 72.38 01969 101.38 01991 43.50 01992 72.50 01996 43.49 01999 Y10004 34.11 27.52 10005 82.19 46.23 10006 39.15 31.48 10007 185.21 59.44 10008 104.40 38.74 10009 303.12 71.98 10010 182.69 52.61 10011 88.62 43.55 10012 88.62 43.55 10021 69.18 41.48 10030 372.49 87.39 10035 312.96 54.59 10036 269.92 27.52 10040 70.42 42.73 10060 77.15 61.86 10061 134.39 113.59 10080 119.74 64.50 10081 179.49 107.21 10120 98.90 65.16 10121 177.89 117.11 10140 109.20 74.85 10160 84.71 59.88 10180 163.01 112.27 11000 35.94 18.05 11001 14.19 9.03

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

11004 382.10 11005 518.32 11006 467.95 11008 182.24 11010 316.39 176.33 11011 349.36 191.08 11012 453.07 268.34 11042 64.85 38.74 11043 150.41 97.96 11044 204.44 144.85 11045 27.01 16.73 11046 47.85 35.44 11047 80.82 62.74 11055 32.90 10.13 11056 40.20 14.31 11057 39.56 18.94 11102 64.10 25.10 11103 34.57 14.53 11104 80.59 31.48 11105 39.61 17.17 11106 97.53 38.30 11107 46.70 20.47 11200 57.46 46.23 11201 12.36 10.57 11300 59.65 22.23 11301 77.84 33.68 11302 91.12 39.62 11303 100.50 46.89 11305 59.77 24.66 11306 78.98 32.80 11307 93.64 42.27 11308 95.04 49.34 11310 73.06 29.94 11311 76.76 41.39 11312 103.48 49.09 11313 108.36 67.17 11400 80.82 51.29 11401 98.44 65.82 11402 109.43 72.42 11403 126.60 93.56 11404 143.55 102.80 11406 206.50 156.52 11420 80.82 51.29 11421 102.79 69.34 11422 115.84 85.85 11423 132.10 98.62 11424 153.16 113.59 11426 219.55 174.57 11440 89.52 65.16

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11441 110.58 82.77 11442 123.40 91.58 11443 146.98 112.49 11444 177.22 150.79 11446 255.50 205.39 11450 257.56 161.36 11451 323.95 206.27 11462 234.60 161.44 11463 309.91 217.50 11470 275.41 177.87 11471 336.77 219.91 11600 120.96 79.68 11601 143.99 99.14 11602 161.63 103.46 11603 184.75 123.94 11604 204.90 136.26 11606 294.19 203.40 11620 127.52 76.83 11621 149.96 95.10 11622 167.13 108.53 11623 195.74 134.28 11624 221.38 152.33 11626 266.49 186.67 11640 126.05 83.39 11641 155.22 99.06 11642 176.97 116.67 11643 208.11 145.73 11644 256.87 180.73 11646 335.17 250.73 11719 9.17 4.80 11720 21.52 9.25 11721 29.53 15.63 11730 70.74 34.78 11732 21.29 11.23 11740 33.43 20.25 11750 100.96 64.28 11755 79.44 46.07 11760 125.00 71.98 11762 169.93 114.94 11765 109.89 58.78 11770 185.44 116.89 11771 384.39 277.59 11772 460.17 365.42 11900 35.26 19.81 11901 44.64 30.60 11920 103.58 73.27 11921 133.70 83.65 11922 39.61 18.71 11960 634.39

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11970 399.96 11971 309.53 201.64 11976 94.09 58.56 11981 92.72 52.83 11982 102.79 63.18 11983 150.18 112.71 12001 57.92 27.96 12002 70.51 36.76 12004 82.65 46.01 12005 107.37 59.66 12006 126.83 73.30 12007 145.83 91.36 12011 70.74 34.56 12013 73.95 36.54 12014 88.83 47.11 12015 107.37 59.22 12016 135.53 80.79 12017 105.75 101.68 12018 118.54 115.12 12031 159.80 96.86 12032 198.03 122.84 12034 207.65 131.20 12035 250.23 152.11 12036 277.02 177.21 12037 313.65 207.15 12041 159.57 94.44 12042 192.54 126.58 12044 238.33 135.82 12045 262.37 169.72 12046 299.06 205.17 12047 303.53 229.77 12051 172.85 108.31 12052 195.74 128.78 12053 228.94 137.80 12054 239.47 140.23 12055 310.67 190.86 12056 333.68 256.41 12057 342.20 277.83 13100 221.16 129.88 13101 260.76 160.04 13102 79.21 47.11 13120 231.00 149.25 13121 280.68 168.84 13122 86.54 54.37 13131 253.89 157.84 13132 312.73 198.78 13133 115.84 82.99 13151 277.70 181.61 13152 331.50 219.91

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

13153 125.92 89.59 13160 525.65 14000 407.51 316.55 14001 522.44 412.09 14020 454.90 357.94 14021 567.54 453.04 14040 496.80 398.44 14041 612.41 491.12 14060 506.19 424.86 14061 658.66 525.46 14301 704.91 555.84 14302 145.15 14350 449.18 15002 227.57 142.43 15003 48.31 29.06 15004 260.53 169.06 15005 80.59 58.12 15050 341.13 282.94 15100 562.73 451.94 15101 121.57 70.88 15110 522.44 436.31 15111 66.77 63.43 15115 501.49 437.10 15116 88.89 84.45 15120 556.09 440.49 15121 136.22 84.97 15130 435.44 351.33 15131 57.68 54.80 15135 561.36 472.41 15136 58.28 55.37 15150 459.02 403.29 15151 76.03 70.22 15152 97.30 87.61 15155 453.90 431.21 15156 94.27 89.56 15157 107.34 101.97 15200 524.58 432.95 15201 90.18 51.83 15220 505.04 388.98 15221 88.60 45.13 15240 610.81 506.53 15241 119.51 70.00 15260 661.18 542.63 15261 131.22 90.13 15271 94.78 53.27 15272 17.40 11.01 15273 199.86 128.56 15274 48.44 29.28 15275 100.05 60.32

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

15276 22.44 16.07 15277 218.64 145.29 15278 57.40 36.54 15570 596.16 463.82 15572 579.90 470.21 15574 591.81 479.67 15576 508.85 427.39 15600 212.91 130.10 15610 232.60 151.01 15620 286.63 204.06 15630 299.68 217.27 15650 306.04 253.86 15730 1,001.39 586.09 15731 733.52 633.11 15733 689.57 15734 994.97 15736 808.16 15738 861.96 15740 660.03 534.27 15750 604.17 15756 1,515.81 15757 1,499.78 15758 1,513.06 15760 520.84 451.25 15770 437.05 15777 143.09 15781 329.30 275.63 Y15820 357.55 309.55 Y15822 265.23 243.31 Y15823 397.67 341.43 Y15830 772.67 Y15832 566.36 Y15834 548.27 Y15835 572.74 Y15840 620.38 15841 937.48 15842 1,549.00 15845 613.78 15847 294.38 Y15850 58.61 26.20 15851 65.25 28.84 15852 30.45 15860 70.97 15876 Y15920 408.43 15922 462.83 15931 456.51 15933 549.84 15934 569.76

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

15935 702.02 15936 588.83 15937 683.39 15940 461.31 15941 552.32 15944 544.03 15945 624.70 15946 1,073.04 15950 376.16 15951 516.70 15952 552.74 15953 588.87 15956 764.20 15958 779.77 15999 Y16020 53.11 34.12 16025 97.53 69.56 16030 123.63 84.09 16035 129.35 16036 54.03 17000 42.35 33.68 17003 3.66 1.54 17004 98.67 62.74 17106 215.98 184.14 17107 264.51 232.55 17108 420.10 334.82 17110 71.66 43.15 17111 84.94 53.05 17250 52.89 23.11 17260 62.04 44.69 17261 94.09 56.79 17262 114.70 72.64 17263 120.07 85.70 17264 128.26 88.31 17266 146.21 102.88 17270 97.07 62.52 17271 106.91 69.12 17272 122.02 79.91 17273 125.27 92.12 17274 148.03 112.99 17276 178.55 135.50 17280 90.89 56.79 17281 111.87 83.15 17282 133.70 90.26 17283 147.60 119.75 17284 168.86 139.90 17286 216.71 186.92 17311 434.53 238.19 17312 257.79 126.80

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

17313 406.37 213.53 17314 246.11 117.55 17315 48.28 34.31 17340 32.56 30.96 17999 Y19000 71.43 27.74 19001 17.63 13.65 19020 309.07 194.60 19030 108.52 49.09 19081 421.71 106.77 19082 344.10 53.71 19083 413.01 100.60 19084 331.73 50.19 19085 627.07 116.67 19086 502.98 58.34 19100 98.90 44.69 19101 220.70 140.67 19110 305.93 228.62 19112 301.06 199.00 19120 327.38 262.40 19125 362.64 291.24 19126 107.14 19260 786.18 19271 1,056.56 19272 1,134.21 19281 157.97 64.06 19282 110.35 32.14 19283 176.97 64.50 19284 128.26 33.47 19285 315.71 55.03 19286 272.67 27.52 19287 533.43 81.89 19288 382.87 43.31 19294 112.57 19296 148.91 141.26 19297 62.96 19298 245.49 205.42 19300 318.59 269.95 19301 431.78 19302 594.56 19303 633.93 19304 384.85 19305 749.32 19306 756.29 19307 792.36 19316 507.56 Y19318 723.22 Y19324 314.57 Y19325 422.62 Y

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

19328 326.70 Y19330 391.33 Y19340 357.91 Y19342 607.38 19350 540.53 425.08 19357 988.10 Y19361 1,035.27 Y19364 1,813.43 Y19366 900.50 Y19367 1,175.38 Y19368 1,362.40 Y19369 1,206.70 Y19370 451.70 Y19371 516.49 Y19380 509.62 Y19499 Y20100 401.56 20101 281.34 139.90 20102 321.43 162.68 20103 380.27 219.91 20150 555.93 20200 130.70 63.47 20205 191.16 98.62 20206 56.70 36.98 20220 70.63 45.35 20225 108.17 67.58 20240 98.67 20245 231.92 20250 263.28 20251 285.03 20500 64.91 56.05 20501 37.22 23.99 20520 134.39 92.46 20525 312.04 156.52 20526 50.37 36.54 20527 48.75 44.24 20550 34.57 24.88 20551 35.03 25.64 20552 35.94 23.99 20553 41.44 27.30 20555 192.03 20600 31.59 22.67 20604 48.08 29.50 20605 32.97 23.55 20606 53.11 33.68 20610 39.15 29.06 20611 59.75 38.52 20612 39.15 26.42 20615 159.11 101.92

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

20650 138.97 100.82 20660 161.86 20661 332.65 20662 247.96 20663 254.09 20664 561.35 20665 71.66 58.34 20670 244.28 92.24 20680 403.39 267.24 20690 393.78 20692 738.79 20693 291.90 20694 279.54 214.19 20697 1,323.18 20802 1,337.08 20805 1,967.56 20808 2,111.48 20816 1,155.30 20822 1,110.16 20824 1,247.64 20827 1,198.96 20838 1,515.33 20900 268.32 118.21 20902 187.73 20910 304.17 20912 303.05 20920 240.54 20922 373.93 325.67 20924 308.59 20926 276.33 20931 74.63 20932 470.24 20933 431.32 20934 470.01 20937 111.72 20938 123.63 20939 43.96 20950 67.26 60.45 20955 1,600.30 20956 1,540.73 20957 1,405.46 20962 1,267.96 20969 1,811.83 20970 1,599.42 20972 1,264.60 20973 1,638.62 20974 46.57 32.98 20975 108.25 20982 370.43 232.90

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

20983 247.32 223.88 20985 97.07 20999 Y21010 456.40 21011 231.69 162.68 21012 223.22 21013 344.10 254.26 21014 343.64 21015 370.71 21016 667.36 21025 569.37 463.82 21026 382.39 316.74 21029 473.20 408.08 21030 331.41 265.66 21031 244.16 188.23 21032 248.19 185.27 21034 858.52 726.66 21040 333.62 277.95 21044 572.17 21045 804.04 21046 695.45 21047 820.29 21048 712.89 21049 793.51 21050 532.10 21060 485.28 21070 413.61 21076 631.87 509.83 21077 1,456.43 1,354.32 21079 983.76 903.50 21080 1,207.20 954.94 21081 1,018.82 923.46 21082 967.80 861.73 21083 902.42 800.66 21084 1,053.48 926.78 21085 481.92 345.83 21086 1,169.88 941.51 21087 1,186.05 993.79 21089 Y21100 377.96 260.35 21110 512.83 419.77 21116 84.16 31.29 21121 502.17 417.83 Y21125 467.74 444.35 21127 555.57 527.79 21137 393.27 Y21138 498.98 21139 638.02 21141 903.40

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

21142 873.88 21143 869.13 21145 1,024.34 21146 1,049.47 21147 1,084.44 21150 893.75 21151 1,090.31 21154 1,171.64 21155 1,258.10 21159 1,540.84 21160 1,670.76 21172 1,225.63 21175 1,334.75 21179 958.40 21180 949.39 21181 429.61 21182 1,194.39 21183 1,435.98 21184 1,313.70 21188 926.44 21193 829.24 21194 800.59 21195 910.51 21196 965.67 21198 757.33 21199 589.07 21206 742.04 21208 1,142.35 534.50 Y21210 1,433.20 548.81 21215 2,626.17 548.80 21230 438.33 Y21235 475.51 357.50 Y21240 696.94 21242 590.45 21243 1,074.99 21244 687.28 21245 700.69 614.50 21246 530.56 21247 930.19 21248 651.90 579.02 Y21249 887.84 823.92 Y21255 783.07 21256 739.48 21260 725.16 21261 1,269.33 21263 1,095.62 21267 1,010.16 21268 1,048.55 21270 581.00 486.38

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

21275 518.08 21295 109.96 21296 262.92 21299 Y21315 179.49 95.10 21320 165.52 84.31 21325 300.61 21330 349.00 21335 470.01 21336 409.61 21338 432.24 21339 513.58 21340 483.31 21343 705.59 21344 907.98 21345 498.48 394.86 21346 608.98 21347 664.61 21348 693.07 21355 258.40 209.62 21356 327.61 238.85 21360 334.25 21365 731.46 21366 794.39 21385 444.77 21386 413.59 21387 450.80 21390 525.65 21395 635.64 21401 282.03 204.72 21406 331.07 21407 424.23 21408 594.10 21421 465.43 378.85 21422 434.30 21423 508.70 21431 426.14 21432 433.97 21433 1,134.13 21435 886.51 21436 1,065.02 21440 357.29 312.00 21445 459.48 396.15 21451 472.35 418.09 21452 225.26 214.00 21453 632.33 520.40 21454 359.21 21461 1,358.62 591.09 21462 1,450.79 687.92

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

21465 592.27 21470 790.76 21480 68.48 20.03 21485 444.83 398.36 21490 546.93 21497 449.18 363.44 21499 Y21501 301.74 204.50 21502 325.18 21510 291.67 21550 170.79 99.28 21552 294.42 21554 482.15 21555 276.33 193.28 21556 347.76 21557 508.06 21558 887.37 21600 362.87 21610 730.95 21615 402.48 21616 492.77 21620 332.42 21627 354.63 21630 811.13 21632 789.67 21685 645.84 21700 229.69 21705 340.49 21720 279.03 21725 288.13 21740 680.41 21742 493.04 21743 493.04 21750 451.24 21811 393.32 21812 482.38 21813 615.17 21825 356.92 21899 Y21920 162.60 101.73 21925 269.46 236.95 21930 316.62 230.92 21931 310.44 21932 422.89 21933 487.41 21935 678.81 21936 937.74 22010 634.85 22015 627.30

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

22100 545.94 22101 567.54 22102 484.26 22103 85.92 22110 632.40 22112 626.30 22114 584.54 22116 80.75 22206 1,576.61 22207 1,477.45 22208 351.55 22210 1,149.94 22212 989.48 22214 993.60 22216 242.91 22220 951.26 22222 845.31 22224 1,050.83 22226 242.22 22310 201.92 179.85 22315 562.45 514.67 22318 1,090.90 22319 1,174.43 22325 960.86 22326 995.20 22327 1,004.59 22328 188.88 22505 78.69 22510 1,140.81 276.05 22511 1,129.36 258.88 22512 586.09 131.86 22513 373.97 329.32 22514 348.43 306.87 22515 157.74 142.21 22532 1,143.30 22533 1,101.66 22534 240.84 22548 1,147.42 22551 1,136.92 22552 266.49 22554 833.34 22556 1,112.19 22558 1,018.55 22585 218.64 22586 891.20 22590 1,052.89 22595 1,004.59 22600 858.07 22610 842.04

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

22612 1,054.50 22614 261.45 22630 1,048.54 22632 208.90 22633 1,232.84 22634 331.50 22800 900.65 22802 1,399.05 22804 1,617.23 22808 1,190.49 22810 1,319.19 22812 1,289.02 22818 1,281.74 22819 1,716.87 22830 540.76 22840 508.25 22842 510.99 22843 546.48 22844 659.80 22845 488.33 22846 507.10 22847 535.03 22848 240.39 22849 863.79 22850 481.69 22852 462.69 22853 172.85 22854 223.90 22855 736.96 22857 114.78 22858 286.37 22859 223.90 22899 Y22900 364.46 22901 439.56 22902 294.19 209.79 22903 290.30 22904 646.54 22905 882.33 22999 Y23000 338.71 238.25 23020 438.63 23030 284.57 158.50 23031 259.68 139.50 23035 445.97 23040 472.53 23044 373.40 23065 129.79 107.19 23066 370.42 228.94

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

23071 276.79 23073 458.80 23075 222.29 207.15 23076 357.15 23077 706.51 23078 949.64 23100 293.65 23101 287.05 23105 389.83 23106 291.29 23107 403.66 23120 384.62 23125 435.78 23130 374.31 23140 326.46 23145 405.91 23146 380.48 23150 401.32 23155 463.22 23156 414.93 23170 341.98 23172 331.86 23174 443.53 23180 420.90 23182 418.24 23184 483.06 23190 347.51 23195 441.17 23200 585.71 23210 676.65 23220 779.27 23330 156.18 107.00 23333 278.39 23334 604.82 23335 843.87 23350 90.16 32.36 23395 787.75 23397 702.04 23400 566.23 23405 406.83 23406 508.25 23410 541.21 23412 561.59 23415 460.40 23420 593.79 23430 490.16 23440 462.14 23450 553.23 23455 634.23

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

23460 635.36 23462 651.00 23465 680.56 23466 735.13 23470 791.90 23472 959.94 23473 1,038.52 23474 1,072.95 23480 504.89 23485 606.98 23490 503.01 23491 644.42 23500 142.86 140.23 23505 221.08 211.50 23515 473.91 23525 229.48 227.63 23530 337.10 23532 394.10 23545 206.09 195.84 23550 374.32 23552 416.47 23570 151.56 150.35 23575 251.43 241.04 23585 645.84 23600 214.52 194.16 23605 305.18 267.90 23615 582.88 23616 818.00 23620 175.14 161.14 23625 224.72 223.53 23630 514.43 23650 208.34 182.49 23655 264.88 23660 342.30 23665 280.45 250.07 23670 557.36 23675 360.81 315.45 23680 612.19 23700 124.72 23800 631.43 23802 749.00 23900 808.48 23920 703.35 23921 277.09 23929 Y23930 232.60 134.94 23931 187.50 98.62 23935 310.51 24000 313.88

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

24006 470.70 24065 161.93 106.53 24066 380.05 268.63 24071 267.86 24073 457.65 24075 330.82 208.69 24076 358.75 24077 650.71 24079 875.47 24100 256.49 24101 329.22 24102 405.91 24105 231.69 24110 356.01 24115 418.12 24116 530.41 24120 341.00 24125 362.78 24126 379.32 24130 322.32 24134 436.24 24136 368.69 24138 412.38 24140 462.69 24145 346.04 24147 395.65 24149 748.10 24150 710.76 24152 483.56 24155 518.93 24160 389.52 24164 352.46 24200 137.82 87.83 24201 362.18 230.48 24220 107.83 42.93 24300 276.33 24301 494.97 24305 379.81 24310 307.47 24320 455.74 24330 441.30 24331 483.63 24332 404.31 24340 402.93 24341 490.39 24342 511.45 24343 467.27 24344 694.93 24345 463.60

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

24346 723.45 24357 262.02 24358 344.55 24359 435.21 24360 524.28 24361 586.51 24362 618.02 24363 960.63 24365 373.22 24366 417.27 24370 898.48 24371 1,035.17 24400 543.05 24410 594.53 24420 601.02 24430 695.98 24435 710.17 24470 346.24 24495 360.81 24498 557.21 24500 233.75 205.83 24505 326.70 283.09 24515 578.53 24516 567.08 24530 248.40 217.71 24535 404.77 358.82 24538 492.45 24545 613.10 24546 685.67 24560 212.69 182.27 24565 335.39 325.20 24566 473.22 24575 482.15 24576 224.36 192.62 24577 361.72 318.09 24579 550.83 24582 534.35 24586 714.98 24587 632.20 24600 241.76 211.33 24605 311.13 24615 470.01 24620 363.56 24635 443.91 24640 65.48 49.09 24650 170.56 151.67 24655 289.84 252.49 24665 429.95 24666 482.83

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

24670 189.56 165.76 24675 300.37 262.62 24685 430.64 24800 509.99 24802 583.96 24900 485.58 24920 428.96 24925 364.18 24930 509.39 24931 446.88 24935 613.49 24940 532.48 24999 Y25000 222.07 25001 226.19 25020 376.15 25023 728.72 25024 513.97 25025 796.94 25028 346.39 25031 219.27 25035 369.95 25040 369.51 25065 154.19 103.12 25066 218.84 25071 279.99 25073 326.89 25075 241.49 200.10 25076 340.89 25077 555.17 25078 744.11 25085 264.11 25100 210.76 25101 255.86 25105 296.68 25107 405.22 25109 353.94 25110 209.69 25111 210.85 25112 245.23 25115 499.09 25116 368.57 25118 250.46 25119 290.70 25120 315.46 25125 348.40 25126 391.72 25130 293.73 25135 326.55

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

25136 288.93 25145 332.76 25150 372.94 25151 382.56 25170 596.69 25210 309.03 25215 406.60 25230 285.03 25240 281.82 25246 97.83 50.03 25248 271.98 25250 310.00 25251 461.88 25260 414.38 25263 412.55 25265 475.62 25270 321.89 25272 350.90 25274 408.34 25275 394.68 25280 370.65 25290 286.86 25295 345.93 25300 448.04 25301 412.93 25310 407.28 25312 419.11 25315 473.84 25316 573.02 25320 648.36 25332 517.87 25335 493.41 25337 586.31 25350 443.91 25355 491.78 25360 431.32 25365 600.97 25370 564.80 25375 519.08 25390 489.80 25391 612.93 25392 590.84 25393 658.21 25394 457.31 25400 529.31 25405 684.53 25415 591.67 25420 717.99 25425 561.11

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

25426 654.07 25430 449.17 25431 460.47 25440 506.64 25441 533.53 25442 531.83 25443 455.94 25444 458.30 25445 419.89 25446 721.18 25447 545.56 25449 606.01 25450 324.02 25455 343.86 25490 440.66 25491 431.52 25492 473.12 25500 180.18 157.62 25505 327.15 286.84 25515 440.71 25520 340.92 323.87 25525 519.46 25526 628.90 25530 170.79 149.69 25535 321.20 285.95 25545 410.03 25560 183.84 158.94 25565 337.00 291.90 25574 443.91 25575 594.33 25600 215.20 196.58 25605 353.71 320.74 25606 436.59 25607 483.98 25608 543.05 25609 691.17 25622 199.18 175.67 25624 315.48 275.83 25628 474.13 25630 198.95 176.99 25635 291.44 262.84 25645 373.86 25650 210.62 188.66 25651 319.14 25652 410.03 25660 270.84 25670 398.36 25671 347.53 25675 286.63 249.85

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

25676 413.92 25680 288.60 25685 466.31 25690 299.06 25695 416.67 25800 465.43 25805 492.57 25810 571.43 25820 407.74 25825 502.06 25830 581.03 25900 468.18 25905 459.94 25907 387.00 25909 450.10 25915 601.08 25920 462.46 25922 338.95 25924 395.12 25927 511.06 25929 348.80 25931 488.33 25999 Y26010 177.20 85.85 26011 263.05 116.23 26020 285.72 26025 277.25 26030 322.58 26034 357.60 26035 566.17 26037 372.49 26040 181.79 26045 287.75 26055 252.53 196.14 26060 156.18 26070 199.81 26075 219.55 26080 257.56 26100 203.74 26105 211.33 26110 196.93 26111 265.39 26113 348.68 26115 339.98 210.01 26116 346.39 26117 474.96 26118 647.59 26121 367.29 26123 549.46

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

26125 180.63 26130 267.85 26135 348.68 26140 294.64 26145 337.69 26160 381.41 211.11 26170 237.13 26180 292.59 26185 322.60 26200 276.69 26205 369.41 26210 280.24 26215 345.39 26230 316.78 26235 323.95 26236 290.07 26250 378.83 26260 353.83 26262 325.28 26320 228.48 26341 60.61 48.02 26350 459.02 26352 494.26 26356 522.21 26357 563.12 26358 645.84 26370 487.41 26372 517.78 26373 510.21 26390 506.59 26392 563.28 26410 363.33 26412 432.42 26415 429.41 26416 440.18 26418 372.03 26420 456.05 26426 308.17 26428 455.97 26432 320.29 26433 340.66 26434 390.05 26437 402.25 26440 398.58 26442 604.33 26445 369.74 26449 440.62 26450 253.21 26455 251.66

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

26460 245.89 26471 383.90 26474 290.76 26476 383.47 26477 352.83 26478 375.79 26479 360.42 26480 483.98 26483 511.06 26485 503.76 26489 556.79 26490 477.66 26492 533.39 26494 466.18 26496 545.94 26497 501.04 26498 729.65 26499 502.56 26500 389.88 26502 443.72 26508 407.05 26510 348.21 26516 407.68 26517 477.40 26518 487.26 26520 405.83 26525 406.05 26530 329.01 26531 383.45 26535 259.04 26536 432.16 26540 424.00 26541 501.09 26542 410.67 26545 418.55 26546 644.01 26548 490.16 26550 947.87 26551 1,699.47 26553 1,725.57 26554 1,834.38 26555 797.45 26556 1,885.35 26560 339.86 26561 583.51 26562 787.91 26565 436.13 26567 439.79 26568 544.24

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

26580 895.79 26587 672.42 26590 900.56 26591 282.97 26593 387.37 26596 474.73 26600 192.08 174.79 26605 211.54 184.47 26607 287.98 26608 314.11 26615 378.21 26641 222.88 211.74 26645 276.22 247.87 26650 314.56 26665 411.63 26670 225.73 195.04 26675 284.44 277.49 26676 330.82 26685 377.52 26686 409.34 26700 214.75 192.18 26705 274.27 240.61 26706 278.45 26715 376.38 26720 128.66 115.79 26725 221.16 190.64 26727 309.53 26735 391.49 26740 144.88 142.91 26742 232.61 221.90 26746 488.56 26750 120.19 116.23 26755 205.82 171.04 26756 274.27 26765 329.22 26770 181.78 160.48 26775 251.60 218.15 26776 290.98 26785 359.66 26820 459.28 26841 439.17 26842 475.33 26843 430.93 26844 473.86 26850 419.40 26852 481.92 26860 364.24 26861 64.02 26862 463.19

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

26863 136.69 26910 467.95 26951 421.71 26952 416.21 26989 Y26990 419.65 26991 447.04 339.55 26992 638.74 27000 267.40 27001 353.71 27003 371.28 27005 476.19 27006 475.28 27025 603.71 27027 543.55 27030 618.60 27033 641.72 27035 584.94 27036 644.42 27040 225.05 125.48 27041 460.40 27043 309.98 27045 489.47 27047 295.73 240.89 27048 402.93 27049 808.35 27050 221.99 27052 339.74 27054 451.93 27057 553.62 27059 1,205.37 27060 272.78 27062 289.53 27065 342.04 27066 529.54 27067 623.57 27070 519.99 27071 610.58 27075 1,292.21 27076 1,071.90 27077 1,648.86 27078 676.90 27080 337.23 27086 151.89 108.00 27087 404.99 27090 548.08 27091 1,054.73 27093 129.63 44.25 27095 67.99 55.59

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

27096 104.40 52.39 27097 449.41 27098 399.43 27100 482.13 27105 505.37 27110 565.05 27111 524.47 27120 854.63 27122 727.11 27125 748.86 27130 894.93 27132 1,106.47 27134 1,265.58 27137 972.54 27138 1,010.54 27140 576.28 27146 843.41 27147 907.49 27151 1,017.92 27156 1,120.43 27158 814.14 27161 774.68 27165 903.17 27170 774.27 27175 389.17 27176 604.40 27177 711.33 27178 536.10 27179 601.24 27181 591.03 27185 409.86 27187 655.91 27197 81.63 27198 198.49 27202 340.34 27215 397.42 27216 611.73 27217 573.95 27218 792.82 27220 350.51 332.40 27222 641.95 27226 697.58 27227 1,097.77 27228 1,244.52 27230 314.79 298.94 27232 490.85 27235 600.51 27236 789.61 27238 303.80

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

27240 631.87 27244 812.97 27245 812.51 27246 254.58 244.13 27248 491.08 27250 126.57 27252 499.09 27253 622.26 27254 834.71 27256 199.18 148.59 27257 217.54 27258 732.84 27259 958.53 27266 383.47 27267 267.76 27268 314.72 27269 820.52 27275 120.65 27279 348.21 27280 811.33 27282 498.87 27284 942.01 27286 962.69 27290 992.77 27295 832.43 27299 Y27301 443.46 319.19 27303 421.94 27305 316.39 27306 226.42 27307 297.78 27310 481.92 27323 164.82 119.06 27324 252.98 27325 324.39 27326 301.14 27327 290.20 209.16 27328 367.60 27329 685.22 27330 256.49 27331 312.73 27332 391.96 27333 343.09 27334 434.63 27335 502.98 27337 276.10 27339 497.49 27340 244.51 27345 293.49

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

27347 347.76 27350 428.35 27355 398.36 27356 467.42 27357 499.37 27358 161.11 27360 567.08 27364 1,035.27 27365 1,093.76 27369 92.95 25.76 27372 390.80 252.49 27380 393.32 27381 507.74 27385 380.27 27386 549.23 27390 294.42 27391 377.52 27392 467.50 27393 336.08 27394 423.54 27395 578.30 27396 360.02 27397 535.11 27400 453.99 27403 422.17 27405 445.29 27407 492.90 27409 633.93 27412 1,020.00 27415 877.69 27418 546.02 27420 489.70 27422 489.70 27424 436.63 27425 296.02 27427 469.10 27428 734.67 27429 825.79 27430 487.41 27435 532.74 27437 404.72 27438 553.35 27440 491.07 27441 480.95 27442 532.54 27443 495.75 27445 799.93 27446 765.12 27447 894.47

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

27448 512.14 27450 670.79 27454 828.73 27455 617.91 27457 602.78 27465 786.86 27466 779.31 27468 757.55 27470 777.02 27472 833.80 27475 421.12 27477 466.98 27479 482.99 27485 443.00 27486 928.12 27487 1,161.41 27488 793.05 27495 744.28 27496 358.52 27497 355.38 27498 431.32 27499 428.76 27500 341.58 303.13 27501 331.96 315.01 27502 500.23 27503 527.48 27506 883.71 27507 641.95 27508 343.64 311.93 27509 426.74 27510 449.64 27511 658.66 27513 819.83 27514 639.43 27516 320.77 317.79 27517 413.45 27519 589.06 27520 210.85 186.23 27524 495.88 27530 197.58 177.21 27532 405.22 365.20 27535 593.41 27536 785.03 27538 313.19 280.89 27540 536.63 27550 341.12 304.01 27552 413.24 27556 578.53 27557 688.88

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

27558 763.88 27560 240.39 212.65 27562 301.28 27566 521.52 27570 99.36 27580 951.93 27590 525.42 27591 636.68 27592 449.87 27594 334.71 27596 474.59 27598 469.56 27599 Y27600 267.40 27601 293.50 27602 319.60 27603 349.13 246.33 27604 310.35 214.66 27605 216.88 117.66 27606 183.38 27607 401.79 27610 429.03 27612 373.86 27613 164.61 101.70 27614 351.55 261.98 27615 635.97 27616 839.98 27618 285.33 199.42 27619 305.18 27620 297.62 27625 375.92 27626 385.01 27630 342.84 232.75 27632 272.90 27634 447.81 27635 382.56 27637 457.68 27638 504.81 27640 548.77 27641 437.05 27645 758.34 27646 665.21 27647 543.75 27648 109.49 33.46 27650 432.70 27652 419.40 27654 450.58 27656 392.99 264.52 27658 244.74

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

27659 311.13 27664 230.38 27665 269.07 27675 323.03 27676 369.20 27680 279.31 27681 347.80 27685 435.90 293.66 27686 359.44 27687 299.22 27690 420.79 27691 491.30 27692 67.12 27695 303.49 27696 340.29 27698 419.88 27700 364.53 27702 569.38 27703 661.95 27704 365.74 27705 500.92 27707 263.51 27709 770.38 27712 706.00 27715 706.97 27720 576.70 27722 571.73 27724 835.40 27725 712.76 27726 614.08 27727 638.66 27730 352.45 27732 248.83 27734 397.76 27740 360.02 27742 396.07 27745 497.72 27750 225.96 200.54 27752 351.65 311.27 27756 380.27 27758 589.06 27759 659.80 27760 217.49 191.96 27762 312.04 272.09 27766 399.50 27767 184.98 27768 269.68 27769 481.23 27780 199.41 175.67

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

27781 281.60 250.07 27784 471.62 27786 205.36 179.85 27788 277.02 242.37 27792 427.89 27808 218.18 189.76 27810 306.55 266.58 27814 507.10 27816 212.23 182.27 27818 318.46 273.85 27822 565.94 27823 641.49 27824 206.50 191.74 27825 359.44 313.25 27826 554.95 27827 726.65 27828 867.00 27829 457.88 27830 232.45 220.83 27831 240.54 27832 465.54 27840 245.19 27842 322.12 27846 474.36 27848 526.56 27860 109.88 27870 676.75 27871 444.11 27880 602.11 27881 570.06 27882 393.78 27884 375.92 27886 432.47 27888 422.16 27889 426.74 27892 362.64 27893 371.76 27894 557.01 27899 Y28001 183.84 107.87 28002 292.81 202.52 28003 461.08 353.76 28005 380.50 28008 276.68 195.49 28010 141.01 138.74 28011 209.25 179.19 28020 345.14 230.86 28022 321.66 205.17 28024 300.83 190.86

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

28035 323.48 225.43 28039 314.34 220.29 28041 299.45 28043 263.05 166.42 28045 325.78 220.13 28046 472.51 28047 690.94 28050 254.85 174.40 28052 266.08 183.04 28054 224.92 146.94 28055 219.59 28060 344.10 227.18 28062 360.91 256.08 28070 319.85 229.35 28072 306.25 208.66 28080 323.06 230.24 28086 336.46 229.31 28088 292.81 179.84 28090 290.09 194.14 28092 256.82 168.95 28100 367.71 264.71 28102 311.44 28103 240.11 28104 325.61 236.03 28106 265.49 28107 333.80 217.57 28108 281.56 192.25 28110 284.56 182.39 28111 323.72 205.17 28112 323.03 197.90 28113 362.61 282.58 28114 640.87 532.76 28116 505.04 365.64 28118 364.31 263.42 28119 323.06 239.73 28120 448.04 315.67 28122 395.38 278.47 28124 316.62 210.01 28126 261.68 157.18 28130 420.33 28140 391.49 277.15 28150 262.87 175.75 28153 249.93 166.11 28160 275.87 169.50 28171 514.20 28173 451.21 28175 286.56 28190 168.27 84.75 28192 309.76 197.90

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

28193 340.04 231.70 28200 326.70 205.17 28202 353.72 269.52 28208 318.46 200.10 28210 345.84 265.49 28220 268.05 189.29 28222 304.88 220.88 28225 264.51 164.66 28226 304.43 254.29 28230 278.90 188.78 28232 248.10 161.68 28234 270.61 167.08 28238 428.66 324.28 28240 289.31 200.82 28250 369.73 270.31 28260 420.88 323.99 28261 600.81 512.20 28262 925.37 716.98 28264 575.49 501.66 28270 326.70 212.21 28272 242.02 158.03 28280 312.95 220.51 28285 354.86 240.17 28286 271.19 187.14 28288 362.58 271.14 28289 482.15 292.34 28291 468.30 297.78 28292 489.02 307.97 28295 631.87 344.73 28296 482.63 323.96 28297 537.27 381.93 28298 444.07 314.31 28299 607.08 367.35 28300 428.58 28302 440.02 28304 542.36 382.59 28305 418.77 28306 404.77 255.58 28307 419.40 292.79 28308 376.38 240.39 28309 557.43 28310 337.10 225.74 28312 307.24 200.15 28313 337.16 225.09 28315 309.03 205.65 28320 360.02 28322 487.03 370.33 28340 344.07 258.63 28341 413.23 307.72

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

28344 291.55 180.11 28345 321.78 227.81 28360 575.37 28400 162.32 143.53 28405 257.10 223.88 28406 347.07 28415 736.27 28420 840.21 28430 155.91 132.30 28435 224.19 204.28 28436 292.69 28445 693.00 28450 139.42 120.41 28455 154.41 146.69 28456 175.08 28465 415.98 28470 143.32 128.34 28475 168.27 143.09 28476 231.46 28485 358.52 28490 94.32 78.59 28495 117.45 94.22 28496 303.57 154.75 28505 438.65 315.45 28510 80.36 75.51 28515 106.91 89.81 28525 376.61 254.04 28530 76.47 64.94 28531 212.71 113.53 28540 123.75 107.78 28545 187.64 175.11 28546 332.18 215.29 28555 570.06 416.05 28570 96.31 91.49 28575 217.04 211.77 28576 237.35 28585 573.27 431.46 28600 122.62 117.05 28605 217.49 186.89 28606 257.56 28615 533.20 28635 113.30 84.09 28636 210.25 130.10 28645 434.30 307.97 28665 101.88 82.77 28666 115.06 28675 360.70 257.44 28705 752.35 28715 620.66

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

28725 514.20 28730 484.21 28735 479.59 28737 444.99 28740 540.75 397.68 28750 529.54 370.49 28755 325.20 220.97 28760 523.59 368.06 28800 352.34 28805 479.17 28810 282.97 28820 370.42 249.41 28825 354.63 234.22 28890 194.98 140.35 28899 Y29000 165.24 135.20 29010 159.56 101.48 29015 153.73 118.96 29035 119.82 93.59 29040 136.09 113.49 29044 165.70 109.60 29046 147.81 123.19 29049 53.42 45.42 29055 139.12 90.21 29058 60.31 57.29 29065 62.27 42.71 29075 56.32 38.96 29085 61.81 42.27 29105 53.34 35.44 29125 41.90 24.88 29126 49.91 30.60 29130 26.79 18.27 29131 33.43 21.13 29200 23.06 11.72 29240 20.20 11.89 29260 19.46 12.33 29305 155.29 103.44 29325 172.79 119.75 29345 88.14 63.18 29355 89.28 70.65 29358 95.91 68.01 29365 79.90 55.25 29405 52.66 37.42 29425 50.37 35.22 29435 71.25 54.12 29440 27.29 18.16 29445 85.39 64.72 29450 95.01 71.76 29505 55.63 31.92

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

29515 46.47 31.26 29520 20.99 11.93 29530 19.69 11.89 29540 18.77 11.45 29550 12.59 7.26 29580 36.31 17.39 29581 43.13 17.61 29584 42.15 10.09 29799 Y29800 301.53 29804 411.16 29805 300.39 29806 699.64 29807 684.07 29819 373.05 29820 351.42 29821 385.53 29822 374.32 29823 407.05 29824 438.88 29825 367.29 29826 176.53 29827 695.06 29828 598.68 29830 266.86 29834 299.02 29835 310.94 29836 337.77 29837 321.78 29838 360.70 29840 292.47 29843 297.96 29844 305.19 29845 366.18 29846 342.72 29847 344.92 29848 336.77 29850 379.20 29851 575.30 29855 516.49 29856 640.40 29860 405.79 29861 442.37 29862 513.50 29863 496.39 29866 661.25 29867 841.12 29868 989.79 29870 355.10 259.10

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

29871 339.29 29873 346.61 29874 342.25 29875 326.47 29876 432.93 29877 409.57 29879 436.36 29880 369.97 29881 356.46 29882 460.17 29883 557.93 29884 404.08 29885 462.99 29886 392.17 29887 492.45 29888 649.04 29889 807.24 29891 415.36 29892 357.93 29893 364.95 266.62 29894 316.56 29895 303.93 29897 331.50 29898 370.42 29899 615.46 29900 263.91 29901 313.54 29902 346.52 29904 373.42 29905 357.89 29906 446.43 29907 512.66 29914 633.35 29915 645.08 29916 666.21 29999 Y30000 139.94 77.36 30020 156.28 74.19 30100 88.16 44.70 30110 144.21 85.01 30115 270.93 30117 587.23 210.45 30118 470.01 30120 310.39 275.88 30124 174.39 30125 380.81 30130 252.29 30140 203.26 112.71 30150 470.44

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

30160 485.36 30200 72.80 36.54 30210 91.19 61.41 30220 189.41 81.53 30300 120.42 69.12 30310 132.10 30320 270.22 30420 376.22 Y30460 526.77 30462 934.38 Y30465 616.07 Y30520 413.01 Y30540 434.63 30545 498.87 30560 182.24 86.95 30580 413.15 336.32 30600 370.88 274.73 30620 376.56 30630 380.05 30801 144.69 87.61 30802 183.84 120.63 30901 65.79 35.66 30903 141.03 49.53 30905 187.40 66.26 30906 170.16 89.87 30915 351.55 30920 543.12 30930 78.53 30999 Y31000 118.36 66.48 31002 119.63 31020 295.41 219.98 31030 433.75 328.14 31032 361.09 31040 505.04 31050 297.32 31051 383.66 31075 479.59 31080 609.95 31081 746.67 31084 748.95 31085 796.97 31086 662.15 31087 636.54 31090 609.16 31200 359.76 31201 450.87 31205 597.76 31225 1,208.80

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

31230 1,273.29 31231 130.27 40.95 31233 169.64 85.19 31235 187.64 105.85 31237 166.21 100.82 31238 164.15 105.66 31239 389.44 31240 104.40 31241 301.26 31253 330.59 31254 190.56 154.31 31255 213.60 31256 118.82 31257 294.87 31259 312.27 31267 175.14 31276 250.00 31287 132.79 31288 154.53 31290 751.15 31291 800.14 31292 649.27 31293 666.52 31294 725.36 31298 2,425.38 164.64 31299 Y31300 826.52 31360 1,369.06 31365 1,690.03 31367 1,430.29 31368 1,438.51 31370 1,223.05 31375 1,161.40 31380 1,145.45 31382 1,381.11 31390 1,840.88 31395 1,978.50 31400 623.60 31420 525.90 31500 81.58 31502 23.12 31505 54.95 30.60 31510 133.58 79.91 31511 129.10 83.39 31512 124.63 82.18 31513 81.25 31515 125.98 68.68 31520 102.57 31525 163.01 100.38

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

31526 102.79 31527 120.16 31528 94.55 31529 105.77 31530 126.49 31531 139.20 31535 124.09 31536 138.28 31540 154.63 31541 172.85 31545 237.87 31546 323.19 31551 902.49 31552 912.47 31553 1,036.18 31554 1,047.60 31560 205.36 31561 224.82 31570 213.55 151.72 31571 163.46 31572 313.46 119.29 31573 174.22 94.00 31574 659.12 94.00 31575 75.78 42.05 31576 150.42 78.29 31577 147.60 85.45 31578 185.01 98.21 31579 119.74 75.29 31580 748.41 31584 907.98 31587 743.19 31590 534.52 31591 661.25 31592 1,069.97 31599 Y31600 203.99 31601 153.70 31603 156.93 31605 129.63 31610 496.86 31611 348.45 31612 52.50 32.20 31613 290.07 31614 482.15 31615 110.58 72.42 31622 156.59 83.21 31623 171.93 83.87 31624 162.55 84.97 31625 219.55 98.84

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

31626 357.82 125.92 31627 865.85 61.64 31628 233.06 111.39 31629 188.52 118.43 31630 130.72 31631 150.64 31632 41.44 31.04 31633 51.97 40.28 31635 183.84 111.39 31636 145.38 31637 47.44 31638 165.07 31640 165.29 31641 169.19 31643 113.42 31645 169.87 92.68 31646 116.56 94.74 31652 572.17 140.67 31653 605.55 155.86 31654 79.51 42.71 31717 94.24 73.66 31720 32.71 31725 53.57 31730 783.89 95.10 31750 905.00 31755 1,032.80 31760 863.88 31766 1,043.82 31770 782.28 31775 803.75 31780 750.75 31781 890.54 31785 669.93 31786 955.59 31800 472.07 31805 511.91 31820 283.20 205.83 31825 392.86 301.80 31830 271.59 224.91 31899 Y32035 428.16 32036 494.89 32096 531.14 32097 530.91 32098 502.98 32100 535.49 32110 971.62 32120 576.24 32124 611.50

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

32140 585.13 32141 1,008.48 32150 663.47 32151 622.71 32160 525.42 32200 702.89 32215 510.62 32220 1,048.32 32225 656.60 32310 602.80 32320 1,056.10 32400 100.96 55.03 32405 97.10 57.46 32440 1,034.12 32442 1,795.97 32445 2,282.13 32480 976.89 32482 1,044.65 32484 946.67 32486 1,509.04 32488 1,401.09 32501 161.86 32503 1,188.66 32504 1,279.04 32505 615.39 32506 103.71 32507 103.48 32540 1,137.60 32550 487.41 131.64 32551 103.71 32552 120.42 100.16 32553 340.89 114.03 32554 195.59 56.79 32555 225.55 70.88 32556 382.82 78.15 32557 367.45 96.64 32560 164.15 49.53 32561 60.90 43.37 32562 54.49 38.74 32601 203.76 32604 318.23 32606 305.63 32607 203.53 32608 249.77 32609 170.56 32650 439.34 32651 723.45 32652 1,098.22 32653 700.78

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

32654 762.14 32655 631.19 32656 528.62 32658 470.24 32659 483.06 32661 524.50 32662 589.52 32663 925.37 32664 541.41 32665 716.89 32666 574.87 32667 103.94 32668 103.94 32669 888.06 32670 1,028.32 32671 1,150.59 32672 895.32 32673 780.22 32674 142.86 32800 556.78 32810 593.18 32815 1,790.15 32820 878.67 32851 1,773.02 32852 1,946.26 32853 2,120.06 32854 2,312.60 32900 935.91 32905 861.96 32906 1,029.57 32940 727.33 32960 81.81 57.94 32994 3,871.07 314.85 Y32997 225.28 32998 1,769.83 282.21 32999 Y33010 71.20 33011 74.44 33015 338.14 33020 581.05 33025 527.02 33030 1,094.59 33031 1,345.87 33050 591.04 33120 1,388.98 33130 821.08 33140 935.31 33141 87.00 33202 512.37

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

33203 474.06 33206 301.06 33207 319.83 33208 346.84 33210 108.98 33211 108.99 33212 213.14 33213 222.99 33214 306.81 33215 206.50 33216 246.34 33217 233.05 33218 257.56 33220 230.63 33221 239.01 33222 224.59 33223 271.75 33224 343.87 33225 312.96 33226 330.82 33227 224.82 33228 234.89 33229 240.36 33230 244.79 33231 254.78 33233 152.93 33234 322.81 33235 424.00 33236 486.82 33237 522.54 33238 612.24 33240 233.09 33241 142.86 33243 908.66 33244 574.41 33249 610.58 33250 873.27 33251 962.29 33254 877.02 33255 975.69 33256 1,157.66 33257 384.85 33258 420.01 33259 558.84 33261 1,043.39 33262 247.71 33263 258.02 33264 269.23 33265 840.71

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

33266 1,097.59 33270 377.06 33271 303.35 33272 229.10 33273 229.17 33274 325.32 33275 345.70 33285 3,344.12 57.01 33286 87.00 55.91 33300 1,625.93 33305 2,637.49 33310 776.33 33315 1,267.41 33320 658.02 33321 707.44 33322 860.70 33330 885.37 33335 1,225.55 33361 903.85 33362 937.87 33363 984.94 33364 928.15 33365 1,021.82 33366 1,216.64 33367 358.36 33368 430.34 33369 568.01 33390 1,279.32 33391 1,453.43 33404 1,039.50 33405 1,503.91 33406 1,904.78 33410 1,686.14 33411 2,228.73 33412 2,085.18 33413 2,024.67 33414 1,419.88 33415 1,345.71 33416 1,341.59 33417 1,102.57 33420 848.25 33422 1,000.11 33425 1,809.54 33426 1,579.00 33427 1,620.89 33430 1,855.79 33440 2,245.90 33460 1,519.35 33463 2,049.24

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

33464 1,618.83 33465 1,829.46 33468 1,480.58 33470 804.34 33471 930.08 33474 1,448.96 33475 1,547.63 33476 989.25 33477 909.35 33478 1,038.47 33496 1,040.41 33500 972.99 33501 670.42 33502 837.54 33503 778.14 33504 872.67 33505 1,291.58 33506 1,327.38 33507 1,138.06 33508 10.76 33510 1,280.92 33511 1,406.84 33512 1,601.89 33513 1,597.43 33514 1,686.93 33516 1,620.10 33517 123.86 33518 273.13 33519 361.27 33521 433.38 33522 486.73 33523 493.36 33530 349.13 33533 1,238.34 33534 1,456.52 33535 1,625.01 33536 1,700.66 33542 1,744.75 33545 2,045.35 33548 1,962.93 33572 152.70 33600 1,066.35 33602 972.14 33606 1,181.33 33608 1,196.44 33610 1,087.35 33611 1,275.16 33612 1,333.12 33615 1,175.39

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

33617 1,401.57 33619 1,817.10 33620 1,092.27 33621 564.36 33622 2,219.51 33641 1,084.72 33645 1,142.18 33647 1,193.92 33660 1,157.98 33665 1,191.20 33670 1,275.77 33675 1,289.85 33676 1,380.56 33677 1,252.59 33681 1,214.07 33684 1,235.74 33688 1,119.66 33690 796.25 33692 1,302.90 33694 1,261.15 33697 1,367.46 33702 920.93 33710 1,321.41 33720 1,022.67 33722 966.03 33724 994.43 33726 1,263.43 33730 1,295.04 33732 1,031.26 33735 763.18 33736 907.06 33737 792.91 33750 838.61 33755 818.16 33762 793.51 33764 874.09 33766 808.48 33767 945.75 33768 259.68 33770 1,305.57 33771 1,360.92 33774 1,126.11 33775 1,210.12 33776 1,278.18 33777 1,174.21 33778 1,563.66 33779 1,452.50 33780 1,521.53 33781 1,445.60

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

33782 1,896.42 33783 2,048.86 33786 1,515.81 33788 1,019.01 33800 637.55 33802 720.02 33803 684.40 33813 757.08 33814 982.92 33820 635.99 33822 678.12 33824 757.13 33840 822.81 33845 867.91 33851 719.91 33852 902.72 33853 1,187.28 33860 2,133.72 33863 2,092.28 33864 2,143.33 33866 683.39 33870 1,679.73 33875 1,715.32 33877 2,407.30 33880 1,190.72 33881 1,021.99 33883 739.93 33884 266.94 33886 582.97 33889 523.13 33891 582.37 33910 1,585.18 33915 899.66 33916 1,605.63 33917 963.61 33920 1,204.45 33922 896.29 33924 184.98 33925 1,076.14 33926 1,652.81 33935 2,461.10 33945 3,235.84 33946 205.82 33947 228.25 33948 158.20 33949 153.85 33951 283.43 33952 284.57 33953 316.85

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

33954 317.77 33955 555.41 33956 554.49 33957 120.28 33958 122.94 33959 156.59 33962 135.70 33963 288.74 33964 295.64 33965 123.17 33966 158.20 33967 173.08 33968 22.44 33969 182.69 33970 235.35 33971 469.56 33973 302.71 33974 535.90 33975 868.83 33976 1,059.30 33977 747.49 33978 890.58 33979 1,297.40 33981 511.86 33982 465.33 33983 603.00 33984 188.88 33985 343.87 33986 329.98 33987 120.31 33988 492.03 33989 284.39 33990 283.89 33991 371.05 33992 132.79 33993 116.53 33999 Y34001 583.17 34051 617.83 34101 396.52 34111 398.13 34151 924.92 34201 681.78 34203 630.27 34401 970.70 34421 488.56 34451 940.71 34471 708.21 34490 424.91

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

34501 542.98 34502 1,022.90 34510 722.14 34520 630.37 34530 561.51 34701 820.75 34702 1,286.95 34703 978.26 34704 1,624.44 34705 1,016.26 34706 1,614.83 34707 804.69 34708 1,295.10 34709 214.75 34710 560.91 34711 210.63 34712 474.22 34713 85.39 34714 179.49 34715 210.40 34716 261.40 34808 135.40 34812 161.16 34813 153.30 34820 253.01 34830 1,163.01 34831 1,147.03 34832 1,147.03 34833 298.59 34834 144.46 35001 702.89 35002 745.43 35005 691.10 35011 652.84 35013 813.22 35021 748.21 35022 871.54 35045 640.87 35081 1,099.11 35082 1,450.79 35091 1,186.37 35092 1,725.35 35102 1,247.95 35103 1,460.97 35111 871.34 35112 1,103.31 35121 1,072.19 35122 1,342.39 35131 837.03

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

35132 983.76 35141 731.92 35142 881.65 35151 821.44 35152 846.48 35180 547.91 35182 1,091.24 35184 628.86 35188 548.50 35189 921.72 35190 504.35 35201 624.55 35206 519.01 35207 498.17 35211 916.67 35216 1,367.00 35221 972.54 35226 552.89 35231 753.51 35236 664.38 35241 851.35 35246 1,014.60 35251 1,109.19 35256 679.72 35261 646.07 35266 562.45 35271 916.22 35276 865.59 35281 1,046.72 35286 605.43 35301 750.69 35302 744.05 35303 823.04 35304 847.54 35305 772.44 35306 285.41 35311 923.30 35321 578.18 35331 969.56 35341 889.87 35351 849.14 35355 684.07 35361 921.92 35363 1,037.33 35371 542.59 35372 649.50 35390 99.11 35400 98.90 35500 212.69

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

35501 910.69 35506 838.84 35508 852.40 35509 856.92 35510 745.45 35511 725.74 35512 731.27 35515 805.92 35516 791.08 35518 753.19 35521 825.40 35522 750.77 35523 807.10 35525 757.33 35526 1,038.11 35531 1,220.30 35533 912.26 35535 1,130.02 35536 1,136.76 35537 1,262.05 35538 1,412.71 35539 1,327.24 35540 1,548.22 35556 927.66 35558 800.82 35560 1,032.01 35563 812.61 35565 865.28 35566 1,107.15 35570 996.59 35571 877.98 35572 230.08 35583 957.88 35585 1,109.67 35587 904.54 35600 170.10 35601 854.16 35606 778.62 35612 685.67 35616 694.82 35621 726.88 35623 866.08 35626 1,053.35 35631 1,229.86 35632 975.69 35633 1,195.87 35634 954.81 35636 965.64 35637 1,087.83

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

35638 1,165.76 35642 616.50 35645 641.61 35646 1,138.75 35647 1,010.82 35650 678.23 35654 908.20 35656 717.50 35661 719.56 35663 812.56 35665 778.40 35666 838.84 35671 725.27 35681 48.06 35682 233.98 35683 246.77 35685 131.87 35686 106.23 35691 573.32 35693 523.12 35694 623.57 35695 621.37 35697 98.44 35700 101.19 35701 375.46 35721 301.97 35741 331.85 35761 260.53 35800 451.86 35820 1,335.18 35840 594.73 35860 381.13 35870 783.07 35875 394.92 35876 627.75 35879 614.25 35881 674.91 35883 760.53 35884 751.55 35901 320.99 35903 373.86 35905 1,017.24 35907 1,205.02 36000 17.63 5.94 36002 102.79 66.92 36005 48.33 30.82 36010 118.61 70.22 36011 153.73 99.94 36012 174.61 110.73

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

36013 128.70 77.49 36014 150.27 96.42 36015 165.92 109.63 36100 141.97 104.23 36140 100.18 57.68 36160 100.09 80.29 36200 148.86 89.15 36215 673.08 135.60 36216 725.28 174.57 36217 1,216.13 209.35 36218 128.41 33.24 36221 671.02 127.68 36222 795.11 180.95 36223 1,006.19 202.08 36224 1,300.27 230.70 36225 969.33 201.64 36226 1,231.24 227.40 36227 165.52 75.07 36228 861.73 154.75 36245 802.14 151.67 36246 544.88 162.68 36247 975.28 193.28 36248 94.09 31.26 36251 897.90 166.20 36252 971.39 230.92 36253 1,433.16 228.28 36254 1,343.78 285.19 36260 430.41 36261 238.50 36262 191.84 36299 Y36420 32.52 36425 26.56 36430 22.67 36440 33.21 36450 82.57 36455 79.37 36460 220.42 Y36465 999.69 80.39 36466 1,045.99 102.07 36468 28.64 Y36470 73.95 25.58 Y36471 122.60 50.65 Y36475 929.50 178.53 36476 195.74 86.51 36478 734.90 177.43 36479 156.86 86.95 36481 337.67 225.60 36500 121.34

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

36510 53.57 33.90 36511 61.53 36512 60.26 36513 57.51 36514 81.75 60.76 36516 48.58 46.15 36522 86.62 61.42 36555 117.57 54.15 36556 112.70 58.79 36557 277.22 202.08 36558 269.21 165.98 36560 332.17 243.03 36561 320.69 214.41 36563 335.64 233.34 36565 314.78 211.99 36566 306.06 246.68 36568 74.56 36569 76.28 36570 229.96 220.44 36571 289.73 198.12 36572 272.44 58.34 36573 256.41 53.93 36575 34.80 23.39 36576 212.65 123.23 36578 180.25 132.10 36580 67.12 42.27 36581 187.14 116.89 36582 273.37 184.47 36583 251.06 217.96 36584 69.58 39.82 36585 213.58 181.83 36589 107.83 87.17 36590 145.15 120.85 36593 20.38 36595 180.18 116.67 36596 38.87 28.18 36597 60.52 38.96 36598 75.55 23.33 36600 19.92 9.91 36620 29.30 36625 69.83 36640 73.33 36660 45.33 36680 38.69 36800 80.82 36810 138.51 36815 88.63 36818 460.40 36819 485.12

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

36820 486.50 36821 440.71 36825 527.71 36830 442.77 36831 330.78 36832 462.14 36833 522.45 36835 266.48 36838 690.50 36860 123.88 80.53 36861 94.14 36901 394.28 107.43 36902 826.24 153.65 36903 3,484.46 203.18 36904 1,111.40 243.63 36905 1,529.32 284.19 36906 4,238.91 338.13 36907 467.72 93.78 36908 1,557.25 132.74 36909 1,258.71 128.56 37140 1,038.92 37145 1,035.66 37160 898.36 37180 1,005.44 37181 1,315.59 37182 544.65 37183 411.98 239.51 37184 433.01 285.51 37185 160.34 106.77 37186 244.51 156.30 37187 401.03 250.95 37188 287.28 176.77 37191 1,601.43 142.87 37192 869.04 240.42 37193 1,008.71 223.44 37195 167.54 37197 993.60 193.28 37200 144.23 37211 256.64 37212 224.59 37213 154.76 37214 81.73 37215 668.73 37216 649.29 37217 704.09 37218 474.53 37220 1,851.55 257.12 37221 2,019.51 317.65 37222 621.93 119.31

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

37223 1,433.39 136.48 37224 1,972.52 284.85 37225 2,127.32 387.66 37226 1,960.85 334.16 37227 1,750.63 466.02 37228 2,092.19 348.03 37229 2,475.21 452.60 37230 1,907.59 448.85 37231 2,370.79 487.82 37232 728.89 128.78 37233 881.96 209.79 37234 976.10 193.90 37235 2,262.73 272.56 37236 2,094.74 284.85 37237 909.89 136.26 37238 1,407.55 194.16 37239 1,130.65 97.30 37241 1,557.49 283.09 37242 2,618.88 305.11 37243 3,305.42 359.48 37244 2,319.37 425.08 37246 1,357.16 222.78 37247 543.18 112.84 37248 970.25 190.64 37249 383.93 92.90 37252 819.15 58.34 37253 128.21 46.89 37500 385.63 37501 Y37565 472.96 37600 457.46 37605 502.13 37606 341.51 37607 247.94 37609 203.07 130.76 37615 347.07 37616 733.75 37617 889.20 37618 254.35 37619 1,062.89 37650 302.89 37660 833.05 37700 161.86 37718 285.03 37722 314.11 37735 384.25 37760 386.86 37761 329.30 37765 409.22 285.29

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

37766 496.60 348.47 37780 154.53 37785 230.54 164.00 37799 Y38100 765.80 38101 767.86 38102 175.14 38115 847.99 38120 698.72 38129 Y38200 74.98 38206 54.72 38220 107.83 43.81 38221 100.50 44.03 38222 111.49 49.31 38232 118.25 38240 105.13 38241 95.30 38242 72.73 38300 188.61 128.78 38305 292.85 38308 297.62 38380 337.77 38381 531.37 38382 394.30 38500 219.32 162.02 38505 81.50 44.47 38510 342.27 265.92 38520 306.78 38525 289.38 38530 369.28 38531 288.46 38542 340.89 38550 322.76 38555 609.63 38562 451.25 38564 467.72 38570 337.23 38571 438.65 38572 611.27 38573 793.03 38589 Y38700 513.72 38720 883.71 38724 953.99 38740 461.54 38745 582.42 38746 142.63 38747 177.89

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

38760 557.93 38765 861.50 38770 535.95 38780 681.78 38790 54.72 38792 28.03 21.13 38794 182.69 38900 91.58 38999 Y39000 317.89 39010 520.38 39200 559.35 39220 750.46 39401 205.13 39402 268.55 39499 Y39501 564.34 39503 3,978.74 39540 557.14 39541 623.86 39545 588.60 39560 530.68 39561 731.86 39599 Y40490 82.19 46.01 40500 306.45 231.36 40510 319.60 224.32 40520 302.42 229.18 40525 363.33 40527 366.72 40530 356.00 254.70 40650 298.08 191.74 40652 326.70 223.88 40654 377.52 269.66 40700 665.76 40701 689.19 40702 577.74 40720 680.18 40761 672.90 40799 Y40800 139.20 81.89 40801 202.26 148.94 40804 117.63 72.64 40805 209.61 148.69 40808 122.94 67.36 40810 137.13 80.13 40812 190.02 123.94 40814 248.34 195.08 40816 264.20 198.56

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

40818 240.39 174.13 40819 207.19 149.47 40820 172.62 108.09 40830 171.91 106.26 40831 227.80 144.19 40840 539.38 398.22 40842 521.98 389.64 40843 672.90 544.91 40844 898.59 700.25 40845 966.35 775.97 40899 Y41000 101.02 75.28 41005 141.22 81.70 41006 233.52 162.02 41007 215.46 171.17 41008 253.67 170.38 41009 259.85 197.35 41010 135.07 68.46 41015 276.10 209.79 41016 293.27 221.46 41017 297.85 223.66 41018 337.23 261.08 41019 315.25 41100 113.10 67.58 41105 109.44 74.58 41108 100.05 56.79 41110 135.57 87.55 41112 215.11 169.32 41113 235.49 179.11 41114 397.07 41115 164.15 91.80 41116 218.64 138.90 41120 706.51 41130 872.03 41135 1,405.58 41140 1,442.55 41145 1,790.38 41150 1,454.23 41153 1,576.25 41155 1,997.04 41250 179.49 97.30 41251 150.34 119.12 41252 209.02 132.30 41510 273.14 41512 414.66 41520 231.46 156.52 41599 Y41800 189.79 95.76 41805 161.21 118.28

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

41806 221.61 175.54 41820 145.08 41821 73.84 41822 175.68 117.10 41823 267.76 211.42 41825 136.24 78.53 41826 203.36 136.76 41827 266.67 197.59 41828 183.16 137.24 41830 261.45 177.65 41850 15.60 41872 248.31 169.28 41874 255.95 163.12 41899 Y42000 101.65 65.38 42100 97.99 69.12 42104 141.94 87.61 42106 171.20 119.75 42107 280.06 221.94 42120 667.13 42140 160.83 97.23 42145 457.65 42160 144.20 93.15 42180 161.86 116.01 42182 211.54 161.36 42200 600.67 42205 549.55 42210 726.20 42215 474.13 42220 308.59 42225 545.30 42226 579.68 42227 504.38 42235 476.65 42260 505.32 418.90 42280 113.47 70.66 42281 139.66 104.56 42299 Y42300 133.13 101.22 42305 281.82 42310 102.56 86.74 42320 154.62 110.64 42330 147.98 104.56 42335 255.04 162.46 42340 287.32 214.30 42400 67.54 34.12 42405 190.29 144.19 42408 279.46 227.64 42409 226.46 141.11

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

42410 385.36 42415 693.92 42420 779.77 42425 517.44 42426 834.97 42440 270.84 42450 279.88 237.42 42500 263.71 216.60 42505 336.39 287.12 42507 310.00 42509 483.12 42510 399.62 42550 50.58 40.51 42600 296.25 229.54 42650 52.89 36.54 42660 69.86 60.09 42665 190.55 129.91 42699 Y42700 124.31 85.41 42720 298.31 247.87 42725 538.01 42800 103.02 71.10 42804 129.35 72.20 42806 144.69 83.87 42808 149.27 102.80 42809 131.64 77.71 42810 253.21 180.51 42815 361.50 42820 190.02 42821 197.35 42825 171.93 42826 165.07 42830 136.22 42831 147.21 42835 126.60 42836 157.74 42842 665.30 42844 871.54 42845 1,441.69 42860 116.55 42870 389.43 42890 944.83 42892 1,186.73 42894 1,569.38 42900 201.08 42950 532.97 42953 639.20 42955 455.54 42960 110.58

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

42961 274.27 42962 339.52 42970 269.07 42971 283.28 42972 317.10 42999 Y43020 342.71 43030 341.58 43045 768.10 43100 372.03 43101 684.30 43107 1,744.97 43108 2,719.66 43112 1,727.96 43113 2,523.30 43116 3,060.98 43117 1,586.35 43118 2,219.02 43121 1,680.95 43122 1,495.03 43123 2,615.09 43124 2,238.91 43130 465.19 43135 873.07 43180 360.58 43191 95.43 43192 94.03 43193 111.72 43194 111.77 43195 121.80 43196 122.29 43197 122.25 52.83 43198 126.73 64.12 43200 93.92 55.69 43201 98.59 67.56 43202 105.03 66.04 43204 108.29 43205 99.97 43210 264.35 43211 139.05 43212 126.83 43213 723.50 175.34 43214 123.06 43215 120.85 91.14 43216 134.12 87.05 43217 130.49 106.29 43220 99.61 75.51 43226 100.33 83.65 43227 151.10 106.55

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

43229 437.05 127.02 43231 148.63 102.36 43232 203.41 128.12 43233 152.93 43235 136.70 78.81 43236 166.25 89.15 43237 131.18 43238 155.91 43239 233.29 89.15 43240 263.28 43241 95.47 43242 176.05 43243 158.88 43244 164.15 43245 147.06 112.93 43246 134.16 43247 156.76 114.03 43248 147.06 106.99 43249 135.78 98.84 43250 148.12 109.41 43251 170.64 126.36 43253 176.28 43254 181.09 43255 220.19 129.22 43257 155.68 43259 151.56 43260 216.35 43261 227.11 43262 239.47 43263 233.27 43264 244.05 43265 290.52 43266 146.29 43270 449.87 144.63 43273 79.90 43274 310.44 43275 252.75 43276 323.26 43277 253.89 43278 282.23 43279 856.01 43280 717.27 43281 1,025.19 43282 1,152.71 43283 100.09 43286 2,170.65 43287 2,384.18 43288 2,585.57 43289 Y

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

43300 402.09 43305 716.58 43310 947.91 43312 1,056.33 43313 1,815.08 43314 1,887.84 43320 890.32 43325 857.97 43327 543.96 43328 703.75 43330 822.41 43331 790.75 43332 769.01 43333 837.46 43334 804.36 43335 777.75 43336 936.84 43337 958.15 43338 76.93 43340 801.18 43341 874.46 43351 776.57 43352 687.84 43360 1,459.74 43361 1,628.08 43400 912.07 43401 912.26 43405 849.24 43410 674.00 43415 1,547.01 43420 600.30 43425 936.62 43450 107.60 50.85 43453 91.48 55.03 43499 Y43500 520.61 43501 893.78 43502 941.30 43510 593.69 43520 456.73 43605 539.20 43610 652.71 43611 814.34 43620 1,251.12 43621 1,510.77 43622 1,464.51 43631 963.61 43632 1,352.58 43633 1,277.71

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

43634 1,355.76 43635 74.63 43640 782.75 43641 699.17 43644 1,150.19 43645 1,140.58 43647 494.03 43651 432.24 43652 490.68 43653 380.50 43659 Y43752 26.79 43753 14.42 43754 59.42 23.47 43755 81.59 39.03 43756 131.53 33.01 43757 201.29 49.09 43761 78.53 65.60 43762 144.46 23.99 43763 214.52 53.05 43770 690.56 43771 786.05 Y43772 585.07 Y43773 740.14 Y43774 591.45 Y43775 740.85 43800 617.91 43810 651.07 43820 892.18 43825 751.55 43830 464.75 43831 396.47 43832 688.65 43840 902.94 43842 605.35 43843 744.67 43846 1,076.25 43847 1,097.19 43848 1,232.04 43850 945.55 43855 980.61 43860 1,085.86 43865 992.04 43870 471.62 43880 1,057.24 43886 215.27 43887 193.60 43888 270.61 Y43999 Y

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

44005 727.11 44010 554.04 44015 94.55 44020 646.75 44021 647.90 44025 653.39 44050 620.88 44055 993.60 44100 66.18 44110 563.88 44111 652.71 44120 812.28 44121 161.17 44125 782.97 44126 1,633.03 44127 1,899.97 44128 162.55 44130 872.72 44135 1,769.16 44139 80.36 44140 891.03 44141 1,211.55 44143 1,105.09 44144 1,175.38 44145 1,100.06 44146 1,404.77 44147 1,242.67 44150 1,238.34 44151 1,434.54 44155 1,377.07 44156 1,350.09 44157 1,331.77 44158 1,494.75 44160 824.41 44180 610.58 44186 431.78 44187 729.86 44188 811.82 44202 918.74 44203 159.34 44204 1,021.30 44205 887.37 44206 1,160.50 44207 1,206.05 44208 1,314.34 44210 1,179.04 44211 1,404.70 44212 1,354.41 44213 124.77

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

44227 1,105.09 44238 Y44300 559.53 44310 692.31 44312 392.17 44314 666.21 44316 875.80 44320 797.86 44322 638.22 44340 412.78 44345 696.89 44346 784.58 44360 96.15 44361 106.46 44363 128.66 44364 133.13 44365 115.21 44366 160.72 44369 164.61 44370 178.57 44372 160.72 44373 128.66 44376 190.48 44377 200.78 44378 250.77 44379 257.21 44380 53.22 36.10 44381 43.98 41.78 44382 63.98 47.11 44384 48.06 44385 128.21 46.01 44386 116.18 57.23 44388 192.77 100.38 44389 173.19 110.51 44390 191.60 138.70 44391 197.48 150.57 44392 185.61 135.27 44394 217.23 153.80 44401 153.40 145.73 44402 178.74 44403 207.73 44404 197.48 114.20 44405 215.86 120.16 44406 176.62 44407 188.38 44408 176.62 44500 12.82 44602 937.74 44603 1,076.25

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

44604 703.07 44605 864.93 44615 712.92 44620 575.55 44625 673.77 44626 1,062.97 44640 930.64 44650 958.57 44660 886.00 44661 1,029.77 44680 623.15 44700 667.59 44701 113.10 44799 Y44800 508.93 44820 539.01 44850 480.93 44899 Y44900 492.01 44950 426.29 44955 56.09 44960 581.74 44970 398.81 44979 Y45000 280.91 45005 174.12 107.94 45020 379.58 45100 197.80 45108 225.43 45110 1,220.94 45111 720.70 45112 1,236.73 45113 1,169.50 45114 1,055.25 45116 919.16 45119 1,250.07 45120 1,054.04 45121 1,073.80 45123 743.83 45126 1,844.34 45130 720.24 45135 798.62 45136 1,067.86 45150 232.40 45160 631.00 45171 399.04 45172 518.38 45190 445.27 45300 79.44 32.73

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

45303 63.52 57.91 45305 67.83 46.45 45307 72.15 63.27 45308 55.40 52.63 45309 115.39 59.99 45315 73.94 71.08 45317 120.76 73.24 45320 119.29 70.30 45321 63.81 45327 75.28 45330 111.72 35.88 45331 70.63 45.79 45332 102.26 67.36 45333 101.93 60.10 45334 128.18 75.73 45335 85.90 42.49 45337 77.15 45338 132.50 77.05 45340 106.78 49.75 45341 82.65 45342 113.74 45346 99.55 94.57 45347 103.48 45349 84.09 45350 84.10 66.21 45378 210.17 119.09 45379 271.52 154.09 45380 269.92 129.22 45381 263.74 129.22 45382 462.92 166.86 45384 300.60 147.05 45385 283.43 164.00 45386 248.35 136.48 45388 58.16 55.25 45389 194.37 45390 222.99 45391 167.92 45392 208.11 45393 169.64 45395 1,307.93 45397 1,422.86 45398 287.63 151.45 45399 Y45400 731.92 45402 937.90 45499 Y45500 320.72 45505 392.86 45520 95.06 25.94

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

45540 700.78 45541 600.31 45550 970.93 45560 452.61 45562 742.91 45563 1,092.73 45800 735.65 45805 852.39 45820 640.87 45825 852.40 45900 125.05 45905 111.49 45910 126.60 45915 222.07 145.07 45990 70.74 45999 Y46020 183.15 149.47 46030 92.49 57.01 46040 354.86 265.04 46045 288.24 46050 136.91 62.08 46060 316.62 46070 129.20 46080 169.64 101.04 46083 119.96 67.80 46200 297.62 208.03 46220 130.26 79.22 46221 177.89 121.29 46230 185.67 109.85 46250 307.70 200.98 46255 336.77 225.64 46257 268.71 46258 286.90 46260 315.71 46261 320.93 46262 338.79 46270 339.06 250.29 46275 357.83 263.94 46280 312.50 46285 339.38 277.72 46288 363.10 46320 124.31 70.88 46500 122.72 79.31 46505 191.16 152.55 46600 61.40 25.98 46601 43.38 41.21 46604 57.74 41.83 46606 65.04 47.77 46607 59.13 56.17

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

46608 64.50 56.05 46610 52.78 50.14 46611 116.97 51.29 46612 159.19 63.56 46614 85.39 41.17 46615 87.41 60.37 46700 401.53 46705 307.75 46706 111.65 46707 301.06 46710 648.02 46712 1,189.18 46715 346.25 46716 708.44 46730 1,282.24 46735 1,180.11 46740 1,278.85 46742 1,648.60 46744 1,961.21 46746 2,238.37 46748 2,442.58 46750 494.51 46751 366.44 46753 376.22 46754 176.90 149.57 46760 644.41 46761 544.57 46900 154.76 86.29 46910 169.19 84.97 46916 145.54 91.67 46917 95.15 85.11 46922 183.15 86.29 46924 345.70 114.69 91.67 254.03 46930 137.82 94.22 46940 138.88 94.29 46942 130.38 85.02 46945 207.88 143.97 46946 209.94 143.09 46947 253.89 46999 Y47000 199.64 56.79 47001 69.14 47010 805.18 47011 12.70 47015 678.10 47100 560.90 47120 1,551.98 47122 2,281.84 47125 2,049.93

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

47130 2,202.40 47135 3,578.33 47300 726.39 47350 908.89 47360 1,247.26 47361 2,014.67 47362 964.29 47370 800.82 47371 730.48 47379 Y47380 924.21 47381 886.55 47382 796.21 474.17 47383 273.55 259.87 47399 Y47400 1,250.62 47420 890.58 47425 795.87 47460 738.95 47480 581.96 47490 218.87 47531 222.33 45.35 47532 531.83 136.04 47533 806.78 170.38 47534 940.03 237.97 47535 651.33 126.58 47536 448.49 84.53 47537 253.42 61.42 47538 2,788.49 151.45 47539 3,092.75 273.63 47540 3,145.63 282.43 47541 712.04 213.97 47542 318.68 86.73 47543 531.23 92.46 47544 538.54 103.31 47550 109.89 47552 199.16 47553 197.82 47554 283.02 47555 217.60 47556 246.51 47562 436.59 47563 475.05 47564 738.79 47570 472.99 47579 Y47600 709.03 47605 746.34 47610 833.11

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

47612 736.78 47620 879.24 47700 666.58 47701 1,047.21 47711 998.87 47712 1,227.78 47715 850.44 47720 709.91 47721 789.17 47740 838.70 47741 859.29 47760 1,446.79 47765 1,762.30 47780 1,645.85 47785 2,162.11 47800 1,011.93 47801 669.54 47802 888.83 47900 910.04 47999 Y48000 1,197.79 48001 1,472.96 48020 686.17 48100 591.35 48102 348.45 152.99 48105 1,887.38 48120 710.22 48140 1,040.53 48145 1,041.84 48146 1,159.93 48148 726.94 48150 2,074.19 48152 1,844.28 48153 2,064.58 48154 1,796.05 48155 1,058.40 48400 64.41 48500 693.32 48510 698.92 48520 722.99 48540 802.64 48545 890.80 48547 1,040.48 48548 1,062.63 48554 1,577.63 48556 746.24 48999 Y49000 510.99 49002 694.60

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

49010 615.85 49020 1,056.10 49040 661.64 49060 728.94 49062 489.70 49082 129.81 46.67 49083 193.23 68.46 49084 71.66 49180 85.22 54.15 49185 660.42 76.61 49203 794.42 49204 1,016.03 49205 1,168.74 49215 1,370.06 49220 552.84 49250 377.04 49255 524.96 49320 215.89 49321 228.25 49322 244.97 49323 418.96 49324 256.41 49325 273.58 49326 125.23 49327 81.03 49329 Y49400 85.28 60.20 49402 568.46 49405 547.85 125.92 49406 547.62 125.92 49407 444.83 133.40 49411 314.79 117.55 49412 52.94 49418 826.93 129.66 49419 292.36 49421 152.02 49422 219.31 49423 73.38 45.57 49424 38.28 24.21 49425 477.34 49426 377.07 49427 29.46 49428 252.10 49429 283.59 49435 78.98 49436 110.29 49440 617.91 131.20 49441 701.24 154.09 49442 572.43 132.55

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

49446 594.10 94.66 49450 430.41 42.27 49451 468.18 57.68 49452 576.01 88.27 49460 467.95 30.60 49465 102.57 19.59 49491 527.48 49492 591.24 49495 266.34 49496 347.13 49500 267.64 49501 394.90 49505 345.01 49507 388.51 49520 419.19 49521 475.51 49525 380.27 49540 431.31 49550 381.87 49553 419.19 49555 368.36 49557 464.10 49560 489.47 49561 616.76 49565 509.62 49566 622.26 49568 177.89 49570 276.33 49572 342.27 49580 214.52 49582 306.09 49585 294.65 49587 315.02 49590 368.08 49600 463.47 49605 3,262.85 49606 753.44 49610 436.11 49611 330.39 49650 284.11 49651 369.74 49652 493.37 49653 616.08 49654 560.67 49655 684.76 49656 608.06 49657 875.47 49659 Y49900 541.21

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

49904 910.03 Y49905 234.66 Y49999 Y50010 485.81 50020 623.14 50040 527.63 50045 529.99 50060 647.37 50065 686.76 50070 673.56 50075 827.77 50080 575.78 50081 846.16 50100 576.42 50120 539.64 50125 598.53 50130 645.81 50135 637.53 50200 140.78 81.67 50205 482.93 50220 694.15 50225 736.92 50230 849.60 50234 833.16 50236 916.41 50240 877.98 50250 693.26 50280 583.79 50290 511.08 50340 576.99 50360 1,550.68 50365 1,831.14 50370 739.48 50380 1,172.43 50382 274.44 164.22 50384 226.73 147.05 50385 679.65 147.31 50386 444.32 105.42 50387 99.12 53.49 50389 54.58 34.34 50390 63.65 50391 69.92 62.92 50396 75.10 50400 768.32 50405 895.19 50430 332.65 98.18 50431 107.37 41.83 50432 534.38 131.64 50433 715.44 163.78

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

50434 564.57 123.28 50435 326.29 63.84 50436 100.05 50437 166.90 50500 815.85 50520 589.07 50525 852.79 50526 824.63 50540 651.90 50541 608.75 50542 713.53 50543 986.04 50544 824.87 50545 887.60 50546 797.86 50548 892.64 50549 Y50551 218.84 190.00 50553 232.45 203.23 50555 234.56 220.63 50557 238.70 223.53 50561 314.11 251.17 50562 330.48 50570 278.69 50572 301.92 50574 321.22 50575 437.90 50576 320.05 50580 345.06 50590 480.77 362.12 50592 293.20 230.70 50593 2,872.97 293.66 50600 533.53 50605 656.37 50606 318.80 98.69 50610 537.27 50620 565.44 50630 507.74 50650 648.64 50660 703.11 50684 50.08 31.92 50686 69.05 56.91 50688 51.51 50690 65.71 44.47 50693 657.97 130.76 50694 725.74 171.04 50695 886.23 219.03 50700 569.12 50705 1,028.50 126.12

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

50706 507.43 116.89 50715 807.01 50722 625.90 50725 626.30 50727 336.77 50728 397.84 50740 755.43 50750 655.25 50760 747.26 50770 655.25 50780 732.15 50782 645.47 50783 692.68 50785 776.45 50800 529.79 50810 761.99 50815 748.84 50820 870.66 50825 1,013.83 50830 1,164.56 50840 753.30 50845 827.85 50860 609.64 50900 484.69 50920 539.34 50930 672.39 50940 504.98 50945 553.04 50947 919.88 50948 723.99 50949 Y50951 249.54 195.70 50953 226.89 220.74 50955 242.06 227.70 50957 244.21 229.12 50961 256.18 201.86 50970 210.34 50972 203.64 50974 268.44 50976 264.70 50980 202.07 51020 268.44 51030 268.64 51040 191.39 51045 325.09 51050 312.73 51060 331.66 51065 353.25 51080 256.95

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

51100 37.00 25.04 51101 73.66 33.74 51102 151.10 92.02 51500 421.25 51520 338.76 51525 524.67 51530 482.99 51535 476.39 51550 638.74 51555 839.98 51565 859.67 51570 976.20 51575 1,033.38 51580 1,184.18 51585 1,290.52 51590 1,281.38 51595 1,450.33 51596 1,560.68 51597 1,434.61 51600 127.19 28.40 51605 21.86 51610 73.49 40.72 51700 48.54 19.15 51701 29.08 16.07 51702 40.29 16.07 51703 86.54 49.09 51705 61.13 33.02 51710 84.48 50.63 51715 175.67 129.13 Y51720 54.95 31.48 51725 129.63 49.89 79.74 51726 181.78 56.32 125.46 51727 196.05 57.96 138.09 51728 218.09 68.74 149.35 51729 233.75 83.11 150.64 51736 18.73 11.82 6.91 51741 26.43 15.47 10.96 51784 76.53 42.82 33.70 51785 183.24 53.15 130.08 51792 146.44 35.44 111.00 51797 77.48 22.75 54.73 51798 9.76 51800 695.75 51820 677.45 51840 441.85 51841 514.43 51845 357.72 51860 493.37 51865 594.10

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

51880 309.30 51900 545.33 51920 471.30 51925 610.15 51940 1,087.92 51960 916.90 51980 456.35 51990 458.31 51992 549.91 51999 Y52000 121.91 51.51 52001 259.16 182.93 52005 184.30 84.53 52007 266.49 111.18 52010 223.95 106.69 52204 247.48 89.81 52214 457.38 112.27 52224 478.48 129.66 52234 163.01 52235 190.94 52240 259.62 52250 146.96 52260 138.97 52265 120.98 108.63 52270 247.09 116.01 52275 253.57 158.28 52276 175.14 52277 204.08 52281 189.59 96.86 52282 215.99 52283 175.67 129.89 52285 194.94 124.60 52287 220.93 107.65 52290 156.40 52300 185.21 52301 191.85 52305 174.17 52310 169.36 96.42 52315 287.54 174.79 52317 354.08 221.24 52318 313.88 52320 163.23 52325 196.93 52327 168.13 52330 269.21 167.96 52332 159.64 99.06 52334 147.54 52341 187.96 52342 198.48

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

52343 210.97 52344 244.74 52345 252.98 52346 273.71 52351 200.32 52352 234.89 52353 259.62 52354 276.56 52355 286.68 52356 275.87 52400 316.62 52402 151.06 52441 688.31 146.68 52442 526.39 38.97 52450 311.13 52500 311.90 52601 482.83 52630 244.16 52640 209.25 52647 490.51 415.61 52648 1,092.96 439.61 52649 490.80 52700 276.44 53000 90.18 53010 194.83 53020 64.10 53025 44.02 53040 239.47 53060 111.44 104.06 53080 256.49 53085 377.36 53200 104.17 90.70 53210 442.54 53215 568.06 53220 259.58 53230 387.45 53235 386.43 53240 260.95 53250 241.66 53260 127.82 115.24 53265 125.45 124.62 53270 131.14 123.23 53275 149.88 53400 489.58 53405 496.90 53410 647.90 53415 748.63 53420 478.39 53425 585.60

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

53430 639.89 53431 708.21 53440 459.80 53442 446.28 53444 451.41 53445 450.50 53446 392.17 53447 460.47 53448 727.53 53450 261.18 53460 279.46 53500 492.91 53502 297.11 53505 321.66 53510 395.58 53515 452.39 53520 340.06 53600 54.72 40.50 53601 48.92 34.65 53605 42.81 53620 73.77 58.60 53621 68.89 46.67 53660 44.53 26.79 53661 44.87 25.76 53665 22.06 53850 1,244.15 388.70 53852 518.56 399.99 53855 498.63 52.61 53899 Y54000 93.71 69.11 54001 124.54 88.49 54015 189.28 54050 83.96 67.05 54055 75.10 59.08 54056 92.26 70.00 54057 81.88 61.05 54060 121.11 82.77 54065 138.46 115.12 54100 129.12 79.03 54105 175.83 135.60 54110 386.64 54111 455.35 54112 532.94 54115 275.42 271.92 54120 418.73 54125 539.61 54130 678.29 54135 858.69 54150 101.19 62.30

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

54160 144.69 91.80 54161 130.50 54162 169.87 127.02 54163 144.46 54164 117.61 54200 71.13 53.27 54205 303.70 54220 136.68 85.19 54230 58.49 51.32 54231 85.07 74.94 54235 58.61 46.45 54240 61.89 36.43 25.45 54300 426.97 54304 496.11 54308 437.05 54312 542.13 54316 624.15 54318 398.43 54322 517.40 54324 641.72 54326 626.15 54328 574.01 54332 671.71 54336 761.17 54340 361.98 54344 606.76 54348 671.71 54352 938.88 54360 477.11 54380 529.54 54385 568.00 54390 798.17 54406 415.76 54415 301.73 54420 430.67 54430 424.23 54435 253.73 54437 445.97 54438 840.50 54440 138.32 54450 45.56 36.76 54500 42.34 54505 138.97 54512 357.38 54520 216.35 54522 378.59 54530 334.94 54535 454.28 54550 325.78

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

54560 419.83 54600 299.91 54620 198.26 54640 316.85 54650 433.64 54670 269.00 54680 521.52 54690 430.73 54692 502.29 54700 141.03 54800 73.66 54830 246.80 54840 212.69 54860 255.85 54861 346.24 54865 205.41 55000 74.21 56.98 55040 223.67 55041 338.14 55060 243.46 55100 143.77 105.66 55110 256.41 55120 218.00 55150 325.78 55175 240.39 55180 456.05 55200 212.45 178.40 55250 209.65 144.85 55300 106.55 55500 241.38 55520 300.37 55530 232.83 55535 262.87 55540 332.84 55550 274.03 55559 Y55600 240.87 55605 297.40 55650 439.18 55680 197.74 55700 159.04 82.99 55705 162.27 55706 246.80 55720 276.69 55725 338.76 55801 621.96 55810 870.43 55812 914.23 55815 1,101.42

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

55821 497.30 55831 577.84 55840 776.33 55842 784.83 55845 903.85 55860 498.08 55862 623.34 55865 758.05 55866 956.51 55873 961.53 491.01 55875 488.03 55876 92.72 64.06 55899 Y55920 286.21 56405 74.41 70.88 56420 83.83 60.54 56440 117.90 56441 90.61 86.08 56442 30.13 56501 90.65 75.07 56515 153.85 127.68 56605 55.63 37.64 56606 24.95 18.71 56620 354.86 56625 383.67 56630 624.09 56631 755.18 56632 931.33 56633 753.27 56634 727.73 56637 847.67 56640 826.99 56700 123.17 56740 198.26 56800 151.97 Y56805 705.44 Y56810 171.48 56820 75.09 54.15 56821 99.82 72.20 57000 113.78 57010 284.57 57020 58.26 51.35 57022 111.26 57023 202.15 57061 78.46 64.28 57065 123.17 114.89 57100 60.44 42.05 57105 94.55 82.55 57106 332.88

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

57107 887.28 57109 971.36 57110 539.34 57111 975.33 57112 958.55 57120 307.75 57130 121.80 101.26 57135 132.79 111.17 57150 31.20 17.09 57155 244.51 178.09 57156 135.53 94.00 57160 43.26 29.28 57170 38.32 30.63 57180 96.98 68.46 57200 203.07 57210 243.36 57220 192.47 57230 259.62 57240 389.20 57250 390.11 57260 498.17 57265 559.30 57267 165.98 57268 319.14 57270 505.75 57280 624.32 57282 333.34 57283 449.18 57284 534.35 57285 424.23 57287 456.73 57288 472.30 57289 414.98 57291 343.58 Y57292 498.30 Y57295 315.25 57296 559.72 57300 356.43 57305 595.02 57307 660.14 57308 402.07 57310 262.72 57311 298.77 57320 337.83 57330 420.49 57335 685.88 57400 82.09 57410 69.83 57415 101.01

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

57420 78.98 57.68 57421 105.77 77.49 57423 574.64 57425 633.71 57426 531.00 57452 74.41 57.68 57454 101.88 83.87 57455 96.15 68.68 57456 90.43 63.84 57460 190.02 100.82 57461 213.83 116.23 57500 87.00 46.89 57505 70.66 60.54 57510 79.11 75.74 57511 100.16 84.97 57513 91.27 88.71 57520 209.71 176.55 57522 178.34 153.65 57530 230.08 57531 1,025.71 57540 459.68 57545 511.91 57550 241.46 57555 354.90 57556 332.84 57558 77.98 70.68 57700 209.02 57720 203.53 57800 41.91 30.16 58100 61.80 51.70 58110 32.97 25.76 58120 175.37 139.79 58140 599.36 58145 361.27 58146 745.20 58150 666.21 58152 787.30 58180 627.07 58200 909.12 58210 1,223.00 58240 1,941.87 58260 537.55 58262 597.53 58263 596.77 58267 636.33 58270 531.69 58275 594.00 58280 621.18 58285 771.84

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

58290 723.94 58291 749.25 58292 823.42 58293 805.32 58294 735.86 58300 50.20 33.90 58301 61.81 42.05 58340 82.37 36.10 58346 251.90 58353 180.55 136.95 Y58356 314.08 216.61 58520 516.37 58540 546.58 58541 458.73 58542 515.49 58543 520.37 58544 563.84 58545 586.54 58546 705.78 58548 1,260.54 58550 570.52 58552 642.18 58553 716.20 58554 861.04 58555 185.19 95.76 58558 294.91 145.95 58559 185.67 58560 204.67 58561 234.89 58562 237.87 139.57 58563 310.96 155.19 58570 513.28 58571 591.35 58572 672.63 58573 801.29 58575 1,246.12 58578 Y58579 Y58600 236.49 58605 214.06 58611 49.68 58615 146.32 58660 439.79 58661 424.68 58662 462.92 58670 236.49 58671 236.72 58672 442.57 58673 513.74

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

58679 Y58700 512.14 58720 488.10 58740 584.71 58770 552.66 58800 190.98 185.98 58805 265.80 58820 201.55 58822 439.06 58825 421.74 Y58900 260.07 58920 454.67 58925 491.30 58940 350.51 58943 782.75 58950 754.81 58951 964.98 58952 1,094.79 58953 1,348.91 58954 1,464.76 58956 915.30 58957 1,059.76 58958 1,066.14 58960 646.98 58999 Y59000 80.82 51.29 59001 117.90 59012 133.24 59015 102.34 83.21 59020 45.56 24.27 21.29 59025 TH 31.36 19.46 11.90 59025 31.36 19.46 11.90 59030 62.44 59074 254.35 196.36 59076 287.11 59100 551.44 59120 527.48 59121 528.16 59130 535.98 59135 480.56 59136 583.11 59140 234.40 59150 511.22 59151 497.26 59160 142.17 112.49 59200 50.20 28.40 59300 132.10 93.78 59320 100.05 59325 153.70

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

59350 159.93 59409 * 1,144.00 59409 702.00 59410 * 1,144.00 59410 TH 1,151.30 59410 832.00 59412 69.92 59414 141.53 59430 45.76 43.47 59514 * 1,144.00 59514 566.36 59515 * 1,144.00 59515 876.12 59525 337.49 59612 * 1,144.00 59612 702.00 59614 * 1,144.00 59614 791.09 59622 * 1,144.00 59622 898.28 59812 214.52 189.10 59820 257.33 229.82 59821 257.56 228.72 59830 292.13 59840 146.44 133.84 59841 234.80 223.06 59850 212.88 59851 237.13 59852 293.26 59855 255.42 59856 300.30 59857 298.97 59866 132.50 59870 321.66 59871 87.46 59899 Y60000 103.40 95.26 60100 73.26 49.97 60200 435.90 60210 466.35 60212 665.53 60220 465.21 60225 612.87 60240 606.00 60252 870.43 60254 1,102.12 60260 720.24 60270 902.94 60271 697.12

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

60280 290.52 60281 385.08 60300 74.44 32.11 60500 638.06 60502 827.57 60505 919.42 60512 160.94 60520 643.55 60521 741.99 60522 904.54 60540 706.97 60545 748.84 60600 860.49 60605 1,026.54 60650 790.07 60659 Y60699 Y61000 71.13 61001 65.78 61020 65.71 61026 66.90 61050 56.09 61055 74.23 61070 37.55 61105 309.30 61107 210.62 61108 595.93 61120 483.81 61140 845.70 61150 880.79 61151 627.18 61154 850.28 61156 836.09 61210 248.63 61215 340.66 61250 509.91 61253 439.21 61304 1,102.35 61305 1,292.06 61312 1,394.01 61313 1,328.77 61314 1,219.56 61315 1,383.48 61316 59.52 61320 1,271.99 61321 1,412.56 61322 1,596.86 61323 1,598.23 61330 1,038.01

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

61333 1,133.56 61340 943.70 61343 1,466.82 61345 1,365.85 61450 1,123.00 61458 1,348.00 61460 1,228.96 61500 874.78 61501 759.39 61510 1,467.28 61512 1,712.70 61514 1,281.15 61516 1,246.81 61517 59.30 61518 1,855.56 61519 1,986.05 61520 2,525.89 61521 2,067.28 61522 1,363.46 61524 1,393.56 61526 2,242.24 61530 2,085.18 61531 717.88 61533 952.58 61534 963.08 61535 667.36 61536 1,722.31 61537 1,658.90 61538 1,685.02 61539 1,594.34 61540 1,402.12 61541 1,435.68 61543 1,413.02 61544 1,282.06 61545 2,129.60 61546 1,480.99 61548 1,049.69 61550 594.64 61552 679.05 61556 954.06 61557 1,001.91 61558 1,030.14 61559 1,420.03 61563 1,282.86 61564 1,398.82 61566 1,413.45 61567 1,619.74 61570 1,248.18 61571 1,312.51

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

61575 1,461.68 61576 2,185.36 61580 1,611.51 61581 1,743.61 61582 1,805.41 61583 1,928.59 61584 1,836.01 61585 2,026.38 61586 1,532.30 61590 2,018.79 61591 1,920.25 61592 2,119.07 61595 1,560.00 61596 1,604.87 61597 1,957.89 61598 1,809.42 61600 1,409.81 61601 1,604.87 61605 1,422.86 61606 1,910.23 61607 1,781.84 61608 2,190.95 61611 215.27 61613 1,925.18 61615 1,328.81 61616 2,227.58 61618 859.90 61619 947.81 61623 380.27 61624 771.76 61626 585.40 61645 554.86 61650 368.59 61651 160.49 61680 1,513.29 61682 2,827.41 61684 1,903.63 61686 3,123.43 61690 1,457.66 61692 2,132.16 61697 2,872.51 61698 3,205.39 61700 2,306.57 61702 2,345.27 61703 796.07 61705 1,669.89 61708 1,263.82 61710 1,158.81 61711 1,735.59

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

61720 744.07 61735 1,071.44 61750 948.27 61751 926.75 61760 1,054.27 61770 1,018.50 61781 158.88 61782 114.93 61783 155.68 61790 590.21 61791 652.69 61796 680.87 61797 148.35 61798 703.27 61799 205.59 61800 103.48 61850 576.27 61860 914.63 61863 1,006.88 61864 191.39 61867 1,423.02 61868 290.50 61870 693.45 61880 356.23 61885 342.72 61886 567.08 61888 264.88 62000 620.72 62005 839.06 62010 1,024.05 62100 1,062.74 62115 736.64 62117 916.60 62120 1,167.47 62121 1,046.94 62140 685.67 62141 759.85 62142 590.66 62143 695.52 62145 939.34 62146 784.58 62147 960.86 62148 85.39 62160 128.44 62161 1,010.54 62162 1,267.18 62163 690.56 62164 1,398.14 62165 1,021.30

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

62180 1,002.55 62190 494.59 62192 654.54 62194 219.41 62200 922.40 62201 810.22 62220 670.34 62223 695.06 62225 352.11 62230 562.05 62252 53.57 30.91 22.67 62256 401.56 62258 745.43 62263 380.35 199.53 62264 170.43 158.20 62267 168.04 100.16 62268 171.47 62269 175.37 62270 96.61 49.09 62272 127.52 53.05 62273 112.87 71.76 62280 187.33 106.53 62281 158.88 100.82 62282 103.78 91.23 62284 128.44 55.91 62287 363.32 62290 152.35 105.88 62291 122.17 111.64 62292 352.24 62294 433.17 62302 150.78 81.76 62303 156.64 77.27 62304 161.17 75.95 62305 175.14 79.25 62320 107.14 62.74 62321 164.61 67.58 62322 99.82 54.15 62323 162.78 62.52 62324 94.32 57.23 62325 152.55 67.80 62326 97.99 56.35 62327 153.16 61.20 62350 263.28 62351 552.49 62355 176.97 62360 197.60 62361 200.49 62362 252.75 62365 195.06

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

62368 35.94 22.23 62369 76.47 22.23 62370 79.44 29.28 62380 567.91 63001 826.01 63003 824.64 63005 788.93 63011 671.85 63012 793.51 63015 989.02 63016 1,016.26 63017 840.21 63020 771.30 63030 645.61 63035 127.75 63040 821.27 63042 861.50 63043 118.39 63044 118.39 63045 856.01 63046 815.94 63047 731.92 63048 141.26 63050 970.07 63051 1,138.06 63055 1,087.24 63056 991.08 63057 207.57 63064 1,096.56 63066 119.94 63075 899.28 63076 160.83 63077 866.57 63078 111.87 63081 1,170.80 63082 177.89 63085 1,281.83 63086 127.75 63087 1,609.90 63088 164.43 63090 1,304.50 63091 117.45 63101 1,552.67 63102 1,512.61 63103 196.89 63170 932.75 63172 864.52 63173 1,076.35 63180 870.52

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

63182 955.01 63185 702.04 63190 824.52 63191 748.01 63194 725.96 63195 899.27 63196 788.00 63197 1,001.68 63198 927.43 63199 1,097.80 63200 1,023.59 63250 1,902.99 63251 1,946.10 63252 1,769.00 63265 1,113.79 63266 1,150.88 63267 911.87 63268 853.18 63270 1,383.48 63271 1,383.48 63272 1,222.83 63273 1,090.31 63275 1,204.45 63276 1,196.67 63277 1,038.47 63278 1,023.64 63280 1,315.40 63281 1,401.80 63282 1,320.98 63283 1,222.52 63285 1,758.72 63286 1,732.16 63287 1,736.28 63290 1,862.20 63295 223.45 63300 1,227.58 63301 1,250.23 63302 1,272.68 63303 1,350.48 63304 1,371.94 63305 1,333.15 63306 1,338.69 63307 1,404.63 63308 216.58 63600 541.81 63610 255.44 63620 581.22 63621 144.76 63650 338.16 260.20

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

63655 533.65 63661 366.41 209.49 63662 501.53 63663 487.44 289.25 63664 556.48 63685 238.10 63688 237.26 63700 813.88 63702 833.68 63704 936.62 63706 1,183.62 63707 617.68 63709 733.75 63710 723.45 63740 646.62 63741 436.18 63744 426.88 63746 377.07 64400 88.45 45.79 64402 92.84 53.93 64405 57.02 38.15 64408 64.57 53.89 64410 76.02 56.14 64413 82.42 51.51 64415 77.38 41.17 64416 52.20 64417 86.08 44.47 64418 72.41 37.11 64420 72.12 42.27 64421 102.11 58.12 64425 82.85 62.31 64430 86.39 50.96 64435 91.58 51.73 64445 89.06 46.01 64446 52.20 64447 61.39 42.05 64448 46.93 64449 55.86 64450 50.14 28.18 64455 77.63 23.16 64461 90.66 51.29 64462 50.37 32.36 64463 109.73 53.27 64479 159.11 82.77 64480 70.66 41.92 64483 147.44 70.22 64484 63.87 32.80 64486 71.43 35.86 64487 93.51 41.17

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

64488 87.68 44.47 64489 123.30 49.97 64490 123.40 66.70 64491 61.36 37.86 64492 61.81 38.30 64493 112.41 56.79 64494 57.01 32.80 64495 57.01 33.24 64505 73.35 59.22 64510 86.54 46.89 64517 116.74 83.62 64520 127.93 51.51 64530 118.51 60.45 64553 133.14 126.48 64555 128.03 121.63 64561 493.62 202.90 64568 421.94 64569 506.19 64570 463.72 64575 203.42 64580 192.51 64581 437.05 64585 131.36 95.66 64590 173.99 102.14 64595 157.74 79.91 64600 239.69 147.98 64605 357.25 225.84 64610 457.04 334.53 64611 78.98 66.70 64612 87.68 74.63 64615 97.76 78.81 64616 87.00 70.00 64617 105.77 69.12 64620 135.30 110.07 64630 145.76 122.72 64632 49.83 43.23 64633 272.21 141.55 64634 122.25 42.93 64635 269.23 139.57 64636 111.04 37.64 64640 88.37 59.22 64642 95.01 68.68 64643 60.67 45.79 64644 110.35 75.29 64645 76.24 52.83 64646 99.59 73.52 64647 117.22 87.17 64650 42.54 27.75 64653 44.68 36.66

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

64680 207.65 102.58 64681 168.53 160.11 64702 331.28 64704 194.17 64708 330.13 64712 384.39 64713 491.74 64714 435.14 64716 343.41 64718 390.11 64719 264.65 64721 285.03 271.21 64722 234.66 64726 159.72 64727 121.57 64732 260.28 64734 228.26 64736 253.28 64738 292.27 64740 271.19 64742 295.43 64744 305.19 64746 255.05 64755 534.33 64760 316.56 64763 321.67 64766 344.66 64771 337.77 64772 372.03 64774 256.49 64776 255.95 64778 96.40 64782 302.66 64783 125.06 64784 478.94 64786 630.04 64787 150.58 64788 254.09 64790 553.81 64792 698.38 64795 129.12 64802 303.90 64804 548.98 64809 417.73 64818 375.19 64820 451.47 64821 408.47 64822 408.47 64823 464.99

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

64831 453.07 64832 222.76 64834 457.89 64835 537.32 64836 537.78 64837 232.45 64840 541.41 64856 669.19 64857 696.89 64858 748.26 64859 164.61 64861 798.82 64862 801.78 64864 570.29 64865 657.61 64866 750.02 64868 660.49 64872 74.08 64874 105.45 64876 105.96 64885 735.81 64886 804.76 64890 714.52 64891 691.88 64892 689.80 64893 742.91 64895 788.97 64896 868.35 64897 753.72 64898 907.52 64901 344.96 64902 394.10 64905 669.65 64907 693.04 64999 Y65091 421.09 65093 416.90 65101 444.49 65103 464.06 65105 560.67 65110 802.43 65112 892.31 65114 884.50 65125 260.80 180.19 65130 441.09 65135 447.47 65140 476.54 65150 343.26 65155 501.27

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

65175 436.07 65205 31.70 26.26 65210 38.68 31.48 65220 38.46 26.20 65222 44.19 32.58 65235 463.83 65260 627.52 65265 704.91 65270 166.14 87.34 65272 288.69 216.44 65273 221.38 65275 378.90 289.48 65280 437.28 65285 722.76 65286 459.48 310.83 65290 293.90 65400 445.06 377.31 65410 84.41 64.68 65420 341.81 236.64 65426 429.49 299.38 65430 75.78 64.72 65435 53.11 43.59 65436 252.98 232.24 65450 195.88 186.09 65600 228.50 211.61 65710 727.11 65730 804.72 65750 808.62 65755 741.18 65756 770.38 65770 907.29 65772 271.80 250.52 65775 321.62 65778 917.59 34.78 65779 752.52 100.76 65780 433.84 65781 774.00 65782 748.18 65785 1,274.78 272.75 65800 78.30 57.01 65810 302.89 65815 418.04 298.72 65820 469.41 65850 546.48 65855 160.49 130.10 65860 186.09 156.82 65865 285.41 65870 384.16 65875 410.26

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

65880 386.80 65900 579.33 65920 513.05 65930 414.15 66020 112.29 86.86 66030 109.73 69.56 66130 412.44 351.24 66150 511.87 66155 511.48 66160 575.88 66170 712.46 66172 776.11 66179 701.93 66180 740.62 66184 437.65 66185 529.89 66225 558.09 66250 490.16 348.47 66500 213.31 66505 227.46 66600 487.06 66605 613.69 66625 269.38 66630 337.66 66635 347.08 66680 336.47 66682 421.02 66700 265.88 242.85 66710 288.46 245.89 66711 418.50 66720 301.28 256.02 66740 255.44 242.85 66761 194.60 147.71 66762 297.74 262.67 66770 308.42 297.98 66820 262.37 66821 215.66 194.82 66825 500.23 66830 447.93 66840 453.07 66850 515.57 66852 549.23 66920 438.01 66930 547.25 66940 508.93 66982 516.49 66983 423.23 66984 415.75 66985 500.46

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

66986 570.65 66990 51.60 66999 Y67005 296.63 67010 353.03 67015 379.58 67025 437.90 418.09 67027 535.20 67028 66.16 62.30 67030 310.05 67031 254.35 223.22 67036 586.31 67039 627.98 67040 678.58 67041 749.78 67042 749.78 67043 783.30 67101 347.98 178.31 67105 287.53 172.15 67107 736.96 67108 780.68 67110 557.83 508.95 67113 871.34 67115 294.15 67120 431.78 348.47 67121 590.89 67141 341.58 304.67 67145 343.87 311.27 67208 361.76 343.67 67210 337.00 312.81 67218 901.56 67220 342.32 309.06 67221 172.13 132.56 67225 17.14 16.28 67227 291.34 158.93 67228 358.88 191.96 67229 758.71 67250 465.33 67255 429.10 67299 Y67311 388.28 67312 463.15 67314 437.28 67316 503.31 67318 443.06 67320 209.94 67331 199.18 67332 216.12 67334 182.69

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

67335 96.38 67340 217.14 67343 410.71 67345 159.34 136.92 67399 Y67400 613.33 67405 496.88 67412 565.02 67413 565.48 67414 872.72 67415 62.24 67420 977.46 67430 727.53 67440 726.71 67445 923.09 67450 784.20 67500 49.18 48.64 67505 54.49 47.53 67515 54.83 52.95 67550 636.91 67560 652.71 67570 777.25 67599 Y67700 179.03 72.86 67710 150.18 60.98 67715 160.16 67.80 67800 83.33 64.50 67801 106.23 83.43 67805 131.87 102.80 67808 239.24 67810 114.24 44.69 67820 24.93 23.69 67825 84.94 76.17 67830 160.36 85.64 67835 264.57 67840 181.09 98.84 67850 140.34 84.53 67875 113.55 60.54 67880 300.37 230.48 67882 328.81 312.46 67901 455.76 356.70 Y67902 437.69 Y67903 357.51 319.41 Y67904 479.40 374.01 Y67906 324.75 Y67908 297.11 261.97 Y67909 323.06 271.69 Y67911 339.86 Y67912 581.96 305.55

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

67914 274.57 201.88 67915 186.42 121.95 67916 370.61 284.90 67917 397.44 286.39 67921 237.02 191.28 67922 184.66 121.53 67923 356.01 266.08 67924 394.32 302.97 67930 228.17 158.90 67935 388.28 277.37 67938 164.61 72.86 67950 375.23 289.70 67961 377.06 284.63 67966 502.75 411.65 67971 439.54 67973 562.95 67974 566.95 67975 415.31 67999 Y68020 78.76 69.34 68040 37.64 30.79 68100 112.29 60.54 68110 150.18 92.90 68115 194.50 121.60 68130 354.40 258.22 68135 94.22 93.25 68200 27.01 21.79 68320 453.24 356.47 68325 398.55 68326 405.83 68328 427.04 68330 363.89 284.78 68335 421.71 68340 340.70 246.29 68360 307.45 253.84 68362 390.54 68400 159.46 81.68 68420 200.49 104.58 68440 63.80 60.61 68500 580.50 68505 578.15 68510 263.93 192.71 68520 416.21 68525 172.16 68530 267.16 170.01 68540 554.41 68550 595.62 68700 393.09 68705 136.78 102.65

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

68720 494.51 68745 456.73 68750 475.33 68760 135.53 91.36 68761 96.61 73.97 68770 374.40 68801 58.84 48.87 68810 102.34 80.13 68811 88.60 68815 256.64 138.90 68816 443.50 98.84 68840 84.02 72.86 68850 34.46 32.74 68899 Y69000 121.11 75.29 69005 140.34 99.06 69020 150.41 88.71 69100 63.87 30.82 69105 91.35 39.40 69110 297.62 202.74 69120 256.97 69140 529.00 69145 243.43 154.17 69150 621.18 69155 989.47 69200 55.26 29.72 69205 64.56 69209 8.77 69210 30.68 20.69 69220 62.22 32.36 69222 140.11 84.53 69300 407.38 307.14 Y69310 710.63 69320 997.03 69399 Y69420 122.71 75.07 69421 96.61 69424 83.11 38.52 69433 129.81 82.55 69436 103.25 69440 435.74 69450 354.17 69501 464.54 69502 626.38 69505 784.81 69511 781.10 69530 985.73 69535 1,709.08 69540 134.39 79.03

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

69550 640.79 69552 935.11 69554 1,491.29 69601 625.32 69602 651.51 69603 822.58 69604 665.49 69605 931.57 69610 247.94 182.05 69620 453.76 305.77 69631 575.33 69632 701.70 69633 680.18 69635 810.22 69636 850.71 69637 913.47 69641 678.12 69642 846.01 69643 796.48 69644 965.67 69645 948.73 69646 1,009.62 69650 482.13 69660 587.05 69661 744.37 69662 736.13 69666 497.66 69667 514.60 69670 601.67 69676 500.05 69700 411.22 69710 566.98 Y69711 531.91 Y69714 697.58 Y69715 788.78 Y69717 697.37 Y69718 796.85 69720 713.15 69725 1,226.20 69740 694.24 69745 731.42 69799 Y69801 197.04 78.81 69805 649.73 69806 563.08 69905 550.67 69910 606.21 69915 912.26 69930 798.08 Y

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

69950 1,052.10 69955 1,171.64 69960 1,137.58 69970 1,267.17 69979 Y69990 146.52 90785 3.67 3.49 90791 89.06 77.93 90792 95.69 88.27 90832 43.50 38.74 90833 31.97 30.37 90834 57.92 51.73 90836 51.91 49.31 90837 87.00 77.71 90838 75.32 67.80 90845 51.37 48.80 90847 69.42 65.16 90849 19.69 19.28 90853 15.31 15.11 90870 113.55 68.68 90887 55.17 47.11 90935 47.39 90937 67.54 90945 55.40 90947 80.36 90951 529.20 90952 238.23 90953 158.17 90954 509.73 90955 286.43 90956 198.94 90957 416.21 90958 282.51 90959 192.31 90960 183.61 90961 154.31 90962 119.28 90963 340.70 90964 285.20 90965 271.37 90966 153.85 90967 10.04 90968 9.36 90969 9.53 90970 5.04 90999 Y91010 121.11 43.00 78.11 91013 14.58 5.39 9.19 91020 140.58 45.52 95.06

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

91022 105.17 45.52 59.65 91030 86.06 28.16 57.90 91034 123.40 33.20 90.20 91035 313.19 54.49 258.70 91037 106.69 33.20 73.49 91038 135.95 17.64 118.31 91040 177.45 26.86 150.59 91065 48.76 6.64 42.12 91110 571.89 84.25 487.64 Y91120 292.67 32.14 260.52 91122 156.82 59.07 97.76 91299 Y92002 54.26 29.94 92004 97.53 61.86 92012 57.01 32.80 92014 81.73 49.53 92015 15.97 12.11 92018 94.55 92019 46.93 92020 17.86 13.21 92025 24.50 13.05 11.45 92060 41.67 24.73 16.94 92071 24.50 20.91 92081 21.98 10.53 11.45 92082 30.91 13.97 16.94 92083 41.44 18.09 23.35 92100 53.11 21.13 92132 20.38 10.76 9.62 92133 24.04 14.42 9.62 92134 26.56 16.71 9.84 92136 48.35 21.73 26.62 92225 17.86 13.43 92226 16.48 11.89 92230 34.88 20.33 92235 59.30 28.16 31.14 92240 133.47 30.91 102.57 92242 149.04 35.71 113.33 92250 35.12 15.23 19.89 92260 11.23 6.71 92265 47.00 24.62 22.39 92270 61.81 27.47 34.34 92273 86.54 24.27 62.27 92274 58.61 21.52 37.09 92283 34.80 5.95 28.85 92284 34.90 7.10 27.80 92285 13.97 2.06 11.90 92286 35.22 20.17 15.05 92287 86.39 27.82 58.57 92340 22.67 11.67

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

92341 26.10 14.97 92342 28.16 16.95 92352 21.66 11.67 92353 25.07 15.85 92499 Y92502 62.50 92504 19.00 5.94 92511 72.12 23.77 92512 37.88 18.76 92516 44.41 14.31 92520 45.52 26.87 92526 55.86 92531 5.72 92532 5.72 92533 14.56 92534 5.72 92537 26.56 20.60 5.95 92538 13.56 10.17 3.39 92540 67.54 51.51 16.03 92541 18.73 9.24 9.49 92542 18.77 16.48 2.29 92544 15.72 5.81 9.92 92545 15.03 5.08 9.96 92546 67.54 9.84 57.69 92547 4.14 92550 14.19 92552 20.38 92553 24.73 92555 15.26 92556 19.82 92557 24.73 20.47 92567 9.84 6.82 92568 10.30 9.69 92570 21.06 18.71 92571 11.98 92572 15.38 92579 29.99 23.99 92582 42.32 92585 87.23 17.40 69.83 92586 56.18 92587 15.03 12.61 2.42 92588 21.52 18.77 2.75 92601 85.07 80.82 92602 57.01 44.47 92603 91.03 80.37 92604 59.52 42.71 92610 56.09 45.35 92611 57.55 92612 124.09 42.71

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

92614 90.61 41.18 92616 122.89 61.66 92620 59.37 50.39 92621 13.96 11.57 92626 58.38 47.55 92627 13.19 10.94 92630 71.61 92633 71.61 92640 35.28 33.52 92700 36.11 Y92920 354.63 92921 195.37 92924 423.08 92925 218.48 92928 394.69 92929 238.87 92933 442.77 92934 208.40 92937 394.46 92938 184.15 92941 443.91 92943 443.69 92944 222.01 92950 204.21 117.77 92953 4.46 92960 103.25 68.90 92961 165.52 92970 118.73 92971 58.28 92973 117.90 92974 93.36 92975 251.38 92977 37.94 92978 178.44 61.49 92979 108.56 49.34 92986 878.67 92987 877.47 92990 723.91 92992 484.12 92993 291.20 92997 437.05 92998 216.12 93000 10.99 93005 5.49 93010 5.49 93015 46.02 93016 14.42 93018 9.62 93024 70.00 33.98 36.03

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

93025 95.49 22.12 73.37 93050 10.53 5.49 5.04 93224 57.46 93227 17.17 93228 16.94 93229 456.73 93268 130.50 93270 5.95 93271 108.06 93272 16.48 93279 34.61 20.41 14.20 93280 40.20 23.95 16.26 93281 45.10 27.93 17.17 93282 43.50 27.70 15.80 93283 54.72 37.55 17.17 93284 59.30 40.98 18.32 93285 29.01 15.88 13.13 93286 18.02 7.83 10.19 93287 25.33 13.70 11.63 93288 25.83 12.60 13.22 93289 38.92 24.27 14.65 93290 21.68 11.30 10.39 93291 24.50 11.90 12.59 93292 22.42 12.00 10.42 93293 33.88 9.84 24.04 93294 19.92 93295 33.82 93296 16.48 93297 17.17 93298 17.17 93303 152.24 41.44 110.81 93304 101.18 23.23 77.95 93306 133.70 47.62 86.08 93307 89.43 28.83 60.60 93308 63.65 16.71 46.93 93312 159.57 71.20 88.37 93313 14.22 93314 154.08 59.75 94.32 93315 428.56 85.71 342.85 93316 18.09 93317 291.39 58.28 233.11 93318 348.75 69.75 279.00 93320 34.57 11.90 22.67 93321 17.40 4.81 12.59 93325 16.25 2.06 14.19 93350 126.32 48.06 78.27 93351 150.41 55.40 95.01 93352 21.75 93355 136.96

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

93451 500.27 85.64 414.63 93452 563.19 158.20 404.99 93453 730.78 212.46 518.32 93454 568.92 160.49 408.43 93455 655.68 187.04 468.64 93456 720.47 208.56 511.91 93457 760.02 226.29 533.73 93458 675.37 198.03 477.34 93459 741.76 224.13 517.63 93460 810.22 250.69 559.53 93461 917.36 277.48 639.89 93462 139.88 93463 64.56 93464 159.94 47.48 112.48 93503 64.83 93505 456.73 146.52 310.21 93530 537.44 135.48 93531 1,322.86 264.57 93532 1,641.86 328.37 93533 1,096.37 219.27 93561 25.18 12.53 93562 11.59 3.94 93563 38.69 93564 39.33 93565 29.99 93566 100.28 29.72 93567 84.94 33.68 93568 90.89 30.38 93571 161.57 55.67 93572 95.17 45.07 93580 651.33 93581 887.60 93582 444.60 93583 428.97 93590 706.59 93591 586.91 93592 258.42 93600 114.30 72.73 93602 94.30 71.25 93603 107.71 71.25 93609 224.21 170.57 93610 129.03 101.02 93612 135.19 100.39 93613 203.36 93615 32.57 27.57 93616 46.09 35.96 93618 229.26 145.47 93619 422.04 248.40 93620 1,971.53 394.31

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

93621 359.42 71.88 93622 525.31 105.06 93623 488.07 97.61 93624 188.84 137.33 93631 353.14 223.70 93640 279.60 118.25 93641 357.41 200.98 93642 223.90 170.79 53.11 93650 393.78 93653 557.70 93654 746.34 93655 283.89 93656 748.63 93657 283.43 93660 103.25 61.13 42.12 93662 430.65 86.13 93701 16.25 93724 153.03 145.89 7.14 93750 36.17 29.06 93770 4.48 93784 34.57 93798 16.48 8.81 93799 Y93880 130.50 26.10 104.40 93882 83.33 16.25 67.08 93886 175.60 30.68 144.92 93888 93.32 15.45 77.87 93890 179.03 33.43 145.61 93892 201.70 39.15 162.55 93893 224.59 39.15 185.44 93922 55.86 8.24 47.62 93923 86.54 14.42 72.12 93924 106.91 16.03 90.89 93925 165.98 25.64 140.34 93926 97.53 15.80 81.73 93930 133.24 25.87 107.37 93931 83.11 16.03 67.08 93970 126.37 22.44 103.94 93971 78.30 14.65 63.65 93975 180.40 37.55 142.86 93976 106.23 25.87 80.36 93978 122.25 25.64 96.61 93979 77.84 16.03 61.81 93980 80.82 40.29 40.52 93981 58.66 13.40 45.27 93990 101.19 16.03 85.17 94002 60.44 94003 43.27 94004 29.56

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

94010 22.89 5.49 17.40 94011 56.05 94012 90.40 94013 16.60 94016 16.48 94060 38.46 8.47 29.99 94070 38.69 18.77 19.92 94150 16.48 94200 17.79 3.65 14.14 94250 17.86 3.66 14.19 94375 25.64 9.62 16.03 94400 35.66 9.76 25.92 94450 45.08 12.47 32.60 94610 36.40 94617 60.90 21.75 39.15 94618 21.98 14.88 7.10 94621 103.94 44.87 59.07 94640 11.68 94644 30.46 94645 8.67 94660 41.44 23.99 94662 22.54 94664 10.99 94667 16.25 94680 35.94 8.24 27.70 94681 35.49 6.64 28.85 94690 34.11 2.52 31.59 94726 34.80 8.01 26.79 94727 28.16 8.01 20.15 94728 26.33 8.24 18.09 94729 35.71 5.95 29.76 94750 54.34 7.02 47.32 94770 10.82 94772 18.20 94774 32.71 Y94777 32.71 94799 Y95004 3.25 95017 4.87 2.55 95018 13.97 4.62 95024 5.27 0.66 95027 2.88 95028 8.29 95044 3.66 95052 4.04 95056 27.38 95060 22.15 95065 15.77 95070 20.60

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

95071 20.88 95076 78.53 47.33 95079 49.76 44.70 95115 5.95 95117 6.87 95144 7.45 2.05 95145 14.92 1.98 95146 23.33 1.98 95147 22.70 1.98 95148 29.81 2.08 95149 46.83 1.98 95165 9.01 1.98 95170 6.58 1.98 95180 89.74 65.16 95782 587.23 81.96 505.27 95783 625.23 89.29 535.95 95805 271.75 38.46 233.29 95808 310.03 45.08 264.95 95810 397.21 78.98 318.23 95811 416.44 81.96 334.48 95812 210.40 37.78 172.62 95813 261.45 56.78 204.67 95816 219.18 35.21 183.96 95819 247.60 33.82 213.78 95822 227.84 34.70 193.14 95827 355.96 33.32 322.64 95829 996.55 179.96 816.59 95831 19.71 9.76 95832 15.95 10.90 95833 21.66 13.63 95834 29.18 19.64 95836 71.89 95851 11.06 4.80 95852 8.86 3.74 95857 32.40 18.58 95860 74.90 32.10 42.80 95861 112.18 54.03 58.15 95863 122.63 56.83 65.80 95864 135.54 58.47 77.07 95865 86.77 51.26 35.52 95866 76.80 38.21 38.59 95867 66.77 26.93 39.84 95868 85.44 39.35 46.09 95869 39.84 8.51 31.34 95870 38.98 11.91 27.07 95872 129.12 100.96 28.16 95873 48.76 13.05 35.71 95874 45.78 11.97 33.81 95885 39.61 12.36 27.24

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

95886 61.36 30.22 31.14 95887 53.34 24.73 28.62 95905 42.32 1.70 40.61 95907 62.27 35.03 27.24 95908 80.59 44.19 36.40 95909 96.15 52.66 43.50 95910 126.15 70.28 55.86 95911 151.56 87.68 63.87 95912 170.33 104.40 65.93 95913 196.66 123.63 73.03 95921 54.03 29.53 24.50 95922 61.81 31.36 30.45 95925 85.39 18.09 67.31 95926 82.65 17.86 64.79 95927 86.39 17.28 69.11 95928 141.94 51.97 89.97 95929 145.38 52.20 93.18 95930 62.82 9.05 53.77 Y95937 56.53 22.34 34.19 95938 224.13 30.22 193.91 95939 330.33 77.64 252.69 95940 21.29 95950 189.33 51.28 138.05 95951 509.78 193.10 95953 287.55 107.14 180.40 95954 231.99 67.63 164.36 95956 675.90 89.08 586.81 95957 174.45 67.54 106.91 95958 354.98 140.78 214.21 95961 198.95 106.23 92.72 95962 158.59 105.23 53.36 95970 38.48 14.38 95971 32.97 25.76 95972 37.94 26.20 95976 26.56 25.10 95977 35.26 33.46 95983 33.43 31.70 95984 29.08 27.74 95990 51.71 95991 75.55 25.10 95992 28.62 23.55 95999 Y96105 52.89 96116 61.81 53.05 96130 75.55 68.24 96131 57.46 51.95 96132 84.94 66.92 96133 64.79 51.29 96136 30.45 15.41

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

96137 28.16 12.11 96360 28.62 96361 8.70 96365 46.25 96366 12.91 96367 20.15 96368 13.51 96369 111.43 96370 8.98 96371 39.58 96372 12.57 96373 12.13 96374 28.40 96375 11.06 96376 12.53 96377 13.05 96401 51.17 96402 19.92 96405 55.16 19.69 96406 70.06 28.82 96409 69.83 96411 37.78 96413 90.89 96415 19.49 96416 91.12 96417 43.96 96420 61.89 96422 101.44 96423 47.00 96425 107.34 96440 211.66 83.44 96450 117.45 49.97 96521 94.55 96522 77.38 96523 17.06 96542 77.76 27.80 96900 13.97 96910 48.98 96912 62.88 96913 79.56 96920 106.23 41.83 96921 116.53 47.11 96922 158.20 75.51 96999 Y97018 5.65 97597 48.57 14.97 97598 18.09 7.04 97602 20.66 97799 Y

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

98925 20.38 14.97 98926 29.30 22.45 98927 38.46 29.72 98928 46.70 37.20 98929 55.86 45.13 98940 16.69 13.84 98941 25.48 21.03 98942 26.98 25.63 99050 7.28 99051 7.28 99151 48.54 15.85 99152 32.97 7.70 99153 6.87 99155 58.15 99156 51.28 99157 39.72 99183 75.29 99188 21.87 6.38 99195 65.48 99201 29.53 16.73 99202 43.54 31.48 99203 64.80 47.33 99204 91.62 80.13 99205 116.44 104.56 99211 TH 12.08 5.72 99211 FP 12.08 5.72 99211 12.08 5.72 99212 21.14 15.85 99212 TH 21.14 15.85 99213 25.76 24.48 99213 TH 25.76 24.48 99214 40.14 38.14 99214 TH 40.14 38.14 99215 58.36 55.44 99215 TH 58.36 55.44 99217 47.16 99218 59.99 99219 87.68 99220 119.74 99221 65.48 99222 88.37 99223 130.50 99224 25.64 99225 47.16 99226 67.54 99231 25.41 99232 46.93 99233 67.08 99234 85.85

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

99235 109.20 99236 140.34 99238 47.16 99239 69.14 99241 30.68 20.25 99242 57.69 42.49 99243 78.98 59.44 99244 118.13 95.54 99245 144.00 118.21 99251 31.59 99252 48.31 99253 74.41 99254 108.06 99255 130.04 99281 13.74 99282 26.79 99283 40.06 99284 76.01 99285 111.95 99291 179.03 138.24 99292 79.21 69.34 99304 58.15 99305 84.02 99306 107.60 99307 28.39 99308 44.41 99309 59.07 99310 87.46 99315 47.39 99316 72.27 99318 61.81 99324 35.71 99325 51.74 99326 89.74 99327 120.42 99328 141.71 99334 38.92 99335 61.36 99336 87.46 99337 125.23 99339 46.36 99340 69.83 99341 35.71 99342 51.51 99343 84.02 99344 117.68 99345 143.09 99347 35.71 99347 TH 35.71

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

99348 54.26 99348 TH 54.26 99349 83.33 99349 TH 83.33 99350 115.61 99350 TH 115.61 99354 52.78 50.14 99354 TH 52.78 50.14 99355 51.28 48.72 99355 TH 51.28 48.72 99356 59.52 99357 59.75 99360 38.32 99381 71.47 47.77 99382 71.47 51.07 99383 FP 71.47 54.15 99383 71.47 54.15 99384 FP 71.47 63.40 99384 71.47 63.40 99385 EP 71.47 60.76 99385 FP 85.17 60.76 99385 85.17 60.76 99386 FP 98.90 73.97 99386 98.90 73.97 99387 107.14 79.47 99391 71.47 43.59 99392 71.47 47.77 99393 FP 71.47 47.77 99393 71.47 47.77 99394 FP 71.47 54.15 99394 71.47 54.15 99395 EP 71.47 55.69 99395 FP 76.92 55.69 99395 76.92 55.69 99396 FP 81.96 60.32 99396 81.96 60.32 99397 88.14 63.40 99401 24.85 15.41 99402 38.54 31.26 99403 FP 44.94 46.67 99406 7.49 7.12 99407 13.27 12.61 99415 6.08 99416 0.43 99460 39.08 99461 47.46 38.85 99462 27.24 99463 51.96 99464 48.54

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

99465 94.55 99468 650.55 99469 261.62 99471 565.82 99472 269.94 99475 362.64 99476 225.73 99477 231.52 99478 91.90 99479 81.73 99480 78.95 99490 26.79 19.81 A4261 55.00 G0101 25.18 17.17 G0127 14.04 4.80 G0166 77.95 G0245 41.21 26.71 G0246 25.27 13.21 G0247 33.81 14.41 G0289 56.05 H1000 52.00 H1001 TG 156.00 H1001 104.00 L8603 376.73 YL8606 197.76 YQ0111 9.35 Q0112 3.64 Q0113 5.00 Q0114 4.00 Q4001 25.12 Q4002 94.96 Q4003 18.05 Q4004 62.48 Q4005 6.65 Q4006 14.99 Q4007 3.33 Q4008 7.50 Q4009 4.44 Q4010 10.00 Q4011 2.22 Q4012 5.00 Q4013 8.08 Q4014 13.64 Q4015 4.04 Q4016 6.82 Q4017 4.68 Q4018 7.46 Q4019 2.34 Q4020 3.73

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Procedure Mod FSI Facility PCI TCI PA

Practitioner Fee Schedule2019

Q4021 3.46 Q4022 6.24 Q4023 1.74 Q4024 3.12 Q4025 19.40 Q4026 60.57 Q4027 9.70 Q4028 30.29 Q4029 14.83 Q4030 39.05 Q4031 7.42 Q4032 19.52 Q4033 13.85 Q4034 34.42 Q4035 6.92 Q4036 17.21 Q4037 8.44 Q4038 21.15 Q4039 4.23 Q4040 10.58 Q4041 10.26 Q4042 17.52 Q4043 5.13 Q4044 8.76 Q4045 5.96 Q4046 9.58 Q4047 2.98 Q4048 4.80 Q4049 1.09 Q4101 26.21 Q4102 6.43 Q4104 9.60 Q4106 35.67 Q4112 YQ4121 21.60 Q4124 123.06 Q4132 140.37 Q4133 138.78 Q4186 179.00 Q4187 179.00 S2401 6,350.00 S2402 6,350.00 S2411 6,350.00 YS4005 200.00 S8415 245.00

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