Professional Services Fee Schedule
Medicine
Effective July 1, 2016
July 1, 2016
Professional Services Fee Schedule
Medicine Fees
Effective for Dates of Service on or After
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CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 1
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
Copyright Information Physicians’ Current Procedural Terminology (CPT®) five-digit codes, descriptions, and other data only are copyright 2015 American Medical Association. All Rights Reserved. CPT® is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein. This document is also on the department’s Internet web site at http://feeschedules.lni.wa.gov/. Updates to this manual can be found under ‘Updates and Corrections’ tab on the department’s Internet web site at http://feeschedules.lni.wa.gov/ Updates to this manual are also announced on the Medical Provider e-News listserv. Individuals may join the listserv at http://www.lni.wa.gov/Main/Listservs/Provider.asp.
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 2
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
MEDICINE FEES
2015 CPT or HCPCS code
CPT CODE/
HCPCS CODE2015 CPT
or HCPCS code
DOLLAR VALUE
NON-FACILITY
SETTING
This column indicates the:
• Maximum dollar amount for covered
services provided in a non-facility
setting, or
• Pricing method for the procedure
code, or
• Coverage status for the procedure
code.
Dollar Value Maximum dollar amount payable for covered Bundled Bundled code, not separately payable.
FIELD KEY: Column Title Column Description Column Values Value Definitions
By Report Service paid on a “by report” basis.
Contracted
Contracted service. Payable only to
department’s contracted vendor for State
Fund claims. Payable to providers treating
Self-Insured injured workers.
Facility Only Procedure code for facility outpatient use
DOLLAR VALUE
FACILITY SETTING
This column indicates the:
• Maximum dollar amount for covered
services provided in a facility setting,
or
• Pricing method for the procedure
code, or
• Coverage status for the procedure
code.
Dollar Value Maximum dollar amount payable for covered Bundled Bundled code, not separately payable.
By Report Service paid on a “by report” basis.
Contracted
Contracted service. Payable only to
department’s contracted vendor for State
Fund claims. Payable to providers treating
Self-Insured injured workers.
Hosp. Only Procedure code for hospital outpatient use
Not Covered Procedure code is not covered.
Not Covered Procedure code is not covered.
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 3
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
PCTC
(26/TC)
Professional and Technical
Component (Modifiers –26 and –TC)
This field identifies whether
professional and technical component
modifiers (-26/-TC) are valid with the
procedure code.
0
Modifiers -26 and -TC are not valid . The
procedure is for physician services only; the
concept of PC/TC does not apply
1
Modifiers -26 and -TC are valid .
Diagnostic test or radiology service which
has both a professional and technical
component.
2
Modifiers -26 and -TC are not valid . Stand
alone code for the professional component of
a diagnostic test. An associated code
describes the technical component of the
diagnostic test or the global procedure
(professional and technical components).
3
Modifiers -26 and -TC are not valid . Stand
alone code for the technical component of a
diagnostic test. An associated code
describes the professional component of the
diagnostic test or the global procedure
(professional and technical components).
FOL UP Follow-up Days for Global Surgery Number
The number of days following surgery during
which charges for normal postoperative care
are bundled in the global surgery fee.
Percent
The percent of the total global surgery dollar
value that is allowed when modifier –56 is
billed.
Percent
The percent of the total global surgery dollar
value that is allowed when modifier -54 is
billed.
Percent
PRE OP
(-56)
Preoperative Percentage
(Modifier –56)
INTRA OP
(-54)
Intraoperative Percentage
(Modifier –54)
POST OP
(-55)
Postoperative Percentage
(Modifier –55)
Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions
The percent of the total global surgery dollar
value that is allowed when modifier -55 is
billed.
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 4
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
PCTC
(26/TC)
Professional and Technical
Component (Modifiers –26 and –TC)
This field identifies whether
professional and technical component
modifiers (-26/-TC) are valid with the
procedure code.
3
Modifiers -26 and -TC are not valid . Stand
alone code for the technical component of a
diagnostic test. An associated code
describes the professional component of the
diagnostic test or the global procedure
(professional and technical components).
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 5
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
PCTC
(26/TC)
(Continued)
Professional and Technical
Component (Modifiers –26 and –TC)
This field identifies whether
professional and technical
component modifiers (-26/-TC) are
valid with the procedure code.
4
Modifiers -26 and -TC are not valid . Stand
alone code for the global procedure for a
diagnostic test. Associated codes describe
the professional and technical components
of the diagnostic test.
Modifier -TC is not valid ; modifier -26
may be valid . Clinical laboratory or other
service for which separate payment for
interpretations by laboratory physicians or
other physicians may be made.
7 This indicator is not currently in use.
Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions
8
Professional component of a clinical
laboratory code; payable only if the physician
interprets an abnormal smear for a hospital
inpatient. No -TC modifier billing is
recognized; payment for the underlying
clinical laboratory test is made to the
hospital. Not payable when furnished to
hospital outpatients or non-hospital patients.
5
Modifiers -26 and -TC are not valid .
Covered service incident to a physician’s
service when provided by auxiliary personnel
employed by and working under the direct
supervision of the physician. This service not
payable when provided to hospital inpatients
or outpatients.
6
9
Modifiers -26 and -TC are not valid .
Concept of a professional/technical
component split does not apply.
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 6
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions
Modifier -51 may be valid . Multiple
endoscopic procedures payment policy
applies if this service is billed with another
endoscopy in the same family.
4 This indicator is not currently in use.
Modifier -51 is not valid . Payment
adjustment rules for multiple surgeries do not
apply.
1 This indicator is not currently in use.
2
Modifier -51 is valid . Standard multiple
surgery payment policy applies (100%, 50%,
50%, 50%, 50%).
0
9Modifier -51 is not valid . Concept of
multiple surgery does not apply.
MSI
Multiple Surgery Indicator
(Modifier –51)
This field indicates whether multiple
surgery payment rules apply to the
service. 3
5 This indicator is not currently in use.
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 7
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
0
3
Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions
BSI
Modifier -50 is not valid . Payment
adjustment rule for bilateral surgery does not
apply.
1
Modifier -50 is valid . Payment adjustment
for bilateral procedures (150%) applies to
this procedure.
2
Modifier -50 is not valid . Payment
adjustment for bilateral procedures does not
apply. Procedures in this category include
services for which the code descriptor
specifically states that the procedure is
bilateral; procedures that are usually
performed as bilateral procedures; or
procedures for which the code descriptor
indicates the procedures may be performed
either unilaterally or bilaterally.
Bilateral Surgery Indicator
(Modifier –50)
This field indicates whether the
procedure is subject to a payment
adjustment for bilateral surgery.
Modifier -50 is not valid . Payment
adjustment for bilateral procedure does not
apply. This is a radiology procedure which is
not subject to payment rules for bilateral
surgeries.
9Modifier -50 is not valid . Concept of
bilateral surgery does not apply.
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 8
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CSI
Co-surgeons Indicator
(Modifier –62)
This field indicates whether or not co-
surgeons may be paid for the
procedure.
ASI
0
9
Assistant Surgeon Indicator
(Modifiers –80, -81, -82)
This field indicates whether or not an
assistant surgeon may be paid for the
procedure.
0
Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions
9Modifiers -80, -81 and -82 are not valid .
Concept does not apply.
Modifiers -80, -81 and -82 are not valid.
Assistant at surgery may not be paid for this
procedure.
2Modifiers -80, -81 and -82 are valid .
Assistant at surgery may be paid.
Modifier -62 is not valid . Co-surgeons not
permitted.
1
Modifier -62 is not valid under normal
situations . Supporting documentation is
required to establish medical necessity of
two surgeons.
2
Modifier -62 is valid . Co-surgeons may be
paid for this procedure. Supporting
documentation is not required if two specialty
requirement is met.
Modifiers -80, -81 and -82 are not valid
under normal situations . Assistant at
surgery is not usually paid for this procedure.
Supporting documentation is necessary to
establish medical necessity.
1
Modifier -62 is not valid with this
procedure. Concept of co-surgeons does
not apply.
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 9
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
Modifier -66 is not valid . Team surgeons
not permitted.
1
Bundled code, not separately payable.
C
Modifier -66 is not valid under normal
situations . Team surgeons may be payable.
Supporting documentation is required to
establish medical necessity of a team.
Modifier -66 is valid. Team surgeons
permitted.
Modifier -66 is not valid . Concept of team
surgery does not apply.
Contracted service. Payable only to
department’s contracted vendor for State
Fund claims. Payable to providers treating
Self-Insured injured workers.
0
2
9
B
TSI
Team Surgeons Indicator
(Modifier -66)
This field indicates whether or not
team surgeons may be paid for the
procedure.
Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions
D
Drug fee based on Average Wholesale Price
(AWP) or Average Average Wholesale Price
(AAWP).
F Flat fee developed by the department
ENDO BASE Endoscopy Base Code Code number
This column contains the endoscopic base
code for procedure codes that are part of an
endoscopy family. The Multiple Surgery
Indicator for procedures in an endoscopy
family is 3.
FSI
Fee Schedule Indicator
This column indicates the payment
status for the procedure code.
For hospital outpatient use only.
R RBRVS fee
L Clinical lab fee
N No fee or RVUs available, code paid by report.
S State Rate
T Tracking code
O
PRIOR AUTH
Prior authorization indicator
This column indicates whether prior
authorization and utilization review is
required.
Y Prior authorization required
X Non-covered code
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 10
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
PRIOR AUTH
Prior authorization indicator
This column indicates whether prior
authorization and utilization review is
required.
Y Prior authorization required
Y-UR Prior authorization and UR required
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 11
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTH
90281 $30.75 $30.75 0 0% 0% 0% 9 9 9 9 9 9 D Y
90283 $684.02 $684.02 0 0% 0% 0% 9 9 9 9 9 9 D Y
90284 $32.62 $32.62 0 0% 0% 0% 9 9 9 9 9 9 D Y
90287 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y
90288 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
90291 $26.42 $26.42 0 0% 0% 0% 9 9 9 9 9 9 D Y
90296 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y
90371 $172.85 $172.85 0 0% 0% 0% 9 9 9 9 9 9 D
90375 $268.96 $268.96 0 0% 0% 0% 9 9 9 9 9 9 D
90376 $268.96 $268.96 0 0% 0% 0% 9 9 9 9 9 9 D
90378 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90384 $127.44 $127.44 0 0% 0% 0% 9 9 9 9 9 9 D
90385 $37.10 $37.10 0 0% 0% 0% 9 9 9 9 9 9 D
90386 $276.49 $276.49 0 0% 0% 0% 9 9 9 9 9 9 D
90389 $407.82 $407.82 0 0% 0% 0% 9 9 9 9 9 9 D
90393 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90396 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90399 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
90460 $45.52 $45.52 0 0% 0% 0% 0 0 0 0 0 0 R
90461 $22.15 $22.15 0 0% 0% 0% 0 0 0 0 0 0 R
90471 $45.52 $45.52 0 0% 0% 0% 5 0 0 0 0 0 R
90472 $22.15 $22.15 0 0% 0% 0% 5 0 0 0 0 0 R
90473 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90474 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90476 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
90477 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
90581 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
90585 $156.76 $156.76 0 0% 0% 0% 9 9 9 9 9 9 D Y
90586 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90625 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
90630 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
90632 $67.34 $67.34 0 0% 0% 0% 9 9 9 9 9 9 D Y
90633 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90634 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90636 $95.42 $95.42 0 0% 0% 0% 9 9 9 9 9 9 D Y
90644 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90644 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
NON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 12
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
90647 $29.81 $29.81 0 0% 0% 0% 9 9 9 9 9 9 D Y
90648 $26.97 $26.97 0 0% 0% 0% 9 9 9 9 9 9 D Y
90649 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90650 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90651 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90653 $11.07 $11.07 0 0% 0% 0% 9 9 9 9 9 9 D Y
90654 $17.24 $17.24 0 0% 0% 0% 9 9 9 9 9 9 D Y
90655 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90656 $12.68 $12.68 0 0% 0% 0% 9 9 9 9 9 9 D Y
90657 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90658 $14.90 $14.90 0 0% 0% 0% 9 9 9 9 9 9 D Y
90660 $23.71 $23.71 0 0% 0% 0% 9 9 9 9 9 9 D Y
90661 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
90662 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
90664 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y
90666 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y
90667 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y
90668 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y
90670 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
90672 $23.71 $23.71 0 0% 0% 0% 9 9 9 9 9 9 D Y
90673 $19.85 $19.85 0 0% 0% 0% 9 9 9 9 9 9 D Y
90675 $91.22 $91.22 0 0% 0% 0% 9 9 9 9 9 9 D Y
90676 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
90680 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90681 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90685 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90686 $16.36 $16.36 0 0% 0% 0% 9 9 9 9 9 9 D Y
90687 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90688 $15.28 $15.28 0 0% 0% 0% 9 9 9 9 9 9 D Y
90690 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90691 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90696 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90698 $82.81 $82.81 0 0% 0% 0% 9 9 9 9 9 9 D Y
90700 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90702 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90707 $3.63 $3.63 0 0% 0% 0% 9 9 9 9 9 9 D Y
90710 $178.71 $178.71 0 0% 0% 0% 9 9 9 9 9 9 D Y
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 13
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
90713 $30.26 $30.26 0 0% 0% 0% 9 9 9 9 9 9 D Y
90714 $41.83 $41.83 0 0% 0% 0% 9 9 9 9 9 9 D
90715 $47.14 $47.14 0 0% 0% 0% 9 9 9 9 9 9 D
90716 $107.92 $107.92 0 0% 0% 0% 9 9 9 9 9 9 D Y
90717 $127.86 $127.86 0 0% 0% 0% 9 9 9 9 9 9 D Y
90723 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90732 $78.17 $78.17 0 0% 0% 0% 9 9 9 9 9 9 D Y
90733 $132.21 $132.21 0 0% 0% 0% 9 9 9 9 9 9 D Y
90734 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90736 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90738 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90739 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90740 $111.78 $111.78 0 0% 0% 0% 9 9 9 9 9 9 D Y
90743 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90744 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90746 $55.89 $55.89 0 0% 0% 0% 9 9 9 9 9 9 D
90747 $111.78 $111.78 0 0% 0% 0% 9 9 9 9 9 9 D
90748 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90748 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
90749 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
90785 $23.99 $23.99 0 0% 0% 0% 0 0 0 9 0 0 R Y
90791 $227.01 $219.63 0 0% 0% 0% 0 0 0 9 0 0 R Y
90792 $251.00 $243.62 0 0% 0% 0% 0 0 0 9 0 0 R Y
90832 $110.12 $108.89 0 0% 0% 0% 0 0 0 9 0 0 R Y
90833 $113.81 $112.58 0 0% 0% 0% 0 0 0 9 0 0 R Y
90834 $146.42 $145.19 0 0% 0% 0% 0 0 0 9 0 0 R Y
90836 $143.96 $142.73 0 0% 0% 0% 0 0 0 9 0 0 R Y
90837 $219.01 $217.78 0 0% 0% 0% 0 0 0 9 0 0 R Y
90838 $190.10 $188.87 0 0% 0% 0% 0 0 0 9 0 0 R Y
90839 $229.47 $227.01 0 0% 0% 0% 0 0 0 0 0 0 R Y
90840 $109.51 $108.89 0 0% 0% 0% 0 0 0 0 0 0 R Y
90845 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90846 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90847 $183.94 $182.10 0 0% 0% 0% 0 0 0 0 0 0 R Y
90849 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90853 $44.29 $43.68 0 0% 0% 0% 0 0 0 0 0 0 R Y
90863 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 14
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
90865 $292.22 $223.32 0 0% 0% 0% 0 0 0 0 0 0 R Y
90867 By Report By Report 0 0% 0% 0% 0 0 0 1 0 0 N Y
90868 By Report By Report 0 0% 0% 0% 0 0 0 1 0 0 N Y
90869 By Report By Report 0 0% 0% 0% 0 0 0 1 0 0 N Y
90870 $313.14 $191.94 0 0% 0% 0% 0 0 0 0 0 0 R Y
90875 $106.43 $106.43 0 0% 0% 0% 9 9 9 9 9 9 R Y
90876 $188.87 $168.56 0 0% 0% 0% 9 9 9 9 9 9 R Y
90880 $175.95 $162.41 0 0% 0% 0% 0 0 0 0 0 0 R Y
90882 $75.18 $75.18 0 0% 0% 0% 9 9 9 9 9 9 F Y
90885 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
90887 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
90889 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
90899 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y
90901 $68.29 $34.45 0 0% 0% 0% 0 0 0 0 0 0 R
90911 $149.49 $76.90 0 0% 0% 0% 0 0 0 0 0 0 R
90935 $125.50 $125.50 0 0% 0% 0% 0 0 0 0 0 0 R
90937 $179.64 $179.64 0 0% 0% 0% 0 0 0 0 0 0 R
90940 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
90945 $149.49 $149.49 0 0% 0% 0% 0 0 0 0 0 0 R
90947 $214.70 $214.70 0 0% 0% 0% 0 0 0 0 0 0 R
90951 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90952 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90953 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90954 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90955 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90956 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90957 $1,117.82 $1,117.82 0 0% 0% 0% 0 0 0 0 0 0 R
90958 $756.08 $756.08 0 0% 0% 0% 0 0 0 0 0 0 R
90959 $514.31 $514.31 0 0% 0% 0% 0 0 0 0 0 0 R
90960 $493.39 $493.39 0 0% 0% 0% 0 0 0 0 0 0 R
90961 $415.26 $415.26 0 0% 0% 0% 0 0 0 0 0 0 R
90962 $321.13 $321.13 0 0% 0% 0% 0 0 0 0 0 0 R
90963 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90964 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
90965 $785.00 $785.00 0 0% 0% 0% 0 0 0 0 0 0 R
90966 $414.03 $414.03 0 0% 0% 0% 0 0 0 0 0 0 R
90967 $31.38 $31.38 0 0% 0% 0% 0 0 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 15
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
90968 $27.07 $27.07 0 0% 0% 0% 0 0 0 0 0 0 R
90969 $26.45 $26.45 0 0% 0% 0% 0 0 0 0 0 0 R
90970 $13.53 $13.53 0 0% 0% 0% 0 0 0 0 0 0 R
90989 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
90993 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
90997 $162.41 $162.41 0 0% 0% 0% 0 0 0 0 0 0 R
90999 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
91010 $316.21 $316.21 0 0% 0% 0% 1 0 0 0 0 0 R Y
91010-26 $117.50 $117.50 0 0% 0% 0% 1 0 0 0 0 0 R Y
91010-TC $198.71 $198.71 0 0% 0% 0% 1 0 0 0 0 0 R Y
91013 $41.83 $41.83 0 0% 0% 0% 1 0 0 0 0 0 R Y
91013-26 $16.61 $16.61 0 0% 0% 0% 1 0 0 0 0 0 R Y
91013-TC $25.22 $25.22 0 0% 0% 0% 1 0 0 0 0 0 R Y
91020 $422.03 $422.03 0 0% 0% 0% 1 0 0 0 0 0 R Y
91020-26 $132.27 $132.27 0 0% 0% 0% 1 0 0 0 0 0 R Y
91020-TC $289.76 $289.76 0 0% 0% 0% 1 0 0 0 0 0 R Y
91022 $300.83 $300.83 0 0% 0% 0% 1 0 0 0 0 0 R
91022-26 $132.88 $132.88 0 0% 0% 0% 1 0 0 0 0 0 R
91022-TC $167.95 $167.95 0 0% 0% 0% 1 0 0 0 0 0 R
91030 $245.46 $245.46 0 0% 0% 0% 1 0 0 0 0 0 R Y
91030-26 $83.05 $83.05 0 0% 0% 0% 1 0 0 0 0 0 R Y
91030-TC $162.41 $162.41 0 0% 0% 0% 1 0 0 0 0 0 R Y
91034 $342.05 $342.05 0 0% 0% 0% 1 0 0 0 0 0 R Y
91034-26 $89.82 $89.82 0 0% 0% 0% 1 0 0 0 0 0 R Y
91034-TC $252.85 $252.85 0 0% 0% 0% 1 0 0 0 0 0 R Y
91035 $872.97 $872.97 0 0% 0% 0% 1 0 0 0 0 0 R Y
91035-26 $146.42 $146.42 0 0% 0% 0% 1 0 0 0 0 0 R Y
91035-TC $726.55 $726.55 0 0% 0% 0% 1 0 0 0 0 0 R Y
91037 $289.14 $289.14 0 0% 0% 0% 1 0 0 0 0 0 R Y
91037-26 $89.20 $89.20 0 0% 0% 0% 1 0 0 0 0 0 R Y
91037-TC $199.94 $199.94 0 0% 0% 0% 1 0 0 0 0 0 R Y
91038 $820.06 $820.06 0 0% 0% 0% 1 0 0 0 0 0 R Y
91038-26 $101.51 $101.51 0 0% 0% 0% 1 0 0 0 0 0 R Y
91038-TC $718.55 $718.55 0 0% 0% 0% 1 0 0 0 0 0 R Y
91040 $792.38 $792.38 0 0% 0% 0% 1 0 0 0 0 0 R Y
91040-26 $88.59 $88.59 0 0% 0% 0% 1 0 0 0 0 0 R Y
91040-TC $703.79 $703.79 0 0% 0% 0% 1 0 0 0 0 0 R Y
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 16
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
91065 $142.11 $142.11 0 0% 0% 0% 1 0 0 0 0 0 R Y
91065-26 $17.84 $17.84 0 0% 0% 0% 1 0 0 0 0 0 R Y
91065-TC $124.27 $124.27 0 0% 0% 0% 1 0 0 0 0 0 R Y
91110 $1,603.21 $1,603.21 0 0% 0% 0% 1 0 0 0 0 0 R
91110-26 $335.28 $335.28 0 0% 0% 0% 1 0 0 0 0 0 R
91110-TC $1,268.54 $1,268.54 0 0% 0% 0% 1 0 0 0 0 0 R
91111 $1,324.53 $1,324.53 0 0% 0% 0% 1 0 0 0 0 0 R
91111-26 $92.28 $92.28 0 0% 0% 0% 1 0 0 0 0 0 R
91111-TC $1,232.25 $1,232.25 0 0% 0% 0% 1 0 0 0 0 0 R
91112 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
91117 $243.00 $243.00 0 0% 0% 0% 0 0 0 0 0 0 R
91120 $775.15 $775.15 0 0% 0% 0% 1 0 0 0 0 0 R
91120-26 $87.36 $87.36 0 0% 0% 0% 1 0 0 0 0 0 R
91120-TC $687.79 $687.79 0 0% 0% 0% 1 0 0 0 0 0 R
91122 $406.03 $406.03 0 0% 0% 0% 1 0 0 0 0 0 R
91122-26 $156.88 $156.88 0 0% 0% 0% 1 0 0 0 0 0 R
91122-TC $249.16 $249.16 0 0% 0% 0% 1 0 0 0 0 0 R
91132 $279.30 $279.30 0 0% 0% 0% 1 0 0 0 0 0 R
91132-26 $47.99 $47.99 0 0% 0% 0% 1 0 0 0 0 0 R
91132-TC $231.32 $231.32 0 0% 0% 0% 1 0 0 0 0 0 R
91133 $311.91 $311.91 0 0% 0% 0% 1 0 0 0 0 0 R
91133-26 $60.90 $60.90 0 0% 0% 0% 1 0 0 0 0 0 R
91133-TC $251.00 $251.00 0 0% 0% 0% 1 0 0 0 0 0 R
91200 $50.45 $50.45 0 0% 0% 0% 1 0 0 0 0 0 R Y
91200-26 $22.76 $22.76 0 0% 0% 0% 1 0 0 0 0 0 R Y
91200-TC $27.68 $27.68 0 0% 0% 0% 1 0 0 0 0 0 R Y
91299 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
91299-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
91299-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
92002 $143.96 $84.28 0 0% 0% 0% 0 0 2 0 0 0 R
92004 $262.69 $174.10 0 0% 0% 0% 0 0 2 0 0 0 R
92012 $151.95 $92.90 0 0% 0% 0% 0 0 2 0 0 0 R
92014 $219.63 $140.27 0 0% 0% 0% 0 0 2 0 0 0 R
92015 $34.45 $33.84 0 0% 0% 0% 9 9 9 9 9 9 R
92018 $256.54 $256.54 0 0% 0% 0% 0 0 0 0 0 0 R
92019 $126.12 $126.12 0 0% 0% 0% 0 0 0 0 0 0 R
92020 $47.37 $36.91 0 0% 0% 0% 0 0 2 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 17
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
92025 $67.67 $67.67 0 0% 0% 0% 1 7 2 0 0 0 R
92025-26 $35.68 $35.68 0 0% 0% 0% 1 7 2 0 0 0 R
92025-TC $31.99 $31.99 0 0% 0% 0% 1 7 2 0 0 0 R
92060 $116.27 $116.27 0 0% 0% 0% 1 7 2 0 0 0 R
92060-26 $67.67 $67.67 0 0% 0% 0% 1 7 2 0 0 0 R
92060-TC $48.60 $48.60 0 0% 0% 0% 1 7 2 0 0 0 R
92065 $92.90 $92.90 0 0% 0% 0% 1 0 2 0 0 0 R Y
92065-26 $30.76 $30.76 0 0% 0% 0% 1 0 2 0 0 0 R Y
92065-TC $62.14 $62.14 0 0% 0% 0% 1 0 2 0 0 0 R Y
92071 $66.44 $59.06 0 0% 0% 0% 0 0 1 0 0 0 R
92072 Not Covered Not Covered 0 0% 0% 0% 0 0 2 0 0 0 X
92081 $60.29 $60.29 0 0% 0% 0% 1 7 2 0 0 0 R
92081-26 $28.91 $28.91 0 0% 0% 0% 1 7 2 0 0 0 R
92081-TC $31.38 $31.38 0 0% 0% 0% 1 7 2 0 0 0 R
92082 $85.51 $85.51 0 0% 0% 0% 1 7 2 0 0 0 R
92082-26 $38.14 $38.14 0 0% 0% 0% 1 7 2 0 0 0 R
92082-TC $47.37 $47.37 0 0% 0% 0% 1 7 2 0 0 0 R
92083 $115.66 $115.66 0 0% 0% 0% 1 7 2 0 0 0 R
92083-26 $49.22 $49.22 0 0% 0% 0% 1 7 2 0 0 0 R
92083-TC $65.83 $65.83 0 0% 0% 0% 1 7 2 0 0 0 R
92100 $143.96 $59.67 0 0% 0% 0% 0 0 2 0 0 0 R
92132 $62.14 $62.14 0 0% 0% 0% 1 7 2 0 0 0 R
92132-26 $33.84 $33.84 0 0% 0% 0% 1 7 2 0 0 0 R
92132-TC $28.30 $28.30 0 0% 0% 0% 1 7 2 0 0 0 R
92133 $78.13 $78.13 0 0% 0% 0% 1 7 2 0 0 0 R
92133-26 $49.22 $49.22 0 0% 0% 0% 1 7 2 0 0 0 R
92133-TC $28.91 $28.91 0 0% 0% 0% 1 7 2 0 0 0 R
92134 $80.59 $80.59 0 0% 0% 0% 1 7 2 0 0 0 R
92134-26 $51.06 $51.06 0 0% 0% 0% 1 7 2 0 0 0 R
92134-TC $29.53 $29.53 0 0% 0% 0% 1 7 2 0 0 0 R
92136 $163.64 $163.64 0 0% 0% 0% 1 7 2 0 0 0 R
92136-26 $55.98 $55.98 0 0% 0% 0% 1 7 3 0 0 0 R
92136-TC $107.66 $107.66 0 0% 0% 0% 1 7 2 0 0 0 R
92140 $113.20 $46.76 0 0% 0% 0% 0 0 2 0 0 0 R Y
92145 $27.68 $27.68 0 0% 0% 0% 1 7 2 0 0 0 R Y
92145-26 $15.38 $15.38 0 0% 0% 0% 1 7 2 0 0 0 R Y
92145-TC $12.30 $12.30 0 0% 0% 0% 1 7 2 0 0 0 R Y
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 18
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
92225 $47.99 $37.53 0 0% 0% 0% 0 0 3 0 0 0 R
92226 $44.29 $33.84 0 0% 0% 0% 0 0 3 0 0 0 R
92227 $26.45 $26.45 0 0% 0% 0% 3 0 2 0 0 0 R
92228 $61.52 $61.52 0 0% 0% 0% 1 7 2 0 0 0 R
92228-26 $36.91 $36.91 0 0% 0% 0% 1 7 2 0 0 0 R
92228-TC $24.61 $24.61 0 0% 0% 0% 1 7 2 0 0 0 R
92230 $103.97 $59.06 0 0% 0% 0% 0 0 3 0 0 0 R
92235 $198.71 $198.71 0 0% 0% 0% 1 7 3 0 0 0 R
92235-26 $83.67 $83.67 0 0% 0% 0% 1 7 3 0 0 0 R
92235-TC $115.04 $115.04 0 0% 0% 0% 1 7 3 0 0 0 R
92240 $464.48 $464.48 0 0% 0% 0% 1 7 3 0 0 0 R Y
92240-26 $113.81 $113.81 0 0% 0% 0% 1 7 3 0 0 0 R Y
92240-TC $350.66 $350.66 0 0% 0% 0% 1 7 3 0 0 0 R Y
92250 $140.88 $140.88 0 0% 0% 0% 1 7 2 0 0 0 R
92250-26 $41.83 $41.83 0 0% 0% 0% 1 7 2 0 0 0 R
92250-TC $99.05 $99.05 0 0% 0% 0% 1 7 2 0 0 0 R
92260 $32.61 $19.07 0 0% 0% 0% 0 0 2 0 0 0 R
92265 $139.65 $139.65 0 0% 0% 0% 1 7 2 0 0 0 R
92265-26 $75.05 $75.05 0 0% 0% 0% 1 7 2 0 0 0 R
92265-TC $64.60 $64.60 0 0% 0% 0% 1 7 2 0 0 0 R
92270 $163.64 $163.64 0 0% 0% 0% 1 7 2 0 0 0 R
92270-26 $72.59 $72.59 0 0% 0% 0% 1 7 2 0 0 0 R
92270-TC $91.05 $91.05 0 0% 0% 0% 1 7 2 0 0 0 R
92275 $265.15 $265.15 0 0% 0% 0% 1 7 2 0 0 0 R
92275-26 $95.36 $95.36 0 0% 0% 0% 1 7 2 0 0 0 R
92275-TC $169.80 $169.80 0 0% 0% 0% 1 7 2 0 0 0 R
92283 $99.66 $99.66 0 0% 0% 0% 1 7 2 0 0 0 R Y
92283-26 $16.00 $16.00 0 0% 0% 0% 1 7 2 0 0 0 R Y
92283-TC $83.67 $83.67 0 0% 0% 0% 1 7 2 0 0 0 R Y
92284 $108.89 $108.89 0 0% 0% 0% 1 7 2 0 0 0 R Y
92284-26 $21.53 $21.53 0 0% 0% 0% 1 7 2 0 0 0 R Y
92284-TC $87.36 $87.36 0 0% 0% 0% 1 7 2 0 0 0 R Y
92285 $36.91 $36.91 0 0% 0% 0% 1 7 2 0 0 0 R
92285-26 $5.54 $5.54 0 0% 0% 0% 1 7 2 0 0 0 R
92285-TC $31.38 $31.38 0 0% 0% 0% 1 7 2 0 0 0 R
92286 $67.67 $67.67 0 0% 0% 0% 1 7 2 0 0 0 R
92286-26 $38.76 $38.76 0 0% 0% 0% 1 7 2 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 19
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
92286-TC $28.91 $28.91 0 0% 0% 0% 1 7 2 0 0 0 R
92287 $250.39 $250.39 0 0% 0% 0% 1 0 2 0 0 0 R Y
92310 $170.41 $103.97 0 0% 0% 0% 9 9 9 9 9 9 R
92311 $178.41 $96.59 0 0% 0% 0% 0 0 0 0 0 0 R
92312 $204.86 $110.74 0 0% 0% 0% 0 0 2 0 0 0 R
92313 $171.03 $82.44 0 0% 0% 0% 0 0 0 0 0 0 R
92314 $142.73 $60.90 0 0% 0% 0% 9 9 9 9 9 9 R
92315 $127.96 $37.53 0 0% 0% 0% 0 0 0 0 0 0 R
92316 $160.57 $57.21 0 0% 0% 0% 0 0 2 0 0 0 R
92317 $135.34 $38.14 0 0% 0% 0% 0 0 0 0 0 0 R
92325 $75.67 $75.67 0 0% 0% 0% 5 0 0 0 0 0 R
92326 $63.98 $63.98 0 0% 0% 0% 5 0 0 0 0 0 R Y
92340 $63.37 $32.61 0 0% 0% 0% 9 9 9 9 9 9 R
92341 $72.59 $41.83 0 0% 0% 0% 9 9 9 9 9 9 R
92342 $77.52 $46.76 0 0% 0% 0% 9 9 9 9 9 9 R
92352 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92353 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92354 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92355 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92358 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92370 $54.75 $28.30 0 0% 0% 0% 9 9 9 9 9 9 R
92371 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92499 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
92499-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
92499-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
92502 $171.64 $171.64 0 0% 0% 0% 0 0 0 0 0 0 R
92504 $54.14 $16.61 0 0% 0% 0% 0 0 0 0 0 0 R
92507 $139.04 $139.04 0 0% 0% 0% 0 5 0 0 0 0 R
92508 $41.22 $41.22 0 0% 0% 0% 0 5 0 0 0 0 R
92511 $203.63 $69.52 0 0% 0% 0% 0 0 0 0 0 0 R
92512 $109.51 $50.45 0 0% 0% 0% 0 0 0 0 0 0 R
92516 $127.96 $40.60 0 0% 0% 0% 0 0 0 0 0 0 R
92520 $134.73 $73.21 0 0% 0% 0% 0 0 0 0 0 0 R
92521 $195.63 $195.63 0 0% 0% 0% 0 5 0 0 0 0 R
92522 $162.41 $162.41 0 0% 0% 0% 0 5 0 0 0 0 R
92523 $342.05 $342.05 0 0% 0% 0% 0 5 0 0 0 0 R
92524 $156.88 $156.88 0 0% 0% 0% 0 5 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 20
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
92526 $151.34 $151.34 0 0% 0% 0% 0 5 0 0 0 0 R
92531 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92532 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92533 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92534 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92537 $71.36 $71.36 0 0% 0% 0% 1 0 1 0 0 0 R
92538 $36.30 $36.30 0 0% 0% 0% 1 0 0 0 0 0 R
92540 $180.25 $180.25 0 0% 0% 0% 1 0 0 0 0 0 R
92540-26 $140.27 $140.27 0 0% 0% 0% 1 0 0 0 0 0 R
92540-TC $39.99 $39.99 0 0% 0% 0% 1 0 0 0 0 0 R
92541 $42.45 $42.45 0 0% 0% 0% 1 0 0 0 0 0 R
92541-26 $36.91 $36.91 0 0% 0% 0% 1 0 0 0 0 0 R
92541-TC $5.54 $5.54 0 0% 0% 0% 1 0 0 0 0 0 R
92542 $48.60 $48.60 0 0% 0% 0% 1 0 0 0 0 0 R
92542-26 $44.29 $44.29 0 0% 0% 0% 1 0 0 0 0 0 R
92542-TC $4.92 $4.92 0 0% 0% 0% 1 0 0 0 0 0 R
92544 $28.91 $28.91 0 0% 0% 0% 1 0 0 0 0 0 R
92544-26 $24.61 $24.61 0 0% 0% 0% 1 0 0 0 0 0 R
92544-TC $4.31 $4.31 0 0% 0% 0% 1 0 0 0 0 0 R
92545 $26.45 $26.45 0 0% 0% 0% 1 0 0 0 0 0 R
92545-26 $22.76 $22.76 0 0% 0% 0% 1 0 0 0 0 0 R
92545-TC $3.69 $3.69 0 0% 0% 0% 1 0 0 0 0 0 R
92546 $186.41 $186.41 0 0% 0% 0% 1 0 0 0 0 0 R
92546-26 $25.84 $25.84 0 0% 0% 0% 1 0 0 0 0 0 R
92546-TC $160.57 $160.57 0 0% 0% 0% 1 0 0 0 0 0 R
92547 $11.07 $11.07 0 0% 0% 0% 3 0 0 0 0 0 R
92548 $184.56 $184.56 0 0% 0% 0% 1 0 0 0 0 0 R
92548-26 $46.14 $46.14 0 0% 0% 0% 1 0 0 0 0 0 R
92548-TC $139.04 $139.04 0 0% 0% 0% 1 0 0 0 0 0 R
92550 $37.53 $37.53 0 0% 0% 0% 0 0 2 0 0 0 R
92551 $21.53 $21.53 0 0% 0% 0% 9 9 9 9 9 9 F
92552 $56.60 $56.60 0 0% 0% 0% 3 0 2 0 0 0 R
92553 $67.67 $67.67 0 0% 0% 0% 3 0 2 0 0 0 R
92555 $41.83 $41.83 0 0% 0% 0% 3 0 2 0 0 0 R
92556 $67.67 $67.67 0 0% 0% 0% 3 0 2 0 0 0 R
92557 $65.83 $57.21 0 0% 0% 0% 0 0 2 0 0 0 R
92558 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 21
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
92559 $126.54 $126.54 0 0% 0% 0% 9 9 9 9 9 9 F
92560 $50.59 $50.59 0 0% 0% 0% 9 9 9 9 9 9 F
92561 $68.90 $68.90 0 0% 0% 0% 3 0 2 0 0 0 R
92562 $84.90 $84.90 0 0% 0% 0% 3 0 2 0 0 0 R
92563 $55.98 $55.98 0 0% 0% 0% 3 0 2 0 0 0 R
92564 $51.06 $51.06 0 0% 0% 0% 3 0 2 0 0 0 R
92565 $28.91 $28.91 0 0% 0% 0% 3 0 2 0 0 0 R
92567 $25.84 $19.07 0 0% 0% 0% 0 0 2 0 0 0 R
92568 $27.68 $27.07 0 0% 0% 0% 0 0 2 0 0 0 R
92570 $56.60 $52.29 0 0% 0% 0% 0 0 2 0 0 0 R
92571 $49.22 $49.22 0 0% 0% 0% 3 0 2 0 0 0 R
92572 $65.21 $65.21 0 0% 0% 0% 3 0 2 0 0 0 R
92575 $131.65 $131.65 0 0% 0% 0% 3 0 2 0 0 0 R
92576 $65.21 $65.21 0 0% 0% 0% 3 0 2 0 0 0 R
92577 $30.14 $30.14 0 0% 0% 0% 3 0 2 0 0 0 R
92579 $73.21 $65.83 0 0% 0% 0% 0 0 2 0 0 0 R
92582 Not Covered Not Covered 0 0% 0% 0% 3 0 2 0 0 0 X
92583 $95.36 $95.36 0 0% 0% 0% 3 0 2 0 0 0 R
92584 $134.11 $134.11 0 0% 0% 0% 3 0 2 0 0 0 R
92585 $245.46 $245.46 0 0% 0% 0% 1 0 2 0 0 0 R
92585-26 $47.37 $47.37 0 0% 0% 0% 1 0 2 0 0 0 R
92585-TC $198.09 $198.09 0 0% 0% 0% 1 0 2 0 0 0 R
92586 $155.65 $155.65 0 0% 0% 0% 3 0 2 0 0 0 R
92587 $38.14 $38.14 0 0% 0% 0% 1 0 2 0 0 0 R
92587-26 $32.61 $32.61 0 0% 0% 0% 1 0 2 0 0 0 R
92587-TC $5.54 $5.54 0 0% 0% 0% 1 0 2 0 0 0 R
92588 $57.83 $57.83 0 0% 0% 0% 1 0 2 0 0 0 R
92588-26 $51.06 $51.06 0 0% 0% 0% 1 0 2 0 0 0 R
92588-TC $6.77 $6.77 0 0% 0% 0% 1 0 2 0 0 0 R
92590 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
92591 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
92592 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
92593 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
92594 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
92595 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
92596 $76.90 $76.90 0 0% 0% 0% 3 0 2 0 0 0 R
92597 $126.12 $126.12 0 0% 0% 0% 0 5 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 22
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
92601 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
92602 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
92603 $268.23 $215.32 0 0% 0% 0% 0 0 0 0 0 0 R Y
92604 $158.11 $119.35 0 0% 0% 0% 0 0 0 0 0 0 R Y
92605 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y
92606 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y
92607 $223.32 $223.32 0 0% 0% 0% 0 5 0 0 0 0 R Y
92608 $93.51 $93.51 0 0% 0% 0% 0 0 0 0 0 0 R Y
92609 $196.86 $196.86 0 0% 0% 0% 0 5 0 0 0 0 R Y
92610 $150.72 $127.96 0 0% 0% 0% 0 0 0 0 0 0 R Y
92611 $152.57 $152.57 0 0% 0% 0% 0 0 0 0 0 0 R Y
92612 $335.90 $119.35 0 0% 0% 0% 0 0 0 0 0 0 R Y
92613 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y
92614 $262.08 $118.73 0 0% 0% 0% 0 0 0 0 0 0 R Y
92615 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y
92616 $374.04 $177.18 0 0% 0% 0% 0 0 0 0 0 0 R Y
92617 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y
92618 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
92620 $166.10 $145.80 0 0% 0% 0% 9 0 2 0 0 0 R Y
92621 $39.37 $33.84 0 0% 0% 0% 9 0 0 0 0 0 R Y
92625 $123.66 $110.12 0 0% 0% 0% 9 0 2 0 0 0 R Y
92626 $158.72 $134.73 0 0% 0% 0% 9 0 2 0 0 0 R
92627 $38.76 $31.99 0 0% 0% 0% 9 0 0 0 0 0 R
92630 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
92633 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
92640 Not Covered Not Covered 0 0% 0% 0% 9 0 2 0 0 0 X
92700 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
92920 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
92921 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
92924 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
92925 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
92928 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
92929 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
92933 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
92934 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
92937 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
92938 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 23
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
92941 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
92943 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
92944 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
92950 $534.61 $321.75 0 0% 0% 0% 0 0 0 0 0 0 R
92953 $19.69 $19.69 0 0% 0% 0% 0 0 0 0 0 0 R Y
92960 $365.43 $213.47 0 0% 0% 0% 0 0 0 0 0 0 R Y
92961 $442.33 $442.33 0 0% 0% 0% 0 9 9 9 9 9 R Y
92970 $319.90 $319.90 0 0% 0% 0% 0 0 0 0 0 0 R Y
92971 $169.80 $169.80 0 0% 0% 0% 0 0 0 0 0 0 R Y
92973 $298.37 $298.37 0 0% 0% 0% 0 0 0 0 0 0 R Y
92974 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
92975 $657.03 $657.03 0 0% 0% 0% 0 2 0 0 0 0 R Y
92977 $108.89 $108.89 0 0% 0% 0% 5 0 0 0 0 0 R Y
92978 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
92978-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
92978-26 $161.80 $161.80 0 0% 0% 0% 1 0 0 0 0 0 R Y
92979 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
92979-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
92979-26 $129.81 $129.81 0 0% 0% 0% 1 0 0 0 0 0 R Y
92986 $2,260.24 $2,260.24 90 9% 84% 7% 0 2 0 0 0 0 R Y
92987 $2,332.84 $2,332.84 90 9% 84% 7% 0 2 0 0 0 0 R Y
92990 $1,841.29 $1,841.29 90 9% 84% 7% 0 2 0 0 0 0 R Y
92992 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X
92993 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X
92997 $1,101.82 $1,101.82 0 0% 0% 0% 0 2 0 0 0 0 R Y
92998 $543.84 $543.84 0 0% 0% 0% 0 0 0 0 0 0 R Y
93000 $30.14 $30.14 0 0% 0% 0% 4 6 0 0 0 0 R
93005 $15.38 $15.38 0 0% 0% 0% 3 6 0 0 0 0 R
93010 $14.76 $14.76 0 0% 0% 0% 2 0 0 0 0 0 R
93015 $134.73 $134.73 0 0% 0% 0% 4 6 0 0 0 0 R
93016 $38.14 $38.14 0 0% 0% 0% 2 0 0 0 0 0 R
93017 $71.36 $71.36 0 0% 0% 0% 3 6 0 0 0 0 R
93018 $25.22 $25.22 0 0% 0% 0% 2 0 0 0 0 0 R
93024 $199.32 $199.32 0 0% 0% 0% 1 6 0 0 0 0 R Y
93024-26 $99.66 $99.66 0 0% 0% 0% 1 6 0 0 0 0 R Y
93024-TC $99.66 $99.66 0 0% 0% 0% 1 6 0 0 0 0 R Y
93025 $288.53 $288.53 0 0% 0% 0% 1 6 0 0 0 0 R Y
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 24
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93025-26 $64.60 $64.60 0 0% 0% 0% 1 6 0 0 0 0 R Y
93025-TC $223.93 $223.93 0 0% 0% 0% 1 6 0 0 0 0 R Y
93040 $22.15 $22.15 0 0% 0% 0% 4 6 0 0 0 0 R
93041 $9.84 $9.84 0 0% 0% 0% 3 6 0 0 0 0 R
93042 $12.30 $12.30 0 0% 0% 0% 2 0 0 0 0 0 R
93050 $31.38 $31.38 0 0% 0% 0% 1 6 2 0 0 0 R
93224 $164.26 $164.26 0 0% 0% 0% 4 6 0 0 0 0 R
93225 $48.60 $48.60 0 0% 0% 0% 3 6 0 0 0 0 R
93226 $69.52 $69.52 0 0% 0% 0% 3 6 0 0 0 0 R
93227 $46.76 $46.76 0 0% 0% 0% 2 0 0 0 0 0 R
93228 $45.52 $45.52 0 0% 0% 0% 2 0 0 0 0 0 R
93229 $1,327.60 $1,327.60 0 0% 0% 0% 3 6 0 0 0 0 R
93260 $118.73 $118.73 0 0% 0% 0% 1 6 0 0 0 0 R Y
93260-26 $78.75 $78.75 0 0% 0% 0% 1 6 0 0 0 0 R Y
93260-TC $39.99 $39.99 0 0% 0% 0% 1 6 0 0 0 0 R Y
93261 $107.66 $107.66 0 0% 0% 0% 1 6 0 0 0 0 R Y
93261-26 $67.67 $67.67 0 0% 0% 0% 1 6 0 0 0 0 R Y
93261-TC $39.99 $39.99 0 0% 0% 0% 1 6 0 0 0 0 R Y
93268 $372.20 $372.20 0 0% 0% 0% 4 6 0 0 0 0 R
93270 $16.61 $16.61 0 0% 0% 0% 3 6 0 0 0 0 R
93271 $311.29 $311.29 0 0% 0% 0% 3 6 0 0 0 0 R
93272 $44.29 $44.29 0 0% 0% 0% 2 0 0 0 0 0 R
93278 $53.52 $53.52 0 0% 0% 0% 1 6 0 0 0 0 R
93278-26 $21.53 $21.53 0 0% 0% 0% 1 6 0 0 0 0 R
93278-TC $31.99 $31.99 0 0% 0% 0% 1 6 0 0 0 0 R
93279 $87.97 $87.97 0 0% 0% 0% 1 6 0 0 0 0 R Y
93279-26 $56.60 $56.60 0 0% 0% 0% 1 6 0 0 0 0 R Y
93279-TC $31.38 $31.38 0 0% 0% 0% 1 6 0 0 0 0 R Y
93280 $102.12 $102.12 0 0% 0% 0% 1 6 0 0 0 0 R Y
93280-26 $67.06 $67.06 0 0% 0% 0% 1 6 0 0 0 0 R Y
93280-TC $35.68 $35.68 0 0% 0% 0% 1 6 0 0 0 0 R Y
93281 $120.58 $120.58 0 0% 0% 0% 1 6 0 0 0 0 R Y
93281-26 $78.75 $78.75 0 0% 0% 0% 1 6 0 0 0 0 R Y
93281-TC $41.83 $41.83 0 0% 0% 0% 1 6 0 0 0 0 R Y
93282 $111.35 $111.35 0 0% 0% 0% 1 6 0 0 0 0 R Y
93282-26 $74.44 $74.44 0 0% 0% 0% 1 6 0 0 0 0 R Y
93282-TC $36.91 $36.91 0 0% 0% 0% 1 6 0 0 0 0 R Y
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 25
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93283 $144.57 $144.57 0 0% 0% 0% 1 6 0 0 0 0 R Y
93283-26 $100.89 $100.89 0 0% 0% 0% 1 6 0 0 0 0 R Y
93283-TC $43.06 $43.06 0 0% 0% 0% 1 6 0 0 0 0 R Y
93284 $159.34 $159.34 0 0% 0% 0% 1 6 0 0 0 0 R Y
93284-26 $110.12 $110.12 0 0% 0% 0% 1 6 0 0 0 0 R Y
93284-TC $49.22 $49.22 0 0% 0% 0% 1 6 0 0 0 0 R Y
93285 $75.05 $75.05 0 0% 0% 0% 1 6 0 0 0 0 R Y
93285-26 $46.14 $46.14 0 0% 0% 0% 1 6 0 0 0 0 R Y
93285-TC $28.91 $28.91 0 0% 0% 0% 1 6 0 0 0 0 R Y
93286 $48.60 $48.60 0 0% 0% 0% 1 6 0 0 0 0 R Y
93286-26 $26.45 $26.45 0 0% 0% 0% 1 6 0 0 0 0 R Y
93286-TC $21.53 $21.53 0 0% 0% 0% 1 6 0 0 0 0 R Y
93287 $63.98 $63.98 0 0% 0% 0% 1 6 0 0 0 0 R Y
93287-26 $39.99 $39.99 0 0% 0% 0% 1 6 0 0 0 0 R Y
93287-TC $23.99 $23.99 0 0% 0% 0% 1 6 0 0 0 0 R Y
93288 $65.21 $65.21 0 0% 0% 0% 1 6 0 0 0 0 R Y
93288-26 $36.91 $36.91 0 0% 0% 0% 1 6 0 0 0 0 R Y
93288-TC $28.30 $28.30 0 0% 0% 0% 1 6 0 0 0 0 R Y
93289 $115.66 $115.66 0 0% 0% 0% 1 6 0 0 0 0 R Y
93289-26 $79.98 $79.98 0 0% 0% 0% 1 6 0 0 0 0 R Y
93289-TC $35.68 $35.68 0 0% 0% 0% 1 6 0 0 0 0 R Y
93290 $54.75 $54.75 0 0% 0% 0% 1 6 0 0 0 0 R Y
93290-26 $37.53 $37.53 0 0% 0% 0% 1 6 0 0 0 0 R Y
93290-TC $17.23 $17.23 0 0% 0% 0% 1 6 0 0 0 0 R Y
93291 $63.98 $63.98 0 0% 0% 0% 1 6 0 0 0 0 R Y
93291-26 $37.53 $37.53 0 0% 0% 0% 1 6 0 0 0 0 R Y
93291-TC $26.45 $26.45 0 0% 0% 0% 1 6 0 0 0 0 R Y
93292 $56.60 $56.60 0 0% 0% 0% 1 6 0 0 0 0 R Y
93292-26 $36.91 $36.91 0 0% 0% 0% 1 6 0 0 0 0 R Y
93292-TC $19.69 $19.69 0 0% 0% 0% 1 6 0 0 0 0 R Y
93293 $95.97 $95.97 0 0% 0% 0% 1 0 0 0 0 0 R Y
93293-26 $27.07 $27.07 0 0% 0% 0% 1 0 0 0 0 0 R Y
93293-TC $68.29 $68.29 0 0% 0% 0% 1 0 0 0 0 0 R Y
93294 $59.06 $59.06 0 0% 0% 0% 2 0 0 0 0 0 R Y
93295 $116.27 $116.27 0 0% 0% 0% 2 0 0 0 0 0 R Y
93296 $47.37 $47.37 0 0% 0% 0% 3 0 0 0 0 0 R Y
93297 $46.14 $46.14 0 0% 0% 0% 2 0 0 0 0 0 R Y
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 26
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93298 $46.14 $46.14 0 0% 0% 0% 2 0 0 0 0 0 R Y
93299 $0.00 $0.00 0 0% 0% 0% 3 0 0 0 0 0 R Y
93303 $430.64 $430.64 0 0% 0% 0% 1 6 0 0 0 0 R Y
93303-26 $111.97 $111.97 0 0% 0% 0% 1 6 0 0 0 0 R Y
93303-TC $318.67 $318.67 0 0% 0% 0% 1 6 0 0 0 0 R Y
93304 $281.76 $281.76 0 0% 0% 0% 1 6 0 0 0 0 R Y
93304-26 $64.60 $64.60 0 0% 0% 0% 1 6 0 0 0 0 R Y
93304-TC $217.78 $217.78 0 0% 0% 0% 1 6 0 0 0 0 R Y
93306 $410.95 $410.95 0 0% 0% 0% 1 6 0 0 0 0 R
93306-26 $111.35 $111.35 0 0% 0% 0% 1 6 0 0 0 0 R
93306-TC $299.60 $299.60 0 0% 0% 0% 1 6 0 0 0 0 R
93307 $234.39 $234.39 0 0% 0% 0% 1 6 0 0 0 0 R
93307-26 $79.36 $79.36 0 0% 0% 0% 1 6 0 0 0 0 R
93307-TC $155.03 $155.03 0 0% 0% 0% 1 6 0 0 0 0 R
93308 $225.78 $225.78 0 0% 0% 0% 1 6 0 0 0 0 R
93308-26 $44.91 $44.91 0 0% 0% 0% 1 6 0 0 0 0 R
93308-TC $180.25 $180.25 0 0% 0% 0% 1 6 0 0 0 0 R
93312 $551.22 $551.22 0 0% 0% 0% 1 6 0 0 0 0 R
93312-26 $212.86 $212.86 0 0% 0% 0% 1 6 0 0 0 0 R
93312-TC $338.36 $338.36 0 0% 0% 0% 1 6 0 0 0 0 R
93313 $39.37 $39.37 0 0% 0% 0% 0 0 0 0 0 0 R
93314 $537.07 $537.07 0 0% 0% 0% 1 6 0 0 0 0 R
93314-26 $179.02 $179.02 0 0% 0% 0% 1 6 0 0 0 0 R
93314-TC $358.05 $358.05 0 0% 0% 0% 1 6 0 0 0 0 R
93315 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93315-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93315-26 $248.54 $248.54 0 0% 0% 0% 1 0 0 0 0 0 R
93316 $66.44 $66.44 0 0% 0% 0% 0 0 0 0 0 0 R
93317 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93317-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93317-26 $182.10 $182.10 0 0% 0% 0% 1 0 0 0 0 0 R
93318 By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N
93318-TC By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N
93318-26 $202.40 $202.40 0 0% 0% 0% 1 6 0 0 0 0 R
93320 $97.82 $97.82 0 0% 0% 0% 1 0 0 0 0 0 R
93320-26 $32.61 $32.61 0 0% 0% 0% 1 0 0 0 0 0 R
93320-TC $65.83 $65.83 0 0% 0% 0% 1 0 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 27
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93321 $49.22 $49.22 0 0% 0% 0% 1 0 0 0 0 0 R
93321-26 $12.92 $12.92 0 0% 0% 0% 1 0 0 0 0 0 R
93321-TC $36.30 $36.30 0 0% 0% 0% 1 0 0 0 0 0 R
93325 $46.76 $46.76 0 0% 0% 0% 1 0 0 0 0 0 R
93325-26 $5.54 $5.54 0 0% 0% 0% 1 0 0 0 0 0 R
93325-TC $41.22 $41.22 0 0% 0% 0% 1 0 0 0 0 0 R
93350 $433.72 $433.72 0 0% 0% 0% 1 6 0 0 0 0 R
93350-26 $124.27 $124.27 0 0% 0% 0% 1 6 0 0 0 0 R
93350-TC $309.45 $309.45 0 0% 0% 0% 1 6 0 0 0 0 R
93351 $487.85 $487.85 0 0% 0% 0% 1 6 0 9 9 9 R
93351-26 $149.49 $149.49 0 0% 0% 0% 1 6 0 9 9 9 R
93351-TC $338.36 $338.36 0 0% 0% 0% 1 6 0 9 9 9 R
93352 $60.90 $60.90 0 0% 0% 0% 0 0 0 0 0 0 R
93355 $393.11 $393.11 0 0% 0% 0% 0 2 0 0 0 0 R
93451 $1,412.50 $1,412.50 0 0% 0% 0% 1 2 0 0 0 0 R Y
93451-26 $243.62 $243.62 0 0% 0% 0% 1 2 0 0 0 0 R Y
93451-TC $1,168.88 $1,168.88 0 0% 0% 0% 1 0 0 0 0 0 R Y
93452 $1,579.22 $1,579.22 0 0% 0% 0% 1 2 0 0 0 0 R Y
93452-26 $428.18 $428.18 0 0% 0% 0% 1 2 0 0 0 0 R Y
93452-TC $1,151.04 $1,151.04 0 0% 0% 0% 1 0 0 0 0 0 R Y
93453 $2,029.54 $2,029.54 0 0% 0% 0% 1 2 0 0 0 0 R Y
93453-26 $562.91 $562.91 0 0% 0% 0% 1 2 0 0 0 0 R Y
93453-TC $1,466.64 $1,466.64 0 0% 0% 0% 1 0 0 0 0 0 R Y
93454 $1,598.29 $1,598.29 0 0% 0% 0% 1 2 0 0 0 0 R Y
93454-26 $431.87 $431.87 0 0% 0% 0% 1 2 0 0 0 0 R Y
93454-TC $1,166.42 $1,166.42 0 0% 0% 0% 1 0 0 0 0 0 R Y
93455 $1,862.21 $1,862.21 0 0% 0% 0% 1 2 0 0 0 0 R Y
93455-26 $499.54 $499.54 0 0% 0% 0% 1 2 0 0 0 0 R Y
93455-TC $1,363.28 $1,363.28 0 0% 0% 0% 1 0 0 0 0 0 R Y
93456 $2,001.86 $2,001.86 0 0% 0% 0% 1 2 0 0 0 0 R Y
93456-26 $554.30 $554.30 0 0% 0% 0% 1 2 0 0 0 0 R Y
93456-TC $1,447.57 $1,447.57 0 0% 0% 0% 1 0 0 0 0 0 R Y
93457 $2,264.55 $2,264.55 0 0% 0% 0% 1 2 0 0 0 0 R Y
93457-26 $621.35 $621.35 0 0% 0% 0% 1 2 0 0 0 0 R Y
93457-TC $1,643.20 $1,643.20 0 0% 0% 0% 1 0 0 0 0 0 R Y
93458 $1,917.58 $1,917.58 0 0% 0% 0% 1 2 0 0 0 0 R Y
93458-26 $527.84 $527.84 0 0% 0% 0% 1 2 0 0 0 0 R Y
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 28
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93458-TC $1,389.74 $1,389.74 0 0% 0% 0% 1 0 0 0 0 0 R Y
93459 $2,117.52 $2,117.52 0 0% 0% 0% 1 2 0 0 0 0 R Y
93459-26 $594.90 $594.90 0 0% 0% 0% 1 2 0 0 0 0 R Y
93459-TC $1,522.62 $1,522.62 0 0% 0% 0% 1 0 0 0 0 0 R Y
93460 $2,268.24 $2,268.24 0 0% 0% 0% 1 2 0 0 0 0 R Y
93460-26 $661.96 $661.96 0 0% 0% 0% 1 2 0 0 0 0 R Y
93460-TC $1,606.29 $1,606.29 0 0% 0% 0% 1 0 0 0 0 0 R Y
93461 $2,596.76 $2,596.76 0 0% 0% 0% 1 2 0 0 0 0 R Y
93461-26 $729.63 $729.63 0 0% 0% 0% 1 2 0 0 0 0 R Y
93461-TC $1,867.13 $1,867.13 0 0% 0% 0% 1 0 0 0 0 0 R Y
93462 $352.51 $352.51 0 0% 0% 0% 0 0 0 0 0 0 R Y
93463 $172.26 $172.26 0 0% 0% 0% 0 0 0 0 0 0 R Y
93464 $494.62 $494.62 0 0% 0% 0% 1 0 0 0 0 0 R Y
93464-26 $153.18 $153.18 0 0% 0% 0% 1 0 0 0 0 0 R Y
93464-TC $341.44 $341.44 0 0% 0% 0% 1 0 0 0 0 0 R Y
93503 $227.01 $227.01 0 0% 0% 0% 0 0 0 0 0 0 R
93505 $1,360.21 $1,360.21 0 0% 0% 0% 1 2 0 0 0 0 R
93505-26 $393.73 $393.73 0 0% 0% 0% 1 2 0 0 0 0 R
93505-TC $966.48 $966.48 0 0% 0% 0% 1 0 0 0 0 0 R
93530 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X
93530-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X
93530-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
93531 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X
93531-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X
93531-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
93532 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X
93532-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X
93532-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
93533 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X
93533-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X
93533-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
93561 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93561-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93561-26 $44.29 $44.29 0 0% 0% 0% 1 0 0 0 0 0 R
93562 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93562-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93562-26 $14.15 $14.15 0 0% 0% 0% 1 0 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 29
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93563 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
93564 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
93565 $78.13 $78.13 0 0% 0% 0% 0 0 0 0 0 0 R
93566 $305.14 $77.52 0 0% 0% 0% 0 0 0 0 0 0 R
93567 $249.16 $87.97 0 0% 0% 0% 0 0 0 0 0 0 R
93568 $273.76 $79.98 0 0% 0% 0% 0 0 0 0 0 0 R
93571 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93571-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93571-26 $161.80 $161.80 0 0% 0% 0% 1 0 0 0 0 0 R
93572 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93572-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93572-26 $129.81 $129.81 0 0% 0% 0% 1 0 0 0 0 0 R
93580 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
93581 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
93582 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X
93583 $1,274.08 $1,274.08 0 0% 0% 0% 0 2 0 0 0 0 R Y
93600 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93600-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93600-26 $200.56 $200.56 0 0% 0% 0% 1 0 0 0 0 0 R Y
93602 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93602-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93602-26 $196.86 $196.86 0 0% 0% 0% 1 0 0 0 0 0 R Y
93603 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93603-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93603-26 $196.86 $196.86 0 0% 0% 0% 1 0 0 0 0 0 R Y
93609 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93609-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93609-26 $470.01 $470.01 0 0% 0% 0% 1 0 0 0 0 0 R Y
93610 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93610-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93610-26 $278.69 $278.69 0 0% 0% 0% 1 0 0 0 0 0 R Y
93612 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93612-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93612-26 $276.84 $276.84 0 0% 0% 0% 1 0 0 0 0 0 R Y
93613 $671.80 $671.80 0 0% 0% 0% 0 0 0 0 0 0 R Y
93615 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93615-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 30
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93615-26 $92.28 $92.28 0 0% 0% 0% 1 0 0 0 0 0 R Y
93616 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93616-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93616-26 $113.81 $113.81 0 0% 0% 0% 1 0 0 0 0 0 R Y
93618 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93618-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93618-26 $401.11 $401.11 0 0% 0% 0% 1 0 0 0 0 0 R Y
93619 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y
93619-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93619-26 $684.10 $684.10 0 0% 0% 0% 1 2 0 0 0 0 R Y
93620 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y
93620-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93620-26 $1,086.44 $1,086.44 0 0% 0% 0% 1 2 0 0 0 0 R Y
93621 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93621-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93621-26 $198.09 $198.09 0 0% 0% 0% 1 0 0 0 0 0 R Y
93622 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93622-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93622-26 $289.76 $289.76 0 0% 0% 0% 1 0 0 0 0 0 R Y
93623 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93623-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93623-26 $269.46 $269.46 0 0% 0% 0% 1 0 0 0 0 0 R Y
93624 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y
93624-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93624-26 $444.17 $444.17 0 0% 0% 0% 1 2 0 0 0 0 R Y
93631 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93631-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93631-26 $673.03 $673.03 0 0% 0% 0% 1 0 0 0 0 0 R Y
93640 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y
93640-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93640-26 $324.83 $324.83 0 0% 0% 0% 1 2 0 0 0 0 R Y
93641 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y
93641-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93641-26 $553.68 $553.68 0 0% 0% 0% 1 2 0 0 0 0 R Y
93642 $737.01 $737.01 0 0% 0% 0% 1 2 0 0 0 0 R Y
93642-26 $459.55 $459.55 0 0% 0% 0% 1 2 0 0 0 0 R Y
93642-TC $277.46 $277.46 0 0% 0% 0% 1 0 0 0 0 0 R Y
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 31
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93644 $498.31 $498.31 0 0% 0% 0% 1 2 0 0 0 0 R Y
93644-26 $305.75 $305.75 0 0% 0% 0% 1 2 0 0 0 0 R Y
93644-TC $192.56 $192.56 0 0% 0% 0% 1 0 0 0 0 0 R Y
93650 $1,020.00 $1,020.00 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR
93653 $1,432.19 $1,432.19 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR
93654 $1,906.50 $1,906.50 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR
93655 $716.09 $716.09 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR
93656 $1,907.74 $1,907.74 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR
93657 $714.86 $714.86 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR
93660 $281.15 $281.15 0 0% 0% 0% 1 2 0 0 0 0 R Y
93660-26 $165.49 $165.49 0 0% 0% 0% 1 2 0 0 0 0 R Y
93660-TC $115.66 $115.66 0 0% 0% 0% 1 0 0 0 0 0 R Y
93662 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93662-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93662-26 $251.62 $251.62 0 0% 0% 0% 1 0 0 0 0 0 R
93668 $35.07 $35.07 0 0% 0% 0% 9 9 9 9 9 9 R Y
93701 $43.68 $43.68 0 0% 0% 0% 3 6 0 0 0 0 R Y
93702 $198.09 $198.09 0 0% 0% 0% 3 6 0 0 0 0 R Y
93724 $476.16 $476.16 0 0% 0% 0% 1 6 0 0 0 0 R Y
93724-26 $425.10 $425.10 0 0% 0% 0% 1 6 0 0 0 0 R Y
93724-TC $51.06 $51.06 0 0% 0% 0% 1 6 0 0 0 0 R Y
93740 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
93745 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93745-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93745-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
93750 $96.59 $79.36 0 0% 0% 0% 0 0 0 0 0 0 R Y
93770 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
93784 $96.59 $96.59 0 0% 0% 0% 4 6 0 0 0 0 R
93786 $54.14 $54.14 0 0% 0% 0% 3 6 0 0 0 0 R
93788 $9.23 $9.23 0 0% 0% 0% 3 6 0 0 0 0 R
93790 $33.22 $33.22 0 0% 0% 0% 2 0 0 0 0 0 R
93797 $28.91 $15.38 0 0% 0% 0% 0 0 0 0 0 0 R Y
93798 $44.91 $24.61 0 0% 0% 0% 0 0 0 0 0 0 R Y
93799 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93799-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93799-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
93880 $367.89 $367.89 0 0% 0% 0% 1 6 2 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 32
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93880-26 $69.52 $69.52 0 0% 0% 0% 1 6 2 0 0 0 R
93880-TC $298.37 $298.37 0 0% 0% 0% 1 6 2 0 0 0 R
93882 $234.39 $234.39 0 0% 0% 0% 1 6 0 0 0 0 R
93882-26 $43.06 $43.06 0 0% 0% 0% 1 6 0 0 0 0 R
93882-TC $191.33 $191.33 0 0% 0% 0% 1 6 0 0 0 0 R
93886 $513.08 $513.08 0 0% 0% 0% 1 6 0 0 0 0 R
93886-26 $82.44 $82.44 0 0% 0% 0% 1 6 0 0 0 0 R
93886-TC $430.64 $430.64 0 0% 0% 0% 1 6 0 0 0 0 R
93888 $267.61 $267.61 0 0% 0% 0% 1 6 0 0 0 0 R
93888-26 $44.29 $44.29 0 0% 0% 0% 1 6 0 0 0 0 R
93888-TC $223.32 $223.32 0 0% 0% 0% 1 6 0 0 0 0 R
93890 $526.00 $526.00 0 0% 0% 0% 1 6 0 0 0 0 R
93890-26 $90.43 $90.43 0 0% 0% 0% 1 6 0 0 0 0 R
93890-TC $435.56 $435.56 0 0% 0% 0% 1 6 0 0 0 0 R
93892 $607.20 $607.20 0 0% 0% 0% 1 6 0 0 0 0 R
93892-26 $105.81 $105.81 0 0% 0% 0% 1 6 0 0 0 0 R
93892-TC $501.39 $501.39 0 0% 0% 0% 1 6 0 0 0 0 R
93893 $631.81 $631.81 0 0% 0% 0% 1 6 0 0 0 0 R
93893-26 $103.97 $103.97 0 0% 0% 0% 1 6 0 0 0 0 R
93893-TC $527.23 $527.23 0 0% 0% 0% 1 6 0 0 0 0 R
93895 By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N
93895-26 By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N
93895-TC By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N
93922 $161.80 $161.80 0 0% 0% 0% 1 6 2 0 0 0 R
93922-26 $21.53 $21.53 0 0% 0% 0% 1 6 2 0 0 0 R
93922-TC $140.27 $140.27 0 0% 0% 0% 1 6 2 0 0 0 R
93923 $251.00 $251.00 0 0% 0% 0% 1 6 2 0 0 0 R
93923-26 $38.76 $38.76 0 0% 0% 0% 1 6 2 0 0 0 R
93923-TC $212.86 $212.86 0 0% 0% 0% 1 6 2 0 0 0 R
93924 $316.21 $316.21 0 0% 0% 0% 1 6 2 0 0 0 R
93924-26 $43.06 $43.06 0 0% 0% 0% 1 6 2 0 0 0 R
93924-TC $273.15 $273.15 0 0% 0% 0% 1 6 2 0 0 0 R
93925 $474.93 $474.93 0 0% 0% 0% 1 6 2 0 0 0 R
93925-26 $68.29 $68.29 0 0% 0% 0% 1 6 2 0 0 0 R
93925-TC $406.65 $406.65 0 0% 0% 0% 1 6 2 0 0 0 R
93926 $278.07 $278.07 0 0% 0% 0% 1 6 0 0 0 0 R
93926-26 $41.83 $41.83 0 0% 0% 0% 1 6 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 33
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93926-TC $236.85 $236.85 0 0% 0% 0% 1 6 0 0 0 0 R
93930 $380.19 $380.19 0 0% 0% 0% 1 6 2 0 0 0 R
93930-26 $68.90 $68.90 0 0% 0% 0% 1 6 2 0 0 0 R
93930-TC $311.29 $311.29 0 0% 0% 0% 1 6 2 0 0 0 R
93931 $233.16 $233.16 0 0% 0% 0% 1 6 0 0 0 0 R
93931-26 $42.45 $42.45 0 0% 0% 0% 1 6 0 0 0 0 R
93931-TC $190.71 $190.71 0 0% 0% 0% 1 6 0 0 0 0 R
93965 $217.17 $217.17 0 0% 0% 0% 1 6 2 0 0 0 R
93965-26 $29.53 $29.53 0 0% 0% 0% 1 6 2 0 0 0 R
93965-TC $187.64 $187.64 0 0% 0% 0% 1 6 2 0 0 0 R
93970 $358.66 $358.66 0 0% 0% 0% 1 6 2 0 0 0 R
93970-26 $60.29 $60.29 0 0% 0% 0% 1 6 2 0 0 0 R
93970-TC $298.37 $298.37 0 0% 0% 0% 1 6 2 0 0 0 R
93971 $218.40 $218.40 0 0% 0% 0% 1 6 0 0 0 0 R
93971-26 $38.76 $38.76 0 0% 0% 0% 1 6 0 0 0 0 R
93971-TC $179.64 $179.64 0 0% 0% 0% 1 6 0 0 0 0 R
93975 $513.69 $513.69 0 0% 0% 0% 1 6 0 0 0 0 R
93975-26 $100.28 $100.28 0 0% 0% 0% 1 6 0 0 0 0 R
93975-TC $413.41 $413.41 0 0% 0% 0% 1 6 0 0 0 0 R
93976 $295.91 $295.91 0 0% 0% 0% 1 6 0 0 0 0 R
93976-26 $69.52 $69.52 0 0% 0% 0% 1 6 0 0 0 0 R
93976-TC $226.39 $226.39 0 0% 0% 0% 1 6 0 0 0 0 R
93978 $346.97 $346.97 0 0% 0% 0% 1 6 0 0 0 0 R
93978-26 $67.67 $67.67 0 0% 0% 0% 1 6 0 0 0 0 R
93978-TC $278.69 $278.69 0 0% 0% 0% 1 6 0 0 0 0 R
93979 $217.17 $217.17 0 0% 0% 0% 1 6 0 0 0 0 R
93979-26 $42.45 $42.45 0 0% 0% 0% 1 6 0 0 0 0 R
93979-TC $174.72 $174.72 0 0% 0% 0% 1 6 0 0 0 0 R
93980 $216.55 $216.55 0 0% 0% 0% 1 6 0 0 0 0 R
93980-26 $107.66 $107.66 0 0% 0% 0% 1 6 0 0 0 0 R
93980-TC $108.89 $108.89 0 0% 0% 0% 1 6 0 0 0 0 R
93981 $131.65 $131.65 0 0% 0% 0% 1 6 0 0 0 0 R
93981-26 $38.14 $38.14 0 0% 0% 0% 1 6 0 0 0 0 R
93981-TC $94.13 $94.13 0 0% 0% 0% 1 6 0 0 0 0 R
93982 $76.90 $76.90 0 0% 0% 0% 0 0 0 0 0 0 R Y
93990 $293.45 $293.45 0 0% 0% 0% 1 6 0 0 0 0 R
93990-26 $41.83 $41.83 0 0% 0% 0% 1 6 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 34
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
93990-TC $251.62 $251.62 0 0% 0% 0% 1 6 0 0 0 0 R
93998 By Report By Report 0 0% 0% 0% 0 0 0 0 1 1 N
94002 $161.18 $161.18 0 0% 0% 0% 0 0 0 0 0 0 R
94003 $115.66 $115.66 0 0% 0% 0% 0 0 0 0 0 0 R
94004 $84.90 $84.90 0 0% 0% 0% 0 0 0 0 0 0 R
94005 $163.03 $163.03 0 0% 0% 0% 9 9 9 9 9 9 R
94010 $64.60 $64.60 0 0% 0% 0% 1 0 0 0 0 0 R
94010-26 $14.76 $14.76 0 0% 0% 0% 1 0 0 0 0 0 R
94010-TC $49.83 $49.83 0 0% 0% 0% 1 0 0 0 0 0 R
94011 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
94012 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
94013 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
94014 $100.89 $100.89 0 0% 0% 0% 4 0 0 0 0 0 R
94015 $55.98 $55.98 0 0% 0% 0% 3 0 0 0 0 0 R
94016 $44.29 $44.29 0 0% 0% 0% 2 0 0 0 0 0 R
94060 $110.12 $110.12 0 0% 0% 0% 1 0 0 0 0 0 R
94060-26 $22.76 $22.76 0 0% 0% 0% 1 0 0 0 0 0 R
94060-TC $87.36 $87.36 0 0% 0% 0% 1 0 0 0 0 0 R
94070 $106.43 $106.43 0 0% 0% 0% 1 0 0 0 0 0 R
94070-26 $50.45 $50.45 0 0% 0% 0% 1 0 0 0 0 0 R
94070-TC $55.98 $55.98 0 0% 0% 0% 1 0 0 0 0 0 R
94150 Bundled Bundled 0 0% 0% 0% 1 9 9 9 9 9 B
94150-26 Bundled Bundled 0 0% 0% 0% 1 9 9 9 9 9 B
94150-TC Bundled Bundled 0 0% 0% 0% 1 9 9 9 9 9 B
94200 $44.91 $44.91 0 0% 0% 0% 1 0 0 0 0 0 R
94200-26 $9.84 $9.84 0 0% 0% 0% 1 0 0 0 0 0 R
94200-TC $35.68 $35.68 0 0% 0% 0% 1 0 0 0 0 0 R
94250 $47.37 $47.37 0 0% 0% 0% 1 0 0 0 0 0 R
94250-26 $9.23 $9.23 0 0% 0% 0% 1 0 0 0 0 0 R
94250-TC $38.14 $38.14 0 0% 0% 0% 1 0 0 0 0 0 R
94375 $70.75 $70.75 0 0% 0% 0% 1 0 0 0 0 0 R
94375-26 $25.84 $25.84 0 0% 0% 0% 1 0 0 0 0 0 R
94375-TC $44.29 $44.29 0 0% 0% 0% 1 0 0 0 0 0 R
94400 $100.28 $100.28 0 0% 0% 0% 1 0 0 0 0 0 R
94400-26 $34.45 $34.45 0 0% 0% 0% 1 0 0 0 0 0 R
94400-TC $65.83 $65.83 0 0% 0% 0% 1 0 0 0 0 0 R
94450 $123.04 $123.04 0 0% 0% 0% 1 0 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 35
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
94450-26 $35.07 $35.07 0 0% 0% 0% 1 0 0 0 0 0 R
94450-TC $87.97 $87.97 0 0% 0% 0% 1 0 0 0 0 0 R
94452 $104.58 $104.58 0 0% 0% 0% 1 0 0 0 0 0 R
94452-26 $25.22 $25.22 0 0% 0% 0% 1 0 0 0 0 0 R
94452-TC $78.75 $78.75 0 0% 0% 0% 1 0 0 0 0 0 R
94453 $144.57 $144.57 0 0% 0% 0% 1 0 0 0 0 0 R
94453-26 $33.22 $33.22 0 0% 0% 0% 1 0 0 0 0 0 R
94453-TC $111.35 $111.35 0 0% 0% 0% 1 0 0 0 0 0 R
94610 $103.97 $103.97 0 0% 0% 0% 0 0 0 0 0 0 R
94620 $99.66 $99.66 0 0% 0% 0% 1 0 0 0 0 0 R
94620-26 $53.52 $53.52 0 0% 0% 0% 1 0 0 0 0 0 R
94620-TC $45.52 $45.52 0 0% 0% 0% 1 0 0 0 0 0 R
94621 $292.22 $292.22 0 0% 0% 0% 1 0 0 0 0 0 R
94621-26 $120.58 $120.58 0 0% 0% 0% 1 0 0 0 0 0 R
94621-TC $171.64 $171.64 0 0% 0% 0% 1 0 0 0 0 0 R
94640 $33.22 $33.22 0 0% 0% 0% 5 0 0 0 0 0 R
94642 By Report By Report 0 0% 0% 0% 5 0 0 0 0 0 N
94644 $79.98 $79.98 0 0% 0% 0% 5 0 0 0 0 0 R
94645 $25.84 $25.84 0 0% 0% 0% 5 0 0 0 0 0 R
94660 $111.97 $65.83 0 0% 0% 0% 0 0 0 0 0 0 R
94662 $63.98 $63.98 0 0% 0% 0% 0 0 0 0 0 0 R
94664 $31.38 $31.38 0 0% 0% 0% 5 0 0 0 0 0 R
94667 $46.76 $46.76 0 0% 0% 0% 5 0 0 0 0 0 R
94668 $51.68 $51.68 0 0% 0% 0% 5 0 0 0 0 0 R
94669 $59.67 $59.67 0 0% 0% 0% 5 0 0 0 0 0 R
94680 $103.97 $103.97 0 0% 0% 0% 1 0 0 0 0 0 R
94680-26 $22.15 $22.15 0 0% 0% 0% 1 0 0 0 0 0 R
94680-TC $81.82 $81.82 0 0% 0% 0% 1 0 0 0 0 0 R
94681 $95.36 $95.36 0 0% 0% 0% 1 0 0 0 0 0 R
94681-26 $17.23 $17.23 0 0% 0% 0% 1 0 0 0 0 0 R
94681-TC $78.13 $78.13 0 0% 0% 0% 1 0 0 0 0 0 R
94690 $91.05 $91.05 0 0% 0% 0% 1 0 0 0 0 0 R
94690-26 $6.77 $6.77 0 0% 0% 0% 1 0 0 0 0 0 R
94690-TC $84.28 $84.28 0 0% 0% 0% 1 0 0 0 0 0 R
94726 $95.36 $95.36 0 0% 0% 0% 1 0 0 0 0 0 R
94726-26 $21.53 $21.53 0 0% 0% 0% 1 0 0 0 0 0 R
94726-TC $73.82 $73.82 0 0% 0% 0% 1 0 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 36
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
94727 $75.67 $75.67 0 0% 0% 0% 1 0 0 0 0 0 R
94727-26 $21.53 $21.53 0 0% 0% 0% 1 0 0 0 0 0 R
94727-TC $54.14 $54.14 0 0% 0% 0% 1 0 0 0 0 0 R
94728 $72.59 $72.59 0 0% 0% 0% 1 0 0 0 0 0 R
94728-26 $22.15 $22.15 0 0% 0% 0% 1 0 0 0 0 0 R
94728-TC $50.45 $50.45 0 0% 0% 0% 1 0 0 0 0 0 R
94729 $99.05 $99.05 0 0% 0% 0% 1 0 0 0 0 0 R
94729-26 $16.00 $16.00 0 0% 0% 0% 1 0 0 0 0 0 R
94729-TC $83.05 $83.05 0 0% 0% 0% 1 0 0 0 0 0 R
94750 $146.42 $146.42 0 0% 0% 0% 1 0 0 0 0 0 R
94750-26 $19.69 $19.69 0 0% 0% 0% 1 0 0 0 0 0 R
94750-TC $126.73 $126.73 0 0% 0% 0% 1 0 0 0 0 0 R
94760 Bundled Bundled 0 0% 0% 0% 3 0 0 0 0 0 B
94761 Bundled Bundled 0 0% 0% 0% 3 0 0 0 0 0 B
94762 $44.29 $44.29 0 0% 0% 0% 3 0 0 0 0 0 R
94770 $12.92 $12.92 0 0% 0% 0% 0 0 0 0 0 0 R
94772 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
94772-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
94772-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
94774 Not Covered Not Covered 0 0% 0% 0% 4 0 0 0 0 0 X
94775 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X
94776 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X
94777 Not Covered Not Covered 0 0% 0% 0% 2 0 0 0 0 0 X
94780 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X
94781 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X
94799 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
94799-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
94799-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
95004 $11.69 $11.69 0 0% 0% 0% 0 0 0 0 0 0 R
95012 $35.07 $35.07 0 0% 0% 0% 5 0 0 0 0 0 R
95017 $13.53 $6.15 0 0% 0% 0% 0 0 0 0 0 0 R
95018 $36.91 $12.30 0 0% 0% 0% 0 0 0 0 0 0 R
95024 $14.15 $1.85 0 0% 0% 0% 0 0 0 0 0 0 R
95027 $8.00 $8.00 0 0% 0% 0% 0 0 0 0 0 0 R
95028 $24.61 $24.61 0 0% 0% 0% 3 0 0 0 0 0 R
95044 $9.84 $9.84 0 0% 0% 0% 5 0 0 0 0 0 R
95052 $12.30 $12.30 0 0% 0% 0% 5 0 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 37
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
95056 $81.21 $81.21 0 0% 0% 0% 5 0 0 0 0 0 R
95060 $63.98 $63.98 0 0% 0% 0% 3 0 0 0 0 0 R
95065 $46.76 $46.76 0 0% 0% 0% 3 0 0 0 0 0 R
95070 $55.37 $55.37 0 0% 0% 0% 3 0 0 0 0 0 R
95071 $63.37 $63.37 0 0% 0% 0% 3 0 0 0 0 0 R
95076 $207.32 $127.96 0 0% 0% 0% 0 0 0 0 0 0 R
95079 $146.42 $117.50 0 0% 0% 0% 0 0 0 0 0 0 R
95115 $16.00 $16.00 0 0% 0% 0% 5 0 0 0 0 0 R Y
95117 $18.46 $18.46 0 0% 0% 0% 5 0 0 0 0 0 R Y
95120 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
95125 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
95130 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
95131 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
95132 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
95133 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
95134 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
95144 $22.15 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y
95145 $39.37 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y
95146 $70.75 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y
95147 $63.98 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y
95148 $95.36 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y
95149 $127.96 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y
95165 $22.76 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y
95170 $17.23 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y
95180 $236.85 $177.79 0 0% 0% 0% 0 0 0 0 0 0 R Y
95199 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
95250 $287.91 $287.91 0 0% 0% 0% 3 0 0 0 0 0 R Y
95251 Not Covered Not Covered 0 0% 0% 0% 2 0 0 0 0 0 X
95782 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
95782-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
95782-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
95783 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
95783-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
95783-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
95800 $321.75 $321.75 0 0% 0% 0% 1 0 0 0 0 0 R Y
95800-26 $91.05 $91.05 0 0% 0% 0% 1 0 0 0 0 0 R Y
95800-TC $230.70 $230.70 0 0% 0% 0% 1 0 0 0 0 0 R Y
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 38
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
95801 $161.18 $161.18 0 0% 0% 0% 1 0 0 0 0 0 R Y
95801-26 $86.13 $86.13 0 0% 0% 0% 1 0 0 0 0 0 R Y
95801-TC $75.05 $75.05 0 0% 0% 0% 1 0 0 0 0 0 R Y
95803 $254.69 $254.69 0 0% 0% 0% 1 0 0 0 0 0 R Y
95803-26 $76.28 $76.28 0 0% 0% 0% 1 0 0 0 0 0 R Y
95803-TC $178.41 $178.41 0 0% 0% 0% 1 0 0 0 0 0 R Y
95805 $776.38 $776.38 0 0% 0% 0% 1 0 0 0 0 0 R Y
95805-26 $103.97 $103.97 0 0% 0% 0% 1 0 0 0 0 0 R Y
95805-TC $672.41 $672.41 0 0% 0% 0% 1 0 0 0 0 0 R Y
95806 $302.68 $302.68 0 0% 0% 0% 1 0 0 0 0 0 R Y
95806-26 $107.04 $107.04 0 0% 0% 0% 1 0 0 0 0 0 R Y
95806-TC $196.25 $196.25 0 0% 0% 0% 1 0 0 0 0 0 R Y
95807 $869.89 $869.89 0 0% 0% 0% 1 0 0 0 0 0 R Y
95807-26 $108.89 $108.89 0 0% 0% 0% 1 0 0 0 0 0 R Y
95807-TC $761.00 $761.00 0 0% 0% 0% 1 0 0 0 0 0 R Y
95808 $1,146.12 $1,146.12 0 0% 0% 0% 1 0 0 0 0 0 R Y
95808-26 $153.80 $153.80 0 0% 0% 0% 1 0 0 0 0 0 R Y
95808-TC $992.32 $992.32 0 0% 0% 0% 1 0 0 0 0 0 R Y
95810 $1,130.12 $1,130.12 0 0% 0% 0% 1 0 0 0 0 0 R Y
95810-26 $213.47 $213.47 0 0% 0% 0% 1 0 0 0 0 0 R Y
95810-TC $916.03 $916.03 0 0% 0% 0% 1 0 0 0 0 0 R Y
95811 $1,186.72 $1,186.72 0 0% 0% 0% 1 0 0 0 0 0 R Y
95811-26 $222.09 $222.09 0 0% 0% 0% 1 0 0 0 0 0 R Y
95811-TC $964.63 $964.63 0 0% 0% 0% 1 0 0 0 0 0 R Y
95812 $634.27 $634.27 0 0% 0% 0% 1 0 0 0 0 0 R
95812-26 $101.51 $101.51 0 0% 0% 0% 1 0 0 0 0 0 R
95812-TC $532.76 $532.76 0 0% 0% 0% 1 0 0 0 0 0 R
95813 $764.08 $764.08 0 0% 0% 0% 1 0 0 0 0 0 R
95813-26 $161.18 $161.18 0 0% 0% 0% 1 0 0 0 0 0 R
95813-TC $602.90 $602.90 0 0% 0% 0% 1 0 0 0 0 0 R
95816 $657.03 $657.03 0 0% 0% 0% 1 0 0 0 0 0 R
95816-26 $101.51 $101.51 0 0% 0% 0% 1 0 0 0 0 0 R
95816-TC $555.53 $555.53 0 0% 0% 0% 1 0 0 0 0 0 R
95819 $751.77 $751.77 0 0% 0% 0% 1 0 0 0 0 0 R
95819-26 $101.51 $101.51 0 0% 0% 0% 1 0 0 0 0 0 R
95819-TC $650.88 $650.88 0 0% 0% 0% 1 0 0 0 0 0 R
95822 $676.72 $676.72 0 0% 0% 0% 1 0 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 39
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
95822-26 $101.51 $101.51 0 0% 0% 0% 1 0 0 0 0 0 R
95822-TC $575.83 $575.83 0 0% 0% 0% 1 0 0 0 0 0 R
95824 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
95824-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
95824-26 $68.90 $68.90 0 0% 0% 0% 1 0 0 0 0 0 R
95827 $1,268.54 $1,268.54 0 0% 0% 0% 1 0 0 0 0 0 R
95827-26 $99.66 $99.66 0 0% 0% 0% 1 0 0 0 0 0 R
95827-TC $1,168.26 $1,168.26 0 0% 0% 0% 1 0 0 0 0 0 R
95829 $3,413.13 $3,413.13 0 0% 0% 0% 1 0 0 0 0 0 R
95829-26 $585.06 $585.06 0 0% 0% 0% 1 0 0 0 0 0 R
95829-TC $2,828.07 $2,828.07 0 0% 0% 0% 1 0 0 0 0 0 R
95830 $440.48 $160.57 0 0% 0% 0% 0 0 0 0 0 0 R
95831 $54.14 $25.84 0 0% 0% 0% 0 0 0 0 0 0 R
95832 $52.29 $27.07 0 0% 0% 0% 0 0 0 0 0 0 R
95833 $66.44 $37.53 0 0% 0% 0% 0 0 0 0 0 0 R
95834 $90.43 $54.75 0 0% 0% 0% 0 0 0 0 0 0 R
95851 $33.22 $13.53 0 0% 0% 0% 0 0 0 0 0 0 R
95852 $29.53 $10.46 0 0% 0% 0% 0 0 0 0 0 0 R
95857 $96.59 $51.68 0 0% 0% 0% 0 0 0 0 0 0 R
95860 $219.63 $219.63 0 0% 0% 0% 1 0 0 0 0 0 R
95860-26 $91.05 $91.05 0 0% 0% 0% 1 0 0 0 0 0 R
95860-TC $128.58 $128.58 0 0% 0% 0% 1 0 0 0 0 0 R
95861 $306.37 $306.37 0 0% 0% 0% 1 0 0 0 0 0 R
95861-26 $145.80 $145.80 0 0% 0% 0% 1 0 0 0 0 0 R
95861-TC $161.18 $161.18 0 0% 0% 0% 1 0 0 0 0 0 R
95863 $381.42 $381.42 0 0% 0% 0% 1 0 0 0 0 0 R
95863-26 $175.95 $175.95 0 0% 0% 0% 1 0 0 0 0 0 R
95863-TC $205.48 $205.48 0 0% 0% 0% 1 0 0 0 0 0 R
95864 $429.41 $429.41 0 0% 0% 0% 1 0 0 0 0 0 R
95864-26 $188.87 $188.87 0 0% 0% 0% 1 0 0 0 0 0 R
95864-TC $241.16 $241.16 0 0% 0% 0% 1 0 0 0 0 0 R
95865 $256.54 $256.54 0 0% 0% 0% 1 0 2 0 0 0 R
95865-26 $148.26 $148.26 0 0% 0% 0% 1 0 2 0 0 0 R
95865-TC $108.28 $108.28 0 0% 0% 0% 1 0 2 0 0 0 R
95866 $239.31 $239.31 0 0% 0% 0% 1 0 1 0 0 0 R
95866-26 $118.73 $118.73 0 0% 0% 0% 1 0 1 0 0 0 R
95866-TC $120.58 $120.58 0 0% 0% 0% 1 0 1 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 40
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
95867 $169.18 $169.18 0 0% 0% 0% 1 0 0 0 0 0 R
95867-26 $73.82 $73.82 0 0% 0% 0% 1 0 0 0 0 0 R
95867-TC $95.97 $95.97 0 0% 0% 0% 1 0 0 0 0 0 R
95868 $237.47 $237.47 0 0% 0% 0% 1 0 2 0 0 0 R
95868-26 $110.74 $110.74 0 0% 0% 0% 1 0 2 0 0 0 R
95868-TC $126.73 $126.73 0 0% 0% 0% 1 0 2 0 0 0 R
95869 $168.56 $168.56 0 0% 0% 0% 1 0 0 0 0 0 R
95869-26 $35.07 $35.07 0 0% 0% 0% 1 0 0 0 0 0 R
95869-TC $133.50 $133.50 0 0% 0% 0% 1 0 0 0 0 0 R
95870 $167.95 $167.95 0 0% 0% 0% 1 0 0 0 0 0 R
95870-26 $34.45 $34.45 0 0% 0% 0% 1 0 0 0 0 0 R
95870-TC $133.50 $133.50 0 0% 0% 0% 1 0 0 0 0 0 R
95872 $346.36 $346.36 0 0% 0% 0% 1 0 0 0 0 0 R
95872-26 $270.07 $270.07 0 0% 0% 0% 1 0 0 0 0 0 R
95872-TC $76.28 $76.28 0 0% 0% 0% 1 0 0 0 0 0 R
95873 $133.50 $133.50 0 0% 0% 0% 1 0 0 0 0 0 R
95873-26 $35.68 $35.68 0 0% 0% 0% 1 0 0 0 0 0 R
95873-TC $98.43 $98.43 0 0% 0% 0% 1 0 0 0 0 0 R
95874 $132.27 $132.27 0 0% 0% 0% 1 0 0 0 0 0 R
95874-26 $35.07 $35.07 0 0% 0% 0% 1 0 0 0 0 0 R
95874-TC $96.59 $96.59 0 0% 0% 0% 1 0 0 0 0 0 R
95875 $223.32 $223.32 0 0% 0% 0% 1 0 0 0 0 0 R
95875-26 $103.35 $103.35 0 0% 0% 0% 1 0 0 0 0 0 R
95875-TC $119.96 $119.96 0 0% 0% 0% 1 0 0 0 0 0 R
95885 $105.81 $105.81 0 0% 0% 0% 1 0 3 0 0 0 R
95885-26 $33.22 $33.22 0 0% 0% 0% 1 0 3 0 0 0 R
95885-TC $71.98 $71.98 0 0% 0% 0% 1 0 3 0 0 0 R
95886 $163.03 $163.03 0 0% 0% 0% 1 0 3 0 0 0 R
95886-26 $81.21 $81.21 0 0% 0% 0% 1 0 3 0 0 0 R
95886-TC $81.82 $81.82 0 0% 0% 0% 1 0 3 0 0 0 R
95887 $145.19 $145.19 0 0% 0% 0% 1 0 3 0 0 0 R
95887-26 $66.44 $66.44 0 0% 0% 0% 1 0 3 0 0 0 R
95887-TC $78.75 $78.75 0 0% 0% 0% 1 0 3 0 0 0 R
95905 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
95905-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
95905-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X
95907 $170.41 $170.41 0 0% 0% 0% 1 0 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 41
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
95907-26 $94.13 $94.13 0 0% 0% 0% 1 0 0 0 0 0 R
95907-TC $76.28 $76.28 0 0% 0% 0% 1 0 0 0 0 0 R
95908 $211.01 $211.01 0 0% 0% 0% 1 0 0 0 0 0 R
95908-26 $116.89 $116.89 0 0% 0% 0% 1 0 0 0 0 0 R
95908-TC $94.13 $94.13 0 0% 0% 0% 1 0 0 0 0 0 R
95909 $257.77 $257.77 0 0% 0% 0% 1 0 0 0 0 0 R
95909-26 $141.50 $141.50 0 0% 0% 0% 1 0 0 0 0 0 R
95909-TC $116.89 $116.89 0 0% 0% 0% 1 0 0 0 0 0 R
95910 $342.67 $342.67 0 0% 0% 0% 1 0 0 0 0 0 R
95910-26 $188.87 $188.87 0 0% 0% 0% 1 0 0 0 0 0 R
95910-TC $153.80 $153.80 0 0% 0% 0% 1 0 0 0 0 0 R
95911 $414.03 $414.03 0 0% 0% 0% 1 0 0 0 0 0 R
95911-26 $236.24 $236.24 0 0% 0% 0% 1 0 0 0 0 0 R
95911-TC $177.79 $177.79 0 0% 0% 0% 1 0 0 0 0 0 R
95912 $462.63 $462.63 0 0% 0% 0% 1 0 0 0 0 0 R
95912-26 $279.30 $279.30 0 0% 0% 0% 1 0 0 0 0 0 R
95912-TC $182.71 $182.71 0 0% 0% 0% 1 0 0 0 0 0 R
95913 $527.84 $527.84 0 0% 0% 0% 1 0 0 0 0 0 R
95913-26 $330.98 $330.98 0 0% 0% 0% 1 0 0 0 0 0 R
95913-TC $197.48 $197.48 0 0% 0% 0% 1 0 0 0 0 0 R
95921 $153.80 $153.80 0 0% 0% 0% 1 0 0 0 0 0 R
95921-26 $79.98 $79.98 0 0% 0% 0% 1 0 0 0 0 0 R
95921-TC $73.82 $73.82 0 0% 0% 0% 1 0 0 0 0 0 R
95922 $180.87 $180.87 0 0% 0% 0% 1 0 0 0 0 0 R
95922-26 $85.51 $85.51 0 0% 0% 0% 1 0 0 0 0 0 R
95922-TC $95.36 $95.36 0 0% 0% 0% 1 0 0 0 0 0 R
95923 $295.91 $295.91 0 0% 0% 0% 1 0 0 0 0 0 R
95923-26 $81.21 $81.21 0 0% 0% 0% 1 0 0 0 0 0 R
95923-TC $214.70 $214.70 0 0% 0% 0% 1 0 0 0 0 0 R
95924 $264.54 $264.54 0 0% 0% 0% 1 0 0 0 0 0 R
95924-26 $156.26 $156.26 0 0% 0% 0% 1 0 0 0 0 0 R
95924-TC $108.28 $108.28 0 0% 0% 0% 1 0 0 0 0 0 R
95925 $281.76 $281.76 0 0% 0% 0% 1 0 2 0 0 0 R
95925-26 $49.22 $49.22 0 0% 0% 0% 1 0 2 0 0 0 R
95925-TC $232.55 $232.55 0 0% 0% 0% 1 0 2 0 0 0 R
95926 $249.16 $249.16 0 0% 0% 0% 1 0 2 0 0 0 R
95926-26 $47.99 $47.99 0 0% 0% 0% 1 0 2 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 42
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
95926-TC $201.17 $201.17 0 0% 0% 0% 1 0 2 0 0 0 R
95927 $257.15 $257.15 0 0% 0% 0% 1 0 0 0 0 0 R
95927-26 $47.99 $47.99 0 0% 0% 0% 1 0 0 0 0 0 R
95927-TC $209.17 $209.17 0 0% 0% 0% 1 0 0 0 0 0 R
95928 $405.42 $405.42 0 0% 0% 0% 1 0 2 0 0 0 R
95928-26 $140.88 $140.88 0 0% 0% 0% 1 0 2 0 0 0 R
95928-TC $264.54 $264.54 0 0% 0% 0% 1 0 2 0 0 0 R
95929 $407.26 $407.26 0 0% 0% 0% 1 0 2 0 0 0 R
95929-26 $140.88 $140.88 0 0% 0% 0% 1 0 2 0 0 0 R
95929-TC $266.38 $266.38 0 0% 0% 0% 1 0 2 0 0 0 R
95930 $232.55 $232.55 0 0% 0% 0% 1 0 2 0 0 0 R
95930-26 $32.61 $32.61 0 0% 0% 0% 1 0 2 0 0 0 R
95930-TC $199.94 $199.94 0 0% 0% 0% 1 0 2 0 0 0 R
95933 $134.73 $134.73 0 0% 0% 0% 1 0 0 0 0 0 R
95933-26 $54.75 $54.75 0 0% 0% 0% 1 0 0 0 0 0 R
95933-TC $79.36 $79.36 0 0% 0% 0% 1 0 0 0 0 0 R
95937 $145.80 $145.80 0 0% 0% 0% 1 0 0 0 0 0 R
95937-26 $60.29 $60.29 0 0% 0% 0% 1 0 0 0 0 0 R
95937-TC $85.51 $85.51 0 0% 0% 0% 1 0 0 0 0 0 R
95938 $620.74 $620.74 0 0% 0% 0% 1 0 2 0 0 0 R
95938-26 $80.59 $80.59 0 0% 0% 0% 1 0 2 0 0 0 R
95938-TC $540.15 $540.15 0 0% 0% 0% 1 0 2 0 0 0 R
95939 $905.57 $905.57 0 0% 0% 0% 1 0 2 0 0 0 R
95939-26 $209.78 $209.78 0 0% 0% 0% 1 0 2 0 0 0 R
95939-TC $695.79 $695.79 0 0% 0% 0% 1 0 2 0 0 0 R
95940 $56.60 $56.60 0 0% 0% 0% 0 0 0 0 0 0 R
95941 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
95943 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
95943-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
95943-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
95950 $597.36 $597.36 0 0% 0% 0% 1 0 0 0 0 0 R
95950-26 $140.27 $140.27 0 0% 0% 0% 1 0 0 0 0 0 R
95950-TC $457.09 $457.09 0 0% 0% 0% 1 0 0 0 0 0 R
95951 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
95951-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
95951-26 $560.45 $560.45 0 0% 0% 0% 1 0 0 0 0 0 R
95953 $756.70 $756.70 0 0% 0% 0% 1 0 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 43
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
95953-26 $287.30 $287.30 0 0% 0% 0% 1 0 0 0 0 0 R
95953-TC $468.78 $468.78 0 0% 0% 0% 1 0 0 0 0 0 R
95954 $820.68 $820.68 0 0% 0% 0% 1 0 0 0 0 0 R
95954-26 $219.63 $219.63 0 0% 0% 0% 1 0 0 0 0 0 R
95954-TC $601.05 $601.05 0 0% 0% 0% 1 0 0 0 0 0 R
95955 $390.65 $390.65 0 0% 0% 0% 1 0 0 0 0 0 R
95955-26 $94.74 $94.74 0 0% 0% 0% 1 0 0 0 0 0 R
95955-TC $295.30 $295.30 0 0% 0% 0% 1 0 0 0 0 0 R
95956 $2,981.87 $2,981.87 0 0% 0% 0% 1 0 0 0 0 0 R
95956-26 $335.90 $335.90 0 0% 0% 0% 1 0 0 0 0 0 R
95956-TC $2,646.59 $2,646.59 0 0% 0% 0% 1 0 0 0 0 0 R
95957 $566.60 $566.60 0 0% 0% 0% 1 0 0 0 0 0 R
95957-26 $184.56 $184.56 0 0% 0% 0% 1 0 0 0 0 0 R
95957-TC $382.04 $382.04 0 0% 0% 0% 1 0 0 0 0 0 R
95958 $1,024.92 $1,024.92 0 0% 0% 0% 1 0 0 0 0 0 R
95958-26 $394.96 $394.96 0 0% 0% 0% 1 0 0 0 0 0 R
95958-TC $629.96 $629.96 0 0% 0% 0% 1 0 0 0 0 0 R
95961 $521.69 $521.69 0 0% 0% 0% 1 0 0 0 0 0 R
95961-26 $281.15 $281.15 0 0% 0% 0% 1 0 0 0 0 0 R
95961-TC $240.54 $240.54 0 0% 0% 0% 1 0 0 0 0 0 R
95962 $463.25 $463.25 0 0% 0% 0% 1 0 0 0 0 0 R
95962-26 $302.68 $302.68 0 0% 0% 0% 1 0 0 0 0 0 R
95962-TC $160.57 $160.57 0 0% 0% 0% 1 0 0 0 0 0 R
95965 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
95965-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
95965-26 $737.01 $737.01 0 0% 0% 0% 1 0 0 0 0 0 R Y
95966 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
95966-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
95966-26 $373.43 $373.43 0 0% 0% 0% 1 0 0 0 0 0 R Y
95967 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
95967-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y
95967-26 $325.44 $325.44 0 0% 0% 0% 1 0 0 0 0 0 R Y
95970 $122.42 $41.83 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR
95971 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
95972 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
95973 Not Covered Not Covered 0% 0% 0% 0 0 0 0 0 0 X
95974 $362.35 $283.61 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 44
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
95975 $195.02 $161.18 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR
95978 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
95979 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
95980 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
95981 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
95982 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
95990 $167.95 $167.95 0 0% 0% 0% 5 0 0 0 0 0 R Y-UR
95991 $220.24 $69.52 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR
95992 $75.67 $65.21 0 0% 0% 0% 0 0 0 0 0 0 R Y
95999 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
96000 $166.10 $166.10 0 0% 0% 0% 0 0 2 0 0 0 R
96001 $183.33 $183.33 0 0% 0% 0% 0 0 2 0 0 0 R
96002 Not Covered Not Covered 0 0% 0% 0% 0 0 2 0 0 0 X
96003 $31.99 $31.99 0 0% 0% 0% 0 0 2 0 0 0 R Y
96004 $203.63 $203.63 0 0% 0% 0% 2 0 2 0 0 0 R Y
96020 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
96020-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N
96020-26 $285.45 $285.45 0 0% 0% 0% 1 0 0 0 0 0 R
96040 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
96101 $138.42 $137.19 0 0% 0% 0% 0 0 0 0 0 0 R
96102 $113.81 $40.60 0 0% 0% 0% 0 0 0 0 0 0 R
96103 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
96105 $188.87 $188.87 0 0% 0% 0% 0 0 0 0 0 0 R
96110 $16.00 $16.00 0 0% 0% 0% 9 9 9 9 9 9 R Y
96111 $225.16 $213.47 0 0% 0% 0% 0 0 0 0 0 0 R Y
96116 $161.18 $150.72 0 0% 0% 0% 0 0 0 0 0 0 R
96118 $171.64 $136.57 0 0% 0% 0% 0 0 0 0 0 0 R
96119 $144.57 $41.22 0 0% 0% 0% 0 0 0 0 0 0 R
96120 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
96125 $207.94 $207.94 0 0% 0% 0% 0 5 0 0 0 0 R Y
96127 $9.23 $9.23 0 0% 0% 0% 3 0 0 0 0 0 R
96150 $37.53 $36.91 0 0% 0% 0% 0 0 0 0 0 0 R
96151 $35.68 $35.07 0 0% 0% 0% 0 0 0 0 0 0 R
96152 $34.45 $33.84 0 0% 0% 0% 0 0 0 0 0 0 R
96153 $8.00 $8.00 0 0% 0% 0% 0 0 0 0 0 0 R
96154 $33.84 $33.22 0 0% 0% 0% 0 0 0 0 0 0 R
96155 $39.37 $39.37 0 0% 0% 0% 9 9 9 9 9 9 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 45
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
96360 $103.35 $103.35 0 0% 0% 0% 5 0 0 0 0 0 R
96361 $27.07 $27.07 0 0% 0% 0% 5 0 0 0 0 0 R
96365 $124.89 $124.89 0 0% 0% 0% 5 0 0 0 0 0 R
96366 $33.84 $33.84 0 0% 0% 0% 5 0 0 0 0 0 R
96367 $54.75 $54.75 0 0% 0% 0% 5 0 0 0 0 0 R
96368 $36.91 $36.91 0 0% 0% 0% 5 0 0 0 0 0 R
96369 $350.05 $350.05 0 0% 0% 0% 5 0 0 0 0 0 R
96370 $26.45 $26.45 0 0% 0% 0% 5 0 0 0 0 0 R
96371 $132.88 $132.88 0 0% 0% 0% 5 0 0 0 0 0 R
96372 $45.52 $45.52 0 0% 0% 0% 5 0 0 0 0 0 R
96373 $34.45 $34.45 0 0% 0% 0% 5 0 0 0 0 0 R
96374 $102.12 $102.12 0 0% 0% 0% 5 0 0 0 0 0 R
96375 $40.60 $40.60 0 0% 0% 0% 5 0 0 0 0 0 R
96376 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
96379 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
96401 $134.11 $134.11 0 0% 0% 0% 5 0 0 0 0 0 R
96402 $57.83 $57.83 0 0% 0% 0% 5 0 0 0 0 0 R
96405 $148.26 $53.52 0 0% 0% 0% 0 2 0 1 0 0 R Y
96406 $209.78 $81.82 0 0% 0% 0% 0 2 0 1 0 0 R Y
96409 $199.32 $199.32 0 0% 0% 0% 5 0 0 0 0 0 R
96411 $111.97 $111.97 0 0% 0% 0% 5 0 0 0 0 0 R
96413 $243.62 $243.62 0 0% 0% 0% 5 0 0 0 0 0 R
96415 $50.45 $50.45 0 0% 0% 0% 5 0 0 0 0 0 R
96416 $253.46 $253.46 0 0% 0% 0% 5 0 0 0 0 0 R
96417 $112.58 $112.58 0 0% 0% 0% 5 0 0 0 0 0 R
96420 $186.41 $186.41 0 0% 0% 0% 5 0 0 0 0 0 R Y
96422 $306.37 $306.37 0 0% 0% 0% 5 0 0 0 0 0 R Y
96423 $141.50 $141.50 0 0% 0% 0% 5 0 0 0 0 0 R Y
96425 $326.67 $326.67 0 0% 0% 0% 5 0 0 0 0 0 R Y
96440 $1,538.62 $235.01 0 0% 0% 0% 0 0 0 0 0 0 R Y
96446 $357.43 $42.45 0 0% 0% 0% 5 0 0 0 0 0 R Y
96450 $324.83 $140.88 0 0% 0% 0% 0 0 0 0 0 0 R Y
96521 $248.54 $248.54 0 0% 0% 0% 5 0 0 0 0 0 R
96522 Not Covered Not Covered 0 0% 0% 0% 5 0 0 0 0 0 X
96523 $44.91 $44.91 0 0% 0% 0% 5 0 0 0 0 0 R
96542 $216.55 $73.82 0 0% 0% 0% 0 0 0 0 0 0 R Y
96549 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 46
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
96567 Not Covered Not Covered 0 0% 0% 0% 5 0 0 0 0 0 X
96570 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X
96571 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X
96900 $37.53 $37.53 0 0% 0% 0% 5 0 0 0 0 0 R Y
96902 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
96904 Not Covered Not Covered 0 0% 0% 0% 5 0 0 0 0 0 X
96910 $131.04 $131.04 0 0% 0% 0% 5 0 0 0 0 0 R Y
96912 $167.33 $167.33 0 0% 0% 0% 5 0 0 0 0 0 R Y
96913 $239.31 $239.31 0 0% 0% 0% 5 0 0 0 0 0 R Y
96920 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X
96921 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X
96922 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X
96931 By Report By Report 0 0% 0% 0% 4 0 0 0 0 0 N
96932 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N
96933 By Report By Report 0 0% 0% 0% 2 0 0 0 0 0 N
96934 By Report By Report 0 0% 0% 0% 4 0 0 0 0 0 N
96935 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N
96936 By Report By Report 0 0% 0% 0% 2 0 0 0 0 0 N
96999 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
97001 $125.68 $125.68 0 0% 0% 0% 0 5 0 0 0 0 F
97002 $74.44 $74.44 0 0% 0% 0% 0 5 0 0 0 0 R
97003 $125.68 $125.68 0 0% 0% 0% 0 5 0 0 0 0 F
97004 $93.51 $93.51 0 0% 0% 0% 0 5 0 0 0 0 R
97005 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
97006 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
97010 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
97012 $28.30 $28.30 0 0% 0% 0% 0 5 0 0 0 0 R
97014 $28.30 $28.30 0 0% 0% 0% 9 9 9 9 9 9 R
97016 $34.45 $34.45 0 0% 0% 0% 0 5 0 0 0 0 R
97018 $19.69 $19.69 0 0% 0% 0% 0 5 0 0 0 0 R
97022 $41.83 $41.83 0 0% 0% 0% 0 5 0 0 0 0 R
97024 $11.07 $11.07 0 0% 0% 0% 0 5 0 0 0 0 R
97026 $10.46 $10.46 0 0% 0% 0% 0 5 0 0 0 0 R
97028 $12.92 $12.92 0 0% 0% 0% 0 5 0 0 0 0 R
97032 $33.84 $33.84 0 0% 0% 0% 0 5 0 0 0 0 R
97033 Not Covered Not Covered 0 0% 0% 0% 0 5 0 0 0 0 X
97034 $31.99 $31.99 0 0% 0% 0% 0 5 0 0 0 0 R
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 47
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
97035 $21.53 $21.53 0 0% 0% 0% 0 5 0 0 0 0 R
97036 $59.06 $59.06 0 0% 0% 0% 0 5 0 0 0 0 R
97039 $18.78 $18.78 0 0% 0% 0% 0 0 0 0 0 0 F
97110 $57.21 $57.21 0 0% 0% 0% 0 5 0 0 0 0 R
97112 $59.67 $59.67 0 0% 0% 0% 0 5 0 0 0 0 R
97113 $76.90 $76.90 0 0% 0% 0% 0 5 0 0 0 0 R
97116 $50.45 $50.45 0 0% 0% 0% 0 5 0 0 0 0 R
97124 $46.76 $46.76 0 0% 0% 0% 0 5 0 0 0 0 R
97139 $26.05 $26.05 0 0% 0% 0% 0 0 0 0 0 0 F
97140 $52.91 $52.91 0 0% 0% 0% 0 5 0 0 0 0 R
97150 $30.76 $30.76 0 0% 0% 0% 0 5 0 0 0 0 R
97530 $62.14 $62.14 0 0% 0% 0% 0 5 0 0 0 0 R
97532 $47.37 $47.37 0 0% 0% 0% 0 0 0 0 0 0 R
97533 $51.68 $51.68 0 0% 0% 0% 0 5 0 0 0 0 R
97535 $62.14 $62.14 0 0% 0% 0% 0 5 0 0 0 0 R
97537 $52.91 $52.91 0 0% 0% 0% 0 5 0 0 0 0 R
97542 $54.75 $54.75 0 0% 0% 0% 0 5 0 0 0 0 R
97545 $147.21 $147.21 0 0% 0% 0% 0 0 0 0 0 0 F Y
97546 $75.12 $75.12 0 0% 0% 0% 0 0 0 0 0 0 F Y
97597 $135.34 $40.60 0 0% 0% 0% 0 0 0 0 0 0 R
97598 $43.68 $19.07 0 0% 0% 0% 0 0 0 0 0 0 R
97602 $52.10 $52.10 0 0% 0% 0% 9 9 9 9 9 9 F
97605 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y
97606 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y
97607 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y
97608 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y
97610 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
97750 $58.44 $58.44 0 0% 0% 0% 0 5 0 0 0 0 R
97755 $63.37 $63.37 0 0% 0% 0% 0 5 0 0 0 0 R
97760 $67.67 $67.67 0 0% 0% 0% 0 5 0 0 0 0 R
97761 $58.44 $58.44 0 0% 0% 0% 0 5 0 0 0 0 R
97762 $86.13 $86.13 0 0% 0% 0% 0 5 0 0 0 0 R
97799 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
97802 $61.52 $57.21 0 0% 0% 0% 0 0 0 0 0 0 R Y
97803 $52.91 $48.60 0 0% 0% 0% 0 0 0 0 0 0 R Y
97804 $27.68 $27.07 0 0% 0% 0% 0 0 0 0 0 0 R Y
97810 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 48
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
97811 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
97813 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
97814 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
98925 $55.37 $41.22 0 0% 0% 0% 0 0 0 0 0 0 R
98926 $80.59 $62.75 0 0% 0% 0% 0 0 0 0 0 0 R
98927 $103.97 $82.44 0 0% 0% 0% 0 0 0 0 0 0 R
98928 $127.35 $103.97 0 0% 0% 0% 0 0 0 0 0 0 R
98929 $152.57 $124.89 0 0% 0% 0% 0 0 0 0 0 0 R
98940 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
98941 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
98942 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
98943 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
98960 $50.45 $50.45 0 0% 0% 0% 9 9 9 9 9 9 R
98961 $24.61 $24.61 0 0% 0% 0% 9 9 9 9 9 9 R
98962 $17.84 $17.84 0 0% 0% 0% 9 9 9 9 9 9 R
98966 $23.99 $22.15 0 0% 0% 0% 9 9 9 9 9 9 R
98967 $46.76 $44.29 0 0% 0% 0% 9 9 9 9 9 9 R
98968 $68.90 $66.44 0 0% 0% 0% 9 9 9 9 9 9 R
98969 $46.04 $43.62 0 0% 0% 0% 9 9 9 9 9 9 F
99000 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99001 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99002 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99024 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99026 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99027 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99050 $47.25 $44.83 0 0% 0% 0% 9 9 9 9 9 9 F
99051 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99053 $21.20 $21.20 0 0% 0% 0% 9 9 9 9 9 9 F
99056 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y
99058 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99060 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
99070 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99071 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99075 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99078 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99080 $46.32 $46.32 0 0% 0% 0% 9 9 9 9 9 9 F
99082 $17.70 $17.70 0 0% 0% 0% 0 0 0 0 0 0 F
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 49
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
99090 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99091 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99100 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99116 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99135 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99140 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99143 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
99144 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B
99145 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B
99148 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
99149 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
99150 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
99170 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X
99172 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
99173 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B
99174 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99175 $30.76 $30.76 0 0% 0% 0% 5 0 0 0 0 0 R
99177 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N
99183 $188.25 $188.25 0 0% 0% 0% 2 0 0 0 0 0 R Y
99184 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
99188 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X
99190 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
99191 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
99192 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y
99195 $180.87 $180.87 0 0% 0% 0% 5 0 0 0 0 0 R
99199 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N
99500 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99501 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99502 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99503 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99504 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99505 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99506 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99507 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99509 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99510 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99511 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 50
Professional Services Fee Schedule
Medicine
Effective July 1, 2016
CPT
CODE
FOL
UP
PRE OP
(-56)
INTRA OP
(-54)
POST OP
(-55)
PCTC
(26/TC)
MSI
(-51)
BSI
(-50)
ASI
(-80)
CSI
(-62)
TSI
(-66)
ENDO
BASE FSI
PRIOR
AUTHNON-FACILITY
SETTING
FACILITY
SETTING
DOLLAR VALUE MODIFIERS
Medicine Fees
99512 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99600 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99601 $158.95 $158.95 0 0% 0% 0% 9 9 9 9 9 9 F Y
99602 $66.84 $66.84 0 0% 0% 0% 9 9 9 9 9 9 F Y
99605 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99606 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
99607 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X
CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 51