department of corrections (doc) ambulatory surgery center ......*multiple procedure discounting...

DOC ASC Fee Schedule Effective 7/1/2018-6/30/2019

Procedure Code

Allowed Amount*Multiple Procedure

Discounting10021-SG Not covered X10022-SG Not covered X10030-SG 495.74$ Y10035-SG Not covered X10036-SG Not covered X10040-SG Bundled X10060-SG 225.30$ Y10061-SG 389.73$ Y10080-SG 343.12$ Y10081-SG 512.09$ Y10120-SG 293.27$ Y10121-SG 901.87$ Y10140-SG 312.69$ Y10160-SG 247.31$ Y10180-SG 1,765.57$ Y11000-SG 104.23$ Y11001-SG Bundled X11010-SG 495.74$ Y11011-SG 495.74$ Y11012-SG 1,765.57$ Y11042-SG 268.96$ Y11043-SG 422.49$ Y11044-SG 901.87$ Y11045-SG Bundled X11046-SG Bundled X11047-SG Bundled X11055-SG Bundled X11056-SG Bundled X11057-SG 126.24$ Y11100-SG 200.69$ Y11101-SG Bundled X11200-SG Bundled X11201-SG Bundled X11300-SG Bundled X11301-SG Bundled X11302-SG Bundled X11303-SG Bundled X11305-SG Bundled X11306-SG Bundled X

Department of Corrections (DOC)Ambulatory Surgery Center Fee Schedule

Effective 7/1/2018 - 6/30/2019


Procedure Code


Discounting11307-SG 146.20$ Y11308-SG Bundled X11310-SG 217.53$ Y11311-SG 211.70$ Y11312-SG 306.22$ Y11313-SG 354.13$ Y11400-SG 239.54$ Y11401-SG 284.86$ Y11402-SG 317.87$ Y11403-SG 365.78$ Y11404-SG 901.87$ Y11406-SG 901.87$ Y11420-SG 234.36$ Y11421-SG 298.45$ Y11422-SG 336.00$ Y11423-SG 381.97$ Y11424-SG 901.87$ Y11426-SG 1,765.57$ Y11440-SG 258.96$ Y11441-SG 320.46$ Y11442-SG 358.01$ Y11443-SG 424.05$ Y11444-SG 901.87$ Y11446-SG 1,765.57$ Y11450-SG 1,765.57$ Y11451-SG 1,765.57$ Y11462-SG 1,765.57$ Y11463-SG 1,765.57$ Y11470-SG 1,765.57$ Y11471-SG 1,765.57$ Y11600-SG 368.37$ Y11601-SG 435.70$ Y11602-SG 471.95$ Y11603-SG 539.93$ Y11604-SG 495.74$ Y11606-SG 901.87$ Y11620-SG 370.96$ Y11621-SG 437.64$ Y11622-SG 487.49$ Y11623-SG 571.01$ Y11624-SG 901.87$ Y11626-SG 1,765.57$ Y11640-SG 382.61$ Y


Procedure Code


Discounting11641-SG 451.89$ Y11642-SG 515.33$ Y11643-SG 605.97$ Y11644-SG 901.87$ Y11646-SG 1,765.57$ Y11719-SG Bundled X11720-SG Bundled X11721-SG Bundled X11730-SG Bundled X11732-SG Bundled X11740-SG Bundled X11750-SG 291.33$ Y11755-SG 250.54$ Y11760-SG 422.49$ Y11762-SG 531.52$ Y11765-SG Bundled X11770-SG 1,765.57$ Y11771-SG 1,765.57$ Y11772-SG 1,765.57$ Y11900-SG Bundled X11901-SG Bundled X11920-SG 326.94$ Y11921-SG 374.84$ Y11922-SG Bundled X11950-SG 132.72$ Y11951-SG 190.98$ Y11952-SG 246.01$ Y11954-SG 294.57$ Y11960-SG 2,345.64$ Y11970-SG 4,520.99$ Y11971-SG 1,765.57$ N11976-SG Not covered X11980-SG Not covered X11981-SG Bundled X11982-SG Bundled X11983-SG Bundled X12001-SG Bundled X12002-SG Bundled X12004-SG Bundled X12005-SG 268.96$ N12006-SG 268.96$ N12007-SG 146.20$ Y12011-SG Bundled X


Procedure Code


Discounting12013-SG Bundled X12014-SG Bundled X12015-SG 146.20$ N12016-SG 268.96$ N12017-SG 268.96$ N12018-SG 146.20$ N12020-SG 422.49$ Y12021-SG 268.96$ Y12031-SG 452.53$ Y12032-SG 268.96$ Y12034-SG 268.96$ Y12035-SG 268.96$ Y12036-SG 422.49$ Y12037-SG 1,357.31$ Y12041-SG 451.89$ N12042-SG 268.96$ Y12044-SG 422.49$ Y12045-SG 422.49$ Y12046-SG 268.96$ Y12047-SG 1,357.31$ Y12051-SG 268.96$ Y12052-SG 268.96$ Y12053-SG 268.96$ Y12054-SG 268.96$ N12055-SG 268.96$ Y12056-SG 268.96$ N12057-SG 268.96$ Y13100-SG 422.49$ Y13101-SG 422.49$ Y13102-SG Bundled X13120-SG 422.49$ Y13121-SG 422.49$ Y13122-SG Bundled X13131-SG 268.96$ Y13132-SG 422.49$ Y13133-SG Bundled X13151-SG 422.49$ Y13152-SG 422.49$ Y13153-SG Bundled X13160-SG 1,357.31$ Y14000-SG 1,357.31$ Y14001-SG 1,357.31$ Y14020-SG 1,357.31$ Y


Procedure Code


Discounting14021-SG 1,357.31$ Y14040-SG 1,357.31$ Y14041-SG 1,357.31$ Y14060-SG 1,357.31$ Y14061-SG 1,357.31$ Y14301-SG 2,345.64$ Y14302-SG Bundled X14350-SG 1,357.31$ Y15002-SG 1,357.31$ Y15003-SG Bundled X15004-SG 422.49$ Y15005-SG Bundled X15040-SG 1,357.31$ Y15050-SG 422.49$ Y15100-SG 1,357.31$ Y15101-SG Bundled X15110-SG 1,357.31$ Y15111-SG Bundled X15115-SG 1,357.31$ Y15116-SG Bundled X15120-SG 2,345.64$ Y15121-SG Bundled X15130-SG 1,357.31$ Y15131-SG Bundled X15135-SG 2,345.64$ Y15136-SG Bundled X15150-SG 1,357.31$ Y15151-SG Bundled X15152-SG Bundled X15155-SG 2,345.64$ Y15156-SG Bundled X15157-SG Bundled X15200-SG 1,357.31$ Y15201-SG Bundled X15220-SG 1,357.31$ Y15221-SG Bundled X15240-SG 1,357.31$ Y15241-SG Bundled X15260-SG 1,357.31$ Y15261-SG Bundled X15271-SG 1,357.31$ Y15272-SG Bundled X15273-SG 2,345.64$ Y


Procedure Code


Discounting15274-SG Bundled X15275-SG 1,357.31$ Y15276-SG Bundled X15277-SG 1,357.31$ Y15278-SG Bundled X15570-SG 1,357.31$ Y15572-SG 2,345.64$ Y15574-SG 1,357.31$ Y15576-SG 1,357.31$ Y15600-SG 2,345.64$ Y15610-SG 1,357.31$ Y15620-SG 1,357.31$ Y15630-SG 1,357.31$ Y15650-SG 1,357.31$ Y15730-SG 2,345.64$ Y15731-SG 2,345.64$ Y15733-SG 2,345.64$ Y15734-SG 2,345.64$ Y15736-SG 1,357.31$ Y15738-SG 2,345.64$ Y15740-SG 1,357.31$ Y15750-SG 2,345.64$ Y15760-SG 1,357.31$ Y15770-SG 2,345.64$ Y15775-SG 268.96$ Y15776-SG 268.96$ Y15777-SG Bundled X15780-SG 1,782.94$ Y15781-SG 495.74$ Y15782-SG 1,154.96$ Y15783-SG 268.96$ Y15786-SG Bundled X15787-SG Bundled X15788-SG Not covered X15789-SG Not covered X15792-SG Not covered X15793-SG Not covered X15819-SG Not covered X15820-SG 1,357.31$ Y15821-SG 1,357.31$ Y15822-SG 1,357.31$ Y15823-SG 1,357.31$ Y15824-SG 1,357.31$ Y


Procedure Code


Discounting15825-SG 2,345.64$ Y15826-SG 2,345.64$ Y15828-SG 2,345.64$ Y15829-SG 2,345.64$ Y15830-SG 3,399.06$ Y15832-SG 1,765.57$ Y15833-SG 1,765.57$ Y15834-SG 1,765.57$ Y15835-SG 1,765.57$ Y15836-SG 1,765.57$ Y15837-SG 1,765.57$ Y15838-SG 1,765.57$ Y15839-SG 1,765.57$ Y15840-SG 2,345.64$ Y15841-SG 2,345.64$ Y15842-SG 1,357.31$ Y15845-SG 2,345.64$ Y15847-SG Bundled X15850-SG 422.49$ Y15851-SG 189.04$ Y15852-SG Bundled X15860-SG Bundled X15876-SG Not covered X15877-SG Not covered X15878-SG Not covered X15879-SG Not covered X15920-SG 1,765.57$ Y15922-SG 2,345.64$ Y15931-SG 901.87$ Y15933-SG 1,765.57$ Y15934-SG 2,345.64$ Y15935-SG 2,345.64$ Y15936-SG 1,357.31$ Y15937-SG 1,357.31$ Y15940-SG 1,765.57$ Y15941-SG 1,765.57$ Y15944-SG 2,345.64$ Y15945-SG 1,357.31$ Y15946-SG 1,357.31$ Y15950-SG 901.87$ Y15951-SG 1,765.57$ Y15952-SG 1,357.31$ Y15953-SG 2,345.64$ Y


Procedure Code


Discounting15956-SG 1,357.31$ Y15958-SG 2,345.64$ Y16000-SG Bundled X16020-SG Bundled X16025-SG 146.20$ Y16030-SG 268.96$ Y16035-SG 268.96$ Y17000-SG Bundled X17003-SG Bundled X17004-SG 273.85$ Y17106-SG 268.96$ Y17107-SG 831.26$ Y17108-SG 1,221.64$ Y17110-SG Bundled X17111-SG Bundled X17250-SG Bundled X17260-SG Bundled X17261-SG Bundled X17262-SG Bundled X17263-SG Bundled X17264-SG 389.73$ Y17266-SG 439.58$ Y17270-SG 146.20$ Y17271-SG 146.20$ Y17272-SG Bundled X17273-SG 393.62$ Y17274-SG 464.83$ Y17276-SG 536.69$ Y17280-SG Bundled X17281-SG 337.94$ Y17282-SG 387.15$ Y17283-SG 462.89$ Y17284-SG 529.57$ Y17286-SG 673.94$ Y17311-SG 422.49$ Y17312-SG Bundled X17313-SG 422.49$ Y17314-SG Bundled X17315-SG Bundled X17340-SG Not covered X17360-SG Not covered X17380-SG Not covered X19000-SG 214.29$ Y


Procedure Code


Discounting19001-SG Bundled X19020-SG 901.87$ Y19030-SG Bundled X19081-SG 901.87$ Y19082-SG Bundled X19083-SG 901.87$ Y19084-SG Bundled X19085-SG 901.87$ Y19086-SG Bundled X19100-SG 901.87$ Y19101-SG 1,711.08$ Y19105-SG Not covered X19110-SG 1,711.08$ Y19112-SG 1,711.08$ Y19120-SG 1,711.08$ Y19125-SG 1,711.08$ Y19126-SG Bundled X19281-SG Bundled X19282-SG Bundled X19283-SG Bundled X19284-SG Bundled X19285-SG Bundled X19286-SG Bundled X19287-SG Bundled X19288-SG Bundled X19294-SG Bundled X19296-SG Not covered X19297-SG Not covered X19298-SG Not covered X19300-SG Not covered X19301-SG Not covered X19302-SG Not covered X19303-SG Not covered X19304-SG Not covered X19316-SG 3,399.06$ Y19318-SG 3,399.06$ Y19324-SG 4,076.27$ Y19325-SG 4,076.27$ Y19328-SG 1,711.08$ N19330-SG 1,711.08$ N19340-SG 3,399.06$ Y19342-SG 4,076.27$ Y19350-SG 1,711.08$ Y


Procedure Code


Discounting19355-SG Not covered X19357-SG 5,134.28$ Y19366-SG 3,399.06$ Y19370-SG 1,711.08$ Y19371-SG 1,711.08$ Y19380-SG 3,399.06$ Y19396-SG 1,711.08$ Y20005-SG 901.87$ Y20103-SG 495.74$ Y20150-SG 2,126.29$ Y20200-SG 901.87$ Y20205-SG 1,765.57$ Y20206-SG 901.87$ Y20220-SG 901.87$ Y20225-SG 901.87$ Y20240-SG 1,765.57$ Y20245-SG 1,765.57$ Y20250-SG 2,126.29$ Y20251-SG 4,520.99$ Y20500-SG 199.40$ Y20501-SG Bundled X20520-SG 390.38$ Y20525-SG 1,765.57$ Y20526-SG 146.31$ Y20527-SG 159.26$ Y20550-SG 99.70$ Y20551-SG 114.59$ Y20552-SG 104.23$ Y20553-SG 120.42$ Y20555-SG Not covered X20600-SG 90.64$ Y20604-SG 135.95$ Y20605-SG 95.17$ Y20606-SG 150.84$ Y20610-SG 113.94$ Y20611-SG 170.91$ Y20612-SG 113.94$ Y20615-SG 457.71$ Y20650-SG 2,126.29$ Y20662-SG 1,225.33$ Y20663-SG 2,126.29$ Y20665-SG 285.59$ N20670-SG 901.87$ N


Procedure Code


Discounting20680-SG 1,765.57$ N20690-SG 4,520.99$ Y20692-SG 15,302.58$ Y20693-SG 4,520.99$ Y20694-SG 1,225.33$ N20696-SG 12,523.68$ Y20697-SG 1,225.33$ Y20822-SG 1,225.33$ Y20900-SG 4,520.99$ Y20902-SG 4,520.99$ Y20910-SG 422.49$ Y20912-SG 2,345.64$ Y20920-SG 1,357.31$ Y20922-SG 1,357.31$ Y20924-SG 4,520.99$ Y20926-SG 2,345.64$ Y20931-SG Bundled X20936-SG Bundled X20939-SG Bundled X20950-SG 495.74$ Y20972-SG 4,520.99$ Y20973-SG 4,520.99$ Y20975-SG Bundled X20979-SG Bundled X20982-SG Not covered X20983-SG Not covered X20985-SG Bundled X21010-SG 1,581.85$ Y21011-SG 661.00$ Y21012-SG 901.87$ Y21013-SG 985.34$ Y21014-SG 1,765.57$ Y21015-SG 1,765.57$ Y21025-SG 3,559.29$ Y21026-SG 3,559.29$ Y21029-SG 1,581.85$ Y21030-SG 989.23$ Y21031-SG 761.34$ Y21032-SG 767.17$ Y21034-SG 3,559.29$ Y21040-SG 1,581.85$ Y21044-SG 3,559.29$ Y21046-SG 3,559.29$ Y


Procedure Code


Discounting21047-SG 3,559.29$ Y21048-SG 3,559.29$ Y21050-SG 3,559.29$ Y21060-SG 3,559.29$ Y21070-SG 3,559.29$ Y21073-SG 735.45$ Y21076-SG 1,863.86$ Y21077-SG 4,690.41$ Y21079-SG 3,167.08$ Y21080-SG 3,566.53$ Y21081-SG 3,281.02$ Y21082-SG 3,093.28$ Y21083-SG 2,950.20$ Y21084-SG 3,383.31$ Y21085-SG 397.97$ Y21086-SG 3,479.78$ Y21087-SG 3,485.60$ Y21088-SG 1,581.85$ Y21100-SG 3,559.29$ Y21110-SG 1,527.86$ N21116-SG Bundled X21120-SG 3,559.29$ Y21121-SG 1,581.85$ Y21122-SG 3,559.29$ Y21123-SG 1,581.85$ Y21125-SG 3,559.29$ Y21127-SG 3,559.29$ Y21137-SG 1,581.85$ Y21138-SG 3,559.29$ Y21139-SG 3,559.29$ Y21150-SG 3,559.29$ Y21181-SG 3,559.29$ Y21198-SG 3,559.29$ Y21199-SG 3,559.29$ Y21206-SG 3,559.29$ Y21208-SG 3,559.29$ Y21209-SG 3,559.29$ Y21210-SG 3,559.29$ Y21215-SG 3,559.29$ Y21230-SG 3,559.29$ Y21235-SG 3,559.29$ Y21240-SG 3,559.29$ Y21242-SG 3,559.29$ Y


Procedure Code


Discounting21243-SG 25,456.84$ Y21244-SG 3,559.29$ Y21245-SG 3,559.29$ Y21246-SG 3,559.29$ Y21248-SG 3,559.29$ Y21249-SG 3,559.29$ Y21260-SG Not covered X21267-SG Not covered X21270-SG 3,559.29$ Y21275-SG 3,559.29$ Y21280-SG 1,581.85$ Y21282-SG 1,581.85$ Y21295-SG Not covered X21296-SG Not covered X21310-SG 185.98$ Y21315-SG 984.97$ Y21320-SG 1,581.85$ Y21325-SG 1,581.85$ Y21330-SG 3,559.29$ Y21335-SG 1,581.85$ Y21336-SG 2,126.29$ Y21337-SG 1,581.85$ Y21338-SG 3,559.29$ Y21339-SG 3,559.29$ Y21340-SG 1,581.85$ Y21345-SG 984.97$ Y21355-SG 1,581.85$ Y21356-SG 3,559.29$ Y21360-SG 3,559.29$ Y21390-SG 3,559.29$ Y21400-SG 397.97$ Y21401-SG 984.97$ Y21406-SG 3,559.29$ Y21407-SG 3,559.29$ Y21421-SG 1,581.85$ Y21440-SG 1,114.18$ Y21445-SG 3,559.29$ Y21450-SG 397.97$ Y21451-SG 984.97$ Y21452-SG 3,559.29$ Y21453-SG 3,559.29$ Y21454-SG 3,559.29$ Y21461-SG 3,559.29$ Y


Procedure Code


Discounting21462-SG 3,559.29$ Y21465-SG 3,559.29$ Y21480-SG 185.98$ Y21485-SG 984.97$ Y21490-SG 1,581.85$ Y21497-SG 984.97$ Y21501-SG 1,765.57$ Y21502-SG 2,126.29$ Y21550-SG 901.87$ Y21552-SG 1,765.57$ Y21554-SG 1,765.57$ Y21555-SG 901.87$ Y21556-SG 1,765.57$ Y21557-SG 1,765.57$ Y21600-SG 4,520.99$ Y21610-SG 2,126.29$ Y21685-SG Not covered X21700-SG 2,126.29$ Y21720-SG 2,126.29$ Y21725-SG 495.74$ Y21820-SG 185.98$ Y21920-SG 490.73$ Y21925-SG 901.87$ Y21930-SG 901.87$ Y21931-SG 901.87$ Y21932-SG 1,765.57$ Y21933-SG 1,765.57$ Y21935-SG 1,765.57$ Y22102-SG 4,520.99$ Y22103-SG Bundled X22310-SG 185.98$ Y22315-SG 1,225.33$ Y22505-SG 1,225.33$ Y22510-SG Not covered X22511-SG Not covered X22512-SG Not covered X22513-SG Not covered X22514-SG Not covered X22515-SG Not covered X22551-SG 16,034.95$ Y22552-SG Bundled X22554-SG 15,453.33$ Y22612-SG 8,421.19$ Y


Procedure Code


Discounting22614-SG Bundled X22845-SG Bundled X22850-SG UR/BR N22852-SG UR/BR N22853-SG Bundled X22854-SG Bundled X22856-SG 24,507.06$ Y22859-SG Bundled X22867-SG 12,523.68$ Y22868-SG Bundled X22869-SG 12,523.68$ Y22870-SG Bundled X22900-SG 1,765.57$ Y22901-SG 1,765.57$ Y22902-SG 901.87$ Y22903-SG 1,765.57$ Y23000-SG 1,765.57$ Y23020-SG 2,126.29$ Y23030-SG 1,765.57$ Y23031-SG 901.87$ Y23035-SG 1,225.33$ Y23040-SG 2,126.29$ Y23044-SG 2,126.29$ Y23065-SG Not covered X23066-SG 1,765.57$ Y23071-SG 901.87$ Y23073-SG 1,765.57$ Y23075-SG 901.87$ Y23076-SG 1,765.57$ Y23077-SG Not covered X23100-SG 1,225.33$ Y23101-SG 2,126.29$ Y23105-SG 4,520.99$ Y23106-SG 2,126.29$ Y23107-SG 4,520.99$ Y23120-SG 2,126.29$ Y23125-SG 2,126.29$ Y23130-SG 2,126.29$ Y23140-SG 2,126.29$ Y23145-SG 2,126.29$ Y23146-SG 4,520.99$ Y23150-SG 2,126.29$ Y23155-SG 4,520.99$ Y


Procedure Code


Discounting23156-SG 4,520.99$ Y23170-SG 1,225.33$ Y23172-SG 2,126.29$ Y23174-SG 2,126.29$ Y23180-SG 2,126.29$ Y23182-SG 2,126.29$ Y23184-SG 4,520.99$ Y23190-SG 2,126.29$ Y23195-SG 4,520.99$ Y23330-SG 495.74$ Y23333-SG 901.87$ Y23334-SG 1,765.57$ Y23350-SG Bundled X23395-SG 4,520.99$ Y23397-SG 4,520.99$ Y23400-SG 4,520.99$ Y23405-SG 4,520.99$ Y23406-SG 4,749.30$ Y23410-SG 4,520.99$ Y23412-SG 4,520.99$ Y23415-SG 4,520.99$ Y23420-SG 4,520.99$ Y23430-SG 4,520.99$ Y23440-SG 2,126.29$ Y23450-SG 4,520.99$ Y23455-SG 4,520.99$ Y23460-SG 4,520.99$ Y23462-SG 4,520.99$ Y23465-SG 4,520.99$ Y23466-SG 4,520.99$ Y23480-SG 4,520.99$ Y23485-SG 8,421.19$ Y23490-SG 4,520.99$ Y23491-SG 8,421.19$ Y23500-SG 185.98$ Y23505-SG 1,225.33$ Y23515-SG 4,520.99$ Y23520-SG 1,225.33$ Y23525-SG 185.98$ Y23530-SG 4,520.99$ Y23532-SG 4,520.99$ Y23540-SG 185.98$ Y23545-SG 185.98$ Y


Procedure Code


Discounting23550-SG 4,520.99$ Y23552-SG 4,520.99$ Y23570-SG 185.98$ Y23575-SG 1,225.33$ Y23585-SG 4,520.99$ Y23600-SG 185.98$ Y23605-SG 1,225.33$ Y23615-SG 15,609.17$ Y23616-SG 24,372.25$ Y23620-SG 185.98$ Y23625-SG 1,225.33$ Y23630-SG 4,520.99$ Y23650-SG 185.98$ Y23655-SG 1,225.33$ Y23660-SG 4,520.99$ Y23665-SG 1,225.33$ Y23670-SG 4,520.99$ Y23675-SG 1,225.33$ Y23680-SG 8,421.19$ Y23700-SG 1,225.33$ Y23800-SG 4,520.99$ Y23802-SG 8,421.19$ Y23921-SG 1,357.31$ Y23930-SG 901.87$ Y23931-SG 901.87$ Y23935-SG 2,126.29$ Y24000-SG 2,126.29$ Y24006-SG 2,126.29$ Y24065-SG 490.73$ Y24066-SG 1,765.57$ Y24071-SG 1,765.57$ Y24073-SG 1,765.57$ Y24075-SG 901.87$ Y24076-SG 1,765.57$ Y24077-SG Not covered X24100-SG 2,126.29$ Y24101-SG 2,126.29$ Y24102-SG 2,126.29$ Y24105-SG 2,126.29$ Y24110-SG 2,126.29$ Y24115-SG 4,520.99$ Y24116-SG 4,520.99$ Y24120-SG 2,126.29$ Y


Procedure Code


Discounting24125-SG 2,126.29$ Y24126-SG 4,520.99$ Y24130-SG 2,126.29$ Y24134-SG 4,520.99$ Y24136-SG 2,126.29$ Y24138-SG 4,520.99$ Y24140-SG 2,126.29$ Y24145-SG 4,520.99$ Y24147-SG 2,126.29$ Y24149-SG 4,520.99$ Y24152-SG Not covered X24155-SG 2,126.29$ Y24160-SG 2,126.29$ N24164-SG 2,126.29$ N24200-SG 396.21$ Y24201-SG 1,765.57$ Y24220-SG Bundled X24300-SG 1,225.33$ Y24301-SG 4,520.99$ Y24305-SG 2,126.29$ Y24310-SG 2,126.29$ Y24320-SG 4,520.99$ Y24330-SG 2,126.29$ Y24331-SG 4,520.99$ Y24332-SG 2,126.29$ Y24340-SG 4,520.99$ Y24341-SG 4,520.99$ Y24342-SG 4,520.99$ Y24343-SG 2,126.29$ Y24344-SG 4,520.99$ Y24345-SG 4,520.99$ Y24346-SG 8,421.19$ Y24357-SG 1,225.33$ Y24358-SG 2,126.29$ Y24359-SG 2,126.29$ Y24360-SG 4,520.99$ Y24361-SG 24,932.72$ Y24362-SG 8,421.19$ Y24363-SG 25,902.19$ Y24365-SG 8,421.19$ Y24366-SG 17,047.42$ Y24370-SG 15,501.19$ Y24371-SG 23,948.09$ Y


Procedure Code


Discounting24400-SG 4,520.99$ Y24410-SG Not covered X24420-SG Not covered X24430-SG 8,421.19$ Y24435-SG 15,259.79$ Y24470-SG 2,126.29$ Y24495-SG 4,520.99$ Y24498-SG 8,421.19$ Y24500-SG 185.98$ Y24505-SG 1,225.33$ Y24515-SG 8,421.19$ Y24516-SG 8,421.19$ Y24530-SG 185.98$ Y24535-SG 1,225.33$ Y24538-SG 4,520.99$ Y24545-SG 15,482.87$ Y24546-SG 22,980.12$ Y24560-SG 185.98$ Y24565-SG 1,225.33$ Y24566-SG 1,225.33$ Y24575-SG 8,421.19$ Y24576-SG 185.98$ Y24577-SG 1,225.33$ Y24579-SG 8,421.19$ Y24582-SG 2,126.29$ Y24586-SG 8,421.19$ Y24587-SG 15,434.99$ Y24600-SG 185.98$ Y24605-SG 1,225.33$ Y24615-SG 4,520.99$ Y24620-SG 1,225.33$ Y24635-SG 4,520.99$ Y24640-SG Not covered X24650-SG 185.98$ Y24655-SG 1,225.33$ Y24665-SG 4,520.99$ Y24666-SG 17,230.77$ Y24670-SG 185.98$ Y24675-SG 1,225.33$ Y24685-SG 4,520.99$ Y24800-SG 4,520.99$ Y24802-SG 8,421.19$ Y24925-SG 2,126.29$ Y


Procedure Code


Discounting25000-SG 1,225.33$ Y25001-SG 1,225.33$ Y25020-SG 1,225.33$ Y25023-SG 2,126.29$ Y25024-SG 2,126.29$ Y25025-SG 1,225.33$ Y25028-SG 2,126.29$ Y25031-SG 1,225.33$ Y25035-SG 4,520.99$ Y25040-SG 2,126.29$ Y25065-SG 485.55$ Y25066-SG 1,765.57$ Y25071-SG 901.87$ Y25073-SG 1,765.57$ Y25075-SG 901.87$ Y25076-SG 901.87$ Y25077-SG Not covered X25085-SG 2,126.29$ Y25100-SG 1,225.33$ Y25101-SG 2,126.29$ Y25105-SG 2,126.29$ Y25107-SG 2,126.29$ Y25109-SG 2,126.29$ Y25110-SG 1,225.33$ Y25111-SG 1,225.33$ Y25112-SG 1,225.33$ Y25115-SG 1,225.33$ Y25116-SG 2,126.29$ Y25118-SG 1,225.33$ Y25119-SG 2,126.29$ Y25120-SG 2,126.29$ Y25125-SG 1,225.33$ Y25126-SG 2,126.29$ Y25130-SG 2,126.29$ Y25135-SG 2,126.29$ Y25136-SG 4,520.99$ Y25145-SG 2,126.29$ Y25150-SG 2,126.29$ Y25151-SG 2,126.29$ Y25210-SG 2,126.29$ Y25215-SG 2,126.29$ Y25230-SG 2,126.29$ Y25240-SG 2,126.29$ Y


Procedure Code


Discounting25246-SG Bundled X25248-SG 1,225.33$ Y25250-SG 1,225.33$ N25251-SG 2,126.29$ N25259-SG 1,225.33$ Y25260-SG 2,126.29$ Y25263-SG 2,126.29$ Y25265-SG 2,126.29$ Y25270-SG 2,126.29$ Y25272-SG 2,126.29$ Y25274-SG 2,126.29$ Y25275-SG 2,126.29$ Y25280-SG 2,126.29$ Y25290-SG 2,126.29$ Y25295-SG 2,126.29$ Y25300-SG 2,126.29$ Y25301-SG 2,126.29$ Y25310-SG 2,126.29$ Y25312-SG 2,126.29$ Y25315-SG 4,520.99$ Y25316-SG 4,520.99$ Y25320-SG 4,520.99$ Y25332-SG 2,126.29$ Y25335-SG Not covered X25337-SG 4,520.99$ Y25350-SG 8,360.79$ Y25355-SG 2,126.29$ Y25360-SG 4,520.99$ Y25365-SG 8,421.19$ Y25370-SG 2,126.29$ Y25375-SG 2,126.29$ Y25390-SG 4,520.99$ Y25391-SG 16,226.42$ Y25392-SG 2,126.29$ Y25393-SG 2,126.29$ Y25394-SG 2,126.29$ Y25400-SG 4,520.99$ Y25405-SG 4,520.99$ Y25415-SG 4,520.99$ Y25420-SG 4,520.99$ Y25425-SG 4,520.99$ Y25426-SG 2,126.29$ Y25430-SG 2,126.29$ Y


Procedure Code


Discounting25431-SG 4,520.99$ Y25440-SG 4,520.99$ Y25441-SG 18,073.15$ Y25442-SG 26,082.46$ Y25443-SG 9,469.78$ Y25444-SG 19,209.89$ Y25445-SG 4,520.99$ Y25446-SG 27,321.57$ Y25447-SG 2,126.29$ Y25449-SG 4,520.99$ Y25450-SG 2,126.29$ Y25455-SG 2,126.29$ Y25490-SG 4,520.99$ Y25491-SG 8,421.19$ Y25492-SG 2,126.29$ Y25500-SG 185.98$ Y25505-SG 1,225.33$ Y25515-SG 4,520.99$ Y25520-SG 1,225.33$ Y25525-SG 4,520.99$ Y25526-SG 4,520.99$ Y25530-SG 185.98$ Y25535-SG 185.98$ Y25545-SG 4,520.99$ Y25560-SG 185.98$ Y25565-SG 1,225.33$ Y25574-SG 4,520.99$ Y25575-SG 4,520.99$ Y25600-SG 185.98$ Y25605-SG 1,225.33$ Y25606-SG 2,126.29$ Y25607-SG 8,349.30$ Y25608-SG 8,335.64$ Y25609-SG 8,426.95$ Y25622-SG 185.98$ Y25624-SG 1,225.33$ Y25628-SG 4,520.99$ Y25630-SG 185.98$ Y25635-SG 1,225.33$ Y25645-SG 2,126.29$ Y25650-SG 185.98$ Y25651-SG 2,126.29$ Y25652-SG 4,520.99$ Y


Procedure Code


Discounting25660-SG 185.98$ Y25670-SG 2,126.29$ Y25671-SG 2,126.29$ Y25675-SG 185.98$ Y25676-SG 4,520.99$ Y25680-SG 185.98$ Y25685-SG 2,126.29$ Y25690-SG 1,225.33$ Y25695-SG 4,520.99$ Y25800-SG 4,520.99$ Y25805-SG 4,520.99$ Y25810-SG 8,421.19$ Y25820-SG 4,520.99$ Y25825-SG 4,520.99$ Y25830-SG 4,520.99$ Y25907-SG 2,126.29$ Y25922-SG 1,225.33$ Y25929-SG 1,357.31$ Y25931-SG 2,126.29$ Y25999-SG UR/BR N26010-SG 146.20$ Y26011-SG 901.87$ Y26020-SG 2,126.29$ Y26025-SG 1,225.33$ Y26030-SG 2,126.29$ Y26034-SG 1,225.33$ Y26035-SG 1,225.33$ Y26040-SG 1,225.33$ Y26045-SG 2,126.29$ Y26055-SG 1,225.33$ Y26060-SG 1,225.33$ Y26070-SG 1,225.33$ Y26075-SG 2,126.29$ Y26080-SG 1,225.33$ Y26100-SG 2,126.29$ Y26105-SG 2,126.29$ Y26110-SG 1,225.33$ Y26111-SG 901.87$ Y26113-SG 901.87$ Y26115-SG 901.87$ Y26116-SG 901.87$ Y26117-SG Not covered X26121-SG 2,126.29$ Y


Procedure Code


Discounting26123-SG 2,126.29$ Y26125-SG Bundled X26130-SG 2,126.29$ Y26135-SG 2,126.29$ Y26140-SG 1,225.33$ Y26145-SG 1,225.33$ Y26160-SG 1,225.33$ Y26170-SG 1,225.33$ Y26180-SG 1,225.33$ Y26185-SG 1,225.33$ Y26200-SG 1,225.33$ Y26205-SG 4,520.99$ Y26210-SG 1,225.33$ Y26215-SG 2,126.29$ Y26230-SG 2,126.29$ Y26235-SG 1,225.33$ Y26236-SG 1,225.33$ Y26250-SG 1,225.33$ Y26260-SG 2,126.29$ Y26262-SG 1,225.33$ Y26320-SG 901.87$ N26340-SG 1,225.33$ Y26341-SG 189.04$ Y26350-SG 2,126.29$ Y26352-SG 2,126.29$ Y26356-SG 2,126.29$ Y26357-SG 2,126.29$ Y26358-SG 2,126.29$ Y26370-SG 2,126.29$ Y26372-SG 4,520.99$ Y26373-SG 2,126.29$ Y26390-SG 4,520.99$ Y26392-SG 4,520.99$ Y26410-SG 1,225.33$ Y26412-SG 2,126.29$ Y26415-SG 1,225.33$ Y26416-SG 2,126.29$ Y26418-SG 1,225.33$ Y26420-SG 2,126.29$ Y26426-SG 2,126.29$ Y26428-SG 2,126.29$ Y26432-SG 1,225.33$ Y26433-SG 2,126.29$ Y


Procedure Code


Discounting26434-SG 2,126.29$ Y26437-SG 1,225.33$ Y26440-SG 1,225.33$ Y26442-SG 2,126.29$ Y26445-SG 2,126.29$ Y26449-SG 2,126.29$ Y26450-SG 2,126.29$ Y26455-SG 1,225.33$ Y26460-SG 1,225.33$ Y26471-SG 2,126.29$ Y26474-SG 1,225.33$ Y26476-SG 1,225.33$ Y26477-SG 2,126.29$ Y26478-SG 2,126.29$ Y26479-SG 1,225.33$ Y26480-SG 2,126.29$ Y26483-SG 2,126.29$ Y26485-SG 2,126.29$ Y26489-SG 2,126.29$ Y26490-SG 2,126.29$ Y26492-SG 2,126.29$ Y26494-SG 2,126.29$ Y26496-SG 2,126.29$ Y26497-SG 2,126.29$ Y26498-SG 2,126.29$ Y26499-SG 1,225.33$ Y26500-SG 4,520.99$ Y26502-SG 2,126.29$ Y26508-SG 2,126.29$ Y26510-SG 2,126.29$ Y26516-SG 2,126.29$ Y26517-SG 2,126.29$ Y26518-SG 2,126.29$ Y26520-SG 2,126.29$ Y26525-SG 1,225.33$ Y26530-SG 2,126.29$ Y26531-SG 8,331.25$ Y26535-SG 2,126.29$ Y26536-SG 4,520.99$ Y26540-SG 2,126.29$ Y26541-SG 2,126.29$ Y26542-SG 2,126.29$ Y26545-SG 2,126.29$ Y


Procedure Code


Discounting26546-SG 4,520.99$ Y26548-SG 2,126.29$ Y26550-SG 2,126.29$ Y26555-SG 4,520.99$ Y26560-SG 1,225.33$ Y26561-SG 2,126.29$ Y26562-SG 2,126.29$ Y26565-SG 2,126.29$ Y26567-SG 2,126.29$ Y26568-SG 4,520.99$ Y26580-SG Not covered X26587-SG Not covered X26590-SG Not covered X26591-SG 1,225.33$ Y26593-SG 2,126.29$ Y26596-SG 2,126.29$ Y26600-SG 185.98$ Y26605-SG 185.98$ Y26607-SG 1,225.33$ Y26608-SG 2,126.29$ Y26615-SG 2,126.29$ Y26641-SG 185.98$ Y26645-SG 1,225.33$ Y26650-SG 2,126.29$ Y26665-SG 2,126.29$ Y26670-SG 185.98$ Y26675-SG 1,225.33$ Y26676-SG 2,126.29$ Y26685-SG 2,126.29$ Y26686-SG 2,126.29$ Y26700-SG 185.98$ Y26705-SG 1,225.33$ Y26706-SG 2,126.29$ Y26715-SG 2,126.29$ Y26720-SG 185.98$ Y26725-SG 185.98$ Y26727-SG 2,126.29$ Y26735-SG 2,126.29$ Y26740-SG 185.98$ Y26742-SG 1,225.33$ Y26746-SG 2,126.29$ Y26750-SG 185.98$ Y26755-SG 185.98$ Y


Procedure Code


Discounting26756-SG 2,126.29$ Y26765-SG 2,126.29$ Y26770-SG 185.98$ Y26775-SG 205.34$ Y26776-SG 2,126.29$ Y26785-SG 2,126.29$ Y26820-SG 4,520.99$ Y26841-SG 4,520.99$ Y26842-SG 4,520.99$ Y26843-SG 4,520.99$ Y26844-SG 4,520.99$ Y26850-SG 4,520.99$ Y26852-SG 4,520.99$ Y26860-SG 2,126.29$ Y26861-SG Bundled X26862-SG 2,126.29$ Y26863-SG Bundled X26910-SG 2,126.29$ Y26951-SG 2,126.29$ Y26952-SG 2,126.29$ Y26990-SG 2,126.29$ Y26991-SG 1,225.33$ Y27000-SG 1,225.33$ Y27001-SG 2,126.29$ Y27003-SG 4,520.99$ Y27033-SG 2,126.29$ Y27035-SG 2,126.29$ Y27040-SG 901.87$ Y27041-SG 901.87$ Y27043-SG 1,765.57$ Y27045-SG 1,765.57$ Y27047-SG 1,765.57$ Y27048-SG 1,765.57$ Y27049-SG Not covered X27050-SG 1,225.33$ Y27052-SG 1,225.33$ Y27060-SG 2,126.29$ Y27062-SG 2,126.29$ Y27065-SG 2,126.29$ Y27066-SG 2,126.29$ Y27067-SG 4,520.99$ Y27080-SG 2,126.29$ Y27086-SG 901.87$ Y


Procedure Code


Discounting27087-SG 2,126.29$ Y27093-SG Bundled X27095-SG Bundled X27097-SG 2,126.29$ Y27098-SG 1,225.33$ Y27100-SG 4,520.99$ Y27105-SG 2,126.29$ Y27110-SG 4,520.99$ Y27111-SG 2,126.29$ Y27197-SG 185.98$ Y27198-SG 185.98$ Y27200-SG 347.01$ Y27202-SG 2,126.29$ Y27220-SG 185.98$ Y27230-SG 185.98$ Y27238-SG 1,225.33$ Y27246-SG 185.98$ Y27250-SG 185.98$ Y27252-SG 1,225.33$ Y27256-SG 185.98$ Y27257-SG 1,225.33$ Y27265-SG 185.98$ Y27266-SG 1,225.33$ Y27267-SG 1,225.33$ Y27275-SG 1,225.33$ Y27279-SG 27,223.11$ Y27301-SG 1,765.57$ Y27305-SG 2,126.29$ Y27306-SG 1,225.33$ Y27307-SG 2,126.29$ Y27310-SG 2,126.29$ Y27323-SG 901.87$ Y27324-SG 1,765.57$ Y27325-SG 1,304.80$ Y27326-SG 1,304.80$ Y27327-SG 901.87$ Y27328-SG 1,765.57$ Y27329-SG 1,765.57$ Y27330-SG 2,126.29$ Y27331-SG 2,126.29$ Y27332-SG 2,126.29$ Y27333-SG 2,126.29$ Y27334-SG 2,126.29$ Y


Procedure Code


Discounting27335-SG 4,520.99$ Y27337-SG 1,765.57$ Y27339-SG 1,765.57$ Y27340-SG 2,126.29$ Y27345-SG 2,126.29$ Y27347-SG 2,126.29$ Y27350-SG 2,126.29$ Y27355-SG 2,126.29$ Y27356-SG 8,421.19$ Y27357-SG 4,520.99$ Y27358-SG Bundled X27360-SG 2,126.29$ Y27370-SG Bundled X27372-SG 1,765.57$ Y27380-SG 4,520.99$ Y27381-SG 4,520.99$ Y27385-SG 4,520.99$ Y27386-SG 4,520.99$ Y27390-SG 2,126.29$ Y27391-SG 2,126.29$ Y27392-SG 2,126.29$ Y27393-SG 2,126.29$ Y27394-SG 4,520.99$ Y27395-SG 2,126.29$ Y27396-SG 4,520.99$ Y27397-SG 4,520.99$ Y27400-SG 4,520.99$ Y27403-SG 2,126.29$ Y27405-SG 4,520.99$ Y27407-SG 4,520.99$ Y27409-SG 4,520.99$ Y27416-SG 4,520.99$ Y27418-SG 4,520.99$ Y27420-SG 4,520.99$ Y27422-SG 4,520.99$ Y27424-SG 4,520.99$ Y27425-SG 2,126.29$ Y27427-SG 4,520.99$ Y27428-SG 8,421.19$ Y27429-SG 8,421.19$ Y27430-SG 4,520.99$ Y27435-SG 2,126.29$ Y27437-SG 4,520.99$ Y


Procedure Code


Discounting27438-SG 15,359.61$ Y27440-SG 15,941.23$ Y27441-SG 8,421.19$ Y27442-SG 16,051.23$ Y27443-SG 8,421.19$ Y27446-SG 16,116.42$ Y27496-SG 2,126.29$ Y27497-SG 2,126.29$ Y27498-SG 1,225.33$ Y27499-SG 2,126.29$ Y27500-SG 185.98$ Y27501-SG 185.98$ Y27502-SG 1,225.33$ Y27503-SG 1,225.33$ Y27508-SG 185.98$ Y27509-SG 4,520.99$ Y27510-SG 1,225.33$ Y27516-SG 185.98$ Y27517-SG 1,225.33$ Y27520-SG 185.98$ Y27524-SG 4,520.99$ Y27530-SG 185.98$ Y27532-SG 2,126.29$ Y27538-SG 185.98$ Y27550-SG 185.98$ Y27552-SG 1,225.33$ Y27560-SG 185.98$ Y27562-SG 185.98$ Y27566-SG 4,520.99$ Y27570-SG 1,225.33$ Y27594-SG 2,126.29$ Y27600-SG 2,126.29$ Y27601-SG 2,126.29$ Y27602-SG 2,126.29$ Y27603-SG 1,765.57$ Y27604-SG 1,225.33$ Y27605-SG 1,225.33$ Y27606-SG 2,126.29$ Y27607-SG 2,126.29$ Y27610-SG 2,126.29$ Y27612-SG 2,126.29$ Y27613-SG 485.55$ Y27614-SG 1,765.57$ Y


Procedure Code


Discounting27615-SG Not covered X27618-SG 901.87$ Y27619-SG 1,765.57$ Y27620-SG 2,126.29$ Y27625-SG 2,126.29$ Y27626-SG 2,126.29$ Y27630-SG 2,126.29$ Y27632-SG 1,765.57$ Y27634-SG 1,765.57$ Y27635-SG 2,126.29$ Y27637-SG 4,520.99$ Y27638-SG 4,520.99$ Y27640-SG 2,126.29$ Y27641-SG 2,126.29$ Y27647-SG 2,126.29$ Y27648-SG Bundled X27650-SG 2,126.29$ Y27652-SG 4,520.99$ Y27654-SG 4,520.99$ Y27656-SG 2,126.29$ Y27658-SG 2,126.29$ Y27659-SG 4,520.99$ Y27664-SG 4,520.99$ Y27665-SG 4,520.99$ Y27675-SG 2,126.29$ Y27676-SG 4,520.99$ Y27680-SG 2,126.29$ Y27681-SG 2,126.29$ Y27685-SG 2,126.29$ Y27686-SG 2,126.29$ Y27687-SG 2,126.29$ Y27690-SG 4,520.99$ Y27691-SG 4,520.99$ Y27692-SG Bundled X27695-SG 4,520.99$ Y27696-SG 4,520.99$ Y27698-SG 4,520.99$ Y27700-SG 4,520.99$ Y27704-SG 2,126.29$ N27705-SG 4,520.99$ Y27707-SG 2,126.29$ Y27709-SG 8,421.19$ Y27726-SG 4,520.99$ Y


Procedure Code


Discounting27730-SG 2,126.29$ Y27732-SG 2,126.29$ Y27734-SG 2,126.29$ Y27740-SG 3,852.24$ Y27742-SG 2,126.29$ Y27745-SG 4,520.99$ Y27750-SG 185.98$ Y27752-SG 1,225.33$ Y27756-SG 4,520.99$ Y27758-SG 8,421.19$ Y27759-SG 8,421.19$ Y27760-SG 185.98$ Y27762-SG 1,225.33$ Y27766-SG 4,520.99$ Y27767-SG 185.98$ Y27768-SG 1,225.33$ Y27769-SG 4,520.99$ Y27780-SG 185.98$ Y27781-SG 1,225.33$ Y27784-SG 4,520.99$ Y27786-SG 185.98$ Y27788-SG 185.98$ Y27792-SG 4,520.99$ Y27808-SG 185.98$ Y27810-SG 1,225.33$ Y27814-SG 4,520.99$ Y27816-SG 185.98$ Y27818-SG 1,225.33$ Y27822-SG 4,520.99$ Y27823-SG 4,520.99$ Y27824-SG 185.98$ Y27825-SG 1,225.33$ Y27826-SG 4,520.99$ Y27827-SG 8,421.19$ Y27828-SG 8,421.19$ Y27829-SG 4,520.99$ Y27830-SG 185.98$ Y27831-SG 2,126.29$ Y27832-SG 4,520.99$ Y27840-SG 185.98$ Y27842-SG 1,225.33$ Y27846-SG 4,520.99$ Y27848-SG 4,520.99$ Y


Procedure Code


Discounting27860-SG 1,225.33$ Y27870-SG 15,679.45$ Y27871-SG 8,421.19$ Y27884-SG 2,126.29$ Y27889-SG 4,520.99$ Y27892-SG 2,126.29$ Y27893-SG 4,520.99$ Y27894-SG 1,225.33$ Y27899-SG 188.20$ Y28001-SG 530.87$ Y28002-SG 1,225.33$ Y28003-SG 2,126.29$ Y28005-SG 2,126.29$ Y28008-SG 2,126.29$ Y28010-SG 442.17$ Y28011-SG 1,225.33$ Y28020-SG 2,126.29$ Y28022-SG 2,126.29$ Y28024-SG 1,225.33$ Y28035-SG 1,304.80$ Y28039-SG 1,765.57$ Y28041-SG 1,765.57$ Y28043-SG 901.87$ Y28045-SG 1,765.57$ Y28046-SG Not covered X28050-SG 2,126.29$ Y28052-SG 2,126.29$ Y28054-SG 2,126.29$ Y28055-SG 1,304.80$ Y28060-SG 2,126.29$ Y28062-SG 2,126.29$ Y28070-SG 2,126.29$ Y28072-SG 2,126.29$ Y28080-SG 1,225.33$ Y28086-SG 2,126.29$ Y28088-SG 1,225.33$ Y28090-SG 1,225.33$ Y28092-SG 1,225.33$ Y28100-SG 2,126.29$ Y28102-SG 4,520.99$ Y28103-SG 4,520.99$ Y28104-SG 2,126.29$ Y28106-SG 4,520.99$ Y


Procedure Code


Discounting28107-SG 4,520.99$ Y28108-SG 1,225.33$ Y28110-SG 2,126.29$ Y28111-SG 2,126.29$ Y28112-SG 2,126.29$ Y28113-SG 2,126.29$ Y28114-SG 2,126.29$ Y28116-SG 2,126.29$ Y28118-SG 2,126.29$ Y28119-SG 2,126.29$ Y28120-SG 2,126.29$ Y28122-SG 2,126.29$ Y28124-SG 921.25$ Y28126-SG 1,225.33$ Y28130-SG 2,126.29$ Y28140-SG 2,126.29$ Y28150-SG 2,126.29$ Y28153-SG 1,225.33$ Y28160-SG 2,126.29$ Y28171-SG Not covered X28173-SG Not covered X28175-SG Not covered X28190-SG 501.09$ Y28192-SG 901.87$ Y28193-SG 901.87$ Y28200-SG 2,126.29$ Y28202-SG 4,520.99$ Y28208-SG 2,126.29$ Y28210-SG 4,520.99$ Y28220-SG 869.46$ Y28222-SG 2,126.29$ Y28225-SG 2,126.29$ Y28226-SG 1,225.33$ Y28230-SG 839.68$ Y28232-SG 748.39$ Y28234-SG 1,225.33$ Y28238-SG 4,520.99$ Y28240-SG 2,126.29$ Y28250-SG 2,126.29$ Y28260-SG 1,225.33$ Y28261-SG 1,225.33$ Y28262-SG 4,520.99$ Y28264-SG 1,225.33$ Y


Procedure Code


Discounting28270-SG 2,126.29$ Y28272-SG 760.05$ Y28280-SG 2,126.29$ Y28285-SG 2,126.29$ Y28286-SG 1,225.33$ Y28288-SG 2,126.29$ Y28289-SG 2,126.29$ Y28291-SG 4,520.99$ Y28292-SG 2,126.29$ Y28295-SG 2,126.29$ Y28296-SG 2,126.29$ Y28297-SG 4,520.99$ Y28298-SG 4,520.99$ Y28299-SG 2,126.29$ Y28300-SG 4,520.99$ Y28302-SG 4,520.99$ Y28304-SG 4,520.99$ Y28305-SG 4,520.99$ Y28306-SG 4,520.99$ Y28307-SG 2,126.29$ Y28308-SG 2,126.29$ Y28309-SG 4,520.99$ Y28310-SG 2,126.29$ Y28312-SG 2,126.29$ Y28313-SG 2,126.29$ Y28315-SG 2,126.29$ Y28320-SG 8,421.19$ Y28322-SG 4,520.99$ Y28340-SG Not covered X28341-SG Not covered X28344-SG Not covered X28345-SG Not covered X28400-SG 185.98$ Y28405-SG 185.98$ Y28406-SG 4,520.99$ Y28415-SG 4,520.99$ Y28420-SG 15,805.77$ Y28430-SG 185.98$ Y28435-SG 1,225.33$ Y28436-SG 4,520.99$ Y28445-SG 4,520.99$ Y28446-SG 4,520.99$ Y28450-SG 185.98$ Y


Procedure Code


Discounting28455-SG 550.29$ Y28456-SG 4,520.99$ Y28465-SG 4,520.99$ Y28470-SG 185.98$ Y28475-SG 185.98$ Y28476-SG 2,126.29$ Y28485-SG 4,520.99$ Y28490-SG 281.62$ Y28495-SG 185.98$ Y28496-SG 2,126.29$ Y28505-SG 2,126.29$ Y28510-SG 238.24$ Y28515-SG 311.40$ Y28525-SG 2,126.29$ Y28530-SG 224.00$ Y28531-SG 4,520.99$ Y28540-SG 185.98$ Y28545-SG 2,126.29$ Y28546-SG 1,225.33$ Y28555-SG 4,520.99$ Y28570-SG 185.98$ Y28575-SG 2,126.29$ Y28576-SG 1,225.33$ Y28585-SG 8,997.87$ Y28600-SG 185.98$ Y28605-SG 185.98$ Y28606-SG 2,126.29$ Y28615-SG 4,520.99$ Y28630-SG 300.39$ Y28635-SG 1,225.33$ Y28636-SG 1,225.33$ Y28645-SG 2,126.29$ Y28660-SG 222.06$ Y28665-SG 205.34$ Y28666-SG 2,126.29$ Y28675-SG 2,126.29$ Y28705-SG 22,977.08$ Y28715-SG 15,887.25$ Y28725-SG 8,421.19$ Y28730-SG 16,209.12$ Y28735-SG 16,156.16$ Y28737-SG 16,286.52$ Y28740-SG 8,337.82$ Y


Procedure Code


Discounting28750-SG 8,333.46$ Y28755-SG 4,520.99$ Y28760-SG 4,520.99$ Y28810-SG 2,126.29$ Y28820-SG 1,225.33$ Y28825-SG 1,225.33$ Y28890-SG Not covered X29000-SG 205.34$ Y29010-SG 205.34$ Y29015-SG 205.34$ Y29035-SG 205.34$ Y29040-SG 205.34$ Y29044-SG 117.19$ Y29046-SG 205.34$ Y29049-SG 189.69$ Y29055-SG 205.34$ Y29058-SG 236.95$ Y29065-SG 183.86$ Y29075-SG 165.73$ Y29085-SG 182.57$ Y29086-SG 153.43$ Y29105-SG 167.68$ Y29125-SG Bundled X29126-SG Bundled X29130-SG Bundled X29131-SG Bundled X29200-SG 59.56$ Y29240-SG Bundled X29260-SG Bundled X29280-SG Bundled X29305-SG 205.34$ Y29325-SG 205.34$ Y29345-SG 258.96$ Y29355-SG 266.73$ Y29358-SG 307.52$ Y29365-SG 235.01$ Y29405-SG 155.38$ Y29425-SG 148.90$ Y29435-SG 225.30$ Y29440-SG 82.87$ Y29445-SG 247.31$ Y29450-SG Not covered X29505-SG 163.14$ Y


Procedure Code


Discounting29515-SG 137.25$ Y29520-SG Bundled X29530-SG Bundled X29540-SG 49.85$ Y29550-SG Bundled X29580-SG 116.53$ Y29581-SG 162.50$ Y29584-SG 152.14$ Y29700-SG 124.30$ Y29705-SG 125.60$ Y29710-SG 235.65$ Y29720-SG 163.14$ Y29730-SG 119.77$ Y29740-SG 189.04$ Y29750-SG Not covered X29800-SG 2,126.29$ Y29804-SG 2,126.29$ Y29805-SG 2,126.29$ Y29806-SG 4,520.99$ Y29807-SG 4,520.99$ Y29819-SG 2,126.29$ Y29820-SG 4,520.99$ Y29821-SG 2,126.29$ Y29822-SG 2,126.29$ Y29823-SG 2,126.29$ Y29824-SG 2,126.29$ Y29825-SG 2,126.29$ Y29826-SG Bundled X29827-SG 4,520.99$ Y29828-SG 4,520.99$ Y29830-SG 2,126.29$ Y29834-SG 2,126.29$ Y29835-SG 2,126.29$ Y29836-SG 4,520.99$ Y29837-SG 2,126.29$ Y29838-SG 2,126.29$ Y29840-SG 2,126.29$ Y29843-SG 2,126.29$ Y29844-SG 2,126.29$ Y29845-SG 2,126.29$ Y29846-SG 2,126.29$ Y29847-SG 4,520.99$ Y29848-SG 1,225.33$ Y


Procedure Code


Discounting29850-SG 1,225.33$ Y29851-SG 1,225.33$ Y29855-SG 8,184.16$ Y29856-SG 17,530.24$ Y29860-SG 4,520.99$ Y29861-SG 2,126.29$ Y29862-SG 4,520.99$ Y29863-SG 2,126.29$ Y29866-SG 4,520.99$ Y29867-SG 8,865.27$ Y29868-SG 4,909.89$ Y29870-SG 2,126.29$ Y29871-SG 2,126.29$ Y29873-SG 2,126.29$ Y29874-SG 2,126.29$ Y29875-SG 2,126.29$ Y29876-SG 2,126.29$ Y29877-SG 2,126.29$ Y29879-SG 2,126.29$ Y29880-SG 2,126.29$ Y29881-SG 2,126.29$ Y29882-SG 2,126.29$ Y29883-SG 2,126.29$ Y29884-SG 2,126.29$ Y29885-SG 4,520.99$ Y29886-SG 2,126.29$ Y29887-SG 4,520.99$ Y29888-SG 4,520.99$ Y29889-SG 8,421.19$ Y29891-SG 2,126.29$ Y29892-SG 4,520.99$ Y29893-SG 2,126.29$ Y29894-SG 2,126.29$ Y29895-SG 2,126.29$ Y29897-SG 2,126.29$ Y29898-SG 2,126.29$ Y29899-SG 4,520.99$ Y29900-SG 2,126.29$ Y29901-SG 2,126.29$ Y29902-SG 1,225.33$ Y29904-SG 2,126.29$ Y29905-SG 2,126.29$ Y29906-SG 2,126.29$ Y


Procedure Code


Discounting29907-SG 8,421.19$ Y29914-SG Not covered X29915-SG Not covered X29916-SG 4,520.99$ Y29999-SG UR/BR N30000-SG 154.47$ Y30020-SG 437.00$ Y30100-SG 263.49$ Y30110-SG 431.17$ Y30115-SG 1,581.85$ Y30117-SG 1,581.85$ Y30118-SG 1,581.85$ Y30120-SG Not covered X30124-SG Not covered X30125-SG Not covered X30130-SG 1,581.85$ Y30140-SG 1,581.85$ Y30150-SG 3,559.29$ Y30160-SG 3,559.29$ Y30200-SG 211.05$ Y30210-SG 281.62$ Y30220-SG 984.97$ Y30300-SG Bundled X30310-SG 1,581.85$ Y30320-SG 984.97$ Y30400-SG 3,559.29$ Y30410-SG 3,559.29$ Y30420-SG 3,559.29$ Y30430-SG 3,559.29$ Y30435-SG 3,559.29$ Y30450-SG 3,559.29$ Y30460-SG Not covered X30462-SG Not covered X30465-SG 3,559.29$ Y30520-SG 1,581.85$ Y30540-SG Not covered X30545-SG Not covered X30560-SG 397.97$ Y30580-SG 3,559.29$ Y30600-SG 3,559.29$ Y30620-SG 3,559.29$ Y30630-SG 1,581.85$ Y30801-SG 984.97$ Y


Procedure Code


Discounting30802-SG 984.97$ Y30901-SG Bundled X30903-SG 90.90$ Y30905-SG 90.90$ Y30906-SG 154.47$ Y30915-SG 2,157.21$ Y30920-SG 2,157.21$ Y30930-SG 1,581.85$ Y31000-SG 154.47$ Y31002-SG 984.97$ Y31020-SG 1,581.85$ Y31030-SG 3,559.29$ Y31032-SG 3,559.29$ Y31040-SG 3,559.29$ Y31050-SG 3,559.29$ Y31051-SG 3,559.29$ Y31070-SG 3,559.29$ Y31075-SG 3,559.29$ Y31080-SG 3,559.29$ Y31081-SG 3,559.29$ Y31084-SG 3,559.29$ Y31085-SG 3,559.29$ Y31086-SG 3,559.29$ Y31087-SG 3,559.29$ Y31090-SG 3,559.29$ Y31200-SG 3,559.29$ Y31201-SG 1,581.85$ Y31205-SG 1,581.85$ Y31231-SG 135.94$ Y31233-SG 324.93$ Y31235-SG 977.20$ Y31237-SG 977.20$ Y31238-SG 977.20$ Y31239-SG 1,907.68$ Y31240-SG Not covered X31253-SG 2,937.22$ Y31254-SG 2,937.22$ Y31255-SG 2,937.22$ Y31256-SG 1,907.68$ Y31257-SG 2,937.22$ Y31259-SG 2,937.22$ Y31267-SG 2,937.22$ Y31276-SG 2,937.22$ Y


Procedure Code


Discounting31287-SG 2,937.22$ Y31288-SG 2,937.22$ Y31295-SG 2,937.22$ Y31296-SG 2,937.22$ Y31297-SG 2,937.22$ Y31298-SG 2,937.22$ Y31300-SG Not covered X31400-SG Not covered X31420-SG Not covered X31500-SG 154.47$ Y31502-SG 154.47$ Y31505-SG 156.02$ Y31510-SG 1,907.68$ Y31511-SG 135.94$ Y31512-SG 1,907.68$ Y31513-SG 324.93$ Y31515-SG 324.93$ Y31520-SG Not covered X31525-SG 977.20$ Y31526-SG 977.20$ Y31527-SG 1,907.68$ Y31528-SG 1,907.68$ Y31529-SG 1,907.68$ Y31530-SG 977.20$ Y31531-SG 1,907.68$ Y31535-SG 1,907.68$ Y31536-SG 1,907.68$ Y31540-SG Not covered X31541-SG Not covered X31545-SG 1,907.68$ Y31546-SG 2,937.22$ Y31551-SG Not covered X31552-SG 3,559.29$ Y31553-SG Not covered X31554-SG 3,559.29$ Y31560-SG Not covered X31561-SG Not covered X31570-SG 1,907.68$ Y31571-SG 1,907.68$ Y31572-SG 1,907.68$ Y31573-SG 977.20$ Y31574-SG 977.20$ Y31575-SG 213.64$ Y


Procedure Code


Discounting31576-SG 977.20$ Y31577-SG 324.93$ Y31578-SG 1,907.68$ Y31579-SG 338.59$ Y31580-SG Not covered X31590-SG 3,559.29$ Y31591-SG 3,559.29$ Y31592-SG 3,559.29$ Y31595-SG Not covered X31603-SG 984.97$ Y31605-SG 397.97$ Y31611-SG 1,581.85$ Y31612-SG 1,581.85$ Y31613-SG 1,581.85$ Y31614-SG 3,559.29$ Y31615-SG 397.97$ Y31622-SG 977.20$ Y31623-SG 977.20$ Y31624-SG 977.20$ Y31625-SG 977.20$ Y31626-SG 2,937.22$ Y31627-SG Bundled X31628-SG 1,907.68$ Y31629-SG 1,907.68$ Y31630-SG 1,907.68$ Y31631-SG 2,937.22$ Y31632-SG Bundled X31633-SG Bundled X31634-SG 2,937.22$ Y31635-SG 977.20$ Y31636-SG 5,465.25$ Y31637-SG Bundled X31638-SG 2,937.22$ Y31640-SG 1,907.68$ Y31641-SG 1,907.68$ Y31643-SG 977.20$ Y31645-SG 977.20$ Y31646-SG 324.93$ Y31647-SG 2,937.22$ Y31648-SG 1,907.68$ Y31649-SG 977.20$ N31651-SG Bundled X31652-SG 1,907.68$ Y


Procedure Code


Discounting31653-SG 1,907.68$ Y31654-SG Bundled X31717-SG 324.93$ Y31720-SG Bundled X31730-SG 977.20$ Y31750-SG 3,559.29$ Y31755-SG 3,559.29$ Y31820-SG 1,581.85$ Y31825-SG 1,581.85$ Y31830-SG 1,581.85$ Y32400-SG 901.87$ Y32405-SG 901.87$ Y32550-SG 2,213.83$ Y32552-SG 530.12$ N32554-SG 530.12$ Y32555-SG 530.12$ Y32556-SG 1,042.35$ Y32557-SG 850.66$ Y32960-SG 530.12$ Y32994-SG 3,483.90$ Y32998-SG 3,483.90$ Y33010-SG 850.66$ Y33011-SG 850.66$ Y33206-SG 17,000.40$ Y33207-SG 17,117.35$ Y33208-SG 17,506.52$ Y33210-SG 6,181.48$ Y33211-SG 13,206.60$ Y33212-SG 12,900.04$ Y33213-SG 17,320.77$ Y33214-SG 16,992.53$ Y33215-SG 2,157.21$ Y33216-SG 6,181.48$ Y33217-SG 12,577.78$ Y33218-SG 2,481.91$ Y33220-SG 2,481.91$ Y33221-SG 28,017.57$ Y33222-SG 1,357.31$ Y33223-SG 1,357.31$ Y33224-SG 17,198.92$ Y33225-SG Bundled X33226-SG 2,157.21$ Y33227-SG 12,801.34$ Y


Procedure Code


Discounting33228-SG 17,063.29$ Y33229-SG 27,932.78$ Y33230-SG 43,089.58$ Y33231-SG 60,796.38$ Y33233-SG 6,181.48$ N33234-SG 2,481.91$ N33235-SG 2,481.91$ N33240-SG 43,715.09$ Y33241-SG 2,481.91$ N33249-SG 59,751.98$ Y33262-SG 42,371.73$ Y33263-SG 42,648.71$ Y33264-SG 59,863.43$ Y33270-SG 59,586.41$ Y33271-SG 13,430.15$ Y33273-SG 2,481.91$ Y33282-SG 13,994.64$ Y33284-SG 495.74$ N33419-SG Bundled X33508-SG Bundled X34713-SG Bundled X34714-SG Bundled X34715-SG Bundled X34716-SG Bundled X35188-SG 3,690.88$ Y35207-SG 2,157.21$ Y35572-SG Bundled X35761-SG 2,157.21$ Y35875-SG 3,690.88$ Y35876-SG 3,690.88$ Y36000-SG Bundled X36002-SG 530.12$ Y36005-SG Bundled X36010-SG Bundled X36011-SG Bundled X36012-SG Bundled X36013-SG Bundled X36014-SG Bundled X36015-SG Bundled X36100-SG Bundled X36140-SG Bundled X36160-SG Bundled X36200-SG Bundled X


Procedure Code


Discounting36215-SG Bundled X36216-SG Bundled X36217-SG Bundled X36218-SG Bundled X36221-SG Bundled X36222-SG Bundled X36223-SG Bundled X36224-SG Bundled X36225-SG Bundled X36226-SG Bundled X36227-SG Bundled X36228-SG Bundled X36245-SG Bundled X36246-SG Bundled X36247-SG Bundled X36248-SG Bundled X36251-SG Bundled X36252-SG Bundled X36253-SG Bundled X36254-SG Bundled X36260-SG Not covered X36261-SG Not covered X36262-SG Not covered X36400-SG Not covered X36405-SG Not covered X36406-SG Not covered X36410-SG Bundled X36416-SG Bundled X36420-SG Not covered X36425-SG Bundled X36430-SG 67.98$ N36440-SG Not covered X36450-SG Not covered X36465-SG 1,357.31$ Y36466-SG 1,357.31$ Y36468-SG Not covered X36470-SG Not covered X36471-SG Not covered X36473-SG 2,157.21$ Y36474-SG Bundled X36475-SG 2,157.21$ Y36476-SG Bundled X36478-SG 2,157.21$ Y


Procedure Code


Discounting36479-SG Bundled X36481-SG Bundled X36482-SG 3,690.88$ Y36483-SG Bundled X36500-SG Bundled X36510-SG Not covered X36511-SG Not covered X36512-SG Not covered X36513-SG Not covered X36514-SG Not covered X36516-SG Not covered X36522-SG Not covered X36555-SG Not covered X36556-SG 850.66$ Y36557-SG Not covered X36558-SG 2,157.21$ Y36560-SG Not covered X36561-SG 2,157.21$ Y36563-SG 8,023.43$ Y36565-SG 2,157.21$ Y36566-SG 3,690.88$ Y36568-SG Not covered X36569-SG 850.66$ Y36570-SG Not covered X36571-SG 2,157.21$ Y36575-SG 530.12$ Y36576-SG 850.66$ Y36578-SG 2,157.21$ Y36580-SG 850.66$ Y36581-SG 2,157.21$ Y36582-SG 2,157.21$ Y36583-SG 8,553.34$ Y36584-SG 850.66$ Y36585-SG 2,157.21$ Y36589-SG 530.12$ N36590-SG 530.12$ N36591-SG Bundled X36592-SG Bundled X36593-SG 60.86$ Y36595-SG 1,127.12$ Y36596-SG 850.66$ Y36597-SG 850.66$ Y36598-SG 213.64$ Y


Procedure Code


Discounting36600-SG Bundled X36620-SG Bundled X36625-SG Bundled X36640-SG Not covered X36680-SG Not covered X36800-SG 3,690.88$ Y36810-SG 2,157.21$ Y36815-SG 3,690.88$ Y36818-SG 3,690.88$ Y36819-SG 3,690.88$ Y36820-SG 3,690.88$ Y36821-SG 2,157.21$ Y36825-SG 3,690.88$ Y36830-SG 3,690.88$ Y36831-SG 3,690.88$ Y36832-SG 3,690.88$ Y36833-SG 3,690.88$ Y36835-SG Not covered X36860-SG 530.12$ Y36861-SG 3,690.88$ Y36901-SG 530.12$ Y36902-SG 4,193.97$ Y36903-SG 7,442.66$ Y36904-SG 4,193.97$ Y36905-SG 7,442.66$ Y36906-SG 11,503.58$ Y36907-SG Bundled X36908-SG Bundled X36909-SG Bundled X37184-SG 4,193.97$ Y37185-SG Bundled X37186-SG Bundled X37187-SG 4,193.97$ Y37188-SG 2,157.21$ Y37197-SG 2,157.21$ Y37200-SG 3,690.88$ Y37211-SG 3,690.88$ Y37212-SG 2,157.21$ Y37220-SG 4,193.97$ Y37221-SG 13,991.67$ Y37222-SG Bundled X37223-SG Bundled X37236-SG 7,442.66$ Y


Procedure Code


Discounting37237-SG Bundled X37238-SG 14,245.55$ Y37239-SG Bundled X37246-SG 4,193.97$ Y37247-SG Bundled X37248-SG 4,193.97$ Y37249-SG Bundled X37252-SG Bundled X37253-SG Bundled X37500-SG 3,690.88$ Y37607-SG 2,157.21$ Y37609-SG 901.87$ Y37650-SG 2,157.21$ Y37700-SG 2,157.21$ Y37718-SG Not covered X37722-SG Not covered X37735-SG 2,157.21$ Y37760-SG 2,157.21$ Y37761-SG 850.66$ Y37765-SG 1,229.41$ Y37766-SG 1,461.18$ Y37780-SG 850.66$ Y37785-SG 2,157.21$ Y37790-SG Not covered X38200-SG Bundled X38204-SG Not covered X38206-SG Not covered X38220-SG 324.35$ Y38221-SG 291.98$ Y38222-SG 324.35$ Y38230-SG 1,057.29$ N38232-SG Not covered X38241-SG Not covered X38242-SG Not covered X38243-SG 1,057.29$ N38300-SG 901.87$ Y38305-SG 901.87$ Y38308-SG Not covered X38500-SG 1,711.08$ Y38505-SG 901.87$ Y38510-SG 1,711.08$ Y38520-SG 1,711.08$ Y38525-SG 1,711.08$ Y


Procedure Code


Discounting38530-SG 1,711.08$ Y38542-SG 3,483.90$ Y38550-SG 1,711.08$ Y38555-SG 3,399.06$ Y38570-SG 3,483.90$ Y38571-SG 5,595.74$ Y38572-SG 5,595.74$ Y38573-SG 5,595.74$ Y38700-SG 3,399.06$ Y38740-SG 3,483.90$ Y38745-SG 3,483.90$ Y38760-SG 3,399.06$ Y38790-SG Bundled X38792-SG Bundled X38794-SG Not covered X38900-SG Not covered X40490-SG Not covered X40500-SG Not covered X40510-SG 1,581.85$ Y40520-SG 1,581.85$ Y40525-SG 1,581.85$ Y40527-SG 3,559.29$ Y40530-SG 1,581.85$ Y40650-SG 397.97$ Y40652-SG 397.97$ Y40654-SG 984.97$ Y40700-SG Not covered X40701-SG Not covered X40702-SG Not covered X40720-SG Not covered X40761-SG Not covered X40800-SG 411.10$ Y40801-SG 397.97$ Y40804-SG Bundled X40805-SG 613.09$ Y40806-SG 201.34$ Y40808-SG Not covered X40810-SG Not covered X40812-SG Not covered X40814-SG Not covered X40816-SG Not covered X40818-SG Not covered X40819-SG 984.97$ Y


Procedure Code


Discounting40820-SG 511.45$ Y40830-SG 154.47$ Y40831-SG 397.97$ Y40840-SG 3,559.29$ Y40842-SG 3,559.29$ Y40843-SG 3,559.29$ Y40844-SG 3,559.29$ Y40845-SG 3,559.29$ Y41000-SG 311.40$ Y41005-SG 154.47$ Y41006-SG 984.97$ Y41007-SG 984.97$ Y41008-SG 1,581.85$ Y41009-SG 397.97$ Y41010-SG 984.97$ Y41015-SG 397.97$ Y41016-SG 3,559.29$ Y41017-SG 1,581.85$ Y41018-SG 984.97$ Y41019-SG Not covered X41100-SG 322.41$ Y41105-SG 328.23$ Y41108-SG 284.86$ Y41110-SG Not covered X41112-SG Not covered X41113-SG Not covered X41114-SG Not covered X41115-SG 470.66$ Y41116-SG Not covered X41120-SG Not covered X41250-SG Bundled X41251-SG 154.47$ Y41252-SG 397.97$ Y41500-SG 1,581.85$ Y41510-SG Not covered X41520-SG 1,581.85$ Y41530-SG 1,871.63$ Y41800-SG Bundled X41805-SG 545.11$ Y41806-SG 750.98$ Y41820-SG Not covered X41821-SG Not covered X41822-SG Not covered X


Procedure Code


Discounting41823-SG Not covered X41825-SG Not covered X41826-SG Not covered X41827-SG Not covered X41828-SG Not covered X41830-SG Not covered X41850-SG 984.97$ Y41870-SG 1,581.85$ Y41872-SG 666.82$ Y41874-SG 739.33$ Y42000-SG 154.47$ Y42100-SG Not covered X42104-SG Not covered X42106-SG Not covered X42107-SG Not covered X42120-SG Not covered X42140-SG 1,581.85$ Y42145-SG 3,559.29$ Y42160-SG Not covered X42180-SG 397.97$ Y42182-SG 3,559.29$ Y42200-SG Not covered X42205-SG Not covered X42210-SG Not covered X42215-SG Not covered X42220-SG Not covered X42226-SG 3,559.29$ Y42235-SG 3,559.29$ Y42260-SG 3,559.29$ Y42280-SG 334.71$ Y42281-SG 3,559.29$ Y42300-SG 984.97$ Y42305-SG 1,581.85$ Y42310-SG 397.97$ Y42320-SG 397.97$ Y42330-SG Not covered X42335-SG Not covered X42340-SG Not covered X42400-SG 200.05$ Y42405-SG 1,581.85$ Y42408-SG 1,581.85$ Y42409-SG 1,581.85$ Y42410-SG Not covered X


Procedure Code


Discounting42415-SG Not covered X42420-SG Not covered X42425-SG Not covered X42440-SG 3,559.29$ Y42450-SG 3,559.29$ Y42500-SG 3,559.29$ Y42505-SG 3,559.29$ Y42507-SG 3,559.29$ Y42509-SG 3,559.29$ Y42510-SG 1,581.85$ Y42550-SG Bundled X42600-SG 1,581.85$ Y42650-SG 157.97$ Y42660-SG 246.66$ Y42665-SG Not covered X42700-SG 154.47$ Y42720-SG 1,581.85$ Y42725-SG 3,559.29$ Y42800-SG 299.10$ Y42804-SG 1,581.85$ Y42806-SG 1,581.85$ Y42808-SG 1,581.85$ Y42809-SG Bundled X42810-SG 1,581.85$ Y42815-SG 3,559.29$ Y42820-SG Not covered X42821-SG 1,581.85$ Y42825-SG Not covered X42826-SG 1,581.85$ Y42830-SG Not covered X42831-SG Not covered X42835-SG Not covered X42836-SG Not covered X42860-SG Not covered X42870-SG 3,559.29$ Y42890-SG Not covered X42892-SG Not covered X42900-SG 984.97$ Y42950-SG 3,559.29$ Y42955-SG 984.97$ Y42960-SG 397.97$ Y42962-SG 1,581.85$ Y42970-SG 154.47$ Y


Procedure Code


Discounting42972-SG 1,581.85$ Y43030-SG 3,559.29$ Y43180-SG 3,559.29$ Y43191-SG 1,042.35$ Y43192-SG 1,042.35$ Y43193-SG 1,042.35$ Y43194-SG 1,042.35$ Y43195-SG 2,013.49$ Y43196-SG 2,013.49$ Y43197-SG 364.49$ Y43198-SG 401.39$ Y43200-SG 643.41$ Y43201-SG 1,042.35$ Y43202-SG 1,042.35$ Y43204-SG 1,042.35$ Y43205-SG 1,042.35$ Y43206-SG 1,042.35$ Y43210-SG 5,595.74$ Y43211-SG 1,042.35$ Y43212-SG 6,062.64$ Y43213-SG 1,042.35$ Y43214-SG 1,042.35$ Y43215-SG 1,042.35$ Y43216-SG Not covered X43217-SG Not covered X43220-SG 1,042.35$ Y43226-SG 1,042.35$ Y43227-SG 1,042.35$ Y43229-SG Not covered X43231-SG 1,042.35$ Y43232-SG 1,042.35$ Y43233-SG 1,042.35$ Y43235-SG 643.41$ Y43236-SG 643.41$ Y43237-SG Not covered X43238-SG Not covered X43239-SG 643.41$ Y43240-SG 2,013.49$ Y43241-SG 1,042.35$ Y43242-SG 1,042.35$ Y43243-SG 1,042.35$ Y43244-SG 1,042.35$ Y43245-SG 1,042.35$ Y


Procedure Code


Discounting43246-SG 1,042.35$ Y43247-SG 643.41$ Y43248-SG 643.41$ Y43249-SG 1,042.35$ Y43250-SG 1,042.35$ Y43251-SG 1,042.35$ Y43252-SG 2,013.49$ Y43253-SG 1,042.35$ Y43254-SG 1,042.35$ Y43255-SG 1,042.35$ Y43257-SG Not covered X43259-SG 1,042.35$ Y43260-SG 2,013.49$ Y43261-SG 2,013.49$ Y43262-SG 2,013.49$ Y43263-SG 2,013.49$ Y43264-SG 2,013.49$ Y43265-SG 3,071.01$ Y43266-SG 6,228.31$ Y43270-SG Not covered X43273-SG Bundled X43274-SG 3,071.01$ Y43275-SG 2,013.49$ Y43276-SG 3,071.01$ Y43277-SG 2,013.49$ Y43278-SG Not covered X43284-SG 5,595.74$ Y43285-SG 3,483.90$ N43450-SG 643.41$ Y43453-SG 1,042.35$ Y43653-SG 3,483.90$ Y43753-SG Bundled X43754-SG Bundled X43755-SG 117.97$ N43756-SG 643.41$ N43757-SG 643.41$ Y43760-SG 198.63$ Y43761-SG 198.63$ Y43870-SG 2,013.49$ Y43886-SG Not covered X43887-SG Not covered X43888-SG Not covered X44100-SG 643.41$ Y


Procedure Code


Discounting44312-SG 2,345.64$ Y44340-SG 2,345.64$ Y44360-SG 1,042.35$ Y44361-SG 1,042.35$ Y44363-SG 1,042.35$ Y44364-SG Not covered X44365-SG Not covered X44366-SG 1,042.35$ Y44369-SG Not covered X44370-SG 3,071.01$ Y44372-SG 1,042.35$ Y44373-SG 1,042.35$ Y44376-SG 1,042.35$ Y44377-SG 1,042.35$ Y44378-SG 1,042.35$ Y44379-SG 3,071.01$ Y44380-SG 643.41$ Y44381-SG Not covered X44382-SG 643.41$ Y44384-SG Not covered X44385-SG 614.42$ Y44386-SG 614.42$ Y44388-SG 614.42$ Y44389-SG 810.35$ Y44390-SG 810.35$ Y44391-SG 810.35$ Y44392-SG 810.35$ Y44394-SG 810.35$ Y44401-SG Not covered X44402-SG Not covered X44403-SG Not covered X44404-SG Not covered X44405-SG Not covered X44406-SG Not covered X44407-SG Not covered X44408-SG Not covered X44500-SG 643.41$ Y44701-SG Bundled X45000-SG 810.35$ Y45005-SG 810.35$ Y45020-SG 1,892.29$ Y45100-SG 1,892.29$ Y45108-SG 1,892.29$ Y


Procedure Code


Discounting45150-SG 810.35$ Y45160-SG Not covered X45190-SG Not covered X45300-SG 240.19$ Y45303-SG 810.35$ Y45305-SG 810.35$ Y45307-SG 1,892.29$ Y45308-SG 1,892.29$ Y45309-SG 810.35$ Y45315-SG 810.35$ Y45317-SG 810.35$ Y45320-SG 1,892.29$ Y45321-SG 1,892.29$ Y45327-SG 3,071.01$ Y45330-SG 323.70$ Y45331-SG 614.42$ Y45332-SG 810.35$ Y45333-SG 614.42$ Y45334-SG 810.35$ Y45335-SG 614.42$ Y45337-SG 810.35$ Y45338-SG 810.35$ Y45340-SG 810.35$ Y45341-SG 810.35$ Y45342-SG 810.35$ Y45346-SG Not covered X45347-SG Not covered X45349-SG Not covered X45350-SG Not covered X45378-SG 614.42$ Y45379-SG 810.35$ Y45380-SG 810.35$ Y45381-SG Not covered X45382-SG 810.35$ Y45384-SG 810.35$ Y45385-SG 810.35$ Y45386-SG 810.35$ Y45388-SG Not covered X45389-SG Not covered X45390-SG Not covered X45391-SG 810.35$ Y45392-SG 810.35$ Y45393-SG Not covered X


Procedure Code


Discounting45398-SG Not covered X45500-SG 1,892.29$ Y45505-SG 1,892.29$ Y45520-SG Bundled X45560-SG 1,892.29$ Y45900-SG 614.42$ Y45905-SG 810.35$ Y45910-SG 810.35$ Y45915-SG 810.35$ Y45990-SG 1,892.29$ Y46020-SG 1,892.29$ Y46030-SG 810.35$ Y46040-SG 810.35$ Y46045-SG 1,892.29$ Y46050-SG 614.42$ Y46060-SG 1,892.29$ Y46070-SG Not covered X46080-SG 1,892.29$ Y46083-SG 198.63$ Y46200-SG 1,892.29$ Y46220-SG 810.35$ Y46221-SG 515.33$ Y46230-SG 1,892.29$ Y46250-SG 1,892.29$ Y46255-SG 1,892.29$ Y46257-SG 1,892.29$ Y46258-SG 1,892.29$ Y46260-SG 1,892.29$ Y46261-SG 1,892.29$ Y46262-SG 1,892.29$ Y46270-SG 1,892.29$ Y46275-SG 1,892.29$ Y46280-SG 1,892.29$ Y46285-SG 1,892.29$ Y46288-SG 1,892.29$ Y46320-SG 354.13$ Y46500-SG 361.90$ Y46505-SG 810.35$ Y46600-SG Bundled X46601-SG Not covered X46604-SG 810.35$ Y46606-SG 438.94$ Y46607-SG Not covered X


Procedure Code


Discounting46608-SG 614.42$ Y46610-SG 1,892.29$ Y46611-SG 614.42$ Y46612-SG 1,892.29$ Y46614-SG 249.25$ Y46615-SG 1,892.29$ Y46700-SG 1,892.29$ Y46706-SG 1,892.29$ Y46707-SG 1,892.29$ Y46750-SG 1,892.29$ Y46753-SG 1,892.29$ Y46754-SG 1,892.29$ Y46760-SG 1,892.29$ Y46761-SG 1,892.29$ Y46762-SG 6,921.44$ Y46900-SG Not covered X46910-SG Not covered X46916-SG Not covered X46917-SG Not covered X46922-SG Not covered X46924-SG Not covered X46930-SG 398.80$ Y46940-SG 436.35$ Y46942-SG 416.93$ Y46945-SG 594.31$ Y46946-SG 1,892.29$ Y46947-SG 1,892.29$ Y47000-SG 901.87$ Y47001-SG Bundled X47382-SG Not covered X47383-SG Not covered X47531-SG Bundled X47532-SG Bundled X47533-SG 2,213.83$ Y47534-SG 2,213.83$ Y47535-SG 2,213.83$ Y47536-SG 2,213.83$ Y47537-SG 643.41$ N47538-SG 6,721.83$ Y47539-SG 3,483.90$ Y47540-SG 6,486.68$ Y47541-SG 2,213.83$ Y47542-SG Bundled X


Procedure Code


Discounting47543-SG Bundled X47544-SG Bundled X47552-SG 2,213.83$ Y47553-SG 2,213.83$ Y47554-SG 3,483.90$ Y47555-SG 2,213.83$ Y47556-SG 3,483.90$ Y47562-SG 3,483.90$ Y47563-SG 3,483.90$ Y47564-SG 3,483.90$ Y48102-SG 901.87$ Y49082-SG 643.41$ Y49083-SG 643.41$ Y49084-SG 643.41$ Y49180-SG 901.87$ Y49250-SG 2,213.83$ Y49320-SG 3,483.90$ Y49321-SG 3,483.90$ Y49322-SG 3,483.90$ Y49327-SG Not covered X49400-SG Bundled X49402-SG 2,213.83$ Y49407-SG 901.87$ Y49419-SG Not covered X49421-SG 2,213.83$ Y49422-SG 2,157.21$ N49423-SG 1,042.35$ Y49424-SG Bundled X49426-SG 2,213.83$ Y49427-SG Bundled X49429-SG 2,157.21$ N49440-SG 1,042.35$ Y49441-SG 1,042.35$ Y49446-SG 1,042.35$ Y49450-SG 643.41$ Y49451-SG 643.41$ Y49452-SG 643.41$ Y49460-SG 643.41$ Y49465-SG 102.77$ N49495-SG Not covered X49496-SG Not covered X49500-SG Not covered X49501-SG Not covered X


Procedure Code


Discounting49505-SG 2,213.83$ Y49507-SG 2,213.83$ Y49520-SG 2,213.83$ Y49521-SG 2,213.83$ Y49525-SG 2,213.83$ Y49540-SG 3,483.90$ Y49550-SG 2,213.83$ Y49553-SG 2,213.83$ Y49555-SG 2,213.83$ Y49557-SG 2,213.83$ Y49560-SG 2,213.83$ Y49561-SG 2,213.83$ Y49565-SG 3,483.90$ Y49566-SG 3,483.90$ Y49568-SG Bundled X49570-SG 2,213.83$ Y49572-SG 2,213.83$ Y49580-SG Not covered X49582-SG Not covered X49585-SG 2,213.83$ Y49587-SG 2,213.83$ Y49590-SG 2,213.83$ Y49600-SG 2,213.83$ Y49650-SG 3,483.90$ Y49651-SG 3,483.90$ Y49652-SG 3,483.90$ Y49653-SG 3,483.90$ Y49654-SG 5,595.74$ Y49655-SG 5,595.74$ Y49656-SG 5,595.74$ Y49657-SG 5,595.74$ Y50200-SG 901.87$ Y50382-SG 1,295.12$ Y50384-SG 1,295.12$ N50385-SG 1,295.12$ Y50386-SG 1,347.24$ N50387-SG 1,295.12$ Y50389-SG 489.47$ N50390-SG 495.74$ Y50391-SG 230.47$ Y50395-SG 2,003.24$ Y50396-SG 1,295.12$ Y50430-SG Bundled X


Procedure Code


Discounting50431-SG Bundled X50432-SG 1,295.12$ Y50433-SG 1,295.12$ Y50434-SG 1,295.12$ Y50435-SG 1,295.12$ Y50551-SG 2,918.85$ Y50553-SG 2,918.85$ Y50555-SG 2,918.85$ Y50557-SG 6,372.41$ Y50561-SG 2,918.85$ Y50562-SG Not covered X50570-SG 1,295.12$ Y50572-SG 489.47$ Y50574-SG 1,295.12$ Y50575-SG 2,918.85$ Y50576-SG 2,918.85$ Y50580-SG 2,918.85$ Y50590-SG 2,918.85$ Y50592-SG Not covered X50606-SG Bundled X50684-SG Bundled X50686-SG 117.97$ N50688-SG 1,295.12$ Y50690-SG Bundled X50693-SG 2,003.24$ Y50694-SG 2,003.24$ Y50695-SG 2,003.24$ Y50705-SG Bundled X50706-SG Bundled X50947-SG 3,483.90$ Y50948-SG 5,595.74$ Y50951-SG 1,295.12$ Y50953-SG 2,918.85$ Y50955-SG 2,918.85$ Y50957-SG 2,918.85$ Y50961-SG 2,918.85$ Y50970-SG 1,295.12$ Y50972-SG 1,295.12$ Y50974-SG 2,918.85$ Y50976-SG 2,918.85$ Y50980-SG 2,918.85$ Y51020-SG 2,003.24$ Y51030-SG 2,003.24$ Y


Procedure Code


Discounting51040-SG 1,295.12$ Y51045-SG 1,295.12$ Y51050-SG Not covered X51065-SG Not covered X51080-SG 1,765.57$ Y51100-SG 117.18$ Y51101-SG 237.60$ N51102-SG 1,295.12$ Y51500-SG 3,483.90$ Y51520-SG 1,295.12$ Y51600-SG Bundled X51605-SG Bundled X51610-SG Bundled X51700-SG 141.13$ Y51701-SG Bundled X51702-SG Bundled X51703-SG 117.97$ N51705-SG 174.80$ Y51710-SG 489.47$ Y51715-SG 2,003.24$ Y51720-SG Not covered X51725-SG 359.95$ Y51726-SG 489.47$ Y51727-SG 599.49$ Y51728-SG 611.15$ Y51729-SG 655.17$ Y51736-SG Bundled X51741-SG Bundled X51784-SG 132.07$ N51785-SG 198.63$ Y51792-SG Bundled X51797-SG Bundled X51798-SG Bundled X51880-SG 2,003.24$ Y51992-SG 3,483.90$ Y52000-SG 489.47$ Y52001-SG 2,003.24$ Y52005-SG 1,295.12$ Y52007-SG 2,003.24$ Y52010-SG 489.47$ Y52204-SG 1,295.12$ Y52214-SG 1,295.12$ Y52224-SG 1,295.12$ Y


Procedure Code


Discounting52234-SG 2,003.24$ Y52235-SG 2,003.24$ Y52240-SG 2,918.85$ Y52250-SG Not covered X52260-SG 1,295.12$ Y52265-SG 701.78$ Y52270-SG 1,295.12$ Y52275-SG 1,295.12$ Y52276-SG 1,295.12$ Y52277-SG 2,003.24$ Y52281-SG 1,295.12$ Y52282-SG 2,003.24$ Y52283-SG 1,295.12$ Y52285-SG 1,295.12$ Y52287-SG 1,295.12$ Y52290-SG 1,295.12$ Y52300-SG 2,003.24$ Y52301-SG 2,003.24$ Y52305-SG 2,918.85$ Y52310-SG 1,295.12$ Y52315-SG 1,295.12$ Y52317-SG 2,003.24$ Y52318-SG 2,918.85$ Y52320-SG 2,918.85$ Y52325-SG 2,918.85$ Y52327-SG 2,918.85$ Y52330-SG 2,003.24$ Y52332-SG 2,003.24$ Y52334-SG 2,003.24$ Y52341-SG 1,295.12$ Y52342-SG 2,918.85$ Y52343-SG 1,295.12$ Y52344-SG 2,003.24$ Y52345-SG 2,918.85$ Y52346-SG 2,918.85$ Y52351-SG 1,295.12$ Y52352-SG 2,918.85$ Y52353-SG 2,918.85$ Y52354-SG 2,918.85$ Y52355-SG Not covered X52356-SG 2,918.85$ Y52400-SG 1,295.12$ Y52402-SG 2,003.24$ Y


Procedure Code


Discounting52450-SG 2,003.24$ Y52500-SG 2,003.24$ Y52601-SG 2,918.85$ Y52630-SG 2,918.85$ Y52640-SG 2,003.24$ Y52647-SG 2,918.85$ Y52648-SG 2,918.85$ Y52700-SG 2,918.85$ Y53000-SG 1,295.12$ Y53010-SG 2,918.85$ Y53020-SG 1,295.12$ Y53025-SG Not covered X53040-SG 2,918.85$ Y53060-SG 345.71$ Y53080-SG 1,295.12$ Y53085-SG 1,295.12$ Y53200-SG 2,003.24$ Y53210-SG Not covered X53215-SG Not covered X53220-SG Not covered X53230-SG 2,918.85$ Y53235-SG 2,918.85$ Y53240-SG 2,918.85$ Y53250-SG 1,295.12$ Y53260-SG Not covered X53265-SG Not covered X53270-SG Not covered X53275-SG Not covered X53400-SG 2,918.85$ Y53405-SG 2,918.85$ Y53410-SG 2,918.85$ Y53420-SG 2,918.85$ Y53425-SG 2,918.85$ Y53430-SG 2,918.85$ Y53431-SG 2,918.85$ Y53440-SG 13,236.05$ Y53442-SG 2,918.85$ Y53444-SG 27,763.19$ Y53445-SG 28,751.38$ Y53446-SG 2,918.85$ N53447-SG 28,129.74$ Y53449-SG 2,918.85$ Y53450-SG 1,295.12$ Y


Procedure Code


Discounting53460-SG 2,918.85$ Y53502-SG 2,003.24$ Y53505-SG 2,918.85$ Y53510-SG 2,918.85$ Y53515-SG 2,918.85$ Y53520-SG 2,918.85$ Y53600-SG 157.97$ Y53601-SG Bundled X53605-SG 1,295.12$ Y53620-SG 221.41$ Y53621-SG 209.11$ Y53660-SG 135.31$ N53661-SG Bundled X53665-SG 1,295.12$ Y53850-SG Not covered X53852-SG Not covered X53860-SG Not covered X54000-SG Not covered X54001-SG Not covered X54015-SG 901.87$ Y54050-SG Bundled X54055-SG 229.18$ Y54056-SG Bundled X54057-SG 1,357.31$ Y54060-SG 1,357.31$ Y54065-SG 1,357.31$ Y54100-SG 901.87$ Y54105-SG 1,765.57$ Y54110-SG Not covered X54111-SG Not covered X54112-SG Not covered X54115-SG 1,765.57$ Y54120-SG 2,918.85$ Y54150-SG Not covered X54160-SG Not covered X54161-SG 1,295.12$ Y54162-SG Not covered X54163-SG Not covered X54164-SG Not covered X54200-SG Not covered X54205-SG Not covered X54220-SG 198.63$ Y54230-SG Bundled X


Procedure Code


Discounting54231-SG 269.32$ Y54235-SG 174.15$ Y54240-SG 200.69$ N54250-SG 229.18$ Y54300-SG Not covered X54304-SG Not covered X54308-SG Not covered X54312-SG Not covered X54316-SG Not covered X54318-SG Not covered X54322-SG Not covered X54324-SG Not covered X54326-SG Not covered X54328-SG Not covered X54340-SG Not covered X54344-SG Not covered X54348-SG Not covered X54352-SG Not covered X54360-SG Not covered X54380-SG Not covered X54385-SG Not covered X54400-SG 28,042.53$ N54401-SG 28,954.84$ N54405-SG 29,008.12$ N54406-SG 2,003.24$ N54408-SG 2,918.85$ Y54410-SG 28,517.26$ N54415-SG 2,003.24$ N54416-SG 28,142.65$ N54420-SG 1,295.12$ Y54435-SG 1,295.12$ Y54437-SG 1,295.12$ Y54440-SG 2,918.85$ Y54450-SG Not covered X54500-SG 1,765.57$ Y54505-SG 2,003.24$ Y54512-SG 1,295.12$ Y54520-SG 2,003.24$ Y54522-SG 2,003.24$ Y54530-SG 2,213.83$ Y54550-SG Not covered X54560-SG Not covered X54600-SG 2,003.24$ Y


Procedure Code


Discounting54620-SG Not covered X54640-SG 2,213.83$ Y54660-SG 5,448.05$ Y54670-SG 1,295.12$ Y54680-SG 1,295.12$ Y54690-SG 3,483.90$ Y54692-SG Not covered X54700-SG 1,295.12$ Y54800-SG 901.87$ Y54830-SG 1,295.12$ Y54840-SG 1,295.12$ Y54860-SG 1,295.12$ Y54861-SG 2,003.24$ Y54865-SG 2,003.24$ Y54900-SG 1,295.12$ Y54901-SG 2,003.24$ Y55000-SG 226.59$ Y55040-SG 2,213.83$ Y55041-SG 2,213.83$ Y55060-SG 1,295.12$ Y55100-SG 901.87$ Y55110-SG 1,295.12$ Y55120-SG 1,295.12$ Y55150-SG Not covered X55175-SG 2,003.24$ Y55180-SG 2,918.85$ Y55200-SG Not covered X55250-SG Not covered X55300-SG Not covered X55400-SG Not covered X55500-SG 2,003.24$ Y55520-SG 2,003.24$ Y55530-SG 2,003.24$ Y55535-SG 2,213.83$ Y55540-SG 2,213.83$ Y55550-SG 3,483.90$ Y55600-SG 1,295.12$ Y55680-SG Not covered X55700-SG 1,295.12$ Y55705-SG 1,295.12$ Y55706-SG Not covered X55720-SG 1,295.12$ Y55725-SG 1,295.12$ Y


Procedure Code


Discounting55860-SG Not covered X55870-SG 334.71$ Y55874-SG 2,918.85$ Y55875-SG Not covered X55876-SG Not covered X55920-SG Not covered X56405-SG 204.58$ Y56420-SG 230.47$ Y56440-SG Not covered X56441-SG Not covered X56442-SG Not covered X56501-SG Not covered X56515-SG Not covered X56605-SG 154.08$ Y56606-SG Bundled X56620-SG Not covered X56625-SG Not covered X56700-SG Not covered X56740-SG Not covered X56800-SG 1,863.92$ Y56805-SG Not covered X56810-SG 1,863.92$ Y56820-SG 211.05$ Y56821-SG 277.09$ Y57000-SG 1,863.92$ Y57010-SG 1,863.92$ Y57020-SG 1,863.92$ Y57022-SG 901.87$ Y57023-SG 1,765.57$ Y57061-SG Not covered X57065-SG Not covered X57100-SG 167.68$ Y57105-SG 1,863.92$ Y57130-SG Not covered X57135-SG Not covered X57150-SG Bundled X57155-SG Not covered X57156-SG Not covered X57160-SG 143.08$ Y57170-SG Not covered X57180-SG 139.07$ Y57200-SG 1,863.92$ Y57210-SG 1,863.92$ Y


Procedure Code


Discounting57220-SG 3,055.46$ Y57230-SG 1,863.92$ Y57240-SG 3,055.46$ Y57250-SG 3,055.46$ Y57260-SG 3,055.46$ Y57265-SG 3,055.46$ Y57267-SG Bundled X57268-SG 1,863.92$ Y57287-SG 1,863.92$ N57288-SG 3,055.46$ Y57289-SG 4,280.91$ Y57291-SG Not covered X57300-SG 1,863.92$ Y57320-SG 3,055.46$ Y57400-SG Not covered X57410-SG 1,863.92$ Y57415-SG 1,863.92$ Y57420-SG 221.41$ Y57421-SG 295.21$ Y57426-SG 4,280.91$ Y57452-SG 203.93$ Y57454-SG 284.21$ Y57455-SG 266.73$ Y57456-SG 251.84$ Y57460-SG 530.87$ Y57461-SG 600.14$ Y57500-SG 240.83$ Y57505-SG 192.93$ Y57510-SG Not covered X57511-SG Not covered X57513-SG Not covered X57520-SG Not covered X57522-SG Not covered X57530-SG Not covered X57550-SG 1,863.92$ Y57556-SG 3,055.46$ Y57558-SG 1,863.92$ Y57700-SG Not covered X57720-SG 1,863.92$ Y57800-SG 112.65$ Y58100-SG 203.28$ Y58110-SG Not covered X58120-SG 1,863.92$ Y


Procedure Code


Discounting58145-SG Not covered X58301-SG Not covered X58321-SG Not covered X58322-SG Not covered X58323-SG Not covered X58340-SG Not covered X58345-SG Not covered X58346-SG Not covered X58350-SG Not covered X58353-SG Not covered X58356-SG Not covered X58545-SG Not covered X58546-SG Not covered X58550-SG 3,483.90$ Y58552-SG 5,595.74$ Y58555-SG 1,863.92$ Y58558-SG 1,863.92$ Y58559-SG 3,055.46$ Y58560-SG Not covered X58561-SG Not covered X58562-SG 1,863.92$ Y58563-SG Not covered X58565-SG Not covered X58600-SG Not covered X58615-SG Not covered X58660-SG 3,483.90$ Y58661-SG Not covered X58662-SG Not covered X58670-SG Not covered X58671-SG Not covered X58672-SG Not covered X58673-SG Not covered X58674-SG Not covered X58800-SG Not covered X58805-SG Not covered X58820-SG Not covered X58900-SG 1,863.92$ Y58970-SG Not covered X58974-SG Not covered X58976-SG Not covered X59000-SG 238.89$ Y59001-SG 232.23$ Y59012-SG 232.23$ Y


Procedure Code


Discounting59015-SG 293.92$ Y59020-SG 134.01$ Y59025-SG 91.28$ Y59070-SG 232.23$ Y59072-SG 232.23$ Y59076-SG 232.23$ Y59100-SG Not covered X59150-SG 3,483.90$ Y59151-SG 3,483.90$ Y59160-SG 1,863.92$ Y59200-SG 136.60$ Y59300-SG 365.78$ Y59320-SG 1,863.92$ Y59412-SG 1,863.92$ Y59414-SG 1,863.92$ Y59812-SG 1,863.92$ Y59820-SG 1,863.92$ Y59821-SG 1,863.92$ Y59840-SG 1,863.92$ Y59841-SG 1,863.92$ Y59866-SG Not covered X59870-SG Not covered X59871-SG 1,863.92$ N60000-SG Not covered X60100-SG 212.99$ Y60200-SG 3,483.90$ Y60280-SG Not covered X60281-SG Not covered X60300-SG 224.65$ Y61000-SG Not covered X61001-SG Not covered X61020-SG 581.70$ Y61026-SG 470.24$ Y61050-SG 211.76$ Y61055-SG 211.76$ Y61070-SG 470.24$ Y61215-SG 3,377.49$ Y61330-SG 1,581.85$ Y61781-SG Bundled X61782-SG Bundled X61783-SG Bundled X61790-SG Not covered X61791-SG Not covered X


Procedure Code


Discounting61880-SG Not covered X61885-SG 35,885.39$ N61886-SG 50,498.55$ N61888-SG 5,150.48$ N62194-SG 1,304.80$ Y62225-SG 3,377.49$ Y62230-SG 3,377.49$ Y62252-SG 160.56$ N62263-SG Not covered X62264-SG 581.70$ Y62267-SG 495.74$ Y62268-SG 581.70$ Y62269-SG 901.87$ Y62270-SG 470.24$ Y62272-SG 470.24$ Y62273-SG 470.24$ Y62280-SG Not covered X62281-SG 581.70$ Y62282-SG 581.70$ Y62284-SG Bundled X62287-SG 3,377.49$ Y62290-SG Bundled X62291-SG Bundled X62292-SG 1,304.80$ Y62294-SG 581.70$ Y62302-SG Bundled X62303-SG Bundled X62304-SG Bundled X62305-SG Bundled X62320-SG 470.24$ Y62321-SG 470.24$ Y62322-SG 470.24$ Y62323-SG 470.24$ Y62324-SG 581.70$ Y62325-SG 581.70$ Y62326-SG 581.70$ Y62327-SG 581.70$ Y62350-SG 3,377.49$ Y62355-SG 1,304.80$ N62360-SG 29,923.01$ Y62361-SG 28,611.11$ Y62362-SG 29,810.23$ Y62365-SG 3,377.49$ N


Procedure Code


Discounting62367-SG 80.28$ N62368-SG 108.12$ N62369-SG 229.18$ N62370-SG 241.48$ N62380-SG 4,520.99$ Y63020-SG 4,520.99$ Y63030-SG 4,520.99$ Y63035-SG Bundled X63042-SG 4,520.99$ Y63044-SG Bundled X63045-SG 4,520.99$ Y63047-SG 4,520.99$ Y63048-SG Bundled X63056-SG 4,520.99$ Y63057-SG Bundled X63075-SG 4,909.89$ Y63076-SG Bundled X63600-SG 1,304.80$ Y63610-SG 1,304.80$ Y63615-SG 1,304.80$ Y63650-SG Not covered X63655-SG Not covered X63661-SG Not covered X63662-SG Not covered X63663-SG Not covered X63664-SG Not covered X63685-SG Not covered X63688-SG Not covered X63709-SG UR/BR N63744-SG 3,377.49$ Y63746-SG 1,304.80$ N64400-SG 249.25$ Y64402-SG Bundled X64405-SG 194.87$ Y64408-SG 220.12$ Y64410-SG 581.70$ Y64413-SG 240.83$ Y64415-SG 581.70$ Y64416-SG 581.70$ Y64417-SG 581.70$ Y64418-SG 222.71$ Y64420-SG 470.24$ Y64421-SG 581.70$ Y


Procedure Code


Discounting64425-SG 253.13$ Y64430-SG 581.70$ Y64435-SG 258.96$ Y64445-SG 260.25$ Y64446-SG 581.70$ Y64447-SG 229.83$ Y64448-SG 581.70$ Y64450-SG 152.14$ Y64455-SG 89.99$ Y64461-SG 280.32$ Y64462-SG Bundled X64463-SG 299.75$ Y64479-SG 581.70$ Y64480-SG Bundled X64483-SG 581.70$ Y64484-SG Bundled X64486-SG Bundled X64487-SG Bundled X64488-SG Bundled X64489-SG Bundled X64490-SG 581.70$ Y64491-SG Bundled X64492-SG Bundled X64493-SG 581.70$ Y64494-SG Bundled X64495-SG Bundled X64505-SG 206.52$ Y64508-SG 91.93$ Y64510-SG 581.70$ Y64517-SG Not covered X64520-SG 581.70$ Y64530-SG 581.70$ Y64553-SG 10,245.09$ N64555-SG Not covered X64561-SG 10,257.55$ N64566-SG Not covered X64568-SG 50,885.38$ N64569-SG 11,967.02$ N64570-SG 3,377.49$ N64575-SG Not covered X64580-SG 32,391.07$ N64581-SG 10,874.30$ N64585-SG 2,491.79$ N


Procedure Code


Discounting64590-SG Not covered X64595-SG 2,491.79$ N64600-SG 581.70$ Y64605-SG 1,304.80$ Y64610-SG 1,304.80$ Y64611-SG 228.53$ Y64612-SG 252.49$ Y64615-SG 275.15$ Y64616-SG 245.36$ Y64617-SG 303.63$ Y64620-SG 581.70$ Y64630-SG 581.70$ Y64632-SG 161.85$ Y64633-SG 1,304.80$ Y64634-SG Bundled X64635-SG 1,304.80$ Y64636-SG Bundled X64640-SG 251.84$ Y64642-SG 271.91$ Y64643-SG Bundled X64644-SG 311.40$ Y64645-SG Bundled X64646-SG 283.56$ Y64647-SG 336.00$ Y64650-SG 148.25$ Y64653-SG 181.92$ Y64680-SG 581.70$ Y64681-SG 581.70$ Y64702-SG 1,304.80$ Y64704-SG 1,304.80$ Y64708-SG 1,304.80$ Y64712-SG 1,304.80$ Y64713-SG 1,304.80$ Y64714-SG 1,304.80$ Y64716-SG 1,304.80$ Y64718-SG 1,304.80$ Y64719-SG 1,304.80$ Y64721-SG 1,304.80$ Y64722-SG 1,304.80$ Y64726-SG 1,304.80$ Y64727-SG Bundled X64732-SG 1,304.80$ Y64734-SG 1,304.80$ Y


Procedure Code


Discounting64736-SG 1,304.80$ Y64738-SG 1,304.80$ Y64740-SG 1,304.80$ Y64742-SG 1,304.80$ Y64744-SG 1,304.80$ Y64746-SG 1,304.80$ Y64763-SG 1,304.80$ Y64766-SG 3,377.49$ Y64771-SG 1,304.80$ Y64772-SG 1,304.80$ Y64774-SG 1,304.80$ Y64776-SG 1,304.80$ Y64778-SG Bundled X64782-SG 1,304.80$ Y64783-SG Bundled X64784-SG 1,304.80$ Y64786-SG 3,377.49$ Y64787-SG Bundled X64788-SG 1,304.80$ Y64790-SG 1,304.80$ Y64792-SG 3,377.49$ Y64795-SG 1,304.80$ Y64802-SG 1,304.80$ Y64820-SG 1,304.80$ Y64821-SG 2,126.29$ Y64822-SG 2,126.29$ Y64823-SG 1,225.33$ Y64831-SG 3,377.49$ Y64832-SG Bundled X64834-SG 3,377.49$ Y64835-SG 3,377.49$ Y64836-SG 3,377.49$ Y64837-SG Bundled X64840-SG 3,377.49$ Y64856-SG 3,377.49$ Y64857-SG 3,377.49$ Y64858-SG 3,377.49$ Y64859-SG Bundled X64861-SG 3,377.49$ Y64862-SG 3,377.49$ Y64864-SG 3,377.49$ Y64865-SG 3,377.49$ Y64872-SG Bundled X


Procedure Code


Discounting64874-SG Bundled X64876-SG Bundled X64885-SG 3,377.49$ Y64886-SG 3,377.49$ Y64890-SG 3,377.49$ Y64891-SG 3,377.49$ Y64892-SG 3,377.49$ Y64893-SG 3,377.49$ Y64895-SG 3,377.49$ Y64896-SG 3,377.49$ Y64897-SG 3,377.49$ Y64898-SG 3,377.49$ Y64901-SG Bundled X64902-SG Bundled X64905-SG 3,377.49$ Y64907-SG 3,377.49$ Y64910-SG 3,377.49$ Y64912-SG 3,377.49$ Y64913-SG Bundled X65091-SG 2,169.53$ Y65093-SG 2,169.53$ Y65101-SG 2,169.53$ Y65103-SG 2,169.53$ Y65105-SG 2,169.53$ Y65110-SG 2,169.53$ Y65112-SG 2,169.53$ Y65114-SG 2,169.53$ Y65125-SG 1,343.11$ Y65130-SG 2,169.53$ Y65135-SG 2,169.53$ Y65140-SG 2,169.53$ Y65150-SG 2,169.53$ Y65155-SG 2,169.53$ Y65175-SG 2,169.53$ Y65205-SG Bundled X65210-SG Bundled X65220-SG Bundled X65222-SG Bundled X65235-SG 1,647.93$ Y65260-SG 1,647.93$ Y65265-SG 1,647.93$ Y65270-SG 1,343.11$ Y65272-SG 1,343.11$ Y


Procedure Code


Discounting65275-SG 2,169.53$ Y65280-SG 2,944.19$ Y65285-SG 2,944.19$ Y65286-SG 1,345.30$ Y65290-SG 2,169.53$ Y65400-SG 699.56$ Y65410-SG 1,343.11$ Y65420-SG 1,343.11$ Y65426-SG 1,343.11$ Y65430-SG Bundled X65435-SG 154.73$ Y65436-SG 736.09$ Y65450-SG 231.63$ Y65600-SG 750.34$ Y65710-SG 2,944.19$ Y65730-SG 2,944.19$ Y65750-SG 2,944.19$ Y65755-SG 2,944.19$ Y65756-SG 2,944.19$ Y65770-SG 15,157.57$ Y65772-SG 699.56$ Y65775-SG 1,343.11$ Y65778-SG Bundled X65779-SG Bundled X65780-SG 2,169.53$ Y65781-SG 2,944.19$ Y65782-SG 2,169.53$ Y65785-SG 2,944.19$ Y65800-SG 1,647.93$ Y65810-SG 1,647.93$ Y65815-SG 1,647.93$ Y65820-SG 2,944.19$ Y65850-SG 1,647.93$ Y65855-SG 465.48$ Y65860-SG 587.84$ Y65865-SG 1,647.93$ Y65870-SG 1,647.93$ Y65875-SG 1,647.93$ Y65880-SG 2,944.19$ Y65900-SG 1,647.93$ Y65920-SG 1,647.93$ Y65930-SG 1,647.93$ Y66020-SG 1,647.93$ Y


Procedure Code


Discounting66030-SG 1,647.93$ Y66130-SG 1,343.11$ Y66150-SG 2,944.19$ Y66155-SG 2,944.19$ Y66160-SG 1,647.93$ Y66170-SG 1,647.93$ Y66172-SG 1,647.93$ Y66174-SG 2,944.19$ Y66175-SG 2,944.19$ Y66179-SG 2,944.19$ Y66180-SG 2,944.19$ Y66183-SG Not covered X66184-SG 1,647.93$ Y66185-SG 1,647.93$ Y66220-SG 1,647.93$ Y66225-SG 2,944.19$ Y66250-SG 1,343.11$ Y66500-SG 1,647.93$ Y66505-SG 1,647.93$ Y66600-SG 2,944.19$ Y66605-SG 1,647.93$ Y66625-SG 1,647.93$ Y66630-SG 1,647.93$ Y66635-SG 1,647.93$ Y66680-SG 1,647.93$ Y66682-SG 1,647.93$ Y66700-SG 1,647.93$ Y66710-SG 1,343.11$ Y66711-SG 1,647.93$ Y66720-SG 1,343.11$ Y66740-SG 1,343.11$ Y66761-SG 566.48$ Y66762-SG 422.30$ Y66770-SG 422.30$ Y66820-SG 1,647.93$ Y66821-SG 422.30$ Y66825-SG 1,647.93$ Y66830-SG 1,647.93$ Y66840-SG 1,647.93$ Y66850-SG 1,647.93$ Y66852-SG 2,944.19$ Y66920-SG 1,647.93$ Y66930-SG 2,944.19$ Y


Procedure Code


Discounting66940-SG 1,647.93$ Y66982-SG 1,647.93$ Y66983-SG 1,647.93$ Y66984-SG 1,647.93$ Y66985-SG 1,647.93$ Y66986-SG 1,647.93$ Y66990-SG Bundled X67005-SG 1,647.93$ Y67010-SG 1,647.93$ Y67015-SG 1,647.93$ Y67025-SG 1,647.93$ Y67027-SG 2,426.45$ Y67028-SG 192.28$ N67030-SG 1,647.93$ Y67031-SG 422.30$ Y67036-SG 2,944.19$ Y67039-SG 2,944.19$ Y67040-SG 2,944.19$ Y67041-SG 2,944.19$ Y67042-SG 2,944.19$ Y67043-SG 2,944.19$ Y67101-SG 624.09$ Y67105-SG 563.24$ Y67107-SG 2,944.19$ Y67108-SG 2,944.19$ Y67110-SG 1,663.82$ Y67113-SG 2,944.19$ Y67115-SG 2,944.19$ Y67120-SG 1,647.93$ Y67121-SG 1,647.93$ Y67141-SG 231.63$ Y67145-SG 422.30$ Y67208-SG 231.63$ Y67210-SG 422.30$ Y67218-SG Not covered X67220-SG 422.30$ Y67221-SG Not covered X67225-SG Not covered X67227-SG 552.88$ Y67228-SG 648.05$ Y67229-SG Not covered X67250-SG 1,343.11$ Y67255-SG 1,647.93$ Y


Procedure Code


Discounting67311-SG 1,343.11$ Y67312-SG 2,169.53$ Y67314-SG 1,343.11$ Y67316-SG 1,343.11$ Y67318-SG 1,343.11$ Y67320-SG Bundled X67331-SG Bundled X67332-SG Bundled X67334-SG Bundled X67335-SG Bundled X67340-SG Bundled X67343-SG 1,343.11$ Y67345-SG 462.24$ Y67346-SG 2,169.53$ Y67400-SG 2,169.53$ Y67405-SG 1,343.11$ Y67412-SG 1,343.11$ Y67413-SG 1,343.11$ Y67414-SG 2,169.53$ Y67415-SG Not covered X67420-SG 2,169.53$ Y67430-SG 2,169.53$ Y67440-SG 2,169.53$ Y67445-SG 2,169.53$ Y67450-SG 2,169.53$ Y67500-SG 231.63$ Y67505-SG 165.09$ Y67515-SG 182.57$ Y67550-SG 2,169.53$ Y67560-SG 2,169.53$ Y67570-SG 2,169.53$ Y67700-SG 231.63$ Y67710-SG 431.82$ Y67715-SG 1,343.11$ Y67800-SG 242.78$ Y67801-SG 308.81$ Y67805-SG 384.56$ Y67808-SG 1,343.11$ Y67810-SG 328.23$ Y67820-SG Bundled X67825-SG 244.07$ Y67830-SG 699.56$ Y67835-SG 1,343.11$ Y


Procedure Code


Discounting67840-SG 527.63$ Y67850-SG 409.80$ Y67875-SG 699.56$ Y67880-SG 1,343.11$ Y67882-SG 1,343.11$ Y67900-SG 1,343.11$ Y67901-SG 1,343.11$ Y67902-SG 2,169.53$ Y67903-SG 1,343.11$ Y67904-SG 1,343.11$ Y67906-SG 2,169.53$ Y67908-SG 1,343.11$ Y67909-SG 1,343.11$ Y67911-SG 1,343.11$ Y67912-SG 1,343.11$ Y67914-SG 1,343.11$ Y67915-SG 561.94$ Y67916-SG 1,343.11$ Y67917-SG 1,343.11$ Y67921-SG 1,343.11$ Y67922-SG 556.76$ Y67923-SG 1,343.11$ Y67924-SG 1,343.11$ Y67930-SG 694.66$ Y67935-SG 1,343.11$ Y67938-SG 231.63$ Y67950-SG 1,343.11$ Y67961-SG 1,343.11$ Y67966-SG 1,343.11$ Y67971-SG 1,343.11$ Y67973-SG 1,343.11$ Y67974-SG 2,169.53$ Y67975-SG 1,343.11$ Y68020-SG 229.18$ Y68040-SG Not covered X68100-SG 326.94$ Y68110-SG 432.46$ Y68115-SG 1,343.11$ Y68130-SG 1,343.11$ Y68135-SG 298.45$ Y68200-SG Bundled X68320-SG 1,343.11$ Y68325-SG 2,169.53$ Y


Procedure Code


Discounting68326-SG 2,169.53$ Y68328-SG 1,343.11$ Y68330-SG 1,647.93$ Y68335-SG 2,169.53$ Y68340-SG 1,343.11$ Y68360-SG 2,169.53$ Y68362-SG 1,343.11$ Y68371-SG 1,343.11$ Y68400-SG 546.41$ Y68420-SG 616.32$ Y68440-SG 194.22$ Y68500-SG 2,169.53$ Y68505-SG 2,169.53$ Y68510-SG 1,343.11$ Y68520-SG 2,169.53$ Y68525-SG 1,343.11$ Y68530-SG 231.63$ Y68540-SG Not covered X68550-SG Not covered X68700-SG 1,343.11$ Y68705-SG 231.63$ Y68720-SG 2,169.53$ Y68745-SG 2,169.53$ Y68750-SG 2,169.53$ Y68760-SG 385.85$ Y68761-SG 282.91$ Y68770-SG 1,343.11$ Y68801-SG Bundled X68810-SG 231.63$ Y68811-SG 1,343.11$ Y68815-SG 1,343.11$ Y68816-SG 1,343.11$ Y68840-SG 244.72$ Y68850-SG Bundled X69000-SG 354.78$ Y69005-SG 401.39$ Y69020-SG 436.35$ Y69100-SG 191.63$ Y69105-SG 264.14$ Y69110-SG 1,765.57$ Y69120-SG 3,559.29$ Y69140-SG 3,559.29$ Y69145-SG 1,765.57$ Y


Procedure Code


Discounting69150-SG Not covered X69200-SG Bundled X69205-SG 901.87$ Y69209-SG Bundled X69210-SG Bundled X69220-SG Bundled X69222-SG 411.10$ Y69300-SG Not covered X69310-SG 3,559.29$ Y69320-SG Not covered X69420-SG 154.47$ Y69421-SG 1,581.85$ Y69424-SG 241.48$ N69433-SG 380.67$ Y69436-SG 984.97$ Y69440-SG 1,581.85$ Y69450-SG 1,581.85$ Y69501-SG 3,559.29$ Y69502-SG 3,559.29$ Y69505-SG 3,559.29$ Y69511-SG 3,559.29$ Y69530-SG 3,559.29$ Y69540-SG Not covered X69550-SG Not covered X69552-SG Not covered X69601-SG 3,559.29$ Y69602-SG 3,559.29$ Y69603-SG 3,559.29$ Y69604-SG 3,559.29$ Y69605-SG 3,559.29$ Y69610-SG 717.97$ Y69620-SG 1,581.85$ Y69631-SG 3,559.29$ Y69632-SG 3,559.29$ Y69633-SG 3,559.29$ Y69635-SG 3,559.29$ Y69636-SG 3,559.29$ Y69637-SG 3,559.29$ Y69641-SG 3,559.29$ Y69642-SG 3,559.29$ Y69643-SG 3,559.29$ Y69644-SG 3,559.29$ Y69645-SG 3,559.29$ Y


Procedure Code


Discounting69646-SG 3,559.29$ Y69650-SG 1,581.85$ Y69660-SG 3,559.29$ Y69661-SG 3,559.29$ Y69662-SG 3,559.29$ Y69666-SG 1,581.85$ Y69667-SG 1,581.85$ Y69670-SG 3,559.29$ Y69676-SG 1,581.85$ Y69700-SG 984.97$ Y69711-SG 1,581.85$ N69714-SG 17,917.30$ Y69715-SG 25,930.98$ Y69717-SG 10,041.22$ Y69718-SG 8,421.19$ Y69720-SG 3,559.29$ Y69740-SG 3,559.29$ Y69745-SG 3,559.29$ Y69801-SG 366.43$ Y69805-SG 3,559.29$ Y69806-SG 3,559.29$ Y69905-SG 3,559.29$ Y69910-SG 3,559.29$ Y69915-SG 1,581.85$ Y69930-SG 66,863.44$ Y69990-SG Bundled X70010-SG Bundled X70015-SG Not covered X70030-SG Bundled X70100-SG Bundled X70110-SG Bundled X70120-SG Bundled X70130-SG Bundled X70134-SG Bundled X70140-SG Bundled X70150-SG Bundled X70160-SG Bundled X70170-SG Bundled X70190-SG Bundled X70200-SG Bundled X70210-SG Bundled X70220-SG Bundled X70240-SG Bundled X


Procedure Code


Discounting70250-SG Bundled X70260-SG Bundled X70300-SG Bundled X70310-SG Bundled X70320-SG Bundled X70328-SG Bundled X70330-SG Bundled X70332-SG Bundled X70336-SG 212.22$ N70350-SG Bundled X70355-SG Bundled X70360-SG Bundled X70370-SG Bundled X70371-SG Bundled X70380-SG Bundled X70390-SG Bundled X70450-SG 102.77$ N70460-SG 310.10$ N70470-SG 364.49$ N70480-SG 102.77$ N70481-SG 218.72$ N70482-SG 218.72$ N70486-SG 102.77$ N70487-SG 318.52$ N70488-SG 218.72$ N70490-SG 102.77$ N70491-SG 218.72$ N70492-SG 218.72$ N70496-SG 218.72$ N70498-SG 218.72$ N70540-SG 212.22$ N70542-SG 394.94$ N70543-SG 394.94$ N70544-SG 212.22$ N70545-SG 218.72$ N70546-SG 394.94$ N70547-SG 212.22$ N70548-SG 218.72$ N70549-SG 394.94$ N70551-SG 212.22$ N70552-SG 218.72$ N70553-SG 394.94$ N70554-SG Not covered X


Procedure Code


Discounting70555-SG Not covered X70557-SG Not covered X70558-SG Not covered X70559-SG Not covered X71045-SG 20.07$ N71046-SG 37.55$ N71047-SG Bundled X71048-SG Bundled X71100-SG Bundled X71101-SG Bundled X71110-SG Bundled X71111-SG Bundled X71120-SG Bundled X71130-SG Bundled X71250-SG 102.77$ N71260-SG 218.72$ N71270-SG 218.72$ N71275-SG 218.72$ N71550-SG 212.22$ N71551-SG 590.10$ N71552-SG 394.94$ N72020-SG Bundled X72040-SG Bundled X72050-SG Bundled X72052-SG Bundled X72070-SG Bundled X72072-SG Bundled X72074-SG Bundled X72080-SG Bundled X72083-SG 143.08$ N72084-SG 102.77$ N72100-SG Bundled X72110-SG Bundled X72114-SG Bundled X72120-SG Bundled X72125-SG 102.77$ N72126-SG 434.41$ N72127-SG 218.72$ N72128-SG 102.77$ N72129-SG 218.72$ N72130-SG 218.72$ N72131-SG 102.77$ N72132-SG 434.41$ N


Procedure Code


Discounting72133-SG 218.72$ N72141-SG 212.22$ N72142-SG 394.94$ N72146-SG 212.22$ N72147-SG 394.94$ N72148-SG 212.22$ N72149-SG 615.03$ N72156-SG 394.94$ N72157-SG 394.94$ N72158-SG 394.94$ N72170-SG Bundled X72190-SG Bundled X72191-SG 218.72$ N72192-SG 102.77$ N72193-SG 218.72$ N72194-SG 218.72$ N72195-SG 212.22$ N72196-SG 394.94$ N72197-SG 394.94$ N72200-SG Bundled X72202-SG Bundled X72220-SG Bundled X72240-SG Bundled X72255-SG Bundled X72265-SG Bundled X72270-SG Bundled X72275-SG Bundled X72285-SG Bundled X72295-SG Bundled X73000-SG Bundled X73010-SG Bundled X73020-SG Bundled X73030-SG Bundled X73040-SG Bundled X73050-SG Bundled X73060-SG Bundled X73070-SG Bundled X73080-SG Bundled X73085-SG Bundled X73090-SG Bundled X73092-SG Not covered X73100-SG Bundled X73110-SG Bundled X


Procedure Code


Discounting73115-SG Bundled X73120-SG Bundled X73130-SG Bundled X73140-SG Bundled X73200-SG 102.77$ N73201-SG 218.72$ N73202-SG 218.72$ N73206-SG 218.72$ N73218-SG 212.22$ N73219-SG 394.94$ N73220-SG 394.94$ N73221-SG 212.22$ N73222-SG 725.74$ N73223-SG 394.94$ N73525-SG Bundled X73560-SG Bundled X73562-SG Bundled X73564-SG Bundled X73565-SG Bundled X73580-SG Bundled X73590-SG Bundled X73592-SG Not covered X73600-SG Bundled X73610-SG Bundled X73615-SG Bundled X73620-SG Bundled X73630-SG Bundled X73650-SG Bundled X73660-SG Bundled X73700-SG 102.77$ N73701-SG 218.72$ N73702-SG 218.72$ N73706-SG 218.72$ N73718-SG 212.22$ N73719-SG 218.72$ N73720-SG 394.94$ N73721-SG 212.22$ N73722-SG 730.27$ N73723-SG 394.94$ N74018-SG Bundled X74019-SG Bundled X74021-SG Bundled X74022-SG Bundled X


Procedure Code


Discounting74150-SG 102.77$ N74160-SG 218.72$ N74170-SG 218.72$ N74174-SG 218.72$ N74175-SG 218.72$ N74176-SG 380.67$ N74177-SG 218.72$ N74178-SG 218.72$ N74181-SG 212.22$ N74182-SG 394.94$ N74183-SG 394.94$ N74190-SG Bundled X74210-SG Bundled X74220-SG Bundled X74230-SG Bundled X74235-SG Bundled X74240-SG 214.29$ N74241-SG 222.71$ N74245-SG 102.77$ N74246-SG 218.72$ N74247-SG 218.72$ N74249-SG 218.72$ N74250-SG 102.77$ N74251-SG 102.77$ N74260-SG Bundled X74261-SG 102.77$ N74262-SG 218.72$ N74270-SG Bundled X74280-SG 218.72$ N74283-SG 218.72$ N74290-SG Bundled X74300-SG Bundled X74301-SG Bundled X74328-SG Bundled X74329-SG Bundled X74330-SG Bundled X74340-SG Bundled X74355-SG Bundled X74360-SG Bundled X74363-SG Bundled X74400-SG 218.72$ N74410-SG 218.72$ N74415-SG 218.72$ N


Procedure Code


Discounting74420-SG 394.94$ N74425-SG Bundled X74430-SG Bundled X74440-SG Bundled X74445-SG Bundled X74450-SG Bundled X74455-SG Bundled X74470-SG Not covered X74485-SG Bundled X74710-SG Not covered X74712-SG Not covered X74740-SG Not covered X74742-SG Not covered X74775-SG 102.77$ N75557-SG 212.22$ N75559-SG 212.22$ N75561-SG 394.94$ N75563-SG 590.10$ N75565-SG Bundled X75571-SG Bundled X75572-SG 218.72$ N75574-SG 218.72$ N75600-SG Bundled X75605-SG Bundled X75625-SG Bundled X75630-SG Bundled X75635-SG Bundled X75705-SG Bundled X75710-SG Bundled X75716-SG Bundled X75726-SG Bundled X75731-SG Bundled X75733-SG Bundled X75736-SG Bundled X75741-SG Bundled X75743-SG Bundled X75746-SG Bundled X75756-SG Bundled X75774-SG Bundled X75801-SG Bundled X75803-SG Bundled X75805-SG Bundled X75807-SG Bundled X


Procedure Code


Discounting75809-SG Bundled X75810-SG Bundled X75820-SG Bundled X75822-SG Bundled X75825-SG Bundled X75827-SG Bundled X75831-SG Bundled X75833-SG Bundled X75840-SG Bundled X75842-SG Bundled X75860-SG Bundled X75870-SG Bundled X75872-SG Bundled X75880-SG Bundled X75885-SG Bundled X75887-SG Bundled X75889-SG Bundled X75891-SG Bundled X75893-SG Bundled X75894-SG Bundled X75898-SG Bundled X75901-SG Bundled X75902-SG Bundled X75970-SG Bundled X75984-SG Bundled X75989-SG Bundled X76000-SG 91.28$ N76001-SG Bundled X76010-SG Not covered X76080-SG Bundled X76098-SG Bundled X76100-SG Bundled X76101-SG 102.77$ N76102-SG 102.77$ N76120-SG Bundled X76125-SG Bundled X76376-SG Bundled X76377-SG Bundled X76380-SG Bundled X76496-SG Bundled X76497-SG Bundled X76498-SG 53.76$ N76499-SG Bundled X


Procedure Code


Discounting76506-SG Bundled X76510-SG Bundled X76511-SG Bundled X76512-SG Bundled X76513-SG Bundled X76514-SG Bundled X76516-SG Bundled X76519-SG Bundled X76529-SG Bundled X76536-SG Bundled X76604-SG Bundled X76641-SG Bundled X76642-SG Bundled X76700-SG 102.77$ N76705-SG 102.77$ N76770-SG 102.77$ N76775-SG Bundled X76776-SG 102.77$ N76800-SG Bundled X76801-SG 102.77$ N76802-SG Bundled X76805-SG 102.77$ N76810-SG Bundled X76811-SG 102.77$ N76812-SG Bundled X76813-SG Bundled X76814-SG Bundled X76815-SG Bundled X76816-SG Bundled X76817-SG Bundled X76818-SG 102.77$ N76819-SG 171.56$ N76820-SG Bundled X76821-SG Bundled X76825-SG 533.46$ N76826-SG 315.28$ N76827-SG Bundled X76828-SG Bundled X76830-SG 102.77$ N76831-SG Not covered X76856-SG 102.77$ N76857-SG 91.93$ N76870-SG Bundled X


Procedure Code


Discounting76872-SG 102.77$ N76873-SG Not covered X76881-SG 102.77$ N76882-SG Bundled X76885-SG Not covered X76886-SG Not covered X76930-SG Bundled X76932-SG Bundled X76936-SG 215.33$ N76937-SG Bundled X76940-SG Not covered X76941-SG Bundled X76942-SG Bundled X76945-SG Not covered X76946-SG Bundled X76948-SG Not covered X76965-SG Not covered X76970-SG Bundled X76975-SG Bundled X76977-SG 14.24$ N76998-SG Bundled X76999-SG Bundled X77001-SG Bundled X77002-SG Bundled X77003-SG Bundled X77011-SG Bundled X77012-SG Bundled X77013-SG Bundled X77014-SG Bundled X77021-SG Not covered X77022-SG Not covered X77053-SG Not covered X77054-SG Not covered X77071-SG Bundled X77072-SG Not covered X77073-SG Bundled X77074-SG Bundled X77075-SG Bundled X77076-SG Not covered X77077-SG Bundled X77078-SG 53.76$ N77080-SG 80.28$ N77081-SG 53.73$ N


Procedure Code


Discounting77084-SG 212.22$ N77085-SG Bundled X77086-SG Bundled X77280-SG 108.48$ N77285-SG 279.60$ N77290-SG 279.60$ N77295-SG 947.79$ N77299-SG 108.48$ N77300-SG 127.54$ N77301-SG 1,026.95$ N77306-SG 288.74$ N77307-SG 555.47$ N77316-SG 364.49$ N77317-SG 475.19$ N77318-SG 279.60$ N77321-SG 179.33$ N77331-SG 122.36$ N77332-SG 112.65$ N77333-SG 187.10$ N77334-SG 247.31$ N77336-SG 108.48$ N77370-SG 108.48$ N77371-SG Not covered X77385-SG Not covered X77386-SG Not covered X77387-SG Not covered X77399-SG 108.48$ N77401-SG 47.91$ N77402-SG 107.94$ N77407-SG 107.94$ N77412-SG 190.25$ N77417-SG Bundled X77423-SG Not covered X77435-SG Bundled X77470-SG 257.67$ N77520-SG 452.01$ N77522-SG 911.71$ N77523-SG 911.71$ N77525-SG 911.71$ N77600-SG 190.25$ N77605-SG 617.99$ N77610-SG 452.01$ N77615-SG 452.01$ N


Procedure Code


Discounting77620-SG 452.01$ N77750-SG 190.25$ N77761-SG 752.28$ N77762-SG 995.05$ N77763-SG 1,421.04$ N77767-SG Not covered X77768-SG Not covered X77770-SG Not covered X77771-SG Not covered X77772-SG Not covered X77778-SG 617.99$ N77789-SG 232.42$ N77790-SG Bundled X77799-SG 107.94$ N78012-SG 302.41$ N78013-SG 302.41$ N78014-SG 302.41$ N78015-SG 302.41$ N78016-SG 302.41$ N78018-SG 392.10$ N78020-SG Bundled X78070-SG 302.41$ N78071-SG 302.41$ N78072-SG 392.10$ N78075-SG 1,040.79$ N78099-SG 302.41$ N78102-SG 302.41$ N78103-SG 302.41$ N78104-SG 302.41$ N78110-SG 1,040.79$ N78111-SG 1,040.79$ N78120-SG 302.41$ N78121-SG 392.10$ N78122-SG 392.10$ N78130-SG 302.41$ N78135-SG 302.41$ N78140-SG 302.41$ N78185-SG 302.41$ N78191-SG 302.41$ N78195-SG 392.10$ N78199-SG 302.41$ N78201-SG 1,040.79$ N78202-SG 1,040.79$ N


Procedure Code


Discounting78205-SG 1,040.79$ N78206-SG 392.10$ N78215-SG 302.41$ N78216-SG 302.41$ N78226-SG 302.41$ N78227-SG 392.10$ N78230-SG 302.41$ N78231-SG 302.41$ N78232-SG 302.41$ N78258-SG 302.41$ N78261-SG 302.41$ N78262-SG 302.41$ N78264-SG 302.41$ N78265-SG 302.41$ N78266-SG 392.10$ N78270-SG Not covered X78271-SG Not covered X78272-SG Not covered X78278-SG 302.41$ N78282-SG 302.41$ N78290-SG 302.41$ N78291-SG 302.41$ N78299-SG 302.41$ N78300-SG 302.41$ N78305-SG 302.41$ N78306-SG 302.41$ N78315-SG 302.41$ N78320-SG 392.10$ N78399-SG 302.41$ N78414-SG 392.10$ N78428-SG 302.41$ N78445-SG 302.41$ N78451-SG 1,040.79$ N78452-SG 1,040.79$ N78453-SG 1,040.79$ N78454-SG 1,040.79$ N78456-SG 1,040.79$ N78457-SG 1,040.79$ N78458-SG 302.41$ N78459-SG 1,040.79$ N78466-SG 302.41$ N78468-SG 392.10$ N78469-SG 1,040.79$ N


Procedure Code


Discounting78472-SG 302.41$ N78473-SG 302.41$ N78481-SG 392.10$ N78483-SG 392.10$ N78491-SG 1,191.83$ N78492-SG 1,191.83$ N78494-SG 302.41$ N78496-SG Bundled X78499-SG 302.41$ N78579-SG 302.41$ N78580-SG 302.41$ N78582-SG 392.10$ N78597-SG 302.41$ N78598-SG 392.10$ N78599-SG 302.41$ N78600-SG 302.41$ N78601-SG 302.41$ N78605-SG 392.10$ N78606-SG 392.10$ N78607-SG 1,040.79$ N78608-SG 1,191.83$ N78610-SG 392.10$ N78630-SG 392.10$ N78635-SG 392.10$ N78645-SG 392.10$ N78647-SG 1,040.79$ N78650-SG 1,040.79$ N78660-SG 302.41$ N78699-SG 302.41$ N78700-SG 302.41$ N78701-SG 302.41$ N78707-SG 392.10$ N78708-SG 392.10$ N78709-SG 392.10$ N78710-SG 392.10$ N78725-SG 302.41$ N78730-SG Bundled X78740-SG 302.41$ N78761-SG 302.41$ N78799-SG 302.41$ N78800-SG 302.41$ N78801-SG 302.41$ N78802-SG 1,040.79$ N


Procedure Code


Discounting78803-SG 392.10$ N78804-SG 1,040.79$ N78805-SG 1,040.79$ N78806-SG 1,040.79$ N78807-SG 392.10$ N78808-SG Bundled X78811-SG Not covered X78812-SG Not covered X78813-SG Not covered X78814-SG Not covered X78815-SG 1,191.83$ N78816-SG Not covered X78999-SG 302.41$ N79005-SG 258.96$ N79101-SG 273.85$ N79200-SG 253.13$ N79300-SG 206.38$ N79403-SG 365.78$ N79440-SG 233.71$ N79445-SG 206.38$ N79999-SG 206.38$ N90371-SG 111.96$ N90375-SG 296.71$ N90376-SG 296.34$ N90385-SG Not covered X90396-SG Not covered X90476-SG Bundled X90585-SG Not covered X90632-SG Bundled X90633-SG Not covered X90634-SG Not covered X90636-SG Bundled X90647-SG Bundled X90648-SG Bundled X90672-SG Bundled X90674-SG Bundled X90675-SG 269.91$ N90676-SG By Report N90680-SG Not covered X90690-SG Not covered X90691-SG Not covered X90698-SG Bundled X90700-SG Not covered X


Procedure Code


Discounting90702-SG Not covered X90707-SG Not covered X90710-SG Not covered X90713-SG Not covered X90714-SG Not covered X90715-SG Not covered X90717-SG Bundled X90733-SG Not covered X90734-SG Not covered X90749-SG Bundled X90756-SG Bundled X91200-SG Not covered X92071-SG Not covered X93261-SG Not covered X93355-SG Not covered X93590-SG Not covered X93591-SG Not covered X93644-SG Not covered X93895-SG Not covered X95940-SG Not covered X95941-SG Not covered X99497-SG Not covered X99498-SG Not covered X0042T-SG Not covered X0100T-SG Not covered X0101T-SG Not covered X0102T-SG Not covered X0174T-SG Not covered X0175T-SG Not covered X0213T-SG 581.70$ Y0214T-SG Bundled X0215T-SG Bundled X0216T-SG 581.70$ Y0217T-SG Bundled X0218T-SG Bundled X0238T-SG 22,551.20$ Y0249T-SG 1,892.29$ Y0253T-SG Not covered X0313T-SG Not covered X0314T-SG Not covered X0315T-SG Not covered X0316T-SG Not covered X0335T-SG Not covered X


Procedure Code


Discounting0338T-SG Not covered X0339T-SG Not covered X0341T-SG Not covered X0342T-SG Not covered X0346T-SG Not covered X0357T-SG Not covered X0376T-SG Not covered X0377T-SG Not covered X0379T-SG Not covered X0380T-SG Not covered X0387T-SG Not covered X0388T-SG Not covered X0390T-SG Not covered X0394T-SG Not covered X0395T-SG Not covered X0402T-SG Not covered X0408T-SG Not covered X0409T-SG Not covered X0410T-SG Not covered X0411T-SG Not covered X0412T-SG Not covered X0413T-SG Not covered X0414T-SG Not covered X0415T-SG Not covered X0416T-SG Not covered X0419T-SG Not covered X0420T-SG Not covered X0422T-SG Not covered X0437T-SG Not covered X0439T-SG Bundled X0440T-SG Not covered X0441T-SG Not covered X0442T-SG Not covered X0443T-SG Bundled X0444T-SG Bundled X0445T-SG Bundled X0446T-SG Not covered X0447T-SG Not covered X0448T-SG Not covered X0449T-SG 2,944.19$ Y0450T-SG Bundled X0471T-SG Not covered X0474T-SG Not covered X


Procedure Code


Discounting0479T-SG Not covered X0480T-SG Not covered X0482T-SG Not covered X0487T-SG Not covered X0491T-SG Not covered X0492T-SG Not covered X0493T-SG Not covered X0502T-SG Not covered X0503T-SG Not covered XA4218-SG Not covered XA4220-SG Not covered XA4248-SG Not covered XA4262-SG Not covered XA4263-SG Not covered XA4270-SG Not covered XA4300-SG Not covered XA4301-SG Not covered XA4305-SG Not covered XA4306-SG Not covered XA4459-SG Not covered XA4602-SG Not covered XA4648-SG Not covered XA4650-SG Not covered XA7048-SG Not covered XA9515-SG Not covered XA9520-SG Bundled XA9527-SG UR/BR NA9575-SG Bundled XA9576-SG Bundled XA9577-SG Bundled XA9578-SG Bundled XA9579-SG Bundled XA9580-SG Bundled XA9581-SG Bundled XA9582-SG Not covered XA9583-SG Bundled XA9584-SG Bundled XA9585-SG Bundled XA9587-SG Not covered XA9588-SG By Report NA9597-SG Not covered XA9598-SG Not covered XA9606-SG Not covered X


Procedure Code


DiscountingA9698-SG Bundled XG0104-SG 323.70$ YG0105-SG 614.42$ YG0121-SG 614.42$ YG0127-SG Not covered XG0130-SG 66.68$ NG0186-SG 422.30$ YG0247-SG Not covered XG0259-SG Not covered XG0260-SG 470.24$ YG0268-SG Not covered XG0269-SG Not covered XG0276-SG Not covered XG0288-SG Not covered XG0289-SG Not covered XG0339-SG Not covered XG0340-SG Not covered XG0453-SG Not covered XG0458-SG Not covered XG0472-SG Not covered XG0516-SG Bundled XG0517-SG Bundled XG0518-SG Bundled XJ0120-SG Not covered XJ0129-SG 50.16$ NJ0130-SG Bundled XJ0131-SG Bundled XJ0132-SG Bundled XJ0133-SG Bundled XJ0135-SG Not covered XJ0153-SG Bundled XJ0171-SG Bundled XJ0178-SG Not covered XJ0180-SG 172.19$ NJ0190-SG Not covered XJ0200-SG Not covered XJ0202-SG Not covered XJ0205-SG Not covered XJ0207-SG 948.18$ NJ0210-SG Bundled XJ0215-SG Not covered XJ0220-SG Not covered XJ0256-SG 4.45$ N


Procedure Code


DiscountingJ0278-SG Not covered XJ0280-SG Bundled XJ0282-SG Bundled XJ0285-SG Bundled XJ0287-SG 17.35$ NJ0288-SG Not covered XJ0289-SG 48.07$ NJ0290-SG Bundled XJ0295-SG Bundled XJ0300-SG 219.91$ NJ0330-SG Bundled XJ0348-SG Bundled XJ0360-SG Bundled XJ0364-SG Not covered XJ0365-SG Not covered XJ0380-SG Not covered XJ0390-SG Not covered XJ0400-SG 0.70$ NJ0401-SG 5.01$ NJ0456-SG Bundled XJ0461-SG Bundled XJ0470-SG 50.91$ N J0475-SG 178.38$ NJ0476-SG 45.98$ NJ0480-SG 3,550.39$ NJ0485-SG 3.89$ NJ0500-SG Bundled XJ0515-SG Bundled XJ0520-SG Not covered XJ0558-SG Bundled XJ0561-SG 12.84$ NJ0565-SG By Report NJ0570-SG 1,229.98$ NJ0583-SG Not covered XJ0585-SG 6.15$ NJ0586-SG 8.23$ NJ0587-SG 11.99$ NJ0588-SG 5.08$ NJ0592-SG Bundled XJ0594-SG 27.95$ NJ0595-SG Bundled XJ0596-SG Not covered XJ0597-SG Not covered X


Procedure Code


DiscountingJ0600-SG 5,594.42$ NJ0606-SG By Report NJ0610-SG Bundled XJ0620-SG Not covered XJ0630-SG 2,461.06$ NJ0636-SG Not covered XJ0637-SG 15.51$ NJ0638-SG Not covered XJ0640-SG Bundled XJ0641-SG 0.36$ NJ0670-SG Bundled XJ0690-SG Bundled XJ0692-SG Bundled XJ0694-SG Bundled XJ0695-SG 4.48$ NJ0696-SG Bundled XJ0697-SG Bundled XJ0698-SG Bundled XJ0702-SG Bundled XJ0706-SG Not covered XJ0710-SG Not covered XJ0712-SG 2.62$ NJ0713-SG Bundled XJ0714-SG 78.64$ NJ0715-SG Not covered XJ0716-SG 5,305.50$ NJ0717-SG Not covered XJ0720-SG Bundled XJ0725-SG Bundled XJ0735-SG Bundled XJ0740-SG 493.46$ NJ0743-SG Bundled XJ0744-SG Bundled XJ0745-SG Not covered XJ0770-SG Bundled XJ0775-SG Not covered XJ0780-SG Bundled XJ0795-SG Not covered XJ0800-SG 3,754.07$ NJ0833-SG Bundled XJ0834-SG Bundled XJ0840-SG 3,086.28$ NJ0850-SG 1,129.12$ N


Procedure Code


DiscountingJ0875-SG 14.73$ NJ0878-SG 0.42$ NJ0881-SG 3.78$ NJ0883-SG 45.60$ NJ0884-SG 45.60$ NJ0885-SG 13.00$ NJ0888-SG 1.90$ NJ0894-SG 16.42$ NJ0895-SG Bundled XJ0897-SG 17.94$ NJ0945-SG Not covered XJ1000-SG Not covered XJ1020-SG Bundled XJ1030-SG Bundled XJ1040-SG Bundled XJ1050-SG Bundled XJ1071-SG Bundled XJ1094-SG Not covered XJ1100-SG Bundled XJ1110-SG 83.35$ NJ1120-SG Bundled XJ1160-SG Bundled XJ1162-SG 3,513.19$ NJ1165-SG Bundled XJ1170-SG Bundled XJ1180-SG Not covered XJ1190-SG 243.13$ NJ1200-SG Bundled XJ1205-SG Bundled XJ1212-SG 549.34$ NJ1230-SG Bundled XJ1240-SG Bundled XJ1245-SG Bundled XJ1250-SG Bundled XJ1260-SG Bundled XJ1265-SG Bundled XJ1267-SG Bundled XJ1270-SG Not covered XJ1290-SG Not covered XJ1300-SG Not covered XJ1320-SG Not covered XJ1322-SG Not covered XJ1324-SG Not covered X


Procedure Code


DiscountingJ1325-SG Bundled XJ1327-SG 31.29$ NJ1330-SG Not covered XJ1335-SG Bundled XJ1364-SG 72.36$ NJ1380-SG Not covered XJ1410-SG Not covered XJ1428-SG Not covered XJ1430-SG Not covered XJ1435-SG Not covered XJ1436-SG Not covered XJ1438-SG 521.34$ NJ1439-SG 1.05$ NJ1442-SG 1.02$ NJ1447-SG 0.61$ N J1450-SG Bundled XJ1451-SG 11.33$ NJ1453-SG 2.10$ NJ1455-SG 15.00$ NJ1457-SG Not covered XJ1458-SG Not covered XJ1459-SG 39.65$ NJ1460-SG 38.79$ NJ1555-SG By Report NJ1556-SG Not covered XJ1559-SG Not covered XJ1560-SG 387.93$ NJ1561-SG 39.15$ NJ1562-SG Not covered XJ1566-SG 35.53$ NJ1568-SG 41.41$ NJ1569-SG 39.69$ NJ1570-SG Bundled XJ1571-SG 62.21$ NJ1572-SG 35.15$ NJ1573-SG 69.12$ NJ1575-SG Not covered XJ1580-SG Bundled XJ1595-SG Not covered XJ1599-SG Bundled XJ1600-SG Not covered XJ1602-SG 24.04$ NJ1610-SG 211.73$ N


Procedure Code


DiscountingJ1620-SG Not covered XJ1626-SG Bundled XJ1627-SG 4.34$ NJ1630-SG Bundled XJ1631-SG Bundled XJ1640-SG 22.36$ NJ1642-SG Bundled XJ1644-SG Bundled XJ1645-SG Bundled XJ1650-SG Bundled XJ1652-SG Bundled XJ1655-SG Not covered XJ1670-SG 451.51$ NJ1700-SG Not covered XJ1710-SG Not covered XJ1720-SG Bundled XJ1726-SG Not covered XJ1729-SG Not covered XJ1730-SG Not covered XJ1740-SG 74.24$ NJ1741-SG Bundled XJ1742-SG 321.30$ NJ1743-SG Not covered XJ1744-SG Not covered XJ1745-SG 83.29$ NJ1756-SG Bundled XJ1786-SG 41.58$ NJ1790-SG Bundled XJ1800-SG Bundled XJ1815-SG Bundled XJ1817-SG Bundled XJ1830-SG 346.17$ NJ1833-SG 0.96$ NJ1835-SG Not covered XJ1840-SG Not covered XJ1850-SG Not covered XJ1885-SG Bundled XJ1890-SG Not covered XJ1930-SG Not covered XJ1931-SG 30.61$ NJ1940-SG Bundled XJ1942-SG 2.43$ NJ1945-SG Not covered X


Procedure Code


DiscountingJ1950-SG 1,089.22$ NJ1953-SG Not covered XJ1956-SG Bundled XJ1960-SG Not covered XJ1980-SG Bundled XJ1990-SG Not covered XJ2001-SG Bundled XJ2010-SG Bundled XJ2020-SG Bundled XJ2060-SG Bundled XJ2150-SG Bundled XJ2170-SG Not covered XJ2175-SG Bundled XJ2180-SG Not covered XJ2182-SG 15.00$ NJ2185-SG Bundled XJ2210-SG Not covered XJ2212-SG Bundled XJ2248-SG Bundled XJ2250-SG Bundled XJ2260-SG Bundled XJ2270-SG Bundled XJ2274-SG Not covered XJ2278-SG 7.44$ NJ2280-SG Bundled XJ2300-SG Bundled XJ2310-SG Bundled XJ2315-SG 3.26$ NJ2320-SG Not covered XJ2323-SG Not covered XJ2325-SG Not covered XJ2326-SG Not covered XJ2350-SG Not covered XJ2353-SG 190.68$ NJ2354-SG Bundled XJ2355-SG 467.22$ NJ2357-SG 36.38$ NJ2358-SG Bundled XJ2360-SG Bundled XJ2370-SG Bundled XJ2400-SG Bundled XJ2405-SG Bundled XJ2407-SG 23.49$ N


Procedure Code


DiscountingJ2410-SG Bundled XJ2425-SG Not covered XJ2426-SG 10.38$ NJ2430-SG Bundled XJ2440-SG Bundled XJ2469-SG 20.02$ NJ2501-SG Not covered XJ2502-SG 246.17$ NJ2503-SG Not covered XJ2504-SG Not covered XJ2505-SG Not covered XJ2510-SG Bundled XJ2513-SG Not covered XJ2515-SG Not covered XJ2540-SG Bundled XJ2543-SG Bundled XJ2547-SG 0.10$ NJ2550-SG Bundled XJ2560-SG Bundled XJ2562-SG 314.44$ NJ2590-SG Not covered XJ2597-SG 13.02$ NJ2650-SG Not covered XJ2670-SG Not covered XJ2675-SG Not covered XJ2680-SG Bundled XJ2690-SG Bundled XJ2700-SG Bundled XJ2704-SG Bundled XJ2710-SG Bundled XJ2720-SG Bundled XJ2724-SG 15.20$ NJ2725-SG Not covered XJ2730-SG Bundled XJ2760-SG 255.00$ NJ2765-SG Not covered XJ2770-SG 419.20$ NJ2778-SG Not covered XJ2780-SG Bundled XJ2783-SG Not covered XJ2785-SG Bundled XJ2786-SG 0.84$ NJ2788-SG Bundled X


Procedure Code


DiscountingJ2790-SG Bundled XJ2791-SG Bundled XJ2792-SG 24.31$ NJ2794-SG 8.98$ NJ2795-SG Bundled XJ2796-SG 68.50$ NJ2800-SG Bundled XJ2805-SG Not covered XJ2810-SG Bundled XJ2820-SG 37.48$ NJ2840-SG Not covered XJ2850-SG Not covered XJ2860-SG Not covered XJ2910-SG Not covered XJ2916-SG Bundled XJ2920-SG Bundled XJ2930-SG Bundled XJ2941-SG Not covered XJ2950-SG Not covered XJ2993-SG Not covered XJ2995-SG Not covered XJ2997-SG 84.58$ NJ3000-SG Bundled XJ3010-SG Bundled XJ3030-SG Bundled XJ3060-SG Not covered XJ3070-SG 108.39$ NJ3090-SG 1.38$ NJ3095-SG 5.39$ NJ3101-SG 111.63$ NJ3105-SG Bundled XJ3121-SG Bundled XJ3145-SG 0.54$ N J3230-SG Bundled XJ3240-SG 1,598.00$ NJ3243-SG 2.63$ NJ3246-SG 11.18$ NJ3250-SG Bundled XJ3260-SG Bundled XJ3262-SG 4.54$ NJ3265-SG Bundled XJ3280-SG Not covered XJ3285-SG Not covered X


Procedure Code


DiscountingJ3300-SG 3.87$ NJ3301-SG Bundled XJ3302-SG Not covered XJ3303-SG Bundled XJ3310-SG Not covered XJ3315-SG Not covered XJ3320-SG Not covered XJ3350-SG Not covered XJ3355-SG Not covered XJ3357-SG 184.94$ NJ3358-SG By Report NJ3360-SG Bundled XJ3364-SG Not covered XJ3365-SG Not covered XJ3370-SG Bundled XJ3380-SG 19.13$ NJ3385-SG Not covered XJ3396-SG Not covered XJ3400-SG Not covered XJ3410-SG Bundled XJ3411-SG Bundled XJ3415-SG Bundled XJ3420-SG Bundled XJ3430-SG Bundled XJ3465-SG 2.10$ NJ3470-SG Bundled XJ3471-SG Bundled XJ3472-SG Bundled XJ3473-SG Bundled XJ3475-SG Bundled XJ3480-SG Bundled XJ3485-SG Bundled XJ3486-SG Bundled XJ3489-SG Bundled XJ3490-SG Bundled XJ3530-SG Not covered XJ3590-SG Bundled XJ7030-SG Bundled XJ7040-SG Bundled XJ7042-SG Bundled XJ7050-SG Bundled XJ7060-SG Bundled XJ7070-SG Bundled X


Procedure Code


DiscountingJ7100-SG Bundled XJ7110-SG Not covered XJ7120-SG Bundled XJ7131-SG Bundled XJ7175-SG 9.86$ NJ7178-SG 0.93$ NJ7179-SG 3.50$ NJ7181-SG 18.29$ NJ7185-SG 1.25$ NJ7186-SG 0.99$ NJ7187-SG 1.13$ NJ7188-SG 12.20$ NJ7189-SG 2.06$ NJ7190-SG 1.04$ NJ7191-SG Not covered XJ7192-SG 1.28$ NJ7193-SG 1.13$ NJ7194-SG 1.40$ NJ7195-SG 1.50$ NJ7196-SG Not covered XJ7197-SG 3.59$ NJ7198-SG 1.99$ NJ7200-SG 1.31$ NJ7201-SG 3.03$ NJ7202-SG 6.34$ NJ7205-SG 2.05$ NJ7207-SG By Report NJ7209-SG By Report NJ7210-SG By Report NJ7211-SG By Report NJ7308-SG Not covered XJ7309-SG Not covered XJ7310-SG Not covered XJ7311-SG 20,166.50$ NJ7312-SG 200.36$ NJ7313-SG 490.28$ NJ7315-SG Bundled XJ7316-SG Not covered XJ7321-SG 88.65$ NJ7322-SG 7.26$ NJ7323-SG 149.92$ NJ7324-SG 149.40$ NJ7325-SG 12.08$ N


Procedure Code


DiscountingJ7326-SG 527.87$ NJ7327-SG 812.55$ NJ7336-SG 3.15$ NJ7340-SG By Report NJ7342-SG Not covered XJ7345-SG Not covered XJ7500-SG Bundled XJ7501-SG Not covered XJ7502-SG Bundled XJ7504-SG 1,937.64$ NJ7505-SG Not covered XJ7507-SG Bundled XJ7508-SG Bundled XJ7509-SG Bundled XJ7510-SG Bundled XJ7511-SG 713.84$ NJ7513-SG Not covered XJ7515-SG Bundled XJ7516-SG Bundled XJ7517-SG Bundled XJ7518-SG Not covered XJ7520-SG Bundled XJ7525-SG 192.81$ NJ7527-SG Bundled XJ7599-SG Bundled XJ7674-SG Bundled XJ7799-SG Bundled XJ8501-SG Not covered XJ8510-SG Bundled XJ8520-SG Bundled XJ8521-SG Bundled XJ8530-SG Bundled XJ8540-SG Bundled XJ8560-SG 74.66$ NJ8562-SG Not covered XJ8597-SG Bundled XJ8600-SG Bundled XJ8610-SG Bundled XJ8655-SG 366.82$ NJ8670-SG 2.27$ NJ8700-SG Bundled XJ8705-SG 103.73$ NJ9000-SG Bundled X


Procedure Code


DiscountingJ9015-SG 2,342.00$ NJ9017-SG 71.82$ NJ9019-SG 409.06$ NJ9020-SG Not covered XJ9022-SG By Report NJ9023-SG Not covered XJ9025-SG Not covered XJ9027-SG Not covered XJ9031-SG 137.67$ NJ9032-SG 36.27$ NJ9033-SG 30.21$ NJ9034-SG 23.75$ NJ9035-SG 77.17$ NJ9039-SG 107.47$ NJ9040-SG Bundled XJ9041-SG 46.66$ NJ9042-SG Not covered XJ9045-SG Bundled XJ9047-SG 34.11$ NJ9050-SG 3,854.59$ NJ9055-SG Not covered XJ9060-SG Bundled XJ9065-SG 22.62$ NJ9070-SG Not covered XJ9098-SG 628.37$ NJ9100-SG Bundled XJ9120-SG 1,580.57$ NJ9130-SG Bundled XJ9145-SG 50.39$ NJ9150-SG 41.58$ NJ9151-SG Not covered XJ9160-SG Not covered XJ9171-SG 1.66$ NJ9175-SG Not covered XJ9176-SG 6.35$ NJ9178-SG Bundled XJ9179-SG 111.28$ NJ9181-SG Bundled XJ9185-SG 76.62$ N J9190-SG Bundled XJ9200-SG Bundled XJ9201-SG Bundled XJ9202-SG 397.59$ N


Procedure Code


DiscountingJ9203-SG By Report NJ9205-SG 42.59$ NJ9206-SG Bundled XJ9207-SG 72.11$ NJ9208-SG Bundled XJ9209-SG Bundled XJ9211-SG 34.28$ NJ9212-SG Bundled XJ9213-SG Not covered XJ9214-SG 31.09$ NJ9215-SG Not covered XJ9216-SG 1,342.37$ NJ9217-SG 209.30$ NJ9218-SG 25.79$ NJ9219-SG Not covered XJ9225-SG Not covered XJ9226-SG Not covered XJ9230-SG 292.48$ NJ9245-SG 1,117.99$ NJ9250-SG Bundled XJ9260-SG Bundled XJ9261-SG 151.90$ NJ9262-SG Not covered XJ9263-SG Bundled XJ9264-SG 11.12$ NJ9266-SG 14,977.05$ NJ9267-SG Bundled XJ9268-SG 2,066.03$ NJ9270-SG Not covered XJ9271-SG 48.71$ NJ9280-SG 140.08$ NJ9285-SG Not covered XJ9293-SG 32.14$ NJ9295-SG 5.36$ NJ9299-SG Not covered XJ9301-SG Not covered XJ9302-SG 56.59$ NJ9303-SG Not covered XJ9305-SG 66.17$ NJ9306-SG 11.51$ NJ9307-SG 262.32$ NJ9308-SG 56.93$ NJ9310-SG 883.68$ N


Procedure Code


DiscountingJ9315-SG Not covered XJ9320-SG 342.79$ NJ9325-SG By Report NJ9328-SG 9.48$ NJ9330-SG 71.69$ NJ9340-SG 1,080.00$ NJ9351-SG Bundled XJ9352-SG By Report NJ9354-SG Not covered XJ9355-SG 101.05$ NJ9357-SG Not covered XJ9360-SG Bundled XJ9370-SG Bundled XJ9371-SG 2,807.15$ NJ9390-SG Bundled XJ9395-SG Not covered XJ9400-SG 8.12$ NJ9600-SG 12,256.00$ NJ9999-SG Bundled XP9041-SG 11.80$ NP9045-SG 54.72$ NP9046-SG 22.49$ NP9047-SG 53.44$ NQ0138-SG 0.95$ NQ0161-SG Bundled XQ0163-SG Bundled XQ0164-SG Bundled XQ0166-SG Bundled XQ0167-SG Bundled XQ0169-SG Bundled XQ0173-SG Bundled XQ0174-SG Not covered XQ0175-SG Bundled XQ0177-SG Bundled XQ0180-SG Bundled XQ0515-SG Not covered XQ2004-SG Bundled XQ2009-SG 0.71$ N Q2017-SG 599.03$ NQ2035-SG Not covered XQ2036-SG Not covered XQ2037-SG Not covered XQ2038-SG Not covered X


Procedure Code


DiscountingQ2039-SG Not covered XQ2040-SG Not covered XQ3027-SG Not covered XQ4100-SG Bundled XQ4101-SG Bundled XQ4102-SG Bundled XQ4103-SG Bundled XQ4104-SG Bundled XQ4105-SG Bundled XQ4106-SG Bundled XQ4107-SG Bundled XQ4108-SG Bundled XQ4110-SG Bundled XQ4112-SG Bundled XQ4113-SG Bundled XQ4114-SG Bundled XQ4118-SG Not covered XQ4121-SG Not covered XQ4131-SG Not covered XQ4132-SG Not covered XQ4133-SG Not covered XQ4137-SG Not covered XQ4138-SG Not covered XQ4139-SG Not covered XQ4140-SG Not covered XQ4141-SG Not covered XQ4142-SG Not covered XQ4143-SG Not covered XQ4145-SG Not covered XQ4146-SG Not covered XQ4147-SG Not covered XQ4148-SG Not covered XQ4149-SG Not covered XQ4150-SG Not covered XQ4151-SG Not covered XQ4152-SG Not covered XQ4153-SG Not covered XQ4154-SG Not covered XQ4155-SG Not covered XQ4156-SG Not covered XQ4157-SG Not covered XQ4158-SG Not covered XQ4159-SG Not covered X


Procedure Code


DiscountingQ4160-SG Not covered XQ4166-SG Not covered XQ4167-SG Not covered XQ4168-SG Not covered XQ4169-SG Not covered XQ4170-SG Not covered XQ4171-SG Not covered XQ4172-SG Not covered XQ4173-SG Not covered XQ4174-SG Not covered XQ4175-SG Not covered XQ4176-SG Not covered XQ4177-SG Not covered XQ4178-SG Not covered XQ4179-SG Not covered XQ4180-SG Not covered XQ4181-SG Not covered XQ4182-SG Not covered XQ9950-SG Bundled XQ9951-SG Bundled XQ9953-SG Bundled XQ9954-SG Bundled XQ9955-SG Bundled XQ9956-SG Bundled XQ9957-SG Bundled XQ9958-SG Bundled XQ9959-SG Bundled XQ9960-SG Bundled XQ9961-SG Bundled XQ9962-SG Bundled XQ9963-SG Bundled XQ9964-SG Bundled XQ9965-SG Bundled XQ9966-SG Bundled XQ9967-SG Bundled XQ9968-SG By Report NV2630-SG Bundled XV2631-SG Bundled XV2632-SG Bundled XV2785-SG UR/BR NV2790-SG Bundled X

department of corrections (doc) ambulatory surgery center ......*multiple procedure discounting...

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