Professional Services Fee Schedule

Medicine

Effective July 1, 2016

July 1, 2016

Professional Services Fee Schedule

Medicine Fees

Effective for Dates of Service on or After

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CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 1

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

Copyright Information Physicians’ Current Procedural Terminology (CPT®) five-digit codes, descriptions, and other data only are copyright 2015 American Medical Association. All Rights Reserved. CPT® is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for data contained or not contained herein. This document is also on the department’s Internet web site at http://feeschedules.lni.wa.gov/. Updates to this manual can be found under ‘Updates and Corrections’ tab on the department’s Internet web site at http://feeschedules.lni.wa.gov/ Updates to this manual are also announced on the Medical Provider e-News listserv. Individuals may join the listserv at http://www.lni.wa.gov/Main/Listservs/Provider.asp.

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 2

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

MEDICINE FEES

2015 CPT or HCPCS code

CPT CODE/

HCPCS CODE2015 CPT

or HCPCS code

DOLLAR VALUE

NON-FACILITY

SETTING

This column indicates the:

• Maximum dollar amount for covered

services provided in a non-facility

setting, or

• Pricing method for the procedure

code, or

• Coverage status for the procedure

code.

Dollar Value Maximum dollar amount payable for covered Bundled Bundled code, not separately payable.

FIELD KEY: Column Title Column Description Column Values Value Definitions

By Report Service paid on a “by report” basis.

Contracted

Contracted service. Payable only to

department’s contracted vendor for State

Fund claims. Payable to providers treating

Self-Insured injured workers.

Facility Only Procedure code for facility outpatient use

DOLLAR VALUE

FACILITY SETTING

This column indicates the:

• Maximum dollar amount for covered

services provided in a facility setting,

or

• Pricing method for the procedure

code, or

• Coverage status for the procedure

code.

Dollar Value Maximum dollar amount payable for covered Bundled Bundled code, not separately payable.

By Report Service paid on a “by report” basis.

Contracted

Contracted service. Payable only to

department’s contracted vendor for State

Fund claims. Payable to providers treating

Self-Insured injured workers.

Hosp. Only Procedure code for hospital outpatient use

Not Covered Procedure code is not covered.

Not Covered Procedure code is not covered.

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 3

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

PCTC

(26/TC)

Professional and Technical

Component (Modifiers –26 and –TC)

This field identifies whether

professional and technical component

modifiers (-26/-TC) are valid with the

procedure code.

0

Modifiers -26 and -TC are not valid . The

procedure is for physician services only; the

concept of PC/TC does not apply

1

Modifiers -26 and -TC are valid .

Diagnostic test or radiology service which

has both a professional and technical

component.

2

Modifiers -26 and -TC are not valid . Stand

alone code for the professional component of

a diagnostic test. An associated code

describes the technical component of the

diagnostic test or the global procedure

(professional and technical components).

3

Modifiers -26 and -TC are not valid . Stand

alone code for the technical component of a

diagnostic test. An associated code

describes the professional component of the

diagnostic test or the global procedure

(professional and technical components).

FOL UP Follow-up Days for Global Surgery Number

The number of days following surgery during

which charges for normal postoperative care

are bundled in the global surgery fee.

Percent

The percent of the total global surgery dollar

value that is allowed when modifier –56 is

billed.

Percent

The percent of the total global surgery dollar

value that is allowed when modifier -54 is

billed.

Percent

PRE OP

(-56)

Preoperative Percentage

(Modifier –56)

INTRA OP

(-54)

Intraoperative Percentage

(Modifier –54)

POST OP

(-55)

Postoperative Percentage

(Modifier –55)

Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions

The percent of the total global surgery dollar

value that is allowed when modifier -55 is

billed.

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 4

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

PCTC

(26/TC)

Professional and Technical

Component (Modifiers –26 and –TC)

This field identifies whether

professional and technical component

modifiers (-26/-TC) are valid with the

procedure code.

3

Modifiers -26 and -TC are not valid . Stand

alone code for the technical component of a

diagnostic test. An associated code

describes the professional component of the

diagnostic test or the global procedure

(professional and technical components).

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 5

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

PCTC

(26/TC)

(Continued)

Professional and Technical

Component (Modifiers –26 and –TC)

This field identifies whether

professional and technical

component modifiers (-26/-TC) are

valid with the procedure code.

4

Modifiers -26 and -TC are not valid . Stand

alone code for the global procedure for a

diagnostic test. Associated codes describe

the professional and technical components

of the diagnostic test.

Modifier -TC is not valid ; modifier -26

may be valid . Clinical laboratory or other

service for which separate payment for

interpretations by laboratory physicians or

other physicians may be made.

7 This indicator is not currently in use.

Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions

8

Professional component of a clinical

laboratory code; payable only if the physician

interprets an abnormal smear for a hospital

inpatient. No -TC modifier billing is

recognized; payment for the underlying

clinical laboratory test is made to the

hospital. Not payable when furnished to

hospital outpatients or non-hospital patients.

5

Modifiers -26 and -TC are not valid .

Covered service incident to a physician’s

service when provided by auxiliary personnel

employed by and working under the direct

supervision of the physician. This service not

payable when provided to hospital inpatients

or outpatients.

6

9

Modifiers -26 and -TC are not valid .

Concept of a professional/technical

component split does not apply.

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 6

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions

Modifier -51 may be valid . Multiple

endoscopic procedures payment policy

applies if this service is billed with another

endoscopy in the same family.

4 This indicator is not currently in use.

Modifier -51 is not valid . Payment

adjustment rules for multiple surgeries do not

apply.

1 This indicator is not currently in use.

2

Modifier -51 is valid . Standard multiple

surgery payment policy applies (100%, 50%,

50%, 50%, 50%).

0

9Modifier -51 is not valid . Concept of

multiple surgery does not apply.

MSI

Multiple Surgery Indicator

(Modifier –51)

This field indicates whether multiple

surgery payment rules apply to the

service. 3

5 This indicator is not currently in use.

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 7

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

0

3

Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions

BSI

Modifier -50 is not valid . Payment

adjustment rule for bilateral surgery does not

apply.

1

Modifier -50 is valid . Payment adjustment

for bilateral procedures (150%) applies to

this procedure.

2

Modifier -50 is not valid . Payment

adjustment for bilateral procedures does not

apply. Procedures in this category include

services for which the code descriptor

specifically states that the procedure is

bilateral; procedures that are usually

performed as bilateral procedures; or

procedures for which the code descriptor

indicates the procedures may be performed

either unilaterally or bilaterally.

Bilateral Surgery Indicator

(Modifier –50)

This field indicates whether the

procedure is subject to a payment

adjustment for bilateral surgery.

Modifier -50 is not valid . Payment

adjustment for bilateral procedure does not

apply. This is a radiology procedure which is

not subject to payment rules for bilateral

surgeries.

9Modifier -50 is not valid . Concept of

bilateral surgery does not apply.

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 8

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CSI

Co-surgeons Indicator

(Modifier –62)

This field indicates whether or not co-

surgeons may be paid for the

procedure.

ASI

0

9

Assistant Surgeon Indicator

(Modifiers –80, -81, -82)

This field indicates whether or not an

assistant surgeon may be paid for the

procedure.

0

Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions

9Modifiers -80, -81 and -82 are not valid .

Concept does not apply.

Modifiers -80, -81 and -82 are not valid.

Assistant at surgery may not be paid for this

procedure.

2Modifiers -80, -81 and -82 are valid .

Assistant at surgery may be paid.

Modifier -62 is not valid . Co-surgeons not

permitted.

1

Modifier -62 is not valid under normal

situations . Supporting documentation is

required to establish medical necessity of

two surgeons.

2

Modifier -62 is valid . Co-surgeons may be

paid for this procedure. Supporting

documentation is not required if two specialty

requirement is met.

Modifiers -80, -81 and -82 are not valid

under normal situations . Assistant at

surgery is not usually paid for this procedure.

Supporting documentation is necessary to

establish medical necessity.

1

Modifier -62 is not valid with this

procedure. Concept of co-surgeons does

not apply.

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 9

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

Modifier -66 is not valid . Team surgeons

not permitted.

1

Bundled code, not separately payable.

C

Modifier -66 is not valid under normal

situations . Team surgeons may be payable.

Supporting documentation is required to

establish medical necessity of a team.

Modifier -66 is valid. Team surgeons

permitted.

Modifier -66 is not valid . Concept of team

surgery does not apply.

Contracted service. Payable only to

department’s contracted vendor for State

Fund claims. Payable to providers treating

Self-Insured injured workers.

0

2

9

B

TSI

Team Surgeons Indicator

(Modifier -66)

This field indicates whether or not

team surgeons may be paid for the

procedure.

Field Key: Medicine (continued)Column Title Column Description Column Values Value Definitions

D

Drug fee based on Average Wholesale Price

(AWP) or Average Average Wholesale Price

(AAWP).

F Flat fee developed by the department

ENDO BASE Endoscopy Base Code Code number

This column contains the endoscopic base

code for procedure codes that are part of an

endoscopy family. The Multiple Surgery

Indicator for procedures in an endoscopy

family is 3.

FSI

Fee Schedule Indicator

This column indicates the payment

status for the procedure code.

For hospital outpatient use only.

R RBRVS fee

L Clinical lab fee

N No fee or RVUs available, code paid by report.

S State Rate

T Tracking code

O

PRIOR AUTH

Prior authorization indicator

This column indicates whether prior

authorization and utilization review is

required.

Y Prior authorization required

X Non-covered code

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 10

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

PRIOR AUTH

Prior authorization indicator

This column indicates whether prior

authorization and utilization review is

required.

Y Prior authorization required

Y-UR Prior authorization and UR required

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 11

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTH

90281 $30.75 $30.75 0 0% 0% 0% 9 9 9 9 9 9 D Y

90283 $684.02 $684.02 0 0% 0% 0% 9 9 9 9 9 9 D Y

90284 $32.62 $32.62 0 0% 0% 0% 9 9 9 9 9 9 D Y

90287 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y

90288 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

90291 $26.42 $26.42 0 0% 0% 0% 9 9 9 9 9 9 D Y

90296 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y

90371 $172.85 $172.85 0 0% 0% 0% 9 9 9 9 9 9 D

90375 $268.96 $268.96 0 0% 0% 0% 9 9 9 9 9 9 D

90376 $268.96 $268.96 0 0% 0% 0% 9 9 9 9 9 9 D

90378 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90384 $127.44 $127.44 0 0% 0% 0% 9 9 9 9 9 9 D

90385 $37.10 $37.10 0 0% 0% 0% 9 9 9 9 9 9 D

90386 $276.49 $276.49 0 0% 0% 0% 9 9 9 9 9 9 D

90389 $407.82 $407.82 0 0% 0% 0% 9 9 9 9 9 9 D

90393 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90396 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90399 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

90460 $45.52 $45.52 0 0% 0% 0% 0 0 0 0 0 0 R

90461 $22.15 $22.15 0 0% 0% 0% 0 0 0 0 0 0 R

90471 $45.52 $45.52 0 0% 0% 0% 5 0 0 0 0 0 R

90472 $22.15 $22.15 0 0% 0% 0% 5 0 0 0 0 0 R

90473 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90474 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90476 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

90477 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

90581 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

90585 $156.76 $156.76 0 0% 0% 0% 9 9 9 9 9 9 D Y

90586 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90625 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

90630 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

90632 $67.34 $67.34 0 0% 0% 0% 9 9 9 9 9 9 D Y

90633 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90634 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90636 $95.42 $95.42 0 0% 0% 0% 9 9 9 9 9 9 D Y

90644 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90644 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

NON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 12

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

90647 $29.81 $29.81 0 0% 0% 0% 9 9 9 9 9 9 D Y

90648 $26.97 $26.97 0 0% 0% 0% 9 9 9 9 9 9 D Y

90649 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90650 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90651 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90653 $11.07 $11.07 0 0% 0% 0% 9 9 9 9 9 9 D Y

90654 $17.24 $17.24 0 0% 0% 0% 9 9 9 9 9 9 D Y

90655 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90656 $12.68 $12.68 0 0% 0% 0% 9 9 9 9 9 9 D Y

90657 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90658 $14.90 $14.90 0 0% 0% 0% 9 9 9 9 9 9 D Y

90660 $23.71 $23.71 0 0% 0% 0% 9 9 9 9 9 9 D Y

90661 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

90662 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

90664 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y

90666 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y

90667 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y

90668 $0.00 $0.00 0 0% 0% 0% 9 9 9 9 9 9 F Y

90670 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

90672 $23.71 $23.71 0 0% 0% 0% 9 9 9 9 9 9 D Y

90673 $19.85 $19.85 0 0% 0% 0% 9 9 9 9 9 9 D Y

90675 $91.22 $91.22 0 0% 0% 0% 9 9 9 9 9 9 D Y

90676 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

90680 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90681 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90685 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90686 $16.36 $16.36 0 0% 0% 0% 9 9 9 9 9 9 D Y

90687 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90688 $15.28 $15.28 0 0% 0% 0% 9 9 9 9 9 9 D Y

90690 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90691 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90696 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90698 $82.81 $82.81 0 0% 0% 0% 9 9 9 9 9 9 D Y

90700 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90702 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90707 $3.63 $3.63 0 0% 0% 0% 9 9 9 9 9 9 D Y

90710 $178.71 $178.71 0 0% 0% 0% 9 9 9 9 9 9 D Y

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 13

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

90713 $30.26 $30.26 0 0% 0% 0% 9 9 9 9 9 9 D Y

90714 $41.83 $41.83 0 0% 0% 0% 9 9 9 9 9 9 D

90715 $47.14 $47.14 0 0% 0% 0% 9 9 9 9 9 9 D

90716 $107.92 $107.92 0 0% 0% 0% 9 9 9 9 9 9 D Y

90717 $127.86 $127.86 0 0% 0% 0% 9 9 9 9 9 9 D Y

90723 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90732 $78.17 $78.17 0 0% 0% 0% 9 9 9 9 9 9 D Y

90733 $132.21 $132.21 0 0% 0% 0% 9 9 9 9 9 9 D Y

90734 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90736 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90738 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90739 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90740 $111.78 $111.78 0 0% 0% 0% 9 9 9 9 9 9 D Y

90743 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90744 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90746 $55.89 $55.89 0 0% 0% 0% 9 9 9 9 9 9 D

90747 $111.78 $111.78 0 0% 0% 0% 9 9 9 9 9 9 D

90748 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90748 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

90749 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

90785 $23.99 $23.99 0 0% 0% 0% 0 0 0 9 0 0 R Y

90791 $227.01 $219.63 0 0% 0% 0% 0 0 0 9 0 0 R Y

90792 $251.00 $243.62 0 0% 0% 0% 0 0 0 9 0 0 R Y

90832 $110.12 $108.89 0 0% 0% 0% 0 0 0 9 0 0 R Y

90833 $113.81 $112.58 0 0% 0% 0% 0 0 0 9 0 0 R Y

90834 $146.42 $145.19 0 0% 0% 0% 0 0 0 9 0 0 R Y

90836 $143.96 $142.73 0 0% 0% 0% 0 0 0 9 0 0 R Y

90837 $219.01 $217.78 0 0% 0% 0% 0 0 0 9 0 0 R Y

90838 $190.10 $188.87 0 0% 0% 0% 0 0 0 9 0 0 R Y

90839 $229.47 $227.01 0 0% 0% 0% 0 0 0 0 0 0 R Y

90840 $109.51 $108.89 0 0% 0% 0% 0 0 0 0 0 0 R Y

90845 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90846 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90847 $183.94 $182.10 0 0% 0% 0% 0 0 0 0 0 0 R Y

90849 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90853 $44.29 $43.68 0 0% 0% 0% 0 0 0 0 0 0 R Y

90863 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 14

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

90865 $292.22 $223.32 0 0% 0% 0% 0 0 0 0 0 0 R Y

90867 By Report By Report 0 0% 0% 0% 0 0 0 1 0 0 N Y

90868 By Report By Report 0 0% 0% 0% 0 0 0 1 0 0 N Y

90869 By Report By Report 0 0% 0% 0% 0 0 0 1 0 0 N Y

90870 $313.14 $191.94 0 0% 0% 0% 0 0 0 0 0 0 R Y

90875 $106.43 $106.43 0 0% 0% 0% 9 9 9 9 9 9 R Y

90876 $188.87 $168.56 0 0% 0% 0% 9 9 9 9 9 9 R Y

90880 $175.95 $162.41 0 0% 0% 0% 0 0 0 0 0 0 R Y

90882 $75.18 $75.18 0 0% 0% 0% 9 9 9 9 9 9 F Y

90885 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

90887 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

90889 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

90899 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y

90901 $68.29 $34.45 0 0% 0% 0% 0 0 0 0 0 0 R

90911 $149.49 $76.90 0 0% 0% 0% 0 0 0 0 0 0 R

90935 $125.50 $125.50 0 0% 0% 0% 0 0 0 0 0 0 R

90937 $179.64 $179.64 0 0% 0% 0% 0 0 0 0 0 0 R

90940 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

90945 $149.49 $149.49 0 0% 0% 0% 0 0 0 0 0 0 R

90947 $214.70 $214.70 0 0% 0% 0% 0 0 0 0 0 0 R

90951 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90952 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90953 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90954 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90955 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90956 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90957 $1,117.82 $1,117.82 0 0% 0% 0% 0 0 0 0 0 0 R

90958 $756.08 $756.08 0 0% 0% 0% 0 0 0 0 0 0 R

90959 $514.31 $514.31 0 0% 0% 0% 0 0 0 0 0 0 R

90960 $493.39 $493.39 0 0% 0% 0% 0 0 0 0 0 0 R

90961 $415.26 $415.26 0 0% 0% 0% 0 0 0 0 0 0 R

90962 $321.13 $321.13 0 0% 0% 0% 0 0 0 0 0 0 R

90963 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90964 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

90965 $785.00 $785.00 0 0% 0% 0% 0 0 0 0 0 0 R

90966 $414.03 $414.03 0 0% 0% 0% 0 0 0 0 0 0 R

90967 $31.38 $31.38 0 0% 0% 0% 0 0 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 15

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

90968 $27.07 $27.07 0 0% 0% 0% 0 0 0 0 0 0 R

90969 $26.45 $26.45 0 0% 0% 0% 0 0 0 0 0 0 R

90970 $13.53 $13.53 0 0% 0% 0% 0 0 0 0 0 0 R

90989 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

90993 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

90997 $162.41 $162.41 0 0% 0% 0% 0 0 0 0 0 0 R

90999 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

91010 $316.21 $316.21 0 0% 0% 0% 1 0 0 0 0 0 R Y

91010-26 $117.50 $117.50 0 0% 0% 0% 1 0 0 0 0 0 R Y

91010-TC $198.71 $198.71 0 0% 0% 0% 1 0 0 0 0 0 R Y

91013 $41.83 $41.83 0 0% 0% 0% 1 0 0 0 0 0 R Y

91013-26 $16.61 $16.61 0 0% 0% 0% 1 0 0 0 0 0 R Y

91013-TC $25.22 $25.22 0 0% 0% 0% 1 0 0 0 0 0 R Y

91020 $422.03 $422.03 0 0% 0% 0% 1 0 0 0 0 0 R Y

91020-26 $132.27 $132.27 0 0% 0% 0% 1 0 0 0 0 0 R Y

91020-TC $289.76 $289.76 0 0% 0% 0% 1 0 0 0 0 0 R Y

91022 $300.83 $300.83 0 0% 0% 0% 1 0 0 0 0 0 R

91022-26 $132.88 $132.88 0 0% 0% 0% 1 0 0 0 0 0 R

91022-TC $167.95 $167.95 0 0% 0% 0% 1 0 0 0 0 0 R

91030 $245.46 $245.46 0 0% 0% 0% 1 0 0 0 0 0 R Y

91030-26 $83.05 $83.05 0 0% 0% 0% 1 0 0 0 0 0 R Y

91030-TC $162.41 $162.41 0 0% 0% 0% 1 0 0 0 0 0 R Y

91034 $342.05 $342.05 0 0% 0% 0% 1 0 0 0 0 0 R Y

91034-26 $89.82 $89.82 0 0% 0% 0% 1 0 0 0 0 0 R Y

91034-TC $252.85 $252.85 0 0% 0% 0% 1 0 0 0 0 0 R Y

91035 $872.97 $872.97 0 0% 0% 0% 1 0 0 0 0 0 R Y

91035-26 $146.42 $146.42 0 0% 0% 0% 1 0 0 0 0 0 R Y

91035-TC $726.55 $726.55 0 0% 0% 0% 1 0 0 0 0 0 R Y

91037 $289.14 $289.14 0 0% 0% 0% 1 0 0 0 0 0 R Y

91037-26 $89.20 $89.20 0 0% 0% 0% 1 0 0 0 0 0 R Y

91037-TC $199.94 $199.94 0 0% 0% 0% 1 0 0 0 0 0 R Y

91038 $820.06 $820.06 0 0% 0% 0% 1 0 0 0 0 0 R Y

91038-26 $101.51 $101.51 0 0% 0% 0% 1 0 0 0 0 0 R Y

91038-TC $718.55 $718.55 0 0% 0% 0% 1 0 0 0 0 0 R Y

91040 $792.38 $792.38 0 0% 0% 0% 1 0 0 0 0 0 R Y

91040-26 $88.59 $88.59 0 0% 0% 0% 1 0 0 0 0 0 R Y

91040-TC $703.79 $703.79 0 0% 0% 0% 1 0 0 0 0 0 R Y

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 16

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

91065 $142.11 $142.11 0 0% 0% 0% 1 0 0 0 0 0 R Y

91065-26 $17.84 $17.84 0 0% 0% 0% 1 0 0 0 0 0 R Y

91065-TC $124.27 $124.27 0 0% 0% 0% 1 0 0 0 0 0 R Y

91110 $1,603.21 $1,603.21 0 0% 0% 0% 1 0 0 0 0 0 R

91110-26 $335.28 $335.28 0 0% 0% 0% 1 0 0 0 0 0 R

91110-TC $1,268.54 $1,268.54 0 0% 0% 0% 1 0 0 0 0 0 R

91111 $1,324.53 $1,324.53 0 0% 0% 0% 1 0 0 0 0 0 R

91111-26 $92.28 $92.28 0 0% 0% 0% 1 0 0 0 0 0 R

91111-TC $1,232.25 $1,232.25 0 0% 0% 0% 1 0 0 0 0 0 R

91112 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

91117 $243.00 $243.00 0 0% 0% 0% 0 0 0 0 0 0 R

91120 $775.15 $775.15 0 0% 0% 0% 1 0 0 0 0 0 R

91120-26 $87.36 $87.36 0 0% 0% 0% 1 0 0 0 0 0 R

91120-TC $687.79 $687.79 0 0% 0% 0% 1 0 0 0 0 0 R

91122 $406.03 $406.03 0 0% 0% 0% 1 0 0 0 0 0 R

91122-26 $156.88 $156.88 0 0% 0% 0% 1 0 0 0 0 0 R

91122-TC $249.16 $249.16 0 0% 0% 0% 1 0 0 0 0 0 R

91132 $279.30 $279.30 0 0% 0% 0% 1 0 0 0 0 0 R

91132-26 $47.99 $47.99 0 0% 0% 0% 1 0 0 0 0 0 R

91132-TC $231.32 $231.32 0 0% 0% 0% 1 0 0 0 0 0 R

91133 $311.91 $311.91 0 0% 0% 0% 1 0 0 0 0 0 R

91133-26 $60.90 $60.90 0 0% 0% 0% 1 0 0 0 0 0 R

91133-TC $251.00 $251.00 0 0% 0% 0% 1 0 0 0 0 0 R

91200 $50.45 $50.45 0 0% 0% 0% 1 0 0 0 0 0 R Y

91200-26 $22.76 $22.76 0 0% 0% 0% 1 0 0 0 0 0 R Y

91200-TC $27.68 $27.68 0 0% 0% 0% 1 0 0 0 0 0 R Y

91299 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

91299-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

91299-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

92002 $143.96 $84.28 0 0% 0% 0% 0 0 2 0 0 0 R

92004 $262.69 $174.10 0 0% 0% 0% 0 0 2 0 0 0 R

92012 $151.95 $92.90 0 0% 0% 0% 0 0 2 0 0 0 R

92014 $219.63 $140.27 0 0% 0% 0% 0 0 2 0 0 0 R

92015 $34.45 $33.84 0 0% 0% 0% 9 9 9 9 9 9 R

92018 $256.54 $256.54 0 0% 0% 0% 0 0 0 0 0 0 R

92019 $126.12 $126.12 0 0% 0% 0% 0 0 0 0 0 0 R

92020 $47.37 $36.91 0 0% 0% 0% 0 0 2 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 17

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

92025 $67.67 $67.67 0 0% 0% 0% 1 7 2 0 0 0 R

92025-26 $35.68 $35.68 0 0% 0% 0% 1 7 2 0 0 0 R

92025-TC $31.99 $31.99 0 0% 0% 0% 1 7 2 0 0 0 R

92060 $116.27 $116.27 0 0% 0% 0% 1 7 2 0 0 0 R

92060-26 $67.67 $67.67 0 0% 0% 0% 1 7 2 0 0 0 R

92060-TC $48.60 $48.60 0 0% 0% 0% 1 7 2 0 0 0 R

92065 $92.90 $92.90 0 0% 0% 0% 1 0 2 0 0 0 R Y

92065-26 $30.76 $30.76 0 0% 0% 0% 1 0 2 0 0 0 R Y

92065-TC $62.14 $62.14 0 0% 0% 0% 1 0 2 0 0 0 R Y

92071 $66.44 $59.06 0 0% 0% 0% 0 0 1 0 0 0 R

92072 Not Covered Not Covered 0 0% 0% 0% 0 0 2 0 0 0 X

92081 $60.29 $60.29 0 0% 0% 0% 1 7 2 0 0 0 R

92081-26 $28.91 $28.91 0 0% 0% 0% 1 7 2 0 0 0 R

92081-TC $31.38 $31.38 0 0% 0% 0% 1 7 2 0 0 0 R

92082 $85.51 $85.51 0 0% 0% 0% 1 7 2 0 0 0 R

92082-26 $38.14 $38.14 0 0% 0% 0% 1 7 2 0 0 0 R

92082-TC $47.37 $47.37 0 0% 0% 0% 1 7 2 0 0 0 R

92083 $115.66 $115.66 0 0% 0% 0% 1 7 2 0 0 0 R

92083-26 $49.22 $49.22 0 0% 0% 0% 1 7 2 0 0 0 R

92083-TC $65.83 $65.83 0 0% 0% 0% 1 7 2 0 0 0 R

92100 $143.96 $59.67 0 0% 0% 0% 0 0 2 0 0 0 R

92132 $62.14 $62.14 0 0% 0% 0% 1 7 2 0 0 0 R

92132-26 $33.84 $33.84 0 0% 0% 0% 1 7 2 0 0 0 R

92132-TC $28.30 $28.30 0 0% 0% 0% 1 7 2 0 0 0 R

92133 $78.13 $78.13 0 0% 0% 0% 1 7 2 0 0 0 R

92133-26 $49.22 $49.22 0 0% 0% 0% 1 7 2 0 0 0 R

92133-TC $28.91 $28.91 0 0% 0% 0% 1 7 2 0 0 0 R

92134 $80.59 $80.59 0 0% 0% 0% 1 7 2 0 0 0 R

92134-26 $51.06 $51.06 0 0% 0% 0% 1 7 2 0 0 0 R

92134-TC $29.53 $29.53 0 0% 0% 0% 1 7 2 0 0 0 R

92136 $163.64 $163.64 0 0% 0% 0% 1 7 2 0 0 0 R

92136-26 $55.98 $55.98 0 0% 0% 0% 1 7 3 0 0 0 R

92136-TC $107.66 $107.66 0 0% 0% 0% 1 7 2 0 0 0 R

92140 $113.20 $46.76 0 0% 0% 0% 0 0 2 0 0 0 R Y

92145 $27.68 $27.68 0 0% 0% 0% 1 7 2 0 0 0 R Y

92145-26 $15.38 $15.38 0 0% 0% 0% 1 7 2 0 0 0 R Y

92145-TC $12.30 $12.30 0 0% 0% 0% 1 7 2 0 0 0 R Y

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 18

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

92225 $47.99 $37.53 0 0% 0% 0% 0 0 3 0 0 0 R

92226 $44.29 $33.84 0 0% 0% 0% 0 0 3 0 0 0 R

92227 $26.45 $26.45 0 0% 0% 0% 3 0 2 0 0 0 R

92228 $61.52 $61.52 0 0% 0% 0% 1 7 2 0 0 0 R

92228-26 $36.91 $36.91 0 0% 0% 0% 1 7 2 0 0 0 R

92228-TC $24.61 $24.61 0 0% 0% 0% 1 7 2 0 0 0 R

92230 $103.97 $59.06 0 0% 0% 0% 0 0 3 0 0 0 R

92235 $198.71 $198.71 0 0% 0% 0% 1 7 3 0 0 0 R

92235-26 $83.67 $83.67 0 0% 0% 0% 1 7 3 0 0 0 R

92235-TC $115.04 $115.04 0 0% 0% 0% 1 7 3 0 0 0 R

92240 $464.48 $464.48 0 0% 0% 0% 1 7 3 0 0 0 R Y

92240-26 $113.81 $113.81 0 0% 0% 0% 1 7 3 0 0 0 R Y

92240-TC $350.66 $350.66 0 0% 0% 0% 1 7 3 0 0 0 R Y

92250 $140.88 $140.88 0 0% 0% 0% 1 7 2 0 0 0 R

92250-26 $41.83 $41.83 0 0% 0% 0% 1 7 2 0 0 0 R

92250-TC $99.05 $99.05 0 0% 0% 0% 1 7 2 0 0 0 R

92260 $32.61 $19.07 0 0% 0% 0% 0 0 2 0 0 0 R

92265 $139.65 $139.65 0 0% 0% 0% 1 7 2 0 0 0 R

92265-26 $75.05 $75.05 0 0% 0% 0% 1 7 2 0 0 0 R

92265-TC $64.60 $64.60 0 0% 0% 0% 1 7 2 0 0 0 R

92270 $163.64 $163.64 0 0% 0% 0% 1 7 2 0 0 0 R

92270-26 $72.59 $72.59 0 0% 0% 0% 1 7 2 0 0 0 R

92270-TC $91.05 $91.05 0 0% 0% 0% 1 7 2 0 0 0 R

92275 $265.15 $265.15 0 0% 0% 0% 1 7 2 0 0 0 R

92275-26 $95.36 $95.36 0 0% 0% 0% 1 7 2 0 0 0 R

92275-TC $169.80 $169.80 0 0% 0% 0% 1 7 2 0 0 0 R

92283 $99.66 $99.66 0 0% 0% 0% 1 7 2 0 0 0 R Y

92283-26 $16.00 $16.00 0 0% 0% 0% 1 7 2 0 0 0 R Y

92283-TC $83.67 $83.67 0 0% 0% 0% 1 7 2 0 0 0 R Y

92284 $108.89 $108.89 0 0% 0% 0% 1 7 2 0 0 0 R Y

92284-26 $21.53 $21.53 0 0% 0% 0% 1 7 2 0 0 0 R Y

92284-TC $87.36 $87.36 0 0% 0% 0% 1 7 2 0 0 0 R Y

92285 $36.91 $36.91 0 0% 0% 0% 1 7 2 0 0 0 R

92285-26 $5.54 $5.54 0 0% 0% 0% 1 7 2 0 0 0 R

92285-TC $31.38 $31.38 0 0% 0% 0% 1 7 2 0 0 0 R

92286 $67.67 $67.67 0 0% 0% 0% 1 7 2 0 0 0 R

92286-26 $38.76 $38.76 0 0% 0% 0% 1 7 2 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 19

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

92286-TC $28.91 $28.91 0 0% 0% 0% 1 7 2 0 0 0 R

92287 $250.39 $250.39 0 0% 0% 0% 1 0 2 0 0 0 R Y

92310 $170.41 $103.97 0 0% 0% 0% 9 9 9 9 9 9 R

92311 $178.41 $96.59 0 0% 0% 0% 0 0 0 0 0 0 R

92312 $204.86 $110.74 0 0% 0% 0% 0 0 2 0 0 0 R

92313 $171.03 $82.44 0 0% 0% 0% 0 0 0 0 0 0 R

92314 $142.73 $60.90 0 0% 0% 0% 9 9 9 9 9 9 R

92315 $127.96 $37.53 0 0% 0% 0% 0 0 0 0 0 0 R

92316 $160.57 $57.21 0 0% 0% 0% 0 0 2 0 0 0 R

92317 $135.34 $38.14 0 0% 0% 0% 0 0 0 0 0 0 R

92325 $75.67 $75.67 0 0% 0% 0% 5 0 0 0 0 0 R

92326 $63.98 $63.98 0 0% 0% 0% 5 0 0 0 0 0 R Y

92340 $63.37 $32.61 0 0% 0% 0% 9 9 9 9 9 9 R

92341 $72.59 $41.83 0 0% 0% 0% 9 9 9 9 9 9 R

92342 $77.52 $46.76 0 0% 0% 0% 9 9 9 9 9 9 R

92352 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92353 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92354 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92355 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92358 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92370 $54.75 $28.30 0 0% 0% 0% 9 9 9 9 9 9 R

92371 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92499 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

92499-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

92499-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

92502 $171.64 $171.64 0 0% 0% 0% 0 0 0 0 0 0 R

92504 $54.14 $16.61 0 0% 0% 0% 0 0 0 0 0 0 R

92507 $139.04 $139.04 0 0% 0% 0% 0 5 0 0 0 0 R

92508 $41.22 $41.22 0 0% 0% 0% 0 5 0 0 0 0 R

92511 $203.63 $69.52 0 0% 0% 0% 0 0 0 0 0 0 R

92512 $109.51 $50.45 0 0% 0% 0% 0 0 0 0 0 0 R

92516 $127.96 $40.60 0 0% 0% 0% 0 0 0 0 0 0 R

92520 $134.73 $73.21 0 0% 0% 0% 0 0 0 0 0 0 R

92521 $195.63 $195.63 0 0% 0% 0% 0 5 0 0 0 0 R

92522 $162.41 $162.41 0 0% 0% 0% 0 5 0 0 0 0 R

92523 $342.05 $342.05 0 0% 0% 0% 0 5 0 0 0 0 R

92524 $156.88 $156.88 0 0% 0% 0% 0 5 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 20

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

92526 $151.34 $151.34 0 0% 0% 0% 0 5 0 0 0 0 R

92531 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92532 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92533 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92534 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92537 $71.36 $71.36 0 0% 0% 0% 1 0 1 0 0 0 R

92538 $36.30 $36.30 0 0% 0% 0% 1 0 0 0 0 0 R

92540 $180.25 $180.25 0 0% 0% 0% 1 0 0 0 0 0 R

92540-26 $140.27 $140.27 0 0% 0% 0% 1 0 0 0 0 0 R

92540-TC $39.99 $39.99 0 0% 0% 0% 1 0 0 0 0 0 R

92541 $42.45 $42.45 0 0% 0% 0% 1 0 0 0 0 0 R

92541-26 $36.91 $36.91 0 0% 0% 0% 1 0 0 0 0 0 R

92541-TC $5.54 $5.54 0 0% 0% 0% 1 0 0 0 0 0 R

92542 $48.60 $48.60 0 0% 0% 0% 1 0 0 0 0 0 R

92542-26 $44.29 $44.29 0 0% 0% 0% 1 0 0 0 0 0 R

92542-TC $4.92 $4.92 0 0% 0% 0% 1 0 0 0 0 0 R

92544 $28.91 $28.91 0 0% 0% 0% 1 0 0 0 0 0 R

92544-26 $24.61 $24.61 0 0% 0% 0% 1 0 0 0 0 0 R

92544-TC $4.31 $4.31 0 0% 0% 0% 1 0 0 0 0 0 R

92545 $26.45 $26.45 0 0% 0% 0% 1 0 0 0 0 0 R

92545-26 $22.76 $22.76 0 0% 0% 0% 1 0 0 0 0 0 R

92545-TC $3.69 $3.69 0 0% 0% 0% 1 0 0 0 0 0 R

92546 $186.41 $186.41 0 0% 0% 0% 1 0 0 0 0 0 R

92546-26 $25.84 $25.84 0 0% 0% 0% 1 0 0 0 0 0 R

92546-TC $160.57 $160.57 0 0% 0% 0% 1 0 0 0 0 0 R

92547 $11.07 $11.07 0 0% 0% 0% 3 0 0 0 0 0 R

92548 $184.56 $184.56 0 0% 0% 0% 1 0 0 0 0 0 R

92548-26 $46.14 $46.14 0 0% 0% 0% 1 0 0 0 0 0 R

92548-TC $139.04 $139.04 0 0% 0% 0% 1 0 0 0 0 0 R

92550 $37.53 $37.53 0 0% 0% 0% 0 0 2 0 0 0 R

92551 $21.53 $21.53 0 0% 0% 0% 9 9 9 9 9 9 F

92552 $56.60 $56.60 0 0% 0% 0% 3 0 2 0 0 0 R

92553 $67.67 $67.67 0 0% 0% 0% 3 0 2 0 0 0 R

92555 $41.83 $41.83 0 0% 0% 0% 3 0 2 0 0 0 R

92556 $67.67 $67.67 0 0% 0% 0% 3 0 2 0 0 0 R

92557 $65.83 $57.21 0 0% 0% 0% 0 0 2 0 0 0 R

92558 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 21

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

92559 $126.54 $126.54 0 0% 0% 0% 9 9 9 9 9 9 F

92560 $50.59 $50.59 0 0% 0% 0% 9 9 9 9 9 9 F

92561 $68.90 $68.90 0 0% 0% 0% 3 0 2 0 0 0 R

92562 $84.90 $84.90 0 0% 0% 0% 3 0 2 0 0 0 R

92563 $55.98 $55.98 0 0% 0% 0% 3 0 2 0 0 0 R

92564 $51.06 $51.06 0 0% 0% 0% 3 0 2 0 0 0 R

92565 $28.91 $28.91 0 0% 0% 0% 3 0 2 0 0 0 R

92567 $25.84 $19.07 0 0% 0% 0% 0 0 2 0 0 0 R

92568 $27.68 $27.07 0 0% 0% 0% 0 0 2 0 0 0 R

92570 $56.60 $52.29 0 0% 0% 0% 0 0 2 0 0 0 R

92571 $49.22 $49.22 0 0% 0% 0% 3 0 2 0 0 0 R

92572 $65.21 $65.21 0 0% 0% 0% 3 0 2 0 0 0 R

92575 $131.65 $131.65 0 0% 0% 0% 3 0 2 0 0 0 R

92576 $65.21 $65.21 0 0% 0% 0% 3 0 2 0 0 0 R

92577 $30.14 $30.14 0 0% 0% 0% 3 0 2 0 0 0 R

92579 $73.21 $65.83 0 0% 0% 0% 0 0 2 0 0 0 R

92582 Not Covered Not Covered 0 0% 0% 0% 3 0 2 0 0 0 X

92583 $95.36 $95.36 0 0% 0% 0% 3 0 2 0 0 0 R

92584 $134.11 $134.11 0 0% 0% 0% 3 0 2 0 0 0 R

92585 $245.46 $245.46 0 0% 0% 0% 1 0 2 0 0 0 R

92585-26 $47.37 $47.37 0 0% 0% 0% 1 0 2 0 0 0 R

92585-TC $198.09 $198.09 0 0% 0% 0% 1 0 2 0 0 0 R

92586 $155.65 $155.65 0 0% 0% 0% 3 0 2 0 0 0 R

92587 $38.14 $38.14 0 0% 0% 0% 1 0 2 0 0 0 R

92587-26 $32.61 $32.61 0 0% 0% 0% 1 0 2 0 0 0 R

92587-TC $5.54 $5.54 0 0% 0% 0% 1 0 2 0 0 0 R

92588 $57.83 $57.83 0 0% 0% 0% 1 0 2 0 0 0 R

92588-26 $51.06 $51.06 0 0% 0% 0% 1 0 2 0 0 0 R

92588-TC $6.77 $6.77 0 0% 0% 0% 1 0 2 0 0 0 R

92590 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

92591 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

92592 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

92593 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

92594 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

92595 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

92596 $76.90 $76.90 0 0% 0% 0% 3 0 2 0 0 0 R

92597 $126.12 $126.12 0 0% 0% 0% 0 5 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 22

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

92601 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

92602 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

92603 $268.23 $215.32 0 0% 0% 0% 0 0 0 0 0 0 R Y

92604 $158.11 $119.35 0 0% 0% 0% 0 0 0 0 0 0 R Y

92605 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y

92606 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y

92607 $223.32 $223.32 0 0% 0% 0% 0 5 0 0 0 0 R Y

92608 $93.51 $93.51 0 0% 0% 0% 0 0 0 0 0 0 R Y

92609 $196.86 $196.86 0 0% 0% 0% 0 5 0 0 0 0 R Y

92610 $150.72 $127.96 0 0% 0% 0% 0 0 0 0 0 0 R Y

92611 $152.57 $152.57 0 0% 0% 0% 0 0 0 0 0 0 R Y

92612 $335.90 $119.35 0 0% 0% 0% 0 0 0 0 0 0 R Y

92613 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y

92614 $262.08 $118.73 0 0% 0% 0% 0 0 0 0 0 0 R Y

92615 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y

92616 $374.04 $177.18 0 0% 0% 0% 0 0 0 0 0 0 R Y

92617 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y

92618 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

92620 $166.10 $145.80 0 0% 0% 0% 9 0 2 0 0 0 R Y

92621 $39.37 $33.84 0 0% 0% 0% 9 0 0 0 0 0 R Y

92625 $123.66 $110.12 0 0% 0% 0% 9 0 2 0 0 0 R Y

92626 $158.72 $134.73 0 0% 0% 0% 9 0 2 0 0 0 R

92627 $38.76 $31.99 0 0% 0% 0% 9 0 0 0 0 0 R

92630 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

92633 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

92640 Not Covered Not Covered 0 0% 0% 0% 9 0 2 0 0 0 X

92700 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

92920 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X

92921 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

92924 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X

92925 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

92928 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X

92929 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

92933 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X

92934 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

92937 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X

92938 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 23

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

92941 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X

92943 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X

92944 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

92950 $534.61 $321.75 0 0% 0% 0% 0 0 0 0 0 0 R

92953 $19.69 $19.69 0 0% 0% 0% 0 0 0 0 0 0 R Y

92960 $365.43 $213.47 0 0% 0% 0% 0 0 0 0 0 0 R Y

92961 $442.33 $442.33 0 0% 0% 0% 0 9 9 9 9 9 R Y

92970 $319.90 $319.90 0 0% 0% 0% 0 0 0 0 0 0 R Y

92971 $169.80 $169.80 0 0% 0% 0% 0 0 0 0 0 0 R Y

92973 $298.37 $298.37 0 0% 0% 0% 0 0 0 0 0 0 R Y

92974 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

92975 $657.03 $657.03 0 0% 0% 0% 0 2 0 0 0 0 R Y

92977 $108.89 $108.89 0 0% 0% 0% 5 0 0 0 0 0 R Y

92978 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

92978-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

92978-26 $161.80 $161.80 0 0% 0% 0% 1 0 0 0 0 0 R Y

92979 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

92979-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

92979-26 $129.81 $129.81 0 0% 0% 0% 1 0 0 0 0 0 R Y

92986 $2,260.24 $2,260.24 90 9% 84% 7% 0 2 0 0 0 0 R Y

92987 $2,332.84 $2,332.84 90 9% 84% 7% 0 2 0 0 0 0 R Y

92990 $1,841.29 $1,841.29 90 9% 84% 7% 0 2 0 0 0 0 R Y

92992 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X

92993 Not Covered Not Covered 90 9% 84% 7% 0 2 0 2 0 0 X

92997 $1,101.82 $1,101.82 0 0% 0% 0% 0 2 0 0 0 0 R Y

92998 $543.84 $543.84 0 0% 0% 0% 0 0 0 0 0 0 R Y

93000 $30.14 $30.14 0 0% 0% 0% 4 6 0 0 0 0 R

93005 $15.38 $15.38 0 0% 0% 0% 3 6 0 0 0 0 R

93010 $14.76 $14.76 0 0% 0% 0% 2 0 0 0 0 0 R

93015 $134.73 $134.73 0 0% 0% 0% 4 6 0 0 0 0 R

93016 $38.14 $38.14 0 0% 0% 0% 2 0 0 0 0 0 R

93017 $71.36 $71.36 0 0% 0% 0% 3 6 0 0 0 0 R

93018 $25.22 $25.22 0 0% 0% 0% 2 0 0 0 0 0 R

93024 $199.32 $199.32 0 0% 0% 0% 1 6 0 0 0 0 R Y

93024-26 $99.66 $99.66 0 0% 0% 0% 1 6 0 0 0 0 R Y

93024-TC $99.66 $99.66 0 0% 0% 0% 1 6 0 0 0 0 R Y

93025 $288.53 $288.53 0 0% 0% 0% 1 6 0 0 0 0 R Y

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 24

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93025-26 $64.60 $64.60 0 0% 0% 0% 1 6 0 0 0 0 R Y

93025-TC $223.93 $223.93 0 0% 0% 0% 1 6 0 0 0 0 R Y

93040 $22.15 $22.15 0 0% 0% 0% 4 6 0 0 0 0 R

93041 $9.84 $9.84 0 0% 0% 0% 3 6 0 0 0 0 R

93042 $12.30 $12.30 0 0% 0% 0% 2 0 0 0 0 0 R

93050 $31.38 $31.38 0 0% 0% 0% 1 6 2 0 0 0 R

93224 $164.26 $164.26 0 0% 0% 0% 4 6 0 0 0 0 R

93225 $48.60 $48.60 0 0% 0% 0% 3 6 0 0 0 0 R

93226 $69.52 $69.52 0 0% 0% 0% 3 6 0 0 0 0 R

93227 $46.76 $46.76 0 0% 0% 0% 2 0 0 0 0 0 R

93228 $45.52 $45.52 0 0% 0% 0% 2 0 0 0 0 0 R

93229 $1,327.60 $1,327.60 0 0% 0% 0% 3 6 0 0 0 0 R

93260 $118.73 $118.73 0 0% 0% 0% 1 6 0 0 0 0 R Y

93260-26 $78.75 $78.75 0 0% 0% 0% 1 6 0 0 0 0 R Y

93260-TC $39.99 $39.99 0 0% 0% 0% 1 6 0 0 0 0 R Y

93261 $107.66 $107.66 0 0% 0% 0% 1 6 0 0 0 0 R Y

93261-26 $67.67 $67.67 0 0% 0% 0% 1 6 0 0 0 0 R Y

93261-TC $39.99 $39.99 0 0% 0% 0% 1 6 0 0 0 0 R Y

93268 $372.20 $372.20 0 0% 0% 0% 4 6 0 0 0 0 R

93270 $16.61 $16.61 0 0% 0% 0% 3 6 0 0 0 0 R

93271 $311.29 $311.29 0 0% 0% 0% 3 6 0 0 0 0 R

93272 $44.29 $44.29 0 0% 0% 0% 2 0 0 0 0 0 R

93278 $53.52 $53.52 0 0% 0% 0% 1 6 0 0 0 0 R

93278-26 $21.53 $21.53 0 0% 0% 0% 1 6 0 0 0 0 R

93278-TC $31.99 $31.99 0 0% 0% 0% 1 6 0 0 0 0 R

93279 $87.97 $87.97 0 0% 0% 0% 1 6 0 0 0 0 R Y

93279-26 $56.60 $56.60 0 0% 0% 0% 1 6 0 0 0 0 R Y

93279-TC $31.38 $31.38 0 0% 0% 0% 1 6 0 0 0 0 R Y

93280 $102.12 $102.12 0 0% 0% 0% 1 6 0 0 0 0 R Y

93280-26 $67.06 $67.06 0 0% 0% 0% 1 6 0 0 0 0 R Y

93280-TC $35.68 $35.68 0 0% 0% 0% 1 6 0 0 0 0 R Y

93281 $120.58 $120.58 0 0% 0% 0% 1 6 0 0 0 0 R Y

93281-26 $78.75 $78.75 0 0% 0% 0% 1 6 0 0 0 0 R Y

93281-TC $41.83 $41.83 0 0% 0% 0% 1 6 0 0 0 0 R Y

93282 $111.35 $111.35 0 0% 0% 0% 1 6 0 0 0 0 R Y

93282-26 $74.44 $74.44 0 0% 0% 0% 1 6 0 0 0 0 R Y

93282-TC $36.91 $36.91 0 0% 0% 0% 1 6 0 0 0 0 R Y

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 25

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93283 $144.57 $144.57 0 0% 0% 0% 1 6 0 0 0 0 R Y

93283-26 $100.89 $100.89 0 0% 0% 0% 1 6 0 0 0 0 R Y

93283-TC $43.06 $43.06 0 0% 0% 0% 1 6 0 0 0 0 R Y

93284 $159.34 $159.34 0 0% 0% 0% 1 6 0 0 0 0 R Y

93284-26 $110.12 $110.12 0 0% 0% 0% 1 6 0 0 0 0 R Y

93284-TC $49.22 $49.22 0 0% 0% 0% 1 6 0 0 0 0 R Y

93285 $75.05 $75.05 0 0% 0% 0% 1 6 0 0 0 0 R Y

93285-26 $46.14 $46.14 0 0% 0% 0% 1 6 0 0 0 0 R Y

93285-TC $28.91 $28.91 0 0% 0% 0% 1 6 0 0 0 0 R Y

93286 $48.60 $48.60 0 0% 0% 0% 1 6 0 0 0 0 R Y

93286-26 $26.45 $26.45 0 0% 0% 0% 1 6 0 0 0 0 R Y

93286-TC $21.53 $21.53 0 0% 0% 0% 1 6 0 0 0 0 R Y

93287 $63.98 $63.98 0 0% 0% 0% 1 6 0 0 0 0 R Y

93287-26 $39.99 $39.99 0 0% 0% 0% 1 6 0 0 0 0 R Y

93287-TC $23.99 $23.99 0 0% 0% 0% 1 6 0 0 0 0 R Y

93288 $65.21 $65.21 0 0% 0% 0% 1 6 0 0 0 0 R Y

93288-26 $36.91 $36.91 0 0% 0% 0% 1 6 0 0 0 0 R Y

93288-TC $28.30 $28.30 0 0% 0% 0% 1 6 0 0 0 0 R Y

93289 $115.66 $115.66 0 0% 0% 0% 1 6 0 0 0 0 R Y

93289-26 $79.98 $79.98 0 0% 0% 0% 1 6 0 0 0 0 R Y

93289-TC $35.68 $35.68 0 0% 0% 0% 1 6 0 0 0 0 R Y

93290 $54.75 $54.75 0 0% 0% 0% 1 6 0 0 0 0 R Y

93290-26 $37.53 $37.53 0 0% 0% 0% 1 6 0 0 0 0 R Y

93290-TC $17.23 $17.23 0 0% 0% 0% 1 6 0 0 0 0 R Y

93291 $63.98 $63.98 0 0% 0% 0% 1 6 0 0 0 0 R Y

93291-26 $37.53 $37.53 0 0% 0% 0% 1 6 0 0 0 0 R Y

93291-TC $26.45 $26.45 0 0% 0% 0% 1 6 0 0 0 0 R Y

93292 $56.60 $56.60 0 0% 0% 0% 1 6 0 0 0 0 R Y

93292-26 $36.91 $36.91 0 0% 0% 0% 1 6 0 0 0 0 R Y

93292-TC $19.69 $19.69 0 0% 0% 0% 1 6 0 0 0 0 R Y

93293 $95.97 $95.97 0 0% 0% 0% 1 0 0 0 0 0 R Y

93293-26 $27.07 $27.07 0 0% 0% 0% 1 0 0 0 0 0 R Y

93293-TC $68.29 $68.29 0 0% 0% 0% 1 0 0 0 0 0 R Y

93294 $59.06 $59.06 0 0% 0% 0% 2 0 0 0 0 0 R Y

93295 $116.27 $116.27 0 0% 0% 0% 2 0 0 0 0 0 R Y

93296 $47.37 $47.37 0 0% 0% 0% 3 0 0 0 0 0 R Y

93297 $46.14 $46.14 0 0% 0% 0% 2 0 0 0 0 0 R Y

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 26

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93298 $46.14 $46.14 0 0% 0% 0% 2 0 0 0 0 0 R Y

93299 $0.00 $0.00 0 0% 0% 0% 3 0 0 0 0 0 R Y

93303 $430.64 $430.64 0 0% 0% 0% 1 6 0 0 0 0 R Y

93303-26 $111.97 $111.97 0 0% 0% 0% 1 6 0 0 0 0 R Y

93303-TC $318.67 $318.67 0 0% 0% 0% 1 6 0 0 0 0 R Y

93304 $281.76 $281.76 0 0% 0% 0% 1 6 0 0 0 0 R Y

93304-26 $64.60 $64.60 0 0% 0% 0% 1 6 0 0 0 0 R Y

93304-TC $217.78 $217.78 0 0% 0% 0% 1 6 0 0 0 0 R Y

93306 $410.95 $410.95 0 0% 0% 0% 1 6 0 0 0 0 R

93306-26 $111.35 $111.35 0 0% 0% 0% 1 6 0 0 0 0 R

93306-TC $299.60 $299.60 0 0% 0% 0% 1 6 0 0 0 0 R

93307 $234.39 $234.39 0 0% 0% 0% 1 6 0 0 0 0 R

93307-26 $79.36 $79.36 0 0% 0% 0% 1 6 0 0 0 0 R

93307-TC $155.03 $155.03 0 0% 0% 0% 1 6 0 0 0 0 R

93308 $225.78 $225.78 0 0% 0% 0% 1 6 0 0 0 0 R

93308-26 $44.91 $44.91 0 0% 0% 0% 1 6 0 0 0 0 R

93308-TC $180.25 $180.25 0 0% 0% 0% 1 6 0 0 0 0 R

93312 $551.22 $551.22 0 0% 0% 0% 1 6 0 0 0 0 R

93312-26 $212.86 $212.86 0 0% 0% 0% 1 6 0 0 0 0 R

93312-TC $338.36 $338.36 0 0% 0% 0% 1 6 0 0 0 0 R

93313 $39.37 $39.37 0 0% 0% 0% 0 0 0 0 0 0 R

93314 $537.07 $537.07 0 0% 0% 0% 1 6 0 0 0 0 R

93314-26 $179.02 $179.02 0 0% 0% 0% 1 6 0 0 0 0 R

93314-TC $358.05 $358.05 0 0% 0% 0% 1 6 0 0 0 0 R

93315 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93315-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93315-26 $248.54 $248.54 0 0% 0% 0% 1 0 0 0 0 0 R

93316 $66.44 $66.44 0 0% 0% 0% 0 0 0 0 0 0 R

93317 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93317-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93317-26 $182.10 $182.10 0 0% 0% 0% 1 0 0 0 0 0 R

93318 By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N

93318-TC By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N

93318-26 $202.40 $202.40 0 0% 0% 0% 1 6 0 0 0 0 R

93320 $97.82 $97.82 0 0% 0% 0% 1 0 0 0 0 0 R

93320-26 $32.61 $32.61 0 0% 0% 0% 1 0 0 0 0 0 R

93320-TC $65.83 $65.83 0 0% 0% 0% 1 0 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 27

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93321 $49.22 $49.22 0 0% 0% 0% 1 0 0 0 0 0 R

93321-26 $12.92 $12.92 0 0% 0% 0% 1 0 0 0 0 0 R

93321-TC $36.30 $36.30 0 0% 0% 0% 1 0 0 0 0 0 R

93325 $46.76 $46.76 0 0% 0% 0% 1 0 0 0 0 0 R

93325-26 $5.54 $5.54 0 0% 0% 0% 1 0 0 0 0 0 R

93325-TC $41.22 $41.22 0 0% 0% 0% 1 0 0 0 0 0 R

93350 $433.72 $433.72 0 0% 0% 0% 1 6 0 0 0 0 R

93350-26 $124.27 $124.27 0 0% 0% 0% 1 6 0 0 0 0 R

93350-TC $309.45 $309.45 0 0% 0% 0% 1 6 0 0 0 0 R

93351 $487.85 $487.85 0 0% 0% 0% 1 6 0 9 9 9 R

93351-26 $149.49 $149.49 0 0% 0% 0% 1 6 0 9 9 9 R

93351-TC $338.36 $338.36 0 0% 0% 0% 1 6 0 9 9 9 R

93352 $60.90 $60.90 0 0% 0% 0% 0 0 0 0 0 0 R

93355 $393.11 $393.11 0 0% 0% 0% 0 2 0 0 0 0 R

93451 $1,412.50 $1,412.50 0 0% 0% 0% 1 2 0 0 0 0 R Y

93451-26 $243.62 $243.62 0 0% 0% 0% 1 2 0 0 0 0 R Y

93451-TC $1,168.88 $1,168.88 0 0% 0% 0% 1 0 0 0 0 0 R Y

93452 $1,579.22 $1,579.22 0 0% 0% 0% 1 2 0 0 0 0 R Y

93452-26 $428.18 $428.18 0 0% 0% 0% 1 2 0 0 0 0 R Y

93452-TC $1,151.04 $1,151.04 0 0% 0% 0% 1 0 0 0 0 0 R Y

93453 $2,029.54 $2,029.54 0 0% 0% 0% 1 2 0 0 0 0 R Y

93453-26 $562.91 $562.91 0 0% 0% 0% 1 2 0 0 0 0 R Y

93453-TC $1,466.64 $1,466.64 0 0% 0% 0% 1 0 0 0 0 0 R Y

93454 $1,598.29 $1,598.29 0 0% 0% 0% 1 2 0 0 0 0 R Y

93454-26 $431.87 $431.87 0 0% 0% 0% 1 2 0 0 0 0 R Y

93454-TC $1,166.42 $1,166.42 0 0% 0% 0% 1 0 0 0 0 0 R Y

93455 $1,862.21 $1,862.21 0 0% 0% 0% 1 2 0 0 0 0 R Y

93455-26 $499.54 $499.54 0 0% 0% 0% 1 2 0 0 0 0 R Y

93455-TC $1,363.28 $1,363.28 0 0% 0% 0% 1 0 0 0 0 0 R Y

93456 $2,001.86 $2,001.86 0 0% 0% 0% 1 2 0 0 0 0 R Y

93456-26 $554.30 $554.30 0 0% 0% 0% 1 2 0 0 0 0 R Y

93456-TC $1,447.57 $1,447.57 0 0% 0% 0% 1 0 0 0 0 0 R Y

93457 $2,264.55 $2,264.55 0 0% 0% 0% 1 2 0 0 0 0 R Y

93457-26 $621.35 $621.35 0 0% 0% 0% 1 2 0 0 0 0 R Y

93457-TC $1,643.20 $1,643.20 0 0% 0% 0% 1 0 0 0 0 0 R Y

93458 $1,917.58 $1,917.58 0 0% 0% 0% 1 2 0 0 0 0 R Y

93458-26 $527.84 $527.84 0 0% 0% 0% 1 2 0 0 0 0 R Y

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 28

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93458-TC $1,389.74 $1,389.74 0 0% 0% 0% 1 0 0 0 0 0 R Y

93459 $2,117.52 $2,117.52 0 0% 0% 0% 1 2 0 0 0 0 R Y

93459-26 $594.90 $594.90 0 0% 0% 0% 1 2 0 0 0 0 R Y

93459-TC $1,522.62 $1,522.62 0 0% 0% 0% 1 0 0 0 0 0 R Y

93460 $2,268.24 $2,268.24 0 0% 0% 0% 1 2 0 0 0 0 R Y

93460-26 $661.96 $661.96 0 0% 0% 0% 1 2 0 0 0 0 R Y

93460-TC $1,606.29 $1,606.29 0 0% 0% 0% 1 0 0 0 0 0 R Y

93461 $2,596.76 $2,596.76 0 0% 0% 0% 1 2 0 0 0 0 R Y

93461-26 $729.63 $729.63 0 0% 0% 0% 1 2 0 0 0 0 R Y

93461-TC $1,867.13 $1,867.13 0 0% 0% 0% 1 0 0 0 0 0 R Y

93462 $352.51 $352.51 0 0% 0% 0% 0 0 0 0 0 0 R Y

93463 $172.26 $172.26 0 0% 0% 0% 0 0 0 0 0 0 R Y

93464 $494.62 $494.62 0 0% 0% 0% 1 0 0 0 0 0 R Y

93464-26 $153.18 $153.18 0 0% 0% 0% 1 0 0 0 0 0 R Y

93464-TC $341.44 $341.44 0 0% 0% 0% 1 0 0 0 0 0 R Y

93503 $227.01 $227.01 0 0% 0% 0% 0 0 0 0 0 0 R

93505 $1,360.21 $1,360.21 0 0% 0% 0% 1 2 0 0 0 0 R

93505-26 $393.73 $393.73 0 0% 0% 0% 1 2 0 0 0 0 R

93505-TC $966.48 $966.48 0 0% 0% 0% 1 0 0 0 0 0 R

93530 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X

93530-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X

93530-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

93531 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X

93531-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X

93531-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

93532 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X

93532-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X

93532-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

93533 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X

93533-26 Not Covered Not Covered 0 0% 0% 0% 1 2 0 0 0 0 X

93533-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

93561 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93561-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93561-26 $44.29 $44.29 0 0% 0% 0% 1 0 0 0 0 0 R

93562 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93562-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93562-26 $14.15 $14.15 0 0% 0% 0% 1 0 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 29

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93563 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

93564 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

93565 $78.13 $78.13 0 0% 0% 0% 0 0 0 0 0 0 R

93566 $305.14 $77.52 0 0% 0% 0% 0 0 0 0 0 0 R

93567 $249.16 $87.97 0 0% 0% 0% 0 0 0 0 0 0 R

93568 $273.76 $79.98 0 0% 0% 0% 0 0 0 0 0 0 R

93571 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93571-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93571-26 $161.80 $161.80 0 0% 0% 0% 1 0 0 0 0 0 R

93572 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93572-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93572-26 $129.81 $129.81 0 0% 0% 0% 1 0 0 0 0 0 R

93580 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X

93581 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X

93582 Not Covered Not Covered 0 0% 0% 0% 0 2 0 0 0 0 X

93583 $1,274.08 $1,274.08 0 0% 0% 0% 0 2 0 0 0 0 R Y

93600 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93600-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93600-26 $200.56 $200.56 0 0% 0% 0% 1 0 0 0 0 0 R Y

93602 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93602-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93602-26 $196.86 $196.86 0 0% 0% 0% 1 0 0 0 0 0 R Y

93603 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93603-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93603-26 $196.86 $196.86 0 0% 0% 0% 1 0 0 0 0 0 R Y

93609 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93609-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93609-26 $470.01 $470.01 0 0% 0% 0% 1 0 0 0 0 0 R Y

93610 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93610-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93610-26 $278.69 $278.69 0 0% 0% 0% 1 0 0 0 0 0 R Y

93612 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93612-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93612-26 $276.84 $276.84 0 0% 0% 0% 1 0 0 0 0 0 R Y

93613 $671.80 $671.80 0 0% 0% 0% 0 0 0 0 0 0 R Y

93615 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93615-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 30

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93615-26 $92.28 $92.28 0 0% 0% 0% 1 0 0 0 0 0 R Y

93616 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93616-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93616-26 $113.81 $113.81 0 0% 0% 0% 1 0 0 0 0 0 R Y

93618 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93618-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93618-26 $401.11 $401.11 0 0% 0% 0% 1 0 0 0 0 0 R Y

93619 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y

93619-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93619-26 $684.10 $684.10 0 0% 0% 0% 1 2 0 0 0 0 R Y

93620 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y

93620-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93620-26 $1,086.44 $1,086.44 0 0% 0% 0% 1 2 0 0 0 0 R Y

93621 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93621-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93621-26 $198.09 $198.09 0 0% 0% 0% 1 0 0 0 0 0 R Y

93622 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93622-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93622-26 $289.76 $289.76 0 0% 0% 0% 1 0 0 0 0 0 R Y

93623 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93623-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93623-26 $269.46 $269.46 0 0% 0% 0% 1 0 0 0 0 0 R Y

93624 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y

93624-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93624-26 $444.17 $444.17 0 0% 0% 0% 1 2 0 0 0 0 R Y

93631 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93631-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93631-26 $673.03 $673.03 0 0% 0% 0% 1 0 0 0 0 0 R Y

93640 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y

93640-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93640-26 $324.83 $324.83 0 0% 0% 0% 1 2 0 0 0 0 R Y

93641 By Report By Report 0 0% 0% 0% 1 2 0 0 0 0 N Y

93641-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93641-26 $553.68 $553.68 0 0% 0% 0% 1 2 0 0 0 0 R Y

93642 $737.01 $737.01 0 0% 0% 0% 1 2 0 0 0 0 R Y

93642-26 $459.55 $459.55 0 0% 0% 0% 1 2 0 0 0 0 R Y

93642-TC $277.46 $277.46 0 0% 0% 0% 1 0 0 0 0 0 R Y

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 31

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93644 $498.31 $498.31 0 0% 0% 0% 1 2 0 0 0 0 R Y

93644-26 $305.75 $305.75 0 0% 0% 0% 1 2 0 0 0 0 R Y

93644-TC $192.56 $192.56 0 0% 0% 0% 1 0 0 0 0 0 R Y

93650 $1,020.00 $1,020.00 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR

93653 $1,432.19 $1,432.19 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR

93654 $1,906.50 $1,906.50 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR

93655 $716.09 $716.09 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR

93656 $1,907.74 $1,907.74 0 0% 0% 0% 0 2 0 0 0 0 R Y-UR

93657 $714.86 $714.86 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR

93660 $281.15 $281.15 0 0% 0% 0% 1 2 0 0 0 0 R Y

93660-26 $165.49 $165.49 0 0% 0% 0% 1 2 0 0 0 0 R Y

93660-TC $115.66 $115.66 0 0% 0% 0% 1 0 0 0 0 0 R Y

93662 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93662-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93662-26 $251.62 $251.62 0 0% 0% 0% 1 0 0 0 0 0 R

93668 $35.07 $35.07 0 0% 0% 0% 9 9 9 9 9 9 R Y

93701 $43.68 $43.68 0 0% 0% 0% 3 6 0 0 0 0 R Y

93702 $198.09 $198.09 0 0% 0% 0% 3 6 0 0 0 0 R Y

93724 $476.16 $476.16 0 0% 0% 0% 1 6 0 0 0 0 R Y

93724-26 $425.10 $425.10 0 0% 0% 0% 1 6 0 0 0 0 R Y

93724-TC $51.06 $51.06 0 0% 0% 0% 1 6 0 0 0 0 R Y

93740 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

93745 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93745-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93745-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

93750 $96.59 $79.36 0 0% 0% 0% 0 0 0 0 0 0 R Y

93770 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

93784 $96.59 $96.59 0 0% 0% 0% 4 6 0 0 0 0 R

93786 $54.14 $54.14 0 0% 0% 0% 3 6 0 0 0 0 R

93788 $9.23 $9.23 0 0% 0% 0% 3 6 0 0 0 0 R

93790 $33.22 $33.22 0 0% 0% 0% 2 0 0 0 0 0 R

93797 $28.91 $15.38 0 0% 0% 0% 0 0 0 0 0 0 R Y

93798 $44.91 $24.61 0 0% 0% 0% 0 0 0 0 0 0 R Y

93799 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93799-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93799-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

93880 $367.89 $367.89 0 0% 0% 0% 1 6 2 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 32

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93880-26 $69.52 $69.52 0 0% 0% 0% 1 6 2 0 0 0 R

93880-TC $298.37 $298.37 0 0% 0% 0% 1 6 2 0 0 0 R

93882 $234.39 $234.39 0 0% 0% 0% 1 6 0 0 0 0 R

93882-26 $43.06 $43.06 0 0% 0% 0% 1 6 0 0 0 0 R

93882-TC $191.33 $191.33 0 0% 0% 0% 1 6 0 0 0 0 R

93886 $513.08 $513.08 0 0% 0% 0% 1 6 0 0 0 0 R

93886-26 $82.44 $82.44 0 0% 0% 0% 1 6 0 0 0 0 R

93886-TC $430.64 $430.64 0 0% 0% 0% 1 6 0 0 0 0 R

93888 $267.61 $267.61 0 0% 0% 0% 1 6 0 0 0 0 R

93888-26 $44.29 $44.29 0 0% 0% 0% 1 6 0 0 0 0 R

93888-TC $223.32 $223.32 0 0% 0% 0% 1 6 0 0 0 0 R

93890 $526.00 $526.00 0 0% 0% 0% 1 6 0 0 0 0 R

93890-26 $90.43 $90.43 0 0% 0% 0% 1 6 0 0 0 0 R

93890-TC $435.56 $435.56 0 0% 0% 0% 1 6 0 0 0 0 R

93892 $607.20 $607.20 0 0% 0% 0% 1 6 0 0 0 0 R

93892-26 $105.81 $105.81 0 0% 0% 0% 1 6 0 0 0 0 R

93892-TC $501.39 $501.39 0 0% 0% 0% 1 6 0 0 0 0 R

93893 $631.81 $631.81 0 0% 0% 0% 1 6 0 0 0 0 R

93893-26 $103.97 $103.97 0 0% 0% 0% 1 6 0 0 0 0 R

93893-TC $527.23 $527.23 0 0% 0% 0% 1 6 0 0 0 0 R

93895 By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N

93895-26 By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N

93895-TC By Report By Report 0 0% 0% 0% 1 6 0 0 0 0 N

93922 $161.80 $161.80 0 0% 0% 0% 1 6 2 0 0 0 R

93922-26 $21.53 $21.53 0 0% 0% 0% 1 6 2 0 0 0 R

93922-TC $140.27 $140.27 0 0% 0% 0% 1 6 2 0 0 0 R

93923 $251.00 $251.00 0 0% 0% 0% 1 6 2 0 0 0 R

93923-26 $38.76 $38.76 0 0% 0% 0% 1 6 2 0 0 0 R

93923-TC $212.86 $212.86 0 0% 0% 0% 1 6 2 0 0 0 R

93924 $316.21 $316.21 0 0% 0% 0% 1 6 2 0 0 0 R

93924-26 $43.06 $43.06 0 0% 0% 0% 1 6 2 0 0 0 R

93924-TC $273.15 $273.15 0 0% 0% 0% 1 6 2 0 0 0 R

93925 $474.93 $474.93 0 0% 0% 0% 1 6 2 0 0 0 R

93925-26 $68.29 $68.29 0 0% 0% 0% 1 6 2 0 0 0 R

93925-TC $406.65 $406.65 0 0% 0% 0% 1 6 2 0 0 0 R

93926 $278.07 $278.07 0 0% 0% 0% 1 6 0 0 0 0 R

93926-26 $41.83 $41.83 0 0% 0% 0% 1 6 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 33

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93926-TC $236.85 $236.85 0 0% 0% 0% 1 6 0 0 0 0 R

93930 $380.19 $380.19 0 0% 0% 0% 1 6 2 0 0 0 R

93930-26 $68.90 $68.90 0 0% 0% 0% 1 6 2 0 0 0 R

93930-TC $311.29 $311.29 0 0% 0% 0% 1 6 2 0 0 0 R

93931 $233.16 $233.16 0 0% 0% 0% 1 6 0 0 0 0 R

93931-26 $42.45 $42.45 0 0% 0% 0% 1 6 0 0 0 0 R

93931-TC $190.71 $190.71 0 0% 0% 0% 1 6 0 0 0 0 R

93965 $217.17 $217.17 0 0% 0% 0% 1 6 2 0 0 0 R

93965-26 $29.53 $29.53 0 0% 0% 0% 1 6 2 0 0 0 R

93965-TC $187.64 $187.64 0 0% 0% 0% 1 6 2 0 0 0 R

93970 $358.66 $358.66 0 0% 0% 0% 1 6 2 0 0 0 R

93970-26 $60.29 $60.29 0 0% 0% 0% 1 6 2 0 0 0 R

93970-TC $298.37 $298.37 0 0% 0% 0% 1 6 2 0 0 0 R

93971 $218.40 $218.40 0 0% 0% 0% 1 6 0 0 0 0 R

93971-26 $38.76 $38.76 0 0% 0% 0% 1 6 0 0 0 0 R

93971-TC $179.64 $179.64 0 0% 0% 0% 1 6 0 0 0 0 R

93975 $513.69 $513.69 0 0% 0% 0% 1 6 0 0 0 0 R

93975-26 $100.28 $100.28 0 0% 0% 0% 1 6 0 0 0 0 R

93975-TC $413.41 $413.41 0 0% 0% 0% 1 6 0 0 0 0 R

93976 $295.91 $295.91 0 0% 0% 0% 1 6 0 0 0 0 R

93976-26 $69.52 $69.52 0 0% 0% 0% 1 6 0 0 0 0 R

93976-TC $226.39 $226.39 0 0% 0% 0% 1 6 0 0 0 0 R

93978 $346.97 $346.97 0 0% 0% 0% 1 6 0 0 0 0 R

93978-26 $67.67 $67.67 0 0% 0% 0% 1 6 0 0 0 0 R

93978-TC $278.69 $278.69 0 0% 0% 0% 1 6 0 0 0 0 R

93979 $217.17 $217.17 0 0% 0% 0% 1 6 0 0 0 0 R

93979-26 $42.45 $42.45 0 0% 0% 0% 1 6 0 0 0 0 R

93979-TC $174.72 $174.72 0 0% 0% 0% 1 6 0 0 0 0 R

93980 $216.55 $216.55 0 0% 0% 0% 1 6 0 0 0 0 R

93980-26 $107.66 $107.66 0 0% 0% 0% 1 6 0 0 0 0 R

93980-TC $108.89 $108.89 0 0% 0% 0% 1 6 0 0 0 0 R

93981 $131.65 $131.65 0 0% 0% 0% 1 6 0 0 0 0 R

93981-26 $38.14 $38.14 0 0% 0% 0% 1 6 0 0 0 0 R

93981-TC $94.13 $94.13 0 0% 0% 0% 1 6 0 0 0 0 R

93982 $76.90 $76.90 0 0% 0% 0% 0 0 0 0 0 0 R Y

93990 $293.45 $293.45 0 0% 0% 0% 1 6 0 0 0 0 R

93990-26 $41.83 $41.83 0 0% 0% 0% 1 6 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 34

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

93990-TC $251.62 $251.62 0 0% 0% 0% 1 6 0 0 0 0 R

93998 By Report By Report 0 0% 0% 0% 0 0 0 0 1 1 N

94002 $161.18 $161.18 0 0% 0% 0% 0 0 0 0 0 0 R

94003 $115.66 $115.66 0 0% 0% 0% 0 0 0 0 0 0 R

94004 $84.90 $84.90 0 0% 0% 0% 0 0 0 0 0 0 R

94005 $163.03 $163.03 0 0% 0% 0% 9 9 9 9 9 9 R

94010 $64.60 $64.60 0 0% 0% 0% 1 0 0 0 0 0 R

94010-26 $14.76 $14.76 0 0% 0% 0% 1 0 0 0 0 0 R

94010-TC $49.83 $49.83 0 0% 0% 0% 1 0 0 0 0 0 R

94011 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

94012 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

94013 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

94014 $100.89 $100.89 0 0% 0% 0% 4 0 0 0 0 0 R

94015 $55.98 $55.98 0 0% 0% 0% 3 0 0 0 0 0 R

94016 $44.29 $44.29 0 0% 0% 0% 2 0 0 0 0 0 R

94060 $110.12 $110.12 0 0% 0% 0% 1 0 0 0 0 0 R

94060-26 $22.76 $22.76 0 0% 0% 0% 1 0 0 0 0 0 R

94060-TC $87.36 $87.36 0 0% 0% 0% 1 0 0 0 0 0 R

94070 $106.43 $106.43 0 0% 0% 0% 1 0 0 0 0 0 R

94070-26 $50.45 $50.45 0 0% 0% 0% 1 0 0 0 0 0 R

94070-TC $55.98 $55.98 0 0% 0% 0% 1 0 0 0 0 0 R

94150 Bundled Bundled 0 0% 0% 0% 1 9 9 9 9 9 B

94150-26 Bundled Bundled 0 0% 0% 0% 1 9 9 9 9 9 B

94150-TC Bundled Bundled 0 0% 0% 0% 1 9 9 9 9 9 B

94200 $44.91 $44.91 0 0% 0% 0% 1 0 0 0 0 0 R

94200-26 $9.84 $9.84 0 0% 0% 0% 1 0 0 0 0 0 R

94200-TC $35.68 $35.68 0 0% 0% 0% 1 0 0 0 0 0 R

94250 $47.37 $47.37 0 0% 0% 0% 1 0 0 0 0 0 R

94250-26 $9.23 $9.23 0 0% 0% 0% 1 0 0 0 0 0 R

94250-TC $38.14 $38.14 0 0% 0% 0% 1 0 0 0 0 0 R

94375 $70.75 $70.75 0 0% 0% 0% 1 0 0 0 0 0 R

94375-26 $25.84 $25.84 0 0% 0% 0% 1 0 0 0 0 0 R

94375-TC $44.29 $44.29 0 0% 0% 0% 1 0 0 0 0 0 R

94400 $100.28 $100.28 0 0% 0% 0% 1 0 0 0 0 0 R

94400-26 $34.45 $34.45 0 0% 0% 0% 1 0 0 0 0 0 R

94400-TC $65.83 $65.83 0 0% 0% 0% 1 0 0 0 0 0 R

94450 $123.04 $123.04 0 0% 0% 0% 1 0 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 35

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

94450-26 $35.07 $35.07 0 0% 0% 0% 1 0 0 0 0 0 R

94450-TC $87.97 $87.97 0 0% 0% 0% 1 0 0 0 0 0 R

94452 $104.58 $104.58 0 0% 0% 0% 1 0 0 0 0 0 R

94452-26 $25.22 $25.22 0 0% 0% 0% 1 0 0 0 0 0 R

94452-TC $78.75 $78.75 0 0% 0% 0% 1 0 0 0 0 0 R

94453 $144.57 $144.57 0 0% 0% 0% 1 0 0 0 0 0 R

94453-26 $33.22 $33.22 0 0% 0% 0% 1 0 0 0 0 0 R

94453-TC $111.35 $111.35 0 0% 0% 0% 1 0 0 0 0 0 R

94610 $103.97 $103.97 0 0% 0% 0% 0 0 0 0 0 0 R

94620 $99.66 $99.66 0 0% 0% 0% 1 0 0 0 0 0 R

94620-26 $53.52 $53.52 0 0% 0% 0% 1 0 0 0 0 0 R

94620-TC $45.52 $45.52 0 0% 0% 0% 1 0 0 0 0 0 R

94621 $292.22 $292.22 0 0% 0% 0% 1 0 0 0 0 0 R

94621-26 $120.58 $120.58 0 0% 0% 0% 1 0 0 0 0 0 R

94621-TC $171.64 $171.64 0 0% 0% 0% 1 0 0 0 0 0 R

94640 $33.22 $33.22 0 0% 0% 0% 5 0 0 0 0 0 R

94642 By Report By Report 0 0% 0% 0% 5 0 0 0 0 0 N

94644 $79.98 $79.98 0 0% 0% 0% 5 0 0 0 0 0 R

94645 $25.84 $25.84 0 0% 0% 0% 5 0 0 0 0 0 R

94660 $111.97 $65.83 0 0% 0% 0% 0 0 0 0 0 0 R

94662 $63.98 $63.98 0 0% 0% 0% 0 0 0 0 0 0 R

94664 $31.38 $31.38 0 0% 0% 0% 5 0 0 0 0 0 R

94667 $46.76 $46.76 0 0% 0% 0% 5 0 0 0 0 0 R

94668 $51.68 $51.68 0 0% 0% 0% 5 0 0 0 0 0 R

94669 $59.67 $59.67 0 0% 0% 0% 5 0 0 0 0 0 R

94680 $103.97 $103.97 0 0% 0% 0% 1 0 0 0 0 0 R

94680-26 $22.15 $22.15 0 0% 0% 0% 1 0 0 0 0 0 R

94680-TC $81.82 $81.82 0 0% 0% 0% 1 0 0 0 0 0 R

94681 $95.36 $95.36 0 0% 0% 0% 1 0 0 0 0 0 R

94681-26 $17.23 $17.23 0 0% 0% 0% 1 0 0 0 0 0 R

94681-TC $78.13 $78.13 0 0% 0% 0% 1 0 0 0 0 0 R

94690 $91.05 $91.05 0 0% 0% 0% 1 0 0 0 0 0 R

94690-26 $6.77 $6.77 0 0% 0% 0% 1 0 0 0 0 0 R

94690-TC $84.28 $84.28 0 0% 0% 0% 1 0 0 0 0 0 R

94726 $95.36 $95.36 0 0% 0% 0% 1 0 0 0 0 0 R

94726-26 $21.53 $21.53 0 0% 0% 0% 1 0 0 0 0 0 R

94726-TC $73.82 $73.82 0 0% 0% 0% 1 0 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 36

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

94727 $75.67 $75.67 0 0% 0% 0% 1 0 0 0 0 0 R

94727-26 $21.53 $21.53 0 0% 0% 0% 1 0 0 0 0 0 R

94727-TC $54.14 $54.14 0 0% 0% 0% 1 0 0 0 0 0 R

94728 $72.59 $72.59 0 0% 0% 0% 1 0 0 0 0 0 R

94728-26 $22.15 $22.15 0 0% 0% 0% 1 0 0 0 0 0 R

94728-TC $50.45 $50.45 0 0% 0% 0% 1 0 0 0 0 0 R

94729 $99.05 $99.05 0 0% 0% 0% 1 0 0 0 0 0 R

94729-26 $16.00 $16.00 0 0% 0% 0% 1 0 0 0 0 0 R

94729-TC $83.05 $83.05 0 0% 0% 0% 1 0 0 0 0 0 R

94750 $146.42 $146.42 0 0% 0% 0% 1 0 0 0 0 0 R

94750-26 $19.69 $19.69 0 0% 0% 0% 1 0 0 0 0 0 R

94750-TC $126.73 $126.73 0 0% 0% 0% 1 0 0 0 0 0 R

94760 Bundled Bundled 0 0% 0% 0% 3 0 0 0 0 0 B

94761 Bundled Bundled 0 0% 0% 0% 3 0 0 0 0 0 B

94762 $44.29 $44.29 0 0% 0% 0% 3 0 0 0 0 0 R

94770 $12.92 $12.92 0 0% 0% 0% 0 0 0 0 0 0 R

94772 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

94772-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

94772-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

94774 Not Covered Not Covered 0 0% 0% 0% 4 0 0 0 0 0 X

94775 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X

94776 Not Covered Not Covered 0 0% 0% 0% 3 0 0 0 0 0 X

94777 Not Covered Not Covered 0 0% 0% 0% 2 0 0 0 0 0 X

94780 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X

94781 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X

94799 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

94799-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

94799-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

95004 $11.69 $11.69 0 0% 0% 0% 0 0 0 0 0 0 R

95012 $35.07 $35.07 0 0% 0% 0% 5 0 0 0 0 0 R

95017 $13.53 $6.15 0 0% 0% 0% 0 0 0 0 0 0 R

95018 $36.91 $12.30 0 0% 0% 0% 0 0 0 0 0 0 R

95024 $14.15 $1.85 0 0% 0% 0% 0 0 0 0 0 0 R

95027 $8.00 $8.00 0 0% 0% 0% 0 0 0 0 0 0 R

95028 $24.61 $24.61 0 0% 0% 0% 3 0 0 0 0 0 R

95044 $9.84 $9.84 0 0% 0% 0% 5 0 0 0 0 0 R

95052 $12.30 $12.30 0 0% 0% 0% 5 0 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 37

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

95056 $81.21 $81.21 0 0% 0% 0% 5 0 0 0 0 0 R

95060 $63.98 $63.98 0 0% 0% 0% 3 0 0 0 0 0 R

95065 $46.76 $46.76 0 0% 0% 0% 3 0 0 0 0 0 R

95070 $55.37 $55.37 0 0% 0% 0% 3 0 0 0 0 0 R

95071 $63.37 $63.37 0 0% 0% 0% 3 0 0 0 0 0 R

95076 $207.32 $127.96 0 0% 0% 0% 0 0 0 0 0 0 R

95079 $146.42 $117.50 0 0% 0% 0% 0 0 0 0 0 0 R

95115 $16.00 $16.00 0 0% 0% 0% 5 0 0 0 0 0 R Y

95117 $18.46 $18.46 0 0% 0% 0% 5 0 0 0 0 0 R Y

95120 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

95125 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

95130 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

95131 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

95132 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

95133 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

95134 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

95144 $22.15 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y

95145 $39.37 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y

95146 $70.75 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y

95147 $63.98 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y

95148 $95.36 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y

95149 $127.96 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y

95165 $22.76 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y

95170 $17.23 $5.54 0 0% 0% 0% 0 0 0 0 0 0 R Y

95180 $236.85 $177.79 0 0% 0% 0% 0 0 0 0 0 0 R Y

95199 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

95250 $287.91 $287.91 0 0% 0% 0% 3 0 0 0 0 0 R Y

95251 Not Covered Not Covered 0 0% 0% 0% 2 0 0 0 0 0 X

95782 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

95782-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

95782-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

95783 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

95783-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

95783-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

95800 $321.75 $321.75 0 0% 0% 0% 1 0 0 0 0 0 R Y

95800-26 $91.05 $91.05 0 0% 0% 0% 1 0 0 0 0 0 R Y

95800-TC $230.70 $230.70 0 0% 0% 0% 1 0 0 0 0 0 R Y

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 38

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

95801 $161.18 $161.18 0 0% 0% 0% 1 0 0 0 0 0 R Y

95801-26 $86.13 $86.13 0 0% 0% 0% 1 0 0 0 0 0 R Y

95801-TC $75.05 $75.05 0 0% 0% 0% 1 0 0 0 0 0 R Y

95803 $254.69 $254.69 0 0% 0% 0% 1 0 0 0 0 0 R Y

95803-26 $76.28 $76.28 0 0% 0% 0% 1 0 0 0 0 0 R Y

95803-TC $178.41 $178.41 0 0% 0% 0% 1 0 0 0 0 0 R Y

95805 $776.38 $776.38 0 0% 0% 0% 1 0 0 0 0 0 R Y

95805-26 $103.97 $103.97 0 0% 0% 0% 1 0 0 0 0 0 R Y

95805-TC $672.41 $672.41 0 0% 0% 0% 1 0 0 0 0 0 R Y

95806 $302.68 $302.68 0 0% 0% 0% 1 0 0 0 0 0 R Y

95806-26 $107.04 $107.04 0 0% 0% 0% 1 0 0 0 0 0 R Y

95806-TC $196.25 $196.25 0 0% 0% 0% 1 0 0 0 0 0 R Y

95807 $869.89 $869.89 0 0% 0% 0% 1 0 0 0 0 0 R Y

95807-26 $108.89 $108.89 0 0% 0% 0% 1 0 0 0 0 0 R Y

95807-TC $761.00 $761.00 0 0% 0% 0% 1 0 0 0 0 0 R Y

95808 $1,146.12 $1,146.12 0 0% 0% 0% 1 0 0 0 0 0 R Y

95808-26 $153.80 $153.80 0 0% 0% 0% 1 0 0 0 0 0 R Y

95808-TC $992.32 $992.32 0 0% 0% 0% 1 0 0 0 0 0 R Y

95810 $1,130.12 $1,130.12 0 0% 0% 0% 1 0 0 0 0 0 R Y

95810-26 $213.47 $213.47 0 0% 0% 0% 1 0 0 0 0 0 R Y

95810-TC $916.03 $916.03 0 0% 0% 0% 1 0 0 0 0 0 R Y

95811 $1,186.72 $1,186.72 0 0% 0% 0% 1 0 0 0 0 0 R Y

95811-26 $222.09 $222.09 0 0% 0% 0% 1 0 0 0 0 0 R Y

95811-TC $964.63 $964.63 0 0% 0% 0% 1 0 0 0 0 0 R Y

95812 $634.27 $634.27 0 0% 0% 0% 1 0 0 0 0 0 R

95812-26 $101.51 $101.51 0 0% 0% 0% 1 0 0 0 0 0 R

95812-TC $532.76 $532.76 0 0% 0% 0% 1 0 0 0 0 0 R

95813 $764.08 $764.08 0 0% 0% 0% 1 0 0 0 0 0 R

95813-26 $161.18 $161.18 0 0% 0% 0% 1 0 0 0 0 0 R

95813-TC $602.90 $602.90 0 0% 0% 0% 1 0 0 0 0 0 R

95816 $657.03 $657.03 0 0% 0% 0% 1 0 0 0 0 0 R

95816-26 $101.51 $101.51 0 0% 0% 0% 1 0 0 0 0 0 R

95816-TC $555.53 $555.53 0 0% 0% 0% 1 0 0 0 0 0 R

95819 $751.77 $751.77 0 0% 0% 0% 1 0 0 0 0 0 R

95819-26 $101.51 $101.51 0 0% 0% 0% 1 0 0 0 0 0 R

95819-TC $650.88 $650.88 0 0% 0% 0% 1 0 0 0 0 0 R

95822 $676.72 $676.72 0 0% 0% 0% 1 0 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 39

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

95822-26 $101.51 $101.51 0 0% 0% 0% 1 0 0 0 0 0 R

95822-TC $575.83 $575.83 0 0% 0% 0% 1 0 0 0 0 0 R

95824 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

95824-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

95824-26 $68.90 $68.90 0 0% 0% 0% 1 0 0 0 0 0 R

95827 $1,268.54 $1,268.54 0 0% 0% 0% 1 0 0 0 0 0 R

95827-26 $99.66 $99.66 0 0% 0% 0% 1 0 0 0 0 0 R

95827-TC $1,168.26 $1,168.26 0 0% 0% 0% 1 0 0 0 0 0 R

95829 $3,413.13 $3,413.13 0 0% 0% 0% 1 0 0 0 0 0 R

95829-26 $585.06 $585.06 0 0% 0% 0% 1 0 0 0 0 0 R

95829-TC $2,828.07 $2,828.07 0 0% 0% 0% 1 0 0 0 0 0 R

95830 $440.48 $160.57 0 0% 0% 0% 0 0 0 0 0 0 R

95831 $54.14 $25.84 0 0% 0% 0% 0 0 0 0 0 0 R

95832 $52.29 $27.07 0 0% 0% 0% 0 0 0 0 0 0 R

95833 $66.44 $37.53 0 0% 0% 0% 0 0 0 0 0 0 R

95834 $90.43 $54.75 0 0% 0% 0% 0 0 0 0 0 0 R

95851 $33.22 $13.53 0 0% 0% 0% 0 0 0 0 0 0 R

95852 $29.53 $10.46 0 0% 0% 0% 0 0 0 0 0 0 R

95857 $96.59 $51.68 0 0% 0% 0% 0 0 0 0 0 0 R

95860 $219.63 $219.63 0 0% 0% 0% 1 0 0 0 0 0 R

95860-26 $91.05 $91.05 0 0% 0% 0% 1 0 0 0 0 0 R

95860-TC $128.58 $128.58 0 0% 0% 0% 1 0 0 0 0 0 R

95861 $306.37 $306.37 0 0% 0% 0% 1 0 0 0 0 0 R

95861-26 $145.80 $145.80 0 0% 0% 0% 1 0 0 0 0 0 R

95861-TC $161.18 $161.18 0 0% 0% 0% 1 0 0 0 0 0 R

95863 $381.42 $381.42 0 0% 0% 0% 1 0 0 0 0 0 R

95863-26 $175.95 $175.95 0 0% 0% 0% 1 0 0 0 0 0 R

95863-TC $205.48 $205.48 0 0% 0% 0% 1 0 0 0 0 0 R

95864 $429.41 $429.41 0 0% 0% 0% 1 0 0 0 0 0 R

95864-26 $188.87 $188.87 0 0% 0% 0% 1 0 0 0 0 0 R

95864-TC $241.16 $241.16 0 0% 0% 0% 1 0 0 0 0 0 R

95865 $256.54 $256.54 0 0% 0% 0% 1 0 2 0 0 0 R

95865-26 $148.26 $148.26 0 0% 0% 0% 1 0 2 0 0 0 R

95865-TC $108.28 $108.28 0 0% 0% 0% 1 0 2 0 0 0 R

95866 $239.31 $239.31 0 0% 0% 0% 1 0 1 0 0 0 R

95866-26 $118.73 $118.73 0 0% 0% 0% 1 0 1 0 0 0 R

95866-TC $120.58 $120.58 0 0% 0% 0% 1 0 1 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 40

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

95867 $169.18 $169.18 0 0% 0% 0% 1 0 0 0 0 0 R

95867-26 $73.82 $73.82 0 0% 0% 0% 1 0 0 0 0 0 R

95867-TC $95.97 $95.97 0 0% 0% 0% 1 0 0 0 0 0 R

95868 $237.47 $237.47 0 0% 0% 0% 1 0 2 0 0 0 R

95868-26 $110.74 $110.74 0 0% 0% 0% 1 0 2 0 0 0 R

95868-TC $126.73 $126.73 0 0% 0% 0% 1 0 2 0 0 0 R

95869 $168.56 $168.56 0 0% 0% 0% 1 0 0 0 0 0 R

95869-26 $35.07 $35.07 0 0% 0% 0% 1 0 0 0 0 0 R

95869-TC $133.50 $133.50 0 0% 0% 0% 1 0 0 0 0 0 R

95870 $167.95 $167.95 0 0% 0% 0% 1 0 0 0 0 0 R

95870-26 $34.45 $34.45 0 0% 0% 0% 1 0 0 0 0 0 R

95870-TC $133.50 $133.50 0 0% 0% 0% 1 0 0 0 0 0 R

95872 $346.36 $346.36 0 0% 0% 0% 1 0 0 0 0 0 R

95872-26 $270.07 $270.07 0 0% 0% 0% 1 0 0 0 0 0 R

95872-TC $76.28 $76.28 0 0% 0% 0% 1 0 0 0 0 0 R

95873 $133.50 $133.50 0 0% 0% 0% 1 0 0 0 0 0 R

95873-26 $35.68 $35.68 0 0% 0% 0% 1 0 0 0 0 0 R

95873-TC $98.43 $98.43 0 0% 0% 0% 1 0 0 0 0 0 R

95874 $132.27 $132.27 0 0% 0% 0% 1 0 0 0 0 0 R

95874-26 $35.07 $35.07 0 0% 0% 0% 1 0 0 0 0 0 R

95874-TC $96.59 $96.59 0 0% 0% 0% 1 0 0 0 0 0 R

95875 $223.32 $223.32 0 0% 0% 0% 1 0 0 0 0 0 R

95875-26 $103.35 $103.35 0 0% 0% 0% 1 0 0 0 0 0 R

95875-TC $119.96 $119.96 0 0% 0% 0% 1 0 0 0 0 0 R

95885 $105.81 $105.81 0 0% 0% 0% 1 0 3 0 0 0 R

95885-26 $33.22 $33.22 0 0% 0% 0% 1 0 3 0 0 0 R

95885-TC $71.98 $71.98 0 0% 0% 0% 1 0 3 0 0 0 R

95886 $163.03 $163.03 0 0% 0% 0% 1 0 3 0 0 0 R

95886-26 $81.21 $81.21 0 0% 0% 0% 1 0 3 0 0 0 R

95886-TC $81.82 $81.82 0 0% 0% 0% 1 0 3 0 0 0 R

95887 $145.19 $145.19 0 0% 0% 0% 1 0 3 0 0 0 R

95887-26 $66.44 $66.44 0 0% 0% 0% 1 0 3 0 0 0 R

95887-TC $78.75 $78.75 0 0% 0% 0% 1 0 3 0 0 0 R

95905 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

95905-26 Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

95905-TC Not Covered Not Covered 0 0% 0% 0% 1 0 0 0 0 0 X

95907 $170.41 $170.41 0 0% 0% 0% 1 0 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 41

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

95907-26 $94.13 $94.13 0 0% 0% 0% 1 0 0 0 0 0 R

95907-TC $76.28 $76.28 0 0% 0% 0% 1 0 0 0 0 0 R

95908 $211.01 $211.01 0 0% 0% 0% 1 0 0 0 0 0 R

95908-26 $116.89 $116.89 0 0% 0% 0% 1 0 0 0 0 0 R

95908-TC $94.13 $94.13 0 0% 0% 0% 1 0 0 0 0 0 R

95909 $257.77 $257.77 0 0% 0% 0% 1 0 0 0 0 0 R

95909-26 $141.50 $141.50 0 0% 0% 0% 1 0 0 0 0 0 R

95909-TC $116.89 $116.89 0 0% 0% 0% 1 0 0 0 0 0 R

95910 $342.67 $342.67 0 0% 0% 0% 1 0 0 0 0 0 R

95910-26 $188.87 $188.87 0 0% 0% 0% 1 0 0 0 0 0 R

95910-TC $153.80 $153.80 0 0% 0% 0% 1 0 0 0 0 0 R

95911 $414.03 $414.03 0 0% 0% 0% 1 0 0 0 0 0 R

95911-26 $236.24 $236.24 0 0% 0% 0% 1 0 0 0 0 0 R

95911-TC $177.79 $177.79 0 0% 0% 0% 1 0 0 0 0 0 R

95912 $462.63 $462.63 0 0% 0% 0% 1 0 0 0 0 0 R

95912-26 $279.30 $279.30 0 0% 0% 0% 1 0 0 0 0 0 R

95912-TC $182.71 $182.71 0 0% 0% 0% 1 0 0 0 0 0 R

95913 $527.84 $527.84 0 0% 0% 0% 1 0 0 0 0 0 R

95913-26 $330.98 $330.98 0 0% 0% 0% 1 0 0 0 0 0 R

95913-TC $197.48 $197.48 0 0% 0% 0% 1 0 0 0 0 0 R

95921 $153.80 $153.80 0 0% 0% 0% 1 0 0 0 0 0 R

95921-26 $79.98 $79.98 0 0% 0% 0% 1 0 0 0 0 0 R

95921-TC $73.82 $73.82 0 0% 0% 0% 1 0 0 0 0 0 R

95922 $180.87 $180.87 0 0% 0% 0% 1 0 0 0 0 0 R

95922-26 $85.51 $85.51 0 0% 0% 0% 1 0 0 0 0 0 R

95922-TC $95.36 $95.36 0 0% 0% 0% 1 0 0 0 0 0 R

95923 $295.91 $295.91 0 0% 0% 0% 1 0 0 0 0 0 R

95923-26 $81.21 $81.21 0 0% 0% 0% 1 0 0 0 0 0 R

95923-TC $214.70 $214.70 0 0% 0% 0% 1 0 0 0 0 0 R

95924 $264.54 $264.54 0 0% 0% 0% 1 0 0 0 0 0 R

95924-26 $156.26 $156.26 0 0% 0% 0% 1 0 0 0 0 0 R

95924-TC $108.28 $108.28 0 0% 0% 0% 1 0 0 0 0 0 R

95925 $281.76 $281.76 0 0% 0% 0% 1 0 2 0 0 0 R

95925-26 $49.22 $49.22 0 0% 0% 0% 1 0 2 0 0 0 R

95925-TC $232.55 $232.55 0 0% 0% 0% 1 0 2 0 0 0 R

95926 $249.16 $249.16 0 0% 0% 0% 1 0 2 0 0 0 R

95926-26 $47.99 $47.99 0 0% 0% 0% 1 0 2 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 42

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

95926-TC $201.17 $201.17 0 0% 0% 0% 1 0 2 0 0 0 R

95927 $257.15 $257.15 0 0% 0% 0% 1 0 0 0 0 0 R

95927-26 $47.99 $47.99 0 0% 0% 0% 1 0 0 0 0 0 R

95927-TC $209.17 $209.17 0 0% 0% 0% 1 0 0 0 0 0 R

95928 $405.42 $405.42 0 0% 0% 0% 1 0 2 0 0 0 R

95928-26 $140.88 $140.88 0 0% 0% 0% 1 0 2 0 0 0 R

95928-TC $264.54 $264.54 0 0% 0% 0% 1 0 2 0 0 0 R

95929 $407.26 $407.26 0 0% 0% 0% 1 0 2 0 0 0 R

95929-26 $140.88 $140.88 0 0% 0% 0% 1 0 2 0 0 0 R

95929-TC $266.38 $266.38 0 0% 0% 0% 1 0 2 0 0 0 R

95930 $232.55 $232.55 0 0% 0% 0% 1 0 2 0 0 0 R

95930-26 $32.61 $32.61 0 0% 0% 0% 1 0 2 0 0 0 R

95930-TC $199.94 $199.94 0 0% 0% 0% 1 0 2 0 0 0 R

95933 $134.73 $134.73 0 0% 0% 0% 1 0 0 0 0 0 R

95933-26 $54.75 $54.75 0 0% 0% 0% 1 0 0 0 0 0 R

95933-TC $79.36 $79.36 0 0% 0% 0% 1 0 0 0 0 0 R

95937 $145.80 $145.80 0 0% 0% 0% 1 0 0 0 0 0 R

95937-26 $60.29 $60.29 0 0% 0% 0% 1 0 0 0 0 0 R

95937-TC $85.51 $85.51 0 0% 0% 0% 1 0 0 0 0 0 R

95938 $620.74 $620.74 0 0% 0% 0% 1 0 2 0 0 0 R

95938-26 $80.59 $80.59 0 0% 0% 0% 1 0 2 0 0 0 R

95938-TC $540.15 $540.15 0 0% 0% 0% 1 0 2 0 0 0 R

95939 $905.57 $905.57 0 0% 0% 0% 1 0 2 0 0 0 R

95939-26 $209.78 $209.78 0 0% 0% 0% 1 0 2 0 0 0 R

95939-TC $695.79 $695.79 0 0% 0% 0% 1 0 2 0 0 0 R

95940 $56.60 $56.60 0 0% 0% 0% 0 0 0 0 0 0 R

95941 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

95943 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

95943-26 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

95943-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

95950 $597.36 $597.36 0 0% 0% 0% 1 0 0 0 0 0 R

95950-26 $140.27 $140.27 0 0% 0% 0% 1 0 0 0 0 0 R

95950-TC $457.09 $457.09 0 0% 0% 0% 1 0 0 0 0 0 R

95951 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

95951-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

95951-26 $560.45 $560.45 0 0% 0% 0% 1 0 0 0 0 0 R

95953 $756.70 $756.70 0 0% 0% 0% 1 0 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 43

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

95953-26 $287.30 $287.30 0 0% 0% 0% 1 0 0 0 0 0 R

95953-TC $468.78 $468.78 0 0% 0% 0% 1 0 0 0 0 0 R

95954 $820.68 $820.68 0 0% 0% 0% 1 0 0 0 0 0 R

95954-26 $219.63 $219.63 0 0% 0% 0% 1 0 0 0 0 0 R

95954-TC $601.05 $601.05 0 0% 0% 0% 1 0 0 0 0 0 R

95955 $390.65 $390.65 0 0% 0% 0% 1 0 0 0 0 0 R

95955-26 $94.74 $94.74 0 0% 0% 0% 1 0 0 0 0 0 R

95955-TC $295.30 $295.30 0 0% 0% 0% 1 0 0 0 0 0 R

95956 $2,981.87 $2,981.87 0 0% 0% 0% 1 0 0 0 0 0 R

95956-26 $335.90 $335.90 0 0% 0% 0% 1 0 0 0 0 0 R

95956-TC $2,646.59 $2,646.59 0 0% 0% 0% 1 0 0 0 0 0 R

95957 $566.60 $566.60 0 0% 0% 0% 1 0 0 0 0 0 R

95957-26 $184.56 $184.56 0 0% 0% 0% 1 0 0 0 0 0 R

95957-TC $382.04 $382.04 0 0% 0% 0% 1 0 0 0 0 0 R

95958 $1,024.92 $1,024.92 0 0% 0% 0% 1 0 0 0 0 0 R

95958-26 $394.96 $394.96 0 0% 0% 0% 1 0 0 0 0 0 R

95958-TC $629.96 $629.96 0 0% 0% 0% 1 0 0 0 0 0 R

95961 $521.69 $521.69 0 0% 0% 0% 1 0 0 0 0 0 R

95961-26 $281.15 $281.15 0 0% 0% 0% 1 0 0 0 0 0 R

95961-TC $240.54 $240.54 0 0% 0% 0% 1 0 0 0 0 0 R

95962 $463.25 $463.25 0 0% 0% 0% 1 0 0 0 0 0 R

95962-26 $302.68 $302.68 0 0% 0% 0% 1 0 0 0 0 0 R

95962-TC $160.57 $160.57 0 0% 0% 0% 1 0 0 0 0 0 R

95965 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

95965-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

95965-26 $737.01 $737.01 0 0% 0% 0% 1 0 0 0 0 0 R Y

95966 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

95966-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

95966-26 $373.43 $373.43 0 0% 0% 0% 1 0 0 0 0 0 R Y

95967 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

95967-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N Y

95967-26 $325.44 $325.44 0 0% 0% 0% 1 0 0 0 0 0 R Y

95970 $122.42 $41.83 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR

95971 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

95972 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

95973 Not Covered Not Covered 0% 0% 0% 0 0 0 0 0 0 X

95974 $362.35 $283.61 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 44

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

95975 $195.02 $161.18 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR

95978 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

95979 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

95980 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

95981 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

95982 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

95990 $167.95 $167.95 0 0% 0% 0% 5 0 0 0 0 0 R Y-UR

95991 $220.24 $69.52 0 0% 0% 0% 0 0 0 0 0 0 R Y-UR

95992 $75.67 $65.21 0 0% 0% 0% 0 0 0 0 0 0 R Y

95999 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

96000 $166.10 $166.10 0 0% 0% 0% 0 0 2 0 0 0 R

96001 $183.33 $183.33 0 0% 0% 0% 0 0 2 0 0 0 R

96002 Not Covered Not Covered 0 0% 0% 0% 0 0 2 0 0 0 X

96003 $31.99 $31.99 0 0% 0% 0% 0 0 2 0 0 0 R Y

96004 $203.63 $203.63 0 0% 0% 0% 2 0 2 0 0 0 R Y

96020 By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

96020-TC By Report By Report 0 0% 0% 0% 1 0 0 0 0 0 N

96020-26 $285.45 $285.45 0 0% 0% 0% 1 0 0 0 0 0 R

96040 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

96101 $138.42 $137.19 0 0% 0% 0% 0 0 0 0 0 0 R

96102 $113.81 $40.60 0 0% 0% 0% 0 0 0 0 0 0 R

96103 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

96105 $188.87 $188.87 0 0% 0% 0% 0 0 0 0 0 0 R

96110 $16.00 $16.00 0 0% 0% 0% 9 9 9 9 9 9 R Y

96111 $225.16 $213.47 0 0% 0% 0% 0 0 0 0 0 0 R Y

96116 $161.18 $150.72 0 0% 0% 0% 0 0 0 0 0 0 R

96118 $171.64 $136.57 0 0% 0% 0% 0 0 0 0 0 0 R

96119 $144.57 $41.22 0 0% 0% 0% 0 0 0 0 0 0 R

96120 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

96125 $207.94 $207.94 0 0% 0% 0% 0 5 0 0 0 0 R Y

96127 $9.23 $9.23 0 0% 0% 0% 3 0 0 0 0 0 R

96150 $37.53 $36.91 0 0% 0% 0% 0 0 0 0 0 0 R

96151 $35.68 $35.07 0 0% 0% 0% 0 0 0 0 0 0 R

96152 $34.45 $33.84 0 0% 0% 0% 0 0 0 0 0 0 R

96153 $8.00 $8.00 0 0% 0% 0% 0 0 0 0 0 0 R

96154 $33.84 $33.22 0 0% 0% 0% 0 0 0 0 0 0 R

96155 $39.37 $39.37 0 0% 0% 0% 9 9 9 9 9 9 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 45

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

96360 $103.35 $103.35 0 0% 0% 0% 5 0 0 0 0 0 R

96361 $27.07 $27.07 0 0% 0% 0% 5 0 0 0 0 0 R

96365 $124.89 $124.89 0 0% 0% 0% 5 0 0 0 0 0 R

96366 $33.84 $33.84 0 0% 0% 0% 5 0 0 0 0 0 R

96367 $54.75 $54.75 0 0% 0% 0% 5 0 0 0 0 0 R

96368 $36.91 $36.91 0 0% 0% 0% 5 0 0 0 0 0 R

96369 $350.05 $350.05 0 0% 0% 0% 5 0 0 0 0 0 R

96370 $26.45 $26.45 0 0% 0% 0% 5 0 0 0 0 0 R

96371 $132.88 $132.88 0 0% 0% 0% 5 0 0 0 0 0 R

96372 $45.52 $45.52 0 0% 0% 0% 5 0 0 0 0 0 R

96373 $34.45 $34.45 0 0% 0% 0% 5 0 0 0 0 0 R

96374 $102.12 $102.12 0 0% 0% 0% 5 0 0 0 0 0 R

96375 $40.60 $40.60 0 0% 0% 0% 5 0 0 0 0 0 R

96376 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

96379 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

96401 $134.11 $134.11 0 0% 0% 0% 5 0 0 0 0 0 R

96402 $57.83 $57.83 0 0% 0% 0% 5 0 0 0 0 0 R

96405 $148.26 $53.52 0 0% 0% 0% 0 2 0 1 0 0 R Y

96406 $209.78 $81.82 0 0% 0% 0% 0 2 0 1 0 0 R Y

96409 $199.32 $199.32 0 0% 0% 0% 5 0 0 0 0 0 R

96411 $111.97 $111.97 0 0% 0% 0% 5 0 0 0 0 0 R

96413 $243.62 $243.62 0 0% 0% 0% 5 0 0 0 0 0 R

96415 $50.45 $50.45 0 0% 0% 0% 5 0 0 0 0 0 R

96416 $253.46 $253.46 0 0% 0% 0% 5 0 0 0 0 0 R

96417 $112.58 $112.58 0 0% 0% 0% 5 0 0 0 0 0 R

96420 $186.41 $186.41 0 0% 0% 0% 5 0 0 0 0 0 R Y

96422 $306.37 $306.37 0 0% 0% 0% 5 0 0 0 0 0 R Y

96423 $141.50 $141.50 0 0% 0% 0% 5 0 0 0 0 0 R Y

96425 $326.67 $326.67 0 0% 0% 0% 5 0 0 0 0 0 R Y

96440 $1,538.62 $235.01 0 0% 0% 0% 0 0 0 0 0 0 R Y

96446 $357.43 $42.45 0 0% 0% 0% 5 0 0 0 0 0 R Y

96450 $324.83 $140.88 0 0% 0% 0% 0 0 0 0 0 0 R Y

96521 $248.54 $248.54 0 0% 0% 0% 5 0 0 0 0 0 R

96522 Not Covered Not Covered 0 0% 0% 0% 5 0 0 0 0 0 X

96523 $44.91 $44.91 0 0% 0% 0% 5 0 0 0 0 0 R

96542 $216.55 $73.82 0 0% 0% 0% 0 0 0 0 0 0 R Y

96549 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 46

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

96567 Not Covered Not Covered 0 0% 0% 0% 5 0 0 0 0 0 X

96570 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X

96571 Not Covered Not Covered 0 0% 0% 0% 0 0 0 1 0 0 X

96900 $37.53 $37.53 0 0% 0% 0% 5 0 0 0 0 0 R Y

96902 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

96904 Not Covered Not Covered 0 0% 0% 0% 5 0 0 0 0 0 X

96910 $131.04 $131.04 0 0% 0% 0% 5 0 0 0 0 0 R Y

96912 $167.33 $167.33 0 0% 0% 0% 5 0 0 0 0 0 R Y

96913 $239.31 $239.31 0 0% 0% 0% 5 0 0 0 0 0 R Y

96920 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X

96921 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X

96922 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X

96931 By Report By Report 0 0% 0% 0% 4 0 0 0 0 0 N

96932 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N

96933 By Report By Report 0 0% 0% 0% 2 0 0 0 0 0 N

96934 By Report By Report 0 0% 0% 0% 4 0 0 0 0 0 N

96935 By Report By Report 0 0% 0% 0% 3 0 0 0 0 0 N

96936 By Report By Report 0 0% 0% 0% 2 0 0 0 0 0 N

96999 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

97001 $125.68 $125.68 0 0% 0% 0% 0 5 0 0 0 0 F

97002 $74.44 $74.44 0 0% 0% 0% 0 5 0 0 0 0 R

97003 $125.68 $125.68 0 0% 0% 0% 0 5 0 0 0 0 F

97004 $93.51 $93.51 0 0% 0% 0% 0 5 0 0 0 0 R

97005 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

97006 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

97010 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

97012 $28.30 $28.30 0 0% 0% 0% 0 5 0 0 0 0 R

97014 $28.30 $28.30 0 0% 0% 0% 9 9 9 9 9 9 R

97016 $34.45 $34.45 0 0% 0% 0% 0 5 0 0 0 0 R

97018 $19.69 $19.69 0 0% 0% 0% 0 5 0 0 0 0 R

97022 $41.83 $41.83 0 0% 0% 0% 0 5 0 0 0 0 R

97024 $11.07 $11.07 0 0% 0% 0% 0 5 0 0 0 0 R

97026 $10.46 $10.46 0 0% 0% 0% 0 5 0 0 0 0 R

97028 $12.92 $12.92 0 0% 0% 0% 0 5 0 0 0 0 R

97032 $33.84 $33.84 0 0% 0% 0% 0 5 0 0 0 0 R

97033 Not Covered Not Covered 0 0% 0% 0% 0 5 0 0 0 0 X

97034 $31.99 $31.99 0 0% 0% 0% 0 5 0 0 0 0 R

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 47

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

97035 $21.53 $21.53 0 0% 0% 0% 0 5 0 0 0 0 R

97036 $59.06 $59.06 0 0% 0% 0% 0 5 0 0 0 0 R

97039 $18.78 $18.78 0 0% 0% 0% 0 0 0 0 0 0 F

97110 $57.21 $57.21 0 0% 0% 0% 0 5 0 0 0 0 R

97112 $59.67 $59.67 0 0% 0% 0% 0 5 0 0 0 0 R

97113 $76.90 $76.90 0 0% 0% 0% 0 5 0 0 0 0 R

97116 $50.45 $50.45 0 0% 0% 0% 0 5 0 0 0 0 R

97124 $46.76 $46.76 0 0% 0% 0% 0 5 0 0 0 0 R

97139 $26.05 $26.05 0 0% 0% 0% 0 0 0 0 0 0 F

97140 $52.91 $52.91 0 0% 0% 0% 0 5 0 0 0 0 R

97150 $30.76 $30.76 0 0% 0% 0% 0 5 0 0 0 0 R

97530 $62.14 $62.14 0 0% 0% 0% 0 5 0 0 0 0 R

97532 $47.37 $47.37 0 0% 0% 0% 0 0 0 0 0 0 R

97533 $51.68 $51.68 0 0% 0% 0% 0 5 0 0 0 0 R

97535 $62.14 $62.14 0 0% 0% 0% 0 5 0 0 0 0 R

97537 $52.91 $52.91 0 0% 0% 0% 0 5 0 0 0 0 R

97542 $54.75 $54.75 0 0% 0% 0% 0 5 0 0 0 0 R

97545 $147.21 $147.21 0 0% 0% 0% 0 0 0 0 0 0 F Y

97546 $75.12 $75.12 0 0% 0% 0% 0 0 0 0 0 0 F Y

97597 $135.34 $40.60 0 0% 0% 0% 0 0 0 0 0 0 R

97598 $43.68 $19.07 0 0% 0% 0% 0 0 0 0 0 0 R

97602 $52.10 $52.10 0 0% 0% 0% 9 9 9 9 9 9 F

97605 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y

97606 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B Y

97607 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y

97608 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N Y

97610 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

97750 $58.44 $58.44 0 0% 0% 0% 0 5 0 0 0 0 R

97755 $63.37 $63.37 0 0% 0% 0% 0 5 0 0 0 0 R

97760 $67.67 $67.67 0 0% 0% 0% 0 5 0 0 0 0 R

97761 $58.44 $58.44 0 0% 0% 0% 0 5 0 0 0 0 R

97762 $86.13 $86.13 0 0% 0% 0% 0 5 0 0 0 0 R

97799 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

97802 $61.52 $57.21 0 0% 0% 0% 0 0 0 0 0 0 R Y

97803 $52.91 $48.60 0 0% 0% 0% 0 0 0 0 0 0 R Y

97804 $27.68 $27.07 0 0% 0% 0% 0 0 0 0 0 0 R Y

97810 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 48

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

97811 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

97813 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

97814 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

98925 $55.37 $41.22 0 0% 0% 0% 0 0 0 0 0 0 R

98926 $80.59 $62.75 0 0% 0% 0% 0 0 0 0 0 0 R

98927 $103.97 $82.44 0 0% 0% 0% 0 0 0 0 0 0 R

98928 $127.35 $103.97 0 0% 0% 0% 0 0 0 0 0 0 R

98929 $152.57 $124.89 0 0% 0% 0% 0 0 0 0 0 0 R

98940 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

98941 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

98942 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

98943 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

98960 $50.45 $50.45 0 0% 0% 0% 9 9 9 9 9 9 R

98961 $24.61 $24.61 0 0% 0% 0% 9 9 9 9 9 9 R

98962 $17.84 $17.84 0 0% 0% 0% 9 9 9 9 9 9 R

98966 $23.99 $22.15 0 0% 0% 0% 9 9 9 9 9 9 R

98967 $46.76 $44.29 0 0% 0% 0% 9 9 9 9 9 9 R

98968 $68.90 $66.44 0 0% 0% 0% 9 9 9 9 9 9 R

98969 $46.04 $43.62 0 0% 0% 0% 9 9 9 9 9 9 F

99000 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99001 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99002 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99024 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99026 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99027 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99050 $47.25 $44.83 0 0% 0% 0% 9 9 9 9 9 9 F

99051 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99053 $21.20 $21.20 0 0% 0% 0% 9 9 9 9 9 9 F

99056 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B Y

99058 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99060 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

99070 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99071 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99075 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99078 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99080 $46.32 $46.32 0 0% 0% 0% 9 9 9 9 9 9 F

99082 $17.70 $17.70 0 0% 0% 0% 0 0 0 0 0 0 F

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 49

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

99090 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99091 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99100 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99116 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99135 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99140 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99143 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

99144 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B

99145 Bundled Bundled 0 0% 0% 0% 0 0 0 0 0 0 B

99148 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

99149 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

99150 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

99170 Not Covered Not Covered 0 0% 0% 0% 0 2 0 1 0 0 X

99172 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

99173 Bundled Bundled 0 0% 0% 0% 9 9 9 9 9 9 B

99174 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99175 $30.76 $30.76 0 0% 0% 0% 5 0 0 0 0 0 R

99177 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N

99183 $188.25 $188.25 0 0% 0% 0% 2 0 0 0 0 0 R Y

99184 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

99188 Not Covered Not Covered 0 0% 0% 0% 0 0 0 0 0 0 X

99190 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

99191 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

99192 By Report By Report 0 0% 0% 0% 9 9 9 9 9 9 N Y

99195 $180.87 $180.87 0 0% 0% 0% 5 0 0 0 0 0 R

99199 By Report By Report 0 0% 0% 0% 0 0 0 0 0 0 N

99500 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99501 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99502 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99503 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99504 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99505 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99506 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99507 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99509 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99510 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99511 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 50

Professional Services Fee Schedule

Medicine

Effective July 1, 2016

CPT

CODE

FOL

UP

PRE OP

(-56)

INTRA OP

(-54)

POST OP

(-55)

PCTC

(26/TC)

MSI

(-51)

BSI

(-50)

ASI

(-80)

CSI

(-62)

TSI

(-66)

ENDO

BASE FSI

PRIOR

AUTHNON-FACILITY

SETTING

FACILITY

SETTING

DOLLAR VALUE MODIFIERS

Medicine Fees

99512 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99600 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99601 $158.95 $158.95 0 0% 0% 0% 9 9 9 9 9 9 F Y

99602 $66.84 $66.84 0 0% 0% 0% 9 9 9 9 9 9 F Y

99605 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99606 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

99607 Not Covered Not Covered 0 0% 0% 0% 9 9 9 9 9 9 X

CPT® only are copyright 2015 American Medical Association. All rights reserved. Refer to Field Key for definitions Medicine Page 51