2019 ambulatory surgery center fee schedule · washington state department of labor and industries...

Washington State Department of Labor and IndustriesAmbulatory Surgery Center Fee Schedule

Ambulatory Surgery CenterEffective July 1, 2019

CPT ® codes and descriptions only are copyright 2018 American Medical Association Refer to Field Key for definitions

CPT ®

HCPCS Code

Jul 2019 ASC Payment Amount

Subject To Multiple

Procedure Discounting

10004 Bundled NA10005 $238.89 Y10006 Bundled NA10007 $543.17 Y10008 Bundled NA10009 $485.08 Y10010 Bundled NA10011 $485.08 Y10012 Bundled NA10021 Not covered NA10030 $495.74 Y10035 Not covered NA10036 Not covered NA10040 Bundled NA10060 $225.30 Y10061 $389.73 Y10080 $343.12 Y10081 $512.09 Y10120 $293.27 Y10121 $901.87 Y10140 $312.69 Y10160 $247.31 Y10180 $1,765.57 Y11000 $104.23 Y11001 Bundled NA11010 $495.74 Y11011 $495.74 Y11012 $1,765.57 Y11042 $268.96 Y11043 $422.49 Y11044 $901.87 Y11045 Bundled NA11046 Bundled NA11047 Bundled NA11055 Bundled NA11056 Bundled NA11057 $126.24 Y11102 $187.75 Y11103 Bundled NA11104 $147.74 Y11105 Bundled NA11106 $285.50 Y11107 Bundled NA11200 Bundled NA11201 Bundled NA11300 Bundled NA11301 Bundled NA11302 Bundled NA11303 Bundled NA11305 Bundled NA11306 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


11307 $146.20 Y11308 Bundled NA11310 $217.53 Y11311 $211.70 Y11312 $306.22 Y11313 $354.13 Y11400 $239.54 Y11401 $284.86 Y11402 $317.87 Y11403 $365.78 Y11404 $901.87 Y11406 $901.87 Y11420 $234.36 Y11421 $298.45 Y11422 $336.00 Y11423 $381.97 Y11424 $901.87 Y11426 $1,765.57 Y11440 $258.96 Y11441 $320.46 Y11442 $358.01 Y11443 $424.05 Y11444 $901.87 Y11446 $1,765.57 Y11450 $1,765.57 Y11451 $1,765.57 Y11462 $1,765.57 Y11463 $1,765.57 Y11470 $1,765.57 Y11471 $1,765.57 Y11600 $368.37 Y11601 $435.70 Y11602 $471.95 Y11603 $539.93 Y11604 $495.74 Y11606 $901.87 Y11620 $370.96 Y11621 $437.64 Y11622 $487.49 Y11623 $571.01 Y11624 $901.87 Y11626 $1,765.57 Y11640 $382.61 Y11641 $451.89 Y11642 $515.33 Y11643 $605.97 Y11644 $901.87 Y11646 $1,765.57 Y11719 Bundled NA11720 Bundled NA11721 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


11730 Bundled NA11732 Bundled NA11740 Bundled NA11750 $291.33 Y11755 $250.54 Y11760 $422.49 Y11762 $531.52 Y11765 Bundled NA11770 $1,765.57 Y11771 $1,765.57 Y11772 $1,765.57 Y11900 Bundled NA11901 Bundled NA11920 $326.94 Y11921 $374.84 Y11922 Bundled NA11950 $132.72 Y11951 $190.98 Y11952 $246.01 Y11954 $294.57 Y11960 $2,345.64 Y11970 $4,520.99 Y11971 $1,765.57 N11976 Not covered NA11980 Not covered NA11981 Bundled NA11982 Bundled NA11983 Bundled NA12001 Bundled NA12002 Bundled NA12004 Bundled NA12005 $268.96 N12006 $268.96 N12007 $146.20 Y12011 Bundled NA12013 Bundled NA12014 Bundled NA12015 $146.20 N12016 $268.96 N12017 $268.96 N12018 $146.20 N12020 $422.49 Y12021 $268.96 Y12031 $452.53 Y12032 $268.96 Y12034 $268.96 Y12035 $268.96 Y12036 $422.49 Y12037 $1,357.31 Y12041 $451.89 N12042 $268.96 Y




CPT ®

HCPCS Code


Subject To Multiple


12044 $422.49 Y12045 $422.49 Y12046 $268.96 Y12047 $1,357.31 Y12051 $268.96 Y12052 $268.96 Y12053 $268.96 Y12054 $268.96 N12055 $268.96 Y12056 $268.96 N12057 $268.96 Y13100 $422.49 Y13101 $422.49 Y13102 Bundled NA13120 $422.49 Y13121 $422.49 Y13122 Bundled NA13131 $268.96 Y13132 $422.49 Y13133 Bundled NA13151 $422.49 Y13152 $422.49 Y13153 Bundled NA13160 $1,357.31 Y14000 $1,357.31 Y14001 $1,357.31 Y14020 $1,357.31 Y14021 $1,357.31 Y14040 $1,357.31 Y14041 $1,357.31 Y14060 $1,357.31 Y14061 $1,357.31 Y14301 $2,345.64 Y14302 Bundled NA14350 $1,357.31 Y15002 $1,357.31 Y15003 Bundled NA15004 $422.49 Y15005 Bundled NA15040 $1,357.31 Y15050 $422.49 Y15100 $1,357.31 Y15101 Bundled NA15110 $1,357.31 Y15111 Bundled NA15115 $1,357.31 Y15116 Bundled NA15120 $2,345.64 Y15121 Bundled NA15130 $1,357.31 Y15131 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


15135 $2,345.64 Y15136 Bundled NA15150 $1,357.31 Y15151 Bundled NA15152 Bundled NA15155 $2,345.64 Y15156 Bundled NA15157 Bundled NA15200 $1,357.31 Y15201 Bundled NA15220 $1,357.31 Y15221 Bundled NA15240 $1,357.31 Y15241 Bundled NA15260 $1,357.31 Y15261 Bundled NA15271 $1,357.31 Y15272 Bundled NA15273 $2,345.64 Y15274 Bundled NA15275 $1,357.31 Y15276 Bundled NA15277 $1,357.31 Y15278 Bundled NA15570 $1,357.31 Y15572 $2,345.64 Y15574 $1,357.31 Y15576 $1,357.31 Y15600 $2,345.64 Y15610 $1,357.31 Y15620 $1,357.31 Y15630 $1,357.31 Y15650 $1,357.31 Y15730 $2,345.64 Y15731 $2,345.64 Y15733 $2,345.64 Y15734 $2,345.64 Y15736 $1,357.31 Y15738 $2,345.64 Y15740 $1,357.31 Y15750 $2,345.64 Y15760 $1,357.31 Y15770 $2,345.64 Y15775 $268.96 Y15776 $268.96 Y15777 Bundled NA15780 $1,782.94 Y15781 $495.74 Y15782 $1,154.96 Y15783 $268.96 Y15786 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


15787 Bundled NA15788 Not covered NA15789 Not covered NA15792 Not covered NA15793 Not covered NA15819 Not covered NA15820 $1,357.31 Y15821 $1,357.31 Y15822 $1,357.31 Y15823 $1,357.31 Y15824 $1,357.31 Y15825 $2,345.64 Y15826 $2,345.64 Y15828 $2,345.64 Y15829 $2,345.64 Y15830 $3,399.06 Y15832 $1,765.57 Y15833 $1,765.57 Y15834 $1,765.57 Y15835 $1,765.57 Y15836 $1,765.57 Y15837 $1,765.57 Y15838 $1,765.57 Y15839 $1,765.57 Y15840 $2,345.64 Y15841 $2,345.64 Y15842 $1,357.31 Y15845 $2,345.64 Y15847 Bundled NA15850 $422.49 Y15851 $189.04 Y15852 Bundled NA15860 Bundled NA15876 Not covered NA15877 Not covered NA15878 Not covered NA15879 Not covered NA15920 $1,765.57 Y15922 $2,345.64 Y15931 $901.87 Y15933 $1,765.57 Y15934 $2,345.64 Y15935 $2,345.64 Y15936 $1,357.31 Y15937 $1,357.31 Y15940 $1,765.57 Y15941 $1,765.57 Y15944 $2,345.64 Y15945 $1,357.31 Y15946 $1,357.31 Y15950 $901.87 Y




CPT ®

HCPCS Code


Subject To Multiple


15951 $1,765.57 Y15952 $1,357.31 Y15953 $2,345.64 Y15956 $1,357.31 Y15958 $2,345.64 Y16000 Bundled NA16020 Bundled NA16025 $146.20 Y16030 $268.96 Y16035 $268.96 Y17000 Bundled NA17003 Bundled NA17004 $273.85 Y17106 $268.96 Y17107 $831.26 Y17108 $1,221.64 Y17110 Bundled NA17111 Bundled NA17250 Bundled NA17260 Bundled NA17261 Bundled NA17262 Bundled NA17263 Bundled NA17264 $389.73 Y17266 $439.58 Y17270 $146.20 Y17271 $146.20 Y17272 Bundled NA17273 $393.62 Y17274 $464.83 Y17276 $536.69 Y17280 Bundled NA17281 $337.94 Y17282 $387.15 Y17283 $462.89 Y17284 $529.57 Y17286 $673.94 Y17311 $422.49 Y17312 Bundled NA17313 $422.49 Y17314 Bundled NA17315 Bundled NA17340 Not covered NA17360 Not covered NA17380 Not covered NA19000 $214.29 Y19001 Bundled NA19020 $901.87 Y19030 Bundled NA19081 $901.87 Y19082 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


19083 $901.87 Y19084 Bundled NA19085 $901.87 Y19086 Bundled NA19100 $901.87 Y19101 $1,711.08 Y19105 Not covered NA19110 $1,711.08 Y19112 $1,711.08 Y19120 $1,711.08 Y19125 $1,711.08 Y19126 Bundled NA19281 Bundled NA19282 Bundled NA19283 Bundled NA19284 Bundled NA19285 Bundled NA19286 Bundled NA19287 Bundled NA19288 Bundled NA19294 Bundled NA19296 Not covered NA19297 Not covered NA19298 Not covered NA19300 Not covered NA19301 Not covered NA19302 Not covered NA19303 Not covered NA19304 Not covered NA19316 $3,399.06 Y19318 $3,399.06 Y19324 $4,076.27 Y19325 $4,076.27 Y19328 $1,711.08 N19330 $1,711.08 N19340 $3,399.06 Y19342 $4,076.27 Y19350 $1,711.08 Y19355 Not covered NA19357 $5,134.28 Y19366 $3,399.06 Y19370 $1,711.08 Y19371 $1,711.08 Y19380 $3,399.06 Y19396 $1,711.08 Y20103 $495.74 Y20150 $2,126.29 Y20200 $901.87 Y20205 $1,765.57 Y20206 $901.87 Y20220 $901.87 Y




CPT ®

HCPCS Code


Subject To Multiple


20225 $901.87 Y20240 $1,765.57 Y20245 $1,765.57 Y20250 $2,126.29 Y20251 $4,520.99 Y20500 $199.40 Y20501 Bundled NA20520 $390.38 Y20525 $1,765.57 Y20526 $146.31 Y20527 $159.26 Y20550 $99.70 Y20551 $114.59 Y20552 $104.23 Y20553 $120.42 Y20555 Not covered NA20600 $90.64 Y20604 $135.95 Y20605 $95.17 Y20606 $150.84 Y20610 $113.94 Y20611 $170.91 Y20612 $113.94 Y20615 $457.71 Y20650 $2,126.29 Y20662 $1,225.33 Y20663 $2,126.29 Y20665 $285.59 N20670 $901.87 N20680 $1,765.57 N20690 $4,520.99 Y20692 $15,302.58 Y20693 $4,520.99 Y20694 $1,225.33 N20696 $12,523.68 Y20697 $1,225.33 Y20822 $1,225.33 Y20900 $4,520.99 Y20902 $4,520.99 Y20910 $422.49 Y20912 $2,345.64 Y20920 $1,357.31 Y20922 $1,357.31 Y20924 $4,520.99 Y20926 $2,345.64 Y20931 Bundled NA20932 Bundled NA20933 Bundled NA20934 Bundled NA20936 Bundled NA20939 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


20950 $495.74 Y20972 $4,520.99 Y20973 $4,520.99 Y20975 Bundled NA20979 Bundled NA20982 Not covered NA20983 Not covered NA20985 Bundled NA21010 $1,581.85 Y21011 $661.00 Y21012 $901.87 Y21013 $985.34 Y21014 $1,765.57 Y21015 $1,765.57 Y21025 $3,559.29 Y21026 $3,559.29 Y21029 $1,581.85 Y21030 $989.23 Y21031 $761.34 Y21032 $767.17 Y21034 $3,559.29 Y21040 $1,581.85 Y21044 $3,559.29 Y21046 $3,559.29 Y21047 $3,559.29 Y21048 $3,559.29 Y21050 $3,559.29 Y21060 $3,559.29 Y21070 $3,559.29 Y21073 $735.45 Y21076 $1,863.86 Y21077 $4,690.41 Y21079 $3,167.08 Y21080 $3,566.53 Y21081 $3,281.02 Y21082 $3,093.28 Y21083 $2,950.20 Y21084 $3,383.31 Y21085 $397.97 Y21086 $3,479.78 Y21087 $3,485.60 Y21088 $1,581.85 Y21100 $3,559.29 Y21110 $1,527.86 N21116 Bundled NA21120 $3,559.29 Y21121 $1,581.85 Y21122 $3,559.29 Y21123 $1,581.85 Y21125 $3,559.29 Y21127 $3,559.29 Y




CPT ®

HCPCS Code


Subject To Multiple


21137 $1,581.85 Y21138 $3,559.29 Y21139 $3,559.29 Y21150 $3,559.29 Y21181 $3,559.29 Y21198 $3,559.29 Y21199 $3,559.29 Y21206 $3,559.29 Y21208 $3,559.29 Y21209 $3,559.29 Y21210 $3,559.29 Y21215 $3,559.29 Y21230 $3,559.29 Y21235 $3,559.29 Y21240 $3,559.29 Y21242 $3,559.29 Y21243 $25,456.84 Y21244 $3,559.29 Y21245 $3,559.29 Y21246 $3,559.29 Y21248 $3,559.29 Y21249 $3,559.29 Y21260 Not covered NA21267 Not covered NA21270 $3,559.29 Y21275 $3,559.29 Y21280 $1,581.85 Y21282 $1,581.85 Y21295 Not covered NA21296 Not covered NA21310 $185.98 Y21315 $984.97 Y21320 $1,581.85 Y21325 $1,581.85 Y21330 $3,559.29 Y21335 $1,581.85 Y21336 $2,126.29 Y21337 $1,581.85 Y21338 $3,559.29 Y21339 $3,559.29 Y21340 $1,581.85 Y21345 $984.97 Y21355 $1,581.85 Y21356 $3,559.29 Y21360 $3,559.29 Y21390 $3,559.29 Y21400 $397.97 Y21401 $984.97 Y21406 $3,559.29 Y21407 $3,559.29 Y21421 $1,581.85 Y




CPT ®

HCPCS Code


Subject To Multiple


21440 $1,114.18 Y21445 $3,559.29 Y21450 $397.97 Y21451 $984.97 Y21452 $3,559.29 Y21453 $3,559.29 Y21454 $3,559.29 Y21461 $3,559.29 Y21462 $3,559.29 Y21465 $3,559.29 Y21480 $185.98 Y21485 $984.97 Y21490 $1,581.85 Y21497 $984.97 Y21501 $1,765.57 Y21502 $2,126.29 Y21550 $901.87 Y21552 $1,765.57 Y21554 $1,765.57 Y21555 $901.87 Y21556 $1,765.57 Y21557 $1,765.57 Y21600 $4,520.99 Y21610 $2,126.29 Y21685 Not covered NA21700 $2,126.29 Y21720 $2,126.29 Y21725 $495.74 Y21820 $185.98 Y21920 $490.73 Y21925 $901.87 Y21930 $901.87 Y21931 $901.87 Y21932 $1,765.57 Y21933 $1,765.57 Y21935 $1,765.57 Y22102 $4,520.99 Y22103 Bundled NA22310 $185.98 Y22315 $1,225.33 Y22505 $1,225.33 Y22510 Not covered NA22511 Not covered NA22512 Not covered NA22513 Not covered NA22514 Not covered NA22515 Not covered NA22551 $16,034.95 Y22552 Bundled NA22554 $15,453.33 Y22612 $8,421.19 Y




CPT ®

HCPCS Code


Subject To Multiple


22614 Bundled NA22845 Bundled NA22850 UR/BR N22852 UR/BR N22853 Bundled NA22854 Bundled NA22856 $24,507.06 Y22858 Bundled NA22859 Bundled NA22867 $12,523.68 Y22868 Bundled NA22869 $12,523.68 Y22870 Bundled NA22900 $1,765.57 Y22901 $1,765.57 Y22902 $901.87 Y22903 $1,765.57 Y23000 $1,765.57 Y23020 $2,126.29 Y23030 $1,765.57 Y23031 $901.87 Y23035 $1,225.33 Y23040 $2,126.29 Y23044 $2,126.29 Y23065 Not covered NA23066 $1,765.57 Y23071 $901.87 Y23073 $1,765.57 Y23075 $901.87 Y23076 $1,765.57 Y23077 Not covered NA23100 $1,225.33 Y23101 $2,126.29 Y23105 $4,520.99 Y23106 $2,126.29 Y23107 $4,520.99 Y23120 $2,126.29 Y23125 $2,126.29 Y23130 $2,126.29 Y23140 $2,126.29 Y23145 $2,126.29 Y23146 $4,520.99 Y23150 $2,126.29 Y23155 $4,520.99 Y23156 $4,520.99 Y23170 $1,225.33 Y23172 $2,126.29 Y23174 $2,126.29 Y23180 $2,126.29 Y23182 $2,126.29 Y23184 $4,520.99 Y




CPT ®

HCPCS Code


Subject To Multiple


23190 $2,126.29 Y23195 $4,520.99 Y23330 $495.74 Y23333 $901.87 Y23334 $1,765.57 Y23350 Bundled NA23395 $4,520.99 Y23397 $4,520.99 Y23400 $4,520.99 Y23405 $4,520.99 Y23406 $4,749.30 Y23410 $4,520.99 Y23412 $4,520.99 Y23415 $4,520.99 Y23420 $4,520.99 Y23430 $4,520.99 Y23440 $2,126.29 Y23450 $4,520.99 Y23455 $4,520.99 Y23460 $4,520.99 Y23462 $4,520.99 Y23465 $4,520.99 Y23466 $4,520.99 Y23480 $4,520.99 Y23485 $8,421.19 Y23490 $4,520.99 Y23491 $8,421.19 Y23500 $185.98 Y23505 $1,225.33 Y23515 $4,520.99 Y23520 $1,225.33 Y23525 $185.98 Y23530 $4,520.99 Y23532 $4,520.99 Y23540 $185.98 Y23545 $185.98 Y23550 $4,520.99 Y23552 $4,520.99 Y23570 $185.98 Y23575 $1,225.33 Y23585 $4,520.99 Y23600 $185.98 Y23605 $1,225.33 Y23615 $15,609.17 Y23616 $24,372.25 Y23620 $185.98 Y23625 $1,225.33 Y23630 $4,520.99 Y23650 $185.98 Y23655 $1,225.33 Y23660 $4,520.99 Y




CPT ®

HCPCS Code


Subject To Multiple


23665 $1,225.33 Y23670 $4,520.99 Y23675 $1,225.33 Y23680 $8,421.19 Y23700 $1,225.33 Y23800 $4,520.99 Y23802 $8,421.19 Y23921 $1,357.31 Y23930 $901.87 Y23931 $901.87 Y23935 $2,126.29 Y24000 $2,126.29 Y24006 $2,126.29 Y24065 $490.73 Y24066 $1,765.57 Y24071 $1,765.57 Y24073 $1,765.57 Y24075 $901.87 Y24076 $1,765.57 Y24077 Not covered NA24100 $2,126.29 Y24101 $2,126.29 Y24102 $2,126.29 Y24105 $2,126.29 Y24110 $2,126.29 Y24115 $4,520.99 Y24116 $4,520.99 Y24120 $2,126.29 Y24125 $2,126.29 Y24126 $4,520.99 Y24130 $2,126.29 Y24134 $4,520.99 Y24136 $2,126.29 Y24138 $4,520.99 Y24140 $2,126.29 Y24145 $4,520.99 Y24147 $2,126.29 Y24149 $4,520.99 Y24152 Not covered NA24155 $2,126.29 Y24160 $2,126.29 N24164 $2,126.29 N24200 $396.21 Y24201 $1,765.57 Y24220 Bundled NA24300 $1,225.33 Y24301 $4,520.99 Y24305 $2,126.29 Y24310 $2,126.29 Y24320 $4,520.99 Y24330 $2,126.29 Y




CPT ®

HCPCS Code


Subject To Multiple


24331 $4,520.99 Y24332 $2,126.29 Y24340 $4,520.99 Y24341 $4,520.99 Y24342 $4,520.99 Y24343 $2,126.29 Y24344 $4,520.99 Y24345 $4,520.99 Y24346 $8,421.19 Y24357 $1,225.33 Y24358 $2,126.29 Y24359 $2,126.29 Y24360 $4,520.99 Y24361 $24,932.72 Y24362 $8,421.19 Y24363 $25,902.19 Y24365 $8,421.19 Y24366 $17,047.42 Y24370 $15,501.19 Y24371 $23,948.09 Y24400 $4,520.99 Y24410 Not covered NA24420 Not covered NA24430 $8,421.19 Y24435 $15,259.79 Y24470 $2,126.29 Y24495 $4,520.99 Y24498 $8,421.19 Y24500 $185.98 Y24505 $1,225.33 Y24515 $8,421.19 Y24516 $8,421.19 Y24530 $185.98 Y24535 $1,225.33 Y24538 $4,520.99 Y24545 $15,482.87 Y24546 $22,980.12 Y24560 $185.98 Y24565 $1,225.33 Y24566 $1,225.33 Y24575 $8,421.19 Y24576 $185.98 Y24577 $1,225.33 Y24579 $8,421.19 Y24582 $2,126.29 Y24586 $8,421.19 Y24587 $15,434.99 Y24600 $185.98 Y24605 $1,225.33 Y24615 $4,520.99 Y24620 $1,225.33 Y




CPT ®

HCPCS Code


Subject To Multiple


24635 $4,520.99 Y24640 Not covered NA24650 $185.98 Y24655 $1,225.33 Y24665 $4,520.99 Y24666 $17,230.77 Y24670 $185.98 Y24675 $1,225.33 Y24685 $4,520.99 Y24800 $4,520.99 Y24802 $8,421.19 Y24925 $2,126.29 Y25000 $1,225.33 Y25001 $1,225.33 Y25020 $1,225.33 Y25023 $2,126.29 Y25024 $2,126.29 Y25025 $1,225.33 Y25028 $2,126.29 Y25031 $1,225.33 Y25035 $4,520.99 Y25040 $2,126.29 Y25065 $485.55 Y25066 $1,765.57 Y25071 $901.87 Y25073 $1,765.57 Y25075 $901.87 Y25076 $901.87 Y25077 Not covered NA25085 $2,126.29 Y25100 $1,225.33 Y25101 $2,126.29 Y25105 $2,126.29 Y25107 $2,126.29 Y25109 $2,126.29 Y25110 $1,225.33 Y25111 $1,225.33 Y25112 $1,225.33 Y25115 $1,225.33 Y25116 $2,126.29 Y25118 $1,225.33 Y25119 $2,126.29 Y25120 $2,126.29 Y25125 $1,225.33 Y25126 $2,126.29 Y25130 $2,126.29 Y25135 $2,126.29 Y25136 $4,520.99 Y25145 $2,126.29 Y25150 $2,126.29 Y25151 $2,126.29 Y




CPT ®

HCPCS Code


Subject To Multiple


25210 $2,126.29 Y25215 $2,126.29 Y25230 $2,126.29 Y25240 $2,126.29 Y25246 Bundled NA25248 $1,225.33 Y25250 $1,225.33 N25251 $2,126.29 N25259 $1,225.33 Y25260 $2,126.29 Y25263 $2,126.29 Y25265 $2,126.29 Y25270 $2,126.29 Y25272 $2,126.29 Y25274 $2,126.29 Y25275 $2,126.29 Y25280 $2,126.29 Y25290 $2,126.29 Y25295 $2,126.29 Y25300 $2,126.29 Y25301 $2,126.29 Y25310 $2,126.29 Y25312 $2,126.29 Y25315 $4,520.99 Y25316 $4,520.99 Y25320 $4,520.99 Y25332 $2,126.29 Y25335 Not covered NA25337 $4,520.99 Y25350 $8,360.79 Y25355 $2,126.29 Y25360 $4,520.99 Y25365 $8,421.19 Y25370 $2,126.29 Y25375 $2,126.29 Y25390 $4,520.99 Y25391 $16,226.42 Y25392 $2,126.29 Y25393 $2,126.29 Y25394 $2,126.29 Y25400 $4,520.99 Y25405 $4,520.99 Y25415 $4,520.99 Y25420 $4,520.99 Y25425 $4,520.99 Y25426 $2,126.29 Y25430 $2,126.29 Y25431 $4,520.99 Y25440 $4,520.99 Y25441 $18,073.15 Y25442 $26,082.46 Y




CPT ®

HCPCS Code


Subject To Multiple


25443 $9,469.78 Y25444 $19,209.89 Y25445 $4,520.99 Y25446 $27,321.57 Y25447 $2,126.29 Y25449 $4,520.99 Y25450 $2,126.29 Y25455 $2,126.29 Y25490 $4,520.99 Y25491 $8,421.19 Y25492 $2,126.29 Y25500 $185.98 Y25505 $1,225.33 Y25515 $4,520.99 Y25520 $1,225.33 Y25525 $4,520.99 Y25526 $4,520.99 Y25530 $185.98 Y25535 $185.98 Y25545 $4,520.99 Y25560 $185.98 Y25565 $1,225.33 Y25574 $4,520.99 Y25575 $4,520.99 Y25600 $185.98 Y25605 $1,225.33 Y25606 $2,126.29 Y25607 $8,349.30 Y25608 $8,335.64 Y25609 $8,426.95 Y25622 $185.98 Y25624 $1,225.33 Y25628 $4,520.99 Y25630 $185.98 Y25635 $1,225.33 Y25645 $2,126.29 Y25650 $185.98 Y25651 $2,126.29 Y25652 $4,520.99 Y25660 $185.98 Y25670 $2,126.29 Y25671 $2,126.29 Y25675 $185.98 Y25676 $4,520.99 Y25680 $185.98 Y25685 $2,126.29 Y25690 $1,225.33 Y25695 $4,520.99 Y25800 $4,520.99 Y25805 $4,520.99 Y25810 $8,421.19 Y




CPT ®

HCPCS Code


Subject To Multiple


25820 $4,520.99 Y25825 $4,520.99 Y25830 $4,520.99 Y25907 $2,126.29 Y25922 $1,225.33 Y25929 $1,357.31 Y25931 $2,126.29 Y25999 UR/BR N26010 $146.20 Y26011 $901.87 Y26020 $2,126.29 Y26025 $1,225.33 Y26030 $2,126.29 Y26034 $1,225.33 Y26035 $1,225.33 Y26040 $1,225.33 Y26045 $2,126.29 Y26055 $1,225.33 Y26060 $1,225.33 Y26070 $1,225.33 Y26075 $2,126.29 Y26080 $1,225.33 Y26100 $2,126.29 Y26105 $2,126.29 Y26110 $1,225.33 Y26111 $901.87 Y26113 $901.87 Y26115 $901.87 Y26116 $901.87 Y26117 Not covered NA26121 $2,126.29 Y26123 $2,126.29 Y26125 Bundled NA26130 $2,126.29 Y26135 $2,126.29 Y26140 $1,225.33 Y26145 $1,225.33 Y26160 $1,225.33 Y26170 $1,225.33 Y26180 $1,225.33 Y26185 $1,225.33 Y26200 $1,225.33 Y26205 $4,520.99 Y26210 $1,225.33 Y26215 $2,126.29 Y26230 $2,126.29 Y26235 $1,225.33 Y26236 $1,225.33 Y26250 $1,225.33 Y26260 $2,126.29 Y26262 $1,225.33 Y




CPT ®

HCPCS Code


Subject To Multiple


26320 $901.87 N26340 $1,225.33 Y26341 $189.04 Y26350 $2,126.29 Y26352 $2,126.29 Y26356 $2,126.29 Y26357 $2,126.29 Y26358 $2,126.29 Y26370 $2,126.29 Y26372 $4,520.99 Y26373 $2,126.29 Y26390 $4,520.99 Y26392 $4,520.99 Y26410 $1,225.33 Y26412 $2,126.29 Y26415 $1,225.33 Y26416 $2,126.29 Y26418 $1,225.33 Y26420 $2,126.29 Y26426 $2,126.29 Y26428 $2,126.29 Y26432 $1,225.33 Y26433 $2,126.29 Y26434 $2,126.29 Y26437 $1,225.33 Y26440 $1,225.33 Y26442 $2,126.29 Y26445 $2,126.29 Y26449 $2,126.29 Y26450 $2,126.29 Y26455 $1,225.33 Y26460 $1,225.33 Y26471 $2,126.29 Y26474 $1,225.33 Y26476 $1,225.33 Y26477 $2,126.29 Y26478 $2,126.29 Y26479 $1,225.33 Y26480 $2,126.29 Y26483 $2,126.29 Y26485 $2,126.29 Y26489 $2,126.29 Y26490 $2,126.29 Y26492 $2,126.29 Y26494 $2,126.29 Y26496 $2,126.29 Y26497 $2,126.29 Y26498 $2,126.29 Y26499 $1,225.33 Y26500 $4,520.99 Y26502 $2,126.29 Y




CPT ®

HCPCS Code


Subject To Multiple


26508 $2,126.29 Y26510 $2,126.29 Y26516 $2,126.29 Y26517 $2,126.29 Y26518 $2,126.29 Y26520 $2,126.29 Y26525 $1,225.33 Y26530 $2,126.29 Y26531 $8,331.25 Y26535 $2,126.29 Y26536 $4,520.99 Y26540 $2,126.29 Y26541 $2,126.29 Y26542 $2,126.29 Y26545 $2,126.29 Y26546 $4,520.99 Y26548 $2,126.29 Y26550 $2,126.29 Y26555 $4,520.99 Y26560 $1,225.33 Y26561 $2,126.29 Y26562 $2,126.29 Y26565 $2,126.29 Y26567 $2,126.29 Y26568 $4,520.99 Y26580 Not covered NA26587 Not covered NA26590 Not covered NA26591 $1,225.33 Y26593 $2,126.29 Y26596 $2,126.29 Y26600 $185.98 Y26605 $185.98 Y26607 $1,225.33 Y26608 $2,126.29 Y26615 $2,126.29 Y26641 $185.98 Y26645 $1,225.33 Y26650 $2,126.29 Y26665 $2,126.29 Y26670 $185.98 Y26675 $1,225.33 Y26676 $2,126.29 Y26685 $2,126.29 Y26686 $2,126.29 Y26700 $185.98 Y26705 $1,225.33 Y26706 $2,126.29 Y26715 $2,126.29 Y26720 $185.98 Y26725 $185.98 Y




CPT ®

HCPCS Code


Subject To Multiple


26727 $2,126.29 Y26735 $2,126.29 Y26740 $185.98 Y26742 $1,225.33 Y26746 $2,126.29 Y26750 $185.98 Y26755 $185.98 Y26756 $2,126.29 Y26765 $2,126.29 Y26770 $185.98 Y26775 $205.34 Y26776 $2,126.29 Y26785 $2,126.29 Y26820 $4,520.99 Y26841 $4,520.99 Y26842 $4,520.99 Y26843 $4,520.99 Y26844 $4,520.99 Y26850 $4,520.99 Y26852 $4,520.99 Y26860 $2,126.29 Y26861 Bundled NA26862 $2,126.29 Y26863 Bundled NA26910 $2,126.29 Y26951 $2,126.29 Y26952 $2,126.29 Y26990 $2,126.29 Y26991 $1,225.33 Y27000 $1,225.33 Y27001 $2,126.29 Y27003 $4,520.99 Y27033 $2,126.29 Y27035 $2,126.29 Y27040 $901.87 Y27041 $901.87 Y27043 $1,765.57 Y27045 $1,765.57 Y27047 $1,765.57 Y27048 $1,765.57 Y27049 Not covered NA27050 $1,225.33 Y27052 $1,225.33 Y27060 $2,126.29 Y27062 $2,126.29 Y27065 $2,126.29 Y27066 $2,126.29 Y27067 $4,520.99 Y27080 $2,126.29 Y27086 $901.87 Y27087 $2,126.29 Y




CPT ®

HCPCS Code


Subject To Multiple


27093 Bundled NA27095 Bundled NA27097 $2,126.29 Y27098 $1,225.33 Y27100 $4,520.99 Y27105 $2,126.29 Y27110 $4,520.99 Y27111 $2,126.29 Y27197 $185.98 Y27198 $185.98 Y27200 $347.01 Y27202 $2,126.29 Y27220 $185.98 Y27230 $185.98 Y27238 $1,225.33 Y27246 $185.98 Y27250 $185.98 Y27252 $1,225.33 Y27256 $185.98 Y27257 $1,225.33 Y27265 $185.98 Y27266 $1,225.33 Y27267 $1,225.33 Y27275 $1,225.33 Y27279 $27,223.11 Y27301 $1,765.57 Y27305 $2,126.29 Y27306 $1,225.33 Y27307 $2,126.29 Y27310 $2,126.29 Y27323 $901.87 Y27324 $1,765.57 Y27325 $1,304.80 Y27326 $1,304.80 Y27327 $901.87 Y27328 $1,765.57 Y27329 $1,765.57 Y27330 $2,126.29 Y27331 $2,126.29 Y27332 $2,126.29 Y27333 $2,126.29 Y27334 $2,126.29 Y27335 $4,520.99 Y27337 $1,765.57 Y27339 $1,765.57 Y27340 $2,126.29 Y27345 $2,126.29 Y27347 $2,126.29 Y27350 $2,126.29 Y27355 $2,126.29 Y27356 $8,421.19 Y




CPT ®

HCPCS Code


Subject To Multiple


27357 $4,520.99 Y27358 Bundled NA27360 $2,126.29 Y27369 Bundled NA27372 $1,765.57 Y27380 $4,520.99 Y27381 $4,520.99 Y27385 $4,520.99 Y27386 $4,520.99 Y27390 $2,126.29 Y27391 $2,126.29 Y27392 $2,126.29 Y27393 $2,126.29 Y27394 $4,520.99 Y27395 $2,126.29 Y27396 $4,520.99 Y27397 $4,520.99 Y27400 $4,520.99 Y27403 $2,126.29 Y27405 $4,520.99 Y27407 $4,520.99 Y27409 $4,520.99 Y27416 $4,520.99 Y27418 $4,520.99 Y27420 $4,520.99 Y27422 $4,520.99 Y27424 $4,520.99 Y27425 $2,126.29 Y27427 $4,520.99 Y27428 $8,421.19 Y27429 $8,421.19 Y27430 $4,520.99 Y27435 $2,126.29 Y27437 $4,520.99 Y27438 $15,359.61 Y27440 $15,941.23 Y27441 $8,421.19 Y27442 $16,051.23 Y27443 $8,421.19 Y27446 $16,116.42 Y27496 $2,126.29 Y27497 $2,126.29 Y27498 $1,225.33 Y27499 $2,126.29 Y27500 $185.98 Y27501 $185.98 Y27502 $1,225.33 Y27503 $1,225.33 Y27508 $185.98 Y27509 $4,520.99 Y27510 $1,225.33 Y




CPT ®

HCPCS Code


Subject To Multiple


27516 $185.98 Y27517 $1,225.33 Y27520 $185.98 Y27524 $4,520.99 Y27530 $185.98 Y27532 $2,126.29 Y27538 $185.98 Y27550 $185.98 Y27552 $1,225.33 Y27560 $185.98 Y27562 $185.98 Y27566 $4,520.99 Y27570 $1,225.33 Y27594 $2,126.29 Y27600 $2,126.29 Y27601 $2,126.29 Y27602 $2,126.29 Y27603 $1,765.57 Y27604 $1,225.33 Y27605 $1,225.33 Y27606 $2,126.29 Y27607 $2,126.29 Y27610 $2,126.29 Y27612 $2,126.29 Y27613 $485.55 Y27614 $1,765.57 Y27615 Not covered NA27618 $901.87 Y27619 $1,765.57 Y27620 $2,126.29 Y27625 $2,126.29 Y27626 $2,126.29 Y27630 $2,126.29 Y27632 $1,765.57 Y27634 $1,765.57 Y27635 $2,126.29 Y27637 $4,520.99 Y27638 $4,520.99 Y27640 $2,126.29 Y27641 $2,126.29 Y27647 $2,126.29 Y27648 Bundled NA27650 $2,126.29 Y27652 $4,520.99 Y27654 $4,520.99 Y27656 $2,126.29 Y27658 $2,126.29 Y27659 $4,520.99 Y27664 $4,520.99 Y27665 $4,520.99 Y27675 $2,126.29 Y




CPT ®

HCPCS Code


Subject To Multiple


27676 $4,520.99 Y27680 $2,126.29 Y27681 $2,126.29 Y27685 $2,126.29 Y27686 $2,126.29 Y27687 $2,126.29 Y27690 $4,520.99 Y27691 $4,520.99 Y27692 Bundled NA27695 $4,520.99 Y27696 $4,520.99 Y27698 $4,520.99 Y27700 $4,520.99 Y27704 $2,126.29 N27705 $4,520.99 Y27707 $2,126.29 Y27709 $8,421.19 Y27726 $4,520.99 Y27730 $2,126.29 Y27732 $2,126.29 Y27734 $2,126.29 Y27740 $3,852.24 Y27742 $2,126.29 Y27745 $4,520.99 Y27750 $185.98 Y27752 $1,225.33 Y27756 $4,520.99 Y27758 $8,421.19 Y27759 $8,421.19 Y27760 $185.98 Y27762 $1,225.33 Y27766 $4,520.99 Y27767 $185.98 Y27768 $1,225.33 Y27769 $4,520.99 Y27780 $185.98 Y27781 $1,225.33 Y27784 $4,520.99 Y27786 $185.98 Y27788 $185.98 Y27792 $4,520.99 Y27808 $185.98 Y27810 $1,225.33 Y27814 $4,520.99 Y27816 $185.98 Y27818 $1,225.33 Y27822 $4,520.99 Y27823 $4,520.99 Y27824 $185.98 Y27825 $1,225.33 Y27826 $4,520.99 Y




CPT ®

HCPCS Code


Subject To Multiple


27827 $8,421.19 Y27828 $8,421.19 Y27829 $4,520.99 Y27830 $185.98 Y27831 $2,126.29 Y27832 $4,520.99 Y27840 $185.98 Y27842 $1,225.33 Y27846 $4,520.99 Y27848 $4,520.99 Y27860 $1,225.33 Y27870 $15,679.45 Y27871 $8,421.19 Y27884 $2,126.29 Y27889 $4,520.99 Y27892 $2,126.29 Y27893 $4,520.99 Y27894 $1,225.33 Y27899 $188.20 Y28001 $530.87 Y28002 $1,225.33 Y28003 $2,126.29 Y28005 $2,126.29 Y28008 $2,126.29 Y28010 $442.17 Y28011 $1,225.33 Y28020 $2,126.29 Y28022 $2,126.29 Y28024 $1,225.33 Y28035 $1,304.80 Y28039 $1,765.57 Y28041 $1,765.57 Y28043 $901.87 Y28045 $1,765.57 Y28046 Not covered NA28050 $2,126.29 Y28052 $2,126.29 Y28054 $2,126.29 Y28055 $1,304.80 Y28060 $2,126.29 Y28062 $2,126.29 Y28070 $2,126.29 Y28072 $2,126.29 Y28080 $1,225.33 Y28086 $2,126.29 Y28088 $1,225.33 Y28090 $1,225.33 Y28092 $1,225.33 Y28100 $2,126.29 Y28102 $4,520.99 Y28103 $4,520.99 Y




CPT ®

HCPCS Code


Subject To Multiple


28104 $2,126.29 Y28106 $4,520.99 Y28107 $4,520.99 Y28108 $1,225.33 Y28110 $2,126.29 Y28111 $2,126.29 Y28112 $2,126.29 Y28113 $2,126.29 Y28114 $2,126.29 Y28116 $2,126.29 Y28118 $2,126.29 Y28119 $2,126.29 Y28120 $2,126.29 Y28122 $2,126.29 Y28124 $921.25 Y28126 $1,225.33 Y28130 $2,126.29 Y28140 $2,126.29 Y28150 $2,126.29 Y28153 $1,225.33 Y28160 $2,126.29 Y28171 Not covered NA28173 Not covered NA28175 Not covered NA28190 $501.09 Y28192 $901.87 Y28193 $901.87 Y28200 $2,126.29 Y28202 $4,520.99 Y28208 $2,126.29 Y28210 $4,520.99 Y28220 $869.46 Y28222 $2,126.29 Y28225 $2,126.29 Y28226 $1,225.33 Y28230 $839.68 Y28232 $748.39 Y28234 $1,225.33 Y28238 $4,520.99 Y28240 $2,126.29 Y28250 $2,126.29 Y28260 $1,225.33 Y28261 $1,225.33 Y28262 $4,520.99 Y28264 $1,225.33 Y28270 $2,126.29 Y28272 $760.05 Y28280 $2,126.29 Y28285 $2,126.29 Y28286 $1,225.33 Y28288 $2,126.29 Y




CPT ®

HCPCS Code


Subject To Multiple


28289 $2,126.29 Y28291 $4,520.99 Y28292 $2,126.29 Y28295 $2,126.29 Y28296 $2,126.29 Y28297 $4,520.99 Y28298 $4,520.99 Y28299 $2,126.29 Y28300 $4,520.99 Y28302 $4,520.99 Y28304 $4,520.99 Y28305 $4,520.99 Y28306 $4,520.99 Y28307 $2,126.29 Y28308 $2,126.29 Y28309 $4,520.99 Y28310 $2,126.29 Y28312 $2,126.29 Y28313 $2,126.29 Y28315 $2,126.29 Y28320 $8,421.19 Y28322 $4,520.99 Y28340 Not covered NA28341 Not covered NA28344 Not covered NA28345 Not covered NA28400 $185.98 Y28405 $185.98 Y28406 $4,520.99 Y28415 $4,520.99 Y28420 $15,805.77 Y28430 $185.98 Y28435 $1,225.33 Y28436 $4,520.99 Y28445 $4,520.99 Y28446 $4,520.99 Y28450 $185.98 Y28455 $550.29 Y28456 $4,520.99 Y28465 $4,520.99 Y28470 $185.98 Y28475 $185.98 Y28476 $2,126.29 Y28485 $4,520.99 Y28490 $281.62 Y28495 $185.98 Y28496 $2,126.29 Y28505 $2,126.29 Y28510 $238.24 Y28515 $311.40 Y28525 $2,126.29 Y




CPT ®

HCPCS Code


Subject To Multiple


28530 $224.00 Y28531 $4,520.99 Y28540 $185.98 Y28545 $2,126.29 Y28546 $1,225.33 Y28555 $4,520.99 Y28570 $185.98 Y28575 $2,126.29 Y28576 $1,225.33 Y28585 $8,997.87 Y28600 $185.98 Y28605 $185.98 Y28606 $2,126.29 Y28615 $4,520.99 Y28630 $300.39 Y28635 $1,225.33 Y28636 $1,225.33 Y28645 $2,126.29 Y28660 $222.06 Y28665 $205.34 Y28666 $2,126.29 Y28675 $2,126.29 Y28705 $22,977.08 Y28715 $15,887.25 Y28725 $8,421.19 Y28730 $16,209.12 Y28735 $16,156.16 Y28737 $16,286.52 Y28740 $8,337.82 Y28750 $8,333.46 Y28755 $4,520.99 Y28760 $4,520.99 Y28810 $2,126.29 Y28820 $1,225.33 Y28825 $1,225.33 Y28890 Not covered NA29000 $205.34 Y29010 $205.34 Y29015 $205.34 Y29035 $205.34 Y29040 $205.34 Y29044 $117.19 Y29046 $205.34 Y29049 $189.69 Y29055 $205.34 Y29058 $236.95 Y29065 $183.86 Y29075 $165.73 Y29085 $182.57 Y29086 $153.43 Y29105 $167.68 Y




CPT ®

HCPCS Code


Subject To Multiple


29125 Bundled NA29126 Bundled NA29130 Bundled NA29131 Bundled NA29200 $59.56 Y29240 Bundled NA29260 Bundled NA29280 Bundled NA29305 $205.34 Y29325 $205.34 Y29345 $258.96 Y29355 $266.73 Y29358 $307.52 Y29365 $235.01 Y29405 $155.38 Y29425 $148.90 Y29435 $225.30 Y29440 $82.87 Y29445 $247.31 Y29450 Not covered NA29505 $163.14 Y29515 $137.25 Y29520 Bundled NA29530 Bundled NA29540 $49.85 Y29550 Bundled NA29580 $116.53 Y29581 $162.50 Y29584 $152.14 Y29700 $124.30 Y29705 $125.60 Y29710 $235.65 Y29720 $163.14 Y29730 $119.77 Y29740 $189.04 Y29750 Not covered NA29800 $2,126.29 Y29804 $2,126.29 Y29805 $2,126.29 Y29806 $4,520.99 Y29807 $4,520.99 Y29819 $2,126.29 Y29820 $4,520.99 Y29821 $2,126.29 Y29822 $2,126.29 Y29823 $2,126.29 Y29824 $2,126.29 Y29825 $2,126.29 Y29826 Bundled NA29827 $4,520.99 Y29828 $4,520.99 Y




CPT ®

HCPCS Code


Subject To Multiple


29830 $2,126.29 Y29834 $2,126.29 Y29835 $2,126.29 Y29836 $4,520.99 Y29837 $2,126.29 Y29838 $2,126.29 Y29840 $2,126.29 Y29843 $2,126.29 Y29844 $2,126.29 Y29845 $2,126.29 Y29846 $2,126.29 Y29847 $4,520.99 Y29848 $1,225.33 Y29850 $1,225.33 Y29851 $1,225.33 Y29855 $8,184.16 Y29856 $17,530.24 Y29860 $4,520.99 Y29861 $2,126.29 Y29862 $4,520.99 Y29863 $2,126.29 Y29866 $4,520.99 Y29867 $8,865.27 Y29868 $4,909.89 Y29870 $2,126.29 Y29871 $2,126.29 Y29873 $2,126.29 Y29874 $2,126.29 Y29875 $2,126.29 Y29876 $2,126.29 Y29877 $2,126.29 Y29879 $2,126.29 Y29880 $2,126.29 Y29881 $2,126.29 Y29882 $2,126.29 Y29883 $2,126.29 Y29884 $2,126.29 Y29885 $4,520.99 Y29886 $2,126.29 Y29887 $4,520.99 Y29888 $4,520.99 Y29889 $8,421.19 Y29891 $2,126.29 Y29892 $4,520.99 Y29893 $2,126.29 Y29894 $2,126.29 Y29895 $2,126.29 Y29897 $2,126.29 Y29898 $2,126.29 Y29899 $4,520.99 Y29900 $2,126.29 Y




CPT ®

HCPCS Code


Subject To Multiple


29901 $2,126.29 Y29902 $1,225.33 Y29904 $2,126.29 Y29905 $2,126.29 Y29906 $2,126.29 Y29907 $8,421.19 Y29914 Not covered NA29915 Not covered NA29916 $4,520.99 Y29999 UR/BR N30000 $154.47 Y30020 $437.00 Y30100 $263.49 Y30110 $431.17 Y30115 $1,581.85 Y30117 $1,581.85 Y30118 $1,581.85 Y30120 Not covered NA30124 Not covered NA30125 Not covered NA30130 $1,581.85 Y30140 $1,581.85 Y30150 $3,559.29 Y30160 $3,559.29 Y30200 $211.05 Y30210 $281.62 Y30220 $984.97 Y30300 Bundled NA30310 $1,581.85 Y30320 $984.97 Y30400 $3,559.29 Y30410 $3,559.29 Y30420 $3,559.29 Y30430 $3,559.29 Y30435 $3,559.29 Y30450 $3,559.29 Y30460 Not covered NA30462 Not covered NA30465 $3,559.29 Y30520 $1,581.85 Y30540 Not covered NA30545 Not covered NA30560 $397.97 Y30580 $3,559.29 Y30600 $3,559.29 Y30620 $3,559.29 Y30630 $1,581.85 Y30801 $984.97 Y30802 $984.97 Y30901 Bundled NA30903 $90.90 Y




CPT ®

HCPCS Code


Subject To Multiple


30905 $90.90 Y30906 $154.47 Y30915 $2,157.21 Y30920 $2,157.21 Y30930 $1,581.85 Y31000 $154.47 Y31002 $984.97 Y31020 $1,581.85 Y31030 $3,559.29 Y31032 $3,559.29 Y31040 $3,559.29 Y31050 $3,559.29 Y31051 $3,559.29 Y31070 $3,559.29 Y31075 $3,559.29 Y31080 $3,559.29 Y31081 $3,559.29 Y31084 $3,559.29 Y31085 $3,559.29 Y31086 $3,559.29 Y31087 $3,559.29 Y31090 $3,559.29 Y31200 $3,559.29 Y31201 $1,581.85 Y31205 $1,581.85 Y31231 $135.94 Y31233 $324.93 Y31235 $977.20 Y31237 $977.20 Y31238 $977.20 Y31239 $1,907.68 Y31240 Not covered NA31253 $2,937.22 Y31254 $2,937.22 Y31255 $2,937.22 Y31256 $1,907.68 Y31257 $2,937.22 Y31259 $2,937.22 Y31267 $2,937.22 Y31276 $2,937.22 Y31287 $2,937.22 Y31288 $2,937.22 Y31295 $2,937.22 Y31296 $2,937.22 Y31297 $2,937.22 Y31298 $2,937.22 Y31300 Not covered NA31400 Not covered NA31420 Not covered NA31500 $154.47 Y31502 $154.47 Y




CPT ®

HCPCS Code


Subject To Multiple


31505 $156.02 Y31510 $1,907.68 Y31511 $135.94 Y31512 $1,907.68 Y31513 $324.93 Y31515 $324.93 Y31520 Not covered NA31525 $977.20 Y31526 $977.20 Y31527 $1,907.68 Y31528 $1,907.68 Y31529 $1,907.68 Y31530 $977.20 Y31531 $1,907.68 Y31535 $1,907.68 Y31536 $1,907.68 Y31540 Not covered NA31541 Not covered NA31545 $1,907.68 Y31546 $2,937.22 Y31551 Not covered NA31552 $3,559.29 Y31553 Not covered NA31554 $3,559.29 Y31560 Not covered NA31561 Not covered NA31570 $1,907.68 Y31571 $1,907.68 Y31572 $1,907.68 Y31573 $977.20 Y31574 $977.20 Y31575 $213.64 Y31576 $977.20 Y31577 $324.93 Y31578 $1,907.68 Y31579 $338.59 Y31580 Not covered NA31590 $3,559.29 Y31591 $3,559.29 Y31592 $3,559.29 Y31595 Not covered NA31603 $984.97 Y31605 $397.97 Y31611 $1,581.85 Y31612 $1,581.85 Y31613 $1,581.85 Y31614 $3,559.29 Y31615 $397.97 Y31622 $977.20 Y31623 $977.20 Y31624 $977.20 Y




CPT ®

HCPCS Code


Subject To Multiple


31625 $977.20 Y31626 $2,937.22 Y31627 Bundled NA31628 $1,907.68 Y31629 $1,907.68 Y31630 $1,907.68 Y31631 $2,937.22 Y31632 Bundled NA31633 Bundled NA31634 $2,937.22 Y31635 $977.20 Y31636 $5,465.25 Y31637 Bundled NA31638 $2,937.22 Y31640 $1,907.68 Y31641 $1,907.68 Y31643 $977.20 Y31645 $977.20 Y31646 $324.93 Y31647 $2,937.22 Y31648 $1,907.68 Y31649 $977.20 N31651 Bundled NA31652 $1,907.68 Y31653 $1,907.68 Y31654 Bundled NA31717 $324.93 Y31720 Bundled NA31730 $977.20 Y31750 $3,559.29 Y31755 $3,559.29 Y31820 $1,581.85 Y31825 $1,581.85 Y31830 $1,581.85 Y32400 $901.87 Y32405 $901.87 Y32550 $2,213.83 Y32552 $530.12 N32554 $530.12 Y32555 $530.12 Y32556 $1,042.35 Y32557 $850.66 Y32960 $530.12 Y32994 $3,483.90 Y32998 $3,483.90 Y33010 $850.66 Y33011 $850.66 Y33206 $17,000.40 Y33207 $17,117.35 Y33208 $17,506.52 Y33210 $6,181.48 Y




CPT ®

HCPCS Code


Subject To Multiple


33211 $13,206.60 Y33212 $12,900.04 Y33213 $17,320.77 Y33214 $16,992.53 Y33215 $2,157.21 Y33216 $6,181.48 Y33217 $12,577.78 Y33218 $2,481.91 Y33220 $2,481.91 Y33221 $28,017.57 Y33222 $1,357.31 Y33223 $1,357.31 Y33224 $17,198.92 Y33225 Bundled NA33226 $2,157.21 Y33227 $12,801.34 Y33228 $17,063.29 Y33229 $27,932.78 Y33230 $43,089.58 Y33231 $60,796.38 Y33233 $6,181.48 N33234 $2,481.91 N33235 $2,481.91 N33240 $43,715.09 Y33241 $2,481.91 N33249 $59,751.98 Y33262 $42,371.73 Y33263 $42,648.71 Y33264 $59,863.43 Y33270 $59,586.41 Y33271 $13,430.15 Y33273 $2,481.91 Y33274 $10,704.10 N33275 $2,122.91 Y33285 $6,019.14 N33286 $485.08 N33419 Bundled NA33508 Bundled NA33866 Not covered NA34713 Bundled NA34714 Bundled NA34715 Bundled NA34716 Bundled NA35188 $3,690.88 Y35207 $2,157.21 Y35572 Bundled NA35761 $2,157.21 Y35875 $3,690.88 Y35876 $3,690.88 Y36000 Bundled NA36002 $530.12 Y




CPT ®

HCPCS Code


Subject To Multiple


36005 Bundled NA36010 Bundled NA36011 Bundled NA36012 Bundled NA36013 Bundled NA36014 Bundled NA36015 Bundled NA36100 Bundled NA36140 Bundled NA36160 Bundled NA36200 Bundled NA36215 Bundled NA36216 Bundled NA36217 Bundled NA36218 Bundled NA36221 Bundled NA36222 Bundled NA36223 Bundled NA36224 Bundled NA36225 Bundled NA36226 Bundled NA36227 Bundled NA36228 Bundled NA36245 Bundled NA36246 Bundled NA36247 Bundled NA36248 Bundled NA36251 Bundled NA36252 Bundled NA36253 Bundled NA36254 Bundled NA36260 Not covered NA36261 Not covered NA36262 Not covered NA36400 Not covered NA36405 Not covered NA36406 Not covered NA36410 Bundled NA36416 Bundled NA36420 Not covered NA36425 Bundled NA36430 $67.98 N36440 Not covered NA36450 Not covered NA36465 $1,357.31 Y36466 $1,357.31 Y36468 Not covered NA36470 Not covered NA36471 Not covered NA36473 $2,157.21 Y36474 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


36475 $2,157.21 Y36476 Bundled NA36478 $2,157.21 Y36479 Bundled NA36481 Bundled NA36482 $3,690.88 Y36483 Bundled NA36500 Bundled NA36510 Not covered NA36511 Not covered NA36512 Not covered NA36513 Not covered NA36514 Not covered NA36516 Not covered NA36522 Not covered NA36555 Not covered NA36556 $850.66 Y36557 Not covered NA36558 $2,157.21 Y36560 Not covered NA36561 $2,157.21 Y36563 $8,023.43 Y36565 $2,157.21 Y36566 $3,690.88 Y36568 Not covered NA36569 $850.66 Y36570 Not covered NA36571 $2,157.21 Y36572 Not covered NA36573 $915.70 Y36575 $530.12 Y36576 $850.66 Y36578 $2,157.21 Y36580 $850.66 Y36581 $2,157.21 Y36582 $2,157.21 Y36583 $8,553.34 Y36584 $850.66 Y36585 $2,157.21 Y36589 $530.12 N36590 $530.12 N36591 Bundled NA36592 Bundled NA36593 $60.86 Y36595 $1,127.12 Y36596 $850.66 Y36597 $850.66 Y36598 $213.64 Y36600 Bundled NA36620 Bundled NA36625 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


36640 Not covered NA36680 Not covered NA36800 $3,690.88 Y36810 $2,157.21 Y36815 $3,690.88 Y36818 $3,690.88 Y36819 $3,690.88 Y36820 $3,690.88 Y36821 $2,157.21 Y36825 $3,690.88 Y36830 $3,690.88 Y36831 $3,690.88 Y36832 $3,690.88 Y36833 $3,690.88 Y36835 Not covered NA36860 $530.12 Y36861 $3,690.88 Y36901 $530.12 Y36902 $4,193.97 Y36903 $7,442.66 Y36904 $4,193.97 Y36905 $7,442.66 Y36906 $11,503.58 Y36907 Bundled NA36908 Bundled NA36909 Bundled NA37184 $4,193.97 Y37185 Bundled NA37186 Bundled NA37187 $4,193.97 Y37188 $2,157.21 Y37197 $2,157.21 Y37200 $3,690.88 Y37211 $3,690.88 Y37212 $2,157.21 Y37220 $4,193.97 Y37221 $13,991.67 Y37222 Bundled NA37223 Bundled NA37236 $7,442.66 Y37237 Bundled NA37238 $14,245.55 Y37239 Bundled NA37246 $4,193.97 Y37247 Bundled NA37248 $4,193.97 Y37249 Bundled NA37252 Bundled NA37253 Bundled NA37500 $3,690.88 Y37607 $2,157.21 Y




CPT ®

HCPCS Code


Subject To Multiple


37609 $901.87 Y37650 $2,157.21 Y37700 $2,157.21 Y37718 Not covered NA37722 Not covered NA37735 $2,157.21 Y37760 $2,157.21 Y37761 $850.66 Y37765 $1,229.41 Y37766 $1,461.18 Y37780 $850.66 Y37785 $2,157.21 Y37790 Not covered NA38200 Bundled NA38204 Not covered NA38206 Not covered NA38220 $324.35 Y38221 $291.98 Y38222 $324.35 Y38230 $1,057.29 N38232 Not covered NA38241 Not covered NA38242 Not covered NA38243 $1,057.29 N38300 $901.87 Y38305 $901.87 Y38308 Not covered NA38500 $1,711.08 Y38505 $901.87 Y38510 $1,711.08 Y38520 $1,711.08 Y38525 $1,711.08 Y38530 $1,711.08 Y38542 $3,483.90 Y38550 $1,711.08 Y38555 $3,399.06 Y38570 $3,483.90 Y38571 $5,595.74 Y38572 $5,595.74 Y38573 $5,595.74 Y38700 $3,399.06 Y38740 $3,483.90 Y38745 $3,483.90 Y38760 $3,399.06 Y38790 Bundled NA38792 Bundled NA38794 Not covered NA38900 Not covered NA40490 Not covered NA40500 Not covered NA40510 $1,581.85 Y




CPT ®

HCPCS Code


Subject To Multiple


40520 $1,581.85 Y40525 $1,581.85 Y40527 $3,559.29 Y40530 $1,581.85 Y40650 $397.97 Y40652 $397.97 Y40654 $984.97 Y40700 Not covered NA40701 Not covered NA40702 Not covered NA40720 Not covered NA40761 Not covered NA40800 $411.10 Y40801 $397.97 Y40804 Bundled NA40805 $613.09 Y40806 $201.34 Y40808 Not covered NA40810 Not covered NA40812 Not covered NA40814 Not covered NA40816 Not covered NA40818 Not covered NA40819 $984.97 Y40820 $511.45 Y40830 $154.47 Y40831 $397.97 Y40840 $3,559.29 Y40842 $3,559.29 Y40843 $3,559.29 Y40844 $3,559.29 Y40845 $3,559.29 Y41000 $311.40 Y41005 $154.47 Y41006 $984.97 Y41007 $984.97 Y41008 $1,581.85 Y41009 $397.97 Y41010 $984.97 Y41015 $397.97 Y41016 $3,559.29 Y41017 $1,581.85 Y41018 $984.97 Y41019 Not covered NA41100 $322.41 Y41105 $328.23 Y41108 $284.86 Y41110 Not covered NA41112 Not covered NA41113 Not covered NA41114 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


41115 $470.66 Y41116 Not covered NA41120 Not covered NA41250 Bundled NA41251 $154.47 Y41252 $397.97 Y41500 $1,581.85 Y41510 Not covered NA41520 $1,581.85 Y41530 $1,871.63 Y41800 Bundled NA41805 $545.11 Y41806 $750.98 Y41820 Not covered NA41821 Not covered NA41822 Not covered NA41823 Not covered NA41825 Not covered NA41826 Not covered NA41827 Not covered NA41828 Not covered NA41830 Not covered NA41850 $984.97 Y41870 $1,581.85 Y41872 $666.82 Y41874 $739.33 Y42000 $154.47 Y42100 Not covered NA42104 Not covered NA42106 Not covered NA42107 Not covered NA42120 Not covered NA42140 $1,581.85 Y42145 $3,559.29 Y42160 Not covered NA42180 $397.97 Y42182 $3,559.29 Y42200 Not covered NA42205 Not covered NA42210 Not covered NA42215 Not covered NA42220 Not covered NA42226 $3,559.29 Y42235 $3,559.29 Y42260 $3,559.29 Y42280 $334.71 Y42281 $3,559.29 Y42300 $984.97 Y42305 $1,581.85 Y42310 $397.97 Y42320 $397.97 Y




CPT ®

HCPCS Code


Subject To Multiple


42330 Not covered NA42335 Not covered NA42340 Not covered NA42400 $200.05 Y42405 $1,581.85 Y42408 $1,581.85 Y42409 $1,581.85 Y42410 Not covered NA42415 Not covered NA42420 Not covered NA42425 Not covered NA42440 $3,559.29 Y42450 $3,559.29 Y42500 $3,559.29 Y42505 $3,559.29 Y42507 $3,559.29 Y42509 $3,559.29 Y42510 $1,581.85 Y42550 Bundled NA42600 $1,581.85 Y42650 $157.97 Y42660 $246.66 Y42665 Not covered NA42700 $154.47 Y42720 $1,581.85 Y42725 $3,559.29 Y42800 $299.10 Y42804 $1,581.85 Y42806 $1,581.85 Y42808 $1,581.85 Y42809 Bundled NA42810 $1,581.85 Y42815 $3,559.29 Y42820 Not covered NA42821 $1,581.85 Y42825 Not covered NA42826 $1,581.85 Y42830 Not covered NA42831 Not covered NA42835 Not covered NA42836 Not covered NA42860 Not covered NA42870 $3,559.29 Y42890 Not covered NA42892 Not covered NA42900 $984.97 Y42950 $3,559.29 Y42955 $984.97 Y42960 $397.97 Y42962 $1,581.85 Y42970 $154.47 Y




CPT ®

HCPCS Code


Subject To Multiple


42972 $1,581.85 Y43030 $3,559.29 Y43180 $3,559.29 Y43191 $1,042.35 Y43192 $1,042.35 Y43193 $1,042.35 Y43194 $1,042.35 Y43195 $2,013.49 Y43196 $2,013.49 Y43197 $364.49 Y43198 $401.39 Y43200 $643.41 Y43201 $1,042.35 Y43202 $1,042.35 Y43204 $1,042.35 Y43205 $1,042.35 Y43206 $1,042.35 Y43210 $5,595.74 Y43211 $1,042.35 Y43212 $6,062.64 Y43213 $1,042.35 Y43214 $1,042.35 Y43215 $1,042.35 Y43216 Not covered NA43217 Not covered NA43220 $1,042.35 Y43226 $1,042.35 Y43227 $1,042.35 Y43229 Not covered NA43231 $1,042.35 Y43232 $1,042.35 Y43233 $1,042.35 Y43235 $643.41 Y43236 $643.41 Y43237 Not covered NA43238 Not covered NA43239 $643.41 Y43240 $2,013.49 Y43241 $1,042.35 Y43242 $1,042.35 Y43243 $1,042.35 Y43244 $1,042.35 Y43245 $1,042.35 Y43246 $1,042.35 Y43247 $643.41 Y43248 $643.41 Y43249 $1,042.35 Y43250 $1,042.35 Y43251 $1,042.35 Y43252 $2,013.49 Y43253 $1,042.35 Y




CPT ®

HCPCS Code


Subject To Multiple


43254 $1,042.35 Y43255 $1,042.35 Y43257 Not covered NA43259 $1,042.35 Y43260 $2,013.49 Y43261 $2,013.49 Y43262 $2,013.49 Y43263 $2,013.49 Y43264 $2,013.49 Y43265 $3,071.01 Y43266 $6,228.31 Y43270 Not covered NA43273 Bundled NA43274 $3,071.01 Y43275 $2,013.49 Y43276 $3,071.01 Y43277 $2,013.49 Y43278 Not covered NA43284 $5,595.74 Y43285 $3,483.90 N43450 $643.41 Y43453 $1,042.35 Y43653 $3,483.90 Y43753 Bundled NA43754 Bundled NA43755 $117.97 N43756 $643.41 N43757 $643.41 Y43761 $198.63 Y43762 $193.77 Y43763 $193.77 Y43870 $2,013.49 Y43886 Not covered NA43887 Not covered NA43888 Not covered NA44100 $643.41 Y44312 $2,345.64 Y44340 $2,345.64 Y44360 $1,042.35 Y44361 $1,042.35 Y44363 $1,042.35 Y44364 Not covered NA44365 Not covered NA44366 $1,042.35 Y44369 Not covered NA44370 $3,071.01 Y44372 $1,042.35 Y44373 $1,042.35 Y44376 $1,042.35 Y44377 $1,042.35 Y44378 $1,042.35 Y




CPT ®

HCPCS Code


Subject To Multiple


44379 $3,071.01 Y44380 $643.41 Y44381 Not covered NA44382 $643.41 Y44384 Not covered NA44385 $614.42 Y44386 $614.42 Y44388 $614.42 Y44389 $810.35 Y44390 $810.35 Y44391 $810.35 Y44392 $810.35 Y44394 $810.35 Y44401 Not covered NA44402 Not covered NA44403 Not covered NA44404 Not covered NA44405 Not covered NA44406 Not covered NA44407 Not covered NA44408 Not covered NA44500 $643.41 Y44701 Bundled NA45000 $810.35 Y45005 $810.35 Y45020 $1,892.29 Y45100 $1,892.29 Y45108 $1,892.29 Y45150 $810.35 Y45160 Not covered NA45190 Not covered NA45300 $240.19 Y45303 $810.35 Y45305 $810.35 Y45307 $1,892.29 Y45308 $1,892.29 Y45309 $810.35 Y45315 $810.35 Y45317 $810.35 Y45320 $1,892.29 Y45321 $1,892.29 Y45327 $3,071.01 Y45330 $323.70 Y45331 $614.42 Y45332 $810.35 Y45333 $614.42 Y45334 $810.35 Y45335 $614.42 Y45337 $810.35 Y45338 $810.35 Y45340 $810.35 Y




CPT ®

HCPCS Code


Subject To Multiple


45341 $810.35 Y45342 $810.35 Y45346 Not covered NA45347 Not covered NA45349 Not covered NA45350 Not covered NA45378 $614.42 Y45379 $810.35 Y45380 $810.35 Y45381 Not covered NA45382 $810.35 Y45384 $810.35 Y45385 $810.35 Y45386 $810.35 Y45388 Not covered NA45389 Not covered NA45390 Not covered NA45391 $810.35 Y45392 $810.35 Y45393 Not covered NA45398 Not covered NA45500 $1,892.29 Y45505 $1,892.29 Y45520 Bundled NA45560 $1,892.29 Y45900 $614.42 Y45905 $810.35 Y45910 $810.35 Y45915 $810.35 Y45990 $1,892.29 Y46020 $1,892.29 Y46030 $810.35 Y46040 $810.35 Y46045 $1,892.29 Y46050 $614.42 Y46060 $1,892.29 Y46070 Not covered NA46080 $1,892.29 Y46083 $198.63 Y46200 $1,892.29 Y46220 $810.35 Y46221 $515.33 Y46230 $1,892.29 Y46250 $1,892.29 Y46255 $1,892.29 Y46257 $1,892.29 Y46258 $1,892.29 Y46260 $1,892.29 Y46261 $1,892.29 Y46262 $1,892.29 Y46270 $1,892.29 Y




CPT ®

HCPCS Code


Subject To Multiple


46275 $1,892.29 Y46280 $1,892.29 Y46285 $1,892.29 Y46288 $1,892.29 Y46320 $354.13 Y46500 $361.90 Y46505 $810.35 Y46600 Bundled NA46601 Not covered NA46604 $810.35 Y46606 $438.94 Y46607 Not covered NA46608 $614.42 Y46610 $1,892.29 Y46611 $614.42 Y46612 $1,892.29 Y46614 $249.25 Y46615 $1,892.29 Y46700 $1,892.29 Y46706 $1,892.29 Y46707 $1,892.29 Y46750 $1,892.29 Y46753 $1,892.29 Y46754 $1,892.29 Y46760 $1,892.29 Y46761 $1,892.29 Y46900 Not covered NA46910 Not covered NA46916 Not covered NA46917 Not covered NA46922 Not covered NA46924 Not covered NA46930 $398.80 Y46940 $436.35 Y46942 $416.93 Y46945 $594.31 Y46946 $1,892.29 Y46947 $1,892.29 Y47000 $901.87 Y47001 Bundled NA47382 Not covered NA47383 Not covered NA47531 Bundled NA47532 Bundled NA47533 $2,213.83 Y47534 $2,213.83 Y47535 $2,213.83 Y47536 $2,213.83 Y47537 $643.41 N47538 $6,721.83 Y47539 $3,483.90 Y




CPT ®

HCPCS Code


Subject To Multiple


47540 $6,486.68 Y47541 $2,213.83 Y47542 Bundled NA47543 Bundled NA47544 Bundled NA47552 $2,213.83 Y47553 $2,213.83 Y47554 $3,483.90 Y47555 $2,213.83 Y47556 $3,483.90 Y47562 $3,483.90 Y47563 $3,483.90 Y47564 $3,483.90 Y48102 $901.87 Y49082 $643.41 Y49083 $643.41 Y49084 $643.41 Y49180 $901.87 Y49250 $2,213.83 Y49320 $3,483.90 Y49321 $3,483.90 Y49322 $3,483.90 Y49327 Not covered NA49400 Bundled NA49402 $2,213.83 Y49407 $901.87 Y49419 Not covered NA49421 $2,213.83 Y49422 $2,157.21 N49423 $1,042.35 Y49424 Bundled NA49426 $2,213.83 Y49427 Bundled NA49429 $2,157.21 N49440 $1,042.35 Y49441 $1,042.35 Y49446 $1,042.35 Y49450 $643.41 Y49451 $643.41 Y49452 $643.41 Y49460 $643.41 Y49465 $102.77 N49495 Not covered NA49496 Not covered NA49500 Not covered NA49501 Not covered NA49505 $2,213.83 Y49507 $2,213.83 Y49520 $2,213.83 Y49521 $2,213.83 Y49525 $2,213.83 Y




CPT ®

HCPCS Code


Subject To Multiple


49540 $3,483.90 Y49550 $2,213.83 Y49553 $2,213.83 Y49555 $2,213.83 Y49557 $2,213.83 Y49560 $2,213.83 Y49561 $2,213.83 Y49565 $3,483.90 Y49566 $3,483.90 Y49568 Bundled NA49570 $2,213.83 Y49572 $2,213.83 Y49580 Not covered NA49582 Not covered NA49585 $2,213.83 Y49587 $2,213.83 Y49590 $2,213.83 Y49600 $2,213.83 Y49650 $3,483.90 Y49651 $3,483.90 Y49652 $3,483.90 Y49653 $3,483.90 Y49654 $5,595.74 Y49655 $5,595.74 Y49656 $5,595.74 Y49657 $5,595.74 Y50200 $901.87 Y50382 $1,295.12 Y50384 $1,295.12 N50385 $1,295.12 Y50386 $1,347.24 N50387 $1,295.12 Y50389 $489.47 N50390 $495.74 Y50391 $230.47 Y50396 $1,295.12 Y50430 Bundled NA50431 Bundled NA50432 $1,295.12 Y50433 $1,295.12 Y50434 $1,295.12 Y50435 $1,295.12 Y50436 $1,277.05 N50437 $2,224.79 N50551 $2,918.85 Y50553 $2,918.85 Y50555 $2,918.85 Y50557 $6,372.41 Y50561 $2,918.85 Y50562 Not covered NA50570 $1,295.12 Y




CPT ®

HCPCS Code


Subject To Multiple


50572 $489.47 Y50574 $1,295.12 Y50575 $2,918.85 Y50576 $2,918.85 Y50580 $2,918.85 Y50590 $2,918.85 Y50592 Not covered NA50606 Bundled NA50684 Bundled NA50686 $117.97 N50688 $1,295.12 Y50690 Bundled NA50693 $2,003.24 Y50694 $2,003.24 Y50695 $2,003.24 Y50705 Bundled NA50706 Bundled NA50947 $3,483.90 Y50948 $5,595.74 Y50951 $1,295.12 Y50953 $2,918.85 Y50955 $2,918.85 Y50957 $2,918.85 Y50961 $2,918.85 Y50970 $1,295.12 Y50972 $1,295.12 Y50974 $2,918.85 Y50976 $2,918.85 Y50980 $2,918.85 Y51020 $2,003.24 Y51030 $2,003.24 Y51040 $1,295.12 Y51045 $1,295.12 Y51050 Not covered NA51065 Not covered NA51080 $1,765.57 Y51100 $117.18 Y51101 $237.60 N51102 $1,295.12 Y51500 $3,483.90 Y51520 $1,295.12 Y51600 Bundled NA51605 Bundled NA51610 Bundled NA51700 $141.13 Y51701 Bundled NA51702 Bundled NA51703 $117.97 N51705 $174.80 Y51710 $489.47 Y51715 $2,003.24 Y




CPT ®

HCPCS Code


Subject To Multiple


51720 Not covered NA51725 $359.95 Y51726 $489.47 Y51727 $599.49 Y51728 $611.15 Y51729 $655.17 Y51736 Bundled NA51741 Bundled NA51784 $132.07 N51785 $198.63 Y51792 Bundled NA51797 Bundled NA51798 Bundled NA51880 $2,003.24 Y51992 $3,483.90 Y52000 $489.47 Y52001 $2,003.24 Y52005 $1,295.12 Y52007 $2,003.24 Y52010 $489.47 Y52204 $1,295.12 Y52214 $1,295.12 Y52224 $1,295.12 Y52234 $2,003.24 Y52235 $2,003.24 Y52240 $2,918.85 Y52250 Not covered NA52260 $1,295.12 Y52265 $701.78 Y52270 $1,295.12 Y52275 $1,295.12 Y52276 $1,295.12 Y52277 $2,003.24 Y52281 $1,295.12 Y52282 $2,003.24 Y52283 $1,295.12 Y52285 $1,295.12 Y52287 $1,295.12 Y52290 $1,295.12 Y52300 $2,003.24 Y52301 $2,003.24 Y52305 $2,918.85 Y52310 $1,295.12 Y52315 $1,295.12 Y52317 $2,003.24 Y52318 $2,918.85 Y52320 $2,918.85 Y52325 $2,918.85 Y52327 $2,918.85 Y52330 $2,003.24 Y52332 $2,003.24 Y




CPT ®

HCPCS Code


Subject To Multiple


52334 $2,003.24 Y52341 $1,295.12 Y52342 $2,918.85 Y52343 $1,295.12 Y52344 $2,003.24 Y52345 $2,918.85 Y52346 $2,918.85 Y52351 $1,295.12 Y52352 $2,918.85 Y52353 $2,918.85 Y52354 $2,918.85 Y52355 Not covered NA52356 $2,918.85 Y52400 $1,295.12 Y52402 $2,003.24 Y52450 $2,003.24 Y52500 $2,003.24 Y52601 $2,918.85 Y52630 $2,918.85 Y52640 $2,003.24 Y52647 $2,918.85 Y52648 $2,918.85 Y52700 $2,918.85 Y53000 $1,295.12 Y53010 $2,918.85 Y53020 $1,295.12 Y53025 Not covered NA53040 $2,918.85 Y53060 $345.71 Y53080 $1,295.12 Y53085 $1,295.12 Y53200 $2,003.24 Y53210 Not covered NA53215 Not covered NA53220 Not covered NA53230 $2,918.85 Y53235 $2,918.85 Y53240 $2,918.85 Y53250 $1,295.12 Y53260 Not covered NA53265 Not covered NA53270 Not covered NA53275 Not covered NA53400 $2,918.85 Y53405 $2,918.85 Y53410 $2,918.85 Y53420 $2,918.85 Y53425 $2,918.85 Y53430 $2,918.85 Y53431 $2,918.85 Y53440 $13,236.05 Y




CPT ®

HCPCS Code


Subject To Multiple


53442 $2,918.85 Y53444 $27,763.19 Y53445 $28,751.38 Y53446 $2,918.85 N53447 $28,129.74 Y53449 $2,918.85 Y53450 $1,295.12 Y53460 $2,918.85 Y53502 $2,003.24 Y53505 $2,918.85 Y53510 $2,918.85 Y53515 $2,918.85 Y53520 $2,918.85 Y53600 $157.97 Y53601 Bundled NA53605 $1,295.12 Y53620 $221.41 Y53621 $209.11 Y53660 $135.31 N53661 Bundled NA53665 $1,295.12 Y53850 Not covered NA53852 Not covered NA53854 $1,277.05 N53860 Not covered NA54000 Not covered NA54001 Not covered NA54015 $901.87 Y54050 Bundled NA54055 $229.18 Y54056 Bundled NA54057 $1,357.31 Y54060 $1,357.31 Y54065 $1,357.31 Y54100 $901.87 Y54105 $1,765.57 Y54110 Not covered NA54111 Not covered NA54112 Not covered NA54115 $1,765.57 Y54120 $2,918.85 Y54150 Not covered NA54160 Not covered NA54161 $1,295.12 Y54162 Not covered NA54163 Not covered NA54164 Not covered NA54200 Not covered NA54205 Not covered NA54220 $198.63 Y54230 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


54231 $269.32 Y54235 $174.15 Y54240 $200.69 N54250 $229.18 Y54300 Not covered NA54304 Not covered NA54308 Not covered NA54312 Not covered NA54316 Not covered NA54318 Not covered NA54322 Not covered NA54324 Not covered NA54326 Not covered NA54328 Not covered NA54340 Not covered NA54344 Not covered NA54348 Not covered NA54352 Not covered NA54360 Not covered NA54380 Not covered NA54385 Not covered NA54400 $28,042.53 N54401 $28,954.84 N54405 $29,008.12 N54406 $2,003.24 N54408 $2,918.85 Y54410 $28,517.26 N54415 $2,003.24 N54416 $28,142.65 N54420 $1,295.12 Y54435 $1,295.12 Y54437 $1,295.12 Y54440 $2,918.85 Y54450 Not covered NA54500 $1,765.57 Y54505 $2,003.24 Y54512 $1,295.12 Y54520 $2,003.24 Y54522 $2,003.24 Y54530 $2,213.83 Y54550 Not covered NA54560 Not covered NA54600 $2,003.24 Y54620 Not covered NA54640 $2,213.83 Y54660 $5,448.05 Y54670 $1,295.12 Y54680 $1,295.12 Y54690 $3,483.90 Y54692 Not covered NA54700 $1,295.12 Y




CPT ®

HCPCS Code


Subject To Multiple


54800 $901.87 Y54830 $1,295.12 Y54840 $1,295.12 Y54860 $1,295.12 Y54861 $2,003.24 Y54865 $2,003.24 Y54900 $1,295.12 Y54901 $2,003.24 Y55000 $226.59 Y55040 $2,213.83 Y55041 $2,213.83 Y55060 $1,295.12 Y55100 $901.87 Y55110 $1,295.12 Y55120 $1,295.12 Y55150 Not covered NA55175 $2,003.24 Y55180 $2,918.85 Y55200 Not covered NA55250 Not covered NA55300 Not covered NA55400 Not covered NA55500 $2,003.24 Y55520 $2,003.24 Y55530 $2,003.24 Y55535 $2,213.83 Y55540 $2,213.83 Y55550 $3,483.90 Y55600 $1,295.12 Y55680 Not covered NA55700 $1,295.12 Y55705 $1,295.12 Y55706 Not covered NA55720 $1,295.12 Y55725 $1,295.12 Y55860 Not covered NA55870 $334.71 Y55874 $2,918.85 Y55875 Not covered NA55876 Not covered NA55920 Not covered NA56405 $204.58 Y56420 $230.47 Y56440 Not covered NA56441 Not covered NA56442 Not covered NA56501 Not covered NA56515 Not covered NA56605 $154.08 Y56606 Bundled NA56620 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


56625 Not covered NA56700 Not covered NA56740 Not covered NA56800 $1,863.92 Y56805 Not covered NA56810 $1,863.92 Y56820 $211.05 Y56821 $277.09 Y57000 $1,863.92 Y57010 $1,863.92 Y57020 $1,863.92 Y57022 $901.87 Y57023 $1,765.57 Y57061 Not covered NA57065 Not covered NA57100 $167.68 Y57105 $1,863.92 Y57130 Not covered NA57135 Not covered NA57150 Bundled NA57155 Not covered NA57156 Not covered NA57160 $143.08 Y57170 Not covered NA57180 $139.07 Y57200 $1,863.92 Y57210 $1,863.92 Y57220 $3,055.46 Y57230 $1,863.92 Y57240 $3,055.46 Y57250 $3,055.46 Y57260 $3,055.46 Y57265 $3,055.46 Y57267 Bundled NA57268 $1,863.92 Y57287 $1,863.92 N57288 $3,055.46 Y57289 $4,280.91 Y57291 Not covered NA57300 $1,863.92 Y57320 $3,055.46 Y57400 Not covered NA57410 $1,863.92 Y57415 $1,863.92 Y57420 $221.41 Y57421 $295.21 Y57426 $4,280.91 Y57452 $203.93 Y57454 $284.21 Y57455 $266.73 Y57456 $251.84 Y




CPT ®

HCPCS Code


Subject To Multiple


57460 $530.87 Y57461 $600.14 Y57500 $240.83 Y57505 $192.93 Y57510 Not covered NA57511 Not covered NA57513 Not covered NA57520 Not covered NA57522 Not covered NA57530 Not covered NA57550 $1,863.92 Y57556 $3,055.46 Y57558 $1,863.92 Y57700 Not covered NA57720 $1,863.92 Y57800 $112.65 Y58100 $203.28 Y58110 Not covered NA58120 $1,863.92 Y58145 Not covered NA58301 Not covered NA58321 Not covered NA58322 Not covered NA58323 Not covered NA58340 Not covered NA58345 Not covered NA58346 Not covered NA58350 Not covered NA58353 Not covered NA58356 Not covered NA58545 Not covered NA58546 Not covered NA58550 $3,483.90 Y58552 $5,595.74 Y58555 $1,863.92 Y58558 $1,863.92 Y58559 $3,055.46 Y58560 Not covered NA58561 Not covered NA58562 $1,863.92 Y58563 Not covered NA58565 Not covered NA58600 Not covered NA58615 Not covered NA58660 $3,483.90 Y58661 Not covered NA58662 Not covered NA58670 Not covered NA58671 Not covered NA58672 Not covered NA58673 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


58674 Not covered NA58800 Not covered NA58805 Not covered NA58820 Not covered NA58900 $1,863.92 Y58970 Not covered NA58974 Not covered NA58976 Not covered NA59000 $238.89 Y59001 $232.23 Y59012 $232.23 Y59015 $293.92 Y59020 $134.01 Y59025 $91.28 Y59070 $232.23 Y59072 $232.23 Y59076 $232.23 Y59100 Not covered NA59150 $3,483.90 Y59151 $3,483.90 Y59160 $1,863.92 Y59200 $136.60 Y59300 $365.78 Y59320 $1,863.92 Y59412 $1,863.92 Y59414 $1,863.92 Y59812 $1,863.92 Y59820 $1,863.92 Y59821 $1,863.92 Y59840 $1,863.92 Y59841 $1,863.92 Y59866 Not covered NA59870 Not covered NA59871 $1,863.92 N60000 Not covered NA60100 $212.99 Y60200 $3,483.90 Y60280 Not covered NA60281 Not covered NA60300 $224.65 Y61000 Not covered NA61001 Not covered NA61020 $581.70 Y61026 $470.24 Y61050 $211.76 Y61055 $211.76 Y61070 $470.24 Y61215 $3,377.49 Y61330 $1,581.85 Y61781 Bundled NA61782 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


61783 Bundled NA61790 Not covered NA61791 Not covered NA61880 Not covered NA61885 $35,885.39 N61886 $50,498.55 N61888 $5,150.48 N62194 $1,304.80 Y62225 $3,377.49 Y62230 $3,377.49 Y62252 $160.56 N62263 Not covered NA62264 $581.70 Y62267 $495.74 Y62268 $581.70 Y62269 $901.87 Y62270 $470.24 Y62272 $470.24 Y62273 $470.24 Y62280 Not covered NA62281 $581.70 Y62282 $581.70 Y62284 Bundled NA62287 $3,377.49 Y62290 Bundled NA62291 Bundled NA62292 $1,304.80 Y62294 $581.70 Y62302 Bundled NA62303 Bundled NA62304 Bundled NA62305 Bundled NA62320 $470.24 Y62321 $470.24 Y62322 $470.24 Y62323 $470.24 Y62324 $581.70 Y62325 $581.70 Y62326 $581.70 Y62327 $581.70 Y62350 $3,377.49 Y62355 $1,304.80 N62360 $29,923.01 Y62361 $28,611.11 Y62362 $29,810.23 Y62365 $3,377.49 N62367 $80.28 N62368 $108.12 N62369 $229.18 N62370 $241.48 N62380 $4,520.99 Y




CPT ®

HCPCS Code


Subject To Multiple


63020 $4,520.99 Y63030 $4,520.99 Y63035 Bundled NA63042 $4,520.99 Y63044 Bundled NA63045 $4,520.99 Y63047 $4,520.99 Y63048 Bundled NA63056 $4,520.99 Y63057 Bundled NA63075 $4,909.89 Y63076 Bundled NA63600 $1,304.80 Y63610 $1,304.80 Y63615 $1,304.80 Y63650 Not covered N63655 Not covered N63661 Not covered N63662 Not covered N63663 Not covered N63664 Not covered N63685 Not covered N63688 Not covered N63709 UR/BR N63744 $3,377.49 Y63746 $1,304.80 N64400 $249.25 Y64402 Bundled NA64405 $194.87 Y64408 $220.12 Y64410 $581.70 Y64413 $240.83 Y64415 $581.70 Y64416 $581.70 Y64417 $581.70 Y64418 $222.71 Y64420 $470.24 Y64421 $581.70 Y64425 $253.13 Y64430 $581.70 Y64435 $258.96 Y64445 $260.25 Y64446 $581.70 Y64447 $229.83 Y64448 $581.70 Y64450 $152.14 Y64455 $89.99 Y64461 $280.32 Y64462 Bundled NA64463 $299.75 Y64479 $581.70 Y




CPT ®

HCPCS Code


Subject To Multiple


64480 Bundled NA64483 $581.70 Y64484 Bundled NA64486 Bundled NA64487 Bundled NA64488 Bundled NA64489 Bundled NA64490 $581.70 Y64491 Bundled NA64492 Bundled NA64493 $581.70 Y64494 Bundled NA64495 Bundled NA64505 $206.52 Y64508 $91.93 Y64510 $581.70 Y64517 Not covered NA64520 $581.70 Y64530 $581.70 Y64553 $10,245.09 N64555 Not covered NA64561 $10,257.55 N64566 Not covered NA64568 $50,885.38 N64569 $11,967.02 N64570 $3,377.49 N64575 Not covered NA64580 $32,391.07 N64581 $10,874.30 N64585 $2,491.79 N64590 Not covered NA64595 $2,491.79 N64600 $581.70 Y64605 $1,304.80 Y64610 $1,304.80 Y64611 $228.53 Y64612 $252.49 Y64615 $275.15 Y64616 $245.36 Y64617 $303.63 Y64620 $581.70 Y64630 $581.70 Y64632 $161.85 Y64633 $1,304.80 Y64634 Bundled NA64635 $1,304.80 Y64636 Bundled NA64640 $251.84 Y64642 $271.91 Y64643 Bundled NA64644 $311.40 Y




CPT ®

HCPCS Code


Subject To Multiple


64645 Bundled NA64646 $283.56 Y64647 $336.00 Y64650 $148.25 Y64653 $181.92 Y64680 $581.70 Y64681 $581.70 Y64702 $1,304.80 Y64704 $1,304.80 Y64708 $1,304.80 Y64712 $1,304.80 Y64713 $1,304.80 Y64714 $1,304.80 Y64716 $1,304.80 Y64718 $1,304.80 Y64719 $1,304.80 Y64721 $1,304.80 Y64722 $1,304.80 Y64726 $1,304.80 Y64727 Bundled NA64732 $1,304.80 Y64734 $1,304.80 Y64736 $1,304.80 Y64738 $1,304.80 Y64740 $1,304.80 Y64742 $1,304.80 Y64744 $1,304.80 Y64746 $1,304.80 Y64763 $1,304.80 Y64766 $3,377.49 Y64771 $1,304.80 Y64772 $1,304.80 Y64774 $1,304.80 Y64776 $1,304.80 Y64778 Bundled NA64782 $1,304.80 Y64783 Bundled NA64784 $1,304.80 Y64786 $3,377.49 Y64787 Bundled NA64788 $1,304.80 Y64790 $1,304.80 Y64792 $3,377.49 Y64795 $1,304.80 Y64802 $1,304.80 Y64820 $1,304.80 Y64821 $2,126.29 Y64822 $2,126.29 Y64823 $1,225.33 Y64831 $3,377.49 Y64832 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


64834 $3,377.49 Y64835 $3,377.49 Y64836 $3,377.49 Y64837 Bundled NA64840 $3,377.49 Y64856 $3,377.49 Y64857 $3,377.49 Y64858 $3,377.49 Y64859 Bundled NA64861 $3,377.49 Y64862 $3,377.49 Y64864 $3,377.49 Y64865 $3,377.49 Y64872 Bundled NA64874 Bundled NA64876 Bundled NA64885 $3,377.49 Y64886 $3,377.49 Y64890 $3,377.49 Y64891 $3,377.49 Y64892 $3,377.49 Y64893 $3,377.49 Y64895 $3,377.49 Y64896 $3,377.49 Y64897 $3,377.49 Y64898 $3,377.49 Y64901 Bundled NA64902 Bundled NA64905 $3,377.49 Y64907 $3,377.49 Y64910 $3,377.49 Y64912 $3,377.49 Y64913 Bundled NA65091 $2,169.53 Y65093 $2,169.53 Y65101 $2,169.53 Y65103 $2,169.53 Y65105 $2,169.53 Y65110 $2,169.53 Y65112 $2,169.53 Y65114 $2,169.53 Y65125 $1,343.11 Y65130 $2,169.53 Y65135 $2,169.53 Y65140 $2,169.53 Y65150 $2,169.53 Y65155 $2,169.53 Y65175 $2,169.53 Y65205 Bundled NA65210 Bundled NA65220 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


65222 Bundled NA65235 $1,647.93 Y65260 $1,647.93 Y65265 $1,647.93 Y65270 $1,343.11 Y65272 $1,343.11 Y65275 $2,169.53 Y65280 $2,944.19 Y65285 $2,944.19 Y65286 $1,345.30 Y65290 $2,169.53 Y65400 $699.56 Y65410 $1,343.11 Y65420 $1,343.11 Y65426 $1,343.11 Y65430 Bundled NA65435 $154.73 Y65436 $736.09 Y65450 $231.63 Y65600 $750.34 Y65710 $2,944.19 Y65730 $2,944.19 Y65750 $2,944.19 Y65755 $2,944.19 Y65756 $2,944.19 Y65770 $15,157.57 Y65772 $699.56 Y65775 $1,343.11 Y65778 Bundled NA65779 Bundled NA65780 $2,169.53 Y65781 $2,944.19 Y65782 $2,169.53 Y65785 $2,944.19 Y65800 $1,647.93 Y65810 $1,647.93 Y65815 $1,647.93 Y65820 $2,944.19 Y65850 $1,647.93 Y65855 $465.48 Y65860 $587.84 Y65865 $1,647.93 Y65870 $1,647.93 Y65875 $1,647.93 Y65880 $2,944.19 Y65900 $1,647.93 Y65920 $1,647.93 Y65930 $1,647.93 Y66020 $1,647.93 Y66030 $1,647.93 Y66130 $1,343.11 Y




CPT ®

HCPCS Code


Subject To Multiple


66150 $2,944.19 Y66155 $2,944.19 Y66160 $1,647.93 Y66170 $1,647.93 Y66172 $1,647.93 Y66174 $2,944.19 Y66175 $2,944.19 Y66179 $2,944.19 Y66180 $2,944.19 Y66183 Not covered NA66184 $1,647.93 Y66185 $1,647.93 Y66220 $1,647.93 Y66225 $2,944.19 Y66250 $1,343.11 Y66500 $1,647.93 Y66505 $1,647.93 Y66600 $2,944.19 Y66605 $1,647.93 Y66625 $1,647.93 Y66630 $1,647.93 Y66635 $1,647.93 Y66680 $1,647.93 Y66682 $1,647.93 Y66700 $1,647.93 Y66710 $1,343.11 Y66711 $1,647.93 Y66720 $1,343.11 Y66740 $1,343.11 Y66761 $566.48 Y66762 $422.30 Y66770 $422.30 Y66820 $1,647.93 Y66821 $422.30 Y66825 $1,647.93 Y66830 $1,647.93 Y66840 $1,647.93 Y66850 $1,647.93 Y66852 $2,944.19 Y66920 $1,647.93 Y66930 $2,944.19 Y66940 $1,647.93 Y66982 $1,647.93 Y66983 $1,647.93 Y66984 $1,647.93 Y66985 $1,647.93 Y66986 $1,647.93 Y66990 Bundled NA67005 $1,647.93 Y67010 $1,647.93 Y67015 $1,647.93 Y




CPT ®

HCPCS Code


Subject To Multiple


67025 $1,647.93 Y67027 $2,426.45 Y67028 $192.28 N67030 $1,647.93 Y67031 $422.30 Y67036 $2,944.19 Y67039 $2,944.19 Y67040 $2,944.19 Y67041 $2,944.19 Y67042 $2,944.19 Y67043 $2,944.19 Y67101 $624.09 Y67105 $563.24 Y67107 $2,944.19 Y67108 $2,944.19 Y67110 $1,663.82 Y67113 $2,944.19 Y67115 $2,944.19 Y67120 $1,647.93 Y67121 $1,647.93 Y67141 $231.63 Y67145 $422.30 Y67208 $231.63 Y67210 $422.30 Y67218 Not covered NA67220 $422.30 Y67221 Not covered NA67225 Not covered NA67227 $552.88 Y67228 $648.05 Y67229 Not covered NA67250 $1,343.11 Y67255 $1,647.93 Y67311 $1,343.11 Y67312 $2,169.53 Y67314 $1,343.11 Y67316 $1,343.11 Y67318 $1,343.11 Y67320 Bundled NA67331 Bundled NA67332 Bundled NA67334 Bundled NA67335 Bundled NA67340 Bundled NA67343 $1,343.11 Y67345 $462.24 Y67346 $2,169.53 Y67400 $2,169.53 Y67405 $1,343.11 Y67412 $1,343.11 Y67413 $1,343.11 Y




CPT ®

HCPCS Code


Subject To Multiple


67414 $2,169.53 Y67415 Not covered NA67420 $2,169.53 Y67430 $2,169.53 Y67440 $2,169.53 Y67445 $2,169.53 Y67450 $2,169.53 Y67500 $231.63 Y67505 $165.09 Y67515 $182.57 Y67550 $2,169.53 Y67560 $2,169.53 Y67570 $2,169.53 Y67700 $231.63 Y67710 $431.82 Y67715 $1,343.11 Y67800 $242.78 Y67801 $308.81 Y67805 $384.56 Y67808 $1,343.11 Y67810 $328.23 Y67820 Bundled NA67825 $244.07 Y67830 $699.56 Y67835 $1,343.11 Y67840 $527.63 Y67850 $409.80 Y67875 $699.56 Y67880 $1,343.11 Y67882 $1,343.11 Y67900 $1,343.11 Y67901 $1,343.11 Y67902 $2,169.53 Y67903 $1,343.11 Y67904 $1,343.11 Y67906 $2,169.53 Y67908 $1,343.11 Y67909 $1,343.11 Y67911 $1,343.11 Y67912 $1,343.11 Y67914 $1,343.11 Y67915 $561.94 Y67916 $1,343.11 Y67917 $1,343.11 Y67921 $1,343.11 Y67922 $556.76 Y67923 $1,343.11 Y67924 $1,343.11 Y67930 $694.66 Y67935 $1,343.11 Y67938 $231.63 Y




CPT ®

HCPCS Code


Subject To Multiple


67950 $1,343.11 Y67961 $1,343.11 Y67966 $1,343.11 Y67971 $1,343.11 Y67973 $1,343.11 Y67974 $2,169.53 Y67975 $1,343.11 Y68020 $229.18 Y68040 Not covered NA68100 $326.94 Y68110 $432.46 Y68115 $1,343.11 Y68130 $1,343.11 Y68135 $298.45 Y68200 Bundled NA68320 $1,343.11 Y68325 $2,169.53 Y68326 $2,169.53 Y68328 $1,343.11 Y68330 $1,647.93 Y68335 $2,169.53 Y68340 $1,343.11 Y68360 $2,169.53 Y68362 $1,343.11 Y68371 $1,343.11 Y68400 $546.41 Y68420 $616.32 Y68440 $194.22 Y68500 $2,169.53 Y68505 $2,169.53 Y68510 $1,343.11 Y68520 $2,169.53 Y68525 $1,343.11 Y68530 $231.63 Y68540 Not covered NA68550 Not covered NA68700 $1,343.11 Y68705 $231.63 Y68720 $2,169.53 Y68745 $2,169.53 Y68750 $2,169.53 Y68760 $385.85 Y68761 $282.91 Y68770 $1,343.11 Y68801 Bundled NA68810 $231.63 Y68811 $1,343.11 Y68815 $1,343.11 Y68816 $1,343.11 Y68840 $244.72 Y68850 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


69000 $354.78 Y69005 $401.39 Y69020 $436.35 Y69100 $191.63 Y69105 $264.14 Y69110 $1,765.57 Y69120 $3,559.29 Y69140 $3,559.29 Y69145 $1,765.57 Y69150 Not covered NA69200 Bundled NA69205 $901.87 Y69209 Bundled NA69210 Bundled NA69220 Bundled NA69222 $411.10 Y69300 Not covered NA69310 $3,559.29 Y69320 Not covered NA69420 $154.47 Y69421 $1,581.85 Y69424 $241.48 N69433 $380.67 Y69436 $984.97 Y69440 $1,581.85 Y69450 $1,581.85 Y69501 $3,559.29 Y69502 $3,559.29 Y69505 $3,559.29 Y69511 $3,559.29 Y69530 $3,559.29 Y69540 Not covered NA69550 Not covered NA69552 Not covered NA69601 $3,559.29 Y69602 $3,559.29 Y69603 $3,559.29 Y69604 $3,559.29 Y69605 $3,559.29 Y69610 $717.97 Y69620 $1,581.85 Y69631 $3,559.29 Y69632 $3,559.29 Y69633 $3,559.29 Y69635 $3,559.29 Y69636 $3,559.29 Y69637 $3,559.29 Y69641 $3,559.29 Y69642 $3,559.29 Y69643 $3,559.29 Y69644 $3,559.29 Y




CPT ®

HCPCS Code


Subject To Multiple


69645 $3,559.29 Y69646 $3,559.29 Y69650 $1,581.85 Y69660 $3,559.29 Y69661 $3,559.29 Y69662 $3,559.29 Y69666 $1,581.85 Y69667 $1,581.85 Y69670 $3,559.29 Y69676 $1,581.85 Y69700 $984.97 Y69711 $1,581.85 N69714 $17,917.30 Y69715 $25,930.98 Y69717 $10,041.22 Y69718 $8,421.19 Y69720 $3,559.29 Y69740 $3,559.29 Y69745 $3,559.29 Y69801 $366.43 Y69805 $3,559.29 Y69806 $3,559.29 Y69905 $3,559.29 Y69910 $3,559.29 Y69915 $1,581.85 Y69930 $66,863.44 Y69990 Bundled NA70010 Bundled NA70015 Not covered NA70030 Bundled NA70100 Bundled NA70110 Bundled NA70120 Bundled NA70130 Bundled NA70134 Bundled NA70140 Bundled NA70150 Bundled NA70160 Bundled NA70170 Bundled NA70190 Bundled NA70200 Bundled NA70210 Bundled NA70220 Bundled NA70240 Bundled NA70250 Bundled NA70260 Bundled NA70300 Bundled NA70310 Bundled NA70320 Bundled NA70328 Bundled NA70330 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


70332 Bundled NA70336 $212.22 N70350 Bundled NA70355 Bundled NA70360 Bundled NA70370 Bundled NA70371 Bundled NA70380 Bundled NA70390 Bundled NA70450 $102.77 N70460 $310.10 N70470 $364.49 N70480 $102.77 N70481 $218.72 N70482 $218.72 N70486 $102.77 N70487 $318.52 N70488 $218.72 N70490 $102.77 N70491 $218.72 N70492 $218.72 N70496 $218.72 N70498 $218.72 N70540 $212.22 N70542 $394.94 N70543 $394.94 N70544 $212.22 N70545 $218.72 N70546 $394.94 N70547 $212.22 N70548 $218.72 N70549 $394.94 N70551 $212.22 N70552 $218.72 N70553 $394.94 N70554 Not covered NA70555 Not covered NA70557 Not covered NA70558 Not covered NA70559 Not covered NA71045 $20.07 N71046 $37.55 N71047 Bundled NA71048 Bundled NA71100 Bundled NA71101 Bundled NA71110 Bundled NA71111 Bundled NA71120 Bundled NA71130 Bundled NA71250 $102.77 N




CPT ®

HCPCS Code


Subject To Multiple


71260 $218.72 N71270 $218.72 N71275 $218.72 N71550 $212.22 N71551 $590.10 N71552 $394.94 N72020 Bundled NA72040 Bundled NA72050 Bundled NA72052 Bundled NA72070 Bundled NA72072 Bundled NA72074 Bundled NA72080 Bundled NA72083 $143.08 N72084 $102.77 N72100 Bundled NA72110 Bundled NA72114 Bundled NA72120 Bundled NA72125 $102.77 N72126 $434.41 N72127 $218.72 N72128 $102.77 N72129 $218.72 N72130 $218.72 N72131 $102.77 N72132 $434.41 N72133 $218.72 N72141 $212.22 N72142 $394.94 N72146 $212.22 N72147 $394.94 N72148 $212.22 N72149 $615.03 N72156 $394.94 N72157 $394.94 N72158 $394.94 N72170 Bundled NA72190 Bundled NA72191 $218.72 N72192 $102.77 N72193 $218.72 N72194 $218.72 N72195 $212.22 N72196 $394.94 N72197 $394.94 N72200 Bundled NA72202 Bundled NA72220 Bundled NA72240 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


72255 Bundled NA72265 Bundled NA72270 Bundled NA72275 Bundled NA72285 Bundled NA72295 Bundled NA73000 Bundled NA73010 Bundled NA73020 Bundled NA73030 Bundled NA73040 Bundled NA73050 Bundled NA73060 Bundled NA73070 Bundled NA73080 Bundled NA73085 Bundled NA73090 Bundled NA73092 Not covered NA73100 Bundled NA73110 Bundled NA73115 Bundled NA73120 Bundled NA73130 Bundled NA73140 Bundled NA73200 $102.77 N73201 $218.72 N73202 $218.72 N73206 $218.72 N73218 $212.22 N73219 $394.94 N73220 $394.94 N73221 $212.22 N73222 $725.74 N73223 $394.94 N73525 Bundled NA73560 Bundled NA73562 Bundled NA73564 Bundled NA73565 Bundled NA73580 Bundled NA73590 Bundled NA73592 Not covered NA73600 Bundled NA73610 Bundled NA73615 Bundled NA73620 Bundled NA73630 Bundled NA73650 Bundled NA73660 Bundled NA73700 $102.77 N73701 $218.72 N




CPT ®

HCPCS Code


Subject To Multiple


73702 $218.72 N73706 $218.72 N73718 $212.22 N73719 $218.72 N73720 $394.94 N73721 $212.22 N73722 $730.27 N73723 $394.94 N74018 Bundled NA74019 Bundled NA74021 Bundled NA74022 Bundled NA74150 $102.77 N74160 $218.72 N74170 $218.72 N74174 $218.72 N74175 $218.72 N74176 $380.67 N74177 $218.72 N74178 $218.72 N74181 $212.22 N74182 $394.94 N74183 $394.94 N74190 Bundled NA74210 Bundled NA74220 Bundled NA74230 Bundled NA74235 Bundled NA74240 $214.29 N74241 $222.71 N74245 $102.77 N74246 $218.72 N74247 $218.72 N74249 $218.72 N74250 $102.77 N74251 $102.77 N74260 Bundled NA74261 $102.77 N74262 $218.72 N74270 Bundled NA74280 $218.72 N74283 $218.72 N74290 Bundled NA74300 Bundled NA74301 Bundled NA74328 Bundled NA74329 Bundled NA74330 Bundled NA74340 Bundled NA74355 Bundled NA74360 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


74363 Bundled NA74400 $218.72 N74410 $218.72 N74415 $218.72 N74420 $394.94 N74425 Bundled NA74430 Bundled NA74440 Bundled NA74445 Bundled NA74450 Bundled NA74455 Bundled NA74470 Not covered NA74485 Bundled NA74710 Not covered NA74712 Not covered NA74740 Not covered NA74742 Not covered NA74775 $102.77 N75557 $212.22 N75559 $212.22 N75561 $394.94 N75563 $590.10 N75565 Bundled NA75571 Bundled NA75572 $218.72 N75574 $218.72 N75600 Bundled NA75605 Bundled NA75625 Bundled NA75630 Bundled NA75635 Bundled NA75705 Bundled NA75710 Bundled NA75716 Bundled NA75726 Bundled NA75731 Bundled NA75733 Bundled NA75736 Bundled NA75741 Bundled NA75743 Bundled NA75746 Bundled NA75756 Bundled NA75774 Bundled NA75801 Bundled NA75803 Bundled NA75805 Bundled NA75807 Bundled NA75809 Bundled NA75810 Bundled NA75820 Bundled NA75822 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


75825 Bundled NA75827 Bundled NA75831 Bundled NA75833 Bundled NA75840 Bundled NA75842 Bundled NA75860 Bundled NA75870 Bundled NA75872 Bundled NA75880 Bundled NA75885 Bundled NA75887 Bundled NA75889 Bundled NA75891 Bundled NA75893 Bundled NA75894 Bundled NA75898 Bundled NA75901 Bundled NA75902 Bundled NA75970 Bundled NA75984 Bundled NA75989 Bundled NA76000 $91.28 N76010 Not covered NA76080 Bundled NA76098 Bundled NA76100 Bundled NA76101 $102.77 N76102 $102.77 N76120 Bundled NA76125 Bundled NA76376 Bundled NA76377 Bundled NA76380 Bundled NA76391 $193.05 N76496 Bundled NA76497 Bundled NA76498 $53.76 N76499 Bundled NA76506 Bundled NA76510 Bundled NA76511 Bundled NA76512 Bundled NA76513 Bundled NA76514 Bundled NA76516 Bundled NA76519 Bundled NA76529 Bundled NA76536 Bundled NA76604 Bundled NA76641 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


76642 Bundled NA76700 $102.77 N76705 $102.77 N76770 $102.77 N76775 Bundled NA76776 $102.77 N76800 Bundled NA76801 $102.77 N76802 Bundled NA76805 $102.77 N76810 Bundled NA76811 $102.77 N76812 Bundled NA76813 Bundled NA76814 Bundled NA76815 Bundled NA76816 Bundled NA76817 Bundled NA76818 $102.77 N76819 $171.56 N76820 Bundled NA76821 Bundled NA76825 $533.46 N76826 $315.28 N76827 Bundled NA76828 Bundled NA76830 $102.77 N76831 Not covered NA76856 $102.77 N76857 $91.93 N76870 Bundled NA76872 $102.77 N76873 Not covered NA76881 $102.77 N76882 Bundled NA76885 Not covered NA76886 Not covered NA76930 Bundled NA76932 Bundled NA76936 $215.33 N76937 Bundled NA76940 Not covered NA76941 Bundled NA76942 Bundled NA76945 Not covered NA76946 Bundled NA76948 Not covered NA76965 Not covered NA76970 Bundled NA76975 Bundled NA76977 $14.24 N




CPT ®

HCPCS Code


Subject To Multiple


76978 $168.91 N76979 Bundled NA76981 $94.20 N76982 $94.20 N76983 Bundled NA76998 Bundled NA76999 Bundled NA77001 Bundled NA77002 Bundled NA77003 Bundled NA77011 Bundled NA77012 Bundled NA77013 Bundled NA77014 Bundled NA77021 Not covered NA77022 Not covered NA77046 $193.05 N77047 $193.05 N77053 Not covered NA77054 Not covered NA77071 Bundled NA77072 Not covered NA77073 Bundled NA77074 Bundled NA77075 Bundled NA77076 Not covered NA77077 Bundled NA77078 $53.76 N77080 $80.28 N77081 $53.73 N77084 $212.22 N77085 Bundled NA77086 Bundled NA77280 $108.48 N77285 $279.60 N77290 $279.60 N77295 $947.79 N77299 $108.48 N77300 $127.54 N77301 $1,026.95 N77306 $288.74 N77307 $555.47 N77316 $364.49 N77317 $475.19 N77318 $279.60 N77321 $179.33 N77331 $122.36 N77332 $112.65 N77333 $187.10 N77334 $247.31 N77336 $108.48 N




CPT ®

HCPCS Code


Subject To Multiple


77370 $108.48 N77371 Not covered NA77385 Not covered NA77386 Not covered NA77387 Not covered NA77399 $108.48 N77401 $47.91 N77402 $107.94 N77407 $107.94 N77412 $190.25 N77417 Bundled NA77423 Not covered NA77435 Bundled NA77470 $257.67 N77520 $452.01 N77522 $911.71 N77523 $911.71 N77525 $911.71 N77600 $190.25 N77605 $617.99 N77610 $452.01 N77615 $452.01 N77620 $452.01 N77750 $190.25 N77761 $752.28 N77762 $995.05 N77763 $1,421.04 N77767 Not covered NA77768 Not covered NA77770 Not covered NA77771 Not covered NA77772 Not covered NA77778 $617.99 N77789 $232.42 N77790 Bundled NA77799 $107.94 N78012 $302.41 N78013 $302.41 N78014 $302.41 N78015 $302.41 N78016 $302.41 N78018 $392.10 N78020 Bundled NA78070 $302.41 N78071 $302.41 N78072 $392.10 N78075 $1,040.79 N78099 $302.41 N78102 $302.41 N78103 $302.41 N78104 $302.41 N




CPT ®

HCPCS Code


Subject To Multiple


78110 $1,040.79 N78111 $1,040.79 N78120 $302.41 N78121 $392.10 N78122 $392.10 N78130 $302.41 N78135 $302.41 N78140 $302.41 N78185 $302.41 N78191 $302.41 N78195 $392.10 N78199 $302.41 N78201 $1,040.79 N78202 $1,040.79 N78205 $1,040.79 N78206 $392.10 N78215 $302.41 N78216 $302.41 N78226 $302.41 N78227 $392.10 N78230 $302.41 N78231 $302.41 N78232 $302.41 N78258 $302.41 N78261 $302.41 N78262 $302.41 N78264 $302.41 N78265 $302.41 N78266 $392.10 N78270 Not covered NA78271 Not covered NA78272 Not covered NA78278 $302.41 N78282 $302.41 N78290 $302.41 N78291 $302.41 N78299 $302.41 N78300 $302.41 N78305 $302.41 N78306 $302.41 N78315 $302.41 N78320 $392.10 N78399 $302.41 N78414 $392.10 N78428 $302.41 N78445 $302.41 N78451 $1,040.79 N78452 $1,040.79 N78453 $1,040.79 N78454 $1,040.79 N78456 $1,040.79 N




CPT ®

HCPCS Code


Subject To Multiple


78457 $1,040.79 N78458 $302.41 N78459 $1,040.79 N78466 $302.41 N78468 $392.10 N78469 $1,040.79 N78472 $302.41 N78473 $302.41 N78481 $392.10 N78483 $392.10 N78491 $1,191.83 N78492 $1,191.83 N78494 $302.41 N78496 Bundled NA78499 $302.41 N78579 $302.41 N78580 $302.41 N78582 $392.10 N78597 $302.41 N78598 $392.10 N78599 $302.41 N78600 $302.41 N78601 $302.41 N78605 $392.10 N78606 $392.10 N78607 $1,040.79 N78608 $1,191.83 N78610 $392.10 N78630 $392.10 N78635 $392.10 N78645 $392.10 N78647 $1,040.79 N78650 $1,040.79 N78660 $302.41 N78699 $302.41 N78700 $302.41 N78701 $302.41 N78707 $392.10 N78708 $392.10 N78709 $392.10 N78710 $392.10 N78725 $302.41 N78730 Bundled NA78740 $302.41 N78761 $302.41 N78799 $302.41 N78800 $302.41 N78801 $302.41 N78802 $1,040.79 N78803 $392.10 N78804 $1,040.79 N




CPT ®

HCPCS Code


Subject To Multiple


78805 $1,040.79 N78806 $1,040.79 N78807 $392.10 N78808 Bundled NA78811 Not covered NA78812 Not covered NA78813 Not covered NA78814 Not covered NA78815 $1,191.83 N78816 Not covered NA78999 $302.41 N79005 $258.96 N79101 $273.85 N79200 $253.13 N79300 $206.38 N79403 $365.78 N79440 $233.71 N79445 $206.38 N79999 $206.38 N90371 $111.96 N90375 $296.71 N90376 $296.34 N90385 Not covered NA90396 Not covered NA90476 Bundled NA90585 Not covered NA90632 Bundled NA90633 Not covered NA90634 Not covered NA90636 Bundled NA90647 Bundled NA90648 Bundled NA90672 Bundled NA90674 Bundled NA90675 $269.91 N90676 By Report N90680 Not covered NA90690 Not covered NA90691 Not covered NA90698 Bundled NA90700 Not covered NA90702 Not covered NA90707 Not covered NA90710 Not covered NA90713 Not covered NA90714 Not covered NA90715 Not covered NA90717 Bundled NA90733 Not covered NA90734 Not covered NA90749 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


90756 Bundled NA91200 Not covered NA92071 Not covered NA93261 Not covered NA93355 Not covered NA93590 Not covered NA93591 Not covered NA93644 Not covered NA93895 Not covered NA95940 Not covered NA95941 Not covered NA99497 Not covered NA99498 Not covered NA0042T Not covered NA0100T Not covered NA0101T Not covered NA0102T Not covered NA0174T Not covered NA0175T Not covered NA0213T $581.70 Y0214T Bundled NA0215T Bundled NA0216T $581.70 Y0217T Bundled NA0218T Bundled NA0238T $22,551.20 Y0249T $1,892.29 Y0253T Not covered NA0313T Not covered NA0314T Not covered NA0315T Not covered NA0316T Not covered NA0335T Not covered NA0338T Not covered NA0339T Not covered NA0341T Not covered NA0342T Not covered NA0357T Not covered NA0376T Not covered NA0377T Not covered NA0379T Not covered NA0380T Not covered NA0394T Not covered NA0395T Not covered NA0402T Not covered NA0408T Not covered NA0409T Not covered NA0410T Not covered NA0411T Not covered NA0412T Not covered NA0413T Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


0414T Not covered NA0415T Not covered NA0416T Not covered NA0419T Not covered NA0420T Not covered NA0422T Not covered NA0437T Not covered NA0439T Bundled NA0440T Not covered NA0441T Not covered NA0442T Not covered NA0443T Bundled NA0444T Bundled NA0445T Bundled NA0446T Not covered NA0447T Not covered NA0448T Not covered NA0449T $2,944.19 Y0450T Bundled NA0471T Not covered NA0474T Not covered NA0479T Not covered NA0480T Not covered NA0482T Not covered NA0487T Not covered NA0491T Not covered NA0492T Not covered NA0493T Not covered NA0502T Not covered NA0503T Not covered NA0510T Not covered NA0511T Not covered NA0512T Not covered NA0513T Not covered NA0514T Bundled NA0523T Bundled NA0524T $2,122.91 Y0525T Not covered NA0526T Not covered NA0527T Not covered NA0530T Not covered NA0531T Not covered NA0532T Not covered NAA4218 Not covered NAA4220 Not covered NAA4248 Not covered NAA4262 Not covered NAA4263 Not covered NAA4270 Not covered NAA4300 Not covered NAA4301 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


A4305 Not covered NAA4306 Not covered NAA4459 Not covered NAA4602 Not covered NAA4648 Not covered NAA4650 Not covered NAA7048 Not covered NAA9515 Not covered NAA9520 Bundled NAA9527 UR/BR NA9575 Bundled NAA9576 Bundled NAA9577 Bundled NAA9578 Bundled NAA9579 Bundled NAA9580 Bundled NAA9581 Bundled NAA9582 Not covered NAA9583 Bundled NAA9584 Bundled NAA9585 Bundled NAA9587 Not covered NAA9588 By Report NA9597 Not covered NAA9598 Not covered NAA9606 Not covered NAA9698 Bundled NAC1713 Bundled NAC1714 Bundled NAC1715 Bundled NAC1716 Not covered NAC1717 Not covered NAC1719 Not covered NAC1721 Bundled NAC1722 Bundled NAC1724 Bundled NAC1725 Bundled NAC1726 Bundled NAC1727 Bundled NAC1728 Bundled NAC1729 Bundled NAC1730 Bundled NAC1731 Bundled NAC1732 Bundled NAC1733 Bundled NAC1750 Bundled NAC1751 Bundled NAC1752 Bundled NAC1753 Bundled NAC1754 Bundled NAC1755 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


C1756 Bundled NAC1757 Bundled NAC1758 Bundled NAC1759 Bundled NAC1760 Bundled NAC1762 Bundled NAC1763 Bundled NAC1764 Bundled NAC1765 Bundled NAC1766 Bundled NAC1767 Bundled NAC1768 Bundled NAC1769 Bundled NAC1770 Bundled NAC1771 Bundled NAC1772 Bundled NAC1773 Bundled NAC1776 Bundled NAC1777 Bundled NAC1778 Bundled NAC1779 Bundled NAC1780 Bundled NAC1781 Bundled NAC1782 Bundled NAC1783 Bundled NAC1784 Bundled NAC1785 Bundled NAC1786 Bundled NAC1787 Bundled NAC1788 Bundled NAC1789 Bundled NAC1813 Bundled NAC1814 Bundled NAC1815 Bundled NAC1816 Bundled NAC1817 Bundled NAC1818 Bundled NAC1819 Bundled NAC1820 Not covered NAC1821 Not covered NAC1822 Not covered NAC1874 Bundled NAC1875 Bundled NAC1876 Bundled NAC1877 Bundled NAC1878 Bundled NAC1880 Bundled NAC1881 Bundled NAC1882 Bundled NAC1883 Bundled NAC1884 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


C1885 Bundled NAC1887 Bundled NAC1888 Bundled NAC1889 Bundled NAC1891 Bundled NAC1892 Bundled NAC1893 Bundled NAC1894 Bundled NAC1895 Bundled NAC1896 Bundled NAC1897 Bundled NAC1898 Bundled NAC1899 Bundled NAC1900 Bundled NAC2613 Not covered NAC2614 Not covered NAC2615 Bundled NAC2616 UR/BR NC2617 Bundled NAC2618 Bundled NAC2619 Bundled NAC2620 Bundled NAC2621 Bundled NAC2622 Bundled NAC2624 Bundled NAC2625 Bundled NAC2626 Bundled NAC2627 Bundled NAC2628 Bundled NAC2629 Bundled NAC2630 Bundled NAC2631 Bundled NAC2634 Not covered NAC2635 Not covered NAC2636 Not covered NAC2638 Not covered NAC2639 Not covered NAC2640 Not covered NAC2641 Not covered NAC2642 Not covered NAC2643 Not covered NAC2698 Not covered NAC2699 Not covered NAC5271 Not covered NAC5272 Not covered NAC5273 Not covered NAC5274 Not covered NAC5275 Not covered NAC5276 Not covered NAC5277 Not covered NAC5278 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


C8900 $218.72 NC8901 $212.22 NC8902 $394.94 NC8903 $218.72 NC8905 $394.94 NC8906 $394.94 NC8908 $394.94 NC8909 $218.72 NC8910 $212.22 NC8911 $394.94 NC8912 $394.94 NC8913 $212.22 NC8914 $394.94 NC8918 $218.72 NC8919 $212.22 NC8920 $394.94 NC9014 Not covered NAC9015 Not covered NAC9016 Not covered NAC9024 By Report NC9028 By Report NC9029 By Report NC9035 Not covered NAC9036 Not covered NAC9037 Not covered NAC9038 Not covered NAC9039 $37.80 NC9113 Bundled NAC9248 Bundled NAC9254 Bundled NAC9275 Not covered NAC9293 $344.56 NC9352 Bundled NAC9353 Bundled NAC9399 UR/BR NAC9407 Not covered NAC9447 Bundled NAC9460 By Report NC9488 $29.93 NC9492 Not Covered NAC9493 Not covered NAC9497 By Report NC9716 Not covered NAC9725 Not covered NAC9726 Not covered NAC9727 $984.97 YC9738 Bundled NAC9745 $6,448.39 YC9746 $24,185.08 YC9747 $11,544.96 YC9752 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


C9754 $6,596.12 NC9755 $6,596.12 NE0616 Not covered NAE0749 Not covered NAE0782 Not covered NAE0783 Not covered NAE0785 Not covered NAE0786 Not covered NAG0104 $323.70 YG0105 $614.42 YG0121 $614.42 YG0127 Not covered NAG0130 $66.68 NG0186 $422.30 YG0247 Not covered NAG0259 Not covered NAG0260 $470.24 YG0268 Not covered NAG0269 Not covered NAG0276 Not covered NAG0288 Not covered NAG0289 Not covered NAG0339 Not covered NAG0340 Not covered NAG0453 Not covered NAG0458 Not covered NAG0464 Not covered NAG0472 Not covered NAG0516 Bundled NAG0517 Bundled NAG0518 Bundled NAJ0120 Not covered NAJ0129 $50.16 NJ0130 Bundled NAJ0131 Bundled NAJ0132 Bundled NAJ0133 Bundled NAJ0135 Not covered NAJ0153 Bundled NAJ0171 Bundled NAJ0178 Not covered NAJ0180 $172.19 NJ0185 $2.68 NJ0190 Not covered NAJ0200 Not covered NAJ0202 Not covered NAJ0205 Not covered NAJ0207 $948.18 NJ0210 Bundled NAJ0215 Not covered NAJ0220 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


J0256 $4.45 NJ0278 Not covered NAJ0280 Bundled NAJ0282 Bundled NAJ0285 Bundled NAJ0287 $17.35 NJ0288 Not covered NAJ0289 $48.07 NJ0290 Bundled NAJ0295 Bundled NAJ0300 $219.91 NJ0330 Bundled NAJ0348 Bundled NAJ0360 Bundled NAJ0364 Not covered NAJ0365 Not covered NAJ0380 Not covered NAJ0390 Not covered NAJ0400 $0.70 NJ0401 $5.01 NJ0456 Bundled NAJ0461 Bundled NAJ0470 $50.91 N J0475 $178.38 NJ0476 $45.98 NJ0480 $3,550.39 NJ0485 $3.89 NJ0500 Bundled NAJ0515 Bundled NAJ0517 $190.08 NJ0520 Not covered NAJ0558 Bundled NAJ0561 $12.84 NJ0565 By Report NJ0567 Not covered NAJ0570 $1,229.98 NJ0583 Not covered NAJ0584 Not covered NAJ0585 $6.15 NJ0586 $8.23 NJ0587 $11.99 NJ0588 $5.08 NJ0592 Bundled NAJ0594 $27.95 NJ0595 Bundled NAJ0596 Not covered NAJ0597 Not covered NAJ0599 Not covered NAJ0600 $5,594.42 NJ0606 By Report NJ0610 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


J0620 Not covered NAJ0630 $2,461.06 NJ0636 Not covered NAJ0637 $15.51 NJ0638 Not covered NAJ0640 Bundled NAJ0641 $0.36 NJ0670 Bundled NAJ0690 Bundled NAJ0692 Bundled NAJ0694 Bundled NAJ0695 $4.48 NJ0696 Bundled NAJ0697 Bundled NAJ0698 Bundled NAJ0702 Bundled NAJ0706 Not covered NAJ0710 Not covered NAJ0712 $2.62 NJ0713 Bundled NAJ0714 $78.64 NJ0715 Not covered NAJ0716 $5,305.50 NJ0717 Not covered NAJ0720 Bundled NAJ0725 Bundled NAJ0735 Bundled NAJ0740 $493.46 NJ0743 Bundled NAJ0744 Bundled NAJ0745 Not covered NAJ0770 Bundled NAJ0775 Not covered NAJ0780 Bundled NAJ0795 Not covered NAJ0800 $3,754.07 NJ0833 Bundled NAJ0834 Bundled NAJ0840 $3,086.28 NJ0841 Not covered NAJ0850 $1,129.12 NJ0875 $14.73 NJ0878 $0.42 NJ0881 $3.78 NJ0883 $45.60 NJ0884 $45.60 NJ0885 $13.00 NJ0888 $1.90 NJ0894 $16.42 NJ0895 Bundled NAJ0897 $17.94 N




CPT ®

HCPCS Code


Subject To Multiple


J0945 Not covered NAJ1000 Not covered NAJ1020 Bundled NAJ1030 Bundled NAJ1040 Bundled NAJ1050 Bundled NAJ1071 Bundled NAJ1094 Not covered NAJ1100 Bundled NAJ1110 $83.35 NJ1120 Bundled NAJ1160 Bundled NAJ1162 $3,513.19 NJ1165 Bundled NAJ1170 Bundled NAJ1180 Not covered NAJ1190 $243.13 NJ1200 Bundled NAJ1205 Bundled NAJ1212 $549.34 NJ1230 Bundled NAJ1240 Bundled NAJ1245 Bundled NAJ1250 Bundled NAJ1260 Bundled NAJ1265 Bundled NAJ1267 Bundled NAJ1270 Not covered NAJ1290 Not covered NAJ1300 Not covered NAJ1301 Not covered NAJ1320 Not covered NAJ1322 Not covered NAJ1324 Not covered NAJ1325 Bundled NAJ1327 $31.29 NJ1330 Not covered NAJ1335 Bundled NAJ1364 $72.36 NJ1380 Not covered NAJ1410 Not covered NAJ1428 Not covered NAJ1430 Not covered NAJ1435 Not covered NAJ1436 Not covered NAJ1438 $521.34 NJ1439 $1.05 NJ1442 $1.02 NJ1447 $0.61 N J1450 Bundled NAJ1451 $11.33 N




CPT ®

HCPCS Code


Subject To Multiple


J1453 $2.10 NJ1454 $612.00 NJ1455 $15.00 NJ1457 Not covered NAJ1458 Not covered NAJ1459 $39.65 NJ1460 $38.79 NJ1555 By Report NJ1556 Not covered NAJ1559 Not covered NAJ1560 $387.93 NJ1561 $39.15 NJ1562 Not covered NAJ1566 $35.53 NJ1568 $41.41 NJ1569 $39.69 NJ1570 Bundled NAJ1571 $62.21 NJ1572 $35.15 NJ1573 $69.12 NJ1575 Not covered NAJ1580 Bundled NAJ1595 Not covered NAJ1599 Bundled NAJ1600 Not covered NAJ1602 $24.04 NJ1610 $211.73 NJ1620 Not covered NAJ1626 Bundled NAJ1627 $4.34 NJ1628 $1,219.00 NJ1630 Bundled NAJ1631 Bundled NAJ1640 $22.36 NJ1642 Bundled NAJ1644 Bundled NAJ1645 Bundled NAJ1650 Bundled NAJ1652 Bundled NAJ1655 Not covered NAJ1670 $451.51 NJ1700 Not covered NAJ1710 Not covered NAJ1720 Bundled NAJ1726 Not covered NAJ1729 Not covered NAJ1730 Not covered NAJ1740 $74.24 NJ1741 Bundled NAJ1742 $321.30 NJ1743 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


J1744 Not covered NAJ1745 $83.29 NJ1746 $101.20 NJ1756 Bundled NAJ1786 $41.58 NJ1790 Bundled NAJ1800 Bundled NAJ1815 Bundled NAJ1817 Bundled NAJ1830 $346.17 NJ1833 $0.96 NJ1835 Not covered NAJ1840 Not covered NAJ1850 Not covered NAJ1885 Bundled NAJ1890 Not covered NAJ1930 Not covered NAJ1931 $30.61 NJ1940 Bundled NAJ1942 $2.43 NJ1945 Not covered NAJ1950 $1,089.22 NJ1953 Not covered NAJ1956 Bundled NAJ1960 Not covered NAJ1980 Bundled NAJ1990 Not covered NAJ2001 Bundled NAJ2010 Bundled NAJ2020 Bundled NAJ2060 Bundled NAJ2062 $18.00 NJ2150 Bundled NAJ2170 Not covered NAJ2175 Bundled NAJ2180 Not covered NAJ2182 $15.00 NJ2185 Bundled NAJ2210 Not covered NAJ2212 Bundled NAJ2248 Bundled NAJ2250 Bundled NAJ2260 Bundled NAJ2270 Bundled NAJ2274 Not covered NAJ2278 $7.44 NJ2280 Bundled NAJ2300 Bundled NAJ2310 Bundled NAJ2315 $3.26 NJ2320 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


J2323 Not covered NAJ2325 Not covered NAJ2326 Not covered NAJ2350 Not covered NAJ2353 $190.68 NJ2354 Bundled NAJ2355 $467.22 NJ2357 $36.38 NJ2358 Bundled NAJ2360 Bundled NAJ2370 Bundled NAJ2400 Bundled NAJ2405 Bundled NAJ2407 $23.49 NJ2410 Bundled NAJ2425 Not covered NAJ2426 $10.38 NJ2430 Bundled NAJ2440 Bundled NAJ2469 $20.02 NJ2501 Bundled NAJ2502 $246.17 NJ2503 Not covered NAJ2504 Not covered NAJ2505 Not covered NAJ2510 Bundled NAJ2513 Not covered NAJ2515 Not covered NAJ2540 Bundled NAJ2543 Bundled NAJ2547 $0.10 NJ2550 Bundled NAJ2560 Bundled NAJ2562 $314.44 NJ2590 Not covered NAJ2597 $13.02 NJ2650 Not covered NAJ2670 Not covered NAJ2675 Not covered NAJ2680 Bundled NAJ2690 Bundled NAJ2700 Bundled NAJ2704 Bundled NAJ2710 Bundled NAJ2720 Bundled NAJ2724 $15.20 NJ2725 Not covered NAJ2730 Bundled NAJ2760 $255.00 NJ2765 Not covered NAJ2770 $419.20 N




CPT ®

HCPCS Code


Subject To Multiple


J2778 Not covered NAJ2780 Bundled NAJ2783 Not covered NAJ2785 Bundled NAJ2786 $0.84 NJ2788 Bundled NAJ2790 Bundled NAJ2791 Bundled NAJ2792 $24.31 NJ2794 $8.98 NJ2795 Bundled NAJ2796 $68.50 NJ2797 By Report NJ2800 Bundled NAJ2805 Not covered NAJ2810 Bundled NAJ2820 $37.48 NJ2840 Not covered NAJ2850 Not covered NAJ2860 Not covered NAJ2910 Not covered NAJ2916 Bundled NAJ2920 Bundled NAJ2930 Bundled NAJ2941 Not covered NAJ2950 Not covered NAJ2993 Not covered NAJ2995 Not covered NAJ2997 $84.58 NJ3000 Bundled NAJ3010 Bundled NAJ3030 Bundled NAJ3060 Not covered NAJ3070 $108.39 NJ3090 $1.38 NJ3095 $5.39 NJ3101 $111.63 NJ3105 Bundled NAJ3121 Bundled NAJ3145 $0.54 N J3230 Bundled NAJ3240 $1,598.00 NJ3243 $2.63 NJ3246 $11.18 NJ3250 Bundled NAJ3260 Bundled NAJ3262 $4.54 NJ3265 Bundled NAJ3280 Not covered NAJ3285 Not covered NAJ3300 $3.87 N




CPT ®

HCPCS Code


Subject To Multiple


J3301 Bundled NAJ3302 Not covered NAJ3303 Bundled NAJ3304 $18.88 NJ3310 Not covered NAJ3315 Not covered NAJ3316 Not covered NAJ3320 Not covered NAJ3350 Not covered NAJ3355 Not covered NAJ3357 $184.94 NJ3358 By Report NJ3360 Bundled NAJ3364 Not covered NAJ3365 Not covered NAJ3370 Bundled NAJ3380 $19.13 NJ3385 Not covered NAJ3396 Not covered NAJ3397 Not covered NAJ3398 Not covered NAJ3400 Not covered NAJ3410 Bundled NAJ3411 Bundled NAJ3415 Bundled NAJ3420 Bundled NAJ3430 Bundled NAJ3465 $2.10 NJ3470 Bundled NAJ3471 Bundled NAJ3472 Bundled NAJ3473 Bundled NAJ3475 Bundled NAJ3480 Bundled NAJ3485 Bundled NAJ3486 Bundled NAJ3489 Bundled NAJ3490 Bundled NAJ3530 Not covered NAJ3590 Bundled NAJ7030 Bundled NAJ7040 Bundled NAJ7042 Bundled NAJ7050 Bundled NAJ7060 Bundled NAJ7070 Bundled NAJ7100 Bundled NAJ7110 Not covered NAJ7120 Bundled NAJ7131 Bundled NAJ7170 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


J7175 $9.86 NJ7177 Not covered NAJ7178 $0.93 NJ7179 $3.50 NJ7181 $18.29 NJ7185 $1.25 NJ7186 $0.99 NJ7187 $1.13 NJ7188 $12.20 NJ7189 $2.06 NJ7190 $1.04 NJ7191 Not covered NAJ7192 $1.28 NJ7193 $1.13 NJ7194 $1.40 NJ7195 $1.50 NJ7196 Not covered NAJ7197 $3.59 NJ7198 $1.99 NJ7200 $1.31 NJ7201 $3.03 NJ7202 $6.34 NJ7203 Not covered NAJ7205 $2.05 NJ7207 By Report NJ7209 By Report NJ7210 By Report NJ7211 By Report NJ7308 Not covered NAJ7309 Not covered NAJ7310 Not covered NAJ7311 $20,166.50 NJ7312 $200.36 NJ7313 $490.28 NJ7315 Bundled NAJ7316 Not covered NAJ7318 $6.50 NJ7321 $88.65 NJ7322 $7.26 NJ7323 $149.92 NJ7324 $149.40 NJ7325 $12.08 NJ7326 $527.87 NJ7327 $812.55 NJ7336 $3.15 NJ7340 By Report NJ7342 Not covered NAJ7345 Not covered NAJ7500 Bundled NAJ7501 Not covered NAJ7502 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


J7504 $1,937.64 NJ7505 Not covered NAJ7507 Bundled NAJ7508 Bundled NAJ7509 Bundled NAJ7510 Bundled NAJ7511 $713.84 NJ7513 Not covered NAJ7515 Bundled NAJ7516 Bundled NAJ7517 Bundled NAJ7518 Not covered NAJ7520 Bundled NAJ7525 $192.81 NJ7527 Bundled NAJ7599 Bundled NAJ7674 Bundled NAJ7799 Bundled NAJ8501 Not covered NAJ8510 Bundled NAJ8520 Bundled NAJ8521 Bundled NAJ8530 Bundled NAJ8540 Bundled NAJ8560 $74.66 NJ8562 Not covered NAJ8597 Bundled NAJ8600 Bundled NAJ8610 Bundled NAJ8655 $366.82 NJ8670 $2.27 NJ8700 Bundled NAJ8705 $103.73 NJ9000 Bundled NAJ9015 $2,342.00 NJ9017 $71.82 NJ9019 $409.06 NJ9020 Not covered NAJ9022 By Report NJ9023 Not covered NAJ9025 Not covered NAJ9027 Not covered NAJ9031 $137.67 NJ9032 $36.27 NJ9033 $30.21 NJ9034 $23.75 NJ9035 $77.17 NJ9039 $107.47 NJ9040 Bundled NAJ9041 $46.66 NJ9042 Not covered NA




CPT ®

HCPCS Code


Subject To Multiple


J9044 Not covered NAJ9045 Bundled NAJ9047 $34.11 NJ9050 $3,854.59 NJ9055 Not covered NAJ9057 Not covered NAJ9060 Bundled NAJ9065 $22.62 NJ9070 Not covered NAJ9098 $628.37 NJ9100 Bundled NAJ9120 $1,580.57 NJ9130 Bundled NAJ9145 $50.39 NJ9150 $41.58 NJ9151 Not covered NAJ9153 Not covered NAJ9160 Not covered NAJ9171 $1.66 NJ9173 Not covered NAJ9175 Not covered NAJ9176 $6.35 NJ9178 Bundled NAJ9179 $111.28 NJ9181 Bundled NAJ9185 $76.62 N J9190 Bundled NAJ9200 Bundled NAJ9201 Bundled NAJ9202 $397.59 NJ9203 By Report NJ9205 $42.59 NJ9206 Bundled NAJ9207 $72.11 NJ9208 Bundled NAJ9209 Bundled NAJ9211 $34.28 NJ9212 Bundled NAJ9213 Not covered NAJ9214 $31.09 NJ9215 Not covered NAJ9216 $1,342.37 NJ9217 $209.30 NJ9218 $25.79 NJ9219 Not covered NAJ9225 Not covered NAJ9226 Not covered NAJ9229 Not covered NAJ9230 $292.48 NJ9245 $1,117.99 NJ9250 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


J9260 Bundled NAJ9261 $151.90 NJ9262 Not covered NAJ9263 Bundled NAJ9264 $11.12 NJ9266 $14,977.05 NJ9267 Bundled NAJ9268 $2,066.03 NJ9270 Not covered NAJ9271 $48.71 NJ9280 $140.08 NJ9285 Not covered NAJ9293 $32.14 NJ9295 $5.36 NJ9299 Not covered NAJ9301 Not covered NAJ9302 $56.59 NJ9303 Not covered NAJ9305 $66.17 NJ9306 $11.51 NJ9307 $262.32 NJ9308 $56.93 NJ9310 $883.68 NJ9311 Not covered NAJ9312 $112.74 NJ9315 Not covered NAJ9320 $342.79 NJ9325 By Report NJ9328 $9.48 NJ9330 $71.69 NJ9340 $1,080.00 NJ9351 Bundled NAJ9352 By Report NJ9354 Not covered NAJ9355 $101.05 NJ9357 Not covered NAJ9360 Bundled NAJ9370 Bundled NAJ9371 $2,807.15 NJ9390 Bundled NAJ9395 Not covered NAJ9400 $8.12 NJ9600 $12,256.00 NJ9999 Bundled NAL8600 Bundled NAL8603 Bundled NAL8604 Bundled NAL8606 Bundled NAL8609 Not covered NAL8610 Bundled NAL8612 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


L8613 Bundled NAL8614 Bundled NAL8630 Bundled NAL8631 Bundled NAL8641 Bundled NAL8642 Bundled NAL8658 Bundled NAL8659 Bundled NAL8670 Bundled NAL8682 Bundled NAL8690 Bundled NAL8699 Bundled NAP9041 $11.80 NP9045 $54.72 NP9046 $22.49 NP9047 $53.44 NQ0138 $0.95 NQ0161 Bundled NAQ0163 Bundled NAQ0164 Bundled NAQ0166 Bundled NAQ0167 Bundled NAQ0169 Bundled NAQ0173 Bundled NAQ0174 Not covered NAQ0175 Bundled NAQ0177 Bundled NAQ0180 Bundled NAQ0515 Not covered NAQ2004 Bundled NAQ2009 $0.71 N Q2017 $599.03 NQ2035 Not covered NAQ2036 Not covered NAQ2037 Not covered NAQ2038 Not covered NAQ2039 Not covered NAQ2040 Not covered NAQ3027 Not covered NAQ4100 Bundled NAQ4101 Bundled NAQ4102 Bundled NAQ4103 Bundled NAQ4104 Bundled NAQ4105 Bundled NAQ4106 Bundled NAQ4107 Bundled NAQ4108 Bundled NAQ4110 Bundled NAQ4112 Bundled NAQ4113 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


Q4114 Bundled NAQ4118 Not covered NAQ4121 Not covered NAQ4131 Not covered NAQ4132 Not covered NAQ4133 Not covered NAQ4137 Not covered NAQ4138 Not covered NAQ4139 Not covered NAQ4140 Not covered NAQ4141 Not covered NAQ4142 Not covered NAQ4143 Not covered NAQ4145 Not covered NAQ4146 Not covered NAQ4147 Not covered NAQ4148 Not covered NAQ4149 Not covered NAQ4150 Not covered NAQ4151 Not covered NAQ4152 Not covered NAQ4153 Not covered NAQ4154 Not covered NAQ4155 Not covered NAQ4156 Not covered NAQ4157 Not covered NAQ4158 Not covered NAQ4159 Not covered NAQ4160 Not covered NAQ4166 Not covered NAQ4167 Not covered NAQ4168 Not covered NAQ4169 Not covered NAQ4170 Not covered NAQ4171 Not covered NAQ4173 Not covered NAQ4174 Not covered NAQ4175 Not covered NAQ4176 Not covered NAQ4177 Not covered NAQ4178 Not covered NAQ4179 Not covered NAQ4180 Not covered NAQ4181 Not covered NAQ4182 Not covered NAQ9950 Bundled NAQ9951 Bundled NAQ9953 Bundled NAQ9954 Bundled NAQ9955 Bundled NAQ9956 Bundled NA




CPT ®

HCPCS Code


Subject To Multiple


Q9957 Bundled NAQ9958 Bundled NAQ9959 Bundled NAQ9960 Bundled NAQ9961 Bundled NAQ9962 Bundled NAQ9963 Bundled NAQ9964 Bundled NAQ9965 Bundled NAQ9966 Bundled NAQ9967 Bundled NAQ9968 By Report NV2630 Bundled NAV2631 Bundled NAV2632 Bundled NAV2785 UR/BR NV2790 Bundled NA

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