calendar year 2015 maryland workers' compensation … · 2014-12-15 · calendar year 2015...

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10111213141516171819202122232425262728293031323334353637383940414243444546474849505152535455565758

A B C D

HCPCS

CodeCMS Payment Indicator CMS 2015 Payment WCC 2015 Payment Rates

10021 P3 $99.17 $131.5910022 P3 $92.73 $123.0410030 P2 $474.65 $629.8010040 N1 $0.00 $0.0010060 P3 $70.53 $93.5810061 P2 $88.78 $117.8010080 P2 $88.78 $117.8010081 P3 $170.77 $226.5910120 P3 $105.26 $139.6710121 A2 $735.25 $975.5910140 P3 $101.68 $134.9210160 P3 $81.27 $107.8410180 A2 $896.60 $1,189.6811000 P3 $31.86 $42.2711001 N1 $0.00 $0.0011010 A2 $453.06 $601.1611011 A2 $207.50 $275.3311012 A2 $453.06 $601.1611042 A2 $155.20 $205.9311043 A2 $155.20 $205.9311044 A2 $453.06 $601.1611045 N1 $0.00 $0.0011046 N1 $0.00 $0.0011047 N1 $0.00 $0.0011055 N1 $0.00 $0.0011056 P3 $39.74 $52.7311057 P3 $41.53 $55.1111100 P3 $71.60 $95.0011101 N1 $0.00 $0.0011200 N1 $0.00 $0.0011201 N1 $0.00 $0.0011300 P3 $74.11 $98.3411301 P2 $80.10 $106.2811302 P2 $80.10 $106.2811303 P2 $80.10 $106.2811305 N1 $0.00 $0.0011306 P2 $80.10 $106.2811307 P2 $80.10 $106.2811308 P2 $80.10 $106.2811310 P2 $80.10 $106.2811311 P3 $68.02 $90.2511312 P2 $80.10 $106.2811313 P2 $80.10 $106.2811400 P3 $88.79 $117.8111401 P3 $98.45 $130.6311402 P3 $107.76 $142.9811403 P3 $117.43 $155.8211404 A2 $735.25 $975.5911406 A2 $735.25 $975.5911420 P3 $83.06 $110.2111421 P3 $99.17 $131.5911422 P3 $108.84 $144.4211423 P3 $119.93 $159.1311424 A2 $735.25 $975.5911426 A2 $999.94 $1,326.8011440 P3 $94.16 $124.94

Calendar Year 2015 Maryland Workers' Compensation Commission Medical Fee GuideASC Covered Surgical Procedures

(including surgical procedures for which payment is packaged and ancillary services approved by CMS) Effective January 1, 2015

Updated December 20141 of 99

Effective January 1, 2015

1

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A B C D

HCPCS




5960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114

11441 P3 $107.40 $142.5111442 P3 $117.43 $155.8211443 P3 $130.32 $172.9211444 A2 $453.06 $601.1611446 A2 $999.94 $1,326.8011450 A2 $999.94 $1,326.8011451 A2 $999.94 $1,326.8011462 A2 $999.94 $1,326.8011463 A2 $999.94 $1,326.8011470 A2 $999.94 $1,326.8011471 A2 $999.94 $1,326.8011600 P3 $128.53 $170.5411601 P3 $146.79 $194.7711602 P3 $157.88 $209.4911603 P3 $170.77 $226.5911604 A2 $453.06 $601.1611606 A2 $735.25 $975.5911620 P3 $129.60 $171.9611621 P3 $147.50 $195.7111622 P3 $160.75 $213.3011623 P3 $176.50 $234.1911624 A2 $735.25 $975.5911626 A2 $999.94 $1,326.8011640 P3 $134.25 $178.1311641 P3 $151.80 $201.4211642 P3 $167.19 $221.8411643 P3 $183.66 $243.6911644 A2 $735.25 $975.5911646 A2 $999.94 $1,326.8011719 N1 $0.00 $0.0011720 N1 $0.00 $0.0011721 N1 $0.00 $0.0011730 P3 $58.00 $76.9611732 N1 $0.00 $0.0011740 N1 $0.00 $0.0011750 P3 $130.32 $172.9211752 P3 $184.38 $244.6511755 P3 $84.49 $112.1111760 G2 $120.55 $159.9611762 P3 $171.13 $227.0711765 P2 $80.10 $106.2811770 A2 $999.94 $1,326.8011771 A2 $999.94 $1,326.8011772 A2 $999.94 $1,326.8011900 N1 $0.00 $0.0011901 N1 $0.00 $0.0011920 P3 $105.97 $140.6111921 P3 $120.65 $160.0911922 N1 $0.00 $0.0011950 P3 $43.68 $57.9611951 P3 $57.28 $76.0011952 P3 $60.86 $80.7511954 P3 $83.42 $110.6911960 A2 $1,261.51 $1,673.8711970 A2 $2,062.56 $2,736.7711971 A2 $999.94 $1,326.80



1

2

A B C D

HCPCS




115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170

11976 P3 $73.39 $97.3811980 N1 $0.00 $0.0011981 N1 $0.00 $0.0011982 N1 $0.00 $0.0011983 N1 $0.00 $0.0012001 N1 $0.00 $0.0012002 N1 $0.00 $0.0012004 N1 $0.00 $0.0012005 A2 $80.10 $106.2812006 A2 $120.55 $159.9612007 A2 $80.10 $106.2812011 N1 $0.00 $0.0012013 N1 $0.00 $0.0012014 N1 $0.00 $0.0012015 G2 $80.10 $106.2812016 A2 $80.10 $106.2812017 A2 $80.10 $106.2812018 A2 $80.10 $106.2812020 A2 $235.76 $312.8312021 A2 $120.55 $159.9612031 P2 $120.55 $159.9612032 P2 $120.55 $159.9612034 A2 $120.55 $159.9612035 A2 $235.76 $312.8312036 A2 $235.76 $312.8312037 A2 $235.76 $312.8312041 P2 $120.55 $159.9612042 P2 $120.55 $159.9612044 A2 $120.55 $159.9612045 A2 $120.55 $159.9612046 A2 $120.55 $159.9612047 A2 $235.76 $312.8312051 P2 $120.55 $159.9612052 P2 $120.55 $159.9612053 P2 $120.55 $159.9612054 A2 $120.55 $159.9612055 A2 $120.55 $159.9612056 A2 $120.55 $159.9612057 A2 $120.55 $159.9613100 A2 $235.76 $312.8313101 A2 $235.76 $312.8313102 N1 $0.00 $0.0013120 A2 $120.55 $159.9613121 A2 $235.76 $312.8313122 N1 $0.00 $0.0013131 A2 $120.55 $159.9613132 A2 $235.76 $312.8313133 N1 $0.00 $0.0013151 A2 $235.76 $312.8313152 A2 $235.76 $312.8313153 N1 $0.00 $0.0013160 A2 $771.43 $1,023.6014000 A2 $771.43 $1,023.6014001 A2 $771.43 $1,023.6014020 A2 $771.43 $1,023.6014021 A2 $771.43 $1,023.60



1

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A B C D

HCPCS




171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226

14040 A2 $771.43 $1,023.6014041 A2 $771.43 $1,023.6014060 A2 $771.43 $1,023.6014061 A2 $771.43 $1,023.6014301 G2 $1,261.51 $1,673.8714302 N1 $0.00 $0.0014350 A2 $771.43 $1,023.6015002 A2 $235.76 $312.8315003 N1 $0.00 $0.0015004 A2 $235.76 $312.8315005 N1 $0.00 $0.0015040 A2 $235.76 $312.8315050 A2 $235.76 $312.8315100 A2 $1,261.51 $1,673.8715101 N1 $0.00 $0.0015110 A2 $235.76 $312.8315111 N1 $0.00 $0.0015115 A2 $771.43 $1,023.6015116 N1 $0.00 $0.0015120 A2 $1,261.51 $1,673.8715121 N1 $0.00 $0.0015130 A2 $1,261.51 $1,673.8715131 N1 $0.00 $0.0015135 A2 $771.43 $1,023.6015136 N1 $0.00 $0.0015150 A2 $771.43 $1,023.6015151 N1 $0.00 $0.0015152 N1 $0.00 $0.0015155 A2 $1,261.51 $1,673.8715156 N1 $0.00 $0.0015157 N1 $0.00 $0.0015200 A2 $1,261.51 $1,673.8715201 N1 $0.00 $0.0015220 A2 $771.43 $1,023.6015221 N1 $0.00 $0.0015240 A2 $771.43 $1,023.6015241 N1 $0.00 $0.0015260 A2 $771.43 $1,023.6015261 N1 $0.00 $0.0015271 G2 $771.43 $1,023.6015272 N1 $0.00 $0.0015273 G2 $1,261.51 $1,673.8715274 N1 $0.00 $0.0015275 G2 $771.43 $1,023.6015276 N1 $0.00 $0.0015277 G2 $771.43 $1,023.6015278 N1 $0.00 $0.0015570 A2 $771.43 $1,023.6015572 A2 $771.43 $1,023.6015574 A2 $771.43 $1,023.6015576 A2 $771.43 $1,023.6015600 A2 $1,261.51 $1,673.8715610 A2 $1,261.51 $1,673.8715620 A2 $771.43 $1,023.6015630 A2 $771.43 $1,023.6015650 A2 $771.43 $1,023.60



1

2

A B C D

HCPCS




227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282

15731 A2 $1,261.51 $1,673.8715732 A2 $771.43 $1,023.6015734 A2 $1,261.51 $1,673.8715736 A2 $771.43 $1,023.6015738 A2 $1,261.51 $1,673.8715740 A2 $771.43 $1,023.6015750 A2 $771.43 $1,023.6015760 A2 $771.43 $1,023.6015770 A2 $1,261.51 $1,673.8715775 A2 $120.55 $159.9615776 A2 $120.55 $159.9615777 N1 $0.00 $0.0015780 P3 $508.74 $675.0415781 P3 $353.72 $469.3415782 P2 $207.50 $275.3315783 P2 $155.20 $205.9315786 N1 $0.00 $0.0015787 N1 $0.00 $0.0015788 N1 $0.00 $0.0015789 P2 $80.10 $106.2815792 N1 $0.00 $0.0015793 N1 $0.00 $0.0015819 G2 $771.43 $1,023.6015820 A2 $771.43 $1,023.6015821 A2 $771.43 $1,023.6015822 A2 $771.43 $1,023.6015823 A2 $771.43 $1,023.6015824 A2 $771.43 $1,023.6015825 A2 $771.43 $1,023.6015826 A2 $1,261.51 $1,673.8715828 A2 $1,261.51 $1,673.8715829 A2 $1,261.51 $1,673.8715830 A2 $2,274.93 $3,018.5615832 A2 $999.94 $1,326.8015833 A2 $999.94 $1,326.8015834 A2 $999.94 $1,326.8015835 A2 $999.94 $1,326.8015836 A2 $735.25 $975.5915837 G2 $735.25 $975.5915838 G2 $735.25 $975.5915839 A2 $735.25 $975.5915840 A2 $1,261.51 $1,673.8715841 A2 $1,261.51 $1,673.8715842 G2 $1,261.51 $1,673.8715845 A2 $1,261.51 $1,673.8715847 N1 $0.00 $0.0015850 G2 $705.82 $936.5415851 P3 $66.23 $87.8815852 N1 $0.00 $0.0015860 N1 $0.00 $0.0015876 A2 $1,261.51 $1,673.8715877 A2 $1,261.51 $1,673.8715878 A2 $1,261.51 $1,673.8715879 A2 $1,261.51 $1,673.8715920 A2 $453.06 $601.1615922 A2 $771.43 $1,023.60



1

2

A B C D

HCPCS




283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338

15931 A2 $999.94 $1,326.8015933 A2 $999.94 $1,326.8015934 A2 $1,261.51 $1,673.8715935 A2 $1,261.51 $1,673.8715936 A2 $771.43 $1,023.6015937 A2 $771.43 $1,023.6015940 A2 $999.94 $1,326.8015941 A2 $999.94 $1,326.8015944 A2 $771.43 $1,023.6015945 A2 $235.76 $312.8315946 A2 $1,261.51 $1,673.8715950 A2 $999.94 $1,326.8015951 A2 $999.94 $1,326.8015952 A2 $1,261.51 $1,673.8715953 A2 $1,261.51 $1,673.8715956 A2 $771.43 $1,023.6015958 A2 $1,261.51 $1,673.8716000 N1 $0.00 $0.0016020 P3 $54.06 $71.7316025 A2 $80.10 $106.2816030 A2 $155.20 $205.9316035 G2 $155.20 $205.9317000 P3 $42.60 $56.5317003 N1 $0.00 $0.0017004 P3 $96.31 $127.7917106 P2 $155.20 $205.9317107 P2 $155.20 $205.9317108 P2 $155.20 $205.9317110 N1 $0.00 $0.0017111 P2 $80.10 $106.2817250 P3 $60.15 $79.8117260 P3 $56.57 $75.0617261 P2 $80.10 $106.2817262 P2 $80.10 $106.2817263 P2 $80.10 $106.2817264 P2 $80.10 $106.2817266 P3 $138.19 $183.3617270 P2 $80.10 $106.2817271 P2 $80.10 $106.2817272 P2 $80.10 $106.2817273 P3 $124.95 $165.7917274 P3 $140.70 $186.6917276 P3 $155.02 $205.6917280 P2 $80.10 $106.2817281 P2 $80.10 $106.2817282 P3 $121.72 $161.5117283 P3 $138.19 $183.3617284 P3 $152.87 $202.8417286 P2 $155.20 $205.9317311 P2 $235.76 $312.8317312 N1 $0.00 $0.0017313 P2 $235.76 $312.8317314 N1 $0.00 $0.0017315 N1 $0.00 $0.0017340 N1 $0.00 $0.0017360 P3 $70.89 $94.06



1

2

A B C D

HCPCS




339340341342343344345346347348349350351352353354355356357358359360361362363364365366367368369370371372373374375376377378379380381382383384385386387388389390391392393394

17380 R2 $155.20 $205.9319000 P3 $80.91 $107.3619001 N1 $0.00 $0.0019020 A2 $896.60 $1,189.6819030 N1 $0.00 $0.0019081 G2 $576.97 $765.5719082 N1 $0.00 $0.0019083 G2 $576.97 $765.5719084 N1 $0.00 $0.0019085 G2 $576.97 $765.5719086 N1 $0.00 $0.0019100 A2 $267.12 $354.4419101 A2 $1,188.12 $1,576.4919105 P2 $1,651.35 $2,191.1419110 A2 $1,188.12 $1,576.4919112 A2 $1,188.12 $1,576.4919120 A2 $1,188.12 $1,576.4919125 A2 $1,188.12 $1,576.4919126 N1 $0.00 $0.0019281 N1 $0.00 $0.0019282 N1 $0.00 $0.0019283 N1 $0.00 $0.0019284 N1 $0.00 $0.0019285 N1 $0.00 $0.0019286 N1 $0.00 $0.0019287 N1 $0.00 $0.0019288 N1 $0.00 $0.0019296 P2 $2,974.98 $3,947.4419297 N1 $0.00 $0.0019298 J8 $4,055.18 $5,380.7419300 A2 $1,188.12 $1,576.4919301 A2 $1,188.12 $1,576.4919302 A2 $2,274.93 $3,018.5619303 A2 $1,651.35 $2,191.1419304 A2 $1,651.35 $2,191.1419316 A2 $1,651.35 $2,191.1419318 A2 $2,274.93 $3,018.5619324 A2 $2,274.93 $3,018.5619325 J8 $4,055.18 $5,380.7419328 A2 $1,651.35 $2,191.1419330 A2 $1,651.35 $2,191.1419340 A2 $2,274.93 $3,018.5619342 J8 $4,055.18 $5,380.7419350 A2 $1,188.12 $1,576.4919355 A2 $1,651.35 $2,191.1419357 J8 $4,055.18 $5,380.7419366 A2 $1,651.35 $2,191.1419370 A2 $1,651.35 $2,191.1419371 A2 $1,651.35 $2,191.1419380 A2 $2,274.93 $3,018.5619396 G2 $1,651.35 $2,191.1420005 G2 $453.06 $601.1620103 G2 $474.65 $629.8020150 G2 $2,062.56 $2,736.7720200 A2 $735.25 $975.5920205 A2 $735.25 $975.59



1

2

A B C D

HCPCS




395396397398399400401402403404405406407408409410411412413414415416417418419420421422423424425426427428429430431432433434435436437438439440441442443444445446447448449450

20206 A2 $576.97 $765.5720220 A2 $453.06 $601.1620225 A2 $735.25 $975.5920240 A2 $999.94 $1,326.8020245 A2 $999.94 $1,326.8020250 A2 $1,426.27 $1,892.4920251 A2 $1,426.27 $1,892.4920500 P3 $55.49 $73.6320501 N1 $0.00 $0.0020520 P3 $129.96 $172.4420525 A2 $999.94 $1,326.8020526 P3 $39.38 $52.2520527 P3 $43.68 $57.9620550 P3 $29.72 $39.4320551 P3 $31.51 $41.8120552 P3 $30.07 $39.9020553 P3 $35.44 $47.0220555 R2 $1,426.27 $1,892.4920600 P3 $22.20 $29.4620604 P3 $37.95 $50.3620605 P3 $23.63 $31.3520606 P3 $41.17 $54.6320610 P3 $28.64 $38.0020611 P3 $47.97 $63.6520612 P3 $33.30 $44.1920615 P3 $157.17 $208.5520650 A2 $1,426.27 $1,892.4920662 R2 $910.33 $1,207.9020663 R2 $1,426.27 $1,892.4920665 G2 $72.21 $95.8120670 A2 $735.25 $975.5920680 A2 $999.94 $1,326.8020690 A2 $1,426.27 $1,892.4920692 A2 $1,426.27 $1,892.4920693 A2 $1,426.27 $1,892.4920694 A2 $910.33 $1,207.9020696 G2 $1,426.27 $1,892.4920697 P2 $390.95 $518.7420822 G2 $1,211.40 $1,607.3820900 A2 $1,426.27 $1,892.4920902 A2 $1,426.27 $1,892.4920910 A2 $235.76 $312.8320912 A2 $1,261.51 $1,673.8720920 A2 $1,261.51 $1,673.8720922 A2 $1,261.51 $1,673.8720924 A2 $1,426.27 $1,892.4920926 A2 $1,261.51 $1,673.8720930 N1 $0.00 $0.0020931 N1 $0.00 $0.0020950 G2 $88.78 $117.8020972 G2 $2,860.71 $3,795.8220973 R2 $2,860.71 $3,795.8220975 N1 $0.00 $0.0020979 N1 $0.00 $0.0020982 G2 $2,062.56 $2,736.7720983 G2 $2,062.56 $2,736.77



1

2

A B C D

HCPCS




451452453454455456457458459460461462463464465466467468469470471472473474475476477478479480481482483484485486487488489490491492493494495496497498499500501502503504505506

20985 N1 $0.00 $0.0021010 A2 $2,044.49 $2,712.7921011 P3 $229.84 $304.9721012 R2 $453.06 $601.1621013 P3 $303.24 $402.3621014 R2 $453.06 $601.1621015 G2 $735.25 $975.5921016 G2 $999.94 $1,326.8021025 A2 $2,044.49 $2,712.7921026 A2 $1,066.74 $1,415.4421029 A2 $1,066.74 $1,415.4421030 P3 $331.52 $439.8921031 P3 $271.02 $359.6121032 P3 $274.95 $364.8321034 A2 $2,044.49 $2,712.7921040 A2 $1,066.74 $1,415.4421044 A2 $2,044.49 $2,712.7921046 A2 $2,044.49 $2,712.7921047 A2 $2,044.49 $2,712.7921048 R2 $2,044.49 $2,712.7921050 A2 $2,044.49 $2,712.7921060 A2 $2,044.49 $2,712.7921070 A2 $2,044.49 $2,712.7921073 P3 $263.50 $349.6321076 P3 $482.24 $639.8721077 P3 $1,208.29 $1,603.2621079 P3 $827.73 $1,098.3021080 P3 $926.18 $1,228.9321081 P3 $868.18 $1,151.9721082 P3 $856.37 $1,136.3021083 P3 $840.61 $1,115.3921084 P3 $943.36 $1,251.7321085 P2 $354.45 $470.3121086 P3 $905.41 $1,201.3721087 P3 $905.41 $1,201.3721088 R2 $2,044.49 $2,712.7921100 A2 $2,044.49 $2,712.7921110 P2 $354.45 $470.3121116 N1 $0.00 $0.0021120 A2 $2,044.49 $2,712.7921121 A2 $1,066.74 $1,415.4421122 A2 $1,066.74 $1,415.4421123 A2 $1,066.74 $1,415.4421125 A2 $1,066.74 $1,415.4421127 A2 $2,044.49 $2,712.7921137 G2 $1,066.74 $1,415.4421138 G2 $2,044.49 $2,712.7921139 G2 $2,044.49 $2,712.7921150 G2 $2,044.49 $2,712.7921181 A2 $2,044.49 $2,712.7921198 G2 $1,066.74 $1,415.4421199 G2 $2,044.49 $2,712.7921206 A2 $2,044.49 $2,712.7921208 A2 $2,044.49 $2,712.7921209 A2 $2,044.49 $2,712.7921210 A2 $2,044.49 $2,712.79



1

2

A B C D

HCPCS




507508509510511512513514515516517518519520521522523524525526527528529530531532533534535536537538539540541542543544545546547548549550551552553554555556557558559560561562

21215 A2 $2,044.49 $2,712.7921230 A2 $2,044.49 $2,712.7921235 A2 $694.39 $921.3721240 A2 $2,044.49 $2,712.7921242 A2 $2,044.49 $2,712.7921243 A2 $2,044.49 $2,712.7921244 A2 $2,044.49 $2,712.7921245 A2 $2,044.49 $2,712.7921246 A2 $2,044.49 $2,712.7921248 A2 $2,044.49 $2,712.7921249 A2 $2,044.49 $2,712.7921260 G2 $2,044.49 $2,712.7921267 A2 $2,044.49 $2,712.7921270 A2 $2,044.49 $2,712.7921275 A2 $2,044.49 $2,712.7921280 A2 $2,044.49 $2,712.7921282 A2 $694.39 $921.3721295 A2 $354.45 $470.3121296 A2 $1,066.74 $1,415.4421310 A2 $71.10 $94.3421315 A2 $694.39 $921.3721320 A2 $694.39 $921.3721325 A2 $1,066.74 $1,415.4421330 A2 $1,066.74 $1,415.4421335 A2 $1,066.74 $1,415.4421336 A2 $1,119.61 $1,485.5921337 A2 $694.39 $921.3721338 A2 $2,044.49 $2,712.7921339 A2 $1,066.74 $1,415.4421340 A2 $2,044.49 $2,712.7921345 A2 $1,066.74 $1,415.4421355 A2 $2,044.49 $2,712.7921356 A2 $1,066.74 $1,415.4421360 G2 $2,044.49 $2,712.7921390 G2 $2,044.49 $2,712.7921400 A2 $354.45 $470.3121401 A2 $354.45 $470.3121406 G2 $2,044.49 $2,712.7921407 G2 $2,044.49 $2,712.7921421 A2 $2,044.49 $2,712.7921440 P3 $454.32 $602.8321445 A2 $2,044.49 $2,712.7921450 A2 $199.13 $264.2221451 A2 $694.39 $921.3721452 A2 $694.39 $921.3721453 A2 $2,044.49 $2,712.7921454 A2 $2,044.49 $2,712.7921461 A2 $2,044.49 $2,712.7921462 A2 $2,044.49 $2,712.7921465 A2 $2,044.49 $2,712.7921480 A2 $71.10 $94.3421485 A2 $1,066.74 $1,415.4421490 A2 $2,044.49 $2,712.7921495 G2 $694.39 $921.3721497 A2 $354.45 $470.3121501 A2 $896.60 $1,189.68



1

2

A B C D

HCPCS




563564565566567568569570571572573574575576577578579580581582583584585586587588589590591592593594595596597598599600601602603604605606607608609610611612613614615616617618

21502 A2 $910.33 $1,207.9021550 G2 $735.25 $975.5921552 G2 $999.94 $1,326.8021554 G2 $999.94 $1,326.8021555 G2 $735.25 $975.5921556 G2 $999.94 $1,326.8021557 G2 $735.25 $975.5921558 G2 $999.94 $1,326.8021600 A2 $1,426.27 $1,892.4921610 A2 $1,426.27 $1,892.4921685 G2 $1,066.74 $1,415.4421700 A2 $910.33 $1,207.9021720 A2 $910.33 $1,207.9021725 A2 $88.78 $117.8021800 D5 $0.00 $0.0021805 A2 $1,119.61 $1,485.5921820 A2 $92.68 $122.9821920 P3 $174.71 $231.8221925 A2 $999.94 $1,326.8021930 G2 $735.25 $975.5921931 G2 $999.94 $1,326.8021932 G2 $735.25 $975.5921933 G2 $999.94 $1,326.8021935 G2 $735.25 $975.5921936 G2 $999.94 $1,326.8022102 G2 $2,254.50 $2,991.4522103 N1 $0.00 $0.0022305 A2 $92.68 $122.9822310 A2 $117.20 $155.5122315 A2 $719.23 $954.3322505 A2 $630.71 $836.8822510 G2 $1,426.27 $1,892.4922511 G2 $1,426.27 $1,892.4922512 N1 $0.00 $0.0022513 G2 $3,465.63 $4,598.4822514 G2 $3,465.63 $4,598.4822515 N1 $0.00 $0.0022520 D5 $0.00 $0.0022521 D5 $0.00 $0.0022522 D5 $0.00 $0.0022523 D5 $0.00 $0.0022524 D5 $0.00 $0.0022525 D5 $0.00 $0.0022551 J8 $7,842.24 $10,405.7122554 J8 $7,842.24 $10,405.7122612 J8 $7,842.24 $10,405.7122614 N1 $0.00 $0.0022900 G2 $999.94 $1,326.8022901 G2 $999.94 $1,326.8022902 G2 $735.25 $975.5922903 G2 $999.94 $1,326.8022904 G2 $735.25 $975.5922905 G2 $999.94 $1,326.8023000 A2 $735.25 $975.5923020 A2 $1,426.27 $1,892.4923030 A2 $896.60 $1,189.68



1

2

A B C D

HCPCS




619620621622623624625626627628629630631632633634635636637638639640641642643644645646647648649650651652653654655656657658659660661662663664665666667668669670671672673674

23031 A2 $896.60 $1,189.6823035 A2 $910.33 $1,207.9023040 A2 $1,426.27 $1,892.4923044 A2 $1,426.27 $1,892.4923065 P3 $125.30 $166.2623066 A2 $999.94 $1,326.8023071 G2 $999.94 $1,326.8023073 G2 $999.94 $1,326.8023075 G2 $735.25 $975.5923076 G2 $735.25 $975.5923077 G2 $735.25 $975.5923078 G2 $999.94 $1,326.8023100 A2 $910.33 $1,207.9023101 A2 $1,426.27 $1,892.4923105 A2 $1,426.27 $1,892.4923106 A2 $1,426.27 $1,892.4923107 A2 $1,426.27 $1,892.4923120 A2 $1,426.27 $1,892.4923125 A2 $1,426.27 $1,892.4923130 A2 $2,062.56 $2,736.7723140 A2 $910.33 $1,207.9023145 A2 $1,426.27 $1,892.4923146 A2 $1,426.27 $1,892.4923150 A2 $1,426.27 $1,892.4923155 A2 $1,426.27 $1,892.4923156 A2 $1,426.27 $1,892.4923170 A2 $1,426.27 $1,892.4923172 A2 $1,426.27 $1,892.4923174 A2 $1,426.27 $1,892.4923180 A2 $1,426.27 $1,892.4923182 A2 $1,426.27 $1,892.4923184 A2 $1,426.27 $1,892.4923190 A2 $1,426.27 $1,892.4923195 A2 $1,426.27 $1,892.4923330 A2 $453.06 $601.1623333 G2 $453.06 $601.1623334 G2 $999.94 $1,326.8023350 N1 $0.00 $0.0023395 A2 $2,062.56 $2,736.7723397 A2 $2,062.56 $2,736.7723400 A2 $1,426.27 $1,892.4923405 A2 $1,426.27 $1,892.4923406 A2 $1,426.27 $1,892.4923410 A2 $2,062.56 $2,736.7723412 A2 $2,062.56 $2,736.7723415 A2 $2,062.56 $2,736.7723420 A2 $2,062.56 $2,736.7723430 A2 $2,062.56 $2,736.7723440 A2 $1,426.27 $1,892.4923450 A2 $3,465.63 $4,598.4823455 A2 $3,465.63 $4,598.4823460 A2 $3,465.63 $4,598.4823462 A2 $2,062.56 $2,736.7723465 A2 $2,062.56 $2,736.7723466 A2 $2,062.56 $2,736.7723480 A2 $2,062.56 $2,736.77



1

2

A B C D

HCPCS




675676677678679680681682683684685686687688689690691692693694695696697698699700701702703704705706707708709710711712713714715716717718719720721722723724725726727728729730

23485 A2 $3,465.63 $4,598.4823490 A2 $3,465.63 $4,598.4823491 A2 $3,465.63 $4,598.4823500 A2 $92.68 $122.9823505 A2 $390.95 $518.7423515 J8 $4,138.76 $5,491.6423520 A2 $719.23 $954.3323525 A2 $117.20 $155.5123530 A2 $2,317.66 $3,075.2623532 A2 $1,119.61 $1,485.5923540 A2 $117.20 $155.5123545 A2 $117.20 $155.5123550 A2 $2,317.66 $3,075.2623552 A2 $2,317.66 $3,075.2623570 A2 $92.68 $122.9823575 A2 $117.20 $155.5123585 J8 $4,138.76 $5,491.6423600 P2 $117.20 $155.5123605 A2 $910.33 $1,207.9023615 J8 $4,138.76 $5,491.6423616 J8 $4,138.76 $5,491.6423620 P2 $117.20 $155.5123625 A2 $719.23 $954.3323630 J8 $4,138.76 $5,491.6423650 A2 $117.20 $155.5123655 A2 $630.71 $836.8823660 A2 $2,317.66 $3,075.2623665 A2 $390.95 $518.7423670 J8 $4,138.76 $5,491.6423675 A2 $117.20 $155.5123680 A2 $2,317.66 $3,075.2623700 A2 $630.71 $836.8823800 A2 $3,465.63 $4,598.4823802 A2 $3,465.63 $4,598.4823921 A2 $1,261.51 $1,673.8723930 A2 $896.60 $1,189.6823931 A2 $474.65 $629.8023935 A2 $910.33 $1,207.9024000 A2 $1,426.27 $1,892.4924006 A2 $1,426.27 $1,892.4924065 P3 $172.92 $229.4424066 A2 $735.25 $975.5924071 G2 $999.94 $1,326.8024073 G2 $999.94 $1,326.8024075 G2 $735.25 $975.5924076 G2 $735.25 $975.5924077 G2 $735.25 $975.5924079 G2 $999.94 $1,326.8024100 A2 $910.33 $1,207.9024101 A2 $1,426.27 $1,892.4924102 A2 $1,426.27 $1,892.4924105 A2 $910.33 $1,207.9024110 A2 $910.33 $1,207.9024115 A2 $1,426.27 $1,892.4924116 A2 $1,426.27 $1,892.4924120 A2 $910.33 $1,207.90



1

2

A B C D

HCPCS




731732733734735736737738739740741742743744745746747748749750751752753754755756757758759760761762763764765766767768769770771772773774775776777778779780781782783784785786

24125 A2 $1,426.27 $1,892.4924126 A2 $1,426.27 $1,892.4924130 A2 $1,426.27 $1,892.4924134 A2 $1,426.27 $1,892.4924136 A2 $1,426.27 $1,892.4924138 A2 $1,426.27 $1,892.4924140 A2 $1,426.27 $1,892.4924145 A2 $1,426.27 $1,892.4924147 A2 $1,426.27 $1,892.4924149 G2 $1,426.27 $1,892.4924152 G2 $2,062.56 $2,736.7724155 A2 $1,426.27 $1,892.4924160 A2 $1,426.27 $1,892.4924164 A2 $1,426.27 $1,892.4924200 P3 $136.04 $180.5124201 A2 $735.25 $975.5924220 N1 $0.00 $0.0024300 G2 $630.71 $836.8824301 A2 $1,426.27 $1,892.4924305 A2 $1,426.27 $1,892.4924310 A2 $910.33 $1,207.9024320 A2 $1,426.27 $1,892.4924330 A2 $3,465.63 $4,598.4824331 A2 $2,062.56 $2,736.7724332 G2 $1,426.27 $1,892.4924340 A2 $2,062.56 $2,736.7724341 A2 $2,062.56 $2,736.7724342 A2 $2,062.56 $2,736.7724343 G2 $1,426.27 $1,892.4924344 G2 $2,062.56 $2,736.7724345 A2 $1,426.27 $1,892.4924346 G2 $2,062.56 $2,736.7724357 G2 $1,426.27 $1,892.4924358 G2 $1,426.27 $1,892.4924359 G2 $1,426.27 $1,892.4924360 A2 $1,844.03 $2,446.8124361 J8 $7,842.24 $10,405.7124362 A2 $1,844.03 $2,446.8124363 J8 $7,842.24 $10,405.7124365 J8 $7,842.24 $10,405.7124366 J8 $7,842.24 $10,405.7124370 J8 $7,842.24 $10,405.7124371 J8 $7,842.24 $10,405.7124400 A2 $2,062.56 $2,736.7724410 A2 $2,062.56 $2,736.7724420 A2 $2,062.56 $2,736.7724430 A2 $3,465.63 $4,598.4824435 J8 $7,842.24 $10,405.7124470 A2 $2,062.56 $2,736.7724495 A2 $1,426.27 $1,892.4924498 J8 $7,842.24 $10,405.7124500 A2 $117.20 $155.5124505 A2 $117.20 $155.5124515 J8 $4,138.76 $5,491.6424516 J8 $4,138.76 $5,491.6424530 A2 $117.20 $155.51



1

2

A B C D

HCPCS




787788789790791792793794795796797798799800801802803804805806807808809810811812813814815816817818819820821822823824825826827828829830831832833834835836837838839840841842

24535 A2 $117.20 $155.5124538 A2 $1,119.61 $1,485.5924545 J8 $4,138.76 $5,491.6424546 J8 $4,138.76 $5,491.6424560 A2 $92.68 $122.9824565 A2 $117.20 $155.5124566 A2 $1,119.61 $1,485.5924575 J8 $4,138.76 $5,491.6424576 A2 $117.20 $155.5124577 A2 $117.20 $155.5124579 J8 $4,138.76 $5,491.6424582 A2 $1,119.61 $1,485.5924586 J8 $4,138.76 $5,491.6424587 J8 $4,138.76 $5,491.6424600 A2 $117.20 $155.5124605 A2 $630.71 $836.8824615 J8 $4,138.76 $5,491.6424620 A2 $719.23 $954.3324635 J8 $4,138.76 $5,491.6424640 P3 $89.50 $118.7624650 P2 $117.20 $155.5124655 A2 $117.20 $155.5124665 A2 $2,317.66 $3,075.2624666 J8 $4,138.76 $5,491.6424670 A2 $92.68 $122.9824675 A2 $117.20 $155.5124685 A2 $2,317.66 $3,075.2624800 A2 $2,062.56 $2,736.7724802 A2 $3,465.63 $4,598.4824925 A2 $910.33 $1,207.9025000 A2 $910.33 $1,207.9025001 G2 $910.33 $1,207.9025020 A2 $1,426.27 $1,892.4925023 A2 $1,426.27 $1,892.4925024 A2 $1,426.27 $1,892.4925025 A2 $1,426.27 $1,892.4925028 A2 $910.33 $1,207.9025031 A2 $910.33 $1,207.9025035 A2 $910.33 $1,207.9025040 A2 $1,426.27 $1,892.4925065 P3 $175.43 $232.7725066 A2 $999.94 $1,326.8025071 G2 $999.94 $1,326.8025073 G2 $999.94 $1,326.8025075 G2 $735.25 $975.5925076 G2 $735.25 $975.5925077 G2 $735.25 $975.5925078 G2 $999.94 $1,326.8025085 A2 $910.33 $1,207.9025100 A2 $910.33 $1,207.9025101 A2 $1,426.27 $1,892.4925105 A2 $1,426.27 $1,892.4925107 A2 $1,426.27 $1,892.4925109 G2 $910.33 $1,207.9025110 A2 $910.33 $1,207.9025111 A2 $910.33 $1,207.90



1

2

A B C D

HCPCS




843844845846847848849850851852853854855856857858859860861862863864865866867868869870871872873874875876877878879880881882883884885886887888889890891892893894895896897898

25112 A2 $910.33 $1,207.9025115 A2 $910.33 $1,207.9025116 A2 $910.33 $1,207.9025118 A2 $1,426.27 $1,892.4925119 A2 $1,426.27 $1,892.4925120 A2 $1,426.27 $1,892.4925125 A2 $1,426.27 $1,892.4925126 A2 $1,426.27 $1,892.4925130 A2 $1,426.27 $1,892.4925135 A2 $1,426.27 $1,892.4925136 A2 $1,426.27 $1,892.4925145 A2 $1,426.27 $1,892.4925150 A2 $1,426.27 $1,892.4925151 A2 $1,426.27 $1,892.4925210 A2 $1,426.27 $1,892.4925215 A2 $1,426.27 $1,892.4925230 A2 $1,426.27 $1,892.4925240 A2 $1,426.27 $1,892.4925246 N1 $0.00 $0.0025248 A2 $910.33 $1,207.9025250 A2 $1,426.27 $1,892.4925251 A2 $1,426.27 $1,892.4925259 G2 $719.23 $954.3325260 A2 $1,426.27 $1,892.4925263 A2 $1,426.27 $1,892.4925265 A2 $1,426.27 $1,892.4925270 A2 $1,426.27 $1,892.4925272 A2 $1,426.27 $1,892.4925274 A2 $1,426.27 $1,892.4925275 A2 $1,426.27 $1,892.4925280 A2 $1,426.27 $1,892.4925290 A2 $1,426.27 $1,892.4925295 A2 $910.33 $1,207.9025300 A2 $1,426.27 $1,892.4925301 A2 $1,426.27 $1,892.4925310 A2 $1,426.27 $1,892.4925312 A2 $2,062.56 $2,736.7725315 A2 $1,426.27 $1,892.4925316 A2 $3,465.63 $4,598.4825320 A2 $2,062.56 $2,736.7725332 A2 $1,844.03 $2,446.8125335 A2 $2,062.56 $2,736.7725337 A2 $2,062.56 $2,736.7725350 A2 $2,062.56 $2,736.7725355 A2 $2,062.56 $2,736.7725360 A2 $2,062.56 $2,736.7725365 A2 $2,062.56 $2,736.7725370 A2 $2,062.56 $2,736.7725375 A2 $2,062.56 $2,736.7725390 A2 $2,062.56 $2,736.7725391 A2 $2,062.56 $2,736.7725392 A2 $1,426.27 $1,892.4925393 A2 $2,062.56 $2,736.7725394 G2 $2,062.56 $2,736.7725400 A2 $3,465.63 $4,598.4825405 A2 $3,465.63 $4,598.48



1

2

A B C D

HCPCS




899900901902903904905906907908909910911912913914915916917918919920921922923924925926927928929930931932933934935936937938939940941942943944945946947948949950951952953954

25415 A2 $3,465.63 $4,598.4825420 A2 $3,465.63 $4,598.4825425 A2 $2,062.56 $2,736.7725426 A2 $2,062.56 $2,736.7725430 G2 $2,062.56 $2,736.7725431 G2 $2,062.56 $2,736.7725440 A2 $2,062.56 $2,736.7725441 J8 $7,842.24 $10,405.7125442 J8 $7,842.24 $10,405.7125443 A2 $1,844.03 $2,446.8125444 J8 $7,842.24 $10,405.7125445 A2 $1,844.03 $2,446.8125446 J8 $7,842.24 $10,405.7125447 A2 $1,844.03 $2,446.8125449 A2 $1,844.03 $2,446.8125450 A2 $2,062.56 $2,736.7725455 A2 $2,062.56 $2,736.7725490 A2 $2,062.56 $2,736.7725491 A2 $2,062.56 $2,736.7725492 A2 $2,062.56 $2,736.7725500 P2 $92.68 $122.9825505 A2 $390.95 $518.7425515 A2 $2,317.66 $3,075.2625520 A2 $117.20 $155.5125525 A2 $2,317.66 $3,075.2625526 A2 $2,317.66 $3,075.2625530 P2 $92.68 $122.9825535 A2 $117.20 $155.5125545 A2 $2,317.66 $3,075.2625560 P2 $92.68 $122.9825565 A2 $117.20 $155.5125574 J8 $4,138.76 $5,491.6425575 J8 $4,138.76 $5,491.6425600 P2 $117.20 $155.5125605 A2 $390.95 $518.7425606 A2 $1,119.61 $1,485.5925607 J8 $4,138.76 $5,491.6425608 J8 $4,138.76 $5,491.6425609 J8 $4,138.76 $5,491.6425622 P2 $117.20 $155.5125624 A2 $390.95 $518.7425628 A2 $2,317.66 $3,075.2625630 P2 $117.20 $155.5125635 A2 $117.20 $155.5125645 A2 $2,317.66 $3,075.2625650 P2 $117.20 $155.5125651 G2 $1,119.61 $1,485.5925652 G2 $2,317.66 $3,075.2625660 A2 $117.20 $155.5125670 A2 $1,119.61 $1,485.5925671 A2 $1,119.61 $1,485.5925675 A2 $117.20 $155.5125676 A2 $1,119.61 $1,485.5925680 A2 $92.68 $122.9825685 A2 $1,119.61 $1,485.5925690 A2 $719.23 $954.33



1

2

A B C D

HCPCS




955956957958959960961962963964965966967968969970971972973974975976977978979980981982983984985986987988989990991992993994995996997998999

10001001100210031004100510061007100810091010

25695 A2 $1,119.61 $1,485.5925800 A2 $3,465.63 $4,598.4825805 A2 $3,465.63 $4,598.4825810 A2 $3,465.63 $4,598.4825820 A2 $2,062.56 $2,736.7725825 A2 $3,465.63 $4,598.4825830 A2 $2,062.56 $2,736.7725907 A2 $910.33 $1,207.9025922 A2 $910.33 $1,207.9025929 A2 $771.43 $1,023.6025931 G2 $910.33 $1,207.9026010 P2 $88.78 $117.8026011 A2 $474.65 $629.8026020 A2 $673.27 $893.3526025 A2 $673.27 $893.3526030 A2 $673.27 $893.3526034 A2 $673.27 $893.3526035 G2 $673.27 $893.3526037 G2 $673.27 $893.3526040 A2 $673.27 $893.3526045 A2 $1,211.40 $1,607.3826055 A2 $673.27 $893.3526060 A2 $673.27 $893.3526070 A2 $673.27 $893.3526075 A2 $673.27 $893.3526080 A2 $673.27 $893.3526100 A2 $673.27 $893.3526105 A2 $673.27 $893.3526110 A2 $673.27 $893.3526111 G2 $999.94 $1,326.8026113 G2 $999.94 $1,326.8026115 G2 $735.25 $975.5926116 G2 $735.25 $975.5926117 G2 $735.25 $975.5926118 G2 $999.94 $1,326.8026121 A2 $1,211.40 $1,607.3826123 A2 $1,211.40 $1,607.3826125 N1 $0.00 $0.0026130 A2 $673.27 $893.3526135 A2 $1,211.40 $1,607.3826140 A2 $673.27 $893.3526145 A2 $673.27 $893.3526160 A2 $673.27 $893.3526170 A2 $673.27 $893.3526180 A2 $673.27 $893.3526185 A2 $673.27 $893.3526200 A2 $673.27 $893.3526205 A2 $1,211.40 $1,607.3826210 A2 $673.27 $893.3526215 A2 $673.27 $893.3526230 A2 $673.27 $893.3526235 A2 $673.27 $893.3526236 A2 $673.27 $893.3526250 A2 $673.27 $893.3526260 A2 $673.27 $893.3526262 A2 $673.27 $893.35



1

2

A B C D

HCPCS




10111012101310141015101610171018101910201021102210231024102510261027102810291030103110321033103410351036103710381039104010411042104310441045104610471048104910501051105210531054105510561057105810591060106110621063106410651066

26320 A2 $735.25 $975.5926340 G2 $117.20 $155.5126341 P3 $62.29 $82.6526350 A2 $1,211.40 $1,607.3826352 A2 $1,211.40 $1,607.3826356 A2 $1,211.40 $1,607.3826357 A2 $1,211.40 $1,607.3826358 A2 $1,211.40 $1,607.3826370 A2 $1,211.40 $1,607.3826372 A2 $1,211.40 $1,607.3826373 A2 $1,211.40 $1,607.3826390 A2 $1,211.40 $1,607.3826392 A2 $1,211.40 $1,607.3826410 A2 $673.27 $893.3526412 A2 $1,211.40 $1,607.3826415 A2 $1,211.40 $1,607.3826416 A2 $1,211.40 $1,607.3826418 A2 $673.27 $893.3526420 A2 $1,211.40 $1,607.3826426 A2 $1,211.40 $1,607.3826428 A2 $1,211.40 $1,607.3826432 A2 $673.27 $893.3526433 A2 $673.27 $893.3526434 A2 $1,211.40 $1,607.3826437 A2 $673.27 $893.3526440 A2 $673.27 $893.3526442 A2 $1,211.40 $1,607.3826445 A2 $673.27 $893.3526449 A2 $1,211.40 $1,607.3826450 A2 $673.27 $893.3526455 A2 $673.27 $893.3526460 A2 $673.27 $893.3526471 A2 $673.27 $893.3526474 A2 $673.27 $893.3526476 A2 $673.27 $893.3526477 A2 $673.27 $893.3526478 A2 $673.27 $893.3526479 A2 $673.27 $893.3526480 A2 $1,211.40 $1,607.3826483 A2 $1,211.40 $1,607.3826485 A2 $1,211.40 $1,607.3826489 A2 $1,211.40 $1,607.3826490 A2 $1,211.40 $1,607.3826492 A2 $1,211.40 $1,607.3826494 A2 $1,211.40 $1,607.3826496 A2 $1,211.40 $1,607.3826497 A2 $1,211.40 $1,607.3826498 A2 $1,211.40 $1,607.3826499 A2 $1,211.40 $1,607.3826500 A2 $673.27 $893.3526502 A2 $1,211.40 $1,607.3826508 A2 $673.27 $893.3526510 A2 $1,211.40 $1,607.3826516 A2 $1,211.40 $1,607.3826517 A2 $1,211.40 $1,607.3826518 A2 $1,211.40 $1,607.38



1

2

A B C D

HCPCS




10671068106910701071107210731074107510761077107810791080108110821083108410851086108710881089109010911092109310941095109610971098109911001101110211031104110511061107110811091110111111121113111411151116111711181119112011211122

26520 A2 $673.27 $893.3526525 A2 $673.27 $893.3526530 A2 $1,844.03 $2,446.8126531 A2 $1,844.03 $2,446.8126535 A2 $1,844.03 $2,446.8126536 A2 $1,844.03 $2,446.8126540 A2 $673.27 $893.3526541 A2 $1,211.40 $1,607.3826542 A2 $673.27 $893.3526545 A2 $1,211.40 $1,607.3826546 A2 $1,211.40 $1,607.3826548 A2 $1,211.40 $1,607.3826550 A2 $1,211.40 $1,607.3826555 A2 $1,211.40 $1,607.3826560 A2 $673.27 $893.3526561 A2 $1,211.40 $1,607.3826562 A2 $1,211.40 $1,607.3826565 A2 $1,211.40 $1,607.3826567 A2 $1,211.40 $1,607.3826568 A2 $1,211.40 $1,607.3826580 A2 $673.27 $893.3526587 A2 $673.27 $893.3526590 A2 $673.27 $893.3526591 A2 $1,211.40 $1,607.3826593 A2 $673.27 $893.3526596 A2 $673.27 $893.3526600 P2 $117.20 $155.5126605 A2 $117.20 $155.5126607 A2 $719.23 $954.3326608 A2 $1,119.61 $1,485.5926615 A2 $2,317.66 $3,075.2626641 P2 $117.20 $155.5126645 A2 $117.20 $155.5126650 A2 $1,119.61 $1,485.5926665 A2 $2,317.66 $3,075.2626670 P2 $92.68 $122.9826675 A2 $117.20 $155.5126676 A2 $1,119.61 $1,485.5926685 A2 $1,119.61 $1,485.5926686 J8 $4,138.76 $5,491.6426700 P2 $117.20 $155.5126705 A2 $117.20 $155.5126706 A2 $719.23 $954.3326715 A2 $1,119.61 $1,485.5926720 P2 $92.68 $122.9826725 P2 $117.20 $155.5126727 A2 $1,119.61 $1,485.5926735 A2 $1,119.61 $1,485.5926740 P2 $117.20 $155.5126742 A2 $117.20 $155.5126746 A2 $1,119.61 $1,485.5926750 P2 $92.68 $122.9826755 G2 $117.20 $155.5126756 A2 $1,119.61 $1,485.5926765 A2 $1,119.61 $1,485.5926770 G2 $92.68 $122.98



1

2

A B C D

HCPCS




11231124112511261127112811291130113111321133113411351136113711381139114011411142114311441145114611471148114911501151115211531154115511561157115811591160116111621163116411651166116711681169117011711172117311741175117611771178

26775 P2 $122.39 $162.4026776 A2 $1,119.61 $1,485.5926785 A2 $1,119.61 $1,485.5926820 A2 $1,211.40 $1,607.3826841 A2 $1,211.40 $1,607.3826842 A2 $1,211.40 $1,607.3826843 A2 $1,211.40 $1,607.3826844 A2 $1,211.40 $1,607.3826850 A2 $1,211.40 $1,607.3826852 A2 $1,211.40 $1,607.3826860 A2 $1,211.40 $1,607.3826861 N1 $0.00 $0.0026862 A2 $1,211.40 $1,607.3826863 N1 $0.00 $0.0026910 A2 $1,211.40 $1,607.3826951 A2 $673.27 $893.3526952 A2 $673.27 $893.3526990 A2 $910.33 $1,207.9026991 A2 $910.33 $1,207.9027000 A2 $910.33 $1,207.9027001 A2 $1,426.27 $1,892.4927003 A2 $1,426.27 $1,892.4927033 A2 $2,062.56 $2,736.7727035 A2 $1,426.27 $1,892.4927040 A2 $453.06 $601.1627041 A2 $453.06 $601.1627043 G2 $999.94 $1,326.8027045 G2 $999.94 $1,326.8027047 G2 $735.25 $975.5927048 G2 $735.25 $975.5927049 G2 $735.25 $975.5927050 A2 $910.33 $1,207.9027052 A2 $910.33 $1,207.9027059 G2 $999.94 $1,326.8027060 A2 $910.33 $1,207.9027062 A2 $910.33 $1,207.9027065 A2 $910.33 $1,207.9027066 A2 $1,426.27 $1,892.4927067 A2 $1,426.27 $1,892.4927080 A2 $1,426.27 $1,892.4927086 A2 $453.06 $601.1627087 A2 $910.33 $1,207.9027093 N1 $0.00 $0.0027095 N1 $0.00 $0.0027097 A2 $1,426.27 $1,892.4927098 A2 $1,426.27 $1,892.4927100 A2 $2,062.56 $2,736.7727105 A2 $2,062.56 $2,736.7727110 A2 $2,062.56 $2,736.7727111 A2 $2,062.56 $2,736.7727193 A2 $117.20 $155.5127194 A2 $390.95 $518.7427200 P2 $92.68 $122.9827202 A2 $2,317.66 $3,075.2627220 G2 $92.68 $122.9827230 A2 $117.20 $155.51



1

2

A B C D

HCPCS




11791180118111821183118411851186118711881189119011911192119311941195119611971198119912001201120212031204120512061207120812091210121112121213121412151216121712181219122012211222122312241225122612271228122912301231123212331234

27238 A2 $117.20 $155.5127246 A2 $117.20 $155.5127250 A2 $117.20 $155.5127252 A2 $390.95 $518.7427256 G2 $92.68 $122.9827257 A2 $390.95 $518.7427265 A2 $117.20 $155.5127266 A2 $630.71 $836.8827267 G2 $719.23 $954.3327275 A2 $630.71 $836.8827279 J8 $7,842.24 $10,405.7127301 A2 $896.60 $1,189.6827305 A2 $910.33 $1,207.9027306 A2 $910.33 $1,207.9027307 A2 $1,426.27 $1,892.4927310 A2 $1,426.27 $1,892.4927323 A2 $453.06 $601.1627324 A2 $999.94 $1,326.8027325 A2 $758.63 $1,006.6127326 A2 $758.63 $1,006.6127327 G2 $999.94 $1,326.8027328 G2 $735.25 $975.5927329 G2 $735.25 $975.5927330 A2 $1,426.27 $1,892.4927331 A2 $1,426.27 $1,892.4927332 A2 $1,426.27 $1,892.4927333 A2 $1,426.27 $1,892.4927334 A2 $1,426.27 $1,892.4927335 A2 $1,426.27 $1,892.4927337 G2 $999.94 $1,326.8027339 G2 $999.94 $1,326.8027340 A2 $910.33 $1,207.9027345 A2 $910.33 $1,207.9027347 A2 $910.33 $1,207.9027350 A2 $1,426.27 $1,892.4927355 A2 $1,426.27 $1,892.4927356 A2 $1,426.27 $1,892.4927357 A2 $1,426.27 $1,892.4927358 N1 $0.00 $0.0027360 A2 $1,426.27 $1,892.4927364 G2 $999.94 $1,326.8027370 N1 $0.00 $0.0027372 A2 $999.94 $1,326.8027380 A2 $1,426.27 $1,892.4927381 A2 $1,426.27 $1,892.4927385 A2 $1,426.27 $1,892.4927386 A2 $1,426.27 $1,892.4927390 A2 $910.33 $1,207.9027391 A2 $910.33 $1,207.9027392 A2 $1,426.27 $1,892.4927393 A2 $1,426.27 $1,892.4927394 A2 $1,426.27 $1,892.4927395 A2 $2,062.56 $2,736.7727396 A2 $1,426.27 $1,892.4927397 A2 $2,062.56 $2,736.7727400 A2 $2,062.56 $2,736.77



1

2

A B C D

HCPCS




12351236123712381239124012411242124312441245124612471248124912501251125212531254125512561257125812591260126112621263126412651266126712681269127012711272127312741275127612771278127912801281128212831284128512861287128812891290

27403 A2 $1,426.27 $1,892.4927405 A2 $2,062.56 $2,736.7727407 A2 $3,465.63 $4,598.4827409 A2 $2,062.56 $2,736.7727415 J8 $7,842.24 $10,405.7127416 G2 $2,062.56 $2,736.7727418 A2 $2,062.56 $2,736.7727420 A2 $2,062.56 $2,736.7727422 A2 $2,062.56 $2,736.7727424 A2 $2,062.56 $2,736.7727425 A2 $1,426.27 $1,892.4927427 A2 $3,465.63 $4,598.4827428 J8 $7,842.24 $10,405.7127429 A2 $3,465.63 $4,598.4827430 A2 $2,062.56 $2,736.7727435 A2 $1,426.27 $1,892.4927437 A2 $1,844.03 $2,446.8127438 J8 $7,842.24 $10,405.7127440 J8 $7,842.24 $10,405.7127441 A2 $1,844.03 $2,446.8127442 J8 $7,842.24 $10,405.7127443 J8 $7,842.24 $10,405.7127446 J8 $7,842.24 $10,405.7127475 G2 $1,426.27 $1,892.4927479 G2 $1,426.27 $1,892.4927496 A2 $1,426.27 $1,892.4927497 A2 $910.33 $1,207.9027498 A2 $1,426.27 $1,892.4927499 A2 $1,426.27 $1,892.4927500 A2 $117.20 $155.5127501 A2 $117.20 $155.5127502 A2 $719.23 $954.3327503 A2 $117.20 $155.5127508 A2 $117.20 $155.5127509 A2 $1,119.61 $1,485.5927510 A2 $117.20 $155.5127516 A2 $92.68 $122.9827517 A2 $117.20 $155.5127520 A2 $117.20 $155.5127524 G2 $2,317.66 $3,075.2627530 A2 $117.20 $155.5127532 A2 $719.23 $954.3327538 A2 $117.20 $155.5127550 A2 $117.20 $155.5127552 A2 $630.71 $836.8827560 A2 $92.68 $122.9827562 A2 $390.95 $518.7427566 A2 $2,317.66 $3,075.2627570 A2 $630.71 $836.8827594 A2 $910.33 $1,207.9027600 A2 $910.33 $1,207.9027601 A2 $910.33 $1,207.9027602 A2 $1,426.27 $1,892.4927603 A2 $896.60 $1,189.6827604 A2 $1,426.27 $1,892.4927605 A2 $955.65 $1,268.03



1

2

A B C D

HCPCS




12911292129312941295129612971298129913001301130213031304130513061307130813091310131113121313131413151316131713181319132013211322132313241325132613271328132913301331133213331334133513361337133813391340134113421343134413451346

27606 A2 $910.33 $1,207.9027607 A2 $910.33 $1,207.9027610 A2 $1,426.27 $1,892.4927612 A2 $1,426.27 $1,892.4927613 P3 $165.76 $219.9427614 A2 $999.94 $1,326.8027615 G2 $735.25 $975.5927616 G2 $999.94 $1,326.8027618 G2 $735.25 $975.5927619 G2 $735.25 $975.5927620 A2 $1,426.27 $1,892.4927625 A2 $1,426.27 $1,892.4927626 A2 $1,426.27 $1,892.4927630 A2 $910.33 $1,207.9027632 G2 $999.94 $1,326.8027634 G2 $999.94 $1,326.8027635 A2 $1,426.27 $1,892.4927637 A2 $1,426.27 $1,892.4927638 A2 $1,426.27 $1,892.4927640 A2 $1,426.27 $1,892.4927641 A2 $1,426.27 $1,892.4927647 A2 $1,426.27 $1,892.4927648 N1 $0.00 $0.0027650 A2 $2,062.56 $2,736.7727652 A2 $2,062.56 $2,736.7727654 A2 $2,062.56 $2,736.7727656 A2 $910.33 $1,207.9027658 A2 $910.33 $1,207.9027659 A2 $910.33 $1,207.9027664 A2 $1,426.27 $1,892.4927665 A2 $1,426.27 $1,892.4927675 A2 $910.33 $1,207.9027676 A2 $1,426.27 $1,892.4927680 A2 $1,426.27 $1,892.4927681 A2 $1,426.27 $1,892.4927685 A2 $1,426.27 $1,892.4927686 A2 $1,426.27 $1,892.4927687 A2 $1,426.27 $1,892.4927690 A2 $2,062.56 $2,736.7727691 A2 $2,062.56 $2,736.7727692 N1 $0.00 $0.0027695 A2 $1,426.27 $1,892.4927696 A2 $1,426.27 $1,892.4927698 A2 $1,426.27 $1,892.4927700 A2 $1,844.03 $2,446.8127704 A2 $910.33 $1,207.9027705 A2 $2,062.56 $2,736.7727707 A2 $1,426.27 $1,892.4927709 A2 $1,426.27 $1,892.4927720 G2 $2,317.66 $3,075.2627726 G2 $2,317.66 $3,075.2627730 A2 $1,426.27 $1,892.4927732 A2 $1,426.27 $1,892.4927734 A2 $1,426.27 $1,892.4927740 A2 $1,426.27 $1,892.4927742 A2 $2,062.56 $2,736.77



1

2

A B C D

HCPCS




13471348134913501351135213531354135513561357135813591360136113621363136413651366136713681369137013711372137313741375137613771378137913801381138213831384138513861387138813891390139113921393139413951396139713981399140014011402

27745 J8 $7,842.24 $10,405.7127750 A2 $117.20 $155.5127752 A2 $719.23 $954.3327756 A2 $1,119.61 $1,485.5927758 A2 $2,317.66 $3,075.2627759 J8 $4,138.76 $5,491.6427760 A2 $117.20 $155.5127762 A2 $719.23 $954.3327766 A2 $2,317.66 $3,075.2627767 P2 $92.68 $122.9827768 G2 $92.68 $122.9827769 G2 $2,317.66 $3,075.2627780 A2 $117.20 $155.5127781 A2 $390.95 $518.7427784 A2 $2,317.66 $3,075.2627786 A2 $117.20 $155.5127788 A2 $117.20 $155.5127792 A2 $2,317.66 $3,075.2627808 A2 $117.20 $155.5127810 A2 $390.95 $518.7427814 A2 $2,317.66 $3,075.2627816 A2 $117.20 $155.5127818 A2 $390.95 $518.7427822 A2 $2,317.66 $3,075.2627823 J8 $4,138.76 $5,491.6427824 A2 $117.20 $155.5127825 A2 $719.23 $954.3327826 A2 $2,317.66 $3,075.2627827 J8 $4,138.76 $5,491.6427828 J8 $4,138.76 $5,491.6427829 A2 $2,317.66 $3,075.2627830 A2 $92.68 $122.9827831 A2 $390.95 $518.7427832 A2 $2,317.66 $3,075.2627840 A2 $117.20 $155.5127842 A2 $630.71 $836.8827846 A2 $2,317.66 $3,075.2627848 A2 $2,317.66 $3,075.2627860 A2 $630.71 $836.8827870 A2 $3,465.63 $4,598.4827871 A2 $3,465.63 $4,598.4827884 A2 $910.33 $1,207.9027889 A2 $1,426.27 $1,892.4927892 A2 $1,426.27 $1,892.4927893 A2 $1,426.27 $1,892.4927894 A2 $1,426.27 $1,892.4928001 P3 $180.44 $239.4228002 A2 $910.33 $1,207.9028003 A2 $910.33 $1,207.9028005 A2 $955.65 $1,268.0328008 A2 $955.65 $1,268.0328010 P3 $123.51 $163.8828011 A2 $955.65 $1,268.0328020 A2 $955.65 $1,268.0328022 A2 $955.65 $1,268.0328024 A2 $955.65 $1,268.03



1

2

A B C D

HCPCS




14031404140514061407140814091410141114121413141414151416141714181419142014211422142314241425142614271428142914301431143214331434143514361437143814391440144114421443144414451446144714481449145014511452145314541455145614571458

28035 A2 $758.63 $1,006.6128039 G2 $999.94 $1,326.8028041 G2 $999.94 $1,326.8028043 G2 $735.25 $975.5928045 G2 $735.25 $975.5928046 G2 $735.25 $975.5928047 G2 $999.94 $1,326.8028050 A2 $955.65 $1,268.0328052 A2 $955.65 $1,268.0328054 A2 $955.65 $1,268.0328055 A2 $758.63 $1,006.6128060 A2 $955.65 $1,268.0328062 A2 $955.65 $1,268.0328070 A2 $955.65 $1,268.0328072 A2 $955.65 $1,268.0328080 A2 $955.65 $1,268.0328086 A2 $955.65 $1,268.0328088 A2 $955.65 $1,268.0328090 A2 $955.65 $1,268.0328092 A2 $955.65 $1,268.0328100 A2 $955.65 $1,268.0328102 A2 $2,860.71 $3,795.8228103 A2 $2,860.71 $3,795.8228104 A2 $955.65 $1,268.0328106 A2 $2,860.71 $3,795.8228107 A2 $2,860.71 $3,795.8228108 A2 $955.65 $1,268.0328110 A2 $955.65 $1,268.0328111 A2 $955.65 $1,268.0328112 A2 $955.65 $1,268.0328113 A2 $955.65 $1,268.0328114 A2 $955.65 $1,268.0328116 A2 $955.65 $1,268.0328118 A2 $955.65 $1,268.0328119 A2 $955.65 $1,268.0328120 A2 $955.65 $1,268.0328122 A2 $955.65 $1,268.0328124 P3 $299.66 $397.6128126 A2 $955.65 $1,268.0328130 A2 $955.65 $1,268.0328140 A2 $955.65 $1,268.0328150 A2 $955.65 $1,268.0328153 A2 $955.65 $1,268.0328160 A2 $955.65 $1,268.0328171 A2 $955.65 $1,268.0328173 A2 $955.65 $1,268.0328175 A2 $955.65 $1,268.0328190 P3 $186.88 $247.9728192 A2 $735.25 $975.5928193 A2 $453.06 $601.1628200 A2 $955.65 $1,268.0328202 A2 $955.65 $1,268.0328208 A2 $955.65 $1,268.0328210 A2 $2,860.71 $3,795.8228220 P3 $285.34 $378.6128222 A2 $955.65 $1,268.03



1

2

A B C D

HCPCS




14591460146114621463146414651466146714681469147014711472147314741475147614771478147914801481148214831484148514861487148814891490149114921493149414951496149714981499150015011502150315041505150615071508150915101511151215131514

28225 A2 $955.65 $1,268.0328226 A2 $955.65 $1,268.0328230 P3 $282.47 $374.8028232 P3 $264.21 $350.5728234 A2 $955.65 $1,268.0328238 A2 $2,860.71 $3,795.8228240 A2 $955.65 $1,268.0328250 A2 $955.65 $1,268.0328260 A2 $955.65 $1,268.0328261 A2 $955.65 $1,268.0328262 A2 $955.65 $1,268.0328264 A2 $2,860.71 $3,795.8228270 A2 $955.65 $1,268.0328272 P3 $257.41 $341.5528280 A2 $955.65 $1,268.0328285 A2 $955.65 $1,268.0328286 A2 $955.65 $1,268.0328288 A2 $955.65 $1,268.0328289 A2 $955.65 $1,268.0328290 A2 $1,467.01 $1,946.5528292 A2 $1,467.01 $1,946.5528293 A2 $1,467.01 $1,946.5528294 A2 $1,467.01 $1,946.5528296 A2 $1,467.01 $1,946.5528297 A2 $1,467.01 $1,946.5528298 A2 $1,467.01 $1,946.5528299 A2 $1,467.01 $1,946.5528300 A2 $2,860.71 $3,795.8228302 A2 $955.65 $1,268.0328304 A2 $2,860.71 $3,795.8228305 A2 $2,860.71 $3,795.8228306 A2 $955.65 $1,268.0328307 A2 $955.65 $1,268.0328308 A2 $955.65 $1,268.0328309 A2 $2,860.71 $3,795.8228310 A2 $955.65 $1,268.0328312 A2 $955.65 $1,268.0328313 A2 $955.65 $1,268.0328315 A2 $955.65 $1,268.0328320 A2 $2,860.71 $3,795.8228322 A2 $955.65 $1,268.0328340 A2 $955.65 $1,268.0328341 A2 $955.65 $1,268.0328344 A2 $955.65 $1,268.0328345 A2 $955.65 $1,268.0328400 A2 $117.20 $155.5128405 A2 $390.95 $518.7428406 A2 $1,119.61 $1,485.5928415 J8 $4,138.76 $5,491.6428420 A2 $2,317.66 $3,075.2628430 P2 $92.68 $122.9828435 A2 $719.23 $954.3328436 A2 $1,119.61 $1,485.5928445 A2 $2,317.66 $3,075.2628446 G2 $2,860.71 $3,795.8228450 P2 $92.68 $122.98



1

2

A B C D

HCPCS




15151516151715181519152015211522152315241525152615271528152915301531153215331534153515361537153815391540154115421543154415451546154715481549155015511552155315541555155615571558155915601561156215631564156515661567156815691570

28455 P2 $92.68 $122.9828456 A2 $1,119.61 $1,485.5928465 A2 $2,317.66 $3,075.2628470 P2 $117.20 $155.5128475 P2 $117.20 $155.5128476 A2 $1,119.61 $1,485.5928485 A2 $2,317.66 $3,075.2628490 P2 $92.68 $122.9828495 P2 $117.20 $155.5128496 A2 $1,119.61 $1,485.5928505 A2 $1,119.61 $1,485.5928510 P3 $80.55 $106.8828515 P3 $104.90 $139.1928525 A2 $1,119.61 $1,485.5928530 P3 $74.82 $99.2828531 A2 $1,119.61 $1,485.5928540 P2 $92.68 $122.9828545 A2 $1,119.61 $1,485.5928546 A2 $1,119.61 $1,485.5928555 A2 $2,317.66 $3,075.2628570 P3 $99.53 $132.0628575 A2 $719.23 $954.3328576 A2 $1,119.61 $1,485.5928585 A2 $1,119.61 $1,485.5928600 P2 $92.68 $122.9828605 A2 $92.68 $122.9828606 A2 $1,119.61 $1,485.5928615 A2 $2,317.66 $3,075.2628630 P3 $89.86 $119.2328635 A2 $719.23 $954.3328636 A2 $1,119.61 $1,485.5928645 A2 $1,119.61 $1,485.5928660 P3 $67.66 $89.7828665 A2 $122.39 $162.4028666 A2 $1,119.61 $1,485.5928675 A2 $1,119.61 $1,485.5928705 A2 $2,860.71 $3,795.8228715 J8 $7,842.24 $10,405.7128725 A2 $2,860.71 $3,795.8228730 A2 $2,860.71 $3,795.8228735 A2 $2,860.71 $3,795.8228737 A2 $2,860.71 $3,795.8228740 A2 $2,860.71 $3,795.8228750 A2 $2,860.71 $3,795.8228755 A2 $955.65 $1,268.0328760 A2 $2,860.71 $3,795.8228810 A2 $955.65 $1,268.0328820 A2 $955.65 $1,268.0328825 A2 $955.65 $1,268.0328890 P3 $199.77 $265.0729000 G2 $122.39 $162.4029010 P2 $122.39 $162.4029015 P2 $122.39 $162.4029020 D5 $0.00 $0.0029025 D5 $0.00 $0.0029035 P2 $122.39 $162.40



1

2

A B C D

HCPCS




15711572157315741575157615771578157915801581158215831584158515861587158815891590159115921593159415951596159715981599160016011602160316041605160616071608160916101611161216131614161516161617161816191620162116221623162416251626

29040 G2 $122.39 $162.4029044 P2 $70.09 $93.0029046 G2 $122.39 $162.4029049 P3 $36.88 $48.9429055 P2 $122.39 $162.4029058 P3 $70.89 $94.0629065 P3 $61.94 $82.1929075 P3 $56.57 $75.0629085 P3 $61.22 $81.2329086 P3 $54.78 $72.6929105 P3 $54.06 $71.7329125 N1 $0.00 $0.0029126 N1 $0.00 $0.0029130 N1 $0.00 $0.0029131 N1 $0.00 $0.0029200 P3 $15.39 $20.4229240 N1 $0.00 $0.0029260 N1 $0.00 $0.0029280 N1 $0.00 $0.0029305 P2 $122.39 $162.4029325 P2 $122.39 $162.4029345 P3 $80.55 $106.8829355 P3 $79.84 $105.9429358 P3 $103.47 $137.2929365 P3 $75.54 $100.2329405 P3 $50.84 $67.4629425 P3 $47.97 $63.6529435 P3 $71.24 $94.5329440 P3 $22.91 $30.4029445 P3 $67.66 $89.7829450 P3 $66.23 $87.8829505 P3 $56.92 $75.5329515 P3 $44.04 $58.4429520 N1 $0.00 $0.0029530 N1 $0.00 $0.0029540 P3 $11.46 $15.2129550 N1 $0.00 $0.0029580 P3 $31.15 $41.3329581 P3 $53.34 $70.7829582 P3 $58.36 $77.4429583 P3 $35.09 $46.5629584 P3 $58.36 $77.4429700 P3 $39.02 $51.7729705 P3 $36.88 $48.9429710 P3 $69.45 $92.1529715 D5 $0.00 $0.0029720 P3 $58.00 $76.9629730 P3 $34.37 $45.6029740 P3 $53.70 $71.2529750 P3 $45.11 $59.8629800 A2 $1,179.31 $1,564.8029804 A2 $1,179.31 $1,564.8029805 A2 $1,179.31 $1,564.8029806 A2 $2,381.87 $3,160.4629807 A2 $2,381.87 $3,160.4629819 A2 $2,381.87 $3,160.46



1

2

A B C D

HCPCS




16271628162916301631163216331634163516361637163816391640164116421643164416451646164716481649165016511652165316541655165616571658165916601661166216631664166516661667166816691670167116721673167416751676167716781679168016811682

29820 A2 $2,381.87 $3,160.4629821 A2 $2,381.87 $3,160.4629822 A2 $1,179.31 $1,564.8029823 A2 $2,381.87 $3,160.4629824 A2 $2,381.87 $3,160.4629825 A2 $2,381.87 $3,160.4629826 N1 $0.00 $0.0029827 A2 $2,381.87 $3,160.4629828 G2 $2,381.87 $3,160.4629830 A2 $2,381.87 $3,160.4629834 A2 $1,179.31 $1,564.8029835 A2 $2,381.87 $3,160.4629836 A2 $2,381.87 $3,160.4629837 A2 $1,179.31 $1,564.8029838 A2 $1,179.31 $1,564.8029840 A2 $1,179.31 $1,564.8029843 A2 $1,179.31 $1,564.8029844 A2 $1,179.31 $1,564.8029845 A2 $1,179.31 $1,564.8029846 A2 $1,179.31 $1,564.8029847 A2 $2,381.87 $3,160.4629848 A2 $1,179.31 $1,564.8029850 A2 $1,179.31 $1,564.8029851 A2 $2,381.87 $3,160.4629855 A2 $2,381.87 $3,160.4629856 A2 $2,381.87 $3,160.4629860 A2 $2,381.87 $3,160.4629861 A2 $2,381.87 $3,160.4629862 A2 $2,381.87 $3,160.4629863 A2 $2,381.87 $3,160.4629866 G2 $2,381.87 $3,160.4629870 A2 $1,179.31 $1,564.8029871 A2 $1,179.31 $1,564.8029873 A2 $1,179.31 $1,564.8029874 A2 $1,179.31 $1,564.8029875 A2 $1,179.31 $1,564.8029876 A2 $1,179.31 $1,564.8029877 A2 $1,179.31 $1,564.8029879 A2 $1,179.31 $1,564.8029880 A2 $1,179.31 $1,564.8029881 A2 $1,179.31 $1,564.8029882 A2 $1,179.31 $1,564.8029883 A2 $1,179.31 $1,564.8029884 A2 $1,179.31 $1,564.8029885 A2 $2,381.87 $3,160.4629886 A2 $1,179.31 $1,564.8029887 A2 $1,179.31 $1,564.8029888 A2 $3,465.63 $4,598.4829889 A2 $3,465.63 $4,598.4829891 A2 $2,381.87 $3,160.4629892 A2 $2,062.56 $2,736.7729893 A2 $955.65 $1,268.0329894 A2 $1,179.31 $1,564.8029895 A2 $1,179.31 $1,564.8029897 A2 $1,179.31 $1,564.8029898 A2 $1,179.31 $1,564.80



1

2

A B C D

HCPCS




16831684168516861687168816891690169116921693169416951696169716981699170017011702170317041705170617071708170917101711171217131714171517161717171817191720172117221723172417251726172717281729173017311732173317341735173617371738

29899 A2 $2,381.87 $3,160.4629900 A2 $1,179.31 $1,564.8029901 A2 $2,381.87 $3,160.4629902 A2 $1,179.31 $1,564.8029904 G2 $1,179.31 $1,564.8029905 G2 $1,179.31 $1,564.8029906 G2 $1,179.31 $1,564.8029907 G2 $2,381.87 $3,160.4629914 G2 $2,381.87 $3,160.4629915 G2 $2,381.87 $3,160.4629916 G2 $2,381.87 $3,160.4630000 P2 $71.10 $94.3430020 P3 $177.22 $235.1530100 P3 $105.61 $140.1330110 P3 $166.48 $220.9030115 A2 $1,066.74 $1,415.4430117 A2 $694.39 $921.3730118 A2 $1,066.74 $1,415.4430120 A2 $1,066.74 $1,415.4430124 R2 $1,066.74 $1,415.4430125 A2 $2,044.49 $2,712.7930130 A2 $1,066.74 $1,415.4430140 A2 $1,066.74 $1,415.4430150 A2 $2,044.49 $2,712.7930160 A2 $2,044.49 $2,712.7930200 P3 $84.13 $111.6330210 P3 $106.69 $141.5630220 A2 $694.39 $921.3730300 N1 $0.00 $0.0030310 A2 $694.39 $921.3730320 A2 $1,066.74 $1,415.4430400 A2 $1,066.74 $1,415.4430410 A2 $2,044.49 $2,712.7930420 A2 $2,044.49 $2,712.7930430 A2 $1,066.74 $1,415.4430435 A2 $2,044.49 $2,712.7930450 A2 $2,044.49 $2,712.7930460 A2 $2,044.49 $2,712.7930462 A2 $2,044.49 $2,712.7930465 A2 $2,044.49 $2,712.7930520 A2 $1,066.74 $1,415.4430540 A2 $2,044.49 $2,712.7930545 A2 $2,044.49 $2,712.7930560 A2 $199.13 $264.2230580 A2 $2,044.49 $2,712.7930600 A2 $2,044.49 $2,712.7930620 A2 $2,044.49 $2,712.7930630 A2 $1,066.74 $1,415.4430801 A2 $354.45 $470.3130802 A2 $694.39 $921.3730901 N1 $0.00 $0.0030903 A2 $71.10 $94.3430905 A2 $71.10 $94.3430906 A2 $71.10 $94.3430915 A2 $1,190.36 $1,579.4630920 A2 $1,190.36 $1,579.46



1

2

A B C D

HCPCS




17391740174117421743174417451746174717481749175017511752175317541755175617571758175917601761176217631764176517661767176817691770177117721773177417751776177717781779178017811782178317841785178617871788178917901791179217931794

30930 A2 $1,066.74 $1,415.4431000 P3 $138.91 $184.3231002 R2 $354.45 $470.3131020 A2 $1,066.74 $1,415.4431030 A2 $2,044.49 $2,712.7931032 A2 $2,044.49 $2,712.7931040 R2 $1,066.74 $1,415.4431050 A2 $2,044.49 $2,712.7931051 A2 $2,044.49 $2,712.7931070 A2 $2,044.49 $2,712.7931075 A2 $2,044.49 $2,712.7931080 A2 $2,044.49 $2,712.7931081 A2 $2,044.49 $2,712.7931084 A2 $2,044.49 $2,712.7931085 A2 $2,044.49 $2,712.7931086 A2 $2,044.49 $2,712.7931087 A2 $2,044.49 $2,712.7931090 A2 $2,044.49 $2,712.7931200 A2 $2,044.49 $2,712.7931201 A2 $1,066.74 $1,415.4431205 A2 $1,066.74 $1,415.4431231 P2 $82.59 $109.5931233 A2 $211.79 $281.0231235 A2 $690.38 $916.0531237 A2 $690.38 $916.0531238 A2 $690.38 $916.0531239 A2 $1,101.86 $1,462.0431240 A2 $1,101.86 $1,462.0431254 A2 $1,101.86 $1,462.0431255 A2 $1,683.14 $2,233.3231256 A2 $1,101.86 $1,462.0431267 A2 $1,101.86 $1,462.0431276 A2 $1,683.14 $2,233.3231287 A2 $1,683.14 $2,233.3231288 A2 $1,683.14 $2,233.3231295 P2 $1,683.14 $2,233.3231296 P2 $1,683.14 $2,233.3231297 P2 $1,101.86 $1,462.0431300 A2 $1,066.74 $1,415.4431320 A2 $2,044.49 $2,712.7931400 A2 $2,044.49 $2,712.7931420 A2 $2,044.49 $2,712.7931500 G2 $71.10 $94.3431502 G2 $71.10 $94.3431505 P3 $60.15 $79.8131510 A2 $690.38 $916.0531511 A2 $82.59 $109.5931512 A2 $1,101.86 $1,462.0431513 A2 $211.79 $281.0231515 A2 $690.38 $916.0531520 G2 $211.79 $281.0231525 A2 $690.38 $916.0531526 A2 $690.38 $916.0531527 A2 $1,101.86 $1,462.0431528 A2 $1,101.86 $1,462.0431529 A2 $1,101.86 $1,462.04



1

2

A B C D

HCPCS




17951796179717981799180018011802180318041805180618071808180918101811181218131814181518161817181818191820182118221823182418251826182718281829183018311832183318341835183618371838183918401841184218431844184518461847184818491850

31530 A2 $690.38 $916.0531531 A2 $690.38 $916.0531535 A2 $1,101.86 $1,462.0431536 A2 $1,101.86 $1,462.0431540 A2 $1,101.86 $1,462.0431541 A2 $1,101.86 $1,462.0431545 A2 $1,101.86 $1,462.0431546 A2 $1,683.14 $2,233.3231560 A2 $1,683.14 $2,233.3231561 A2 $1,101.86 $1,462.0431570 A2 $690.38 $916.0531571 A2 $1,101.86 $1,462.0431575 P3 $71.60 $95.0031576 A2 $690.38 $916.0531577 A2 $211.79 $281.0231578 A2 $690.38 $916.0531579 P3 $123.16 $163.4231580 A2 $2,044.49 $2,712.7931582 A2 $2,044.49 $2,712.7931588 A2 $2,044.49 $2,712.7931590 A2 $2,044.49 $2,712.7931595 A2 $2,044.49 $2,712.7931603 A2 $354.45 $470.3131605 G2 $354.45 $470.3131611 A2 $1,066.74 $1,415.4431612 A2 $2,044.49 $2,712.7931613 A2 $1,066.74 $1,415.4431614 A2 $2,044.49 $2,712.7931615 A2 $354.45 $470.3131620 N1 $0.00 $0.0031622 A2 $578.33 $767.3731623 A2 $578.33 $767.3731624 A2 $578.33 $767.3731625 A2 $578.33 $767.3731626 G2 $1,236.75 $1,641.0231627 N1 $0.00 $0.0031628 A2 $578.33 $767.3731629 A2 $1,236.75 $1,641.0231630 A2 $1,236.75 $1,641.0231631 A2 $1,236.75 $1,641.0231632 N1 $0.00 $0.0031633 N1 $0.00 $0.0031634 G2 $1,236.75 $1,641.0231635 A2 $578.33 $767.3731636 A2 $1,236.75 $1,641.0231637 N1 $0.00 $0.0031638 A2 $1,236.75 $1,641.0231640 A2 $1,236.75 $1,641.0231641 A2 $1,236.75 $1,641.0231643 A2 $578.33 $767.3731645 A2 $578.33 $767.3731646 A2 $578.33 $767.3731647 G2 $1,236.75 $1,641.0231648 G2 $1,236.75 $1,641.0231649 G2 $578.33 $767.3731651 N1 $0.00 $0.00



1

2

A B C D

HCPCS




18511852185318541855185618571858185918601861186218631864186518661867186818691870187118721873187418751876187718781879188018811882188318841885188618871888188918901891189218931894189518961897189818991900190119021903190419051906

31717 A2 $211.79 $281.0231720 N1 $0.00 $0.0031730 A2 $211.79 $281.0231750 A2 $2,044.49 $2,712.7931755 A2 $2,044.49 $2,712.7931820 A2 $1,066.74 $1,415.4431825 A2 $1,066.74 $1,415.4431830 A2 $1,066.74 $1,415.4432400 A2 $576.97 $765.5732405 A2 $576.97 $765.5732550 G2 $1,254.22 $1,664.2032552 G2 $268.22 $355.9032553 G2 $569.23 $755.3032554 G2 $268.22 $355.9032555 G2 $268.22 $355.9032556 G2 $268.22 $355.9032557 G2 $268.22 $355.9032960 G2 $268.22 $355.9032998 G2 $2,245.03 $2,978.8933010 A2 $268.22 $355.9033011 A2 $268.22 $355.9033206 J8 $7,851.02 $10,417.3633207 J8 $7,851.02 $10,417.3633208 J8 $7,851.02 $10,417.3633210 J8 $5,649.82 $7,496.6333211 J8 $5,649.82 $7,496.6333212 J8 $5,649.82 $7,496.6333213 J8 $7,851.02 $10,417.3633214 J8 $7,851.02 $10,417.3633215 G2 $863.86 $1,146.2433216 J8 $5,649.82 $7,496.6333217 J8 $5,649.82 $7,496.6333218 G2 $1,286.56 $1,707.1133220 G2 $1,286.56 $1,707.1133221 J8 $12,514.72 $16,605.5333222 A2 $771.43 $1,023.6033223 A2 $771.43 $1,023.6033224 J8 $7,851.02 $10,417.3633225 N1 $0.00 $0.0033226 G2 $863.86 $1,146.2433227 J8 $5,649.82 $7,496.6333228 J8 $7,851.02 $10,417.3633229 J8 $12,514.72 $16,605.5333230 J8 $20,286.25 $26,917.4233231 J8 $27,203.55 $36,095.8533233 J8 $5,649.82 $7,496.6333234 G2 $1,286.56 $1,707.1133235 G2 $1,286.56 $1,707.1133240 J8 $20,286.25 $26,917.4233241 G2 $1,286.56 $1,707.1133249 J8 $27,203.55 $36,095.8533262 J8 $20,286.25 $26,917.4233263 J8 $20,286.25 $26,917.4233264 J8 $27,203.55 $36,095.8533270 J8 $27,203.55 $36,095.8533271 J8 $5,649.82 $7,496.63



1

2

A B C D

HCPCS




19071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962

33273 G2 $1,286.56 $1,707.1133282 J8 $5,649.82 $7,496.6333284 G2 $453.06 $601.1633419 N1 $0.00 $0.0033508 N1 $0.00 $0.0034490 G2 $1,765.41 $2,342.4935188 A2 $1,765.41 $2,342.4935207 A2 $1,765.41 $2,342.4935460 G2 $2,220.28 $2,946.0535475 P3 $1,319.99 $1,751.4735476 P3 $1,244.81 $1,651.7135572 N1 $0.00 $0.0035761 G2 $1,370.93 $1,819.0635875 A2 $1,765.41 $2,342.4935876 A2 $1,765.41 $2,342.4936000 N1 $0.00 $0.0036002 G2 $103.94 $137.9236005 N1 $0.00 $0.0036010 N1 $0.00 $0.0036011 N1 $0.00 $0.0036012 N1 $0.00 $0.0036013 N1 $0.00 $0.0036014 N1 $0.00 $0.0036015 N1 $0.00 $0.0036100 N1 $0.00 $0.0036120 N1 $0.00 $0.0036140 N1 $0.00 $0.0036147 P2 $453.58 $601.8536148 N1 $0.00 $0.0036160 N1 $0.00 $0.0036200 N1 $0.00 $0.0036215 N1 $0.00 $0.0036216 N1 $0.00 $0.0036217 N1 $0.00 $0.0036218 N1 $0.00 $0.0036221 N1 $0.00 $0.0036222 N1 $0.00 $0.0036223 N1 $0.00 $0.0036224 N1 $0.00 $0.0036225 N1 $0.00 $0.0036226 N1 $0.00 $0.0036227 N1 $0.00 $0.0036228 N1 $0.00 $0.0036245 N1 $0.00 $0.0036246 N1 $0.00 $0.0036247 N1 $0.00 $0.0036248 N1 $0.00 $0.0036251 N1 $0.00 $0.0036252 N1 $0.00 $0.0036253 N1 $0.00 $0.0036254 N1 $0.00 $0.0036260 A2 $1,225.74 $1,626.4136261 A2 $1,286.56 $1,707.1136262 A2 $1,286.56 $1,707.1136400 N1 $0.00 $0.0036405 N1 $0.00 $0.00



1

2

A B C D

HCPCS




19631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018

36406 N1 $0.00 $0.0036410 N1 $0.00 $0.0036416 N1 $0.00 $0.0036420 N1 $0.00 $0.0036425 N1 $0.00 $0.0036430 P3 $34.37 $45.6036440 R2 $162.96 $216.2336450 R2 $162.96 $216.2336455 G2 $162.96 $216.2336468 R2 $80.10 $106.2836469 D5 $0.00 $0.0036470 P3 $105.61 $140.1336471 P2 $80.10 $106.2836475 A2 $1,190.36 $1,579.4636476 N1 $0.00 $0.0036478 A2 $1,190.36 $1,579.4636479 N1 $0.00 $0.0036481 N1 $0.00 $0.0036500 N1 $0.00 $0.0036510 N1 $0.00 $0.0036511 G2 $578.48 $767.5736512 G2 $578.48 $767.5736513 G2 $578.48 $767.5736514 G2 $578.48 $767.5736515 P2 $1,559.83 $2,069.7136516 P2 $1,559.83 $2,069.7136522 G2 $1,559.83 $2,069.7136555 A2 $462.34 $613.4736556 A2 $462.34 $613.4736557 A2 $1,225.74 $1,626.4136558 A2 $1,225.74 $1,626.4136560 A2 $1,225.74 $1,626.4136561 A2 $1,225.74 $1,626.4136563 A2 $1,225.74 $1,626.4136565 A2 $1,225.74 $1,626.4136566 A2 $1,225.74 $1,626.4136568 A2 $462.34 $613.4736569 A2 $462.34 $613.4736570 A2 $1,225.74 $1,626.4136571 A2 $1,225.74 $1,626.4136575 A2 $267.52 $354.9736576 A2 $462.34 $613.4736578 A2 $1,225.74 $1,626.4136580 A2 $462.34 $613.4736581 A2 $1,225.74 $1,626.4136582 A2 $1,225.74 $1,626.4136583 A2 $1,225.74 $1,626.4136584 A2 $462.34 $613.4736585 A2 $1,225.74 $1,626.4136589 A2 $267.52 $354.9736590 A2 $462.34 $613.4736591 N1 $0.00 $0.0036592 N1 $0.00 $0.0036593 P3 $30.79 $40.8536595 P3 $453.60 $601.8736596 G2 $462.34 $613.47



1

2

A B C D

HCPCS




20192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074

36597 G2 $462.34 $613.4736598 P3 $83.06 $110.2136600 N1 $0.00 $0.0036620 N1 $0.00 $0.0036625 N1 $0.00 $0.0036640 A2 $1,225.74 $1,626.4136680 N1 $0.00 $0.0036800 A2 $1,225.74 $1,626.4136810 A2 $1,225.74 $1,626.4136815 A2 $1,225.74 $1,626.4136818 A2 $1,765.41 $2,342.4936819 A2 $1,765.41 $2,342.4936820 A2 $1,765.41 $2,342.4936821 A2 $1,765.41 $2,342.4936825 A2 $1,765.41 $2,342.4936830 A2 $1,765.41 $2,342.4936831 A2 $1,765.41 $2,342.4936832 A2 $1,765.41 $2,342.4936833 A2 $1,765.41 $2,342.4936835 A2 $1,225.74 $1,626.4136860 A2 $106.99 $141.9636861 A2 $1,225.74 $1,626.4136870 A2 $2,220.28 $2,946.0537184 G2 $1,765.41 $2,342.4937185 N1 $0.00 $0.0037186 N1 $0.00 $0.0037187 G2 $1,765.41 $2,342.4937188 G2 $1,765.41 $2,342.4937197 G2 $1,225.74 $1,626.4137200 G2 $1,225.74 $1,626.4137202 G2 $863.86 $1,146.2437211 G2 $462.34 $613.4737212 G2 $462.34 $613.4737220 G2 $2,220.28 $2,946.0537221 J8 $6,060.86 $8,042.0337222 N1 $0.00 $0.0037223 N1 $0.00 $0.0037224 G2 $2,220.28 $2,946.0537225 J8 $6,060.86 $8,042.0337226 J8 $6,060.86 $8,042.0337227 J8 $9,739.78 $12,923.5237228 J8 $6,060.86 $8,042.0337229 J8 $9,739.78 $12,923.5237230 J8 $9,739.78 $12,923.5237231 J8 $9,739.78 $12,923.5237232 N1 $0.00 $0.0037233 N1 $0.00 $0.0037234 N1 $0.00 $0.0037235 N1 $0.00 $0.0037236 J8 $6,060.86 $8,042.0337237 N1 $0.00 $0.0037238 J8 $6,060.86 $8,042.0337239 N1 $0.00 $0.0037250 N1 $0.00 $0.0037251 N1 $0.00 $0.0037500 A2 $1,190.36 $1,579.46



1

2

A B C D

HCPCS




20752076207720782079208020812082208320842085208620872088208920902091209220932094209520962097209820992100210121022103210421052106210721082109211021112112211321142115211621172118211921202121212221232124212521262127212821292130

37607 A2 $1,190.36 $1,579.4637609 A2 $735.25 $975.5937650 A2 $1,190.36 $1,579.4637700 A2 $1,190.36 $1,579.4637718 A2 $1,190.36 $1,579.4637722 A2 $1,190.36 $1,579.4637735 A2 $1,190.36 $1,579.4637760 A2 $1,190.36 $1,579.4637761 R2 $1,190.36 $1,579.4637765 P3 $342.98 $455.0937766 P3 $386.30 $512.5737780 A2 $1,190.36 $1,579.4637785 A2 $1,190.36 $1,579.4637790 A2 $1,225.15 $1,625.6338200 N1 $0.00 $0.0038204 N1 $0.00 $0.0038206 G2 $578.48 $767.5738220 P3 $123.51 $163.8838221 P3 $117.79 $156.2938230 G2 $1,559.83 $2,069.7138232 G2 $1,559.83 $2,069.7138241 G2 $1,559.83 $2,069.7138242 R2 $578.48 $767.5738243 R2 $578.48 $767.5738300 A2 $474.65 $629.8038305 A2 $896.60 $1,189.6838308 A2 $1,285.06 $1,705.1238500 A2 $1,285.06 $1,705.1238505 A2 $576.97 $765.5738510 A2 $1,285.06 $1,705.1238520 A2 $1,285.06 $1,705.1238525 A2 $1,285.06 $1,705.1238530 A2 $1,285.06 $1,705.1238542 A2 $2,323.80 $3,083.4038550 A2 $1,285.06 $1,705.1238555 A2 $1,285.06 $1,705.1238570 A2 $2,071.55 $2,748.7038571 A2 $3,003.21 $3,984.9038572 A2 $2,071.55 $2,748.7038700 G2 $1,285.06 $1,705.1238740 A2 $2,323.80 $3,083.4038745 A2 $2,323.80 $3,083.4038760 A2 $1,285.06 $1,705.1238790 N1 $0.00 $0.0038792 N1 $0.00 $0.0038794 N1 $0.00 $0.0038900 N1 $0.00 $0.0040490 P3 $81.98 $108.7840500 A2 $694.39 $921.3740510 A2 $1,066.74 $1,415.4440520 A2 $694.39 $921.3740525 A2 $1,066.74 $1,415.4440527 A2 $2,044.49 $2,712.7940530 A2 $1,066.74 $1,415.4440650 A2 $354.45 $470.3140652 A2 $354.45 $470.31



1

2

A B C D

HCPCS




21312132213321342135213621372138213921402141214221432144214521462147214821492150215121522153215421552156215721582159216021612162216321642165216621672168216921702171217221732174217521762177217821792180218121822183218421852186

40654 A2 $354.45 $470.3140700 A2 $2,044.49 $2,712.7940701 A2 $2,044.49 $2,712.7940702 R2 $2,044.49 $2,712.7940720 A2 $2,044.49 $2,712.7940761 A2 $2,044.49 $2,712.7940800 P2 $88.78 $117.8040801 A2 $354.45 $470.3140804 N1 $0.00 $0.0040805 P3 $221.25 $293.5740806 P3 $98.81 $131.1140808 P3 $153.23 $203.3240810 P3 $159.32 $211.4040812 P3 $203.35 $269.8240814 A2 $1,066.74 $1,415.4440816 A2 $1,066.74 $1,415.4440818 A2 $199.13 $264.2240819 A2 $694.39 $921.3740820 P3 $222.68 $295.4740830 G2 $199.13 $264.2240831 A2 $354.45 $470.3140840 A2 $1,066.74 $1,415.4440842 A2 $2,044.49 $2,712.7940843 A2 $1,066.74 $1,415.4440844 A2 $2,044.49 $2,712.7940845 A2 $2,044.49 $2,712.7941000 P3 $113.85 $151.0741005 A2 $199.13 $264.2241006 A2 $1,066.74 $1,415.4441007 A2 $1,066.74 $1,415.4441008 A2 $694.39 $921.3741009 A2 $199.13 $264.2241010 A2 $354.45 $470.3141015 A2 $199.13 $264.2241016 A2 $1,066.74 $1,415.4441017 A2 $694.39 $921.3741018 A2 $354.45 $470.3141019 G2 $1,066.74 $1,415.4441100 P3 $116.35 $154.3841105 P3 $117.43 $155.8241108 P3 $108.84 $144.4241110 P3 $156.81 $208.0741112 A2 $694.39 $921.3741113 A2 $694.39 $921.3741114 A2 $1,066.74 $1,415.4441115 P3 $183.30 $243.2241116 A2 $1,066.74 $1,415.4441120 A2 $2,044.49 $2,712.7941250 A2 $71.10 $94.3441251 A2 $199.13 $264.2241252 A2 $354.45 $470.3141500 A2 $694.39 $921.3741510 A2 $694.39 $921.3741512 G2 $2,044.49 $2,712.7941520 A2 $2,044.49 $2,712.7941530 P2 $1,066.74 $1,415.44



1

2

A B C D

HCPCS




21872188218921902191219221932194219521962197219821992200220122022203220422052206220722082209221022112212221322142215221622172218221922202221222222232224222522262227222822292230223122322233223422352236223722382239224022412242

41800 A2 $88.78 $117.8041805 P3 $203.71 $270.3041806 P3 $255.26 $338.7041820 R2 $1,066.74 $1,415.4441821 G2 $354.45 $470.3141822 P3 $224.12 $297.3841823 P3 $317.20 $420.8941825 P3 $162.90 $216.1541826 P3 $229.84 $304.9741827 A2 $2,044.49 $2,712.7941828 P3 $191.54 $254.1541830 P3 $268.87 $356.7641850 R2 $1,066.74 $1,415.4441870 G2 $2,044.49 $2,712.7941872 P3 $265.29 $352.0141874 P3 $262.78 $348.6842000 A2 $199.13 $264.2242100 P3 $100.24 $133.0142104 P3 $154.66 $205.2242106 P3 $196.91 $261.2842107 A2 $2,044.49 $2,712.7942120 A2 $1,066.74 $1,415.4442140 A2 $694.39 $921.3742145 A2 $2,044.49 $2,712.7942160 P3 $165.76 $219.9442180 A2 $199.13 $264.2242182 A2 $1,066.74 $1,415.4442200 A2 $2,044.49 $2,712.7942205 A2 $2,044.49 $2,712.7942210 A2 $2,044.49 $2,712.7942215 A2 $2,044.49 $2,712.7942220 A2 $2,044.49 $2,712.7942225 G2 $2,044.49 $2,712.7942226 A2 $2,044.49 $2,712.7942227 G2 $2,044.49 $2,712.7942235 A2 $2,044.49 $2,712.7942260 A2 $1,066.74 $1,415.4442280 P3 $105.26 $139.6742281 G2 $694.39 $921.3742300 A2 $354.45 $470.3142305 A2 $1,066.74 $1,415.4442310 A2 $199.13 $264.2242320 A2 $199.13 $264.2242330 P3 $148.58 $197.1542335 P3 $248.82 $330.1542340 A2 $694.39 $921.3742400 P3 $78.40 $104.0342405 A2 $1,066.74 $1,415.4442408 A2 $1,066.74 $1,415.4442409 A2 $1,066.74 $1,415.4442410 A2 $2,044.49 $2,712.7942415 A2 $2,044.49 $2,712.7942420 A2 $2,044.49 $2,712.7942425 A2 $2,044.49 $2,712.7942440 A2 $2,044.49 $2,712.7942450 A2 $2,044.49 $2,712.79



1

2

A B C D

HCPCS




22432244224522462247224822492250225122522253225422552256225722582259226022612262226322642265226622672268226922702271227222732274227522762277227822792280228122822283228422852286228722882289229022912292229322942295229622972298

42500 A2 $1,066.74 $1,415.4442505 A2 $2,044.49 $2,712.7942507 A2 $2,044.49 $2,712.7942508 D5 $0.00 $0.0042509 A2 $2,044.49 $2,712.7942510 A2 $2,044.49 $2,712.7942550 N1 $0.00 $0.0042600 A2 $694.39 $921.3742650 P3 $55.13 $73.1542660 P3 $79.12 $104.9842665 A2 $2,044.49 $2,712.7942700 A2 $199.13 $264.2242720 A2 $694.39 $921.3742725 A2 $2,044.49 $2,712.7942800 P3 $105.26 $139.6742804 A2 $694.39 $921.3742806 A2 $1,066.74 $1,415.4442808 A2 $1,066.74 $1,415.4442809 N1 $0.00 $0.0042810 A2 $1,066.74 $1,415.4442815 A2 $2,044.49 $2,712.7942820 A2 $1,066.74 $1,415.4442821 A2 $1,066.74 $1,415.4442825 A2 $2,044.49 $2,712.7942826 A2 $1,066.74 $1,415.4442830 A2 $2,044.49 $2,712.7942831 A2 $1,066.74 $1,415.4442835 A2 $1,066.74 $1,415.4442836 A2 $1,066.74 $1,415.4442860 A2 $2,044.49 $2,712.7942870 A2 $1,066.74 $1,415.4442890 A2 $2,044.49 $2,712.7942892 A2 $2,044.49 $2,712.7942900 A2 $1,066.74 $1,415.4442950 A2 $2,044.49 $2,712.7942955 A2 $1,066.74 $1,415.4442960 A2 $71.10 $94.3442962 A2 $1,066.74 $1,415.4442970 R2 $71.10 $94.3442972 A2 $694.39 $921.3743030 G2 $2,044.49 $2,712.7943130 G2 $2,044.49 $2,712.7943180 G2 $1,066.74 $1,415.4443191 G2 $408.68 $542.2743192 G2 $583.67 $774.4643193 G2 $583.67 $774.4643194 G2 $583.67 $774.4643195 G2 $583.67 $774.4643196 G2 $583.67 $774.4643197 G2 $408.68 $542.2743198 G2 $408.68 $542.2743200 A2 $408.68 $542.2743201 A2 $583.67 $774.4643202 A2 $408.68 $542.2743204 A2 $408.68 $542.2743205 A2 $583.67 $774.46



1

2

A B C D

HCPCS




22992300230123022303230423052306230723082309231023112312231323142315231623172318231923202321232223232324232523262327232823292330233123322333233423352336233723382339234023412342234323442345234623472348234923502351235223532354

43206 G2 $583.67 $774.4643211 G2 $583.67 $774.4643212 G2 $1,313.33 $1,742.6343213 G2 $583.67 $774.4643214 G2 $583.67 $774.4643215 A2 $583.67 $774.4643216 A2 $1,049.73 $1,392.8743217 A2 $583.67 $774.4643220 A2 $583.67 $774.4643226 A2 $583.67 $774.4643227 A2 $583.67 $774.4643229 G2 $1,049.73 $1,392.8743231 A2 $583.67 $774.4643232 A2 $583.67 $774.4643233 G2 $583.67 $774.4643235 A2 $408.68 $542.2743236 A2 $408.68 $542.2743237 A2 $583.67 $774.4643238 A2 $583.67 $774.4643239 A2 $408.68 $542.2743240 A2 $1,049.73 $1,392.8743241 A2 $408.68 $542.2743242 A2 $583.67 $774.4643243 A2 $408.68 $542.2743244 A2 $583.67 $774.4643245 A2 $583.67 $774.4643246 A2 $583.67 $774.4643247 A2 $408.68 $542.2743248 A2 $408.68 $542.2743249 A2 $583.67 $774.4643250 A2 $583.67 $774.4643251 A2 $583.67 $774.4643252 G2 $583.67 $774.4643253 G2 $583.67 $774.4643254 G2 $583.67 $774.4643255 A2 $583.67 $774.4643257 A2 $1,049.73 $1,392.8743259 A2 $583.67 $774.4643260 A2 $1,070.51 $1,420.4443261 A2 $1,070.51 $1,420.4443262 A2 $1,070.51 $1,420.4443263 A2 $1,070.51 $1,420.4443264 A2 $1,070.51 $1,420.4443265 A2 $1,070.51 $1,420.4443266 G2 $1,313.33 $1,742.6343270 G2 $583.67 $774.4643273 N1 $0.00 $0.0043274 G2 $1,313.33 $1,742.6343275 G2 $1,070.51 $1,420.4443276 G2 $1,313.33 $1,742.6343277 G2 $1,070.51 $1,420.4443278 G2 $1,070.51 $1,420.4443450 A2 $408.68 $542.2743453 A2 $583.67 $774.4643653 A2 $2,071.55 $2,748.7043752 G2 $82.76 $109.81



1

2

A B C D

HCPCS




23552356235723582359236023612362236323642365236623672368236923702371237223732374237523762377237823792380238123822383238423852386238723882389239023912392239323942395239623972398239924002401240224032404240524062407240824092410

43753 N1 $0.00 $0.0043754 N1 $0.00 $0.0043755 G2 $180.75 $239.8343756 G2 $87.44 $116.0243757 G2 $87.44 $116.0243760 A2 $106.99 $141.9643761 A2 $408.68 $542.2743870 A2 $1,049.73 $1,392.8743886 G2 $1,261.51 $1,673.8743887 G2 $771.43 $1,023.6043888 G2 $1,261.51 $1,673.8744100 A2 $583.67 $774.4644312 A2 $1,261.51 $1,673.8744340 A2 $1,261.51 $1,673.8744360 A2 $467.23 $619.9644361 A2 $467.23 $619.9644363 A2 $467.23 $619.9644364 A2 $684.82 $908.6744365 A2 $684.82 $908.6744366 A2 $684.82 $908.6744369 A2 $684.82 $908.6744370 A2 $1,313.33 $1,742.6344372 A2 $684.82 $908.6744373 A2 $684.82 $908.6744376 A2 $467.23 $619.9644377 A2 $684.82 $908.6744378 A2 $684.82 $908.6744379 A2 $1,313.33 $1,742.6344380 A2 $467.23 $619.9644381 G2 $467.23 $619.9644382 A2 $467.23 $619.9644383 D5 $0.00 $0.0044384 G2 $467.23 $619.9644385 A2 $432.94 $574.4644386 A2 $432.94 $574.4644388 A2 $432.94 $574.4644389 A2 $432.94 $574.4644390 A2 $432.94 $574.4644391 A2 $432.94 $574.4644392 A2 $432.94 $574.4644393 D5 $0.00 $0.0044394 A2 $432.94 $574.4644397 D5 $0.00 $0.0044401 G2 $432.94 $574.4644402 G2 $432.94 $574.4644403 G2 $432.94 $574.4644404 G2 $432.94 $574.4644405 G2 $432.94 $574.4644406 G2 $432.94 $574.4644407 G2 $432.94 $574.4644408 G2 $432.94 $574.4644500 G2 $267.52 $354.9744701 N1 $0.00 $0.0045000 A2 $1,064.13 $1,411.9745005 A2 $797.60 $1,058.3245020 A2 $797.60 $1,058.32



1

2

A B C D

HCPCS




24112412241324142415241624172418241924202421242224232424242524262427242824292430243124322433243424352436243724382439244024412442244324442445244624472448244924502451245224532454245524562457245824592460246124622463246424652466

45100 A2 $797.60 $1,058.3245108 A2 $1,064.13 $1,411.9745150 A2 $1,064.13 $1,411.9745160 A2 $1,064.13 $1,411.9745171 G2 $1,064.13 $1,411.9745172 G2 $1,425.69 $1,891.7245190 A2 $1,064.13 $1,411.9745300 P3 $93.08 $123.5145303 P2 $453.53 $601.7845305 A2 $453.53 $601.7845307 A2 $908.60 $1,205.6045308 A2 $453.53 $601.7845309 A2 $453.53 $601.7845315 A2 $453.53 $601.7845317 A2 $453.53 $601.7845320 A2 $908.60 $1,205.6045321 A2 $908.60 $1,205.6045327 A2 $1,313.33 $1,742.6345330 P3 $99.89 $132.5445331 A2 $270.60 $359.0545332 A2 $453.53 $601.7845333 A2 $270.60 $359.0545334 A2 $453.53 $601.7845335 A2 $270.60 $359.0545337 A2 $453.53 $601.7845338 A2 $453.53 $601.7845339 D5 $0.00 $0.0045340 A2 $453.53 $601.7845341 A2 $453.53 $601.7845342 A2 $453.53 $601.7845345 D5 $0.00 $0.0045346 G2 $453.53 $601.7845347 G2 $453.53 $601.7845349 G2 $453.53 $601.7845350 G2 $453.53 $601.7845355 D5 $0.00 $0.0045378 A2 $432.94 $574.4645379 A2 $432.94 $574.4645380 A2 $432.94 $574.4645381 A2 $432.94 $574.4645382 A2 $432.94 $574.4645383 D5 $0.00 $0.0045384 A2 $432.94 $574.4645385 A2 $432.94 $574.4645386 A2 $432.94 $574.4645387 D5 $0.00 $0.0045388 G2 $432.94 $574.4645389 G2 $432.94 $574.4645390 G2 $432.94 $574.4645391 A2 $432.94 $574.4645392 A2 $432.94 $574.4645393 G2 $432.94 $574.4645398 G2 $432.94 $574.4645500 A2 $1,064.13 $1,411.9745505 A2 $1,425.69 $1,891.7245520 P2 $80.10 $106.28



1

2

A B C D

HCPCS




24672468246924702471247224732474247524762477247824792480248124822483248424852486248724882489249024912492249324942495249624972498249925002501250225032504250525062507250825092510251125122513251425152516251725182519252025212522

45541 G2 $1,425.69 $1,891.7245560 A2 $1,425.69 $1,891.7245900 A2 $242.54 $321.8245905 A2 $797.60 $1,058.3245910 A2 $797.60 $1,058.3245915 A2 $797.60 $1,058.3245990 A2 $797.60 $1,058.3246020 A2 $1,064.13 $1,411.9746030 A2 $242.54 $321.8246040 A2 $797.60 $1,058.3246045 A2 $1,064.13 $1,411.9746050 A2 $242.54 $321.8246060 A2 $797.60 $1,058.3246070 G2 $797.60 $1,058.3246080 A2 $797.60 $1,058.3246083 P2 $117.18 $155.4846200 A2 $1,064.13 $1,411.9746220 A2 $797.60 $1,058.3246221 P3 $179.36 $237.9946230 A2 $797.60 $1,058.3246250 A2 $1,064.13 $1,411.9746255 A2 $1,064.13 $1,411.9746257 A2 $1,064.13 $1,411.9746258 A2 $1,064.13 $1,411.9746260 A2 $1,064.13 $1,411.9746261 A2 $1,064.13 $1,411.9746262 A2 $1,064.13 $1,411.9746270 A2 $1,064.13 $1,411.9746275 A2 $1,064.13 $1,411.9746280 A2 $1,064.13 $1,411.9746285 A2 $1,064.13 $1,411.9746288 A2 $1,425.69 $1,891.7246320 P3 $118.50 $157.2446500 P3 $175.43 $232.7746505 G2 $797.60 $1,058.3246600 N1 $0.00 $0.0046601 N1 $0.00 $0.0046604 P2 $453.53 $601.7846606 P3 $180.80 $239.9046607 G2 $453.53 $601.7846608 A2 $453.53 $601.7846610 A2 $908.60 $1,205.6046611 A2 $453.53 $601.7846612 A2 $908.60 $1,205.6046614 P3 $90.58 $120.1946615 A2 $908.60 $1,205.6046700 A2 $1,064.13 $1,411.9746706 A2 $1,064.13 $1,411.9746707 G2 $1,425.69 $1,891.7246750 A2 $1,425.69 $1,891.7246753 A2 $1,064.13 $1,411.9746754 A2 $797.60 $1,058.3246760 A2 $1,425.69 $1,891.7246761 A2 $1,425.69 $1,891.7246762 A2 $1,425.69 $1,891.7246900 P2 $155.20 $205.93



1

2

A B C D

HCPCS




25232524252525262527252825292530253125322533253425352536253725382539254025412542254325442545254625472548254925502551255225532554255525562557255825592560256125622563256425652566256725682569257025712572257325742575257625772578

46910 P3 $182.23 $241.8046916 P2 $80.10 $106.2846917 A2 $1,064.13 $1,411.9746922 A2 $1,064.13 $1,411.9746924 A2 $1,064.13 $1,411.9746930 P3 $146.07 $193.8246940 P3 $138.55 $183.8446942 P3 $137.84 $182.9046945 P3 $223.04 $295.9546946 A2 $1,064.13 $1,411.9746947 A2 $1,425.69 $1,891.7247000 A2 $576.97 $765.5747001 N1 $0.00 $0.0047382 G2 $2,245.03 $2,978.8947383 G2 $2,245.03 $2,978.8947500 N1 $0.00 $0.0047505 N1 $0.00 $0.0047510 A2 $1,004.97 $1,333.4747511 A2 $2,245.03 $2,978.8947525 A2 $706.56 $937.5247530 A2 $706.56 $937.5247552 A2 $1,004.97 $1,333.4747553 A2 $2,245.03 $2,978.8947554 A2 $1,004.97 $1,333.4747555 A2 $1,004.97 $1,333.4747556 A2 $2,245.03 $2,978.8947560 A2 $1,653.63 $2,194.1747561 A2 $1,653.63 $2,194.1747562 G2 $2,071.55 $2,748.7047563 G2 $2,071.55 $2,748.7047564 G2 $2,071.55 $2,748.7047630 A2 $1,004.97 $1,333.4748102 A2 $576.97 $765.5749082 G2 $268.22 $355.9049083 G2 $268.22 $355.9049084 G2 $268.22 $355.9049180 A2 $576.97 $765.5749250 A2 $1,252.95 $1,662.5149320 A2 $1,653.63 $2,194.1749321 A2 $1,653.63 $2,194.1749322 A2 $1,653.63 $2,194.1749324 G2 $1,653.63 $2,194.1749325 G2 $1,653.63 $2,194.1749326 N1 $0.00 $0.0049327 N1 $0.00 $0.0049400 N1 $0.00 $0.0049402 A2 $1,252.95 $1,662.5149407 G2 $576.97 $765.5749411 P3 $409.57 $543.4549418 G2 $1,254.22 $1,664.2049419 A2 $1,225.74 $1,626.4149421 G2 $1,254.22 $1,664.2049422 A2 $863.86 $1,146.2449423 G2 $706.56 $937.5249424 N1 $0.00 $0.0049426 A2 $1,252.95 $1,662.51



1

2

A B C D

HCPCS




25792580258125822583258425852586258725882589259025912592259325942595259625972598259926002601260226032604260526062607260826092610261126122613261426152616261726182619262026212622262326242625262626272628262926302631263226332634

49427 N1 $0.00 $0.0049429 G2 $863.86 $1,146.2449435 N1 $0.00 $0.0049436 G2 $706.56 $937.5249440 G2 $583.67 $774.4649441 G2 $583.67 $774.4649442 G2 $797.60 $1,058.3249446 G2 $583.67 $774.4649450 G2 $267.52 $354.9749451 G2 $267.52 $354.9749452 G2 $267.52 $354.9749460 G2 $267.52 $354.9749465 G2 $82.76 $109.8149495 A2 $1,466.45 $1,945.8049496 A2 $1,466.45 $1,945.8049500 A2 $1,466.45 $1,945.8049501 A2 $1,466.45 $1,945.8049505 A2 $1,466.45 $1,945.8049507 A2 $1,466.45 $1,945.8049520 A2 $1,466.45 $1,945.8049521 A2 $1,466.45 $1,945.8049525 A2 $1,466.45 $1,945.8049540 A2 $1,466.45 $1,945.8049550 A2 $1,466.45 $1,945.8049553 A2 $1,466.45 $1,945.8049555 A2 $1,466.45 $1,945.8049557 A2 $1,466.45 $1,945.8049560 A2 $1,466.45 $1,945.8049561 A2 $1,466.45 $1,945.8049565 A2 $1,466.45 $1,945.8049566 A2 $1,466.45 $1,945.8049568 N1 $0.00 $0.0049570 A2 $1,466.45 $1,945.8049572 A2 $1,466.45 $1,945.8049580 A2 $1,466.45 $1,945.8049582 A2 $1,466.45 $1,945.8049585 A2 $1,466.45 $1,945.8049587 A2 $1,466.45 $1,945.8049590 A2 $1,466.45 $1,945.8049600 A2 $1,466.45 $1,945.8049650 A2 $2,071.55 $2,748.7049651 A2 $2,071.55 $2,748.7049652 G2 $3,003.21 $3,984.9049653 G2 $3,003.21 $3,984.9049654 G2 $3,003.21 $3,984.9049655 G2 $3,003.21 $3,984.9049656 G2 $3,003.21 $3,984.9049657 G2 $3,003.21 $3,984.9050080 G2 $1,706.71 $2,264.6050081 G2 $1,706.71 $2,264.6050200 A2 $576.97 $765.5750382 G2 $1,142.74 $1,516.2850384 G2 $672.51 $892.3450385 G2 $1,142.74 $1,516.2850386 P2 $300.88 $399.2350387 G2 $706.56 $937.52



1

2

A B C D

HCPCS




26352636263726382639264026412642264326442645264626472648264926502651265226532654265526562657265826592660266126622663266426652666266726682669267026712672267326742675267626772678267926802681268226832684268526862687268826892690

50389 G2 $300.88 $399.2350390 A2 $576.97 $765.5750391 P3 $47.62 $63.1950392 A2 $672.51 $892.3450393 A2 $1,142.74 $1,516.2850394 N1 $0.00 $0.0050395 A2 $1,142.74 $1,516.2850396 A2 $117.18 $155.4850398 A2 $706.56 $937.5250551 A2 $300.88 $399.2350553 A2 $1,142.74 $1,516.2850555 A2 $300.88 $399.2350557 A2 $1,142.74 $1,516.2850561 A2 $1,142.74 $1,516.2850562 G2 $300.88 $399.2350570 G2 $300.88 $399.2350572 G2 $300.88 $399.2350574 G2 $300.88 $399.2350575 G2 $1,706.71 $2,264.6050576 G2 $672.51 $892.3450580 G2 $672.51 $892.3450590 G2 $1,706.71 $2,264.6050592 G2 $2,245.03 $2,978.8950593 G2 $2,245.03 $2,978.8950684 N1 $0.00 $0.0050686 P2 $62.07 $82.3650688 A2 $706.56 $937.5250690 N1 $0.00 $0.0050727 G2 $754.08 $1,000.5750947 A2 $2,071.55 $2,748.7050948 A2 $2,071.55 $2,748.7050951 A2 $300.88 $399.2350953 A2 $300.88 $399.2350955 A2 $1,142.74 $1,516.2850957 A2 $1,142.74 $1,516.2850961 A2 $1,142.74 $1,516.2850970 A2 $300.88 $399.2350972 A2 $300.88 $399.2350974 A2 $672.51 $892.3450976 A2 $672.51 $892.3450980 A2 $1,142.74 $1,516.2851020 A2 $1,142.74 $1,516.2851030 A2 $1,142.74 $1,516.2851040 A2 $1,142.74 $1,516.2851045 A2 $300.88 $399.2351050 A2 $1,142.74 $1,516.2851065 A2 $1,142.74 $1,516.2851080 A2 $896.60 $1,189.6851100 P3 $32.22 $42.7551101 P2 $62.07 $82.3651102 A2 $754.08 $1,000.5751500 A2 $1,466.45 $1,945.8051520 A2 $1,142.74 $1,516.2851535 G2 $1,142.74 $1,516.2851600 N1 $0.00 $0.0051605 N1 $0.00 $0.00



1

2

A B C D

HCPCS




26912692269326942695269626972698269927002701270227032704270527062707270827092710271127122713271427152716271727182719272027212722272327242725272627272728272927302731273227332734273527362737273827392740274127422743274427452746

51610 N1 $0.00 $0.0051700 P3 $49.41 $65.5651701 N1 $0.00 $0.0051702 N1 $0.00 $0.0051703 P2 $62.07 $82.3651705 P3 $56.57 $75.0651710 A2 $267.52 $354.9751715 A2 $1,375.54 $1,825.1851720 P3 $51.20 $67.9451725 P3 $110.63 $146.7951726 A2 $204.89 $271.8651727 P3 $204.78 $271.7251728 P2 $204.89 $271.8651729 P2 $204.89 $271.8651736 N1 $0.00 $0.0051741 P3 $7.16 $9.5051784 P2 $62.07 $82.3651785 A2 $117.18 $155.4851792 P2 $62.07 $82.3651797 N1 $0.00 $0.0051798 N1 $0.00 $0.0051880 A2 $1,142.74 $1,516.2851992 A2 $2,071.55 $2,748.7052000 A2 $300.88 $399.2352001 A2 $672.51 $892.3452005 A2 $1,142.74 $1,516.2852007 A2 $1,142.74 $1,516.2852010 A2 $300.88 $399.2352204 A2 $1,142.74 $1,516.2852214 A2 $1,142.74 $1,516.2852224 A2 $1,142.74 $1,516.2852234 A2 $1,142.74 $1,516.2852235 A2 $1,142.74 $1,516.2852240 A2 $1,142.74 $1,516.2852250 A2 $1,142.74 $1,516.2852260 A2 $672.51 $892.3452265 P3 $253.47 $336.3252270 A2 $672.51 $892.3452275 A2 $1,142.74 $1,516.2852276 A2 $1,142.74 $1,516.2852277 A2 $1,142.74 $1,516.2852281 A2 $672.51 $892.3452282 A2 $1,142.74 $1,516.2852283 A2 $1,142.74 $1,516.2852285 A2 $672.51 $892.3452287 G2 $672.51 $892.3452290 A2 $1,142.74 $1,516.2852300 A2 $1,142.74 $1,516.2852301 A2 $1,142.74 $1,516.2852305 A2 $1,142.74 $1,516.2852310 A2 $672.51 $892.3452315 A2 $1,142.74 $1,516.2852317 A2 $1,142.74 $1,516.2852318 A2 $1,142.74 $1,516.2852320 A2 $1,142.74 $1,516.2852325 A2 $1,142.74 $1,516.28



1

2

A B C D

HCPCS




27472748274927502751275227532754275527562757275827592760276127622763276427652766276727682769277027712772277327742775277627772778277927802781278227832784278527862787278827892790279127922793279427952796279727982799280028012802

52327 A2 $1,706.71 $2,264.6052330 A2 $1,142.74 $1,516.2852332 A2 $1,142.74 $1,516.2852334 A2 $1,142.74 $1,516.2852341 A2 $1,142.74 $1,516.2852342 A2 $1,142.74 $1,516.2852343 A2 $1,142.74 $1,516.2852344 A2 $1,142.74 $1,516.2852345 A2 $1,142.74 $1,516.2852346 A2 $1,142.74 $1,516.2852351 A2 $1,142.74 $1,516.2852352 A2 $1,142.74 $1,516.2852353 A2 $1,706.71 $2,264.6052354 A2 $1,142.74 $1,516.2852355 A2 $1,142.74 $1,516.2852356 G2 $1,706.71 $2,264.6052400 A2 $1,142.74 $1,516.2852402 A2 $1,142.74 $1,516.2852450 A2 $1,142.74 $1,516.2852500 A2 $1,142.74 $1,516.2852601 A2 $1,706.71 $2,264.6052630 A2 $1,706.71 $2,264.6052640 A2 $1,142.74 $1,516.2852647 A2 $1,706.71 $2,264.6052648 A2 $1,706.71 $2,264.6052649 G2 $1,706.71 $2,264.6052700 A2 $1,142.74 $1,516.2853000 A2 $892.75 $1,184.5753010 A2 $892.75 $1,184.5753020 A2 $892.75 $1,184.5753025 R2 $892.75 $1,184.5753040 A2 $892.75 $1,184.5753060 P3 $80.55 $106.8853080 A2 $892.75 $1,184.5753085 G2 $892.75 $1,184.5753200 A2 $892.75 $1,184.5753210 A2 $1,375.54 $1,825.1853215 A2 $892.75 $1,184.5753220 A2 $1,375.54 $1,825.1853230 A2 $1,375.54 $1,825.1853235 A2 $892.75 $1,184.5753240 A2 $1,375.54 $1,825.1853250 A2 $892.75 $1,184.5753260 A2 $892.75 $1,184.5753265 A2 $892.75 $1,184.5753270 A2 $892.75 $1,184.5753275 A2 $892.75 $1,184.5753400 A2 $1,375.54 $1,825.1853405 A2 $1,375.54 $1,825.1853410 A2 $1,375.54 $1,825.1853420 A2 $1,375.54 $1,825.1853425 A2 $1,375.54 $1,825.1853430 A2 $1,375.54 $1,825.1853431 A2 $1,375.54 $1,825.1853440 J8 $6,627.11 $8,793.3853442 A2 $1,375.54 $1,825.18



1

2

A B C D

HCPCS




28032804280528062807280828092810281128122813281428152816281728182819282028212822282328242825282628272828282928302831283228332834283528362837283828392840284128422843284428452846284728482849285028512852285328542855285628572858

53444 J8 $6,627.11 $8,793.3853445 J8 $11,765.30 $15,611.1453446 A2 $1,375.54 $1,825.1853447 J8 $11,765.30 $15,611.1453449 A2 $1,375.54 $1,825.1853450 A2 $1,375.54 $1,825.1853460 A2 $892.75 $1,184.5753502 A2 $892.75 $1,184.5753505 A2 $1,375.54 $1,825.1853510 A2 $892.75 $1,184.5753515 A2 $1,375.54 $1,825.1853520 A2 $1,375.54 $1,825.1853600 P3 $36.52 $48.4653601 P3 $43.32 $57.4853605 A2 $672.51 $892.3453620 P3 $53.70 $71.2553621 P3 $57.64 $76.4853660 P3 $43.32 $57.4853661 P3 $41.53 $55.1153665 A2 $892.75 $1,184.5753850 P2 $672.51 $892.3453852 P3 $1,500.43 $1,990.8953855 P2 $300.88 $399.2353860 P2 $754.08 $1,000.5754000 A2 $892.75 $1,184.5754001 A2 $892.75 $1,184.5754015 A2 $896.60 $1,189.6854050 P2 $80.10 $106.2854055 P3 $70.89 $94.0654056 N1 $0.00 $0.0054057 A2 $705.82 $936.5454060 A2 $705.82 $936.5454065 A2 $705.82 $936.5454100 A2 $735.25 $975.5954105 A2 $999.94 $1,326.8054110 A2 $1,872.55 $2,484.6554111 A2 $1,872.55 $2,484.6554112 A2 $1,872.55 $2,484.6554115 A2 $896.60 $1,189.6854120 A2 $1,225.15 $1,625.6354150 A2 $993.29 $1,317.9854160 A2 $993.29 $1,317.9854161 A2 $993.29 $1,317.9854162 A2 $993.29 $1,317.9854163 A2 $993.29 $1,317.9854164 A2 $993.29 $1,317.9854200 P3 $64.80 $85.9854205 A2 $1,225.15 $1,625.6354220 A2 $117.18 $155.4854230 N1 $0.00 $0.0054231 P3 $61.94 $82.1954235 P3 $44.75 $59.3854240 P3 $35.09 $46.5654250 P3 $10.74 $14.2554300 A2 $1,872.55 $2,484.6554304 A2 $1,872.55 $2,484.65



1

2

A B C D

HCPCS




28592860286128622863286428652866286728682869287028712872287328742875287628772878287928802881288228832884288528862887288828892890289128922893289428952896289728982899290029012902290329042905290629072908290929102911291229132914

54308 A2 $1,872.55 $2,484.6554312 A2 $1,225.15 $1,625.6354316 A2 $1,225.15 $1,625.6354318 A2 $1,225.15 $1,625.6354322 A2 $1,225.15 $1,625.6354324 A2 $1,872.55 $2,484.6554326 A2 $1,225.15 $1,625.6354328 A2 $1,872.55 $2,484.6554340 A2 $1,225.15 $1,625.6354344 A2 $1,225.15 $1,625.6354348 A2 $1,225.15 $1,625.6354352 A2 $1,872.55 $2,484.6554360 A2 $1,872.55 $2,484.6554380 A2 $1,225.15 $1,625.6354385 A2 $1,225.15 $1,625.6354400 J8 $6,627.11 $8,793.3854401 J8 $11,765.30 $15,611.1454405 J8 $11,765.30 $15,611.1454406 A2 $1,225.15 $1,625.6354408 A2 $1,872.55 $2,484.6554410 J8 $11,765.30 $15,611.1454415 A2 $1,225.15 $1,625.6354416 J8 $11,765.30 $15,611.1454420 A2 $1,225.15 $1,625.6354435 A2 $1,225.15 $1,625.6354440 A2 $1,225.15 $1,625.6354450 A2 $117.18 $155.4854500 A2 $576.97 $765.5754505 A2 $993.29 $1,317.9854512 A2 $993.29 $1,317.9854520 A2 $1,225.15 $1,625.6354522 A2 $993.29 $1,317.9854530 A2 $1,466.45 $1,945.8054550 A2 $1,466.45 $1,945.8054560 G2 $993.29 $1,317.9854600 A2 $993.29 $1,317.9854620 A2 $993.29 $1,317.9854640 A2 $1,466.45 $1,945.8054660 A2 $993.29 $1,317.9854670 A2 $993.29 $1,317.9854680 A2 $993.29 $1,317.9854690 A2 $2,071.55 $2,748.7054692 G2 $3,003.21 $3,984.9054700 A2 $993.29 $1,317.9854800 A2 $267.12 $354.4454830 A2 $993.29 $1,317.9854840 A2 $993.29 $1,317.9854860 A2 $993.29 $1,317.9854861 A2 $993.29 $1,317.9854865 A2 $993.29 $1,317.9854900 A2 $993.29 $1,317.9854901 A2 $993.29 $1,317.9855000 P3 $61.94 $82.1955040 A2 $1,466.45 $1,945.8055041 A2 $1,466.45 $1,945.8055060 A2 $993.29 $1,317.98



1

2

A B C D

HCPCS




29152916291729182919292029212922292329242925292629272928292929302931293229332934293529362937293829392940294129422943294429452946294729482949295029512952295329542955295629572958295929602961296229632964296529662967296829692970

55100 A2 $474.65 $629.8055110 A2 $993.29 $1,317.9855120 A2 $993.29 $1,317.9855150 A2 $993.29 $1,317.9855175 A2 $1,872.55 $2,484.6555180 A2 $993.29 $1,317.9855200 A2 $993.29 $1,317.9855250 A2 $993.29 $1,317.9855300 N1 $0.00 $0.0055400 A2 $993.29 $1,317.9855450 P3 $189.03 $250.8255500 A2 $1,225.15 $1,625.6355520 A2 $993.29 $1,317.9855530 A2 $993.29 $1,317.9855535 A2 $1,466.45 $1,945.8055540 A2 $1,466.45 $1,945.8055550 A2 $2,071.55 $2,748.7055600 R2 $993.29 $1,317.9855680 A2 $993.29 $1,317.9855700 A2 $801.51 $1,063.5155705 A2 $801.51 $1,063.5155706 G2 $801.51 $1,063.5155720 A2 $1,142.74 $1,516.2855725 A2 $1,142.74 $1,516.2855860 G2 $754.08 $1,000.5755870 P3 $76.61 $101.6555873 J8 $6,627.11 $8,793.3855875 A2 $1,142.74 $1,516.2855876 P3 $69.45 $92.1555920 G2 $1,252.95 $1,662.5156405 P3 $50.84 $67.4656420 P3 $65.52 $86.9456440 A2 $1,011.93 $1,342.7156441 A2 $1,011.93 $1,342.7156442 A2 $1,011.93 $1,342.7156501 P3 $68.74 $91.2156515 A2 $705.82 $936.5456605 P3 $39.02 $51.7756606 N1 $0.00 $0.0056620 A2 $1,011.93 $1,342.7156625 A2 $1,011.93 $1,342.7156700 A2 $1,011.93 $1,342.7156740 A2 $1,011.93 $1,342.7156800 A2 $1,011.93 $1,342.7156805 G2 $1,011.93 $1,342.7156810 A2 $1,011.93 $1,342.7156820 P3 $51.91 $68.8856821 P3 $66.23 $87.8857000 A2 $1,011.93 $1,342.7157010 A2 $1,011.93 $1,342.7157020 A2 $1,011.93 $1,342.7157022 R2 $474.65 $629.8057023 A2 $896.60 $1,189.6857061 P3 $62.65 $83.1357065 A2 $1,011.93 $1,342.7157100 P3 $41.17 $54.63



1

2

A B C D

HCPCS




29712972297329742975297629772978297929802981298229832984298529862987298829892990299129922993299429952996299729982999300030013002300330043005300630073008300930103011301230133014301530163017301830193020302130223023302430253026

57105 A2 $1,011.93 $1,342.7157130 A2 $1,011.93 $1,342.7157135 A2 $1,011.93 $1,342.7157150 P3 $23.63 $31.3557155 A2 $267.07 $354.3757156 G2 $123.96 $164.4857160 P3 $41.53 $55.1157170 P3 $25.06 $33.2557180 A2 $71.79 $95.2657200 A2 $1,011.93 $1,342.7157210 A2 $1,011.93 $1,342.7157220 A2 $1,813.15 $2,405.8357230 A2 $1,011.93 $1,342.7157240 A2 $1,813.15 $2,405.8357250 A2 $1,813.15 $2,405.8357260 A2 $1,813.15 $2,405.8357265 A2 $1,813.15 $2,405.8357267 N1 $0.00 $0.0057268 A2 $1,011.93 $1,342.7157287 G2 $1,011.93 $1,342.7157288 A2 $1,813.15 $2,405.8357289 A2 $1,813.15 $2,405.8357291 A2 $1,011.93 $1,342.7157295 G2 $1,011.93 $1,342.7157300 A2 $1,011.93 $1,342.7157320 G2 $1,813.15 $2,405.8357400 A2 $1,011.93 $1,342.7157410 A2 $1,011.93 $1,342.7157415 A2 $1,011.93 $1,342.7157420 P3 $53.34 $70.7857421 P3 $69.45 $92.1557426 G2 $1,813.15 $2,405.8357452 P3 $49.76 $66.0357454 P3 $61.58 $81.7157455 P3 $64.44 $85.5057456 P3 $61.94 $82.1957460 P3 $172.20 $228.4957461 P3 $185.45 $246.0757500 P3 $80.91 $107.3657505 P3 $55.13 $73.1557510 P3 $56.21 $74.5857511 P3 $68.74 $91.2157513 A2 $1,011.93 $1,342.7157520 A2 $1,011.93 $1,342.7157522 A2 $1,011.93 $1,342.7157530 A2 $1,011.93 $1,342.7157550 A2 $1,011.93 $1,342.7157556 A2 $1,813.15 $2,405.8357558 A2 $1,011.93 $1,342.7157700 A2 $1,011.93 $1,342.7157720 A2 $1,011.93 $1,342.7157800 P3 $30.43 $40.3858100 P3 $49.05 $65.0858110 N1 $0.00 $0.0058120 A2 $1,011.93 $1,342.7158145 A2 $1,011.93 $1,342.71



1

2

A B C D

HCPCS




30273028302930303031303230333034303530363037303830393040304130423043304430453046304730483049305030513052305330543055305630573058305930603061306230633064306530663067306830693070307130723073307430753076307730783079308030813082

58301 P3 $45.11 $59.8658321 P3 $40.46 $53.6958322 P3 $42.60 $56.5358323 P3 $6.44 $8.5558340 N1 $0.00 $0.0058345 R2 $1,011.93 $1,342.7158346 A2 $1,011.93 $1,342.7158350 A2 $1,813.15 $2,405.8358353 A2 $1,813.15 $2,405.8358356 P3 $1,637.91 $2,173.3158541 G2 $3,003.21 $3,984.9058542 G2 $3,003.21 $3,984.9058545 A2 $1,653.63 $2,194.1758546 A2 $2,071.55 $2,748.7058550 A2 $3,003.21 $3,984.9058552 G2 $2,071.55 $2,748.7058555 A2 $1,011.93 $1,342.7158558 A2 $1,011.93 $1,342.7158559 A2 $1,813.15 $2,405.8358560 A2 $1,813.15 $2,405.8358561 A2 $1,813.15 $2,405.8358562 A2 $1,011.93 $1,342.7158563 A2 $1,813.15 $2,405.8358565 A2 $1,813.15 $2,405.8358570 G2 $2,071.55 $2,748.7058571 G2 $2,071.55 $2,748.7058600 G2 $1,011.93 $1,342.7158615 G2 $1,011.93 $1,342.7158660 A2 $2,071.55 $2,748.7058661 A2 $2,071.55 $2,748.7058662 A2 $2,071.55 $2,748.7058670 A2 $2,071.55 $2,748.7058671 A2 $2,071.55 $2,748.7058672 A2 $2,071.55 $2,748.7058673 A2 $2,071.55 $2,748.7058800 A2 $1,011.93 $1,342.7158805 G2 $1,011.93 $1,342.7158820 A2 $1,011.93 $1,342.7158900 A2 $1,011.93 $1,342.7158970 A2 $267.07 $354.3758974 A2 $267.07 $354.3758976 A2 $123.96 $164.4859000 P3 $70.53 $93.5859001 R2 $123.96 $164.4859012 G2 $123.96 $164.4859015 P3 $61.58 $81.7159020 P3 $34.01 $45.1359025 P3 $18.26 $24.2359070 G2 $267.07 $354.3759072 G2 $123.96 $164.4859074 G2 $123.96 $164.4859076 G2 $123.96 $164.4859100 R2 $1,011.93 $1,342.7159150 G2 $2,071.55 $2,748.7059151 G2 $2,071.55 $2,748.7059160 A2 $1,011.93 $1,342.71



1

2

A B C D

HCPCS




30833084308530863087308830893090309130923093309430953096309730983099310031013102310331043105310631073108310931103111311231133114311531163117311831193120312131223123312431253126312731283129313031313132313331343135313631373138

59200 P3 $38.31 $50.8359300 P3 $90.22 $119.7159320 A2 $1,011.93 $1,342.7159412 G2 $1,011.93 $1,342.7159414 G2 $1,011.93 $1,342.7159812 A2 $1,011.93 $1,342.7159820 A2 $1,011.93 $1,342.7159821 A2 $1,011.93 $1,342.7159840 A2 $1,011.93 $1,342.7159841 A2 $1,011.93 $1,342.7159866 G2 $123.96 $164.4859870 A2 $1,011.93 $1,342.7159871 A2 $1,011.93 $1,342.7160000 A2 $354.45 $470.3160100 P3 $54.06 $71.7360200 A2 $2,323.80 $3,083.4060210 G2 $2,323.80 $3,083.4060212 G2 $2,323.80 $3,083.4060220 G2 $2,323.80 $3,083.4060225 G2 $2,323.80 $3,083.4060240 G2 $2,323.80 $3,083.4060280 A2 $2,323.80 $3,083.4060281 A2 $2,323.80 $3,083.4060300 P3 $81.98 $108.7860500 G2 $2,044.49 $2,712.7961000 R2 $368.37 $488.7861001 R2 $368.37 $488.7861020 A2 $368.37 $488.7861026 A2 $368.37 $488.7861050 A2 $805.75 $1,069.1361055 A2 $368.37 $488.7861070 A2 $267.52 $354.9761215 A2 $1,615.60 $2,143.7161330 G2 $2,044.49 $2,712.7961334 D5 $0.00 $0.0061770 G2 $1,615.60 $2,143.7161781 N1 $0.00 $0.0061782 N1 $0.00 $0.0061783 N1 $0.00 $0.0061790 A2 $758.63 $1,006.6161791 A2 $805.75 $1,069.1361880 G2 $1,166.84 $1,548.2661885 J8 $15,854.21 $21,036.6361886 J8 $20,806.60 $27,607.8661888 J8 $3,836.95 $5,091.1762160 N1 $0.00 $0.0062194 A2 $805.75 $1,069.1362225 A2 $706.56 $937.5262230 A2 $1,615.60 $2,143.7162252 P3 $39.38 $52.2562263 A2 $805.75 $1,069.1362264 A2 $368.37 $488.7862267 G2 $267.12 $354.4462268 A2 $368.37 $488.7862269 A2 $576.97 $765.5762270 A2 $204.32 $271.11



1

2

A B C D

HCPCS




31393140314131423143314431453146314731483149315031513152315331543155315631573158315931603161316231633164316531663167316831693170317131723173317431753176317731783179318031813182318331843185318631873188318931903191319231933194

62272 A2 $204.32 $271.1162273 A2 $368.37 $488.7862280 A2 $368.37 $488.7862281 A2 $805.75 $1,069.1362282 A2 $805.75 $1,069.1362284 N1 $0.00 $0.0062287 A2 $1,615.60 $2,143.7162290 N1 $0.00 $0.0062291 N1 $0.00 $0.0062292 R2 $805.75 $1,069.1362294 A2 $368.37 $488.7862302 N1 $0.00 $0.0062303 N1 $0.00 $0.0062304 N1 $0.00 $0.0062305 N1 $0.00 $0.0062310 A2 $368.37 $488.7862311 A2 $368.37 $488.7862318 A2 $368.37 $488.7862319 A2 $368.37 $488.7862350 A2 $2,007.50 $2,663.7162355 A2 $805.75 $1,069.1362360 A2 $2,007.50 $2,663.7162361 J8 $13,237.22 $17,564.2062362 J8 $13,237.22 $17,564.2062365 A2 $1,615.60 $2,143.7162367 P3 $22.91 $30.4062368 P3 $31.51 $41.8162369 P3 $96.31 $127.7962370 P3 $93.80 $124.4663001 G2 $2,254.50 $2,991.4563003 G2 $2,254.50 $2,991.4563005 G2 $2,254.50 $2,991.4563020 G2 $2,254.50 $2,991.4563030 G2 $2,254.50 $2,991.4563042 G2 $2,254.50 $2,991.4563044 N1 $0.00 $0.0063045 G2 $2,254.50 $2,991.4563047 G2 $2,254.50 $2,991.4563056 G2 $2,254.50 $2,991.4563600 A2 $758.63 $1,006.6163610 A2 $758.63 $1,006.6163615 R2 $758.63 $1,006.6163650 J8 $3,836.95 $5,091.1763655 J8 $15,854.21 $21,036.6363661 G2 $758.63 $1,006.6163662 G2 $1,166.84 $1,548.2663663 J8 $3,836.95 $5,091.1763664 J8 $3,836.95 $5,091.1763685 J8 $20,806.60 $27,607.8663688 A2 $1,166.84 $1,548.2663744 A2 $1,615.60 $2,143.7163746 A2 $805.75 $1,069.1364400 P3 $81.98 $108.7864402 N1 $0.00 $0.0064405 P3 $62.29 $82.6564408 P3 $63.37 $84.08



1

2

A B C D

HCPCS




31953196319731983199320032013202320332043205320632073208320932103211321232133214321532163217321832193220322132223223322432253226322732283229323032313232323332343235323632373238323932403241324232433244324532463247324832493250

64410 A2 $115.77 $153.6164412 P3 $96.66 $128.2664413 P3 $73.75 $97.8664415 A2 $204.32 $271.1164416 G2 $368.37 $488.7864417 A2 $204.32 $271.1164418 P3 $96.66 $128.2664420 A2 $204.32 $271.1164421 A2 $368.37 $488.7864425 P3 $65.16 $86.4664430 A2 $368.37 $488.7864435 P3 $79.48 $105.4664445 P3 $78.76 $104.5164446 G2 $368.37 $488.7864447 P3 $63.01 $83.6164448 G2 $805.75 $1,069.1364449 G2 $368.37 $488.7864450 P3 $52.27 $69.3664455 P3 $19.69 $26.1364479 A2 $368.37 $488.7864480 N1 $0.00 $0.0064483 A2 $368.37 $488.7864484 N1 $0.00 $0.0064486 N1 $0.00 $0.0064487 N1 $0.00 $0.0064488 N1 $0.00 $0.0064489 N1 $0.00 $0.0064490 G2 $368.37 $488.7864491 N1 $0.00 $0.0064492 N1 $0.00 $0.0064493 G2 $368.37 $488.7864494 N1 $0.00 $0.0064495 N1 $0.00 $0.0064505 P3 $52.27 $69.3664508 P3 $14.68 $19.4864510 A2 $368.37 $488.7864517 A2 $368.37 $488.7864520 A2 $368.37 $488.7864530 A2 $368.37 $488.7864553 J8 $3,836.95 $5,091.1764555 J8 $3,836.95 $5,091.1764561 J8 $3,836.95 $5,091.1764565 J8 $3,836.95 $5,091.1764566 P3 $99.17 $131.5964568 J8 $20,806.60 $27,607.8664569 J8 $3,836.95 $5,091.1764570 G2 $1,615.60 $2,143.7164575 J8 $3,836.95 $5,091.1764580 J8 $15,854.21 $21,036.6364581 J8 $3,836.95 $5,091.1764585 A2 $1,166.84 $1,548.2664590 J8 $15,854.21 $21,036.6364595 A2 $1,166.84 $1,548.2664600 A2 $805.75 $1,069.1364605 A2 $758.63 $1,006.6164610 A2 $758.63 $1,006.61



1

2

A B C D

HCPCS




32513252325332543255325632573258325932603261326232633264326532663267326832693270327132723273327432753276327732783279328032813282328332843285328632873288328932903291329232933294329532963297329832993300330133023303330433053306

64611 P3 $68.74 $91.2164612 P3 $72.68 $96.4464615 P3 $60.15 $79.8164616 P3 $55.13 $73.1564617 P3 $115.64 $153.4464620 A2 $805.75 $1,069.1364630 A2 $368.37 $488.7864632 P3 $40.10 $53.2164633 G2 $805.75 $1,069.1364634 N1 $0.00 $0.0064635 G2 $805.75 $1,069.1364636 N1 $0.00 $0.0064640 P3 $87.71 $116.3864642 P3 $71.96 $95.4864643 N1 $0.00 $0.0064644 P3 $85.21 $113.0664645 N1 $0.00 $0.0064646 P3 $76.97 $102.1364647 P3 $87.71 $116.3864650 P3 $50.12 $66.5064653 P3 $56.92 $75.5364680 A2 $805.75 $1,069.1364681 A2 $368.37 $488.7864702 A2 $758.63 $1,006.6164704 A2 $758.63 $1,006.6164708 G2 $758.63 $1,006.6164712 G2 $758.63 $1,006.6164713 G2 $758.63 $1,006.6164714 G2 $758.63 $1,006.6164716 A2 $758.63 $1,006.6164718 A2 $758.63 $1,006.6164719 A2 $758.63 $1,006.6164721 A2 $758.63 $1,006.6164722 A2 $758.63 $1,006.6164726 A2 $758.63 $1,006.6164727 N1 $0.00 $0.0064732 A2 $758.63 $1,006.6164734 A2 $758.63 $1,006.6164736 A2 $758.63 $1,006.6164738 A2 $758.63 $1,006.6164740 A2 $758.63 $1,006.6164742 A2 $758.63 $1,006.6164744 A2 $758.63 $1,006.6164746 A2 $758.63 $1,006.6164761 D5 $0.00 $0.0064763 G2 $758.63 $1,006.6164766 G2 $1,615.60 $2,143.7164771 A2 $758.63 $1,006.6164772 A2 $758.63 $1,006.6164774 A2 $758.63 $1,006.6164776 A2 $758.63 $1,006.6164778 N1 $0.00 $0.0064782 A2 $758.63 $1,006.6164783 N1 $0.00 $0.0064784 A2 $758.63 $1,006.6164786 A2 $1,615.60 $2,143.71



1

2

A B C D

HCPCS




33073308330933103311331233133314331533163317331833193320332133223323332433253326332733283329333033313332333333343335333633373338333933403341334233433344334533463347334833493350335133523353335433553356335733583359336033613362

64787 N1 $0.00 $0.0064788 A2 $758.63 $1,006.6164790 A2 $758.63 $1,006.6164792 A2 $1,615.60 $2,143.7164795 A2 $758.63 $1,006.6164802 A2 $758.63 $1,006.6164820 G2 $758.63 $1,006.6164821 A2 $1,211.40 $1,607.3864822 G2 $1,211.40 $1,607.3864823 G2 $1,211.40 $1,607.3864831 A2 $1,615.60 $2,143.7164832 N1 $0.00 $0.0064834 A2 $1,615.60 $2,143.7164835 A2 $1,615.60 $2,143.7164836 A2 $1,615.60 $2,143.7164837 N1 $0.00 $0.0064840 A2 $1,615.60 $2,143.7164856 A2 $1,615.60 $2,143.7164857 A2 $1,615.60 $2,143.7164858 A2 $1,615.60 $2,143.7164859 N1 $0.00 $0.0064861 A2 $1,615.60 $2,143.7164862 A2 $1,615.60 $2,143.7164864 A2 $1,615.60 $2,143.7164865 A2 $1,615.60 $2,143.7164870 D5 $0.00 $0.0064872 N1 $0.00 $0.0064874 N1 $0.00 $0.0064876 N1 $0.00 $0.0064885 A2 $1,615.60 $2,143.7164886 A2 $1,615.60 $2,143.7164890 A2 $1,615.60 $2,143.7164891 A2 $1,615.60 $2,143.7164892 A2 $1,615.60 $2,143.7164893 A2 $1,615.60 $2,143.7164895 A2 $1,615.60 $2,143.7164896 A2 $1,615.60 $2,143.7164897 A2 $1,615.60 $2,143.7164898 A2 $1,615.60 $2,143.7164901 N1 $0.00 $0.0064902 N1 $0.00 $0.0064905 A2 $1,615.60 $2,143.7164907 A2 $1,615.60 $2,143.7164910 G2 $1,615.60 $2,143.7165091 A2 $841.18 $1,116.1465093 A2 $1,462.37 $1,940.3965101 A2 $1,462.37 $1,940.3965103 A2 $1,462.37 $1,940.3965105 A2 $1,462.37 $1,940.3965110 A2 $1,462.37 $1,940.3965112 A2 $1,462.37 $1,940.3965114 A2 $1,462.37 $1,940.3965125 G2 $841.18 $1,116.1465130 A2 $1,462.37 $1,940.3965135 A2 $1,462.37 $1,940.3965140 A2 $1,462.37 $1,940.39



1

2

A B C D

HCPCS




33633364336533663367336833693370337133723373337433753376337733783379338033813382338333843385338633873388338933903391339233933394339533963397339833993400340134023403340434053406340734083409341034113412341334143415341634173418

65150 A2 $841.18 $1,116.1465155 A2 $1,462.37 $1,940.3965175 A2 $841.18 $1,116.1465205 N1 $0.00 $0.0065210 N1 $0.00 $0.0065220 N1 $0.00 $0.0065222 N1 $0.00 $0.0065235 A2 $960.64 $1,274.6565260 A2 $172.34 $228.6765265 A2 $960.64 $1,274.6565270 A2 $841.18 $1,116.1465272 A2 $841.18 $1,116.1465275 A2 $1,462.37 $1,940.3965280 A2 $960.64 $1,274.6565285 A2 $960.64 $1,274.6565286 P2 $412.28 $547.0565290 A2 $841.18 $1,116.1465400 A2 $384.59 $510.3065410 A2 $384.59 $510.3065420 A2 $841.18 $1,116.1465426 A2 $841.18 $1,116.1465430 N1 $0.00 $0.0065435 P3 $45.47 $60.3365436 P3 $207.29 $275.0565450 G2 $163.53 $216.9865600 P3 $238.08 $315.9065710 A2 $1,711.53 $2,270.9965730 A2 $1,711.53 $2,270.9965750 A2 $1,711.53 $2,270.9965755 A2 $1,711.53 $2,270.9965756 G2 $1,711.53 $2,270.9965757 N1 $0.00 $0.0065770 J8 $6,683.30 $8,867.9465772 A2 $384.59 $510.3065775 A2 $841.18 $1,116.1465778 N1 $0.00 $0.0065779 N1 $0.00 $0.0065780 A2 $1,462.37 $1,940.3965781 A2 $1,711.53 $2,270.9965782 A2 $1,462.37 $1,940.3965800 A2 $172.34 $228.6765810 A2 $960.64 $1,274.6565815 A2 $960.64 $1,274.6565820 A2 $960.64 $1,274.6565850 A2 $960.64 $1,274.6565855 P3 $189.39 $251.3065860 P3 $174.71 $231.8265865 A2 $960.64 $1,274.6565870 A2 $960.64 $1,274.6565875 A2 $960.64 $1,274.6565880 A2 $960.64 $1,274.6565900 A2 $960.64 $1,274.6565920 A2 $960.64 $1,274.6565930 A2 $960.64 $1,274.6566020 A2 $412.28 $547.0566030 A2 $412.28 $547.05



1

2

A B C D

HCPCS




34193420342134223423342434253426342734283429343034313432343334343435343634373438343934403441344234433444344534463447344834493450345134523453345434553456345734583459346034613462346334643465346634673468346934703471347234733474

66130 A2 $841.18 $1,116.1466150 A2 $960.64 $1,274.6566155 A2 $960.64 $1,274.6566160 A2 $960.64 $1,274.6566165 D5 $0.00 $0.0066170 A2 $960.64 $1,274.6566172 A2 $960.64 $1,274.6566174 A2 $1,711.53 $2,270.9966175 A2 $1,711.53 $2,270.9966179 G2 $1,711.53 $2,270.9966180 A2 $1,711.53 $2,270.9966183 G2 $1,711.53 $2,270.9966184 G2 $960.64 $1,274.6566185 A2 $960.64 $1,274.6566220 A2 $960.64 $1,274.6566225 A2 $960.64 $1,274.6566250 A2 $960.64 $1,274.6566500 A2 $172.34 $228.6766505 A2 $412.28 $547.0566600 A2 $960.64 $1,274.6566605 A2 $1,711.53 $2,270.9966625 A2 $412.28 $547.0566630 A2 $412.28 $547.0566635 A2 $960.64 $1,274.6566680 A2 $960.64 $1,274.6566682 A2 $960.64 $1,274.6566700 A2 $412.28 $547.0566710 A2 $841.18 $1,116.1466711 A2 $960.64 $1,274.6566720 A2 $841.18 $1,116.1466740 A2 $841.18 $1,116.1466761 P3 $184.38 $244.6566762 P2 $243.16 $322.6466770 P2 $243.16 $322.6466820 G2 $172.34 $228.6766821 A2 $243.16 $322.6466825 A2 $960.64 $1,274.6566830 A2 $960.64 $1,274.6566840 A2 $960.64 $1,274.6566850 A2 $960.64 $1,274.6566852 A2 $1,711.53 $2,270.9966920 A2 $960.64 $1,274.6566930 A2 $960.64 $1,274.6566940 A2 $412.28 $547.0566982 A2 $960.64 $1,274.6566983 A2 $960.64 $1,274.6566984 A2 $960.64 $1,274.6566985 A2 $960.64 $1,274.6566986 A2 $960.64 $1,274.6566990 N1 $0.00 $0.0067005 A2 $960.64 $1,274.6567010 A2 $960.64 $1,274.6567015 A2 $960.64 $1,274.6567025 A2 $960.64 $1,274.6567027 A2 $1,711.53 $2,270.9967028 P3 $47.97 $63.65



1

2

A B C D

HCPCS




34753476347734783479348034813482348334843485348634873488348934903491349234933494349534963497349834993500350135023503350435053506350735083509351035113512351335143515351635173518351935203521352235233524352535263527352835293530

67030 A2 $960.64 $1,274.6567031 A2 $243.16 $322.6467036 A2 $1,711.53 $2,270.9967039 A2 $1,711.53 $2,270.9967040 A2 $1,711.53 $2,270.9967041 G2 $1,711.53 $2,270.9967042 G2 $1,711.53 $2,270.9967043 G2 $1,711.53 $2,270.9967101 P3 $456.11 $605.2067105 P2 $243.16 $322.6467107 A2 $1,711.53 $2,270.9967108 A2 $1,711.53 $2,270.9967110 P3 $486.90 $646.0667112 A2 $1,711.53 $2,270.9967113 G2 $1,711.53 $2,270.9967115 A2 $960.64 $1,274.6567120 A2 $960.64 $1,274.6567121 A2 $1,711.53 $2,270.9967141 A2 $163.53 $216.9867145 P2 $243.16 $322.6467208 P2 $163.53 $216.9867210 P2 $243.16 $322.6467218 A2 $841.18 $1,116.1467220 P2 $243.16 $322.6467221 P3 $157.88 $209.4967225 N1 $0.00 $0.0067227 A2 $1,462.37 $1,940.3967228 P2 $243.16 $322.6467229 R2 $243.16 $322.6467250 A2 $841.18 $1,116.1467255 A2 $960.64 $1,274.6567311 A2 $841.18 $1,116.1467312 A2 $841.18 $1,116.1467314 A2 $841.18 $1,116.1467316 A2 $841.18 $1,116.1467318 A2 $841.18 $1,116.1467320 N1 $0.00 $0.0067331 N1 $0.00 $0.0067332 N1 $0.00 $0.0067334 N1 $0.00 $0.0067335 N1 $0.00 $0.0067340 N1 $0.00 $0.0067343 A2 $841.18 $1,116.1467345 P3 $123.87 $164.3667346 A2 $841.18 $1,116.1467400 A2 $1,462.37 $1,940.3967405 A2 $841.18 $1,116.1467412 A2 $841.18 $1,116.1467413 A2 $841.18 $1,116.1467414 G2 $1,462.37 $1,940.3967415 A2 $841.18 $1,116.1467420 A2 $1,462.37 $1,940.3967430 A2 $1,462.37 $1,940.3967440 A2 $1,462.37 $1,940.3967445 A2 $1,462.37 $1,940.3967450 A2 $1,462.37 $1,940.39



1

2

A B C D

HCPCS




35313532353335343535353635373538353935403541354235433544354535463547354835493550355135523553355435553556355735583559356035613562356335643565356635673568356935703571357235733574357535763577357835793580358135823583358435853586

67500 G2 $163.53 $216.9867505 P3 $41.53 $55.1167515 P3 $44.39 $58.9067550 A2 $1,462.37 $1,940.3967560 A2 $841.18 $1,116.1467570 A2 $841.18 $1,116.1467700 P2 $163.53 $216.9867710 P3 $184.38 $244.6567715 A2 $841.18 $1,116.1467800 P3 $74.47 $98.8167801 P3 $90.58 $120.1967805 P3 $116.71 $154.8667808 A2 $841.18 $1,116.1467810 P3 $126.38 $167.6967820 N1 $0.00 $0.0067825 P3 $75.18 $99.7567830 A2 $384.59 $510.3067835 A2 $841.18 $1,116.1467840 P3 $197.27 $261.7567850 P3 $147.86 $196.1967875 G2 $384.59 $510.3067880 A2 $841.18 $1,116.1467882 A2 $841.18 $1,116.1467900 A2 $841.18 $1,116.1467901 A2 $841.18 $1,116.1467902 A2 $1,462.37 $1,940.3967903 A2 $841.18 $1,116.1467904 A2 $841.18 $1,116.1467906 A2 $841.18 $1,116.1467908 A2 $841.18 $1,116.1467909 A2 $841.18 $1,116.1467911 A2 $841.18 $1,116.1467912 A2 $841.18 $1,116.1467914 A2 $841.18 $1,116.1467915 P3 $216.96 $287.8867916 A2 $841.18 $1,116.1467917 A2 $841.18 $1,116.1467921 A2 $841.18 $1,116.1467922 P3 $214.09 $284.0767923 A2 $841.18 $1,116.1467924 A2 $841.18 $1,116.1467930 P3 $227.34 $301.6567935 A2 $841.18 $1,116.1467938 P2 $163.53 $216.9867950 A2 $841.18 $1,116.1467961 A2 $841.18 $1,116.1467966 A2 $841.18 $1,116.1467971 A2 $841.18 $1,116.1467973 A2 $841.18 $1,116.1467974 A2 $841.18 $1,116.1467975 A2 $841.18 $1,116.1468020 P3 $66.59 $88.3668040 P3 $30.79 $40.8568100 P3 $119.22 $158.1968110 P3 $157.88 $209.4968115 A2 $841.18 $1,116.14



1

2

A B C D

HCPCS




35873588358935903591359235933594359535963597359835993600360136023603360436053606360736083609361036113612361336143615361636173618361936203621362236233624362536263627362836293630363136323633363436353636363736383639364036413642

68130 A2 $841.18 $1,116.1468135 P3 $85.92 $114.0168200 N1 $0.00 $0.0068320 A2 $841.18 $1,116.1468325 A2 $1,462.37 $1,940.3968326 A2 $1,462.37 $1,940.3968328 A2 $841.18 $1,116.1468330 A2 $960.64 $1,274.6568335 A2 $1,462.37 $1,940.3968340 A2 $841.18 $1,116.1468360 A2 $1,462.37 $1,940.3968362 A2 $841.18 $1,116.1468371 A2 $841.18 $1,116.1468400 P3 $220.18 $292.1568420 P3 $233.07 $309.2668440 P3 $65.52 $86.9468500 A2 $1,462.37 $1,940.3968505 A2 $841.18 $1,116.1468510 A2 $841.18 $1,116.1468520 A2 $1,462.37 $1,940.3968525 A2 $841.18 $1,116.1468530 P2 $163.53 $216.9868540 A2 $841.18 $1,116.1468550 A2 $1,462.37 $1,940.3968700 A2 $841.18 $1,116.1468705 P3 $157.53 $209.0268720 A2 $1,462.37 $1,940.3968745 A2 $1,462.37 $1,940.3968750 A2 $841.18 $1,116.1468760 P3 $134.97 $179.0968761 P3 $95.23 $126.3668770 A2 $384.59 $510.3068801 N1 $0.00 $0.0068810 A2 $163.53 $216.9868811 A2 $841.18 $1,116.1468815 A2 $841.18 $1,116.1468816 G2 $841.18 $1,116.1468840 P3 $79.48 $105.4668850 N1 $0.00 $0.0069000 P2 $88.78 $117.8069005 P3 $131.39 $174.3469020 P2 $88.78 $117.8069100 P3 $69.10 $91.6969105 P3 $108.48 $143.9469110 A2 $735.25 $975.5969120 A2 $1,066.74 $1,415.4469140 A2 $2,044.49 $2,712.7969145 A2 $735.25 $975.5969150 A2 $1,066.74 $1,415.4469200 N1 $0.00 $0.0069205 A2 $999.94 $1,326.8069210 N1 $0.00 $0.0069220 N1 $0.00 $0.0069222 P3 $165.04 $218.9969300 A2 $1,066.74 $1,415.4469310 A2 $2,044.49 $2,712.79



1

2

A B C D

HCPCS




36433644364536463647364836493650365136523653365436553656365736583659366036613662366336643665366636673668366936703671367236733674367536763677367836793680368136823683368436853686368736883689369036913692369336943695369636973698

69320 A2 $2,044.49 $2,712.7969400 D5 $0.00 $0.0069401 D5 $0.00 $0.0069405 D5 $0.00 $0.0069420 P3 $139.27 $184.7969421 A2 $694.39 $921.3769424 P3 $96.31 $127.7969433 P3 $142.85 $189.5469436 A2 $694.39 $921.3769440 A2 $2,044.49 $2,712.7969450 A2 $2,044.49 $2,712.7969501 A2 $2,044.49 $2,712.7969502 A2 $2,044.49 $2,712.7969505 A2 $2,044.49 $2,712.7969511 A2 $2,044.49 $2,712.7969530 A2 $2,044.49 $2,712.7969540 P3 $162.18 $215.1969550 A2 $2,044.49 $2,712.7969552 A2 $2,044.49 $2,712.7969601 A2 $2,044.49 $2,712.7969602 A2 $2,044.49 $2,712.7969603 A2 $2,044.49 $2,712.7969604 A2 $2,044.49 $2,712.7969605 A2 $2,044.49 $2,712.7969610 P3 $210.87 $279.8069620 A2 $1,066.74 $1,415.4469631 A2 $2,044.49 $2,712.7969632 A2 $2,044.49 $2,712.7969633 A2 $2,044.49 $2,712.7969635 A2 $2,044.49 $2,712.7969636 A2 $2,044.49 $2,712.7969637 A2 $2,044.49 $2,712.7969641 A2 $2,044.49 $2,712.7969642 A2 $2,044.49 $2,712.7969643 A2 $2,044.49 $2,712.7969644 A2 $2,044.49 $2,712.7969645 A2 $2,044.49 $2,712.7969646 A2 $2,044.49 $2,712.7969650 A2 $2,044.49 $2,712.7969660 A2 $2,044.49 $2,712.7969661 A2 $2,044.49 $2,712.7969662 A2 $2,044.49 $2,712.7969666 A2 $1,066.74 $1,415.4469667 A2 $1,066.74 $1,415.4469670 A2 $2,044.49 $2,712.7969676 A2 $1,066.74 $1,415.4469700 A2 $1,066.74 $1,415.4469711 A2 $2,044.49 $2,712.7969714 J8 $7,842.24 $10,405.7169715 J8 $7,842.24 $10,405.7169717 G2 $1,844.03 $2,446.8169718 J8 $7,842.24 $10,405.7169720 A2 $2,044.49 $2,712.7969740 A2 $2,044.49 $2,712.7969745 A2 $2,044.49 $2,712.7969801 P3 $116.35 $154.38



1

2

A B C D

HCPCS




36993700370137023703370437053706370737083709371037113712371337143715371637173718371937203721372237233724372537263727372837293730373137323733373437353736373737383739374037413742374337443745374637473748374937503751375237533754

69805 A2 $2,044.49 $2,712.7969806 A2 $2,044.49 $2,712.7969820 A2 $2,044.49 $2,712.7969840 A2 $2,044.49 $2,712.7969905 A2 $2,044.49 $2,712.7969910 A2 $2,044.49 $2,712.7969915 A2 $2,044.49 $2,712.7969930 J8 $27,877.06 $36,989.5169990 N1 $0.00 $0.000099T R2 $960.64 $1,274.650100T G2 $1,711.53 $2,270.990101T G2 $1,426.27 $1,892.490102T G2 $1,426.27 $1,892.490123T G2 $960.64 $1,274.650190T N1 $0.00 $0.000191T G2 $1,711.53 $2,270.990200T G2 $1,426.27 $1,892.490201T G2 $1,426.27 $1,892.490213T R2 $368.37 $488.780214T N1 $0.00 $0.000215T N1 $0.00 $0.000216T R2 $368.37 $488.780217T N1 $0.00 $0.000218T N1 $0.00 $0.000226T D5 $0.00 $0.000227T D5 $0.00 $0.000228T G2 $368.37 $488.780229T N1 $0.00 $0.000230T G2 $368.37 $488.780231T N1 $0.00 $0.000232T N1 $0.00 $0.000238T J8 $9,739.78 $12,923.520249T G2 $1,425.69 $1,891.720253T G2 $1,711.53 $2,270.990263T G2 $1,559.83 $2,069.710264T G2 $1,559.83 $2,069.710265T G2 $1,559.83 $2,069.710269T G2 $1,615.60 $2,143.710270T G2 $1,166.84 $1,548.260271T G2 $1,166.84 $1,548.260274T G2 $2,254.50 $2,991.450275T G2 $2,254.50 $2,991.450282T J8 $3,836.95 $5,091.170283T J8 $20,806.60 $27,607.860284T G2 $1,166.84 $1,548.260288T G2 $1,425.69 $1,891.720289T N1 $0.00 $0.000290T N1 $0.00 $0.000299T R2 $120.55 $159.960300T N1 $0.00 $0.000301T G2 $1,043.19 $1,384.190302T J8 $7,851.02 $10,417.360303T J8 $5,649.82 $7,496.630304T J8 $5,649.82 $7,496.630307T G2 $1,286.56 $1,707.110308T J8 $22,674.60 $30,086.47



1

2

A B C D

HCPCS




3755375637573758375937603761376237633764376537663767376837693770377137723773377437753776377737783779378037813782378337843785378637873788378937903791379237933794379537963797379837993800380138023803380438053806380738083809

0313T G2 $1,166.84 $1,548.260314T G2 $1,166.84 $1,548.260315T G2 $1,166.84 $1,548.260316T J8 $15,854.21 $21,036.630319T D5 $0.00 $0.000320T D5 $0.00 $0.000321T D5 $0.00 $0.000322T D5 $0.00 $0.000323T D5 $0.00 $0.000325T D5 $0.00 $0.000326T D5 $0.00 $0.000334T D5 $0.00 $0.000335T G2 $1,119.61 $1,485.590336T G2 $4,423.26 $5,869.140338T G2 $1,403.41 $1,862.160339T G2 $1,403.41 $1,862.160340T G2 $2,245.03 $2,978.890341T N1 $0.00 $0.000342T G2 $1,559.83 $2,069.710357T N1 $0.00 $0.000376T N1 $0.00 $0.000377T G2 $1,425.69 $1,891.720379T N1 $0.00 $0.000380T N1 $0.00 $0.000387T J8 $9,739.78 $12,923.520388T G2 $1,225.74 $1,626.410390T N1 $0.00 $0.00C5271 G2 $235.76 $312.83C5272 N1 $0.00 $0.00C5273 G2 $771.43 $1,023.60C5274 N1 $0.00 $0.00C5275 G2 $235.76 $312.83C5276 N1 $0.00 $0.00C5277 G2 $235.76 $312.83C5278 N1 $0.00 $0.00C9724 G2 $1,049.73 $1,392.87C9725 G2 $242.54 $321.82C9726 N1 $0.00 $0.00C9727 G2 $354.45 $470.31C9728 R2 $569.23 $755.30C9735 D5 $0.00 $0.00C9737 G2 $4,423.26 $5,869.14C9739 G2 $1,142.74 $1,516.28C9740 G2 $2,604.57 $3,455.95C9742 G2 $690.38 $916.05C9800 R2 $771.43 $1,023.60G0104 P3 $99.89 $132.54G0105 A2 $359.04 $476.40G0121 A2 $359.04 $476.40G0127 N1 $0.00 $0.00G0186 R2 $243.16 $322.64G0247 N1 $0.00 $0.00G0259 N1 $0.00 $0.00G0260 A2 $368.37 $488.78G0268 N1 $0.00 $0.00



1

2

A B C D

HCPCS




38103811381238133814381538163817381838193820382138223823382438253826382738283829383038313832383338343835383638373838383938403841384238433844384538463847384838493850385138523853385438553856385738583859386038613862386338643865

G0269 N1 $0.00 $0.00G0276 G2 $2,254.50 $2,991.45G0289 N1 $0.00 $0.00G0364 N1 $0.00 $0.00G0365 P2 $103.94 $137.92G0458 G2 $1,978.62 $2,625.3970010 N1 $0.00 $0.0070015 N1 $0.00 $0.0070030 N1 $0.00 $0.0070100 N1 $0.00 $0.0070110 N1 $0.00 $0.0070120 N1 $0.00 $0.0070130 N1 $0.00 $0.0070134 N1 $0.00 $0.0070140 N1 $0.00 $0.0070150 N1 $0.00 $0.0070160 N1 $0.00 $0.0070170 N1 $0.00 $0.0070190 N1 $0.00 $0.0070200 N1 $0.00 $0.0070210 N1 $0.00 $0.0070220 N1 $0.00 $0.0070240 N1 $0.00 $0.0070250 N1 $0.00 $0.0070260 N1 $0.00 $0.0070300 N1 $0.00 $0.0070310 N1 $0.00 $0.0070320 N1 $0.00 $0.0070328 N1 $0.00 $0.0070330 N1 $0.00 $0.0070332 N1 $0.00 $0.0070336 Z2 $156.99 $208.3170350 N1 $0.00 $0.0070355 N1 $0.00 $0.0070360 N1 $0.00 $0.0070370 Z3 $63.73 $84.5670371 Z3 $47.26 $62.7170373 N1 $0.00 $0.0070380 N1 $0.00 $0.0070390 N1 $0.00 $0.0070450 Z2 $65.78 $87.2870460 Z3 $104.54 $138.7170470 Z3 $127.09 $168.6370480 Z2 $65.78 $87.2870481 Z2 $132.05 $175.2170482 Z2 $147.83 $196.1570486 Z2 $65.78 $87.2870487 Z3 $110.98 $147.2670488 Z3 $141.06 $187.1770490 Z2 $65.78 $87.2870491 Z2 $132.05 $175.2170492 Z2 $147.83 $196.1570496 Z2 $154.53 $205.0470498 Z2 $154.53 $205.0470540 Z2 $156.99 $208.3170542 Z2 $234.07 $310.58



1

2

A B C D

HCPCS




38663867386838693870387138723873387438753876387738783879388038813882388338843885388638873888388938903891389238933894389538963897389838993900390139023903390439053906390739083909391039113912391339143915391639173918391939203921

70543 Z2 $264.79 $351.3470544 Z2 $156.99 $208.3170545 Z2 $234.07 $310.5870546 Z2 $264.79 $351.3470547 Z2 $156.99 $208.3170548 Z2 $234.07 $310.5870549 Z2 $264.79 $351.3470551 Z3 $155.38 $206.1770552 Z3 $229.13 $304.0370553 Z3 $261.35 $346.7870554 Z2 $156.99 $208.3170555 Z2 $156.99 $208.3170557 Z2 $156.99 $208.3170558 Z2 $234.07 $310.5870559 Z2 $264.79 $351.3471010 Z3 $12.89 $17.1071015 Z3 $16.11 $21.3871020 Z3 $16.47 $21.8571021 N1 $0.00 $0.0071022 N1 $0.00 $0.0071023 N1 $0.00 $0.0071030 N1 $0.00 $0.0071034 Z3 $60.15 $79.8171035 N1 $0.00 $0.0071100 N1 $0.00 $0.0071101 N1 $0.00 $0.0071110 N1 $0.00 $0.0071111 N1 $0.00 $0.0071120 N1 $0.00 $0.0071130 N1 $0.00 $0.0071250 Z2 $65.78 $87.2871260 Z2 $132.05 $175.2171270 Z2 $147.83 $196.1571275 Z2 $154.53 $205.0471550 Z2 $156.99 $208.3171551 Z2 $234.07 $310.5871552 Z2 $264.79 $351.3472010 Z3 $46.18 $61.2872020 N1 $0.00 $0.0072040 N1 $0.00 $0.0072050 N1 $0.00 $0.0072052 N1 $0.00 $0.0072069 N1 $0.00 $0.0072070 N1 $0.00 $0.0072072 N1 $0.00 $0.0072074 N1 $0.00 $0.0072080 N1 $0.00 $0.0072090 N1 $0.00 $0.0072100 N1 $0.00 $0.0072110 N1 $0.00 $0.0072114 N1 $0.00 $0.0072120 N1 $0.00 $0.0072125 Z2 $65.78 $87.2872126 Z2 $132.05 $175.2172127 Z2 $147.83 $196.1572128 Z2 $65.78 $87.28



1

2

A B C D

HCPCS




39223923392439253926392739283929393039313932393339343935393639373938393939403941394239433944394539463947394839493950395139523953395439553956395739583959396039613962396339643965396639673968396939703971397239733974397539763977

72129 Z2 $132.05 $175.2172130 Z2 $147.83 $196.1572131 Z2 $65.78 $87.2872132 Z2 $132.05 $175.2172133 Z2 $147.83 $196.1572141 Z3 $148.58 $197.1572142 Z3 $233.42 $309.7272146 Z3 $148.58 $197.1572147 Z3 $230.92 $306.4072148 Z3 $147.14 $195.2472149 Z3 $229.13 $304.0372156 Z3 $263.50 $349.6372157 Z3 $263.86 $350.1172158 Z3 $261.71 $347.2672170 N1 $0.00 $0.0072190 N1 $0.00 $0.0072191 Z2 $154.53 $205.0472192 Z2 $65.78 $87.2872193 Z2 $132.05 $175.2172194 Z2 $147.83 $196.1572195 Z2 $156.99 $208.3172196 Z2 $234.07 $310.5872197 Z2 $264.79 $351.3472200 N1 $0.00 $0.0072202 N1 $0.00 $0.0072220 N1 $0.00 $0.0072240 N1 $0.00 $0.0072255 N1 $0.00 $0.0072265 N1 $0.00 $0.0072270 N1 $0.00 $0.0072275 N1 $0.00 $0.0072285 N1 $0.00 $0.0072291 D5 $0.00 $0.0072292 D5 $0.00 $0.0072295 N1 $0.00 $0.0073000 N1 $0.00 $0.0073010 N1 $0.00 $0.0073020 N1 $0.00 $0.0073030 N1 $0.00 $0.0073040 N1 $0.00 $0.0073050 N1 $0.00 $0.0073060 N1 $0.00 $0.0073070 N1 $0.00 $0.0073080 N1 $0.00 $0.0073085 N1 $0.00 $0.0073090 N1 $0.00 $0.0073092 N1 $0.00 $0.0073100 N1 $0.00 $0.0073110 N1 $0.00 $0.0073115 N1 $0.00 $0.0073120 N1 $0.00 $0.0073130 N1 $0.00 $0.0073140 N1 $0.00 $0.0073200 Z2 $65.78 $87.2873201 Z2 $132.05 $175.2173202 Z2 $147.83 $196.15



1

2

A B C D

HCPCS




39783979398039813982398339843985398639873988398939903991399239933994399539963997399839994000400140024003400440054006400740084009401040114012401340144015401640174018401940204021402240234024402540264027402840294030403140324033

73206 Z2 $154.53 $205.0473218 Z2 $156.99 $208.3173219 Z2 $234.07 $310.5873220 Z2 $264.79 $351.3473221 Z2 $156.99 $208.3173222 Z2 $234.07 $310.5873223 Z2 $264.79 $351.3473500 N1 $0.00 $0.0073510 N1 $0.00 $0.0073520 N1 $0.00 $0.0073525 N1 $0.00 $0.0073530 N1 $0.00 $0.0073540 N1 $0.00 $0.0073550 N1 $0.00 $0.0073560 N1 $0.00 $0.0073562 N1 $0.00 $0.0073564 N1 $0.00 $0.0073565 N1 $0.00 $0.0073580 N1 $0.00 $0.0073590 N1 $0.00 $0.0073592 N1 $0.00 $0.0073600 N1 $0.00 $0.0073610 N1 $0.00 $0.0073615 N1 $0.00 $0.0073620 N1 $0.00 $0.0073630 N1 $0.00 $0.0073650 N1 $0.00 $0.0073660 N1 $0.00 $0.0073700 Z2 $65.78 $87.2873701 Z2 $132.05 $175.2173702 Z2 $147.83 $196.1573706 Z2 $154.53 $205.0473718 Z2 $156.99 $208.3173719 Z2 $234.07 $310.5873720 Z2 $264.79 $351.3473721 Z2 $156.99 $208.3173722 Z2 $234.07 $310.5873723 Z2 $264.79 $351.3474000 N1 $0.00 $0.0074010 N1 $0.00 $0.0074020 N1 $0.00 $0.0074022 N1 $0.00 $0.0074150 Z2 $65.78 $87.2874160 Z2 $132.05 $175.2174170 Z2 $147.83 $196.1574174 Z2 $205.86 $273.1574175 Z2 $154.53 $205.0474176 Z3 $111.70 $148.2174177 Z2 $205.86 $273.1574178 Z2 $205.86 $273.1574181 Z2 $156.99 $208.3174182 Z2 $234.07 $310.5874183 Z2 $264.79 $351.3474190 N1 $0.00 $0.0074210 Z2 $55.74 $73.9674220 Z2 $55.74 $73.96



1

2

A B C D

HCPCS




40344035403640374038403940404041404240434044404540464047404840494050405140524053405440554056405740584059406040614062406340644065406640674068406940704071407240734074407540764077407840794080408140824083408440854086408740884089

74230 Z2 $55.74 $73.9674235 N1 $0.00 $0.0074240 Z3 $77.69 $103.0974241 Z3 $82.34 $109.2674245 Z2 $82.76 $109.8174246 Z2 $82.76 $109.8174247 Z2 $82.76 $109.8174249 Z2 $82.76 $109.8174250 Z2 $55.74 $73.9674251 Z2 $82.76 $109.8174260 Z2 $55.74 $73.9674261 Z2 $65.78 $87.2874262 Z2 $132.05 $175.2174270 Z2 $82.76 $109.8174280 Z2 $82.76 $109.8174283 Z2 $82.76 $109.8174290 Z2 $55.74 $73.9674291 D5 $0.00 $0.0074300 N1 $0.00 $0.0074301 N1 $0.00 $0.0074305 N1 $0.00 $0.0074320 N1 $0.00 $0.0074327 N1 $0.00 $0.0074328 N1 $0.00 $0.0074329 N1 $0.00 $0.0074330 N1 $0.00 $0.0074340 N1 $0.00 $0.0074355 N1 $0.00 $0.0074360 N1 $0.00 $0.0074363 N1 $0.00 $0.0074400 Z2 $145.39 $192.9274410 Z2 $145.39 $192.9274415 Z2 $145.39 $192.9274420 Z2 $145.39 $192.9274425 N1 $0.00 $0.0074430 N1 $0.00 $0.0074440 N1 $0.00 $0.0074445 N1 $0.00 $0.0074450 N1 $0.00 $0.0074455 N1 $0.00 $0.0074470 N1 $0.00 $0.0074475 N1 $0.00 $0.0074480 N1 $0.00 $0.0074485 N1 $0.00 $0.0074710 N1 $0.00 $0.0074740 N1 $0.00 $0.0074742 N1 $0.00 $0.0074775 Z2 $145.39 $192.9275557 Z2 $156.99 $208.3175559 Z2 $156.99 $208.3175561 Z2 $264.79 $351.3475563 Z3 $354.79 $470.7675565 N1 $0.00 $0.0075571 N1 $0.00 $0.0075572 Z2 $118.42 $157.1375573 Z2 $118.42 $157.13



1

2

A B C D

HCPCS




40904091409240934094409540964097409840994100410141024103410441054106410741084109411041114112411341144115411641174118411941204121412241234124412541264127412841294130413141324133413441354136413741384139414041414142414341444145

75574 Z2 $118.42 $157.1375600 N1 $0.00 $0.0075605 N1 $0.00 $0.0075625 N1 $0.00 $0.0075630 N1 $0.00 $0.0075635 N1 $0.00 $0.0075658 N1 $0.00 $0.0075705 N1 $0.00 $0.0075710 N1 $0.00 $0.0075716 N1 $0.00 $0.0075726 N1 $0.00 $0.0075731 N1 $0.00 $0.0075733 N1 $0.00 $0.0075736 N1 $0.00 $0.0075741 N1 $0.00 $0.0075743 N1 $0.00 $0.0075746 N1 $0.00 $0.0075756 N1 $0.00 $0.0075774 N1 $0.00 $0.0075791 N1 $0.00 $0.0075801 N1 $0.00 $0.0075803 N1 $0.00 $0.0075805 N1 $0.00 $0.0075807 N1 $0.00 $0.0075809 N1 $0.00 $0.0075810 N1 $0.00 $0.0075820 N1 $0.00 $0.0075822 N1 $0.00 $0.0075825 N1 $0.00 $0.0075827 N1 $0.00 $0.0075831 N1 $0.00 $0.0075833 N1 $0.00 $0.0075840 N1 $0.00 $0.0075842 N1 $0.00 $0.0075860 N1 $0.00 $0.0075870 N1 $0.00 $0.0075872 N1 $0.00 $0.0075880 N1 $0.00 $0.0075885 N1 $0.00 $0.0075887 N1 $0.00 $0.0075889 N1 $0.00 $0.0075891 N1 $0.00 $0.0075893 N1 $0.00 $0.0075894 N1 $0.00 $0.0075896 N1 $0.00 $0.0075898 N1 $0.00 $0.0075901 N1 $0.00 $0.0075902 N1 $0.00 $0.0075945 N1 $0.00 $0.0075946 N1 $0.00 $0.0075962 N1 $0.00 $0.0075964 N1 $0.00 $0.0075966 N1 $0.00 $0.0075968 N1 $0.00 $0.0075970 N1 $0.00 $0.0075978 N1 $0.00 $0.00



1

2

A B C D

HCPCS




41464147414841494150415141524153415441554156415741584159416041614162416341644165416641674168416941704171417241734174417541764177417841794180418141824183418441854186418741884189419041914192419341944195419641974198419942004201

75980 N1 $0.00 $0.0075982 N1 $0.00 $0.0075984 N1 $0.00 $0.0075989 N1 $0.00 $0.0076000 Z3 $37.95 $50.3676001 N1 $0.00 $0.0076010 N1 $0.00 $0.0076080 N1 $0.00 $0.0076098 N1 $0.00 $0.0076100 N1 $0.00 $0.0076101 Z3 $97.02 $128.7376102 Z3 $138.91 $184.3276120 Z3 $70.17 $93.1176125 N1 $0.00 $0.0076376 N1 $0.00 $0.0076377 N1 $0.00 $0.0076380 N1 $0.00 $0.0076496 Z2 $87.44 $116.0276497 N1 $0.00 $0.0076498 Z2 $156.99 $208.3176499 N1 $0.00 $0.0076506 Z2 $73.92 $98.0876510 N1 $0.00 $0.0076511 Z3 $49.05 $65.0876512 Z3 $39.74 $52.7376513 Z3 $60.15 $79.8176514 N1 $0.00 $0.0076516 N1 $0.00 $0.0076519 N1 $0.00 $0.0076529 Z3 $46.90 $62.2376536 Z2 $73.92 $98.0876604 Z3 $60.86 $80.7576641 N1 $0.00 $0.0076642 N1 $0.00 $0.0076645 D5 $0.00 $0.0076700 Z2 $73.92 $98.0876705 Z2 $73.92 $98.0876770 Z2 $73.92 $98.0876775 Z3 $28.64 $38.0076776 Z2 $73.92 $98.0876800 N1 $0.00 $0.0076801 Z3 $73.39 $97.3876802 N1 $0.00 $0.0076805 Z2 $73.92 $98.0876810 N1 $0.00 $0.0076811 Z3 $83.42 $110.6976812 N1 $0.00 $0.0076813 Z3 $60.15 $79.8176814 N1 $0.00 $0.0076815 Z3 $51.55 $68.4076816 N1 $0.00 $0.0076817 Z3 $59.07 $78.3876818 Z3 $66.95 $88.8376819 Z3 $49.05 $65.0876820 N1 $0.00 $0.0076821 N1 $0.00 $0.00



1

2

A B C D

HCPCS




42024203420442054206420742084209421042114212421342144215421642174218421942204221422242234224422542264227422842294230423142324233423442354236423742384239424042414242424342444245424642474248424942504251425242534254425542564257

76825 Z3 $193.69 $257.0076826 Z3 $123.16 $163.4276827 N1 $0.00 $0.0076828 N1 $0.00 $0.0076830 Z2 $73.92 $98.0876831 Z3 $81.98 $108.7876856 Z2 $73.92 $98.0876857 Z3 $22.55 $29.9276870 Z3 $35.09 $46.5676872 Z3 $60.15 $79.8176873 Z3 $89.15 $118.2976881 Z2 $73.92 $98.0876882 N1 $0.00 $0.0076885 N1 $0.00 $0.0076886 N1 $0.00 $0.0076930 N1 $0.00 $0.0076932 N1 $0.00 $0.0076936 Z3 $173.99 $230.8676937 N1 $0.00 $0.0076940 N1 $0.00 $0.0076941 N1 $0.00 $0.0076942 N1 $0.00 $0.0076945 N1 $0.00 $0.0076946 N1 $0.00 $0.0076948 N1 $0.00 $0.0076950 D5 $0.00 $0.0076965 N1 $0.00 $0.0076970 N1 $0.00 $0.0076975 N1 $0.00 $0.0076977 Z3 $3.94 $5.2376998 N1 $0.00 $0.0076999 N1 $0.00 $0.0077001 N1 $0.00 $0.0077002 N1 $0.00 $0.0077003 N1 $0.00 $0.0077011 N1 $0.00 $0.0077012 N1 $0.00 $0.0077013 N1 $0.00 $0.0077014 N1 $0.00 $0.0077021 N1 $0.00 $0.0077022 N1 $0.00 $0.0077053 N1 $0.00 $0.0077054 N1 $0.00 $0.0077071 N1 $0.00 $0.0077072 N1 $0.00 $0.0077073 N1 $0.00 $0.0077074 N1 $0.00 $0.0077075 Z3 $59.43 $78.8677076 N1 $0.00 $0.0077077 N1 $0.00 $0.0077078 Z2 $32.54 $43.1877080 Z3 $29.72 $39.4377081 Z3 $16.83 $22.3377082 D5 $0.00 $0.0077084 Z2 $156.99 $208.3177085 N1 $0.00 $0.00



1

2

A B C D

HCPCS




42584259426042614262426342644265426642674268426942704271427242734274427542764277427842794280428142824283428442854286428742884289429042914292429342944295429642974298429943004301430243034304430543064307430843094310431143124313

77086 N1 $0.00 $0.0077280 Z2 $62.03 $82.3177285 Z2 $172.41 $228.7777290 Z2 $172.41 $228.7777295 Z3 $265.29 $352.0177299 Z2 $62.03 $82.3177300 Z3 $30.79 $40.8577301 Z2 $569.23 $755.3077305 D5 $0.00 $0.0077306 Z2 $62.03 $82.3177307 Z2 $62.03 $82.3177310 D5 $0.00 $0.0077315 D5 $0.00 $0.0077316 Z2 $62.03 $82.3177317 Z3 $148.22 $196.6777318 Z2 $172.41 $228.7777321 Z3 $42.96 $57.0077326 D5 $0.00 $0.0077327 D5 $0.00 $0.0077328 D5 $0.00 $0.0077331 Z3 $18.62 $24.7177332 Z3 $54.06 $71.7377333 Z3 $8.95 $11.8877334 Z3 $87.71 $116.3877336 Z2 $62.03 $82.3177338 Z2 $172.41 $228.7777370 Z2 $62.03 $82.3177371 Z2 $1,943.10 $2,578.2677372 Z3 $1,062.94 $1,410.3977373 Z2 $1,043.19 $1,384.1977385 Z2 $278.31 $369.2877386 Z2 $278.31 $369.2877387 N1 $0.00 $0.0077399 Z2 $62.03 $82.3177401 Z3 $20.41 $27.0877402 Z2 $54.89 $72.8377403 D5 $0.00 $0.0077404 D5 $0.00 $0.0077406 D5 $0.00 $0.0077407 Z2 $54.89 $72.8377408 D5 $0.00 $0.0077409 D5 $0.00 $0.0077411 D5 $0.00 $0.0077412 Z2 $105.92 $140.5477413 D5 $0.00 $0.0077414 D5 $0.00 $0.0077416 D5 $0.00 $0.0077417 N1 $0.00 $0.0077418 D5 $0.00 $0.0077421 D5 $0.00 $0.0077422 Z3 $32.94 $43.7177423 Z3 $64.80 $85.9877424 Z2 $2,974.98 $3,947.4477425 Z2 $2,974.98 $3,947.4477435 N1 $0.00 $0.0077470 Z3 $46.90 $62.23



1

2

A B C D

HCPCS




43144315431643174318431943204321432243234324432543264327432843294330433143324333433443354336433743384339434043414342434343444345434643474348434943504351435243534354435543564357435843594360436143624363436443654366436743684369

77520 Z2 $278.31 $369.2877522 Z2 $587.78 $779.9177523 Z2 $587.78 $779.9177525 Z2 $587.78 $779.9177600 Z2 $105.92 $140.5477605 Z2 $278.31 $369.2877610 Z2 $278.31 $369.2877615 Z2 $278.31 $369.2877620 Z2 $278.31 $369.2877750 Z2 $105.92 $140.5477761 Z3 $190.10 $252.2477762 Z2 $217.01 $287.9577763 Z2 $217.01 $287.9577776 Z2 $217.01 $287.9577777 Z3 $194.40 $257.9577778 Z3 $286.41 $380.0377785 Z3 $165.40 $219.4777786 Z3 $320.42 $425.1677787 Z2 $399.95 $530.6977789 Z3 $59.79 $79.3377790 N1 $0.00 $0.0077799 Z2 $217.01 $287.9578012 Z2 $103.68 $137.5778013 Z2 $104.10 $138.1378014 Z2 $154.57 $205.1078015 Z2 $206.82 $274.4378016 Z2 $206.82 $274.4378018 Z2 $206.82 $274.4378020 N1 $0.00 $0.0078070 Z2 $154.57 $205.1078071 Z2 $206.82 $274.4378072 Z2 $206.82 $274.4378075 Z2 $651.57 $864.5678099 Z2 $104.10 $138.1378102 Z2 $202.59 $268.8178103 Z2 $202.59 $268.8178104 Z2 $202.59 $268.8178110 Z2 $344.32 $456.8778111 Z2 $344.32 $456.8778120 Z2 $344.32 $456.8778121 Z2 $344.32 $456.8778122 Z2 $344.32 $456.8778130 Z2 $344.32 $456.8778135 Z2 $344.32 $456.8778140 Z2 $344.32 $456.8778185 Z2 $202.59 $268.8178190 Z2 $153.62 $203.8478191 Z2 $153.62 $203.8478195 Z2 $202.59 $268.8178199 Z2 $202.59 $268.8178201 Z2 $204.48 $271.3278202 Z2 $204.48 $271.3278205 Z2 $204.48 $271.3278206 Z2 $204.48 $271.3278215 Z2 $204.48 $271.3278216 Z2 $204.48 $271.32



1

2

A B C D

HCPCS




43704371437243734374437543764377437843794380438143824383438443854386438743884389439043914392439343944395439643974398439944004401440244034404440544064407440844094410441144124413441444154416441744184419442044214422442344244425

78226 Z2 $204.48 $271.3278227 Z2 $204.48 $271.3278230 Z2 $179.21 $237.7978231 Z2 $179.21 $237.7978232 Z2 $179.21 $237.7978258 Z2 $179.21 $237.7978261 Z2 $179.21 $237.7978262 Z2 $179.21 $237.7978264 Z2 $179.21 $237.7978270 Z2 $153.62 $203.8478271 Z2 $153.62 $203.8478272 Z2 $153.62 $203.8478278 Z2 $179.21 $237.7978282 Z2 $179.21 $237.7978290 Z2 $179.21 $237.7978291 Z2 $179.21 $237.7978299 Z2 $179.21 $237.7978300 Z2 $182.15 $241.6978305 Z2 $182.15 $241.6978306 Z2 $182.15 $241.6978315 Z2 $182.15 $241.6978320 Z2 $182.15 $241.6978399 Z2 $182.15 $241.6978414 Z2 $204.76 $271.6978428 Z2 $204.76 $271.6978445 Z2 $184.73 $245.1178451 Z2 $625.15 $829.5078452 Z2 $625.15 $829.5078453 Z2 $625.15 $829.5078454 Z2 $625.15 $829.5078456 Z2 $445.73 $591.4378457 Z2 $184.73 $245.1178458 Z2 $184.73 $245.1178459 Z2 $705.00 $935.4578466 Z2 $204.76 $271.6978468 Z2 $204.76 $271.6978469 Z2 $204.76 $271.6978472 Z2 $204.76 $271.6978473 Z2 $204.76 $271.6978481 Z2 $204.76 $271.6978483 Z2 $625.15 $829.5078491 Z2 $705.00 $935.4578492 Z2 $705.00 $935.4578494 Z2 $204.76 $271.6978496 N1 $0.00 $0.0078499 Z2 $204.76 $271.6978579 Z2 $173.14 $229.7478580 Z2 $173.14 $229.7478582 Z2 $241.36 $320.2678597 Z2 $173.14 $229.7478598 Z2 $241.36 $320.2678599 Z2 $173.14 $229.7478600 Z2 $97.05 $128.7778601 Z2 $305.44 $405.2878605 Z2 $305.44 $405.2878606 Z2 $305.44 $405.28



1

2

A B C D

HCPCS




44264427442844294430443144324433443444354436443744384439444044414442444344444445444644474448444944504451445244534454445544564457445844594460446144624463446444654466446744684469447044714472447344744475447644774478447944804481

78607 Z2 $651.57 $864.5678608 Z2 $705.00 $935.4578610 Z2 $305.44 $405.2878630 Z2 $305.44 $405.2878635 Z2 $305.44 $405.2878645 Z2 $305.44 $405.2878647 Z2 $305.44 $405.2878650 Z2 $305.44 $405.2878660 Z2 $97.05 $128.7778699 Z2 $97.05 $128.7778700 Z2 $230.57 $305.9478701 Z2 $230.57 $305.9478707 Z2 $230.57 $305.9478708 Z2 $230.57 $305.9478709 Z2 $230.57 $305.9478710 Z2 $230.57 $305.9478725 Z2 $153.62 $203.8478730 N1 $0.00 $0.0078740 Z2 $230.57 $305.9478761 Z2 $230.57 $305.9478799 Z2 $230.57 $305.9478800 Z2 $206.82 $274.4378801 Z2 $206.82 $274.4378802 Z2 $387.37 $513.9978803 Z2 $387.37 $513.9978804 Z2 $651.57 $864.5678805 Z2 $387.37 $513.9978806 Z2 $387.37 $513.9978807 Z2 $387.37 $513.9978808 N1 $0.00 $0.0078811 Z2 $705.00 $935.4578812 Z2 $705.00 $935.4578813 Z2 $705.00 $935.4578814 Z2 $705.00 $935.4578815 Z2 $705.00 $935.4578816 Z2 $705.00 $935.4578999 Z2 $103.68 $137.5779005 Z3 $49.05 $65.0879101 Z3 $47.97 $63.6579200 Z3 $51.55 $68.4079300 Z2 $151.79 $201.4179403 Z3 $79.84 $105.9479440 Z3 $40.10 $53.2179445 Z2 $151.79 $201.4179999 Z2 $151.79 $201.4190371 K2 $117.38 $155.7590375 K2 $247.57 $328.5090376 K2 $237.82 $315.5690378 K2 $1,947.79 $2,584.4890385 N1 $0.00 $0.0090396 K2 $119.45 $158.5090476 N1 $0.00 $0.0090581 K2 $94.05 $124.7990585 K2 $121.96 $161.8390632 N1 $0.00 $0.0090633 N1 $0.00 $0.00



1

2

A B C D

HCPCS




44824483448444854486448744884489449044914492449344944495449644974498449945004501450245034504450545064507450845094510451145124513451445154516451745184519452045214522452345244525452645274528452945304531453245334534453545364537

90634 N1 $0.00 $0.0090636 N1 $0.00 $0.0090645 N1 $0.00 $0.0090646 N1 $0.00 $0.0090647 N1 $0.00 $0.0090648 N1 $0.00 $0.0090654 L1 $0.00 $0.0090655 L1 $0.00 $0.0090656 L1 $0.00 $0.0090657 L1 $0.00 $0.0090660 L1 $0.00 $0.0090661 L1 $0.00 $0.0090662 L1 $0.00 $0.0090669 L1 $0.00 $0.0090670 L1 $0.00 $0.0090672 L1 $0.00 $0.0090673 L1 $0.00 $0.0090675 K2 $223.78 $296.9390676 K2 $172.30 $228.6290680 N1 $0.00 $0.0090687 L1 $0.00 $0.0090688 L1 $0.00 $0.0090690 N1 $0.00 $0.0090691 N1 $0.00 $0.0090692 N1 $0.00 $0.0090696 N1 $0.00 $0.0090698 N1 $0.00 $0.0090700 N1 $0.00 $0.0090702 N1 $0.00 $0.0090703 N1 $0.00 $0.0090704 N1 $0.00 $0.0090705 N1 $0.00 $0.0090707 N1 $0.00 $0.0090708 N1 $0.00 $0.0090710 N1 $0.00 $0.0090712 N1 $0.00 $0.0090713 N1 $0.00 $0.0090714 N1 $0.00 $0.0090715 N1 $0.00 $0.0090717 N1 $0.00 $0.0090719 N1 $0.00 $0.0090720 N1 $0.00 $0.0090721 N1 $0.00 $0.0090732 L1 $0.00 $0.0090733 K2 $106.49 $141.3090734 N1 $0.00 $0.0090735 K2 $108.29 $143.6990740 F4 $0.00 $0.0090743 F4 $0.00 $0.0090744 F4 $0.00 $0.0090746 F4 $0.00 $0.0090747 F4 $0.00 $0.0090749 N1 $0.00 $0.0091035 Z2 $180.18 $239.0891200 Z3 $21.12 $28.0292071 N1 $0.00 $0.00



1

2

A B C D

HCPCS




45384539454045414542454345444545454645474548454945504551455245534554455545564557455845594560456145624563456445654566456745684569457045714572457345744575457645774578457945804581458245834584458545864587458845894590459145924593

92072 N1 $0.00 $0.0093261 N1 $0.00 $0.0093355 N1 $0.00 $0.0093644 N1 $0.00 $0.0093895 N1 $0.00 $0.0095940 N1 $0.00 $0.0095941 N1 $0.00 $0.0099497 N1 $0.00 $0.0099498 N1 $0.00 $0.000042T N1 $0.00 $0.000073T D5 $0.00 $0.000174T N1 $0.00 $0.000175T N1 $0.00 $0.000182T Z2 $399.95 $530.690286T N1 $0.00 $0.000287T N1 $0.00 $0.000291T N1 $0.00 $0.000292T N1 $0.00 $0.000331T Z2 $625.15 $829.500332T Z2 $625.15 $829.500346T N1 $0.00 $0.00A4218 N1 $0.00 $0.00A4220 N1 $0.00 $0.00A4248 N1 $0.00 $0.00A4262 N1 $0.00 $0.00A4263 N1 $0.00 $0.00A4270 N1 $0.00 $0.00A4300 N1 $0.00 $0.00A4301 N1 $0.00 $0.00A4305 N1 $0.00 $0.00A4306 N1 $0.00 $0.00A4459 N1 $0.00 $0.00A4602 N1 $0.00 $0.00A4641 N1 $0.00 $0.00A4642 N1 $0.00 $0.00A4648 N1 $0.00 $0.00A4650 N1 $0.00 $0.00A7048 N1 $0.00 $0.00A9500 N1 $0.00 $0.00A9501 N1 $0.00 $0.00A9502 N1 $0.00 $0.00A9503 N1 $0.00 $0.00A9504 N1 $0.00 $0.00A9505 N1 $0.00 $0.00A9507 N1 $0.00 $0.00A9508 N1 $0.00 $0.00A9509 N1 $0.00 $0.00A9510 N1 $0.00 $0.00A9512 N1 $0.00 $0.00A9516 N1 $0.00 $0.00A9520 K2 $240.00 $318.45A9521 N1 $0.00 $0.00A9524 N1 $0.00 $0.00A9526 N1 $0.00 $0.00A9527 H2 $13.25 $17.58A9528 N1 $0.00 $0.00



1

2

A B C D

HCPCS




45944595459645974598459946004601460246034604460546064607460846094610461146124613461446154616461746184619462046214622462346244625462646274628462946304631463246334634463546364637463846394640464146424643464446454646464746484649

A9529 N1 $0.00 $0.00A9531 N1 $0.00 $0.00A9532 N1 $0.00 $0.00A9536 N1 $0.00 $0.00A9537 N1 $0.00 $0.00A9538 N1 $0.00 $0.00A9539 N1 $0.00 $0.00A9540 N1 $0.00 $0.00A9541 N1 $0.00 $0.00A9542 N1 $0.00 $0.00A9544 N1 $0.00 $0.00A9546 N1 $0.00 $0.00A9547 N1 $0.00 $0.00A9548 N1 $0.00 $0.00A9550 N1 $0.00 $0.00A9551 N1 $0.00 $0.00A9552 N1 $0.00 $0.00A9553 N1 $0.00 $0.00A9554 N1 $0.00 $0.00A9555 N1 $0.00 $0.00A9556 N1 $0.00 $0.00A9557 N1 $0.00 $0.00A9558 N1 $0.00 $0.00A9559 N1 $0.00 $0.00A9560 N1 $0.00 $0.00A9561 N1 $0.00 $0.00A9562 N1 $0.00 $0.00A9566 N1 $0.00 $0.00A9567 N1 $0.00 $0.00A9568 N1 $0.00 $0.00A9569 N1 $0.00 $0.00A9570 N1 $0.00 $0.00A9571 N1 $0.00 $0.00A9572 N1 $0.00 $0.00A9575 N1 $0.00 $0.00A9576 N1 $0.00 $0.00A9577 N1 $0.00 $0.00A9578 N1 $0.00 $0.00A9579 N1 $0.00 $0.00A9580 N1 $0.00 $0.00A9581 N1 $0.00 $0.00A9582 N1 $0.00 $0.00A9583 N1 $0.00 $0.00A9584 N1 $0.00 $0.00A9585 N1 $0.00 $0.00A9586 K2 $2,756.00 $3,656.88A9599 N1 $0.00 $0.00A9606 K2 $120.65 $160.09A9698 N1 $0.00 $0.00C1713 N1 $0.00 $0.00C1714 N1 $0.00 $0.00C1715 N1 $0.00 $0.00C1716 H2 $37.29 $49.48C1717 H2 $272.27 $361.27C1719 H2 $53.71 $71.27C1721 N1 $0.00 $0.00



1

2

A B C D

HCPCS




46504651465246534654465546564657465846594660466146624663466446654666466746684669467046714672467346744675467646774678467946804681468246834684468546864687468846894690469146924693469446954696469746984699470047014702470347044705

C1722 N1 $0.00 $0.00C1724 N1 $0.00 $0.00C1725 N1 $0.00 $0.00C1726 N1 $0.00 $0.00C1727 N1 $0.00 $0.00C1728 N1 $0.00 $0.00C1729 N1 $0.00 $0.00C1730 N1 $0.00 $0.00C1731 N1 $0.00 $0.00C1732 N1 $0.00 $0.00C1733 N1 $0.00 $0.00C1749 N1 $0.00 $0.00C1750 N1 $0.00 $0.00C1751 N1 $0.00 $0.00C1752 N1 $0.00 $0.00C1753 N1 $0.00 $0.00C1754 N1 $0.00 $0.00C1755 N1 $0.00 $0.00C1756 N1 $0.00 $0.00C1757 N1 $0.00 $0.00C1758 N1 $0.00 $0.00C1759 N1 $0.00 $0.00C1760 N1 $0.00 $0.00C1762 N1 $0.00 $0.00C1763 N1 $0.00 $0.00C1764 N1 $0.00 $0.00C1765 N1 $0.00 $0.00C1766 N1 $0.00 $0.00C1767 N1 $0.00 $0.00C1768 N1 $0.00 $0.00C1769 N1 $0.00 $0.00C1770 N1 $0.00 $0.00C1771 N1 $0.00 $0.00C1772 N1 $0.00 $0.00C1773 N1 $0.00 $0.00C1776 N1 $0.00 $0.00C1777 N1 $0.00 $0.00C1778 N1 $0.00 $0.00C1779 N1 $0.00 $0.00C1780 N1 $0.00 $0.00C1781 N1 $0.00 $0.00C1782 N1 $0.00 $0.00C1783 N1 $0.00 $0.00C1784 N1 $0.00 $0.00C1785 N1 $0.00 $0.00C1786 N1 $0.00 $0.00C1787 N1 $0.00 $0.00C1788 N1 $0.00 $0.00C1789 N1 $0.00 $0.00C1813 N1 $0.00 $0.00C1814 N1 $0.00 $0.00C1815 N1 $0.00 $0.00C1816 N1 $0.00 $0.00C1817 N1 $0.00 $0.00C1818 N1 $0.00 $0.00C1819 N1 $0.00 $0.00



1

2

A B C D

HCPCS




47064707470847094710471147124713471447154716471747184719472047214722472347244725472647274728472947304731473247334734473547364737473847394740474147424743474447454746474747484749475047514752475347544755475647574758475947604761

C1820 N1 $0.00 $0.00C1821 N1 $0.00 $0.00C1830 N1 $0.00 $0.00C1840 N1 $0.00 $0.00C1841 J7 $0.00 $0.00C1874 N1 $0.00 $0.00C1875 N1 $0.00 $0.00C1876 N1 $0.00 $0.00C1877 N1 $0.00 $0.00C1878 N1 $0.00 $0.00C1880 N1 $0.00 $0.00C1881 N1 $0.00 $0.00C1882 N1 $0.00 $0.00C1883 N1 $0.00 $0.00C1884 N1 $0.00 $0.00C1885 N1 $0.00 $0.00C1886 N1 $0.00 $0.00C1887 N1 $0.00 $0.00C1888 N1 $0.00 $0.00C1891 N1 $0.00 $0.00C1892 N1 $0.00 $0.00C1893 N1 $0.00 $0.00C1894 N1 $0.00 $0.00C1895 N1 $0.00 $0.00C1896 N1 $0.00 $0.00C1897 N1 $0.00 $0.00C1898 N1 $0.00 $0.00C1899 N1 $0.00 $0.00C1900 N1 $0.00 $0.00C2614 N1 $0.00 $0.00C2615 N1 $0.00 $0.00C2616 H2 $0.00 $0.00C2617 N1 $0.00 $0.00C2618 N1 $0.00 $0.00C2619 N1 $0.00 $0.00C2620 N1 $0.00 $0.00C2621 N1 $0.00 $0.00C2622 N1 $0.00 $0.00C2624 J7 $0.00 $0.00C2625 N1 $0.00 $0.00C2626 N1 $0.00 $0.00C2627 N1 $0.00 $0.00C2628 N1 $0.00 $0.00C2629 N1 $0.00 $0.00C2630 N1 $0.00 $0.00C2631 N1 $0.00 $0.00C2634 H2 $85.78 $113.82C2635 H2 $25.80 $34.23C2636 H2 $19.43 $25.78C2638 H2 $42.40 $56.26C2639 H2 $37.03 $49.13C2640 H2 $65.48 $86.88C2641 H2 $67.90 $90.10C2642 H2 $105.35 $139.79C2643 H2 $54.69 $72.57C2644 H2 $13.25 $17.58



1

2

A B C D

HCPCS




47624763476447654766476747684769477047714772477347744775477647774778477947804781478247834784478547864787478847894790479147924793479447954796479747984799480048014802480348044805480648074808480948104811481248134814481548164817

C2698 H2 $42.40 $56.26C2699 H2 $19.43 $25.78C8900 Z2 $234.07 $310.58C8901 Z2 $156.99 $208.31C8902 Z2 $264.79 $351.34C8903 Z2 $234.07 $310.58C8904 Z2 $156.99 $208.31C8905 Z2 $264.79 $351.34C8906 Z2 $234.07 $310.58C8907 Z2 $156.99 $208.31C8908 Z2 $264.79 $351.34C8909 Z2 $234.07 $310.58C8910 Z2 $156.99 $208.31C8911 Z2 $264.79 $351.34C8912 Z2 $234.07 $310.58C8913 Z2 $156.99 $208.31C8914 Z2 $264.79 $351.34C8918 Z2 $234.07 $310.58C8919 Z2 $156.99 $208.31C8920 Z2 $264.79 $351.34C8931 Z2 $234.07 $310.58C8932 Z2 $156.99 $208.31C8933 Z2 $264.79 $351.34C8934 Z2 $234.07 $310.58C8935 Z2 $156.99 $208.31C8936 Z2 $264.79 $351.34C9021 D5 $0.00 $0.00C9027 K2 $45.75 $60.70C9113 N1 $0.00 $0.00C9121 K2 $21.13 $28.04C9132 K2 $1.39 $1.84C9133 D5 $0.00 $0.00C9136 K2 $2.10 $2.79C9248 K2 $4.22 $5.60C9250 N1 $0.00 $0.00C9254 N1 $0.00 $0.00C9257 K2 $6.96 $9.24C9275 N1 $0.00 $0.00C9285 N1 $0.00 $0.00C9290 N1 $0.00 $0.00C9293 K2 $223.85 $297.02C9349 K2 $109.18 $144.87C9352 N1 $0.00 $0.00C9353 N1 $0.00 $0.00C9354 N1 $0.00 $0.00C9355 N1 $0.00 $0.00C9356 N1 $0.00 $0.00C9358 N1 $0.00 $0.00C9359 N1 $0.00 $0.00C9360 N1 $0.00 $0.00C9361 N1 $0.00 $0.00C9362 N1 $0.00 $0.00C9363 N1 $0.00 $0.00C9364 N1 $0.00 $0.00C9399 K7 $0.00 $0.00C9442 K2 $31.80 $42.19



1

2

A B C D

HCPCS




48184819482048214822482348244825482648274828482948304831483248334834483548364837483848394840484148424843484448454846484748484849485048514852485348544855485648574858485948604861486248634864486548664867486848694870487148724873

C9443 K2 $31.59 $41.92C9444 K2 $25.62 $33.99C9446 K2 $1.25 $1.66C9447 K2 $418.70 $555.56C9497 K2 $153.70 $203.94C9733 N1 $0.00 $0.00G0130 Z3 $22.91 $30.40G0288 N1 $0.00 $0.00G0453 N1 $0.00 $0.00G0464 N1 $0.00 $0.00G0472 N1 $0.00 $0.00J0120 K2 $97.97 $129.99J0129 K2 $32.25 $42.79J0130 K2 $739.17 $980.79J0131 N1 $0.00 $0.00J0132 K2 $2.19 $2.91J0133 N1 $0.00 $0.00J0135 K2 $570.94 $757.57J0150 D5 $0.00 $0.00J0151 D5 $0.00 $0.00J0153 N1 $0.00 $0.00J0171 N1 $0.00 $0.00J0178 K2 $980.50 $1,301.01J0180 K2 $152.35 $202.15J0200 K2 $38.86 $51.56J0207 K2 $310.72 $412.29J0210 N1 $0.00 $0.00J0215 K2 $41.64 $55.25J0220 K2 $206.63 $274.17J0221 K2 $153.64 $203.86J0256 K2 $4.11 $5.45J0257 K2 $3.98 $5.28J0278 N1 $0.00 $0.00J0280 N1 $0.00 $0.00J0282 N1 $0.00 $0.00J0285 N1 $0.00 $0.00J0287 K2 $10.41 $13.81J0288 N1 $0.00 $0.00J0289 K2 $16.83 $22.33J0290 N1 $0.00 $0.00J0295 N1 $0.00 $0.00J0300 K2 $146.51 $194.40J0330 N1 $0.00 $0.00J0348 N1 $0.00 $0.00J0360 N1 $0.00 $0.00J0380 N1 $0.00 $0.00J0390 N1 $0.00 $0.00J0400 N1 $0.00 $0.00J0401 K2 $3.87 $5.14J0456 N1 $0.00 $0.00J0461 N1 $0.00 $0.00J0470 N1 $0.00 $0.00J0475 K2 $162.80 $216.02J0476 K2 $76.29 $101.23J0480 K2 $2,716.18 $3,604.04J0485 K2 $3.81 $5.06



1

2

A B C D

HCPCS




48744875487648774878487948804881488248834884488548864887488848894890489148924893489448954896489748984899490049014902490349044905490649074908490949104911491249134914491549164917491849194920492149224923492449254926492749284929

J0490 K2 $39.48 $52.39J0500 N1 $0.00 $0.00J0515 N1 $0.00 $0.00J0520 N1 $0.00 $0.00J0558 N1 $0.00 $0.00J0561 N1 $0.00 $0.00J0583 K2 $3.42 $4.54J0585 K2 $5.56 $7.38J0586 K2 $7.43 $9.86J0587 K2 $11.30 $14.99J0588 K2 $4.48 $5.94J0592 N1 $0.00 $0.00J0594 K2 $28.94 $38.40J0595 N1 $0.00 $0.00J0597 K2 $37.64 $49.94J0598 K2 $51.86 $68.81J0600 K2 $3,477.51 $4,614.24J0610 N1 $0.00 $0.00J0620 N1 $0.00 $0.00J0630 K2 $69.29 $91.94J0636 N1 $0.00 $0.00J0637 K2 $11.84 $15.71J0638 K2 $90.96 $120.69J0640 N1 $0.00 $0.00J0641 K2 $1.77 $2.35J0670 N1 $0.00 $0.00J0690 N1 $0.00 $0.00J0692 N1 $0.00 $0.00J0694 N1 $0.00 $0.00J0696 N1 $0.00 $0.00J0697 N1 $0.00 $0.00J0698 N1 $0.00 $0.00J0702 N1 $0.00 $0.00J0706 N1 $0.00 $0.00J0712 N1 $0.00 $0.00J0713 N1 $0.00 $0.00J0715 N1 $0.00 $0.00J0716 K2 $1,210.30 $1,605.92J0717 K2 $6.56 $8.70J0720 N1 $0.00 $0.00J0725 K2 $18.07 $23.98J0735 N1 $0.00 $0.00J0740 K2 $588.10 $780.34J0743 N1 $0.00 $0.00J0744 N1 $0.00 $0.00J0745 N1 $0.00 $0.00J0760 N1 $0.00 $0.00J0770 N1 $0.00 $0.00J0775 K2 $38.26 $50.77J0780 N1 $0.00 $0.00J0795 K2 $7.72 $10.24J0800 K2 $3,324.92 $4,411.77J0833 K2 $84.68 $112.36J0834 N1 $0.00 $0.00J0840 K2 $2,493.12 $3,308.07J0850 K2 $1,013.87 $1,345.28



1

2

A B C D

HCPCS




49304931493249334934493549364937493849394940494149424943494449454946494749484949495049514952495349544955495649574958495949604961496249634964496549664967496849694970497149724973497449754976497749784979498049814982498349844985

J0878 K2 $0.67 $0.89J0881 K2 $3.77 $5.00J0885 K2 $11.65 $15.46J0888 N1 $0.00 $0.00J0894 K2 $28.25 $37.48J0895 N1 $0.00 $0.00J0897 K2 $14.45 $19.17J0900 D5 $0.00 $0.00J0945 N1 $0.00 $0.00J1000 N1 $0.00 $0.00J1020 N1 $0.00 $0.00J1030 N1 $0.00 $0.00J1040 N1 $0.00 $0.00J1050 N1 $0.00 $0.00J1060 D5 $0.00 $0.00J1070 D5 $0.00 $0.00J1071 N1 $0.00 $0.00J1080 D5 $0.00 $0.00J1094 N1 $0.00 $0.00J1100 N1 $0.00 $0.00J1110 N1 $0.00 $0.00J1120 N1 $0.00 $0.00J1160 N1 $0.00 $0.00J1162 K2 $2,051.63 $2,722.27J1165 N1 $0.00 $0.00J1170 N1 $0.00 $0.00J1190 K2 $144.86 $192.21J1200 N1 $0.00 $0.00J1205 K2 $122.65 $162.74J1212 N1 $0.00 $0.00J1230 N1 $0.00 $0.00J1240 N1 $0.00 $0.00J1245 N1 $0.00 $0.00J1250 N1 $0.00 $0.00J1260 N1 $0.00 $0.00J1265 N1 $0.00 $0.00J1267 N1 $0.00 $0.00J1270 N1 $0.00 $0.00J1290 K2 $375.64 $498.43J1300 K2 $206.14 $273.52J1320 N1 $0.00 $0.00J1322 K2 $222.13 $294.74J1324 K2 $18.63 $24.72J1325 N1 $0.00 $0.00J1327 K2 $24.09 $31.96J1330 N1 $0.00 $0.00J1335 N1 $0.00 $0.00J1364 K2 $45.01 $59.72J1380 N1 $0.00 $0.00J1410 K2 $180.14 $239.02J1430 K2 $311.06 $412.74J1436 N1 $0.00 $0.00J1438 K2 $285.27 $378.52J1439 K2 $1.05 $1.39J1442 K2 $0.99 $1.31J1446 K2 $3.99 $5.29



1

2

A B C D

HCPCS




49864987498849894990499149924993499449954996499749984999500050015002500350045005500650075008500950105011501250135014501550165017501850195020502150225023502450255026502750285029503050315032503350345035503650375038503950405041

J1450 N1 $0.00 $0.00J1451 K2 $9.45 $12.54J1452 N1 $0.00 $0.00J1453 K2 $1.73 $2.30J1455 N1 $0.00 $0.00J1457 N1 $0.00 $0.00J1458 K2 $359.12 $476.51J1459 K2 $37.03 $49.13J1460 N1 $0.00 $0.00J1556 K2 $36.21 $48.05J1557 K2 $35.84 $47.56J1559 K2 $7.94 $10.54J1560 N1 $0.00 $0.00J1561 K2 $40.02 $53.10J1566 K2 $26.75 $35.49J1568 K2 $36.92 $48.99J1569 K2 $39.36 $52.23J1570 N1 $0.00 $0.00J1571 K2 $53.70 $71.25J1572 K2 $37.76 $50.10J1573 K2 $68.11 $90.37J1580 N1 $0.00 $0.00J1590 N1 $0.00 $0.00J1595 K2 $188.39 $249.97J1599 N1 $0.00 $0.00J1600 K2 $4.27 $5.67J1602 K2 $24.16 $32.06J1610 K2 $146.07 $193.82J1626 N1 $0.00 $0.00J1630 N1 $0.00 $0.00J1631 N1 $0.00 $0.00J1640 K2 $20.73 $27.51J1642 N1 $0.00 $0.00J1644 N1 $0.00 $0.00J1645 N1 $0.00 $0.00J1650 N1 $0.00 $0.00J1652 N1 $0.00 $0.00J1670 K2 $326.32 $432.99J1700 N1 $0.00 $0.00J1710 N1 $0.00 $0.00J1720 N1 $0.00 $0.00J1725 K2 $1.45 $1.92J1740 K2 $151.80 $201.42J1741 N1 $0.00 $0.00J1742 K2 $112.30 $149.01J1743 K2 $483.05 $640.95J1744 K2 $192.18 $255.00J1745 K2 $74.34 $98.64J1750 K2 $12.16 $16.13J1756 N1 $0.00 $0.00J1786 K2 $42.01 $55.74J1790 N1 $0.00 $0.00J1800 N1 $0.00 $0.00J1815 N1 $0.00 $0.00J1817 N1 $0.00 $0.00J1830 K2 $243.48 $323.07



1

2

A B C D

HCPCS




50425043504450455046504750485049505050515052505350545055505650575058505950605061506250635064506550665067506850695070507150725073507450755076507750785079508050815082508350845085508650875088508950905091509250935094509550965097

J1840 N1 $0.00 $0.00J1850 N1 $0.00 $0.00J1885 N1 $0.00 $0.00J1890 N1 $0.00 $0.00J1930 K2 $41.40 $54.93J1931 K2 $29.45 $39.08J1940 N1 $0.00 $0.00J1945 K2 $235.52 $312.51J1950 K2 $829.72 $1,100.94J1953 N1 $0.00 $0.00J1956 N1 $0.00 $0.00J1960 N1 $0.00 $0.00J1980 N1 $0.00 $0.00J1990 N1 $0.00 $0.00J2001 N1 $0.00 $0.00J2010 N1 $0.00 $0.00J2020 K2 $45.66 $60.59J2060 N1 $0.00 $0.00J2150 N1 $0.00 $0.00J2170 N1 $0.00 $0.00J2175 N1 $0.00 $0.00J2180 N1 $0.00 $0.00J2185 N1 $0.00 $0.00J2210 N1 $0.00 $0.00J2212 N1 $0.00 $0.00J2248 K2 $0.98 $1.30J2250 N1 $0.00 $0.00J2260 N1 $0.00 $0.00J2265 N1 $0.00 $0.00J2270 N1 $0.00 $0.00J2271 D5 $0.00 $0.00J2274 N1 $0.00 $0.00J2275 D5 $0.00 $0.00J2278 K2 $6.87 $9.12J2280 N1 $0.00 $0.00J2300 N1 $0.00 $0.00J2310 N1 $0.00 $0.00J2315 K2 $2.88 $3.82J2320 K2 $122.78 $162.91J2323 K2 $14.91 $19.78J2325 K2 $55.27 $73.34J2353 K2 $141.87 $188.24J2354 N1 $0.00 $0.00J2355 K2 $321.88 $427.10J2357 K2 $27.85 $36.95J2358 K2 $2.75 $3.65J2360 N1 $0.00 $0.00J2370 N1 $0.00 $0.00J2400 N1 $0.00 $0.00J2405 N1 $0.00 $0.00J2410 N1 $0.00 $0.00J2425 K2 $14.85 $19.70J2426 K2 $7.91 $10.50J2430 N1 $0.00 $0.00J2440 N1 $0.00 $0.00J2469 K2 $20.01 $26.55



1

2

A B C D

HCPCS




50985099510051015102510351045105510651075108510951105111511251135114511551165117511851195120512151225123512451255126512751285129513051315132513351345135513651375138513951405141514251435144514551465147514851495150515151525153

J2501 N1 $0.00 $0.00J2503 K2 $1,034.02 $1,372.02J2504 K2 $281.40 $373.38J2505 K2 $3,403.54 $4,516.09J2507 K2 $856.64 $1,136.66J2510 N1 $0.00 $0.00J2515 K2 $35.82 $47.53J2540 N1 $0.00 $0.00J2543 N1 $0.00 $0.00J2550 N1 $0.00 $0.00J2560 N1 $0.00 $0.00J2562 K2 $301.20 $399.66J2590 N1 $0.00 $0.00J2597 K2 $5.08 $6.74J2650 N1 $0.00 $0.00J2675 N1 $0.00 $0.00J2680 N1 $0.00 $0.00J2690 N1 $0.00 $0.00J2700 N1 $0.00 $0.00J2704 N1 $0.00 $0.00J2710 N1 $0.00 $0.00J2720 N1 $0.00 $0.00J2724 K2 $14.52 $19.27J2730 K2 $89.16 $118.30J2760 K2 $113.40 $150.47J2765 N1 $0.00 $0.00J2770 K2 $245.22 $325.38J2778 K2 $396.43 $526.02J2780 N1 $0.00 $0.00J2783 K2 $218.75 $290.26J2785 N1 $0.00 $0.00J2788 N1 $0.00 $0.00J2790 N1 $0.00 $0.00J2791 K2 $4.80 $6.37J2792 K2 $18.85 $25.01J2793 K2 $0.15 $0.20J2794 K2 $6.16 $8.17J2795 N1 $0.00 $0.00J2796 K2 $53.63 $71.16J2800 N1 $0.00 $0.00J2805 N1 $0.00 $0.00J2810 N1 $0.00 $0.00J2820 K2 $30.13 $39.98J2850 K2 $34.78 $46.15J2910 N1 $0.00 $0.00J2916 N1 $0.00 $0.00J2920 N1 $0.00 $0.00J2930 N1 $0.00 $0.00J2941 K2 $50.28 $66.72J2950 N1 $0.00 $0.00J2993 K2 $2,301.91 $3,054.36J2995 N1 $0.00 $0.00J2997 K2 $64.30 $85.32J3000 N1 $0.00 $0.00J3010 N1 $0.00 $0.00J3030 N1 $0.00 $0.00



1

2

A B C D

HCPCS




51545155515651575158515951605161516251635164516551665167516851695170517151725173517451755176517751785179518051815182518351845185518651875188518951905191519251935194519551965197519851995200520152025203520452055206520752085209

J3060 K2 $31.94 $42.38J3070 K2 $140.12 $185.92J3095 K2 $4.52 $6.00J3101 K2 $86.21 $114.39J3105 N1 $0.00 $0.00J3120 D5 $0.00 $0.00J3121 N1 $0.00 $0.00J3130 D5 $0.00 $0.00J3140 D5 $0.00 $0.00J3145 K2 $1.15 $1.53J3150 D5 $0.00 $0.00J3230 N1 $0.00 $0.00J3240 K2 $1,430.43 $1,898.01J3243 K2 $2.00 $2.65J3246 K2 $9.84 $13.06J3250 N1 $0.00 $0.00J3260 N1 $0.00 $0.00J3262 K2 $3.68 $4.88J3265 N1 $0.00 $0.00J3280 N1 $0.00 $0.00J3285 K2 $61.24 $81.26J3300 K2 $3.73 $4.95J3301 N1 $0.00 $0.00J3302 N1 $0.00 $0.00J3303 N1 $0.00 $0.00J3310 N1 $0.00 $0.00J3315 K2 $170.77 $226.59J3350 K2 $39.97 $53.04J3355 K2 $130.98 $173.79J3357 K2 $162.29 $215.34J3360 N1 $0.00 $0.00J3364 N1 $0.00 $0.00J3370 N1 $0.00 $0.00J3385 K2 $353.35 $468.85J3396 K2 $10.79 $14.32J3410 N1 $0.00 $0.00J3411 N1 $0.00 $0.00J3415 N1 $0.00 $0.00J3420 N1 $0.00 $0.00J3430 N1 $0.00 $0.00J3465 K2 $3.97 $5.27J3470 N1 $0.00 $0.00J3471 N1 $0.00 $0.00J3472 N1 $0.00 $0.00J3473 N1 $0.00 $0.00J3475 N1 $0.00 $0.00J3480 N1 $0.00 $0.00J3485 K2 $1.50 $1.99J3486 N1 $0.00 $0.00J3489 K2 $47.48 $63.00J3490 N1 $0.00 $0.00J3530 N1 $0.00 $0.00J3590 N1 $0.00 $0.00J7030 N1 $0.00 $0.00J7040 N1 $0.00 $0.00J7042 N1 $0.00 $0.00



1

2

A B C D

HCPCS




52105211521252135214521552165217521852195220522152225223522452255226522752285229523052315232523352345235523652375238523952405241524252435244524552465247524852495250525152525253525452555256525752585259526052615262526352645265

J7050 N1 $0.00 $0.00J7060 N1 $0.00 $0.00J7070 N1 $0.00 $0.00J7100 N1 $0.00 $0.00J7110 N1 $0.00 $0.00J7120 N1 $0.00 $0.00J7131 N1 $0.00 $0.00J7178 K2 $0.90 $1.19J7180 N1 $0.00 $0.00J7181 K2 $13.69 $18.16J7183 K2 $0.95 $1.26J7185 K2 $1.17 $1.55J7186 K2 $0.94 $1.25J7187 K2 $0.95 $1.26J7189 K2 $1.73 $2.30J7190 K2 $0.93 $1.23J7191 K2 $0.20 $0.27J7192 K2 $1.14 $1.51J7193 K2 $1.01 $1.34J7194 K2 $1.12 $1.49J7195 K2 $1.35 $1.79J7196 K2 $103.35 $137.13J7197 K2 $3.27 $4.34J7198 K2 $1.70 $2.26J7200 K2 $1.22 $1.62J7201 K2 $3.02 $4.01J7308 K2 $242.30 $321.50J7309 K2 $106.33 $141.09J7310 K2 $16,960.00 $22,503.88J7311 K2 $19,641.05 $26,061.32J7312 K2 $201.31 $267.11J7315 K2 $57.71 $76.57J7316 K2 $1,046.75 $1,388.91J7321 K2 $90.81 $120.49J7323 K2 $160.42 $212.86J7324 K2 $186.89 $247.98J7325 K2 $12.50 $16.59J7326 K2 $562.08 $745.81J7327 K2 $977.92 $1,297.58J7335 D5 $0.00 $0.00J7336 K2 $2.65 $3.52J7500 N1 $0.00 $0.00J7501 K2 $217.30 $288.33J7502 N1 $0.00 $0.00J7504 K2 $852.69 $1,131.42J7505 N1 $0.00 $0.00J7506 N1 $0.00 $0.00J7507 N1 $0.00 $0.00J7508 K2 $0.40 $0.53J7509 N1 $0.00 $0.00J7510 N1 $0.00 $0.00J7511 K2 $594.74 $789.15J7515 N1 $0.00 $0.00J7516 N1 $0.00 $0.00J7517 N1 $0.00 $0.00J7518 N1 $0.00 $0.00



1

2

A B C D

HCPCS




52665267526852695270527152725273527452755276527752785279528052815282528352845285528652875288528952905291529252935294529552965297529852995300530153025303530453055306530753085309531053115312531353145315531653175318531953205321

J7520 N1 $0.00 $0.00J7525 K2 $141.10 $187.22J7527 N1 $0.00 $0.00J7599 N1 $0.00 $0.00J7665 N1 $0.00 $0.00J7674 N1 $0.00 $0.00J7799 N1 $0.00 $0.00J8501 K2 $7.68 $10.19J8510 N1 $0.00 $0.00J8520 K2 $8.67 $11.50J8521 K2 $28.63 $37.99J8530 N1 $0.00 $0.00J8540 N1 $0.00 $0.00J8560 K2 $57.09 $75.75J8597 N1 $0.00 $0.00J8600 N1 $0.00 $0.00J8610 N1 $0.00 $0.00J8650 K2 $28.42 $37.71J8700 K2 $5.39 $7.15J8705 K2 $94.74 $125.71J9000 N1 $0.00 $0.00J9015 K2 $2,110.63 $2,800.55J9017 K2 $53.58 $71.09J9019 K2 $354.76 $470.72J9020 K2 $64.56 $85.66J9025 K2 $4.08 $5.41J9027 K2 $134.10 $177.93J9031 K2 $121.96 $161.83J9033 K2 $22.21 $29.47J9035 K2 $66.65 $88.44J9040 N1 $0.00 $0.00J9041 K2 $46.08 $61.14J9042 K2 $110.82 $147.04J9043 K2 $142.42 $188.97J9045 N1 $0.00 $0.00J9047 K2 $29.81 $39.55J9050 K2 $1,861.12 $2,469.48J9055 K2 $53.29 $70.71J9060 N1 $0.00 $0.00J9065 K2 $21.21 $28.14J9070 K2 $63.16 $83.81J9098 K2 $561.39 $744.90J9100 N1 $0.00 $0.00J9120 K2 $807.19 $1,071.04J9130 N1 $0.00 $0.00J9150 K2 $22.56 $29.93J9151 K2 $238.92 $317.02J9155 K2 $3.55 $4.71J9171 K2 $4.66 $6.18J9175 N1 $0.00 $0.00J9178 N1 $0.00 $0.00J9179 K2 $99.01 $131.37J9181 N1 $0.00 $0.00J9185 K2 $70.98 $94.18J9190 N1 $0.00 $0.00J9200 K2 $55.65 $73.84



1

2

A B C D

HCPCS




53225323532453255326532753285329533053315332533353345335533653375338533953405341534253435344534553465347534853495350535153525353535453555356535753585359536053615362536353645365536653675368536953705371537253735374537553765377

J9201 N1 $0.00 $0.00J9202 K2 $225.02 $298.57J9206 N1 $0.00 $0.00J9207 K2 $70.21 $93.16J9208 K2 $33.41 $44.33J9209 N1 $0.00 $0.00J9211 K2 $49.11 $65.16J9213 K2 $733.57 $973.36J9214 K2 $21.17 $28.09J9215 N1 $0.00 $0.00J9216 K2 $297.17 $394.31J9217 K2 $229.26 $304.20J9218 N1 $0.00 $0.00J9225 K2 $3,001.59 $3,982.75J9226 K2 $18,317.24 $24,304.78J9228 K2 $133.61 $177.28J9230 K2 $189.63 $251.62J9245 K2 $1,226.63 $1,627.59J9250 N1 $0.00 $0.00J9260 N1 $0.00 $0.00J9261 K2 $138.87 $184.26J9262 K2 $2.48 $3.29J9263 K2 $0.58 $0.77J9264 K2 $9.70 $12.87J9265 D5 $0.00 $0.00J9266 K2 $6,220.80 $8,254.26J9267 N1 $0.00 $0.00J9268 K2 $1,483.27 $1,968.12J9270 N1 $0.00 $0.00J9280 K2 $20.88 $27.71J9293 K2 $32.34 $42.91J9301 K2 $54.27 $72.01J9302 K2 $47.76 $63.37J9303 K2 $94.79 $125.77J9305 K2 $60.27 $79.97J9306 K2 $10.22 $13.56J9307 K2 $197.12 $261.55J9310 K2 $708.68 $940.33J9315 K2 $270.64 $359.11J9320 K2 $335.28 $444.88J9328 K2 $5.68 $7.54J9330 K2 $58.83 $78.06J9340 K2 $408.51 $542.04J9351 K2 $1.83 $2.43J9354 K2 $29.14 $38.67J9355 K2 $82.49 $109.45J9357 K2 $1,085.29 $1,440.05J9360 N1 $0.00 $0.00J9370 N1 $0.00 $0.00J9371 K2 $2,148.20 $2,850.40J9390 N1 $0.00 $0.00J9395 K2 $91.27 $121.10J9400 K2 $8.12 $10.77J9600 K2 $16,231.65 $21,537.45J9999 N1 $0.00 $0.00P9041 K2 $10.91 $14.48



1

2

A B C D

HCPCS




53785379538053815382538353845385538653875388538953905391539253935394539553965397539853995400540154025403540454055406540754085409541054115412541354145415541654175418541954205421542254235424542554265427542854295430543154325433

P9045 K2 $54.54 $72.37P9046 K2 $22.49 $29.84P9047 K2 $53.44 $70.91Q0138 K2 $0.74 $0.98Q0161 N1 $0.00 $0.00Q0162 N1 $0.00 $0.00Q0163 N1 $0.00 $0.00Q0164 N1 $0.00 $0.00Q0166 N1 $0.00 $0.00Q0167 N1 $0.00 $0.00Q0169 N1 $0.00 $0.00Q0173 N1 $0.00 $0.00Q0175 N1 $0.00 $0.00Q0177 N1 $0.00 $0.00Q0180 N1 $0.00 $0.00Q0181 N1 $0.00 $0.00Q0507 N1 $0.00 $0.00Q0508 N1 $0.00 $0.00Q0509 N1 $0.00 $0.00Q2004 N1 $0.00 $0.00Q2009 N1 $0.00 $0.00Q2017 K2 $2.39 $3.17Q2034 L1 $0.00 $0.00Q2035 L1 $0.00 $0.00Q2036 L1 $0.00 $0.00Q2037 L1 $0.00 $0.00Q2038 L1 $0.00 $0.00Q2039 L1 $0.00 $0.00Q2043 K2 $35,094.12 $46,565.69Q2049 K2 $508.43 $674.63Q2050 K2 $490.49 $650.82Q3027 K2 $36.37 $48.26Q3031 N1 $0.00 $0.00Q4100 N1 $0.00 $0.00Q4101 N1 $0.00 $0.00Q4102 N1 $0.00 $0.00Q4103 N1 $0.00 $0.00Q4104 N1 $0.00 $0.00Q4105 N1 $0.00 $0.00Q4106 N1 $0.00 $0.00Q4107 N1 $0.00 $0.00Q4108 N1 $0.00 $0.00Q4110 N1 $0.00 $0.00Q4111 N1 $0.00 $0.00Q4112 N1 $0.00 $0.00Q4113 N1 $0.00 $0.00Q4114 N1 $0.00 $0.00Q4115 N1 $0.00 $0.00Q4116 N1 $0.00 $0.00Q4118 N1 $0.00 $0.00Q4119 N1 $0.00 $0.00Q4121 K2 $32.42 $43.02Q4122 K2 $130.23 $172.80Q4123 N1 $0.00 $0.00Q4124 N1 $0.00 $0.00Q4125 N1 $0.00 $0.00



1

2

A B C D

HCPCS




543454355436543754385439544054415442544354445445544654475448544954505451545254535454545554565457545854595460546154625463546454655466546754685469547054715472547354745475547654775478547954805481548254835484548554865487

Q4127 K2 $4.65 $6.17Q4128 N1 $0.00 $0.00Q4130 N1 $0.00 $0.00Q4131 N1 $0.00 $0.00Q4132 N1 $0.00 $0.00Q4133 N1 $0.00 $0.00Q4137 N1 $0.00 $0.00Q4138 N1 $0.00 $0.00Q4139 N1 $0.00 $0.00Q4140 N1 $0.00 $0.00Q4141 N1 $0.00 $0.00Q4142 N1 $0.00 $0.00Q4143 N1 $0.00 $0.00Q4145 N1 $0.00 $0.00Q4146 N1 $0.00 $0.00Q4147 N1 $0.00 $0.00Q4148 N1 $0.00 $0.00Q4149 N1 $0.00 $0.00Q4150 N1 $0.00 $0.00Q4151 N1 $0.00 $0.00Q4152 N1 $0.00 $0.00Q4153 N1 $0.00 $0.00Q4154 N1 $0.00 $0.00Q4155 N1 $0.00 $0.00Q4156 N1 $0.00 $0.00Q4157 N1 $0.00 $0.00Q4158 N1 $0.00 $0.00Q4159 N1 $0.00 $0.00Q4160 N1 $0.00 $0.00Q9951 N1 $0.00 $0.00Q9953 N1 $0.00 $0.00Q9954 N1 $0.00 $0.00Q9955 N1 $0.00 $0.00Q9956 N1 $0.00 $0.00Q9957 N1 $0.00 $0.00Q9958 N1 $0.00 $0.00Q9959 N1 $0.00 $0.00Q9960 N1 $0.00 $0.00Q9961 N1 $0.00 $0.00Q9962 N1 $0.00 $0.00Q9963 N1 $0.00 $0.00Q9964 N1 $0.00 $0.00Q9965 N1 $0.00 $0.00Q9966 N1 $0.00 $0.00Q9967 N1 $0.00 $0.00Q9968 K2 $4.39 $5.83Q9970 D5 $0.00 $0.00V2630 N1 $0.00 $0.00V2631 N1 $0.00 $0.00V2632 N1 $0.00 $0.00V2785 F4 $0.00 $0.00V2790 N1 $0.00 $0.00

Payment Indicator Description

CPT codes are a registered trademark of the American Medical Association. Applicable FARS/DFARS apply



1

2

A B C D

HCPCS




548854895490549154925493

5494

5495

5496

549754985499

5500

5501

5502

A2

D5F4

G2

H7

H8

J7

J8

K2

K7

L1

L6

N1

P2

P3

Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPSrate.

Unclassified drugs and biologicals; payment contractor-priced..

Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate payment made.

New Technology Intraocular Lens (NTIOL); special payment.

Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight

Deleted/discontinued code; no payment made.

Corneal tissue acquisition, hepatitis B vaccine; paid at reasonable cost.

Packaged service/item; no separate payment made.Packaged service/item; no separate payment made.

Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weightr-

Brachytherapy source paid separately when provided integral to a surgical procedure on ASC list; payment contractor-

Device-intensive procedure on ASC list in CY 2007; paid at adjusted rate.

OPPS pass-through device paid separately when provided integral to a surgical procedure on ASC list; payment contractorpriced.

Device-intensive procedure; paid at adjusted rate.

Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS non-facility PE RVUs; payment based on OPPS relative payment weight

Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS non-facility PE RVUs; payment based on MPFS non-facility PE RVUs.



calendar year 2015 maryland workers' compensation … · 2014-12-15 · calendar year 2015...

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