Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No....

84
Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040 Effective April 1, 2017 Link to medical fee and payment rules HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days 10021 $331.21 $190.90 N/A 11446 $1,060.45 $893.41 010 10022 $381.80 $179.45 N/A 11450 $914.57 $611.68 090 10030 $1,889.91 $426.66 000 11451 $1,165.15 $788.02 090 10035 $1,455.61 $245.31 000 11462 $893.48 $584.68 090 10036 $1,258.99 $122.18 ZZZ 11463 $1,180.34 $792.23 090 10040 $275.85 $241.49 010 11470 $987.13 $679.18 090 10060 $317.85 $265.35 010 11471 $1,224.21 $847.07 090 10061 $559.34 $489.66 010 11600 $521.16 $327.39 010 10080 $484.89 $280.62 010 11601 $620.42 $409.48 010 10081 $728.28 $462.93 010 11602 $672.92 $449.57 010 10120 $412.34 $281.58 010 11603 $769.33 $539.29 010 10121 $741.65 $506.84 010 11604 $855.23 $593.70 010 10140 $441.93 $322.62 010 11606 $1,223.67 $881.96 010 10160 $351.26 $261.53 010 11620 $525.93 $331.21 010 10180 $668.15 $488.70 010 11621 $624.24 $412.34 010 11000 $146.99 $78.27 000 11622 $695.83 $472.48 010 11001 $58.22 $39.13 ZZZ 11623 $816.10 $584.15 010 11004 $1,599.74 $1,599.74 000 11624 $921.09 $662.42 010 11005 $2,163.85 $2,163.85 000 11626 $1,108.17 $811.32 010 11006 $1,948.13 $1,948.13 000 11640 $543.11 $342.67 010 11008 $760.74 $760.74 ZZZ 11641 $645.24 $429.52 010 11010 $1,371.62 $782.69 010 11642 $736.87 $506.84 010 11011 $1,457.52 $825.64 000 11643 $868.59 $634.74 010 11012 $1,930.95 $1,174.03 000 11644 $1,069.99 $784.60 010 11042 $314.98 $168.95 000 11646 $1,399.30 $1,090.04 010 11043 $618.52 $427.62 000 11719 $38.18 $21.00 000 11044 $853.32 $634.74 000 11720 $86.86 $40.09 000 11045 $110.72 $71.59 ZZZ 11721 $121.22 $67.77 000 11046 $199.49 $154.63 ZZZ 11730 $283.49 $151.77 000 11047 $338.85 $274.90 ZZZ 11732 $85.90 $48.68 ZZZ 11055 $128.86 $43.91 000 11740 $133.63 $88.77 000 11056 $157.49 $62.04 000 11750 $414.25 $309.26 010 11057 $176.58 $81.13 000 11755 $359.85 $211.90 000 11100 $279.67 $134.58 000 11760 $510.66 $313.08 010 11101 $88.77 $68.72 ZZZ 11762 $754.05 $499.20 010 11200 $239.58 $201.40 010 11765 $452.43 $256.76 010 11201 $51.54 $45.82 ZZZ 11770 $751.19 $506.84 010 11300 $265.35 $97.36 000 11771 $1,375.23 $1,051.25 090 11301 $326.44 $147.95 000 11772 $1,666.31 $1,392.95 090 11302 $384.66 $173.72 000 11900 $150.81 $85.90 000 11303 $424.75 $205.22 000 11901 $189.95 $133.63 000 11305 $268.21 $107.86 000 11920 $461.02 $312.12 000 11306 $332.17 $143.17 000 11921 $535.47 $367.48 000 11307 $390.39 $184.22 000 11922 $166.08 $82.09 ZZZ 11308 $409.48 $202.35 000 11950 $210.94 $146.04 000 11310 $309.26 $130.77 000 11951 $271.08 $199.49 000 11311 $300.67 $180.40 000 11952 $337.89 $256.76 000 11312 $436.21 $215.72 000 11954 $428.57 $315.94 000 11313 $505.88 $276.80 000 11960 $2,299.93 $2,299.93 090 11400 $335.98 $220.49 010 11970 $1,476.48 $1,476.48 090 11401 $403.75 $284.44 010 11971 $1,124.65 $768.61 090 11402 $449.57 $312.12 010 11976 $386.57 $257.71 000 11403 $520.20 $403.75 010 11980 $254.85 $154.63 000 11404 $590.84 $444.80 010 11981 $382.75 $228.13 N/A 11406 $851.41 $676.74 010 11982 $434.30 $276.80 N/A 11420 $331.21 $223.35 010 11983 $612.79 $482.98 N/A 11421 $423.80 $301.62 010 12001 $242.44 $121.22 000 11422 $475.34 $371.30 010 12002 $293.99 $160.36 000 11423 $545.97 $429.52 010 12004 $345.53 $200.44 000 11424 $633.79 $493.48 010 12005 $436.21 $260.58 000 11426 $905.82 $754.05 010 12006 $515.43 $320.71 000 11440 $363.66 $280.62 010 12007 $592.74 $401.84 000 11441 $454.34 $357.94 010 12011 $295.89 $150.81 000 11442 $508.75 $397.07 010 12013 $308.30 $158.45 000 11443 $607.06 $487.75 010 12014 $360.80 $204.26 000 11444 $763.60 $622.33 010 12015 $437.16 $257.71 000 Appendix B for Administrative Order No. 17-050 Physician Fee Schedule CPT only copyright 2016 American Medical Association. All rights reserved. *ZZZ means the code is related to another service that is always included in the global period of the other service. Page 1 of 84

Transcript of Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No....

Page 1: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days10021 $331.21 $190.90 N/A 11446 $1,060.45 $893.41 01010022 $381.80 $179.45 N/A 11450 $914.57 $611.68 09010030 $1,889.91 $426.66 000 11451 $1,165.15 $788.02 09010035 $1,455.61 $245.31 000 11462 $893.48 $584.68 09010036 $1,258.99 $122.18 ZZZ 11463 $1,180.34 $792.23 09010040 $275.85 $241.49 010 11470 $987.13 $679.18 09010060 $317.85 $265.35 010 11471 $1,224.21 $847.07 09010061 $559.34 $489.66 010 11600 $521.16 $327.39 01010080 $484.89 $280.62 010 11601 $620.42 $409.48 01010081 $728.28 $462.93 010 11602 $672.92 $449.57 01010120 $412.34 $281.58 010 11603 $769.33 $539.29 01010121 $741.65 $506.84 010 11604 $855.23 $593.70 01010140 $441.93 $322.62 010 11606 $1,223.67 $881.96 01010160 $351.26 $261.53 010 11620 $525.93 $331.21 01010180 $668.15 $488.70 010 11621 $624.24 $412.34 01011000 $146.99 $78.27 000 11622 $695.83 $472.48 01011001 $58.22 $39.13 ZZZ 11623 $816.10 $584.15 01011004 $1,599.74 $1,599.74 000 11624 $921.09 $662.42 01011005 $2,163.85 $2,163.85 000 11626 $1,108.17 $811.32 01011006 $1,948.13 $1,948.13 000 11640 $543.11 $342.67 01011008 $760.74 $760.74 ZZZ 11641 $645.24 $429.52 01011010 $1,371.62 $782.69 010 11642 $736.87 $506.84 01011011 $1,457.52 $825.64 000 11643 $868.59 $634.74 01011012 $1,930.95 $1,174.03 000 11644 $1,069.99 $784.60 01011042 $314.98 $168.95 000 11646 $1,399.30 $1,090.04 01011043 $618.52 $427.62 000 11719 $38.18 $21.00 00011044 $853.32 $634.74 000 11720 $86.86 $40.09 00011045 $110.72 $71.59 ZZZ 11721 $121.22 $67.77 00011046 $199.49 $154.63 ZZZ 11730 $283.49 $151.77 00011047 $338.85 $274.90 ZZZ 11732 $85.90 $48.68 ZZZ11055 $128.86 $43.91 000 11740 $133.63 $88.77 00011056 $157.49 $62.04 000 11750 $414.25 $309.26 01011057 $176.58 $81.13 000 11755 $359.85 $211.90 00011100 $279.67 $134.58 000 11760 $510.66 $313.08 01011101 $88.77 $68.72 ZZZ 11762 $754.05 $499.20 01011200 $239.58 $201.40 010 11765 $452.43 $256.76 01011201 $51.54 $45.82 ZZZ 11770 $751.19 $506.84 01011300 $265.35 $97.36 000 11771 $1,375.23 $1,051.25 09011301 $326.44 $147.95 000 11772 $1,666.31 $1,392.95 09011302 $384.66 $173.72 000 11900 $150.81 $85.90 00011303 $424.75 $205.22 000 11901 $189.95 $133.63 00011305 $268.21 $107.86 000 11920 $461.02 $312.12 00011306 $332.17 $143.17 000 11921 $535.47 $367.48 00011307 $390.39 $184.22 000 11922 $166.08 $82.09 ZZZ11308 $409.48 $202.35 000 11950 $210.94 $146.04 00011310 $309.26 $130.77 000 11951 $271.08 $199.49 00011311 $300.67 $180.40 000 11952 $337.89 $256.76 00011312 $436.21 $215.72 000 11954 $428.57 $315.94 00011313 $505.88 $276.80 000 11960 $2,299.93 $2,299.93 09011400 $335.98 $220.49 010 11970 $1,476.48 $1,476.48 09011401 $403.75 $284.44 010 11971 $1,124.65 $768.61 09011402 $449.57 $312.12 010 11976 $386.57 $257.71 00011403 $520.20 $403.75 010 11980 $254.85 $154.63 00011404 $590.84 $444.80 010 11981 $382.75 $228.13 N/A11406 $851.41 $676.74 010 11982 $434.30 $276.80 N/A11420 $331.21 $223.35 010 11983 $612.79 $482.98 N/A11421 $423.80 $301.62 010 12001 $242.44 $121.22 00011422 $475.34 $371.30 010 12002 $293.99 $160.36 00011423 $545.97 $429.52 010 12004 $345.53 $200.44 00011424 $633.79 $493.48 010 12005 $436.21 $260.58 00011426 $905.82 $754.05 010 12006 $515.43 $320.71 00011440 $363.66 $280.62 010 12007 $592.74 $401.84 00011441 $454.34 $357.94 010 12011 $295.89 $150.81 00011442 $508.75 $397.07 010 12013 $308.30 $158.45 00011443 $607.06 $487.75 010 12014 $360.80 $204.26 00011444 $763.60 $622.33 010 12015 $437.16 $257.71 000

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 1 of 84

Page 2: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

12016 $552.66 $351.26 000 15150 $1,648.59 $1,514.44 09012017 $427.62 $427.62 000 15151 $330.26 $305.44 ZZZ12018 $483.93 $483.93 000 15152 $403.75 $379.89 ZZZ12020 $759.78 $516.38 010 15155 $1,728.74 $1,603.87 09012021 $440.02 $376.07 010 15156 $446.71 $423.80 ZZZ12031 $643.33 $420.93 010 15157 $503.02 $470.57 ZZZ12032 $821.82 $536.43 010 15200 $1,997.88 $1,633.40 09012034 $845.69 $570.79 010 15201 $397.07 $216.67 ZZZ12035 $1,031.81 $659.56 010 15220 $1,852.77 $1,495.04 09012036 $1,141.58 $766.46 010 15221 $370.35 $197.58 ZZZ12037 $1,305.76 $903.91 010 15240 $2,244.24 $1,948.10 09012041 $642.38 $414.25 010 15241 $501.11 $307.35 ZZZ12042 $783.64 $552.66 010 15260 $2,435.76 $2,090.69 09012044 $972.64 $590.84 010 15261 $584.15 $386.57 ZZZ12045 $1,085.27 $740.69 010 15271 $379.89 $232.90 00012046 $1,288.57 $849.50 010 15272 $73.50 $47.72 ZZZ12047 $1,486.16 $1,015.59 010 15273 $815.14 $560.29 00012051 $698.69 $471.52 010 15274 $194.72 $126.95 ZZZ12052 $797.01 $562.20 010 15275 $403.75 $263.44 00012053 $935.41 $599.43 010 15276 $94.50 $69.68 ZZZ12054 $975.50 $611.83 010 15277 $888.64 $628.06 00012055 $1,263.76 $839.01 010 15278 $232.90 $159.40 ZZZ12056 $1,328.66 $940.18 010 15570 $2,196.99 $1,786.11 09012057 $1,472.79 $1,076.68 010 15572 $2,140.47 $1,815.64 09013100 $906.77 $567.93 010 15574 $2,192.78 $1,859.51 09013101 $1,072.86 $698.69 010 15576 $1,937.98 $1,629.18 09013102 $329.30 $205.22 ZZZ 15600 $771.14 $499.47 09013120 $948.77 $650.97 010 15610 $853.82 $586.37 09013121 $1,157.81 $737.83 010 15620 $1,047.88 $786.33 09013122 $361.76 $236.72 ZZZ 15630 $1,101.03 $839.48 09013131 $1,045.18 $690.10 010 15650 $1,213.24 $928.91 09013132 $1,291.44 $869.55 010 15731 $2,708.28 $2,442.51 09013133 $485.84 $363.66 ZZZ 15732 $3,087.10 $2,702.37 09013151 $1,145.40 $793.19 010 15734 $3,623.69 $3,201.84 09013152 $1,374.48 $962.14 010 15736 $3,179.91 $2,764.80 09013153 $527.84 $391.34 ZZZ 15738 $3,374.80 $2,985.01 09013160 $1,947.26 $1,947.26 090 15740 $2,449.26 $2,072.97 09014000 $1,493.35 $1,219.15 090 15750 $2,224.84 $2,224.84 09014001 $1,927.85 $1,594.59 090 15756 $5,636.76 $5,636.76 09014020 $1,672.21 $1,379.45 090 15757 $5,558.30 $5,558.30 09014021 $2,093.22 $1,747.30 090 15758 $5,574.33 $5,574.33 09014040 $1,829.99 $1,536.38 090 15760 $2,051.03 $1,721.15 09014041 $2,268.71 $1,894.95 090 15770 $1,619.06 $1,619.06 09014060 $1,867.11 $1,636.78 090 15775 $817.05 $612.79 00014061 $2,440.82 $2,027.41 090 15776 $1,322.94 $965.00 00014301 $2,591.00 $2,146.37 090 15777 $594.65 $594.65 ZZZ14302 $610.88 $610.88 ZZZ 15780 $2,068.75 $1,569.28 09014350 $1,663.78 $1,663.78 090 15781 $1,331.36 $1,047.88 09015002 $943.05 $625.20 000 15782 $1,528.78 $1,079.94 09015003 $205.22 $125.99 ZZZ 15783 $1,145.74 $896.01 09015004 $1,087.18 $742.60 000 15786 $664.33 $373.21 01015005 $339.80 $251.99 ZZZ 15787 $133.63 $46.77 ZZZ15040 $689.15 $351.26 000 15788 $1,099.34 $593.12 09015050 $1,344.86 $1,074.03 090 15789 $1,336.42 $1,028.47 09015100 $2,062.85 $1,736.33 090 15792 $1,045.34 $620.96 09015101 $504.93 $306.39 ZZZ 15793 $1,186.24 $891.79 09015110 $1,913.51 $1,673.90 090 15819 $1,919.42 $1,919.42 09015111 $315.94 $285.40 ZZZ 15820 $1,401.39 $1,262.18 09015115 $1,929.54 $1,689.93 090 15821 $1,452.01 $1,305.20 09015116 $446.71 $408.53 ZZZ 15822 $1,066.44 $937.35 09015120 $2,044.29 $1,692.46 090 15823 $1,452.01 $1,303.52 09015121 $566.97 $367.48 ZZZ 15824 80% of billed 80% of billed 00015130 $1,603.87 $1,356.67 090 15825 80% of billed 80% of billed 00015131 $246.26 $226.22 ZZZ 15826 80% of billed 80% of billed 00015135 $2,019.82 $1,777.68 090 15828 80% of billed 80% of billed 00015136 $236.72 $222.40 ZZZ 15829 80% of billed 80% of billed 000

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 2 of 84

Page 3: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

15830 $2,849.17 $2,849.17 090 17273 $563.15 $397.07 01015832 $2,217.24 $2,217.24 090 17274 $666.24 $485.84 01015833 $2,070.44 $2,070.44 090 17276 $769.33 $580.34 01015834 $2,150.59 $2,150.59 090 17280 $381.80 $250.08 01015835 $2,213.87 $2,213.87 090 17281 $482.02 $343.62 01015836 $1,908.45 $1,908.45 090 17282 $553.61 $395.16 01015837 $2,056.10 $1,725.37 090 17283 $663.38 $494.43 01015838 $1,375.23 $1,375.23 090 17284 $757.87 $577.47 01015839 $2,121.91 $1,786.11 090 17286 $971.68 $774.10 01015840 $2,433.23 $2,433.23 090 17311 $1,793.51 $1,044.22 00015841 $3,857.40 $3,857.40 090 17312 $1,053.77 $555.52 ZZZ15842 $5,916.87 $5,916.87 090 17313 $1,676.10 $936.36 00015845 $2,412.14 $2,412.14 090 17314 $1,010.82 $515.43 ZZZ15847 80% of billed 80% of billed N/A 17315 $217.63 $146.99 ZZZ15850 $239.58 $113.59 N/A 17340 $140.31 $133.63 01015851 $267.26 $125.04 000 17360 $348.39 $270.12 01015852 $128.86 $128.86 000 17380 80% of billed 80% of billed 00015860 $302.58 $302.58 000 17999 80% of billed 80% of billed N/A15876 80% of billed 80% of billed 000 19000 $305.44 $120.27 00015877 80% of billed 80% of billed 000 19001 $73.50 $60.13 ZZZ15878 80% of billed 80% of billed 000 19020 $1,133.93 $740.77 09015879 80% of billed 80% of billed 000 19030 $447.66 $214.76 00015920 $1,502.63 $1,502.63 090 19081 $1,874.64 $466.75 00015922 $1,893.26 $1,893.26 090 19082 $1,547.24 $234.81 ZZZ15931 $1,666.31 $1,666.31 090 19083 $1,818.32 $439.07 00015933 $2,046.82 $2,046.82 090 19084 $1,487.11 $218.58 ZZZ15934 $2,259.43 $2,259.43 090 19085 $2,762.32 $512.57 00015935 $2,673.69 $2,673.69 090 19086 $2,209.67 $254.85 ZZZ15936 $2,158.18 $2,158.18 090 19100 $408.53 $192.81 00015937 $2,499.88 $2,499.88 090 19101 $925.86 $607.06 01015940 $1,694.99 $1,694.99 090 19105 $6,351.24 $551.70 00015941 $2,174.21 $2,174.21 090 19110 $1,165.15 $829.36 09015944 $2,153.97 $2,153.97 090 19112 $1,103.56 $756.80 09015945 $2,379.23 $2,379.23 090 19120 $1,188.77 $1,002.32 09015946 $3,965.39 $3,965.39 090 19125 $1,317.86 $1,112.84 09015950 $1,432.60 $1,432.60 090 19126 $446.71 $446.71 ZZZ15951 $2,102.50 $2,102.50 090 19260 $2,920.89 $2,920.89 09015952 $2,175.06 $2,175.06 090 19271 $3,946.83 $3,946.83 09015953 $2,410.45 $2,410.45 090 19272 $4,319.74 $4,319.74 09015956 $2,784.21 $2,784.21 090 19281 $650.97 $279.67 00015958 $2,840.74 $2,840.74 090 19282 $451.48 $140.31 ZZZ15999 80% of billed 80% of billed N/A 19283 $734.96 $282.53 00016000 $187.08 $125.99 000 19284 $552.66 $142.22 ZZZ16020 $221.44 $147.95 000 19285 $1,400.25 $239.58 00016025 $399.94 $305.44 000 19286 $1,220.81 $120.27 ZZZ16030 $503.98 $367.48 000 19287 $2,343.30 $357.94 00016035 $534.52 $534.52 000 19288 $1,885.14 $178.49 ZZZ16036 $224.31 $224.31 ZZZ 19296 $10,685.63 $581.29 00017000 $180.40 $145.08 010 19297 $262.49 $262.49 ZZZ17003 $15.27 $6.68 ZZZ 19298 $2,655.42 $865.73 00017004 $406.62 $272.99 010 19300 $1,258.80 $999.78 09017106 $822.61 $671.59 090 19301 $1,583.62 $1,583.62 09017107 $1,038.59 $838.64 090 19302 $2,185.18 $2,185.18 09017108 $1,545.66 $1,283.27 090 19303 $2,454.32 $2,454.32 09017110 $299.71 $190.90 010 19304 $1,398.01 $1,398.01 09017111 $356.03 $234.81 010 19305 $2,743.71 $2,743.71 09017250 $213.81 $101.18 000 19306 $2,880.39 $2,880.39 09017260 $256.76 $192.81 010 19307 $2,905.70 $2,905.70 09017261 $387.53 $251.03 010 19316 $1,869.64 $1,869.64 09017262 $473.43 $319.76 010 19318 $2,677.06 $2,677.06 09017263 $517.34 $354.12 010 19324 $1,198.05 $1,198.05 09017264 $552.66 $377.03 010 19325 $1,556.63 $1,556.63 09017266 $629.97 $443.84 010 19328 $1,199.74 $1,199.74 09017270 $407.57 $274.90 010 19330 $1,536.38 $1,536.38 09017271 $441.93 $304.49 010 19340 $2,435.76 $2,435.76 09017272 $503.98 $350.30 010 19342 $2,237.49 $2,237.49 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 3 of 84

Page 4: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

19350 $1,985.23 $1,633.40 090 20816 $5,127.17 $5,127.17 09019355 $1,681.49 $1,382.82 090 20822 $4,357.71 $4,357.71 09019357 $3,650.69 $3,650.69 090 20824 $4,751.72 $4,751.72 09019361 $3,829.55 $3,829.55 090 20827 $4,468.24 $4,468.24 09019364 $6,704.04 $6,704.04 090 20838 $6,555.55 $6,555.55 09019366 $3,429.64 $3,429.64 090 20900 $1,132.04 $521.16 00019367 $4,346.74 $4,346.74 090 20902 $786.51 $786.51 00019368 $5,357.50 $5,357.50 090 20910 $1,095.12 $1,095.12 09019369 $4,928.90 $4,928.90 090 20912 $1,154.18 $1,154.18 09019370 $1,663.78 $1,663.78 090 20920 $955.07 $955.07 09019371 $1,901.70 $1,901.70 090 20922 $1,424.17 $1,186.24 09019380 $1,876.39 $1,876.39 090 20924 $1,229.27 $1,229.27 09019396 $794.14 $401.84 000 20926 $1,025.10 $1,025.10 09019499 80% of billed 80% of billed N/A 20930 80% of billed 80% of billed N/A20005 $847.60 $643.33 010 20931 $314.03 $314.03 ZZZ20100 $1,671.33 $1,671.33 010 20936 80% of billed 80% of billed N/A20101 $1,212.21 $573.65 010 20937 $467.70 $467.70 ZZZ20102 $1,321.98 $700.60 010 20938 $517.34 $517.34 ZZZ20103 $1,584.47 $957.36 010 20950 $682.47 $250.08 00020150 $2,294.02 $2,294.02 090 20955 $6,094.89 $6,094.89 09020200 $563.15 $263.44 000 20956 $6,472.02 $6,472.02 09020205 $786.51 $430.48 000 20957 $5,526.24 $5,526.24 09020206 $637.61 $163.22 000 20962 $5,232.63 $5,232.63 09020220 $455.30 $198.54 000 20969 $6,718.38 $6,718.38 09020225 $1,413.61 $298.76 000 20970 $7,006.93 $7,006.93 09020240 $420.93 $420.93 000 20972 $5,871.31 $5,871.31 09020245 $974.54 $974.54 010 20973 $6,020.64 $6,020.64 09020250 $1,069.04 $1,069.04 010 20974 $209.99 $139.36 00020251 $1,170.22 $1,170.22 010 20975 $492.52 $492.52 00020500 $279.67 $229.08 010 20979 $141.27 $88.77 00020501 $319.76 $104.99 000 20982 $4,617.87 $1,017.50 00020520 $553.61 $400.89 010 20983 $17,032.10 $1,020.36 00020525 $1,299.07 $679.60 010 20985 $406.62 $406.62 ZZZ20526 $209.99 $158.45 000 20999 80% of billed 80% of billed N/A20527 $229.08 $183.26 000 21010 $1,837.58 $1,837.58 09020550 $143.17 $107.86 000 21011 $837.79 $628.56 09020551 $164.17 $116.45 000 21012 $822.61 $822.61 09020552 $149.86 $104.04 000 21013 $1,250.36 $973.63 09020553 $172.76 $118.36 000 21014 $1,265.55 $1,265.55 09020555 $897.23 $897.23 000 21015 $1,716.93 $1,716.93 09020600 $129.81 $97.36 000 21016 $2,478.79 $2,478.79 09020604 $196.63 $127.90 000 21025 $2,165.78 $1,835.89 09020605 $136.49 $102.13 000 21026 $1,501.79 $1,219.15 09020606 $217.63 $145.08 000 21029 $1,864.58 $1,555.78 09020610 $164.17 $126.95 000 21030 $1,262.18 $1,020.88 09020611 $247.22 $168.95 000 21031 $961.82 $723.05 09020612 $164.17 $114.54 000 21032 $972.79 $712.93 09020615 $655.74 $443.84 010 21034 $3,195.94 $2,823.86 09020650 $567.93 $432.39 010 21040 $1,270.61 $1,021.72 09020660 $681.51 $681.51 000 21044 $2,129.50 $2,129.50 09020661 $1,227.58 $1,227.58 090 21045 $2,981.64 $2,981.64 09020662 $1,052.09 $1,052.09 090 21046 $2,730.21 $2,730.21 09020663 $1,098.50 $1,098.50 090 21047 $3,209.43 $3,209.43 09020664 $2,137.94 $2,137.94 090 21048 $2,801.08 $2,801.08 09020665 $288.26 $248.17 010 21049 $2,934.39 $2,934.39 09020670 $1,028.95 $402.80 010 21050 $2,026.57 $2,026.57 09020680 $1,486.60 $1,025.94 090 21060 $1,951.48 $1,951.48 09020690 $1,444.41 $1,444.41 090 21070 $1,477.32 $1,477.32 09020692 $2,715.87 $2,715.87 090 21073 $966.04 $625.18 09020693 $1,075.72 $1,075.72 090 21076 $2,737.51 $2,298.44 01020694 $1,022.56 $818.39 090 21077 $6,110.92 $5,147.41 09020696 $2,933.54 $2,933.54 090 21079 $4,117.26 $3,429.64 09020697 $5,701.23 $5,701.23 000 21080 $4,624.32 $3,819.43 09020802 $6,727.66 $6,727.66 090 21081 $4,264.90 $3,513.17 09020805 $7,605.11 $7,605.11 090 21082 $4,021.07 $3,275.24 09020808 $9,730.39 $9,730.39 090 21083 $3,837.15 $3,049.13 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 4 of 84

Page 5: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

21084 $4,399.05 $3,532.57 090 21267 $3,847.27 $3,847.27 09021085 $2,087.49 $1,569.20 010 21268 $4,234.53 $4,234.53 09021086 $4,540.79 $3,810.99 090 21270 $2,341.27 $1,762.49 09021087 $4,517.17 $3,783.15 090 21275 $2,037.54 $2,037.54 09021088 80% of billed 80% of billed 090 21280 $1,371.86 $1,371.86 09021089 80% of billed 80% of billed N/A 21282 $917.10 $917.10 09021100 $2,016.44 $986.29 090 21295 $449.69 $449.69 09021110 $1,953.17 $1,640.15 090 21296 $1,075.72 $1,075.72 09021116 $399.94 $122.18 000 21299 80% of billed 80% of billed N/A21120 $1,452.01 $1,159.24 090 21310 $359.85 $74.45 00021121 $1,956.54 $1,640.15 090 21315 $750.24 $414.25 01021122 $1,603.03 $1,603.03 090 21320 $695.83 $369.39 01021123 $2,199.53 $2,199.53 090 21325 $1,144.90 $1,144.90 09021125 $7,720.70 $1,791.18 090 21330 $1,384.51 $1,384.51 09021127 $10,565.66 $2,171.68 090 21335 $1,749.83 $1,749.83 09021137 $1,687.40 $1,687.40 090 21336 $1,560.00 $1,560.00 09021138 $2,234.96 $2,234.96 090 21337 $973.63 $714.61 09021139 $2,633.19 $2,633.19 090 21338 $1,821.55 $1,821.55 09021141 $3,310.68 $3,310.68 090 21339 $2,052.72 $2,052.72 09021142 $3,508.95 $3,508.95 090 21340 $1,942.20 $1,942.20 09021143 $3,570.54 $3,570.54 090 21343 $2,951.26 $2,951.26 09021145 $3,901.27 $3,901.27 090 21344 $3,377.33 $3,377.33 09021146 $4,064.10 $4,064.10 090 21345 $1,947.26 $1,569.28 09021147 $4,094.48 $4,094.48 090 21346 $2,195.31 $2,195.31 09021150 $4,230.31 $4,230.31 090 21347 $2,763.12 $2,763.12 09021151 $4,903.58 $4,903.58 090 21348 $2,920.89 $2,920.89 09021154 $4,585.51 $4,585.51 090 21355 $1,229.40 $916.32 01021155 $5,088.35 $5,088.35 090 21356 $1,371.62 $1,037.54 01021159 $6,389.34 $6,389.34 090 21360 $1,310.27 $1,310.27 09021160 $6,622.20 $6,622.20 090 21365 $2,704.90 $2,704.90 09021172 $5,020.02 $5,020.02 090 21366 $2,750.46 $2,750.46 09021175 $5,137.29 $5,137.29 090 21385 $1,641.84 $1,641.84 09021179 $3,318.27 $3,318.27 090 21386 $1,686.56 $1,686.56 09021180 $3,869.21 $3,869.21 090 21387 $1,716.93 $1,716.93 09021181 $1,798.77 $1,798.77 090 21390 $1,927.85 $1,927.85 09021182 $4,814.15 $4,814.15 090 21395 $2,457.70 $2,457.70 09021183 $5,425.83 $5,425.83 090 21400 $464.04 $377.98 09021184 $6,641.61 $6,641.61 090 21401 $1,173.59 $738.24 09021188 $3,971.30 $3,971.30 090 21406 $1,386.20 $1,386.20 09021193 $2,871.11 $2,871.11 090 21407 $1,566.75 $1,566.75 09021194 $3,605.13 $3,605.13 090 21408 $2,168.31 $2,168.31 09021195 $3,210.28 $3,210.28 090 21421 $2,049.35 $1,697.52 09021196 $3,622.00 $3,622.00 090 21422 $1,645.22 $1,645.22 09021198 $2,849.17 $2,849.17 090 21423 $1,919.42 $1,919.42 09021199 $2,461.07 $2,461.07 090 21431 $1,781.89 $1,781.89 09021206 $2,968.14 $2,968.14 090 21432 $1,652.81 $1,652.81 09021208 $4,462.33 $2,050.19 090 21433 $4,229.47 $4,229.47 09021209 $1,970.88 $1,505.16 090 21435 $3,087.94 $3,087.94 09021210 $5,500.92 $2,117.69 090 21436 $4,618.41 $4,618.41 09021215 $9,694.11 $2,203.74 090 21440 $1,403.07 $1,141.53 09021230 $1,810.58 $1,810.58 090 21445 $1,863.73 $1,520.35 09021235 $1,749.83 $1,374.39 090 21450 $1,498.41 $1,202.27 09021240 $2,736.12 $2,736.12 090 21451 $1,992.82 $1,644.37 09021242 $2,517.60 $2,517.60 090 21452 $1,381.98 $817.55 09021243 $4,178.00 $4,178.00 090 21453 $2,213.87 $1,899.17 09021244 $2,590.16 $2,590.16 090 21454 $1,403.92 $1,403.92 09021245 $2,668.62 $2,143.84 090 21461 $5,174.41 $2,286.43 09021246 $2,153.97 $2,153.97 090 21462 $5,501.77 $2,550.51 09021247 $3,732.53 $3,732.53 090 21465 $2,288.96 $2,288.96 09021248 $2,703.21 $2,217.24 090 21470 $2,939.45 $2,939.45 09021249 $3,684.44 $3,134.35 090 21480 $268.21 $87.81 00021255 $3,372.27 $3,372.27 090 21485 $1,694.15 $1,419.95 09021256 $2,922.58 $2,922.58 090 21490 $2,234.12 $2,234.12 09021260 $3,035.63 $3,035.63 090 21497 $1,795.39 $1,494.19 09021261 $5,131.38 $5,131.38 090 21499 80% of billed 80% of billed N/A21263 $4,739.06 $4,739.06 090 21501 $1,089.22 $777.05 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 5 of 84

Page 6: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

21502 $1,232.65 $1,232.65 090 22326 $3,656.60 $3,656.60 09021510 $1,085.00 $1,085.00 090 22327 $3,677.69 $3,677.69 09021550 $714.92 $433.34 010 22328 $789.37 $789.37 ZZZ21552 $1,084.15 $1,084.15 090 22505 $364.62 $364.62 01021554 $1,777.68 $1,777.68 090 22510 $4,559.65 $1,205.53 01021555 $999.78 $742.46 090 22511 $4,517.65 $1,131.08 01021556 $1,284.11 $1,284.11 090 22512 $2,594.33 $579.38 ZZZ21557 $2,331.14 $2,331.14 090 22513 $19,441.26 $1,442.25 01021558 $3,273.56 $3,273.56 090 22514 $19,328.62 $1,342.03 01021600 $1,349.08 $1,349.08 090 22515 $11,794.76 $624.24 ZZZ21610 $2,882.92 $2,882.92 090 22526 $6,261.52 $927.77 01021615 $1,517.82 $1,517.82 090 22527 $5,286.98 $439.07 ZZZ21616 $1,835.89 $1,835.89 090 22532 $4,354.34 $4,354.34 09021620 $1,225.05 $1,225.05 090 22533 $4,060.73 $4,060.73 09021627 $1,311.11 $1,311.11 090 22534 $1,006.04 $1,006.04 ZZZ21630 $2,953.79 $2,953.79 090 22548 $4,799.81 $4,799.81 09021632 $2,909.92 $2,909.92 090 22551 $4,207.53 $4,207.53 09021685 $2,412.14 $2,412.14 090 22552 $1,114.86 $1,114.86 ZZZ21700 $899.38 $899.38 090 22554 $3,077.82 $3,077.82 09021705 $1,344.01 $1,344.01 090 22556 $4,093.63 $4,093.63 09021720 $1,203.96 $1,203.96 090 22558 $3,766.28 $3,766.28 09021725 $1,310.27 $1,310.27 090 22585 $917.27 $917.27 ZZZ21740 $2,505.79 $2,505.79 090 22586 $4,679.16 $4,679.16 09021742 80% of billed 80% of billed 090 22590 $3,883.55 $3,883.55 09021743 80% of billed 80% of billed 090 22595 $3,704.69 $3,704.69 09021750 $1,665.46 $1,665.46 090 22600 $3,164.72 $3,164.72 09021811 $1,678.01 $1,678.01 000 22610 $3,096.38 $3,096.38 09021812 $2,013.04 $2,013.04 000 22612 $3,892.83 $3,892.83 09021813 $2,650.65 $2,650.65 000 22614 $1,094.81 $1,094.81 ZZZ21820 $337.48 $345.92 090 22630 $3,860.77 $3,860.77 09021825 $1,311.11 $1,311.11 090 22632 $900.09 $900.09 ZZZ21899 80% of billed 80% of billed N/A 22633 $4,552.61 $4,552.61 09021920 $700.60 $440.02 010 22634 $1,388.80 $1,388.80 ZZZ21925 $1,084.15 $866.48 090 22800 $3,307.30 $3,307.30 09021930 $1,140.68 $886.73 090 22802 $5,147.41 $5,147.41 09021931 $1,143.21 $1,143.21 090 22804 $5,952.30 $5,952.30 09021932 $1,610.62 $1,610.62 090 22808 $4,534.04 $4,534.04 09021933 $1,796.24 $1,796.24 090 22810 $5,024.23 $5,024.23 09021935 $2,506.63 $2,506.63 090 22812 $5,367.62 $5,367.62 09021936 $3,443.14 $3,443.14 090 22818 $5,365.09 $5,365.09 09022010 $2,325.24 $2,325.24 090 22819 $6,700.67 $6,700.67 09022015 $2,289.80 $2,289.80 090 22830 $1,990.29 $1,990.29 09022100 $2,246.77 $2,246.77 090 22840 $2,124.72 $2,124.72 ZZZ22101 $2,074.66 $2,074.66 090 22841 80% of billed 80% of billed N/A22102 $1,901.70 $1,901.70 090 22842 $2,133.31 $2,133.31 ZZZ22103 $389.44 $389.44 ZZZ 22843 $2,282.21 $2,282.21 ZZZ22110 $2,552.19 $2,552.19 090 22844 $2,753.73 $2,753.73 ZZZ22112 $2,693.93 $2,693.93 090 22845 $2,044.54 $2,044.54 ZZZ22114 $2,410.45 $2,410.45 090 22846 $2,122.81 $2,122.81 ZZZ22116 $393.25 $393.25 ZZZ 22847 $2,322.30 $2,322.30 ZZZ22206 $6,004.61 $6,004.61 090 22848 $1,004.13 $1,004.13 ZZZ22207 $5,888.18 $5,888.18 090 22849 $3,184.97 $3,184.97 09022208 $1,623.60 $1,623.60 ZZZ 22850 $1,770.08 $1,770.08 09022210 $4,379.65 $4,379.65 090 22852 $1,694.15 $1,694.15 09022212 $3,632.97 $3,632.97 090 22853 $729.24 $729.24 ZZZ22214 $3,642.25 $3,642.25 090 22854 $944.00 $944.00 ZZZ22216 $1,013.68 $1,013.68 ZZZ 22855 $2,715.87 $2,715.87 09022220 $3,913.08 $3,913.08 090 22856 $4,017.70 $4,017.70 09022222 $3,665.88 $3,665.88 090 22857 $4,339.15 $4,339.15 09022224 $3,869.21 $3,869.21 090 22858 $1,396.43 $1,396.43 ZZZ22226 $1,008.91 $1,008.91 ZZZ 22859 $944.00 $944.00 ZZZ22310 $744.14 $685.93 090 22861 $4,809.93 $4,809.93 09022315 $2,142.15 $1,877.23 090 22862 $5,210.69 $5,210.69 09022318 $4,032.04 $4,032.04 090 22864 $5,093.42 $5,093.42 09022319 $4,496.92 $4,496.92 090 22865 $4,980.36 $4,980.36 09022325 $3,522.45 $3,522.45 090 22867 $2,408.76 $2,408.76 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 6 of 84

Page 7: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

22868 $681.51 $681.51 ZZZ 23440 $1,829.14 $1,829.14 09022869 $1,324.61 $1,324.61 090 23450 $2,304.99 $2,304.99 09022870 $397.07 $397.07 ZZZ 23455 $2,415.51 $2,415.51 09022899 80% of billed 80% of billed N/A 23460 $2,639.94 $2,639.94 09022900 $1,372.70 $1,372.70 090 23462 $2,564.00 $2,564.00 09022901 $1,622.44 $1,622.44 090 23465 $2,698.15 $2,698.15 09022902 $1,057.16 $802.36 090 23466 $2,715.87 $2,715.87 09022903 $1,067.28 $1,067.28 090 23470 $2,919.20 $2,919.20 09022904 $2,559.79 $2,559.79 090 23472 $3,541.85 $3,541.85 09022905 $3,245.71 $3,245.71 090 23473 $3,955.27 $3,955.27 09022999 80% of billed 80% of billed N/A 23474 $4,272.50 $4,272.50 09023000 $1,397.17 $893.48 090 23480 $1,988.60 $1,988.60 09023020 $1,670.53 $1,670.53 090 23485 $2,311.74 $2,311.74 09023030 $1,205.53 $702.51 010 23490 $2,035.85 $2,035.85 09023031 $1,157.81 $601.33 010 23491 $2,454.32 $2,454.32 09023035 $1,646.90 $1,646.90 090 23500 $523.94 $532.37 09023040 $1,738.02 $1,738.02 090 23505 $842.01 $795.61 09023044 $1,375.23 $1,375.23 090 23515 $1,745.62 $1,745.62 09023065 $592.74 $461.02 010 23520 $549.25 $557.69 09023066 $1,343.17 $865.64 090 23525 $895.17 $829.36 09023071 $1,019.19 $1,019.19 090 23530 $1,381.14 $1,381.14 09023073 $1,688.24 $1,688.24 090 23532 $1,500.94 $1,500.94 09023075 $1,129.71 $792.23 090 23540 $537.44 $545.87 09023076 $1,309.42 $1,309.42 090 23545 $807.42 $735.71 09023077 $2,782.52 $2,782.52 090 23550 $1,355.83 $1,355.83 09023078 $3,493.76 $3,493.76 090 23552 $1,586.16 $1,586.16 09023100 $1,208.18 $1,208.18 090 23570 $556.84 $574.56 09023101 $1,081.62 $1,081.62 090 23575 $957.60 $898.54 09023105 $1,541.44 $1,541.44 090 23585 $2,378.39 $2,378.39 09023106 $1,164.31 $1,164.31 090 23600 $782.95 $738.24 09023107 $1,602.19 $1,602.19 090 23605 $1,112.84 $1,020.03 09023120 $1,414.04 $1,414.04 090 23615 $2,144.69 $2,144.69 09023125 $1,683.18 $1,683.18 090 23616 $3,017.07 $3,017.07 09023130 $1,475.63 $1,475.63 090 23620 $645.43 $615.06 09023140 $1,305.20 $1,305.20 090 23625 $906.98 $844.54 09023145 $1,662.93 $1,662.93 090 23630 $1,889.89 $1,889.89 09023146 $1,490.82 $1,490.82 090 23650 $752.58 $691.83 09023150 $1,594.59 $1,594.59 090 23655 $967.72 $967.72 09023155 $1,914.36 $1,914.36 090 23660 $1,407.29 $1,407.29 09023156 $1,621.59 $1,621.59 090 23665 $1,022.56 $952.54 09023170 $1,357.51 $1,357.51 090 23670 $2,122.75 $2,122.75 09023172 $1,342.33 $1,342.33 090 23675 $1,320.39 $1,204.80 09023174 $1,838.42 $1,838.42 090 23680 $2,245.93 $2,245.93 09023180 $1,603.03 $1,603.03 090 23700 $537.38 $537.38 01023182 $1,592.91 $1,592.91 090 23800 $2,467.82 $2,467.82 09023184 $1,775.14 $1,775.14 090 23802 $3,105.66 $3,105.66 09023190 $1,383.67 $1,383.67 090 23900 $3,376.49 $3,376.49 09023195 $1,830.83 $1,830.83 090 23920 $2,678.75 $2,678.75 09023200 $3,673.47 $3,673.47 090 23921 $1,126.34 $1,126.34 09023210 $4,298.65 $4,298.65 090 23929 80% of billed 80% of billed N/A23220 $4,738.22 $4,738.22 090 23930 $965.95 $593.70 01023330 $672.92 $422.84 010 23931 $779.83 $437.16 01023333 $1,092.59 $1,092.59 090 23935 $1,224.21 $1,224.21 09023334 $2,615.47 $2,615.47 090 24000 $1,155.87 $1,155.87 09023335 $3,113.25 $3,113.25 090 24006 $1,723.68 $1,723.68 09023350 $353.16 $140.31 000 24065 $697.74 $461.02 01023395 $3,111.57 $3,111.57 090 24066 $1,504.32 $1,008.22 09023397 $2,774.09 $2,774.09 090 24071 $985.44 $985.44 09023400 $2,289.80 $2,289.80 090 24073 $1,683.18 $1,683.18 09023405 $1,508.54 $1,508.54 090 24075 $1,181.18 $800.67 09023406 $1,865.42 $1,865.42 090 24076 $1,317.02 $1,317.02 09023410 $1,992.82 $1,992.82 090 24077 $2,520.13 $2,520.13 09023412 $2,065.38 $2,065.38 090 24079 $3,233.90 $3,233.90 09023415 $1,689.93 $1,689.93 090 24100 $1,001.47 $1,001.47 09023420 $2,350.55 $2,350.55 090 24101 $1,203.96 $1,203.96 09023430 $1,806.36 $1,806.36 090 24102 $1,491.66 $1,491.66 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 7 of 84

Page 8: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

24105 $845.39 $845.39 090 24560 $768.61 $690.15 09024110 $1,409.82 $1,409.82 090 24565 $1,277.36 $1,174.43 09024115 $1,757.43 $1,757.43 090 24566 $1,738.02 $1,738.02 09024116 $2,093.22 $2,093.22 090 24575 $1,777.68 $1,777.68 09024120 $1,279.05 $1,279.05 090 24576 $815.01 $733.18 09024125 $1,486.60 $1,486.60 090 24577 $1,309.42 $1,203.12 09024126 $1,557.47 $1,557.47 090 24579 $2,024.88 $2,024.88 09024130 $1,227.58 $1,227.58 090 24582 $1,958.23 $1,958.23 09024134 $1,812.27 $1,812.27 090 24586 $2,626.44 $2,626.44 09024136 $1,438.51 $1,438.51 090 24587 $2,630.66 $2,630.66 09024138 $1,630.87 $1,630.87 090 24600 $873.23 $800.67 09024140 $1,703.43 $1,703.43 090 24605 $1,132.25 $1,132.25 09024145 $1,415.73 $1,415.73 090 24615 $1,725.37 $1,725.37 09024147 $1,506.85 $1,506.85 090 24620 $1,324.61 $1,324.61 09024149 $2,849.17 $2,849.17 090 24635 $1,629.18 $1,629.18 09024150 $3,790.74 $3,790.74 090 24640 $317.85 $233.85 01024152 $3,250.78 $3,250.78 090 24650 $626.87 $576.25 09024155 $2,072.13 $2,072.13 090 24655 $1,046.19 $953.38 09024160 $3,076.97 $3,076.97 090 24665 $1,579.41 $1,579.41 09024164 $1,770.93 $1,770.93 090 24666 $1,775.99 $1,775.99 09024200 $562.20 $381.80 010 24670 $696.90 $630.24 09024201 $1,318.70 $877.45 090 24675 $1,085.00 $991.35 09024220 $430.48 $188.99 000 24685 $1,581.94 $1,581.94 09024300 $1,002.32 $1,002.32 090 24800 $2,012.22 $2,012.22 09024301 $1,816.49 $1,816.49 090 24802 $2,391.89 $2,391.89 09024305 $1,394.64 $1,394.64 090 24900 $1,771.77 $1,771.77 09024310 $1,132.25 $1,132.25 090 24920 $1,746.46 $1,746.46 09024320 $1,851.92 $1,851.92 090 24925 $1,257.96 $1,257.96 09024330 $1,735.49 $1,735.49 090 24930 $1,841.80 $1,841.80 09024331 $1,882.29 $1,882.29 090 24931 $1,943.88 $1,943.88 09024332 $1,483.22 $1,483.22 090 24935 $2,357.30 $2,357.30 09024340 $1,483.22 $1,483.22 090 24940 80% of billed 80% of billed 09024341 $1,806.36 $1,806.36 090 24999 80% of billed 80% of billed N/A24342 $1,878.92 $1,878.92 090 25000 $810.80 $810.80 09024343 $1,711.87 $1,711.87 090 25001 $828.51 $828.51 09024344 $2,646.69 $2,646.69 090 25020 $1,385.36 $1,385.36 09024345 $1,703.43 $1,703.43 090 25023 $2,658.50 $2,658.50 09024346 $2,664.40 $2,664.40 090 25024 $1,878.08 $1,878.08 09024357 $1,019.19 $1,019.19 090 25025 $2,971.51 $2,971.51 09024358 $1,263.02 $1,263.02 090 25028 $1,263.02 $1,263.02 09024359 $1,596.28 $1,596.28 090 25031 $876.60 $876.60 09024360 $2,182.65 $2,182.65 090 25035 $1,408.98 $1,408.98 09024361 $2,433.23 $2,433.23 090 25040 $1,360.04 $1,360.04 09024362 $2,574.13 $2,574.13 090 25065 $689.15 $447.66 01024363 $3,540.17 $3,540.17 090 25066 $869.01 $869.01 09024365 $1,546.50 $1,546.50 090 25071 $1,032.69 $1,032.69 09024366 $1,648.59 $1,648.59 090 25073 $1,293.39 $1,293.39 09024370 $3,772.18 $3,772.18 090 25075 $1,148.28 $766.08 09024371 $4,339.15 $4,339.15 090 25076 $1,253.74 $1,253.74 09024400 $1,984.38 $1,984.38 090 25077 $2,160.72 $2,160.72 09024410 $2,568.22 $2,568.22 090 25078 $2,833.99 $2,833.99 09024420 $2,390.20 $2,390.20 090 25085 $1,082.47 $1,082.47 09024430 $2,567.38 $2,567.38 090 25100 $814.17 $814.17 09024435 $2,611.25 $2,611.25 090 25101 $974.47 $974.47 09024470 $1,625.81 $1,625.81 090 25105 $1,164.31 $1,164.31 09024495 $1,290.86 $1,290.86 090 25107 $1,489.13 $1,489.13 09024498 $2,095.75 $2,095.75 090 25109 $1,300.99 $1,300.99 09024500 $859.73 $783.80 090 25110 $824.29 $824.29 09024505 $1,198.90 $1,085.00 090 25111 $772.83 $772.83 09024515 $2,125.28 $2,125.28 090 25112 $933.98 $933.98 09024516 $2,084.78 $2,084.78 090 25115 $1,836.73 $1,836.73 09024530 $912.88 $827.67 090 25116 $1,450.32 $1,450.32 09024535 $1,477.32 $1,366.79 090 25118 $920.48 $920.48 09024538 $1,804.67 $1,804.67 090 25119 $1,192.15 $1,192.15 09024545 $2,254.37 $2,254.37 090 25120 $1,201.43 $1,201.43 09024546 $2,522.66 $2,522.66 090 25125 $1,424.17 $1,424.17 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 8 of 84

Page 9: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

25126 $1,425.01 $1,425.01 090 25455 $1,757.43 $1,757.43 09025130 $1,075.72 $1,075.72 090 25490 $1,742.24 $1,742.24 09025135 $1,349.92 $1,349.92 090 25491 $1,792.86 $1,792.86 09025136 $1,171.90 $1,171.90 090 25492 $2,193.62 $2,193.62 09025145 $1,251.21 $1,251.21 090 25500 $655.55 $602.40 09025150 $1,365.11 $1,365.11 090 25505 $1,200.59 $1,101.03 09025151 $1,408.98 $1,408.98 090 25515 $1,618.22 $1,618.22 09025170 $3,595.85 $3,595.85 090 25520 $1,359.20 $1,290.86 09025210 $1,176.96 $1,176.96 090 25525 $1,900.86 $1,900.86 09025215 $1,494.19 $1,494.19 090 25526 $2,305.83 $2,305.83 09025230 $1,044.50 $1,044.50 090 25530 $627.71 $569.50 09025240 $1,033.53 $1,033.53 090 25535 $1,172.74 $1,087.53 09025246 $438.12 $207.13 000 25545 $1,507.69 $1,507.69 09025248 $994.72 $994.72 090 25560 $665.68 $603.25 09025250 $1,282.42 $1,282.42 090 25565 $1,242.77 $1,124.65 09025251 $1,741.40 $1,741.40 090 25574 $1,631.72 $1,631.72 09025259 $1,000.63 $1,000.63 090 25575 $2,183.50 $2,183.50 09025260 $1,521.19 $1,521.19 090 25600 $786.33 $744.14 09025263 $1,508.54 $1,508.54 090 25605 $1,306.05 $1,230.11 09025265 $1,811.42 $1,811.42 090 25606 $1,603.03 $1,603.03 09025270 $1,182.87 $1,182.87 090 25607 $1,778.52 $1,778.52 09025272 $1,336.42 $1,336.42 090 25608 $1,995.35 $1,995.35 09025274 $1,600.50 $1,600.50 090 25609 $2,537.85 $2,537.85 09025275 $1,620.75 $1,620.75 090 25622 $729.80 $666.52 09025280 $1,361.73 $1,361.73 090 25624 $1,144.90 $1,045.34 09025290 $1,053.78 $1,053.78 090 25628 $1,744.77 $1,744.77 09025295 $1,267.24 $1,267.24 090 25630 $732.33 $674.12 09025300 $1,645.22 $1,645.22 090 25635 $1,009.07 $905.29 09025301 $1,555.78 $1,555.78 090 25645 $1,364.26 $1,364.26 09025310 $1,497.57 $1,497.57 090 25650 $765.24 $718.83 09025312 $1,736.33 $1,736.33 090 25651 $1,165.99 $1,165.99 09025315 $1,868.80 $1,868.80 090 25652 $1,508.54 $1,508.54 09025316 $2,207.96 $2,207.96 090 25660 $989.66 $989.66 09025320 $2,387.67 $2,387.67 090 25670 $1,465.51 $1,465.51 09025332 $2,038.38 $2,038.38 090 25671 $1,281.58 $1,281.58 09025335 $2,288.96 $2,288.96 090 25675 $1,036.91 $945.79 09025337 $2,157.34 $2,157.34 090 25676 $1,519.50 $1,519.50 09025350 $1,629.18 $1,629.18 090 25680 $1,155.87 $1,155.87 09025355 $1,844.33 $1,844.33 090 25685 $1,775.99 $1,775.99 09025360 $1,580.25 $1,580.25 090 25690 $1,139.00 $1,139.00 09025365 $2,219.77 $2,219.77 090 25695 $1,532.16 $1,532.16 09025370 $2,441.67 $2,441.67 090 25800 $1,772.61 $1,772.61 09025375 $2,312.58 $2,312.58 090 25805 $2,048.50 $2,048.50 09025390 $1,865.42 $1,865.42 090 25810 $2,103.34 $2,103.34 09025391 $2,416.36 $2,416.36 090 25820 $1,485.76 $1,485.76 09025392 $2,475.42 $2,475.42 090 25825 $1,832.52 $1,832.52 09025393 $2,720.93 $2,720.93 090 25830 $2,278.83 $2,278.83 09025394 $1,898.33 $1,898.33 090 25900 $1,715.24 $1,715.24 09025400 $1,945.57 $1,945.57 090 25905 $1,700.90 $1,700.90 09025405 $2,514.23 $2,514.23 090 25907 $1,473.94 $1,473.94 09025415 $2,347.17 $2,347.17 090 25909 $1,652.81 $1,652.81 09025420 $2,820.49 $2,820.49 090 25915 $2,460.23 $2,460.23 09025425 $2,336.21 $2,336.21 090 25920 $1,684.87 $1,684.87 09025426 $2,653.44 $2,653.44 090 25922 $1,231.80 $1,231.80 09025430 $1,772.61 $1,772.61 090 25924 $1,609.78 $1,609.78 09025431 $1,907.61 $1,907.61 090 25927 $1,946.42 $1,946.42 09025440 $1,862.89 $1,862.89 090 25929 $1,381.98 $1,381.98 09025441 $2,266.18 $2,266.18 090 25931 $1,750.68 $1,750.68 09025442 $1,951.48 $1,951.48 090 25999 80% of billed 80% of billed N/A25443 $1,877.23 $1,877.23 090 26010 $716.83 $374.16 01025444 $1,981.85 $1,981.85 090 26011 $1,056.63 $504.93 01025445 $1,748.99 $1,748.99 090 26020 $1,045.34 $1,045.34 09025446 $2,845.80 $2,845.80 090 26025 $1,019.19 $1,019.19 09025447 $2,005.47 $2,005.47 090 26030 $1,190.46 $1,190.46 09025449 $2,504.10 $2,504.10 090 26034 $1,302.67 $1,302.67 09025450 $1,252.89 $1,252.89 090 26035 $2,073.81 $2,073.81 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 9 of 84

Page 10: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

26037 $1,367.64 $1,367.64 090 26449 $1,678.12 $1,678.12 09026040 $751.74 $751.74 090 26450 $964.35 $964.35 09026045 $1,130.56 $1,130.56 090 26455 $958.44 $958.44 09026055 $1,337.26 $747.52 090 26460 $936.51 $936.51 09026060 $627.71 $627.71 090 26471 $1,462.13 $1,462.13 09026070 $761.02 $761.02 090 26474 $1,427.54 $1,427.54 09026075 $803.20 $803.20 090 26476 $1,373.54 $1,373.54 09026080 $940.73 $940.73 090 26477 $1,384.51 $1,384.51 09026100 $782.11 $782.11 090 26478 $1,473.10 $1,473.10 09026105 $804.89 $804.89 090 26479 $1,460.44 $1,460.44 09026110 $776.20 $776.20 090 26480 $1,786.96 $1,786.96 09026111 $1,010.75 $1,010.75 090 26483 $2,001.26 $2,001.26 09026113 $1,327.98 $1,327.98 090 26485 $1,918.57 $1,918.57 09026115 $1,209.87 $803.20 090 26489 $2,223.15 $2,223.15 09026116 $1,273.99 $1,273.99 090 26490 $1,900.86 $1,900.86 09026117 $1,808.89 $1,808.89 090 26492 $2,109.25 $2,109.25 09026118 $2,558.10 $2,558.10 090 26494 $1,862.05 $1,862.05 09026121 $1,443.57 $1,443.57 090 26496 $2,045.13 $2,045.13 09026123 $2,018.97 $2,018.97 090 26497 $2,068.75 $2,068.75 09026125 $755.96 $755.96 ZZZ 26498 $2,714.18 $2,714.18 09026130 $1,116.22 $1,116.22 090 26499 $1,955.70 $1,955.70 09026135 $1,327.98 $1,327.98 090 26500 $1,484.91 $1,484.91 09026140 $1,217.46 $1,217.46 090 26502 $1,689.93 $1,689.93 09026145 $1,238.55 $1,238.55 090 26508 $1,499.25 $1,499.25 09026160 $1,375.23 $804.89 090 26510 $1,414.04 $1,414.04 09026170 $979.54 $979.54 090 26516 $1,666.31 $1,666.31 09026180 $1,068.12 $1,068.12 090 26517 $1,863.73 $1,863.73 09026185 $1,312.80 $1,312.80 090 26518 $1,965.82 $1,965.82 09026200 $1,084.15 $1,084.15 090 26520 $1,545.66 $1,545.66 09026205 $1,441.88 $1,441.88 090 26525 $1,546.50 $1,546.50 09026210 $1,067.28 $1,067.28 090 26530 $1,299.30 $1,299.30 09026215 $1,350.76 $1,350.76 090 26531 $1,507.69 $1,507.69 09026230 $1,206.49 $1,206.49 090 26535 $1,020.03 $1,020.03 09026235 $1,188.77 $1,188.77 090 26536 $1,683.18 $1,683.18 09026236 $1,063.91 $1,063.91 090 26540 $1,563.38 $1,563.38 09026250 $2,616.31 $2,616.31 090 26541 $1,908.45 $1,908.45 09026260 $1,948.95 $1,948.95 090 26542 $1,614.00 $1,614.00 09026262 $1,522.88 $1,522.88 090 26545 $1,678.96 $1,678.96 09026320 $836.11 $836.11 090 26546 $2,373.33 $2,373.33 09026340 $802.36 $802.36 090 26548 $1,804.67 $1,804.67 09026341 $268.21 $205.22 010 26550 $3,931.64 $3,931.64 09026350 $1,693.31 $1,693.31 090 26551 $8,079.27 $8,079.27 09026352 $1,905.92 $1,905.92 090 26553 $6,830.60 $6,830.60 09026356 $1,916.89 $1,916.89 090 26554 $7,997.43 $7,997.43 09026357 $2,144.69 $2,144.69 090 26555 $3,075.29 $3,075.29 09026358 $2,360.67 $2,360.67 090 26556 $8,238.73 $8,238.73 09026370 $1,803.83 $1,803.83 090 26560 $1,382.82 $1,382.82 09026372 $2,051.88 $2,051.88 090 26561 $2,222.31 $2,222.31 09026373 $1,986.07 $1,986.07 090 26562 $3,192.56 $3,192.56 09026390 $1,997.04 $1,997.04 090 26565 $1,611.47 $1,611.47 09026392 $2,315.96 $2,315.96 090 26567 $1,614.84 $1,614.84 09026410 $1,342.33 $1,342.33 090 26568 $2,143.84 $2,143.84 09026412 $1,646.90 $1,646.90 090 26580 $3,587.41 $3,587.41 09026415 $1,620.75 $1,620.75 090 26587 $2,428.17 $2,428.17 09026416 $2,063.69 $2,063.69 090 26590 $3,153.75 $3,153.75 09026418 $1,371.86 $1,371.86 090 26591 $1,032.69 $1,032.69 09026420 $1,679.81 $1,679.81 090 26593 $1,427.54 $1,427.54 09026426 $1,209.87 $1,209.87 090 26596 $1,808.05 $1,808.05 09026428 $1,761.65 $1,761.65 090 26600 $704.49 $663.15 09026432 $1,184.55 $1,184.55 090 26605 $769.45 $702.80 09026433 $1,257.96 $1,257.96 090 26607 $1,096.81 $1,096.81 09026434 $1,538.07 $1,538.07 090 26608 $1,147.43 $1,147.43 09026437 $1,480.69 $1,480.69 090 26615 $1,391.26 $1,391.26 09026440 $1,470.57 $1,470.57 090 26641 $899.38 $820.92 09026442 $2,301.61 $2,301.61 090 26645 $1,025.10 $942.41 09026445 $1,368.48 $1,368.48 090 26650 $1,149.96 $1,149.96 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 10 of 84

Page 11: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

26665 $1,516.13 $1,516.13 090 27060 $1,120.43 $1,120.43 09026670 $813.33 $739.08 090 27062 $1,102.72 $1,102.72 09026675 $1,083.31 $997.25 090 27065 $1,250.36 $1,250.36 09026676 $1,203.96 $1,203.96 090 27066 $1,971.73 $1,971.73 09026685 $1,390.42 $1,390.42 090 27067 $2,484.70 $2,484.70 09026686 $1,508.54 $1,508.54 090 27070 $2,066.22 $2,066.22 09026700 $774.52 $728.11 090 27071 $2,219.77 $2,219.77 09026705 $991.35 $909.51 090 27075 $5,083.29 $5,083.29 09026706 $1,060.53 $1,060.53 090 27076 $6,153.95 $6,153.95 09026715 $1,381.98 $1,381.98 090 27077 $6,865.19 $6,865.19 09026720 $474.16 $441.26 090 27078 $5,016.64 $5,016.64 09026725 $805.73 $728.11 090 27080 $1,239.40 $1,239.40 09026727 $1,131.40 $1,131.40 090 27086 $755.01 $440.02 01026735 $1,441.04 $1,441.04 090 27087 $1,497.57 $1,497.57 09026740 $551.78 $518.88 090 27090 $2,011.38 $2,011.38 09026742 $885.89 $804.05 090 27091 $3,884.39 $3,884.39 09026746 $1,795.39 $1,795.39 090 27093 $507.79 $192.81 00026750 $439.57 $441.26 090 27095 $659.56 $229.08 00026755 $750.89 $654.71 090 27096 $431.43 $229.08 00026756 $1,004.00 $1,004.00 090 27097 $1,641.00 $1,641.00 09026765 $1,208.18 $1,208.18 090 27098 $1,548.19 $1,548.19 09026770 $658.09 $610.00 090 27100 $1,981.85 $1,981.85 09026775 $917.10 $831.89 090 27105 $2,103.34 $2,103.34 09026776 $1,066.44 $1,066.44 090 27110 $2,353.08 $2,353.08 09026785 $1,322.08 $1,322.08 090 27111 $2,189.40 $2,189.40 09026820 $1,829.14 $1,829.14 090 27120 $3,146.16 $3,146.16 09026841 $1,726.21 $1,726.21 090 27122 $2,674.53 $2,674.53 09026842 $1,866.26 $1,866.26 090 27125 $2,756.37 $2,756.37 09026843 $1,754.05 $1,754.05 090 27130 $3,299.71 $3,299.71 09026844 $1,956.54 $1,956.54 090 27132 $4,076.76 $4,076.76 09026850 $1,645.22 $1,645.22 090 27134 $4,668.19 $4,668.19 09026852 $1,894.95 $1,894.95 090 27137 $3,586.57 $3,586.57 09026860 $1,341.48 $1,341.48 090 27138 $3,725.78 $3,725.78 09026861 $285.40 $285.40 ZZZ 27140 $2,165.78 $2,165.78 09026862 $1,727.90 $1,727.90 090 27146 $3,096.38 $3,096.38 09026863 $637.61 $637.61 ZZZ 27147 $3,552.82 $3,552.82 09026910 $1,718.62 $1,718.62 090 27151 $3,876.80 $3,876.80 09026951 $1,552.41 $1,552.41 090 27156 $4,123.16 $4,123.16 09026952 $1,533.00 $1,533.00 090 27158 $3,413.61 $3,413.61 09026989 80% of billed 80% of billed N/A 27161 $2,950.42 $2,950.42 09026990 $1,516.97 $1,516.97 090 27165 $3,337.68 $3,337.68 09026991 $1,702.59 $1,267.24 090 27170 $2,859.30 $2,859.30 09026992 $2,325.24 $2,325.24 090 27175 $1,591.22 $1,591.22 09027000 $985.44 $985.44 090 27176 $2,230.74 $2,230.74 09027001 $1,311.95 $1,311.95 090 27177 $2,709.12 $2,709.12 09027003 $1,414.04 $1,414.04 090 27178 $1,948.10 $1,948.10 09027005 $1,754.05 $1,754.05 090 27179 $2,317.64 $2,317.64 09027006 $1,779.36 $1,779.36 090 27181 $3,108.19 $3,108.19 09027025 $2,212.18 $2,212.18 090 27185 $1,741.40 $1,741.40 09027027 $2,151.44 $2,151.44 090 27187 $2,407.92 $2,407.92 09027030 $2,272.08 $2,272.08 090 27197 $319.76 $319.76 00027033 $2,361.52 $2,361.52 090 27198 $815.14 $815.14 00027035 $2,576.66 $2,576.66 090 27200 $436.19 $453.91 09027036 $2,454.32 $2,454.32 090 27202 $1,344.01 $1,344.01 09027040 $937.32 $547.88 010 27215 $1,513.60 $1,513.60 09027041 $1,679.81 $1,679.81 090 27216 $2,244.24 $2,244.24 09027043 $1,144.06 $1,144.06 090 27217 $2,105.88 $2,105.88 09027045 $1,819.02 $1,819.02 090 27218 $2,910.77 $2,910.77 09027047 $1,126.34 $879.14 090 27220 $1,281.58 $1,271.46 09027048 $1,484.91 $1,484.91 090 27222 $2,365.73 $2,365.73 09027049 $3,238.12 $3,238.12 090 27226 $2,569.07 $2,569.07 09027050 $934.82 $934.82 090 27227 $4,043.85 $4,043.85 09027052 $1,404.76 $1,404.76 090 27228 $4,595.63 $4,595.63 09027054 $1,657.87 $1,657.87 090 27230 $1,147.43 $1,139.84 09027057 $2,456.01 $2,456.01 090 27232 $1,816.49 $1,816.49 09027059 $4,414.24 $4,414.24 090 27235 $2,209.65 $2,209.65 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 11 of 84

Page 12: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

27236 $2,909.08 $2,909.08 090 27386 $2,004.63 $2,004.63 09027238 $1,112.84 $1,112.84 090 27390 $1,067.28 $1,067.28 09027240 $2,325.24 $2,325.24 090 27391 $1,384.51 $1,384.51 09027244 $2,994.29 $2,994.29 090 27392 $1,695.84 $1,695.84 09027245 $2,994.29 $2,994.29 090 27393 $1,233.49 $1,233.49 09027246 $928.91 $933.98 090 27394 $1,539.75 $1,539.75 09027248 $1,802.99 $1,802.99 090 27395 $2,132.03 $2,132.03 09027250 $495.39 $495.39 000 27396 $1,483.22 $1,483.22 09027252 $1,837.58 $1,837.58 090 27397 $2,194.46 $2,194.46 09027253 $2,288.11 $2,288.11 090 27400 $1,657.87 $1,657.87 09027254 $3,082.04 $3,082.04 090 27403 $1,549.03 $1,549.03 09027256 $814.19 $642.38 010 27405 $1,632.56 $1,632.56 09027257 $937.32 $937.32 010 27407 $1,877.23 $1,877.23 09027258 $2,696.47 $2,696.47 090 27409 $2,343.80 $2,343.80 09027259 $3,782.31 $3,782.31 090 27412 $4,023.61 $4,023.61 09027265 $960.13 $960.13 090 27415 $3,342.74 $3,342.74 09027266 $1,407.29 $1,407.29 090 27416 $2,383.45 $2,383.45 09027267 $1,046.19 $1,046.19 090 27418 $1,997.88 $1,997.88 09027268 $1,284.11 $1,284.11 090 27420 $1,799.61 $1,799.61 09027269 $3,024.66 $3,024.66 090 27422 $1,799.61 $1,799.61 09027275 $498.25 $498.25 010 27424 $1,814.80 $1,814.80 09027279 $1,681.49 $1,681.49 090 27425 $1,082.47 $1,082.47 09027280 $3,323.33 $3,323.33 090 27427 $1,722.84 $1,722.84 09027282 $1,974.26 $1,974.26 090 27428 $2,696.47 $2,696.47 09027284 $3,602.60 $3,602.60 090 27429 $3,013.70 $3,013.70 09027286 $3,949.36 $3,949.36 090 27430 $1,790.33 $1,790.33 09027290 $3,914.77 $3,914.77 090 27435 $1,954.01 $1,954.01 09027295 $3,078.66 $3,078.66 090 27437 $1,603.87 $1,603.87 09027299 80% of billed 80% of billed N/A 27438 $2,036.69 $2,036.69 09027301 $1,619.06 $1,215.77 090 27440 $1,929.54 $1,929.54 09027303 $1,551.56 $1,551.56 090 27441 $2,002.10 $2,002.10 09027305 $1,160.93 $1,160.93 090 27442 $2,110.09 $2,110.09 09027306 $850.45 $850.45 090 27443 $1,973.41 $1,973.41 09027307 $1,031.00 $1,031.00 090 27445 $3,046.60 $3,046.60 09027310 $1,770.93 $1,770.93 090 27446 $2,819.65 $2,819.65 09027323 $737.83 $489.66 010 27447 $3,298.02 $3,298.02 09027324 $963.51 $963.51 090 27448 $1,867.11 $1,867.11 09027325 $1,238.55 $1,238.55 090 27450 $2,460.23 $2,460.23 09027326 $1,207.33 $1,207.33 090 27454 $3,156.28 $3,156.28 09027327 $1,105.25 $761.02 090 27455 $2,283.90 $2,283.90 09027328 $1,508.54 $1,508.54 090 27457 $2,295.71 $2,295.71 09027329 $2,528.57 $2,528.57 090 27465 $2,996.82 $2,996.82 09027330 $995.57 $995.57 090 27466 $2,853.39 $2,853.39 09027331 $1,148.28 $1,148.28 090 27468 $3,268.49 $3,268.49 09027332 $1,553.25 $1,553.25 090 27470 $2,855.92 $2,855.92 09027333 $1,419.10 $1,419.10 090 27472 $3,068.54 $3,068.54 09027334 $1,655.34 $1,655.34 090 27475 $1,603.87 $1,603.87 09027335 $1,846.86 $1,846.86 090 27477 $1,778.52 $1,778.52 09027337 $1,014.97 $1,014.97 090 27479 $2,236.65 $2,236.65 09027339 $1,831.67 $1,831.67 090 27485 $1,615.69 $1,615.69 09027340 $897.70 $897.70 090 27486 $3,422.05 $3,422.05 09027345 $1,160.09 $1,160.09 090 27487 $4,280.09 $4,280.09 09027347 $1,279.05 $1,279.05 090 27488 $2,917.51 $2,917.51 09027350 $1,576.03 $1,576.03 090 27495 $2,734.43 $2,734.43 09027355 $1,459.60 $1,459.60 090 27496 $1,300.14 $1,300.14 09027356 $1,780.21 $1,780.21 090 27497 $1,399.70 $1,399.70 09027357 $1,972.57 $1,972.57 090 27498 $1,575.19 $1,575.19 09027358 $771.24 $771.24 ZZZ 27499 $1,674.74 $1,674.74 09027360 $2,058.63 $2,058.63 090 27500 $1,252.05 $1,160.09 09027364 $3,798.34 $3,798.34 090 27501 $1,217.46 $1,207.33 09027365 $5,024.23 $5,024.23 090 27502 $1,842.64 $1,842.64 09027370 $417.12 $139.36 000 27503 $1,938.82 $1,938.82 09027372 $1,451.16 $972.79 090 27506 $3,252.46 $3,252.46 09027380 $1,434.29 $1,434.29 090 27507 $2,364.05 $2,364.05 09027381 $1,933.76 $1,933.76 090 27508 $1,265.55 $1,191.30 09027385 $1,387.89 $1,387.89 090 27509 $1,553.25 $1,553.25 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 12 of 84

Page 13: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

27510 $1,652.81 $1,652.81 090 27656 $1,496.72 $944.94 09027511 $2,424.79 $2,424.79 090 27658 $902.76 $902.76 09027513 $3,017.91 $3,017.91 090 27659 $1,158.40 $1,158.40 09027514 $2,350.55 $2,350.55 090 27664 $877.45 $877.45 09027516 $1,221.68 $1,147.43 090 27665 $993.88 $993.88 09027517 $1,551.56 $1,551.56 090 27675 $1,187.09 $1,187.09 09027519 $2,169.15 $2,169.15 090 27676 $1,470.57 $1,470.57 09027520 $775.36 $708.71 090 27680 $1,040.28 $1,040.28 09027524 $1,823.24 $1,823.24 090 27681 $1,324.61 $1,324.61 09027530 $724.74 $673.27 090 27685 $1,604.72 $1,123.81 09027532 $1,484.91 $1,395.48 090 27686 $1,354.98 $1,354.98 09027535 $2,180.96 $2,180.96 090 27687 $1,099.34 $1,099.34 09027536 $2,890.52 $2,890.52 090 27690 $1,534.69 $1,534.69 09027538 $1,146.59 $1,074.87 090 27691 $1,813.11 $1,813.11 09027540 $1,968.35 $1,968.35 090 27692 $289.21 $289.21 ZZZ27550 $1,221.68 $1,133.93 090 27695 $1,155.87 $1,155.87 09027552 $1,516.97 $1,516.97 090 27696 $1,338.95 $1,338.95 09027556 $2,097.44 $2,097.44 090 27698 $1,553.25 $1,553.25 09027557 $2,483.85 $2,483.85 090 27700 $1,476.48 $1,476.48 09027558 $2,910.77 $2,910.77 090 27702 $2,339.58 $2,339.58 09027560 $863.95 $798.14 090 27703 $2,693.09 $2,693.09 09027562 $1,147.43 $1,147.43 090 27704 $1,392.95 $1,392.95 09027566 $2,158.18 $2,158.18 090 27705 $1,838.42 $1,838.42 09027570 $413.30 $413.30 010 27707 $967.72 $967.72 09027580 $3,491.23 $3,491.23 090 27709 $2,847.49 $2,847.49 09027590 $1,958.23 $1,958.23 090 27712 $2,688.87 $2,688.87 09027591 $2,347.17 $2,347.17 090 27715 $2,553.04 $2,553.04 09027592 $1,668.84 $1,668.84 090 27720 $2,121.91 $2,121.91 09027594 $1,230.11 $1,230.11 090 27722 $2,162.40 $2,162.40 09027596 $1,763.33 $1,763.33 090 27724 $3,073.60 $3,073.60 09027598 $1,748.15 $1,748.15 090 27725 $2,895.58 $2,895.58 09027599 80% of billed 80% of billed N/A 27726 $2,338.74 $2,338.74 09027600 $990.50 $990.50 090 27727 $2,167.47 $2,167.47 09027601 $1,083.31 $1,083.31 090 27730 $1,342.33 $1,342.33 09027602 $1,190.46 $1,190.46 090 27732 $897.70 $897.70 09027603 $1,273.99 $939.04 090 27734 $1,590.37 $1,590.37 09027604 $1,182.02 $831.89 090 27740 $1,681.49 $1,681.49 09027605 $934.46 $507.79 010 27742 $1,829.99 $1,829.99 09027606 $773.14 $773.14 010 27745 $1,833.36 $1,833.36 09027607 $1,473.94 $1,473.94 090 27750 $832.73 $764.39 09027610 $1,574.34 $1,574.34 090 27752 $1,292.55 $1,194.68 09027612 $1,364.26 $1,364.26 090 27756 $1,396.32 $1,396.32 09027613 $688.19 $446.71 010 27758 $2,162.40 $2,162.40 09027614 $1,398.85 $984.60 090 27759 $2,425.64 $2,425.64 09027615 $2,487.23 $2,487.23 090 27760 $798.98 $729.80 09027616 $3,088.79 $3,088.79 090 27762 $1,131.40 $1,031.85 09027618 $1,086.69 $748.36 090 27766 $1,474.79 $1,474.79 09027619 $1,133.93 $1,133.93 090 27767 $673.27 $677.49 09027620 $1,101.03 $1,101.03 090 27768 $1,058.00 $1,058.00 09027625 $1,403.92 $1,403.92 090 27769 $1,752.36 $1,752.36 09027626 $1,466.35 $1,466.35 090 27780 $734.86 $669.90 09027630 $1,349.08 $882.51 090 27781 $1,025.94 $952.54 09027632 $1,003.16 $1,003.16 090 27784 $1,732.96 $1,732.96 09027634 $1,664.62 $1,664.62 090 27786 $758.49 $687.62 09027635 $1,418.26 $1,418.26 090 27788 $1,011.60 $924.70 09027637 $1,847.70 $1,847.70 090 27792 $1,581.09 $1,581.09 09027638 $1,848.55 $1,848.55 090 27808 $802.36 $721.36 09027640 $2,024.04 $2,024.04 090 27810 $1,120.43 $1,017.50 09027641 $1,619.06 $1,619.06 090 27814 $1,870.48 $1,870.48 09027645 $4,319.74 $4,319.74 090 27816 $772.83 $694.37 09027646 $3,611.88 $3,611.88 090 27818 $1,162.62 $1,043.66 09027647 $2,489.76 $2,489.76 090 27822 $2,081.41 $2,081.41 09027648 $449.57 $145.08 000 27823 $2,360.67 $2,360.67 09027650 $1,594.59 $1,594.59 090 27824 $754.27 $733.18 09027652 $1,659.56 $1,659.56 090 27825 $1,311.95 $1,192.15 09027654 $1,716.09 $1,716.09 090 27826 $2,061.16 $2,061.16 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 13 of 84

Page 14: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

27827 $2,666.94 $2,666.94 090 28116 $1,850.23 $1,391.26 09027828 $3,190.03 $3,190.03 090 28118 $1,441.04 $998.94 09027829 $1,685.71 $1,685.71 090 28119 $1,279.89 $876.60 09027830 $906.13 $845.39 090 28120 $1,645.22 $1,206.49 09027831 $912.88 $912.88 090 28122 $1,459.60 $1,068.97 09027832 $1,835.05 $1,835.05 090 28124 $1,163.46 $802.36 09027840 $885.04 $885.04 090 28126 $965.19 $604.09 09027842 $1,192.15 $1,192.15 090 28130 $1,560.85 $1,560.85 09027846 $1,765.86 $1,765.86 090 28140 $1,451.16 $1,067.28 09027848 $1,955.70 $1,955.70 090 28150 $1,039.44 $680.87 09027860 $473.43 $473.43 010 28153 $1,001.47 $639.52 09027870 $2,500.73 $2,500.73 090 28160 $1,023.41 $653.02 09027871 $1,659.56 $1,659.56 090 28171 $2,059.47 $2,059.47 09027880 $2,244.24 $2,244.24 090 28173 $1,845.17 $1,845.17 09027881 $2,116.84 $2,116.84 090 28175 $1,189.62 $1,189.62 09027882 $1,468.04 $1,468.04 090 28190 $708.24 $367.48 01027884 $1,405.60 $1,405.60 090 28192 $1,142.37 $761.02 09027886 $1,606.40 $1,606.40 090 28193 $1,295.08 $896.85 09027888 $1,676.43 $1,676.43 090 28200 $1,197.21 $782.11 09027889 $1,584.47 $1,584.47 090 28202 $1,446.10 $1,030.16 09027892 $1,349.08 $1,349.08 090 28208 $1,162.62 $761.86 09027893 $1,468.88 $1,468.88 090 28210 $1,421.63 $1,007.38 09027894 $2,083.94 $2,083.94 090 28220 $1,101.87 $735.71 09027899 80% of billed 80% of billed N/A 28222 $1,236.86 $848.76 09028001 $759.78 $464.84 010 28225 $1,007.38 $634.46 09028002 $1,212.21 $872.41 010 28226 $1,194.68 $769.45 09028003 $1,703.43 $1,360.89 090 28230 $1,062.22 $689.30 09028005 $1,399.70 $1,399.70 090 28232 $944.94 $590.59 09028008 $1,053.78 $712.93 090 28234 $995.57 $640.37 09028010 $561.90 $506.22 090 28238 $1,632.56 $1,181.18 09028011 $777.89 $695.21 090 28240 $1,101.87 $719.68 09028020 $1,314.48 $879.14 090 28250 $1,408.14 $978.69 09028022 $1,182.02 $785.48 090 28260 $1,688.24 $1,250.36 09028024 $1,117.90 $737.39 090 28261 $2,439.14 $1,922.79 09028035 $1,284.11 $863.11 090 28262 $3,574.76 $2,877.02 09028039 $1,235.18 $849.61 090 28264 $2,130.34 $1,634.25 09028041 $1,110.31 $1,110.31 090 28270 $1,200.59 $812.48 09028043 $977.00 $639.52 090 28272 $961.82 $617.59 09028045 $1,209.87 $846.23 090 28280 $1,258.80 $848.76 09028046 $1,770.08 $1,770.08 090 28285 $1,304.36 $917.95 09028047 $2,587.63 $2,587.63 090 28286 $1,098.50 $725.58 09028050 $1,156.71 $751.74 090 28288 $1,471.41 $1,041.97 09028052 $1,079.94 $688.46 090 28289 $1,820.70 $1,128.87 09028054 $937.35 $583.84 090 28291 $1,783.58 $1,167.68 09028055 $915.41 $915.41 090 28292 $1,820.70 $1,174.43 09028060 $1,259.64 $865.64 090 28295 $2,286.43 $1,300.99 09028062 $1,430.07 $990.50 090 28296 $2,221.46 $1,251.21 09028070 $1,308.58 $870.70 090 28297 $2,552.19 $1,463.82 09028072 $1,241.08 $809.95 090 28298 $2,071.28 $1,203.96 09028080 $1,280.74 $892.63 090 28299 $2,440.82 $1,407.29 09028086 $1,328.83 $874.07 090 28300 $1,580.25 $1,580.25 09028088 $1,087.53 $685.08 090 28302 $1,737.18 $1,737.18 09028090 $1,145.74 $748.36 090 28304 $2,016.44 $1,476.48 09028092 $1,034.38 $654.71 090 28305 $1,618.22 $1,618.22 09028100 $1,477.32 $1,002.32 090 28306 $1,498.41 $981.22 09028102 $1,468.04 $1,468.04 090 28307 $1,624.97 $1,070.66 09028103 $963.51 $963.51 090 28308 $1,382.82 $917.10 09028104 $1,286.64 $858.89 090 28309 $2,186.87 $2,186.87 09028106 $1,041.13 $1,041.13 090 28310 $1,336.42 $871.54 09028107 $1,260.49 $848.76 090 28312 $1,240.24 $774.52 09028108 $1,072.34 $700.27 090 28313 $1,284.11 $868.17 09028110 $1,129.71 $703.65 090 28315 $1,176.96 $792.23 09028111 $1,201.43 $792.23 090 28320 $1,485.76 $1,485.76 09028112 $1,192.99 $761.02 090 28322 $1,915.20 $1,400.54 09028113 $1,441.04 $1,032.69 090 28340 $1,410.67 $1,004.00 09028114 $2,617.16 $2,036.69 090 28341 $1,636.78 $1,194.68 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 14 of 84

Page 15: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

28344 $1,359.20 $865.64 090 28899 80% of billed 80% of billed N/A28345 $1,294.24 $900.23 090 29000 $819.92 $498.25 00028360 $2,237.49 $2,237.49 090 29010 $596.56 $379.89 00028400 $599.03 $547.56 090 29015 $727.33 $464.84 00028405 $948.32 $861.42 090 29035 $697.74 $396.12 00028406 $1,259.64 $1,259.64 090 29040 $615.65 $399.94 00028415 $2,725.99 $2,725.99 090 29044 $681.51 $420.93 00028420 $3,088.79 $3,088.79 090 29046 $713.01 $454.34 00028430 $569.50 $506.22 090 29049 $200.44 $154.63 00028435 $776.20 $694.37 090 29055 $599.43 $377.98 00028436 $1,077.40 $1,077.40 090 29058 $335.03 $257.71 00028445 $2,581.72 $2,581.72 090 29065 $261.53 $187.08 00028446 $2,930.17 $2,930.17 090 29075 $236.72 $170.86 00028450 $520.56 $464.04 090 29085 $260.58 $186.13 00028455 $694.37 $624.34 090 29086 $207.13 $136.49 00028456 $761.02 $761.02 090 29105 $239.58 $163.22 00028465 $1,523.72 $1,523.72 090 29125 $175.63 $107.86 00028470 $527.31 $492.72 090 29126 $206.17 $131.72 00028475 $616.74 $548.41 090 29130 $111.68 $78.27 00028476 $852.14 $852.14 090 29131 $138.40 $90.68 00028485 $1,312.80 $1,312.80 090 29200 $81.13 $49.63 00028490 $350.98 $302.04 090 29240 $77.31 $49.63 00028495 $430.29 $362.79 090 29260 $78.27 $53.45 00028496 $1,086.69 $577.09 090 29280 $78.27 $53.45 00028505 $1,628.34 $1,215.77 090 29305 $669.10 $435.25 00028510 $298.67 $290.23 090 29325 $744.51 $488.70 00028515 $390.63 $345.07 090 29345 $372.25 $277.76 00028525 $1,372.70 $962.66 090 29355 $384.66 $293.03 00028530 $278.42 $247.20 090 29358 $438.12 $285.40 00028531 $835.26 $442.10 090 29365 $335.03 $240.53 00028540 $465.72 $421.01 090 29405 $223.35 $165.13 00028545 $714.61 $634.46 090 29425 $213.81 $155.58 00028546 $1,364.26 $803.20 090 29435 $320.71 $229.08 00028555 $2,136.25 $1,619.90 090 29440 $119.31 $79.22 00028570 $435.35 $368.70 090 29445 $366.53 $285.40 00028575 $856.36 $775.36 090 29450 $395.16 $311.17 00028576 $955.91 $955.91 090 29505 $228.13 $136.49 00028585 $2,100.81 $1,642.68 090 29515 $196.63 $136.49 00028600 $534.91 $458.97 090 29520 $84.95 $50.59 00028605 $790.55 $711.24 090 29530 $77.31 $49.63 00028606 $960.13 $960.13 090 29540 $70.63 $49.63 00028615 $1,950.63 $1,950.63 090 29550 $51.54 $31.50 00028630 $435.25 $304.49 010 29580 $142.22 $97.36 00028635 $482.02 $362.71 010 29581 $168.95 $35.32 00028636 $960.23 $615.65 010 29582 $190.90 $42.95 00028645 $1,597.97 $1,176.96 090 29583 $119.31 $30.54 00028660 $319.76 $244.35 010 29584 $190.90 $42.95 00028665 $425.71 $361.76 010 29700 $171.81 $92.59 00028666 $508.75 $508.75 010 29705 $182.31 $129.81 00028675 $1,422.48 $999.78 090 29710 $332.17 $229.08 00028705 $3,029.73 $3,029.73 090 29720 $231.94 $122.18 00028715 $2,279.68 $2,279.68 090 29730 $175.63 $123.13 00028725 $1,889.04 $1,889.04 090 29740 $272.03 $193.76 00028730 $1,778.52 $1,778.52 090 29750 $247.22 $188.99 00028735 $1,902.54 $1,902.54 090 29799 80% of billed 80% of billed N/A28737 $1,691.62 $1,691.62 090 29800 $1,279.89 $1,279.89 09028740 $2,059.47 $1,512.75 090 29804 $1,565.91 $1,565.91 09028750 $1,973.41 $1,430.92 090 29805 $1,144.06 $1,144.06 09028755 $1,238.55 $802.36 090 29806 $2,580.03 $2,580.03 09028760 $1,935.45 $1,410.67 090 29807 $2,515.91 $2,515.91 09028800 $1,314.48 $1,314.48 090 29819 $1,420.79 $1,420.79 09028805 $1,781.89 $1,781.89 090 29820 $1,295.08 $1,295.08 09028810 $1,050.41 $1,050.41 090 29821 $1,414.88 $1,414.88 09028820 $1,373.54 $960.97 090 29822 $1,374.39 $1,374.39 09028825 $1,312.80 $901.92 090 29823 $1,499.25 $1,499.25 09028890 $788.02 $547.56 090 29824 $1,615.69 $1,615.69 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 15 of 84

Page 16: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

29825 $1,398.85 $1,398.85 090 30020 $627.11 $322.62 01029826 $1,577.28 $1,577.28 090 30100 $379.89 $187.08 00029827 $2,561.47 $2,561.47 090 30110 $621.38 $353.16 01029828 $2,210.49 $2,210.49 090 30115 $1,031.85 $1,031.85 09029830 $1,106.93 $1,106.93 090 30117 $2,086.47 $814.17 09029834 $1,180.34 $1,180.34 090 30118 $1,842.64 $1,842.64 09029835 $1,214.08 $1,214.08 090 30120 $1,252.05 $1,058.84 09029836 $1,385.36 $1,385.36 090 30124 $683.40 $683.40 09029837 $1,266.39 $1,266.39 090 30125 $1,450.32 $1,450.32 09029838 $1,424.17 $1,424.17 090 30130 $910.35 $910.35 09029840 $1,090.90 $1,090.90 090 30140 $1,051.25 $1,051.25 09029843 $1,174.43 $1,174.43 090 30150 $1,840.95 $1,840.95 09029844 $1,200.59 $1,200.59 090 30160 $1,848.55 $1,848.55 09029845 $1,394.64 $1,394.64 090 30200 $304.49 $161.31 00029846 $1,259.64 $1,259.64 090 30210 $403.75 $270.12 01029847 $1,313.64 $1,313.64 090 30220 $816.10 $338.85 01029848 $1,238.55 $1,238.55 090 30300 $481.07 $287.30 01029850 $1,471.41 $1,471.41 090 30310 $558.38 $558.38 01029851 $2,191.09 $2,191.09 090 30320 $1,079.94 $1,079.94 09029855 $1,898.33 $1,898.33 090 30400 $2,415.51 $2,415.51 09029856 $2,410.45 $2,410.45 090 30410 $2,813.74 $2,813.74 09029860 $1,602.19 $1,602.19 090 30420 $3,278.62 $3,278.62 09029861 $1,749.83 $1,749.83 090 30430 $2,046.82 $2,046.82 09029862 $1,955.70 $1,955.70 090 30435 $3,011.17 $3,011.17 09029863 $1,954.85 $1,954.85 090 30450 $3,571.38 $3,571.38 09029866 $2,518.44 $2,518.44 090 30460 $1,956.54 $1,956.54 09029867 $3,113.25 $3,113.25 090 30462 $3,379.02 $3,379.02 09029868 $4,008.42 $4,008.42 090 30465 $2,346.33 $2,346.33 09029870 $1,406.45 $997.25 090 30520 $1,489.13 $1,489.13 09029871 $1,248.68 $1,248.68 090 30540 $1,655.34 $1,655.34 09029873 $1,268.08 $1,268.08 090 30545 $2,124.44 $2,124.44 09029874 $1,303.52 $1,303.52 090 30560 $722.56 $371.30 01029875 $1,200.59 $1,200.59 090 30580 $1,573.50 $1,238.55 09029876 $1,596.28 $1,596.28 090 30600 $1,364.26 $1,027.63 09029877 $1,507.69 $1,507.69 090 30620 $1,493.35 $1,493.35 09029879 $1,607.25 $1,607.25 090 30630 $1,487.44 $1,487.44 09029880 $1,364.26 $1,364.26 090 30801 $617.56 $369.39 01029881 $1,312.80 $1,312.80 090 30802 $783.64 $514.48 01029882 $1,703.43 $1,703.43 090 30901 $257.71 $155.58 00029883 $2,051.88 $2,051.88 090 30903 $597.52 $220.49 00029884 $1,489.13 $1,489.13 090 30905 $734.01 $291.12 00029885 $1,813.96 $1,813.96 090 30906 $939.23 $375.12 00029886 $1,541.44 $1,541.44 090 30915 $1,376.07 $1,376.07 09029887 $1,794.55 $1,794.55 090 30920 $2,002.94 $2,002.94 09029888 $2,394.42 $2,394.42 090 30930 $333.12 $333.12 01029889 $2,970.67 $2,970.67 090 30999 80% of billed 80% of billed N/A29891 $1,630.03 $1,630.03 090 31000 $497.29 $287.30 01029892 $1,570.97 $1,570.97 090 31002 $515.43 $515.43 01029893 $1,486.60 $1,036.91 090 31020 $1,160.09 $862.26 09029894 $1,205.65 $1,205.65 090 31030 $1,651.96 $1,268.08 09029895 $1,157.56 $1,157.56 090 31032 $1,375.23 $1,375.23 09029897 $1,220.83 $1,220.83 090 31040 $1,826.61 $1,826.61 09029898 $1,368.48 $1,368.48 090 31050 $1,156.71 $1,156.71 09029899 $2,522.66 $2,522.66 090 31051 $1,543.13 $1,543.13 09029900 $1,018.35 $1,018.35 090 31070 $1,047.88 $1,047.88 09029901 $1,276.52 $1,276.52 090 31075 $1,878.92 $1,878.92 09029902 $1,177.81 $1,177.81 090 31080 $2,501.57 $2,501.57 09029904 $1,523.72 $1,523.72 090 31081 $3,587.41 $3,587.41 09029905 $1,649.43 $1,649.43 090 31084 $2,845.80 $2,845.80 09029906 $1,678.96 $1,678.96 090 31085 $3,828.71 $3,828.71 09029907 $2,126.97 $2,126.97 090 31086 $2,715.03 $2,715.03 09029914 $2,412.14 $2,412.14 090 31087 $2,611.25 $2,611.25 09029915 $2,456.85 $2,456.85 090 31090 $2,450.10 $2,450.10 09029916 $2,459.39 $2,459.39 090 31200 $1,370.17 $1,370.17 09029999 80% of billed 80% of billed N/A 31201 $1,770.08 $1,770.08 09030000 $618.52 $319.76 010 31205 $2,155.65 $2,155.65 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 16 of 84

Page 17: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

31225 $4,507.89 $4,507.89 090 31561 $944.00 $944.00 00031230 $4,961.80 $4,961.80 090 31570 $920.14 $631.88 00031231 $565.06 $177.54 000 31571 $688.19 $688.19 00031233 $708.24 $373.21 000 31572 $1,350.62 $497.29 00031235 $808.46 $440.98 000 31573 $718.74 $410.43 00031237 $698.69 $440.02 000 31574 $2,783.32 $410.43 00031238 $697.74 $461.02 000 31575 $308.30 $185.17 00031239 $1,678.01 $1,678.01 010 31576 $718.74 $327.39 00031240 $439.07 $439.07 000 31577 $744.51 $369.39 00031254 $746.42 $746.42 000 31578 $818.01 $410.43 00031255 $1,092.90 $1,092.90 000 31579 $481.07 $328.35 00031256 $540.25 $540.25 000 31580 $3,014.54 $3,014.54 09031267 $866.69 $866.69 000 31584 $3,345.27 $3,345.27 09031276 $1,378.30 $1,378.30 000 31587 $2,807.83 $2,807.83 09031287 $633.79 $633.79 000 31590 $2,105.03 $2,105.03 09031288 $734.96 $734.96 000 31591 $2,518.44 $2,518.44 09031290 $3,153.67 $3,153.67 010 31592 $4,075.07 $4,075.07 09031291 $3,365.57 $3,365.57 010 31595 $1,827.45 $1,827.45 09031292 $2,726.05 $2,726.05 010 31599 80% of billed 80% of billed N/A31293 $2,961.81 $2,961.81 010 31600 $1,093.86 $1,093.86 00031294 $3,426.65 $3,426.65 010 31601 $582.24 $582.24 00031295 $5,470.24 $447.66 000 31603 $614.70 $614.70 00031296 $5,580.01 $536.43 000 31605 $507.79 $507.79 00031297 $5,478.83 $439.07 000 31610 $1,720.30 $1,720.30 09031299 80% of billed 80% of billed N/A 31611 $1,292.55 $1,292.55 09031300 $3,147.84 $3,147.84 090 31612 $226.22 $132.68 00031320 $1,355.83 $1,355.83 090 31613 $1,093.44 $1,093.44 09031360 $5,098.48 $5,098.48 090 31614 $1,816.49 $1,816.49 09031365 $6,288.10 $6,288.10 090 31615 $457.21 $315.94 00031367 $5,387.87 $5,387.87 090 31622 $654.79 $363.66 00031368 $5,997.02 $5,997.02 090 31623 $734.96 $369.39 00031370 $5,073.17 $5,073.17 090 31624 $687.24 $374.16 00031375 $4,809.93 $4,809.93 090 31625 $900.09 $432.39 00031380 $4,744.97 $4,744.97 090 31626 $2,283.16 $549.79 00031382 $5,219.97 $5,219.97 090 31627 $3,784.59 $269.17 ZZZ31390 $7,011.15 $7,011.15 090 31628 $954.50 $485.84 00031395 $7,411.90 $7,411.90 090 31629 $1,179.76 $517.34 00031400 $2,375.02 $2,375.02 090 31630 $551.70 $551.70 00031420 $2,002.94 $2,002.94 090 31631 $632.83 $632.83 00031500 $388.48 $388.48 000 31632 $175.63 $135.54 ZZZ31502 $96.40 $96.40 000 31633 $218.58 $174.67 ZZZ31505 $223.35 $134.58 000 31634 $4,856.50 $535.47 00031510 $575.56 $334.07 000 31635 $759.78 $483.93 00031511 $574.61 $356.03 000 31636 $608.02 $608.02 00031512 $560.29 $356.98 000 31637 $204.26 $204.26 ZZZ31513 $362.71 $362.71 000 31638 $692.97 $692.97 00031515 $493.48 $285.40 000 31640 $696.78 $696.78 00031520 $430.48 $430.48 000 31641 $711.10 $711.10 00031525 $687.24 $440.02 000 31643 $488.70 $488.70 00031526 $432.39 $432.39 000 31645 $692.01 $411.39 00031527 $535.47 $535.47 000 31646 $623.29 $351.26 00031528 $398.03 $398.03 000 31647 $582.24 $582.24 00031529 $444.80 $444.80 000 31648 $531.66 $531.66 00031530 $545.02 $545.02 000 31649 $191.85 $191.85 ZZZ31531 $583.20 $583.20 000 31651 $205.22 $205.22 ZZZ31535 $521.16 $521.16 000 31652 $2,241.17 $612.79 00031536 $580.34 $580.34 000 31653 $2,371.93 $678.65 00031540 $666.24 $666.24 000 31654 $342.67 $187.08 ZZZ31541 $726.37 $726.37 000 31660 $540.25 $540.25 00031545 $997.45 $997.45 000 31661 $569.84 $569.84 00031546 $1,515.75 $1,515.75 000 31717 $705.38 $297.80 00031551 $3,437.23 $3,437.23 090 31720 $143.17 $143.17 00031552 $3,475.20 $3,475.20 090 31725 $214.76 $214.76 00031553 $3,789.06 $3,789.06 090 31730 $3,347.43 $412.34 00031554 $3,989.86 $3,989.86 090 31750 $3,387.46 $3,387.46 09031560 $861.91 $861.91 000 31755 $4,287.68 $4,287.68 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 17 of 84

Page 18: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

31760 $3,395.05 $3,395.05 090 32607 $853.32 $853.32 00031766 $4,354.34 $4,354.34 090 32608 $1,047.09 $1,047.09 00031770 $3,260.06 $3,260.06 090 32609 $715.87 $715.87 00031775 $3,116.63 $3,116.63 090 32650 $1,623.28 $1,623.28 09031780 $2,859.30 $2,859.30 090 32651 $2,674.53 $2,674.53 09031781 $3,391.67 $3,391.67 090 32652 $4,059.04 $4,059.04 09031785 $2,622.22 $2,622.22 090 32653 $2,585.10 $2,585.10 09031786 $3,642.25 $3,642.25 090 32654 $2,890.52 $2,890.52 09031800 $1,771.77 $1,771.77 090 32655 $2,333.67 $2,333.67 09031805 $1,996.19 $1,996.19 090 32656 $1,954.85 $1,954.85 09031820 $1,040.28 $789.70 090 32658 $1,741.40 $1,741.40 09031825 $1,441.04 $1,155.87 090 32659 $1,785.27 $1,785.27 09031830 $1,061.37 $828.51 090 32661 $1,951.48 $1,951.48 09031899 80% of billed 80% of billed N/A 32662 $2,178.43 $2,178.43 09032035 $1,765.02 $1,765.02 090 32663 $3,422.05 $3,422.05 09032036 $1,884.83 $1,884.83 090 32664 $2,062.00 $2,062.00 09032096 $1,968.35 $1,968.35 090 32665 $3,015.38 $3,015.38 09032097 $1,963.29 $1,963.29 090 32666 $2,126.12 $2,126.12 09032098 $1,862.05 $1,862.05 090 32667 $435.25 $435.25 ZZZ32100 $1,980.16 $1,980.16 090 32668 $435.25 $435.25 ZZZ32110 $3,573.07 $3,573.07 090 32669 $3,287.06 $3,287.06 09032120 $2,127.81 $2,127.81 090 32670 $3,916.46 $3,916.46 09032124 $2,262.80 $2,262.80 090 32671 $4,342.52 $4,342.52 09032140 $2,407.08 $2,407.08 090 32672 $3,723.25 $3,723.25 09032141 $3,722.40 $3,722.40 090 32673 $2,971.51 $2,971.51 09032150 $2,453.48 $2,453.48 090 32674 $598.47 $598.47 ZZZ32151 $2,446.73 $2,446.73 090 32701 $592.74 $592.74 N/A32160 $1,929.54 $1,929.54 090 32800 $2,308.36 $2,308.36 09032200 $2,754.68 $2,754.68 090 32810 $2,179.28 $2,179.28 09032215 $1,944.73 $1,944.73 090 32815 $6,817.94 $6,817.94 09032220 $3,864.15 $3,864.15 090 32820 $3,434.70 $3,434.70 09032225 $2,423.95 $2,423.95 090 32850 80% of billed 80% of billed N/A32310 $2,230.74 $2,230.74 090 32851 $8,068.30 $8,068.30 09032320 $3,899.58 $3,899.58 090 32852 $8,814.13 $8,814.13 09032400 $410.43 $240.53 000 32853 $11,251.58 $11,251.58 09032405 $1,052.81 $251.99 000 32854 $11,945.10 $11,945.10 09032440 $3,820.27 $3,820.27 090 32855 80% of billed 80% of billed N/A32442 $7,518.21 $7,518.21 090 32856 80% of billed 80% of billed N/A32445 $8,669.02 $8,669.02 090 32900 $3,436.39 $3,436.39 09032480 $3,610.19 $3,610.19 090 32905 $3,282.84 $3,282.84 09032482 $3,862.46 $3,862.46 090 32906 $4,046.39 $4,046.39 09032484 $3,506.42 $3,506.42 090 32940 $3,023.82 $3,023.82 09032486 $5,747.28 $5,747.28 090 32960 $349.35 $255.81 00032488 $5,869.62 $5,869.62 090 32997 $943.05 $943.05 00032491 $3,595.85 $3,595.85 090 32998 $5,244.98 $781.74 00032501 $677.69 $677.69 ZZZ 32999 80% of billed 80% of billed N/A32503 $4,415.08 $4,415.08 090 33010 $296.85 $296.85 00032504 $5,072.32 $5,072.32 090 33011 $299.71 $299.71 00032505 $2,273.77 $2,273.77 090 33015 $1,250.36 $1,250.36 09032506 $433.34 $433.34 ZZZ 33020 $2,150.59 $2,150.59 09032507 $433.34 $433.34 ZZZ 33025 $1,950.63 $1,950.63 09032540 $4,237.91 $4,237.91 090 33030 $4,901.90 $4,901.90 09032550 $1,930.00 $577.47 000 33031 $6,046.80 $6,046.80 09032551 $435.25 $435.25 000 33050 $2,439.14 $2,439.14 09032552 $503.98 $437.16 010 33120 $5,138.13 $5,138.13 09032553 $1,416.48 $501.11 000 33130 $3,379.02 $3,379.02 09032554 $547.88 $247.22 000 33140 $3,862.46 $3,862.46 09032555 $786.51 $310.21 000 33141 $365.57 $365.57 ZZZ32556 $1,499.52 $339.80 000 33202 $1,897.48 $1,897.48 09032557 $1,385.93 $422.84 000 33203 $1,969.20 $1,969.20 09032560 $661.47 $215.72 000 33206 $1,103.56 $1,103.56 09032561 $251.99 $188.99 000 33207 $1,176.96 $1,176.96 09032562 $226.22 $169.90 000 33208 $1,277.36 $1,277.36 09032601 $853.32 $853.32 000 33210 $459.11 $459.11 00032604 $1,337.25 $1,337.25 000 33211 $469.61 $469.61 00032606 $1,279.98 $1,279.98 000 33212 $782.95 $782.95 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 18 of 84

Page 19: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

33213 $819.23 $819.23 090 33368 $2,074.13 $2,074.13 ZZZ33214 $1,168.52 $1,168.52 090 33369 $2,743.23 $2,743.23 ZZZ33215 $760.17 $760.17 090 33390 $4,671.57 $4,671.57 09033216 $905.29 $905.29 090 33391 $5,535.52 $5,535.52 09033217 $887.57 $887.57 090 33404 $4,296.12 $4,296.12 09033218 $951.69 $951.69 090 33405 $5,555.76 $5,555.76 09033220 $952.54 $952.54 090 33406 $7,048.27 $7,048.27 09033221 $882.51 $882.51 090 33410 $6,228.19 $6,228.19 09033222 $821.76 $821.76 090 33411 $8,220.17 $8,220.17 09033223 $997.25 $997.25 090 33412 $7,771.32 $7,771.32 09033224 $1,433.66 $1,433.66 000 33413 $7,954.40 $7,954.40 09033225 $1,306.71 $1,306.71 ZZZ 33414 $5,290.84 $5,290.84 09033226 $1,379.25 $1,379.25 000 33415 $4,980.36 $4,980.36 09033227 $825.98 $825.98 090 33416 $4,971.08 $4,971.08 09033228 $863.95 $863.95 090 33417 $4,098.69 $4,098.69 09033229 $915.41 $915.41 090 33418 $4,422.68 $4,422.68 09033230 $936.51 $936.51 090 33419 $1,182.63 $1,182.63 ZZZ33231 $984.60 $984.60 090 33420 $3,577.29 $3,577.29 09033233 $561.06 $561.06 090 33422 $4,091.10 $4,091.10 09033234 $1,187.09 $1,187.09 090 33425 $6,688.01 $6,688.01 09033235 $1,560.00 $1,560.00 090 33426 $5,832.50 $5,832.50 09033236 $1,916.04 $1,916.04 090 33427 $5,989.43 $5,989.43 09033237 $2,046.82 $2,046.82 090 33430 $6,850.84 $6,850.84 09033238 $2,281.36 $2,281.36 090 33460 $5,946.40 $5,946.40 09033240 $893.48 $893.48 090 33463 $7,568.83 $7,568.83 09033241 $525.63 $525.63 090 33464 $5,980.15 $5,980.15 09033243 $3,349.49 $3,349.49 090 33465 $6,756.35 $6,756.35 09033244 $2,105.88 $2,105.88 090 33468 $6,031.61 $6,031.61 09033249 $2,245.09 $2,245.09 090 33470 $3,181.59 $3,181.59 09033250 $3,555.35 $3,555.35 090 33471 $3,400.11 $3,400.11 09033251 $3,974.67 $3,974.67 090 33474 $5,356.65 $5,356.65 09033254 $3,340.21 $3,340.21 090 33475 $5,709.32 $5,709.32 09033255 $4,022.76 $4,022.76 090 33476 $3,739.28 $3,739.28 09033256 $4,757.62 $4,757.62 090 33477 $3,629.01 $3,629.01 00033257 $1,610.24 $1,610.24 ZZZ 33478 $3,864.15 $3,864.15 09033258 $1,809.73 $1,809.73 ZZZ 33496 $4,097.85 $4,097.85 09033259 $2,336.62 $2,336.62 ZZZ 33500 $3,827.87 $3,827.87 09033261 $3,973.83 $3,973.83 090 33501 $2,725.99 $2,725.99 09033262 $912.04 $912.04 090 33502 $3,135.19 $3,135.19 09033263 $950.01 $950.01 090 33503 $3,257.53 $3,257.53 09033264 $990.50 $990.50 090 33504 $3,601.76 $3,601.76 09033265 $3,322.49 $3,322.49 090 33505 $5,078.23 $5,078.23 09033266 $4,519.70 $4,519.70 090 33506 $5,055.45 $5,055.45 09033270 $1,445.26 $1,445.26 090 33507 $4,241.28 $4,241.28 09033271 $1,209.02 $1,209.02 090 33508 $44.86 $44.86 ZZZ33272 $853.82 $853.82 090 33510 $4,730.63 $4,730.63 09033273 $997.25 $997.25 090 33511 $5,199.72 $5,199.72 09033282 $550.94 $550.94 090 33512 $5,910.12 $5,910.12 09033284 $484.28 $484.28 090 33513 $6,083.92 $6,083.92 09033300 $6,000.39 $6,000.39 090 33514 $6,424.78 $6,424.78 09033305 $10,045.09 $10,045.09 090 33516 $6,726.82 $6,726.82 09033310 $2,887.14 $2,887.14 090 33517 $520.20 $520.20 ZZZ33315 $4,682.54 $4,682.54 090 33518 $1,142.54 $1,142.54 ZZZ33320 $2,599.44 $2,599.44 090 33519 $1,510.97 $1,510.97 ZZZ33321 $2,912.45 $2,912.45 090 33521 $1,812.60 $1,812.60 ZZZ33322 $3,396.74 $3,396.74 090 33522 $2,034.04 $2,034.04 ZZZ33330 $3,497.98 $3,497.98 090 33523 $2,305.12 $2,305.12 ZZZ33335 $4,592.26 $4,592.26 090 33530 $1,459.43 $1,459.43 ZZZ33340 $2,216.35 $2,216.35 000 33533 $4,574.54 $4,574.54 09033361 $3,778.87 $3,778.87 000 33534 $5,382.81 $5,382.81 09033362 $4,123.44 $4,123.44 000 33535 $6,008.83 $6,008.83 09033363 $4,341.07 $4,341.07 000 33536 $6,477.09 $6,477.09 09033364 $4,501.42 $4,501.42 000 33542 $6,427.31 $6,427.31 09033365 $4,951.95 $4,951.95 000 33545 $7,586.55 $7,586.55 09033366 $5,355.70 $5,355.70 000 33548 $7,264.26 $7,264.26 09033367 $1,737.19 $1,737.19 ZZZ 33572 $638.56 $638.56 ZZZ

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 19 of 84

Page 20: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

33600 $4,223.56 $4,223.56 090 33820 $2,381.77 $2,381.77 09033602 $4,099.54 $4,099.54 090 33822 $2,626.44 $2,626.44 09033606 $4,370.37 $4,370.37 090 33824 $2,897.27 $2,897.27 09033608 $4,424.36 $4,424.36 090 33840 $3,178.22 $3,178.22 09033610 $4,364.46 $4,364.46 090 33845 $3,276.93 $3,276.93 09033611 $4,803.18 $4,803.18 090 33851 $3,266.81 $3,266.81 09033612 $4,931.43 $4,931.43 090 33852 $3,438.08 $3,438.08 09033615 $4,910.33 $4,910.33 090 33853 $4,506.20 $4,506.20 09033617 $5,320.37 $5,320.37 090 33860 $7,870.88 $7,870.88 09033619 $6,704.04 $6,704.04 090 33863 $7,722.39 $7,722.39 09033620 $4,062.42 $4,062.42 090 33864 $7,913.06 $7,913.06 09033621 $2,288.11 $2,288.11 090 33870 $6,191.07 $6,191.07 09033622 $8,955.03 $8,955.03 090 33875 $6,717.54 $6,717.54 09033641 $4,034.57 $4,034.57 090 33877 $8,923.82 $8,923.82 09033645 $4,258.15 $4,258.15 090 33880 $4,429.43 $4,429.43 09033647 $4,473.30 $4,473.30 090 33881 $3,805.09 $3,805.09 09033660 $4,322.28 $4,322.28 090 33883 $2,761.43 $2,761.43 09033665 $4,836.93 $4,836.93 090 33884 $1,150.17 $1,150.17 ZZZ33670 $4,858.87 $4,858.87 090 33886 $2,376.70 $2,376.70 09033675 $4,854.65 $4,854.65 090 33889 $2,197.26 $2,197.26 00033676 $5,257.94 $5,257.94 090 33891 $2,730.82 $2,730.82 00033677 $5,462.96 $5,462.96 090 33910 $6,458.52 $6,458.52 09033681 $4,520.54 $4,520.54 090 33915 $3,114.94 $3,114.94 09033684 $4,649.63 $4,649.63 090 33916 $10,295.67 $10,295.67 09033688 $4,903.58 $4,903.58 090 33917 $3,581.51 $3,581.51 09033690 $2,947.04 $2,947.04 090 33920 $4,689.28 $4,689.28 09033692 $5,095.10 $5,095.10 090 33922 $3,413.61 $3,413.61 09033694 $4,803.18 $4,803.18 090 33924 $797.01 $797.01 ZZZ33697 $5,059.67 $5,059.67 090 33925 $4,228.62 $4,228.62 09033702 $3,800.02 $3,800.02 090 33926 $6,294.85 $6,294.85 09033710 $5,050.39 $5,050.39 090 33930 80% of billed 80% of billed N/A33720 $3,802.56 $3,802.56 090 33933 80% of billed 80% of billed N/A33722 $3,998.29 $3,998.29 090 33935 $12,185.56 $12,185.56 09033724 $3,787.37 $3,787.37 090 33940 80% of billed 80% of billed N/A33726 $5,005.67 $5,005.67 090 33944 80% of billed 80% of billed N/A33730 $4,932.27 $4,932.27 090 33945 $11,913.89 $11,913.89 09033732 $4,050.60 $4,050.60 090 33946 $856.19 $856.19 N/A33735 $3,183.28 $3,183.28 090 33947 $950.68 $950.68 N/A33736 $3,455.80 $3,455.80 090 33948 $662.42 $662.42 N/A33737 $3,188.34 $3,188.34 090 33949 $649.06 $649.06 N/A33750 $3,252.46 $3,252.46 090 33951 $1,189.31 $1,189.31 00033755 $3,376.49 $3,376.49 090 33952 $1,189.31 $1,189.31 00033762 $3,303.93 $3,303.93 090 33953 $1,328.66 $1,328.66 00033764 $3,234.75 $3,234.75 090 33954 $1,328.66 $1,328.66 00033766 $3,437.23 $3,437.23 090 33955 $2,327.07 $2,327.07 00033767 $3,497.98 $3,497.98 090 33956 $2,317.53 $2,317.53 00033768 $1,237.03 $1,237.03 ZZZ 33957 $518.29 $518.29 00033770 $5,511.05 $5,511.05 090 33958 $505.88 $505.88 00033771 $5,683.16 $5,683.16 090 33959 $656.70 $656.70 00033774 $4,423.52 $4,423.52 090 33962 $656.70 $656.70 00033775 $4,787.15 $4,787.15 090 33963 $1,313.39 $1,313.39 00033776 $5,057.98 $5,057.98 090 33964 $1,342.98 $1,342.98 00033777 $4,653.01 $4,653.01 090 33965 $518.29 $518.29 00033778 $5,780.19 $5,780.19 090 33966 $659.56 $659.56 00033779 $6,061.98 $6,061.98 090 33967 $721.60 $721.60 00033780 $6,169.98 $6,169.98 090 33968 $93.54 $93.54 00033781 $6,034.14 $6,034.14 090 33969 $767.42 $767.42 00033782 $7,951.03 $7,951.03 090 33970 $986.95 $986.95 00033783 $8,591.40 $8,591.40 090 33971 $1,739.71 $1,739.71 09033786 $5,918.56 $5,918.56 090 33973 $1,431.75 $1,431.75 00033788 $3,962.86 $3,962.86 090 33974 $2,188.56 $2,188.56 09033800 $2,428.17 $2,428.17 090 33975 $3,640.46 $3,640.46 N/A33802 $2,662.72 $2,662.72 090 33976 $4,437.47 $4,437.47 N/A33803 $2,827.24 $2,827.24 090 33977 $3,131.71 $3,131.71 N/A33813 $3,181.59 $3,181.59 090 33978 $3,709.19 $3,709.19 N/A33814 $3,743.50 $3,743.50 090 33979 $5,428.24 $5,428.24 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 20 of 84

Page 21: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

33980 $4,959.58 $4,959.58 N/A 35045 $2,440.82 $2,440.82 09033981 $2,305.12 $2,305.12 N/A 35081 $4,312.15 $4,312.15 09033982 $5,448.29 $5,448.29 N/A 35082 $5,428.37 $5,428.37 09033983 $6,441.92 $6,441.92 N/A 35091 $4,431.96 $4,431.96 09033984 $797.01 $797.01 000 35092 $6,441.65 $6,441.65 09033985 $1,437.48 $1,437.48 000 35102 $4,660.60 $4,660.60 09033986 $1,453.70 $1,453.70 000 35103 $5,564.20 $5,564.20 09033987 $584.15 $584.15 ZZZ 35111 $3,276.93 $3,276.93 09033988 $2,181.03 $2,181.03 000 35112 $4,660.60 $4,660.60 09033989 $1,381.16 $1,381.16 000 35121 $4,083.51 $4,083.51 09033990 $1,184.53 $1,184.53 N/A 35122 $5,333.03 $5,333.03 09033991 $1,734.33 $1,734.33 N/A 35131 $3,436.39 $3,436.39 09033992 $557.43 $557.43 N/A 35132 $4,041.32 $4,041.32 09033993 $486.79 $486.79 N/A 35141 $2,735.28 $2,735.28 09033999 80% of billed 80% of billed N/A 35142 $3,272.71 $3,272.71 09034001 $2,391.05 $2,391.05 090 35151 $3,070.22 $3,070.22 09034051 $2,191.93 $2,191.93 090 35152 $3,437.23 $3,437.23 09034101 $1,480.69 $1,480.69 090 35180 $2,348.86 $2,348.86 09034111 $1,479.85 $1,479.85 090 35182 $4,390.61 $4,390.61 09034151 $3,465.08 $3,465.08 090 35184 $2,767.34 $2,767.34 09034201 $2,547.97 $2,547.97 090 35188 $2,626.44 $2,626.44 09034203 $2,358.99 $2,358.99 090 35189 $3,927.42 $3,927.42 09034401 $3,598.38 $3,598.38 090 35190 $1,878.08 $1,878.08 09034421 $1,791.18 $1,791.18 090 35201 $2,330.30 $2,330.30 09034451 $4,024.45 $4,024.45 090 35206 $1,918.57 $1,918.57 09034471 $2,688.87 $2,688.87 090 35207 $1,840.11 $1,840.11 09034490 $1,501.79 $1,501.79 090 35211 $3,379.86 $3,379.86 09034501 $2,214.71 $2,214.71 090 35216 $5,025.92 $5,025.92 09034502 $3,787.37 $3,787.37 090 35221 $3,596.69 $3,596.69 09034510 $2,941.98 $2,941.98 090 35226 $2,058.63 $2,058.63 09034520 $2,598.60 $2,598.60 090 35231 $3,038.16 $3,038.16 09034530 $2,347.17 $2,347.17 090 35236 $2,428.17 $2,428.17 09034800 $2,790.12 $2,790.12 090 35241 $3,382.39 $3,382.39 09034802 $3,080.35 $3,080.35 090 35246 $3,864.15 $3,864.15 09034803 $3,194.25 $3,194.25 090 35251 $4,224.41 $4,224.41 09034804 $3,085.41 $3,085.41 090 35256 $2,517.60 $2,517.60 09034805 $2,947.04 $2,947.04 090 35261 $2,624.75 $2,624.75 09034806 $278.71 $278.71 ZZZ 35266 $2,142.15 $2,142.15 09034808 $580.34 $580.34 ZZZ 35271 $3,400.11 $3,400.11 09034812 $943.05 $943.05 000 35276 $3,593.32 $3,593.32 09034813 $660.51 $660.51 ZZZ 35281 $3,986.48 $3,986.48 09034820 $1,367.80 $1,367.80 000 35286 $2,305.83 $2,305.83 09034825 $1,718.62 $1,718.62 090 35301 $2,800.24 $2,800.24 09034826 $574.61 $574.61 ZZZ 35302 $2,781.68 $2,781.68 09034830 $4,447.99 $4,447.99 090 35303 $3,068.54 $3,068.54 09034831 $4,707.00 $4,707.00 090 35304 $3,184.97 $3,184.97 09034832 $4,674.10 $4,674.10 090 35305 $3,044.91 $3,044.91 09034833 $1,699.96 $1,699.96 000 35306 $1,244.67 $1,244.67 ZZZ34834 $760.74 $760.74 000 35311 $3,838.84 $3,838.84 09034839 80% of billed 80% of billed N/A 35321 $2,202.06 $2,202.06 09034841 80% of billed 80% of billed N/A 35331 $3,589.94 $3,589.94 09034842 80% of billed 80% of billed N/A 35341 $3,389.14 $3,389.14 09034843 80% of billed 80% of billed N/A 35351 $3,163.88 $3,163.88 09034844 80% of billed 80% of billed N/A 35355 $2,558.10 $2,558.10 09034845 80% of billed 80% of billed N/A 35361 $3,767.96 $3,767.96 09034846 80% of billed 80% of billed N/A 35363 $4,362.77 $4,362.77 09034847 80% of billed 80% of billed N/A 35371 $2,025.72 $2,025.72 09034848 80% of billed 80% of billed N/A 35372 $2,427.32 $2,427.32 09034900 $2,206.28 $2,206.28 090 35390 $446.71 $446.71 ZZZ35001 $2,756.37 $2,756.37 090 35400 $417.12 $417.12 ZZZ35002 $2,828.93 $2,828.93 090 35500 $893.41 $893.41 ZZZ35005 $2,776.62 $2,776.62 090 35501 $3,708.06 $3,708.06 09035011 $2,486.38 $2,486.38 090 35506 $3,155.44 $3,155.44 09035013 $3,097.22 $3,097.22 090 35508 $3,306.46 $3,306.46 09035021 $3,049.98 $3,049.98 090 35509 $3,491.23 $3,491.23 09035022 $3,519.07 $3,519.07 090 35510 $3,036.48 $3,036.48 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 21 of 84

Page 22: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

35511 $3,012.01 $3,012.01 090 35697 $413.30 $413.30 ZZZ35512 $3,395.89 $3,395.89 090 35700 $427.62 $427.62 ZZZ35515 $3,577.29 $3,577.29 090 35701 $1,389.57 $1,389.57 09035516 $3,012.85 $3,012.85 090 35721 $1,130.56 $1,130.56 09035518 $2,868.58 $2,868.58 090 35741 $1,263.86 $1,263.86 09035521 $3,028.88 $3,028.88 090 35761 $960.97 $960.97 09035522 $2,993.45 $2,993.45 090 35800 $1,759.11 $1,759.11 09035523 $3,166.41 $3,166.41 090 35820 $4,934.80 $4,934.80 09035525 $2,841.58 $2,841.58 090 35840 $2,925.11 $2,925.11 09035526 $4,169.57 $4,169.57 090 35860 $2,072.97 $2,072.97 09035531 $5,016.64 $5,016.64 090 35870 $3,077.82 $3,077.82 09035533 $3,703.84 $3,703.84 090 35875 $1,473.10 $1,473.10 09035535 $4,739.06 $4,739.06 090 35876 $2,343.80 $2,343.80 09035536 $4,255.62 $4,255.62 090 35879 $2,282.21 $2,282.21 09035537 $5,876.37 $5,876.37 090 35881 $2,524.35 $2,524.35 09035538 $5,815.62 $5,815.62 090 35883 $2,990.92 $2,990.92 09035539 $5,509.36 $5,509.36 090 35884 $3,063.47 $3,063.47 09035540 $6,337.03 $6,337.03 090 35901 $1,222.52 $1,222.52 09035556 $3,466.76 $3,466.76 090 35903 $1,391.26 $1,391.26 09035558 $3,049.98 $3,049.98 090 35905 $4,377.12 $4,377.12 09035560 $4,224.41 $4,224.41 090 35907 $4,731.47 $4,731.47 09035563 $3,705.53 $3,705.53 090 36000 $69.68 $25.77 N/A35565 $3,295.49 $3,295.49 090 36002 $439.07 $294.94 00035566 $4,137.50 $4,137.50 090 36005 $873.37 $133.63 00035570 $3,738.43 $3,738.43 090 36010 $1,308.62 $304.49 N/A35571 $3,287.06 $3,287.06 090 36011 $2,239.26 $436.21 N/A35572 $967.86 $967.86 ZZZ 36012 $2,307.98 $482.02 N/A35583 $3,584.88 $3,584.88 090 36013 $2,082.72 $341.71 N/A35585 $4,156.07 $4,156.07 090 36014 $2,159.08 $419.03 N/A35587 $3,390.83 $3,390.83 090 36015 $2,330.89 $475.34 N/A35600 $709.19 $709.19 ZZZ 36100 $1,295.26 $426.66 N/A35601 $3,467.61 $3,467.61 090 36120 $1,136.81 $280.62 N/A35606 $2,906.55 $2,906.55 090 36140 $1,144.45 $251.03 N/A35612 $2,633.19 $2,633.19 090 36160 $1,329.62 $343.62 N/A35616 $2,736.12 $2,736.12 090 36200 $1,520.52 $390.39 00035621 $2,721.78 $2,721.78 090 36215 $3,039.13 $650.01 N/A35623 $3,270.18 $3,270.18 090 36216 $3,142.21 $754.05 N/A35626 $3,888.61 $3,888.61 090 36217 $5,142.85 $897.23 N/A35631 $4,587.20 $4,587.20 090 36218 $503.02 $144.13 ZZZ35632 $4,464.86 $4,464.86 090 36221 $2,788.09 $561.25 00035633 $4,962.64 $4,962.64 090 36222 $3,259.62 $784.60 00035634 $4,458.11 $4,458.11 090 36223 $3,999.35 $866.69 00035636 $4,016.01 $4,016.01 090 36224 $5,093.21 $985.04 00035637 $4,296.96 $4,296.96 090 36225 $3,847.59 $862.87 00035638 $4,366.99 $4,366.99 090 36226 $4,829.77 $971.68 00035642 $2,711.65 $2,711.65 090 36227 $687.24 $322.62 ZZZ35645 $2,578.35 $2,578.35 090 36228 $3,459.11 $660.51 ZZZ35646 $4,251.40 $4,251.40 090 36245 $3,522.10 $666.24 N/A35647 $3,849.80 $3,849.80 090 36246 $2,227.80 $712.06 00035650 $2,693.93 $2,693.93 090 36247 $4,051.85 $846.64 00035654 $3,395.05 $3,395.05 090 36248 $413.30 $136.49 ZZZ35656 $2,684.65 $2,684.65 090 36251 $3,714.91 $738.78 00035661 $2,689.72 $2,689.72 090 36252 $4,024.17 $1,007.00 00035663 $3,094.69 $3,094.69 090 36253 $5,960.85 $1,007.00 00035665 $2,904.02 $2,904.02 090 36254 $5,790.00 $1,175.94 00035666 $3,132.66 $3,132.66 090 36260 $1,560.00 $1,560.00 09035671 $2,762.27 $2,762.27 090 36261 $792.23 $792.23 09035681 $225.26 $225.26 ZZZ 36262 $730.64 $730.64 09035682 $989.82 $989.82 ZZZ 36299 80% of billed 80% of billed N/A35683 $1,143.49 $1,143.49 ZZZ 36400 $73.50 $49.63 N/A35685 $556.47 $556.47 ZZZ 36405 $69.68 $44.86 N/A35686 $448.61 $448.61 ZZZ 36406 $50.59 $24.82 N/A35691 $2,323.55 $2,323.55 090 36410 $45.82 $25.77 N/A35693 $2,065.38 $2,065.38 090 36415 80% of billed 80% of billed N/A35694 $2,444.20 $2,444.20 090 36416 80% of billed 80% of billed N/A35695 $2,578.35 $2,578.35 090 36420 $148.90 $148.90 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 22 of 84

Page 23: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

36425 $110.72 $110.72 N/A 36818 $1,714.40 $1,714.40 09036430 $94.50 $94.50 N/A 36819 $1,810.58 $1,810.58 09036440 $149.86 $149.86 N/A 36820 $1,808.89 $1,808.89 09036450 $515.43 $515.43 N/A 36821 $1,641.00 $1,641.00 09036455 $354.12 $354.12 N/A 36823 $3,395.05 $3,395.05 09036456 $294.94 $294.94 N/A 36825 $1,974.26 $1,974.26 09036460 $949.73 $949.73 N/A 36830 $1,650.28 $1,650.28 09036468 80% of billed 80% of billed 000 36831 $1,524.57 $1,524.57 09036470 $399.94 $229.08 010 36832 $1,870.48 $1,870.48 09036471 $474.39 $276.80 010 36833 $2,007.16 $2,007.16 09036473 $4,048.99 $478.20 000 36835 $1,206.49 $1,206.49 09036474 $741.65 $239.58 ZZZ 36838 $2,831.46 $2,831.46 09036475 $4,111.03 $778.87 000 36860 $567.93 $305.44 00036476 $800.83 $378.94 ZZZ 36861 $373.21 $373.21 00036478 $3,254.84 $774.10 000 36901 $1,544.38 $401.84 00036479 $840.91 $380.85 ZZZ 36902 $3,284.43 $598.47 00036481 $5,307.97 $933.50 000 36903 $15,062.01 $818.96 00036500 $505.88 $505.88 000 36904 $4,788.73 $943.05 00036510 $235.76 $154.63 000 36905 $6,127.89 $1,183.58 00036511 $256.76 $256.76 000 36906 $18,264.36 $1,381.16 00036512 $259.62 $259.62 000 36907 $1,965.32 $344.57 ZZZ36513 $267.26 $267.26 000 36908 $7,238.93 $516.38 ZZZ36514 $1,464.20 $256.76 000 36909 $5,280.29 $490.61 ZZZ36515 $5,633.46 $244.35 000 37140 $5,664.60 $5,664.60 09036516 $5,685.96 $192.81 000 37145 $5,263.84 $5,263.84 09036522 $3,843.77 $281.58 000 37160 $5,408.12 $5,408.12 09036555 $556.47 $293.03 000 37180 $5,203.94 $5,203.94 09036556 $633.79 $332.17 000 37181 $5,266.38 $5,266.38 09036557 $2,492.20 $866.69 010 37182 $2,299.39 $2,299.39 00036558 $1,942.41 $728.28 010 37183 $15,713.93 $1,050.90 00036560 $2,726.05 $943.05 010 37184 $6,010.49 $1,255.17 00036561 $2,952.27 $940.18 010 37185 $1,909.00 $469.61 ZZZ36563 $3,335.98 $1,020.36 010 37186 $3,614.69 $689.15 ZZZ36565 $2,404.39 $925.86 010 37187 $5,329.93 $1,094.81 00036566 $14,648.71 $1,033.72 010 37188 $4,549.15 $776.96 00036568 $671.01 $234.81 000 37191 $6,938.26 $628.06 00036569 $677.69 $252.94 000 37192 $4,329.61 $1,008.91 00036570 $3,348.39 $874.32 010 37193 $4,135.85 $979.32 00036571 $3,292.07 $857.14 010 37195 80% of billed 80% of billed N/A36575 $449.57 $96.40 000 37197 $3,900.09 $841.87 00036576 $855.23 $509.70 010 37200 $608.02 $608.02 00036578 $1,216.99 $561.25 010 37211 $1,074.77 $1,074.77 00036580 $579.38 $184.22 000 37212 $937.32 $937.32 00036581 $1,908.05 $506.84 010 37213 $651.92 $651.92 00036582 $2,733.69 $806.55 010 37214 $342.67 $342.67 00036583 $3,383.70 $895.32 010 37215 $2,454.32 $2,454.32 09036584 $554.56 $183.26 000 37216 80% of billed 80% of billed 09036585 $2,916.00 $755.96 010 37217 $2,709.96 $2,709.96 09036589 $447.66 $378.94 010 37218 $2,008.01 $2,008.01 09036590 $606.11 $527.84 010 37220 $8,281.24 $1,124.40 00036591 $63.95 $63.95 N/A 37221 $12,279.64 $1,389.75 00036592 $71.59 $71.59 N/A 37222 $2,324.21 $523.07 ZZZ36593 $84.95 $84.95 N/A 37223 $6,889.58 $599.43 ZZZ36595 $1,586.38 $507.79 000 37224 $10,044.20 $1,242.76 00036596 $356.98 $123.13 000 37225 $29,423.42 $1,697.10 00036597 $344.57 $168.95 000 37226 $24,109.71 $1,465.16 00036598 $300.67 $102.13 000 37227 $39,858.96 $2,045.49 00036600 $84.95 $42.00 N/A 37228 $14,385.27 $1,523.38 00036620 $140.31 $140.31 000 37229 $29,005.35 $1,984.41 00036625 $288.26 $288.26 000 37230 $22,161.58 $1,959.59 00036640 $315.94 $315.94 000 37231 $35,885.38 $2,126.63 00036660 $203.31 $203.31 000 37232 $3,209.98 $566.97 ZZZ36680 $161.31 $161.31 000 37233 $3,880.04 $921.09 ZZZ36800 $340.76 $340.76 000 37234 $10,501.41 $797.96 ZZZ36810 $597.52 $597.52 000 37235 $11,282.19 $1,106.27 ZZZ36815 $381.80 $381.80 000 37236 $10,684.67 $1,233.21 000

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 23 of 84

Page 24: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

37237 $6,527.83 $596.56 ZZZ 38242 $326.44 $326.44 00037238 $11,143.79 $836.14 000 38243 $326.44 $326.44 00037239 $5,412.97 $421.89 ZZZ 38300 $738.78 $499.20 01037241 $12,813.21 $1,234.17 000 38305 $1,115.37 $1,115.37 09037242 $20,091.27 $1,341.07 000 38308 $1,087.53 $1,087.53 09037243 $26,108.44 $1,582.56 000 38380 $1,362.58 $1,362.58 09037244 $18,209.00 $1,863.18 000 38381 $1,964.13 $1,964.13 09037246 $5,784.27 $982.18 000 38382 $1,638.47 $1,638.47 09037247 $2,340.43 $486.79 ZZZ 38500 $905.82 $700.60 01037248 $4,006.99 $844.73 000 38505 $342.67 $196.63 00037249 $1,717.15 $414.25 ZZZ 38510 $1,419.34 $1,156.85 01037252 $3,727.32 $256.76 ZZZ 38520 $1,128.87 $1,128.87 09037253 $561.25 $207.13 ZZZ 38525 $1,064.75 $1,064.75 09037500 $1,592.06 $1,592.06 090 38530 $1,349.08 $1,349.08 09037501 80% of billed 80% of billed N/A 38542 $1,260.49 $1,260.49 09037565 $1,801.30 $1,801.30 090 38550 $1,229.27 $1,229.27 09037600 $1,742.24 $1,742.24 090 38555 $2,475.42 $2,475.42 09037605 $1,940.51 $1,940.51 090 38562 $1,718.62 $1,718.62 09037606 $1,272.30 $1,272.30 090 38564 $1,708.49 $1,708.49 09037607 $924.70 $924.70 090 38570 $1,391.66 $1,391.66 01037609 $843.78 $571.75 010 38571 $1,846.00 $1,846.00 01037615 $1,241.93 $1,241.93 090 38572 $2,593.38 $2,593.38 01037616 $2,699.00 $2,699.00 090 38589 80% of billed 80% of billed N/A37617 $3,288.74 $3,288.74 090 38700 $1,956.54 $1,956.54 09037618 $939.88 $939.88 090 38720 $3,265.96 $3,265.96 09037619 $4,048.07 $4,048.07 090 38724 $3,529.20 $3,529.20 09037650 $1,139.00 $1,139.00 090 38740 $1,693.31 $1,693.31 09037660 $3,185.81 $3,185.81 090 38745 $2,139.62 $2,139.62 09037700 $610.00 $610.00 090 38746 $596.56 $596.56 ZZZ37718 $1,066.44 $1,066.44 090 38747 $739.74 $739.74 ZZZ37722 $1,172.74 $1,172.74 090 38760 $2,056.94 $2,056.94 09037735 $1,437.66 $1,437.66 090 38765 $3,161.34 $3,161.34 09037760 $1,510.22 $1,510.22 090 38770 $1,972.57 $1,972.57 09037761 $1,350.76 $1,350.76 090 38780 $2,504.95 $2,504.95 09037765 $1,576.03 $1,104.40 090 38790 $229.08 $229.08 00037766 $1,871.33 $1,348.23 090 38792 $109.77 $109.77 00037780 $616.74 $616.74 090 38794 $730.64 $730.64 09037785 $860.57 $643.74 090 38900 $382.75 $382.75 ZZZ37788 $3,080.35 $3,080.35 090 38999 80% of billed 80% of billed N/A37790 $1,187.93 $1,187.93 090 39000 $1,210.71 $1,210.71 09037799 80% of billed 80% of billed N/A 39010 $1,923.64 $1,923.64 09038100 $2,819.65 $2,819.65 090 39200 $2,130.34 $2,130.34 09038101 $2,823.02 $2,823.02 090 39220 $2,772.40 $2,772.40 09038102 $727.33 $727.33 ZZZ 39401 $860.96 $860.96 00038115 $3,102.29 $3,102.29 090 39402 $1,124.40 $1,124.40 00038120 $2,570.75 $2,570.75 090 39499 80% of billed 80% of billed N/A38129 80% of billed 80% of billed N/A 39501 $2,072.13 $2,072.13 09038200 $374.16 $374.16 000 39503 $14,516.70 $14,516.70 09038204 $290.17 $290.17 N/A 39540 $2,121.91 $2,121.91 09038205 $229.08 $229.08 000 39541 $2,305.83 $2,305.83 09038206 $229.08 $229.08 000 39545 $2,164.93 $2,164.93 09038207 $128.86 $128.86 N/A 39560 $1,949.79 $1,949.79 09038208 $82.09 $82.09 N/A 39561 $3,035.63 $3,035.63 09038209 $34.36 $34.36 N/A 39599 80% of billed 80% of billed N/A38210 $227.17 $227.17 N/A 40490 $352.21 $203.31 00038211 $206.17 $206.17 N/A 40500 $1,225.05 $887.57 09038212 $136.49 $136.49 N/A 40510 $1,172.74 $869.85 09038213 $34.36 $34.36 N/A 40520 $1,185.40 $874.07 09038214 $117.40 $117.40 N/A 40525 $1,344.01 $1,344.01 09038215 $136.49 $136.49 N/A 40527 $1,519.50 $1,519.50 09038220 $455.30 $169.90 N/A 40530 $1,300.14 $979.54 09038221 $455.30 $205.22 N/A 40650 $1,061.37 $728.11 09038230 $546.93 $546.93 000 40652 $1,190.46 $863.11 09038232 $539.29 $539.29 000 40654 $1,386.20 $1,041.13 09038240 $616.61 $616.61 N/A 40700 $2,463.60 $2,463.60 09038241 $461.02 $461.02 N/A 40701 $2,919.20 $2,919.20 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 24 of 84

Page 25: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

40702 $2,200.37 $2,200.37 090 41820 80% of billed 80% of billed 00040720 $2,433.23 $2,433.23 090 41821 80% of billed 80% of billed 00040761 $2,366.58 $2,366.58 090 41822 $870.50 $517.34 01040799 80% of billed 80% of billed N/A 41823 $1,123.81 $825.14 09040800 $587.97 $367.48 010 41825 $587.02 $340.76 01040801 $871.46 $621.38 010 41826 $876.23 $596.56 01040804 $506.84 $315.94 010 41827 $1,084.15 $762.70 09040805 $890.55 $650.01 010 41828 $854.28 $599.43 01040806 $288.26 $91.63 000 41830 $1,091.95 $794.14 01040808 $514.48 $301.62 010 41850 80% of billed 80% of billed 00040810 $569.84 $355.07 010 41870 80% of billed 80% of billed 00040812 $799.87 $551.70 010 41872 $922.16 $649.65 09040814 $945.79 $753.42 090 41874 $931.44 $636.99 09040816 $985.44 $780.42 090 41899 80% of billed 80% of billed N/A40818 $880.82 $673.27 090 42000 $440.02 $289.21 01040819 $774.52 $592.28 090 42100 $414.25 $303.53 01040820 $734.01 $481.07 010 42104 $594.65 $386.57 01040830 $740.69 $462.93 010 42106 $758.83 $499.20 01040831 $933.50 $628.06 010 42107 $1,127.18 $850.45 09040840 $1,971.73 $1,535.53 090 42120 $2,488.92 $2,488.92 09040842 $1,994.51 $1,593.75 090 42140 $612.53 $377.13 09040843 $2,647.53 $2,097.44 090 42145 $1,714.40 $1,714.40 09040844 $3,142.78 $2,565.69 090 42160 $639.51 $407.57 01040845 $3,555.35 $2,995.98 090 42180 $669.10 $505.88 01040899 80% of billed 80% of billed N/A 42182 $880.05 $706.33 01041000 $447.66 $312.12 010 42200 $2,079.72 $2,079.72 09041005 $625.20 $346.48 010 42205 $2,223.99 $2,223.99 09041006 $946.63 $665.68 090 42210 $2,537.01 $2,537.01 09041007 $933.13 $645.43 090 42215 $1,768.40 $1,768.40 09041008 $932.29 $668.21 090 42220 $1,289.17 $1,289.17 09041009 $989.66 $725.58 090 42225 $2,127.81 $2,127.81 09041010 $550.75 $296.85 010 42226 $2,209.65 $2,209.65 09041015 $1,114.53 $866.48 090 42227 $2,081.41 $2,081.41 09041016 $1,081.62 $869.01 090 42235 $1,778.52 $1,778.52 09041017 $1,095.12 $874.92 090 42260 $2,045.13 $1,703.43 09041018 $1,241.93 $1,020.03 090 42280 $452.43 $308.30 01041019 $1,301.94 $1,301.94 000 42281 $562.20 $416.16 01041100 $462.93 $298.76 010 42299 80% of billed 80% of billed N/A41105 $471.52 $311.17 010 42300 $573.65 $420.93 01041108 $408.53 $251.99 010 42305 $1,053.78 $1,053.78 09041110 $584.15 $364.62 010 42310 $441.93 $341.71 01041112 $819.23 $624.34 090 42320 $680.56 $481.07 01041113 $896.85 $690.99 090 42330 $637.61 $455.30 01041114 $1,560.00 $1,560.00 090 42335 $907.82 $628.56 09041115 $677.69 $401.84 010 42340 $1,130.56 $822.61 09041116 $809.11 $541.66 090 42400 $288.26 $151.77 00041120 $2,645.00 $2,645.00 090 42405 $819.92 $624.24 01041130 $3,254.99 $3,254.99 090 42408 $1,101.87 $797.30 09041135 $5,353.28 $5,353.28 090 42409 $808.26 $541.66 09041140 $5,393.77 $5,393.77 090 42410 $1,512.75 $1,512.75 09041145 $6,818.78 $6,818.78 090 42415 $2,569.07 $2,569.07 09041150 $5,419.93 $5,419.93 090 42420 $2,882.92 $2,882.92 09041153 $5,893.24 $5,893.24 090 42425 $2,033.32 $2,033.32 09041155 $7,425.40 $7,425.40 090 42426 $3,285.37 $3,285.37 09041250 $735.92 $425.71 010 42440 $1,001.47 $1,001.47 09041251 $790.33 $503.02 010 42450 $1,099.34 $874.07 09041252 $874.32 $587.02 010 42500 $1,053.78 $834.42 09041500 $1,101.87 $1,101.87 090 42505 $1,347.39 $1,102.72 09041510 $1,040.28 $1,040.28 090 42507 $1,222.52 $1,222.52 09041512 $1,617.37 $1,617.37 090 42509 $2,054.41 $2,054.41 09041520 $862.26 $634.46 090 42510 $1,571.81 $1,571.81 09041530 $2,683.10 $1,038.50 000 42550 $369.39 $174.67 00041599 80% of billed 80% of billed N/A 42600 $1,143.21 $836.11 09041800 $761.69 $411.39 010 42650 $229.08 $162.26 00041805 $682.47 $475.34 010 42660 $353.16 $248.17 00041806 $980.27 $724.47 010 42665 $766.08 $507.06 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 25 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

42699 80% of billed 80% of billed N/A 43201 $599.43 $288.26 00042700 $519.25 $373.21 010 43202 $832.32 $289.21 00042720 $1,245.62 $1,079.54 010 43204 $380.85 $380.85 00042725 $1,999.57 $1,999.57 090 43205 $396.12 $396.12 00042800 $434.30 $308.30 010 43206 $721.60 $374.16 00042804 $534.52 $311.17 010 43210 $1,205.53 $1,205.53 00042806 $600.38 $362.71 010 43211 $661.47 $661.47 00042808 $622.33 $446.71 010 43212 $532.61 $532.61 00042809 $549.79 $336.94 010 43213 $3,117.40 $724.47 00042810 $937.35 $702.80 090 43214 $539.29 $539.29 00042815 $1,360.04 $1,360.04 090 43215 $976.45 $397.07 00042820 $701.96 $701.96 090 43216 $965.95 $377.03 00042821 $732.33 $732.33 090 43217 $1,029.91 $450.52 00042825 $636.99 $636.99 090 43220 $2,901.68 $330.26 00042826 $611.68 $611.68 090 43226 $860.96 $365.57 00042830 $503.69 $503.69 090 43227 $1,700.92 $462.93 00042831 $544.19 $544.19 090 43229 $1,749.60 $553.61 00042835 $442.10 $442.10 090 43231 $908.68 $448.61 00042836 $585.53 $585.53 090 43232 $1,090.99 $554.56 00042842 $2,485.54 $2,485.54 090 43233 $638.56 $638.56 00042844 $3,419.52 $3,419.52 090 43235 $694.88 $344.57 00042845 $5,490.80 $5,490.80 090 43236 $891.50 $388.48 00042860 $457.29 $457.29 090 43237 $548.84 $548.84 00042870 $1,460.44 $1,460.44 090 43238 $653.83 $653.83 00042890 $3,524.98 $3,524.98 090 43239 $928.73 $389.44 00042892 $4,653.01 $4,653.01 090 43240 $1,102.45 $1,102.45 00042894 $5,845.15 $5,845.15 090 43241 $399.94 $399.94 00042900 $931.59 $931.59 010 43242 $737.83 $737.83 00042950 $2,005.47 $2,005.47 090 43243 $665.29 $665.29 00042953 $2,408.76 $2,408.76 090 43244 $689.15 $689.15 00042955 $1,867.95 $1,867.95 090 43245 $1,495.70 $492.52 00042960 $468.66 $468.66 010 43246 $561.25 $561.25 00042961 $1,027.63 $1,027.63 090 43247 $948.77 $496.34 00042962 $1,265.55 $1,265.55 090 43248 $949.73 $465.80 00042970 $995.57 $995.57 090 43249 $2,750.87 $431.43 00042971 $1,120.43 $1,120.43 090 43250 $1,076.68 $477.25 00042972 $1,243.61 $1,243.61 090 43251 $1,193.12 $549.79 00042999 80% of billed 80% of billed N/A 43252 $818.96 $472.48 00043020 $1,305.20 $1,305.20 090 43253 $737.83 $737.83 00043030 $1,260.49 $1,260.49 090 43254 $759.78 $759.78 00043045 $3,180.75 $3,180.75 090 43255 $1,800.19 $564.11 00043100 $1,512.75 $1,512.75 090 43257 $651.92 $651.92 00043101 $2,606.19 $2,606.19 090 43259 $634.74 $634.74 00043107 $6,257.72 $6,257.72 090 43260 $904.87 $904.87 00043108 $11,420.32 $11,420.32 090 43261 $950.68 $950.68 00043112 $6,611.23 $6,611.23 090 43262 $1,003.18 $1,003.18 00043113 $10,683.77 $10,683.77 090 43263 $1,005.09 $1,005.09 00043116 $12,844.49 $12,844.49 090 43264 $1,022.27 $1,022.27 00043117 $6,041.74 $6,041.74 090 43265 $1,216.99 $1,216.99 00043118 $9,274.79 $9,274.79 090 43266 $612.79 $612.79 00043121 $6,989.21 $6,989.21 090 43270 $1,805.91 $630.92 00043122 $6,272.07 $6,272.07 090 43273 $335.98 $335.98 ZZZ43123 $11,522.41 $11,522.41 090 43274 $1,300.03 $1,300.03 00043124 $9,409.79 $9,409.79 090 43275 $1,057.59 $1,057.59 00043130 $1,911.82 $1,911.82 090 43276 $1,353.48 $1,353.48 00043135 $3,629.60 $3,629.60 090 43277 $1,063.31 $1,063.31 00043180 $1,336.42 $1,336.42 090 43278 $1,216.03 $1,216.03 00043191 $426.66 $426.66 000 43279 $3,157.97 $3,157.97 09043192 $469.61 $469.61 000 43280 $2,643.31 $2,643.31 09043193 $468.66 $468.66 000 43281 $3,778.09 $3,778.09 09043194 $535.47 $535.47 000 43282 $4,249.72 $4,249.72 09043195 $511.61 $511.61 000 43283 $440.02 $440.02 ZZZ43196 $545.97 $545.97 000 43284 $1,585.31 $1,585.31 09043197 $512.57 $230.03 000 43285 $1,603.87 $1,603.87 09043198 $567.93 $274.90 000 43289 80% of billed 80% of billed N/A43200 $587.02 $244.35 000 43300 $1,506.85 $1,506.85 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 26 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

43305 $2,656.81 $2,656.81 090 43756 $547.88 $140.31 00043310 $3,610.19 $3,610.19 090 43757 $788.42 $214.76 00043312 $3,940.92 $3,940.92 090 43760 $1,326.75 $129.81 00043313 $6,630.64 $6,630.64 090 43761 $320.71 $284.44 00043314 $7,292.94 $7,292.94 090 43770 $2,736.12 $2,736.12 09043320 $3,390.83 $3,390.83 090 43771 $3,107.35 $3,107.35 09043325 $3,267.65 $3,267.65 090 43772 $2,314.27 $2,314.27 09043327 $2,004.63 $2,004.63 090 43773 $3,114.10 $3,114.10 09043328 $2,759.74 $2,759.74 090 43774 $2,342.95 $2,342.95 09043330 $3,265.96 $3,265.96 090 43775 $2,697.31 $2,697.31 09043331 $3,275.24 $3,275.24 090 43800 $2,272.93 $2,272.93 09043332 $2,839.89 $2,839.89 090 43810 $2,479.63 $2,479.63 09043333 $3,099.75 $3,099.75 090 43820 $3,279.46 $3,279.46 09043334 $3,063.47 $3,063.47 090 43825 $3,159.66 $3,159.66 09043335 $3,286.21 $3,286.21 090 43830 $1,705.96 $1,705.96 09043336 $3,691.19 $3,691.19 090 43831 $1,372.70 $1,372.70 09043337 $3,978.89 $3,978.89 090 43832 $2,533.63 $2,533.63 09043338 $322.62 $322.62 ZZZ 43840 $3,321.65 $3,321.65 09043340 $3,346.96 $3,346.96 090 43842 $2,907.39 $2,907.39 09043341 $3,437.23 $3,437.23 090 43843 $3,105.66 $3,105.66 09043351 $3,373.11 $3,373.11 090 43845 $4,797.28 $4,797.28 09043352 $2,619.69 $2,619.69 090 43846 $3,957.80 $3,957.80 09043360 $5,781.88 $5,781.88 090 43847 $4,339.99 $4,339.99 09043361 $6,314.25 $6,314.25 090 43848 $4,702.78 $4,702.78 09043400 $3,640.57 $3,640.57 090 43850 $3,946.83 $3,946.83 09043401 $3,606.82 $3,606.82 090 43855 $4,083.51 $4,083.51 09043405 $3,741.81 $3,741.81 090 43860 $3,999.14 $3,999.14 09043410 $2,570.75 $2,570.75 090 43865 $4,141.72 $4,141.72 09043415 $6,292.31 $6,292.31 090 43870 $1,736.33 $1,736.33 09043420 $2,478.79 $2,478.79 090 43880 $3,910.55 $3,910.55 09043425 $3,567.16 $3,567.16 090 43881 80% of billed 80% of billed N/A43450 $425.71 $222.40 000 43882 80% of billed 80% of billed N/A43453 $2,459.75 $240.53 000 43886 $882.51 $882.51 09043460 $597.52 $597.52 000 43887 $795.61 $795.61 09043496 80% of billed 80% of billed 090 43888 $1,117.06 $1,117.06 09043499 80% of billed 80% of billed N/A 43999 80% of billed 80% of billed N/A43500 $1,920.26 $1,920.26 090 44005 $2,677.06 $2,677.06 09043501 $3,291.27 $3,291.27 090 44010 $2,110.09 $2,110.09 09043502 $3,679.38 $3,679.38 090 44015 $395.16 $395.16 ZZZ43510 $2,261.12 $2,261.12 090 44020 $2,378.39 $2,378.39 09043520 $1,678.12 $1,678.12 090 44021 $2,380.08 $2,380.08 09043605 $2,053.57 $2,053.57 090 44025 $2,402.86 $2,402.86 09043610 $2,394.42 $2,394.42 090 44050 $2,283.90 $2,283.90 09043611 $2,988.39 $2,988.39 090 44055 $3,645.63 $3,645.63 09043620 $4,813.31 $4,813.31 090 44100 $302.58 $302.58 00043621 $5,551.55 $5,551.55 090 44110 $2,082.25 $2,082.25 09043622 $5,612.29 $5,612.29 090 44111 $2,398.64 $2,398.64 09043631 $3,546.07 $3,546.07 090 44120 $2,991.76 $2,991.76 09043632 $4,971.08 $4,971.08 090 44121 $671.97 $671.97 ZZZ43633 $4,701.10 $4,701.10 090 44125 $2,887.14 $2,887.14 09043634 $5,185.38 $5,185.38 090 44126 $5,956.52 $5,956.52 09043635 $313.08 $313.08 ZZZ 44127 $6,769.01 $6,769.01 09043640 $2,881.24 $2,881.24 090 44128 $679.60 $679.60 ZZZ43641 $2,916.67 $2,916.67 090 44130 $3,211.12 $3,211.12 09043644 $4,237.91 $4,237.91 090 44132 80% of billed 80% of billed N/A43645 $4,515.48 $4,515.48 090 44133 80% of billed 80% of billed N/A43647 80% of billed 80% of billed N/A 44135 80% of billed 80% of billed N/A43648 80% of billed 80% of billed N/A 44136 80% of billed 80% of billed N/A43651 $1,593.75 $1,593.75 090 44137 80% of billed 80% of billed N/A43652 $1,868.80 $1,868.80 090 44139 $336.94 $336.94 ZZZ43653 $1,398.01 $1,398.01 090 44140 $3,280.31 $3,280.31 09043659 80% of billed 80% of billed N/A 44141 $4,466.55 $4,466.55 09043752 $112.63 $112.63 000 44143 $4,072.54 $4,072.54 09043753 $60.13 $60.13 000 44144 $4,328.18 $4,328.18 09043754 $332.17 $97.36 000 44145 $4,057.35 $4,057.35 09043755 $374.16 $166.08 000 44146 $5,191.29 $5,191.29 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 27 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

44147 $4,753.41 $4,753.41 090 44405 $1,460.38 $513.52 00044150 $4,572.01 $4,572.01 090 44406 $644.29 $644.29 00044151 $5,219.97 $5,219.97 090 44407 $772.19 $772.19 00044155 $5,099.32 $5,099.32 090 44408 $650.01 $650.01 00044156 $5,546.48 $5,546.48 090 44500 $53.45 $53.45 00044157 $5,279.87 $5,279.87 090 44602 $3,454.11 $3,454.11 09044158 $5,464.65 $5,464.65 090 44603 $3,967.08 $3,967.08 09044160 $3,036.48 $3,036.48 090 44604 $2,588.47 $2,588.47 09044180 $2,246.77 $2,246.77 090 44605 $3,187.50 $3,187.50 09044186 $1,591.22 $1,591.22 090 44615 $2,625.59 $2,625.59 09044187 $2,701.53 $2,701.53 090 44620 $2,122.75 $2,122.75 09044188 $2,995.14 $2,995.14 090 44625 $2,487.23 $2,487.23 09044202 $3,389.14 $3,389.14 090 44626 $3,923.21 $3,923.21 09044203 $669.10 $669.10 ZZZ 44640 $3,431.33 $3,431.33 09044204 $3,764.59 $3,764.59 090 44650 $3,539.32 $3,539.32 09044205 $3,274.40 $3,274.40 090 44660 $3,271.03 $3,271.03 09044206 $4,286.00 $4,286.00 090 44661 $3,794.12 $3,794.12 09044207 $4,455.58 $4,455.58 090 44680 $2,609.56 $2,609.56 09044208 $4,863.93 $4,863.93 090 44700 $2,488.07 $2,488.07 09044210 $4,358.55 $4,358.55 090 44701 $466.75 $466.75 ZZZ44211 $5,349.90 $5,349.90 090 44705 80% of billed 80% of billed N/A44212 $5,010.73 $5,010.73 090 44715 80% of billed 80% of billed N/A44213 $523.07 $523.07 ZZZ 44720 $841.87 $841.87 N/A44227 $4,079.29 $4,079.29 090 44721 $1,067.13 $1,067.13 N/A44238 80% of billed 80% of billed N/A 44799 80% of billed 80% of billed N/A44300 $2,056.10 $2,056.10 090 44800 $1,868.80 $1,868.80 09044310 $2,553.04 $2,553.04 090 44820 $2,043.44 $2,043.44 09044312 $1,441.88 $1,441.88 090 44850 $1,831.67 $1,831.67 09044314 $2,452.64 $2,452.64 090 44899 80% of billed 80% of billed N/A44316 $3,467.61 $3,467.61 090 44900 $1,873.86 $1,873.86 09044320 $2,937.76 $2,937.76 090 44950 $1,568.44 $1,568.44 09044322 $2,430.70 $2,430.70 090 44955 $232.90 $232.90 ZZZ44340 $1,522.03 $1,522.03 090 44960 $2,136.25 $2,136.25 09044345 $2,571.60 $2,571.60 090 44970 $1,466.35 $1,466.35 09044346 $2,893.05 $2,893.05 090 44979 80% of billed 80% of billed N/A44360 $403.75 $403.75 000 45000 $1,031.85 $1,031.85 09044361 $445.75 $445.75 000 45005 $750.24 $444.80 01044363 $538.34 $538.34 000 45020 $1,396.32 $1,396.32 09044364 $573.65 $573.65 000 45100 $728.96 $728.96 09044365 $505.88 $505.88 000 45108 $888.42 $888.42 09044366 $673.88 $673.88 000 45110 $4,516.33 $4,516.33 09044369 $691.06 $691.06 000 45111 $2,655.97 $2,655.97 09044370 $748.33 $748.33 000 45112 $4,592.26 $4,592.26 09044372 $674.83 $674.83 000 45113 $4,726.41 $4,726.41 09044373 $539.29 $539.29 000 45114 $4,415.93 $4,415.93 09044376 $797.96 $797.96 000 45116 $3,956.11 $3,956.11 09044377 $840.91 $840.91 000 45119 $4,761.00 $4,761.00 09044378 $1,080.49 $1,080.49 000 45120 $3,880.18 $3,880.18 09044379 $1,151.13 $1,151.13 000 45121 $4,059.88 $4,059.88 09044380 $455.30 $157.49 000 45123 $2,737.81 $2,737.81 09044381 $2,532.29 $237.67 000 45126 $6,825.53 $6,825.53 09044382 $709.19 $205.22 000 45130 $2,661.87 $2,661.87 09044384 $427.62 $427.62 000 45135 $3,340.21 $3,340.21 09044385 $517.34 $201.40 000 45136 $4,670.72 $4,670.72 09044386 $773.14 $249.12 000 45150 $879.14 $879.14 09044388 $783.64 $438.12 000 45160 $2,493.98 $2,493.98 09044388 53 $389.44 $216.67 000 45171 $1,464.66 $1,464.66 09044389 $1,027.04 $482.02 000 45172 $1,974.26 $1,974.26 09044390 $1,016.54 $591.79 000 45190 $1,695.84 $1,695.84 09044391 $1,876.55 $646.20 000 45300 $335.03 $149.86 00044392 $950.68 $555.52 000 45303 $2,444.47 $240.53 00044394 $1,096.72 $632.83 000 45305 $387.53 $203.31 00044401 $8,599.09 $679.60 000 45307 $452.43 $270.12 00044402 $730.19 $730.19 000 45308 $434.30 $232.90 00044403 $851.41 $851.41 000 45309 $452.43 $248.17 00044404 $976.45 $482.02 000 45315 $491.57 $292.08 000

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 28 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

45317 $496.34 $311.17 000 46070 $550.94 $550.94 09045320 $482.02 $289.21 000 46080 $677.69 $440.02 01045321 $281.58 $281.58 000 46083 $481.07 $293.03 01045327 $314.98 $314.98 000 46200 $1,076.56 $791.39 09045330 $452.43 $156.54 000 46220 $561.25 $326.44 01045331 $693.92 $201.40 000 46221 $731.15 $523.07 01045332 $680.56 $294.94 000 46230 $745.46 $475.34 01045333 $795.10 $263.44 000 46250 $1,117.06 $766.08 09045334 $1,490.93 $330.26 000 46255 $1,222.52 $860.57 09045335 $632.83 $186.13 000 46257 $1,023.41 $1,023.41 09045337 $323.58 $323.58 000 46258 $1,128.03 $1,128.03 09045338 $728.28 $337.89 000 46260 $1,156.71 $1,156.71 09045340 $1,167.35 $217.63 000 46261 $1,270.61 $1,270.61 09045341 $347.44 $347.44 000 46262 $1,346.55 $1,346.55 09045342 $476.30 $476.30 000 46270 $1,226.74 $951.69 09045346 $8,260.24 $450.52 000 46275 $1,300.14 $1,005.69 09045347 $433.34 $433.34 000 46280 $1,140.68 $1,140.68 09045349 $556.47 $556.47 000 46285 $1,292.55 $1,004.85 09045350 $1,419.34 $282.53 000 46288 $1,338.95 $1,338.95 09045378 $858.10 $519.25 000 46320 $501.11 $305.44 01045378 53 $430.48 $261.53 000 46500 $511.61 $338.85 01045379 $1,107.22 $671.01 000 46505 $778.87 $655.74 01045380 $1,097.67 $563.15 000 46600 $240.53 $112.63 00045381 $1,049.00 $563.15 000 46601 $371.30 $259.62 00045382 $1,951.95 $727.33 000 46604 $1,685.65 $184.22 00045384 $1,217.94 $640.47 000 46606 $614.70 $209.99 00045385 $1,153.99 $713.97 000 46607 $524.02 $351.26 00045386 $1,584.47 $594.65 000 46608 $637.61 $230.99 00045388 $8,682.13 $759.78 000 46610 $619.47 $225.26 00045389 $814.19 $814.19 000 46611 $480.11 $225.26 00045390 $932.55 $932.55 000 46612 $677.69 $253.90 00045391 $723.51 $723.51 000 46614 $349.35 $178.49 00045392 $853.32 $853.32 000 46615 $390.39 $255.81 00045393 $709.19 $709.19 000 46700 $1,592.91 $1,592.91 09045395 $4,836.93 $4,836.93 090 46705 $1,217.46 $1,217.46 09045397 $5,267.22 $5,267.22 090 46706 $481.07 $481.07 01045398 $1,822.14 $658.60 000 46707 $1,146.59 $1,146.59 09045399 80% of billed 80% of billed N/A 46710 $2,541.22 $2,541.22 09045400 $2,787.58 $2,787.58 090 46712 $5,160.91 $5,160.91 09045402 $3,717.34 $3,717.34 090 46715 $1,318.70 $1,318.70 09045499 80% of billed 80% of billed N/A 46716 $2,698.15 $2,698.15 09045500 $1,272.30 $1,272.30 090 46730 $4,439.55 $4,439.55 09045505 $1,442.73 $1,442.73 090 46735 $5,142.35 $5,142.35 09045520 $421.89 $111.68 000 46740 $4,955.05 $4,955.05 09045540 $2,584.25 $2,584.25 090 46742 $6,639.08 $6,639.08 09045541 $2,304.14 $2,304.14 090 46744 $8,615.86 $8,615.86 09045550 $3,574.76 $3,574.76 090 46746 $8,743.26 $8,743.26 09045560 $1,675.59 $1,675.59 090 46748 $9,674.71 $9,674.71 09045562 $2,744.56 $2,744.56 090 46750 $1,836.73 $1,836.73 09045563 $4,009.26 $4,009.26 090 46751 $1,450.32 $1,450.32 09045800 $2,941.14 $2,941.14 090 46753 $1,407.29 $1,407.29 09045805 $3,501.36 $3,501.36 090 46754 $804.64 $624.24 01045820 $2,756.37 $2,756.37 090 46760 $2,696.47 $2,696.47 09045825 $3,497.14 $3,497.14 090 46761 $2,248.46 $2,248.46 09045900 $558.38 $558.38 010 46762 $2,225.68 $2,225.68 09045905 $464.84 $464.84 010 46900 $659.56 $377.03 01045910 $533.57 $533.57 010 46910 $698.69 $367.48 01045915 $904.87 $624.24 010 46916 $627.11 $394.21 01045990 $297.80 $297.80 000 46917 $1,237.03 $364.62 01045999 80% of billed 80% of billed N/A 46922 $727.33 $372.25 01046020 $755.96 $644.29 010 46924 $1,449.89 $504.93 01046030 $379.89 $249.12 010 46930 $495.25 $356.04 09046040 $1,293.39 $1,007.38 090 46940 $623.29 $402.80 01046045 $1,058.00 $1,058.00 090 46942 $588.93 $361.76 01046050 $548.84 $268.21 010 46945 $744.99 $548.41 09046060 $1,158.40 $1,158.40 090 46946 $755.96 $546.72 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 29 of 84

Page 30: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

46947 $929.76 $929.76 090 47605 $2,744.56 $2,744.56 09046999 80% of billed 80% of billed N/A 47610 $3,066.01 $3,066.01 09047000 $830.41 $249.12 000 47612 $3,097.22 $3,097.22 09047001 $289.21 $289.21 ZZZ 47620 $3,348.65 $3,348.65 09047010 $2,946.20 $2,946.20 090 47700 $2,538.69 $2,538.69 09047015 $2,839.05 $2,839.05 090 47701 $4,173.78 $4,173.78 09047100 $2,060.32 $2,060.32 090 47711 $3,804.24 $3,804.24 09047120 $5,697.51 $5,697.51 090 47712 $4,875.74 $4,875.74 09047122 $8,387.22 $8,387.22 090 47715 $3,238.96 $3,238.96 09047125 $7,519.05 $7,519.05 090 47720 $2,789.27 $2,789.27 09047130 $8,078.43 $8,078.43 090 47721 $3,300.55 $3,300.55 09047133 80% of billed 80% of billed N/A 47740 $3,194.25 $3,194.25 09047135 $13,122.91 $13,122.91 090 47741 $3,546.07 $3,546.07 09047140 $8,173.77 $8,173.77 090 47760 $5,510.20 $5,510.20 09047141 $10,438.26 $10,438.26 090 47765 $7,435.53 $7,435.53 09047142 $11,454.92 $11,454.92 090 47780 $6,050.17 $6,050.17 09047143 80% of billed 80% of billed N/A 47785 $7,931.62 $7,931.62 09047144 80% of billed 80% of billed 090 47800 $3,854.02 $3,854.02 09047145 80% of billed 80% of billed N/A 47801 $2,447.57 $2,447.57 09047146 $915.37 $915.37 N/A 47802 $3,724.09 $3,724.09 09047147 $1,062.36 $1,062.36 N/A 47900 $3,352.86 $3,352.86 09047300 $2,766.49 $2,766.49 090 47999 80% of billed 80% of billed N/A47350 $3,343.58 $3,343.58 090 48000 $4,561.89 $4,561.89 09047360 $4,527.29 $4,527.29 090 48001 $5,657.01 $5,657.01 09047361 $7,421.19 $7,421.19 090 48020 $2,836.52 $2,836.52 09047362 $3,546.07 $3,546.07 090 48100 $2,173.37 $2,173.37 09047370 $3,049.98 $3,049.98 090 48102 $1,447.98 $669.10 01047371 $3,033.95 $3,033.95 090 48105 $6,967.27 $6,967.27 09047379 80% of billed 80% of billed N/A 48120 $2,704.90 $2,704.90 09047380 $3,519.92 $3,519.92 090 48140 $3,822.80 $3,822.80 09047381 $3,376.49 $3,376.49 090 48145 $3,967.92 $3,967.92 09047382 $13,091.92 $2,082.72 010 48146 $4,577.92 $4,577.92 09047383 $18,399.90 $1,256.12 010 48148 $3,038.16 $3,038.16 09047399 80% of billed 80% of billed N/A 48150 $7,617.77 $7,617.77 09047400 $5,216.60 $5,216.60 090 48152 $7,058.39 $7,058.39 09047420 $3,275.24 $3,275.24 090 48153 $7,573.90 $7,573.90 09047425 $3,190.87 $3,190.87 090 48154 $7,055.02 $7,055.02 09047460 $3,073.60 $3,073.60 090 48155 $4,442.08 $4,442.08 09047480 $2,139.62 $2,139.62 090 48160 80% of billed 80% of billed N/A47490 $913.46 $913.46 010 48400 $295.89 $295.89 ZZZ47531 $847.60 $196.63 000 48500 $2,763.12 $2,763.12 09047532 $2,173.40 $594.65 000 48510 $2,661.87 $2,661.87 09047533 $3,352.20 $746.42 000 48520 $2,668.62 $2,668.62 09047534 $3,991.72 $1,039.45 000 48540 $3,205.22 $3,205.22 09047535 $2,753.73 $553.61 000 48545 $3,286.21 $3,286.21 09047536 $1,868.91 $370.35 000 48547 $4,362.77 $4,362.77 09047537 $992.68 $269.17 000 48548 $4,051.45 $4,051.45 09047538 $11,680.22 $658.60 000 48550 80% of billed 80% of billed N/A47539 $12,926.79 $1,194.08 000 48551 80% of billed 80% of billed N/A47540 $13,249.41 $1,237.03 000 48552 $650.01 $650.01 N/A47541 $3,178.48 $930.64 000 48554 $6,231.57 $6,231.57 09047542 $1,250.39 $378.94 ZZZ 48556 $3,095.54 $3,095.54 09047543 $1,562.52 $443.84 ZZZ 48999 80% of billed 80% of billed N/A47544 $2,945.59 $449.57 ZZZ 49000 $1,880.61 $1,880.61 09047550 $459.11 $459.11 ZZZ 49002 $2,554.72 $2,554.72 09047552 $858.10 $858.10 000 49010 $2,283.05 $2,283.05 09047553 $852.37 $852.37 000 49020 $3,888.61 $3,888.61 09047554 $1,313.39 $1,313.39 000 49040 $2,439.98 $2,439.98 09047555 $1,011.77 $1,011.77 000 49060 $2,682.97 $2,682.97 09047556 $1,153.99 $1,153.99 000 49062 $1,805.52 $1,805.52 09047562 $1,605.56 $1,605.56 090 49082 $523.07 $205.22 00047563 $1,743.93 $1,743.93 090 49083 $797.96 $300.67 00047564 $2,718.40 $2,718.40 090 49084 $300.67 $300.67 00047570 $1,896.64 $1,896.64 090 49180 $442.89 $236.72 00047579 80% of billed 80% of billed N/A 49185 $2,651.60 $337.89 00047600 $2,607.03 $2,607.03 090 49203 $2,926.80 $2,926.80 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 30 of 84

Page 31: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

49204 $3,747.72 $3,747.72 090 49572 $1,257.96 $1,257.96 09049205 $4,303.71 $4,303.71 090 49580 $798.14 $798.14 09049215 $5,427.52 $5,427.52 090 49582 $1,125.50 $1,125.50 09049220 $2,374.17 $2,374.17 090 49585 $1,084.15 $1,084.15 09049250 $1,435.98 $1,435.98 090 49587 $1,157.56 $1,157.56 09049255 $1,931.23 $1,931.23 090 49590 $1,396.32 $1,396.32 09049320 $898.18 $898.18 010 49600 $1,604.72 $1,604.72 09049321 $951.64 $951.64 010 49605 $12,098.66 $12,098.66 09049322 $1,018.45 $1,018.45 010 49606 $2,770.71 $2,770.71 09049323 $1,553.25 $1,553.25 090 49610 $1,588.69 $1,588.69 09049324 $1,074.77 $1,074.77 010 49611 $1,365.95 $1,365.95 09049325 $1,146.35 $1,146.35 010 49650 $1,043.66 $1,043.66 09049326 $524.02 $524.02 ZZZ 49651 $1,356.67 $1,356.67 09049327 $362.71 $362.71 ZZZ 49652 $1,814.80 $1,814.80 09049329 80% of billed 80% of billed N/A 49653 $2,264.49 $2,264.49 09049400 $367.48 $257.71 000 49654 $2,064.53 $2,064.53 09049402 $2,089.84 $2,089.84 090 49655 $2,519.29 $2,519.29 09049405 $2,186.76 $550.75 000 49656 $2,240.02 $2,240.02 09049406 $2,187.71 $550.75 000 49657 $3,226.31 $3,226.31 09049407 $1,776.32 $586.06 000 49659 80% of billed 80% of billed N/A49411 $1,307.66 $510.66 000 49900 $1,986.91 $1,986.91 09049412 $228.13 $228.13 ZZZ 49904 $3,465.92 $3,465.92 09049418 $3,693.91 $567.93 000 49905 $979.32 $979.32 ZZZ49419 $1,085.00 $1,085.00 090 49906 80% of billed 80% of billed 09049421 $636.65 $636.65 000 49999 80% of billed 80% of billed N/A49422 $1,049.95 $1,049.95 010 50010 $1,802.99 $1,802.99 09049423 $1,480.43 $198.54 000 50020 $2,473.73 $2,473.73 09049424 $395.16 $105.95 000 50040 $2,256.90 $2,256.90 09049425 $1,759.11 $1,759.11 090 50045 $2,290.65 $2,290.65 09049426 $1,490.82 $1,490.82 090 50060 $2,781.68 $2,781.68 09049427 $126.95 $126.95 000 50065 $2,947.89 $2,947.89 09049428 $1,268.53 $1,268.53 010 50070 $3,020.45 $3,020.45 09049429 $1,270.44 $1,270.44 010 50075 $3,557.88 $3,557.88 09049435 $331.21 $331.21 ZZZ 50080 $2,119.37 $2,119.37 09049436 $514.48 $514.48 010 50081 $3,111.57 $3,111.57 09049440 $2,626.78 $575.56 010 50100 $2,681.28 $2,681.28 09049441 $2,964.68 $671.97 010 50120 $2,349.70 $2,349.70 09049442 $2,466.43 $579.38 010 50125 $2,503.26 $2,503.26 09049446 $2,523.70 $415.21 000 50130 $2,515.91 $2,515.91 09049450 $1,803.05 $185.17 000 50135 $2,734.43 $2,734.43 09049451 $1,970.09 $251.03 000 50200 $1,451.79 $357.94 00049452 $2,435.88 $386.57 000 50205 $1,839.27 $1,839.27 09049460 $1,993.95 $132.68 000 50220 $2,551.35 $2,551.35 09049465 $444.80 $85.90 000 50225 $2,928.48 $2,928.48 09049491 $1,910.98 $1,910.98 090 50230 $3,126.75 $3,126.75 09049492 $2,337.05 $2,337.05 090 50234 $3,173.16 $3,173.16 09049495 $922.16 $922.16 090 50236 $3,577.29 $3,577.29 09049496 $1,322.08 $1,322.08 090 50240 $3,226.31 $3,226.31 09049500 $960.13 $960.13 090 50250 $2,948.73 $2,948.73 09049501 $1,477.32 $1,477.32 090 50280 $2,337.05 $2,337.05 09049505 $1,268.92 $1,268.92 090 50290 $2,189.40 $2,189.40 09049507 $1,426.70 $1,426.70 090 50300 80% of billed 80% of billed N/A49520 $1,541.44 $1,541.44 090 50320 $3,666.72 $3,666.72 09049521 $1,748.15 $1,748.15 090 50323 80% of billed 80% of billed N/A49525 $1,397.17 $1,397.17 090 50325 80% of billed 80% of billed N/A49540 $1,642.68 $1,642.68 090 50327 $601.33 $601.33 N/A49550 $1,403.07 $1,403.07 090 50328 $526.88 $526.88 N/A49553 $1,538.07 $1,538.07 090 50329 $497.29 $497.29 N/A49555 $1,457.91 $1,457.91 090 50340 $2,306.68 $2,306.68 09049557 $1,767.55 $1,767.55 090 50360 $5,905.90 $5,905.90 09049560 $1,800.46 $1,800.46 090 50365 $6,974.02 $6,974.02 09049561 $2,270.40 $2,270.40 090 50370 $2,932.70 $2,932.70 09049565 $1,874.70 $1,874.70 090 50380 $4,688.44 $4,688.44 09049566 $2,290.65 $2,290.65 090 50382 $3,007.63 $713.97 00049568 $740.69 $740.69 ZZZ 50384 $2,360.48 $644.29 00049570 $1,014.97 $1,014.97 090 50385 $2,928.41 $607.06 000

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 31 of 84

Page 32: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

50386 $1,867.00 $453.39 000 50728 $1,700.90 $1,700.90 09050387 $1,328.66 $234.81 000 50740 $2,961.39 $2,961.39 09050389 $805.60 $149.86 000 50750 $2,796.87 $2,796.87 09050390 $266.31 $266.31 000 50760 $2,743.71 $2,743.71 09050391 $333.12 $270.12 000 50770 $2,863.52 $2,863.52 09050395 $492.52 $492.52 000 50780 $2,700.68 $2,700.68 09050396 $323.58 $323.58 000 50782 $2,909.92 $2,909.92 09050400 $2,824.71 $2,824.71 090 50783 $2,761.43 $2,761.43 09050405 $3,409.39 $3,409.39 090 50785 $2,957.17 $2,957.17 09050430 $1,237.99 $425.71 000 50800 $2,250.15 $2,250.15 09050431 $441.93 $183.26 000 50810 $3,334.30 $3,334.30 09050432 $2,093.22 $574.61 000 50815 $2,988.39 $2,988.39 09050433 $2,863.50 $716.83 000 50820 $3,206.06 $3,206.06 09050434 $2,247.85 $542.16 000 50825 $4,044.70 $4,044.70 09050435 $1,278.08 $279.67 000 50830 $4,435.33 $4,435.33 09050500 $2,824.71 $2,824.71 090 50840 $3,001.04 $3,001.04 09050520 $2,511.69 $2,511.69 090 50845 $3,047.44 $3,047.44 09050525 $3,870.05 $3,870.05 090 50860 $2,321.86 $2,321.86 09050526 $3,609.35 $3,609.35 090 50900 $2,093.22 $2,093.22 09050540 $2,778.30 $2,778.30 090 50920 $2,231.59 $2,231.59 09050541 $2,240.02 $2,240.02 090 50930 $2,687.18 $2,687.18 09050542 $2,842.43 $2,842.43 090 50940 $2,151.44 $2,151.44 09050543 $3,627.07 $3,627.07 090 50945 $2,381.77 $2,381.77 09050544 $3,039.85 $3,039.85 090 50947 $3,384.92 $3,384.92 09050545 $3,268.49 $3,268.49 090 50948 $3,113.25 $3,113.25 09050546 $2,933.54 $2,933.54 090 50949 80% of billed 80% of billed N/A50547 $3,927.42 $3,927.42 090 50951 $1,032.77 $847.60 00050548 $3,287.06 $3,287.06 090 50953 $1,090.99 $900.09 00050549 80% of billed 80% of billed N/A 50955 $1,168.31 $974.54 00050551 $988.86 $814.19 000 50957 $1,179.76 $981.23 00050553 $1,053.77 $864.78 000 50961 $1,063.31 $877.19 00050555 $1,132.04 $943.05 000 50970 $1,024.18 $1,024.18 00050557 $1,153.04 $957.36 000 50972 $989.82 $989.82 00050561 $1,304.80 $1,089.08 000 50974 $1,307.66 $1,307.66 00050562 $1,418.26 $1,418.26 090 50976 $1,289.53 $1,289.53 00050570 $1,363.98 $1,363.98 000 50980 $984.09 $984.09 00050572 $1,470.88 $1,470.88 000 51020 $1,142.37 $1,142.37 09050574 $1,563.47 $1,563.47 000 51030 $1,144.90 $1,144.90 09050575 $1,976.77 $1,976.77 000 51040 $704.49 $704.49 09050576 $1,559.65 $1,559.65 000 51045 $1,189.62 $1,189.62 09050580 $1,680.87 $1,680.87 000 51050 $1,149.12 $1,149.12 09050590 $1,742.24 $1,382.82 090 51060 $1,409.82 $1,409.82 09050592 $3,340.75 $959.27 010 51065 $1,409.82 $1,409.82 09050593 $12,251.01 $1,285.71 010 51080 $998.94 $998.94 09050600 $2,296.55 $2,296.55 090 51100 $167.99 $107.86 00050605 $2,404.55 $2,404.55 090 51101 $335.98 $143.17 00050606 $1,907.09 $433.34 ZZZ 51102 $618.52 $398.98 00050610 $2,359.83 $2,359.83 090 51500 $1,554.94 $1,554.94 09050620 $2,199.53 $2,199.53 090 51520 $1,451.16 $1,451.16 09050630 $2,187.71 $2,187.71 090 51525 $2,094.06 $2,094.06 09050650 $2,524.35 $2,524.35 090 51530 $1,942.20 $1,942.20 09050660 $2,824.71 $2,824.71 090 51535 $1,902.54 $1,902.54 09050684 $289.21 $139.36 000 51550 $2,352.24 $2,352.24 09050686 $399.94 $247.22 000 51555 $3,090.47 $3,090.47 09050688 $218.58 $218.58 010 51565 $3,170.62 $3,170.62 09050690 $269.17 $194.72 000 51570 $3,605.97 $3,605.97 09050693 $2,675.46 $568.88 000 51575 $4,442.92 $4,442.92 09050694 $2,937.00 $744.51 000 51580 $4,690.13 $4,690.13 09050695 $3,606.10 $954.50 000 51585 $5,159.23 $5,159.23 09050700 $2,250.99 $2,250.99 090 51590 $4,716.28 $4,716.28 09050705 $5,244.02 $552.66 ZZZ 51595 $5,337.25 $5,337.25 09050706 $2,704.10 $521.16 ZZZ 51596 $5,740.53 $5,740.53 09050715 $2,979.95 $2,979.95 090 51597 $5,589.51 $5,589.51 09050722 $2,558.94 $2,558.94 090 51600 $498.25 $122.18 00050725 $2,747.09 $2,747.09 090 51605 $105.95 $105.95 00050727 $1,239.40 $1,239.40 090 51610 $290.17 $177.54 000

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 32 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

51700 $197.58 $99.27 000 52224 $1,876.55 $564.11 00051701 $128.86 $70.63 000 52234 $680.56 $680.56 00051702 $170.86 $70.63 000 52235 $797.96 $797.96 00051703 $339.80 $211.90 000 52240 $1,083.36 $1,083.36 00051705 $247.22 $143.17 000 52250 $661.47 $661.47 00051710 $350.30 $220.49 000 52260 $581.29 $581.29 00051715 $793.19 $550.75 000 52265 $992.68 $448.61 00051720 $239.58 $177.54 000 52270 $967.86 $503.02 00051725 $507.79 $507.79 000 52275 $1,305.76 $687.24 00051725 TC $297.80 $297.80 000 52276 $732.10 $732.10 00051725 26 $209.99 $209.99 000 52277 $893.41 $893.41 00051726 $714.92 $714.92 000 52281 $742.60 $420.93 00051726 TC $480.11 $480.11 000 52282 $930.64 $930.64 00051726 26 $234.81 $234.81 000 52283 $756.92 $556.47 00051727 $844.73 $844.73 000 52285 $763.60 $541.20 00051727 TC $549.79 $549.79 000 52287 $847.60 $467.70 00051727 26 $294.94 $294.94 000 52290 $673.88 $673.88 00051728 $854.28 $854.28 000 52300 $775.05 $775.05 00051728 TC $566.02 $566.02 000 52301 $801.78 $801.78 00051728 26 $288.26 $288.26 000 52305 $771.24 $771.24 00051729 $923.00 $923.00 000 52310 $663.38 $419.03 00051729 TC $574.61 $574.61 000 52315 $1,126.31 $758.83 00051729 26 $348.39 $348.39 000 52317 $2,185.80 $960.23 00051736 $42.00 $42.00 N/A 52318 $1,308.62 $1,308.62 00051736 TC $19.09 $19.09 N/A 52320 $682.47 $682.47 00051736 26 $22.91 $22.91 N/A 52325 $887.68 $887.68 00051741 $42.95 $42.95 N/A 52327 $724.47 $724.47 00051741 TC $20.04 $20.04 N/A 52330 $1,344.89 $729.24 00051741 26 $22.91 $22.91 N/A 52332 $1,328.66 $430.48 00051784 $188.04 $188.04 N/A 52334 $706.33 $706.33 00051784 TC $84.95 $84.95 N/A 52341 $785.55 $785.55 00051784 26 $103.09 $103.09 N/A 52342 $855.23 $855.23 00051785 $717.78 $717.78 N/A 52343 $950.68 $950.68 00051785 TC $472.48 $472.48 N/A 52344 $1,021.31 $1,021.31 00051785 26 $245.31 $245.31 N/A 52345 $1,090.04 $1,090.04 00051792 $573.65 $573.65 000 52346 $1,233.21 $1,233.21 00051792 TC $421.89 $421.89 000 52351 $837.10 $837.10 00051792 26 $151.77 $151.77 000 52352 $978.36 $978.36 00051797 $303.53 $303.53 ZZZ 52353 $1,083.36 $1,083.36 00051797 TC $192.81 $192.81 ZZZ 52354 $1,153.04 $1,153.04 00051797 26 $110.72 $110.72 ZZZ 52355 $1,292.39 $1,292.39 00051798 $52.50 $52.50 N/A 52356 $1,149.22 $1,149.22 00051800 $2,548.82 $2,548.82 090 52400 $1,165.99 $1,165.99 09051820 $2,862.67 $2,862.67 090 52402 $737.83 $737.83 00051840 $1,597.12 $1,597.12 090 52441 $3,361.75 $626.15 00051841 $1,905.07 $1,905.07 090 52442 $2,572.38 $167.04 ZZZ51845 $1,420.79 $1,420.79 090 52450 $1,144.06 $1,144.06 09051860 $1,817.33 $1,817.33 090 52500 $1,187.93 $1,187.93 09051865 $2,182.65 $2,182.65 090 52601 $2,061.16 $2,061.16 09051880 $1,139.00 $1,139.00 090 52630 $974.47 $974.47 09051900 $2,043.44 $2,043.44 090 52640 $766.92 $766.92 09051920 $1,906.76 $1,906.76 090 52647 $4,276.72 $1,576.88 09051925 $2,512.54 $2,512.54 090 52648 $4,400.74 $1,680.65 09051940 $4,035.42 $4,035.42 090 52649 $2,005.47 $2,005.47 09051960 $3,379.02 $3,379.02 090 52700 $1,076.56 $1,076.56 09051980 $1,738.02 $1,738.02 090 53000 $406.62 $406.62 01051990 $1,829.99 $1,829.99 090 53010 $717.15 $717.15 09051992 $2,044.29 $2,044.29 090 53020 $268.21 $268.21 00051999 80% of billed 80% of billed N/A 53025 $197.58 $197.58 00052000 $446.71 $280.62 000 53040 $955.91 $955.91 09052001 $1,017.50 $794.14 000 53060 $503.02 $452.43 01052005 $723.51 $368.44 000 53080 $1,022.56 $1,022.56 09052007 $1,205.53 $458.16 000 53085 $1,604.72 $1,604.72 09052010 $999.36 $458.16 000 53200 $428.57 $393.25 00052204 $1,002.22 $391.34 000 53210 $1,895.79 $1,895.79 09052214 $1,791.60 $487.75 000 53215 $2,263.65 $2,263.65 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 33 of 84

Page 34: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

53220 $1,114.53 $1,114.53 090 54160 $599.43 $397.07 01053230 $1,475.63 $1,475.63 090 54161 $542.16 $542.16 01053235 $1,544.81 $1,544.81 090 54162 $701.56 $546.93 01053240 $1,034.38 $1,034.38 090 54163 $602.29 $602.29 01053250 $995.57 $995.57 090 54164 $533.57 $533.57 01053260 $550.75 $494.43 010 54200 $292.08 $230.03 01053265 $596.56 $511.61 010 54205 $1,295.92 $1,295.92 09053270 $565.06 $506.84 010 54220 $558.38 $370.35 00053275 $725.42 $725.42 010 54230 $264.40 $219.53 00053400 $1,949.79 $1,949.79 090 54231 $383.71 $321.67 00053405 $2,141.31 $2,141.31 090 54235 $247.22 $202.35 00053410 $2,382.61 $2,382.61 090 54240 $284.44 $284.44 00053415 $2,754.68 $2,754.68 090 54240 TC $94.50 $94.50 00053420 $2,050.19 $2,050.19 090 54240 26 $189.95 $189.95 00053425 $2,283.05 $2,283.05 090 54250 $332.17 $332.17 00053430 $2,355.61 $2,355.61 090 54250 TC $29.59 $29.59 00053431 $2,812.90 $2,812.90 090 54250 26 $302.58 $302.58 00053440 $1,834.20 $1,834.20 090 54300 $1,565.91 $1,565.91 09053442 $1,905.92 $1,905.92 090 54304 $1,823.24 $1,823.24 09053444 $1,931.23 $1,931.23 090 54308 $1,742.24 $1,742.24 09053445 $1,834.20 $1,834.20 090 54312 $2,085.63 $2,085.63 09053446 $1,563.38 $1,563.38 090 54316 $2,542.91 $2,542.91 09053447 $1,969.20 $1,969.20 090 54318 $1,732.12 $1,732.12 09053448 $3,124.22 $3,124.22 090 54322 $1,883.14 $1,883.14 09053449 $1,489.13 $1,489.13 090 54324 $2,357.30 $2,357.30 09053450 $994.72 $994.72 090 54326 $2,304.99 $2,304.99 09053460 $1,115.37 $1,115.37 090 54328 $2,331.99 $2,331.99 09053500 $1,822.39 $1,822.39 090 54332 $2,580.88 $2,580.88 09053502 $1,184.55 $1,184.55 090 54336 $2,898.95 $2,898.95 09053505 $1,182.87 $1,182.87 090 54340 $1,378.61 $1,378.61 09053510 $1,537.22 $1,537.22 090 54344 $2,310.89 $2,310.89 09053515 $1,924.48 $1,924.48 090 54348 $2,472.04 $2,472.04 09053520 $1,354.14 $1,354.14 090 54352 $3,454.11 $3,454.11 09053600 $227.17 $175.63 000 54360 $1,756.58 $1,756.58 09053601 $221.44 $147.95 000 54380 $1,948.10 $1,948.10 09053605 $178.49 $178.49 000 54385 $2,366.58 $2,366.58 09053620 $317.85 $241.49 000 54390 $3,024.66 $3,024.66 09053621 $297.80 $199.49 000 54400 $1,289.17 $1,289.17 09053660 $191.85 $115.49 000 54401 $1,594.59 $1,594.59 09053661 $188.99 $111.68 000 54405 $1,970.04 $1,970.04 09053665 $106.90 $106.90 000 54406 $1,780.21 $1,780.21 09053850 $4,973.61 $1,477.32 090 54408 $1,926.17 $1,926.17 09053852 $4,588.88 $1,516.13 090 54410 $2,094.06 $2,094.06 09053855 $2,108.49 $228.13 000 54411 $2,500.73 $2,500.73 09053860 $3,756.15 $548.41 090 54415 $1,287.49 $1,287.49 09053899 80% of billed 80% of billed N/A 54416 $1,730.43 $1,730.43 09054000 $403.75 $297.80 010 54417 $2,190.25 $2,190.25 09054001 $503.98 $381.80 010 54420 $1,714.40 $1,714.40 09054015 $848.55 $848.55 010 54430 $1,557.47 $1,557.47 09054050 $361.76 $291.12 010 54435 $1,015.81 $1,015.81 09054055 $323.58 $254.85 010 54437 $1,651.96 $1,651.96 09054056 $386.57 $304.49 010 54438 $3,283.68 $3,283.68 09054057 $371.30 $261.53 010 54440 80% of billed 80% of billed 09054060 $489.66 $358.89 010 54450 $191.85 $159.40 00054065 $596.56 $475.34 010 54500 $206.17 $206.17 00054100 $540.25 $347.44 000 54505 $578.43 $578.43 01054105 $722.56 $587.02 010 54512 $1,316.17 $1,316.17 09054110 $1,524.57 $1,524.57 090 54520 $794.77 $794.77 09054111 $1,966.66 $1,966.66 090 54522 $1,441.88 $1,441.88 09054112 $2,285.58 $2,285.58 090 54530 $1,230.11 $1,230.11 09054115 $1,104.40 $1,040.28 090 54535 $1,831.67 $1,831.67 09054120 $1,539.75 $1,539.75 090 54550 $1,208.18 $1,208.18 09054125 $1,984.38 $1,984.38 090 54560 $1,750.68 $1,750.68 09054130 $2,909.08 $2,909.08 090 54600 $1,108.62 $1,108.62 09054135 $3,686.97 $3,686.97 090 54620 $826.60 $826.60 01054150 $421.89 $270.12 000 54640 $1,164.31 $1,164.31 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 34 of 84

Page 35: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

54650 $1,770.08 $1,770.08 090 55970 80% of billed 80% of billed N/A54660 $885.89 $885.89 090 55980 80% of billed 80% of billed N/A54670 $998.10 $998.10 090 56405 $296.85 $294.94 01054680 $1,956.54 $1,956.54 090 56420 $328.35 $248.17 01054690 $1,609.78 $1,609.78 090 56440 $495.39 $495.39 01054692 $1,948.10 $1,948.10 090 56441 $390.39 $377.03 01054699 80% of billed 80% of billed N/A 56442 $129.81 $129.81 00054700 $588.93 $588.93 010 56501 $355.07 $313.08 01054800 $367.48 $367.48 000 56515 $615.65 $548.84 01054830 $907.82 $907.82 090 56605 $223.35 $165.13 00054840 $782.11 $782.11 090 56606 $103.09 $82.09 ZZZ54860 $1,020.03 $1,020.03 090 56620 $1,258.80 $1,258.80 09054861 $1,377.76 $1,377.76 090 56625 $1,531.32 $1,531.32 09054865 $874.07 $874.07 090 56630 $2,257.74 $2,257.74 09054900 $2,040.07 $2,040.07 090 56631 $2,876.17 $2,876.17 09054901 $2,573.29 $2,573.29 090 56632 $3,354.55 $3,354.55 09055000 $319.76 $234.81 000 56633 $2,947.04 $2,947.04 09055040 $823.45 $823.45 090 56634 $3,157.97 $3,157.97 09055041 $1,242.77 $1,242.77 090 56637 $3,683.59 $3,683.59 09055060 $927.23 $927.23 090 56640 $3,708.06 $3,708.06 09055100 $587.97 $456.25 010 56700 $509.70 $509.70 01055110 $944.94 $944.94 090 56740 $818.96 $818.96 01055120 $876.60 $876.60 090 56800 $654.79 $654.79 01055150 $1,198.05 $1,198.05 090 56805 $3,050.82 $3,050.82 09055175 $886.73 $886.73 090 56810 $707.28 $707.28 01055180 $1,675.59 $1,675.59 090 56820 $305.44 $237.67 00055200 $1,044.50 $666.52 090 56821 $401.84 $316.89 00055250 $929.76 $555.15 090 57000 $501.11 $501.11 01055300 $518.29 $518.29 000 57010 $1,042.81 $1,042.81 09055400 $1,214.08 $1,214.08 090 57020 $251.03 $219.53 00055450 $1,001.27 $720.65 010 57022 $466.75 $466.75 01055500 $963.51 $963.51 090 57023 $839.96 $839.96 01055520 $1,103.56 $1,103.56 090 57061 $307.35 $267.26 01055530 $856.36 $856.36 090 57065 $530.70 $475.34 01055535 $1,047.88 $1,047.88 090 57100 $243.40 $184.22 00055540 $1,344.86 $1,344.86 090 57105 $370.35 $344.57 01055550 $1,043.66 $1,043.66 090 57106 $1,192.15 $1,192.15 09055559 80% of billed 80% of billed N/A 57107 $3,519.92 $3,519.92 09055600 $1,026.78 $1,026.78 090 57109 $4,269.12 $4,269.12 09055605 $1,329.67 $1,329.67 090 57110 $2,143.00 $2,143.00 09055650 $1,751.52 $1,751.52 090 57111 $3,900.43 $3,900.43 09055680 $886.73 $886.73 090 57112 $4,369.52 $4,369.52 09055700 $673.88 $361.76 000 57120 $1,219.99 $1,219.99 09055705 $734.01 $734.01 010 57130 $479.16 $430.48 01055706 $1,026.09 $1,026.09 010 57135 $521.16 $471.52 01055720 $1,101.03 $1,101.03 090 57150 $122.18 $79.22 00055725 $1,593.75 $1,593.75 090 57155 $990.77 $761.69 00055801 $2,673.69 $2,673.69 090 57156 $539.29 $401.84 00055810 $3,195.09 $3,195.09 090 57160 $207.13 $127.90 00055812 $4,032.89 $4,032.89 090 57170 $165.13 $132.68 00055815 $4,316.37 $4,316.37 090 57180 $379.89 $286.35 01055821 $2,129.50 $2,129.50 090 57200 $727.27 $727.27 09055831 $2,303.30 $2,303.30 090 57210 $879.98 $879.98 09055840 $2,857.61 $2,857.61 090 57220 $766.92 $766.92 09055842 $2,856.77 $2,856.77 090 57230 $946.63 $946.63 09055845 $3,325.02 $3,325.02 090 57240 $1,612.31 $1,612.31 09055860 $2,133.72 $2,133.72 090 57250 $1,621.59 $1,621.59 09055862 $2,733.59 $2,733.59 090 57260 $1,997.04 $1,997.04 09055865 $3,252.46 $3,252.46 090 57265 $2,188.56 $2,188.56 09055866 $3,521.60 $3,521.60 090 57267 $697.74 $697.74 ZZZ55870 $481.07 $393.25 000 57268 $1,161.77 $1,161.77 09055873 $16,917.87 $1,862.05 090 57270 $1,926.17 $1,926.17 09055875 $1,858.67 $1,858.67 090 57280 $2,292.33 $2,292.33 09055876 $370.35 $277.76 000 57282 $1,201.43 $1,201.43 09055899 80% of billed 80% of billed N/A 57283 $1,652.81 $1,652.81 09055920 $1,233.21 $1,233.21 000 57284 $1,959.07 $1,959.07 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 35 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

57285 $1,615.69 $1,615.69 090 58275 $2,358.99 $2,358.99 09057287 $1,640.15 $1,640.15 090 58280 $2,514.23 $2,514.23 09057288 $1,723.68 $1,723.68 090 58285 $3,462.54 $3,462.54 09057289 $1,775.14 $1,775.14 090 58290 $2,757.21 $2,757.21 09057291 $1,266.39 $1,266.39 090 58291 $2,974.04 $2,974.04 09057292 $1,962.45 $1,962.45 090 58292 $3,136.03 $3,136.03 09057295 $1,146.59 $1,146.59 090 58293 $3,264.28 $3,264.28 09057296 $2,250.15 $2,250.15 090 58294 $2,909.92 $2,909.92 09057300 $1,357.51 $1,357.51 090 58300 $196.63 $146.99 N/A57305 $2,266.18 $2,266.18 090 58301 $256.76 $184.22 00057307 $2,550.51 $2,550.51 090 58321 $208.08 $132.68 00057308 $1,531.32 $1,531.32 090 58322 $231.94 $159.40 00057310 $1,122.12 $1,122.12 090 58323 $41.04 $32.45 00057311 $1,273.14 $1,273.14 090 58340 $322.62 $158.45 00057320 $1,286.64 $1,286.64 090 58345 $753.10 $753.10 01057330 $1,821.55 $1,821.55 090 58346 $1,096.81 $1,096.81 09057335 $3,007.79 $3,007.79 090 58350 $261.53 $213.81 01057400 $367.48 $367.48 000 58353 $2,711.73 $593.70 01057410 $293.99 $293.99 000 58356 $5,077.94 $937.32 01057415 $435.25 $435.25 010 58400 $1,056.31 $1,056.31 09057420 $320.71 $251.99 000 58410 $1,934.60 $1,934.60 09057421 $427.62 $339.80 000 58520 $2,013.91 $2,013.91 09057423 $2,188.56 $2,188.56 090 58540 $2,158.18 $2,158.18 09057425 $2,331.14 $2,331.14 090 58541 $1,718.62 $1,718.62 09057426 $2,022.35 $2,022.35 090 58542 $1,963.29 $1,963.29 09057452 $295.89 $251.99 000 58543 $1,981.85 $1,981.85 09057454 $414.25 $370.35 000 58544 $2,162.40 $2,162.40 09057455 $386.57 $302.58 000 58545 $2,170.00 $2,170.00 09057456 $364.62 $281.58 000 58546 $2,688.03 $2,688.03 09057460 $763.60 $442.89 000 58548 $4,623.48 $4,623.48 09057461 $864.78 $511.61 000 58550 $2,113.47 $2,113.47 09057500 $345.53 $207.13 000 58552 $2,371.64 $2,371.64 09057505 $276.80 $251.03 010 58553 $2,727.68 $2,727.68 09057510 $355.07 $314.03 010 58554 $3,187.50 $3,187.50 09057511 $392.30 $358.89 010 58555 $725.42 $419.98 00057513 $393.25 $364.62 010 58558 $3,675.78 $641.42 00057520 $738.24 $663.99 090 58559 $790.33 $790.33 00057522 $631.09 $584.68 090 58560 $865.73 $865.73 00057530 $835.26 $835.26 090 58561 $1,195.03 $1,195.03 00057531 $4,467.39 $4,467.39 090 58562 $920.14 $633.79 00057540 $2,029.10 $2,029.10 090 58563 $4,292.39 $746.42 00057545 $2,006.32 $2,006.32 090 58565 $4,485.11 $1,039.44 09057550 $971.94 $971.94 090 58570 $1,871.33 $1,871.33 09057555 $1,444.41 $1,444.41 090 58571 $2,163.25 $2,163.25 09057556 $1,354.98 $1,354.98 090 58572 $2,452.64 $2,452.64 09057558 $335.98 $307.35 010 58573 $2,932.70 $2,932.70 09057700 $751.74 $751.74 090 58578 80% of billed 80% of billed N/A57720 $737.39 $737.39 090 58579 80% of billed 80% of billed N/A57800 $164.17 $132.68 000 58600 $869.01 $869.01 09058100 $295.89 $238.62 000 58605 $787.17 $787.17 09058110 $129.81 $111.68 ZZZ 58611 $209.04 $209.04 ZZZ58120 $700.60 $595.61 010 58615 $674.83 $674.83 01058140 $2,207.12 $2,207.12 090 58660 $1,618.22 $1,618.22 09058145 $1,316.17 $1,316.17 090 58661 $1,767.73 $1,767.73 01058146 $2,766.49 $2,766.49 090 58662 $1,706.81 $1,706.81 09058150 $2,447.57 $2,447.57 090 58670 $873.23 $873.23 09058152 $2,998.51 $2,998.51 090 58671 $870.70 $870.70 09058180 $2,314.27 $2,314.27 090 58672 $1,756.58 $1,756.58 09058200 $3,328.40 $3,328.40 090 58673 $1,911.82 $1,911.82 09058210 $4,488.48 $4,488.48 090 58674 $1,959.92 $1,959.92 09058240 $7,066.83 $7,066.83 090 58679 80% of billed 80% of billed N/A58260 $1,979.32 $1,979.32 090 58700 $1,874.70 $1,874.70 09058262 $2,208.81 $2,208.81 090 58720 $1,778.52 $1,778.52 09058263 $2,369.95 $2,369.95 090 58740 $2,126.12 $2,126.12 09058267 $2,513.38 $2,513.38 090 58750 $2,315.96 $2,315.96 09058270 $2,113.47 $2,113.47 090 58752 $2,176.75 $2,176.75 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 36 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

58760 $1,934.60 $1,934.60 090 59514 $2,537.06 $2,537.06 N/A58770 $2,094.06 $2,094.06 090 59515 $3,492.52 $3,492.52 N/A58800 $757.64 $711.24 090 59525 $1,345.84 $1,345.84 ZZZ58805 $971.10 $971.10 090 59610 $6,056.30 $6,056.30 N/A58820 $783.80 $783.80 090 59612 $2,539.92 $2,539.92 N/A58822 $1,672.21 $1,672.21 090 59614 $3,158.44 $3,158.44 N/A58825 $1,820.70 $1,820.70 090 59618 $6,472.46 $6,472.46 N/A58900 $990.50 $990.50 090 59620 $2,592.42 $2,592.42 N/A58920 $1,818.17 $1,818.17 090 59622 $3,557.42 $3,557.42 N/A58925 $1,797.08 $1,797.08 090 59812 $773.67 $720.52 09058940 $1,268.92 $1,268.92 090 59820 $920.48 $867.32 09058943 $2,844.96 $2,844.96 090 59821 $928.07 $869.01 09058950 $2,742.87 $2,742.87 090 59830 $1,064.75 $1,064.75 09058951 $3,535.10 $3,535.10 090 59840 $595.61 $571.75 01058952 $4,000.83 $4,000.83 090 59841 $1,053.77 $996.50 01058953 $4,949.99 $4,949.99 090 59850 $927.23 $927.23 09058954 $5,377.74 $5,377.74 090 59851 $971.94 $971.94 09058956 $3,360.46 $3,360.46 090 59852 $1,221.68 $1,221.68 09058957 $3,864.15 $3,864.15 090 59855 $1,013.28 $1,013.28 09058958 $4,262.37 $4,262.37 090 59856 $1,191.30 $1,191.30 09058960 $2,351.39 $2,351.39 090 59857 $1,255.43 $1,255.43 09058970 $603.24 $543.11 000 59866 $593.70 $593.70 00058974 80% of billed 80% of billed 000 59870 $1,149.12 $1,149.12 09058976 $685.33 $593.70 000 59871 $371.30 $371.30 00058999 80% of billed 80% of billed N/A 59897 80% of billed 80% of billed N/A59000 $343.62 $224.31 000 59898 80% of billed 80% of billed N/A59001 $497.29 $497.29 000 59899 80% of billed 80% of billed N/A59012 $562.20 $562.20 000 60000 $433.34 $390.39 01059015 $428.57 $367.48 000 60100 $307.35 $217.63 00059020 $193.76 $193.76 000 60200 $1,603.03 $1,603.03 09059020 TC $91.63 $91.63 000 60210 $1,718.62 $1,718.62 09059020 26 $102.13 $102.13 000 60212 $2,452.64 $2,452.64 09059025 $131.72 $131.72 000 60220 $1,714.40 $1,714.40 09059025 TC $49.63 $49.63 000 60225 $2,261.12 $2,261.12 09059025 26 $82.09 $82.09 000 60240 $2,234.12 $2,234.12 09059030 $275.85 $275.85 000 60252 $3,212.81 $3,212.81 09059050 $132.68 $132.68 N/A 60254 $4,053.98 $4,053.98 09059051 $117.40 $117.40 N/A 60260 $2,656.81 $2,656.81 09059070 $1,098.63 $845.69 000 60270 $3,332.62 $3,332.62 09059072 $1,289.53 $1,289.53 000 60271 $2,571.60 $2,571.60 09059074 $1,057.59 $833.28 000 60280 $1,070.66 $1,070.66 09059076 $1,289.53 $1,289.53 000 60281 $1,430.92 $1,430.92 09059100 $1,909.29 $1,909.29 090 60300 $320.71 $137.45 00059120 $1,927.85 $1,927.85 090 60500 $2,348.02 $2,348.02 09059121 $1,933.76 $1,933.76 090 60502 $3,133.50 $3,133.50 09059130 $2,267.87 $2,267.87 090 60505 $3,368.89 $3,368.89 09059135 $2,016.44 $2,016.44 090 60512 $671.01 $671.01 ZZZ59136 $2,147.22 $2,147.22 090 60520 $2,542.91 $2,542.91 09059140 $901.92 $901.92 090 60521 $2,737.81 $2,737.81 09059150 $1,871.33 $1,871.33 090 60522 $3,326.71 $3,326.71 09059151 $1,824.08 $1,824.08 090 60540 $2,596.91 $2,596.91 09059160 $558.38 $478.20 010 60545 $2,971.51 $2,971.51 09059200 $196.63 $124.08 000 60600 $3,390.83 $3,390.83 09059300 $527.84 $408.53 000 60605 $4,718.81 $4,718.81 09059320 $422.84 $422.84 000 60650 $2,912.45 $2,912.45 09059325 $671.97 $671.97 000 60659 80% of billed 80% of billed N/A59350 $761.69 $761.69 000 60699 80% of billed 80% of billed N/A59400 $5,753.73 $5,753.73 N/A 61000 $313.08 $313.08 00059409 $2,250.71 $2,250.71 N/A 61001 $230.99 $230.99 00059410 $2,873.04 $2,873.04 N/A 61020 $280.62 $280.62 00059412 $285.40 $285.40 N/A 61026 $288.26 $288.26 00059414 $254.85 $254.85 N/A 61050 $236.72 $236.72 00059425 $1,248.49 $984.09 N/A 61055 $335.98 $335.98 00059426 $2,235.44 $1,737.19 N/A 61070 $158.45 $158.45 00059430 $506.84 $384.66 N/A 61105 $1,090.06 $1,090.06 09059510 $6,386.56 $6,386.56 N/A 61107 $884.82 $884.82 000

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 37 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

61108 $2,233.27 $2,233.27 090 61558 $4,668.19 $4,668.19 09061120 $1,842.64 $1,842.64 090 61559 $5,651.10 $5,651.10 09061140 $3,118.32 $3,118.32 090 61563 $4,885.87 $4,885.87 09061150 $3,354.55 $3,354.55 090 61564 $5,651.10 $5,651.10 09061151 $2,468.67 $2,468.67 090 61566 $5,593.73 $5,593.73 09061154 $3,139.41 $3,139.41 090 61567 $5,857.81 $5,857.81 09061156 $3,086.25 $3,086.25 090 61570 $4,554.29 $4,554.29 09061210 $1,041.36 $1,041.36 000 61571 $4,946.61 $4,946.61 09061215 $1,253.74 $1,253.74 090 61575 $6,158.17 $6,158.17 09061250 $2,043.44 $2,043.44 090 61576 $8,323.10 $8,323.10 09061253 $1,979.32 $1,979.32 090 61580 $6,026.55 $6,026.55 09061304 $4,047.23 $4,047.23 090 61581 $6,445.87 $6,445.87 09061305 $4,998.92 $4,998.92 090 61582 $7,395.87 $7,395.87 09061312 $5,150.79 $5,150.79 090 61583 $7,121.67 $7,121.67 09061313 $4,907.80 $4,907.80 090 61584 $6,992.59 $6,992.59 09061314 $4,523.92 $4,523.92 090 61585 $7,805.07 $7,805.07 09061315 $5,127.17 $5,127.17 090 61586 $5,835.87 $5,835.87 09061316 $250.08 $250.08 ZZZ 61590 $7,421.19 $7,421.19 09061320 $4,704.47 $4,704.47 090 61591 $7,519.90 $7,519.90 09061321 $5,236.00 $5,236.00 090 61592 $7,818.57 $7,818.57 09061322 $5,893.24 $5,893.24 090 61595 $5,729.57 $5,729.57 09061323 $5,969.18 $5,969.18 090 61596 $5,939.65 $5,939.65 09061330 $4,348.43 $4,348.43 090 61597 $7,023.80 $7,023.80 09061332 $4,165.35 $4,165.35 090 61598 $6,891.34 $6,891.34 09061333 $4,409.18 $4,409.18 090 61600 $5,182.01 $5,182.01 09061340 $3,594.16 $3,594.16 090 61601 $5,889.03 $5,889.03 09061343 $5,433.43 $5,433.43 090 61605 $5,268.06 $5,268.06 09061345 $5,038.58 $5,038.58 090 61606 $7,275.23 $7,275.23 09061450 $4,785.47 $4,785.47 090 61607 $6,601.11 $6,601.11 09061458 $4,976.99 $4,976.99 090 61608 $8,013.46 $8,013.46 09061460 $5,101.01 $5,101.01 090 61610 $4,588.28 $4,588.28 ZZZ61480 $4,828.50 $4,828.50 090 61611 $1,073.81 $1,073.81 ZZZ61500 $3,243.18 $3,243.18 090 61612 $3,308.30 $3,308.30 ZZZ61501 $2,817.11 $2,817.11 090 61613 $7,939.22 $7,939.22 09061510 $5,403.05 $5,403.05 090 61615 $6,044.27 $6,044.27 09061512 $6,310.03 $6,310.03 090 61616 $8,183.89 $8,183.89 09061514 $4,707.00 $4,707.00 090 61618 $3,183.28 $3,183.28 09061516 $4,596.48 $4,596.48 090 61619 $3,517.39 $3,517.39 09061517 $246.26 $246.26 ZZZ 61623 $1,586.38 $1,586.38 00061518 $6,823.85 $6,823.85 090 61624 $3,190.89 $3,190.89 00061519 $7,284.51 $7,284.51 090 61626 $2,389.11 $2,389.11 00061520 $9,314.45 $9,314.45 090 61630 $3,738.78 $3,738.78 N/A61521 $7,873.41 $7,873.41 090 61635 $3,988.86 $3,988.86 N/A61522 $5,441.87 $5,441.87 090 61640 $1,337.25 $1,337.25 00061524 $5,160.91 $5,160.91 090 61641 $469.61 $469.61 ZZZ61526 $9,094.24 $9,094.24 090 61642 $939.23 $939.23 ZZZ61530 $7,588.24 $7,588.24 090 61645 $2,173.40 $2,173.40 00061531 $2,974.04 $2,974.04 090 61650 $1,486.16 $1,486.16 00061533 $3,746.87 $3,746.87 090 61651 $631.88 $631.88 ZZZ61534 $4,089.41 $4,089.41 090 61680 $5,596.26 $5,596.26 09061535 $2,433.23 $2,433.23 090 61682 $10,326.89 $10,326.89 09061536 $6,343.78 $6,343.78 090 61684 $7,082.86 $7,082.86 09061537 $6,138.76 $6,138.76 090 61686 $11,200.12 $11,200.12 09061538 $6,617.14 $6,617.14 090 61690 $5,394.62 $5,394.62 09061539 $5,876.37 $5,876.37 090 61692 $9,082.43 $9,082.43 09061540 $5,354.96 $5,354.96 090 61697 $10,454.29 $10,454.29 09061541 $5,347.37 $5,347.37 090 61698 $11,523.25 $11,523.25 09061543 $5,176.94 $5,176.94 090 61700 $8,446.28 $8,446.28 09061544 $4,733.16 $4,733.16 090 61702 $9,949.75 $9,949.75 09061545 $7,929.09 $7,929.09 090 61703 $3,039.01 $3,039.01 09061546 $5,712.69 $5,712.69 090 61705 $6,482.15 $6,482.15 09061548 $3,884.39 $3,884.39 090 61708 $5,729.57 $5,729.57 09061550 $2,939.45 $2,939.45 090 61710 $5,279.87 $5,279.87 09061552 $2,831.46 $2,831.46 090 61711 $6,464.43 $6,464.43 09061556 $3,827.02 $3,827.02 090 61720 $3,155.44 $3,155.44 09061557 $4,177.16 $4,177.16 090 61735 $3,951.89 $3,951.89 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 38 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

61750 $3,486.17 $3,486.17 090 62269 $736.87 $736.87 00061751 $3,418.67 $3,418.67 090 62270 $430.48 $214.76 00061760 $3,913.08 $3,913.08 090 62272 $547.88 $231.94 00061770 $4,038.79 $4,038.79 090 62273 $467.70 $311.17 00061781 $664.33 $664.33 ZZZ 62280 $818.01 $440.02 01061782 $483.93 $483.93 ZZZ 62281 $655.74 $430.48 01061783 $651.92 $651.92 ZZZ 62282 $804.64 $401.84 01061790 $2,174.21 $2,174.21 090 62284 $507.79 $241.49 00061791 $2,705.75 $2,705.75 090 62287 $1,392.11 $1,392.11 09061796 $2,516.76 $2,516.76 090 62290 $893.41 $468.66 00061797 $622.33 $622.33 ZZZ 62291 $898.18 $465.80 00061798 $3,426.27 $3,426.27 090 62292 $1,400.54 $1,400.54 09061799 $860.96 $860.96 ZZZ 62294 $2,349.70 $2,349.70 09061800 $434.30 $434.30 ZZZ 62302 $658.60 $338.85 00061850 $2,437.45 $2,437.45 090 62303 $678.65 $341.71 00061860 $3,839.68 $3,839.68 090 62304 $650.01 $332.17 00061863 $3,720.72 $3,720.72 090 62305 $707.28 $347.44 00061864 $802.73 $802.73 ZZZ 62320 $453.39 $280.62 00061867 $5,652.79 $5,652.79 090 62321 $673.88 $302.58 00061868 $1,409.80 $1,409.80 ZZZ 62322 $422.84 $241.49 00061870 $2,539.54 $2,539.54 090 62323 $661.47 $275.85 00061880 $1,399.70 $1,399.70 090 62324 $396.12 $255.81 00061885 $1,264.71 $1,264.71 090 62325 $597.52 $293.99 00061886 $2,078.03 $2,078.03 090 62326 $416.16 $251.03 00061888 $1,105.31 $1,105.31 010 62327 $608.97 $267.26 00062000 $2,364.05 $2,364.05 090 62350 $1,099.58 $1,099.58 01062005 $3,114.94 $3,114.94 090 62351 $2,104.19 $2,104.19 09062010 $3,785.68 $3,785.68 090 62355 $736.87 $736.87 01062100 $3,908.02 $3,908.02 090 62360 $851.41 $851.41 01062115 $3,191.72 $3,191.72 090 62361 $1,170.22 $1,170.22 01062117 $4,882.49 $4,882.49 090 62362 $1,060.45 $1,060.45 01062120 $4,042.17 $4,042.17 090 62365 $820.87 $820.87 01062121 $3,897.05 $3,897.05 090 62367 $111.68 $69.68 N/A62140 $2,549.66 $2,549.66 090 62368 $152.72 $96.40 N/A62141 $2,815.43 $2,815.43 090 62369 $320.71 $97.36 N/A62142 $2,189.40 $2,189.40 090 62370 $338.85 $126.95 N/A62143 $2,573.29 $2,573.29 090 62380 80% of billed 80% of billed 09062145 $3,498.82 $3,498.82 090 63001 $3,056.73 $3,056.73 09062146 $2,959.70 $2,959.70 090 63003 $3,052.51 $3,052.51 09062147 $3,514.01 $3,514.01 090 63005 $2,906.55 $2,906.55 09062148 $356.98 $356.98 ZZZ 63011 $2,676.22 $2,676.22 09062160 $537.38 $537.38 ZZZ 63012 $2,926.80 $2,926.80 09062161 $3,750.25 $3,750.25 090 63015 $3,653.22 $3,653.22 09062162 $4,677.47 $4,677.47 090 63016 $3,756.15 $3,756.15 09062163 $3,039.01 $3,039.01 090 63017 $3,093.85 $3,093.85 09062164 $5,144.88 $5,144.88 090 63020 $2,852.55 $2,852.55 09062165 $3,786.53 $3,786.53 090 63030 $2,379.23 $2,379.23 09062180 $3,978.89 $3,978.89 090 63035 $535.47 $535.47 ZZZ62190 $1,765.02 $1,765.02 090 63040 $3,423.73 $3,423.73 09062192 $2,415.51 $2,415.51 090 63042 $3,178.22 $3,178.22 09062194 $1,232.26 $1,232.26 010 63043 80% of billed 80% of billed ZZZ62200 $3,347.80 $3,347.80 090 63044 80% of billed 80% of billed ZZZ62201 $2,976.57 $2,976.57 090 63045 $3,170.62 $3,170.62 09062220 $2,551.35 $2,551.35 090 63046 $3,001.88 $3,001.88 09062223 $2,576.66 $2,576.66 090 63047 $2,704.90 $2,704.90 09062225 $1,246.14 $1,246.14 090 63048 $590.84 $590.84 ZZZ62230 $2,075.50 $2,075.50 090 63050 $3,694.56 $3,694.56 09062252 $234.81 $234.81 N/A 63051 $4,200.78 $4,200.78 09062252 TC $104.04 $104.04 N/A 63055 $4,015.17 $4,015.17 09062252 26 $130.77 $130.77 N/A 63056 $3,645.63 $3,645.63 09062256 $1,477.32 $1,477.32 090 63057 $894.37 $894.37 ZZZ62258 $2,763.12 $2,763.12 090 63064 $4,366.15 $4,366.15 09062263 $1,639.83 $887.68 010 63066 $580.34 $580.34 ZZZ62264 $1,135.85 $650.97 010 63075 $3,327.55 $3,327.55 09062267 $676.74 $439.07 000 63076 $692.97 $692.97 ZZZ62268 $713.01 $713.01 000 63077 $3,661.66 $3,661.66 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 39 of 84

Page 40: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

63078 $541.20 $541.20 ZZZ 63655 $2,032.47 $2,032.47 09063081 $4,318.90 $4,318.90 090 63661 $1,578.74 $884.82 01063082 $744.51 $744.51 ZZZ 63662 $2,052.72 $2,052.72 09063085 $4,707.85 $4,707.85 090 63663 $2,129.49 $1,234.17 01063086 $532.61 $532.61 ZZZ 63664 $2,119.37 $2,119.37 09063087 $5,927.84 $5,927.84 090 63685 $1,006.04 $1,006.04 01063088 $726.37 $726.37 ZZZ 63688 $1,022.27 $1,022.27 01063090 $4,794.75 $4,794.75 090 63700 $2,817.96 $2,817.96 09063091 $494.43 $494.43 ZZZ 63702 $3,131.81 $3,131.81 09063101 $5,699.19 $5,699.19 090 63704 $3,567.16 $3,567.16 09063102 $5,585.29 $5,585.29 090 63706 $4,283.47 $4,283.47 09063103 $818.01 $818.01 ZZZ 63707 $2,258.58 $2,258.58 09063170 $3,957.80 $3,957.80 090 63709 $2,701.53 $2,701.53 09063172 $3,485.32 $3,485.32 090 63710 $2,655.12 $2,655.12 09063173 $4,223.56 $4,223.56 090 63740 $2,301.61 $2,301.61 09063180 $3,293.80 $3,293.80 090 63741 $1,661.25 $1,661.25 09063182 $4,054.82 $4,054.82 090 63744 $1,625.81 $1,625.81 09063185 $2,801.93 $2,801.93 090 63746 $1,484.91 $1,484.91 09063190 $3,140.25 $3,140.25 090 64400 $346.48 $195.67 00063191 $3,109.03 $3,109.03 090 64402 $363.66 $221.44 00063194 $3,427.95 $3,427.95 090 64405 $272.99 $172.76 00063195 $3,099.75 $3,099.75 090 64408 $322.62 $237.67 00063196 $3,445.67 $3,445.67 090 64410 $367.48 $207.13 00063197 $3,451.58 $3,451.58 090 64413 $345.53 $222.40 00063198 $4,059.88 $4,059.88 090 64415 $316.89 $177.54 00063199 $4,259.84 $4,259.84 090 64416 $215.72 $215.72 00063200 $3,795.81 $3,795.81 090 64417 $346.48 $191.85 00063250 $7,396.72 $7,396.72 090 64418 $393.25 $209.04 00063251 $7,486.99 $7,486.99 090 64420 $300.67 $185.17 00063252 $7,513.99 $7,513.99 090 64421 $405.66 $251.03 00063265 $4,116.41 $4,116.41 090 64425 $356.98 $255.81 00063266 $4,242.12 $4,242.12 090 64430 $372.25 $222.40 00063267 $3,368.05 $3,368.05 090 64435 $366.53 $227.17 00063268 $3,439.77 $3,439.77 090 64445 $366.53 $197.58 00063270 $5,144.04 $5,144.04 090 64446 $215.72 $215.72 00063271 $5,097.64 $5,097.64 090 64447 $322.62 $181.35 00063272 $4,657.22 $4,657.22 090 64448 $194.72 $194.72 00063273 $4,526.45 $4,526.45 090 64449 $229.08 $229.08 00063275 $4,437.86 $4,437.86 090 64450 $216.67 $124.08 00063276 $4,413.39 $4,413.39 090 64455 $129.81 $95.45 00063277 $3,817.74 $3,817.74 090 64461 $401.84 $238.62 00063278 $3,904.64 $3,904.64 090 64462 $228.13 $149.86 ZZZ63280 $5,214.91 $5,214.91 090 64463 $450.52 $245.31 00063281 $5,175.26 $5,175.26 090 64479 $634.74 $361.76 00063282 $4,866.46 $4,866.46 090 64480 $304.49 $173.72 ZZZ63283 $4,669.04 $4,669.04 090 64483 $588.93 $306.39 00063285 $6,514.21 $6,514.21 090 64484 $236.72 $142.22 ZZZ63286 $6,346.31 $6,346.31 090 64486 $329.30 $170.86 00063287 $6,835.66 $6,835.66 090 64487 $364.62 $185.17 00063290 $6,916.65 $6,916.65 090 64488 $377.98 $202.35 00063295 $937.32 $937.32 ZZZ 64489 $482.98 $215.72 00063300 $4,521.39 $4,521.39 090 64490 $510.66 $291.12 00063301 $5,118.73 $5,118.73 090 64491 $252.94 $165.13 ZZZ63302 $5,326.28 $5,326.28 090 64492 $253.90 $167.04 ZZZ63303 $5,570.11 $5,570.11 090 64493 $462.93 $248.17 00063304 $5,736.32 $5,736.32 090 64494 $232.90 $142.22 ZZZ63305 $5,943.87 $5,943.87 090 64495 $233.85 $144.13 ZZZ63306 $5,098.48 $5,098.48 090 64505 $287.30 $240.53 00063307 $5,346.53 $5,346.53 090 64508 $163.22 $196.63 00063308 $903.91 $903.91 ZZZ 64510 $342.67 $200.44 00063600 $2,175.06 $2,175.06 090 64517 $503.02 $339.80 00063610 $1,239.90 $1,239.90 000 64520 $501.11 $221.44 00063615 $3,075.29 $3,075.29 090 64530 $510.66 $250.08 00063620 $2,774.09 $2,774.09 090 64550 $42.95 $23.86 00063621 $707.28 $707.28 ZZZ 64553 $550.75 $415.21 01063650 $3,554.56 $1,128.22 010 64555 $571.75 $418.07 010

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 40 of 84

Page 41: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

64561 $2,235.44 $834.23 010 64776 $940.73 $940.73 09064565 $524.97 $367.48 010 64778 $390.39 $390.39 ZZZ64566 $344.57 $83.04 000 64782 $1,102.72 $1,102.72 09064568 $1,592.06 $1,592.06 090 64783 $611.83 $611.83 ZZZ64569 $1,916.89 $1,916.89 090 64784 $1,770.08 $1,770.08 09064570 $1,605.56 $1,605.56 090 64786 $2,635.72 $2,635.72 09064575 $777.89 $777.89 090 64787 $671.01 $671.01 ZZZ64580 $733.18 $733.18 090 64788 $967.72 $967.72 09064581 $1,614.84 $1,614.84 090 64790 $2,061.16 $2,061.16 09064585 $666.24 $393.25 010 64792 $2,636.56 $2,636.56 09064590 $721.60 $441.93 010 64795 $535.47 $535.47 00064595 $668.15 $346.48 010 64802 $1,564.22 $1,564.22 09064600 $1,067.13 $605.15 010 64804 $2,182.65 $2,182.65 09064605 $1,654.15 $950.68 010 64809 $2,205.43 $2,205.43 09064610 $2,036.90 $1,360.16 010 64818 $1,387.04 $1,387.04 09064611 $321.67 $283.49 010 64820 $1,719.46 $1,719.46 09064612 $356.03 $319.76 010 64821 $1,673.90 $1,673.90 09064615 $397.07 $345.53 010 64822 $1,673.06 $1,673.06 09064616 $348.39 $303.53 010 64823 $1,913.51 $1,913.51 09064617 $488.70 $325.48 010 64831 $1,664.62 $1,664.62 09064620 $553.61 $468.66 010 64832 $933.50 $933.50 ZZZ64630 $628.06 $524.97 010 64834 $1,810.58 $1,810.58 09064632 $231.94 $188.04 010 64835 $1,957.38 $1,957.38 09064633 $1,132.99 $617.56 010 64836 $2,001.26 $2,001.26 09064634 $507.79 $187.08 ZZZ 64837 $1,053.77 $1,053.77 ZZZ64635 $1,120.58 $608.97 010 64840 $2,366.58 $2,366.58 09064636 $461.98 $163.22 ZZZ 64856 $2,462.76 $2,462.76 09064640 $357.94 $253.90 010 64857 $2,566.54 $2,566.54 09064642 $387.53 $300.67 000 64858 $2,850.86 $2,850.86 09064643 $252.94 $199.49 ZZZ 64859 $693.92 $693.92 ZZZ64644 $445.75 $328.35 000 64861 $3,042.38 $3,042.38 09064645 $313.08 $230.99 ZZZ 64862 $3,390.83 $3,390.83 09064646 $406.62 $321.67 000 64864 $2,138.78 $2,138.78 09064647 $484.89 $380.85 000 64865 $2,709.96 $2,709.96 09064650 $210.94 $116.45 000 64866 $2,779.15 $2,779.15 09064653 $256.76 $148.90 000 64868 $2,510.85 $2,510.85 09064680 $829.46 $451.48 010 64872 $323.58 $323.58 ZZZ64681 $1,424.11 $747.37 010 64874 $454.34 $454.34 ZZZ64702 $1,209.87 $1,209.87 090 64876 $488.70 $488.70 ZZZ64704 $772.83 $772.83 090 64885 $2,763.96 $2,763.96 09064708 $1,207.33 $1,207.33 090 64886 $3,162.19 $3,162.19 09064712 $1,408.98 $1,408.98 090 64890 $2,653.44 $2,653.44 09064713 $1,866.26 $1,866.26 090 64891 $2,807.83 $2,807.83 09064714 $1,721.15 $1,721.15 090 64892 $2,540.38 $2,540.38 09064716 $1,291.70 $1,291.70 090 64893 $2,770.71 $2,770.71 09064718 $1,432.60 $1,432.60 090 64895 $3,270.18 $3,270.18 09064719 $968.57 $968.57 090 64896 $3,502.20 $3,502.20 09064721 $1,037.75 $1,031.85 090 64897 $3,129.28 $3,129.28 09064722 $879.98 $879.98 090 64898 $3,616.94 $3,616.94 09064726 $660.62 $660.62 090 64901 $1,536.74 $1,536.74 ZZZ64727 $510.66 $510.66 ZZZ 64902 $1,798.28 $1,798.28 ZZZ64732 $911.20 $911.20 090 64905 $2,515.07 $2,515.07 09064734 $1,228.43 $1,228.43 090 64907 $3,234.75 $3,234.75 09064736 $942.41 $942.41 090 64910 $1,995.35 $1,995.35 09064738 $1,116.22 $1,116.22 090 64911 $2,470.35 $2,470.35 09064740 $1,095.12 $1,095.12 090 64999 80% of billed 80% of billed N/A64742 $1,101.87 $1,101.87 090 65091 $1,518.66 $1,518.66 09064744 $1,197.21 $1,197.21 090 65093 $1,500.10 $1,500.10 09064746 $1,031.85 $1,031.85 090 65101 $1,763.33 $1,763.33 09064755 $2,132.87 $2,132.87 090 65103 $1,839.27 $1,839.27 09064760 $1,205.65 $1,205.65 090 65105 $2,026.57 $2,026.57 09064763 $1,164.31 $1,164.31 090 65110 $2,926.80 $2,926.80 09064766 $1,367.64 $1,367.64 090 65112 $3,398.42 $3,398.42 09064771 $1,457.07 $1,457.07 090 65114 $3,539.32 $3,539.32 09064772 $1,368.48 $1,368.48 090 65125 $1,077.40 $690.99 09064774 $1,004.85 $1,004.85 090 65130 $1,745.62 $1,745.62 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 41 of 84

Page 42: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

65135 $1,772.61 $1,772.61 090 66155 $2,093.22 $2,093.22 09065140 $1,926.17 $1,926.17 090 66160 $2,360.67 $2,360.67 09065150 $1,381.14 $1,381.14 090 66170 $2,616.31 $2,616.31 09065155 $2,017.29 $2,017.29 090 66172 $2,846.64 $2,846.64 09065175 $1,570.13 $1,570.13 090 66174 $2,267.02 $2,267.02 09065205 $151.77 $119.31 000 66175 $2,374.17 $2,374.17 09065210 $185.17 $144.13 000 66179 $2,576.66 $2,576.66 09065220 $157.49 $115.49 000 66180 $2,719.25 $2,719.25 09065222 $180.40 $141.27 000 66183 $2,461.92 $2,461.92 09065235 $1,696.68 $1,696.68 090 66184 $1,876.39 $1,876.39 09065260 $2,296.55 $2,296.55 090 66185 $2,018.13 $2,018.13 09065265 $2,585.10 $2,585.10 090 66220 $1,697.52 $1,697.52 09065270 $715.87 $379.89 010 66225 $2,229.06 $2,229.06 09065272 $1,198.05 $839.48 090 66250 $1,786.11 $1,333.05 09065273 $912.04 $912.04 090 66500 $846.23 $846.23 09065275 $1,378.61 $1,104.40 090 66505 $933.13 $933.13 09065280 $1,606.40 $1,606.40 090 66600 $1,989.44 $1,989.44 09065285 $2,651.75 $2,651.75 090 66605 $2,526.04 $2,526.04 09065286 $1,678.96 $1,185.40 090 66625 $1,025.94 $1,025.94 09065290 $1,176.96 $1,176.96 090 66630 $1,361.73 $1,361.73 09065400 $1,622.44 $1,442.73 090 66635 $1,373.54 $1,373.54 09065410 $385.62 $283.49 000 66680 $1,238.55 $1,238.55 09065420 $1,230.96 $902.76 090 66682 $1,523.72 $1,523.72 09065426 $1,554.94 $1,144.90 090 66700 $1,074.87 $940.73 09065430 $308.30 $280.62 000 66710 $1,049.56 $939.88 09065435 $215.72 $188.99 000 66711 $1,537.22 $1,537.22 09065436 $925.54 $889.26 090 66720 $1,098.50 $978.69 09065450 $776.20 $768.61 090 66740 $1,042.81 $939.88 09065600 $941.57 $823.45 090 66761 $798.92 $638.56 01065710 $2,643.31 $2,643.31 090 66762 $1,133.93 $1,020.03 09065730 $2,934.39 $2,934.39 090 66770 $1,260.49 $1,157.56 09065750 $2,950.42 $2,950.42 090 66820 $941.57 $941.57 09065755 $2,935.23 $2,935.23 090 66821 $787.17 $743.30 09065756 $2,833.99 $2,833.99 090 66825 $1,815.64 $1,815.64 09065757 80% of billed 80% of billed ZZZ 66830 $1,705.96 $1,705.96 09065760 80% of billed 80% of billed N/A 66840 $1,665.46 $1,665.46 09065765 80% of billed 80% of billed N/A 66850 $1,895.79 $1,895.79 09065767 80% of billed 80% of billed N/A 66852 $2,018.97 $2,018.97 09065770 $3,352.86 $3,352.86 090 66920 $1,803.83 $1,803.83 09065771 80% of billed 80% of billed N/A 66930 $2,045.13 $2,045.13 09065772 $1,077.40 $971.94 090 66940 $1,870.48 $1,870.48 09065775 $1,317.86 $1,317.86 090 66982 $1,901.70 $1,901.70 09065778 $3,830.41 $155.58 000 66983 $1,773.46 $1,773.46 09065779 $3,242.44 $412.34 000 66984 $1,530.47 $1,530.47 09065780 $1,593.75 $1,593.75 090 66985 $1,840.95 $1,840.95 09065781 $3,189.19 $3,189.19 090 66986 $2,173.37 $2,173.37 09065782 $2,752.15 $2,752.15 090 66990 $245.31 $245.31 ZZZ65785 $5,044.48 $929.76 090 66999 80% of billed 80% of billed N/A65800 $321.67 $248.17 000 67005 $1,129.71 $1,129.71 09065810 $1,112.84 $1,112.84 090 67010 $1,297.61 $1,297.61 09065815 $1,520.35 $1,142.37 090 67015 $1,387.04 $1,387.04 09065820 $1,787.80 $1,787.80 090 67025 $1,732.96 $1,512.75 09065850 $2,007.16 $2,007.16 090 67027 $2,038.38 $2,038.38 09065855 $660.51 $563.15 010 67028 $275.85 $272.03 00065860 $736.55 $606.62 090 67030 $1,272.30 $1,272.30 09065865 $1,130.56 $1,130.56 090 67031 $928.07 $852.98 09065870 $1,413.20 $1,413.20 090 67036 $2,154.81 $2,154.81 09065875 $1,506.85 $1,506.85 090 67039 $2,309.21 $2,309.21 09065880 $1,586.16 $1,586.16 090 67040 $2,496.51 $2,496.51 09065900 $2,303.30 $2,303.30 090 67041 $2,755.52 $2,755.52 09065920 $1,883.98 $1,883.98 090 67042 $2,758.06 $2,758.06 09065930 $1,523.72 $1,523.72 090 67043 $2,912.45 $2,912.45 09066020 $503.02 $355.07 010 67101 $885.78 $770.28 01066030 $447.66 $299.71 010 67105 $801.78 $744.51 01066130 $1,662.09 $1,362.58 090 67107 $2,709.96 $2,709.96 09066150 $2,094.91 $2,094.91 090 67108 $2,873.64 $2,873.64 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 42 of 84

Page 43: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

67110 $2,094.06 $1,943.88 090 67875 $461.98 $264.40 00067113 $3,206.90 $3,206.90 090 67880 $1,092.59 $881.67 09067115 $1,195.52 $1,195.52 090 67882 $1,344.86 $1,129.71 09067120 $1,569.28 $1,334.73 090 67900 $1,527.94 $1,220.83 09067121 $2,172.53 $2,172.53 090 67901 $1,804.67 $1,381.14 09067141 $1,250.36 $1,166.84 090 67902 $1,730.43 $1,730.43 09067145 $1,257.96 $1,191.30 090 67903 $1,415.73 $1,158.40 09067208 $1,432.60 $1,383.67 090 67904 $1,747.30 $1,430.92 09067210 $1,238.55 $1,197.21 090 67906 $1,216.62 $1,216.62 09067218 $3,311.52 $3,311.52 090 67908 $1,176.12 $1,014.97 09067220 $1,275.67 $1,197.21 090 67909 $1,279.05 $1,050.41 09067221 $775.05 $579.38 000 67911 $1,346.55 $1,346.55 09067225 $80.18 $76.36 ZZZ 67912 $2,096.59 $1,173.59 09067227 $783.64 $695.83 010 67914 $1,118.75 $783.80 09067228 $921.09 $832.32 010 67915 $695.21 $472.47 09067229 $2,789.27 $2,789.27 090 67916 $1,411.51 $1,032.69 09067250 $1,865.42 $1,865.42 090 67917 $1,436.82 $1,096.81 09067255 $1,634.25 $1,634.25 090 67921 $1,095.12 $742.46 09067299 80% of billed 80% of billed N/A 67922 $689.30 $472.47 09067311 $1,429.23 $1,429.23 090 67923 $1,408.98 $1,031.00 09067312 $1,701.74 $1,701.74 090 67924 $1,501.79 $1,096.81 09067314 $1,608.09 $1,608.09 090 67930 $983.13 $651.92 01067316 $1,916.89 $1,916.89 090 67935 $1,418.26 $1,060.53 09067318 $1,687.40 $1,687.40 090 67938 $655.74 $314.98 01067320 $875.28 $875.28 ZZZ 67950 $1,365.95 $1,110.31 09067331 $831.37 $831.37 ZZZ 67961 $1,370.17 $1,089.22 09067332 $902.00 $902.00 ZZZ 67966 $1,833.36 $1,574.34 09067334 $818.96 $818.96 ZZZ 67971 $1,732.12 $1,732.12 09067335 $403.75 $403.75 ZZZ 67973 $2,229.06 $2,229.06 09067340 $973.59 $973.59 ZZZ 67974 $2,223.15 $2,223.15 09067343 $1,564.22 $1,564.22 090 67975 $1,638.47 $1,638.47 09067345 $655.74 $591.79 010 67999 80% of billed 80% of billed N/A67346 $525.93 $525.93 000 68020 $322.62 $298.76 01067399 80% of billed 80% of billed N/A 68040 $167.04 $136.49 00067400 $2,221.46 $2,221.46 090 68100 $457.21 $264.40 00067405 $1,892.42 $1,892.42 090 68110 $607.06 $401.84 01067412 $2,032.47 $2,032.47 090 68115 $838.05 $498.25 01067413 $2,040.91 $2,040.91 090 68130 $1,283.27 $985.44 09067414 $3,172.31 $3,172.31 090 68135 $422.84 $408.53 01067415 $285.40 $285.40 000 68200 $111.68 $94.50 00067420 $3,870.90 $3,870.90 090 68320 $1,726.21 $1,290.02 09067430 $2,954.64 $2,954.64 090 68325 $1,576.03 $1,576.03 09067440 $2,880.39 $2,880.39 090 68326 $1,545.66 $1,545.66 09067445 $3,352.86 $3,352.86 090 68328 $1,696.68 $1,696.68 09067450 $2,986.70 $2,986.70 090 68330 $1,440.20 $1,103.56 09067500 $211.90 $194.72 000 68335 $1,551.56 $1,551.56 09067505 $239.58 $219.53 000 68340 $1,297.61 $955.07 09067515 $262.49 $242.44 000 68360 $1,268.08 $986.29 09067550 $2,304.14 $2,304.14 090 68362 $1,570.97 $1,570.97 09067560 $2,360.67 $2,360.67 090 68371 $1,117.72 $1,117.72 01067570 $2,789.27 $2,789.27 090 68399 80% of billed 80% of billed N/A67599 80% of billed 80% of billed N/A 68400 $763.60 $356.98 01067700 $721.60 $314.98 010 68420 $863.82 $456.25 01067710 $600.38 $262.49 010 68440 $274.90 $267.26 01067715 $644.29 $293.03 010 68500 $2,340.42 $2,340.42 09067800 $341.71 $280.62 010 68505 $2,318.49 $2,318.49 09067801 $437.16 $360.80 010 68510 $1,198.85 $791.28 00067805 $543.11 $445.75 010 68520 $1,642.68 $1,642.68 09067808 $880.82 $880.82 090 68525 $717.78 $717.78 00067810 $464.84 $196.63 000 68530 $1,151.13 $698.69 01067820 $135.54 $144.13 000 68540 $2,222.31 $2,222.31 09067825 $346.48 $328.35 010 68550 $2,662.72 $2,662.72 09067830 $714.92 $373.21 010 68700 $1,445.26 $1,445.26 09067835 $1,050.41 $1,050.41 090 68705 $637.61 $450.52 01067840 $740.69 $428.57 010 68720 $1,810.58 $1,810.58 09067850 $580.34 $369.39 010 68745 $1,817.33 $1,817.33 090

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 43 of 84

Page 44: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

68750 $1,881.45 $1,881.45 090 69643 $2,952.11 $2,952.11 09068760 $542.16 $395.16 010 69644 $3,564.63 $3,564.63 09068761 $398.03 $321.67 010 69645 $3,503.89 $3,503.89 09068770 $1,506.85 $1,506.85 090 69646 $3,721.56 $3,721.56 09068801 $238.62 $213.81 010 69650 $1,947.26 $1,947.26 09068810 $424.75 $345.53 010 69660 $2,235.81 $2,235.81 09068811 $369.39 $369.39 010 69661 $2,909.08 $2,909.08 09068815 $1,069.99 $600.38 010 69662 $2,803.62 $2,803.62 09068816 $1,737.19 $441.93 010 69666 $1,959.92 $1,959.92 09068840 $344.57 $314.98 010 69667 $1,959.92 $1,959.92 09068850 $167.04 $153.67 000 69670 $2,291.49 $2,291.49 09068899 80% of billed 80% of billed N/A 69676 $2,002.94 $2,002.94 09069000 $507.79 $324.53 010 69700 $1,673.90 $1,673.90 09069005 $582.24 $427.62 010 69710 80% of billed 80% of billed N/A69020 $628.06 $387.53 010 69711 $2,078.88 $2,078.88 09069090 80% of billed 80% of billed N/A 69714 $2,602.81 $2,602.81 09069100 $272.99 $134.58 000 69715 $3,335.99 $3,335.99 09069105 $378.94 $173.72 000 69717 $2,736.96 $2,736.96 09069110 $1,100.18 $782.95 090 69718 $3,242.34 $3,242.34 09069120 $978.69 $978.69 090 69720 $2,940.29 $2,940.29 09069140 $2,108.41 $2,108.41 090 69725 $4,543.32 $4,543.32 09069145 $948.32 $600.71 090 69740 $2,886.30 $2,886.30 09069150 $2,527.73 $2,527.73 090 69745 $2,831.46 $2,831.46 09069155 $4,026.14 $4,026.14 090 69799 80% of billed 80% of billed N/A69200 $224.31 $129.81 000 69801 $530.70 $345.53 00069205 $276.80 $276.80 010 69805 $2,545.44 $2,545.44 09069209 $34.36 $34.36 000 69806 $2,282.21 $2,282.21 09069210 $132.68 $89.72 000 69820 $2,018.13 $2,018.13 09069220 $244.35 $141.27 000 69840 $2,181.81 $2,181.81 09069222 $593.70 $372.25 010 69905 $2,212.18 $2,212.18 09069300 $1,611.20 $1,258.03 N/A 69910 $2,472.04 $2,472.04 09069310 $2,628.97 $2,628.97 090 69915 $3,837.99 $3,837.99 09069320 $3,673.47 $3,673.47 090 69930 $2,957.17 $2,957.17 09069399 80% of billed 80% of billed N/A 69949 80% of billed 80% of billed N/A69420 $517.34 $328.35 010 69950 $4,393.15 $4,393.15 09069421 $405.66 $405.66 010 69955 $4,766.91 $4,766.91 09069424 $344.57 $169.90 000 69960 $4,654.69 $4,654.69 09069433 $547.88 $360.80 010 69970 $5,180.32 $5,180.32 09069436 $437.16 $437.16 010 69979 80% of billed 80% of billed N/A69440 $1,659.56 $1,659.56 090 69990 $613.74 $613.74 ZZZ69450 $1,312.80 $1,312.80 090 70010 $144.13 $144.13 N/A69501 $1,769.24 $1,769.24 090 70015 $333.78 $333.78 N/A69502 $2,355.61 $2,355.61 090 70015 TC $197.99 $197.99 N/A69505 $2,901.48 $2,901.48 090 70015 26 $135.79 $135.79 N/A69511 $2,974.89 $2,974.89 090 70030 $59.17 $59.17 N/A69530 $4,030.36 $4,030.36 090 70030 TC $40.96 $40.96 N/A69535 $6,509.15 $6,509.15 090 70030 26 $18.21 $18.21 N/A69540 $565.06 $345.53 010 70100 $70.55 $70.55 N/A69550 $2,508.32 $2,508.32 090 70100 TC $50.83 $50.83 N/A69552 $3,761.21 $3,761.21 090 70100 26 $19.72 $19.72 N/A69554 $6,088.14 $6,088.14 090 70110 $81.17 $81.17 N/A69601 $2,523.51 $2,523.51 090 70110 TC $53.86 $53.86 N/A69602 $2,635.72 $2,635.72 090 70110 26 $27.31 $27.31 N/A69603 $3,055.88 $3,055.88 090 70120 $72.07 $72.07 N/A69604 $2,682.97 $2,682.97 090 70120 TC $52.34 $52.34 N/A69605 $4,047.23 $4,047.23 090 70120 26 $19.72 $19.72 N/A69610 $1,043.27 $796.05 010 70130 $116.82 $116.82 N/A69620 $1,662.09 $1,177.81 090 70130 TC $79.65 $79.65 N/A69631 $2,131.19 $2,131.19 090 70130 26 $37.17 $37.17 N/A69632 $2,599.44 $2,599.44 090 70134 $110.76 $110.76 N/A69633 $2,519.29 $2,519.29 090 70134 TC $72.83 $72.83 N/A69635 $2,981.64 $2,981.64 090 70134 26 $37.93 $37.93 N/A69636 $3,326.71 $3,326.71 090 70140 $63.72 $63.72 N/A69637 $3,378.17 $3,378.17 090 70140 TC $40.96 $40.96 N/A69641 $2,511.69 $2,511.69 090 70140 26 $22.76 $22.76 N/A69642 $3,222.09 $3,222.09 090 70150 $88.76 $88.76 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 44 of 84

Page 45: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

70150 TC $59.93 $59.93 N/A 70380 TC $56.90 $56.90 N/A70150 26 $28.83 $28.83 N/A 70380 26 $19.72 $19.72 N/A70160 $69.79 $69.79 N/A 70390 $200.27 $200.27 N/A70160 TC $50.83 $50.83 N/A 70390 TC $159.31 $159.31 N/A70160 26 $18.97 $18.97 N/A 70390 26 $40.96 $40.96 N/A70170 80% of billed 80% of billed N/A 70450 $248.82 $248.82 N/A70170 TC 80% of billed 80% of billed N/A 70450 TC $156.27 $156.27 N/A70170 26 $32.62 $32.62 N/A 70450 26 $92.55 $92.55 N/A70190 $75.86 $75.86 N/A 70460 $347.44 $347.44 N/A70190 TC $51.58 $51.58 N/A 70460 TC $225.30 $225.30 N/A70190 26 $24.28 $24.28 N/A 70460 26 $122.13 $122.13 N/A70200 $90.27 $90.27 N/A 70470 $411.16 $411.16 N/A70200 TC $59.93 $59.93 N/A 70470 TC $273.10 $273.10 N/A70200 26 $30.34 $30.34 N/A 70470 26 $138.07 $138.07 N/A70210 $63.72 $63.72 N/A 70480 $499.16 $499.16 N/A70210 TC $44.76 $44.76 N/A 70480 TC $360.34 $360.34 N/A70210 26 $18.97 $18.97 N/A 70480 26 $138.82 $138.82 N/A70220 $80.41 $80.41 N/A 70481 $590.19 $590.19 N/A70220 TC $53.10 $53.10 N/A 70481 TC $440.75 $440.75 N/A70220 26 $27.31 $27.31 N/A 70481 26 $149.44 $149.44 N/A70240 $64.48 $64.48 N/A 70482 $644.05 $644.05 N/A70240 TC $43.24 $43.24 N/A 70482 TC $487.78 $487.78 N/A70240 26 $21.24 $21.24 N/A 70482 26 $156.27 $156.27 N/A70250 $77.38 $77.38 N/A 70486 $298.13 $298.13 N/A70250 TC $50.07 $50.07 N/A 70486 TC $205.58 $205.58 N/A70250 26 $27.31 $27.31 N/A 70486 26 $92.55 $92.55 N/A70260 $97.86 $97.86 N/A 70487 $358.82 $358.82 N/A70260 TC $59.93 $59.93 N/A 70487 TC $236.68 $236.68 N/A70260 26 $37.93 $37.93 N/A 70487 26 $122.13 $122.13 N/A70300 $31.86 $31.86 N/A 70488 $437.71 $437.71 N/A70300 TC $18.97 $18.97 N/A 70488 TC $300.41 $300.41 N/A70300 26 $12.90 $12.90 N/A 70488 26 $137.31 $137.31 N/A70310 $77.38 $77.38 N/A 70490 $413.44 $413.44 N/A70310 TC $59.93 $59.93 N/A 70490 TC $274.61 $274.61 N/A70310 26 $17.45 $17.45 N/A 70490 26 $138.82 $138.82 N/A70320 $113.79 $113.79 N/A 70491 $504.47 $504.47 N/A70320 TC $87.24 $87.24 N/A 70491 TC $354.27 $354.27 N/A70320 26 $26.55 $26.55 N/A 70491 26 $150.20 $150.20 N/A70328 $65.24 $65.24 N/A 70492 $594.74 $594.74 N/A70328 TC $45.52 $45.52 N/A 70492 TC $437.71 $437.71 N/A70328 26 $19.72 $19.72 N/A 70492 26 $157.03 $157.03 N/A70330 $103.17 $103.17 N/A 70496 $628.12 $628.12 N/A70330 TC $75.86 $75.86 N/A 70496 TC $438.47 $438.47 N/A70330 26 $27.31 $27.31 N/A 70496 26 $189.65 $189.65 N/A70332 $171.44 $171.44 N/A 70498 $626.60 $626.60 N/A70332 TC $104.69 $104.69 N/A 70498 TC $436.95 $436.95 N/A70332 26 $66.76 $66.76 N/A 70498 26 $189.65 $189.65 N/A70336 $688.81 $688.81 N/A 70540 $647.09 $647.09 N/A70336 TC $529.50 $529.50 N/A 70540 TC $501.43 $501.43 N/A70336 26 $159.31 $159.31 N/A 70540 26 $145.65 $145.65 N/A70350 $42.48 $42.48 N/A 70542 $726.74 $726.74 N/A70350 TC $20.48 $20.48 N/A 70542 TC $550.74 $550.74 N/A70350 26 $22.00 $22.00 N/A 70542 26 $176.00 $176.00 N/A70355 $44.76 $44.76 N/A 70543 $892.11 $892.11 N/A70355 TC $20.48 $20.48 N/A 70543 TC $659.98 $659.98 N/A70355 26 $24.28 $24.28 N/A 70543 26 $232.13 $232.13 N/A70360 $59.93 $59.93 N/A 70544 $839.77 $839.77 N/A70360 TC $41.72 $41.72 N/A 70544 TC $709.29 $709.29 N/A70360 26 $18.21 $18.21 N/A 70544 26 $130.48 $130.48 N/A70370 $164.62 $164.62 N/A 70545 $831.43 $831.43 N/A70370 TC $129.72 $129.72 N/A 70545 TC $701.71 $701.71 N/A70370 26 $34.90 $34.90 N/A 70545 26 $129.72 $129.72 N/A70371 $192.68 $192.68 N/A 70546 $1,281.28 $1,281.28 N/A70371 TC $102.41 $102.41 N/A 70546 TC $1,086.32 $1,086.32 N/A70371 26 $90.27 $90.27 N/A 70546 26 $194.96 $194.96 N/A70380 $76.62 $76.62 N/A 70547 $843.56 $843.56 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 45 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

70547 TC $713.08 $713.08 N/A 71110 TC $50.83 $50.83 N/A70547 26 $130.48 $130.48 N/A 71110 26 $29.59 $29.59 N/A70548 $884.53 $884.53 N/A 71111 $103.17 $103.17 N/A70548 TC $754.05 $754.05 N/A 71111 TC $67.52 $67.52 N/A70548 26 $130.48 $130.48 N/A 71111 26 $35.65 $35.65 N/A70549 $1,288.86 $1,288.86 N/A 71120 $62.96 $62.96 N/A70549 TC $1,093.90 $1,093.90 N/A 71120 TC $40.96 $40.96 N/A70549 26 $194.96 $194.96 N/A 71120 26 $22.00 $22.00 N/A70551 $494.61 $494.61 N/A 71130 $76.62 $76.62 N/A70551 TC $334.54 $334.54 N/A 71130 TC $52.34 $52.34 N/A70551 26 $160.06 $160.06 N/A 71130 26 $24.28 $24.28 N/A70552 $685.77 $685.77 N/A 71250 $386.89 $386.89 N/A70552 TC $492.33 $492.33 N/A 71250 TC $276.13 $276.13 N/A70552 26 $193.44 $193.44 N/A 71250 26 $110.76 $110.76 N/A70553 $808.67 $808.67 N/A 71260 $491.57 $491.57 N/A70553 TC $560.61 $560.61 N/A 71260 TC $356.54 $356.54 N/A70553 26 $248.06 $248.06 N/A 71260 26 $135.03 $135.03 N/A70554 $962.66 $962.66 N/A 71270 $588.67 $588.67 N/A70554 TC $732.81 $732.81 N/A 71270 TC $439.23 $439.23 N/A70554 26 $229.86 $229.86 N/A 71270 26 $149.44 $149.44 N/A70555 80% of billed 80% of billed N/A 71275 $643.29 $643.29 N/A70555 TC 80% of billed 80% of billed N/A 71275 TC $446.06 $446.06 N/A70555 26 $270.82 $270.82 N/A 71275 26 $197.24 $197.24 N/A70557 80% of billed 80% of billed N/A 71550 $889.08 $889.08 N/A70557 TC 80% of billed 80% of billed N/A 71550 TC $731.29 $731.29 N/A70557 26 $317.85 $317.85 N/A 71550 26 $157.79 $157.79 N/A70558 80% of billed 80% of billed N/A 71551 $988.46 $988.46 N/A70558 TC 80% of billed 80% of billed N/A 71551 TC $801.08 $801.08 N/A70558 26 $346.68 $346.68 N/A 71551 26 $187.37 $187.37 N/A70559 80% of billed 80% of billed N/A 71552 $1,241.07 $1,241.07 N/A70559 TC 80% of billed 80% of billed N/A 71552 TC $996.04 $996.04 N/A70559 26 $351.23 $351.23 N/A 71552 26 $245.03 $245.03 N/A71010 $48.55 $48.55 N/A 71555 $852.67 $852.67 N/A71010 TC $28.83 $28.83 N/A 71555 TC $659.22 $659.22 N/A71010 26 $19.72 $19.72 N/A 71555 26 $193.44 $193.44 N/A71015 $59.17 $59.17 N/A 72020 $47.03 $47.03 N/A71015 TC $35.65 $35.65 N/A 72020 TC $30.34 $30.34 N/A71015 26 $23.52 $23.52 N/A 72020 26 $16.69 $16.69 N/A71020 $59.93 $59.93 N/A 72040 $70.55 $70.55 N/A71020 TC $36.41 $36.41 N/A 72040 TC $46.27 $46.27 N/A71020 26 $23.52 $23.52 N/A 72040 26 $24.28 $24.28 N/A71021 $72.83 $72.83 N/A 72050 $97.10 $97.10 N/A71021 TC $43.24 $43.24 N/A 72050 TC $62.96 $62.96 N/A71021 26 $29.59 $29.59 N/A 72050 26 $34.14 $34.14 N/A71022 $88.76 $88.76 N/A 72052 $119.86 $119.86 N/A71022 TC $53.10 $53.10 N/A 72052 TC $80.41 $80.41 N/A71022 26 $35.65 $35.65 N/A 72052 26 $39.45 $39.45 N/A71023 $135.79 $135.79 N/A 72070 $72.83 $72.83 N/A71023 TC $94.83 $94.83 N/A 72070 TC $48.55 $48.55 N/A71023 26 $40.96 $40.96 N/A 72070 26 $24.28 $24.28 N/A71030 $89.51 $89.51 N/A 72072 $73.58 $73.58 N/A71030 TC $55.38 $55.38 N/A 72072 TC $50.07 $50.07 N/A71030 26 $34.14 $34.14 N/A 72072 26 $23.52 $23.52 N/A71034 $176.75 $176.75 N/A 72074 $83.45 $83.45 N/A71034 TC $126.69 $126.69 N/A 72074 TC $59.93 $59.93 N/A71034 26 $50.07 $50.07 N/A 72074 26 $23.52 $23.52 N/A71035 $69.79 $69.79 N/A 72080 $65.24 $65.24 N/A71035 TC $50.07 $50.07 N/A 72080 TC $41.72 $41.72 N/A71035 26 $19.72 $19.72 N/A 72080 26 $23.52 $23.52 N/A71100 $70.55 $70.55 N/A 72081 $83.45 $83.45 N/A71100 TC $46.27 $46.27 N/A 72081 TC $54.62 $54.62 N/A71100 26 $24.28 $24.28 N/A 72081 26 $28.83 $28.83 N/A71101 $78.14 $78.14 N/A 72082 $133.51 $133.51 N/A71101 TC $48.55 $48.55 N/A 72082 TC $98.62 $98.62 N/A71101 26 $29.59 $29.59 N/A 72082 26 $34.90 $34.90 N/A71110 $80.41 $80.41 N/A 72083 $144.89 $144.89 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 46 of 84

Page 47: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

72083 TC $106.96 $106.96 N/A 72157 TC $567.43 $567.43 N/A72083 26 $37.93 $37.93 N/A 72157 26 $248.06 $248.06 N/A72084 $172.20 $172.20 N/A 72158 $810.94 $810.94 N/A72084 TC $128.20 $128.20 N/A 72158 TC $562.12 $562.12 N/A72084 26 $44.00 $44.00 N/A 72158 26 $248.82 $248.82 N/A72100 $75.10 $75.10 N/A 72159 $891.36 $891.36 N/A72100 TC $50.83 $50.83 N/A 72159 TC $695.64 $695.64 N/A72100 26 $24.28 $24.28 N/A 72159 26 $195.72 $195.72 N/A72110 $104.69 $104.69 N/A 72170 $68.27 $68.27 N/A72110 TC $70.55 $70.55 N/A 72170 TC $49.31 $49.31 N/A72110 26 $34.14 $34.14 N/A 72170 26 $18.97 $18.97 N/A72114 $132.76 $132.76 N/A 72190 $81.17 $81.17 N/A72114 TC $97.10 $97.10 N/A 72190 TC $57.65 $57.65 N/A72114 26 $35.65 $35.65 N/A 72190 26 $23.52 $23.52 N/A72120 $86.48 $86.48 N/A 72191 $655.43 $655.43 N/A72120 TC $62.21 $62.21 N/A 72191 TC $459.71 $459.71 N/A72120 26 $24.28 $24.28 N/A 72191 26 $195.72 $195.72 N/A72125 $395.99 $395.99 N/A 72192 $313.30 $313.30 N/A72125 TC $279.92 $279.92 N/A 72192 TC $194.96 $194.96 N/A72125 26 $116.07 $116.07 N/A 72192 26 $118.34 $118.34 N/A72126 $489.30 $489.30 N/A 72193 $483.99 $483.99 N/A72126 TC $357.30 $357.30 N/A 72193 TC $358.06 $358.06 N/A72126 26 $132.00 $132.00 N/A 72193 26 $125.93 $125.93 N/A72127 $578.05 $578.05 N/A 72194 $556.81 $556.81 N/A72127 TC $440.75 $440.75 N/A 72194 TC $424.82 $424.82 N/A72127 26 $137.31 $137.31 N/A 72194 26 $132.00 $132.00 N/A72128 $386.89 $386.89 N/A 72195 $803.36 $803.36 N/A72128 TC $278.41 $278.41 N/A 72195 TC $644.81 $644.81 N/A72128 26 $108.48 $108.48 N/A 72195 26 $158.55 $158.55 N/A72129 $491.57 $491.57 N/A 72196 $879.22 $879.22 N/A72129 TC $358.82 $358.82 N/A 72196 TC $691.08 $691.08 N/A72129 26 $132.76 $132.76 N/A 72196 26 $188.13 $188.13 N/A72130 $580.33 $580.33 N/A 72197 $1,082.52 $1,082.52 N/A72130 TC $443.02 $443.02 N/A 72197 TC $837.49 $837.49 N/A72130 26 $137.31 $137.31 N/A 72197 26 $245.03 $245.03 N/A72131 $385.37 $385.37 N/A 72198 $859.49 $859.49 N/A72131 TC $276.89 $276.89 N/A 72198 TC $666.05 $666.05 N/A72131 26 $108.48 $108.48 N/A 72198 26 $193.44 $193.44 N/A72132 $488.54 $488.54 N/A 72200 $60.69 $60.69 N/A72132 TC $356.54 $356.54 N/A 72200 TC $41.72 $41.72 N/A72132 26 $132.00 $132.00 N/A 72200 26 $18.97 $18.97 N/A72133 $577.29 $577.29 N/A 72202 $70.55 $70.55 N/A72133 TC $439.99 $439.99 N/A 72202 TC $50.07 $50.07 N/A72133 26 $137.31 $137.31 N/A 72202 26 $20.48 $20.48 N/A72141 $851.74 $851.74 N/A 72220 $59.93 $59.93 N/A72141 TC $690.92 $690.92 N/A 72220 TC $40.96 $40.96 N/A72141 26 $160.82 $160.82 N/A 72220 26 $18.97 $18.97 N/A72142 $696.39 $696.39 N/A 72240 $210.89 $210.89 N/A72142 TC $502.95 $502.95 N/A 72240 TC $113.03 $113.03 N/A72142 26 $193.44 $193.44 N/A 72240 26 $97.86 $97.86 N/A72146 $481.71 $481.71 N/A 72255 $211.65 $211.65 N/A72146 TC $320.89 $320.89 N/A 72255 TC $110.76 $110.76 N/A72146 26 $160.82 $160.82 N/A 72255 26 $100.89 $100.89 N/A72147 $691.84 $691.84 N/A 72265 $197.99 $197.99 N/A72147 TC $498.40 $498.40 N/A 72265 TC $108.48 $108.48 N/A72147 26 $193.44 $193.44 N/A 72265 26 $89.51 $89.51 N/A72148 $858.45 $858.45 N/A 72270 $273.10 $273.10 N/A72148 TC $696.87 $696.87 N/A 72270 TC $128.20 $128.20 N/A72148 26 $161.58 $161.58 N/A 72270 26 $144.89 $144.89 N/A72149 $688.81 $688.81 N/A 72275 $247.30 $247.30 N/A72149 TC $494.61 $494.61 N/A 72275 TC $163.10 $163.10 N/A72149 26 $194.20 $194.20 N/A 72275 26 $84.20 $84.20 N/A72156 $813.98 $813.98 N/A 72285 $241.99 $241.99 N/A72156 TC $565.92 $565.92 N/A 72285 TC $111.51 $111.51 N/A72156 26 $248.06 $248.06 N/A 72285 26 $130.48 $130.48 N/A72157 $815.50 $815.50 N/A 72295 $209.37 $209.37 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 47 of 84

Page 48: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

72295 TC $116.07 $116.07 N/A 73206 TC $509.02 $509.02 N/A72295 26 $93.31 $93.31 N/A 73206 26 $194.20 $194.20 N/A73000 $59.17 $59.17 N/A 73218 $782.12 $782.12 N/A73000 TC $40.96 $40.96 N/A 73218 TC $634.95 $634.95 N/A73000 26 $18.21 $18.21 N/A 73218 26 $147.17 $147.17 N/A73010 $64.48 $64.48 N/A 73219 $860.25 $860.25 N/A73010 TC $44.76 $44.76 N/A 73219 TC $684.26 $684.26 N/A73010 26 $19.72 $19.72 N/A 73219 26 $176.00 $176.00 N/A73020 $49.31 $49.31 N/A 73220 $1,070.38 $1,070.38 N/A73020 TC $31.86 $31.86 N/A 73220 TC $837.49 $837.49 N/A73020 26 $17.45 $17.45 N/A 73220 26 $232.89 $232.89 N/A73030 $62.21 $62.21 N/A 73221 $901.60 $901.60 N/A73030 TC $41.72 $41.72 N/A 73221 TC $753.67 $753.67 N/A73030 26 $20.48 $20.48 N/A 73221 26 $147.93 $147.93 N/A73040 $213.93 $213.93 N/A 73222 $809.43 $809.43 N/A73040 TC $154.75 $154.75 N/A 73222 TC $633.43 $633.43 N/A73040 26 $59.17 $59.17 N/A 73222 26 $176.00 $176.00 N/A73050 $75.86 $75.86 N/A 73223 $1,006.66 $1,006.66 N/A73050 TC $53.10 $53.10 N/A 73223 TC $773.01 $773.01 N/A73050 26 $22.76 $22.76 N/A 73223 26 $233.65 $233.65 N/A73060 $62.21 $62.21 N/A 73225 $875.42 $875.42 N/A73060 TC $44.00 $44.00 N/A 73225 TC $689.57 $689.57 N/A73060 26 $18.21 $18.21 N/A 73225 26 $185.86 $185.86 N/A73070 $58.41 $58.41 N/A 73501 $63.72 $63.72 N/A73070 TC $40.96 $40.96 N/A 73501 TC $43.24 $43.24 N/A73070 26 $17.45 $17.45 N/A 73501 26 $20.48 $20.48 N/A73080 $66.76 $66.76 N/A 73502 $88.76 $88.76 N/A73080 TC $47.79 $47.79 N/A 73502 TC $64.48 $64.48 N/A73080 26 $18.97 $18.97 N/A 73502 26 $24.28 $24.28 N/A73085 $204.82 $204.82 N/A 73503 $110.76 $110.76 N/A73085 TC $142.62 $142.62 N/A 73503 TC $79.65 $79.65 N/A73085 26 $62.21 $62.21 N/A 73503 26 $31.10 $31.10 N/A73090 $55.38 $55.38 N/A 73521 $84.96 $84.96 N/A73090 TC $37.17 $37.17 N/A 73521 TC $59.93 $59.93 N/A73090 26 $18.21 $18.21 N/A 73521 26 $25.03 $25.03 N/A73092 $59.17 $59.17 N/A 73522 $104.69 $104.69 N/A73092 TC $41.72 $41.72 N/A 73522 TC $72.07 $72.07 N/A73092 26 $17.45 $17.45 N/A 73522 26 $32.62 $32.62 N/A73100 $62.21 $62.21 N/A 73523 $121.38 $121.38 N/A73100 TC $44.00 $44.00 N/A 73523 TC $86.48 $86.48 N/A73100 26 $18.21 $18.21 N/A 73523 26 $34.90 $34.90 N/A73110 $75.86 $75.86 N/A 73525 $217.72 $217.72 N/A73110 TC $56.90 $56.90 N/A 73525 TC $155.51 $155.51 N/A73110 26 $18.97 $18.97 N/A 73525 26 $62.21 $62.21 N/A73115 $227.58 $227.58 N/A 73551 $59.93 $59.93 N/A73115 TC $166.13 $166.13 N/A 73551 TC $41.72 $41.72 N/A73115 26 $61.45 $61.45 N/A 73551 26 $18.21 $18.21 N/A73120 $56.14 $56.14 N/A 73552 $69.79 $69.79 N/A73120 TC $37.93 $37.93 N/A 73552 TC $49.31 $49.31 N/A73120 26 $18.21 $18.21 N/A 73552 26 $20.48 $20.48 N/A73130 $66.00 $66.00 N/A 73560 $66.00 $66.00 N/A73130 TC $47.03 $47.03 N/A 73560 TC $47.79 $47.79 N/A73130 26 $18.97 $18.97 N/A 73560 26 $18.21 $18.21 N/A73140 $67.52 $67.52 N/A 73562 $76.62 $76.62 N/A73140 TC $52.34 $52.34 N/A 73562 TC $56.14 $56.14 N/A73140 26 $15.17 $15.17 N/A 73562 26 $20.48 $20.48 N/A73200 $384.61 $384.61 N/A 73564 $84.96 $84.96 N/A73200 TC $276.13 $276.13 N/A 73564 TC $60.69 $60.69 N/A73200 26 $108.48 $108.48 N/A 73564 26 $24.28 $24.28 N/A73201 $476.40 $476.40 N/A 73565 $76.62 $76.62 N/A73201 TC $350.47 $350.47 N/A 73565 TC $57.65 $57.65 N/A73201 26 $125.93 $125.93 N/A 73565 26 $18.97 $18.97 N/A73202 $593.23 $593.23 N/A 73580 $243.51 $243.51 N/A73202 TC $461.23 $461.23 N/A 73580 TC $182.82 $182.82 N/A73202 26 $132.00 $132.00 N/A 73580 26 $60.69 $60.69 N/A73206 $703.22 $703.22 N/A 73590 $61.45 $61.45 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 48 of 84

Page 49: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

73590 TC $43.24 $43.24 N/A 74020 TC $50.83 $50.83 N/A73590 26 $18.21 $18.21 N/A 74020 26 $29.59 $29.59 N/A73592 $59.17 $59.17 N/A 74022 $95.58 $95.58 N/A73592 TC $41.72 $41.72 N/A 74022 TC $60.69 $60.69 N/A73592 26 $17.45 $17.45 N/A 74022 26 $34.90 $34.90 N/A73600 $63.72 $63.72 N/A 74150 $320.89 $320.89 N/A73600 TC $45.52 $45.52 N/A 74150 TC $191.93 $191.93 N/A73600 26 $18.21 $18.21 N/A 74150 26 $128.96 $128.96 N/A73610 $67.52 $67.52 N/A 74160 $494.61 $494.61 N/A73610 TC $48.55 $48.55 N/A 74160 TC $356.54 $356.54 N/A73610 26 $18.97 $18.97 N/A 74160 26 $138.07 $138.07 N/A73615 $225.30 $225.30 N/A 74170 $562.12 $562.12 N/A73615 TC $163.86 $163.86 N/A 74170 TC $410.40 $410.40 N/A73615 26 $61.45 $61.45 N/A 74170 26 $151.72 $151.72 N/A73620 $55.38 $55.38 N/A 74174 $832.94 $832.94 N/A73620 TC $38.69 $38.69 N/A 74174 TC $595.50 $595.50 N/A73620 26 $16.69 $16.69 N/A 74174 26 $237.44 $237.44 N/A73630 $62.21 $62.21 N/A 74175 $657.71 $657.71 N/A73630 TC $44.00 $44.00 N/A 74175 TC $461.99 $461.99 N/A73630 26 $18.21 $18.21 N/A 74175 26 $195.72 $195.72 N/A73650 $57.65 $57.65 N/A 74176 $430.88 $430.88 N/A73650 TC $40.21 $40.21 N/A 74176 TC $241.99 $241.99 N/A73650 26 $17.45 $17.45 N/A 74176 26 $188.89 $188.89 N/A73660 $59.93 $59.93 N/A 74177 $666.81 $666.81 N/A73660 TC $45.52 $45.52 N/A 74177 TC $469.57 $469.57 N/A73660 26 $14.41 $14.41 N/A 74177 26 $197.24 $197.24 N/A73700 $385.37 $385.37 N/A 74178 $757.08 $757.08 N/A73700 TC $276.89 $276.89 N/A 74178 TC $539.36 $539.36 N/A73700 26 $108.48 $108.48 N/A 74178 26 $217.72 $217.72 N/A73701 $483.99 $483.99 N/A 74181 $712.33 $712.33 N/A73701 TC $358.06 $358.06 N/A 74181 TC $554.54 $554.54 N/A73701 26 $125.93 $125.93 N/A 74181 26 $157.79 $157.79 N/A73702 $586.40 $586.40 N/A 74182 $973.28 $973.28 N/A73702 TC $454.40 $454.40 N/A 74182 TC $785.15 $785.15 N/A73702 26 $132.00 $132.00 N/A 74182 26 $188.13 $188.13 N/A73706 $761.63 $761.63 N/A 74183 $1,084.80 $1,084.80 N/A73706 TC $556.81 $556.81 N/A 74183 TC $839.77 $839.77 N/A73706 26 $204.82 $204.82 N/A 74183 26 $245.03 $245.03 N/A73718 $780.60 $780.60 N/A 74185 $863.29 $863.29 N/A73718 TC $634.19 $634.19 N/A 74185 TC $669.84 $669.84 N/A73718 26 $146.41 $146.41 N/A 74185 26 $193.44 $193.44 N/A73719 $867.08 $867.08 N/A 74190 80% of billed 80% of billed N/A73719 TC $691.08 $691.08 N/A 74190 TC 80% of billed 80% of billed N/A73719 26 $176.00 $176.00 N/A 74190 26 $50.83 $50.83 N/A73720 $1,075.69 $1,075.69 N/A 74210 $166.13 $166.13 N/A73720 TC $842.80 $842.80 N/A 74210 TC $126.69 $126.69 N/A73720 26 $232.89 $232.89 N/A 74210 26 $39.45 $39.45 N/A73721 $920.00 $920.00 N/A 74220 $188.89 $188.89 N/A73721 TC $772.83 $772.83 N/A 74220 TC $138.82 $138.82 N/A73721 26 $147.17 $147.17 N/A 74220 26 $50.07 $50.07 N/A73722 $816.25 $816.25 N/A 74230 $273.85 $273.85 N/A73722 TC $640.26 $640.26 N/A 74230 TC $216.20 $216.20 N/A73722 26 $176.00 $176.00 N/A 74230 26 $57.65 $57.65 N/A73723 $1,007.42 $1,007.42 N/A 74235 80% of billed 80% of billed N/A73723 TC $774.53 $774.53 N/A 74235 TC 80% of billed 80% of billed N/A73723 26 $232.89 $232.89 N/A 74235 26 $133.51 $133.51 N/A73725 $859.49 $859.49 N/A 74240 $241.23 $241.23 N/A73725 TC $664.53 $664.53 N/A 74240 TC $166.13 $166.13 N/A73725 26 $194.96 $194.96 N/A 74240 26 $75.10 $75.10 N/A74000 $50.83 $50.83 N/A 74241 $251.86 $251.86 N/A74000 TC $31.10 $31.10 N/A 74241 TC $176.75 $176.75 N/A74000 26 $19.72 $19.72 N/A 74241 26 $75.10 $75.10 N/A74010 $75.10 $75.10 N/A 74245 $366.40 $366.40 N/A74010 TC $50.07 $50.07 N/A 74245 TC $267.79 $267.79 N/A74010 26 $25.03 $25.03 N/A 74245 26 $98.62 $98.62 N/A74020 $80.41 $80.41 N/A 74246 $271.58 $271.58 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 49 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

74246 TC $196.48 $196.48 N/A 74400 TC $182.82 $182.82 N/A74246 26 $75.10 $75.10 N/A 74400 26 $53.10 $53.10 N/A74247 $302.68 $302.68 N/A 74410 $232.89 $232.89 N/A74247 TC $227.58 $227.58 N/A 74410 TC $179.79 $179.79 N/A74247 26 $75.10 $75.10 N/A 74410 26 $53.10 $53.10 N/A74249 $392.95 $392.95 N/A 74415 $292.06 $292.06 N/A74249 TC $294.34 $294.34 N/A 74415 TC $238.96 $238.96 N/A74249 26 $98.62 $98.62 N/A 74415 26 $53.10 $53.10 N/A74250 $222.27 $222.27 N/A 74420 80% of billed 80% of billed N/A74250 TC $170.69 $170.69 N/A 74420 TC 80% of billed 80% of billed N/A74250 26 $51.58 $51.58 N/A 74420 26 $37.93 $37.93 N/A74251 $897.42 $897.42 N/A 74425 80% of billed 80% of billed N/A74251 TC $822.32 $822.32 N/A 74425 TC 80% of billed 80% of billed N/A74251 26 $75.10 $75.10 N/A 74425 26 $37.93 $37.93 N/A74260 $732.81 $732.81 N/A 74430 $81.17 $81.17 N/A74260 TC $678.19 $678.19 N/A 74430 TC $46.27 $46.27 N/A74260 26 $54.62 $54.62 N/A 74430 26 $34.90 $34.90 N/A74261 $1,041.56 $1,041.56 N/A 74440 $173.72 $173.72 N/A74261 TC $780.60 $780.60 N/A 74440 TC $133.51 $133.51 N/A74261 26 $260.96 $260.96 N/A 74440 26 $40.21 $40.21 N/A74262 $1,167.49 $1,167.49 N/A 74445 80% of billed 80% of billed N/A74262 TC $895.91 $895.91 N/A 74445 TC 80% of billed 80% of billed N/A74262 26 $271.58 $271.58 N/A 74445 26 $116.82 $116.82 N/A74263 $1,613.54 $1,613.54 N/A 74450 80% of billed 80% of billed N/A74263 TC $1,368.51 $1,368.51 N/A 74450 TC 80% of billed 80% of billed N/A74263 26 $245.03 $245.03 N/A 74450 26 $35.65 $35.65 N/A74270 $320.89 $320.89 N/A 74455 $175.24 $175.24 N/A74270 TC $245.79 $245.79 N/A 74455 TC $139.58 $139.58 N/A74270 26 $75.10 $75.10 N/A 74455 26 $35.65 $35.65 N/A74280 $456.68 $456.68 N/A 74470 80% of billed 80% of billed N/A74280 TC $348.96 $348.96 N/A 74470 TC 80% of billed 80% of billed N/A74280 26 $107.72 $107.72 N/A 74470 26 $56.90 $56.90 N/A74283 $447.57 $447.57 N/A 74485 $196.48 $196.48 N/A74283 TC $224.55 $224.55 N/A 74485 TC $140.34 $140.34 N/A74283 26 $223.03 $223.03 N/A 74485 26 $56.14 $56.14 N/A74290 $150.20 $150.20 N/A 74710 $78.89 $78.89 N/A74290 TC $115.31 $115.31 N/A 74710 TC $41.72 $41.72 N/A74290 26 $34.90 $34.90 N/A 74710 26 $37.17 $37.17 N/A74300 80% of billed 80% of billed N/A 74712 $1,030.94 $1,030.94 N/A74300 TC 80% of billed 80% of billed N/A 74712 TC $704.74 $704.74 N/A74300 26 $39.45 $39.45 N/A 74712 26 $326.20 $326.20 N/A74301 80% of billed 80% of billed ZZZ 74713 $499.16 $499.16 ZZZ74301 TC 80% of billed 80% of billed ZZZ 74713 TC $298.13 $298.13 ZZZ74301 26 $22.76 $22.76 ZZZ 74713 26 $201.03 $201.03 ZZZ74328 80% of billed 80% of billed N/A 74740 $160.06 $160.06 N/A74328 TC 80% of billed 80% of billed N/A 74740 TC $119.10 $119.10 N/A74328 26 $77.38 $77.38 N/A 74740 26 $40.96 $40.96 N/A74329 80% of billed 80% of billed N/A 74742 80% of billed 80% of billed N/A74329 TC 80% of billed 80% of billed N/A 74742 TC 80% of billed 80% of billed N/A74329 26 $77.38 $77.38 N/A 74742 26 $66.00 $66.00 N/A74330 80% of billed 80% of billed N/A 74775 80% of billed 80% of billed N/A74330 TC 80% of billed 80% of billed N/A 74775 TC 80% of billed 80% of billed N/A74330 26 $98.62 $98.62 N/A 74775 26 $67.52 $67.52 N/A74340 80% of billed 80% of billed N/A 75557 $685.77 $685.77 N/A74340 TC 80% of billed 80% of billed N/A 75557 TC $435.44 $435.44 N/A74340 26 $58.41 $58.41 N/A 75557 26 $250.34 $250.34 N/A74355 80% of billed 80% of billed N/A 75559 $936.87 $936.87 N/A74355 TC 80% of billed 80% of billed N/A 75559 TC $628.12 $628.12 N/A74355 26 $82.69 $82.69 N/A 75559 26 $308.75 $308.75 N/A74360 80% of billed 80% of billed N/A 75561 $910.32 $910.32 N/A74360 TC 80% of billed 80% of billed N/A 75561 TC $633.43 $633.43 N/A74360 26 $60.69 $60.69 N/A 75561 26 $276.89 $276.89 N/A74363 80% of billed 80% of billed N/A 75563 $1,084.80 $1,084.80 N/A74363 TC 80% of billed 80% of billed N/A 75563 TC $767.70 $767.70 N/A74363 26 $92.55 $92.55 N/A 75563 26 $317.09 $317.09 N/A74400 $235.92 $235.92 N/A 75565 $117.58 $117.58 ZZZ

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 50 of 84

Page 51: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

75565 TC $91.03 $91.03 ZZZ 75774 TC $147.17 $147.17 ZZZ75565 26 $26.55 $26.55 ZZZ 75774 26 $37.93 $37.93 ZZZ75571 $216.20 $216.20 N/A 75801 80% of billed 80% of billed N/A75571 TC $154.00 $154.00 N/A 75801 TC 80% of billed 80% of billed N/A75571 26 $62.21 $62.21 N/A 75801 26 $96.34 $96.34 N/A75572 $607.64 $607.64 N/A 75803 80% of billed 80% of billed N/A75572 TC $420.26 $420.26 N/A 75803 TC 80% of billed 80% of billed N/A75572 26 $187.37 $187.37 N/A 75803 26 $131.24 $131.24 N/A75573 $836.74 $836.74 N/A 75805 80% of billed 80% of billed N/A75573 TC $563.64 $563.64 N/A 75805 TC 80% of billed 80% of billed N/A75573 26 $273.10 $273.10 N/A 75805 26 $88.00 $88.00 N/A75574 $901.98 $901.98 N/A 75807 80% of billed 80% of billed N/A75574 TC $645.57 $645.57 N/A 75807 TC 80% of billed 80% of billed N/A75574 26 $256.41 $256.41 N/A 75807 26 $127.44 $127.44 N/A75600 $423.30 $423.30 N/A 75809 $211.65 $211.65 N/A75600 TC $370.96 $370.96 N/A 75809 TC $160.06 $160.06 N/A75600 26 $52.34 $52.34 N/A 75809 26 $51.58 $51.58 N/A75605 $295.85 $295.85 N/A 75810 80% of billed 80% of billed N/A75605 TC $175.24 $175.24 N/A 75810 TC 80% of billed 80% of billed N/A75605 26 $120.62 $120.62 N/A 75810 26 $124.41 $124.41 N/A75625 $294.34 $294.34 N/A 75820 $247.30 $247.30 N/A75625 TC $173.72 $173.72 N/A 75820 TC $172.20 $172.20 N/A75625 26 $120.62 $120.62 N/A 75820 26 $75.10 $75.10 N/A75630 $364.89 $364.89 N/A 75822 $293.58 $293.58 N/A75630 TC $175.24 $175.24 N/A 75822 TC $180.55 $180.55 N/A75630 26 $189.65 $189.65 N/A 75822 26 $113.03 $113.03 N/A75635 $817.77 $817.77 N/A 75825 $290.54 $290.54 N/A75635 TC $559.85 $559.85 N/A 75825 TC $169.17 $169.17 N/A75635 26 $257.92 $257.92 N/A 75825 26 $121.38 $121.38 N/A75658 $361.09 $361.09 N/A 75827 $296.61 $296.61 N/A75658 TC $222.27 $222.27 N/A 75827 TC $175.24 $175.24 N/A75658 26 $138.82 $138.82 N/A 75827 26 $121.38 $121.38 N/A75705 $530.26 $530.26 N/A 75831 $300.41 $300.41 N/A75705 TC $282.20 $282.20 N/A 75831 TC $181.31 $181.31 N/A75705 26 $248.06 $248.06 N/A 75831 26 $119.10 $119.10 N/A75710 $347.44 $347.44 N/A 75833 $353.51 $353.51 N/A75710 TC $226.06 $226.06 N/A 75833 TC $197.24 $197.24 N/A75710 26 $121.38 $121.38 N/A 75833 26 $156.27 $156.27 N/A75716 $399.78 $399.78 N/A 75840 $320.13 $320.13 N/A75716 TC $261.72 $261.72 N/A 75840 TC $195.72 $195.72 N/A75716 26 $138.07 $138.07 N/A 75840 26 $124.41 $124.41 N/A75726 $320.13 $320.13 N/A 75842 $384.61 $384.61 N/A75726 TC $200.27 $200.27 N/A 75842 TC $226.82 $226.82 N/A75726 26 $119.86 $119.86 N/A 75842 26 $157.79 $157.79 N/A75731 $367.92 $367.92 N/A 75860 $307.99 $307.99 N/A75731 TC $244.27 $244.27 N/A 75860 TC $187.37 $187.37 N/A75731 26 $123.65 $123.65 N/A 75860 26 $120.62 $120.62 N/A75733 $398.27 $398.27 N/A 75870 $320.13 $320.13 N/A75733 TC $260.96 $260.96 N/A 75870 TC $195.72 $195.72 N/A75733 26 $137.31 $137.31 N/A 75870 26 $124.41 $124.41 N/A75736 $342.89 $342.89 N/A 75872 $333.03 $333.03 N/A75736 TC $223.79 $223.79 N/A 75872 TC $210.13 $210.13 N/A75736 26 $119.10 $119.10 N/A 75872 26 $122.89 $122.89 N/A75741 $323.16 $323.16 N/A 75880 $314.82 $314.82 N/A75741 TC $185.86 $185.86 N/A 75880 TC $237.44 $237.44 N/A75741 26 $137.31 $137.31 N/A 75880 26 $77.38 $77.38 N/A75743 $361.85 $361.85 N/A 75885 $335.30 $335.30 N/A75743 TC $188.13 $188.13 N/A 75885 TC $188.13 $188.13 N/A75743 26 $173.72 $173.72 N/A 75885 26 $147.17 $147.17 N/A75746 $328.47 $328.47 N/A 75887 $339.09 $339.09 N/A75746 TC $207.10 $207.10 N/A 75887 TC $190.41 $190.41 N/A75746 26 $121.38 $121.38 N/A 75887 26 $148.69 $148.69 N/A75756 $364.13 $364.13 N/A 75889 $307.99 $307.99 N/A75756 TC $241.23 $241.23 N/A 75889 TC $189.65 $189.65 N/A75756 26 $122.89 $122.89 N/A 75889 26 $118.34 $118.34 N/A75774 $185.10 $185.10 ZZZ 75891 $311.78 $311.78 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 51 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

75891 TC $191.17 $191.17 N/A 76101 TC $206.34 $206.34 N/A75891 26 $120.62 $120.62 N/A 76101 26 $75.86 $75.86 N/A75893 $254.89 $254.89 N/A 76102 $367.92 $367.92 N/A75893 TC $196.48 $196.48 N/A 76102 TC $295.85 $295.85 N/A75893 26 $58.41 $58.41 N/A 76102 26 $72.07 $72.07 N/A75894 80% of billed 80% of billed N/A 76120 $181.31 $181.31 N/A75894 TC 80% of billed 80% of billed N/A 76120 TC $139.58 $139.58 N/A75894 26 $147.17 $147.17 N/A 76120 26 $41.72 $41.72 N/A75898 80% of billed 80% of billed N/A 76125 80% of billed 80% of billed ZZZ75898 TC 80% of billed 80% of billed N/A 76125 TC 80% of billed 80% of billed ZZZ75898 26 $186.62 $186.62 N/A 76125 26 $31.10 $31.10 ZZZ75901 $379.30 $379.30 N/A 76140 80% of billed 80% of billed N/A75901 TC $328.47 $328.47 N/A 76376 $50.07 $50.07 N/A75901 26 $50.83 $50.83 N/A 76376 TC $28.83 $28.83 N/A75902 $154.75 $154.75 N/A 76376 26 $21.24 $21.24 N/A75902 TC $113.79 $113.79 N/A 76377 $153.24 $153.24 N/A75902 26 $40.96 $40.96 N/A 76377 TC $66.76 $66.76 N/A75952 80% of billed 80% of billed N/A 76377 26 $86.48 $86.48 N/A75952 TC 80% of billed 80% of billed N/A 76380 $312.54 $312.54 N/A75952 26 $482.47 $482.47 N/A 76380 TC $206.34 $206.34 N/A75953 80% of billed 80% of billed N/A 76380 26 $106.20 $106.20 N/A75953 TC 80% of billed 80% of billed N/A 76390 $951.28 $951.28 N/A75953 26 $146.41 $146.41 N/A 76390 TC $801.08 $801.08 N/A75954 80% of billed 80% of billed N/A 76390 26 $150.20 $150.20 N/A75954 TC 80% of billed 80% of billed N/A 76496 80% of billed 80% of billed N/A75954 26 $245.03 $245.03 N/A 76496 TC 80% of billed 80% of billed N/A75956 80% of billed 80% of billed N/A 76496 26 80% of billed 80% of billed N/A75956 TC 80% of billed 80% of billed N/A 76497 80% of billed 80% of billed N/A75956 26 $751.77 $751.77 N/A 76497 TC 80% of billed 80% of billed N/A75957 80% of billed 80% of billed N/A 76497 26 80% of billed 80% of billed N/A75957 TC 80% of billed 80% of billed N/A 76498 80% of billed 80% of billed N/A75957 26 $645.57 $645.57 N/A 76498 TC 80% of billed 80% of billed N/A75958 80% of billed 80% of billed N/A 76498 26 80% of billed 80% of billed N/A75958 TC 80% of billed 80% of billed N/A 76499 80% of billed 80% of billed N/A75958 26 $430.13 $430.13 N/A 76499 TC 80% of billed 80% of billed N/A75959 80% of billed 80% of billed N/A 76499 26 80% of billed 80% of billed N/A75959 TC 80% of billed 80% of billed N/A 76506 $254.89 $254.89 N/A75959 26 $367.16 $367.16 N/A 76506 TC $185.10 $185.10 N/A75970 80% of billed 80% of billed N/A 76506 26 $69.79 $69.79 N/A75970 TC 80% of billed 80% of billed N/A 76510 $364.13 $364.13 N/A75970 26 $86.48 $86.48 N/A 76510 TC $172.96 $172.96 N/A75984 $226.82 $226.82 N/A 76510 26 $191.17 $191.17 N/A75984 TC $151.72 $151.72 N/A 76511 $218.48 $218.48 N/A75984 26 $75.10 $75.10 N/A 76511 TC $103.93 $103.93 N/A75989 $259.44 $259.44 N/A 76511 26 $114.55 $114.55 N/A75989 TC $133.51 $133.51 N/A 76512 $198.75 $198.75 N/A75989 26 $125.93 $125.93 N/A 76512 TC $84.96 $84.96 N/A76000 $101.65 $101.65 N/A 76512 26 $113.79 $113.79 N/A76000 TC $82.69 $82.69 N/A 76513 $204.06 $204.06 N/A76000 26 $18.97 $18.97 N/A 76513 TC $127.44 $127.44 N/A76001 80% of billed 80% of billed N/A 76513 26 $76.62 $76.62 N/A76001 TC 80% of billed 80% of billed N/A 76514 $32.62 $32.62 N/A76001 26 $78.89 $78.89 N/A 76514 TC $11.38 $11.38 N/A76010 $56.14 $56.14 N/A 76514 26 $21.24 $21.24 N/A76010 TC $36.41 $36.41 N/A 76516 $168.41 $168.41 N/A76010 26 $19.72 $19.72 N/A 76516 TC $101.65 $101.65 N/A76080 $118.34 $118.34 N/A 76516 26 $66.76 $66.76 N/A76080 TC $61.45 $61.45 N/A 76519 $181.31 $181.31 N/A76080 26 $56.90 $56.90 N/A 76519 TC $113.79 $113.79 N/A76098 $35.65 $35.65 N/A 76519 26 $67.52 $67.52 N/A76098 TC $18.21 $18.21 N/A 76529 $169.17 $169.17 N/A76098 26 $17.45 $17.45 N/A 76529 TC $100.14 $100.14 N/A76100 $196.48 $196.48 N/A 76529 26 $69.03 $69.03 N/A76100 TC $128.20 $128.20 N/A 76536 $251.10 $251.10 N/A76100 26 $68.27 $68.27 N/A 76536 TC $190.41 $190.41 N/A76101 $282.20 $282.20 N/A 76536 26 $60.69 $60.69 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 52 of 84

Page 53: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

76604 $190.41 $190.41 N/A 76819 $195.72 $195.72 N/A76604 TC $132.00 $132.00 N/A 76819 TC $110.00 $110.00 N/A76604 26 $58.41 $58.41 N/A 76819 26 $85.72 $85.72 N/A76641 $231.37 $231.37 N/A 76820 $104.69 $104.69 N/A76641 TC $152.48 $152.48 N/A 76820 TC $48.55 $48.55 N/A76641 26 $78.89 $78.89 N/A 76820 26 $56.14 $56.14 N/A76642 $190.41 $190.41 N/A 76821 $201.79 $201.79 N/A76642 TC $116.82 $116.82 N/A 76821 TC $122.89 $122.89 N/A76642 26 $73.58 $73.58 N/A 76821 26 $78.89 $78.89 N/A76700 $263.99 $263.99 N/A 76825 $601.57 $601.57 N/A76700 TC $176.75 $176.75 N/A 76825 TC $419.51 $419.51 N/A76700 26 $87.24 $87.24 N/A 76825 26 $182.06 $182.06 N/A76705 $197.24 $197.24 N/A 76826 $353.51 $353.51 N/A76705 TC $133.51 $133.51 N/A 76826 TC $263.99 $263.99 N/A76705 26 $63.72 $63.72 N/A 76826 26 $89.51 $89.51 N/A76706 $201.79 $201.79 N/A 76827 $163.86 $163.86 N/A76706 TC $141.86 $141.86 N/A 76827 TC $100.89 $100.89 N/A76706 26 $59.93 $59.93 N/A 76827 26 $62.96 $62.96 N/A76770 $244.27 $244.27 N/A 76828 $116.82 $116.82 N/A76770 TC $164.62 $164.62 N/A 76828 TC $54.62 $54.62 N/A76770 26 $79.65 $79.65 N/A 76828 26 $62.21 $62.21 N/A76775 $125.93 $125.93 N/A 76830 $263.99 $263.99 N/A76775 TC $63.72 $63.72 N/A 76830 TC $188.89 $188.89 N/A76775 26 $62.21 $62.21 N/A 76830 26 $75.10 $75.10 N/A76776 $338.34 $338.34 N/A 76831 $258.68 $258.68 N/A76776 TC $256.41 $256.41 N/A 76831 TC $179.03 $179.03 N/A76776 26 $81.93 $81.93 N/A 76831 26 $79.65 $79.65 N/A76800 $307.99 $307.99 N/A 76856 $238.20 $238.20 N/A76800 TC $178.27 $178.27 N/A 76856 TC $163.10 $163.10 N/A76800 26 $129.72 $129.72 N/A 76856 26 $75.10 $75.10 N/A76801 $267.03 $267.03 N/A 76857 $103.93 $103.93 N/A76801 TC $158.55 $158.55 N/A 76857 TC $50.07 $50.07 N/A76801 26 $108.48 $108.48 N/A 76857 26 $53.86 $53.86 N/A76802 $139.58 $139.58 ZZZ 76870 $147.17 $147.17 N/A76802 TC $47.79 $47.79 ZZZ 76870 TC $77.38 $77.38 N/A76802 26 $91.79 $91.79 ZZZ 76870 26 $69.79 $69.79 N/A76805 $307.99 $307.99 N/A 76872 $204.82 $204.82 N/A76805 TC $198.75 $198.75 N/A 76872 TC $132.76 $132.76 N/A76805 26 $109.24 $109.24 N/A 76872 26 $72.07 $72.07 N/A76810 $201.79 $201.79 ZZZ 76873 $368.68 $368.68 N/A76810 TC $93.31 $93.31 ZZZ 76873 TC $200.27 $200.27 N/A76810 26 $108.48 $108.48 ZZZ 76873 26 $168.41 $168.41 N/A76811 $397.51 $397.51 N/A 76881 $254.89 $254.89 N/A76811 TC $184.34 $184.34 N/A 76881 TC $186.62 $186.62 N/A76811 26 $213.17 $213.17 N/A 76881 26 $68.27 $68.27 N/A76812 $445.30 $445.30 ZZZ 76882 $77.38 $77.38 N/A76812 TC $244.27 $244.27 ZZZ 76882 TC $24.28 $24.28 N/A76812 26 $201.03 $201.03 ZZZ 76882 26 $53.10 $53.10 N/A76813 $264.75 $264.75 N/A 76885 $316.34 $316.34 N/A76813 TC $132.00 $132.00 N/A 76885 TC $235.92 $235.92 N/A76813 26 $132.76 $132.76 N/A 76885 26 $80.41 $80.41 N/A76814 $176.00 $176.00 N/A 76886 $235.17 $235.17 N/A76814 TC $64.48 $64.48 N/A 76886 TC $170.69 $170.69 N/A76814 26 $111.51 $111.51 N/A 76886 26 $64.48 $64.48 N/A76815 $183.58 $183.58 N/A 76930 80% of billed 80% of billed N/A76815 TC $112.27 $112.27 N/A 76930 TC 80% of billed 80% of billed N/A76815 26 $71.31 $71.31 N/A 76930 26 $71.31 $71.31 N/A76816 $251.10 $251.10 N/A 76932 80% of billed 80% of billed N/A76816 TC $155.51 $155.51 N/A 76932 TC 80% of billed 80% of billed N/A76816 26 $95.58 $95.58 N/A 76932 26 $70.55 $70.55 N/A76817 $210.89 $210.89 N/A 76936 $587.16 $587.16 N/A76817 TC $128.20 $128.20 N/A 76936 TC $375.51 $375.51 N/A76817 26 $82.69 $82.69 N/A 76936 26 $211.65 $211.65 N/A76818 $267.79 $267.79 N/A 76937 $67.52 $67.52 ZZZ76818 TC $149.44 $149.44 N/A 76937 TC $36.41 $36.41 ZZZ76818 26 $118.34 $118.34 N/A 76937 26 $31.10 $31.10 ZZZ

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 53 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

76940 80% of billed 80% of billed N/A 77054 $166.13 $166.13 N/A76940 TC 80% of billed 80% of billed N/A 77054 TC $116.82 $116.82 N/A76940 26 $223.79 $223.79 N/A 77054 26 $49.31 $49.31 N/A76941 80% of billed 80% of billed N/A 77058 $1,159.90 $1,159.90 N/A76941 TC 80% of billed 80% of billed N/A 77058 TC $983.15 $983.15 N/A76941 26 $139.58 $139.58 N/A 77058 26 $176.75 $176.75 N/A76942 $129.72 $129.72 N/A 77059 $1,152.31 $1,152.31 N/A76942 TC $59.93 $59.93 N/A 77059 TC $975.56 $975.56 N/A76942 26 $69.79 $69.79 N/A 77059 26 $176.75 $176.75 N/A76945 80% of billed 80% of billed N/A 77061 80% of billed 80% of billed N/A76945 TC 80% of billed 80% of billed N/A 77061 TC 80% of billed 80% of billed N/A76945 26 $75.86 $75.86 N/A 77061 26 80% of billed 80% of billed N/A76946 $70.55 $70.55 N/A 77062 80% of billed 80% of billed N/A76946 TC $28.07 $28.07 N/A 77062 TC 80% of billed 80% of billed N/A76946 26 $42.48 $42.48 N/A 77062 26 80% of billed 80% of billed N/A76948 $154.00 $154.00 N/A 77063 $119.10 $119.10 ZZZ76948 TC $81.17 $81.17 N/A 77063 TC $53.86 $53.86 ZZZ76948 26 $72.83 $72.83 N/A 77063 26 $65.24 $65.24 ZZZ76965 $195.72 $195.72 N/A 77065 80% of billed 80% of billed N/A76965 TC $51.58 $51.58 N/A 77065 TC 80% of billed 80% of billed N/A76965 26 $144.13 $144.13 N/A 77065 26 80% of billed 80% of billed N/A76970 $198.75 $198.75 N/A 77066 80% of billed 80% of billed N/A76970 TC $157.03 $157.03 N/A 77066 TC 80% of billed 80% of billed N/A76970 26 $41.72 $41.72 N/A 77066 26 80% of billed 80% of billed N/A76975 80% of billed 80% of billed N/A 77067 80% of billed 80% of billed N/A76975 TC 80% of billed 80% of billed N/A 77067 TC 80% of billed 80% of billed N/A76975 26 $91.03 $91.03 N/A 77067 26 80% of billed 80% of billed N/A76977 $15.93 $15.93 N/A 77071 $103.93 $103.93 N/A76977 TC $9.86 $9.86 N/A 77072 $49.31 $49.31 N/A76977 26 $6.07 $6.07 N/A 77072 TC $28.83 $28.83 N/A76998 80% of billed 80% of billed N/A 77072 26 $20.48 $20.48 N/A76998 TC 80% of billed 80% of billed N/A 77073 $76.62 $76.62 N/A76998 26 $137.31 $137.31 N/A 77073 TC $45.52 $45.52 N/A76999 80% of billed 80% of billed N/A 77073 26 $31.10 $31.10 N/A76999 TC 80% of billed 80% of billed N/A 77074 $138.07 $138.07 N/A76999 26 80% of billed 80% of billed N/A 77074 TC $88.76 $88.76 N/A77001 $180.55 $180.55 ZZZ 77074 26 $49.31 $49.31 N/A77001 TC $139.58 $139.58 ZZZ 77075 $186.62 $186.62 N/A77001 26 $40.96 $40.96 ZZZ 77075 TC $128.20 $128.20 N/A77002 $199.51 $199.51 ZZZ 77075 26 $58.41 $58.41 N/A77002 TC $138.82 $138.82 ZZZ 77076 $207.10 $207.10 N/A77002 26 $60.69 $60.69 ZZZ 77076 TC $131.24 $131.24 N/A77003 $201.79 $201.79 ZZZ 77076 26 $75.86 $75.86 N/A77003 TC $137.31 $137.31 ZZZ 77077 $79.65 $79.65 N/A77003 26 $64.48 $64.48 ZZZ 77077 TC $44.76 $44.76 N/A77011 $480.19 $480.19 N/A 77077 26 $34.90 $34.90 N/A77011 TC $344.40 $344.40 N/A 77078 $245.03 $245.03 N/A77011 26 $135.79 $135.79 N/A 77078 TC $218.48 $218.48 N/A77012 $266.27 $266.27 N/A 77078 26 $26.55 $26.55 N/A77012 TC $142.62 $142.62 N/A 77080 $88.00 $88.00 N/A77012 26 $123.65 $123.65 N/A 77080 TC $66.00 $66.00 N/A77013 80% of billed 80% of billed N/A 77080 26 $22.00 $22.00 N/A77013 TC 80% of billed 80% of billed N/A 77081 $59.93 $59.93 N/A77013 26 $420.26 $420.26 N/A 77081 TC $36.41 $36.41 N/A77014 $254.13 $254.13 N/A 77081 26 $23.52 $23.52 N/A77014 TC $159.31 $159.31 N/A 77084 $835.98 $835.98 N/A77014 26 $94.83 $94.83 N/A 77084 TC $661.50 $661.50 N/A77021 $857.22 $857.22 N/A 77084 26 $174.48 $174.48 N/A77021 TC $696.39 $696.39 N/A 77085 $119.86 $119.86 N/A77021 26 $160.82 $160.82 N/A 77085 TC $86.48 $86.48 N/A77022 80% of billed 80% of billed N/A 77085 26 $33.38 $33.38 N/A77022 TC 80% of billed 80% of billed N/A 77086 $75.86 $75.86 N/A77022 26 $460.47 $460.47 N/A 77086 TC $56.90 $56.90 N/A77053 $125.93 $125.93 N/A 77086 26 $18.97 $18.97 N/A77053 TC $86.48 $86.48 N/A 77261 $163.86 $163.86 N/A77053 26 $39.45 $39.45 N/A 77262 $243.51 $243.51 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 54 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

77263 $357.30 $357.30 N/A 77399 80% of billed 80% of billed N/A77280 $589.43 $589.43 N/A 77399 TC 80% of billed 80% of billed N/A77280 TC $511.30 $511.30 N/A 77399 26 80% of billed 80% of billed N/A77280 26 $78.14 $78.14 N/A 77401 $53.10 $53.10 N/A77285 $939.15 $939.15 N/A 77402 80% of billed 80% of billed N/A77285 TC $821.56 $821.56 N/A 77407 80% of billed 80% of billed N/A77285 26 $117.58 $117.58 N/A 77412 80% of billed 80% of billed N/A77290 $1,110.59 $1,110.59 N/A 77417 $23.52 $23.52 N/A77290 TC $936.11 $936.11 N/A 77422 80% of billed 80% of billed N/A77290 26 $174.48 $174.48 N/A 77423 80% of billed 80% of billed N/A77293 $1,003.63 $1,003.63 ZZZ 77424 80% of billed 80% of billed N/A77293 TC $779.84 $779.84 ZZZ 77425 80% of billed 80% of billed N/A77293 26 $223.79 $223.79 ZZZ 77427 $399.78 $399.78 N/A77295 $1,055.97 $1,055.97 N/A 77431 $219.99 $219.99 N/A77295 TC $578.81 $578.81 N/A 77432 $900.46 $900.46 N/A77295 26 $477.16 $477.16 N/A 77435 $1,357.14 $1,357.14 N/A77299 80% of billed 80% of billed N/A 77469 $691.84 $691.84 N/A77299 TC 80% of billed 80% of billed N/A 77470 $310.27 $310.27 N/A77299 26 80% of billed 80% of billed N/A 77470 TC $83.45 $83.45 N/A77300 $143.38 $143.38 N/A 77470 26 $226.82 $226.82 N/A77300 TC $73.58 $73.58 N/A 77499 80% of billed 80% of billed N/A77300 26 $69.79 $69.79 N/A 77499 TC 80% of billed 80% of billed N/A77301 $4,205.68 $4,205.68 N/A 77499 26 80% of billed 80% of billed N/A77301 TC $3,315.84 $3,315.84 N/A 77520 80% of billed 80% of billed N/A77301 26 $889.84 $889.84 N/A 77522 80% of billed 80% of billed N/A77306 $321.65 $321.65 N/A 77523 80% of billed 80% of billed N/A77306 TC $165.37 $165.37 N/A 77525 80% of billed 80% of billed N/A77306 26 $156.27 $156.27 N/A 77600 $891.36 $891.36 N/A77307 $622.05 $622.05 N/A 77600 TC $741.15 $741.15 N/A77307 TC $298.89 $298.89 N/A 77600 26 $150.20 $150.20 N/A77307 26 $323.16 $323.16 N/A 77605 $1,675.75 $1,675.75 N/A77316 $405.85 $405.85 N/A 77605 TC $1,456.51 $1,456.51 N/A77316 TC $249.58 $249.58 N/A 77605 26 $219.24 $219.24 N/A77316 26 $156.27 $156.27 N/A 77610 $1,849.47 $1,849.47 N/A77317 $528.74 $528.74 N/A 77610 TC $1,700.78 $1,700.78 N/A77317 TC $324.68 $324.68 N/A 77610 26 $148.69 $148.69 N/A77317 26 $204.06 $204.06 N/A 77615 $2,203.73 $2,203.73 N/A77318 $763.91 $763.91 N/A 77615 TC $1,998.91 $1,998.91 N/A77318 TC $440.75 $440.75 N/A 77615 26 $204.82 $204.82 N/A77318 26 $323.16 $323.16 N/A 77620 $994.52 $994.52 N/A77321 $200.27 $200.27 N/A 77620 TC $807.91 $807.91 N/A77321 TC $94.07 $94.07 N/A 77620 26 $186.62 $186.62 N/A77321 26 $106.20 $106.20 N/A 77750 $801.08 $801.08 09077331 $138.07 $138.07 N/A 77750 TC $244.27 $244.27 09077331 TC $40.96 $40.96 N/A 77750 26 $556.81 $556.81 09077331 26 $97.10 $97.10 N/A 77761 $842.05 $842.05 09077332 $144.89 $144.89 N/A 77761 TC $416.47 $416.47 09077332 TC $94.07 $94.07 N/A 77761 26 $425.57 $425.57 09077332 26 $50.83 $50.83 N/A 77762 $1,123.49 $1,123.49 09077333 $207.86 $207.86 N/A 77762 TC $481.71 $481.71 09077333 TC $124.41 $124.41 N/A 77762 26 $641.78 $641.78 09077333 26 $83.45 $83.45 N/A 77763 $1,583.20 $1,583.20 09077334 $281.44 $281.44 N/A 77763 TC $618.26 $618.26 09077334 TC $153.24 $153.24 N/A 77763 26 $964.94 $964.94 09077334 26 $128.20 $128.20 N/A 77767 $483.99 $483.99 N/A77336 $170.69 $170.69 N/A 77767 TC $366.40 $366.40 N/A77338 $1,092.38 $1,092.38 N/A 77767 26 $117.58 $117.58 N/A77338 TC $615.22 $615.22 N/A 77768 $759.36 $759.36 N/A77338 26 $477.16 $477.16 N/A 77768 TC $603.09 $603.09 N/A77370 $262.48 $262.48 N/A 77768 26 $156.27 $156.27 N/A77371 80% of billed 80% of billed N/A 77770 $690.33 $690.33 N/A77372 $2,309.94 $2,309.94 N/A 77770 TC $473.37 $473.37 N/A77373 $2,931.99 $2,931.99 N/A 77770 26 $216.96 $216.96 N/A77385 80% of billed 80% of billed N/A 77771 $1,285.83 $1,285.83 N/A77386 80% of billed 80% of billed N/A 77771 TC $862.53 $862.53 N/A77387 80% of billed 80% of billed N/A 77771 26 $423.30 $423.30 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 55 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

77772 $1,964.77 $1,964.77 N/A 78120 26 $25.03 $25.03 N/A77772 TC $1,364.72 $1,364.72 N/A 78121 $230.61 $230.61 N/A77772 26 $600.05 $600.05 N/A 78121 TC $196.48 $196.48 N/A77778 $1,768.30 $1,768.30 000 78121 26 $34.14 $34.14 N/A77778 TC $792.74 $792.74 000 78122 $213.17 $213.17 N/A77778 26 $975.56 $975.56 000 78122 TC $167.65 $167.65 N/A77789 $255.65 $255.65 000 78122 26 $45.52 $45.52 N/A77789 TC $128.20 $128.20 000 78130 $370.96 $370.96 N/A77789 26 $127.44 $127.44 000 78130 TC $305.72 $305.72 N/A77790 $31.86 $31.86 N/A 78130 26 $65.24 $65.24 N/A77799 80% of billed 80% of billed N/A 78135 $782.12 $782.12 N/A77799 TC 80% of billed 80% of billed N/A 78135 TC $712.33 $712.33 N/A77799 26 80% of billed 80% of billed N/A 78135 26 $69.79 $69.79 N/A78012 $178.27 $178.27 N/A 78140 $306.47 $306.47 N/A78012 TC $157.79 $157.79 N/A 78140 TC $240.48 $240.48 N/A78012 26 $20.48 $20.48 N/A 78140 26 $66.00 $66.00 N/A78013 $424.06 $424.06 N/A 78185 $468.81 $468.81 N/A78013 TC $384.61 $384.61 N/A 78185 TC $425.57 $425.57 N/A78013 26 $39.45 $39.45 N/A 78185 26 $43.24 $43.24 N/A78014 $536.33 $536.33 N/A 78190 $872.39 $872.39 N/A78014 TC $482.47 $482.47 N/A 78190 TC $755.57 $755.57 N/A78014 26 $53.86 $53.86 N/A 78190 26 $116.82 $116.82 N/A78015 $492.33 $492.33 N/A 78191 $370.96 $370.96 N/A78015 TC $421.02 $421.02 N/A 78191 TC $305.72 $305.72 N/A78015 26 $71.31 $71.31 N/A 78191 26 $65.24 $65.24 N/A78016 $630.40 $630.40 N/A 78195 $790.46 $790.46 N/A78016 TC $556.05 $556.05 N/A 78195 TC $663.02 $663.02 N/A78016 26 $74.34 $74.34 N/A 78195 26 $127.44 $127.44 N/A78018 $694.88 $694.88 N/A 78199 80% of billed 80% of billed N/A78018 TC $605.36 $605.36 N/A 78199 TC 80% of billed 80% of billed N/A78018 26 $89.51 $89.51 N/A 78199 26 80% of billed 80% of billed N/A78020 $184.34 $184.34 ZZZ 78201 $418.75 $418.75 N/A78020 TC $124.41 $124.41 ZZZ 78201 TC $373.23 $373.23 N/A78020 26 $59.93 $59.93 ZZZ 78201 26 $45.52 $45.52 N/A78070 $666.05 $666.05 N/A 78202 $443.78 $443.78 N/A78070 TC $581.09 $581.09 N/A 78202 TC $392.95 $392.95 N/A78070 26 $84.96 $84.96 N/A 78202 26 $50.83 $50.83 N/A78071 $792.74 $792.74 N/A 78205 $468.06 $468.06 N/A78071 TC $666.05 $666.05 N/A 78205 TC $395.23 $395.23 N/A78071 26 $126.69 $126.69 N/A 78205 26 $72.83 $72.83 N/A78072 $914.11 $914.11 N/A 78206 $759.36 $759.36 N/A78072 TC $748.74 $748.74 N/A 78206 TC $658.46 $658.46 N/A78072 26 $165.37 $165.37 N/A 78206 26 $100.89 $100.89 N/A78075 $985.42 $985.42 N/A 78215 $430.88 $430.88 N/A78075 TC $905.77 $905.77 N/A 78215 TC $378.54 $378.54 N/A78075 26 $79.65 $79.65 N/A 78215 26 $52.34 $52.34 N/A78099 80% of billed 80% of billed N/A 78216 $280.68 $280.68 N/A78099 TC 80% of billed 80% of billed N/A 78216 TC $221.51 $221.51 N/A78099 26 80% of billed 80% of billed N/A 78216 26 $59.17 $59.17 N/A78102 $377.78 $377.78 N/A 78226 $734.32 $734.32 N/A78102 TC $320.13 $320.13 N/A 78226 TC $655.43 $655.43 N/A78102 26 $57.65 $57.65 N/A 78226 26 $78.89 $78.89 N/A78103 $487.02 $487.02 N/A 78227 $996.04 $996.04 N/A78103 TC $410.40 $410.40 N/A 78227 TC $899.70 $899.70 N/A78103 26 $76.62 $76.62 N/A 78227 26 $96.34 $96.34 N/A78104 $543.92 $543.92 N/A 78230 $387.64 $387.64 N/A78104 TC $461.23 $461.23 N/A 78230 TC $338.34 $338.34 N/A78104 26 $82.69 $82.69 N/A 78230 26 $49.31 $49.31 N/A78110 $221.51 $221.51 N/A 78231 $285.23 $285.23 N/A78110 TC $200.27 $200.27 N/A 78231 TC $229.10 $229.10 N/A78110 26 $21.24 $21.24 N/A 78231 26 $56.14 $56.14 N/A78111 $210.89 $210.89 N/A 78232 $221.51 $221.51 N/A78111 TC $187.37 $187.37 N/A 78232 TC $179.03 $179.03 N/A78111 26 $23.52 $23.52 N/A 78232 26 $42.48 $42.48 N/A78120 $207.86 $207.86 N/A 78258 $499.16 $499.16 N/A78120 TC $182.82 $182.82 N/A 78258 TC $419.51 $419.51 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 56 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

78258 26 $79.65 $79.65 N/A 78414 26 $47.79 $47.79 N/A78261 $544.67 $544.67 N/A 78428 $401.30 $401.30 N/A78261 TC $471.85 $471.85 N/A 78428 TC $320.13 $320.13 N/A78261 26 $72.83 $72.83 N/A 78428 26 $81.17 $81.17 N/A78262 $537.85 $537.85 N/A 78445 $402.82 $402.82 N/A78262 TC $466.54 $466.54 N/A 78445 TC $350.47 $350.47 N/A78262 26 $71.31 $71.31 N/A 78445 26 $52.34 $52.34 N/A78264 $746.46 $746.46 N/A 78451 $752.53 $752.53 N/A78264 TC $662.26 $662.26 N/A 78451 TC $607.64 $607.64 N/A78264 26 $84.20 $84.20 N/A 78451 26 $144.89 $144.89 N/A78265 $885.29 $885.29 N/A 78452 $1,045.35 $1,045.35 N/A78265 TC $780.60 $780.60 N/A 78452 TC $875.42 $875.42 N/A78265 26 $104.69 $104.69 N/A 78452 26 $169.93 $169.93 N/A78266 $1,049.14 $1,049.14 N/A 78453 $672.88 $672.88 N/A78266 TC $933.84 $933.84 N/A 78453 TC $565.92 $565.92 N/A78266 26 $115.31 $115.31 N/A 78453 26 $106.96 $106.96 N/A78267 80% of billed 80% of billed N/A 78454 $967.97 $967.97 N/A78268 80% of billed 80% of billed N/A 78454 TC $823.84 $823.84 N/A78270 $224.55 $224.55 N/A 78454 26 $144.13 $144.13 N/A78270 TC $201.79 $201.79 N/A 78456 $708.53 $708.53 N/A78270 26 $22.76 $22.76 N/A 78456 TC $603.09 $603.09 N/A78271 $198.75 $198.75 N/A 78456 26 $105.45 $105.45 N/A78271 TC $176.75 $176.75 N/A 78457 $389.16 $389.16 N/A78271 26 $22.00 $22.00 N/A 78457 TC $308.75 $308.75 N/A78272 $216.96 $216.96 N/A 78457 26 $80.41 $80.41 N/A78272 TC $188.13 $188.13 N/A 78458 $453.64 $453.64 N/A78272 26 $28.83 $28.83 N/A 78458 TC $355.78 $355.78 N/A78278 $773.01 $773.01 N/A 78458 26 $97.86 $97.86 N/A78278 TC $667.57 $667.57 N/A 78459 80% of billed 80% of billed N/A78278 26 $105.45 $105.45 N/A 78459 TC 80% of billed 80% of billed N/A78282 80% of billed 80% of billed N/A 78459 26 $152.48 $152.48 N/A78282 TC 80% of billed 80% of billed N/A 78466 $433.16 $433.16 N/A78282 26 $40.96 $40.96 N/A 78466 TC $357.30 $357.30 N/A78290 $736.60 $736.60 N/A 78466 26 $75.86 $75.86 N/A78290 TC $663.78 $663.78 N/A 78468 $430.13 $430.13 N/A78290 26 $72.83 $72.83 N/A 78468 TC $345.92 $345.92 N/A78291 $567.43 $567.43 N/A 78468 26 $84.20 $84.20 N/A78291 TC $474.88 $474.88 N/A 78469 $502.95 $502.95 N/A78291 26 $92.55 $92.55 N/A 78469 TC $405.85 $405.85 N/A78299 80% of billed 80% of billed N/A 78469 26 $97.10 $97.10 N/A78299 TC 80% of billed 80% of billed N/A 78472 $506.74 $506.74 N/A78299 26 80% of billed 80% of billed N/A 78472 TC $402.82 $402.82 N/A78300 $402.06 $402.06 N/A 78472 26 $103.93 $103.93 N/A78300 TC $334.54 $334.54 N/A 78473 $638.74 $638.74 N/A78300 26 $67.52 $67.52 N/A 78473 TC $485.50 $485.50 N/A78305 $514.33 $514.33 N/A 78473 26 $153.24 $153.24 N/A78305 TC $424.82 $424.82 N/A 78481 $386.13 $386.13 N/A78305 26 $89.51 $89.51 N/A 78481 TC $282.96 $282.96 N/A78306 $557.57 $557.57 N/A 78481 26 $103.17 $103.17 N/A78306 TC $466.54 $466.54 N/A 78483 $535.57 $535.57 N/A78306 26 $91.03 $91.03 N/A 78483 TC $381.58 $381.58 N/A78315 $767.70 $767.70 N/A 78483 26 $154.00 $154.00 N/A78315 TC $659.22 $659.22 N/A 78491 80% of billed 80% of billed N/A78315 26 $108.48 $108.48 N/A 78491 TC 80% of billed 80% of billed N/A78320 $505.99 $505.99 N/A 78491 26 $154.00 $154.00 N/A78320 TC $396.75 $396.75 N/A 78492 80% of billed 80% of billed N/A78320 26 $109.24 $109.24 N/A 78492 TC 80% of billed 80% of billed N/A78350 $70.55 $70.55 N/A 78492 26 $193.44 $193.44 N/A78350 TC $47.03 $47.03 N/A 78494 $496.12 $496.12 N/A78350 26 $23.52 $23.52 N/A 78494 TC $370.96 $370.96 N/A78351 $33.38 $33.38 N/A 78494 26 $125.17 $125.17 N/A78399 80% of billed 80% of billed N/A 78496 $96.34 $96.34 ZZZ78399 TC 80% of billed 80% of billed N/A 78496 TC $44.00 $44.00 ZZZ78399 26 80% of billed 80% of billed N/A 78496 26 $52.34 $52.34 ZZZ78414 80% of billed 80% of billed N/A 78499 80% of billed 80% of billed N/A78414 TC 80% of billed 80% of billed N/A 78499 TC 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 57 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

78499 26 80% of billed 80% of billed N/A 78700 26 $47.79 $47.79 N/A78579 $412.68 $412.68 N/A 78701 $468.81 $468.81 N/A78579 TC $361.09 $361.09 N/A 78701 TC $417.99 $417.99 N/A78579 26 $51.58 $51.58 N/A 78701 26 $50.83 $50.83 N/A78580 $530.26 $530.26 N/A 78707 $515.85 $515.85 N/A78580 TC $451.37 $451.37 N/A 78707 TC $414.95 $414.95 N/A78580 26 $78.89 $78.89 N/A 78707 26 $100.89 $100.89 N/A78582 $742.67 $742.67 N/A 78708 $389.16 $389.16 N/A78582 TC $628.12 $628.12 N/A 78708 TC $260.96 $260.96 N/A78582 26 $114.55 $114.55 N/A 78708 26 $128.20 $128.20 N/A78597 $447.57 $447.57 N/A 78709 $808.67 $808.67 N/A78597 TC $370.96 $370.96 N/A 78709 TC $660.74 $660.74 N/A78597 26 $76.62 $76.62 N/A 78709 26 $147.93 $147.93 N/A78598 $678.95 $678.95 N/A 78710 $445.30 $445.30 N/A78598 TC $589.43 $589.43 N/A 78710 TC $379.30 $379.30 N/A78598 26 $89.51 $89.51 N/A 78710 26 $66.00 $66.00 N/A78599 80% of billed 80% of billed N/A 78725 $235.92 $235.92 N/A78599 TC 80% of billed 80% of billed N/A 78725 TC $196.48 $196.48 N/A78599 26 80% of billed 80% of billed N/A 78725 26 $39.45 $39.45 N/A78600 $411.16 $411.16 N/A 78730 $156.27 $156.27 ZZZ78600 TC $362.61 $362.61 N/A 78730 TC $140.34 $140.34 ZZZ78600 26 $48.55 $48.55 N/A 78730 26 $15.93 $15.93 ZZZ78601 $476.40 $476.40 N/A 78740 $485.50 $485.50 N/A78601 TC $422.54 $422.54 N/A 78740 TC $426.33 $426.33 N/A78601 26 $53.86 $53.86 N/A 78740 26 $59.17 $59.17 N/A78605 $444.54 $444.54 N/A 78761 $473.37 $473.37 N/A78605 TC $386.89 $386.89 N/A 78761 TC $395.99 $395.99 N/A78605 26 $57.65 $57.65 N/A 78761 26 $77.38 $77.38 N/A78606 $732.05 $732.05 N/A 78799 80% of billed 80% of billed N/A78606 TC $664.53 $664.53 N/A 78799 TC 80% of billed 80% of billed N/A78606 26 $67.52 $67.52 N/A 78799 26 80% of billed 80% of billed N/A78607 $779.84 $779.84 N/A 78800 $427.09 $427.09 N/A78607 TC $651.64 $651.64 N/A 78800 TC $354.27 $354.27 N/A78607 26 $128.20 $128.20 N/A 78800 26 $72.83 $72.83 N/A78608 80% of billed 80% of billed N/A 78801 $582.60 $582.60 N/A78608 TC 80% of billed 80% of billed N/A 78801 TC $496.12 $496.12 N/A78608 26 $154.75 $154.75 N/A 78801 26 $86.48 $86.48 N/A78609 $160.82 $160.82 N/A 78802 $718.39 $718.39 N/A78609 TC 80% of billed 80% of billed N/A 78802 TC $628.12 $628.12 N/A78609 26 $160.82 $160.82 N/A 78802 26 $90.27 $90.27 N/A78610 $388.40 $388.40 N/A 78803 $757.84 $757.84 N/A78610 TC $355.78 $355.78 N/A 78803 TC $645.57 $645.57 N/A78610 26 $32.62 $32.62 N/A 78803 26 $112.27 $112.27 N/A78630 $751.77 $751.77 N/A 78804 $1,256.24 $1,256.24 N/A78630 TC $678.95 $678.95 N/A 78804 TC $1,143.97 $1,143.97 N/A78630 26 $72.83 $72.83 N/A 78804 26 $112.27 $112.27 N/A78635 $759.36 $759.36 N/A 78805 $405.85 $405.85 N/A78635 TC $691.84 $691.84 N/A 78805 TC $328.47 $328.47 N/A78635 26 $67.52 $67.52 N/A 78805 26 $77.38 $77.38 N/A78645 $719.91 $719.91 N/A 78806 $739.64 $739.64 N/A78645 TC $659.98 $659.98 N/A 78806 TC $649.36 $649.36 N/A78645 26 $59.93 $59.93 N/A 78806 26 $90.27 $90.27 N/A78647 $785.91 $785.91 N/A 78807 $759.36 $759.36 N/A78647 TC $687.29 $687.29 N/A 78807 TC $647.09 $647.09 N/A78647 26 $98.62 $98.62 N/A 78807 26 $112.27 $112.27 N/A78650 $735.08 $735.08 N/A 78808 $97.10 $97.10 N/A78650 TC $670.60 $670.60 N/A 78811 80% of billed 80% of billed N/A78650 26 $64.48 $64.48 N/A 78811 TC 80% of billed 80% of billed N/A78660 $398.27 $398.27 N/A 78811 26 $166.13 $166.13 N/A78660 TC $341.37 $341.37 N/A 78812 80% of billed 80% of billed N/A78660 26 $56.90 $56.90 N/A 78812 TC 80% of billed 80% of billed N/A78699 80% of billed 80% of billed N/A 78812 26 $202.55 $202.55 N/A78699 TC 80% of billed 80% of billed N/A 78813 80% of billed 80% of billed N/A78699 26 80% of billed 80% of billed N/A 78813 TC 80% of billed 80% of billed N/A78700 $380.06 $380.06 N/A 78813 26 $210.89 $210.89 N/A78700 TC $332.27 $332.27 N/A 78814 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 58 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

78814 TC 80% of billed 80% of billed N/A 80183 80% of billed 80% of billed N/A78814 26 $234.41 $234.41 N/A 80184 80% of billed 80% of billed N/A78815 80% of billed 80% of billed N/A 80185 80% of billed 80% of billed N/A78815 TC 80% of billed 80% of billed N/A 80186 80% of billed 80% of billed N/A78815 26 $257.92 $257.92 N/A 80188 80% of billed 80% of billed N/A78816 80% of billed 80% of billed N/A 80190 80% of billed 80% of billed N/A78816 TC 80% of billed 80% of billed N/A 80192 80% of billed 80% of billed N/A78816 26 $260.96 $260.96 N/A 80194 80% of billed 80% of billed N/A78999 80% of billed 80% of billed N/A 80195 80% of billed 80% of billed N/A78999 TC 80% of billed 80% of billed N/A 80197 80% of billed 80% of billed N/A78999 26 80% of billed 80% of billed N/A 80198 80% of billed 80% of billed N/A79005 $295.85 $295.85 N/A 80199 80% of billed 80% of billed N/A79005 TC $106.20 $106.20 N/A 80200 80% of billed 80% of billed N/A79005 26 $189.65 $189.65 N/A 80201 80% of billed 80% of billed N/A79101 $310.27 $310.27 N/A 80202 80% of billed 80% of billed N/A79101 TC $103.17 $103.17 N/A 80203 80% of billed 80% of billed N/A79101 26 $207.10 $207.10 N/A 80299 $50.47 $50.47 N/A79200 $302.68 $302.68 N/A 80300 $45.32 $45.32 N/A79200 TC $117.58 $117.58 N/A 80301 $26.78 $26.78 N/A79200 26 $185.10 $185.10 N/A 80305 80% of billed 80% of billed N/A79300 80% of billed 80% of billed N/A 80306 80% of billed 80% of billed N/A79300 TC 80% of billed 80% of billed N/A 80307 80% of billed 80% of billed N/A79300 26 $173.72 $173.72 N/A 80320 $46.35 $46.35 N/A79403 $414.95 $414.95 N/A 80321 80% of billed 80% of billed N/A79403 TC $177.51 $177.51 N/A 80322 80% of billed 80% of billed N/A79403 26 $237.44 $237.44 N/A 80323 80% of billed 80% of billed N/A79440 $319.37 $319.37 N/A 80324 $45.32 $45.32 N/A79440 TC $109.24 $109.24 N/A 80325 80% of billed 80% of billed N/A79440 26 $210.13 $210.13 N/A 80326 80% of billed 80% of billed N/A79445 80% of billed 80% of billed N/A 80327 80% of billed 80% of billed N/A79445 TC 80% of billed 80% of billed N/A 80328 80% of billed 80% of billed N/A79445 26 $248.82 $248.82 N/A 80329 80% of billed 80% of billed N/A79999 80% of billed 80% of billed N/A 80330 80% of billed 80% of billed N/A79999 TC 80% of billed 80% of billed N/A 80331 80% of billed 80% of billed N/A79999 26 80% of billed 80% of billed N/A 80332 80% of billed 80% of billed N/A80047 80% of billed 80% of billed N/A 80333 80% of billed 80% of billed N/A80048 80% of billed 80% of billed N/A 80334 80% of billed 80% of billed N/A80050 80% of billed 80% of billed N/A 80335 80% of billed 80% of billed N/A80051 80% of billed 80% of billed N/A 80336 80% of billed 80% of billed N/A80053 80% of billed 80% of billed N/A 80337 80% of billed 80% of billed N/A80055 80% of billed 80% of billed N/A 80338 80% of billed 80% of billed N/A80061 80% of billed 80% of billed N/A 80339 80% of billed 80% of billed N/A80069 80% of billed 80% of billed N/A 80340 80% of billed 80% of billed N/A80074 80% of billed 80% of billed N/A 80341 80% of billed 80% of billed N/A80076 80% of billed 80% of billed N/A 80342 80% of billed 80% of billed N/A80081 80% of billed 80% of billed N/A 80343 80% of billed 80% of billed N/A80150 80% of billed 80% of billed N/A 80344 80% of billed 80% of billed N/A80155 80% of billed 80% of billed N/A 80345 80% of billed 80% of billed N/A80156 80% of billed 80% of billed N/A 80346 $54.59 $54.59 N/A80157 80% of billed 80% of billed N/A 80347 80% of billed 80% of billed N/A80158 80% of billed 80% of billed N/A 80348 80% of billed 80% of billed N/A80159 80% of billed 80% of billed N/A 80349 80% of billed 80% of billed N/A80162 80% of billed 80% of billed N/A 80350 80% of billed 80% of billed N/A80163 80% of billed 80% of billed N/A 80351 80% of billed 80% of billed N/A80164 80% of billed 80% of billed N/A 80352 80% of billed 80% of billed N/A80165 80% of billed 80% of billed N/A 80353 $44.29 $44.29 N/A80168 80% of billed 80% of billed N/A 80354 80% of billed 80% of billed N/A80169 80% of billed 80% of billed N/A 80355 80% of billed 80% of billed N/A80170 80% of billed 80% of billed N/A 80356 80% of billed 80% of billed N/A80171 80% of billed 80% of billed N/A 80357 80% of billed 80% of billed N/A80173 80% of billed 80% of billed N/A 80358 $56.65 $56.65 N/A80175 80% of billed 80% of billed N/A 80359 80% of billed 80% of billed N/A80176 80% of billed 80% of billed N/A 80360 80% of billed 80% of billed N/A80177 80% of billed 80% of billed N/A 80361 80% of billed 80% of billed N/A80178 80% of billed 80% of billed N/A 80362 80% of billed 80% of billed N/A80180 80% of billed 80% of billed N/A 80363 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 59 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

80364 80% of billed 80% of billed N/A 81214 80% of billed 80% of billed N/A80365 80% of billed 80% of billed N/A 81215 80% of billed 80% of billed N/A80366 80% of billed 80% of billed N/A 81216 80% of billed 80% of billed N/A80367 80% of billed 80% of billed N/A 81217 80% of billed 80% of billed N/A80368 80% of billed 80% of billed N/A 81218 80% of billed 80% of billed N/A80369 80% of billed 80% of billed N/A 81219 80% of billed 80% of billed N/A80370 80% of billed 80% of billed N/A 81220 80% of billed 80% of billed N/A80371 80% of billed 80% of billed N/A 81221 80% of billed 80% of billed N/A80372 80% of billed 80% of billed N/A 81222 80% of billed 80% of billed N/A80373 80% of billed 80% of billed N/A 81223 80% of billed 80% of billed N/A80374 80% of billed 80% of billed N/A 81224 80% of billed 80% of billed N/A80375 80% of billed 80% of billed N/A 81225 80% of billed 80% of billed N/A80376 80% of billed 80% of billed N/A 81226 80% of billed 80% of billed N/A80377 80% of billed 80% of billed N/A 81227 80% of billed 80% of billed N/A80400 80% of billed 80% of billed N/A 81228 80% of billed 80% of billed N/A80402 80% of billed 80% of billed N/A 81229 80% of billed 80% of billed N/A80406 80% of billed 80% of billed N/A 81235 80% of billed 80% of billed N/A80408 80% of billed 80% of billed N/A 81240 80% of billed 80% of billed N/A80410 80% of billed 80% of billed N/A 81241 80% of billed 80% of billed N/A80412 80% of billed 80% of billed N/A 81242 80% of billed 80% of billed N/A80414 80% of billed 80% of billed N/A 81243 80% of billed 80% of billed N/A80415 80% of billed 80% of billed N/A 81244 80% of billed 80% of billed N/A80416 80% of billed 80% of billed N/A 81245 80% of billed 80% of billed N/A80417 80% of billed 80% of billed N/A 81246 80% of billed 80% of billed N/A80418 80% of billed 80% of billed N/A 81250 80% of billed 80% of billed N/A80420 80% of billed 80% of billed N/A 81251 80% of billed 80% of billed N/A80422 80% of billed 80% of billed N/A 81252 80% of billed 80% of billed N/A80424 80% of billed 80% of billed N/A 81253 80% of billed 80% of billed N/A80426 80% of billed 80% of billed N/A 81254 80% of billed 80% of billed N/A80428 80% of billed 80% of billed N/A 81255 80% of billed 80% of billed N/A80430 80% of billed 80% of billed N/A 81256 80% of billed 80% of billed N/A80432 80% of billed 80% of billed N/A 81257 80% of billed 80% of billed N/A80434 80% of billed 80% of billed N/A 81260 80% of billed 80% of billed N/A80435 80% of billed 80% of billed N/A 81261 80% of billed 80% of billed N/A80436 80% of billed 80% of billed N/A 81262 80% of billed 80% of billed N/A80438 80% of billed 80% of billed N/A 81263 80% of billed 80% of billed N/A80439 80% of billed 80% of billed N/A 81264 80% of billed 80% of billed N/A80500 $38.00 $32.81 N/A 81265 80% of billed 80% of billed N/A80502 $120.32 $115.72 N/A 81266 80% of billed 80% of billed N/A81000 80% of billed 80% of billed N/A 81267 80% of billed 80% of billed N/A81001 80% of billed 80% of billed N/A 81268 80% of billed 80% of billed N/A81002 80% of billed 80% of billed N/A 81270 80% of billed 80% of billed N/A81003 $15.45 $15.45 N/A 81272 80% of billed 80% of billed N/A81005 $6.18 $6.18 N/A 81273 80% of billed 80% of billed N/A81007 80% of billed 80% of billed N/A 81275 80% of billed 80% of billed N/A81015 80% of billed 80% of billed N/A 81276 80% of billed 80% of billed N/A81020 80% of billed 80% of billed N/A 81287 80% of billed 80% of billed N/A81025 80% of billed 80% of billed N/A 81288 80% of billed 80% of billed N/A81050 80% of billed 80% of billed N/A 81290 80% of billed 80% of billed N/A81099 80% of billed 80% of billed N/A 81291 80% of billed 80% of billed N/A81161 80% of billed 80% of billed N/A 81292 80% of billed 80% of billed N/A81162 80% of billed 80% of billed N/A 81293 80% of billed 80% of billed N/A81170 80% of billed 80% of billed N/A 81294 80% of billed 80% of billed N/A81200 80% of billed 80% of billed N/A 81295 80% of billed 80% of billed N/A81201 80% of billed 80% of billed N/A 81296 80% of billed 80% of billed N/A81202 80% of billed 80% of billed N/A 81297 80% of billed 80% of billed N/A81203 80% of billed 80% of billed N/A 81298 80% of billed 80% of billed N/A81205 80% of billed 80% of billed N/A 81299 80% of billed 80% of billed N/A81206 80% of billed 80% of billed N/A 81300 80% of billed 80% of billed N/A81207 80% of billed 80% of billed N/A 81301 80% of billed 80% of billed N/A81208 80% of billed 80% of billed N/A 81302 80% of billed 80% of billed N/A81209 80% of billed 80% of billed N/A 81303 80% of billed 80% of billed N/A81210 80% of billed 80% of billed N/A 81304 80% of billed 80% of billed N/A81211 80% of billed 80% of billed N/A 81310 80% of billed 80% of billed N/A81212 80% of billed 80% of billed N/A 81311 80% of billed 80% of billed N/A81213 80% of billed 80% of billed N/A 81313 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 60 of 84

Page 61: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

81314 80% of billed 80% of billed N/A 81439 80% of billed 80% of billed N/A81315 80% of billed 80% of billed N/A 81440 80% of billed 80% of billed N/A81316 80% of billed 80% of billed N/A 81442 80% of billed 80% of billed N/A81317 80% of billed 80% of billed N/A 81445 80% of billed 80% of billed N/A81318 80% of billed 80% of billed N/A 81450 80% of billed 80% of billed N/A81319 80% of billed 80% of billed N/A 81455 80% of billed 80% of billed N/A81321 80% of billed 80% of billed N/A 81460 80% of billed 80% of billed N/A81322 80% of billed 80% of billed N/A 81465 80% of billed 80% of billed N/A81323 80% of billed 80% of billed N/A 81470 80% of billed 80% of billed N/A81324 80% of billed 80% of billed N/A 81471 80% of billed 80% of billed N/A81325 80% of billed 80% of billed N/A 81479 80% of billed 80% of billed N/A81326 80% of billed 80% of billed N/A 81490 80% of billed 80% of billed N/A81327 80% of billed 80% of billed N/A 81493 80% of billed 80% of billed N/A81330 80% of billed 80% of billed N/A 81500 80% of billed 80% of billed N/A81331 80% of billed 80% of billed N/A 81503 80% of billed 80% of billed N/A81332 80% of billed 80% of billed N/A 81504 80% of billed 80% of billed N/A81340 80% of billed 80% of billed N/A 81506 80% of billed 80% of billed N/A81341 80% of billed 80% of billed N/A 81507 80% of billed 80% of billed N/A81342 80% of billed 80% of billed N/A 81508 80% of billed 80% of billed N/A81350 80% of billed 80% of billed N/A 81509 80% of billed 80% of billed N/A81355 80% of billed 80% of billed N/A 81510 80% of billed 80% of billed N/A81370 80% of billed 80% of billed N/A 81511 80% of billed 80% of billed N/A81371 80% of billed 80% of billed N/A 81512 80% of billed 80% of billed N/A81372 80% of billed 80% of billed N/A 81519 80% of billed 80% of billed N/A81373 80% of billed 80% of billed N/A 81525 80% of billed 80% of billed N/A81374 80% of billed 80% of billed N/A 81528 80% of billed 80% of billed N/A81375 80% of billed 80% of billed N/A 81535 80% of billed 80% of billed N/A81376 80% of billed 80% of billed N/A 81536 80% of billed 80% of billed N/A81377 80% of billed 80% of billed N/A 81538 80% of billed 80% of billed N/A81378 80% of billed 80% of billed N/A 81539 80% of billed 80% of billed N/A81379 80% of billed 80% of billed N/A 81540 80% of billed 80% of billed N/A81380 80% of billed 80% of billed N/A 81545 80% of billed 80% of billed N/A81381 80% of billed 80% of billed N/A 81595 80% of billed 80% of billed N/A81382 80% of billed 80% of billed N/A 81599 80% of billed 80% of billed N/A81383 80% of billed 80% of billed N/A 82009 80% of billed 80% of billed N/A81400 80% of billed 80% of billed N/A 82010 80% of billed 80% of billed N/A81401 80% of billed 80% of billed N/A 82013 80% of billed 80% of billed N/A81402 80% of billed 80% of billed N/A 82016 80% of billed 80% of billed N/A81403 80% of billed 80% of billed N/A 82017 80% of billed 80% of billed N/A81404 80% of billed 80% of billed N/A 82024 80% of billed 80% of billed N/A81405 80% of billed 80% of billed N/A 82030 80% of billed 80% of billed N/A81406 80% of billed 80% of billed N/A 82040 80% of billed 80% of billed N/A81407 80% of billed 80% of billed N/A 82042 80% of billed 80% of billed N/A81408 80% of billed 80% of billed N/A 82043 80% of billed 80% of billed N/A81410 80% of billed 80% of billed N/A 82044 80% of billed 80% of billed N/A81411 80% of billed 80% of billed N/A 82045 80% of billed 80% of billed N/A81412 80% of billed 80% of billed N/A 82075 80% of billed 80% of billed N/A81413 80% of billed 80% of billed N/A 82085 80% of billed 80% of billed N/A81414 80% of billed 80% of billed N/A 82088 80% of billed 80% of billed N/A81415 80% of billed 80% of billed N/A 82103 80% of billed 80% of billed N/A81416 80% of billed 80% of billed N/A 82104 80% of billed 80% of billed N/A81417 80% of billed 80% of billed N/A 82105 80% of billed 80% of billed N/A81420 80% of billed 80% of billed N/A 82106 80% of billed 80% of billed N/A81422 80% of billed 80% of billed N/A 82107 80% of billed 80% of billed N/A81425 80% of billed 80% of billed N/A 82108 80% of billed 80% of billed N/A81426 80% of billed 80% of billed N/A 82120 80% of billed 80% of billed N/A81427 80% of billed 80% of billed N/A 82127 80% of billed 80% of billed N/A81430 80% of billed 80% of billed N/A 82128 80% of billed 80% of billed N/A81431 80% of billed 80% of billed N/A 82131 80% of billed 80% of billed N/A81432 80% of billed 80% of billed N/A 82135 80% of billed 80% of billed N/A81433 80% of billed 80% of billed N/A 82136 80% of billed 80% of billed N/A81434 80% of billed 80% of billed N/A 82139 80% of billed 80% of billed N/A81435 80% of billed 80% of billed N/A 82140 80% of billed 80% of billed N/A81436 80% of billed 80% of billed N/A 82143 80% of billed 80% of billed N/A81437 80% of billed 80% of billed N/A 82150 80% of billed 80% of billed N/A81438 80% of billed 80% of billed N/A 82154 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 61 of 84

Page 62: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

82157 80% of billed 80% of billed N/A 82565 80% of billed 80% of billed N/A82160 80% of billed 80% of billed N/A 82570 $19.57 $19.57 N/A82163 80% of billed 80% of billed N/A 82575 80% of billed 80% of billed N/A82164 80% of billed 80% of billed N/A 82585 80% of billed 80% of billed N/A82172 80% of billed 80% of billed N/A 82595 80% of billed 80% of billed N/A82175 80% of billed 80% of billed N/A 82600 80% of billed 80% of billed N/A82180 80% of billed 80% of billed N/A 82607 80% of billed 80% of billed N/A82190 80% of billed 80% of billed N/A 82608 80% of billed 80% of billed N/A82232 80% of billed 80% of billed N/A 82610 80% of billed 80% of billed N/A82239 80% of billed 80% of billed N/A 82615 80% of billed 80% of billed N/A82240 80% of billed 80% of billed N/A 82626 80% of billed 80% of billed N/A82247 80% of billed 80% of billed N/A 82627 80% of billed 80% of billed N/A82248 80% of billed 80% of billed N/A 82633 80% of billed 80% of billed N/A82252 80% of billed 80% of billed N/A 82634 80% of billed 80% of billed N/A82261 80% of billed 80% of billed N/A 82638 80% of billed 80% of billed N/A82270 80% of billed 80% of billed N/A 82652 80% of billed 80% of billed N/A82271 80% of billed 80% of billed N/A 82656 80% of billed 80% of billed N/A82272 80% of billed 80% of billed N/A 82657 80% of billed 80% of billed N/A82274 80% of billed 80% of billed N/A 82658 80% of billed 80% of billed N/A82286 80% of billed 80% of billed N/A 82664 80% of billed 80% of billed N/A82300 80% of billed 80% of billed N/A 82668 80% of billed 80% of billed N/A82306 80% of billed 80% of billed N/A 82670 80% of billed 80% of billed N/A82308 80% of billed 80% of billed N/A 82671 80% of billed 80% of billed N/A82310 80% of billed 80% of billed N/A 82672 80% of billed 80% of billed N/A82330 80% of billed 80% of billed N/A 82677 80% of billed 80% of billed N/A82331 80% of billed 80% of billed N/A 82679 80% of billed 80% of billed N/A82340 80% of billed 80% of billed N/A 82693 80% of billed 80% of billed N/A82355 80% of billed 80% of billed N/A 82696 80% of billed 80% of billed N/A82360 80% of billed 80% of billed N/A 82705 80% of billed 80% of billed N/A82365 80% of billed 80% of billed N/A 82710 80% of billed 80% of billed N/A82370 80% of billed 80% of billed N/A 82715 80% of billed 80% of billed N/A82373 80% of billed 80% of billed N/A 82725 80% of billed 80% of billed N/A82374 80% of billed 80% of billed N/A 82726 80% of billed 80% of billed N/A82375 80% of billed 80% of billed N/A 82728 80% of billed 80% of billed N/A82376 80% of billed 80% of billed N/A 82731 80% of billed 80% of billed N/A82378 80% of billed 80% of billed N/A 82735 80% of billed 80% of billed N/A82379 80% of billed 80% of billed N/A 82746 80% of billed 80% of billed N/A82380 80% of billed 80% of billed N/A 82747 80% of billed 80% of billed N/A82382 80% of billed 80% of billed N/A 82757 80% of billed 80% of billed N/A82383 80% of billed 80% of billed N/A 82759 80% of billed 80% of billed N/A82384 80% of billed 80% of billed N/A 82760 80% of billed 80% of billed N/A82387 80% of billed 80% of billed N/A 82775 80% of billed 80% of billed N/A82390 80% of billed 80% of billed N/A 82776 80% of billed 80% of billed N/A82397 80% of billed 80% of billed N/A 82777 80% of billed 80% of billed N/A82415 80% of billed 80% of billed N/A 82784 80% of billed 80% of billed N/A82435 80% of billed 80% of billed N/A 82785 80% of billed 80% of billed N/A82436 80% of billed 80% of billed N/A 82787 80% of billed 80% of billed N/A82438 80% of billed 80% of billed N/A 82800 80% of billed 80% of billed N/A82441 80% of billed 80% of billed N/A 82803 80% of billed 80% of billed N/A82465 80% of billed 80% of billed N/A 82805 80% of billed 80% of billed N/A82480 80% of billed 80% of billed N/A 82810 80% of billed 80% of billed N/A82482 80% of billed 80% of billed N/A 82820 80% of billed 80% of billed N/A82485 80% of billed 80% of billed N/A 82930 80% of billed 80% of billed N/A82495 80% of billed 80% of billed N/A 82938 80% of billed 80% of billed N/A82507 80% of billed 80% of billed N/A 82941 80% of billed 80% of billed N/A82523 80% of billed 80% of billed N/A 82943 80% of billed 80% of billed N/A82525 80% of billed 80% of billed N/A 82945 80% of billed 80% of billed N/A82528 80% of billed 80% of billed N/A 82946 80% of billed 80% of billed N/A82530 80% of billed 80% of billed N/A 82947 80% of billed 80% of billed N/A82533 80% of billed 80% of billed N/A 82948 80% of billed 80% of billed N/A82540 80% of billed 80% of billed N/A 82950 80% of billed 80% of billed N/A82542 80% of billed 80% of billed N/A 82951 80% of billed 80% of billed N/A82550 80% of billed 80% of billed N/A 82952 80% of billed 80% of billed N/A82552 80% of billed 80% of billed N/A 82955 80% of billed 80% of billed N/A82553 80% of billed 80% of billed N/A 82960 80% of billed 80% of billed N/A82554 80% of billed 80% of billed N/A 82962 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 62 of 84

Page 63: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

82963 80% of billed 80% of billed N/A 83663 80% of billed 80% of billed N/A82965 80% of billed 80% of billed N/A 83664 80% of billed 80% of billed N/A82977 80% of billed 80% of billed N/A 83670 80% of billed 80% of billed N/A82978 80% of billed 80% of billed N/A 83690 80% of billed 80% of billed N/A82979 80% of billed 80% of billed N/A 83695 80% of billed 80% of billed N/A82985 80% of billed 80% of billed N/A 83698 80% of billed 80% of billed N/A83001 80% of billed 80% of billed N/A 83700 80% of billed 80% of billed N/A83002 80% of billed 80% of billed N/A 83701 80% of billed 80% of billed N/A83003 80% of billed 80% of billed N/A 83704 80% of billed 80% of billed N/A83006 80% of billed 80% of billed N/A 83718 80% of billed 80% of billed N/A83009 80% of billed 80% of billed N/A 83719 80% of billed 80% of billed N/A83010 80% of billed 80% of billed N/A 83721 80% of billed 80% of billed N/A83012 80% of billed 80% of billed N/A 83727 80% of billed 80% of billed N/A83013 80% of billed 80% of billed N/A 83735 80% of billed 80% of billed N/A83014 80% of billed 80% of billed N/A 83775 80% of billed 80% of billed N/A83015 80% of billed 80% of billed N/A 83785 80% of billed 80% of billed N/A83018 80% of billed 80% of billed N/A 83789 80% of billed 80% of billed N/A83020 80% of billed 80% of billed N/A 83825 80% of billed 80% of billed N/A83020 26 $29.94 $29.94 N/A 83835 80% of billed 80% of billed N/A83021 80% of billed 80% of billed N/A 83857 80% of billed 80% of billed N/A83026 80% of billed 80% of billed N/A 83861 80% of billed 80% of billed N/A83030 80% of billed 80% of billed N/A 83864 80% of billed 80% of billed N/A83033 80% of billed 80% of billed N/A 83872 80% of billed 80% of billed N/A83036 80% of billed 80% of billed N/A 83873 80% of billed 80% of billed N/A83037 80% of billed 80% of billed N/A 83874 80% of billed 80% of billed N/A83045 80% of billed 80% of billed N/A 83876 80% of billed 80% of billed N/A83050 80% of billed 80% of billed N/A 83880 80% of billed 80% of billed N/A83051 80% of billed 80% of billed N/A 83883 80% of billed 80% of billed N/A83060 80% of billed 80% of billed N/A 83885 80% of billed 80% of billed N/A83065 80% of billed 80% of billed N/A 83915 80% of billed 80% of billed N/A83068 80% of billed 80% of billed N/A 83916 80% of billed 80% of billed N/A83069 80% of billed 80% of billed N/A 83918 80% of billed 80% of billed N/A83070 80% of billed 80% of billed N/A 83919 80% of billed 80% of billed N/A83080 80% of billed 80% of billed N/A 83921 80% of billed 80% of billed N/A83088 80% of billed 80% of billed N/A 83930 80% of billed 80% of billed N/A83090 80% of billed 80% of billed N/A 83935 80% of billed 80% of billed N/A83150 80% of billed 80% of billed N/A 83937 80% of billed 80% of billed N/A83491 80% of billed 80% of billed N/A 83945 80% of billed 80% of billed N/A83497 80% of billed 80% of billed N/A 83950 80% of billed 80% of billed N/A83498 80% of billed 80% of billed N/A 83951 80% of billed 80% of billed N/A83499 80% of billed 80% of billed N/A 83970 80% of billed 80% of billed N/A83500 80% of billed 80% of billed N/A 83986 80% of billed 80% of billed N/A83505 80% of billed 80% of billed N/A 83987 80% of billed 80% of billed N/A83516 80% of billed 80% of billed N/A 83992 $37.08 $37.08 N/A83518 80% of billed 80% of billed N/A 83993 80% of billed 80% of billed N/A83519 80% of billed 80% of billed N/A 84030 80% of billed 80% of billed N/A83520 80% of billed 80% of billed N/A 84035 80% of billed 80% of billed N/A83525 80% of billed 80% of billed N/A 84060 80% of billed 80% of billed N/A83527 80% of billed 80% of billed N/A 84061 80% of billed 80% of billed N/A83528 80% of billed 80% of billed N/A 84066 80% of billed 80% of billed N/A83540 80% of billed 80% of billed N/A 84075 80% of billed 80% of billed N/A83550 80% of billed 80% of billed N/A 84078 80% of billed 80% of billed N/A83570 80% of billed 80% of billed N/A 84080 80% of billed 80% of billed N/A83582 80% of billed 80% of billed N/A 84081 80% of billed 80% of billed N/A83586 80% of billed 80% of billed N/A 84085 80% of billed 80% of billed N/A83593 80% of billed 80% of billed N/A 84087 80% of billed 80% of billed N/A83605 80% of billed 80% of billed N/A 84100 80% of billed 80% of billed N/A83615 80% of billed 80% of billed N/A 84105 80% of billed 80% of billed N/A83625 80% of billed 80% of billed N/A 84106 80% of billed 80% of billed N/A83630 80% of billed 80% of billed N/A 84110 80% of billed 80% of billed N/A83631 80% of billed 80% of billed N/A 84112 80% of billed 80% of billed N/A83632 80% of billed 80% of billed N/A 84119 80% of billed 80% of billed N/A83633 80% of billed 80% of billed N/A 84120 80% of billed 80% of billed N/A83655 80% of billed 80% of billed N/A 84126 80% of billed 80% of billed N/A83661 80% of billed 80% of billed N/A 84132 80% of billed 80% of billed N/A83662 80% of billed 80% of billed N/A 84133 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 63 of 84

Page 64: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

84134 80% of billed 80% of billed N/A 84442 80% of billed 80% of billed N/A84135 80% of billed 80% of billed N/A 84443 80% of billed 80% of billed N/A84138 80% of billed 80% of billed N/A 84445 80% of billed 80% of billed N/A84140 80% of billed 80% of billed N/A 84446 80% of billed 80% of billed N/A84143 80% of billed 80% of billed N/A 84449 80% of billed 80% of billed N/A84144 80% of billed 80% of billed N/A 84450 80% of billed 80% of billed N/A84145 80% of billed 80% of billed N/A 84460 80% of billed 80% of billed N/A84146 80% of billed 80% of billed N/A 84466 80% of billed 80% of billed N/A84150 80% of billed 80% of billed N/A 84478 80% of billed 80% of billed N/A84152 80% of billed 80% of billed N/A 84479 80% of billed 80% of billed N/A84153 80% of billed 80% of billed N/A 84480 80% of billed 80% of billed N/A84154 80% of billed 80% of billed N/A 84481 80% of billed 80% of billed N/A84155 80% of billed 80% of billed N/A 84482 80% of billed 80% of billed N/A84156 80% of billed 80% of billed N/A 84484 80% of billed 80% of billed N/A84157 80% of billed 80% of billed N/A 84485 80% of billed 80% of billed N/A84160 80% of billed 80% of billed N/A 84488 80% of billed 80% of billed N/A84163 80% of billed 80% of billed N/A 84490 80% of billed 80% of billed N/A84165 80% of billed 80% of billed N/A 84510 80% of billed 80% of billed N/A84165 26 $29.94 $29.94 N/A 84512 80% of billed 80% of billed N/A84166 80% of billed 80% of billed N/A 84520 80% of billed 80% of billed N/A84166 26 $29.94 $29.94 N/A 84525 80% of billed 80% of billed N/A84181 80% of billed 80% of billed N/A 84540 80% of billed 80% of billed N/A84181 26 $29.94 $29.94 N/A 84545 80% of billed 80% of billed N/A84182 80% of billed 80% of billed N/A 84550 80% of billed 80% of billed N/A84182 26 $29.94 $29.94 N/A 84560 80% of billed 80% of billed N/A84202 80% of billed 80% of billed N/A 84577 80% of billed 80% of billed N/A84203 80% of billed 80% of billed N/A 84578 80% of billed 80% of billed N/A84206 80% of billed 80% of billed N/A 84580 80% of billed 80% of billed N/A84207 80% of billed 80% of billed N/A 84583 80% of billed 80% of billed N/A84210 80% of billed 80% of billed N/A 84585 80% of billed 80% of billed N/A84220 80% of billed 80% of billed N/A 84586 80% of billed 80% of billed N/A84228 80% of billed 80% of billed N/A 84588 80% of billed 80% of billed N/A84233 80% of billed 80% of billed N/A 84590 80% of billed 80% of billed N/A84234 80% of billed 80% of billed N/A 84591 80% of billed 80% of billed N/A84235 80% of billed 80% of billed N/A 84597 80% of billed 80% of billed N/A84238 80% of billed 80% of billed N/A 84600 80% of billed 80% of billed N/A84244 80% of billed 80% of billed N/A 84620 80% of billed 80% of billed N/A84252 80% of billed 80% of billed N/A 84630 80% of billed 80% of billed N/A84255 80% of billed 80% of billed N/A 84681 80% of billed 80% of billed N/A84260 80% of billed 80% of billed N/A 84702 80% of billed 80% of billed N/A84270 80% of billed 80% of billed N/A 84703 80% of billed 80% of billed N/A84275 80% of billed 80% of billed N/A 84704 80% of billed 80% of billed N/A84285 80% of billed 80% of billed N/A 84830 80% of billed 80% of billed N/A84295 80% of billed 80% of billed N/A 84999 80% of billed 80% of billed N/A84300 80% of billed 80% of billed N/A 85002 80% of billed 80% of billed N/A84302 80% of billed 80% of billed N/A 85004 80% of billed 80% of billed N/A84305 80% of billed 80% of billed N/A 85007 80% of billed 80% of billed N/A84307 80% of billed 80% of billed N/A 85008 80% of billed 80% of billed N/A84311 80% of billed 80% of billed N/A 85009 80% of billed 80% of billed N/A84315 80% of billed 80% of billed N/A 85013 80% of billed 80% of billed N/A84375 80% of billed 80% of billed N/A 85014 80% of billed 80% of billed N/A84376 80% of billed 80% of billed N/A 85018 80% of billed 80% of billed N/A84377 80% of billed 80% of billed N/A 85025 80% of billed 80% of billed N/A84378 80% of billed 80% of billed N/A 85027 80% of billed 80% of billed N/A84379 80% of billed 80% of billed N/A 85032 80% of billed 80% of billed N/A84392 80% of billed 80% of billed N/A 85041 80% of billed 80% of billed N/A84402 80% of billed 80% of billed N/A 85044 80% of billed 80% of billed N/A84403 80% of billed 80% of billed N/A 85045 80% of billed 80% of billed N/A84410 80% of billed 80% of billed N/A 85046 80% of billed 80% of billed N/A84425 80% of billed 80% of billed N/A 85048 80% of billed 80% of billed N/A84430 80% of billed 80% of billed N/A 85049 80% of billed 80% of billed N/A84431 80% of billed 80% of billed N/A 85055 80% of billed 80% of billed N/A84432 80% of billed 80% of billed N/A 85060 $40.87 $40.87 N/A84436 80% of billed 80% of billed N/A 85097 $147.95 $82.33 N/A84437 80% of billed 80% of billed N/A 85130 80% of billed 80% of billed N/A84439 80% of billed 80% of billed N/A 85170 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 64 of 84

Page 65: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

85175 80% of billed 80% of billed N/A 85611 80% of billed 80% of billed N/A85210 80% of billed 80% of billed N/A 85612 80% of billed 80% of billed N/A85220 80% of billed 80% of billed N/A 85613 80% of billed 80% of billed N/A85230 80% of billed 80% of billed N/A 85635 80% of billed 80% of billed N/A85240 80% of billed 80% of billed N/A 85651 80% of billed 80% of billed N/A85244 80% of billed 80% of billed N/A 85652 80% of billed 80% of billed N/A85245 80% of billed 80% of billed N/A 85660 80% of billed 80% of billed N/A85246 80% of billed 80% of billed N/A 85670 80% of billed 80% of billed N/A85247 80% of billed 80% of billed N/A 85675 80% of billed 80% of billed N/A85250 80% of billed 80% of billed N/A 85705 80% of billed 80% of billed N/A85260 80% of billed 80% of billed N/A 85730 80% of billed 80% of billed N/A85270 80% of billed 80% of billed N/A 85732 80% of billed 80% of billed N/A85280 80% of billed 80% of billed N/A 85810 80% of billed 80% of billed N/A85290 80% of billed 80% of billed N/A 85999 80% of billed 80% of billed N/A85291 80% of billed 80% of billed N/A 86000 80% of billed 80% of billed N/A85292 80% of billed 80% of billed N/A 86001 80% of billed 80% of billed N/A85293 80% of billed 80% of billed N/A 86003 80% of billed 80% of billed N/A85300 80% of billed 80% of billed N/A 86005 80% of billed 80% of billed N/A85301 80% of billed 80% of billed N/A 86021 80% of billed 80% of billed N/A85302 80% of billed 80% of billed N/A 86022 80% of billed 80% of billed N/A85303 80% of billed 80% of billed N/A 86023 80% of billed 80% of billed N/A85305 80% of billed 80% of billed N/A 86038 80% of billed 80% of billed N/A85306 80% of billed 80% of billed N/A 86039 80% of billed 80% of billed N/A85307 80% of billed 80% of billed N/A 86060 80% of billed 80% of billed N/A85335 80% of billed 80% of billed N/A 86063 80% of billed 80% of billed N/A85337 80% of billed 80% of billed N/A 86077 $92.11 $85.78 N/A85345 80% of billed 80% of billed N/A 86078 $92.11 $85.20 N/A85347 80% of billed 80% of billed N/A 86079 $91.54 $85.20 N/A85348 80% of billed 80% of billed N/A 86140 80% of billed 80% of billed N/A85360 80% of billed 80% of billed N/A 86141 80% of billed 80% of billed N/A85362 80% of billed 80% of billed N/A 86146 80% of billed 80% of billed N/A85366 80% of billed 80% of billed N/A 86147 80% of billed 80% of billed N/A85370 80% of billed 80% of billed N/A 86148 80% of billed 80% of billed N/A85378 80% of billed 80% of billed N/A 86152 80% of billed 80% of billed N/A85379 80% of billed 80% of billed N/A 86153 26 $56.42 $56.42 N/A85380 80% of billed 80% of billed N/A 86155 80% of billed 80% of billed N/A85384 80% of billed 80% of billed N/A 86156 80% of billed 80% of billed N/A85385 80% of billed 80% of billed N/A 86157 80% of billed 80% of billed N/A85390 80% of billed 80% of billed N/A 86160 80% of billed 80% of billed N/A85390 26 $29.94 $29.94 N/A 86161 80% of billed 80% of billed N/A85396 $33.97 $33.97 N/A 86162 80% of billed 80% of billed N/A85397 80% of billed 80% of billed N/A 86171 80% of billed 80% of billed N/A85400 80% of billed 80% of billed N/A 86185 80% of billed 80% of billed N/A85410 80% of billed 80% of billed N/A 86200 80% of billed 80% of billed N/A85415 80% of billed 80% of billed N/A 86215 80% of billed 80% of billed N/A85420 80% of billed 80% of billed N/A 86225 80% of billed 80% of billed N/A85421 80% of billed 80% of billed N/A 86226 80% of billed 80% of billed N/A85441 80% of billed 80% of billed N/A 86235 80% of billed 80% of billed N/A85445 80% of billed 80% of billed N/A 86243 80% of billed 80% of billed N/A85460 80% of billed 80% of billed N/A 86255 80% of billed 80% of billed N/A85461 80% of billed 80% of billed N/A 86255 26 $29.94 $29.94 N/A85475 80% of billed 80% of billed N/A 86256 80% of billed 80% of billed N/A85520 80% of billed 80% of billed N/A 86256 26 $29.94 $29.94 N/A85525 80% of billed 80% of billed N/A 86277 80% of billed 80% of billed N/A85530 80% of billed 80% of billed N/A 86280 80% of billed 80% of billed N/A85536 80% of billed 80% of billed N/A 86294 80% of billed 80% of billed N/A85540 80% of billed 80% of billed N/A 86300 80% of billed 80% of billed N/A85547 80% of billed 80% of billed N/A 86301 80% of billed 80% of billed N/A85549 80% of billed 80% of billed N/A 86304 80% of billed 80% of billed N/A85555 80% of billed 80% of billed N/A 86305 80% of billed 80% of billed N/A85557 80% of billed 80% of billed N/A 86308 80% of billed 80% of billed N/A85576 80% of billed 80% of billed N/A 86309 80% of billed 80% of billed N/A85576 26 $29.94 $29.94 N/A 86310 80% of billed 80% of billed N/A85597 80% of billed 80% of billed N/A 86316 80% of billed 80% of billed N/A85598 80% of billed 80% of billed N/A 86317 80% of billed 80% of billed N/A85610 80% of billed 80% of billed N/A 86318 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 65 of 84

Page 66: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

86320 80% of billed 80% of billed N/A 86645 80% of billed 80% of billed N/A86320 26 $29.94 $29.94 N/A 86648 80% of billed 80% of billed N/A86325 80% of billed 80% of billed N/A 86651 80% of billed 80% of billed N/A86325 26 $29.94 $29.94 N/A 86652 80% of billed 80% of billed N/A86327 80% of billed 80% of billed N/A 86653 80% of billed 80% of billed N/A86327 26 $33.97 $33.97 N/A 86654 80% of billed 80% of billed N/A86329 80% of billed 80% of billed N/A 86658 80% of billed 80% of billed N/A86331 80% of billed 80% of billed N/A 86663 80% of billed 80% of billed N/A86332 80% of billed 80% of billed N/A 86664 80% of billed 80% of billed N/A86334 80% of billed 80% of billed N/A 86665 80% of billed 80% of billed N/A86334 26 $29.94 $29.94 N/A 86666 80% of billed 80% of billed N/A86335 80% of billed 80% of billed N/A 86668 80% of billed 80% of billed N/A86335 26 $29.94 $29.94 N/A 86671 80% of billed 80% of billed N/A86336 80% of billed 80% of billed N/A 86674 80% of billed 80% of billed N/A86337 80% of billed 80% of billed N/A 86677 80% of billed 80% of billed N/A86340 80% of billed 80% of billed N/A 86682 80% of billed 80% of billed N/A86341 80% of billed 80% of billed N/A 86684 80% of billed 80% of billed N/A86343 80% of billed 80% of billed N/A 86687 80% of billed 80% of billed N/A86344 80% of billed 80% of billed N/A 86688 80% of billed 80% of billed N/A86352 80% of billed 80% of billed N/A 86689 80% of billed 80% of billed N/A86353 80% of billed 80% of billed N/A 86692 80% of billed 80% of billed N/A86355 80% of billed 80% of billed N/A 86694 80% of billed 80% of billed N/A86356 80% of billed 80% of billed N/A 86695 80% of billed 80% of billed N/A86357 80% of billed 80% of billed N/A 86696 80% of billed 80% of billed N/A86359 80% of billed 80% of billed N/A 86698 80% of billed 80% of billed N/A86360 80% of billed 80% of billed N/A 86701 80% of billed 80% of billed N/A86361 80% of billed 80% of billed N/A 86702 80% of billed 80% of billed N/A86367 80% of billed 80% of billed N/A 86703 80% of billed 80% of billed N/A86376 80% of billed 80% of billed N/A 86704 80% of billed 80% of billed N/A86378 80% of billed 80% of billed N/A 86705 80% of billed 80% of billed N/A86382 80% of billed 80% of billed N/A 86706 80% of billed 80% of billed N/A86384 80% of billed 80% of billed N/A 86707 80% of billed 80% of billed N/A86386 80% of billed 80% of billed N/A 86708 80% of billed 80% of billed N/A86403 80% of billed 80% of billed N/A 86709 80% of billed 80% of billed N/A86406 80% of billed 80% of billed N/A 86710 80% of billed 80% of billed N/A86430 80% of billed 80% of billed N/A 86711 80% of billed 80% of billed N/A86431 80% of billed 80% of billed N/A 86713 80% of billed 80% of billed N/A86480 80% of billed 80% of billed N/A 86717 80% of billed 80% of billed N/A86481 80% of billed 80% of billed N/A 86720 80% of billed 80% of billed N/A86485 80% of billed 80% of billed N/A 86723 80% of billed 80% of billed N/A86486 $8.06 $8.06 N/A 86727 80% of billed 80% of billed N/A86490 $118.59 $118.59 N/A 86729 80% of billed 80% of billed N/A86510 $9.79 $9.79 N/A 86732 80% of billed 80% of billed N/A86580 $13.24 $13.24 N/A 86735 80% of billed 80% of billed N/A86590 80% of billed 80% of billed N/A 86738 80% of billed 80% of billed N/A86592 80% of billed 80% of billed N/A 86741 80% of billed 80% of billed N/A86593 80% of billed 80% of billed N/A 86744 80% of billed 80% of billed N/A86602 80% of billed 80% of billed N/A 86747 80% of billed 80% of billed N/A86603 80% of billed 80% of billed N/A 86750 80% of billed 80% of billed N/A86606 80% of billed 80% of billed N/A 86753 80% of billed 80% of billed N/A86609 80% of billed 80% of billed N/A 86756 80% of billed 80% of billed N/A86611 80% of billed 80% of billed N/A 86757 80% of billed 80% of billed N/A86612 80% of billed 80% of billed N/A 86759 80% of billed 80% of billed N/A86615 80% of billed 80% of billed N/A 86762 80% of billed 80% of billed N/A86617 80% of billed 80% of billed N/A 86765 80% of billed 80% of billed N/A86618 80% of billed 80% of billed N/A 86768 80% of billed 80% of billed N/A86619 80% of billed 80% of billed N/A 86771 80% of billed 80% of billed N/A86622 80% of billed 80% of billed N/A 86774 80% of billed 80% of billed N/A86625 80% of billed 80% of billed N/A 86777 80% of billed 80% of billed N/A86628 80% of billed 80% of billed N/A 86778 80% of billed 80% of billed N/A86631 80% of billed 80% of billed N/A 86780 80% of billed 80% of billed N/A86632 80% of billed 80% of billed N/A 86784 80% of billed 80% of billed N/A86635 80% of billed 80% of billed N/A 86787 80% of billed 80% of billed N/A86638 80% of billed 80% of billed N/A 86788 80% of billed 80% of billed N/A86641 80% of billed 80% of billed N/A 86789 80% of billed 80% of billed N/A86644 80% of billed 80% of billed N/A 86790 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 66 of 84

Page 67: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

86793 80% of billed 80% of billed N/A 87040 80% of billed 80% of billed N/A86800 80% of billed 80% of billed N/A 87045 80% of billed 80% of billed N/A86803 80% of billed 80% of billed N/A 87046 80% of billed 80% of billed N/A86804 80% of billed 80% of billed N/A 87070 80% of billed 80% of billed N/A86805 80% of billed 80% of billed N/A 87071 80% of billed 80% of billed N/A86806 80% of billed 80% of billed N/A 87073 80% of billed 80% of billed N/A86807 80% of billed 80% of billed N/A 87075 80% of billed 80% of billed N/A86808 80% of billed 80% of billed N/A 87076 80% of billed 80% of billed N/A86812 80% of billed 80% of billed N/A 87077 80% of billed 80% of billed N/A86813 80% of billed 80% of billed N/A 87081 80% of billed 80% of billed N/A86816 80% of billed 80% of billed N/A 87084 80% of billed 80% of billed N/A86817 80% of billed 80% of billed N/A 87086 80% of billed 80% of billed N/A86821 80% of billed 80% of billed N/A 87088 80% of billed 80% of billed N/A86822 80% of billed 80% of billed N/A 87101 80% of billed 80% of billed N/A86825 80% of billed 80% of billed N/A 87102 80% of billed 80% of billed N/A86826 80% of billed 80% of billed N/A 87103 80% of billed 80% of billed N/A86828 80% of billed 80% of billed N/A 87106 80% of billed 80% of billed N/A86829 80% of billed 80% of billed N/A 87107 80% of billed 80% of billed N/A86830 80% of billed 80% of billed N/A 87109 80% of billed 80% of billed N/A86831 80% of billed 80% of billed N/A 87110 80% of billed 80% of billed N/A86832 80% of billed 80% of billed N/A 87116 80% of billed 80% of billed N/A86833 80% of billed 80% of billed N/A 87118 80% of billed 80% of billed N/A86834 80% of billed 80% of billed N/A 87140 80% of billed 80% of billed N/A86835 80% of billed 80% of billed N/A 87143 80% of billed 80% of billed N/A86849 80% of billed 80% of billed N/A 87147 80% of billed 80% of billed N/A86850 80% of billed 80% of billed N/A 87149 80% of billed 80% of billed N/A86860 80% of billed 80% of billed N/A 87150 80% of billed 80% of billed N/A86870 80% of billed 80% of billed N/A 87152 80% of billed 80% of billed N/A86880 80% of billed 80% of billed N/A 87153 80% of billed 80% of billed N/A86885 80% of billed 80% of billed N/A 87158 80% of billed 80% of billed N/A86886 80% of billed 80% of billed N/A 87164 80% of billed 80% of billed N/A86890 80% of billed 80% of billed N/A 87164 26 $29.94 $29.94 N/A86891 80% of billed 80% of billed N/A 87166 80% of billed 80% of billed N/A86900 80% of billed 80% of billed N/A 87168 80% of billed 80% of billed N/A86901 80% of billed 80% of billed N/A 87169 80% of billed 80% of billed N/A86902 80% of billed 80% of billed N/A 87172 80% of billed 80% of billed N/A86904 80% of billed 80% of billed N/A 87176 80% of billed 80% of billed N/A86905 80% of billed 80% of billed N/A 87177 80% of billed 80% of billed N/A86906 80% of billed 80% of billed N/A 87181 80% of billed 80% of billed N/A86910 80% of billed 80% of billed N/A 87184 80% of billed 80% of billed N/A86911 80% of billed 80% of billed N/A 87185 80% of billed 80% of billed N/A86920 80% of billed 80% of billed N/A 87186 80% of billed 80% of billed N/A86921 80% of billed 80% of billed N/A 87187 80% of billed 80% of billed N/A86922 80% of billed 80% of billed N/A 87188 80% of billed 80% of billed N/A86923 80% of billed 80% of billed N/A 87190 80% of billed 80% of billed N/A86927 80% of billed 80% of billed N/A 87197 80% of billed 80% of billed N/A86930 80% of billed 80% of billed N/A 87205 80% of billed 80% of billed N/A86931 80% of billed 80% of billed N/A 87206 80% of billed 80% of billed N/A86932 80% of billed 80% of billed N/A 87207 80% of billed 80% of billed N/A86940 80% of billed 80% of billed N/A 87207 26 $29.94 $29.94 N/A86941 80% of billed 80% of billed N/A 87209 80% of billed 80% of billed N/A86945 80% of billed 80% of billed N/A 87210 80% of billed 80% of billed N/A86950 80% of billed 80% of billed N/A 87220 80% of billed 80% of billed N/A86960 80% of billed 80% of billed N/A 87230 80% of billed 80% of billed N/A86965 80% of billed 80% of billed N/A 87250 80% of billed 80% of billed N/A86970 80% of billed 80% of billed N/A 87252 80% of billed 80% of billed N/A86971 80% of billed 80% of billed N/A 87253 80% of billed 80% of billed N/A86972 80% of billed 80% of billed N/A 87254 80% of billed 80% of billed N/A86975 80% of billed 80% of billed N/A 87255 80% of billed 80% of billed N/A86976 80% of billed 80% of billed N/A 87260 80% of billed 80% of billed N/A86977 80% of billed 80% of billed N/A 87265 80% of billed 80% of billed N/A86978 80% of billed 80% of billed N/A 87267 80% of billed 80% of billed N/A86985 80% of billed 80% of billed N/A 87269 80% of billed 80% of billed N/A86999 80% of billed 80% of billed N/A 87270 80% of billed 80% of billed N/A87003 80% of billed 80% of billed N/A 87271 80% of billed 80% of billed N/A87015 80% of billed 80% of billed N/A 87272 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 67 of 84

Page 68: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

87273 80% of billed 80% of billed N/A 87502 80% of billed 80% of billed N/A87274 80% of billed 80% of billed N/A 87503 80% of billed 80% of billed N/A87275 80% of billed 80% of billed N/A 87505 80% of billed 80% of billed N/A87276 80% of billed 80% of billed N/A 87506 80% of billed 80% of billed N/A87277 80% of billed 80% of billed N/A 87507 80% of billed 80% of billed N/A87278 80% of billed 80% of billed N/A 87510 80% of billed 80% of billed N/A87279 80% of billed 80% of billed N/A 87511 80% of billed 80% of billed N/A87280 80% of billed 80% of billed N/A 87512 80% of billed 80% of billed N/A87281 80% of billed 80% of billed N/A 87515 80% of billed 80% of billed N/A87283 80% of billed 80% of billed N/A 87516 80% of billed 80% of billed N/A87285 80% of billed 80% of billed N/A 87517 80% of billed 80% of billed N/A87290 80% of billed 80% of billed N/A 87520 80% of billed 80% of billed N/A87299 80% of billed 80% of billed N/A 87521 80% of billed 80% of billed N/A87300 80% of billed 80% of billed N/A 87522 80% of billed 80% of billed N/A87301 80% of billed 80% of billed N/A 87525 80% of billed 80% of billed N/A87305 80% of billed 80% of billed N/A 87526 80% of billed 80% of billed N/A87320 80% of billed 80% of billed N/A 87527 80% of billed 80% of billed N/A87324 80% of billed 80% of billed N/A 87528 80% of billed 80% of billed N/A87327 80% of billed 80% of billed N/A 87529 80% of billed 80% of billed N/A87328 80% of billed 80% of billed N/A 87530 80% of billed 80% of billed N/A87329 80% of billed 80% of billed N/A 87531 80% of billed 80% of billed N/A87332 80% of billed 80% of billed N/A 87532 80% of billed 80% of billed N/A87335 80% of billed 80% of billed N/A 87533 80% of billed 80% of billed N/A87336 80% of billed 80% of billed N/A 87534 80% of billed 80% of billed N/A87337 80% of billed 80% of billed N/A 87535 80% of billed 80% of billed N/A87338 80% of billed 80% of billed N/A 87536 80% of billed 80% of billed N/A87339 80% of billed 80% of billed N/A 87537 80% of billed 80% of billed N/A87340 80% of billed 80% of billed N/A 87538 80% of billed 80% of billed N/A87341 80% of billed 80% of billed N/A 87539 80% of billed 80% of billed N/A87350 80% of billed 80% of billed N/A 87540 80% of billed 80% of billed N/A87380 80% of billed 80% of billed N/A 87541 80% of billed 80% of billed N/A87385 80% of billed 80% of billed N/A 87542 80% of billed 80% of billed N/A87389 80% of billed 80% of billed N/A 87550 80% of billed 80% of billed N/A87390 80% of billed 80% of billed N/A 87551 80% of billed 80% of billed N/A87391 80% of billed 80% of billed N/A 87552 80% of billed 80% of billed N/A87400 80% of billed 80% of billed N/A 87555 80% of billed 80% of billed N/A87420 80% of billed 80% of billed N/A 87556 80% of billed 80% of billed N/A87425 80% of billed 80% of billed N/A 87557 80% of billed 80% of billed N/A87427 80% of billed 80% of billed N/A 87560 80% of billed 80% of billed N/A87430 80% of billed 80% of billed N/A 87561 80% of billed 80% of billed N/A87449 80% of billed 80% of billed N/A 87562 80% of billed 80% of billed N/A87450 80% of billed 80% of billed N/A 87580 80% of billed 80% of billed N/A87451 80% of billed 80% of billed N/A 87581 80% of billed 80% of billed N/A87470 80% of billed 80% of billed N/A 87582 80% of billed 80% of billed N/A87471 80% of billed 80% of billed N/A 87590 80% of billed 80% of billed N/A87472 80% of billed 80% of billed N/A 87591 80% of billed 80% of billed N/A87475 80% of billed 80% of billed N/A 87592 80% of billed 80% of billed N/A87476 80% of billed 80% of billed N/A 87623 80% of billed 80% of billed N/A87477 80% of billed 80% of billed N/A 87624 80% of billed 80% of billed N/A87480 80% of billed 80% of billed N/A 87625 80% of billed 80% of billed N/A87481 80% of billed 80% of billed N/A 87631 80% of billed 80% of billed N/A87482 80% of billed 80% of billed N/A 87632 80% of billed 80% of billed N/A87483 80% of billed 80% of billed N/A 87633 80% of billed 80% of billed N/A87485 80% of billed 80% of billed N/A 87640 80% of billed 80% of billed N/A87486 80% of billed 80% of billed N/A 87641 80% of billed 80% of billed N/A87487 80% of billed 80% of billed N/A 87650 80% of billed 80% of billed N/A87490 80% of billed 80% of billed N/A 87651 80% of billed 80% of billed N/A87491 80% of billed 80% of billed N/A 87652 80% of billed 80% of billed N/A87492 80% of billed 80% of billed N/A 87653 80% of billed 80% of billed N/A87493 80% of billed 80% of billed N/A 87660 80% of billed 80% of billed N/A87495 80% of billed 80% of billed N/A 87661 80% of billed 80% of billed N/A87496 80% of billed 80% of billed N/A 87797 80% of billed 80% of billed N/A87497 80% of billed 80% of billed N/A 87798 80% of billed 80% of billed N/A87498 80% of billed 80% of billed N/A 87799 80% of billed 80% of billed N/A87500 80% of billed 80% of billed N/A 87800 80% of billed 80% of billed N/A87501 80% of billed 80% of billed N/A 87801 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 68 of 84

Page 69: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

87802 80% of billed 80% of billed N/A 88152 80% of billed 80% of billed N/A87803 80% of billed 80% of billed N/A 88153 80% of billed 80% of billed N/A87804 80% of billed 80% of billed N/A 88154 80% of billed 80% of billed N/A87806 80% of billed 80% of billed N/A 88155 80% of billed 80% of billed N/A87807 80% of billed 80% of billed N/A 88160 $118.02 $118.02 N/A87808 80% of billed 80% of billed N/A 88160 TC $74.27 $74.27 N/A87809 80% of billed 80% of billed N/A 88160 26 $43.75 $43.75 N/A87810 80% of billed 80% of billed N/A 88161 $106.50 $106.50 N/A87850 80% of billed 80% of billed N/A 88161 TC $64.48 $64.48 N/A87880 80% of billed 80% of billed N/A 88161 26 $42.03 $42.03 N/A87899 80% of billed 80% of billed N/A 88162 $162.35 $162.35 N/A87900 80% of billed 80% of billed N/A 88162 TC $96.72 $96.72 N/A87901 80% of billed 80% of billed N/A 88162 26 $65.63 $65.63 N/A87902 80% of billed 80% of billed N/A 88164 80% of billed 80% of billed N/A87903 80% of billed 80% of billed N/A 88165 80% of billed 80% of billed N/A87904 80% of billed 80% of billed N/A 88166 80% of billed 80% of billed N/A87905 80% of billed 80% of billed N/A 88167 80% of billed 80% of billed N/A87906 80% of billed 80% of billed N/A 88172 $93.26 $93.26 N/A87910 80% of billed 80% of billed N/A 88172 TC $32.24 $32.24 N/A87912 80% of billed 80% of billed N/A 88172 26 $61.02 $61.02 N/A87999 80% of billed 80% of billed N/A 88173 $249.85 $249.85 N/A88000 80% of billed 80% of billed N/A 88173 TC $130.68 $130.68 N/A88005 80% of billed 80% of billed N/A 88173 26 $119.17 $119.17 N/A88007 80% of billed 80% of billed N/A 88174 80% of billed 80% of billed N/A88012 80% of billed 80% of billed N/A 88175 80% of billed 80% of billed N/A88014 80% of billed 80% of billed N/A 88177 $49.51 $49.51 ZZZ88016 80% of billed 80% of billed N/A 88177 TC $12.09 $12.09 ZZZ88020 80% of billed 80% of billed N/A 88177 26 $37.42 $37.42 ZZZ88025 80% of billed 80% of billed N/A 88182 $194.59 $194.59 N/A88027 80% of billed 80% of billed N/A 88182 TC $132.41 $132.41 N/A88028 80% of billed 80% of billed N/A 88182 26 $62.18 $62.18 N/A88029 80% of billed 80% of billed N/A 88184 $99.02 $99.02 N/A88036 80% of billed 80% of billed N/A 88185 $60.45 $60.45 ZZZ88037 80% of billed 80% of billed N/A 88187 $94.99 $94.99 N/A88040 80% of billed 80% of billed N/A 88188 $120.90 $120.90 N/A88045 80% of billed 80% of billed N/A 88189 $148.53 $148.53 N/A88099 80% of billed 80% of billed N/A 88199 80% of billed 80% of billed N/A88104 $120.90 $120.90 N/A 88199 TC 80% of billed 80% of billed N/A88104 TC $72.54 $72.54 N/A 88199 26 80% of billed 80% of billed N/A88104 26 $48.36 $48.36 N/A 88230 80% of billed 80% of billed N/A88106 $104.20 $104.20 N/A 88233 80% of billed 80% of billed N/A88106 TC $71.39 $71.39 N/A 88235 80% of billed 80% of billed N/A88106 26 $32.81 $32.81 N/A 88237 80% of billed 80% of billed N/A88108 $101.90 $101.90 N/A 88239 80% of billed 80% of billed N/A88108 TC $63.90 $63.90 N/A 88240 80% of billed 80% of billed N/A88108 26 $38.00 $38.00 N/A 88241 80% of billed 80% of billed N/A88112 $110.53 $110.53 N/A 88245 80% of billed 80% of billed N/A88112 TC $63.90 $63.90 N/A 88248 80% of billed 80% of billed N/A88112 26 $46.63 $46.63 N/A 88249 80% of billed 80% of billed N/A88120 $1,028.20 $1,028.20 N/A 88261 80% of billed 80% of billed N/A88120 TC $930.91 $930.91 N/A 88262 80% of billed 80% of billed N/A88120 26 $97.29 $97.29 N/A 88263 80% of billed 80% of billed N/A88121 $888.31 $888.31 N/A 88264 80% of billed 80% of billed N/A88121 TC $804.83 $804.83 N/A 88267 80% of billed 80% of billed N/A88121 26 $83.48 $83.48 N/A 88269 80% of billed 80% of billed N/A88125 $33.97 $33.97 N/A 88271 80% of billed 80% of billed N/A88125 TC $12.67 $12.67 N/A 88272 80% of billed 80% of billed N/A88125 26 $21.30 $21.30 N/A 88273 80% of billed 80% of billed N/A88130 80% of billed 80% of billed N/A 88274 80% of billed 80% of billed N/A88140 80% of billed 80% of billed N/A 88275 80% of billed 80% of billed N/A88141 $52.96 $52.96 N/A 88280 80% of billed 80% of billed N/A88142 80% of billed 80% of billed N/A 88283 80% of billed 80% of billed N/A88143 80% of billed 80% of billed N/A 88285 80% of billed 80% of billed N/A88147 80% of billed 80% of billed N/A 88289 80% of billed 80% of billed N/A88148 80% of billed 80% of billed N/A 88291 $52.96 $52.96 N/A88150 80% of billed 80% of billed N/A 88299 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 69 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

88300 $26.48 $26.48 N/A 88350 $119.17 $119.17 ZZZ88300 TC $19.00 $19.00 N/A 88350 TC $70.81 $70.81 ZZZ88300 26 $7.48 $7.48 N/A 88350 26 $48.36 $48.36 ZZZ88302 $50.09 $50.09 N/A 88355 $232.01 $232.01 N/A88302 TC $38.00 $38.00 N/A 88355 TC $96.14 $96.14 N/A88302 26 $12.09 $12.09 N/A 88355 26 $135.87 $135.87 N/A88304 $66.78 $66.78 N/A 88356 $340.24 $340.24 N/A88304 TC $47.21 $47.21 N/A 88356 TC $139.90 $139.90 N/A88304 26 $19.57 $19.57 N/A 88356 26 $200.34 $200.34 N/A88305 $111.69 $111.69 N/A 88358 $145.65 $145.65 N/A88305 TC $47.78 $47.78 N/A 88358 TC $69.08 $69.08 N/A88305 26 $63.90 $63.90 N/A 88358 26 $76.57 $76.57 N/A88307 $432.93 $432.93 N/A 88360 $227.98 $227.98 N/A88307 TC $291.88 $291.88 N/A 88360 TC $135.87 $135.87 N/A88307 26 $141.05 $141.05 N/A 88360 26 $92.11 $92.11 N/A88309 $663.78 $663.78 N/A 88361 $251.58 $251.58 N/A88309 TC $414.50 $414.50 N/A 88361 TC $153.71 $153.71 N/A88309 26 $249.28 $249.28 N/A 88361 26 $97.87 $97.87 N/A88311 $36.27 $36.27 N/A 88362 $376.51 $376.51 N/A88311 TC $14.97 $14.97 N/A 88362 TC $192.86 $192.86 N/A88311 26 $21.30 $21.30 N/A 88362 26 $183.65 $183.65 N/A88312 $160.04 $160.04 N/A 88363 $38.57 $32.81 N/A88312 TC $114.56 $114.56 N/A 88364 $213.58 $213.58 ZZZ88312 26 $45.48 $45.48 N/A 88364 TC $154.86 $154.86 ZZZ88313 $113.41 $113.41 N/A 88364 26 $58.72 $58.72 ZZZ88313 TC $93.26 $93.26 N/A 88365 $288.43 $288.43 N/A88313 26 $20.15 $20.15 N/A 88365 TC $214.16 $214.16 N/A88314 $127.23 $127.23 N/A 88365 26 $74.27 $74.27 N/A88314 TC $89.81 $89.81 N/A 88366 $417.38 $417.38 N/A88314 26 $37.42 $37.42 N/A 88366 TC $313.18 $313.18 N/A88319 $144.50 $144.50 N/A 88366 26 $104.20 $104.20 N/A88319 TC $99.60 $99.60 N/A 88367 $172.13 $172.13 N/A88319 26 $44.90 $44.90 N/A 88367 TC $113.99 $113.99 N/A88321 $168.10 $141.62 N/A 88367 26 $58.15 $58.15 N/A88323 $211.28 $211.28 N/A 88368 $189.98 $189.98 N/A88323 TC $66.21 $66.21 N/A 88368 TC $122.05 $122.05 N/A88323 26 $145.08 $145.08 N/A 88368 26 $67.93 $67.93 N/A88325 $306.85 $253.88 N/A 88369 $173.86 $173.86 ZZZ88329 $85.20 $61.02 N/A 88369 TC $120.32 $120.32 ZZZ88331 $158.32 $158.32 N/A 88369 26 $53.54 $53.54 ZZZ88331 TC $52.39 $52.39 N/A 88371 80% of billed 80% of billed N/A88331 26 $105.93 $105.93 N/A 88371 26 $29.94 $29.94 N/A88332 $85.78 $85.78 N/A 88372 80% of billed 80% of billed N/A88332 TC $33.39 $33.39 N/A 88372 26 $29.94 $29.94 N/A88332 26 $52.39 $52.39 N/A 88373 $128.38 $128.38 ZZZ88333 $153.14 $153.14 N/A 88373 TC $82.33 $82.33 ZZZ88333 TC $46.63 $46.63 N/A 88373 26 $46.06 $46.06 ZZZ88333 26 $106.50 $106.50 N/A 88374 $550.94 $550.94 N/A88334 $96.72 $96.72 N/A 88374 TC $476.68 $476.68 N/A88334 TC $31.66 $31.66 N/A 88374 26 $74.27 $74.27 N/A88334 26 $65.05 $65.05 N/A 88375 $75.42 $75.42 N/A88341 $147.95 $147.95 ZZZ 88377 $658.03 $658.03 N/A88341 TC $100.17 $100.17 ZZZ 88377 TC $550.94 $550.94 N/A88341 26 $47.78 $47.78 ZZZ 88377 26 $107.08 $107.08 N/A88342 $173.86 $173.86 N/A 88380 $222.22 $222.22 N/A88342 TC $113.99 $113.99 N/A 88380 TC $130.11 $130.11 N/A88342 26 $59.87 $59.87 N/A 88380 26 $92.11 $92.11 N/A88344 $280.37 $280.37 N/A 88381 $197.47 $197.47 N/A88344 TC $214.74 $214.74 N/A 88381 TC $155.44 $155.44 N/A88344 26 $65.63 $65.63 N/A 88381 26 $42.03 $42.03 N/A88346 $153.71 $153.71 N/A 88387 $62.18 $62.18 N/A88346 TC $92.69 $92.69 N/A 88387 TC $12.09 $12.09 N/A88346 26 $61.02 $61.02 N/A 88387 26 $50.09 $50.09 N/A88348 $563.61 $563.61 N/A 88388 $56.42 $56.42 N/A88348 TC $435.80 $435.80 N/A 88388 TC $16.12 $16.12 N/A88348 26 $127.81 $127.81 N/A 88388 26 $40.30 $40.30 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 70 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

88399 80% of billed 80% of billed N/A 90376 80% of billed 80% of billed N/A88399 TC 80% of billed 80% of billed N/A 90378 80% of billed 80% of billed N/A88399 26 80% of billed 80% of billed N/A 90384 80% of billed 80% of billed N/A88720 80% of billed 80% of billed N/A 90385 80% of billed 80% of billed N/A88738 80% of billed 80% of billed N/A 90386 80% of billed 80% of billed N/A88740 80% of billed 80% of billed N/A 90389 80% of billed 80% of billed N/A88741 80% of billed 80% of billed N/A 90393 80% of billed 80% of billed N/A88749 80% of billed 80% of billed N/A 90396 80% of billed 80% of billed N/A89049 $434.08 $107.66 N/A 90399 80% of billed 80% of billed N/A89050 80% of billed 80% of billed N/A 90460 $47.86 $47.86 N/A89051 80% of billed 80% of billed N/A 90461 $23.93 $23.93 ZZZ89055 80% of billed 80% of billed N/A 90471 $47.86 $47.86 N/A89060 80% of billed 80% of billed N/A 90472 $23.93 $23.93 ZZZ89060 26 $29.94 $29.94 N/A 90473 $47.86 $47.86 N/A89125 80% of billed 80% of billed N/A 90474 $23.93 $23.93 ZZZ89160 80% of billed 80% of billed N/A 90476 80% of billed 80% of billed N/A89190 80% of billed 80% of billed N/A 90477 80% of billed 80% of billed N/A89220 $26.48 $26.48 N/A 90581 80% of billed 80% of billed N/A89230 $6.91 $6.91 N/A 90585 80% of billed 80% of billed N/A89240 80% of billed 80% of billed N/A 90586 80% of billed 80% of billed N/A89250 80% of billed 80% of billed N/A 90620 80% of billed 80% of billed N/A89251 80% of billed 80% of billed N/A 90621 80% of billed 80% of billed N/A89253 80% of billed 80% of billed N/A 90625 80% of billed 80% of billed N/A89254 80% of billed 80% of billed N/A 90630 80% of billed 80% of billed N/A89255 80% of billed 80% of billed N/A 90632 80% of billed 80% of billed N/A89257 80% of billed 80% of billed N/A 90633 80% of billed 80% of billed N/A89258 80% of billed 80% of billed N/A 90634 80% of billed 80% of billed N/A89259 80% of billed 80% of billed N/A 90636 80% of billed 80% of billed N/A89260 80% of billed 80% of billed N/A 90644 80% of billed 80% of billed N/A89261 80% of billed 80% of billed N/A 90647 80% of billed 80% of billed N/A89264 80% of billed 80% of billed N/A 90648 80% of billed 80% of billed N/A89268 80% of billed 80% of billed N/A 90649 80% of billed 80% of billed N/A89272 80% of billed 80% of billed N/A 90650 80% of billed 80% of billed N/A89280 80% of billed 80% of billed N/A 90651 80% of billed 80% of billed N/A89281 80% of billed 80% of billed N/A 90653 80% of billed 80% of billed N/A89290 80% of billed 80% of billed N/A 90654 80% of billed 80% of billed N/A89291 80% of billed 80% of billed N/A 90655 80% of billed 80% of billed N/A89300 80% of billed 80% of billed N/A 90656 80% of billed 80% of billed N/A89310 80% of billed 80% of billed N/A 90657 80% of billed 80% of billed N/A89320 80% of billed 80% of billed N/A 90658 80% of billed 80% of billed N/A89321 80% of billed 80% of billed N/A 90660 80% of billed 80% of billed N/A89322 80% of billed 80% of billed N/A 90661 80% of billed 80% of billed N/A89325 80% of billed 80% of billed N/A 90662 80% of billed 80% of billed N/A89329 80% of billed 80% of billed N/A 90664 80% of billed 80% of billed N/A89330 80% of billed 80% of billed N/A 90666 80% of billed 80% of billed N/A89331 80% of billed 80% of billed N/A 90667 80% of billed 80% of billed N/A89335 80% of billed 80% of billed N/A 90668 80% of billed 80% of billed N/A89337 80% of billed 80% of billed N/A 90670 80% of billed 80% of billed N/A89342 80% of billed 80% of billed N/A 90672 80% of billed 80% of billed N/A89343 80% of billed 80% of billed N/A 90673 80% of billed 80% of billed N/A89344 80% of billed 80% of billed N/A 90674 80% of billed 80% of billed N/A89346 80% of billed 80% of billed N/A 90675 80% of billed 80% of billed N/A89352 80% of billed 80% of billed N/A 90676 80% of billed 80% of billed N/A89353 80% of billed 80% of billed N/A 90680 80% of billed 80% of billed N/A89354 80% of billed 80% of billed N/A 90681 80% of billed 80% of billed N/A89356 80% of billed 80% of billed N/A 90682 80% of billed 80% of billed N/A89398 80% of billed 80% of billed N/A 90685 80% of billed 80% of billed N/A90281 80% of billed 80% of billed N/A 90686 80% of billed 80% of billed N/A90283 80% of billed 80% of billed N/A 90687 80% of billed 80% of billed N/A90284 80% of billed 80% of billed N/A 90688 80% of billed 80% of billed N/A90287 80% of billed 80% of billed N/A 90690 80% of billed 80% of billed N/A90288 80% of billed 80% of billed N/A 90691 80% of billed 80% of billed N/A90291 80% of billed 80% of billed N/A 90696 80% of billed 80% of billed N/A90296 80% of billed 80% of billed N/A 90697 80% of billed 80% of billed N/A90371 80% of billed 80% of billed N/A 90698 80% of billed 80% of billed N/A90375 80% of billed 80% of billed N/A 90700 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 71 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

90702 80% of billed 80% of billed N/A 90957 $1,208.42 $1,208.42 N/A90707 80% of billed 80% of billed N/A 90958 $817.58 $817.58 N/A90710 80% of billed 80% of billed N/A 90959 $555.69 $555.69 N/A90713 80% of billed 80% of billed N/A 90960 $531.76 $531.76 N/A90714 80% of billed 80% of billed N/A 90961 $446.68 $446.68 N/A90715 80% of billed 80% of billed N/A 90962 $344.31 $344.31 N/A90716 80% of billed 80% of billed N/A 90963 $1,022.31 $1,022.31 N/A90717 80% of billed 80% of billed N/A 90964 $894.02 $894.02 N/A90723 80% of billed 80% of billed N/A 90965 $850.82 $850.82 N/A90732 80% of billed 80% of billed N/A 90966 $445.35 $445.35 N/A90733 80% of billed 80% of billed N/A 90967 $33.90 $33.90 N/A90734 80% of billed 80% of billed N/A 90968 $29.25 $29.25 N/A90736 80% of billed 80% of billed N/A 90969 $28.58 $28.58 N/A90738 80% of billed 80% of billed N/A 90970 $14.62 $14.62 N/A90739 80% of billed 80% of billed N/A 90989 80% of billed 80% of billed N/A90740 80% of billed 80% of billed N/A 90993 80% of billed 80% of billed N/A90743 80% of billed 80% of billed N/A 90997 $168.83 $168.83 00090744 80% of billed 80% of billed N/A 90999 80% of billed 80% of billed N/A90746 80% of billed 80% of billed N/A 91010 $330.36 $330.36 00090747 80% of billed 80% of billed N/A 91010 TC $203.40 $203.40 00090748 80% of billed 80% of billed N/A 91010 26 $126.96 $126.96 00090749 80% of billed 80% of billed N/A 91013 $43.87 $43.87 ZZZ90750 80% of billed 80% of billed N/A 91013 TC $25.92 $25.92 ZZZ90785 $25.92 $25.92 ZZZ 91013 26 $17.95 $17.95 ZZZ90791 $244.61 $236.63 N/A 91020 $437.37 $437.37 00090792 $274.52 $266.54 N/A 91020 TC $295.79 $295.79 00090832 $118.98 $117.65 N/A 91020 26 $141.58 $141.58 00090833 $123.63 $122.30 ZZZ 91022 $315.07 $315.07 00090834 $158.20 $156.87 N/A 91022 TC $172.82 $172.82 00090836 $156.20 $154.88 ZZZ 91022 26 $142.25 $142.25 00090837 $237.30 $235.97 N/A 91030 $251.92 $251.92 00090838 $206.06 $204.73 ZZZ 91030 TC $163.52 $163.52 00090839 $247.93 $245.94 N/A 91030 26 $88.41 $88.41 00090840 $118.32 $117.65 ZZZ 91034 $352.96 $352.96 00090845 $170.16 $169.50 N/A 91034 TC $256.57 $256.57 00090846 $191.43 $190.10 N/A 91034 26 $96.38 $96.38 00090847 $198.75 $197.42 N/A 91035 $900.67 $900.67 00090849 $65.14 $58.49 N/A 91035 TC $741.81 $741.81 00090853 $47.86 $47.19 N/A 91035 26 $158.86 $158.86 00090863 80% of billed 80% of billed N/A 91037 $300.44 $300.44 00090865 $313.07 $240.62 N/A 91037 TC $204.73 $204.73 00090867 80% of billed 80% of billed 000 91037 26 $95.72 $95.72 00090868 80% of billed 80% of billed 000 91038 $840.85 $840.85 00090869 80% of billed 80% of billed 000 91038 TC $731.83 $731.83 00090870 $331.02 $207.39 000 91038 26 $109.01 $109.01 00090875 $115.66 $114.99 N/A 91040 $800.30 $800.30 00090876 $202.73 $182.13 N/A 91040 TC $705.25 $705.25 00090880 $189.44 $174.15 N/A 91040 26 $95.05 $95.05 00090882 80% of billed 80% of billed N/A 91065 $140.25 $140.25 00090885 $93.06 $93.06 N/A 91065 TC $120.98 $120.98 00090887 $165.51 $142.25 N/A 91065 26 $19.28 $19.28 00090889 80% of billed 80% of billed N/A 91110 $1,738.86 $1,738.86 N/A90899 80% of billed 80% of billed N/A 91110 TC $1,448.38 $1,448.38 N/A90901 $69.13 $36.56 000 91110 26 $290.47 $290.47 N/A90911 $158.86 $83.75 000 91111 $1,399.19 $1,399.19 N/A90935 $135.60 $135.60 000 91111 TC $1,300.15 $1,300.15 N/A90937 $195.42 $195.42 000 91111 26 $99.04 $99.04 N/A90940 80% of billed 80% of billed N/A 91112 $2,017.36 $2,017.36 N/A90945 $160.86 $160.86 000 91112 TC $1,809.98 $1,809.98 N/A90947 $232.65 $232.65 000 91112 26 $207.39 $207.39 N/A90951 $1,770.10 $1,770.10 N/A 91117 $265.22 $265.22 00090952 80% of billed 80% of billed N/A 91120 $798.30 $798.30 N/A90953 80% of billed 80% of billed N/A 91120 TC $703.25 $703.25 N/A90954 $1,529.47 $1,529.47 N/A 91120 26 $95.05 $95.05 N/A90955 $859.46 $859.46 N/A 91122 $430.06 $430.06 00090956 $596.90 $596.90 N/A 91122 TC $257.90 $257.90 000

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 72 of 84

Page 73: Appendix B for Administrative Order No. 17-050 Physician ...Appendix B for Administrative Order No. 17-050 Physician Fee Schedule. Effective April 1, 2017 Link to medical fee and payment

Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

91122 26 $172.16 $172.16 000 92235 26 $81.76 $81.76 N/A91132 $276.52 $276.52 N/A 92240 $390.18 $390.18 N/A91132 TC $225.33 $225.33 N/A 92240 TC $302.44 $302.44 N/A91132 26 $51.18 $51.18 N/A 92240 26 $87.74 $87.74 N/A91133 $322.38 $322.38 N/A 92242 $425.41 $425.41 N/A91133 TC $256.57 $256.57 N/A 92242 TC $321.05 $321.05 N/A91133 26 $65.81 $65.81 N/A 92242 26 $104.36 $104.36 N/A91200 $72.45 $72.45 N/A 92250 $123.63 $123.63 N/A91200 TC $46.53 $46.53 N/A 92250 TC $82.42 $82.42 N/A91200 26 $25.92 $25.92 N/A 92250 26 $41.21 $41.21 N/A91299 80% of billed 80% of billed N/A 92260 $34.56 $20.61 N/A91299 TC 80% of billed 80% of billed N/A 92265 $160.19 $160.19 N/A91299 26 80% of billed 80% of billed N/A 92265 TC $72.45 $72.45 N/A92002 $152.22 $90.40 N/A 92265 26 $87.74 $87.74 N/A92004 $279.17 $188.11 N/A 92270 $172.16 $172.16 N/A92012 $160.19 $99.71 N/A 92270 TC $95.05 $95.05 N/A92014 $231.98 $150.89 N/A 92270 26 $77.11 $77.11 N/A92015 $37.22 $36.56 N/A 92275 $279.17 $279.17 N/A92018 $273.86 $273.86 N/A 92275 TC $176.81 $176.81 N/A92019 $136.26 $136.26 N/A 92275 26 $102.36 $102.36 N/A92020 $50.52 $39.88 N/A 92283 $105.02 $105.02 N/A92025 $71.12 $71.12 N/A 92283 TC $87.08 $87.08 N/A92025 TC $33.24 $33.24 N/A 92283 26 $17.95 $17.95 N/A92025 26 $37.89 $37.89 N/A 92284 $117.65 $117.65 N/A92060 $122.30 $122.30 N/A 92284 TC $93.72 $93.72 N/A92060 TC $49.85 $49.85 N/A 92284 26 $23.93 $23.93 N/A92060 26 $72.45 $72.45 N/A 92285 $39.22 $39.22 N/A92065 $101.70 $101.70 N/A 92285 TC $33.24 $33.24 N/A92065 TC $67.80 $67.80 N/A 92285 26 $5.98 $5.98 N/A92065 26 $33.90 $33.90 N/A 92286 $72.45 $72.45 N/A92071 $71.12 $63.15 N/A 92286 TC $30.58 $30.58 N/A92072 $251.92 $193.43 N/A 92286 26 $41.88 $41.88 N/A92081 $63.81 $63.81 N/A 92287 $258.57 $258.57 N/A92081 TC $33.24 $33.24 N/A 92287 TC $170.16 $170.16 N/A92081 26 $30.58 $30.58 N/A 92287 26 $88.41 $88.41 N/A92082 $91.06 $91.06 N/A 92310 $180.13 $112.33 N/A92082 TC $49.85 $49.85 N/A 92311 $189.44 $105.02 N/A92082 26 $41.21 $41.21 N/A 92312 $220.68 $121.64 N/A92083 $120.98 $120.98 N/A 92313 $180.80 $89.07 N/A92083 TC $68.46 $68.46 N/A 92314 $149.56 $66.47 N/A92083 26 $52.51 $52.51 N/A 92315 $138.92 $41.88 N/A92100 $150.22 $64.48 N/A 92316 $174.15 $62.48 N/A92132 $58.49 $58.49 N/A 92317 $142.25 $43.21 N/A92132 TC $27.25 $27.25 N/A 92325 $79.10 $79.10 N/A92132 26 $31.24 $31.24 N/A 92326 $65.81 $65.81 N/A92133 $70.46 $70.46 N/A 92340 $66.47 $35.23 N/A92133 TC $27.92 $27.92 N/A 92341 $75.78 $45.20 N/A92133 26 $42.54 $42.54 N/A 92342 $81.76 $50.52 N/A92134 $77.11 $77.11 N/A 92352 $75.78 $35.23 N/A92134 TC $28.58 $28.58 N/A 92353 $88.41 $47.86 N/A92134 26 $48.52 $48.52 N/A 92354 $25.26 $25.26 N/A92136 $168.83 $168.83 N/A 92355 $39.22 $39.22 N/A92136 TC $109.68 $109.68 N/A 92358 $21.27 $21.27 N/A92136 26 $59.16 $59.16 N/A 92370 $57.83 $30.58 N/A92145 $33.90 $33.90 N/A 92371 $21.94 $21.94 N/A92145 TC $15.29 $15.29 N/A 92499 80% of billed 80% of billed N/A92145 26 $18.61 $18.61 N/A 92499 TC 80% of billed 80% of billed N/A92225 $50.52 $40.55 N/A 92499 26 80% of billed 80% of billed N/A92226 $46.53 $35.89 N/A 92502 $182.13 $182.13 00092227 $27.25 $27.25 N/A 92504 $55.83 $17.95 N/A92228 $65.14 $65.14 N/A 92507 $148.23 $148.23 N/A92228 TC $25.26 $25.26 N/A 92508 $43.21 $43.21 N/A92228 26 $39.88 $39.88 N/A 92511 $207.39 $71.79 00092230 $108.35 $61.82 N/A 92512 $113.66 $53.84 N/A92235 $160.86 $160.86 N/A 92516 $130.95 $43.21 N/A92235 TC $79.10 $79.10 N/A 92520 $142.91 $77.77 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 73 of 84

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Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

92521 $208.72 $208.72 N/A 92585 26 $50.52 $50.52 N/A92522 $172.82 $172.82 N/A 92586 $162.19 $162.19 N/A92523 $368.91 $368.91 N/A 92587 $40.55 $40.55 N/A92524 $166.84 $166.84 N/A 92587 TC $5.98 $5.98 N/A92526 $161.52 $161.52 N/A 92587 26 $34.56 $34.56 N/A92531 80% of billed 80% of billed N/A 92588 $62.48 $62.48 N/A92532 80% of billed 80% of billed N/A 92588 TC $7.31 $7.31 N/A92533 80% of billed 80% of billed N/A 92588 26 $55.17 $55.17 N/A92534 80% of billed 80% of billed N/A 92590 80% of billed 80% of billed N/A92537 $75.78 $75.78 N/A 92591 80% of billed 80% of billed N/A92537 TC $15.95 $15.95 N/A 92592 80% of billed 80% of billed N/A92537 26 $59.82 $59.82 N/A 92593 80% of billed 80% of billed N/A92538 $38.55 $38.55 N/A 92594 80% of billed 80% of billed N/A92538 TC $8.64 $8.64 N/A 92595 80% of billed 80% of billed N/A92538 26 $29.91 $29.91 N/A 92596 $77.77 $77.77 N/A92540 $192.10 $192.10 N/A 92597 $136.26 $136.26 N/A92540 TC $41.88 $41.88 N/A 92601 $278.51 $229.32 N/A92540 26 $150.22 $150.22 N/A 92602 $155.54 $124.96 N/A92541 $46.53 $46.53 N/A 92603 $285.82 $230.65 N/A92541 TC $6.65 $6.65 N/A 92604 $169.50 $128.29 N/A92541 26 $39.88 $39.88 N/A 92605 $175.48 $167.50 N/A92542 $52.51 $52.51 N/A 92606 $156.20 $134.27 N/A92542 TC $5.32 $5.32 N/A 92607 $239.96 $239.96 N/A92542 26 $47.19 $47.19 N/A 92608 $99.71 $99.71 ZZZ92544 $31.91 $31.91 N/A 92609 $207.39 $207.39 N/A92544 TC $4.65 $4.65 N/A 92610 $161.52 $137.59 N/A92544 26 $27.25 $27.25 N/A 92611 $163.52 $163.52 N/A92545 $28.58 $28.58 N/A 92612 $352.96 $129.62 N/A92545 TC $3.99 $3.99 N/A 92613 $72.45 $72.45 N/A92545 26 $24.59 $24.59 N/A 92614 $271.86 $126.96 N/A92546 $192.76 $192.76 N/A 92615 $63.15 $63.15 N/A92546 TC $164.85 $164.85 N/A 92616 $389.51 $190.77 N/A92546 26 $27.92 $27.92 N/A 92617 $79.10 $79.10 N/A92547 $11.30 $11.30 ZZZ 92618 $63.81 $62.48 ZZZ92548 $186.78 $186.78 N/A 92620 $178.14 $156.20 N/A92548 TC $137.59 $137.59 N/A 92621 $41.88 $35.89 ZZZ92548 26 $49.19 $49.19 N/A 92625 $132.94 $118.32 N/A92550 $39.88 $39.88 N/A 92626 $169.50 $144.24 N/A92551 $22.60 $22.60 N/A 92627 $41.88 $33.90 ZZZ92552 $59.16 $59.16 N/A 92630 80% of billed 80% of billed N/A92553 $70.46 $70.46 N/A 92633 80% of billed 80% of billed N/A92555 $43.87 $43.87 N/A 92640 $210.05 $180.80 N/A92556 $71.12 $71.12 N/A 92700 80% of billed 80% of billed N/A92557 $71.12 $61.82 N/A 92920 $1,029.62 $1,029.62 00092558 80% of billed 80% of billed N/A 92921 80% of billed 80% of billed ZZZ92559 80% of billed 80% of billed N/A 92924 $1,229.03 $1,229.03 00092560 80% of billed 80% of billed N/A 92925 80% of billed 80% of billed ZZZ92561 $72.45 $72.45 N/A 92928 $1,145.94 $1,145.94 00092562 $87.08 $87.08 N/A 92929 80% of billed 80% of billed ZZZ92563 $57.83 $57.83 N/A 92933 $1,285.53 $1,285.53 00092564 $51.18 $51.18 N/A 92934 80% of billed 80% of billed ZZZ92565 $29.25 $29.25 N/A 92937 $1,145.28 $1,145.28 00092567 $27.25 $20.61 N/A 92938 80% of billed 80% of billed ZZZ92568 $29.91 $29.25 N/A 92941 $1,288.19 $1,288.19 00092570 $60.49 $56.50 N/A 92943 $1,286.86 $1,286.86 00092571 $51.18 $51.18 N/A 92944 80% of billed 80% of billed ZZZ92572 $59.16 $59.16 N/A 92950 $572.31 $355.61 00092575 $109.68 $109.68 N/A 92953 $1.99 $1.99 00092576 $68.46 $68.46 N/A 92960 $298.45 $208.72 00092577 $28.58 $28.58 N/A 92961 $480.58 $480.58 00092579 $85.75 $72.45 N/A 92970 $356.28 $356.28 00092582 $125.63 $125.63 N/A 92971 $194.76 $194.76 00092583 $94.39 $94.39 N/A 92973 $342.32 $342.32 ZZZ92584 $138.26 $138.26 N/A 92974 $313.74 $313.74 ZZZ92585 $254.58 $254.58 N/A 92975 $729.84 $729.84 00092585 TC $204.06 $204.06 N/A 92977 $130.28 $130.28 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 74 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

92978 80% of billed 80% of billed ZZZ 93284 $170.16 $170.16 N/A92978 TC 80% of billed 80% of billed ZZZ 93284 TC $51.18 $51.18 N/A92978 26 $184.79 $184.79 ZZZ 93284 26 $118.98 $118.98 N/A92979 80% of billed 80% of billed ZZZ 93285 $79.10 $79.10 N/A92979 TC 80% of billed 80% of billed ZZZ 93285 TC $29.91 $29.91 N/A92979 26 $148.23 $148.23 ZZZ 93285 26 $49.19 $49.19 N/A92986 $2,551.12 $2,551.12 090 93286 $51.18 $51.18 N/A92987 $2,632.88 $2,632.88 090 93286 TC $22.60 $22.60 N/A92990 $2,099.79 $2,099.79 090 93286 26 $28.58 $28.58 N/A92992 80% of billed 80% of billed 090 93287 $69.13 $69.13 N/A92993 80% of billed 80% of billed 090 93287 TC $25.26 $25.26 N/A92997 $1,252.29 $1,252.29 000 93287 26 $43.87 $43.87 N/A92998 $618.84 $618.84 ZZZ 93288 $70.46 $70.46 N/A93000 $31.91 $31.91 N/A 93288 TC $29.91 $29.91 N/A93005 $15.95 $15.95 N/A 93288 26 $40.55 $40.55 N/A93010 $15.95 $15.95 N/A 93289 $123.63 $123.63 N/A93015 $143.58 $143.58 N/A 93289 TC $37.22 $37.22 N/A93016 $41.88 $41.88 N/A 93289 26 $86.41 $86.41 N/A93017 $73.78 $73.78 N/A 93290 $59.16 $59.16 N/A93018 $27.92 $27.92 N/A 93290 TC $17.95 $17.95 N/A93024 $210.05 $210.05 N/A 93290 26 $41.21 $41.21 N/A93024 TC $102.36 $102.36 N/A 93291 $69.13 $69.13 N/A93024 26 $107.68 $107.68 N/A 93291 TC $27.92 $27.92 N/A93025 $305.76 $305.76 N/A 93291 26 $41.21 $41.21 N/A93025 TC $235.97 $235.97 N/A 93292 $61.15 $61.15 N/A93025 26 $69.79 $69.79 N/A 93292 TC $20.61 $20.61 N/A93040 $23.93 $23.93 N/A 93292 26 $40.55 $40.55 N/A93041 $10.64 $10.64 N/A 93293 $101.03 $101.03 N/A93042 $13.29 $13.29 N/A 93293 TC $71.12 $71.12 N/A93050 $33.24 $33.24 N/A 93293 26 $29.91 $29.91 N/A93050 TC $16.62 $16.62 N/A 93294 $63.81 $63.81 N/A93050 26 $16.62 $16.62 N/A 93295 $127.62 $127.62 N/A93224 $171.49 $171.49 N/A 93296 $49.19 $49.19 N/A93225 $49.85 $49.85 N/A 93297 $49.85 $49.85 N/A93226 $71.12 $71.12 N/A 93298 $50.52 $50.52 N/A93227 $50.52 $50.52 N/A 93299 80% of billed 80% of billed N/A93228 $49.19 $49.19 N/A 93303 $444.68 $444.68 N/A93229 $1,350.01 $1,350.01 N/A 93303 TC $324.37 $324.37 N/A93260 $122.30 $122.30 N/A 93303 26 $120.31 $120.31 N/A93260 TC $39.88 $39.88 N/A 93304 $291.80 $291.80 N/A93260 26 $82.42 $82.42 N/A 93304 TC $222.67 $222.67 N/A93261 $112.33 $112.33 N/A 93304 26 $69.13 $69.13 N/A93261 TC $39.88 $39.88 N/A 93306 $428.73 $428.73 N/A93261 26 $72.45 $72.45 N/A 93306 TC $308.42 $308.42 N/A93268 $382.87 $382.87 N/A 93306 26 $120.31 $120.31 N/A93270 $17.28 $17.28 N/A 93307 $243.94 $243.94 N/A93271 $317.73 $317.73 N/A 93307 TC $158.86 $158.86 N/A93272 $47.86 $47.86 N/A 93307 26 $85.08 $85.08 N/A93278 $57.16 $57.16 N/A 93308 $234.64 $234.64 N/A93278 TC $33.90 $33.90 N/A 93308 TC $186.12 $186.12 N/A93278 26 $23.26 $23.26 N/A 93308 26 $48.52 $48.52 N/A93279 $94.39 $94.39 N/A 93312 $462.63 $462.63 N/A93279 TC $33.24 $33.24 N/A 93312 TC $255.91 $255.91 N/A93279 26 $61.15 $61.15 N/A 93312 26 $206.72 $206.72 N/A93280 $109.68 $109.68 N/A 93313 $21.94 $21.94 N/A93280 TC $37.22 $37.22 N/A 93314 $444.68 $444.68 N/A93280 26 $72.45 $72.45 N/A 93314 TC $271.86 $271.86 N/A93281 $128.95 $128.95 N/A 93314 26 $172.82 $172.82 N/A93281 TC $43.87 $43.87 N/A 93315 80% of billed 80% of billed N/A93281 26 $85.08 $85.08 N/A 93315 TC 80% of billed 80% of billed N/A93282 $118.98 $118.98 N/A 93315 26 $243.94 $243.94 N/A93282 TC $38.55 $38.55 N/A 93316 $51.18 $51.18 N/A93282 26 $80.43 $80.43 N/A 93317 80% of billed 80% of billed N/A93283 $153.55 $153.55 N/A 93317 TC 80% of billed 80% of billed N/A93283 TC $44.53 $44.53 N/A 93317 26 $176.81 $176.81 N/A93283 26 $109.01 $109.01 N/A 93318 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 75 of 84

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Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

93318 TC 80% of billed 80% of billed N/A 93531 26 $826.22 $826.22 00093318 26 $198.75 $198.75 N/A 93532 80% of billed 80% of billed 00093320 $101.70 $101.70 ZZZ 93532 TC 80% of billed 80% of billed 00093320 TC $67.13 $67.13 ZZZ 93532 26 $1,028.96 $1,028.96 00093320 26 $34.56 $34.56 ZZZ 93533 80% of billed 80% of billed 00093321 $51.18 $51.18 ZZZ 93533 TC 80% of billed 80% of billed 00093321 TC $37.22 $37.22 ZZZ 93533 26 $687.30 $687.30 00093321 26 $13.96 $13.96 ZZZ 93561 80% of billed 80% of billed 00093325 $47.86 $47.86 ZZZ 93561 TC 80% of billed 80% of billed 00093325 TC $41.88 $41.88 ZZZ 93561 26 $24.59 $24.59 00093325 26 $5.98 $5.98 ZZZ 93562 80% of billed 80% of billed 00093350 $452.00 $452.00 N/A 93562 TC 80% of billed 80% of billed 00093350 TC $317.73 $317.73 N/A 93562 26 $1.99 $1.99 00093350 26 $134.27 $134.27 N/A 93563 $113.00 $113.00 ZZZ93351 $509.16 $509.16 N/A 93564 $118.98 $118.98 ZZZ93351 TC $348.30 $348.30 N/A 93565 $87.74 $87.74 ZZZ93351 26 $160.86 $160.86 N/A 93566 $304.43 $89.73 ZZZ93352 $63.81 $63.81 ZZZ 93567 $257.24 $101.70 ZZZ93355 $430.06 $430.06 N/A 93568 $272.53 $91.73 ZZZ93451 $1,364.63 $1,364.63 000 93571 80% of billed 80% of billed ZZZ93451 TC $1,112.04 $1,112.04 000 93571 TC 80% of billed 80% of billed ZZZ93451 26 $252.59 $252.59 000 93571 26 $184.79 $184.79 ZZZ93452 $1,553.40 $1,553.40 000 93572 80% of billed 80% of billed ZZZ93452 TC $1,093.43 $1,093.43 000 93572 TC 80% of billed 80% of billed ZZZ93452 26 $459.97 $459.97 000 93572 26 $148.23 $148.23 ZZZ93453 $2,016.70 $2,016.70 000 93580 $1,892.40 $1,892.40 00093453 TC $1,401.19 $1,401.19 000 93581 $2,598.31 $2,598.31 00093453 26 $615.51 $615.51 000 93582 $1,266.92 $1,266.92 00093454 $1,576.67 $1,576.67 000 93583 $1,435.75 $1,435.75 00093454 TC $1,110.71 $1,110.71 000 93590 $2,306.51 $2,306.51 00093454 26 $465.95 $465.95 000 93591 $1,914.34 $1,914.34 00093455 $1,843.21 $1,843.21 000 93592 $843.50 $843.50 ZZZ93455 TC $1,300.82 $1,300.82 000 93600 80% of billed 80% of billed 00093455 26 $542.40 $542.40 000 93600 TC 80% of billed 80% of billed 00093456 $1,993.44 $1,993.44 000 93600 26 $229.32 $229.32 00093456 TC $1,387.89 $1,387.89 000 93602 80% of billed 80% of billed 00093456 26 $605.54 $605.54 000 93602 TC 80% of billed 80% of billed 00093457 $2,258.65 $2,258.65 000 93602 26 $224.00 $224.00 00093457 TC $1,576.67 $1,576.67 000 93603 80% of billed 80% of billed 00093457 26 $681.98 $681.98 000 93603 TC 80% of billed 80% of billed 00093458 $1,899.05 $1,899.05 000 93603 26 $224.00 $224.00 00093458 TC $1,324.08 $1,324.08 000 93609 80% of billed 80% of billed ZZZ93458 26 $574.97 $574.97 000 93609 TC 80% of billed 80% of billed ZZZ93459 $2,105.10 $2,105.10 000 93609 26 $537.08 $537.08 ZZZ93459 TC $1,453.70 $1,453.70 000 93610 80% of billed 80% of billed 00093459 26 $651.41 $651.41 000 93610 TC 80% of billed 80% of billed 00093460 $2,268.62 $2,268.62 000 93610 26 $317.06 $317.06 00093460 TC $1,539.45 $1,539.45 000 93612 80% of billed 80% of billed 00093460 26 $729.18 $729.18 000 93612 TC 80% of billed 80% of billed 00093461 $2,596.32 $2,596.32 000 93612 26 $314.40 $314.40 00093461 TC $1,790.04 $1,790.04 000 93613 $769.72 $769.72 ZZZ93461 26 $806.28 $806.28 000 93615 80% of billed 80% of billed 00093462 $404.80 $404.80 ZZZ 93615 TC 80% of billed 80% of billed 00093463 $187.45 $187.45 ZZZ 93615 26 $73.12 $73.12 00093464 $479.91 $479.91 ZZZ 93616 80% of billed 80% of billed 00093464 TC $314.40 $314.40 ZZZ 93616 TC 80% of billed 80% of billed 00093464 26 $165.51 $165.51 ZZZ 93616 26 $101.03 $101.03 00093503 $245.27 $245.27 000 93618 80% of billed 80% of billed 00093505 $1,318.76 $1,318.76 000 93618 TC 80% of billed 80% of billed 00093505 TC $896.02 $896.02 000 93618 26 $428.07 $428.07 00093505 26 $422.75 $422.75 000 93619 80% of billed 80% of billed 00093530 80% of billed 80% of billed 000 93619 TC 80% of billed 80% of billed 00093530 TC 80% of billed 80% of billed 000 93619 26 $755.10 $755.10 00093530 26 $399.48 $399.48 000 93620 80% of billed 80% of billed 00093531 80% of billed 80% of billed 000 93620 TC 80% of billed 80% of billed 00093531 TC 80% of billed 80% of billed 000 93620 26 $1,214.41 $1,214.41 000

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 76 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

93621 80% of billed 80% of billed ZZZ 93886 $519.13 $519.13 N/A93621 TC 80% of billed 80% of billed ZZZ 93886 TC $430.06 $430.06 N/A93621 26 $227.33 $227.33 ZZZ 93886 26 $89.07 $89.07 N/A93622 80% of billed 80% of billed ZZZ 93888 $282.50 $282.50 N/A93622 TC 80% of billed 80% of billed ZZZ 93888 TC $233.31 $233.31 N/A93622 26 $333.01 $333.01 ZZZ 93888 26 $49.19 $49.19 N/A93623 80% of billed 80% of billed ZZZ 93890 $535.08 $535.08 N/A93623 TC 80% of billed 80% of billed ZZZ 93890 TC $438.04 $438.04 N/A93623 26 $308.42 $308.42 ZZZ 93890 26 $97.05 $97.05 N/A93624 80% of billed 80% of billed 000 93892 $618.84 $618.84 N/A93624 TC 80% of billed 80% of billed 000 93892 TC $505.17 $505.17 N/A93624 26 $467.28 $467.28 000 93892 26 $113.66 $113.66 N/A93631 80% of billed 80% of billed 000 93893 $651.41 $651.41 N/A93631 TC 80% of billed 80% of billed 000 93893 TC $538.41 $538.41 N/A93631 26 $766.40 $766.40 000 93893 26 $113.00 $113.00 N/A93640 80% of billed 80% of billed 000 93895 80% of billed 80% of billed N/A93640 TC 80% of billed 80% of billed 000 93895 TC 80% of billed 80% of billed N/A93640 26 $346.31 $346.31 000 93895 26 80% of billed 80% of billed N/A93641 80% of billed 80% of billed 000 93922 $166.84 $166.84 N/A93641 TC 80% of billed 80% of billed 000 93922 TC $142.91 $142.91 N/A93641 26 $604.21 $604.21 000 93922 26 $23.93 $23.93 N/A93642 $650.74 $650.74 000 93923 $259.23 $259.23 N/A93642 TC $153.55 $153.55 000 93923 TC $216.69 $216.69 N/A93642 26 $497.20 $497.20 000 93923 26 $42.54 $42.54 N/A93644 $410.78 $410.78 000 93924 $323.04 $323.04 N/A93644 TC $109.01 $109.01 000 93924 TC $275.85 $275.85 N/A93644 26 $301.77 $301.77 000 93924 26 $47.19 $47.19 N/A93650 $1,143.95 $1,143.95 000 93925 $487.23 $487.23 N/A93653 $1,618.54 $1,618.54 000 93925 TC $412.78 $412.78 N/A93654 $2,167.59 $2,167.59 000 93925 26 $74.45 $74.45 N/A93655 $824.89 $824.89 ZZZ 93926 $285.82 $285.82 N/A93656 $2,174.90 $2,174.90 000 93926 TC $239.96 $239.96 N/A93657 $822.90 $822.90 ZZZ 93926 26 $45.86 $45.86 N/A93660 $297.79 $297.79 000 93930 $391.51 $391.51 N/A93660 TC $119.65 $119.65 000 93930 TC $315.73 $315.73 N/A93660 26 $178.14 $178.14 000 93930 26 $75.78 $75.78 N/A93662 80% of billed 80% of billed ZZZ 93931 $241.95 $241.95 N/A93662 TC 80% of billed 80% of billed ZZZ 93931 TC $195.42 $195.42 N/A93662 26 $271.86 $271.86 ZZZ 93931 26 $46.53 $46.53 N/A93668 $35.89 $35.89 N/A 93970 $370.90 $370.90 N/A93701 $45.86 $45.86 N/A 93970 TC $305.10 $305.10 N/A93702 $231.98 $231.98 N/A 93970 26 $65.81 $65.81 N/A93724 $511.15 $511.15 000 93971 $226.00 $226.00 N/A93724 TC $52.51 $52.51 000 93971 TC $184.12 $184.12 N/A93724 26 $458.64 $458.64 000 93971 26 $41.88 $41.88 N/A93740 $15.29 $15.29 N/A 93975 $530.43 $530.43 N/A93745 80% of billed 80% of billed N/A 93975 TC $420.76 $420.76 N/A93745 TC 80% of billed 80% of billed N/A 93975 26 $109.68 $109.68 N/A93745 26 80% of billed 80% of billed N/A 93976 $307.76 $307.76 N/A93750 $105.02 $87.74 N/A 93976 TC $231.98 $231.98 N/A93770 $15.29 $15.29 N/A 93976 26 $75.78 $75.78 N/A93784 $101.03 $101.03 N/A 93978 $358.94 $358.94 N/A93786 $55.83 $55.83 N/A 93978 TC $283.83 $283.83 N/A93788 $9.97 $9.97 N/A 93978 26 $75.11 $75.11 N/A93790 $35.23 $35.23 N/A 93979 $225.33 $225.33 N/A93797 $30.58 $16.62 000 93979 TC $178.14 $178.14 N/A93798 $47.19 $26.59 000 93979 26 $47.19 $47.19 N/A93799 80% of billed 80% of billed N/A 93980 $228.66 $228.66 N/A93799 TC 80% of billed 80% of billed N/A 93980 TC $112.33 $112.33 N/A93799 26 80% of billed 80% of billed N/A 93980 26 $116.32 $116.32 N/A93880 $380.87 $380.87 N/A 93981 $138.92 $138.92 N/A93880 TC $305.10 $305.10 N/A 93981 TC $97.05 $97.05 N/A93880 26 $75.78 $75.78 N/A 93981 26 $41.88 $41.88 N/A93882 $242.62 $242.62 N/A 93982 $83.09 $83.09 N/A93882 TC $194.76 $194.76 N/A 93990 $299.78 $299.78 N/A93882 26 $47.86 $47.86 N/A 93990 TC $253.25 $253.25 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 77 of 84

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Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

93990 26 $46.53 $46.53 N/A 94681 TC $82.42 $82.42 N/A93998 80% of billed 80% of billed N/A 94681 26 $19.28 $19.28 N/A94002 $174.82 $174.82 N/A 94690 $96.38 $96.38 N/A94003 $126.29 $126.29 N/A 94690 TC $89.07 $89.07 N/A94004 $93.06 $93.06 N/A 94690 26 $7.31 $7.31 N/A94005 $174.82 $174.82 N/A 94726 $99.04 $99.04 N/A94010 $67.13 $67.13 N/A 94726 TC $75.78 $75.78 N/A94010 TC $51.18 $51.18 N/A 94726 26 $23.26 $23.26 N/A94010 26 $15.95 $15.95 N/A 94727 $79.10 $79.10 N/A94011 $173.49 $173.49 N/A 94727 TC $55.83 $55.83 N/A94012 $279.17 $279.17 N/A 94727 26 $23.26 $23.26 N/A94013 $37.89 $37.89 N/A 94728 $74.45 $74.45 N/A94014 $106.35 $106.35 N/A 94728 TC $50.52 $50.52 N/A94015 $58.49 $58.49 N/A 94728 26 $23.93 $23.93 N/A94016 $47.86 $47.86 N/A 94729 $102.36 $102.36 ZZZ94060 $114.33 $114.33 N/A 94729 TC $85.08 $85.08 ZZZ94060 TC $89.73 $89.73 N/A 94729 26 $17.28 $17.28 ZZZ94060 26 $24.59 $24.59 N/A 94750 $148.23 $148.23 N/A94070 $113.00 $113.00 N/A 94750 TC $127.62 $127.62 N/A94070 TC $58.49 $58.49 N/A 94750 26 $20.61 $20.61 N/A94070 26 $54.51 $54.51 N/A 94760 $5.98 $5.98 N/A94150 $47.19 $47.19 N/A 94761 $8.64 $8.64 N/A94150 TC $39.88 $39.88 N/A 94762 $45.86 $45.86 N/A94150 26 $7.31 $7.31 N/A 94770 $13.96 $13.96 N/A94200 $48.52 $48.52 N/A 94772 80% of billed 80% of billed N/A94200 TC $37.89 $37.89 N/A 94772 TC 80% of billed 80% of billed N/A94200 26 $10.64 $10.64 N/A 94772 26 80% of billed 80% of billed N/A94250 $49.85 $49.85 N/A 94774 80% of billed 80% of billed N/A94250 TC $39.22 $39.22 N/A 94775 80% of billed 80% of billed N/A94250 26 $10.64 $10.64 N/A 94776 80% of billed 80% of billed N/A94375 $74.45 $74.45 N/A 94777 80% of billed 80% of billed N/A94375 TC $46.53 $46.53 N/A 94780 $111.67 $46.53 N/A94375 26 $27.92 $27.92 N/A 94781 $43.21 $16.62 ZZZ94400 $107.02 $107.02 N/A 94799 80% of billed 80% of billed N/A94400 TC $69.79 $69.79 N/A 94799 TC 80% of billed 80% of billed N/A94400 26 $37.22 $37.22 N/A 94799 26 80% of billed 80% of billed N/A94450 $130.28 $130.28 N/A 95004 $12.63 $12.63 N/A94450 TC $92.39 $92.39 N/A 95012 $35.89 $35.89 N/A94450 26 $37.89 $37.89 N/A 95017 $14.62 $6.65 N/A94452 $108.35 $108.35 N/A 95018 $38.55 $13.29 N/A94452 TC $81.09 $81.09 N/A 95024 $14.62 $1.99 N/A94452 26 $27.25 $27.25 N/A 95027 $8.64 $8.64 N/A94453 $150.22 $150.22 N/A 95028 $25.26 $25.26 N/A94453 TC $114.33 $114.33 N/A 95044 $10.64 $10.64 N/A94453 26 $35.89 $35.89 N/A 95052 $12.63 $12.63 N/A94610 $105.69 $105.69 N/A 95056 $83.09 $83.09 N/A94620 $105.69 $105.69 N/A 95060 $66.47 $66.47 N/A94620 TC $47.86 $47.86 N/A 95065 $47.19 $47.19 N/A94620 26 $57.83 $57.83 N/A 95070 $57.83 $57.83 N/A94621 $305.76 $305.76 N/A 95071 $68.46 $68.46 N/A94621 TC $175.48 $175.48 N/A 95076 $218.02 $138.26 N/A94621 26 $130.28 $130.28 N/A 95079 $155.54 $126.29 ZZZ94640 $34.56 $34.56 N/A 95115 $16.62 $16.62 N/A94642 80% of billed 80% of billed N/A 95117 $19.28 $19.28 N/A94644 $83.09 $83.09 N/A 95120 80% of billed 80% of billed N/A94645 $27.25 $27.25 N/A 95125 80% of billed 80% of billed N/A94660 $119.65 $72.45 N/A 95130 80% of billed 80% of billed N/A94662 $66.47 $66.47 N/A 95131 80% of billed 80% of billed N/A94664 $32.57 $32.57 N/A 95132 80% of billed 80% of billed N/A94667 $49.85 $49.85 N/A 95133 80% of billed 80% of billed N/A94668 $55.17 $55.17 N/A 95134 80% of billed 80% of billed N/A94669 $61.82 $61.82 N/A 95144 $24.59 $5.98 N/A94680 $107.02 $107.02 N/A 95145 $47.19 $5.98 N/A94680 TC $83.09 $83.09 N/A 95146 $86.41 $5.98 N/A94680 26 $23.93 $23.93 N/A 95147 $91.73 $5.98 N/A94681 $101.70 $101.70 N/A 95148 $129.62 $5.98 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 78 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

95149 $171.49 $5.98 N/A 95832 $58.49 $31.91 N/A95165 $24.59 $5.98 N/A 95833 $69.79 $40.55 N/A95170 $17.95 $5.98 N/A 95834 $98.38 $59.16 N/A95180 $250.59 $190.77 N/A 95851 $33.90 $14.62 N/A95199 80% of billed 80% of billed N/A 95852 $29.25 $10.64 N/A95250 $295.79 $295.79 N/A 95857 $101.70 $56.50 N/A95251 $82.42 $82.42 N/A 95860 $229.99 $229.99 N/A95782 $1,917.66 $1,917.66 N/A 95860 TC $132.28 $132.28 N/A95782 TC $1,679.03 $1,679.03 N/A 95860 26 $97.71 $97.71 N/A95782 26 $238.63 $238.63 N/A 95861 $327.03 $327.03 N/A95783 $2,179.55 $2,179.55 N/A 95861 TC $170.16 $170.16 N/A95783 TC $1,908.35 $1,908.35 N/A 95861 26 $156.87 $156.87 N/A95783 26 $271.20 $271.20 N/A 95863 $410.78 $410.78 N/A95800 $335.01 $335.01 N/A 95863 TC $221.35 $221.35 N/A95800 TC $236.63 $236.63 N/A 95863 26 $189.44 $189.44 N/A95800 26 $98.38 $98.38 N/A 95864 $461.97 $461.97 N/A95801 $170.83 $170.83 N/A 95864 TC $258.57 $258.57 N/A95801 TC $77.77 $77.77 N/A 95864 26 $203.40 $203.40 N/A95801 26 $93.06 $93.06 N/A 95865 $275.85 $275.85 N/A95803 $264.55 $264.55 N/A 95865 TC $115.66 $115.66 N/A95803 TC $182.13 $182.13 N/A 95865 26 $160.19 $160.19 N/A95803 26 $82.42 $82.42 N/A 95866 $255.24 $255.24 N/A95805 $803.62 $803.62 N/A 95866 TC $126.96 $126.96 N/A95805 TC $691.95 $691.95 N/A 95866 26 $128.29 $128.29 N/A95805 26 $111.67 $111.67 N/A 95867 $182.13 $182.13 N/A95806 $318.39 $318.39 N/A 95867 TC $103.03 $103.03 N/A95806 TC $202.73 $202.73 N/A 95867 26 $79.10 $79.10 N/A95806 26 $115.66 $115.66 N/A 95868 $253.25 $253.25 N/A95807 $873.42 $873.42 N/A 95868 TC $132.94 $132.94 N/A95807 TC $755.76 $755.76 N/A 95868 26 $120.31 $120.31 N/A95807 26 $117.65 $117.65 N/A 95869 $172.16 $172.16 N/A95808 $1,201.78 $1,201.78 N/A 95869 TC $134.27 $134.27 N/A95808 TC $1,034.94 $1,034.94 N/A 95869 26 $37.89 $37.89 N/A95808 26 $166.84 $166.84 N/A 95870 $174.15 $174.15 N/A95810 $1,169.21 $1,169.21 N/A 95870 TC $136.26 $136.26 N/A95810 TC $939.22 $939.22 N/A 95870 26 $37.89 $37.89 N/A95810 26 $229.99 $229.99 N/A 95872 $370.90 $370.90 N/A95811 $1,228.37 $1,228.37 N/A 95872 TC $79.10 $79.10 N/A95811 TC $989.07 $989.07 N/A 95872 26 $291.80 $291.80 N/A95811 26 $239.29 $239.29 N/A 95873 $137.59 $137.59 ZZZ95812 $608.20 $608.20 N/A 95873 TC $99.71 $99.71 ZZZ95812 TC $499.19 $499.19 N/A 95873 26 $37.89 $37.89 ZZZ95812 26 $109.01 $109.01 N/A 95874 $138.92 $138.92 ZZZ95813 $766.40 $766.40 N/A 95874 TC $101.03 $101.03 ZZZ95813 TC $601.55 $601.55 N/A 95874 26 $37.89 $37.89 ZZZ95813 26 $164.85 $164.85 N/A 95875 $220.68 $220.68 N/A95816 $678.66 $678.66 N/A 95875 TC $109.01 $109.01 N/A95816 TC $569.65 $569.65 N/A 95875 26 $111.67 $111.67 N/A95816 26 $109.01 $109.01 N/A 95885 $110.34 $110.34 ZZZ95819 $780.36 $780.36 N/A 95885 TC $74.45 $74.45 ZZZ95819 TC $670.68 $670.68 N/A 95885 26 $35.89 $35.89 ZZZ95819 26 $109.68 $109.68 N/A 95886 $171.49 $171.49 ZZZ95822 $704.58 $704.58 N/A 95886 TC $83.75 $83.75 ZZZ95822 TC $594.91 $594.91 N/A 95886 26 $87.74 $87.74 ZZZ95822 26 $109.68 $109.68 N/A 95887 $151.55 $151.55 ZZZ95824 80% of billed 80% of billed N/A 95887 TC $79.76 $79.76 ZZZ95824 TC 80% of billed 80% of billed N/A 95887 26 $71.79 $71.79 ZZZ95824 26 $74.45 $74.45 N/A 95905 $134.27 $134.27 N/A95827 $1,247.64 $1,247.64 N/A 95905 TC $128.95 $128.95 N/A95827 TC $1,139.96 $1,139.96 N/A 95905 26 $5.32 $5.32 N/A95827 26 $107.68 $107.68 N/A 95907 $183.46 $183.46 N/A95829 $3,598.02 $3,598.02 N/A 95907 TC $81.76 $81.76 N/A95829 TC $2,959.91 $2,959.91 N/A 95907 26 $101.70 $101.70 N/A95829 26 $638.11 $638.11 N/A 95908 $235.97 $235.97 N/A95830 $412.11 $173.49 N/A 95908 TC $108.35 $108.35 N/A95831 $59.16 $29.91 N/A 95908 26 $127.62 $127.62 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 79 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

95909 $281.17 $281.17 N/A 95951 TC 80% of billed 80% of billed N/A95909 TC $128.29 $128.29 N/A 95951 26 $606.21 $606.21 N/A95909 26 $152.88 $152.88 N/A 95953 $797.64 $797.64 N/A95910 $371.57 $371.57 N/A 95953 TC $486.56 $486.56 N/A95910 TC $167.50 $167.50 N/A 95953 26 $311.08 $311.08 N/A95910 26 $204.06 $204.06 N/A 95954 $851.48 $851.48 N/A95911 $442.69 $442.69 N/A 95954 TC $613.52 $613.52 N/A95911 TC $188.11 $188.11 N/A 95954 26 $237.96 $237.96 N/A95911 26 $254.58 $254.58 N/A 95955 $402.14 $402.14 N/A95912 $488.55 $488.55 N/A 95955 TC $300.44 $300.44 N/A95912 TC $187.45 $187.45 N/A 95955 26 $101.70 $101.70 N/A95912 26 $301.11 $301.11 N/A 95956 $3,062.27 $3,062.27 N/A95913 $561.01 $561.01 N/A 95956 TC $2,700.01 $2,700.01 N/A95913 TC $204.73 $204.73 N/A 95956 26 $362.26 $362.26 N/A95913 26 $356.28 $356.28 N/A 95957 $574.30 $574.30 N/A95921 $160.19 $160.19 N/A 95957 TC $375.56 $375.56 N/A95921 TC $74.45 $74.45 N/A 95957 26 $198.75 $198.75 N/A95921 26 $85.75 $85.75 N/A 95958 $1,092.10 $1,092.10 N/A95922 $188.11 $188.11 N/A 95958 TC $663.37 $663.37 N/A95922 TC $96.38 $96.38 N/A 95958 26 $428.73 $428.73 N/A95922 26 $91.73 $91.73 N/A 95961 $576.96 $576.96 N/A95923 $265.22 $265.22 N/A 95961 TC $268.54 $268.54 N/A95923 TC $178.14 $178.14 N/A 95961 26 $308.42 $308.42 N/A95923 26 $87.08 $87.08 N/A 95962 $493.87 $493.87 ZZZ95924 $287.15 $287.15 N/A 95962 TC $164.85 $164.85 ZZZ95924 TC $116.99 $116.99 N/A 95962 26 $329.03 $329.03 ZZZ95924 26 $170.16 $170.16 N/A 95965 80% of billed 80% of billed N/A95925 $260.56 $260.56 N/A 95965 TC 80% of billed 80% of billed N/A95925 TC $208.05 $208.05 N/A 95965 26 $798.30 $798.30 N/A95925 26 $52.51 $52.51 N/A 95966 80% of billed 80% of billed N/A95926 $252.59 $252.59 N/A 95966 TC 80% of billed 80% of billed N/A95926 TC $200.74 $200.74 N/A 95966 26 $400.15 $400.15 N/A95926 26 $51.85 $51.85 N/A 95967 80% of billed 80% of billed ZZZ95927 $259.23 $259.23 N/A 95967 TC 80% of billed 80% of billed ZZZ95927 TC $207.39 $207.39 N/A 95967 26 $350.96 $350.96 ZZZ95927 26 $51.85 $51.85 N/A 95970 $128.29 $45.86 N/A95928 $401.48 $401.48 N/A 95971 $95.05 $77.11 N/A95928 TC $249.26 $249.26 N/A 95972 $109.68 $79.10 N/A95928 26 $152.22 $152.22 N/A 95974 $392.17 $311.74 N/A95929 $413.44 $413.44 N/A 95975 $210.71 $176.15 ZZZ95929 TC $260.56 $260.56 N/A 95978 $470.61 $364.92 N/A95929 26 $152.88 $152.88 N/A 95979 $204.06 $170.16 ZZZ95930 $243.28 $243.28 N/A 95980 $87.74 $87.74 N/A95930 TC $208.05 $208.05 N/A 95981 $60.49 $33.90 N/A95930 26 $35.23 $35.23 N/A 95982 $99.71 $69.13 N/A95933 $144.24 $144.24 N/A 95990 $170.16 $170.16 N/A95933 TC $84.42 $84.42 N/A 95991 $224.00 $75.11 N/A95933 26 $59.82 $59.82 N/A 95992 $81.09 $70.46 N/A95937 $154.21 $154.21 N/A 95999 80% of billed 80% of billed N/A95937 TC $89.07 $89.07 N/A 96000 $180.13 $180.13 N/A95937 26 $65.14 $65.14 N/A 96001 $230.65 $230.65 N/A95938 $644.09 $644.09 N/A 96002 $41.21 $41.21 N/A95938 TC $556.35 $556.35 N/A 96003 $31.24 $31.24 N/A95938 26 $87.74 $87.74 N/A 96004 $221.35 $221.35 N/A95939 $949.19 $949.19 N/A 96020 80% of billed 80% of billed N/A95939 TC $721.86 $721.86 N/A 96020 TC 80% of billed 80% of billed N/A95939 26 $227.33 $227.33 N/A 96020 26 $304.43 $304.43 N/A95940 $61.82 $61.82 N/A 96040 $88.41 $88.41 N/A95941 80% of billed 80% of billed N/A 96101 $149.56 $148.23 N/A95943 80% of billed 80% of billed N/A 96102 $116.32 $44.53 N/A95943 TC 80% of billed 80% of billed N/A 96103 $51.85 $49.85 N/A95943 26 80% of billed 80% of billed N/A 96105 $202.07 $202.07 N/A95950 $626.81 $626.81 N/A 96110 $17.95 $17.95 N/A95950 TC $475.26 $475.26 N/A 96111 $246.60 $235.30 N/A95950 26 $151.55 $151.55 N/A 96116 $172.82 $162.19 N/A95951 80% of billed 80% of billed N/A 96118 $182.79 $147.56 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 80 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

96119 $148.89 $44.53 N/A 96936 $81.09 $81.09 ZZZ96120 $90.40 $49.19 N/A 96999 80% of billed 80% of billed N/A96125 $218.02 $218.02 N/A 97010 $10.01 $10.01 N/A96127 $10.64 $10.64 N/A 97012 $27.09 $27.09 N/A96150 $40.55 $39.88 N/A 97014 $26.51 $26.51 N/A96151 $39.22 $38.55 N/A 97016 $32.40 $32.40 N/A96152 $37.22 $36.56 N/A 97018 $18.26 $18.26 N/A96153 $8.64 $7.98 N/A 97022 $39.46 $39.46 N/A96154 $36.56 $35.89 N/A 97024 $11.19 $11.19 N/A96155 $42.54 $42.54 N/A 97026 $10.01 $10.01 N/A96160 $8.64 $8.64 ZZZ 97028 $12.37 $12.37 N/A96161 $8.64 $8.64 ZZZ 97032 $31.81 $31.81 N/A96360 $108.35 $108.35 N/A 97033 $36.52 $36.52 N/A96361 $28.58 $28.58 ZZZ 97034 $30.04 $30.04 N/A96365 $129.62 $129.62 N/A 97035 $21.20 $21.20 N/A96366 $35.23 $35.23 ZZZ 97036 $54.78 $54.78 N/A96367 $57.83 $57.83 ZZZ 97039 80% of billed 80% of billed N/A96368 $38.55 $38.55 ZZZ 97110 $54.19 $54.19 N/A96369 $334.34 $334.34 N/A 97112 $56.54 $56.54 N/A96370 $28.58 $28.58 ZZZ 97113 $71.86 $71.86 N/A96371 $128.29 $128.29 ZZZ 97116 $47.12 $47.12 N/A96372 $47.86 $47.86 N/A 97124 $43.59 $43.59 N/A96373 $35.89 $35.89 N/A 97139 80% of billed 80% of billed N/A96374 $107.68 $107.68 N/A 97140 $50.07 $50.07 N/A96375 $41.88 $41.88 ZZZ 97150 $28.86 $28.86 N/A96376 80% of billed 80% of billed ZZZ 97161 $134.29 $134.29 N/A96379 80% of billed 80% of billed N/A 97162 $134.29 $134.29 N/A96401 $139.59 $139.59 N/A 97163 $134.29 $134.29 N/A96402 $61.15 $61.15 N/A 97164 $91.30 $91.30 N/A96405 $153.55 $57.16 000 97165 $130.17 $130.17 N/A96406 $224.67 $87.74 000 97166 $130.17 $130.17 N/A96409 $208.05 $208.05 N/A 97167 $130.17 $130.17 N/A96411 $116.99 $116.99 ZZZ 97168 $85.99 $85.99 N/A96413 $258.57 $258.57 N/A 97530 $58.31 $58.31 N/A96415 $53.18 $53.18 ZZZ 97532 $44.18 $35.93 N/A96416 $261.23 $261.23 N/A 97533 $48.89 $48.89 N/A96417 $122.30 $122.30 ZZZ 97535 $58.31 $58.31 N/A96420 $199.41 $199.41 N/A 97537 $50.65 $50.65 N/A96422 $346.97 $346.97 N/A 97542 $51.24 $51.24 N/A96423 $140.92 $140.92 ZZZ 97545 80% of billed 80% of billed N/A96425 $343.65 $343.65 N/A 97546 80% of billed 80% of billed ZZZ96440 $1,463.00 $238.63 000 97597 $125.46 $38.87 00096446 $380.87 $54.51 N/A 97598 $41.23 $18.26 ZZZ96450 $340.99 $152.88 000 97602 80% of billed 80% of billed N/A96521 $262.56 $262.56 N/A 97605 $68.91 $41.82 N/A96522 $214.03 $214.03 N/A 97606 $81.28 $45.35 N/A96523 $46.53 $46.53 N/A 97607 80% of billed 80% of billed N/A96542 $233.31 $79.76 N/A 97608 80% of billed 80% of billed N/A96549 80% of billed 80% of billed N/A 97610 $199.67 $26.51 N/A96567 $253.92 $253.92 N/A 97642 $63.74 $63.74 N/A96570 $108.35 $108.35 ZZZ 97643 $32.22 $32.22 N/A96571 $49.85 $49.85 ZZZ 97644 $101.56 $101.56 N/A96900 $39.22 $39.22 N/A 97645 $51.13 $51.13 N/A96902 $40.55 $39.22 N/A 97646 $63.74 $63.74 N/A96904 $117.65 $117.65 N/A 97647 $32.22 $32.22 N/A96910 $133.60 $133.60 N/A 97648 $105.06 $105.06 N/A96912 $171.49 $171.49 N/A 97649 $52.53 $52.53 N/A96913 $243.28 $243.28 N/A 97650 $56.73 $56.73 N/A96920 $293.13 $127.62 000 97651 $28.72 $28.72 N/A96921 $323.04 $144.24 000 97652 $37.82 $37.82 N/A96922 $446.01 $231.32 000 97653 $19.61 $19.61 N/A96931 $299.78 $299.78 N/A 97654 $28.72 $28.72 N/A96932 $194.09 $194.09 N/A 97655 $27.32 $27.32 N/A96933 $85.08 $85.08 N/A 97656 $54.63 $54.63 N/A96934 $154.21 $154.21 ZZZ 97657 $94.55 $94.55 N/A96935 $65.14 $65.14 ZZZ 97658 $47.63 $47.63 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 81 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

97659 $120.47 $120.47 N/A 99151 $144.90 $44.53 N/A97660 $60.23 $60.23 N/A 99152 $96.38 $23.26 N/A97661 $162.49 $162.49 N/A 99153 $20.61 $20.61 ZZZ97662 $65.84 $65.84 N/A 99155 $174.82 $174.82 N/A97663 $32.92 $32.92 N/A 99156 $142.91 $142.91 N/A97664 $88.98 $88.98 N/A 99157 $108.35 $108.35 ZZZ97665 $44.13 $44.13 N/A 99170 $310.41 $166.18 00097666 $71.44 $71.44 N/A 99172 80% of billed 80% of billed N/A97667 $36.42 $36.42 N/A 99173 $5.98 $5.98 N/A97668 $74.94 $74.94 N/A 99174 80% of billed 80% of billed N/A97669 $37.82 $37.82 N/A 99175 $29.91 $29.91 N/A97670 $468.65 $468.65 N/A 99177 80% of billed 80% of billed N/A97671 $529.50 $529.50 N/A 99183 $208.72 $208.72 N/A97750 $54.78 $54.78 N/A 99184 $401.48 $401.48 N/A97755 $59.49 $59.49 N/A 99188 80% of billed 80% of billed N/A97760 $63.61 $63.61 N/A 99190 80% of billed 80% of billed N/A97761 $55.37 $55.37 N/A 99191 80% of billed 80% of billed N/A97762 $80.10 $80.10 N/A 99192 80% of billed 80% of billed N/A97799 80% of billed 80% of billed N/A 99193 $56.03 $56.03 N/A97802 $65.14 $61.15 N/A 99195 $188.11 $188.11 N/A97803 $56.50 $51.85 N/A 99196 $168.10 $168.10 N/A97804 $29.91 $28.58 N/A 99197 $560.32 $560.32 N/A97810 $68.46 $57.83 N/A 99198 $1,120.64 $1,120.64 N/A97811 $51.18 $47.86 ZZZ 99199 80% of billed 80% of billed N/A97813 $73.12 $62.48 N/A 99201 $87.73 $53.77 N/A97814 $57.83 $52.51 ZZZ 99202 $149.28 $101.17 N/A98925 $59.16 $45.20 000 99203 $215.79 $153.53 N/A98926 $85.75 $67.80 000 99204 $327.57 $259.65 N/A98927 $112.33 $89.73 000 99205 $412.47 $338.18 N/A98928 $136.93 $112.33 000 99211 $40.33 $18.40 N/A98929 $163.52 $136.26 000 99212 $87.02 $50.94 N/A98940 $56.84 $56.84 000 99213 $145.74 $101.88 N/A98941 $79.58 $79.58 000 99214 $214.37 $157.07 N/A98942 $101.56 $101.56 000 99215 $288.66 $222.16 N/A98943 $53.82 $53.82 N/A 99217 $145.74 $145.74 N/A98960 $52.51 $52.51 N/A 99218 $199.52 $199.52 N/A98961 $25.26 $25.26 N/A 99219 $271.68 $271.68 N/A98962 $18.61 $18.61 N/A 99220 $371.44 $371.44 N/A98966 $25.92 $23.93 N/A 99221 $203.05 $203.05 N/A98967 $50.52 $47.86 N/A 99222 $273.80 $273.80 N/A98968 $74.45 $71.79 N/A 99223 $405.40 $405.40 N/A98969 80% of billed 80% of billed N/A 99224 $79.95 $79.95 N/A99000 80% of billed 80% of billed N/A 99225 $145.74 $145.74 N/A99001 80% of billed 80% of billed N/A 99226 $210.13 $210.13 N/A99002 80% of billed 80% of billed N/A 99231 $78.53 $78.53 N/A99024 80% of billed 80% of billed N/A 99232 $144.33 $144.33 N/A99026 80% of billed 80% of billed N/A 99233 $208.71 $208.71 N/A99027 80% of billed 80% of billed N/A 99234 $266.73 $266.73 N/A99050 80% of billed 80% of billed N/A 99235 $338.18 $338.18 N/A99051 80% of billed 80% of billed N/A 99236 $435.82 $435.82 N/A99053 80% of billed 80% of billed N/A 99238 $145.04 $145.04 N/A99056 80% of billed 80% of billed N/A 99239 $215.08 $215.08 N/A99058 80% of billed 80% of billed N/A 99241 $94.80 $65.09 N/A99060 80% of billed 80% of billed N/A 99242 $178.29 $136.55 N/A99070 80% of billed 80% of billed N/A 99243 $244.09 $191.02 N/A99071 80% of billed 80% of billed N/A 99244 $365.07 $307.06 N/A99075 80% of billed 80% of billed N/A 99245 $445.02 $379.93 N/A99078 80% of billed 80% of billed N/A 99251 $97.64 $97.64 N/A99080 80% of billed 80% of billed N/A 99252 $149.28 $149.28 N/A99082 80% of billed 80% of billed N/A 99253 $229.23 $229.23 N/A99090 80% of billed 80% of billed N/A 99254 $333.23 $333.23 N/A99091 $105.69 $105.69 N/A 99255 $401.86 $401.86 N/A99100 80% of billed 80% of billed ZZZ 99281 $42.45 $42.45 N/A99116 80% of billed 80% of billed ZZZ 99282 $82.78 $82.78 N/A99135 80% of billed 80% of billed ZZZ 99283 $123.81 $123.81 N/A99140 80% of billed 80% of billed ZZZ 99284 $234.89 $234.89 N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 82 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

99285 $346.68 $346.68 N/A 99401 $72.17 $48.82 N/A99288 80% of billed 80% of billed N/A 99402 $123.10 $100.46 N/A99291 $548.31 $447.14 N/A 99403 $172.63 $149.28 N/A99292 $245.50 $224.28 ZZZ 99404 $222.16 $199.52 N/A99304 $182.54 $182.54 N/A 99406 $29.01 $24.76 N/A99305 $260.36 $260.36 N/A 99407 $55.89 $51.65 N/A99306 $333.23 $333.23 N/A 99408 $70.04 $66.50 N/A99307 $89.14 $89.14 N/A 99409 $136.55 $133.01 N/A99308 $137.96 $137.96 N/A 99411 $32.54 $15.56 N/A99309 $182.54 $182.54 N/A 99412 $42.45 $25.47 N/A99310 $271.68 $271.68 N/A 99415 $17.69 $17.69 ZZZ99315 $146.45 $146.45 N/A 99416 $9.20 $9.20 ZZZ99316 $211.54 $211.54 N/A 99429 80% of billed 80% of billed N/A99318 $192.44 $192.44 N/A 99441 $27.59 $25.47 N/A99324 $110.37 $110.37 N/A 99442 $53.77 $50.94 N/A99325 $160.60 $160.60 N/A 99443 $79.24 $76.41 N/A99326 $278.76 $278.76 N/A 99444 80% of billed 80% of billed N/A99327 $371.44 $371.44 N/A 99446 80% of billed 80% of billed N/A99328 $435.11 $435.11 N/A 99447 80% of billed 80% of billed N/A99334 $120.28 $120.28 N/A 99448 80% of billed 80% of billed N/A99335 $189.61 $189.61 N/A 99449 80% of billed 80% of billed N/A99336 $269.56 $269.56 N/A 99450 80% of billed 80% of billed N/A99337 $385.59 $385.59 N/A 99455 80% of billed 80% of billed N/A99339 $154.24 $154.24 N/A 99456 80% of billed 80% of billed N/A99340 $216.50 $216.50 N/A 99460 $200.22 $200.22 N/A99341 $109.66 $109.66 N/A 99461 $186.07 $126.64 N/A99342 $158.48 $158.48 N/A 99462 $89.14 $89.14 N/A99343 $260.36 $260.36 N/A 99463 $239.14 $239.14 N/A99344 $365.07 $365.07 N/A 99464 $154.24 $154.24 N/A99345 $442.19 $442.19 N/A 99465 $305.64 $305.64 N/A99347 $110.37 $110.37 N/A 99466 $487.47 $487.47 N/A99348 $168.38 $168.38 N/A 99467 $244.80 $244.80 ZZZ99349 $256.82 $256.82 N/A 99468 $1,988.08 $1,988.08 N/A99350 $355.87 $355.87 N/A 99469 $799.48 $799.48 N/A99354 $258.94 $244.09 ZZZ 99471 $1,729.13 $1,729.13 N/A99355 $195.27 $181.12 ZZZ 99472 $824.94 $824.94 N/A99356 $183.95 $183.95 ZZZ 99475 $1,153.93 $1,153.93 N/A99357 $183.95 $183.95 ZZZ 99476 $689.10 $689.10 N/A99358 $223.57 $223.57 N/A 99477 $707.50 $707.50 N/A99359 $107.54 $107.54 ZZZ 99478 $280.88 $280.88 N/A99360 $122.40 $122.40 N/A 99479 $249.75 $249.75 N/A99363 $253.28 $168.38 N/A 99480 $241.26 $241.26 N/A99364 $86.32 $64.38 N/A 99485 $153.53 $153.53 N/A99366 $85.61 $84.19 N/A 99486 $133.01 $133.01 N/A99367 $112.49 $112.49 N/A 99487 $184.66 $104.00 N/A99368 $73.58 $73.58 N/A 99489 $92.68 $52.36 ZZZ99374 $140.08 $112.49 N/A 99490 $84.19 $64.38 N/A99375 $208.71 $176.17 N/A 99495 $326.16 $220.74 N/A99377 $140.08 $112.49 N/A 99496 $461.29 $319.79 N/A99378 $208.71 $176.17 N/A 99497 $163.43 $153.53 N/A99379 $140.08 $112.49 N/A 99498 $142.92 $142.92 ZZZ99380 $208.71 $176.17 N/A 99499 80% of billed 80% of billed N/A99381 $220.03 $153.53 N/A 99500 80% of billed 80% of billed N/A99382 $229.94 $162.72 N/A 99501 80% of billed 80% of billed N/A99383 $239.84 $173.34 N/A 99502 80% of billed 80% of billed N/A99384 $269.56 $204.47 N/A 99503 80% of billed 80% of billed N/A99385 $261.07 $195.98 N/A 99504 80% of billed 80% of billed N/A99386 $303.52 $238.43 N/A 99505 80% of billed 80% of billed N/A99387 $328.99 $255.41 N/A 99506 80% of billed 80% of billed N/A99391 $197.39 $140.08 N/A 99507 80% of billed 80% of billed N/A99392 $210.84 $153.53 N/A 99509 80% of billed 80% of billed N/A99393 $210.13 $153.53 N/A 99510 80% of billed 80% of billed N/A99394 $230.64 $173.34 N/A 99511 80% of billed 80% of billed N/A99395 $235.60 $178.29 N/A 99512 80% of billed 80% of billed N/A99396 $251.16 $193.86 N/A 99600 80% of billed 80% of billed N/A99397 $270.26 $204.47 N/A 99601 80% of billed 80% of billed N/A

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 83 of 84

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Note: Listing of a payment amount does not guarantee payment. See OAR 436-009-0040

Effective April 1, 2017 Link to medical fee and payment rules

HCPCS/ Non-Facility Facility Global HCPCS/ Non-Facility Facility Global

OSC Mod Maximum Maximum Days OSC Mod Maximum Maximum Days

Appendix B for Administrative Order No. 17-050

Physician Fee Schedule

CPT only copyright 2016 American Medical Association. All rights reserved.

99602 80% of billed 80% of billed N/A99605 80% of billed 80% of billed N/A99606 80% of billed 80% of billed N/A99607 80% of billed 80% of billed N/AAR001 $358.60 $358.60 N/AAR002 $477.67 $477.67 N/AAR003 $597.44 $597.44 N/AAR004 $179.30 $179.30 N/AAR011 $61.64 $61.64 N/AAR012 $92.45 $92.45 N/AAR013 $123.97 $123.97 N/AAR021 $61.64 $61.64 N/AAR022 $154.79 $154.79 N/AAR023 $371.21 $371.21 N/AAR024 $716.51 $716.51 N/AAR025 $956.05 $956.05 N/AAR031 $61.64 $61.64 N/AAR032 $123.97 $123.97 N/ACE001 80% of billed 80% of billed N/ACR001 80% of billed 80% of billed N/AD0001 as billed as billed N/AD0002 as billed as billed N/AD0003 as billed as billed N/AD0019 as billed as billed N/AD0030 as billed as billed N/AG0477 $21.75 $21.75 N/AG0478 $29.00 $29.00 N/AG0479 $116.00 $116.00 N/AG0480 $127.75 $127.75 N/AG0481 $196.53 $196.53 N/AG0482 $265.32 $265.32 N/AG0483 $343.93 $343.93 N/AN0001 $119.77 $119.77 N/AN0002 $238.84 $238.84 N/AP0001 $299.07 $299.07 N/AP0003 $299.07 $299.07 N/AP0004 $358.60 $358.60 N/AP0005 $151.99 $151.99 N/AR0001 $10.00 1st pg $10.00 1st pg N/A

R0002 $35.00 $35.00 N/AW0001 as billed as billed N/A

$.50 for each page thereafter

*ZZZ means the code is related to another service that is always included in the global period of the other service. Page 84 of 84