Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf ·...

263
Healthcare and Family Services Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice Nurses, Imaging Centers, Portable X-ray Companies, School- Based/Linked Health Centers, Local Health Departments, Encounter Rate Clinics, Independent Laboratories, Fee-For-Service Hospitals, and Optometrists and Dentists Providing Medical Services Instructions for billing multiples Note is A: Enter in the days/units field the number of tests performed on a single date of service. When the quantity exceeds 5, claim must be submitted on paper with all test results attached. Note is B and Procedures: -are bilateral, submit the procedure code once with modifier 50 and show quantity “1” in days/units field to represent two procedures performed. -are not bilateral, submit on paper with all test results attached. Submit the procedure code on one service section, and submit in the next service section the unlisted procedure code for any quantity beyond the first. List total number and name of additional tests in description field. Note is C and procedures: -are bilateral, submit the procedure code with modifier RT and quantity “1” in days/units field, and in the subsequent service section submit the same procedure code with modifier LT and quantity “1” in days/units field -are not bilateral, submit on paper with all test results attached. Submit the procedure code on one service section, and submit in the next service section the unlisted procedure code for any quantity beyond the first. List total number and name of additional tests in description field. Maximum Quantity is greater than 1: Submit in the days/units field the number of units performed or dispensed on a single date of service. HP=Y: *The number listed in the days/units field must be “1” -Practitioner purchased and administered drugs: May be submitted electronically or on paper. The claim must contain the name of the drug, strength of the drug, and the amount given shown in the description/note field and must be billed according to NDC billing guidelines available on our Web site at http://www.hfs.illinois.gov/assets/122107n.pdf -Medical/surgical procedures: Claims must be submitted on paper. The name of the procedure and total number of times performed must be submitted in the description/note field, and the procedure note must be attached. HP = N; Max qty is “1” or blank, and note fields are blank, and procedures: -are bilateral, submit the procedure code with modifier RT and quantity “1” in days/units field, and in the subsequent service section submit the same procedure code with modifier LT and quantity “1” in days/units field -are not bilateral, claims must be submitted on paper with procedure report attached. Submit the procedure code on one service section, and submit in the next service section the unlisted procedure code for any quantity beyond the first. List total number and name of additional tests in description field.

Transcript of Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf ·...

Page 1: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

Healthcare and Family Services Practitioner Fee Schedule Key

2/1/2010

For charges submitted by Physicians, Advanced Practice Nurses, Imaging Centers, Portable X-ray Companies, School-Based/Linked Health Centers, Local Health Departments, Encounter Rate Clinics, Independent Laboratories, Fee-For-Service

Hospitals, and Optometrists and Dentists Providing Medical Services

Instructions for billing multiples

Note is A: Enter in the days/units field the number of tests performed on a single date of service. When the quantity exceeds 5, claim must be submitted on paper with all test results attached.

Note is B and Procedures:

-are bilateral, submit the procedure code once with modifier 50 and show quantity “1” in days/units field to represent two procedures performed. -are not bilateral, submit on paper with all test results attached. Submit the procedure code on one service section, and submit in the next service section the unlisted procedure code for any quantity beyond the first. List total number and name of additional tests in description field.

Note is C and procedures:

-are bilateral, submit the procedure code with modifier RT and quantity “1” in days/units field, and in the subsequent service section submit the same procedure code with modifier LT and quantity “1” in days/units field -are not bilateral, submit on paper with all test results attached. Submit the procedure code on one service section, and submit in the next service section the unlisted procedure code for any quantity beyond the first. List total number and name of additional tests in description field.

Maximum Quantity is greater than 1:

Submit in the days/units field the number of units performed or dispensed on a single date of service.

HP=Y: *The number listed in the days/units field must be “1” -Practitioner purchased and administered drugs: May be submitted electronically or on paper. The claim must contain the name of the drug, strength of the drug, and the amount given shown in the description/note field and must be billed according to NDC billing guidelines available on our Web site at http://www.hfs.illinois.gov/assets/122107n.pdf -Medical/surgical procedures: Claims must be submitted on paper. The name of the procedure and total number of times performed must be submitted in the description/note field, and the procedure note must be attached.

HP = N; Max qty is “1” or blank, and note fields are blank, and procedures:

-are bilateral, submit the procedure code with modifier RT and quantity “1” in days/units field, and in the subsequent service section submit the same procedure code with modifier LT and quantity “1” in days/units field -are not bilateral, claims must be submitted on paper with procedure report attached. Submit the procedure code on one service section, and submit in the next service section the unlisted procedure code for any quantity beyond the first. List total number and name of additional tests in description field.

Page 2: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

Healthcare and Family Services Practitioner Fee Schedule Key

2/1/2010

Fee Schedule Key COLUMN HEADING COLUMN DESCRIPTION

HCPCS CPT-4 or HCPCS procedure code

Note Special billing information applies to the code A Professional and technical components are each reimbursed at

50% of the state maximum. B Professional and technical components are each reimbursed at

50% of the state maximum, rounded to the nearest cent. C Reimbursements for professional and technical components split at

a rate other than 50% D Code is billable by encounter rate clinic only. E Vaccine is supplied through the Vaccines For Children (VFC)

program. The department reimburses for the administrative cost (practice expense) of the vaccine only, for ages 0-19 years, as shown in the Unit Price column.

F Vaccine is not available through the VFC. The department reimburses for the vaccine when it is medically necessary.

G Vaccine is supplied for children, but not adults, through the VFC. The department reimburses for the administrative cost (practice expense) of the vaccine for ages 0-18 years as shown in the Unit Price column. The department reimburses for the vaccine for adults, ages 19 and older, as shown in the State Max column when medically necessary.

H Removed

I Removed

J Covered only for blood lead draws as a Healthy Kids service for ages 0-20 years, and must be billed with the U1 modifier as documentation that the service meets this description.

M Age restricted to 9-26 years. Vaccine is supplied through the VFC program for ages 9-18 years. The department reimburses VFC-enrolled providers for administrative cost (practice expense) as shown in the Unit Price column. The department reimburses for the vaccine for ages 19-26 years, and ages 9-26 years for non-VFC providers, as shown in the State Max column. Additional information is provided at http://www.hfs.illinois.gov/physicians/.

N Prior approval required for physician-purchased and administered drug. Prior approval guidelines are provided at http://www.hfs.illinois.gov/pharmacy/guidelines.html.

P Add-on applies only when the Primary Care Physician provides services.

Q State maximum amount now includes the Maternal Child Health Add-on amount for all providers.

R Covered only for ages 0-20 years. Reimbursement for professional and technical components splits at a rate other than 50%.

Page 3: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

Healthcare and Family Services Practitioner Fee Schedule Key

2/1/2010

S © indicates child professional and technical components, (A) indicates adult professional and technical components

Prog Cov (Program Coverage)

02-Title XIX coverage only (limited Transitional Assistance coverage) 04-Medicaid covered services 09-Qualified Medicare Beneficiary (QMB) coverage only (See Chap 100 Section 120.12, posted on our Web site at <http://www.hfs.illinois.gov/handbooks/chapter100.html

Eff Date (Effective Date)

Effective date of codes added on or after 01/01/07 or date of change in payment policy.

HP (Hand Priced Indicator)

If “Y”, special pricing methodology is applied.

NDC Ind (NDC indicator)

If “Y”, the 11-digit NDC must be billed according to NDC billing guidelines available on our Web site at http://www.hfs.illinois.gov/assets/122107n.pdf

Surg Ind (Surgery Indicator)

B = Obstetrical service N = Not considered surgical I = Incidental. Procedure may not pay separately when billed with other surgical codes. M = Major. Reimbursement for procedure includes 30-day postoperative care.

AV (Anesthesia Value)

Value assigned by dept and used in the calculation of anesthesia payment.

M1 (Modifier 1) 26 Rate paid for the professional component of the procedure. M2 (Modifier 2) TC Rate paid for the technical component of the procedure.

Assist Surg (Assist Surgeon)

“Y” indicates services of an assistant at surgery may be paid.

CoSurg (Co-Surgeon) “Y” indicates services of a co-surgeon may be paid Unit Price Price for each unit when multiple quantities are billable or base

amount payable for ages 0-20 years when followed by “C”. Max Qty

(Maximum Quantity) The maximum number of units payable for the code.

State Max (State Maximum)

The maximum allowable reimbursement (reflects combined professional and technical components where applicable) or The base amount payable for ages 21 years and older when followed by “(A)”.

Add-On Surg: The amount added to the state maximum when the procedure is performed in the practitioner’s office. This amount covers such items as casting and surgical supplies. Child: The amount added to the state maximum for services rendered to ages 0-20 years. Preventive medicine and Evaluation and Management code add-ons are payable only to Primary Care Providers. Adult: The amount added to the state maximum for services rendered to ages 21 years and older. Preventive medicine and Evaluation and Management code add-ons are payable only to Primary Care Providers.

Page 4: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

Updated 02/01/10

MOD DESCRIPTION HOW PAYMENT IS AFFECTED

25 Significant, separately identifiable E&M service same physician same dMay allow E&M payment separate from another service

26 Professional componentPays professional component only (*see practitioner fee schedule, Notes A, B, C)

50 Bilateral procedureBill procedure code one time with modifier and quantity "1" to indicate bilaterals performed (*see practitioner fee schedule, Note B)

51 Multiple proceduresApplies only to billing multiple NDCs (**see Informational Notice to Physicians dated 12-21-07)

52 Reduced services Goes to hand pricing, requires attachment of additional information53 Discontinued procedure Not payable; bill only for services completed57 Decision for surgery Goes to hand pricing to determine if payable outside surgical package59 Distinct procedural service Applies to Medicare crossovers only62 Two surgeons Each surgeon is paid at 50% state maximum

73 Discontinued outpatient procedure prior to anesthesia administration Not payable; bill only for services completed

74 Discontinued outpatient procedure after anesthesia administration Not payable; bill only for services completed

76 Repeat procedure by same physicianApplies only to billing multiple NDCs (**see Informational Notice to Physicians dated 12-21-07)

80 Assistant surgeon Payment is based on minutes billed81 Minimum assistant surgeon Payment is based on minutes billed82 Assistant surgeon when qualified resident surgeon not available Payment is based on minutes billed90 Reference (outside) laboratory Not payable for APL or inpatient procedures91 Repeat clinical diagnostic laboratory test Applies to Medicare crossovers onlyAH Clinical psychologist Billable only by FQHC and RHCAJ Clinical social worker Billable only by FQHC and RHC

ASPhysician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery Payment is based on minutes billed

AT Acute Treatment Sterilization permit not required when procedure performed for acute reason and not for sterilization purposes

MODIFIERS RECOGNIZED IN PROCESSING SERVICE CLAIMSILLINOIS HEALTHCARE AND FAMILY SERVICES CLAIMS

Page 5: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

MOD DESCRIPTION HOW PAYMENT IS AFFECTEDE1 Upper left eyelid Processes separately from same CPT with different eyelid modifierE2 Lower left eyelid Processes separately from same CPT with different eyelid modifierE3 Upper right eyelid Processes separately from same CPT with different eyelid modifierE4 Lower right eyelid Processes separately from same CPT with different eyelid modifier

EPService provided as part of medicaid early periodic screening diagnosis and treatment (EPSDT) program Service is processed as a Healthy Kids service

F1 Left hand, second digit Processes separately from same CPT with different digit modifierF2 Left hand, third digit Processes separately from same CPT with different digit modifierF3 Left hand, fourth digit Processes separately from same CPT with different digit modifierF4 Left hand, fifth digit Processes separately from same CPT with different digit modifierF5 Right hand, thumb Processes separately from same CPT with different digit modifierF6 Right hand, second digit Processes separately from same CPT with different digit modifierF7 Right hand, third digit Processes separately from same CPT with different digit modifierF8 Right hand, fourth digit Processes separately from same CPT with different digit modifierF9 Right hand, fifth digit Processes separately from same CPT with different digit modifierFA Left hand, thumb Processes separately from same CPT with different digit modifierFP Service provided as part of family planning program Service is processed as a family planning serviceGN Outpatient speech therapy **See Therapists Provider Notice dated 061605GO Outpatient occupational therapy **See Therapists Provider Notice dated 061605GP Outpatient physical therapy **See Therapists Provider Notice dated 061605GT Via interactive audio and video telecommunication systems **See Expansion of Telehealth Services Notice dated 011210

GZItem or service expected to be denied as not reasonable and necessary Not payable

HD Pregnant/parenting women's program Service is processed as a postpartum depression screening

HE Mental health programInpatient/outpatient psychiatric consultation or inpatient psychiatric subsequent care rate (**see Physician Provider Notice dated 102903)

HO Masters degree level; added 060108 effective 10/22/07 Billable only by FQHC and RHC

LC Left circumflex coronary arteryProcesses separately from same CPT with different coronary artery modifier

LD Left anterior descending coronary arteryProcesses separately from same CPT with different coronary artery modifier

LT Left side Processes separately from same CPT with RT modifierNU New equipment Processes as PurchaseP1 Normal, healthy patient Anesthesia converts to modifying units "0"P2 Patient with mild systemic disease Anesthesia converts to modifying units "1"

Page 6: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

MOD DESCRIPTION HOW PAYMENT IS AFFECTEDP3 Patient with severe systemic disease Anesthesia converts to modifying units "2"P4 Patient with severe systemic disease that is a constant threat to life Anesthesia converts to modifying units "3"P5 Moribund patient not expected to survive without the operation Anesthesia converts to modifying units "4"

P6Declared brain-dead patient whose organs are being removed for donor purposes Anesthesia converts to modifying units "0"

QL Patient pronounced dead after ambulance called Not payable

QMAmbulance service provided under arrangement by a provider of services Not payable

QW CLIA waived testProcesses at the waived CLIA rate (*see practitioner fee schedule, Note I)

RC Right coronary arteryProcesses separately from same CPT with different coronary artery modifier

RR Rental Processes as rentalRT Right side Processes separately from same CPT with LT modifier

SL State supplied vaccineProcesses HPV vaccine to Obstetricians not enrolled with VFC (**see Physician Provider Notice dated 061507)

T1 Left foot, second digit Processes separately from same CPT with different digit modifierT2 Left foot, third digit Processes separately from same CPT with different digit modifierT3 Left foot, fourth digit Processes separately from same CPT with different digit modifierT4 Left foot, fifth digit Processes separately from same CPT with different digit modifierT5 Right foot, great toe Processes separately from same CPT with different digit modifierT6 Right foot, second digit Processes separately from same CPT with different digit modifierT7 Right foot, third digit Processes separately from same CPT with different digit modifierT8 Right foot, fourth digit Processes separately from same CPT with different digit modifierT9 Right foot, fifth digit Processes separately from same CPT with different digit modifierTA Left foot, great toe Processes separately from same CPT with different digit modifier

TC Technical componentPays technical component only (*see practitioner fee schedule, Notes A, B, C)

TTIndividualized service provided to more than one patient in same setting

Processes as coincident visit Long Term care(**see Physician Provider Notice dated 102903)

U1 Local modifier-Blood lead drawBlood specimen drawn for lead analysis as part of Healthy Kids program (***see Chapter HK-200 Section 202.1)

U2 Local modifier-Home Health nursing assessment visitProcesses as assessment visit only (***see Home Health Handbook Section R-203.1)

U4 Local modifier-Pregnancy resulting from rape Claim requires abortion payment application HFS form 2390

Page 7: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

MOD DESCRIPTION HOW PAYMENT IS AFFECTED

U5 Local modifier-Obstetrical/gynecological services Processes as Ob/Gyn Direct Access service available without a referral

U6 Local modifier-Service provided within 60 days of hospital dischargeProcesses as therapy visit within 60 days of hospital discharge(***see Therapy Providers Handbook Section J-211)

U7 Local modifier-Pregnancy resulting from incest Claim requires abortion payment application HFS form 2390U8 Local modifier-Pregnancy threatening the mother's life Claim requires abortion payment application HFS form 2390

Page 8: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

Add-On

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

00100 04 Y I 300102 04 Y M 300103 04 Y M 500104 02 N N 44.4000120 04 Y M 400124 04 Y I 300126 04 Y I 300140 04 Y M 500142 04 Y M 500144 04 Y M 500145 04 Y M 500147 04 Y M 500148 04 Y I 300160 04 Y M 400162 04 Y M 400164 04 Y I 400170 04 Y I 500172 04 Y M 500174 04 Y M 400176 04 Y M 400190 04 Y M 400192 04 Y M 400210 04 Y M 900211 04 01-Jan-09 Y M 900212 04 Y M 400214 04 Y M 900215 04 Y M 900216 04 Y M 900218 04 Y M 900220 04 Y M 1100222 04 Y M 900300 04 Y M 300320 04 Y M 6

Healthcare and Family ServicesPractitioner Fee Schedule

Revised 02/01/10

Page 9: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

00322 04 Y M 300326 04 Y M 400350 04 Y M 1500352 04 Y M 500400 04 Y I 300402 04 Y M 400404 04 Y M 400406 04 Y M 400410 04 N I 112.4000450 04 Y M 300452 04 Y M 600454 04 Y I 300470 04 Y M 400472 04 Y M 700474 04 Y M 500500 04 Y M 900520 04 Y M 400522 04 Y I 400524 04 Y M 400528 04 Y M 400529 04 Y N 500530 04 Y M 500532 04 Y I 300534 04 Y M 500537 04 Y I 500539 04 Y M 1100540 04 Y M 1100541 04 Y M 1100542 04 Y M 1100546 04 Y M 700548 04 Y M 1100550 04 Y M 300560 04 Y M 2000561 04 Y M 2000562 04 Y M 2000563 04 Y M 2000566 04 Y M 2000567 04 01-Jan-09 Y M 20

Page 10: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

00580 04 Y M 2000600 04 Y M 800604 04 Y M 800620 04 Y M 800622 04 Y M 1100625 04 01-Jan-07 Y M 1000626 04 01-Jan-07 Y N 1000630 04 Y M 700632 04 Y M 400634 04 Y M 400635 04 Y I 300640 04 Y M 800670 04 Y M 700700 04 Y M 400702 04 Y I 300730 04 Y M 400740 04 Y M 400750 04 Y M 300752 04 Y M 300754 04 Y M 300756 04 Y M 600770 04 Y M 1500790 04 Y M 600792 04 Y M 1200794 04 Y M 600796 04 Y M 1200797 04 Y M 500800 04 Y M 400802 04 Y M 30080T 04 Y N 1500810 04 Y M 400820 04 Y M 400830 04 Y M 300832 04 Y M 300834 04 Y M 300836 04 Y M 300840 04 Y M 400842 04 Y I 4

Page 11: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

00844 04 Y M 600846 04 Y M 500848 04 Y M 600851 04 Y M 400860 04 Y M 400862 04 Y M 500864 04 Y M 700865 04 Y M 600866 04 Y M 900868 04 Y M 500870 04 Y M 500872 04 Y M 300873 04 Y M 300880 04 Y M 400882 04 Y M 500902 04 Y M 400904 04 Y M 300906 04 Y M 300908 04 Y M 600910 04 Y M 300912 04 Y M 300914 04 Y M 500916 04 Y M 500918 04 Y M 300920 04 Y M 300921 04 Y M 300922 04 Y M 300924 04 Y M 400926 04 Y M 300928 04 Y M 400930 04 Y M 300932 04 Y M 300934 04 Y M 400936 04 Y M 400938 04 Y M 300940 04 Y I 300942 04 Y M 300944 04 Y M 5

Page 12: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

00948 04 Y I 300950 04 Y I 300952 04 Y I 301112 04 Y I 301120 04 Y M 301130 04 Y I 301140 04 Y M 1101150 04 Y M 1101160 04 Y M 301170 04 Y M 301173 04 Y M 301180 04 Y M 301190 04 Y M 301200 04 Y M 501202 04 Y M 301210 04 Y M 301212 04 Y M 801214 04 Y M 301215 04 Y I 301220 04 Y M 301230 04 Y M 401232 04 Y M 301234 04 Y M 601250 04 Y M 301260 04 Y M 1001270 04 Y M 1001272 04 Y M 501274 04 Y M 501320 04 Y M 301340 04 Y M 301360 04 Y M 401380 04 Y M 301382 04 Y M 301390 04 Y M 401392 04 Y M 401400 04 Y M 301402 04 Y M 301404 04 Y M 3

Page 13: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

01420 04 Y I 301430 04 Y M 501432 04 Y M 501440 04 Y M 501442 04 Y M 501444 04 Y M 501462 04 Y M 301464 04 Y M 301470 04 Y M 401472 04 Y M 301474 04 Y M 301480 04 Y M 301482 04 Y M 301484 04 Y M 301486 04 Y M 301490 04 Y I 301500 04 Y M 1001502 04 Y M 501520 04 Y M 1001522 04 Y M 501610 04 Y M 301620 04 Y M 301622 04 Y M 301630 04 Y M 301634 04 Y M 501636 04 Y M 1101638 04 Y M 301650 04 Y M 501652 04 Y M 1501654 04 Y M 1001656 04 Y M 1001670 04 Y M 1001680 04 Y I 301682 04 Y I 301710 04 Y M 301712 04 Y M 301714 04 Y M 301716 04 Y M 3

Page 14: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

01730 04 Y M 301732 04 Y M 301740 04 Y M 301742 04 Y M 301744 04 Y M 301756 04 Y M 301758 04 Y M 301760 04 Y M 301770 04 Y M 501772 04 Y M 501780 04 Y M 501782 04 Y M 301810 04 Y M 301820 04 Y M 301829 04 N M 3 356.1001830 04 Y M 301832 04 Y M 301840 04 Y M 501842 04 Y M 501844 04 Y M 501850 04 Y M 1001852 04 Y M 301860 04 Y M 301916 04 Y I 301920 04 Y M 301922 04 Y I 301924 04 Y M 301925 04 Y M 301926 04 Y I 301930 04 Y M 501931 04 Y M 801932 04 Y M 601933 04 Y M 901935 04 01-Jan-08 Y M 501936 04 01-Jan-08 Y M 501951 04 Y I 301952 04 Y I 301953 04 Y I 3

Page 15: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

01958 04 Y M 401960 09 Y M 401961 04 Y M 501962 04 Y M 501963 04 Y M 501965 04 Y M 301966 04 01-Jul-08 Y M 301967 04 Y M 301968 04 Y M 301969 04 Y M 301991 04 Y I 301992 04 Y I 301996 04 N I 14.2501999 04 Y M 310021 04 N I 3 49.8010022 04 N I 3 56.7010040 04 N I 3 35.2010060 04 N I 3 36.0010061 04 N I 3 66.5010080 04 N I 3 70.65.10081 04 N I 4 131.8010120 04 N I 3 39.0510121 04 N I 3 77.6010140 04 N I 3 41.5010160 04 N I 3 35.9510180 04 N I 3 Y 130.5511000 04 N I 3 77.7011001 04 N I 3 20.8511004 04 N M 3 Y Y 154.4311005 04 N M 3 Y Y 154.4311006 04 N M 3 Y Y 154.4311008 04 N M 3 Y Y 154.4311010 04 N I 3 127.6011011 04 N I 3 157.9011012 04 N I 3 218.4011040 04 N I 3 34.1011041 04 01-Jan-10 N I 3 51.9011042 04 01-Jan-10 N I 3 70.55

Page 16: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

11043 04 01-Jan-10 N M 3 170.5511044 04 N M 3 Y 219.3511055 04 N I 3 22.1511056 04 Y I 311057 04 Y I 311100 04 N I 3 50.20 17.0011101 04 N I 3 22.1511200 04 N I 3 35.65 17.0011201 04 N I 3 15.2011300 04 N I 3 21.1011301 04 N I 3 29.2011302 04 N I 3 37.5011303 04 N I 3 45.7011305 04 N I 3 22.2511306 04 N I 3 31.2511307 04 N I 3 37.5011308 04 N I 3 45.7011310 04 N I 3 32.4011311 04 N I 3 40.5511312 04 N I 3 48.8011313 04 N I 3 57.1011400 04 N I 3 39.05 17.0011401 04 N I 3 50.20 17.0011402 04 N I 3 64.80 17.0011403 04 N I 3 77.90 17.0011404 04 N I 3 92.40 17.0011406 04 N I 3 108.00 17.0011420 04 N I 3 38.30 17.0011421 04 N I 3 50.85 17.0011422 04 N I 3 64.80 17.0011423 04 N I 3 77.90 17.0011424 04 N I 3 92.40 17.0011426 04 N I 3 127.48 17.0011440 04 N I 3 54.15 17.0011441 04 N I 3 75.30 17.0011442 04 N I 3 96.40 17.0011443 04 N I 3 111.00 17.0011444 04 N I 3 117.55 17.00

Page 17: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

11446 04 N I 3 146.37 17.0011450 04 N M 3 Y 215.40 34.0011451 04 N M 3 Y 244.10 34.0011462 04 N M 3 Y 215.40 34.0011463 04 N M 3 Y 232.2011470 04 N M 3 Y 291.3011471 04 N M 3 Y 297.0011600 04 N I 3 54.15 17.0011601 04 N I 3 75.30 17.0011602 04 N I 3 96.40 17.0011603 04 N I 3 117.55 17.0011604 04 N I 3 138.75 17.0011606 04 N M 3 185.52 17.0011620 04 N I 3 54.15 17.0011621 04 N I 3 75.30 17.0011622 04 N I 3 96.40 17.0011623 04 N I 3 117.55 17.0011624 04 N I 3 138.75 17.0011626 04 N M 3 185.52 17.0011640 04 N I 3 107.00 17.0011641 04 N I 3 149.25 17.0011642 04 N M 3 192.95 17.0011643 04 N M 3 235.20 17.0011644 04 N M 3 278.80 17.0011646 04 N M 3 294.77 17.0011719 04 N I 3 15.9011720 04 N I 15.9011721 04 N I 18.1011730 04 N I 3 34.30 17.0011732 04 N I 3 14.4511740 04 N I 3 36.0011750 04 N I 3 61.85 34.0011752 04 01-Jan-10 N M 3 167.40 34.0011755 04 N I 3 38.8011760 04 N I 3 60.80 17.0011762 04 N I 3 87.75 17.0011765 04 N I 3 38.4011770 04 N M 4 215.40 34.00

Page 18: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

11771 04 N M 4 Y 291.3011772 04 N M 4 Y 341.2511900 04 N I 3 21.10 17.0011901 04 Y I 311920 09 Y M Y Y11921 04 N I 63.5711922 04 N I 16.1311950 09 Y M11951 09 Y M11952 09 Y M11954 09 Y M11960 04 N M 3 Y 350.0511970 04 N M 3 475.7011971 04 N I 3 Y Y 135.0011975 04 N I 3 108.0011976 04 N I 3 108.0011977 04 N I 3 108.0011980 04 N M 3 108.0011981 04 N I 3 72.3011982 04 N I 3 87.0011983 04 N I 3 108.0012001 04 01-Jan-10 N I 3 53.10 17.0012002 04 N I 3 58.40 17.0012004 04 N I 3 69.70 17.0012005 04 N I 3 100.40 17.0012006 04 N I 3 145.80 17.0012007 04 Y M 312011 04 N I 3 56.40 17.0012013 04 N I 3 64.00 17.0012014 04 N I 3 112.90 17.0012015 04 N I 3 125.50 17.0012016 04 N I 3 200.75 17.0012017 04 N M 3 259.20 17.0012018 04 N M 3 272.6312020 04 N I 3 139.30 17.0012021 04 N I 3 88.70 17.0012031 04 N I 3 64.70 17.0012032 04 N I 3 81.60 17.00

Page 19: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

12034 04 N I 3 106.65 17.0012035 04 N I 3 144.30 17.0012036 04 N M 3 194.50 17.0012037 04 N M 3 261.1212041 04 N I 3 72.10 17.0012042 04 N I 3 94.10 17.0012044 04 N I 3 119.20 17.0012045 04 N I 3 156.85 17.0012046 04 N M 3 207.10 17.0012047 04 N M 3 270.4512051 04 N I 3 74.70 17.0012052 04 N I 3 94.10 17.0012053 04 N I 3 112.90 17.0012054 04 N I 3 131.80 17.0012055 04 N I 3 169.40 17.0012056 04 N M 3 219.60 17.0012057 04 N M 3 305.6813100 04 N I 3 110.0413101 04 N I 3 127.5713102 04 Y I 313120 04 N I 3 114.9813121 04 N I 3 138.5513122 04 Y I 313131 04 N I 3 127.8513132 04 N I 3 178.1813133 04 Y I 313150 04 N I 3 150.6713151 04 N I 3 160.8313152 04 N I 3 205.5513153 04 Y I 313160 04 N M 3 Y 295.8814000 04 N M 3 224.2514001 04 N M 3 291.6914020 04 N M 3 Y 244.4014021 04 N M 3 Y 328.0714040 04 N M 3 Y 277.0714041 04 N M 3 Y 375.1014060 04 N M 3 Y 299.29

Page 20: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

14061 04 N M 3 Y 405.2014301 04 01-Jan-10 N M 3 Y 496.6514302 04 01-Jan-10 Y M 3 Y14350 04 N M 3 270.2015002 04 01-Jan-10 N M 3 Y 87.8515003 04 01-Jan-07 Y M 3 Y15004 04 01-Jan-10 N M 3 Y 102.6315005 04 01-Jan-07 Y M 3 Y15040 04 N M 3 71.0115050 04 N M 3 Y 131.8015100 04 N M 3 Y 263.5515101 04 Y M 315110 04 N M 3 71.0115111 04 N M 3 Y 71.0015115 04 N M 3 Y 382.2115116 04 N M 3 Y 84.0115120 04 N M 3 Y 307.9015121 04 Y M 3 Y15130 04 N M 3 Y 297.4415131 04 N M 3 Y 50.1115135 04 N M 3 Y 414.0315136 04 N M 3 Y 50.4115150 04 N M 3 Y 330.8715151 04 N M 3 Y 66.7515152 04 N M 3 Y 83.3915155 04 N M 3 Y 354.6615156 04 N M 3 Y 92.4815157 04 N M 3 Y 100.7715170 04 N M 3 Y 167.6315171 04 N M 3 Y 50.2915175 04 N M 3 Y 249.0715176 04 N M 3 Y 79.4215200 04 N M 3 Y 318.6015201 04 Y M 3 Y15220 04 N M 3 Y 307.9015221 04 Y M 3 Y15240 04 N M 3 Y 308.9615241 04 Y M 3 Y

Page 21: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

15260 04 N M 3 Y 332.7215261 04 Y M 3 Y15300 04 N M 3 Y 141.6915301 04 N M 3 Y 32.9015320 04 N M 3 Y 165.1115321 04 N M 3 Y 49.1615330 04 N M 3 Y 141.5015331 04 N M 3 Y 32.9015335 04 01-Jan-10 N M 3 158.2915336 04 N M 3 Y 47.0115340 04 01-Jan-10 N I 3 143.6015341 04 N M 3 Y 16.1915360 04 N M 3 Y 153.6215361 04 N M 3 Y 37.2915365 04 N M 3 Y 162.5615366 04 N M 3 Y 46.8515400 04 N M 3 165.3015401 04 Y M 315420 04 N M 3 Y 183.0715421 04 N M 3 Y 49.7315430 04 N M 3 Y 267.3915431 04 Y M 3 Y15570 04 N M 3 Y 298.2415572 04 N M 3 Y 292.3415574 04 N M 3 Y 466.6115576 04 N M 3 Y 296.3015600 04 N M 3 Y 259.8115610 04 N M 3 Y 97.4715620 04 N M 3 Y 158.2615630 04 N M 3 Y 310.6115650 04 N M 3 Y 168.2715731 04 01-Jan-07 N M 5 Y 168.2715732 04 N M 3 Y Y 536.6015734 04 N M 3 Y Y 569.2515736 04 N M 3 Y 512.7015738 04 N M 3 Y 520.2515740 04 N M 3 Y 321.6915750 04 N M 3 Y 339.54

Page 22: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

15756 04 N M 3 Y Y 1,306.6515757 04 N M 3 Y Y 1,306.6515758 04 N M 3 Y Y 1,306.6515760 04 N M 3 Y 300.0515770 04 N M 3 Y 307.9015775 09 Y M15776 09 Y M15780 09 Y M15781 09 Y M15782 09 Y M15783 09 Y M15786 09 Y I15787 09 Y M15819 04 N M 3 Y 274.3615820 04 N M 3 651.1015821 04 N M 3 651.1015822 04 N M 3 651.1015823 04 N M 3 651.1015830 04 01-Jan-10 Y M 5 Y Y15832 04 N M 3 340.1515833 04 N M 3 306.7515834 04 N M 3 308.3015835 04 N M 3 319.1015836 04 N M 3 265.3015837 04 N M 3 255.0015838 04 N M 3 Y 219.3515839 04 N M 3 Y 237.8015840 04 N M 3 Y 891.1015841 04 N M 3 Y 663.9615842 04 N M 3 Y 1,063.0315845 04 N M 3 Y 355.8315847 04 01-Jan-07 Y M 10 Y15850 04 N I 3 31.4015851 04 N I 3 48.6015852 04 N I 3 Y 31.9515860 04 N I 3 Y 55.5015876 04 Y M 315877 04 Y M 3

Page 23: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

15878 04 Y M 315879 04 Y M 315920 04 N M 4 Y 374.5515922 04 N M 4 Y 449.5015931 04 N M 3 Y Y 449.5015933 04 N M 3 Y 674.2015934 04 N M 3 Y Y 749.2015935 04 N M 3 Y Y 749.2015936 04 N M 3 Y 749.2015937 04 N M 3 Y Y 749.2015940 04 N M 3 Y 449.5015941 04 N M 3 Y 524.4015944 04 N M 3 Y 524.4015945 04 N M 3 Y 600.0015946 04 N M 3 Y 674.2015950 04 N M 3 Y 449.5015951 04 N M 3 Y 524.4015952 04 N M 3 Y 524.4015953 04 N M 3 Y 599.3515956 04 N M 3 Y 727.4015958 04 N M 3 Y 727.4015962 04 Y M 3 Y Y15963 04 Y M 3 Y Y15999 04 Y M 3 Y Y16000 04 01-Jan-10 N I 45.8016020 04 N I 24.90 17.0016025 04 N I 49.50 34.0016030 04 N I 61.65 34.0016035 04 N M 3 92.79 34.0016036 04 N M 3 36.7417000 04 N I 52.7017003 04 N I 3 8.85 13 115.0517004 04 N I 3 Y 86.5917106 04 N I 3 125.3517107 04 N M 3 238.8017108 04 N M 3 372.3017110 04 N I 3 74.9017111 04 N I 3 43.05

Page 24: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

17250 04 N I 3 18.9017260 04 N I 3 40.6017261 04 N I 3 60.7017262 04 N I 3 80.8517263 04 N I 3 100.9017264 04 N I 3 117.5517266 04 N M 3 162.0017270 04 N I 3 45.2517271 04 N I 3 64.5017272 04 N I 3 85.6017273 04 N I 3 106.7517274 04 N I 3 117.2017276 04 N M 3 162.0017280 04 N I 3 96.2017281 04 N I 3 127.7017282 04 N M 3 171.3017283 04 N M 3 213.6017284 04 N M 3 257.1017286 04 Y I 317311 04 01-Jan-07 N M 3 216.0017312 04 01-Jan-07 Y M 317313 04 01-Jan-10 N M 3 191.0917314 04 01-Jan-07 Y M 317315 04 01-Jan-07 Y M 317340 04 N I 3 26.2017360 04 N I 3 38.6517380 04 Y I 317999 04 Y M 3 Y Y19000 04 N I 3 37.4019001 04 N I 3 17.8019020 04 N I 3 135.9019030 04 N I 3 102.5019100 04 N I 3 59.6019101 04 N M 3 192.85 34.0019102 04 N M 3 164.85 34.0019103 04 N M 3 324.90 34.0019105 04 01-Jan-07 Y M 519110 04 N M 3 240.00 34.00

Page 25: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

19112 04 N M 3 240.0019120 04 N M 3 240.00 34.0019125 04 N M 3 240.0019126 04 N M 3 74.4519260 04 N M 4 Y 430.6419271 04 N M 4 Y 534.4519272 04 N M 4 Y 598.3419290 04 N I 3 59.4019291 04 N I 3 27.0019295 04 N I 3 63.1019296 04 N I 3 109.0119297 04 N I 3 109.0119298 04 N I 3 109.0119300 04 01-Jan-07 N M 3 Y 374.5519301 04 01-Jan-07 N M 3 Y 310.8019302 04 01-Jan-07 N M 5 Y 601.4519303 04 01-Jan-07 N M 3 Y 461.9519304 04 01-Jan-07 N M 3 Y 574.3519305 04 01-Jan-07 N M 5 Y 787.9519306 04 01-Jan-07 N M 4 Y 948.9019307 04 01-Jan-07 N M 5 Y 738.1019316 04 N M 3 Y 567.1019318 04 N M 3 Y 374.6019324 04 N M 3 Y 567.1019325 04 N M 3 Y 567.1019328 04 N M 3 Y 240.0019330 04 N M 3 Y 240.0019340 04 N M 3 Y 310.8019342 04 N M 3 Y 354.2019350 04 N M 3 Y 310.5519355 04 N M 3 Y Y 275.0019357 04 N M 3 Y 532.3019361 04 N M 3 Y 609.8019364 04 N M 3 Y 558.1519366 04 N M 3 Y 558.1519367 04 N M 3 Y Y 755.2019368 04 N M 3 Y 1,306.6519369 04 N M 3 Y 852.25

Page 26: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

19370 04 N M 3 Y 242.7019371 04 N M 3 Y 297.0019380 04 N M 3 Y 280.4019396 04 N M 3 136.8819499 04 Y M 3 Y20000 04 N I 3 59.80 17.0020005 04 N I 3 125.50 17.0020100 04 N M 3 Y 372.6520101 04 N M 3 Y 599.3520102 04 N M 4 Y 480.0020103 04 N M 3 Y 189.37 34.0020150 04 Y M 3 Y20200 04 N I 3 113.60 17.0020205 04 N M 3 252.35 17.0020206 04 N I 3 53.50 17.0020220 04 N I 90.1020225 04 N I 3 187.30 34.0020240 04 N M 3 220.5520245 04 N M 3 289.9020250 04 N M 3 163.0520251 04 N M 3 277.5020500 04 N I 3 61.4020501 04 N I 3 105.9020520 04 N M 3 107.00 17.0020525 04 N M 3 167.8020526 04 N I 31.3520550 04 N I 3 31.7520551 04 N I 3 31.7520552 04 N I 3 31.7520553 04 N I 3 31.7520555 04 01-Jan-08 N I 3 176.1020600 04 N I 3 30.40 17.0020605 04 N I 3 33.00 17.0020610 04 N I 3 31.80 17.0020612 04 N I 31.8020615 04 N I 3 73.3520650 04 N I 3 Y 141.5020660 04 N M 3 Y 192.85

Page 27: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

20661 04 N M 3 192.8520662 04 N I 3 203.8520663 04 N I 3 170.0520664 04 N M 3 Y 271.4520665 04 N I 3 134.6020670 04 N I 3 134.6020680 04 N M 3 Y 233.0020690 04 N I 3 Y Y 172.8020692 04 N I 3 Y 297.0020693 04 N I 3 Y 243.0020694 04 N I 3 Y 152.9520696 04 01-Jan-09 N M 3 Y 332.6420697 04 01-Jan-09 N I 3 349.2720802 04 Y M 5 Y Y20805 04 Y M 5 Y Y20808 04 Y M 5 Y Y20816 04 Y M 5 Y Y20822 04 Y M 3 Y Y20824 04 Y M 3 Y Y20827 04 Y M 3 Y Y20838 04 Y M 5 Y Y20900 04 N M 3 Y Y 224.7020902 04 N M 7 Y Y 374.5520910 04 Y M 7 Y Y20912 04 Y M 5 Y Y20920 04 N M 3 Y Y 168.1020922 04 N M 3 Y Y 231.1020924 04 N M 4 Y Y 212.9020926 04 Y M 3 Y Y20930 09 Y M20931 09 Y M20936 09 Y M20937 09 Y M20938 09 Y M20950 04 N I 3 44.8020955 04 Y M 5 Y Y20956 04 Y M 5 Y Y20957 04 Y M 5 Y Y

Page 28: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

20962 04 Y M 5 Y Y20969 04 Y M 5 Y Y20970 04 Y M 5 Y Y20972 04 Y M 3 Y Y20973 04 Y M 3 Y Y20974 09 Y M20975 04 N I 3 Y 82.9020979 04 N I 176.7020982 04 N M 4 Y 220.5720985 04 01-Jan-08 N M 5 Y 83.2320999 04 Y M 3 Y21010 04 N M 3 Y 374.5521011 04 01-Jan-10 N M 3 Y 135.0021012 04 01-Jan-10 N M 3 Y 186.1521013 04 01-Jan-10 N M 3 Y 219.0721014 04 01-Jan-10 N M 3 Y 287.9221015 04 01-Jan-10 N M 4 Y 333.3521016 04 01-Jan-10 N M 4 Y 583.6421025 04 N M 4 Y Y 299.7021026 04 N M 4 Y Y 299.7021029 04 Y M 4 Y21030 04 N M 3 Y 299.7021031 04 N M 3 Y 299.7021032 04 N M 3 Y 299.7021034 04 N M 4 Y 421.1021040 04 N M 3 Y 299.7021044 04 N M 4 Y 350.5521045 04 N M 4 Y Y 1,678.6521046 04 N M 5 Y Y 397.2021047 04 Y M 5 Y Y21048 04 Y M 5 Y Y21049 04 Y M 5 Y Y21050 04 N M 5 Y 524.4021060 04 N M 5 Y 524.4021070 04 N M 4 Y 299.7021073 04 01-Jan-08 N M 3 Y 188.9321076 04 Y I 321077 04 Y I 3

Page 29: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

21079 04 Y I 321080 04 Y I 321081 04 Y I 321082 04 Y I 321083 04 Y I 321084 04 Y I 321085 04 Y I 321086 04 Y I 321087 04 Y I 321088 04 Y I 321089 04 Y I 321100 04 N M 3 192.8521110 04 N M 3 Y 176.7021116 04 N I 3 73.2021120 04 N M 5 Y Y 1,198.7021121 04 N M 5 Y Y 1,198.7021122 04 N M 5 Y Y 1,414.7021123 04 N M 5 Y Y 1,522.7021125 04 N M 5 Y Y 1,198.7021127 04 N M 5 Y Y 1,306.6521137 04 N M 5 Y Y 958.6021138 04 N M 5 Y Y 1,198.7021139 04 N M 7 Y Y 1,522.7021141 04 N M 5 Y Y 1,198.7021142 04 N M 5 Y Y 1,306.6521143 04 N M 5 Y Y 1,414.7021145 04 N M 5 Y Y 1,306.6521146 04 N M 5 Y Y 1,522.7021147 04 N M 5 Y Y 1,522.7021150 04 N M 5 Y Y 1,306.6521151 04 N M 5 Y Y 1,522.7021154 04 N M 5 Y Y 1,306.6521155 04 N M 5 Y Y 1,522.7021159 04 N M 7 Y Y 1,522.7021160 04 N M 7 Y Y 1,522.7021172 04 N M 7 Y Y 1,522.7021175 04 N M 7 Y Y 1,522.7021179 04 N M 7 Y Y 1,414.70

Page 30: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

21180 04 N M 7 Y Y 1,522.7021181 04 N M 5 Y Y 958.6021182 04 N M 7 Y Y 1,522.7021183 04 N M 7 Y Y 1,522.7021184 04 N M 7 Y Y 1,630.7021188 04 N M 5 Y Y 1,306.6521193 04 N M 5 Y Y 1,198.7021194 04 N M 5 Y Y 1,414.7021195 04 N M 5 Y Y 1,198.7021196 04 N M 5 Y Y 1,198.7021198 04 N M 5 Y Y 958.6021199 04 N M 5 Y Y 700.7021206 04 N M 4 Y 1,198.7021208 04 N M 4 Y Y 1,198.7021209 04 N M 4 Y Y 1,198.7021210 04 N M 7 Y Y 636.8021215 04 N M 7 Y Y 1,048.8521230 04 N M 7 Y Y 957.2521235 04 N M 7 Y Y 449.5021240 04 N M 5 Y Y 599.3521242 04 N M 5 Y Y 599.3521243 04 N M 5 Y Y 1,198.7021244 04 N M 5 Y Y 1,198.7021245 04 N M 5 Y Y 1,198.7021246 04 N M 5 Y Y 1,198.7021247 04 N M 5 Y Y 1,306.6521248 04 N M 5 Y Y 1,198.7021249 04 N M 5 Y Y 1,198.7021255 04 N M 5 Y Y 1,306.6521256 04 N M 5 Y Y 1,306.6521260 04 N M 7 Y Y 1,306.6521261 04 N M 7 Y Y 1,522.7021263 04 N M 7 Y Y 1,522.7021267 04 N M 7 Y Y 1,306.6521268 04 N M 7 Y Y 1,522.7021270 04 N M 7 Y Y 1,048.8521275 04 N M 5 Y Y 1,048.8521280 04 N M 5 Y Y 359.30

Page 31: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

21282 04 N M 5 Y Y 359.3021295 04 N M 5 Y Y 449.5021296 04 N M 5 Y Y 449.5021299 04 Y M 7 Y Y21310 04 N I 4 138.7521315 04 N M 4 176.2021320 04 N M 4 280.2521325 04 N M 4 Y 337.1021330 04 N M 4 Y 424.4521335 04 N M 4 Y 571.6021336 04 N M 4 Y 337.1021337 04 N M 4 Y Y 224.7021338 04 N M 4 Y Y 334.4021339 04 N M 4 Y Y 457.7021340 04 N M 6 Y Y 749.2021343 04 N M 4 Y 898.9521344 04 N M 4 Y 1,048.8521345 04 N M 4 Y Y 749.2021346 04 N M 4 Y Y 749.2021347 04 N M 4 Y Y 766.9021348 04 N M 4 Y 954.2021355 04 N M 4 Y 149.8021356 04 N M 4 Y 539.6521360 04 N M 4 Y 539.6521365 04 N M 4 Y Y 689.5021366 04 N M 4 Y Y 954.2021385 04 N M 4 Y Y 599.3521386 04 N M 5 Y Y 599.3521387 04 N M 5 Y Y 749.2021390 04 N M 5 Y Y 861.5021395 04 N M 5 Y Y 861.5021400 04 N I 149.8021401 04 N M 5 Y 224.7021406 04 N M 5 Y 599.3521407 04 N M 5 Y 749.2021408 04 N M 4 Y 749.2021421 04 N M 4 Y 457.7021422 04 N M 4 Y 678.40

Page 32: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

21423 04 N M 4 Y 828.2021431 04 N M 4 Y 524.4021432 04 N M 4 Y 749.2021433 04 N M 6 Y Y 898.9521435 04 N M 6 Y Y 1,048.8521436 04 N M 4 Y 1,048.8521440 04 N M 4 374.5521445 04 N M 4 Y 599.3521450 04 N I 117.6021451 04 N M 4 Y Y 498.1021452 04 N I 4 Y Y 112.4021453 04 N M 4 Y Y 498.1021454 04 N M 4 Y Y 498.1021461 04 N M 4 Y 706.1521462 04 N M 4 Y 706.1521465 04 N M 4 Y 498.1021470 04 N M 4 Y 885.2021480 04 N M 3 240.0021485 04 N M 4 240.0021490 04 N M 4 Y 749.2021495 04 N M 4 Y 449.5021497 04 N M 4 149.8021499 04 Y M Y21501 04 N I 3 115.30 17.0021502 04 N M 3 224.7021510 04 N M 3 224.7021550 04 N I 3 99.10 17.0021552 04 01-Jan-10 N M 3 Y 251.32 1 251.3221554 04 01-Jan-10 N M 3 Y 413.28 1 413.2821555 04 01-Jan-10 N M 3 124.00 17.0021556 04 01-Jan-10 N M 3 270.2721557 04 01-Jan-10 N M 3 Y Y 460.6621558 04 01-Jan-10 N M 3 Y Y 778.2421600 04 N M 3 Y 299.7021610 04 N M 3 Y 399.5021615 04 N M 4 Y 449.5021616 04 N M 6 Y 599.3521620 04 N M 3 Y 250.40

Page 33: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

21627 04 Y M 3 Y21630 04 N M 6 Y Y 749.2021632 04 N M 6 Y Y 749.2021685 04 N M 4 Y 491.5021700 04 N M 4 Y 374.5521705 04 N M 4 Y 449.5021720 04 N M 4 Y 577.1021725 04 N M 4 Y 599.3521740 04 N M 5 Y 898.9521742 04 N M 5 Y 898.9521743 04 N M 5 Y 898.9521750 04 N M 3 Y 368.2021800 04 N I 3 52.7021805 04 N I 3 111.0021810 04 N M 3 Y 242.4021820 04 N I 3 74.9021825 04 N M 3 374.5521899 04 Y M21920 04 N I 3 113.50 17.0021925 04 N M 3 180.20 17.0021930 04 N M 3 149.8021931 04 01-Jan-10 N M 3 Y 263.7221932 04 01-Jan-10 N M 3 Y 378.7721933 04 01-Jan-10 N M 3 Y 418.5621935 04 01-Jan-10 N M 3 Y 581.8521936 04 01-Jan-10 N M 3 Y 812.4122010 04 N M 3 Y 453.3022015 04 N M 3 Y 449.2522100 04 N M 7 Y 311.4022101 04 N M 7 Y 315.5022102 04 N M 7 Y 299.7022103 04 Y M 7 Y Y22110 04 N M 7 Y 718.7022112 04 N M 7 Y 718.7022114 04 N M 7 Y 718.7022116 04 Y M 7 Y Y22206 04 01-Jan-08 N M 7 Y Y 1270.1322207 04 01-Jan-08 N M 7 Y Y 1253.30

Page 34: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

22208 04 01-Jan-08 N M 7 Y Y 325.8022210 04 N M 7 Y Y 973.9022212 04 N M 7 Y Y 973.9022214 04 N M 7 Y Y 973.9022216 04 Y M 7 Y Y22220 04 N M 7 Y Y 973.9022222 04 N M 7 Y Y 973.9022224 04 N M 7 Y Y 973.9022226 04 Y M 7 Y Y22305 04 N M 3 259.4022310 04 N I 98.8022315 04 N M 3 276.2022318 04 N M 7 Y Y 1,417.2022319 04 N M 7 Y Y 1,558.9022325 04 N M 3 Y 599.3522326 04 N M 4 Y 627.3022327 04 N M 3 Y 608.5022328 04 Y M 7 Y Y22505 04 N I 3 149.8022520 04 01-Jan-10 N M 7 Y 353.8522521 04 01-Jan-10 N M 7 Y 331.9022522 04 01-Jan-10 Y M 7 Y22523 04 N M 3 Y 343.1322524 04 N M 3 Y 328.6622525 04 01-Jan-10 Y M 3 Y22532 04 01-Jan-10 N M 7 Y Y 876.6822533 04 01-Jan-10 N M 7 Y Y 816.4322534 04 01-Jan-10 Y M 7 Y Y22548 04 N M 7 Y 1,642.1522554 04 N M 7 Y Y 1,642.6522556 04 N M 7 Y Y 1,642.6522558 04 N M 7 Y Y 1,642.6522585 04 Y M 7 Y Y22590 04 N M 7 Y Y 1,198.7022595 04 N M 7 Y Y 1,198.7022600 04 N M 7 Y Y 1,198.7022610 04 N M 7 Y Y 1,198.7022612 04 N M 7 Y Y 1,198.70

Page 35: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

22614 04 Y M 7 Y Y22630 04 N M 7 Y Y 1,198.7022632 04 Y M 7 Y Y22800 04 N M 7 Y Y 1,086.3022802 04 N M 7 Y Y 1,086.3022804 04 N M 7 Y Y 1,782.3022808 04 N M 7 Y Y 1,086.3022810 04 N M 7 Y Y 1,086.3022812 04 N M 7 Y Y 1,086.3022818 04 N M 7 Y Y 1,610.6522819 04 N M 7 Y Y 1,610.6522830 04 N M 7 Y Y 443.3922840 04 N M 7 Y Y 1,872.9022841 04 N M 7 Y Y 1,872.9022842 04 N M 7 Y Y 1,872.9022843 04 N M 7 Y Y 1,872.9022844 04 N M 7 Y Y 1,872.9022845 04 N M 7 Y Y 1,872.9022846 04 N M 7 Y Y 1,872.9022847 04 N M 7 Y Y 1,872.9022848 04 N M 7 Y Y 351.0022849 04 N M 7 Y Y 1,134.1022850 04 N M 7 Y 449.5022851 04 N M 7 Y Y 750.7022852 04 N M 7 Y Y 449.5022855 04 N M 7 Y 449.5022856 04 01-Jan-09 N M 8 Y Y 925.0022857 04 01-Jan-10 N M 8 Y Y 938.7122861 04 01-Jan-09 N M 8 Y Y 1,121.2322862 04 01-Jan-10 N M 8 Y Y 1104.4522864 04 01-Jan-10 N M 8 Y Y 1051.3922865 04 01-Jan-10 N M 8 Y Y 1166.3522899 04 Y M Y Y22900 04 01-Jan-10 N M 3 Y Y 224.7022901 04 01-Jan-10 N M 3 Y Y 373.9122902 04 01-Jan-10 N M 3 Y Y 185.3722903 04 01-Jan-10 N M 3 Y Y 245.8022904 04 01-Jan-10 N M 4 Y Y 588.58

Page 36: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

22905 04 01-Jan-10 N M 4 Y Y 763.2322999 04 Y M Y23000 04 N M 3 Y 359.3023020 04 N M 3 Y 299.7023030 04 N I 3 125.50 17.0023031 04 N I 3 99.10 17.0023035 04 N M 3 Y 317.4023040 04 N M 3 Y 599.3523044 04 N M 3 Y 599.3523065 04 N I 3 113.60 17.0023066 04 N I 3 149.25 17.0023071 04 01-Jan-10 N M 3 Y 233.5723073 04 01-Jan-10 N M 3 Y 387.8323075 04 N M 3 224.7023076 04 01-Jan-10 N M 3 449.5023077 04 01-Jan-10 N M 7 Y Y 641.3823078 04 01-Jan-10 N M 7 Y Y 794.5323100 04 N M 3 Y 374.5523101 04 N M 3 Y 599.3523105 04 N M 3 Y 599.3523106 04 N M 3 Y 599.3523107 04 N M 3 Y Y 473.5023120 04 N M 3 Y 362.0023125 04 N M 3 Y 718.7023130 04 N M 3 Y 362.0023140 04 N M 3 Y 264.9023145 04 N M 3 Y 480.0023146 04 N M 3 Y 480.0023150 04 N M 3 Y 275.8023155 04 N M 3 Y 480.0023156 04 N M 3 Y 480.0023170 04 N M 3 Y 240.0023172 04 N M 3 Y 240.0023174 04 N M 3 Y 480.0023180 04 N M 3 Y 299.7023182 04 N M 3 Y 480.0023184 04 N M 3 Y 480.0023190 04 N M 3 Y 480.00

Page 37: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

23195 04 N M 3 Y 599.3523200 04 01-Jan-10 N M 6 Y Y 718.7023210 04 01-Jan-10 N M 6 Y Y 718.7023220 04 01-Jan-10 N M 6 Y Y 718.7023330 04 N I 3 17.00 107.0023331 04 N M 3 Y 233.0023332 04 Y M 323350 04 N I 3 88.3023395 04 N M 3 Y 501.3523397 04 N M 3 Y 599.3523400 04 N M 6 Y 839.3523405 04 N M 3 Y 299.7023406 04 N M 3 Y 449.5023410 04 N M 3 Y 779.7023412 04 N M 3 Y 779.7023415 04 N M 3 Y 674.2023420 04 N M 3 Y 674.2023430 04 N M 3 Y 449.5023440 04 N M 3 Y 449.5023450 04 N M 3 Y 839.3523455 04 N M 3 Y 839.3523460 04 N M 3 Y 839.3523462 04 N M 3 Y 839.3523465 04 N M 3 Y 733.8523466 04 N M 3 Y 584.4023470 04 N M 3 Y 839.3523472 04 N M 3 Y 1,498.3023480 04 N M 3 Y 480.0023485 04 N M 3 Y 486.9023490 04 N M 3 Y Y 379.4023491 04 N M 3 Y Y 464.4523500 04 N I 3 112.4023505 04 N M 3 187.3023515 04 N M 3 Y 419.0023520 04 N I 112.4023525 04 N M 3 162.3023530 04 N M 3 Y 720.0023532 04 N I 3 Y 786.60

Page 38: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

23540 04 N I 112.4023545 04 N M 3 228.9023550 04 N M 3 Y 503.6023552 04 N M 3 Y 561.8523570 04 N I 79.6023575 04 N M 3 241.3523585 04 N M 3 Y 449.5023600 04 N M 194.2023605 04 N M 3 277.5023615 04 N M 3 Y 545.2523616 04 N M 3 Y 975.2523620 04 N I 111.0023625 04 N M 3 163.7023630 04 N M 3 Y 524.4023650 04 N M 178.9023655 04 N M 3 255.2023660 04 N M 3 Y 419.0023665 04 N M 3 206.7023670 04 N M 3 Y 842.1023675 04 N M 3 299.7023680 04 N M 3 Y 599.3523700 04 N M 3 194.2023800 04 N M 3 Y 839.3523802 04 N M 3 Y 839.3523900 04 N M 11 Y 1198.7023920 04 N M 5 Y 1048.8523921 04 N M 3 Y 224.7023929 04 Y M 3 Y23930 04 N M 3 179.70 17.0023931 04 N I 3 141.30 17.0023935 04 N M 3 Y 240.0024000 04 N M 3 Y 299.7024006 04 N M 3 Y 380.1524065 04 N I 3 113.60 17.0024066 04 N M 3 Y 264.25 17.0024071 04 01-Jan-10 N M 3 Y 226.2924073 04 01-Jan-10 N M 3 Y 389.5924075 04 N M 3 149.80

Page 39: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

24076 04 01-Jan-10 N M 3 224.7024077 04 01-Jan-10 N M 7 Y 319.0224079 04 01-Jan-10 N M 7 Y Y 731.9424100 04 N M 3 Y 299.7024101 04 N M 3 Y 480.0024102 04 N M 3 Y 524.4024105 04 N M 3 380.1524110 04 N M 3 Y 527.2024115 04 N M 3 Y 749.2024116 04 N M 3 Y 749.2024120 04 N M 3 Y 449.5024125 04 N M 7 Y 749.2024126 04 N M 7 Y 749.2024130 04 N M 3 Y 492.5524134 04 N M 3 Y 351.0024136 04 N M 3 Y 262.8024138 04 N M 3 Y 254.8024140 04 N M 3 Y 480.0024145 04 N M 3 Y 480.0024147 04 N M 3 Y 480.0024149 04 Y M 6 Y24150 04 01-Jan-10 N M 6 Y Y 1198.7024152 04 01-Jan-10 N M 6 Y Y 958.6024155 04 N M 3 Y 749.2024160 04 N M 3 Y 299.7024164 04 N M 3 492.5524200 04 N M 3 169.3024201 04 N M 3 Y 245.5524220 04 N I 3 105.1524300 04 N I 3 66.7024301 04 N M 3 Y 453.7024305 04 N M 3 Y 359.3024310 04 N M 3 Y 188.7024320 04 N M 3 Y 599.3524330 04 N M 3 Y 599.3524331 04 N M 3 Y 599.3524332 04 N M 3 Y 326.3024340 04 N M 3 Y 299.70

Page 40: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

24341 04 N M 3 Y 274.2024342 04 N M 3 Y 535.4524343 04 N M 3 Y 430.1524344 04 N M 3 Y 651.9524345 04 N M 3 Y 430.1524346 04 N M 3 Y 651.9524357 04 01-Jan-08 N M 3 Y 233.9424358 04 01-Jan-08 N M 3 Y 275.7124359 04 01-Jan-08 N M 3 Y 341.0424360 04 N M 3 Y 718.7024361 04 N M 3 Y 1123.7024362 04 N M 3 Y 1123.7024363 04 N M 3 Y 1123.7024365 04 N M 3 Y 1123.7024366 04 N M 3 Y 1123.7024400 04 N M 3 Y 541.0524410 04 N M 3 Y 481.6524420 04 N M 3 Y 898.9524430 04 N M 3 Y 636.8024435 04 N M 7 Y 958.6024470 04 N M 3 Y 374.5524495 04 N M 3 Y 299.7024498 04 N M 3 Y Y 491.5024500 04 N M 153.9524505 04 N M 3 295.5024515 04 N M 3 Y 624.3024516 04 N M 3 Y 624.3024530 04 N M 299.7024535 04 N M 3 334.4024538 04 N M 3 Y 405.1024545 04 N M 3 Y 718.7024546 04 N M 3 Y 718.7024560 04 N M 199.7524565 04 N M 3 242.8024566 04 N M 3 Y 257.3024575 04 N M 3 Y 718.7024576 04 N M 188.7024577 04 N M 3 245.55

Page 41: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

24579 04 N M 3 Y 718.7024582 04 N M Y 405.1024586 04 N M 3 Y 480.6524587 04 N M 3 Y 1123.7024600 04 N M 208.0524605 04 N M 3 242.8024615 04 N M 3 Y 419.0024620 04 N M 3 259.4024635 04 N M 3 Y 482.8024640 04 N M 3 180.3024650 04 N I 3 142.9024655 04 N M 3 Y 208.0524665 04 N M 3 Y 400.9024666 04 N M 3 Y 449.5024670 04 N M 3 181.6524675 04 N M 3 206.7024685 04 N M 3 Y 556.3524800 04 N M 3 Y 718.7024802 04 N M 3 Y 839.3524900 04 N M 3 Y 313.5024920 04 N M 3 Y 595.2024925 04 N M 3 Y 262.2024930 04 N M 3 Y 595.2024931 04 N M 3 Y 674.2024935 04 N M 3 Y 599.3524940 04 N M 3 Y 621.1024999 04 Y M 0 Y25000 04 N M 3 Y 351.0025001 04 N M 3 Y 207.9525020 04 N M 3 Y 388.5025023 04 N M 3 Y 394.8025024 04 N M 3 Y 458.2025025 04 N M 3 Y 588.1525028 04 N I 3 179.25 17.0025031 04 N M 3 232.55 17.0025035 04 N M 3 287.6025040 04 N M 3 Y 480.0025065 04 N I 3 113.60 17.00

Page 42: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

25066 04 N I 3 149.25 17.0025071 04 01-Jan-10 N M 3 Y 236.7025073 04 01-Jan-10 N M 3 Y 293.9725075 04 01-Jan-10 N M 3 149.8025076 04 01-Jan-10 N M 3 262.2025077 04 01-Jan-10 N M 7 467.4925078 04 01-Jan-10 N M 3 Y 637.8425085 04 N M 3 Y 262.2025100 04 N M 3 Y 419.0025101 04 N M 3 Y 480.0025105 04 N M 3 Y 480.0025107 04 N M 3 Y 480.0025109 04 01-Jan-07 N M 3 Y 240.0025110 04 N M 3 217.8025111 04 N M 3 214.00 34.0025112 04 N M 3 214.00 34.0025115 04 N M 3 Y 599.3525116 04 N M 3 Y 599.3525118 04 N M 3 Y 480.0025119 04 N M 3 Y 659.0025120 04 N M 3 Y 599.3525125 04 N M 7 Y 674.2025126 04 N M 7 Y 674.2025130 04 N M 3 Y 299.7025135 04 N M 7 Y 449.5025136 04 N M 7 Y 449.5025145 04 N M 3 Y 359.3025150 04 01-Jan-10 N M 3 Y 359.3025151 04 01-Jan-10 N M 3 Y Y 359.3025170 04 01-Jan-10 N M 3 Y Y 721.9825210 04 N M 3 Y 480.0025215 04 N M 3 Y 480.0025230 04 N M 3 Y 299.7025240 04 N M 3 Y 359.3025246 04 N I 3 96.9025248 04 N M 3 181.2525250 04 N M 3 224.7025251 04 N M 3 339.50

Page 43: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

25259 04 N M 3 230.1525260 04 N M 3 Y 283.5025263 04 N M 3 Y 302.6025265 04 N M 3 Y 484.2025270 04 N M 3 Y 369.0525272 04 N M 3 Y 256.8525274 04 N M 3 Y 359.3025275 04 N M 3 Y 442.5025280 04 N M 3 Y 359.3025290 04 N M 3 Y 302.4025295 04 N M 3 Y 277.5025300 04 N M 4 Y 359.3025301 04 N M 4 Y 359.3025310 04 N M 4 Y 480.0025312 04 N M 4 Y 524.4025315 04 N M 3 Y 480.0025316 04 N M 3 Y 524.4025320 04 N M 3 Y 449.5025332 04 N M 3 Y 749.2025335 04 N M 3 Y 749.2025337 04 N M 3 Y 718.7025350 04 N M 3 Y 374.5525355 04 N M 3 Y 480.0025360 04 N M 3 Y 316.1025365 04 N M 3 Y 561.8525370 04 N M 3 Y 480.0025375 04 N M 3 Y 524.4025390 04 N M 3 Y 599.3525391 40 N M 7 Y 898.9525392 04 N M 3 Y 898.9525393 04 N M 7 Y 898.9525394 04 N M 3 Y 514.8025400 04 N M 3 Y 524.4025405 04 N M 7 Y 599.3525415 04 N M 3 Y 488.0025420 04 N M 7 Y 839.3525425 04 N M 7 Y 599.3525426 04 N M 7 Y 749.20

Page 44: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

25430 04 N M 3 Y 451.9025431 04 N M 3 Y 449.1025440 04 N M 3 Y 599.3525441 04 N M 3 Y 659.0025442 04 N M 3 Y 659.0025443 04 N M 3 Y 749.2025444 04 N M 3 Y 749.2025445 04 N M 3 Y 749.2025446 04 N M 3 Y 898.9525447 04 Y M 3 Y25449 04 N M 3 Y 659.0025450 04 N M 3 Y 299.7025455 04 N M 3 Y 449.5025490 04 N M 3 Y Y 356.5025491 04 N M 3 Y Y 365.6025492 04 N M 3 Y Y 459.0525500 04 N I 3 112.4025505 04 N M 3 210.9025515 04 N M 3 Y 554.9025520 04 N M 3 267.8025525 04 N M 3 Y 443.9525526 04 N M 3 Y 592.4025530 04 N M 199.7525535 04 N M 3 240.0025545 04 N M 3 Y 538.2025560 04 N M 3 176.2025565 04 N M 3 292.6025574 04 N M 3 Y 538.2025575 04 N M 3 Y 592.4025600 04 N M 155.3525605 04 N M 3 294.1025606 04 01-Jan-07 N M 3 301.0025607 04 01-Jan-07 N M 3 443.9525608 04 01-Jan-07 N M 3 443.9525609 04 01-Jan-07 N M 443.9525622 04 N I 147.1025624 04 N I 3 181.1025628 04 N M 3 Y 335.70

Page 45: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

25630 04 N M 201.1025635 04 N I 3 174.6025645 04 N M 3 Y 335.7025650 04 N I 3 Y Y 126.9025651 04 N M 3 Y 271.2525652 04 N M 3 Y 374.0025660 04 N I 3 139.0025670 04 N M 3 Y 266.7025671 04 N M 3 Y 205.3025675 04 N I 3 168.2525676 04 N M 3 Y 270.4025680 04 N M 3 240.0025685 04 N M 3 Y 449.5025690 04 N I 3 188.6525695 04 N M 3 Y 276.5025800 04 N M 3 Y 718.7025805 04 N M 3 Y 786.6025810 04 N M 3 Y 839.3525820 04 N M 3 Y 664.2525825 04 N M 7 Y 718.7025830 04 N M 3 Y 786.6025900 04 N M 3 Y 359.3025905 04 N M 3 Y 359.3025907 04 N M 3 Y 290.3025909 04 N M 3 Y 359.3025915 04 N M 3 Y 1198.7025920 04 N M 3 Y 359.3025922 04 N M 3 Y 244.5025924 04 N M 3 Y 359.3025927 04 N M 3 Y 302.6025929 04 N M 3 Y 236.3025931 04 N M 3 Y 285.8025999 04 Y M26010 04 N I 3 76.2526011 04 N I 3 97.4026020 04 N M 3 191.8026025 04 N M 3 201.6026030 04 N M 3 237.15

Page 46: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

26034 04 N M 3 Y 240.0026035 04 N M 3 Y 321.6526037 04 N M 3 Y 265.2026040 04 N M 3 Y 264.9026045 04 N M 3 Y 449.5026055 04 N M 3 Y 235.8026060 04 N I 3 Y 107.9026070 04 N M 3 Y 224.7026075 04 N M 3 Y 224.7026080 04 N M 3 Y 187.3026100 04 N M 3 Y 299.7026105 04 N M 3 Y 262.2026110 04 N M 3 Y 187.3026111 04 01-Jan-10 N M 3 Y 228.0726113 04 01-Jan-10 N M 3 Y 299.9426115 04 01-Jan-10 N M 3 149.8026116 04 01-Jan-10 N M 3 224.7026117 04 01-Jan-10 N M 7 380.0826118 04 01-Jan-10 N M 7 Y 592.3926121 04 N M 3 Y 449.5026123 04 N M 3 Y 524.4026125 04 Y M 3 Y26130 04 N M 3 Y 374.5526135 04 N M 3 Y 270.6026140 04 N M 3 Y 245.3526145 04 N M 3 Y 252.8026160 04 N M 3 Y 210.10 34.0026170 04 N M 3 Y 240.0026180 04 N M 3 Y 240.0026185 04 Y M 3 Y26200 04 N M 3 Y 299.7026205 04 N M 3 Y 374.5526210 04 N M 3 Y 224.7026215 04 N M 3 Y 314.9526230 04 N M 3 Y 299.7026235 04 N M 3 Y 224.7026236 04 N M 3 Y 204.0526250 04 N M 3 Y 449.50

Page 47: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

26260 04 N M 3 Y 374.5526262 04 N M 3 Y 299.7026320 04 N M 3 Y 233.0026340 04 N I 3 139.7026350 04 N M 3 Y 274.4026352 04 N M 3 Y 480.0026356 04 N M 3 Y 359.3026357 04 N M 4 Y Y 359.3026358 04 N M 3 Y 599.3526370 04 N M 3 Y 307.2026372 04 N M 3 Y 480.0026373 04 N M 3 Y 480.0026390 04 N M 3 Y 480.0026392 04 N M 3 Y 480.0026410 04 N M 4 Y 222.0026412 04 N M 4 Y 299.7026415 04 N M 3 Y Y 306.9526416 04 N M 3 Y Y 414.9026418 04 N M 4 Y 201.6526420 04 N M 4 Y 299.7026426 04 N M 4 Y 480.0026428 04 N M 4 Y 599.3526432 04 N M 4 Y 359.3026433 04 N M 4 Y 222.0026434 04 N M 4 Y 359.3026437 04 N M 4 Y 225.1026440 04 N M 3 Y 417.6026442 04 N M 3 Y 627.0526445 04 N M 4 Y 240.0026449 04 N M 4 Y 359.3026450 04 N M 3 Y 240.0026455 04 N M 3 Y 240.0026460 04 N M 4 Y 240.0026471 04 N M 3 Y 299.7026474 04 N M 3 Y 359.3026476 04 N M 4 Y 359.3026477 04 N M 4 Y 359.3026478 04 N M 4 Y Y 359.30

Page 48: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

26479 04 N M 4 Y Y 359.3026480 04 N M 3 Y 480.0026483 04 N M 3 Y 480.0026485 04 N M 3 Y 480.0026489 04 N M 3 Y 561.8526490 04 N M 3 Y 356.6026492 04 N M 3 Y 449.5026494 04 N M 3 Y 356.6026496 04 Y M 3 Y26497 04 N M 3 Y 374.5526498 04 N M 3 Y 693.7026499 04 N M 3 Y 374.5526500 04 N M 3 Y 226.5026502 04 N M 3 Y 419.0026508 04 N M 3 Y 232.5526510 04 N M 3 Y 442.9026514 04 Y I 326516 04 N M 3 Y 255.0026517 04 N M 3 Y 374.5526518 04 N M 3 Y 416.2026520 04 N M 3 Y 262.2026525 04 N M 3 Y 262.2026530 04 N M 3 Y 289.3026531 04 N M 3 Y 337.1026535 04 N M 3 Y 524.4026536 04 N M 3 Y 524.4026540 04 N M 3 Y 346.7526541 04 N M 3 Y 374.5526542 04 N M 3 Y 374.5526545 04 N M 3 Y 299.7026546 04 Y M 3 Y26548 04 N M 3 Y Y 299.7026550 04 N M 3 Y 680.5026551 04 Y M 3 Y Y26553 04 Y M 3 Y Y26554 04 Y M 3 Y Y26555 04 N M 3 Y 571.1026556 04 Y M 3 Y Y

Page 49: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

26560 04 N M 3 Y 584.0526561 04 N M 3 Y 639.6026562 04 N M 3 Y 898.9526565 04 N M 3 Y 359.3026567 04 N M 3 Y 359.3026568 04 N M 3 Y 415.8526580 04 N M 3 Y 579.0526587 04 N M 3 Y Y 259.2026590 04 N M 3 Y 587.4026591 04 N M 3 Y 237.6026593 04 N M 3 Y 259.2026596 04 Y M 3 Y26600 04 N I 93.7026605 04 N I 3 138.7526607 04 N M 3 Y 299.7026608 04 N M 3 Y 299.7026615 04 N M 3 Y 299.7026641 04 N M 3 166.4026645 04 N M 3 166.4026650 04 N M 3 Y 240.0026665 04 N M 3 Y 374.5526670 04 N I 134.2526675 04 N I 3 181.5526676 04 N M 3 Y 262.2026685 04 N M 3 Y 233.3026686 04 N M 3 Y 280.8026700 04 N I 107.0026705 04 N M 3 166.4026706 04 N M 3 Y 237.8526715 04 N M 3 Y 274.6526720 04 N I 3 97.0526725 04 N I 3 130.3526727 04 N M 3 Y 171.0026735 04 N M 3 Y 263.5526740 04 N I 3 97.0526742 04 N I 3 150.5026746 04 N M 3 Y 263.5526750 04 N I 97.05

Page 50: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

26755 04 N I 3 104.1026756 04 N M 3 Y 224.7026765 04 N M 3 Y 285.8026770 04 N I 92.5026775 04 N I 3 132.4526776 04 N M 3 Y 224.7026785 04 N I 3 Y 148.6026820 04 N M 3 Y 310.1026841 04 N M 3 Y 299.7026842 04 N M 3 Y 374.5526843 04 N M 3 Y 299.7026844 04 N M 3 Y 374.5526850 04 N M 3 Y 262.2026852 04 N M 3 Y 301.7026860 04 N M 3 Y 200.6526861 04 N M 3 Y 90.1026862 04 N M 3 Y 274.6026863 04 N M 3 Y 119.2526910 04 N M 3 Y 271.9026951 04 N M 3 Y 271.9026952 04 N M 3 Y 259.4026989 04 Y M Y26990 04 N I 3 262.45 17.0026991 04 N I 3 215.80 17.0026992 04 N M 3 Y 418.8027000 04 N M 3 Y 197.0027001 04 N M 3 Y 202.2027003 04 N M 3 Y 299.7027005 04 N M 3 Y 274.6527006 04 N M 3 Y 289.2027025 04 N M 3 Y 374.5527027 04 01-Jan-09 N M 3 Y 367.5727030 04 N M 3 Y 524.4027033 04 N M 3 Y 599.3527035 04 N M 3 Y 599.3527036 04 Y M 3 Y27040 04 N I 3 113.60 17.0027041 04 01-Jan-10 N M 3 258.20 17.00

Page 51: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

27043 04 01-Jan-10 N M 3 263.3427045 04 01-Jan-10 N M 4 Y Y 418.8127047 04 N M 3 224.7027048 04 01-Jan-10 N M 3 Y Y 374.5527049 04 01-Jan-10 N M 3 Y Y 694.8527050 04 01-Jan-10 N M 3 Y Y 524.4027052 04 01-Jan-10 N M 3 Y Y 524.4027054 04 01-Jan-10 N M 3 Y Y 749.2027057 04 01-Jan-09 N M 3 Y 374.5527059 04 01-Jan-10 N M 3 Y Y 1,032.1927060 04 N M 3 Y 277.5027062 04 N M 3 Y 374.5527065 04 N M 3 Y 599.3527066 04 N M 3 Y 674.2027067 04 N M 3 Y 749.2027070 04 N M 3 Y 419.0027071 04 N M 3 Y 480.0027075 04 01-Jan-10 N M 3 Y Y 599.3527076 04 N M 3 Y Y 681.1027077 04 01-Jan-10 N M 3 Y Y 723.2027078 04 01-Jan-10 N M 3 Y Y 599.3527080 04 N M 4 Y 359.3027086 04 N I 3 107.00 17.0027087 04 N M 3 Y 247.20 17.0027090 04 N M 3 Y 412.0027091 04 N M 5 Y 694.4527093 04 N I 106.7027095 04 N I 3 111.7027096 04 N I 3 172.5027097 04 N M 3 Y 290.2527098 04 N M 3 Y 345.7027100 04 N M 3 Y 561.8527105 04 N M 3 Y 636.8027110 04 N M 3 Y 674.2027111 04 N M 3 Y 674.2027120 04 N M 5 Y 898.9527122 04 N M 5 Y 954.5027125 04 N M 5 Y 1026.65

Page 52: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

27130 04 N M 5 Y 1749.5027132 04 N M 5 Y 1798.0527134 04 N M 5 Y 1048.8527137 04 N M 5 Y 1048.8527138 04 N M 5 Y 1048.8527140 04 N M 3 Y 718.7027146 04 N M 3 Y 718.7027147 04 N M 5 Y 839.3527151 04 N M 5 Y 1011.4027156 04 N M 5 Y 1123.7027158 04 N M 3 Y 583.0027161 04 N M 3 Y 749.2027165 04 N M 5 Y 898.9527170 04 N M 5 Y 898.9527175 04 N M 3 Y 599.3527176 04 N M 5 Y 599.3527177 04 N M 5 Y 958.6027178 04 N M 3 Y 958.6027179 04 N M 5 Y 839.3527181 04 N M 5 Y 958.6027185 04 N M 5 Y 779.7027187 04 N M 5 Y Y 950.5027193 04 N I 170.8027194 04 N I 3 Y 272.4027200 04 N M 149.8027202 04 N M 3 Y 374.5527215 04 N M 3 Y 674.2027216 04 N M 3 Y 550.9027217 04 N M 3 Y 599.3527218 04 N M 3 Y 599.3527220 04 N M 412.0027222 04 N M 3 Y 412.0027226 04 N M 3 Y 930.9027227 04 N M 3 Y 930.9027228 04 N M 3 Y 1198.7027230 04 N I 179.1527232 04 N M 3 Y 449.5027235 04 N M 5 Y 674.20

Page 53: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

27236 04 N M 5 Y 1019.7027238 04 N I 183.8027240 04 N M 3 Y 449.5027244 04 N M 5 Y 933.8027245 04 N M 3 Y 933.8027246 04 N I 167.0027248 04 N M 5 Y 779.7027250 04 N M 242.8027252 04 N M 3 284.9027253 04 N M 3 Y 599.3527254 04 N M 3 Y 606.3027256 04 N M 3 208.0527257 04 N M 3 Y 277.5027258 04 N M 5 Y 733.8527259 04 N M 5 Y 958.6027265 04 N M 242.8027266 04 N M 3 Y 283.0027267 04 01-Jan-08 N M Y Y 220.8227268 04 01-Jan-08 N M 3 Y Y 273.0827269 04 01-Jan-08 N M 5 Y Y 655.5827275 04 N M 3 Y 240.0027280 04 N M 3 Y 958.6027282 04 N M 3 Y 958.6027284 04 N M 5 Y 898.9527286 04 N M 5 Y 1033.5027290 04 N M 11 Y Y 1678.6527295 04 N M 8 Y 1198.7027299 04 Y M 5 Y27301 04 N M 3 242.1027303 04 N M 3 Y 298.2027305 04 N M 3 Y 374.5527306 04 N M 3 Y 374.5527307 04 N M 3 Y 561.8527310 04 N M 4 486.9027323 04 N I 3 113.60 17.0027324 04 N M 3 Y 264.25 17.0027325 04 01-Jan-07 N M 4 Y 412.0027326 04 01-Jan-07 N M 4 Y 412.00

Page 54: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

27327 04 01-Jan-10 N I 3 156.3027328 04 01-Jan-10 N M 3 295.5027329 04 01-Jan-10 N M 3 Y Y 570.2027330 04 N M 3 Y 374.5527331 04 N M 3 Y 599.3527332 04 N M 3 Y 621.5027333 04 N M 3 Y 621.5027334 04 N M 3 Y 621.5027335 04 N M 3 Y 621.5027337 04 01-Jan-10 N M 3 Y 233.8827339 04 01-Jan-10 N M 3 Y 422.8127340 04 N M 3 Y 240.0027345 04 N M 4 Y 381.5027347 04 N M 4 Y 381.5027350 04 N M 3 Y 636.8027355 04 N M 3 Y 599.3527356 04 N M 3 Y 674.2027357 04 N M 6 Y 674.2027358 04 N M 6 Y 674.2027360 04 01-Jan-10 N M 3 Y Y 480.0027364 04 01-Jan-10 N M 6 Y Y 886.8927365 04 01-Jan-10 N M 6 Y Y 898.9527370 04 N I 3 101.1027372 04 N M 3 Y 174.1027380 04 N M 3 Y 412.0027381 04 N M 3 Y 524.4027385 04 N M 3 Y 419.0027386 04 N M 3 Y 524.4027390 04 N M 3 Y 359.3027391 04 N M 3 Y 458.4027392 04 N M 3 Y 661.1527393 04 N M 3 Y 359.3027394 04 N M 3 Y 458.4027395 04 N M 3 Y 661.1527396 04 N M 3 Y 599.3527397 04 N M 3 Y 550.9027400 04 N M 3 Y 599.3527403 04 N M 3 Y Y 621.50

Page 55: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

27405 04 N M 3 Y 524.4027407 04 N M 3 Y 524.4027409 04 N M 3 Y 674.2027412 04 N M 3 621.5027415 04 N M 3 621.5027416 04 01-Jan-08 N M 3 Y 513.3227418 04 N M 3 Y 486.1027420 04 N M 3 Y 620.1027422 04 N M 3 Y 620.1027424 04 N M 3 Y 636.8027425 04 N M 3 Y Y 561.8527427 04 N M 3 Y Y 524.4027428 04 N M 3 Y Y 621.1027429 04 N M 3 Y Y 674.2027430 04 N M 3 Y 561.8527435 04 N M 3 Y 524.4027437 04 N M 3 Y 599.3527438 04 N M 3 Y 958.6027440 04 N M 3 Y 599.3527441 04 N M 3 Y 599.3527442 04 N M 3 Y 881.0027443 04 N M 3 Y 881.0027445 04 N M 3 Y 1473.3527446 04 N M 3 Y 1473.3527447 04 N M 3 Y 1473.3527448 04 N M 3 Y 599.3527450 04 N M 4 Y 689.5027454 04 N M 4 Y 749.2027455 04 N M 3 Y 524.4027457 04 N M 3 Y 524.4027465 04 N M 3 Y 749.2027466 04 N M 3 Y 898.9527468 04 N M 3 Y 1198.7027470 04 N M 4 Y 839.3527472 04 N M 4 Y 958.6027475 04 N M 3 Y 659.0027477 04 N M 3 Y 659.0027479 04 N M 3 Y 958.60

Page 56: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

27485 04 N M 3 Y 561.8527486 04 N M 3 Y 736.6027487 04 N M 3 Y 1473.3027488 04 N M 3 524.6527495 04 Y M 5 Y Y27496 04 N M 3 Y 374.5527497 04 N M 3 Y 374.5527498 04 N M 3 Y 383.4527499 04 N M 3 Y 383.4527500 04 N M 3 257.4027501 04 N M 3 263.2027502 04 N M 3 Y 338.5027503 04 N M 3 Y 338.5027506 04 N M 4 Y Y 910.1027507 04 N M 4 Y 910.1027508 04 N M 209.0027509 04 N M 3 Y 524.4027510 04 N M 4 524.4027511 04 N M 4 Y 836.5527513 04 N M 4 Y 826.3027514 04 N M 4 Y 836.5527516 04 N M 3 599.3527517 04 N M 3 599.3527519 04 N M 3 Y 836.5527520 04 N M 191.5027524 04 N M 3 Y 629.9027530 04 N M 288.5027532 04 N M 3 321.9027535 04 N M 4 Y 839.3527536 04 N M 3 Y 839.3527538 04 N M 3 213.6527540 04 N M 3 Y 958.6027550 04 N M 194.2527552 04 N M 3 227.4027556 04 N M 3 Y 656.2027557 04 N M 3 Y 749.2027558 04 N M 3 Y 749.2027560 04 N I 149.80

Page 57: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

27562 04 N M 3 187.8027566 04 N M 3 Y 383.2527570 04 N I 3 66.7027580 04 N M 3 Y 1384.6027590 04 N M 3 Y 649.2527591 04 N M 3 Y 749.2027592 04 N M 3 Y 574.3527594 04 N M 3 Y 224.7027596 04 N M 3 Y 574.3527598 04 N M 3 Y 480.0027599 04 Y M Y27600 04 N M 3 Y 189.8027601 04 N M 3 Y 190.2027602 04 N M 3 Y 262.2027603 04 N M 3 Y 211.60 17.0027604 04 N I 3 156.50 17.0027605 04 N M Y 359.3027606 04 N M 3 Y 359.3027607 04 N M 3 Y 292.3027610 04 N M 3 Y 480.0027612 04 N M 3 Y 374.5527613 04 N I 3 113.60 17.0027614 04 N I 3 264.25 17.0027615 04 N M 3 Y Y 521.5627616 04 01-Jan-10 N M 3 Y Y 722.2127618 04 01-Jan-10 N M 3 186.9027619 04 01-Jan-10 N M 3 268.4027620 04 01-Jan-10 N M 3 Y Y 480.0027625 04 N M 3 Y 480.0027626 04 N M 3 Y 480.0027630 04 01-Jan-10 N M 3 188.6527632 04 01-Jan-10 N M 3 Y 230.5027634 04 01-Jan-10 N M 3 Y 376.8427635 04 N M 3 Y 374.5527637 04 N M 3 Y 599.3527638 04 N M 3 Y 599.3527640 04 01-Jan-10 N M 3 Y 407.8027641 04 01-Jan-10 N M 3 Y 335.00

Page 58: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

27645 04 01-Jan-10 N M 6 Y Y 599.3527646 04 01-Jan-10 N M 6 Y Y 599.3527647 04 N M 3 Y 449.5027648 04 N I 3 82.7527650 04 N M 3 Y 359.3027652 04 N M 3 Y 480.0027654 04 N M 3 Y 449.5027656 04 N M 3 Y 299.7027658 04 N M 3 Y 224.7027659 04 N M 3 Y 416.2027664 04 N M 3 Y 182.5027665 04 N M 3 Y 302.4027675 04 N M 3 Y 239.3027676 04 N M 3 Y 313.2027680 04 N M 3 Y 381.5027681 04 N M 3 Y 231.0027685 04 N M 3 Y 262.2027686 04 N M 3 Y 257.0027687 04 N M 3 Y 262.2027690 04 N M 4 Y 299.7027691 04 N M 4 Y 524.4027692 04 N M 4 Y 149.8027695 04 N M 3 Y 374.5527696 04 N M 3 Y 561.8527698 04 N M 3 Y 453.7027700 04 N M 3 Y 718.7027702 04 N M 3 Y 749.2027703 04 Y M 3 Y27704 04 N M 3 Y 249.3527705 04 N M 3 Y 412.0027707 04 N M 3 Y 359.3027709 04 N M 3 Y 524.4027712 04 N M 3 Y 674.2027715 04 N M 3 Y 749.2027720 04 N M 3 Y 629.9027722 04 N M 3 Y 733.8527724 04 N M 3 Y 840.7527725 04 N M 3 Y 840.75

Page 59: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

27726 04 01-Jan-08 N M 3 Y 478.6627727 04 N M 3 Y 648.1027730 04 N M 3 Y 412.0027732 04 N M 3 Y 314.9527734 04 N M 3 Y 599.3527740 04 N M 3 Y 839.3527742 04 N M 3 Y 839.3527745 04 N M 3 Y Y 378.0527750 04 N M 208.0527752 04 N M 3 320.4527756 04 N M 3 Y 738.1027758 04 N M 3 Y 839.3527759 04 N M 3 Y 839.3527760 04 N M 3 166.4027762 04 N M 3 235.8027766 04 N M 3 Y 535.4527767 04 01-Jan-08 N M 3 Y 131.6327768 04 01-Jan-08 N M 3 Y 208.3227769 04 01-Jan-08 N M 3 Y 362.8127780 04 N M 152.6027781 04 N M 3 217.8027784 04 N M 3 Y 416.2027786 04 N M 3 152.6027788 04 N M 3 222.0027792 04 N M 3 Y 299.7027808 04 N M 3 208.0527810 04 N M 3 305.1527814 04 N M 3 Y 610.4527816 04 N M 3 224.7027818 04 N M 3 369.0527822 04 N M 3 Y 599.3527823 04 N M 3 Y 599.3527824 04 N M 3 Y 232.2027825 04 N M 3 Y 286.2027826 04 N M 3 Y 515.7027827 04 N M 3 Y 638.0027828 04 N M 3 Y 696.9027829 04 N M 3 Y 412.00

Page 60: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

27830 04 N M 153.7527831 04 N M 3 224.7027832 04 N M 3 Y 599.3527840 04 N M 138.2027842 04 N M 3 208.0527846 04 N M 3 Y 378.7027848 04 N M 3 Y 481.9027860 04 N I 3 77.1027870 04 N M 3 Y 659.0027871 04 N M 3 Y 659.0027880 04 N M 3 Y 613.2027881 04 N M 3 Y 674.2027882 04 N M 3 Y 588.2027884 04 N M 3 Y 252.6527886 04 N M 3 Y 374.5527888 04 N M 3 Y 599.3527889 04 N M 3 Y 374.5527892 04 N M 3 Y 220.4027893 04 N M 3 Y 212.8027894 04 N M 3 Y 293.2027899 04 Y M Y28001 04 01-Jan-10 N I 3 136.05 17.0028002 04 01-Jan-10 N I 3 143.9528003 04 N M 3 246.8528005 04 01-Jan-10 N M 3 270.5028008 04 N I 3 147.9528010 04 N I 3 Y 123.3528011 04 Y M 3 Y28020 04 N M 3 Y 224.7028022 04 N M 3 Y 153.6528024 04 N I 3 Y 146.1528035 04 01-Jan-10 N M 4 Y Y 524.4028039 04 01-Jan-10 N M 3 Y 189.1028041 04 01-Jan-10 N M 3 Y 248.9028043 04 01-Jan-10 N M 3 149.8028045 04 N M 3 Y 224.7028046 04 01-Jan-10 N M 3 Y 408.0928047 04 01-Jan-10 N M 3 Y Y 527.94

Page 61: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

28050 04 N M 3 Y 299.7028052 04 N M 3 Y 299.7028054 04 N M 3 Y 224.7028055 04 01-Jan-07 N M 3 Y 302.4028060 04 N M 3 Y 224.7028062 04 Y M 3 Y28070 04 N M 3 Y 224.7028072 04 N M 3 Y 161.9028080 04 N M 3 Y 180.3028086 04 N M 3 Y 184.5028088 04 N M 3 Y 184.5028090 04 N M 3 Y 175.75 34.0028092 04 N M 3 Y 211.35 34.0028100 04 N M 3 Y 224.7028102 04 N M 3 Y 718.7028103 04 N M 3 Y 718.7028104 04 N M 3 Y 259.4028106 04 N M 3 Y 449.5028107 04 N M 3 Y 449.5028108 04 N M 3 Y 259.4028110 04 N M 3 Y 359.3028111 04 N M 3 Y 359.3028112 04 N M 3 Y 314.9528113 04 N M 3 Y 314.9528114 04 N M 3 Y 943.4028116 04 N M 3 Y 346.7528118 04 N M 3 Y 346.7528119 04 N M 3 Y 264.9028120 04 N M 3 Y 259.4028122 04 N M 3 Y 253.9028124 04 N M 3 Y 259.4028126 04 N M 3 Y 209.4028130 04 N M 3 Y 412.0028140 04 N M 3 Y 394.0028150 04 N M 3 Y 209.4028153 04 N M 3 Y 144.7028160 04 N M 3 Y 224.7028171 04 01-Jan-10 N M 3 Y 467.16

Page 62: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

28173 04 01-Jan-10 N M 3 Y 418.5128175 04 01-Jan-10 N M 3 Y 262.1728190 04 N I 3 107.00 17.0028192 04 N M 3 Y 159.80 17.0028193 04 N M 3 Y 180.3028200 04 N M 3 Y 353.7528202 04 N M 3 Y 480.0028208 04 N M 3 299.7028210 04 N M 3 Y 378.0528220 04 N M 3 Y 212.3028222 04 Y M 3 Y28225 04 N M 3 Y 212.3028226 04 Y M 4 Y28230 04 N M 3 Y 173.4028232 04 N I 3 Y 121.1028234 04 N I 4 Y 121.0528238 04 N M 3 Y 299.7028240 04 N M 3 Y 140.7528250 04 N M 3 Y 359.3028260 04 N M 3 Y 299.7028261 04 N M 3 Y 363.4528262 04 N M 3 Y 524.4028264 04 N M 3 Y 449.5028270 04 N M 3 Y 299.7028272 04 N M 3 Y 224.7028280 04 N M 3 Y 162.3528285 04 N M 3 Y 270.5028286 04 N M 3 Y 337.1028288 04 N M 3 Y 299.7028289 04 N M 3 Y 359.3028290 04 N M 3 Y 424.4528292 04 N M 3 Y 359.3028293 04 N M 3 Y 359.3028294 04 N M 3 Y 359.3028296 04 N M 3 Y 419.0028297 04 N M 3 Y 419.0028298 04 N M 3 Y 359.3028299 04 N M 3 Y 430.51

Page 63: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

28300 04 N M 3 Y 374.5528302 04 N M 3 Y 337.9028304 04 N M 3 Y 283.6028305 04 N M 3 Y 373.7028306 04 N M 3 Y 262.2028307 04 N M 3 Y 299.7028308 04 N M 3 Y 202.5028309 04 N M 3 Y 358.0528310 04 N M 3 Y 262.2028312 04 N M 3 Y 169.8528313 04 N M 3 Y 167.1028315 04 N M 3 Y 224.7028320 04 N M 3 Y 378.0528322 04 N M 3 Y 244.9028340 04 N M 3 Y 270.0028341 04 N M 3 Y 307.9028344 04 N M 3 Y 172.8028345 04 N M 3 Y 216.0028360 04 Y M 3 Y28400 04 N I 114.2028405 04 N M 3 Y 228.9028406 04 N M 3 Y 231.6528415 04 N M 3 Y 642.4528420 04 N M 3 Y 671.8528430 04 N M 109.0028435 04 N M 3 Y 215.0528436 04 N M 3 Y 318.6028445 04 N M 3 Y 718.7028446 04 01-Jan-08 N M 3 Y Y 626.7428450 04 N M 98.0028455 04 N M 3 277.5028456 04 N M 3 Y 313.2028465 04 N M 3 Y 599.3528470 04 N I 97.0528475 04 N M 3 173.4028476 04 N M 3 Y 237.8528485 04 N M 3 Y 301.0028490 04 N I 55.40

Page 64: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

28495 04 N I 3 69.3028496 04 N M 3 Y 113.6028505 04 N M 3 Y 230.8028510 04 N I 3 41.6028515 04 N I 3 97.0528525 04 N I 3 Y 202.9028530 04 N I 3 57.3028531 04 N M 3 Y 224.7028540 04 N I 138.7528545 04 N I 3 152.6028546 04 N I 3 Y 134.6028555 04 N M 3 Y 480.0028570 04 N I 113.6528575 04 N M 3 151.1528576 04 N M 3 Y 262.2028585 04 N M 3 Y 427.2028600 04 N M 299.7028605 04 N M 3 299.7028606 04 N M 3 Y 299.7028615 04 N M 3 Y 368.4528630 04 N I 112.4028635 04 N M 3 262.2028636 04 N M 3 Y 262.2028645 04 N M 3 Y 240.0028660 04 N I 104.1028665 04 N I 3 117.8528666 04 N M 3 Y 133.3528675 04 N M 3 Y 241.3528705 04 N M 3 Y 599.3528715 04 N M 3 Y 599.3528725 04 N M 3 Y 480.0028730 04 N M 3 Y 480.0028735 04 N M 3 Y 599.3528737 04 N M 3 Y 599.3528740 04 N M 3 Y 337.1028750 04 N M 3 Y 262.2028755 04 N M 3 Y 169.1028760 04 N M 4 Y 239.10

Page 65: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

28800 04 N M 3 Y 485.5028805 04 N M 3 Y 482.8028810 04 N M 3 Y 419.0028820 04 N I 3 Y 167.1028825 04 N I 3 Y 145.6028890 04 N M 3 121.8028899 04 Y M 3 Y29000 04 N I 3 156.8029010 04 N I 3 141.5029015 04 N I 3 188.7029020 04 N I 3 205.3029025 04 N I 3 227.5029035 04 N I 3 152.6029040 04 N I 3 181.6529044 04 N I 3 173.4029046 04 N I 3 187.3029049 04 N I 3 66.10 34.0029055 04 N I 3 115.80 34.0029058 04 N I 3 79.30 34.0029065 04 N I 3 59.45 34.0029075 04 N I 3 59.45 34.0029085 04 N I 3 49.30 17.0029086 04 N I 3 30.7029105 04 N I 3 42.10 17.0029125 04 N I 3 32.15 17.0029126 04 N I 3 39.30 17.0029130 04 N I 23.00 17.0029131 04 N I 23.50 17.0029200 04 N I 24.2529240 04 N I 37.4029260 04 N I 19.9529280 04 N I 19.3029305 04 N I 3 166.4029325 04 N I 3 194.2029345 04 N I 3 79.30 34.0029355 04 N I 3 92.40 34.0029358 04 N I 3 174.40 34.0029365 04 N I 3 79.30 34.00

Page 66: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

29405 04 N I 3 70.00 34.0029425 04 N I 3 75.30 34.0029435 04 N I 3 79.30 34.0029440 04 N I 29.8029445 04 N I 3 91.6529450 04 N I 3 43.50 17.0029505 04 N I 3 43.50 17.0029515 04 N I 3 35.85 17.0029520 04 N I Y 21.4029530 04 N I 3 21.8029540 04 N I 3 15.4029550 04 N I 14.2029580 04 N I 27.00 17.0029581 04 01-Jan-10 N I 18.6329590 04 N I 22.1529700 04 N I 3 24.1529705 04 N I 25.6029710 04 N I 56.8029715 04 N I 94.3029720 04 N I 59.6029730 04 N I 36.0029740 04 N I 46.5529750 04 N I 44.3029799 04 Y I29800 04 N M 4 Y 374.5529804 04 N M 4 Y 355.8029805 04 N M 3 Y 325.2029806 04 N M 3 Y 673.3029807 04 N M 3 Y 673.3029819 04 N M 3 Y 480.0029820 04 N M 3 Y 480.0029821 04 N M 3 Y 480.0029822 04 N M 3 Y 480.0029823 04 N M 3 Y 480.0029824 04 N M 3 Y 526.4529825 04 N M 3 Y 480.0029826 04 N M 3 Y 480.0029827 04 N M 3 Y 674.20

Page 67: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

29828 04 01-Jan-08 N M 3 Y 484.9029830 04 N M 3 Y 394.5029834 04 N M 3 Y 480.0029835 04 N M 3 Y 480.0029836 04 N M 3 Y 480.0029837 04 N M 3 Y 480.0029838 04 N M 3 Y 480.0029840 04 N M 3 Y Y 356.1029843 04 N M 3 Y Y 356.1029844 04 N M 3 Y Y 480.0029845 04 N M 3 Y Y 480.0029846 04 N M 3 Y Y 356.1029847 04 N M 3 Y Y 480.0029848 04 N M 3 Y 456.0029850 04 N M 3 Y 675.1029851 04 N M 3 Y 958.6029855 04 N M 3 Y 629.9029856 04 N M 3 Y 839.3529860 04 N M 3 Y 374.5529861 04 N M 3 Y 486.9029862 04 N M 3 Y 599.3529863 04 N M 3 Y 599.3529866 04 Y M 329867 04 Y M 329868 04 Y M 329870 04 N M 3 Y 374.5529871 04 N M 3 Y 374.5529873 04 N M 3 Y 374.5529874 04 N M 3 Y 486.9029875 04 N M 3 Y 599.3529876 04 N M 3 Y 599.3529877 04 N M 3 Y 599.3529879 04 N M 3 Y 599.3529880 04 N M 3 Y Y 621.5029881 04 N M 3 Y 621.5029882 04 N M 3 Y 621.5029883 04 N M 3 Y Y 599.3529884 04 N M 3 Y 599.35

Page 68: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

29885 04 N M 3 Y Y 621.5029886 04 N M 3 Y 599.3529887 04 N M 3 Y 599.3529888 04 N M 3 Y Y 621.5029889 04 N M 3 Y Y 621.5029891 04 N M 3 Y 480.0029892 04 N M 3 Y 480.0029893 04 N M 3 171.9029894 04 N M 3 480.0029895 04 N M 3 Y 480.0029897 04 N M 3 480.0029898 04 N M 3 Y 480.0029899 04 N M 3 Y 659.0029900 04 N M 3 Y 288.6029901 04 N M 3 Y 318.8029902 04 N M 3 Y 342.5529904 04 01-Jan-08 N M 3 Y 323.3729905 04 01-Jan-08 N M 3 Y 347.9629906 04 01-Jan-08 N M 3 Y 366.4629907 04 01-Jan-08 N M 3 Y 451.2029999 04 Y M 3 Y30000 04 N I 3 46.70 17.0030020 04 N I 3 47.80 17.0030100 04 N I 3 55.40 17.0030110 04 N I 3 57.10 17.0030115 04 N M 4 156.8030117 04 N I 4 109.3030118 04 N I 4 299.3530120 04 N M 4 Y 480.0030124 04 N I 3 89.10 17.0030125 04 N I 4 218.9530130 04 N M 4 180.3030140 04 N M 4 Y 180.3030150 04 Y M 4 Y30160 04 Y M 4 Y Y30200 04 N I 3 24.9030210 04 N I 3 34.8030220 04 N I 4 Y Y 56.00

Page 69: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

30300 04 N I 39.0530310 04 N I 3 74.9030320 04 N I 3 152.6030400 04 N M 4 Y Y 749.2030410 04 N M 4 Y 749.2030420 04 N M 4 Y Y 980.8530430 04 N M 4 Y 374.5530435 04 Y M 4 Y Y30450 04 N M 4 Y 599.3530460 04 N M 4 Y Y 599.3530462 04 N M 4 Y Y 815.5030465 04 N M 4 Y 547.6030520 04 N M 4 Y 417.6030540 04 N M 4 Y Y 524.4030545 04 N M 4 Y Y 674.2030560 04 N I 4 42.0030580 04 N M 4 Y 374.5530600 04 N M 4 Y 374.5530620 04 N M 4 524.4030630 04 N M 4 Y Y 524.4030801 04 N I 4 50.0530802 04 N I 4 71.1530901 04 01-Jan-10 N I 4 74.9030903 04 N I 4 Y Y 71.40 17.0030905 04 N I 4 80.75 17.0030906 04 N I 4 85.70 17.0030915 04 N M 4 359.3030920 04 N M 4 359.3030930 04 N I 4 Y Y 90.1030999 04 Y M Y31000 04 N I 4 39.3531002 04 N I 4 51.5031020 04 N M 4 180.3031030 04 N M 4 480.0031032 04 N M 4 Y Y 718.7031040 04 N M 4 Y 359.3031050 04 N M 4 Y 412.0031051 04 N M 4 Y 412.00

Page 70: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

31070 04 N M 4 180.3031075 04 N M 4 Y 599.3531080 04 N M 4 Y 898.9531081 04 N M 4 Y 898.9531084 04 N M 4 Y 898.9531085 04 N M 5 Y 898.9531086 04 N M 4 Y 898.9531087 04 N M 4 Y 898.9531090 04 N M 4 Y 718.7031200 04 N M 4 Y 262.2031201 04 N M 4 449.5031205 04 N M 4 Y 449.5031225 04 N M 5 Y 898.9531230 04 N M 5 Y 1,198.7031231 04 N I 3 107.0031233 04 N I 4 112.4031235 04 N I 4 107.0031237 04 N I 4 102.5531238 04 N I 4 113.1031239 04 Y M 431240 04 N M 4 221.9031254 04 N M 4 Y 262.2031255 04 N M 4 Y 449.5031256 04 N M 4 Y 180.3031267 04 N M 4 Y 224.7031276 04 N M 4 253.3031287 04 N M 4 205.9531288 04 N M 4 412.0031290 04 Y M 431291 04 Y M 431292 04 N M 4 451.5031293 04 N M 4 492.1531294 04 N M 4 581.0031299 04 Y M Y31300 04 N M 6 Y 524.4031320 04 N M 4 299.7031360 04 N M 6 Y Y 1,198.7031365 04 N M 6 Y Y 1,537.15

Page 71: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

31367 04 N M 6 Y Y 958.6031368 04 N M 6 Y Y 1,537.1531370 04 N M 6 Y Y 958.6031375 04 N M 6 Y Y 958.6031380 04 N M 6 Y 958.6031382 04 N M 6 Y Y 958.6031390 04 N M 6 Y Y 1,537.1531395 04 N M 6 Y Y 1,728.2531400 04 N M 6 Y 749.2031420 04 N M 6 Y Y 524.4031500 04 N I 55.5031502 04 N I 3 Y 28.5031505 04 N I 4 37.4031510 04 N I 4 74.9031511 04 N I 4 202.5031512 04 N M 4 202.5031513 04 N M 4 Y Y 235.8031515 04 N I 4 107.00 17.0031520 04 N I 4 112.4031525 04 N I 4 107.00 17.0031526 04 N I 4 192.95 17.0031527 04 N M 4 Y Y 192.95 17.0031528 04 N I 4 Y Y 192.95 17.0031529 04 N I 4 Y Y 192.95 17.0031530 04 N M 4 192.95 34.0031531 04 N M 4 224.60 34.0031535 04 N I 4 224.60 34.0031536 04 N I 4 224.60 34.0031540 04 N M 4 268.20 34.0031541 04 N M 4 268.20 34.0031545 04 N M 4 268.2031546 04 N M 4 577.1631560 04 N M 4 Y 499.45 34.0031561 04 N M 4 499.45 34.0031570 04 N M 4 224.60 34.0031571 04 N M 4 224.60 34.0031575 04 N I 4 Y Y 107.00 34.0031576 04 N I 4 Y Y 224.60 34.00

Page 72: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

31577 04 N M 4 Y Y 192.95 34.0031578 04 N M 4 Y Y 268.20 34.0031579 04 N I 4 192.9531580 04 N M 4 Y 524.3531582 04 N M 4 Y 686.8031584 04 N M 4 591.6031587 04 N M 4 Y Y 524.3531588 04 Y M 4 Y31590 04 N M 4 Y Y 839.3531595 04 N M 4 Y Y 360.7031599 04 Y M Y31600 04 N I 4 266.4031601 04 N I 4 284.4031603 04 N I 4 Y 266.4031605 04 N I 4 266.4031610 04 N I 4 289.4031611 04 N M 11 Y Y 374.6031612 04 N I 4 149.8031613 04 N M 3 Y Y 208.0531614 04 Y M 3 Y Y31615 04 N I 4 107.00 17.0031620 04 01-Jan-10 N I 4 40.0031622 04 N I 3 235.20 56.7031623 04 01-Jan-10 N I 3 235.20 56.731624 04 01-Jan-10 N I 3 270.50 56.731625 04 01-Jan-10 N I 3 235.20 56.7031626 04 01-Jan-10 N I 3 Y 121.44 56.731627 04 01-Jan-10 N I 3 Y 59.0231628 04 01-Jan-10 N I 4 246.95 56.731629 04 01-Jan-10 N I 4 235.20 56.731630 04 N M 4 251.1031631 04 N M 4 Y 251.1031632 04 N I 4 30.9431633 04 N I 4 38.5131635 04 N M 4 239.15 56.7031636 04 N M 4 Y 251.1031637 04 N M 4 Y 251.1031638 04 N M 4 Y 251.10

Page 73: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

31640 04 N M 4 251.1031641 04 N M 4 251.1031643 04 N I 4 235.9531645 04 N I 4 219.35 56.7031646 04 N I 4 219.35 56.7031656 04 N I 4 270.5031715 04 N I 4 74.9031717 04 N I 4 230.2531720 04 N I 4 224.7031725 04 N I 4 224.7031730 04 N I 4 Y 88.9031750 04 N M 6 Y Y 713.5031755 04 N M 6 Y 527.5031760 04 N M 11 Y Y 1,123.7031766 04 N M 4 Y Y 1,198.7031770 04 N M 4 Y Y 1,048.8531775 04 N M 4 Y Y 1,123.7031780 04 N M 6 Y Y 749.2031781 04 N M 11 Y Y 1,123.7031785 04 N M 6 Y Y 1,198.7031786 04 N M 11 Y Y 1,198.7031800 04 N M 6 Y Y 524.4031805 04 N M 11 Y Y 749.2031820 04 N M 4 214.00 34.0031825 04 N M 5 Y 374.5531830 04 N M 3 Y 166.7531899 04 Y M Y32035 04 N M 4 Y 524.4032036 04 N M 4 Y 331.1532095 04 N M 11 Y 419.0032100 04 N M 11 Y 811.5032110 04 N M 11 Y 811.5032120 04 N M 11 Y 599.3532124 04 N M 11 Y 599.3532140 04 N M 11 Y 599.3532141 04 N M 11 Y 599.3532150 04 N M 11 Y 599.3532151 04 N M 11 Y 599.35

Page 74: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

32160 04 N M 11 Y 374.5532200 04 N M 11 Y 480.0032201 04 N M 4 434.4532215 04 N M 11 Y 599.3532220 04 N M 11 Y 749.2032225 04 N M 11 Y 599.3532310 04 N M 11 Y 958.6032320 04 N M 11 Y 1,198.7032400 04 N I 4 71.40 34.0032402 04 N M 11 Y 524.4032405 04 N I 4 107.00 34.0032420 04 N I 4 107.00 34.0032421 04 01-Jan-08 N I 3 87.9832422 04 01-Jan-08 N I 4 108.5132440 04 N M 11 Y Y 1,198.7032442 04 N M 11 Y Y 1,414.7032445 04 N M 11 Y Y 1,198.7032480 04 N M 11 Y Y 1,213.9532482 04 N M 11 Y Y 1,213.9532484 04 N M 11 Y Y 1,213.9532486 04 N M 11 Y Y 1,350.1532488 04 N M 11 Y Y 1,213.9532491 04 N M 11 Y Y 1,213.9532500 04 N M 11 Y 718.7032501 04 N M 4 Y Y 324.0532503 04 N M 11 Y 1,050.3432504 04 N M 11 Y 1,203.1332540 04 N M 11 Y Y 958.60

32550 04 01-Jan-08 N M 4 127.01 318.4632551 04 01-Jan-08 N M 4 224.7032552 04 01-Jan-10 N I 3 Y 92.8832553 04 01-Jan-10 N I 3 Y 121.6832560 04 01-Jan-10 N I 3 198.2032561 04 01-Jan-10 N I 3 42.2832562 04 01-Jan-10 N I 3 37.8332601 04 N I 4 Y 167.2032602 04 N I 4 Y 181.35

Page 75: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

32603 04 N I 4 Y 302.4032604 04 N I 4 Y 302.4032605 04 N I 4 Y 314.9532606 04 N I 4 Y 314.9532650 04 N M 4 Y 349.8532651 04 N M 11 Y 426.1032652 04 N M 11 Y 591.4032653 04 N M 11 Y 418.5032654 04 N M 11 Y 400.8032655 04 N M 11 Y 838.9532656 04 N M 11 Y 523.8532657 04 N M 11 Y 523.8532658 04 N M 11 Y 415.9032659 04 N M 11 Y 415.5532660 04 N M 11 Y 648.1032661 04 N M 11 Y 523.8532662 04 N M 11 Y 598.4032663 04 N M 11 Y 1,213.8532664 04 N M 11 Y 749.2032665 04 N M 11 Y 1,082.1032800 04 Y M 11 Y Y32810 04 N M 4 398.4032815 04 N M 11 Y 813.2632820 04 Y M 11 Y32850 04 N M Y 1,134.1032851 04 N M 11 Y Y 2,106.3032852 04 N M 11 Y Y 2,397.4032853 04 N M 11 Y Y 3,402.5032854 04 N M 11 Y Y 3,834.5532900 04 N M 4 Y 564.9032905 04 N M 7 Y 749.2032906 04 N M 7 Y 772.9032940 04 N M 6 Y Y 571.5532960 04 N I 4 299.7032997 04 N M 3 246.4032998 04 01-Jan-07 N M 3 214.2432999 04 Y M Y33010 04 N I 3 61.25

Page 76: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

33011 04 N I 3 57.5533015 04 N I 3 204.0533020 04 N M 20 Y Y 733.8533025 04 N M 20 Y Y 839.3533030 04 N M 20 Y Y 839.3533031 04 N M 20 Y Y 2,397.4033050 04 N M 20 Y Y 1,048.8533120 04 N M 20 Y Y 2,397.4033130 04 N M 20 Y Y 749.2033140 04 N M 11 Y 828.4833141 04 N M 11 Y 86.2933202 04 01-Jan-07 N M 11 Y 861.5033203 04 01-Jan-07 N M Y 349.8533206 04 N M 5 Y 861.5033207 04 N M 5 Y Y 861.5033208 04 N M 5 Y 861.5033210 04 N I 5 Y 240.0033211 04 N I 5 Y 240.0033212 04 N I 5 Y 240.0033213 04 N I 5 Y 240.0033214 04 N M 5 Y 299.7033215 04 N M 5 299.7033216 04 01-Jan-10 N M 5 299.7033217 04 01-Jan-10 N M 5 299.7033218 04 N M 5 299.7033220 04 N M 5 245.6533222 04 01-Jan-10 N M 5 299.7033223 04 N M 5 Y 299.7033224 04 01-Jan-10 N M 5 299.7033225 04 N M 5 Y Y 299.7033226 04 N M Y Y 299.7033233 04 N M 5 Y 167.4033234 04 N M 5 Y 351.0033235 04 N M 5 Y 351.0033236 04 N M 11 Y Y 419.0033237 04 N M 11 Y Y 433.9533238 04 N M 11 Y Y 452.8033240 04 Y I 5 Y

Page 77: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

33241 04 Y I 5 Y33243 04 Y M 11 Y Y33244 04 Y I 5 Y33249 04 N M 5 Y 642.6033250 04 N M 15 Y Y 1,798.1033251 04 N M 20 Y Y 2,397.4033254 04 01-Jan-07 N M 20 Y 2,397.4033255 04 01-Jan-07 N M 20 Y 2,397.4033256 04 01-Jan-07 N M 20 Y 2,397.4033257 04 01-Jan-08 N M 20 Y 327.7433258 04 01-Jan-08 N M 20 Y 371.2733259 04 01-Jan-08 N M 20 489.4833261 04 N M 20 Y Y 2,397.4033265 04 01-Jan-07 N M 20 Y 2,397.4033266 04 01-Jan-07 N M 20 Y 2,397.4033282 04 N M 5 584.8033284 04 N M 5 444.0533300 04 N M 15 Y Y 629.9033305 04 N M 20 Y Y 2,397.4033310 04 N M 20 Y Y 1,048.8533315 04 N M 20 Y Y 2,397.4033320 04 N M 15 Y Y 749.2033321 04 N M 15 Y Y 1,798.0533322 04 N M 20 Y Y 2,397.4033330 04 N M 20 Y Y 1,198.7033332 04 N M 20 Y Y 2,397.4033335 04 N M 20 Y Y 2,397.4033400 04 N M 20 Y Y 2,397.4033401 04 N M 20 Y Y 2,397.4033403 04 N M 20 Y Y 2,397.4033404 04 Y M 20 Y Y33405 04 N M 20 Y Y 2,397.4033406 04 N M 20 Y Y 2,397.4033410 04 N M 20 Y 2,397.4033411 04 N M 20 Y Y 2,397.4033412 04 N M 20 Y Y 2,397.4033413 04 N M 20 Y Y 2,397.4033414 04 Y M 20 Y Y

Page 78: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

33415 04 N M 20 Y Y 1,198.7033416 04 N M 20 Y Y 2,397.4033417 04 Y M 20 Y Y33420 04 N M 20 Y Y 1,048.8533422 04 N M 20 Y Y 2,397.4033425 04 N M 20 Y Y 2,397.4033426 04 N M 20 Y Y 2,397.4033427 04 N M 20 Y Y 2,397.4033430 04 N M 20 Y Y 2,397.4033460 04 N M 20 Y Y 2,397.4033463 04 N M 20 Y Y 2,397.4033464 04 N M 20 Y Y 2,397.4033465 04 N M 20 Y Y 2,397.4033468 04 N M 20 Y Y 2,397.4033470 04 N M 20 Y Y 749.2033471 04 N M 20 Y Y 1,198.7033472 04 N M 20 Y Y 1,198.7033474 04 N M 20 Y Y 2,397.4033475 04 N M 20 Y Y 2,397.4033476 04 N M 20 Y Y 1,198.7033478 04 N M 20 Y Y 2,277.5033496 04 N M 20 Y Y 2,397.4033500 04 N M 20 Y Y 2,397.4033501 04 N M 20 Y Y 1,198.7033502 04 N M 20 Y Y 749.2033503 04 N M 20 Y Y 2,397.4033504 04 N M 20 Y Y 2,397.4033505 04 Y M 20 Y Y33506 04 Y M 20 Y Y33507 04 N M 20 Y Y 1,014.9933508 04 N M 5 Y Y 17.0433510 04 N M 20 Y Y 2,397.4033511 04 N M 20 Y Y 2,397.4033512 04 N M 20 Y Y 2,397.4033513 04 N M 20 Y Y 2,397.4033514 04 N M 20 Y Y 2,397.4033516 04 N M 20 Y Y 2,397.4033517 04 N M 20 Y Y 2,397.40

Page 79: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

33518 04 N M 20 Y Y 2,397.4033519 04 N M 20 Y Y 2,397.4033521 04 N M 20 Y Y 2,397.4033522 04 N M 20 Y Y 2,397.4033523 04 N M 20 Y Y 2,397.4033530 04 N M 20 Y Y 2,397.4033533 04 N M 20 Y Y 2,397.4033534 04 N M 20 Y Y 2,397.4033535 04 N M 20 Y Y 2,397.4033536 04 N M 20 Y Y 2,397.4033542 04 N M 20 Y Y 1,198.7033545 04 N M 20 Y Y 2,397.4033548 04 N M 20 Y 1,333.1233572 04 N M 20 Y Y 2,397.4033600 04 Y M 20 Y Y33602 04 Y M 20 Y Y33606 04 Y M 20 Y Y33608 04 Y M 20 Y Y33610 04 Y M 20 Y Y33611 04 Y M 20 Y Y33612 04 Y M 20 Y Y33615 04 N M 20 Y Y 2,397.4033617 04 N M 20 Y Y 2,397.4033619 04 N M 20 Y Y 2,397.4033641 04 N M 20 Y Y 2,397.4033645 04 N M 20 Y Y 2,397.4033647 04 N M 20 Y Y 2,397.4033660 04 N M 20 Y Y 2,397.4033665 04 N M 20 Y Y 2,397.4033670 04 N M 20 Y Y 2,397.4033675 04 01-Jan-07 N M 20 Y 2,397.4033676 04 01-Jan-07 N M 20 Y 2,397.4033677 04 01-Jan-07 N M 20 Y 2,397.4033681 04 N M 20 Y Y 2,397.4033684 04 N M 20 Y Y 2,397.4033688 04 N M 20 Y Y 2,397.4033690 04 N M 20 Y Y 958.6033692 04 N M 20 Y Y 2,397.40

Page 80: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

33694 04 N M 20 Y Y 2,397.4033697 04 N M 20 Y Y 2,996.8033702 04 N M 20 Y Y 2,397.4033710 04 N M 20 Y Y 2,397.4033720 04 N M 20 Y Y 2,397.4033722 04 Y M 20 Y Y33724 04 01-Jan-07 N M 20 Y 2,397.4033726 04 01-Jan-07 N M 20 2,721.4533730 04 N M 20 Y Y 2,721.4533732 04 N M 20 Y Y 2,397.4033735 04 N M 20 Y Y 1,198.7033736 04 N M 20 Y Y 2,397.4033737 04 N M 20 Y Y 2,397.4033750 04 N M 20 Y Y 1,079.3033755 04 N M 20 Y Y 1,079.3033762 04 N M 20 Y Y 1,079.3033764 04 N M 20 Y Y 1,198.7033766 04 N M 20 Y Y 1,079.3033767 04 N M 20 Y Y 2,397.4033768 04 N M 20 Y Y 255.0033770 04 N M 20 Y Y 2,996.8033771 04 N M 20 Y Y 2,996.8033774 04 N M 20 Y Y 2,397.4033775 04 N M 20 Y Y 2,397.4033776 04 N M 20 Y Y 2,996.6033777 04 N M 20 Y Y 2,996.6033778 04 N M 20 Y Y 2,397.4033779 04 N M 20 Y Y 2,397.4033780 04 N M 20 Y Y 2,996.6033781 04 N M 20 Y Y 2,996.6033782 04 01-Jan-10 N M 20 Y Y 1,272.8033783 04 01-Jan-10 N M 20 Y Y 1,927.2033786 04 N M 20 Y Y 2,397.4033788 04 N M 20 Y Y 2,057.8033800 04 N M 20 Y Y 1,123.7033802 04 N M 20 Y Y 1,123.7033803 04 N M 20 Y Y 1,501.7533813 04 N M 15 Y Y 1,797.95

Page 81: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

33814 04 N M 20 Y Y 2,397.4033820 04 N M 15 Y Y 839.3533822 04 N M 15 Y Y 839.3533824 04 N M 15 Y Y 1,079.3033840 04 N M 20 Y Y 1,198.7033845 04 N M 20 Y Y 1,198.7033851 04 N M 20 Y Y 1,198.7033852 04 N M 20 Y Y 2,397.4033853 04 N M 20 Y Y 2,397.4033860 04 N M 20 Y Y 2,397.4033861 04 N M 20 Y Y 2,397.4033863 04 N M 20 Y Y 2,397.4033864 04 01-Jan-08 N M 20 Y 1794.4833870 04 N M 20 Y Y 2,397.4033875 04 Y M 15 Y Y33877 04 Y M 20 Y Y33880 04 N M 20 Y Y 1,042.9733881 04 N M 20 Y Y 894.7133883 04 N M 20 Y Y 662.8333884 04 N M 20 Y Y 249.0933886 04 N M 20 Y Y 571.5133889 04 N M 20 Y Y 499.9933891 04 N M 20 Y Y 636.6733910 04 N M 20 Y Y 2,397.4033915 04 Y M 20 Y Y33916 04 N M 20 Y Y 2,397.4033917 04 N M 20 Y Y 2,397.4033920 04 N M 20 Y Y 2,397.4033922 04 N M 20 Y Y 2,397.4033924 04 N M 20 Y Y 324.0533925 04 N M 20 Y Y 1,037.6833926 04 N M 20 Y Y 1,407.8033930 04 N M Y 1,306.6533935 04 N M 20 Y Y 4,104.6033940 04 N M Y 1,198.7033945 04 N M 20 Y Y 2,894.3033960 04 N I 453.7033961 04 N I 295.60

Page 82: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

33967 04 N I 3 230.2033968 04 N M 3 162.0033970 04 N M 5 689.5033971 04 N M 5 Y Y 334.8033973 04 N M 5 Y Y 689.5033974 04 N M 5 Y Y 419.2533975 04 N M 5 Y Y 1,350.1533976 04 N M 5 Y Y 1,674.2033977 04 N M 5 Y Y 1,215.1533978 04 N M 5 Y Y 1,458.2033979 04 N M 5 Y Y 730.8533980 04 N M 5 Y Y 787.9033981 04 01-Jan-10 Y M 20 Y33982 04 01-Jan-10 Y M 20 Y33983 04 01-Jan-10 Y M 20 Y33999 04 Y M Y Y34001 04 N M 5 Y 718.7034051 04 N M 5 Y 718.7034101 04 N M 5 Y 718.7034111 04 N M 5 Y 718.7034151 04 N M 5 Y 718.7034201 04 N M 5 Y 718.7034203 04 N M 5 Y 718.7034401 04 N M 5 Y 718.7034421 04 N M 5 Y 718.7034451 04 N M 5 Y 898.9534471 04 N M 5 Y 599.3534490 04 N M 5 Y 599.3534501 04 N M 10 Y Y 480.0034502 04 Y M 10 Y Y34510 04 N M 10 Y Y 480.0034520 04 N M 10 Y Y 480.0034530 04 N M 10 Y Y 599.3534800 04 N M 11 Y 819.6034802 04 N M 15 Y 904.7534803 04 N M 8 Y Y 1,148.6034804 04 N M 15 Y 904.7534805 04 N M 11 Y Y 669.46

Page 83: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

34806 04 01-Oct-09 N M 11 Y 64.6834808 04 N M 5 Y Y 156.1034812 04 N M 5 Y Y 255.7034813 04 N M 5 Y Y 181.5534820 04 N M 10 Y Y 369.0534825 04 N M 10 Y Y 488.6034826 04 01-Jan-10 N M 10 Y Y 156.1034830 04 N M 10 Y Y 1,276.3034831 04 N M 10 Y Y 1,379.9534832 04 N M 10 Y Y 1,379.9534833 04 N M 4 Y Y 488.6034834 04 N M 4 Y Y 369.0534900 04 N M 5 Y Y 488.6035001 04 N M 15 Y 1,123.7035002 04 N M 15 Y 1,306.6535005 04 N M 15 Y 1,414.7035011 04 N M 15 Y 898.9535013 04 N M 15 Y 1,198.7035021 04 N M 15 Y 1,198.7035022 04 N M 15 Y 1,414.7035045 04 N M 15 Y 599.3535081 04 N M 15 Y 1,198.7035082 04 N M 15 Y 1,630.7035091 04 N M 15 Y 1,198.7035092 04 N M 15 Y 1,630.7035102 04 N M 15 Y 1,198.7035103 04 N M 15 Y Y 1,630.7035111 04 N M 15 Y 1,198.7035112 04 N M 15 Y 1,630.7035121 04 N M 15 Y 1198.7035122 04 N M 15 Y 1630.7035131 04 N M 10 Y 958.6035132 04 N M 10 Y 1,198.7035141 04 N M 10 Y 958.6035142 04 N M 10 Y 1,198.7035151 04 N M 10 Y 958.6035152 04 N M 10 Y 1,198.7035180 04 N M 10 Y 1,198.70

Page 84: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

35182 04 N M 10 Y 952.1035184 04 N M 10 Y 599.3535188 04 N M 10 Y 1,198.7035189 04 N M 10 Y 952.1035190 04 N M 10 Y 599.3535201 04 N M 10 Y 1,198.7035206 04 N M 10 Y 599.3535207 04 N M 10 Y 341.2035211 04 N M 15 Y 1,498.3035216 04 N M 15 Y 1,198.7035221 04 N M 15 Y 1,198.7035226 04 N M 10 Y 599.3535231 04 N M 10 Y 599.3535236 04 N M 10 Y 599.3535241 04 N M 15 Y 1498.3035246 04 N M 15 Y 1,198.7035251 04 N M 15 Y 1198.7035256 04 N M 10 Y 599.3535261 04 N M 10 Y 599.3535266 04 N M 10 Y 599.3535271 04 N M 15 Y 1498.3035276 04 N M 15 Y 1198.7035281 04 N M 15 Y 1198.7035286 04 N M 10 Y 599.3535301 04 N M 15 Y 1101.6035302 04 01-Jan-07 N M 10 Y 958.6035303 04 01-Jan-07 N M 10 Y 958.6035304 04 01-Jan-07 N M 10 Y 958.6035305 04 01-Jan-07 N M 10 Y 958.6035306 04 01-Jan-07 N M 10 Y 958.6035311 04 N M 15 Y 749.2035321 04 N M 15 Y 749.2035331 04 N M 15 Y 1198.7035341 04 N M 15 Y 958.6035351 04 N M 10 Y 958.6035355 04 N M 10 Y 958.6035361 04 N M 15 Y 1,198.7035363 04 N M 10 Y 1,198.70

Page 85: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

35371 04 N M 10 Y 958.6035372 04 N M 10 Y Y 1,021.1535390 04 Y M 15 Y Y35400 04 Y I35450 04 N M 3 682.8035452 04 N M 3 682.8035454 04 N M 3 682.8035456 04 N M 3 479.0035458 04 N M 3 479.0035459 04 N M 3 479.0035460 04 N M 3 479.0035470 04 N M 3 479.0035471 04 N M 3 479.0035472 04 N M 3 Y 479.0035473 04 N M 3 479.0035474 04 N M 3 479.0035475 04 N M 3 479.0035476 04 N M 3 479.0035480 04 N M 3 Y Y 1,101.2035481 04 N M 3 Y Y 1,198.7035482 04 N M 3 Y Y 958.6035483 04 N M 3 Y Y 958.6035484 04 N M 3 Y Y 749.2035485 04 N M 3 Y 958.6035490 04 N M 3 Y 1,024.1535491 04 N M 3 Y 1,024.1535492 04 N M 3 Y 1,024.1535493 04 N M 3 Y 718.5035494 04 N M 3 Y 718.5035495 04 N M 3 Y 718.5035500 04 N M 3 Y 209.7535501 04 N M 10 Y 839.3535506 04 N M 10 Y 958.6035508 04 N M 10 Y 958.6035509 04 N M 10 Y 958.6035510 04 N M 10 Y Y 708.0535511 04 N M 10 Y 958.6035512 04 N M 10 Y Y 694.72

Page 86: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

35515 04 N M 10 Y 958.6035516 04 N M 10 Y 958.6035518 04 N M 10 Y 958.6035521 04 N M 10 Y 1,198.7035522 04 N M 10 Y Y 674.9935523 04 01-Jan-08 N M 10 Y Y 726.1435525 04 N M 10 Y Y 644.9135526 04 N M 10 Y 958.6035531 04 N M 8 Y 958.6035533 04 N M 10 Y 1,198.7035535 04 01-Jan-09 N M 8 Y 1109.7535536 04 N M 8 Y 958.6035537 04 01-Jan-07 N M 10 Y 1,198.7035538 04 01-Jan-07 N M 10 Y 1,198.7035539 04 01-Jan-07 N M 10 Y 839.3535540 04 01-Jan-07 N M 10 Y 839.3535548 04 N M 10 Y 839.3535549 04 N M 10 Y Y 1,198.7035551 04 N M 10 Y Y 1,198.7035556 04 N M 10 Y Y 958.6035558 04 N M 10 Y Y 1,079.3035560 04 N M 10 Y 1,198.7035563 04 N M 10 Y Y 1,198.7035565 04 N M 10 Y Y 1,198.7035566 04 N M 10 Y Y 958.6035570 04 01-Jan-09 N M 10 Y Y 958.6035571 04 N M 10 Y Y 958.6035572 04 N M 5 Y Y 209.7535583 04 N M 10 Y Y 958.6035585 04 N M 10 Y Y 958.6035587 04 N M 10 Y Y 958.6035600 04 N M 3 Y Y 192.7535601 04 N M 10 Y Y 839.3535606 04 N M 10 Y Y 958.6035612 04 N M 10 Y Y 958.6035616 04 N M 10 Y 958.6035621 04 N M 10 Y Y 1,198.7035623 04 N M 10 Y Y 1,306.65

Page 87: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

35626 04 N M 10 Y 958.6035631 04 N M 8 Y Y 1,198.7035632 04 01-Jan-09 N M 8 Y Y 1198.7035633 04 01-Jan-09 N M 8 Y Y 1198.7035634 04 01-Jan-09 N M 8 Y Y 1198.7035636 04 N M 8 Y Y 1,079.3035637 04 01-Jan-07 N M 10 Y 1,198.7035638 04 01-Jan-07 N M 10 Y 1,198.7035642 04 N M 10 Y 958.6035645 04 N M 10 Y 958.6035646 04 N M 10 Y Y 1,198.7035647 04 N M 10 Y Y 1,053.8035650 04 N M 10 Y 1,079.3035651 04 N M 10 Y Y 1,198.7035654 04 N M 10 Y 1,198.7035656 04 N M 10 Y Y 958.6035661 04 N M 10 Y Y 1,079.3035663 04 N M 10 Y Y 1,198.7035665 04 N M 10 Y Y 1,198.7035666 04 N M 10 Y Y 958.6035671 04 N M 10 Y Y 958.6035681 04 Y M 10 Y35682 04 N M 10 Y 314.6035683 04 N M 10 Y 314.6035685 04 N I 3 Y 146.5035686 04 N I 3 129.2535691 04 N M 10 Y Y 1,198.7035693 04 N M 10 Y Y 1,198.7035694 04 N M 10 Y Y 1,198.7035695 04 N M 10 Y Y 1,198.7035697 04 N M 10 Y Y 90.0235700 04 Y M 10 Y Y35701 04 N M 5 Y Y 374.5535721 04 N M 5 Y Y 299.7035741 04 N M 5 Y Y 299.7035761 04 Y M 535800 04 N M 5 Y Y 374.5535820 04 N M 11 Y Y 524.40

Page 88: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

35840 04 N M 4 Y 480.0035860 04 N M 3 Y 449.5035870 04 Y M 5 Y35875 04 N M 5 Y 449.5035876 04 N M 10 Y Y 455.1535879 04 N M 10 Y 599.3535881 04 N M 10 Y 789.8035883 04 01-Jan-07 N M 10 Y 599.3535884 04 01-Jan-07 N M 10 Y 599.3535901 04 N M 5 Y Y 599.3535903 04 N M 5 Y Y 449.5035905 04 N M 5 Y Y 811.5035907 04 N M 5 Y Y 599.3536000 09 Y I36002 04 Y I 336005 04 N I 136.6536010 04 N I 3 224.7036011 04 N I 3 249.3536012 04 N I 3 264.8036013 04 N I 3 213.5036014 04 N I 3 213.5036015 04 N I 3 249.3536100 04 N I 3 213.6536120 04 N I 3 233.0036140 04 N I 3 188.7036147 04 01-Jan-10 N I 3 Y 110.8936148 04 01-Jan-10 N I 3 Y 29.6536160 04 N I 3 202.5036200 04 N I 3 224.7036215 04 N I 3 198.9036216 04 N I 3 264.8036217 04 N I 3 281.0036218 04 N I 3 281.0036245 04 N I 3 213.5036246 04 N I 3 264.8036247 04 N I 3 281.0036248 04 N I 3 281.0036260 04 Y M 3

Page 89: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

36261 04 Y M 336262 04 Y M 336299 04 Y I 3 Y36400 04 N I 16.6536405 04 N I 16.6536406 04 N I 16.6536410 04 N I 16.6536415 J 04 N I 4.1036416 J 04 01-May-07 N I 4.1036420 04 N I 3 37.4036425 04 N I 3 37.4036430 04 N I 16.6536440 04 N I 28.8036450 04 N I 3 308.0036455 04 N I 3 338.5036460 04 N I 3 176.9036470 04 Y I 3 17.0036471 04 Y I 3 17.0036475 04 N M 3 213.5236476 04 N M 3 104.5736478 04 N M 3 213.5236479 04 N M 3 104.5736481 04 N I 3 264.8036500 04 N I 3 71.0536510 04 N I 25.2036511 04 Y I 336512 04 Y I 336513 04 Y I 336514 04 Y I 336515 04 Y I 336516 04 Y I 336522 04 N M 5 Y Y 599.3036555 04 N I 3 74.3836556 04 N I 3 67.1336557 04 N I 3 166.1836558 04 N I 3 158.0236560 04 N I 3 196.6636561 04 N I 3 190.09

Page 90: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

36563 04 N I 3 197.8136565 04 N I 3 190.0936566 04 N I 3 203.2436568 04 N I 3 55.0136569 04 N I 3 51.6136570 04 N I 3 171.9736571 04 N I 3 171.3736575 04 N I 3 33.1036576 04 N I 3 112.2136578 04 N I 3 126.7536580 04 N I 3 38.2536581 04 N I 3 118.7836582 04 N I 3 171.7736583 04 N I 3 173.1736584 04 N I 3 38.6436585 04 N I 3 161.2136589 04 N I 3 78.7336590 04 N I 3 107.5436593 04 01-Jan-08 N I 3 22.1436595 04 N I 3 107.2336596 04 N I 3 25.8536597 04 N I 3 34.3736598 04 N I 3 67.5136600 09 Y I36620 04 N I 37.4036625 04 N I 3 52.7036640 04 N I 3 74.9036660 04 N I 37.4036680 04 N I 3 90.1036800 04 N M 3 424.4536810 04 N M 5 424.4536815 04 N I 3 112.4036818 04 N M 5 Y 850.3036819 04 N M 5 Y 850.3036820 04 N M 5 541.1536821 04 N M 5 578.5536822 04 N M 5 Y Y 599.3036823 04 N M 5 Y 578.55

Page 91: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

36825 04 N M 5 578.5536830 04 N M 5 578.5536831 04 N M 5 578.5536832 04 N M 5 578.5536833 04 N M 5 Y 578.5536835 04 N M 5 578.5536838 04 N M 5 666.7136860 04 N I 3 112.4036861 04 N I 3 419.0036870 04 N M 3 Y 884.8037140 04 N M 8 Y Y 1198.7037145 04 N M 8 Y Y 1079.3037160 04 N M 8 Y Y 1079.3037180 04 N M 8 Y Y 1079.3037181 04 N M 8 Y 1079.3037182 04 N M 5 Y 910.7037183 04 01-Jan-10 N M 5 Y 429.0737184 04 N M 3 265.8137185 04 N I 97.6437186 04 N M 3 146.5037187 04 N M 3 247.1237188 04 N I 3 178.3837195 04 N M 3 472.4037200 04 N I 3 189.0037201 04 N I 3 472.4037202 04 N I 3 189.0037203 04 N M 3 682.8037204 04 N M 3 Y 682.8037205 04 N M 5 Y 910.7037206 04 Y M 337207 04 N M 3 910.7037208 04 Y M 337209 04 N M 3 213.5037210 04 01-Jan-07 N M 3 682.8037215 04 N M 5 Y 910.7037216 04 N M 3 Y 910.7037250 04 N I 89.1037251 04 N I 57.65

Page 92: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

37500 04 N I 4 299.7037501 04 Y I 337565 04 N M 5 Y 374.5537600 04 N M 5 Y 374.5537605 04 N M 5 Y 449.5037606 04 N M 5 Y 449.5037607 04 N M 3 Y Y 262.2037609 04 N I 3 112.4037615 04 N M 5 Y 374.5537616 04 N M 11 Y 524.4037617 04 N M 5 Y 524.4037618 04 N M 5 Y 262.2037620 04 N M 5 Y 449.5037650 04 N M 3 Y 374.5537660 04 N M 3 Y 449.5037700 04 N M 3 Y 203.9537718 04 N I 3 Y 227.3937722 04 N I 3 Y 275.0237735 04 N M 3 Y 419.0037760 04 01-Jan-10 N M 3 Y 299.7037761 04 01-Jan-10 N M 3 Y Y 331.9937765 04 N M 3 245.9037766 04 N M 3 298.8137780 04 N M 3 149.8037785 04 N I 3 131.2537788 04 Y M 337790 04 Y M 3 Y37799 04 Y M 5 Y38100 04 N M 5 Y Y 770.0038101 04 N M 5 Y 770.0038102 04 Y M 5 Y Y38115 04 N M 5 Y 770.0038120 04 N M 5 Y 770.0038129 04 Y M 5 Y38200 04 N I 3 66.5038204 09 Y I38205 04 Y I38206 04 Y I

Page 93: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

38207 09 Y I38208 09 Y I38209 09 Y I38210 09 Y I38211 09 Y I38212 09 Y I38213 09 Y I38214 09 Y I38215 09 Y I38220 04 N I 3 50.1538221 04 N I 3 Y 78.4538230 04 N M 3 Y 660.6538240 04 N M 3 Y Y 220.2038241 04 N M 3 Y Y 220.2038242 04 N I 3 Y 80.5538300 04 N I 3 71.40 17.0038305 04 N I 3 156.95 17.0038308 04 N M 3 246.4738380 04 N M 4 Y 556.2538381 04 N M 11 Y 811.6038382 04 N M 11 Y 612.1538500 04 N I 3 85.70 17.0038505 04 N I 3 106.80 17.0038510 04 N I 3 127.7038520 04 N I 3 157.9038525 04 N I 3 135.6038530 04 N I 3 189.2538542 04 N I 3 Y Y 185.4538550 04 N M 3 224.7038555 04 N M 3 Y 656.6038562 04 N M 3 Y 480.0038564 04 N M 4 Y 599.3538570 04 N M 4 Y 302.4038571 04 N M 4 Y 599.3538572 04 N M 4 Y 599.3538589 04 Y M 4 Y38700 04 N M 4 Y 786.6038720 04 N M 4 Y 861.50

Page 94: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

38724 04 N M 4 Y Y 645.4538740 04 N M 4 Y 524.4038745 04 N M 4 Y 524.4038746 04 N M 11 Y Y 216.0238747 04 N M 4 Y Y 158.5738760 04 N M 3 299.7038765 04 N M 3 Y 918.4038770 04 N M 3 Y 918.4038780 04 N M 4 Y 998.8038790 04 N I 3 220.8538792 04 N I 3 105.4038794 04 Y M 338999 04 Y M Y39000 04 N M 11 Y Y 718.7039010 04 N M 11 Y Y 718.7039200 04 N M 11 Y 749.2039220 04 N M 11 Y 749.2039400 04 N I 4 314.9539499 04 Y M Y39501 04 N M 6 Y Y 648.6039502 04 N M 6 Y Y 826.5039503 04 N M 6 Y Y 960.5539520 04 N M 11 Y Y 682.6039530 04 N M 11 Y Y 682.6039531 04 N M 11 Y Y 735.4539540 04 N M 6 Y Y 682.6039541 04 N M 6 Y Y 682.6039545 04 N M 6 Y Y 682.6039560 04 N M 6 Y Y 708.6039561 04 N M 6 Y 803.0539599 04 Y M Y40490 04 N I 4 46.25 17.0040500 04 N M 4 165.1040510 04 N I 4 170.4540520 04 N M 4 Y Y 524.4040525 04 N M 4 Y Y 629.9040527 04 N M 5 Y Y 718.7040530 04 N M 5 Y Y 524.35

Page 95: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

40650 04 N M 5 Y Y 629.9040652 04 N M 5 Y Y 629.9040654 04 N M 5 Y Y 629.9040700 04 N M 5 Y Y 718.7040701 04 N M 5 Y Y 958.6040702 04 N M 5 Y 958.6040720 04 N M 5 Y Y 718.7040761 04 N M 5 Y Y 802.0040799 04 Y M Y40800 04 N I 4 39.90 17.0040801 04 N I 5 76.1540804 04 N I 4 44.10 17.0040805 04 N I 5 89.1040806 04 N I 4 35.65 17.0040808 04 N I 4 50.20 17.0040810 04 N I 4 50.95 17.0040812 04 N I 4 73.70 17.0040814 04 N I 5 117.6540816 04 N I 5 142.70 34.0040818 04 N I 4 113.4040819 04 N M 4 149.8040820 04 N I 4 142.70 17.0040830 04 N I 4 107.00 17.0040831 04 N I 5 132.75 17.0040840 04 N M 5 Y Y 252.0040842 04 N M 5 Y Y 251.0540843 04 N M 5 Y Y 347.2040844 04 N M 5 Y Y 496.9040845 04 N M 5 Y Y 629.1040899 04 Y M Y41000 04 N I 4 44.65 17.0041005 04 N I 4 41.70 17.0041006 04 N I 4 93.6041007 04 N I 4 102.95 17.0041008 04 N I 4 92.70 17.0041009 04 N I 4 116.5041010 04 N I 4 42.45 17.0041015 04 N I 4 106.45 17.00

Page 96: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

41016 04 N I 4 130.40 17.0041017 04 N I 4 113.10 17.0041018 04 N I 4 154.9541019 04 01-Jan-08 N I 4 Y 259.6541100 04 N I 4 88.50 17.0041105 04 N I 4 181.00 17.0041108 04 N I 4 88.50 17.0041110 04 N M 4 214.00 17.0041112 04 N M 4 299.7041113 04 N M 4 299.7041114 04 N M 4 249.7041115 04 N M 4 224.7041116 04 N M 4 224.7041120 04 N M 6 Y Y 524.4041130 04 N M 6 Y Y 524.4041135 04 N M 6 Y Y 861.5041140 04 N M 6 Y Y 735.6541145 04 N M 6 Y Y 1048.8541150 04 N M 6 Y Y 1498.3041153 04 N M 6 Y Y 1498.3041155 04 N M 6 Y Y 1798.0541250 04 N I 5 71.40 34.0041251 04 N I 5 74.10 34.0041252 04 N I 5 95.25 34.0041500 04 N I 4 121.7041510 04 N M 4 374.5541512 04 01-Jan-09 N I 5 71.4041520 04 N I 4 92.7041530 04 01-Jan-09 N I 222.8141599 04 Y M Y41800 04 N I 3 39.70 17.0041805 04 N I 4 42.30 17.0041806 04 N I 4 90.1041820 04 N I 4 99.0541821 04 N I 4 71.6041822 04 N I 4 90.1041823 04 N M 4 169.4041825 04 N I 4 76.95

Page 97: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

41826 04 N M 4 224.7041827 04 N M 4 299.7041828 04 N I 4 110.3541830 04 N M 4 224.7041850 04 N I 4 41.2541870 04 N M 4 Y Y 169.4041872 04 N M 4 169.4041874 04 N M 4 169.4041899 04 Y M 4 Y42000 04 N I 5 43.05 17.0042100 04 N I 5 50.20 34.0042104 04 N I 5 79.30 34.0042106 04 N M 5 Y Y 480.0042107 04 N M 5 Y Y 506.4042120 04 N M 5 Y Y 647.9042140 04 N M 5 184.5042145 04 N M 5 Y 359.3042160 04 N I 5 64.10 17.0042180 04 N M 5 Y Y 149.8042182 04 N M 5 Y Y 215.9042200 04 N M 5 Y Y 718.7042205 04 N M 5 Y Y 718.7042210 04 N M 5 Y Y 850.8042215 04 N M 5 Y Y 491.5042220 04 N M 5 Y Y 718.7042225 04 N M 5 Y Y 986.3542226 04 N M 5 Y Y 784.7542227 04 N M 5 Y Y 784.7542235 04 N M 5 Y Y 374.5542260 04 N M 5 Y Y 718.7042280 04 N I 5 Y Y 53.8542281 04 N I 5 Y 58.4542299 04 Y M Y42300 04 N I 4 79.30 17.0042305 04 N I 4 164.9042310 04 N I 4 79.30 17.0042320 04 N I 4 113.60 17.0042330 04 N I 4 113.60 34.00

Page 98: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

42335 04 N M 4 240.0042340 04 N M 4 240.0042381 04 01-Jan-1042400 04 N I 4 113.60 17.0042405 04 N I 4 113.60 34.0042408 04 N I 4 137.80 34.0042409 04 N I 4 113.60 34.0042410 04 N M 4 Y Y 749.2042415 04 N M 4 Y Y 754.6542420 04 N M 4 Y Y 867.1042425 04 N M 4 Y Y 892.0042426 04 N M 6 Y Y 1079.3042440 04 N M 4 Y 480.0042450 04 N M 4 Y Y 480.0042500 04 N M 4 Y Y 359.3042505 04 N M 4 Y Y 359.3042507 04 N M 4 Y Y 767.6042508 04 N M 4 Y Y 839.3542509 04 N M 4 Y Y 1079.3042510 04 N M 4 Y Y 839.3542550 04 N I 3 109.9542600 04 N M 4 359.3042650 04 N I 4 30.40 17.0042660 04 N I 4 34.30 17.0042665 04 N I 4 160.2042699 04 Y M Y42700 04 N I 4 79.30 34.0042720 04 N I 4 157.3042725 04 N I 4 291.9042800 04 N I 4 79.30 34.0042802 04 N I 4 79.30 34.0042804 04 N I 4 79.30 34.0042806 04 N I 4 79.30 34.0042808 04 N M 4 192.95 34.0042809 04 N M 4 202.50 34.0042810 04 N M 3 374.5542815 04 N M 3 Y 431.4042820 04 N M 3 194.20

Page 99: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

42821 04 N M 4 202.5042825 04 N M 3 194.2042826 04 N M 4 202.5042830 04 N M 3 142.9042831 04 N M 3 142.9042835 04 N M 3 142.9042836 04 N M 3 142.9042842 04 N M 4 Y 702.1042844 04 N M 4 Y 810.1042845 04 N M 4 Y 918.1542860 04 N I 3 119.25 34.0042870 04 N I 3 156.65 34.0042890 04 N M 4 Y Y 958.6042892 04 N M 4 Y Y 912.8042894 04 N M 4 Y Y 1188.2042900 04 Y M 4 Y Y 34.0042950 04 N M 4 Y Y 939.5042953 04 Y M 11 Y Y42955 04 N M 4 266.4042960 04 N I 3 74.90 34.0042961 04 N M 3 150.8042962 04 N M 3 220.1042970 04 N I 3 131.20 34.0042971 04 N M 3 173.4042972 04 N M 4 206.4042999 04 Y M Y43020 04 N M 6 Y Y 480.0043030 04 N M 6 Y Y 819.1043045 04 N M 11 Y Y 839.3543100 04 N M 6 Y Y 749.2043101 04 N M 11 Y Y 749.2043107 04 N M 6 Y Y 1467.8043108 04 N M 11 Y Y 1782.3043112 04 N M 11 Y Y 1467.8043113 04 N M 11 Y Y 1782.3043116 04 N M 11 Y Y 2106.3043117 04 N M 11 Y Y 1467.8043118 04 N M 11 Y Y 1782.30

Page 100: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

43121 04 N M 11 Y Y 1467.8043122 04 N M 11 Y Y 1467.8043123 04 N M 11 Y Y 1782.3043124 04 Y M 11 Y Y43130 04 N M 6 Y Y 718.7043135 04 N M 11 Y Y 718.7043200 04 N I 4 186.20 56.7043201 04 N I 4 113.5543202 04 N I 4 199.50 56.7043204 04 N M 4 Y Y 256.6043205 04 N M 4 256.6043215 04 N I 4 244.50 56.7043216 04 N I 4 244.5043217 04 N I 4 244.50 56.7043219 04 N I 4 244.50 56.7043220 04 N I 4 142.70 56.7043226 04 N M 4 224.60 56.7043227 04 N I 4 235.20 56.7043228 04 N M 4 235.20 56.7043231 04 N I 3 Y 158.2043232 04 N I 4 Y 183.7043234 04 N I 4 159.35 56.7043235 04 N I 4 239.15 56.7043236 04 N I 4 239.1543237 04 N I 4 117.6743238 04 N I 4 145.3443239 04 N I 4 249.70 56.7043240 04 N I 4 Y 201.5543241 04 N I 4 249.70 56.7043242 04 N I 4 Y 201.5543243 04 N M 4 256.6043244 04 N M 4 256.6043245 04 N I 4 249.70 56.7043246 04 N I 4 Y 249.70 56.7043247 04 N M 4 249.70 56.7043248 04 N I 4 295.9543249 04 N I 4 113.4043250 04 N I 4 249.70

Page 101: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

43251 04 N I 4 249.70 56.7043255 04 N I 4 249.70 56.7043256 04 N M 4 Y 159.3543257 04 N I 4 170.5343258 04 N M 4 249.7043259 04 N I 4 240.3043260 04 N I 4 264.25 56.7043261 04 N I 4 264.2543262 04 N M 4 390.10 56.7043263 04 N I 4 Y Y 264.25 56.7043264 04 N M 4 390.10 56.7043265 04 N M 4 390.1043267 04 N I 4 264.25 56.7043268 04 N M 4 358.60 56.7043269 04 N M 4 358.6043271 04 N M 4 358.60 56.7043272 04 N M 4 390.10 56.7043273 04 01-Jan-09 N M 4 Y 117.0343279 04 01-Jan-09 N M 11 Y 682.6043280 04 N M 11 Y Y 682.6043281 4 01-Jan-10 N M 7 Y Y 897.4043282 04 01-Jan-10 N M 7 Y Y 1,009.7843289 04 Y M 11 Y43300 04 N M 11 Y Y 786.6043305 04 N M 11 Y Y 1258.3543310 04 N M 11 Y Y 839.3543312 04 N M 11 Y Y 1258.3543313 04 N M 11 Y Y 1188.5043314 04 N M 11 Y Y 1564.9043320 04 N M 11 Y Y 958.6043324 04 N M 11 Y Y 682.6043325 04 N M 11 Y Y 749.2043326 04 N M 11 Y 749.2043330 04 N M 11 Y Y 1082.1043331 04 N M 11 Y Y 1082.1043340 04 N M 11 Y Y 1198.7043341 04 N M 11 Y Y 1082.1043350 04 N M 11 Y Y 839.35

Page 102: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

43351 04 N M 11 Y Y 839.3543352 04 N M 11 Y Y 839.3543360 04 N M 11 Y Y 1467.8043361 04 N M 11 Y Y 1782.3043400 04 N M 7 Y Y 480.0043401 04 N M 7 Y 822.8043405 04 Y M 7 Y Y43410 04 N M 7 Y Y 480.0043415 04 N M 11 Y Y 839.3543420 04 N M 7 Y Y 480.0043425 04 N M 11 Y Y 839.3543450 04 N I 4 74.9043453 04 N I 4 74.9043456 04 N I 4 112.4043458 04 N I 4 142.7043460 04 N I 4 93.0543496 04 N M 4 Y Y 1778.6043499 04 Y M Y43500 04 N M 5 Y Y 599.3543501 04 N M 5 Y Y 599.3543502 04 N M 5 Y Y 658.9043510 04 N M 5 Y Y 599.3543520 04 N M 5 Y Y 599.3543600 04 N I 3 108.2043605 04 N M 5 Y Y 599.3543610 04 N M 5 Y Y 718.7043611 04 N M 5 Y Y 564.9943620 04 N M 6 Y Y 1011.4043621 04 N M 6 Y Y 1011.4043622 04 N M 6 Y Y 1173.4043631 04 N M 6 Y Y 915.6543632 04 N M 6 Y Y 915.6543633 04 N M 6 Y Y 915.6543634 04 N M 6 Y Y 1077.7043635 04 N M 6 Y Y 1026.6543640 04 N M 5 Y Y 812.9043641 04 N M 5 Y 812.9043644 04 N M 5 Y 942.28

Page 103: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

43645 04 N M 5 Y 1017.0543647 04 01-Jan-07 N M 5 Y 399.5943648 04 01-Jan-07 N M 5 399.5043651 04 N M 5 Y 524.4043652 04 N M 5 Y 524.4043653 04 N M 5 Y 399.5043659 04 Y M 5 Y43752 04 N I 4 Y 35.0543760 04 N I 3 35.65 17.0043761 04 N I 3 48.5043770 04 01-Jan-10 N M Y Y 565.4743771 04 01-Jan-10 N M Y Y 652.0143772 04 01-Jan-10 N M Y Y 497.2043773 04 01-Jan-10 N M Y Y 652.2743774 04 01-Jan-10 N M Y Y 497.7843775 04 01-Jan-10 N M Y Y 750.8143800 04 N M 5 Y Y 699.2043810 04 N M 5 Y Y 718.7043820 04 N M 5 Y Y 718.7043825 04 N M 5 Y Y 898.9543830 04 N M 5 Y Y 399.5043831 04 N M 5 Y Y 399.5043832 04 N M 5 Y Y 399.5043840 04 N M 5 Y Y 678.4043842 04 N M 5 Y 718.7043843 04 N M 5 Y 718.7043845 04 N M 5 Y 982.1843846 04 N M 5 Y Y 770.0043847 04 N M 5 Y Y 986.0043848 04 N M 5 Y Y 770.0043850 04 N M 5 Y Y 718.7043855 04 N M 5 Y Y 793.6043860 04 N M 5 Y Y 718.7043865 04 N M 5 Y Y 793.6043870 04 N M 4 Y Y 240.0043880 04 N M 4 Y Y 958.6043881 04 01-Jan-07 N M 5 Y 599.3543882 04 01-Jan-07 N M 5 Y 599.35

Page 104: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

43886 04 N I 5 Y 152.7343887 04 N I 5 Y 151.5643888 04 N I 5 Y 215.3843999 04 Y M Y44005 04 N M 4 Y Y 643.6544010 04 N M 4 Y Y 599.3544015 04 N M 4 Y 399.5044020 04 N M 4 Y Y 599.3544021 04 N M 4 Y Y 599.3544025 04 N M 5 Y Y 599.3544050 04 N M 5 Y Y 599.3544055 04 N M 5 Y 599.3544100 04 N I 3 108.2044110 04 N M 4 Y Y 599.3544111 04 N M 4 Y Y 599.3544120 04 N M 4 Y Y 806.1044121 04 N M 4 Y Y 403.0544125 04 N M 4 Y Y 733.8544126 04 N M 4 Y Y 1039.7044127 04 N M 4 Y Y 1195.8044128 04 N M 4 Y Y 175.2044130 04 N M 4 Y Y 718.7044132 04 N M Y Y 1039.7044133 04 N M 12 Y Y 1039.7044135 04 N M 12 Y Y 1180.9544136 04 N M 12 Y Y 1180.9544137 04 N M 5 Y 806.1044139 04 N M 4 Y Y 108.0044140 04 N M 5 Y Y 951.8044141 04 N M 5 Y Y 951.8044143 04 N M 6 Y Y 951.8044144 04 N M 6 Y Y 951.8044145 04 N M 6 Y Y 958.6044146 04 N M 6 Y Y 951.8044147 04 N M 5 Y Y 1198.7044150 04 N M 6 Y Y 1079.3044151 04 N M 6 Y Y 1079.1044155 04 N M 6 Y Y 1198.70

Page 105: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

44156 04 N M 6 Y Y 1198.7044157 04 01-Jan-07 N M 6 Y 1198.7044158 04 01-Jan-07 N M 6 Y 1198.7044160 04 N M 6 Y Y 1198.7044180 04 N I 4 Y 479.2044186 04 N I 4 Y 335.8044187 04 N I 4 Y 553.1844188 04 N I 4 Y 607.8844202 04 N M 4 Y 806.1044203 04 N M 4 Y Y 191.8044204 04 N M 5 Y Y 973.8044205 04 N M 6 Y Y 861.8044206 04 N M 6 Y Y 951.8044207 04 N M 6 Y Y 958.6044208 04 N M 6 Y Y 951.8044210 04 N M 6 Y Y 1255.8844211 04 N M 6 Y Y 1079.3044212 04 N M 6 Y Y 1198.7044213 04 N I 4 Y 110.4644227 04 N I 4 Y 864.0644238 04 Y M 4 Y Y44300 04 N M 5 Y Y 599.3544310 04 N M 5 Y Y 629.9044312 04 N M 5 Y Y 374.5544314 04 N M 5 Y Y 599.3544316 04 N M 5 Y Y 535.4544320 04 N M 5 Y Y 535.4544322 04 N M 5 Y Y 535.4544340 04 N M 5 Y Y 299.7044345 04 N M 5 Y Y 480.0044346 04 N M 5 Y Y 951.8044360 04 N I 4 264.25 56.7044361 04 N I 4 285.40 56.7044363 04 N M 4 Y 285.40 56.7044364 04 N M 4 356.70 56.7044365 04 N M 4 356.7044366 04 N M 4 285.40 56.7044369 04 N M 4 285.40 56.70

Page 106: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

44370 04 N M 4 158.3044372 04 N M 4 285.4044373 04 N M 4 356.7044376 04 N I 4 318.3044377 04 N I 4 318.3044378 04 N M 4 318.3044379 04 N M 4 258.5544380 04 N I 4 182.30 56.7044382 04 N I 4 218.00 56.7044383 04 N I 4 88.3044385 04 N I 4 182.30 56.7044386 04 N I 4 182.30 56.7044388 04 N I 3 192.85 56.7044389 04 N I 3 192.85 56.7044390 04 N I 3 192.85 56.7044391 04 N I 3 283.40 56.7044392 04 N M 3 230.80 56.7044393 04 N M 3 230.80 56.7044394 04 N M 3 318.3044397 04 N M 4 165.0044500 04 N I 3 99.1044602 04 N M 5 Y Y 599.3544603 04 N M 5 Y Y 674.2044604 04 N M 5 Y Y 599.3544605 04 N M 5 Y Y 718.7044615 04 N M 5 Y Y 599.3544620 04 N M 5 Y Y 359.3044625 04 N M 5 Y Y 729.7044626 04 N M 5 Y Y 729.7044640 04 N M 5 Y Y 480.0044650 04 N M 5 Y Y 629.9044660 04 N M 5 Y Y 958.6044661 04 N M 5 Y Y 958.6044680 04 N M 4 Y Y 599.3544700 04 N M 3 Y Y 480.0044701 04 N I 3 72.3444799 04 Y M Y44800 04 N M 4 Y Y 480.00

Page 107: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

44820 04 N M 4 Y Y 599.3544850 04 N M 4 Y Y 480.0044899 04 Y M Y44900 04 N M 4 Y 310.8044901 04 N M 4 Y 310.8044950 04 N M 4 Y 374.5544955 04 N M 4 Y 374.5544960 04 N M 4 Y 480.0044970 04 N M 3 Y 374.5544979 04 Y M 4 Y45000 04 N M 3 170.6545005 04 N I 3 107.00 34.0045020 04 N I 3 134.0045100 04 N I 3 118.0045108 04 N M 4 Y 262.2045110 04 N M 6 Y Y 1079.3045111 04 N M 6 Y Y 1079.3045112 04 N M 6 Y Y 1079.3045113 04 N M 6 Y Y 1631.0545114 04 N M 6 Y Y 1138.7045116 04 N M 6 Y Y 1079.3045119 04 N M 6 Y Y 1630.7045120 04 N M 7 Y Y 1198.7045121 04 N M 7 Y Y 1450.4045123 04 N M 7 Y Y 540.0045126 04 Y M 7 Y45130 04 N M 4 Y 383.7045135 04 N M 4 Y 524.4045136 04 N M 4 Y Y 1028.7045150 04 Y I 4 Y45160 04 01-Jan-10 N M 4 Y Y 1138.7045171 04 01-Jan-10 N M 4 Y Y 331.0645172 04 01-Jan-10 N M 4 Y Y 457.4945190 04 N I 4 Y 240.0045300 04 N I 3 42.30 17.0045303 04 N I 3 42.30 17.0045305 04 N I 3 72.60 17.0045307 04 N M 3 72.60 17.00

Page 108: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

45308 04 N I 3 125.5045309 04 N I 3 125.5045315 04 N I 3 107.00 17.0045317 04 N I 3 76.85 17.0045320 04 N M 3 Y 201.30 56.7045321 04 N I 3 125.50 17.0045327 04 N I 3 61.6545330 04 N I 3 107.00 34.0045331 04 N I 3 142.70 34.0045332 04 N I 3 125.50 34.0045333 04 N M 3 161.20 34.0045334 04 N I 3 142.70 34.0045335 04 N I 3 68.1445337 04 N I 3 125.50 34.0045338 04 N M 3 161.2045339 04 N M 3 201.3045340 04 N I 3 42.3045341 04 N I 3 137.3045342 04 N I 3 158.6045345 04 N M 3 106.0545355 04 N I 3 112.40 56.7045378 04 N I 3 214.00 56.7045379 04 N M 3 214.00 56.7045380 04 N I 3 214.00 56.7045381 04 N I 3 184.2845382 04 N M 3 283.40 56.7045383 04 N M 3 285.40 56.7045384 04 N M 3 285.4045385 04 N M 3 285.40 56.7045386 04 N I 108.8645387 04 N M 3 215.3545391 04 N M 5 Y 204.0045392 04 N I 5 Y 214.0045395 04 N I 4 Y 1015.2845397 04 N I 4 Y 1103.4545400 04 N I 4 Y 592.9045402 04 N I 4 Y 805.7545499 04 Y I 6 Y

Page 109: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

45500 04 N M 3 Y 419.0045505 04 N M 3 Y 419.0045520 04 N I 74.9045540 04 N M 4 Y 599.3545541 04 N M 3 Y 599.3545550 04 N M 6 Y Y 749.2045560 04 N M 3 Y 227.7045562 04 N M 3 Y Y 496.1245563 04 N M 5 Y Y 756.6045800 04 N M 5 Y Y 599.3545805 04 N M 5 Y Y 674.2045820 04 N M 5 Y Y 599.3545825 04 N M 5 Y Y 674.2045900 04 N I 4 44.4045905 04 N I 4 58.0545910 04 N I 3 73.4045915 04 N I 3 77.6045990 04 N I 6 Y 58.4245999 04 Y M Y46020 04 N I 3 140.7546030 04 N I 3 71.40 34.0046040 04 N M 4 149.8046045 04 N M 3 149.8046050 04 N I 3 71.40 34.0046060 04 N M 3 471.7046070 04 N I 3 81.2046080 04 N I 3 119.2546083 04 N I 3 64.10 17.0046200 04 N M 3 262.2046220 04 N I 3 71.40 17.0046221 04 N I 3 107.00 17.0046230 04 N I 3 84.65 17.0046250 04 N M 3 248.30 34.0046255 04 N M 3 342.6546257 04 N M 3 417.6046258 04 01-Jan-10 N M 3 Y 471.7046260 04 N M 3 449.5046261 04 N M 3 524.40

Page 110: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

46262 04 N M 3 578.5546270 04 N M 3 471.7046275 04 N M 3 471.7046280 04 01-Jan-10 N M 3 471.7046285 04 N M 3 471.7046288 04 01-Jan-10 N M 3 471.7046320 04 01-Jan-10 N M 3 Y 62.90 17.0046500 04 N I 51.50 17.0046505 04 N I Y 102.9946600 04 N I 3 19.80 17.0046604 04 N I 34.10 17.0046606 04 N I 3 24.20 17.0046608 04 N I 3 49.85 17.0046610 04 N I 3 71.40 17.0046611 04 N I 3 71.4046612 04 N I 3 89.85 17.0046614 04 N I 3 62.00 17.0046615 04 N I 3 91.0646700 04 N M 3 Y 299.7046705 04 N M 3 Y 299.7046706 04 01-Jan-10 N I 3 62.3246707 04 01-Jan-10 N M 5 Y 252.1846710 04 N I 530.1046712 04 N I 1118.2246715 04 N M 3 Y 449.5046716 04 N M 3 Y 449.5046730 04 N M 3 Y 571.2546735 04 N M 4 Y Y 1079.3046740 04 N M 5 Y Y 788.6546742 04 N M 5 Y Y 1079.3046744 04 N M 5 Y Y 918.1546746 04 N M 5 Y Y 1139.4046748 04 N M 5 Y Y 1139.4046750 04 N M 3 Y 419.0046751 04 N M 3 Y 419.0046753 04 N I 3 Y 187.9046754 04 N I 3 134.6046760 04 N M 3 Y 524.40

Page 111: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

46761 04 N M 3 Y 524.4046762 04 N M 3 Y 739.9046900 04 N I 3 62.70 17.0046910 04 N I 3 108.30 17.0046916 04 N I 3 108.30 34.0046917 04 N I 3 108.30 34.0046922 04 N I 3 108.30 17.0046924 04 N M 3 181.00 17.0046930 04 01-Jan-09 N M 3 127.2046940 04 N I 3 68.50 17.0046942 04 01-Jan-10 N I 3 Y 61.15 17.0046945 04 01-Jan-10 N M 3 72.45 17.0046946 04 01-Jan-10 N M 3 112.4046947 04 N M 3 342.6546999 04 Y M Y47000 04 N I 3 106.8047001 04 N I 3 65.9047010 04 N M 4 Y 599.3547011 04 N M 4 Y Y 599.3547015 04 N M 4 Y Y 480.0047100 04 N M 4 Y 480.0047120 04 N M 12 Y 682.6047122 04 N M 12 Y Y 1048.8547125 04 N M 12 Y Y 1048.8547130 04 N M 12 Y Y 1048.8547133 04 N M 12 Y Y 1048.8547135 04 N M 12 Y Y 3299.3047136 04 N M 12 Y Y 3299.3047140 04 N M 12 Y Y 1660.1847141 04 N M 12 Y Y 2001.2347142 04 N M 12 Y Y 2201.1747300 04 N M 6 Y 718.7047350 04 N M 9 Y 659.0047360 04 N M 9 Y 697.9047361 04 N M 9 Y 810.1047362 04 N M 9 Y 523.8547370 04 N M 6 Y Y 761.1047371 04 N M 6 Y Y 761.10

Page 112: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

47379 04 Y M 9 Y Y47380 04 N M 6 Y Y 892.8047381 04 N M 6 Y Y 892.8047382 04 01-Jan-10 N I 3 474.2047399 04 Y M Y47400 04 N M 6 Y 718.7047420 04 N M 6 Y 647.9047425 04 N M 6 Y 682.6047460 04 N M 6 Y 463.8047480 04 N M 6 Y 647.9047490 04 N M 4 599.3547500 04 N I 3 50.7547505 04 N I 3 127.5047510 04 N M 4 230.7547511 04 N M 4 284.6047525 04 01-Jan-10 N I 4 129.9047530 04 01-Jan-10 N I 4 199.8047550 04 N M 6 94.3047552 04 N I 4 135.7047553 04 N I 4 155.7547554 04 N I 4 220.3047555 04 N I 4 169.1047556 04 N I 4 187.9047560 04 N M 4 Y 299.7047561 04 N M 4 Y 317.6047562 04 N M 6 Y 647.9047563 04 N M 6 Y 699.2047564 04 N M 6 Y 801.9047570 04 N M 6 Y 685.4047579 04 Y M 6 Y47600 04 N M 6 Y 647.9047605 04 N M 6 Y 699.2047610 04 N M 6 Y 801.9047612 04 N M 6 Y 801.9047620 04 N M 6 Y 801.9047630 04 N M 6 Y 299.7047700 04 N M 6 Y 449.5047701 04 N M 6 Y Y 685.40

Page 113: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

47711 04 N M 6 Y Y 801.9047712 04 N M 6 Y Y 1198.7047715 04 N M 6 Y Y 862.3047720 04 N M 6 Y Y 685.4047721 04 N M 6 Y Y 1044.7047740 04 N M 6 Y Y 685.4047741 04 N M 6 Y Y 1044.7047760 04 N M 6 Y Y 685.4047765 04 N M 6 Y Y 1438.7047780 04 N M 6 Y Y 770.0047785 04 N M 6 Y Y 1438.7047800 04 N M 6 Y Y 770.0047801 04 N M 6 Y 621.9547802 04 N M 6 Y 948.9047900 04 N M 6 Y Y 621.9547999 04 Y M48000 04 N M 4 Y 718.7048001 04 N M 4 Y Y 801.9048020 04 N M 6 Y 839.3548100 04 N M 6 Y 480.0048102 04 N I 3 Y 154.9048105 04 01-Jan-07 N M 7 Y 810.1048120 04 N M 6 Y 599.3548140 04 N M 6 Y Y 839.3548145 04 N M 6 Y Y 1438.7048146 04 N M 6 Y 1438.7048148 04 N M 6 Y 859.0048150 04 N M 6 Y Y 1438.7048152 04 N M 6 Y Y 1438.7048153 04 N M 6 Y Y 1438.7048154 04 N M 6 Y Y 1438.7048155 04 N M 6 Y Y 1438.7048160 04 N M 6 Y Y 2397.4048400 04 N I 3 47.3048500 04 N M 6 Y 839.3548510 04 N M 6 Y 839.3548511 04 N M 6 Y Y 839.3548520 04 N M 6 Y Y 839.35

Page 114: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

48540 04 N M 6 Y Y 839.3548545 04 N M 6 Y Y 599.3548547 04 N M 6 Y Y 718.7048548 04 01-Jan-07 N M 7 Y 958.6048550 04 N M 6 Y Y 599.3548554 04 N M 6 Y Y 2397.4048556 04 N M 6 Y 599.3548999 04 Y M Y49000 04 N M 4 Y 480.0049002 04 N M 4 Y 480.0049010 04 N M 4 Y 480.0049020 04 N M 4 Y 480.0049021 04 N M 3 314.6049040 04 N M 4 Y 480.0049041 04 N M 4 Y Y 480.0049060 04 N M 4 Y 480.0049061 04 N M 4 Y Y 480.0049062 04 N M 4 Y 480.0049080 04 N I 3 71.40 34.0049081 04 N I 3 71.40 34.0049180 04 N I 3 106.8049203 04 01-Jan-08 N M 4 Y 480.0049204 04 01-Jan-08 N M 4 Y 704.7549205 04 01-Jan-08 N M 4 Y 947.2749215 04 N M 4 Y Y 766.9049220 04 N M 5 Y 998.8049250 04 N M 3 Y 374.5549255 04 N M 3 Y 599.3549320 04 N M 4 Y 302.4049321 04 N M 4 Y 302.4049322 04 Y M 4 Y49323 04 N M 4 Y 480.0049324 04 01-Jan-07 N M 4 Y 480.0049325 04 01-Jan-07 N M 4 Y 480.0049326 04 01-Jan-07 N M 4 Y 480.0049329 04 Y M 4 Y49400 04 N I 3 47.0049402 04 01-Jan-10 N M 4 Y 406.05

Page 115: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

49411 04 01-Jan-10 N I 3 Y 114.2949419 04 01-Jan-10 N M 5 180.4649420 04 N I 4 74.9049421 04 N M 4 299.7049422 04 N M 4 240.0049423 04 N M 4 262.2049424 04 N I 20.9549425 04 N M 5 Y Y 718.7049426 04 Y M 5 Y49427 04 N I 3 37.4049428 04 Y M 4 Y Y49429 04 Y M 4 Y Y49435 04 01-Jan-07 N M 4 60.9049436 04 01-Jan-07 N M 4 88.75

49440 04 01-Jan-08 N I 5 Y 133.76 465.96

49441 04 01-Jan-08 N I 5 Y 144.19 563.56

49442 04 01-Jan-08 N I 5 Y 119.66 457.55

49446 04 01-Jan-08 N I 5 Y 94.47 493.6149450 04 01-Jan-08 Y I 5 Y49451 04 01-Jan-08 Y I 5 Y49452 04 01-Jan-08 Y I 5 Y

49460 04 01-Jan-08 N I 5 Y 27.00 406.4449465 04 01-Jan-08 N I 5 Y 17.80 73.5549491 04 N M 3 Y Y 433.7049492 04 N M 3 Y Y 535.0049495 04 N M 3 Y 362.0049496 04 N M 3 Y 362.0049500 04 N M 3 Y 362.0049501 04 N M 3 Y 387.0549505 04 N M 3 Y 387.0549507 04 N M 3 Y 387.0549520 04 N M 3 Y 409.2049521 04 N M 3 Y 387.05

Page 116: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

49525 04 N M 3 Y 464.8049540 04 N M 3 Y 337.1049550 04 N M 3 Y 409.2049553 04 N M 3 Y 409.2049555 04 N M 3 Y 460.6049557 04 N M 3 Y 460.6049560 04 N M 3 Y 503.6049561 04 N M 3 Y 503.6049565 04 N M 3 Y 546.6549566 04 N M 3 Y 572.5049568 04 N M 3 Y 460.6049570 04 N M 3 Y 345.5049572 04 N M 3 Y 345.5049580 04 N M 3 Y Y 342.6549582 04 N M 3 Y 374.5549585 04 N M 3 Y 374.5549587 04 N M 3 Y 374.5549590 04 N M 3 Y 374.5549600 04 N M 3 Y 275.8049605 04 N M 3 Y 573.1049606 04 N M 3 Y 506.5049610 04 N M 3 Y 599.3549611 04 N M 3 Y 449.5049650 04 N M 3 Y 387.0549651 04 N M 3 Y 409.2049652 04 01-Jan-09 N M 3 Y 387.0549653 04 01-Jan-09 N M 3 Y 387.0549654 04 01-Jan-09 N M Y 387.0549655 04 01-Jan-09 N M 3 Y 387.0549656 04 01-Jan-09 N M 3 Y 387.0549657 04 01-Jan-09 N M Y 387.0549659 04 Y M 3 Y49900 04 N M 4 Y 307.0549904 04 N M 4 Y Y 617.4049905 04 N M 5 Y Y 442.9049906 04 N M 4 Y Y 1306.6549999 04 Y M 4 Y50010 04 N M 5 Y 480.00

Page 117: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

50020 04 N M 5 Y 398.3550021 04 N M 5 299.7050040 04 N M 5 Y 775.6050045 04 N M 5 Y 718.7050060 04 N M 5 Y 718.7050065 04 N M 5 Y 599.3550070 04 N M 5 Y 749.2050075 04 N M 5 Y 749.2050080 04 N M 5 434.2050081 04 N M 5 600.5550100 04 N M 5 Y 767.2050120 04 N M 5 Y 839.3550125 04 N M 5 Y 839.3550130 04 N M 5 Y 837.9050135 04 Y M 5 Y Y50200 04 N I 5 112.4050205 04 01-Jan-10 N M 5 Y Y 480.0050220 04 N M 5 Y Y 933.8050225 04 N M 5 Y Y 933.8050230 04 N M 5 Y Y 1057.2050234 04 N M 5 Y Y 933.8050236 04 Y M 5 Y Y50240 04 N M 5 Y 749.2050250 04 N M 6 Y 373.7450280 04 N M 5 Y 718.7050290 04 N M 5 Y 718.7050300 04 Y M 5 Y50320 04 N M 5 Y Y 933.8050323 09 Y M50328 09 Y M50340 04 N M 5 Y 933.8050360 04 N M 5 Y Y 1366.6050365 04 N M 5 Y Y 1833.4550370 04 N M 5 Y Y 933.8050380 04 Y M 5 Y Y50382 04 N I 3 163.5850384 04 N I 3 148.92

Page 118: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

50385 04 01-Jan-08 N M 3 Y 137.81 572.99

50386 04 01-Jan-08 N M 3 Y 104.23 356.1450387 04 N I 3 59.2050389 04 N I 3 32.7550390 04 N I 5 119.2550391 04 N I 3 117.9550392 04 N I 5 119.2550393 04 N I 3 Y Y 119.2550394 04 N I 3 117.3550395 04 N I 3 119.2550396 04 N I 3 50.20 34.0050398 04 N I 3 36.70 34.0050400 04 N M 5 Y Y 958.6050405 04 N M 5 Y Y 958.6050500 04 N M 5 Y 718.7050520 04 N M 5 Y 480.0050525 04 N M 5 Y 674.2050526 04 N M 5 Y 674.2050540 04 N M 5 Y Y 1198.7050541 04 N M 5 Y 718.7050542 04 N M 6 Y Y 718.7050543 04 N M 5 Y Y 749.2050544 04 N M 5 Y 958.6050545 04 N M 5 Y Y 906.4050546 04 N M 5 933.8050547 04 N M 5 Y Y 933.8050548 04 N M 5 Y 933.8050549 04 Y M 4 Y50551 04 N I 3 151.00 56.7050553 04 N I 3 245.35 56.7050555 04 N I 3 250.35 56.7050557 04 N I 3 294.80 56.7050561 04 N I 3 301.85 56.7050562 04 N M 3 301.9550570 04 N I 3 204.7050572 04 N I 3 268.20

Page 119: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

50574 04 N I 3 281.0550575 04 N I 3 365.1550576 04 N I 3 294.8050580 04 N I 3 269.7050590 04 N M 3 Y Y 749.2050592 04 N I 3 214.22

50593 04 01-Jan-08 N M 3 Y 267.81 2228.050600 04 N M 5 Y 718.7050605 04 N M 5 Y 738.1050610 04 N M 5 Y 738.1050620 04 N M 5 Y 738.1050630 04 N M 5 Y 738.1050650 04 N M 5 Y 599.3550660 04 N M 5 Y Y 599.3550684 04 N I 3 120.00 17.0050686 04 N I 3 64.10 34.0050688 04 N I 3 37.40 34.0050690 04 N I 3 129.70 17.0050700 04 N M 5 Y 958.6050715 04 N M 5 Y 749.2050722 04 N M 5 Y 749.2050725 04 N M 5 Y 958.6050727 04 N M 5 Y Y 455.8050728 04 N M 5 Y Y 567.1050740 04 N M 5 Y 958.6050750 04 N M 5 Y 958.6050760 04 N M 5 Y 958.6050770 04 N M 5 Y 958.6050780 04 N M 5 Y 958.6050782 04 N M 5 Y Y 945.1550783 04 N M 5 Y Y 945.1550785 04 N M 5 Y 958.6050800 04 N M 5 Y 718.7050810 04 N M 6 Y 718.7050815 04 N M 6 Y 718.7050820 04 N M 6 Y 718.7050825 04 N M 6 Y Y 1438.70

Page 120: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

50830 04 Y M 6 Y Y50840 04 N M 6 Y 718.7050845 04 Y M 5 Y50860 04 N M 5 Y 958.6050900 04 N M 5 Y Y 958.6050920 04 N M 5 Y 480.0050930 04 N M 5 Y 629.9050940 04 N M 5 Y 934.7050945 04 N M 5 Y 738.1050947 04 N M 5 Y Y 973.5550948 04 N M 5 Y 890.5050949 04 Y M 5 Y Y50951 04 N I 3 152.60 56.7050953 04 N I 3 251.25 56.7050955 04 N I 3 235.50 56.7050957 04 N I 3 236.20 56.7050961 04 N M 3 297.95 56.7050970 04 N I 3 187.7050972 04 N I 3 152.1050974 04 N I 3 243.4050976 04 N I 3 236.2050980 04 N M 3 262.2051020 04 N M 5 Y 524.4051030 04 N M 5 Y 524.4051040 04 N M 5 Y 449.5051045 04 N M 5 Y 449.5051050 04 N M 5 Y 599.3551060 04 N M 5 Y 738.1051065 04 N M 5 Y 738.1051080 04 N M 5 Y 599.3551100 04 01-Jan-08 N I 5 22.55 13.0251101 04 01-Jan-08 N I 5 30.11 41.4951102 04 01-Jan-08 N I 5 141.08 47.6951500 04 N M 3 Y 599.3551520 04 N M 5 Y 480.0051525 04 N M 5 Y 718.7051530 04 N M 5 Y 599.3551535 04 N M 5 Y 599.35

Page 121: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

51550 04 N M 6 Y 599.3551555 04 N M 6 Y 599.3551565 04 N M 6 Y Y 958.6051570 04 N M 7 Y Y 749.2051575 04 N M 7 Y Y 1198.7051580 04 N M 7 Y Y 1438.7051585 04 N M 7 Y Y 1438.7051590 04 N M 7 Y Y 1438.7051595 04 N M 7 Y Y 1498.3051596 04 N M 7 Y Y 1438.7051597 04 N M 7 Y Y 1498.3051600 04 N I 3 121.35 17.0051605 04 N I 3 121.35 17.0051610 04 N I 3 130.80 17.0051700 04 N I 44.6051701 04 N I 24.0251702 04 N I 24.0251703 04 N I 26.1851705 04 N I 3 38.85 17.0051710 04 N I 3 66.85 17.0051715 04 N I 3 295.9551720 04 N I 3 66.85 17.0051725 C 04 01-Jan-10 N I 16.87 27.53 44.4051726 C 04 01-Jan-10 N I 15.00 35.05 50.0551727 C 04 01-Jan-10 N I 62.18 97.28 159.4651728 C 04 01-Jan-10 N I 60.46 98.66 159.1251729 C 04 01-Jan-10 N I 72.06 99.51 171.5751736 C 04 01-Jan-10 N I 10.38 6.92 17.3051741 C 04 01-Jan-10 N I 37.42 15.20 52.7051784 04 N I 52.7051785 04 N I 52.7051792 04 N I 74.9051797 C 04 01-Jan-10 N I 14.85 30.15 45.0051798 A 04 N I 8.78 8.78 17.5651800 04 N M 5 Y 599.3551820 04 N M 5 Y 839.3551840 04 N M 4 Y 631.2551841 04 N M 4 Y 631.25

Page 122: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

51845 04 N M 5 Y 631.2551860 04 N M 5 Y Y 599.3551865 04 N M 5 Y Y 599.3551880 04 N M 5 216.6551900 04 N M 5 Y 958.6051920 04 N M 5 Y 958.6051925 04 N M 5 Y 958.6051940 04 N M 5 Y 839.3551960 04 N M 5 Y 1105.8051980 04 N M 5 Y 449.5051990 04 N M 5 Y 631.2551992 04 N M 4 Y 631.2551999 04 Y M 352000 04 N I 3 85.90 56.7052001 04 N I 3 90.4052005 04 N I 3 118.90 56.7052007 04 N M 3 154.60 56.7052010 04 N I 3 118.90 56.7052204 04 N I 3 163.90 56.7052214 04 N M 3 178.30 56.7052224 04 N M 3 295.95 56.7052234 04 N M 3 374.5552235 04 N M 3 374.5552240 04 N M 3 524.4052250 04 N I 3 141.30 56.7052260 04 N I 3 149.8052265 04 N I 142.70 56.7052270 04 N M 3 180.3052275 04 N M 3 194.2052276 04 N M 3 209.4052277 04 N M 3 180.3052281 04 N I 3 134.80 56.7052282 04 01-Jan-10 N I 3 204.1052283 04 N I 3 149.8052285 04 N I 3 135.7052290 04 N M 3 184.5052300 04 N M 3 240.0052301 04 N M 3 240.00

Page 123: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

52305 04 N M 3 297.0052310 04 N I 3 180.30 56.7052315 04 N M 3 239.00 56.7052317 04 N M 3 Y Y 342.15 56.7052318 04 N M 3 Y Y 339.25 56.7052320 04 N M 3 249.70 56.7052325 04 N M 3 379.4052327 04 N I 3 295.9552330 04 N M 3 260.80 56.7052332 04 N I 3 138.9052334 04 N M 3 308.3552341 04 N M 3 224.4552342 04 N M 3 242.9052343 04 N M 3 269.1052344 04 N M 3 287.6052345 04 N M 3 306.6052346 04 N M 3 344.9052351 04 N I 3 178.3052352 04 N M 3 293.7552353 04 N M 3 262.2052354 04 N M 3 249.7052355 04 N M 3 337.0052400 04 N M 3 398.8552402 04 N M 3 537.1552450 04 N M 3 249.0052500 04 N M 3 480.0052601 04 N M 5 775.6052630 04 N M 5 599.3552640 04 N M 3 486.9052647 04 N M 5 599.3552648 04 N M 5 599.3552649 04 01-Jan-08 N M 5 Y 562.4252700 04 N M 3 314.9552920 04 Y 3 Y53000 04 N M 3 Y 240.0053010 04 N M 3 314.9553020 04 N I 3 67.80 17.0053025 04 N I 3 58.60 17.00

Page 124: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

53040 04 N I 3 197.80 17.0053060 04 N I 3 95.30 17.0053080 04 Y M 3 17.0053085 04 Y M 353200 04 N I 3 92.70 17.0053210 04 N M 5 449.5053215 04 N M 5 524.4053220 04 N M 3 449.5053230 04 N M 3 Y 599.3553235 04 N M 3 Y 599.3553240 04 N M 3 449.5053250 04 Y M 3 34.0053260 04 N I 3 113.60 34.0053265 04 N I 3 115.00 34.0053270 04 N I 3 113.60 34.0053275 04 N I 3 122.20 34.0053400 04 N M 3 Y 599.3553405 04 N M 3 Y 599.3553410 04 N M 3 Y 599.3553415 04 N M 3 Y 745.3053420 04 N M 3 Y 599.3553425 04 N M 3 Y 449.5053430 04 N M 3 517.4053431 04 N M 3 709.9553440 04 N M 3 599.3553442 04 N M 3 Y 449.5053444 04 N M 3 540.4053445 04 Y M 353446 04 N M 3 494.9053447 04 N M 3 449.5053448 04 N M 842.2553449 04 Y M 353450 04 N M 3 164.3053460 04 N M 3 224.7053500 04 N M 5 Y Y 386.2553502 04 Y M 353505 04 Y M 353510 04 Y M 3

Page 125: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

53515 04 Y M 353520 04 N M 3 314.9553600 04 N I 3 52.8053601 04 N I 3 47.8053605 04 N I 3 47.8053620 04 N I 3 75.1053621 04 N I 3 69.5553660 04 N I 3 41.8053661 04 N I 3 42.1053665 04 N I 3 36.0053850 04 N M 5 576.8053852 04 N M 5 576.8053855 04 01-Jan-10 N I 3 Y 47.8153899 04 Y M Y54000 04 N I 3 74.90 17.0054001 04 N I 3 87.85 17.0054015 04 N I 3 156.75 17.0054050 04 N I 52.70 17.0054055 04 N I 3 72.10 17.0054056 04 N I 3 71.40 17.0054057 04 N I 3 71.40 17.0054060 04 N I 3 88.50 17.0054065 04 N I 3 107.00 34.0054100 04 N I 3 88.50 17.0054105 04 N I 3 114.25 17.0054110 04 N M 3 321.4554111 04 N M 3 585.7554112 04 N M 3 717.9054115 04 Y M 354120 04 N M 3 Y 285.1054125 04 N M 3 Y 449.5054130 04 N M 3 Y Y 749.2054135 04 N M 4 Y Y 749.2054150 04 N I 3 77.5054160 04 N I 3 99.8054161 04 N I 3 146.70 34.0054162 04 N I 3 97.2554163 04 N I 3 137.40

Page 126: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

54164 04 N I 3 120.3054200 04 N I 3 38.6054205 04 Y I 354220 04 N M 3 299.7054230 04 N I 3 38.2054231 04 N I 3 118.8054235 04 N I 3 Y 37.4054240 09 Y I54250 04 N I 54.5554300 04 N M 3 Y Y 425.8054304 04 N M 3 Y 670.1054308 04 N M 3 Y 599.3554312 04 N M 3 Y 670.1054316 04 N M 3 Y 670.1054318 04 N M 3 Y 670.1054322 04 N M 3 Y 480.0054324 04 N M 3 Y 538.0054326 04 N M 3 Y 670.1054328 04 N M 3 Y 958.6054332 04 N M 3 Y Y 670.1054336 04 N M 3 Y Y 958.6054340 04 N M 3 Y 538.0054344 04 N M 3 Y 670.1054348 04 N M 3 Y 958.6054352 04 Y M 3 Y Y54360 04 N M 3 Y Y 690.7854380 04 N M 3 Y 386.3054385 04 N M 3 Y 446.0054390 04 N M 3 Y 600.7054400 09 Y M54401 09 Y M54405 09 Y M54406 09 Y M54408 09 Y M54410 09 Y M54411 09 Y M54415 09 Y M54416 09 Y M

Page 127: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

54417 09 Y M54420 04 N M 3 Y 409.2054430 04 N M 3 Y 409.2054435 04 N M 3 405.1054440 04 N M 3 Y 224.7054450 04 N I 3 37.4554500 04 N I 3 68.20 17.0054505 04 N I 3 113.60 17.0054512 04 N M 3 356.0554520 04 N M 3 Y 351.0054522 04 N M 3 404.2054530 04 N M 3 Y 958.6054535 04 N M 4 Y 958.6054550 04 N M 3 Y 359.3054560 04 N M 4 Y 480.0054600 04 N M 3 Y 359.3054620 04 N M 3 Y 299.7054640 04 N M 3 Y 504.9054650 04 N M 3 Y 480.0054660 09 Y M54670 04 Y M 354680 04 Y M 3 Y54690 04 N M 3 Y 351.0054692 04 N M 3 Y 504.9054699 04 Y M 3 Y54700 04 N I 3 128.30 17.0054800 04 N I 3 119.2554830 04 N M 3 299.7054840 04 N M 3 299.7054860 04 N M 3 359.3054861 04 N M 3 480.0054865 04 01-Jan-07 N M 3 179.4754900 04 N M 3 Y 480.0054901 04 N M 3 Y 599.3555000 04 N I 3 42.35 17.0055040 04 N M 3 Y 299.7055041 04 N M 3 449.5055060 04 N M 3 Y 259.40

Page 128: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

55100 04 N I 3 110.90 17.0055110 04 Y M 355120 04 N I 3 129.30 17.0055150 04 N I 3 206.1055175 04 Y M 355180 04 Y M 3 Y55200 04 N I 3 147.95 56.7055250 04 N I 3 147.95 56.7055300 04 N I 3 112.4055400 04 Y M 3 Y55450 04 N M 3 150.40 56.7055500 04 N M 3 359.3055520 04 N M 3 240.0055530 04 N M 3 359.3055535 04 N M 4 Y 359.3055540 04 N M 3 Y 480.0055550 04 N M 3 Y 359.3055559 04 Y M 3 Y55600 04 N I 3 178.3055605 04 N M 3 223.6055650 04 N M 3 Y 958.6055680 04 N I 3 Y 299.7055700 04 N I 3 113.60 17.0055705 04 N M 3 187.3055706 04 01-Jan-09 N I 3 291.0355720 04 N M 3 359.3055725 04 N M 3 359.3055801 04 N M 6 Y 839.3555810 04 N M 6 Y 1198.7055812 04 N M 6 Y 1678.6555815 04 N M 6 Y 1809.2555821 04 N M 6 Y 958.6055831 04 N M 6 Y 958.6055840 04 N M 6 Y Y 1198.7055842 04 N M 6 Y 1285.4055845 04 N M 6 Y Y 1438.7055860 04 Y M 3 Y55862 04 Y M 3 Y

Page 129: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

55865 04 Y M 6 Y Y55866 04 Y M 6 Y Y55870 09 Y I55873 04 01-Jan-10 N M 3 739.1555875 04 01-Jan-10 N I 3 Y 359.3055876 04 01-Jan-10 N I 3 59.3455899 04 Y M Y Y55920 04 01-Jan-08 N M 3 Y 246.0656405 04 N I 3 95.0556420 04 N I 3 103.05 17.0056440 04 N M 3 202.5056441 04 N I 3 127.9056442 04 01-Jan-07 N I 3 68.6556501 04 N I 3 Y 52.70 17.0056515 04 N M 3 Y 181.00 34.0056605 04 N I 3 108.3056606 04 N I 3 35.6556620 04 N M 3 Y 335.7056625 04 N M 3 Y 480.0056630 04 N M 3 Y 524.4056631 04 N M 4 Y 511.2056632 04 N M 4 Y 599.6556633 04 N M 4 Y 524.4056634 04 N M 4 Y 599.3556637 04 N M 4 Y 749.2056640 04 N M 3 Y 749.2056700 04 N I 3 113.6056740 04 N M 3 226.1056800 04 N I 3 119.2556805 04 N M 3 496.9056810 04 N M 3 Y 190.0056820 04 N I 3 37.4056821 04 N I 3 50.2057000 04 N M 3 202.5557010 04 N M 3 224.7057020 04 N I 3 79.30 17.0057022 04 N I 3 109.5057023 04 N I 3 109.50

Page 130: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

57061 04 N I 3 45.40 17.0057065 04 N I 3 91.3557100 04 N I 3 107.00 17.0057105 04 N I 3 107.00 17.0057106 04 N M 3 Y 299.7057107 04 N M 3 Y 544.5057109 04 N M 3 Y 782.8057110 04 N M 3 Y 374.3057111 04 N M 3 Y 782.8057112 04 N M 3 Y 1022.8057120 04 N M 3 Y 299.7057130 04 N M 3 180.3057135 04 N I 3 121.55 17.0057150 04 N I 18.2557155 04 N I 257.4057160 04 N I 27.6557170 04 N I 28.6057180 04 N I 3 48.75 17.0057200 04 N M 3 188.90 34.0057210 04 N M 3 206.05 34.0057220 04 N M 3 355.1057230 04 N M 3 517.4057240 04 N M 3 Y 355.1057250 04 N M 3 Y 314.9557260 04 N M 3 Y 525.8057265 04 N M 3 Y 532.8057267 04 N M 3 167.7957268 04 N M 3 Y 532.8057270 04 N M 4 Y 480.0057280 04 N M 4 599.3557282 04 N M 4 Y 480.0057283 04 N M Y 599.3557284 04 N M 3 532.8057285 04 01-Jan-08 N M 3 Y Y 352.3657287 04 N M 4 Y 467.5057288 04 N M 4 Y Y 631.2557289 04 N M 3 Y 674.2057291 04 Y M 3 Y Y

Page 131: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

57292 04 Y M 3 Y Y57295 04 N M 3 269.3157296 04 01-Jan-07 N M 481.1957300 04 N M 3 Y 466.1557305 04 N M 4 Y 1127.9057307 04 N M 5 Y 1127.9057308 04 N M 3 Y Y 728.3557310 04 N M 5 Y 718.7057311 04 N M 5 Y 799.7057320 04 N M 5 Y 597.9057330 04 N M 5 Y 524.4057335 04 N M 3 466.1557400 04 N I 3 111.0057410 04 N I 3 53.3057415 04 N I 3 Y 111.0057420 04 N I 3 37.4057421 04 N I 3 50.2057423 04 01-Jan-08 N M 3 Y Y 497.7557425 04 01-Jan-10 N M 4 Y Y 487.7757426 04 01-Jan-10 N M 3 Y Y 491.9857452 04 N I 3 37.4057454 04 N I 3 50.20 34.0057455 04 N I 3 50.2057456 04 N I 3 50.2057460 04 N I 3 Y 77.00 34.0057461 04 N I 3 172.0557500 04 N I 3 142.70 17.0057505 04 N I 3 48.5557510 04 N I 3 60.6057511 04 N I 3 58.1057513 04 N I 3 131.1057520 04 N M 3 321.9057522 04 N M 3 305.80 34.0057530 04 N M 3 Y 308.0057531 04 N M 5 Y Y 1030.8057540 04 N M 4 Y 599.3557545 04 N M 4 Y 599.3557550 04 N M 3 Y 599.35

Page 132: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

57555 04 N M 3 Y 674.2057556 04 N M 3 Y 674.2057558 04 01-Jan-07 N I 149.8057700 04 N M 3 313.5057720 04 N M 3 559.3057800 04 N I 3 119.2558100 04 N I 3 52.90 34.0058110 04 N M 3 24.9058120 04 N M 3 206.8558140 04 N M 5 Y 718.7058145 04 N M 5 Y 718.7058146 04 N M 4 Y 718.7058150 04 N M 5 Y 772.7058152 04 N M 5 Y 1096.0558180 04 N M 5 Y 652.0558200 04 N M 5 Y 772.7058210 04 N M 5 Y 1030.8058240 04 N M 6 Y 1423.4558260 04 N M 5 Y 725.6058262 04 N M 5 Y 725.6058263 04 N M 5 Y 725.6058267 04 N M 5 Y 856.0058270 04 N M 5 Y 856.0058275 04 N M 5 Y 875.4058280 04 N M 5 Y 800.5058285 04 N M 5 Y 950.3058290 04 N M 5 Y 725.6058291 04 N M 5 Y 725.6058292 04 N M 5 Y 725.6058293 04 N M 5 Y 856.0058294 04 N M 5 Y 856.0058300 04 N I 44.0058301 04 N I 37.4058340 04 N I 3 93.4058346 04 N I 3 274.0058350 04 N I 3 37.5058353 04 N I 3 Y 150.6058356 04 N M 3 201.30

Page 133: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

58400 04 N M 4 Y 449.5058410 04 N M 4 Y 449.5058520 04 N M 6 Y 480.0058540 04 N M 5 Y 501.3858541 04 01-Jan-07 N M 5 Y 433.9458542 04 01-Jan-07 N M 5 Y 479.3358543 04 01-Jan-07 N M 5 Y 487.5558544 04 01-Jan-07 N M 5 Y 528.1158545 04 N M 5 Y 480.0058546 04 N M 4 Y 480.0058548 04 01-Jan-07 N M 5 Y 924.5658550 04 N M 5 Y 725.6058552 04 N M 5 Y 725.0058553 04 N M 5 Y 725.0058554 04 N M 5 Y 725.0058555 04 N I 3 95.7558558 04 N I 3 145.8058559 04 N I 4 160.8058560 04 N I 4 160.8058561 04 N M 4 361.8558562 04 N M 5 361.8558563 04 N I 3 300.4358565 04 N M 4 327.4558570 04 01-Jan-08 N M 5 Y Y 496.1758571 04 01-Jan-08 N M 5 Y Y 542.0558572 04 01-Jan-08 N M 5 Y Y 617.1958573 04 01-Jan-08 N M 5 Y Y 693.5958578 04 Y M 458579 04 Y M 358600 04 N M 4 Y 327.4558605 04 N M 4 Y 327.4558611 04 N M 4 Y 97.3058615 04 N M 4 327.4558660 04 N M 4 Y 302.4058661 04 N M 4 Y 480.0058662 04 N M 4 Y 302.4058670 04 N M 4 363.4558671 04 N M 4 363.45

Page 134: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

58672 09 Y M58673 04 N M 4 Y 480.0058679 04 Y M 458700 04 N M 4 Y 481.9058720 04 N M 4 Y 525.8558740 04 N M 4 Y 480.0058752 09 Y M58770 04 N M 4 Y 480.0058800 04 N M 4 Y 359.3058805 04 N M 4 Y 480.0058820 04 N M 4 Y 240.0058822 04 N M 4 Y 480.0058823 04 N M 4 302.9058825 04 01-Oct-09 N M Y 542.4058900 04 N M 4 Y 480.0058920 04 N M 4 Y 529.9558925 04 N M 4 Y 524.4058940 04 N M 4 Y 554.9058943 04 N M 4 Y Y 958.6058950 04 N M 4 Y Y 704.7058951 04 N M 5 Y Y 898.9558952 04 N M 4 Y Y 958.6058953 04 N M 5 Y Y 1241.7558954 04 N M 5 Y Y 1350.3558956 04 N M 5 Y Y 1241.7558957 04 01-Jan-07 N M 4 Y 749.4358958 04 01-Jan-07 N M 5 Y 830.1158960 04 N M 4 Y Y 599.3558999 04 Y M 3 Y59000 04 N I 4 58.35 34.0059001 04 N B 4 Y 89.8059012 04 N I 4 115.0059015 04 Y I 359020 C 04 N I 7.90 25.80 33.7059025 C 04 N I 3 7.90 25.80 33.7059030 04 N I 79.0059050 04 N I 25.4059051 09 Y N

Page 135: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

59070 04 N I 4 158.5559074 04 N I 4 158.5559076 04 N M 4 Y 257.8859100 04 N M 5 Y 540.0059120 04 N M 4 Y 540.0059121 04 N M 4 Y 540.0059130 04 N M 4 Y 540.0059135 04 N M 5 Y 696.1559136 04 N M 5 Y 540.0059140 04 N M 5 Y 540.0059150 04 N M 4 Y 540.0059151 04 N M 4 Y 540.0059160 04 N M 3 199.9559200 04 N B 3 27.8059300 04 N B 3 74.9559320 04 N M 3 282.4559325 04 N M 5 Y 540.1059350 04 N M 6 Y 540.0059409 Q 04 01-Apr-09 N B 924.4559410 Q 04 01-Apr-09 N B 924.4559412 04 N B 72.9559414 04 N B 67.5059430 04 N B 50.1559510 09 Y N59514 Q 04 01-Apr-09 N B 5 Y 1070.4559515 Q 04 01-Apr-09 N B 5 Y 1070.4559525 04 N M 5 Y 299.3059610 09 Y N59612 Q 04 01-Apr-09 N B 924.4559614 Q 04 01-Apr-09 N B 924.4559618 09 Y B59620 Q 04 01-Apr-09 N B 5 Y 1070.4559622 Q 04 01-Apr-09 N B 5 Y 1070.4559812 04 N M 4 298.7059820 04 N M 3 199.9559821 04 N M 4 Y 298.7059830 04 N M 3 Y 223.7059840 04 N M 3 Y 199.95

Page 136: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

59841 04 N B 3 199.9559850 04 N M Y 199.9559851 04 N M 3 Y 199.9559855 04 N M Y 199.9559856 04 N M Y 199.9559857 04 N M Y 199.9559866 09 Y M59870 04 N M 4 Y 389.2559871 04 01-Jan-10 N I 3 Y 66.9559897 04 01-Jan-10 Y B 4 Y59898 04 Y B Y59899 04 Y B Y60000 04 N I 3 113.60 17.0060100 04 N I 3 50.20 17.0060200 04 N M 5 Y 360.7060210 04 N M 5 Y Y 550.9060212 04 N M 5 Y Y 718.7060220 04 N M 5 Y Y 703.3060225 04 N M 5 Y Y 703.3060240 04 N M 5 Y Y 718.7060252 04 N M 5 Y Y 1198.7060254 04 N M 6 Y Y 1198.7060260 04 N M 5 Y Y 718.7060270 04 N M 5 Y Y 839.3560271 04 N M 5 Y Y 749.2060280 04 N M 5 Y Y 718.7060281 04 N M 5 Y 718.7060300 04 01-Jan-08 N I 3 27.75 27.0560500 04 N M 5 Y Y 839.3560502 04 N M 5 Y Y 839.3560505 04 N M 11 Y Y 839.3560512 04 N M 11 Y Y 135.0060520 04 N M 5 Y Y 749.2060521 04 N M 5 Y Y 839.3560522 04 N M 5 Y Y 1198.7060540 04 N M 9 Y Y 839.3560545 04 N M 9 Y Y 958.6060600 04 N M 9 Y Y 839.35

Page 137: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

60605 04 N M 9 Y Y 839.3560650 04 N M 9 Y 839.3560659 04 Y M 5 Y60699 04 Y M Y61000 04 N I 4 112.4061020 04 N I 4 112.4061026 04 N M 4 62.1561050 04 N I 3 112.4061055 04 N M 4 157.5061070 04 N I 4 112.4061105 04 N M 9 Y Y 359.3061107 04 N M 9 Y 359.3061108 04 N M 9 Y 599.3561120 04 N M 9 Y Y 359.3061140 04 N M 9 Y Y 510.3061150 04 N M 9 Y Y 958.6061151 04 N I 9 Y Y 330.8061154 04 N M 9 Y Y 599.3561156 04 N M 9 Y Y 599.3561210 04 N M 9 Y Y 449.5061215 04 N M 9 Y 449.5061250 04 N M 9 Y Y 449.5061253 04 N M 9 Y Y 449.5061304 04 N M 9 Y Y 749.2061305 04 N M 9 Y Y 886.9061312 04 N M 9 Y Y 861.5061313 04 N M 9 Y Y 861.5061314 04 N M 9 Y Y 861.5061315 04 N M 9 Y Y 1198.7061316 04 Y M Y Y61320 04 N M 9 Y Y 1123.7061321 04 N M 9 Y Y 1123.7061322 04 N M 9 Y Y 1123.7061323 04 N M 9 Y Y 1123.7061330 04 N M 9 Y Y 973.9061332 04 N M 9 Y Y 973.9061333 04 N M 9 Y Y 1198.7061334 04 N M 9 Y Y 1198.70

Page 138: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

61340 04 N M 9 Y Y 839.3561343 04 N M 9 Y Y 1738.8061345 04 N M 9 Y Y 1198.7061440 04 N M 9 Y Y 839.3561450 04 N M 9 Y Y 839.3561458 04 N M 9 Y Y 893.2561460 04 N M 9 Y Y 891.3061470 04 N M 9 Y Y 958.6061480 04 N M 9 Y Y 958.6061490 04 N M 9 Y Y 1198.7061500 04 N M 9 Y Y 1198.7061501 04 N M 9 Y Y 1198.7061510 04 N M 9 Y Y 1198.7061512 04 N M 9 Y Y 1198.7061514 04 N M 9 Y Y 1198.7061516 04 N M 9 Y Y 1198.7061517 04 N I 3 Y 49.8561518 04 N M 9 Y Y 1198.7061519 04 N M 9 Y Y 1271.1061520 04 N M 9 Y Y 1604.8561521 04 N M 9 Y Y 1351.2061522 04 N M 9 Y Y 1198.7061524 04 N M 9 Y Y 1198.7061526 04 N M 9 Y Y 1499.1061530 04 N M 9 Y Y 1327.0061531 04 N M 9 Y 1138.7061533 04 N M 9 Y Y 1138.7061534 04 N M 9 Y Y 1198.7061535 04 Y M 9 Y Y61536 04 N M 9 Y Y 1198.7061537 04 N M 9 Y Y 939.1361538 04 N M 9 Y Y 1198.7061539 04 N M 9 Y Y 1198.7061540 04 N M 9 Y Y 1134.1361541 04 N M 9 Y Y 1701.9561542 04 N M 9 Y Y 1198.7061543 04 N M 9 Y Y 1198.7061544 04 N M 9 Y Y 1198.70

Page 139: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

61545 04 N M 9 Y Y 1283.1561546 04 N M 9 Y Y 1198.7061548 04 N M 9 Y Y 1198.7061550 04 N M 9 Y Y 898.9561552 04 N M 9 Y Y 1198.7061556 04 N M 9 Y Y 1144.6561557 04 N M 9 Y Y 1690.5061558 04 N M 9 Y Y 1689.9061559 04 N M 9 Y Y 1689.9061563 04 Y M 9 Y Y61564 04 Y M 9 Y61566 04 N M 9 Y Y 1116.2861567 04 N M 9 Y Y 1270.2861570 04 N M 9 Y Y 1198.7061571 04 N M 9 Y Y 1198.7061575 04 N M 9 Y Y 1198.7061576 04 N M 9 Y Y 1630.7061580 04 N M 9 Y Y 1198.7061581 04 N M 9 Y 1630.7061582 04 N M 9 Y Y 1198.7061583 04 N M 9 Y Y 1306.6561584 04 N M 9 Y Y 1306.6561585 04 N M 9 Y Y 1630.7061586 04 N M 9 Y Y 1306.6561590 04 N M 9 Y Y 1630.7061591 04 N M 9 Y Y 1630.7061592 04 N M 9 Y Y 1630.7061595 04 N M 9 Y Y 1414.7061596 04 N M 9 Y Y 1630.7061597 04 N M 9 Y Y 1630.7061598 04 N M 9 Y Y 1522.7061600 04 N M 9 Y Y 1198.7061601 04 N M 9 Y Y 1198.7061605 04 N M 9 Y Y 1138.7061606 04 N M 9 Y Y 1198.7061607 04 N M 9 Y Y 1198.7061608 04 N M 9 Y Y 1274.8061609 04 N M 9 Y Y 1198.70

Page 140: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

61610 04 N M 9 Y Y 1306.6561611 04 N M 9 Y Y 1198.7061612 04 N M 9 Y Y 1306.6561613 04 N M 9 Y Y 1244.8061615 04 N M 9 Y Y 1198.7061616 04 N M 9 Y Y 1306.6561618 04 N M 9 Y Y 958.6061619 04 Y M 9 Y Y61623 04 N I 3 241.2061624 04 N M 3 682.8061626 04 N M 3 682.8061630 04 01-Jan-10 N I 3 Y Y 731.4061635 04 01-Jan-10 N I 3 Y Y 790.5361640 04 Y M 361641 04 Y M 361642 04 Y M 361680 04 N M 9 Y Y 1048.8561682 04 N M 9 Y Y 1784.2061684 04 N M 9 Y Y 1231.2061686 04 N M 9 Y Y 1871.1561690 04 N M 9 Y Y 973.9061692 04 N M 9 Y Y 1480.9061697 04 N M 9 Y Y 2267.1061698 04 N M 9 Y 2182.1561700 04 N M 9 Y Y 1498.8561702 04 N M 9 Y Y 1481.2061703 04 N M 9 Y Y 718.7061705 04 N M 9 Y Y 1198.7061708 04 N M 9 Y Y 1198.7061710 04 N M 9 Y Y 787.4061711 04 N M 9 Y Y 1158.1061720 04 N M 9 Y Y 1198.7061735 04 N M 9 Y Y 1198.7061750 04 N M 9 Y Y 1306.6561751 04 N M 9 Y Y 1198.7061760 04 N M 9 Y Y 1138.7061770 04 N M 9 Y Y 749.2061790 04 N M 9 Y Y 749.20

Page 141: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

61791 04 N M 9 Y Y 1198.7061795 04 N M 9 Y Y 230.3061796 04 01-Jan-09 N M 9 Y 1198.7061797 04 01-Jan-09 N M 9 Y 1198.7061798 04 01-Jan-09 N N 9 1198.7061799 04 01-Jan-09 N M 9 Y 1198.7061800 04 01-Jan-09 N M 9 Y 1198.7061850 04 N M 9 Y Y 749.2061860 04 N M 9 Y Y 1198.7061863 04 N M 9 Y Y 574.1961867 04 N M 9 Y Y 843.8361868 04 01-Jan-10 Y I 9 Y Y61870 04 N M 9 Y Y 958.6061875 04 N M 9 Y Y 958.6061880 04 N M 3 Y Y 749.2061885 04 N M 3 Y Y 749.2061886 04 N M 3 Y Y 749.2061888 04 N M 3 Y Y 749.2062000 04 N M 9 Y Y 789.3062005 04 N M 9 Y Y 1347.1062010 04 N M 9 Y Y 1347.1062100 04 N M 9 Y Y 1198.7062115 04 N M 9 Y 1296.2062116 04 N M 9 Y 1458.2062117 04 N M 9 Y 1458.2062120 04 N M 9 Y Y 698.4062121 04 N M 9 Y Y 1198.7062140 04 N M 9 Y Y 749.2062141 04 N M 9 Y Y 1048.8562142 04 N M 9 Y Y 749.2062143 04 N M 9 Y Y 1048.8562145 04 N M 9 Y Y 1198.7062146 04 N M 9 Y Y 1350.1562147 04 N M 9 Y Y 1458.2062148 04 N M 9 Y Y 105.0062160 04 N M 9 Y Y 156.5262161 04 N M 9 Y Y 985.6062162 04 N M 9 Y Y 1036.85

Page 142: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

62163 04 N M 9 Y Y 861.5062164 04 N M 9 Y Y 1198.7062165 04 N M 9 Y Y 1198.7062180 04 N M 11 Y Y 839.3562190 04 N M 11 Y Y 839.3562192 04 N M 11 Y Y 761.6062194 04 N M 8 Y Y 599.3562200 04 N M 11 Y Y 839.3562201 04 N M 11 Y Y 1048.8562220 04 N M 11 Y Y 839.3562223 04 N M 11 Y Y 761.6062225 04 N M 8 Y Y 374.5562230 04 N M 8 Y Y 374.5562252 04 N I 3 Y 54.2062256 04 N M 8 Y Y 225.8062258 04 N M 11 Y Y 599.3562263 04 N M 3 193.6062264 04 N M 3 193.6062267 04 01-Jan-09 N M 3 481.8062268 04 N M 3 449.5062269 04 N M 3 449.5062270 04 N I 3 53.7062272 04 N I 3 59.1062273 04 N I 3 74.9062280 04 N I 4 158.2062281 04 N I 4 81.1062282 04 N I 4 158.2062284 04 N I 4 158.2062287 04 N M 4 Y 481.8062290 04 N I 4 158.2062291 04 N I 4 158.2062292 04 N M 4 Y 852.0562294 04 N M 3 852.0562310 04 N I 4 85.9062311 04 N I 4 86.0062318 04 Y M 362319 04 Y M 362350 04 N M 8 Y Y 545.10

Page 143: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

62351 04 N M 8 Y Y 839.3562355 04 N M 3 Y Y 180.3062360 04 N M 8 Y Y 545.1062361 04 N M 8 Y Y 545.1062362 04 N M 8 Y Y 545.1062365 04 N M 8 Y Y 162.0062367 04 N I 27.5562368 04 N I 40.4563001 04 N M 8 Y Y 1102.9563003 04 N M 8 Y Y 1102.9563005 04 N M 7 Y Y 1102.9563011 04 N M 7 Y Y 881.0063012 04 N M 8 Y 1404.2063015 04 N M 8 Y Y 1161.2063016 04 N M 8 Y Y 1161.2063017 04 N M 8 Y Y 1161.2063020 04 Y M 7 Y Y63030 04 N M 7 Y Y 1129.3063035 04 Y M 7 Y Y63040 04 N M 7 Y Y 1129.3063042 04 N M 7 Y Y 1129.3063043 04 01-Jan-10 Y M 7 Y Y63044 04 01-Jan-10 Y M 7 Y Y63045 04 N M 7 Y Y 1129.3063046 04 N M 7 Y Y 1129.3063047 04 N M 7 Y Y 1129.3063048 04 Y M 7 Y Y63050 04 N M 8 Y Y 843.8863051 04 N M 7 Y Y 947.1163055 04 N M 7 Y Y 1291.7063056 04 N M 7 Y Y 1291.7063057 04 Y M 7 Y Y63064 04 N M 7 Y Y 1198.7063066 04 Y M 7 Y Y63075 04 N M 7 Y Y 1198.7063076 04 N M 7 Y Y 1198.7063077 04 N M 7 Y Y 1198.7063078 04 N M 7 Y Y 1198.70

Page 144: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

63081 04 N M 7 Y Y 1291.7063082 04 Y M 7 Y Y63085 04 N M 7 Y Y 1291.7063086 04 Y M 7 Y Y63087 04 N M 7 Y Y 1291.7063088 04 Y M 7 Y Y63090 04 N M 7 Y Y 1291.7063091 04 Y M 7 Y Y63101 04 N M 7 Y Y 1153.5763102 04 N M 7 Y Y 1153.5763103 04 Y M 7 Y Y63170 04 N M 7 Y Y 1291.7063172 04 N M 8 Y Y 1198.7063173 04 N M 8 Y Y 1393.7563180 04 N M 7 Y Y 1198.7063182 04 N M 7 Y Y 1198.7063185 04 N M 8 Y Y 839.3563190 04 N M 8 Y Y 1079.3063191 04 Y M 8 Y Y63194 04 N M 8 Y Y 958.6063195 04 N M 8 Y Y 958.6063196 04 N M 8 Y Y 958.6063197 04 N M 8 Y Y 958.6063198 04 N M 8 Y Y 1291.7063199 04 Y M 8 Y Y63200 04 N M 7 Y Y 1198.7063250 04 N M 8 Y Y 1198.7063251 04 N M 8 Y Y 1198.7063252 04 N M 8 Y Y 1224.3063265 04 N M 8 Y Y 1198.7063266 04 N M 8 Y Y 1198.7063267 04 N M 8 Y Y 1198.7063268 04 N M 8 Y Y 1198.7063270 04 N M 8 Y Y 1198.7063271 04 N M 8 Y Y 1198.7063272 04 N M 8 Y Y 1198.7063273 04 N M 8 Y Y 1198.7063275 04 N M 8 Y Y 1198.70

Page 145: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

63276 04 N M 8 Y Y 1198.7063277 04 N M 8 Y Y 1198.7063278 04 N M 8 Y Y 1198.7063280 04 N M 8 Y Y 1198.7063281 04 N M 8 Y Y 1198.7063282 04 N M 8 Y Y 1198.7063283 04 N M 8 Y Y 1198.7063285 04 N M 8 Y Y 1198.7063286 04 N M 8 Y Y 1198.7063287 04 N M 8 Y Y 1198.7063290 04 N M 8 Y Y 1198.7063295 04 N M 7 Y Y 190.1863300 04 N M 8 Y Y 1606.3063301 04 N M 8 Y Y 1615.7063302 04 N M 8 Y Y 1291.7063303 04 N M 8 Y Y 1291.7063304 04 N M 8 Y Y 1291.7063305 04 N M 8 Y Y 1291.7063306 04 N M 8 Y Y 1291.7063307 04 N M 8 Y Y 1291.7063308 04 Y M 8 Y63600 04 N M 8 Y Y 898.9563610 04 N M 7 Y Y 599.3563615 04 N M 3 Y Y 898.9563620 04 01-Jan-09 N M 9 Y 629.2763621 04 01-Jan-09 N M 9 Y 201.3763650 04 N M 3 Y Y 524.4063655 04 N M 7 Y Y 733.8563661 04 01-Jan-10 N I 3 Y Y 168.2763662 04 01-Jan-10 N M 3 Y Y 393.1963663 04 01-Jan-10 N I 3 Y Y 265.2763664 04 01-Jan-10 N M 7 Y Y 409.7563685 04 N M 3 Y Y 599.3563688 04 N M 3 Y Y 374.5563700 04 N M 9 Y Y 599.3563702 04 N M 9 Y 599.3563704 04 N M 9 Y Y 630.1063706 04 N M 9 Y Y 689.00

Page 146: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

63707 04 N M 9 Y Y 1198.7063709 04 N M 9 Y Y 1198.7063710 04 N M 9 Y Y 1102.9563740 04 N M 11 Y Y 839.3563741 04 N M 8 Y Y 324.0563744 04 N M 8 Y Y 374.5563746 04 N M 8 Y Y 194.0564400 04 N I 74.9064402 04 N I 74.9064405 04 N I 74.9064408 04 N I 52.4064410 04 N I 49.4064412 04 N I 46.6564413 04 N I 52.7064415 04 N I 52.7064416 04 N I 74.9064417 04 N I 48.4064418 04 N I 47.1564420 04 N I 43.2564421 04 N I 56.4064425 04 N I 52.6564430 04 N I 51.1064435 04 N I 50.5564445 04 N I 53.2064446 04 N I 74.9064447 04 N I 53.2064448 04 N I 74.9064449 04 N I 81.4064450 04 N I 38.9564455 04 01-Jan-09 N M 38.9564479 04 N I 95.9064480 04 N I 85.7564483 04 N I 88.2564484 04 N I 83.2064490 04 01-Jan-10 N I 61.5464491 04 01-Jan-10 N I 35.6264492 04 01-Jan-10 Y I64493 04 01-Jan-10 N I 52.13

Page 147: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

64494 04 01-Jan-10 N I 30.3964495 04 01-Jan-10 Y I64505 04 N I 59.6064508 04 N I 59.6064510 04 N I 59.6064517 04 N I 64.4064520 04 N I 56.2064530 04 N I 58.7064550 04 N I 3 22.1564553 04 N I 3 149.8064555 04 N I 3 60.8064560 04 N I 3 97.2064561 04 N M 3 171.5064565 04 Y I 364573 04 N M 3 Y 599.3564575 04 N M 3 Y Y 599.3564577 04 N M 3 Y 599.3564580 04 N M 3 Y 599.3564581 04 N M 3 Y Y 332.0064585 04 N I 3 Y 149.8064590 04 N M 3 Y 599.3564595 04 N M 3 149.8064600 04 N I 100.0064605 04 N I 140.6564610 04 N I 233.0064612 04 N I 71.1564613 04 N I 71.1564614 04 N I 3 27.1064620 04 N I 80.9064622 04 N I 99.7064623 04 N I 48.2064626 04 N I 113.4064627 04 N I 66.5064630 04 N I 88.5064632 04 01-Jan-09 N I 90.5064640 04 N I 90.5064650 04 N I 3 22.4264653 04 N I 3 28.36

Page 148: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

64680 04 N M 224.7064681 04 N I 116.1164702 04 N M 4 Y Y 524.4064704 04 N M 4 Y Y 524.4064708 04 N M 4 Y Y 524.4064712 04 N M 4 Y Y 524.4064713 04 N M 4 Y Y 647.9064714 04 N M 4 Y Y 647.9064716 04 Y M 4 Y Y64718 04 N M 4 Y Y 524.4064719 04 N M 4 Y Y 524.4064721 04 N M 4 Y Y 524.4064722 04 N M 4 Y Y 524.4064726 04 N M 4 Y Y 524.4064727 04 N M 4 Y Y 524.4064732 04 N I 9 Y Y 148.2064734 04 N M 9 Y Y 158.3064736 04 N M 9 224.7064738 04 N M 9 Y Y 374.5564740 04 N M 9 Y Y 224.7064742 04 N M 9 Y Y 224.7064744 04 N M 9 Y Y 607.6064746 04 N I 4 Y Y 181.0564752 04 N M 5 Y Y 524.4064755 04 N M 5 Y Y 524.4064760 04 N M 5 Y Y 524.4064761 04 N M 4 Y Y 299.7064763 04 N M 3 Y Y 224.7064766 04 N M 4 Y Y 374.5564771 04 N M 9 Y 374.5564772 04 N M 8 Y Y 374.5564774 04 N I 4 Y 144.55 34.0064776 04 N M 3 Y Y 180.3064778 04 Y M 3 Y Y64782 04 N M 3 Y Y 240.0064783 04 N M 3 Y Y 120.6064784 04 N M 3 Y Y 359.3064786 04 N M 3 Y Y 470.15

Page 149: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

64787 04 N M 3 Y Y 124.7064788 04 N I 4 Y 139.60 34.0064790 04 N M 3 Y Y 359.3064792 04 Y M 3 Y Y64795 04 N I 3 112.4064802 04 N M 6 Y Y 480.0064804 04 N M 11 Y Y 599.3564809 04 N M 11 Y Y 749.2064818 04 N M 4 Y Y 653.4064820 04 Y M 4 Y Y64821 04 N M 4 Y 407.4064822 04 N M 4 Y 407.4064823 04 N M 4 Y 471.0064831 04 N M 4 Y Y 252.4564832 04 N M 4 Y Y 139.0064834 04 N M 4 Y Y 299.7064835 04 N M 4 Y Y 599.3564836 04 N M 4 Y Y 599.3564837 04 N M 4 Y Y 299.7064840 04 N M 4 Y Y 449.5064856 04 N M 4 Y Y 449.5064857 04 N M 4 Y Y 449.5064858 04 N M 4 Y Y 599.3564859 04 N M 4 Y Y 229.7064861 04 N M 4 Y Y 718.7064862 04 N M 4 Y Y 718.7064864 04 N M 4 Y Y 599.3564865 04 N M 4 Y Y 861.5064866 04 N M 4 Y Y 599.3564868 04 N M 4 Y Y 599.3564870 04 N M 4 Y Y 599.3564872 04 N M 4 Y Y 449.5064874 04 N M 4 Y Y 749.2064876 04 N M 4 Y Y 524.4064885 04 N M 4 Y Y 507.1564886 04 N M 4 Y Y 600.6564890 04 N M 4 Y Y 455.9064891 04 N M 4 Y Y 457.30

Page 150: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

64892 04 N M 4 Y Y 557.4564893 04 N M 4 Y Y 557.4564895 04 N M 4 Y Y 551.1064896 04 N M 4 Y Y 619.5064897 04 N M 4 Y Y 665.5064898 04 N M 4 Y Y 665.5064901 04 N M 4 Y Y 316.5564902 04 N M 4 Y Y 359.7064905 04 Y M 4 Y Y64907 04 Y M 4 Y Y64910 04 01-Jan-07 Y M 464911 04 01-Jan-07 Y M64999 04 Y M Y Y65091 04 N M 5 359.3065093 04 N M 5 480.0065101 04 N M 5 359.3065103 04 N M 5 480.0065105 04 N M 5 599.3565110 04 N M 5 898.9565112 04 N M 5 973.9065114 04 N M 5 1048.8565125 04 Y M 565130 04 N M 5 749.2065135 04 N M 5 449.5065140 04 N M 5 599.3565150 04 N M 5 524.4065155 04 N M 5 475.2565175 04 N M 5 236.7065205 04 N I 3 58.1565210 04 N I 5 62.6065220 04 N I 3 73.5065222 04 N I 3 64.6065235 04 N M 5 480.0065260 04 N M 5 480.0065265 04 N M 5 480.0065270 04 N M 5 107.00 17.0065272 04 N M 5 142.70 17.0065273 04 N M 5 224.70

Page 151: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

65275 04 N M 5 359.3065280 04 N M 5 599.3565285 04 N M 5 599.3565286 04 N M 5 359.3065290 04 N M 5 449.5065400 04 N M 5 323.3065410 04 N I 5 51.40 17.0065420 04 N M 5 Y 273.3065426 04 N M 5 348.1565430 04 N I 3 78.50 17.0065435 04 N I 5 48.5565436 04 N I 5 125.2565450 04 N I 5 Y 135.4065600 04 N M 5 240.0065710 04 N M 5 839.2565730 04 N M 5 Y 1317.9565750 04 N M 5 1317.9565755 04 N M 5 Y 1317.9565756 04 01-Jan-09 N M 5 839.3565760 04 N M 5 1560.8065765 04 N M 5 1560.8065767 04 N M 5 Y 1560.8065770 04 Y M 565772 04 N M 5 Y 1252.0065775 04 N M 5 Y 648.1065780 04 N M 5 Y Y 403.9065781 04 N M 5 Y Y 617.7865782 04 N M 5 Y Y 532.6165800 04 N M 5 240.0065805 04 N M 5 299.7065810 04 N M 5 299.7065815 04 N M 5 480.0065820 04 N M 5 599.3565850 04 N M 5 Y 599.3565855 04 N M 5 599.3565860 04 N M 5 Y 299.7065865 04 N M 5 299.7065870 04 N M 5 297.00

Page 152: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

65875 04 N M 5 324.0565880 04 N M 5 299.7065900 04 N M 5 378.0565920 04 Y M 565930 04 N M 5 480.0066020 04 N M 5 180.3066030 04 N M 5 180.3066130 04 N M 5 273.3066150 04 N M 5 718.7066155 04 N M 5 718.7066160 04 N M 5 718.7066165 04 N M 5 599.3566170 04 N M 5 Y 718.7066172 04 N M 5 Y 810.1066180 04 N M 5 Y 799.7066185 04 N M 5 Y 351.0066220 04 N M 5 550.9066225 04 N M 5 675.1066250 04 Y M 566500 04 N M 5 149.8066505 04 N M 5 240.0066600 04 N M 5 581.3066605 04 N M 5 581.3066625 04 N M 5 581.3066630 04 N M 5 581.3066635 04 N M 5 581.3066680 04 N M 5 471.7066682 04 N M 5 Y Y 471.7066700 04 N M 5 341.3066710 04 N M 5 341.3066711 04 N M 5 341.3066720 04 N M 5 Y 341.3066740 04 N M 5 569.3066761 04 N M 5 449.5066762 04 N M 5 449.5066770 04 N M 5 374.5566820 04 N M 5 Y 299.7066821 04 N M 6 299.70

Page 153: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

66825 04 N M 5 Y 299.7066830 04 N M 5 Y 374.5566840 04 N M 5 Y 751.9066850 04 N M 5 Y 751.9066852 04 N M 5 Y 751.9066920 04 N M 5 Y 751.9066930 04 N M 5 Y 751.9066940 04 N M 5 Y 751.9066982 04 N M 5 587.6066983 04 N M 5 Y 1051.6066984 04 N M 5 1051.6066985 04 N M 5 574.7566986 04 N M 5 546.0066990 09 Y N66999 04 Y M Y67005 04 N M 5 Y 749.2067010 04 N M 5 Y 749.2067015 04 N M 5 Y 861.5067025 04 N M 5 Y 818.4567027 04 N M 5 Y 524.3567028 04 N M 5 Y 287.1067030 04 N M 5 Y 818.4567031 04 N M 5 818.4567036 04 N M 5 Y 1086.3067039 04 N M 5 Y 1086.3067040 04 N M 5 Y Y 1086.3067041 04 01-Jan-08 N M Y Y 613.6567042 04 01-Jan-08 N M 5 Y Y 703.0067043 04 01-Jan-08 N M 5 Y Y 737.5567101 04 N M 6 434.3067105 04 N M 6 457.2067107 04 N M 6 Y 980.8567108 04 N M 6 Y 1086.3067110 04 N M 6 Y 434.3067112 04 Y M 667113 04 01-Jan-08 N M 6 Y Y 809.6667115 04 N M 3 Y 735.6067120 04 N M 5 958.60

Page 154: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

67121 04 Y M 5 Y67141 04 N M 6 443.9567145 04 N M 6 Y 443.9567208 04 N M 6 Y 443.9567210 04 N M 6 Y 443.9567218 04 N M 6 486.1067220 04 N M 6 Y 443.9567221 04 N M 6 Y 225.3067225 04 N I 3 42.5567227 04 N M 6 Y 443.9567228 04 N M 6 466.1567229 04 01-Jan-08 N M 532.1967250 04 N M 5 749.2067255 04 N M 5 898.9567299 04 Y M Y67311 04 N M 5 Y 511.9067312 04 N M 5 Y 511.9067314 04 N M 5 Y 511.9067316 04 N M 5 Y 511.9067318 04 N M 5 Y 550.9067320 04 N M 5 Y 647.2067331 04 N M 5 Y 374.5567332 04 N M 5 Y 511.9067334 04 N M 5 Y 511.9067335 09 Y N67340 04 N M 5 Y 405.1067343 04 N M 5 Y 399.6067345 04 N M 5 Y 100.0067346 04 01-Jan-07 N I 5 107.0067399 04 Y M Y67400 04 N M 5 Y 681.1067405 04 N M 5 Y 524.4067412 04 N M 5 Y 839.3567413 04 N M 5 Y 839.3567414 04 N M 5 Y 797.4067415 04 N I 5 56.80 17.0067420 04 N M 5 Y 1079.3067430 04 N M 5 1079.30

Page 155: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

67440 04 N M 5 681.1067445 04 N M 5 Y 1025.4067450 04 N M 5 Y 681.1067500 04 N I 5 78.2067505 04 N M 5 74.9067515 04 N I 5 74.9067550 04 N M 5 415.8567560 04 N M 5 340.9067570 04 N M 5 Y 797.4067599 04 Y M Y67700 04 N I 3 73.5067710 04 N M 4 224.7067715 04 N I 4 59.6067800 04 N I 3 77.20 17.0067801 04 N I 3 91.85 17.0067805 04 N M 3 99.05 17.0067808 04 N I 3 112.8067810 04 N I 3 68.10 17.0067820 04 N I 3 30.5067825 04 N I 3 88.5067830 04 N I 3 112.6067835 04 N M 4 187.3067840 04 N I 3 93.30 17.0067850 04 N I 3 90.2067875 04 N M 4 Y 187.3067880 04 N M 4 187.3067882 04 N M 4 Y 231.5067900 04 N M Y 216.0067901 04 N M 4 685.4067902 04 N M 4 685.4067903 04 N M 4 685.4067904 04 N M 4 Y 685.4067906 04 N M 4 749.2067908 04 N M 4 749.2067909 04 N M 4 749.2067911 04 N M 4 749.2067912 04 N M 4 Y 221.6467914 04 N M 4 359.30

Page 156: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

67915 04 N I 4 133.9067916 04 N M 4 299.7067917 04 N M 4 359.3067921 04 N M 4 359.3067922 04 N I 4 130.7067923 04 N M 4 299.7067924 04 N M 4 359.3067930 04 N M 4 189.00 17.0067935 04 N M 4 244.50 17.0067938 04 N I 80.90 17.0067950 04 N M 4 359.3067961 04 N M 4 324.0567966 04 N M 4 345.7067971 04 N M 4 449.5067973 04 N M 4 449.5067974 04 N M 4 449.5067975 04 N M 4 449.5067999 04 Y M Y68020 04 N I 3 72.55 17.0068040 04 N I 3 71.40 17.0068100 04 N I 4 77.60 17.0068110 04 N M 4 180.3068115 04 N M 4 180.3068130 04 N M 4 224.7068135 04 N M 4 224.7068200 04 N I 3 56.6068320 04 N M 4 449.5068325 04 N M 4 531.3068326 04 N M 4 531.3068328 04 N M 4 531.3068330 04 N M 4 299.7068335 04 N M 4 524.4068340 04 N M 4 299.7068360 04 N M 4 240.0068362 04 N M 4 359.3068371 04 N M 3 Y 191.2568399 04 Y M Y Y68400 04 N I 4 103.60 17.00

Page 157: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

68420 04 N I 4 117.70 17.0068440 04 N I 4 66.90 17.0068500 04 N M 4 599.3568505 04 N M 5 336.4568510 04 N I 4 191.40 17.0068520 04 N M 4 599.3568525 04 N I 4 124.50 17.0068530 04 N I 4 174.60 17.0068540 04 N M 4 599.3568550 04 N M 4 648.1068700 04 N M 4 359.3068705 04 N I 4 93.6068720 04 N M 4 Y Y 839.3568745 04 N M 4 839.3568750 04 N M 4 Y 858.7068760 04 N I 4 84.1068761 04 N I 4 75.5068770 04 Y M 468801 04 N I 4 71.7068810 04 N I 4 103.5068811 04 N I 4 115.1068815 04 N I 4 143.40

68816 04 01-Jan-08 N I 4 115.00 205.2368840 04 N I 4 83.3068850 04 N I 4 116.3568899 04 Y M Y69000 04 N I 3 42.40 17.0069005 04 N I 3 64.10 17.0069020 04 N I 3 44.60 17.0069100 04 N I 4 31.15 17.0069105 04 N I 4 50.20 17.0069110 04 N M 4 209.4069120 04 N M 4 240.0069140 04 N M 4 480.0069145 04 N I 4 90.1069150 04 N M 4 Y 718.7069155 04 N M 5 Y 1198.70

Page 158: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

69200 04 N I 26.6069205 04 N I 4 74.9069210 04 N I 3 21.4069220 04 N I 3 Y Y 28.5069222 04 N I 3 Y Y 57.3069300 09 Y M69310 04 N M 3 694.4069320 04 N M 3 958.6069399 04 Y M Y69400 04 N I 3 28.1569401 04 N I 3 22.1569405 04 N I 3 Y Y 115.1069420 04 N I 3 43.80 17.0069421 04 N I 3 56.6069424 04 N I 3 30.3569433 04 N I 76.60 34.0069436 04 N I 3 80.5069440 04 N M 4 599.3569450 04 N I 4 191.1069501 04 N M 4 Y Y 692.2069502 04 N M 4 Y Y 692.2069505 04 N M 4 Y Y 749.2069511 04 N M 4 Y Y 839.3569530 04 N M 4 Y Y 1198.7069535 04 N M 4 Y Y 1198.7069540 04 N I 4 Y 50.20 17.0069550 04 N I 4 Y 363.60 17.0069552 04 N M 4 Y 674.2069554 04 N M 4 Y Y 954.9569601 04 N M 4 Y Y 695.0569602 04 N M 4 Y 695.0569603 04 N M 4 Y Y 695.0569604 04 N M 4 Y Y 695.0569605 04 N M 4 Y Y 695.0569610 04 Y M 4 Y Y69620 04 Y M 4 Y Y69631 04 N M 4 Y Y 749.2069632 04 N M 4 Y Y 749.20

Page 159: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

69633 04 N M 4 Y 861.5069635 04 N M 4 Y Y 749.2069636 04 N M 4 Y Y 749.2069637 04 N M 4 Y 861.5069641 04 N M 4 Y Y 1048.8569642 04 N M 4 Y Y 1048.8569643 04 N M 4 Y Y 1048.8569644 04 N M 4 Y 1048.8569645 04 N M 4 Y Y 1048.8569646 04 N M 4 Y Y 1048.8569650 04 N M 4 Y Y 743.6569660 04 N M 4 Y Y 749.2069661 04 N M 5 Y Y 749.2069662 04 N M 4 Y Y 749.2069666 04 N M 4 Y Y 749.2069667 04 N M 4 Y Y 749.2069670 04 N M 4 Y Y 1079.3069676 04 N M 4 Y Y 834.5069700 04 N M 4 Y Y 299.7069710 04 N M 3 918.1569711 04 N M 3 Y 550.9069714 04 N M 3 Y 604.6569715 04 N M 3 Y 765.8569717 04 N M 3 Y 623.2569718 04 N M 3 Y 775.2069720 04 N M 4 Y Y 749.2069725 04 N M 4 Y Y 749.2069740 04 N M 4 Y Y 599.3569745 04 N M 4 Y Y 947.2069799 04 Y M Y69801 04 N M 5 Y Y 749.2069802 04 N M 5 Y Y 749.2069805 04 N M 5 Y Y 749.2069806 04 N M 5 Y Y 749.2069820 04 N M 5 Y Y 749.2069840 04 N M 5 Y Y 749.2069905 04 N M 5 Y Y 1198.7069910 04 N M 5 Y 1198.70

Page 160: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

69915 04 N M 5 Y Y 1198.7069930 04 N M 3 Y 1296.2069949 04 Y M Y69950 04 N M 4 Y Y 1079.3069955 04 N M 4 Y Y 1079.3069960 04 N M 4 Y Y 1198.7069970 04 N M 4 Y Y 1188.2069979 04 Y M Y69990 09 Y N70010 04 N I 28.7070015 04 N I 39.2070030 A 04 N N 10.75 10.75 21.5070100 A 04 N N 11.40 11.40 22.8070110 A 04 N N 15.65 15.65 31.3070120 A 04 N N 11.40 11.40 22.8070130 A 04 N N 15.65 15.65 31.3070134 A 04 N N 20.25 20.25 40.5070140 A 04 N N 14.35 14.35 28.7070150 A 04 N N 17.62 15.62 35.2570160 A 04 N N 10.47 10.47 20.9570170 04 N I 18.3070190 A 04 N N 11.40 11.40 22.8070200 A 04 N N 17.62 17.62 35.2570210 A 04 N N 11.10 11.10 22.2070220 A 04 N N 14.35 14.35 28.7070240 A 04 N N 11.40 11.40 22.8070250 A 04 N N 10.75 10.75 21.5070260 A 04 N N 17.62 17.62 35.2570300 A 04 N N 5.90 5.90 11.8070310 A 04 N N 7.17 7.17 14.3570320 A 04 N N 14.35 14.35 28.7070328 A 04 N N 14.35 14.35 28.7070330 A 04 N N 14.35 14.35 28.7070332 04 N I 23.3070336 B 04 N N 3 148.30 148.30 296.6070350 A 04 N N 7.17 7.17 14.3570355 A 04 N N 14.35 14.35 28.7070360 A 04 N N 7.17 7.17 14.35

Page 161: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

70370 A 04 N N 13.07 13.07 26.1570371 A 04 N N 12.70 12.70 25.4070373 04 N I 20.2070380 A 04 N N 11.10 11.10 22.2070390 04 N I 22.2070450 B 04 N N 3 123.58 123.58 247.1570460 B 04 N N 3 141.23 141.22 282.4570470 B 04 N N 3 141.22 141.22 282.4570480 B 04 N N 3 31.35 31.35 62.7070481 B 04 N N 4 37.95 37.95 75.9070482 B 04 N N 4 54.92 54.92 109.9570486 B 04 N N 3 31.35 31.35 62.7070487 B 04 N N 3 37.95 37.95 75.9070488 B 04 N N 3 54.92 54.92 109.8570490 B 04 N N 3 31.35 31.35 62.7070491 B 04 N N 3 37.95 37.95 75.9070492 B 04 N N 3 54.92 54.92 109.8570496 B 04 N N 3 123.52 123.52 247.0570498 B 04 N N 3 123.52 123.52 247.0570540 B 04 N N 148.30 148.30 296.6070542 B 04 N N 3 148.30 148.30 296.6070543 B 04 N N 3 223.93 223.92 447.8570544 B 04 N N 3 148.30 148.30 296.6070545 B 04 N N 3 148.30 148.30 296.6070546 B 04 N N 3 204.77 204.78 409.5570547 B 04 N N 3 148.30 148.30 296.6070548 B 04 N N 3 148.30 148.30 296.6070549 B 04 N N 3 204.77 204.78 409.5570551 B 04 N N 3 148.30 148.30 296.6070552 B 04 N N 148.30 148.30 296.6070553 B 04 N N 148.30 148.30 296.6070554 C 04 01-Jan-07 N N 50.42 246.18 1 296.6070555 04 01-Jan-07 N N 64.3270557 04 N M 79.0670558 04 N M 87.5370559 04 N N 88.0271010 A 04 N N 8.50 8.50 17.0071015 A 04 N N 10.75 10.75 21.50

Page 162: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

71020 A 04 N N 10.75 10.75 21.5071021 A 04 N N 10.75 10.75 21.5071022 A 04 N N 10.75 10.75 21.5071023 A 04 N N 10.75 10.75 21.5071030 A 04 N N 14.35 14.35 28.7071034 A 04 N N 14.35 14.35 28.7071035 A 04 N N 14.35 14.35 28.7071040 04 N I 32.7071060 04 N I 52.3071090 04 N I 103.3071100 A 04 N N 10.75 10.75 21.5071101 A 04 N N 12.40 12.40 24.8071110 A 04 N N 13.07 13.08 26.1571111 A 04 N N 14.35 14.35 28.7071120 A 04 N N 10.75 10.75 21.5071130 A 04 N N 14.35 14.35 28.7071250 B 04 N N 4 31.35 31.35 62.7071260 B 04 N N 3 37.95 37.95 75.9071270 B 04 N N 3 54.93 54.92 109.8571275 B 04 N N 3 132.50 132.50 265.0071550 B 04 N N 148.30 148.30 296.6071551 B 04 N N 3 148.30 148.30 296.6071552 B 04 N N 3 224.03 224.02 448.0571555 B 04 N N 3 148.30 148.30 296.6072010 A 04 N N 35.95 35.95 71.9072020 A 04 N N 12.07 12.08 24.1572040 A 04 N N 12.07 12.08 24.1572050 A 04 N N 17.63 17.62 35.2572052 A 04 N N 18.25 18.25 36.5072069 A 04 N N 11.40 11.40 22.8072070 A 04 N N 11.40 11.40 22.8072072 A 04 N N 10.47 10.48 20.9572074 A 04 N N 10.75 10.75 21.5072080 A 04 N N 12.70 12.70 25.4072090 A 04 N N 29.45 29.45 58.9072100 A 04 N N 14.35 14.35 28.7072110 A 04 N N 18.95 18.95 37.9072114 A 04 N N 18.95 18.95 37.90

Page 163: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

72120 A 04 N N 18.95 18.95 37.9072125 B 04 N N 4 31.35 31.35 62.7072126 B 04 N N 4 37.95 37.95 75.9072127 B 04 N N 4 54.93 54.92 109.8572128 B 04 N N 4 31.35 31.35 62.7072129 B 04 N N 4 37.95 37.95 75.9072130 B 04 N N 4 54.93 54.92 109.8572131 B 04 N N 4 31.35 31.35 62.7072132 B 04 N N 4 37.95 37.95 75.9072133 B 04 N N 4 54.93 54.92 109.8572141 B 04 N N 148.30 148.30 296.6072142 B 04 N N 148.30 148.30 296.6072146 B 04 N N 148.30 148.30 296.6072147 B 04 N N 148.30 148.30 296.6072148 B 04 N N 148.30 148.30 296.6072149 B 04 N N 148.30 148.30 296.6072156 B 04 N N 148.30 148.30 296.6072157 B 04 N N 148.30 148.30 296.6072158 B 04 N N 148.30 148.30 296.6072159 B 04 N N 148.30 148.30 296.6072170 A 04 N N 7.85 7.85 15.7072190 A 04 N N 17.63 17.62 35.2572191 B 04 N N 3 128.30 128.30 256.6072192 B 04 N N 3 31.35 31.35 62.7072193 B 04 N N 3 37.95 37.95 75.9072194 B 04 N N 3 54.93 54.92 109.8572195 B 04 N N 3 148.30 148.30 296.6072196 B 04 N N 148.30 148.30 296.6072197 B 04 N N 3 226.15 226.15 452.3072198 B 04 N N 148.30 148.30 296.6072200 A 04 N N 10.75 10.75 21.5072202 A 04 N N 11.40 11.40 22.8072220 A 04 N N 10.75 10.75 21.5072240 04 N I 65.3572255 04 N I 52.3072265 04 N N 52.3072270 04 N N 99.3572275 04 N I 57.45

Page 164: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

72285 04 N I 52.3072291 04 01-Jan-10 N I 78.0572292 04 01-Jan-10 N I 62.5072295 04 N I 45.8073000 A 04 N N 7.50 7.50 15.0073010 A 04 N N 10.75 10.75 21.5073020 A 04 N N 10.75 10.75 21.5073030 A 04 N N 11.10 11.10 22.2073040 C 04 N I 6.03 17.47 23.5073050 A 04 N N 10.07 10.08 20.1573060 A 04 N N 7.85 7.85 15.7073070 A 04 N N 9.80 9.80 19.6073080 A 04 N N 10.75 10.75 21.5073085 04 N I 22.2073090 A 04 N N 9.15 9.15 18.3073092 A 04 N N 7.17 7.18 14.3573100 A 04 N N 10.75 10.75 21.5073110 A 04 N N 11.10 11.10 22.2073115 04 N I 30.1073120 A 04 N N 8.50 8.50 17.0073130 A 04 N N 9.15 9.15 18.3073140 A 04 N N 7.17 7.18 14.3573200 B 04 N N 3 31.35 31.35 62.7073201 B 04 N N 3 37.95 37.95 75.9073202 B 04 N N 3 54.93 54.92 109.8573206 B 04 N N 3 115.55 115.55 231.1073218 B 04 N N 3 148.30 148.30 296.6073219 B 04 N N 3 148.30 148.30 296.6073220 B 04 N N 148.30 148.30 296.6073221 B 04 N N 3 148.30 148.30 296.6073222 B 04 N N 3 148.30 148.30 296.6073223 B 04 N N 3 223.92 223.92 447.8573225 B 04 N N 148.30 148.30 296.6073500 A 04 N N 10.75 10.75 21.5073510 A 04 N N 14.35 14.35 28.7073520 A 04 N N 19.60 19.60 39.2073525 C 04 N I 14.02 38.28 52.3073530 A 04 N N 24.85 24.85 49.70

Page 165: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

73540 A 04 N N 17.00 17.00 34.0073542 04 N I 120.9073550 A 04 N N 10.75 10.75 21.5073560 A 04 N N 9.80 9.80 19.6073562 A 04 N N 10.10 10.10 20.2073564 A 04 N N 11.10 11.10 22.2073565 A 04 N N 16.70 16.70 33.4073580 04 N I 37.9073590 A 04 N N 10.75 10.75 21.5073592 A 04 N N 10.75 10.75 21.5073600 A 04 N N 10.75 10.75 21.5073610 A 04 N N 14.35 14.35 28.7073615 04 N I 26.1573620 A 04 N N 8.50 8.50 17.0073630 A 04 N N 10.75 10.75 21.5073650 A 04 N N 8.50 8.50 17.0073660 A 04 N N 7.17 7.17 14.3573700 B 04 N N 3 31.35 31.35 62.7073701 B 04 N N 3 37.95 37.95 75.9073702 B 04 N N 54.92 54.92 109.8573706 B 04 N N 3 115.55 115.55 231.1073718 B 04 N N 3 148.30 148.30 296.6073719 B 04 N N 3 148.30 148.30 296.6073720 B 04 N N 3 148.30 148.30 296.6073721 B 04 N N 3 148.30 148.30 296.6073722 B 04 N N 3 148.30 148.30 296.6073723 B 04 N N 3 223.92 223.92 447.8573725 B 04 N N 148.30 148.30 296.6074000 A 04 N N 10.75 10.75 21.5074010 A 04 N N 12.70 12.70 25.4074020 A 04 N N 12.70 12.70 25.4074022 A 04 N N 20.95 20.95 41.9074150 B 04 N N 4 31.35 31.35 62.7074160 B 04 N N 4 37.95 37.95 75.9074170 B 04 N N 4 54.92 54.92 109.8574175 B 04 N N 3 128.32 128.32 256.6574181 B 04 N N 148.30 148.30 296.6074182 B 04 N N 3 148.30 148.30 296.60

Page 166: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

74183 B 04 N N 3 226.15 226.15 452.3074185 B 04 N N 148.30 148.30 296.6074190 04 N I 21.5074210 A 04 N N 14.35 14.35 28.7074220 A 04 N N 14.35 14.35 28.7074230 A 04 N N 12.70 12.70 25.4074235 04 N I 4 122.4074240 B 04 N N 24.85 24.85 49.7074241 B 04 N N 25.50 25.50 51.0074245 B 04 N N 32.02 32.02 64.0574246 B 04 N N 26.15 26.15 52.3074247 B 04 N N 26.80 26.80 53.6074249 B 04 N N 32.02 32.02 64.0574250 B 04 N N 21.57 21.57 43.1574251 B 04 N N 29.45 29.45 58.9074260 B 04 N N 18.25 18.25 36.5074270 B 04 N N 24.85 24.85 49.7074280 B 04 N N 29.45 29.45 58.9074283 B 04 N N 29.45 29.45 58.9074290 B 04 N N 17.62 17.62 35.2574291 B 04 N N 17.62 17.62 35.2574300 04 N I 35.2574301 04 Y I74305 04 N I 35.2574320 04 N I 57.5574327 04 N I 3 168.6574328 04 N I 3 64.0574329 04 N I 3 92.8074330 04 N I 3 100.6574340 04 N I 3 51.0074355 04 N I 3 118.6074360 04 N I 3 44.9074363 04 N I 4 170.0074400 B 04 N N 24.85 24.85 49.7074410 B 04 N N 28.77 28.77 57.5574415 B 04 N N 28.77 28.77 57.5574420 B 04 N N 14.35 14.35 28.7074425 04 N I 28.70

Page 167: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

74430 04 N I 23.5074440 04 N I 32.7074445 04 N I 28.7074450 04 N I 26.1574455 04 N I 26.1574470 04 N I 18.3074475 04 N I 3 14.3574480 04 N I 3 71.9074485 04 N I 3 28.5074710 B 04 N N 22.90 22.90 45.8074740 C 04 N I 10.65 28.55 39.2074742 04 N I 3 39.2074775 04 N N 71.2075557 C 04 01-Jan-10 N N 68.87 230.81 299.6875559 C 04 01-Jan-10 N N 87.60 344.24 431.8475561 C 04 01-Jan-10 N N 76.18 325.65 401.8375563 C 04 01-Jan-10 N N 90.99 404.09 495.0875565 C 04 01-Jan-10 N N 7.36 41.70 49.0675571 R 04 01-Jan-10 N N 21.37 88.48 109.8575572 R 04 01-Jan-10 N N 21.37 88.48 109.8575573 R 04 01-Jan-10 N N 21.37 88.48 109.8575574 R 04 01-Jan-10 N N 21.37 88.48 109.8575600 04 N I 109.8575605 04 N I 77.2075625 04 N I 98.1075630 04 N I 130.8075635 C 04 N I 3 51.14 230.26 281.4075650 04 N I 163.4075658 04 N I 78.4575660 04 N I 84.9075662 04 N I 130.8075665 04 N I 98.1075671 04 N I 130.8075676 04 N I 78.4575680 04 N I 104.6075685 04 N I 78.4575705 04 N I 98.1075710 04 N I 78.45

Page 168: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

75716 04 N I 111.1075722 04 N I 78.4575724 04 N I 111.1075726 04 N I 91.4575731 04 N I 91.4575733 04 N I 115.1075736 04 N I 91.4575741 04 N I 91.4575743 04 N I 117.6075746 04 N I 65.3575756 04 N I 39.2075774 04 N I 3 25.1075791 C 04 01-Jan-10 N I 48.04 117.63 165.6775801 04 N I 35.2575803 04 N I 75.9075805 04 N I 77.2075807 04 N I 91.4575809 04 N I 3 77.2075810 04 N I 91.4575820 04 N I 45.8075822 04 N I 65.3575825 04 N I 78.4575827 04 N I 100.6575831 04 N I 91.4575833 04 N I 111.1075840 04 N I 57.5575842 04 N I 91.4575860 04 N I 78.4575870 04 N I 52.3075872 04 N I 130.8075880 04 N I 28.7075885 04 N I 3 64.3075887 04 N I 3 54.6075889 04 N I 128.2075891 04 N I 93.4075893 04 N I 98.1075894 04 N I 3 64.0575896 04 N I 3 64.05

Page 169: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

75898 04 N I 3 56.2075900 04 N I 201.2075901 04 N I 3 66.6075902 04 N I 3 66.6075940 04 N I 3 66.6075945 04 N I 3 64.0575946 04 N I 3 49.4075952 04 N I 3 162.8575953 04 N I 3 68.3075954 04 N I 3 83.0075956 04 N M 8 Y 221.1075957 04 N M 8 Y 189.4275958 04 N M 8 Y 126.2675959 04 N M 8 Y 110.5275960 04 N I 3 83.0075961 04 N I 3 62.1575962 04 N I 3 83.0075964 04 N I 3 83.0075966 04 N I 3 83.0075968 04 N I 3 83.0075970 04 N I 3 78.9075978 04 N I 3 65.3575980 04 N I 3 83.0075982 04 N I 3 41.9075984 04 N I 3 53.6075989 04 N I 3 84.9075992 04 N I 3 83.0075993 04 Y I 375994 04 N I 3 83.0075995 04 N I 3 83.0075996 04 Y I 376000 04 N I 32.7076001 04 N I 56.4576010 A 04 N N 16.20 16.20 32.4076080 04 N I 26.1576098 A 04 N N 6.20 6.20 12.4076100 A 04 N N 24.85 24.85 49.7076101 A 04 N N 17.62 17.62 35.25

Page 170: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

76102 A 04 N N 24.85 24.85 49.7076120 A 04 N N 10.47 10.47 20.9576125 A 04 N N 24.85 24.85 49.7076140 04 N N 19.6076150 B 04 Y N76350 B 04 Y N76376 C 04 N I 6.18 66.99 1 73.1776377 C 04 N I 24.33 72.94 1 97.2776380 04 N N 59.5576390 B 04 N I 148.30 148.30 296.6076496 A 04 Y I 376497 B 04 Y I76498 B 04 Y I76499 04 Y N 376506 B 04 N N 32.02 32.02 64.0576510 A 04 N N 32.67 32.67 65.3576511 A 04 N N 24.85 24.85 49.7076512 A 04 N N 32.67 32.67 65.3576513 A 04 N N 32.67 32.67 65.3576514 C 04 N N 5.20 1.37 1 6.5776516 A 04 N N 24.85 24.85 49.7076519 A 04 N N 24.90 24.90 49.8076529 A 04 N N 32.67 32.67 65.3576536 B 04 N N 34.00 34.00 68.0076604 B 04 N N 31.35 31.35 62.7076645 B 04 N N 31.35 31.35 62.7076700 B 04 N N 37.95 37.95 75.9076705 B 04 N N 31.35 31.35 62.7076770 B 04 N N 37.95 37.95 75.9076775 B 04 N N 31.35 31.35 62.7076776 C 04 01-Jan-07 N N 53.13 22.77 1 75.9076800 B 04 N N 37.95 37.95 75.9076801 B 04 N N 35.95 35.95 71.9076802 B 04 N N 22.52 22.52 45.0576805 B 04 N N 35.95 35.95 71.9076810 B 04 N N 22.52 22.52 45.0576811 B 04 N N 35.95 35.95 71.9076812 B 04 N N 22.52 22.52 45.05

Page 171: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

76813 C 04 01-Jan-07 N N 32.36 39.54 1 71.9076814 C 04 01-Jan-07 N N 25.23 19.82 1 45.0576815 B 04 N N 35.95 35.95 71.9076816 B 04 N N 35.95 35.95 71.9076817 B 04 N N 35.95 35.95 71.9076818 B 04 N N 31.97 31.97 63.9576819 B 04 N N 15.55 15.55 31.1076820 B 04 N N 35.95 35.95 71.9076821 B 04 N N 35.95 35.95 71.9076825 B 04 N N 35.95 35.95 71.9076826 B 04 N N 35.95 35.95 71.9076827 B 04 N N 35.95 35.95 71.9076828 B 04 N N 35.95 35.95 71.9076830 B 04 N N 35.95 35.95 71.9076831 B 04 N N 35.95 35.90 71.9076856 B 04 N N 35.95 35.95 71.9076857 B 04 N N 35.95 35.95 71.9076870 B 04 N N 24.85 24.85 49.7076872 B 04 N N 35.95 35.95 71.9076873 B 04 N N 71.35 71.35 142.7076880 B 04 N N 24.85 24.85 49.7076885 B 04 N N 35.95 35.95 71.9076886 B 04 N N 35.95 35.95 71.9076930 04 N I 56.2076932 04 N I 65.3576936 04 N I 56.2076937 C 04 N I 3 9.21 9.60 1 18.8176940 C 04 N I 55.84 35.48 1 91.3276941 04 N I 56.2076942 04 N I 60.1076945 04 N I 49.7076946 04 N I 51.0076950 B 04 N N 31.35 31.35 62.7076965 B 04 N N 24.85 24.85 49.7076970 A 04 Y N76975 04 N I 51.0076977 B 04 N N 17.25 17.25 34.5076998 04 01-Jan-07 N N 33.37

Page 172: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

76999 04 Y N77001 C 04 01-Jan-07 N N 8.75 29.29 1 38.0477002 C 04 01-Jan-07 N N 13.27 24.63 1 37.9077003 C 04 01-Jan-07 N N 20.40 31.90 1 52.3077011 C 04 01-Jan-07 N N 7.31 48.89 1 56.2077012 C 04 01-Jan-07 N N 10.12 46.08 1 56.2077013 04 N N 233.7077014 C 04 01-Jan-07 N N 14.05 42.15 1 56.2077021 C 04 01-Jan-07 N N 53.61 281.44 1 335.0577022 C 04 01-Jan-07 N N 53.61 281.44 1 335.0577031 C 04 01-Jan-07 N N 26.08 9.17 1 35.2577032 C 04 01-Jan-07 N N 13.75 21.50 1 35.2577051 C 04 01-Jan-07 N N 1.89 8.07 1 9.9677052 C 04 01-Jan-07 N N 1.89 8.07 1 9.9677053 C 04 01-Jan-07 N N 9.18 41.82 1 51.0077054 C 04 01-Jan-07 N N 11.44 60.06 1 71.5077055 C 04 01-Jan-07 N N 17.64 21.56 1 39.2077056 C 04 01-Jan-07 N N 31.64 40.26 1 71.9077057 C 04 01-Jan-07 N N 30.20 41.70 1 71.9077058 C 04 01-Jan-07 N N 29.66 266.94 1 296.6077059 C 04 01-Jan-07 N N 23.73 272.87 1 296.6077071 04 01-Jan-07 N N 15.5377072 C 04 01-Jan-07 N N 8.81 12.69 1 21.5077073 C 04 01-Jan-07 N N 9.18 19.52 1 28.7077074 C 04 01-Jan-07 N N 20.72 36.83 1 57.5577075 C 04 01-Jan-07 N N 30.41 67.69 1 98.1077076 C 04 01-Jan-07 N N 16.92 18.33 1 35.2577077 C 04 01-Jan-07 N N 12.57 29.33 1 41.9077078 C 04 01-Jan-07 N N 3.20 32.40 1 35.6077079 C 04 01-Jan-07 N N 3.92 31.68 1 35.6077080 C 04 01-Jan-07 N N 9.81 88.29 1 98.1077081 C 04 01-Jan-07 N N 28.45 69.65 1 98.1077082 C 04 01-Jan-07 N N 24.53 73.57 1 98.1077083 C 04 01-Jan-07 N N 30.10 73.70 1 103.8077084 C 04 01-Jan-07 N N 48.83 238.43 1 287.2677261 09 Y N77262 09 Y N77263 09 Y I

Page 173: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

77280 09 Y N77285 09 Y N77290 09 Y N77295 09 Y N77299 09 Y N77300 09 Y N77301 09 Y N77305 09 Y N77310 09 Y N77315 09 Y N77321 09 Y N77326 09 Y N77327 09 Y N77328 09 Y N77331 09 Y N77332 09 Y N77333 09 Y N77334 09 Y N77336 09 Y N77338 09 01-Jan-10 Y N77370 09 Y N77371 04 01-Jan-07 N N 574.1377372 04 01-Jan-07 N N 435.9677373 04 01-Jan-07 N N 812.2777399 09 Y N 177401 B 04 N N 12.07 12.07 24.1577402 B 04 N N 12.07 12.07 24.1577403 B 04 N N 13.00 13.00 26.0077404 B 04 N N 13.85 13.85 27.7077406 B 04 N N 15.05 15.05 30.1077407 B 04 N N 19.47 19.47 38.9577408 B 04 N N 21.00 21.00 42.0077409 B 04 N N 22.90 22.90 45.8077411 B 04 N N 23.70 23.70 47.4077412 B 04 N N 21.00 21.00 42.0077413 B 04 N N 21.80 21.80 43.6077414 B 04 N N 22.90 22.90 45.8077416 B 04 N N 24.55 24.55 49.10

Page 174: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

77417 09 Y N77418 B 04 N N 123.25 123.25 246.5077421 C 04 N I 11.99 69.33 81.3277422 04 N I 35.7377423 04 N I 46.1477427 04 N N 70.8577431 04 N N 35.6577432 04 N I 254.6077435 04 01-Jan-07 N N 350.1977470 04 N N 240.1077499 04 Y N 377520 B 04 N N 35.42 35.42 70.8577522 04 Y N77523 B 04 N N 44.87 44.87 89.7577525 04 Y N77600 04 N N 21.3077605 04 N N 28.4577610 04 N N 58.8077615 B 04 N N 35.30 35.30 70.6077620 04 N N 74.1077750 04 N N 105.98 35.32 141.3077761 04 N I 3 143.53 112.77 256.3077762 04 N I 3 158.90 97.40 256.3077763 04 N I 3 169.15 87.15 256.3077776 04 N I 3 94.11 62.74 156.8577777 04 N I 3 124.50 58.60 183.1077778 04 N I 146.47 62.78 209.2577785 04 01-Jan-09 N 29.96 44.93 74.8977786 04 01-Jan-09 N 66.97 156.28 223.2577787 04 01-Jan-09 N 106.26 225.80 332.0677789 04 N N 55.12 41.58 96.7077790 04 N N 22.65 13.30 35.9577799 04 Y N78000 B 04 N N 10.75 10.75 21.5078001 B 04 N N 14.35 14.35 28.7078003 B 04 N N 15.05 15.05 30.1078006 B 04 N N 32.67 32.67 65.3578007 B 04 N N 32.67 32.67 65.35

Page 175: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

78010 B 04 N N 32.67 32.67 65.3578011 B 04 N N 35.30 35.30 70.6078015 B 04 N N 39.22 39.22 78.4578016 B 04 N N 49.05 49.05 98.1078018 04 N N 84.9078020 04 N N 78.4578070 B 04 N N 29.45 29.45 58.9078075 B 04 N N 32.67 32.67 65.3578099 04 Y N78102 B 04 N N 3 42.45 42.45 84.9078103 B 04 N N 58.80 58.80 117.6078104 B 04 N N 58.80 58.80 117.6078110 B 04 N N 10.47 10.47 20.9578111 B 04 N N 16.35 16.35 32.7078120 B 04 N N 16.35 16.35 32.7078121 B 04 N N 28.77 28.77 57.5578122 A 04 N N 28.77 28.77 57.5578130 B 04 N N 32.67 32.67 65.3578135 B 04 N N 39.22 39.22 78.4578140 B 04 N N 21.57 21.57 43.1578185 B 04 N N 49.05 49.05 98.1078190 04 Y N78191 04 N N 18.6578195 B 04 N N 49.05 49.05 98.1078199 04 Y N78201 B 04 N N 65.40 65.40 130.8078202 B 04 N N 65.40 65.40 130.8078205 B 04 N N 65.40 65.40 130.8078206 B 04 N N 65.40 65.40 130.8078215 B 04 N N 65.40 65.40 130.8078216 B 04 N N 65.40 65.40 130.8078220 B 04 N N 32.67 32.67 65.3578223 B 04 N N 35.30 35.30 70.6078230 B 04 N N 16.35 16.35 32.7078231 04 N N 28.7078232 04 N N 14.2578258 B 04 N N 35.30 35.30 70.6078261 04 N N 28.70

Page 176: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

78262 04 N N 28.7078264 04 N N 41.9078267 04 Y N78268 B 04 N N 30.58 30.58 61.1778270 B 04 N N 16.35 16.35 32.7078271 B 04 N N 16.35 16.35 32.7078272 B 04 N N 16.35 16.35 32.7078278 C 04 N N 9.64 32.26 41.9078282 B 04 N N 22.90 22.90 45.8078290 B 04 N N 49.05 49.05 98.1078291 B 04 N N 12.45 12.45 24.9078299 04 Y N78300 B 04 N N 39.22 39.22 78.4578305 B 04 N N 58.80 58.80 117.6078306 B 04 N N 58.80 58.80 117.6078315 B 04 N N 17.62 17.62 35.2578320 B 04 N N 33.67 33.67 67.3578350 B 04 N N 62.25 62.25 124.5078351 B 04 N N 74.75 74.75 149.5078399 04 Y N78414 04 N N 49.7078428 04 N N 49.7078445 B 04 N N 24.85 24.85 49.7078451 C 04 01-Jan-10 N N 38.67 82.16 120.8378452 C 04 01-Jan-10 N N 44.98 159.48 204.4678453 C 04 01-Jan-10 N N 28.28 76.45 104.7378454 C 04 01-Jan-10 N N 37.63 64.07 101.7078456 B 04 N N 70.85 70.85 141.7078457 C 04 01-Jan-10 N N 15.02 45.08 60.1078458 C 04 01-Jan-10 N N 21.22 63.68 84.9078459 B 04 N N 3 65.40 65.40 130.8078466 B 04 N N 3 24.85 24.85 49.7078468 B 04 N N 3 24.85 24.85 49.7078469 B 04 N N 3 65.40 65.40 130.8078472 B 04 N N 3 32.67 32.67 65.3578473 B 04 N N 37.20 37.20 74.4078481 B 04 N N 3 24.85 24.85 49.7078483 B 04 N N 31.07 31.07 62.15

Page 177: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

78491 B 04 N I 3 65.40 65.40 130.8078492 B 04 N I 3 65.40 65.40 130.8078494 B 04 N N 31.07 31.07 62.1578496 B 04 N N 31.07 31.07 62.1578499 04 Y N78580 B 04 N N 32.67 32.67 65.3578584 B 04 N N 35.30 35.30 70.6078585 B 04 N N 35.30 35.30 70.6078586 B 04 N N 32.67 32.67 65.3578587 B 04 N N 32.67 32.67 65.3578588 B 04 N N 32.67 32.67 65.3578591 B 04 N N 32.67 32.67 65.3578593 B 04 N N 32.67 32.67 65.3578594 B 04 N N 35.95 35.95 71.9078596 B 04 N N 35.95 35.95 71.9078599 A 04 Y N78600 B 04 N N 3 49.05 49.05 98.1078601 B 04 N N 3 65.40 65.40 130.8078605 B 04 N N 3 49.05 49.05 98.1078606 B 04 N N 3 65.40 65.40 130.8078607 B 04 N N 3 65.40 65.40 130.8078608 B 04 N N 65.40 65.40 130.8078609 B 04 N N 65.40 65.40 130.8078610 B 04 N N 3 65.40 65.40 130.8078630 B 04 N N 49.05 49.05 98.1078635 B 04 N N 49.05 49.05 98.1078645 B 04 N N 20.95 20.95 41.9078647 B 04 N N 24.85 24.85 49.7078650 B 04 N N 20.95 20.95 41.9078660 B 04 N N 16.35 16.35 32.7078699 04 Y N78700 B 04 N N 39.22 39.22 78.4578701 B 04 N N 39.22 39.22 78.4578707 B 04 N N 42.45 42.45 84.9078708 B 04 N N 47.20 47.20 94.4078709 B 04 N N 47.20 47.20 94.4078710 B 04 N N 3 39.22 39.22 78.4578725 B 04 N N 39.22 39.22 78.45

Page 178: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

78730 04 N N 28.7078740 B 04 N N 17.62 17.62 35.2578761 B 04 N N 24.85 24.85 49.7078799 04 Y N78800 B 04 N N 32.02 32.02 64.0578801 B 04 N N 35.95 35.95 71.9078802 B 04 N N 42.45 42.45 84.9078803 B 04 N N 32.02 32.02 64.0578804 C 04 N N 29.65 86.89 116.5478805 B 04 N N 32.02 32.02 64.0578806 B 04 N N 42.45 42.45 84.9078807 B 04 N N 32.02 32.02 64.0578808 09 01-Jan-09 Y78811 B 04 N N 3 65.40 65.40 130.8078812 B 04 N N 3 65.40 65.40 130.8078813 B 04 N N 3 65.40 65.40 130.8078814 B 04 N N 3 65.40 65.40 130.8078815 B 04 N N 3 65.40 65.40 130.8078816 B 04 N N 3 65.40 65.40 130.8078999 04 Y N79005 04 N N 52.5079101 04 N N 57.3079200 C 04 N N 61.51 56.11 117.6279300 B 04 N N 70.60 70.60 141.2079403 C 04 N N 65.05 82.93 147.9879440 B 04 N N 52.95 52.95 105.9079445 04 Y N79999 04 Y N80047 04 01-Jan-10 Y N80048 B 04 01-Jan-10 N N 4.14 4.14 8.2880051 A 04 01-Jan-10 N N 3.43 3.43 6.8680053 B 04 01-Jan-10 N N 5.18 5.18 10.3680055 B 04 01-Jan-10 N N 15.71 15.71 31.4280061 B 04 01-Jan-10 N N 3.11 3.11 6.2280069 B 04 01-Jan-10 N N 4.26 4.26 8.5280074 B 04 01-Jan-10 N N 19.24 19.24 38.4880076 B 04 01-Jan-10 N N 3.99 3.99 7.9880100 09 Y N

Page 179: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

80101 B 04 01-Oct-08 N N 6.71 6.71 13.4280102 09 Y N80103 A 09 Y N80150 A 04 01-Jan-10 N N 2.70 2.70 5.4080152 A 04 01-Jan-10 N N 5.25 5.25 10.5080154 A 04 01-Jan-10 N N 3.75 3.75 7.5080156 A 04 01-Jan-10 N N 4.43 4.43 8.8680157 A 04 01-Jan-10 N N 3.90 3.90 7.8080158 A 04 01-Jan-10 N N 6.32 6.32 12.6480160 A 04 01-Jan-10 N N 3.95 3.95 7.9080162 A 04 01-Jan-10 N N 6.49 6.49 12.9880164 A 04 01-Jan-10 N N 4.43 4.43 8.8680166 A 04 01-Jan-10 N N 6.71 6.71 13.4280168 A 04 01-Jan-10 N N 5.66 5.66 11.3280170 A 04 01-Jan-10 N N 2.94 2.94 5.8880172 A 04 01-Jan-10 N N 4.82 4.82 9.6480173 A 04 01-Jan-10 N N 5.70 5.70 11.4080174 A 04 01-Jan-10 N N 5.25 5.25 10.5080176 A 04 01-Jan-10 N N .86 .86 1.7280178 A 04 01-Jan-10 N N 3.23 3.23 6.4680182 A 04 01-Jan-10 N N 4.43 4.43 8.8680184 A 04 01-Jan-10 N N 4.43 4.43 8.8680185 A 04 01-Jan-10 N N 6.49 6.49 12.9880186 A 04 01-Jan-10 N N 6.75 6.75 13.5080188 A 04 01-Jan-10 N N 5.48 5.48 10.9680190 A 04 01-Jan-10 N N 4.61 4.61 9.2280192 A 04 01-Jan-10 N N 4.61 4.61 9.2280194 A 04 01-Jan-10 N N 5.25 5.25 10.5080195 04 01-Jan-10 N N 4.31 4.31 8.6280196 A 04 01-Jan-10 N N 2.70 2.70 5.4080197 A 04 01-Jan-10 N N 5.25 5.25 10.5080198 A 04 01-Jan-10 N N 4.61 4.61 9.2280200 A 04 01-Jan-10 N N 4.39 4.39 8.7880201 A 04 01-Jan-10 N N 5.66 5.66 11.3280202 A 04 01-Jan-10 N N 6.64 6.64 13.2880299 A 04 01-Jan-10 Y N80400 B 04 01-Jan-10 N N 13.48 13.48 26.9680402 B 04 01-Jan-10 N N 22.29 22.29 44.58

Page 180: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

80406 B 04 01-Jan-10 N N 22.73 22.73 45.4680408 B 04 01-Jan-10 N N 61.43 61.43 122.8680410 B 04 01-Jan-10 N N 12.60 12.60 25.2080412 B 04 01-Jan-10 N N 80.89 80.89 161.7880414 B 04 01-Jan-10 N N 25.28 25.28 50.5680415 B 04 01-Jan-10 N N 10.20 10.20 20.4080416 B 04 01-Jan-10 N N 64.61 64.61 129.2280417 B 04 01-Jan-10 N N 21.54 21.54 43.0880418 B 04 01-Jan-10 Y N80420 B 04 01-Jan-10 N N 29.51 29.51 59.0280422 B 04 01-Jan-10 N N 19.99 19.99 39.9880424 B 04 01-Jan-10 N N 15.15 15.15 30.3080426 B 04 01-Jan-10 N N 60.11 60.11 120.2280428 B 04 01-Jan-10 N N 17.64 17.64 35.2880430 B 04 01-Jan-10 N N 24.39 24.39 48.7880432 B 04 01-Jan-10 N N 47.72 47.72 95.4480434 B 04 01-Jan-10 N N 44.86 44.86 89.9280435 B 04 01-Jan-10 N N 33.30 33.30 66.6080436 B 04 01-Jan-10 N N 29.03 29.03 58.0680438 B 04 01-Jan-10 N N 24.68 24.68 49.3680439 B 04 01-Jan-10 N N 32.89 32.89 65.7880440 B 04 01-Jan-10 N N 20.23 20.23 40.4680500 04 N N 12.4080502 04 N N 49.8081000 A 04 01-Jan-10 N N 1.31 1.31 2.6281001 A 04 01-Jan-10 N N 1.43 1.43 2.8681002 04 N N 1.30 1.30 2.6081003 A 04 01-Jan-10 N N 1.09 1.09 2.1881005 A 04 01-Oct-08 N N .86 .86 1.7281007 A 04 01-Oct-08 N N 1.26 1.26 2.5281015 A 04 01-Oct-08 N N 1.31 1.31 2.6281020 A 04 01-Oct-08 N N 1.39 1.39 2.7881025 A 04 01-Oct-08 N N 1.29 1.29 2.5881050 A 04 01-Oct-08 N N 1.28 1.28 2.5681099 04 01-Oct-08 Y N82000 A 04 01-Oct-08 N N 3.96 3.96 7.9282003 A 04 01-Oct-08 N N 3.96 3.96 7.9282009 A 04 01-Oct-08 N N .86 .86 1.72

Page 181: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

82010 A 04 01-Oct-08 N N .86 .86 1.7282013 A 04 01-Oct-08 N N 2.70 2.70 5.4082016 A 04 01-Oct-08 N N 2.55 2.55 5.1082017 A 04 01-Oct-08 N N 5.82 5.82 11.6482024 A 04 01-Oct-08 N N 6.71 6.71 13.4282030 B 04 01-Oct-08 N N 4.43 4.43 8.8682040 A 04 01-Oct-08 N N 2.25 2.25 4.5082042 A 04 01-Oct-08 N N 2.25 2.25 4.5082043 A 04 01-Oct-08 N N 1.97 1.97 3.9482044 A 04 01-Oct-08 N N 1.97 1.97 3.9482045 A 04 01-Oct-08 N N 12.42 12.42 24.8482055 A 04 01-Oct-08 N N 4.31 4.31 8.6282075 A 04 01-Oct-08 N N 2.51 2.51 5.0282085 B 04 01-Oct-08 N N 3.15 3.15 6.3082088 A 04 01-Oct-08 N N 19.95 19.95 39.9082101 A 04 01-Oct-08 N N 8.85 8.85 17.7082103 B 04 01-Oct-08 N N 4.43 4.43 8.8682104 B 04 01-Oct-08 N N 3.58 3.58 7.1682105 B 04 01-Oct-08 N N 8.21 8.21 16.4282106 B 04 01-Oct-08 N N 3.11 3.11 6.2282107 B 04 01-Oct-08 N N 14.72 14.72 29.4482108 A 04 01-Oct-08 N N 2.51 2.51 5.0282120 A 04 01-Oct-08 N N 1.84 1.84 3.6882127 A 04 01-Oct-08 N N 2.55 2.55 5.1082128 A 04 01-Oct-08 N N 2.55 2.55 5.1082131 A 04 01-Oct-08 N N 5.81 5.81 11.6282135 B 04 01-Oct-08 N N 4.43 4.43 8.8682136 A 04 01-Oct-08 N N 5.81 5.81 11.6282139 A 04 01-Oct-08 N N 5.81 5.81 11.6282140 A 04 01-Oct-08 N N 3.58 3.58 7.1682143 A 04 01-Oct-08 N N 3.36 3.36 6.7282145 A 04 01-Oct-08 N N 5.25 5.25 10.5082150 A 04 01-Oct-08 N N 3.19 3.19 6.3882154 B 04 01-Oct-08 N N 8.40 8.40 16.8082157 B 04 01-Oct-08 N N 8.40 8.40 16.8082160 A 04 01-Oct-08 N N 2.70 2.70 5.4082163 B 04 01-Oct-08 N N 3.75 3.75 7.5082164 B 04 01-Oct-08 N N 3.58 3.58 7.16

Page 182: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

82172 A 04 01-Oct-08 N N 6.00 6.00 12.0082175 A 04 01-Oct-08 N N 4.43 4.43 8.8682180 B 04 01-Oct-08 N N 2.51 2.51 5.0282190 A 04 01-Oct-08 N N 7.31 7.31 14.6282205 A 04 01-Oct-08 N N 4.43 4.43 8.8682232 A 04 01-Oct-08 N N 3.96 3.96 7.9282239 B 04 01-Oct-08 N N 8.38 8.38 16.7682240 B 04 01-Oct-08 N N 6.38 6.38 12.7682247 A 04 01-Oct-08 N N 2.33 2.33 4.6682248 A 04 01-Oct-08 N N 2.33 2.33 4.6682252 A 04 01-Oct-08 N N 1.31 1.31 2.6282261 B 04 01-Oct-08 N N 8.25 8.25 16.5082270 A 04 01-Oct-08 N N 1.24 1.24 2.4882271 A 04 01-Oct-08 N N 1.02 1.02 2.0482272 A 04 01-Oct-08 N N 1.02 1.02 2.0482274 A 04 01-Oct-08 N N 5.00 5.00 10.0082286 A 04 01-Oct-08 N N 2.01 2.01 4.0282300 A 04 01-Oct-08 N N 3.34 3.34 6.6882306 B 04 01-Jan-10 N N 4.43 4.43 8.8682308 A 04 01-Oct-08 N N 3.15 3.15 6.3082310 A 04 01-Oct-08 N N 2.33 2.33 4.6682330 A 04 01-Oct-08 N N 6.68 6.68 13.3682331 A 04 01-Oct-08 N N 2.08 2.08 4.1682340 A 04 01-Oct-08 N N 2.70 2.70 5.4082355 A 04 01-Oct-08 N N 2.33 2.33 4.6682360 A 04 01-Oct-08 N N 4.54 4.54 9.0882365 A 04 01-Oct-08 N N 2.33 2.33 4.6682370 A 04 01-Oct-08 N N 2.33 2.33 4.6682373 A 04 01-Oct-08 N N 2.81 2.81 5.6282374 A 04 01-Oct-08 N N 2.40 2.40 4.8082375 A 04 01-Oct-08 N N 2.33 2.33 4.6682376 A 04 01-Oct-08 N N 2.33 2.33 4.6682378 B 04 01-Oct-08 N N 6.71 6.71 13.4282379 A 04 01-Oct-08 N N 5.81 5.81 11.6282380 A 04 01-Oct-08 N N 2.33 2.33 4.6682382 B 04 01-Oct-08 N N 7.58 7.58 15.1682383 B 04 01-Oct-08 N N 7.58 7.58 15.1682384 B 04 01-Oct-08 N N 7.58 7.58 15.16

Page 183: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

82387 B 04 01-Oct-08 N N 5.74 5.74 11.4882390 B 04 01-Oct-08 N N 4.43 4.43 8.8682397 A 04 01-Oct-08 N N 6.92 6.92 13.8482415 A 04 01-Oct-08 N N 4.43 4.43 8.8682435 A 04 01-Oct-08 N N 2.25 2.25 4.5082436 A 04 01-Oct-08 N N 2.33 2.33 4.6682438 A 04 01-Oct-08 N N 2.40 2.40 4.8082441 A 04 01-Oct-08 N N 2.14 2.14 4.2882465 A 04 01-Oct-08 N N 2.12 2.12 4.2482480 A 04 01-Oct-08 N N 3.58 3.58 7.1682482 A 04 01-Oct-08 N N 1.31 1.31 2.6282485 A 04 01-Oct-08 N N 5.04 5.04 10.0882486 B 04 01-Oct-08 N N 3.58 3.58 7.1582487 B 04 01-Oct-08 N N 4.22 4.22 8.4482488 B 04 01-Oct-08 N N 6.41 6.41 12.8282489 B 04 01-Oct-08 N N 1.69 1.69 3.3882491 B 04 01-Oct-08 N N 6.09 6.09 12.1882492 B 04 01-Oct-08 N N 6.09 6.09 12.1882495 A 04 01-Oct-08 N N 6.71 6.71 13.4282507 A 04 01-Oct-08 N N 2.70 2.70 5.4082520 A 04 01-Oct-08 N N 3.58 3.58 7.1682523 09 Y N82525 A 04 01-Oct-08 N N 5.55 5.55 11.1082528 B 04 01-Oct-08 N N 8.85 8.85 17.7082530 A 04 01-Oct-08 N N 6.71 6.71 13.4282533 A 04 01-Oct-08 N N 6.71 6.71 13.4282540 A 04 01-Oct-08 N N 2.25 2.25 4.5082541 B 04 01-Oct-08 N N 3.58 3.58 7.1682542 B 04 01-Oct-08 N N 6.09 6.09 12.1882543 B 04 01-Oct-08 N N 6.09 6.09 12.1882544 B 04 01-Oct-08 N N 6.09 6.09 12.1882550 A 04 01-Oct-08 N N 3.04 3.04 6.0882552 A 04 01-Oct-08 N N 3.15 3.15 6.3082553 A 04 01-Oct-08 N N 3.71 3.71 7.4282554 A 04 01-Oct-08 N N 3.08 3.08 6.1682565 A 04 01-Oct-08 N N 2.33 2.33 4.6682570 A 04 01-Oct-08 N N 2.33 2.33 4.6682575 B 04 01-Oct-08 N N 4.61 4.61 9.22

Page 184: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

82585 B 04 01-Oct-08 N N 4.20 4.20 8.4082595 B 04 01-Oct-08 N N 2.33 2.33 4.6682600 A 04 01-Oct-08 N N 3.34 3.34 6.6882607 B 04 01-Oct-08 N N 6.00 6.00 12.0082608 B 04 01-Oct-08 N N 6.01 6.01 12.0282610 04 01-Oct-08 N N 4.28 4.28 8.5682615 A 04 01-Oct-08 N N 3.15 3.15 6.3082626 B 04 01-Oct-08 N N 4.43 4.43 8.8682627 B 04 01-Oct-08 N N 3.48 3.48 7.9682633 B 04 01-Oct-08 N N 5.04 5.04 10.0882634 A 04 01-Oct-08 N N 7.76 7.76 15.5282638 A 04 01-Oct-08 N N 3.58 3.58 7.1682646 A 04 01-Oct-08 N N 1.76 1.76 3.5282649 A 04 01-Oct-08 N N 4.43 4.43 8.8682651 B 04 01-Oct-08 N N 10.09 10.09 20.1882652 B 04 01-Jan-10 N N 8.03 8.03 16.0682654 B 04 01-Oct-08 N N 1.69 1.69 3.3882656 A 04 01-Oct-08 N N 3.63 3.63 7.2682657 A 04 01-Oct-08 N N 6.09 6.09 12.1882658 A 04 01-Oct-08 N N 6.09 6.09 12.1882664 B 04 01-Oct-08 N N 13.53 13.53 27.0682666 B 04 01-Oct-08 N N 4.43 4.43 8.8682668 B 04 01-Oct-08 N N 5.21 5.21 10.4282670 A 04 01-Oct-08 N N 5.06 5.06 10.1282671 B 04 01-Oct-08 N N 8.85 8.85 17.7082672 B 04 01-Oct-08 N N 8.85 8.85 17.7082677 B 04 01-Oct-08 N N 5.06 5.06 10.1282679 B 04 01-Oct-08 N N 5.06 5.06 10.1282690 A 04 01-Oct-08 N N 4.22 4.22 8.4482693 A 04 01-Oct-08 N N 7.31 7.31 14.6282696 B 04 01-Oct-08 N N 5.04 5.04 10.0882705 A 04 01-Oct-08 N N 1.28 1.28 2.5682710 A 04 01-Oct-08 N N 1.54 1.54 3.0882715 A 04 01-Oct-08 N N 1.61 1.61 3.2282725 A 04 01-Oct-08 N N 1.31 1.31 2.6282726 B 04 01-Oct-08 N N 6.09 6.09 12.1882728 A 04 01-Oct-08 N N 3.58 3.58 7.1682731 B 04 01-Oct-08 N N 18.39 18.39 36.78

Page 185: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

82735 A 04 01-Oct-08 N N 3.58 3.58 7.1682742 A 04 01-Oct-08 N N 3.58 3.58 7.1682746 B 04 01-Oct-08 N N 5.73 5.73 11.4682747 B 04 01-Oct-08 N N 6.64 6.64 13.2882757 A 04 01-Oct-08 N N 3.98 3.98 7.9682759 A 04 01-Oct-08 N N 2.33 2.33 4.6682760 A 04 01-Oct-08 N N 2.33 2.33 4.6682775 A 04 01-Oct-08 N N 6.71 6.71 13.4282776 A 04 01-Oct-08 N N 2.51 2.51 5.0282784 A 04 01-Jan-10 N N 4.54 4.54 9.0882785 A 04 01-Oct-08 N N 3.58 3.58 7.1682787 A 04 01-Oct-08 N N 3.94 3.94 7.8882800 A 04 01-Oct-08 N N 2.33 2.33 4.6682803 A 04 01-Oct-08 N N 5.44 5.44 10.8882805 A 04 01-Oct-08 N N 5.44 5.44 10.8882810 A 04 01-Oct-08 N N 2.85 2.85 5.7082820 A 04 01-Oct-08 N N 4.89 4.89 9.7882926 A 04 01-Oct-08 N N 2.66 2.66 5.3282928 A 04 01-Oct-08 N N 1.76 1.76 3.5282938 04 01-Oct-08 N N 8.40 8.40 16.8082941 B 04 01-Oct-08 N N 3.96 3.96 7.9282943 A 04 01-Oct-08 N N 3.51 3.51 7.0282945 A 04 01-Oct-08 N N 1.54 1.54 3.0882946 B 04 01-Oct-08 N N 5.25 5.25 10.5082947 A 04 01-Oct-08 N N 1.91 1.91 3.8282948 A 04 01-Oct-08 N N .86 .86 1.7282950 A 04 01-Oct-08 N N 2.33 2.33 4.6682951 B 04 01-Oct-08 N N 6.30 6.30 12.6082952 A 04 01-Oct-08 N N 1.91 1.91 3.8282953 A 04 01-Oct-08 N N 2.33 2.33 4.6682955 A 04 01-Oct-08 N N 4.31 4.31 8.6282960 A 04 01-Oct-08 N N 2.96 2.96 5.9282962 A 04 01-Oct-08 N N .84 .84 1.6882963 B 04 01-Oct-08 N N 6.32 6.32 12.6482965 A 04 01-Oct-08 N N 3.58 3.58 7.1682975 B 04 01-Oct-08 N N 2.70 2.70 5.4082977 A 04 01-Oct-08 N N 2.70 2.70 5.4082978 A 04 01-Oct-08 N N 4.80 4.80 9.60

Page 186: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

82979 A 04 01-Oct-08 N N 1.76 1.76 3.5282980 A 04 01-Oct-08 N N 3.08 3.08 6.1682985 B 04 01-Oct-08 N N 6.71 6.71 13.4283001 A 04 01-Oct-08 N N 9.09 9.09 18.1883002 A 04 01-Oct-08 N N 4.43 4.43 8.8683003 A 04 01-Oct-08 N N 4.43 4.43 8.8683008 A 04 01-Oct-08 N N 5.63 5.63 11.2683009 A 04 01-Oct-08 N N 21.18 21.18 42.3683010 A 04 01-Oct-08 N N 4.43 4.43 8.8683012 A 04 01-Oct-08 N N 3.34 3.34 6.6883013 B 04 01-Oct-08 N N 4.31 4.31 8.6283014 B 04 01-Oct-08 N N 3.83 3.83 7.6683015 B 04 01-Oct-08 N N 9.23 9.23 18.4683018 A 04 01-Oct-08 N N 2.33 2.33 4.6683020 B 04 01-Oct-08 N N 4.31 4.31 8.6283021 B 04 01-Oct-08 N N 6.09 6.09 12.1883026 A 04 01-Oct-08 N N 1.14 1.14 2.2883030 A 04 01-Oct-08 N N 1.61 1.61 3.2283033 A 04 01-Oct-08 N N 2.93 2.93 5.8683036 B 04 01-Oct-08 N N 3.15 3.15 6.3083037 04 01-Oct-08 N N .74 .74 1.4883045 A 04 01-Oct-08 N N 2.33 2.33 4.6683050 A 04 01-Oct-08 N N 1.50 1.50 3.0083051 A 04 01-Oct-08 N N 1.61 1.61 3.2283055 A 04 01-Oct-08 N N 1.61 1.61 3.2283060 A 04 01-Oct-08 N N 1.61 1.61 3.2283065 A 04 01-Oct-08 N N 1.61 1.61 3.2283068 A 04 01-Oct-08 N N 1.61 1.61 3.2283069 A 04 01-Oct-08 N N .77 .77 1.5483070 A 04 01-Oct-08 N N 1.31 1.31 2.6283071 A 04 01-Oct-08 N N 1.61 1.61 3.2283080 B 04 01-Oct-08 N N 5.81 5.81 11.6283088 B 04 01-Oct-08 N N 8.85 8.85 17.7083090 B 04 01-Oct-08 N N 6.60 6.60 13.2083150 B 04 01-Oct-08 N N 5.48 5.48 10.9683491 B 04 01-Oct-08 N N 3.58 3.58 7.1683497 B 04 01-Oct-08 N N 6.32 6.32 12.6483498 B 04 01-Oct-08 N N 4.43 4.43 8.86

Page 187: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

83499 B 04 01-Oct-08 N N 8.03 8.03 16.0683500 B 04 01-Oct-08 N N 7.14 7.14 14.2883505 B 04 01-Oct-08 N N 8.85 8.85 17.7083516 A 04 01-Oct-08 N N 4.39 4.39 8.7883518 A 04 01-Oct-08 N N 4.14 4.14 8.2883519 A 04 01-Oct-08 N N 6.60 6.60 13.2083520 A 04 01-Oct-08 N N 6.34 6.34 12.6883525 A 04 01-Oct-08 N N 4.43 4.43 8.8683527 A 04 01-Oct-08 N N 4.43 4.43 8.8683528 A 04 01-Oct-08 N N 3.98 3.98 7.9683540 A 04 01-Oct-08 N N 3.19 3.19 6.3883550 A 04 01-Oct-08 N N 4.28 4.28 8.5683570 A 04 01-Oct-08 N N 3.58 3.58 7.1683582 B 04 01-Oct-08 N N 6.09 6.09 12.1883586 B 04 01-Oct-08 N N 3.28 3.28 6.5683593 B 04 01-Oct-08 N N 7.76 7.76 15.5283605 A 04 01-Oct-08 N N 4.43 4.43 8.8683615 A 04 01-Oct-08 N N 2.96 2.96 5.9283625 B 04 01-Oct-08 N N 5.21 5.21 10.4283630 04 01-Oct-08 N N 3.61 3.61 7.2283631 B 04 01-Oct-08 N N 6.17 6.17 12.3483632 B 04 01-Oct-08 N N 4.43 4.43 8.8683633 A 04 01-Oct-08 N N 2.70 2.70 5.4083634 A 04 01-Oct-08 N N 2.96 2.96 5.9283655 B 04 01-Oct-08 N N 5.93 5.93 11.8683661 B 04 01-Oct-08 N N 6.71 6.71 13.4283662 B 04 01-Oct-08 N N 6.21 6.21 12.4283663 B 04 01-Oct-08 N N 3.68 3.68 7.3683664 B 04 01-Oct-08 N N 1.86 1.86 3.7283670 B 04 01-Oct-08 N N 3.15 3.15 6.3083690 A 04 01-Oct-08 N N 3.36 3.36 6.7283695 B 04 01-Oct-08 N N 4.07 4.07 8.1483698 04 01-Oct-08 N N 8.92 8.92 17.8483700 04 01-Oct-08 N N 3.54 3.54 7.0883701 04 01-Oct-08 N N 7.80 7.80 15.6083704 04 01-Oct-08 N N 9.92 9.92 19.8483718 B 04 01-Oct-08 N N 4.01 4.01 8.0283719 B 04 01-Oct-08 N N 5.70 5.70 11.40

Page 188: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

83721 B 04 01-Oct-08 N N 4.67 4.67 9.3483727 A 04 01-Oct-08 N N 4.43 4.43 8.8683735 A 04 01-Oct-08 N N 3.28 3.28 6.5683775 A 04 01-Oct-08 N N 2.78 2.78 5.5683785 A 04 01-Oct-08 N N .64 .64 1.2883788 A 04 01-Oct-08 N N 3.58 3.58 7.1683789 A 04 01-Oct-08 N N 3.58 3.58 7.1683805 A 04 01-Oct-08 N N 3.53 3.53 7.0683825 A 04 01-Oct-08 N N 3.96 3.96 7.9283835 B 04 01-Oct-08 N N 6.71 6.71 13.4283840 A 04 01-Oct-08 N N 4.43 4.43 8.8683857 A 04 01-Oct-08 N N 1.31 1.31 2.6283858 A 04 01-Oct-08 N N 3.96 3.96 7.9283864 B 04 01-Oct-08 N N 5.25 5.25 10.5083866 B 04 01-Oct-08 N N 4.46 4.46 8.9283872 A 04 01-Oct-08 N N 1.31 1.31 2.6283873 B 04 01-Oct-08 N N 4.82 4.82 9.6483874 B 04 01-Oct-08 N N 6.32 6.32 12.6483876 B 04 01-Jan-09 N N 5.68 5.68 11.3683880 B 04 01-Oct-08 N N 7.43 7.43 14.8683883 A 04 01-Oct-08 N N 5.22 5.22 10.4483885 A 04 01-Oct-08 N N 3.96 3.96 7.9283887 A 04 01-Oct-08 N N 3.34 3.34 6.6883890 B 04 N N 2.62 2.62 5.2583891 B 04 N N 2.62 2.62 5.2583892 B 04 N N 2.52 2.52 5.0583893 B 04 N N 2.62 2.62 5.2583894 B 04 N N 2.52 2.52 5.0583896 B 04 N N 2.62 2.62 5.2583897 B 04 N N 2.62 2.62 5.2583898 B 04 N N 10.95 10.95 21.9083900 B 04 N N 14.05 14.05 28.1083901 B 04 N N 10.95 10.95 21.9083902 B 04 N N 9.25 9.25 18.5083903 B 04 N N 10.95 10.95 21.9083904 B 04 N N 10.95 10.95 21.9083905 B 04 N N 10.95 10.95 21.9083906 B 04 N N 10.95 10.95 21.90

Page 189: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

83907 B 04 N N 5.59 5.59 11.1983908 B 04 N N 7.02 7.02 14.0583909 B 04 N N 7.02 7.02 14.0583912 B 04 N N 2.62 2.62 5.2583913 B 04 01-Jan-07 N N 5.60 5.60 11.2083914 B 04 N N 7.02 7.02 14.0583915 B 04 01-Oct-08 N N 2.70 2.70 5.4083916 B 04 01-Oct-08 N N 3.34 3.34 6.6883918 B 04 01-Oct-08 N N 8.06 8.06 16.1283919 B 04 01-Oct-08 N N 8.06 8.06 16.1283921 B 04 01-Oct-08 N N 6.45 6.45 12.9083925 A 04 01-Oct-08 N N 8.48 8.48 16.9683930 A 04 01-Oct-08 N N 2.33 2.33 4.6683935 A 04 01-Oct-08 N N 2.33 2.33 4.6683937 04 01-Oct-08 N N 6.71 6.71 13.4283945 A 04 01-Oct-08 N N 1.54 1.54 3.0883950 B 04 01-Oct-08 N N 22.41 22.41 44.8283951 B 04 01-Jan-09 N N 20.50 20.50 41.0083970 B 04 01-Oct-08 N N 15.56 15.56 31.1283986 A 04 01-Oct-08 N N 1.76 1.76 3.5283992 A 04 01-Oct-08 N N 2.33 2.33 4.6683993 04 01-Oct-08 N N 6.17 6.17 12.3484022 A 04 01-Oct-08 N N 2.70 2.70 5.4084030 A 04 01-Oct-08 N N 2.63 2.63 5.2684035 A 04 01-Oct-08 N N .86 .86 1.7284060 A 04 01-Oct-08 N N 3.58 3.58 7.1684061 A 04 01-Oct-08 N N 3.15 3.15 6.3084066 A 04 01-Oct-08 N N 1.54 1.54 3.0884075 A 04 01-Oct-08 N N 2.51 2.51 5.0284078 A 04 01-Oct-08 N N 3.58 3.58 7.1684080 A 04 01-Oct-08 N N 4.43 4.43 8.8684081 A 04 01-Oct-08 N N 1.26 1.26 2.5284085 A 04 01-Oct-08 N N 1.76 1.76 3.5284087 A 04 01-Oct-08 N N 2.78 2.78 5.5684100 A 04 01-Oct-08 N N 2.33 2.33 4.6684105 A 04 01-Oct-08 N N 1.13 1.13 2.2684106 A 04 01-Oct-08 N N 2.10 2.10 4.2084110 A 04 01-Oct-08 N N 2.33 2.33 4.66

Page 190: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

84119 B 04 01-Oct-08 N N 4.22 4.22 8.4484120 B 04 01-Oct-08 N N 6.71 6.71 13.4284126 B 04 01-Oct-08 N N 10.95 10.95 21.9084127 B 04 01-Oct-08 N N 5.48 5.48 10.9684132 A 04 01-Oct-08 N N 2.25 2.25 4.5084133 A 04 01-Oct-08 N N 2.10 2.10 4.2084134 A 04 01-Oct-08 N N 2.79 2.79 5.5884135 B 04 01-Oct-08 N N 3.96 3.96 7.9284138 B 04 01-Oct-08 N N 4.43 4.43 8.8684140 04 01-Oct-08 N N 4.43 4.43 8.8684143 04 01-Oct-08 N N 4.61 4.61 9.2284144 A 04 01-Oct-08 N N 4.61 4.61 9.2284146 A 04 01-Oct-08 N N 6.71 6.71 13.4284150 A 04 01-Oct-08 N N 1.76 1.76 3.5284152 B 04 01-Oct-08 N N 7.20 7.20 14.4084153 B 04 01-Oct-08 N N 6.60 6.60 13.2084154 B 04 01-Oct-08 N N 6.60 6.60 13.2084155 A 04 01-Oct-08 N N 1.80 1.80 3.6084156 B 04 01-Oct-08 N N 1.15 1.15 2.3084157 B 04 01-Oct-08 N N 1.15 1.15 2.3084160 A 04 01-Oct-08 N N 1.31 1.31 2.6284163 04 01-Oct-08 N N 4.79 4.79 9.5884165 B 04 01-Oct-08 N N 5.25 5.25 10.5084166 04 01-Oct-08 N N 5.61 5.61 11.2284181 B 04 01-Oct-08 N N 8.33 8.33 16.6684182 B 04 01-Oct-08 N N 8.80 8.80 17.6084202 A 04 01-Oct-08 N N 1.76 1.76 3.5284203 A 04 01-Oct-08 N N 1.31 1.31 2.6284206 B 04 01-Oct-08 N N 3.58 3.58 7.1684207 B 04 01-Oct-08 N N 6.00 6.00 12.0084210 A 04 01-Oct-08 N N 3.58 3.58 7.1684220 A 04 01-Oct-08 N N 2.33 2.33 4.6684228 A 04 01-Oct-08 N N 5.25 5.25 10.5084233 B 04 01-Oct-08 N N 16.50 16.50 33.0084234 B 04 01-Oct-08 N N 2.70 2.70 5.4084235 A 04 01-Oct-08 N N 2.70 2.70 5.4084238 B 04 01-Oct-08 N N 10.01 10.01 20.0284244 A 04 01-Oct-08 N N 10.76 10.76 21.52

Page 191: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

84252 B 04 01-Oct-08 N N 1.31 1.31 2.6284255 A 04 01-Oct-08 N N 2.40 2.40 4.8084260 A 04 01-Oct-08 N N 2.51 2.51 5.0284270 B 04 01-Oct-08 N N 8.19 8.19 16.3884275 A 04 01-Oct-08 N N 1.76 1.76 3.5284285 A 04 01-Oct-08 N N 1.80 1.80 3.6084295 A 04 01-Oct-08 N N 2.33 2.33 4.6684300 A 04 01-Oct-08 N N 2.12 2.12 4.2484302 B 04 01-Oct-08 N N 1.28 1.28 2.5684305 B 04 01-Oct-08 N N 7.54 7.54 15.0884307 B 04 01-Oct-08 N N 7.54 7.54 15.0884311 A 04 01-Oct-08 N N 3.44 3.44 6.8884315 A 04 01-Oct-08 N N 1.22 1.22 2.4484375 A 04 01-Oct-08 N N 2.33 2.33 4.6684376 A 04 01-Oct-08 N N 2.70 2.70 5.4084377 A 04 01-Oct-08 N N 2.70 2.70 5.4084378 A 04 01-Oct-08 N N 2.96 2.96 5.9284379 A 04 01-Oct-08 N N 2.96 2.96 5.9284392 A 04 01-Oct-08 N N 2.33 2.33 4.6684402 A 04 01-Oct-08 N N 9.17 9.17 18.3484403 A 04 01-Oct-08 N N 12.64 12.64 25.2884425 B 04 01-Oct-08 N N 6.41 6.41 12.8284430 B 04 01-Oct-08 N N 3.58 3.58 7.1684432 B 04 01-Oct-08 N N 7.86 7.86 15.7284436 B 04 01-Oct-08 N N 3.36 3.36 6.7284437 B 04 01-Oct-08 N N 3.19 3.19 6.3884439 B 04 01-Oct-08 N N 4.43 4.43 8.8684442 B 04 01-Oct-08 N N 4.43 4.43 8.8684443 B 04 01-Oct-08 N N 8.21 8.21 16.4284445 B 04 01-Oct-08 N N 13.48 13.48 26.9684446 B 04 01-Oct-08 N N 4.43 4.43 8.8684449 04 01-Oct-08 N N 6.71 6.71 13.4284450 A 04 01-Oct-08 N N 2.51 2.51 5.0284460 A 04 01-Oct-08 N N 2.59 2.59 5.1884466 A 04 01-Oct-08 N N 4.39 4.39 8.7884478 B 04 01-Oct-08 N N 2.70 2.70 5.4084479 B 04 01-Oct-08 N N 3.19 3.19 6.3884480 B 04 01-Oct-08 N N 4.78 4.78 9.56

Page 192: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

84481 B 04 01-Oct-08 N N 5.06 5.06 10.1284482 B 04 01-Oct-08 N N 3.41 3.41 6.8284484 A 04 01-Oct-08 N N 3.71 3.71 7.4284485 A 04 01-Oct-08 N N 2.70 2.70 5.4084488 B 04 01-Oct-08 N N 2.70 2.70 5.4084490 B 04 01-Oct-08 N N 2.70 2.70 5.4084510 B 04 01-Oct-08 N N 5.10 5.10 10.2084512 A 04 01-Oct-08 N N 3.71 3.71 7.4284520 A 04 01-Oct-08 N N 1.93 1.93 3.8684525 A 04 01-Oct-08 N N .86 .86 1.7284540 A 04 01-Oct-08 N N 1.76 1.76 3.5284545 A 04 01-Oct-08 N N 2.01 2.01 4.0284550 A 04 01-Oct-08 N N 2.21 2.21 4.4284560 A 04 01-Oct-08 N N 1.31 1.31 2.6284577 A 04 01-Oct-08 N N 2.70 2.70 5.4084578 A 04 01-Oct-08 N N .86 .86 1.7284580 A 04 01-Oct-08 N N 2.01 2.01 4.0284583 A 04 01-Oct-08 N N 1.31 1.31 2.6284585 B 04 01-Oct-08 N N 7.58 7.58 15.1684586 B 04 01-Oct-08 N N 3.49 3.49 6.9884588 B 04 01-Oct-08 N N 2.33 2.33 4.6684590 B 04 01-Oct-08 N N 2.33 2.33 4.6684591 B 04 01-Oct-08 N N 4.54 4.54 9.0884597 B 04 01-Oct-08 N N 2.51 2.51 5.0284600 A 04 01-Oct-08 N N 1.76 1.76 3.5284620 A 04 01-Oct-08 N N 3.75 3.75 7.5084630 B 04 01-Oct-08 N N 5.04 5.04 10.0884681 B 04 01-Oct-08 N N 6.41 6.41 12.8284702 B 04 01-Oct-08 N N 4.43 4.43 8.8684703 B 04 01-Oct-08 N N 3.58 3.58 7.1684704 04 01-Oct-08 N N 4.73 4.73 9.4684999 04 01-Oct-08 Y N85002 A 04 01-Oct-08 N N .86 .86 1.7285004 A 04 01-Oct-08 N N 1.70 1.70 3.4085007 A 04 N N 1.75 1.75 3.5085008 A 04 01-Oct-08 N N 1.69 1.69 3.3885009 A 04 N N 1.75 1.75 3.5085013 A 04 01-Oct-08 N N 1.16 1.16 2.32

Page 193: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

85014 A 04 01-Oct-08 N N 1.16 1.16 2.3285018 A 04 01-Oct-08 N N 1.16 1.16 2.3285025 A 04 01-Oct-08 N N 2.87 2.87 5.7485027 A 04 01-Oct-08 N N 2.87 2.87 5.7485032 A 04 N N 1.50 1.50 3.0085041 A 04 01-Oct-08 N N .86 .86 1.7285044 04 N N 1.75 1.75 3.5085045 A 04 01-Oct-08 N N 1.31 1.31 2.6285046 A 04 01-Oct-08 N N 2.74 2.74 5.4885048 A 04 01-Oct-08 N N .86 .86 1.7285049 A 04 01-Oct-08 N N 1.17 1.17 2.3485055 A 04 01-Oct-08 N N 4.25 4.25 8.5085060 04 N N 4.5085097 04 N N 22.4085130 B 04 01-Oct-08 N N 5.82 5.82 11.6485170 A 04 01-Oct-08 N N 2.23 2.23 4.4685175 A 04 01-Oct-08 N N 2.23 2.23 4.4685210 B 04 01-Oct-08 N N 4.43 4.43 8.8685220 B 04 01-Oct-08 N N 4.43 4.43 8.8685230 B 04 01-Oct-08 N N 4.43 4.43 8.8685240 B 04 01-Oct-08 N N 4.43 4.43 8.8685244 B 04 01-Oct-08 N N 3.58 3.58 7.1685245 B 04 01-Oct-08 N N 3.60 3.60 7.2085246 B 04 01-Oct-08 N N 3.60 3.60 7.2085247 B 04 01-Oct-08 N N 6.94 6.94 13.8885250 B 04 01-Oct-08 N N 4.43 4.43 8.8685260 B 04 01-Oct-08 N N 4.43 4.43 8.8685270 B 04 01-Oct-08 N N 4.43 4.43 8.8685280 B 04 01-Oct-08 N N 4.43 4.43 8.8685290 B 04 01-Oct-08 N N 4.43 4.43 8.8685291 B 04 01-Oct-08 N N 4.35 4.35 8.7085292 B 04 01-Oct-08 N N 5.63 5.63 11.2685293 B 04 01-Oct-08 N N 5.63 5.63 11.2685300 B 04 01-Oct-08 N N 4.43 4.43 8.8685301 B 04 01-Oct-08 N N 5.29 5.29 10.5885302 B 04 01-Oct-08 N N 5.89 5.89 11.7885303 B 04 01-Oct-08 N N 5.85 5.85 11.7085305 B 04 01-Oct-08 N N 5.66 5.66 11.32

Page 194: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

85306 B 04 01-Oct-08 N N 5.85 5.85 11.7085307 B 04 01-Oct-08 N N 6.00 6.00 12.0085335 A 04 01-Oct-08 N N 5.29 5.29 10.5885337 A 04 01-Oct-08 N N 5.10 5.10 10.2085345 A 04 01-Oct-08 N N 1.50 1.50 3.0085347 A 04 01-Oct-08 N N 1.31 1.31 2.6285348 A 04 01-Oct-08 N N 1.84 1.84 3.6885360 A 04 01-Oct-08 N N 2.96 2.96 5.9285362 A 04 01-Oct-08 N N 1.31 1.31 2.6285366 A 04 01-Oct-08 N N 2.74 2.74 5.4885370 A 04 01-Oct-08 N N 2.74 2.74 5.4885378 B 04 01-Oct-08 N N 3.49 3.49 6.9885379 B 04 01-Oct-08 N N 3.75 3.75 7.5085380 B 04 01-Oct-08 N N 2.67 2.67 5.3485384 A 04 01-Oct-08 N N 2.63 2.63 5.2685385 A 04 01-Oct-08 N N 2.63 2.63 5.2685390 A 04 N N 1.62 1.62 3.2585396 A 04 N N 5.84 5.84 11.6985397 B 04 01-Jan-09 N N 6.21 6.21 12.4285400 A 04 01-Oct-08 N N 2.33 2.33 4.6685410 A 04 01-Oct-08 N N 2.33 2.33 4.6685415 A 04 01-Oct-08 N N 4.31 4.31 8.6285420 A 04 01-Oct-08 N N 2.33 2.33 4.6685421 A 04 01-Oct-08 N N 3.23 3.23 6.4685441 A 04 01-Oct-08 N N 2.04 2.04 4.0885445 A 04 01-Oct-08 N N .86 .86 1.7285460 A 04 01-Oct-08 N N 1.61 1.61 3.2285461 A 04 01-Oct-08 N N 1.58 1.58 3.1685475 A 04 01-Oct-08 N N 4.35 4.35 8.7085520 B 04 01-Oct-08 N N 3.15 3.15 6.3085525 B 04 01-Oct-08 N N 5.38 5.38 10.7685530 B 04 01-Oct-08 N N 3.15 3.15 6.3085536 A 04 01-Oct-08 N N 2.53 2.53 5.0685540 A 04 01-Oct-08 N N 1.76 1.76 3.5285547 A 04 01-Oct-08 N N 1.14 1.14 2.2885549 A 04 01-Oct-08 N N 3.58 3.58 7.1685555 A 04 01-Oct-08 N N 2.33 2.33 4.6685557 A 04 01-Oct-08 N N 2.33 2.33 4.66

Page 195: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

85576 A 04 01-Oct-08 N N 2.55 2.55 5.1085597 A 04 01-Oct-08 N N 2.74 2.74 5.4885610 A 04 01-Oct-08 N N 1.91 1.91 3.8285611 A 04 01-Oct-08 N N 1.93 1.93 3.8685612 B 04 01-Oct-08 N N 2.78 2.78 5.5685613 B 04 01-Oct-08 N N 3.51 3.51 7.0285635 B 04 01-Oct-08 N N 1.31 1.31 2.6285651 A 04 N N 2.30 2.30 4.6085652 A 04 01-Oct-08 N N 1.31 1.31 2.6285660 A 04 01-Oct-08 N N 2.33 2.33 4.6685670 A 04 01-Oct-08 N N 2.33 2.33 4.6685675 A 04 01-Oct-08 N N 3.19 3.19 6.3885705 A 04 01-Oct-08 N N 4.35 4.35 8.7085730 A 04 01-Oct-08 N N 2.94 2.94 5.8885732 A 04 01-Oct-08 N N 3.19 3.19 6.3885810 A 04 01-Oct-08 N N 2.70 2.70 5.4085999 A 04 01-Oct-08 Y N86000 A 04 N N 3.70 3.70 7.4086001 A 04 N N 2.72 2.72 5.4586003 A 04 N N 0.57 0.57 1.1586005 A 04 N N 5.20 5.20 10.4086021 A 04 N N 3.10 3.10 6.2086022 A 04 N N 9.52 9.52 19.0586023 B 04 N N 4.70 4.70 9.4086038 B 04 N N 7.90 7.90 15.8086039 B 04 N N 5.35 5.35 10.7086060 B 04 N N 4.30 4.30 8.6086063 B 04 N N 3.77 3.77 7.5586077 04 N N 39.3086078 04 N N 16.8586079 04 N N 20.3586140 B 04 N N 2.35 2.35 4.7086141 B 04 N N 8.45 8.45 16.9086146 B 04 N N 13.30 13.30 26.6086147 B 04 N N 6.35 6.35 12.7086148 B 04 N N 6.35 6.35 12.7086155 A 04 N N 4.30 4.30 8.6086156 B 04 N N 2.62 2.62 5.25

Page 196: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

86157 B 04 N N 3.30 3.30 6.6086160 A 04 N N 4.62 4.62 9.2586161 A 04 N N 5.15 5.15 10.3086162 B 04 N N 8.95 8.95 17.9086171 09 Y N86185 04 N N 4.20 4.20 8.4086200 04 N N 5.42 5.42 10.8586215 B 04 N N 5.90 5.90 11.8086225 B 04 N N 5.90 5.90 11.8086226 B 04 N N 6.67 6.67 13.3586235 A 04 N N 5.90 5.90 11.8086243 A 04 N N 5.90 5.90 11.8086255 A 04 N N 3.60 3.60 7.2086256 A 04 N N 5.90 5.90 11.8086277 A 04 N N 10.27 10.27 20.5586280 A 04 N N 4.10 4.10 8.2086294 A 04 Y N86300 B 04 N N 10.85 10.85 21.7086301 B 04 N N 10.85 10.85 21.7086304 B 04 N N 10.85 10.85 21.7086308 B 04 N N 2.40 2.40 4.8086309 B 04 N N 4.25 4.25 8.5086310 B 04 N N 4.82 4.82 9.6586316 A 04 N N 5.05 5.05 10.1086317 09 Y86318 A 04 N N 8.45 8.45 16.9086320 B 04 N N 10.65 10.65 21.3086325 B 04 N N 5.90 5.90 11.8086327 B 04 N N 7.00 7.00 14.0086329 A 04 N N 9.15 9.15 18.3086331 A 04 N N 5.90 5.90 11.8086332 B 04 N N 9.40 9.40 18.8086334 B 04 N N 13.95 13.95 27.9086335 A 04 N N 12.30 12.30 24.6086336 B 04 N N 10.87 10.87 21.7586337 B 04 N N 5.90 5.90 11.8086340 A 04 N N 5.90 5.90 11.8086341 B 04 N N 5.9 5.90 11.80

Page 197: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

86343 B 04 N N 8.07 8.07 16.1586344 A 04 N N 1.15 1.15 2.3086352 B 04 01-Jan-10 N N 29.19 29.19 58.3886353 B 04 N N 5.90 5.90 11.8086355 B 04 N N 15.81 15.81 31.6286356 04 01-Jan-08 N N 11.3386357 B 04 N N 15.81 15.81 31.6286359 B 04 N N 3.82 3.82 7.6586360 B 04 N N 4.85 4.85 9.7086361 B 04 N N 4.85 4.85 9.7086367 B 04 N N 15.81 15.81 31.6286376 A 04 N N 4.20 4.20 8.4086378 B 04 N N 6.95 6.95 13.9086382 A 04 N N 3.60 3.60 7.2086384 A 04 N N 2.35 2.35 4.7086403 A 04 N N 3.00 3.00 6.0086406 A 04 N N 5.90 5.90 11.8086430 B 04 N N 3.10 3.10 6.2086431 B 04 N N 3.62 3.62 7.2586480 B 04 N N 25.97 25.97 51.9586485 B 04 N N 2.00 2.00 4.0086486 04 01-Jan-08 Y N86490 B 04 N N 2.57 2.57 5.1586510 B 04 N N 2.57 2.57 5.1586580 04 N N 4.0086590 B 04 N N 5.90 5.90 11.8086592 B 04 N N 2.00 2.00 4.0086593 B 04 N N 2.00 2.00 4.0086602 B 04 N N 5.10 5.10 10.2086603 A 04 N N 7.40 7.40 14.8086606 B 04 N N 5.10 5.10 10.2086609 B 04 N N 5.12 5.12 10.2586611 B 04 N N 5.30 5.30 10.6086612 B 04 N N 5.10 5.10 10.2086615 B 04 N N 5.95 5.95 11.9086617 B 04 N N 10.10 10.10 20.2086618 B 04 N N 11.10 11.10 22.2086619 B 04 N N 5.10 5.10 10.20

Page 198: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

86622 B 04 N N 5.10 5.10 10.2086625 B 04 N N 4.85 4.85 9.7086628 B 04 N N 5.10 5.10 10.2086631 B 04 N N 7.70 7.70 15.4086632 B 04 N N 8.27 8.27 16.5586635 B 04 N N 5.10 5.10 10.2086638 B 04 N N 5.10 5.10 10.2086641 B 04 N N 5.10 5.10 10.2086644 B 04 N N 6.67 6.67 13.3586645 B 04 N N 9.12 9.12 18.2586648 B 04 N N 9.60 9.60 19.2086651 B 04 N N 8.00 8.00 16.0086652 B 04 N N 8.00 8.00 16.0086653 B 04 N N 7.80 7.80 15.6086654 B 04 N N 8.00 8.00 16.0086658 B 04 N N 8.50 8.50 17.0086663 B 04 N N 8.57 8.57 17.1586664 B 04 N N 8.80 8.80 17.6086665 B 04 N N 9.60 9.60 19.2086666 B 04 N N 5.30 5.30 10.6086668 B 04 N N 5.10 5.10 10.2086671 B 04 N N 8.01 8.01 16.0286674 B 04 N N 5.10 5.10 10.2086677 B 04 N N 7.50 7.50 15.0086682 B 04 Y N86684 B 04 N N 9.60 9.60 19.2086687 B 04 N N 5.10 5.10 10.2086688 B 04 N N 6.72 6.72 13.4586689 B 04 N N 11.19 11.19 22.3986692 B 04 N N 5.05 5.05 10.1086694 B 04 N N 6.67 6.67 13.3586695 B 04 N N 7.65 7.65 15.3086696 B 04 N N 10.10 10.10 20.2086698 B 04 N N 8.15 8.15 16.3086701 B 04 01-Mar-09 N N 6.48 6.48 12.9686702 B 04 N N 5.10 5.10 10.2086703 B 04 01-Mar-09 N N 10.01 10.01 20.0286704 B 04 N N 7.85 7.85 15.70

Page 199: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

86705 B 04 N N 7.70 7.70 15.4086706 B 04 N N 7.00 7.00 14.0086707 B 04 N N 4.77 4.77 9.5586708 B 04 N N 4.77 4.77 9.5586709 B 04 N N 2.77 2.77 5.5586710 B 04 N N 8.85 8.85 17.7086713 B 04 N N 2.62 2.62 5.2586717 B 04 N N 5.10 5.10 10.2086720 B 04 N N 5.10 5.10 10.2086723 B 04 N N 8.32 8.32 16.6586727 B 04 N N 7.80 7.80 15.6086729 B 04 N N 7.65 7.65 15.3086732 B 04 N N 5.10 5.10 10.2086735 B 04 N N 6.35 6.35 12.7086738 B 04 N N 5.10 5.10 10.2086741 B 04 N N 5.10 5.10 10.2086744 B 04 N N 5.10 5.10 10.2086747 B 04 N N 9.80 9.80 19.6086750 B 04 N N 5.10 5.10 10.2086753 B 04 N N 8.08 8.08 16.1786756 B 04 N N 8.42 8.42 16.8586757 B 04 N N 10.10 10.10 20.2086759 B 04 N N 8.40 8.40 16.8086762 B 04 N N 4.10 4.10 8.2086765 B 04 N N 4.10 4.10 8.2086768 B 04 N N 5.10 5.10 10.2086771 B 04 N N 5.10 5.10 10.2086774 B 04 N N 9.65 9.65 19.3086777 B 04 N N 6.35 6.35 12.7086778 B 04 N N 9.40 9.40 18.8086780 B 04 01-Jan-10 N N 8.64 8.64 17.2986784 B 04 N N 5.10 5.10 10.2086787 B 04 N N 7.50 7.50 15.0086788 B 04 01-Jan-07 N N 7.06 7.06 14.1286789 B 04 01-Jan-07 N N 6.03 6.03 12.0786790 B 04 N N 8.42 8.42 16.8586793 B 04 N N 5.10 5.10 10.2086800 B 04 N N 5.90 5.90 11.80

Page 200: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

86803 B 04 N N 8.42 8.42 16.8586804 B 04 N N 6.20 6.20 12.4086805 B 04 N N 23.90 23.90 47.8086806 B 04 N N 21.72 21.72 43.4586807 B 04 N N 18.05 18.05 36.1086808 B 04 N N 13.55 13.55 27.1086812 B 04 N N 3.10 3.10 6.2086813 B 04 N N 8.42 8.42 16.8586816 B 04 N N 7.50 7.50 15.0086817 B 04 N N 14.00 14.00 28.0086821 B 04 N N 28.05 28.05 56.1086822 B 04 N N 13.35 13.35 26.7086825 B 04 01-Jan-10 N N 17.42 17.42 34.8086826 A 04 01-Jan-10 N N 7.31 7.31 14.6286849 04 Y N86850 A 04 N N 2.82 2.82 5.6586860 A 04 N N 5.95 5.95 11.9086870 A 04 N N 7.17 7.17 14.3586880 A 04 N N 2.90 2.90 5.8086885 A 04 N N 3.05 3.05 6.1086886 A 04 N N 3.10 3.10 6.2086890 04 N N 40.4086891 04 N N 101.8086900 A 04 N N 1.75 1.75 3.5086901 A 04 N N 2.35 2.35 4.7086903 A 04 N N 6.15 6.15 12.3086904 A 04 N N 6.20 6.20 12.4086905 A 04 N N 2.47 2.47 4.9586906 A 04 N N 2.30 2.30 4.6086910 A 04 N N 12.02 12.02 24.0586911 A 04 N N 3.40 3.40 6.8086920 A 04 N N 2.35 2.35 4.7086921 A 04 N N 4.70 4.70 9.4086922 A 04 N N 4.70 4.70 9.4086927 09 Y N86930 09 Y N86931 09 Y N86932 09 Y N

Page 201: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

86940 A 04 N N 2.77 2.77 5.5586941 A 04 N N 2.35 2.35 4.7086945 04 N N 6.6086950 04 N N 25.7086965 04 N N 5.0586970 04 N N 10.1086971 04 N N 8.2086972 04 N N 8.2086975 04 N N 8.2086976 04 N N 8.2086977 04 N N 8.2086978 04 N N 10.1086985 A 04 N N 4.10 4.10 8.2086999 A 04 Y N87001 B 04 N N 8.60 8.60 17.2087003 B 04 N N 8.95 8.95 17.9087015 A 04 N N 3.60 3.60 7.2087040 B 04 N N 6.75 6.75 13.5087045 B 04 N N 6.15 6.15 12.3087046 B 04 N N 1.20 1.20 2.4087070 B 04 N N 3.10 3.10 6.2087071 09 Y N87073 09 Y N87075 B 04 N N 6.17 6.17 12.3587076 09 Y N87077 09 Y N87081 B 04 N N 2.90 2.90 5.8087084 B 04 N N 3.00 3.00 6.0087086 B 04 N N 5.25 5.25 10.5087088 09 N Y 6.2087101 B 04 N N 3.10 3.10 6.2087102 B 04 N N 3.10 3.10 6.2087103 B 04 N N 3.10 3.10 6.2087106 09 Y N87107 09 Y N87109 B 04 N N 4.77 4.77 9.5587110 B 04 N N 8.42 8.42 16.8587116 B 04 N N 5.85 5.85 11.70

Page 202: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

87118 09 Y N87140 B 04 N N 0.57 0.57 1.1587143 B 04 N N 3.60 3.60 7.2087147 B 04 N N 1.60 1.60 3.2087149 09 Y N87150 09 01-Jan-10 Y N87152 09 Y N87153 09 01-Jan-10 N N87158 B 04 N N 0.57 0.57 1.1587164 04 N N 14.0087166 04 N N 14.7587168 B 04 N N 2.25 2.25 4.5087169 B 04 N N 2.25 2.25 4.5087172 A 04 N N 2.25 2.25 4.5087176 A 04 N N 3.85 3.85 7.7087177 A 04 N N 3.60 3.60 7.2087181 B 04 N 6.2087184 B 04 N N 4.50 4.50 9.0087185 A 04 N N 2.47 2.47 4.9587186 B 04 N N 5.65 5.65 11.3087187 B 04 N N 4.30 4.30 8.6087188 B 04 N N 4.32 4.32 8.6587190 04 N N 7.4087197 B 04 N N 6.40 6.40 12.8087205 B 04 N N 1.75 1.75 3.5087206 B 04 N N 2.10 2.10 Y 4.2087207 B 04 N N 1.75 1.75 3.5087209 B 04 N N 7.53 7.53 15.0687210 B 04 N N 2.35 2.35 4.7087220 B 04 N N 2.35 2.35 4.7087230 B 04 N N 7.50 7.50 15.0087250 04 N N 12.8087252 B 04 N N 6.40 6.40 12.8087253 B 04 N N 7.50 7.50 15.0087254 A 04 N N 3.20 3.20 6.4087255 A 04 N N 11.83 11.83 23.6687260 B 04 N N 7.85 7.85 15.7087265 B 04 N N 7.85 7.85 15.70

Page 203: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

87267 B 04 N N 4.19 4.19 8.3887269 B 04 N N 5.02 5.02 10.0587270 B 04 N N 7.85 7.85 15.7087271 B 04 N N 4.19 4.19 8.3887272 B 04 N N 7.85 7.85 15.7087273 B 04 N N 6.25 6.25 12.5087274 B 04 N N 7.85 7.85 15.7087275 B 04 N N 6.25 6.25 12.5087276 B 04 N N 7.85 7.85 15.7087277 B 04 N N 6.25 6.25 12.5087278 B 04 N N 7.85 7.85 15.7087279 A 04 N N 6.25 6.25 12.5087280 B 04 N N 7.85 7.85 15.7087281 B 04 N N 6.25 6.25 12.5087283 B 04 N N 6.25 6.25 12.5087285 B 04 N N 7.85 7.85 15.7087290 B 04 N N 7.85 7.85 15.7087299 A 04 Y N87300 A 04 N N 3.10 3.10 6.2087301 B 04 N N 7.85 7.85 15.7087305 B 04 N N 7.85 7.85 15.7087320 B 04 N N 7.85 7.85 15.7087324 B 04 N N 7.85 7.85 15.7087327 B 04 N N 6.25 6.25 12.5087328 B 04 N N 7.85 7.85 15.7087329 B 04 N N 5.02 5.02 10.0587332 B 04 N N 7.85 7.85 15.7087335 B 04 N N 7.85 7.85 15.7087336 B 04 N N 6.25 6.25 12.5087337 B 04 N N 6.25 6.25 12.5087338 B 04 N N 9.40 9.40 18.8087339 B 04 N N 6.25 6.25 12.5087340 B 04 N N 6.75 6.75 13.5087341 B 04 N N 5.40 5.40 10.8087350 B 04 N N 7.52 7.52 15.0587380 B 04 N N 10.70 10.70 21.4087385 B 04 N N 7.85 7.85 15.7087390 B 04 N N 11.50 11.50 23.00

Page 204: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

87391 B 04 N N 11.50 11.50 23.0087400 A 04 01-Oct-09 N N 3.10 3.10 6.2087420 B 04 N N 7.85 7.85 15.7087425 B 04 N N 7.85 7.85 15.7087427 B 04 N N 6.25 6.25 12.5087430 B 04 N N 7.85 7.85 15.7087449 A 04 N N 7.84 7.84 15.6887450 A 04 Y N87451 B 04 N N 5.00 5.00 10.0087470 B 04 N N 13.10 13.10 26.2087471 B 04 N N 22.90 22.90 45.8087472 B 04 N N 27.95 27.95 55.9187475 B 04 N N 13.10 13.10 26.2087476 B 04 N N 22.90 22.90 45.8087477 B 04 N N 27.95 27.95 55.9187480 B 04 N N 13.10 13.10 26.2087481 B 04 N N 22.90 22.90 45.8087482 B 04 N N 27.25 27.25 54.5087485 B 04 N N 13.10 13.10 26.2087486 B 04 N N 22.90 22.90 45.8087487 B 04 N N 27.95 27.95 55.9187490 B 04 N N 13.10 13.10 26.2087491 B 04 N N 22.90 22.90 45.8087492 B 04 N N 22.81 22.81 45.6387493 B 04 01-Jan-10 N N 22.91 22.91 45.8287495 B 04 N N 13.10 13.10 26.2087496 B 04 N N 22.90 22.90 45.8087497 B 04 N N 22.81 22.81 45.6387498 B 04 N N 22.91 22.91 45.8387500 B 04 01-Jan-10 N N 14.71 14.71 29.4287510 B 04 N N 13.10 13.10 26.2087511 B 04 N N 22.90 22.90 45.8087512 B 04 01-Jan-10 N N 17.93 17.93 35.8687515 B 04 N N 13.10 13.10 26.2087516 B 04 N N 22.90 22.90 45.8087517 B 04 N N 27.95 27.95 55.9087520 B 04 N N 13.10 13.10 26.2087521 B 04 N N 22.90 22.90 45.80

Page 205: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

87522 B 04 N N 27.95 27.95 55.9087525 B 04 N N 13.10 13.10 26.2087526 B 04 N N 22.90 22.90 45.8087527 B 04 01-Jan-10 N N 17.93 17.93 35.8687528 B 04 N N 13.10 13.10 26.2087529 B 04 N N 22.90 22.90 45.8087530 B 04 01-Jan-10 N N 18.40 18.40 36.8087531 B 04 N N 13.10 13.10 26.2087532 B 04 N N 22.90 22.90 45.8087533 B 04 01-Jan-10 N N 17.93 17.93 35.8687534 B 04 N N 13.10 13.10 26.2087535 B 04 N N 22.90 22.90 45.8087536 B 04 N N 43.45 43.45 86.9087537 B 04 N N 13.10 13.10 26.2087538 B 04 N N 22.90 22.90 45.8087539 B 04 01-Jan-10 N N 18.41 18.41 36.7287540 B 04 N N 13.10 13.10 26.2087541 B 04 N N 22.90 22.90 45.8087542 B 04 01-Jan-10 N N 17.93 17.93 35.8687550 B 04 N N 13.10 13.10 26.2087551 B 04 N N 22.90 22.90 45.8087552 B 04 01-Jan-10 N N 18.41 18.41 36.8287555 B 04 N N 13.10 13.10 26.2087556 B 04 N N 22.90 22.90 45.8087557 B 04 01-Jan-10 N N 18.41 18.41 36.8287560 B 04 N N 13.10 13.10 26.2087561 B 04 N N 22.90 22.90 45.8087562 B 04 01-Jan-10 N N 18.41 18.41 36.8287580 B 04 N N 13.10 13.10 26.2087581 B 04 N N 22.90 22.90 45.8087582 B 04 01-Jan-10 N N 17.93 17.93 35.8687590 B 04 N N 13.10 13.10 26.2087591 B 04 N N 22.90 22.90 45.8087592 B 04 01-Jan-10 N N 18.41 18.41 36.8287620 B 04 N N 13.10 13.10 26.2087621 B 04 N N 22.90 22.90 45.8087622 B 04 01-Jan-10 N N 17.93 17.93 35.8687640 B 04 N N 22.91 22.91 45.83

Page 206: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

87641 B 04 N N 22.91 22.91 45.8387650 B 04 N N 13.10 13.10 26.2087651 B 04 N N 22.90 22.90 45.8087652 B 04 01-Jan-10 N N 17.93 17.93 35.8687653 B 04 N N 22.91 22.92 45.8387660 B 04 N N 8.40 8.40 16.8187797 A 04 N N 13.10 13.10 26.2087798 A 04 N N 22.91 22.91 45.8387799 A 04 N N 25.94 25.94 51.8987800 B 04 N N 10.47 10.47 20.9587801 B 04 N N 18.30 18.30 36.6087802 B 04 N N 7.82 7.82 15.6587803 B 04 N N 7.82 7.82 15.6587804 A 04 N N 7.82 7.82 15.6587807 B 04 01-Jan-10 N N 5.03 5.03 10.0687808 B 04 01-Jan-10 N N 7.82 7.82 15.6587809 B 04 01-Jan-10 N N 5.03 5.03 10.0687810 B 04 N N 7.85 7.85 15.7087850 B 04 N N 7.85 7.85 15.7087880 B 04 01-Dec-09 N N 7.85 7.85 15.7087899 04 01-Jan-10 Y N87900 04 N N 162.2087901 04 N N 168.0587902 B 04 N N 84.02 84.02 168.0587903 04 N N 682.7287904 04 N N 32.44 9 291.9687905 B 04 01-Jan-09 N N 5.27 5.27 10.5487999 04 Y N88104 B 04 N N 5.90 5.90 11.8088106 B 04 N N 5.90 5.90 11.8088107 B 04 N N 5.90 5.90 11.8088108 B 04 N N 4.45 4.45 8.9088112 C 04 N N 29.33 23.68 63.6188125 B 04 N N 1.67 1.67 3.3588130 B 04 N N 7.00 7.00 14.0088140 B 04 N N 4.77 4.77 9.5588141 04 N N 3.5088142 04 N N 3.35

Page 207: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

88143 04 N N 3.5088147 04 N N 3.5088148 04 N N 3.5088150 04 N N 1 3.5088152 04 N N 3.5088153 04 N N 3.5088154 04 N N 3.5088155 04 N N 1 4.1088160 B 04 N N 5.90 5.90 11.8088161 B 04 N N 5.62 5.62 11.2588162 B 04 N N 11.80 11.80 23.6088164 04 N N 3.5088165 04 N N 3.5088166 04 N N 3.5088167 04 N N 3.5088172 04 N N 16.8588173 B 04 N N 14.00 14.00 28.0088174 B 04 N N 7.46 7.46 14.9388175 B 04 N N 9.20 9.20 18.4188182 B 04 N N 15.25 15.25 30.5088184 04 N N 2.1088185 04 N N 1.05 24 25.2088187 04 N N 40.1188188 04 N N 50.0088189 04 N N 65.8588199 04 01-Jan-10 Y N88230 B 04 N N 45.40 45.40 90..8088233 B 04 N N 58.77 58.77 117.5588235 B 04 N N 66.80 66.80 133.6088237 B 04 N N 53.47 53.47 106.9588239 B 04 N N 66.80 66.80 133.6088240 09 Y N88241 09 Y N88245 B 04 N N 43.82 43.82 87.6588248 B 04 N N 44.12 44.12 88.2588249 B 04 N N 43.77 43.77 87.5588261 B 04 N N 58.90 58.90 117.8088262 B 04 N N 81.37 81.37 162.75

Page 208: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

88263 B 04 N N 94.37 94.37 188.7588264 B 04 N N 81.37 81.37 162.7588267 B 04 N N 44.30 44.30 88.6088269 B 04 N N 38.17 38.17 76.3588271 B 04 N N 9.45 9.45 18.9088272 B 04 N N 16.52 16.52 33.0588273 B 04 N N 20.95 20.95 41.9088274 B 04 N N 22.70 22.70 45.4088275 B 04 N N 26.20 26.20 52.4088280 B 04 N N 16.35 16.35 32.7088283 B 04 N N 12.27 12.27 24.5588285 B 04 N N 12.40 12.40 24.8088289 B 04 N N 8.55 8.55 17.1088291 B 04 N N 2.62 2.62 5.2588299 04 Y N88300 A 04 N N 6.52 6.52 13.0588302 A 04 N N 10.47 10.47 20.9588304 A 04 N N 18.67 18.67 37.3588305 A 04 N N 20.55 20.55 41.1088307 A 04 N N 21.80 21.80 43.6088309 A 04 N N 23.70 23.70 47.4088311 B 04 N N 5.75 5.75 11.5088312 A 04 N N 5.90 5.90 11.8088313 A 04 N N 3.35 3.35 6.7088314 B 04 N N 3.10 3.10 6.2088318 B 04 N N 20.90 20.90 41.8088319 B 04 N N 11.20 11.20 22.4088321 04 N N 6.2088323 04 N N 17.9088325 04 N N 19.9088329 04 N N 48.5588331 04 N N 48.5588332 04 N N 19.9088333 04 N N 50.8688334 04 N N 26.4088342 A 04 N N 6.72 6.72 Y 13.4588346 A 04 N N 8.42 8.42 16.8588347 A 04 N N 8.42 8.42 16.85

Page 209: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

88348 B 04 N N 23.60 23.60 47.2088349 B 04 N N 35.35 35.35 70.7088355 B 04 N N 54.30 54.30 108.6088356 B 04 N N 54.30 54.30 108.6088358 B 04 N N 54.30 54.30 108.6088360 A 04 N N 30.91 30.91 61.8388361 C 04 N N 24.79 35.80 72.7088362 04 Y N88365 04 N N 40.8188367 A 04 N N 57.57 57.57 115.1588368 04 N N 105.2088371 B 04 N N 14.22 14.22 28.4588372 B 04 N N 14.85 14.85 29.7088380 04 Y N88381 C 04 01-Jan-08 N N 31.82 83.72 115.5488384 04 Y N88385 04 N N 46.4188386 04 N N 58.3988387 C 04 01-Jan-10 N N 17.75 4.43 22.1888388 C 04 01-Jan-10 N N 11.3 2.15 13.4588398 04 01-Jan-1088399 A 04 Y N88720 B 04 01-Jan-09 N N 2.20 2.20 4.4088738 04 01-Jan-1088740 B 04 01-Jan-09 N N 2.20 2.20 4.4088741 B 04 01-Jan-09 N N 2.20 2.20 4.4089049 B 04 N N 18.52 18.52 37.0589050 B 04 N N 1.75 1.75 3.5089051 B 04 N N 3.10 3.10 6.2089055 A 04 N N 1.49 1.49 2.9889060 B 04 N N 4.67 4.67 9.3589100 B 04 N N 3.10 3.10 6.2089105 B 04 N N 29.75 29.75 59.5089125 B 04 N N 1.67 1.67 3.3589130 A 04 N I 14.60 14.60 29.2089132 A 04 Y N89135 B 04 N N 14.60 14.60 29.2089136 B 04 Y N

Page 210: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

89140 B 04 N N 23.60 23.60 47.2089141 A 04 N N 14.00 14.00 28.0089160 B 04 N N 0.67 0.67 1.3589190 B 04 N N 1.67 1.67 3.3589225 B 04 N N 1.40 1.40 2.8089235 B 04 N N 2.30 2.30 4.6189240 A 04 Y N89250 09 Y N89310 B 04 N N 3.35 3.35 6.7089321 B 04 01-Jan-08 N N 4.21 4.21 8.4389322 04 01-Jan-08 N N 11.3690375 04 Y Y N90376 04 Y Y N90378 04 Y Y N90384 04 N Y N 107.7090385 04 N Y N 37.7090386 04 Y Y N90393 04 Y Y N90399 04 Y Y N90470 01-Jan-10 N N 6.40 1 6.4090471 09 Y N90472 09 Y N90473 09 Y N90474 09 Y N90476 F 04 Y N90477 F 04 Y N90581 F 04 Y N90585 F 04 Y N90586 F 04 Y N90632 G 04 N N 6.40 56.1590633 E 04 N N 6.4090634 E 04 N N 6.4090636 G 04 N N 6.40 111.1890645 E 04 N N 6.4090646 E 04 N N 6.4090647 E 04 N N 6.4090648 E 04 N N 6.4090649 M 04 21-Oct-09 Y N 6.40 149.33

Page 211: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

90650 M 04 19-Oct-09 Y N 6.40 153.1090655 E 04 N N 6.4090656 G 04 N N 6.40 11.1990657 E 04 N N 6.4090658 G 04 N N 6.40 11.1990660 G 04 N N 6.40 22.3790665 09 Y Y N90669 E 04 N N 6.4090675 F 04 Y N90676 F 04 Y N90680 E 04 N N 6.4090681 E 04 01-Aug-08 N N 6.4090690 09 Y N90691 09 Y N90692 09 Y N90693 09 Y N90696 E 04 01-Aug-08 N N 6.4090698 E 04 01-Aug-08 N N 6.4090700 E 04 N N 6.4090701 E 04 N N 6.4090702 F 04 N N 2.7090703 F 04 N N 1.85 1.8590704 F 04 Y N90705 F 04 Y N90706 F 04 Y N90707 G 04 N N 6.40 39.7090708 F 04 Y N90710 E 04 N N 6.4090712 F 04 N N 14.0090713 E 04 N N 6.4090714 G 04 N N 6.40 18.9290715 G 04 N N 6.40 38.2890716 G 04 N N 6.40 46.6090717 09 Y N90718 G 04 N N 6.40 2.7090719 F 04 N N 3.4090721 F 04 N N 35.2590723 E 04 N N 6.40

Page 212: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

90725 09 Y N90727 09 Y N90732 G 04 N N 6.40 14.6090733 F 04 N N 85.0090734 G 04 N N 6.40 116.7890735 F 04 N N 243.80 243.8090736 F 04 N N 190.0290738 F 04 01-Jul-08 Y90740 F 04 Y N90743 F 04 Y N90744 E 04 N N 6.4090746 G 04 N N 6.40 74.3890747 F 04 Y N90748 E 04 N N 6.4090749 F 04 Y N90801 02 01-Jun-09 N N 67.50 52.11 52.1190802 02 01-Jun-09 N N 27.55 92.06 92.0690804 02 N N 27.5590805 02 N N 30.9090806 02 N N 47.5090807 02 N N 47.5090808 02 N N 64.8090809 02 N N 67.5090810 02 N N 31.7090811 02 N N 34.8590812 02 N N 47.5090813 02 N N 47.5090814 02 N N 63.4590815 02 N N 66.3090816 02 N N 31.6590817 02 N N 31.6590818 02 N N 47.5090819 02 N N 47.5090821 02 N N 65.9090822 02 N N 68.3090823 02 N N 33.3090824 02 N N 35.9590826 02 N N 47.50

Page 213: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

90827 02 N N 48.6590828 02 N N 65.0590829 02 N N 66.9090845 D 04 N N90846 09 Y N90847 02 N N 61.2090849 02 N N 61.2090853 02 N N 33.7090857 09 Y N90862 04 N N 22.4590865 02 N N 63.4090870 04 N I 44.4090875 02 N N 28.7090876 02 N N 47.5090880 09 Y N90885 09 Y N90887 09 Y N90889 09 Y N90899 02 Y N90901 09 Y I90911 09 Y I90935 04 N I 35.7590937 04 N I 61.7090940 04 Y I90945 04 N I 36.5090947 04 N N 60.9090951 04 01-Jan-09 N I 252.3590952 04 01-Jan-09 N I 252.3590953 04 01-Jan-09 N I 252.3590954 04 01-Jan-09 N I 213.6590955 04 01-Jan-09 N I 213.6590956 04 01-Jan-09 N I 213.6590957 04 01-Jan-09 N I 213.6590958 04 01-Jan-09 N I 213.6590959 04 01-Jan-09 N I 213.6590960 04 01-Jan-09 N I 213.6590961 04 01-Jan-09 N I 213.6590962 04 01-Jan-09 N I 213.65

Page 214: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

90963 04 01-Jan-09 N I 252.3590964 04 01-Jan-09 N I 213.6590965 04 01-Jan-09 N I 213.6590966 04 01-Jan-09 N I 213.6590967 04 01-Jan-09 N I 8.3090968 04 01-Jan-09 N I 7.1090969 04 01-Jan-09 N I 7.1090970 04 01-Jan-09 N I 7.1090989 09 Y I90993 09 Y I90997 04 Y N90999 04 Y I91000 04 N I 3 20.8091010 04 N I 3 52.7091011 04 N I 3 60.6091012 04 N I 3 74.9091020 04 N I 3 74.9091022 C 04 N N 3 42.72 75.37 1 118.0991030 04 N I 3 74.9091034 C 04 N I 3 31.17 99.11 1 130.2891035 04 N I 3 255.6291037 04 N I 3 84.0091038 C 04 N I 3 32.73 40.00 72.7391040 04 N I 3 248.2791052 04 N I 3 25.6591055 04 N I 3 27.8591065 04 N I 29.6591105 04 N I 40.8591110 C 04 N I 140.95 563.92 704.9091111 C 04 N N 28.37 343.76 372.1391120 04 N I 3 245.0091122 04 N I 3 57.2091123 04 N I 3 194.2091132 04 Y I91133 04 Y I91299 04 Y I92002 04 N N 27.5592004 04 N N 46.45

Page 215: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

92012 04 N N 23.3092014 04 N N 44.4592015 04 N I 18.4592018 04 N I 3 152.6092019 04 N I 3 152.6092020 04 N I 19.5092025 C 04 N I 9.04 6.29 15.3392060 C 04 01-Aug-08 N I 16.68 8.22 24.9092065 C 04 01-Aug-08 N I 9.75 12.40 22.1592070 09 Y N92081 C 04 01-Aug-08 N I 8.18 12.27 20.4592082 C 04 01-Aug-08 N I 11.29 19.21 30.5092083 C 04 01-Aug-08 N I 13.84 23.56 37.4092100 04 N I 23.8092120 04 N I 22.3092130 04 N I 24.5592135 C 04 01-Aug-08 N I 23.72 28.98 52.7092136 C 04 01-Aug-08 N I 19.02 31.03 50.0592140 04 N I 22.1592225 04 N I 30.5092226 04 N I 30.5092230 B 04 N I 22.20 22.20 44.4092235 C 04 01-Aug-08 N I 20.03 32.67 52.7092240 C 04 01-Aug-08 N I 15.82 40.68 56.5092250 C 04 01-Aug-08 N I 15.98 28.42 44.4092260 B 04 N I 26.35 26.35 52.7092265 04 N I 74.9092270 04 N I 52.7092275 B 04 N I 26.35 26.35 52.7092283 04 N I 22.1592284 B 04 N I 7.60 7.60 15.2092285 04 N I 30.5092286 04 N I 52.7092287 04 N I 69.3092310 04 Y N92311 09 Y N92312 09 Y N92313 09 Y N

Page 216: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

92314 09 Y N92315 09 Y N92316 09 Y N92317 09 Y N92325 09 Y N92326 09 Y N92340 04 N N 30.0992341 09 Y N92342 09 Y N92352 09 Y N92353 09 Y N92354 09 Y N92355 09 Y N92358 09 Y N92370 04 N N 4.7692371 09 Y N92499 04 Y I92502 04 N I 4 52.7092504 04 N I 3 37.4092506 04 N I 37.4092507 04 N I 19.8592508 09 Y I92511 04 N I 3 112.4092512 04 N I 20.0592516 04 N I 15.9092520 04 N I 30.5092526 04 Y I92531 04 N I 30.5092532 04 N I 30.5092533 04 N I 22.1592534 04 N I 22.1592540 C 04 01-Jan-10 N I 44.40 9.10 53.5092541 C 04 01-Oct-09 N I 8.35 13.80 22.1592542 C 04 01-Oct-09 N I 6.64 15.51 22.1592543 C 04 01-Oct-09 N I 4.77 17.38 22.1592544 C 04 01-Oct-09 N I 4.75 17.40 22.1592545 C 04 01-Oct-09 N I 6.14 16.01 22.1592546 C 04 01-Oct-09 N I 4.32 17.83 22.15

Page 217: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

92547 04 01-Jan-10 N I 22.1592548 C 04 01-Jan-10 N I 11.80 27.55 39.3592550 04 01-Jan-10 N N 11.6592551 04 N N 15.20 1 15.2092552 04 N I 15.2092553 04 N I 15.2092555 04 N I 15.2092556 04 N I 15.2092557 04 N I 37.4092559 09 Y N92560 04 N I 15.2092561 04 N I 26.3592562 04 N N 7.6092563 04 N N 15.2092564 04 N N 15.2092565 04 N N 15.2092567 04 N N 15.2092568 04 N N 13.7092570 04 01-Jan-10 N N 16.9092571 04 N N 15.2092572 04 N N 15.2092575 04 N N 15.2092576 04 N N 15.2092577 04 N N 12.2092579 04 N N 22.1592582 04 N N 22.1592583 04 N N 15.1592584 04 N I 74.9092585 04 N I 53.7592586 04 N I 47.8092587 04 N I 52.7092588 04 N I 61.0092590 04 N I 37.4092591 04 N I 37.4092592 04 N I 15.2092593 04 N I 15.2092594 04 N I 15.2092595 04 N I 15.20

Page 218: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

92596 04 N I 15.2092597 04 N I 43.1892601 04 N I 55.0192602 04 N I 38.7292603 04 N I 37.1892604 04 N I 25.4992605 04 N I 24.9092606 04 N I 24.9092607 04 N I 45.8592608 04 N N 9.2592609 04 N I 24.9092610 04 N I 18.0092611 04 N I 19.5592612 04 N I 30.2592613 04 N I 30.2592614 04 N I 30.2592615 04 N I 30.2592616 04 N I 44.0092617 04 N I 44.0092620 04 N I 24.4692621 04 N I 6.6392625 04 N I 24.0692626 09 Y N92627 09 Y N92630 09 Y N92633 09 Y N92640 04 N N 26.6792700 04 Y I92950 04 N I Y Y 112.5092953 04 N I Y Y 6.3792960 04 N I 112.4092961 04 N I 3 112.4092970 04 Y I92971 04 Y I92973 04 N I 3 Y 156.5092974 04 N I 3 183.9092975 04 Y M 392977 04 Y M 3

Page 219: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

92978 04 N I 120.7092979 04 N I 74.2092980 04 N M 3 Y 910.7092981 04 Y M 3 Y92982 04 N M 3 Y 718.7092984 04 Y M 3 Y92986 04 N M 3 Y 682.8092987 04 N M 3 Y Y 682.8092990 04 N M 3 Y 682.8092992 04 N M 3 Y 898.7592993 04 N M 3 Y 958.6092995 04 N M 3 Y 898.7592996 04 Y M 3 Y92997 04 N M 3 Y 718.7092998 04 Y M 3 Y93000 A 04 N I 11.08 11.07 22.1593005 04 N I 11.0593010 04 N I 11.05 5 55.2593012 04 N I 39.5093014 04 N I 13.9093015 04 N I 67.9093016 04 N I 21.6093017 04 N I 27.9093018 04 N I 22.1593024 04 N I 3 59.6093025 04 N I 3 Y 168.2093040 A 04 N I 3.80 3.80 7.6093041 04 N I 3.8093042 04 N I 4.2093224 04 N I 180.3093225 04 N I 135.9093226 04 N I 44.4093227 04 N I 44.4093228 04 01-Jan-09 N N 21.6093229 04 01-Jan-09 N N 39.5093230 04 N I 158.7093231 04 N I 135.9093232 04 N I 44.40

Page 220: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

93233 04 N I 44.4093235 04 N I 180.3093236 04 N I 44.4093237 04 N I 44.4093268 04 N I 73.7093270 04 N I 21.6093271 04 N I 39.5093272 04 N I 21.6093278 04 N I 27.0093279 C 04 01-Jan-10 N I 20.88 10.77 31.6593280 C 04 01-Jan-10 N I 24.99 12.22 37.2193281 C 04 01-Jan-10 N I 29.15 14.38 43.5393282 C 04 01-Jan-10 N I 27.37 13.05 40.4293283 C 04 01-Jan-10 N I 34.44 14.76 49.2093284 C 04 01-Jan-10 N I 40.86 16.67 57.5393285 C 04 01-Jan-10 N I 17.11 10.19 27.3093286 C 04 01-Jan-10 N I 8.92 6.62 15.5493287 C 04 01-Jan-10 N I 12.86 7.72 20.5893288 C 04 01-Jan-10 N I 13.95 10.38 24.3393289 C 04 01-Jan-10 N I 25.21 12.22 37.4393290 C 04 01-Jan-10 N I 12.50 6.00 18.5093291 C 04 01-Jan-10 N I 14.21 9.17 23.3893292 C 04 01-Jan-10 N I 13.95 7.33 21.2893293 C 04 01-Jan-10 N I 9.93 23.46 33.3993294 04 01-Jan-09 N I 21.3393295 04 01-Jan-09 N I 38.3793296 04 01-Jan-09 N I 19.3093297 04 01-Jan-09 N I 15.0293298 04 01-Jan-09 N I 17.1193299 04 01-Jan-09 Y I93303 B 04 N I 49.05 49.05 98.1093304 B 04 N I 26.50 26.50 53.0093306 C 04 01-Jan-09 N N 27.30 63.70 91.0093307 B 04 N I 45.50 45.50 91.0093308 B 04 N I 26.35 26.35 52.7093312 B 04 N I 81.85 81.85 163.7093313 B 04 N I 55.50 55.50 111.0093314 B 04 N I 47.15 47.15 94.30

Page 221: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

93315 B 04 N I 81.85 81.85 163.7093316 B 04 N I 55.50 55.50 111.0093317 B 04 N I 53.13 53.12 106.2593318 B 04 N I 81.85 81.85 163.7093320 B 04 N I 19.90 19.90 39.8093321 B 04 N I 12.95 12.95 25.9093325 B 04 N I 25.17 25.17 50.3593350 B 04 N I 81.85 81.85 163.7093351 04 01-Jan-09 N I 214.4593352 0493501 04 N I 3 371.0093503 04 N I 3 149.8093505 04 N I 3 154.8093508 04 N I 3 318.8093510 04 N I 3 727.5093511 04 N I 3 723.2093514 04 N I 3 783.7093524 04 N I 3 963.7093526 04 N I 3 969.9593527 04 N I 3 991.5093528 04 N I 3 1008.0593529 04 N I 3 899.7093530 04 N I 3 399.9093531 04 N I 3 1021.9593532 04 N I 3 1050.7593533 04 N I 3 940.3093539 04 N I 3 74.9093540 04 N I 3 74.9093541 04 N I 3 74.9093542 04 N I 3 74.9093543 04 N I 3 74.9093544 04 N I 3 74.9093545 04 N I 3 299.7093555 04 N I 121.0093556 04 N I 181.3593561 04 N I 3 109.2093562 04 N I 3 149.8093571 B 04 N I 57.82 57.82 115.65

Page 222: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

93572 B 04 N I 52.75 52.75 105.5093580 04 Y M 3 Y93581 04 Y M 3 Y93600 04 N I 3 224.7093602 04 N I 3 224.7093603 04 N I 3 224.7093609 04 N I 3 282.4093610 04 N I 3 224.7093612 04 N I 224.7093613 04 N I 3 252.1593615 04 N I 3 224.7093616 04 N I 3 374.6093618 04 N I 3 374.6093619 04 N I 3 343.7093620 04 N I 3 489.6093621 04 N I 3 374.6093622 04 N I 3 374.6093623 04 N I 3 374.6093624 04 N I 3 224.7093631 04 N I 3 310.9593640 04 N I 222.3593641 04 N I 293.5593642 04 N I 262.2593650 04 N M 5 550.9093651 04 N M 5 550.9093652 04 N M 5 550.9093660 04 N I 69.3093662 04 N I 205.0093668 04 N I 28.3593701 04 N I 30.1093720 04 N I 74.9093721 04 N I 44.4093722 04 N I 22.1593724 04 N I 224.7093740 04 N I 7.6093745 04 N I 36.9093750 04 01-Jan-10 N I 26.1993770 04 N I 16.65

Page 223: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

93784 04 N I 180.3093786 04 N I 134.6093788 04 N I 44.4093790 04 N I 44.4093797 04 N N 21.1093798 04 N N 43.3593799 04 Y I Y93875 A 04 N I 25.03 25.02 50.0593880 A 04 N I 39.40 39.40 78.8093882 A 04 N I 26.20 26.20 52.4093886 A 04 N I 47.15 47.15 94.3093888 A 04 N I 31.53 31.52 63.0593890 A 04 N I 84.30 84.30 168.6093892 A 04 N I 70.87 70.86 141.7393893 A 04 N I 69.56 69.56 139.1293922 A 04 N I 25.03 25.02 50.0593923 A 04 N I 25.47 25.47 50.9593924 A 04 N I 28.00 28.00 56.0093925 A 04 N I 39.40 39.40 78.8093926 A 04 N I 26.35 26.35 52.7093930 A 04 N I 40.07 40.08 80.1593931 A 04 N I 26.60 26.60 53.2093965 A 04 N I 25.03 25.02 50.0593970 C 04 N I 17.38 70.17 87.5593971 C 04 N I 10.77 47.48 58.2593975 A 04 N I 59.60 59.60 119.2093976 A 04 N I 39.85 39.85 79.7093978 A 04 N I 41.15 41.15 82.3093979 A 04 N I 27.40 27.40 54.8093980 A 04 N I 45.83 45.82 91.6593981 A 04 N I 33.65 33.65 67.3093982 04 01-Jan-08 N I 22.2593990 A 04 N I 40.93 40.92 81.8594002 04 N I 46.3494003 04 N I 33.6194004 04 N I 24.4794010 C 04 N I 7.65 29.75 37.4094014 04 N I 52.90

Page 224: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

94015 04 N I 29.9094016 04 N I 23.0094060 C 04 N I 12.50 40.20 52.7094070 C 04 N I 15.25 37.45 52.7094150 C 04 N I 1.60 6.00 7.6094200 C 04 N I 1.55 15.10 16.6594240 C 04 N I 4.50 26.00 30.5094250 C 04 N I 3.20 4.40 7.6094260 C 04 N I 4.45 10.75 15.2094350 C 04 N I 1.60 51.10 52.7094360 C 04 N I 1.60 21.20 22.8094370 C 04 N I 4.45 10.75 15.2094375 C 04 N I 7.70 36.70 44.4094400 C 04 N I 4.45 17.70 22.1594450 C 04 N I 4.45 17.70 22.1594452 A 04 N I 14.29 14.28 28.5794453 A 04 N I 20.21 20.21 40.4294610 04 N N 35.0694620 C 04 N I 12.30 29.80 42.1094621 04 N I 59.0094640 04 N N 14.5094642 04 N N 22.0594644 04 N N 17.8794645 04 N N 6.9294660 09 Y I94662 04 Y I94664 04 N N 15.2094667 04 N N 15.2094668 04 N N 8.2094680 C 04 N I 7.65 29.75 37.4094681 C 04 N I 7.70 36.70 44.4094690 C 04 N I 4.50 26.00 30.5094720 C 04 N I 9.40 28.00 37.4094725 C 04 N I 3.40 34.00 37.4094750 C 04 N I 4.45 17.70 22.1594760 C 04 N I 1.50 2.90 4.4094761 C 04 N I 4.45 10.75 15.2094762 C 04 N I 7.55 14.60 22.15

Page 225: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

94770 C 04 N I 1.60 13.60 15.2094772 04 Y I94774 04 N I 52.9094777 04 N N 23.0094799 04 Y I95004 04 N N 1.70 65 110.5095010 04 N N 6.60 65 429.0095012 04 N I 9.3195015 04 N N 6.95 80 556.0095024 04 N N 2.50 40 100.0095027 04 N N 4.10 40 164.0095028 04 N N 3.85 40 154.0095044 04 N N 3.40 65 221.0095052 04 N N 4.10 200 820.0095056 04 N N 2.90 1 2.9095060 04 N N 7.2095065 04 N N 7.2095070 04 N N 105.4095071 04 N N 59.0495075 04 N N 38.8495115 04 N I 6.5095117 04 N I 8.3095120 04 N I 6.5095125 04 N I 8.3095130 04 N I 4.2095131 04 N I 8.6095132 04 N I 12.7595133 04 N I 17.0095134 04 N I 21.3095144 04 N I 14.3095145 04 N I 21.6095146 04 N I 32.4095147 04 N I 37.8095148 04 N I 43.2595149 04 N I 48.6095165 04 N I 36.0095170 04 N I 12.3095180 04 N N 47.50

Page 226: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

95199 04 Y I95250 04 01-Sep-09 N N 67.8795251 04 N N 15.4095803 04 01-Jan-09 Y N95805 B 04 N I 76.05 76.05 152.1095806 B 04 N I 55.27 55.28 110.5595807 B 04 N I 77.35 77.35 154.7095808 B 04 N I 96.65 96.65 193.3095810 B 04 N I 130.80 130.80 261.6095811 B 04 N I 136.15 136.15 272.3095812 A 04 N I 29.40 29.40 58.8095813 A 04 N I 40.90 40.90 81.8095816 A 04 N I 28.55 28.55 57.1095819 A 04 N I 26.35 26.35 52.7095822 A 04 N I 27.65 27.65 55.3095824 A 04 N I 26.35 26.35 52.7095827 A 04 N I 33.40 33.40 66.8095829 04 N I 3 163.5095830 04 N I 4 79.1095831 04 N I 25.6095832 04 N I 22.1595833 04 N I 52.7095834 04 N I 52.7095851 04 N I 30.5095852 04 N I 30.5095857 04 N I 25.6095860 C 04 01-Jan-09 N I 23.56 13.84 37.4095861 C 04 01-Jan-09 N I 39.19 17.61 56.8095863 C 04 01-Jan-09 N I 45.33 20.37 65.7095864 C 04 01-Jan-09 N I 54.59 30.71 85.3095865 C 04 N I 50.72 13.65 64.3795866 C 04 N I 39.54 4.56 44.1095867 C 04 01-Jan-09 N I 18.11 12.59 30.7095868 C 04 01-Jan-09 N I 29.63 16.67 46.3095869 C 04 01-Jan-09 N I 23.19 29.51 52.7095870 C 04 01-Jan-09 N I 23.71 28.99 52.7095872 C 04 01-Jul-09 N I 48.28 8.52 56.8095873 C 04 N I 11.58 4.30 15.88

Page 227: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

95874 C 04 N N 11.76 4.30 16.0695875 04 N I 36.6095900 04 Y I95903 04 Y I95904 04 Y I95905 04 01-Jan-10 Y I95920 04 Y M 395921 04 N I 44.5095922 04 N I 44.5095923 04 N I 44.8095925 04 N I 74.9095926 04 N I 74.9095927 04 N I 74.9095928 04 N I 97.0595929 04 N I 100.8595930 04 N I 52.7095933 04 N I 30.5095934 04 N I 37.4095936 04 N I 37.4095937 04 N I 37.4095950 C 04 N I 61.31 118.99 180.30

95951 S 04 01-Feb-09 N I 81.51 *© 326.05 *© 407.56 51.66

95951 S 04 01-Jun-09 N I81.51 *(A)

326.05 *(A) 407.56

95953 C 04 N I 77.53 102.77 180.3095954 C 04 N I 119.09 106.61 1 224.7095955 04 N I 4 62.0595956 C 04 N I 100.41 294.32 394.7395957 C 04 N I 65.03 37.30 102.3395958 04 N I 142.0595961 04 N I 180.3095962 04 Y I95965 A 04 N I 138.25 138.25 276.5095966 A 04 N I 93.83 93.82 187.6595967 A 04 N I 82.35 82.35 164.7095970 04 N I 41.9095971 04 N I 41.90

Page 228: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

95972 04 N I 41.9095973 04 N I 41.9095974 04 N I 68.5095975 04 N I 41.9095978 04 N I 110.5195979 04 N I 53.2895980 04 01-Jan-08 N I Y 22.9295981 04 01-Jan-08 N I Y 8.89 6.4195982 04 01-Jan-08 N I Y 18.00 5.8195990 04 N I 29.4195991 04 N I 29.4195999 04 Y I Y96000 04 N I 82.0096001 04 N N 97.8096002 04 N I 19.2096003 04 N I 17.9096004 04 N I 67.5096020 04 N I 85.3196040 04 01-Aug-08 N N 40.2096105 04 N I 52.7096110 04 N N 16.07 2 32.1596111 04 N N 16.07 2 32.1596116 09 Y I96118 09 Y N96119 09 Y N96120 09 Y N96125 09 01-Jan-08 N N 46.07 7.8196150 04 Y N96151 04 Y N96152 04 Y N96153 04 Y N96154 04 Y N96155 04 Y N96360 04 01-Jan-09 N N 19.1196361 04 01-Jan-09 N N 152.90 8 1223.2096365 04 01-Jan-09 N I 19.1196366 04 01-Jan-09 N I 152.90 8 1223.2096367 04 01-Jan-09 N I 19.11

Page 229: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

96368 04 01-Jan-09 N I 19.1196369 04 01-Jan-09 N I 84.5196370 04 01-Jan-09 N M 9.1596371 04 01-Jan-09 N I 36.9596372 04 01-Jan-09 N I 9.8196373 04 01-Jan-09 N I 10.2696374 04 01-Jan-09 N I 29.5596375 04 01-Jan-09 N I 27.98 2 55.9696376 04 01-Jan-09 Y M96379 04 01-Jan-09 Y96401 04 N I 22.1596402 04 N I 18.3996405 04 N I 65.3596406 04 N I 78.3896409 04 N I 62.2296411 04 N I 36.3696413 04 N I 25.4096415 04 N I 19.11 8 152.9096416 04 N I 22.1596417 04 N I 25.4096420 04 N I 37.4096422 04 N I 37.4096423 04 N I 14.17 8 113.4096425 04 N I 33.8096440 04 N I 102.0096445 04 N I 101.3096450 04 N I 3 83.2096521 04 N I 32.9096522 04 N I 34.7096523 09 Y N96542 04 Y I96549 04 Y I96567 04 Y I96570 04 01-Jan-10 N I 34.2796571 04 Y I96900 04 N I 6.6096902 04 N N 10.5096910 04 N I 9.55

Page 230: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

96912 04 N I 10.9596913 04 N I 30.0596920 04 Y I96921 04 Y I96922 04 Y I96999 04 Y I97001 09 Y I97002 09 Y I97003 09 Y I97004 09 Y I97005 04 Y N97006 04 Y N97010 04 N I 4.4097012 04 N I 7.7097014 04 N I 6.5097016 04 N I 7.0097018 04 N I 5.9597022 04 N I 6.5097024 04 N I 4.5097026 04 N I 4.4097028 04 N I 4.7097032 04 N I 7.4097033 04 N I 7.7097034 04 N I 6.4097035 04 N I 5.5097036 04 N I 8.9597039 04 Y I97110 04 N N 10.4097112 04 N I 10.9097113 04 N N 11.5097116 04 N I 9.7597124 04 N I 8.9097139 04 Y I97140 04 N I 11.8097150 04 N I 8.4097530 04 N I 22.1597532 09 Y I97533 04 N I 18.75

Page 231: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

97535 04 N I 11.2097537 04 N I 11.0097542 04 N I 7.5597545 04 N I 27.0097546 09 Y I97597 04 N I 27.7897598 04 N I 35.9797602 04 N I 28.3597605 04 Y I97606 04 Y I97750 04 N I 22.1597760 09 Y N97761 09 Y N97762 09 Y N97799 04 Y I97802 09 Y N97803 09 Y N97804 09 Y N98925 04 N I 12.5598926 04 N I 17.6098927 04 N I 22.0598928 04 N I 25.5098929 04 N I 28.6098940 09 Y N98941 02 Y N98942 09 Y N98943 09 Y N99000 09 Y N99001 09 Y N99002 09 Y N99056 04 N N 14.3599058 04 N N 14.3599070 04 Y N99071 09 Y N99075 09 Y N99078 09 Y N99082 04 Y N99090 09 Y N

Page 232: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

99091 09 Y N99100 09 Y N99116 09 Y N99135 09 Y N99140 09 Y N99143 04 01-Feb-10 Y99144 04 Y I99145 04 Y I99148 04 Y I99149 04 Y I99150 04 Y I99170 04 N I 3 58.9099172 04 Y I99173 04 N N 7.45 1 7.4599175 09 Y N99183 04 N I 60.5099190 04 Y I Y99191 04 Y I Y99192 04 Y I Y99195 04 N I 33.2599199 04 Y I Y Y99201 P 04 01-Feb-09 N N 27.95 1 27.95 1.60 1.6099202 P 04 01-Feb-09 N N 32.00 1 32.00 1.60 1.6099203 P 04 01-Feb-09 N N 41.60 1 41.60 1.95 1.9599204 P 04 01-Feb-09 N N 66.40 1 66.40 3.25 3.2599205 P 04 01-Feb-09 N N 70.85 1 70.85 3.25 3.2599211 P 04 01-Feb-09 N N 12.30 1 12.30 .58 .5899212 P 04 01-Feb-09 N N 24.25 1 24.25 1.40 1.4099213 P 04 01-Feb-09 N N 28.35 1 28.35 18.21 18.2199214 P 04 01-Feb-09 N N 42.50 1 42.50 30.47 30.4799215 P 04 01-Feb-09 N N 48.00 1 48.00 1.95 1.9599217 09 Y N99218 04 N N 69.5599219 04 N N 69.5599220 04 N N 69.5599221 04 N N 33.9099222 04 N N 51.4099223 04 N N 69.00

Page 233: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

99231 04 N N 16.4099232 04 N N 24.9099233 04 N N 35.0599234 04 N N 69.5599235 04 N N 76.6599236 04 N N 94.2099238 04 N N 29.6599239 04 N N 39.0599241 04 01-Jun-09 N N 32.15 7.04 7.0499242 04 01-Jun-09 N N 40.20 32.71 32.7199243 04 01-Jun-09 N N 51.30 48.56 48.5699244 04 01-Jun-09 N N 71.40 75.84 75.8499245 04 01-Jun-09 N N 92.80 90.02 90.0299251 04 N N 32.1599252 04 N N 33.9599253 04 N N 46.4599254 04 N N 66.4099255 04 N N 87.1099281 04 N N 14.3599282 04 N N 24.2099283 04 N N 32.2099284 04 N N 44.0099285 04 N N 69.2599288 09 Y N99291 04 01-Jun-09 N N 84.90 55.20 55.2099292 04 N N 42.3599304 04 N N 27.5599305 04 N N 36.1099306 04 N N 47.7099307 04 N N 14.8099308 04 N N 18.9199309 04 N N 23.4099310 04 N N 32.0599315 04 N N 26.5599316 04 N N 34.0099318 04 N N 23.1099324 04 N N 18.6099325 04 N N 26.70

Page 234: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

99326 04 N N 34.8599327 04 N N 42.9599328 04 N N 51.0599334 04 N N 16.0099335 04 N N 21.0099336 04 N N 26.0599337 04 N N 31.0599341 04 N N 27.95 8.86 8.8699342 04 N N 37.40 16.23 16.2399343 04 N N 54.90 31.38 31.3899344 04 N N 70.55 42.78 42.7899345 04 N N 85.55 50.85 50.8599347 04 N N 24.25 11.56 11.5699348 04 N N 31.30 22.82 22.8299349 04 N N 47.50 31.43 31.4399350 04 N N 68.85 41.29 41.2999354 04 Y I99355 04 Y I99356 04 Y I99357 04 Y I99360 09 Y I99374 09 Y N99377 09 Y N99379 09 Y N99380 09 Y N99381 P 04 N N 32.15 59.7599382 P 04 N N 32.15 66.5099383 P 04 N N 32.15 64.4599384 P 04 N N 32.15 72.8199385 P 04 01-Feb-09 N N 32.15 C 66.40 (A) 72.81 38.5699386 P 04 01-Feb-09 N N 66.40 38.5699387 P 04 01-Feb-09 N N 66.40 38.5699391 P 04 N N 32.15 C 32.15 37.3799392 P 04 N N 32.15 C 32.15 45.7299393 P 04 N N 32.15 C 32.15 44.6999394 P 04 N N 32.15 C 32.15 52.4799395 P 04 N N 32.15 C 42.50 A 53.50 43.1599396 P 04 N N 42.50 43.15

Page 235: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

99397 P 04 N N 42.50 43.1599420 04 N N 14.60 1 14.6099450 09 Y N99455 09 Y N99456 09 Y N99460 04 01-Jan-09 N 38.7599461 04 01-Jan-09 N 16.4099462 04 01-Jan-09 N 16.4099463 04 01-Jan-09 N 42.5599464 04 01-Jan-09 N 83.7099465 04 01-Jan-09 N 94.5099466 04 01-Jan-09 N I 149.0499467 04 01-Jan-09 N 74.0499468 04 01-Feb-09 N 586.7099469 04 01-Feb-09 N 251.6999471 04 01-Feb-09 N 510.6799472 04 01-Feb-09 N 249.5199475 04 01-Jan-09 N 84.9099476 04 01-Jan-09 N 42.3599477 04 01-Feb-09 N N 220.7399478 04 01-Feb-09 N 88.8599479 04 01-Jan-09 N 81.2299480 04 01-Feb-09 N 79.0499499 04 Y N99500 04 Y N99501 04 Y N99502 04 Y N99503 04 Y N99504 04 Y N99505 04 Y N99506 04 Y N99507 04 Y N99509 04 Y N99510 04 N N 24.2599511 04 Y N99512 04 Y N99600 04 Y N99999 04 Y N Y Y

Page 236: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

0500F 04 N B 44.100502F 04 N B 44.100503F 04 N B 50.150016T 04 Y M 6 Y0017T 04 Y M 60019T 04 Y I 30030T 04 Y N0042T B 04 N N 141.22 141.22 282.450048T 04 Y M 5 Y0051T 04 Y M 10 Y Y0052T 04 Y M 10 Y Y0053T 04 Y M 20 Y Y0073T 04 N N 364.510075T 04 N I 3 83.000076T 04 N I 3 83.000078T 04 N M 15 Y Y 1,148.600079T 04 Y M 15 Y Y0080T 04 Y N 150081T 04 Y M 150095T 04 Y M 8 Y0101T 04 Y M 30102T 04 Y M 30123T 04 Y M 50124T 04 Y M 30143T 04 Y NA4206 04 N N 0.13 5 0.65A4207 04 N N 0.05 5 0.25A4208 04 N N 0.27 5 1.35A4209 04 N N 0.26 5 1.30A4212 04 N N 2.53 1 2.53A4213 04 N N 0.32 5 1.60A4215 04 N N 0.05 5 0.25A4261 04 N N 61.17A4264 04 01-Jan-10 N N 1245.00 1 1245.00A4267 04 N N 0.45 30 13.62A4268 04 N N 1.12 30 33.82A4269 04 Y Y NA9502 09 Y N

Page 237: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

A9503 09 Y NA9507 09 Y NA9526 09 Y NA9527 04 01-Jan-07 Y NA9528 09 Y NA9529 09 Y NA9530 09 Y NA9531 09 Y NA9532 09 Y NA9543 04 Y Y NA9545 04 Y Y NA9563 04 Y NA9564 04 Y NA9604 04 01-Jan-10 Y N ND1203 04 N N 26.00G0008 04 N N 6.40G0009 04 N N 6.40G0010 04 N N 6.40G0101 04 N I 32.86G0102 04 N I 28.35G0103 B 04 N N 8.80 8.80 17.60G0104 04 Y I 3G0105 04 N I 3 214.00G0108 09 Y NG0109 09 Y NG0111 09 Y NG0117 04 Y IG0118 04 Y IG0121 04 N I 3 214.00G0123 04 N N 3.50G0124 04 N N 11.45G0125 04 N N 4 920.70G0127 04 N N 3 14.35G0128 09 Y NG0130 B 04 N N 48.52 48.52 97.05G0141 04 N N 11.45G0143 04 N N 3.45G0144 04 N N 3.45

Page 238: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

G0145 04 N N 3.45G0147 04 N N 3.45G0148 04 N N 3.45G0159 04 N M 5 Y 449.50G0166 04 N I 66.70G0168 04 N I 22.55G0169 04 Y IG0170 04 Y M 3 Y YG0173 04 Y M 9 YG0175 09 Y NG0179 09 Y NG0180 09 Y NG0181 09 Y NG0182 09 Y NG0186 04 Y IG0202 B 04 N N 35.95 35.95 71.90G0204 B 04 N N 35.95 35.95 71.90G0206 B 04 N N 19.60 19.60 39.20G0219 B 04 N N 35.25 35.25 70.50G0237 04 Y IG0238 04 Y IG0239 04 Y IG0245 09 Y NG0246 09 Y NG0247 09 Y NG0248 09 Y NG0249 09 Y NG0250 09 Y NG0251 04 Y N 9 Y YG0252 04 N N 35.25 35.25 70.50G0255 04 Y IG0256 04 N I 3 256.30G0257 04 N I 35.75G0259 04 N I 3 172.50G0260 04 N I 31.80G0261 04 N I 3 256.30G0265 09 Y NG0266 09 Y N

Page 239: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

G0268 04 N I 3 21.40G0269 04 Y I 3G0270 09 Y NG0271 09 Y NG0275 04 N I 3 78.45G0278 04 N I 3 78.45G0281 04 Y IG0282 04 Y IG0283 04 Y IG0288 B 04 Y IG0289 04 Y M 3 YG0290 04 Y M 3 YG0291 04 Y N M 3 YG0293 09 Y MG0294 09 Y IG0295 09 Y IG0297 04 N M 5 Y 256.00G0300 04 N M 5 Y 470.00G0306 A 04 N N 2.69 2.69 5.39G0307 A 04 N N 3.21 3.21 6.42G0328 A 04 N N 6.66 6.66 13.33G0329 04 N I 9.05G0339 B 04 Y N 9 YG0340 B 04 Y N 9 YG0365 A 04 N I 25.03 25.02 50.05G0377 04 01-Jan-07 N N 9.81G0380 04 01-Jan-07 N N 14.35G0381 04 01-Jan-07 N N 24.20G0382 04 01-Jan-07 N N 32.20G0383 04 01-Jan-07 N N 44.00G0384 04 01-Jan-07 N N 69.25G0394 04 01-Jan-07 N N 2.72G0402 09 01-Jan-09 Y NG0412 04 01-Jan-09 N 3 Y 674.20G0413 04 01-Jan-09 N Y 550.90G0414 04 01-Jan-09 N Y 599.35G0415 04 01-Jan-09 N M 3 Y 599.35G0422 04 01-Jan-10 N N 43.35

Page 240: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

G0423 04 01-Jan-10 N N 21.10G0424 04 01-Jan-10 N N 5.66G0430 A 04 01-Jan-10 N N 6.71 6.71 13.42G0431 A 04 01-Jan-10 N N 6.71 6.71 13.42G3001 04 Y Y NG9001 09 Y NG9002 09 Y NG9003 09 Y NG9004 09 Y NG9005 09 Y NG9006 09 Y NG9007 09 Y NG9008 04 Y NG9009 09 Y NG9010 09 Y NG9011 09 Y NG9012 09 Y NG9016 09 Y NG9021 09 Y NG9022 09 Y NG9023 09 Y NG9024 09 Y NG9025 09 Y NG9026 09 Y NG9027 09 Y NG9028 09 Y NG9029 09 Y NG9030 09 Y NG9031 09 Y NG9032 09 Y NG9033 09 Y Y NG9034 09 Y NG9050 09 Y NG9051 09 Y NG9052 09 Y NG9053 09 Y NG9054 09 Y NG9055 09 Y N

Page 241: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

G9056 09 Y NG9057 09 Y NG9058 09 Y NG9059 09 Y NG9060 09 Y NG9061 09 Y NG9062 09 Y NG9063 09 Y NG9064 09 Y NG9065 09 Y NG9066 09 Y NG9067 09 Y NG9068 09 Y NG9069 09 Y NG9070 09 Y NG9071 09 Y NG9072 09 Y NG9073 09 Y NG9074 09 Y NG9075 09 Y NG9077 09 Y NG9078 09 Y NG9079 09 Y NG9080 09 Y NG9083 09 Y NG9084 09 Y NG9085 09 Y NG9086 09 Y NG9087 09 Y NG9088 09 Y NG9089 09 Y NG9090 09 Y NG9091 09 Y NG9092 09 Y NG9093 09 Y NG9094 09 Y NG9095 09 Y NG9096 09 Y N

Page 242: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

G9097 09 Y NG9098 09 Y NG9099 09 Y NG9100 09 Y NG9101 09 Y NG9102 09 Y NG9103 09 Y NG9104 09 Y NG9105 09 Y NG9106 09 Y NG9107 09 Y NG9108 09 Y NG9109 09 Y NG9110 09 Y NG9111 09 Y NG9112 09 Y NG9113 09 Y NG9114 09 Y NG9115 09 Y NG9116 09 Y NG9117 09 Y NG9123 09 Y NG9124 09 Y NG9125 09 Y NG9126 09 Y NG9128 09 Y NG9129 09 Y NG9130 09 Y NG9141 04 01-Oct-09 N N 6.40G9142 04 01-Oct-09 N N 0.00H0033 04 N N 118.10 1 118.10H1000 04 N N 14.60J0120 04 N Y N 5.49 1 5.49J0128 04 N Y N 80.66 10 806.60J0129 04 01-Jan-07 N Y N 22.98 75 1723.50J0132 04 N Y N 0.32 2 0.64J0133 04 N Y N 0.14 10 1.40J0135 04 N Y N 862.86 8 6902.88

Page 243: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J0150 04 N Y N 39.55 5 197.75J0152 04 N Y N 87.14 3 261.42J0170 04 N Y N 0.14 24 3.36J0180 04 N Y N 149.52 105 15699.60J0190 04 Y Y NJ0200 04 Y Y NJ0205 04 N Y N 44.74 8 357.92J0207 04 N Y N 540.07 2 1080.14J0210 04 N Y N 0.83 16 13.28J0215 N 04 Y Y NJ0220 04 01-Jan-08 Y Y NJ0256 04 N Y N 2.94 600 1764.00J0278 04 N Y N 1.37 3 4.11J0280 04 N Y N 0.67 6 4.02J0282 04 N Y N 0.77 5 3.85J0285 04 N Y N 17.36 6 104.16J0287 04 N Y N 23.92 50 1196.00J0288 04 N Y N 15.94 40 637.60J0289 04 N Y N 39.12 50 1956.00J0290 04 N Y N 3.39 4 13.56J0295 04 N Y N 9.39 8 75.12J0300 04 Y Y NJ0348 04 01-Jan-07 Y Y NJ0350 04 Y Y NJ0360 04 N Y N 15.92 12 191.04J0364 04 01-Jan-07 N Y N 4.95 6 29.70J0365 04 N Y N 2.82 1 2.82J0370 04 N Y N 1.85J0380 04 N Y N 13.31 10 133.10J0390 04 N Y N 3.50J0395 04 N Y N 191.39 1 191.39J0400 04 01-Jan-08 N Y N 2.61 120 313.20J0456 04 N Y N 30.58 1 30.58J0461 04 01-Jan-10 N Y N 0.1 300 3.00J0470 04 N Y N 28.55 5 142.75J0475 04 N Y N 257.19 12 3086.28J0476 04 N Y N 83.73 1 83.73J0480 04 N Y N 1,765.65 1 1765.65

Page 244: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J0500 04 N Y N 17.81 4 71.24J0515 04 N Y N 4.10 8 32.80J0520 04 N Y N 5.42 2 10.84J0559 04 01-Jan-10 Y Y NJ0560 04 N Y N 16.36 4 65.44J0570 04 N Y N 33.25 2 66.50J0580 04 N Y N 53.78 1 53.78J0583 04 N Y N 1.81 10 18.10J0585 N 04 01-Jan-10 Y Y NJ0586 N 04 01-Jan-10 Y Y NJ0587 N 04 01-Jan-10 Y Y NJ0592 04 N Y N 1.24 6 7.44J0594 04 01-Jan-07 N Y N 15.07 60 904.20J0595 04 N Y N 3.17 2 6.34J0598 04 01-Jan-10 N Y N 41.11 100 4111.00J0600 04 N Y N 48.14 2 96.28J0610 04 N Y N 0.55 10 5.50J0620 04 N Y N 12.49 6 74.94J0630 04 N Y N 45.30 2 90.60J0636 04 N Y N 1.11 40 44.40J0637 04 N Y N 41.05 14 574.70J0640 04 N Y N 3.73 30 111.90J0641 04 01-Jan-09 N Y N 1.23 150 184.50J0690 04 N Y N 1.83 4 7.32J0692 04 N Y N 9.49 8 75.92J0694 04 N Y N 9.54 12 114.48J0695 04 Y Y NJ0696 04 N Y N 16.42 16 262.72J0697 04 N Y N Y Y 5.43 4 21.72J0698 04 N Y N 8.49 10 84.90J0702 04 N Y N 3.02 4 12.08J0704 04 N Y N 4.03 3 12.09J0706 04 N Y N 4.05 4 16.20J0710 04 N Y N 1.63 2 3.26J0713 04 N Y N 7.08 12 84.96J0715 04 N Y N 5.90 12 70.80J0718 04 01-Jan-10 N Y N 4.37 400 1748.00J0720 04 N Y N 6.71 7 46.97

Page 245: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J0725 04 Y Y NJ0735 04 N Y N 74.44 2 148.88J0740 04 N Y N 885.21 2 1770.42J0743 04 N Y N 18.88 6 113.28J0744 04 N Y N 15.55 5 77.75J0745 04 N Y N 0.55 12 6.60J0760 04 N Y N 7.72 2 15.44J0770 04 N Y N 29.73 4 118.92J0780 04 N Y N 7.90 10 79.00J0795 04 N Y N 5.15 10 51.50J0800 04 N Y N 129.26 2 258.52J0833 04 01-Jan-10 N Y N 119.53 1 119.53J0834 04 01-Jan-10 N Y N 127.49 1 127.49J0878 04 N Y N 0.35 500 175.00J0881 04 N Y N 5.54 500 2770.00J0882 04 N Y N 5.54 500 2770.00J0885 04 N Y N 15.16 80 1212.80J0886 04 N Y N 15.16 80 1212.80J0894 04 01-Jan-07 Y Y NJ0895 04 N Y N Y Y 15.36 6 92.16J0900 04 Y Y NJ0945 04 N Y N 0.77 10 7.70J0950 04 N Y N 8.10J0970 04 N Y N 34.14 1 34.14J1000 04 N Y N 6.35 1 6.35J1015 04 N Y N 18.63J1020 04 N Y N 2.20 8 17.60J1030 04 N Y N 4.93 4 19.72J1040 04 N Y N 9.87 4 39.48J1051 04 N Y N 20.56 9 185.04J1055 04 N Y N 61.69 1 61.69J1060 04 Y Y NJ1070 04 N Y N 6.18 3 18.54J1080 04 N Y N 11.80 2 23.60J1094 04 N Y N 0.86 32 27.52J1100 04 N Y N 0.10 40 4.00J1110 04 N Y N 50.87 3 152.61J1120 04 N Y N 22.42 2 44.84

Page 246: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J1160 04 N Y N 2.53 3 7.59J1162 04 N Y N 755.86 80 60468.80J1165 04 N Y N 0.40 20 8.00J1170 04 N Y N 1.78 2 3.56J1180 04 Y Y NJ1190 04 N Y N 255.72 4 1022.88J1200 04 N Y N 0.79 2 1.58J1205 04 N Y N 10.99 1 10.99J1212 04 N Y N 50.97 1 50.97J1230 04 N Y N 3.62 6 21.72J1240 04 N Y N 0.27 8 2.16J1245 04 N Y N 5.09 6 30.54J1250 04 N Y N 3.99 1 3.99J1260 04 N Y N 4.85 20 97.00J1265 04 N Y N 0.06 7 0.42J1267 04 01-Jan-09 N Y N 0.95 50 47.50J1270 04 N Y N 6.00 4 24.00J1300 04 01-Jan-08 N Y N 207.34 90 18660.60J1320 04 N Y N 2.62 15 39.30J1324 04 01-Jan-07 N Y N 31.46 90 2831.40J1325 04 N Y N 22.18 3 66.54J1327 04 N Y N 24.32 5 121.60J1330 04 Y Y NJ1335 04 N Y N 23.76 2 47.52J1364 04 N Y N 12.25 8 98.00J1380 04 N Y N 0.55 4 2.20J1390 04 N Y N 1.12 2 2.24J1405 04 N Y N 10.00J1410 04 N Y N 68.03 4 272.12J1430 04 N Y N 41.74 1 41.74J1435 04 N Y N 0.19 5 0.95J1436 04 Y Y NJ1438 04 N Y N 186.86 4 747.44J1440 04 N Y N 197.17 2 394.34J1441 04 N Y N 363.48 1 363.48J1450 04 N Y N 103.11 2 206.22J1451 04 N Y N 13.79 1 13.79J1452 04 Y Y N

Page 247: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J1453 04 01-Jan-09 N Y N 1.89 115 217.35J1455 04 N Y N 88.16 2 176.32J1457 04 Y Y NJ1458 04 01-Jan-07 Y Y NJ1459 04 01-Jan-09 N Y N 45.87 112 5137.44J1460 04 N Y N 14.21 156 2216.76J1470 04 Y Y NJ1480 04 Y Y NJ1490 04 Y Y NJ1500 04 Y Y NJ1510 04 Y Y NJ1520 04 Y Y NJ1530 04 Y Y NJ1540 04 Y Y NJ1550 04 Y Y NJ1560 04 Y Y NJ1561 04 01-Jan-08 Y Y NJ1562 04 01-Jan-07 N Y N 14.95 140 2093.00J1566 04 Y Y NJ1568 04 01-Jan-08 Y Y NJ1569 04 01-Jan-08 Y Y NJ1570 04 N Y N 61.95 2 123.90J1571 04 01-Jan-08 N Y N 79.74 9 717.66J1572 04 01-Jan-08 Y Y NJ1573 04 01-Jan-08 Y Y NJ1580 04 N Y N 0.70 5 3.50J1590 04 Y Y NJ1595 04 Y Y NJ1600 04 N Y N 10.80 1 10.80J1626 04 N Y N 19.45 20 389.00J1630 04 N Y N 2.37 40 94.80J1631 04 N Y N 23.86 6 143.16J1640 04 N Y N 7.65 1 7.65J1642 04 N Y N 0.03 5 0.15J1644 04 N Y N 1.18 10 11.80J1645 04 N Y N 19.89 4 79.56J1650 04 N Y N 7.40 84 621.60J1652 04 N Y N 43.36 20 867.20

Page 248: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J1655 04 N Y N 4.51 20 90.20J1670 04 N Y N 107.66 1 107.66J1675 04 N Y N 3.39 10 33.90J1680 04 01-Jan-10 N Y N 107.00 13 1391.00J1700 04 Y Y NJ1710 04 N Y N 5.83 5 29.15J1720 04 N Y N 2.26 10 22.60J1730 04 Y Y NJ1740 04 01-Jan-07 N Y N 167.69 3 503.07J1742 04 N Y N 302.88 1 302.88J1743 04 01-Jan-08 Y Y NJ1756 04 N Y N 0.67 100 67.00J1785 04 N Y N 4.61 400 1844.00J1790 04 N Y N 4.23 1 4.23J1800 04 N Y N 8.22 3 24.66J1810 04 Y Y NJ1815 04 N Y N 0.23 20 4.60J1817 04 N Y N 2.17 2 4.34J1825 04 N Y N 601.23 1 601.23J1835 04 N Y N 44.31 8 354.48J1840 04 N Y N 2.93 3 8.79J1850 04 N Y N 0.43 14 6.02J1885 04 N Y N 1.05 8 8.40J1890 04 Y Y NJ1930 04 01-Jan-09 N Y N 31.24 90 2811.60J1931 04 Y Y NJ1940 04 N Y N 0.45 10 4.50J1945 04 N Y N 179.93 1 179.93J1950 04 N Y N 591.46 2 1182.92J1953 04 01-Jan-09 N Y N 0.81 50 40.50J1955 04 N Y N 11.67 4 46.68J1956 04 N Y N 22.65 2 45.30J1960 04 N Y N 3.94 2 7.88J1980 04 N Y N 10.99 8 87.92J1990 04 N Y N 26.22 3 78.66J2001 04 N Y N 0.06 20 1.20J2010 04 N Y N 3.52 4 14.08J2020 04 N Y N 42.60 6 255.60

Page 249: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J2060 04 N Y N 1.18 4 4.72J2150 04 N Y N 1.01 8 8.08J2175 04 N Y N 0.87 6 5.22J2180 04 Y Y NJ2185 04 N Y N 6.15 10 61.50J2210 04 N Y N 6.71 1 6.71J2248 04 01-Jan-07 N Y N 2.32 150 348.00J2250 04 N Y N 0.62 10 6.20J2260 04 N Y N 35.45 1 35.45J2270 04 N Y N 0.78 10 7.80J2271 04 N Y N 1.81 3 5.43J2275 04 N Y N 2.49 10 24.90J2278 04 N Y N 7.58 50 379.00J2280 04 N Y N 10.90 4 43.60J2300 04 N Y N 0.66 16 10.56J2310 04 N Y N 5.57 2 11.14J2315 04 01-Jan-07 N Y N 2.27 380 862.60J2320 04 N Y N 4.02 4 16.08J2321 04 N Y N 8.04 2 16.08J2322 04 N Y N 16.94 1 16.94J2323 04 01-Jan-08 N Y N 8.01 300 2403.08J2325 04 N Y N 31.68 5 158.40J2353 04 Y Y NJ2354 04 N Y N 3.39 20 67.80J2355 04 N Y N 305.04 1 305.04J2357 04 Y Y NJ2360 04 N Y N 20.43 1 20.43J2370 04 N Y N 2.65 1 2.65J2400 04 N Y N 16.66 2 33.32J2405 04 N Y N 6.38 40 255.20J2410 04 N Y N 3.23 10 32.30J2425 04 N Y N 13.70 100 1370.00J2430 04 N Y N 237.76 3 713.28J2440 04 N Y N 2.96 3 8.88J2460 04 N Y N 0.71 10 7.10J2469 04 N Y N 35.64 10 356.40J2501 04 N Y N 5.82 20 116.40J2503 04 N Y N 1239.83 1 1239.83

Page 250: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J2504 04 N Y N 195.38 1 195.38J2505 04 N Y N 3243.53 1 3243.53J2510 04 N Y N 10.86 1 10.86J2513 04 N Y N 76.09 1 76.09J2515 04 N Y N 5.24 4 20.96J2540 04 N Y N 2.92 1 2.92J2543 04 N Y N 12.38 12 148.56J2545 04 N Y N 40.10 1 40.10J2550 04 N Y N 0.48 1 0.48J2560 04 N Y N 1.85 5 9.25J2562 04 01-Jan-10 N Y N 311.50 40 12460.00J2590 04 N Y N 3.57 3 10.71J2597 04 N Y N 3.61 4 14.44J2650 04 Y Y NJ2670 04 Y Y NJ2675 04 N Y N 3.28 3 9.84J2680 04 N Y N 21.30 4 85.20J2690 04 N Y N 2.96 1 2.96J2700 04 N Y N 1.26 20 25.20J2710 04 N Y N 1.56 8 12.48J2720 04 N Y N 0.79 5 3.95J2724 04 01-Jan-08 Y Y NJ2730 04 N Y N 108.03 3 324.09J2760 04 N Y N 67.28 2 134.56J2765 04 N Y N 0.40 14 5.60J2770 04 N Y N 110.30 4 441.20J2778 04 01-Jan-08 N Y N 485.97 5 2429.85J2780 04 N Y N 1.50 2 3.00J2783 04 N Y N 133.87 3 401.61J2785 04 01-Jan-09 N Y N 63.03 4 252.12J2788 04 N Y N 33.03 6 198.18J2790 04 N Y N 99.92 1 99.92J2791 04 01-Jan-08 Y Y NJ2792 04 N Y N 23.58 340 8017.20J2793 04 01-Jan-10 N Y N 27.18 320 8,697.60J2794 04 Y Y NJ2795 04 N Y N 0.36 2 0.72J2796 04 01-Jan-10 N Y N 51.85 25 1296.25

Page 251: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J2800 04 N Y N 15.49 3 46.47J2810 04 Y Y NJ2820 04 N Y N 37.21 15 558.15J2910 04 N Y N 16.70 1 16.70J2916 04 N Y N 8.56 10 85.60J2920 04 N Y N 1.73 3 5.19J2930 04 N Y N 2.88 4 11.52J2940 04 N Y N 52.69 2 105.38J2941 04 N Y N 35.68 20 713.60J2993 04 N Y N 1,503.32 2 3006.64J2994 04 Y Y NJ2995 04 Y Y NJ2996 04 N Y N 280.60J2997 04 N Y N 40.41 4 161.64J3000 04 N Y N 9.06 2 18.12J3010 04 N Y N 0.29 20 5.80J3030 04 N Y N 65.71 1 65.71J3070 04 N Y N 2.49 12 29.88J3101 04 01-Jan-09 N Y N 59.91 50 2995.57J3105 04 N Y N 19.09 3 57.27J3110 04 N Y N 12.25 2 24.50J3120 04 N Y N 8.46 4 33.84J3130 04 N Y N 16.93 2 33.86J3140 04 N Y N 0.41 4 1.64J3150 04 N Y N 0.83 4 3.32J3230 04 N Y N 12.86 8 102.88J3240 04 N Y N 822.41 1 822.41J3243 04 01-Jan-07 N Y N 1.33 100 133.00J3246 04 N Y N 105.80 1 105.80J3250 04 N Y N 5.46 4 21.84J3260 04 N Y N 7.73 5 38.65J3265 04 N Y N 2.03 10 20.30J3280 04 Y Y NJ3285 04 N Y N 64.79 2 129.58J3300 04 01-Jan-09 N Y N 3.86 4 15.44J3301 04 N Y N 1.78 8 14.24J3302 04 N Y N 0.54 32 17.28J3303 04 N Y N 1.76 4 7.04

Page 252: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J3305 04 N Y N 175.99 5 879.95J3310 04 N Y N 1.75J3315 04 N Y N 604.34 3 1813.02J3320 04 N Y N 35.36 1 35.36J3350 04 Y Y NJ3360 04 N Y N 0.14 6 0.84J3364 04 N Y N 56.42 2 112.84J3365 04 N Y N Y Y 538.08 2 1076.16J3370 04 N Y N 3.34 4 13.36J3396 04 N Y N 11.20 150 1680.00J3400 04 N Y N 3.80J3410 04 N Y N 0.27 4 1.08J3411 04 N Y N 0.84 2 1.68J3415 04 N Y N 0.61 5 3.05J3420 04 N Y N 0.18 1 0.18J3430 04 N Y N 0.19 25 4.87J3465 04 N Y N 5.72 60 343.20J3470 04 N Y N 24.92 1 24.92J3471 04 N Y N 0.13 999 129.87J3472 04 N Y N 0.13 1,000 130.00J3473 04 01-Jan-07 Y Y NJ3475 04 N Y N 0.07 20 1.40J3480 04 N Y N 0.13 20 2.60J3485 04 N Y N 1.21 50 60.50J3486 04 N Y N 23.84 4 95.36J3487 04 N Y N 237.65 4 950.60J3488 04 01-Jan-08 Y Y NJ3490 04 Y Y NJ3520 04 N Y N 1.40 20 28.00J3530 04 Y NJ3590 04 Y Y NJ7030 04 N Y N 1.30 2 2.60J7040 04 N Y N 1.17 2 2.34J7042 04 N Y N 1.52 2 3.04J7050 04 N Y N 3.64 2 7.28J7060 04 N Y N 4.24 2 8.48J7070 04 N Y N 1.43 2 2.86J7100 04 Y N

Page 253: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J7110 04 Y NJ7120 04 N N 1.61 2 3.22J7130 04 Y NJ7185 04 01-Jan-10 N Y N 1.21 2000 2420.00J7186 04 01-Jan-09 N Y N 1.04J7187 04 01-Jan-07 Y Y NJ7189 04 N Y N 1.15 1,000 1150.00J7190 04 N Y N 0.75 1250 937.50J7191 04 N Y N 2.18 550 1199.00J7192 04 N Y N 0.67 2000 1340.00J7193 04 N Y N 0.91 812 738.92J7194 04 N Y N 0.47 1000 470.00J7195 04 N Y N 1.03 1000 1030.00J7198 04 N Y N 1.15 615 707.25J7199 04 Y Y NJ7300 04 N Y N 423.10J7302 04 N Y N 530.86 1 530.86J7303 04 N Y N 43.80 3 131.40J7304 04 N Y N 15.67 9 141.03J7306 04 Y Y NJ7307 04 01-Jan-08 N Y N 651.69 1 651.69J7308 04 N Y N 105.91 1 105.91J7310 04 N Y N 4,984.32 1 4984.32J7311 04 01-Jan-07 Y Y NJ7321 04 01-Jan-08 Y N NJ7323 04 01-Jan-08 Y N NJ7324 04 01-Jan-08 Y N NJ7325 04 01-Jan-10 N N N 17.54 96 1683.84J7330 04 Y NJ7500 09 Y N NJ7501 04 N Y N 72.21 5 361.05J7502 04 N Y N 6.70 15 100.50J7504 04 N Y N 359.26 12 4311.12J7505 04 N Y N 980.75 1 980.75J7506 04 N Y N 0.02 20 0.40J7507 04 N Y N 4.12 20 82.40J7509 04 N Y N 0.31 12 3.72J7510 04 N Y N 0.11 40 4.40

Page 254: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J7511 04 N Y N 429.89 1 429.89J7513 04 N Y N 512.28 4 2049.12J7515 04 N Y N 1.67 20 33.40J7516 04 N Y N 24.77 3 74.31J7517 04 N Y N 3.21 8 25.68J7518 04 Y Y NJ7520 04 N Y N 8.31 6 49.86J7525 04 N Y N 164.48 1 164.48J7599 04 Y Y NJ7604 04 01-Jan-08 N Y N 5.53 1 5.53J7605 04 01-Jan-08 N Y N 5.73 1 5.73J7606 04 01-Jan-09 N Y N 6.13 1 6.13J7607 04 01-Jan-07 Y Y NJ7608 04 N Y N 3.28 4 13.12J7609 04 01-Jan-07 Y Y NJ7610 04 01-Jan-07 Y Y NJ7611 04 01-Apr-08 N Y N 0.03 5 0.15J7612 04 01-Apr-08 N Y N 1.15 5 5.75J7613 04 01-Apr-08 N Y N 0.06 5 0.30J7614 04 01-Apr-08 N Y N 2.11 5 10.55J7615 04 01-Jan-07 Y Y NJ7620 04 Y Y NJ7625 04 N Y N 1.10J7626 04 N Y N 4.91 4 19.64J7627 04 N Y N 0.09 4 0.36J7628 04 Y Y NJ7629 04 Y Y NJ7630 04 N Y N 1.10J7631 04 N Y N 0.33 2 0.66J7632 04 01-Jan-08 N Y N 0.33 2 0.66J7633 04 N Y N 5.16 2 10.32J7634 04 01-Jan-07 Y Y NJ7635 04 N Y N 0.40 2 0.80J7636 04 Y Y NJ7637 04 N Y N 11.21 1 11.21J7638 04 Y Y NJ7639 04 N Y N 22.56 2 45.12J7640 04 N Y N 1.85 5 9.25

Page 255: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J7642 04 Y Y NJ7644 04 N Y N 0.40 5 2.00J7645 04 01-Jan-07 Y Y NJ7647 04 01-Jan-07 Y Y NJ7648 04 Y Y NJ7649 04 Y Y NJ7650 04 01-Jan-07 Y Y NJ7657 04 01-Jan-07 Y Y NJ7658 04 Y Y NJ7659 04 Y Y NJ7660 04 01-Jan-07 Y Y NJ7665 04 N Y N 2.15J7667 04 01-Jan-07 Y Y NJ7668 04 Y Y NJ7669 04 N Y N 0.54 1 0.54J7670 04 01-Jan-07 Y Y NJ7674 04 N Y N 0.47 2 0.94J7676 04 01-Jan-08 Y Y NJ7680 04 Y Y NJ7681 04 Y Y NJ7682 04 N Y N 63.79 1 63.79J7683 04 Y Y NJ7684 04 Y Y NJ7685 04 01-Jan-07 Y Y NJ7699 04 Y Y NJ7799 04 Y Y NJ8499 04 Y Y NJ8501 04 Y Y NJ8510 04 Y Y NJ8520 04 N Y N 3.91 100 391.00J8521 04 N Y N 13.07 200 2614.00J8530 04 N Y N 1.91 60 114.60J8560 04 N Y N 63.56 4 254.24J8565 04 N Y N 70.68 1 70.68J8600 04 N Y N 5.39 3 16.17J8610 04 N Y N 0.36 12 4.32J8700 04 N Y N 8.84 50 442.00J8705 04 01-Jan-09 N Y N 82.16 10 821.60

Page 256: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J8999 04 Y Y NJ9000 04 N Y N 11.67 20 233.40J9001 04 N Y N 459.35 10 4593.50J9010 04 N Y N 637.29 3 1911.87J9015 04 N Y N 891.57 1 891.57J9017 04 N Y N 39.87 15 598.05J9020 04 N Y N 65.70 2 131.40J9025 04 N Y N 4.93 185 912.05J9027 04 Y Y NJ9031 04 N Y N 190.89 1 190.89J9033 04 01-Jan-09 N Y N 22.42 300 6726.00J9035 04 N Y N 68.53 160 10964.80J9040 04 N Y N 248.46 3 745.38J9041 04 N Y N 36.12 35 1264.20J9045 04 N Y N 28.98 20 579.60J9050 04 N Y N 169.76 8 1358.08J9055 04 N Y N 59.81 100 5981.00J9060 04 N Y N 40.78 30 1223.40J9062 04 N Y N 203.90 4 815.60J9065 04 N Y N 47.78 10 477.80J9070 04 N Y N 2.87 20 57.40J9080 04 N Y N 5.74 10 57.46J9090 04 N Y N 13.49 4 53.96J9091 04 N Y N 28.78 2 57.56J9092 04 N Y N 44.59 1 44.59J9093 04 N Y N 2.87 20 57.40J9094 04 N Y N 9.99 4 39.96J9095 04 N Y N 13.49 4 53.96J9096 04 N Y N 28.78 2 57.56J9097 04 N Y N 44.59 2 89.18J9098 04 N Y N 454.56 5 2272.80J9100 04 N Y N 3.18 60 190.80J9110 04 N Y N 9.01 4 36.04J9120 04 N Y N 14.54 3 43.62J9130 04 N Y N 11.76 10 117.60J9140 04 N Y N 19.65 5 98.25J9150 04 N Y N 32.68 6 196.08J9151 04 N Y N 67.74 8 541.92

Page 257: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J9155 04 01-Jan-10 Y Y NJ9160 04 N Y N 1,694.66 6 10167.96J9165 04 Y Y NJ9171 04 01-Jan-10 N Y N 23.15 260 6019.00J9175 04 Y Y NJ9178 04 N Y N 29.87 100 2987.00J9181 04 N Y N 13.38 45 602.10J9185 04 N Y N 292.33 1 292.33J9190 04 N Y N 3.18 12 38.16J9200 04 N Y N 127.44 1 127.44J9201 04 N Y N 142.20 10 1422.00J9202 04 N Y N 468.51 3 1405.53J9206 04 N Y N 152.95 44 6729.80J9207 04 01-Jan-09 N Y N 76.58 90 6892.20J9208 04 N Y N 134.50 5 672.50J9209 04 N Y N 35.75 25 893.75J9211 04 N Y N 417.26 10 4172.60J9212 04 N Y N 14.16 90 1274.40J9213 04 N Y N 42.02 1 42.02J9214 04 N Y N 14.16 90 1274.40J9215 04 N Y N 8.23 20 164.60J9216 04 N Y N 379.81 2 759.62J9217 04 N Y N 736.43 6 4418.58J9218 04 N Y N 154.69 12 1856.28J9219 04 N Y N 5,666.17 1 5666.17J9225 04 N Y N 5,500.00 1 5,500.00

J9226 04 01-Jan-08 N Y N15,400.0

0 1 15,400.00J9230 04 N Y N 12.59 3 37.77J9245 04 N Y N 1948.76 1 1948.76J9250 04 N Y N 0.21 20 4.20J9260 04 N Y N 2.24 600 1344.00J9261 04 01-Jan-07 N Y N 117.01 30 3510.30J9263 04 N Y N 10.30 400 4120.00J9264 04 N Y N 9.91 500 4955.00J9265 04 N Y N 146.69 15 2200.35J9266 04 N Y N 1,894.04 5 9470.20J9268 04 N Y N 2,354.63 1 2354.63

Page 258: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

J9270 04 N Y N 98.41 1 98.41J9280 04 N Y N 92.36 8 738.88J9290 04 N Y N 369.46 2 738.92J9291 04 N Y N 895.77 1 895.77J9293 04 N Y N 411.65 5 2058.25J9300 04 N Y N 2,751.34 3 8254.02J9303 04 01-Jan-08 Y Y NJ9305 04 N Y N 49.80 100 4980.00J9310 04 N Y N 546.80 10 5468.00J9320 04 N Y N 185.66 1 185.66J9328 04 01-Jan-10 N Y N 5.64 500 2820.00J9330 04 01-Jan-09 N Y N 57.45 25 1436.25J9340 04 N Y N 104.60 3 313.80J9350 04 N Y N Y 972.24 3 2916.72J9355 04 N Y N 66.34 100 6634.00J9357 04 28-May-09 N Y N 916.50 4 3666.00J9360 04 N Y N 1.01 20 20.20J9370 04 N Y N 15.97 4 63.88J9375 04 N Y N 31.94 1 31.94J9380 04 N Y N 79.86 1 79.86J9390 04 N Y N 119.14 8 953.12J9395 04 N Y N 196.11 10 1961.10J9600 04 N Y N 3,005.31 2 6010.62J9999 04 Y Y NM0064 02 N N 10.00M0075 04 Y NM0076 04 Y NP3000 04 N N 3.55P3001 04 N N 11.45P7001 A 04 N N 6.40 6.40 12.80P9041 09 Y NP9043 09 Y NP9045 09 Y NP9046 09 Y NP9047 09 Y NP9048 09 Y NP9050 04 Y NP9604 04 N N 2.90

Page 259: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

P9612 09 Y NP9615 09 Y NQ0044 02 N N 7.60Q0081 04 Y IQ0083 04 N I 19.00Q0084 04 N I 19.00Q0085 04 N I 19.00Q0111 B 04 N N 2.40 2.40 4.80Q0112 B 04 N N 2.40 2.40 4.80Q0113 B 04 N N 2.40 2.40 4.80Q0114 B 04 N N 2.40 2.40 4.80Q0138 04 01-Jan-10 N Y N 0.93 510 474.30Q0139 04 01-Jan-10 N Y N 0.93 510 474.30Q0163 04 N Y N 0.09 2 0.18Q0164 04 N Y N 0.44 10 4.40Q0165 04 N Y N 0.64 5 3.20Q0166 04 N Y N 46.88 2 93.76Q0168 04 N Y N 10.47 2 20.94Q0169 04 N Y N 0.28 4 1.12Q0170 04 N Y N 0.57 2 1.14Q0171 04 N Y N 0.27 5 1.35Q0172 04 N Y N 0.41 16 6.56Q0173 04 N Y N 0.28 4 1.12Q0174 04 N Y N 0.60 6 3.60Q0175 04 N Y N 0.79 6 4.74Q0176 04 N Y N 0.96 3 2.88Q0177 04 N Y N 0.09 16 1.44Q0178 04 N Y N 0.11 8 0.88Q0179 04 N Y N 28.80 4 115.20Q0180 04 N Y N 75.99 1 75.99Q0181 04 Y Y NQ0515 04 Y Y NQ2004 04 Y Y NQ2009 04 N Y N 7.30 40 292.00Q2017 04 N Y N 320.97 6 1925.82Q3014 04 29-Jan-10 N N 25.00Q3025 04 Y Y NQ3026 04 N Y N 55.40

Page 260: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

Q3031 04 Y NQ4001 09 Y NQ4002 09 Y NQ4003 09 Y NQ4004 09 Y NQ4005 09 Y NQ4011 09 Y NQ4013 09 Y NQ4014 09 Y NQ4015 09 Y NQ4016 09 Y NQ4018 09 Y NQ4019 09 Y NQ4020 09 Y NQ4024 09 Y NQ4025 09 Y NQ4026 09 Y NQ4027 09 Y NQ4028 09 Y NQ4029 09 Y NQ4031 09 Y NQ4033 09 Y NQ4035 09 Y NQ4036 09 Y NQ4037 09 Y NQ4041 09 Y NQ4044 09 Y NQ4045 09 Y NQ4046 09 Y NQ4047 09 Y NQ4048 09 Y NQ4049 09 Y NQ4050 09 Y NQ4051 09 Y NQ4074 04 01-Jan-10 Y Y NQ4081 04 01-Jan-07 N Y N 1 1.56 800 1248.00Q4083 04 01-Jan-07 N Y N 145.54 2 291.08Q4084 04 01-Jan-07 N Y N 244.63 2 489.26

Page 261: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

Q4085 04 01-Jan-07 N Y N 123.87 2 247.74Q4086 04 01-Jan-07 N N 260.53 2 521.06Q4087 04 01-Jul-07 YQ4088 04 01-Jul-07 YQ4089 04 01-Jul-07 YQ4090 04 01-Jul-07 YQ4091 04 YQ4092 04 YQ4100 04 01-Jan-09 Y NQ4101 04 01-Jan-09 Y NQ4102 04 01-Jan-09 Y NQ4103 04 01-Jan-09 Y NQ4104 04 01-Jan-09 Y NQ4105 04 01-Jan-09 Y NQ4106 04 01-Jan-09 Y NQ4107 04 01-Jan-09 Y NQ4108 04 01-Jan-09 Y NQ4109 04 01-Jan-09 Y NQ4110 04 01-Jan-09 Y NQ4111 04 01-Jan-09 Y NQ4112 04 01-Jan-09 Y NQ4113 04 01-Jan-09 Y NQ4114 04 01-Jan-09 Y NQ4115 04 01-Jan-10 Y NQ4116 04 01-Jan-10 Y NR0070 04 N N 4.10R0075 04 N N 4.10R0076 09 Y NS0017 04 N Y N 1.01 6 6.06S0021 04 Y Y NS0023 04 N Y N 1.04 4 4.16S0028 04 N Y N 1.24 2 2.48S0030 04 N Y N 27.61 3 82.83S0032 04 N Y N 6.58 3 19.74S0034 04 N Y N 27.50 2 55.00S0039 04 N Y N 5.86 12 70.32S0040 04 N Y N 15.64 10 156.40S0073 04 N Y N 14.90 16 238.40

Page 262: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

S0074 04 N Y N 7.28 12 87.36S0077 04 N Y N 2.74 6 16.44S0078 04 N Y N 109.50 2 219.00S0080 04 N Y N 40.10 1 40.10S0081 04 N Y N 2.16 12 25.92S0088 04 N Y N 25.42 6 152.52S0092 04 N Y N 97.36 1 97.36S0093 04 N Y N 9.05 1 9.05S0142 04 Y Y NS0145 04 Y Y NS0146 04 Y Y NS0155 04 Y Y NS0166 04 N Y N 6.07 4 24.28S0190 04 N Y N 306.10S0191 04 N Y N 2.40S0195 04 N N 72.27S0630 04 N I 24.35S1015 04 Y NS1016 04 Y NS2066 04 01-Jan-08 Y MS2067 04 01-Jan-08 Y M 3S2068 04 Y M YS2070 04 N I 3 198.98S2075 04 Y M 3 YS2079 04 Y M 11 Y YS2080 04 N M 5 Y 388.70S2083 04 N N 10.00S2118 04 01-Jan-10 Y MS2225 04 N I 3 43.80 17.00S2270 04 01-Jan-09 Y NS2325 04 Y M YS3626 04 Y NS3711 04 01-Jan-09 Y NS4981 04 Y I 3S4989 04 Y NS4990 09 Y NS4993 04 N Y N 1.35 91 122.85S5000 09 01-Jan-08 Y Y N

Page 263: Healthcare and Family Services Practitioner Fee Schedule ... › ... › 022210fee.pdf · Practitioner Fee Schedule Key 2/1/2010 For charges submitted by Physicians, Advanced Practice

HCPCS NoteProgCov Eff Date HP

NDC Ind

Surg Ind AV M1 (26) M2 (TC)

Asst Surg

Co-Surg Unitprice MaxQty StateMax Surg Child Adult

S9123 09 Y NS9124 09 Y NS9125 09 Y NS9127 09 Y NS9460 09 Y NS9474 09 Y NS9480 04 N NT1015 D 04 Y N 0.0000 1T1029 04 N N Y 41.30