|
ABBREVIATIONS: Asst Surg = assistant surgeon allowed, BM
= bilateral modifier, BR = by report (i.e., report is needed to
establish fee), CPT = Current Procedural Terminology, FAC
= services were performed in a facility setting, FUD = follow-up
days (i.e., number of days in global period), Mod 51 Exempt =
Modifier 51 cannot be used with this code, NA = no allowance, OFF
= services were performed in physician office setting, PC (26) =
professional component, PER AGM = per agreement, SC =
special consideration (see Guides or contact Industrial Commission), TBA
= to be assigned, TC (27) = technical component, Total =
total fee, and Units = requires time or number of units. |
| CPT CODE | TOTAL | OFF | FAC | TC (27) | PC (26) | FUD | Group | Asst Surg | Mod 51 exempt |
| 14301 | $1,971.17 | $1,670.00 | 90 | 3 | yes | ||||
| 14302 | $433.73 | $433.73 | 3 | no | |||||
| 21011 | $587.29 | $460.08 | 90 | 3 | yes | ||||
| 21012 | $629.33 | 90 | 3 | yes | |||||
| 21013 | $912.64 | $741.44 | 90 | 3 | yes | ||||
| 21014 | $972.07 | 90 | 3 | yes | |||||
| 21016 | $1,948.20 | 90 | 3 | yes | |||||
| 21552 | $837.72 | 90 | 3 | yes | |||||
| 21554 | $1,376.55 | 90 | 3 | yes | |||||
| 21558 | $2,584.25 | 90 | 3 | yes | |||||
| 21931 | $876.12 | 90 | 3 | yes | |||||
| 21932 | $1,257.16 | 90 | 3 | yes | |||||
| 21933 | $1,385.99 | 90 | 3 | yes | |||||
| 21936 | $2,686.45 | 90 | 3 | yes | |||||
| 22901 | $1,238.00 | 90 | 3 | yes | |||||
| 22902 | $783.67 | $627.58 | 90 | 3 | yes | ||||
| 22903 | $820.58 | 90 | 3 | yes | |||||
| 22904 | $1,937.31 | 90 | 3 | yes | |||||
| 22905 | $2,512.31 | 90 | 3 | yes | |||||
| 23071 | $778.33 | 90 | 3 | yes | |||||
| 23073 | $1,289.60 | 90 | 3 | yes | |||||
| 23078 | $2,614.22 | 90 | 3 | yes | |||||
| 24071 | $755.30 | 90 | 3 | yes | |||||
| 24073 | $1,296.91 | 90 | 3 | yes | |||||
| 24079 | $2,410.41 | 90 | 3 | yes | |||||
| 25071 | $791.58 | 90 | 3 | yes | |||||
| 25073 | $986.72 | 90 | 3 | yes | |||||
| 25078 | $2,103.96 | 90 | 3 | yes | |||||
| 26111 | $768.61 | 90 | 3 | yes | |||||
| 26113 | $1,011.60 | 90 | 3 | yes | |||||
| 26118 | $1,980.57 | 90 | 3 | yes | |||||
| 27043 | $874.74 | 90 | 3 | yes | |||||
| 27045 | $1,390.25 | 90 | 3 | yes | |||||
| 27059 | $3,411.50 | 90 | 3 | yes | |||||
| 27337 | $779.94 | 90 | 3 | yes | |||||
| 27339 | $1,404.69 | 90 | 3 | yes | |||||
| 27364 | $2,935.13 | 90 | 3 | yes | |||||
| 27616 | $2,395.99 | 90 | 3 | no | |||||
| 27632 | $771.12 | 90 | 3 | yes | |||||
| 27634 | $1,259.55 | 90 | 3 | yes | |||||
| 28039 | $893.36 | $642.39 | 90 | 3 | yes | ||||
| 28041 | $844.74 | 90 | 3 | no | |||||
| 28047 | $1,791.03 | 90 | 3 | yes | |||||
| 29581 | $165.83 | $61.99 | 0 | 3 | no | ||||
| 31626 | $814.94 | $411.32 | 0 | 3 | no | ||||
| 31627 | $2,224.84 | $199.88 | 3 | no | |||||
| 32552 | $344.25 | $305.04 | 10 | 3 | yes | ||||
| 32553 | $1,107.15 | $393.42 | 0 | 3 | yes | ||||
| 32561 | $180.41 | $138.47 | 0 | 3 | yes | ||||
| 32562 | $160.39 | $123.95 | 0 | 3 | yes | ||||
| 33782 | $6,234.94 | 90 | 3 | yes | |||||
| 33783 | $6,739.62 | 90 | 3 | yes | |||||
| 33981 | 3 | ||||||||
| 33982 | 3 | ||||||||
| 33983 | 3 | ||||||||
| 36147 | $1,468.00 | $368.27 | 3 | yes | |||||
| 36148 | $462.02 | $98.28 | 3 | yes | |||||
| 37761 | $1,094.89 | 90 | 3 | yes | |||||
| 43281 | $2,939.50 | 90 | 3 | yes | |||||
| 43282 | $3,306.05 | 90 | 3 | yes | |||||
| 43775 | $2,467.55 | 90 | 3 | yes | |||||
| 45171 | $1,111.80 | 90 | 3 | yes | |||||
| 45172 | $1,526.87 | 90 | 3 | yes | |||||
| 46707 | $854.22 | 90 | 3 | no | |||||
| 49411 | $969.19 | $385.43 | 0 | 3 | no | ||||
| 51727 | $532.32 | $331.48 | $200.84 | 0 | 3 | no | |||
| 51728 | $532.08 | $333.44 | $198.65 | 0 | 3 | no | |||
| 51729 | $573.32 | $337.37 | $235.94 | 0 | 3 | no | |||
| 53855 | $1,245.15 | $160.80 | 0 | 3 | no | ||||
| 57426 | $1,637.06 | 90 | 3 | yes | |||||
| 63661 | $1,036.55 | $586.85 | 10 | 3 | yes | ||||
| 63662 | $1,323.34 | 90 | 3 | yes | |||||
| 63663 | $1,519.68 | $889.86 | 10 | 3 | yes | ||||
| 63664 | $1,378.18 | 90 | 3 | yes | |||||
| 64490 | $349.87 | $208.22 | 0 | 3 | yes | ||||
| 64491 | $176.75 | $119.69 | 3 | yes | |||||
| 64492 | $178.81 | $121.75 | 3 | yes | |||||
| 64493 | $313.04 | $176.89 | 3 | yes | |||||
| 64494 | $160.80 | $102.36 | 3 | yes | |||||
| 64495 | $162.88 | $104.42 | 3 | yes | |||||
| 74261 | $747.19 | $540.82 | $206.37 | 4 | |||||
| 74262 | $839.31 | $612.79 | $226.52 | 4 | |||||
| 74263 | 4 | ||||||||
| 75565 | $166.58 | $143.06 | $23.52 | 4 | |||||
| 75571 | $164.21 | $111.66 | $52.55 | 4 | |||||
| 75572 | $482.16 | $322.32 | $159.84 | 4 | |||||
| 75573 | $685.26 | $456.44 | $228.81 | 4 | |||||
| 75574 | $1,059.16 | $841.11 | $218.05 | 4 | |||||
| 75791 | $558.82 | $403.45 | $155.37 | 4 | |||||
| 77338 | $877.59 | $457.09 | $420.50 | 4 | |||||
| 78451 | $407.01 | $281.77 | $125.24 | 4 | |||||
| 78452 | $692.84 | $544.76 | $148.08 | 4 | |||||
| 78453 | $353.62 | $262.80 | $90.83 | 4 | |||||
| 78454 | $341.43 | $220.91 | $120.52 | 4 | |||||
| 83987 | 5 | ||||||||
| 84145 | 5 | ||||||||
| 84431 | 5 | ||||||||
| 86305 | 5 | ||||||||
| 86352 | 5 | ||||||||
| 86780 | 5 | ||||||||
| 86825 | 5 | ||||||||
| 86826 | 5 | ||||||||
| 87150 | 5 | ||||||||
| 87153 | 5 | ||||||||
| 87493 | 5 | ||||||||
| 88387 | $58.82 | $11.44 | $47.38 | 5 | |||||
| 88388 | $35.16 | $5.64 | $29.51 | 5 | |||||
| 88738 | 5 | ||||||||
| 89398 | 5 | ||||||||
| 90670 | 1 | ||||||||
| 92540 | $185.21 | $31.42 | $153.80 | 1 | |||||
| 92570 | $61.31 | $57.87 | 1 | ||||||
| 93750 | $101.35 | $88.99 | 1 | ||||||
| 94011 | $189.97 | 1 | |||||||
| 94012 | $292.17 | 1 | |||||||
| 94013 | $61.47 | 1 | |||||||
| 95905 | $144.82 | $139.36 | $5.46 | 1 | |||||
©Current Procedural Terminology (CPT) Codes and Descriptors
Are Copyrighted by the American Medical Association.