|
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. |
| CODE | TOTAL | OFF | FAC | TC (27) | PC (26) | FUD | Group | Asst Surg | Mod 51 exempt |
| 11045 | 60.63 | $35.08 | 3 | yes | |||||
| 11046 | $105.64 | $74.74 | 3 | yes | |||||
| 11047 | $173.49 | $129.82 | 3 | yes | |||||
| 22551 | $3,349.35 | 90 | 3 | yes | |||||
| 22552 | $782.24 | 3 | yes | ||||||
| 29914 | $2,018.04 | 90 | 3 | yes | |||||
| 29915 | $2,056.44 | 90 | 3 | yes | |||||
| 29916 | $2,056.44 | 90 | 3 | yes | |||||
| 31295 | $4,020.40 | $347.01 | 0 | 3 | yes | ||||
| 31296 | $7,527.32 | $414.41 | 0 | 3 | yes | ||||
| 31297 | $7,456.62 | $339.67 | 0 | 3 | yes | ||||
| 31634 | $3,571.57 | $412.89 | 0 | 3 | yes | ||||
| 33620 | $3,348.67 | 90 | 3 | yes | |||||
| 33621 | $1,803.76 | 90 | 3 | yes | |||||
| 33622 | $7,070.44 | 90 | 3 | yes | |||||
| 37220 | $6,260.57 | $850.97 | 0 | 3 | yes | ||||
| 37221 | $9,256.59 | $1,038.38 | 0 | 3 | no | ||||
| 37222 | $1,803.49 | $386.44 | 0 | 3 | yes | ||||
| 37223 | $5,098.38 | $439.30 | 0 | 3 | yes | ||||
| 37224 | $7,523.24 | $937.79 | 0 | 3 | yes | ||||
| 37225 | $21,254.96 | $1,261.40 | 0 | 3 | yes | ||||
| 37226 | $17,809.13 | $1,056.88 | 0 | 3 | yes | ||||
| 37227 | $28,737.47 | $1,523.49 | 0 | 3 | yes | ||||
| 37228 | $10,710.46 | $1,145.05 | 0 | 3 | yes | ||||
| 37229 | $21,069.76 | $1,476.65 | 0 | 3 | yes | ||||
| 37230 | $16,556.06 | $1,430.53 | 0 | 3 | yes | ||||
| 37231 | $26,572.27 | $1,554.76 | 0 | 3 | yes | ||||
| 37232 | $2,403.71 | $414.16 | 0 | 3 | yes | ||||
| 37233 | $2,934.82 | $679.88 | 0 | 3 | yes | ||||
| 37234 | $7,664.09 | $567.98 | 0 | 3 | yes | ||||
| 37235 | $8,185.78 | $806.10 | 0 | 3 | yes | ||||
| 38900 | $267.47 | $267.47 | 0 | 3 | yes | ||||
| 43283 | $320.37 | 0 | 3 | yes | |||||
| 43327 | $1,611.97 | 90 | 3 | yes | |||||
| 43328 | $2,351.98 | 90 | 3 | yes | |||||
| 43332 | $2,307.94 | 90 | 3 | yes | |||||
| 43333 | $2,506.34 | 90 | 3 | yes | |||||
| 43334 | $2,532.42 | 90 | 3 | yes | |||||
| 43335 | $2,728.82 | 90 | 3 | yes | |||||
| 43336 | $2,982.76 | 90 | 3 | yes | |||||
| 43337 | $3,256.70 | 90 | 3 | yes | |||||
| 43338 | $265.27 | 0 | 3 | yes | |||||
| 43753 | $41.63 | 0 | 3 | yes | |||||
| 43754 | $156.31 | $62.91 | 0 | 3 | yes | ||||
| 43755 | $238.84 | $115.20 | 0 | 3 | yes | ||||
| 43757 | $556.88 | $150.36 | 0 | 3 | yes | ||||
| 49327 | $258.10 | 0 | 3 | yes | |||||
| 49412 | $161.26 | 0 | 3 | yes | |||||
| 49418 | $3,002.88 | $463.03 | 0 | 3 | yes | ||||
| 53860 | $2,884.25 | $459.30 | 90 | 3 | yes | ||||
| 57156 | $298.23 | $204.85 | 0 | 3 | yes | ||||
| 61781 | $463.69 | 0 | 3 | yes | |||||
| 61782 | $383.94 | 0 | 3 | yes | |||||
| 61783 | $463.69 | 0 | 3 | yes | |||||
| 64566 | $255.98 | $59.78 | 0 | 3 | yes | ||||
| 64568 | $1,268.55 | 90 | 3 | yes | |||||
| 64569 | $1,218.45 | 90 | 3 | yes | |||||
| 64570 | $1,061.02 | 90 | 3 | yes | |||||
| 64611 | $195.08 | $176.27 | 10 | 3 | yes | ||||
| 65778 | $2,481.00 | $148.09 | 10 | 3 | yes | ||||
| 65779 | $2,244.25 | $573.85 | 10 | 3 | yes | ||||
| 66174 | $1,931.46 | 90 | 3 | yes | |||||
| 66175 | $2,139.72 | 0 | 3 | yes | |||||
| 74176 | $409.70 | $247.84 | $161.86 | 4 | |||||
| 74177 | $642.63 | $472.89 | $169.74 | 4 | |||||
| 74178 | $812.79 | $625.04 | $187.75 | 4 | |||||
| 76881 | $217.31 | $162.19 | $55.12 | 4 | |||||
| 76882 | $57.19 | $18.97 | $38.22 | 4 | |||||
| 80104 | 5 | ||||||||
| 82930 | 5 | ||||||||
| 83861 | 5 | ||||||||
| 84112 | 5 | ||||||||
| 85598 | 5 | ||||||||
| 86481 | 5 | ||||||||
| 86902 | 5 | ||||||||
| 87501 | 5 | ||||||||
| 87502 | 5 | ||||||||
| 87503 | 5 | ||||||||
| 87906 | 5 | ||||||||
| 88120 | $693.75 | $612.28 | $81.46 | 5 | |||||
| 88121 | $585.91 | $513.64 | $72.27 | 5 | |||||
| 88177 | $42.85 | $9.64 | $33.21 | 5 | |||||
| 88363 | $58.03 | $26.09 | 5 | ||||||
| 88749 | 5 | ||||||||
| 90460 | $45.96 | 1 | |||||||
| 90461 | $23.05 | 1 | |||||||
| 90470 | 1 | ||||||||
| 90644 | 1 | ||||||||
| 90664 | 1 | ||||||||
| 90666 | 1 | ||||||||
| 90667 | 1 | ||||||||
| 90668 | 1 | ||||||||
| 90867 | 1 | ||||||||
| 90868 | 1 | ||||||||
| 91013 | $45.77 | $26.00 | $19.78 | 1 | |||||
| 91117 | $280.51 | $298.66 | 1 | ||||||
| 92132 | $72.06 | $30.03 | $42.02 | 1 | |||||
| 92133 | $88.60 | $30.03 | $58.57 | 1 | |||||
| 92134 | $88.60 | $30.03 | $58.57 | 1 | |||||
| 92227 | $22.64 | 1 | |||||||
| 92228 | $59.55 | $24.66 | $34.90 | 1 | |||||
| 93451 | $1,504.56 | $1,215.54 | $289.02 | 1 | |||||
| 93452 | $1,667.14 | $1,161.12 | $506.02 | 1 | |||||
| 93453 | $2,182.08 | $1,518.38 | $663.69 | 1 | |||||
| 93454 | $1,719.69 | $1,209.51 | $510.18 | 1 | |||||
| 93455 | $2,006.71 | $1,417.59 | $589.12 | 1 | |||||
| 93456 | $2,152.41 | $1,498.90 | $653.51 | 1 | |||||
| 93457 | $2,439.20 | $1,706.50 | $732.70 | 1 | |||||
| 93458 | $2,075.12 | $1,452.53 | $622.59 | 1 | |||||
| 93459 | $2,292.02 | $1,590.94 | $701.08 | 1 | |||||
| 93460 | $2,452.74 | $1,671.57 | $781.17 | 1 | |||||
| 93461 | $2,810.38 | $1,948.86 | $861.51 | 1 | |||||
| 93462 | $397.02 | $397.02 | 1 | ||||||
| 93463 | $211.19 | $211.19 | 1 | ||||||
| 93464 | $496.13 | $310.22 | $185.92 | 1 | |||||
| 93565 | $86.09 | $86.09 | 1 | ||||||
| 93566 | $335.37 | $86.09 | 1 | ||||||
| 93567 | $277.21 | $97.15 | 1 | ||||||
| 93568 | $303.17 | $88.15 | 1 | ||||||
| 95800 | $408.42 | $291.41 | $117.01 | 1 | |||||
| 95801 | $193.27 | $89.84 | $103.43 | 1 | |||||
| 96446 | $349.66 | $41.92 | 1 |
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Are Copyrighted by the American Medical Association.